3 erythrocytes in the field of view); Already the presence of 5 ml. blood in 1 liter of urine is visible to the "naked" eye - an emergency for the patient. Hematuria as a true medical emergency" title="(!LANG:HEMATURIA TYPES: gross hematuria (blood clots) and microhematuria (>3 red blood cells per field of view); Already the presence of 5 ml of blood in 1 liter of urine is visible to the "naked" eye emergency for the patient Hematuria as a true emergency for the doctor" class="link_thumb"> 3 !} HEMATURIA TYPES: gross hematuria (blood clots) and microhematuria (>3 red blood cells per field of view); Already the presence of 5 ml. blood in 1 liter of urine is visible to the "naked" eye - an emergency for the patient. Hematuria, as a true emergency for a doctor: - tamponade of the bladder with blood clots; - renal colic with obstruction of the ureter by a blood clot; - anemia and hemoglobin 3 erythrocytes in the field of view); Already the presence of 5 ml. blood in 1 liter of urine is visible to the "naked" eye - an emergency for the patient. Hematuria, as a true emergency for the doctor"\u003e 3 red blood cells in the field of view); Already the presence of 5 ml. blood clots; - renal colic with obstruction of the ureter by a blood clot; - anemia and hemoglobin 3 erythrocytes in the field of view); Already the presence of 5 ml of blood in 1 liter of urine can be seen with the "naked" eye, an emergency for the patient. Hematuria, as a true emergency for doctor" title="(!LANG:HEMATURIA TYPES: macrohematuria (blood clots) and microhematuria (>3 erythrocytes per field of view); Already the presence of 5 ml of blood in 1 liter of urine can be seen with the "naked" eye an emergency for the patient. Hematuria, like a true emergency for a doctor"> title="HEMATURIA TYPES: gross hematuria (blood clots) and microhematuria (>3 red blood cells per field of view); Already the presence of 5 ml. blood in 1 liter of urine is visible to the "naked" eye - an emergency for the patient. Hematuria as a true medical emergency">!}

Often patients with "red urine" end up in emergency and emergency hospitals, but as a rule, this is not a true emergency and requires confirmation by catheter urine sampling! Differential diagnosis: - bleeding from the genital tract in women; - hemoglobinuria; - myoglobinuria; - ingestion of food and urine-coloring drugs.

CAUSES OF HEMATURIA Glomerular hematuria (NEPHROLOGICAL PATIENT) nephritis? dysmorphic erythrocytes (deformed when passing through the glomeruli), accompanied by erythrocyte cylindruria and proteinuria. Non-glomerular hematuria (UROLOGICAL PATIENT) can be caused by any urological disease. Erythrocytes are not deformed, there are no erythrocyte casts and proteinuria.

UROLOGICAL CAUSES OF HEMATURIA 1. Oncological diseases (tumor of the kidney, bladder, ureter, pelvis, prostate cancer); 2. Bleeding from the veins of prostate hyperplasia; 3. Urolithiasis; 4. Injury to the organs of the MPS; 5. Foreign bodies; 6. Infections of the urinary system.

ANURIA 1. SECRETORY (prerenal or renal) complete cessation of urine production in the kidneys (NEUROLOGICAL); 2. EXECRETORY (postrenal) complete obstruction of one or both ureters and no urine in the bladder. Prolonged obstruction is postrenal acute renal failure, which has serious life-threatening consequences: hyperkalemia (cause of death), fluid overload of the vascular bed and edematous syndrome.

POSTRENAL ANURIA D/D with OZM: urine. the bubble is not palpated and is not determined by percussion. Confirmation of the diagnosis during catheterization or ultrasound, the levels of urea and creatinine increase in the blood. REASONS - a stone in the ureter of a single kidney or both ureters at the same time; - iatrogenic injuries (ligation) of the ureters; - other reasons. TREATMENT 1. Drainage (PNS, placement of a stent in the ureter)

500 ml) and elimination of pain by catheterization and evacuation of urine. When AUR is usually evacuated" title="(!LANG:DEFINITION AUR is the inability to urinate when the bladder is full. The basis of the diagnosis is the presence of a large amount of urine in the bladder (> 500 ml.) And the elimination of pain by catheterization and evacuation of urine. In AUR usually evacuee" class="link_thumb"> 18 !} DEFINITION OZM - the inability to urinate when the bladder is full. The basis of the diagnosis is the presence in the bladder of a large amount of urine (> 500 ml.) And the elimination of pain by catheterization and evacuation of urine. With OZM, ml is usually evacuated. urine. Volume >800 ml. defined as chronic urinary retention. 500 ml) and elimination of pain by catheterization and evacuation of urine. In AUR usually evacuate "> 500 ml.) and eliminate pain by catheterization and evacuate urine. In AUR, 500-800 ml of urine is usually evacuated. A volume > 800 ml is defined as chronic urinary retention "> 500 ml.) and eliminate pain by catheterization and evacuation of urine. When AUR is usually evacuated" title="(!LANG:DEFINITION AUR is the inability to urinate when the bladder is full. The basis of the diagnosis is the presence of a large amount of urine in the bladder (> 500 ml.) And the elimination of pain by catheterization and evacuation of urine. In AUR usually evacuee"> title="DEFINITION OZM - the inability to urinate when the bladder is full. The basis of the diagnosis is the presence in the bladder of a large amount of urine (> 500 ml.) And the elimination of pain by catheterization and evacuation of urine. When OZM is usually evacuated"> !}

PATHOPHYSIOLOGY 3 mechanisms: - Increased resistance in the urethra (infravesical obstruction); - Low pressure in the bladder (atony or hypotension of the bladder muscle); - Violation of sensory or motor innervation (neurogenic bladder).

CAUSES IN MEN - BPH or prostate cancer, detrusor atrophy; - stricture or stone of the urethra; - purulent prostatitis or prostate abscess; - neurogenic bladder. PROVOCATING RISK FACTORS: - anesthetics and anticholinergic drugs (eg atropine) relaxation of the bladder; - sympathomimetics, stress, operations, hypothermia sphincter spasm; - immobilization lying position; - alcohol abuse swelling of the prostate.

TACTICS in AUR against the background of BPH: urethral catheter for 3 days + per os selective α1 - adrenoblocker (tamsulosin - OMNIK®, TULOZIN®). REPEATED AUR re-attempt at catheterization or surgical treatment (removal of BPH, insertion of a suprapubic catheter). Keep the catheter in the urethra for >3 days. men are not recommended! 3 days Not recommended for men!

CAUSES (GENERAL) IN WOMEN AUR is less common. there are features of the anatomical structure (no prostate and short urethra). - neurogenic bladder (diabetes mellitus, alcoholism, etc...); - prolapse of the pelvic organs: cystocele, rectocele, hysterocele; - rupture / separation of the urethra from the urine. bubble; - Tumors of the small pelvis with compression of the urethra.

OZM against the background of CZM - 1-2 liters of urine are evacuated during catheterization - the level of urea and creatinine is increased in the blood; - Ultrasound and excretory urogram reveal ureterohydronephrosis (UGN). Tactics - installation of a suprapubic catheter for 1-2 months. and antibacterial, anti-inflammatory therapy, treatment of CRF.

POST-CATHETERIZATION PERIOD AFTER CMM Restoration of diuresis of polyuria requires restoration of BCC (infusion of 0.9% NaCL = fluid loss ml.).

TWIST OF THE SPERMAL CORD - sudden severe pain in the scrotum radiating to the groin; - previously "intermittent" torsion, the pain suddenly disappeared; - temperature; - objectively: the testicle is edematous, dense, tense, located high and sometimes horizontally in the scrotum, scrotal hyperemia; - Ultrasound: lack of blood flow in the testicle with Doppler ultrasound; - The "open book" rule - the possibility of manual "unwinding" of the testicle.

Torsion of the spermatic cord with a duration of >6 hours necrosis, treatment: orchiectomy. TREATMENT up to 6 hours, with a viable testicle: orchopexy,. 6 hours necrosis, treatment: orchiectomy. TREATMENT up to 6 hours, with a viable testicle: orchiopexy, "> 6 hours necrosis, treatment: orchiectomy. TREATMENT up to 6 hours, with a viable testicle: orchiopexy,."> 6 hours necrosis, treatment: orchiectomy. TREATMENT up to 6 hours, with viable testicle: orchopexy,." title="(!LANG: Torsion of the spermatic cord with duration >6 hours necrosis, treatment: orchiectomy. TREATMENT up to 6 hours, with viable testicle: orchopexy,."> title="Torsion of the spermatic cord with a duration of >6 hours necrosis, treatment: orchiectomy. TREATMENT up to 6 hours, with a viable testicle: orchopexy,."> !}

TREATMENT - bed rest; - analgesics; - antibiotics (cephalosporins, aminoglycosides, fluoroquinolones); - if C. trachomatis is detected - doxycycline or macrolides; - suspensory on the scrotum; - in severe cases, sepsis (KLA) glucocorticoids. Complications: abscess formation, testicular infarction, chronic pain, infertility.

TWISTING OF PENDANTS Pendants are rudiments. - An appendage of the testicle (Morgagni's hydatid) - the remainder of the Müllerian (female) duct, has a leg and is prone to torsion, which causes pain; - Attachment of the epididymis - the remainder of the Wolffian duct, has a leg. Like the hydatid, it can twist and cause sharp pain.

PAIN IN THE LUMBAR AREA - is considered by most doctors as a "classic symptom" of pathology of the kidneys or ureters; - about 50% of patients with such pain syndrome KSD; - the other 50% of patients have "non-urolithiasis" and other diseases; - with completely different diseases, there are similar mechanisms that lead to pain in the lumbar region.

CAUSES OF RENAL COLICA UROLOGY: KSD, tumors and injuries of the kidneys and ureters, UTI (pyelonephritis, kidney abscess, paranephritis, pyonephrosis), "acute scrotum", UML obstruction. RENAL COLICA CAN BE SIMULATED BY THERAPY: myocardial infarction, pneumonia. GYNECOLOGY AND OBSTETRICS: torsion of the leg or hemorrhage into the cyst, ectopic pregnancy, adnexitis. OTHER NEUROLOGICAL CAUSES: - Acute abdomen, herpes zoster, gastritis, diverticulitis, inflammatory bowel disease, rib fractures, PE. RIGHT-SIDE PAIN SYNDROME: appendicitis, biliary colic, cholecystitis, hepatitis.

CLINIC OF "KIDNEY COLICA" - sudden unbearable cramping pain; - localization in the costovertebral angle; - irradiation "down" in the abdomen, iliac region, scrotum, penis, inside the thigh; - always restless behavior of the patient, attempts to reduce or stop the pain with any painkillers; - the pain does not increase with movement (on the contrary, with peritonitis, ectopic pregnancy, sciatica); - Almost always there are accompanying symptoms: nausea, vomiting, urination disorders, hematuria.

INDICATIONS FOR HOSPITALIZATION FOR RENAL COLICA Renal colic for the first time or lack of effect from drug therapy; Acute obstructive purulent forms of pyelonephritis: pustular (apostematous) pyelonephritis, carbuncle, kidney abscess, purulent paranephritis; Anuria and renal colic in the presence of a single kidney or stones in both ureters.

TREATMENT OF PATIENTS WITH RENAL COLICA - with an unclear diagnosis - enter only myotropic antispasmodics (but - shpa, papaverine, platifillin); - NSAIDs rapid and effective elimination of pain syndrome: DICLOFENAC 2.5% -3 ml. in / m. (for long-term pain relief suppositories 50 mg diclofenac 2-3 times a day); - other analgesics (tramadol, ketorolac); - in doubtful cases: dynamic observation in the surgical department to exclude surgical pathology; - in extremely rare cases - narcotic analgesics.

SPONTANEOUS STONE EXHAUST In some cases, with small stones (3-4 mm) of the ureter, dynamic observation is recommended for about 1 month. "under the guise" of conservative therapy, herbal medicine, "water loads", physiotherapy% of stones 5 mm. the probability of discharge is small (URS - ureterorenoscopy or DLT - remote lithotripsy of the stone is recommended).

The method of choice in the treatment of a patient with ureteral stones and renal colic is ureterorenoscopy with contact lithotripsy and ureterolithoextraction. URETERORENOSCOPE inserted into the ureter Orifices of the ureters Bladder Ureter Lower calyx of the kidney Upper calyx of the kidney Pelvis Stone in/3 of the ureter captured in the "basket"

38°C obstructive pyelonephritis, indicated: - IV infusion and broad-spectrum antibacterial drugs; - with severe pain and temperature for several days" title="(!LANG: FEVER WITH RENAL COLICA In case of renal colic and temperature >38°C, obstructive pyelonephritis is indicated: - IV infusion and broad-spectrum antibacterial drugs; - with severe pain and temperature for several days" class="link_thumb"> 60 !} FEVER WITH RENAL COLICA In renal colic and temperature >38°C, obstructive pyelonephritis is indicated: - IV infusion and broad-spectrum antibiotics; - with severe pain and temperature for several days - drainage (ureter catheterization or nephrostomy); - in the absence of the effect of drainage, suspicion of purulent forms of pyelonephritis, percutaneous puncture of the abscess or surgical treatment. 38°C obstructive pyelonephritis, indicated: - IV infusion and broad-spectrum antibacterial drugs; - with severe pain and temperature for several days "\u003e 38 ° C obstructive pyelonephritis, it is shown: - intravenous infusion and broad-spectrum antibacterial drugs; - with severe pain and temperature for several days - drainage (ureter catheterization or nephrostomy); - in the absence of the effect of drainage, suspicion of a purulent form of pyelonephritis, percutaneous puncture of the abscess or surgical treatment. "> 38 ° C obstructive pyelonephritis, it is shown: - with severe pain and temperature for several days" title="(!LANG: FEVER WITH RENAL COLICA In case of renal colic and temperature >38°C, obstructive pyelonephritis is indicated: - IV infusion and broad-spectrum antibacterial drugs; - with severe pain and temperature for several days"> title="FEVER WITH RENAL COLICA In renal colic and temperature >38°C, obstructive pyelonephritis is indicated: - IV infusion and broad-spectrum antibiotics; - with severe pain and temperature for several days"> !}

The book "Selected Lectures on Urology"

ISBN: 5-89481-626-2

The book contains information on the most pressing problems of modern urology, on the difficulties that arise in the process of diagnosis and treatment. Considerable attention is paid to general issues of urology, inflammation of the genitourinary system, tumors, urolithiasis and sexual disorders in men. Radiation diagnostic methods, principles of urogenital reconstruction in exstrophy and epispadias, organ-preserving surgical interventions in kidney cancer, treatment of metastatic and locally advanced bladder cancer, surgical treatment of erectile dysfunction in men, laparoscopic pelvic lymphadenectomy in prostate cancer, and so on are considered. The information presented in the book will help the clinician to navigate the complex cases encountered in urology. Recommended for urologists, general practitioners, surgeons, medical students.

