1. Urinary Tract Infection and Urodynamics Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. Urinary Tract Infection • Acute infection • Chronic infection • Non-specific UTI • Granulomatous UTI- Tuberculosis • Genital tract infection • Complicated UTI- Surgery, Calculi

3. Acute Cystitis • The most common form of Female UTI • Annual incidence 0.5-0.7/person-year • 25% of women have recurrent UTI • 1/3 of women have recurrent cystitis within 3 months, 75-80% recur within 2 years • Sporadic or recurrent cystitis

4. Pathogenesis of recurrent UTI • Bacterial factors – Longer duration of colonization of vaginal introitus with pathogenic E. coli • Host factors –Women with recurrent UTI are 3-4 times more likely to be nonsecretors of ABH blood-group antigen

5. Pathogenesis of recurrent UTI • Immune status – local and systemic immune response are weak in women with recurrent UTI • Estrogen depletion – Increased susceptibility of UTI in post-menopause women, a lower glycogen content in vaginal epithelium, vaginal bacterial flora shift toward E. coli & G(-) bacilli

6. Pathogenesis of recurrent UTI • Anatomical factors – Distal urethral meatal stenosis, uterine prolapse, cystocele, increased postvoid residual urine • Microbial ecology – Lack of inhibitory effects of hydrogen peroxide producing lactobacilli against pathogenic micro-organisms including E. coli

7. Treatment of Acute cystitis • First line antibiotics for 7 days • 90% self-treatment cure rate • Routine culture before therapy is not necessary • Prophylactic therapy (>2 UTI / 6Mo) decreases recurrence rate by 95% • Nitrofurantoin or sulfamethoxazole once daily for 6 to 12 months

8. Acute pyelonephritis (APN) • Uncomplicated or complicated APN • Ampicillin or broad-spectrum cephalosporin combined with aminoglycoside for 2 weeks • For relapsed APN a 6 weeks therapy according to culture is necessary

9. Asymptomatic bacteriuria • Treatment for asymptomatic pyuria with positive culture is not mandatory • Should be treated in diabetic, preganant women as well as women undergoing invasive GU procedures • 70-80% pregnant women cured after therapy for 7-10 days

10. Management of recurrent UTI • Intermittent self-start therapy 92% responded clinically • Estrogen therapy – oral or topical estriol • Behavioral therapy – increased E coli bacteriuria after sexual intercourse; certain contraceptives alter vaginal flora • Anal sex, masturbation, sex during menstruation increase risk for UTI

11. Prophylaxis of recurrent UTI • Cranberry – contains fructose which interferes adhesion of type I fimbriated E. coli to uroepithelium • Acupuncture – 85% vs 58% sham & 36% control group during 6 months • Intravesical heparin therapy – prevent bacterial adhesion to urothelium

12. Urodynamics and Recurrent UTI in Women • Detrusor instability & pseudo-dyssynergia (Dysfunctional voiding) • Pelvic floor hypertonicity • Detrusor external sphincter dyssynergia • Poor compliant bladder • Detrusor underactivity & residual urine • Bladder outlet obstruction

13. Detrusor Overactivity • Idiopathic or neuropathic • Involuntary contraction of external sphincter at initiation of voiding • Increased intravesical pressure at bladder capacity • Combined with inadequate contractility in elderly and CVA patients

14. Idiopathic Detrusor Overactivity

15. Increased Sphincter activity during Detrusor overactivity

16. Detrusor instability & Inadequate contractility

17. Low bladder compliance and low contractility after surgery

18. Pelvic floor hypertonicity • Poor relaxation of pelvic floor • Low detrusor contractility and low efficient voiding • Moderate to large residual urine developed • Associated with constipation and increased vaginal colonization of E.coli

19. Spastic urethral sphincter & High voiding pressure

20. Detrusor underactivity and Low efficient voiding

21. Detrusor external sphincter dyssynergia (DESD) • Neuropathy in origin • High voiding pressure and low bladder compliance • Large residual urine • Upper tract deterioration

22. Detrusor external sphincter dyssynergia in an SCI woman

23. Poor Bladder Compliance • Increased intravesical pressure at bladder capacity • Urothelium damage • Increased bacterial adherance to urothelium • Diminished detrusor contractility • Large residual urine

24. Bladder Outlet Obstruction • Bladder neck dysfunction • Urethral stricture • Spastic urethral sphincter • Cystocele • Urethral meatal stenosis

25. Dysfunctional voiding in woman with UTI, incontinence

26. Cystocele with Bladder outlet obstruction

27. Nocturnal polyuria and Recurrent UTI • Women may have large nocturnal urine volume (>900mL or >33% total volume) and small bladder capacity or lower compliance • UTI develops during night time • Treatment with antidiuretics (DDAVP) or CISC before bed time

