UTI

DEFENISIDysuria is any discomfort associated with urination. Abnormally frequent urination (e.g., once
every hour or two) is termed urinary frequency. Urgency is an abrupt, strong, often overwhelming, need to
urinate.
The term dysuria is used to describe painful urination, which often signifies an infection of the lower urinary
tract. The discomfort is usually described by the patient as burning, stinging, or itching. Pain occurring at the
beginning of or during urination suggests a urethral site of disease, whereas pain after voiding implies
pathology within the bladder or prostate area. Sometimes a patient will relate a history of pain in the suprapubic
area.
IDENTIFIKASI DISURIA
In women with dysuria, the first question should be whether the discomfort is internal or external; in addition to
urinary tract inflammation or infection, vaginal inflammation can cause dysuria as urine passes by the inflamed
labia. If the sensation is internal or suprapubic, a urinary tract source is more likely; questions about associated
fever, chills, back pain, nausea, vomiting, and prior urinary tract infections should be asked in an attempt to
differentiate upper from lower urinary tract infection. If the sensation is "outside," then a vaginal etiology
should be suspected. Questions about a vaginal dischargeor itching should always be asked. Vaginitis and a
urinary tract infection often coexist, and vaginal infections in some populations are seen almost six times more
frequently than urinary tract infections. Remember that women often do not spontaneously volunteer
information about a vaginal discharge or vaginal itching. To help delineate the etiology of dysuria in the
individual patient, both a urinalysis and a pelvic examination will often be necessary.
FREKUENSI
Urinary frequency should be differentiated from polyuria, which specifically relates to the passage of an
abnormally large volume of urine in a relatively short period of time. Frequency of normal urination may vary
considerably from individual to individual depending on personality traits, bladder capacity, or drinking habits.
Because of this fact, a history of frequency is sometimes difficult to obtain. Changes in the pattern of frequency
or a history of voiding more than once at night after retiring, however, are clues to urinary pathology. Ask about
volume and voiding times, since a large bladder capacity may conceal an increase in urine production.
Frequency commonly accompanies the dysuria associated with urinary tract infections but less commonly with
vaginitis. Ask also about periodicity of symptoms because day frequency without nocturia, or frequency lasting
only a few hours at a time, suggests nervous tension or a psychiatric cause.
URGENSI
Urgency may occur with or without voiding and frequently culminates in incontinence. With severe lower
urinary tract inflammation, the desire to urinate may be constant with only a few milliliters of urine eliminated
with each voiding. Urge incontinence must be differentiated from the other types of incontinence, especially
stress incontinence. Urgency also more commonly accompanies the dysuria associated with urinary tract
infections than that associated with vaginitis.
Dysuria is related to inflammation of the lower urinary tract. Although an infection is usually the cause, other
etiologies include crystalluria, calculi in the bladder and lower ureters, tumors (both frank carcinoma and
carcinoma in situ), interstitial cystitis, trauma related to intercourse, local irritation or allergy from foreign
bodies, instrumentation, applied chemicals, and the desiccation and thinning of urethral mucosa that occurs
after the menopause in women. Significant infections without symptoms occur in between 6% and 9% of
ambulatory women and about 4% of men. Conversely, up to 23% of women and 14% of men with dysuria do
not have an infection. In certain subpopulations an increased prevalence of asymptomatic infections is seen.
Risk factors include diabetes mellitus, pregnancy, and bladder pathology such as cystoceles, diverticula, and
prostatic hypertrophy, or other conditions contributing to an increased residual volume.

The average adult bladder holds between 400 and 700 ml of urine. Normal patterns of urination may vary
considerably; adults generally void 5 to 6 times daily but no more than once after retiring. The average 24-hour
urinary output is 1200 to 1500 ml. Urinary frequency may occur because of either increased urine volume or
decreased bladder capicity (i.e., less than 200 ml).
