ANATOMY AND PHYSIOLOGY

How does the urinary system work? The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left behind in the bowel and in the blood. The urinary system keeps the chemicals and water in balance by removing a type of waste, called urea, from the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys. Urinary system parts and their functions: Two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to: Remove liquid waste from the blood in the form of urine. Keep a stable balance of salts and other substances in the blood. Produce erythropoietin, a hormone that aids the formation of red blood cells. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney. Two ureters - narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters. Bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.

Two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. Nerves in the bladder -alert a person when it is time to urinate, or empty the bladder. Urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the bladder. At the same time,the brain signals the sphincter muscles to relax to let urine exit the bladder through theurethra. When all the signals occur in the correct order, normal urination occurs. IV. WHAT IS UTI? A urinary tract infection (UTI) is an infection caused by pathogenic organisms (for example, bacteria, fungi, or parasites) in any of the structures that comprise the urinary tract. Types are urethritis(urethral infection), cystitis(bladder infection), ureter infection, and pyelonephritis (kidney infection). Other structures that eventually connect to or share close anatomic proximity to the urinary tract (for example, prostate, epididymis, and vagina) are sometimes included in the discussion of UTIs because they may either cause or be caused by UTIs. Etiology: Causative organism: - Escherichia Coli
90% of UTI in women. - Enterocobacter - Pseudomonas - Staphylococcus saprophyticus - Candida Route of entry: - Ascent from the urethra (most common) - Circulating blood. Contributing causes: y y obstruction usually congenital vesicoureteral reflux

infections elsewhere in the body 1.) upper respiratory 2.) gastrointestinal - diarrhea -poor perineal hygiene -short female urethra -catheterization -Inherent defect in the ability of the bladder mucosa to protect it from -microbial infection. PATHOPHYSIOLOGY OF UTI For infection to occur, bacteria must gain access to the bladder, attach to and colonize theepithelium of the urinary tract to avoid being washed out with voiding, evade host defensemechanisms, and

initiate inflammation. Most UTIs result from fecal organisms that ascend fromthe perineum to the urethra and the bladder and then adhere to the mucosal surfaces. Bacterial Invasion of the Urinary Tract By increasing the normal slow shedding of bladder epithelial cells (resulting in bacteriaremoval), the bladder can clear itself of even large numbers of bacteria.Glycosaminoglycan(GAG), a hydrophilic protein, normally exerts a nonadherent protective effect against variousbacteria. TheGAG molecule attracts water molecules, forming water barrier that serves asdefensive layer between the bladder and the urine.GAG may be impaired by certain agents(cyclamate, saccharin, aspartame, and trytophan metabolites). The normal bacterial flora of thevagina and urethral area also interfere with adherence ofEsc h eric hia c oli (the most commonmicroorganisms causing UTI). Urinary immunoglobulin A (IgA) in the urethra may also provide abarrier to bacteria. Reflux An obstruction to free-flowing urine is a problem known as urethrovesical reflux, which is the reflux (backward flow) of urine from the urethra into the bladder. With coughing, sneezing, or straining, the bladder pressure rises, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the anterior portions of the urethra. urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. The urethrovesical angle and urethral closure pressure may be altered with menopause, increasing the incidence of infection inpostmenopausal women. Reflux is most often noted, however, in young children. Treatment is based on its severity. Ureterovesical or vesicoureteral reflux refers to the backflow of urine from the bladderinto one or both ureters. Normally, the ureteroveical junction prevents urine from travelingback into the urether. The ureters tunnel into the bladder wall so that the bladder musculature compresses a small portion of the ureter during normal voiding. When the ureterovesical valveis impaired by congenital causes or ureteral abnormalities, the bacteria may reach and eventually destroy the kidney Symptoms Symptoms of Urinary Tract Infection (UTIs) include:
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Abdominal pain Blood in the urine Cloudy urine Lower back pain Painful urination, often with a burning sensation Urgent and constant need to urinate Severe

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Chills Fever Nausea Severe pain in the mid-back Vomiting

Transmission Women get the infection more often because it is much easier for bacteria to enter the urethra and work its way up into the bladder as it is so close to the vagina and the anus. Urinary tract infections include: Urethritis
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infection of the urethra

Cystitis
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infection of the bladder

Pyelonephritis
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the kidneys become infected when bacteria ascends up the ureters

Contributing Factors Some factors that may result in urinary tract infections are: Sexual Intercourse:
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can transfer bacteria from the anal-vaginal area to the urethra and the bladder may irritate tissues

Birth Control Methods:

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Ill-fitting diaphragms may place pressure on the bladder The chemicals in spermicides may irritate vaginal tissues

