MINISTRY OF HEALTH OF UZBEKISTAN
DEVELOPMENT CENTRE OF MEDICAL EDUCATION
Tashkent Medical Academy
"Approved"
Prorector for educational proceedings of TMA
Prof. Teshaev O.R.
«_____»_________________ 2012
Department: UROLOGY
Subject: Urology
SUBJECT: Pyelonephritis and its complications
Educational-methodical course book
(For teachers and students of medical institutes)
Tashkent-2012
Compiled by:
Mirkhamidov D.H. - docent of Urology department, TMA
Zakirov H.K. - Assistant of Urology department, TMA
Nuraliyev T.Yu. - Assistant of Urology department, TMA
Reviewers:
Gaybullaev A.A. - Head of the Department of Urology and Nephrology operational
Tashkent Institute of Postgraduate Education, PhD.
Fakirov A.Z. - Docent of Pediatric Surgery, Tashkent Medical Academy,
Candidate of Medical Sciences.
Methodical development approved:
- At a meeting of ICC TMA, protocol № __ "___"_______ of 2012.
- The Academic Council of TMA, protocol № ___ of "___"____ 2012.
Subject: Pyelonephritis and its complications
1. Venue lessons, equipment
- Department of Urology;
- A set of posters, computer slides, tables;
- Computer.
- Visual aids, models, phantoms, patients - visual aids, models, phantoms, the patients, distributing
materials, x-rays.
2. The duration of the study subjects
Number of hours - 40
3. Session Purpose:
Form a general idea on how to diagnose urological disorders.
To teach students to diagnose and identify the main symptoms of diseases of the genitourinary system.
Objectives:
The student should know:
1. Collect complaints, patient medical history.
2. Quantitative and qualitative changes in the urine.
3. Methods of investigation of patients with various forms of disturbances of urination.
4. Normal values for total urine sample and the sample Nechiporenko.
5. Biochemical parameters of blood, indicating a state of total renal function: normal levels of blood
urea and creatinine.
6. Methods of ultrasound of the kidneys, bladder, prostate.
7. Methods of functional renal study (survey and excretory urography in the descending and miction
urethrography).
The student should be able to:
1. Properly gather history, highlight features inherent violation of urination.
2. Properly inspect the patient, palpation and percussion of kidneys and bladder;
3. Make an objective examination of the patient, examine the external genitalia.
4. Perform digital rectal examination of prostate cancer.
5. Interpret laboratory data, tool, x-ray, ultrasound and the results of computer and magnetic resonance
imaging.
4. Motivation
Acquired knowledge in diagnosis of urological diseases will allow general practitioners to correctly
diagnose urological diseases, acute conditions to identify and assign an effective treatment.
5. Interdisciplinary communication and inside subject connections
Teaching this topic is based on the knowledge bases of students of biochemistry, microbiology, normal
physiology.
Obtained during the course knowledge can be used in the work of GPD and medical related specialty.
Without knowledge of key issues diagnosis of urological diseases can not be given qualified support to
the patient with urological pathology, especially in emergency cases and the appearance of
complications.
6. The content of lessons
6.1. Theoretical part
Pyelonephritis and its complications
Acute uncomplicated pyelonephritis
Description.
Acute pyelonephritis – A clinical diagnosis based on the presence of fever, flank pain, and
tenderness, often with an elevated white count. It may affect one or both kidneys. There are usually
accompanying symptoms suggestive of a lower UTI (frequency, urgency, suprapubic pain, urethral
burning or pain on voiding) responsible for the ascending infection which resulted in the subsequent
acute pyelonephritis. Nausea and vomiting are common.
Diagnosis. Clinical manifestations.
Specific complaints are: temperature is 38,5-40С, sometimes with fever, pain is in waist (in one
or two directions), sometimes rapid diuresis is common. During palpation one can establish pain in
costo-lumbar angle.
Laboratory findings.
In blood test the leukocytosis, high ESR is common. Urine tests shows high leukocytosis, in 1ml
of urine one can establish more than 100000 microbes. After 2-3 days of the beginning of the disease
can the cilindres can be found. If the leukocyturia and bacteruria are found the urine must be placed on
sterile cup and be placed on refrigerator (+4 - +6 degrees by celcium, duration 8 hours ) and saved for
biological laboratory
Methods of instrumental examination.
