EXAMINATION OF THE PATIENT WITH KIDNEY AND URINARY PULMONARY DISEASES. SYMPTOMS AND PHARMACOTHERAPY OF URINARY OUTLOOK INFECTION
As a result of studying the chapter, the student must:
• Symptoms and syndromes in diseases of the kidneys and urinary tract;
• modern aspects of the clinical pharmacology of drugs used in infectious inflammatory and immunopathological diseases of the kidneys and urinary tract;
be able to
• identify the main areas of therapy for pyelonephritis and cystitis: measures aimed at eliminating infection, restoring urodynamics, increasing the body's resistance;
• the appointment of antimicrobials for infectious inflammatory and immunopathological diseases of the kidneys and urinary tract.
The attention of the physician should involve complaints of the patient for pain in the lumbar region, a decrease in diuresis (oliguria) or an increase in it (polyuria) with a predominant release of urine at night (nuturia), thirst, swelling, fever. Assess complaints of a general nature - headache, fatigue, weakness, impaired sweating.
Dull pain in the lumbar region occurs with many kidney diseases. Stupid one-sided pains are observed with a tumor of the kidney, chronic pyelonephritis. Back pain is possible with acute glomerulonephritis (mainly with a hematuric form). Intensive gradually increasing pain in the lower back is typical for the dilatation of the renal capsule; paroxysmal back pains with typical for renal colic irradiation, dysuria, nausea are noted with obstruction of the urinary tract. Renal colic is most often associated with impaired urine outflow from the kidney, but it is also noted in circulatory disorders of the kidney. With kidney dystopia, pain can be localized atypically (for example, in a small pelvis with pelvic dystopia of the kidney). Pain when urinating in the lower abdomen, in the perineum, in the urethra is noted in diseases of the lower urinary tract. Disorders of urination (dysuria) are manifested by his frequent (pollakiuria), difficulty (strangury), soreness; they can occur not only with urological, but also with neurological, gynecological and other diseases.
The delay in urination can be acute and chronic (paradoxical ishuria). It is necessary to distinguish incontinence, including night (enuresis), from urinary incontinence. Urinary incontinence is observed with inflammatory processes in the bladder. Sometimes the main complaint is a patient to discharge from the urethra of the blood (urethrorrhagia).
Oliguria usually precedes the appearance or strengthening of edema (of any origin). With the convergence of edema, as well as in patients with pyelonephritis, polyuria is observed.
Changes in diuresis can be characterized by a change in the physical and chemical properties of urine. Possible admixture to the urine of pus (pyuria), blood (hematuria), lymph (hiluria). There are salts, bacteria, scraps of necrotic kidney tissue, tumor tissue, insect larvae, parasites.
When collecting an anamnesis of the disease, analyze the onset of the disease (acute, gradual, accidentally detected). Establish a sequence of symptoms of the disease (pain, then hematuria or hematuria, and then the appearance of pain). Clarify their possible relationship with previous acute (eg, angina, influenza) or chronic (tuberculosis, diabetes) diseases or with various exogenous effects (endovesticular studies, preventive vaccinations, medication, contact with poisons, etc.). The data on earlier treatment (medicinal, surgical, sanatorium-resort), in women also about the transferred gynecological operations, the course of pregnancy (pyelonephritis of pregnant women) are important.
When examining a patient, pay attention to his behavior (rushing from pain in renal colic) or position in bed, skin color, smell from the mouth, the condition of the musculoskeletal system, external genital organs, the presence of edema, post-operative scars, and varicose veins veins on the legs.
When examining the abdomen in patients with a delay in urination, one can see a bulging bladder.
Inspection allows to reveal such important signs as characteristic pallor, puffiness of the face, edema, hemorrhages, scratching, asymmetry of the lumbar region (as a result of bulging of the corresponding side of the abdomen in tumors or perineal festering), abdominal enlargement (with polycystic kidneys) etc.
