URINARY TRACT

INFECTIONS(UTIs)
Learning Outcomes

 By the end of the lesson the

student should be able to:
 Describe different types of
urinary tract infections
 Explain their etiology
 Describe the pathophysiology
Learning Outcomes

 Explain diagnostic procedures

 Describe their medical/surgical
managements
 Describe the nursing
management/prevention
 Explain UTIs complications
The Urinary system organs
Introduction

 Urinary tract infections occur when pathogens

colonize the urinary tract and overpower its
strong defenses
 Urinary tract infections can occur on both the
upper and lower urinary tract
 UTIs are classified as;
 Complicated or uncomplicated depending on the
patient’s related condition
Introduction
 UTI-Presence of significant
bacteriuria in presence of
symptoms at any level of urinary
tract:
 Urethra: urethritis
 Bladder: cystitis
 Renal pelvis: pyelitis
 Renal parenchyma: pyelonephritis
-
Terminology in UTI
 UNCOMPLICATED –infection of urinary
system in host without underlying renal or
neurologic disease. Occurs in healthy women
 COMPLICATED-infection in setting of
underlying structural, functional medical or
neurologic disease
 Recurrent-2 symptomatic UTI within a 12
months following clinical resolution of each
previous UTI after therapy
Terminology in UTI cont.
 Re-infection recurrent UTI caused by different
pathogens at anytime or original infection strain
13 days after therapy of original UTI
 Relapse recurrent UTI caused by same species
causing original UTI within 2weeks after therapy
Lower UTIs
 Bacterial cystitis- affecting the bladder
 Bacterial prostatitis-affecting the prostrate
 Bacterial urethritis –affecting the urethra
Upper UTIs
 Acute or chronic pyelonephritis.
 Interstitial nephritis
 Renal abscesses
 Perirenal abscess
PATHOPHYSIOLOGY
COLONISATION-
Pathogen colonizes the periuretheral area and
ascends through the urethra upwards towards the
bladder.
UROEPITHELIUM PENETRATION-
Fimbria allows bladder attachment and penetration.
Following penetration, bacteria continues to
replicate and may form biofilms.
 Pathophysiology cont…..
 ASCENSION-
After bacterial colonization, bacteria may ascend on the ureter
towards the kidney.
Fimbria may aid in ascension process.
Bacterial toxins may also play a role by inhibiting peristalsis.
PYELONEPHRITIS-
Infection of the renal parenchyma causes an inflammatory
response called pyelonephritis.
Usually as a result of bacterial ascension or hematogenous
spread
Pathophysiology cont…
 ACUTE KIDNEY INJURY-
If the inflammatory cascade continues, tubular
obstruction and damage occurs.
Interstitial edema results
Resulting to interstitial nephritis, causing acute
kidney injury
RISK FACTORS
A.Iatrogenic /drugs
 Indwelling catheter
 Antibiotic use
 spermicides
Risk factors cont…
B. Behavioral
 Voiding dysfunction
 Frequent or recent intercourse
Risk factors cont……
C. Anatomic/ physiologic
 Vesico- ureteral reflux
 Female gender
 Pregnancy
 Risk factors cont……

D. Genetic
 Familial tendencies
 Susceptible uroepithelial cells
 Properties of the vaginal mucus
CLINICAL PRESENTATION

 Dysuria
 Frequency and urgency of micturition
 Hematuria
 Suprapubic tenderness
 Chills and sweating
 Flank pain
Diagnostics
 Dipstick sample
 Urine culture & sensitivity
 Cellular studies
 CBC sample analysis
 CT scan to detect pyelonephritis/ abscess
 Ultrasound
 Trans rectal ultrasound
 Medical/surgical
management
 Trimethoprim-sulfamethoxazole
 Inhibition of microbial DNA synthesis by inhibiting the folic
acid synthesis and consequently the purines required for DNA
 Fluoroquinolones
 Inhibition of microbial DNA synthesis by blocking DNA
gyrase and topoisomerase needed for successful DNA
replication and transcription.
Medical/surgical
management
 Nitrofurantoin
 The mechanism is not fully understood, but it
directly causes selective damage to microbial
DNA, which metabolizes the toxic
intermediates of nitrofurantoin more rapidly
than human cells.
Medical/surgical
management cont….
 Monitor laboratory tests: electrolytes,
creatinine, BUN
Rational: control of renal dysfunction
- Take action to keep the urine acidic: increase
berry juice input and give medicines to
increase urine acidity.
Rational: urine acidity inhibits the growth of
germs
Increased juice input may affect the treatment
of urinary tract infections
Nursing management

