The clinical manifestations of UTI are variable. Approximately 50% of infections do not produce recognizable illness and are discovered incidentally during a general medical examination. Infections in infants produce symptoms of a nonspecific nature, including fever, vomiting, and failure to thrive. Manifestations in older children and adults, when present, often suggest the diagnosis and sometimes the localization of the infection within the urinary tract.
The symptoms of cystitis are dysuria (painful urination), frequency (frequent voiding), and urgency (an imperative “call to toilet”). These findings are similar to those of urethri-tis caused by sexually transmitted agents. The cystitis complex is, in fact, produced by irritation of the mucosal surface of the urethra as well as the bladder. It is clinically dis-tinguished from pure urethritis by a more acute onset, more severe symptoms, the pres-ence of bacteriuria, and in approximately 50% of cases, hematuria. The urine is often cloudy and malodorous and occasionally frankly bloody. Cystitis patients also experience pain and tenderness in the suprapubic area. Fever and systemic manifestations of illness are usually absent unless the infection spreads to involve the kidney.
The typical presentation of upper urinary infection consists of flank pain and fever that exceeds 38.3°C. These findings may be preceded or accompanied by manifestations of cystitis. Rigors, vomiting, diarrhea, and tachycardia are present in more severely ill pa-tients. Physical examination reveals tenderness over the costovertebral areas of the back and, occasionally, evidence of septic shock. In the absence of obstruction, the clinical manifestations usually abate within a few days, leaving the kidneys functionally intact. It has been estimated, however, that 20 to 50% of pregnant women with acute pyelonephri-tis give birth to premature infants, one of the most serious consequences of UTI. In the presence of obstruction, a neurogenic bladder, or vesicoureteral reflux, clinical manifesta-tions are more persistent, occasionally leading to necrosis of the renal papillae and pro-gressive impairment of kidney function with chronic bacteriuria. If a renal calculus or necrotic renal papilla impacts in the ureter, severe flank pain with radiation to the groin occurs. The term chronic pyelonephritis is used to describe inflamed, scarred, contracted kidneys often in association with compromised renal function. There is no known con-nection between UTI and chronic pyelonephritis.
Infection of the prostate is typically manifested as pain in the lower back, perirectal area, and testicles. In acute infection, the pain may be severe and accompanied by high fever, chills, and the signs and symptoms of cystitis. Inflammatory swelling can lead to obstruc-tion of the neighboring urethra and urinary retention. On rectal palpation, the prostate is boggy and exquisitely tender. Response to antibiotic therapy is good, but occasionally ab-scess formation, epididymitis, and seminal vesiculitis or chronic infection develop. Typi-cally, acute prostatitis develops in young adults; however, it can also follow placement of an indwelling catheter in an older man. Patients with chronic prostatitis seldom give a history of an acute episode. Many are totally without symptoms; others experience low-grade pain and dysuria. Periodic spread of prostatic organisms to the urine in the bladder produces recurrent bouts of cystitis. In fact, chronic prostatitis is probably the major cause of recurrent bacteriuria in men. The etiologic agents are the same as in cystitis and pyelonephritis.
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