泌尿、男生殖系統(tǒng)感染

2023/1/31泌尿、男生殖系統(tǒng)感染GenitourinaryInfection程帆ChengFanDepart.UrologyRenminHospitalWuhanUniversity2023/1/31Genitourinarysystem2023/1/31概要GeneralPrinciples尿路感染：Urinarytractinfections(UTIs)Inflammatoryreactionofurinarytractcausedbypathogenicbacteria(病原菌)

ThemostcommonclinicalproblemsinUrology,justsecondarytorespiratoryinfection(僅次于呼吸系統(tǒng)感染)2023/1/31Mostpatients:nounderlyinganatomic,metabolicorfunctionalabnormalitiesGeneralfactors:age,sex,stateofimmunocompetence(免疫活性狀態(tài)),siteofinfection,infectiousagentsLocalfactors:bloodsupply,andthepresenceofobstruction2023/1/31分類Classification自然病程

Naturalhistory:firstinfectionandrecurrentinfection(unresolvedbacteriuria,bacterialpersistenceandreinfection)解剖部位Anatomicposition:upperandlowerurinarytractinfection2023/1/31病原微生物PathogenicorganismMostUTIsarecausedbyaerobicgram-negativerods（需氧革蘭氏陰性桿菌）Certaingram-positivecoccialsocauseUTIswithsomefrequencySomeorganismsrequiredspecialtechniquesofidentification:Chlamydiatrachomatis(衣原體),Ureaplasmaurealyticum(支原體)Gram-positiverodsandunaerobicbacteria(厭氧菌)arerarelyimplicatedinUTIs2023/1/31發(fā)病機(jī)制Pathogenesis

ofurinarytractinfections病原菌的毒力和宿主的抵抗力

Bacterialpathogenesisintheurinarytractdependsonanumberoffactors,chiefofwhicharethevirulencecharacteristicsofthebacteriathemselvesandthehost’sabilitytoprotectitselfagainstinfectionTheinterplaybetweenthese2forcesdeterminesthepathogenicpotential2023/1/31病原菌因素BacterialFactors病原菌量

Quantityofbacteriasmorethan105/ml細(xì)菌毒力

Virulence細(xì)菌生物膜

Bacterialbiofilm2023/1/31宿主抗感染能力

Host’sabilityto

protectitselfagainstinfectionNormalorganismsinurethra：對(duì)病原菌的抑制與平衡作用NormalurineandvoidingEstrone:Vaginalepithelialcellandurethralepithelialcell2023/1/31易感因素

SusceptibleFactorsLowerimmunocompetence梗阻Obstruction醫(yī)源性因素Iatrogenicfactors

2023/1/31感染途徑

Modesofbacterial

entryintourinarytract上行

Ascending血行

Hematogenousspread淋巴

Lymphatogenousspread直接蔓延

Directextension2023/1/31上行感染

Ascendinginfectionfromtheurethra最常見的感染途徑ThemostprevalentcauseofUTIs,HigherinwomenAshortenedurethraandAtendencyforrectalbacteriatocolonizetheperineum（會(huì)陰）andvaginalvestibule（陰道前庭）大腸桿菌最常見2023/1/31血行感染

Hematogenousspreadofinfectionintourinarytract機(jī)體其他部位感染病灶—入循環(huán)系統(tǒng)—泌尿系統(tǒng)MuchlesscommoninadultsButmaybeimportantinneonates（新生兒）Usually,producerenalandperirenalabscesses（膿腫）金黃色葡萄球菌最多見2023/1/31淋巴感染：Lymphatogenousspreadisprobablyveryrare

直接蔓延：Directextensionofinfectionfromneighbouringorgansmayoccurincertaincircumstance2023/1/31診斷

DiagnosisTypicalsymptoms:frequencyurgencypainanddysuriaRelyprimarilyonurinalysisandurineculture感染的定位：Localizationtechniquescansupplementinformationwhenthesourceofinfectionispresumed（治療與預(yù)防）2023/1/31尿液的收集

UrinecollectionToimprovethereliabilityofresultsMidstreamurineCatheterization（女患者多采用）Suprapubicneedleaspirationofbladder2023/1/31尿液分析

UrinalysisMicroscopicexaminationofurinesedimentoftenallowspresumptivediagnosisifUTIsLeukocytes:Threeormorefreshleukocytesperhigh-powerfieldsuggestinfectionErythrocytesMicroorganismsEpithelialcellsCrystals2023/1/31尿液培養(yǎng)

UrinecultureQuantitativeurinecultureconfirmsthepresenceofpathogenicbacteriaColonycount（急性期未應(yīng)用抗菌藥物時(shí)）morethan100000/ml-infectionLessthan10000/ml-contamination

10000-100000/ml-suspicious2023/1/31上尿路感染的定位檢查

UpperurinarytractlocalizationstudiesSymptomsUreteralcatheterEndoscopy2023/1/31影像學(xué)檢查

