NONSPEСIFIC INFLAMMATORY DISEASES OF GENITOURINARY ORGANS

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NONSPEСIFIC INFLAMMATORY DISEASES OF GENITOURINARY ORGANS

UroloUrology.gy.

17.04.23 Anomalies of Genito-urinary Tract 2

To nonspecific inflammatory diseases of genitourinary organs we refer: an acute and chronic pyelonephritis, and also their complication - apostematous pyelonephritis, renal abscess, necrosis of renal papillae, pyonephrosis, para-nephritis; inflammatory diseases of urinary paths -cystitis, paracystitis, urethritis; illnesses of genital organs - prostatitis, vesiculitis, epidi-dymitis, orchitis, balanitis, balanoposthitis, cavernitis. The nonspecific inflammatory diseases of genitourinary organs make up 2/3 of urological diseases. Most frequent of them is pyelonephritis.


Pyelonephritis is nonspecific inflammatory infectious process, in which parenchyma and pelvis of a kidney are affected. A pyelonephritis is the most often occurred disease of kidneys for the people of a different sex and age, since early childhood. The pyelonephritis in children takes the second place by its frequency, right after the diseases of respiratory organs. According to pathologoanatomic statistics, pyelonephritis was found in 6-20 % of all autopsies, and in the life-time this diagnosis was established only for 20-30 % of patients.

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It is accepted to consider, that the infection penetrates into a kidney by two routes: (1) hema-togenous; (2) ascending through a lumen of urinary tract.

The ascending path in urinary tract is the most wide-spread. Thus, bacteria come retrograde from a bladder through an ureter into renal pelvis and parenchyma. Ascending route of renal infection is possible only in the presence of a vesicoureteral reflux.

The hematogenous path of penetration of an infection takes place less often. Such drift of infection


into a kidney is possible, when the primary focus of infection is localized in urinary paths (cystitis, ureth-ritis) or in genital organs (prostatitis, vesiculitis, orchitis, epididymitis, adnexitis) and also from the distant inflammatory focus in an organism (tonsil-litis, sinusitis, otitis, carious teeth, bronchitis, pneumonia, furuncle, anthrax, mastitis, osteomye-litis, etc.). The general condition of the organism plays the important role in originating and develop-ment of pyelonephritis. It is established, that of the general factors the immunological reactivity is of great significance.


Of the local factors contributing to originating pyelonephritis, most often is the disturbance of outflow of urine, the main reasons of which are different anomalies of kidneys and urinary paths. Approximately 7 times more often pyelonephritis occurs in persons with such anomalies, as the polycystic kidneys disease, fused kidney, double kidney, etc. Factors, which promote development of an acute pyelonephritis - are stones of a kidney, ureter and urethra, adenoma of prostate, stricture of urethra, neurogenic bladder and long drainage with a catheter or stent. For the women a disturbance of draining the upper urinary tract can be observed at the abnormal pregnancy, at gynaecological disorders.


Acute Pyelonephritis It can be primary, if it is not preceded by the

diseases of kidneys and urinary paths, and secondary, when it arises due to other urological disease interfering with the outflow of urine or disorder of blood and lymph flow in a kidney.

In the course of acute pyelonephritis we distinguish two stages: serous inflammatory process and purulent inflammation. To serous, purulent inflammatory processes of a kidney, we attribute complications - apostematous (acute, purulent, focal) nephritis, renal abscess and pyonephrosis.


The triad of symptoms – a high body tempera-ture, pain in lumbar area, changes in urine, characteristic of inflammatory process (leukocy-turia, bacteriuria), is typical of the primary acute pyelonephritis. The disease is generally starts with fatigue, chill, fervescence up to 390-400C, occurrence of pain in the area of a kidney, affected by inflammatory process (i.e. in lumbar area, in hypochondrium). The pains may be intensive and dull. Patients complains - a headache, general weakness, absence of appetite, and, sometimes, vomiting, abdominal distention.

Tongue is dry. Pulse is rapid. Body temperature on evenings reaches 390-400 C and is reduced by a morning to 370- 380 C.

