Urinary Tract Infections

In medical practiceUrinary tract infections are among the most common infections. According to statistics in the US, urinary tract infections are the leading infections in hospital conditions. Infected urinary system is the most important source of bacteremia and sepsis.

The only part of the urinary system that bacterial flora found is Urethri. The urine is proximal to the ureterovezical junction, and the bacteria that reach the bladder as ascites are removed by the mucosal defense mechanisms and the mechanical cleaning of the urine flow. The prevalence of urinary tract infections is affected by some factors. Patient age, gender, characteristics of responsible pathogen, presence of structural or anatomical anomalies in urinary system, self-catheterization or permanent catheterization and presence of urinary stone disease are the main ones. UTI may be associated with the functional – anatomical pathologies and / or anomalies of the urinary system, and in this case, the definition of complicated urinary infection is used. Non-complicated infections are common in humans with normal urinary system and are rare in men. UTIs are the most common bacterial infection in all ages in humans.

The prevalence of UTI in the neonatal period is 1%, and it is more common in boys (M / F = 1.5 / 1). In this age group, the frequency of infection is 2-3% and the ratio of male to female is 1/10. In school age, 5% of girls spend one or more times URI.

In adult age, UTI increases with marital and sexual activity in women. The prevalence of UTI in pregnant women is 4.7% and in non-pregnant patients it is 1-5%. In adult reproductive women, UTI is higher than in men (M / F = 1/50). This rate drops to M / F = 1/2 towards 65 years of age. Increased frequency of infection with age; The incidence of concomitant systemic disease (DM, CRF, KC Parenchyma Disease, etc.) is proportional to the increase in the rate of stay in hospital and chronically care homes and age. The prevalence in adult males is about 0.1%. Bacteriuria is seen in 10% of males (over 65 years) and 20% in females. The increase in UTI with age in men is due to infravezical obstruction (BPH) and the decrease in antibacterial activity in prostate.

The factor that makes URI a female disease is the anatomical structure of the urethra. The female urethra is short (4 cm). Therefore, it is easier for bacteria to enter the bladder. Furthermore, the urethra close to the vagina during the reproductive period leaves the urethra open to trauma, especially during sexual intercourse and delivery. Therefore, non-complicated UTIs are closely related to sexual activity and birth in women. The fact that UTI is rare in  nuns and honeymoon cystitis seen in the period when sexual activity starts in young women after marriage can be shown as examples.

In studies conducted in women aged 15-50 years in various countries, 4-6% of these women have been shown to have significant bacteriuria at any time. This shows that most women spend at least once in their lives. About half of the cases with significant bacteriuria are symptomatic.

Complicated UTIs are the result of functional and / or anatomical anomalies of the urinary system and any diagnostic and therapeutic intervention related to the urinary system. These infections occur in almost equal proportions in men and women. Risk factors ; Obstructive uropathy, VUR, voiding dysfunction, congenital anomalies, urological instrumentation, previous urological surgery and so on. The risk of infection is high in hospitalized patients. Pregnancy is an important factor. UTI is more common in low socio-economic situations. The number of births increases the frequency of UTIs.

Current Classification and Treatment Approaches in Urinary Tract Infections
1) Acute noncomplexed UTI

2) Acute noncomplexed pyelonephritis,

3) Acute complicated pyelonephritis

4) Special forms

– primary urethritis (often sexually transmitted)

– prostatitis

– epididymitis and orchitis

Acute noncomplicated urinary tract infection (acute cystitis):
It is mostly seen in women and it is followed by dysuria, pollakiuria, pyuria, and bacteriuria. 20-30% of women experience one or more episodes of dysuria per year and most of them refer to UTI. Patients with recurrent urinary tract infections may have extrinsic risk factors, such as increased tendency to adhesion and high prevalence of vaginal colonization, and / or intrinsic risk factors, in particular spermicide and diaphragm use. There is a correlation between sexual activity in some women and acute cystitis that starts within 24-48 hours.

Women with recurrent UTI were not thought to secrete specific blood group antigens. However, 80-90% of recurrent infections are in the form of reinfection from the perineal flora rather than relapse. Acute noncomplicated cystitis can be very uncomfortable for the patient as a result of the rapid and sometimes unexpected onset and affect of normal social life due to pollakuria and dysuria.

The aim of treatment in acute cystitis is the rapid prophylaxis of symptoms, reduction of morbidity and effective prophylaxis of frequent recurrences.

