Pyelonephritis

Pyelonephritis

is an infectious inflammatory process in the kidney that primarily affects the pyelocaliceal system of the kidney.
The prevalence of pyelonephritis
in adults is 1 per 100 people;
In children, pyelonephritis is less common - 1:200. The main age of patients with pyelonephritis
is 30-40 years.

According to the frequency of pyelonephritis

ranks second after respiratory tract infections.
Most often,
people aged 30-40 years suffer
from pyelonephritis In young girls, pyelonephritis
sometimes develops soon after the onset of sexual activity.

Classification of pyelonephritis

In Russia it is customary to use the following classifications of pyelonephritis:

According to A. Ya. Pytel and S. D. Goligorsky (1977)

By area affected: unilateral pyelonephritis, bilateral pyelonephritis.
According to the conditions of occurrence: primary pyelonephritis (without initial kidney pathology), secondary pyelonephritis (developing against the background of another kidney or urinary tract disease - urolithiasis, congenital anomalies of the kidneys, prostate adenoma, etc.).
According to the nature of the course: acute pyelonephritis, chronic pyelonephritis.
Along the path of spread of the infectious agent: hematogenous pyelonephritis, ascending (urogenic) pyelonephritis.
According to the patency of the urinary tract: non-obstructive pyelonephritis, obstructive pyelonephritis.

According to N. A. Lopatkin (1992)

Unilateral pyelonephritis, bilateral pyelonephritis.
Primary pyelonephritis, secondary pyelonephritis.
Acute pyelonephritis (serous, purulent, necrotizing papillitis), chronic pyelonephritis (phase of active inflammation, phase of latent inflammation, remission).

Purulent forms of pyelonephritis are distinguished into separate diseases:
apostematous pyelonephritis, kidney carbuncle, kidney abscess, corrugation of the night, pyonephrosis.
Acute pyelonephritis

depending on the measures taken, it either ends in recovery or develops into chronic pyelonephritis.
Chronic pyelonephritis
leads to secondary shrinkage of the kidney or the development of pyonephrosis - a purulent-destructive lesion of the kidneys with the formation of cavities in the parenchyma.

Rare forms of pyelonephritis

are
emphysematous pyelonephritis, xanthogranulomatous pyelonephritis, pyelonephritis in pregnant women, pyelonephritis in the elderly (senile pyelonephritis), pyelonephritis in diabetes mellitus
, etc.

Therapy

Therapy involves the simultaneous elimination of:

stone disease;
calculous pyelonephritis.

For successful treatment, the cause of the disease must be eliminated, i.e. stones and treatment of inflammation.

The goal of therapy is to restore the physiological process of formation and outflow of urine.

The course includes:

Selection of diet and drinking regimen - columns 7 and 7a are used depending on the type of metabolism, mineral water according to the same principle;
drug therapy;
operational methods;
prevention.

Therapy is prescribed taking into account the culture of urine and bacterial flora, the composition and size of the stones, and their location.

Applicable:

antispasmodics Baralgin, No Shpa, Spazmalgon;
preparations for dissolving stones;
diuretics;
antibacterial drugs Nitrofurantoin;
restoratives for the prevention of anemia.

To remove sand and debris:

Diuretics with water (the patient drinks 2 liters of warm liquid, takes antispasmodics and diuretics (Baralgin, Furosemide);
To relieve the manifestations of renal colic during the natural passage of stones, antispasmodics and heat are used;
if the procedure is ineffective, surgical removal by crushing, decapsulation, or stenting is used.

Indications for surgical intervention:

Urine is not released;
medications do not affect;
attacks of severe pain and colic;
separation of blood from the urethra;
stones and sand in one kidney;
purulent complications.

Symptoms of pyelonephritis

Acute pyelonephritis

Pain in the lower back (anterior abdominal wall, costovertebral angle) of a dull, aching nature, low or moderate intensity.
Pain of a paroxysmal nature (for example, with obstruction of the ureter by a stone).
Urinary disorders (dysuria).
Fever up to 38-40°C with chills and profuse sweating.
Thirst, general weakness and malaise.
Decreased appetite.
Headache.
Nausea or vomiting.

In children and elderly patients, pyelonephritis

may proceed atypically. In children, abdominal syndrome (abdominal pain) may occur, and in the elderly, symptoms may be mild or absent altogether.

Chronic pyelonephritis

Dull pain in the lumbar region on the side of the affected kidney.
Slight increase in temperature (only during exacerbation in approximately 20% of patients).
Symptoms may be pronounced only during exacerbations, and may be absent the rest of the time.