Imaging

Ultra-soundKUB+IVUCTTofindthesusceptiblefactors2023/1/31治療

Treatment

治療目標(biāo)OurgoalCompleteeliminationofbacterialgrowthintheurineToreleasetheirritatedvoidingsymptomsToprotecttherenalfunctionTopreventthespreadofinfectionToeliminatethesusceptiblefactors2023/1/31治療

Treatment

Appropriateantibioticsshouldbeadministeredimmediately（尿培養(yǎng)+藥敏）Moreoften,theidentificationoforganismsandsensitiveantibioticsareunknown,antimicrobialcoverageshouldbebroadened（廣譜抗生素）支持、對(duì)癥與誘因的治療AndCardiovascularsupportPulmonarysupportCorticosteroidsadministration2023/1/31上尿路感染

Infectionoftheupperurinarytract

Upperurinarytract急性腎盂腎炎

Acutepyelonephritis腎積膿

Pyonephrosis多發(fā)腎膿腫

Mutiplerenalabscess腎周圍炎

Perinephritis2023/1/31急性腎盂腎炎

AcutepyelonephritisBacterialinfectioncausingacuteinflammationoftheparenchymaandpelvisofthekidney2023/1/31病因與病理

EtiologyandpathogenesisThemostcommoncauseisaerobicgram-negativebacteriaAscentfromthelowertractisthemostcommonmechanismofinfection，其次為血行感染(G+)VesicoureteralrefluxObstructionAnatomicfactor:morecommoninfemalefortheshorterurethra2023/1/31臨床表現(xiàn)

ClinicalFeaturesIncludingFeverandchillsFlankpainFrequencyurgencysuprapubicpainanddysuria頭疼、惡性嘔吐等全身癥狀Systemicsignsofinfection2023/1/31ClinicalFeaturesUrinalysis:PyuriaHematuriaUrineculture:growthofthecausativeorganismPhysicalexamination:tendernessofthecostovertebralangleandabdominaltenderness2023/1/31診斷

Diagnosis:veryeasytoconfirmaccordingtohistory,signsandexamination鑒別診斷

Differentialdiagnosisincludes膽囊炎cholecystitis,急性闌尾炎acuteappendicitis,and急性胰腺炎

acutepancreatitis2023/1/31治療

Management抗菌藥物治療：

Inanycase,empiricantibiotictherapydirectedagainstthemostcommonpathogensshouldbestarted（7-14天）支持治療：

Inpatientswithamoretoxicappearance,hospitalizationwithbedrest,intravenousfluidsandparenteralantibioticsmayberequired誘因治療：

Itisimportanttodiagnoseandtreatcomplicatingfactorssuchasobstructionandstone2023/1/31并發(fā)癥的治療

ComplicationTreatedadequately,withoutleavingrenalscarsoranypermanentdamageProducingscarsandpermanentlydiminishrenalfunctionThemostseriouscomplicationissepticemia(敗血癥)withshockandpapillarynecrosis(腎乳頭壞死)2023/1/31腎積膿

PyonephrosisLatestageofbacterialinfectioninahydronephronic,obstructedkidney（腎積水或梗阻性腎并發(fā)感染的晚期階段）Withpyonephrosis,suppurativedestructionoftherenalparenchymaresultsinsignificantlossofrenalfunction（腎實(shí)質(zhì)遭到化膿性破壞導(dǎo)致腎喪失）病原菌多為G—桿菌2023/1/31診斷

DiagnosisSymptoms:HighfeverchillsandflankpainHistory:Calculi.UTIsandpreviousurologicsurgeryImaging:Ultra-sound,CTetal2023/1/31治療

ManagementBroad-spectrumparenteralantibiotictherapyReliefofobstructionanddrainageofpurulentmaterialNephrectomyisrecommendedtokidneywithlossoffunction2023/1/31多發(fā)腎膿腫

MutiplerenalabscessUsuallyarisingfromhematogenousspreadofbacteriaMostlystaphylococci(金黃色葡萄球菌)Predisposingfactors:infectedskinlesionsanddiabetes2023/1/31臨床表現(xiàn)

ClinicalFindings突發(fā)發(fā)熱寒戰(zhàn)：AcuteonsetoffeverchillsandflankpainIVU:aspace-occupyinglesionCT:themostdiagnostic,itcanidentifytheabscessanditsextensionandsurroundingstructures(最具有診斷意義,它可以明確膿腫及其范圍和周圍組織)2023/1/31治療

ManagementEarlyenoughintrovenousantibioticsmaybesufficientmanagement(早期足量靜脈抗生素使用)(6-8weeks)Ifnofavorableclinicalresponsesisapparentafter48hofantibiotictreatment,ultrasound-guidedaspirationanddrainageshouldbeemployedNephrectomy2023/1/31腎周圍炎

