Prenatal diagnosis of fetal urinary ascites.

We report on a rare in utero appearance of the rupture of the fetal bladder caused by low urinary tract obstruction with subsequent urinary ascites. The findings on prenatal sonography, postnatal X-ray examinations and postnatal surgical treatment are described and the literature is reviewed.     

Contribution of prenatal imaging to the anatomical assessment of fetal hydrocolpos.

Hydrocolpos may be associated with a lower urinary tract obstruction in a spectrum of urorectal malformations ranging from persistent urogenital sinus to cloacal dysgenesis. As cloacal dysgenesis carries the worst postnatal prognosis, detailed prenatal ultrasound should focus on the fetal pelvic anatomy to provide the parents with appropriate prenatal counseling. We report three cases of fetal hydrocolpos associated with low urinary tract obstructions, including two with a normal appearance of the anal canal and rectum on prenatal ultrasound and one with a complex cloacal malformation which contributed to the precise prenatal assignment of the malformation in each case within the spectrum of urogenital sequence malformations.     

A case of urinary tract infection caused by Kluyvera ascorbata in an infant: case report and review of the literature

We experienced a case of urinary tract infection in a 3-month-old child caused by Kluyvera ascorbata. The authors report the case and review the literature regarding Kluyvera urinary tract infection exclusively in children. Kluyvera infection, which had been extremely rare, has increasingly been reported, including urinary tract infection. A prompt identification of Kluyvera species in clinical infections is important. Recognition of its disease-producing potential and the subsequent initiation of effective antimicrobial coverage are essential for appropriate management in the pediatric population.     

Urinary glycosaminoglycans in recurrent urinary tract infections in kidney transplant patients.

Glycosaminoglycans have generalized antibacterial anti-adherent activity, and cooperate with secretory immunoglobulin-A in anti-infection defense mechanisms of the urinary tract. Cyclosporin A modulates T-lymphocytes and fibroblast functions. In this report we analyze urinary glycosaminoglycans and secretory immunoglobulin-A in renal transplant patients with recurrent urinary tract infections treated with cyclosporin. The results show a significant decrease of total glycosaminoglycans and secretory immunoglobulin-A in recurrent urinary tract infections which is unrelated to cyclosporin treatment. The data support the hypothesis that recurrent urinary tract infections may be the consequence of a genetic pathology rather than cyclosporin-induced alterations.     

Interleukin-8 and the neutrophil response to mucosal gram-negative infection.

Urinary tract infections activate a mucosal inflammatory response, which includes cytokine secretion and neutrophil influx. The mechanisms involved in the neutrophil influx have not been identified. Interleukin-8, a potent chemoattractant for neutrophils, is produced by urinary tract epithelial cell lines in vitro. This study analyzed the human IL-8 response to deliberate Escherichia coli infection of the urinary tract. Urine and serum samples were obtained before and after intravesical instillation of E. coli. Neutrophil numbers were determined on uncentrifuged urine, and IL-8 levels were measured by ELISA. A urinary IL-8 response was found in all patients after bacterial instillation, but no serum IL-8 was detected. There was a strong correlation between urinary IL-8 levels and urinary neutrophil numbers. The same E. coli strains used to colonize the patients stimulated IL-8 production in urinary tract epithelial cells. The level of IL-8 secreted by epithelial cell lines was influenced by the fimbrial properties of the E. coli. These results demonstrated that E. coli elicit a mucosal IL-8 response in humans, and suggested that IL-8 is involved in the onset of pyuria. Epithelial cells may be an important source of IL-8 during urinary tract infection.     

Host defense mechanisms in the pathogenesis of urinary tract infection

Certain microorganisms have a propensity for causing urinary tract infection, and the route (either ascending or hematogenous) by which microorganisms contaminate the urinary tract from external sources is frequently characteristic of the microorganism. There are local defense mechanisms both in the urine and at each anatomic site in the urinary tract (urethra, bladder, ureter, and kidney). The defense mechanisms at one site may have opposing effects on microbial growth at other sites in the urinary tract. The outcome following entrance of microorganisms into the urinary tract is a result of competing forces, which consist of these local urinary defense mechanisms, the initial numbers of microorganisms contaminating the urinary tract, and microbial virulence factors.     

Bacterial infection induces nitric oxide synthase in human neutrophils.