General questions of urology

Sacral neuromodulation in the treatment of neurogenic disorders

urination

Botulinum toxin in the treatment of functional disorders of urination

Radiation diagnostic methods in modern urology

Modern methods of radionuclide diagnostics in urology

Intracavitary ultrasonography in the diagnosis and treatment of diseases of the kidneys and upper urinary tract

Modern methods of continent cutaneous urine diversion

Principles of urogenital reconstruction for epispadias and exstrophy in adults

Bladder diverticula

Endoscopic treatment of vesicoureteral reflux in children

hydronephrosis

Reproductive and sexual health of boys

Modern principles of diagnosis and treatment of iatrogenic injuries of the ureter

Inflammatory diseases of the genitourinary system

Urethral catheter as a risk factor for the development of nosocomial urinary infection

Urodynamics of the upper urinary tract in pyelonephritis

Features of the use of antimicrobials in the treatment of urinary tract infections in children

Ultrasound diagnosis of inflammatory diseases of the prostate gland and seminal vesicles

Modern methods of treatment of septic conditions in urology

Ozone therapy in urology

Urolithiasis disease

What is external shock wave lithotripsy?

Drug treatment and prevention of urolithiasis

Coral nephrolithiasis

Modern methods of surgical treatment of urolithiasis in children

Mistakes, dangers and complications of remote shock wave nephroureterolithotripsy

Remote nephrolithotripsy in patients with anomalies of kidney development, nephroptosis and after kidney transplantation

Tumors of the genitourinary system

Interstitial radiotherapy (brachytherapy) for localized prostate cancer

Magnetic resonance imaging in the diagnosis of bladder cancer

Is organ-sparing treatment of invasive bladder cancer possible?

Quality of life of oncourological patients after intestinal derivation of urine

Papillary tumors of the upper urinary tract: endoscopic methods of diagnosis and treatment

Organ-preserving surgery for kidney cancer

Transurethral electrosurgery of the prostate: yesterday, today, tomorrow

Laser surgery for prostate adenoma

Endoscopic methods of diagnosis and treatment of superficial bladder cancer

Tactics for the treatment of locally advanced and metastatic bladder cancer, taking into account the principles of evidence-based medicine

Laparoscopic pelvic lymphadenectomy for prostate cancer

Diseases of the genital organs, urethra and sexual disorders in men

The choice of the method of surgical intervention for Peyronie's disease

Some aspects of complex therapy for congenital or acquired "deformed penis" syndrome

Endoscopic treatments for urethral strictures

Urethroprostatic stenting in the treatment of obstructive diseases of the lower urinary tract

Treatment of urinary incontinence in men with implantation of an artificial sphincter

Bladder

Physiological aspects of erection

Surgical treatment of erectile dysfunction

Epidemiology and pharmacotherapy of erectile dysfunction

Elephantiasis of the external genitalia

The speaker raises the most acute problem of early renal replacement therapy for kidney disease. Methods for preventing the development of chronic kidney disease are given. It tells about the methods of diagnosis, assessment of risk factors, as well as the selection of adequate therapy for cardiovascular diseases.

Doctor's notes: Atony of the bladder in a woman

Dear colleagues, I offer you a clinical case for analysis. A 60-year-old woman who has been seen in our clinic for 16 years has been treated by us several times - before she was seen by another female urologist, and now by me. History: when she was 3 months old, she underwent surgery on the sacrum. At the age of 10 - residual urine 300 ml, operation: enterovesicoplexy. All his life he suffers from incontinence, the urge to urinate is weak.

In July last year, she was admitted to the clinic with pain in the suprapubic region and fever. An overview picture shows bladder stones, bilateral hydroureteronephrosis. PCLS on the right 48 mm, on the left - 12 mm. The parenchyma on the right is thinned to 12 mm. In the bladder 400 ml of residue. Conducted on a urinary catheter and Ciprofloxacin 500 mg for 10 days. Urine with a significant admixture of flakes, mucus, and detritus passed through the catheter. urine pH - 9.0

Performed cystolithotripsy - bladder stones are "eggs" - outside the shell of urates, inside - detritus. The mucosa of the bladder literally decomposes and is rejected. According to histology - chronic active inflammation. In the lab analyzes - creatinine and urea are normal. The stones were crushed, in general, the condition improved. Discharged A week ago comes with right-sided renal colic, fever, vomiting.

According to ultrasound - PCLS on the right is 30 mm, on the left is 25 mm. Thinning of the parenchyma on both sides up to 5-7 mm!!! Residual urine again 400 ml. Creatinine 198 mmol/l, urea 14.3 mmol/l. Urine pH 9.0 while taking Methionine 6 tablets per day. Again, a catheter was placed and Ciprofloxacin 500 was prescribed. After 3 days, a significant improvement in health, fever was stopped, leukocytosis decreased to 8.2. Creatinine dropped to 131 mmol/l.

Colleagues, the question is - what is the tactic with this patient? We are all leaning toward cystectomy because the bubble slowly rots and will rot. Confuses the progressive reduction of the renal parenchyma. the patient is not psychologically ready for cystectomy.

“A course of lectures on urology Test [IRKUTSK STATE MEDICAL UNIVERSITY] Chapter. General clinical research methods LECTURE COURSE ON UROLOGY FOR STUDENTS...»

-- [ Page 1 ] --

IRKUTSK STATE MEDICAL UNIVERSITY

Course of lectures on urology

[IRKUTSK STATE MEDICAL UNIVERSITY]

Chapter ". General clinical research methods

COURSE OF LECTURES ON UROLOGY FOR STUDENTS OF MEDICAL, PEDIATRIC AND MEDICAL PREVENTIVE FACULTIES OF MEDICAL UNIVERSITY.

Urology is a field of clinical medicine that studies the etiology, pathogenesis, diagnosis of diseases of the urinary system, the male reproductive system, diseases of the adrenal glands and other pathological processes in the retroperitoneal space and develops methods for their treatment and prevention.

Urology is a surgical discipline, a branch of surgery. Therefore, unlike nephrology, urology deals mainly with the surgical treatment of diseases of the above organs and systems. Due to the clinical challenges faced by a urologist, he requires knowledge of pediatrics, gynecology, endocrinology, oncology, neurology, dermatovenereology and a number of other medical specialties.

HISTORY OF THE DEVELOPMENT OF UROLOGY

The science of "urology" (Greek uron urine, logos doctrine) originated in ancient times. Already Hippocrates (IV century BC) in his writings described the most characteristic changes in urine: changes in color and smell, the appearance of pathological inclusions in it (pus, blood, etc.), and also tried to classify some diseases of the kidneys, bladder.

In the time of Hippocrates, there were "stone cutters" - people who knew how to remove stones from the bladder with perineal access.

In the "Canon of Medicine" Avicenna describes in detail the technique of the operation of removing stones from the bladder, he also developed the technique of catheterization of the bladder.

Some historians consider Francisco Diaz to be the founder of urology as a separate medical discipline; his monograph, published in Madrid in 1588, is completely devoted to the causes, clinic, diagnosis, treatment of urological diseases, the technique of urological operations, and a description of urological instruments.

In Russia, I. P. Venediktov, who lived in the second half of the 18th century, performed more than 3000 stone cuts during his life (with a postoperative mortality of about 4%), an outstanding "stone cutter" was I.P. Venediktov.

The world's first specialized urological department was opened in Paris in 1830, headed by J. Civiale, who first proposed cystolithotripsy.

The first epicystolithotomy in Russia was performed in 1823 by K. I. Grum-Grzhimailo, the first cystolithotripsy was performed in 1830 by A. I. Pohl (according to the method of J. Civiale). The development of domestic urology is inextricably linked with the names of I.V. Buyalsky, A.M.A.M. Shumlyansky, N.I. Pirogov, F.I. Inozemtsev. The first Russian monograph on urology is H. Zuber's dissertation "On Bladder Diseases".

In 1890, Felix Guyon became the first professor of urology in Paris, and urology began to be taught as a separate course in general surgical surgery.

A particularly large leap in the development of urology as a science occurred in the second half of the 19th century. So, in 1869, the German doctor Simon successfully removed a kidney for the first time. Since that time, the creation of urological clinics throughout Europe has begun.

In Russia, the development of urology is associated with the names of T.I. Vdovikovsky (in 1863 he opened the first urological department), I.V. Buyalsky, who developed surgical methods for the treatment of the bladder.

However, the founder of this field of medicine in Russia is still S.P. Fedorov is a well-known surgeon, author of the book "Surgery of the kidneys and ureters", founder of the Russian Urological Society. Precisely according to him

initiative in Russia, urology began to stand out as an independent science in 1904, and in 1923 a government decree was issued to open departments of urology in the country's leading medical universities.

In 1923, the journal "Urology" was established in Russia, and in 1926 the 1st All-Russian Congress of Urologists was held in Moscow. 1965 - kidney transplant.

Endoscopic research methods take their history from the beginning of the 19th century, when the German doctor Bozzini manufactured the Lichtleiter apparatus for illuminating the bladder and urethra, which subsequently did not find practical application.

Further attempts to create instruments for examining the mucosa of the lower urinary tract are associated with the names of Segalas, Desormaux and Grunfeld. The technical idea of ​​these authors was to supply light from the outside, through various tubes inserted into the urethra.

Some authors give the palm in the invention of the cystoscope to the Parisian surgeon Antoine Jean Desormeaux, who demonstrated his cystoscope in 1853. at the Paris Medical Academy, and in 1865. published an essay describing this device and the first attempts at endoscopic therapy. The world's first model of a cystoscope was proposed in 1877 by M. Nitze, who, continuing to improve his invention, created various versions of the cystoscope (examination, irrigation, evacuation, operating), in 1893 he made the world's first cystoscopic photograph, and in 1894 He also published the world's first cystophotographic atlas. In 1897, the Cuban I. Albarran improved the cystoscope with a special device (the so-called "Albarran lift"), which made it possible to catheterize the ureters.

In 1907, the International Association of Urologists was established in Paris, in 1908 the 1st International Congress of Urologists was held there.

The further development of urology was greatly facilitated by the discovery of x-rays. Around the same time, there was an intensified development of general surgery, which also accelerated the formation of urology as an independent medical discipline.

In the 20th century, new diagnostic methods were actively developed:

chromocystoscopy, pyelography, transurethral electroresection, etc., for the first time an operation was performed using an artificial kidney.

In modern urology, the latest methods of diagnosis and treatment are used: computed tomography, percutaneous puncture (percutaneous) methods for extracting and crushing stones in the kidneys and urinary tract, remote shock wave lithotripsy, X-ray endovascular methods for the treatment of diseases of the vessels of the genitourinary organs, endoscopic operations on the upper and lower urinary tract - then there is a replacement of traditional surgical interventions with “closed”, transabdominal and retroperitoneal methods of treatment, which

Chapter ". General clinical research methods

less traumatic, easier to tolerate by patients and help to reduce the length of their stay in the hospital. In recent years, robot-associated operations on Da Vinci devices have been performed in the world and Russia, which made it possible to avoid errors and complications arising from endoscopic operations.

Domestic urology closely cooperates with the European Society of Urology and the American Urological Association, which allows it to be one of the most developed medical disciplines in the world.

Thus, modern urology is a discipline that is actively developing and is in close contact with many medical fields.

What sections does modern urology include?

Urology is a part of surgery. However, the rapid development of science and technology has led to the formation of subdisciplines of urology, developing at the interface with other specialties of clinical medicine. American

The Urological Association has proposed eight areas (subdisciplines) of urology:

1. Pediatric (children's) Urology (Pediatric Urology) - the study and treatment of congenital and acquired urological diseases of children.

2. Urologic Oncology (oncourology) (Urologic Oncology) -- the study and treatment of malignant neoplasms of the male and female urinary tract and male reproductive organs (including cancer of the kidney, ureter, prostate, bladder, testicular cancer in men and bladder cancer in women) .

3. Renal Transplantation - issues of kidney transplantation in renal failure.

4. Erectile dysfunction or impotence.

5. Male Infertility (Male Infertility).

6. Stones of the urinary tract (Urinary Tract Stones) - treatment of stones in the urinary tract, which are formed as a result of metabolic disorders and excessive excretion by the kidneys of those substances that go to build a stone.

7. Female (urogynecology) Urology (Female Urology) -- treatment of urinary incontinence, pelvic disorders, trauma and other diseases.

8. Neurological urology (Neurourology) - treatment of urological disorders that are caused by neurological trauma or neurological diseases, such as multiple sclerosis, muscular dystrophy, Parkinson's disease or spina bifida.

In Russia, the subdisciplines of urology are: oncourology, pediatric urology, urogynecology, phthisiourology, endourology, andrology. In addition to them, neurourology has been actively developing in recent years.

–  –  –

SYMPTOMS AND SYNDROMES IN UROLOGY

All the variety of clinical manifestations of urological diseases can be reduced to 4 groups of symptoms: 1) pain; 2) urination disorders; 3) changes (qualitative and quantitative) of urine; 4) pathological changes in sperm and discharge from the urethra.

The clinical picture of urological diseases is characterized by significant polymorphism. The main specific syndrome in urology is acute or dull pain in the lumbar region and abdomen, over the womb and perineum, in the genitals. Pain occurs both during physical exertion and at rest, in the vertical position of the patient's body, and in the supine position.

Thus, pains differ in localization and irradiation; by intensity: sharp and blunt; with the flow:

constant, intermittent; due to: during exercise, without exercise.

It is often noted that acute colicky pains, accompanied by nausea, vomiting, peritoneal symptoms, hyperthermia, if misinterpreted, lead to an erroneous diagnosis. So, nephroptosis with an atypical clinical picture is often diagnosed as acute appendicitis, while appendectomy is unjustifiably performed. It happens that acute pains are accompanied by frequent urge to urinate and anuria, and sometimes jaundice. It should be noted that an asymptomatic course of urological diseases is often observed, which ranges from 8% to 20% of cases.

Urination disorders.

An important indicator of urine is e specific gravity, which depends on the weight of the molecules dissolved in 1 ml of urine. With a normal diet, an average of 1200 mOsm of substances are excreted in the urine, which, with a specific gravity of 1036, are excreted in 1000 ml of urine, and with a specific gravity of 1006, with 6 liters of urine. Consequently, the 1200 mOsm substances to be excreted by the kidneys are excreted in different amounts of urine of different specific gravity, depending on the concentration ability of the kidneys. With the usual intake of food and liquid, the specific gravity in a healthy person fluctuates in daily urine between 1015 and 1025.

