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Urology Course Non-specific infections of the genitourinary system

3. Non-specific infections of the genitourinary system


OVERVIEW Non specific infections are frequent and raise remarkable problems in the form of serious lesions, sometimes irreversible, which they produce at the level of the renal parenchyma or the excretive system. Consequently, the treatment of these infections is sometimes very difficult and may put the urologist in extremely delicate instances. Urinary infections appear at all ages. During the first 3 months 75% of the new born children suffer from them, and then up to 1 year old the number of cases seriously decreases to 11%. During pre-school age the urinary tract infections (UTIs) are predominant with females, being usually grafted on a disorder of the urinary system. During adult age the frequency of the bacteriuria and of UTIs increases with females, especially while pregnant, more specifically in the second half of the term. Bacteriuria appears with men over 70 years old with an incidence of 3 4 % while being connected to obstructive symptoms of the lower urinary tract.

EPIDEMIOLOGY The pathogens mostly responsible are the Gram-negative germs: Escherichia Coli, Pseudomonas aeruginosa, Klebsiella, Enterobacter, Proteus; more seldom the Grampositive cocci occur: Staphylococcus aureus, Enterococcus. Out of the numerous groups of E. Coli and Proteus bacteria, only a few are pathogen at the level of urinary system. Membrane antigens (K) and surface antigens (H) allow the pathogenic stems to fix on the urothelial cells and ascend from the bladder to the renal parenchyma. Hence, under certain conditions, some of them known, some others unknown, the germs hosted by the urinary system end to affect the renal parenchyma or excretive system, determining several types of UTIs. The pathogens may penetrate the urinary tract through the following ways and means:

Urology Course Non-specific infections of the genitourinary system

The ascendant way (urogenous), more frequent with women due to the short urethra and to the proximity to the perineal-anal region, facilitates the contamination of the urinary system. The ascension of the germs to the bladder is facilitated by the vesicoureteral reflux. With men, the frequency of UTIs is incomparably lower due to the length of the urethra and to the antibacterial properties of the prostates secretions.

Hematogenous way. Out of numerous extraurinary infections, germs get into the blood. If they are pathogens for the urinary system and moreover, if they find favorable field (general and local predisposing factors), they may cause urogenital infection, mainly at the level of parenchyma organs (kidneys, prostate, testis).

Lymphatic way. This is a fairly rare propagating means of the infection. The starting point is usually an inflammatory disorder of a proximal organ (colitis, cervicitis, prostatis).

Iatrogenic way relatively frequent nowadays due to the endoscopic treatment and diagnosis methods, it is the result of an innappropriate instrumentation of the urinary system. A series of saprophite germs that sometimes may become pathogens are thus introduced up to the bladder or the ascending urinary tract.

Local predisposing causes are related to the urogenitary system: 1. Existence of a continuity solution at the level of urothelium (calculi, ulcerated tumours, subsequent lesions). 2. Disorders in the physiologic flux of evacuating urine: obstacle, compression, spasm, inflammation, which accomplish different degrees of urinary stasis. The urinary stasis is the most frequent and important local predisposing factor. 3. Deficiency of defence mechanism of the bladder under the condition of urinary stasis (sub bladder obstacle, neurogenous bladder) and of the consecutive congestion of the bladder mucosa it increases the parietal permeability and alters the mucoproteic structure of the mucosa. 4. Vesicoureteral reflux. It plays a significant role in making UTIs chronic. The vesicoureteral reflux occurs in acute cystitis due to the oedema and congestion of

Urology Course Non-specific infections of the genitourinary system

the mucosa of the ureter orificeand determines a functional insufficiency of the vesicoureteral junction. General pathologic causes: endocrine or neurovegetative disorders, diabetes, systemic diseases, colitis, chronic constipation etc. all constitute general factors that favour and have an important role in the occurrence and chronicization of the UTIs. Knowledge of ethiopathogenic mechanisms of UTIs is necessary for an accurate diagnosis, as well as for an appropriate therapeutic conduct.

PATHOLOGICAL ANATOMY It has been well known that staphylococcus has a peculiar affinity to the parenchyma and the Coli bacteria to the urinary tract. The causes of these germs behaviour are unknown. The infection may either directly approach the renal parenchyma or get propagated down the urinary tract. When it is gets up to the renal parenchyma, the lesions may be inflammatory (pyelonephritis) or supurative (pyonephritis) and may result in the more complicated perinephritis; in case the infection persists, pyonephrosis of the scleroatrophic kidney represents the terminal stages of the pyelo-renal infections. DIAGNOSIS It is difficult to put a diagnosis sometimes due to the varying character of the symptoms or some other times to the poor symptomatic pictures. The settlement of a diagnosis of a urinary infection must contain the following steps:

1. Knowledge of the source of infection. Its discovery needs a close interdisciplinary cooperation (urologist, gynaecologist, general medicine etc.). 2. Confirmation of the urinary infection. This is the decisive stage in the diagnosis of an infection. The urinalysis shall highlight the leukocyturia, the presence and type of germs. The Addis test (minute leukocyturia) is a quantitative confirmation of the pyuria.

Urology Course Non-specific infections of the genitourinary system

The negative result of the urin culture urinalysis is interpreted as follows: if the leukocyturia and germs are not present in the urinary sediment sample, the urinary infection may be excluded; if the leukocyturia has an increased value and/or on the urinary sample a significant number of germs appear, the negative result of the urinalysis cannot infirm the infection, and the urinalysis must be repeated.

The positive result of the urine culture shall be interpreted as follows: Under 10,000 germs/ml the result is negative ( sample ingathering germs); between 10,000 and 50,000 germs/ml, the urinary infection is very highly probable; over 100,000 germs/ml, the urinary infection is sure. A persistent leukocyturia with negative result of the urine culture urinalysis

(sterile pyuria) imposes additional investigations in order to identify the Koch bacteria. 3. The favouring causes of the urinary infection shall be discovered within a complex urologic examination. Especially with children congenital malformations shall be searched, while with aged persons the adenoma or prostate cancer, the inflammatory urethral strictures etc. shall be focused on. Additionally to the local favouring causes, the general predisposing factors must be discovered: diabetes mellitus, neuroendocrine disorders, constipation etc. 4. The consequences that infections may have upon parenchyma must also be known. The most serious repercussions of urinary infections are eventually on the renal parenchyma, as the stasis and the infection are the two major circumstances that contribute to the malfunction of the kidney.

TREATMENT 1. The hygienic- dietetic treatment is recommended especially in case of acute forms and consists in rest, hydration (oral or parenteral), diet low in salt and condiments.

Urology Course Non-specific infections of the genitourinary system

2. The symptomatic treatment: antialgics (Algocalmin, Piafen, Fortral), spasmolitics (Papaverine, Scobutil), sedatives (Plegomazin), nonspecific antiinflammatories (Diclofenac, Indometacin, Fenilbutazone), antipyretics (Antipirine, Piramidon, Paracetamol etc.). 3. The treatment of local predisposing factors is mandatory, is often the most important and consists of: high urinary derivation, ablation of a calculus or of a prostate adenoma, solving a urethral stricture through urethrotomy, etc. Similarly important is the correct treatment for the equilibration of a diabetes mellitus or for gynaecopathies with persistent urinary infections as side effects. In acute stages instrumental explorations must be avoided. 4. The antimicrobial treatment. In the case of urinary infections with no stasis, entitled medical, the antimicrobial treatment is on top of all treatments; in the case of urinary stasis infections, entitled urologic, the objective is to remove the obstructive factor which is associated with the antimicrobial treatment. The urinary infection is usually produced by only one germ as rarely does a combined infection, produced by associated germs, occur.

CHOICE OF MEDICATION An antibiotic or a urinary chemotherapeutic must contain the following conditions: Appropriate microbial spectrum. The antimicrobial treatment must be applied focused, according to the antibiogram. In case of acute infections treatment must be started urgently, before having the result of the antibiogram, and consists in administering a wide spectrum antibiotic, usually cephalosporin. High urine concentration in active form. The antibiotic or urinary chemotherapeutic must be eliminated through the kidneys in active form and have optimal urinary concentrations. Up to a creatinine level of 1.5 mg%, all these medications are administered in normal doses; when the levels are higher, in case of renal failure, the doses shall be adapted in close relationship with the creatinines level or clearance, by administering the so called urinary doses.

Urology Course Non-specific infections of the genitourinary system

Optimal activity depending on the urinary pH. Neglecting to keep the urinary pH at a correct level, depending on the medication taken, represents one of the failure causes with non-specific urinary infections. Urine is acidified with the help of food diet or with administration of diluted phosphorous acid (1%) 3x40 drops/day, Metionine or Vitamin C, and the alkalinization is obtained with Na bicarbonate 6-8 gr/day or Uralyt U, Blemaren N or vegetarian diet.

