Unspecific infections of the

genito-urinary tract
UTI
 Definition and classification

•  UTI - defined as the inflammatory response of the urothelium

to the invasion of microorganisms, usually bacteria.
•  Bacteriuria - the presence of bacteria in the urine, confirmed
by urine culture
•  Bacteriuria+ clinical simptoms = sympthomatic UTI
•  Bacteriuria - clinical sympthoms= asympthomatic
bacteriuria
•  Uncomplicated UTI - an infection in a healthy patient with a
normal structured and functional urinary tract.
•  Complicated UTI -are associated with factors that favors
bacterial growth and decrease therapy efficiency
 Complicated UTI
- Factors that may suggest a potential complicated
UTI -
•  Presence of permanent catheters, indwelling stents
(urethral, ureteral and renal) or intermittent catheterization of
bladder.
•  post-void residual volume >100ml
•  obstructive uropathy
•  vesico-ureteral reflux or other functional abnormalities
•  urinary tract modification
•  radiation and/or chemical alteration of urothelial properties
•  UTI before and after surgery
•  Renal failure, kidney transplant, diabetes mellitus and an
altered immune system
 Classification
- relationship with other UTI -
•  Primary UTI or isolated UTI is defined as first
bacteriological documentation of a significant bacteriuria in a
person that never had a UTI
- has an infection free interval of at least 6 months between episodes.
•  Unresolved UTI implies inadequate therapy, caused by :
- treatment resistant bacteria,
- multiple organism infection and/or
- rapid reinfection
Recurrent UTI’s : >2 infections episodes within 6 month or 3
infectious episodes within 12 months
•  due to reinfection after documented and successfully treated
pathology
•  Caused by:
•  reinfection - infection by a different bacteria
•  Bacterial persistence - infection with the same microorganism from
another urinary source
 The spectrum and prevalence of
uropathogens
Uropathogens Particularities
Community-acquired flora Hospital- acquired flora
Escherichia Coli 80% 40% The most frequent uropathogen

Proteus mirabilis 6% 11% Frequently associated with lithiasis and complicated UTI’s

Klebsiella, Enterobacter, Serratia, Frequently associated with complicated UTI’s and multi-drug
< 5% 25%
Citobacter spp., Pseudomonas resistance.

Frequently associated with UTI’s in young, sexualy active

Staphylococcus saprophyticus 7% < 5%
women.

Staphylococcus aureus < 5% 16% Frequent in imunocompromised patience.

Staphylococcus epidermidis Important associations with chronica urinary cathethers users.

Transplant associated, aproximatly 8% of UTI’s lead to

Entecoccus spp.
urosepsis.

Frequently associated with antibiotic treatment and

Candida spp. < 1% 5%
imunosuppresion, systemic infections.
Pathogenic mechanism of UTI’s
 Pathogenic mechanism of UTI’s

•  Ascendant - most common path

•  through the urethra to the bladder and even to the
kidneys through the ureters;
•  Hematogenous - especially in immunocompromised
patience and newborn's.
•  Lymphatic - from the colon, rectum and uterus.
•  Direct extension from nearby organs.
•  Patients with intraperitoneal abscess , vesicointestinal
or vesicovaginal fistulas
 Functional and anatomical factors that
prevent urinary tract infections:

•  Anatomical integrity of urinary tract

•  Normal urinary function
•  Integrity of the immune system
•  Normally structured and functional urothelium
•  General resistance factors to pathogen aggression
(immune status, metabolic balance).
 Predisposing factors for UTI’s:

•  Dysfunction of local protection factors:

•  factors that obstruct urine flow
•  mechanic (stones, tumors, congenital
malformations) or
•  or functional (urinary dysfunctions such as
neurologic dysfunction or vesico-ureteral reflux)
•  low urinary output secondary to dehydration or low
water intake.
•  urothelial lesions
•  urinary tract foreign bodies(stones, catheters)
•  direct infection through therapeutic
 Predisposing factors for UTI’s:

•  General protection factors dysfunction:

•  Dysfunctional immune system, may they be acquired

or congenital (immunosuppressive treatments,
radiation therapy, AIDS).
•  Metabolic disorders (diabetes mellitus,
hyperuricemia).
•  Increased and/or aggressive bacterial load.
•  Miscellaneous causes : poor local hygiene,
uncontrolled antibiotic use.
 Laboratory findings.

