LECTURE No. 9. Other urological diseases
1. Nephroptosis
Nephroptosis (prolapse of the kidney, wandering kidney) is a pathological condition in which the kidney leaves its bed and in an upright position shifts beyond the limits of physiological mobility. It occurs mainly in women aged 25-40 years, more often on the right. Currently, nephroptosis can be detected in 1.54% of women and 0.12% of men. Normally located and not having pathological adhesions with the surrounding tissues, the kidneys have mobility within one lumbar vertebra.
Etiology.The main role is played by factors leading to significant changes in the ligamentous apparatus of the kidney (infectious diseases, weight loss) and to a decrease in the tone of the anterior abdominal wall during pregnancy or for other reasons. Trauma (a fall from a height, a blow to the lumbar region, a sharp increase in weight), leading to overstretching or rupture of the ligamentous apparatus, can contribute to the development of nephroptosis. The more frequent occurrence of nephroptosis in women is explained by their constitutional feature (wider pelvis), right-sided nephroptosis is observed more often, which is associated with a lower standing of the right kidney and a stronger ligamentous apparatus of the left.
Nephroptosis is characterized by a change in the position of the kidney, its vessels and the ureter. The most serious changes occur in the vessels of the kidney. The kidney, moving downward, sharply changes the angle of origin of the renal artery and vein; vessels, stretching, lengthen, their diameter decreases. The upper part of the ureter forms kinks; fixing, they violate the patency of the ureter. With nephroptosis, a torsion of the renal vein is formed, which leads to venous renal hypertension, varicose veins easily occur.
Classification.Nephroptosis can be fixed and mobile. There are three stages of nephroptosis. At stage I, the lower pole of the kidney is palpated during inhalation, but during inhalation it goes into the hypochondrium. At stage II, the entire kidney leaves the hypochondrium in the vertical position of the patient, and its rotation around the vascular pedicle is significant; while the vessels of the kidney are stretched, bent, twisted; in the horizontal position of the body, the kidney returns to its usual place. At stage III, the kidney completely leaves the hypochondrium, displaces into the large or small pelvis. At this stage, a fixed bend of the ureter may occur, leading to an expansion of the calyx-pelvis system. At stages II and II, stretching and torsion of the vascular renal pedicle occurs with a decrease in its lumen. Changes in the position and mobility of the kidney and its vessels lead to venous stasis and hypoxia of the organ, conditions are created for the development of urostasis and infection in the renal parenchyma.
Clinic.Complaints may be absent, and a mobile kidney is detected by chance. Clinical manifestations of nephroptosis without hemodynamic and urodynamic disturbances are scarce. At the initial stage, patients complain of slight dull pain in the lumbar region in an upright position of the body and during physical exertion.
Pain relief occurs in the position on the affected side, while lying on the healthy side, patients feel heaviness or dull pain in the opposite side of the lower back or abdomen.
The study of urine usually does not detect changes. At stage II, the pain intensifies somewhat, spreads throughout the abdomen with irradiation to the back, the area of \u200b\u200bthe bladder, stomach, sometimes acquiring the character of renal colic. Proteinuria and erythrocyturia can be detected as a result of damage to the fornical veins due to increased pressure in the venous system. At stage III of nephroptosis, the intensity of pain increases sharply, they become permanent, lead to mental depression, appetite disappears, headaches, dyspepsia, fatigue, irritability appear.
With the development of pyelonephritis in the drooping kidney, the body temperature rises (either constant and moderate rises in chronic pyelonephritis, or periodic rises to high numbers with tremendous chills in acute pyelonephritis). Changes in urine characteristic of pyelonephritis also appear: leukocyturia, bacteriuria. Over time, kidney function decreases sharply, which contributes to the development of arterial hypertension. It is characteristic that with nephroptosis, blood pressure rises in an upright position.
Complications.Hydronephrosis and hydroureter as a result of kinks of the ureter, fixed with cicatricial cords, accessory vessels. A frequent complication of nephroptosis is venous hypertension in the kidney, manifested by hematuria, which occurs during physical exertion and disappears at rest, in a horizontal position of the patient. Another common complication of nephroptosis is pyelonephritis, a prerequisite for which is venous stasis in the kidney, urodynamic disorders and changes in the neuromuscular apparatus of the kidney. Pyelonephritis sharply complicates the course of nephroptosis. Arterial hypertension is another serious complication of nephroptosis: when the kidney descends, the angle of origin of the renal artery and vein changes sharply, the vessels stretch, lengthen, their diameter greatly decreases, tears of the intima and the inner elastic membrane of the renal artery occur, followed by the development of cicatricial processes - fibromuscular dysplasia of the renal artery with the development of vasorenal hypertension. Nephroptosis can also lead to fornical bleeding.
Diagnostics.Recognition of nephroptosis presents certain difficulties, since the symptoms of its complications prevail in the clinical picture. When making a diagnosis, the presence of a trauma in the anamnesis, the relationship of pain with the vertical position of the patient and physical activity, episodes of pyelonephritis, hematuria, and high blood pressure are taken into account. Palpation of the kidney is carried out not only in the horizontal, but also in the vertical position of the patient, in which in most cases it is possible to palpate the lowered kidney. Instrumental and radiological research methods help to clarify the diagnosis. Excretory urography in the horizontal and vertical position of the patient allows you to determine the degree of their displacement and functional ability, ultrasound is performed. Renal angiography, duplex examination of the vessels of the kidney can reveal fibromuscular changes in the renal artery. To clarify the functional state of the kidney, isotope renography, kidney scintigraphy are used.
Differential diagnostics.Differential diagnosis is carried out with renal dystopia using aortography (with renal dystopia, the renal arteries extend from the aorta below the usual level). When making a diagnosis of nephroptosis, a kidney tumor, an abdominal tumor is excluded.
Treatment.Conservative therapy consists in the appointment of antispasmodic, analgesic, anti-inflammatory drugs, warm baths, horizontal position of the patient. Early prescription of the bandage prevents the progression of nephroptosis and its complications. Wear the bandage only in a horizontal position, in the morning, before getting out of bed, while exhaling. In addition, a special set of gymnastic exercises to strengthen the muscles of the anterior abdominal wall will not be superfluous. If rapid weight loss contributed to the formation of nephroptosis, it is necessary for the patient to gain weight (flour, sweet food). In case of complications of nephroptosis (pyelonephritis, vasorenal hypertension, fornical bleeding, hydronephrotic transformation), surgery is indicated - nephroplexia.
Forecast.The prognosis without treatment is poor due to the progression of the disease and its complications. Timely treatment leads to a full recovery of working capacity.
Prevention.Elimination of sharp physical efforts, repeated injuries of the renal region, prolonged physical work in an upright or bent position of the body. Prevention during pregnancy and after childbirth is especially important. It is necessary to completely exclude heavy physical exertion, work associated with straining, tension of the abdominal press, but regularly perform light physical exercises in order to strengthen the muscles of the anterior abdominal wall, wear a bandage, a corset until the tone of the muscles of the anterior abdominal wall is restored after childbirth. Weight control is of great importance for the prevention of nephroptosis, especially with an asthenic constitution, when an increase in body weight should be recommended. Women who, in order to lose weight, subject themselves to a strict diet, should remember that a decrease in body weight below normal is fraught with undesirable consequences, including nephroptosis.
This text is an introductory fragment.Lecture number 2. Diseases caused by Neisseria
Lecture № 12. Diseases of the nasal cavity 1. Curvature of the nasal septum Curvature of the nasal septum is one of the most common rhinological pathologies. The causes of frequent deformity can be anomalies in the development of the facial skeleton, as well as rickets, trauma. IN
Lecture No. 17. Chronic diseases of the pharynx 1. Hypertrophy of the tonsils Adenoids Children have a tendency to hypertrophy of the pharyngeal tonsils, especially the nasopharyngeal (so-called adenoids). During puberty, the tonsils usually atrophy, with the exception of
LECTURE No. 17. Diseases of the lungs 1. Pneumonia Pneumonia is a disease characterized by inflammatory changes in the lung tissue. In this case, the accumulation of inflammatory exudate occurs in the pulmonary alveoli. In the vast majority of cases
LECTURE No. 18. Diseases of the pulmonary system 1. Acute bronchitis Acute bronchitis is a disease characterized by inflammation of the mucous membrane of the bronchi. Etiology. Bacteria (pneumococci), viruses (adenoviruses, respiratory syncytial
LECTURE № 28. Liver diseases 1. Hemolytic, hepatic and obstructive jaundice. Essence, subjective, objective symptoms Jaundice is a clinical and biochemical syndrome that occurs when there is bilirubin in the blood. As a bile pigment, it
LECTURE № 6. Inflammatory diseases of bones 1. Acute and chronic osteomyelitis Osteomyelitis is a purulent inflammation of the bone marrow and bone, accompanied by the involvement of the periosteum and surrounding soft tissues in this process, as well as general disorders of the systems and
LECTURE No. 5. Pustular skin diseases Pustular skin diseases (pyoderma) are infectious skin lesions caused by the introduction of staphylococci or streptococci. More rarely, other pathogens can cause pyoderma - Pseudomonas aeruginosa
LECTURE No. 6. Rickets, rickets-like diseases Rickets is a disease of infants and young children with bone formation disorder and bone mineralization deficiency, the leading link is vitamin D deficiency and its active metabolites during the most
LECTURE No. 1. Diseases of the esophagus Brief anatomical and physiological characteristics. There are three parts of the esophagus - cervical, thoracic and abdominal. Its total length is on average 25 cm.The esophagus is fixed only in cervical spine and in the area of \u200b\u200bthe diaphragm, the rest of its sections are quite
Metabolic disorders and other diseases Atherosclerosis A disease associated with lipid metabolism, which leads to the deposition of cholesterol and calcium in the walls of the arteries. This leads to a thickening of the walls and a decrease in the elasticity of blood vessels, a decrease in their lumen and
Urological diseases Urological diseases include inflammatory diseases of the male genitourinary system - acute and chronic diseases of the kidneys and urinary tract, such as prostatitis and others. In acute and chronic forms, take
Urological diseases This is the second area of \u200b\u200bmedicine in which hirudotherapy is especially effective. Most often, leeches are used to treat prostatitis, prostate adenoma, urolithiasis, secondary infertility in
Name: Urology. Lecture notesOsipova O.V.
The year of publishing: 2008
Tongue: Russian
The size: 0.4 MB
Format: pdf
Methodical guide "Urology. Lecture notes" edited by Osipova OV, considers practical and theoretical issues of urological practice. Inflammatory diseases of the urinary system and male genital organs, damage to the urinary and male genital organs, sexual disorders in men, impaired copulatory function, oncopathology of the urinary system, tuberculosis of the genitourinary system, urolithiasis, anomalies in the development of the genitourinary system, nephroptosis, enuresis, urology, overactive bladder.
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Name: Enuresis. Classification, causes, diagnosis and treatment
Kazanskaya I.V., Otpuschennikova T.V.
The year of publishing: 2005
Tongue: Russian
The size: 0.39 MB
Format: pdf
Description: The presented methodological recommendation "Enuresis. Classification, causes, diagnosis and treatment" under the editorship of Kazanskaya IV, et al., Considers a review of the literature covering problematic aspects ... Download the manual
Name: Evidence-based treatment of primary nocturnal enuresis in children
Maslova O.I., Studenikin V.M., Vishnevsky E.L.
The year of publishing: 2002
Tongue: Russian
The size: 0.99 MB
Format: pdf
Description: Methodical recommendation "Treatment of primary nocturnal enuresis in children from the standpoint of evidence-based medicine", ed., Maslova OI, et al., Considers current information about nocturnal enuresis. Outlined ... Download the training manual
Name: Edematous syndrome
Mukhin N.A., Svistunov A.A.,
The year of publishing: 2011
Tongue: Russian
The size: 7.07 MB
Format: pdf
Description: Methodical recommendation "Edema syndrome", ed., Mukhina N.A., et al., Considers the historical aspects of the clinic, diagnosis and therapy of edema syndrome. The clinical characteristics are presented ... Download the manual
Name: Chronic kidney disease and nephroprotective therapy
Shilov E.M.
The year of publishing: 2012
Tongue: Russian
The size: 4.63 MB
Format: pdf
Description: The presented methodological recommendation "Chronic kidney disease and nephroprotective therapy" under the editorship of Shilova E.M., et al., Considers the diagnostic criteria and principles of classification of chronic kidney disease ...
Book "Selected Lectures on Urology"
ISBN: 5-89481-626-2
The book contains information on the most pressing problems of modern urology, on the difficulties arising in the process of diagnosis and treatment. Considerable attention is paid to general issues of urology, inflammation of the genitourinary system, tumors, urolithiasis and sexual disorders in men. Radiation diagnostic methods, principles of urogenital reconstruction in exstrophy and epispadias, organ-preserving surgical interventions for kidney cancer, treatment of metastatic and locally advanced bladder cancer, surgical treatment of erectile dysfunction in men, laparoscopic pelvic lymphadenectomy in prostate cancer, and so on are considered. The information presented in the book will help the clinician navigate difficult cases encountered in urology. It is recommended for urologists, general practitioners, surgeons, students of medical universities.
General questions of urology
Sacral neuromodulation in the treatment of neurogenic disorders
urination
Botulinum toxin in the treatment of functional urinary disorders
Radiation diagnostic methods in modern urology
Modern methods of radionuclide diagnostics in urology
Intracavitary ultrasonography in the diagnosis and treatment of kidney and upper urinary tract diseases
Modern methods of continental cutaneous urine diversion
Principles of urogenital reconstruction in epispadias and exstrophy in adults
Bladder diverticula
Endoscopic treatment of vesicoureteral reflux in children
Hydronephrosis
Boys' Reproductive and Sexual Health
Modern principles of diagnosis and treatment of iatrogenic ureteral injuries
Inflammatory diseases of the genitourinary system
Urethral catheter as a risk factor for the development of hospital urinary infection
Urodynamics of the upper urinary tract with pyelonephritis
Features of the use of antimicrobial drugs in the treatment of urinary tract infections in children
Ultrasound diagnosis of inflammatory diseases of the prostate and seminal vesicles
Modern methods of treatment of septic conditions in urology
Ozone therapy in urology
Urolithiasis disease
What is extracorporeal shock wave lithotripsy?
