Bozhedomov V.A.

Introduction

Patients with infection or disease of the genitourinary tract make up the largest group of patients visiting doctors from such fields as urology and gynecology.

Urology can be divided into several smaller branches of medicine, each of which has a narrower focus.

Andro urology(andrology) specializes in the study and treatment of male genital organs, and also deals with the problems of their development.

Geriatric urology specializes in the treatment of genitourinary problems in elderly patients. With age, changes occur in the entire structure of a person; many functions, including protective ones, deteriorate. This cannot but affect susceptibility to infectious urological diseases, for example, urethritis (disease of the urethra). Elderly women may suffer from urinary incontinence, which can be caused by low muscle tone of the pelvic organs after childbirth or constant physical activity. An important feature of geriatric urology is that surgical intervention is much more dangerous in its consequences.

Onco-urology includes diagnosis, treatment and surgery on tumors of various etiologies. These can be both benign and malignant tumors of the genitourinary system. Typically, patients of oncologists are men with cancerous tumors of the testicles, penis, prostate gland, and bladder.

Pediatric urology. This section of urology is one of the most difficult. Many developmental abnormalities are best treated in childhood.

A disease should be understood as a dysfunction of an organ, accompanied by pain, swelling, fever, redness, expressed to varying degrees. Acute inflammation usually begins in the external genitalia and is the result of infection through sexual contact. After a certain period of time, called incubation (depending on the pathogen, it can range from 1 day to several weeks), discharge appears from the urethra and/or vagina. They can have a purulent, mucous, foamy or cheesy appearance, can be abundant, scanty, observed only in the morning or, when becoming chronic, be episodic. In this case, the patient may be bothered by itching, burning, and sometimes pain when urinating or regardless of it. Without treatment or with improper treatment, such acute phenomena gradually subside, but the infection is not eliminated, but becomes chronic. By ascending route, pathogens penetrate the internal genital organs, causing their inflammatory development. Signs of an inflammatory process of the internal genital organs are pain in the lower abdomen, groin area, lower back, and in men - testicles, sometimes radiating to the inner thighs.

Infection of the internal genital organs can also occur hematogenously in the presence of foci of acute or chronic infection in the body, such as tonsillitis, sinusitis, frontal sinusitis, otitis media, carious teeth, chronic pneumonia, cholecystitis, pustular skin lesions, etc. With the hematogenous route of infection, the disease is more common In general, it has an acute onset and purulent character. The lymphogenic route of penetration is possible in case of inflammatory and purulent diseases of neighboring pelvic organs, for example, prostate disease may be caused by proctitis or thrombophlebitis of hemorrhoidal veins. Infections of the upper urinary tract and internal genital organs are more dangerous, but infection or inflammation of the lower urinary tract is more common.

Often inflammation proceeds for a long time without complaints (symptoms) or they are very scarce. For example, patients occasionally notice a tingling sensation when urinating (usually provoked by hypothermia or drinking alcohol), in men there is sticking of the external opening of the urethra or plaque on the head of the penis; in women - cervical erosion. The insidiousness of such a sluggish inflammatory process is that the function of the affected organs is gradually disrupted, which leads to infertility, makes it impossible to have a full sexual life and serves as a prerequisite for various neoplasms.

Inflammatory diseases in men

Depending on the location of the inflammatory process in men, they distinguish: inflammation of the glans (balanitis) and the inner layer of the foreskin (posthitis) of the penis, which most often occur together (balanoposthitis); urethra (urethritis); prostate gland (inflammation of the prostate); testicles (orchitis); epididymis (epididymitis), bladder (cystitis), etc.

Balanitis And posts develop most often as a consequence of elementary uncleanliness. Decomposition of the released smegma in the foreskin sac during prolonged sexual abstinence creates conditions for the proliferation of microorganisms and causes inflammation. A predisposing factor is congenital or acquired narrowing of the foreskin opening (phimosis). Sometimes, even when performing hygienic procedures, the disease occurs in the elderly and patients with diabetes. With balanitis, the foreskin is hyperemic and swollen, erosions and purulent plaque appear on its inner surface and head, the man is bothered by itching and pain when trying to have sexual intercourse. Sometimes the head is not exposed, the penis swells, becomes hyperemic, and lymphadenitis of the inguinal lymph nodes appears. A rare but serious complication is penile gangrene, accompanied by tissue necrosis. Ordinary balanoposthitis, caused by banal microflora and fungi, must be differentiated, using laboratory methods, from specific ulcerative lesions that can be caused by donovanosis, syphilis, genital herpes, chancroid and their combinations. Genital warts and bowenoid papules in the prepuce sac can be caused by the human papillomavirus (HPV), serotypes 16 and 18 of which, in addition, are oncogenic (Skripkin Yu.K., 1995). Therapy aimed at improving balanoposthitis is aimed primarily at sanitizing damaged surfaces with local means: washing with solutions of potassium permanganate or furacillin, lubrication with anti-inflammatory and antiseptic ointments (clotrimazole, etc.). To treat condylomas, various methods are used that have a destructive effect: podophyllin, podophyllotoxin, 5-fluorouracil, trichloroacetic acid, cryotherapy, laser excision, etc. In the presence of phimosis, surgical intervention is recommended - circumcision (circular excision of the foreskin). This is also indicated for patients with persistent recurrent disease due to diabetes.

Urethritis is the most common disease of the genitourinary tract, which forces men to consult a doctor. Depending on the severity of clinical signs, acute, torpid and chronic forms are distinguished, depending on the localization of the process - anterior and posterior, depending on the causative factor - gonorrheal, trichomonas, chlamydial, bacterial, viral, mycotic, traumatic, etc. (Tiktinsky O .L., 1990). Critical urethritis is characterized by an abundance of secretions that flow freely from the urethra, forming yellowish crusts on the head of the penis; the urethral sponges become bright red, swollen, and upon palpation the urethra is thickened and painful. Subjective disorders are sharply expressed: burning and pain at the beginning of urination; when the posterior part of the urethra is involved in inflammation, urination becomes more frequent, at the end there is a sharp pain, and sometimes blood appears. The clinical picture of torpid and chronic urethritis is the same: mild symptoms of discomfort, itching in the urethra, especially in the area of ​​the scaphoid fossa, discharge is usually absent or appears in the form of a mucous-watery drop in the morning, sticking of the external opening of the urethra is often observed. If the listed symptoms are present in the first two months, urethritis is considered torpid, with a further course - chronic. Identification of the pathogen is crucial in diagnosis. For this purpose, methods of staining smears from the urethra and/or urine sediment according to Romanovsky-Giemsa, Gram, acridine orange, study of the native drug with isotonic solution or Ringer-Locke solution, bacterial culture, enzyme-linked immunosorbent assay for specific antigens, DNA hybridization, etc. are used. The most common causes of inflammation are Neiser's gonococcus, Trichomonas vaginalis, and Chlamydia trachomatis. Often, especially against the background of a general decrease in immunity, the cause of inflammation is a banal microflora: epidermal staphylococcus, s-hemolytic streptococcus, Proteus. Recently, viral lesions of the urethra caused by human papillomaviruses (HPV) and herpes simplex viruses (HSV-2) have attracted more attention. The former are capable of causing the formation of growths not only on the head of the penis and around the anus, but also in the urethra; the second are recurrent bubble-erosive lesions of the mucous membranes. A positive correlation has been shown between the prevalence and severity of viral lesions of the urethra and penis with non-traditional forms (homosexuality) of sexual activity (Bernard K. et al., 1994). Treatment of urethritis is carried out taking into account the etiological factor.

Reason nonspecific urethritis, which occurs in 1-2% of patients with these symptoms, there may be a persistent alkaline reaction of the urine, which promotes the deposition of calcium phosphate crystals, causing irritation of the urethra (Rouse S., 1979). This phenomenon is often caused by poor diet. This disease can be diagnosed by examining urine sediment after centrifugation, if a sediment of crystals 2-3 cm thick is found at the bottom of the tube and the urine pH is constantly 6.8 or higher. In this case, the dissolution of the crystals and the disappearance of symptoms is facilitated by daily intake of 2-3 g of ascorbic acid (you need to be careful, since uric acid and cystine stones begin to precipitate in acidic urine).

Another common inflammatory disease in men is prostate disease, the symptoms of which are very unpleasant for any man. It is usually the result of untreated urethritis. For example, Ilyin I.I. et al. (1993) based on the results of a survey of more than 4000 people, it was shown that in chronic non-gonococcal urethritis the symptoms prostatitis are observed in 44-59% of cases, while in newly diagnosed urethritis - 3-4 times less often. The picture is even more clear in the presence of inflammation caused by gonococcus: with chronic gonorrhea, prostate disease occurs 40 times more often than with acute gonorrhea. At the same time, the prostate can also be infected hematogenously as a result of the introduction of pathogenic agents from a distant source of inflammation, such as the tonsils.

Prostate disease can be acute and chronic. In the acute form of prostate disease, in addition to general symptoms (poor health, fever, sweating, weakness), patients note frequent, painful, sometimes difficult urination, severe pain in the perineum, radiating to the anus and head of the penis, pain during defecation, in severe cases - for acute urinary retention. Patients in such a situation require immediate hospitalization. More often prostatitis is a sluggish chronic infection that does not manifest itself for years after the infection enters the prostate. This stage is called latent. Only after certain stressful situations, for example, prolonged hypothermia, after suffering from somatic diseases (influenza, etc.), severe abnormalities in sexual life, the disease begins to manifest itself clinically.

Symptoms of chronic prostatitis include: 1) aching pain in the perineum, spreading to the external organs, above the pubis, in the sacral area, more pronounced at rest; 2) painful and frequent urination, especially at night; 3) deterioration of erection and/or shortening of sexual intercourse, decreased severity of orgasm. These symptoms can occur all together or in various combinations. The diagnosis is made on the basis of a digital rectal examination, which allows detecting changes in shape, general and focal consistency, assessing the degree of soreness of the prostate gland, and laboratory test data demonstrating an increase in the number of leukocytes (more than 10 in the field of view of a microscope at high magnification), epithelial cells, red blood cells, bacteria. Transrectal ultrasound (TRUS) can additionally identify focal changes in the area of ​​the bladder neck and ventral surface of the gland that cannot be palpated: a decrease (edema) and an increase (fibrosis) in the echogenicity of the tissue, the presence of stones and cysts.

Good reasons for urgent treatment of prostatitis. Untreated prostatitis usually leads to degeneration of the gland, in which prostatic glands and smooth muscles are replaced by connective tissue, and these disorders become irreversible.

There is a widespread misconception that inflammation can be caused simply by hypothermia (cold). This is not true. We agree with the opinion of D.S. Sarkisov (1975) that the chronic course of any inflammatory process is supported by the presence of an infectious agent. Sarkisov showed this using the example of pulmonary tuberculosis caused by the L-form of the bacillus, and rejected the possibility of aseptic inflammation. He believes that after the disappearance of the infectious agent from the source of inflammation, not only does inflammation cease, but also almost complete restoration of the lung parenchyma is possible, even in areas that have undergone fibrosis. The same can be said about chronic prostatitis, regarding which there is an opinion that it is incurable. Determining the etiology (cause) of the inflammatory process in the prostate, identifying the specific pathogen(s), selecting effective antibiotics and methods that increase their penetration into the gland, ensuring adequate outflow of secretions allows in most cases to achieve a clinical cure and disappearance of complaints. However, to a decisive extent this depends on how long the process has been and the nature of the violations that have arisen.

Recently, the existence of an autoimmune component in prostate lesions has been recognized, but, as in classical autoimmune inflammatory processes (rheumatoid arthritis, asthma, glomerulonephritis), inflammation begins with one or another pathogenic microorganism, the antigenic surface properties of which are similar to the antigens of its own cells. This leads to an “error” of the immune system, resulting in an attack on the tissues of one’s own body. The situation is aggravated by the fact that mimicry - the ability to “camouflage” - is a universal property of all microorganisms living in multicellular host macroorganisms, and is supported by natural selection.

Many (Tiktinsky O.L., 1990, Weidner W. E.a., 1995, etc.) consider it necessary to separate the bacterial prostatitis symptoms: signs of inflammation (leukocytosis in prostate juice) and non-bacterial - so-called. prostatodynia (congestive or congestive prostatitis), having similar symptoms. The pathogenesis of congestive prostatitis is associated mainly with various dysrhythmias in sexual life: interrupted sexual intercourse, artificially prolonged intercourse, episodic sexual excesses and, conversely, prolonged abstinence. Incomplete ejaculation, devoid of emotional coloring, which occurs with the so-called “habitual coitus”, is also one of the causes of congestion. This form of prostatitis is most typical for older men with a disturbed rhythm of sexual life and for young men who are not sexually active and do not masturbate. Pain syndromes are similar to inflammatory prostatitis, but less pronounced. There is an increase in pain with prolonged abstinence and deliberate delay of sexual intercourse. Sometimes in the first half of the day urination becomes more frequent and the stream of urine is weakened. If the night before during coitus there was not only a physiological, but also a psychological orgasm, the noted complaints disappear for some time. Congestive prostatitis symptoms are difficult to distinguish from infectious ones, since venous stagnation and stagnation of secretions create conditions for the development of the inflammatory process, and the absence of inflammation does not guarantee, on the other hand, against the presence of pathological agents such as chlamydia or ureaplasma in the gland. Improving methods for diagnosing infections inevitably reduces the proportion of “non-bacterial” prostatitis. In addition, it is necessary to carry out a differential diagnosis of prostatitis with benign hyperplasia (adenoma) and prostate cancer.

Inflammatory diseases of the scrotum are epididymitis and orchitis. They are often seen together.

Epididymitis- inflammation of the epididymis, which can be caused by various microorganisms, and most often is a consequence of urethritis and prostatitis. Sometimes it occurs after operations on the prostate gland and surgical treatment of varicose veins of the spermatic cord. The development of epididymitis is promoted by hypothermia, trauma, and prolonged sexual arousal. Almost always the development is one-sided.

According to the clinical course, they distinguish between acute and chronic forms, and according to morphological characteristics - serous, infiltrative and purulent (Shabad A.L., 1996). Critical begins suddenly with a sharp increase in temperature to 39. C, severe pain appears in the inguinal canal or lower abdomen, which after 1-2 hours (sometimes after 1-2 days) is localized in one half of the scrotum, the skin on this side turns red, observed swelling. Upon palpation, a sharply enlarged appendage is determined, which seems to cover the testicle and is not limited to it. Ultrasound examination demonstrates an increase in its size and a decrease in echogenicity due to edema. Ultrasound also makes it possible to timely recognize purulent-destructive abscess formation, which serves as an indication for surgical treatment: making “relaxing” incisions of the tunica albuginea in order to reduce swelling or, in advanced cases, removal of the appendage - epididymectomy. When the inflammatory process moves to the testicle, which often happens, and there are severe symptoms of general intoxication, it is recommended to remove the epididymis along with the testicle - hemicastration, since inflammation of the testicle most often leads to its atrophy with complete loss of function.

Permanent epididymitis, which is usually the outcome of acute epididymitis, is manifested by moderate enlargement and hardening of the epididymis, minor pain; body temperature is normal, the skin of the scrotum is not changed.

Microbiological research and hybridization in situ find that the acute form of epididymitis is usually associated with gram-negative bacterial microflora ( E.coli etc.), and “primary chronic” is most often caused by chlamydia.

Differential diagnosis is carried out with tuberculous lesions of the epididymis, which is characterized by the appearance of purulent fistulas of the scrotum, a “bead-shaped” compaction of the spermatic cord and the detection of mycobacteria in the urine and secretions of the prostate, as well as a tumor. In the latter case, a biopsy is crucial.

Treatment includes the prescription of antibiotics, taking into account the etiology of previous urethritis or prostatitis, absorbable drugs, and physical therapy. Recently, the high effectiveness of using low-intensity laser radiation on the scrotum in the area of ​​the inflamed appendage for epididymitis (both acute and chronic) has been shown. Simultaneous treatment of concomitant inflammatory diseases is mandatory.

Orchitis, not associated with inflammation of the appendage, is quite rare. Unlike epididymitis and epididymo-orchitis, which are usually caused by a bacterial infection, isolated inflammation of the testicle is the result of the penetration of viruses into the organ during mumps and influenza, or is the result of injury. In the latter case, orchitis is called aseptic, since the autoimmune process plays a decisive role in organ damage, when the spermatogenic cells themselves become the object of the immune attack.

According to the course, acute forms and chronic orchitis are distinguished. The acute form of orchitis begins with the appearance of pain in the testicle, the cause of which is stretching of the tunica albuginea as a result of edema. At first the pain is dull, then intensifies, there is a uniform increase in the size of the testicle, the skin of the scrotum over it is hot and swollen. Pain may appear along the spermatic cord, body temperature rises to 39-40. C, chills are observed, ESR increases. The acute form of orchitis can be complicated by a testicular abscess. In this case, a softening area is palpated at the junction of the skin of the scrotum with the testicle. After a few days, the abscess may spontaneously open. Mumps, occurring in a clinically pronounced (including the parotid gland) or subclinical (in the absence of local signs) form, is the most common cause of orchitis of viral etiology, which is accompanied by the greatest swelling of the testicle. In chronic orchitis, which is the result of acute inflammation or initially had a mild clinical course, the pain is moderate, focal compactions are palpable in the organ, and the temperature can rise to subfebrile. With a long-term disease, organ atrophy may occur, and with bilateral disease, infertility may occur.

Acute orchitis must be distinguished from inflammation of the epididymis, hydrocele, testicular torsion, strangulated hernia, and tumor. With epididymitis, the testicle is not enlarged, but only the epididymis itself is enlarged; with dropsy, the testicle is enlarged evenly, painlessly, with a soft-elastic consistency, with transillumination (diaphanoscopy) a transparent homogeneous content under the membrane is determined, with ultrasound - liquid; with torsion, the pain increases rapidly, the cord is sharply thickened, the evenly enlarged testicle is in the upper position and the epididymis is often palpated from the front; with a hernia, intense pain is usually localized in the abdominal cavity, nausea and vomiting are observed, and a normal testicle and epididymis are detected in the scrotum below the thickened cord; with cancer, the testicle is slightly enlarged, compacted to a “stony” density, or uneven with compactions of 1 cm, usually in the lower pole.

In acute non-abscessing orchitis, intervention is conservative. Prescribe bed rest, wearing a suspension, cold for the first 2-3 days, antibiotics, novocaine blockade of the spermatic cord is advisable. 4-5 days after the temperature has normalized and the acute phenomena have subsided, warming compresses, UHF therapy, sodium iodide electrophoresis are used, and in case of prolonged course, corticosteroids are used. For the treatment of chronic orchitis, physiotherapy is used mainly: UV therapy, UHF, amplipulse therapy, paraffin baths (Kozlov V.A., 1996).