•  For a correct urine analysis it is important to respect two

essential conditions:
•  Obtaining a urine sample without any exterior
contamination.
•  The sample must be analyzed before bacterial
replication
•  Urine samples must be examined in no more than 2 hours
from moment of preservation, because bacteria may
rapidly multiply and therefore they must be preserved at
4°C and must be cultured within 24 hours from
preservation.
 Laboratory findings.

•  Direct urine examination its useful when one ore more

bacteria and/or leucocytes may be observed on
microscope field.
•  Fresh Urine Exam
•  Centrifuged urine – high power microscope – 400x
Pyuria - the presence of at least 5 leucocytes/microscope
field in men and more than 20 leucocytes/ microscope
field in women
Dipstick Test (special reactive strips)
•  Urine Culture
Counting the viable bacteria in a correctly collected urine
sample represents the “gold standard” for diagnosis.
 Urine Culture

•  False-negative results
•  antibiotic therapy
•  detergents used in personal hygiene
•  diluted urine, or urinary frequency that might artificially
reduce bacterial load
•  False-positive results
•  sample contamination during urine collection
•  delay between collection and examination, witch allow
bacteria to multiply
 Significant bacteriuria
- adults -
•  ≥103 bacteria/ml in the midstream urine in women with
acute uncomplicated cystitis.
•  ≥104 bacteria/ml in the midstream urine in women with
acute uncomplicated pyelonefritis
•  ≥105 bacteria/ml in midstream urine in men or 104
bacteria/ml in midstream urine in men (or in women with
urine sample obtained through urinary catheterization)
with complicated UTI’s
•  Any kind of bacteria (the number does not matter) found
in urine samples obtained through suprapubic needle
aspiration.
 Meares – Stamey Test

Urethral bacteria Bladder bacteria Expressed prostate Bladder and prostate

secretion bacteria.

 Clinical syndromes.

•  Acute pyelonefritis

•  Chronic pyelonefritis

•  Acute cystitis

•  Prostatitis

•  Urethritis

•  Septic syndrome in urology - urosepsis

 Clinical diagnostic criteria of sepsis and
septic soc
•  Bacteriemia – presence of bacteria in blood stream;
confirmed by urine culture;
•  SIRS – infectious etiology, but may also be non-
infectious(burns, pancreatitis
Ø Systemic response is manifested by two or more of
the following:
•  Body temperature >38°C or <36°C
•  Tachycardia (HR> 90bpm)
•  Respiratory rate > 20 respirations/min hypocapnia –
< 32 PaCO2 mmHg
•  Leukocytosis(>12000/mm3), leucopenia(<4000/mm3) or
more then 10% immature cells
 Clinical diagnostic criteria of sepsis and
septic soc
•  Sepsis - activation of inflammatory process due to
infection
•  Hypotension - Systolic blood pressure <90 mmHg or a
sudden decrease in blood pressure with > 40 mmHg
from basal blood pressure
•  Severe sepsis – sepsis + organ dysfunction(renal
failure, respiratory dysfunction, metabolic acidosis),
hypoperfusion and hypotension.
•  Septic soc – Severe sepsis + hypotension and signs of
hypoperfusion, while adequate volemic resuscitation is
conducted.
•  Refractory septic soc- Septic soc that has a duration
over 1 hour and does not respond to fluid administration
and pharmacologic intervention.
 Urinary sepsis
- etiology -

•  caused by aerobe Gram – negative bacteria like E

Coli(most common), Klebsiella, Enterobacter,
Pseudomonas and Proteus

•  In patience with hospital – acquired infections and

urinary catheters are commonly found multi-drug
resistant microorganisms : P. Aeruginosa, Proteus,
Providencia and Serratia.
 SIRS
- pathophyziology -

•  Infectious agent(bacteria, bacterial wall fragment, toxins)

•  ↓
•  Target cell(monocyte, macrophage, neurophils, endothelial cells)
•  ↓
•  Immune system mediators(cytokines, free radical oxygen species,
nitric oxide, arachidonic acid breakdown products, activated
complement fractions)
•  ↓
•  Biologic effects of mediators (hemodynamic, metabolic)
•  ↓
•  Clinical effects (sepsis, septic sock, MSOF)
 Urinary sepsis
- stages -
1. Sepsis – SIRS + thrombocytopenia

