泌尿生殖道感染.pptx

泌尿生殖道感染泌尿生殖道感染泌尿生殖道感染第1页 Urinary tract infections(UTIs)caused by pathogenic bacteria can involve any of the genital or urinary organs and eventually can spread from one site to anyor all of the others.泌尿生殖道感染第2页Definitions 1Definitions 1 Urinary tract infection is an inflammatory response of the urothelium to bacterial invasion that is usually associated with bacteriuria and pyuria.泌尿生殖道感染第3页Most UTIs are caused by aerobic gram-negative rods,(Escherichia coli.),gram-positive cocci(enterococci)and to a lesser extent by anaerobic bacteria.Definitions 2Definitions 2泌尿生殖道感染第4页Definitions 3Definitions 3Bacteriuria is the presence of bacteria in the urine,which is normally free of bacteria,and implies that these bacteria are from the urinary tract and are not contaminants from the skin,vagina,or prepuce.泌尿生殖道感染第5页Definitions 4Definitions 4Pyuria is the presence of white blood cells in the urine Bacteriuria without pyuria indicates bacterial colonization rather than infection.Pyuria without bacteriuria warrants evaluation for tuberculosis,stone,or cancer.泌尿生殖道感染第6页 Classification泌尿生殖道感染第7页According to their nature history First infections/Isolated InfectionRecurrent infections Bacterial persistence Reinfections泌尿生殖道感染第8页Reinfection is recurrent infection with different bacteria from outside the urinary tract.Each infection is a new event;the urine must show no growth after the preceding infection.泌尿生殖道感染第9页Bacterial persistence refers to a recurrent urinary tract infection caused by the same bacteria from a focus within the urinary tract,such as an infection stone or the prostate.泌尿生殖道感染第10页According to Their Site of OriginUpper urinary tract infection Lower urinary tract infectionGenital system infection泌尿生殖道感染第11页泌尿生殖道感染第12页Upper-tract infectionAcute pyelonephritisChronic pyelonephritisEmphysematous pyelonephritisRenal abscess Perinephric abscessXanthogranulomatous pyelonephritis泌尿生殖道感染第13页Lower-tract infectionAcute urethral syndrome(Women)Acute cystitis泌尿生殖道感染第14页 Genital infectionAcute and chronic bacterial prostatitis.Acute and chronic epididymitis.泌尿生殖道感染第15页PathogenesisBacterial pathogenesis in the urinary tract depends on a number of facters,chief of which are the Bacterial Virulence Facters and the Host Susceptibility Factor泌尿生殖道感染第16页 Bacterial virulence factors Ability of adherence to urothelial cells Ability to resist bactericidal activity Ability to produce hemolysin.