The optimal antimicrobial effect is obtained under the following values of urinary pH levels, depending on medication: Sensitive to very acid pH (pH 5-6): Negram, Nitrofurantoin, Peniciline G, Oxaciline; Sensitive to acid pH (pH 6-6,8): Ampiciline, Carbeniciline, Colistin; Sensitive to neuter pH (pH 7): Cephalosporine, Rifampicine, Neoxazol, sulfamide retard; Sensitive to alkalin pH (arround 8): Eritromicine, Tetracicline, Streptomicine, Kanamicine, Gentamicine. Nephrotoxicity and general toxicity as reduced as possible. An ideal urinary antibiotic must completely lack renal toxicity. Short term treatments or treatment with sub-doses are performed (Kanamicine, gentamicine, Colimicine). Combinations of antibiotics. In current medical practice a single antimicrobial agent is being administered within one treatment. Combinations are used only in cases of serious evolution and in combined infections with germs sensitive to several antibiotics or chemotherapeutics. When antibiotics are correctly administered, their combinations reduce the danger of bacterias resistance and have an increased efficiency. A. CHEMOTHERAPEUTICS I. SULFAMIDS They have bacteriostatic action; out of the non-specific infections of the urinary tract they and are mostly prescribed in case of acute and chronic cystitis. Sulfamids were the first chemotherapeutics systematically used for the prevention and treatment of bacteria infections with humans. They have an important role in treatment of the noncomplicated UTI. They are contraindicated in case of hepatic medical conditions or allergies to sulfamids. 6

Urology Course Non-specific infections of the genitourinary system

1. Neoxazol. It has bacteriostatic action on Coli bacteria but is not effective against Proteus bacteria, Pyocyanic bacteria ans other negative Gram germs. It is rapidly digested and is eliminated slowly through urine in active form under conditions of acide pH. The attack dose is of de 6-8 g/day in the first day (3- 4 tablets/6 hours), and then 2-4 g/day for 7-14 days. 2. Sulfametin. It is a sulfamid with extended action. It is not effective against Proteus bacteria, Pseudomonas and other negative Gram germs, but it is effective against positive Gram cocci, Chlamydia, Neiserria and protozoa (Toxoplasma). It is contraindicated in the last 3 months of pregnancy. The attack dose is of 2 g/day for 3 days (2 tablets/12 hours), and then treatment is continued with 1 g/day for 14 days. 3. Trimetoprim. They are antagonistic to the 4-Aminobenzoic acid and interferes with the metabolism if the folic acid. It is metabolised by the liver and eliminated through urine in the form of active metabolites. It has a broad spectrum on negative- and positive- Gram germs. The dose is of 2x2 tablets/day. It has a bactericidal or bacteriostatic action, depending on the type of the germ. II. METRONIDAZOL It is a synthetic derivative of nitroimidazol, which has an important role in the treatment of infections with anaerobe germs, as well as in the treatment with protozoa (toxoplasma). It is active for all anaerobe germs, with bactericidal action, hence is administered to all patients that have infections with anaerobe germs. It is well absorbed in the digestive tract and this is why it is orally administered in the form of tablets, too. The dose is of 3x1 tb/day. Parenteral administration is done only in serious cases. Side effects: cephalea, gastrointestinal disorders and neurotoxic effects (dizziness, ataxy, pheripheral neuropathy). III. URINARY ANTISEPTICS 1. Nitrofurantoin it is a chemotherapeutic agent with short action, determining rapid renal elimination and high urinary concentrations. The dose is of 4x1 tb/day (400 mg/day) for 14 days. It is contraindicated in case of kidney failure. 2. Nalidixic Acid it is a bacteriostatic agent with main action on negative Gram germs. The dose is of 4x2 tb/day (4 g/day) for 7 days. it is not used with sucklings. It

Urology Course Non-specific infections of the genitourinary system

is contraindicated in case of renal failure. Similarly to Nitrofurantoin, it causes digestive disorders. 3. Methenamine. It is rapidly absorbed by the intestine and excreted through urine. With acid pH it forms formaldehyde with antibacterial effects. The dose is of 4x1 tb/day (4 g/day). It is effective in the chronic forms of urinary infections. B. ANTIBIOTICS 1. Penicillin with broad spectrum Ampicillin, Carbenicillin, Methicillin, Oxacillin. They are effective against positiveand negative- Gram germs, except for Pseudomonas, Klebsiella, some stems of Proteus and Enterobacter. A series of aminopenicillins (Azlocilllin, Mezlocillin, Piperacilin) have broad spectrum and are effective against Pseudomonas aeruginosa. Cephalosporins 1st generation (C1G) (Cefalonium) seldom used, they have an inferior bacterial 2nd generation (C2G). They are frequently used: Cefoxitin, Cefotetan, spectrum compared to the current agents belonging to new generations. Cefamandole, Cefuroxime (Zinacef) against positive Gram germs, but also against negative Gram germs such as Enterobacter. A series of germs are resistant though: Clostridium perfringens, Pseudomonas aeruginosa. 3rd generation (C3G). Despite their broad spectrum against negative Gram germs, their effectiveness against positive Gram germs is inferior to that of the cephalosporins in the first 2 generations. Out of this generation the most well known are Ceftazidime, very effective against Pseudomonas aeruginosa, Ceftriaxone (Rocephin) and Ceftazidime (Fortum), also effective against P. aeruginosa. 4th generation IV-a, (C4G) are Cefepime (Maxipime) - administered in parenteral manner 1-2 g/12 hours, and Cefpirome the same posology. They are very sensitive towards Pseudomonas aeruginosa, some stems of Enterobacter and Serratia. 2. Aminoglycosides are a series of semi-synthetic antibiotics with large spectrum against negative Gram bacteria. The most used antibiotics belonging to this series are: GEentamicin, Tobramycin and Amikacin. The group also includes Streptomycin, Neomycin and Kanamycin.

Urology Course Non-specific infections of the genitourinary system

The aminoglycosides are protein synthesis inhibitors and interferate with the mARN carriage. This mechanism explains the bactericidal action of these drugs. They have a high level of concentration in the renal cortex. They are excreted through glomerular filtrate, attatining efficient urinary concentrations. The antibiotics belonging to this category of medicines are effective against Enterobacter, Pseudomonas. They are ineffective against anaerobe germs and have low action over Gram positive cocci. Their side effects are ototoxic by destroying the vestibular and cochlear sensors. They are nephrotoxic through accumulation, after 5 7 days, hence they are not administered in case of renal failure. The dose is of 3x80 mg/day with adults, 3x40 mg/day with children. The newest aminoglycosides are: Netilmicin (Netromycin); Isepamicin 8-15 mg/ kg body; Spectinomycin (Trobicin). 3. Glycopeptides - Vancomycin and Teicoplanin. They are bacteriocidal against Staphylococci (aureus and and epidermidis) and bacterostatic against Faecalis Staphylococcus. They are effective against Enterococci and Clostridium perfringens, but are ineffective against Gram negative bacteria. They present long half life (70-100 hours). They are administered either IM or IV (phlebitis may be caused). 4.Aminosides. Netilmicin is used especially in combinations of antibiotics. . 5. Quinolones. Ciprofloxacin, Ofloxacin, Norfloxacin, Levofloxacin and Pefloxacin are DNA inhibitors. They are effective against Gram positive cocci and Gram negative aerobes, including Pseudomonas and some Mycobacteria. Elimination is done via liver and kidneys. They are little bonded to proteins; they are well spread in the renal parenchyma and reach high concentration levels even in the prostatic parenchyma. The dose is of 1 g/day (2x500 mg IV or per os.). 6. Macrolides. Chloramphenicol, Erythromycin, Lincomycin and Clindamycin have an excellent digestive absorbtion and hence are ofted used in ambulatory treatments. Erythromycin is both bactericidal and bacteriostatic, depending on the blood concentration. These antibiotics bond well in the intracellulary liquid and have a good penetration in the prostate. The intravenously administration may cause phlebitis. They are effective, Erythromycin especially, against Staphylococcus aureus, Haemophilus

Urology Course Non-specific infections of the genitourinary system

influenzae and Neisseria gonorrhoeae. Clindamycin is different from Erythromycin as it has great effectiveness against some anaerobes (CI Perfringens). They are protein inhibitors at the level of bacetrial ribosomes. Macrolides are metabolised by the liver and eliminated through urine. The adverse effects may be: medullar depression, cutaneus eruptions and diarrhea, disturbance of equilibrium in microbiota (bacterial flora). 7. Tetracyclines have a broad spectrum bacterostatic effect against Gram positive- and Gram negative- germs (except for Pseudomonas and Proteus). They are not administered in the second term of pregnancy and in children up to 6 years. The new generation is represented by Vibramycin (Doxyciclyne). 8. Carbapenems. Antibiotics such as: Imipenem, Meropenem, Ertapenem etc. belong to this class. The first is administered in a dose of 0.5 g/6 hours(2 g/day), and the second 0.5 g-1 g/8 hours. Carbapenem are a -lactam antibiotic with broad spectrum used intrevanously (perfusions). characterized by a powerfull bactericidal action of larger spectrum of any other known antibiotic. It is resistant to the bacterial -lactamase enzymes, which confers effectiveness against a large number of germs, mainly: Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus phaecalis and Bacteroides fragilis usually resistant to other antibiotics.

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Urology Course Non-specific infections of the genitourinary system

NON SPECIFIC INFECTIONS OF THE ASCENDING URINARY TRACT


I. PYELONEPHRITIS Pyelonephritises represent infections with non specific bacteria with simultaneous action on both the renal pelvis and the renal interstitium (the space formed by a connective network separating the uriniferous tubules from the glomeruli). Practically there are no isolated pyelitises as the inflammatory processes act simultaneously and constantly on the mucosa of the renal pelvis and the interstitium. Pyelonephritis is one of the main causes of renal failure. The medical condition may be mono- or bilateral and, depeding on its evolution, it may be acute or chronic. Bacteria penetrate the kidney via one of the ways described.

ACUTE PYELONEPHRITIS (APN) The disease may appear at any age. It is more frequent with females, especially during pregnancy. It often appears as a complication of the excretory system, with or without obstruction, or the pathogens may graft on an existing renal lesion.