Stages of calculous pyelonephritis

The disease has three main stages:

latent;
aggravated;
remission.

During the latent stage of calculous pyelonephritis, the patient does not know that there are hard deposits in his kidney that provoke the development of the inflammatory process. There are no symptoms of the disease during this period. Only a differential blood test (counting immune cells, red blood cells and platelets) can indicate the onset of the disorder, since the number of leukocytes increases due to inflammation. At this stage, sand already appears in the urine, so laboratory testing will also help to recognize the pathology in time.

The acute stage of calculous inflammation of the renal structures is characterized by the appearance of obvious symptoms of pyelonephritis, which cause severe discomfort to the patient. During this period, without timely treatment, the patient's condition will begin to deteriorate, increasing the risk of ureteral obstruction (obstruction), renal failure and other complications.

If the therapy was selected correctly and in a timely manner, the patient enters a period of remission. At this time, there are no symptoms of the inflammatory process, but it is too early to talk about a complete cure, since the health of the kidneys is severely undermined by pyelonephritis and it must be restored and maintained with medication to avoid relapse.

Causes and risk factors for the development of pyelonephritis

Local factors.
Anatomical and functional features of the genitourinary organs.
Urodynamic disorders of the lower and upper urinary tract.
Neurogenic disorders.
Obstructive factor in the presence of a pathogenic infectious agent.
Compression factor (gravid uterus, neoplasms).
Pathogenic microorganisms, infectious and inflammatory processes.
General background that aggravates the development of acute pyelonephritis.
Hormonal status.
Dysbacteriosis.
Backflow of urine from the bladder into the upper urinary tract.
Instrumental methods of examination and treatment.
Chemotherapy.
Eating disorder.
Diabetes.
Alcoholism, smoking, drug addiction.
Immunity disorders, autoimmune diseases.

Pyelonephritis is an infectious and inflammatory process in the kidneys, which can be caused by various pathogenic bacteria that have penetrated the upper urinary tract. Depending on the severity of clinical manifestations and morphological changes in the organ, serous, purulent pyelonephritis, and necrotizing papillitis are distinguished. Changes in the kidneys with purulent pyelonephritis can manifest themselves in the form of apostema of small pustules about 2 mm in diameter), a carbuncle or an abscess. There are many different classifications of pyelonephritis. We believe that N.A. Lopatkin’s classification is the most successful, sufficiently fully reflecting various situations and forms of the infectious-inflammatory process in the kidney. and Rodoman V.E. (1974)

Pyelonephritis can be:

Primary acute, developing in an intact kidney (without developmental anomalies and visible disturbances in the urodynamics of the upper urinary tract).
Secondary acute, arising against the background of diseases that interfere with the passage of urine:
Urolithiasis (UCD)
Stricture (narrowing) of the ureter of various etiologies
Ormond's disease
Vesicoureteral reflux and reflux nephropathy
Adenoma, cancer, prostate sclerosis
Bladder neck sclerosis
Urethral strictures
Neurogenic bladder
MP neoplasms
Pregnancy

Pyelonephritis is classified according to localization:

Unilateral
Bilateral

Stages of acute pyelonephritis:

1. Serous inflammation 2. Necrotizing papillitis 3. Purulent inflammation:

Apostematous pyelonephritis
Kidney carbuncle
Kidney abscess

Epidemiology

Pyelonephritis is the most common kidney disease, occurring at any age and ranking second in prevalence after acute respiratory viral infections. In 33% of patients, purulent-destructive forms of inflammation develop. The incidence of acute pyelonephritis in Russia is 0.9-1.3 million. cases annually, or 100 patients per 100 thousand. Human. Women predominate among patients with acute pyelonephritis. They are 5 times more likely than men to be hospitalized with this diagnosis. There are 11.7 hospitalizations per 10 thousand women, and only 2.4 per 10 thousand men.

Risk factors for developing pyelonephritis

1. Local factors:

Anatomical and functional features of the genitourinary organs
Urodynamic disorders of the lower and upper MPs
Neurogenic disorders
Obstructive factor in the presence of a pathogenic infectious agent
Compression factor (gravid uterus, neoplasms)
Pathogenic microorganisms

2. General background that promotes and aggravates the development of acute pyelonephritis

Hormonal background
Dysbacteriosis
Reverse reflux of urine from the bladder into the upper bladder
Instrumental methods of examination and treatment
Chemotherapy
Eating disorder
Diabetes
Alcoholism or drug addiction
Immunity disorders

Etiopathogenesis

When analyzing the causes of acute pyelonephritis, as well as other diseases of an infectious nature, it is necessary to take into account the type of pathogen and its virulence, factors contributing to infection of the organ or tissues and the nature of the immune response of the macroorganism (Fig. 2).