Physical Structural Problems: Some women may have an actual physical problem which predisposes them to urinary tract infections (UTIs). A physical examination and medical history will determine if there is any problem. Risk Factors In Children:
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Babies born with abnormalities of the urinary tract, such as posterior urethral valves or vesicoureteral reflux, which may require surgery Small girls have a shorter urethra than boys so get infected easier Soiled diapers on young children can cause an infection if left on too long

Uncircumcised boys more than circumcised boys because bacteria survives in warm, moist areas under the foreskin

In Adults
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Low water intake will cause less urination, which flushes out the system People with diabetes have a higher risk of infection because of changes in the immune system Sexually active teenagers and adult women because of friction occurring at the meatus during intercourse Wiping from back to front after using the toilet can expose the vaginal and meatal area to rectal bacteria, oftenEscherichia coli (E. coli) Women with specific blood types

Other Factors Catheters or tubes placed in the bladder:

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when urination is impossible when people are unconscious or critically ill on the elderly on those with nervous system disorders such as spinal cord injury where loss of bladder control may require catheters permanently

Infections can be caused by the bacteria:

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Citrobacter Enterobacter Escherichia coli (E. coli) Klebsiella Proteus Pseudomonas Serratia Staphylococcus aureus Streptococcus fecalis

Diagnosis
Health professional will check your symptoms and test your urine, which is essential as other conditions have similar symptoms, including:
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Bladder cancer Chlamydia Gonorrhea Irritable bladder Vaginal infection

Prevention
Help Factors Drink
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a cup of water with a half a teaspoon of baking soda 1-2 times a day cranberry juice as it helps reduce the amount of bacteria in your urine large amounts of water to help flush the bacteria out of the system

Avoid
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acid foods alcohol caffeine alcohol

Other Factors
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Drink water before and after sex so that you will urinate a good volume with a steady stream afterward Regular testing of urine during pregnancy Urinating after sexual intercourse Wiping from the vagina to the anus after urinating to avoid spreading bacteria Wear cotton underwear as it is less irritating and provides more ventilation than nylon

Risk Factors
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Tight clothing and pantyhose may irritate tissues, trap heat and promote bacterial growth

Prognosis
Complications Recurrent Cystitis Some women suffer from recurrent urinary tract infections:
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20% of women who have had one urinary tract infection (UTI) will have one recurrence 30% of those women will have more than one recurrence

The recurrent infection usually stems from a different strain or type of bacteria from the original urinary tract infection (UTI) During Pregnancy If a pregnant woman develops a urinary tract infection (UTI) it often travels to the kidney causing pyelonephritis, due to hormonal changes and fluctuations and increased pressure on the bladder In Babies
y y

If left untreated the infection can harm the fetus Newborn babies may get a systemic infection called Sepsis

After Menopause Infection can occur when vaginal tissues start to break down due to a decrease in estrogen levels

Urinary Tract Infections Treatment UTI Home Remedy Because the symptoms of a urinary tract infection mimic those of other conditions, you should see your health-care provider if you think you have a urinary tract infection. A urine test is needed to confirm that you have an infection. Self-care is not recommended. You can help reduce the discomfort by taking the following steps:
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Follow your health-care provider's treatment recommendations. Finish all antibiotic medication even if you are feeling better before the medication is gone. Take a pain-relieving medication. Use a hot-water bottle to ease pain.

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Drink plenty of water. Avoid coffee, alcohol, and spicy foods, all of which irritate the bladder. Quit smoking. Smoking irritates the bladder and is known to cause bladder cancer. Avoid eating Junk foods. Drink plenty of water every day. Drink cranberry juice daily as this juice seems to help prevent UTIs Eat parsley, celery and watermelon Urinate when you need to, don
t hold it in. Empty your bladder completely when you urinate. Always wipe from front to back to prevent fecal matter from entering the urethra. Avoid bubble baths. DIAGNOSTIC TESTS
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Urine tests y Urinalysis y Intravenous pyelogram (IVP) y Cystoscopy Urinalysis (UA) simply means analysis of urine. This is a very commonly ordered test that is performed in many clinical settings such as hospitals, clinics, emergency departments, and outpatient laboratories. Urinalysis is a simple test, which can provide important clinical information, it has a quick turn-around time, and it is also cost effective. o diagnosing urinary tract infections (UTIs), diagnosing kidney stones, screening for and evaluating many types of kidney diseases, and monitoring the progression of diseases such as diabetes mellitus and high blood pressure

Urine Test A urine test checks different components of urine, a waste product made by the kidneys. A regular urine test may be done to help find the cause of symptoms. The test can give information about your health and problems you may have. Intravenous Pyelogram (IVP) An intravenous pyelogram (IVP) is an X-ray test that provides pictures of the kidneys, the bladder, the ureters, and the urethra (urinary tract ). An IVP can show the size, shape, and position of the urinary tract, and it can evaluate the collecting system inside the kidneys. An intravenous pyelogram (IVP) is done to:
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Look for problems with the structure of the urinary tract. Find the cause of blood in the urine. Find the cause of ongoing back or flank pain. Locate and measure a tumor of the urinary tract. Locate and measure a kidney stone. Find the cause of recurring urinary tract infections. Look for damage to the urinary tract after an injury.