In an anamnesis attention is paid to the presence of suppurative foci in the organism (furuncle, pulpitis, mastitis, etc.), and also to the past infectious diseases (influenza, angina, pneumonia, cholecystitis, coloenteritis, etc.).

For diagnostics of an acute pyelonephritis are the laboratory methods of investigations, first of all, a detection of a bacteriuria and leukocyturia plays the extremely significant role.

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Radiological researches in patients with an acute pyelonephritis are necessary to exclude accompanying diseases, which promote development of infectious process. The acute pyelonephritis should be differentiated from general infectious diseases (sepsis, influenza, etc.), and more often from an acute appendicitis and acute cholecystitis. Routine survey urography is used for exclusion of gas in a renal parenchyma. In patients with diabetes the glycolysis of gas-producing organisms which is visualized as air bubbles in a renal parenchyma.

In patients with diabetes the glycolysis of gas-producing organisms which is visualized as air bubbles in a renal parenchyma. This condition has received the name of Emphysematous pyelonephritis


Treatment of a primary acute pyelonephritis in most cases is conservative. The patient’s regimen should be a bed rest. A copious drink (juices) up to 2-2.5 litres per day. The treatment of an acute pyelonephritis is necessary to start with the most effective antibiotics and chemical antibacterial drugs. The antibacterial therapy should go on continuously not less than 6 weeks, to reduce a probability of a relapse of disease and transition it into the chronic form. In the recent years, the antibacterial drugs are successfully combined with the drugs giving immunostimulating effect. . If the acute pyelonephritis is transformed into the chronic form of disease, the prognosis becomes unfavorable because of the development of complications (chronic renal failure, nephrogenic arterial hypertension,urolithiasis).


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Secondary Acute Pyelonephritis The most often cause of the secondary acute

pyelonephritis (approximately for 2/3 of patients) are the stones of a kidney and ureter, then there are anomalies of urinary paths, pregnancy, stricture of ureter and urethra, adenoma of prostate, and for children – infravesical obstruction.

X-ray method of testings takes the most relevant place in diagnostics of the secondary acute pyelonephritis.

The survey and excretory urograms of urinary system allows to reveal stones of a kidney or ureter and

determine obstacles ureters, renal pelvis and calices, to exclude congenital anomalies. Ultrasonic scan, computer tomography and scinti-graphy of kidneys helps in diagnostics of degree of lesion of a parenchyma of a kidney, cicatricial processes, renal abscesses. The treatment of the secondary acute pyelonephritis should be started with a restoration of passage of urine from a kidney. In the acute pyelonephritis caused by a nephrolithiasis, the treatment of urolithiasis is recom-mended. In multiple abscesses of a kidney, pyonephrosis and good function of a contralateral kidney we resort to a nephrectomy.

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The acute pyelonephritis of pregnant women is observed, on the average, in 2.5% of all pregnant women, almost exclusively in the second half of pregnancy. The factors contributing to originating a pyelonephritis for the pregnant women, are: (1) decrease of tone of the upper urinary paths owing to neurohumoral shifts; (2) mechanical pressure of a pregnant uterus on the ureters; (3) presence of asymptomatic bacteriuria for 5-10 % of all pregnant women. The restoration of the passage of urine is indicated with the help of introdution of ureteral catheter into renal pelvis and leaving it for 2-3 days.

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In cases, when the conservative treatment does not result in liquidation of attack of an acute pyelonephritis, it is necessary to undertake drainage of a kidney by placement of retrograde ureteral stent or an operative measure - percutaneous nephrostomy or surgical incision.

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Chronic Pyelonephritis Chronic pyelonephritis - as a rule, is a consequence of an acute pyelonephritis. Of great value in diagnostics of a chronic pyelonephritis are laboratory, X-ray and tracer techniques of research. The leukocyturia is one of the most relevant and frequently occured signs of chronic pyelonephritis. X-ray signs of disease are: (1) changes of dimen-sions and contours of kidneys; (2) disturbance of excre-tion by a kidney of radiopaque matter; (3) patholo-gical values of renocortical index (RCI); (4) deformations of a pyelocaliceal system; 5) Hodson’s symptom;


(6) changes of angioarchitectonics of a kidney.