Urine specimens must be cultured promptly within 2 hours or be preserved by refrigeration or a
suitable chemical additive (e.g., boric acid sodium formate preservative). Acceptable methods of
collection are:
Midstream urine voided into a sterile container after careful washing (water or saline) of external
genitalia (any soap must be rinsed away)
Urine obtained by single catheterization or suprapubic needle aspirationof the bladder
Sterile needle aspiration of urine from the tube of a closed catheter drainage system (do not
disconnect tubing to get specimen)
.
Differential diagnosis.
1. Torsion of the testicle is the main differential diagnosis. A preceding history of symptoms
suggestive of urethritis or urinary infection (burning when passing urine, frequency, urgency, and
suprapubic pain) suggest that epididymitis is the cause of the scrotal pain, but these symptoms may
not always be present in epididymitis. In epididymitis pain, tenderness and swelling may be
confined to the epididymis, whereas in torsion, the pain and swelling are localized to the testis.
However, there may be overlap in these physical signs.
2. Where doubt exist where you are unsure whether you are dealing with a torsion or epididymitis
exploration is the safest option. Though radionuclide scanning can differentiate between a torsion
and epididymitis, this is not available in many hospitals. Colour doppler ultrasonography, which
provides a visual image of blood flow, can differentiate between a torsion and epididymitis, but its
sensitivity for diagnosing torsion is only 80% (i.e. it misses the diagnosis in as many as 20% of
cases these 20% have torsion but normal findings on doppler ultrasonography of the testis). Its
sensitivity for diagnosing epididymitis is about 70%. Again, if in doubt, explore.
Treatment
The occurrence of flank pain, chills and fever, and nausea and vomiting with or without dysuria
suggests acute bacterial pyelonephritis. In this clinical setting, blood cultures and quantitative cultures
of urine should be obtained. Whether ambulatory patients should be admitted to the hospital for
treatment depends in part on a subjective assessment of toxicity, likely compliance with therapy, and
the home situation. When the assessment is doubtful, the patient should be treated in the hospital, at
least until a clear response to therapy has occurred. This policy also applies to patients with known
underlying uropathies, because complications are more common in these patients.
Tactics.
After 48 hours from first conservative treatment patients if doesn’t feel good must be administered
to urinologist.
Principles of recovering.
If there is no any symptoms seen above, disappearing of clinical symptoms, normalization of
urine and blood tests.
Individual prevention of the patients.
Nonantimicrobial prophylaxis issues. Encouraging women to practice regular and complete
emptying of the bladder may help prevent recurrent cystitis. Postcoital emptying of the bladder has
also been widely recommended, although one prospective study failed to demonstrate any relationship
with recurrent infections. Moreover, several theoretical preventive measures relate to the use of an
alternative contraceptive method: to use a properly fitted diaphragm, to void frequently when wearing
a diaphragm, and to limit diaphragm use to the recommended 6 to 8 hours after intercourse. In
postmenopausal women, intravaginal administration of estriol can reduce recurrent UTIs by modifying
the milieu for vaginal flora. Cranberry juice (300 mL per day) was effective in decreasing
asymptomatic bacteriuria with pyuria in postmenopausal women. The small difference in symptomatic
UTIs was not statistically significant.
Family-field prevention.
Early recognition and possible prevention depend on an understanding of the pathogenesis and
epidemiology of UTIs. Figure 7-1 shows the major risk periods of life for symptomatic UTIs; the
increasing prevalence of asymptomatic bacteriuria that accompanies aging is apparent. Much has been
learned about the risk factors for UTIs (2). Associations have been established between UTI and age;
pregnancy; sexual intercourse; use of diaphragms, condoms, and spermicides, particularly Nonoxynol9; delayed postcoital micturition; menopause; and a history of recent UTI. Factors that do not seem to
increase the risk include diet, use of tampons, clothing, and personal hygiene, including directions of
cleansing after defecation and bathing practices
Acute complicated pyelonephritis.
Definition.