Drug treatment and prevention of urolithiasis
Coral nephrolithiasis
Modern methods of surgical treatment of urolithiasis in children
Errors, dangers and complications of extracorporeal shock wave nephroureterolithotripsy
Remote nephrolithotripsy in patients with kidney malformations, nephroptosis and after kidney transplantation
Tumors of the genitourinary system
Interstitial radiation therapy (brachytherapy) for localized prostate cancer
Magnetic resonance imaging in the diagnosis of bladder cancer
Is organ-sparing treatment possible for invasive bladder cancer?
Quality of life of urological cancer patients after intestinal urine diversion
Papillary tumors of the upper urinary tract: endoscopic diagnostic and treatment methods
Organ-preserving surgery for kidney cancer
Transurethral electrosurgery of the prostate: yesterday, today, tomorrow
Laser surgery for prostate adenoma
Endoscopic methods of diagnosis and treatment of superficial bladder cancer
Evidence-Based Medicine Tactics for Treatment of Locally Advanced and Metastatic Bladder Cancer
Laparoscopic pelvic lymphadenectomy for prostate cancer
Diseases of the genitals, urethra and sexual disorders in men
Choosing a surgical method for Peyronie's disease
Some aspects of complex therapy for congenital or acquired syndrome of "deformed penis"
Endoscopic treatments for urethral strictures
Urethroprostatic stenting in the treatment of obstructive lower urinary tract diseases
Treatment of urinary incontinence in men with artificial sphincter implantation
bladder
Physiological aspects of erection
Surgical treatment of erectile dysfunction
Epidemiology and pharmacotherapy of erectile dysfunction
Elephantiasis of the external genital organs
Title: Urology. Lecture notes.
In this book you will find all the necessary lecture notes for the course "Urology".
Content.
LECTURE No. 1. Inflammatory diseases of the urinary system and male genital organs
1. Urinary tract infections
2. Acute pyelonephritis
3. Chronic pyelonephritis
4. Kidney abscess
5. Kidney carbuncle
6. Apostematous pyelonephritis
7. Infectious toxic shock
8. Paranephritis
9. Cystitis
10. Chronic cystitis
11. Urethritis
12. Stricture of the urethra
13. Acute prostatitis
14. Abscess of the prostate
15. Chronic prostatitis
16. Orchitis
17. Acute vesiculitis
18. Vesiculitis chronic
19. Differentitis
20. Cavernite
21. Prostate stones
22. Cooperite
23. Epididymitis
24. Funicular
LECTURE No. 2. Copulatory dysfunctions. Sexual disorders in men
1. Age-related changes in the male body
2. Erectile dysfunction
3. Female sexual dysfunction (FSD)
4. Infertility in men
5. Aspermia
6. Virilization
7. Delayed puberty
8. Puberty premature
LECTURE No. 3. Damage to the urinary and male genital organs
1. Foreign bodies of the bladder
2. Foreign bodies of the urethra
3. Foreign bodies of the kidney
4. Damage to the bladder
5. Damage to the urethra
6. Damage to the ureters
7. Damage to the scrotum
8. Injury to the penis
9. Kidney damage
10. Damage to the testicle and its epididymis
11. Urogenital fistulas in women
12. Gallbladder fistulas
13. Urethral fistulas
14. Torsion of the spermatic cord
15. Paraphimosis
LECTURE No. 4. Tuberculosis of the genitourinary system
1. Tuberculosis of the kidney
2. Tuberculosis of the penis
3. Tuberculosis of the bladder
4. Tuberculosis of the urethra
5. Tuberculosis of the ureter
6. Tuberculosis of the prostate and seminal vesicles
7. Tuberculosis of the testicle and its epididymis
LECTURE No. 5. Urolithiasis disease
1. Coral kidney stones
2. Ureteral stones
3. Bladder stones
4. Stones of the urethra
LECTURE No. 6. Tumors of the kidneys, urinary tract, and male genital organs
1. Adenocarcinoma of the kidney
2. Adenosarcoma of the kidney
3. Kidney tumor
4. Tumors of the ureter
5. Tumors of the bladder
6. Tumors of the urethra
7. Benign tumors of the urethra in women
8. Malignant tumors of the urethra in women
9. Benign tumors of the urethra in men
10. Malignant tumors of the urethra in men
11. Prostate cancer
12. Adenoma of the prostate
13. Testicular tumors
14. Tumors of the penis
LECTURE No. 7. Abnormalities of the urinary and male genital organs
1. Aplasia of the kidney
2. Kidney hypoplasia
3. Kidney dystopia
4. Accessory kidney
5. Horseshoe kidney
6. Doubling of the kidney
7. Spongy kidney
8. Polycystic kidney disease
9. Kidney cysts
10. Solitary renal cysts
11. Dermoid cyst
12. Hydronephrosis
13. Hydroureteronephrosis
14. Doubling of the ureters
15. Neuromuscular dysplasia of the ureter
16. Ureterocele
17. Ectopia of the ureteral opening
18. Exstrophy of the bladder
19. Bladder diverticulum
20. Non-clogging of the urinary duct
21. Congenital valves of the urethra
22. Congenital diverticula of the urethra
23. Congenital strictures of the urethra
24. Hypospadias
25. Epispadias
26. Short frenulum of the foreskin
27. Phimosis
28. Anarchism
29. Monorchism
30. Cryptorchidism
31. Klinefelter's syndrome
32. Shereshevsky-Turner syndrome
33. Spermatocele
34. Dropsy of the membranes of the testicle and spermatic cord
LECTURE No. 8. Emergencies in urology
1. Hematuria
2. Acute urinary retention
3. Anuria
4. Renal colic
LECTURE No. 9. Other urological diseases
1. Nephroptosis
2. Necrosis of the renal papillae
3. Retroperitoneal fibrosis
4. Pelvic-renal reflux
5. Vesicoureteral reflux
6. Overactive bladder
7. Enuresis
8. Varicocele
9. Plastic induration of the penis
Urinary tract infections - the state of infection of the urinary tract by microflora, which causes its inflammation. In Russia, the prevalence of UTI is 1000 cases per 100 thousand population per year, this is the most common infection. UTIs are 50 times more common in women than in men. The most common acute uncomplicated cystitis, somewhat less often - uncomplicated pyelonephritis. Recurrent UTIs develop in 20–30% of pre-menopausal women.
By the age of 50, the frequency of UTIs in men and women is comparable. The cost of treating UTIs in the United States is $ 1.6 billion per year, and one episode of acute cystitis is $ 40-80. Nosocomial UTIs cause death in 50,000 patients annually.
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"Course of lectures on urology Test [IRKUTSK STATE MEDICAL UNIVERSITY] Chapter. General clinical research methods COURSE OF LECTURES ON UROLOGY FOR STUDENTS ... "
-- [ Page 1 ] --
IRKUTSK STATE MEDICAL UNIVERSITY
Course of lectures in urology
[IRKUTSK STATE MEDICAL UNIVERSITY]
Chapter ". General clinical research methods
COURSE OF LECTURES ON UROLOGY FOR STUDENTS OF MEDICAL, PEDIATRIC AND MEDICO-PREVENTIVE FACILITIES OF MEDICAL UNIVERSITY.
Urology is a field of clinical medicine that studies the etiology, pathogenesis, diagnosis of diseases of the urinary system, the male reproductive system, diseases of the adrenal glands and other pathological processes in the retroperitoneal space and develops methods for their treatment and prevention.
Urology is a surgical discipline, a branch of surgery. Therefore, unlike nephrology, urology deals mainly with the issues of surgical treatment of diseases of the above organs and systems. Due to the clinical problems faced by the urologist, he requires knowledge of pediatrics, gynecology, endocrinology, oncology, neurology, dermatovenerology and a number of other medical specialties.
HISTORY OF UROLOGY DEVELOPMENT
The science of "urology" (Greek uron urine, logos teaching) originated in ancient times. Already Hippocrates (IV century BC) in his writings described the most characteristic changes in urine: changes in color and odor, the appearance of pathological inclusions (pus, blood, etc.) in it, and also tried to classify some diseases of the kidneys and bladder.At the time of Hippocrates, there were "kamneseks" - people who can remove stones from the bladder by perineal access.
Avicenna's "Canon of Medicine" describes in detail the technique of surgery to remove stones from the bladder, and he also developed a technique for catheterization of the bladder.
Some historians consider Francisco Diaz to be the founder of urology, as a separate medical discipline, his monograph, published in Madrid in 1588, is completely devoted to the causes of occurrence, clinic, diagnosis, treatment of urological diseases, urological surgery technique, description of urological instrumentation.
In Russia, IP Venediktov, who lived in the second half of the 18th century, was an outstanding "stonecutter", who performed more than 3000 stonecutting during his life (with a postoperative mortality rate of about 4%).
The world's first specialized urological department was opened in Paris in 1830, headed by J. Civiale, who was the first to offer cystolithotripsy.
The first epicystolithotomy in Russia was performed in 1823 by K.I.Grum-Grzhimailo, the first cystolithotripsy - in 1830 by A.I.Pole (according to the method of J. Civiale). The development of domestic urology is inextricably linked with the names of I.V.Buyalsky, A.M.A.M.Shumlyansky, N.I. Pirogov, F.I. Inozemtsev. The first Russian monograph on urology is considered H. Zuber's dissertation "On diseases of the urinary bladder."
In 1890, Felix Guyon became the first professor of urology in Paris, and urology was taught as a separate course in general operating surgery.
An especially great leap forward in the development of urology as a science took place in the second half of the 19th century. So, in 1869, the German doctor Simon successfully removed a kidney for the first time. Since that time, the creation of urological clinics throughout Europe began.
In Russia, the development of urology is associated with the names of T.I. Vdovikovsky (in 1863 he opened the first urological department), I.V. Buyalsky, who developed surgical methods for treating the bladder.
However, the founder of this field of medicine in Russia is still S.P. Fedorov is a famous surgeon, author of the book "Surgery of the kidneys and ureters", founder of the Russian Urological Society. It is for his
an initiative in Russia, urology began to stand out as an independent science in 1904, and in 1923 a government decree was issued on the opening of urology departments in leading medical universities in the country.
In 1923, the journal "Urology" was established in Russia, and in 1926, the 1st All-Russian Congress of Urologists was held in Moscow. Since 1929, excretory urography began to be used in the USSR, since 1956 - hemodialysis, since 1958 - transfemoral renal angiography, with 1965 - kidney transplant.
Endoscopic research methods go back to the beginning of the 19th century, when the German physician Bozzini manufactured the "Lichtleiter" apparatus for illumination of the bladder and urethra, which subsequently did not find practical application.
Further attempts to create instruments for examining the mucous membrane of the lower urinary tract are associated with the names Segalas, Desormaux and Grunfeld. The technical idea of \u200b\u200bthese authors was to supply light from the outside, through various tubes inserted into the urethra.
Some authors give the palm in the invention of the cystoscope to the Parisian surgeon Antoine Jean Desormeaux, who demonstrated his cystoscope in 1853. at the Paris Medical Academy, and in 1865. published an essay describing this device and the first attempts at endoscopic therapy. The world's first model of a cystoscope was proposed in 1877 by M. Nitze, who, continuing to improve his invention, created various versions of a cystoscope (viewing, irrigation, evacuation, operating), in 1893 he made the world's first cystoscopic photography, and in 1894 he also published the world's first cystophotographic atlas. In 1897, the Cuban I. Albarran improved the cystoscope with a special device (the so-called "Albarran's lift"), which made it possible to catheterize the ureters.
In 1907, the International Association of Urologists was created in Paris, and in 1908 the 1st International Congress of Urologists was held there.
The further development of urology was largely facilitated by the discovery of X-rays. Around the same time, there was an intensified development of general surgery, which also accelerated the formation of urology as an independent medical discipline.
In the 20th century, new diagnostic methods were actively developed:
chromocystoscopy, pyelography, transurethral electroresection, etc., for the first time an operation was performed using an artificial kidney.
In modern urology, the latest diagnostic and treatment methods are used: computed tomography, percutaneous puncture (percutaneous) methods of extraction and crushing of kidney and urinary tract stones, remote shock wave lithotripsy, X-ray endovascular methods of treating vascular diseases of the genitourinary organs, endoscopic operations on the upper and lower urinary tract - that there is a replacement of traditional surgical interventions with "closed", transabdominal and retroperitoneal methods of treatment, which
Chapter ". General clinical research methods
less traumatic, easier to tolerate by patients and help to reduce the length of their stay in the hospital. In recent years, in the world and in Russia, robot-associated operations on Da Vinci devices have begun to be performed, which made it possible to avoid errors and complications arising from endoscopic operations.
Domestic urology works closely with the European Society of Urology and the American Association of Urology, which makes it one of the most developed medical disciplines in the world.
Thus, modern urology is a discipline that is actively developing and is closely related to many medical areas.
What sections does modern urology include?
Urology is a part of surgery. However, the rapid development of science and technology has led to the formation of subdisciplines of urology, developing at the junction with other specialties of clinical medicine. American
The Urological Association has proposed eight areas (subdisciplines) of urology:
1. Pediatric (children's) Urology (Pediatric Urology) - the study and treatment of congenital and acquired urological diseases in children.
2. Urological Oncology (Urologic Oncology) - study and treatment of malignant neoplasms of the male and female urinary tract and male reproductive organs (including kidney, ureter, prostate, bladder cancer, testicular cancer in men and bladder cancer in women) ...
3. Renal Transplantation - issues of kidney transplantation in renal failure.
4. Erectile dysfunction or impotence.
5. Male Infertility.
6. Stones of the urinary tract (Urinary Tract Stones) - treatment of stones in the urinary tract, which are formed as a result of metabolic disorders and excessive kidney excretion of those substances that go to build a stone.
7. Female (urogynecology) Urology (Female Urology) - treatment of urinary incontinence, pelvic disorders, trauma and other diseases.
8. Neurological urology (Neurourology) - treatment of urological disorders that are caused by neurological trauma or neurological diseases, such as multiple sclerosis, muscular dystrophy, Parkinson's disease or spina bifida.
In Russia, the subdisciplines of urology are: oncourology, pediatric urology, urogynecology, phthisiourology, endourology, andrology. In addition to them, neuro-urology has begun to actively develop in recent years.
