Purulent inflammatory processes of the genitourinary system. Inflammatory diseases of the urinary system
In women, the reproductive organs include the uterus with fallopian tubes, ovaries, vagina, and vulva.
The organs of the urinary and reproductive systems are closely related due to the peculiarities anatomical structure. Inflammation of the genitourinary organs is quite common in both men and women.
Diseases
Due to the anatomical features genitourinary system In women, infection of the genitourinary tract with pathogenic microorganisms occurs in them much more often than in men. Female risk factors - age, pregnancy, childbirth. Because of this, the walls of the small pelvis from below weaken and lose the ability to support the organs at the required level.
Ignoring the rules of personal hygiene also contributes to inflammation of the organs of the system.
Among the inflammatory diseases of the genitourinary system, the most common are:
Moreover, chronic forms of diseases are more common, the symptoms of which are absent during remission.
Urethritis
Urethritis - inflammation of the urethra. The symptoms of this disease are:
- painful difficulty urinating, during which a burning sensation appears; the number of calls to the toilet increases;
- discharge from the urethra, which leads to redness and sticking of the opening of the urethra;
- a high level of leukocytes in the urine, which indicates the presence of a focus of inflammation, but there are no traces of the pathogen.
Depending on the pathogen that caused urethritis, the disease is divided into two types:
- specific infectious urethritis, for example, as a result of the development of gonorrhea;
- nonspecific urethritis, the causative agent of which is chlamydia, ureaplasma, viruses and other microorganisms (pathogenic and conditionally pathogenic).
In addition, the cause of inflammation may not be an infection, but a banal allergic reaction or injury after an incorrect insertion of the catheter.
Cystitis
Cystitis is an inflammation of the lining of the bladder. This disease is more common in women than in men. The cause of infectious cystitis is Escherichia coli, chlamydia or ureaplasma. However, the ingestion of these pathogens into the body does not necessarily cause disease. Risk factors are:
- prolonged sitting, frequent constipation, preference for tight clothing, resulting in impaired blood circulation in the pelvic area;
- deterioration of immunity;
- irritating effect on the walls of the bladder of substances that are part of the urine (when eating spicy or overcooked food);
- menopause;
- diabetes;
- congenital pathologies;
- hypothermia.
In the presence of an inflammatory process in other organs of the genitourinary system, there is a high probability of infection entering the bladder.
The acute form of cystitis is manifested by frequent urge to urinate, the process becomes painful, the amount of urine decreases sharply. Appearance urine changes, in particular, transparency disappears. Pain also appears between urges in the pubic region. It is dull, cutting or burning in nature. In severe cases, in addition to these symptoms, fever, nausea and vomiting appear.
Pyelonephritis
Inflammation of the pelvis of the kidney is the most dangerous among other infections of the genitourinary system. A common cause of pyelonephritis in women is a violation of the outflow of urine, which happens during pregnancy due to an increase in the uterus and pressure on nearby organs.
In men, this disease is a complication of prostate adenoma, in children it is a complication of influenza, pneumonia, etc.
Acute pyelonephritis develops suddenly. First, the temperature rises sharply and weakness, headache and chills appear. Sweating increases. Associated symptoms may include nausea and vomiting. In the absence of treatment, there are two ways of developing the disease:
- transition to chronic form;
- the development of suppurative processes in the organ (signs of such are sharp jumps in temperature and deterioration of the patient's condition).
endometritis
This disease is characterized by an inflammatory process in the uterus. It is caused by staphylococcus, streptococcus, Escherichia coli and other microbes. The penetration of infection into the uterine cavity is facilitated by ignoring the rules of hygiene, promiscuity, and a decrease in general immunity.
In addition, inflammation can develop as a result of complicated surgical interventions, such as abortion, probing or hysteroscopy.
The main symptoms of the disease are:
- temperature rise;
- pain in the lower abdomen;
- vaginal discharge (bloody or purulent).
cervicitis
Inflammation of the cervix occurs as a result of infection in its cavity, which is sexually transmitted. Viral diseases can also provoke the development of cervicitis: herpes, papilloma, etc. Any damage (during childbirth, abortion, medical procedures) causes the disease due to a violation of the integrity of the mucous membrane.
Clinical manifestations are typical for the inflammatory process:
- discomfort during intercourse, sometimes pain;
- mucous discharge from the vagina;
- discomfort or pain in the lower abdomen;
- fever, general malaise.
Colpitis
Colpitis, or vaginitis - an inflammation of the vagina, which is caused by Trichomonas, Candida fungi, herpes viruses, E. coli. The patient complains of the following symptoms:
- discharge;
- heaviness in the lower abdomen or in the vaginal area;
- burning;
- discomfort during urination.
During the examination, the doctor observes hyperemia, swelling of the mucous membrane, rashes, pigmented formations. In some cases, erosive areas appear.
Vulvitis
Inflammation of the external genitalia. These include the pubis, labia, hymen (or its remnants), vestibule, Bartholin's glands, bulb. Vulvitis is caused by infectious pathogens: streptococci, E. coli, chlamydia, etc.
The provoking factors are:
- oral sex;
- taking antibiotics, hormonal drugs and drugs that suppress the immune system;
- diabetes;
- leukemia;
- oncological diseases;
- inflammatory processes in other organs of the genitourinary system;
- urinary incontinence;
- frequent masturbation;
- taking an excessively hot bath;
- non-compliance with personal hygiene.
You can identify the presence of an inflammatory process by the following symptoms:
- redness of the skin;
- edema;
- pain in the vulva;
- burning and itching;
- the presence of bubbles, plaque, ulcers.
Prostatitis
Inflammation of the prostate. The chronic form of the disease affects about 30% of men aged 20 to 50 years. There are two groups depending on the cause of occurrence:
- infectious prostatitis caused by bacteria, viruses or fungi;
- congestive prostatitis, which occurs due to the corresponding processes in the prostate gland (in violation of sexual activity, sedentary work, preference for tight underwear, alcohol abuse).
There are risk factors that additionally provoke the development of the inflammatory process. These include:
- decreased immunity;
- hormonal disorders;
- inflammatory processes in nearby organs.
You can identify the disease by its characteristic symptoms. The patient feels unwell, which may be accompanied by fever, complains of pain in the perineum and frequent urge to urinate. The chronic form of prostatitis can be asymptomatic and remind of itself only during periods of exacerbation.
Diagnostics
Before prescribing treatment, patients with suspected inflammation of the genitourinary system need a urological examination.
- ultrasound examination of the kidneys, bladder;
- examination of urine and blood;
- it is possible to perform cystoscopy, computed tomography, pyelography according to individual indications.
The results of the examination determine which diagnosis will be established and what treatment is prescribed to the patient.
Treatment
To stop the inflammatory process, medications are used.
The goal of etiological treatment is to eliminate the cause of the disease. To do this, you need to correctly determine the pathogen and its sensitivity to antibacterial agents. Common causative agents of urinary tract infections are Escherichia coli, Enterococcus, Staphylococcus aureus, Proteus, Pseudomonas aeruginosa.
The selection of the drug takes into account the type of pathogen and the individual characteristics of the patient's body. Broad-spectrum antibiotics are often prescribed. The selectivity of these drugs is high, the toxic effect on the body is minimal.
Symptomatic treatment is aimed at eliminating the general and local symptoms of the disease.
During treatment, the patient is under strict medical supervision.
You can speed up the healing process by observing the following rules:
- Drink enough water per day and at least 1 tbsp. cranberry juice without sugar.
- Avoid salty and spicy foods from your diet.
- Limit the use of sweets and starchy foods during treatment.
- Maintain the hygiene of the external genital organs.
- Use acid soap (Lactophilus or Feminu).
- Cancel access to public waters, including hot tubs and pools.
- Refuse frequent change of sexual partners.
Attention should also be paid to improving immunity. This will avoid recurrence of the disease.
Inflammation of the genitourinary system is a common problem modern society. Therefore, regular examinations and preventive visits to the doctor should become the norm.
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Diseases of the genitourinary system in women
Common diseases of the genitourinary system in women.
In order to monitor your health, you must first of all have an idea about the structure of your body. In women, the organs of the genitourinary system are extremely vulnerable, the diseases are very unpleasant and easily flow from an acute form to a chronic one. Knowing about the symptoms when infections occur will make it easier for a woman to protect herself from them.
The organs of the female genitourinary system include:
The female genitourinary system consists of the reproductive and excretory organs. The main difference from the male one is the length of the urethra (the female one is about five cm, and the male one is about twenty cm). Consequently, inflammatory processes bother women more often than men. With the same disease, it is usually more difficult for a woman to recover.
Infections are the main cause of inflammation. It can be urological and gynecological. And if the organs of both systems are in close proximity, then the infection can affect both. With the first symptoms, a woman should consult a specialist; if left untreated, severe complications may occur. The consequences of infectious diseases can be ectopic pregnancy, infertility, etc.
INFLAMMATORY PROCESSES SYMPTOMS IN WOMEN
Symptoms of inflammation that occurs in the female genitourinary system may differ. The organs of the reproductive and urinary female systems are closely located and interact with each other. Well, when the inflammation has already begun in one place, it quickly spreads to the organs that are nearby.
DISEASES OF THE URINARY SYSTEM IN WOMEN
cystitis in women. Symptoms. Video
Cystitis (bladder inflammation) is characterized by frequent urge to urinate, pain when urinating in the lower abdomen. Urine is often cloudy with blood impurities. The patient may have a feeling of emptying an incomplete bladder. A complicated form of cystitis leads to the development of pyelonephritis. The patient complains of pain in the lumbar region, discoloration of urine, chills, fever, which has a fetid odor, etc.
Almost every woman has encountered this unpleasant disease, cutting pains characterized by urination, a feeling of discomfort in the lower abdomen. With exacerbation of cystitis, there may be blood excretion in the urine, the pain syndrome is strong, a significant increase in T. By the way, unpleasant sensations in the urethra are a common phenomenon and may indicate various diseases, a characteristic sign without being one of some kind. More often, women suffer from cystitis, their urethral canal is short and the vagina is located near the anus, which easily allows microbes to enter the bladder.
If due attention is not paid to cystitis treatment, then it can "grow" into inflammation of the renal pelvis - pyelonephritis. Symptoms of cystitis will be accompanied by back pain, nausea, and swelling.
Bacterial genital infections include: syphilis, chlamydia, gonorrhea, ureaplasma and mycoplasma.
Viral infections include genital herpes, condylomas, cytomegalovirus infection.
Infections are transmitted sexually mainly, infection is not excluded by household and transplacental.
Microorganisms and bacteria affect the organs of the genitourinary system, adversely affect the reproductive function of women.
DISEASES OF THE URINARY SYSTEM IN WOMEN, TREATMENT
Bacterial vaginosis (vaginitis), symptoms and prevention. Video
With this disease, a woman feels pain during sexual intercourse, a burning sensation in the vagina and the urethra, discharge is present (with acute vaginitis, the discharge is abundant, and the pain is quite sharp; in the form of chronic pain, they can completely disappear and rarely appear, but the disease manifests itself with the strength of a new hypothermia, stress, etc.)
Treatment of any "female" disease should be carried out under the supervision of a gynecologist. Self-medication is dangerous and can also be as if untreated. Any bacterial infection is treated with antibiotics. In diseases of the urinary system, herbal infusions and decoctions are used as an additional means of therapy, and you can drink them to remove the infection from the body, and do douching.
Gonorrhea in women. Symptoms. Video
Gonorrhea. Its causative agent is gonococcus, which affects the mucous membranes of the urinary tract and genital organs. The process of inflammation spreads to the departments different systems urogenital. The main symptoms of gonorrhea: inflammation in the vaginal area, presence of mucopurulent discharge from the cervical canal, pain during urination, urethral swelling, itching in the vagina.
Genital herpes in women. Symptoms. Video
Genital herpes. Unlike other sexually transmitted infections, the appearance is characterized by the appearance of small vesicles on the mucous membrane with a cloudy liquid. Their formation is preceded by itching, burning and redness at the localization site. In addition, the patient's lymph nodes increase, T appears, pain in the muscles.
Condylomas. Gynecology. Symptoms. Video
Condylomatosis. This disease is characterized by genital warts occurring in the vaginal area. The causative agent is papillomavirus infection. Condylomas are small warts that gradually grow, resembling cauliflower.
Syphilis in women. Symptoms. Video
Syphilis is a sexually transmitted disease, the causative agent of which is pale treponema. appears in a patient on the membranes of the mucous chancre, the lymph nodes increase. There are primary, secondary and tertiary syphilis, which differ in the degree of localization on the mucous membrane of treponema.
Chlamydia in a woman. Symptoms. Video
Chlamydia. The main sign - the presence of chlamydia in the body appear from the genital organs of the discharge of pale yellow, pain sensation during urination, sexual intercourse, pain before menstruation. The main danger of chlamydia is that complications can lead to lesions of the uterus and appendages in a woman.
Ureaplasmosis in women. Symptoms. Video
Ureaplasmosis. This microorganism ureaplasma urealiticum causes the appearance of ureaplasmosis, if it enters the body for a long time, it does not make itself felt. The disease is almost asymptomatic, and therefore women rarely pay attention to minor changes in the body. After the end of the incubation period, the patient is worried about burning during urination, the appearance of mucous secretions, pain in the lower abdomen. With a decrease in immunity, any physical factors (stress, colds, hypothermia, physical activity are large) activate the infection.
DISEASES OF THE URINARY ORGANS
Mycoplasmosis. symptoms in women. Video
Mycoplasmosis. The disease manifests itself in the form of colorless, white or yellow discharge, burning during urination. After intercourse, pain often appears in the area of \u200b\u200bthe inguinal pain. With weakened immunity, pathogens of mycoplasmosis can be transferred to other organs (urinary tract, kidneys, urethra).
Most infections are asymptomatic, passing over time from the acute stage to the chronic form.
When certain symptoms appear, it is imperative to visit a gynecologist for a qualified diagnosis of the conduct and elimination of the infection.
Thrush (candidiasis). Symptoms. Video
Thrush (candidiasis). This disease is fungal, the most common in women. The main reason is personal hygiene rules, non-compliance and violation of the microflora of the normal vagina (for example, after long-term antibiotics). Accompanied by thrush during urination, burning, itching, strong, curdled white discharge, redness of the labia minora. It is treated simply (flucostat or fluconazole, vaginal suppositories). The disease is not dangerous and does not have serious consequences, but it causes a lot of discomfort, and it is better not to delay treatment and cure it quickly (medicines are sold in any pharmacy and are quite inexpensive).
Urethritis in a woman. Symptoms. Video
Urethritis. A sharp pain with urethritis of the patient worries before urination, mucus discharge from the urethra, with impurities of pus, sometimes with a characteristic smell. A woman can bring the infection into the urethra, and then into the urinary bladder, if personal hygiene rules are not followed. This can also happen during intercourse or as a result of an injury to the resulting vulva. Symptoms of urethritis are much less common, more often cystitis develops, since the urethra is very short. Even, when the infection has got into it, then from there it is washed out with a powerful stream of urine.
More about folk treatment diseases of the female genitourinary system:
Diseases of the genitourinary system in women. Video.
New Articles
Cystitis in women and drugs for its treatment
Cystitis is one of the most "popular" urological diseases. It is more common in young women. Even without treatment, unpleasant symptoms may disappear, but the disease cannot be left unattended. Launched infectious inflammation can cause serious damage to the organs of the genitourinary system.
What is cystitis
Cystitis is an inflammation of the bladder or urinary infection, resulting in inflammation of the mucosa. Most often, the causative agent of the disease is Escherichia coli, less often - infections.
Women are more likely to suffer from cystitis due to anatomical features: their urinary canal is wider and shorter, it is easier for a stick to get on the mucous membrane. A stick that has entered the urinary tract destroys the mucous membrane. It has bleeding ulcers. Without the necessary treatment, the process spreads throughout the body, passing to the kidneys.
Cystitis is often called a "cold" disease: it is believed that it occurs due to hypothermia. This is not so: the pathogen enters the urethra from the rectum. Cold weather can be a favorable factor and accelerate the inflammatory process by reducing immunity.
Related reasons also include:
- stasis of urine;
- difficult childbirth;
- pregnancy;
- operations on the organs of the urinary system;
- avitaminosis;
- not proper nutrition;
- hormonal disorders;
- non-compliance with hygiene rules.
Acute cystitis can also occur after unprotected intercourse with an untested partner. In this case, the causative agent will be chlamydia.
Symptoms and signs
In the acute form of the disease, the symptoms are pronounced, during chronic cystitis, the signs are blurred and may not cause much discomfort. The first obvious sign of cystitis is discomfort when urinating. A burning sensation appears in the urethra, the process of emptying the bladder is delayed.
- frequent false urge to urinate;
- pain in the vulva;
- pain in the lower abdomen;
- cloudy sediment in the urine;
- temperature rise;
- weakness;
- bad smell;
- feeling of incomplete emptying;
- general malaise.
In advanced cases, blood appears in the urine. The further the inflammatory process goes, the more often the symptoms recur. If at the initial stage the urge to urinate occurs every 1-1.5 hours, then later the time is reduced to a minute. The pain syndrome first manifests itself during the emptying of the urinary tract, after - constantly.
Forms of the disease
There are two forms of cystitis: acute and chronic. In the first case, the inflammatory process is “one-time”, in the second, clinical cases occur more often than twice a year. Chronic inflammation is one of the main causes of functional and structural changes in the bladder.
In rare cases, a third form is diagnosed - sluggish cystitis. It does not have any characteristic exacerbations. The main symptom is frequent urination, characterized by discomfort and a slight burning sensation.
Acute cystitis has two forms of flow. It is subdivided into:
Primary occurs due to infection, secondary often develops due to diseases of nearby organs or the bladder.
Possible Complications
Under favorable conditions, the symptoms of primary acute cystitis can go away on their own. For many women, this is a reason to refuse a visit to the doctor. But the disappearance of obvious signs of the disease is not always evidence that the inflammatory process has been stopped.
If the infection remains in the urinary tract, hemorrhagic cystitis may develop. It occurs due to the strong destruction of the mucous membrane. At the same time, vascular permeability increases, and hemorrhage occurs. The most obvious sign of such a complication is urine with a rich red tint and sharp sharp pains in the lower abdomen.
The following negative consequences are possible:
- Iron-deficiency anemia;
- dysfunction of the bladder;
- overgrowing of the walls with connective tissue;
- urinary incontinence;
- bladder rupture;
- peritonitis;
- pyelonephritis.
If sexually transmitted infections join cystitis, age increases the risk of adhesions of the fallopian tubes, which causes infertility. In addition, the disease significantly reduces immunity. The body loses its ability to resist diseases and infections.
Necessary diagnostics
At the first symptoms of cystitis, you should consult a general practitioner or urologist. In some cases, the diagnosis can be made after the first visit, solely on the basis of the patient's complaints. The prescribed treatment is carried out at home under the supervision of a doctor.
To confirm the diagnosis, it is necessary to pass a series of tests. This should be done before the use of any medications: they begin to act quickly, and the very next day the clinical picture may change and affect the results of the studies.
The symptoms characteristic of cystitis overlap with signs of other pathologies - urolithiasis, sexually transmitted diseases, uterine cancer or tumor processes in the urinary tract. All these diseases can be excluded only after receiving the test results.
- urine;
- blood;
- smear from the mucous membrane of the vagina or cervix;
- cystoscopy;
- Ultrasound of the genitourinary system.
Additionally, in controversial cases, a biopsy may be required.
Traditional treatment
For the treatment of female cystitis, the following drugs are used:
In most cases, the main "bet" is on antibiotics. You cannot choose the medicine yourself. When choosing, the doctor takes into account many factors, from the age of the patient to the clinical picture of the disease. The duration of the course is of particular importance: extra pills “hit” the body, and untreated inflammation is dangerous with a secondary exacerbation.
Before use, you need to carefully study the instructions, paying attention to contraindications. Some drugs are allowed to be used even by children (for example, Nolicin), others are prohibited for people with kidney failure, allergies, pregnant or lactating women.
To alleviate the most unpleasant symptoms of cystitis (pain and burning), antispasmodics and analgesics are needed - Papaverine and No-shpa (Drotaverine). Phytopreparations help to restore the normal microflora: Cyston, Phytolysin, Canephron, Spazmotsistenal. Vitamin and mineral complexes are used to stimulate the immune system.
In chronic cystitis it is necessary:
- normalize hormonal disorders;
- support the immune system;
- eliminate structural pathologies of the urinary;
- activate the blood supply to the affected organs;
- adjust the rules of personal hygiene.
During an exacerbation, antibiotics and anti-inflammatory drugs are used.
Folk remedies
Folk remedies can relieve pain and stop inflammation, but it is forbidden to completely replace the recommended drug therapy with them. When choosing a suitable recipe, you need to focus on its composition: if you are allergic to at least one component, you should refuse to use it. If possible, you should consult with your doctor about the chosen method of auxiliary treatment.
- rosehip roots: two tablespoons are poured hot water and boil for 15 minutes. After two hours, the cooled broth is filtered. You need to drink everything in a day, dividing the liquid into four times. Consume before meals for one week.
- dry or fresh celandine grass: 150 gr. plants are crushed in a blender. The resulting slurry is wrapped in a bandage or gauze and immersed in a liter jar of warm water. Infuse for three hours, drink a third of a glass every three hours.
- lingonberry leaves: two teaspoons per glass of boiling water, warm over medium flame for a minute, cool and strain. Drink in small sips four times a day. You can not store the broth, every day you need to prepare a new one. Consume until symptoms disappear.