On examination, the condition of the soft tissues of the face is carefully assessed - there is no edema. Particularly carefully studied eyelids. Swelling on the face almost always has a "kidney character. Pathological is not only the presence of edema, but also puffiness.
When examining the lumbar region, assess the presence of inflammation (swelling, redness of the skin).
Symptom loosening the waist & quot ;. The patient's position is standing, his hands are lowered, his back is straight. The doctor has a palm on the patient's lumbar region, directly under the XII rib, in the longitudinal direction, slightly lateral to the spine. Fingers closed, pointing up. The second hand (the lateral part of the fist or the edge of the palm) the doctor performs strokes on the fingers of the first. The impact should be strong enough, however, such that the patient does not lose balance. A symptom is considered positive if the patient observes the appearance of soreness during the study.
Symptom Pasternatsky - perform loosening at the waist, and then immediately ask the patient to urinate. A symptom is considered positive if there is an impurity in the urine.
Pasternatsky's symptom is observed with swelling and tension of the parenchyma, with the dilatation of the renal capsule. However, it is peculiar not only to kidney diseases, but also to radiculitis, myositis, acute diseases of the liver and biliary tract.
The palpation of the kidneys is carried out in the horizontal (on the back and side) and the vertical position of the patient. In the standing position, a depressed and wandering kidney is defined.
The normal kidney is not probed, the kidney is palpated when it is enlarged by a factor of 1.5-2. An ectopic kidney is always palpated.
Simultaneously with palpation of the kidney in the position of the patient on the back, palpation of the kidney on the side should be performed.
The omission of the kidney - nephroptosis, is more common in women and mostly on the right. This is explained by the fact that, in norm, the kidney bed is narrower and slighter in women, especially on the right. Lowering the tone of the abdominal wall, reducing intra-abdominal pressure, weight loss, asthenic physique of a patient contribute to kidney weakness.
There are three degrees of omission and displacement of the kidneys by Strazhesko.
1. A palpable kidney. In this case, only the lower pole of the kidney is determined for 1/3 or 1/2 of its magnitude. The kidney moves up and down with the breath, in the lateral directions, the displacement is negligible.
2. Movable kidney. The kidney is probed all whole, including from above, but does not enter the other half of the abdominal cavity, i.e. does not cross the line of the spine.
3. Wandering kidney - the kidney freely moves in the abdominal cavity in various directions, goes behind the spine in the opposite direction and easily returns to the normal bed.
A palpable and mobile kidney can easily be confused with other organs. In differential diagnosis, it should be remembered that the kidney has a bean-shaped shape, elastic-elastic consistency, a smooth surface and easily returns to a normal bed.
The ureter is normally painless and not palpable. If it contains infiltrates or large stones, these formations can sometimes be probed in women with a flabby stomach or in very thin men.
Palpation of the pubic area allows to detect the bladder when it is overfilled with urine in the form of a spherical elastic body and an enlarged uterus during pregnancy or a tumor.
Percussion is used to determine bladder overflow. The finger-plessimetre is located parallel to the pubis on the anterior abdominal wall at the level of the navel and percussion along the anterior median line from top to bottom. When the bladder overflows, dullness appears, if the bladder is empty, then a tympanic sound is produced.
With an acute cessation of urinary output, a general examination often makes it possible to distinguish the delay of urine from acute renal failure. In acute kidney failure, signs of hyperhydration (peripheral edema, stagnant wet wheezing in the lungs) are found, while percussion the bladder is empty. On the presence of chronic renal failure may indicate polyuria with nicture, pallor and dryness of the skin, hypertension. For terminal uraemia, a large noisy breathing of Kussmaul, a smell of urine in the exhaled air, a pericardial friction noise can be detected.
Additional methods are used to study urine (the detection of so-called urinary syndrome), the functional state of the kidneys (according to the results of laboratory tests of urine, blood, measurement of glomerular filtration and tubular reabsorption, blood flow in the kidneys, etc.) , their morphological changes.
