泌尿生殖道感染1ppt課件

1、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 1Definition

2、s 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 bacter

3、ia. 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

4、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 InfectionRecu

5、rrent 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

6、 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 pyelonephritisEmphysemat

7、ous 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 depe

8、nds 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 urineSur

9、face 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 leukocyte

10、s/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

11、 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 infectio

12、n. 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, vom

13、iting, 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 Pyu

14、ria, 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 diseas

15、eand 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 ch

16、ronic bacterial prostatitis,(2) nonbacterial prostatitis(3) prostatodynia. NIDDK categorization and Drach classificationNIDDK Classification(2019)Drach classification (1978)Category 1 Acute bacterial prostatitis Acute bacterial prostatitis Category 2 Chronic bacterial prostatitis Chronic bacterial p

17、rostatitis 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 (

18、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 fea

19、tures 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

20、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 m

21、easures 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 or

22、ganismsThe 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 symptomsClinic

23、al 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鑒別診斷II型和III型應(yīng)與能夠?qū)е鹿桥鑵^(qū)域疼痛和排尿異常的疾病進(jìn)展鑒別診斷間質(zhì)性膀胱炎、睪丸附睪和精索疾病、肛門直腸疾病

24、、腰椎疾病BPH、膀胱過度活動(dòng)癥、神經(jīng)原性膀胱膀胱腫瘤、前列腺癌治療原那么慢性前列腺炎無明確的進(jìn)展性，缺乏以要挾患者的生命和重要器官功能，并非一切的前列腺炎均需治療。慢性前列腺炎的治療目的主要是緩解疼痛、改善排尿病癥和提高生活質(zhì)量，療效評(píng)價(jià)應(yīng)以病癥改善為主。前列腺炎應(yīng)采取綜合治療。治療方法治療方法 一、一、型型一旦臨床診斷或得到血、尿培育結(jié)果后，應(yīng)立刻運(yùn)一旦臨床診斷或得到血、尿培育結(jié)果后，應(yīng)立刻運(yùn)用抗生素。用抗生素。開場時(shí)可經(jīng)靜脈運(yùn)用抗生素，如：廣譜青霉素、三開場時(shí)可經(jīng)靜脈運(yùn)用抗生素，如：廣譜青霉素、三代頭孢菌素代頭孢菌素 、氨基糖甙類或氟喹諾酮等。、氨基糖甙類或氟喹諾酮等。待患者的發(fā)熱等病癥

25、改善后，改用口服藥物如氟待患者的發(fā)熱等病癥改善后，改用口服藥物如氟喹喹 諾酮等，療程至少諾酮等，療程至少4周。周。并發(fā)癥處置：并發(fā)癥處置： 伴尿潴留者伴尿潴留者細(xì)管導(dǎo)尿或膀胱穿刺造瘺。細(xì)管導(dǎo)尿或膀胱穿刺造瘺。 伴膿腫構(gòu)成者伴膿腫構(gòu)成者可采取穿刺引流、經(jīng)尿道切開可采取穿刺引流、經(jīng)尿道切開引流引流治療方法治療方法二、二、型和型和型型一普通治療一普通治療 ： 安康教育、心思和行為輔導(dǎo)有積極作安康教育、心思和行為輔導(dǎo)有積極作用。用。 慢性前列腺炎患者應(yīng)戒酒，忌辛辣刺慢性前列腺炎患者應(yīng)戒酒，忌辛辣刺激食激食 物；防止憋尿、久坐，留意保暖，加物；防止憋尿、久坐，留意保暖，加強(qiáng)體育鍛煉。強(qiáng)體育鍛煉。 熱水坐