The identification of human inflammatory cells that express inducible nitric oxide synthase and the clarification of the role of inducible nitric oxide synthase in human infectious or inflammatory processes have been elusive. In neutrophil-enriched fractions from urine, we demonstrate a 43-fold increase in nitric oxide synthase activity in patients with urinary tract infections compared with that in neutrophil-enriched fractions from noninfected controls. Partially purified inducible nitric oxide synthase is primarily membrane associated, calcium independent, and inhibited by arginine analogues with a rank order consistent with that of purified human inducible nitric oxide synthase. Molecular, biochemical, and immunocytochemical evidence unequivocally identifies inducible nitric oxide synthase as the major nitric oxide synthase isoform found in neutrophils isolated from urine during urinary tract infections. Elevated inducible nitric oxide synthase activity and elevated nitric oxide synthase protein measured in patients with urinary tract infections and treated with antibiotics does not decrease until 6-10 d of antibiotic treatment. The extended elevation of neutrophil inducible nitric oxide synthase during urinary tract infections may have both antimicrobial and proinflammatory functions.     

Severe uropathy and normal amniotic fluid volume in a male fetus: sonographic surveillance leading to the diagnosis of megacystis-microcolon-intestinal hypoperistalsis syndrome

The widespread use of sonography as a screening tool for fetal anomalies has facilitated prenatal detection of several fetal conditions characterized by urinary tract dilatation. These conditions are more common in male fetuses and are generally a result of an anatomic defect causing obstruction along the urinary tract system. Although the prognosis of these conditions largely depends on the specific anomaly, several poor prognostic factors have been described. These factors include detection at an early gestational age, bilateral marked dilatation, a persistently obstructed bladder, oligohydramnios causing pulmonary hypoplasia, and the presence of associated fetal or chromosomal anomalies. We report a case in which a male fetus at 14 weeks' gestation had a diagnosis of rapidly progressing bilateral hydronephrosis, massive bladder dilatation, hydroureter, and a surprisingly normal amniotic fluid volume. Serial sonographic surveillance assisted us in obtaining the correct diagnosis, which was important for adequately consulting the patient regarding the fetal prognosis in the affected index pregnancy as well as the likelihood of recurrence in future gestations.     

Cannon‐ball bladder stones: a complication of prolonged recumbence and benign prostate enlargement

Chronically bedridden patients are predisposed to various urological complications such as urinary infections, incomplete urinary bladder emptying after voiding and stone formation in the urinary tract, more so in the absence of good nursing care. Multiple giant bladder stones giving rise to ‘cannon ball’ appearance have rarely been reported. We present the case of an 85‐year‐old frail gentleman who was bedridden for the last 25 years and presented with haematuria. On evaluation he was found to have multiple large bladder stones and bladder diverticuli with enlarged prostate gland. This case highlights a relatively rare urological complication of prolonged recumbency, and emphasizes the importance of proper nursing care, early detection, management and prevention of such complications.     

Emergence of OXA-162 Carbapenemase- and DHA-1 AmpC Cephalosporinase-Producing Sequence Type 11 Klebsiella pneumoniae Causing Community-Onset Infection in Greece

OXA-48-like carbapenemases have only recently emerged in Europe. OXA-162 is a rare OXA-48 variant usually coexpressed with extended-spectrum β-lactamases. Here, we report the identification of the first OXA-162 carbapenemase-producing Klebsiella pneumoniae isolates, which coexpressed an AmpC cephalosporinase (DHA-1), retrieved from a patient in Greece. They belonged to a single sequence type (ST11) and caused the first documented community-onset urinary tract infections attributable to an OXA-48-like-producing Enterobacteriaceae strain.     

原发泌尿道肿瘤MR影像诊断价值

目的总结泌尿道原发肿瘤MR影像诊断价值。方法回顾性总结经证实的泌尿道原发肿瘤41例，共53个瘤灶，多发占22．0％(9／41)，其中移行细胞癌占90．6％(48／53)。常规快速自旋回波序列(TSE)T1WI、T2WI扫描，包括重T2WI泌尿道水成像(MRU)，分析瘤灶MR等影像特征。结果肿瘤分布于肾孟26．4％(14／53)、榆尿管28．3％(15／53)和膀胱45.3％(24／53))。瘤灶大多TIWI、T2WI均为中等信号强度，表现与器官壁相连的腔内充盈缺损及梗阻以上泌尿道集合系统积水。远处转移32．1％(17／53)。结论MR泌尿系统成像在显示泌尿道肿瘤特征方面具有效率高、定位准确和安全无创等重要价值，是常规检查重要补充手段.     

Prenatal diagnosis of intestinal pseudo-obstruction.

The appearance of polyhydramnios and dilated bowel loops on prenatal sonographic examination usually implies mechanical obstruction. The prognosis is variable, depending on the etiology. Congenital pseudo-obstruction, a potentially lethal disease, comprises a group of disorders characterized by intestinal obstruction in the absence of an anatomic lesion. This report focuses on the prenatal diagnosis of intestinal pseudo-obstruction, and two cases of transient congenital intestinal pseudo-obstruction in one family are described. In both, the prenatal sonographic presentation was of small bowel obstruction. In one case there was postnatal suspicion of neurogenic bladder, and in the other there was unilateral hydronephrosis. The sonographic appearance of intestinal pseudo-obstruction is similar to that of mechanical obstruction. The clues to the prenatal diagnosis of pseudo-obstruction include associated urinary tract abnormalities and a family history of pseudo-obstruction.     