Under conditions of normal life, 700 osmotically active substances should be excreted from the body daily with urine. To remove such a quantity at the maximum possible osmolality of urine (1000 my / kg), you need at least 700 ml of urine per day. This daily volume of urine is called obligate diuresis, or obligate volume.

Changes in urine can be quantitative: 1) oligo- and anuria; 2) polyuria; 3) nocturia; 4) hypo- and isostenuria and qualitative: 1) proteinuria; 2) hematuria; 3) cylindruria; 4) leukocyturia (pyuria).

Quantitative change in urine: Assessing the total amount of urine excreted per day, one should be guided by

–  –  –

not only on the absolute values ​​of this indicator, but also on the ratio of the daily volume of urine and the amount of liquid drunk and in food. In a healthy person, approximately 3/4 (65–80%) of the liquid drunk is normally excreted during the day.

An increase in diuresis of more than 80% of the liquid drunk per day in patients with congestive circulatory failure may indicate the beginning of the convergence of edema, and a decrease below 65% may indicate their increase.

The daily amount of urine varies physiologically within certain limits depending on the food taken, the amount of liquid injected, the external temperature, the work performed, and other factors. Men normally excrete an average of 1500 - 2000 ml of urine per day, and women - 1200 - 1600 ml. The largest amount of urine is excreted between 15 and 18 hours, and the smallest - between 3 and 6 hours. in the morning, with most of the urine (80%) excreted during the day.

Dysuria is a general definition of a urinary disorder (often referred to as frequent and painful urination).

Anuria is the complete absence of diuresis.

The cause of oliguria is a violation of glomerular filtration. Oliguria occurs when, under the influence of prerenal, renal, and postrenal factors, the glomerular filtration rate falls below 10 ml/min.

Oliguria leads to: 1) an increase in the volume of extracellular fluid - hyperhydria; 2) accumulation of osmotically active substances in the body. In particular, hypernatremia, hyperkalemia develop; 3) accumulation in the blood of the end products of metabolism - azotemia.

Polyuria is an increase in daily diuresis over 1.8 liters. In humans, the maximum possible diuresis, provided that it is not osmotic, is 25 l / day, which is 15% of the volume of filtered water.

The causes of polyuria can be extrarenal (psychogenic polydipsia, disorders of water-salt metabolism and its regulation, for example, diabetes insipidus) and renal (polyuric stage of acute and chronic kidney failure) factors.

Depending on the mechanisms of development, the following types of polyuria are distinguished.

1. Water diuresis. Due to a decrease in facultative reabsorption of water. Occurs with water stress, diabetes insipidus. Urine with such polyuria is hypotonic, i.e. contains few osmotically active substances.

–  –  –

2. Osmotic diuresis (saluresis). It is associated with an increase in the content of unreabsorbed osmotically active substances in the urine, which leads to a secondary violation of water reabsorption. Polyuria of this type develops when:

a) impaired reabsorption of electrolytes;

b) an increase in the content of the so-called threshold substances in the primary urine (for example, glucose in diabetes mellitus);

c) the action of exogenous substances that are poorly reabsorbed (mannitol) or disrupt the reabsorption of electrolytes (saluretics).

Under conditions of maximum osmotic diuresis, urine output can reach 40% of the glomerular filtration rate.

3. Hypertensive diuresis. It develops with arterial hypertension, when the speed of blood movement in the direct vessels of the medulla of the kidneys increases (these vessels run parallel to the knees of the loop of Henle). At the same time, the convection transport of substances increases; it is this transport, and not diffusion, that becomes the leading one.

The consequence of increased convection transport is the "washout" of sodium, chlorine, urea from the interstitium. This leads to a decrease in the osmotic pressure of the extracellular fluid, as a result, water reabsorption in the descending loop of Henle decreases and polyuria develops.

Oliguria is a decrease in daily diuresis below the obligate volume, i.e. less than 700 ml/day. The cause of oliguria is a violation of glomerular filtration. Oliguria occurs when, under the influence of prerenal, renal, and postrenal factors, the glomerular filtration rate falls below 10 ml/min.

Oliguria leads to: 1) an increase in the volume of extracellular fluid - hyperhydria; 2) accumulation of osmotically active substances in the body. In particular, hypernatremia, hyperkalemia develop; 3) accumulation in the blood of metabolic end products - azotemia.

Pollakiuria - frequent painless urination (20 - 30 times a day or more). The causes of pollakiuria can be: cardiovascular diseases, taking diuretics and cardiac glycosides, diabetes mellitus, acute and chronic glomerulonephritis, chronic pyelonephritis, polycystic kidney disease, interstitial cystitis, functional and organic diseases of the nervous system (tumor neurosis and brain injury, etc.) .

Nocturia (from the Latin noctu) is the need to get up at night one or more times in order to empty the bladder. “Bladder aging” and LUTS/BPH are common causes of nocturia.

–  –  –

Nocturia - (from the Greek nyctos) - nocturnal polyuria. Nocturia is a pathological sign, the essence of which is the predominance of the night part of diuresis over the day.

Normally, 60-80% of the daily amount of urine is excreted in the period from 8 to 20 hours, i.e. the ratio of night diuresis to daytime is 1:2.

With nocturia, the nightly portion of urine can be more than twice the daytime.

Depending on the reasons, they distinguish:

1) cardiac nocturia - develops with heart failure. During the day, patients increase the load on the heart and water intake, which leads to stagnation of blood and water retention in the tissues (edema). At night, in a horizontal position, venous outflow improves and the load on the heart decreases. This causes the release of atrial Nauric hormone, an increase in diuresis and a decrease in edema;

2) renal nocturia - characteristic of kidney damage. It is explained by the improvement at night of disturbed renal blood flow. As a result, the movement of blood through the vessels of the kidneys is accelerated, and hypertensive diuresis develops.

Stranguria is difficulty urinating. Often associated with frequent and painful urination (dysuria). Causes - infravesical obstruction (LUTS / BPH), urethral strictures.

Urinary incontinence is the involuntary release of urine without the urge to urinate. Urinary incontinence can be true (without anatomical defects) and false (ectopia).

Urinary incontinence is the inability to retain urine in the bladder with an imperative (imperative) urge. Among the causes of urinary incontinence, inflammatory bladder diseases (cystitis) and neurological (OAB, multiple sclerosis, Parkinson's disease, spinal syndrome) should be distinguished, diseases of the prostate gland (BPH) , prostatitis, cancer).

Enuresis is urinary incontinence.

Nocturnal enuresis is bedwetting.

Ischuria - urinary retention (acute and chronic; complete and incomplete). With ischuria, there is residual urine in the bladder after urination.

Paradoxical ischuria is a paradoxical combination of complete chronic urinary retention and urinary incontinence.

–  –  –

polyuria - an increase in the amount of urine excreted per day (more than 2800 ml), with a low relative density (1002 - 1012). Causes - excessive fluid intake, diabetes mellitus, diabetes insipidus, oliguria - a decrease in the amount of daily urine less than 500 (400) ml / day (below 16 ml / hour), anuria - a life-threatening condition when urine is either not produced by the kidneys (below 4 ml /hour), or does not enter the bladder Qualitative change in urine: The reaction of urine depends on the amount of free hydrogen ions released during the dissociation of organic acids and acid salts - the actual reaction of urine (pH). Under normal conditions, in healthy people, urine has a slightly acidic reaction, pH and varies depending on the diet between 4.5 and

8. Urine is a well-buffered solution, as a result of which the pH ratios do not allow for true fluctuations in the body's AFR. In many urological diseases, a qualitative change in the composition of urine occurs. Among them are:

Hematuria is a pathological symptom characterized by the appearance of red blood cells in the urine. There are microscopic and macroscopic hematuria. To clarify the localization of the source of bleeding, a two- and three-glass test is performed: in this case, the patient is offered to urinate sequentially in two or three glasses.

Macroscopic hematuria can be of three types:

1) Initial (initial), when only the first portion of urine is stained with blood, the remaining portions are of a normal color. With initial hematuria, the pathological process is more often localized in the urethra. It is necessary to distinguish initial hematuria from urethrorrhagia, in which blood is released from the urethra outside the act of urination. When clarifying the nature of hematuria in women, it is necessary to exclude bleeding from the genital organs. In such cases, examine the middle portion of urine during self-urination or urine obtained from the bladder by catheterization. Hematuria in women coinciding with the premenstrual period should suggest bladder endometriosis.

2) Terminal (final), in which no blood impurities are visually detected in the first portion of urine and only the last portions of urine contain blood, which indicates the presence of a process in the posterior urethra or bladder. Such hematuria is more often observed in acute cystitis, prostatitis, stone and tumor of the bladder.

3) Total, when the urine in all portions is equally colored with blood, which may be due to the localization of the pathological process either in the kidney, or in the ureter, or in the bladder. The most common causes of total hematuria are tumor, stone, kidney injury, bladder tumor, less often benign prostatic hyperplasia, bladder and kidney tuberculosis, pyelonephritis, renal papillary necrosis, nephroptosis, venous renal hypertension, hydronephrotic transformation, etc.

In the case of admixture of blood, urine acquires a red color of varying intensity - from the color of "meat slops" to dark cherry. But the degree of blood loss cannot be assessed by the color of urine, because. the content of 1 ml of blood in 1 liter of urine already gives it a red color. The intensity of bleeding is determined by the presence of blood clots, the degree of blood loss - an indicator of hemoglobin, and more precisely - hematocrit. Scarlet blood excreted in the urine indicates ongoing bleeding. In cases where the urine becomes brown, it should be considered that the bleeding has stopped, and the color of the urine is due to the dissolution of blood clots by urine.

A putrid smell indicates stagnation of urine and infection. It should be remembered that the color of urine may change when taking various medications and foods: from madder

–  –  –

- brownish-red, from phenolphthalein and beets - red, from pyramidon - pink, 5-NOC - saffron-yellow, from rhubarb and senna - brown, from purgen, with an alkaline reaction of urine - raspberry.

Hemoglobinuria should be distinguished from hematuria - while the bloody color of urine depends on the breakdown of red blood cells in the blood and the excretion of hemoglobin in the urine, which is in it in the form of cylinders. The color of urine with hemoglobinuria does not change even with prolonged standing, while with hematuria, erythrocytes quickly settle to the bottom of the vessel and the upper layers of urine acquire a normal yellowish color. Hemoglobinuria is observed after transfusion of incompatible blood, in case of poisoning with aniline, mushrooms, berthollet salt, carbolic acid, prolonged cooling and extensive burns. The admixture of myoglobin in the urine gives it a reddish-brown color. Myoglobin, a protein similar in composition to hemoglobin, enters the blood from crushed muscles during the so-called. "crash syndrome" (prolonged squeezing and crushing of tissues), because its molecule is three times smaller than hemoglobin, it easily penetrates into the urine.

Topical diagnosis of the source of hematuria is helped by the nature of blood clots.

Worm-shaped clots indicate bleeding from the upper urinary tract and forming in the ureter. However, the formation of such clots is possible in the lumen of the urethra after a traumatically performed bladder catheterization in a patient with benign prostatic hyperplasia (adenoma). Shapeless clots often form in the bladder. For a topical diagnosis, pain in the lumbar region is important, which is caused by an acute violation of the passage of urine from the kidney by the formed clots.

The combination of two symptoms - hematuria and pain - makes it possible to differentiate a kidney neoplasm from nephrolithiasis. With nephrolithiasis, hematuria occurs not so much as a result of injury to the urothelium of the pelvis with a calculus, but as a result of a violation of the integrity of the fornic venous plexuses with a sharp increase in intrapelvic pressure. That. hematuria with nephrolithiasis occurs after an attack of pain (renal colic), i.e. after restoration of the passage of urine along the upper urinary tract. With a kidney tumor, hematuria appears suddenly and may stop on its own. As a rule, it is painless, however, when the ureter is occluded by blood clots, pain occurs after hematuria.

Essential hematuria combines a number of conditions in which the etiology, pathogenesis is unknown, and clinical, radiological and morphological studies do not allow us to find out the cause of bleeding. a sign of recovery or stop the development of the disease. Hematuria is an absolute indicator for the hospitalization of a patient in a hospital (in particular, in the urological department). To determine the tactics of treating a patient in a hospital, an important role belongs to the collection of analysis and examination of the patient at the prehospital stage. It is necessary to find out the conditions for the occurrence of hematuria, its degree, nature and duration, the time of occurrence before or after an attack of renal colic, the presence of blood clots in the urine, their shape, the presence or absence of pain and dysuria during urination. The cessation of hematuria does not always indicate a resolution of the problem. Often, hematuria recurs, the "light intervals" between e episodes become shorter.

Leukocyturia - the appearance in the urine of leukocytes over 5 in the field of view. Leukocyturia, in which a very large number of leukocytes in the urine, including those destroyed, is found, is called pyuria.

The main cause of leukocyturia is inflammatory processes in the renal tissue and urinary tract.

Pyuria - pus in the urine, a sign of an inflammatory process in the urinary system;

Proteinuria - the presence of protein in the urine (sometimes true - renal and false - extrarenal); What are the mechanisms of proteinuria? The following mechanisms may underlie its development:

–  –  –

1) an increase in the permeability of the glomerular filter due to damage to the basement membrane (glomerular proteinuria)",

2) decrease in tubular reabsorption of filtered protein (tubular proteinuria);

3) pathological intake of protein into the lumen of the tubules from damaged cells of the tubular epithelium or from the peritubular lymphatic fluid (secretory proteinuria).

Proteinuria can be selective, when only low molecular weight proteins are detected in the urine, and non-selective, which is characterized by the appearance in the urine of both low and high molecular weight proteins.

According to the degree of selectivity, the nephrotic type of proteinuria is distinguished (only albumins or albumins + a-globulins in the urine) and the nephritic type (all classes of blood plasma proteins are determined in the urine - albumins, a-, (3- and y-globulins).

Bacteriuria - the presence of bacteria in the urine;

Hemoglobinuria - the presence of free hemoglobin in the urine (blood diseases, incompatible blood during hemotransfusions, septic abortions, poisoning with carbolic acid, aniline, bertolet salt);

Pneumaturia - excretion of gas with urine during urination (intestinal-urinary fistulas, emphysematous cystitis);

Cylindruria - detection in the urine of cylinders formed in the kidneys as a result of protein coagulation in the tubules. The cylinders are casts of the renal tubules. They are formed when the epithelium of the tubules is damaged and consist of coagulated protein and dead cells. Different types of cylinders are formed by the deposition of various components of urine, such as erythrocytes, leukocytes, epithelial cells, pigments, etc., on the protein cast of the cylinder. Allocate: Hyaline cylinders - can be observed in healthy people. Their number increases with physical activity, proteinuria.

