泌尿生殖道感染.ppt

1、Infection of the Genitourinary Tract Hongshu Ma Department of Urology Tianjin First Central Hospital Urinary tract infections (UTIs) caused by pathogenic bacteria can involve any of the genital or urinary organs and eventually can spread from one site to any or all of the others. Definitions 1 Urina

2、ry tract infection is an inflammatory response of the urothelium to bacterial invasion that is usually associated with bacteriuria and pyuria. Most UTIs are caused by aerobic gram-negative rods, (Escherichia coli.), gram-positive cocci (enterococci) and to a lesser extent by anaerobic bacteria. Defi

3、nitions 2 Definitions 3 Bacteriuria is the presence of bacteria in the urine, which is normally free of bacteria, and implies that these bacteria are from the urinary tract and are not contaminants from the skin, vagina, or prepuce. Definitions 4 Pyuria is the presence of white blood cells in the ur

4、ine Bacteriuria without pyuria indicates bacterial colonization rather than infection. Pyuria without bacteriuria warrants evaluation for tuberculosis, stone, or cancer. Classification According to their nature history First infections/Isolated Infection Recurrent infections Bacterial persistence Re

5、infections Reinfection is recurrent infection with different bacteria from outside the urinary tract. Each infection is a new event; the urine must show no growth after the preceding infection. Bacterial persistence refers to a recurrent urinary tract infection caused by the same bacteria from a foc

6、us within the urinary tract, such as an infection stone or the prostate. According to Their Site of Origin Upper urinary tract infection Lower urinary tract infection Genital system infection Upper-tract infection Acute pyelonephritis Chronic pyelonephritis Emphysematous pyelonephritis Renal abscess

7、 Perinephric abscess Xanthogranulomatous pyelonephritis Lower-tract infection Acute urethral syndrome (Women) Acute cystitis Genital infection Acute and chronic bacterial prostatitis. Acute and chronic epididymitis. Pathogenesis Bacterial pathogenesis in the urinary tract depends on a number of fact

8、ers, chief of which are the Bacterial Virulence Facters and the Host Susceptibility Factor Bacterial virulence factors Ability of adherence to urothelial cells Ability to resist bactericidal activity Ability to produce hemolysin. Host susceptibility factors Emptying of urine Surface mucins Urinary a

9、ntibodies Urinary osmolality pH Routes of infection (1) Ascending infection (2) Hematogenous spread (3) Lymphatogenous spread (4) Direct extension DIAGNOSIS Urine Collection Suprapubic Aspiration Urethral Catheterization Segment Voided Urine Specimens Urinlysis More than 3 fresh leukocytes/High- pow

10、er field Quantitative urine culture Colonies forming units per milliliter (cfu/ml) 100,000 cfu/ml 1000 to 10,000 cfu/ml Location of urinary tract nfection. Symptoms and signs Laboratory findings X-Ray findings Radionuclide imaging MRI findings Treatment strategy. Antimicrobial drug Mdication for pai

11、n, fever, and nausea. To give fluids intravenously and orally Complicating factors (eg. Obstructive urography or infected stones) Acute Pyelonephritis Definitions Acute pyelonephritis is defined as inflammation of the parenchyma and the pelvis of the kidney causing by bacterial infection. Etiology &

12、 Pathogenesis Aerobic gram-negative bacteria E coli Gram-negative entric organisms Enterococci, and staphylococcus aureus Ascending infection (VUR) Hematogenous Clinical findings 1 An abrupt onset of chill , moderate to high fever Dysuria, frenquency, urgency. Abdominal pain, nausea, vomiting, and e

13、ven diarrhea. Clinical findings 2 Costovertebral angle tenderness Palpation or percussion over the costovertebral angle on the affected kidney usually causes pain. The patient sometimes has abdominal distention, tenderness, and a quiet intestine Dignosis 1 Laboratory findings: Leukocytosis Pyuria, B

14、acteriuria, Proteinuria, Hematuria Quantitative urine culture Total renal function Dignosis 2 Imaging: Plain film Excretory urograms . Voiding cystogram CT Ultrasonography Radionuclide Differential Diagnosis Pancreatitis Basal pneumonia Acute-intra-abdominal disease Women pelvic inflammatory disease

