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antimicrobials and the latter requiring hospitalization, catheterization or operative care. Although lower
urinary tract infections are often less problematic, all cases of symptomatic urinary infection require
antimicrobial treatment regardless of the locus.
Oral fluoroquinolones are excellent medications for the outpatient care of many urological infections.
These medications allow for excellent urinary coverage of most uropathogens and provide “tissue
penetration” for parenchymal infectious diseases such as pyelonephritis and prostatitis. Trimethoprimsulfamethoxazole
is an alternative medication; in many cases, it is less effective and it has a high
incidence of microbial resistance. Ampicillin or cephalosporins are often required in gram-positive
infections. Complicated infections with enterobacter species, pseudomonas or gram-negative bacilli may
require combination therapy with aminoglycosides and ampicillin or broad-spectrum cephalosporins.
Although duration of therapy is a subject of debate, most uncomplicated cases of cystitis in females
should be eradicated within five days if the bacteria are sensitive to the antimicrobial. Uncomplicated
pyelonephritis usually requires fourteen days of therapy for complete resolution. In this scenario, urine
cultures should be repeated after five to seven days of therapy to ensure adequate response. Lower urinary
infections in men should raise suspicion of concomitant prostatic infection. In the case of prostatic
infection, treatment should continue for 21 days or longer, ensuring negative urine cultures at the
conclusion of therapy.
Finally, guidance on the recommended treatment for sexually transmitted diseases changes periodically
and is regularly updated by the World Health Organization. Typically, gonococcal and chlamydial
infections are found simultaneously in up to 50% of patients presenting with urethritis subsequent to
suspicious sexual encounters. For this reason, these patients should be covered for both diseases and
screened for the others previously mentioned.
Aeromedical considerations
As already mentioned, all urological infections should be considered disqualifying for aviation duties
during acute disease. Medical assessment should not be entertained until a number of criteria are met:
• Assurance of no idiosyncratic reaction to appropriate culture-driven antimicrobial therapy.
• Complete haemodynamic stability after acute treatment has been initiated
ICAO Preliminary Unedited Version — November 2009 III-6-10
• Culture-specific antimicrobial coverage for a minimum of 14 days except in cases of simple
cystitis in a female patient.
• Repeat cultures revealing complete eradication of any organism
• In complicated infections, full urological consultation for any anatomical or other aberrations.
• Assurance that recurrent urinary infection has been completely eradicated or suppressed.
• A patient with a urological condition that has a high likelihood of causing recurrent urinary
infections with rapid onset of symptoms should be disqualified from aviation duties until that
condition is resolved.
CONGENITAL AND RENAL CYSTIC DISEASES
Disease process
The urinary tract harbours more survivable congenital abnormalities than any other organ in the body. In
childhood, diminished renal function commonly serves as the presenting factor to diagnosis of an
anomaly. In adulthood, urological evaluations for haematuria, infection, and nephroureterolithiasis
commonly uncover congenital cystic and renal anomalies. These anomalies may also be found
incidentally on radiographic evaluations for other problems. They range from simple cysts and collecting
system duplications to major anatomical problems that may cause end stage renal dysfunction and other
systemic illness.
Simple cysts present typically as a discrete finding that may occur within the renal parenchyma or arise
from its surface. They are commonly oval to round in shape, with a smooth outline bordered by a single
layer of flattened epithelium and contain a clear or straw-coloured fluid. Simple renal cysts are commonly
found in individuals during the third decade of life or later. They may be singular, multiple, unilateral or
bilateral.
Medullary sponge kidney is an adult disease, commonly found incidentally during imaging of the
abdomen. Its incidence is about 1 in 5 000 with nearly a two to one male predominance. Its cause is
unknown and it does not follow any classical inheritance pattern. Although the disease is characterized by
dilation of the papillary ducts of the renal medulla, renal function is usually normal. Cysts lined with
cuboidal or transitional epithelium may be found in these ducts.
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Manual of Civil Aviation Medicine 1(154)
