Page 273 - Medicine and Surgery

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Chapter 6: Urinary tract infections 269

Investigations renal failure, and chronic inflammation predisposes to
The scarring of reflux nephropathy is best visualised by squamous cell carcinoma of the bladder. S. mansoni
DMSA scans. Intravenous pyelogram and renal ultra- and japonicum can cause proteinuria and nephrotic syn-
sound may also identify damaged kidneys (but are less drome by immune complex deposition and may cause
sensitive) and dilated ureters. Infants and young chil- other systemic features.
dren are screened for VUR following a single UTI, as
should siblings, and infants of mothers with proven Investigations
VUR. Screening may involve renal ultrasound, DMSA Dipstick urine to look for blood. Urine microscopy to
scan,micturatingcystourogram(MCUG)orMAG3scan look for eggs with a terminal spine. Anti-schistosomal
with indirect cystourogram dependant on age. antibodiescanbemeasured,althoughthesetakeamonth
to become positive.
Management
Managment
Patients with chronic renal failure require appropriate
Praziquantel is the treatment of choice.
treatment (see Chronic Renal Failure page 237). Patients
with VUR should be treated with prophylactic antibi-
otics until reflux is shown to have resolved or puberty. Acute epididymo-orchitis
Previously severe reflux was treated with surgical re-
Definition
implantation of the ureters, this has now been shown to
Acute primary infection of the epididymis and the testis.
have no additional benefit and risks urinary obstruction.
Age
Urinary schistosomiasis (bilharzia) Normally under 40 years.
Definition Sex
Schistosomiasis is the disease caused by the parasitic Male
flukes, schistosomes.
Aetiology/pathophysiology
Incidence/prevalence The most common causes are N. gonococcus, Chlamy-
Schistosomiasis affects 200 million people worldwide. dia trachomatis, E. coli and other gram-negative bacilli.
Orchitis is also an important complication of mumps.
Geography TB is an important differential. The infection starts in
Urinary schistosomiasis occurs in Africa, the Middle the lower genital tract either as a sexually transmitted
East, Spain, Portugal, Greece and the Indian Ocean, par- infection or as a urinary tract infection. Resolution is
ticularlyinruralareaswherethesnailvectorsarepresent. usually accompanied by healing and scarring, there may
Travellers may pick up the infection, even with brief ex- be permanent damage to the tubules risking infertility.
posure to contaminated water.
Clinical features
Pathophysiology Patients present with a greatly enlarged and very tender
The eggs of S. haematobium are excreted through the testis,thepainusuallycomesonquickly(30–60minutes)
bladderwallintotheurinecausinghaematuria.Eggsthat and is sometimes released by supporting the scrotum.
are trapped in tissue cause local inflammation, scarring Other causes of a painful scrotal swelling are shown in
and fibrosis in the bladder and ureters, which can lead Table 6.14.
to obstruction, calcification and hydronephrosis.
Table 6.14 Causes painful scrotal swelling
Clinical features Torsion of testis or testicular appendage
Patients with S. haematobium may be asymptomatic, Incarcerated hernia
or have frequency, dysuria, haematuria (microscopic Infarcted germ cell tumor
Scrotal cellulitis and fasciitis
or macroscopic) and incontinence. Secondary anaemia
Post-traumatic causes
may occur. Complications include hydronephrosis and