PATHOLOGY The kidney is augmented, may be decapsulated easily, the mucosa of the renal pelvis is congested, edema marked. The kidney has a smooth, lightly granulated surface on which little yellow abcesses are noticed. Sectionally, both medullary and cortical, multiples microabcesses are present. Microscopically, inflammatory infiltrates with polynucleus neutrophils and abcessed area are revealed. The tubules contain leukocytes and pus. SYMPTOMATOLOGY The debute may be sudden onset of fever, shaking chills, degenerated general state, bilateral lumbar pains irradiating towards hypogastrium, oliguria and oligoanuria. Pollakiurria, pyuria, smarting pains when urinating are other symptoms that join lumbar pains; they are less intense in cases of less brutal debut. The renal pains are weak but still clear enough to assume the renal origin of the infectious syndrome. Cephalea, asthenia, fatigue, nausea, vomiting are also associated. 11

Urology Course Non-specific infections of the genitourinary system

Laboratory examinations: urinalysis reveals pyuria and bacteriuria, microscopic haematuria. The leukocyturia at different times shows an important increase of leukocytes. The peripheral blood sample identifies leukocytosis with polynucleus neutrophils, increased ESR and the haemoculture may be positive. The bacteriologic test is done directly on the sample with Gram staining on the germ. The antibiogram urinalysis identifies the germ and tests its resistance to antibiotics. The renal functional tests reveal early and constant degenerations of the renal function. These changes remain for weeks or even months after apparent cure. Imagistic investigations The echography reveals a kidney that is increased in size, with high parenchyma index (inflammatory process) having a more transonic image (congestion and edema). The central echogen complex has normal volume and aspect. When the acute pyelonephritis appears on superior obstructive uropathy, litiasic or non litiasic, the echographic examination shall reveal dilation of collecting system and of the ureter and possible echogene images with shadow cones (calculi). KUB x-ray reveals the renal shadow increased in volume unilaterally or bilaterally, possible radioopaque calculi. IVU (intravenous urography) secretion present bilaterally, weker intensity on the affected part. The ureter also is hypotonic and may be completely opaque up to the bladder. In case of acute pyelonephritis that develops on a kidney with ascending obstructive uropathy, the IVU reveals stasis in the ascending urinary tract and the obstruction, which may be a radioopaque or radiolucent calculus.

POSITIVE DIAGNOSIS It is based on the patients antecedents, on the clinical examination and shall be confirmed by the laboratory and imagistic investigations above mentioned. DIFFERENTIAL DIAGNOSIS

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Urology Course Non-specific infections of the genitourinary system

The acute pyelonephritis shall be differentiated from other general infectious diseases, of the surgical abdomen, of the renal suppurations and the suppurations of the perirenal tissue. TREATAMENT General and symptomatic. Rest in bed, diet, no condiments, vitamin therapy; analgesics and antispastics for pain relief (Algocalmin, Piafen, Papaverine, Scobutil). Medication. The antimicrobial treatment shall be immediately begun the moment the patient gets hospitalized. A broad spectrum antibiotic is administered, usually a cephalosporine, until the result of the antibiogram urinalysis is obtained. Thereafter, the antibiotic or chemotherapeutic substance that is most effective against the germ is administered, either with or excluding the cephalosporine, until fever lowers and the urine becomes sterile; the treatment shall then be continued with sulphamides for 2 3 weeks. Surgery. If the acute pyelonephritis appears on an ascending obstructive uropathy, the obstruction shall be removed (the favouring factor of the acute pyelonephritis): calculus, prostate adenoma, urethral stricture, pyelo ureter junction syndrome etc. As far as the efficiency of treatment is concerned, the following instances may appear: Healing after 6 months from the treatment end the urocultures remain sterile. Relaps of infection after a few months after the treatments end the infection with the same germ relapses. The persistence of the infection during the treatment reveals either the resistance of the germ to the antibiotic or an insufficient dose of the antibiotic administered. Re-infection: after a period of sterilization the infection of the urinary tract with a different germ occurs. CHRONIC PYELONEPHRITIS It is a non specific, chronic microbial inflammation of the renal pelvis and of the renal interstitium with a persistent infection, on the basis of a congenital disorder which represents the cause of the perpetuation of the infection. Very often though the obstruction has been removed and there is no stasis any longer, the chronic pyelonephritis persists.

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Urology Course Non-specific infections of the genitourinary system

PATHOLOGY In chronic pyelonephritis the kidney presents variable atrophy. It has a granular aspect with irregular scars. The capsule is adherent, the kidney being difficult to decapsulate, especially at the level of scars. Microscopically a difuse inflammatory infiltrate composed of lymphocytes is observed; the scarry areas present marked sclerosis and glomerular hialinizations. The arteries are thickened, hialinized, with reduced or obturated lumen. Pyelonephritis xantogranulomatosa is a particular form of the chronic pyelonephritis occurring more often after chronis supurated inflammations and lithiasis. The kidney is increased in volume and has an adherent capsule; sectionally, the renal parenchyma presents areas of yellowish colour, sometimes with pseudotumoral aspect, with abcesses on pyelocaliceal level. Microsopically, a lympho-plasma infiltrate may be noticed, and occasionally cholesterol crystals surrounded by gigantic cells pertaining to a different mass.

SYMPTOMATOLOGY The chronic pyelonephritis develops in 3 acute stages or may be chronic from the very beginning. The clinical picture is polymorph and non characteristic. General symptoms appear in the first year: asthenia, anhemia, cephalea, fatigue, feverish condition. As far as the urinary system is concerned, the symptoms are of uneasiness or pains in the lumbar region, disorders of urination (smarting pains, pollakiuria). The followings may also be associated: digestive disorders, anhorexia, constipation, alternationg with diarrhea and abdomen swelling after eating. Within 50 60% of cases the HTN is present. The evolution is prolonged, interrupted by periods of calmness overcrossed by feverish strokes. In late stage the symptoms of chronic pyelonephritis are those of the chronic kidney failure. The laboratory tests are the same as with the acute pyelonephritis; additionally, changes pertaining to already installed chronic renal failure appear: in creased values over normal of the blood urea and creatinin, acidosis, anhemia). Renal function tests

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Urology Course Non-specific infections of the genitourinary system

reveal disorders of dilution and concentration and pathologic values of the tubular clearance. Imiging tests Echography shows a kidney reduced in volume, with irregular convexity and diffusely delimitated, especially in the advanced stages of the illness. The parenchyma index is reduced, the parenchyma is more echogenic due to the parenchyma sclerosis processes that are characteristic to the chronic inflammatory process. Images of calculi may also be revealed in the pyelocaliceal system. When there are no obstructive conditions (usually lithiasis), stasis is not identified. Otherwise (lithiasis, congenital malformations etc.) the echography highlights stasis and the dilation more or less emphasized of the excretory system. The echography may reveal vesical diverticules or calculi, secondary to a subvesical obstruction (BPH, postate cancer, urethral strictures); moreover, if the investigation continued, it reveals the prostate cancer as well as its sizes and volume. The urethral strictures also may be revealed by the echography, as well as their number and location. KUB x-ray- reveals possible radioopaque calculi. IVU offers information that is more or less accurate related to the degree of the renal insufficiency. In case of chronic renal failure with high levels of urea and creatinin, it has no indication whatsoever. Yet, in case the renal insufficiency is not very severe, IVU may reveal a series of pyelocaliceal changes that are the results of the parenchyma retraction and calyceal hipotony: oblated calices, caliceal bubbles that are deviated and modify the pyelocaliceal fan. The retrograde urethrocystography reveals the subvesical obstruction and its consequences and/or a potential vesico-ureteral reflux. Renal biopsy lesions with chronic pyelonephritis are few, delimitated at the beginning, with normal intercalated parenchyma; hence the diagnosis of chronic pyelonephritis cannot be excluded when renal biopsy shows a normal parenchyma.

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Urology Course Non-specific infections of the genitourinary system

DIAGNOSIS It is based on the antecedents of the patient (renal lithiasis, BPH, numerous strokes of acute pyelonephritis) and on the clinical picture. Varying functional pictures are met with chronic pyelonephritis, which makes interpretation of the laboratory tests difficult, especially as far as functional tests are concerned. The laboratory tests provide information about urinary sediment with numerous leukocytes, microbial germs, especially Gram negative, wherefrom E. Coli is the most prevalent. When presence of Sternheimer-Malbin cells outnumbers 10% of the urinary leukocytes, chronic pyelonephritis may be diagnosed. 1. Addis test reveals increased leukocyturia. 2. Urinalysis and antibiogram identify the type of germ and its sensitivity to antibiotics. 3. Renal function tests identify renal tubular insufficiency. 4. The imagistic investigations and eventually the renal biopsy are important for diagnosis of chronic pyelonephritis and establishment of its etiology. DIFFERENTIAL DIAGNOSIS It is done with any arterial hypertension (HTN) and with anhemias lacking causes; with chronic glumeronephritis, where haematuria is prevalent and at the beginning only filtration tests are modified, while tubular tests are modified only later. It is also done with renal tuberculosis and renal tumors, especially in case of xantogranulomatosa pyelonephritis.

EVOLUTION It is variable. Sometimes the renal function is rapidly compromised during few months. In the most cases the evolution is slow as the parenchyma that is not affected may ensure a satisfactory renal functioning. If there is not HTN, a slow relatively benign evolution of the disease with no vascular changes may be reckoned.

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Urology Course Non-specific infections of the genitourinary system

COMPLICATIONS The most frequent complications are the cases of pyelonephritis as complications of renal infections, perinephritis and pyonephrosis, a suppurative complication with massive damage of renal parenchyma, when usually obstructive factors are also associated (stenosis, calculi).

TREATAMENT It is able to cure the chronic pyelonephritis or at least to stop its evolution and prevent acute strokes. Hygieno- dietetic treatment: light diet rich in liquids, change of urinary pH through acidification. Medication Killing pains: antialgics and antispastics. The antiinfection treatment is started with the antibiotic or chemotherapeutic agent that the germ is most sensitive to, perhaps a combination of antibiotics for 10 -1 5 days. When treatment is efficient the leukocyturia should decrease and the urinalysis findings get negative. After treatment with antibiotics, it is started treatment with the chemotherapeutic that the germ has been found to be sensitive to. Treatment of general or local favouring factors. The factors that maintain stasis in the urinary system must be treated: congenital disorders, lithiasis, urethral strictures, prostate adenoma etc. Treatment of HTN.

PYELONEPHRITIS IN PREGNANCY It appears mainly between the 5th and the 7th months of the preganancy, more frequent at women with more than one birth deliveries. The normal clinical form is not severe and is cured after normal treatment with antibiotics. The more serious forms appear in the first half of the pregnancy and may be complicated by septicaemia. The favourable causes are: hormonal hypotony of the excretive system, hormonal congestion of the urothelium and the mechanic compression of the uterus of the pregnant woman.

