Urinary Tract InfectionsUrinary Tract Infections

Urinary Tract InfectionsUrinary Tract Infections

Most common urinary pathologyMost common urinary pathology 7million hospital visits7million hospital visits 1million admissions complicated with UTIs1million admissions complicated with UTIs

Common in both sexesCommon in both sexes More common in female More common in female Among Males == neonates and elderly Among Males == neonates and elderly

more affectedmore affected

Urinary Tract InfectionsUrinary Tract Infections

INFLAMATORY RESPONSE OF INFLAMATORY RESPONSE OF UROTHELIUM TO THE UROTHELIUM TO THE BACTERIAL INVASION THAT IS BACTERIAL INVASION THAT IS USUALLY ASSOCIATED WITH USUALLY ASSOCIATED WITH BACTERIURIA AND PYURIABACTERIURIA AND PYURIA

BACTERIURIA BACTERIURIA ( bacteria in urine. Normally free of) ( bacteria in urine. Normally free of) Not contamination from vagina,introitus, prepuce, skinNot contamination from vagina,introitus, prepuce, skin Collection technique ( suprapubic aspirate, cath, vioded, MSU)Collection technique ( suprapubic aspirate, cath, vioded, MSU)

SIGNIFICANT BACTERIURIASIGNIFICANT BACTERIURIA ( # that exceeds that caused by contamination) ( # that exceeds that caused by contamination) ((10 10 55 ) )

Symptomatic and Asymptomatic BacteriuriaSymptomatic and Asymptomatic Bacteriuria PYURIA PYURIA

( white blood / pus cells in urine. Indicates inflammation) ( white blood / pus cells in urine. Indicates inflammation)

BACTERIURIA WITHOUT PYURIABACTERIURIA WITHOUT PYURIA (colonization)(colonization)

PYURIA WITHOUT BACTERIUTIAPYURIA WITHOUT BACTERIUTIA Tuberculosis, stones and cancerTuberculosis, stones and cancer

Urinary Tract InfectionsUrinary Tract Infections

CLASSIFICATIONCLASSIFICATION1.1. Acute - chronic Acute - chronic 2.2. Non – SpecificNon – Specific

Gram –ve rodsGram –ve rods Gram +ve cocci.Gram +ve cocci.

Specific Specific T.B T.B CandidiasisCandidiasis ActinomycosisActinomycosis SchistosomiasisSchistosomiasis

33 Site Site UpperUpper

PylonephritPylonephrit Lower Lower

CystitsCystits UrethritisUrethritis

44 UncomplicatedUncomplicated Structurely and functionally normal tractStructurely and functionally normal tract

Complicated Complicated Structural / functionall abnormality, decreasing antimicrobial efficacyStructural / functionall abnormality, decreasing antimicrobial efficacy

CLASSIFICATIONCLASSIFICATION1.1. 11stst infection infection

Nonhospitalized pt, Structurely and functionally normal tractNonhospitalized pt, Structurely and functionally normal tract

2.2. Isolated Isolated If occur at least 6 months apartIf occur at least 6 months apart

3.3. Unresolved bacteriuria Unresolved bacteriuria Culture during treatment ------ original pathogen not eradicatedCulture during treatment ------ original pathogen not eradicated

Resistent to the drugResistent to the drug Azotemia / papillary necrosis / Azotemia / papillary necrosis / mass of bacterial groth too great for antimicribial inhibition / deceptionmass of bacterial groth too great for antimicribial inhibition / deception

4.4. Recurrence Recurrence Re-emergence of infection after documented sterilizationRe-emergence of infection after documented sterilization

Bacterial persistenceBacterial persistence Same bacteria from within the urinary tract Same bacteria from within the urinary tract 12 urologic abnormalities12 urologic abnormalities

Re-infectionsRe-infections New infection with Different bacteria from outside urinary tract New infection with Different bacteria from outside urinary tract

(susceptibility factors)(susceptibility factors)

CLASSIFICATIONCLASSIFICATION

1.1. DOMICILIARYDOMICILIARY ENTEROENTERO STAPHSTAPH

2.2. NOSOCOMIALNOSOCOMIAL PSEUDOMONAPSEUDOMONA

ROUTES OF INFECTIONROUTES OF INFECTION

AscndingAscnding Both men & womenBoth men & women

HematogenousHematogenous Tuberculosis, staphlococciTuberculosis, staphlococci

LymphatogenousLymphatogenous Not well esteblishedNot well esteblished

Direct extensionDirect extension Neighboring organs. IBD, PID, VVF, VIFNeighboring organs. IBD, PID, VVF, VIF