Granular cylinders - are formed during the advanced disintegration of adherent cells, in which a granular structure of cylinders is formed. With the further development of the process of cell degeneration and with their longer stay in the tubules, waxy cylinders are formed (with chronic renal failure, polyuria after acute renal failure).

Hypostenuria occurs when the ability of the kidneys to concentrate urine decreases. It is characterized by a decrease in the relative density of urine to 1012-1006, and changes in this density during the day are insignificant. The combination of hypostenuria with polyuria indicates damage to the tubules with relatively sufficient glomerular function. If hypostenuria occurs against the background of oliguria, then this is a sign of damage to all structures of the nephrons (tubules and glomeruli).

With a complete loss of the ability of the kidneys to concentrate and dilute urine, isostenuria develops, in which the relative density of urine is equal to the density of the filtrate, i.e. 1010, and does not change throughout the day

–  –  –

(monotonous diuresis). Isosthenuria is a sign of a very severe disorder in which the renal tubules essentially become normal tubes carrying filtrate into the renal pelvis.

Otki. Pathogenetically, three types of edema are distinguished that develop with different kidney lesions.

1. Edema in acute and chronic kidney failure. The main mechanism of their development is hydrostatic (hypervolemic). A decrease in glomerular filtration rate, characteristic of renal failure, leads to sodium and water retention in the body (positive water balance) and, as a result, to hypervolemia. The latter, being the cause of an increase in hydrostatic pressure in the capillaries, causes the development of edema by the Starling mechanism.

2. Nephrotic edema. The main mechanism of their development is oncotic (hypoproteinemic).

Glomerular filter disorders in nephrosis cause massive proteinuria, resulting in hypoproteinemia and a drop in oncotic blood pressure. This, in turn, by the Starling mechanism causes the transfer of water from the vessels into the tissues - edema develops.

3. Nephritic edema. Develop in acute and chronic glomerulonephritis. The pathogenesis of these edema is complex and includes the following mechanisms:

a) inflammation of the glomeruli of stagnant blood in the vessels of the kidneys hypoxia of the juxtaglomerular apparatus activation of the renin-angiotensin system secretion of aldosterone sodium retention in the body and an increase in blood osmotic pressure secretion of antidiuretic hormone water retention hypervolemia edema;

b) inflammation of the glomeruli; violations of the renal circulation; a decrease in the glomerular filtration rate; retention of sodium and water in the body; hypervolemia; edema;

c) inflammation of the glomeruli, an increase in the permeability of the renal filter, proteinuria, hypoproteinemia, and edema.

Urination disorders Acute urinary retention (AUR). This is a sudden absence of urination with a full bladder and painful urge. The causes of AUR can be benign prostatic hyperplasia (adenoma), prostate cancer, acute prostatitis, sclerosis of the bladder neck, foreign body of the urethra, stone and rupture of the urethra, neoplasm of the lower urinary tract. Less often, the causes of AUR can be diseases and damage to the central nervous system (tumor, trauma, etc.). AUR of a reflex nature often occurs after surgery, especially in elderly and senile men and children. Often

Chapter ". General clinical research methods

the occurrence of AUR in older men, preceded by the use of atropine or M2 - M3 cholinomimetics. In this case, OZM is a consequence of a decrease in detrusor tone, more often with an already existing urological disease, for example, with benign prostatic hyperplasia (adenoma).

Clinical picture of OZM. The patient is worried, experiencing severe pain in the suprapubic region, painful urge to urinate, a feeling of fullness in the lower abdomen. When examining the abdomen, you can find an ovoid bulge between the womb and the navel with acute urinary retention or paradoxical ischuria. This is nothing more than a significantly overflowing bladder with urine, the so-called bladder ball (globus vesicalis).

Palpable formation has a smooth surface, elastic consistency. Palpation in acute urinary retention increases pain and causes painful urge to urinate. With paradoxical ischuria, there is less palpation soreness. The lower pole of the formation goes posterior to the pubic symphysis, the upper one often reaches the navel. With a significant filling of the bladder, its upper pole can be given small pendulum-like movements by hand, the lower pole remains motionless. Quite often in the area of ​​"protrusion" fluctuation can be detected. Percussion above the formation is determined by a dull sound. After emptying the bladder with a catheter, the palpable formation disappears.

Diagnosis is primarily based on anamnesis data, examination of the patient. When questioning, it is important to pay attention to how the patient urinated before OZM, what color the urine was, whether he took any drugs that promote urinary retention. It is necessary to clarify all the points that could lead to this state. Knowledge of the causes and pathogenesis of AUR will help to develop the most correct solution in each case.

Differential diagnosis. It is very important to differentiate AUR from anuria. With AUR, the patient is disturbed by the painful urge to urinate, and with anuria they are absent, palpation of the suprapubic region does not cause sharp pain, since the bladder is empty. We must not forget about such a form of urinary retention as "paradoxical ischuria", in which the bladder is full, the patient cannot empty the bladder on his own, but urine is involuntarily excreted in drops. If such a patient passes urine with a urethral catheter, the leakage of urine stops for a while (until the bladder is full again).

Treatment. Urgent action is the urgent emptying of the bladder. At the prehospital stage, this can be done by catheterization of the bladder with an elastic catheter. If AUR lasts more than a day, it is advisable to leave the catheter in the urinary tract with the appointment of prophylactic antibiotic therapy.

Contraindications to bladder catheterization are: acute urethritis and epididymitis (orchitis), acute prostatitis and / or prostate abscess, trauma to the urethra. If at least one of the listed factors is present, it is necessary to resort to the installation of suprapubic bladder drainage (trocar epicystostomy or sectio alta). The issue of hospitalization of the patient each time is decided individually. If there were difficulties in the first catheterization, signs of urethrorrhagia, acute inflammation of the urethra, organs of the scrotum and prostate gland, trauma to the urethra, impossibility of passing a catheter (more than two attempts are unacceptable), urgent hospitalization in the urological department is indicated. In the case of AUR after the administration of medications or reflex nature, treatment can be outpatient. Pre-hospital use of a metal catheter should be avoided. Epicystostomy is performed only in a urological or surgical hospital.

–  –  –

1. Arenal anuria (renoprival) - with congenital aplasia (agenesis) of both kidneys, with accidental or deliberate removal of both (or the only functioning) kidney.

2. Prerenal anuria - prerenal disorders of renal functions caused by circulatory disorders in the kidneys are called prerenal.

Mechanisms of its development:

a) decrease in cardiac output (cardiogenic shock, heart attack);

b) systemic vasodilation (sepsis, neurogenic shock);

c) hypovolemia and a sharp decrease in the volume of circulating blood (blood loss, plasma loss (with extensive burns), dehydration (with vomiting, diarrhea, forced diuresis), the appearance of a "third space" (with sequestration of fluid into the abdominal cavity - ascites, into the subcutaneous tissue - edema and other reasons).The intensity of renal blood flow is normally very high (about 1300 ml / min, or 25% of the minute volume of blood at rest), which is due to its specific function, i.e. participation in the implementation of filtration and reabsorption. Since So, with acute renal failure, GFR rapidly decreases from 100–140 to 10–1 ml/min.

The initial stage of CNP is characterized by a drop in GFR from 100-140 to 30 ml / min, for early polyuric - from 30 to 10 ml / min, for late oliguric - from 10 to 5 ml / min, for terminal - below 5 ml / min.

Pathogenesis - disorders of general hemodynamics and circulation with a sharp depletion of renal circulation induce afferent vasoconstriction with redistribution (shunting) of renal blood flow, ischemia of the cortical layer and a decrease in glomerular filtration rate in the kidney. With aggravation of renal ischemia, prerenal anuria can turn into renal due to ischemic necrosis of the epithelium of the renal convoluted tubules.

3. Renal anuria - in most cases caused by acute tubular necrosis, the causes of which can most often be:

a) renal ischemia (with prolonged clamping of the renal artery, with thrombosis and thromboembolism of the renal vessels - intravascular block, hypoperfusion of the kidneys - as a result of prolonged arterial hypotension (prerenal factor).

b) nephrotoxic factors: iodine-containing radiopaque agents in angiography, salts of heavy metals (lead, mercury, copper, barium, arsenic, gold), antibiotics (aminoglycosides, amphotericin B), organic solvents (glycols, dichloroethane, carbon tetrachloride), uricuric crises ( intrarenal tubular occlusion with uric acid crystals - for gout, chemotherapy for myelo- and lymphocytic leukemia, in the treatment of sulfonamides), etc.

–  –  –

c) other causes of renal anuria - acute and chronic terminal renal failure due to glomerulonephritis, malignant arterial hypertension, hemorrhagic fever with renal syndrome, etc.

4. Postrenal anuria - an acute violation of the outflow of urine from the kidneys to the bladder. This is the so-called acute supravesical urinary retention resulting from occlusion of the upper urinary tract on both sides. In the case of a single or only functioning kidney, this form of anuria occurs as a result of obstruction of its ureter. The most common cause of postrenal anuria is urolithiasis, predominantly in the form of ureteral stones. This circumstance served as the basis for calling this form of anuria obstructive or excretory, while the prerenal and renal forms were called secretory.

Other causes leading to postrenal anuria include external compression of the urinary tract in retroperitoneal fibrosis, cancer of the uterus, ovaries, and others.

clinical picture. Early symptoms of anuria are always associated with its cause: disease or exacerbation of chronic lesions of the cardiovascular system, trauma, accidental or suicidal ingestion of unknown or clearly dangerous drugs or substances, exacerbation of already known chronic diseases - urolithiasis, gout, diseases of the pelvic organs etc.

Among the signs of the clinical course of anuria are:

- violation of water-electrolyte metabolism

- violation of the acid-base state

– damage to the central nervous system (uremic intoxication)

- increasing azotemia

- damage to the lungs

- acute bacterial and non-bacterial inflammation of organs.

One of the most dangerous manifestations of a violation of water-electrolyte metabolism is hyperkalemia - an increase in the concentration of potassium in the serum to a level of more than 5.5 meq / l, which is observed during hypercatabolic processes, when the accumulation of potassium is not only a consequence of blockade of renal excretion, but also a consequence of its intake from necrotic muscles, hemolyzed erythrocytes. In this case, life-threatening hyperkalemia (more than 7 mEq/l) may develop on the first day of illness. Metabolic hyperchloremic acidosis occurs in most cases as a result of a decrease in blood bicarbonate levels to 13-15 mol / l. With severe violations of the acid-base state, there is a "big noisy" Kussmaul breathing and other signs of CNS damage. Azotemia is a cardinal sign of anuria, and its severity reflects the severity of its course.

With severe overhydration, uremic pulmonary edema develops, manifested by progressive respiratory failure.

Diagnostics. The main thing in the success of the elimination of anuria is early diagnosis, and although this is a condition for almost all emergency conditions, in this case it determines - emergency hospitalization in the specialized department of the hospital, an urgent need for hemodialysis (ethylene glycol, heavy metals) and much more, which helps prevent destructive processes in the kidneys, severe suffering of the patient and often - to save his life.

At the slightest suspicion of anuria, hospitalization should be mandatory. This suspicion arises after

Chapter ". General clinical research methods

collected anamnesis; pronounced acidosis with a high anion deficiency develops as a result of a violation of the excretion of sulfates and phosphates by the kidneys, as well as due to ketoacidotic (diabetic and alcoholic) coma, intoxication with alcohol surrogates (methanol, ethylene glycol), in shock, carbon monoxide poisoning, etc., and in in any case - determining the presence of urine in the bladder. This is important in all cases, but especially when the patient's consciousness is "confused", the memory is "clouded", the explanation of relatives is not clear, etc. For differential diagnosis with acute urinary retention, bladder catheterization is performed.

To resolve the issue of the form of anuria, it is necessary to find out whether there was an impact of nephrotoxic factors;

you need to know about the presence of diseases leading to anuria (urolithiasis, prostate disease, gynecological diseases, heart disease, etc.), whether there have been episodes of renal colic. When examining a patient, it is necessary to pay attention to the presence of free fluid and the presence of massive edema, to measure blood pressure (at blood pressure levels below 70 mm Hg, prerenal anuria may develop). Auscultation may reveal the presence of moist rales of various sizes over the entire surface of the lungs, if there is uremic pulmonary edema, radiologically characterized by multiple cloud-like infiltrates in both lungs, a butterfly symptom. The leading role in the detection of hyperkalemia and control of potassium levels belongs to biochemical monitoring and ECG. Electrocardiography reveals hyperkalemia by high, narrow, pointed positive T waves, a gradual shortening of the electrical systole of the ventricles - the Q-T interval, with a possible slowing of atrioventricular and intraventricular conduction and a tendency to sinus bradycardia.

Treatment. With the diagnosis of anuria, the success of treatment is in emergency hospitalization. However, in the case of its prerenal form, which occurs as a consequence of cardiogenic shock or collapse, it is necessary to control cardiac activity, peripheral vascular tone in order to stabilize blood pressure. In the case of postrenal anuria, emergency hospitalization in a urological clinic is indicated, and in case of renal anuria due to poisoning, it is possible before that an emergency gastric lavage through a probe or a "restaurant" method, as well as the introduction of antidotes with a precisely established toxic substance. Physical methods of examination of patients, along with laboratory methods, remain leading in clinical medicine

EXAMINATION METHODS IN UROLOGY.

1. General clinical (physical)

2. Laboratory

3. Special.

1. General clinical (physical) methods of examination: examination, palpation, percussion, auscultation.

Physical examination methods, along with laboratory ones, remain leading in clinical medicine and urology in particular.