MEK URINARY FREQUENCY
Increased urine volume can result from diuretic use, diabetes mellitus with osmotic diuresis, diabetes insipidus,
compulsive water drinking, or loss of renal concentrating ability. The latter occurs early in many types of renal
parenchymal disease including infection. There is also a diuretic response after termination of supraventricular
tachyarrhythmias and with bedrest in the setting of edema.
Decreased bladder capacity can result from anxiety, operative procedures, obstruction with resulting residual
urine and decreased functional capacity, a thickened inelastic fibrotic wall (from interstitial cystitis, irradiation,
chronic infections such as tuberculosis and schistosomiasis) or inflammatory conditions that increase bladder
sensitivity (e.g., pressure from intrinsic or extrinsic masses, calculi, or infections). Spastic neurogenic bladders
also cause a decreased bladder capacity, whereas hypotonic neurogenic bladders with chronic large residual
volumes (greater than 30 ml) mimic bladder outlet obstruction with a decreased functional capacity. Very low or
high urinary pH can rarely cause frequency. Psychiatric disturbances are not infrequently reflected with
symptoms of urinary frequency. Frequency is a common response to emotional stress.
Urinary urgency implies inflammation, often involving the trigone and posterior urethra. Stretch receptors in
the bladder and posterior urethra subserve reflexes responsible for the urge to void. The urge to urinate usually
occurs when the bladder approaches maximum capacity. Either inflammatory or neuropathic processes can lead
to increased sensitivity of these receptors. Common clinical conditions resulting in urgency include urinary
tract infections, trauma, calculi, bladder tumors (especially carcinoma in situ), foreign bodies, and all the
conditions that can lead to a decreased bladder capacity. Inflammatory edema of the mucosa, submucosa, and
even the muscularis mucosa results in loss of bladder elasticity and subsequent pain from even mild stretching
of the bladder. Urge incontinence is common in the clinical settings previously mentioned (including after a
recent prostatectomy) and must be distinguished from other forms of incontinence, such as overflow or stress
incontinence.
FLANK
Costovertebral angle tenderness is a term used to describe having pain and tenderness in a region of the lower
back adjacent to the spine. Often, medical professionals check for the presence of tenderness in this area by
tapping patients on their backs. Having pain in this area could signify the presence of diseases such as
pyelonephritis, perinephric abscesses, or kidney stones.
In order to fully understand what having costovertebral angle tenderness represents, it helps to understand some
of the basic anatomy underlying this area of the body. The ribs, which wrap around the chest, protecting
important structures such as the heart and lungs, originate in the spinal column and end in the sternum at the
front of the body. The area where the vertebral column intersects the lower ribs is known as the costovertebral
angle. It is an important area because it marks the spot where the kidneys are typically found.
Healthcare professionals often check for tenderness in this area by tapping their fists on this region of the body.
This maneuver was originated by John Benjamin Murphy, an American physician, and it is sometimes referred
to as the "kidney punch." If the maneuver elicits pain, positive costovertebral angle tenderness is said to be
present. Typically, a medical professional would check for tenderness both on the right and left sides of the
body.
Tenderness is most closely associated with the presence of pyelonephritis, an infection of the kidneys. Renal
stones, a condition also known as pyelonephritis, can also cause this type of pain. Having an infection or

abscess in the area surrounding the kidney could also cause soreness in this region. Other causes of could
include a rib fracture, rashes in the skin overlying the region, or bruising in the area secondary to previous
trauma.
One of the most important reasons to check for tenderness at the costovertebral angle is to distinguish between
pyelonephritis and urinary tract infections. Pyelonephritis, whichinvolves inflammation and infection of the
kidney itself, is often caused by the spread of bacteria from outside the body up the urinary tract through the
bladder into the kidneys. As a result, a simple urinary tract infection affecting the bladder could eventually
cause pyelonephritis if it not treated. Whereas having a urinary tract infection does not causecostovertebral
angle tenderness, pyelonephritis does. The presence of tenderness therefore helps identify sicker patients who
have developed more advanced infections and might require more aggressive treatment.