2. Septic sock – Sepsis + hypotension, with alteration of

titular perfusion, manifested by :
•  Oligo-anuria – diuresis <500ml/24 hours.
•  Alteration of consciousness.
•  Increased lactic acid levels >1,6 mmol/l in normovolemic
conditions.
 Urinary sepsis
- stages -
3. Multiple system organ failure (MSOF) defined as
sepsis and failure of at least 3 systems or organs :
•  Respiratory failure (dyspnea, tachypnea, hypoxemia – adult
respiratory distress syndrome - ARDS).
•  Liver failure – jaundice – total bilirubin > 4mg/dl.
•  Acute renal failure – oliguria – urinary output<0.5 ml/kg/hour for 1
hour.
•  Hemodynamic failure – arterial hypotension, cardiac index <1,5 ml/
min/m2
•  Metabolic acidosis – pH ≤7,30 or a base deficit ≥5 mEq/l
•  Hematologic : thrombocytopenia (thrombocytes< 80000/mm3),
INR>1,5.
 Therapy algorithm in sepsis
•  Causal therapy
1. Antimicrobial therapy
2. Source control
Ø  Septic focar treatment – drainage, excision
Ø  Urinary tract desobstruction – nefrostomy, JJ
stent, UV catheter
•  Supportive therapy
1. Hemodynamic support
2. Respiratory support
•  Adjunctive therapy
1. Glucocorticoids
2. Increased insulin therapy
 Anthibiotic therapy in urinary sepsis
Suspected bacterial IV antibiotics Alternative IV Oral antibiotic
agent antibiotic
Community–acquired Enterocateriacee Ceftriaxone 1g/24hx7 Amikacinum 1g/ Levofloxacin 500mg/
infection (treatment days 24hx7days 24hx7 days
start based on Gram Or Or Or
stain) Levofloxacin 500mg/ Aztreonam 2g/8hx7 TMP-SMX 80/400mg/
24hx7 days days 12hx7 days
E. Fecalis A m p i c i l i n 2 g / 4 h x 7 M e r o n e m 1 g / 8 h x 7 Amoxicilin 1g/8hx7
Group B Streptococi days days days
Or
Levofloxacin 500mg/
24hx7
(Absence of Gram Enterocateriacee P i p e r a c i l i n / Doripenem 1g/8hx7 Levofloxacin 500mg/
staining) E. Fecalis tazobactam 3375mg/ days 24hx7
Group B Streptococi 6hx7 days
Or
Meronem 1g/8hx7
days
Urologic procedures P. Aeruginosa C i p o r o f l o x a c i n Piperacilin 4g/8hx7 Ciprofloxacin 750mg/
Enterobacter 500mg/8hx7 days days 12hx 7days
Klebsiella OR OR OR
Serratia C e f e p i m e 2 g / 8 h x 7 Aztreonam 2g/8hx7 Levofloxacin 750mg/
days days 24hx7 days.
M e r o n e m 1 g / 8 h x 7 OR
days Amikacinum 1g/
24hx7days
OR
Doripenem 1g/8hx7
Therapy: 7-10 days days
 Acute pyelonephritis
•  Definition - acute inflammation of the parenchyma, the
calyces and the renal pelvis, which subsequently leads
to renal scars
•  Etiology:
•  Most frequent pathogens are Gram-negative bacteria:
•  Escherichia coli (90%), Proteus, Pseudomonas, Klebsiella
•  Rarely Gram-positive bacteria :
•  Streptococcus faecalis and Staphilococcus saprophiticus
•  Patients with deficient immune system
•  Citobacter freundi, Serratia marcescens, Providencia
•  Most frequent –ascending mechanism
•  E. Colli produces an endotoxin which suppresses
ureteral motility → stasis → ↑retrograd pressure →
ascension and their getting through the renal medulla →
inflamation→ tubular and interstitial lesions
 Acute pyelonephritis
•  The risk factors are :
• the vesicoureteral reflux
• the obstruction of the urinary tract – congenital or acquired
• the hematogenous infection - frequently triggered by staphylococci
disseminated from a cutaneous focus or gram-negative bacteria
from the gastrointestinal tract.
• anatomical factors - more frequent in women
• Diabetes
•  The clinical symptomatology
•  classical triad: sudden fever, pain at the lumbar level and
pyuria.
•  sudden debut, with high fever (39-40°C), associated with or
preceded by chills and alteration of the general condition
•  Gastro-intestinal symptoms: anorexia, nausea and vomiting.
•  Objective examination: sensitivity of the lumbar region and flank,
pain at palpation and percussion of the rib-vertebral angle
 Acute pyelonephritis
•  Laboratory data:
•  leukocytosis with neutrophilia and deviation to the left of the
leukocyte formula
•  12-20 % positive hemoculture
•  The urinary sediment shows pyuria (> 20 leukocytes/field),
leukocyte cylinders, microscopic haematuria, proteinuria, and
bacteriuria
•  Uroculture - significant bacteriuria and identifies the microorganism
•  Imaging data:
• Renal ultrasound – growth of renal size
• Plain abdominal radiograph- nephromegaly or radiopaque calculi
• IVU - renal ↑ , pale nephrogram and narrowing of the caliceal ducts
• CT – more sensitive than the ultrasound or IVU
– alterations in the perfusion of renal parenchyma and in the
excretion of the contrast substance
– showing the size of the kidney, the attenuation of the
parenchyma, and the compression in the collector system
Acute pyelonephritis
 Acute pyelonephritis
- particular clinical forms-
•  in children – the signs and symptoms observed in adults are
frequently absent; the developed symptoms are: marked
hyperthermia, difficulties in alimentation, vomiting and alteration of
the general condition.
•  in elders – they may show typical manifestations or they may
present with fever, modification in mental status, decompensation of
another organ or system, or alteration of the general condition.
•  in diabetics – tumultuous because of glucosuria, microangiopaty
and nephrosclerosis, and it may lead to the complications of acute
pyelonephritis
•  pregnant women – encouraged by the modifications induced by
the pregnancy that lead to stasis and dilatation of the urinary tracts.
It is more frequent in the second trimester
•  in men –APN is more rare, being secondary to risk factors that need
to be identified
•  in immunodepressed patients – APN may develop severe forms.
 Acute pyelonephritis
- complications -

