ACUTE PYELONEPHRITIS

ACUTE ACUTE PYELONEPHRITISPYELONEPHRITIS

ACUTE PYELONEPHRITIS

The acute pyelonephritis is a The acute pyelonephritis is a nonspecific infectious disease that nonspecific infectious disease that involves the pelvis of the kidney, involves the pelvis of the kidney, calyces and parenchyma, particularly calyces and parenchyma, particularly its interstitial tissue.its interstitial tissue.

20-40% of the patients with the renal 20-40% of the patients with the renal

diseases suffers of the pyelonephritisdiseases suffers of the pyelonephritis..

ACUTE PYELONEPHRITIS

Approximately 250,000 cases of acute Approximately 250,000 cases of acute pyelonephritis occur each year, resulting in more pyelonephritis occur each year, resulting in more than 100,000 hospitalizations.than 100,000 hospitalizations.

Women are approximately five times more likely Women are approximately five times more likely than men to be hospitalized with this condition than men to be hospitalized with this condition (11.7 versus 2.4 hospitalizations per 10,000 (11.7 versus 2.4 hospitalizations per 10,000 cases, respectively); however, women have a cases, respectively); however, women have a lower mortality rate than men (7.3 versus 16.5 lower mortality rate than men (7.3 versus 16.5 deaths per 1,000 cases, respectively) deaths per 1,000 cases, respectively)

Microbial Organisms Causing Specific Types of Urinary Tract InfectionsMicrobial Organisms Causing Specific Types of Urinary Tract Infections Microbial organism

Acute uncomplicated cystitis (%)*

Acuteuncomplicated pyelonephritis (%)

ComplicatedUTI(%)

Catheter-associated UTI (%)

Escherichia coli 68 89 32 24

Staphylococcus saprophyticus

8 0 1 0

Proteus 6 4 4 6

Klebsiella 4 4 5 8

Enterococci 3 0 22 7

Pseudomonas 0 0 20 9

Mixed 3 5 10 11

Yeast 0 0 15 8

PathogenesisPathogenesis

Renal infection usually ascends from the Renal infection usually ascends from the urethra and lower genitourinary tract. urethra and lower genitourinary tract. Hematogenous infection of the kidney occurs Hematogenous infection of the kidney occurs infrequently; lymphatic spread occurs rarely, if infrequently; lymphatic spread occurs rarely, if ever.ever.

The short urethra in girls and women and its The short urethra in girls and women and its close proximity to the anus allow periurethral close proximity to the anus allow periurethral pathogenic bacteria easy access to the pathogenic bacteria easy access to the bladder during sexual intercourse or urethral bladder during sexual intercourse or urethral manipulation. manipulation.

Once bladder infection is established, Once bladder infection is established, whether infection ascends via the ureters and whether infection ascends via the ureters and involves the kidneys is influenced by microbial involves the kidneys is influenced by microbial virulence factors, the presence or absence of virulence factors, the presence or absence of vesicoureteral reflux, the quality of ureteral vesicoureteral reflux, the quality of ureteral peristalsis, and the susceptibility of the renal peristalsis, and the susceptibility of the renal medulla to infection.medulla to infection.


A. A. Hematogenous spread.Hematogenous spread. Infections spread from the distant place /otitis, tonsillitis, bronchitis, pneumonia, Infections spread from the distant place /otitis, tonsillitis, bronchitis, pneumonia,

osteomyelitis, mastitis, furunculosis, wounds/.osteomyelitis, mastitis, furunculosis, wounds/.

B. B. Urinogenic spread.Urinogenic spread. Infection goes at the ureter from the bladder because of the vesicoureteral reflux. Infection goes at the ureter from the bladder because of the vesicoureteral reflux.

The pelvicovenous, pelvicolymphathic, fornical and tubular refluxes may occur.The pelvicovenous, pelvicolymphathic, fornical and tubular refluxes may occur.

C. C. Ascending infection.Ascending infection. Ascending infection from the ureter at the subepithelial tissue passes direct into Ascending infection from the ureter at the subepithelial tissue passes direct into

the interstitial tissue of the kidney.the interstitial tissue of the kidney.

D. D. Lymphatogenous spread.Lymphatogenous spread. The infection by means of the lymphatic channels probably occurs but it is rare. The infection by means of the lymphatic channels probably occurs but it is rare.

The promote factors are general /avitaminosis, supercooling, overheating, other The promote factors are general /avitaminosis, supercooling, overheating, other infection diseases, gastric ulcer, etc./ and local /intravesical obstruction, infection diseases, gastric ulcer, etc./ and local /intravesical obstruction, neuromuscular dysplasia of ureter, benign prostate hyperplasia, etc/.neuromuscular dysplasia of ureter, benign prostate hyperplasia, etc/.