Functional correlates of Doppler flow study of the female urethral vasculature.

OBJECTIVES: To examine the effect of individual patient factors (age, parity, body mass index, menstrual cycle, menopause, hormone replacement therapy, bladder neck position and urethral mobility) on the appearance of Doppler flow in urethral vessels, to investigate the association between the Doppler flow parameters and intrinsic urethral function, storage and voiding, and to explore differences in the urethral vasculature between subjects with and without urodynamic stress incontinence (USI). METHODS: Over a 4-year period we prospectively performed imaging studies in 355 women, including 244 who denied any lower urinary tract symptoms within the previous 3 months (Group A) and 111 who had had lower urinary tract symptoms (Group B). Studies included morphologic assessment and Doppler flow investigation of the lower urinary tract. Vascular flow velocity and vessel density in the urethral vasculature were measured. For women in Group B, multichannel urodynamic studies were also performed. RESULTS: The urethral vasculature has five main branches of vessels. Their appearance was not affected by the menstrual cycle or menopause except for those of the anterior vaginal vessel and anterior branch of the middle urethral vessel. Other than that of the posterior urethral vessel, in which there was a correlation with parity, the resistance index (RI) was not affected by individual patient factors. However, there was a correlation between the vascular index (VI) and individual factors such as age (r = -0.336, P = 0.002), body mass index (r = -0.287, P = 0.028), menopause (r = -0.402, P < 0.001), and hormone replacement therapy (r = 0.392, P = 0.027). Only the VI and RI of the posterior urethral vessel correlated significantly with the urethral pressure profile. In subjects with lower urinary tract symptoms, the appearance of the urethral vasculature on power Doppler imaging and the corresponding RI and VI values were not correlated with objective evidence of USI. CONCLUSION: Patient factors may affect specific Doppler flow parameters of the urethral vasculature, which are related to intrinsic resting urethral closure. There is no difference in the appearance of the urethral vasculature in subjects with or without USI.     

Pathogenesis and management of bacterial biofilms in the urinary tract

Conclusion In conclusion, a classification of the modes of bacterial infection is presented in Fig. 16. In urinary tract infections, only uropathogenic bacteria with invading and adhering activities (virulence factors) in the urinary tract can cause acute infection in patients without local underlying diseases. Local abnormalities which disturb the normal urinary stream permit the entry of non-uropathogenic bacteria into the urinary tract, establishing chronic complicated urinary tract infections. Non-uropathogenic bacteria, which would not normally cause infection, enter the urinary tract into an environment which does not readily permit them to survive, and form a biofilm for protection. The biofilm infection itself is an indolent infection, and the biofilm bacteria may barely survive via a symbiotic relationship with human beings in the urinary tract. However, it is possible that acute aggravation of the local conditions destroys this symbiotic relationship, bringing about acute exacerbation of the chronic indolent infection. Therefore, it should be again noted that the management of the local urinary conditions and removal of the local underlying diseases are the most effective approaches to treating urinary biofilm infections. Hopefully, new therapeutic strategies will be devised to effectively control biofilm infections in the near future.     

α–Intercalated cells defend the urinary system from bacterial infection

α–Intercalated cells (A-ICs) within the collecting duct of the kidney are critical for acid-base homeostasis. Here, we have shown that A-ICs also serve as both sentinels and effectors in the defense against urinary infections. In a murine urinary tract infection model, A-ICs bound uropathogenic E. coli and responded by acidifying the urine and secreting the bacteriostatic protein lipocalin 2 (LCN2; also known as NGAL). A-IC–dependent LCN2 secretion required TLR4, as mice expressing an LPS-insensitive form of TLR4 expressed reduced levels of LCN2. The presence of LCN2 in urine was both necessary and sufficient to control the urinary tract infection through iron sequestration, even in the harsh condition of urine acidification. In mice lacking A-ICs, both urinary LCN2 and urinary acidification were reduced, and consequently bacterial clearance was limited. Together these results indicate that A-ICs, which are known to regulate acid-base metabolism, are also critical for urinary defense against pathogenic bacteria. They respond to both cystitis and pyelonephritis by delivering bacteriostatic chemical agents to the lower urinary system.     

