830

Journal of the Royal Society of Medicine Volume 71 November 1978

Symposium: Urinary tract infection'

Role of excretion urography in management of recurrent urinary tract infection in women I Kelsey Fry FRCP FRCR St Bartholomew's Hospital, London EC]

The excretion urogram in women presenting with recurrent urinary tract infection is used to answer three main questions. (1) Will the kidney be damaged if the infection persists? The evidence suggests that persistent urinary tract infection does not damage the kidney unless there is already some abnormality of the upper urinary tract or some associated disease which might itself cause renal damage. The urographic appearances, therefore, indicate whether control of the infection needs to be meticulous in order to prevent renal damage or whether it can be less stringent and directed mainly to the relief of symptoms. Not all abnormalities of the kidney are likely to lead to progressive renal damage if infection is not controlled. The two most important abnormalities in this context are obstruction and calculus disease. Infection in patients with papillary necrosis may also lead to renal damage, not only because a sloughed papilla may cause obstruction and possible pyelonephrosis, but also because in a few patients the papillary necrosis seems to progress more rapidly than would be expected in the absence of infection. Chronic pyelonephritis or post-obstructive atrophy do not seem to be associated with progressive kidney damage in adults even if infection persists, provided they are not accompanied by calculus disease or severe reflux and provided that obstruction is no longer present (Gower 1973). Severe acute infection may cause renal parenchymal damage even in the absence of evidence of previous renal disease. This is especially likely to occur in patients with diabetes in whom acute infection may cause severe papillary necrosis. Whether infection plays a part in the pathogenesis of the more chronic forms of papillary necrosis in diabetes or in the development of analgesic nephropathy remains uncertain. It may perhaps be wise to treat urinary tract infection enthusiastically in patients with conditions liable to lead to papillary necrosis, even if the initial urogram appears normal, especially as the earliest radiological signs of papillary necrosis are difficult to detect. (2) Is there any abnormality which may predispose to difficulty in eradicating infection or predispose to repeated reinfections ? Any condition where there is stasis or a focus of infection may contribute to difficulty in controlling the infection. Relapse tends to be associated with lesions of the upper urinary tract, particularly stones. Reinfection is more commonly associated with inadequate bladder emptying. (3) Is there some other disease accounting for the symptoms? This is particularly important if one of the symptoms is haematuria. The incidence of radiological abnormalities in women with bacteriuria is surprisingly high. Papers read to Section of Urology and Section of Surgery, 24 November 1977 0 141-0768/78/110830-02/$O 1.00/0

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1978 The Royal Society of Medicine

Journal of the Royal Society of Medicine Volume 71 November 1978

831

In a Cardiff study 23% of women with asymptomatic bacteriuria showed significant radiological abnormalities such as stones, scars or hydronephrosis (Asscher et al. 1973). It is open to question whether a patient presenting with symptoms suggestive of infection and found to have bacteriuria should have a urogram, and even more debatable in the patient who has symptoms but is not bacteriuric. The place of any investigation in the management of a particular condition will vary from centre to centre or from doctor to doctor; but many clinicians will take the view that, by the time a woman has been referred to a hospital clinic with a history of urinary tract infection, the problem is likely to be severe enough to warrant an excretion urogram as part of the initial investigation. Excretion urography is, however, a potentially hazardous investigation and almost always unpleasant for the patient. It should, therefore, only be used when it can be expected to have a significant effect on the patient's management. The following summary reflects the practice of my colleagues in the Renal Infection Clinic at St Bartholomew's Hospital. If the patient is bacteriuric an excretion urogram is indicated if there is: (a) no response to treatment; (b) relapse; (c) repeated reinfection; (d) haematuria. If the patient has symptoms but is not bacteriuric there is no indication for urography unless: (a) symptoms persist despite symptomatic treatment, in which case it becomes important to exclude other disease such as tuberculosis which may be causing the symptoms; (b) the patient becomes bacteriuric. Patients with frequency/dysuria who are not initially bacteriuric fall into two groups: those who are never bacteriuric and those who eventually become bacteriuric. In the latter group the incidence of abnormality is similar to that in patients who are bacteriuric at the initial examination, and they require urography for the same reasons.

References Asscher A W, Chick S, Radford N, Waters W E, Sussman M, Evans J S, McLachlan M S F & Williams J E (1973) In: Urinary Tract Infection. Ed. W Brumfitt and A W Asscher. Oxford University Press, London; p 51 Gower P E (1973) In: Urinary Tract Infection. Ed. W Brumfitt and A W Asscher. Oxford University Press, London; p 74

Treatment of urinary tract infection Professor A W Asscher MD FRCP KRUF Institute of Renal Disease, Royal Infirmary, Cardiff CF2 I SZ

The two questions in the treatment of urinary infection are whom to treat and how to treat. Patients with symptoms require treatment but for every symptomatic infection there are at least ten covert infections. Long-term follow-up studies of adult women with such covert infection have established that they are benign and need neither detection nor treatment. In contrast, covert infections in pregnancy predispose to acute pyelonephritis and hence need detection and treatment. In young girls the condition may lead to renal damage, particularly when bacteriuria and vesicoureteric reflux coexist. In the elderly and also in immunosuppressed patients the infected urinary tract is an important source of gram-negative septicaemia which can be eliminated by detection and treatment of covert infection. Numerous potent antibacterial agents are now available for treatment of urinary infections. Provided the pathogen is sensitive a cure rate in excess of 90% may be expected whatever drug is used. However, some 50% of infections recur within one year of stopping the treatment. The early recurrences (usually within one month) are due to relapse with infection by the same organism and indicate a failure of initial treatment. These patients require careful investigation, which must include a urogram to look for an underlying abnormality. The major causes of relapsing infection together with suggested remedial actions are shown in Table 1. 0 1 41-0768/78/110831-02/$O 1.00/0

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1978 The Royal Society of Medicine

Role of excretion urography in management of recurrent urinary tract infection in women.

830 Journal of the Royal Society of Medicine Volume 71 November 1978 Symposium: Urinary tract infection' Role of excretion urography in management...
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