•  renal abscesses,

•  septic syndrome,

•  acute renal failure,

•  xanthogranulomatous pyelonephritis

•  papillary necrosis.
 Acute pyelonephritis
- treatment -
•  Patients with APN can be divided into 3 categories:
1. Uncomplicated infections that do not require
hospitalization- ambulatory treatment per os

•  Ciprofloxacin 500 mg x 2/day

•  Levofloxacin 500mg/day
•  Amoxicilină/acid clavulanic – Augmentin 1 g x 2/zi sau
•  3rd generation cephalosporines – Ceftibuten 400 mg/zi
•  therapy continues for a total of 7 to 14 days
 Acute pyelonephritis
- treatment -
2. Uncomplicated infections that require hospitalization - parenteral
therapy, in patients with normal urinary tract, but with present or severe
digestive symptomatology;
•  Ciprofloxacin 400mg/day
•  Levofloxacin 500 mg/day
•  Cefotaxim 2 g/day
•  Ceftriaxon 1-2 g/day
•  Amikacin 15mg/kgc/day
•  Gentamicin 5 mg/kgc/day
•  clinical symptoms improve after 72 hours – p.o therapy for 10-14
days
•  10 days after the end the therapy – follow-up uroculture
3. Complicated infections that require hospitalization, urological
interventions, in patients with modified urinary tract.
 Pregnant women therapy

•  Ceftriaxone 1-2 g/day,

•  Aztreonam 2-3 g/day,

•  Ampicilin 2 g/zi + Gentamicin 3-5 mg/kg/day,

•  Imipenem-Cilastatin 2g/day.