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SYMPTOMS AND SYNDROMES IN UROLOGY
The whole variety of clinical manifestations of urological diseases can be brought to 4 groups of symptoms: 1) pain; 2) disorders of urination; 3) changes (qualitative and quantitative) urine; 4) pathological changes in sperm and discharge from the urethra.The clinical picture of urological diseases is characterized by significant polyformism. The main specific syndrome in urology is acute or dull pain in the lower back and abdomen, above the bosom and perineum, in the genitals. Pain occurs both during physical exertion and at rest, in the upright position of the patient's body, and in the supine position.
Thus, pains differ in localization and irradiation; by intensity: sharp and dull; with the flow:
constant, intermittent; for a reason: during physical activity, without physical activity.
It is often noted that acute colicky pains accompanied by nausea, vomiting, peritoneal symptoms, and hyperthermia, if interpreted incorrectly, lead to an erroneous diagnosis. So, nephroptosis with an atypical clinical picture is often diagnosed as acute appendicitis, while appendectomy is unnecessarily performed. It happens that acute pains are accompanied by frequent urge to urinate and anuria, and sometimes jaundice. It should be noted that the asymptomatic course of urological diseases is often observed, which ranges from 8% to 20% of cases.
Disorders of urination.
An important indicator of urine is e specific gravity, which depends on the weight of the molecules dissolved in 1 ml of urine. With a normal diet, an average of 1200 mOsm of substances are excreted in the urine, which, with a specific gravity of 1036, are excreted in 1000 ml of urine, and with a specific gravity of 1006 - from 6 liters of urine. Consequently, 1200 mOsm of substances to be excreted by the kidneys are excreted in different amounts of urine of different specific gravity, depending on the concentration capacity of the kidneys. With the usual intake of food and liquid, the specific gravity in a healthy person fluctuates between 1015 and 1025 in daily urine.
Under normal conditions of life, 700 osmotically active substances should be excreted from the body in the urine every day. To remove such an amount with the maximum possible urine osmolality (1000 my / kg), you need at least 700 ml of urine per day. Such a daily volume of urine is called obligate diuresis, or obligate volume.
Changes in urine can be quantitative: 1) oligo- and anuria; 2) polyuria; 3) nocturia; 4) hypo- and isostenuria and qualitative: 1) proteinuria; 2) hematuria; 3) cylindruria; 4) leukocyturia (pyuria).
Quantitative change in urine: Assessing the total amount of excreted urine per day, one should be guided
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not only on the absolute values \u200b\u200bof this indicator, but also on the ratio of the daily volume of urine and the amount of liquid drunk and in food. A healthy person normally excretes about 3/4 (65–80%) of the liquid drunk during the day.
An increase in diuresis of more than 80% of the fluid drunk per day in patients with congestive circulatory insufficiency may indicate the onset of edema convergence, and a decrease below 65% indicates their increase.
The daily amount of urine fluctuates physiologically within certain limits depending on the food intake, the amount of fluid injected, the external temperature, the work performed, and other factors. Men normally excrete an average of 1500 - 2000 ml of urine per day, and women - 1200 - 1600 ml. The largest amount of urine is excreted between 3 and 6 pm, and the least between 3 and 6 hours. in the morning, and most of the urine (80%) is excreted dnm.
Dysuria is a general definition of a urinary disorder (often referred to as frequent and painful urination).
Anuria is a complete absence of diuresis.
The cause of oliguria is a violation of glomerular filtration. Oliguria occurs when, under the influence of prerenal, renal and postrenal factors, the glomerular filtration rate falls below 10 ml / min.
Oliguria leads to: 1) an increase in the volume of extracellular fluid - hyperhydria; 2) the accumulation of osmotically active substances in the body. In particular, hypernatremia, hyperkalemia develop; 3) the accumulation of metabolic end products in the blood - azotemia.
Polyuria is an increase in daily urine output over 1.8 liters. In humans, the maximum possible diuresis, provided that it is not osmotic, is 25 l / day, which is 15% of the volume of filtered water.
The causes of polyuria can be extrarenal (psychogenic polydipsia, disorders of water-salt metabolism and its regulation, for example, diabetes insipidus) and renal (polyuric stage of acute and chronic kidney failure) factors.
Depending on the mechanisms of development, the following types of polyuria are distinguished.
1. Water diuresis. It is caused by a decrease in the facultative reabsorption of water. Occurs with water load, diabetes insipidus. Urine with such polyuria is hypotonic, i.e. contains few osmotically active substances.
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2. Osmotic diuresis (saluresis). It is associated with an increase in the content of unreabsorbed osmotically active substances in the urine, which leads to a secondary violation of water reabsorption. Polyuria of this type develops when:
a) violation of electrolyte reabsorption;
b) an increase in the content in the primary urine of the so-called threshold substances (for example, glucose in diabetes mellitus);
c) the action of exogenous substances that are poorly reabsorbed (mannitol) or disrupt the reabsorption of electrolytes (saluretics).
Under conditions of maximum osmotic diuresis, urine excretion can reach 40% of the value of glomerular filtration.
3. Hypertensive diuresis. It develops with arterial hypertension, when the speed of blood movement in the direct vessels of the medulla of the kidneys increases (these vessels run parallel to the knees of Henle's loop). In this case, the convection transport of substances increases, it is this transport, and not diffusion, that becomes the leading one.
The consequence of increased convection transport is the "leaching" of sodium, chlorine, urea from the interstitium. This leads to a decrease in the osmotic pressure of the extracellular fluid, as a result, the reabsorption of water in the descending part of the Henle loop decreases and polyuria develops.
Oliguria is a decrease in daily urine output below the obligate volume, i.e. less than 700 ml / day. The cause of oliguria is a violation of glomerular filtration. Oliguria occurs when, under the influence of prerenal, renal and postrenal factors, the glomerular filtration rate falls below 10 ml / min.
Oliguria leads to: 1) an increase in the volume of extracellular fluid - hyperhydria; 2) the accumulation of osmotically active substances in the body. In particular, hypernatremia, hyperkalemia develop; 3) the accumulation of metabolic end products in the blood - azotemia.
Pollakiuria - frequent painless urination (20-30 times a day or more). Pollakiuria can be caused by: cardiovascular diseases, taking diuretics and cardiac glycosides, diabetes mellitus, acute and chronic glomerulonephritis, chronic pyelonephritis, polycystic kidney disease, interstitial cystitis, functional and organic diseases of the nervous system (tumor neuroses and brain injuries, etc.) ...
Nocturia (from Latin noctu) - the need to get up at night one or more times in order to empty the bladder. Aging of the bladder and LUTS / BPH are common causes of nocturia.
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Nocturia - (from the Greek nyctos) - nocturnal polyuria. Nocturia is a pathological symptom, the essence of which is the predominance of the nocturnal part of diuresis over the daytime.
Normally, 60-80% of the daily amount of urine is secreted from 8 to 20 hours, i.e. the ratio of nocturnal diuresis to daytime is 1: 2.
With nocturia, the nighttime urine portion can be more than twice the daytime portion.
Depending on the reasons, there are:
1) cardiac nocturia - develops with heart failure. During the day, patients increase the load on the heart and water intake, which leads to blood stagnation and water retention in the tissues (edema). At night, in a horizontal position, venous outflow improves and the load on the heart decreases. This causes the release of atrial Nauric hormone, an increase in urine output and a decrease in edema;
2) renal nocturia - characteristic of kidney damage. It is attributed to an improvement in renal blood flow at night. As a result, the movement of blood through the vessels of the kidneys is accelerated, hypertensive diuresis develops.
Stranguria - Difficulty urinating. Often combined with frequent and painful urination (dysuria). Causes - bladder outlet obstruction (LUTS / BPH), urethral strictures.
Urinary incontinence is the involuntary flow of urine without the urge to urinate. Urinary incontinence can be true (no anatomical defects) and false (ectopia).
Urinary incontinence - the inability to retain urine in the bladder with an imperative (imperative) urge. Among the causes of urinary incontinence, inflammatory (cystitis) and neurological (OAB, multiple sclerosis, Parkinson's disease, spinal syndrome) diseases of the bladder, diseases of the prostate gland (BPH) , prostatitis, cancer).
Enuresis is urinary incontinence.
Nocturnal enuresis - bedwetting.
Ishuria - urinary retention (acute and chronic; complete and incomplete). In ischuria, there is residual urine in the bladder after urination.
Paradoxical ischuria - is a paradoxical combination of complete chronic urinary retention and urinary incontinence.
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polyuria - an increase in the amount of urine excreted per day (more than 2800 ml), with a low relative density (1002 - 1012). Reasons - excessive fluid intake, diabetes mellitus, diabetes insipidus, oliguria - a decrease in the amount of daily urine less than 500 (400) ml / day (below 16 ml / hour), anuria - a life-threatening condition when urine is or is not formed by the kidneys (below 4 ml / hour), or does not enter the bladder Qualitative change in urine: The reaction of urine depends on the amount of free hydrogen ions released during the dissociation of organic acids and acidic salts - the actual reaction of urine (pH). Under normal conditions in healthy people, urine has a slightly acidic reaction, pH and fluctuates, depending on the diet, between 4.5 and
8. Urine is a well-buffered solution, as a result of which the pH ratio does not allow true fluctuations in the body's acid-base balance. With many urological diseases, a qualitative change in the composition of urine occurs. Among them are:
Hematuria is a pathological symptom characterized by the appearance of red blood cells in the urine. There are micro- and macroscopic hematuria. To clarify the localization of the source of bleeding, a two- and three-glass test is performed: in this case, the patient is offered to urinate sequentially in two or three glasses.
Macroscopic hematuria can be of three types:
1) Initial (initial), when only the first portion of urine is stained with blood, the rest of the portions are of normal color. With initial hematuria, the pathological process is often localized in the urethra. It is necessary to distinguish initial hematuria from urethrorrhagia, in which blood is released from the urethra outside the act of urination. When specifying the nature of hematuria in women, it is necessary to exclude bleeding from the genitals. In such cases, examine the middle portion of urine during spontaneous urination or urine obtained from the bladder by catheterization. Hematuria in women that coincides with the premenstrual period should suggest bladder endometriosis.
2) Terminal (final), in which no blood impurity is visually detected in the first portion of urine and only the last portions of urine contain blood, which indicates the presence of a process in the posterior urethra or in the bladder. Such hematuria is more often observed in acute cystitis, prostatitis, stone and bladder tumor.
3) Total, when the urine in all portions is equally colored with blood, which may be due to the localization of the pathological process either in the kidney, or in the ureter, or in the bladder. The most common causes of total hematuria are a tumor, stone, kidney injury, bladder tumor, less often benign prostatic hyperplasia, bladder and kidney tuberculosis, pyelonephritis, renal papillary necrosis, nephroptosis, renal venous hypertension, hydronephrotic transformation, etc.
In the case of an admixture of blood, the urine acquires a red color of varying intensity - from the color of "meat slops" to dark cherry. But the degree of blood loss cannot be assessed by the color of urine, because the content of 1 ml of blood in 1 liter of urine already gives it a red color. The intensity of bleeding is determined by the presence of blood clots, the degree of blood loss is determined by the hemoglobin indicator, and more precisely, the hematocrit. Scarlet blood excreted in the urine indicates ongoing bleeding. In cases where the urine becomes brown, it should be considered that the bleeding has stopped, and the color of the urine is due to the dissolution of blood clots in the urine.
A putrid odor indicates urinary stagnation and infection. It should be remembered that the color of urine can change when taking various medications and food: from madder dye
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- brownish red, from phenolphthalein and beet - red, from pyramidon - pink, 5-NOC - saffron-yellow, from rhubarb and senna - brown, from purgen, with an alkaline reaction of urine - raspberry.
Hematuria should be distinguished from hemoglobinuria - while the bloody coloration of urine depends on the breakdown of erythrocytes in the blood and the excretion of hemoglobin in the urine, which is in it in the form of cylinders. The color of urine with hemoglobinuria does not change even with prolonged standing, while with hematuria, erythrocytes quickly settle to the bottom of the vessel and the upper layers of urine acquire a normal yellowish color. Hemoglobinuria is observed after transfusion of incompatible blood, with poisoning with aniline, mushrooms, berthollet's salt, carbolic acid, prolonged cooling and extensive burns. An admixture of myoglobin in urine gives it a reddish-brown color. Myoglobin, a protein similar in composition to hemoglobin, enters the bloodstream from crushed muscles during the so-called. "Crash syndrome" (prolonged compression and crushing of tissues), because its molecule is three times less than hemoglobin, it easily penetrates into urine.
Topical diagnosis of the source of hematuria is helped by the nature of the blood clots.
Worm-shaped clots indicate bleeding from the upper urinary tract and their formation in the ureter. However, the formation of such clots is possible in the lumen of the urethra after traumatic catheterization of the bladder in a patient with benign prostatic hyperplasia (adenoma). Shapeless clots are more likely to form in the bladder. For the topical diagnosis, pain in the lumbar region is important, which are caused by an acute violation of the passage of urine from the kidney by the formed clots.
The combination of two symptoms - hematuria and pain - makes it possible to differentiate the neoplasm of the kidney from nephrolithiasis. In nephrolithiasis, hematuria occurs not so much as a result of trauma to the urothelium of the pelvis with calculus, but as a result of a violation of the integrity of the fornical venous plexus with a sharp increase in intralochanical pressure. So hematuria with nephrolithiasis occurs after an attack of pain (renal colic), i.e. after restoration of the passage of urine through the upper urinary tract. With a kidney tumor, hematuria appears suddenly and can stop on its own. As a rule, it is painless, however, when the ureter is occluded by blood clots, pain occurs after hematuria.
Essential hematuria combines a number of conditions in which the etiology, pathogenesis is unknown, and clinical and radiological and morphological studies do not allow to find out the cause of bleeding. a sign of recovery or stopping the development of the disease. Hematuria is an absolute indicator for hospitalization of a patient in a hospital (in particular, in the urology department). To determine the tactics of treating a patient in a hospital, an important role belongs to the collection of analysis and examination of the patient at the pre-hospital stage. It is necessary to find out the conditions for the occurrence of hematuria, its degree, nature and duration, the time of e occurrence before or after an attack of renal colic, the presence of blood clots in the urine, their shape, the presence or absence of pain and dysuria during urination. The cessation of hematuria does not always indicate the resolution of the problem. Often hematuria recurs, the "light gaps" between episodes become shorter.
Leukocyturia - the appearance of leukocytes in the urine over 5 in the field of view. Leukocyturia, in which a very large number of leukocytes are found in the urine, including those destroyed, is called pyuria.
The main cause of leukocyturia is inflammation in the renal tissue and urinary tract.