Urinogenic spread.Urinogenic spread. Infection goes at the ureter from the bladder because of the vesicoureteral Infection goes at the ureter from the bladder because of the vesicoureteral

reflux.reflux.

ClassificationClassification

The primary and secondary pyelonephritis The primary and secondary pyelonephritis are distinguished.are distinguished.

There is no dysfunction of the urine There is no dysfunction of the urine outflow during the primary pyelonephritis.outflow during the primary pyelonephritis.

The secondary pyelonephritis goes with The secondary pyelonephritis goes with urostasis.urostasis.

The reasons of the secondary pyelonephritisThe reasons of the secondary pyelonephritis


1/ The unilateral and bilateral.1/ The unilateral and bilateral. a/ Acute /purulent, serous/a/ Acute /purulent, serous/ b/ Chronic;b/ Chronic; c/ Relapsing course.c/ Relapsing course.2/ By the mode of bacteria pathway there are differed:2/ By the mode of bacteria pathway there are differed:3/ a/ hematogenous /ascending/;3/ a/ hematogenous /ascending/;b/ urogenic /ascending/;b/ urogenic /ascending/;c/ urolithiasis /infected urinary stones/;c/ urolithiasis /infected urinary stones/;d/ tuberculosis of the kidneys;d/ tuberculosis of the kidneys;e/ the other renal diseases.e/ the other renal diseases.By the course, age, stage of the organism there are differed:By the course, age, stage of the organism there are differed:1/ the pyelonephritis of newborn;1/ the pyelonephritis of newborn; 2/ the pyelonephritis of the aged patients;2/ the pyelonephritis of the aged patients; 3/ the pyelonephritis of the pregnant women;3/ the pyelonephritis of the pregnant women; 4/ the pyelonephritis in diabetes mellitus patients.4/ the pyelonephritis in diabetes mellitus patients. The acute pyelonephritis may be complicated with purulent The acute pyelonephritis may be complicated with purulent nephritis, carbuncle of the kidney, the renal abscess, renal nephritis, carbuncle of the kidney, the renal abscess, renal insufficiency. insufficiency.

Risk Factors for Complicated Acute Pyelonephritis Age Immunosuppressed state Obstruction

Infants Diabetes mellitus Foreign body

Elderly (> 60 years of age) Sickle cell disease Calculi

Anatomic/functional abnormality Transplantation Bladder neck obstruction

Polycystic kidney disease Malignancy Posterior urethral valve

Horseshoe kidney Chemoradiation Benign prostatic hypertrophy

Double ureter HIV infections Neurogenic bladder

Ureterocele Corticosteroid use Pregnancy

Vesicoureteric reflux Male sex Inappropriate antibiotics

Clinical FindingsClinical Findings

A.A. SymptomsSymptoms:: Symptoms of cystitis: frequency, Symptoms of cystitis: frequency, nocturia, urgency, and dysuria.nocturia, urgency, and dysuria.

Significant malaise and prostration are Significant malaise and prostration are the rule; nausea, vomiting, and even the rule; nausea, vomiting, and even diarrhea are common. diarrhea are common.

Young children most often complain of Young children most often complain of poorly localized abdominal discomfort poorly localized abdominal discomfort and seldom localize the discomfort and seldom localize the discomfort specifically to the flank.specifically to the flank.

Clinical FindingsClinical FindingsB.B. Signs:Signs: The patient generally appears quite ill. Intermittent chills are associated with fever ranging from 38.5 to 40 °C (101-104 °F) and tachycardia (the pulse rate may range from 90/min to 140/min or faster).

Fist percussion over the costovertebral angle overlying the affected kidney usually causes pain.

Laboratory FindingsLaboratory Findings

The hemogram typically shows significant leukocytosis; the erythrocyte sedimentation rate is increased.

Urinalysis usually shows cloudy fluid with heavy pyuria, bacteriuria, mild proteinuria, and often microscopic or gross hematuria. Urine cultures are positive in 90 percent of patients with acute pyelonephritis, and cultures should be obtained before antibiotics therapy is initiated. The use of blood cultures should be reserved for patients with an uncertain diagnosis, those who are immunocompromised, and those who are suspected of having hematogenous infections

UltrasonographyUltrasonography

Ultrasonography shows flattering and dilatation of the calyces and renal Ultrasonography shows flattering and dilatation of the calyces and renal pelvis, dysfunction of the urine passages, edema of the adipose capsule pelvis, dysfunction of the urine passages, edema of the adipose capsule looks as rarefaction about the kidney.looks as rarefaction about the kidney.

