The most common of the inflammatory diseases of the urinary organs, constituting about 2/3 of all urological diseases is the pyelonephritis. This infectious inflammatory process in renal tissue and tubules.
Pyelonephritis is the most common kidney disease and common in people of different sex and age, therefore such patients have to treat the doctors of many specialties – urologists, nephrologists, paediatricians, physicians, obstetricians and gynaecologists, surgeons and other specialists. Pyelonephritis in children is on the second place after respiratory diseases. Acute pyelonephritis is observed at an average of 2.5 % of pregnant women, and often in the second half of pregnancy. This is due to the decreased tone of the urinary tract as a result of hormonal changes occurring in pregnancy and compression of the ureters pregnant uterus. These factors create favorable conditions for the occurrence of acute exacerbation of chronic pyelonephritis during pregnancy.
Women suffer from acute and chronic pyelonephritis in 5 times more often than men, due to the peculiarities of the anatomical structure of the urethra in women: it is much shorter than in men, is close to the vagina, which facilitates easier penetration of infection by ascending into the bladder.
Pyelonephritis in men young and middle age is more often secondary and associated mainly with urolithiasis, chronic prostatitis,various anomalies of the kidney and urinary tract infections and other diseases.
In the elderly, in males, the frequency of pyelonephritis increases dramatically, due to difficult outflow of urine when the prostate gland adenoma.
However, during the life of this diagnosis is only 1/4 of the patients. In 60-75 % of cases the disease develops at the age of 30-40 years, especially, as already mentioned, in women during pregnancy and in the postpartum period. In children the peak of the diagnosis of pyelonephritis at the age of 2-3 years. With age, the frequency of pyelonephritis is increased mainly in girls.
Vulvovaginitis is one of the most common causes of infection of the urinary tract in girls. Predispose to the development of pyelonephritis in such cases, the reduction of protective forces of an organism of the child as a result of hypothermia or infectious disease.
In children there is a close relationship between the presence of pyelonephritis and congenital abnormality of the glomeruli and tubules of the kidney. Congenital immaturity of renal structures (fermentopathy, hereditary immunodeficiency States) creates a favorable background for the development of infection.
Among the most frequent factors predisposing to the development of pyelonephritis in children include a violation of the free patency of the urinary tract (90 % of cases of pyelonephritis.
Pyelonephritis is an infectious process without the specific causative agent. It can be caused by microbes resident in the human body, and microflora penetrating the body from the environment. From the urine of patients with pyelonephritis most frequently isolated E. coli and bacteria of the group Proteus, Staphylococcus, Enterococcus, Pseudomonas aeruginosa, Klebsiella. Proven pathological role of mycoplasmas, viruses and fungi.
Staphylococcus aureus is most often isolated from urine of patients recently undergoing various inflammatory diseases (panaritium, mastitis, furuncle, tonsillitis, pulpitis, sinusitis, otitis, etc.). E. coli the bowl found in the urine of patients with pyelonephritis, occurs after exposure to cold or gastro-intestinal diseases. Bacteria of the group Proteus, Pseudomonas aeruginosa found in the urine of patients with pyelonephritis, which has made the bladder catheterization, surgery, in instrumental examination of the urinary tract (hospital microflora.
Micro-organisms in some patients with pyelonephritis under the influence of adverse factors (antibiotic therapy, change of pH of urine) may become more resistant to external influences. However, if there are favourable conditions for them they become active and cause a relapse. Pyelonephritis caused by such forms of microorganisms that are difficult to heal, which often facilitates the transition of acute pyelonephritis into chronic.
In recent years, especially the increased role of hospital bacteria as causative agents of pyelonephritis. This underlines the need for strict compliance with the rules of asepsis and antisepsis when performing various instrumental methods of examination (cystoscopy, retrograde pyelography etc.
In the kidney, the infection can penetrate through the lumen of the urinary tract along the wall of the urinary tract and lymphokine, but the most common microbial flora enters the kidney tissue with blood flow. This can occur when the localization of the primary inflammatory focus as outside the urinary tract (otitis media, tonsillitis, dental caries, bronchitis, pneumonia, furuncle, osteomyelitis, mastitis, an infected wound, etc.) and in the urinary tract (cystitis, urethritis) or the genitals (prostatitis, vesiculitis, orchitis, epididymitis adnexitis, vulvovaginitis.
