Download Methodological Instructions to Practical Lesson

Methodological Instructions for Students
Theme: Clinical Assessment of Urological Symptoms.
Aim: To analyze urologic complaints and main symptoms correctly.
Professional Motivation:
Urologic symptoms are very different in nature. They are important in diagnosis of diseases and to
differentiate among them. All urologic symptoms can be divided into four groups:
1) low back and flank pain with irradiation;
2) urine output pathology;
3) urine pathology;
4) pathologic urethral discharge and semen pathology.
Basic Level:
1. You should be able to obtain case history.
2. You should be able to determine symptoms from patient's history that could be related to urine
output pathology.
3. You should be able to analyze data of urine examination.
4. You should be able to make uretheral discharge slides and to know semen characteristics both in
normal and pathology.
Student's Independent Study Program
I. Objectives for Students Independent Studies.
1. Urologic symptoms: pain symptoms, symptoms of abnormal urine output, urine pathology.
2. You must know the symptoms of diseases: as low back pain, altered urination, pathology of
urine specimen are typical.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Anatomy of kidneys, ureters, urine bladder and urethra.
The kidneys lie along the borders of the psoas muscles and are therefore obliquely placed. The
position of the liver causes the right kidney to be lower than the left. The adult kidney weighs about 150
g. The kidneys are supported by the perirenal fat (which is enclosed in the perirenal fascia), the renal
vascular pedicle, abdominal muscle tone, and the general bulk of the abdominal viscera. Variations in
these factors permit variations in the degree of renal mobility. The average descent on inspiration or on
assuming the upright position is 4-5 cm.
The adult ureter is about 30 cm long, varying in direct relation to the height of the individual. It
follows a rather smooth S curve. Areas of relative narrowing are found (1) at the ureteropelvic junction,
(2) where the ureter crosses over the iliac vessels, and (3) where it passes through the bladder wall.
The adult bladder normally has a capacity of 350 – 450 mL. When empty, the adult bladder lies
behind the pubic symphysis and is largely a pelvic organ.
2.
Physiology of kidneys, ureters, urinary bladder and urethra.
The kidneys play a central role in the maintenance of a constant internal environment for body
cells in response to cellular catabolism and wide variations of dietary intake. It achieves this by
regulating extracellular fluid and solute concentrations by the excretion of salts, water, metabolic
waste products and foreingn substances. The process involves the productions of a plasma ultrafiltrate
of 180 L per day. This passes down two million tubules from which essential solutes and water are
reabsorbed into the blood and non-essential solutes secreted from the blood into the remaining fluid,
which becomes the final urine. The other functions of the kidney include hormone production and
gluconeogenesis.
3.
Main urologic symptoms.
Systemic manifestations, local & referred pain (kidney pain, pseudorenal pain,ureteral pain,
vesical pain, prostatic pain, testicular pain, epididymal pain, back & leg pain), gastrointestinal symptoms
of urologic disease, symptoms related to the act of urination (frequency, nocturia, & urgency, burning
sensation during urination, enuresis, symptoms of prostatic obstruction, symptoms of urethral
obstruction, incontinence, oliguria & anuria, pneumaturia, cloudy urine, bloody urine), other objective
manifestations (urethral discharge, skin lesions of the external genitalia, visible or palpable masses,
edema, bloody ejaculation, gynecomastia, size of penis in infant or child), complaints related to sexual
problems.
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4.
Pain in urologic pathology: character, localization, and irradiation.
Typical renal pain is usually felt as a dull and constant ache in the costovertebral angle just lateral
to the sacrospinalis muscle and just below the 12th rib. This pain often spreads along the subcostal area
towards the umbilicus or lower abdominal quadrant. It may be expected in those renal diseases that cause
sudden distention of the renal capsule. Acute pyelonephritis and acute ureteral obstruction both cause this
typical pain. Such disease include cancer, chronic pyelonephritis, staghorn calculus, tuberculosis,
polycystic kidney, and hydronephrosis due to mild ureteral obstruction.
5.
Etiology of renal colic.
The pressure within the renal pelvis is normally close to zero. When this pressure increases because
of obstruction or reflux, the pelvis and calices dilate. The degree of hydronephrosis that develops depends
upon the duration, degree, and site of the obstruction. The higher the obstruction, the greater the effect
upon kidney.
6.
Altered urination: dysuria, pollakiuria, precipitant urination, frequent urination, urinary difficulty,
chronic urinary retention, paradoxical ischuria.
Chronic urinary retention: this may cause little discomfort to the patent even though there is great
hesitancy in starting the stream and marked reduction of its force and caliber. Constant dribbling of urine
(paradoxic incontinence) may be experienced. It may be likened to water pouring over a dam.
7.
Urinary incontinence. Enuresis.
Incontinence (true incontinence, stress incontinence, urge incontinence, paradoxic incontinence).
Strictly speaking, enuresis means bedwetting at night. It is physiologic during the first 2 or 3 years of life.
8.
Acute urinary retention (etiology, treatment).
Sudden inability to urinate may supervene. The patient experiences increasingly agonizing
suprapubic pain associated with severe urgency and may dribble only small amounts of urine.
9.
Anuria (settings, emergency aid).
Oliguria and anuria may be caused by acute renal failure (due to shock or dehydration), fluid-ion
imbalance, or bilateral ureteral obstruction.
10) Differentiation within real urine incontinence and paradoxical incontinence, acute
urine retention and anuria.
11) Proteinuria, bacteriuria (kinds).
Proteinuria of any significant degree (2-4+) is suggestive of “medical” renal disease (parenchymal
involvement).
a)
“Pathologic” proteinurias ; b) “Nonpathologic” proteinurias (physiologic, orthostatic).
A presumptive diagnosis of bacterial infection may be made on the basis of results of
microscopic examination of the urinary sediment.
12) Pyuria. Three-glass maneuver.
In the sediment from clean-voided midstream specimen from men and those obtained by
suprapubic aspiration or catheterization in women, more than 5-8 white blood cells per high-power field
is generally considered abnormal (pyuria).
13) Abnormal urine specimen (altered urine output, pathological urine sediments).
Patients with recurrent urolithiasis may have an underlying abnormality of excretion of calcium,
uric acid, oxalate, magnesium, or citrate.
14) Hematuria (settings). Two-glass maneuver.
The presence of even a few red blood cells in the urine (hematuria) is always abnormal and requires
further investigation. If red blood cells predominate in the initial portion of the speciment, they are
usually from the anterior urethra; those in the terminal portion are generally from the bladder neck or
posterior urethra; and the presence of equal numbers of red blood cells in all containers usually indicates
a source above the bladder neck (bladder, ureters, or kidneys).
Key words and phrases:
Pyuria, proteinuria, bacteriuria, acute urinary retention, dysuria, pollakiuria, paradoxical ischuria.
II. Tests and Assignments for Self-assessment
1. Causes of renal anuria.
A. Incompatible blood transfusion.
B. Shock, collapse.
C. Gall-stones in ureters.
D. Ureters'bandaging during gynaecologic operations.
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E. Nephrectomy of solitary kidney.
2. A frequent urination during normal diurnal diuresis. How it’s called?
A.
Polyuria.
B.
Polydipsia.
C.
Pollakuria.
D.
Policetemia.
E. Disuria.
3. Which diurnal diuresis could be related to oliguria?
A. from 250 to 500 ml.
B. from 150 to 700ml.
C. from 0 to 50 ml.
D. from 100 to 500 ml.
E. from 50 to 200 ml.
4. Which diurnal diuresis could be related to polyuria?
A. over 2000 ml.
B. over 3500 ml.
C. 1500-2000 ml.
D. 1000-1500 ml.
E. over 1000ml.
Multiple choice. Choose the correct answer/statement:
Real life situations to be solved:
1. Patient S., at the age of 69; was admitted to the urology department, his complaints are urinary
difficulty, increased urinary frequency, bloody urine. Was noted after urination dullness of the percussion
sound under symphisis. Pastematzkiy's symptom is negative. The urination is 4 times during the night.
How the urinary difficulty and the urinary frequency called? How the bloody urine is called? Name
of the diseases that these symptoms are typical for. What does the dullness of the percussion sound
mean?
2. Patient C., at the age of 52, was admitted at the urology department; his complained of left low
back pains, absence of urine or 2 days. There is one fact from his case history: patient suffers from
urolithiasis for 12 years. The operation of right side nephrectonomy 3 years ago.
What is a preliminary diagnosis? How is it possible to differentiate acute urinary retention from
anuria?
III. Answers to the Self-assessment.
The correct answers to the tests:
1. A.
2. C.
3. D.
4. A.
The correct answers to the real life situations:
1. Stranguria. Hematuria. These symptoms are typical for nonmalignant hyperplasia of prostate.
Chronic urinary retention.
2. Left side renal colic. Postrenal anuria.
To provide catheterization of urinary bladder.
Visual Aids and Material Tools:
1. Slides.
2. X-ray photographs.
3. Tables.
Students Practical Activities:
Students must know:
1. Anatomy and physiology of ureters, kidneys, urine bladder, urethra.
2. Etiology of renal colics.
3. Main symptoms of urologic diseases.
4. Altered urination.
5. Abnormal urine specimen.
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6. The constants of general urine specimen examination, test of Zemnitski, biochemical indicators
of blood.
Students should be able to:
1. Provide catheterisation of urinary bladder with rubber catheter.
2. Measure residual urine volume.
3. Determine main symptoms of urologic diseases.
4. Analyze datas from the antecedent history that could be related to altered urination.
5. Analyze datas of diagnostic tests (general urine specimen examination, urine examination by
Netchyporenko, Amburge, test of Zemnitski).
6. Provide palpation and percussion of the kidneys and urinary bladder.
7. Analyze semen test in urologic pathology.
Methodological Instructions to Lesson 2 for Students
Theme: Instrumental Methods of Examination in Urology
Aim: Introduction of instrumental usage in urology (cytoscopy, cathetor etc). To teach the
construction and usage of some of them. Showing urinary bladder catheterization, cytoscopy and to
introduce process of catheterization of ureter.
Professional Motivation:
In every urological practice Instrumental and Endoscopic methods of Examination of urinary
bladder in patients plays very important role. To learn the usage of catheters, uretherscopy and
cytoscopy.
Basic Level:
1. Usage of Intsruments in Diagnosis and Examination.
2. Anatomic-Morphological functions of the upper and lower urinary tracks.
Student's Independent Study Program
I. You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. The method of cathetarisation of urinary canal with plastic cathetor.
After proper cleansing and lubrication, the catheter can be manipulated with a sterile-gloved hand.
However, it may be simpler to grasp the catheter near its tip with a sterile clamp and hold the other end of
the catheter between the fourth and fifth fingers of the same hand. The catheter can then be advanced
with the clamp without being touched by the unsterile hand. Begin catheterization with the penis pointed
slightly drawn out.
2. Types of urethral catheters.
In general, straight rubber catheters are used for routine diagnostic catheterization. However, a
coude (elbow) catheter, which is stiffer and has a curved tip, may be more readily manipulated over an
enlarged prostate that has elevated the bladder neck. Uretheral catheters are: Foley, Whistle-tip, Pezzer,
Malecot, Robinson, Coude.
3. Method of catheterization of urinary canal with metallic cathetor (in women and men).
After proper urethral lubrication, the tip of the conductor enters the urethra. The conductor is in the
horizontal position over the groin. The penis is pulled out on the conductor, which is advanced drown the
urethra and moved simultaneously to the midline; its handle is gradually moved to the vertical position.
The conductor will usually pass through the external urinary sphincter if gentle pressure is exerted on the
handle at right angles to its shaft with one finger. When the conductor has passed all the way into the
bladder it should be possible to rotate it freely.
4. Filiform & Followers.
Filiform and followers are instruments used to dilate narrow strictures. Filiforms have woven fiber
cores with a coated surface; they are very pliable and smooth. Useful sizes are 3-6F. The follower is
made of metal or of woven pliable fiber. Useful sizes are 8-30F.
5. Technique of passing filliforms.
After lubricant jelly has been instilled into the urethra, the filiform is introduced. If it is arrested, it
must be partially withdrawn, and readvanced. If this fails, one or filiforms should be added to the first
and all manipulplation should be epeated..
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6. Observation of cystoscopy.
Modern cystourethroscopes have a metal sheath ranging in size from 8F to 26F and interchangeable
fiberoptic telescopes allowing a view from 0 to 170 degress. The 0- or 30-degree lenses are best for
visualizing the urethra, whereas the bladder walls are best inspected with the 70-degree lens. A retrograde
(170-degree) lens must be used to see the vesical side of the bladder neck, particularly where prostatic
tissue obstructs the view.
Complete endosscopic studies are among the most precise diagnostic tests in all medicine. Any
urethral lesion ( eg, verrucae, tumors, strictures and diverticular), as well as the size and configuration of
the prostate and bladder neck, are noted before the bladder is inspected. When the bladder is entered, the
trigone is visualized and the size, shape, position, and number of ureteral orifices noted. The bladder wall
is carefully inspected for tumors, stones, diverticula, ulcers, trabeculation, hemorrhage, and edema. The
normal and abnormal cystourethroscopic findings must be specifically described.
7. Contraindications to cystoscopy.
Cystoscopy is contraindicated in acute urinary tract infection, because trauma may exacerbate the
infection and lead to sepsis. It is relatively contraindicated in the presence of severe symptoms of
prostatic obstruction, since trauma may produce just enough edema of the bladder neck to cause complete
urinary retention. Of course, if cystoscopy is essential, this risk must be accepted.
8. Condition which is not necessary to carry on with cystoscopy.
Passage of urethra, volume of bladder more than 75 ml, transparence of environment.
9. Normal cystoscopic picture.
The bladder wall is dynamic, and as the bladder fills, small lesions will move away and may escape
the examiner`s field. Special care must be taken not to overdistend the bladder and to make sure that all
areas have been completely inspected, often with the bladder minimally filled initially. In adults, most of
the bladder wall cannot be seen if the bladder contains more than 200-300 mL of urine.
10. Method of punction of urinary bladder.
A suprapubic catheter is useful in males when the urethra is impassable (eg, traumatic disruption or
stricture), when there is epididymitis or severe urethritis, or when prolonged bladder drainage by means
of an indwelling catheter is necessary. An indwelling urethral catheter predisposes to meatitis, urethritis,
and epididymitis.
The skin of the suprapubic area is prepared and infiltrated with a local anesthetic. If the patients is
in urinary retention, the bladder is usually readily palpated. The bladder must usually contain a minimum
of 200-300 mL of urine before a suprapubic catheter can be inserted successfully.
The patient may be placed in the Trendelenburg position to move the intestine upwards. A thin
lumbar puncture needle is inserted above the symphysis pubica and angled toward the perineum to locate
the bladder a trocar is inserted into the bladder and the suprapubic tube passed. Size 8F, 10F, and 12F
suprapubic catheters are available in prepackaged sets.
11. Ureteral catheterization.
These techniques are utilized in the evaluation of hematuria, chronic or recurrent urinary infection,
unexplained urologic symptoms (eg, enuresis, frequency), and evaluation of congenital anomalies. They
are also useful in any clinical situation in which excretory urograms have suggested pathologic change
but have not furnished all the information necessary for definitive diagnosis and treatment.
Key words and phrases:
Cystoscope, cromocystoscopy, catheter.
П. Tests and Assignments for Self-assessment
1. With the help of which substance below, urological instruments work out?
(cystoscope, rezektoscope)?
A. Glycerin.
B. Vasilin.
C. Kolargol.
D. Novokain.
2. What is the physiological capacity of urinary bladder?
A. 100-150 ml.
B. 400-450 ml
C. 200-250 ml.
D. 300-400 ml.
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Multiple choice. Choose the correct answer/statement:
Real life situation to be solved:
1. Patient P., 36 years complains of intensive pain in the left abdominal and right below the rib
cage, a frequent urination. She fealt sick a day ago after a very tiredsome travel (vibrations). On
examination stomach was normal and soft, in accordance to the left part under the rib cage. Symptom
Pasternatskiy’s positive on the left part.
Approximate diagnosis?
What should be done to give exact diagnosis?
2. Patient L., 68 years after frequent urge to avoid urination, pain below stomach, after wich there
was retention or (suppresion) of urine ischuria. Which type of medical aid is necessary to provide? What
should be done to give accurate diagnosis?
III. Answers to the Self-assessment.
The correct answers to the tests:
1. A.
2. С.
The correct answers to the real life situations:
1. Left sided Renal colic. Chromocystoscopy should be done.
2. Catheterate urinary bladder. To get accurate diagnosis cystoscopy should be done.
Visual Aids and Materials.
1. Slides
1. 1 Rezektoscopy.
1. 2 Uretroscopy.
2. Instrumentation (different types of catheters, bouge, catheterization cystoscop, operative
cystoscop).
Students' Practical Activities:
Students must know:
1. Anatomical and physiologal position especially the upper and lower urinary canals.
2. Method of catheterization of urinary bladder with metallic catheter.
3. To know catheters, bouge, cystoscope.
4. How to use cystoscope and chromocystoscope.
5. Normals in cystoscope.
6. Methodic of punction of urinary bladder.
Students should be able to:
1. Know how to provide catheterization of urinary bladder with elastic catheter.
2. Know all instruments ready to be used in urology.
3. To know normal graphs in instrumental examination of patients (cystoscope, chromoscope
and etc). Methodological Instruction to Lesson 3 for Students
Theme: X-rays and radioisotopic diagnostics of urological diseases.
Aim: To teach the students how to prepare the patient to urography, indications and
contrindications to excretory and retrograde urography to read excretory, retrograde and intravenous
urograms, to diagnose X-ray positive and X-ray negative stones of urinary tracts, to diagnose
hydrourethronephrose, to show the students urological cabinet, to demonstrate isotopic reno- and
scanograms.
Professional orientation of students: X-rays diagnostic has a great importance nowadays.
Without X-ray and radioisotopic methods of diagnostic any of urological diseases is impossible to
diagnose.