- Bedstraw herb: four tablespoons of dry herb in a glass of boiling water. Cool at room temperature. Drink half a glass before meals. The course is two weeks.
With an exacerbation of cystitis, it is recommended to observe bed rest and refuse exercise. You need to follow a simple diet: exclude foods with a high level of calcium (milk, kefir, cheeses and yogurts) and add as many fresh vegetables and fruits to the diet as possible.
Drinking should be plentiful and natural - blueberry, cranberry or lingonberry fruit drinks or still mineral water at room temperature are suitable. Bad habits during this period are especially dangerous - they undermine the already impaired immunity. Under a complete ban, alcohol is included, which is not compatible with drugs.
Prevention
To avoid recurrence, you must carefully monitor your health. Even mild colds need urgent treatment. Problematic teeth, dysbacteriosis or tonsillitis can provoke secondary cystitis.
To avoid stagnant processes in the pelvis, you need to move as much as possible. This is especially true for office workers. Although once an hour a small warm-up is done, consisting of bends, squats and a quiet walk. It is better to refuse the elevator in favor of the stairs.
During washing, it is undesirable to use fragrant soaps and gels with a large number of flavors: they negatively affect the mucous membrane, drying it out. You need to visit the bath at least once a day, change linen regularly. During critical days, tampons are replaced with sanitary pads.
Tight underwear made of synthetic fabrics often provokes circulatory disorders of the pelvic organs. With a tendency to cystitis, the choice is made in favor of comfortable cotton panties.
Preventive visits to the gynecologist and urologist should be made at least twice a year. Secondary cystitis is rarely an independent disease. In order to block the inflammatory process in the urinary tract in time, it is necessary to identify the underlying disease in a timely manner.
First aid for cystitis
Of course, at the first signs of cystitis, you should immediately consult a doctor. But at the initial stage, the disease often goes unnoticed, and the obvious symptoms are so acute that they cannot be tolerated. To quickly get rid of pain, antispasmodics or any suitable painkillers are suitable - Drotaverine, Ketorol, Pentalgin, Nurofen.
To provoke the withdrawal of the infection from the urinary tract, an abundant warm drink is used - at least two liters of fluid per day. From strong tea, coffee, soda and packaged store juices are refused during the problem period.
Despite the abundance of antibiotics that act for cystitis, you should not prescribe them yourself. It is better to replace medicines with natural decoctions of calendula, bearberry, chamomile, lingonberry, nettle, St. John's wort and yarrow.
New on site
Be sure to consult with your physician.
Dear readers!
This publication will focus on infectious and inflammatory diseases - pyelonephritis (including in pregnant women), cystitis (including interstitial), orchitis and epididymitis, urethritis and prostatitis.
The information is presented in a form that is understandable to patients. This was done with two goals: the first is to help the doctor to more effectively build a dialogue with the patient, intelligibly explain the essence of his illness and treatment tactics in a limited time; the second is to provide information support for patients interested in various problems of urology. We are confident that the more a patient knows about his illness, about what is happening in his body, the easier it is for him, together with the doctor, to make a decision on the correct tactics of examination and treatment, the higher will be his adherence to treatment and, accordingly, the better the result of therapy. Currently, there is a constant increase in the variety of drugs and treatment methods that can be offered for the same disease. Each of the methods has its positive aspects, and you can make the right choice only by making a joint decision. Trusting relationships and good information are the main keys to the success of treatment.
The authors express the hope that this material will be useful in the daily practice of urologists in our country.
Keywords: pyelonephritis, pregnancy, cystitis, interstitial cystitis, orchitis, epididymitis, urethritis, prostatitis, information support for patients.
For citation: Rasner P.I., Vasiliev A.O., Pushkar D.Yu. Inflammatory diseases of the urinary system // BC. 2016. No. 23. S. 1553-1561
Inflammatory disorders of the urinary system
Rasner P.I., Vasil "ev A.O., Pushkar" D.Yu.
A.I. Evdokimov Moscow State University of Medicine and Dentistry
Dear readers!
This paper discusses infectious inflammatory urinary disorders, i.e., pyelonephritis (in particular, in pregnant women), cystitis (in particular, interstitial), orchitis and epididymitis, urethritis and prostatitis.
The information is easy to read and understand. The publication has two goals. The first goal is to improve patient-physician communication, to explain the nature of the disease and treatment approach in limited time. The second goal is to provide information for patients who are interested in urology. The more the patient is informed about his/her disease, the easier is the decision on diagnostic and therapeutic strategy and the better is treatment adherence and outcomes. Currently, the set of pharmaceutical agents and treatment methods for a given disorder is growing. Each method has specific advantages, therefore, the doctor and the patient should cooperate to make the right treatment choice. Trust and information secure perfect treatment outcomes.
The authors hope that these materials will be useful for daily urological practice in Russia.
key words: pyelonephritis, pregnancy, cystitis, interstitial cystitis, orchitis, epididymitis, urethritis, prostatitis, information for patients.
For quote: Rasner P.I., Vasil "ev A.O., Pushkar" D.Yu. Inflammatory disorders of the urinary system // RMJ. 2016. No. 23. P.1553–1561.
The article is devoted to inflammatory diseases of the urinary system
The genitourinary system is at high risk due to poor lifestyle and infectious diseases.
With age, these risks increase significantly, so the state of the organs responsible for sexual and urinary function should be given more and more attention.
Since the organs in the system are connected, the deterioration of the state of one leads to risks for the other, therefore, in order to avoid serious consequences, the treatment of diseases of the genitourinary system should be as fast and of high quality as possible.
Infectious diseases are the most common pathology of the genitourinary system. Modern medicine has many such diseases, most often caused by bacteria or fungi.
Inflammations are often diagnosed with a delay, since they usually go unnoticed by the patient, sometimes they can only be recognized by complications in other organs.
The structure of the male genitourinary system
Most often, inflammatory processes that have begun in the genitourinary system can be found in the following:
- external manifestations on the genitals;
- lack of erection.
Prostatitis
Of all the disorders of the genitourinary system, the largest number of cases occur in, which, in fact, is an inflammation of the prostate gland caused by bacteria (most often chlamydia).
Diagnosis is complicated by hidden and the fact that many other diseases are common.
Symptoms:
- painful urination;
- weak;
- discomfort in the lower abdomen;
- small amount of urine.
Urethritis
The disease is characterized by an inflammatory process inside the urethra. It may not manifest itself for a long time, and later make itself felt under, or another disease. The main source of infection is unprotected intercourse.
Symptoms:
- burning sensation when urinating;
- pain and itching;
- discharge;
- pain and cramps are felt in the lower abdomen.
With untimely treatment, inflammation of other organs is possible.
BPH
- frequent urination (sometimes with interruption of sleep);
- weak intermittent urine stream;
- feeling of incomplete emptying of the bladder;
- inability to urinate without straining;
- urinary incontinence.
Cystitis
For complex therapy, Ursulfan or is used. Of the plant uroantiseptics, Phytolysin is most often used. To relieve pain, antispasmodics are used:, etc.
Of the diuretics, Diuver or Furosemide is used. Multivitamin complexes Alvittil, Milgamma, Tetrafolevit are excellent for stimulating the immune system, preparations containing selenium and are additionally prescribed.
Diet
Diets are prescribed most often for kidney diseases:
- diet number 6. Helps limit salt intake, increase the proportion of dairy products, liquids, vegetables and fruits in the diet;
- diet number 7a. Allows you to remove metabolic products from the body, reduce pressure and swelling.
- diet number 7b. Increases the amount of proteins compared to 7a.
Depending on the type of disease, there are many types of prescribed diets, they are prescribed only by the attending physician based on the results of the tests.
Physiotherapy
The main purpose of physiotherapy for urological diseases is to strengthen drug treatment. It is also used to directly eliminate certain diseases or is used in cases where medications are contraindicated for the patient.
The main types of applied procedures:
- EHF-therapy;
- ultrasound treatment;
- electrophoresis;
- inductothermy.
Therapy with folk remedies
In parallel with drug treatment, they are used. Infection in the urinary tract destroys coconut oil (used orally), asparagus and celery help relieve inflammation.
Coconut oil is great for infection
An infusion of boiled onions and basil is used as an antibacterial and diuretic. Garlic is useful in kidney diseases.
For the greatest effectiveness, drugs, folk remedies and physiotherapy are used in combination.
Prevention of inflammatory diseases
The main element in the prevention of diseases of the genitourinary system is hygiene, which includes both regular washing and protected sex.
Despite the simplicity, many ignore these measures. The absence of hypothermia, leading, for example, to cystitis, guarantees the right clothing for the season. To help the body get rid of harmful bacteria, you need to drink 1.5 to 2.5 liters of fluid per day.
They will help to normalize the functioning of the body. Proper nutrition, activity and the rejection of bad habits will help to significantly reduce the risk.
With proper prevention and attention to your health, you can greatly reduce the risk of developing urological diseases.
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About the principles of treatment of diseases of the genitourinary system in the video:
Pathologies of the genitourinary system pose a huge threat to the body up to the danger of death. But it is not difficult to prevent these diseases by following a number of simple recommendations. A timely visit to the doctor will help prevent complications and make the treatment as simple, quick and painless as possible.
One of the most common reasons for visiting a doctor is urinary tract infections in women. The fair sex is more likely to face this problem due to the anatomical features of the body. The urinary canal is located in close proximity to the vagina and anus. This contributes to the rapid movement of pathogenic organisms in the genitourinary system.
What are infections?
Infection is an infection with a pathogenic microorganism that negatively affects a specific organ system, in this case the genitourinary system. In the absence of diagnosis and timely therapy, the infection causes inflammatory complications. Ignoring the disease leads to a transition to a chronic course, which negatively affects all areas of human life. Inflammation of the urinary tract can have unpleasant complications for women.
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Causes and types
Inflammatory processes occur as a result of the entry or active reproduction of pathogens in one or more organs.
The cause and route of infection are very different. Unlike sexually transmitted diseases, urinary tract infections can result from reduced immunity or organ injury. The most common factors are:
- neglect of personal hygiene;
- unprotected sex;
- reduced immunity;
- hypothermia;
- stress;
- pathogen transfer from other infected organs;
Diseases of the genitourinary system are characterized by the presence of infection in one or more of its organs. Depending on the concentration of pathogenic microorganisms, they are divided into: infections of the upper urinary tract and infections of the lower urinary tract. They cause such diseases:
Pathogenic microorganisms can cause salpingitis.- glomerulonephritis;
- pyelonephritis;
- cystitis;
- adnexitis;
- salpingitis;
- endometritis;
- epididymitis;
- urethritis;
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pathogens
There are many microorganisms that can cause diseases of the genitourinary tract. They are differentiated as: pathogenic and conditionally pathogenic. The first become the cause of the disease when it enters one or another organ. Opportunistic pathogens can be part of the normal flora of a woman, but under a certain set of circumstances (trauma, decreased immunity), they multiply and cause an infectious-inflammatory process. Medicine distinguishes the following types of pathogens:
- ureoplasma;
- mycoplasma;
- pale treponema;
- fungal microorganisms;
- chlamydia;
- intestinal and Pseudomonas aeruginosa;
- trichomonas;
- listeria;
- klebsiella;
- Proteus;
- cocci;
Sometimes the inflammatory process occurs against the background of another disease, for example, in the context of herpes, papillomavirus and cytomegalovirus. Most of the above pathogenic organisms can migrate in the human body along with the blood and cause diseases of various organs and systems. The risk of getting infected increases when a woman begins to live sexually, since almost all infections are sexually transmitted.
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Symptoms of urinary tract infections in women
Diseases of the genitourinary system in women have extensive symptoms. Some infections present with specific symptoms and signs, while others are asymptomatic. There are also hidden infections, they are characterized by a complete absence of symptoms. Often, the patient finds out about the presence of a latent infection by chance, passing general analysis urine during pregnancy or before surgery. Symptoms of the disease include:
- unusual vaginal discharge;
- discharge from the urethra;
- the process of urination is accompanied by burning, pain;
- discomfort during intercourse;
- itching of the genitals;
- swelling of the external genitalia and anus;
- lower abdominal pain;
- lumbar pain;
- the appearance of formations on the genitals;
- impurities of blood and pus in the urine;
- elevated temperature.
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How are women's infections different from men's?
Medicine divides infections into “male” and “female” according to the specifics of the course of diseases, but the causative agents of inflammatory processes are the same in both sexes.
Vesiculitis refers only to male diseases.
Due to the differences in the structure of the male and female urinary organs, the disease is localized in different places. Exclusively "male" diseases are: balanoposthitis (inflammatory process of the head of the penis and its foreskin), prostatitis (inflammation of the prostate gland), vesiculitis (inflammatory process of the seminal vesicles) and balanitis (inflammation of the head). The symptoms of some diseases are also different. This is due to the natural anatomy, lifestyle and culture of human nutrition. However, differences in the course of the disease does not indicate different pathogens.
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General signs
The infectious disease has common features in both sexes. As a rule, patients feel discomfort when urinating. The inflamed mucous tissue of the urethra reacts with a burning sensation to the ingress of urine. Uncharacteristic discharge from the urethra is also characteristic, both in men and women. Pyelonephritis, manifested by lumbar pain. Sometimes, with an infectious disease, the temperature rises. The appearance of neoplasms on the skin, or on the external genital organs, can also serve as the onset of the disease, regardless of gender.
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Differences in the course of some diseases
Statistically, inflammation of the genitourinary system occurs more frequently in women than in men. The fact is that the female urethra is only 4-5 cm long, while the length of the male is 11-16 cm. Infections that enter the body of a woman rise faster and affect the bladder and kidneys. However, it is precisely due to the relatively long urethra that inflammation of the ureter in men is more acute and takes much longer to heal. In women, the course of this disease is less noticeable, so it often becomes chronic. Also, the fair sex is more likely to have latent genitourinary infections. Due to the absence of symptoms, women are more likely to carry pathogens than men.
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Diagnosis of diseases of the genitourinary system
To make a diagnosis, you need to take a general blood test.The topic of infections of the urogenital tract is well studied and, as a rule, a specialist does not have problems with their detection. As a rule, the doctor collects information about the symptoms and conducts an examination. Further, appoints a number of clinical and laboratory studies. Standard analyzes include:
- general clinical blood and urine tests;
- radioimmunoassay;
- bacteriological culture;
- immunofluorescence reaction;
- test provocation;
- computer research;
Special tests are also prescribed to determine the sensitivity of bacteria to certain antibiotics. The results obtained give a complete picture of the type of pathogen, the stage of development of the disease, its impact on other organs and systems of the human body. After establishing an accurate diagnosis, the doctor develops a treatment regimen.
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Methods of treatment
In the treatment of diseases of the urinary system, a complex scheme is prescribed, which consists of drug treatment, dietary nutrition and a certain drinking regime. Early diagnosis of infectious diseases, elimination of the cause and implementation of preventive measures help to quickly cure the disease with minimal consequences for the body.
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General principles
All therapeutic measures are prescribed by a doctor.Treatment of the genitourinary system is aimed at the destruction of infectious pathogens, the removal of inflammatory processes, the restoration of a healthy flora of the organ and the prevention of disease in the future. Correct therapy is developed only by the doctor and the task of the patient is to strictly follow it. Proper treatment of diseases of the genitourinary system helps to prevent their occurrence in the future.
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Antibiotics
The main drugs used for infections are antibiotic drugs. The necessary tablets are selected based on the sensitivity of the pathogenic microorganism to a particular type of antibiotic.
The medicine is taken in a course, the duration of which is determined by the doctor, depending on the degree of development of the disease. It is extremely important to completely drink the required amount of the drug. Even if all manifestations of the disease have passed, this does not mean that the patient has got rid of all pathogens. When antibiotic treatment is interrupted, pathogenic microorganisms may develop resistance to the drug and repeated treatment will not bring results. Traditionally, inflammation of the urinary tract is treated with antibiotics such as:
- Ampicillin;
- Amoxiclav;
- Amoxicillin;
- Cephalexin;
- Biseptol;
- Ceftriaxone;
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Pain Remedies
To relieve pain, Baralgin is prescribed.Diseases of the urinary system are accompanied by pain, which significantly affects the quality of life of the patient. In order to relieve or relieve pain, antispasmodics and painkillers are used. Among the most common: "No-shpa", "Drotaverin", "Baralgin" and "Pentalgin". It should be noted that these drugs relieve pain symptoms, but do not treat the root cause of the disease.
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Other drugs
In combination with antibiotics, antiseptics, immunomodulators and vitamins are used. Antiseptics, such as iodine, chlorhexidine and a solution of potassium permanganate, are applied topically for external damage to the external genitalia and mucosal tissues. A very important role in the treatment is played by supporting and strengthening drugs. Antibiotics, in addition to pathogens, also destroy beneficial bacteria, which disrupts the flora of the body, which, as a result, causes fungal infections and upset the digestive system.
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Treatment with folk remedies
Pathologies can be treated folk remedies. It is worth treating infectious diseases with herbs carefully and after consulting a doctor. As a rule, herbs that have a diuretic effect are used, with their help, pathogenic organisms will quickly exit through the urinary tract. Among them are lingonberries, rose hips, cranberries and chicory. Herbs such as chamomile and horsetail have soothing and antiseptic properties. The herb lungwort has tannic properties, and treats inflammation of the mucous tissues of the bladder and other organs.
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Diet for diseases of the genitourinary system
During treatment, it is important to abandon smoked foods.The genitourinary system responds positively to compliance certain system nutrition in parallel with the main therapy.
The patient is advised to limit the use of spicy dishes, pickles and smoked meats. An excess of spices irritates the inflamed mucosa and prevents the complete release of fluid from the body. It is also recommended to drink at least 2 liters of water, this will stimulate the work of the kidneys and help to ensure that the genitourinary infection comes out.
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Possible Complications
A urinary tract infection is fraught with unpleasant consequences. The most common is the transition of diseases to chronic forms. Untreated ailments lead to impaired reproductive function, intimate sphere, pregnancy pathologies, kidney failure, and in severe cases, death. The decision not to treat an infectious disease is irresponsible in relation to the sexual partner. After all, almost any urinary tract infection is transmitted during sexual intercourse.
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Preventive actions
Prevention of diseases of the urinary system includes a number of simple rules and measures:
- active lifestyle;
- proper nutrition;
- taking vitamins;
- timely completion of scheduled medical examinations;
- rejection of uncomfortable synthetic underwear;
- condom use;
A very important factor in prevention is the appeal to a qualified specialist when the first symptoms of the disease occur. Reporting the disorder and treating it early gives the most favorable outcome and reduces the risk of recurrence later on. Compliance with these simple principles will help prevent diseases of the genitourinary tract.
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Urinary system of women
If we talk about how the urinary system of a woman is arranged, then it practically does not differ from the male, the main difference is the length and function of the urethra. If the length of the female urethra is only 3-5 cm, then in men in a calm state the length of the urethra can be 20-23 cm. The purpose of the female urethra is to remove urine from the body, and the male also ejects sperm. All this leads to the fact that inflammation of the genitourinary system in women is more common.
Urine is collected first in the kidneys, which pass about 200 liters of blood per day, while it is cleansed of toxins and toxins. After such filtration, 1.5-2 liters of urine is formed. It accumulates in the renal pelvis, then it enters the bladder through the ureter and is excreted from the body through the urethra.
If we talk about the reproductive system, then it has both external and internal genital organs. Inside the small pelvis is the uterus, fallopian tubes and ovaries.
Infections of the genitourinary system in women are the main causes that cause inflammatory diseases. These pathologies can be both gynecological and urological and are quite dangerous for the female body. Inflammation of the genitourinary system can lead not only to violations of the process of urination and menstrual irregularities, they can also provoke the development of an ectopic pregnancy, and often the development of infertility.
Diseases of the genitourinary system
If a woman did not notice the symptoms of the development of the inflammatory process in time and did not completely cure the acute form of the disease, it can turn into a chronic form, which will worsen from time to time and bring problems and discomfort to the woman.
Diseases of the genitourinary system, which are inflammatory in nature, are caused by pathogens of the following pathologies:
- gonorrhea, syphilis or trichomoniasis;
- chlamydia, mycoplasmosis;
- tuberculosis and herpes;
- thrush.
In addition to the cases described, an inflammatory process can also be provoked by conditionally pathogenic microbes, for example, Pseudomonas aeruginosa, staphylococcus aureus, E. coli, and others.
Which disease a woman begins to develop depends largely on where exactly these uninvited guests “settle”.
If they enter the vagina, then inflammation of its mucous membrane develops. This disease is called vaginitis. In the event that microbes settle in the urethra, urethritis develops.
With the development of an inflammatory process in the bladder, a disease called cystitis develops. Inflammation of the mucous membrane of the uterus is called endometritis, and if the infection is in the appendages, then adnexitis develops. Pyelonephritis is an inflammation of the renal pelvis.
Symptoms of inflammatory processes
Symptoms of inflammation that occur in the female genitourinary system may vary. The organs of the female reproductive and urinary systems are located close and interact with each other. If the inflammation began in one place, it spreads very quickly to the organs that are located nearby.
Most often, women suffer from cystitis, as their urethra is short and located near the anus and vagina, which allows germs to easily enter the bladder.
A woman can bring the infection into the urethra, and then into the bladder, if she does not follow the rules of personal hygiene. This can also happen during intercourse or as a result of an injury to the vulva.
Symptoms of urethritis are much less common, cystitis develops more often, since the urethra is very short. Even if the infection has got into it, then it is washed out from there with a powerful stream of urine.
