Presentations:- Symptomatic-

·       Frequency-dysuria syndrome (urgency, strangury, initial/ terminal haematuria, suprapubic discomfort.)

·       Bacterial cystitis

·       Abacterial cystitis ( urethral syndrome)

·       Acute pyelonephritis

·       Acute prostatitis Asymptomatic bacteriuria Classification of UTIs:- Uncomplicated-

·       Normal renal functions

·       Normal urinary tract

·       Healthy females

Complicated-

·       Abnormal tract (stones, VUReflux, indwelling catheter, Atonic bladder)

·       Impaired host defences ( Neutropenia, immunosuppressive therapy, Organ transplant recipient,Diabetes mellitus)

·       Impaired renal function

·       Virulent organisms ( Staph., Proteus)

·       All males

Clinical examination:-

Females:-      Look for cystocele, vaginitis, cervicitis while doing a per-speculum and per- vaginalexamination

Males:-          Look for phimosis, paraphimosis, feel for urethral strictures in the perineum, per-rectal tofeel the prostate

Diagnosis of UTI:-

Urine culture:-

A single MSU (mid stream urine) sample showing >105colony count has patient has a CI of more than95%

Routine screening for asymptomatic bacteriuria is recommended only in pregnancy (risk of pretermlabor)

A prostatitis should be diagnosed by collecting the first 5-10ml of urine after massaging the prostateper-rectally

Symptomatic females-103 colonies of a potential pathogen/ml of urine Asymptomatic females – 105 colonies of a potential pathogen/ml of urine Any male – 103 colonies /ml of urine

Suprapubic sample/indwelling catheter-102 colonies /ml of urine is significant

Catheter in-and-out technique-103 colonies/ml of urine

INTERPRETING URINE MICROSCOPY AND CULTURE

 Bacteria without pyuria:-

Asymptomatic bacteriuria

Contaminants (>5 epithelial cells/ HPF signifies contamination0

Pyuria without bacteria ( sterilepyuria):-

Culture inhibited by antibiotics

Antiseptic contamination of specimenTuberculosis (typical/atypical) Fungal

Acute febrile episodes Diabetes mellitus Glucocorticoid therapy Calculi (renal/ bladder) Papillary necrosis

Chemical cystitis (Cyclophosphamide) Analgesic nephropathy/ Interstitial nephritis Non-bacterial (Chlamydia)

False pyuria (Cervicitis/ vaginitis)

Investigating an UTI:-

If complicated UTI is suspected from history and examination,

1.      X-Ray KUB(stones, renal shadows)

2.      Ultrasound abdomen (hydroureters, hydrnephrosis, structural anomalies)

3.      Intravenous pyelogram(tract abnormalities, functional status)

4.      Residual volume of urine (prostatic obstruction)

5.      Uroflowmetry studies (Obstructive uropathy)

6.      Cystometrogram (Detrusor instability/Atonic bladder / Stress incontinence

7.      Cystoscopy (chronic cystitis, isolated haematuria)

Management of UTIs (use any one of the regimen) Uncomplicated UTI-

Single dose regimen:-

·       Cotrimoxazole DS 2 tabs

·       Norfloxacin 800 mg

·       Ciprofloxacin 500 mg

·       Trimethoprim 600 mg

Short course (3day) regimen:-

·       Cotrimoxazole DS 1 Bd

·       Norfloxacin 400 mg BD

·       Amoxycillin 250 mg q8hly

·       Ciprofloxacin 250 mg BD

·       Lomefloxacin 400 mg OD

·       Augmentin(500mg mg max/ 125 mg Clav) q12hly

·       Nalidixic acid- 500 mg/q8hly

·       Nitrofurantoin 50 mg/q8hly

Complicated UTI:-

With poor renal function:-

3 day regimen-

Cephalexin 250mg q8hly Cefaclor 250mg q8hly

With prostatitis:-

Duration of therapy 2-4 weeks-

DOC-Quinolones in the dosages mentioned above Repeat C/S after 2 weeks of antibiotics

In pregnancy:-

DOC- Cotrimoxazole DS 1 BD x 3 days Repeat C/S after 7-10 days

With pyelonephritis:-

Intravenous antibiotic therapy for 5 days

Gentamicin 3mg/kg loading, followed by 1mg/kg q8hly Amikacin 2.5-3.5 mg/kg Q12 hly (5.0-7.5 mg/kg/day) Ciprofloxacin 100mg q12hly- switch over to oral after 48h Amoxycillin 1g Q8hly

Cefazolin 1g Q8hly Cephradine 1g Q8hly

Ceftriaxone 2g Q24hly ( no need for dose adjustment in renal failure0 Imipenem / Cilastin 500mg /500mg Q8hly

Augmentin 1g amox /200mg Clav Q8hly

Recurrent UTI:- Prophylaxis- Norfloxacin 200mg OD Cotrimoxazole 1 tab OD Nitrofurantoin 50mg OD Cephalexin 125mg OD

Followup:-

Repeat C/S after 10-14 days

Urologic evaluation needed for all males, complicated UTIs and neonates for urinary tractabnormalities

Prophylactic antibiotics recommended for recurrent UTIs in women

In post-menopausal women, gynaecological to rule out a senile vaginitis/ urethral stricture/ carcinoma cervix . Vaginal oestrogen creams, +/- dilatation ( in case of urethral stricture), +/- HRTmay be needed.