Basic level of knowledges:
1. Preparation of the patient to urography.
2. To detect the sensitivity of the patient to iodine preparations.
3. To differ excretory from retrograde urograms, normal reno- and scanograms from patological.
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4. To determine on urograms the shadows which ocursed by luquid or gaseous, stone contrastive.
Student’s Independent Study Program
I. You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Preparation of the patient to X- ray diagnostic of kidney and urinary tract.
It is no longer considered necessary that patients should be dehydrated in preparation for urograthy.
Indeed, dehydration is to be avoided in infants, debilitated and aged patients, and patients with diabetes
mellitus, renal failure, multiple myeloma, or hyperuricemic states. On the other hand, preliminary bowel
cleansing is very desirable, although children under age 10 years usually need no bowel preparation for
urography.
2. View urography (KUB). Sceletopy of kidneys, urine bladder, urether.
A plain film of the abdomen, frequently called a KUB ( kidney-ureter-bladder) film, is the simplest
uroradiologic study and the first perfomed in any radiographic examination of the abdomen or urinary
tract. It is usually the preliminary radiogram in more extended radiologic examinations of the urinary
tract, such as urography. The size of normal kidneys varies widely, not only between like individuals but
also with age, sex, and body stature. The long diameter of the kidney is the most widely used and most
convenient radiographic measurement. The average adult kidney is about 12-14 cm long, and the left
kidney is ordinarily slightly longer than the right one.
3. X-ray contrastive stones, their diagnostic.
Identification on the plain film of calcification or calculi anywhere in the urinary tract may help to
identify specific kidney diseases ( eg, the calcifications occasionally seen in a kidney cancer) or may
suggest primary disease elsewhere (eg, the occasional patient with nephrocalcinosis whose underlying
primary disease is hyperparathyroidism).
4. Contrastive substences (luquid, gaseous), the ways of using.
Such radiographic contrast media include liquids (almost all of which contain iodine), gels, solids
(eg, barium preparations), and gases (most commonly air, nitrous oxide, and carbon dioxide). Some
contrast media can only be administered by one route, which limits their usefulness for multisystem
anatomic imaging.
5. Excretory urography. Indications and contrindications.
The excretory urogram, formerly called an intravenous pyelogram, is most commonly used.
Excretory urograms can demonstrate a wide variety of urinary tract lesions, are simple to perform, and
are well tolerated by most patients. Occasionally, however, retrograde urograms (see below) may be
required if the excretory urogram is unsatisfactory or the patient has a history of significant adverse
reaction to intravascular contrast media. The advent of excretory urography using high volumes of
radiopaque contrast media and ureteral compression (see below) has decreased the need for retrograde
urograms.
6. The types of excretory urograms.
Abdominal (ureteral) compression devices that temporarily obstruct the upper urinary tracts during
excretory urograms dramatically improve the filling of renal collecting structures.
7. Retrograde urography. Method, indications and contrindications.
Retrograde urography is a moderately invasive procedure that requires cystoscopy and the
placement of catheters in the ureters. A radiopaque contrast medium is introduced into the ureters or renal
collecting structures through the ureteral catheters, and tadiograms of the abdomen are then taken. The
study, which is more difficult than an excretory urogram, must be perfomed by a urologist. Some type of
local or general anesthesia must be used, and the procedure can occasionally cause later morbidity or
urinary tract infection.
8. Infusional urography, indications.
The use of greater than average amounts of standard contrast medium – and thus greater amounts of
iodine per kilogram of body weight – may be indicated in selected patients. The high volumes may be
injected either rapidly as a bolus or more slowly as an infusion; the bolus method produces better
visualization and a better urographic nephrogram than the infusion method.
9. Cystography, its types.
A cystogram is a radiogram showing radiopaque outlining of the bladder cavity. Cystograms are
seen as part of ordinary excretory urograms, but direct radiographic cystograms can be obtained by
instilling a radiopaque fluid directly into the bladder. The contrast medium is usually instilled via a
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transurethral catheter, but when necessary, it can be administered via percutaneous suprapubic bladder
puncture. Radiograms of the filled bladder are taken using standard overhead x-ray tube equipment, or
less frequently, “spot” films are taken during real-time, direct, image-intensified fluoroscopy.
10. Urethrography. Method, indications and contrindications.
The urethra can be imaged radiographically by retrograde injection of radiopaque fluid or in
antegrade fashion with voiding cystourethrography. The antegrade technique is required when lesions of
the posterior urethra, eg, posterior urethral valves, are suspected; the retrograde technique is more useful
for examining the anterior urethra. An antegrade urethrogram can also be obtained by taking radiograms
as the patient voids at the termination of an excretory urogram, when the bladder is filled with contrast
medium.
11. Antegrade urography.
This method of outlining the renal collecting structures and ureters is occasionally used when
urinary tract imaging is necessary but excretory or retrograde urography has failed or is contraindicated
or when there is a nephrostomy tube in place and delineation of the collecting system of the upper urinary
tract is desired. The contrast medium is introduced either through nephrostomy tubes, if these are present
(nephrostogram), or by direct injection into the renal collecting structures via a percutaneous puncture
through the patient`s back.
12. Method, indications and contrindications for arteriography of the kidneys.
Anteriographic study of the kidneys is performed almost exclusively by percutaneous needle
puncture and catheterization of the common femoral arteries or, much less often, the axillary arteries.
Rapid serial radiograms are obtained during and aften bolus injection of suitsble radiopaque contrast
medium into the aorta at the level of the renal arteries (aortorenal arteriogram, “flush” abdominal
aortogram) or into one of the renal arteries (selective renal arteriogram).
13. Isotopic renography.
Radioisotopic techniques provide a means of investigating the structure and function of internal
organs without disturbing normal physiologic processes. Currently, 4 general types of renal radioisotopic
labels are used. Classified according to the mechanisms of labeling, they are as follows: (1) renal cortex
labels, which are retained in the renal tubular cells; (2) intravascular comparment labels; (3) renal tubular
function labels, which briefly label the renal cortex as they are accumulated by renal tubular cells and
then are passed into the urine and cleared from the kidney; and (4) substances cleared solely by
glomerular filtration, which allow determination of the glomerular filtration rate.
Real life situation to be solved:
1. Patient S., 28 years. During intravenous infusion of 76% urographine (3 ml), starts voumiting,
headache, and apnoe.
A.
What does it mean?
B.
Your tactics?
2. Women K., 67 years. In anamnesis urolithic disease with small stone exretion. In blood: glucose
5,4; urea 10,3; creatinine 0,18m. mols/l.
A. What type of excretory urogram is necessary to use?
B. Methodic of excretory urogram.
Tests.
1. What of this preparation must be used for excretory urography?
A.
Iodlipole
B.
Urographyne
C.
Barium
D.
Bilitrast
E.
Bilignost
2. What of this preparation neutralise iodcontent substences?
A. Natrium Thyosulfate
B. Magnium sulfate
C. Dimedrole
D. Prednisolone
3. What is the volume of kidney cavity?
A. 10-15ml.
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B. 15-20ml.
C. 5-6ml.
D. 20-25ml.
E. 2-3ml.
Answers:
1. a. Alergical reaction on iodcontent preparation. b. To stopped inffusion of urographyne, it is
necessary to inffuse Natrium Thyosulfate.
2. a. Inffusional urography. b. 60ml. of contrast +120ml. NaCl 0,9% to inffuse intravenous
slowly.
Tests: 1-B; 2-A; 3-C.
Student should know:
1. View urography.
2. Excretory urography. Indications and contrindications.
3. Methods of excretory urography.
4. The types of excretory urograms.
5. Retrograde urography.
6. Antegrade uretherography.
7. Cystography, its types.
8. Angiography.
9. Echographia, scanograms.
Student must be able to:
1. Prepare the patien to urography.
2. Determine indications and contrindications for excretory and retrograde urography.
3. Read view and contrastive urograms, isotopic reno- and scanograms.
4. Diagnose X- ray possitive stones of urine tracts with other same shadows.
5. Diagnose hydronephrose, anomalies of development the kidneys (anomalies of quantity,
situation, structure).
Methodological Instructions to Lesson 4 for Students
Theme: Acute pyelonephritis.
Aim: To teach students to diagnose acute pyelonephritis and principles of treatment of this disease.
Professional Motivation:
Pyelonephritis is common disease. Acute pyelonephritis during the pregnancy is noted 1,5-2,5% in
pregnant women. In elder people this disease is noticed 100 patients out of 10 000 people.
Basic Level:
1. Anatomy, physiology of kidneys.
2. Symptoms of acute pyelonephritis and reasons of them.
3. X-ray, instrumental, laboratory, functional and endoscopic methods of investigation used to
diagnose pathology of kidneys.
4. Principles of acute pyelonephritis treatment.
Student's Independent Study Program
I.
Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Classification of pyelonephritis.
1- The unilateral and bilateral. a-Acute /purulent, serous/ b-chronic; c-relapsing course.
2- By the mode of bacteria pathway there are differed: a- hematogenous /ascending/;
b- urogenic /ascending/;c- urolithiasis /infected urinary stones; d- tuberculosis of the kidneys; eother renal diseases.
By the course, age, stage of the organism there are differed:1- the pyelonephritis of newborn;2 – the
pyelonephritis of the aged patients;3- the pyelonephritis of the pregnant women;4- the pyelonephritis in
diabetes mellitus patients.
The acute pyelonephritis may be complicated with purulent nephritis, carbuncle of the kidney, the
renal abscess, renal insufficiency.
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1.
Pyelonephritis etiology and pathogenesis.
The pyelonephritis arises because of entry of the bacteria into the kidneys and development of the
inflammatory process within the interstitial tissue, renal pelvis and calyces.
The principal causative agents are E. Coli, Staphylococci, Vulgar proteus, Enterococci, etc. Due to
urine pH changes or antibiotics instillations these bacteria transform into L-forms and protoplasts. When
the conditions become better they transfer back to the vegetative form. That’s why there is no growth at
the culture mediums while laboratory diagnosis and there isn’t an effect of common treatment. The
peculiarity of the pyelonephritis is mixed infections with the resistant bacterial strains. The most common
association is Proteus with Pseudomonas Auruginosa /Blue pus bacillus/ not so frequent the Hemoliticus
strains of the E. Coli, Enterococci and staphylococci.
3. Primary acute pyelonephritis (clinical signs, diagnosis).
The general symptoms include shaking chills associated with intermittent fever moderate to
excessive sweating, headache, mialgia, artralgia, nausea, vomiting, the patients appear quiet ill. The local
signs are pain at the lumbar region that irradiates to the upper portion of the abdomen, into back. The fist
percussion over the costovertebral angle overlying the affected kidney is rather painful, positive
Pasternatskiy’s symptom. The overlying muscles’ spasm, abdominal distention may be marked. The
enlarged painful kidney also may be palpated on first days. The laboratory findings play the main role.
There is bacteriuria. The quantitative research of culture in 1 ml of urine, kind of pathogen flora,
leukocyteuria and Shternheimer-Malbin cells are found out. There are changes that are typical to any
infection at the beginning: leukocyteuria /40-60 and more, erythrocyteuria /10-20 to 30-40 in field of
vision, proteinuria to 1g/l
4. Treatment of the first acute pyelonephritis.
The main scheme includes the diet, bed rest, hydratation, desintoxication, general strengthening
and specific antibacterial treatment. The bed rest and hospitalization are required. The difficulties of the
treatment include the bacterial resistance to the drugs, change of the bacterial strains, alergisation. The
diet should be sparing. The energetic support provides carbohydrates and plants fats. The source of
proteins may be cheese, hen eggs, then boiled fish and meat. Spices are forbidden. Vitamins and a lot of
fluid are necessary. The salt is limited. Perorate hydratation includes to 3-l of fluid during a day on equal
portions. The parenteral hydratation means the endovenous infusion of isotonic, Ringer-Lokk’s, glucose,
Polyglycine solutions with vitamins and antibacterial agents. 1,5-2l of the certain solution may be infused
for two times a day. Albumin, plasma, g-globulin are also infused. Antimicrobial treatment with
desintoxicative and general stimulative measures are effective in case of primary process.
5. Secondary acute pyelonephritis (clinical signs, diagnosis).
The excretory urograms show the enlargement of the infected kidney. The outline of the ileopsoas
muscle is absent sometimes, the diffuse shadow about the kidney and moderate scoliosis at the side of the
disease are present. There is a slow excretion of the contrast. Calyces are flattered and clubbed, they are
filled with contrast later than normal kidney. The intravenous excretory urogram shows the significant
atrophy of the parenchyma of the affected kidney, its deformation because of infiltrates and atonia of the
ureter. Chromocystoscopia shows the range even sometimes the cause of the functional loss of the urine
outflow. There can be seen the bullous edema of the uretral orifice because of calculus at the intravesical
portion, ureterocele, tumour compression.
The noninvasive methods are useful. These are radionuclide scintygrpahia, nondirect angiographia,
ultrasonography
6. Treatment of secondary acute pyelonephritis.
The secondary pyelonephritis requires draining of the kidney, sometimes even the purulent source
removal. Before the urine outflow isn’t restored the antibacterial mediums are dangerous especially of the
strong action. The bacteriemic shock may develop.
7. Pyelonephritis of pregnant women (etiology, clinical signs, diagnosis).
The inflammatory process develops while pregnancy, delivery and puerperal period. Most
frequently it is observed in pregnant (48%) more rare in puerperal (35%) women. It develops in 1st
pregnancy, 2 trimester often. There are women 18-25 years old. That is explained by a not complete
adaptation to immunologic, hormone changes of the pregnancy. It is supposed not to be a primary disease
but activation of latent pyelonephritis. Diagnosis is rather difficult. The enlarged uterine hinders the
palpation. The right kidney damage should be differed from the acute appendicitis and cholecystitis. Xray imaging is inadmissible exclusive rare occasions. The endoscope investigation isn’t recommended
10
too. In case of the suspicion of purulent process the complete clinical research is required including
chromocystoscopia, radionuclide renography, scanning, excretory urography, ultrasonography.
8. Treatment of pyelonephritis in pregnant women.
Antibiotics shouldn’t be harmful to fetus. The natural and semisynthetic penicillines are
recommended at the 1st trimester. Wider choice of antibiotics is at the 2nd and 3rd trimesters because
placenta has its barrier function then. The puerperal women may transfer drugs to child with milk.
Treatment should be continuous. Nitrofuranes are admissible after 2nd month in dosage 50-100mg per
day. Nalidixone acid is admissible after the 4th month of pregnancy (2g per day for 2-3 weeks). But its
administration must be stopped before delivery. The acute purulent pyelonephritis in pregnant women
requires the obligate surgical measures. Its scope depends on form of the disease. It is necessary anyway
until the delivery.
9. Apostematous pyelonephritis (clinical signs, diagnosis).
There are no change in the urine analysis initially, then proteinuria, leukocyteuria and bacteriuria
appear. The hemogram shows leukocytosis and shift to the left.
A plain film of the abdomen may show the enlarging of the kidney. Excretory urograms show
kidneys dysfunction. The renogram shows the abnormalities of vascularisation, secretion, excretion. The
renograms may be of the obstructive type that evident the pathologic process in the kidney. Its location
may be showed by the scyntygraphia with computing. There are the focuses with decreased accumulation
of radionuclide at the scanogram. The primary cause of the disease,calculus of the kidney or ureter may
be found while secondary apostematous pyelonephritis at the X-ray examination.
10. Treatment of apostematous pyelonephritis.
The urgent surgical measures are required. The subcostal lumbotomia is performed. The kidney is
nuded and decapsulated. The purulent focuses are incised. The retroperitoneal space should be drained
and free output of the urine provided by means of the nephrostomia. The surgical drainage should be
present until the urine output becomes free, inflammation disappears and renal function normalizes. The
postoperative period requires the antibacterial and desintoxicative treatment that is similar to chronic
pyelonephritis.
11. Abscess and carbuncle of kidney (clinical signs, diagnosis).
X-Ray-finding is very important. If the renal outline is visible the plain film may show the enlarged
kidney or a bulge of the external renal contour. With the perinephral oedema, however, often the renal
outline is obliterated and the psoas shadow indistinct. The shadows of the concrements may be
sometimes. One can see the deformation and narrowing of the renal pelvis, deviation and indistinct
outlines of the calyces on the excretory urograms and pyelograms. Pyelonephritic changes, urolithiasis
may be observed. Delayed pacification may be found. Carbuncle may be confused with tumour
sometimes while the X-ray imaging. The renal angiography usually makes the diagnosis.
12. Treatment of abscess and carbuncle of kidney.
Treatment includes the urgent surgical measures. Lumbotomia is performed. Then decapsulation of
the kidney and cone-shaped excision of the carbuncle are done. Incision, curettage and draining of the
kidney or enucleating of the carbuncle with its incision may be performed too. The cone excision is organ
preserving surgical operation. The cross-shaped incision is made up to the health tissues just after
decapsulation (nuding) of the kidney and revision of its surface. It shouldn’t be deeper than 0,5 cm. Then
the assistant pull out the internal angles by means of miniature acute hooks. The surgeon with ophthalmic
scalpel removes gradually by circular incisions the necrotic masses. But the surgeon gets it out from the
surface and next from the deep tissues, orientating to the colour of the tissues and bleeding range.
Moderate venous diffusion evidents the demarcating of necrosis zone from the health tissues. The coneshaped hollow cavity forms after the extraction. Moderate tight tamponade with gauze favors the
hemostasis and outflow of the vulnus secretion.
The postoperative period requires the antimicrobial treatment with considering of the urine culture
and renal tissue culture.
II. Tests and Assignments for Self-assessment
Multiple choice. Choose the correct answer/statement:
1. First change in urine which will prove acute hematogenic first pyelonephritis:
A. Bacteriuria.
B. Leukocyturia.
11
C. Proteinuria.
D. Haematuria.
E. Hyaline casts.
2. What should we have to do firstly to diagnose pyelonephritis of pregnant
women?