For the occurrence of pyelonephritis is not enough penetration of microflora in the kidney. This requires predisposing factors, among which are hypothermia, disturbance of outflow of urine from the kidney and disorders of the blood and lymph circulation in the body. However, in some cases microorganisms are able to cause acute pyelonephritis in the absence of any predisposing causes.
Germs with the blood flow gets into the vascular loops of the glomeruli, where cause inflammatory and degenerative changes and penetrate into the lumen of the tubules. Around bacterial thrombi formed tissue infiltration, the fate of which depends on the performed treatment and the General condition of the body. Under favorable course of the disease the infiltrates are replaced by connective tissue with subsequent scarring, and the progression of the process are multiple ulcers. Ascending (through the lumen of the urinary tract) route of infection is possible only in the presence of vesico-ureteral renal pelvis reflux (urine reflux). With a reverse current of urine microflora from the bladder enters the pelvis, where it can penetrate into the blood circulation.
Predisposing factors contributing to the occurrence of acute pyelonephritis and acute exacerbation of chronic can be divided into General and local.
The General condition of the body plays an important role in the origin and development of pyelonephritis. Of the common factors is the key immunological reactivity. It is often reduced in patients with prolonged, sluggish inflammatory processes of any localization. A decrease in immune defenses contributes to the recurrence of pyelonephritis, increases the susceptibility of the organism even to laboratornoi infection. Diabetes is also a factor predisposing to the development of pyelonephritis. It was found that patients with diabetes mellitus pyelonephritis is observed in 4-5 times more often often associated with various complications. In children the development of pyelonephritis contributes to complications during fetal development. To the common factors also include the presence of any disease or other reasons that reduce the protective forces of the patient (fatigue, General and local hypothermia, alcoholism, etc.
Local factors are the most common disrupted the flow of urine and the presence of vesicoureteral reflux (reflux). The main causes of violation of the outflow of urine are various anomalies of the kidneys and urinary tract, their trauma, stones of kidney and ureter, benign hyperplasia (adenoma) of the prostate gland, a narrowing of the urethra. Approximately 7-10 times more frequently pyelonephritis occurs in individuals with such anomalies, like polycystic kidney disease, horseshoe kidney, double kidney, etc. In women, the violation of the emptying of the upper urinary tract was observed in complicated pregnancies, gynecological diseases, after operations on the genitalia. Less disturbance of outflow of urine occurs due to compression of ureter from outside of tumor formation, and inflammatory infiltration.
Among local predisposing factors, particular importance is vesicoureteral reflux, which is often seen in people with chronic cystitis, bladder neck sclerosis, narrowing or valve of the urethra in patients with benign hyperplasia (adenoma) of the prostate, narrowing of the urethra or with a long-existing inflammatory process in the bladder.
The development of pyelonephritis contribute to a variety of instrumental research of kidneys and urinary tract: cystoscopy, urethrography. cystography, especially retrograde pielografia. The big danger these studies are in connection with the existence of hospital infections, is highly resistant to most antibiotics and chemical antibacterial drugs. Care about even a simple catheterization of the bladder, which may be complicated by infection of the urinary tract with subsequent development of urethritis, prostatitis, and pyelonephritis then. Finding a permanent catheter in the bladder for 24 h led to infection of the urinary tract in 100% of patients.
Pyelonephritis can be primary and secondary. Primary considered to be an inflammatory process, which does not identify violations of the dynamics of urine and any other kidney diseases. However, in most cases, the occurrence of pyelonephritis precede, albeit short-term, disturbances of the current of urine, and in some cases, there may be pathological changes in the kidneys and urinary tract, which is not always possible to identify modern methods of research. If the inflammatory process occurs in the background of any disease of the kidneys and urinary tract, pyelonephritis is considered secondary. Clinical course of pyelonephritis can be acute (serous or purulent), chronic and recurrent. Purulent forms of pyelonephritis develops in 25-30 % of patients.