PATHOGENESIS AND SOURCES OF INFECTION

Vast majority of UTIs, bacteria gain access to the

bladder via the urethra.
Ascent of bacteria from the bladder to kidney
renal parenchyma infections.
The vaginal introitus and distal urethra: normally
colonized by diphtheroids, streptococcal species,
lactobacilli, and staphylococcal species but not
by the enteric gram-negative bacilli that
commonly cause UTIs.
Factors that predispose to periurethral
colonization with gram-negative bacilli poorly
understood, but alteration of the normal vaginal
flora by antibiotics, other genital infections, or
contraceptives (especially spermicide) appears
to play an important role.
Loss of the normally dominant H2O2-producing
lactobacilli in the vaginal flora facilitate
colonization by E.coli.
Periurethral bacteria gain entry to the bladder
frequently (facilitated in some cases by urethral
massage during intercourse)
Whether bladder infection ensues depends on
the pathogenicity of the strain, the inoculum
size, and the local and systemic host defense
mechanisms.
Normal circumstances: bacteria in the bladder
are rapidly cleared, through the flushing and
dilutional effects of voiding + antibacterial
properties of urine and the bladder mucosa.
High urea concentration and high osmolarity
urine of many normal persons inhibits or kills
bacteria.
Prostatic secretions possess antibacterial
properties as well.
PMN enter the bladder epithelium and the urine
soon after infection arises clearing bacteria
The role of locally produced antibody remains
unclear.
Hematogenous pyelonephritis occurs most often
in debilitated patients (chronically ill or receiving
immunosuppressive therapy)
Metastatic staphylococcal or candidal infections
of the kidney may follow bacteremia or
fungemia, spreading from distant foci of
infection in the bone, skin, vasculature, or
elsewhere.

CONDITIONS AFFECTING PATHOGENESIS
Gender and Sexual Activity
The female urethra: prone to colonization with
colonic gram-negative bacilli because of its
proximity to the anus, its short length (<4 cm),
and its termination beneath the labia.
Sexual intercourse introduction of bacteria
into the bladder and is temporally associated
with the onset of cystitis; it thus appears to be
important in the pathogenesis of UTIs in younger
women.
Voiding after intercourse reduces the risk of
cystitis( promotes the clearance of bacteria
introduced during intercourse)
Use of spermicidal compounds with a diaphragm
or cervical cap or use of spermicide-coated
condoms alters the normal introital bacterial
flora and has been associated with marked
increases in vaginal colonization with E. coli and
in the risk of UTI.
In males ( <50 years old, no history of
heterosexual or homosexual rectal intercourse)
UTI is exceedingly uncommon
An important factor predisposing to bacteriuria
in men is urethral obstruction due to prostatic
hypertrophy.
Insertive rectal intercourse increased risk of
cystitis in men.
Men (and women) who are infected with HIV
and who have CD4+ T cell counts of <200/L
increased risk of both bacteriuria and
symptomatic UTI.
Lack of circumcision risk factor for UTI in both
neonates and young men.
Pregnancy UTIs are detected in 2 to 8% of
pregnant women.
Decreased ureteral tone, decreased ureteral
peristalsis, and temporary incompetence of the
vesicoureteral valves predisposition to upper
tract infection during pregnancy
Bladder catheterization during or after delivery
causes additional infections.
UTIs during pregnancy, particularly infections
involving the upper tract Increased incidences
of low-birth-weight infants, premature delivery,
and newborn mortality.

Obstruction
Any impediment to the free flow of urine
tumor, stricture, stone, or prostatic
hypertrophyresults in hydronephrosis and a
greatly increased frequency of UTI.
Infection superimposed on urinary tract
obstruction may lead to rapid destruction of
renal tissue.
When an obstruction is minor and is not
progressive or associated with infection
attempting surgical correction.
Neurogenic Bladder Dysfunction
Interference with bladder enervation, as in
spinal cord injury, tabes dorsalis, multiple
sclerosis, diabetes, and other diseases, may be
associated with UTI.
The infection may be initiated by the use of
catheters for bladder drainage and is favored by
the prolonged stasis of urine in the bladder.
An additional factor often operative in these
cases is bone demineralization due to
immobilization, which causes hypercalciuria,
calculus formation, and obstructive uropathy.
Vesicoureteral Reflux
Defined as reflux of urine from the bladder
cavity up into the ureters and sometimes into
the renal pelvis
Occurs during voiding or with elevation of
pressure in the bladder.
An anatomically impaired vesicoureteral junction
facilitates reflux of bacteria upper tract
infection.
Common among children with anatomic
abnormalities of the urinary tract as well as
among children with anatomically normal but
infected urinary tracts.
In the latter group, reflux disappears with
advancing age and is probably attributable to
factors other than UTI.
Long-term follow-up of children with UTI who
have reflux has established that renal damage
correlates with marked reflux, not with infection