menopausal urinary tract infection
Introduction
Introduction to menopausal urinary tract infection The main symptoms of urinary tract infections in menopausal women include frequent urination, urgency, difficulty in urinating, nocturia, urinary incontinence and tension incontinence. However, in the early 20th century, these urinary tract dysfunctions rarely attracted people's attention. With the deepening of basic theory and clinical research, the pathophysiology of these symptoms has been recognized, which provides a more reasonable means for the evaluation and treatment of the disease. Urinary tract infections can be divided into upper urinary tract infection and lower urinary tract infection. The former includes pyelonephritis, renal cortical infection, perirenal abscess, and renal empyema. The latter includes cystitis and urethritis. basic knowledge The proportion of illness: 23% Susceptible population: menopausal women Mode of infection: non-infectious Complications: cystitis pyelonephritis diabetes urinary tract obstruction sepsis acute renal failure abscess kidney stones
Cause
Causes of menopausal urinary tract infection
(1) Causes of the disease
The cause of urinary tract infection in elderly women: the reduction of keratinocytes, the vaginal self-cleaning effect is reduced, the bacteria are easy to breed in the vestibule and the vagina, although women are prone to urinary tract infections, but whether it occurs, mainly depends on the internal factors of the body. It is closely related to the weakening of the body's resistance, urethral anatomy and physiological characteristics and internal environment abnormalities.
Most of the bacteria causing urinary tract infections are Gram-negative bacilli, accounting for 62.6%, mainly including Escherichia coli and Escherichia coli, accounting for 60% to 80%, followed by Proteus and Klebsiella. Aeromonas, Pseudomonas aeruginosa, etc., Gram-positive cocci are 33.6%, of which 55.6% are Staphylococcus and Streptococcus, and fungi, viruses, parasites, etc., as well as complicated factors or nosocomial infections. .
In most cases, infection with Escherichia coli is limited to the lower urinary tract. Proteobacteria infection is common in the upper urinary tract. In the intestinal flora, anaerobic bacteria are much more abundant than aerobic bacteria, but urinary tract infections caused by anaerobic bacteria are Very rare.
(two) pathogenesis
Urinary tract defense function
(1) The ovarian secretion of estrogen keeps the pH value of the vestibular and vaginal in an acidic environment of 4.5. The bacteria are not easy to multiply. The pH value can reach 7 in juvenile or postmenopausal. In an alkaline environment, the bacteria are more likely to multiply and become infected.
(2) The bladder regularly urinates, the urine continuously flows, and a small amount of bacteria can be diluted and discharged into the bladder. As long as the urine flows smoothly and the bladder is empty, the bacteria are difficult to stay in the urinary tract, so the more residual urine, the more The longer the intravesical period, the greater the likelihood of a urinary tract infection.
(3) bladder mucosa has bactericidal ability, can secrete IgA, has antibacterial effect, high concentration of urea and organic acid in urine is unfavorable for bacterial growth, white blood cells in bladder mucosa have phagocytosis and kill bacteria, and mucin in urine can prevent bacteria Adhered to the urinary tract mucosa.
(4) In acute cystitis, the bladder mucosa epithelium can be accelerated to accelerate the elimination of bacteria adhering to the bladder mucosa.
2. Route of infection
(1) Ascending infection: Under normal circumstances, the urethra often has bacterial growth and enters the urethra. At the end of urination, the urine of the posterior urethra can flow back to the bladder, and the bacteria enter the bladder, which damages the urine due to various factors. The road mucosal defense ability causes inflammation.
(2) Blood infection: A bacterial infection occurs somewhere in the body. The bacteria in the infected area enter the bloodstream, and the blood flow circulates to the kidneys to form multiple small abscesses. The renal tubules spread down the renal tubules and cause pyelonephritis. Only Staphylococcus aureus sepsis. About 3%.
(3) Lymphatic infection: pelvic organ infection, appendicitis, colitis, bacteria can enter the right kidney through the lymphatics, but very rare.
3. Susceptibility factors
(1) female urethra is short and wide, about 3.5cm long, sphincter weak, bacteria easy to invade, plus female urethra is close to the vagina and anus, if you do not pay attention to the vulva clean, and have bad habits, will bring bacteria into the urethra Infection around the mouth.
(2) gynecological genital tract inflammation is easy to cause cystitis, urethritis.
(3) Estrogen has an important role in maintaining the integrity of the bladder and urethra mucosa. If the estrogen level in the elderly is seriously reduced, it is easy to cause atrophic cystitis, and the vaginal mucosa shrinks and retracts inward, so that the urethra is also Pulling inward, it is prone to urethritis, urethral meat and cystitis.