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Hodson’s symptom

To quantify and define a quality of functioning parenchyma it is expedient to apply a scintigraphy.

Treatment of a chronic pyelonephritis: (1) removal of causes producing a disturbance of urine passage; (2) administering antibacterial drugs in consideration of the data of an antibiogram; (3) rising an immune reactivity of an organism. After achieving the stage of a remission of disease in the patient the antibacterial treatment should be prolonged by intermittent courses. The chronic pyelonephritis is the most often cause of chronic renal failure and nephrogenic arterial hyper-tension. The prognosis becomes particularly unfavo-rable in combination of both these complications.

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Pyonephrosis Pyonephrosis means the final stage of specific or nonspecific purulent - destructive inflammatory lesion of a kidney. The pyonephrotic kidney represents the organ, exposed to purulent destruction, consisting of separate cavities, filled with pus, urine and products of nephrolysis. On excretory urograms the radiopaque matter in the affected kidney is not revealed at all. 50% of the obstructed pyonephrotic kidneys are nonfunctioning. A diagnosis is best made by renal ultrasound and CT scan being aided by diagnostic needle aspiration. Treatment of pyonephrosis is only operative. We resort to a nephrectomy more often.

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In patients with pyonephrosis with deep morphological and functional changes in the opposite kidney, which are accompanied by renal failure, sometimes, it is necessary to limit palliative operation – percutaneous nephrostomy.

Apostematous Pyelonephritis Apostematous pyelonephritis - represents a purulent-inflammatory process with the formation of numerous, small-sized pustules (apostemas) predominantly in a renal cortex. A body temperature (up to 390-400 С) with repeated shaking chill and profuse sweat, with the sharply expressed and fast developing signs of intoxication. An enlarged and sharply morbid kidney is quite often palpated. In nephroscintigraphy the increase of the affected kidney in its size, diffuse-and-irregular isotope accumulation in its cortex are marked.

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When an apostematous pyelonephritis is found the urgent operative measure is required. Frequently it is necessary to drain a kidney by nephro-or pyelostomy; in elderly people in case of expressed intoxication, considerable renal lesion and absence of noticeable changes in the contralateral kidney, it is, sometimes, more expedient to make a nephrectomy to save patient’s life. The prognosis is always severe because of a high lethality.

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Abscess of a KidneyAbscess of a kidney - represents a purulent-necrotic lesion with the formation of a restricted infiltrate in a renal cortex. It may arise as the primary disease owing to a massive bacterial invasion from the distant suppurative focus. The abscess may proceed into a medullary layer of a kidney and open either into pelvis, or into paranephral fat, that results in the development of a purulent para-nephritis. Typical signs of this status are a fever, a pain and morbidity on palpation in the costovertebral angle.

The main information on the presence of an abscess in retroperitoneal space gives an ultrasonic research and, especially, a computer tomography.

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A renal arteriography and radionuclide researches in diagnostics are seldom applied. It is possible to manage patients conservatively only if there are small, circumscribed lesions and fast effect of antibacterial therapy.

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The fundamental principle is the drainage of an abscess. If the abscess is not divided into loculi, it is possible to use the percutaneous drain, which has been carried out under ultrasonic control. If the drainage is ineffective, urgent performance of an open surgical drainage is necessary. Traditionally, an open drainage is applied. Nephrectomy is rarely, needed.

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Perinephric Abscess Perinephric abscess – is a purulent-inflammatory process in a pararenal fatty tissue. Perinephric abscess is divided into primary and secondary. Primary is considered as paranephritis arising in the absence of renal disease as a result of infection of paranephral fat by a hematogenous way from the distant foci of a purulent inflammation in an organism (a furuncle, osteomyelitis, pulpitis, angina, etc.). The secondary – a perinephric abscess arises as a complication of purulent-inflammatory process in a kidney.