Pyelonephritis is a disease of a bacterial nature, but without a specific pathogen. It is caused by various microorganisms - bacteria, mycoplasmas, viruses, fungi. The most common causative agent of pyelonephritis is gram-positive and gram-negative opportunistic bacteria, many of which belong to the normal human microflora that populates the skin and mucous membranes. Most often, pyelonephritis is caused by: Escherichia coli, Proteus, Enterobacter, Klebsiella, Pseudomonas aeruginosa, staphylococci (aureus, epidermal, saprophytic), enterococci, etc. Speaking about the type and nature of the infection, it should be noted that currently associations of several microorganisms are often observed, causing pyelonephritis, and rarely only one type of microorganism is determined. The importance of distinguishing uncomplicated and complicated pyelonephritis is justified by the large differences in the causes and mechanisms of their occurrence. The main causative agent of community-acquired uncomplicated forms of pyelonephritis is E. Coli, which is found in approximately 80% of cases. Of the gram-positive microorganisms, saprophytic staphylococcus is most often isolated, which is detected in 10-11% of patients. In complicated forms of pyelonephritis, the proportion of gram-negative bacteria is about 70%, and E. coli is found much less frequently than in uncomplicated infections. The main route of infection of the bladder and kidneys is ascending (from the bladder to the kidneys), urinogenic (through urine). Their hematogenous infection (through blood) occurs rarely - in 3-5% of cases. Normally, microorganisms that colonize the periurethral area and perineum can penetrate in men only into the initial parts of the urethra, which explains the low incidence of pyelonephritis in men. Often one of the conditions for MP infection is a change in the microbial landscape of these areas, when E.coli becomes the leader microbe. The reasons for this phenomenon still remain unclear, although there is a connection with intestinal dysbiosis, vaginal dysbiosis, hormonal imbalance, and in menopausal women - with an increase in the pH of the vaginal environment as a result of estrogen deficiency and with the replacement of the lactobacilli that normally predominate there with various enterobacteria. The entry of microorganisms into the bladder of women is facilitated by the structural features of the urethra (it is short - about 4 cm versus 17 in men and has a larger diameter) and the proximity of the anogenital zone. The reverse flow of urine and the movement of the microorganism along the mucous membrane of the bladder, as well as increased intrarenal pressure, which underlies pyelovenous and pyelolymphatic refluxes, ensure further contamination of the kidney with microorganisms and the progression of the inflammatory process. Simple infection of the bladder and kidneys is not enough for the development of an inflammatory process in them. Both the mucous membrane of the bladder and the kidney structures are easily freed from the infection that has penetrated them, unless additional factors prevent this. The infectious-inflammatory process develops most rapidly in conditions of impaired immunity and difficulty in the outflow of urine from the kidney through the upper urinary tract.

Diagnostics

Acute pyelonephritis is characterized by a classic triad of clinical signs:

Pain in the lumbar region
Fever with high temperature
Characteristic changes in urine analysis (see below)

There are also complaints due to intoxication

General weakness
Headache
Thirst
Nausea
Vomit

Frequent urination is characteristic of ascending acute pyelonephritis without disruption of urine flow through the upper bladder.

Laboratory and instrumental studies

1. A general urine test reveals:

Multiple leukocytes
Possible protein admixture and blood admixture of varying intensity
Bacteria

2. In a microbiological analysis of urine, which should be examined before prescribing antibiotics to a patient, the causative agent of the disease is identified, which makes it possible to prescribe an adequate drug and adjust the treatment.

3. In a general blood test, pay attention to:

Changing the blood formula
Increased ESR

4. A biochemical blood test is carried out to clarify the functional state of the kidneys and liver

5. Ultrasound and Doppler examinations make it possible to diagnose swelling of the parenchyma (kidney tissue) and purulent foci, as well as the degree of blood flow disturbance. The expansion of the pyelocaliceal system indicates a violation of the outflow of urine from the kidney and the secondary nature of the disease

6. Survey urography (X-ray examination) helps to diagnose the presence of stones and their localization

7. Excretory urography (X-ray examination using a contrast agent) determines the condition of the kidneys and bladder, impaired urine outflow

8. Computer and magnetic resonance imaging can reveal:

Purulent destruction of kidney tissue
The degree of circulatory impairment in the kidney
The severity of the disturbance of urine flow through the bladder and its causes.

Treatment

The goal of treatment - the elimination of the infectious-inflammatory process - can only be achieved by restoring the outflow of urine and eliminating the pathogen.