15、and acute prostatitis Renal abscess Perinephric abcess. Treatment 1 Antimicrobial drugs: The appropriate intravenous treatment Oral drug Repeat urine cultures Treatment 2 Specific measures: Any complicating factors (eg. obstructive urography) Prostatitis Types of protatitis Drach (1978) (1) acute an

16、d chronic bacterial prostatitis, (2) nonbacterial prostatitis (3) prostatodynia. NIDDK categorization and Drach classification NIDDK Classification (1995) Drach classification (1978) Category 1 Acute bacterial prostatitis Acute bacterial prostatitis Category 2 Chronic bacterial prostatitis Chronic b

17、acterial prostatitis Category 3 Chronic pelvic pain syndrom 3a Inflammatory type Nonbacterial prostatitis 3b Noninflammatory type Prostatodynia Category 4 Asymptomatic inflammatory prostatitis Diagnostic techniques The expressed prostatic secretions (EPS) Leukocytes 10 per high-power field (hpf) The

18、 4-glass test (Stamey 1968) Urethritis Cystitis prostatitis VB1 + +/- -/+ VB2 - + - EPS - -/+ + (10 times than VB1) VB3 - -/+ + Acute bacterial prostatitis Etiology & Pathogenesis E coli 80% Enterococci 5-10% Anaerobes rarely Intraprostatic reflux of urine Invasion by rectal bacteria Hematogenous sp

19、read Clinical features The sudden onset of fever, chills. Low back and perineal pain. Frenquency and urgency, nocturia, dysuria Varying degrees of bladder outlet obstruction. Digital rectal examination (DRE) Tender, swollen prostate gland, irregularly firm and warm Urine may be cloudy and malodorous

20、, and gross hematuria is observed Diagnosis A complete blood count shows leukocytosis with a shift toward immature forms. The voided urine shows pyuria, microscopic hematuria, and bacteria. Culture of voided urine sample usually identifies the pathogens Ultrasonography Treatment Antibiotic treatment

21、 for 4-6 weeks Supportive measures include antipyretics, analgesics, stool sorfteners, hydration, and bed rest. Any transurethral catheterization or instrumentation is contraindicated. Acute urinary retention should be managed with suprapubic drainage Chronic bacterial prostatitis Etiology & Pathoge

22、nesis The gram-nagative organisms The gram-positive organisms Mycoplasmal, chlamydial species Intraprostatic reflux of urine pH of prostatic secretions Zinc Clinical findings 1 Irritative voiding dysfunction(dysuria urgency, frequency, nocturia ) Low back or perineal pain Sexual dysfunction Myalgia

23、and arthralgia Other symptoms Clinical findings 2 DRE: normal, tenderness, swelling, firmness Secondary epididymitis Hematouria, hematospermia, urethral discharge Diagnosis The 4-glass test The expressed prostatic secretions (EPS) Leukocytes 10 per high-power field (hpf) Sonography 鉴别诊断 II型和 III型应与可

24、能导致骨盆区域疼痛和排 尿异常的疾病进行鉴别诊断 间质性膀胱炎、睾丸附睾和精索疾病、肛门 直肠疾病、腰椎疾病 BPH、膀胱过度活动症、神经原性膀胱 膀胱肿瘤、前列腺癌 治疗原则 慢性前列腺炎无明确的进展性，不足以 威胁患者的生命和重要器官功能，并非 所有的前列腺炎均需治疗。 慢性前列腺炎的治疗目标主要是缓解疼 痛、改善排尿症状和提高生活质量，疗 效评价应以症状改善为主。 前列腺炎应采取综合治疗。 治疗方法 一、 型 一旦临床诊断或得到血、尿培养结果后，应立即应用 抗生素。 开始时可经静脉应用抗生素，如：广谱青霉素、三代 头孢菌素 、氨基糖甙类或氟喹诺酮等。 待患者的发热等症状改善后，改用口服药