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(abscess of the kidney, pyonephrosis of paranephral fat), in others (in pyelonephritis). According to the nature of inflammatory process we distinguish an acute and chronic perinephric abscess. If the purulent process in paranephral fat, tends to diffusion, interfascial septa are usually disintegrated and the pus is directed toward the most weak places of lumbar area – Petit’s and Lesshaft-Grynfeltt’s triangles. In further development of the process the pus gets outside the limits of perinephral fat, forming a phlegmon in retroperitoneal space.

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The primary treatment of the perinephric abscess is percutaneous drainage. In a purulent paranephritis the operative treatment is indicated: lumbotomy and good drainage of a wound. Nephrectomy indicated if the kidney is nonfunctioning or severely infected.

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It is necessary to fulfil computer tomography and ultrasonic research for every patient with a suspicion of a retroperitoneal abscess.

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Cystitis Cystitis - infection-inflammatory process in the wall of a urinary bladder is one of the most frequent urological diseases. Cystitis is observed much more often in women, and it is accepted to be connected with a spreading of infection by an ascending way in the lumen of urethra owing to its anatomic features. For men cystitis occurs much less often, the infection of urinary bladder can be observed in inflammatory processes in prostate, seminal vesicles, epididymes and urethra. Quite often the infection is introduced to the urinary bladder upon its catheterization.

Characteristic signs of acute cystitis are the desires on an emiction , pain in the field of the urinary bladder, pyuria and terminal hematuria. The hematuria, in acute cystitis, usually happens to be terminal owing to a discharge of blood from bleeding inflamed mucosa of the urinary bladder upon its contraction. The acute cystitis is seldom accompanied by a fever of patient. After antibacterial treatment in 7-10 days there usually comes a clinical convalescence. However, for preventing a relapse of the disease the antibacterial treatment is to be continued for no less than 3 weeks. In identification of chronic cystitis a cystoscopy and X-ray examination of kidneys and upper urinary paths plays the relevant role. 34

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In chronic cystitis a removal of reasons of inflammatory process in the urinary bladder (a stone of urinary bladder, diverticulum, adenoma of prostate, stricture of urethra, etc.) is importance in the treatment. Patient with chronic cystitis alongside with antibacterial drugs is prescribed an instillation of Silver nitrate solution into the urinary bladder, as well as diathermy, electropho-resis of antibacterial drugs.

Prostatitis Prostatitis - is the most common disease of genital organs in men. The infection can penetrate into a prostate by ascending canalicular route as the result of the inflam-matory process in urethra, urinary bladder, while instru-mental urological researches. In other cases the infection gets in a prostate by a hematogenous way from the purulent inflammatory foci of patient (furuncle, abscess, angina, pneumonia, etc.). The following forms of an acute prostatitis are distinguished: catarrhal, follicular, parenchymatous and abscess of prostate.

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It is based on the data of an anamnesis and patient’s complaints (pain in a perineum, rectum, morbid emiction, mucopurulent discharge from urethra, fever up to 380-390 chill). The digital examination of prostate reveals its augmentation, pastousity, morbidness.

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For patients with acute prostatitis a bed regimen, diet, an intensive care with antibiotics of a broad spectrum of action or quinolones, in combination with sulfonamides is prescribed. For a decrease of pains and painful desires for an emiction we recommend suppositories with Anaes-thesin, Promedol. If the acute prostatitis is complicated by abscess of prostate, one should resort to an operative measure – opening the abscess through a rectum. The prognosis in an acute prostatitis, as a rule, is favourable, if a well-timed treatment has been started. The chronic prostatitis can be a consequence of poor treatment of an acute prostatitis.

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The formation of the expanded cavities owing to an occlusion of ducts and accumulation of a stagnant secretion is characteristic of a chronic prostatitis. Dull pains in a perineum, sacrum, rectum, irradiating to the external genitals, in the urethra are characteristic of a chronic prostatitis. Upon defecation or at the end of an emiction a discharge of a secretion from prostate (prostatorrhea), is marked. Quite often the patients, complain of disorders of a sexual function (failure of erection, accelerated ejaculation). In rectal examination it is possible to find out irregular elargement of lobes of the prostate, sites of induration (infiltration), morbidness when pressed.