A special case is post-traumatic orchitis. Given the rich blood supply to the testicles, injuries to the scrotum often lead to the formation of hematomas. Hematomas are divided into superficial, involving the superficial layers of the scrotum, extravaginal, which occur when vessels rupture at the lower pole of the testicle or in the spermatic cord, and intravaginal, which occur when the testicular membrane is damaged or ruptures of the testicle and epididymis. As a result of injuries, the blood supply to the organ is disrupted, edema develops, which leads to tissue ischemia and, thus, a significant impairment of organ function. But in the case of the formation of intravaginal hematomas and especially rupture of the tunica albuginea, in addition, an autoimmune process develops in which antibodies and sensitized T-lymphocytes are produced against one’s own sperm. Let us recall that germ cells develop under the protection of a special blood-testis barrier (BTB), which prevents the entry of immunologically “foreign” antigens of differentiating germ cells into the blood. The main “filter” of this system are Sertoli cells. On the other hand, normally through the testicular network ( rete testis), which is also part of the GTB, only granulocytes and suppressor T-lymphocytes can penetrate from the peripheral bloodstream into the testicular vessels, but not T-helper cells, without which an effective immune attack is impossible (El-Demiry e.a., 1987). Damage to the blood-testis barrier leads to the formation of antisperm immunity, most often leading to irreversible loss of fertility (Raitsina S.S., 1985). Neither timely surgical revision of the scrotum, nor the use of antibacterial therapy, nor the use of anticoagulants often avoids the formation of antisperm antibodies and prevents testicular atrophy (Tarasov N.I., Amannazarov A., 1990). Spermatogenesis can be preserved using large doses of corticosteroids (Endolov V.V., 1986), which, however, have a number of side effects. We have proposed and patented original methods for preventing testicular atrophy and preserving spermatogenesis after surgical interventions on the testicle, based on the use of an analogue of the nucleotides hypoxanthine riboside (inosine) and lipoic (thioic) acid, the use of which has no side effects (Bozhedomov V.A., Bilic G. .L., 1992,1993).

Inflammatory diseases in women

In women, inflammation of the vaginal mucosa (vaginitis and vaginosis) is most often observed; cervical canal (cervicitis); uterine mucosa (endometritis); fallopian tubes (salpingitis) and ovaries (oophoritis), which are usually observed together (salpingoophoritis).

Vaginitis (colpitis) can cause gonococci, trichomonas, chlamydia, as well as opportunistic microorganisms such as staphylococci, streptococci, fungi of the genus Candida, E. coli, etc. There are acute and permanent vaginitis. During an acute process, women complain of itching in the area of ​​the vaginal vestibule, burning, a feeling of pressure, heat in the genitals and pelvis, many report dysuric disorders. Characteristic is copious discharge - leucorrhoea. The inflammatory process caused by various pathogens has its own characteristics. For example, profuse, frothy, yellowish-green discharge with an unpleasant odor is characteristic of Trichomonas vaginitis; discharge of a white, curd-like appearance - for fungal. In chronic forms of inflammation, there is no pain; patients mainly complain of discharge, itching, burning, and small ulcerations in the area of ​​the vaginal vestibule. The diagnosis is made on the basis of a gynecological examination and the results of an examination of vaginal discharge. Upon examination, diffuse hyperemia and swelling of the vaginal mucosa is visible, which begins to bleed easily with minimal trauma. The mucous membrane is covered with abundant plaque. When examining smears, a large number of leukocytes (30-60 per field of view), epithelial cells, and associations of various microorganisms are detected. In the case of nonspecific vaginitis, there is no pathogenic flora, but there is an excessive number of conditionally pathogenic forms.

Complex treatment includes: 1) antibiotics in accordance with the nature of the isolated microflora; 2) correction of endocrine and other functional disorders; 3) cessation of sexual activity until completion of treatment; 4) examination and treatment of the sexual partner; 5) diet, exclusion of alcohol, spicy and salty foods, strong coffee. It is recommended to treat the vaginal mucosa with antiseptic solutions: a weak solution of potassium permanganate, rivanol, chamomile decoction. Recently, for nonspecific vaginitis, Polygynax and Macmiror have been used topically with success; for fungal infections, an infusion of borax in glycerin and pimafucin is effective; for trichomoniasis, vaginal tablets of tinidazole and ornidazole are effective (Smetnik V.P., Tumilovich L.G., 1995).

Since the 80s, a new term has appeared in gynecology - bacterial vaginosis - which identifies one of the forms of nonspecific vaginitis, which is characterized by copious foul-smelling discharge in the absence of pathogenic pathogens and the absence of visual signs of inflammation of the vaginal mucosa. Often women complain of discomfort and burning in the vagina. Recently, bacterial vaginosis has been considered as a kind of vaginal dysbacteriosis, which occurs when the number of lactobacilli secreting lactic acid decreases and the pH of the vaginal secretion increases (more than 4.5). This creates conditions for the massive proliferation of microorganisms such as gardnerella and obligate anaerobic bacteria. This disease is rare in prepubertal girls and postmenopausal women, indicating a significant hormonal component in causing this imbalance. The most informative method of laboratory diagnosis is the detection in Gram-stained smears of so-called “key cells” - desquamated cells of the vaginal epithelium, covered with small gram-negative rods.

The diagnosis of “bacterial vaginosis” is made if 3 of 4 signs are present: copious homogeneous discharge, an ammonia odor when tested with 10% alkali, the presence of “key cells” and a pH above 4.5. It is advisable to carry out treatment in two stages. At the first stage, it is necessary to restore a physiologically normal environment in the vagina, for which purpose instill 100 ml of a 2-3% solution of lactic or boric acids daily for 5-7 days, insert suppositories or ointment tampons with metronidazole, sinestrol, folliculin, vitamin C. At the second stage Local use of preparations of live lacto- and bifidum bacteria is necessary, 2-3 biodoses 2 times a day for up to 10 days.

Cervicitis is an inflammation of the cervix that occurs as a result of penetration into the cervical canal of gonococci, trichomonas, chlamydia, staphylococci, streptococci and other bacteria, less commonly viruses. The occurrence is facilitated by cervical ruptures during childbirth, prolapse of the genital organs, infectious processes in the vagina and, conversely, in the internal genital organs. In an acute process, a woman is bothered by mild pain in the lower abdomen, discomfort in the vagina, sometimes itching, mucous or purulent mucous discharge from the vagina. When examined with a mirror or colposcope, hyperemia, swelling of the cervix, inflammatory infiltrates are detected, and with a long course, often erosion. In a chronic process, complaints are less pronounced. Treatment is prescribed taking into account the identified pathogens, but local treatment is used only after acute symptoms have subsided in order to avoid the risk of developing an ascending infection. If conservative treatment fails, diathermocoagulation, cryotherapy, laser therapy, and zinc electrophoresis using a special electrode are used (Smetnik V.P., 1996). After rejection of the necrotic mucous membrane, regeneration occurs due to intact columnar epithelial cells.

Endometritis - inflammation of the mucous membrane of the uterine body - usually occurs as a result of penetration of pathogenic microorganisms into the uterus from the vagina, as well as by hematogenous and lymphogenous routes; may be a complication of intrauterine diagnostic and therapeutic procedures. The acute form of endometritis usually develops 3-4 days after childbirth or abortion. Predisposing factors are the retention of membranes, blood clots in the uterine cavity, and a large number of pathogenic and conditionally pathogenic (Esherechia, Proteus, etc.) microorganisms in the vaginal biocenosis. The disease begins with an increase in temperature to 38.5 C, pain appears in the lower abdomen, sometimes purulent discharge, women complain of weakness and headache. On palpation, the uterus is enlarged, soft, swollen, painful in the lateral sections (along the lymphatic vessels). Without treatment, inflammation can spread to all layers of the uterus and parametrium - the tissue located between the layers of the broad ligaments of the uterus. Parametritis develops. Parametritis is promoted by lateral ruptures of the cervix during childbirth or miscarriage, purulent melting of blood clots in the vessels during endometritis. The acute form of parametritis can lead to a parametrium abscess, which sometimes spontaneously opens into the rectum, uterus, abdominal cavity or bladder. In this case, during a gynecological examination, a tight-elastic infiltrate is palpated, usually on the side of the uterus, displacing it to the opposite side. When suppuration occurs, pockets of softening are identified. With inadequate treatment, development becomes chronic. Chronic endometritis is characterized by light serous discharge from the genital tract, periodic uterine bleeding - menorrhagia. The uterus is slightly enlarged, dense, painless. Atrophy of the glands is observed or, conversely, cysts are formed. Lymphoid infiltrates and stromal fibrosis are characteristic. Chronic parametritis is characterized by intermittent aching pain in the lower abdomen, abnormal position of the uterus as a result of the formation of adhesions and deformation of the ligamentous apparatus. Treatment includes the prescription of antibacterial drugs, usually tetracyclines, semisynthetic penicillins or aminoglycosides in combination with metronidazole, desensitizing and restorative therapy. If there is no effect, wash the uterine cavity with solutions of antiseptic agents, for example dioxidine, and remove the elements of the fertilized egg retained in it. In the case of a parametrium abscess, it is opened under ultrasound guidance. In the treatment of the chronic process, physiotherapeutic methods play a decisive role: diathermy, UHF, microwave, therapeutic mud, electrophoresis of zinc and iodine.

The most common inflammatory disease in women is salpingo-oophoritis. More often, the infection penetrates into the tubes and ovaries from the uterine cavity during childbirth and abortion, less often with blood or lymph from the rectum and appendix. The inflammatory process begins with the mucous membrane of the tube, where swelling, hyperemia develops, infiltrates are formed, then spreads to the muscular layer, as a result of which the fallopian tube thickens and lengthens, becoming sharply painful on palpation (salpingitis). The lesion can be one- or two-sided: the inflammatory process caused by opportunistic microflora is characterized by a one-sided process, while gonorrhea is characterized by a two-sided process. As a result of inflammation, sometimes the uterine and ampullary ends of the tube become soldered and exudate accumulates in the tube. The accumulation of serous contents in the tube is called hydrosalpinx, and the accumulation of purulent contents is called pyosalpinx. If left untreated, the inflammatory process quickly spreads to the ovaries, and oophoritis develops. In an acute process, the germinal epithelium of the ovary is usually first affected, then, after ovulation, the epithelium and stroma of the ruptured follicle. Infection of the ovary at the time of ovulation causes the formation of pouch “tumors” with liquid or purulent contents, which can lead to an abscess and even purulent melting of the ovary. The ovaries fuse with the fallopian tubes, forming a single inflammatory conglomerate - a tubo-ovarian formation. Often the intestines, peritoneum, and omentum are involved in the inflammatory process.

During an acute process, women complain of weakness, pain in the lower abdomen, lower back, sacrum, sometimes radiating to the rectum, mucopurulent leucorrhoea, body temperature rises to 38. C. Usually these phenomena last 5-7 days, then gradually subside. But a complete cure does not occur; more often the disease becomes chronic. Exacerbation of salpingoophoritis can begin under the influence of many external factors: hypothermia, overheating, fatigue, and is less often associated with reinfection. During an exacerbation, the temperature rises, pain in the lower abdomen appears or intensifies, and the amount of discharge increases. Usually the pain intensifies before and during menstruation, and sometimes the cycle is disrupted. Up to half of patients note sexual dysfunction: libido disappears, coitus becomes painful. With a prolonged course and frequent relapses, the urinary, nervous, endocrine, and vascular systems are involved in the pathological process, and the disease takes on the character of a multisystem process.

Urological pathology very often causes serious problems in a man’s life, from discomfort and deterioration of well-being to decreased self-esteem and loss of self-confidence.

More than half of the cases of these diseases are carried by men without any symptoms, progress and gradually become chronic. In addition, many men, feeling discomfort in the genitourinary organs, still do not go to the doctor due to fear, inconvenience, shame, or in the hope that the disease will sooner or later end on its own.

This approach to this problem ends, as usual, sadly.
It is necessary to understand that early detection of urological pathology almost always contributes to its complete cure, without becoming chronic. Therefore, postponing a visit to the doctor for such problems is quite dangerous.

Male urological diseases

Men in the age group from 18 to 45 years most often suffer from the following urological pathology:

1. Sexually transmitted diseases:
- syphilis
- gonorrhea
- trichomoniasis and other sexually transmitted infections.

2. Inflammatory diseases. Affected areas:
- urethra;
- foreskin and glans;
- prostate;
- testicles and their appendages;
- bladder;
- renal parenchyma and pyelocaliceal system;

3. Disease associated with kidney stones (urolithiasis)

4. Diseases of the intimate and reproductive sphere:
- violation and lack of erection;
- reproductive dysfunction leading to the inability to have offspring

5. Oncological pathology:
- prostate adenoma (benign prostate tumor), etc.

Clinical signs

Often urological pathology in men occurs without manifestations and remains undetected. At the same time, it is necessary to highlight a number of pronounced manifestations that occur most often. These include the following manifestations:
- rashes, discharge and hyperemia of the scrotum and penis;
- pain, burning and itching;
- urinary disturbance;
- pain during intercourse.
- excessive fatigue, weakness, lethargy
- enlargement and thickening of the inguinal lymph nodes.
If a man who is actively sexually active reveals these signs, then he immediately needs to seek help from a dermatovenerologist and urologist.

Urethritis

This disease is often manifested by discomfort and pain during urination, as well as scanty discharge from the urethra. More often, urethritis develops as a result of infection or mechanical trauma resulting from damage to the urethra by passing small urinary calculi.

Balanoposthitis

This disease can be either acute or chronic. In acute balanoposthitis, erosion, discharge, pain, swelling, hyperemia, and occasionally whitish deposits occur in the area of ​​the foreskin and on the head of the penis. The temperature often rises, weakness increases, often leading to loss of consciousness. The chronic form of balanoposthitis is characterized by more muted symptoms, and the skin in the affected areas gradually wrinkles.

Adenoma and inflammation of the prostate gland

Prostate adenoma is characterized by such manifestations as increased frequency of urination, difficulty and intermittency, and a feeling of a full bladder. These sensations at night can even lead to involuntary urination during sleep.
Prostatitis can cause pain in the lower abdomen and lower back, hyperthermia, pain during ejaculation, decreased libido and erectile function.

Orchiepididymitis

In acute orchiepididymitis, intense pain in the scrotum area, elevated temperature, scrotal hyperemia, enlargement and hardening of the testicle appear. If this disease is not detected and treated in a timely manner, it takes a sluggish, chronic course, but the enlargement, hardening and slight soreness of the testicle persist.

Cystitis

With cystitis, the patient notes pain, increased urination, and low-grade body temperature. Also characteristic are dysuric phenomena such as constant urge, pain and burning during urination. Blood and mucus may appear in the urine.
Pyelonephritis
This disease in most cases appears in elderly men in an ascending manner with chronic cystitis, urethritis, and prostatitis.
In acute pyelonephritis, the body temperature rises sharply to 39-40 degrees, there is a nagging pain in the lumbar region, there may be a headache and nausea.

Urolithiasis disease

With this pathology, salts of one or another composition (oxalates, urates) begin to be deposited in the renal collecting system of the kidneys, as a result of metabolic disorders. As these salt deposits accumulate, they form stones that gradually increase in size. Stones very often begin to flow out of the kidney through the ureter with a stream of urine. During this process, the latter is traumatized, which causes severe renal colic in the patient, in which pain can radiate to the lower abdomen and perineum, difficulty urinating, and sometimes the stone can stop in the ureter. Small stones passing through the urethra can also seriously injure it and cause pain and bleeding.

Impotence

With impotence, men note a weakening or complete absence of erection. It is impossible to finish or start sexual intercourse, and ejaculation can occur very quickly.

Diagnostic methods

To make a timely diagnosis, you must urgently contact a qualified specialist (urologist or dermatovenerologist). The doctor will perform all the necessary studies, determine the nature of the disease, and also outline a treatment and rehabilitation plan.
At the first stage, a questioning and initial examination of the patient is performed.

When examining the genital organs, some inflammatory and infectious diseases can be identified. At this stage, a digital examination of the final section of the rectum is also required to identify prostate tumors.
For an accurate diagnosis, the urologist resorts to laboratory and instrumental examination methods.
The patient must have a urine test and a smear from the urethra to determine the causative agent of the disease and select specific, adequate antibiotic therapy.

If necessary, the patient also undergoes urethroscopy or cystoscopy. It is an examination of the walls of the urethra and bladder from the inside using endoscopic equipment. With such a study, it is possible to identify some defects in the mucous membrane of these organs.
A very informative research method for urological pathology is ultrasound examination of the kidneys, urinary tract and prostate. This method will reveal the presence of stones and oncological processes in them.
Very often, male ailments appear due to hormonal imbalance. Therefore, when diagnosing male problems, a blood test for hormones will be very important.

Therapy of some urological diseases

Treatment of male diseases must be comprehensive, and primarily aimed at combating etiological factors.

1. In the treatment of urethritis they are used:
- antibiotics, which are selected by a doctor after examining a smear for the presence of microorganisms, and sometimes after determining the sensitivity of the microflora to drugs;
- nonspecific anti-inflammatory drugs to relieve pain and dysuria
- local antiseptic solutions for sanitation of the urethra;
- immunostimulants and vitamins to strengthen the body's defenses;
- drugs that normalize intestinal microflora after and during antibiotic therapy.

2. For balanoposthitis it is necessary:
- antibacterial drugs;
- antifungal drugs;
- sanitation of this area with furatsilin, miramistin, chlorhexidine and similar antiseptic agents;
- applying ointments with antibiotics or antiseptics;
- a surgical treatment method can also be used (dissection or circumcision of the foreskin in order to provide wider access for sanitation and hygienic procedures);

3. Prostate adenoma is treated mainly with surgery. Antibacterial therapy and immunostimulating agents are also prescribed.

4. Used to treat prostatitis:
- antibacterial agents;
- adrenergic blockers;
- immunomodulators;
- physiotherapy;
- prostate massage.
Prostate massage is used more often in chronic prostatitis in order to improve its trophism and blood circulation in it. Only a doctor in an outpatient setting should perform gland massage.

5. To combat cystitis and pyelonephritis antibiotics, diuretics and immunostimulants are mainly used;

6. Treatment of urolithiasis can be either conservative (antispasmodics, lithotripsy) or surgical (removal of large stones from the kidneys and ureters during abdominal surgery);
It should be noted that special men's absorbent pads that protect clothing are now available for patients suffering from urinary incontinence. This improves the quality of life and social adaptation of men suffering from urinary incontinence.

Prevention of male urological diseases

Treatment of urological pathology must be combined with a healthy lifestyle. Food should be varied and nutritious. Sometimes it is useful to use a salt-free diet to remove excess fluid from the body, thereby reducing swelling. The daily diet must include protein foods, which have a positive effect on reproductive function and libido.
Regular intimate hygiene of the external genitalia is also important. It is necessary to take a shower daily; if this is not possible, then at least wash the external genitalia using an antibacterial gel. It is recommended to change your underwear daily, which should preferably be made of cotton fabrics.
When having sexual intercourse, it is best to use a condom to protect against pathogens entering the urethra.
Constant physical activity, playing sports and giving up bad habits are very important for the male body.
Due to the recent increase in cases of sexually transmitted diseases, men need to visit a urologist for a preventive examination at least twice a year. After all, if the disease is detected in a timely manner, you can get rid of it completely.