Pyuria - pus in the urine, a sign of inflammation in the urinary system;
Proteinuria - the presence of protein in the urine (sometimes true - renal and false - extrarenal); What are the mechanisms of proteinuria? Its development may be based on the following mechanisms:
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1) an increase in the permeability of the glomerular filter due to damage to the basement membrane (glomerular proteinuria) ",
2) a decrease in the tubular reabsorption of the filtered protein (tubular proteinuria);
3) pathological intake of protein into the lumen of the tubules from damaged cells of the tubular epithelium or from the peritubular lymphatic fluid (secretory proteinuria).
Proteinuria can be selective, when only low-molecular-weight proteins are detected in the urine, and non-selective, which is characterized by the appearance of both low- and high-molecular proteins in the urine.
According to the degree of selectivity, nephrotic type of proteinuria is distinguished (in urine only albumin or albumin + a-globulins) and nephritic type (all classes of blood plasma proteins are determined in urine - albumin, a-, (3- and y-globulins).
Bacteriuria - the presence of bacteria in the urine;
Hemoglobinuria - the presence of free hemoglobin in the urine (blood diseases, incompatible blood during blood transfusions, septic abortions, poisoning with carbolic acid, aniline, berthollet's salt);
Pneumaturia - excretion of gas in the urine during urination (intestinal-urinary fistulas, emphysematous cystitis);
Cylindruria is the detection in urine of cylinders formed in the kidneys as a result of protein coagulation in the tubules. The cylinders are casts of the renal tubules. They are formed when the tubular epithelium is damaged and consist of coagulated protein and dead cells. Different types of cylinders are formed by the deposition of various constituents of urine, such as erythrocytes, leukocytes, epithelial cells, pigments, etc., on a protein cast of the cylinder. Allocate: Hyaline cylinders - can be observed in healthy people. Their number increases with exercise, proteinuria.
Granular cylinders - are formed when the decay of adhered cells has gone far, in which a granular structure of the cylinders is formed. With the further development of the process of cell degeneration and with their longer stay in the tubules, waxy cylinders are formed (with chronic renal failure, polyuria after acute renal failure).
Hypostenuria occurs when the kidneys' ability to concentrate urine decreases. It is characterized by a decrease in the relative density of urine to 1012-1006, and changes in this density throughout the day are insignificant. The combination of hypostenuria with polyuria indicates tubular damage with relatively sufficient glomerular function. If hypostenuria occurs against the background of oliguria, then this is a sign of damage to all structures of the nephrons (tubules and glomeruli).
When the kidneys completely lose the ability to concentrate and dilute urine, isostenuria develops, in which the relative density of urine is equal to the density of the filtrate, i.e. 1010, and does not change throughout the day
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(monotonous diuresis). Isotenuria is a sign of very severe disorders in which the renal tubules are essentially converted into ordinary tubes that carry filtrate into the renal pelvis.
Otki. Pathogenetically, there are three types of edema that develop with different kidney damage.
1. Edema in acute and chronic kidney failure. The main mechanism of their development is hydrostatic (hypervolemic). A decrease in the glomerular filtration rate, characteristic of renal failure, leads to sodium and water retention in the body (positive water balance) and, as a result, to hypervolemia. The latter, being the reason for the increase in hydrostatic pressure in the capillaries, causes the development of edema according to the Starling mechanism.
2. Nephrotic edema. The main mechanism of their development is oncotic (hypoproteinemic).
Disorders of the glomerular filter in nephrosis cause massive proteinuria, as a result of which hypoproteinemia develops and oncotic blood pressure drops. This, in turn, by the Starling mechanism causes the transfer of water from the vessels to the tissues - edema develops.
3. Nephritic edema. They develop in acute and chronic glomerulonephritis. The pathogenesis of these edema is complex and includes the following mechanisms:
a) inflammation of the glomeruli of congested blood in the vessels of the kidneys hypoxia of the juxtaglomerular apparatus activation of the renin-angiotensin system aldosterone secretion sodium retention in the body and increased osmotic blood pressure antidiuretic hormone secretion water retention hypervolemia edema;
b) inflammation of the glomeruli; impaired renal circulation; decreased glomerular filtration rate; sodium and water retention in the body; hypervolemia; edema;
c) glomerular inflammation, increased renal filter permeability, proteinuria, hypoproteinemia.
Urinary Disorders Acute urinary retention (AUR). This is the sudden absence of an act of urination with an overflowing bladder and painful urge. AUR can be caused by benign prostatic hyperplasia (adenoma), prostate cancer, acute prostatitis, bladder neck sclerosis, urethral foreign body, urethral stone and rupture, neoplasm of the lower urinary tract. Less commonly, diseases and damage to the central nervous system (tumor, trauma, etc.) can be the causes of AUR. AUR of a reflex nature often occurs after operations, especially in elderly and senile men and children. Often
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the occurrence of AUR in elderly men is preceded by prim atropine or M2 - M3 cholinomimetics. In this case, AUR is a consequence of a decrease in detrusor tone, more often with an already existing urological disease, for example, with benign prostatic hyperplasia (adenoma).
The clinical picture of AUR. The patient is worried, experiencing severe pain in the suprapubic region, painful urge to urinate, a feeling of fullness in the lower abdomen. When examining the abdomen, you can find an ovoid swelling between the bosom and the navel in acute urinary retention or paradoxical ischuria. This is nothing more than a significantly overflowing bladder with urine, the so-called bladder ball (globus vesicalis).
The palpable formation has a smooth surface, elastic consistency. Palpation with acute urinary retention increases pain and causes excruciating urge to urinate. With paradoxical ischuria, there is less palpation pain. The lower pole of the formation goes posterior to the pubic articulation, the upper one often reaches the navel. With a significant filling of the bladder, its upper pole manages to give the hand small pendulum-like movements, the lower pole remains motionless. Fluctuations can often be detected in the area of \u200b\u200b"protrusion". Percussion above the formation is determined by a dull sound. After emptying the bladder with a catheter, the palpable mass disappears.
Diagnosis is primarily based on the history data, examination of the patient. When interviewing, it is important to pay attention to how the patient urinated before AUR, what color the urine was, whether he took any drugs that promote urinary retention. It is necessary to clarify all the points that could lead to this condition. Knowledge of the causes and pathogenesis of AUR will help to develop the most correct solution in each specific case.
Differential diagnostics. It is very important to differentiate AUR from anuria. With AUR, the patient is disturbed by the painful urge to urinate, but with anuria they are absent, palpation of the suprapubic region does not cause severe pain, since the bladder is empty. We must not forget about this type of urinary retention, such as "paradoxical ischuria", in which the bladder is full, the patient cannot empty the bladder on his own, but urine is involuntarily excreted in drops. If urine is released from such a patient with a urethral catheter, urine leakage stops for a while (until the bladder is again full).
Treatment. Urgent emptying of the bladder is an urgent measure. At the prehospital stage, this can be done by catheterizing the bladder with an elastic catheter. If AUR lasts more than a day, it is advisable to leave the catheter in the urinary tract with the appointment of prophylactic antibiotic therapy.
Contraindications to bladder catheterization are: acute urethritis and epididymitis (orchitis), acute prostatitis and / or prostate abscess, urethral trauma. In the event that at least one of the listed factors is present, it is necessary to resort to the installation of a suprapubic urinary drainage system (trocar epicystostomy or seсtio alta). The issue of hospitalization of the patient is decided individually each time. With the existing difficulties of the first catheterization, signs of urethrorrhagia, acute inflammation of the urethra, scrotum and prostate organs, trauma to the urethra, inability to insert the catheter (more than two attempts are unacceptable) - urgent hospitalization in the urology department is indicated. In the case of AUR after the administration of medications or of a reflex nature, treatment can be outpatient. The use of a metal catheter in the pre-hospital stage should be avoided. Epicystostomy is performed only in a urological or surgical hospital.
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1. Arenal anuria (renoprivna) - with congenital aplasia (agenesis) of both kidneys, with accidental or deliberate removal of both (or the only functioning) kidneys.
2. Prerenal anuria - called prerenal disorders of renal functions caused by circulatory disorders in the kidneys.
Mechanisms of its development:
a) decreased cardiac output (cardiogenic shock, heart attack);
b) systemic vasodilation (sepsis, neurogenic shock);
c) hypovolemia and a sharp decrease in the volume of circulating blood (blood loss, plasma loss (with extensive burns), dehydration (with vomiting, diarrhea, forced diuresis), the emergence of a "third space" (with sequestration of fluid into the abdominal cavity - ascites, into the subcutaneous tissue - edema and other reasons.) The intensity of renal blood flow is normally very high (about 1300 ml / min, or 25% of the minute blood volume at rest), which is due to its specific function, i.e. participation in the implementation of filtration and reabsorption. with acute renal failure, GFR rapidly decreases from 100-140 to 10-1 ml / min.
For the initial stage of chronic renal failure, a drop in GFR from 100-140 to 30 ml / min is characteristic, for early polyuric - from 30 to 10 ml / min, for late oliguric - from 10 to 5 ml / min, for terminal - below 5 ml / min.
Pathogenesis - disorders of general hemodynamics and circulation with a sharp depletion of renal blood circulation induce afferent vasoconstriction with redistribution (shunting) of renal blood flow, ischemia of the cortical layer and a decrease in the glomerular filtration rate in the kidney. With aggravation of renal ischemia, prerenal anuria can turn into renal due to ischemic necrosis of the epithelium of the renal convoluted tubules.
3. Renal anuria - in most cases caused by acute tubular necrosis, the causes of which can most often be:
a) renal ischemia (with prolonged clamping of the renal artery, with thrombosis and thromboembolism of the renal vessels - intravascular block, renal hypoperfusion - as a result of prolonged arterial hypotension (prerenal factor).
b) nephrotoxic factors: iodine-containing X-ray contrast agents during angiography, salts of heavy metals (lead, mercury, copper, barium, arsenic, gold), antibiotics (aminoglycosides, amphotericin B), organic solvents (glycols, dichloroethane, carbon tetrachloride), uricuric crises ( intrarenal tubule occlusion with uric acid crystals - with gout, chemotherapy for myelo- and lymphocytic leukemia, with sulfonamides), etc.
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c) other causes of renal anuria - acute and chronic end-stage renal failure due to glomerulonephritis, malignant arterial hypertension, hemorrhagic fever with renal syndrome, etc.
4. Postrenal anuria - acute violation outflow of urine from the kidneys into the bladder. This is the so-called acute supravesical urinary retention resulting from occlusion of the upper urinary tract on both sides. In the case of a single or only functioning kidney, this form of anuria occurs as a result of obstruction of its ureter. The most common cause of postrenal anuria is urolithiasis, mainly in the form of ureteral stones. This circumstance served as the basis for calling this form of anuria obstructive or excretory, while the prerenal and renal forms were called secretory.
Other reasons leading to postrenal anuria include external urinary tract compression in retroperitoneal fibrosis, uterine and ovarian cancer, and others.
The clinical picture. The early symptoms of anuria are always associated with its cause: disease or exacerbation of chronic damage to the organs of the cardiovascular vascular system, trauma, accidental or suicidal intake of unknown or clearly dangerous drugs or substances, exacerbation of already known chronic diseases - urolithiasis, gout, diseases of the pelvic organs, etc.
Among the signs of the clinical course of anuria are:
- violation of water and electrolyte metabolism
- violation of the acid-base state
- damage to the central nervous system (uremic intoxication)
- increasing azotemia
- lung damage
- acute bacterial and non-bacterial organ inflammation.
One of the most dangerous manifestations of a violation of water-electrolyte metabolism is hyperkalemia - an increase in the concentration of potassium in the serum to a level of more than 5.5 meq / l, which is observed in hypercatabolic processes, when the accumulation of potassium is a consequence of not only blockade of renal excretion, but also a consequence of its intake from necrotic muscles, hemolyzed erythrocytes. In this case, life-threatening hyperkalemia (more than 7 meq / l) can develop on the first day of the disease. Metabolic hyperchloremic acidosis occurs in most cases as a result of a decrease in blood bicarbonate levels to 13-15 mol / L. With pronounced violations of the acid-base state, there is a "big noisy" breathing of Kussmaul and other signs of damage to the central nervous system. Azotemia is a cardinal sign of anuria, and its severity reflects the severity of its course.
With severe overhydration, uremic pulmonary edema develops, manifested by progressive respiratory failure.
Diagnostics. The main thing in the success of the elimination of anuria is early diagnosis, and although this is a condition for almost all emergency conditions, in this case it determines - an emergency hospitalization in a specialized department of the hospital, an urgent need for hemodialysis (ethylene glycol, heavy metals) and much more, which makes it possible to prevent destructive processes in the kidneys, severe suffering of the patient and often - to save his life.
At the slightest suspicion of anuria, hospitalization should be mandatory. This suspicion arises after
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collected anamnesis; severe acidosis with high anionic deficiency develops due to impaired renal excretion of sulfates and phosphates, as well as due to ketoacidotic (diabetic and alcoholic) coma, intoxication with alcohol surrogates (methanol, ethylene glycol), in shock, carbon monoxide poisoning, etc., and in in any case - determining the presence of urine in the bladder. This is important in all cases, but especially when the patient's consciousness is "confused", memory is "clouded", the explanation of relatives is not clear, etc. For differential diagnosis with acute urinary retention, bladder catheterization is performed.
To resolve the issue of the form of anuria, it is necessary to find out whether there was an effect of nephrotoxic factors;
you need to know about the presence of diseases leading to anuria (urolithiasis, prostate disease, gynecological diseases, heart disease, etc.), whether there have been episodes of renal colic. When examining a patient, it is necessary to pay attention to the presence of free fluid and the presence of massive edema, to measure blood pressure (at a blood pressure below 70 mm Hg, prerenal anuria may develop). Auscultation can reveal the presence of moist rales of various sizes over the entire surface of the lungs, if there is uremic pulmonary edema, radiographically characterized by multiple cloudy infiltrates in both lungs, a butterfly symptom. Biochemical monitoring and ECG play a leading role in the detection of hyperkalemia and control of potassium levels. Electrocardiography reveals hyperkalemia by high, narrow, pointed positive T waves, a gradual shortening of the electrical systole of the ventricles - the Q – T interval, with a possible slowdown in atrioventricular and intraventricular conduction and a tendency to sinus bradycardia.