Acute complicated pyelonephritis – For the clinician, another important distinction is made
between uncomplicated and complicated infections. An uncomplicated infection is an episode of
cystourethritis following bacterial colonization of the urethral and bladder mucosae in the absence of
upper tract disease. This type of infection is considered uncomplicated because sequelae are rare and
exclusively due to the morbidity associated with reinfections in a subset of women. Complicated UTIs
may also occur with pregnancy, diabetes, immunosuppression, structural abnormalities of the urinary
tract, symptoms lasting for greater than 2 weeks, and previous pyelonephritis. Young women constitute
a subset of patients with
Diagnosis and symptoms.
Specific complaints are: temperature is 38,5-40С, sometimes with fever, pain is in waist (in one
or two directions), sometimes rapid diuresis is common. During palpation one can establish pain in
costo-lumbar angle.
Laboratory findings.
In blood test the leukocytosis, high ESR is common. Urine tests shows high leukocytosis, in 1ml
of urine one can establish more than 100000 microbes. After 2-3 days of the beginning of the disease
can the cilindres can be found. If the Leukocyturia and bacteruria are found the urine must be placed
on sterile cup and be placed on refrigerator (+4 - +6 degrees by celcium, duration 8 hours ) and saved
for biological laboratory
Methods of instrumental examination.
Urine specimens must be cultured promptly within 2 hours or be preserved by refrigeration or a
suitable chemical additive (e.g., boric acid sodium formate preservative). Acceptable methods of
collection are:
Midstream urine voided into a sterile container after careful washing (water or saline) of external
genitalia (any soap must be rinsed away)
Urine obtained by single catheterization or suprapubic needle aspiration of the bladder.
Sterile needle aspiration of urine from the tube of a closed catheter drainage system (do not
disconnect tubing to get specimen)
Rehabilitation and clinical examination of the patient with the acute complicated pyelonephritis
When compared to the normal U.S. population, patients on HD have a much lower employment rate
and a much higher percentage of disability recipients. Efforts to improve these figures through
vocational rehabilitation have been only marginally successful. However, on quality of life
questionnaires, most HD patients rate their quality of life only slightly below the general population.
Despite their overall high self-rating on quality of life questionnaires, many dialysis patients suffer
from depression and anxiety disorders. A social worker is a critical member of all dialysis facility
teams and can play a vital role in helping patients adjust to dialysis and deal with feelings of
depression and anxiety.
Although PD allows individual patients more control over their health care and a more flexible
dialysis schedule, the percent of PD patients in the work force and the percent on disability are no
different from those on HD. On quality of life questionnaires, PD patients as a group rate their quality
of life about the same as HD patients. Unfortunately, no prospective studies are available, and the
variability in patient selection is certainly a major factor in these outcomes.
Chronic pyelonephritis.
Definition.
Chronic pyelonephritis has a histopathology that is similar to tubulointerstitial nephritis, a renal
disease caused by a variety of disorders, such as chronic obstructive uropathy, vesical ureteral reflux
(reflux nephropathy), renal medullary disease, drugs and toxins, and possibly chronic or recurring renal
bacteriuria.
Diagnosis and symptoms
Essentially, then, chronic pyelonephritis is the end result of longstanding reflux (non-obstructive
chronic pyelonephritis) or of obstruction (obstructive chronic pyelonephritis). These processes damage
the kidneys leading to scarring, and the degree of damage and subsequent scarring is more marked if
infection has supervened.
The scars are closely related to a deformed renal calyx. Distortion and dilatation of the calyces is
due to scarring of the renal pyramids. These scars typically affect the upper and lower poles of the
kidneys, because these sites are more prone to intrarenal reflux. The cortex and medulla in the region
of a scar is thin. The kidney may be so scarred that it becomes small and atrophic. Scars can be seen
radiologically on a renal ultrasound, an IVU, renal isotope scan, or a CT.
Laboratory findings.
In blood test the leukocytosis, high ESR is common. Urine tests shows high leukocytosis, in 1ml
of urine one can establish more than 100000 microbes. After 2-3 days of the beginning of the disease
can the cilindres can be found. If the leukocyturia and bacteruria are found the urine must be placed on
sterile cup and be placed on refrigerator (+4 - +6 degrees by celcium, duration 8 hours ) and saved for
biological laboratory
Methods of instrumental examination.