 Monitor input and output characteristics of the

urine.
Rational: provides information about renal
function and presence of complications
 Determine the patient's voiding pattern
 Encourage increased fluid intake
Rationale: increased hydration will flush the
bacteria.
Nursing management
cont…..
 Observations of changes in mental status:,
behavior or level of consciousness
Rational: the accumulation of residual uremic
and electrolyte imbalance can be toxic to the
central nervous system
 Provide pain relief
 Administer prescribed medication
Nursing management
cont…..
 If bed riden, reposition the patient every two
hours
Rational: To prevent stasis of urine and pressure
sores
 Monitor input and output characteristics of the
urine
Rational: provides information about renal
function and presence of complications
Nursing management
 Provide information on: sources of infecting
pathogens, measures to prevent the spread,
explain the administration of antibiotics,
diagnostic examination: objectives, a brief
overview, preparation required prior to
inspection, examination after treatment
 Rational: Knowledge of what is expected to
reduce anxiety and help develop client adherence
to therapeutic plan.
Nursing management
cont…..
 Instruct patient to use the given drugs,
 drink as much as approximately eight glasses a
day, especially cranberry juices.
Rationale: Patients often discontinue their
medication, if the signs of the disease subsided.
 Fluids to help flush the kidneys. Pyruvic acid
from berry juice helps to maintain the state of the
urine acid and prevent bacterial growth.
Lower UTIs

Bacterial Cystitis
Bacterial prostatitis
Bacterial urethritis
 Bacterial Cystitis
 Bacteria may be introduced into the urinary system from many
sources:
 Hygiene – A common cause in women, due to females having a
shorter urethra than males and its situation close to the anus
 Catheters – During catheterization, trauma (damage) may occur to
the urethra or bladder, which may increase the risk of infection
Bacterial Cystitis cont.

 Contraceptive devices– ill-fitting diaphragms

may press against the bladder resulting in
incomplete emptying of the bladder
 Pregnancy – Pressure from the uterus may result
in incomplete emptying of the bladder, thus
encouraging bacterial growth
 Sexual intercourse may introduce bacteria to, or
cause bruising of, the urethra causing cystitis-
like symptoms
 Bacterial Cystitis cont…

 Women’s Underwear – It has been proven that wearing thongs

can bring bacteria from the anus forward to the periurethral
(bladder opening)
 Diabetes- The urine of diabetics can contain a lot of sugar,
encouraging bacteria growth
 Sexually transmitted diseases (STD) - Infections such as
chlamydia and gonorrhea can cause symptoms similar to
cystitis, particularly when they are present in young, sexually
active men
Bacterial cystitis pathophysiology
 Begins by pathogenic invasion of the epithelial
wall of the bladder, ureter or renal pelvis
 Increased levels of anti-proliferative factor,
decreases the levels of epithelial growth factor in
the urine that prevents normal epithelial healing.
 Abnormalities develop in the (GAG)
Glycosaminoglycan layer, allowing irritating
metabolites such as potassium to leak into the sub
mucosal space
 This leakage cause activation of sensory nerves,
inflammatory reaction and local damage
Bacterial prostatitis

 Prostatitis is swelling and irritation of the

prostate gland. Reffered to bacterial prostatitis
when it is caused by a pathogenic bacteria
 Acute bacterial prostatitis of rapid onset
 While chronic bacterial prostatitis lasts for more
than three months
 Ongoing irritation of the prostate that is not
caused by bacteria is called chronic nonbacterial
prostatitis
Prostatitis Pathophysiology

 E coli is the most isolated organism

 Gram negative Organisms such as klebsiela,
proteus and pseudomonas are common causative
organisms too
 E coli in bacterial prostatitis is more virulent than
the strains seen in uncomplicated urinary tract
 Infection by pathogens mostly arises from the
distal urethra
Prostate inflammation
 Risk factors

 Certain sexual practices, unprotected sex without a condom

 Having many sexual partners
 Epididymitis
 Urethritis
 Urinary tract infections
 Bladder outlet obstruction
.
Risk factors

Injury to the area between the scrotum and anus

(perineum)
 Urinary catheter, cystoscopy, or prostate biopsy
 Men age 50 or older who have an enlarged
prostate (benign prostatic hyperplasia) have a
higher risk for prostatitis.
 Bacterial urethritis

 Urethritis is inflammation of the urethra.