The main symptoms of cystitis: during urination, a woman has a strong burning sensation and pain, often the urge to urinate is false, just a few drops of urine come out, a feeling of heaviness and discomfort appears in the suprapubic part. In addition, the symptoms of cystitis can be in the form of an increase in body temperature, a general deterioration in health.
If you do not start treating cystitis in time, inflammation can develop and pyelonephritis will begin. In addition to the symptoms already described, a woman develops pain in the lower back and lateral sections of the abdomen, often nausea, which ends in vomiting.
If the inflamed organs of the urinary system are not treated, it is more likely that the inflammation will spread to the organs of the reproductive system, as a result of which a disease such as endometritis or vaginitis, adnexitis may develop.
The initial task of the attending physician is to determine the causative agent of the disease, for this a urinalysis is performed, a swab is taken from the vagina and urethra, and bakposev is prescribed.
As an additional diagnostic method, an examination of the bladder can be performed using a special probe. An ultrasound examination, computed tomography and magnetic resonance imaging are performed, and an X-ray examination can also be prescribed.
To identify diseases of the genitourinary system, there are many diagnostic methods that allow you to correctly diagnose, after which the doctor determines an effective treatment regimen.
Treatment Methods
Treatment of the genitourinary system involves drugs that fight infection, that is, antibiotics. You cannot prescribe such drugs on your own, they must be prescribed by a doctor, and he also determines the time of treatment. It is impossible to stop the course of treatment earlier, even if it seems that you are already completely healthy.
If you take antibiotics incorrectly or finish taking them before the specified time, you can only harm the body. Pathogenic microbes in this case are not completely destroyed, they develop resistance to the antibiotic used, and the next time it will be ineffective, and the disease can become chronic.
Together with antibiotics, the doctor may prescribe medications that increase immunity, relieve inflammation, certain vitamins and trace elements can be prescribed.
In addition to drug treatment, you will also have to follow a diet, you will have to limit yourself to taking spicy food, you need to drink at least 2 liters of water per day. How adjuvant treatment can be used and ethnoscience, but everything must first be agreed with the attending physician.
Preventive actions
Even in the case when the treatment is carried out correctly and effectively, if certain rules are not followed, there is a high probability of a relapse of the disease.
Hypothermia of the body should not be allowed, underwear should not only be comfortable and not squeeze the genitals, but also made of natural materials, it is better to refuse synthetic underwear.
When using sanitary napkins, the time limits specified by the manufacturer must not be exceeded. Be sure to observe personal hygiene, it is best to wash the genitals after each visit to the toilet, if this is not always possible, then this must be done in the morning and evening. Urinate before and after intercourse to prevent the spread of infection.
Do not allow injury to organs that are part of the genitourinary system. In order to avoid stagnation of blood in the small pelvis, one must be active, exercise moderately, walk more. If you notice the first signs of the development of these diseases, you should immediately consult a doctor. The sooner this is done, the faster, easier and more effective treatment is.
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What are urinary infections?
Infectious diseases are understood as pathologies that are caused by certain microorganisms and proceed with the development of an inflammatory reaction, which can result in a complete recovery or a chronic process, when periods of relative well-being alternate with exacerbations.
What diseases are among them?
Often patients and some medical workers put an equal sign between the genitourinary infections and diseases. However, such representations do not quite accurately reflect the essence of each term. The World Health Organization recommends referring specific clinical nosologies to genitourinary infections, in which an organ of the reproductive or urinary system is affected. Moreover, pathogens can be different. And sexually transmitted diseases include a group that has an appropriate distribution path, but can affect many organs, and the division of infections is determined according to the type of pathogen. Thus, we are talking about classifications according to different criteria. According to the recommendations of the World Health Organization, the following diseases are understood as genitourinary infections:
- urethritis (inflammation of the urethra);
- cystitis (inflammation of the bladder);
- pyelonephritis or glomerulonephritis (inflammation of the kidneys);
- adnexitis (inflammation of the ovaries);
- salpingitis (inflammation of the fallopian tubes);
- endometritis (inflammation of the uterine mucosa);
- balanitis (inflammation of the glans penis);
- balanoposthitis (inflammation of the head and foreskin of the penis);
- prostatitis (inflammation of the prostate);
- vesiculitis (inflammation of seminal vesicles);
- epididymitis (inflammation of the epididymis).
Thus, genitourinary infections concern exclusively the organs that make up these systems of the human body.
What pathogens cause urinary tract infections?
Urinary infections can be caused huge amount microorganisms, among which there are purely pathogenic and conditionally pathogenic. Pathogenic microbes always cause an infectious disease, and are never part of the normal human microflora. Conditionally pathogenic microorganisms are normally part of the microflora, but do not cause an infectious-inflammatory process. With the onset of any predisposing factors (falling immunity, severe somatic diseases, viral infection, trauma to the skin and mucous membranes, etc.), opportunistic microorganisms become pathogenic and lead to an infectious-inflammatory process.
Most often, genitourinary infections are caused by the following pathogens:
- gonococcus;
- mycoplasma;
- ureaplasma;
- chlamydia;
- trichomonas;
- pale treponema (syphilis);
- sticks (Escherichia coli, Pseudomonas aeruginosa);
- fungi (candidiasis);
- klebsiella;
- listeria;
- coliform bacteria;
- Proteus;
- viruses (herpes, cytomegalovirus, papillomavirus, etc.).
To date, these microbes are the main factors in the development of genitourinary infections. At the same time, cocci, E. coli and fungi of the genus Candida are classified as conditionally pathogenic microorganisms, all the rest are pathogenic. All these microorganisms cause the development of an infectious-inflammatory process, but each has its own characteristics.
Classification of infections: specific and non-specific
The division of urinary tract infection into specific and non-specific is based on the type of inflammatory reaction, the development of which is provoked by the causative microorganism. So, a number of microbes form inflammation with distinctive features that are unique to this pathogen and this infection, so it is called specific. If the microorganism causes the usual inflammation without any specific symptoms and features of the course, then we are talking about a non-specific infection.
Specific infections of the genitourinary organs include those caused by the following microorganisms:
1.
Gonorrhea.
2.
Trichomoniasis.
3.
Syphilis.
4.
Mixed infection.
This means that, for example, urethritis caused by syphilis or gonorrhea is specific. Mixed infection is a combination of several pathogens of a specific infection with the formation of a severe inflammatory process.
Nonspecific infections of the urogenital area are caused by the following microorganisms:
- cocci (staphylococci, streptococci);
- sticks (Escherichia, Pseudomonas aeruginosa);
- viruses (eg herpes, cytomegalovirus, etc.);
- chlamydia;
- gardnerella;
- ureaplasma;
- fungi of the genus Candida.
These pathogens lead to the development of an inflammatory process, which is typical and does not have any features. Therefore, for example, adnexitis caused by chlamydia or staphylococci will be called non-specific.
Ways of infection
Today, three main groups of pathways have been identified in which infection with genitourinary infections is possible:
1.
Dangerous sexual contact of any type (vaginal, oral, anal) without the use of barrier contraceptives (condom).
2.
The ascent of the infection (the entry of microbes from the skin into the urethra or vagina, and the rise to the kidneys or ovaries) as a result of neglecting the rules of hygiene.
3.
Transfer with blood and lymph flow from other organs in which there are various diseases of inflammatory origin (caries, pneumonia, influenza, colitis, enteritis, tonsillitis, etc.).
Many pathogenic microorganisms have an affinity for a particular organ, the inflammation of which they cause. Other microbes have an affinity for several organs, so they can form inflammation either in one, or in another, or in all at once. For example, angina is often caused by group B streptococcus, which has an affinity for the tissues of the kidneys and tonsils, that is, it can cause glomerulonephritis or tonsillitis. For what reasons this type of streptococcus settles in the tonsils or kidneys has not been clarified to date. However, having caused a sore throat, streptococcus can reach the kidneys with blood flow, and also provoke glomerulonephritis.
Differences in the course of genitourinary infections in men and women
Men and women have different genitals, which is understandable and known to everyone. The structure of the organs of the urinary system (bladder, urethra) also has significant differences and different surrounding tissues.
The urethra (urethra) of men is three to four times longer than the female. Due to the length of the male urethra, its inflammation (urethritis) is more difficult to treat and takes more time. Urethritis in women is cured faster and easier. But such a length of the urethra in men is a kind of barrier, protection against penetration genital infection to the upper urinary tract, such as the bladder and kidneys. The short and wide urethra of women does not pose a serious obstacle to the ascent of the infection, therefore, the fairer sex is more likely to develop complications of primary urethritis - cystitis, pyelonephritis, adnexitis and salpingitis.
That is why men mostly suffer from urethritis and prostatitis. Cystitis, pyelonephritis or glomerulonephritis are less common in men than in women, and the cause of these pathologies is more often structural features, diet, lifestyle, etc. Most often, inflammation of the glans penis or its foreskin, as well as cystitis and nonspecific urethritis , in addition to an infectious cause, may be associated with anal sex and ignoring the rules of personal hygiene.
Urethritis in men appears sharper and more acute than in women. Representatives of the stronger sex suffer from pain, pain and burning throughout the entire urethra when trying to urinate, as well as a feeling of heaviness in the perineum.
Due to the short urethra in women, the infection easily ascends to the bladder and kidneys. In addition, women are characterized by a milder and latent course of genitourinary infections, compared with men. Therefore, women often have a symptom of a latent genitourinary infection - bacteriuria (the presence of bacteria in the urine against the background of the absence of any symptoms and signs of the disease). Usually asymptomatic bacteriuria is not treated. The only exceptions are cases of preoperative preparation or pregnancy.
Due to the latent forms of the course of genitourinary infection, women are more likely than men to be carriers of diseases, often without knowing about their presence.
General signs
Consider the symptoms and features of the most common urinary tract infections. Any genitourinary infection is accompanied by the development of the following symptoms:
- soreness and discomfort in the organs of the genitourinary system;
- tingling sensation;
- the presence of discharge from the vagina in women, from the urethra - in men and women;
- various urination disorders (burning, itching, difficulty, increased frequency, etc.);
- the appearance of unusual structures on the external genitalia (raids, film, vesicles, papillomas, condylomas).
In the case of the development of a specific infection, the following signs are added to the above signs:
1.
Purulent discharge from the urethra or vagina.
2.
Frequent urination in gonorrhea or trichomoniasis.
3.
Sore with dense edges and enlarged lymph nodes in syphilis.
If the infection is nonspecific, then the symptoms may be more subtle, less noticeable. A viral infection leads to the appearance of some unusual structures on the surface of the external genital organs - vesicles, sores, warts, etc.
Symptoms and features of the course of various urinary tract infections
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And now let's take a closer look at how this or that infection of the genitourinary system manifests itself, so that you can navigate and consult a doctor in time for qualified help.
Urethritis
This condition is an inflammation of the urethra. Urethritis develops acutely, and is manifested by the following unpleasant symptoms:
- burning and sharp severe pain during urination;
- feeling of incomplete emptying of the bladder;
- increased burning and pain towards the end of the urination process;
- a burning sensation is localized in women mainly in the area of the end of the urethra (outside), and in men - along the entire length of the urethra;
- frequent urge to urinate after 15-20 minutes;
- the appearance of discharge from the urethra of a mucous or mucopurulent nature, which cause redness of the surface of the skin of the perineum or penis around the external opening of the urethra;
- the appearance of drops of blood at the end of the urination process;
- adhesion of the external opening of the urethra;
- pain during erection in men;
- the appearance of leukocytes in large numbers in the general analysis of urine;
- cloudy urine of the color of "meat slops".
Along with the listed specific symptoms of urethritis, general symptoms may be observed. infectious disease- headaches, fatigue, fatigue, sleep disturbance, etc.
Urethritis develops when a microorganism enters the lumen of the urethra as a result of sexual intercourse of any type (oral, vaginal or anal), the introduction of a microbe from the surface of the skin of the perineum, ignoring personal hygiene measures, or as a result of bringing bacteria with blood or lymph. The path of introducing an infectious agent with blood and lymph into the urethra is most often observed in the presence of chronic foci of infection in the body, for example, periodontitis or tonsillitis.
Urethritis can be acute, subacute and torpid. In the acute course of urethritis, all symptoms are strongly pronounced, the clinical picture is bright, the person experiences a significant deterioration in the quality of life. The subacute form of urethritis is characterized by mild symptoms, among which a slight burning sensation, tingling during urination and an itching sensation prevail. Other symptoms may be completely absent. The torpid form of urethritis is characterized by a periodic feeling of mild discomfort at the very beginning of the act of urination. Torpid and subacute forms of urethritis present certain difficulties for diagnosis. From the urethra, a pathogenic microbe can rise higher and cause cystitis or pyelonephritis.
After the onset, urethritis occurs with damage to the mucous membrane of the urethra, as a result of which the epithelium is reborn into a different form. If therapy is started on time, then urethritis can be completely cured. As a result, after healing or self-healing, the urethral mucosa is restored, but only partially. Unfortunately, some areas of the changed mucous membrane of the urethra will remain forever. If there is no cure for urethritis, then the process becomes chronic.
Chronic urethritis proceeds sluggishly, periods of relative calm and exacerbations alternate, the symptoms of which are the same as in acute urethritis. An exacerbation can have varying degrees of severity, and therefore, a different intensity of symptoms. Usually patients feel a slight burning and tingling in the urethra during urination, itching, a small amount of mucopurulent discharge and gluing of the external opening of the urethra, especially after a night's sleep. There may also be an increase in the frequency of going to the toilet.
Urethritis is most often caused by gonococci (gonorrheal), Escherichia coli, ureaplasma, or chlamydia.
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Cystitis
This disease is an inflammation of the bladder. Cystitis can develop as a result of exposure to a number of adverse factors:
- irregular flow of urine (congestion);
- urolithiasis disease;
- neoplasms in the bladder;
- hypothermia;
- food with a large amount of smoked, salty and spicy foods in the diet;
- alcohol intake;
- ignoring the rules of personal hygiene;
- the introduction of an infectious agent from other organs (for example, the kidneys or urethra).
Cystitis, like any other inflammatory process, can occur in acute or chronic form.
Acute cystitis is manifested by the following symptoms:
- frequent urination (after 10-15 minutes);
- small portions of excreted urine;
- cloudy urine;
- pain when urinating;
- pains of a different nature, located above the pubis, intensifying towards the end of urination.
The pain above the pubis can be dull, pulling, cutting or burning. Cystitis in women is most often caused by Escherichia coli (80% of all cystitis) or staphylococcus aureus (10-15% of all cystitis), which is part of the skin microflora. Less often, cystitis is caused by other microorganisms that can be brought in with blood or lymph flow, drift from the urethra or kidneys.
Usually, cystitis is acute and well treated. Therefore, the development of repeated cystitis some time after the primary attack is due to secondary infection. However, acute cystitis may not result in a complete cure, but in a chronic process.
Chronic cystitis occurs with alternating periods of well-being and periodic exacerbations, the symptoms of which are identical to those of the acute form of the disease.
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Pyelonephritis
This disease is an inflammation of the renal pelvis. The first manifestation of pyelonephritis often develops during pregnancy, when the kidney is compressed by the enlarging uterus. Also, during pregnancy, chronic pyelonephritis is almost always exacerbated. In addition to these reasons, pyelonephritis can be formed due to infection from the bladder, urethra, or from other organs (for example, with tonsillitis, influenza or pneumonia). Pyelonephritis can develop in both kidneys at the same time, or affect only one organ.
The first attack of pyelonephritis is usually acute, and is characterized by the presence of the following symptoms:
- temperature rise;
- soreness on the lateral surface of the waist and abdomen;
- feeling of pulling in the abdomen;
- urinalysis reveals leukocytes, bacteria, or casts.
As a result of adequate therapy, pyelonephritis is cured. If the inflammation has not been adequately treated, then the infection becomes chronic. Then the pathology mostly proceeds without pronounced symptoms, sometimes disturbing with exacerbations of lower back pain, fever and poor urinalysis.
Vaginitis
This disease is an inflammation of the mucous membrane of the vagina. Most often, vaginitis is combined with inflammation of the vaginal vestibule. This symptom complex is called vulvovaginitis. Vaginitis can develop under the influence of many microbes - chlamydia, gonococci, Trichomonas, fungi, etc. However, vaginitis of any cause is characterized by the following symptoms:
- unusual vaginal discharge (increase in amount, change in color or smell);
- itching, feeling of irritation of the vagina;
- pressure and feeling of fullness of the vagina;
- pain during sexual contact;
- pain during urination;
- easy bleeding;
- redness and swelling of the vulva and vagina.
Let us consider in more detail how the nature of the discharge changes with vaginitis caused by different microbes:
1.
Vaginitis caused by gonococcus causes a thick discharge that is purulent and yellow-white in color.
2.
Trichomonas vaginitis is characterized by secretions of a foamy structure, painted in a greenish-yellow color.
3.
Coccal vaginitis results in a yellow-white discharge.
4.
Candida vaginitis is characterized by cheesy discharge, painted in a gray-white color.
5.
Gardnerellosis imparts a rotten fish odor to vaginal discharge.
Acute vaginitis is characterized by a strong severity of symptoms, and chronic vaginitis is characterized by more blurred signs. The chronic form of the disease lasts for many years, recurring against the background of viral infections, hypothermia, alcohol intake, during menstruation or pregnancy.
More about vaginitis
Adnexitis
This disease is an inflammation of the ovaries in women, which can be acute or chronic. Acute adnexitis is characterized by the following symptoms:
- soreness in the lower abdomen;
- pain in the lumbar region;
- temperature rise;
- tense abdominal wall in the lower part;
- pressure on the abdomen is painful;
- sweating;
- headache;
- various urination disorders;
- violation of the menstrual cycle;
- pain during intercourse.
Chronic adnexitis occurs with alternating periods of remissions and exacerbations. During periods of exacerbation, the symptoms of chronic adnexitis are the same as in the acute process. Negative factors are similar: fatigue, stress, cooling, serious illness - all this leads to exacerbations of chronic adnexitis. The menstrual cycle changes markedly:
- the appearance of pain during menstruation;
- an increase in their number;
- an increase in the duration of bleeding;
- Rarely, menstruation is shortened and becomes scanty.
More about adnexitis
This disease is an inflammation of the fallopian tubes, which can be provoked by staphylococci, streptococci, Escherichia coli, Proteus, gonococci, Trichomonas, chlamydia and fungi. Usually salpingitis is the result of the action of several microbes at the same time.
Microbes in the fallopian tubes can be introduced from the vagina, appendix, sigmoid colon, or from other organs, with the blood or lymph flow. Acute salpingitis is manifested by the following symptoms:
- pain in the sacrum and lower abdomen;
- spread of pain in the rectum;
- rise in temperature;
- weakness;
- headache;
- urination disorders;
- an increase in the number of leukocytes in the blood.
The acute process gradually subsides, completely cured or becomes chronic. Chronic salpingitis is usually manifested by constant pain in the lower abdomen in the absence of other symptoms. With a relapse of the disease, all the symptoms of an acute process develop again.
More about salpingitis
Prostatitis
This disease is an inflammation of the male prostate gland. Prostatitis very often has a chronic course, and acute is quite rare. Men are concerned about discharge from the urethra that occurs during defecation or urination. There are also extremely unpleasant sensations that cannot be accurately described and characterized. They are associated with itching in the urethra, soreness of the perineum, scrotum, groin, pubis or sacrum. In the morning, patients note adhesion of the outer part of the urethra. Often, prostatitis leads to an increase in the number of urination at night.
More about prostatitis
This disease is characterized by inflammation of the seminal vesicles in men, which usually develops against the background of prostatitis or epididymitis. The clinic of vesiculitis is very modest: men complain of pain in the pelvis, discomfort and a feeling of fullness in the perineum, mild soreness in the groin, sacrum and testicles. Sometimes discomfort during urination is possible. Chronic vesiculitis disrupts sexual function - erectile weakness and early ejaculation occur. As a rule, vesiculitis is the result of a mixed infection.
Epididymitis
This disease is characterized by inflammation of the tissues of the epididymis. Epididymitis develops against the background of urethritis, prostatitis or vesiculitis. It can be acute, subacute and chronic. Pathology may be accompanied by the following clinical signs:
- redness of the skin of the scrotum;
- the scrotum on the affected side is hot to the touch;
- a tumor-like formation is palpated in the scrotum;
- violation of sexual function;
- deterioration in sperm quality.
More about epididymitis
Tests to detect urinary infection
To correctly diagnose a genitourinary infection, the doctor resorts to questioning, examination, palpation and listening, as well as instrumental and laboratory methods. During the questioning, the specialist finds out in detail all the patient's complaints, the duration of the symptoms, their characteristics, connection with any actions, etc. Then he examines the patient's urinary organs, noting all the characteristics. Further, the patient can be referred for ultrasound, cystoscopy, ureteroscopy, computed tomography, etc.
One of the most important diagnostic tools is laboratory tests. To detect a genitourinary infection, it is necessary to pass a general and special (Nechiporenko test, three-glass, etc.) urinalysis, a complete blood count, blood biochemistry and a smear of the discharge of the urethra, vagina or rectum. A smear can determine the type of pathogen in the case of gonorrhea, trichomoniasis or syphilis. If these tests are not enough to determine the causative agent of the infection, then resort to the following methods:
- Serological reactions (RSK, MRP, RPGA, etc.);
- enzyme immunoassay (ELISA);
- Polymerase chain reaction (PCR);
- Bacteriological seeding on the environment;
- radioimmunoassay;
- Immunofluorescence reaction;
- The test is a provocation.
