泌尿道保健-关於泌尿道感染

泌尿道保健 -關於泌尿道感染 慈濟醫院泌尿科 陳景亮 腎臟 輸尿管 膀胱 泌尿道 泌尿道感染 最常見於：生育年齡的女性，懷孕婦女、男士前列腺增大、 上廁所的習慣差劣、患有糖尿病或患有鐮刀型紅血球疾病 的人士罹患泌尿道感染的風險也較高。 嬰兒、小孩（小於六歲）和小於 50歲男性極少出現泌尿道 感染，如有則通常和泌尿道結構畸型（膀胱逆流、尿路阻 塞）有關。 下泌尿道感染（ lower urinary tract infections）和膀胱炎 的主因通常是細菌通過尿道進入，但上泌尿道感染 （ upper urinary tract infections）如腎盂腎炎則不然。上 泌尿道感染的主因可能是 血原性 （ hematogenous）的。 Definitions (定義 ) Bacteriuria(菌尿症 )- bacteria in urine Pyuria(膿尿症 )- WBCs in urine Uncomplicated- healthy patient with a structurally and functionally normal urinary tract. Complicated- obstruction, anatomic or functional disorder, calculi, instrumentation, incontinence, pregnancy. Unresolved bacteriuria- resistence, multiple organisms, rapid reinfection, azotemia, papillary necrosis, infected stones or foreign body, patient noncompliance Recurrent infection- persistence or reinfection Pathogenesis(1) Ascending infection - most common Hematogenous spread - immunocompromised and neonates - uncommon except Staphylococcus, Candida and TB Lymphatogenous spread - little evidence, iatrogenic? Direct extension - intraperitoneal abscess, vesicointestinal or V-V fistula Pathogenesis(2) Host factor - Anatomic or functional abnormalities - Secretion of IL-8 from renal cells may participate in the initiation and maintenance of renal inflammation. - Increase adherence due to more receptors - Change of pH or estrogen levels, Zn Bacterial factors - Uropathogenic E.coli(O,K,H) have pili(type1, P) and hemolysin, resistant to serum bactericidal activity Pathogenesis(3) Causative pathogens - aerobic Escherichia coli(80%), Proteus mirabilis, Klebsiella Staphylococci, Pseudomonas(nosocomial) - anaerobic bacteria (suppurative infections) Bacteroides fragilis, Clostridium perfringens Diabetes more likely caused by Klebsiella, group B streptococci S. saprophyticus causing approximately 10% of symptomatic lower UTIs in young, sexually active females 膀胱感染的症狀 尿急（ urinary urgency） 尿頻（ urinary frequency），並且在只有少量尿液時仍覺 得需要排尿（ urinate） 夜尿（ nocturia）：需要在夜間排尿。 尿道炎（ urethritis）：排尿時尿道口感到不適或疼痛，或 是整個尿道有燒灼感 排尿困難（ dysuria） 膿尿（ pyuria）：尿液含膿或尿道排膿 血尿：尿中帶血 發燒：輕微發燒 尿液臭和混濁 小便失禁（ urinary incontinence） 腎臟感染的症狀 尿液檢查可能正常 ! 腎臟感染的症狀 噁心 嘔吐 背痛 （ back pain）、 腰痛 （ flank pain）或 腹股 溝疼痛 （ groin pain） 腹痛 （ Abdominal pain） Knocking pain at CV angle Shaking chills and high spiking fever 睡覺時出汗 極度疲勞 Diagnosis Urine Collection midstream urine collection urethral catheterization suprapubic aspiration Localization study Urinalysis Pyuria- 5WBC/HPF(M), 20WBC/HPF(F) Pyuria may be present in the absence of UTI(25%) Sterile pyuria- antibiotic effect, atypical organisms, tumor, stones Dipstick tests for bacteriuria (nitrite) or pyuria (leukocyte esterase) less sensitive Urine culture- 105 CFU/ml 婦女泌尿道感染的診斷 E.Coli in urine analysis 腎膿瘍 Kidney infection Acute pyelonephritis inflammation of kidney and renal pelvis, diagnosis made clinically Presentations- chills, fever, and costovertebral angle tenderness CT scan: perfusion defects (segmental, multifocal or diffuse), renal enlargement Tx: parenteral antibiotics for 7-10 days then oral antibiotics for 10-14 days Kidney infection Chronic Pyelonephritis Repeat renal infection- renal scarring, atrophy and renal insufficiency. Refers to radiologic findings of the small, contracted, atrophic kidney, focal coarse Correct underlying problems, prophylactic antibiotics Removal if hypertension or nonfunction with stone burden Kidney infection Emphysematous Pyelonephritis acute necrotizing infection caused by gas- forming uropathogens(E.coli, Klebsiella) 80-90% have DM KUB and CT: gas presentation Poor prognosis: CRE, Platelet, renal/perirenal fluid in association with a bubble/loculated gas, gas in collecting system Tx: Drainage combination with medical treatment Kidney infection Renal Abscess Renal/ Perinephric / Paranephric abscess Most hematogenous spread before but now E.coli more common Ultrasonography: echo-free or lowecho-density space-occupying lesion CT: hypodnesity- fluid collection with rim enhancement Tx: empiric therapy plus aminoglycoside or 3rd- generation cephalosporin Percutaneous drainage is indicated if treatment failure Kidney infection Xanthogranulomatous Pyelonephritis黃色肉芽腎盂腎炎 rare, severe, chronic infection diffuse renal destruction. Lipid laden macrophages, mistaken for RCC Most unilateral, nonfunctioning, enlarged kidney associated with obstructive uropathy secondary to nephrolithiasis. CT: large heterogenous, reniform mass with central calcification Nephrectomy 居家保健 多喝水 (1600-2000ml/day)，避免憋尿， 避免食糖和含糖食品， 飲用未加糖的蔓越莓汁，服用 蔓越莓 濃縮 膠囊 (cranberry supplements), 漿果 (berry) 類食物 以及在每天最後一餐時服用 維生素 C，可縮 短感染的時間。 台灣產的漿果 台灣產的漿果很多，一般菜市場可以買得 到的有： 大漿果類 ：木瓜 、鳳梨 、奇異果 、百香 果 、番荔枝 、香蕉 等。 小漿果類 ：楊桃 、蓮霧 、番石榴 、葡萄 、 草莓 (?) 、小番茄 等。 謝謝聆聽