Unit 2 Crological Disorders

UNIT 2 CROLOGICAL DISORDERS Structure 2.0 Objectives 2.1 Introduction 22 Urinary Tract Infections 2.2.1 Pathogenesis of Urinary Tract Infections 2.2.2 Diagnosis of UTI 2.2.3 Management 2.2.4 Recurrent Urinary Tract Infection 2.3 Renal Failure 2.3.1 Aetiology of Acute Renal Failure 2.3.2'. Approach to Patient of Acute Renal Failure 2.3.3 Management of Acute Renal Failure 2.3.4 Chronic Renal Failure (CRF) 2.4 Diseases of the Prostate 2.4.1 Benign Hypertrophy of Prostate (BPH) 2.4.2 Prostatitis 2.4.3 Prostatic Abscess 2.4.4 Cancer of the Prostate 2.5 Let Us Sum Up 2.6 Key Words 2.7 Answers to Check Your Progress 2.8 Further Reading. OBJECTIVES After reading this unit, you should be able to: I diagnose and manage urinary tract infections; diagnose acute and chronic renal failure and outline principles of management; and identlfy various prostatic problem and offer appropriate therapy. 1I 2.1 INTRODUCTION I In this unit, you will be reading about acute urinary tract infection, which is a problem commonly faced by the elderly. Besides, acute and chronic renal failure, diseases of the prostate, the section acute urinary tract infection deals with collection of urine sample for tests, and the i tests that are commonly performed on the sample, various drugs used for the treatment and I how long the treatment should continue. It also deals with complicated and recurrent urinary tract infection. You will be reading about urinary incontinenence in elderly women, a major problem in the following Unit 3. The next section deals with renal failure both acute and chronic. Acute renal failure can be prevented or reversed if timelyhelp in many cases are available. You will be learning about chronic renal failure, how to manage them, when to refer them and also to decide who are fit for renal transplant. Diseases ofprostate cause mainly urinary problems besides other prostate hypertrophy and carcinoma of the prostate are described. URINARY TRACT INFECTIONS The prevalence of women to nlen with bacteriuria progressively decreases with age and 20% of women and 10% of men over 65 years of age have bacteriuria. It is more prevalent in Genitourinary and institutionalised as compared to healthy donlicilliary subjects. Probability of urinary tract Endocrinological Disorders infection increases with the number of previous infections and decreases with an inverse proportion to the elapsed time between the first and second infections. Most reinfections occur after 2 weeks and within first 5 months of an isolated urinary tract infection. The risk of bacteriuriarernains the same, treatment appears to alterthe time until recurrence. The long tern1 effects of an uncomplicated recurrent urinary tract infections are not completely known. 2.2.1 Pathogenesis of Urinary Tract Infections You may remember fiom your undergraduate classes, that urinary tract infection is tlie result of imbalance between host resistance and virulence of bacteria. The infection is most frequently caused by gram negative enterobacteriae group of organisms. E. coli is the most common cause accounting for 85% of comnlunity acquired and 50% of hospital acquired infections. Other bacteria are Proteus, Klebsiella, E. faecalis and staphylococcus. Ascending infections is most common and most bacteria enter tl~eurinary tract from the faecal reservoir via urethra into the bladder. In 50% of instances of bladder infections there is further extension of infection into the upper urinary tract. This is greatly increased if bacteria have special adhesion (pilli) that interfere with nom~alureteral peristalsis and uretheral obstruction. An uncommon route is haemotogenous route where staphylococcus, aureus from oral sites and candida reach urinary tract through bacterimia. Direct extension of bacteria through lymphatics nlay occur from adjacent organs such as severe bowel obstruction or retroperitoneal abscesses. Factors which increase incidence of urinary tract infectioils are: lminunocompromised hosts (AIDS, Post renal transplantation, Lymphomas), Coexistent diseases such as malignancies and diabetes mellitus, Trauma. Imnlunosupressant drugs (glucocorticoids, cytotoxic drugs) foreign body, malnutrition and congenital diseases impairing phagocytic capacity of neutrophils. 