Bacteria that commonly cause urethritis include:
 E. coli and other bacteria present in stool
 Gonococcus, which is sexually transmitted and causes
gonorrhea.
 Chlamydia trachomatis, which is sexually transmitted and
causes chlamydia.
Urethritis Pathophysiology
 Chlamydia Trachomatis infects mucosal surfaces
and epithelial cells.
 Infection leads to an acute inflammatory reaction
with lymphocyte infiltration of mucosa and sub
mucosa.
 Local antibody response may be suppressed by
estradiol.
 Severe disease results primarily from the
immunopathological response.
 Left untreated would lead to orchitis, prostatitis,
cervicitis or urethral stricture.
Symptoms of urethritis include:

 Pain during sexual intercourse

 Discharge from the urethral opening or vagina
 In men, blood in the semen or urine
urethritis
UPPER UTIs
Interstitial nephritis

DEF;
 Interstitial nephritis is a kidney disorder in which
the tissue between the kidney tubules become
swollen (inflamed)
Pathophysiology of Interstitial
Nephritis

 Acute/ chronic interstitial nephritis are the result

of the interplay of renal cells and inflammatory
cells and their products.
 Lethal injury to renal cells leads to new chemo-
attractant cytokines.
 These cytokines are produced by inflammatory
cells and also by the renal cells.
 causes

 Allergic reaction to a drug (acute interstitial allergic

nephritis)
 Autoimmune disorders such as anti-tubular basement
membrane disease, Kawasaki’s disease, systemic lupus
erythematosus, or Wegener’s granulomatosis
 Infections
 Long-term use of medications such as non steroidal anti-
inflammatory drugs (NSAIDS).
causes

 Side effect of certain antibiotics (including

penicillin, ampicillin, methicillin, sulfonamide
medications)
 Side effect of other medications such as
furosemide, thiazide diuretics, omeprazole,
triamterene, and allopurinol
 Too little potassium in the blood(hypokalemia)
 Too much calcium or uric acid in the blood
Signs & Symptoms

 Hematuria(blood in urine)
 Fever
 Increased or decreased urine output
 Mental status changes (drowsiness, confusion,
coma)
 Nausea, vomiting
 Rash
 Swelling of the body, any area
 Weight gain (from retaining fluid)
Common tests include

 Arterial blood gas analysis

 Blood/bone chemistry
 BUN and blood creatinine levels
 Total blood count
 Kidney biopsy
 Kidney ultrasound
 Urinalysis
Treatment

 Avoid medications that lead to this condition

 Limiting salt and fluid in the diet can improve
swelling and high blood pressure.
 Limiting protein in the diet can help control the
buildup of nitrogenous waste products in the
blood (azotemia)
 If dialysis is necessary, it usually is required for
only a short time.
 Corticosteroids or stronger anti-inflammatory
medications such as cyclophosphamide can
sometimes be helpful.
Perirenal abscess

 Perirenal abscess is a pocket of pus caused by an

infection around one or both kidneys.
 CAUSES

 urinary tract infections that start in the bladder, spread to

the kidney, and then spread to the area around the kidney.
 Surgery in the urinary tract or reproductive system and a
bloodstream infection
 Kidney stones that block the flow of urine and provide a
place for an infection to grow. Bacteria tend to stick to the
stones and antibiotics can't kill the bacteria there
 Diabetes
 Having an abnormal urinary tract
 Trauma
Signs & Symptoms

 Chills
 Fever
 Pain in the flank (side of the abdomen) or
abdomen, which may extend to the groin or
down the leg
 Sweats
Exams and Tests

 Blood culture
 CT scan of the abdomen
 Ultrasound-KUB
 Urinalysis
 Urine culture/sensitivity
Treatment

 The pus can be drained through a catheter that is

placed through the skin or with surgery.
 Antibiotics ( preferably intravenous antibiotics)
Pyelonephritis

 Introduction
 Pyelonephritis is a bacterial infection of
the renal pelvis, tubules, and interstitial
matrix of one or both kidneys
 Pyelonephritis can be acute or chronic in
nature
 Acute pyelonephritis is a sudden and
severe kidney infection. It causes the
kidneys to swell and may permanently
damage them and can be life-threatening
Introduction

 When repeated or persistent attacks occur,

the kidney(s) tissue is affected and could
lead to chronic pyelonephritis. The chronic
form is rare, but it happens more often in
children or people with urinary obstructions.