HOLDING URINE
The bladder is a muscle that is located in the pelvic region and supported by pelvic muscles. It is a muscle that
holds urine until it is expended from the body. The bladder ends in the sphincter muscles that hold the urine in
until it is manually or involuntarily expelled. The nervous system sends out signals to let us know when to
urinate and then the muscles of the bladder release to allow urine to escape.
Holding a bladder for long periods may lead to a loss of bladder control or voiding dysfunction. Voiding
dysfunction may occur in children who hold their urine too long and extend their bladder unnecessarily. In
addition, the sphincter may not respond correctly if urine is constantly held in the bladder. If the nerves that
carry messages are not firing correctly it may cause you to retain urine due to the inability of the sphincter
muscles to relax. This may cause urine retention that can lead to overflow or accumulation of bacteria.
Holding urine longer than necessary can lead to several urinary related problems, including urinary or bladder
infection and kidney disease. When urine is allowed to sit in the bladder for long periods it can develop high
levels of bacteria that may lead to these infections. A urinary tract infectionsor UTIcan lead to the more
serious bladder and kidney infections. These conditions are characterized by symptoms such as pain during
urination, persistent need to urinate, fever, chills and stomach pain.
PATHOGENESIS
Acute uncomplicated pyelonephritis most often develops as a result of an ascending UTI. In these cases,
symptoms of cystitis often precede acute pyelonephritis, particularly in patients with uncomplicated infections.
Alternatively, pathogenesis may involve haematogenous seeding of the kidneys in patients with bacteraemia.
Typically, in women who develop acute pyelonephritis, pathogens first colonise the distal urethra and vaginal
introitus and then ascend via the bladder and ureters to the kidney. Women with cystitis-like symptoms (e.g.,
burning on urinating, urgency) commonly (30%) have asymptomatic pyelonephritis, rarely causing kidney
damage.
Men are more prone to prostatitis and BPH, which cause a urethral obstruction leading to bacteriuria and
consequently often pyelonephritis. Dilation and obstruction of the ureter cause inflammation of the kidney
parenchyma, which is seen on histopathological examination as purulent exudates in the renal tubules.
Additionally, obstruction as a result of any cause (e.g., calculi, tumour, foreign body, BPH, or neurogenic
bladder) often leads to treatment failure and eventual renal abscess, as continued blockage may lead to reinfection. Chronically ill patients and those receiving immunosuppressive therapy are at highest risk. [2]
Seeding in the kidney from bone or skin may occur from metastatic staphylococcal or fungal infections as well.
UropathogenicE coli are a common cause of infection in patients with normal urinary tract anatomy. [5] The
enhanced virulence potential of uropathogenicE coli is thought to derive mainly from factors that enhance the
ability of these strains to adhere to and colonise the urinary tract. These factors include flagella, which increase
motility, haemolysins that break down RBCs, and iron-scavenging molecules that pick up the iron released
from red cell lysis to use for cell growth and adhesions on the bacterial fimbriae that help the organisms stick to

the uroepithelial surface. The proteins requied for P-fimbrial biogenesis, a mannose-resistant adhesin of
uropathogenicEscherchia coli, are encoded by the pap gene cluster codons. P fimbriae appear to play some role
in mediating adherence to uroepithelial cells in vivo and establishing an inflammatory response during renal
colonisation, thus contributing to kidney damage during acute pyelonephritis. [15] Other properties assist the
bacteria in avoiding or subverting host defences, injuring or invading host cells and tissues, and stimulating a
noxious inflammatory response. [16] Virulence of uropathogenicE coli has been linked to the presence of
pathogenicity islands, unstable large regions of the bacterial genome encoding for these virulence factors,
which are present in approximately 80% of E coli strains identified in the blood and urine of patients with acute
pyelonephritis. [17] More than 30 bacterial species carrying pathogenicity islands have been described