泌尿生殖道感染第17页 Host susceptibility factorsEmptying of urineSurface mucins Urinary antibodiesUrinary osmolalitypH泌尿生殖道感染第18页Routes of infection(1)Ascending infection(2)Hematogenous spread(3)Lymphatogenous spread(4)Direct extension 泌尿生殖道感染第19页泌尿生殖道感染第20页泌尿生殖道感染第21页泌尿生殖道感染第22页 DIAGNOSIS泌尿生殖道感染第23页Urine CollectionSuprapubic AspirationUrethral CatheterizationSegment Voided Urine Specimens泌尿生殖道感染第24页泌尿生殖道感染第25页Urinlysis More than 3 fresh leukocytes/High-power field泌尿生殖道感染第26页Quantitative urine culture Colonies forming units per milliliter(cfu/ml)100,000 cfu/ml 1000 to 10,000 cfu/ml 泌尿生殖道感染第27页Location of urinary tract nfection.Symptoms and signsLaboratory findingsX-Ray findingsRadionuclide imagingMRI findings泌尿生殖道感染第28页 Treatment strategy.Antimicrobial drug Mdication for pain,fever,and nausea.To give fluids intravenously and orally Complicating factors(eg.Obstructive urography or infected stones)泌尿生殖道感染第29页 Acute Pyelonephritis泌尿生殖道感染第30页DefinitionsDefinitionsAcute pyelonephritis is defined as inflammation of the parenchyma and the pelvis of the kidney causing by bacterial infection.泌尿生殖道感染第31页Etiology&PathogenesisAerobic gram-negative bacteria E coli Gram-negative entric organisms Enterococci,and staphylococcus aureusAscending infection (VUR)Hematogenous泌尿生殖道感染第32页Clinical findings 1An abrupt onset of chill,moderate to high fever Dysuria,frenquency,urgency.Abdominal pain,nausea,vomiting,and even diarrhea.泌尿生殖道感染第33页Clinical findings 2Costovertebral angle tendernessPalpation or percussion over the costovertebral angle on the affected kidney usually causes pain.The patient sometimes has abdominal distention,tenderness,and a quiet intestine泌尿生殖道感染第34页Dignosis 1Laboratory findings:Leukocytosis Pyuria,Bacteriuria,Proteinuria,HematuriaQuantitative urine culture Total renal function泌尿生殖道感染第35页 Dignosis 2Imaging:Plain film Excretory urograms .Voiding cystogram CT Ultrasonography Radionuclide泌尿生殖道感染第36页Differential DiagnosisPancreatitis Basal pneumonia Acute-intra-abdominal disease Women pelvic inflammatory diseaseand acute prostatitis Renal abscess Perinephric abcess.泌尿生殖道感染第37页 Treatment 1 Antimicrobial drugs:The appropriate intravenous treatment Oral drug Repeat urine cultures泌尿生殖道感染第38页 Treatment 2Specific measures:Any complicating factors(eg.obstructive urography)泌尿生殖道感染第39页 Prostatitis泌尿生殖道感染第40页Types of protatitisDrach(1978)(1)acute and chronic bacterial prostatitis,(2)nonbacterial prostatitis(3)prostatodynia.