泌尿生殖道感染课件

Infection of the Genitourinary TractHongshu MaDepartment of UrologyTianjin 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 anyor all of the others.Definitions 1Definitions 1 Urinary 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.Definitions 2Definitions 2Definitions 3Definitions 3Bacteriuria 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 4Definitions 4Pyuria is the presence of white blood cells in the urine Bacteriuria without pyuria indicates bacterial colonization rather than infection.Pyuria without bacteriuria warrants evaluation for tuberculosis,stone,or cancer.ClassificationAccording to their nature history First infections/Isolated InfectionRecurrent infections Bacterial persistence ReinfectionsReinfection 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 focus within the urinary tract,such as an infection stone or the prostate.According to Their Site of OriginUpper urinary tract infection Lower urinary tract infectionGenital system infectionUpper-tract infectionAcute pyelonephritisChronic pyelonephritisEmphysematous pyelonephritisRenal abscess Perinephric abscessXanthogranulomatous pyelonephritisLower-tract infectionAcute urethral syndrome(Women)Acute cystitis Genital infectionAcute and chronic bacterial prostatitis.Acute and chronic epididymitis.PathogenesisBacterial pathogenesis in the urinary tract depends on a number of facters,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 factorsEmptying of urineSurface mucins Urinary antibodiesUrinary osmolalitypHRoutes of infection(1)Ascending infection(2)Hematogenous spread(3)Lymphatogenous spread(4)Direct extension DIAGNOSISUrine CollectionSuprapubic AspirationUrethral CatheterizationSegment Voided Urine SpecimensUrinlysis More than 3 fresh leukocytes/High-power fieldQuantitative 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 signsLaboratory findingsX-Ray findingsRadionuclide imagingMRI findings Treatment strategy.Antimicrobial drug Mdication for pain,fever,and nausea.To give fluids intravenously and orally Complicating factors(eg.Obstructive urography or infected stones)Acute PyelonephritisDefinitionsDefinitionsAcute pyelonephritis is defined as inflammation of the parenchyma and the pelvis of the kidney causing by bacterial infection.Etiology&PathogenesisAerobic gram-negative bacteria E coli Gram-negative entric organisms Enterococci,and staphylococcus aureusAscending infection (VUR)HematogenousClinical findings 1An abrupt onset of chill,moderate to high fever Dysuria,frenquency,urgency.Abdominal pain,nausea,vomiting,and even diarrhea.Clinical findings 2Costovertebral angle tendernessPalpation or percussion over the costovertebral angle on the affected kidney usually causes pain.The patient sometimes has abdominal distention,tenderness,and a quiet intestineDignosis 1Laboratory findings:Leukocytosis Pyuria,Bacteriuria,Proteinuria,HematuriaQuantitative urine culture Total renal function Dignosis 2Imaging:Plain film Excretory urograms .Voiding cystogram CT Ultrasonography RadionuclideDifferential DiagnosisPancreatitis Basal pneumonia Acute-intra-abdominal disease Women pelvic inflammatory diseaseand acute prostatitis Renal abscess Perinephric abcess.Treatment 1 Antimicrobial drugs:The appropriate intravenous treatment Oral drug Repeat urine cultures Treatment 2Specific measures:Any complicating factors(eg.obstructive urography)ProstatitisTypes of protatitisDrach(1978)(1)acute and chronic bacterial prostatitis,(2)nonbacterial prostatitis(3)prostatodynia.NIDDK categorization and Drach classificationNIDDK Classification(1995)Drach classification(1978)Category 1 Acute bacterial prostatitis Acute bacterial prostatitis Category 2 Chronic bacterial prostatitis Chronic bacterial prostatitis Category 3 Chronic pelvic pain syndrom 3a Inflammatory typeNonbacterial prostatitis 3b Noninflammatory type ProstatodyniaCategory 4 Asymptomatic inflammatory prostatitisDiagnostic techniquesThe expressed prostatic secretions(EPS)Leukocytes 10 per high-power field(hpf)The 4-glass test(Stamey 