Infection, Inflammation, and Basic Science of the Genitourinary Tract
Classification and treatment
Distinguish uncomplicated from complicated urinary tract infection. Asymptomatic bacteriuria should not be treated except in pregnancy and before urologic procedures involving mucosal trauma. Culture-directed therapy is preferred, with local resistance patterns guiding empiric choice.
Clinical syndromes
Acute bacterial prostatitis presents with fever and perineal pain; prostatic massage is avoided. Chronic prostatitis and chronic pelvic pain syndrome are often non-bacterial. Epididymitis is sexually transmitted in younger men and enteric in older men. Fournier gangrene is a necrotising fasciitis requiring urgent debridement and broad-spectrum antibiotics. Xanthogranulomatous pyelonephritis is associated with obstructing stones. Genitourinary tuberculosis presents with sterile pyuria and requires repeated morning urine samples.
Basic science
Biofilm formation on catheters and stones protects organisms from antibiotics. Urease-producing organisms alkalinise urine and promote struvite stones. Urothelial defence involves mucin layers, cytokines, and inflammatory mediators; interstitial cystitis and bladder pain syndrome are diagnoses of exclusion supported by cystoscopy.
Traps
Treating asymptomatic bacteriuria in a catheterised patient; missing Fournier gangrene; relying on fluoroquinolones where resistance is high; forgetting that sterile pyuria warrants tuberculosis testing; treating non-bacterial prostatitis with repeated antibiotic courses.
Worked example
A catheterised patient with cloudy urine but no fever, pain, or leukocytosis should not receive antibiotics; the urine reflects colonisation, and treatment selects resistant organisms.