Treatment. With the diagnosis of anuria, the success of treatment is in emergency hospitalization. However, in the case of its prerenal form, which arises as a consequence of cardiogenic shock or collapse, it is necessary to control cardiac activity, vascular peripheral tone in order to stabilize blood pressure. In the case of postrenal anuria, emergency hospitalization in a urological clinic is indicated, and in case of renal anuria due to poisoning, it is possible before that emergency gastric lavage by a tube or "restaurant" method, as well as the introduction of antidotes with a well-defined poisonous substance. Physical methods of examining patients, along with laboratory ones, remain the leading ones in clinical medicine
METHODS OF EXAMINATION IN UROLOGY.
1.General (physical)
2. Laboratory
3. Special.
1. General clinical (physical) examination methods: examination, palpation, percussion, auscultation.
Physical examination methods, along with laboratory ones, remain the leading ones in clinical medicine and urology in particular.
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Before palpating the kidneys, a visual examination of the patient should be performed: determine the condition of the skin (hyperemia, abrasions, postoperative scars, turgor and other changes), pay attention to the condition of the spine (scoliosis), muscle development, etc. .Only after that carry out the palp and c and yu organs of the abdominal wall. It should be carried out warm hands with short cropped nails. Palpation of the anterior abdominal wall and lumbar regions determine the degree of muscle tension and soreness. Reflex muscle tension can be observed in renal colic, and sharp pain in the costolumbar angle and muscle tension in the lumbar region and the corresponding hypochondrium are characteristic of acute pyelonephritis. In healthy people, with correct palpation, it is far from always possible to palpate the kidney: in obese people it is almost impossible to palpate a healthy kidney, and in thin, asthenic people, palpation of the kidney can always be determined. Palpation of the kidneys must be done in three positions of the patient: on the back, on the side and standing. Palpation provides invaluable services in the study of patients with surgical kidney diseases (cancer, abscess, cyst, etc.), since in the latter the kidneys are very often enlarged. In addition, palpation plays a major role in recognizing kidney displacements. The best position of the patient on palpation of the kidneys is recumbency, since this achieves the relaxation of the abdominal muscles necessary for successful palpation.When palpating the kidneys in the supine position, the patient lies on his back with his legs extended and his head resting on a low pillow, making deep, even breathing movements with his stomach. Palpation is performed bimanually. The doctor, located to the right of the patient (palpation method according to J. Petit, ND Strazhesko and S. P. Fedorov), puts the palm of his left hand under the corresponding half of the waist. If the right kidney is probed, then the palm of the left hand is positioned so that its proximal part is at the right contour of the patient's waist, and the ends of the extended fingers reach the spine. If the left kidney is palpable, then the palm, placed on the right side, moves further to the left until its proximal part is to the left of the spine, and the ends of the fingers cover the left waist contour. The doctor places the palm of the right hand with slightly bent ends of 2-5 fingers on the outer part of the corresponding hypochondrium. Since the long axis of the kidney is directed somewhat obliquely from top to bottom and outward, according to Obraztsov's method, the same should be the direction of the line formed by the ends of the folded fingers of the right hand. Following, further, the patient's breathing and using the relaxation of the abdominal muscles with each exhalation, the examiner plunges the fingers of the right palm deeper and deeper, at the same time feeding the lumbar region with his left palm towards the palpating fingers. This is done until there is a feeling of touching both hands through the abdominal integument and the layer of the lumbar muscles. After that, the patient is offered to breathe deeply with his stomach. If the kidney is enlarged or
Chapter ". General clinical research methods
is displaced so that when it is lowered at the moment of inhalation, the lower pole reaches the point of contact of both hands of the examiner, then the fingers of the right hand receive a clear palpation sensation from this pole. Pressing the palpable pole of the kidney with the right hand through the abdomen to the left hand lying on the lower back, slide the fingers of the right palm, continuing to press the kidney down along its front surface and bypassing its lower pole.
In this case, an idea is obtained about the following physical properties of the palpable part of the kidney: 1) about its shape,
2) size, 3), the thickness of the lower pole, 4) the nature of the anterior surface of the kidney, 5) consistency, 6) mobility and 7) palpation tenderness of the kidney. If the kidney is greatly enlarged, then it is possible to probe most of its anterior surface. With a significant prolapse of the kidney, it is possible to bypass with palpating fingers and its upper pole.
G. Marion (1931) proposed to palpate the kidneys both on the left and on the right side of the patient, which created certain difficulties, and often the impossibility of changing sides.
More often, when palpating the left kidney, the doctor remains on the right side of the patient, brings the right hand on the left side of the patient under the left costovertebral angle so that it can push the kidney forward, and puts the left hand in front on the left hypochondrium and palpates it.
Simultaneously with palpation of the kidney in the patient's supine position, palpation of the kidney on the side (according to Israel) should be performed. With this palpation, the patient lies on a healthy side, the leg on the affected side is slightly bent at the knee and hip joints. In this position, the enlarged or lowered kidney seems to come out of its bed and palpation becomes available. In this case, the intestine is displaced in the opposite direction and does not interfere
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When examining the left kidney, the patient lies on the right side, when examining the right kidney, on the left side.
Having felt the kidney between two hands, with the bent fingers of the left hand lying on the lower back, they apply jerky blows to the lumbar region. With each push, the kidney approaches the palm of the right hand lying on the hypochondrium, hits the fingers and moves back again. This ability to run is very characteristic of the kidney, unless it is excessively enlarged and fixed by inflammatory adhesions. This method was proposed by the French urologist Guyon. The gallbladder, spleen and the curvature of the colon do not have this ability.
However, to recognize the prolapse of the kidneys, it is necessary to palpate both in the supine and standing position, when the kidney is slightly displaced downward and anteriorly both due to gravity and due to the lower standing of the dome of the diaphragm. In order for the abdominal muscles to relax somewhat and in the standing position of the patient, he should be asked to lean forward a little. The method of palpation of the kidneys in a standing position was proposed by S.P. Botkin. The position of the doctor's hands and the technique are similar, only the position of the patient changes: he stands facing the doctor, who sits directly in front of the patient.
With palpation of mobile kidneys, you can use the Glenar technique. At the same time, we cover the right flank with our left hand, placing the thumb under the costal arch, and the rest in the lumbar region. Squeezing the hand, as it were, we displace the kidney inward, while it is better palpated with the right hand.
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more comfortable than standing on your side.
Perkus and I have a certain value in the study of palpation detected education.
The intestine is located anterior to the enlarged kidney, in this regard, with percussion of the abdominal wall, it is possible to determine the tympanitis zone above the kidney. When a palpable organ or tumor is located in the abdominal cavity above the formation, a dull sound is noted percussion. However, with a significant increase in the size of the kidney (advanced cancer, giant cyst), a dull percussion sound is often observed above the kidney, because the latter in these cases is in close contact with the abdominal wall, pushing the intestines to the side.
Soreness when tapping the lumbar region is noted in many diseases of the kidneys and retroperitoneal space. In the domestic literature, this symptom was named after the author - F.I. Pasternatsky. He noted that in renal pathology, pain occurs during tapping in the kidney area, followed by a short-term appearance or increased erythrocyturia. At present, the symptom has been somewhat modified, evaluating only its first part (the onset of pain), the second part of the symptom (the appearance of erythrocyturia) has less diagnostic value. The symptom of Pasternatsky is determined in the patient's standing or sitting position by applying short, light blows with the edge of the palm (lateral surface of the hand) along the lumbar region below the XII rib alternately on each side. Some clinicians prefer to lightly punch the right hand against the left hand on the corresponding side of the lower back. When pain appears, the symptom is considered positive, which is explained by the concussion of the affected kidney or paranephron.
In foreign (primarily American) literature, the pain that occurs when tapping the area of \u200b\u200bthe costovertebral angle (similar to Pasternatsky's) is described as a Murphy symptom.And in the kidney zone is primarily important for the diagnosis of vasorenal hypertension. A slight systolic murmur, which is most clearly heard in the right or left upper quadrant of the abdomen and behind in the region of the costovertebral angle on one side or the other, indicates the possibility of renal artery stenosis. With arteriovenous fistula in the kidney and with atheromatous lesions of the abdominal aorta, the systolic murmur is rough, prolonged.
With fibrous or fibromuscular stenosis of the renal artery in the upper abdomen, a prolonged high-frequency murmur with late systolic amplification is often determined.
Ureters There are three ureteral points (Fig.). The superior ureteral point is located 3 transverse fingers outward (to the right or left) of the navel. The middle ureteral point (Tournais point) is located on the horizontal line connecting both anterosuperior spines of the iliac bones, at the intersection with the vertical line passing at the junction of the inner and two outer thirds of the pupar ligament. The lower ureteral point is located in the small pelvis and is available for palpation during vaginal or rectal examination (if there is a calculus in this part of the ureter). The ureteral points indicate its trajectory. At these points, as well as along the ureter, sites can be identified ____________________ _______________________________________________________________________
Chapter 2. Clinical methods, painfulness in urolithiasis, tuberculosis of the ureter and some other diseases of the ureter was investigated.
Only the classics of urology - S.P. Fedorov, B.N.Kholtsov, R.M., managed to palpate the ureters through the abdominal wall.
Fronstein, N. A. Lopatkin. (cited by MI Davidov, 2003) Palpation of the juxtavesical part of the ureter during bimanual examination through the vagina in women is quite accessible to any doctor in two pathological conditions: first, with stones in this part of the ureter; secondly, with tuberculous ureteritis and periureteritis, when the ureter is palpated in the form of a rigid, thick cord. In men, even in these situations, with a bimanual rectal examination, palpation of the juxtavesical part of the ureter is practically impossible due to the higher location of the ureter in relation to the examining finger.
Bladder The empty bladder is not palpable and is a collapsed sac, "hidden" behind the pubic articulation. It becomes available for examination, palpation and percussion when filling with urine, when it comes out from under the pubic articulation, or its pre-pathological state (tumors, blood clots).
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rectus abdominis muscle. In a malignant tumor of the testicle, in some cases, it is possible to palpate the packages of enlarged paraaortic and paracaval lymph nodes (Fig.).
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Laboratory methods of examination.
Laboratory examination methods include: study of the main indicators of peripheral and venous blood:
General blood test, with an expanded leukocyte formula, determining the number of reticulocytes, studying the morphology of erythrocytes, platelets;
Biochemical blood profile with quantitative (according to indications) determination of more than 60 indicators and fractions: fractions of blood proteins (globulins, albumin), study of liver enzymes, liver tests (thymol, sublimate), markers of renal function, pancreas, glucose levels, markers of inflammation, etc. dr.
Lipid profile: cholesterol, cholesterol-HDL, cholesterol-LDL, triglycerides;
Urine examination: carried out in order to exclude quantitative and qualitative changes: Qualitative changes: 1) proteinuria; 2) hematuria; 3) cylindruria; 4) leukocyturia (pyuria). Quantitative changes: 1) oligo- and anuria; 2) polyuria; 3) nocturia; 4) hypo- and isostenuria.
General urine analysis; urine analysis according to Nechiporenko, Addis - Kakovsky, Amburzhe.
The collection of urine is carried out after a thorough toilet of the external genital organs, so that no discharge from them gets into the urine. Bedridden patients are preliminarily washed with a weak solution of potassium permanganate or another antiseptic solution, then the perineum is wiped with a dry sterile cotton swab in the direction from the genitals to the anus. When collecting urine from bedridden patients, it is necessary to ensure that the vessel is located above the perineum in order to avoid contamination from the area. EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General clinic of the anal opening. Correct urine collection is necessary to obtain a reliable test result.
Collecting urine must be performed before various endourethral and endovesical studies and procedures. After cystoscopy, urine analysis can be prescribed no earlier than 5 to 7 days. The urine should be collected in a dry, clean dish, well washed from cleaning and disinfecting agents. It is advisable to use a vessel with a wide neck and a lid. If possible, urine should be collected directly into a container in which it will be delivered to the laboratory. If this fails, it is advisable to collect it in a clean dish (plate, jar, etc.), where there was no urine before (since a precipitate of phosphates forms in pots and vessels, which remains even after rinsing and promotes the decomposition of fresh urine), and then pour the entire portion obtained into a vessel.
It is best to collect the urine in special plastic cups with lids.
Men, when urinating, should, completely pulling the skin fold, free the external opening of the urethra. Women should part their labia and thoroughly wipe the urethra area with a damp swab before urinating.
It is advisable to put a tampon in the vagina before collecting material to prevent leukocytes, bacteria, erythrocytes from entering the urine. Also, do not collect urine during menstruation. Particular attention should be paid to the collection of urine by pregnant women.
A catheter or bladder puncture can be used to collect urine only in extreme cases - in newborns, infants, patients with prostate diseases, and sometimes for microbiological studies (catheterization increases the desquamation of cells in the urethra and bladder). Urine cannot be taken from a long-standing catheter for research! If urine was taken with a catheter, this is noted in the direction.
Urine collected for analysis can be stored for no more than 1.5 - 2 hours (always in the cold), the use of preservatives is undesirable, but it is allowed if more than 2 hours pass between urination and examination. Prolonged standing leads to a change in physical properties, the growth of bacteria and the destruction of urine sediment elements. This will cause the urine pH to shift to higher values \u200b\u200bdue to the ammonia released into the urine by bacteria. Microorganisms consume glucose, therefore, with glucosuria, negative or underestimated results can be obtained.
Bile pigments are destroyed in daylight. The most acceptable way to preserve urine is refrigeration (you can store it in the refrigerator, but not freeze). During cooling, the uniforms are not destroyed. CHAPTER 2. General clinical elements, but it is possible to influence the results of determining the relative density.
Preservatives are added when collecting daily urine (in the first portion of urine). Thymol is more often used as a preservative (several crystals per 100 ml of urine), sometimes toluene (several milliliters of toluene is added to a vessel with urine so that it covers the entire surface of urine in a thin layer; it gives a good bacteriostatic effect, does not interfere with chemical analyzes, but causes slight turbidity), boric acid (3-4 granules per 100 ml of urine, gives a sufficient bacteriostatic effect), glacial acetic acid (5 ml for the entire amount of daily urine).
Dishes with urine are delivered to the laboratory with a direction in which the patient's surname and initials, department, surname of the attending physician, diagnosis, time of urine collection, name of the study to which the material is sent are noted.
For a general urine analysis, the entire morning portion is collected, which accumulates in the bladder during the night. This reduces the natural daily fluctuations of physical and chemical parameters and thereby ensures their clearer connection with the pathogenetic processes in the patient's body.