Cystoscopy Cystoscopy is a test that allows your doctor to look at the inside of the bladder and the urethra using a thin, lighted instrument called acystoscope Why It Is Done Cystoscopy may be done to:
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Find the cause of symptoms such as blood in the urine (hematuria), painful urination (dysuria), urinary incontinence, urinary frequency or hesitancy, an inability to pass urine (retention), or a sudden and overwhelming need to urinate (urgency). Find the cause of problems of the urinary tract, such as frequent, repeatedurinary tract infections or urinary tract infections that do not respond to treatment. Look for problems in the urinary tract, such as blockage in the urethra caused by an enlarged prostate, kidney stones, or tumors. Evaluate problems that cannot be seen on X-ray or to further investigate problems detected by ultrasound or during intravenous pyelography, such as kidney stonesor tumors. Remove tissue samples for biopsy. Remove foreign objects. Place ureteral catheters (stents) to help urine flow from the kidneys to the bladder. Treat urinary tract problems. For example, cystoscopy can be done to remove urinary tract stones or growths, treat bleeding in the bladder, relieve blockages in the urethra, or treat or remove tumors. Place a catheter in the ureter for an X-ray test called retrograde pyelography. A dye that shows up on an X-ray picture is injected through the catheter to fill and outline the ureter and the inside of the kidney. DRUGS OF CHOICE y GENERIC NAME: trimethoprim

BRAND NAMES: Trimpex, Proloprim, Primsol DRUG CLASS AND MECHANISM: Trimethoprim is a synthetic (man-made) antibiotic that interferes with the production of tetrahydrofolic acid, a chemical that is necessary in order for bacteria and human cells to produce proteins. Trimethoprim inhibits production of tetrahydrofolic acid by inhibiting the enzyme responsible for making tetrahydrofolic acid from dihydrofolic acid. Trimethoprim inhibits the bacterial enzyme more than the corresponding human enzyme. Therefore, trimethoprim has less effect on the production of tetrahydrofolic acid by humans. Trimethoprim is effective against a wide variety of bacteria. Trimethoprim was first approved by the FDA in combination with sulfamethoxazole (for example, Bactrim, Septra) in 1973. It was approved as a stand-alone drug in 1980. PRESCRIPTION: Yes GENERIC AVAILABLE: Yes PREPARATIONS: Tablets: 100, and 200 mg. Solution: 50 mg/5 ml STORAGE: Tablets should be kept at room temperature, 15-30 C (59-86 F).

PRESCRIBED FOR: Trimethoprim is used for the treatment of urinary tract infections , traveler's diarrhea, respiratory and middle ear infections, and, when combined with either sulfamethoxazole or dapsone, for prevention and treatment of Pneumocystis infections. DOSING: The usual dose is 100 mg every 12 hours or 200 mg every 24 hours for 10 days. As with all antibiotics, it is important to complete the entire course of trimethoprim even if symptoms improve early in therapy. Persons with kidney diseases may need to receive lower doses. (Diseased kidneys may not eliminate trimethoprim adequately from the body, and levels of trimethoprim may increase in the body and lead to side effects.) DRUG INTERACTIONS: Changes in one patient's mental status occurred when a combination of trimethoprim and sulfamethoxazole was given withamantadine (Symmetrel). Blood levels of phenytoin (Dilantin) may be increased by treatment with trimethoprim. This may lead to side effects associated with phenytoin such as dizziness, and reduced attention. Trimethoprim also may increase blood levels of digoxin (Lanoxin) and warfarin (Coumadin) and lead to serious toxic effects. Anemia, due to a reduction in folic acid, can occur in persons receiving trimethoprim in combination with divalproex, valproic acid, methotrexate, pyrimethamine, triamterene, or trimetrexate. The combination of trimethoprim and cyclosporine can increase the risk of kidney damage from cyclosporine. When trimethoprim and dapsone are used together, increased blood concentrations of both drugs can occur, sometimes with side effects that include a toxic condition called methemoglobinemia. Rifampin can increase the elimination of trimethoprim by the kidneys and may reduce the effectiveness of trimethoprim. PREGNANCY: Although there are no human studies that have examined the effects of trimethoprim on the fetus, animal studies have shown adverse effects. Therefore, the physician must weigh the potential risks to the fetus against the potential benefits to the mother when considering trimethoprim therapy for pregnant women . y GENERIC NAME: ciprofloxacin

