uti and incontinence. urinary tract infections (uti) prevalence most common bacterial infection...
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UTI and incontinence
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Urinary Tract Infections (UTI)Prevalence
• Most common bacterial infection
male female
First year of life 1.5% 1%
1 to 8 2% 8%
20 to 40 1% 30%
Over 60 40% 50%
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UTI
• Upper UTI
pyelonephritis, pyonephrosis, kidney abscess
• Lower UTI
cystitis, prostatitis, epididymo-orchitis
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UTIPathogenesis
• Ascending
• Hemotogenous to kidney
• Host immunity – age, DM
• Microorganism virulence
• Prostate with antibacterial secretion
• Colonisation of vagina with uropathogens
• Bladder emptying
• Abnormal urinary tract – reflux, obstruction
• Short urethra and sexual activity in female
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UTIMicro-organism
• Gram negative bacteria
Commonest E. Coli 70 – 90%
• Gram positive
• Yeast and fungus
• Viral
• Specific infection - mycobacteria
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UTIUncomplicated and Complicated
• Uncomplicated UTI
No structural or functional disease
• Complicated UTI
With structural or functional disease
reflux, obstruction, neurological, DM
higher chance of getting renal damage, septicaemia
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UTISymptoms
• Acute cystitis
suprapubic pain, frequency, dysuria, urgency
• Acute pyelonephritis
loin pain, fever, frequency, dysuria
• Acute prostatitis
suprapubic/perineal pain, frequency, fever, dysuria, slow streeam
• Acute epididymo-orchitis
scrotal swelling and pain, fever
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UTIDiagnosis
• History & Physical Examination
• Mid-stream urine
microscopy for pyuria
male 5WBC/HPF, female 10WBC/HPF
(cell counter method
dip-stick leukocyte esterase test)
pyuria can be due to other inflammatory conditions
bladder stone, radiation, chemotherapy, autoimmune disease, interstitial cystitis
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UTIDiagnosis
• MSU
culture for bacteria
culture plate method
dip-slide method
>105/ml sensitivity of 50% and specificity of 99%
(most Urology centres reported to 103/ml)
suprapubic aspiration, urethral catheterisation - invasive
dip-stick test for nitrite for screening of bacteriuria
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UTIDiagnosis
• Abacterial pyuria
partially treated UTI
virus
other inflammatory conditions
TB
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UTITreatment
• Cystitisuncomplicated - 3 days oral drugscomplicated – 7 to 10 days drugs
• Pyelonephritis2 weeks drugsif bacteraemia – parenteral then to oral
• Prostatitis6 weeks drugs
• Epididymo-orchitis10 – 14 days drugs
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UTIInvestigations
• Uncomplicated cystitiscost-effective, most would treat patients on clinical diagnosis
• Complicated infectionto check for structural or functional abnormalitiesrenal functional testurine for asymptomatic bacteriuriaultrasound / intravenous urography /radiological
teststreatment of underlying problems
DM, obstructive causes, reflux
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Acute Pyelonephritis Vs Pyonephrosis
• Acute pyelonephritisInfection of renal parenchymaMedical infection
• Acute pyonephrosisInfection of stagnant urineSurgical infection
• Differentiation by ultrasonographymoderate to severe hydronephrosis in acute
pyonephrosis and effectively drained by percutaneous drainage
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Acute Epididymo-orchitis Vs Acute Torsion of Testis
• Testes can stand ischaemia for 6 hours
• All testes would be dead after ischaemia for 24 hour
• Acute surgical condition
• Differentiation by Doppler ultrasound
decrease vascular blood supply to torsion
emergency surgical correction
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Urinary IncontinencePrevalence
• UK
male female
15 – 44 5-7%
45 – 64 8-15%
15 – 64 3%
>65 7-10% 10-20%
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Urinary IncontinenceClassification
• Genuine stress incontinence
• Urge incontinence
• Mixed stress and urge incontinence
• Overflow incontinence
• Continuous incontinence
• (terminal dribble vs post-micturition dribble)
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Genuine Stress Incontinence
• Involuntary loss of urine during coughing, exertion
• Most common cause of incontinence in female
• Due to weakness of pelvic floor and could not support the proximal urethra inside the pelvic cavity
pregnancy, vaginal delivery, pelvic surgery, congenital
• Some may be due to weakness of external urethral sphincter
TURP, radical prostatectomy
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Urge Incontinence
• Involuntary loss of urine after sudden urge feeling
• Second commonest cause of incontinence in female
• Due to detrusor instability
idiopathic – aging, BPH
if neurological causes found, called detrusor hyperreflexia
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Overflow Incontinence
• Sporadic involuntary loss of urine
• Slow stream, frequency, palpable bladder
• Due to bladder underactivity
hypotonia, DM, drugs, pelvic mass, chronic obstruction
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Continuous Incontinence
• Continuous loss of urine
• Due to fistula
congenital ureteric fistula
after surgery or trauma
vesico-vagina fistula, uretero-vaginal fistula
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Post-micturition Dribble
• Leaking of small amount of urine up to few minutes after micturition
• Due to storing of some urine in the proximal bulbous urethra after micturition
Terminal dribble• Slow dribble at the end of micturition
• Due to bladder outflow obstruction
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History & Examination
• Micturition pattern
• Obstetrical history
• Neurological problems
• Surgery
• Drugs
• Abdominal masses, palbable bladder
• Vaginal prolapse
• Marshall test for stress incontinence
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Investigations
• MSU
• Bladder diary
• Pad test – verify and quantify leakage
• Uroflowmetry – obstructed flow
• Cystometry – detrusor instability, detrusor contraction pressure
• Urethral pressure profile
• Radiological tests
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Treatment of Genuine Stress Incontinence
• Pelvic floor exercise to strengthen the pelvic floor muscle
• Surgery to suspend the bladder neck
Due to sphincter weakness
• Sling procedure
• Injection of material at sphincter level
• Sphincter prostheses implantation
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Treatment of Urge Incontinence
• Bladder training
• Anticholinergic drugs
• Correction of underlying problems e.g. BOO
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Treatment of Overflow Incontinence
• Correction of underlying cause eg BOO
• Intermittent catheterisation
• Catheter drainage
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Treatment of Urinary Fistula
• Surgical repair of corresponding abnormalities