The Nechiporenko method. To determine the number of formed elements in 1 ml of urine by the Nechiporenko method, an average portion of the first morning urine is collected - no more than 15 - 20 ml.
Kakovsky-Addis method. To count the formed elements in a daily amount according to the Kakovsky-Addis method, one of the conditions for conducting this study is some limitation of fluid intake during the examination period: the patient should not drink at night and drink less during the day. At the same time, the relative density of urine (1020 - 1025) and its pH (5.5) are standardized, which is very important when judging the number of hyaline cylinders, which easily dissolve in alkaline and low-concentration urine with a low relative density and remain longer in acidic and concentrated urine with high relative density. Urine is collected in 10 - 12 hours. The patient urinates before bedtime (this portion of urine is poured out), marks the time and after 10 - 12 hours urinates into the prepared dishes. This portion of urine is delivered to the laboratory for research. If it is impossible to keep urination for 10 - 12 hours, the patient EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. The general clinic urinates into the prepared dishes in several stages and notes the time of the last urination.
Amburge method. Determination of the amount of formed elements excreted in the urine in 1 min, according to the Amburge method. When examining this method, the patient limits fluid intake during the day and excludes at night.
The urine is collected in 3 hours. In the morning, the patient empties the bladder (this urine is discarded), marks the time and exactly 3 hours later collects urine for examination.
Three-glass test. To carry out a three-glass sample, a morning urine sample is collected. In the morning on an empty stomach, after waking up and thoroughly using the external genitalia, the patient begins to urinate into the first vessel, continues in the second and finishes in the third. The second portion should prevail in volume. When carrying out a three-glass test in men, the last (third) portion of urine is collected after prostate massage. All vessels are prepared in advance, each must indicate the portion number.
Two-glass test. more commonly used in urology in women. When urinating, urine is divided into two parts. It is important that the first portion in this case is small in volume. The dishes are also pre-prepared and the serving number is indicated on each vessel.
Collection of daily urine. The patient collects urine within 24 hours, observing the usual drinking regimen (1.5 - 2 liters per day). In the morning at 6 - 8 o'clock, he empties the bladder and marks the time (this portion of urine is poured out), and then, during the day, all urine is collected in a clean wide-necked vessel with a capacity of at least 2 liters, with a tight-fitting lid. The last portion is taken exactly at the same time when the collection was started the day before (the start and end times of the collection are noted). If not all urine is sent to the laboratory, then the amount of daily urine is measured with a graduated cylinder, a part is poured into a clean container, in which it is delivered to the laboratory, and the volume of daily urine must be indicated.
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Total functional tests:
Determination of daily diuresis (night diuresis is normally 1/3, daytime - 2/3) The Zimnitsky test is the simplest and most burdensome for the patient, but, nevertheless, an approximate way to assess the functional state of the kidneys. It allows you to assess the concentration function of the kidneys (i.e., the ability of the kidneys to concentrate and dilute urine).
The essence of the method is that the patient collects urine every 3 hours during the day (a total of 8 servings).
The following indicators are evaluated in the laboratory:
The amount of urine in each of the 3-hour portions The relative density of urine in each portion Daily diuresis (total amount of urine excreted per day) Daytime diuresis (urine volume from 6 a.m. to 6 p.m. (1-4 portions)) Night diuresis (volume urine from 6 pm to 6 am (5-8 servings)) Indications for the purpose of the analysis: assessment of the functional state of the kidneys;
material for research: daily urine Preparation for research, rules of sampling and transportation: the sample is carried out under the conditions of the usual drinking regime and the nature of the diet (excessive fluid intake is not allowed). It is necessary to exclude the intake of diuretics on the day of the study. Violation of these conditions leads to an artificial increase in the amount of urine discharge (polyuria) and a decrease in its relative density, which makes it impossible to correctly interpret the results of the study. For the same reason, carrying out a test according to Zimnitsky is inappropriate in patients with diabetes insipidus and diencephalic disorders.
EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinic
Urine for research is collected throughout the day (24 hours), including at night. At 6 in the morning, the patient empties the bladder, this portion is poured out. Then, starting at 9 a.m., exactly every 3 hours, the patient collects 8 portions of urine in a dry, clean container. The volume of each collected portion is measured, the urine is stirred and drawn into a vacuum tube (tube and urine collection holder are available from the CMD registry).
On each of the 8 tubes, indicate the portion number, the volume of excreted urine and the time of collection. If within three hours the patient has no urge to urinate, the portion is skipped. The collection of urine is completed at 6 a.m. the next day, after which all tubes are delivered to the laboratory.
Important! On the day of the study, it is also necessary to measure the daily amount of liquids drunk and in food (this information will be needed by your doctor to interpret the result).
Term of execution: 1 day
Reference values \u200b\u200band interpretation of results:
1. The amount of urine and the relative density in each portion. Normally, in an adult, fluctuations in the volume of urine in individual portions range from 40 to 300 ml; fluctuations in the relative density of urine between the maximum and minimum values \u200b\u200bshould be at least 0.012–0.016 (for example, from 1008 to 1025 or from 1010 to 1026, etc.). Significant daily fluctuations in the relative density of urine (normally from about 1008 to 1025 and even more) are associated with the preserved ability of the kidneys to either concentrate or dilute urine, depending on the constantly changing needs of the body.
The normal concentration function of the kidneys is characterized by the ability to increase the relative density of urine to maximum values \u200b\u200b(over 1020) during the day, and the normal ability to dilute is characterized by the ability to reduce the relative density of urine below the osmotic concentration (osmolarity) of protein-free plasma, equal to 1010-1012. With pathology, there can be both a decrease in the concentration function EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinic of the kidneys, and a violation of their ability to dilute urine.
Violation of the ability of the kidneys to concentrate urine is manifested by a decrease in the maximum values \u200b\u200bof the relative density, while in none of the portions of urine during the Zimnitsky test, including at night, the relative density does not exceed 1020 (hypostenuria). At the same time, the kidneys' ability to dilute urine remains for a long time, therefore, the minimum relative density of urine can reach, as in the norm, 1005.
At the heart of violations of the concentration ability of the kidneys is a decrease in osmotic pressure in the tissue of the medulla of the kidneys.
The reasons for this are:
A decrease in the number of functioning nephrons in patients with chronic renal failure (CRF), when the kidney loses its ability to create a sufficiently high osmotic concentration in the medulla.
Inflammatory edema of the interstitial tissue of the medullary layer of the kidneys and thickening of the walls of the collecting ducts (for example, in chronic pyelonephritis, tubulointerstitial nephritis, etc.), which leads to a decrease in reabsorption (reabsorption) of urea and sodium ions and, accordingly, to a decrease in osmotic concentration in the medulla kidneys.
Hemodynamic edema of the interstitial tissue of the kidneys, for example, with congestive circulatory failure.
Taking osmotic diuretics (concentrated glucose solution, urea, etc.), which increase the speed of movement of tubular fluid along the nephron and, accordingly, reduce Na + reabsorption. This, in turn, leads to disruption of the process of creating a concentration gradient in the medulla of the kidneys.
A decrease in the concentration capacity of the kidneys leads to a decrease in the relative density of urine (hypostenuria) and an increase in the amount of urine (polyuria).
EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General Clinic Impaired ability of the kidneys to dilute With severe kidney damage and progressive renal failure, a decrease in concentration ability is combined with impaired ability of the kidneys to dilute. In this case, the osmotic concentration of urine approaches the osmotic concentration of protein-free plasma and the relative density of urine during the day fluctuates within narrow limits (about 1009-1011). In none of the urine portions, the relative density is below this indicator. This condition is called isostenuria. Isostenuria is an earlier sign of renal failure than an increase in creatinine and blood urea, and is possible with their normal levels in the blood.
Finally, in some cases of severe renal failure, when the concentration of osmotically active substances in urine becomes lower than in plasma, a sharp narrowing of the amplitude of daily fluctuations in the relative density of urine occurs at an even lower level (1004-1009). Many authors call this condition "hypoisostenuria", although this term is rather controversial.
It must be remembered that low urine density and small fluctuations during the day may depend on extrarenal factors:
In the presence of edema, density fluctuations can be reduced. The density of urine in these cases (in the absence of renal failure) is high; hypostenuria is observed only during the period of edema convergence (in particular, when using diuretics).
With long-term adherence to a protein-free and salt-free diet, urine density can also remain at low numbers during the day.
Low urine density with small fluctuations (1000-1001), with rare rises to 1003-1004 is observed in diabetes insipidus, due to inhibition of antidiuretic hormone (ADH) secretion and a decrease in water reabsorption in the distal sections of the convoluted tubules and in the collecting ducts.
Much less often in the clinic there is an increase in the relative EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General clinical urine density, detected during the test according to Zimnitsky. The reasons for this increase are: pathological conditions, accompanied by a decrease in renal perfusion with the preserved concentration of the kidneys (congestive heart failure, the initial stages of acute glomerulonephritis), etc.; diseases and syndromes accompanied by severe proteinuria (nephrotic syndrome); hypovolemic conditions; diabetes mellitus with severe glucosuria;
toxicosis of pregnant women.
Folhard's test - a test for concentration (dry food) and dilution.
The sample is not physiological, urine collection after 4 hours, as in the Zimnitsky test.
The test allows you to identify the functional renal reserve.
Rehberg's test - Tareev - determination of renal function. Glomerular filtration rate (GFR) is the volume of blood plasma that is filtered into the renal tubules per unit of time.
GFR is determined by inulin clearance.
Inulin clearance is the volume of plasma that is completely cleared of this substance by the kidneys in 1 min:
where Cin is inulin clearance; f / in is the concentration of inulin in urine; An ~ concentration of inulin in plasma; V - diuresis in 1 min.
Normally, Cin, and hence the GFR, are 100-140 ml / min.
A decrease in endogenous creatinine GFR is the main indicator of the development of kidney failure. Allows you to determine the degree of involvement in the pathological process of the glomeruli and tubules of the nephron. Glomerular filtration is normally 100 - 120 ml per minute, tubular reabsorption
– 97 – 99 %.
Since GFR \u003d EFC-Kf, where EFD is the effective filtration pressure; K, |, - filtration coefficient, then two groups of mechanisms of glomerular filtration disorders can be distinguished.
I. Decrease in EFD. Since EFD \u003d Pk - (P0 + Pt), where Pk is the hydrostatic pressure in the capillaries of the glomeruli; P0 - oncotic blood pressure; RT - EXAMINATION OF A UROLOGICAL PATIENT Chapter 2.
Clinically, hydrostatic pressure in the glomerular capsule is the so-called tissue pressure, then a decrease in GFR may be due to:
1) a decrease in hydrostatic pressure in the capillaries of the glomeruli (Pk) due to general and local circulatory disorders (see Question 32.8);
2) an increase in oncotic blood pressure (P0), which happens, for example, with dehydration;
3) an increase in tissue pressure in the kidneys (RT). The reason for this is the obstruction of the outflow of filtrate or urine in case of damage to the tubules (clogging of the tubules by necrotic masses and cylinders), with interstitial inflammation (compression of the tubules by edematous fluid), in violation of the patency of the ureters and urinary tract (stones, strictures, tumor compression).
P. Reducing the filtration coefficient (Kf).
It may be due to:
1) a decrease in the total filtration area, which, in turn, depends on the number of active nephrons;
2) a decrease in the permeability of the wall of the glomerular filter, which is observed with thickening of the membrane (for example, with diabetic nephropathy), sclerosing of the glomeruli (a consequence of glomerulonephritis), clogging of the pores of the filter with proteins (hemoglobin, myoglobin, respectively, with hemolysis of erythrocytes and crushing of muscle tissue).
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Andrological studies: microbiological examination of sperm; functional tests, as well as hormonal studies:
Full spectrum of blood hormones: FSH, LH, estradiol, progesterone, prolactin, testosterone, DHA sulfate, DHA, thyroid hormones, cortisol, 17-hydroxyprogesterone, -HG;
Hormonal urine tests: 17-KS, 17-OCS.
Diagnostics of all types of infections: PCR diagnostics of infections with the study of smears, blood, urine, saliva, sperm: chlamydia, mycoplasma, ureaplasma, gardnerella, gonococcus, Trichomonas, cytomegalovirus, herpes simplex virus, Epstein-Barr virus, human papillomavirus, human serotyping streptococci, lactobacilli;
Blood tumor markers: Blood test for Ca - 125, free and total PSA, phosphatase (acidic and alkaline) Bacteriological examination of blood, urine, sperm with the release of a pathogenic pathogen and determination of sensitivity to antibacterial drugs.
3. Special methods of examination.
These include X-ray, radiological, ultrasound, instrumental, rheological, urodynamic, endoscopic studies.
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X-ray research methods are leading in the diagnosis of urological diseases. X-ray examination of the kidneys and urinary tract includes a survey roentgenography EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2.
General clinical practice of the abdominal cavity, when a snapshot is simply taken, and the study of the urinary tract using contrast agents (intravenous excretory urography). This allows you to get an X-ray image of the kidneys and urinary tract. The diagnostic capabilities of plain urography are limited, with a high degree of probability coral-shaped pelvic stones are detected with it, and stones in the ureters are less accurate. The method also makes it possible to roughly judge the location and size of the kidneys and their changes (prolapse of the kidneys, a significant increase in the size of one of the kidneys with hydronephrosis).
Excretory urography in these cases is of paramount importance.
To obtain maximum information when performing excretory urography V.Yu. Bosin (1989) recommends the following:
1) completely empty the bladder immediately before the administration of the contrast agent;
2) if possible, exclude the use of drugs, the effect of which on the state of renal function and urodynamics remains unknown;
4) inject the heated contrast agent at the highest possible speed;
5) take all pictures at the same focal length;
6) perform X-ray at possibly low exposures in the phase of maximum expiration;
7) the development time of the images of each series should be the same so that there are no differences in contrast.
We consider 7-10 and 15-20 minutes to be optimal for taking pictures. In this case, the first picture at the 7-10th minute is taken in a horizontal position, and the next one - in a vertical position. Such an EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinic mode of performing roentgenograms allows you to register the phase of tight filling of the pelvic-pelvic systems and to clearly reveal the anatomical and functional features of the kidneys.
