Methodological Instructions for Students Theme: Inflammation of lower urinary tract and genital organs icon

Methodological Instructions for Students Theme: Inflammation of lower urinary tract and genital organs




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НазваMethodological Instructions for Students Theme: Inflammation of lower urinary tract and genital organs
Дата29.06.2012
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Methodological Instructions for Students

Theme: Inflammation of lower urinary tract and genital organs




Aim: learn clinic, diagnostics and principles of treatment of inflammation of lower urinary tract and genital organs.

Professional motivation: inflammation of lower urinary tract is one of most common urological diseases, the incidence of acute cystitis is much greater in girls and women than in boys and men.

Basic level:

1. Anatomy: structure and blood supply of the bladder.

2. Pathology: pathologycal changes attached to urinary bladder inflammation.

3. Propedeutics: symptomatology of acute and chronic cystitis, clinical diagnostics of cystitis.

4. Pharmacology: plan of the treatment of patients with cystitis.

Student’s Independent Study Program


Student should know:

- pathogenesis of cystites;

- classification of cystites;

- clinic and diagnostics of cystites;

- principles of cystites treatment.

Student should be able to:

- prepare the plan of clinical, laboratory, endoskopical, X-ray examination; of patients with inflammation of urinary bladder;

- examine the patient with cystitis.

^ Materials for students independent study:

Acute cystitis:

Etiology & Pathogenesis:

Acute bacterial cystitis is an infection of the urinary bladder caused mainly by coliform bacteria (usually strains of E coli} and less often by gram-positive aerobic bacteria (especially Staphylococcus sapro-phyticus and enterococci). The infection usually ascends to the bladder from the urethra. Adenovirus infection may lead to hemorrhagic cystitis in children; however, viral cystitis rarely is found in adults.

Clinical Findings:

Irritative voiding symptoms prevail: frequency, urgency, nocturia, burning on urination, and dysuria. Low back and suprapubic pain and discomfort are common complaints. Although suprapubic tenderness is sometimes elicited, no specific physical signs are characteristic. Possible associated contributing factors should be sought; vaginal, introital, orurethral abnormalities (eg, urethral diverticulum) or vaginal discharge in female patients; urethral discharge or a swollen, tender prostate or epididymis in male patients.

Laboratory Findings:

The hemogram may be normal or show mild leukocytosis. Urinalysis typically shows pyuria and bacteriuria; gross or microscopic hematuria is seen on occasion. The infecting pathogen will be found on urine culture. Unless the patient has associated urologic disorders, the serum creatinine and blood urea nitrogen values are normal.

X-Ray Findings:

Radiographic evaluation is warranted only if renal infection or genitourinary tract abnormalities are suspected. In patients with Proteus infections that do not respond promptly to therapy or that relapse, x-rays should be taken to investigate the possibility of infected struvite calculi.

Instrumental Examination:

Cystoscopy usually is indicated when hematuria is prominent; however, the procedure should be delayed until the acute phase is over and the infection has been treated adequately.
^

Differential Diagnosis


In female patients, acute bacterial cystitis must be distinguished from several other infectious processes. Vulvovaginitis may mimic the symptoms of cystitis but can be diagnosed accurately by pelvic examination coupled with proper examination of vaginal discharge for pathogens. Acute urethral syndrome causes frequency and dysuria, but urine cultures show low counts or no growth of bacteria. Acute pyelonephritis often causes symptoms of vesical irritability but typically produces loin pain and significant fever. In children, vulval and urethral irritation caused by detergents in bubble bath or by pinworms may mimic the symptoms of cystitis.

In male patients, acute bacterial cystitis must be distinguished mainly from infections of the urethra, prostate, and kidney. Appropriate physical examination and laboratory tests usually enable the physician to make a specific diagnosis.

Noninfectious types of cystitis produce symptoms that exactly mimic those of bacterial cystitis. Some of these conditions include cystitis resulting from anticancer therapy (eg, irradiation, cyclophos-phamide), interstitial cystitis, eosinophilic cystitis ("allergic" cystitis), bladder carcinoma (especially carcinoma in situ), and psychosomatic disorders.