It also shows the sizes of the concrement in the kidney.It also shows the sizes of the concrement in the kidney.


Dilated pelvicaliceal system in a female patient with acute onset of flank Dilated pelvicaliceal system in a female patient with acute onset of flank pain radiating to the genitalia.pain radiating to the genitalia.

X-Ray FindingsX-Ray Findings

A plain film of the abdomen may show some degree of obliteration of the renal outline A plain film of the abdomen may show some degree of obliteration of the renal outline owing to edema of the kidney and perinephric fat.owing to edema of the kidney and perinephric fat.The outline of the ileopsoas muscle is absent sometimes, the diffuse shadow about The outline of the ileopsoas muscle is absent sometimes, the diffuse shadow about the kidney and moderate scoliosis at the side of the disease are present.the kidney and moderate scoliosis at the side of the disease are present. Suspicious calcifications, must be carefully evaluated, because infected renal stones Suspicious calcifications, must be carefully evaluated, because infected renal stones and calculous obstruction complicating pyelonephritis require special management.and calculous obstruction complicating pyelonephritis require special management.


The excretory urograms show the enlargement of the infected kidney. The excretory urograms show the enlargement of the infected kidney. There is a slow excretion of the contrast. Calyces are flattered and clubbed, they are There is a slow excretion of the contrast. Calyces are flattered and clubbed, they are filled with contrast later than normal kidney. filled with contrast later than normal kidney. The intravenous excretory urogram shows the significant atrophy of the parenchyma The intravenous excretory urogram shows the significant atrophy of the parenchyma of the affected kidney, its deformation because of infiltrates and atonia of the ureter.of the affected kidney, its deformation because of infiltrates and atonia of the ureter.

Instrumental ExaminationInstrumental Examination

There can be seen the bullous edema of the urethral orifice because of calculus at There can be seen the bullous edema of the urethral orifice because of calculus at the intravesical portion, ureterocele, tumor compression.the intravesical portion, ureterocele, tumor compression.Chromocystoscopia shows the range even sometimes the cause of the functional Chromocystoscopia shows the range even sometimes the cause of the functional loss of the urine outflow.loss of the urine outflow.

Differential DiagnosisDifferential Diagnosis

The differential diagnosis of acute The differential diagnosis of acute pyelonephritis includes pelvic inflammatory pyelonephritis includes pelvic inflammatory disease, cholecystitis, appendicitis, lower disease, cholecystitis, appendicitis, lower lobe pneumonia, perforated viscus, and the lobe pneumonia, perforated viscus, and the prodrome of herpes zoster. prodrome of herpes zoster.

Differential DiagnosisDifferential Diagnosis

TreatmentTreatment

A.A. Specific MeasuresSpecific Measures

B. General MeasuresB. General Measures

C.C. Failure of ResponseFailure of Response

D. Follow-Up CareD. Follow-Up Care

TreatmentTreatment

Specific Measures:Specific Measures: When the infection is severe or When the infection is severe or complicating factors are present, complicating factors are present, hospitalization may be required. hospitalization may be required.

Urine and blood specimens must be Urine and blood specimens must be obtained immediately for culture; obtained immediately for culture; recognized pathogens must be tested recognized pathogens must be tested for antimicrobial sensitivity.for antimicrobial sensitivity.Until the results of these tests are Until the results of these tests are known, antimicrobial drugs should be known, antimicrobial drugs should be given empirically. given empirically.

Indications for Hospitalization in Patients with Indications for Hospitalization in Patients with Acute PyelonephritisAcute Pyelonephritis

Absolute indications

Persistent vomiting

Progression of uncomplicated UTI

Suspected sepsis

Uncertain diagnosis

Urinary tract obstruction

Relative indications

Age > 60 years

Anatomic urinary tract abnormality

Immunocompromised (diabetes mellitus, cancer, sickle cell disease, organ transplant)

Inadequate access to follow-up

Frailty, poor social support

TreatmentTreatment

General Measures: General Measures: Complete bed rest is Complete bed rest is advised until symptoms subside.advised until symptoms subside.

Medication should be given for pain, fever, and Medication should be given for pain, fever, and nausea.nausea.

It is important to give fluids intravenously and It is important to give fluids intravenously and orally to ensure adequate hydration and orally to ensure adequate hydration and maintenance of adequate urinary output.maintenance of adequate urinary output.