1. Retrograde urography.
2. Excretory urography.
3. Cystoscopy.
4. Radiologic examination.
5. Chromocystoscopy.
Real life situation to be solved:
1. In cabinet of urology came a women with clinical findings of acute pyelonephritis on right side
(body temperature is 38 ° C-40 °С; there are proteines less, leucocytes in analysis of urine). What
methods of diagnostic we should provide? What are tactics of treatment?
2. Patient K., at the age of 42, complaints of pain in left side back at the region of kidney with
temperature of body is 39,2°C; he's shivering and weak. He is suffering from stone in left kidney during
six years.
What complication of disease appears in this patient? What methods of examination we should do
to the patient? What are tactics of treatment?
III. Answers to the Self-as'sessment.
The correct answers to the tests:
1. A.
2. E.
The correct answers to the real life situations:
l. We must do chromocystoscopy. In case when kidney won't function we should do catherization
of kidney.
2. Acute chronic pyelonephritis (the complication apostematous nephritis). We must provide
ultrasound screening, retrograde and excretory urography. An operative treatment.
Visual Aids and Material Tools:
1. Slides (chronic pyelonephritis, x-ray of pyelonephritis).
2. Excretory pyelogram.
3. Retrograde pyelogram.
Students' Practical Activities:
Students must know:
1. Pyelonephritis (etiology, pathogenesis).
2. Classification of pyelonephritis.
3. Primary acute pyelonephritis (clinical signs, diagnosis).
4. Treatment of primary acute pyelonephritis.
5. Differential diagnosis of the primary acute pyelonephritis from tuberculosis of urinary system,
from acute diseases of organs of abdominal cavity.
6. Secondary acute pyelonephritis (clinical signs, diagnosis).
7. Treatment of secondary acute pyelonephritis.
8. Pyelonephritis in pregnant women.
9. Treatment of pyelonephritis in pregnant women.
10. Forms of acute pyelonephritis (clinical signs, diagnosis, treatment).
11. Apostematous pyelonephritis (clinical signs, diagnosis, treatment).
12. Abscess and carbuncle of "kidney (clinical signs, diagnosis, treatment).
Students should be able to:
1. suspect acute pyelonephritis with the complaints of a patient and anamnesis (life history).
2. make plan of investigation.
3. make differential diagnosis.
4. plan of treatment the patient suffering from acute pyelonephritis.
5. estimate analysis of blood and urine biochemical analysis of blood, x-ray, radio-isotopical and
vascular examination.
12
Methodological Instructions to Lesson 5 for Students
Theme: Pyonephrosis and paranephritis.
Aim: Students Should be able to diagnose, should know the principles of treatment of pyonephrosis
and paranephritis and know the operative methods of treatment.
Professional Motivation:
Pyonephrosis is terminal stage of non specific or specific destructive pyelonephritis. This disease is
often noted at the age of 30-50 years, with complication of death.
Basic Level:
1. Anatomy, physiology of kidneys and paranephra.
2. X-ray, instrumental, functional, endoscopic methods used in examination and diagnose of
pyonephrosis and paranephritis.
3. Using of etiologycal, pathogenetic, symptomatical therapy: medicamental, radiational, operative
methods of treatment.
Student's Independent Study Program
I.
Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1.
Etiology and pathogenesis of pyonephrosis.
Pyonephrosis is the end stage of a severely infected and obstructed kidney. The kidney is
functionless and filled with thick pus. At times, a plain film of the abdomen may show an air urogram
caused by gas liberated by infecting organisms.
2.
Clinical findings of pyonephrosis.
The usual symptoms of pyonephritis include abrupt oncet of shaking chills, moderate to high fever,
a constant ache in the loin (unilateral or bilateral), and symptoms of cystitis: frequency, nocturia,
urgency, and dysuria. Significant malaise and prostration are the rule; nausea, vomiting, and even
diarrhea are common.
3.
Diagnose of pyonephrosis.
Ultrasonography reveales massive dilatation of the renal collecting systems, and computed
tomography confirmes the diagnosis of bilateral hydronephrosis. There however is no difference in the
appearance of fluid within each of the kidneys.
Percutaneous nephrostomies is inserted on a semiemergent basis. Purulent material with the
consistency of mud is evacuated from the right collecting system, but clear urine is drained from the left.
4.
Differential diagnosis of pyonephrosis.
Pyonephrosis must be distinguished from other causes of chronic tubulointerstitial renal disease,
especially analgesic nephropathy. Renal tuberculosis must be considered in the differential diagnosis.
Urine smears and cultures are positive for mycobacteria and urograms showing the changes typical of
renal tuberculosis make this differentiation. At times, renal scans, angiograms, or CT scans are needed to
differentiate renal tumors from the changes of pyonephrosis noted on urograms.
5.
Treatment of pyonephrosis.
Contributing anatomic defects (particularly those causing obstructive uropathy) should be corrected
and calculi (especially infected stones) removed by surgical means. If progressive renal damage and
functional loss are to be minimized, the patient must be followed closely, urinary tract infections must be
controlled tightly, and complications must be identified promptly and treated adequately. The
hypertension associated with unilateral atrophic pyelonephritis may be renin-mediated; the patient should
be evaluated for possible therapeutic nephrectomy.
6.
Etiology and pathogenesis of paranephritis.
Perinephric abscesses lie between the renal capsule and the perirenal (Gerota`s) fascia. Most result
from rupture of an intrarenal abscess into the perinephric space; the causative organisms are usually coliform bacteria and Pseudomonas, less often staphylococci and obligate anaerobes.
7.
Clinical signs of paranephritis.
Fever tends to be low-grade unless generalized sepsis evolves. There is usually marked tenderness
over the affected kidney and costovertebral angle. A large mass may be felt or percussed in the flank.
13
Abdominal tenderness accompanied by variable rebound tenderness may be elicited. The diaphragm on
the affected side may be elevated and fixed. Ipsilateral pleural effusion is common.
8.
Diagnose of paranephritis.
Erythema and edema of the overlying skin may be evident. Minimal edema is best demonstrated by
having the patient lie on a rough towel for a few minutes.
Leukocytosis is usual but may be mild; a shift to the left is commonly seen. The erythrocyte
sedimentation rate usually is elevated; anemia may be present. Pyuria and bacteriuria are found
commonly but not routinely. Blood cultures may be positive. Unless bilateral renal disease is present, the
serum creatinine and blood urea nitrogen values generally are normal.
9.
Differential diagnosis of paranephritis.
Acute renal infections cause many of the symptoms that accompany perinephric abscess: fever,
localized pain, and tenderness. In acute pyelonephritis, the urine uniformly shows evidence of infection;
in perinephric abscess, the urine may or may not show evidence of infection. X-ray studies and scans,
however, should facilitate differentiation of these 2 conditions.
10.
X-ray signs of paranephritis.
A plain film of the abdomen typically shows evidence of a flank mass. Surrounding edema often
results in obliteration of the renal and psoas shadows on the affected side. Scoliosis with the concavity to
the affected side is common. The presresulting from calculous pyonephrosis. Occasionally, a localized
collection of gas caused by infection with gas-forming (coliform) organisms may be observed in the
perirenal area.
Excretory urograms may show delayed visualization or nonfunction related to obstructive uropathy
or parenchymal disease.
11.
Treatment of paranephritis. Generally, treatment is similar to
treatment for renal abscesses, except that surgical drainage usually is required for perinephric
abscesses but may not be required for intrarenal abscesses. Intensive antimicrobial therapy,
based upon culture and sensivity testing of the pathogen isolated from urine, blood, or pus
obtained by needle aspiration of the lesion, is mandatory. Unless adequate percutaneous
drainage needed. Because of underlying renal disease, nephrectomy may be required, either
acutely or subsequent to initial control of the abscess.
12.
Complications of paranephritis. Unless the correct diagnosis is
made promptly and effective therapy is initiated early, the mortality rate from generalized sepsis
is quite high. Rarely, the perinephric abscess may point just above the iliac crest posterolaterally
or extend downward into the iliac fossa and inguinal region. It is most unusual for the phlegmon
to extend within the perirenal fascia across the midline to involve the opposite side of the body.
The abscess may produce considerable ureteral compression, giving rise to hydronephrosis. Even
after drainage of the abscess, ureteral stenosis from periureteritis may evolve during the healing process.
II. Tests and Assignments for Self-assessment
l. Cystoscopic signs of pyonephros are:
A. Hyperemia of left ureteric orifice.
B. Secretion of blood of the ureteric orifice.
C. Suppuration of the ureteric orifice.
D. Deformation of the ureteric orifice.
E. Ureterocele.
2. What is characteristic for paranephritis on urography?
A. Smoothing out of transverse muscle.
B. A suspicious shadow.
C. Deformation of lower pole of kidney.
Diminution of contours of kidney.
E. Deformation of upper pole of kidney.
3. During suppurative paranephritis they use:
A. Pyelonimotomia
B. Decapsulation and nephrectomy.
C. Nephrectomy.
D. Opening/drainage of abscess.
E. Nephrostomy.
14
Multiple choice. Choose the correct answer/statement:
Real life situation to be solved:
1. Patient K., at the age of 67, complains of pain at the right lumbar with raising of temperature 39 °С
and chill, the fact from her anamnesis (life history) is that she is suffering with stone in right kidney since 12
years. From chromocystoscopy, it is noted that thick pus is coming from right ureteric orifice. Objective: right
kidney is bulged, painful. Symptom of Pastematzkiy is positive. What is a diagnosis? What are the tactics of
treatment?
2. Patient S., at the age of 34, came to the polyclinic with complains of pain in the back region of
the kidney which increases when he bends right leg; the temperature is 39,2°C.
Objective: reddish, right-side skin in the region of kidney, painful when it is touched. In X-ray
intensifying screens at the breast-cage it came to know that at only one part of diaphragm is moving.
What is the diagnosie? What are the tactics of treatment?
III.
Answers to the Self-assessment.
The correct answers to the tests:
l. C.
2. A.
3. D.
The correct, answers to the real life situations:
1. Stone in right kidney. Right pyonephros. Nephrectomy should be done.
2. Acute pyelonephritis of right side. The patient should be hospitalised. Operative lumbotomia of
right side and draine the pus.
Visual Aids and Material Tools:
1. Slides (retrograde pyelogram-pyelonephros).
2. X-ray photographs:
a) urography-pyelonephros;
b) pyelogram-pyelonephros.
3. Cystoscopic drawings (suppuration of the ureteric orifice)
Students' Practical Activities:
Students must know:
1. Etiology and pathogenesis of pyonephros.
2. Clinical signs of pyonephros.
3. Diagnose and differential diagnosis of pyonephros.
4. Treatment of pyonephros.
5. Paranephritis classification.
6. Symptoms and clinical signs of paranephritis.
7. Diagnosis of paranephritis.
8. Differential diagnosis of paranephritis.
9. X-ray signs of paranephritis.
10. Treatment of paranephritis.
11. Complications of paranephritis.
Students should be able to:
1. To select from anamnesis (life history) and medical card characteristic features of pyonephros
and paranephritis.
2. To plan an examination of a patient.
3. To select main characteristics of pyonephros and paranephritis.
4. To plan a treatment of a patient suffering from pyonephros and paranephritis.
5. To analyze data of diagnostic tests (general urine specimen examination, urine examination by
Netchyporenko, Amburge, test of Zemnitski).
6. To provide palpation and percussion of the kidneys.
To estimate excretory urography, ultrasound screening, retrography, pyelogram, results of
chromocystoscopy. Methodological Instructions to Lesson 6 for Students
Theme: Tuberculosis of kidneys.
15
Aim: Students should know how to diagnose and specific principles for the of treatment the
patients suffering from tuberculosis of uro-genital organs and should know methods of operation used for
treatment.
Professional Motivation:
Tuberculosis of uro-genital organs is noted in 10-15% of patients suffering from tuberculosis.
Clinical findings of tuberculosis were written in 1841. First operation of this disease was successfully
done in 1872.
Basic Level:
1. Anatomy, physiology of urinary-sexual system.
2. Etiology, pathogenesis, morphological changes in kidney urinary bladder in the case of
tuberculosis.
3. X-ray, functional, instrumental, laboratory, endoscopic methods of investigation.
4. Principles in treatment of patients suffering from tuberculosis in urology.
Student's Independent Study Program
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Etiology and pathogenesis of tuberculosis of kidneys.
A process is predetermined by the specific exciter — microbacteria of tuberculosis (by the Koch
stick). Basic by diffusion of tubercular infection there is hematogenical. At first buds are struck, and from
there the infection on the blood vessels gets in the kidney bowl, ureter, urinary bladder. Infication takes
place in the period of primary or secondary generalisation of tubercular process from the basic cell in the
lungs, lymphatic nodes, bones and muscles. Although the tubercular cells develop in both kidneys, but in
70 % cases it is unilateral. Only after the unfavourable terms to the clinical symptoms of tuberculosis of
one kidney the secondary symptoms join and second kidney which was until now considered healthy also
suffers. That it is the principal reason of transformation of milliar tuberculosis of crust matter of kideny
in the destructive damage of cerebral matter.
2. Classification of kidney's tuberculosis with the help of X-ray, clinical findings.
In practice they make use of the сlinical-roentgenologic classification of tuberculosis of buds
offered by М. О. Lopatkin with coll (1977): I stage — non destructive (infiltrative) tuberculosis of bud;
II — initial destruction (papillitis or small, by diameter about 1 cm, single cavities); III — measured
destruction (cavity of largenesses or policavernosical tuberculosis one of bud segments); IV — total or
subtotal destruction (policavernose tuberculosis of two segments, tubercular pyonefrose, calcification
buds).
3. Pathological anatomy of tuberculosis of kidney and urinary tract.
In acute form of tuberculosis of kidneys in the crust matter the typical lymphoidal or epitheliodal
cellular humps, that have characteristic giant cages, similar to the Pirogov-Lanhgance cages arise up. In
chronic form of tuberculosis of kidneys humps are disposed at first in the crust and cerebral matter,
mainly in area of kidney papillae and pyramids. Gradually they take shelter by ulcers, are added
disintegration and form the cavities, which unite with the kidney bowl.
Petrification of those cells or substitution of them by the fibrose fabric can take place in some
cases, in other ones — form plural cavities, which often unite between itself. Round cavities the
inflammatory changes arise up and the humps appear, that testifies to combination of different stages of
motion of tubercular process. These changes can be completed by full destruction of bud with
development of pyonefrose. Gradually the tubercular process engulfs a fibre, and then fatty capsule of
bud, that results in development of sclerosic or festering paranefritis.
4. Symptomatology and course of tuberculosis of kidney and urinary tract.
On the early stages of disease, when in parenhima the first tubercular humps appear, sometimes
general weakness, indisposition, rapid fatigue, reduction of body mass, losing of appetite, dull pain in the
lumbar area, subfebril temperature of body exist. In the case of the process sharpening, penetration of
tubercular cell in the kidney bowl the chill can appear. The temperature curve gains a hectic character,
sharp or dull pain appear in the lumbar area, disurical discords exist. The kidney pain exists at the
corking by ureter rawsimilar (caseosic) the masses. On the late stages of process, especially in case of
bilateral defeat, all signs of chronic insufficiency of buds appear.
5. Diagnose of kidney's tuberculosis.
16
In the initial stages of disease the pathological changes on excretory urograms can’t be fixed if
there are the same violations, however in unspecific pyonefritis or necrotic papillitis — seen uneven
contours in area of small bowls. As far as progress of process in excretory urograms expose single or
plural cavities, which have uneven edges. At the productive stage of bud tuberculosis on urograms it is
possible to expose a defect of the filling, compression or amputation of bowl. The expansion often exists
and even obliteration of kidney bowl. In the case of diffusion of tubercular process on ureter pulls, even
narrowing and expansion of it without the visible peristaltic waves are marked. After wards the plural
narrowing of ureterus appears.
6. Laboratory diagnosis of kidney's tuberculosis.
The most reliable and objective sign of tuberculosis of urinary organs is an exposure in sediment of
urine of micobacteria of tuberculosis. For this purpose they apply bacterioscopical, bacteriological,
biological methods of research, a frequent sowing of urine and other.
7. X-ray and endoscopical diagnose kidney's tuberculosis.
The cystoscopy is the most informative method of diagnostics of tuberculosis of urinary bladder. In
the early stages of tuberculosis of urinary bladder the mucus membrane can be normal. On background
pink coloued mucus shell expose small areas of hyperemia and hemorrhages. Near the opening of the
ureterus staggered bud it is possible to expose a shallow primrose or grey-yellow tubercular humps with
the reddish rim on periphery. The opening ureterus is pulled in, deformed, it has the shape of crater.
8. Differential diagnosis of kidney's tuberculosis.
Chronic nonspecifik cystitis or pyelonephritis may mimik tuberculosis perfectly, especially since
15-20% of cases of tuberculosis are secondarily invaded by pyogenik organisms. If nonspecific infections
do not respond to adequate therapy, a search for tubercle bacilli should be made. Painless epididymitis
points to tuberculosis. Cystoscopic demonstration of tuberculosis and ulceration of the bladder wall
means tuberculosis. Urograms are usually definitive.
Acute or chronic nonspecific epididymitis may be confused with tuberculosis, since the onset of
tuberculosis is occasionally quite painfull. It is rare to have palpatory changes in the seminal vesicles
with nonspecific epididymitis, but these are almost routine findings in tuberculosis of the epididymis.
9. Convincing symptoms of kidney's tuberculosis.
To including X-ray examinaition, endoscopic and laboratory method.
10. Conservative methods of treatment and prognosis of tuberculosis of kidneys.
They usually apply simultaneously three specific antituberculouse preparations of different
mechanism of action. To preparations of Ist row belong streptomycin, sodium of paraaminosalicylatis,
isoniasid (tubasin) and its marching (phtivasid, metasid, salusid, larusan, inga-17І). To preparations IInd
row belong aetionamid, cycloserine, tyoacetason, aetoxid, pirasinamid and florimycin sulfate.