These techniques allow you to identify the type of causative agent of the genitourinary infection, determine its sensitivity to antibiotics, on the basis of which the doctor will be able to prescribe an effective treatment.
Principles of treatment
Therapy of genitourinary infections has several aspects:
1.
It is necessary to use etiotropic therapy (drugs that kill the microbe pathogen).
2.
If possible, use immunostimulating drugs.
3.
It is rational to combine and take a number of drugs (for example, painkillers) that reduce unpleasant symptoms that significantly reduce the quality of life.
The choice of a specific etiotropic drug (antibiotic, sulfanilamide, uroantiseptic) is determined by the type of microbe-causative agent and the characteristics of the pathological process: its severity, localization, extent of the lesion. In some complex cases of mixed infection, surgery will be required, during which the affected area is removed, since the microbes that caused the pathological process are very difficult to neutralize and stop the further spread of the infection. Depending on the severity of the urinary tract infection, drugs may be taken by mouth, intramuscularly, or intravenously.
In addition to systemic antibacterial agents, in the treatment of genitourinary infections, local antiseptic agents (potassium permanganate solution, chlorhexidine, iodine solution, etc.) are often used, which treat the affected surfaces of organs.
If there is a suspicion of a severe infection caused by several microorganisms, doctors prefer to administer intravenous strong antibiotics - Ampicillin, Ceftazidime, etc. If urethritis or cystitis occurs without complications, then it is quite enough to take a course of taking Bactrim or Augmentin tablets.
When a person is re-infected after a complete cure, the course of treatment is identical to the course for primary acute infection. But if we are talking about a chronic infection, then the course of treatment will be longer - at least 1.5 months, since a shorter period of taking medications does not completely remove the microbe and stop inflammation. Most often, re-infection is observed in women, therefore, representatives of the weaker sex are recommended to use antiseptic solutions (for example, chlorhexidine) after sexual contact for prevention. In men, as a rule, the causative agent of the infection remains in the prostate for quite a long time, so they are more likely to have relapses rather than re-infections.
Drugs that are often used to treat major genitourinary infections in men and women, and which have a good therapeutic effect, are presented in the table:
Genitourinary infection | Medicines for treatment |
Urethritis | Local: antiseptics (potassium permanganate solution, Miramistin, Protargol, Vagotil) and immunomodulators (Polyoxidonium, Cycloferon). |
Inside: antibiotics (Amoxiclav, Abaktal, Ciprofloxacin), immunomodulators (Flogenzym, Urovaxone), homeopathic (Canephron N, Gentos, Cyston). | |
Cystitis | Antibiotics and uroantiseptics: Biseptol, Amosin, Negram, Macmirror, Nitroxoline, Cedex, Monural. |
Painkillers: Buscopan, No-shpa, Spazmotsistenal. | |
Phytopreparations: Canephron N, Cyston. | |
Pyelonephritis | Antibiotics: Ampicillin, Amoxicillin, Cefalexin, Cefuroxime, Biseptol, Gentamicin, Imipinem, Ciprofloxacin. |
Phytopreparations: Canephron N, Cyston. |
Healing Control
After a course of treatment for any infectious pathology of the genitourinary organs, it is necessary to make a control bacteriological culture of urine on the medium. In the case of chronic infection, seeding should be repeated three months after the end of the course of therapy.
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Infections of the genitourinary system in women are pathological effects caused by specific harmful microorganisms. Diseases of the urinary tract are characterized by inflammation, which is easy to cure in the initial stage, or if the signs are ignored, it becomes chronic. Which doctor treats diseases? The answer depends only on the scope of the genitourinary system and its stage. It can be a therapist, urologist, gynecologist, infectious disease specialist and even a surgeon.
Chapter 9Chapter 9
9.1. pyelonephritis
Pyelonephritis- an infectious and inflammatory disease of the kidneys with a primary lesion of the pyelocaliceal system, tubulointerstitial tissue and subsequent involvement of the glomerular apparatus in the process.
Epidemiology. Pyelonephritis is the most common inflammatory disease of the urinary system: it accounts for 65-70% of cases. In adults, pyelonephritis occurs in one person in 100, and in children - in one in 200. Most often, the disease develops at the age of 30-40 years.
Young women suffer from pyelonephritis more often than men. This is due to the anatomical and physiological characteristics of the urethra in women. The female urethra is much shorter, located next to the vagina and rectum, making it easier and faster for the infection to penetrate through it into the bladder, and then into the upper urinary tract and kidneys. In a woman's life, there are three periods of increased risk of urinary tract infection. The first - at birth, during the passage through the infected birth canal of the mother; the second - during defloration and the third - during pregnancy.
Men more often develop secondary pyelonephritis, caused by anomalies of the genitourinary system, narrowing of the ureters, urolithiasis, benign prostatic hyperplasia, etc.
Etiology and pathogenesis. The causative agents of pyelonephritis can be endogenous(internal) or exogenous(penetrating from environment) microorganisms. The most common are Escherichia coli, Proteus, Staphylococcus, Enterococcus, Pseudomonas aeruginosa and Klebsiella. Perhaps the development of pyelonephritis with the participation of viruses, fungi, mycoplasmas.
Microorganisms enter the kidney in three ways.
Ascending, or urinogenic (urina- urine), the path is most common in children. In this case, microorganisms enter the kidney from the lower urinary tract with a reverse flow of urine, that is, in a pathological condition called VUR.
ascending path- along the wall of the ureter into the pelvis and kidney. A number of microorganisms have the ability to adhere (stick) and move up the urothelium with the help of special cell structures - fimbria.
In addition, infectious agents can spread upward as a result of inflammatory and destructive changes in the ureteral wall.
With the localization of the primary inflammatory focus in any other organ (skin, tonsils, nasopharynx, lungs, etc.), microorganisms enter a healthy kidney hematogenous by, that is, with the blood flow, and cause a violation of microcirculation in it and the development of an infectious-inflammatory process. Factors predisposing to the development of hematogenous pyelonephritis can be: a circulatory disorder in the kidney and a violation of the outflow of urine. Microorganisms brought in by blood settle on the vascular loops of the renal glomeruli, leading to inflammatory changes in the vascular wall, destroy it, penetrate into the lumen of the renal tubules and are excreted in the urine. An inflammatory process develops around the formed infectious thrombi.
Most often, pyelonephritis develops in the hematogenous and urinogenic pathways.
The development of the disease is facilitated by predisposing factors, which are divided into general and local. To general include violation of the state immune system body, stress, hypothermia, hypovitaminosis, severe somatic pathology, diabetes mellitus. local factors are a violation of the blood supply to the kidney and a violation of the urodynamics of the upper urinary tract (anomalies of the kidneys and urinary tract, ICD, trauma, narrowing of the ureters, benign prostatic hyperplasia, etc.). In some cases, the development of pyelonephritis is facilitated by various instrumental and endoscopic methods of investigation (bladder catheterization, urethral bougienage, cystoscopy, ureteral stenting).
Classification. According to the clinical course, there are acute, chronic and recurrent pyelonephritis.
According to the reasons for the occurrence and condition of the patency of the urinary tract, primary(without obstruction) and secondary(obstructive) pyelonephritis, which is much more common, in 80-85% of cases.
By the number of affected kidneys, pyelonephritis can be unilateral and bilateral. Unilateral pyelonephritis is much more common.
There are also anatomical and morphological forms of pyelonephritis: serous and destructive(purulent): apostematous pyelonephritis (Fig. 57, see color insert), carbuncle (Fig. 58, see color insert), kidney abscess, necrotic papillitis.
Sometimes there are such rare forms of the disease as emphysematous pyelonephritis and xanthogranular pyelonephritis.
Pathological anatomy. Morphologically, both primary and secondary acute pyelonephritis can occur as a serous (more often) and purulent (less often) inflammatory process.
At acute serous pyelonephritis the kidney is enlarged, dark red. Due to the increase in intrarenal pressure during the dissection of the fibrous capsule, the parenchyma is edematous, tense, and prolapses through the opened capsule. Histologically, perivascular infiltrates are found in the interstitial tissue. Serous pyelonephritis is characterized by focality and polymorphism of the lesion: foci of inflammatory infiltration alternate
with areas of unchanged (healthy) renal tissue. There is also swelling of the interstitium with compression of the renal tubules. In most cases, phenomena of paranephritis with edema of the perirenal tissue are observed. With timely treatment and a favorable course of the disease, it is possible to achieve a reverse development of the inflammatory process. Otherwise, serous pyelonephritis becomes purulent with a more severe clinical course.
Acute purulent pyelonephritis morphologically manifested as pustular (apostematous) nephritis (Fig. 57, see color insert), kidney carbuncle (Fig. 58, see color insert) or abscess. In the case of penetration of the infection by the urogenous route, significant changes are observed in the pelvis and calyces: their mucous membrane is hyperemic, the cavities are enlarged, and pus is contained in the lumen. Often there is necrosis of the papillae of the pyramids - papillary necrosis. Foci of purulent inflammation can merge with each other and lead to the destruction of the pyramids. In the future, the cortical substance of the kidney is also involved in the pathological process with the development of small abscesses (pustules) in it - apostematous pyelonephritis.
With the hematogenous route of infection, multiple pustules ranging in size from 2 to 5 mm are initially formed in the cortex, and then in the medulla of the kidney. Initially, they are in the interstitium, then they affect the tubules and, finally, the glomeruli. Pustules can be located in the form of single small abscesses or be disseminated, merging into larger inflammatory foci. When removing the fibrous capsule, superficially located pustules are opened. On the cut, they are visible both in the cortex and in the medulla. The kidney is enlarged, dark cherry in color, the perirenal tissue is sharply edematous. Changes in the pelvis and calyces are usually less pronounced than in urogenic purulent pyelonephritis. Merging with each other, small pustules form a larger abscess - a solitary abscess.
Carbuncle kidney is a segmental ischemic inflammatory-necrotic area of the kidney. It is formed as a result of the closure of a blood vessel by a septic thrombus, followed by necrosis and purulent fusion of the corresponding segment of the kidney (Fig. 58, see color insert). Outwardly, it resembles a carbuncle of the skin, by analogy with which it got its name. Often, the carbuncle of the kidney is combined with apostematous pyelonephritis, more often it is unilateral or solitary. The simultaneous development of carbuncles in both kidneys is extremely rare. As with other forms of acute purulent pyelonephritis, the development of purulent paranephritis is possible (Fig. 59, see color insert).
The considered variants of acute purulent pyelonephritis are different stages of the same purulent-inflammatory process. Microscopically, after the active inflammatory process subsides, scar tissue develops in the interstitial tissue at the site of infiltrative foci. When recovering from acute pyelonephritis, wrinkling of the kidney does not occur, since the development of cicatricial changes due to the death of renal tissue is not diffuse, but focal.
9.1.1. Acute pyelonephritis
Symptoms and clinical course. Acute pyelonephritis- This is an infectious-inflammatory disease that occurs with vivid symptoms. The initial clinical manifestations of primary acute pyelonephritis usually occur within a few days or weeks (on average, after 2-4 weeks) after the attenuation of foci of infection in other organs (tonsillitis, exacerbation of chronic tonsillitis, mastitis, osteomyelitis, furunculosis).
The clinical picture of acute pyelonephritis is characterized by general and local symptoms. With primary purulent pyelonephritis and the hematogenous route of infection, the general symptoms of the disease are more pronounced, and with secondary pyelonephritis, local obstructive symptoms come to the fore. In typical cases, a triad of symptoms is characteristic: fever, accompanied by chills, pain in the corresponding lumbar region and dysuric phenomena.
Acute pyelonephritis often begins with general symptoms due to intoxication: headache, weakness, general malaise, muscle and joint pain, fever with chills and subsequent profuse sweating. The severity of these clinical manifestations is different and depends on the severity of the inflammatory process in the kidney.
Purulent pyelonephritis is much more severe than serous, sometimes with the rapid development of urosepsis and bacteremic shock. Chills are amazing with a subsequent increase in temperature to 39-40 ° C and above. After 1-2 hours, profuse sweat appears, and the temperature short term decreases. Chills with a sharp rise in temperature and profuse sweating are repeated daily, several times a day. Purulent pyelonephritis is characterized by a hectic-type temperature with daily fluctuations of up to 1-2 ° C or more, but it can also remain persistently elevated. Repeated hectic temperature increase at certain intervals is due to the appearance of new pustules (in patients with apostematous pyelonephritis) or the formation of a kidney carbuncle.
Local symptoms of acute pyelonephritis - pain in the lumbar region and dysuric phenomena - have varying degrees of severity depending on the nature and severity of the disease. Pain in the lumbar region in one form or another is present in almost every patient. They can be different: from pronounced, in the form of renal colic, to a feeling of heaviness in the area bounded by a triangle, the spine-the place of attachment of the lower rib-conditional line at the level of the lowest point of the bend (arc) of the rib. For these pains, there is typically a lack of connection with movement, body position, however, they are aggravated by deep inspiration, shaking of the body and tapping in the kidney area. Initially, pain in the lumbar region or in the upper abdomen is of uncertain nature and location. Only after 2-3 days they are localized in the region of the right or left kidney, often with irradiation in the corresponding hypochondrium, in the inguinal region, genitals; aggravated at night, by coughing, by moving the leg. In some patients, in the first days of pyelonephritis development, the pain syndrome may be mild or even
absent and appear in 3-5 days. There is pain when tapping on the lumbar region - the so-called positive symptom of Pasternatsky. Soreness and protective tension of the abdominal muscles on the side of the affected kidney are characteristic. If the abscess is localized on the anterior surface of the kidney, the peritoneum may be involved in the inflammatory process with the development of peritoneal symptoms. In such cases, severe pain, combined with symptoms of peritoneal irritation, often leads to an erroneous diagnosis of acute appendicitis, cholecystitis, pancreatitis, perforated gastric ulcer and other acute surgical diseases of the abdominal organs. In these cases, the differential diagnosis is especially difficult if there are no dysuric phenomena and pathological changes in the urine, as is often the case in the first days of the disease. With frequent and painful urination, the diagnosis of pyelonephritis is simplified.
Diagnostics. Examination of patients with pyelonephritis includes the collection of complaints, anamnesis, physical examination, after which they proceed to special diagnostic methods.
At laboratory research in the blood test, there is a pronounced leukocytosis (up to 30-40 thousand) with a significant neutrophilic shift of the leukocyte formula to the left to young forms, an increase in ESR to 40-80 mm / h. However, a clear dependence of changes in the peripheral blood on the severity of clinical manifestations is not always observed: in severe cases of the disease, as well as in debilitated patients, leukocytosis may be moderate, insignificant or absent, leukopenia is sometimes noted.
Characteristic signs of acute pyelonephritis in the study of urine sediment are proteinuria, leukocyturia and significant (true) bacteriuria, especially if they are found simultaneously. False proteinuria in the inflammatory process in the kidney is caused by the breakdown of blood cells when they enter the urine and in most cases does not exceed 1.0 g / l (from traces to 0.033-1.0 g / l). It is represented mainly by albumins, less often by gamma globulins. Leukocyturia (pyuria) - most feature pyelonephritis. It often reaches significant severity (leukocytes cover the entire field of view or are found in clusters) and may be absent only when the inflammatory process is localized only in the cortical substance of the kidney or when the ureter is obstructed. With pyelonephritis, erythrocyturia (microhematuria) can be observed, less often - macrohematuria (with necrosis of the renal papillae, calculous pyelonephritis). The severe course of the disease is accompanied by cylindruria (granular and waxy casts). Bacteriuria is found in most cases, however, like leukocyturia, it is intermittent, so repeated urine tests for microflora are important. To confirm pyelonephritis, only the presence of true bacteriuria matters, which implies the presence of at least 50-100 thousand microbial bodies in 1 ml of urine.
Sowing urine and determining the sensitivity of microorganisms to antibiotics is carried out before, during and after the end of treatment of the patient. In uncomplicated acute pyelonephritis, a control urine culture is performed on the 4th day and 10 days after the end of antibiotic therapy, with
complicated pyelonephritis - respectively on the 5-7th day and after 4-6 weeks. Such a bacteriological study is necessary to identify resistant forms of microorganisms and correct antibiotic therapy during treatment, as well as to determine the recurrence of infection after a course of therapy.
Blood culture with the determination of the sensitivity of microflora to antibiotics is indicated for patients with a clinical picture of sepsis. In general, bacteremia is detected in approximately 20% of all cases of acute pyelonephritis.
An increase in serum creatinine and urea is a sign of renal failure. The level of creatinine and urea in the blood serum should be determined before conducting studies with intravenous administration of radiopaque agents. An increase in the content of urea and creatinine in the blood as a result of impaired renal function is possible with severe purulent pyelonephritis with severe intoxication or a bilateral process. In these cases, liver damage and the development of hepatorenal syndrome are often observed with a violation of protein-forming, detoxification, pigment (with the presence of jaundice), prothrombin-forming and its other functions.
Ultrasound of the kidneys has high accuracy in identifying the size of the kidney, heterogeneity of its structure, deformation of the pyelocaliceal system, the presence of pyonephrosis and the state of the perirenal fatty tissue. Reducing the mobility of the kidney in combination with its increase is the most important ultrasound sign of acute pyelonephritis, and the expansion of the pyelocaliceal system testifies in favor of the obstructive (secondary) nature of the disease.
By using sonography Focal changes (as a rule, hypoechoic areas) are found in the parenchyma of the kidney and in the paranephria, resulting from their purulent lesion.
Plain and excretory urography allows you to determine the cause and level of urinary tract obstruction. In the first 3-4 days, acute pyelonephritis may not be accompanied by leukocyturia. In such cases, the diagnosis of primary pyelonephritis is especially difficult, since there are no signs of a violation of the outflow of urine from the kidney. In such patients, excretory urography with inspiratory and expiratory images on the same film is of great diagnostic value: it allows you to identify the limitation of kidney mobility on the side of the lesion.
CT is the most modern and informative diagnostic method for the study of purulent-inflammatory diseases of the kidneys. CT allows you to determine the cause and level of possible obstruction of the ureter, to detect foci of destruction of the renal parenchyma. The diagnostic value of this method is due to its high resolution and the ability to clearly differentiate normal tissues from pathologically altered ones. The results of CT make it easier for the surgeon to choose the optimal approach for open or percutaneous intervention, in particular for renal carbuncle or perinephric abscess.
If VUR is suspected (for example, in patients with neurogenic bladder or children), voiding cystography is reasonable.
Acute pyelonephritis must be differentiated from diseases that occur with symptoms of general intoxication, high body temperature, and a severe general condition. There may be a picture of an acute abdomen with peritoneal symptoms and local pain, simulating acute appendicitis, cholecystitis, pancreatitis, perforated ulcer of the stomach and duodenum, and others. acute diseases abdominal organs. Acute pyelonephritis, accompanied by severe headache and meningeal symptoms, is sometimes mistakenly regarded as an acute infectious disease (typhoid and typhoid fever, paratyphoid fever, meningococcal infection, etc.), which often gives rise to erroneous hospitalization of such patients in an infectious diseases hospital. In the latent course of acute pyelonephritis, there are difficulties in differential diagnosis with acute or chronic glomerulonephritis, manifested only by an isolated urinary syndrome.
Treatment. Acute pyelonephritis requires treatment in a hospital setting. In identifying the obstructive nature of the disease, it is first necessary to ensure adequate outflow of urine from the affected kidney. Restoring the patency of the ureter can be done by catheterization (Fig. 21, see color insert) or stenting (Fig. 22, see color insert). If it is impossible to pass a catheter through the ureter above the site of its obstruction, percutaneous puncture nephrostomy should be performed. Further treatment consists in the appointment of antibacterial and symptomatic therapy, bed rest, the use of non-steroidal anti-inflammatory drugs and the use of large amounts of fluid.
Empiric antibiotic therapy should include parenteral administration of broad-spectrum drugs that mainly affect the gram-negative flora (fluoroquinolones, cephalosporins, aminoglycosides). In the future, the treatment is corrected taking into account the results of urine cultures and determining the sensitivity of the pathogen to antibiotics. The course of treatment for acute uncomplicated pyelonephritis is 7-14 days.
Quinolones and fluoroquinolones. The drugs of this group are widely used in the treatment of infections of the kidneys and urinary tract. Non-fluorinated quinolones (pipemidic, oxolinic, nalidixic acids) have a lower microbiological activity compared to fluoroquinolones, which limits their use. The most rational for empirical therapy of pyelonephritis are modern fluorinated quinolones: levofloxacin (500 mg 1 time per day), ciprofloxacin (500 mg 2 times a day), ofloxacin (200 mg 2 times a day), etc. They are characterized by broad antimicrobial spectrum and high activity against the main pathogens of pyelonephritis. Fluoroquinolones have good bioavailability, provide high bactericidal concentrations in the urine and in the renal parenchyma.
Cephalosporins- one of the most extensive classes of antibiotics, characterized by high efficiency and low toxicity. In case of uncomplicated mild pyelonephritis, it is sufficient to use oral forms of cephalosporins: cefuroxime axetil (500 mg 2 times a day),
cefixime (400 mg once a day). For the treatment of complicated urinary tract infections, parenteral forms are used (cefuroxime, cefotaxime, cefepime, ceftriaxone).
Aminoglycosides(gentamicin, amikacin, neomycin, tobramycin) are active against most pathogens of pyelonephritis, but in clinical practice they should be used with caution, usually in a hospital setting. The drugs of this group have potential oto- and nephro-toxicity.
