Introduction of urosepsis Sepsis is a life-threatening bacterial infection of the blood; urosepsis is sepsis that complicates a urinary tract or prostate

infection. Urosepsis requires treatment with antibiotics and may require supportive therapies such as intravenous fluids and oxygen. If undiagnosed or untreated, urosepsis can progress to septic shock, a serious and life-threatening condition complicated by dropping blood pressure, rapid heart and breathing rates, decreasing urine output, and alterations in mental status. The urinary tract consists of the kidneys, ureters, bladder and urethra. The kidneys filter the blood, creating urine, which travels through the ureters to the bladder, where it is stored until it exits the body through the urethra. In the male, the prostate wraps around the urethra as it travels from the bladder to the penis. Most of the time, bacteria that cause urosepsis enter the body through the urethra and make their way to the prostate or kidney before entering the bloodstream. Symptoms of uncomplicated urinary tract infections can include burning with urination, the need to go to the bathroom frequently or urgently, cloudy urine, and pelvic or lower abdominal discomfort. Fever may be present. If pyelonephritis (kidney infection) is present, back or abdominal pain, nausea and vomiting, high fever, shaking chills, night sweats, and fatigue may also occur. Any of these symptoms may precede the development of urosepsis. Urosepsis is the acute condition of a systemic infection in the blood that develops secondary to a urinary tract infection (UTI), and then circulates throughout the entire body. A lay term for this critical condition is blood poisoning because an infection is in the bloodstream. Sepsis, if not treated properly, may result in major organ damage, septic shock or death. Sepsis risk is increased for infants, the elderly, black men and frequently occurs in hospitalized patients, especially with in-dwelling tubes such as catheters, Individuals with compromised immune systems also are vulnerable to sepsis. Urosepsis is more common in women than in men, and is more likely to occur in the elderly or people who have weakened immune systems or conditions such as diabetes. Obstruction of the flow of urine by an enlarged prostate, kidney or bladder stones, tumors, or urethral scarring increases the risk of urosepsis, as does any condition that interferes with bladder emptying. Instrumentation of the urinary tract during surgeries, procedures, or catheterization increases the risk of infections that can lead to urosepsis.

History of urosepsis Urosepsis is caused by the invasion, from a focus in the urinary tract, of pathogenic or commensal microorganisms, or their constituents into the body, prompting a complex response by the synthesis of endogenous mediators responsible for the clinical phenomena. Progress of sepsis to severe sepsis and septic shock correlates with an increased risk of death. Severe Sepsis If sepsis progresses to the next level, some typical signs involve a decreased platelet (blood) count as well as decreased urine production and output. Problems with breathing and heart function continue with the possible addition of a change in orientation or mental state. Also, the skin may show areas or patches of blotched and colored skin (mottled appearance). Septic Shock If the systemic infection advances to septic shock, the signs and symptoms of those displayed at the severe phase continue. However, at this life-threatening stage, the significant sign of dramatically low blood pressure is present for the diagnosis of septic shock to be made. Urosepsis is caused by Gram-negative bacteria E.Coli, Enterobacteriaceae, Pseudomonas aeruginosa. Gram positive bacteria Enterococcus, Staphylococcus aureus and other pathogenic bacteria in nosocomial urosepsis. A number of factors increase the risk of developing urosepsis. Not all people with risk factors will get urosepsis. Risk factors for urosepsis include:
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Advanced age Compromised immune system due to such conditions as HIV and AIDS, taking corticosteroids, organ transplant, or cancer and cancer treatment Diabetes Fecal incontinence (inability to control stools) Female gender Immobility Incomplete bladder emptying or urinary retention Polycystic kidney disease Pregnancy Surgeries or procedures involving the urinary tract Urinary tract obstruction by stones, an enlarged prostate, urethral scarring, or other causes Use of catheters to drain urine