The primary course of continuous medical treatment by the antituberculouse preparations does
notproceed le than n year. It is carried out under surveillance of urologist-phtisiatrist. The antirecidive
courses by duration the 1,5— 2 months are conducted during the 3—4 years in the spring-autumn
periods. For the medical treatment they use one of the marching tubasidum in combination with
aetoxidum or to sodium of paraaminosalicylatis.
11. Operative treatment of tuberculosis of kidneys.
If the destructive tuberculosis of bud has a limited nature, shown cavernotomy, cavernectomy,
resection of bud. Cavernectomy and cavernotomy aren’t now practically applied. In case of the single
narrowing of ureterus on the small distance they execute the resection of this area and they impose
anastomosis after type end in end, at stricturas of pyeloureteral segment — resection with imposition of
anastomosis after the Anderson-Haync method or Coachman. In the case of stricturas pelvic part of
ureterus necessary direct or indirect ureterocystoneostomy. At plural stricturas ureterus they execute an
operation of substitution by its a thin bowel on mesenterium, that is the intestinal plastic of ureterus.
After operations a sick is to get antituberculosic preparations for a year.
12. Complications of tuberculosis of kidneys.
A. Renal Tuberculosis. Perinephrik abscess may cause an enlarging mass in the flank. A plain film
of the abdomen will show obliteration of the renal and psoas shadows. Sonograms and CT scans may be
more helpful. Renal stones may develop if secondery nonspecific infection is present. Uremia is the end
stage if both kidneys are involved.
17
B. Ureteral Tuberculosis : Scarring with strcture formation is one of the typical lesions of
tuberculosis and most commonly effects the juxtavesical portion of the ureter. This may cause
progressive hydronephrosis. Complete ureteral obstruction may cause complete nofunion of the kidney.
C. Vesical Tuberculosis: When severely damaged, the bladder wall becomes fibrosed and
contracted. Stenosis of the ureteres or reflux occurs, causing hydronephrotic atrophy.
Key words and phrases:
tuberculosis, aseptical piuria.
II. Tests and Assignments for Self-assessment
1. Biological tests of microbacteria experimented on:
A: mice.
B: guinea-pigs.
C: flies.
D:dogs.
E: rats.
2. Symptom of tuberculosis in urine-excretory system which is noted in urography is:
A: deposits of calcium in kidney.
B: shadow in renal pelvis projection.
C: increase of kidney in size.
D: smoothing of transverse muscle.
E: decrease of kidney's size.
3. Symptom of tuberculosis in urine excretory system which is noted in retrograde cystoscopy is?
A: increase of size of urinary bladder.
B: deffect in filling.
C: microcyst, bladder-urinary reflex.
D: diverticulum of urinary bladder.
E. protuberant in neck of urinary bladder.
Real life situation to be solved:
1. Patient C., at the age of 54, complains of periodical dysuria which brings pain and problem
during urine excretion. Usage ofuroseptics didn't bring any improvement. What type of disease gives this
type of symptoms? What should we do for absolute diagnosis for this patient?
2. Patient C., at the age of 51, complaints on dysuria. In analysis of urine microhaematuria is noted;
in cystocopy the volume of bladder is 110 ml; in the region of right ureter's opening the mucous is
hypertrophied, dropsical.
Which disease can be the patient suffering from?
Which extra methods are needed for absolute diagnose?
III.
Answers to the Self-assessment.
The correct answers to the tests:
l. B.
2. A.
3. C.
The correct answers to the real life situations:
1. Tuberculosis; normal ulcer, cancer of urinary bladder. We must do cystoscopy.
2. We should think of tuberculosis urine-excretory system. We must do few times B. K and
excretory urography.
Students' Practical Activities:
Students must know:
1. Etiology and pathogenesis of kidney's tuberculosis.
2. Clinical X-ray classification of kidney's tuberculosis.
3. Pathological anatomy of tuberculosis of kidneys and urinary tract.
4. Symptomatology and treatment of tuberculosis of kidneys and urinary tract.
5. Diagnosis of kidney's tuberculosis.
6. Lab diagnose of tuberculosis of kidneys.
7. X-ray and endoscopic diagnose of kidney's tuberculosis.
8. Differential diagnose of kidney's tuberculosis.
18
9. Convincing symptoms tuberculosis of kidneys.
10. Conservative treatment and prognosis tuberculosis of kidneys.
11. Operative treatment tuberculosis of kidneys.
12. Complications of kidney's tuberculosis.
13. Peculiarities ofdysuria and piuria in case of kidney's tuberculosis.
14. Aseptical piuria and diagnostic importance.
Students should be able to:
1. To note symptoms and syndromes of tuberculosis of kidneys, urinary bladder.
2. To diagnose tuberculosis of kidneys and urinary tract.
3. To diagnose different stages of tuberculosis of kidneys and urinary tract.
4. To formulate and explain a clinical diagnosis.
5. To define tactics of treatment in case of tuberculosis of kidneys and urinary tract.
6. To study X-ray of patients suffering from tuberculosis of kidneys and urinary bladder.
Methodological Instructions to Lesson 7 for Students
Theme: Tumors of the kidneys and ureter.
Aim: Teach students how to diagnose tumors of the kidney and ureter. Principles of treatment and
pathology of this disease.
Professional Motivation:
Tumors of the kidneys are noted in majors 2-3% out of all tumors. Men suffers 2 times more than
woman. Cancer is noted 80-90 %. Out of all kinds of tumors in the kidney's tumors of urinary tract are
noted up to 1%.
Basic Level:
1. Anatomy and physiology of the kidneys and ureter.
2. Collect anamnesis, carry out physical examination.
3. Etiology and pathogenesis of the tumors kidneys and ureter.
4. X-ray, functional, instrumental, laboratory, endoscopial, morphological methods of investigation
used to diagnose tumors of the kidneys.
5. Principles of treatment of tumors of the kidneys and ureter.
Student's Independent Study Program
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1.
Etiology and pathogenesis of the tumors kidneys and ureter.
In the kidney tumour genesis it is led to the role of hormone violations, influencing an ionizing
radiation and chemical matters and lacks of development. Some authors abide by the viral theory of
origin of new formations of kidney. In origin of kidney tumour the smoking assists. A prognosis and
tactic of medical treatment at tumours is built on the basis of results of morphological and histological
researches of remote neu formation. About 90 % malignant tumours of kidney make a cancer. The kidney
cancer makes 5-6 % of all urology diseases and 2-3 % of neu formations. It arises up mainly in age 40-70
years, at men – in the 2,5-3 times more frequent. It develops from epithelium of different departments of
nefron and collective tubes: ball capsule epithelium, kidney tubulla (descending part of loop of nefron,
distal part of tubulla loop of nefron). Actually lightcellular, alveolar, grainycellular (darkcellular),
polymorphic.
2.
Classification of the kidney's tumors.
They classify the tumours by system of TNM:
Т – a primary tumour;
Тх – it’s impossible to set a presence and tumour diffusion degree. This category can be used for
histological or citological confirmed metastases in the region lymphatic knots or remote organs;
Т0 – there are the signs of primary tumour. This category is applied in that cases and Тх;
Т1 – a tumor is 7 cm, thin bounds of kidney. They set from the datas of roentgenologic and radionuclid
research;
T2 – a tumor by size over 7 cm within bounds of kidney; palpated, mobile. The clinic-roentgenologic
19
data testifies to the tumour presence;
T3 – a tumor by size over 7 cm outside kidney fascia; palpated, mobile;
Т4 – the tumour spreads outside fat renalis and others organs;
N – regional lymphatic nodes;
Nx – it is impossible to set the presence of metastases in the region of the lymphatic nodes.
There isn’t any deformation of lymphatic nodes region, after which it is possible to mark the presence of
metastases;
N2 – there are metastases in the remote lymphatic nodes by size over 2 cm, but less than 5 cm;
Мз – there are metastases in the lymphatic nodes by size over 5 cm;
М – there are remotemetastases;
Мх – the defining of remote metastases is impossible
Мо – there are the signs of remote metastases;
In case of clinical supervision of sick with tumours of the kidney (and of peripheral organs of the
urogenital system) and by the suspicion on the malignant new formation they can divide them in such
groups:
I – with the diseases; II – with the malignant tumours, which is the subject of a special medical treatment;
III – practically healthy patients in which a radical medical treatment is conducted; relapses of tumour
and its metastases does not exist; By the IV-with neglected forms of malignant neu formations, which
need a palliative or a symptomatic medical treatment.
3.
Pathological anatomy of the kidney's tumors.
They distinguish ferrous, papillari and solid-cellular forms of kidney cancer after the morphological
structure. As the great number of various morphological forms of kidney cancer exists that’s why it is
very difficult to clear up the nature of neu formation – a primary tumor or a metastasis.
The kidney sarcoma seldom exists, in 3,3 % cases. The source of its origin can be connecting
tissue, kidney capsule, remains of muscles and kidney, wall of kidney vessels. The tumour’s consistency
is soft (liposarcoma) or dense (fibrosarcoma); it is grey, grey-rouse or yellow on section.
4.
Tract of metastases of the kidney's tumors.
By the basic symptoms of the metastasis in bones there is a pain and a slight swelling above the
defected place. The metastases in liver can be single and plural. Thus the function of organ can’t be
violated. They mark a high temperature of body, weakness, hydrosis. Antyhotting facilities in this cases
are uneffective. Kidney cancer metastases in lung are accompanied by the rise of body temperature, by
cough with sputum, sometimes with the blood admixtures, by pain in side or after breastbone. A plural
new formations appear. Sometimes the metastasis in lung has a type of solitarry (single) knot, that is not
clinically shown for a long time. In such case it is possible to delete a metastatic tumour. The clinical
displays of metastases in the central nervous system rely on localization of pathological cell.
5.
Symptoms and clinical findings of kidney's tumours.
The clinical picture of tumours of kidney is extraordinary various. In some cases tumours are not
accompanied by the subjective feeling for a long time. A diagnosis is setting in case of inspection of
patients concerning other disease, most frequently in the tie with appearance of metastases in lights,
bones and others like that. However in majority of sicks in case of tumor appearance the general state of
body gets worse as a result of intoxication by products of exchange in the tumular fabric. A sick mark a
general weakness, rapid fatigue, decline or loss of appetite, he is becoming thin, it is a rising of body
temperature (sometimes about 38-39С),chill, anemization.
In most cases of kidney tumour total haematuria (60-88 %) is shown. It appears suddenly or on the
pain background in area of kidney. Sometimes after haematuria there is the typical attack of kidney colic
which stops when the clots of blood in the ureter are passed out thorough urine. Haematuria exists at onetwo urinations or a few hours proceed or days, and then it is suddenly halted. The next bleeding can
appear in a few days, months and even years.
Haematuria due to kidney tumours often has a profuse nature, it can causes the tamponede urinary
bladder and the sharp delay of urine. Then there is a pain after the value symptom of kidney tumour. It
exists in 50 % sick, it can be dull and sharp, permanent and changed. A third symptom of kidney tumour
is palpation of neu formation. It exists in 50-75% sick. The kidney tumour symptoms often haven’t
urological nature, continue for few months, and sometimes years. It is inludes unknown rising of body
temperature (20-30% sick), general weakness (20-40%), weight loss(20-30%), loss of appetite, nausea,
20
vomiting (10-15 %), neuropatia, miozitis (4-6 %) and etc. About 30 % sicks enter to a permanent
establishment with the undiagnosed tumour.
6.
Diagnose of the kidney's tumors.
Excretory urography helps to estimate a functional and anatomic state of kidney. Function of
kidney, staggered by tumor, is satisfactory for a long time. The absence of selection by kidney of
renthgenocontrastive matter (“mute” kidney) testifies the prevalence of tumular process or about
infiltration by tumor of vessels of kidney leg. On excretoryl urogram expansion of contours of kidney is
exposed on account of tumular knot, defect of the filling or pushing back a bowl and bowls, amputated or
arched of bowls, deformation of cap-bowl system, displacement of overhead department of uterus to the
middle line.
Nefrothomography gives a possibility to expose the surplus satiation by the rentgenocontrastive
matter of tumor area. The tumor differs from the kidney cyst, in area of which contrasting expressed
considerably less. Retrograde pielography is executed only after the strict testimonies, in the case of
necessity to differentiate a kidney tumor with the papillary tumor of bowl and uterus. On retrograde
pyelography deformation of bowls, amputation of bowls, compression and displacement of them,
increase of corner between them are frequently exposed. These changes vary and can combine. Besides
the excretory urography and retrograde pyelography conduct at haematuria and for the first days after it,
so far as the blood clots in bowls or bowls can simulate a defect of the filling, conditioned by tumor. In
such case kidney angiogram, kavography, scanning and scintigraphy of kidney, echography have a great
value. Kidney angiography is done with aim of exposure of early forms of kidney tumors, by this method
is conducted the differential diagnostics between tumor and kidney cyst, set the location of tumor in
relation to the arterial vessels. A wide range of vascularisation malignant tumors is marked on
angiogram: from expressed pathological to avascularisatia. Tumor vessels are sharply deformed,
chaotically located, often arcuated or, opposite, straightened, have sinuosity or ampule expansion. Area
of pathological vascularisation can be expressly marked off from surrounding parenchime or have signs
of infiltration with diffusion of process for the fibre capsule of kidney.
7.
Differential diagnosis of the kidney's tumors.
Frequently it has to differentiate a kidney tumor with the solitary and cyst, polycistos, by the
kidney carbuncle, by tuberculosis, by hydronefrose, by the urostones illness, paranefrut.
Kidney tumor that have solitary cyst have a row of general clinic-roentgenologic signs. At that rate
important diagnostic value have data of x-ray photography computer thomography, kidney angiography,
echography, punction cystography, hefrotomography.
For the polycystosis kidney character their chronic insufficiency, bilateral changes on pielograma
as a promoted fork of bowls, clench and lengthening kidney bowls, and also presence on arteriograma
much rounded areas and lengthened thin arteries.
8.
Nefroblastoma (Wilms` Tumor ).
Nephroblastoma, or Wilms` tumor, is a malignant mixed renal tumor that occurs predominantly in
children but can in adolescents and adults. The median age of incidence is 2 years 11 months. Wilms`
tumor is associated with congenital anomalies in 15% of patients. Wilms` tumor is believed to be at least
in part congenital, as it is the only common tumor of mixed embryonic origin.
9.
Treatment of the kidney's tumors.
The low sensitity of kidney cancer to the radial therapy,so is apply the combined medical treatment.
Conduct distance gamut-therapy after the intensive method from two meeting fields size 8х10 and 10х15
sm (depending on the tumor size). Hearth dose (POD)-5 Gr, total (SOD) – 20 Gr. Nefrectomia execute
through 24-48 hours after the radial therapy.
If the tumor germinated in the kidney leg and the infiltration of leg and surrounding fabrics or
metastases in the region lymphatic knots exist, appoint a postoperation radial therapy. SOD promote
about 60 Gr. How independent method of medical treatment radial therapy possible only in the not
operatioonisation cases. After the irradiation the tumour diminishes and becomes operation
10.
Symptoms tumors of the ureter.
The most common symptom is hematuria, wich occurs in 59-99% of patients and is usually
intermittent and sometimes quite profuse. Flanc pain is observed in 20-50% of patients. Chronic
obstruction from the enlarged ureteral tumor causes dull flanc pain, while passage of clots down the
ureter causes acute and severe pain. Symptoms of bladder irritation ( frequency, urgency, dysuria) are
21
reported in 10-52% of patients. The tumor is silent in 12-26 % of patients and is discovered on excretory
urograms or endoscopic examination in patients with a history of bladder cancer.
11.
Diagnosis of tumors of the ureter.
The excretory urogram usually shows abnormal findings in all patients with carcinoma of the
ureter. The 2 most common urographic findings are an intraluminal filling defect and hydronephrosis,
with or without hydroureter. In over one-third of patients, the kidney on the affected side is
nonfunctioning and fails to visualize. Angiography is of little value because of the avascular nature of
most urotherial tumors.
Ultrasonography and CT Scanning: Not enough patients have been evaluated with either
ultrasonography or CT scanning to allow adequate assessment of these procedures in helping to establish
a diagnosis.
Instrumental examination: If the patient is actively bleeding, cystoscopy shoud be perfomed
immediately in order to locate the source of the blood. At cystoscopy, the ureteral tumor is seen
protruding trom the ureteral orifice in 6-18 % of patients. In these patients, biopsy confirms the
diagnosis.
12.
Treatment of tumor of the ureter.
In the absence of demonstrable metastases, nephroureterectomy with resection of the periureteral
bladder wall and adjacent vesical mucosa remains standard therapy. However, in patients with
noninvasive low-grade tumors of the lower ureter, distal ureterectomy with reimplantation may be
considered. Partial ureterectomy for lesions located elsewhere in the ureter (middle- or upper-third)
carries with it a high risk of tumor developing later below the line of resection; therefore, local resection
should be avoided.
1. Tests and Assignments for Self-assessment
1. Which tumor of the kidney mostly we can feel by fingers?
A. Tumor of Williams.
B. Tumor of Graves.
C. Adenocarcinoma of the kidney.
D. Hypemephroma.
Answer: A
2. What is the main character of tumor of Williams?
A. Non-malignant.
B. Embrional adenocarcinoma of the kidney.
C. Metastasis of the kidney's tumor.
D. Angiosarcoma of the kidney.
E. Dermoid of the kidney.
Answer: В
3. Symptom «dead flower» characterize for:
A. Tumor of down pole.
B. Tumor of.
C. Tumor of the ureter.
D. Tumor of upper pole.
E. Tumor of pelvis cavity.
Answer: D
Real life situation to be solved:
1. Patient K., at the age of 54, complains of left side back pain in the region of the kidney,urine
with blood since a week. Examination. of left side it is noted thick round structure 10*14 cm with out
pain when it is touched.
A. What is the diagnosis?
B. What methods should be used to put a correct diagnosis?
Answer: Tumor of the left kidney. Patient should be done ultrasound screening.
Excretory urography.
