泌尿生殖道感染1課件

Infectionof

theGenitourinaryTractHongshuMaDepartmentofUrologyTianjinFirstCentralHospital

Urinarytractinfections(UTIs)causedbypathogenicbacteria

caninvolveanyofthegenitalorurinaryorgansandeventually

canspreadfromonesitetoany

oralloftheothers.

Definitions1

Urinarytractinfectionisaninflammatoryresponseoftheurotheliumtobacterialinvasionthatisusuallyassociatedwithbacteriuriaandpyuria.Definitions3Bacteriuriaisthepresenceofbacteriaintheurine,whichisnormallyfreeofbacteria,andimpliesthatthesebacteriaarefromtheurinarytractandarenotcontaminantsfromtheskin,vagina,orprepuce.Definitions4Pyuria

isthepresenceofwhiteblood

cellsintheurineBacteriuriawithoutpyuriaindicates

bacterialcolonizationratherthan

infection.Pyuriawithoutbacteriuriawarrants

evaluationfortuberculosis,stone,orcancer.ClassificationReinfection

isrecurrentinfectionwithdifferentbacteriafromoutsidetheurinarytract.Eachinfectionisanewevent;theurinemustshownogrowth

aftertheprecedinginfection.Bacterial

persistencereferstoarecurrenturinarytractinfectioncausedbythesamebacteriafromafocuswithintheurinarytract,suchasaninfectionstoneortheprostate.

AccordingtoTheirSiteofOrigin

Upperurinarytractinfection

Lowerurinarytractinfection

Genitalsysteminfection

Upper-tractinfectionAcutepyelonephritisChronicpyelonephritisEmphysematouspyelonephritisRenalabscessPerinephricabscessXanthogranulomatouspyelonephritis Lower-tractinfectionAcuteurethralsyndrome(Women)Acutecystitis

GenitalinfectionAcuteandchronicbacterialprostatitis.Acuteandchronicepididymitis.

Bacterialvirulencefactors

AbilityofadherencetourothelialcellsAbilitytoresistbactericidalactivityAbilitytoproducehemolysin.

HostsusceptibilityfactorsEmptyingofurineSurfacemucinsUrinaryantibodiesUrinaryosmolalitypHRoutesofinfection(1)Ascendinginfection(2)Hematogenousspread(3)Lymphatogenousspread(4)Directextension

DIAGNOSISUrinlysis

Morethan3freshleukocytes/High-powerfieldTreatmentstrategy.Antimicrobialdrug

Mdicationforpain,fever,andnausea.

Togivefluidsintravenouslyandorally

Complicatingfactors(eg.Obstructiveurographyorinfectedstones)

AcutePyelonephritisDefinitionsAcutepyelonephritisisdefinedasinflammationoftheparenchymaandthepelvisofthekidneycausingbybacterialinfection.Etiology&PathogenesisAerobicgram-negativebacteriaEcoli

Gram-negativeentricorganisms

Enterococci,andstaphylococcusaureusAscendinginfection(VUR)HematogenousClinicalfindings1Anabruptonsetofchill,moderatetohighfeverDysuria,frenquency,urgency.Abdominalpain,nausea,vomiting,andevendiarrhea.

Clinicalfindings2CostovertebralangletendernessPalpationorpercussionoverthecostovertebralangleontheaffectedkidneyusuallycausespain.Thepatientsometimeshasabdominaldistention,tenderness,andaquietintestineDignosis1Laboratoryfindings:LeukocytosisPyuria,Bacteriuria,Proteinuria,HematuriaQuantitativeurinecultureTotalrenalfunction

Dignosis2

Imaging:PlainfilmExcretoryurograms.VoidingcystogramCTUltrasonographyRadionuclideDifferentialDiagnosisPancreatitisBasalpneumoniaAcute-intra-abdominaldiseaseWomenpelvicinflammatorydiseaseandacuteprostatitisRenalabscessPerinephricabcess.

Treatment1Antimicrobialdrugs:TheappropriateintravenoustreatmentOraldrugRepeaturinecultures

Treatment2Specificmeasures:Anycomplicatingfactors(eg.obstructiveurography)

ProstatitisTypesofprotatitisDrach(1978)(1)acuteandchronicbacterialprostatitis,(2)nonbacterialprostatitis(3)prostatodynia.NIDDKcategorizationandDrachclassificationNIDDKClassification(1995)Drachclassification(1978)Category1AcutebacterialprostatitisAcutebacterialprostatitisCategory2ChronicbacterialprostatitisChronicbacterialprostatitisCategory3Chronicpelvicpainsyndrom3aInflammatorytypeNonbacterialprostatitis

3bNoninflammatorytype

ProstatodyniaCategory4AsymptomaticinflammatoryprostatitisDiagnostictechniquesTheexpressedprostaticsecretions(EPS)Leukocytes<10perhigh-powerfield(hpf)

The4-glasstest(Stamey1968)UrethritisCystitisprostatitisVB1++/--/+VB2-+-EPS--/++(10timesthanVB1)VB3--/++AcutebacterialprostatitisEtiology&Pathogenesis