•  Therapy is administered for a period of 7 to 10 days

•  Follow-up uroculture is done 10 days after the end of

therapy
 Chronic Pyelonephritis
•  Definition - inflammation and fibrosis of renal structures (interstice, pelvis,
calyx) ← recurrent or persistent renal bacterial infections, vesicoureteral
reflux and other causes of obstruction of the urinary tract
•  slow, progressive evolution to chronic renal failure.
•  clinical picture – non-characteristic
•  Bacteriuria - usually present, urine cultures - inconstantly positive.
•  diagnosis based on imaging
•  IVU
Ø  ↓ the kidney size and of the parenchyma index ←cortical atrophy,
Ø  deformation and dilatation of calyces ← renal scars,
Ø delayed opacification of calyces ← the deficit of elimination of the
contrast substance from the duct, hypotonic pelvis or ureteral dilatation
•  Chronicization criteria - history of more than 3 months.
•  Treatment
Ø  treating the present infection
Ø preventing urinary infections
Ø monitoring and preserving the renal function
 Xanthogranulomatous Pyelonephritis
•  Definition - rare chronic renal infection, which typically leads to the
diffuse destruction of the kidney; associated with the dysfunctions that
determined its development: renal calculi and renal obstruction
•  E. Coli + Proteus
•  the macrophages full of fat (xanthogranulomas) are deposited around the
abscess, in the renal parenchyma.
•  clinical picture - fever, chills, anemia, non-colicative lumbar pain,
palpable mass in the lumbar region, bacteriuria, and pyuria
•  Imagistic
•  renal ultrasound - enlarged kidney, with non-homogenous mosaic
structure
•  IVU – a silent kidney with calculi in the collector system
•  CT - indicates the existence of renal calcifications inside the renal mass
that does not capture the contrast substance, as well as the presence of
the pus and the cellular disintegration products
•  Treatment – NEPHRECTOMY
Xanthogranulomatous Pyelonephritis
 Emphysematous Pyelonephritis

•  Definition - severe necrotizing infection of the renal parenchyma,

which leads to gasforming organisms in the renal collector system,
the renal parenchyma and/or the perirenal tissues
•  frequent in diabetics + obstruction determinated by ureteral calculi
•  the infection has a severe evolution and it can be fatal without
treatment.
•  Symptoms – comon APN+crepitations in the flank .
•  Pneumaturia – rarely, only if associated with emphysematous
cystitis.
•  Imaging investigations – presence of gas around the kidney
•  Therapy
Ø  antibiotic therapy
Ø  surgical interventions – JJ stent, nefrostomy
Ø  diabetes control
Emphysematous Pyelonephritis
 Renal Abscess
•  Definition - collection of purulent material limited to the renal
parenchyma, which may develop as a result of complicated
obstructive acute pyelonephritis or hematogenously.
•  The cortical abscess (renal carbuncle) –infection hematogenously
propagated from the distance , 90 % Staphilococcus aureus; urine –
sterile.
•  Corticomedullary abscess –ascendant dissemination of pathogen
agents, E. Coli, Proteus, Klebsiella, uroculture – pozitive, symptoms
- APN
•  Clinical signs - fever, chills, lumbar or abdominal pain.
•  Hemocultures – pozitive
•  Imaging – Ultrasound, CT – space-occupying lesion,
•  Treatment: antibiotic therapy +/- drainage (˃ 5 cm)
•  Cortical abcess : oxacilin, 100-200 mg/kg/day, vancomicin 1g iv at
12h, cefazolin 2 g iv at 12 hours or cephrom 1 g at 12 hours
•  Corticomedullary abscess : iv cephalosporines, aminoglicozides or
cephalosporines
Renal Abscess
 Pyonephrosis
•  Definition - infected hydronephrosis + destruction of the
renal parenchyma + loss of renal function