Previous studies have shown that short-term treatments with a single dose or up to 3 days are sufficient and no further lengthening is necessary. The advantages of such an application include good patient compliance, low cost, fewer side effects, and reduction of colonization, which may lead to the development of resistant strains in the periurethral, ​​rectal and vaginal flora. Only patients with short-term treatment failures may be considered to be required to undergo further urological evaluation.

Which patients should be offered prophylactic treatment?
Prophylactic treatment should be recommended to the patient at 6 months or more than 2 months or more than 3 times a year.

There are 3 options in antibacterial prophylaxis:

a) Continuous daily low-dose therapy with a suitable antibacterial agent, for example nitrafurantoin 50 mg, TMP 50 mg, co-trimaxazole 40-200 mg, a flurochinolone or an oral cephalosporin such as cephalexin 250 mg for pregnant or lactating women
b) In cases where recurrent UTI episodes are associated with sexual activity, the post-coital dose may be appropriate.
c) In the presence of rarely observed recurrent UTI, some patients prefer to start treatment as soon as clinical symptoms occur. In this case, it is recommended to show bacterial elimination in the urine sample a week after the treatment.
In postmenopausal women, periurethral and intravaginal hormonal support with estrogen cream (0.5 mg / g) twice a week for 2 weeks and for 8 months every 2 weeks may significantly reduce the frequency of recurrences and should be recommended before the antibacterial prophylaxis.

2) Acute noncomplexed pyelonephritis:
In cases of acute pyelonephritis diagnosed with fever, side pain, pyuria, bacteriuria and / or lower urinary tract symptoms, effective antibacterial treatment should be started as early as possible, especially in children and adolescents to prevent renal parenchymal damage and renal scar development. In order to classify acute pyelonephritis as noncomplicated, functional or anatomical anomalies in the urinary tract should be excluded by USG or other appropriate methods. In particular, antibiotics that are effective against E-coli, the most common cause of acute noncompacted pyelonephritis, are used parenterally or orally according to the patient’s condition (nausea, vomiting, etc.). In this case, Aminopenicillins may be appropriate in combination with either the 2nd or 3rd generation Cephalosporins, Aminoglycosides, Fluoroquinolones or Beta lactamase inhibitors. If the initial treatment is parenteral, oral treatment should be started as soon as possible.

Generally, cures of 5-10-14 days are sufficient. CRP, guidelines for the duration of treatment can be accepted. Usually pyelonephritis is diffuse. In this case, a quick response to antibacterial treatment can be expected.

If focal pyelonephritis or abscess development is indicated by CT or MG 3 scintigraphy, longer-term treatment may be required in this case extending to 4-6-8 weeks. Otherwise, frequent recurrences may occur with a short interval.

3) Complicated urinary tract infections:
Urinary incontinence; The presence of anatomical or functional anomalies in the urinary system, renal parenchymal disease, or other diseases that prepare the underlying UTI is classified as complicated UTI. The aim of treatment of complicated UTIs is to provide normal urodynamic and renal functions as soon as possible in addition to effective antibacterial treatment. This is important in preventing the development of urosepsis as well as prevention of recurrences. There is a much wider range of bacterial agents than noncomplexed cystitis or pyelonephritis, which require hospitalization or complicated UTI. Other enterobacteria, Pseudomonas spp, Enterococci and Staphylococci play an important role besides e-coli. However, the bacterial spectrum can vary from hospital to hospital and from day to day.

Special Forms:
Urethritis 
Pathogens include N.gonorea, Chlamydia trachomatis, Mycoplasma genitalis and Trichomonas vaginalis. Primary urethritis should be distinguished from secondary urethritis, including uropathogens and staflococci, which may occur in cases of catheterization or urethral stricture. In addition to the infectious causes, chemical and mechanical causes should be considered. From a therapeutic and clinical point of view, gonorrhea urethritis should be distinguished from nonspecific urethra. The frequency of different strains depends mainly on the population studied. In males, trichomonas is characterized by relatively mild symptoms. The antibiotics that can be used in the treatment of gonorrhea include: Ciprofloxacin (500 mg single dose); ofloxosin (400 mg single dose); ceftriaxone (250 mg im, single dose). Gonorrhea is often associated with chlamydial infection and may need to be added in anticlamydial therapy.