–  –  –

Before palpation of the kidneys, a visual examination of the patient should be made: determine the condition of the skin (hyperemia, abrasions, postoperative scars, e turgor and other changes), pay attention to the condition of the spine (scoliosis), muscle development, etc. Only after that, palpation of the organs of the abdominal wall is carried out. It should be carried out with warm hands with short-cut nails. On palpation of the anterior abdominal wall and lumbar regions, the degree of muscle tension and their soreness are determined. Reflex muscle tension can be observed with renal colic, and sharp pain in the costolumbar angle and muscle tension in the lumbar region and the corresponding hypochondrium are characteristic of acute pyelonephritis. In healthy people, with proper palpation, it is far from always possible to feel the kidney: in obese people, it is almost impossible to palpate a healthy kidney, and in thin, asthenic people, the kidney can always be palpated. Palpation of the kidneys must be performed in three positions of the patient: on the back, on the side and standing. Palpation provides invaluable services in the study of patients with surgical diseases of the kidneys (cancer, abscess, cyst, etc.), since in the latter the kidneys are very often enlarged. In addition, palpation plays a major role in recognizing kidney displacements. The best position for the patient during palpation of the kidneys is lying down, since this achieves the relaxation of the abdominal muscles necessary for successful palpation. When palpating the kidneys in the supine position, the patient lies on his back with his legs outstretched and his head resting on a low pillow, making deep, even breathing movements with his stomach. Palpation is done bimanually. The doctor is located to the right of the patient (palpation method according to J. Petit, N. D. Strazhesko and S. P. Fedorov), puts the palm of his left hand under the corresponding half of the lower back. If the right kidney is palpated, then the palm of the left hand is located so that its proximal part is located at the right contour of the patient's waist, and the ends of the outstretched fingers reach the spine. If the left kidney is palpated, then the palm placed on the right side moves further to the left until its proximal part is to the left of the spine, and the ends of the fingers cover the left waist contour. The doctor places the palm of the right hand with slightly bent ends of 2-5 fingers on the outer part of the corresponding hypochondrium. Since the long axis of the kidney is directed somewhat obliquely from top to bottom and out, according to Obraztsov's method, the direction of the line formed by the ends of the folded fingers of the right hand should be the same. Following, further, the patient's breathing and taking advantage of the relaxation of the abdominal muscles with each exhalation, the examiner plunges the fingers of the right palm deeper and deeper, at the same time giving the lumbar region with the left palm towards the palpating fingers. This is done until there is a feeling of contact between both hands through the abdominal integument and the layer of the lumbar muscles. After that, the patient is offered to take a deep “breathe in the stomach”. If the kidney is enlarged or

Chapter ". General clinical research methods

is displaced so much that when it is lowered at the moment of inhalation, the lower pole reaches the point of contact of both hands of the examiner, then the fingers of the right hand receive a clear palpation sensation from this pole. Pressing the palpable pole of the kidney with the right hand through the abdominal integument to the left hand lying on the lower back, slide the fingers of the right palm, continuing to press the kidney, down its front surface and bypassing its lower pole.

This gives an idea of ​​the following physical properties of the palpable part of the kidney: 1) its shape,

2) size, 3), thickness of the lower pole, 4) nature of the anterior surface of the kidney, 5) consistency, 6) mobility, and 7) palpatory tenderness of the kidney. If the kidney is greatly enlarged, then it is possible to palpate most of its anterior surface. With a significant omission of the kidney, it is possible to bypass its upper pole with palpating fingers.

G. Marion (1931) proposed to palpate the kidneys both on the left and on the right side of the patient, which created certain difficulties, and often the inability to change sides.

More often, when palpating the left kidney, the doctor remains on the right side of the patient, brings the right hand on the left side of the patient under the left costovertebral angle so that the kidney can be advanced with it, and the left hand lies in front on the left hypochondrium and palpates with it.

Simultaneously with palpation of the kidney in the position of the patient on the back, palpation of the kidney on the side (according to Israel) should be carried out. With such palpation, the patient lies on a healthy side, the leg on the side of the lesion is slightly bent at the knee and hip joints. In this position, the enlarged or lowered kidney, as it were, leaves its bed and becomes available for palpation. In this case, the intestine is shifted in the opposite direction and does not interfere

–  –  –

When examining the left kidney, the patient lies on the right side, when examining the right kidney - on the left side.

Having felt the kidney between the two hands, the bent fingers of the left hand lying on the lower back are applied jerky blows to the lumbar region. With each push, the kidney approaches the palm of the right hand lying on the hypochondrium, hits the fingers and again moves backward. This ability to run is very characteristic of the kidney, unless it is excessively enlarged and fixed by inflammatory adhesions. This method was suggested by the French urologist Guyon. The gallbladder, spleen and curvature of the colon do not have this ability.

However, to recognize the prolapse of the kidneys, one should palpate both in the supine and in the standing position, when the kidney is slightly displaced downward and anteriorly, both due to gravity and due to the lower standing of the dome of the diaphragm. In order for the abdominal muscles to relax somewhat even in the standing position of the patient, he should be asked to lean forward a little. The method of palpation of the kidneys in a standing position was proposed by S.P. Botkin. The position of the hands of the doctor and the technique are similar, only the position of the patient changes: he stands facing the doctor, who sits directly in front of the patient.

When palpation of mobile kidneys, you can use the Glenar technique. At the same time, with the left hand, we cover the right flank, placing the thumb under the costal arch, and the rest in the lumbar region. Squeezing the hand, as if we are displacing the kidney inside, while it is better palpated with the right hand.

–  –  –

more comfortable than the position strictly on the side.

Perk with with and I have a certain value in the study of palpation detected education.

The intestine is located anterior to the enlarged kidney, in connection with this, with percussion of the abdominal wall, it is possible to determine a zone of tympanitis above the kidney. When a palpable organ or tumor is located in the abdominal cavity, a dull sound is noted percussion over the formation. However, with a significant increase in the size of the kidney (advanced cancer, giant cyst), a dull percussion sound is often observed above the kidney, because the latter in these cases comes into close contact with the abdominal wall, pushing the intestine to the side.

Soreness when tapping the lumbar region is noted in many diseases of the kidneys and retroperitoneal space. In domestic literature, this symptom was named after the author - F.I. Pasternatsky. He noted that in renal pathology, pain occurs when tapping in the kidney area, followed by a short-term appearance or increase in erythrocyturia. At present, the symptom has been somewhat modified, evaluating only its first part (the onset of pain), the second part of the symptom (the appearance of erythrocyturia) has less diagnostic value. Pasternatsky's symptom is determined in the patient's standing or sitting position by applying short, gentle blows with the edge of the palm (lateral surface of the hand) in the lumbar region below the XII rib alternately on each side. Some clinicians prefer to apply light blows with the fist of the right hand to the left hand, attached to the corresponding side of the lower back. When pain occurs, the symptom is considered positive, which is explained by concussion of the affected kidney or paranephron.

In foreign (primarily American) literature, the pain that occurs when tapping the area of ​​the costovertebral angle (similar to Pasternatsky) is described as Murphy's symptom. A slight systolic murmur, which is most clearly heard in the right or left upper quadrant of the abdomen and behind in the area of ​​the costovertebral angle on one side or the other, indicates the possibility of renal artery stenosis. With an arteriovenous fistula in the kidney and with atheromatous lesions of the abdominal aorta, the systolic murmur is coarse and prolonged.

With fibrous or fibromuscular stenosis of the renal artery in the upper abdomen, a prolonged high-frequency murmur with late systolic amplification is often determined.

Ureters There are three ureteral points (Fig.). The upper ureteric point is located 3 transverse fingers outward (to the right or left) from the navel. The middle ureteral point (Tournay point) is located on a horizontal line connecting both anterior superior iliac spines, at the point of intersection with a vertical line passing at the junction of the inner and two outer thirds of the pupart ligament. The lower ureteral point is located in the small pelvis and is available for palpation during vaginal or rectal examination (if there is a calculus in this section of the ureter). The ureteral points indicate its trajectory. At these points, as well as along the ureter, it is possible to determine the areas ____________________ _________________________________________________________________________

Chapter 2. General clinical methods Pain in urolithiasis, tuberculosis of the ureter and some other diseases of the ureter was studied.

Only the classics of urology - S.P. Fedorov, B.N. Holtsov, R.M.

Fronshtein, N. A. Lopatkin. (cited by M.I. Davidov, 2003) Palpation of the juxtavesical ureter during bimanual examination through the vagina in women is quite accessible to any doctor in two pathological conditions: first, with stones in this ureter; secondly, with tuberculous ureteritis and periureteritis, when the ureter is palpated in the form of a rigid, thick cord. In men, even in these situations, with a bimanual rectal examination, palpation of the juxtavesical ureter is practically impossible due to the higher location of the ureter in relation to the examining finger.

Bladder Empty bladder palpation is not available and is a collapsed bag, "hidden" behind the pubic joint. It becomes available for inspection, palpation and percussion when filled with urine, when it comes out from under the pubic joint, or in its pathological condition (tumors, blood clots).

–  –  –

rectus abdominis. With a malignant tumor of the testicle, in some cases, it is possible to palpate packets of enlarged para-aortic and paracaval lymph nodes (Fig.).

–  –  –

Laboratory methods of examination.

Laboratory examination methods include: examination of the main indicators of peripheral and venous blood:

Complete blood count, with a detailed leukocyte formula, determining the number of reticulocytes, studying the morphology of erythrocytes, platelets;

Biochemical blood profile with quantitative (according to indications) determination of more than 60 indicators and fractions: fractions of blood proteins (globulins, albumins), the study of liver enzymes, liver tests (thymol, sublimate), markers of kidney function, pancreas, glucose levels, markers of inflammation and others

Lipid profile: cholesterol, cholesterol-HDL, cholesterol-LDL, triglycerides;

Urinalysis: carried out in order to exclude quantitative and qualitative changes: Qualitative changes: 1) proteinuria; 2) hematuria; 3) cylindruria; 4) leukocyturia (pyuria). Quantitative changes: 1) oligo- and anuria; 2) polyuria; 3) nocturia; 4) hypo- and isosthenuria.

General urine analysis; urinalysis according to Nechiporenko, Addis - Kakovsky, Amburge.

Urine collection is carried out after a thorough toilet of the external genitalia, so that the discharge from them does not get into the urine. Bedridden patients are preliminarily washed with a weak solution of potassium permanganate or another antiseptic solution, then the perineum is wiped with a dry sterile cotton swab in the direction from the genitals to the anus. When collecting urine from bedridden patients, it is necessary to ensure that the vessel is located above the perineum in order to avoid contamination from the area. Proper collection of urine is needed to obtain a reliable test result.

Urine collection must be performed before various endourethral and endovesical examinations and procedures. After cystoscopy, a urine test can be prescribed no earlier than 5 to 7 days later. Urine should be collected in a dry, clean, well-washed dish from cleaning and disinfecting agents. It is advisable to use a vessel with a wide neck and a lid. If possible, urine should be collected immediately in the dishes in which it will be delivered to the laboratory. If this fails, it is advisable to collect it in a clean container (plate, jar, etc.), where there was no urine before (since pots and vessels form a precipitate of phosphates, which remains even after rinsing and contributes to the decomposition of fresh urine), and then pour the entire portion received into a vessel.

It is best to collect urine in special plastic cups with lids.

When urinating, men should, by completely pulling back the skin fold, release the external opening of the urethra. Women should part the labia and carefully wipe the area of ​​the urethra before urinating with a wet swab.

It is advisable to put a swab in the vagina before collecting the material to prevent leukocytes, bacteria, erythrocytes from entering the urine. Also, do not collect urine during menstruation. Particular attention should be paid to the collection of urine by pregnant women.

A catheter or puncture of the bladder can be used to collect urine only in extreme cases - in newborns, infants, patients with prostate diseases, sometimes for microbiological studies (catheterization increases the desquamation of the cells of the urethra and bladder). It is impossible to take urine for research from a long standing catheter! If urine was taken with a catheter, this is noted in the direction.

Urine collected for analysis can be stored for no more than 1.5 - 2 hours (necessarily in the cold), the use of preservatives is undesirable, but it is allowed if more than 2 hours pass between urination and the study. Prolonged standing leads to a change in physical properties, the multiplication of bacteria and the destruction of elements of the urine sediment. In this case, the pH of the urine will shift to higher values ​​due to the ammonia released into the urine by bacteria. Microorganisms consume glucose, therefore, with glucosuria, negative or low results can be obtained.

Bile pigments are destroyed by daylight. The most acceptable way to store urine is refrigeration (can be stored in the refrigerator, but not brought to freezing). Cooling does not destroy uniforms. EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical elements, but it is possible to influence the results of determining the relative density.

Preservatives are added when collecting daily urine (in the first portion of urine). Thymol is often used as a preservative (several crystals per 100 ml of urine), sometimes toluene (several milliliters of toluene is added to a vessel with urine so that it covers the entire surface of the urine with a thin layer; gives a good bacteriostatic effect, does not interfere with chemical analyzes, but causes slight turbidity), boric acid (3-4 granules per 100 ml of urine, gives a sufficient bacteriostatic effect), glacial acetic acid (5 ml for the entire amount of daily urine).

Dishes with urine are delivered to the laboratory with a direction in which the patient's surname and initials, department, surname of the attending physician, diagnosis, time of urine collection, name of the study to which the material is sent are noted.

For a general urine test, the entire morning portion is collected, which accumulates in the bladder during the night. This reduces the natural daily fluctuations of physicochemical parameters and thus provides them with a clearer connection with the pathogenetic processes occurring in the patient's body.

Nechiporenko method. To determine the amount of formed elements in 1 ml of urine, according to the Nechiporenko method, an average portion of the first morning urine is collected - no more than 15 - 20 ml.

Kakovsky-Addis method. To calculate the formed elements in a daily amount according to the Kakovsky-Addis method, one of the conditions for conducting this study is some restriction of fluid intake during the examination period: the patient should not drink at night and drink less during the day. At the same time, the relative density of urine (1020 - 1025) and its pH (5.5) are standardized, which is very important when judging the number of hyaline cylinders, which are easily dissolved in alkaline and low-concentrated urine with a low relative density and remain longer in acidic and concentrated urine. with high relative density. Urine is collected for 10 - 12 hours. The patient urinates before going to bed (this portion of urine is poured out), notes the time and after 10-12 hours urinates into the prepared dishes. This portion of urine is delivered to the laboratory for analysis. If it is impossible to keep urination for 10 - 12 hours, the patient EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. The general clinical urinates into the prepared dishes in several doses and notes the time of the last urination.

Amburge method. Determination of the amount of formed elements excreted in the urine in 1 min, according to the Ambourger method. When examining this method, the patient limits fluid intake during the day and excludes it at night.

Urine is collected for 3 hours. In the morning, the patient empties the bladder (this urine is discarded), notes the time, and exactly 3 hours later collects urine for examination.

Three glass test. To conduct a three-glass sample, a morning portion of urine is collected. In the morning on an empty stomach, after waking up and thoroughly toileting the external genitalia, the patient begins to urinate into the first vessel, continues into the second, and finishes in the third. The second portion should be predominant in volume. When conducting a three-cup test in men, the last (third) portion of urine is collected after prostate massage. All vessels are prepared in advance, each must indicate the portion number.