Carbapenems(imipenem, meropenem) are considered as reserve drugs for the ineffectiveness of first-line antibiotics.
One of the important components of treatment is therapy aimed at increasing immunity and improving the general condition of the body. Among immunomodulators, Wobenzym, Lavomax, Echinacea preparations (immunal, etc.) are used.
Complex treatment of both acute and chronic pyelonephritis includes the appointment of phytouroseptics that have a diuretic, antibacterial, anti-inflammatory, astringent and tonic effect (cowberry leaf, bearberry, St. John's wort, kidney tea, birch buds, juniper berries, etc.).
As a rule, acute pyelonephritis with timely treatment proceeds favorably. After 3-5 days, the temperature decreases, the manifestations of intoxication and pain in the lumbar region decrease, the blood picture improves. Within 7-10 days, bacteriuria and leukocyturia are practically eliminated. Absolute recovery occurs in 3-4 weeks.
Forecast. Acute serous pyelonephritis in most cases ends in recovery. The success of treatment is determined by timely prescribed antibiotic therapy and ensuring adequate outflow of urine from the kidney in the obstructive form of the disease. They impede the final recovery and contribute to the transition of acute pyelonephritis to chronic late-started, insufficiently active and prematurely completed treatment; resistance of microflora to antimicrobial drugs; the presence of severe concomitant pathology that weakens the body's defenses, etc. In such cases, pyelonephritis acquires a chronic course with the subsequent development of chronic renal failure. At purulent forms of the disease the prognosis is unfavorable and depends on the timeliness of the performed surgical intervention.
After the treatment of acute pyelonephritis, dispensary observation and the appointment, if necessary, of anti-relapse treatment are necessary. This is due to the risk of the disease becoming chronic, which is observed in 20-25% of cases.
9.1.2. Chronic pyelonephritis
In most cases, it is a consequence of acute pyelonephritis. The main reasons for the transition of the disease into a chronic form are:
■ inadequate and untimely treatment of acute pyelonephritis;
■ violation of the outflow of urine from the cavitary system of the kidney with KSD, strictures of the ureter, VUR, benign prostatic hyperplasia, nephroptosis, etc.;
■ the transition of bacteria into L-forms, which can be in an inactive state in the renal tissue for a long time, and with a decrease in immunity, go into the initial state, causing an exacerbation of the inflammatory process;
■ common concomitant diseases that cause weakening of the body - diabetes, obesity, diseases of the gastrointestinal tract, etc.;
■ immunodeficiency states.
There are frequent cases of chronic pyelonephritis in childhood (especially in girls). A typical variant is the manifestation of an acute form of the disease, which, for various reasons, is not completely cured, but acquires a latent course. In the future, various acute inflammatory diseases can cause exacerbation of pyelonephritis with a typical clinical picture. Over time, its course becomes undulating. Thus, long-term chronic pyelonephritis with periodic exacerbations each time involves more and more new areas of the renal parenchyma in the pathological process. As a result, each affected area is subsequently replaced by scar tissue. There is a deformation of the parenchyma and pyelocaliceal system of the kidney, a decrease in the size (wrinkling) of the organ with the development of functional failure.
Depending on the activity of the inflammatory process, the following phases of the course of chronic pyelonephritis are distinguished.
1. active phase. The clinical picture is as in acute pyelonephritis. Leukocytes, bacteria are found in the urine, in the blood test - signs of an inflammatory process in the body, an increase in ESR. In the treatment of chronic pyelonephritis, and sometimes without it, the acute phase passes into the next - latent.
2. latent phase. Clinical manifestations are scarce or absent. There may be general symptoms in the form of weakness, subfebrile condition, fatigue, decreased performance, loss of appetite, unpleasant taste in the mouth, discomfort in the lumbar region, that is, symptoms characteristic of a sluggish infectious and inflammatory process, when there are minimal signs of intoxication.
3. remission phase means clinical recovery and implies the absence of any manifestations of the disease.
The clinical course of chronic pyelonephritis depends on many factors, including localization in one or both kidneys, the prevalence of the inflammatory process, the presence or absence of an obstruction to the outflow of urine, the effectiveness of previous treatment, and the nature of concomitant diseases. The greatest diagnostic difficulties are presented by chronic pyelonephritis in the latent phase or during remission. In such patients
pain in the lumbar region is insignificant and intermittent, aching or pulling. Dysuric phenomena in most cases are absent or are observed occasionally and are not very pronounced. Body temperature is normal or subfebrile.
The long course of chronic pyelonephritis leads to scarring of the renal tissue and the development of chronic renal failure. Patients complain of increased fatigue, decreased performance, loss of appetite, weight loss, lethargy, drowsiness, recurrent headaches. Later, dyspeptic phenomena, dryness and peeling of the skin join. The skin acquires a peculiar grayish-yellow color with an earthy tint. The face is puffy, with constant pastiness of the eyelids; the tongue is dry, coated with a dirty brown coating, the mucous membrane of the lips and mouth is dry and rough. Symptomatic arterial hypertension develops in 40-70% of patients with chronic pyelonephritis as the disease progresses with an outcome in kidney shrinkage. Approximately 20-25% of patients have it already in the initial stage of the disease. Antihypertensive therapy in the absence of etiotropic treatment is ineffective.
For the later stages of chronic pyelonephritis, polyuria is characteristic with the release of up to 2-3 liters or more of urine during the day. Cases of polyuria reaching 5-7 liters per day are described, which can lead to the development of hypokalemia, hyponatremia and hypochloremia. Polyuria is accompanied by pollakiuria and nocturia, hypostenuria. As a result of polyuria, thirst and dry mouth appear.
Diagnostics. Clinical and laboratory signs chronic pyelonephritis are most pronounced in the acute phase and are insignificant in the latent phase and during remission. An exacerbation of the disease may resemble acute pyelonephritis and be accompanied by a similar clinical picture with relevant laboratory data.
Proteinuria and leukocyturia may be mild and intermittent. The concentration of protein in the urine ranges from traces to 0.033-0.099 g / l. The number of leukocytes in repeated urine tests does not exceed the norm, or reaches 6-8, less often 10-15 in the field of view. Active leukocytes and bacteriuria in most cases are not detected. Often there is a slight or moderate anemia, a slight increase in ESR.
Sonographic features chronic pyelonephritis are a decrease in the size of the kidney, deformation of its contours and the pyelocaliceal system, which indicates a wrinkling of the organ.
One of the main methods for diagnosing chronic pyelonephritis is excretory urography. The X-ray picture differs in polymorphism. X-ray signs characteristic of this disease are a decrease in the tone of the calyces, pelvis and upper third of the ureter in the form of their moderate expansion, the appearance of a symptom of the edge of the lumbar muscle (at the point of contact of the pelvis and ureter with the edge m. psoas an even flattening of their contour is observed). Over time, various deformations of the cups develop: they become mushroom-shaped, club-shaped, shift, their necks lengthen and narrow, the papillae smooth out. Approximately 30% of patients with chronic pyelonephritis have Hodson's symptom.
Its essence lies in the fact that if the cups of a pyelonephritically altered kidney are connected on an excretory urogram, a sharply sinuous line will be obtained, which normally should be evenly convex, parallel to the outer contour of the kidney. The disease is accompanied by a gradual decrease in the functioning parenchyma of the kidney, which can be determined using the renal-cortical index - the ratio of the area of the pyelocaliceal system to the area of the kidney.
Renal arteriography is not the main method for diagnosing chronic pyelonephritis, however, it allows you to evaluate the architectonics and features of the blood supply to the affected kidney. A characteristic sign of the disease is a decrease in the number or even complete disappearance of small segmental arteries (a symptom of a burnt tree.)
Radioisotope diagnostics in patients with chronic pyelonephritis, it allows to determine the amount of functioning renal parenchyma, to study the separate function of the kidneys. With the help of static and dynamic scintigraphy, the size of the kidney, the nature of the accumulation and distribution of the drug in it are assessed. With segmental damage to the organ, scintigraphy reveals a delay in the transport of hippuran in the area of cicatricial-sclerotic changes. The method also allows dynamic monitoring of the restoration of kidney function during treatment.
Differential diagnosis. Chronic pyelonephritis must be differentiated primarily from chronic glomerulonephritis, renal amyloidosis, diabetic glomerulosclerosis and hypertension.
Treatment. Chronic pyelonephritis can take the form of a frequently relapsing disease. In this case, long-term use of antibacterial drugs in adequate doses is indicated. When prescribing such therapy, it is necessary to take into account the possibility of the emergence of resistant strains of microorganisms, allergic reactions and individual intolerance to drugs.
The reason for the constant recurrence of infection and the transition of the disease to a chronic form may be a violation of the adequate passage of urine through the urinary tract. Often, chronic pyelonephritis is observed in patients with VUR, narrowing of the ureters of various origins, KSD, obstruction of the bladder neck, benign prostatic hyperplasia, etc. It is impossible to stop the infectious process without restoring the normal outflow of urine from the kidneys.
It is quite difficult to achieve a high concentration of antibiotics in the renal tissue, which explains the frequent recurrence of chronic pyelonephritis, despite long-term treatment. It is necessary to prescribe antibacterial drugs that selectively accumulate in the renal tissue with their subsequent high concentration in the urine. The choice and rotation of antibiotics should be made taking into account regular urine cultures to monitor the effectiveness of treatment and confirm the absence of recurrence of the infection. In the case of reinfection, correction of therapy is required with the periodic administration of appropriate drugs for a long time, sometimes reaching periods of 1 to 3 years. If the urine remains sterile after the first
3-6-month course and within six months after stopping treatment, urine cultures are performed every 3-6 months for the next year, and then annually.
Spa treatment is in demand in the complex therapy of chronic pyelonephritis. The preferred resorts are Kislovodsk, Zheleznovodsk, Truskavets, Jermuk, Sairme. Healing mineral drinking water should have an anti-inflammatory effect, have a diuretic effect, improving renal blood flow and urine filtration. Drinking water from some sources reduces spasm of the smooth muscles of the renal pelvis and ureter. The composition of mineral waters of various sources is heterogeneous. The medicinal waters of the Slavyansky, Smirnovsky and Lermontovsky sources are hydrocarbonate-sulfate-sodium-calcium, which is the reason for their anti-inflammatory effect. Naftusya (Truskavets) - hydrocarbonate-calcium-magnesium mineral water with a high content of naftalan substances - has an anti-inflammatory effect. At the Truskavets resort, mineral water is often combined with ozocerite applications and other methods of physical treatment. Contraindications to spa treatment are general (cardiovascular and cardiopulmonary insufficiency, oncological diseases, etc.) and local (impaired urine outflow requiring surgical treatment, chronic renal failure and pyelonephritis in the active phase) factors.
Forecast in chronic pyelonephritis, it is favorable if the cause that supports the inflammatory process is eliminated in a timely manner (sanation of chronic foci of infection, elimination of urinary tract obstruction, VUR). The long course of chronic pyelonephritis with frequent exacerbations of the infectious and inflammatory process leads to cicatricial wrinkling of the kidneys, the development of arterial hypertension and chronic renal failure.
9.1.3. Pyelonephritis of pregnant women
Pyelonephritis during pregnancy is singled out as a separate nosological group and is characterized as an infectious and inflammatory process of the renal parenchyma and pelvicalyceal system, which develops during pregnancy. In varying degrees, the disease occurs in 1-10% of pregnant women.
Etiology and pathogenesis. The etiological factor is microorganisms that penetrate into the kidney both by the urinogenic, ascending, and hematogenous route in the presence of foci of infection. The mechanism of development of pyelonephritis during pregnancy is due to compression of the ureters by an enlarged uterus. Urostasis is promoted by changes in the hormonal background, a decrease in the tone of the sympathetic nervous system, hypocalcemia. From the 10th to the 30th week of pregnancy, muscle tone and contractility of the ureters decrease, there is an increase in filtration and a decrease in water reabsorption, the formation of more daily urine, which also contributes to the development of hydroureteronephrosis. The above changes create favorable
conditions for the development of infection in the kidney. As a rule, Escherichia coli, Proteus, Klebsiella, Enterobacteria, etc. are detected. The right kidney is most often affected, and the disease can be both unilateral and bilateral.
Symptoms and clinical course. If the inflammatory process is mild, the clinical picture remains poor. There may be aching pain in the lumbar region, pathological changes in the urine. With active inflammation, the clinical manifestations are identical to acute pyelonephritis.
Diagnostics. Urinalysis revealed leukocyturia and bacteriuria. Urine culture is required. Ultrasound scanning reveals the expansion of the ureter and pelvicalyceal system of the kidney, thickening of the parenchyma due to its edema.
Treatment carried out in collaboration with obstetricians and gynecologists. Hospitalization in a specialized institution is recommended. With a pronounced expansion of the cavitary system of the kidney, stenting of the ureter or percutaneous nephrostomy is performed. The installation of a stent, as a rule, is simple and is carried out in the position of the patient on the back, which is important during pregnancy. The use of a stent with an anti-reflux mechanism is recommended.
Antibacterial therapy during pregnancy is associated with the risk of embryotoxic and teratogenic effects of antibiotics, especially fluoroquinolone and cephalosporin series. Therefore, semi-synthetic penicillins are most often used in the treatment of pyelonephritis in pregnant women. In severe cases, cephalosporins may be prescribed. In the presence of destructive forms of pyelonephritis, lumbotomy, decapsulation of the kidney and nephrostomy are indicated.
For the purpose of prevention during pregnancy planning, it is recommended to sanitize all possible foci of infection (treatment of caries, otitis media, etc.). Sexual intercourse during pregnancy is recommended with an empty bladder and with the obligatory use of barrier contraceptives.
Forecast favorable in most cases.
9.1.4. pyonephrosis
pyonephrosis, or purulent kidney- this is the final stage of obstructive chronic pyelonephritis (infected hydronephrosis).
Etiology and pathogenesis. Due to the purulent-destructive process, the kidney tissue completely melts, the organ consists of foci of purulent detritus, cavities filled with urine, and areas of decaying parenchyma. The inflammatory process, as a rule, passes to the surrounding fatty tissue.
Symptoms and clinical course. Pyonephrosis is manifested by dull aching pains in the lumbar region. They can significantly increase during an exacerbation of the inflammatory process. Enlarged soil
Rice. 9.1. Sonogram. Pyonephrosis: the level of purulent urine in the dilated cavitary system of the kidney is determined (arrow)
ka is palpated through the anterior abdominal wall. If the ureter is completely occluded, they speak of closed pyonephrosis. The course of the disease acquires a severe septic character: the patient has hectic body temperature, chills, signs of intoxication - pallor, weakness, sweating. At open pyonephrosis, the patency of the ureter is partially preserved, which ensures the drainage of purulent contents. In such cases, the course of pyonephrosis is less severe. With a bilateral process, chronic renal failure rapidly develops and progresses.
Diagnostics. AT laboratory analysis X characteristic inflammatory changes are present. In the blood test, there is a pronounced leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR. In patients with open pyonephrosis, the urine is purulent, cloudy, with a large amount of flakes and sediment. With closed pyonephrosis against the background of a severe septic picture, changes in the urine may be absent.
With cystoscopy, there is a discharge of pus from the mouth of the affected ureter.
ultrasound allows you to identify a significantly enlarged kidney with thinning of the parenchyma. Characterized by a sharp expansion and deformation of the cavitary system of the organ, the presence in the lumen of an inhomogeneous suspension, detritus, calculi (Fig. 9.1).
On the plain radiograph shadows of calculi can be determined in the pro-
urinary tract sections, enlarged kidney.
On the excretory urograms the release of a contrast agent by a diseased kidney is sharply slowed down or, more often, absent.
CT reveals a significantly enlarged kidney, the parenchyma of which is thinned or is a cicatricial pyogenic capsule. The cavitary system of the kidney is expanded, deformed and is a single cavity separated by septa containing a liquid of heterogeneous composition.
(Fig. 9.2).
Rice. 9.2. CT with contrast, axial view. Large left-sided pyonephrosis is determined (arrow)
Differential diagnosis pyonephrosis is carried out with a festering cyst, tuberculosis and a tumor of the kidney.
Treatment pyonephrosis is exceptionally operative and consists depending on the level of ureteral obstruction in nephrectomy or nephroureterectomy.
Forecast with unilateral pyonephrosis and timely surgical treatment is favorable. After the operation, the patient should be under the supervision of a urologist.
9.2. paranephritis
paranephritis- infectious and inflammatory process in the perirenal adipose tissue.
Epidemiology. Paranephritis is relatively rare. The most common risk factor for the development of paranephritis is KSD with urinary tract obstruction and purulent forms of pyelonephritis (Fig. 59, see color insert). In persons suffering from paranephritis, urinary stones are found in 20-60% of cases. Other risk factors include congenital and acquired anomalies of the urinary system, surgeries and injuries of the urinary tract, and diabetes mellitus.
Etiology and pathogenesis. Paranephritis is caused by staphylococcus, Escherichia coli, Proteus, Pseudomonas aeruginosa, Klebsiella and other types of microorganisms.
There are primary and secondary paranephritis. Primary occurs as a result of infection of the pararenal tissue by the hematogenous route from distant foci of purulent inflammation in the body (panaritium, furuncle, osteomyelitis, pulpitis, tonsillitis, etc.). Its development is facilitated by trauma to the lumbar region, hypothermia and other exogenous factors. Secondary paranephritis occurs in 80% of cases. It develops as a complication of the purulent-inflammatory process in the kidney: in some cases, with the direct spread of pus from the focus of inflammation (kidney carbuncle, abscess, pyonephrosis) to the perirenal tissue, in others (with pyelonephritis) - through the lymphatic tract and hematogenously.
Classification. Depending on the localization of the purulent-inflammatory focus in the perirenal tissue, front, rear, top, bottom and total paranephritis. Most often, posterior paranephritis is observed due to the greater development of fatty tissue along the posterior surface of the kidney. The lesion can be unilateral or bilateral. The inflammatory process develops rapidly, since the perirenal fiber is a favorable environment for the development of infection.
According to the nature of the inflammatory process, acute and chronic paranephritis are distinguished.
Acute paranephritis first goes through the stage of exudative inflammation, which can undergo regression or go into a purulent form. If the purulent process in the perirenal tissue tends to spread, the interfascial septa and pus usually melt
rushes to the places of the lumbar region that have the least resistance. With the further development of the process, it goes beyond the perirenal tissue, forming a phlegmon of the retroperitoneal space. The latter can break into the intestine, abdominal or pleural cavities, into the bladder or under the skin of the inguinal region, spreading along the psoas muscle, and through the obturator opening to the inner surface of the thigh. In recent years, due to the widespread use of antibiotics, paranephritis, especially its common purulent forms, is much less common.
Chronic paranephritis most often occurs as a complication of chronic calculous pyelonephritis or as an outcome of acute paranephritis. It is often the result of surgical interventions on the kidney (as a result of urine entering the perinephric tissue), traumatic injuries of the kidney with the development of urohematoma. Chronic paranephritis proceeds according to the type of productive inflammation with the replacement of perirenal fiber with connective tissue ("armored" paranephritis) or fibrous-lipomatous tissue. The kidney is walled up in an infiltrate of woody density and considerable thickness, which greatly complicates surgical intervention.
Symptoms and clinical course. Acute paranephritis in the initial stage of the disease has no characteristic symptoms and begins with an increase in body temperature to 39-40 ° C, chills, and malaise. Only after three or four days or more do local signs appear in the form of pain in the lumbar region of varying intensity, pain on palpation in the costovertebral angle on the corresponding side. Somewhat later, a curvature of the lumbar spine is detected due to a protective contraction. m. psoas, the characteristic position of the patient with the hip brought to the stomach and sharp pain when it is extended due to the involvement of the lumbar muscle in the process. Pay attention to pastosity of the skin, local hyperemia, higher leukocytosis of blood taken from the lumbar region on the side of the disease. Obtaining pus during puncture of perinephric tissue is a convincing confirmation of purulent paranephritis, but a negative result of the study does not exclude it. Sometimes paranephritis can mimic appendicitis, subphrenic space abscess, pneumonia.
Diagnostics. Blood analysis detects neutrophilic leukocytosis with a shift of the formula to the left. Sometimes, with erased forms of paranephritis, the count of leukocytes in blood taken from three points (from the finger, lumbar region on the right and left) has diagnostic value.
Urine with primary paranephritis is not changed; in the secondary, changes characteristic of the renal disease that caused it (usually pyuria) are found in it.
Significant assistance in recognizing acute paranephritis is provided radiological methods research. Chest X-ray with upper paranephritis reveals a decrease in the mobility of the corresponding dome of the diaphragm, and often an effusion in the pleural cavity. Plain x-ray of the urinary tract shows scoliosis of the spine in the healthy direction. contours m. psoas on the affected side are smoothed or absent, while on the healthy side they are clearly visible.
Rice. 9.3. Sonogram:
1 - paranephritis; 2 - kidney
excretory urography, performed on inhalation and exhalation, allows you to identify the absence or a sharp limitation of the mobility of the affected kidney. Ultrasound Scan in acute purulent paranephritis, it clearly visualizes the focus of purulent fusion of fatty tissue, and in chronic - its heterogeneous echostructure (Fig. 9.3).
More accurate information can be obtained by using MRI or multislice CT.
Chronic paranephritis is diagnosed using the same methods
tods, which is the acute form, but it is much more difficult to detect it. Therefore, the disease may remain unrecognized for a long time.