Current conservative treatment of renal colic: value of prostaglandin synthesis inhibitors

Prostaglandin synthesis inhibitors and parasympatholytic drugs are often used as analgetics in the case of renal colic. This paper analyzes how and whether these drug effects are important for the analgetic therapy. In an animal and in a human model with acutely obstructed kidneys we found that intravenous application of Indometacine and dipyrone significantly reduces renal pelvic pressure. The parasympatholytic drug hyoscine butylbromide did not produce any change of upper urinary tract dynamics. Inhibitors of prostaglandin synthesis thus effect pressure reduction in the renal pelvis, which is necessary for analgetic therapy. In contrast, hyoscine butylbromide does not have any influence on the acute upper urinary tract obstruction; consequently its usefulness in the treatment of renal colic is rather doubtful.     

Polyarteritis nodosa in a patient with type 1 autoimmune hepatitis

Polyarteritis nodosa is a systemic necrotizing vasculitis that affects small- and medium-sized arteries. Liver involvement in patients with polyarteritis nodosa has been described, and ranges from asymptomatic elevation of aminotransferases to hepatic aneurysm rupture. We describe the case of a patient with type 1 autoimmune hepatitis and compensated liver cirrhosis who developed classic polyarteritis nodosa, complicated with cytomegalovirus and repeated urinary tract infections. After a long bedridden hospitalization, the patient's condition was stabilized. She is currently in good health, with well-controlled blood pressure, and stable kidney and liver function. To our knowledge, this is the first case report in the literature with concurrent appearance of both diseases.     

Acute gram-negative urosepsis mimicking an acute hemolytic transfusion reaction

BACKGROUND: The acute hemolytic transfusion reaction (AHTR) is one of the most feared complications of blood transfusion. Over the years, several clinical conditions, as well as errors in blood component preparation and administration, that mimic AHTR have been identified. This report describes a novel variation on the theme of pseudo-AHTR. CASE REPORT: A 47-year-old diabetic man with drug-induced pancytopenia suddenly manifested severe shaking chills, flank pain, and back pain during a red cell transfusion. The passage of bright red urine immediately after the transfusion virtually confirmed for the clinicians administering the transfusion that an AHTR had occurred. In the laboratory, the hematuria was shown to be due principally to red cells and not to free hemoglobin. Further posttransfusion work-up showed a urinary tract infection and overwhelming bacterial sepsis with Escherichia coli. CONCLUSION: As a pseudo-AHTR, gram-negative bacterial sepsis of urinary tract origin may surpass other forms of sepsis. Urosepsis should be considered in the work-up of a suspected AHTR in a pancytopenic patient with a urinary tract infection.     

Upregulation of retinoic acid-inducible gene-I in T24 urinary bladder carcinoma cells stimulated with interferon-gamma

Urinary bladder epithelial cells play an important role in the host defense against urinary tract infections. Interferon-gamma (IFN-gamma) is a potent cytokine that regulates immune responses by inducing multiple genes in many types of cells including urinary bladder epithelial cells. Retinoic acid-inducible gene-I (RIG-I) is a member of the DExH-box family, which is involved in various reactions related to RNA metabolism, and is induced in leukemic cells by retinoic acid or in endothelial cells by lipopolysaccharide. We have studied the expression of RIG-I in T24 cells, a cell line derived from human urinary bladder epithelial carcinoma cells. IFN-gamma stimulated T24 cells to express RIG-I mRNA and protein in concentration- and time-dependent manners. Immunohistochemical analysis revealed the expression of RIG-I in the urinary bladder epithelium from a patient with chronic urinary tract infection and in a bladder epithelial carcinoma. We conclude that RIG-I may play some role in inflammatory reactions in the urinary tract epithelium.     

Guidelines for preventing urinary retention and bladder damage during hospital care

Aims and objectives. To develop evidence‐based guidelines for adult patients in order to prevent urinary retention and to minimise bladder damage and urinary tract infection. Background. Urinary retention causing bladder damage is a well known complication in patients during hospital care. The most common treatment for urinary retention is an indwelling urinary catheter, which causes 80% of hospital‐acquired urinary tract infections. Appropriate use of bladder ultrasonography can reduce the rate of bladder damage as well as the need to use an indwelling urinary catheter. It can also lead to a decrease in the rate of urinary tract infections, a lower risk of spread of multiresistant Gram‐negative bacteria, and lower hospital costs. Design. An expert group was established, and a literature review was performed. Methods. On the basis of literature findings and consensus in the expert group, guidelines for clinical situations were constructed. Results. The main points of the guidelines are the following: identification of risk factors for urinary retention, managing patients at risk of urinary retention, strategies for patients with urinary retention and patient documentation and information. Conclusion. Using literature review and consensus technique based on a multiprofessional group of experts, evidence‐based guidelines have been developed. Although consensus was reached, there are parts of the guidelines where the knowledge is weak. Relevance to clinical practice. These guidelines are designed to be easy to use in clinical work and could be an important step towards minimising bladder damage and hospital‐acquired urinary tract infections and their serious consequences, such as bacteraemia and the spread of multidrug‐resistant bacteria in hospitals.