Double test. more commonly used in urology in women. Urine during urination is divided into two parts. It is important that the first portion in this case be small in volume. The dishes are also prepared in advance and indicate the number of servings on each vessel.

Collection of daily urine. The patient collects urine for 24 hours, observing the usual drinking regimen (1.5 - 2 liters per day). In the morning at 6-8 o'clock, he empties the bladder and notes the time (this portion of urine is poured out), and then during the day they collect all the urine in a clean, wide-mouthed vessel with a capacity of at least 2 liters, with a tightly closed lid. The last portion is taken exactly at the same time when the collection was started the day before (the start and end times of the collection are noted). If not all urine is sent to the laboratory, then the amount of daily urine is measured with a measuring cylinder, a part is poured into a clean container in which it is delivered to the laboratory, and the volume of daily urine is necessarily indicated.

–  –  –

Total functional tests:

Determination of daily diuresis (night diuresis is normally 1/3, daytime - 2/3) The Zimnitsky test is the simplest and easiest for the patient, but, nevertheless, an approximate way to assess the functional state of the kidneys. It allows you to evaluate the concentration function of the kidneys (i.e. the ability of the kidneys to concentrate and dilute urine).

The essence of the method lies in the fact that the patient during the day collects urine every 3 hours (only 8 servings).

The following indicators are evaluated in the laboratory:

Amount of urine in each of the 3-hour portions Relative gravity of urine in each portion Diurnal diuresis (total amount of urine excreted per day) Diurnal diuresis (urine volume from 6 am to 6 pm (1-4 servings)) Nocturnal diuresis (volume urine from 18 pm to 6 am (5-8 portions)) Indications for the purpose of the analysis: assessment of the functional state of the kidneys;

material for the study: daily urine Preparation for the study, rules for sampling and transportation: the sample is carried out under the conditions of the usual drinking regimen and diet (excessive fluid intake is not allowed). It is necessary to exclude the use of diuretics on the day of the study. Violation of these conditions leads to an artificial increase in the amount of urine separated (polyuria) and a decrease in its relative density, which makes it impossible to correctly interpret the results of the study. For the same reason, the Zimnitsky test is not advisable in patients with diabetes insipidus and diencephalic disorders.

EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical

Urine for research is collected throughout the day (24 hours), including at night. At 6 am the patient empties the bladder, this portion is poured out. Then, starting at 9 am, exactly every 3 hours, the patient collects 8 portions of urine in a dry, clean container. The volume of each collected portion is measured, the urine is mixed and collected in a vacuum tube (tube and holder for urine collection can be obtained from the CMD registry).

On each of the 8 tubes, indicate the portion number, the volume of urine excreted and the time of sampling. If within three hours the patient does not have the urge to urinate, the portion is skipped. Urine collection is completed at 6 am the next day, after which all tubes are delivered to the laboratory.

Important! On the day of the study, you must also measure the daily amount of fluid drunk and in food (this information will be needed by your doctor to interpret the result).

Deadline: 1 day

Reference values ​​and interpretation of results:

1. Amount of urine and relative gravity in each serving. Normally, in an adult, fluctuations in the volume of urine in individual portions range from 40 to 300 ml; fluctuations in the relative density of urine between the maximum and minimum values ​​​​should be at least 0.012-0.016 (for example, from 1008 to 1025 or from 1010 to 1026, etc.). Significant daily fluctuations in the relative density of urine (normally from about 1008 to 1025 and even more) are associated with the preserved ability of the kidneys to either concentrate or dilute urine, depending on the constantly changing needs of the body.

The normal concentration function of the kidneys is characterized by the ability to increase during the day the relative density of urine to maximum values ​​(over 1020), and the normal ability to dilute - the ability to reduce the relative density of urine below the osmotic concentration (osmolarity) of protein-free plasma, equal to 1010–1012. In pathology, both a decrease in the concentration function can occur, as well as a violation of their ability to dilute urine.

Violation of the ability of the kidneys to concentrate urine is manifested by a decrease in the maximum values ​​of the relative density, while in none of the portions of urine during the Zimnitsky test, including at night, the relative density does not exceed 1020 (hypostenuria). At the same time, the ability of the kidneys to dilute urine is preserved for a long time, so the minimum relative density of urine can reach, as in the norm, 1005.

The basis of violations of the concentration ability of the kidneys is a decrease in osmotic pressure in the tissue of the medulla of the kidneys.

The reasons for this are:

A decrease in the number of functioning nephrons in patients with chronic renal failure (CRF), when the kidney loses the ability to create a sufficiently high osmotic concentration in the medulla.

Inflammatory edema of the interstitial tissue of the medulla of the kidneys and thickening of the walls of the collecting ducts (for example, in chronic pyelonephritis, tubulointerstitial nephritis, etc.), which leads to a decrease in reabsorption (reabsorption) of urea and sodium ions and, accordingly, to a decrease in osmotic concentration in the medulla kidneys.

Hemodynamic edema of the interstitial tissue of the kidneys, for example, with congestive circulatory failure.

Reception of osmotic diuretics (concentrated glucose solution, urea, etc.), which increase the speed of movement of the tubular fluid along the nephron and, accordingly, reduce the reabsorption of Na +. This, in turn, leads to disruption of the process of creating a concentration gradient in the medulla of the kidneys.

A decrease in the concentration ability of the kidneys leads to a decrease in the relative density of urine (hypostenuria) and an increase in the amount of urine (polyuria).

EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General Clinical Violation of the ability of the kidneys to dilute In severe kidney damage and progressive renal failure, a decrease in the concentration ability is combined with a violation of the ability of the kidneys to dilute. At the same time, the osmotic concentration of urine approaches the osmotic concentration of protein-free plasma, and the relative density of urine during the day fluctuates within narrow limits (about 1009–1011). In none of the portions of urine, the relative density is not lower than this indicator. This condition is called isosthenuria. Isosthenuria is an earlier sign of renal failure than an increase in creatinine and blood urea, and is possible with their normal content in the blood.

Finally, in some cases of severe renal insufficiency, when the concentration of osmotically active substances in the urine becomes lower than in plasma, a sharp narrowing of the amplitude of diurnal fluctuations in the relative density of urine occurs at an even lower level (1004-1009). Many authors call this condition "hypoisosthenuria", although this term is quite controversial.

It must be remembered that the low density of urine and its small fluctuations during the day may depend on extrarenal factors:

In the presence of edema, fluctuations in density can be reduced. The density of urine in these cases (in the absence of renal failure) is high; hypostenuria is observed only during the period of convergence of edema (in particular, with the use of diuretics).

With long-term observance of a protein-free and salt-free diet, urine density can also remain low during the day.

Low urine density with small fluctuations (1000-1001), with rare rises up to 1003-1004, is observed in diabetes insipidus, due to inhibition of antidiuretic hormone (ADH) secretion and a decrease in water reabsorption in the distal convoluted tubules and in the collecting ducts.

Much less often in the clinic there is an increase in the relative density of urine, detected during the test according to Zimnitsky. The reasons for this increase are: pathological condition, accompanied by a decrease in renal perfusion while maintaining the concentration ability of the kidneys (congestive heart failure, the initial stages of acute glomerulonephritis), etc.; diseases and syndromes accompanied by severe proteinuria (nephrotic syndrome); hypovolemic conditions; diabetes mellitus with severe glucosuria;

toxicosis of pregnant women.

Folgard's test - a test for concentration (dry food) and dilution.

The test is not physiological, urine collection after 4 hours, as in the Zimnitsky test.

The test allows the detection of functional renal reserve.

Reberg-Tareev test - determination of kidney function. The glomerular filtration rate (GFR) is the volume of blood plasma that is filtered into the renal tubules per unit of time.

GFR is determined by inulin clearance.

Inulin clearance is the volume of plasma that is completely cleared of this substance by the kidneys in 1 minute:

where Cin is the clearance of inulin; f/in is the concentration of inulin in the urine; An ~ concentration of inulin in plasma; V - diuresis in 1 min.

Normally, Cin and, consequently, GFR are 100-140 ml/min.

A decrease in GFR based on endogenous creatinine is the main indicator of the development of kidney failure. Allows you to determine the degree of involvement in the pathological process of the glomeruli and tubules of the nephron. Glomerular filtration is normally 100 - 120 ml per 1 minute, tubular reabsorption

– 97 – 99 %.

Since GFR \u003d EFTs-Kf, where EFD is the effective filtration pressure; K, |, - filtration coefficient, then two groups of mechanisms of glomerular filtration disorders can be distinguished.

I. EPD reduction. Since EFD \u003d Pk - (P0 + Pt), where Pk is the hydrostatic pressure in the glomerular capillaries; P0 - oncotic blood pressure; RT - EXAMINATION OF A UROLOGICAL PATIENT Chapter 2.

General clinical hydrostatic pressure in the glomerular capsule - the so-called tissue pressure, then a decrease in GFR may be due to:

1) a decrease in hydrostatic pressure in the glomerular capillaries (Pk) due to general and local circulatory disorders (see question 32.8);

2) an increase in oncotic blood pressure (P0), which happens, for example, during dehydration;

3) an increase in tissue pressure in the kidneys (Pt). The reason for this is the obstruction of the outflow of filtrate or urine in case of damage to the tubules (blockage of the tubules by necrotic masses and cylinders), with interstitial inflammation (compression of the tubules by edematous fluid), with violations of the patency of the ureters and urinary tract (stones, strictures, tumor compression).

P. Reducing the filtration coefficient (Kf).

It may be due to:

1) a decrease in the total filtration area, which, in turn, depends on the number of active nephrons;

2) a decrease in the permeability of the glomerular filter wall, which is observed with thickening of the membrane (for example, with diabetic nephropathy), sclerosis of the glomeruli (a consequence of glomerulonephritis), clogging of the filter pores with proteins (hemoglobin, myoglobin, respectively, during hemolysis of erythrocytes and crushing of muscle tissue).

–  –  –

Andrological studies: microbiological examination of semen; functional tests, as well as hormonal studies:

Full spectrum of blood hormones: FSH, LH, estradiol, progesterone, prolactin, testosterone, DHA-sulfate, DHA, thyroid hormones, cortisol, 17-hydroxyprogesterone, -CG;

Hormonal studies of urine: 17-KS, 17-OKS.

Diagnosis of all types of infections: PCR diagnostics of infections with the study of smears, blood, urine, saliva, semen: chlamydia, mycoplasma, ureaplasma, gardnerella, gonococcus, Trichomonas, cytomegalovirus, herpes simplex virus, Epstein-Barr virus, human papillomavirus with serotyping, streptococci, lactobacilli;

Blood tumor markers: Blood test for Ca - 125, PSA free and total, phosphatase (acid and alkaline) Bacteriological examination of blood, urine, semen with the isolation of a pathogenic agent and determination of sensitivity to antibacterial drugs.

3. Special examination methods.

These include x-ray, radiological, ultrasound, instrumental, rheological, urodynamic, endoscopic studies.

–  –  –

Radiological research methods are leading in the diagnosis of urological diseases. X-ray examination of the kidneys and urinary tract includes a survey radiography EXAMINATION OF A UROLOGICAL PATIENT Chapter 2.

General clinical of the abdominal cavity, when a picture is simply taken, and the study of the urinary tract using contrast agents (intravenous excretory urography). This allows you to get an image of the kidneys and urinary tract on x-rays. The diagnostic capabilities of survey urography are limited, with a high degree of probability, staghorn stones of the pelvis are detected with it, and stones in the ureters are less accurate. The method also allows you to roughly judge the location and size of the kidneys and their changes (omission of the kidneys, a significant increase in the size of one of the kidneys with hydronephrosis).

Excretory urography in these cases is of paramount importance.

To obtain maximum information when performing excretory urography, V.Yu. Bosin (1989) recommends the following:

1) immediately before the introduction of a contrast agent, completely empty the bladder;

2) if possible, exclude the use of drugs, the effect of which on the state of renal function and urodynamics remains unknown;

4) warmed contrast agent should be injected as fast as possible;

5) take all pictures at the same focal length;

6) radiography to produce at possibly low exposures in the phase of maximum exhalation;

7) the development time of the images of each series must be the same so that there are no differences in contrast.

We consider the optimal time for taking pictures to be 7–10 and 15–20 minutes. In this case, the first shot at the 7-10th minute is performed in a horizontal position, and the next one - in a vertical position. Such an EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. The general clinical mode of performing X-rays allows you to register the phase of tight filling of the pelvicalyceal systems and clearly identify the anatomical and functional features of the kidneys.

The physiological mobility of the kidneys associated with a change in body position depends on the age of the patient and his constitution. On radiographs, the degree of kidney mobility was determined by comparing the amplitude of its displacement with the height of one lumbar vertebra. The method is often decisive in chronic pyelonephritis, kidney tumors, urolithiasis, hydronephrosis. By indirect signs, one can judge about some other diseases of the kidneys, renal vessels and urinary tract. In the last 15-20 years, due to the widespread use of ultrasound, magnetic resonance and computed tomography, intravenous excretory urography has become less common. The main danger during excretory urography is the presence of an allergy to a radiopaque substance in a patient. Therefore, it is very important to warn the doctor referring to the procedure about such phenomena. It is necessary to warn in general about any allergy to medicines. It is impossible to conduct a study during pregnancy, despite the fact that the radiation load during this procedure is low and does not pose a danger to the patient.

–  –  –

The first use of radioactive tracers dates back to 1911 and is associated with the name of György de Hevesy. The clinical use of radiotracers came into practice in the 1950s. Methods are being developed to detect the presence (radiometry), kinetics (radiography), and distribution (scanning) of a radiotracer in the organ under study.

A fundamentally new stage of radioisotope imaging is associated with the development of devices for a wide field of view (scintillation gamma cameras) and the imaging method - scintigraphy. Often, the term "scintigraphy" refers to studies conducted using both a linear scanner and a scintillation gamma camera. This terminological stereotype is associated with the formation of misconceptions about the diagnostic capabilities of the methods.

EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General Clinical Scanning and scintigraphy are different methods of radioisotope imaging. Scintigraphy is significantly superior to scanning in terms of the volume and accuracy of diagnostic information. Modern scintillation cameras are computer scintigraphic complexes that allow obtaining, storing and processing images of an individual organ and the whole body in a wide range of scintigraphic modes: static and dynamic, planar and tomographic. Regardless of the type of image obtained, it always reflects the specific function of the organ under study. Essentially, it is a mapping of functioning tissue. It is in the functional aspect that the fundamental distinguishing feature of scintigraphy from other imaging methods lies. An attempt to look at the results of scintigraphy from anatomical or morphological positions is another false stereotype that affects the expected effectiveness of the method.