TreatmentTreatment

Antimicrobial treatment with Antimicrobial treatment with desintoxicative and general stimulate desintoxicative and general stimulate measures are effective in case of measures are effective in case of primary process.primary process.An acute primary pyelonephritis is An acute primary pyelonephritis is treated massively with the maximal treated massively with the maximal dosage of the antibacterial mediums in dosage of the antibacterial mediums in different combinations.different combinations.

The secondary pyelonephritis requires The secondary pyelonephritis requires draining of the kidney, sometimes draining of the kidney, sometimes even the purulent source removal. even the purulent source removal. Before the urine outflow isn’t restored Before the urine outflow isn’t restored the antibacterial mediums are the antibacterial mediums are dangerous especially of the strong dangerous especially of the strong action. The bacteriemic shock may action. The bacteriemic shock may develop.develop.

Antimicrobial Agents Used in the Treatment of Acute PyelonephritisAntimicrobial Agents Used in the Treatment of Acute Pyelonephritis Agent

Dosing scheduleOral dose

IV dose Comments

Amoxicillin Every 8 to 12 hours 500 - None

Amoxicillin- clavulanate potassium (Augmentin)

Every 8 to 12 hours 500/125 - GI side effects*

Ampicillin-sulbactam(Unasyn)

Every 4 to 6 hours - 150 to 200 mg

per kg per day

GI side effects*

Aztreonam (Azactam) Every 6 to 8 hours - 1 to 2 g Phlebitis; GI side effects*

Cefotaxime (Claforan) Every 8 to 12 hours - 1 to 2 g Thrombophlebitis

Ceftriaxone (Rocephin) Once in 24 hours - 1 to 2 g Leukopenia; elevated BUN

Cephalexin (Keflex) Every 6 hours 500 - GI side effects*

Ciprofloxacin (Cipro) Every 12 hours 500 400 mg Nausea; headache; photosensitivity; pregnancy category C

Norfloxacini Every 12 hours 500 400 mg Nausea; headache; photosensitivity; pregnancy category C

Acute purulent pyelonephritisAcute purulent pyelonephritis

Apostematous pyelonephritisApostematous pyelonephritis Renal carbuncle Renal carbuncle Abscesses of the kidneyAbscesses of the kidney

Apostematous pyelonephritisApostematous pyelonephritis

It is the suppuration of the parenchyma It is the suppuration of the parenchyma of the kidney with formation of the small of the kidney with formation of the small multiply purulent focuses /apostems/. multiply purulent focuses /apostems/.

The process occurs unilateral and The process occurs unilateral and bilateral. The purulent focuses are direct bilateral. The purulent focuses are direct under the fibrous capsule, 1-3 mm in under the fibrous capsule, 1-3 mm in size and merging sometimes.size and merging sometimes.

Renal abscessRenal abscess

Renal cortical abscesses develop primarily as a result Renal cortical abscesses develop primarily as a result of hematogenous spread of of hematogenous spread of Staphylococcus aureus Staphylococcus aureus infections at distant sites, most often the skin infections at distant sites, most often the skin (furunculosis, felon, mastitis).(furunculosis, felon, mastitis). At times, foci of primary renal infections caused At times, foci of primary renal infections caused mainly by gram-negative bacteria (coliform organisms) mainly by gram-negative bacteria (coliform organisms) coalesce in the renal medulla to form abscesses.coalesce in the renal medulla to form abscesses.

In the past, most renal abscesses were caused by In the past, most renal abscesses were caused by staphylococci; recently, coliform bacteria have staphylococci; recently, coliform bacteria have become the predominant pathogens in renal become the predominant pathogens in renal abscesses.abscesses.

Renal carbuncleRenal carbuncle It is the suppurate-necrotic damage with It is the suppurate-necrotic damage with formation of the bordered infiltrate in the formation of the bordered infiltrate in the cortex of the kidney.cortex of the kidney.

Renal cortical carbuncles develop primary as Renal cortical carbuncles develop primary as a result of the hematogenous spread of a result of the hematogenous spread of infection form the distant sites /most often infection form the distant sites /most often from the respiratory tract, suppurative from the respiratory tract, suppurative diseases of kidney, skin, furunculosis, felon, diseases of kidney, skin, furunculosis, felon, mastitis, etc./mastitis, etc./

Mechanism of carbuncle formation is the Mechanism of carbuncle formation is the septic embolism of the renal artery that septic embolism of the renal artery that causes the septic infarction of the kidney and causes the septic infarction of the kidney and the development of carbuncle.the development of carbuncle.