泌尿生殖道感染第41页 NIDDK categorization and Drach classificationNIDDK Classification(1995)Drach classification(1978)Category 1 Acute bacterial prostatitis Acute bacterial prostatitis Category 2 Chronic bacterial prostatitis Chronic bacterial prostatitis Category 3 Chronic pelvic pain syndrom 3a Inflammatory typeNonbacterial prostatitis 3b Noninflammatory type ProstatodyniaCategory 4 Asymptomatic inflammatory prostatitis泌尿生殖道感染第42页Diagnostic techniquesThe expressed prostatic secretions(EPS)Leukocytes 10 per high-power field(hpf)泌尿生殖道感染第43页泌尿生殖道感染第44页泌尿生殖道感染第45页泌尿生殖道感染第46页The 4-glass test(Stamey 1968)Urethritis CystitisprostatitisVB1 +/-/+VB2 -+-EPS -/+(10 times than VB1)VB3 -/+泌尿生殖道感染第47页泌尿生殖道感染第48页泌尿生殖道感染第49页 Acute bacterial prostatitis泌尿生殖道感染第50页Etiology&Pathogenesis E coli 80%Enterococci 5-10%Anaerobes rarely Intraprostatic reflux of urine Invasion by rectal bacteria Hematogenous spread 泌尿生殖道感染第51页Clinical features The sudden onset of fever,chills.Low back and perineal pain.Frenquency and urgency,nocturia,dysuriaVarying degrees of bladder outlet obstruction.泌尿生殖道感染第52页Digital rectal examination(DRE)Tender,swollen prostate gland,irregularly firm and warmUrine may be cloudy and malodorous,and gross hematuria is observed泌尿生殖道感染第53页Diagnosis A complete blood count shows leukocytosis with a shift toward immature forms.The voided urine shows pyuria,microscopic hematuria,and bacteria.Culture of voided urine sample usually identifies the pathogensUltrasonography泌尿生殖道感染第54页TreatmentAntibiotic treatment for 4-6 weeks Supportive measures include antipyretics,analgesics,stool sorfteners,hydration,and bed rest.Any transurethral catheterization or instrumentation is contraindicated.Acute urinary retention should be managed with suprapubic drainage 泌尿生殖道感染第55页Chronic bacterial prostatitis泌尿生殖道感染第56页Etiology&PathogenesisThe gram-nagative organismsThe gram-positive organismsMycoplasmal,chlamydial speciesIntraprostatic reflux of urinepH of prostatic secretionsZinc 泌尿生殖道感染第57页Clinical findings 1Irritative voiding dysfunction(dysuria urgency,frequency,nocturia)Low back or perineal painSexual dysfunctionMyalgia and arthralgia Other symptoms泌尿生殖道感染第58页Clinical findings 2DRE:normal,tenderness,swelling,firmnessSecondary epididymitis Hematouria,hematospermia,urethral discharge泌尿生殖道感染第59页DiagnosisThe 4-glass testThe expressed prostatic secretions(EPS)Leukocytes 10 per high-power field(hpf)Sonography泌尿生殖道感染第60页判别诊疗II型和III型应与可能造成骨盆区域疼痛和排尿异常疾病进行判别诊疗间质性膀胱炎、睾丸附睾和精索疾病、肛门直肠疾病、腰椎疾病BPH、膀胱过分活动症、神经原性膀胱膀胱肿瘤、前列腺癌泌尿生殖道感染第61页治疗标准慢性前列腺炎无明确进展性，不足以威胁患者生命和主要器官功效，并非全部前列腺炎均需治疗。慢性前列腺炎治疗目标主要是缓解疼痛、改进排尿症状和提升生活质量，疗效评价应以症状改进为主。前列腺炎应采取综合治疗。泌尿生殖道感染第62页治疗方法治疗方法 一、一、型型一旦临床诊疗或得到血、尿培养结果后，应马上应用一旦临床诊疗或得到血、尿培养结果后，应马上应用抗生素。抗生素。开始时可经静脉应用抗生素，如：广谱青霉素、三代开始时可经静脉应用抗生素，如：广谱青霉素、三代头孢菌素头孢菌素、氨基糖甙类或氟喹诺酮等。