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1、Urinary tract infection 尿路感染,Case,23y woman, unmarried She complained the painful urination (like burning sensation), frequent urination (every 10-20min) and urge to urinate Her urine is muddy No fever, No flank pain Swimming,Introduction,Urinary tract infection (UTI) is the most common of all bacte
2、rial infections, affecting humans throughout their life span. Not only is UTI common, but the range of clinical effects it can produce is exceptionally broad, from acute pyelonephritis with gram-negtive sepsis to asymtomatic bacteriuria.,Introduction,UTI upper pelvic 肾盂 calyx 肾盏 ureter 输尿管 lower bla
3、dder 膀胱 urethra 尿道 pyelonephritis ureteritis cystitis urethritis Female:male 10:1,Definition,UTI: a broad term that encompasses both asymptomatic microbial colonization of the urine and symptomatic infection with microbial invasion and inflammation of urinary tract structures.,Terms,Acute pyelonephr
4、itis (急性肾盂肾炎): a pyogenic, focal infection of the renal parenchyma accompanied by local and systemic symptoms of infection. Chronic pyelonephritis（慢性肾盂肾炎）: the pathologic and radiologic findings of chronic cortical scarrings, tubulointerstitial damage, and deformity of the underlying calyx. Cystitis
5、 （膀胱炎）：inflammation of the bladder, specifically, inflammation of the wall of the bladder.,Pathogen,Gram-negtive enterobacteria is the most common 95% E.coli大肠杆菌 60-80% Proteus mirabilis 变形杆菌 Klebsiella sp克雷伯杆菌 Pseudomonas sp 绿脓杆菌 (urinary tract instrumentation) Serratia sp 沙雷杆菌 Gram-positive organi
6、sms 5-10% Streptococcus faecalis 粪链球菌 Staphylococcus aureus 金黄色葡萄球菌 Staphylococcus albus 白色葡萄球菌 Fungi 真菌 Yeasts 原虫 Viruses 病毒,Lithangiuria（尿路结石）,Possible routes of infection,Ascending infection Most UTI are believed to occur by the ascending route. urethrabladderureterpelviscalyx parenchyma Hematoge
7、nous infection Relatively rare Staphylococcal bacteremia 金葡菌血症 Intestine to kidney by way of lymphatics 盆腔器官炎症 阑尾炎 结肠炎 Direct infection 外伤 肾周器官感染,Ascending infection： urethrabladderureterpelviscalyx parenchyma,Hematogenous infection： circulation parenchyma calyx pelvis,The defence mechanism of urina
8、ry tract,Valve at the junction of ureter and bladder. The dilution and removal of bacteria in urine which occurs with micturition. The high concentration of urea and low pH in urine restrict the growth of bacteria. Antibacterial ability of mucosa: secret IgA, IgG. Prostatic fluid,Factors predisposin
9、g to infection,Obstruction to the flow of urine anywhere from the kidney to urethra is well recognized as the most important predisposing cause. Congenital abnormalities such as polycystic kidney disease 多囊肾, vesicoureteral reflux 膀胱输尿管返流. urinary tract instrumentation Female urethra Disturbence of
10、immune capacity such as diabetes, anemia, chronic hepatic disease, chronic kidney disease, tumor and so on. Inflammation of near area Other factors,Pathology - Acute Phase,Macroscopic examination: Mucosa is edematous and congestive, and contain a variable number of abscesses on the capsular surface
11、and on cut sections of the cortex and medulla. Occasionally, areas of inflammation extend from the cortex into the medulla in the shape of wedge.,Pathology - Acute Phase,Histologic changes: Tubular epithelial cells are edematous, necrosis and detach from basement membrane. Some tubules are damaged a
12、nd others are destroyed, many tubules contain leukocytes. Acute inflammation with polymorphonuclear leukocyte infiltraton may be found. The glomeruli and blood vessels are relatively free of inflammatory changes.,Pathology - Chronic Phase,Macroscopic examination: Parenchymal scarring and underlying
13、caliceal deformity. The kidneys are frequently irregular, and reduction in size is often unilateral or asymmetrical. The kidney usually has flat-based or U-shaped scars.,Chronic pyelonephritis. Note the irregularly scared kidney, dilated and blunted calices.,Chronic pyelonephritis broad scars in a p
14、atient with chronic VUR.,Pathology - Chronic Phase,Histologic changes: increase in interstitial fibrous tissue tubule atrophy and necrosis periglomerular fibrosis,Clinical presentations,Lower UTI Absence of systemic symptoms Local manifestations: Dysuria, frequancy and nocturia. Back and loin pain (
15、with exquisite tenderness on percussion of the costovertebral angle). Urine: Cloudy urine, pyuria, hematuria.,Clinical presentations,Acute pyelonephritis Systemic symptoms: rigors and high fever, often with fatigue, nausea and vomiting, abdominal pain or diarrhea. Local manifestations: Dysuria frequ
16、ancy, and nocturia. Back and loin pain (with exquisite tenderness on percussion of the costovertebral angle). Urine: Cloudy urine, pyuria.,Clinical presentations,Chronic pyelonephritis Asymptomatic bacteriuria, dysuria and frequency, vague complaints of flank or abdominal discomfort, and intermittent low-grade fevers. May be divided into the following five types: Recurrent type; Low-grade fever type; Hematuria type; Insidious type; Hypertension type,