Differential diagnosis. It is carried out with a swollen abscess for tuberculosis of the spine, when a plain radiography reveals the destruction of one or more vertebrae in the absence of a temperature reaction. A dense, bumpy tumor-like formation, palpable in the lumbar region with chronic paranephritis, should be differentiated from dystopia, kidney tumor, hydronephrosis, etc.
Treatment. In the early stage of acute paranephritis, the use of antibacterial (fluoroquinolones, cephalosporins, protected penicillins) and detoxification therapy allows recovery in most patients without surgical intervention. Be sure to sanitize other foci of infection and prescribe drugs to increase the body's immune defenses. Purulent forms of the disease are an indication for emergency surgery. With an isolated abscess of the retroperitoneal tissue, its puncture is possible with the evacuation of the contents and drainage. Lumbotomy with rehabilitation of the retroperitoneal space is indicated for a more common process, including for performing kidney surgery for the disease that caused paranephritis.
Treatment of chronic paranephritis includes the appointment of antibiotics in combination with physiotherapy, general strengthening agents and resolving therapy.
Forecast favorable with timely and adequate treatment of the disease. In chronic paranephritis, the prognosis is largely determined by the nature of the underlying disease.
9.3. urosepsis
Urosepsis represents the most formidable complication of inflammatory diseases of the genitourinary system and is characterized by generalization of infection with the development of septicopyemia, bacteremic shock and a high risk
lethal outcome. Urosepsis can be a consequence of acute pyelonephritis, epididymitis, purulent prostatitis.
Etiology and pathogenesis. The mechanism of development of urosepsis is primarily associated with the presence of urinary tract obstruction. As a result, there is an increase in intrapelvic pressure with the development of pelvic-renal refluxes and the penetration of virulent microorganisms into the blood vessels. The entry of a urinary infection into the blood stream is also possible with rough, traumatic catheterization of the bladder, with instrumental studies (urethrocystoscopy), during retrograde ureteropyelography, and endoscopic surgical interventions.
Classification. The following clinical forms of urosepsis are distinguished: acute, subacute, chronic and bacteremic (endotoxic) shock.
Symptoms and clinical course urosepsis correspond to one or another inflammatory disease that led to the development of urosepsis. As a rule, this is a high body temperature, amazing chills, weakness, headache and other signs of intoxication. The skin is pale, petechial hemorrhagic rashes may occur. Confusion is possible.
When examining blood, leukocytosis is determined with a pronounced shift of the formula to the left, an increase in ESR. Urine is purulent. A bacteriological blood test is required to confirm the diagnosis.
The most common clinical manifestation of urosepsis is bacteremic shock. The mechanism of its development is due to the release into the bloodstream of a large number of bacteria from the focus of urinary infection. The endotoxins formed as a result of their decay affect the vascular wall, significantly increasing the lumen of the vascular bed and disrupting microcirculation in organs and tissues.
There are the following stages of bacteremic shock: early stage of clinical manifestations and terminal. The early stage is characterized by a sharp and sudden rise in body temperature to high numbers, chills, and a decrease in the amount of urine. Patients have a decrease in blood pressure, tachycardia, cold sweat. Further, the patient's condition worsens: lethargy, impaired consciousness appear. In this stage, there is a slight decrease in body temperature. In the third stage, irreversible changes develop in the body.
Diagnostics. Examination of patients with urosepsis begins with the identification of the urological disease that caused it. Ultrasound, excretory urography and CT are the most informative methods for diagnosing purulent-inflammatory diseases of the genitourinary organs. The final diagnosis of sepsis is established after three bacteriological blood cultures and a blood test for procalcitonin.
Treatment consists in carrying out urgent resuscitation measures followed by emergency surgical intervention. Depending on the severity of the condition, percutaneous puncture or open nephrostomy or nephrectomy may be performed.
Forecast and prevention. The prognosis for adequate treatment and dispensary observation is favorable. Measures to prevent urosepsis are
in the timely and thorough treatment of patients with acute inflammatory diseases of the genitourinary organs, the timely elimination of the causes that prevent the normal outflow of urine from the kidney, the sanitation of chronic foci of infection.
9.4. RETROPERITONEAL FIBROSIS (ORMOND'S DISEASE)
First retroperitoneal or retroperitoneal fibrosis was described in 1948 by Ormond. Almost always the disease is bilateral. Progressive cicatricial fibrosis of the retroperitoneal tissue leads to compression of the ureters in any area from the pyeloureteral segment to the promontorium. The most common localization of retroperitoneal fibrosis is the level of the IV and V lumbar vertebrae. Sometimes the inferior vena cava and aorta are involved in the inflammatory process.
Etiology and pathogenesis. Ormond's disease is a nonspecific inflammatory process in the retroperitoneal tissue with the formation of dense fibrous tissue. The reasons for the development of this disease are not yet fully understood. There are several theories of its development.
According to inflammatory theory, there is no independent defeat of retroperitoneal tissue and retroperitoneal fibrosis occurs a second time, due to the transition of the infectious and inflammatory process from the renal parenchyma (pyelonephritis) or perirenal tissue (paranephritis), female genital organs (colpitis, endometritis), gastrointestinal tract (pancreatitis, cholecystitis , colitis).
In accordance with trauma theory The trigger for the development of Ormond's disease is traumatic damage to the organs of the retroperitoneal space.
immunoallergic theory implies that non-specific inflammation in the retroperitoneal tissue with the formation of dense fibrous tissue occurs as a result of an autoimmune reaction.
Pathological anatomy. There are three phases of nonspecific inflammation of the retroperitoneal tissue. The first is characterized by eosinophilic, lymphocytic and histiocytic tissue infiltration. In the second phase, connective tissue fibrous changes with gradual collagenosis are formed. Sclerosis and wrinkling of the retroperitoneal tissue with the formation of dense fibrous tissue are observed in the third phase of Ormond's disease.
Symptoms and clinical course. Patients complain of dull, aching pain in the lumbar region, in the corresponding flank of the abdomen. The clinical picture is characteristic of hydronephrosis. Arterial hypertension occurs in 80% of cases. With the progression of bilateral hydronephrosis as a result of obstruction of the ureters, chronic renal failure develops.
Diagnostics. The survey includes general blood tests, urine tests, determination of biochemical parameters (urea, creatinine, electrolytes). Perform Ultrasound, survey and excretory urography, CT and MRI. With help
these studies can reveal signs of retroperitoneal fibrosis and hydroureteronephrosis. Characterized by bilateral obstruction of the ureters at the level of their decussation with the iliac vessels, above which they are dilated, and below are not changed. Dynamic and static scintigraphy kidneys is used to determine their functional state.
Differential Diagnosis Ormond's disease is carried out with hydroureteronephrosis, retroperitoneal inorganic formations and chronic paranephritis.
Treatment. In the early stages, treatment with glucocorticosteroids and other drugs that contribute to the prevention or resorption of scar tissue is carried out. Antibacterial therapy is prescribed. Surgical treatment is indicated for the pronounced development of fibrous tissue and the formation of hydroureteronephrosis. Ureterolysis, resection of the ureter with ureteroureteroanastomosis, isolation of the ureters from the scar tissues of the retroperitoneal tissue by moving them into the abdominal cavity can be performed. With extended strictures - replacement of the ureter with a segment of the small intestine or endoprosthetics.
Forecast favorable with timely treatment and unfavorable in identifying the disease at the stage of bilateral hydronephrotic transformation and chronic renal failure.
9.5. CYSTITIS
Cystitis- an infectious and inflammatory disease of the bladder wall with a predominant lesion of its mucous membrane.
Epidemiology. Women get sick more often than men, in a ratio of 3: 1, which is due to:
■ anatomical and physiological features of the genitourinary system of women (short and wide urethra, proximity of the genital tract and rectum);
■ gynecological diseases;
■ changes in the hormonal background during pregnancy, when taking hormonal contraceptives, in the postmenopausal period (microcirculation disorders leading to a weakening of local immunity, atrophy of the vaginal mucosa, a decrease in the formation of mucus).
In men, this disease is much less common and may be due to inflammatory processes in the prostate gland, seminal vesicles, epididymis and urethra. A common cause of secondary cystitis in men is infravesical obstruction with chronic urinary retention as a result of urethral strictures and tumor diseases of the prostate gland.
Etiology and pathogenesis. The most common cause of cystitis is a bacterial infection. In addition, the causative agents of the disease can be viruses, mycoplasmas, chlamydia, fungi. Most often, in patients with cystitis in the urine, Escherichia coli, Staphylococcus, Enterobacter, Proteus, Pseudomonas aeruginosa, Klebsiella are determined. The leading microbial pathogen in acute cystitis is
coli (80-90% of observations), which is explained by the high pathogenic and adaptive capabilities of this microorganism (adhesion phenomenon, high reproduction rate, production of ammonia, which weakens the immune system and disrupts the function of smooth muscle fibers of the urinary tract).
Ways of penetration of infection into the bladder are as follows:
■ ascending- the most common variant of infection from the external environment through the urethra;
■ descending- infection from the upper urinary tract, kidneys in chronic pyelonephritis;
■ hematogenous- is rare, may occur in the presence of a distant focus of chronic infection, including in the pelvic organs;
■ lymphogenous- observed in diseases of the genital organs: in women - this is endometritis, salpingo-oophoritis, etc., in men - vesiculitis, prostatitis, etc.;
■ contact- possible in the presence of purulent diseases of the organs surrounding the bladder: parametritis, prostate abscess, etc. Direct infection of the bladder can occur in the presence of urinary fistulas, be the result of various instrumental manipulations (bladder catheterization, cystoscopy, etc.).
Risk factors the development of cystitis are as follows:
■ decrease in the overall resistance of the body due to hypovitaminosis, stress, hypothermia, changes in hormonal levels;
■ violation of the outflow of urine from the bladder. In men, the causes of this are benign prostatic hyperplasia, strictures of the urethra, prostatitis. In women, a violation of urodynamics may be due to stenosis (narrowing) of the urethra, ectopia of the external opening of the urethra, fibrosis (growth of dense connective tissue) in the urethra. Various anomalies of the genitourinary apparatus also adversely affect the process of urination and are often accompanied by inflammatory diseases of both the bladder and upper urinary tract;
■ violation of blood circulation in the pelvic organs;
■ traumatic injuries of the bladder mucosa during endoscopic examinations and operations;
■ endocrine diseases (diabetes mellitus) and metabolic disorders (eg hypercalciuria);
■ the presence of stones and neoplasms in the bladder;
■ sexual activity, especially in the presence of hypermobility or ectopic urethra in women.
less common non-infectious (allergic) cystitis. A wide variety of substances can act as allergens: foods (legumes, citrus fruits, nuts), medicines (non-steroidal anti-inflammatory drugs), household and perfume chemicals.
Allergic reactions are also sometimes observed after the use of vaginal tampons and condoms.
Classification. Cystitis is classified according to a number of criteria. By clinical course:
■ sharp;
■ chronic;
■ interstitial.
By involvement of the bladder in the pathological process:
■ primary;
■ secondary, which is a consequence of any disease (infravesical obstruction, trauma, ICD, etc.).
By reason for the development of the disease:
■ infectious;
■ allergic;
■ chemical;
■ radiation, or radiation.
By type of infectious agent:
■ non-specific, in which the cause of the disease is its own conditionally pathogenic microflora;
■ specific, when a specific pathogen is detected (chlamydia, mycoplasma, ureaplasma, trichomonas, tuberculosis, candidiasis).
According to the same factor, cystitis can be divided:
■ bacterial;
■ viral;
■ caused by a fungal infection.
By prevalence and localization of the infectious process:
■ focal (cervical, trigonitis);
■ total, or widespread.
Symptoms and clinical course.Acute cystitis characterized by a sudden, violent onset caused by some provoking factor (hypothermia, endoscopic intervention, trauma), and rapid regression in the case of timely prescribed therapy. The severity of symptoms increases during the first two days.
Patients complain of frequent painful urination, pain in the lower abdomen and the appearance of blood at the end of urination (terminal hematuria, especially characteristic of cervical cystitis). Inflammatory reaction and swelling of the bladder wall are accompanied by irritation of the nerve endings. Even a slight accumulation of urine causes contraction of the muscular wall of the bladder, and the patient feels a very strong urge to urinate. The more pronounced the pathological process, the shorter the intervals between urination. In severe cases, this time period is reduced to 15-20 minutes, which is extremely exhausting for the patient. Characteristic is urgency urinary incontinence, that is, the imperative (imperative) urge to urinate is so strong that the patient loses urine before he can reach the toilet.
Cystitis is accompanied painful sensations in the region of the bladder and perineum of varying degrees of intensity. The pain syndrome is characterized by constancy, which disrupts the habitual life of a person and his rest, since it does not stop even at night.
terminal hematuria- also a very characteristic symptom of the disease. It appears at the end of urination in the form of a clearly visible impurity or even drops of blood. Urine with cystitis loses transparency due to the presence of a large number of microorganisms, blood cells, epithelial cells and salts. It becomes cloudy and acquires an unpleasant odor.
An increase in temperature with cystitis is not observed, which is due to the reduced ability of the bladder wall to absorb substances, including inflammatory toxins. Normally, this mechanism prevents the penetration of nitrogen metabolism products from concentrated urine into the blood.
Severe forms of acute cystitis are extremely rare - phlegmonous, gangrenous, hemorrhagic, ulcerative. They are characterized by severe intoxication, high body temperature, oliguria.
O recurrent course acute cystitis is said when symptoms of the disease appear at least twice in six months or three times in a year. The cause of cystitis in this case is reinfection, that is, re-infection with pathogenic microflora, the source of which is both a nearby focus of chronic infection and a sexual partner. Also, the risk of recurrence is increased by interrupted treatment, uncontrolled use of antibiotics and non-compliance with personal hygiene rules.
chronic cystitis, as a rule, is a consequence of a previous inflammatory or predisposing disease and is secondary. Inflammation of the bladder develops and is maintained as a result of:
■ infravesical obstruction (sclerotic changes in the bladder neck, benign hyperplasia, prostate cancer, narrowing of the urethra, phimosis);
■ ICD (bladder stones);
■ neoplasms of the bladder;
■ Bladder diverticula.
In the absence of the above pathological conditions and the chronic course of cystitis, resistant to ongoing therapy, it is necessary to exclude specific diseases, primarily urogenital tuberculosis.
The clinical symptoms of chronic cystitis repeat those of the acute form. The difference lies only in the degree of their expression. The course of the disease is characterized by periodic exacerbations, which are clinically very similar to acute cystitis and are treated in the same way. It is also possible to have a stable course of chronic cystitis with a minimal set of complaints and constant laboratory signs, such as leukocyturia and bacteriuria.
Diagnostics. The rapid onset of the disease with characteristic symptoms makes it possible to immediately suspect acute cystitis. In clinical and biochemical blood tests, pathological changes, as a rule, are not observed.
Urine cloudy, odorous. In the study, its reaction is often alkaline, a large number of leukocytes and bacteria are always determined, erythrocytes, epithelium, cylinders may be present, false proteinuria is noted, that is, due to the decay of a large number of blood cells.
Bacterioscopy allows you to visually (using a microscope) determine the presence of an infectious agent. More informative urine culture with bacterial culture determination and antibiotic susceptibility testing. The disadvantage of this method is the duration of its implementation, therefore, with a clinically confirmed diagnosis of cystitis, antibiotic therapy with broad-spectrum drugs is started without waiting for the results of the culture.
It is important to note that invasive diagnostic methods, primarily cystoscopy, are contraindicated in acute cystitis. Firstly, this procedure does not carry significant information, secondly, in the presence of acute inflammation, it is extremely painful and, thirdly, it can lead to reinfection and / or aggravate the course of the infectious process. Cystoscopy is possible and indicated for chronic cystitis, it can be used to identify areas of hyperemia, a pronounced vascular pattern (Fig. 19, see color insert), fibrinous overlays, ulcers, leukoplakia, stones, etc.
Differential diagnosis. In acute cystitis, the diagnosis is usually beyond doubt. Chronic cystitis, especially in cases of the absence of characteristic clinical symptoms and treatment failure, should be differentiated primarily from tuberculosis and bladder neoplasms.
The hallmarks of tuberculous cystitis are the acid reaction of urine and the absence of microbial growth when it is sown on ordinary media. Repeated microscopy of the urine sediment for Mycobacterium tuberculosis and its inoculation on special media are necessary. The most characteristic symptom of neoplasms of the bladder is total painless macrohematuria. The diagnosis can be established by sonography, CT and cystoscopy with a biopsy of the bladder wall.
Treatment. Therapeutic tactics for acute cystitis is to prescribe antibiotic therapy, rest is recommended, plentiful drink, heat on the lower abdomen, spicy and extractive dishes are excluded from the diet.
Currently, there are a number of effective schemes antibiotic therapy depending on the duration of admission: single dose, three-day and seven-day courses. The clinical effectiveness of short-term courses of treatment for women of reproductive age has been proven.
The best single use drug is fosfomycin (monural). It is a broad-spectrum antibiotic effective against Escherichia coli, Staphylococcus aureus, Proteus, Pseudomonas aeruginosa, Klebsiella, etc. Microflora resistance to this drug is negligible. During treatment uncomplicated cystitis shows a single dose of 3 g of phosphomycin, the effect of which lasts for 5 days. Its use is justified in case of bacteriuria of pregnant women, as well as as a prophylaxis before invasive studies (cystoscopy) and surgical interventions. A single dose of levofloxacin at a dose of 250 mg also has a good effect; the cure after it reached 95% of patients.
More long course antibiotic therapy is indicated in the treatment of cystitis in patients with risk factors for recurrence and chronic infection. These should include:
■ acute cystitis in men;
■ cystitis in women over 65;
■ persistence of clinical symptoms for more than 7 days;
■ pregnancy;
■ diabetes mellitus and other metabolic disorders;
■ use of diaphragms and spermicides.
For these patients, it is most appropriate to prescribe fluoroquinolones, 3rd and 4th generation cephalosporins, and protected penicillins.
From the point of view of a combination of such qualities of drugs as efficacy, low cost and low recurrence, currently the drugs of choice are fluoroquinolones. Possessing a wide spectrum of action and having been present on the pharmacological market for quite a long time, they are still characterized by the lowest level of microflora resistance. Ciprofloxacin, levofloxacin, norfloxacin, and ofloxacin are commonly prescribed from this group. The standard seven-day course of these drugs allows you to completely remove the symptoms of cystitis and eliminate the pathogen.
Dosage of fluoroquinolones for a three-day course: levofloxacin - 500 mg 1 time per day; ciprofloxacin - 250 mg 2 times a day or 500 mg 1 time a day; norfloxacin - 400 mg 2 times a day; ofloxacin - 200 mg 2 times a day.
Cephalosporins well proven in the treatment of urinary tract infections. They are highly effective against almost all Gram-negative (Proteus, Klebsiella, Enterobacter) bacteria, including hospital-acquired strains resistant to many antibiotics, and many Gram-positive (Staphylococcus, Streptococcus) microorganisms. Among the latest generations of oral cephalosporins, cefixime (400 mg 1 time per day or 200 mg 2 times a day) and ceftibuten (400 mg 1 time per day) should be noted.
Semi-synthetic penicillins(Augmentin, Amoxiclav) contain clavulanic acid, which allows to neutralize the enzymatic protection of gram-positive bacteria. The recommended dose is 625 mg 2 times a day for a three-day course of treatment and 375 mg 1 time per day for a seven-day course.
In addition to antibiotics, it should be noted the positive effect uroantiseptics. Representatives of this group are nitrofurantoin (furadonin) and furazidin (furagin). These drugs, being absorbed in the gastrointestinal tract, pass through the urinary tract unchanged, have a low level of resistance to Escherichia coli (1%), in addition, they are cheap. Drugs with low efficiency due to the high level of microflora resistance are co-trimoxazole (biseptol), nitroxoline, nalidixic acid. The resistance of bacteria to these drugs sometimes reaches 90%, but, nevertheless, they are still popular.
Symptomatic therapy. Pain can be relieved by the appointment of non-steroidal anti-inflammatory drugs that have anti-inflammatory and analgesic effects (solpadeine, diclofenac, lornoxicam, etc.). Of the antispasmodics, no-shpa, baralgin, cyste-nal, platifillin, etc. are used.
Rice. 9.4. Sonogram. Interstitial cystitis: deformation and thickening of the bladder wall (1), decrease in its capacity (2), expansion of the ureter as a result of cicatricial lesions of the mouth (3)
The criteria for the cure of cystitis are the complete absence of clinical symptoms, the absence of leukocyturia and the growth of bacterial colonies during urine culture after the end of antibiotic therapy. A control general analysis and urine culture for microflora should be taken at least a week after antibiotics are discontinued.
Treatment of chronic cystitis more complex and lengthy. Therapy consists of taking antibiotics.
within 7-14 days, and sometimes several weeks. It is especially important to eliminate the cause of the chronic infectious and inflammatory process, to sanitize the foci of chronic infection and correct the immunodeficiency state.
In the prevention of cystitis, an important role is played by personal hygiene, timely treatment of inflammatory diseases and urodynamic disorders, prevention of hypothermia, adherence to asepsis during endovesical studies and bladder catheterization.
Forecast with timely and proper treatment of acute cystitis favorable. Cystitis is not a cause of death, with the exception of gangrene of the bladder. Untimely and irrational treatment of acute cystitis contributes to its transition to a chronic form, in which the prognosis is less favorable.
Interstitial cystitis is a special form of chronic non-specific inflammation of the bladder with cicatricial degeneration of its wall and the development of microcystis. It is characterized by sterile urine cultures and lack of effect from antibiotic therapy.