Urological diseases - diseases of the urinary system in women, genitourinary - in men and pathological processes in the retroperitoneal space.

Symptoms of urological diseases

The main groups of symptoms of urological diseases:

• general (systemic) manifestations;
• urinary disorders;
• pain syndrome;
• changes in urine;
• pathological discharge from the urethra (discharge of blood, pus) during and outside urination, and changes in sperm;
• changes in the external genitalia in men - enlargement of the genitals, narrowing of the foreskin (phimosis), absence of testicles in the scrotum (can occur with cryptorchidism).

Systemic manifestations

Common manifestations of urological diseases are weight loss, fever and gynecomastia.

High body temperature (up to 38-40 degrees C) occurs during acute inflammatory processes (acute pyelonephritis or acute prostatitis).

Weight loss is observed with progressive chronic renal failure.

Gynecomastia is enlargement of the mammary glands in men. Gynecomastia in men can develop from a testicular tumor.

Urinary disorders

Normally, a healthy person produces about 1.5 liters of urine per day. The normal frequency of urination is 4-6 times a day.

Urinary disorders include pollakiuria, nocturia, stranguria, difficulty urinating and urinary incontinence.

• Pollakiuria – frequent urination. This symptom occurs in diseases of the lower urinary tract and prostate.
• Strangury is frequent difficulty urinating, accompanied by pain. Strangury is a symptom indicating pathology in the bladder.
• Nocturia is frequent and copious urination at night; at night the volume of urine produced is greater than during the day. It happens with cardiovascular failure, diabetes mellitus and prostate diseases.
• Urinary incontinence - urine is released involuntarily, without the urge to urinate. Urinary incontinence can occur in stressful situations, with acute cystitis, prostate adenoma, or damage to the bladder neck by a tumor.
• Difficulty urinating - with this pathology, urine is released in a sluggish, thin stream or drops. Difficulty urinating is characteristic of adenoma and prostate cancer.

Pain syndrome

Urological diseases can be accompanied by acute or dull pain. Localization of pain in most cases helps to diagnose which organ is affected:

• pain in the lumbar region indicates kidney problems;
• if the pain radiates to the groin, this may indicate diseases of the ureters;
• pain is felt in the suprapubic region - a sign of bladder disease;
• pain in the perineum - you can suspect a pathology of the prostate gland, seminal vesicles;
• pain during urination is characteristic of sexually transmitted diseases, and can also occur with cystitis, urethritis, and prostatitis.

Changes in urine

Changes in urine can be quantitative and qualitative.

Quantitative changes in urine - polyuria, oliguria and anuria.

Polyuria is an increase in the amount of urine excreted. Polyuria is a symptom of diabetes mellitus and can appear with chronic pyelonephritis, chronic renal failure, prostate adenoma, and polycystic kidney disease.

Oliguria is a decrease in the amount of urine excreted per day (100-500 ml of urine is excreted per day). Oliguria occurs with renal failure, heart failure, conditions accompanied by the loss of a large amount of fluid from the body (bleeding, vomiting, diarrhea).

Anuria is the cessation of urine flow into the bladder. This symptom can occur with a sharp disruption of the blood supply to both kidneys or a single one; it can develop with severe shock, with acute glomerulonephritis, with bilateral kidney or ureteral stones.

Qualitative changes in urine include changes in color (darkening of urine), urine density, the appearance of protein (proteinuria), salts, bacteria in the urine, an increase in the number of red blood cells, leukocytes, and casts in the urine.

The most common urological diseases

Urolithiasis disease– a disease in which stones form in the kidneys and urinary tract due to metabolic disorders. If the stones begin to change their position and move, this is accompanied by severe pain and the appearance of blood in the urine.

Prostate adenoma (prostatic hyperplasia)– increase in size (proliferation) of the prostate gland. Prostate adenoma is manifested by frequent difficult or intermittent urination in small portions (especially at night), a feeling of incomplete emptying of the bladder, urinary incontinence, and a strong urge to urinate.

Pyelonephritis– the most common nonspecific inflammatory disease of the urinary organs. This term refers to a nonspecific infectious and inflammatory process that affects the renal parenchyma and pelvis. Pyelonephritis is manifested by a significant increase in body temperature, intense dull constant pain in the lumbar region or hypochondrium, and changes in the urine.

Glomerulonephritis– immunoinflammatory kidney disease, manifested by damage to the glomeruli. Symptoms of glomerulonephritis are swelling in the legs, pain in the lumbar region, the appearance of red blood cells and protein in the urine. There may also be many other symptoms that differ between acute and chronic glomerulonephritis.

Cystitis- cystitis. Cystitis is manifested by pain in the lower abdomen, frequent painful urination and the appearance of pus in the urine.

Prostatitis– inflammation of the prostate gland. Prostatitis manifests itself as intoxication, pain in the perineum and groin, frequent difficult, copious and painful urination, and purulent discharge from the urethra.

Acute renal failure– sudden disruption of all kidney functions. The most pronounced symptom of acute renal failure is the sudden cessation of urine flow into the bladder (anuria), followed by a sharp deterioration in the patient's condition.

Chronic renal failure– a symptom complex manifested by the gradual death of renal nephrons due to chronic progressive renal disease. Since the kidneys do not perform their function for a long time, intoxication of the body develops.

Read more about individual diseases of the genitourinary system.

Chapter 9. NON-SPECIFIC INFLAMMATORY DISEASES OF THE GINOROGENITAL SYSTEM

Chapter 9. NON-SPECIFIC INFLAMMATORY DISEASES OF THE GINOROGENITAL SYSTEM

9.1. PYELONEPHRITIS

Pyelonephritis- infectious-inflammatory disease of the kidneys with predominant damage to the pyelocaliceal system, tubulointerstitial tissue and subsequent involvement of the glomerular apparatus in the process.

Epidemiology. Pyelonephritis is the most common inflammatory disease of the urinary system: it accounts for 65-70% of cases. In adults, pyelonephritis occurs in one person out of 100, and in children - in one out of 200. Most often, the disease develops at the age of 30-40 years.

Young women suffer from pyelonephritis more often than men. This is explained by the anatomical and physiological characteristics of the urethra in women. The female urethra is much shorter, located next to the vagina and rectum, making it easier and faster for infection to penetrate through it into the bladder, and then into the upper urinary tract and kidneys. There are three periods of increased risk of urinary tract infection in a woman's life. The first is at birth, during passage through the mother’s infected birth canal; the second - during defloration and the third - during pregnancy.

In men, secondary pyelonephritis more often develops, caused by anomalies of the genitourinary system, narrowing of the ureters, urolithiasis, benign prostatic hyperplasia, etc.

Etiology and pathogenesis. The causative agents of pyelonephritis can be endogenous(internal) or exogenous(penetrating from the environment) microorganisms. The most common are Escherichia coli, Proteus, Staphylococcus, Enterococcus, Pseudomonas aeruginosa and Klebsiella. It is possible to develop pyelonephritis with the participation of viruses, fungi, and mycoplasmas.

Microorganisms enter the kidney in three ways.

Ascending, or urinogenic (urina- urine), the route most often found in children. In this case, microorganisms enter the kidney from the lower urinary tract with the reverse flow of urine, that is, in a pathological condition called PMR.

Rising Path- along the wall of the ureter into the pelvis and kidney. A number of microorganisms have the ability to adhesion (stick) and move up the urothelium with the help of special cellular structures - fimbriae.

In addition, infectious agents can spread upward as a result of inflammatory and destructive changes in the wall of the ureter.

When the primary inflammatory focus is localized in any other organ (skin, tonsils, nasopharynx, lungs, etc.), microorganisms enter a healthy kidney hematogenous way, that is, with the blood flow, and cause a violation of microcirculation in it and the development of an infectious-inflammatory process. Factors predisposing to the development of hematogenous pyelonephritis may be: circulatory disorders in the kidney and impaired urine outflow. Microorganisms brought in by the blood settle on the vascular loops of the renal glomeruli, leading to inflammatory changes in the vascular wall, destroy it, penetrate the lumen of the renal tubules and are excreted in the urine. An inflammatory process develops around the formed infectious blood clots.

Most often, pyelonephritis develops by hematogenous and urinogenic routes.

The development of the disease is facilitated by predisposing factors, which are divided into general and local. TO general include a violation of the body's immune system, stress, hypothermia, hypovitaminosis, severe somatic pathology, diabetes mellitus. Local factors are a violation of the blood supply to the kidney and a violation of the urodynamics of the upper urinary tract (anomalies of the kidneys and urinary tract, urolithiasis, trauma, narrowing of the ureters, benign prostatic hyperplasia, etc.). In some cases, the development of pyelonephritis is facilitated by various instrumental and endoscopic research methods (catheterization of the bladder, bougie of the urethra, cystoscopy, stenting of the ureters).

Classification. According to the clinical course there are acute, chronic and recurrent pyelonephritis.

According to the causes of occurrence and the state of patency of the urinary tract, they are divided into: primary(without obstruction) and secondary(obstructive) pyelonephritis, which occurs much more often, in 80-85% of cases.

According to the number of kidneys affected, pyelonephritis can be one-sided And bilateral. Unilateral pyelonephritis is much more common.

There are also anatomical and morphological forms of pyelonephritis: serous And destructive(purulent): apostematous pyelonephritis (Fig. 57, see color insert), carbuncle (Fig. 58, see color insert), kidney abscess, necrotizing papillitis.

Sometimes rare forms of the disease such as emphysematous pyelonephritis and xanthogranulous pyelonephritis occur.

Pathological anatomy. Morphologically, both primary and secondary acute pyelonephritis can occur in the form of a serous (more often) and purulent (less often) inflammatory process.

At acute serous pyelonephritis the kidney is enlarged, dark red. Due to the increase in intrarenal pressure when the fibrous capsule is dissected, the parenchyma is swollen, tense, and prolapses through the opened capsule. Histologically, perivascular infiltrates are detected in the interstitial tissue. Serous pyelonephritis is characterized by focality and polymorphism of the lesion: foci of inflammatory infiltration alternate

with areas of unchanged (healthy) kidney tissue. There is also swelling of the interstitium with compression of the renal tubules. In most cases, phenomena of paranephritis with edema of the perinephric tissue are observed. With timely treatment and a favorable course of the disease, it is possible to reverse the development of the inflammatory process. Otherwise, serous pyelonephritis turns into purulent with a more severe clinical course.

Acute purulent pyelonephritis morphologically manifests itself in the form of pustular (apostematous) nephritis (Fig. 57, see color insert), renal carbuncle (Fig. 58, see color insert) or abscess. If the infection penetrates urogenously, significant changes are observed in the pelvis and calyces: their mucous membrane is hyperemic, the cavities are dilated, and the lumen contains pus. Necrosis of the papillae of the pyramids often occurs - papillary necrosis. Foci of purulent inflammation can merge with each other and lead to the destruction of the pyramids. Subsequently, the renal cortex is also involved in the pathological process with the development of small abscesses (pustules) in it - apostematous pyelonephritis.

With the hematogenous spread of infection, multiple pustules measuring from 2 to 5 mm initially form in the cortex and then in the medulla of the kidney. Initially they are located in the interstitium, then they affect the tubules and, finally, the glomeruli. Pustules can be located in the form of single small abscesses or be disseminated in nature, merging into larger inflammatory foci. When the fibrous capsule is removed, the superficially located pustules are opened. On section they are visible in both the cortex and medulla. The kidney is enlarged, dark cherry in color, the perinephric tissue is sharply swollen. Changes in the pelvis and calyces are usually less pronounced than with urogenic purulent pyelonephritis. Merging with each other, small pustules form a larger abscess - a solitary abscess.

Carbuncle kidney is a segmental ischemic inflammatory-necrotic area of ​​the kidney. It is formed as a result of the closure of a blood vessel by a septic thrombus, followed by necrosis and purulent melting of the corresponding kidney segment (Fig. 58, see color insert). Outwardly, it resembles a skin carbuncle, by analogy with which it got its name. Often, renal carbuncle is combined with apostematous pyelonephritis, more often it is unilateral or solitary. The simultaneous development of carbuncles in both kidneys is extremely rare. As with other forms of acute purulent pyelonephritis, the development of purulent paranephritis is possible (Fig. 59, see color insert).

The considered variants of acute purulent pyelonephritis represent different stages of the same purulent-inflammatory process. Microscopically, after the active inflammatory process subsides in the interstitial tissue, scar tissue develops at the site of infiltrative foci. During recovery from acute pyelonephritis, the kidney does not shrink, since the development of scar changes due to the death of renal tissue is not diffuse, but focal.

9.1.1. Acute pyelonephritis

Symptoms and clinical course. Acute pyelonephritis is an infectious-inflammatory disease that occurs with vivid symptoms. The initial clinical manifestations of primary acute pyelonephritis usually occur several days or weeks (on average 2-4 weeks) after the attenuation of foci of infection in other organs (angina, exacerbation of chronic tonsillitis, mastitis, osteomyelitis, furunculosis).

The clinical picture of acute pyelonephritis is characterized by general and local symptoms. With primary purulent pyelonephritis and the hematogenous route of infection, the general symptoms of the disease are more pronounced, and with secondary pyelonephritis, local obstructive symptoms come to the fore. In typical cases, a triad of symptoms is characteristic: fever, accompanied by chills, pain in the corresponding lumbar region and dysuric phenomena.

Acute pyelonephritis often begins with general symptoms caused by intoxication: headache, weakness, general malaise, pain in muscles, joints, fever with chills and subsequent profuse sweating. The severity of these clinical manifestations varies and depends on the severity of the inflammatory process in the kidney.

Purulent pyelonephritis is much more severe than serous pyelonephritis, sometimes with the rapid development of urosepsis and bacteremic shock. Chills can be overwhelming, followed by a rise in temperature to 39-40 °C and higher. After 1-2 hours, profuse sweat appears and the temperature drops for a short period of time. Chills with a sharp rise in temperature and profuse sweating are repeated daily, several times a day. Purulent pyelonephritis is characterized by a hectic-type temperature with daily fluctuations of up to 1-2 °C or more, but it can remain persistently elevated. Repeated hectic rise in temperature at certain intervals is caused by the appearance of new pustules (in patients with apostematous pyelonephritis) or the formation of a renal carbuncle.

Local symptoms of acute pyelonephritis - pain in the lumbar region and dysuria - have varying degrees of severity depending on the nature and severity of the disease. Almost every patient has pain in the lumbar region in one form or another. They can be different: from pronounced, in the form of renal colic, to a feeling of heaviness in the area limited by the triangle of the spine - the place of attachment of the lower rib - the conditional line at the level of the lowest point of bend (arc) of the rib. These pains are typically characterized by a lack of connection with movement and body position, but they intensify with a deep breath, shaking the body, and with tapping in the kidney area. Initially, pain in the lumbar region or in the upper abdomen is of an uncertain nature and location. Only after 2-3 days they are localized in the area of ​​the right or left kidney, often radiating to the corresponding hypochondrium, groin area, genitals; worse at night, when coughing, moving the leg. In some patients, in the first days of development of pyelonephritis, the pain syndrome may be mild or not expressed at all.

be absent and appear in 3-5 days. There is pain when tapping the lumbar region - the so-called positive Pasternatsky symptom. Characterized by soreness and protective tension of the abdominal muscles on the side of the affected kidney. If the abscess is localized on the anterior surface of the kidney, the peritoneum may be involved in the inflammatory process with the development of peritoneal symptoms. In such cases, severe pain combined with symptoms of peritoneal irritation often lead to an erroneous diagnosis of acute appendicitis, cholecystitis, pancreatitis, perforated gastric ulcer and other acute surgical diseases of the abdominal organs. In these cases, differential diagnosis is especially difficult if dysuria and pathological changes in the urine are absent, as is often the case in the first days of the disease. With frequent and painful urination, the diagnosis of pyelonephritis is simplified.

Diagnostics. Examination of patients with pyelonephritis includes the collection of complaints, anamnesis, physical examination, after which they move on to special diagnostic methods.

At laboratory research The blood test shows pronounced leukocytosis (up to 30-40 thousand) with a significant neutrophilic shift in the leukocyte formula to the left to young forms, an increase in ESR to 40-80 mm/h. However, a clear dependence of changes in peripheral blood on the severity of clinical manifestations is not always observed: in severe cases of the disease, as well as in weakened patients, leukocytosis can be moderate, insignificant or absent, and leukopenia is sometimes observed.

Characteristic signs of acute pyelonephritis when examining urine sediment are proteinuria, leukocyturia and significant (true) bacteriuria, especially if they are detected simultaneously. False proteinuria during the inflammatory process in the kidney is caused by the breakdown of blood cells when they enter the urine and in most cases does not exceed 1.0 g/l (from traces to 0.033-1.0 g/l). It is represented mainly by albumins, less often by gammaglobulins. Leukocyturia (pyuria) is the most characteristic sign of pyelonephritis. It often reaches significant severity (leukocytes cover the entire field of view or are found in clusters) and may be absent only when the inflammatory process is localized only in the renal cortex or when the ureter is obstructed. With pyelonephritis, erythrocyturia (microhematuria) can be observed, less often - macrohematuria (with necrosis of the renal papillae, calculous pyelonephritis). Severe disease is accompanied by cylindruria (granular and waxy casts). Bacteriuria is detected in most cases, however, like leukocyturia, it is intermittent in nature, so repeated urine tests for microflora are important. To confirm pyelonephritis, only the presence of true bacteriuria is important, implying the presence of at least 50-100 thousand microbial bodies in 1 ml of urine.

Urine culture and determination of the sensitivity of microorganisms to antibiotics are carried out before, during and after the end of treatment of the patient. In uncomplicated acute pyelonephritis, control urine culture is performed on the 4th day and 10 days after the end of antibiotic therapy, if

complicated pyelonephritis - respectively on the 5-7th day and after 4-6 weeks. Such a bacteriological study is necessary to identify resistant forms of microorganisms and correct antibiotic therapy during treatment, as well as to determine the recurrence of infection after a course of therapy.

Blood culture to determine the sensitivity of microflora to antibiotics is indicated for patients with a clinical picture of sepsis. In general, bacteremia is detected in approximately 20% of all cases of acute pyelonephritis.

Elevated serum creatinine and urea levels are a sign of renal failure. The level of creatinine and urea in the blood serum should be determined before studies with intravenous administration of radiocontrast agents. An increase in the level of urea and creatinine in the blood as a consequence of impaired renal function is possible in severe purulent pyelonephritis with severe intoxication or a bilateral process. In these cases, liver damage and the development of hepatorenal syndrome are often observed with disruption of protein-forming, detoxification, pigment (with the presence of jaundice), prothrombin-forming and other functions.

Kidney ultrasound has high accuracy in identifying the size of the kidney, the heterogeneity of its structure, deformation of the pyelocaliceal system, the presence of pyonephrosis and the condition of the perinephric fatty tissue. A decrease in the mobility of the kidney in combination with its increase is the most important ultrasound sign of acute pyelonephritis, and the expansion of the pyelocaliceal system indicates the obstructive (secondary) nature of the disease.