Doxycycline and azithromycin are equally effective in the treatment of chlamydial infections. The price of doxycycline is more reasonable and requires compliance with the treatment. Azithromycin can be administered rapidly in a controlled manner. Erythromycin is less effective and causes more side effects. Ofloxacin is more expensive than the first preferred drugs. If the treatment fails, T. vaginalis or mycoplasma infections should be considered, and they can be treated with a combination of metronidazole (single dose 2 mg) and erythromycin (7 g daily 4 times 500 mg oral). As with other sexually transmitted diseases, it is absolutely necessary to treat the partner to prevent reinfection. Patients with urethritis should stay away from sexual intercourse during treatment and as long as the symptoms persist.

 

Prostatitis
Prostatitis syndrome is one of the most difficult cases of urology for diagnosis and treatment. There are reports in the literature that 35-50% of all men are exposed to this situation at some point in their lives. The American National Health Organization (MH) has started international initiatives due to the lack of information on the epidemiology, pathophysiology, diagnosis and treatment of prostatitis. A new classification has been proposed to provide uniform definitions of various types of prostatitis to facilitate joint work in the first plan. The NIH / NIDDK (National Association for Diabetes, Digestive and Kidney Disease) presented the classification shown below in 1995 and rearranged it in 1998. According to this:

Category 1 – Acute bacterial prostatitis
Category 2 – Chronic bacterial prostatitis
Category 3 – Chronic pelvic pain syndrome (CPPS)
3A -CPPS.Inflammatory

3B -CPPS.Non-inflammatory

Category 4 – Asymptomatic inflammatory prostatitis

Prostate treatment is, of course, correct and well categorized.

 

Epididymitis and Orchitis
Epididymitis is the inflammation of the epididymis that causes pain and swelling. It is almost always unilateral and its beginning is relatively acute. In many cases, the inflammatory process holds the testicle and takes the name epididymo-orchitis. On the other hand, the inflammatory process of the testis, especially the orchids of viral origin, may also hold the epididymis. The inflammatory processes of the testis and the epididymis should be classified as acute and chronic according to the onset. In the case of testicular involvement, chronic inflammation can result in testicular atrophy and destruction of spermatogenesis. Epididymoorchitis complications, abscess formation, testicular infarction, testicular atrophy, chronic epididymal induration development and infertility can be counted.

Epididymides caused by sexually transmitted microorganisms are mostly seen in sexually active males under the age of 35 years. Most of the cases of epididymitis are usually related to common urinary pathogens and the most common cause of acute epididymitis are microorganisms which cause bacteriuria. Bladder outlet obstruction and urogenital malformations are risk factors for such infections.

Typically, epididymitis due to common bacteria and sexually transmitted microorganisms occurs when the infection spreads from the urethra or bladder. Orchitis and measles orchids in children are of hematogenous origin. Typical systemic diseases are tuberculosis, brucellosis, cryptococcal diseases.

For the physician, the differential diagnosis between epididymitis and spermatic cord torsion is urgently required, and all findings such as age of patient, urethritis, clinical findings and evaluation of testicular blood flow with doppler should be used.

In sexually active young men, chlamydia trachomatis and BPH or other menstrual disorders in older males, mostly uropathogens as etiological agents, empirical treatment should be chosen accordingly. Studies comparing the epididymis puncture, urethral samples and the microbiological results of urine samples show a very good correlation. Therefore, prior to antibiotic therapy, urethral specimen and medium flow idioms should be taken for microbiological research. Again, preferably fluoroquinolones such as ofloxacin, levofloxacin and gatifloxacin, which are active against C.trachomatis, should be the first choice drugs due to their wide antibacterial spectra and their favorable penetration into the tissues of the urogenital system.

In cases where C.trachomatis is detected as an etiologic agent, the treatment should be continued with at least two weeks of 200 mg doxycycline. In this case, macrolides can also be alternative agents. Supportive treatment includes bed rest, testicular elevation and cold application. Since epididymitis in young men may lead to permanent occlusion of the epididymal canal and ultimately lead to infertility, it is preferred to start with 40 mg methyl prednisolone in antiphlogistic treatment and to reduce the half-dose every two days.

C.trachomatis epididymitis should also be treated in sexual partners. When uropathogens are found as causative agents, investigations should be made about micturition disorders and corrected to prevent relapse. abscess abscess formation in epididymitis and orchitis should be treated surgically. It should also be noted that chronic epididymitis may sometimes be the first clinical manifestation of urogenital tuberculosis.