Diagnostics is based on ultrasound, which determines the small capacity of the bladder, the deformation and thickening of its walls, the expansion of the distal ureters (Fig. 9.4).
Essential for the diagnosis are the test with potassium chloride, a comprehensive urodynamic study and cystoscopy with a biopsy of the altered bladder wall.
Treatment consists in the appointment of antihistamines, antidepressants, instillations of heparin, dimethyl sulfoxide and hyaluronic acid. With microcystis, surgical treatment is indicated, which consists in excision of the cicatricial-wrinkled bladder with its replacement with a detubularized section of the intestine - augmentation cystoplasty.
Forecast with interstitial cystitis in terms of maintaining the bladder is unfavorable. A long course of interstitial cystitis leads to microcystis and requires surgical treatment - replacing it with a section of the ileum on the mesentery.
9.6. URETHRITIS
Urethritis- inflammation of the urethra. Due to the anatomical and physiological features, it practically does not occur as an independent disease in women, and the urethra is involved in the pathological process during inflammation of nearby organs (cystitis, suppuration of the paraurethral glands, etc.).
The disease occurs mainly in people of reproductive age.
Etiology and pathogenesis.The vast majority of urethritis is sexually transmitted. The incubation period can range from several hours to several months. A significant role in the pathogenesis of urethritis is played by the state of the macroorganism. Contributing local factors are hypo- and epispadias, narrowing of the urethra.
Classification. Distinguish non-specific and specific(gonococcal) urethritis. Gonococcal urethritis is caused by microorganisms Neisseria gon-orrhoeae(gram-negative intracellular diplococci).
Urethritis may be primary and secondary. In primary urethritis, the inflammatory process begins directly from the mucous membrane of the urethra. With a secondary infection, it enters the urethra from an inflammatory focus in another organ (bladder, prostate, vagina, etc.).
Depending on the etiological factor, the following types of urethritis are distinguished.
Infectious urethritis:
■ bacterial;
■ Trichomonas (or caused by other protozoa);
■ viral;
■ Candidiasis (or caused by other fungi);
■ mycoplasma;
■ chlamydia. Non-infectious urethritis:
■ allergic;
■ chemical.
Symptoms and clinical course. There are three main forms of urethritis: acute, torpid and chronic.
Acute gonorrheal urethritis characterized by an abundance of discharge from the urethra. On the head of the penis, they can shrink, forming crusts. The lips of the urethra are red, edematous, its mucous membrane turns outward a little. On palpation, the urethra is thickened and painful. Affected large urethral glands are found in the form of small, sand-like formations. Patients complain of burning and severe pain during urination, especially at its beginning (as a result of stretching of the urethra by passing urine). Symptoms in case of damage to the posterior urethra change: the amount of discharge decreases somewhat, the frequency of urination increases, at the end of them there is a sharp pain, sometimes there is a discharge of blood.
Depending on the virulence of the pathogen and the immune status of the body, urethritis can take a persistent course and become chronic.
form. When inflammation of the seminal tubercle (colliculitis) is attached, ejaculation disorders and hemospermia can be observed. Clinical picture torpid (subacute) and chronic urethritis are similar. As a rule, complaints are mild: symptoms of discomfort, paresthesia, itching in the urethra are characteristic. Scanty discharge is noted in the morning before urination, moderate hyperemia and sticking of the urethral sponges are noted (urethritis with the above symptoms in the first two months of the course is considered torpid, and if it continues to exist, chronic).
Trichomonas urethritis are called Trichomonas vaginalis. The duration of the incubation period of Trichomonas urethritis is 10-12 days. The disease is characterized by the appearance of itching, burning in the area of the external opening of the urethra. In the first portion of urine, when shaken, many small bubbles are found, which is associated with mucus formation. However, the same picture can be observed in the initial phase of allergic urethritis. Then discharges appear, first mucous, then mucopurulent. They may be profuse, have a yellowish color and do not differ from the discharge in acute gonorrheal urethritis. Without treatment, after 3-4 weeks, acute phenomena subside, and urethritis acquires a torpid course. One of the complications may be inflammation of the excretory ducts of the prostate gland.
Mycoplasmic and chlamydial urethritis sexually transmitted and can cause infertility. Pathogens differ from bacteria in the plasticity of the outer membrane. Hence - polymorphism and the possibility of passing through bacterial filters. These urethritis are characterized by the complete absence of any specificity, so the search for mycoplasmas and chlamydia should be carried out for all long-term torpid and chronic urethritis. Patients with chlamydial urethritis may experience extragenital manifestations of the disease (conjunctivitis, arthritis, lesions of internal organs and skin) - the so-called Reiter's syndrome.
Viral urethritis most commonly caused by the herpes virus. The duration of the incubation period varies widely. The beginning of herpetic urethritis is accompanied by a burning sensation, a feeling of discomfort in the urethra. Groups of tense hemispherical small vesicles appear on the skin, after opening them, painful erosions remain. An important feature of the course of herpetic urethritis is its persistent recurrence. The disease can last for decades, aggravating without obvious periodicity.
Fungal (mycotic) urethritis develops as a result of damage to the mucous membrane of the urethra by yeast fungi and is relatively rare. Most often it is a complication of long-term antibiotic therapy, less often it is transmitted from a sexual partner suffering from candidamic vulvovaginitis. Clinical manifestations are very poor.
Complications of urethritis are prostatitis, orchiepididymitis, cystitis, and in the long term - narrowing of the urethra.
The etiology of urethritis always requires clarification, therefore, specific urethritis should be differentiated from nonspecific and other pathological processes in the urethra (polyps, condylomas,
neoplasms and urethral stones). In addition to the above complaints, the diagnosis is established on the basis of a history of sexual contact, microscopic examination of discharge from the urethra (and, if necessary, from the oropharynx and rectum) in a native and Gram-stained smear. In addition to microbes and protozoa, cellular elements (leukocytes, epithelium), mucus are detected, the evaluation of which allows us to clarify the etiological and pathogenetic factors of urethritis. It is obligatory to carry out bacteriological research methods, including sowing the material on special nutrient media.
Currently, reactions are widely used in the diagnosis of urethritis. immunofluorescence and PCR diagnostics. The PCR method is based on the detection of a specific section of the DNA of the desired microorganism. It is highly sensitive (95%) and highly specific (90-100%).
Helps to establish a diagnosis multi-glass samples and ureteroscopy. The latter is contraindicated in acute urethritis, but in torpid and chronic course it turns out to be very informative. Multi-glass samples are of great importance for the topical diagnosis of the inflammatory process (urethritis, prostatitis, cystitis).
The main treatment for urethritis is antibiotic therapy, based on the sensitivity of the identified pathogens to the drugs used. Depending on the form and severity of the disease, antibiotics of various groups are used: semi-synthetic penicillins, tetracyclines, cephalosporins of the 2nd and 3rd generation.
At bacterial urethritis various variants of streptococci, staphylococci, Escherichia coli, enterococci and other microorganisms are found that can exist in the genitourinary system of healthy men and women. Recommended treatment regimens include the use of antibacterial drugs (doxycycline 100 mg 2 times a day for 7 days or azithromycin 1000 mg once). As alternative agents, macrolides (erythromycin, clarithromycin, roxithromycin) or fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) are prescribed. Treatment of gonorrheal urethritis consists of 400 mg of cefexime orally or 250 mg of ceftriaxone as a single dose. Second line drugs are fluoroquinolones. They are used when the pathogen is resistant to cephalosporins.
In treatment Trichomonas urethritis metronidazole (orally 2 g once) or tinidazole (orally 2 g once) is used.
Therapy mycoplasmic and chlamydial urethritis consists in the appointment of azithromycin and doxycycline, and as alternative drugs - roxithromycin and clarithromycin.
At the initial clinical episode herpetic urethritis antiviral drugs are used (acyclovir - 200 mg, famciclovir - 500 mg). With frequent (more than 6 times a year) relapses, suppressive therapy should be started.
Treatment fungal urethritis consists in the abolition of antibacterial drugs and the appointment of antifungal agents (ketoconazole, fluconazole).
Local treatment chronic urethritis includes instillations into the urethra of 0.25-0.5% silver nitrate solution, 1-3% protargol solution or 0.5% dioxidine solution.
Forecast. With timely treatment of acute urethritis, the prognosis is favorable. Chronic urethritis can be complicated by narrowing of the urethra, orchiepididymitis and the development of infertility.
9.7. PROSTATITIS
Prostatitis- inflammation of the prostate gland. This is the most common disease of the genital organs in men of reproductive age.
Etiology and pathogenesis. The main causes of the disease are infectious and non-bacterial inflammatory processes that develop as a result of functional, microcirculatory and congestive disorders. infectious factors there may be pathogenic bacteria, viruses, fungi, etc. The absence of pathogenic flora in the secretion of the prostate gland may be due to the presence of transformed L-forms of bacteria, mycoplasmas, chlamydia, and viruses. Occasionally there are also representatives of anaerobic flora.
Infection can enter the prostate ascending canalicular route with urethritis, cystitis, after endoscopic manipulations. Less commonly, bacteria enter the prostate gland by hematogenous route from purulent foci in the body (boils, carbuncles, sinusitis, etc.).
In development non-bacterial prostatitis Predisposing factors are of great importance - venous stasis and secretion stagnation, since the secret of the prostate gland itself has a bactericidal effect. Provoking factors are constipation, alcohol abuse, long-term sedentary work.
Classification. Several classifications of prostatitis have been proposed. Some of the most popular are clinical and anatomical and National Institute Health (USA, 1995).
Clinical and anatomical classification:
■ acute prostatitis (catarrhal, follicular, parenchymal);
■ prostate abscess;
■ acute hyperemia of the prostate gland (prostatism);
■ chronic prostatitis;
■ granulomatous prostatitis;
■ congestive or congestive prostatitis;
■ prostate atony;
■ prostate sclerosis.
NIH classification:
■ acute bacterial prostatitis;
■ chronic bacterial prostatitis;
■ chronic non-bacterial prostatitis/chronic pelvic pain syndrome:
inflammatory chronic pelvic pain syndrome (leukocytes are determined in the secretion of the prostate, urine and ejaculate);
non-inflammatory chronic pelvic pain syndrome, no signs of inflammation;
■ asymptomatic chronic prostatitis (in the absence of clinical symptoms of the disease, the diagnosis is established according to the histological examination of the prostate).
9.7.1. Acute and chronic prostatitis
Symptoms and clinical course. Acute bacterial prostatitis is rare and does not exceed 2-3% of all inflammatory processes in the prostate gland. The clinical picture of the disease is characterized by a rapid onset and consists of severe pain in the perineum, lower abdomen, sacrum, malaise, fever, often with chills, frequent painful and difficult urination. The patient is pale, tachycardia is observed, there may be nausea. With transrectal palpation, the prostate gland is enlarged, tense, sharply painful, in the presence of an abscess, fluctuation is determined. Sometimes the pains are so severe that patients do not allow to fully conduct this study.
Chronic prostatitis is much more common and occurs in 10-35% of men of reproductive age. Patients complain mainly of pain in the lower abdomen, perineum. Their irradiation is possible in the anus, scrotum, sacrum, inguinal region. Sometimes patients experience a burning sensation in the perineum and urethra. As a rule, there is a clear relationship of pain with sexual intercourse: their intensification during sexual abstinence and relief up to disappearance after coitus. During bowel movements, there may be unpleasant or painful sensations in the pelvic area associated with the pressure of fecal masses on the inflamed gland.
In some cases, dysuric phenomena are noted. Patients complain of frequent, painful urination, imperative urges, a feeling of incomplete emptying of the bladder, less often - difficulty urinating, a weak stream of urine.
A change in the state of the erogenous zones of the small pelvis can lead to an increase in their excitability or, conversely, to inhibition of sensitivity, which may be accompanied by disorders of sexual function.
The course of chronic prostatitis may be accompanied by the release of a small amount of cloudy fluid from the urethra in the morning (prostorrhea). Sometimes there is a clear connection between discharge and the process of defecation. Prostatorrhea is caused by hyperproduction of prostate secretion and impaired function of the locking mechanisms of the distal tubules and the area of the seminal tubercle.
Most of the patients, with a detailed history taking, note an increase in mental and physical fatigue, depression, and psychasthenia phenomena.
Diagnostics is based on the study of the patient's complaints, careful history taking, laboratory and special methods for examining the state of the prostate gland.
One of the most reliable and informative diagnostic methods is digital rectal examination of the prostate. In chronic prostatitis, it is more often of normal size, asymmetric, soft-elastic or doughy consistency, heterogeneous, with areas of cicatricial retractions, moderately painful on palpation. After the massage, the iron becomes softer, sometimes even flabby, which indicates the normal evacuation of the contents into the lumen of the urethra.
After inspection, you must prostate secret for microscopic and bacteriological research. The detection of leukocytes in it, a decrease in the number of lecithin grains indicate an inflammatory process. As a rule, there is an inverse relationship between the number of leukocytes and lecithin grains (which is influenced by the degree of activity of the inflammatory process). The secretion of the prostate may also contain epithelial cells. The prismatic epithelium is exfoliated from the tubular apparatus of the prostate gland, and the secretory epithelium is exfoliated from its acini. The detection of pathogenic microorganisms during bacteriological culture testifies to the bacterial (infectious) nature of the disease. Prostate material can also be obtained from the Stamey-Mears test.
ultrasound of the prostate gland is the third most important after digital examination and microscopy of the resulting secret. It is carried out through the anterior abdominal wall and rectal probe. The most highly informative is transrectal ultrasound. Sonography can reveal asymmetry, changes in the size of the gland, the presence of nodes, formations, inclusions, cavities, calcifications, diffuse changes in the parenchyma.
ureteroscopy allows you to assess the state of the prostatic part of the urethra and the zone of the seed tubercle (Fig. 2, see color insert). The presence of inflammatory processes, cicatricial changes, anatomical defects, narrowing of the lumen of the urethra and some other changes are revealed.
X-ray methods of research are used only in the presence of specific indications (for example, the detection of prostate stones).
Differential diagnosis. Chronic prostatitis should be primarily differentiated from neoplastic diseases and tuberculosis of the prostate, as well as inflammation of nearby organs (vesiculitis, cystitis, paraproctitis). In most cases, laboratory data (tumor markers, bacterioscopic and bacteriological examination of the secretion of the prostate gland for Mycobacterium tuberculosis), ultrasound, CT and MRI, skeletal scintigraphy and prostate biopsy make it possible to establish the correct diagnosis.
Treatment. Etiotropic antibiotic therapy includes broad-spectrum antibiotics that allow to eliminate the entire spectrum of microorganisms identified in the prostate secretion.
Acute prostatitis requires emergency hospitalization with parenteral administration of antibacterial drugs, anti-inflammatory, detoxification, restorative therapy.
At chronic prostatitis long-term multi-course complex treatment is needed, as a rule, on an outpatient basis.
The duration of antibiotic therapy for acute prostatitis is 2-4 weeks, and for chronic - 4-6 weeks. The drugs of choice are fluoroquinolones (levofloxacin, ciprofloxacin - 500 mg orally 1-2 times a day, lomefloxacin, moxifloxacin, ofloxacin - 400 mg orally 1-2 times a day). Second-line drugs are doxycycline and trimethoprim, and reserve drugs are cefotaxime, ceftriaxone, and amikacin.
Non-steroidal anti-inflammatory drugs (diclofenac sodium - orally 50 mg 2 times a day after meals, for 20 days) can eliminate pain. Bioregulatory peptides: prostate extract (vitaprost, prostatilen) is used for 30 days in the form of suppositories at night. Alpha-1-blockers (tamsulosin, alfuzosin, doxazosin) are prescribed to patients with chronic prostatitis for severe urination disorders. In 20-70% of patients with chronic prostatitis, various mental disorders are observed that require correction. In these cases, patients are prescribed tranquilizers and antidepressants.
Patients with chronic prostatitis are recommended sanatorium treatment in Zheleznovodsk, Kislovodsk, Saki, Staraya Russa. They are prescribed turpentine, salt and coniferous baths, as well as mud rectal tampons.
In some cases, to evacuate congestive inflammatory discharge formed in the excretory ducts of the prostate gland, prostate massage can be performed. The restoration of full-fledged microcirculation in the pelvic organs is facilitated by the appointment of physiotherapy, physiotherapy exercises and local procedures (warm microclysters with chamomile, sage).
Patients are shown an active lifestyle, playing sports to eliminate congestion in the pelvic organs and increase the muscle tone of the pelvic diaphragm.
Diet therapy is a complete healthy eating with a high content of B vitamins and ascorbic acid. It is necessary to exclude spicy foods, alcohol.
Regular sex life contributes to the prevention and elimination of congestive phenomena in the prostate gland.
Forecast with timely diagnosis and treatment of the disease is favorable. Acute prostatitis in the absence of adequate therapy can become chronic or lead to the development of an abscess of the prostate gland.
9.7.2. prostate abscess
Etiology and pathogenesis. The causative agents of prostate abscess are predominantly gram-positive microorganisms. Virulent strains can enter the prostate in septicopyemia
from various purulent foci (hydradenitis, furuncle, osteomyelitis, tonsillitis, etc.). Factors predisposing to the development of prostate abscess are hypothermia, intercurrent diseases, immunodeficiency states, congestive phenomena in the prostate. The latter are associated with irregular sexual life, bad habits (alcohol, smoking), diseases of the pelvic organs, accompanied by constipation, as well as long-term sedentary, sedentary work. Prostate abscess may be a complication of acute bacterial prostatitis.
Classification. Distinguish primary and secondary prostate abscess. In the primary infection enters the prostate tissue hematogenously from distant purulent foci. Secondary prostate abscess is a consequence of acute prostatitis.
Symptoms and clinical course. An abscess of the prostate gland is characterized by a clinical picture of an acute purulent inflammatory process. The disease begins with an increase in body temperature to 39-40 ° C, the patient is disturbed by chills, weakness, thirst, intense pain in the lower abdomen, perineum and sacrum. There is difficult, painful urination associated with swelling of the prostate gland and compression of the prostatic urethra, up to acute urinary retention. Characterized by intense throbbing pain in the perineum, then in the rectum. An abscess may break into the urethra, bladder or rectum, which is manifested by a sharp clouding of the urine or purulent discharge during defecation with the simultaneous normalization of body temperature.
Diagnostics based on the history and complaints of the patient. A digital rectal examination of the prostate gland reveals its enlargement, pastosity, soreness and an area of fluctuation, which is a sign of an abscess.
At transrectal ultrasound prostate abscess is detected as a hypoechoic formation with indistinct contours (Fig. 9.5).
CT indicates the presence of a limited fluid formation in the prostate tissue. Its transrectal puncture allows you to accurately establish the diagnosis and is the initial stage in the treatment of the disease.
Differential diagnosis prostate abscess should be carried out primarily with acute paraproctitis and vesiculitis. Correct diagnosis can be made by digital rectal examination, sonography and computed tomography of the pelvic organs.
Treatment. A patient with a prostate abscess is indicated for emergency hospitalization in a hospital. In parallel with the antibacterial, detoxification, restorative therapy under ultrasound control, an abscess is punctured, and then it is opened and
Rice. 9.5. Transrectal sonogram. Prostate abscess (arrow)
drainage by perineal or transrectal access. Perhaps transurethral opening with a resectoscope.
Broad-spectrum antibiotics are used (doxycycline - 200 mg / day; ciprofloxacin - 500 mg / day; ofloxacin - 400 mg / day; ceftriaxone - 500 mg / day). In the postoperative period, to accelerate the resorption of infiltrates and prevent the development of cicatricial-sclerotic changes, lidase (64 units subcutaneously), aloe extract (2.0 subcutaneously), microclysters with antiseptic drugs (10-15% solution of dimexide, dioxidine), rectal suppositories are effective. with anti-inflammatory effect.
Forecast favorable, with timely opening and drainage of the abscess, recovery occurs. Late appeal of the patient for medical help and belated treatment can lead to a life-threatening complication - sepsis.
9.7.3. prostate stones
This is a rare disease in which stones form in the excretory ducts and acini of the prostate.
Etiology and pathogenesis. The reasons for the formation of stones are associated with a prolonged inflammatory process in the prostate gland and a decrease in the concentration of zinc, which keeps calcium salts in a bound state. One of the reasons is the reflux of urine from the urethra in the presence of an obstruction to urination. In the vast majority of cases, prostate stones can be considered as a complication of chronic prostatitis.
Pathological anatomy. The core of the stones consists of amyloid bodies and desquamated epithelium, on which phosphates and calcium salts are layered. Stones of yellowish color, various in size, can be single and multiple. Stone obstruction of the excretory ducts of the acini of the prostate causes stagnation of the secretion of the prostate gland and inflammation. A prolonged inflammatory process can lead to the formation of abscesses, and if the outflow from the seminal vesicles is difficult, vesiculitis develops. The prostate gland gradually atrophies.
Symptoms and clinical course. Patients complain of constant dull pain in the perineum, sacrum, rapid, painful, difficult urination. Possible terminal hematuria, hemospermia. When inflammation is attached, there is an increase in pain during intercourse. Sexual desire and potency are reduced.
Diagnostics prostate stones are based on digital rectal examination, in which there is crepitus in the hard, painful, sometimes flabby prostate.
On the plain radiograph shadows of stones, usually small and multiple, are determined in the projection of the symphysis below the contour of the bladder (Fig. 9.6). On the cystogram the shadows of the stones are also clearly visible below the contour of the bladder. The diagnosis is confirmed and ultrasound.