Ecoli80%

Enterococci5-10%AnaerobesrarelyIntraprostaticrefluxofurineInvasionbyrectalbacteriaHematogenousspread

Clinicalfeatures

Thesuddenonsetoffever,chills.Lowbackandperinealpain.Frenquencyandurgency,nocturia,dysuriaVaryingdegreesofbladderoutletobstruction.Digitalrectalexamination(DRE)Tender,swollenprostategland,irregularlyfirmandwarmUrinemaybecloudyandmalodorous,andgrosshematuriaisobservedDiagnosis

Acompletebloodcountshowsleukocytosiswithashifttowardimmatureforms.Thevoidedurineshowspyuria,microscopichematuria,andbacteria.CultureofvoidedurinesampleusuallyidentifiesthepathogensUltrasonographyTreatmentAntibiotictreatmentfor4-6weeksSupportivemeasuresincludeantipyretics,analgesics,stoolsorfteners,hydration,andbedrest.Anytransurethralcatheterizationorinstrumentationiscontraindicated.Acuteurinaryretentionshouldbemanagedwithsuprapubicdrainage

ChronicbacterialprostatitisEtiology&PathogenesisThegram-nagativeorganismsThegram-positiveorganismsMycoplasmal,chlamydialspeciesIntraprostaticrefluxofurinepHofprostaticsecretionsZincClinicalfindings1Irritativevoidingdysfunction(dysuriaurgency,frequency,nocturia)LowbackorperinealpainSexualdysfunctionMyalgiaandarthralgiaOthersymptomsClinicalfindings2DRE:normal,tenderness,swelling,firmnessSecondaryepididymitisHematouria,hematospermia,urethraldischargeDiagnosisThe4-glasstestTheexpressedprostaticsecretions(EPS)Leukocytes<10perhigh-powerfield(hpf)Sonography鑒別診斷II型和III型應(yīng)與可能導(dǎo)致骨盆區(qū)域疼痛和排尿異常的疾病進(jìn)行鑒別診斷間質(zhì)性膀胱炎、睪丸附睪和精索疾病、肛門直腸疾病、腰椎疾病BPH、膀胱過度活動(dòng)癥、神經(jīng)原性膀胱膀胱腫瘤、前列腺癌治療原則慢性前列腺炎無明確的進(jìn)展性，不足以威脅患者的生命和重要器官功能，并非所有的前列腺炎均需治療。慢性前列腺炎的治療目標(biāo)主要是緩解疼痛、改善排尿癥狀和提高生活質(zhì)量，療效評(píng)價(jià)應(yīng)以癥狀改善為主。前列腺炎應(yīng)采取綜合治療。治療方法

一、Ⅰ型一旦臨床診斷或得到血、尿培養(yǎng)結(jié)果后，應(yīng)立即應(yīng)用抗生素。開始時(shí)可經(jīng)靜脈應(yīng)用抗生素，如：廣譜青霉素、三代頭孢菌素、氨基糖甙類或氟喹諾酮等。待患者的發(fā)熱等癥狀改善后，改用口服藥物（如氟喹諾酮等），療程至少4周。并發(fā)癥處理：伴尿潴留者——細(xì)管導(dǎo)尿或膀胱穿刺造瘺。伴膿腫形成者——可采取穿刺引流、經(jīng)尿道切開引流治療方法二、Ⅱ型和Ⅲ型（一）一般治療：

健康教育、心理和行為輔導(dǎo)有積極作用。慢性前列腺炎患者應(yīng)戒酒，忌辛辣刺激食物；避免憋尿、久坐，注意保暖，加強(qiáng)體育鍛煉。熱水坐浴有助于緩解疼痛癥狀。治療方法

二、Ⅱ型和Ⅲ型（二）藥物治療

1．抗生素

2．α-受體阻滯劑

3．非甾體抗炎鎮(zhèn)痛藥

4．植物制劑

5．M-受體阻滯劑

6．抗抑郁藥及抗焦慮藥

7．中醫(yī)中藥治療方法

抗生素

Ⅱ型：根據(jù)細(xì)菌培養(yǎng)結(jié)果和藥物穿透前列腺的能力選擇抗生素。藥物穿透前列腺的能力取決于其離子化程度、脂溶性、蛋白結(jié)合率、相對(duì)分子質(zhì)量及分子結(jié)構(gòu)等。常用的抗生素是氟喹諾酮類藥物（如環(huán)丙沙星、左氧氟沙星和洛美沙星等）、四環(huán)素類（如米諾環(huán)素等）和磺胺類（如復(fù)方新諾明）。前列腺炎確診后，抗生素治療療程為4~6周，治療方法

ⅢA型：抗生素治療大多為經(jīng)驗(yàn)性治療。推薦先口服氟喹諾酮或四環(huán)素等類抗生素2~4周，然后根據(jù)其療效反饋決定是否繼續(xù)抗生素治療。只有當(dāng)患者的臨床癥狀確有減輕時(shí)，才建議繼續(xù)應(yīng)用抗生素。推薦的總療程為4~6周。部分患者可能存在衣原體、支原體等病原體感染，可口服四環(huán)素類或大環(huán)內(nèi)酯類抗生素治療