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Urology Course Non-specific infections of the genitourinary system

SYMPTOMATOLOGY Symptoms are less significant at debut of the condition, but while the disease develops, fever, lumbar pains, pollakuria, smarting pains, pyuria and bacteriuria appear. Haemoculture is usually positive. Sometimes the severity of the condition is due to the renal failure and arterial hypertension, the infectious syndrome being less serious. TREATMENT Treatment is the same as in the case of acute and chronic pyelonephritis, but needs more precautions. Preventive treatment consists in periodical examinations aiming at finding of possible proteinuria and oligo-symptomatic bacteria. Curative treatment antibiotics and chemotherapeutics selected on the basis of tibiogram, but without including medication with teratogenous effect: Tetraciclin, Chloramphenicol. The degree of severity of the condition may cause pregnancy interruption or premature delivery.

II. PYONEPHRITIS It is a purulent inflammation of the renal parenchyma with 2 ethiopathologic possible forms: pyonephritis staphiloccocus metastasis and pyonephritis complication of an infection of the ascending urinary tract.

PYONEPHRITIS STAPHYLOCCOCUS METASTASIS ETIOPATHOGENY The pathogen is represented by the Staphyloccocus aureus, which gets to the kidney via blood circulation. The starting point is usually a primary focus of cutaneous infection (furuncle, pyodermitis, panaritium and abscess), seldom osteomyelitis. Between the apparition of the infections focus and the occurrence of renal suppuration there is a period of 3 5 weeks, sometimes longer.

PATHOLOGICAL ANATOMY Three different anatomopathological forms of pyonephritis are known: disseminated millet size abscesses, large abscesses and renal antrax (carbuncle). From

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Urology Course Non-specific infections of the genitourinary system

the pathogenic point of view, the carbuncle represents the septic necrosis of a part of renal parenchyma belonging to a region irrigated by a lobular artery that is obstructed by a microbial embolism. Sectionally, the lesion has the form of a triangle with the angle in the depth of the renal parenchyma whereto it is connected through an arterial vessel. The carbuncle is separated from the healthy parenchyma by a clivage plane that allows its enucleation as a benign tumor. In the moment of enucleation the arterial vessel, initially embolized, bleeds. SYMPTOMATOLOGY It clinically manifests with fever and pain. The fever is increased and persistent (suppurative process). The curve is irregular, in plateau, or wavy. The pain manifests in the lumbar area, is spontaneous or caused and has a varying intensity. Local examination reveals lumbar region sensitive to palpation. Giordano sign is present. Laboratory tests Urine is clear, with no pathological elements, as long as the suppurative lesion does not communicate with excretory tracts. The urinanalysis findings are sterile in the same conditions above mentiones. Haemoculture sometimes reveals Staphyloccocus aureus. The leukocytosis with polynucleus neutrophils is revealed in the peripheral blood picture. ESR has increased values. Imagistic investigations Echography. In the millet size abscesses the echographic examination is not conclusive. Perhaps it could provide information about a pole that is increased in volume with a nonhomogenous structure parenchyma. In the large abscesses forms the echographic examination highlights a transonic area of variable sizes at the level of abscessed part and normal echographic structure in the rest of the image. In the case of carbuncle it is revealed also an area where the echographic structure of the parenchyma is modified towards non-homogenity: areas that are more transonic alternate with areas having a more echogenic structure. KUB x ray does not provide important information for the diagnosis. IVU especially in cases of renal carbuncle but also in those of large abscess, images similar to those in cases of tumour are identified: calices that seem

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Urology Course Non-specific infections of the genitourinary system

elongated, curved, compressed, deviated. In cases of millet size abscesses the image of the renal cavity system does not get modified. Retrograde ureteroscopy provides a better image that that given by the IVU. CT discovers the intra-renal modifications caused by the inflammatory process and remaining encapsulated, more or less iodophil, depending on the intensity of the distructive process. Also, the inflammatory perpendicular adenopathy is revealed; the latter is sometimes difficult to differentiate from a tumour adenopathy. Arteriography seldom prescribed, it reveals an area that has no blood vessels in the zone of the carbuncle or large abscess. Renoscintigraphy reveals that the radioisotope is not fixed into the affected area. Pulmonary radiography reveals the hypomobility of the diaphragma in the affected part.

DIAGNOSIS In order to put a diagnosis it is very important how it is interpreted a feverish condition whose cause does not seem obvious; this generally appears with yourng patients with variable lumbar pain, with clear urine and who has had as antecedents (in the course of latest weeks) a cutaneous infection (furuncle, panaritium or other staphyloccocus infection) with hyperleukocytosis and signes of renal tumour provided by the IVU. In the clinical contest above mentioned the echography, which cannot reveal a tumour, may nevertheless set the question over a non specific inflammatory process, a pyonephritis, probably caused by a staphylococcus. DIFFERENTIAL DIAGNOSIS The medical condition must be differentiated from other forms of pyelorenal infections, from neighbouring suppurations and renal tumour processes. In case of acute pyelonephritis pyuria and bacteriuria are always present, but IVU does not reveal dezorientation of the collecting system; In case of acute colecystitis the disease history is characteristic; the radiological and echographic investigations clarify the diagnosis.

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Urology Course Non-specific infections of the genitourinary system

Renal tumour - febrile form the urine has no pathological elements and the diagnosis is rendered by the imagistic investigations. EVOLUTION. PROGNOSIS Pyonephritis may be cured or may get complicated with a perinephretic phlegmon

or, more rarely, with septicaemia. In rare cases the kidney is completely destroyed by multiple disseminated supurative centers. The prognosis may be provided depending on the clinical form and the early start of the treatment.

TREATAMENT Antibiotherapy (oxacillin, cephalosporines) administered correctly and especially in early stages of the disease may cure pyonephritis with millet size abscesses even without after effects. The antibiotics treatment is associated with antialgics, antipyretics. The failure of medical treatment imposes a more energic therapeutical attitude; in the case of renal abscess or furuncle open surgery is indicated from the beginning. In these cases renal decapsulation permitting opening and drainage of abscesses or enucleation in the case of renal carbuncle are followed by healing. With renal abscess the following may be beneficial: percutaneous puncture wherefrom pus is aspirated, followed by creating a percutaneous trajectory in the abscess cavity and elimination of purulent contents and then installation of a NP balloon catheter, with double circuit. The next days this bag can serve for washing the abscessed cavity with antibiotics. The ballon catheter is removed after 5 days. Administration of combination of antibiotics with broad spectrum in the course of the next days is mandatory.

PYONEPHRITIS- COMPLICATION OF AN INFECTION OF THE ASCENDING URINARY TRACT With this ethiological form of pyonephritis, the infection of the renal parenchyma represents the complication of a canalicular infection of the urinary tract. Hence, neither this form of pyonephritis is a self standing medical condition, but a complication of a urinary infection already existing.

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Urology Course Non-specific infections of the genitourinary system

ETHIOPATHOGENY The pathogen is not specific: most frequent E.. Coli, satphyloccocus, Proteus or associated microbial flora are encountered. The disease appears as a result of acute or chronic pyelonephritis and especially as a complication of a vesical-prostate-urethral infection. It represents the frequent complication of the disectasia of the bladder neck, in the stage of vesical distension, of the vesical or ureterovaginal fistulas, of ureteral orifice invasive bladder tomors and ureteral stasis. The parenchyma is attacked either canaliculary (pyelovein reflux, pyelocanalicular or pyelointerstitiary, vesico-ureteral reflux) or via blood circulation. In cases of patients with vesical distension (prostate adenoma) pyonephritis is often bilateral, extremely serious. PATHOLOGICAL ANATOMY The inflammatory process is prevalent in the medullary area, the suppurating clusters spread radially, starting from the papilla, in the form of yellowish striations. The lesions develop further towards diffuse suppurated nephritis or sclerosis chronic nephritis. SYMPTOMATOLOGY Clinical symptoms: lumbar pains, fever, shivering, vomiting, cephalea, anhorexia all occurring as a consequence of a pyelonephritis. The kidney is enlarged, causing pain when palpated, the renal lodge is sensible, Giordano manoeuvre present. Laboratory tests: the urine is cloudy (pus and blooc cell). The uroculture is infected. Hyperleukocytosis and haemoculture usually positive. Paraclinical investigations: are the same as described in the case of Pyonephritis metastasis staphylococcus; they must additionally identify the favouring urinary medical conditions. The EVOLUTION of this pyonephritis is extremely serious and may cause death within few days; others have a slower evolution, causing damage of the kidney through diffuse suppurated nephritis (septic kidney), pyo- or nephro-sclerosis. The whole kidney

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Urology Course Non-specific infections of the genitourinary system

accommodates disseminated abscesses and the perirenal fatty tissue is congested and edematous. TREATMENT The treatment consists in: administration of antibiotics, which at early stages may stop the evolution of the suppurative process at the level of the kidney; treatment of the urinary condition accountable for the disease: congenital malformation, prostate adenoma, urethral stricture etc. and ensuring an efficient urinary drainage. In the cases of renal abscess, the treatment consists in lombotomy, incision, evacuation and drainage. In the severe cases, nephrectomy is the only therapeutic method for unilateral lesions.

III. PERINEPHRITIS Perinephritis denotes the suppuration of the perirenal connective and fatty tissue. It is secondary to suppurative processes of the kidney, most frequently to pyonephritis or pyonephrosis. More seldom, it may be a consequence of a pyelonephritis or of trauma or surgical perirenal haematoma. There is no primitive perinephritis. Its frequency has considerably reduced in the antibiotics era but still remains as option in making a diagnosis on the symptom of prolonged high fever. ETHIOPATOGENY The accountable microbial germs are those characteristic to non specific renal inflammatory processes. Germs penetration is possible either through direct extension (pyonephritis, pyelonephritis, pyonephrosis) or via blood starting from a cutaneous or prostatic septic cluster etc. PATHOLOGICAL ANATOMY The primitive renal lesion is one of the two original lesions of perinephritis: pyonephritis and pyonephrosis. Perinephritis may appear under three forms: 1. Sclerolipomatous form sclerosis lesions associated with an exaggerated proliferation of the perirenal fat tissue. 2. Suppurated form or perinephric phlegmon represents the suppuration of the connective and fatty tissue around the kidney. Depending on its evolution, three stages may be differentiated: edematous infiltration, localized or diffuse suppuration.