URINARY PATHOGENSURINARY PATHOGENS

PredictablePredictable Most UTIs == Most UTIs == Aerobic gram negative rodsAerobic gram negative rods

E.Coli,E.Coli, Proteus,Proteus, KlebsiellaKlebsiella Pseudomonas Pseudomonas CitrobactorCitrobactor SerratiaSerratia

Gram positive cocciGram positive cocci, == , == EnterococciEnterococci Staph. Aureus, Epidermidis and SaprophyticusStaph. Aureus, Epidermidis and Saprophyticus Strept. Group B&DStrept. Group B&D

Gram negative cocciGram negative cocci == Neisseria Gonorrhoeae == Neisseria Gonorrhoeae Gram positive rods and anaerobesGram positive rods and anaerobes == rarely implicated == rarely implicated OthersOthers == == special identification technique special identification technique

Chlamydiae ( C. Tracomatous), Chlamydiae ( C. Tracomatous), Mycoplasmas ( ureaplasma urealyticum)Mycoplasmas ( ureaplasma urealyticum)

DIAGNOSISDIAGNOSIS

URINE ANALYSISURINE ANALYSIS Microscopic exam high power Microscopic exam high power 3 or more (5-8 in females) pus cells3 or more (5-8 in females) pus cells NITRITE (bacteria)NITRITE (bacteria) LEUKOCYTE ESTRASE (LEUKOCYTEs)LEUKOCYTE ESTRASE (LEUKOCYTEs)

URINE CULTUREURINE CULTURE Qualitative Qualitative Quantified (CFU/ML)Quantified (CFU/ML) 10105 == 5 == significant bactereuria // sumptomatic bactereuriasignificant bactereuria // sumptomatic bactereuria

COLLECTIONCOLLECTION SuprapubicSuprapubic CatheterCatheter Segmented voidedSegmented voided

RADIOLOGIC STUDIESRADIOLOGIC STUDIES

IndicationsIndications CalculiCalculi Ureter refluxUreter reflux Poor responsePoor response Papillary necrosisPapillary necrosis Neuropathic bladderNeuropathic bladder

PLAIN FILMPLAIN FILM IVUIVU MCGMCG CYSTOSCOPY & CYSTOSCOPY &

URSURS CT-MRICT-MRI RADIONUCLIDE RADIONUCLIDE

SCANESSCANES

Localization studies Localization studies

Stamey’s technique of ureteric catheterization Stamey’s technique of ureteric catheterization under cystoscopic guidanceunder cystoscopic guidance

Immunological technequesImmunological techneques Agglutination tests and ELISA Agglutination tests and ELISA

Prostatic and urethral localizationProstatic and urethral localization Tissue and stone culturesTissue and stone cultures

PRINCIPLES of PRINCIPLES of MANAGEMENTMANAGEMENT

INITIAL ELEMINATIONINITIAL ELEMINATION Medical measuresMedical measures

SERUM/URINARY LEVELSSERUM/URINARY LEVELS BACTERIAL RESISTENCEBACTERIAL RESISTENCE

Surgical measures Surgical measures

Identification of underlying causeIdentification of underlying cause Treatment of underlying abnormalityTreatment of underlying abnormality Prophylactic and suppressive treatmentProphylactic and suppressive treatment

Recurrent attacks in women and single Recurrent attacks in women and single episode in men or children either sex episode in men or children either sex should be evaluated further to find the should be evaluated further to find the underlying causeunderlying cause

ANTIBIOTICSANTIBIOTICS

TMP-SMXTMP-SMX NITROFURANTIONNITROFURANTION CEPHALOSPORINSCEPHALOSPORINS AMINOPENICILLINSAMINOPENICILLINS AMINOGLYCOSIDESAMINOGLYCOSIDES AZTREONAMAZTREONAM FLUOROQUINOLONESFLUOROQUINOLONES

CHOICECHOICE

COMLICATEDCOMLICATED SPECTRUMSPECTRUM SIDE EFFECTSSIDE EFFECTS COSTCOST

DURATIONDURATION

Acute PyelonephritisAcute Pyelonephritis

Inflammation of parenchyma & pelvis of KidneyInflammation of parenchyma & pelvis of Kidney Bacteriology - E. Coli 80%Bacteriology - E. Coli 80% - Klebsiela,- Klebsiela, - Proteus, pseudomonas- Proteus, pseudomonas - Enterobacter, Staph.- Enterobacter, Staph.