2.2.2 Diagnosis of UTI Diagnosis of UTI is done on the basis of clinical history and urine analysis. a) Clinical Diagnosis You may already be aware of the symptoms of acute UTI. Urinary infection produces symptoms such as frequency of micturition, incontinence both urge and stress can clearly be caused by UTI. There may be haeinaturia. Lower abdominal tenderness on bimanual exmination in the bladder area may be present in lower UTI whereas fever, continuous pain in lumbar area or flanks indicate upper urinary infection. b) Laboratory Diagnosis Urine examination is routinely done to diagnose UTI. Collection of Urine You may recollect the method of collection of urine from your earlier student days. Patient is asked to self collect midurinary stream sample ofuriile in a clean sterile bottlc after cleaniilg the meatus in males. In females spread the labia, clean the vulva1 area from front to back with soap and tap water and dry with clean gauze. Don't use any antiseptic solutions as it may interfere with growth of bacteria if specimen is sent for culture. After initial few cc of urine, froin the midstream sample is collected in the bottle. The mouth of both should not touch any part of labia. The sample of urine is examined microscopically and sent for culture and sensitivity. Urine Anulysis i) hficroscopy of Urine A clean catch mid stream first morning urine is collected as described earlier and isexanlined within one hour of collection. a Put one drop of urine on a clean slide, and place a coverslip over it. Look for pus cells Urologicnl Disorders under high power. If more than 6-7, pus cells are foundMPF, UTI is very likely. a About 10-15 ml of urine sl~ouldbe centrifuged for 5 min. at 3000 revolutions/inin. The supernatant is then poured off and the sediments is resuspended in the centrifuge tube. A small amount of fluid from tube is placed on microscopic slide and covered with cover slip. The slide is examined both under low power ( XI 00) and high power ( X400). The bacterial count should be approximately 30,000 ml before bacteria can be found in the sediments, stained or unstained. Therefore, negative urinanalysis never exclude the presence ofbacteria in numbers of 30,000 or less. Pyriuria and bacteriuria are commonly seen together. Bacteriuriawithout pyriuria is seen in asypmptomaticbacteriuria Pyuria without bacteriuria is more common and seen in tuberculosis of urinary tract, infection with chlamydia, or chemical cystitis. ii) Urine Culture Urine must be refrigerated immediately upon collection and should be cultured within 24 hours of refrigeration. The colony counts are done count of more than 1V are considered significant. However, this magic number need not be adhered in case of dysuric females. Cultures showing polymicrobial infection indicates contamination and needs to be repeated unless the patient is on in dwelling catheter, stones or tumour etc. 2.2.3 Management You must know about the common drugs used in acute UTI. The common antimicrobial used with their mechanism of action are shown in Table 2.1. Table 2.1: Antimicrobials for Management of UTI with their Mechanisms of Actions Drug or Drug Class Mechanism of action Mechanism of raisbecc Beta-lactam (Pencillin Inhibit bacterial cell wall Alteration in binding sites cephal osporins) synthesis Production of beta Mamate Aminoglycosides Inhibition of ribosomal protein Down reguiltion of uptakc synthesis. Bacterial production of modifying enzyme. Quinolones Inhibition of bacterial DNA Mutation of gyrase- binding gYraee sites. Nitrofurantoin Inhibition of several bacterial Change in cell wall protein enzyme eysteme size (decrease pnkration) Not fully understood Trimethoprim- Antagonism of bacterial folate Draws folate from sulfamcthoxazole metnboliem environment, multiple levels Inhibit bactedal cell wall by production of diffcnnt eyntheeis. phenotype of protein. Principles of antiinicrobial therapy are: e The treatment inust result in urine showing no bacterial growth. The concentration of antimicrobial sl~ouldbe highest in urine. e The choice of antimicrobial should be dictated by whether the infection is complicated or uncomplicated and spectrum of activity of antibiotic including its toxic effects. e A histoty of hypersensitivity, renal and hepatic functions should always be elicited before starting therapy. Durntlon of Therapy This depends on the extent and duration of tissue invasion, achievable concentration of antimicrobial in wine and risk factors that impair the host and natural defence mechanisms. The peral guidelines are outline in Table 2.2. - Genitourinary and Table General Guidelines for Duration Antimicrobial Therapy Endocrinological Disorders Uncomplicated urinary tract infection 3 days treatment Acute cystitis 3 days treatment Acute cystitis with persistence of symptoms 7 days treatment Age > 65 years 7 days treatment Diabetes mellitus 7 days treatment Acute uncomplicated pyelonephritis 10-14 days Undved or complicated infections 10-21 days Route of Administration There is no evidence that parenteral antibiotics are more effective than oral except in cases of very sick patients or intolerance to oral medications. Whenever patient can tolerate, oral medications should be started. Follow up ofpatient Following Treatment with Urinary Tract Infections

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