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Urology Course Non-specific infections of the genitourinary system

3. Chronic form- wooden phlegmon: the perirenal fat accommodates sclerotic reaction. Suppuration is usually located on the posterior side of the kidney (figure 3.1). Reported to the kidney, suppuration may have other locations too: Superior polar phlegmon; Inferior polar phlegmon; Prerenal phlegmon. Retrorenal phlegmon

Suppuration may extend to the posterior abdominal wall and then penetrate through the latters weak points: Grynfeltt quadrangle and triangle of Petit almost reach under teguments. Rarely the perinephric phlegmon may penetrate in the thoracic cavity through the lumbar hiatus; similarly, the inferior phlegmon,
Fig. 3.1. Perirenal abcess

as above mentioned, or the posterior one, penetrate in the femoral triangle (of Scarpa) or through the sciatic cavity, and thus reach the gluteal muscles. Perinephritis must be differentiated from the inflammation of the perirenal fatty tissue of Gerotas fascia, secondary to a suppuration of the abdominal visceras (colon, vermix etc.) SYMPTOMATOLOGY Perinephritis is preceded by the symptoms of the causative disease. There usually appears only one symptom: fever. Clear urine with no pathological elements determines sometimes that the possibility of renal infection be eliminated. Discovering of cutaneous infection in the patients antecedents represents the key in the correct interpretation of the feverish condition. Hyperaemia that is not joined by other symptoms corresponds to renal parenchyma stage. Obvious local inflammatory symptoms appear late, the phlegmon already being located thoroughly, and depend on the phlegmons place. Retrorenal phlegmon is characterized by parietal signs: painfull lomb, somtime with muscle contracture; sometimes congestion and edhema of lombar tegument

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Urology Course Non-specific infections of the genitourinary system

is noticed (the folds of the underwear and bedclothes are impregnated on the tegument). Superior polar phlegmon- clinically it is revealed by thoracic symptoms: pain, hypomotility of the corresponding hemidiaphragm, pleural reaction. Thoracic radiography confirms the hypomotility of the corresponding hemidiaphragm. Inferior polar phlegmon: pain in the flank, vicious conduct of the thigh (psoitis): external flexion and rotation. The anterior phlegmon gives symptoms of peritoneal irritation and may be misinterpreted for any acute abdominal syndrome. DIAGNOSIS The anamnesis discovers a staphylococcus infection in the past few weeks, fever, lumbar pain, immobility or hypomobility of the diaphragm. Laboratory tests Hyperleukocytosis with polinuclears. Increased ESR Urinalysis: with no pathological elements or pyohaematuria (complication of a pyonephrosis) Positive urineculture Staphyloccocus aureus or germs of non-specific urinary infections, generally Gram negative germs. Imagistic investigations Echography provides information related to the renal pains, signs of renal abscess or modification that may raise the suspicion of renal carbuncle; sometimes it reveals pyonephrosis. It also identifies the location of the phlegmon, which appears as a transonic area with polar placement on the anterior or posterior part of the kidney. Pulmonary radiography reveals the hypomobility of the diaphragm in the affected side. KUB x-ray reveals a lack of the kidneys contour and the external margin of the psoas. Lumbar scoliosis with concavity on the affected side. IVU identifies the modifications caused by the renal pains; when it is pyonephrosis, the kidney is silent from the urographic point of view. 25

Urology Course Non-specific infections of the genitourinary system

CT examination confirms the information obtained within US. Lumbar puncture under echographic supervision- if it is a posterior phlegmon, inferior polar or even superior polar, when puncture findings are positive (pus is extracted), the diagnosis of perirenal phlegmon is confirmed. TREATMENT Medical treatment: antibiotics, non specific anti-inflammatory medication may

heal some forms of pyonephritis, especially the edematous forms. Shortcoming: by modifying evolution it often hinders accurate diagnosis and extends the evolution of the medical condition. Surgical treatment is mandatory when lumbar puncture extracts pus and when, after medical treatment, the echographic examination reveals intensification of the abscess in the known locations. It consists in lombotomy, evacuation of the pus and drainage of lumbar region. The cause of the abscess shall also be solved: renal carbuncle, renal abscess or pyonephrosis. If from the urographic point of view the contralateral kidney is normal, nephrectomy shall be performed, as the pyonephrotic kidney is morphofunctionally compromised.

IV. PYONEPHROSIS Pyonephrosis represents suppuration of the pyelocaliceal cavities and of renal parenchyma joined by the latters damage. The pyonephrotic kidney of increased volume, with unequal consistency, with no parenchyma is transformed into a bag of pus spread into cavities via septa, where calculi may exist as cause or consequence of pyelorenal infection. There is always a perirenal reaction involved (sclerolipomatous perinephritis). ETHIOLOGY There are no specific germs; E. coli is the most frequently met, but many times it appears as a germ of secondary infection. PATHOLOGICAL ANATOMY The kidney is enlarged, with irregular surface and expanded cavitary system. The renal parenchyma is atrophic, thinner, with wide sclerotic areas. The renal pedicle is surrounded by a mass of sclerolipomatous tissue.

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Urology Course Non-specific infections of the genitourinary system

Microscopically, the kidney presents an extremely marked process of sclerosis, being replaced by a scarry fiber tissue where hyalinized glomeruli and atrophic tubes persist. SYMPTOMATOLOGY The main clinical symptoms of pyonephrosis are: fever, pyuria, malaise, lumbar pains in the affected part, one larger kidney when palpated, lumbar muscles contraction and Giordano sign present. Pyonephrosis is an extremely serios condition due to its septic character. Even if the disease is unilateral, the septic retention has large impact on the global renal function, oligoanuria and ARF being frequently associated to the septic process. DIAGNOSIS Within anamnesis the following antecedents of the patient are important to consider: lithiasis with spontaneous elimination of calculi or surgeries for their removal; fever, shivering strokes, malaise, vomiting, nausea, one large and paiful kidney at palpation. The urinalysis reveals pus in the urine and the urine microscopy identifies the germ (or germs) causing suppuration. The presence of ordinary germs does not remove the possibility of tuberculous origin of the pyonephrosis, which may be infected with usual germs. The haemoculture during shiveringmay identify the germ. The KUB x-ray shall reveal the enlarged renal shadow; sometimes renal or urethral calculus is discovered the cause of pyonephrosis. With IVU the pyonephrotic kidney is dumb; still, the urography is compulsory, as it provides information about the other kidney. Renoscintigraphy shows the absence of the radioactive substance in the side of the pyonephrotic kidney and provides information about the other kidney. With infected hydronephrosis and pyelonephritis with septic retention it reveals the value of the affected kidneys parenchyma, being a good method in differential diagnosis with pyonephrosis. Within cystoscopic examination purulent discharge from the affected kidney through ureter orificeare noticed.

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Urology Course Non-specific infections of the genitourinary system

Withind retrograde ureteropyelogram undertaken before surgery the expansion of renal pelvis and calices is observed in case of infected hydronephrosis or the characteristic aspect of pyonephrosis: large irregular volumed cavities communicating through orifices of the narrow caliceal canes, sometimes with hydroair levels; at ureteral level it is often irregular, expanded or filiform. PROGNOSIS The essential elements of the life prognosis are: the state of the other kidney and the patients resistance. The increased values of urea and cretinin encountered at these patients sometimes reveal global renal insufficiency as the pyonephrotic kidney has an inhibitory effect on the other kidney. The values of urea and creatinin come back to normal after pus is drained or the pyonephrotic kidney is removed. TREATMENT The only treatment of pyonephrotic kidney is nephrectomy provided that the other kidney and the general health condition of the patient allow this surgical intervention. In the serious forms when the quo ad vitam prognosis is severe, nephrectomy may be preceded by temporary nephrostomy for drainage of pus; nephrectomy is performed after the general health condition of the patient improves. The pre-surgery treatment in acute forms is short termed as obtaining reequilibrium aims at reducing the surgery shock. Simultaneously the antimicrobial treatment is started, as well as the treatment for electrolytes and acido-basic balance. In cases of hyperazotemia and malaise, haemodialysis improves biological data and the general health condition of the patient and so allow for performance of nephrectomy.

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Urology Course Non-specific infections of the genitourinary system

NONSPECIFIC INFECTIONS DESCENDING GENITORINARY SYSTEM I. CYSTITIS They are infections with no fever, except for pancyctitis (vesical gangrene) as a result of the localization of nonspecific infection at the level of urinary bladder. ETHIOPATOGENY There are multiple ethilogic forms, out of which the most frequent are the bacterial forms as infections with Gram positive and Gram negative germs. As far as their frequency is concerned, the following are the parasite origined forms (trichomoniasis) and mycotic (Candida albicans). Some chemical substances in high levelled concentrations in the urine determine apparition of acute haemorragic cystitis: sublimate poisoning, methylic alcohol, flutamide, urothropine (the local irritating effect of formaldehyde). Cytostatics, roentgen therapy or cobalt therapy may bring about serious acute cystitis. With females, acute cystitis is prevalent in ascending urethral tract and is most frequent with sexually active women. The local favouring causes are: short urethra, vicinity with perineal region (septic ares) and inflammations of the uterus and its annexes. The onset factors are: cold, humidity and sexual intercourse. At climacterium period, cystitis occurs due to hormonal deficiency (estrogenic) which causes trophic disorders of the trigonal mucosa. With males, cystitis is most frequent with old people and is secondary to a subvesical obstruction. With children it is usually related to obstructive malformations of the descending urinary tract. PATHOLOGICAL ANATOMY Depending on the character of the exudates, the acute cystitis may be: catarrhal, fibrinopurulent, diphteroid, hemorrhagic and gangrenous. At the beginning oedema with hyperaemia of the mucosa appears, followed by its ulceration. The ulcerated areas are covered by fibrin- based membranes or false purulent membranes. Microscopically lymphatic infiltrates with neutorphils are revealed.