 The infection may occur through

hematological spread(systemic) or as an
upward spread from the urinary bladder
Etiology/predisposing
factors
 Instrumentation of the urinary
tract
 Urinary flow obstruction
 Chronic debilitating diseases like
Diabetes mellitus
 Renal stones
 Tumors
Etiology/

 Uretero-vesical reflux
 Immunosuppression
 Indwelling catheters
 Anatomical
Types of pyelonephritis

 Acute pyelonephritis

 Chronic pyelonephritis
Causative Organisms

 Enterobacteria-Example
Escherichia coli(E. coli)
 Proteus
 Klebsiella
 Pathogens from the
hematogenous route are
staphylococcal aureus,
Salmonella, and Candida species
Acute pyelonephritis
 Pathophysiology
 Results from bacterial invasion of the
renal parenchyma through ascension
from the lower urinary tract
 In all age groups, episodes of
bacteriuria occur commonly, but most
are asymptomatic and do not lead to
infection
 The development of infection is
influenced by bacterial and host
factors
Pathophysiology cont.
 With a weak host immune system
the pathogens multiply and
create a local and systemic
inflammatory response, usually in
the renal medulla
 Slow movement of blood within
the renal medulla favors
multiplication of pathogens as it
delays the arrival of leucocytes
hence delay in phagocytosis
Pathophysiology cont.

 The renal parenchyma becomes

edematous with congested
circulation leading to acute
tubular necrosis(ATN)
 ATN may be local or diffuse
inflammation
Clinical manifestations

 Pyrexia, chills& rigors

 Flank pain at the costo-vertebral
angle
 Pyuria
 Frequency and urgency of
micturition
 Nausea and vomiting
Clinical manifestations

 Abdominal pain or low back pain

 Significant leukocytosis
 Hematuria in acute phase
 Patient may develop AKI
Diagnosis

 Urinalysis
 Urine culture and microscopy
&sensitivity
 Ultra-sound scan
 An IV pyelogram
Medical/surgical
management
 Goals of management
 To eradicate the pathogen(s)
 Relieve symptoms
 To preserve kidney function
 To prevent septicemia
 To prevent recurrence
Nursing diagnoses

 Brain storm
Management

 History taking
 Patient assessment
 Isolate the predisposing factors
 Take urine and blood samples for
culture and sensitivity to aid in
proper diagnosis and treatment
Management

 Blood sample for Total blood

count(TBC), and U, E, Cr
 Take vital signs, T, P, RR, BP,
and oxygen saturation
Management

 Administer drugs prescribed

accordingly
 Ensure client takes adequate
amounts of water
 Pain management
 Patient education and follow-up
Drugs of choice

 This should be according to

culture and sensitivity
 Aminoglycosides-gentamicin,
amikacin
 Cephalosporins
 Penicillins
Drugs of choice

 Urinary antiseptics-
Nitrofurantoin( contraindicated in
pregnancy, renal failure and neonates)
 Analgesics-Phenazopyridine(relieves
burning sensation, dysuria and urgency)
 Fluoroquinolones-Norfloxacin,
ciprofloxacin
 Monitor patient for side effects of drugs,
report, take action and document
Chronic pyelonephritis
 This is when the patient
experiences long standing
symptoms and signs of
pyelonephritis
 It may occur in patients with
predisposing urological
conditions/abnormalities(urine
flow obstruction, vesico-ureteric
reflux, or neurogenic bladder)
Chronic pyelonephritis

 An intravenous
pyelogram(IVP)will show
irregularly outlined renal pelvis
with cortical scars and typical
pathological changes
Pathophysiology

 The long standing inflammation

of the renal tissue causes scar
formation
 Pathological changes usually
begin in the interstitial space of
the medulla and papillae with
connective tissue, lymphocytes
and plasma cells completely
replacing interstitium and tubules
Pathophysiology

 There is wide spread destruction

of the nephrons with scar
formation
 Renal function is reduced and
patient may present with signs
and symptoms of CKD
Etiology& management

 Etiology and management-same

as in the acute pyelonephritis
 Drugs contraindicated and to be
avoided in renal failure
 Tetracyclines
 Nitrofurantoin
Cont.

 Potassium salts
 Cephalosporins
 Nalidixic acid
COMPLICATIONS OF UTIs

 Ureteral & urethral strictures

 Abscesses
 Fistulas
 Kidney stones
Complications of UTIs

 Kidney damage
 Bladder cancer
 Chronic kidney disease/ESRD
PREVENTION OF UTIs

 Drink plenty of water/fluids

 Empty bladder as soon as you feel the need
to urinate, rather than holding
 Encourage females to wipe from front to
back after going to the toilet
 Practice good hygiene by washing your
genitals every day, and before having sex
Prevention of UTIs

 Empty bladder after having sex( females)

 Treat constipation promptly
 Diaphragms and condoms ( used
appropriately)
THE END
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