The physiological mobility of the kidneys associated with a change in body position depends on the age of the patient and his constitution. On radiographs, the degree of mobility of the kidney was determined by comparing the amplitude of its displacement with the height of one lumbar vertebra. The method is often decisive in chronic pyelonephritis, kidney tumors, urolithiasis, hydronephrosis. By indirect signs, one can judge about some other diseases of the kidneys, renal vessels and urinary tract. In the last 15-20 years, due to the widespread use of ultrasound, magnetic resonance imaging and computed tomography, intravenous excretory urography has become less common. The main danger during excretory urography is the presence of an allergy to a radiopaque substance in a patient. Therefore, it is very important to warn the doctor referring to the procedure about such phenomena. It is necessary to warn in general about any allergy to drugs. It is impossible to conduct a study during pregnancy, despite the fact that the radiation load during this procedure is low and does not pose a danger to the patient.
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The first use of radioactive tracers dates back to 1911 and is associated with the name of György de Hevesy. The clinical use of radiotracers came into practice in the 50s. Methods are being developed that make it possible to detect the presence (radiometry), kinetics (radiography) and distribution (scanning) of a radio indicator in the examined organ.
A fundamentally new stage in radioisotope imaging is associated with the development of devices with a wide field of view (scintillation gamma cameras) and the imaging method - scintigraphy. Often the term "scintigraphy" refers to studies carried out using both a line scanner and a gamma scintillation camera. This terminological stereotype is associated with the formation of misconceptions about the diagnostic capabilities of methods.
EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General Clinic Scanning and scintigraphy are different methods of radioisotope imaging. Scintigraphy is significantly superior to scanning in terms of the volume and accuracy of diagnostic information. Modern scintillation chambers are computer scintigraphic complexes that allow obtaining, storing and processing images of an individual organ and the whole body in a wide range of scintigraphic modes: static and dynamic, planar and tomographic. Regardless of the type of image obtained, it always reflects the specific function of the organ under study. Basically, it is a mapping of functioning tissue. It is in the functional aspect that the fundamental distinguishing feature of scintigraphy from other imaging methods lies. An attempt to look at the results of scintigraphy from anatomical or morphological positions is another false stereotype that affects the estimated effectiveness of the method.
The diagnostic focus of a radioisotope study is determined by the used radiopharmaceutical (RFP). What is RFP? A radiopharmaceutical is a chemical compound with known pharmacological and pharmacokinetic characteristics. It differs from conventional pharmaceuticals not only in radioactivity, but also in another important feature - the amount of the basic substance is so small that when introduced into the body it does not cause side pharmacological effects (for example, allergic).
The specificity of the RP in relation to certain morphological and functional structures determines its organotropy. Understanding the mechanisms of RFP localization serves as the basis for an adequate interpretation of radionuclide studies. The introduction of RP is associated with a small dose of radiation that is incapable of causing any adverse specific effects. In this case, it is customary to talk about the danger of overexposure, but this does not take into account the pace of development of modern radiopharmaceuticals.
EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General Clinic The radiation exposure is determined by the physical characteristics of the radio indicator (half-life) and the amount of the injected RP.
Today is the day of radionuclide diagnostics using short-lived radionuclides. The most popular of these is technetium-99m (half-life 6 hours). This artificial radionuclide is obtained immediately before the study from special devices (generators) in the form of pertechnetate and is used for the preparation of various RFPs. The radioactivity values \u200b\u200bintroduced for one scintigraphic study create radiation exposure levels within 0.5-5% of the permissible dose. It is important to emphasize that the duration of the scintigraphic examination, the number of images or tomographic sections obtained no longer affect the "specified" radiation dose.
Clinical application. Renal imaging (dynamic renoscintigraphy) is a simple and accurate method of simultaneous assessment of the functional and anatomotopographic state of the urinary system. The basis is the registration of the transport of nephrotropic RP and the subsequent calculation of parameters that objectify two successive stages. Analysis of the vascular phase (angiophase) is aimed at assessing the symmetry of the passage of the "bolus" through the renal arteries and the relative volumes of blood flowing to each kidney per unit of time. The analysis of the parenchymal phase provides for the characterization of the relative function of the kidneys (contribution to the total cleansing capacity) and the time of passage of the RP through each kidney or its parts.
Clinical interpretation is largely determined by the mechanism for elimination of RP.
There are two types of RFPs that can be used in dynamic visualization methods:
l. glomerulotropic (DTPA derivatives), are almost completely filtered by the glomeruli and reflect the state and rate of glomerular filtration;
2. tubulotropic (analogs of hippuran) are secreted by the epithelium. EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinic of the proximal tubule and reflect the state of tubular secretion, as well as effective renal blood flow. Indications for research include urological and nephrological pathology, as well as diseases where the kidneys are target organs.
In different clinical situations, both the shape of the curves and their quantitative characteristics can change. However, it should be emphasized that the nature and magnitude of the changes are not very specific for a specific pathology and, first of all, reflect the severity of the pathological process. The greatest information content of renoscintigraphy is manifested in the differentiation of one or two-sided kidney damage. The leading sign that determines the side of the lesion is the asymmetry of the amplitude-time characteristics of angionephroscintigrams. The asymmetry of the vascular parameters, and above all the pronounced difference in the time of RP entering the renal arteries, is one of the criteria for renal artery stenosis. Symmetry of changes in parenchymal function is more typical, in particular, for glomerulonephritis; asymmetry is a fairly constant sign of pyelonephritis, not only with one-, but also with a bilateral process. Similar changes can accompany various variants of anomalies of the kidneys and upper urinary tract (nephroptosis, doubling of the collecting system, hydronephrosis).
Rheography
Rheography is a non-invasive method for studying the blood supply to organs, which is based on the principle of registering changes electrical resistance tissues due to changing blood supply. The more blood flow to tissues, the less their resistance. To obtain a rheogram, an alternating current with a frequency of 50 kHz, low strength (no more than 10 μA), created by a special generator, is passed through the patient's body. The principal development of the rheographic technique belongs to N. Mann (1937). In the future, the technique (electroplethysmography, impedance plethysmography) was developed in the examination of a urologic patient Chapter 2. General clinical works of A.A. Kedrov and T. Yu. Lieberman (1941-1949) and others. Detailed development and implementation of the rheography method into clinical practice is connected with the names of Austrian researchers W. Holzer, K. Polzer and A. Marko. He also owns essentially the first monograph (Rheokardiographie, Wien, 1946), in which the authors not only highlighted the technical aspects of the method (electrical circuits of the apparatus, generator options alternating current and others), but also presented the results of the clinical use of rheography in various diseases of the cardiovascular system. A significant contribution to the development of the rheography method was made by Yu.T. Pushkar, who created the domestic design of the apparatus and changed the method of registering a rheogram (precardial rheocardiography). Currently, the clinical significance of the application of the rheography method has been proven.
The fundamental basis of the rheography method is the dependence of changes in resistance on changes in blood circulation in the studied area of \u200b\u200bthe human body. In other words, pulse fluctuations of electrical resistance are studied. Registration of rheograms is carried out using rheographs. The latter consist of the following elements: a high-frequency generator, an impedance-voltage converter, a detector, an amplifier, a calibration device, and a differentiating circuit. In the bipolar technique, 2 electrodes are applied, each of which is simultaneously current and measuring, the electrodes are fixed on the corresponding part of the body. To reduce the contact resistance between the electrode and the skin, the same techniques are used as when recording an ECG.
When using the tetrapolar technique, the study area is limited by a pair of measuring electrodes, and the voltage that has arisen in them is removed using another pair of electrodes located outward with respect to the first (current). The tetrapolar technique is more accurate, because the influence of contact resistance is sharply (to a minimum) reduced (there is no need to apply gaskets moistened with solutions of salts or alkalis, and also to use electrode paste) and electrode examination of a UROLOGICAL PATIENT Chapter 2. General clinical polarization. This makes it possible to measure the impedance of deep tissues with a high degree of accuracy. Rheograms are recorded in a warm room 1.5-2 hours after a meal or on an empty stomach, in the supine position after 15 minutes of rest. Simultaneously with two rheograms (main and differential). An ECG is recorded in the II standard lead and sometimes a PCG at the V point or above the apex on one of the mid-frequency ranges.
It is advisable to record the rheogram while holding the breath with incomplete exhalation. Recording is performed at a tape drive speed of 25-50 mm / s (less often - 100 mm / s).
A rheogram is a curve that reflects pulse fluctuations in electrical resistance. With an increase in blood filling, an increase in the amplitude of the curve takes place and vice versa, in other words, the dynamics of the impedance in reverse polarity is recorded. On the rheogram (Fig.), The systolic and diastolic parts are distinguished. The first is due to blood flow, the second is associated with venous outflow.
Figure: Rheogram is normal
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Qualitative analysis takes into account the shape of the curve, the nature of the anacrot and the catacrota, the topography (rounded, pointed, plateau-like, saddle-like, etc.), the severity and quantity. plateau-like, saddle-like, etc.), the severity and number of additional waves, their location on the descending knee of the curve, the presence or absence of a presystolic wave.
Quantitative analysis provides for the determination of the following indicators (Fig.
1. The amplitude of the systolic wave in mm is measured from the base of the systolic wave to highest point rheograms.
2. The amplitude of the diastolic wave in mm is measured from the base of the diastolic wave to its highest point.
3. Rheographic index (systolic - RSI and diastolic - RDI) the ratio of the systolic (diastolic) wave to the standard calibration signal (0.1 Ohm \u003d 10 mm), expressed in relative units. This indicator characterizes the size and rate of blood inflow (outflow) in the investigated area. The amplitude of the curve is measured from the isoline to the highest point of the wave.
The method in urology is not often used, although its capabilities make it possible to identify functional and organic changes in the kidneys and urinary tract.
UROFLOWMETRY
The method of direct graphical registration of the dynamics of the volumetric flow rate of urine during the act of urination, used to summarize the tone of the detrusor contractile activity and the patency of the urethra. The flow rate is recorded on the recording device of the apparatus. Based on theoretical premises and results of clinical studies, uroflowmetry can be considered a method for assessing the functional state of the detrusor and urethra. For a more accurate determination of the influence of the urethra on the EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General clinical urine flow, the volumetric rate should be compared with the intravesical pressure.Literature:
1. A. V. Papayan, N. D. Savenkova "Clinical nephrology of children", St. Petersburg, SOTIS, 1997
2.L.V. Kozlovskaya, A. Yu. Nikolaev. Study guide for clinical laboratory research methods. Moscow, Medicine, 1985
3. Handbook of clinical laboratory research methods, ed. E. A. Kost. Moscow "Medicine" 1975
4. Guide to practical exercises in clinical laboratory diagnostics. Ed. prof. M. A. Bazarnova, prof.
V. T. Morozova. Kiev, "Vishcha school", 1988
5. A. Ya. Lyubina, L. P. Ilyicheva et al. "Clinical laboratory research", Moscow., "Medicine", 1984
6. Handbook of functional diagnostics. Under the general editorship of Academician of the USSR Academy of Medical Sciences prof. I.A.Kassirsky.
Moscow, "Medicine", 1970
8. A. Ya. Altgauzen "Clinical laboratory diagnostics", M., Medgiz, 1959
EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinic
9. Handbook of clinical laboratory research methods, ed. E. A. Kost. Moscow "Medicine" 1975
10. Reference book "Laboratory research methods in the clinic" ed. prof. V. V. Menshikova Moscow "Medicine" 1987
11. Guidelines for clinical laboratory diagnostics. (Parts 1 - 2) Ed. prof. M. A. Bazarnova, academician of the USSR Academy of Medical Sciences A.
I. Vorobyov. Kiev, "Vishcha school", 1991
12. A guide to practical exercises in clinical laboratory diagnostics. Ed. prof. M. A. Bazarnova, prof. V. T. Morozova. Kiev, "Vishcha school", 1988
13. Bondarenko B.B. Kiseleva E.I. // Epidemiology and course of chronic renal failure. In the book: Chronic renal failure / Edited by S.I. Ryabova. - 1976. - p. 34
Lecture 2. URINE STONE DISEASE.
Urolithiasis is a disease caused by metabolic disorders, due to various endogenous or exogenous causes, often hereditary in nature, determined by the presence of a stone in the urinary system or the discharge of a stone.
The ICD is widespread and ranks second after nonspecific infectious and inflammatory diseases of the urinary system.
ICD is detected at any age, but more often 30-55 years. Bilateral urolithiasis is diagnosed in 15-30% of patients.
The risk of stone formation throughout life is up to 10%. The disease is more common in men than in women (1: 3) There are regions where this disease is especially common ie.
is endemic. In Russia, these are the Transcaucasia, the Urals, the Volga region, the Don and Kama basins. EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General Clinic In Europe, the countries of Scandinavia, the Netherlands, Italy, the south of France and Spain A single concept of stone formation does not exist.
Urolithiasis is one of the most common urological diseases, occurring in at least 3% of the population. In 2002, the incidence of ICD in Russia was 535.8 cases per 100,000 population (Lopatkin N.A., Dzeranov N.A., 2003; Beshliev D.A., 2003). The endemicity of the regions of Russia has been proven not only in frequency, but also in the type of urinary stones formed (for example, stones from uric acid compounds dominate in the southern regions, and oxalates in the Moscow region) (Lopatkin N.A., Dzeranov N.A., 2003 ). Patients make up 30-40% of the entire contingent of urological hospitals. In most patients, ICD is detected at the most working age of 30-50 years. Classification. 1. According to ICD - 10 №20 - Kidney and ureter stones №21 - Stones of the lower urinary tract №22 - Urinary tract stones in diseases classified elsewhere
2. By the number of stones:
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Etiology. Nephrolithiasis (urolithiasis, nephrolithiasis) is a disease manifested by the deposition of salts in the kidneys. Nephrolithiasis can occur as a result of exposure to a single and multiple factors, EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinic to have exogenous and endogenous origin. Exogenous: dietary habits (consumption of large amounts of protein, alcohol, reduced fluid intake, deficiency of vitamins A and B6, hypervitaminosis D, intake of alkaline mineral waters etc.); features of the life of a modern person (physical inactivity, profession, climatic, environmental conditions, etc.);
taking medications (vitamin D preparations, calcium preparations;
sulfonamides, triamterene, indinavir, intake of ascorbic acid more than 4 g / day). Endogenous: urinary tract infections; endocrinopathies (hyperparathyroidism, hyperthyroidism, Cushing's syndrome); anatomical changes in the upper and lower urinary tract, leading to a violation of the outflow of urine (nephroptosis, stenosis of the LMS, stricture of the urethra, etc.); diseases of internal organs (neoplastic processes, metabolic disorders of various origins, chronic renal failure, etc.); genetic factors (cystinuria, Lesch-Nyhan syndrome - a pronounced deficiency of hypoxanthingguanine phosphoribosyltransferase, etc.).