1968)Urethritis CystitisprostatitisVB1 +/-/+VB2 -+-EPS -/+(10 times than VB1)VB3 -/+Acute bacterial prostatitisEtiology&Pathogenesis E coli 80%Enterococci 5-10%Anaerobes rarely Intraprostatic reflux of urine Invasion by rectal bacteria Hematogenous spread Clinical features The sudden onset of fever,chills.Low back and perineal pain.Frenquency and urgency,nocturia,dysuriaVarying degrees of bladder outlet obstruction.Digital rectal examination(DRE)Tender,swollen prostate gland,irregularly firm and warmUrine may be cloudy and malodorous,and gross hematuria is observedDiagnosis 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 pathogensUltrasonographyTreatmentAntibiotic treatment 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 prostatitisEtiology&PathogenesisThe gram-nagative organismsThe gram-positive organismsMycoplasmal,chlamydial speciesIntraprostatic reflux of urinepH of prostatic secretionsZinc Clinical findings 1Irritative voiding dysfunction(dysuria urgency,frequency,nocturia)Low back or perineal painSexual dysfunctionMyalgia and arthralgia Other symptomsClinical findings 2DRE:normal,tenderness,swelling,firmnessSecondary epididymitis Hematouria,hematospermia,urethral dischargeDiagnosisThe 4-glass testThe expressed prostatic secretions(EPS)Leukocytes 10 per high-power field(hpf)Sonography鉴别诊断II型和III型应与可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。治疗方法治疗方法 一、一、型型一旦临床诊断或得到血、尿培养结果后，应立即应用一旦临床诊断或得到血、尿培养结果后，应立即应用抗生素。抗生素。开始时可经静脉应用抗生素，如：广谱青霉素、三代开始时可经静脉应用抗生素，如：广谱青霉素、三代头孢菌素头孢菌素、氨基糖甙类或氟喹诺酮等。、氨基糖甙类或氟喹诺酮等。待患者的发热等症状改善后，改用口服药物（如氟待患者的发热等症状改善后，改用口服药物（如氟喹喹 诺酮等），疗程至少诺酮等），疗程至少4周。周。并发症处理：并发症处理：伴尿潴留者伴尿潴留者细管导尿或膀胱穿刺造瘘。细管导尿或膀胱穿刺造瘘。伴脓肿形成者伴脓肿形成者可采取穿刺引流、经尿道切开引可采取穿刺引流、经尿道切开引流流治疗方法治疗方法二、二、型和型和型型（一）一般治疗（一）一般治疗：健康教育、心理和行为辅导有积极作用。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，忌辛辣刺激慢性前列腺炎患者应戒酒，忌辛辣刺激食食 物；避免憋尿、久坐，注意保暖，加强物；避免憋尿、久坐，注意保暖，加强体育锻炼。体育锻炼。热水坐浴有助于缓解疼痛症状。热水坐浴有助于缓解疼痛症状。治疗方法治疗方法 二、二、型和型和型型 （二）药物治疗（二）药物治疗 1抗生素抗生素 2-受体阻滞剂受体阻滞剂 3非甾体抗炎镇痛药非甾体抗炎镇痛药 4植物制剂植物制剂 5M-受体阻滞剂受体阻滞剂 6抗抑郁药及抗焦虑药抗抑郁药及抗焦虑药 7中医中药中医中药 治疗方法治疗方法 抗生素抗生素 型：型：根据细菌培养结果和药物穿透前列腺的能力选择抗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决于其离子化程度、生素。药物穿透前列腺的能力取决于其离子化程度、脂溶性、蛋白结合率、相对分子质量及分子结构等。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）、氧氟沙星和洛美沙星等）、四环素类（如米诺环素四环素类（如米诺环素等）等）和磺胺类（如复方新诺明）。和磺胺类（如复方新诺明）。前列腺炎确诊后，前列腺炎确诊后，抗生素治疗疗程为抗生素治疗疗程为46周周，治疗方法治疗方法 A型：型：抗生素治疗大多为经验性治疗。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推荐先口服氟喹诺酮或四环素等类抗生素24周，然后周，然后根据其根据其 疗效反馈决定是否继续抗生素治疗。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。推荐的总疗程为抗生素。推荐的总疗程为4 6周。周。部分患者可能存在衣原体、支原体等病原体感染，部分患者可能存在衣原体、支原体等病原体感染，可可口服四环素类或大环内酯类抗生素治疗。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。型：不推荐使用抗生素治疗。治疗方法治疗方法-受体阻滞剂受体阻滞剂-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，为治疗改善下尿路症状和疼痛，为治疗型型/型前列腺炎的型前列腺炎的 基本药物之一。基本药物之一。可选择不同的可选择不同的-受体阻滞剂治疗。常用药物有：阿夫受体阻滞剂治疗。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。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受体阻滞剂的疗程至少应在12周以上。周以上。治疗中应注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。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型前列腺炎单一使用抗生素或-受体阻滞剂疗效不受体阻滞剂疗效不佳时，可二者联合使用，疗程佳时，可二者联合使用，疗程6周以上。周以上。治疗方法治疗方法 非甾体抗炎镇痛药非甾体抗炎镇痛药 非甾体抗炎镇痛药是治疗非甾体抗炎镇痛药是治疗型前列腺炎型前列腺炎相关症状的经验性用药。其主要目的是相关症状的经验性用药。其主要目的是缓解疼痛和不适。缓解疼痛和不适。迄今为止，只有数项随机、安慰剂对照迄今为止，只有数项随机、安慰剂对照研究评价此类药物的疗效。研究评价此类药物的疗效。临床对照研究证实塞来昔布对改善临床对照研究证实塞来昔布对改善a型型前列腺炎患者的疼痛等症状有效。前列腺炎患者的疼痛等症状有效。治疗方法治疗方法 植物制剂植物制剂 为为型和型和型前列腺炎可选择的辅助治疗方型前列腺炎可选择的辅助治疗方法。法。主要指花粉类制剂与植物提取物，其药理作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。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。常用的植物制剂有：普适泰等。治疗方法治疗方法 M-受体阻滞剂受体阻滞剂 对伴有膀胱过度活动症（对伴有膀胱过度活动症（OAB）表现，）表现，如尿急、尿频和夜尿但无尿路梗阻的前如尿急、尿频和夜尿但无尿路梗阻的前列腺炎患者，可以使用列腺炎患者，可以使用M-受体阻滞剂托受体阻滞剂托特罗定治疗。特罗定治疗。治疗方法治疗方法手术治疗手术治疗 经尿道膀胱颈切开术、经尿道前列腺切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列腺相关疾病有手术适应证时选择上述手术。手术。治疗方法治疗方法IV型型一般无需治疗。一般无需治疗。患者如合并血清患者如合并血清PSA升高或不育症等，升高或不育症等，应注意鉴别诊断并进行相应治疗。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升高者应用抗生素治疗有助于前列腺癌的鉴别诊断。腺癌的鉴别诊断。TreatmentAntibiotics (at least 6 weeks)Alpha blockerPhysical therapySurgical therapy