Urine specimens must be cultured promptly within 2 hours or be preserved by refrigeration or a
suitable chemical additive (e.g., boric acid sodium formate preservative). Acceptable methods of
collection are:
Midstream urine voided into a sterile container after careful washing (water or saline) of external
genitalia (any soap must be rinsed away)
Urine obtained by single catheterization or suprapubic needle aspiration of the bladder.
Sterile needle aspiration of urine from the tube of a closed catheter drainage system (do not
disconnect tubing to get specimen)
Rehabilitation and clinical examination of the patient with the chronic pyelonephritis
When compared to the normal population, patients on HD have a much lower employment rate
and a much higher percentage of disability recipients. Efforts to improve these figures through
vocational rehabilitation have been only marginally successful. However, on quality of life
questionnaires, most HD patients rate their quality of life only slightly below the general population.
Despite their overall high self-rating on quality of life questionnaires, many dialysis patients suffer
from depression and anxiety disorders. A social worker is a critical member of all dialysis facility
teams and can play a vital role in helping patients adjust to dialysis and deal with feelings of
depression and anxiety.
Although PD allows individual patients more control over their health care and a more flexible
dialysis schedule, the percent of PD patients in the work force and the percent on disability are no
different from those on HD. On quality of life questionnaires, PD patients as a group rate their quality
of life about the same as HD patients. Unfortunately, no prospective studies are available, and the
variability in patient selection is certainly a major factor in these outcomes
Paranephric abscess (paranephritis).
Definition.
Paranephric abscess develops as a consequence of extension of infection outside the parenchyma
of the kidney in acute pyelonephritis, or more rarely, nowadays, from haematogenous spread of
infection from a distant site. The abscess develops within Gerota's fascia. These patients are often
diabetic, and associated conditions such as an obstructing ureteric calculus may be the precipitating
event leading to development of the perinephric abscess.
Failure of a seemingly straightforward case of acute pyelonephritis to respond to intravenous
antibiotics within a few days arouses the suspicion that there is an accumulation of pus in or around the
kidney, or obstruction with infection. Imaging studies, such as ultrasound and more especially CT will
establish the diagnosis, and allow radiographically controlled percutaneous drainage of the abscess. If
the pus collection is large, formal open surgical drainage under general anaesthetic will provide more
effective drainage.
Diagnosis and symptoms.
More common clinical symptoms are: increased temperature, fever. During palpation one can
establish pain in costo-lumbar angle, deformation and swelling in lumbar field, scoliosis. Sometimes
these symptoms can’t be established, due to this one cant made a diagnosis as usual. During palpation
one can establish pain in costo-lumbar angle.
Laboratory findings.
In blood test the leukocytosis, high ESR is common. Urine tests shows high leukocytosis, in 1ml
of urine one can establish more than 100000 microbes. After 2-3 days of the beginning of the disease
can the cilindres can be found. If the Leukocyturia and bacteruria are found the urine must be placed
on sterile cup and be placed on refrigerator (+4 - +6 degrees by celcium, duration 8 hours ) and saved
for biological laboratory
Methods of instrumental examination.
Urine specimens must be cultured promptly within 2 hours or be preserved by refrigeration or a
suitable chemical additive (e.g., boric acid sodium formate preservative). Acceptable methods of
collection are:
Midstream urine voided into a sterile container after careful washing (water or saline) of external
genitalia (any soap must be rinsed away)
Urine obtained by single catheterization or suprapubic needle aspirationof the bladder
Sterile needle aspiration of urine from the tube of a closed catheter drainage system (do not
disconnect tubing to get specimen)
Tactics.
After 48 hours from first conservative treatment patients if doesn’t feel good must be administered
to urologist.
Used in this lesson, new teaching technologies, "Round Table".
USING "Round Table".
The method provides for joint activities and active participation in the classroom each student, the
teacher works with the entire group.
Embarks on a circle piece of paper with the job. Each student writes his answer sheet and passes
the other. All write down their answers, followed by discussion: crossed out the wrong answers, the
number of correct - evaluate the student's knowledge.
To think about each answer the student is given 3 minutes. Then, the answers are discussed. At the
end of the method of teacher comments on your answer is correct, its validity, the activity level of
students.
This methodology promotes student speech, forming the foundations of critical thinking as In this
case, the student learns to assert his view, analyze responses band members - participants of the
contest.