•  The main risk factor - obstructive calculus at the level of

the pyeloureteral junction or the ureter

•  Clinical symptoms – varies from asymptomatic bacteriuria

to sepsis

•  Imaging diagnosis : ultrasound, IVU, CT

•  Treatment – surgery – NEPHRECTOMY, only if the

general condition of the patient and the opposite kidney
allow the exeresis - under strong pre- and post-operative
therapy with antibiotics
Pyonephrosis
 Perinephritis and Perirenal Abscess
•  Definition: is a collection of suppurative material in the perirenal area
delimited by Gerota’s fascia
•  symptomatology develops insidiously, lasts more than 14 days
•  Local signs may be:
- signs of upper diaphragmatic irritation
- signs of peritoneal or digestive irritation, even suggesting a
dynamic front occlusion
- lumbar pain and contracture in the back area, with possible
infiltration of teguments and fistulization
- signs of irritation of the psoas muscle, with characteristic functional
impotence (flexion of the body on thigh, internal rotation of the thigh) in
the lower area.
•  Imaging: ultrasound, CT
•  Treatment: drainage under antibiotic protection ( beta-lactamaze
inhibitor + aminoglicozide)
Perirenal Abscess
 Acute bacterial cystitis– in women
• Etiology - Escherichia coli 70-95%
- Staphylococcus saprophyticus in 5-10%
•  Clinical symptoms: sudden debut; establishes diagnosis
•  includes burning upon urination
•  polakiuria
•  mictional imperiosity with evacuation of a small quantity of urine
•  pyuria
•  suprapubic pain
•  Laboratory data:
•  urine exam : pyuria, hematuria, bacteriuria, and positive nitrates.
•  Urine culture – bacterial identification + antibiogram
1000 germs/ml in the middle urinary jet= non-complicated acute
cystitis in women (according to the EAU guidelines).
Urine culture is recommended in patients with: suspicion of acute
pyelonephritis, symptoms that do not disappear or reappear 2 to 4 weeks
after treatment, and atypical symptoms.
 Acute bacterial cystitis in women
- treatment = antibiotic therapy -
•  The first infection - 3 methods of treatment:
•  unique dose, which has the disadvantage of more frequent
recidivism
•  three days treatment, with results similar to the seven days
treatment, but with less adverse effects and smaller costs
•  seven days treatment, which guarantees a smaller rate of recidivism.
Antibiotics Daily dose Therapy duration
Fosfomycin 3 g unique dose 1 day
Nitrofurantoin 50 mg every 6 h 7 days
Nitrofurantoin macrocrystal 100 mg x 2 5-7 days
Alternatives
Ciprofloxacin 250 mg x 2 3 days
Levofloxacin 250 mg 3 days
Norfloxacin 400 mg x 2 3 days
Ofloxacin 200 mg x 2 3 days
If the local resistance of the germ is known (resistance E. Coli < 20%)
Trimethoprim-Sulfamethoxazole 160/800 mg x 2 3 days
Trimethoprim 200 mg x 2 5 days

•  Recurent UTI – bacterial persistence) or by a new bacteria outside

the urinary apparatus (reinfection)
- prophylaxis – 6 months
 Urethritis
•  Definition - acute and chronic inflammations located in the
urethra
•  Clasification:
1. Gonococal urethritis (GU)- specific
2. Nongonococal urethritis (NGU)
● Bacterial
- nonspecific
- Chlamydia trachomatis, Mycoplasma hominis,
Ureaplasma urealyticum
- iatrogenic
● Parasitic: T. vaginalis
● Fungal: Candida albicans
● Viral : Herpes simplex
 Urethritis in men
•  = gonorrhea, also called blenoragy
•  Neisseria gonorrhoeae
•  35% will present also Chlamydia
•  Clinical features: secretions, dysuria, urethral burning and itching voiding
•  Sudden debute, 4-14 days after sexual contact
•  25% asymptomatic
•  Diagnosis: urethral smear, culture and DNA amplification tests ( PCR-
polymerase chain reaction)
•  polymorphonuclear leukocytes with intracellular gram-negative diplococci
•  Treatment: Ceftriaxone 250 mg i.m. – unique dose
•  In assotiation with Chlamydia
•  Azithromicin 1 g oral – unique dose or
•  Doxycyclin 2 x 100 mg/day - 7 days
•  Alternative: Erytromicin 4 x 500 mg/day -14 day
Ofloxacin 2 x 200 mg/day - 7 days
Levofloxacin 500 mg/day - 7 days
Abstain from sexual activity 7 days
 Nongonococcal urethritis (NGU).
•  Etiology - Chlamydia trachomatis, more rarely Ureaplasma
urealyticum, Mycoplasma genitalium and Trichomonas vaginalis.
•  Symptoms –similar to gonorrhea , dysuria si urethral secretion
•  Diagnosis + : urethral secretion in the absence of gonococcal infection
•  Chlamydia - include additional cultures, direct
immunofluorescence, ELISA and DNA amplification tests
•  Trichomonas vaginalis – direct microscopic examination
•  Ureaplasma urealyticum – cultivation on special media
•  Mycoplasma genitalium – PCR
•  Treatment : T. vaginalis and/or Mycoplasma
•  Combination: metronidazole (2 g oral – unique dose)
and erytromycin (500 mg oral four times/day – 7 days)
 Diffuse periurethritis or Fournier
gangrene
•  Definition - polymicrobial necrotizing fasciitis of the perineal region,
anus or genitals
•  Etiology – polymicrobial infection - average of four bacteria
•  anaerobic bacteria (Bacteroides, Clostridium, Streptococcus) +
•  aerobic (E.Coli, Streptococcus, Staphylococcus, Proteus,
Klebsiella, Enterococcus, Pseudomonas)