Treatment


A. Specific Measures: Although its efficacy has not been proved in men, the use of short-term antimicrobial therapy (1-3 days or even a single dose) is effective in acute uncomplicated cystitis in women. Ideally, an antimicrobial agent should be selected on the basis of culture and sensitivity testing, Since most uncomplicated infections occurring outside the hospital environment are due to stains of E coli, sensitive to many antibiotics, sulfonamides, trimethoprim-sulfamethoxazole, nitrofurantoin, or ampicillin usually is effective. Urologic evaluation is warranted when the response is unsatisfactory.

B. General Measures: Because acute uncomplicated cystitis responds rapidly to proper antimicrobial therapy, additional measures usually are unnecessary. Hot sitz baths, anticholinergics (eg, propantheiine bromide), and urinary analgesics (eg, phenazopyridine hydrochloride) are occasionally warranted for relief of symptoms.

Chronic cystitis:

Etiology & Pathogenesis:

"Chronic cystitis" means unresolved or persist bladder infection, it is used after of 1 year of disease. Chronic infectious cystitis is caused by the same pathogens that cause acute cystitis and acute and chronic pyelonephritis.


Clinical Findings

A. Symptoms: Patients with chronic cystitis are asymptomatic or have variable symptoms of vesical irritability. If the bladder infection is caused by a persistent source of infection in the kidneys or prostate, there may also be symptoms associated with the primary infection. Pneumaturia suggests an enterovcs-ical fistula or infection caused by a gas-forming patho-Effl(usually a coliform organism). The latter is seen most often in diabetics.

B. Signs: Physical findings often are absent and usually are sparse and nonspecific.

C. Laboratory Findings: Unless chronic cystitis is associated with serious primary genitourinary tract disorder, the hemogram and renal function studies usually are normal. Urinalysis typically shows significant bacteriuria but may show surprisingly little pjuria. Urine culture generally is positive.

D. X-Ray Findings: Unless chronic cystitis is associated with other genitourinary tract disease, ra-fcgraphic studies usually are normal. Excretory and ograde urograms and voiding cystograms may demonstrate associated conditions (eg, obstructive ttpaihy, vesicoureteral reflux, atrophic pyelonephritis, vesicoenteric or vesicovaginal fistulas).

E. Instrumental Examination: Urethral calibration, catheterization, and urethrocystoscopy may be isfoted to evaluate whether contributing conditions : urethral stricture, prostatic obstruction) exist.

Differential Diagnosis

Infectious types of chronic cystitis must be languished from other infectious diseases of the ttniioarinary tract in men and women. Sometimes te conditions mimic cystitis; sometimes they are. ated with or contribute to chronic cystitis. bipb include infectious vaginitis, prostatitis, and itisand renal infections. Tuberculosis of the kid-ty or bladder must be considered in the differential Kis of chronic cystitis characterized by “sterile”

Noninfectious conditions that must be considered in the differential diagnosis include senile vaginitis and urethritis related to hormonal deficiency, noninfec-tious urethral disease, nonbacterial forms of prostatitis, interstitial cystitis, "allergic" cystitis, radiation cystitis, cystitis secondary to the use of chemothera-peutic (including anticancer) agents, and various psychosomatic syndromes.

Treatment

The causative organism should be identified by culture, and the infection should be treated with appropriate antimicrobial therapy based upon susceptibility testing. Long-term preventive therapy or suppressive therapy with agents such as nitrofurantoin, trimetlio-prim-sulfamethoxazole, or methenamine plus an acidifier may prove necessary. The most important aspect of treatment is thorough evaluation for underlying causes and appropriate correction of contributing factors when possible.

Materials for the self-assesment:

1. Etiology, pathogenesis of acute cystitis.

2. Etiology, pathogenesis of chronic cystitis.

3. Classification of cystites.

4. Clinic acute cystitis.

5. Clinic chronic cystitis.

6. Diagnostics acute cystitis.

7. Diagnostics chronic cystitis.

8. Differential diagnostics of acute cystitis.

9. Differential diagnostics of chronic cystitis.

10. Treatment of acute cystitis.

11. Treatment of chronic cystitis.

Real life situations to be solved:

32 years woman, was hospitalized in urology department with the complaints on often urination with sharp pains, excretion of urine with impurities of a blood, rising temperature of a body up to 38 C. Data of palpation: appreciable pain in suprapubical region.

1. Previous diagnosis?

2. Plan of examination?

3. Treatment?

4. Differential diagnosis?

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