6.2. Analitical part:
Situational tasks:
Task 1. Patient 36 years old, a male, complains of the increased temperature and pain in lumbar region
On objective examination asymmetry of this region, redness of right lumbar field, were established
- Initial diagnosis
- Laboratory finding of blood tests
- Laboratory findings of urine tests
- Tactics of general practitioner
Answers:
1. Paranephritis (right sight)
2. Blood tests results: increased ESR, leukocytosis
3. Urine test results: bacteruria, leukocyturia
4. Administer to urologist immediately
6.3. Practical part
The interview with the patient in the urology department, conducting physical examination,
determination of diagnostic procedures in patients with urological diseases.
7. Forms of control knowledge, skills and abilities
- Viva voice examination;
- Writing;
- Solution of tasks;
- Tests.
8. Criteria for evaluating the current control
Achievement
as a
№
percentage (%) and
scoring the
student's knowledge
level rating
1.
86-100
Achievement as a
percentage (%)
and scoring the
student's
knowledge level
rating
Excellent "5"
Achievement as a percentage (%) and scoring
the student's knowledge level rating
Independently analyses
Uses in practice
Shows high activity, a creative approach to the
conduct of interactive games
Correctly solves the case studies with full
justification for the answer
Understands the subject matter
Knows, says confident
Has a faithful representation
2.
71-85
Good "4"
Uses in practice
Shows high activity during the interactive games
Correctly solve situational problems, but the
rationale for the answer not full enough
Understands the subject matter
Knows, says confident
Has a faithful representation
3.
4.
55-71
54 and less
Satisfactorily
"3"
Unsatisfactorily
"2"
Knows, says not sure
Has a partial view
It does not accurately represent
Do not know
9. Chronological map of classes
№
1.
2.
3.
4.
5.
6.
7.
8.
Stages of training
Lead-in tutor (study subjects).
Discussion topics practical training, assessment
of baseline knowledge of students with new
educational technologies (round table, case
studies, slides), as well as checking the source of
students' knowledge, the use of visual aids
(slides, models, phantoms, ultrasound, x-ray,
etc.).
Summing up the discussion.
Giving students tasks to perform the practical
part of training. Cottage explanations and notes
for the task. Self-Supervision.
The assimilation of skills a student with a teacher
(Supervision thematic patient)
Analysis of the results of laboratory and
instrumental studies thematic patient,
differential diagnosis, treatment plan and
rehabilitation, prescriptions, etc.
Talk degree goal classes on the basis of developed
theoretical knowledge and practical experience
on the results of the student, and with this in
mind, evaluation of the group.
Conclusion of the teacher on this lesson.
Assessment of the students on a 100 point system
and its publication. Cottage set students the next
class (a set of questions)
Forms of
employment
The survey, an
explanation
Continued a
resident of
Property in the
minutes. 225
10
50
15
30
Medical history,
clinical role-playing
case studies
work with the
clinical laboratory
instruments
40
Oral questioning,
test, debate,
discussion of the
practical work
Information,
questions for selftraining.
30
10. Questions:
1. What laboratory studies are used in urological diseases?
2. What instrumental methods used in urological diseases?
3. What changes occur in blood and urine in renal colic?
4. What information is provided by ultrasound in renal colic?
5. Describe the panoramic photograph of the urinary tract patient with UTI.
6. What changes are observed in the excretory urogram in the kidney and ureter stones?
7. Methods of diagnosis of bladder injury.
11. Recommended Reading
1. Tutorial: "Urology." M. Medicine, 2004
2. Manual of Urology in 3 volumes. Ed. Acad. NA Lopatkina M, 1998.
3. Emergency urology. A. Pytel, II Zolotarev. M. Medicine, 1985.
More:
1. Martin I. Resnick. Secrets of Urology. 1998.
2. Directory of GP. J. Mert. M. practice. 1998.
30
20
3. Urology and Andrology at the questions and answers. Ed. OA Tiktinsky, V. Mickle. "Peter". St.
Petersburg, 1998. - 377s.
4. Urology by Donald Smith. Ed. E. Tanago and Dzh.Makanincha. Translated from English. "Practice."
M. 2005. - 819s.
5. Internet: (www.uroweb.ru; www.uro.ru; www.medscape.com; www.medicalstudents.com;
www.uroweb.org; www.bju.org; www.europeanurology.com).