•  The clinical course of the disease goes through the following phases:
1. Prodromal symptoms of fever and lethargy which may be present for 2 - 7
days
2. Intense genital pain and tenderness that is commonly associated with
genital skin edema
3. Increasing genital pain and tenderness on palpation with erythematous
progression in the genital skin
4. Crepitation of the subcutaneous tissue
5. Gangrene of a portion of the genital skin, purulent drainage from lesions.
 Fournier Gangrene
- treatment principles -
1. Emergency debridation on a large area, in the first 24
hours, with excision of necrotic tissue to the healthy, possibly
with limiting incisions and leaving the wound open
2. Sampling for bacteriological examinations to identify
germs
3. Temporary urinary derivation by cystostomy, colostomy
may sometimes be necessary in case of colorectal perforation
4. Broad-spectrum antibiotics, generally associating third
generation cephalosporin + aminoglycoside (gentamicin,
amikacin) and an antibiotic effective against anaerobes
(clindamycin) initially, until the bacteriological results
5. Hyperbaric oxygen therapy is useful, if it is possible.
Fournier Gangrene
 Prostate infections
- clasification -
•  Acute bacterial prostatitis (ABP)
•  Chronic bacterial prostatitis (CBP)

•  Chronic pelvic pain syndrome (CPPS), characterized by the

absence of bacterial involvement:
•  Inflammatory (presence of leukocytes in EPS, VB3,
semen)
•  Non-inflammatory
•  Asymptomatic inflammatory prostatitis ( histological
prostatitis).
 Prostate infections
- Algorithm for the diagnosis -

•  - Clinical examination
•  - Urinary sediment and urine culture
•  - Exclusion of STDs
•  - Micturition journal, uroflowmetry and urinary residue
•  - The test of four glasses-Meares-Stamey test
•  - Microscopy and bacterial cultures of prostatic secretion,
wich can not be made in acute
•  - Trying antibiotics in the presence of inflammatory signs.
 Acute bacterial prostatitis
•  Definition - acute infection of prostatic parenchyma, associated with low
urinary tract infection and generalized sepsis
•  Etiology – E. Coli 80%
•  Symptoms – sudden debut
•  local symptoms - irritable bladder, pollakiuria, dysuria, perineal pain,
complete retention of urine
•  general symptoms – fever over 38 ° C, prostration, chills, pallor,
myalgia, arthralgia, tachycardia and hypotension
•  Rectal exam: prostate is enlarged, firm, congested and painful
•  Treatment: antibiotic therapy – initially parentheral, than p.o. – 2-4
weeks
•  3-rd generation cephalosporines
•  fluorochinolones
•  +/- aminoglycosides
 Acute epididymitis and orchiepidydimitis
•  Definition - acute inflammation, focal or diffuse, often of infectious origin
of the testis and epidydimis
•  Etiology – young men 18-35 years : STDs (C. trachomatis), the rest –
urinary tract infections
•  Symptoms: sudden debut – acute severe pain of the scrotum
•  Clinically - scrotum is congested, red and the testis and epididymis are
sensitive to touch and increased in volume, presenting a common mass
•  Ultrasound exam - mandatory
•  Treatment:
•  Hygienic-dietary measures
•  Drug treatment
•  Antibiotics – 14 days
•  Pain killers, antiinflammatory, antithermic drugs
•  Surgery – complications