(4) Any factor destroys the function of the ureteral opening valve. When the intravesical pressure increases, the urine will flow back to the ureter, and it is easy to bring the bacteria in the bladder to the renal pelvis to cause upper urinary tract infection. Adults cause this urinary tract infection. Accounted for 24.9% to 30.4%, elderly patients with diabetes or neurogenic bladder often secondary to vesicoureteral reflux, reflux accounted for 8.3% of the susceptibility factors of urinary tract infection, is also the main cause of upper urinary tract infection.
(5) Bladder bulging causes the direction of the bladder and urinary tract to change direction. Every time urination is difficult to drain, due to a small amount of urinary retention for a long time, it is easy to cause urinary tract infection.
(6) When the urinary tract application device is inspected or treated, it often damages the urinary tract mucosa. If the bacteria are brought into the urinary tract during the operation, it is convenient for bacterial invasion. It is reported that the incidence of infection caused by catheterization is 1% to 3%. Among them, 10 to 15% of patients with severe illness stayed, and the open drainage tube was left for 1 day, the infection rate was 5%. It is difficult to avoid urinary tract infection after 4 days of indwelling, and the susceptibility factors of urinary tract infection in the elderly with catheter or indwelling catheter It accounts for 6.6%. In recent years, a closed catheterization device has been used, and infection does not occur within 2 weeks, but it is difficult to avoid for a long time.
(7) systemic diseases, long-term use of adrenal cortex hormones or the use of immunosuppressive drugs, etc., are prone to urinary tract infections, elderly women with physiological decline is also accompanied by local and systemic immune function of the urinary tract.
Upper urinary tract infection can occur in unilateral or bilateral kidneys, purulent secretions on the surface of the renal pelvis and renal pelvis, mucosal congestion, edema, submucosal small inflammatory lesions, in small cases can be fused into small abscesses, massive neutrophil infiltration There is purulent secretion in the renal tubule, the epithelial cells are swollen, necrotic, and shedding. In some cases, extensive hemorrhage occurs to form superficial ulcers, but the glomerular morphology is normal.
No anatomical changes occurred in the lower urinary tract infection. Acute cystitis showed bladder mucosal congestion, epithelial cell swelling, submucosal tissue congestion, and leukocyte infiltration. In a few severe cases, bladder mucosal punctate or flaky hemorrhage or mucosal ulcer occurred.
Prevention
Menopausal urinary tract infection prevention
Reducing the known susceptibility factors is the key to prevent urinary tract infections. Pay attention to the genital cleansing, change underwear, drink plenty of water, urinate once every 2 to 3 hours. This is the simplest and most practical way to remove bacteria in the urinary tract. Methods, try to avoid urinary tract equipment examination, 48 hours after the examination should be used for urinary bacterial culture, there have been urinary tract infections, repeated attacks or existing urinary tract function or anatomical abnormalities, oral antibiotics should be taken 48 hours before and after the device examination to prevent infection.
Complication
Postmenopausal complications of urinary tract infection Complications cystitis pyelonephritis diabetes urinary tract obstruction acute renal failure abscess kidney stones
Most urinary tract infections, especially cystitis, are self-limiting diseases. In severe cases, the patients continue to have high fever and significant increase of white blood cells after treatment. They should be alert to the occurrence of complications, mainly the following:
Renal papillary necrosis
Often occurs in severe pyelonephritis with diabetes or urinary tract obstruction, may be complicated by Gram-negative septicemia, or lead to acute renal failure.
2. Peri-renal abscess
Often caused by severe pyelonephritis, there are many unfavorable factors such as diabetes and urinary calculi.
3. Infectious stones
Pyelonephritis caused by proteobacteria and other bacteria that cause urea can often cause kidney stones, called infectious stones. Because antibacterial drugs are not easy to reach, it is easy to cause urinary tract infection treatment failure. Infection and urinary tract obstruction can lead to kidney. Substantial destruction and impaired kidney function.
4. Gram-negative bacilli sepsis
Most occur in acute urinary tract infections, especially after the use of cystoscopy or catheter, severe complicated urinary tract infections, especially those with acute renal papillary necrosis are also prone to Gram-negative bacilli sepsis.
Symptom
Symptoms of menopausal urinary tract infections Common symptoms Urinary urinary dysuria, urgency, nausea and vomiting, bladder, pus, chills, urinary pain, menopause, urinary incontinence
Older urinary tract infections, the above urinary tract infections are more common, only 35% of patients with urinary tract irritation, the rest of the symptoms are not typical.