Clinical featuresClinical features prodronal symptoms= prodronal symptoms= Nausea, vomiting, malaiseNausea, vomiting, malaise

Abrupt onset of feverAbrupt onset of fever Chills, flank painChills, flank pain LUTS – frequency, urgency, dysuriaLUTS – frequency, urgency, dysuria Signs:Signs: Tachycardia, temperature 101 - 104Tachycardia, temperature 101 - 10400 F, F, Renal angle tenderness, Renal angle tenderness,

Abdominal signs.Abdominal signs.

Acute PyelonephritisAcute Pyelonephritis

Diagnosis:Diagnosis: Bld. C/P- Leucocytosis-NeutrophilsBld. C/P- Leucocytosis-Neutrophils Urinalysis – Pyuria, bactiuria, haematuriaUrinalysis – Pyuria, bactiuria, haematuria Urine C/S – 100,000 CFU/mlUrine C/S – 100,000 CFU/ml Blood culture – Bacteraemia / SepticemiaBlood culture – Bacteraemia / Septicemia Doppler USG – CT, Isotope ScanDoppler USG – CT, Isotope Scan

Dif diagnosisDif diagnosis Pnumonia,appendicitis, cholecystitisPnumonia,appendicitis, cholecystitis PID.renal & perirenal abscessesPID.renal & perirenal abscesses

ManagementManagement

HospitalizationHospitalization AntibioticsAntibiotics

culture reports culture reports AntipyreticsAntipyretics

Antiemetics Antiemetics I/V & oral fluidsI/V & oral fluids

Urinary alkalinisationUrinary alkalinisation EColi , strept------acidicEColi , strept------acidic Staph, protes, psodoonas, klebsiella, provodentia= alkalineStaph, protes, psodoonas, klebsiella, provodentia= alkaline

Correction of anatomical / functional anomaliesCorrection of anatomical / functional anomalies

Chronic PyelonephritisChronic Pyelonephritis

Interstitial inflammation = patchy scaring Interstitial inflammation = patchy scaring of parenchyma==renal insufficencyof parenchyma==renal insufficency

Tubules atrophic & dilatedTubules atrophic & dilated Glomeruli retain structure till lateGlomeruli retain structure till late

Reflux nephropathyReflux nephropathy Clinical featureClinical feature

Pain, LUTS,dysurea, constitutional symptoms Pain, LUTS,dysurea, constitutional symptoms hypertention, pyrexia, anemiahypertention, pyrexia, anemia

Chronic PyelonephritisChronic Pyelonephritis

InvestigatiosInvestigatios Protinurea <3g/DProtinurea <3g/D Pus cell but no castsPus cell but no casts Bact. Exam Bact. Exam IVU and USIVU and US

TreatmentTreatment Eradicate predisposing factorsEradicate predisposing factors

Stones, obstruction, refluxStones, obstruction, reflux Repeated courses of antiioticsRepeated courses of antiiotics Nephrectomy == infection, hypertentionNephrectomy == infection, hypertention End stage renal disease – transplantation,dialysisEnd stage renal disease – transplantation,dialysis

Pyonephrosis Pyonephrosis

Infected hydronephrosis,calculus, pyelonephritisInfected hydronephrosis,calculus, pyelonephritis Pus containing multilocular sacPus containing multilocular sac Destruction of parenchyma due to obstruction & Destruction of parenchyma due to obstruction &

infection====septicemiainfection====septicemia Clinical featuresClinical features

Anemia, fever, loin swellingAnemia, fever, loin swelling

KUB, US, IVU—calculus, dilatation, functionKUB, US, IVU—calculus, dilatation, function Antibiotics,Antibiotics, Drainage==PCN, open nephrostomyDrainage==PCN, open nephrostomy nephreectomynephreectomy

Renal abscessRenal abscess

Parenchymal abscess--encapsulatedParenchymal abscess--encapsulated Blood bornBlood born Coliforms, Staph aureusColiforms, Staph aureus Hematoma,DM, AIDS, drug abusersHematoma,DM, AIDS, drug abusers Tender loin swelling, fever,Tender loin swelling, fever, LeucocytosisLeucocytosis US, IVU, CT SCAN == SOLUS, IVU, CT SCAN == SOL AntibioticsAntibiotics Percuteneous aspirationPercuteneous aspiration Open drainageOpen drainage

Perinephric abscessPerinephric abscess

Pus between kidney & gerota's fasciaPus between kidney & gerota's fascia EtiologyEtiology