In the study of urine, its relative density, changes in color and acidity, the magnitude and type of proteinuria (organic, functional), the nature and degree of leukocyturia and erythrocyturia are established. Proteinuria, hematuria are characteristic of glomerulonephritis. Leukocyturia, bacteriuria, a decrease in the specific gravity of urine are noted with pyelonephritis. The combination of proteinuria, hypoproteinemia, hypercholesterolemia and edema is characteristic of nephrotic syndrome with glomerulonephritis. Uraturia is noted for urolithiasis with urate stones, oxaluria for urolithiasis with oxalate stones. Phosphaturia is characteristic of urolithiasis with phosphate stones.To assess the functional state of the kidneys, the determination of the level of creatinine in the blood (norm 0.044-0.1 mmol/L), the relative density of morning urine (norm 1.018 g/l and more), the measurement of daily diuresis, the sampling of Zimnitsky is of primary importance. In the hospital, the glomerular filtration and tubular reabsorption are measured by the creatinine clearance (Reberg's test), the ability of the kidneys to dilute and urine acidification is determined, the concentration in the blood and excretion in the urine of potassium, sodium, calcium are measured. Pathology is defined as a decrease in glomerular filtration (less than 80 ml/min) and its increase (more than 140-150 ml/min).
The relative density of urine with normal capacity for osmotic concentration increases to 1,024 or more, and with a preserved ability to dilute urine (for example, in a Folgard test) decreases to 1,001 - 1,002 g/l. Polyuria with hypostenuria are considered as an early sign of chronic renal failure. Polyuria with normal relative density of urine requires the exclusion of diabetes mellitus. The inability to reduce urine pH below 6.0 under metabolic acidosis (acid loading tests) is noted with tubulopathies (renal tubular acidosis, Fanconi syndrome). A persistently acidic urine reaction is characteristic of gouty nephropathy, kidney tuberculosis.
radionuclide and ultrasound are used as the safest and requiring special training. Dynamic renoscintigraphy and radionuclide (indirect) renal angiography help to detect a decrease in the excretory function and blood supply of the kidneys or the asymmetry of these indices - a symptom characteristic of pyelonephritis, of renovascular hypertension. With the help of ultrasound, asymmetry of the size of the kidneys, focal changes in their parenchyma (cyst, tumor) and in the cup-and-pelvis system (hydronephrosis, concrements, including X-ray negative) can be detected.
In hospital, if necessary, urological examination, including X-ray and endoscopic methods, and sometimes also computer X-ray tomography, which is especially informative when combined with intravenous urography (detection of foci in the renal parenchyma, changes in the bowel and pelvis system and urodynamics) are performed if necessary. If there is a suspected renal arterial hypertension, ultrasound dopplerography of the renal arteries is performed. Suspicion of a kidney tumor serves as an indisputable indication for radiopaque renal angiography and phlebography.
A kidney biopsy for the purpose of clarifying the diagnosis is the final stage of examination of a patient with kidney disease. It is carried out in a specialized nephrological department.
Cystitis is a common inflammatory disease of the bladder. Urinary tract infections (IMI) include cystitis, urethritis, pyelonephritis.
Etiology . Cystitis is a nonspecific inflammation of the bladder. Mostly sick girls and women, which is probably due to the peculiarities of their endocrine status and anatomical structure. The most frequent pathogens of the disease can be bacteria, viruses, mycoplasmas, chlamydia, fungi and even helminthic invasion. Most often, patients with cystitis in urine determine the E. coli, Staphylococcus, Enterobacter, Proteus, Pseudomonas aeruginosa, Klebsiella.
Immediate causes of cystitis:
• supercooling of the body;
• inflammation of the vagina - colpitis, or violation of the vaginal microflora;
• trauma to the urethra.
The leading microbial pathogen in acute cystitis is E. coli - E. coli (in 80-90% of observations). This is explained by the high pathogenic and adaptive capabilities of this microorganism (the phenomenon of adhesion, high rate of reproduction, the production of ammonia, which weakens immunity and disrupts the function of smooth muscle fibers of the urinary tract). Other guilty pathogens are enterococci (obligate flora of the intestine), Proteus, Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella.