26、浴有助于緩解疼痛病癥。熱水坐浴有助于緩解疼痛病癥。 治療方法治療方法 二、二、型和型和型型 二藥物治療二藥物治療 1抗生素抗生素 2-受體阻滯劑受體阻滯劑 3非甾體抗炎鎮(zhèn)痛藥非甾體抗炎鎮(zhèn)痛藥 4植物制劑植物制劑 5M-受體阻滯劑受體阻滯劑 6抗抑郁藥及抗焦慮藥抗抑郁藥及抗焦慮藥 7中醫(yī)中藥中醫(yī)中藥 治療方法治療方法 抗生素抗生素 型：型： 根據(jù)細(xì)菌培育結(jié)果和藥物穿透前列腺的才干選擇抗生根據(jù)細(xì)菌培育結(jié)果和藥物穿透前列腺的才干選擇抗生素。藥物穿透前列腺的才干取決于其離子化程度、素。藥物穿透前列腺的才干取決于其離子化程度、脂溶性、蛋白結(jié)合率、相對(duì)分子質(zhì)量及分子構(gòu)造等。脂溶性、蛋白結(jié)合率、相對(duì)分子質(zhì)量

27、及分子構(gòu)造等。 常用的抗生素是氟喹諾酮類藥物如環(huán)丙沙星、左氧常用的抗生素是氟喹諾酮類藥物如環(huán)丙沙星、左氧氟沙星和洛美沙星等、四環(huán)素類如米諾環(huán)素等氟沙星和洛美沙星等、四環(huán)素類如米諾環(huán)素等和磺胺類如復(fù)方新諾明。和磺胺類如復(fù)方新諾明。前列腺炎確診后，抗生素治療療程為前列腺炎確診后，抗生素治療療程為46周，周，治療方法治療方法 A型：型：抗生素治療大多為閱歷性治療。抗生素治療大多為閱歷性治療。引薦先口服氟喹諾酮或四環(huán)素等類抗生素引薦先口服氟喹諾酮或四環(huán)素等類抗生素24周，然后周，然后根據(jù)其根據(jù)其 療效反響決議能否繼續(xù)抗生素治療。療效反響決議能否繼續(xù)抗生素治療。只需當(dāng)患者的臨床病癥確有減輕時(shí)，才建議繼續(xù)

28、運(yùn)用只需當(dāng)患者的臨床病癥確有減輕時(shí)，才建議繼續(xù)運(yùn)用抗生素。引薦的總療程為抗生素。引薦的總療程為4 6周。周。部分患者能夠存在衣原體、支原體等病原體感染，部分患者能夠存在衣原體、支原體等病原體感染， 可可口服四環(huán)素類或大環(huán)內(nèi)酯類抗生素治療。口服四環(huán)素類或大環(huán)內(nèi)酯類抗生素治療。B型：不引薦運(yùn)用抗生素治療。型：不引薦運(yùn)用抗生素治療。 治療方法治療方法-受體阻滯劑受體阻滯劑 -受體阻滯劑能松弛前列腺和膀胱等部位的平滑肌而改受體阻滯劑能松弛前列腺和膀胱等部位的平滑肌而改善下尿路病癥和疼痛，為治療善下尿路病癥和疼痛，為治療型型/型前列腺炎的型前列腺炎的 根本藥物之一。根本藥物之一?？蛇x擇不同的可選擇不同的-受體阻滯劑治療。常用藥物有：阿夫唑受體阻滯劑治療。常用藥物有：阿夫唑嗪、多沙唑嗪、萘哌地爾、坦索羅辛和特拉唑嗪等。嗪、多沙唑嗪、萘哌地爾、坦索羅辛和特拉唑嗪等。-受體阻滯劑的療程至少應(yīng)在受體阻滯劑的療程至少應(yīng)在12周以上。治療中應(yīng)留意周以上。治療中應(yīng)留意該類藥物導(dǎo)致的眩暈和體位性低血壓等不良反響。該類藥物導(dǎo)致的眩暈和體位性低血壓等不良反響。a型前列腺炎單一運(yùn)用抗生素或型前列腺炎單一運(yùn)用抗生素或-受體阻滯劑療效不佳受體阻滯劑療效不佳時(shí)，可二者結(jié)合運(yùn)用，療程時(shí)，可二者結(jié)合