A.A. Symptoms:Symptoms: renal abscess is typified by an renal abscess is typified by an abrupt onset of chills, fever, and localized abrupt onset of chills, fever, and localized costovertebral pain. In the early stages, when costovertebral pain. In the early stages, when the abscess does not communicate with the the abscess does not communicate with the collecting system, symptoms of vesical collecting system, symptoms of vesical irritability are absent and urinalysis is normal, irritability are absent and urinalysis is normal, although the patient may appear quite septic. although the patient may appear quite septic. The clinical picture often mimics that of acute The clinical picture often mimics that of acute pyelonephritis.pyelonephritis.

B.B. Signs: Signs: In acute cases, localizing signs are In acute cases, localizing signs are flank tenderness, possibly a palpable mass, flank tenderness, possibly a palpable mass, and erythema and edema of the skin of the and erythema and edema of the skin of the overlying loin. At times, however, abscesses overlying loin. At times, however, abscesses associated with both acute and chronic associated with both acute and chronic infections present as febrile illnesses with few infections present as febrile illnesses with few localizing signs.localizing signs.


The hemogram usually shows marked leukocytosis with The hemogram usually shows marked leukocytosis with a shift to the left. a shift to the left.

With cortical abscesses that do not communicate with With cortical abscesses that do not communicate with the collecting system, urinalysis shows no pyuria or the collecting system, urinalysis shows no pyuria or bacteriuria, and urine culture is negative.bacteriuria, and urine culture is negative.

Medullary abscesses generally are associated with Medullary abscesses generally are associated with heavy pyuria, bacteriuria, and positive urine cultures.heavy pyuria, bacteriuria, and positive urine cultures.

Blood cultures may be positive.Blood cultures may be positive.

Depending upon the extent of renal involvement and Depending upon the extent of renal involvement and associated renal abnormalities, the serum creatinine and associated renal abnormalities, the serum creatinine and urea nitrogen values may be normal or elevated. urea nitrogen values may be normal or elevated.


If the renal outline is visible, the plain film may show an enlarged kidney or a If the renal outline is visible, the plain film may show an enlarged kidney or a bulge of the external renal contour. With perinephric edema, however, often bulge of the external renal contour. With perinephric edema, however, often the renal outline is obliterated and the psoas shadow indistinct.the renal outline is obliterated and the psoas shadow indistinct. Unless the abscess has ruptured into the perinephric space or is quite Unless the abscess has ruptured into the perinephric space or is quite large, scoliosis generally is not observed. Renal stones may be noted.large, scoliosis generally is not observed. Renal stones may be noted.


When cortical abscesses are small, the excretory urogram may appear normal; most often, When cortical abscesses are small, the excretory urogram may appear normal; most often, however, a space-occupying lesion (the abscess) is delineated. however, a space-occupying lesion (the abscess) is delineated. Pyelonephritic changes, hydronephrosis, and urolithiasis also may be observed. Pyelonephritic changes, hydronephrosis, and urolithiasis also may be observed.


Pyelonephritic changes, hydronephrosis, and urolithiasis also may be observedPyelonephritic changes, hydronephrosis, and urolithiasis also may be observed. .


Intrarenal abscesses appear as well-marginated round or oval masses with irregular Intrarenal abscesses appear as well-marginated round or oval masses with irregular walls on ultrasonography.walls on ultrasonography.

The mass may be echo-free or slightly echogenic due to the presence of necrotic The mass may be echo-free or slightly echogenic due to the presence of necrotic debris.debris.

Treatment /Apostematous Pyelonephritis/Treatment /Apostematous Pyelonephritis/ The urgent surgical measures are required.The urgent surgical measures are required.The subcostal lumbotomia is performed. The The subcostal lumbotomia is performed. The kidney is nude and decapsulated. The kidney is nude and decapsulated. The purulent focuses are incised. The purulent focuses are incised. The retroperitoneal space should be drained and retroperitoneal space should be drained and free output of the urine provided by means of free output of the urine provided by means of the nephrostomy. the nephrostomy. The surgical drainage should be present until The surgical drainage should be present until the urine output becomes free, inflammation the urine output becomes free, inflammation disappears and renal function normalizes.disappears and renal function normalizes.

The postoperative period requires the The postoperative period requires the antibacterial and desintoxicative treatment antibacterial and desintoxicative treatment that is similar to chronic pyelonephritis.that is similar to chronic pyelonephritis.

TreatmentTreatment

Renal carbuncleRenal carbuncle

Lumbotomia is performed. Then decapsulation Lumbotomia is performed. Then decapsulation of the kidney and cone-shaped excision of the of the kidney and cone-shaped excision of the carbuncle are done. carbuncle are done.

Incision, curettage and draining of the kidney or Incision, curettage and draining of the kidney or enucleating of the carbuncle with its incision enucleating of the carbuncle with its incision may be performed too.may be performed too.