、氨基糖甙类或氟喹诺酮等。待患者发烧等症状改进后，改用口服药品（如氟喹待患者发烧等症状改进后，改用口服药品（如氟喹 诺酮等），疗程最少诺酮等），疗程最少4周。周。并发症处理：并发症处理：伴尿潴留者伴尿潴留者细管导尿或膀胱穿刺造瘘。细管导尿或膀胱穿刺造瘘。伴脓肿形成者伴脓肿形成者可采取穿刺引流、经尿道切开引可采取穿刺引流、经尿道切开引流流泌尿生殖道感染第63页治疗方法治疗方法二、二、型和型和型型（一）普通治疗（一）普通治疗：健康教育、心理和行为辅导有主动作用。健康教育、心理和行为辅导有主动作用。慢性前列腺炎患者应戒酒，忌辛辣刺激慢性前列腺炎患者应戒酒，忌辛辣刺激食食 物；防止憋尿、久坐，注意保暖，加强物；防止憋尿、久坐，注意保暖，加强体育锻炼。体育锻炼。热水坐浴有利于缓解疼痛症状。热水坐浴有利于缓解疼痛症状。泌尿生殖道感染第64页治疗方法治疗方法 二、二、型和型和型型 （二）药品治疗（二）药品治疗 1抗生素抗生素 2-受体阻滞剂受体阻滞剂 3非甾体抗炎镇痛药非甾体抗炎镇痛药 4植物制剂植物制剂 5M-受体阻滞剂受体阻滞剂 6抗抑郁药及抗焦虑药抗抑郁药及抗焦虑药 7中医中药中医中药 泌尿生殖道感染第65页治疗方法治疗方法 抗生素抗生素 型：型：依据细菌培养结果和药品穿透前列腺能力选择抗生依据细菌培养结果和药品穿透前列腺能力选择抗生素。药品穿透前列腺能力取决于其离子化程度、脂素。药品穿透前列腺能力取决于其离子化程度、脂溶性、蛋白结合率、相对分子质量及分子结构等。溶性、蛋白结合率、相对分子质量及分子结构等。常见抗生素是氟喹诺酮类药品（如环丙沙星、左氧常见抗生素是氟喹诺酮类药品（如环丙沙星、左氧氟沙星和洛美沙星等）、氟沙星和洛美沙星等）、四环素类（如米诺环素等）四环素类（如米诺环素等）和磺胺类（如复方新诺明）。和磺胺类（如复方新诺明）。前列腺炎确诊后，前列腺炎确诊后，抗生素治疗疗程为抗生素治疗疗程为46周周，泌尿生殖道感染第66页治疗方法治疗方法 A型：型：抗生素治疗大多为经验性治疗。抗生素治疗大多为经验性治疗。推荐先口服氟喹诺酮或四环素等类抗生素推荐先口服氟喹诺酮或四环素等类抗生素24周，然后周，然后依据其依据其 疗效反馈决定是否继续抗生素治疗。疗效反馈决定是否继续抗生素治疗。只有当患者临床症状确有减轻时，才提议继续应用抗只有当患者临床症状确有减轻时，才提议继续应用抗生素。推荐总疗程为生素。推荐总疗程为4 6周。周。个别患者可能存在衣原体、支原体等病原体感染，个别患者可能存在衣原体、支原体等病原体感染，可可口服四环素类或大环内酯类抗生素治疗。口服四环素类或大环内酯类抗生素治疗。B型：不推荐使用抗生素治疗。型：不推荐使用抗生素治疗。泌尿生殖道感染第67页治疗方法治疗方法-受体阻滞剂受体阻滞剂-受体阻滞剂能松弛前列腺和膀胱等部位平滑肌而改受体阻滞剂能松弛前列腺和膀胱等部位平滑肌而改进下尿路症状和疼痛，为治疗进下尿路症状和疼痛，为治疗型型/型前列腺炎型前列腺炎 基础药品之一。基础药品之一。可选择不一样可选择不一样-受体阻滞剂治疗。常见药品有：阿夫受体阻滞剂治疗。常见药品有：阿夫唑嗪、多沙唑嗪、萘哌地尔、坦索罗辛和特拉唑嗪等。唑嗪、多沙唑嗪、萘哌地尔、坦索罗辛和特拉唑嗪等。-受体阻滞剂疗程最少应在受体阻滞剂疗程最少应在12周以上。周以上。治疗中应注意治疗中应注意该类药品造成眩晕和体位性低血压等不良反应。该类药品造成眩晕和体位性低血压等不良反应。a型前列腺炎单一使用抗生素或型前列腺炎单一使用抗生素或-受体阻滞剂疗效不受体阻滞剂疗效不佳时，可二者联合使用，疗程佳时，可二者联合使用，疗程6周以上。周以上。泌尿生殖道感染第68页治疗方法治疗方法 非甾体抗炎镇痛药非甾体抗炎镇痛药 非甾体抗炎镇痛药是治疗非甾体抗炎镇痛药是治疗型前列腺炎型前列腺炎相关症状经验性用药。其主要目标是缓相关症状经验性用药。其主要目标是缓解疼痛和不适。解疼痛和不适。迄今为止，只有数项随机、抚慰剂对照迄今为止，只有数项随机、抚慰剂对照研究评价这类药品疗效。研究评价这类药品疗效。临床对照研究证实塞来昔布对改进临床对照研究证实塞来昔布对改进a型型前列腺炎患者疼痛等症状有效。前列腺炎患者疼痛等症状有效。泌尿生殖道感染第69页治疗方法治疗方法 植物制剂植物制剂 为为型和型和型前列腺炎可选择辅助治疗方法。型前列腺炎可选择辅助治疗方法。主要指花粉类制剂与植物提取物，其药理作主要指花粉类制剂与植物提取物，其药理作用较为广泛，如非特异性抗炎、抗水肿、促用较为广泛，如非特异性抗炎、抗水肿、促 进膀胱逼尿肌收缩与尿道平滑肌松弛等作用。进膀胱逼尿肌收缩与尿道平滑肌松弛等作用。常见植物制剂有：普适泰等。常见植物制剂有：普适泰等。泌尿生殖道感染第70页治疗方法治疗方法 M-受体阻滞剂受体阻滞剂 对伴有膀胱过分活动症（对伴有膀胱过分活动症（OAB）表现，）表现，如尿急、尿频和夜尿但无尿路梗阻前列如尿急、尿频和夜尿但无尿路梗阻前列腺炎患者，能够使用腺炎患者，能够使用M-受体阻滞剂托特受体阻滞剂托特罗定治疗。罗定治疗。泌尿生殖道感染第71页治疗方法治疗方法手术治疗手术治疗 经尿道膀胱颈切开术、经尿道前列腺切经尿道膀胱颈切开术、经尿道前列腺切除术或根治性前列腺切除术对于慢性前除术或根治性前列腺切除术对于慢性前列腺炎极难起到治疗作用，只在合并前列腺炎极难起到治疗作用，只在合并前列腺相关疾病有手术适应证时选择上述列腺相关疾病有手术适应证时选择上述手术。手术。泌尿生殖道感染第72页治疗方法治疗方法IV型型普通无需治疗。普通无需治疗。患者如合并血清患者如合并血清PSA升高或不育症等，升高或不育症等，应注意判别诊疗并进行对应治疗。应注意判别诊疗并进行对应治疗。PSA升高者应用抗生素治疗有利于前列升高者应用抗生素治疗有利于前列腺癌判别诊疗。腺癌判别诊疗。泌尿生殖道感染第73页TreatmentAntibiotics (at least 6 weeks)Alpha blockerPhysical therapySurgical therapy 泌尿生殖道感染第74页泌尿生殖道感染第75页