28. Recurrent UTI in Children • In neonates UTI occurs more commonly in boys (2.7%) than girls (0.7%) • In children >1 y/o UTI is 9 times more frequent in girls than boys • In asymptomatic children reflux is 1% • Reflux is diagnosed in 50% of infants < 1 years, 25% of children > 4 years

29. Evaluation of UTI in Children • All children regardless of sex and age be examined by ultrasound and VCUG after first UTI • Radionuclide cystograpgy is more sensitive to detect VUR in younger child • Renal scarring can be detected by ultrasound, IVP, DMSA scintigraphy

30. Voiding cystourethrography in Vesicoureteral reflux

31. Recurrent UTI or VUR • In girls with UTI, 40-60% have symptoms of urgency, frequency, squatting behaviour, and diurnal incontinence. In most girls with VUR, infrequent voids with large volume • In boys, frequent small voids in more children with VUR (36%) than healthy boys (15%)

32. Vesicoureteral Reflux • Primary – A short submucosal tunnel • Secondary – Increased bladder pressure due to neuropathic bladder, anatomical abnormality, outlet obstruction • At birth the majority of VUR is seen in boys, by age 1 the incidence of VUR is greater in girls • Many girls have secondary VUR because of voiding dysfunction

33. Dysfunctional voiding in a girl with incontinence & VUR

34. Children & Voiding dysfunction • External sphincter as a role of UTI • Close association of constipation with voiding dysfunction, recurrent UTI and vesicoureteral reflux (dysfunctional elimination syndromes) • Non-invasive programs for pelvic floor hypertonicity can successfully treat incontinence, recurrent UTI, reducing surgical intervention for reflux

35. Voiding dysfunction and Incontinence in children • Detrusor overactivity and/or Pelvic floor dysfunction • Anticholinergics and behavioral therapy • Diurnal enuresis or nocturnal enuresis • Increased fluid intake, time voiding, correction of constipation cured 15-20% of children with voiding dysfunction

36. Detrusor overactivity in a boy with urge incontinence

37. Dysfunctional voiding & UTI • Breakthrough UTI occurs 43% with DV leading to surgery versus 11% without DV • VUR resolved spontaneously in 61% of girls with normal voiding and in 45% with DV after receiving antimicrobials and oxybutynin

38. Bilateral VUR in a girl with Meningomyelocele

39. Resolution of VUR after antibiotics and oxybutynin

40. Detrusor instability and VUR • 28% unilateral VUR and 78% bilateral VUR have detrusor instability • In cases with bilateral VUR 26% failed antireflux surgery • Failed surgery for reflux is often associated with voiding dysfunction • 70% VUR resolved after anticholinergics

41. Detrusor instability & Pelvic floor overactivity • Pelvic floor contracts with an uninhibited detrusor contraction • Chronic contraction of pelvic floor can cause uninhibited detrusor contractions through collateral innervation • Voiding dysfunction associates with constipation • Anticholinergics and alpha-adrenergic blocker are effective

42. Voiding dysfunction and Pseudodyssynergia • Bilateral VUR is a positive predictor for voiding dysfunction • In voiding dysfunction with VUR, detrusor instability 55%, large bladder capacity 14%, pseudodyssynergia 30% • Managing constipation and voiding dysfunction has the biggest impact on preventing recurrent UTI

43. Pelvic Floor Therapy • Individually adapted voiding & drinking schedule • Pelvic floor relaxation biofeedback • Instruction on toilet behaviour • Biofeedback uroflowmetry • Prophylactic antimicrobials during treatment • In 83% girls UTI was effectively treated, in 64% incontinence cured, in 7/8 reflux cured

44. Diagnosis of Dysfunctional voiding • Uroflowmetry combined with EMG • Pressure flow study – high voiding pressure low flow rate and overactive external sphincter EMG during voiding • Videourodynamic study- high voiding pressure low flow rate, and a spinning top urethrogram

45. Voiding cystourethrographyof Dysfunctional voiding

46. Videourodynamic study forDysfunctional voiding

47. Factors for Recurrent UTI • Low bladder compliance • Large residual urine • High voiding pressure • Pseudodyssynergia • Constipation • Large bladder capacity and infrequent voids

48. Treatment of recurrent UTI in Children • Treat constipation,recurrent UTI, voiding dysfunction together • Increased fluid intake for constipation • Trimethoprim- Sulfamethoxazole is the drug of choice • Patients > 4 years pelvic floor retraining • Start prophylactic antimicrobial if breakthrough UTI develops

49. Genital Tract Infection • Acute & chronic prostatitis • Acute & chronic epididymitis • Should search for urinary tract obstruction such as prostate obstruction, urethral stricture, poor relaxation of urethral sphincter

50. Poor relaxation of urethral sphincter • In younger population men • Severe hesitancy, poor stream, intermittency, residual urine sensation • Combined with chronic prostatitis • No frequency or nocturia • Low voiding pressure low flow urodynamic tracing