BRAND NAME: Cipro, Cipro XR, Proquin XR DRUG CLASS AND MECHANISM: Ciprofloxacin is an antibiotic that is used to treat bacterial infections. Ciprofloxacin belongs to the fluoroquinolone class of antibiotics which includes levofloxacin (Levaquin), ofloxacin (Floxin),gatifloxacin (Tequin), norfloxacin (Noroxin), moxi floxacin (Avelox),trovafloxacin (Trovan) and others. Ciprofloxacin stops the multiplication of bacteria by inhibiting the reproduction and repair of their genetic material (DNA). The FDA approved ciprofloxacin in October 1987. PRESCRIPTION: Yes GENERIC AVAILABLE: Yes PREPARATIONS: Tablets: 250, 500, and 750 mg. Tablets extended release (XR): 500 and 1000 mg. Microcapsules for suspension: 250 mg/5 ml, 500 mg/5 ml. Injection or Injection concentrate: 200 and 400 mg.

STORAGE: Immediate release tablets: store below 30C (86F). Extended release tablets: store between 15-30C (59-86F). Microcapsules: store below 25C (77F) and protect from freezing. Injection: Store between 5-30C (41-86F) and avoid freezing. PRESCRIBED FOR: Ciprofloxacin is used to treat infections of the skin, lungs, airways, bones, and joints caused by susceptible bacteria. Ciprofloxacin is also frequently used to treat urinary infections caused by bacteria such as E. coli. Ciprofloxacin is effective in treating infectious diarrheas caused by E. coli, Campylobacter jejuni, and Shigella bacteria. DOSING: For most infections the recommended oral dose for adults is 250-750 mg (immediate release tablets) every 12 hours or 500-1000 mg (extended release tablets) every 24 hours. The usual intravenous dose is 200-400 mg every 8-12 hours. DRUG INTERACTIONS: Ciprofloxacin administered together withtheophylline can lead to elevated, toxic blood levels of theophylline. Theophylline is used to open airways in the treatment of asthma. Toxic levels of theophylline can lead to seizures, and disturbances in heart rhythm. If concurrent use of ciprofloxacin and theophylline cannot be avoided, frequent blood tests to monitor theophylline blood levels are recommended. Iron salts (for example, ferrous sulfate) may reduce the absorption of ciprofloxacin because of formation of a ciprofloxacin-iron complex that is not absorbable. Antacids also may reduce the absorption of ciprofloxacin. If patients are receiving iron salts or antacids and ciprofloxacin, the ciprofloxacin should be given two hours before or six ours after the iron salt or antacid. Ciprofloxacin may increase the blood thinning effect of warfarin (Coumadin). The reason for this is unknown. Anticoagulant activity should be monitored after starting or stopping ciprofloxacin. y GENERIC NAME: ofloxacin

BRAND NAME: Floxin DRUG CLASS AND MECHANISM: Many common infections in humans are caused by single cell living organisms called bacteria. Bacteria invade the body, and then grow, multiply, and spread. Medicines that control and eradicate these bacteria are called antibiotics. Ofloxacin is an antibiotic that stops bacteria multiplication by inhibiting the reproduction and repair of their genetic material (DNA). PRESCRIPTION: yes GENERIC AVAILABLE: no PREPARATIONS: Tablets: 200mg, 300mg, 400mg. STORAGE: Ofloxacin should be stored in a tight container and below 86F. PRESCRIBED FOR: Ofloxacin is used to treat pneumonia and bronchitiscaused by Haemophilus influenzae and Streptococcus pneumoniae. It is also used in treating skin infections caused by staphylococcus aureus, andstreptococcus pyogenes bacteria. Ofloxacin is used to treat sexually transmitted diseases, such as gonorrhea and chlamydia, but is not effective against syphilis. Ofloxacin is often used to treat urinary infections andprostate infections caused by E. Coli. Some strains of streptococcus,enterococcus, and anaerobic bacteria are resistant to ofloxacin. DOSING: Ofloxacin should not be taken with food. Ofloxacin is partially metabolized by the liver and excreted by the kidney. Dosages require adjustment in patients with severely abnormal liver or

kidney function. Antacids, minerals, and vitamins with iron block the absorption of ofloxacin and they should not be taken together. DRUG INTERACTIONS: Ofloxacin administered together with theophyllinecan lead to elevated blood levels of theophylline. Theophylline is used to open airways in the treatment of asthma. If concurrent use of ofloxacin and theophylline cannot be avoided, frequent blood tests to monitor theophylline blood levels should be performed. Ofloxacin should be used with caution in patients with central nervous system diseases such as seizures, because rare seizures have been reported in patients receiving this medication. Ofloxacin should be avoided in children and adolescents under 18 years old, as safe use in these patients have not been established.