By using sonography focal changes are detected (usually hypoechoic areas) in the kidney parenchyma and paranephria, resulting from their purulent lesions.

Survey and excretory urography allows you to determine the cause and level of urinary tract obstruction. In the first 3-4 days, acute pyelonephritis may not be accompanied by leukocyturia. In such cases, the diagnosis of primary pyelonephritis is especially difficult, since there are no signs of impaired urine outflow from the kidney. In such patients, excretory urography with taking pictures during inhalation and exhalation on one film has great diagnostic value: it allows you to identify limited mobility of the kidney on the affected side.

CT is the most modern and informative diagnostic method for studying purulent-inflammatory kidney diseases. CT allows you to determine the cause and level of possible ureteral obstruction and detect foci of destruction of the renal parenchyma. The diagnostic value of this method is due to its high resolution and the ability to clearly differentiate normal tissues from pathologically altered ones. CT results make it easier for the surgeon to choose the optimal approach for open or percutaneous intervention, in particular for renal carbuncle or perinephric abscess.

If VUR is suspected (for example, in patients with a neurogenic bladder or children), it is advisable to perform voiding cystography.

Acute pyelonephritis must be differentiated from diseases that occur with symptoms of general intoxication, high body temperature, and severe general condition. A picture of an acute abdomen with peritoneal symptoms and local pain simulating acute appendicitis, cholecystitis, pancreatitis, perforated gastric and duodenal ulcers and other acute diseases of the abdominal organs may be observed. Acute pyelonephritis, accompanied by severe headache and meningeal symptoms, is sometimes mistakenly regarded as an acute infectious disease (typhoid and typhoid fever, paratyphoid fever, meningococcal infection, etc.), which often gives rise to the erroneous hospitalization of such patients in an infectious diseases hospital. In the latent course of acute pyelonephritis, difficulties arise in differential diagnosis with acute or chronic glomerulonephritis, manifested only by isolated urinary syndrome.

Treatment. Acute pyelonephritis requires treatment in a hospital. When identifying the obstructive nature of the disease, it is first necessary to ensure adequate outflow of urine from the affected kidney. The patency of the ureter can be restored by catheterization (Fig. 21, see color insert) or stenting (Fig. 22, see color insert). If it is impossible to pass the catheter through the ureter above the site of its obstruction, percutaneous puncture nephrostomy should be performed. Further treatment consists of prescribing antibacterial and symptomatic therapy, maintaining bed rest, using non-steroidal anti-inflammatory drugs and drinking plenty of fluids.

Empirical antibacterial therapy should include parenteral administration of broad-spectrum drugs that primarily affect gram-negative flora (fluoroquinolones, cephalosporins, aminoglycosides). In the future, treatment is adjusted taking into account the results of urine cultures and determining the sensitivity of the pathogen to antibiotics. The course of treatment for acute uncomplicated pyelonephritis is 7-14 days.

Quinolones and fluoroquinolones. Drugs of this group are widely used in the treatment of kidney and urinary tract infections. Non-fluorinated quinolones (pipemidic, oxolinic, nalidixic acids) have lower microbiological activity compared to fluoroquinolones, which limits their use. The most rational for empirical treatment of pyelonephritis are modern fluorinated quinolones: levofloxacin (500 mg 1 time per day), ciprofloxacin (500 mg 2 times per day), ofloxacin (200 mg 2 times per day), etc. They are characterized by wide antimicrobial spectrum and high activity against the main pathogens of pyelonephritis. Fluoroquinolones have good bioavailability and provide high bactericidal concentrations in the urine and renal parenchyma.

Cephalosporins- one of the most extensive classes of antibiotics, characterized by high efficiency and low toxicity. For uncomplicated mild pyelonephritis, it is sufficient to use oral forms of cephalosporins: cefuroxime axetil (500 mg 2 times a day),

cefixime (400 mg 1 time per day). For the treatment of complicated urinary tract infections, parenteral forms are used (cefuroxime, cefotaxime, cefepime, ceftriaxone).

Aminoglycosides(gentamicin, amikacin, neomycin, tobramycin) are active against most pathogens of pyelonephritis, but in clinical practice they should be used with caution, usually in a hospital setting. Drugs in this group have potential oto- and nephrotoxicity.

Carbapenems(imipenem, meropenem) are considered as reserve drugs when first-line antibiotics are ineffective.

One of the important components of treatment is therapy aimed at increasing immunity and improving the general condition of the body. Among the immunomodulators used are Wobenzym, Lavomax, and Echinacea preparations (Immunal, etc.).

Complex treatment of both acute and chronic pyelonephritis includes the prescription of phytouroseptics that have a diuretic, antibacterial, anti-inflammatory, astringent and tonic effect (lingonberry leaf, bearberry, St. John's wort herb, kidney tea, birch buds, juniper berries, etc.).

As a rule, acute pyelonephritis with timely treatment begins favorably. After 3-5 days, the temperature decreases, the manifestations of intoxication and pain in the lumbar region decrease, and the blood picture improves. Within 7-10 days, bacteriuria and leukocyturia are practically eliminated. Absolute recovery occurs after 3-4 weeks.

Forecast. Acute serous pyelonephritis in most cases it ends in recovery. The success of treatment is determined by timely prescribed antibacterial therapy and ensuring adequate urine outflow from the kidney in the obstructive form of the disease. Late-started, insufficiently active and prematurely completed treatment prevents final recovery and contributes to the transition of acute pyelonephritis to chronic; microflora resistance to antimicrobial drugs; the presence of severe concomitant pathology that weakens the body's defenses, etc. In such cases, pyelonephritis becomes chronic with the subsequent development of chronic renal failure. At purulent forms of the disease the prognosis is unfavorable and depends on the timeliness of the surgical intervention.

After treatment of acute pyelonephritis, clinical observation and prescription of anti-relapse treatment, if necessary, are necessary. This is due to the risk of the disease becoming chronic, which is observed in 20-25% of cases.

9.1.2. Chronic pyelonephritis

In most cases, it is a consequence of acute pyelonephritis. The main reasons for the disease to become chronic are:

■ inadequate and untimely treatment of acute pyelonephritis;

■ violation of the outflow of urine from the renal cavity system with urolithiasis, ureteral strictures, VUR, benign prostatic hyperplasia, nephroptosis, etc.;

■ transition of bacteria into L-forms, which can remain in an inactive state in the kidney tissue for a long time, and when immunity decreases, return to their original state, causing an exacerbation of the inflammatory process;

■ common concomitant diseases that cause weakening of the body - diabetes mellitus, obesity, diseases of the gastrointestinal tract, etc.;

■ immunodeficiency states.

There are frequent cases of chronic pyelonephritis in childhood (especially in girls). A typical option is the manifestation of an acute form of the disease, which for various reasons is not completely cured, but acquires a latent course. In the future, various acute inflammatory diseases can cause exacerbation of pyelonephritis with a typical clinical picture. Over time, its flow becomes wave-like. Thus, long-term chronic pyelonephritis with periodic exacerbations each time involves more and more new areas of the renal parenchyma in the pathological process. As a result, each affected area is subsequently replaced by scar tissue. Deformation of the parenchyma and pyelocaliceal system of the kidney occurs, a decrease in the size (wrinkling) of the organ with the development of functional failure.

Depending on the activity of the inflammatory process, the following phases of the course of chronic pyelonephritis are distinguished.

1. Active phase. The clinical picture is similar to that of acute pyelonephritis. Leukocytes and bacteria are found in the urine; in a blood test - signs of an inflammatory process in the body, an increase in ESR. When treating chronic pyelonephritis, and sometimes without it, the acute phase passes into the next one - latent.

2. Latent phase. Clinical manifestations are scanty or absent. General symptoms may be observed in the form of weakness, low-grade fever, fatigue, decreased performance, loss of appetite, unpleasant taste in the mouth, discomfort in the lumbar region, that is, symptoms characteristic of a sluggish infectious-inflammatory process when there are minimal signs of intoxication.

3. Remission phase means clinical recovery and implies the absence of any manifestations of the disease.

The clinical course of chronic pyelonephritis depends on many factors, including localization in one or both kidneys, the extent of the inflammatory process, the presence or absence of an obstruction to the outflow of urine, the effectiveness of previous treatment, and the nature of concomitant diseases. The greatest diagnostic difficulties are presented by chronic pyelonephritis in the latent phase or during remission. In such patients

pain in the lumbar region is insignificant and intermittent, aching or pulling. Dysuric phenomena are absent in most cases or are observed occasionally and are mildly expressed. Body temperature is normal or subfebrile.

A long course of chronic pyelonephritis leads to scarring of the kidney tissue and the development of chronic renal failure. Patients complain of increased fatigue, decreased performance, loss of appetite, weight loss, lethargy, drowsiness, and periodic headaches. Later, dyspeptic symptoms, dryness and peeling of the skin appear. The skin takes on a peculiar grayish-yellow color with an earthy tint. The face is puffy, with constant pastiness of the eyelids; the tongue is dry, covered with a dirty brown coating, the mucous membranes of the lips and mouth are dry and rough. In 40-70% of patients with chronic pyelonephritis, as the disease progresses, resulting in kidney shrinkage, symptomatic arterial hypertension develops. Approximately 20-25% of patients have it already in the initial stage of the disease. Antihypertensive therapy in the absence of etiotropic treatment is ineffective.

The late stages of chronic pyelonephritis are characterized by polyuria with the release of up to 2-3 liters or more of urine during the day. Cases of polyuria reaching 5-7 liters per day have been described, which can lead to the development of hypokalemia, hyponatremia and hypochloremia. Polyuria is accompanied by pollakiuria and nocturia, hyposthenuria. As a consequence of polyuria, thirst and dry mouth appear.

Diagnostics. Clinical And laboratory signs chronic pyelonephritis are most pronounced in the acute phase and insignificant in the latent phase and during remission. An exacerbation of the disease may resemble acute pyelonephritis and be accompanied by a similar clinical picture with corresponding laboratory data.

Proteinuria and leukocyturia may be minor and variable. The protein concentration in urine ranges from traces to 0.033-0.099 g/l. The number of leukocytes during repeated urine tests does not exceed the norm, or reaches 6-8, less often 10-15 in the field of view. Active leukocytes and bacteriuria are not detected in most cases. Slight or moderate anemia and a slight increase in ESR are often observed.

Sonographic signs Chronic pyelonephritis is a decrease in the size of the kidney, deformation of its contours and the collecting system, which indicates shrinkage of the organ.

One of the main methods for diagnosing chronic pyelonephritis is excretory urography. The X-ray picture is characterized by polymorphism. Radiological signs characteristic of this disease are a decrease in the tone of the calyces, pelvis and upper third of the ureter in the form of their moderate expansion, the appearance of a symptom of the edge of the psoas muscle (at the point of contact of the pelvis and ureter with the edge m. psoas there is an even flattening of their contour). Over time, various deformations of the calyxes develop: they acquire a mushroom-shaped, club-shaped shape, are displaced, their necks lengthen and narrow, and the papillae are smoothed out. Approximately 30% of patients with chronic pyelonephritis have Hodson's symptom.

Its essence lies in the fact that if you connect the calyces of a pyelonephritic kidney on an excretory urogram, you will get a sharply sinuous line, which normally should be uniformly convex, parallel to the outer contour of the kidney. The disease is accompanied by a gradual decrease in the functioning renal parenchyma, which can be determined using the renal-cortical index - the ratio of the area of ​​the collecting system to the area of ​​the kidney.

Renal arteriography is not the main method for diagnosing chronic pyelonephritis, but it allows one to evaluate the architecture and characteristics of the blood supply to the affected kidney. A characteristic sign of the disease is a decrease in the number or even complete disappearance of small segmental arteries (a symptom of charred wood.)

Radioisotope diagnostics in patients with chronic pyelonephritis, it allows you to determine the amount of functioning renal parenchyma and study the separate function of the kidneys. Using static and dynamic scintigraphy, the size of the kidney, the nature of accumulation and distribution of the drug in it are assessed. In case of segmental organ damage, scintigraphy reveals a delay in the transport of hippuran in the area of ​​scar-sclerotic changes. The method also allows for dynamic monitoring of renal function recovery during treatment.

Differential diagnosis. Chronic pyelonephritis must be differentiated primarily from chronic glomerulonephritis, renal amyloidosis, diabetic glomerulosclerosis and hypertension.

Treatment. Chronic pyelonephritis can take the form of a frequently relapsing disease. In this case, long-term use of antibacterial drugs in adequate doses is indicated. When prescribing such therapy, it is necessary to take into account the possibility of the emergence of resistant strains of microorganisms, allergic reactions and individual intolerance to drugs.

The reason for the constant recurrence of the infection and the transition of the disease to a chronic form may be a violation of the adequate passage of urine through the urinary tract. Chronic pyelonephritis is often observed in patients with VUR, narrowing of the ureters of various origins, urolithiasis, obstruction of the bladder neck, benign prostatic hyperplasia, etc. It is impossible to stop the infectious process without restoring the normal outflow of urine from the kidneys.

It is quite difficult to achieve a high concentration of antibiotics in the renal tissue, which explains the frequent recurrence of chronic pyelonephritis, despite long-term treatment. It is necessary to prescribe antibacterial drugs that selectively accumulate in the kidney tissue with subsequent high concentrations in the urine. The choice and rotation of antibiotics should be made taking into account regular urine cultures to monitor the effectiveness of treatment and confirm the absence of recurrence of infection. In case of reinfection, adjustment of therapy is required with periodic administration of appropriate drugs for a long time, sometimes reaching periods of 1 to 3 years. If urine remains sterile after the first

3-6 month course and for six months after cessation of treatment, urine culture is performed every 3-6 months over the next year, and then annually.

Spa treatment is in demand in the complex therapy of chronic pyelonephritis. The preferred resorts are Kislovodsk, Zheleznovodsk, Truskavets, Jermuk, Sairme. Therapeutic mineral drinking waters should have an anti-inflammatory effect, have a diuretic effect, improving renal blood flow and urine filtration. Drinking water from some sources reduces spasm of the smooth muscles of the renal pelvis and ureter. The composition of mineral waters from various sources is heterogeneous. The healing waters of the Slavyansky, Smirnovsky and Lermontovsky springs are hydrocarbonate-sulfate-sodium-calcium, which determines their anti-inflammatory effect. Naftusya (Truskavets) - hydro-carbonate-calcium-magnesium mineral water with a high content of naftalan substances - has an anti-inflammatory effect. At the Truskavets resort, drinking mineral water is often combined with ozokerite applications and other methods of physical treatment. Contraindications to sanatorium-resort treatment are general (cardiovascular and cardiopulmonary failure, cancer, etc.) and local (impaired urine outflow requiring surgical treatment, chronic renal failure and pyelonephritis in the active phase) factors.

Forecast in chronic pyelonephritis, it is favorable if the cause that supports the inflammatory process is promptly eliminated (remediation of chronic foci of infection, elimination of urinary tract obstruction, PMR). A long course of chronic pyelonephritis with frequent exacerbations of the infectious and inflammatory process leads to scarring of the kidneys, the development of arterial hypertension and chronic renal failure.

9.1.3. Pyelonephritis in pregnant women

Pyelonephritis during pregnancy is classified as a separate nosological group and is characterized as an infectious-inflammatory process of the renal parenchyma and pyelocaliceal system, which develops during pregnancy. To varying degrees, the disease occurs in 1-10% of pregnant women.

Etiology and pathogenesis. The etiological factor is microorganisms that penetrate the kidney both by urinogenic, ascending, and hematogenous routes in the presence of foci of infection. The mechanism of development of pyelonephritis during pregnancy is due to compression of the ureters by the enlarged uterus. Urostasis is promoted by changes in hormonal levels, decreased tone of the sympathetic nervous system, and hypocalcemia. From the 10th to the 30th week of pregnancy, muscle tone and contractility of the ureters decrease, filtration increases and water reabsorption decreases, and more daily urine is formed, which also contributes to the development of hydroureteronephrosis. The above changes create favorable

conditions for the development of infection in the kidney. As a rule, E. coli, Proteus, Klebsiella, enterobacteria, etc. are detected. The right kidney is most often affected, and the disease can be either unilateral or bilateral.

Symptoms and clinical course. If the inflammatory process is mild, the clinical picture remains poor. Aching pain in the lumbar region and pathological changes in the urine may be observed. With active inflammation, the clinical manifestations are identical to acute pyelonephritis.

Diagnostics. Urine tests show leukocyturia and bacteriuria. A urine culture test is required. Ultrasound scanning allows us to detect dilation of the ureter and pyelocaliceal system of the kidney, thickening of the parenchyma due to its edema.

Treatment carried out jointly with obstetricians and gynecologists. Hospitalization in a specialized institution is recommended. If there is a pronounced dilation of the renal cavity system, ureteral stenting or percutaneous nephrostomy is performed. Installation of a stent is usually simple and is performed with the patient in the supine position, which is important during pregnancy. The use of a stent with an antireflux mechanism is recommended.

Antibacterial therapy during pregnancy is associated with the risk of embryotoxic and teratogenic effects of antibiotics, especially fluoroquinolone and cephalosporin series. Therefore, semisynthetic penicillins are most often used in the treatment of pyelonephritis in pregnant women. In severe cases, cephalosporins may be prescribed. In the presence of destructive forms of pyelonephritis, lumbotomy, kidney decapsulation and nephrostomy are indicated.

For the purpose of prevention during pregnancy planning, it is recommended to carry out sanitation of all possible foci of infection (treatment of caries, otitis media, etc.). Sexual intercourse during pregnancy is recommended with an empty bladder and with the mandatory use of barrier contraceptives.

Forecast in most cases favorable.

9.1.4. Pyonephrosis

Pyonephrosis, or purulent kidney- this is the final stage of obstructive chronic pyelonephritis (infected hydronephrosis).

Etiology and pathogenesis. As a result of the purulent-destructive process, the kidney tissue completely melts; the organ consists of foci of purulent detritus, cavities filled with urine, and areas of decaying parenchyma. The inflammatory process, as a rule, spreads to the surrounding fatty tissue.

Symptoms and clinical course. Pyonephrosis manifests itself as dull aching pain in the lumbar region. They can intensify significantly during exacerbation of the inflammatory process. Increased in size

Rice. 9.1. Sonogram. Pyonephrosis: the level of purulent urine in the dilated abdominal cavity system of the kidney is determined (arrow)

it can be felt through the anterior abdominal wall. If the ureter is completely occluded, it is said to be closed pyonephrosis. The course of the disease becomes severely septic: the patient experiences hectic body temperature, chills, and signs of intoxication - pallor, weakness, sweating. At open In pyonephrosis, the patency of the ureter is partially preserved, which ensures drainage of purulent contents. In such cases, the course of pyonephrosis is less severe. With a bilateral process, chronic renal failure quickly develops and progresses.

Diagnostics. IN laboratory analysis X characteristic inflammatory changes are present. In the blood test, pronounced leukocytosis is observed with a shift in the leukocyte formula to the left, and an increase in ESR. In patients with open pyonephrosis, the urine is purulent, cloudy, with a large amount of flakes and sediment. With closed pyonephrosis against the background of a severe septic picture, changes in the urine may be absent.