Perinephritis

腎周圍膿腫

perinephricabscessPerinephritisisthesuppurativedestructionoftheperirenaltissuePerinephricabscessesarecollectionsofpurulentmaterialwithintheperinephricspace,whichliesbetweenkidneyandGerota’sfascia2023/1/31下尿路感染

Infectionof

theLowerUrinaryTract2023/1/31急性細(xì)菌性膀胱炎

AcutebacterialcystitisAcuteuncomplicatedbacterialcystitispredominantlyaffectswomen(解剖原因）2023/1/31病因與病機(jī)

EtiologyandPathogenesisAbsenceofanatomicorfunctionalabnormalityoftheurinarytract上行感染：Ascendingfecal-perineal-urethralrouteistheprimarymodeofinfectionHoneymonthcystitisMalepatientsalmostcausedbyoutflowobstruction,endoscopeexam,etal2023/1/31臨床表現(xiàn)

ClinicalFindingsOnsetofdysuria,frequency,urgency,lowbackandsuprapubicpainPyuria(100%)Hematuria(50%infemale)Feverandotherconstitutionalsymptomsareunusual2023/1/31內(nèi)鏡檢查

EndoscopyEndoscopyisindicatedinthepresenceofgrossormicroscopichematuriathatpersistsaftertheinfectionistreated（抗感染治療后持續(xù)存在肉眼或鏡下血尿）Cystoscopyshouldbedelayeduntiltheacuteinfectionhasbeentreated2023/1/312023/1/31治療TreatmentSensitivemedicineshouldbegivenintwoweeksaftertheurineissterile敏感抗生素要在尿液分析無(wú)菌后繼續(xù)使用2周Broad-spectrumantibioticsUrinecultureandsensitivetestwhenrequired2023/1/31ChronicbacterialcystitisAcuteurethritis2023/1/31

男生殖系統(tǒng)感染

Infectionofmalegenitalsystem2023/1/31前列腺炎綜合征

Prostatitissyndrome

Approximately50%ofmenexperienceprostaticsymptomsatsometimeinlifeThemostcommonurologicdiagnosisinmenwith50yearsofageandthirdmostcommoninoldermen2023/1/31前列腺炎綜合征的傳統(tǒng)分類TraditionalclassificationtoprostatitissyndromeAcutebacterialprostatitis,ABPChronicbacterialprostatitis,CBPChronicnonbacterialprostatitis,NBPProstatodynia,PD2023/1/31NewclassificationofNIH

(NationalInstisutesofHealth)Category Name

CriteriaⅠ急性細(xì)菌性前列腺炎(ABP

) Acute,symptomaticbacterialinfectionⅡ慢性細(xì)菌性前列腺炎

(CBP) RecurrentprostateinfectionⅢ慢性前列腺炎/慢性骨盆疼痛綜合征

NoclearlyidentifiableinfectionⅢAInflammatorytype(CNP)LeukocytespresentinEPS/VB3/SemenⅢBNoinflammatorytype(CP)NoleukocytesinEPS/VB3/SemenⅣ無(wú)癥狀性前列腺炎

NosubjectivesymptomsAsymptomaticinflammatoryprostatitis(AIP)2023/1/31急性細(xì)菌性前列腺炎

AcutebacterialprostatitisEtiologyandpathogenesis

多于勞累、飲酒、性生活過(guò)頻后發(fā)生UsuallyresultsfromascendingurethralinfectionAlsohematogenous,directorvialymphogenousspreadAerobicgram-negativeorganisms(常見)2023/1/31臨床表現(xiàn)

ClinicalFeaturesCharacterizedbySuddenonsetoffever,chillLowbackandperinealpainDysuria（排尿困難）Digitalrectalexamination:Exquisitelytender,enlargedgland（觸痛、腫大、波動(dòng)感、溫度升高等）UsuallyprostatemassageisforbiddenOftenconcomitanturinaryinfection2023/1/31診斷

Diagnosis1.Symptoms2.Physicalexamination3.尿液中白細(xì)胞數(shù)量升高，血液或/和尿液中的細(xì)菌培養(yǎng)陽(yáng)性

4.Transrectalultrasound(TRUS)：腺體增大、回聲不均勻5.CT2023/1/31治療

Management全身支持治療Antibiotictherapy關(guān)鍵Durationoftherapyatleast4-6weekstoensureeradicationofinfectionBladderdrainageshouldbemanagedwithasuprapubictube,ifretentionTransurethralcatheterizationshouldbeavoided2023/1/31慢性前列腺炎

ChronicprostatitisClinicalfeaturesDysuriaaswellasurgency,frequencyandnocturiaLowbackorperinealpainordiscomfortEDSymptomsfrombeingnervoustoCP2023/1/31慢性前列腺炎的診斷方法

MethodstodiagnoseCP前列腺按摩液

EPSExpressedprostaticsecretionMorethan10LeukocytesperHPEPSorVB3culturetocomfirmCBP2023/1/31Meares-StameyTest-1968VB1:初始尿液

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