Nephrectomy and partial nephrectomy are Nephrectomy and partial nephrectomy are required less often today than in the past.required less often today than in the past.

Gestation pyelonephritisGestation pyelonephritis

The inflammatory process develops while pregnancy, delivery and puerperal period.The inflammatory process develops while pregnancy, delivery and puerperal period.

Gestation pyelonephritisGestation pyelonephritis(Pyelonephritis of pregnancy)(Pyelonephritis of pregnancy)

Most frequently it is observed in pregnant Most frequently it is observed in pregnant (48%) more rare in puerperal (35%) (48%) more rare in puerperal (35%) women.women.

It develops while 1 pregnancy 2 trimester It develops while 1 pregnancy 2 trimester often.often.

There are women 18-25 years old. There are women 18-25 years old.

Etiology Etiology /Pyelonephritis of pregnancy//Pyelonephritis of pregnancy/

Urinoculture finds out E.Coli, Staphylococcus Urinoculture finds out E.Coli, Staphylococcus albicans, Clebsiella in pregnant women. albicans, Clebsiella in pregnant women. Association of the Proteus and Blue pus bacilli is Association of the Proteus and Blue pus bacilli is observed in puerperal women. observed in puerperal women. The primary source of the infection may be any The primary source of the infection may be any purulent inflammatory place (furunculosis, dental purulent inflammatory place (furunculosis, dental caries, inflammatory diseases of the genital caries, inflammatory diseases of the genital organs).organs).

PathogenesisPathogenesis /Pyelonephritis of pregnancy//Pyelonephritis of pregnancy/

The pathogenetic sign is bacteriuria. It is observed in 7% only. The pathogenetic sign is bacteriuria. It is observed in 7% only. 20-40% of women with asymptomatic bacteriuria develop 20-40% of women with asymptomatic bacteriuria develop pyelonephritis during pregnancy. Treatment of the bacteriuria pyelonephritis during pregnancy. Treatment of the bacteriuria lowers this risklowers this risk.. Urodynamic dysfunction favors the pyelonephritis development.Urodynamic dysfunction favors the pyelonephritis development. Pathogenesis may be explained with mechanical, neurohumoral Pathogenesis may be explained with mechanical, neurohumoral and endocrine factors.and endocrine factors. The enlarged uterus compresses the pelvic portion of the The enlarged uterus compresses the pelvic portion of the ureters causing ureteropyeloectasia while pregnancy. ureters causing ureteropyeloectasia while pregnancy. The moderate hypotonia and hypokinesia of the calicopelvic of The moderate hypotonia and hypokinesia of the calicopelvic of the both kidneys and ureters are observed on 8th week.the both kidneys and ureters are observed on 8th week.Changes of the upper portion of the urinary tract may be Changes of the upper portion of the urinary tract may be explained by weakening of the sympathetic nervous system explained by weakening of the sympathetic nervous system tonus. tonus. Dysfunction of the urinary output because of the urinary pathway Dysfunction of the urinary output because of the urinary pathway atonia is a condition for pathogen activation. Vesicoureteral and atonia is a condition for pathogen activation. Vesicoureteral and pelvicorenal refluxes favor spreading of the infection into the pelvicorenal refluxes favor spreading of the infection into the interstitial tissue of the renal parenchyma.interstitial tissue of the renal parenchyma.

Clinical findingsClinical findings /Pyelonephritis of pregnancy/ /Pyelonephritis of pregnancy/

Clinical findings have the own peculiarities Clinical findings have the own peculiarities according to the different terms of pregnancy. according to the different terms of pregnancy. They also depend on the range of the urinary They also depend on the range of the urinary output damage.output damage.

A sharp pain in loin that irradiates to the lower A sharp pain in loin that irradiates to the lower portions of the abdomen, genitals are at the 1 portions of the abdomen, genitals are at the 1 trimester. trimester. 2nd and 3rd trimesters are characterized with 2nd and 3rd trimesters are characterized with a moderate pain because of the dilatation of a moderate pain because of the dilatation of the upper urinary tract and intrarenal pressure the upper urinary tract and intrarenal pressure decreasing.decreasing.

An acute purulent pyelonephritis develops An acute purulent pyelonephritis develops more frequently in pregnant and postpueral more frequently in pregnant and postpueral women.women.

Clinical findingsClinical findings /Pyelonephritis of pregnancy/ /Pyelonephritis of pregnancy/

SymptomsSymptoms: : The usual symptoms of acute pregnancy The usual symptoms of acute pregnancy pyelonephritis include abrupt onset of shaking pyelonephritis include abrupt onset of shaking chills, moderate to high fever, a constant ache in chills, moderate to high fever, a constant ache in the loin (unilateral or bilateral).the loin (unilateral or bilateral).