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Urology Course Non-specific infections of the genitourinary system

In chronic forms the wall of the urinary bladder is thickened. Mucosa is sometimes eroded with polypoid formations that are prominent in the bladders cavity. The vesical wall presents an interstitial fibrosis and infiltrates with lymphocytes and plasmocytes. 1. ACUTE CYSTITIS It manifests through polakiuria, pyuria and pain. It may be joined by haematuria and dysuria. Polakiuria appears due to reduced capacity of the urinary bladder. Pain has variable intensity, generally intense enough; it is present with urination and gets exaggerated at its ending. Pyuria is intense or discreet and haematuria may be total or present only at urinations ending, with character of terminal haematuria, which in general is not abundant. Fever appears with pancystitis or after a complication of cystitis, as a result of vesical-urethral reflux (oedema, congestion of mucosa at the level of ureteral orifice) and of consecutive pyelonephritis. Clinical examination. Rectal or vaginal examination provides information related to the internal genitary organs. Sometimes a large and painful kidney is revealed at palpation, as well as vesical stasis, periurethral, epididimary or prostate inflammations. The existence of urethral, vaginal or prostate secretion imposes direct examination on sample or culture. Urinalysis - leukocyturia (sediment, Addis-Hamburger test), urine culture identifies the germs and the microscopic urine antibiogram identifies the germs sensitivity. Echographic examination revelas prostate adenoma, vesical lithiasis etc. and/or vesical residue. Radiological examination is compulsory. KUB x-ray and IVU reveal medical conditions that are the direct causes of cystitis. Instrumental manoeuvres are contraindicated with acute phases of cystitits. TREATMENT The general principles pertaining to urinary infections must be complied with: chemo or antibiotics- therapy with high levelled urine concentration: sulphamids, urinary antiseptic (Nitrofurantoin, Negram); out of antibiotics quinolons are preferred.

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Urology Course Non-specific infections of the genitourinary system

Alcohol and condiments are contraindicated; light diet and highly hydric ingestion are recommended, as well as warm baths and heat application on the hypogastric region. Antialgics and antispastics are necessary The local and general favouring causes must be solved prevention of recidivations. 2. CHRONIC CYSTITIS It is a chronic infection of the urinary bladder caused by non specific germs. It may be the consequence of acute cystitis, of other disorders of the urinary tract that maintain the infection through stasis or of an adjacent genitary infection. Pathological anatomy. The persistence of vesical infection in the acute phase brings about chronic cystitis which is different from the acute cystitis through the character of the inflammatory infiltrate. In early stages of chronic cystitis the vesical mucosa gradually becomes edematous, congested and friable and may get ulcerated. In advanced stages of chronic inflammation, the submucosa is infiltrated with fibroblasts, lymphocytes and plasmocytes. The vesical wall gets thickened and develops fibrosis. Symptomatology is the same with acute forms. The symptomatic triad of cystitis is: polakiuria, pyuria and pain. Treatment may be effective provided that it cures the local and general favouring factors. ACUTE URETHRAL SYNDROME It consists of dysuria and polakiuria. A series of vesical or urethral symptoms associate (hypogastric or retro-pubis pain, dysuria, stinging and burning sensations after urination). Uroculture is sterile with these women. Causes maybe numerous: existence of a colpitis, a pretty large stenosis of the urethral meatus, prolaps of urethral mucosa, vulvular injuries, pre-menstrual or climacterium hormonal modifications, ovarian insufficiency (bilateral anexectomy). Some women with insignificant pyuria and bacteriuria usually have uretrocystitis and shall be treated with usuala antibiotics or chemotherapeutics. Some others have positive urocultures for the germs that may be sexually transmitted: these women and their partners shall betreated with antibiotics that have broad spectrum against Chlamydia trachomatis (Tetracicline, Erithromicin, Klacid), or against Neiseria gonorhaeae. There is for healing and

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Urology Course Non-specific infections of the genitourinary system

a reduced number of women that have neither pyuria nor identificable pathogenic germs and do not respond to the antimicrobial treatment they probably have vesical functional disfunctions.

II. NON SPECIFIC INFECTIONS OF THE MALE GENITARY TRACT

NON SPECIFIC PROSTATITIS Prostatitis includes both infectious inflammatory conditions of the prostate (acute and chronic bacterial prostatitis) and non bacterial inflammatory conditions of the prostate (nonbacterial prostatitis) and prostate painful conditions (prostatodynia). The criterion of this classification resides in the examination of the prostatic fluid/secretion obtained through prostate massage (expressed prostatic fluid/secretion). The urine and the expressed prostatic secretion obtained are divided into several fractions: 1. The first urinary fraction (FU1) represents the first 10 ml of urine; it represents the urethral bacterial protective lining. 2. The second urinary fraction (FU2) represents the sample of the middle urinary stream and translates the high vesical or urinary origin of the infection. 3. The expressed prostatic secretion is obtained as a result of prostate massage, after collection of FU2 and may identify the germs within cultures, as well as, microscopically, the presence of pus. 4. After expressed prostatic secretion is collected, the patient urinates another 10 ml of urine FU3. As FU3 contains also expressed prostatic secretion, this fraction receives prostatic significance when expressed prostatic secretion is not obtained through prostatic massage. INTERPRETATION OF FINDINGS The urine in the bladder must be sterile in order to differentiate urinary infection from prostatic infection through comparison between the number of germs in the urethral fraction (FU1) and the number of germs in the prostatic (expressed prostatic secretion and FU3). In case of urethral infection, the number of germs in FU1 is much higher than the number of germs in expressed prostate secretion or in the FU3. On the other hand, in

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Urology Course Non-specific infections of the genitourinary system

case of prostatic infection, the expressed prostatic secretion and the FU3 contain more germs than the FU1 and FU2. If the urine in the bladder is infected, all urine fractions shall contain a larger number of germs and so the sample cannot be interpreted but after the urine is sterilized. The study of the ejaculated fluids (culture, sediment, spermogram) may reveal potential participation of the seminal vesicles to the infectious prostatic process and thus clarify over a possible ethiology of sterility. 1. BACTERIAL PROSTATITIS A) ACUTE BACTERIAL PROSTATITIS ETHIOPATHOGENY Acute bacterial prostatitis is usually caused by aerobe Gram negative germs (E.Coli, Pseudomonas aeruginosa). As per some authors, enterococci (streptococcus faecalis) and other Gram positive germs are less accountable. The local favouring causes that are most often encountered are the sub-vesical obstructive lesions: urethral strictures, prostate adenoma, as well as the endoscopic maneuvers for diagnosis or therapeutic reasons. PATHOLOGICAL ANATOMY When it is about urethrogenic penetration means, the infection spreads in retrograde manner from the urethral mucosa, thorugh the tubes of the prostatic glands to the prostate glandular acini, causing apparition of microabscesses. In a more advanced stage, the microabscesses get united in large abscesses which remain on a single lobe or encapsulate the whole gland. Haematogenic means. From an infection focus at distance (sinusitis, dental granuloma etc.) blood transports the infection, which invades at first the interstitial tissue, then locates in the glandular tissue, causing abscess in a prostate that is apparently healthy or bearing a prostate adenoma. DIAGNOSIS Clinical symptoms: General symptoms: fever, shivering, malaise, myalgia, arthralgia, pain in the perineal or pelvic region.

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Urology Course Non-specific infections of the genitourinary system

Urinary symptoms: pollakiuria, dysuria, stringing sensations with urination, cloudy urine. The congestion of prostate causes sometimes acute retention of urine. Also, initial, terminal or more rarely total haematuria may be encountered.

DRE is extremely painful, sometimes impossible to undergo. The prostate is enlarged and very sensible. Sometimes one may feel at the level of one lobe a fluctuation which means that the abscess is forming. Laboratory. Leukocytosis - left deviation of the leukocyte formula. Urinalysis

presence of pus. Urine culture identifies the germs and their resistance. The prostatic massage is contraindicated: on the one hand because of the patients pains, on the other hand because it may cause bacteraemia. Echographic examination: in the stage when the abscess is formed, the suprapubis echography and especially the transrectal US reveal and accurately locate the abscess (transonic well determined area in one of the lobes or encompassing the whole gland). The instrumental methods of examination are contraindicated with acute prostatitis. In case of complete urinary retention, the bladder shall be drained through a Foley catheter or, more correctly, through a minima cystotomy that shall be maintained until healing of acute prostatitis. DIFFERENTIAL DIAGNOSIS The abscess of Cowper gland. The pain is felt in the perineum close to the medial line in a Cowper gland. Granulomatous prostatitis cannot be differentiated in acute stage from a bacterial prostatitis. In its chronic form it is difficult or impossible to clinically differentiate from a prostate cancer. The diagnosis cannot be made but histopathologically. EVOLUTION The evolution is usually favourable under antibiotics treatment. Complications appear in case of treatment that is incorrectly prescribed or undergone too late. Prostatic abscess. Fluctuation area in the prostate which is very painful during DRE. It usually opens spontaneously in the urethra and more rarely in the perineum.

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Urology Course Non-specific infections of the genitourinary system

Bacteriaemia, septic shock may appear with at patients with comorbidities. Acute epididimitis may be associated or secondary to acute prostatitis. Acute cystitis usually joins acute prostatitis. TREATMENT Being an acute inflammatory bacterial process caused by Gram negative germs,

aminoglycosides are usually administered: Gentamicine or Tobramicine - 3x80 mg before eating, combined with Ampiciline 4x2 g I.V or a cephalosporine. Favourable results are obtained also with the help of fluorquinolones: Ciprofloxacin, Levofloxacin (Tavanic). Rest in bed, antialgics, non specific inflammatory medication, hydration, light diet with no condiments. The urinary retention that may appear shall be solved through a minimal cystotomy. In case the prostatic abscess is already formed, the general therapeutic measures are identical. Additionally rectally or perineally puncture or incision shall be performed in order to drain the abscess. B) CHRONIC BACTERIAL PROSTATITIS ETHIOPATHOGENY The chronic bacterial prostatitis, as the acute one, is caused by the aerobe Gram negative germs. Aseries of Gram positive cocci are also accountable (streptococci, staphylococci). Rarely does chronic prostatitis have Chlamydia or Ureaplasma as pathogenic agents. In majority of cases it is associated with infection of seminal vesicles (prostate-vesiculitis). The infection penetration means is the same as with acute bacterial prostatitis. Moreover, chronic bacterial prostatitis appears as consequence of incorrectly trated acute bacterial prostatitis.