The diagnostic orientation of a radioisotope study is determined by the radiopharmaceutical preparation (RP) used. What is RFP? A radiopharmaceutical is a chemical compound with known pharmacological and pharmacokinetic characteristics. It differs from conventional pharmaceuticals not only in radioactivity, but also in another important feature - the amount of the main substance is so small that it does not cause side pharmacological effects (for example, allergic) when introduced into the body.

The specificity of the radiopharmaceutical in relation to certain morphofunctional structures determines its organotropism. Understanding the mechanisms of radionuclide localization serves as the basis for an adequate interpretation of radionuclide studies. The introduction of radiopharmaceuticals is associated with a small dose of radiation, unable to cause any adverse specific effects. In this case, it is customary to talk about the danger of overexposure, but this does not take into account the pace of development of modern radiopharmaceuticals.

EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General Clinical Radiation exposure is determined by the physical characteristics of the radiotracer (half-life) and the amount of radiopharmaceutical administered.

The present day of radionuclide diagnostics is the use of short-lived radionuclides. The most popular of these is technetium-99m (half-life 6 hours). This artificial radionuclide is obtained immediately before the study from special devices (generators) in the form of pertechnetate and is used to prepare various radiopharmaceuticals. The values ​​of radioactivity introduced for a single scintigraphic study, create levels of radiation exposure in the range of 0.5-5% of the allowable dose. It is important to emphasize that the duration of the scintigraphic study, the number of images or tomographic sections obtained no longer affect the “set” radiation dose.

Clinical application. Visualization of the kidneys (dynamic renoscintigraphy) is a simple and accurate method for the simultaneous assessment of the functional and anatomical topographic state of the urinary system. It is based on the registration of the transport of nephrotropic radiopharmaceuticals and the subsequent calculation of parameters that objectify two successive stages. Analysis of the vascular phase (angiophase) is aimed at assessing the symmetry of the passage of the "bolus" through the renal arteries and the relative volumes of blood flowing to each kidney per unit time. Analysis of the parenchymal phase provides a characteristic of the relative function of the kidneys (contribution to the total cleaning capacity) and the time of passage of the radiopharmaceutical through each kidney or its departments.

Clinical interpretation is largely determined by the mechanism of RP elimination.

Two types of radiopharmaceuticals can be used in dynamic visualization methods:

l. glomerulotropic (DTPA derivatives), almost completely filtered by the glomeruli and reflect the state and rate of glomerular filtration;

2. tubulotropic (analogues of hippuran) are secreted by the epithelium. Indications for the study include urological and nephrological pathology, as well as diseases where the kidneys are target organs.

In various clinical situations, both the shape of the curves and their quantitative characteristics can change. However, it should be emphasized that the nature and magnitude of changes are not specific for a particular pathology and primarily reflect the severity of the pathological process. The greatest information content of renoscintigraphy is manifested in the differentiation of unilateral or bilateral kidney damage. The leading sign that determines the side of the lesion is the asymmetry of the amplitude-time characteristics of angionephroscintigrams. The asymmetry of vascular parameters, and above all, the pronounced difference in the time of receipt of radiopharmaceuticals in the renal arteries, is one of the criteria for renal artery stenosis. The symmetry of changes in parenchymal function is more typical, in particular, for glomerulonephritis; asymmetry is a fairly constant sign of pyelonephritis, not only with one, but also with a bilateral process. Similar changes may accompany various types of anomalies of the kidneys and upper urinary tract (nephroptosis, doubling of the collecting system, hydronephrosis).

Rheography

Rheography is a non-invasive method for studying the blood supply to organs, which is based on the principle of registering changes in the electrical resistance of tissues due to changing blood supply. The more blood flow to the tissues, the less their resistance. To obtain a rheogram, an alternating current with a frequency of 50 kHz, low power (no more than 10 μA), created by a special generator, is passed through the patient's body. The principal development of the rheographic technique belongs to N. Mann (1937). In the future, the technique (electroplethysmography, impedance plethysmography) was developed in the EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General clinical works of A. A. Kedrov and T. Yu. Lieberman (1941-1949) and others. with the names of Austrian researchers W. Holzer, K. Polzer and A. Marko. They also own, in essence, the first monograph (Rheocardiographie, Wien, 1946), in which the authors not only highlighted the technical aspects of the method (electrical circuits of the device, alternator options, etc.), but also presented the results of the clinical use of rheography in various diseases of the cardiovascular system. systems. A significant contribution to the development of the rheography method was made by Yu.T. Pushkar, who created the domestic design of the device and changed the method of registering the rheogram (precardial rheocardiography). At present, the clinical significance of the use of the rheography method has been proven.

The fundamental basis of the rheography method is the dependence of resistance changes on changes in blood supply in the studied area of ​​the human body. In other words, pulse oscillations of electrical resistance are studied. Registration of rheograms is carried out with the help of rheographs. The latter consist of the following elements: a high-frequency generator, an impedance-voltage converter, a detector, an amplifier, a calibration device, and a differentiating circuit. With the bipolar technique, 2 electrodes are applied, each of which is simultaneously current and measuring, the electrodes are fixed on the corresponding part of the body. To reduce the contact resistance between the electrode and the skin, the same techniques are used as when recording an ECG.

When using the tetrapolar technique, the study area is limited to a pair of measuring electrodes, and the voltage that has arisen in them is removed using another pair of electrodes located outward with respect to the first (current). The tetrapolar technique is more accurate, because the effect of contact resistance decreases sharply (to a minimum) (there is no need to apply gaskets moistened with salt or alkali solutions, and also use electrode paste) and electrode. This makes it possible to measure the impedance of deep tissues with a high degree of accuracy. Rheograms are recorded in a warm room 1.5-2 hours after a meal or on an empty stomach, in the supine position after a 15-minute rest. Simultaneously with two rheograms (basic and differential). An ECG is recorded in the II standard lead and sometimes FCG at the V point or above the apex in one of the mid-frequency ranges.

It is desirable to register the rheogram while holding the breath with incomplete exhalation. Recording is performed at a speed of movement of the tape drive mechanism of 25-50 mm/s (less often - 100 mm/s).

A rheogram is a curve that reflects pulse fluctuations in electrical resistance. With an increase in blood filling, the amplitude of the curve increases and vice versa, in other words, the dynamics of the impedance in reverse polarity is recorded. On the rheogram (Fig.), systolic and diastolic parts are distinguished. The first is due to blood flow, the second is associated with venous outflow.

Figure. Rheogram is normal

–  –  –

Qualitative analysis takes into account the shape of the curve, the nature of the anacrota and catacrota, the relief of the apex (rounded, pointed, plateau-like, saddle-shaped, etc.), severity and quantity. plateau-shaped, saddle-shaped, etc.), the severity and number of additional waves, their location on the descending knee of the curve, the presence or absence of a presystolic wave.

Quantitative analysis involves the determination of the following indicators (Fig.

1. The amplitude of the systolic wave in mm is measured from the base of the systolic wave to the highest point of the rheogram.

2. The amplitude of the diastolic wave in mm is measured from the base of the diastolic wave to its highest point.

3. The rheographic index (systolic - RSI and diastolic - RDI) is the ratio of the systolic (diastolic) wave to the standard calibration signal (0.1 Ohm \u003d 10 mm), expressed in relative units. This indicator characterizes the magnitude and rate of inflow (outflow) of blood in the study area. The amplitude of the curve is measured from the isoline to the highest point of the wave.

The method is not often used in urology, although its capabilities make it possible to detect functional and organic changes in the kidneys and urinary tract.

UROFLOWMETRY

The method of direct graphic registration of the dynamics of the volumetric flow rate of urine during the act of urination, used to determine the total tone of the contractile activity of the detrusor and the patency of the urethra. The flow rate is recorded on the recording device of the apparatus. Based on the theoretical background and results of clinical studies, uroflowmetry can be considered a method for assessing the functional state of the detrusor and urethra. To more accurately determine the effect of the urethra on the SURVEY OF THE UROLOGICAL PATIENT Chapter 2. General clinical flow of urine, volumetric flow rates should be compared with intravesical pressure.

Literature:

1. A. V. Papayan, N. D. Savenkova "Clinical Pediatric Nephrology", St. Petersburg, SOTIS, 1997

2. L. V. Kozlovskaya and A. Yu. Nikolaev. Textbook on clinical laboratory research methods. Moscow, Medicine, 1985

3. Handbook of clinical laboratory research methods, ed. E. A. Kost. Moscow "Medicine" 1975

4. Guide to practical exercises in clinical laboratory diagnostics. Ed. prof. M. A. Bazarnova, prof.

V. T. Morozova. Kyiv, "Vishcha school", 1988

5. A. Ya. Lyubina, L. P. Il'icheva, et al. "Clinical laboratory research", Moscow., "Medicine", 1984

6. Handbook of functional diagnostics. Under the general editorship of Academician of the Academy of Medical Sciences of the USSR prof. I. A. Kassirsky.

Moscow, "Medicine", 1970

8. A. Ya. Althausen "Clinical laboratory diagnostics", M., Medgiz, 1959

EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical

9. Handbook of clinical laboratory research methods, ed. E. A. Kost. Moscow "Medicine" 1975

10. Handbook "Laboratory research methods in the clinic", ed. prof. V. V. Menshikov Moscow "Medicine" 1987

11. Guidelines for clinical laboratory diagnostics. (Parts 1 - 2) Ed. prof. M. A. Bazarnova, academician of the USSR Academy of Medical Sciences A.

I. Vorobiev. Kyiv, "Vishcha school", 1991

12. Guide to practical exercises in clinical laboratory diagnostics. Ed. prof. M. A. Bazarnova, prof. V. T. Morozova. Kyiv, "Vishcha school", 1988

13. Bondarenko B.B. Kiseleva EI//Epidemiology and course of chronic renal failure. In the book: Chronic renal failure / Edited by S.I. Ryabova.- 1976.- P.34

Lecture 2. urolithiasis.

Urolithiasis is a disease caused by a metabolic disorder, due to various endogenous or exogenous causes, often hereditary, determined by the presence of a stone in the urinary system or the passage of a stone.

ICD is widespread, taking second place after nonspecific infectious and inflammatory diseases of the urinary system.

KSD is detected at any age, but more often than 30-55 years Bilateral urolithiasis is diagnosed in 15-30% of patients.

Lifetime risk of stone formation is up to 10% The disease is more common in men than in women (1:3) There are regions where this disease is particularly common ie.

is endemic. In Russia, these are Transcaucasia, the Urals, the Volga region, the Don and Kama basins EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical In Europe, the countries of Scandinavia, the Netherlands, Italy, southern France and Spain There is no single concept of stone formation.

Urolithiasis is one of the most common urological diseases, occurring in at least 3% of the population. In 2002, in Russia, the incidence of KSD was 535.8 cases per 100,000 population (Lopatkin N.A., Dzeranov N.A., 2003; Beshliev D.A., 2003). The endemicity of Russian regions has been proven not only in terms of frequency, but also in terms of the type of urinary stones formed (for example, stones from uric acid compounds dominate in the Southern regions, and oxalates dominate in the Moscow region) (Lopatkin N.A., Dzeranov N.A., 2003 ). Patients make up 30-40% of the total contingent of urological hospitals. In most patients, KSD is detected at the most able-bodied age of 30-50 years. Classification. 1. According to ICD - 10 No. 20 - Stones of the kidney and ureter No. 21 - Stones of the lower urinary tract No. 22 - Stones of the urinary tract in diseases classified elsewhere

2. By the number of stones:

–  –  –

Etiology. Nephrolithiasis (urolithiasis, nephrolithiasis) is a disease manifested by the deposition of salts in the kidneys. Nephrolithiasis can occur as a result of exposure to single and multiple factors, EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General clinical have exogenous and endogenous origin. Exogenous: nutritional features (consumption of large amounts of protein, alcohol, reduced fluid intake, deficiency of vitamins A and B6, hypervitaminosis D, intake of alkaline mineral waters, etc.); features of the life of a modern person (physical inactivity, profession, climatic, environmental conditions, etc.);

taking medications (vitamin D preparations, calcium preparations;

sulfonamides, triamterene, indinavir, intake of ascorbic acid more than 4 g/day). Endogenous: urinary tract infections; endocrinopathy (hyperparathyroidism, hyperthyroidism, Cushing's syndrome); anatomical changes in the upper and lower urinary tract, leading to a violation of the outflow of urine (nephroptosis, stenosis of the LMS, urethral stricture, etc.); diseases of internal organs (neoplastic processes, metabolic disorders of various origins, chronic renal failure, etc.); genetic factors (cystinuria, Lesch-Nyhan syndrome - a pronounced deficiency of hypoxanthinguanine phosphoribosyltransferase, etc.).

Endogenous etiological factors: urological factors: Local congenital and acquired changes in the urinary tract (strictures);

the only functioning kidney; urinary tract infection.

General factors: a state of deficiency and hyperproduction of a number of enzymes (hyperparathyroidism, gout); disease of the gastrointestinal tract, liver, biliary tract;

bowel resection, small-colonic anastomoses, etc.

Exogenous etiological factors: climate, physical and chemical properties of water and flora, drinking and food regimen of the population; working conditions;

excessive and monotonous consumption with food of a large amount of stone-forming substances affecting the concentration of stone formation protectors, pH, diuresis, etc.; lack of vitamins A and group B.

The chemical composition and microstructure of urinary stones largely depends on the causes of their formation. So, in violation of purine metabolism, urate stones can form, in violation of the metabolism of oxalic acid EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical oxalate; Phosphate stones appear mainly when there is a violation of the phosphate-calcium metabolism and in the presence of a urinary tract infection that causes an alkaline urine reaction. Violation of phosphorus-calcium balance in the body is possible due to several reasons. The main regulatory role in the exchange of calcium and phosphorus is played by the parathyroid glands. With excessive intake of parahormone from the parathyroid glands into the blood (due to adenoma, hyperplasia, etc.), patients develop hypercalcemia, hypophosphatemia, and hypercalciuria.

Violation of the metabolism of oxalic acid plays a role in the occurrence of nephrolithiasis with the formation of oxalate stones or salts. Normally, the daily excretion of oxalic acid in the urine is 30 + 15 mg; in pathological conditions, it can be 200 mg or more. Oxalaturia also develops as a result of increased adsorption of oxalic acid in the gastrointestinal tract, especially when it is consumed in excess with food. The endogenous source of oxalates in humans is glyoxylic acid, which is formed mainly from glycine. An excess of glycine in the body can be in violation of carbohydrate metabolism and other pathological conditions. In the development of nephrolithiasis with the formation of urate stones and urinary salts, the etiological role is played by a violation of purine metabolism.