Clinical signs and symptoms of urosepsis Urosepsis shares many of the same symptoms as other types of sepsis, including rapid heart rate, rapid breathing, weak pulse, profuse sweating, unusual anxiety, changes in mental status or level of consciousness, and decreased or absent urinary output. Prior to the development of these symptoms, you may experience symptoms of a urinary tract infection. Common symptoms of a urinary tract infection Symptoms of a urinary tract infection vary from individual to individual. Common urinary tract infection symptoms include:
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Abdominal, pelvic or back pain or cramping Bloody or pink-colored urine (hematuria) Cloudy urine Difficult or painful urination, or burning with urination (dysuria) Fever and chills Foul-smelling urine Frequent urination General ill feeling Pain during sexual intercourse Urgent need to urinate Serious symptoms that might indicate a life-threatening condition

Urosepsis can be life threatening. Seek immediate medical care if you, or someone you are with, have any of these life-threatening symptoms:
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Change in level of consciousness or alertness, such as passing out or unresponsiveness High fever (higher than 101 degrees Fahrenheit) Low temperature (hypothermia; temperature 96.8 degrees Fahrenheit or lower) Not producing any urine Profuse sweating and unusual anxiety Rapid heart rate (tachycardia) Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing Severe abdominal, pelvic, or back pain Severe nausea and vomiting Weak pulse

Anatomy and Physiology of urosepsis The basic anatomy of the ureter is as follows

Anatomy of the ureter. Most of the pain receptors of the upper urinary tract responsible for the perception of renal colic are located submucosally in the renal pelvis, calices, renal capsule, and upper ureter. Acute distention seems to be more important in the development of the pain of acute renal colic than spasm, local irritation, or ureteral hyperperistalsis. Stimulation of the peripelvic renal capsule causes flank pain, while stimulation of the renal pelvis and calices causes typical renal colic. Mucosal irritation can be sensed in the renal pelvis to some degree by chemoreceptors, but this irritation is thought to play only a minor role in the perception of renal or ureteral colic.

Renal colic and flank pain. Renal pain fibers are primarily preganglionic sympathetic nerves that reach spinal cord levels T11 to L-2 through the dorsal nerve roots. Aortorenal, celiac, and inferior mesenteric ganglia are also involved. Spinal transmission of renal pain signals occurs primarily through the ascending spinothalamic tracts.

Nerve supply of the kidney

Nerve supply of the kidney.

In the lower ureter, pain signals are also distributed through the genitofemoral and ilioinguinal nerves. The nervi erigentes, which innervate the intramural ureter and bladder, are responsible for some of the bladder symptoms that often accompany an intramural ureteral calculus.

Distribution of nerves in the flank.

True sepsis is a common cause of hospitalization, development of urosepsis due to benign urinary tract obstruction caused by prostatic hypertrophy. Patients with diabetes, systemic lupus erythematosus (SLE), or alcoholism or who are taking steroids are also at an increased risk for bacteremia. Sustained bacteremia, in contrast to transient bacteremia, may result in a sustained febrile response that may be associated with organ dysfunction. Septicemia refers to the active multiplication of bacteria in the bloodstream that results in an overwhelming infection. Sepsis is not a random occurrence and is usually associated with other conditions, such as perforation, compromise, or rupture of an intra-abdominal or pelvic structure. Intrarenal infection (pyelonephritis), renal abscess (intrarenal or extrarenal), acute prostatitis, or prostatic abscess may cause urosepsis in immunocompetent hosts.

Bacteremia due to bacteruria (urosepsis) may complicate cystitis in compromised hosts, and sepsis may be caused by overwhelming pneumococcal infection in patients with impaired or absent splenic function. Urosepsis is complex and results from the effects of circulating bacterial products, mediated by cytokine release, caused by sustained bacteremia. Cytokines, previously termed endotoxins, are responsible for the clinically observable effects of the bacteremia in the host. Impaired pulmonary, hepatic, or renal function may result from excessive cytokine release during the septic process.