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Urology Course Non-specific infections of the genitourinary system

PATHOLOGICAL ANATOMY The inflammatory reaction is less intense and placed within the gland, as compared to the acute forms. It is noticed a lymphoplasmacellular inflammatory infiltrate at peri- and intra- levels of the prostate acini and in the stroma, which causes the increase in volume of a part of or of the whole gland (chronic hypertrophic prostatitis). When the inflammatory process is partial but disseminated into the whole gland, the chronic nodular prostatitis is diagnosed. DIAGNOSIS Clinical symptomatology is usually non-characteristic. Some patients are completely asymptomatic and diagnosis is made only because they have an asymptomatic bacteriuria accidentally discovered; most of the patients have irritative symptomatology (urgent need to urinate, pollakiuria) and less obstructive (dysuria). Patients also accuse pains in different regions of the perineum with radial spread in the inguinal, retropubic or hypogastric regions or in the gland. Psychosomatic disorders are present with the majority of patients: insomnia, neurasthenia, sexual disorders (painful erections and ejaculations with hemospermia). DRE: prostate with variable volume, even or nodular consistency. Laboratory the test of fractioned uroculture provides the exact diagnosis: in the expressed prostatic secretion more then 10 leukocites on the microscopic sample are identified, which represents a doubtless sign. When there is a secondary cystitis, in the FU2 fraction pyuria and bacteriuria are identified. Imagistic investigations. Echography may reveal more echogenic areas in the prostate (fibrosis) in the case of nodular prostatitis, or even echogenic areas with shadow cones (prostatic calculi). Radiology: retrograde uretrocystography- except for some uretroprostatic conditions (urethral strictures, prostate adenoma etc.) that are local favouring factors, it reveals the presence of prostatic pathological cavities communicating with the urethra. Endoscopic exploration discovers lesions of chronic urethritis, coliculitis and purulent secretions permeating from the orifices of prostatic canals.

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Urology Course Non-specific infections of the genitourinary system

EVOLUTION Chronic prostatitis may develop into fibrosis of the prostate parenchyma and sclerosis of the vesical tube. TREATMENT Antimicrobial treatment does not often succeeds in removing the germs from the prostate because most of the antibiotics and chemotherapeutics do not reach an optimal prostatic concentration. The following are used: Eritromicin, Clyndamicin, Vibramicin, Tetracicline and Quinolones (Ciprofoxacin, Levofloxacine). Antiinflammatory medication shall be associated, as well as warm bath and microenemas with antipirine. Surgical treatment. Some of the cases of chronic prostatitis located besides the urethral wall may be opened and drained into the urethra. Thus the favouring factors shall be solved too: urethral strictures, stenosis of urethral meatus etc. 2. NON BACTERIAL PROSTATITIS ETHIOLOGY This is the most frequent form of prostatitis. The cause is unknown. Males with non bacterial prostatitis have an increased number of leukocytes in the expressed prostatic secretion but germs cannot be identified. The efforts to identify different pathogenic agents (anaerobes, Chlamydia, Trichomonas, protozoa or viruses) were generally unsuccessful. PATHOGENESIS The ethiology and pathogenesis of non bacterial prostatitis are not known. The histopathological modifications resemble the ones encountered in chronic bacterial prostatitis. SYMPTOMATOLOGY It is non characteristic and overlaps the symptomatology of chronic bacterial prostatitis. Urethral secretion lacks and the DRE is not conclusive.

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Urology Course Non-specific infections of the genitourinary system

LABORATORY The test of the urine fractions identifies pus and absence of ordinary germs in the expressed prostatic secretion and the FU3. identified. TREATMENT When ethiologic agents are identified, giving the right treatment is not difficult to do; in the cases when germs are not identified, the supposition of prostatitis caused by Chlamydia or Ureoplasma must be made. Eritromicin or Doxyciline is administered for 14 days as they are effective against Chlamydia or Ureaplasma. 3. PROSTATODYNIA It seems to be a neuro-vegetative disorder in the male genitary system with no organic lesions. The infectious cause can be removed through the test of urine fractions, where cultures are negative and there are no leukocytes in the expressed prostatic secretion and the FU3. DIAGNOSIS The symptoms resemble the ones of prostatitis. The patiens accuses painful sensations of different intensity, from a simple discomfort to unbearable pain, appearing in perineum, hypogastric region or renal pelvis. Irritative urination disorders are associated: urgent need to urinate, pollakiuria especially related to cold and disorders of sexual appetite and potency. There are cases when patients accuse prostatorrhea or spermatorrhea during excretion. DRE reveals a prostate of normal volume or lightly increased and the sensitivity of the whole gland. By prostatic massage a serous and abundant fluid is obtained (retention). Psychomotor disorders are also present: irascibility, insomnia, neurasthenia and fatigue. Sometimes, with the help of special techniques, Chlamydia trachomatis, Ureoplasma urealyticum and viruses may be

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Urology Course Non-specific infections of the genitourinary system

DIFFERENTIAL DIAGNOSIS Differentiating from the chronic bacterial prostatitis is possible with the help of fractioned urocultures test. The anal-rectal syndrome encompasses the presence if hemorrhoids, anal fissures and fistulas, as well as lesions of proctitis revealed by proctoscopy. TREATMENT It is recommended to avoid cold and humidity, alcohol and condiments. Sedatives. Non specific anti-inflammatory medication (Phenilbutozone, Indometacin). Alpha blocking agents seem to have good results (Tamsulosin 4 mg/day). The treatment with antibiotics is useless, abusive and not efficient.

III. NON SPECIFIC INFECTIONS OF THE EPIDIDYMIS Due to the fact that specific epididymitis (tuberculosis and gonococci) play nowadays a secondary role, the most encountered cases of epididymitis are those of non specific epididymitis. The highest incidence is with young sexually active males and with patients with subvesical obstructive medical conditions. The first are associated with urthritis and usually have Chlamydia trachomatis as ethiologic agent (sexually transmitted epididymitis). Non specific bacterial epididymitis associated with UTI and bacterial prostatitis belong to the second category of patients; most often they are caused by Enterobacterias or Pseudomonas aeruginosa.

1. ACUTE EPIDIDYMITIS ETHIOPATHOGENY The infection reaches the epididymis through several ways: Ascending (deferential) way: the most frequent, it starts from the posterior urethra or prostate, wherefrom the pathogenic germs, due to the increased pressure during urination, may penetrate the ejaculating channels and along the vas deferens reach the epididymis. Lymphatic way (perideferential network) is also involved.

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Urology Course Non-specific infections of the genitourinary system

The hematogenic way implies a focus at distance whose ethiology is usually staphylococcus; yet, this way is rare. The local favouring factors are: pre-existent urethroprostatitis or subvesical osbstructive conditions (prostate adenoma after enucleation or transurethral resection; ejaculant ducts communicate directly with prostatic lodge), prrevious urethral strictures etc. PATHOLOGICAL ANATOMY The epididymis is swollen and has increased consistency. The infection usually

starts at the tail of epididymis and then extends to the whole organ. Sectionally numerous little abscesses are noticed. A reactive hydrocele might be encountered (vaginalis reflects the pathology of epididymis). Microscopically an inflammatory infiltrate with neutophils is encountered. SYMPTOMATHOLOGY The pain is extremely intense, at first localized and then irradiated along the whole sperm cord, inguinal duct to the iliac fosa. Fever and shiverings are associated with a rapid increase in volume of the epididymis. The hemiscrotum is increased in volume, with congested, edematous and warm teguments. When suppuration appears, the teguments become plae, thinner and fluctuating and the abscess may open spontaneously on the posterior side of the scrotum. DIAGNOSIS The sudden onset and characteristic symptomatology sometimes associated with urethral secretion with sexually active young males, with males having urethral stricture or having undergone surgery for prostate adenoma orientates the diagnosis towards acute epididymitis. The urinalysis and urine culture identify or remove the possibility of infection with ordinary germs. Echography the epididymis is increased in volume, presenting transonic echostructure (congestion and oedema) or with small dispersed transonic areas (microabscesses). Some other times a large transonic area is revealed (already formed abscess). The whole testis and epididymis may be encompassed in a transonic cavity (reactive hydrocele).

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Urology Course Non-specific infections of the genitourinary system

DIFFERENTIAL DIAGNOSIS 1. Tuberculous epididymitis in its acute form it has identical symptomathology. The presence of specific antecedents, acide sterile pyuria and positive baciloscopy help making a diagnosis. The presence of b. Coli in the cultures on specific environments reinstates the diagnosis. 2. Testicular tumours. The testicular tumoural mass is clearly distinguished from the normal epididymis. The inflammatory signs of the scrotum and sperm cord are usually absent. The echography reveals the testis that is enlarged in volume, usually with non homogenous structure or a hypoechogenic area surrounded by healthy tissue. Some other times transonic areas within tumoural mass may be discovered (tumoural necrosis). 3. Spermatic cord torsion. With sudden onset, during the night, the epididymis is placed in front of the testis, at first, and then forms a unique and very sensitive mass. The testis is raised towards the internal orifice of the inguinal duct. The smooth raising of the scrotum is followed by calming down the pain in case of epididymitis and accentuating pain in case of spermatic cord torsion (prehn sign). Doppler investigation identifies the absence of pulsations of spermatic artery in torsion. The echography is not specific as the echographic aspect of the affected testis resembles the one in the case of orchiepidedymitis. 4. Acute orchitis. The echography is not specific but may identify the increase in volume of the testis and epididymis, which have a more transonic aspect due to the inflammatory process. The inflammation of the epididymis and testis may be joined by a reactive hydrocele; this is also visualized within echography. EVOLUTION In acute stage the resolution of the inflammation of the epididymis is achieved with a consequent induration at the level of the tail of epididymis or of the whole organ. The abscess forms end in fistulas with characteristic locating on the posterior side of the scrotum.