Non-drug treatment For acute pyelonephritis and restored/not impaired urine outflow, the volume of fluid consumed should be 2000-2500 ml/day. It is recommended to use diuretics, fortified decoctions (fruit drinks) with antiseptic properties (cranberries, lingonberries, rose hips). It is impossible to prescribe heavy drinking or large-volume intravenous infusions with concomitant cardiopulmonary failure, arterial hypertension and impaired urine outflow through the bladder. If there is a carbohydrate metabolism disorder (diabetes), the liquid you drink should not contain sugar.

Drug treatment

Acute pyelonephritis without signs of urinary flow disturbance is subject to immediate treatment with antibacterial agents
Acute pyelonephritis, accompanied by a violation of the outflow of urine from the kidneys, begins to be treated by restoring the passage of urine using a ureteral catheter, a stent, or by installing a drainage tube in the collecting system of the kidney (under ultrasound control percutaneously or during open percutaneous surgery), after which antibacterial therapy is prescribed . If you change the sequence of actions, endotoxic shock may develop. Adequate selection of antibacterial therapy is possible only after performing a bacteriological analysis of urine with identification of the pathogen and determination of its sensitivity to various antibiotics. However, in acute pyelonephritis, success directly depends on the time of initiation of treatment and delay is extremely undesirable. In this case, an empirical selection of drugs is appropriate, the nature of which can be adjusted after receiving the answer from a bacteriological study. In any case, SELF-MEDICATION IS NOT ACCEPTABLE!!!!! The choice of medication should always be made by a doctor!

Symptomatic treatment

Aimed at correcting fluid deficiency in the body and reducing symptoms of intoxication. The regimen in each specific case is determined depending on the volume of the lesion and the patient’s condition.

Surgery

Acute secondary pyelonephritis is considered as an indication for emergency surgical treatment:

Catheterization of the ureter and pelvis or installation of a ureteral stent is carried out in case of acute secondary pyelonephritis as an emergency aid to restore the passage of urine or as one of the main measures in the extremely severe general condition of the patient and the impossibility of surgical treatment
Ultrasound-guided percutaneous nephrostomy (PENS) is one of the main methods of urine diversion in acute obstructive pyelonephritis. The method is indicated for patients who are expected to undergo relatively long-term kidney drainage. It allows you to stop acute pyelonephritis and, 3-4 weeks after the inflammation subsides, rid the patient of the cause of pyelonephritis and subsequently normalize the flow of urine through the ureters.

Prevention of pyelonephritis

Avoiding hypothermia
Treatment of focal infectious processes
Treatment of concomitant diseases
Timely treatment of the underlying disease

Acute pyelonephritis is a serious and life-threatening disease! Its treatment is the prerogative of urologists and is performed mainly in inpatient settings. One of the main guarantees of treatment success is the patient’s timely visit to the doctor and earlier initiation of therapy. Chronic pyelonephritis develops in a situation where adequate treatment of the acute inflammatory process has not been carried out or the cause has not been eliminated; this inflammation is supportive. The scope of measures to eliminate chronic pyelonephritis is very variable and is determined individually after a thorough examination. If you suspect acute pyelonephritis, if there are signs of chronic pyelonephritis and you need advice, contact us.

If you need advice, please call +7 or at the address indicated on the contacts page.

Diagnosis of pyelonephritis

Acute pyelonephritis

characterized by a classic triad of signs:

Pain in the lumbar region.
Fever with high temperature.
Characteristic changes in urine analysis.

Patients complain of general weakness, “weakness,” headache, thirst, nausea or vomiting, and frequent urination.

In addition to the clinical examination, the diagnosis of pyelonephritis

includes:

Clinical urine analysis (multiple leukocytes are detected, possible protein admixture and blood admixture of varying intensity).
Biochemical urine analysis.
Urine culture with determination of sensitivity to antibiotics.
Ultrasound of the kidneys, Dopplerography.
Urography, excretory urography (x-ray with contrast).
CT and MRI of the kidneys (assessment of the destruction of kidney tissue, the degree of circulatory disorders, the severity of disturbances in the outflow of urine through the urinary tract, etc.)

Causes of calculous pyelonephritis

The development of calculous pyelonephritis is provoked by urolithiasis:

phosphate stones in the renal pelvis or ureters;
oxalate solid deposits;
urates;
xanthine crystal formations;
cystine stones;
strumina (hard deposits that form during a bacterial infection in the kidneys);
combined stones.

The exact cause of the inflammatory process can only be found out during laboratory and instrumental diagnostics. Further treatment depends on the type of solid deposits identified, since stones have different chemical properties and unequal ability to dissolve.