2. Patient M., at the age of 62, in the examination of ultrasound screening in left kidney upper pole
echogen 8*6 cm is noted. Through X-ray blood vessels are bulged. From his life history haematuria is
noted 2 times in last year.
A. What is a diagnosis?
22
В. Extra examinations which should be done to the patient?
C. What is the tactics of treatment?
Answer: Tumor of left kidney. We should do excretory urography. Nephroectomy of left kidney.
Visual Aids and Material Tools:
1. Slides.
2. X-ray photographs. Excretory urography – tumors of parenchyma of kidneys. Retrograde
ureteropyelography- tumor of the kidney, computer tomography.
3. Ultrasound screening.
Students' Practical Activities:
Students-must know:
1. Classification the kidney's tumors.
2. Pathanatomy of the kidney's tumors.
3. Pass of metastases of the kidney's tumors.
4. Symptoms and clinical findings of the kidney's tumors.
5. Diagnosis of the kidney's tumors.
6. Tactics of therapist and urologist at the case of haematuria.
7. Differential diagnosis of tumors of the kidney with hydronephrosis, polycystits, carbuncles.
8. Tumor of Williams.
9. Treatment of tumors of the kidney.
10. Symptoms of tumors of the ureter.
11. Diagnose tumors of the ureter.
12. Treatment tumors of the ureter.
Students should be able to:
1. Note main symptoms and symptoms of tumors of the urinary tract.
2. Motivate clinical diagnosis.
3. Know tactics of treatment of tumors of the kidneys and ureter.
4. Note and to point out analysis of blood and urine, ultrasound screening of kidneys, X-ray
(excretory urography, retrograde pyelogram), computer tomography.
Methodological Instructions to Lesson 8 for Students
Theme: Tumors of urinary bladder.
Aim: should know to diagnose, principles of treatment of tumor of urinary bladder; to know
methods of operation.
Professional Motivation:
In statistics tumors of urinary bladder comes to 35-50% of all tumors of urology. Cancer of urinary
bladder is often noted in people older than 40 years; men suffer more than women 3-4 times from this
disease.
Basic Level:
1. Anatomy, physiology of urinary bladder.
2. To know anamnesis (life history) and should know to do physical method of investigation.
3. X-ray, instrumental, laboratory, morphological methods of investigation which is used to
diagnose tumors of urinary bladder.
4. You should know etiological, pathogenical, symptomatical therapy: medicamental, radiational,
operative methods of treatment.
Student's Independent Study Program
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Etiology and pathogenesis of tumors of urinary bladder.
The development of multiple tumors at different sites in the urothelium represents similar
tumorigenic changes occurring either simultaneously or successively within single cells at multiple sites.
23
In the process of initiation of cells transformation, a normal cell is changed into a latent or dormant
malignant cell. This is usually the results of multiple, complex interactions of a number of carcinogens
acting over a period of time rather than the result of exposure to a single specific carcinogen.
The vast majority of bladder tumors (98 %) are epithelial in origin; 92 % of these are transitional
cell carcinoma, 7% are squamous cell carcinoma, and 1-2% are adenocarcinoma. Sarcomas,
pheochromocytomas, malignant lymphomas, mixed mesodermal tumors, and primary carcinoid tumors
account for most of the nonepithelial tumors.
2. General clinical symptoms tumors of the bladder.
The predominant symptom is hematuria, which is both painless and macroscopic in 75-80% of
patients. Blood is usually noted throughout urination, although occasionally it may be present only at the
beginning (initial hematuria) or at the end ( terminal hematuria) of urination. In 17% of patients, bleeding
may be so severe that clot retention develops. Symptoms of vesical irritability, usually the result of a
secondary bacterial infection, are present in one-fourth of patients presenting with bladder cancer. These
symptoms include increased urinary frequency, dysuria, urgency, and nocturia. Pain in the flank may be
noted if the growth obstructs a ureteral orifice and produces hydronephrosis. Twenty percent of patients
have no specific symptoms, and malignant disease is discovered during an evaluation for occult
hematuria, pyuria, etc.
3. Diagnostic tumor of the bladder.
Although debate has been increasing in recent years regarding the cost-effectiveness of excretory
urography in screening patients with various urologic disorders, the first step in diagnosing a bladder
tumor is still an excretory urogram. The procedure aids in eliminating the upper urinary tract diseases
(renal parenchyma, ureters, pelves, and calices ) as the source of the patient`s symptoms. The excretory
cystogram, which is an integral part of the urographic studies, frequently raises the suspicion of a bladder
tumor by demonstrating an irregular radiolucent filling defect.
Radiographic procedures other than excretory urography are generally perfomed to aid in assessing
the extent of the malignant growth rather than to help make a diagnosis. However, increasing experience
with ultrasonographic assessment of bladder tumors suggests that ultrasonography may be helpful in
diagnosing cases in which cystoscopy cannot be perfomed or is inconclusive, as in patients with tumors
located in a diverticulum.
Cystourethroscopy almost always reveals the tumor. Methodical inspection of the entire vesical and
uretheral urothelium should be performed before biopsy. Ideally, tissue from the base of the tumor,
including muscle, should be included with the specimen. In addition, biopsies of the primary tumor
should include adjacent normal-appearing epithelium. inadequate biopses can severely restrict the
pathologist`s ability to assess the extent of the disease and can thereby adversely affect the patient`s
prognosis, since improper therapy is likely to result.
4. Methods of operative treatment of urinary bladder`s tumor.
Transurethral resection of the malignant areas, followed by a course of intravesical instillations of
thiotepa, shoud be considered when the lesion is confined to a relatively small( to 5 cm), reasonably well
delineated area of the bladder; the tumor does not involve the prostatic urethra, vesical neck, or either
ureteral orifice; the results of cytologicstudies of urine specimens from the upper tracts are negative; and
the symptoms are not excessive. Superficial bladder carcinoma is usually managed by transurethral
resection and fulguration.
Endoscopic resection is indicated only in highly selected patiens in whom the malignant disease is
usually of intermittent grade and has penetrated only the most superficial portion of the mucularis. When
the invasive tumor is solitary, has well-defined margins, occurs away from the fixed portion of the
bladder (base, trigone, or neck), and allows for wide surgical excision, a partial or segmental resection
may be employed.
Radical cystectomy with urinary diversion is usually the treatment of choice for invasive bladder
carcinoma. Five-year survival rates following external radiotherapy alone have been in the range of 1723%.
II. Tests and Assignments for Self-assessment
1. What method of investigation gives the complete information of urinary bladder's
tumors?
A. Ultrasound screening.
B. Doppler graphy.
24
C. Retrograde cystography.
D. Cystoscopy.
E. Cystography.
2. Main symptom of urinary tract's tumour in retrograde cystography is:
A. Deffect wall of urinary bladder.
B. Calcium deposits.
C. Diverticulum of urinary bladder.
D. Microcyst.
E. Before bladder.
Multiple choice. Choose the correct answer/statement:
Real life situation to be solved:
1. Patient M., at the. age of 44; during cystoscopy investigation-tumor 1,5/2 cm is noted with
elements of necrosis, diameter of tumor is large. What is the diagnose? What are the tactics of doctor in
polyclinic, treatment of this patient?
2. Patient C., at the age of 54, admitted in urological department, complaints with blood
after urine; in retrograde cystography defect is noted in the region of neck of urinary
bladder. What is the diagnose? What are the tactics of treatment?
III.
Answers to the Self-assessment.
The correct answers to the tests:
l. D.
2. A.
The correct answers to the real life situations:
1. Tumor of urinary bladder. Patient should be sent to special urological department, necessary to
provide transvasical resection of urinary bladder and next we should do radiational therapy.
2. Tumour of neck of urinary bladder we should make cystoscopy. When diagnosis is confirmed we
should make resection of urinary bladder (in region of urinary bladder's neck).
Visual Aids and Material Tools:
1. Slides.
2. X-ray photographs.
3. Cystography (tumours of urinary bladder).
4. Retrograde cystography (tumors of urinary bladder).
5. Medial chart of patient.
Students' Practical Activities;
Students must know:
1. Etiology, pathogenesis tumor of urinary bladder.
2. Path. anatomy of urinary bladder's tumor.
3. Classification of urinary bladder's tumor with stages and clinical groups.
4. Symptomatology and clinical symptoms of urinary bladder's tumor.
5. Diagnosis of urinary bladder's tumor.
6. X-ray symptoms of urinary bladder's tumor.
7. Endovisical symptoms of urinary bladder's tumor.
8. Differential diagnosis of urinary bladder's tumor.
9. Tactics of therapist and urologist in case of haematuria.
10. Treatment of urinary bladder's tumour: chemical-radiational treatment.
11. Methods of operative treatment of urinary bladder's tumor.
12. Path. metastases of urinary bladder's tumor.
Students should be able to:
1. Select main syndromes and symptoms of urinary bladder's tumor.
2. Reform clinical diagnosis.
3. Make differential diagnosis.
4. Note program of extra methods of investigation.
5. Know tactics of treatment in tumors of urinary bladder.
6. Know practical knowledge: palpation, percussion of urinary bladder, to note cystography and
results of cystoscopy. Methodological Instructions to Lesson 9 for Students
25
Theme: Benign prostatic hyperplasia.
Aim: How to diagnose, specific clinical findings of benign prostatic hyperplasia and carcinoma of
glands before urinary bladder, teach plan of investigation of patient and form diagnosis and differential
diagnosis benign prostatic hyperplasia, form plan of treatment.
Professional Motivation:
In observation of men older than 50 years benign prostatic hyperplasia is noted in everyone of two
men. Till now benign prostatic hyperplasia is 10% in glands.
Basic Level:
1. Anatomy, physiology of prostate and urinary bladder.
2. To know how to collect anamnesis (life history). and should know to do physical methods of
investigation.
3. X-ray, functional, innstrumental, laboratory, endoscopial, morphological methods of
investigation to diagnose of benign prostatic hyperplasia.
4. You should know the usage of hormones in the treatment of benign prostatic hyperplasia.
Student's Independent Study Program
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Anatomy, physiology of prostatic glands.
BPH primarily effects three anatomic structures: the prostate, urethra, and bladder (Fig. 1). Of the
three zones that comprise the prostate-peripheral, transition, and central-the transition zone in the central
part of the organ is the area affected in BPH. Stromal nodules appear in the periurethral area of that zone
as glandular hyperplasia develops. In contrast, prostate cancer generally develops in the peripheral zone
of the organ.
In the normal prostate, cell growth is regulated by a balance between cell death (apoptosis) and cell
growth (proliferation). Investigators examining prostate tissue at the cellular level have found a
substantial decrease in the total number of both glandular and basal epithelial cells dying in hyperplastic
tissue compared with normal tissue. This suggests a deregulation of apoptotic cell death mechanisms in
prostate tissue that results in a growth imbalance in favor of cell proliferation in the presence of BPH.
2. Etiology and pathogenesis of benign prostatic hyperplasia.
The bladder obstruction that occurs with BPH has both static and dynamic components. In the
early stages of disease, normal prostatic tissue is compressed by hyperplastic tissue, which impinges on
the prostatic urethra, creating the static component. The bladder detrusor muscle responds to this
obstruction of urine flow with smooth muscle hypertrophy and changes in the composition of the
extracellular matrix. This results in the increased voiding pressure, decreased bladder compliance, and
involuntary bladder contractions that comprise the dynamic component of obstruction. Untreated,
advanced disease that involves prolonged obstruction may cause chronic urinary retention. The classic
obstructive symptoms include hesitancy, weak urine stream, straining, prolonged micturition, feeling of
incomplete bladder emptying, urgency, frequency, nocturia, and urge incontinence.
3. Classification of benign prostatic hyperplasia.
4. Main clinical symptoms of benign prostatic hyperplasia.
The initial evaluative step is to quantify symptoms and quality of life to establish a baseline for
severity and frequency of symptoms and to employ as a monitor of progress with or without treatment.
The American Urological Association (AUA) has developed, tested, and validated a four-part index that
rates symptoms of urinary problems (eg, urgency, frequency, nocturia), the degree to which these
symptoms are a problem to the patient, the impact of the symptoms on the patient's life (eg, physical
discomfort, worry, bother), and the overall quality of the patient's life. A more widely used evaluation
based on that developed by the AUA is the International Prostate Symptom Score (IPSS). This
simplified, easily administered form assesses symptoms and general quality of life.
5. Diagnosis of benign prostatic hyperplasia.
The physical examination should focus on two specific tests: the digital rectal examination (DRE)
and a neurologic examination. The DRE is especially important in assessing the size, consistency, and
anatomic limits of the prostate; findings may be especially helpful in differentiating BPH from prostatic
cancer. The prostate that contains a nodule or that is diffusely hardened and asymmetric may indicate
cancer in contrast to the smooth, symmetric, and elastic consistency of a benign gland. Urinalysis via
26
dipstick testing or microscopic examination of sediment is employed both to differentiate BPH from
urinary tract infection or bladder cancer and to prompt the use of additional tests if findings are
pathologic. Such optional tests might include upper urinary tract imaging or endoscopy. Renal function is
assessed via measurement of serum creatinine. If the crea-tinine is elevated, indicating compromised
renal function, ultrasonography is the appropriate follow-up study. PSA has been suggested as a
screening tool for prostatic cancer, but the antigen is produced by normal, hyperplastic, and cancerous
tissue, which can limit its diagnostic usefulness as a single test. However, the patient should be told that
there is a good possibility of a false-positive or false-negative result that might require the use
oftransrectal ultrasonographic (TRUS)-guided biopsy to confirm or refute the diagnosis of malignancy.
6. Endovesical symptoms of benign prostatic hyperplasia.
Urethrocystoscopy may be appropriate as a guideline when surgical treatment is planned to rule out
pathology and to assess the size and shape of the prostate. This form of endoscopy can provide visual
documentation of an enlarged prostate that is obstructing the urethra and bladder neck, obstruction of the
bladder neck by a high posterior lip, muscular hypertrophy of the detrusor muscle (indicated by muscular
trabeculation and formation of cellules and diverticula), formation of bladder stones, and retention of
urine in the bladder.
7. X-ray symptoms of benign prostatic hyperplasia.
A plain film of the abdomen may demonstrate the presence of prostatic calculi outlining an
enlarged prostate. Intravenous urography identifies hydroureteronephrosis, thickening and trabeculation
of the bladder, and elevation of the bladder base and trigone by the enlarged prostate. The presence of
residual urine on the postevacuation film furthe confirms the severity of obstruction. When obstruction is
severe, bladder diverticula and bladder calculi may develop.
1.
Differential diagnosis of benign prostatic hyperplasia.
Symptoms similar to those of BPH can be caused by neurogenic dysfunction of the bladder and by
anatomic abnormalities of the bladder outlet and urethra. Spinal cord injury, causing hypertonicity of the
musculature of the pelvis and lower extremity, can produce sphincter dyssynergia. Either contracture of
the vesical neck secondary to surgery or the presence of urethral strictures secondary to trauma or
infection can mimic the the symptoms of prostatism by decreasing the size and caliber of the stream and
reducing the urinary flow rate.
2.
Chemical therapy of benign prostatic hyperplasia.
Inhibit 5-alpha reductase, the enzyme that converts testosterone to dihydrotesterone (DHT). DHT is
a key component involved in control of prostate growth, so inhibition of its formation can limit prostate
hyperplasia and, in fact, reverse its development. Thus, these drugs address the mechanical component of
obstruction in BPH. The primary agent in this class is finasteride. Clinical studies have shown that it can
reduce the volume of the prostate by about 20%. The use of alpha blockers in treatment of BPH is based
on the finding of a high density of adrenergic nerves in the urogenital system and, particularly, a high
density of alpha1 adrenoceptors in the smooth muscle cells of the prostate, urethra, and bladder neck. The
alpha, adrenoceptor is activated when an agonist such as norepinephrine attaches to it; such activation
can cause smooth muscle contraction. Alpha blockers compete with the agonists in occupying the
adrenoceptor and, thus, prevent smooth muscle contraction in the prostate. Thus, these agents address the
dynamic component of obstruction in BPH. Natural compounds have been used for many years in Europe
in the treatment of BPH. Many of these compounds are undergoing critical clinical evaluation in an effort
to determine their mechanism of action and efficacy. Four compounds have received the most intensive
in vitro and clinical examination: pollen extract, Sabal Serrulata, Serenoa Repens, and Pygeum
Africanum.
3.
Operative treatment of benign prostatic hyperplasia.
Transurethral prostatectomy (TURP) is the most commonly performed surgical approach to BPH,
although, as noted earlier, the frequency with which this procedure is performed has decreased in the past
few years as less invasive medical therapies have become more available. Absolute indications for the
procedure include BPH leading to bladder stones or obstruction of the upper urinary tract with uremia.
Because of their potential for serious consequences, recurrent urinary retention or urinary tract infections
suggest the need for surgical treatment. Open prostatectomy is the most invasive of the surgical
procedures and is indicated when the prostate is >70 g resectable weight. Laser prostatectomy can be
performed at low-power density, which results in tissue coagulation, or high-power density, which causes
27
vaporization of tissue. Transurethral electrovaporization of the prostate (TVP) is a modification of TURP
that combines electrosurgical vaporization with dessication to remove hyperplastic tissue.
II. Tests and Assignments for Self-assessment
1. Main characteristic symptom of benign prostatic hyperplasia in excretory urography is:
A. Chain shaped urinary canal
B. Structure of ureter.
C. Bent urinary tract in 1/3 part
D. Symptom «fishhook».
E. Symptom «lion's face».
2. For III stage of benign prostatic hyperplasia main characteristic is:
A. Aseptical pyuria.
B. Stranguria.
C. Chronic obstruction of urine.
D. Paradoxical ishuria.
E. Acute obstruction of urine.
Multiple choice.
Choose the correct answer/statement:
Real life situation to be solved:
1. Patient K., at the age of 74, admitted with complaints of excretion of urine in drops, with out
sensation of urinary secretion, thirst and weakness. Objective: above the lap when the percussive sound is
dumb and when touched it is painful. Symptom of. Pastematzkiy is doubling in two sides, prostate is
bulged 6/6,5 cm, elastic, between two doles it is smooth. What is your diagnose? What should we do to
the patient to confirm diagnosis and tactics in treatment?