Pathogenesis. Risk factors for developing cystitis: impairment of bladder emptying, local blood circulation disorder, cooling, irritation of the mucous membrane of the urinary bladder by chemicals, decreased resistance of the body as a result of fatigue, the transferred disease, the presence of diabetes, vulvitis and vulvovaginitis, etc.
The pathways of infection into the bladder are different:
• urogenic (ascending along the urethra);
• lymphogenous (by lymphatic vessels from the pelvic organs and the abdominal cavity);
• hematogenous (by blood vessels from distant sources of infection).
Clinic. In the course of the disease, acute and chronic cystitis is distinguished. Symptoms of cystitis: pain in the bladder, dysuria (urination disorder). The main symptoms of acute cystitis are frequent desires. There is pain when urinating without raising the temperature, the pain intensifies at the end of urination, when a drop of blood can appear from the urethra (terminal hematuria). There is a heaviness in the lower abdomen.
The palpation of the area of the bladder is painful. Leukocyturia (pyuria (pus in the urine), leukocytes in the urine), hematuria, insignificant proteinuria are found out.
Acute cystitis occurs quickly, almost immediately after hypothermia or other provocation. The intensity of pain when urinating increases and assumes a permanent character. The frequency of urge to urinate sharply increases. If the patient at the same time tightens the treatment to the doctor and tries to get out of the situation by self-medication, the cystitis passes into a chronic stage, while the infectious diseases that cause cystitis begin to progress.
To acute cystitis is:
• first arising cystitis;
• rarely occurring (no more than 2 times a year);
• often occurring (2 times a year or more).
In chronic cystitis, dysuric phenomena can be observed only during a period of exacerbation. There are blunt pains in the abdomen, urinary incontinence, nocturnal enuresis (bedwetting), spontaneous leukocyturia (leukocytes in the analysis of urine), insignificant proteinuria (a small amount of protein in urine analysis).
The appearance of low back pain, accompanied by fever and increased leukocyturia, indicates a complication of cystitis with pyelonephritis.
For the diagnosis of cystitis the doctor uses:
1) Specific symptoms;
2) deviation of urinalysis;
3) abundant growth of bacteria in urine culture;
4) signs of inflammation with ultrasound;
6) for women suffering from chronic cystitis, mandatory screening for sexual infections and the study of the vaginal microflora.
Treatment . In acute cystitis, bed rest is prescribed, a diet with the exception of acute, salty, roast; abundant warm drink; heat on the bladder area, warm sessile baths.
The main means of etiotropic therapy of urinary tract infections until today remain uroseptics. Pharmacological preparations related to uroseptics are presented in Table. 10.1.
Pharmacological preparations related to uroseptics
Amoxicillin + clavulanic acid
Ampicillin + sulbactam
Co-trimoxazole [sulfamethoxazole + trimethoprim]
Derivatives of 8-hydroxyquinolone
Nalidixic acid (Nevigramon®, Negram)
Pipemidic acid (Pali®)
Furazidine (Furagin, Furamag®)
Aminoglycosides. Mechanism of action: inhibition of protein biosynthesis by binding to the 308 subunit of the ribosome; diffusion through the outer membrane as a result of the displacement of Ca2 + and Mg2 'ions from the binding sites; transport through the internal membrane - an energy-dependent process.