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The essential value for diagnostics of a chronic prostatitis has a research of a prostatic secretion. The treatment of the patient with chronic prostatitis should be complex. To control the infection antibiotics of a broad spectrum quinolones, chemical antibacterial drugs (Furagin, Biseptol) are applied. The medicinal treatment should be combined with local physiotherapeutic effects (massage of prostate, hot sitting baths, hot microclysters, rectal diathermy, mud rectal tampons). It is necessary to recommend for the patients an active regimen (more to move, less to sit), diet.

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The treatment of a chronic prostatitis in connection with a persistent clinical course of the disease should be long (many months), and consists of several courses with alternating the listed above methods of treatment.The chronic prostatitis is distinquished by its persistent, relapsing clinical course. Approximately for 1/3 of patients with chronic prostatitis the prognosis is unfavorable.

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Orсhitis Orсhitis is the inflammation of a testicle arising owing to its trauma or as a complication of infectious diseases, first of all, such, as epidemic parotitis, brucellosis, rheumatic polyarthritis, pneumonia, etc. Patients complain of suddenly arising pains in a testicle, chill, fever, enlargement of a testicle. Patient needs a bed regimen and maximum rest for the inflamed organ. Applying antibiotics of a broad spectrum is expedient. The origin of a testicular abscess is the indication to its opening. For the elderly people with a purulent orchitis it is expedient to make orchectomy.

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Epididymitis Epididymitis - the inflammation of epididymes, deve-lops more often owing to a penetration of the infection into an epididymis by a hematogenous route, as a complica-tion of infectious diseases (angina, pneumonia, etc.). Quite often the infection gets into an epididymis through a deferent duct owing to its antiperistaltic contractions, in presence of inflammatory process in the urethra, as well as at damage during instrumental research of the latter. The acute epididymitis starts suddenly with the fast increasing enlargement of an epididymis, sharp pains in it, fervescence and chill.

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The patient with acute epididymitis needs, first of all, a bed regimen, a diet, locally a cold is applied to a scrotum. Antibiotics of a broad spectrum of action are used. After abating of the acute inflammatory process a hot compress on a scrotum, diathermy for a resorption of an inflammatory infiltrate should be prescribed. If arises an abscess of the epididymis, the operative measure – opening an abscess is necessary. The prognosis of a epididymitis is favourable. However, in recurrence of disease the obstruction of an epididymis and deferent duct may develop and if the affection is bilateral, sets in a sterility.

HydroceleThe edema of sheaths of a testicle is characterized by an accumulation of serous fluid between visceral and parietal layers of own serous sheaths of a testicle. The causes of the acquired edema of sheaths of a testicle most often are the inflammatory diseases of epididymes and their trauma, inherent – non-closure of vaginal process of the peritoneum after a descent of testis into a scrotum. In acute inflammatory processes in a testicle and its epididymis a reactive, "symptomatic" edema of testicular sheaths, occur quite often which passes according to the extent of elimination of the basic disease

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According to clinical presentations there are two forms of hydrocele being distinguished - acute and chronic.The accumulation of a fluid proceeds slowly.The elargement of a scrotum can be small, but, sometimes, it reaches the sizes of a goose egg and even the head of the child. In an edema of sheaths of testicule of the very large sizes there are some difficulties occurred on an emiction and coitus.

Hydrocele has a smooth surface and densely - elastic consistency, painless upon a palpation, a fluctuation is also determined. Ussually it fails to palpate the testicle and only in small edema it can be defined. The reactive edema of sheaths of a testicle in an acute epididymitis and orchitis requires carrying out a conservative treatment - full rest, wearing a suspensory, antibacterial therapy. A puncture of hydrocele with the subsequent aspiration of its contents,) is not a radical method of treatment, that is fraught with hazard of development of complications (pyocele or hematocele). Of the radical methods of operative treatment the best are the Lord’s, Winkelman’s and Bergman’s operations

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NONSPEСIFIC INFLAMMATORY DISEASES OF GENITOURINARY ORGANS