2. During cystoscopy patient M., at the age of 72, complains of frequent, hard, urine excretion,
night 2-3 times noted: urine 180 ml, positive symptom of «curtain». Rectal. prostate 5/5/4 cm is elastic.
What is the clinical diagnose? What are the tactics of treatment?
III.
Answers to the Self-assessment.
The correct answers to the tests:
l. D.
2. D.
The correct answers to the real life situations:
1 benign prostatic hyperplasia we should put a permanent catheter if the patient is doing well, we
should do prostatectomy.
2. benign prostatic hyperplasia of II stage, chronic obstruction of urine, we should do
prostatectomy.
Visual Aids and Material Tools:
1. Slides.
a) retrograde cystoscopy;
b) excretory urography.
2. X-ray photographs.
a) excretory urography (symptom of «fishhook»).
b) retrograde cystoscopy (deffect in the region of urinary bladder).
3. Tables (symptom of «curtain», a good quality prostatic hyperplasia and stone in urinary bladder).
Students' Practical Activities:
Students must know:
1. Classification of benign prostatic hyperplasia in stages.
2. Symptomatology of benign prostatic hyperplasia.
3. Clinical sings of benign prostatic hyperplasia.
4. Diagnose of benign prostatic hyperplasia.
5. Differential diagnosis of benign prostatic hyperplasia.
6. Treatment of benign prostatic hyperplasia.
Students should be able to:
1. know main symptoms of benign prostatic hyperplasia.
28
2. make differential diagnosis of benign prostatic hyperplasia of prostatic glands with cancer of
urinary bladder, cancer prostate, acute and chronic prostatitis, tuberculosis of prostatic glands, structure
ofurether.
3; To diagnose different stages of benign prostatic hyperplasia, to form diagnosis.
4. know tactics of treatment of benign prostatic hyperplasia in different stages.
5. provide palpation of prostatic glands, to do catheterization of urinary bladder with elastic
catheter and percussion of urinary bladder.
Methodological Instructions to Lesson 10 for Students
Theme: Cancer of prostate.
Aim: How to diagnose, specific clinical findings carcinoma of prostate, teach plan of investigation
of patient, diagnosis and differential diagnosis of carcinoma of glands, form plan of treatment.
Professional Motivation:
In observation of men older than 50 years benign prostatic hyperplasia is noted in everyone of two
men. Till now benign prostatic hyperplasia is 10% in glands, before urinary bladder and 40% patients
with carcinoma have metastases.
Basic Level:
1. Anatomy, physiology of prostate and urinary bladder.
2. To know how to collect anamnesis (life history) and should know to do physical method of
investigation. •
3. – X-ray, functional, instrumental, laboratory, endoscopial, morphological methods of
investigation to diagnose of carcinoma of prostate.
4. You should know the usage of hormones in the treatment of this disease.
Student's Independent Study Program
I. Objectives for Students' Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Anatomy, physiology of prostatic glands.
Of the three zones that comprise the prostate-peripheral, transition, and central-the transition zone
in the central part of the organ is the area affected in BPH. Stromal nodules appear in the periurethral
area of that zone as glandular hyperplasia develops. In contrast, prostate cancer generally develops in the
peripheral zone of the organ. In the normal prostate, cell growth is regulated by a balance between cell
death (apoptosis) and cell growth (proliferation). Investigators examining prostate tissue at the cellular
level have found a substantial decrease in the total number of both glandular and basal epithelial cells
dying in hyperplastic tissue compared with normal tissue. This suggests a deregulation of apoptotic cell
death mechanisms in prostate tissue that results in a growth imbalance in favor of cell proliferation in the
presence of BPH. The implications of these findings for clinical treatment are under investigation.
2. Etiology and pathogenesis of carcinoma prostatic glands.
Cancer development causes aren’t finally cleared up, but the data of experimental and clinical
researches testify to that, that a pathology is predetermined by violation of the endocrine adjusting of
balance of sexual hormones by the caused changes in the hypotalamohypophysial system (in case of
violation of hormone-regulation in the adrenal and sexual glands). Proof of hormone dependence of
cancer of prostata there is a reverse development of neu formations during castration and
estrogenotherapy.
3. Classification of carcinoma prostatic glands.
The classification of the cancer of prostata by system of TNM:
Т – primary tumour;
Т0 – the tumour not palpated;
Т1 – the single tumular knot doesn’t go outside capsule of prostata;
Т2 – the tumour occupies a greater part of gland and germinates its capsule;
Т3 – the tumour occupies all prostate, increases, deforms it, but doesn’t go out outside gland;
Т – the tumour germinates surrounding fabrics and organs;
М0 – remote metastases ;
М1 – metastases in bones;
29
M2 – metastases in bones and inlying organs.
4. Main clinical symptoms of carcinoma prostatic glands.
Sustained bladder outlet obstruction plus hypertrophy or overdistention of the bladder may cause
vesicoureteral reflux or obstruction of the upper tracts, resulting in hydroureteronephrosis. Flank pain
may occur during the act of micturition. When obstruction is severe enough to produce renal failure,
symptoms of uremia orazotemia occur: nausea and vomiting, somnolence or disorientation, fatigue, and
weight loss. Acute urinary retention may occur after a prolonged period of putting off urination, allowing
the bladder to become overdistended and atonic. Local extension of the tumor may cause rectal or
perineal pain. Hematospermia and hematuria may accompany BPH, but their presence in patients over
age 50 should always warrant a careful assessment to rule out malignant disease.
5. Diagnosis of carcinoma prostatic glands.
In the early stage of disease the finger research of prostata through rectum is very important. Thus
some or numerous knots palpation in one of parts. Thus the gland can be and not megascopic. Sometimes
bands of infiltrate, which goes from the prostata to seminal vesicles palpation (positive symptom of
“bovine horns”). Later the tumular conglomerate can occupy a greater part (or and all) of gland, passes to
the surrounding fabrics and bones of pelvis. The tumour has dense, cartilagonoid or osteoid consistency.
However it is necessary to remember, that other diseases also can be shown the similar symptoms.
Ultrasonic echography settles to expose the areas of heterogeneous compression without the clear
contours at the changed structure of prostata.
6. Tract of metastases of carcinoma prostatic glands.
Approximately 15-40 % of patients present with symptoms caused by metastasis. In an elderly
man, complaints of persistent bone paine ( either localized or multifocal and especially in the spine or
pelvis ) should always prompt a search for prostatic cancer. fatigue, weight loss, and malaise are
nonspecific indications of extensive disease.
7. Endovesical symptoms of carcinoma prostatic glands.
Cystoscopy is an auxiliary method of diagnostics of cancer of prostata. During the conducting
cystoscopy deviation of urine can be marked by the tumular knots. At cystoscopy is a successfully to
expose the asymmetric deformation of neck of urinary bladder. A changed mucus shell, fibrosis tapes,
ulcers, excrescence of tumour are determined in the tumour germination in wall of urinary bladder place.
Thus it is difficult to clear up, what tumour is primary
8. X-ray symptoms of carcinoma prostatic glands.
An excretory urography settles to estimate a function of buds and urodynamic overhead urinary
ways. Ureterectasy and ureterohydronephros are an investigation of clench of pelvic departments of
ureters by tumour. Such changes are often from one side. At full obstructions the ureter bud doesn’t
functionate and the shade on the clench side doesn’t appear. The characteristic changes exist at
sciagraphy of bones of pelvis and lumbar department of vertebral post: osteoplastic (osteosclerotic),
considerably rarely there are the osteolitic (osteoclastic) and their combination. As a result of duty of
changed areas the bones of pelvis have a marble kind. Lymphangioadenography settles to expose the
defeat of regional lymphatic knots, but not all they are noticeable on lymphograms.
9. Differential diagnosis of carcinoma prostatic glands.
A cancer of prostata is differentiated with prostatitis, hyperplasia, tuberculosis, sclerosis, stone of
prostata, cancer of neck of urinary bladder.
At chronic prostatitis and cancer the data of finger rectal research can be similar. About chronic
prostatitis they testify an anamnesis data about carried sharp prostatitis, duty of periods of the sharpening
and fading, appearance during palpations of pain in area of prostata, exposure of areas of the softening. In
a sick on cancer in case of finger rectal research early expose limitation of gland mobility, tumular
infiltration in areas, which are contained nearer to periphery of organ. In the case of doubt set a diagnosis
on the basis of data of punction biopsy of organ.
Stone of prostata are usually accompanied by pain in crotch and rectum, by discord of urination.
Palpations of gland causes a pain, a symptom of crepitation is determined (as a result of friction of stone).
On the surveying urogram in area of prostata the shades of concrements appear. However it is needed to
remember, that in one sick there can be the stone and cancer of prostata simultaneously.
At tuberculosis during palpations of prostata it is possible to expose the areas of compression on
background of unchanged tissue. As a rule, the tuberculosis of prostata exists at the sick on tuberculosis
urinary organs. The characteristic changes expose at such patients: cavities in buds, small urinary
30
bladder, rash on the mucus shell of urinary bladder, retraction opening of ureters. In the case of doubt the
running to the biopsy of prostata comes.
10. Chemical therapy of carcinoma prostatic glands.
The chemotherapy at cancer of prostata has only an auxiliary value through the low sensitiveness of
tumours to chemopreparations. It’s expedient its setting at hormone resistens tumours. Frequently they
apply adriamyciny, cyclophoshany, ftoruracyly, cysplatyny, metotrexaty. The temporal objective effect
(reduction of primary tumour or its metastases) exists in 8-40 % sick, and subjective (reduction of pain,
improvement of urination)-у 40-90%. Duration of remissions is 2-16 months. Chemopreparations appoint
in the different combinations, same effective there is an application of hormonocytostatics with
estracytis. The consequences of medical treatment rely on time of appeal of sick to the doctor. About 95
% sick get in the permanent establishment and their state isn’t operable. That’s why for the active
exposure of a sick it is necessary to conduct the planned reviews of men by age over 40 years.
11. X-ray treatment of carcinoma prostatic glands.
When tunors are confined to the prostate and periprostatic tissue, tumoricidal doses of 6500-7000
rads are generaiiy delivered at a rate of 275-200 rads daily. Teletherapy using Co linear accelerators or
betatron can produce photon beams with energy of 6-25 million eletron volts. The higher the energy, the
greater the depth of penentration of the maximum dose, makingit possible to deliver a tumoricidal dose to
the prostate deep in the pelvis while sparing surrounding tissue.
12. Operative treatment of carcinoma prostatic glands.
Radical prostatectomy foresees the removal of all prostata with capsule, seminal vesicles, by the
prostate part of urine, neck of urinary bladder, adjoin tissue and pelvic lymphatic nodes. They execute
this operation in the І-ІІ stage of disease, if it is germination of tumour in the fatty cellulose and adjoint
organs. The duration of life of a sick doesn’t rely not so much on their age, sizes and degree of tumour
malignant, as on degree of defeat of lymphatic nodes. The frequency of application of radical method of
medical treatment makes 3-5 %, that is explained by complication of exposure of initial stages of disease,
operation weight, elderly age of majority of sick and others like that. Index of survival of a sick after
prostatektomy during five years makes disease stages 80%, at II-76%. Depending on access to the
prostata distinguish crotch in, postpubical, transvesicle and transabdominal prostatectomy. The
transabdominal prostatectomy in combination with the resection of neck of urinary bladder and
postpubical prostatectomy with retroperitoneal limphadenectomy are most widespread. For the exception
of hormone influence of testicles on growth of tumour sick apply orchidectomy or subcapsular
enucleation (removal of parenchyma) testicles.
II. Tests and Assignments for Self-assessment
1. What method of examination gives the complete information of carcinoma prostatic glands?
A. Function of prostate.
B. Doppler graphy.
C. Retrograde cystography.
D. Cystoscopy.
E. Cystography.
Multiple choice. Choose the correct answer/statement:
Real life situation to be solved:
1. Patient K., at the age of 74, admitted with complaints of excretion of urine in drops, with out
sensation of urinary secretion, blood of urine, thirst and weakness. Objective: above the lap when the
percussive sound is dumb and when touched it is painful. Symptom of Pasternatzkiy is doubling in two
sides, prostate is bulged 6/6,5 cm, bumpy.
What is your diagnosis? What should we do to the patient to confirm diagnosis and tactics in
treatment?
III. Answers to the Self-assessment.
The correct answers to the tests:
l. A.
The correct answers to the real life situations:
l. cancer of prostate, we should keep permanent catheter if the patient is doing well, we should do
orchepididimectomy and hormones. X-ray treatment.
Visual Aids and Material Tools:
31
1. Slides.
a) retrograde cystography;
b) excretory urography.
2. X-ray photographs. a) retrograde cystography;
Students' Practical Activities:
Students must know:
1. Classification of cancer prostate in stages.
2. Symptomatology of cancer prostate.
3. Clinical sings of cancer prostate.
4. Diagnose of cancer prostate.
5. Differential diagnosis of cancer prostate.
6. Direction ofmetastases cancer ofprostatic glands.
7. Treatment of cancer prostate.
Students should be able to:
1. Know main symptoms of cancer prostate.
2. Make differential diagnosis of cancer prostate with cancer of urinary bladder, acute and chronic
prostatitis, tuberculosis ofprostatic glands, structure ofurether.
3. Diagnose different stages of cancer prostate, to form diagnosis.
4. Know tactics of treatment of cancer prostate in different stages.
5. Provide palpation ofprostatic glands, to do catheterization of urinary bladder with elastic
catheter.
Methodological Instructions to Lesson 11 for Students
32
Theme: Urinary Stones (Urolithiasis).
Aim: To study symptoms, signs and laboratory findings of urolithiasis, its complications,
indications for conservative and surgical treatment. Typical diagnostic and tactical mistakes and ways of
prevention.
Professional Motivation:
Urinary lithiasis is one of the most common diseases of the urinary tract, it is known from the
ancient times. It’s frequency among all urologic diseases is from 30 to 45%. Now there is some
predominance of women among the patients, especially with corallire stones.
Basic Level:
1. Anatomy and physiology of urinary tract.
2. To know how to collect life history and physical examination.
3. Etiology and pathogenesis of the urolithiasis.
4. X-Ray, instrumental, laboratory, endoscopic methods in urolithiasis diagnosis.
5. Conservative measures of etiologic, pathogenetic and symptomatic treatment.
Students' Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. General clinical symptoms of the urinary stones.
The following factors are known to influence the formation and growth of uroliths: hyperexcretion
of relatively insoluble urinary constituents (calcium, oxalate, cystine, uric acid xanthine, silicon dioxide),
physical changes which occurs in the urine, a nidus (core or "nucleus")upon which precipitation occurs,
structural anomalies, including calicestasis and medullary sponge kidney. There are such kinds of urinary
stones: phosphate, oxalate, ammonium phosphate, cystine, uric acid, xanthine. If the stone is submucosal
or adherent to the parenchyma there are no symptoms; if it obstructs the calix or the uretero-pelvic
junction the colic will be due to hyperperistalsis. The main symptoms are the followings pain in loin,
hematuria, passage of salts and stones. The intensity and irradiation of pain depends upon its location.
A dull pain is typical for hardly mobile stones. It is intensified while movements and great
introduction of fluid and manifests as renal colic. It may be caused by sudden obstruction of the upper
urinary tract and continues for different term. It is accompanied by general weakness, dryness in mouth,
headache, fever, disuria, excitement. The lower stone passes the disuria intensifies. Micro and gross
hematuria appears due to injury, pyelonephritis, venostasis of the mucosa of the calyces, renal pelvis,
ureter. It stops after the complete obstruction. Ache precedes hematuria. Other diseases followed with
hematuria are characterized the notifying the blood in urine by patient by himself initially and then ache
appears. Massive hematuria may appear due to large stone that don’t completely obstruct urinary tract
after long driving. This bleeding stops soon, but may relapse.
Complication of the urinary stone disease is the hydronephrotic degeneration of the kidney. It may
not be manifested for a long period. In case of complete destruction of both kidneys because of
pyelonephritis and hydronephrosis anuria develops as a terminal phase of the disease. Anuria is a result
of chronic renal insufficiency. Anuria appears owing to obstruction of the ureter of the single kidney (that
left after the removal of another kidney or congenital the only kidney) commonly. The reflective anuria
appears when the second kidney dysfunction is present on account of circulative and spastic changes at
the opposite side while renal colic.
2. Proving and formulation of clinical diagnosis.
Tenderness in the controverbal angle or over the kidney may or may not be present. Acute renal
infection may cause more definite findings. The white blood cells may be increased in the blood count;
protein may be noted because there is presence of hematuria, pus cells and bacteria may be seen. Renal
function tests may be normal or depressed in case of bilateral obstruction. 90 % of renal stones are
radiopaque and readily visible on a plain film of the abdomen unless they're small or overlie bone.
Isotope studies may prove in farther assessing of X-ray examination.
3. Differential diagnosis with renal tumors, renal tuberculosis, nonspecific renal infections, acute
surgical pathology of abdominal cavity.
Urography will establish the differential diagnosis with renal tumors, renal tuberculosis;
nonspecific renal infections have the other symptoms of acute process: high temperature, dysuria, hyper33
gamma-globulinemia etc. ; acute surgical pathology of abdominal cavity show other physical symptoms
of abdominal pathology.
4. Medical tactics in patients with urinary stones: indications and contrindications to the surgical
and conservative treatment.
Conservative treatment is neccesary in the following cases: submucosal stones, a small stone
trapped in the minor calix and causing few of any symptoms, in the elderly poor-risk patients a coralline
stone; is best left alone unless it causes significant symptoms, stones due to renal tubular acidosis.