Upper urinary tract infection
According to the severity of inflammation, the clinical manifestations are quite different. In addition to the above-mentioned urinary tract irritation and bladder tenderness, it is often accompanied by systemic manifestations, rapid onset, chills, fever, headache, nausea, vomiting, low back pain, kidney. There is no obvious symptom in the area.
2. Lower urinary tract infection
Can be without symptoms, can also be expressed as frequent urination, urgency, dysuria, turbid pyuria in severe cases, known as urinary tract irritation, sometimes accompanied by poor urination and residual urinary sensation, lower abdomen full of pain, dysuria, sometimes Impulsive urinary incontinence, severe bladder spasms, frequent urination and poor urination.
Examine
Examination of menopausal urinary tract infections
In the acute phase, there may be acute inflammatory manifestations, such as increased white blood cell count and increased neutrophil percentage, but the following tests are more meaningful for diagnosis.
Urine routine examination
It is the easiest and most reliable test method. It is advisable to leave the first urine test in the morning. More than 5 (>5/HP) white blood cells in each high power field are called pyuria, and about 96% have symptomatic urinary tract infection. (UTI) patients may have pyuria, direct microscopic examination is very unreliable, detection of leukocytic excretion rate is more accurate, but too cumbersome, it is now advocated the use of white blood cell lipase test, when white blood cells more than 10 / ml positive reaction, its sensitivity Sexuality and specificity are 75% to 96% and 94% to 98%, respectively. In addition to pyuria, acute urinary tract infections can often be found in leukocyte casts, bacteriuria, sometimes with microscopic hematuria or gross hematuria, especially cloth. When there is infection with Brucella, Nocardia and actinomycetes (including Mycobacterium tuberculosis), occasionally micro-proteinuria, if there is more proteinuria, it indicates glomerular involvement.
2. Urinary bacteriological examination
More than 95% of UTI is caused by Gram-negative bacteria. Sausage-producing staphylococci and Enterococcus faecalis can occur in sexually active women, while some bacteria that are parasitic in the urethra, skin and vagina, such as Staphylococcus epidermidis, Lactobacillus, and anaerobic bacteria Corynebacterium (Diphtheria bacilli) rarely causes UTI. Except for special cases, there are more than two types of bacteria in urine culture, which are more likely to be contaminated by specimens. In the past, it was considered clinically meaningful to have a colony count of more than 105/ml in the middle of clean, less than 104/ml. Due to pollution, it is now found that many UTI patients do not have a high colony count, even 102/ml, which may include: acute urethral syndrome; saprophytic staphylococcus and candida infection; antibiotic therapy has begun; rapid diuresis; urine Extremely acidic acid; urinary tract obstruction; extraluminal infection, etc., the American Society of Infectious Diseases recommends the following criteria: symptoms of lower urinary tract infection, colony count 103 / ml; pyelonephritis symptoms, colony count 104 / ml Considering infection, the sensitivity and specificity were 80% and 90% in the former and 95% in the latter.
3. UTI positioning check
Invasive examination and non-invasive examination, bilateral ureteral catheterization method is very accurate, but must be taken through cystoscopy or percutaneous nephrolithotomy, so it is not commonly used for traumatic examination, bladder irrigation is simple and easy, clinical Commonly used and accurate more than 90%, the specific method is to inject 20ml of 2% neomycin solution into the catheter to sterilize the bladder, then rinse with salt water, then collect the urine flowing into the bladder for culture, take urine every 10 minutes. Specimens once, for 3 consecutive times, if cystitis, bacterial culture should be negative; if it is pyelonephritis, it is positive, and the number of colonies rises.
Non-invasive tests include urine concentration, urine enzymes, and immune response tests. Acute and chronic pyelonephritis is often associated with tubular dysfunction. However, this test is not sensitive enough to be used as a routine examination. In some patients with pyelonephritis, lactate dehydrogenase or N-acetyl-BD aminoglucose can be elevated, but lacks specificity. Urine enzymes that have been able to help UTI localization are still under investigation. Recently, more applications have been used to detect bacterial-encapsulated bacteria in urine. The antibody is encapsulated, and the bacteria from the bladder are not coated with antibodies, so it can be used to distinguish upper and lower urinary tract infections, but the accuracy is only 33%, vaginal or rectal flora contamination, massive proteinuria or infection, and the outer urinary tract epithelium (such as prostatitis) , hemorrhagic cystitis, etc.) can lead to false positives, about 16% to 38% of adults with acute pyelonephritis and most children can have false negatives, so it is not routinely used.
