1. URINARY TRACT STRUCTURE & INFECTION

4. Innervation of the Urinary Tract Sympathetic fibers from the lower splanchnic nerves – lumbar ganglion – kidney Parasympathetic vagal fibers via the coeliac plexus Regulation vasomotor tone, renal blood flow Stimulation – causes intrarenal vasoconstriction and reduces renal blood flow, enhances Na reabsorption stimulates local RAAS Both sympathetic and parasympathetic nerve fibers supply the ureter, vesica urinaria

5. Infection of the Urinary Tract Asymptomatic bacteriuria, presence of bacteria in UT, absence of symptoms, colonization from female periurethral area Significant bacteriuria = > 100.000 bct/ ml in 2 voided specimens or 1 in-out catheter specimen in a woman, or 1 voided specimen in a man Treatment only when risk factors for potential complicated UTI, eg pregnancy,

6. Acute UTI Lower UTI : dysuria, frequency, urgency. Upper UTI : infection involving the kidney Complicated, uncomplicated Clinical presentation in children more variable and frequently nonspecific Cystitis Prostatitis, urethritis Acute bacterial Pyelonephritis: bacterial invasion of the kidney, clinical syndrome w/ chills and fever, flank pain, constitutional symptoms Chronic pyelonephritis, path ~ tubulointerstitial nephritis caused by # of disorders: VUR, chronic obstructive uropathy, drugs & toxins, renal medullary ds, chronic / recurrent renal bacteriuria Complicated infection :abnormal anatomy, obstruction, dilatation & impaired drainage risk of renal damage, abcess formation,septicemia

8. 85%50%

9. Urease Proteus mirabilis, P vulgaris, S saprophyticus Involved in tissue adherence Splitting urea into into CO2 & Ammonia Urinary alkalinization Precipitation of Mg, NH4, PO4 Stone formation, struvite

10. Investigation of UTI Dx: Microbiological: bacterial count >10 CFU /ml Midstream urine collection Women, introitus should be cleaned with NaCl, midstream urine is collected with the labia spread apart Suprapubic aspiration ( infants % children ) Urine can be stored at 4’C for up to 48h before culture Infection may be present CFU 10 - 10 Mixed culture w/ low colony counts in F ~ contamination Urinalysis ~first line screen, nitrates, leucocytes + hematuria, proteinuria Urine microscopy, white cell casts ~ renal parenchymal infection 5 2 5

11. Obstructions Prostate, Urethral stricture Congenital anomalies Of urinary tract: Reflux, urethral valves IVP Abscess

12. Displacement / lateral ectopia Of the ureteric orifice, Loss of valve like action

14. Treatment of UTI Most cases, uncomplicated lower UTI, 3 day course of antibiotics, no culture needed Trimethoprim, cephalexin, amox/clavulanate, ciprofloxacin Relapsing infections, 10 – 14 days if persist / recurs, further investigation Prophylactic low dose antibiotics for recurrent, >3x/y UTI In patients w/ clear relation between infection and sexual activity, single dose after intercourse may be effective Acute pyelonephritis ~ Rx in Hospital, IV fluids & antibiotics started before culture results Antibiotics IV – oral, 2 weeks If no improvement in 48H, review AB, further investigation (obstruction, abscess?)