Clinical Note

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Urinary Tract Infection

An otherwise healthy 21-year-old woman is seen at an outpatient clinic. She complains of a burning sensation upon urination and an increase in her frequency and urgency of urination. A review of her medical history reveals no significant medical problems, but she has had a recent increase in sexual activity. Physical examination reveals no abnormalities. Her blood pressure and pulse are normal and she has no fever; however, laboratory results show that her urine sediment has abundant bacteria and white blood cells. The diagnosis is cystitis, that is, an infection of the bladder.

Cystitis is a frequent medical complaint of sexually active young women, with an incidence of up to 5% yearly in women of reproductive age. Women are particularly susceptible to UTI because of the typical bacterial flora of the vagina and the shorter length of the female urethra. The incidence of UTI in males is much less also because the prostate and seminal vesicles secrete antibacterial agents. However, when prostatic or other diseases interfere with complete voiding, cystitis is a frequent presenting symptom in the male as well. UTI is usually confined to the bladder and urethra because of the barriers provided by the ureterove-sicular valve and the normal descending flow of urine from the kidneys to the bladder. However, congenital abnormalities and incomplete development can lead to failure of this valve, such that contraction of the bladder during micturition produces reflux of the urine from the bladder to the kidneys. Reflux can lead to pyelonephritis, an infection that ascends from the bladder and reaches the kidneys. Pyelonephritis is a more serious disease and is usually accompanied by fever, chills, and tenderness and pain in the flank region over either or both kidneys. In addition, the white blood cells in the urinary sediment frequently form long cylindrical clumps called casts because they take the cylindrical form of the nephrons in which they form. These characteristics usually allow the physician to discriminate between cystitis and pyelonephritis based on the history and physical, and an examination of the urinary sediment.

the pontine center rather than by direct stimulation of efferents to the internal or external sphincter. However, even when the bladder is painfully full and the pontine center cannot be suppressed, voluntary constriction of the pelvic floor muscles can delay or greatly reduce voiding.

Suggested Readings

Blok BFM. Central pathways controlling micturition and urinary continence. Urology 2002;59(Suppl 5A):13-17.

chancellor MB, Yoshimura N. Physiology and pharmacology of the bladder and urethra. In Walsh, Pc, ed., Campbell's urology, 8th ed. Philadelphia: Saunders, 2002, pp 831-886.

Kriz W, Kaissling B. Structural organization of the mammalian kidney. In Seldin DW, Giebisch G, eds., The kidney: Physiology and pathophysiology, Vol 1, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2000, pp 587-654.

Reilly RF, Ellison DH. Mammalian distal tubule: Physiology, pathophysiology, and molecular anatomy. Physiol Rev 2000;80:277-313.

Tisher cc, Madsen KM. Anatomy of the kidney. In Brenner, BM, ed., Brenner & Rector's the kidney, 6th ed. Philadelphia: Saunders, 2000, pp 3-67.

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