Endogenous etiological factors: urological factors: Local congenital and acquired changes in the urinary tract (strictures);
the only functioning kidney; urinary tract infection.
General factors: deficiency and hyperproduction of a number of enzymes (hyperparathyroidism, gout); diseases of the gastrointestinal tract, liver, biliary tract;
intestinal resection, small intestinal anastomoses, etc.
Exogenous etiological factors: climate, physical and chemical properties of water and flora, drinking and food regime of the population; working conditions;
excessive and monotonous consumption with food of a large amount of stone-forming substances affecting the concentration of stone formation protectors, pH, diuresis, etc. lack of vitamins A and B.
The chemical composition and microstructure of urinary stones largely depends on the reasons for their formation. So, in violation of purine metabolism, urate stones can form, in violation of the metabolism of oxalic acid. EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical oxalate; phosphate stones appear mainly with impaired calcium-phosphate metabolism and in the presence of a urinary tract infection that causes an alkaline urine reaction. Disruption of the phosphorus-calcium balance in the body is possible due to several reasons. The parathyroid glands play the main regulatory role in the exchange of calcium and phosphorus. With an excessive intake of parahormone from the parathyroid glands (as a result of adenoma, hyperplasia, etc.), patients develop hypercalcemia, hypophosphatemia, hypercalciuria.
Disturbance of oxalic acid metabolism plays a role in the onset of nephrolithiasis with the formation of oxalate stones or salts. Normally, the daily excretion of oxalic acid in the urine is 30 + 15 mg in pathological conditions, it can be 200 mg or more. Oxalaturia also develops due to increased adsorption of oxalic acid in the gastrointestinal tract, especially when it is excessively ingested with food. The endogenous source of oxalates in humans is glyoxylic acid, which is formed mainly from glycine. An excess of glycine in the body can be in violation of carbohydrate metabolism and other pathological conditions. In the development of nephrolithiasis with the formation of urate stones and urinary salts, an etiological role is played by a violation of purine metabolism.
Uric acid enters the bloodstream from two sources: exogenous - from food protein and endogenous - from purine bases formed during the cleavage of DNA and RNA under conditions of protein catabolism and treatment of cytoproliferative processes (blood diseases, etc.) Sometimes hyperuricemia is familial and hereditary. In addition, hyperuricemia can occur due to impaired reabsorption of uric acid in nephropathies, toxic effects on the kidneys, etc.
Urinary tract infection is an etiological factor in nephrolithiasis. Chronic pyelonephritis is common. In many patients, it is primary, i.e. precedes the development of nephrolithiasis. In case of pyelonephritis microcirculation and lymph outflow are disturbed. EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinic of the kidney and urodynamics. Most of the microorganisms that cause pyelonephritis (Escherichia coli, Proteus, Staphylococcus aureus, etc.) decompose urine urea, and the resulting ammonia alkalizes the urine. Due to the products of inflammation (urotemia, erythrocytes, leukocytes, mucus, etc.), hydrophobic colloids accumulate, and the viscosity of urine increases. In an alkaline environment, phosphates easily precipitate, there is the possibility of developing phosphaturia or the formation of phosphate urinary stones.
A definite etiological relationship exists between nephrolithiasis and some diseases. So with anomalies in the development of the kidneys and urinary tract, stone formation occurs mainly in the presence of urinary stasis, or urostasis, and the addition of infection. Tumors of the small pelvis, obstruction of the urinary tract also contributes to urostasis and stone formation.
Under the influence of various combinations of exogenous, endogenous and genetic factors, metabolic disorders in biological media occur, which is accompanied by an increase in the level of stone-forming substances (calcium, uric acid, etc.) in the blood serum. An increase in stone-forming substances in the blood serum leads to an increase in their excretion by the kidneys, as the main organ involved in maintaining homeostasis, and to urine oversaturation. In a supersaturated solution, salt precipitation is observed in the form of crystals, which can later serve as a factor in the formation of microliths first, and then, due to the settling of new crystals, the formation of urinary stones. However, urine is often oversaturated with salts (due to changes in the nature of nutrition, changes in climatic conditions, etc.), but the formation of calculi does not occur. The presence of only one supersaturation of urine is not enough for the formation of calculus. For the development of KSD, other factors are also necessary, such as impaired outflow of urine, urinary tract infection, etc. In addition, there are substances in the urine that help maintain salts in a dissolved form and prevent their crystallization - citrate, magnesium ions, zinc ions, inorganic pyrophosphate, glycosaminoglycans, EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. Clinical general nephrocalcin, Tamm-Horswall protein, etc. Nephrocalcin is an anionic protein that is formed in the proximal renal tubules and the loop of Henle. If its structure is abnormal, it contributes to stone formation.
Low citrate concentrations can be idiopathic or secondary (metabolic acidosis, decreased potassium, thiazide diuretics, decreased magnesium concentration, renal tubular acidosis, diarrhea).
Citrate is freely filtered by the glomeruli of the kidneys and in 75% is reabsorbed in the proximal convoluted tubules. Most of the secondary causes lead to a decrease in the excretion of citrate in the urine due to increased reabsorption in the proximal convoluted tubules. In most patients with urolithiasis, the concentration of these substances in the urine is reduced or absent.
A necessary condition for maintaining dissolved salts is the concentration of hydrogen ions, i.e. urine pH. A normal urine pH of 5.8-6.2 ensures a stable colloidal state of urine.
Daily fluctuations in urine pH Urine pH values \u200b\u200brelevant for various types of urolithiasis
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Pathogenesis. Currently, there is no unified theory of the pathogenesis of nephrolithiasis. There are two types of processes that determine the factors of formal and causal genesis of stone formation.
1. According to the colloidal crystallization theory for the nucleation of a stone, a certain situation is needed in which a high concentration of salts and the presence of hydrophobic colloids in the urine are combined, as well as the corresponding crystallization point of the existing salts, the pH of urine and urine urine. In the absence of urostasis and pathological changes in the colloidal system of urine, the process ends with the formation of free crystals. The beginning of the formation of the primary center of the stone can be both crystallization of salts and conglomeration of organic substances; it depends mainly on which of the two urine media (calloid or saline) the changes are initially more pronounced. The growth of stones occurs rhythmically, with alternating processes of salt crystallization and precipitation of organic matter. The nucleation of stones can also begin at the level of the tubules, where microliths are found in the form of spheres and other shapes. Currently, a number of substances have been identified that affect the colloidal stability and maintenance of salts in a dissolved state, and vice versa, their absence contributes to the crystallization of salts. In normal urine, these substances are urea, creatinine, hippuronic acid, sodium chloride, citrates, magnesium, EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical inorganic pyrophosphate, etc. Calloid-crystallization theory is considered the most scientifically substantiated and proven.
2. According to another theory (Randell and Carr), urinary stones may occur on the papillae of the kidney. Carr discovered microparticles (nodules containing calcium and glycolisoaminoglycans) in the kidney tissue.
In his opinion, there is a constant movement of the formed nodules into the lymphatic system of the kidney. In case of impaired lymph flow due to pyelonephritis, as well as when the kidney is overloaded with calcium salts, etc.
conditions arise for the development of stone formation. The nodules migrate towards the renal papillae, forming plaques on them, which were described by Randell.
These plaques compress the papillary capillaries. Salts crystallize on necrotic renal papillae and stones form.
Etiopathogenetic pathways for the formation of urinary stones. Clinical picture.
Pain syndrome of varying degrees of intensity:
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2. Renal colic.
Renal colic is manifested by acute pain in the lumbar region or hypochondrium, radiating along the ureter. It is accompanied by nausea, vomiting, flatulence. Oliguria is possible.
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Instrumental research:
2. Excretory urography (a contrast agent is injected into a vein, which is secreted by the kidneys, and a series of X-rays are taken.
The method allows you to assess the entire anatomy of the genitourinary system, to detect stones in all parts of the genitourinary system.)
4. Radioisotope study 5. Dynamic nephroscintigraphy (contrast is injected into a vein and the kidneys are scanned with a special sensor. A very informative study that allows you to assess kidney function. It is also used to diagnose the so-called "renal pressure".)
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Mineralogical classification is used to classify urinary stones. About 60–80% of all urinary stones are inorganic calcium compounds: calcium - oxalate (Weddellite, Vevellite), calcium - phosphate (vitlokite, brushite, apatite, hydroxyapatite, etc.). Stones consisting of uric acid (uric acid dihydrate) and uric acid salts (sodium urate and ammonium urate) occur in 7-15% of cases. Magnesium - containing stones (newberite, struvite) account for 7-10% of all urinary stones and are often associated with infection. Bacteria (Oxalobacter formingenes) contained in the intestine are an important component in maintaining calcium oxalate homeostasis, and their absence may increase the risk of calcium oxalate calculi formation. The most rare stones are protein stones - cystine (detected in 1-3% of cases). In most cases, stones have a mixed composition, which is associated with a violation in several metabolic links at once and the addition of infection.
Uric acid stones are composed primarily of uric acid. Their formation can be caused by a high concentration of uric acid in the urine or a low urine pH. The concentration of uric acid depends on both the volume of urine and the amount of uric acid excretion. Two thirds of urates are eliminated via the kidneys. The excretion of uric acid is increased in conditions associated with an increase in endogenous urate production or when eating foods rich in purines.
An increase in endogenous urate production occurs due to mutation of enzymes that regulate the synthesis and reutilization of purines. Increased hyperexcretion of urates can be observed in tumor diseases, but stones do not always appear. The presence of a normal level of urate in the blood serum does not exclude a high excretion of urate in the urine, just as an increase in the concentration of uric acid in the blood does not indicate a high content of urate in the urine - much more often it is secondary in response to a low excretion of uric acid in the urine. Formation of urate stones EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical practice is accompanied in some patients by disorders in purine metabolism in the form of hyperuricemia (6.5 mmol / l) and hyperuricuria (4 mmol / l). Many patients with uric acid stones have normal serum and urine uric acid concentrations. In this case, stones are formed due to low urine pH, which is associated with a decrease in ammonium production by the kidneys. Calcium oxalate urolithiasis. Hyperoxaluria is the main predisposing factor for the formation of calcium oxalate stones.
Hyperoxaluria is associated with an enzyme deficiency. "Intestinal" hyperoxaluria is more common and results from excessive absorption of oxalates from the colon. Excessive absorption of oxalate can be due to the binding of calcium to dietary fiber in the intestine, consumption of large amounts of plant foods. The ascorbic acid found in vegetables and fruits is converted to oxalate, which leads to increased absorption of oxalate from the intestines. On the other hand, oxalate reduces the absorption and excretion of calcium in the urine due to the complex formation between calcium and oxalate in the intestinal lumen.
Magnesium reduces the absorption and excretion of oxalate in the urine by complexing with oxalate. The combination of calcium urolithiasis and hyperoxaluria is observed in 40-50% of cases. Patients with hypercalciuria in conditions of normocalcemia are referred to persons with "idiopathic hypercalciuria". "Idiopathic" hypercalciuria is one of the most common causes of recurrent calcium oxalate urolithiasis. Hypercalciuria can be "absorptive" and "renal".
"Absorptive" hypercalciuria is associated with a primary increase in calcium absorption in the small intestine and is considered hereditary. "Renal"
hypercalciuria is associated with a tubular defect, which leads to inadequate reabsorption of calcium in the kidney tubules and is accompanied by excessive compensatory absorption of it in the gastrointestinal tract. In 5 and 3% of cases, calcium stones are formed as a result of primary hyperparathyroidism and EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. Clinical General
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Cystinuria is a hereditary disease with an autosomal recessive inheritance pattern. At the heart of cystinuria is a violation of transmembrane transport, leading to a violation of absorption in the intestine and resorption in the proximal tubule of dibasic amino acids (cystine, ornithine, lysine, arginine). Cystine urolithiasis is manifested by cystinuria and occurs only in homozygous individuals. Stones can form during childhood, but the incidence peaks in the second and third decades. Cystine is poorly soluble in urine, which leads to its precipitation in the form of crystals.
EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinic Treatment of ICD. Treatment of urolithiasis can be operative (remote shock wave lithotripsy, X-ray endourological operations and “traditional” open surgery), medication and prophylactic. The choice of treatment method is based on the results of the patient's clinical examination, the chemical structure of the calculus, the presence of concomitant diseases.
Despite the development of modern methods of treatment, the need for the use of pharmacological drugs remains. Their use reduces the risk of recurrent stone formation by correcting biochemical changes in the blood and urine, and also promotes the discharge of stones up to 0.5 cm in size. In this article, we decided to focus on the basic principles of drug treatment of patients with ICD. General recommendations include: diet therapy, control of daily fluid intake, exercise therapy, physiotherapy and balneological procedures. The nature of the diet is one of the main risk factors for the development of urinary stones and, given this, diet therapy, adequate maintenance of water balance, etc., play an important role.
Dietary recommendations for urate urolithiasis: exclusion of foods with a high content of purine compounds (which are sources of uric acid formation in the body), such as various meat products (sausages, broths, offal), legumes, coffee, chocolate, cocoa. Low urinary pH and citrate excretion are associated with high animal protein and alcohol intake due to metabolic acidosis. Excretion of citrate is reduced in acidosis due to reabsorption of low pH fluid in the proximal renal tubules. The elimination of alcohol and a decrease in protein in a balanced diet leads to an increase in pH and citrate excretion. The patient should be advised EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General clinical daily intake of 2.5-3.0 liters of fluid to achieve a urine volume of more than 2 liters / day. Moreover, the consumption of alkaline ions (potassium) and organic acids (citrate and lactate) from vegetables and their transition to bicarbonate explains the further increase in pH and excretion of citrate.
Dietary recommendations for calcium oxalate urolithiasis are to limit the intake of foods high in calcium, ascorbic acid and oxalate. These foods include milk and dairy products, cheese, chocolate, green vegetables, black currants, strawberries, strong tea, cocoa. The daily volume of liquid should be at least 2 liters per day. These recommendations are especially important for "absorbent"
hypercalciuria.
The diet for calcium - phosphate urolithiasis involves limiting the consumption of foods rich in inorganic phosphorus by the patient:
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