Symptoms of cystitis: frequency, urgency, and Symptoms of cystitis: frequency, urgency, and dysuria.dysuria.

Significant malaise and prostration are the rule; Significant malaise and prostration are the rule; nausea, vomiting.nausea, vomiting.

DiagnosisDiagnosis /Pyelonephritis of pregnancy//Pyelonephritis of pregnancy/

The enlarged uterine hinders the The enlarged uterine hinders the palpationpalpation


ChromocystoscopiaChromocystoscopia


Chromocystoscopia Chromocystoscopia //Pyelonephritis of pregnancy/Pyelonephritis of pregnancy/

UltrasonographyUltrasonography /Pyelonephritis of pregnancy//Pyelonephritis of pregnancy/

Ultrasonography shows dilatation of the calyces and renal pelvis, dysfunction of the Ultrasonography shows dilatation of the calyces and renal pelvis, dysfunction of the urine passages, edema of the adipose capsule looks as rarefaction about the kidney.urine passages, edema of the adipose capsule looks as rarefaction about the kidney.

TreatmentTreatment /Pyelonephritis of pregnancy/

Antibiotics shouldn’t be harmful to Antibiotics shouldn’t be harmful to fetus. The natural and semi-synthetic fetus. The natural and semi-synthetic penicillin's are recommended at the penicillin's are recommended at the 1st trimester.1st trimester.

The puerperal women may transfer The puerperal women may transfer drugs to child with milk.drugs to child with milk.

The acute purulent pyelonephritis in The acute purulent pyelonephritis in pregnant women requires the obligate pregnant women requires the obligate surgical measures. surgical measures.

Treatment Treatment /Pyelonephritis of pregnancy//Pyelonephritis of pregnancy/

TUBERCULOSISTUBERCULOSIS

EtiologyEtiology

The infecting organism is The infecting organism is Mycobacterium tuberculosis, Mycobacterium tuberculosis, which reaches the genitourinary organs by the which reaches the genitourinary organs by the hematogenous route from the lungs. The primary site hematogenous route from the lungs. The primary site is often not symptomatic or apparent.is often not symptomatic or apparent.

..


The diagnosis rests upon the demonstration of The diagnosis rests upon the demonstration of tubercle bacilli in the urine by culture. tubercle bacilli in the urine by culture. The extent of the infection is determined by: The extent of the infection is determined by: (1) the palpable findings in the epididymides, vasa (1) the palpable findings in the epididymides, vasa deferentia, prostate, and seminal vesicles; deferentia, prostate, and seminal vesicles; (2) the renal and ureteral lesions as revealed by (2) the renal and ureteral lesions as revealed by excretory urograms; excretory urograms; (3) involvement of the bladder as seen through the (3) involvement of the bladder as seen through the cystoscope; cystoscope; (4) the degree of renal damage as measured by (4) the degree of renal damage as measured by loss of function; loss of function; (5) the presence of tubercle bacilli in one or both (5) the presence of tubercle bacilli in one or both kidneys.kidneys.


I — nondestructive (infiltrate) tuberculosis of I — nondestructive (infiltrate) tuberculosis of kidney;kidney;II — initial II — initial destructiondestruction (papillitis or small, by (papillitis or small, by diameter about 1 cm, single cavity); diameter about 1 cm, single cavity); III —marked III —marked destructiondestruction (caverns or (caverns or policavernosialpolicavernosial tuberculosis one of kidney tuberculosis one of kidney segments);segments);IV — total or IV — total or subtotal destructionsubtotal destruction

SymptomsSymptoms

BladderBladderThe The earliest symptoms of renal tuberculosis earliest symptoms of renal tuberculosis may arise from secondary vesical involvement. may arise from secondary vesical involvement.

These include burning, frequency, and These include burning, frequency, and nocturia. nocturia.

Hematuria is occasionally found and is of either Hematuria is occasionally found and is of either renal or vesical origin. renal or vesical origin.

SymptomsSymptomsGenital tractGenital tract

Tuberculosis of the prostate and seminal Tuberculosis of the prostate and seminal vesicles usually causes no symptoms. The vesicles usually causes no symptoms. The first clue to the presence of tuberculous first clue to the presence of tuberculous infection of these organs is the onset of a infection of these organs is the onset of a tuberculous epididymitis.tuberculous epididymitis.