Prevention

The acute form of pyelocystitis can become chronic in the absence of adequate treatment. Both medical care and self-prevention can prevent this. The latter plays an important role in preventing the occurrence and chronicity of diseases, so it should not be neglected.

Each age has its own recommendations for maintaining the health of the genitourinary system. There are many general points, but some features of prevention are important and should not be overlooked.

To prevent the occurrence of pyelocystitis and its progression, adults should adhere to the following recommendations:

use protection during sexual intercourse;
Be treated only under the supervision of a doctor;
for women using contraceptive diaphragms, it is possible to take prophylactic medications as prescribed by a doctor;
Penile hygiene is important for men: with phimosis and uncircumcised foreskin, it is necessary to take water procedures 1-2 times a day, and the penis does not have to be washed with soap, it is enough to remove accumulated smegma with warm water;
It is worth monitoring your nutrition and the presence of sufficient vitamins and minerals in your diet;
It is necessary to avoid hypothermia, which contributes to the exacerbation of infectious processes.

To prevent the occurrence of pyelocystitis, protection should be used during sexual intercourse.

To prevent pyelocystitis in a child, follow these tips:

Take care of your intestinal health. Infrequent bowel movements can lead to stagnation of blood in the colon and bladder, which contributes to the development of infection. Eating decoctions of prunes, fermented milk products, beets and wholemeal bread will help avoid this.
Take care of your child's intimate hygiene. Irregular water procedures can be the main cause of inflammation. Use a personal towel to dry your child to prevent possible exposure to germs found in adults.
Try to prevent your child from getting hypothermic.
Seek help from a doctor promptly. Infections of the genitourinary system can occur as a result of other untreated diseases.
Give your child more vitamins to maintain immunity, especially in the autumn-winter period.

Varieties and symptoms

It is customary to distinguish between two fundamental forms of calculous pyelonephritis - acute and chronic. The first type is characterized by distinct symptomatic manifestations, a rapid course, as well as serous or purulent inflammation of the kidneys. As a result of the progression of the process, the acute form can become chronic. Chronic calculous pyelonephritis does not have severe symptoms, is sluggish and difficult to cure. It may worsen as a result of the formation of new stones and their relocation. The inflammatory process develops due to two pathways: hematogenous and urinogenic mechanisms. In the first option, pathogenic agents are introduced into the kidneys due to their circulation through the bloodstream. The urinogenic mechanism is caused by infectious diseases of the urinary tract. There are three main stages of formation of both acute and chronic types of calculous pyelonephritis:

The latent or latent period is characterized by minimal symptoms, is not manifested by a feeling of pain and the outflow of urine is not impaired.
The period of exacerbation is characterized by deterioration of the condition, the symptoms are more pronounced.
During the remission stage, the outflow of urine is normalized and the general condition of the patient improves.

The entire list of symptomatic manifestations is divided into general and specific. Common signs of the disease include:

loss of appetite, against this background you can notice a decrease in body weight;
insomnia;
lack of performance, drowsiness, weakness, malaise;
pallor of the skin and mucous membrane; in the acute form, swelling of the facial part is noted.

Specific signs of calculous pyelonephritis are observed mainly during its acute course or exacerbation of the chronic form. The characteristic symptoms in this case are:

fever, feeling of chills, persistent increase in temperature up to 39 degrees;
renal colic, which manifests itself in the form of lumbar pain radiating to the groin, thigh, hypochondrium and abdomen;
there is blood in the urine, this phenomenon is called hematuria;
difficulty urinating, constant urge.

In addition to the list of symptoms outlined, signs of intoxication of the body may appear in the form of nausea and vomiting. If the disease begins to progress, symptomatic manifestations of chronic renal failure are added, namely unquenchable thirst, increased urine production, and frequent night urges.

Prevention of kidney diseases

timely treatment of common diseases,
timely and complete treatment of diseases of the genitourinary system,
regular medical examinations,
balanced diet,
drinking clean water in sufficient quantities,
moderation in caffeine intake,
rejection of bad habits,
physical activity.

To prevent pyelonephritis in children, it is important to properly care for the baby from the first days. Urine and feces are a breeding ground for bacteria, so be sure to regularly change diapers, bathe and properly wash and dry your baby - from the front to the tailbone. At an early age, promptly instill in children personal hygiene skills and conduct hardening. It is necessary to explain to teenagers, girls first of all, the peculiarities of puberty, caring for one’s body and intimate hygiene during menstruation. The personal example of parents, trust in the family and a healthy lifestyle will help maintain health.

Source: EtoPochki.ru