Surgical measures – removing of the stone are indicated if the stone is obstructive and саises due pain or
progressive renal damage or if the infection complicated the stone can not be eradicated. To prevent
relapsing the local reasons of relapses should be eradicated. Pyelolithtomy is used often. Depending the
wall incised the anterior, posterior, superior and inferior methods of pyelolithotomy are differed. The
most common is posterior pyelolithotomy because there are magistral vessels going across the anterior
surface of the renal pelvis. Operation is performed “in situ”. The kidney isn’t mobilized from the
surrounding tissues an dislocated into the operative wound.
Key words and phrases: urolithiasis, urinary stones, urinary tract, surgical and conservative
treatment of urolithiasis.
II. Tests and Assignments for Self-assesment:
Multiply choice. Choose the correct answer/statement:
1. What kinds of stones formes in alkaline urine?
A. Phosphate.
B. Urate.
C. Cystine.
D. Oxalate.
2. The method to confirm renal colic is:
A. Urography.
B. Ultrasonography..
C. Chromocystoscopy.
D. Cystoscopy.
E. Retrograde pyelography.
Real life situations to be solved.
1. Patient S., 52 years old, complains on intensive pain in right iliac and lumbal regions, painful
excretion of urine. Region of right ureter is tenderness, Pasternatski’y symptom present on the right side.
No shades was found on urogram. What is the preliminary diagnose? What is the differential diagnose?
What method is necessary to hold the specificity of the diagnosis?
2. In patient L., 34 years old, there is typical renal colic, but no changes in the urine analysis were
found. What diagnostic procedure is necessary to specify the diagnosis? How can you explain absence of
any changes in urine analysis?
III. Answers to the Self-Assesment.
The correct answers to the tests:
1-А.
2-C.
The correct answers to the real situations:
1-renal colic on the right side; appendicite; chromocystoscopy, ultrasonography, retrograde
pneumoweteropyelography;
2-urography and excretory urography; if there is total ureter obstruction normal urine will arrive to
the urinary bladder from the second kidney.
Work 1. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination, detects main
clinical signs of the urolithiasis, forms diagnostic programme, formulates diagnosis
Questions for the student:
1. What are the clinical symptoms of urolithiasis?
2. What are the complications of urolithiasis?
3. What are the main methods of examination of the patients with urolithiasis?
Work 2. Make differential diagnosis of urolithiasis.
34
Student make differentional diagnosis of urolithiasis, using complains of disease and life history
physical examination, laboratory and sonography signs.
Questions for the student:
1. What diseases it is necessary to differentiate?
2. What is the medical tactics in the patients with urolithiasis?
3. What are the modern methods of urolithiasis treatment?
Visual aids and material tools:
1. Slides:
1. 1 Different kinds of pyeloureteroplasty.
1. 2 Nephrectomy.
1. 3 Pyelolithotomy.
2. Pictures on the stand: urinary bladder stones.
3. Roentgenograms:
3. 1 Urography – stones of different regions of urinary tract.
3. 2 Excretory urography – ureteral stone.
3. 3 Excretory urography – coralline renal stone.
3. 4 Retrograde pyelography – coralline renal stone.
3. 5 Retrograde pneumoureterography – ureteral stone.
3. 6 Retrograde pneumoureteropyelography – renal stone.
3. 7 Urography – ureteral stone extraction.
Students Practical Activities:
Student must know:
1. Etiology and pathogenesis of the urolithiasis.
2. Chemical characteristics and conditions of the urinary stones formation.
3. Symptoms and clinical cdurse of the renal and ureteral stones.
4. Renal and ureteral stones diagnosis.
5. Differential diagnosis of the renal colic and acute surgical pathology of the abdominal cavity.
6. Conservative treatment of renal and ureteral stones.
7. Surgical treatment of renal and ureteral stones.
8. Treatment of renal colic.
9. Urolithiasis in childs and pregnants.
10. Complications of urolithiasis.
11. Reason and diagnostic of the urinary bladder stones.
12. Differential diagnostic of the urinary bladder stones.
13. Medical tactics in patients with urinary bladder stones.
Students should be able to:
1. Detect main clinical signs of the urinary stones.
2. Define necessary quantity and sequence of patients examination: physical, laboratory,
roentgenological, endovesical.
3. Should be able to detect signs ofurolithiasis on urograms, excretory urograms with different
contrasts and oxygen, retrograde ureteropyelograms etc.
4. Prove and formulate clinical diagnosis.
5. Spend differential diagnosis.
6. Prove conservative treatment and indications for the conservative treatment. Methodological
Instructions to Lesson № 12 for Students
Theme: Injuries to the kidney and ureter.
Site: Classroom, hospital ward, X-Ray cabinet, operating room, casuality ward, hospital ward,
dressing room, cystoscopic room.
Aim: To study symptoms and principles of treatment injuries of kidneys and ureter.
Professional Motivation:
For the last time as a result of increasing of accidents and urbanization we have augmentation of
closed renal injuries. Indirect ("contrecoup")injury, caused by falling from a height and landing on the
feet or buttocks, is less common. On rare occasion, acute abdominal muscle contraction have caused a
hydronephrotic kidney to burst.
35
Basic Level:
1. Anatomy and physiology of urinary tract.
2. To take history and physical examination.
3. X-Ray, instrumental, laboratory, endoscopic methods in injuries of kidneys and ureter diagnosis.
4. Conservative measures of etiologic, pathogenetic and symptomatic treatment; different kinds of
surgical treatment.
Students' Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. General clinical symptoms of the renal injury.
Gross hematuria following any injury means trauma to the urinary tract. Signs and symptoms
localized to one flank and the findings of impared function of the kidney are strongly suggestive.
Extravazation of opaque medium, as shown on x-ray films, is diagnostic. A history or evidence of
physical injury is usually present. Pain in the renal area may be obscured by the severity of other injuries
(e. g, fractures or injuty to the viscera). Gross hematuria, not necessarily proportionate to the severity of
the injury, is usually noted with the first voiding. It may be intermittent or continuous. Nausea, vomiting,
and abdominal distention due to intestinal ileus are common in the presence of retroperitoneal bleeding.
Urinary retention may occur from clots in the bladder. There may be symptoms of injuries to the other
organs. Shock or signs of hemorrhage may be found with severe renal injury or in the presence of
multiple injuries. Ecchymosis may be noted over the flank or back. Local tenderness is present. A mass
in the flank may be caused by extravasation of blood of urine, but if the overlying peritoneum has been
these fluids may leak into the peritoneal cavity; hence, no flank mass develops. Rigidity of the abdominal
muscles on the effected side and rebound tenderness are common. Abdominal distention and
hypoperistalsis are to be expected. The ipsilateral testicle may be hypertensive The possibility of injuries
to organs of the chest or the abdomen should be explored. Fracture of the pelvis should cause one to
suspect injury to the bladder or urethra. Oliguria may accompany the hypotensive phase of shock. The
hematocrit, especially when followed serially, is of the gratest importance; progressive anemia means
progressive hemorrhage which may require immediate surgical intervention. Hematuria is present in
almost all cases. It is usually marked at first. Infection may be found later if ureteral obstruction
develops.
If the accident is not recognized at the time of surgery, the patient usually complains of pain in the
flank and lower abdominal quadrant. Vomiting may be severe. Paralytic ileus is often marked. The
patient will become quite ill if pyelonephritis or peritonitis complicates the picture. Urine may suddenly
begin to drain through the vagina, which may relieve all the foregoing symptoms.
2. Classification of the injuries to kidney and ureter. There 2 main kinds of renal injuries: opened
and closed. The main types of the renal injuries are: simple bruising or ecchymosis, hematoma,
fissures,lacerations, upture of the renal vascular pedicle, other pathologic lesions associated with renal
lacerations include peritoneal tears with intraperitoneal bleeding, other visceral injuries, and fractures of
the spine or ribs.
3. Diagnosis of the injuries to kidney.
Diagnostics of the isolated closed renal damage is not difficult in general. The anamnesis, presence
of trauma signs and hemorrhages, pain in lumbar region, positive Pasternatsky's symptom testify
probability of renal trauma. Chromocystoscopy, if possible, also helps to establish the correct diagnosis.
This method of research sometimes allows to find a location of bleeding (that it is very important in case
of combined trauma), to analyse functions of damaged and opposite kidney, state of urinary bladder wall.
However for a choice of method of treatment it is necessary to know the character of damage and its
localization. Chromocystoscopy for children is very rarely performed, because narcosis is necessary for
it. Without anesthesia this test can be performed only for girls in age above 7 years. For diagnostics of
kidney trauma of children X-radiography is expedient, which begins from a observing radiography.
The method allows to find damage of bones, to suspect presence of retroperitoneal hematoma
(contours of kidney and lumbar muscles are absent). Excretory urography gives an opportunity to define
the side of damage, anatomical and function status of injured and opposite kidney. X-ray signs of renal
damage are weak and later spreading of X-ray contrast solution in calyces-bowling systems, subcapsular
36
and retrorenal spreading of X-ray contrast, deformation of renal bowl and calyces. In angiogramms one
can see violation of arterial and venous circulation attached to marginal injuries, filling of pararenal
tissue with X-ray contrast due to injuries of real artery branches.
For diagnostics of closed trauma of kidney radionuclide and ultrasonic methods are used.
Radionuclide method is used to study function of damaged kidney. If it is saved up, during the
scintigraphies it is possible to establish localization of damage and even its degree. On scinti- and
scanogram one can see defect, which responds to the region of renal damage. On ultrasonic scanogram
the sites of violation of renal tissue are defined. Main role in diagnostics play radionuclide methods,
ultrasonic scanning.
4. Indications for the surgical treatment of closed renal injuries (nephrectomy, nephropexy) and
injuries to the ureter. Emergency measures of the treatment of the renal injuries are to treat shock and
hemorrhage. Surgical measures – since two-thirds of injured kidneys are merely contused, bleeding will
cease spontaneously. Even some of the ruptured organs will heal without surgical care. 10 to 20% of
cases may require early surgical intervention because of alarming hemorrhage. Drainage of the perirenal
space, suture of the renal laceration, or partial or total nephrectomy may be necessary. Opiates for pain
should be withheld until the completion of the diagnostic steps; they may mask accompanying
intraabdominal or pulmonary lesions. Bed rest is indicated until hematuria has ceased and local signs of
injury have largely subsided. Permephric injection requires surgical drainage; late complications may
require nephrectomy or repair of secondary ureteral obstruction. In case of ureteral injury reparative
surgery should be undertaken as soon as as the injury is recognized. In simple perforation from a ureteral
catheter or other instrument, surgical drainage is usually not necessary. The ureteral wall will heal
spontaneously.
Key words and phrases: injuries to the kidney and ureter, surgical treatment of closed
renal injuries and the injuries to the ureter.
Visual aids and material tools:
1. Slides:
1. 1 Rupture of the left kidney.
1. 2 Rupture or the right kidney.
2. Excretory urography – subcapsular kidney rupture.
II. Test and Assignments for Self-assesment:
Multiply choice. Choose the correct answer/statement:
1. In patient with closed renal rupture and shock the emergency measures are:
A. Nephrectomy.
B. Nephropyelostomy.
C. Treat shock and hemorrhage.
D. Infusion of the opiates.
E. Treatment of the secondery infection.
Real life situations to be solved.
A. The patient was brought to the hospital with multiple traumas. In the left lumbar region
hematoma was found. Hematuria. Pulse 94/min, blood pressure 105/70 mm Hg. What is the initial
diagnose? What methods of examination are necessary in this case?
Task 1. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination, detects main
clinical signs of the closed renal ruptures, forms diagnostic program, formulates diagnosis.
Questions for the student:
1. What are the clinical symptoms of the closed renal ruptures?
2. What are the methods of examination of the patients with the closed renal ruptures?
3. What is the medical tactics in the patients with the closed renal ruptures?
Task 2. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination, detects main
clinical signs of the ruptures of ureter, forms diagnostic programme, formulates diagnosis.
Questions for the student:
4. What are the clinical symptoms of the ruptures of ureter?
5. What are the methods of examination of the patients with the ruptures of ureter?
6. What is the medical tactics in the patients with the ruptures of ureter?
37
III. Answers to the SeIf-Assesment.
1.
С.
A- closed renal rupture; urography and excretory urography are useful.
Students Practical Activities:
Student must know:
1. Classification of the ruptures of kidneys.
2. Symptoms and clinical course of the ruptures of kidneys.
3. Diagnosis of the ruptures of kidneys.
4. Differential diagnosis of the renal ruptures.
5. Conservative treatment of the renal ruptures.
6. Surgical treatment of the ruptures of kidneys.
7. Symptoms and clinical course of the ruptures of ureter.
8. Diagnosis of the ruptures of ureter.
9. Differential diagnosis of the ruptures of ureter.
10. Principles of treatment of the renal ruptures.
Students should be able to:
1. Detect main clinical signs of the ruptures of kidney and ureter.
2. Define necessary quantity and sequence of patients examination: physical, laboratory,
roentgenological, endovesical.
3. Should be able to detect signs of the ruptures of kidney and ureter on excretory urograms,
retrograde ureteropyelograms etc.
4. Form diagnostic program for the patient with rupture kidney and ureter.
5. Prove and formulate clinical diagnosis.
6. Spend differential diagnosis.
7. Prove conservative treatment and indications for the surgical treatment. Methodological
Instructions to Lesson № 13 for Students
Theme: Injuries to the bladder and urethra.
Site: Classroom, hospital ward, X-ray cabinet, operating room, casuality ward, hospital ward,
dressing room, cystoscopic room.
Aim: To study symptoms and principles of treatment injuries to the bladder and urethra.
Professional Motivation:
Lately as a result of increasing of accidents and urbanization we have augmentation of injuries of
the organs of genitourinary tract. Indirect ("contrecoup") injury, caused by falling from a height and
landing on the feet or buttocks, is less common. Rarely acute abdominal muscle contraction have caused
a hydronephrotic kidney to burst.
Basic Level:
1. Anatomy and physiology of urinary tract.
2. To take history and physical examination.
3. X-Ray, instrumental, laboratory, endoscopic methods in injuries of kidneys and ureter diagnosis.
4. Conservative measures of etiologic, pathogenetic and symptomatic treatment; different kinds of
surgical treatment.
Students' Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. General clinical symptoms of the bladder and urethra injuries.
The urinary bladder may be injured by external forces: during surgery, including accidental incision
in pelvic surgery or in the repair of hernia; and in transurethral manipulations. An injury or blow to the
lower abdomen followed by low abdominal pain and hematuria is strongly suggestive of vesical injury.
Fracture of the pelvis is commonly accompained by injury to the bladder. The finding of suprapubic
tenderness or a mass is suggestive; signs of peritonitis may be elicited. If the patient can urinate
hematuria is to be expected, but he may not be able to urinate at all. Pain is present low in the abdomen.
Pain in the shoulder may be noted if there is urine in the abdominal cavity. Shock may be profound,
especially if multiply injuries have been suffered. There may be evidence of local trauma such as a bullet
38
or knife wound or ecchymosis. Marked tenderness in the suprapubic area is to be expected. There may be
rebound tenderness if the laceration involves the peritoneum. Spasms of the muscles of the lower
abdomen occurs even though the extravasation is perivesical. A board-like abdomen suggests
intraperitoneal rupture. The skin over the symphysis commonly becomes quite cool immediately after
extraperitoneal rupture occurs. A large suprabubic mass may be felt or percussed as the perivesical
collection of fluid develops. This will contain blood, urine and sometimes pus. Rectal examination may
revael a large boggy mass obliterating the normal landmarks. Evidence of other injuries is usually
present. If urethra is injured urethral bleeding may be noted. A history of injury, usually severe, is always
obtained. Pain is present in the peritoneum or low in the abdomen. The patient may be unable to void.
Urethral bleeding or hematuria is present. There may be a mass in the suprapubic area. The area may be
dull to percussion. Suprapubic tenderness may be marked. This may be due to extravasation or to a
fracture with associated hematoma. Rectal examination may reveal a large boggy mass of extravasated
blood or urine.
2. Diagnosis of the bladder and urethra injuries. In case of the bladder injury the hematocrit may
demonstrate anemia from loss of blood or hemoconcentration from shock. The white blood count and
neutrophils are increased.
Urinalysis hematuria, either gross or microscopic. The presence of bacteria means infectoin, either
preexisting or new. If a significant amount of urine escapes into the peritoneal cavity, the serum
BUN:creatinine ratio is significantly insreased. A plain film may reveal fractures of the pelvic bones.
Increased grayness from from a perivesical collection of urine and blood may be seen. A cystogram is the
most dependable test for vesical injury. Instill 350-400 ml ofradiopaque fluid and take anteroposterior
and oblique films. Then drain the vesical contents and take another film. This may reveal small amounts
of extravasated fluid lying behind the bladder or in the cul-de-sac. X-Ray findings with radiopaque fluid
are useful to show the site of extravasation in case of urethra injury. 3. Indications for the consrevative
and surgical treatment of the injuries to the bladder and urethra.
Emergency measures are to treat shock and hemorrhage. If the rupture of the bladder is
extraperitoneal, the site of the injury should be drained surgically. Urologists as a rule favor suprapubic
cystostomy as a more reliable method than catheterization for keeping the bladder empty and at rest. The
peritoneum should be opened and intraperitoneal organs explored for associated injury. If there is
evidence of a fractured pelvis and massive hemorrhage, a transfemoral iliac angiogram should be done to
seek the site of the bleeding. In case of urethral rupture if a wethral catheter of adequate size can be
passed to the bladder, it should be left in place for 14-21 days. Simple lacerations usually heal well with
only this splinting. If a catheter cannot be passed to the bladder, surgical intervention is imperative.
Conservative therapy is effective for patients with recent nonpenetrating damage of urethra: rest,
cool compression, antibiotics. Within 7-8 days after trauma thermal procedures and resorption agents are
prescribed. In case of ischuria instead of a high cystotomy it is possible to perform troacar epicystostomy.