Tuberculosis of the epididymis usually Tuberculosis of the epididymis usually presents as a painless or only mildly painful presents as a painless or only mildly painful swelling. An abscess may drain spontaneously swelling. An abscess may drain spontaneously through the scrotal wall. A chronic draining through the scrotal wall. A chronic draining sinus should be regarded as tuberculous until sinus should be regarded as tuberculous until proved otherwise. proved otherwise.

In rare cases, the onset is quite acute and may In rare cases, the onset is quite acute and may simulate an acute nonspecific epididymitis.simulate an acute nonspecific epididymitis.


If tuberculosis is suspected, perform the tuberculin test.If tuberculosis is suspected, perform the tuberculin test.

A positive test, particularly in an adult, is hardly A positive test, particularly in an adult, is hardly diagnostic; but a negative test in an otherwise healthy diagnostic; but a negative test in an otherwise healthy patient speaks against a diagnosis of tuberculosis.patient speaks against a diagnosis of tuberculosis.


A plain film of the abdomen may show enlargement A plain film of the abdomen may show enlargement of one kidney or obliteration of the renal and psoas of one kidney or obliteration of the renal and psoas shadows due to perinephric abscess. Punctate shadows due to perinephric abscess. Punctate calcification in the renal parenchyma may be due to calcification in the renal parenchyma may be due to tuberculosis.tuberculosis.


Excretory urograms can be diagnostic Excretory urograms can be diagnostic

if the lesion is moderately advanced.if the lesion is moderately advanced.

Instrumental ExaminationInstrumental Examination

TreatmentTreatment

Tuberculosis must be treated as a generalized Tuberculosis must be treated as a generalized disease. Even when it can be demonstrated disease. Even when it can be demonstrated only in the urogenital tract, one must assume only in the urogenital tract, one must assume activity elsewhere. activity elsewhere.

This means that basically the treatment is This means that basically the treatment is medical. Surgical excision of an infected organ, medical. Surgical excision of an infected organ, when indicated, is merely an adjunct to overall when indicated, is merely an adjunct to overall therapy.therapy.

TreatmentTreatment Renal TuberculosisRenal Tuberculosis

A strict medical regimen should be instituted.A strict medical regimen should be instituted.The following combinations of drugs can be utilized. The following combinations of drugs can be utilized. 11 - - Cycloserine, aminosalicylic acid (PAS), and isoniazid Cycloserine, aminosalicylic acid (PAS), and isoniazid (INH). (INH). 22 - - Cycloserine, ethambutol, and INH. Cycloserine, ethambutol, and INH.33 - - Rifampin, ethambutol, and INH. Rifampin, ethambutol, and INH.

The oral dose of each is as follows: Cycloserine, 250 mg The oral dose of each is as follows: Cycloserine, 250 mg twice daily; PAS, 15 g in divided doses; INH, 300 mg; twice daily; PAS, 15 g in divided doses; INH, 300 mg; ethambutol, 1.2 g; rifampin, 600 mg. Sensitivity test ing may ethambutol, 1.2 g; rifampin, 600 mg. Sensitivity test ing may indicate the use of streptomycin intramuscularly. Administer indicate the use of streptomycin intramuscularly. Administer 1 g/d the first month, 1 g 3 times a week for the next month, 1 g/d the first month, 1 g 3 times a week for the next month, and then 1 g twice a week. and then 1 g twice a week.

TreatmentTreatment Renal TuberculosisRenal Tuberculosis

While most authorities advise appropriate medication for 2 While most authorities advise appropriate medication for 2 years (or longer if cultures remain posi tive), Gow (1979) finds years (or longer if cultures remain posi tive), Gow (1979) finds that a 6-month course of drugs is adequate.that a 6-month course of drugs is adequate.

He recommends 600 mg of rifampin, 300 mg of INH, 1 g of He recommends 600 mg of rifampin, 300 mg of INH, 1 g of pyrazinamide, and 1 g of vitamin C daily for 2 months, pyrazinamide, and 1 g of vitamin C daily for 2 months, followed by 900 mg of rifampin, 1.5 g of pyrazinamide, and 1 followed by 900 mg of rifampin, 1.5 g of pyrazinamide, and 1 g of vitamin C twice a week for 4 months.g of vitamin C twice a week for 4 months.

If, after 3 months, cultures are still positive and gross If, after 3 months, cultures are still positive and gross involvement of the affected kidney is radiologically evident, involvement of the affected kidney is radiologically evident, nephrectomy should be considered. Gow (1979) nephrectomy should be considered. Gow (1979) recommends that nonfunctioning kidneys be removed after 1-recommends that nonfunctioning kidneys be removed after 1-2 months of medical therapy.2 months of medical therapy.

ACUTE PYELONEPHRITIS

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