Uric acid enters the bloodstream from two sources: exogenous - from food protein and endogenous - from purine bases formed during the cleavage of DNA and RNA under conditions of protein catabolism and the treatment of cytoproliferative processes (blood diseases, etc.) Sometimes hyperuricemia is familial and hereditary. In addition, hyperuricemia can occur due to impaired reabsorption of uric acid in nephropathies, toxic effects on the kidneys, etc.

Infectious lesions of the urinary tract is the etiological factor of nephrolithiasis. Chronic pyelonephritis is common. In many patients, it is primary, i.e. precedes the development of nephrolithiasis. When pyelonephritis is disturbed microcirculation, lymph flow EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General clinical of the kidney and urodynamics. Most of the microorganisms that cause pyelonephritis (E. coli, Proteus, Staphylococcus, etc.) decompose urine urea, and the resulting ammonia alkalizes the urine. Due to the products of inflammation (urotemia, erythrocytes, leukocytes, mucus, etc.), hydrophobic colloids accumulate, urine viscosity increases. In an alkaline environment, phosphates easily precipitate, and there is a possibility of developing phosphaturia or the formation of phosphate urinary stones.

A certain etiological relationship exists between nephrolithiasis and certain diseases. So, with abnormalities in the development of the kidneys and urinary tract, stone formation occurs mainly in the presence of urinary stasis, or urostasis, and infection. Tumors of the small pelvis, obstruction of the urinary tract also contributes to urostasis and stone formation.

Under the influence of various combinations of exogenous, endogenous and genetic factors, metabolic disorders occur in biological media, which is accompanied by an increase in the level of stone-forming substances (calcium, uric acid, etc.) in the blood serum. An increase in stone-forming substances in the blood serum leads to an increase in their excretion by the kidneys, as the main organ involved in maintaining homeostasis, and to a supersaturation of urine. In a supersaturated solution, precipitation of salts in the form of crystals is observed, which can subsequently serve as a factor in the formation of microlites first, and then, due to the settling of new crystals, the formation of urinary stones. However, urine is often supersaturated with salts (due to changes in the nature of nutrition, changes in climatic conditions, etc.), but the formation of stones does not occur. The presence of only one supersaturation of urine is not enough for the formation of a calculus. For the development of KSD, other factors are also necessary, such as a violation of the outflow of urine, urinary tract infection, etc. In addition, there are substances in the urine that help maintain salts in dissolved form and prevent their crystallization - citrate, magnesium ions, zinc ions, inorganic pyrophosphate, glycosaminoglycans, EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical nephrocalcin, Tamm-Horsvall protein, etc. Nephrocalcin is an anionic protein that is produced in the proximal renal tubule and the loop of Henle. If its structure is abnormal, it promotes stone formation.

Low citrate levels may be idiopathic or secondary (metabolic acidosis, decreased potassium, thiazide diuretics, decreased magnesium, renal tubular acidosis, diarrhea).

Citrate is freely filtered by the glomeruli of the kidneys and 75% is reabsorbed in the proximal convoluted tubules. Most secondary causes result in decreased urinary citrate excretion due to increased reabsorption in the proximal convoluted tubules. In most patients with urolithiasis, the concentration of these substances in the urine is reduced or absent.

A necessary condition for maintaining salts in a dissolved form is the concentration of hydrogen ions, i.e. urine pH. The normal pH value of urine 5.8 - 6.2 provides a stable colloidal state of urine.

Daily fluctuations in urine pH Urine pH values ​​relevant for different types of urolithiasis

–  –  –

Pathogenesis. Currently, there is no unified theory of the pathogenesis of nephrolithiasis. There are two types of processes determining the factors of formal and causal genesis of stone formation.

1. According to the colloid-crystallization theory, for the formation of a stone, a certain situation is needed in which a high concentration of salts and the presence of hydrophobic colloids in the urine are combined, as well as the corresponding point of crystallization of the existing salts, the pH value of the urine and urostasis. In the absence of urostasis and pathological changes in the colloidal system of urine, the process ends with the formation of free crystals. The beginning of the formation of the primary center of the stone can be both the crystallization of salts and the conglomeration of organic substances; it depends mainly on which of the two environments of the urine (calloidal or saline) is initially more pronounced changes. The growth of stones occurs rhythmically, with alternating processes of salt crystallization and sedimentation of organic matter. The origin of stones can also begin at the level of the tubules, where microliths are found in the form of spheres and other shapes. Currently, a number of substances have been identified that affect the colloidal stability and maintenance of salts in a dissolved state, and vice versa, their absence contributes to the crystallization of salts. In normal urine, these substances are urea, creatinine, hippuronic acid, sodium chloride, citrates, magnesium.

2. According to another theory (Rundell and Carr), the origin of urinary stones can occur on the renal papillae. Carr found microparticles (concretions containing calcium and glycolysoaminoglycans) in the kidney tissue.

In his opinion, there is a constant movement of the formed nodules into the lymphatic system of the kidney. In case of impaired lymphatic drainage due to pyelonephritis, as well as when the kidney is overloaded with calcium salts, etc.

there are conditions for the development of stone formation. The nodules migrate towards the renal papillae, forming plaques on them, which Randell described.

These plaques compress the capillaries of the papillae. On necrotic renal papillae, salts crystallize and stones form.

Etiopathogenetic ways of formation of urinary stones Clinical picture.

Pain syndrome of varying degrees of intensity:

–  –  –

2. Renal colic.

Renal colic is manifested by acute pain in the lumbar region or hypochondrium, radiating along the ureter. Accompanied by nausea, vomiting, flatulence. Possible oliguria.

–  –  –

Instrumental research:

2. Excretory urography (a contrast agent is injected into the vein, which is excreted by the kidneys, and a series of x-rays is taken.

The method allows you to evaluate the entire anatomy of the genitourinary system, to detect stones in all parts of the genitourinary system.)

4. Radioisotope study 5. Dynamic nephroscintigraphy (contrast is injected into a vein and the kidneys are scanned with a special sensor. A very informative study that allows you to evaluate kidney function. Also used to diagnose the so-called "renal pressure".)

–  –  –

Mineralogical classification is used to classify urinary stones. About 60-80% of all urinary stones are inorganic calcium compounds: calcium - oxalate (Weddellite, Wevellite), calcium - phosphate (Whitlockite, brushite, apatite, hydroxyapatite, etc.). Stones composed of uric acid (uric acid dihydrate) and uric acid salts (sodium urate and ammonium urate) occur in 7-15% of cases. Magnesium - containing stones (newberite, struvite) account for 7-10% of all urinary stones and are often combined with infection. Intestinal bacteria (Oxalobacter formingenes) are an important component in maintaining calcium oxalate homeostasis, and their absence may increase the risk of calcium oxalate stone formation. The most rare stones are protein stones - cystine (detected in 1-3% of cases). In most cases, stones have a mixed composition, which is associated with a violation in several metabolic links at once and the addition of an infection.

Urate stones are predominantly composed of uric acid. Their formation may be due to a high concentration of uric acid in the urine or a low urine pH. The concentration of uric acid depends on both the volume of urine and the amount of excretion of uric acid. Two thirds of urates are eliminated through the kidneys. Uric acid excretion is increased in conditions associated with an increase in endogenous urate production or when eating foods rich in purines.

An increase in the endogenous production of urates occurs due to the mutation of enzymes that regulate the synthesis and recycling of purines. Increased hyperexcretion of urates can be observed in neoplastic diseases, but stones do not always occur. The presence of a normal level of urate in the blood serum does not exclude high urinary urate excretion, just as an increase in the concentration of uric acid in the blood does not indicate a high content of urate in the urine - much more often it is secondary in response to a low excretion of uric acid in the urine. Formation of uric acid stones EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical practice is accompanied in some patients by disturbances in purine metabolism in the form of hyperuricemia (6.5 mmol/l) and hyperuricuria (4 mmol/l). Many patients with uric acid stones have normal levels of uric acid in serum and urine. In this case, stones are formed due to low urinary pH, which is associated with a decrease in ammonium production by the kidneys Calcium oxalate urolithiasis. Hyperoxaluria is a major predisposing factor for the formation of calcium oxalate stones.

Hyperoxaluria is associated with enzyme deficiency. "Intestinal" hyperoxaluria is more common and occurs due to excessive absorption of oxalates from the colon. Excessive absorption of oxalate may be due to the binding of calcium to dietary fiber in the intestine, the use of large amounts of plant foods. Ascorbic acid found in fruits and vegetables is converted to oxalate, which leads to increased absorption of oxalate from the intestines. On the other hand, oxalate reduces the absorption and excretion of calcium in the urine due to the formation of a complex compound between calcium and oxalate in the intestinal lumen.

Magnesium reduces the absorption and excretion of oxalate in the urine by forming complexes with oxalate. The combination of calcium urolithiasis and hyperoxaluria is observed in 40-50% of cases. Patients with hypercalciuria in conditions of normocalcemia are referred to as "idiopathic hypercalciuria". "Idiopathic" hypercalciuria is one of the most common causes of recurrent calcium oxalate urolithiasis. Hypercalciuria can be "absorptive" and "renal".

"Absorptive" hypercalciuria is associated with a primary increase in calcium absorption in the small intestine and is considered hereditary. "Renal"

hypercalciuria is associated with a tubular defect, which leads to inadequate reabsorption of calcium in the tubules of the kidneys and is accompanied by excessive compensatory calcium absorption in the gastrointestinal tract. In 5 and 3% of cases, calcium stones are formed due to primary hyperparathyroidism and EXAMINATION OF THE UROLOGICAL PATIENT Chapter 2. General clinical

–  –  –

Cystinuria is a hereditary disorder with an autosomal recessive pattern of inheritance. The basis of cystinuria is a violation of transmembrane transport, leading to impaired absorption in the intestine and resorption in the proximal tubule of dibasic amino acids (cystine, ornithine, lysine, arginine). Cystine urolithiasis is manifested by cystinuria and occurs only in homozygous individuals. Stones can form during childhood, but the incidence peaks in the second and third decades. Cystine is poorly soluble in urine, which leads to its precipitation in the form of crystals.

EXAMINATION OF A UROLOGICAL PATIENT Chapter 2. General clinical treatment of ICD. Treatment of urolithiasis can be operational (remote shock wave lithotripsy, X-ray endourological surgery and "traditional" open surgery), medical and prophylactic. The choice of treatment method is based on the results of a clinical examination of the patient, the chemical structure of the calculus, and the presence of concomitant diseases.

Despite the development of modern methods of treatment, the need for the use of pharmacological drugs remains. Their use reduces the risk of recurrent stone formation by correcting biochemical changes in the blood and urine, and also contributes to the removal of stones up to 0.5 cm in size. In this article, we decided to dwell on the basic principles of drug treatment of patients with KSD. General recommendations include: diet therapy, control of daily fluid intake, exercise therapy, physiotherapy and balneological procedures. The nature of nutrition is one of the main risk factors for the development of urinary stones and, given this, diet therapy, adequate maintenance of water balance, etc., acquire an important role.

Dietary recommendations for urate urolithiasis: exclusion of foods high in purine compounds (which are sources of uric acid formation in the body), such as various meat products (sausages, meat broths, offal), legumes, coffee, chocolate, cocoa. Low urine pH and citrate excretion are associated with high intake of animal protein and alcohol due to metabolic acidosis. Citrate excretion decreases in acidosis due to reabsorption of low pH fluid in the proximal tubule. Eliminating alcohol and reducing protein in a balanced diet results in an increase in pH and excretion of citrate. The patient should be advised. Moreover, consumption of alkali ions (potassium) and organic acids (citrate and lactate) with vegetables and their conversion to bicarbonate explains the further increase in pH and excretion of citrate.

Dietary recommendations for calcium oxalate urolithiasis are to limit the intake of foods high in calcium, ascorbic acid and oxalate. These products include milk and dairy products, cheese, chocolate, green vegetables, black currants, strawberries, strong tea, cocoa. The daily volume of fluid should be at least 2 liters per day. These recommendations are especially important for "absorptive"

hypercalciuria.

The diet for calcium-phosphate urolithiasis provides for limiting the consumption of foods rich in inorganic phosphorus by the patient:

Similar works:

Recommendations Saint-Petersburg MINISTRY OF HEALTH AND SOCIAL DEVELOPMENT OF THE RUSSIAN FEDERATION OF SAN...» OF DISEASES July 11, 2011 with amendments and additions approved by Order No. 50 of 09.02.2012 1. General Provisions, 2. Object of Insurance, 3. St... "of the musculoskeletal system: Scientific book; 2013 Annotation Indian onion is a houseplant familiar to many. The juice of this plant is widely used in non-traditional ... "Medical Sciences Supervisor: Doctor of Medical Sciences, Kucheryavenko Aida Fatikhovna VOLGOGRAD –. .. "and clarifying the diagnosis of lung cancer" in the specialty 14.01.12 - oncology. During the secret ballot, the dissertation council in the amount of 20 people, all doctors of science in... "

« MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS I APPROVE First Deputy Minister R.A. Chasnoit December 18, 2009 Registration No. 106-1009 CLINICAL DIAGNOSTIC ALGORITHM FOR DEMENTIA OF LATE AGE instructions for use INSTITUTIONS-DEVELOPERS: EE "Grodno State Medical University", ME "Grodno..."

« ) Foreword At a young age, I felt addicted to doctors, prescription drugs, emergency rooms, and hospitalizations focused more on symptoms, illnesses and emergencies rather than preventive measures and cures. Life experience pushed me to get a medical education ... "

Dissertations for the degree of candidate me...»

« NORTHERN SCIENTIFIC CENTER SZ RAMS STATE BUDGET EDUCATIONAL INSTITUTION OF HIGHER PROFESSIONAL EDUCATION "NORTHERN STATE MEDICAL UNIVERSITY" OF THE MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION BULLETIN OF THE NORTHERN STATE MEDICAL UNIVERSITY II International Youth...»

« Russian Respiratory Society Federal clinical guidelines for the diagnosis and treatment of bronchial asthma February Table of contents Methodology........ 3 1. Definition, principles of diagnosis in adults and children. 5 2. Diagnosis of asthma in children..... 7 2.1. Diagnosis of asthma in adults....... 10 2.2. Differential diagnosis of AD...»

In the allowance ... "

2017 www.site - "Free electronic library - various materials"

The materials of this site are posted for review, all rights belong to their authors.
If you do not agree that your material is posted on this site, please write to us We will remove it within 1-2 business days.