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Urology Course Non-specific infections of the genitourinary system

TREATMENT The inappropriate or inefficient treatment brings about the chronicization of the infection. Bed rest is compulsory for 10 15 days. Pain is killed by administration of antialgics and by infiltration of the sperm cord with Xiline 1%. Local cold applications are very important (ice bags): on the scrotum that has precviously been raised in fixed in position. Non specific anti-inflammatory agents are beneficial too (Phenylbutazone, Indometacin, Diclofenac). Antibiotherapy: Tetracicline, Doxyciline, Ciprofloxacin, Levofloxacine or other quinolones present high chances to heal due to the optimal diffusion in the acute inflammatory process. Surgical treatment is indicated when abscesses are formed or opened and consists in orchiectomy. 2. CHRONIC EPIDIDYMITIS It represents the irreversible result of an acute epididymitis that has been incorrectly treated. Chronic epididymitis is characterised by fibrosclerous reactions with total or partial induration of epididymis and occlusion of tubules. When the process is bilateral this constitutes a cause of sterility. Clinically the only syndrome is diffuse pain that the patient feels at the level of that hemiscrotum, giving a sensation of uneasiness. The epididymis and the sperm cord are thickened. Non specific inflammatory lesions of the prostate or urethra may be present. US - the epididymis has variable volume non- precisely delimitated from the testis and hyperechogenic image due to the sclerosis process. Sometimes it may be visualized a secondary reative hydrocele. DIFERENTIAL DIAGNOSIS Tuberculous epididymitis from the palpatory point of view it is very similar to chronic epididymitis; the two medical conditions are impossible to delimitate exclusively on the basis of clinical investigations. Palpation of seminal vesicles on the same thickened side, acide sterile pyuria and baciloscopy are essential to make a diagnosis of the tuberculous epididymitis.

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Urology Course Non-specific infections of the genitourinary system

Testicular tumours. Careful bimanual palpation differentiates a normal epididymis from a testis that is enlarged in volume and weight and has the specific organ sensibility lost. TREATMENT

The chronic inflammatory tissue with the fibrosclerosis processes hinders the diffusion of antibiotics in the inflammatory process. Treatment of a potential UTIs or of an existent prostatitis is recommended. In case symptomathology persists, epididyctomy may be performed and thus the histopathological examination which can make a doubtless positive diagnosis.

IV. NON SPECIFIC INFECTIONS OF MALE URETHRA 1. ACUTE URETHRITIS ETHIOPATHOGENY In case of iatrogenic infections (endoscopic maneouvers for making a diagnosis or for theraphy), the accountable germs are the known Gram negative and Gram positive ones. The sexually transmitted urethritis (non-gonoccocal) is caused by Chlamydia and Mycoplasma. The non specific urethritis is usually the consequence of ascending infections but may have prostate as starting point, when the formation mechanism is descending. PATHOLOGICAL ANATOMY In case of acute form the mucosa is congested, edematous and may present ulcerations. Periurethritis is frequent with severe forms and the periurethral abscesses may appear immediately or too late. The periurethral glands are interested too. SYMPTOMATHOLOGY The acute non specific urethritis manifests similarly to the gonoccocal urethritis through abundant purulent urethral discharge joined by urination disorders (pollakiuria, urgent need to urinate, burning sensations at urination). The urethral meatus is congested, edematous. Laboratory examinations. The native sample identifies Trichomonas and the Gram staint identifies the non-specific germs. In the absence of above mentioned

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Urology Course Non-specific infections of the genitourinary system

microroganisms and of Candyda albicans, the ethiology of urethritis is virotic; Chlamydia and Mycoplasma should be considered as possible ehiological agents. In acute stage the instrumental examination of urethra and of other segments of the urinary tract is contraindicated. DIFFERENTUAL DIAGNOSIS The microscopic examination of the urethral secretion differentiates the various ethiological forms from urethritis. COMPLICATIONS The periurethral abscess usually appears as a result of instrumental maneuvers performed in acute stage. Epididymitis, prostatitis and cystitis appear as a result of the ascending extension of the inflammatory process. TREATMENT Chemotherapy or antibiotherapy focused as per the ethiology and antibiogram findings. The sexually transmitted urethritis (nongonoccocal) is treated with 2nd generation tetraciclins (Doxyciline). Erithromicine is another efficient antibiotic. The mycotic urethritis is treated with antifungics (Stamicin, Nistatin). The trichomoniazic urethritis is treated with Metronidazol and Fasigyn. Intermittent smooth catheterism with catheters of thin calyber may be performed in case of acute complete urine retention, or, more correctly, an a minima cystotomy with temporary character should be made. 2. CHRONIC URETHRITIS It is the consequence of acute non specific urethritis that has been treated inappropriately. Some other times it is the result of a sexually transmitted nongonoccocal urethritis. ETHIOPATHOGENY The pathogenic agents are identical with those encountered at acute urethritis. PATHOLOGICAL ANATOMY The purulent discharge is less abundant and the urinary symptoms are more alleviated. The urethral mucosa is slightly granular. The infection extends to the prostate and seminal vesicles; at the level of urethra, urethral strictures may be born.

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Urology Course Non-specific infections of the genitourinary system

DIAGNOSIS The urethral secretion and symptoms are a lot more reduced as intensity, as compared to acute forms. The laboratory examination may reveal the germs described within the acute form. Radiological examination the retrograde urethrocistography usually identifies the favouring factors: anomalies, strictures etc. with location in the urethra. Urethrocystoscopy reveals the inflammation of urethral mucosa, diverticular orifices and urethral stricture. The purulent discharge through the orifices of prostatic glands suggests prostatitis as consequence of urethritis. DIFFERENTIAL DIAGNOSIS Chronic urethritis differentiates on the basis of laboratory tests. COMPLICATIONS consist of spreading of the urethral infections to the prostate, bladder and even ascending urinary tract. Locally the most frequent complications are the urethral strictures and, more rarely, periurethritis. TREATMENT. The treatment of chronic urethritis is given in closerelationship to the ethiology. The primary treatment of urethral strictures consists in internal urethrotom. The Otis urethrotomy is applied in cases of strictures of the anterior urethra, while for posterios urethra the internal optical urethrotomy (Sachse) is performed. PERIURETHRITIS It represents the inflammatory process of the periurethral tissues. Reported to its evolution, it may be acute and chronic; reported to the limits of the lesions, periurethritis may be circumscribed or diffuse. ETHIOPATHOGENY Periurethral tissues are infected through septic inoculation. This is favoured by lesions of the urethra such as: strictures, accidental or surgical plagues, urethral calculi, permanent urethral catheter etc. Out of all these, mostly strictures cause onset of periurethritis through chronic suprastrictural urethritis which may complicate in inflammations of Littre and Cowper glands, in phlebitis of the erectile tissue or in

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Urology Course Non-specific infections of the genitourinary system

lymphangitis. Out of these foci the infection may extend to the periurethral tissue, where it may undertake one or the other form. Germs are usually anaerobes (Clostridium perfringens, b. fragilis, and b. funduliformis). THE CIRCUMSCRIBED PENILE PERIURETHRITIS has superficial or profound urethral origin with starting point in a urethral stricture or in urethritis that, by extension, has encapsulated the periurethral tissue. The patient has a limited swollen part on the urethra trajectory. The lesion is associated with fever; it is painful, presents fluctuations and opens spontaneously in the urethra or on the skin, being followed by a urinary fistula. THE DIFFUSE PENILE PERIURETHRITIS (gangrene of the genitary organs developing extremely rapid) is mostly encountered with young males. The penetration orifice is usually represented by the prepuce. The germs are represented by streptococcus and anaerobe agents. The disease has an extensive and necrosis producing character. The onset is sudden, joined by fever, shivering strokes, malaise and cephalea. The prepuce is edematous, congested; the inflammatory process extends along the penis up to the scrotum. Thereafter lesions and partial necrosis appear and the general health state is profoundly alterated. Differential diagnosis is made against the diffuse perirenal phlegmon that expanded to the penis. Under correct antibiotics treatment the tissues undergoing necrosis are removed; healing is obtained with vicious scars that need plastic surgery. Out of pulmonary complications death may survene. TREATMENT consists in antibiotherapy in profound incisions along the penis; continuous washing showers and locally administered antibiotics are undertaken. Antigangrenous serum is also administered. DIFFUSE PERIURETHRAL PHLEGMON is the most severe form of periurethritis. It occurs with patients that have organic medical conditions (diabetes, CKF). The infection is rapidly spread towards scrotum, penis and pubis; crepitations, lesions and sphacels. One should also mention: high fever, shivering strokes, profound alteration of general health condition, sleepiness, obnubilation.

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Urology Course Non-specific infections of the genitourinary system

Treatment is given in emergency manner: phlegmon, drainage, oxygenated water,

cystotomy, wide opening of the Wide spectrum antibiotics.

Rivanol.

Metronidazol, anti-gangrenous serum, support of the general health condition of the patient. If the patient remains alive, plastic surgery of the penis and treatment of the urethral strictures shall be done thereafter. 5. BALANOPOSTHITIS It is an inflammation of the glans penis and of the prepuce. ETHIOPATHOGENY. The pathogens are represented by the Gram positive and Gram negative germs; rarely it may be caused by fungi.The lesions are favoured by stagnation of secretions as consequence of precarious hygiene or of neglected phimosis. It is manifested in pruritus and burning sensations and further on the prepuce gets edematous and painful. The purulent secretion is discharged through the fireskins slot. The medical condition may cause, especially with children, balanopreputial adherence. TREATMENT With cases that are not severe local hygiene with camomile infusions or disinfecting substances: silver nitrate, mercuric oxide, Rivanol, hydrogen borate are necessary; if these fail, circumcision (postectomy) is necessary.

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