Rupture of renal abscessRupture of renal abscess Ascending infection in urinary stasis,Ascending infection in urinary stasis, Obstruction, Calculi, neurogenic bladder, diabetes.hematoma, pyonephrosis, TB, Obstruction, Calculi, neurogenic bladder, diabetes.hematoma, pyonephrosis, TB,

Clinical featuresClinical features Fever, flank pain, & LUTS, Tender flank mass, skin erythema, anaemiaFever, flank pain, & LUTS, Tender flank mass, skin erythema, anaemia DiagnosisDiagnosis

Bld C/PBld C/P UrinalysisUrinalysis Urine C/SUrine C/S Bld. C/SBld. C/S P/C aspirationP/C aspiration U.s,U.s, IVU & CTIVU & CT

ManagementManagement AntibioticsAntibiotics P/C aspiration -----C/SP/C aspiration -----C/S Open drainageOpen drainage

Acute Cystitis and urethritis Acute Cystitis and urethritis VUR, and vesical diverticulum VUR, and vesical diverticulum

neurogenic bladder / decompensation of bladderneurogenic bladder / decompensation of bladderCystocele / UV prolapseCystocele / UV prolapse vesical calculus, foreign body vesical calculus, foreign body neoplasm of blader, urethra, prostate and penis neoplasm of blader, urethra, prostate and penis

bladder neck stenosis, Post urethral,valve Urethral stricture bladder neck stenosis, Post urethral,valve Urethral stricture Enlarged prostate--------- benign / malignant / inflammatoryEnlarged prostate--------- benign / malignant / inflammatoryUrethral Stone / foreign body impactionUrethral Stone / foreign body impactionExt, meatal stenoaiaExt, meatal stenoaiaPhemosis / fused synichae,Phemosis / fused synichae,

Detrusor sphincter dyssynergiaDetrusor sphincter dyssynergiafrequency – dysuria syndromefrequency – dysuria syndrome

Atrophic urethritis (senile)Atrophic urethritis (senile)Distal urethral syndromeDistal urethral syndromeAbacterial cystitis /urethritis ( mycoplasma, herpes, chemical)Abacterial cystitis /urethritis ( mycoplasma, herpes, chemical)TB, schistosomiasisTB, schistosomiasisIntersitial cystitisIntersitial cystitisCystitis cystca and Alkaline encrustin cystitisCystitis cystca and Alkaline encrustin cystitisPregnancy, diabetes, LVF, CCF, diuretics, polyuriaPregnancy, diabetes, LVF, CCF, diuretics, polyuria

Causes of Frequency – DysuriaCauses of Frequency – Dysuria

Acute CystitisAcute Cystitis

More common in women than under 50 menMore common in women than under 50 men Short urethraShort urethra Sexual intercourse Sexual intercourse child birth traumachild birth trauma MentruationMentruation

Asymtomatic bacteriurea 5-10 % ( without any Asymtomatic bacteriurea 5-10 % ( without any demonstrable cause)demonstrable cause)

Men are protected due to prostatic secretionsMen are protected due to prostatic secretions

URINARY PATHOGENS/ URINARY PATHOGENS/ ROUTESROUTES

Ascending route – faecal – perineal –UrethralAscending route – faecal – perineal –Urethral Descending route- TBDescending route- TB Adjoining organs – fallopian tubes, vagina, GutAdjoining organs – fallopian tubes, vagina, Gut

E. Coli – 80%E. Coli – 80% ProteusProteus Staph EpidermidisStaph Epidermidis Strept fecalisStrept fecalis

long standing cath / neurogenic bladderlong standing cath / neurogenic bladder KlebsiellaKlebsiella PseudomonasPseudomonas Staph. AureusStaph. Aureus

Predisposing factorsPredisposing factors

Incomplete emptying Incomplete emptying (BOO(BOO

bladder neck stenosisbladder neck stenosis Enlarged prostate--------- benign / malignant / inflamatoryEnlarged prostate--------- benign / malignant / inflamatory Post urethral valvePost urethral valve Urethral strictureUrethral stricture Stone / foreign body impactionStone / foreign body impaction Ext, meatal stenoaiaExt, meatal stenoaia PhemosisPhemosis Detrusor sphincter dyssynergiaDetrusor sphincter dyssynergia Penile carcinomaPenile carcinoma