During cystoscopy, discharge of pus from the mouth of the affected ureter is observed.

Ultrasound allows us to identify a significantly enlarged kidney with thinning of the parenchyma. Characterized by a sharp expansion and deformation of the cavity system of the organ, the presence of heterogeneous suspension, detritus, and concretions in the lumen (Fig. 9.1).

On plain radiograph shadows of stones can be detected in the pro-

sections of the urinary tract, enlarged kidney.

On excretory urograms the release of the contrast agent by the diseased kidney is sharply slowed down or, more often, absent.

CT reveals a significantly enlarged kidney, the parenchyma of which is thinned or represents a scar pyogenic capsule. The abdominal cavity system of the kidney is expanded, deformed and represents a single cavity separated by partitions containing fluid of heterogeneous composition

(Fig. 9.2).

Rice. 9.2. CT with contrast, axial projection. Large left-sided pyonephrosis is detected (arrow)

Differential diagnosis pyonephrosis is carried out with a suppurating cyst, tuberculosis and kidney tumor.

Treatment pyonephrosis is exclusively surgical and depends on the level of ureteral obstruction in nephrectomy or nephroureterectomy.

Forecast with unilateral pyonephrosis and timely surgical treatment, favorable. After the operation, the patient should be under the medical supervision of a urologist.

9.2. PARANEPHRITIS

Paranephritis- infectious-inflammatory process in perinephric fatty tissue.

Epidemiology. Paranephritis is relatively rare. The most common risk factors for the development of paranephritis are urolithiasis with urinary tract obstruction and purulent forms of pyelonephritis (Fig. 59, see color insert). In persons suffering from paranephritis, urinary stones are found in 20-60% of cases. Other risk factors include congenital and acquired anomalies of the urinary system, previous surgeries and injuries to the urinary tract, as well as diabetes mellitus.

Etiology and pathogenesis. Paranephritis is caused by staphylococcus, Escherichia coli, Proteus, Pseudomonas aeruginosa, Klebsiella and other types of microorganisms.

There are primary and secondary paranephritis. Primary occurs as a result of infection of perirenal tissue by hematogenous route from distant foci of purulent inflammation in the body (felon, boil, osteomyelitis, pulpitis, sore throat, etc.). Its development is facilitated by trauma to the lumbar region, hypothermia and other exogenous factors. Secondary paranephritis occurs in 80% of cases. It develops as a complication of the purulent-inflammatory process in the kidney: in some cases, with the direct spread of pus from the source of inflammation (kidney carbuncle, abscess, pyonephrosis) to the perinephric tissue, in others (with pyelonephritis) - through the lymphatic tract and hematogenously.

Classification. Depending on the localization of the purulent-inflammatory focus in the perinephric tissue, front, rear, top, bottom And total paranephritis. Most often, posterior paranephritis is observed due to the greater development of fatty tissue along the posterior surface of the kidney. The lesion can be unilateral or bilateral. The inflammatory process develops quickly, since the perinephric tissue is a favorable environment for the development of infection.

According to the nature of the inflammatory process, acute and chronic paranephritis are distinguished.

Acute paranephritis first goes through the stage of exudative inflammation, which may undergo reverse development or turn into a purulent form. If the purulent process in the perinephric tissue tends to spread, the interfascial septa and pus usually melt

rushes to places in the lumbar region that have the least resistance. With further development of the process, it goes beyond the perinephric tissue, forming phlegmon of the retroperitoneal space. The latter can break into the intestine, abdominal or pleural cavities, into the bladder or under the skin of the groin area, spreading along the psoas muscle, and through the obturator foramen to the inner surface of the thigh. In recent years, due to the widespread use of antibiotics, paranephritis, especially its common purulent forms, is much less common.

Chronic paranephritis most often occurs as a complication of chronic calculous pyelonephritis or as an outcome of acute paranephritis. It is often a consequence of surgical interventions on the kidney (as a result of urine entering the perinephric tissue), traumatic damage to the kidney with the development of urohematoma. Chronic paranephritis occurs as a productive inflammation with the replacement of perinephric tissue with connective tissue (“armored” paranephritis) or fibrous-lipomatous tissue. The kidney turns out to be immured in an infiltrate of woody density and considerable thickness, which greatly complicates surgical intervention.

Symptoms and clinical course. Acute paranephritis in the initial stage of the disease has no characteristic symptoms and begins with an increase in body temperature to 39-40 ° C, chills, and malaise. Only after three to four days or more do local signs appear in the form of pain in the lumbar region of varying intensity, pain on palpation in the costovertebral angle on the corresponding side. Somewhat later, curvature of the lumbar spine is discovered due to protective contraction m. psoas, the characteristic position of the patient with the thigh adducted to the abdomen and sharp pain when it is extended due to the involvement of the lumbar muscle in the process. Pay attention to the pastiness of the skin, local hyperemia, and higher leukocytosis of blood taken from the lumbar region on the side of the disease. Obtaining pus during puncture of the perinephric tissue provides convincing evidence of purulent paranephritis, but a negative test result does not exclude it. Sometimes paranephritis can imitate appendicitis, abscess of the subdiaphragmatic space, or pneumonia.

Diagnostics. Blood analysis detects neutrophilic leukocytosis with a shift of the formula to the left. Sometimes, with erased forms of paranephritis, the count of leukocytes in blood taken from three points (from the finger, the lumbar region on the right and left) has diagnostic value.

Urine in primary paranephritis is not changed; in the secondary case, changes are found in it that are characteristic of the renal disease that caused it (usually pyuria).

Significant assistance in recognizing acute paranephritis is provided by X-ray methods research. X-ray of the chest with upper paranephritis reveals a decrease in the mobility of the corresponding dome of the diaphragm, and often effusion in the pleural cavity. A plain X-ray of the urinary tract reveals scoliosis of the spine in the healthy direction. Outlines m. psoas on the affected side they are smoothed out or absent, while on the healthy side they are clearly visible.

Rice. 9.3. Sonogram:

1 - paranephritis; 2 - kidney

excretory urography, performed during inhalation and exhalation, it allows us to identify the absence or sharp limitation of the mobility of the affected kidney. Ultrasound scanning in acute purulent paranephritis, it clearly visualizes the focus of purulent melting of fatty tissue, and in chronic - its heterogeneous echostructure (Fig. 9.3).

More accurate information can be obtained by using MRI or multislice CT.

Chronic paranephritis is diagnosed using the same methods

similar to the acute form, but it is much more difficult to detect. Therefore, the disease may remain unrecognized for a long time.

Differential diagnosis. It is carried out with an abscess in cases of spinal tuberculosis, when a survey X-ray reveals destruction of one or more vertebrae in the absence of a temperature reaction. A dense, lumpy tumor-like formation palpated in the lumbar region with chronic paranephritis should be differentiated from dystopia, kidney tumor, hydronephrosis, etc.

Treatment. In the early stage of acute paranephritis, the use of antibacterial (fluoroquinolones, cephalosporins, protected penicillins) and detoxification therapy allows for recovery in most patients without surgical intervention. Be sure to sanitize other foci of infection and prescribe medications to increase the body’s immune defense. Purulent forms of the disease are an indication for emergency surgery. With an isolated abscess of the retroperitoneal tissue, puncture with evacuation of the contents and drainage is possible. Lumbotomy with sanitation of the retroperitoneal space is indicated for a more common process, including for performing kidney surgery for the disease that caused paranephritis.

Treatment of chronic paranephritis includes the prescription of antibiotics in combination with physiotherapeutic procedures, restoratives and resorption therapy.

Forecast favorable with timely and adequate treatment of the disease. In chronic paranephritis, the prognosis is largely determined by the nature of the underlying disease.

9.3. UROSEPSIS

Urosepsis represents the most serious complication of inflammatory diseases of the genitourinary system and is characterized by generalization of infection with the development of septicopyemia, bacteremic shock and high risk

lethal outcome. Urosepsis can be a consequence of acute pyelonephritis, epididymitis, purulent prostatitis.

Etiology and pathogenesis. The mechanism of development of urosepsis is primarily associated with the presence of urinary tract obstruction. As a result, there is an increase in intrapelvic pressure with the development of renal pelvic reflux and the penetration of virulent microorganisms into the blood vessels. A urinary infection can also enter the bloodstream during rough, traumatic catheterization of the bladder, during instrumental studies (urethrocystoscopy), during retrograde ureteropyelography, and endoscopic surgical interventions.

Classification. The following clinical forms of urosepsis are distinguished: acute, subacute, chronic And bacteremic (endotoxic) shock.

Symptoms and clinical course urosepsis correspond to one or another inflammatory disease that led to the development of urosepsis. As a rule, this is a high body temperature, tremendous chills, weakness, headache and other signs of intoxication. The skin is pale, and petechial hemorrhagic rashes may occur. Confusion may occur.

A blood test reveals leukocytosis with a pronounced shift of the formula to the left, and an increase in ESR. The urine is purulent. A bacteriological blood test is required to confirm the diagnosis.

The most common clinical manifestation of urosepsis is bacteremic shock. The mechanism of its development is due to the release of a large number of bacteria into the bloodstream from the source of urinary infection. Endotoxins formed as a result of their breakdown affect the vascular wall, significantly increasing the lumen of the vascular bed and disrupting microcirculation in organs and tissues.

The following stages of bacteremic shock are distinguished: early stage of clinical manifestations And terminal. The early stage is characterized by a sharp and sudden rise in body temperature to high numbers, chills, and a decrease in the amount of urine. Patients experience decreased blood pressure, tachycardia, and cold sweats. Further, the patient’s condition worsens: lethargy and impaired consciousness appear. At this stage, there is a slight decrease in body temperature. In the third stage, irreversible changes develop in the body.

Diagnostics. Examination of patients with urosepsis begins with identifying the urological disease that caused it. Ultrasound, excretory urography and CT are the most informative methods for diagnosing purulent-inflammatory diseases of the genitourinary organs. The final diagnosis of sepsis is established after three bacteriological blood cultures and a blood test for procalcitonin.

Treatment consists of carrying out emergency resuscitation measures followed by emergency surgical intervention. Depending on the severity of the condition, percutaneous puncture or open nephrostomy or nephrectomy may be performed.

Forecast and prevention. The prognosis with adequate treatment and follow-up is favorable. Measures to prevent urosepsis include:

in the timely and thorough treatment of patients with acute inflammatory diseases of the genitourinary organs, the timely elimination of causes that impede the normal outflow of urine from the kidney, and the rehabilitation of chronic foci of infection.

9.4. RETROPERITONEAL FIBROSIS (ORMOND'S DISEASE)

First retroperitoneal, or retroperitoneal, fibrosis was described in 1948 by Ormond. Almost always the disease is bilateral. Progressive cicatricial fibrosis of the retroperitoneal tissue leads to compression of the ureters in any area from the pyeloureteral segment to the promontorium. The most common localization of retroperitoneal fibrosis is the level of the IV and V lumbar vertebrae. Sometimes the inferior vena cava and aorta are involved in the inflammatory process.

Etiology and pathogenesis. Ormond's disease is a nonspecific inflammatory process in the retroperitoneal tissue with the formation of dense fibrous tissue. The reasons for the development of this disease are not yet fully understood. There are several theories of its development.

According to inflammatory theory, There is no independent lesion of retroperitoneal tissue and retroperitoneal fibrosis occurs secondary, due to the transition of an infectious-inflammatory process from the renal parenchyma (pyelonephritis) or perinephric tissue (paranephritis), female genital organs (colpitis, endometritis), gastrointestinal tract (pancreatitis, cholecystitis , colitis).

In accordance with traumatic theory The trigger for the development of Ormond's disease is traumatic injury to the organs of the retroperitoneal space.

Immunoallergic theory implies that nonspecific inflammation in the retroperitoneal tissue with the formation of dense fibrous tissue occurs as a result of an autoimmune reaction.

Pathological anatomy. There are three phases of nonspecific inflammation of the retroperitoneal tissue. The first is characterized by eosinophilic, lymphocytic and histiocytic infiltration of tissues. In the second phase, connective tissue fibrous changes with gradual collagenosis are formed. Sclerosis and wrinkling of the retroperitoneal tissue with the formation of dense fibrous tissue are observed in the third phase of Ormond's disease.

Symptoms and clinical course. Patients complain of dull, aching pain in the lumbar region, in the corresponding flank of the abdomen. The clinical picture is characteristic of hydronephrosis. In 80% of cases, arterial hypertension occurs. With the progression of bilateral hydronephrosis as a result of ureteral obstruction, chronic renal failure develops.

Diagnostics. The examination includes general blood tests, urine tests, determination of biochemical parameters (urea, creatinine, electrolytes). Execute Ultrasound, survey and excretory urography, CT and MRI. With help

These studies can reveal signs of fibrosis of the retroperitoneal tissue and hydroureteronephrosis. Characteristic is bilateral obstruction of the ureters at the level of their intersection with the iliac vessels, above which they are dilated and below which they are not changed. Dynamic and static scintigraphy kidneys is used to determine their functional state.

Differential diagnosis Ormond's disease is associated with hydrouretero-nephrosis, retroperitoneal non-organ formations and chronic paranephritis.

Treatment. In the early stages, treatment is carried out with glucocorticosteroids and other drugs that help prevent or resolve scar tissue. Antibacterial therapy is prescribed. Surgical treatment is indicated for pronounced development of fibrous tissue and the formation of hydroureteronephrosis. Ureterolysis, resection of the ureter with ureteroureteroanastomosis, isolation of the ureters from scar tissue of the retroperitoneal tissue by moving them into the abdominal cavity can be performed. For extended strictures, replacement of the ureter with a segment of the small intestine or endoprosthetics.

Forecast favorable with timely treatment and unfavorable if the disease is detected at the stage of bilateral hydronephrotic transformation and chronic renal failure.

9.5. CYSTITIS

Cystitis- an infectious-inflammatory disease of the bladder wall with a predominant lesion of its mucous membrane.

Epidemiology. Women get sick more often than men, in a ratio of 3:1, which is due to:

■ anatomical and physiological characteristics of the female genitourinary system (short and wide urethra, proximity of the genital tract and rectum);

■ gynecological diseases;

■ changes in hormonal levels during pregnancy, when taking hormonal contraceptives, in the postmenopausal period (microcirculation disorders leading to weakening of local immunity, atrophy of the vaginal mucosa, decreased mucus formation).

In men, this disease is much less common and can be caused by inflammatory processes in the prostate gland, seminal vesicles, epididymis and urethra. A common cause of secondary cystitis in men is bladder outlet obstruction with chronic urinary retention as a result of urethral strictures and tumor diseases of the prostate gland.

Etiology and pathogenesis. The most common cause of cystitis is a bacterial infection. In addition, the causative agents of the disease can be viruses, mycoplasmas, chlamydia, and fungi. Most often, in patients with cystitis, Escherichia coli, Staphylococcus, Enterobacter, Proteus, Pseudomonas aeruginosa, and Klebsiella are detected in the urine. The leading microbial pathogen in acute cystitis is

Escherichia coli (80-90% of observations), which is explained by the high pathogenic and adaptive capabilities of this microorganism (adhesion phenomenon, high reproduction rate, production of ammonia, which weakens the immune system and disrupts the function of smooth muscle fibers of the urinary tract).

The ways of infection entering the bladder are as follows:

■ ascending- the most common variant of infection from the external environment through the urethra;

■ descending- infection from the upper urinary tract, kidneys in chronic pyelonephritis;

■ hematogenous- is rare, can occur in the presence of a distant focus of chronic infection, including in the pelvic organs;

■ lymphogenous- observed in diseases of the genital organs: in women - endometritis, salpingoophoritis, etc., in men - vesiculitis, prostatitis, etc.;

■ contact- possible in the presence of purulent diseases of the organs surrounding the bladder: parametritis, prostate abscess, etc. Direct infection of the bladder can occur in the presence of urinary fistulas, or be a consequence of various instrumental manipulations (catheterization of the bladder, cystoscopy, etc.).

Risk factors The development of cystitis is as follows:

■ decrease in the overall resistance of the body due to hypovitaminosis, stress, hypothermia, changes in hormonal levels;

■ violation of the outflow of urine from the bladder. In men, the causes of this are benign prostatic hyperplasia, urethral strictures, and prostatitis. In women, disturbances in urodynamics may be caused by stenosis (narrowing) of the urethra, ectopia of the external opening of the urethra, fibrosis (growth of dense connective tissue) in the urethral area. Various anomalies of the genitourinary system also negatively affect the process of urination and are often accompanied by inflammatory diseases of both the bladder and the upper urinary tract;

■ circulatory disorders in the pelvic organs;

■ traumatic injuries to the bladder mucosa during endoscopic examinations and operations;

■ endocrine diseases (diabetes mellitus) and metabolic disorders (for example, hypercalciuria);

■ the presence of stones and neoplasms in the bladder;

■ sexual activity, especially in the presence of hypermobility or ectopic urethra in women.

Less common non-infectious (allergic) cystitis. A wide variety of substances can act as allergens: food products (legumes, citrus fruits, nuts), medications (non-steroidal anti-inflammatory drugs), household and perfume chemicals.

Allergic reactions are also sometimes observed after using vaginal tampons and condoms.

Classification. Cystitis is classified according to a number of characteristics. By clinical course:

■ spicy;

■ chronic;

■ interstitial.

By involvement of the bladder in the pathological process:

■ primary;

■ secondary, resulting from any disease (infravesical obstruction, trauma, urolithiasis, etc.).

By reason for the development of the disease:

■ infectious;

■ allergic;

■ chemical;

■ beam, or radiation.

By type of infectious agent:

■ nonspecific, in which the cause of the disease is its own opportunistic microflora;

■ specific, when a specific pathogen is detected (chlamydia, mycoplasma, ureaplasma, trichomonas, tuberculosis, candidiasis).

According to the same factor, cystitis can be divided:

■ bacterial;

■ viral;

■ caused by a fungal infection.

By prevalence And localization of the infectious process:

■ focal (cervical, trigonitis);

■ total, or widespread.

Symptoms and clinical course.Acute cystitis characterized by a sudden, violent onset caused by some provoking factor (hypothermia, endoscopic intervention, trauma), and rapid regression in the case of timely prescribed therapy. The severity of symptoms increases during the first two days.

Patients complain of frequent painful urination, pain in the lower abdomen and the appearance of blood at the end of urination (terminal hematuria, especially characteristic of cervical cystitis). The inflammatory reaction and swelling of the bladder wall are accompanied by irritation of the nerve endings. Even a slight accumulation of urine causes the muscular wall of the bladder to contract, and the patient feels a very strong urge to urinate. The more pronounced the pathological process, the shorter the intervals between urinations. In severe cases, this time period is reduced to 15-20 minutes, which is extremely exhausting for the patient. Characteristic is Urgent urinary incontinence, that is, the imperative (imperative) urge to urinate is so strong that the patient loses urine before reaching the toilet.

Cystitis is accompanied painful sensations in the area of ​​the bladder and perineum of varying degrees of intensity. The pain syndrome is characterized by constancy, which disrupts a person’s usual life activities and rest, since it does not stop at night.