In addition, urine 2 microglobulin determination also helps identify upper and lower urinary tract infections, upper urinary tract infections easily affect renal tubular reabsorption of small proteins, elevated urine 2 microglobulin, and lower urinary tract infection urine 2 Microglobulin does not increase. It has been reported in the literature that serum C-reactive protein is significantly increased in pyelonephritis and can reflect the therapeutic effect, but it is not elevated in acute cystitis, but C-reactive protein can also be elevated due to other infections. Therefore, it affects the reliability of the test.
4. X-ray inspection
Because acute urinary tract infection itself is prone to vesicoureteral reflux, intravenous or retrograde pyelography should be performed 4 to 8 weeks after infection is eliminated. Acute pyelonephritis and uncomplicated recurrent UTI do not advocate routine pyelography. For patients with chronic or long-term treatment, urinary tract plain film, intravenous pyelography, retrograde pyelography and urinary bladder ureter angiography may be performed as needed to check for obstruction, calculi, ureteral stricture or compression, renal ptosis, and urinary system congenital Sexual malformation and vesicoureteral reflux phenomenon, in addition to the renal pelvis, renal pelvis morphology and function, in order to distinguish with renal tuberculosis, kidney tumors, renal angiography can show that small blood vessels of chronic pyelonephritis have different degrees of distortion, necessary A CT scan or a magnetic resonance scan can be performed to rule out other kidney diseases.
5. Nuclide kidney diagram examination
Can understand the function of kidney, urinary tract obstruction, vesicoureteral reflux and bladder residual urine. The renal pattern of acute pyelonephritis is characterized by peak shift, the secretion segment appears to be delayed by 0.5~1.0min, and the excretion segment declines slowly; chronic pyelonephritis The slope of the secretory segment of nephritis is reduced, the peak is blunt or widened and moved backward, and the beginning of the excretory segment is delayed, parabolic, but the above changes have no obvious specificity.
6. Ultrasound examination
It is the most widely used and easiest method. It can screen urinary tract dysplasia, congenital malformation, polycystic kidney disease, renal artery stenosis caused by uneven kidney size, stones, severe hydronephrosis, tumor and prostate diseases, etc. .
Diagnosis
Diagnosis and diagnosis of urinary tract infection in menopause
Diagnostic criteria
The diagnosis of urinary tract infection can not rely solely on clinical symptoms and signs, mainly relying on laboratory tests, and its diagnostic criteria:
1. Regular clean mid-stage urine (requires urine to stay in the bladder for 4-6h or more). Quantitative culture of bacteria, the number of colonies is 105/ml.
2. Refer to the cleaned centrifuge mid-stage urine sediment white blood cell count > 10 / HFP, or have urinary tract infection symptoms.
Have 1,2 can be diagnosed. If there is no 2, then the urine bacteria count should be reviewed again. If it is still 105/ml, and the two bacteria are the same, the diagnosis can be confirmed.
3. For bladder puncture urine culture, such as bacterial positive (regardless of the number of bacteria), can also be diagnosed.
4. There is no condition for urinary bacteria culture count, you can use the normal method of cleaning the middle part of the urine before the treatment (urine stays in the bladder for 4-6h or more), the normal method of centrifugal urine sediment Gram staining to find bacteria, such as bacteria > 1 / oil mirror field of view, Combined with clinical symptoms, can also be diagnosed.
5. The number of urinary bacteria in the 104 ~ 105 / ml, should be reviewed, if still in the 104 ~ 105 / ml, combined with clinical manifestations or bladder puncture urine culture to confirm the diagnosis.
Differential diagnosis
Febrile disease
When the symptoms of acute urinary tract infection are not obvious, but the symptoms of systemic infection are prominent, it is easy to be confused with fever, malaria, sepsis, typhoid and other febrile diseases.
2. Abdominal organ inflammation
Some urinary tract infections have no local symptoms of urinary tract, but manifest as abdominal pain, nausea, vomiting and other symptoms, easily confused with acute gastroenteritis, appendicitis and annexitis.
3. Acute urethral syndrome
Is a group of the most common syndrome associated with urinary tract infections, mainly refers to lower urinary tract infection syndrome, that is, frequent urination, urgency, dysuria or dysuria, bladder pain, etc., but neither pyuria nor bacterial urine, The cause is unknown, more common in middle-aged women, frequent urination is more prominent than urinary discomfort, have a long history of antibiotic use and invalid history.
4. kidney tuberculosis
Some urinary tract infections are mainly manifested by hematuria, and the bladder irritation sign is obvious. It is easily misdiagnosed as renal tuberculosis and needs to be identified by laboratory tests.