, VUR, , VUR, vesical diverticulum, vesical diverticulum, neurogenic bladder/decompensation of bladderneurogenic bladder/decompensation of bladder Cystocele / UV prolapseCystocele / UV prolapse

calculus, calculus, foreign body,foreign body, neoplasm neoplasm estrogen def.estrogen def. , Perineal colonization with E. Coli, Perineal colonization with E. Coli instrumentationinstrumentation

Clinical FeaturesClinical Features Irritative voiding symptomsIrritative voiding symptoms Low back ache & Suprapubic, penile, labial, parineal painLow back ache & Suprapubic, penile, labial, parineal pain Cloudy foul smelling urine, haemeturiaCloudy foul smelling urine, haemeturia Constitutional symptomic – rareConstitutional symptomic – rare Tenderness HypogastriumTenderness Hypogastrium

DiagnosisDiagnosis Urine R/EUrine R/E Urine C/SUrine C/S Further investigationsFurther investigations

CystoscopyCystoscopy UroflowmeteryUroflowmetery US for PVRUUS for PVRU IVUIVU urodynamicsurodynamics

PYURIA WITHOUT BACTERIUTIAPYURIA WITHOUT BACTERIUTIA

Tuberculosis,Tuberculosis, Neisseria GonorrhoeaeNeisseria Gonorrhoeae Abacterial cystitisAbacterial cystitis stones stones carcinoma in situcarcinoma in situ Renal papillary necrosisRenal papillary necrosis Incomplete treatment of UTIIncomplete treatment of UTI

PRINCIPLES of PRINCIPLES of MANAGEMENTMANAGEMENT

INITIAL ELEMINATIONINITIAL ELEMINATION Medical measuresMedical measures

SERUM/URINARY LEVELSSERUM/URINARY LEVELS BACTERIAL RESISTENCEBACTERIAL RESISTENCE

Surgical measures Surgical measures

Identification of underlying causeIdentification of underlying cause Treatment of underlying abnormalityTreatment of underlying abnormality Prophylactic and suppressive treatmentProphylactic and suppressive treatment

FACTORSFACTORS

TOXINSTOXINS K antigensK antigens ADHESINS-pili-MSADHESINS-pili-MS

EPTHELIAL CELLSEPTHELIAL CELLS HLA-A3antigenHLA-A3antigen LEWIS BLOOD LEWIS BLOOD

GROUPGROUP FLOW OF FLOW OF

URINE,PHURINE,PH ANTIBODIES IL6&8ANTIBODIES IL6&8 MUCO-PMUCO-P

MUTANTSMUTANTS

5-10%5-10%

TRANSFERABLE TRANSFERABLE RESISTANCERESISTANCE

MORE COMMONMORE COMMON MULTIPLE STRAINSMULTIPLE STRAINS FECAL FLORAFECAL FLORA NITROFURANTOINNITROFURANTOIN

Suppressive Suppressive ProphylacticProphylactic

NATURAL RESISTANCENATURAL RESISTANCE

PROTEUSPROTEUS Strepto-Faecalis-cephalexinStrepto-Faecalis-cephalexin

BACTERIAL RESISTANCEBACTERIAL RESISTANCE

NATURALNATURAL RESISTANT MUTANTSRESISTANT MUTANTS R FACTOR TRANSFERABLE R FACTOR TRANSFERABLE

EXTRACHROMOSOMAL PLASMID MEDIATEDEXTRACHROMOSOMAL PLASMID MEDIATED MICMIC DRUGSDRUGS HYDRATIONHYDRATION COMLIANCECOMLIANCE

Genito urinary tuberculosisGenito urinary tuberculosis

              Always secondaryAlways secondary Haematogenous routeHaematogenous route Focus ??Focus ??

            involvedinvolved Kidney & prostateKidney & prostate

          

PathogenesisPathogenesis Usually one kidney, both in miliary TBUsually one kidney, both in miliary TB Edematous, friable, damage proneEdematous, friable, damage prone

Tubercle granuloma renal pyramids -> UlcerTubercle granuloma renal pyramids -> Ulcer Pus & mycobacteria -> urinePus & mycobacteria -> urine UlcerUlcer breaks into calyx -> Calyceal Stricturebreaks into calyx -> Calyceal Stricture Pyonephrosis, renal abscess, (localized) Pyonephrosis, renal abscess, (localized) CaseationCaseation (putty kidney) -> calcified ( cement kidney) (putty kidney) -> calcified ( cement kidney) Perirenal   abscess     Perirenal   abscess      Pseudo calculi.Pseudo calculi. Uretrel stricture & fibrosis Uretrel stricture & fibrosis Tubercles & ulcer around ureteric orificeTubercles & ulcer around ureteric orifice Contracted bladder. Contracted bladder. Epidedymo-orchitisEpidedymo-orchitis