Terminal hematuria- also a very characteristic sign of the disease. It appears at the end of urination in the form of a clearly visible impurity or even drops of blood. Urine with cystitis loses transparency due to the presence of a large number of microorganisms, blood cells, epithelial cells and salts. It becomes cloudy and acquires an unpleasant odor.

There is no increase in temperature during cystitis, which is due to the reduced ability of the bladder wall to absorb substances, including inflammatory toxins. Normally, this mechanism prevents the products of nitrogen metabolism from concentrated urine from entering the blood.

Severe forms of acute cystitis occur extremely rarely - phlegmonous, gangrenous, hemorrhagic, ulcerative. They are characterized by severe intoxication, high body temperature, and oliguria.

ABOUT relapsing course Acute cystitis is said to occur when symptoms of the disease appear at least twice in six months or three times in a year. The cause of cystitis in this case is reinfection, that is, repeated infection with pathogenic microflora, the source of which is both a nearby focus of chronic infection and a sexual partner. Also, the risk of relapse is increased by interrupted treatment, uncontrolled use of antibiotics and failure to comply with personal hygiene rules.

Chronic cystitis, as a rule, it is a consequence of a previous inflammatory or predisposing disease and is secondary in nature. Inflammation of the bladder develops and is maintained as a result of:

■ bladder outlet obstruction (sclerotic changes in the bladder neck, benign hyperplasia, prostate cancer, narrowing of the urethra, phimosis);

■ UCD (bladder stones);

■ bladder tumors;

■ bladder diverticula.

In the absence of the above pathological conditions and chronic cystitis resistant to therapy, it is necessary to exclude specific diseases, primarily genitourinary tuberculosis.

The clinical symptoms of chronic cystitis repeat those of the acute form. The difference lies only in the degree of their expression. The course of the disease is characterized by periodic exacerbations, which are clinically very similar to acute cystitis and are treated in the same way. A stable course of chronic cystitis with a minimal set of complaints and constant laboratory signs, such as leukocyturia and bacteriuria, is also possible.

Diagnostics. The rapid onset of the disease with characteristic symptoms allows one to immediately suspect acute cystitis. As a rule, no pathological changes are observed in clinical and biochemical blood tests.

Urine is cloudy and has an odor. When examined, its reaction is often alkaline, a large number of leukocytes and bacteria are always determined, red blood cells, epithelium, cylinders may be present, and false proteinuria is noted, that is, caused by the breakdown of a large number of blood cells.

Bacterioscopy allows you to visually (using a microscope) determine the presence of an infectious pathogen. More informative urine culture with determination of bacterial culture and antibiotic sensitivity test. The disadvantage of this method is the duration of its implementation, therefore, with a clinically confirmed diagnosis of cystitis, antibacterial therapy with broad-spectrum drugs is started without waiting for culture results.

It is important to note that in acute cystitis, invasive diagnostic methods, primarily cystoscopy, are contraindicated. Firstly, this procedure does not provide significant information, secondly, in the presence of acute inflammation it is extremely painful and, thirdly, it can lead to reinfection and/or aggravate the course of the infectious process. Cystoscopy is possible and indicated for chronic cystitis; it can be used to identify areas of hyperemia, a pronounced vascular pattern (Fig. 19, see color insert), fibrinous deposits, ulcers, leukoplakia, stones, etc.

Differential diagnosis. In acute cystitis, the diagnosis is usually beyond doubt. Chronic cystitis, especially in cases where there are no characteristic clinical symptoms and treatment is ineffective, should be differentiated primarily from tuberculosis and bladder tumors.

Distinctive signs of tuberculous cystitis are the acidic reaction of urine and the absence of microbial growth when inoculated on ordinary media. Repeated microscopy of urine sediment for Mycobacterium tuberculosis and its inoculation on special media are necessary. The most characteristic sign of bladder tumors is total painless gross hematuria. The diagnosis can be made by sonography, CT and cystoscopy with a biopsy of the bladder wall.

Treatment. Therapeutic tactics for acute cystitis include prescribing antibacterial therapy; rest, plenty of fluids, and warmth in the lower abdomen are recommended; spicy and extractive foods are excluded from the diet.

Currently, there are a number of effective schemes antibiotic therapy depending on the duration of use: single dose, three-day and seven-day courses. The clinical effectiveness of short-term courses of treatment for women of reproductive age has been proven.

The best one-time use drug is fosfomycin (monural). This is a broad-spectrum antibiotic, effective against Escherichia coli, staphylococcus, Proteus, Pseudomonas aeruginosa, Klebsiella, etc. The resistance of microflora to this drug is insignificant. During treatment uncomplicated For cystitis, a single dose of 3 g of fosfomycin is indicated, the effect of which lasts for 5 days. Its use is justified for bacteriuria in pregnant women, as well as as a prophylaxis before invasive studies (cystoscopy) and surgical interventions. A single dose of levofloxacin at a dose of 250 mg also has a good effect; cure after it reached 95% of patients.

More long course Antibiotic therapy is indicated in the treatment of cystitis in patients with risk factors for recurrent and chronic infection. These include:

■ acute cystitis in men;

■ cystitis in women over 65 years of age;

■ persistence of clinical symptoms for more than 7 days;

■ pregnancy;

■ diabetes and other metabolic disorders;

■ use of diaphragms and spermicides.

For these patients, it is most appropriate to prescribe fluoroquinolones, 3rd and 4th generation cephalosporins and protected penicillins.

From the point of view of the combination of such qualities of drugs as effectiveness, low cost and low probability of relapse, currently the drugs of choice are fluoroquinolones. Having a wide spectrum of action and having been present on the pharmacological market for quite a long time, they are still characterized by the lowest level of microflora resistance. From this group, ciprofloxacin, levofloxacin, norfloxacin and ofloxacin are usually prescribed. A standard seven-day course of these drugs allows you to completely relieve the symptoms of cystitis and eliminate the pathogen.

Dosage of fluoroquinolones for a three-day course: levofloxacin - 500 mg 1 time per day; ciprofloxacin - 250 mg 2 times a day or 500 mg 1 time a day; norfloxacin - 400 mg 2 times a day; ofloxacin - 200 mg 2 times a day.

Cephalosporins have proven themselves in the treatment of urinary tract infections. They are highly effective against almost all gram-negative (Proteus, Klebsiella, Enterobacter) bacteria, including nosocomial strains resistant to many antibiotics, and many gram-positive (staphylococci, streptococci) microorganisms. Among the latest generations of oral cephalosporins, cefixime (400 mg once daily or 200 mg twice daily) and ceftibuten (400 mg once daily) should be noted.

Semi-synthetic penicillins(Augmentin, Amoxiclav) contain clavulanic acid, which allows you to neutralize the enzymatic defense of gram-positive bacteria. The recommended dose is 625 mg 2 times a day for a three-day course of treatment and 375 mg 1 time a day for a seven-day course.

In addition to antibiotics, it should be noted the positive effect uroantiseptics. Representatives of this group are nitrofurantoin (furado-nin) and furazidin (furagin). These drugs, being absorbed in the gastrointestinal tract, pass through the urinary tract unchanged, have a low level of resistance to E. coli (1%), and they are also cheap. Drugs with low effectiveness due to the high level of microflora resistance are co-trimoxazole (Biseptol), nitroxoline, and nalidixic acid. Bacterial resistance to these drugs sometimes reaches 90%, but, nevertheless, they are still popular.

Symptomatic therapy. Pain can be relieved by prescribing nonsteroidal anti-inflammatory drugs that have anti-inflammatory and analgesic effects (solpadeine, diclofenac, lornoxicam, etc.). Antispasmodics include no-spa, baralgin, cystenal, platifillin, etc.

Rice. 9.4. Sonogram. Interstitial cystitis: deformation and thickening of the bladder wall (1), decrease in its capacity (2), dilation of the ureter as a result of scar damage to the mouth (3)

The criteria for cure of cystitis are the complete absence of clinical symptoms, the absence of leukocyturia and the growth of bacterial colonies in urine culture after the end of antibacterial therapy. You should take a control general analysis and urine culture for microflora at least a week after stopping antibiotics.

Treatment of chronic cystitis more complex and lengthy. Therapy consists of taking antibiotics

within 7-14 days, and sometimes several weeks. It is especially important to eliminate the cause of the chronic infectious-inflammatory process, to sanitize foci of chronic infection and correct the immunodeficiency state.

In the prevention of cystitis, an important role is played by compliance with the rules of personal hygiene, timely treatment of inflammatory diseases and urodynamic disorders, prevention of hypothermia, observance of asepsis during endovesical examinations and bladder catheterization.

Forecast with timely and correct treatment of acute cystitis, favorable. Cystitis is not a cause of death, with the exception of gangrene of the bladder. Untimely and irrational treatment of acute cystitis contributes to its transition to a chronic form, in which the prognosis is less favorable.

Interstitial cystitis is a special form of chronic nonspecific inflammation of the bladder with cicatricial degeneration of its wall and the development of microcystis. It is characterized by sterile urine cultures and lack of effect from antibacterial therapy.

Diagnostics is based on ultrasound, which determines the small capacity of the bladder, deformation and thickening of its walls, and expansion of the distal ureters (Fig. 9.4).

Essential for diagnosis are a potassium chloride test, a comprehensive urodynamic study and cystoscopy with a biopsy of the altered bladder wall.

Treatment consists of prescribing antihistamines, antidepressants, instillations of heparin, dimethyl sulfoxide and hyaluronic acid. For microcystis, surgical treatment is indicated, which consists of excision of the scar-wrinkled bladder and its replacement with a detubularized section of the intestine - augmentation cystoplasty.

Forecast with interstitial cystitis, the preservation of the bladder is unfavorable. A long course of interstitial cystitis leads to microcystis and requires surgical treatment - replacing it with a section of the ileum on the mesentery.

9.6. URETHRITIS

Urethritis- inflammation of the urethra. Due to anatomical and physiological characteristics, it practically does not occur as an independent disease in women, and the urethra is involved in the pathological process during inflammation of nearby organs (cystitis, suppuration of the paraurethral glands, etc.).

The disease occurs mainly in people of reproductive age.

Etiology and pathogenesis.The vast majority of urethritis is transmitted sexually. The incubation period can range from several hours to several months. The state of the macroorganism plays a significant role in the pathogenesis of urethritis. Contributing local factors are hypo- and epispadias, narrowing of the urethra.

Classification. Distinguish nonspecific And specific(gonococcal) urethritis. Gonococcal urethritis is caused by microorganisms Neisseria gonorrhoeae(Gram-negative intracellular diplococci).

Urethritis may be primary And secondary. With primary urethritis, the inflammatory process begins directly from the mucous membrane of the urethra. In a secondary case, the infection enters the urethra from an inflammatory focus located in another organ (bladder, prostate, vagina, etc.).

Depending on the etiological factor, the following types of urethritis are distinguished.

Infectious urethritis:

■ bacterial;

■ Trichomonas (or caused by other protozoa);

■ viral;

■ candida (or caused by other fungi);

■ mycoplasma;

■ chlamydial. Non-infectious urethritis:

■ allergic;

■ chemical.

Symptoms and clinical course. There are three main forms of urethritis: acute, torpid and chronic.

Acute gonorrheal urethritis characterized by an abundance of discharge from the urethra. On the head of the penis they can shrink, forming crusts. The urethral sponges are red, swollen, and its mucous membrane is slightly turned outward. On palpation, the urethra is thickened and painful. The affected large urethral glands are found in the form of small, sand-like formations. Patients complain of burning and severe pain when urinating, especially at the beginning (as a result of stretching of the urethra by passing urine). Symptoms when the posterior part of the urethra is affected changes: the amount of discharge decreases somewhat, the frequency of urination increases, at the end of it there is a sharp pain, and sometimes blood is discharged.

Depending on the virulence of the pathogen and the immune status of the body, urethritis can become persistent and become chronic.

form. When inflammation of the seminal tubercle (colliculitis) occurs, ejaculation disorders and hemospermia may occur. Clinical picture torpid (subacute) And chronic urethritis are similar. As a rule, complaints are mild: discomfort, paresthesia, and itching in the urethral area are characteristic. Scanty discharge is observed in the morning hours before urination, moderate hyperemia and adhesion of the urethral sponges are noted (urethritis with the above symptoms in the first two months of its course is considered torpid, and if it persists - chronic).

Trichomonas urethritis are called Trichomonas vaginalis. The incubation period for Trichomonas urethritis is 10-12 days. The disease is characterized by itching and burning in the area of ​​the external opening of the urethra. In the first portion of urine, when shaken, many small bubbles are found, which is associated with mucus formation. However, the same picture can be observed in the initial phase of allergic urethritis. Then discharge appears, first mucous, then mucopurulent. They can be abundant, have a yellowish color and do not differ from the discharge during acute gonorrheal urethritis. Without treatment, after 3-4 weeks, acute symptoms subside, and urethritis takes on a torpid course. One of the complications may be inflammation of the excretory ducts of the prostate gland.

Mycoplasmic And chlamydial urethritis are sexually transmitted and can cause infertility. Pathogens differ from bacteria in the plasticity of their outer membrane. Hence the polymorphism and the ability to pass through bacterial filters. These urethritis are characterized by a complete lack of any specificity, therefore the search for mycoplasmas and chlamydia should be carried out in all long-term torpid and chronic urethritis. Patients with chlamydial urethritis may experience extragenital manifestations of the disease (conjunctivitis, arthritis, damage to internal organs and skin) - the so-called Reiter's syndrome.

Viral urethritis most often caused by the herpes virus. The duration of the incubation period varies widely. The onset of herpetic urethritis is accompanied by a burning sensation and a feeling of discomfort in the urethra. Groups of tense hemispherical small bubbles appear on the skin; after their opening, painful erosions remain. An important feature of the course of herpetic urethritis is its persistent recurrence. The disease can last for decades, exacerbating without obvious frequency.

Fungal (mycotic) urethritis develops as a result of damage to the urethral mucosa by yeast fungi and is relatively rare. Most often it is a complication of long-term antibacterial therapy, less often it is transmitted from a sexual partner suffering from candidiasis vulvovaginitis. Clinical manifestations are very scarce.

Complications of urethritis are prostatitis, orchiepididymitis, cystitis, and in the long term - narrowing of the urethra.

The etiology of urethritis always requires clarification, therefore it is necessary to differentiate specific urethritis from nonspecific and other pathological processes in the urethra (polyps, condylomas,

neoplasms and urethral stones). In addition to the above complaints, the diagnosis is established on the basis of a history of sexual contact, microscopic examination of discharge from the urethra (and, if necessary, from the oropharynx and rectum) in a native and Gram-stained smear. In addition to microbes and protozoa, cellular elements (leukocytes, epithelium), mucus are detected, the assessment of which makes it possible to clarify the etiological and pathogenetic factors of urethritis. It is mandatory to carry out bacteriological research methods, including inoculating the material on special nutrient media.

Currently, reactions are widely used in the diagnosis of urethritis immunofluorescence And PCR diagnostics. The PCR method is based on the detection of a specific DNA section of the desired microorganism. It is highly sensitive (95%) and highly specific (90-100%).

Diagnosis is facilitated multi-glass samples And urethroscopy. The latter is contraindicated in acute urethritis, but in torpid and chronic cases it turns out to be very informative. Multi-glass tests are of great importance for topical diagnosis of the inflammatory process (urethritis, prostatitis, cystitis).

The main method of treating urethritis is antibacterial therapy, based on the sensitivity of the identified pathogens to the drugs used. Depending on the form and severity of the disease, antibiotics of various groups are used: semisynthetic penicillins, tetracyclines, 2nd and 3rd generation cephalosporins.

At bacterial urethritis various variants of streptococci, staphylococci, E. coli, enterococci and other microorganisms are found that can exist in the genitourinary system of healthy men and women. Recommended treatment regimens include the use of antibacterial drugs (doxycycline 100 mg 2 times a day for 7 days or azithromycin 1000 mg once). Macrolides (erythromycin, clarithromycin, roxithromycin) or fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) are prescribed as alternative agents. Treatment of gonorrheal urethritis consists of prescribing cefexime once orally at a dose of 400 mg or ceftriaxone at a dose of 250 mg once. Second-line drugs are fluoroquinolones. They are used when the pathogen is resistant to cephalosporins.

In treatment trichomonas urethritis metronidazole (orally 2 g once) or tinidazole (orally 2 g once) is used.

Therapy mycoplasmic And chlamydial urethritis consists of prescribing azithromycin and doxycycline, and roxithromycin and clarithromycin as alternative drugs.

During the initial clinical episode herpetic urethritis antiviral drugs are used (acyclovir - 200 mg, famciclovir - 500 mg). With frequent (more than 6 times a year) relapses, suppressive therapy should be started.

Treatment fungal urethritis consists of discontinuing antibacterial drugs and prescribing antifungal agents (ketoconazole, fluconazole).

Local treatment chronic urethritis includes instillation into the urethra of 0.25-0.5% solution of silver nitrate, 1-3% solution of protargol or 0.5% solution of dioxidine.

Forecast. With timely treatment of acute urethritis, the prognosis is favorable. Chronic urethritis can be complicated by narrowing of the urethra, orchiepididymitis and the development of infertility.

9.7. PROSTATITIS

Prostatitis- inflammation of the prostate gland. This is the most common disease of the genital organs in men of reproductive age.

Etiology and pathogenesis. The main causes of the disease are infectious and non-bacterial inflammatory processes that develop as a result of functional, microcirculatory and congestive disorders. Infectious factors there may be pathogenic bacteria, viruses, fungi, etc. The absence of pathogenic flora in the secretion of the prostate gland may be due to the presence of transformed L-forms of bacteria, mycoplasma, chlamydia, and viruses. Representatives of anaerobic flora are also occasionally found.

The infection may reach the prostate ascending canalicular pathway for urethritis, cystitis, after endoscopic manipulations. Less commonly, bacteria penetrate the prostate gland hematogenously from purulent foci in the body (boils, carbuncles, sinusitis, etc.).

In development nonbacterial prostatitis predisposing factors are of great importance - venous stasis and stagnation of secretions, since the secretion of the prostate gland itself has a bactericidal effect. Provoking factors are constipation, alcohol abuse, prolonged sedentary work.

Classification. Several classifications of prostatitis have been proposed. Some of the most popular are clinical-anatomical and National Institutes of Health (USA, 1995).

Clinical and anatomical classification:

■ acute prostatitis (catarrhal, follicular, parenchymal);

■ prostate abscess;

■ acute hyperemia of the prostate gland (prostatism);

■ chronic prostatitis;

■ granulomatous prostatitis;

■ congestive, or congestive, prostatitis;

■ prostate atony;

■ sclerosis of the prostate gland.

National Institutes of Health classification:

■ acute bacterial prostatitis;

■ chronic bacterial prostatitis;

■ chronic non-bacterial prostatitis/chronic pelvic pain syndrome:

inflammatory chronic pelvic pain syndrome (leukocytes are detected in prostate secretions, urine and ejaculate);

non-inflammatory chronic pelvic pain syndrome, no signs of inflammation;

■ asymptomatic chronic prostatitis (in the absence of clinical symptoms of the disease, the diagnosis is established according to histological examination of the prostate).

