The Several Lower Urinary Tract Infections And Management Of Urinary Infections In General
Urinary Tract Infections In Their Forms
The commonest lower urinary tract infections are: Acute bacterial cystitis, bacterial urethritis, acute bacterial prostatitis and Pyelonephritis.
Acute bacterial cystitis: This leads to urinary frequency, urgency, dysuria, nocturia, suprapublic discomfort and often low back pain. Fever and chills may occur. Hematuria, pyuria, and bacteriuria may be present. However, casts are generally absent.
Bactgerial urethritis: This causes burning pain on micturition with or without increased frequency, Gonococcus is the common organism causing urethritis during the sexually active period of life. Other organisms such as Chlamydia trachomatis and Ureaplasma urealyticum may also be encountered.
Acute bacterial prostatitis: This is characterized by sudden onset of high fever, pain over the low back and perineum, frequency, dysuria and arthralgia. Digital examination of the rectum reveals the exquisitely tender, swollen prostate. Acutely inflamed prostate should not be manipulated without starting the patient on antibiotics. Bacterial prostatitis is often associated with cystitis and urethritis.
The management of lower urinary infection depends upon its site and severity. Uncomplicated cystitis requires treatment with an appropriate bactericidal antibiotic for 10 days. Trimethoprim-sulphamethoxazole, ampicillin or nitrofurantoin can be used. The organisms producing non-gonococcal urethritis namely Chlamydia trachomatis and ureaplasma urealyticum respond to tetracyclines given for 5-10 days. Infections of the prostate may require treatment for up to 30 days.
Systemic manifestations of infection like fever, chills, back pain and arthralgia are the presenting features. The abdominal pain may resemble that of appendicitis or cholecystitis in some cases. Physical examination may reveal renal tenderness. In severe cases, hypotension and shock may develop. In children, fever, vomiting, abdominal pain and tenderness, nocturnal enuresis or failure to grow normally may be the presenting features. Urine may be turbid or blood stained. Microscopic examination reveals numerous pus cells, erythrocytes, leukocyte casts, and clumps of bacteria. The reaction of the urine depends on the infecting organism. Varying degrees of proteinuria may be present. Renal function is not impaired. Neutrophil leukocytosis is common.
Course and prognosis: In uncomplicated cases, the symptoms subside gradually but the bacteriuria may persist. Rarely acute pyelonephritis may progress to renal or perinephric abscess or septicemia and shock. In severe cases, especially diabetics, renal papillary necrosis and acute renal failure may develop once the urinary tract gets infected, there is a great tendency for recurrence and chronicity. Recurrent infection is more frequent in the presence of structural abnormalities, foreign bodies, and stasis. Chemical abnormalities of the urine as in diabetes mellitus or nephrotic syndrome also predispose recurrent infection. Persistence of infection leads to chronic pyelonephritis.
Chronic Pyelonephritis: This may follow incompletely treated acute pyelonephritis, especially when any of the predisposing causes is present. After several episodes of recurrent infections, features of chronic pyelonephritis is characterized by impairment of renal function (especially tubular defects) polyuria, nocturia, hypertension, bone pains due to renal osteodystrophy and symptoms of uraemia.
Management of Urinary Infections
General measures include the administration of adequate fluid and alteration of the pH of urine. Administration of sodium bicarbonate 4g or sodium citrate 2g, every 6 hours, which helps to alkanise the urine. Oral administration of ammonium chloride (2g/6 hours) or with vitamin C (500 mg/6hours) makes the urine acidic. Changing the reaction of urine gives immediate relief to dysuria. In uncomplicated infections, trimethoprim-sulphamethoxazole, ampicillin, nitrofurantoin, nalidixic acid or tetracycline may be given for ten to fourteen days. Trimethoprim-sulphamethoxazole acts better in alkaline pH. Alkalinisation also reduce the chances for drug crystal formation. The choice of antibiotic is based on the sensitivity of the organisms in in vitro tests. Cases with complications or severe infections may require more powerful antibiotic combinations including the aminoglycosides like gentamicin, tobramycin or amikacin. Gentamicin and tobramycin are similar in effectiveness. The former is more active against Serratia whereas the latter is more effective against most strains of Pseudomonas. These drugs are given in a dose of 3-5 mg/Kg/day. Amikacin which is a semi-synthetic derivative of kanamycin (15 mg/Kg/day) is active against Pseudomonas aeruginosa and other gram-negative organisms generally resistant to other aminoglycosides. Other drugs like cephalexin or carbenicillin may be required exceptionally.
In children and adults, who experience frequent symptomatic recurrence of urinary tract infection, long-term low dose chemo-prophylaxis may be continued after treating the intial infection with full course of antibiotics. The drugs used are cotrimoxazole half table daily at bed time (40 mg trimethoprim and 200 mg sulphamethoxazole), mandelamin (0.5g) with ascorbic acid 0.5g four times daily, nitrofurantoin 50- 100 mg daily at bed time or sulfisoxazole 500 mg at bed time daily. This chemoprophylaxis is continued for 6 months to 2 years.
When urinary tract infection does not respond to a full course of correctly chose antibiotics, full investigation of the urinary tract should be undertaken to exclude structural abnormalities. Predisposing metabolic disorders should also be looed for and treated. Early detection and correction of these factors goes a long way in preventing one of the more common causes of chronic renal failure in later life.
© 2014 Funom Theophilus Makama