25、物（如氟 喹 诺酮等），疗程至少 4周。 并发症处理： 伴尿潴留者 细管导尿或膀胱穿刺造瘘。 伴脓肿形成者 可采取穿刺引流、经尿道切开引 流 治疗方法 二、 型和 型 （一）一般治疗 ： 健康教育、心理和行为辅导有积极作用 。 慢性前列腺炎患者应戒酒，忌辛辣刺激 食 物；避免憋尿、久坐，注意保暖，加强 体育锻炼。 热水坐浴有助于缓解疼痛症状。 治疗方法 二、 型和 型 （二）药物治疗 1抗生素 2 -受体阻滞剂 3非甾体抗炎镇痛药 4植物制剂 5 M-受体阻滞剂 6抗抑郁药及抗焦虑药 7中医中药 治疗方法 抗生素 型： 根据细菌培养结果和药物穿透前列腺的能力选择抗 生素。药物穿透前列腺的能力取

26、决于其离子化程度 、脂溶性、蛋白结合率、相对分子质量及分子结构 等。 常用的抗生素是氟喹诺酮类药物（如环丙沙星、左 氧氟沙星和洛美沙星等）、 四环素类（如米诺环素 等） 和磺胺类（如复方新诺明）。 前列腺炎确诊后， 抗生素治疗疗程为 46周 ， 治疗方法 A型： 抗生素治疗大多为经验性治疗。 推荐先口服氟喹诺酮或四环素等类抗生素 24周，然后 根据其 疗效反馈决定是否继续抗生素治疗。 只有当患者的临床症状确有减轻时，才建议继续应用 抗生素。推荐的总疗程为 4 6周。 部分患者可能存在衣原体、支原体等病原体感染， 可 口服四环素类或大环内酯类抗生素治疗。 B型：不推荐使用抗生素治疗。 治疗方法

27、-受体阻滞剂 -受体阻滞剂能松弛前列腺和膀胱等部位的平滑肌而 改善下尿路症状和疼痛，为治疗 型 / 型前列腺炎的 基本药物之一。 可选择不同的 -受体阻滞剂治疗。常用药物有：阿夫 唑嗪、多沙唑嗪、萘哌地尔、坦索罗辛和特拉唑嗪等 。 -受体阻滞剂的疗程至少应在 12周以上。 治疗中应注 意该类药物导致的眩晕和体位性低血压等不良反应。 a型前列腺炎单一使用抗生素或 -受体阻滞剂疗效不 佳时，可二者联合使用，疗程 6周以上。 治疗方法 非甾体抗炎镇痛药 非甾体抗炎镇痛药是治疗 型前列腺炎 相关症状的经验性用药。其主要目的是 缓解疼痛和不适。 迄今为止，只有数项随机、安慰剂对照 研究评价此类药物的疗效

28、。 临床对照研究证实塞来昔布对改善 a型 前列腺炎患者的疼痛等症状有效。 治疗方法 植物制剂 为 型和 型前列腺炎可选择的辅助治疗方 法。 主要指花粉类制剂与植物提取物，其药理作 用较为广泛，如非特异性抗炎、抗水肿、促 进膀胱逼尿肌收缩与尿道平滑肌松弛等作用 。 常用的植物制剂有：普适泰等。 治疗方法 M-受体阻滞剂 对伴有膀胱过度活动症（ OAB）表现， 如尿急、尿频和夜尿但无尿路梗阻的前 列腺炎患者，可以使用 M-受体阻滞剂托 特罗定治疗。 治疗方法 手术治疗 经尿道膀胱颈切开术、经尿道前列腺切 除术或根治性前列腺切除术对于慢性前 列腺炎很难起到治疗作用，只在合并前 列腺相关疾病有手术适应证时选择上述 手术。 治疗方法 IV型 一般无需治疗。 患者如合并血清 PSA升高或不育症等， 应注意鉴别诊断并进行相应治疗。 PSA升高者应用抗生素治疗有助于前列 腺癌的鉴别诊断。 Treatment Antibiotics ( at least 6 weeks) Alpha blocker Physical therapy Surgical therapy