9.7.1. Acute and chronic prostatitis

Symptoms and clinical course. Acute bacterial prostatitis is rare and does not exceed 2-3% of all inflammatory processes in the prostate gland. The clinical picture of the disease is characterized by a violent onset and consists of severe pain in the perineum, lower abdomen, sacrum, malaise, fever, often with chills, frequent painful and difficult urination. The patient is pale, there is tachycardia, and there may be nausea. On transrectal palpation, the prostate gland is enlarged, tense, sharply painful, and in the presence of an abscess, fluctuation is determined. Sometimes the pain is so severe that patients do not allow this study to be fully completed.

Chronic prostatitis is much more common and is observed in 1035% of men of reproductive age. Patients complain mainly of pain in the lower abdomen and perineum. Their irradiation is possible in the anus, scrotum, sacrum, and groin areas. Sometimes patients experience a burning sensation in the perineum and urethra. As a rule, there is a clear relationship between pain and sexual intercourse: it intensifies during sexual abstinence and relieves pain until it disappears after coitus. When defecating, unpleasant or painful sensations may occur in the pelvic area associated with the pressure of feces on the inflamed gland.

In some cases, dysuric phenomena are observed. Patients complain of frequent, painful urination, imperative urges, a feeling of incomplete emptying of the bladder, and less often - difficulty urinating, a weak stream of urine.

A change in the state of the erogenous zones of the pelvis can lead to an increase in their excitability or, conversely, to a depression of sensitivity, which can be accompanied by disorders of sexual function.

The course of chronic prostatitis may be accompanied by the discharge of a small amount of cloudy fluid from the urethra in the morning (prostatorrhea). Sometimes there is a clear connection between the discharge and the process of defecation. Prostatorrhea is caused by hyperproduction of prostate secretions and dysfunction of the obturator mechanisms of the distal tubules and the area of ​​the seminal tubercle.

Most patients, when taking a detailed history, note an increase in mental and physical fatigue, depression, and symptoms of psychasthenia.

Diagnostics is based on the study of patient complaints, careful collection of anamnesis, laboratory and special methods for studying the condition of the prostate gland.

One of the most reliable and informative diagnostic methods is digital rectal examination of the prostate gland. In chronic prostatitis, it is more often of normal size, asymmetrical, soft-elastic or doughy consistency, heterogeneous, with areas of scar retractions, moderately painful on palpation. After the massage, the gland becomes softer, sometimes even flabby, which indicates normal evacuation of the contents into the lumen of the urethra.

After inspection you must receive prostate secret for microscopic and bacteriological examination. The detection of leukocytes in it and a decrease in the number of lecithin grains indicate an inflammatory process. As a rule, there is an inverse relationship between the number of leukocytes and lecithin grains (which is influenced by the degree of activity of the inflammatory process). Prostate secretions may also contain epithelial cells. The prismatic epithelium is exfoliated from the canalicular apparatus of the prostate gland, and the secretory epithelium is exfoliated from its acini. Identification of pathogenic microorganisms during a bacteriological culture study indicates the bacterial (infectious) nature of the disease. Material for research from the prostate gland can also be obtained using the Stamey-Mears test.

Ultrasound prostate gland is the third most important after digital examination and microscopy of the obtained secretion. It is carried out through the anterior abdominal wall and a rectal sensor. The most highly informative is transrectal ultrasound. Sonography can reveal asymmetry, changes in the size of the gland, the presence of nodes, formations, inclusions, cavities, calcifications, diffuse changes in the parenchyma.

Urethroscopy allows you to assess the condition of the prostatic part of the urethra and the area of ​​the seminal tubercle (Fig. 2, see color insert). The presence of inflammatory processes, scar changes, anatomical defects, narrowing of the lumen of the urethra and some other changes are revealed.

X-ray research methods are used only if there are specific indications (for example, identifying prostate stones).

Differential diagnosis. Chronic prostatitis should first of all be differentiated from tumor diseases and tuberculosis of the prostate gland, as well as inflammation of nearby organs (vesiculitis, cystitis, paraproctitis). In most cases, laboratory data (tumor markers, bacterioscopic and bacteriological examination of prostate secretions for Mycobacterium tuberculosis), ultrasound, CT and MRI, skeletal scintigraphy and prostate biopsy allow us to establish the correct diagnosis.

Treatment. Etiotropic antibacterial therapy includes broad-spectrum antibiotics that make it possible to eliminate the entire spectrum of microorganisms identified in the secretion of the prostate gland.

Acute prostatitis requires emergency hospitalization with parenteral administration of antibacterial drugs, anti-inflammatory, detoxification, and restorative therapy.

At chronic prostatitis long-term multi-course complex treatment is required, usually on an outpatient basis.

The duration of antibacterial therapy for acute prostatitis is 2-4 weeks, and for chronic prostatitis - 4-6 weeks. The drugs of choice are fluoroquinolones (levofloxacin, ciprofloxacin - 500 mg orally 1-2 times a day, lomefloxacin, moxifloxacin, ofloxacin - 400 mg orally 1-2 times a day). Second-line drugs are doxycycline and trimethoprim, and reserve drugs are cefotaxime, ceftriaxone and amikacin.

Non-steroidal anti-inflammatory drugs (diclofenac sodium - 50 mg orally 2 times a day after meals, for 20 days) can eliminate pain. Bioregulatory peptides: prostate extract (vi-taprost, prostatilen) is used for 30 days in the form of suppositories at night. Alpha-1-blockers (tamsulosin, alfuzosin, doxazosin) are prescribed to patients with chronic prostatitis for severe urinary disorders. 20-70% of patients with chronic prostatitis have various mental disorders that require correction. In these cases, patients are prescribed tranquilizers and antidepressants.

For patients with chronic prostatitis, sanatorium-resort treatment is recommended in Zheleznovodsk, Kislovodsk, Saki, Staraya Russa. They are prescribed turpentine, salt and pine baths, as well as rectal mud tampons.

In some cases, to evacuate stagnant inflammatory discharge formed in the excretory ducts of the prostate gland, massage of the prostate gland can be performed. The restoration of full microcirculation in the pelvic organs is facilitated by the appointment of physiotherapy, physical therapy and local procedures (warm microenemas with chamomile, sage).

Patients are advised to have an active lifestyle and exercise to eliminate congestion in the pelvic organs and increase muscle tone of the pelvic diaphragm.

Diet therapy consists of a complete healthy diet high in B vitamins and ascorbic acid. It is necessary to exclude spicy foods and alcohol.

Regular sex life helps prevent and eliminate congestive phenomena in the prostate gland.

Forecast with timely diagnosis and treatment of the disease, favorable. Acute prostatitis, in the absence of adequate therapy, can become chronic or lead to the development of a prostate abscess.

9.7.2. Prostate abscess

Etiology and pathogenesis. The causative agents of prostate abscess are predominantly gram-positive microorganisms. Virulent strains can penetrate the prostate gland during septicopyemia

from various purulent foci (hidradenitis, boils, osteomyelitis, tonsillitis, etc.). Factors predisposing to the development of prostate abscess are hypothermia, intercurrent diseases, immunodeficiency states, and congestive phenomena in the prostate. The latter are associated with irregular sex life, bad habits (alcohol, smoking), diseases of the pelvic organs accompanied by constipation, as well as prolonged sedentary work. Prostate abscess can be a complication of acute bacterial prostatitis.

Classification. Distinguish primary And secondary prostate abscess. In the primary case, the infection enters the prostate tissue hematogenously from distant purulent foci. Secondary prostate abscess is a consequence of acute prostatitis.

Symptoms and clinical course. Prostate abscess is characterized by a clinical picture of an acute purulent inflammatory process. The disease begins with an increase in body temperature to 39-40 ° C, the patient is bothered by chills, weakness, thirst, intense pain in the lower abdomen, perineum and sacrum. Difficulty, painful urination occurs, associated with swelling of the prostate gland and compression of the prostatic urethra, up to acute urinary retention. Characterized by intense throbbing pain in the perineum, then in the rectum. An abscess may break through into the urethra, bladder or rectum, which is manifested by sudden cloudiness of urine or purulent discharge during bowel movements with simultaneous normalization of body temperature.

Diagnostics based on medical history and complaints of the patient. A digital rectal examination of the prostate gland reveals its enlargement, pastiness, pain and an area of ​​fluctuation, which is a sign of an abscess.

At transrectal ultrasound prostate abscess is detected as a hypoechoic formation with unclear contours (Fig. 9.5).

CT indicates the presence of limited fluid formation in the prostate tissue. Its transrectal puncture makes it possible to accurately establish the diagnosis and is the initial stage of treatment of the disease.

Differential diagnosis prostate abscess should be carried out primarily with acute paraproctitis and vesiculitis. Digital rectal examination, sonography and computed tomography of the pelvic organs allow a correct diagnosis.

Treatment. A patient with a prostate abscess is indicated for emergency hospitalization. In parallel with antibacterial, detoxification, restorative therapy, an abscess is punctured under ultrasound control, and then it is opened and

Rice. 9.5. Transrectal sonogram. Prostate abscess (arrow)

drainage via perineal or transrectal access. Transurethral opening using a resectoscope is possible.

Broad-spectrum antibiotics are used (doxycycline - 200 mg/day; ciprofloxacin - 500 mg/day; ofloxacin - 400 mg/day; ceftriaxone - 500 mg/day). In the postoperative period, to accelerate the resorption of infiltrates and prevent the development of scar-sclerotic changes, lidase (64 units subcutaneously), aloe extract (2.0 subcutaneously), microenemas with antiseptic drugs (10-15% solution of dimexide, dioxidine), rectal suppositories are effective with anti-inflammatory effect.

Forecast favorable; with timely opening and drainage of the abscess, recovery occurs. Late patient seeking medical help and delayed treatment can lead to a life-threatening complication - sepsis.

9.7.3. Prostate stones

This is a rare disease in which stones form in the excretory ducts and acini of the prostate gland.

Etiology and pathogenesis. The causes of stone formation are associated with a long-term inflammatory process in the prostate gland and a decrease in the concentration of zinc, which keeps calcium salts in a bound state. One of the reasons is reflux of urine from the urethra in the presence of an obstruction to urination. In the vast majority of cases, prostate stones can be considered a complication of chronic prostatitis.

Pathological anatomy. The core of the stones consists of amyloid bodies and desquamated epithelium, on which phosphates and calcium salts are layered. The stones are yellowish in color, vary in size, and can be single or multiple. Obstruction of the excretory ducts of the prostate acini by stones causes stagnation of prostate secretions and inflammation. A prolonged inflammatory process can lead to the formation of abscesses, and if the outflow from the seminal vesicles is obstructed, vesiculitis develops. The prostate gland gradually atrophies.

Symptoms and clinical course. Patients complain of constant dull pain in the perineum, sacrum, frequent, painful, and difficult urination. Terminal hematuria and hemospermia are possible. When inflammation occurs, there is an increase in pain during sexual intercourse. Sexual desire and potency decrease.

Diagnostics prostate stones is based on digital rectal examination, in which crepitus is felt in the dense, painful, sometimes flabby prostate gland.

On plain radiograph shadows of stones, usually small and multiple, are determined in the projection of the symphysis below the contour of the bladder (Fig. 9.6). On cystogram the shadows of the stones are also clearly visible below the contour of the bladder. The diagnosis is confirmed by Ultrasound.

Differential diagnosis. Changes in the prostate gland (enlargement, thickening, lumpiness) may resemble those seen in tuberculosis and

Rice. 9.6. Plain X-ray of the pelvis. Prostate stones (arrows)

prostate cancer. Tuberculosis is characterized by the presence of a specific inflammatory process in other organs, and cancer is characterized by an increase in the level of prostate-specific antigen, general symptoms of malignancy.

Treatment. Patients with incidentally detected and uncomplicated prostate stones do not require special treatment. Prostate stones in combination with chronic prostatitis require conservative anti-inflammatory treatment, massage of the organ is excluded. In case of abscess formation, surgical treatment is carried out aimed at eliminating the purulent focus and stones (adenomectomy, prostatectomy, TUR of the prostate gland).

Forecast favorable with adequate treatment.

9.8. VESICULITIS

Vesiculitis (spermatocystitis)- inflammation of the seminal vesicles.

Etiology and pathogenesis. As an independent disease, vesiculitis is quite rare and can be caused by both nonspecific and specific microflora. The route of infection in the vast majority of cases is canalicular, less often hematogenous.

Classification. Distinguish spicy And chronic vesiculitis.

Vesiculitis may be primary or secondary, being a complication of urethritis, prostatitis, epididymitis.

Symptoms and clinical course. Acute vesiculitis is accompanied by an increase in body temperature to 38-39 ° C, malaise, chills, pain in the rectum, perineum, which intensifies with defecation. Characteristic symptoms are pain during ejaculation and the appearance of blood in the ejaculate (hemospermia).

Chronic vesiculitis most often occurs as a result of an untreated acute inflammatory process in the seminal vesicles. Patients complain of pain in the perineum, painful erections, hemo- and pio-spermia.

Diagnostics. In case of acute vesiculitis with enlarged, sharply painful seminal vesicles are palpated. After palpation, a large number of leukocytes and red blood cells are detected in the discharge from the urethra (or in the urine). In a three-glass sample, pyuria is detected mainly in the third portion.

Rice. 9.7. Transrectal sonogram. Vesiculitis (arrow)

At ultrasound examination seminal vesicles are easily identified as hypoechoic formations.

In case of chronic vesiculitis with digital rectal examination dense and painful seminal vesicles are found above the prostate gland. Important for diagnosis is the detection in the seminal fluid of a large number of leukocytes and erythrocytes, dead sperm after massage of the seminal vesicles. Helps clarify the diagnosis Ultrasound(Fig. 9.7).

Differential diagnosis acute vesiculitis is primarily carried out with acute prostatitis, prostate abscess and paraproctitis; chronic - with chronic prostatitis and prostate tuberculosis. Digital rectal examination, sonography of the prostate gland and computed tomography help to establish the correct diagnosis.

Treatment. Antibacterial therapy is carried out with broad-spectrum drugs. The most effective are fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin), protected penicillins (amoxiclav) and 2-3rd generation cephalosporins (cefuroxime, ceftriaxone, cefotaxime). Analgesics and antispasmodics are often used in the form of suppositories. To prevent constipation, it is necessary to use laxatives. Hot microenemas (with a 10-15% dimexide solution, chamomile and sage decoctions) have proven themselves well.

If acute vesiculitis is complicated by empyema of the seminal vesicles, then emergency surgical intervention is indicated - puncture and drainage of the abscess under ultrasound control.

For chronic vesiculitis, treatment consists of antibacterial therapy, massage of the seminal vesicles, the use of mud applications on the perineum and mud rectal tampons, hot microenemas with anti-inflammatory drugs.

Forecast with timely treatment and adequate therapy, favorable.

9.9. EPIDIDYMITIS

Epididymitis- inflammation of the epididymis.

Etiology and pathogenesis. Epididymitis develops mainly due to the penetration of infection into the appendage or hematogenously from foci of purulent infection (angina, boil, hidradenitis, pneumonia, etc.), or canalicularly, along the vas deferens, in the presence of an inflammatory process in the urethra or prostate gland. Possible development of epididymis

mit after instrumental (catheterization of the bladder, bougienage of the urethra) and endoscopic (urethrocystoscopy) interventions.

Much less commonly, the cause of epididymitis can be developmental anomalies of the lower urinary tract (diverticula, posterior urethral valves) and injuries to the scrotal organs.

Aseptic inflammation of the epididymis can develop as a result of selective accumulation of amiodarone, a drug used in cardiological practice.

Pathological anatomy. The epididymis is compacted and sharply enlarged due to inflammatory infiltration and swelling due to compression of the blood and lymphatic vessels. The tubules of the appendage are dilated and filled with mucus and purulent contents. The vas deferens is thickened, infiltrated, its lumen is narrowed. The membranes of the spermatic cord are also involved in the inflammatory process (differentitis and funiculitis). Epididymitis is often combined with inflammation of the testicle - orchitis. In such cases they talk about epididymo-orchitis.

Classification epididymitis and orchitis is as follows.

By etiology:

■ infectious:

specific (tuberculosis, gonorrheal, trichomonas); nonspecific (bacterial, viral, caused by mycoplasma and chlamydia);

■ necrotic-infectious (with torsion and necrotization of hydatid or testicle);

■ granulomatous (caused by seminal granuloma);

■ post-traumatic. According to the course of the disease:

■ acute (serous and purulent);

■ chronic.

Symptoms and clinical course. Acute epididymitis begins with a rapidly increasing enlargement of the epididymis, sharp pain in it, an increase in body temperature to 40 ° C with chills. Inflammation and swelling spread to the membranes of the testicle and scrotum, as a result of which the skin stretches, loses its folds, and becomes hyperemic. When the testicle is involved in the pathological process (epididymo-orchitis), the boundary between them is no longer defined. A reactive hydrocele usually develops. The pain radiates to the groin area, sharply intensifies with movement, and therefore patients are forced to stay in bed. Due to untimely initiation or inadequate treatment of acute epididymitis, the disease can abscess or become chronic.

Chronic epididymitis is characterized by a latent course. The pain is insignificant. The presence of a node or limited compaction in the head of the epididymis indicates its hematogenous origin. When there is a process in the tail of the appendage, one should look for a connection with a disease of the urethra or instrumental examination.

Diagnostics in most cases it does not cause any difficulties. The diagnosis is established based on examination data and palpation of the scrotal organs.

The corresponding half of the scrotum is enlarged and swollen, its skin is hyperemic, the folds are smoothed. The appendage is significantly enlarged, compacted, and sharply painful. When abscess formation occurs, fluctuation is determined.

The appearance of symptomatic dropsy is confirmed diaphanoscopy and ultrasound. IN blood tests leukocytosis with a shift of the formula to the left and an increase in ESR are determined.

A three-glass urine sample and its bacterioscopic and bacteriological examination can clarify the diagnosis.

Differential diagnosis. Nonspecific epididymitis in its clinical picture is sometimes difficult to distinguish from tuberculosis of the epididymis. Of decisive importance is a thorough collection of epidemiological history, identification of Mycobacterium tuberculosis in the puncture of the epididymis, and the presence of bilateral lesions with the formation of purulent fistulas of the scrotum.

Acute epididymitis should be distinguished from hydatid or testicular torsion, which requires emergency surgical treatment, and testicular neoplasms. Testicular torsion characterized by the sudden appearance of severe pain in the corresponding half of the scrotum, absence of temperature reaction, hyperemia of the scrotal skin and significant enlargement of the epididymis. Testicular neoplasms often develop at a young age. The testicle is significantly increased in size, there are no signs of inflammation. Ultrasound of the scrotum and determination of tumor markers in the blood serum help clarify the diagnosis.

Treatment. A patient with acute epididymitis is prescribed bed rest. To ensure the rest of the inflamed organ, a jockstrap (tight swimming trunks) is used; in the first 2-3 days, local cold is applied.