                                        

Clinical FindingsClinical Findings 20-40 yrs. Men > women. R>L20-40 yrs. Men > women. R>L Slow progression – 15 – 20 yearsSlow progression – 15 – 20 years No symptoms initiallyNo symptoms initially LUTS – (F) when lower tract involvedLUTS – (F) when lower tract involved Cystitis not responding to antibioticCystitis not responding to antibiotic Sterile pyuriaSterile pyuria Haematuria, Haematuria, StrarguryStrargury Pain Pain

On bladder filling - suprapubicOn bladder filling - suprapubic On micturation – burningOn micturation – burning Superadded infection – agonizing, penis tip, vulvaSuperadded infection – agonizing, penis tip, vulva Renal , minimal, dull acheRenal , minimal, dull ache

Constitutional painConstitutional pain Weight loss, evening pyrexiaWeight loss, evening pyrexia High grade fever- superadded infection, milliary TBHigh grade fever- superadded infection, milliary TB

Examination Examination

Kidney not palpable except lateKidney not palpable except late Enlarged non tender epididymus, vasa Enlarged non tender epididymus, vasa

and seminal vesicalsand seminal vesicals Chronic draining scortal sinusChronic draining scortal sinus Induration or nodulation of prostateInduration or nodulation of prostate

DiagnosisDiagnosis Urine R/EUrine R/E Urine C/SUrine C/S Urine AFB (3 morning- ZN) & culture Urine AFB (3 morning- ZN) & culture

( LJ) ( LJ) X-ray chest, abdomenX-ray chest, abdomen Not detected radiologically/culture till Not detected radiologically/culture till

advancedadvanced

IVUIVU Normal, NFK (auto-nephrectomy)Normal, NFK (auto-nephrectomy) Indistint papilla (ulcer), moth eaten Indistint papilla (ulcer), moth eaten Calyceal stenosisCalyceal stenosis Hydronephrosis (stricture pelvis / ureter – lower, Hydronephrosis (stricture pelvis / ureter – lower,

multiple) multiple) Abscess (SOL) splaying calyces, communicating to Abscess (SOL) splaying calyces, communicating to

calycescalyces Shrunken thick / irregular wall bladderShrunken thick / irregular wall bladder Obstructed ureter ( passing thru thick bladder wall)Obstructed ureter ( passing thru thick bladder wall)

RPUGRPUG Cystoscopy / biopsyCystoscopy / biopsy

Peri ureteral tubercles / ulcersPeri ureteral tubercles / ulcers Small capacity Small capacity Golf hole orifecesGolf hole orifeces

  

Treatment, medicalTreatment, medicalATTATT

Radiological evidenceRadiological evidence Demonstration of AFB / cultureDemonstration of AFB / culture Tissue diagnosis (Bx)Tissue diagnosis (Bx)         D.O.T D.O.T

            Isoniazid – 300mgIsoniazid – 300mg             Rifampicin – 600mgRifampicin – 600mg             Ethambutol – 25mg / kgEthambutol – 25mg / kg             Pyrazinamide – 1.5 gmPyrazinamide – 1.5 gm

Surgeon : ensure review in first few weeks stricturing Surgeon : ensure review in first few weeks stricturing continues after treatment startdcontinues after treatment startd

Steroids Steroids

SurgerySurgeryconservativeconservative

Aim: remove infective fociAim: remove infective focirelieve obstructionrelieve obstruction

Time : 6-12 weeks ATTTime : 6-12 weeks ATT

Kidney – Kidney –  ureter ureter Salvage procedureSalvage procedure

Uretero-calycostomyUretero-calycostomy PyeloplastyPyeloplasty Ureteric re-implantUreteric re-implant Boari flap, bowl interpositionBoari flap, bowl interposition

Nephro-ureterectomyNephro-ureterectomy Bladder –Bladder –

    Fulgration of ulcerFulgration of ulcer     Ilio / Caeco Ilio / Caeco cystoplasty, detubularisedcystoplasty, detubularised

TestisTestis EpididymectomyEpididymectomy

Prognosis Prognosis goodgood Complications Complications

AnemiaAnemia NFK / Renal failureNFK / Renal failure Fistulae formationFistulae formation PeritonitisPeritonitis Milliary TBMilliary TB InfertilityInfertility