Differential diagnosis. Changes in the prostate gland (enlargement, thickening, tuberosity) may resemble those in tuberculosis and
Rice. 9.6. Plain radiograph of the pelvis. Prostate stones (arrows)
prostate cancer. Tuberculosis is characterized by the presence of a specific inflammatory process in other organs, and cancer is characterized by an increase in the level of prostate-specific antigen, common symptoms of malignancy.
Treatment. Patients with incidentally identified and uncomplicated prostate stones do not need special treatment. Prostate stones in combination with chronic prostatitis require conservative anti-inflammatory treatment, organ massage is excluded. With abscess formation, surgical treatment is carried out aimed at eliminating the purulent focus and stones (adenomectomy, prostatectomy, TUR of the prostate gland).
Forecast favorable with adequate treatment.
9.8. VESICULITH
Vesiculitis (spermatocystitis)- inflammation of the seminal vesicles.
Etiology and pathogenesis. As an independent disease, vesiculitis is quite rare and can be caused by both nonspecific and specific microflora. The route of penetration of infection in the vast majority of cases is canalicular, less often hematogenous.
Classification. Distinguish spicy and chronic vesiculitis.
Vesiculitis may be primary or secondary, being a complication of urethritis, prostatitis, epididymitis.
Symptoms and clinical course. Acute vesiculitis is accompanied by an increase in body temperature up to 38-39 ° C, malaise, chills, pain in the rectum, perineum, which are aggravated by defecation. Typical symptoms are pain during ejaculation and the appearance of blood in the ejaculate (hemospermia).
Chronic vesiculitis most often occurs as a result of an untreated acute inflammatory process in the seminal vesicles. Patients complain of pain in the perineum, painful erections, hemo- and pyospermia.
Diagnostics. In the case of acute vesiculitis with enlarged, sharply painful seminal vesicles are palpated. After palpation, a large number of leukocytes and erythrocytes are found in the discharge from the urethra (or in the urine). In a three-glass sample, pyuria is detected mainly in the third portion.
Rice. 9.7. Transrectal sonogram. Vesiculitis (arrow)
At ultrasound examination seminal vesicles are easily defined as hypoechoic formations.
In the case of chronic vesiculitis with digital rectal examination over the prostate gland, dense and painful seminal vesicles are found. Important for diagnosis is the detection in the seminal fluid of a large number of leukocytes and erythrocytes, dead spermatozoa after massage of the seminal vesicles. Helps clarify the diagnosis ultrasound(Fig. 9.7).
Differential Diagnosis acute vesiculitis is primarily carried out with acute prostatitis, prostate abscess and paraproctitis; chronic - with chronic prostatitis and prostate tuberculosis. Digital rectal examination, sonography of the prostate gland and computed tomography help to establish the correct diagnosis.
Treatment. Antibacterial therapy is carried out with broad-spectrum drugs. The most effective are fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin), protected penicillins (amoxiclav) and 2-3rd generation cephalosporins (cefuroxime, ceftriaxone, cefotaxime). Analgesics and antispasmodics are often used in the form of suppositories. Laxatives should be used to prevent constipation. Hot microclysters have proven themselves well (with a 10-15% solution of dimexide, decoctions of chamomile, sage).
If acute vesiculitis is complicated by empyema of the seminal vesicles, then emergency surgery is indicated - puncture and drainage of the abscess under ultrasound control.
In chronic vesiculitis, treatment consists of antibiotic therapy, seminal vesicle massage, the use of mud applications on the perineum and mud rectal tampons, hot microclysters with anti-inflammatory drugs.
Forecast with timely treatment and adequate therapy favorable.
9.9. epididymitis
Epididymitis- inflammation of the epididymis.
Etiology and pathogenesis. Epididymitis develops mainly as a result of infection entering the epididymis or hematogenously from foci of purulent infection (tonsillitis, furuncle, hydradenitis, pneumonia, etc.), or canalicularly, along the vas deferens, in the presence of an inflammatory process in the urethra or prostate gland. It is possible to develop epididi-
mita after instrumental (bladder catheterization, urethral bougienage) and endoscopic (urethrocystoscopy) interventions.
Much less often, the cause of epididymitis can be anomalies in the development of the lower urinary tract (diverticula, valves of the posterior urethra) and trauma to the scrotum.
Aseptic inflammation of the epididymis can develop as a result of the selective accumulation of amiodarone in it, a drug used in cardiology practice.
Pathological anatomy. The epididymis is compacted, sharply enlarged due to inflammatory infiltration and edema due to compression of the blood and lymphatic vessels. The tubules of the appendage are dilated and filled with mucus-purulent contents. The vas deferens is thickened, infiltrated, its lumen is narrowed. The membranes of the spermatic cord (differentitis and funiculitis) are also involved in the inflammatory process. Often epididymitis is combined with testicular inflammation - orchitis. In such cases, they speak of epididymo-orchitis.
Classification epididymitis and orchitis next.
By etiology:
■ infectious:
specific (tuberculous, gonorrheal, trichomonas); nonspecific (bacterial, viral, caused by mycoplasmas and chlamydia);
■ necrotic-infectious (with torsion and necrotization of hydatids or testicles);
■ granulomatous (caused by seminal granuloma);
■ post-traumatic. According to the course of the disease:
■ acute (serous and purulent);
■ chronic.
Symptoms and clinical course. Acute epididymitis begins with a rapidly increasing increase in the epididymis, sharp pains in it, an increase in body temperature up to 40 ° C with chills. Inflammation and edema spread to the testicular membranes and scrotum, as a result of which its skin stretches, loses folding, and becomes hyperemic. When the testis is involved in the pathological process (epididymo-orchitis), the boundary between them ceases to be determined. A reactive hydrocele usually develops. Pain radiates to the inguinal region, increases sharply with movement, and therefore patients are forced to stay in bed. Due to untimely started or inadequate therapy of acute epididymitis, the disease can abscess or become chronic.
Chronic epididymitis is characterized by a latent course. Pain is minor. The presence of a knot or limited seal in the head of the epididymis indicates its hematogenous origin. In the process in the tail of the appendage, a connection with a disease of the urethra or instrumental examination should be sought.
Diagnostics in most cases does not cause problems. Diagnosis is based on physical examination and palpation of the scrotum.
An enlarged and edematous corresponding half of the scrotum is determined, its skin is hyperemic, the folding is smoothed. The appendage is significantly enlarged, compacted, sharply painful. When abscessing is determined fluctuation.
The appearance of symptomatic dropsy is confirmed diaphanoscopy and ultrasound. AT blood tests leukocytosis is determined with a shift of the formula to the left, an increase in ESR.
A three-glass urine sample and its bacterioscopic and bacteriological examination allow to clarify the diagnosis.
Differential diagnosis. Nonspecific epididymitis in its clinical picture is sometimes difficult to distinguish from tuberculosis of the epididymis. Of decisive importance is the careful collection of an epidemiological history, the detection of Mycobacterium tuberculosis in the punctate of the epididymis, the presence of a bilateral lesion with the formation of purulent fistulas of the scrotum.
Acute epididymitis must be distinguished from hydatid or testicular torsion requiring urgent surgical treatment and testicular neoplasms. Testicular torsion characterized by the sudden onset of severe pain in the corresponding half of the scrotum, the absence of a temperature reaction, hyperemia of the skin of the scrotum and a significant increase in the epididymis. Testicular neoplasms often develop at a young age. The testicle is significantly enlarged in size, there are no signs of an inflammatory process. Ultrasound of the scrotum organs and the determination of tumor markers in the blood serum help to clarify the diagnosis.
Treatment. A patient with acute epididymitis is shown bed rest. To ensure the rest of the inflamed organ, a suspensorium (tight swimming trunks) is used, in the first 2-3 days - locally cold.
Broad-spectrum antibiotics are prescribed (doxycycline - 200 mg / day; ciprofloxacin - 500 mg / day; ofloxacin - 400 mg / day; ceftriaxone - 500 mg / day). Locally apply compresses with a 10-15% solution of dimexide, electrophoresis with potassium iodide, novocaine. Magnetic laser therapy has proven itself well.
After the inflammatory process subsides, heat is prescribed to the scrotum, diathermy, UHF.
If an abscess of the epididymis occurs, surgical treatment is indicated - opening and draining of the abscess, with massive damage to the organ, epididymectomy is performed.
Forecast with nonspecific epididymitis, it is favorable with adequate and timely treatment. In the case of bilateral chronic inflammation, the disease can be complicated by excretory infertility.
9.10. ORCHITIS
Orchitis- inflammation of the testicle.
Etiology and pathogenesis. The causes and course of the disease are the same as in acute epididymitis. Due to the close relationship and mutual arrangement of the testicle and its epididymis, both organs are often involved in the pathological process - it develops epididymo-orchitis.
The etiology of nonspecific epididymitis may be viral. Viral infections often affect the testicle, and not its epididymis. First of all, this takes place in mumps, leading to severe damage to the testicular parenchyma with the development of infertility.
Pathological anatomy. Anatomical changes are determined by the degree of degradation of the tubular system of the testis. Turgor decreases, and parenchyma hypotrophy increases (up to atrophy of Sertoli cells). The mechanism of development of the pathological process is based on the primary damaging effect on the tissue, leading to edema, tissue death, impaired permeability of the hemotesticular barrier. In connection with the onset of the production of autoantibodies, over time, a violation of the process of spermatogenesis can also occur in a healthy testicle. Even after the elimination of the inflammatory process, the production of autoantibodies by the body continues.
Symptoms and clinical course. The disease begins acutely. Patients complain of sudden pain in the testicle, chills, fever up to 39-40 ° C, testicular enlargement. The pain radiates to the inguinal region, sharply intensifies with movement. The patient's condition worsens due to intoxication, the body temperature remains high, swelling and hyperemia of the scrotal skin appear, and its smoothness disappears. With mumps, orchitis develops on the 3rd-10th day of illness or in the first week of recovery. In 30% of cases, the lesion is bilateral.
When the epididymis is involved in the pathological process (epididymoorchitis), the boundary between the epididymis and the testis ceases to be determined. Reactive dropsy of the testicles develops.
Diagnostics. History data confirming trauma or primary diseases, and the clinical picture contribute to the correct diagnosis. With an isolated lesion of the testicle, its epididymis is not enlarged, the spermatic cord is thickened, the vas deferens is palpated distinctly, without infiltrative changes.
Ultrasound of the scrotum allows you to determine the presence of a reactive hydrocele, swelling of the testicular parenchyma, and with abscessing - hypoechoic areas.
Differential diagnosis. Nonspecific orchitis should be differentiated from torsion, tuberculosis, testicular tumors, and strangulated inguinal-scrotal hernia. The main methods of differential diagnosis, as in epididymitis, are specific tuberculosis tests, the determination of tumor markers and ultrasound of the scrotum.
Treatment. Conservative therapy is the same as for acute epididymitis. If an abscess of the testicle occurs, surgical treatment is indicated - opening the abscess and draining the scrotum. With purulent orchitis, especially in the elderly after prostate surgery, it is advisable to perform an orchiectomy. With orchitis of parotid origin, glucocorticosteroids (prednisolone - 20 mg / day) and acetylsalicylic acid (1.5 g / day) are added to the general anti-inflammatory therapy.
Forecast favorable for nonspecific orchitis. Bilateral orchitis, especially as a complication of infectious mumps in children, can lead to infertility.
9.11. BALANOPOSTIT
Balanitis is an inflammation of the head of the penis. Postit- inflammation of the foreskin. Balanitis and postitis, as a rule, occur simultaneously, so almost always it is a single form of the disease - balanoposthitis.
Etiology and pathogenesis. The causes of balanoposthitis can be infectious and non-infectious agents. In the first case, nonspecific (bacteria, viruses, fungi) and specific (mycobacterium tuberculosis, chlamydia, mycoplasma, Trichomonas) microflora can cause balanoposthitis. The second group consists of non-infectious balanoposthitis: xerotic obliterating balanoposthitis, Zoon's plasma cell balanitis, psoriasis, allergic contact dermatitis, chemical balanoposthitis or balanoposthitis as a result of the introduction of various oily substances under the skin of the foreskin.
The development of the disease is promoted by local factors, primarily congenital or acquired phimosis. In such cases, the impossibility of exposing the head leads to stagnation of the contents of the preputial sac with the decomposition of sebaceous lubricant and urine in it.
Classification. Depending on the clinical course, balanoposthitis is divided into spicy and chronic.
Factors contributing to the development of the disease:
■ non-compliance with hygiene measures in relation to the glans penis and foreskin;
■ phimosis;
■ chronic urethritis;
■ diseases of the glans penis (genital warts, soft and hard chancre, tumors);
■ diabetes mellitus and other immunosuppressive diseases, especially in older men;
■ Traumatization of the glans penis and foreskin (during sexual intercourse, underwear, foreign bodies).
Symptoms and clinical course. The patient is concerned about itching and pain in the head of the penis, pain during urination. On examination, the foreskin is edematous, hyperemic, purulent discharge from the preputial sac is noted. The severity of the inflammatory process can vary from minimal (slight hyperemia and / or spot redness on the head) to the development of severe purulent balanoposthitis with erosion and destruction of the skin.
If treatment is not carried out, then the disease is complicated by lymphangitis, manifested by red stripes on the back of the penis. With the progression of the process, hyperemia becomes continuous, swelling of the organ increases. Inguinal lymphadenitis appears, gangrene of the penis is possible with severe intoxication, fever and the development of urosepsis.
Diagnostics. Complaints and a characteristic clinical picture allow in most cases to immediately establish a diagnosis. used to identify the pathogen bacterioscopic and bacteriological examination, as well as PCR diagnostics.
Differential diagnosis. It is carried out with primary diseases of the glans penis that caused balanoposthitis, primarily with syphilis, genital warts and neoplasms. For this purpose, the presence of a circular narrowing of the foreskin should be eliminated, the preputial sac, the head of the penis should be sanitized and inspected.
Treatment should be aimed at eliminating the primary disease. First of all, you should ensure the free opening of the foreskin and glans penis. It is imperative to carry out hygiene measures - the sanitation of the glans penis and the inner leaf of the foreskin with weak solutions of potassium permanganate, furacilin, chlorhexidine and other antiseptics. Underwear should be changed regularly. Surgical treatment (circumcision) is used for medical reasons with constantly recurrent chronic balanoposthitis.
Forecast favorable with timely and adequate treatment.
9.12. CAVERNITE
Cavernite- inflammation of the cavernous bodies of the penis.
Etiology and pathogenesis. Infection of the cavernous bodies occurs as a result of hematogenous introduction of virulent microflora from existing foci of chronic infection. The penetration of microorganisms is facilitated by damage to the cavernous bodies as a result of household trauma, penile prosthesis, intracavernous injections of various substances, including drugs.
Symptoms and clinical course. The disease begins acutely. Patients complain of pain in the penis, which may be accompanied by erections, fever. The penis increases in size, a dense painful infiltrate is palpated. With belated treatment, an abscess of the cavernous body is formed at the site of the inflammatory infiltrate, which can break into the lumen of the urethra. Together with pus, necrotic masses of cavernous bodies are rejected. In some cases, a septic condition develops.
Diagnosis and differential diagnosis, usually do not cause problems. The diagnosis is established on the basis of characteristic complaints, anamnesis and physical data of the patient. Differentiate acute cavernitis should be primarily with priapism. The hallmarks of acute cavernitis are an increase in body temperature, a palpable infiltrate or an area of fluctuation in the cavernous tissue of the penis, and blood leukocytosis with a shift of the formula to the left.
Treatment. Patients with acute cavernitis should be urgently hospitalized. Parenteral antibacterial detoxification and restorative therapy is prescribed. With its ineffectiveness and the appearance of signs of abscess formation, surgical treatment is indicated, which consists in opening and draining purulent foci of the cavernous bodies. Subsequently, much attention is paid to physiotherapy with the use of absorbable agents (potassium iodide, aloe extract, lidase).
Forecast favorable with timely conservative treatment. With necrosis of the connective tissue septa of the cavernous bodies as a result of abscess formation, which required surgical treatment, the prognosis in terms of maintaining erectile function is unfavorable.
9.13. NECROTISIUS FASCIITIS OF THE GENITAL ORGANS (FOURNIER'S GANGRENE)
Necrotizing fasciitis of the genitals- suddenly starting and rapidly flowing acute anaerobic inflammatory process in the external genital organs with the rapid development of tissue necrosis. The disease was first described by the French venereologist Furnie in 1883. Before the discovery of antibiotics, the mortality rate for it was 40%, and at present it is 3-7%.
Etiology and pathogenesis. In most cases, gangrene of the scrotum is caused by anaerobic microorganisms, such as Clostridium perfringes, Clostridium septicum, Clostridium oedematiens, Clostridium septicum and others. Factors predisposing to its development are: traumatic injuries of the scrotum, immunodeficiency states, dyshormonal disorders, pathology of the blood coagulation system.
Pathological anatomy. The localization of the process in the area of the external genitalia is facilitated by the peculiarity of their anatomical structure. The skin of the scrotum is characterized by a significant friability of the epithelial cover, the epidermis layer is much thinner than in the skin of other parts of the body. The subcutaneous tissue is loose and poorly developed. Moisturizing the skin with discharge of the sebaceous glands, a lot of hair follicles reduce resistance and contribute to the development of inflammation. Multiple thrombosis of small vessels exacerbates the course of the disease. Histological examination in Fournier gangrene reveals multiple necrotic areas, leukocyte infiltration and multiple microabscesses with areas of septic thrombosis.
Symptoms and clinical course. Fournier's gangrene begins with diffuse and rapidly growing swelling of the scrotum. The scrotum significantly increases in size, brightly hyperemic, sharply painful on palpation, areas of subcutaneous crepitus appear. Already on the first day of the disease, blisters with serous-hemorrhagic contents are found on the skin of the scrotum. At the same time, the patient's condition deteriorates sharply, signs of severe intoxication appear. On the 2-3rd day, the blisters open with the formation of erosions, with the development of necrosis of the skin and underlying tissues. Necrosis with a characteristic blackening of the skin can quickly spread to the skin of the penis, groin, limbs, back.
By the end of the first week, the demarcation line is determined and the rejection of dead areas of the skin of the genital organs begins, accompanied by a large amount of purulent discharge of a dirty gray color with gas bubbles and a fetid odor. Swelling of the penis and scrotum can cause difficulty urinating, up to acute urinary retention.
With untimely treatment, the process of melting and complete rejection of the scrotum ends by the 10-12th day. The testicles completely lose their skin, have a bright red color and hang on the spermatic cords. The phenomena of intoxication are reduced. With untimely treatment, the process acquires a generalized form with necrotic skin lesions in many parts of the body, the development of severe anaerobic sepsis, which in most cases leads to death.
Diagnosis and differential diagnosis. The diagnosis of Fournier's gangrene is established on the basis of characteristic complaints, the clinical picture and objective data. At the beginning of the development of the disease before the appearance of areas of skin necrosis, it should be differentiated from epididymo-orchitis and cavernitis.
Treatment. Patients with Fournier's gangrene are subject to emergency hospitalization. Assign parenteral administration of broad-spectrum antibiotics in high doses, detoxification and restorative therapy. Purulent-necrotic tissue areas are widely excised and drained. The wound is washed with oxygen-evolving solutions (3% hydrogen peroxide, 0.5% potassium permanganate solution), and then dressings are applied, richly moistened with these solutions. Polyvalent antigangrenous serum is administered intravenously - 15,000 units. After obtaining data from a bacteriological examination of the discharge, an appropriate serum and a specific bacteriophage are introduced. With a limited area of damage, the skin of the scrotum, due to its exceptional regenerative ability, is restored and has a normal appearance. After excision of a large skin mass with total gangrene, plastic surgery is subsequently performed to replace the skin of the scrotum and penis.
Forecast unfavorable, in about 3-7% of cases Fournier's gangrene ends in death. Timely and adequate treatment leads to recovery.
test questions
1. What is the etiology of chronic pyelonephritis? How is it classified?
2. What is the clinical picture of acute pyelonephritis?
3. Name the main reasons for the transition of pyelonephritis to a chronic form.
4. How is chronic pyelonephritis and pyonephrosis diagnosed?
5. What are the reasons for the development of paranephritis?
6. Give the classification of cystitis.
7. What is the treatment for acute inflammation of the bladder?
8. What factors contribute to the development and maintenance of a chronic infectious and inflammatory process in the bladder?
9. What are the causative agents of urethritis?
10. What is Reiter's syndrome characterized by?
11. What does the etiotropic treatment of urethritis include?
12. How is the clinical course of acute and chronic epididymitis?
13. With what and how is the differential diagnosis of chronic orchitis carried out?
14. What is the treatment of balanoposthitis?
Clinical task 1
A 43-year-old patient complains of general weakness, malaise, fever up to 39°C, chills, pain in the left half of the lower back and abdomen. Sick for 6 days. Three weeks ago I had acute tonsillitis. On examination: the position is forced - the left thigh is brought to the stomach, with its extension, a sharp pain is determined. Palpation in the left osteovertebral angle is also painful. Urinalysis without pathology.
Establish a preliminary diagnosis. What is the plan of examination and tactics of treatment of the patient?
Clinical task 2
Patient, 23 years old. I got acutely ill. Complains of frequent painful urination, pain in the suprapubic region, turbidity of urine, bleeding at the end of the act of urination. Body temperature is normal, objectively - pain in the suprapubic region.