Broad-spectrum antibiotics are prescribed (doxycycline - 200 mg/day; ciprofloxacin - 500 mg/day; ofloxacin - 400 mg/day; ceftriaxone - 500 mg/day). Compresses with a 10-15% solution of dimexide, electrophoresis with potassium iodide, and novocaine are used locally. Magnetic laser therapy has proven itself well.

After the inflammatory process subsides, heat to the scrotum, diathermy, and UHF are prescribed.

If an abscess of the epididymis occurs, surgical treatment is indicated - opening and draining the abscess; in case of massive damage to the organ, an epididymectomy is performed.

Forecast for nonspecific epididymitis, favorable with adequate and timely treatment. In the case of bilateral chronic inflammation, the disease may be complicated by excretory infertility.

9.10. ORCHITIS

Orchitis- inflammation of the testicle.

Etiology and pathogenesis. The causes and course of the disease are the same as for acute epididymitis. Due to the close relationship and relative position of the testicle and its epididymis, both organs are often involved in the pathological process - it develops epididymo-orchitis.

The etiology of nonspecific epididymitis may be viral. Viral infections often affect the testicle rather than the epididymis. First of all, this occurs with mumps, which leads to severe damage to the testicular parenchyma with the development of infertility.

Pathological anatomy. Anatomical changes are determined by the degree of degradation of the testicular tubular system. Turgor decreases and parenchyma hypotrophy increases (up to atrophy of Sertoli cells). The mechanism of development of the pathological process is based on a primary damaging effect on the tissue, leading to edema, tissue death, and disruption of the permeability of the hemotesticular barrier. Due to the onset of the production of autoantibodies, a disruption of the spermatogenesis process in a healthy testicle may occur over time. Even after the elimination of the inflammatory process, the body continues to produce autoantibodies.

Symptoms and clinical course. The disease begins acutely. Patients complain of sudden pain in the testicle, chills, increased body temperature to 39-40 °C, and testicular enlargement. The pain radiates to the groin area and sharply intensifies with movement. The patient's condition worsens due to intoxication, the body temperature remains high, swelling and hyperemia of the skin of the scrotum appears, and its smoothness disappears. With mumps, orchitis develops on the 3-10th day of illness or in the first week of recovery. In 30% of cases, the lesion is bilateral.

When the epididymis is involved in the pathological process (epididymoorchitis), the border between the epididymis and the testicle is no longer defined. Reactive hydrocele of the testicular membranes develops.

Diagnostics. Anamnesis data confirming injury or primary diseases and the clinical picture contribute to the correct diagnosis. With an isolated lesion of the testicle, the epididymis is not enlarged, the spermatic cord is thickened, the vas deferens is clearly palpated, without infiltrative changes.

Ultrasound of the scrotal organs allows us to determine the presence of a reactive hydrocele, swelling of the testicular parenchyma, and in case of abscess formation, hypoechoic areas.

Differential diagnosis. Nonspecific orchitis should be differentiated from torsion, tuberculosis, testicular tumors and strangulated inguinal-scrotal hernia. The main methods of differential diagnosis, as with epididymitis, are specific tuberculosis tests, determination of tumor markers and ultrasound of the scrotal organs.

Treatment. Conservative therapy is the same as for acute epididymitis. If a testicular abscess occurs, surgical treatment is indicated - opening the abscess and draining the scrotum. For purulent orchitis, especially in older people after prostate surgery, it is advisable to perform an orchiectomy. For orchitis of parotid origin, glucocorticosteroids (prednisolone - 20 mg/day) and acetylsalicylic acid (1.5 g/day) are added to general anti-inflammatory therapy.

Forecast with nonspecific orchitis, favorable. Bilateral orchitis, especially as a complication of infectious mumps in children, can lead to infertility.

9.11. BALANOPOSTHITIS

Balanitis is an inflammation of the head of the penis. Posts- inflammation of the foreskin. Balanitis and posthitis, as a rule, occur simultaneously, so it is almost always a single form of the disease - balanoposthitis.

Etiology and pathogenesis. The causes of balanoposthitis may be infectious And non-infectious agents. In the first case, balanoposthitis can be caused by nonspecific (bacteria, viruses, fungi) and specific (mycobacterium tuberculosis, chlamydia, mycoplasma, trichomonas) microflora. The second group consists of non-infectious balanoposthitis: xerotic obliterating balanoposthitis, Zoon plasma cell balanitis, psoriasis, allergic contact dermatitis, chemical balanoposthitis or balanoposthitis as a result of the introduction of various oily substances under the skin of the foreskin.

The development of the disease is facilitated by local factors, primarily congenital or acquired phimosis. In such cases, the inability to expose the head leads to stagnation of the contents of the preputial sac with the decomposition of sebaceous lubricant and urine in it.

Classification. Depending on the clinical course, balanoposthitis is divided into spicy And chronic.

Factors contributing to the development of the disease:

■ failure to comply with hygiene measures regarding the glans penis and foreskin;

■ phimosis;

■ chronic urethritis;

■ diseases of the glans penis (genital warts, soft and hard chancre, tumors);

■ diabetes mellitus and other immunosuppressive diseases, especially in older men;

■ traumatization of the glans penis and foreskin (during sexual intercourse, underwear, foreign bodies).

Symptoms and clinical course. The patient is bothered by itching and pain in the head of the penis, pain when urinating. On examination, the foreskin is swollen, hyperemic, and purulent discharge from the preputial sac is noted. The severity of the inflammatory process can vary from minimal (minor hyperemia and/or pinpoint redness on the head) to the development of severe purulent balanoposthitis with erosion and destruction of the skin.

If treatment is not carried out, the disease is complicated by lymphangitis, which appears as red stripes on the back of the penis. As the process progresses, hyperemia becomes continuous, and swelling of the organ increases. Inguinal lymphadenitis appears, gangrene of the penis is possible with severe intoxication, fever and the development of urosepsis.

Diagnostics. Complaints and a characteristic clinical picture allow in most cases to immediately establish a diagnosis. To identify the pathogen, use bacterioscopic and bacteriological examination, and PCR diagnostics.

Differential diagnosis. It is carried out with primary diseases of the glans penis that have caused balanoposthitis, primarily with syphilis, genital warts and neoplasms. For this purpose, the presence of a circular narrowing of the foreskin should be eliminated, the prepuce sac and the glans penis should be sanitized and examined.

Treatment should be aimed at eliminating the primary disease. First of all, you should ensure the free opening of the foreskin and glans penis. It is mandatory to carry out hygienic measures - sanitization of the glans penis and the inner layer of the foreskin with weak solutions of potassium permanganate, furatsilin, chlorhexidine and other antiseptics. Underwear should be changed regularly. Surgical treatment (circumcision) is used for medical reasons for constantly recurrent chronic balanoposthitis.

Forecast favorable with timely and adequate treatment.

9.12. CAVERNITE

Cavernite- inflammation of the cavernous bodies of the penis.

Etiology and pathogenesis. Infection of the corpora cavernosa occurs as a result of hematogenous introduction of virulent microflora from existing foci of chronic infection. The penetration of microorganisms is facilitated by damage to the cavernous bodies as a result of domestic trauma, penile prosthesis, intracavernous injections of various substances, including medications.

Symptoms and clinical course. The disease begins acutely. Patients complain of pain in the penis, which may be accompanied by erections and increased body temperature. The penis increases in size, a dense painful infiltrate is palpated. With delayed treatment, an abscess of the corpus cavernosum forms at the site of the inflammatory infiltrate, which can break into the lumen of the urethra. Necrotic masses of the cavernous bodies are rejected along with pus. In some cases, a septic condition develops.

Diagnostics and differential diagnosis, As a rule, they do not cause any difficulties. The diagnosis is established on the basis of characteristic complaints, anamnesis and physical data of the patient. Acute cavernitis should be differentiated primarily from priapism. Distinctive signs of acute cavernitis are an increase in body temperature, a palpable infiltrate or an area of ​​fluctuation in the cavernous tissue of the penis, and blood leukocytosis with a shift to the left.

Treatment. Patients with acute cavernitis should be urgently hospitalized. Parenteral antibacterial detoxification and restorative therapy is prescribed. If it is ineffective and signs of abscess formation appear, surgical treatment is indicated, which consists of opening and draining purulent foci of the corpora cavernosa. Subsequently, much attention is paid to physiotherapy with the use of absorbable agents (potassium iodide, aloe extract, lidase).

Forecast favorable with timely conservative treatment. In case of necrosis of the connective tissue septa of the corpora cavernosa as a result of abscess formation, which required surgical treatment, the prognosis in terms of maintaining erectile function is unfavorable.

9.13. NECROTIZING FACCIITIS OF THE GENITAL ORGANS (FOURNIER'S GANGRENE)

Necrotizing fasciitis of the genital organs- a sudden onset and rapidly occurring acute anaerobic inflammatory process in the external genitalia with the rapid development of tissue necrosis. The disease was first described by the French venereologist Furnie in 1883. Before the discovery of antibiotics, its mortality rate was 40%, and currently it is 3-7%.

Etiology and pathogenesis. In most cases, scrotal gangrene is caused by anaerobic microorganisms such as Clostridium perfringes, Clostridium septi-cum, Clostridium oedematiens, Clostridium septicum etc. Factors predisposing to its development are: traumatic injuries to the scrotum, immunodeficiency states, dishormonal disorders, pathology of the blood coagulation system.

Pathological anatomy. The localization of the process in the area of ​​the external genitalia is facilitated by the peculiarity of their anatomical structure. The skin of the scrotum is characterized by significant looseness of the epithelial cover; the epidermal layer is much thinner than in the skin of other parts of the body. The subcutaneous tissue is loose and poorly developed. Moisturizing the skin with sebaceous gland secretions and multiple hair follicles reduces resistance and promotes the development of inflammation. Multiple thrombosis of small vessels aggravates the course of the disease. Histological examination of Fournier's gangrene reveals multiple necrotic areas, leukocyte infiltration and multiple microabscesses with areas of septic thrombosis.

Symptoms and clinical course. Fournier's gangrene begins with widespread and rapidly growing swelling of the scrotum. The scrotum significantly increases in size, is clearly hyperemic, sharply painful on palpation, and areas of subcutaneous crepitus appear. Already on the first day of the disease, blisters with serous-hemorrhagic contents are found on the skin of the scrotum. The patient's condition deteriorates sharply, and signs of severe intoxication appear. On the 2-3rd day, the blisters open with the formation of erosions, with the development of necrosis of the skin and underlying tissues. Necrosis with characteristic blackening of the skin can quickly spread to the skin of the penis, groin areas, limbs, and back.

By the end of the first week, a demarcation line is determined and the rejection of dead skin areas of the genital organs begins, accompanied by a large amount of purulent discharge of a dirty gray color with gas bubbles and a fetid odor. Swelling of the penis and scrotum can cause difficulty urinating, including acute urinary retention.

If treatment is not timely, the process of melting and complete rejection of the scrotum ends by the 10-12th day. The testicles are completely skinless, have a bright red color and hang on the spermatic cords. Intoxication phenomena are reduced. If treatment is not timely, the process takes on a generalized form with necrotic skin lesions in many parts of the body, the development of severe anaerobic sepsis, which in most cases leads to death.

Diagnosis and differential diagnosis. The diagnosis of Fournier's gangrene is established on the basis of characteristic complaints, clinical picture and objective data. At the beginning of the development of the disease, before the appearance of areas of skin necrosis, it should be differentiated from epididymo-orchitis and cavernitis.

Treatment. Patients with Fournier's gangrene are subject to emergency hospitalization. Parenteral administration of broad-spectrum antibiotics in high doses, detoxification and restorative therapy are prescribed. Purulent-necrotic areas of tissue are widely excised and drained. The wound is washed with solutions that release oxygen (3% hydrogen peroxide, 0.5% potassium permanganate solution), and then bandages are applied, generously moistened with these solutions. Polyvalent anti-gangrenous serum is administered intravenously - 15,000 units. After obtaining data from a bacteriological examination of the discharge, the appropriate serum and specific bacteriophage are administered. With a limited area of ​​damage, the skin of the scrotum, due to its exceptional regenerative ability, is restored and has a normal appearance. After excision of a large mass of skin in case of total gangrene, plastic surgery is subsequently performed to replace the skin of the scrotum and penis.

Forecast unfavorable, in approximately 3-7% of cases, Fournier’s gangrene is fatal. Timely and adequate treatment leads to recovery.

Control questions

1. What is the etiology of chronic pyelonephritis? How is it classified?

2. What is the clinical picture of acute pyelonephritis?

3. Name the main reasons for the transition of pyelonephritis to the chronic form.

4. How is chronic pyelonephritis and pyonephrosis diagnosed?

5. What are the reasons for the development of paranephritis?

6. Give a classification of cystitis.

7. What is the treatment for acute bladder inflammation?

8. What factors contribute to the development and maintenance of a chronic infectious-inflammatory process in the bladder?

9. What are the causative agents of urethritis?

10. What is Reiter's syndrome characterized by?

11. What does etiotropic treatment of urethritis include?

12. What is the clinical course of acute and chronic epididymitis?

13. What and how is differential diagnosis of chronic orchitis carried out?

14. What is the treatment for balanoposthitis?

Clinical task 1

A 43-year-old patient complains of general weakness, malaise, increased body temperature to 39 °C, chills, pain in the left half of the lower back and abdomen. Sick for 6 days. Three weeks ago I suffered from acute tonsillitis. Upon examination: the position is forced - the left thigh is brought to the stomach, when it is extended, sharp pain is detected. Palpation in the left osteovertebral angle is also painful. Urinalysis without pathology.

Establish a preliminary diagnosis. What is the examination plan and treatment tactics for the patient?

Clinical task 2

Patient, 23 years old. She became acutely ill. Complains of frequent painful urination, pain in the suprapubic region, cloudy urine, bleeding at the end of urination. The body temperature is normal, objectively there is pain in the suprapubic area.

Urology is a field of medicine that studies diseases of the genitourinary system that occur in men. For urological diseases in men, you should consult a urologist. In most cases, problems in the urinary system lower the self-esteem of the stronger sex and have an extremely negative impact on the body. Often diseases become chronic and can progress unnoticed.

Many men are not even aware of the presence of disturbances in genitourinary functions. However, every person needs to undergo a timely examination and, if a urological disease is detected, begin treatment. Otherwise, complications develop in the body, and it is much more difficult to cure the advanced stage. Urological disease provokes infertility and impotence.

Types of diseases

Both young and mature men are susceptible to diseases of the genitourinary system. Often, problems with the functions of the urinary organs occur in old age. The following urological diseases are distinguished:

Inflammation also develops in the bladder (cystitis) and kidneys (pyelonephritis). Urological diseases include urolithiasis and various disorders in the intimate area.

Typically, men consult a doctor only with obvious symptoms. Diseases await representatives of the stronger sex at any age. Therefore, every man needs to think about urological problems and monitor his own body. At the first problems with urination, pain and cramping, you should definitely visit a qualified specialist at the clinic.

Primary alarm bells from the male body are pain in the lumbar region, pain, urine production in droplets or a thin stream, . You cannot ignore the too frequent urge to go to the toilet.

Urological diseases in men: symptoms

Often, urinary tract diseases occur completely asymptomatically in representatives of the stronger sex. The obvious clinical picture is characterized by:

• pain and burning when passing urine;
• urinary disorders;
• discharge from the penis;
• skin rash on the genitals;
• rapid fatigue;
• pain during sexual intercourse;
• enlarged inguinal lymph nodes.

If a man, during an active sexual life, discovers any disturbances and the above symptoms, he urgently needs to undergo examination and consult a urologist. It is also necessary to visit a venereologist.

Urethritis

The disease can be triggered by an infectious-inflammatory process, genetic prerequisites, or trauma. Urethritis is often accompanied by sharp pain when urinating, burning in the canal and discomfort.

Balanoposthitis

Urology treatment

In the treatment of urological diseases in men, it is important to take into account the causes of developing pathology. Therapy should be aimed at eliminating the infectious process, as well as eliminating symptoms.

Treatment of any urological disease includes suppression of pathogenic microorganisms in the urinary tract with drugs. A man requires the use of immunomodulators, antibacterial agents, and probiotics. Are used:

• Ribomunil,
• Bifiform and other medicines.

Injecting an antiseptic solution into the urethra helps get rid of pathogenic microorganisms that cause infection and inflammation.

Treatment is prescribed by a doctor after identifying a pathogenic pathogen. The antibacterial drug is used depending on the microflora present in the urethra. Appointed:

• Ampicillin,
• Amoxicillin,
• Ceftibuten,
• Norfloxacin,
• Levofloxacin,
• Fosfomycin.

To restore the functions of the prostate gland, complex use of medications is indicated. Therapy includes the use of drugs that eliminate the infectious and inflammatory process in the tissues of the genital organs. Products are used whose action is aimed at eliminating pain and restoring urination. To prevent the process from becoming chronic, treatment requires antibiotics and antiseptics.

For urological diseases, the head of the penis and foreskin are often washed with antiseptic solutions. For this, hydrogen peroxide or furacillin are used. The affected areas of the genital organs are treated with such agents as Chlorhexidine, Miramistin, and Syntomycin ointment. An antiviral drug may be prescribed together with an antibiotic.

Among immunomodulating drugs, Pyrogenal and Rioferon are used. In complex therapy of prostate adenoma, alpha-blockers and antibiotics are used. Prostate massages through the rectum and various physical procedures help well.

• For urinary incontinence, special urological products are used that absorb involuntary fluid. The pad protects the patient's underwear and facilitates the socialization of the sick person.
• In particularly difficult situations, surgery or circumcision of the foreskin is performed. Expansion of the external opening of the urethra helps eliminate the inflammatory process and its symptoms.

Additional treatment methods include:

• establish a daily routine,
• sexual activity,
• switch to a balanced diet.

Urological diseases in men require diet and exercise therapy. Sports exercises improve men's health. Daily physical activity in the fresh air during a walk helps eliminate congestion in the prostate gland.

In the complex treatment of ailments, decoctions and infusions of various medicinal herbs are used. Rose hips, St. John's wort, lingonberries, cornflowers, nettles, and strawberries help get rid of urological diseases. Traditional recipes effectively eliminate the inflammatory process in the urinary tract and promote rapid recovery.

Prevention of urological diseases

To avoid urological disease in men, urologists recommend adhering to a healthy lifestyle. Bad habits have an extremely negative effect on the functions of the genitourinary system.

Diseases are provoked by:

• hypothermia,
• failure to comply with necessary hygiene rules,
• infection entering the urethra.

Unprotected sexual intercourse often causes infection and the development of ureaplasmosis. The body may be at risk of developing a urological disease with reduced immunity. It is necessary to regularly maintain normal immune system functions - walk more in the fresh air, eat right and perform moderate exercise. Exercising helps to get rid of congestion in the male genitourinary organs.

The disease can be caused by the use of certain medications. You should not take drugs that cause problems with the urethra. Every man should know that ignoring a urological disease leads to serious complications.