The mechanism of action of betalactams: suppression of the function of penicillin-binding proteins (PSB); diffusion occurs through the porin channels - OprF, etc. Imipenem uses for diffusion a unique OprD channel. Hydrophobic (lipophilic) and amphiphilic antibiotics, such as fluoroquinolones, tetracyclines and chloramphenicol, are able to penetrate the outer membrane of Gram-negative microorganisms, bypassing the porin canals. Lipophilic antibiotics penetrate well enough through the cytoplasmic membrane into the cytoplasm, where the targets of their action are localized (ribosomes for tetracyclines and chloramphenicol and topoisomerase enzymes for fluoroquinolones). Fluoroquinolones inhibit DNA-gyrase; Due to lipophilic properties, diffusion is possible directly through the membranes, but they are partially excreted through the MeXA-MexB-OrgM system. MehA and MehB proteins are associated with the cytoplasmic membrane and carry transport from the cytoplasm to the periplasm, the OgrM protein is localized in the outer membrane and carries out excretion from the periplasm to the external environment. The genes of MeH, MehB, ORGM proteins are organized into a single operon, the level of their expression is regulated by the MexR gene. The difference in the mechanisms of action of antimicrobial agents is shown in Fig. 10.1. In addition to uroseptics, with acute uncomplicated cystitis, the use of antispasmodics, analgesics, and drugs that alter general and local reactivity is indicated.
With frequent painful urges, warm microclysters with analgesics are prescribed. Drugs for the empirical therapy of acute uncomplicated cystitis in women are presented in Table. 10.2.
Acute uncomplicated cystitis in women
Recommended empirical therapy
S. saprophyticus More rarely other enterobacteria
Orally for 3-5 days: fluoroquinolone (norfloxacin, ofloxacin, psfloxacin, ciprofloxacin, etc.), amoxicillin/clavulanate, phosphomycin
Preservation of symptoms for more than 7 days Recurrent UTI Using diaphragms and spermicides
Age over 65 years
Orally for 7 days: fluoroquinolone or amoxicillin/clavulanate
Orally for 10-14 days: cephalosporin, amoxicillin, nitrofurantoin, co-trimoxazole
Fig. 10.1. Different mechanisms for the action of antimicrobials:
OprF, OprD, OprM - porin kan; PSB - penicillin-binding protein, MehA, MehB, OrgM - quinolone excretion systems
In chronic cystitis, a complex of therapeutic measures includes physiotherapy (UHF, diathermy) on the urinary bladder, depending on the type of cystitis by cauterizing or oily solutions. Local cystitis treatment (rinsing) is performed in the hospital.
With an exacerbation of chronic cystitis, treatment tactics are the same as for acute cystitis.
Directions of phytotherapy:
• Destroy the causative agent (antibacterial action);
• eliminate inflammation of the mucous membrane (anti-inflammatory effect);
• eliminate pain;
• Ensure rapid and complete outflow of urine from the bladder (diuretic effect).
Many plants have antibacterial action. For the treatment of cystitis, those that contain antibiotic substances selectively accumulating in the urine are suitable: the descending goldenrod, lingonberry, bearberry, juniper Cossack, St. John's wort, camomile chamomile, Icelandic chamomile, marsh rosemary, thymus creeping, etc.>
Covering agents are used in the complex treatment of cystitis. These are herbs that give a lot of mucus in the broth. Slime envelops the bladder from the inside, thus preventing the irritating and damaging effects of substances contained in the urine. Mucus often has antibacterial properties. This is a medicinal althaea, a flax seed, an Icelandic cetrarium, a normal soap, a medicinal angelica, a wood doe, a large plantain, an elephant tall.
As a non-specific anti-inflammatory drug can be applied aplicata alder, roots and leaves of bdan, licorice naked, gravelite city.
Pain with cystitis is spastic. Therefore, for its elimination, plant antispasmodics are mainly used: St. John's wort, chamomile, gooseberry, tansy, tusk wheaten, medicinal immortelle, rhomboid rhizome.
Sedimentary baths and foot baths lasting 10-15 minutes have a good effect.
During the entire treatment, it is imperative to keep the legs, lower back and lower abdomen warm. On the feet wear warm woolen socks, a woolen shawl is tied on the waist, a heating pad is placed on the bladder area.
Warm microclysters (temperature 40 ° С) with infusion of chamomile - 10 g per 100 ml of water, sage - 5 g per 100 ml of water, yarrow - 10 g per 1000 ml of water, hops cone - 5 g provide calming and analgesic effect. per 100 ml of water.
Microclysters are best done before bedtime.
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