In case of fractures of pelvic bones with rupture of urethra patients often are in shock state. After
removing such state the operation is immediately performed: abduction of urine is provided to prevent its
flow and to reduce suffering of the patient, and urethra is restored. If condition of the patient is very
serious, it is necessary to limit operation with abduction of urine through suprapubic urethrovesical
fistula. In case of early hospitalization (within 6 hours from the moment of trauma), insignificant
fractures of pelvic bones or absence of those and massive urohematomas it is expedient to perform
primary urethrourethroanastomosis, i. e. urethra connection after incision of damaged edges of rupture
from perineal access. After that additional measures are necessary concerning treatment of pelvic
fractures and prophylaxis of connected with them complications.
The primary plastics of urethra has advantage over its restore in late terms. Due to a primary plasty
the duration of hospitaization of the patient is reduced, there's no necessity bougieurage of urethra, as
after some kinds of urethro plasty. In a case of urine flow and signs of infection, which are observed in
case of late hospitalization, the primary plasty is impossible. Urine is evacuated through suprapubic
fistula of urinary bladder with insertion of two synthetic tubes through suprapubic dissecting for a
constant irrigation of urinary bladder with antiseptic solution. Urinary flows are drainaged. Urethral
conduction is restored after improvement of general patient condition. In late terms epicystostomia is
performed, urinary flows are dissected and drainaged. If not only urethra, but also a rectum is injured,
two-canal fistula of sygmoidal colon is created. In case of separation of urethra from neck of urinary
39
bladder, serious combined damage it is necessary to limit operation with suprapubic fistula and drainage
of paravesical space. Restoring operation is performed after some period of time.
Key words and phrases: injuries to the bladder and urethra, intraperitoneal rupture, fractured pelvis,
surgical and conservative measures of the treatment.
II. Tests and Assignments for Self-assesment:
Multiply choice. Choose the correct answer/statement:
1. What disease may be found by Zeidovich test?
A. Rupture of the bladder.
B. Rupture of the liver.
C. Rupture of the urethra.
D. Rupture of the kidney.
E. Rupture of the ureter.
Real life situations to be solved.
2. Patient K., 34 years old, crashed by car. At the causality ward fracture of the pelvis was found.
Urethrorrhage. What is the previous diagnosis? What methods of examination is indicated in this case?
Labour 1. Prove and formulate clinical diagnosis. Student takes complains, disease and life history
of the patient, physical examination, detects main clinical signs of the ruptures of the bladder, forms
diagnostic program, formulates diagnosis.
Questions for the student:
1. What are the clinical symptoms of the ruptures of the bladder?
2. What are the methods of examination of the patients with the ruptures of the bladder?
3. What is the medical tactics in the patients with the ruptures of the bladder?
Labour 2. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination, detects main
clinical signs of the ruptures of urethra, forms diagnostic programme, formulates diagnosis.
Questions for the student:
4. What are the clinical symptoms of the ruptures of urethra?
5. What are the methods of examination of the patients with the ruptures of urethra?
6. What is the medical tactics in the patients with the ruptures of urethra?
III. Answers to the Self-Assesment:
1-A.
2 – suspitio on the fracture of the urethra; retrograde urethrocystograohy.
Visual aids and material tools:
I. Roentgenograms:
1. 1 Retrograde cystography — intraabdominal rupture of the bladder.
1. 2 Retrograde cystography – extraabdominal rupture of the bladder.
1. 3 Retrograde urethrography – rupture of the urethra.
Students Practical Activities:
Student must know:
1. Classification of injuries to the bladder.
2. Symptoms and clinical course of the injuries to the bladder.
3. Diagnosis of the injuries to the bladder.
4. Differential diagnosis of the injuries to the bladder.
5. Conservative treatment of the bladder injuries.
6. Surgical treatment of the bladder injuries.
7. Symptoms and clinical course of the urethra injuries.
8. Diagnosis of the urethra injuries.
9. Differential diagnosis of the urethra injuries.
10. Principles of treatment of the urethra injuries.
Students should be able to:
1. Detect main clinical signs of the injuries to the bladder and urethra.
2. Define necessary quantity and sequence of patients examination: physical, laboratory,
roentgenological, endovesical.
40
3. Should be able to detect signs of the injuries to the bladder and urethra on cystograms,
urethrograms etc.
4. Form diagnostic program for the patient with the injuries to the bladder and urethra.
5. Prove and formulate clinical diagnosis.
6. Spend differential diagnosis.
7. Prove conservative treatment and indications for the surgical treatment.
Methodological Instructions to Lesson 14 for Students
Theme: Nephroptosis and hydronephrosis.
Aim: To study symptoms and signs of hydroncphrosis and nephroptosis, principles of treatment the
patients with hydronephrosis and nephroptosis, methods of surgical treatment.
Professional Motivation:
Hydronephrosis takes the 10th place among the diseases of the urinary tract; this disease is wide
spread amoung young chilren. In 25% disease is; bilateral and is observed with other urologic diseases of
controlateral organ. Now nephroptosis is registrated in 1,5% female and 0,1 % male at the' age from 25 to
40.
Basic Level:
1. Anatomy and physiology of urinary tract.
2. To take history, complains and physical examination.
3. Etiology and pathogenesis of the hydronephrosis and nephroptosis.
4. X-Ray, instrumental, laboratory, endoscopic methods in hydronephrosis and nephroptosis
diagnosis.
5. Principles of etiologic, pathogenic and symptomatic therapy of hydronephrosis and nephroptosis;
nephropexy, its kinds.
Students’ Independent Study Program.
A.
Objectives for Students' Independent Studies.
You should prepare for Ihe practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. General clinical symptoms of the hydroncphrosis and nephroptosis.
Patients with nephroptosis complain of weak periodical pain in lumbar region, exactly during
physical work, walking; pain wakes the patient in bed. Renal colic in patients is assosiated with rotation
of the mobile organ. Finally there are mild hypertension, hematuiria and other disorders of renal
functions.
There are no specific symptoms of hydronephrosis. Aseptic unilateral hydronephrotic atrophy is
continuously asymptomatic. Course of the disease is circulating. The intensity of signs depends on the
stage of urinary tract constriction presence, activity of the infection, etc. The pain in loin is frequent. Its
intensity depends on stage of structure of the urinary tract and infection activity. It may be dull,
intermitting, renal colic, permanent ache.
Renal colic is observed in case of initial hydronephrotic atrophy; dull pain and feeling of swelling
appears while cumulating of urine within the kidney. The kidney is palpable, enlarged and painful while
renal colic attacks. If colic is cupped off, ache is still present for some time, but kidney isn’t palpable.
This intermittent filling of kidney with the urine and its emptying may occur without pain, especially in
children. Parents may notice swelling of the loin, that disappears. Ache often is followed by hematuria,
fever. Therefore, hematuria may be the only sign of hydronephrosis.
Renal concrements cause activation of hydronephrosis clinical signs, progress of atrophy and
sclerosis. Stone forms due to urine congestion and retardation of its passage. Rather significant
hydronephrosis, especially in children, may defigurate the abdomen. The kidney may be palpated as a
large, mobile cyst, lying lower than common location. It is elastically resistant, with smooth surface,
painful.
Frequent complication is acute or chronic pyelonephritis. Hydronephrosis, that is complicated with
pyelonephritis, manifests in acute pain, fever, nausea, vomiting, sometimes – elevation of the blood
pressure rate. The significant hydronephrosis may be ruptured because of trauma.
2. Classification of hydronephrosis and nephroplosis.
There are 4 stages of nephroptosis development:
41
I – we can palpate the lower pole of the kidney,
II – we can palpate; all kidney.
III – Kidney descends into the pelvic cavity and is mobile,
IV – rotation of kidney.
There are 2 types of hydronephrosis: primary (as a result of innate renal obstruction) and secondary
(as a complication of different kidney diseases: urolithiasis, renal tumors etc. ).
Stages of hydronephrosis:
I – pyeloectasis,
II -hydrocalicosis (ectasis of calix with mild renal parenchyma failure).
III – hydronephrosis, parenchymal atrophia.
3. Conservative treatment of nephroptosis.
Conservative treatment is indicated only in the 1st stage of nephroptosis: complex of gymnastic
excercises, wearing of special corset, spasmolytics.
4. Indications to the surgical treatment of nephroptosis; nephropexy and its kinds.
In case of complications of nephroptosis surgical methods of treatment are indicated. There are
such kinds of nephropexy: autoplastic – using renal capsule, fixation with fascia or muscle, dermal piece;
alloplastic; using the combinations of materials with pyelolithotomy, reocclusion of a. renalis.
5. Surgical treatment of hydronephrosis. There are different methods of plactic and reconstructive
operations: uretcrolysis, lateral ureteral anastomosis; nephroetomy
Key words and phrases: nephroptosis and hydronephrosis, urinary tract, surgical and conservative
treatment of nerhroptosis and hydronephrosis, nephropexy.
II. Tests and Assignments for Self-assesment.
Task 1. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination
detects main clinical signs of the nephroplosis, forms diagnostic programme, formulate; diagnosis.
Questions for the student:
1. What are the clinical symptoms of the nephroptosis?
2. What are the complications of the nephroptosis?
3. What is the classification of the nephroptosis?
4. What are the main methods of the examination of patients with nephroptosis?
Task 2. Differential diagnosis of the nephroplosis.
Student makes differentional diagnosis of the nephroptosis, using complains, disease and life
history, physical examination, laboratory and sonography signs.
Questions for the student:
1. What diseases is it necessary to make differential diagnosis with?
2. What is the medical tactics in the patients with the nephroptosis?
3. What kinds of the nephropexy do you know?
Task 3. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination, detects main
clinical signs of the hydronephrosis, make the diagnostic program, formulate diagnosis.
Questions for the student:
1.. What are the clinical symptoms of the hydronephrosis?
2. What is the classification of the hydronephrosis?
3. What are the main methods of the examination of patients with hydronephrosis?
Task 4. Differential diagnosis of the hydronephrosis.
Student makes differentional diagnosis of hydronephrosis, using complains, disease and life
history, physical examination,-laboratory and sonography signs.
Questions for the student
1. What diseases it is necessary to make differential diagnosis with?
2. What is the medical tactics to the patients with hydronephrosis?
3. What kinds of surgical treatment of hydronephrosis do you know?
Multiple Choice.
Choose the correct answer/statement.
1. The sign of the I stage of hydronephrosis on excretory urogram is:
42
A. Dilatation of the upper calix.
B. Enlargement of the pyelos and calix.
C. Enlargement of the pyelos.
D. Amputation of the calix.
2. At the II stage of hydronephrosis is necessary:
A. Pyeloureteroplastic.
B. Nephreectomya.
C. Pyelolithotomya.
D. Nephrostomya.
E. Resection of the upper pole.
Real life situations to be solved:
A. The young person after therapeutic deprivation lost 14 kg. Now he complains of weak, dull pain
in the right hypogasfrium and in the lumbar region after physical work. What do you think about this
clinical case? What methods of examination are useful in this situation?
B. In a patient K. 56 years old on excretory urogram are detected dilatation of right pyelos and
calyx with stricture of the pyeloureteral segment. He was 5 years old, when at the first time appeared dull
pain in the right lumbar region. What is the primary diagnosis? What are the therapeutic tactics?
Answers to the Setf-Assesment:
1.
C;
2.
A.
1.
nephroptosis of the right kidney, excretory orthostatic urography;
B – hydroncphrosis of the right kidney in the II stage, is indicated pyelouretroplastic operation.
Visual aids and material tools:
1. Roentgcnograms:
1. 1 Excretory urography – hydroncphrosis III st.
1. 2 Excretory urography – nephroptosis I and II st.
1. 3 Retrograde ureleropyelography – hydronephrosis II and III st.
1. 4 Retrograde uretheropyelography – lumbar dystopy.
Students Practical Activities:
Student must know:
1. Etiology and pathogcncsis of hydroncphrosis.
2. Classification of hydronephrosis.
3. Symptoms and clinical course. of hydronephrosis.
4. Diagnosis of hydronephrosis.
5. Differential diagnosis hydronephrosis.
6. Treatment of hydroncphrosis.
7. Etiology of nephroptosis. '
8.. Classification of nephroptosis.
9. Clinical signs of nephroptosis.
10. Diagnosis of nephroptosis.
11. Differential diagnosis of nephroptosis.
12. Treatment of nephroptosis.
Students should be able to:
1. Detect main clinical signs of nephroptosis and hydronephrosis.
2. Prove and formulate clinical diagnosis.
3. Define necessary quantity and sequence of palients examinalion: physical, laboratory,
roentgenological, endovesical
4. Should be able to detect signs of nephroptosis and hydronephrosis on urograms and excretory
urograms.
5. Make differential diagnosis.
6. Prove conservative treatment and indications for
the surgical treatment. Methodological Instructions for Lesson № 15 Students
43
Theme: Nephrogenie Arterial Hypertension.
Aim: to diagnose nephrogenic hypertension, to learn the principles of its treatment.
Professional Motivation:
Among the patients, who are ill with hypertension, in 30-40% it is of nephrogenic origin. Vasorenal
hypertension is a disease of any age, however more often (93% of patients) before the age of 50, it has a
malignant character (18-30% of the patients).
Basic Level:
1. Anatomy-physiological features of kidneys.
2. To know how to collect anamnesis and to know the indications of the arterial hypertension.
3. X-ray, functional, instrumental, laboratory, endoscopic methods of the research in nephrogenic
hypertensional diagnosis.
4. To know hypotensial means and mechanism how they operate.
Student's Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Pathogenesis renovascular hypertension.
The renin-angiotensin-aldosterone system is an integrated hormonal cascade that simultaneously
controls blood pressure and sodium and potassium balance and influences regional blood flow. Renin is
proteolytic enzyme produced in the juxtaglomerular cells of the afferent arterioles. It acts on renin
substrate (angiotensinogen), α2 globulin produced in the liver, to form the decapeptide angiotensin I.
Converting enzyme, found in the lung and kidney, cleaves α-amino acids from angiotensin I to form the
octapeptide angiotensin II, a potent arterial vasoconstrictor. Angiotensin II also stimulates the zona
glomerulosa of the adrenal gland to secrete aldosterone. Evelation of blood pressure and restoration of
sodium balance inhibit further renin secretion.
2. Clinical clues suggestive of renovascular hypertension.
Suspect renovascular hypertension if the family history is negative; however, about one-third of
patients with renovascular hypertension have a positive family history. Average age of onset of essential
hypertension is 31+10 (SD) years. Children and young adults usually have fibromuscular disease,
whereas adults over age 45 years are more likely to have atherosclerotic narrowing of the arteries.
Essential hypertension usually begings with a labile phase before mild hypertension becomes established,
whereas the natural history in renovascular hypertension is usually more compressed with the disease
often appearing initially as moderate hypertension of recent onset. Renovascular hypertension often
becomes moderately severe and may cause accelerated or malignat hypertension; both forms of
hypertension involve markedly increased secretion of renin. Essential hypertension is usually
asymptomatic; headaches occur more commonly with renovascular hypertension and may be related to
its greater severity or the high levels of angiotensin II (a potent cerebrovascular vasoconstrictor)
associated with this disease. A recent survey showed that 74% of patients with fibromuscular renal artery
stenosis are smokers; 88% of those with atherosclerotic disease smoke. Renovascular hypertension is
uncommon in blacks. Renovascular hypertension typically responds poorly to diuretics and often
responds only transiently to antiadrenergic drugs. Angiotensin Converting enzyme(ACE) inhibitors block
the renin-angiotensin-aldosterone system most effectively and are highly specific agents.
3. Indications and contra-indication to the surgical treatment of the nephrogenic hypertension.
Medical trteatment with converting enzyme inhibitors and beta-blockers should be reserved for
higher-risk patients who are not good candidates for surgery and for those patients in whom
revascularization procedures have failed. Medical management of patients with correctable renal artery
lesions requires close monitoring of both blood pressure control and renal function.
Patients who meet the criteria for reversible renovascular hypertension can now be treated with
percutaneous transluminal balloon dilatation of the stenotic renal artery (transluminal angioplasty).
Surgely is reserved for patients in whom percutaneous transluminal dilatation is not successful. The
first surgical cure of hypertension was achieved by unilateral nephrectomy. However, unilateral
nephrectomy has benefited only 26-37% of the large group of unselected patients with hypertension who
have been so treated. Unilateral nephrectomy is now reserved for treatment of 2 groups of patients with
hypertension: (1) those who have poor or absent renal function in the involved kidney but normal
function in the contralateral kidney and in whom attempts at revascularization have failed, and (2) those
44
at such high risk that the loss of functioning nephrons is offset by the elimination of the cause of
significant excess renin secretion. Partial nephrectomy may be performed if the kidney has multiple renal
arteries and only one is stenotic.
Today, surgical treatment emphasizes preservation of renal function. Accordingly, various methods
may be used to attempt to revascularize an ischemic kidney; these include endarterectomy, aortorenal
bypass graft utilizing the saphenous vein or hypogastric artery, and hepatorenal and splenorenal bypass
procedures for patients with severely diseased aortas.
Visual aids and material tools:
1. Slides.
2. Tables.
Test and Assignments for Self-assesment.
Work 1. To confirm and to formulate the clinical diagnosis.
The student collects the complaints, anamnesis of the disease and life of the patient, conducts an
objective examination, finds out the main clinical indications of the nephrogenic hypertension, makes up
a diagnostic program, formulates the diagnosis.
The student must answer the next questions:
1. What are the main symptoms of the nephrogenic hypertension ?
2. What is the classification of the nephrogenic hypertension ?
3. What methods of the research are necessary to be carried out to the patients with
nephrogenic hypertension.
Work 2. Realisation of the differential diagnosis.
Based on the complaints, anamnesis of disease and life facts of the objective examination,
laboratory, X-ray and USR the student carries out the differential diagnosis of the patients with
nephrogenic hypertension.
The student must answer the questions:
1. What diseases will you conduct the differential diagnosis with ?
2. What is the clinical tactics of taking care of the patient with nephrogenic hypertension ?
Real-life situations to be solved:
1. The patients P. 24 years old, often has complains of headaches, lumbar pain, increased arterial
pressure 180 and 120 mm/Hg, that can not be corrected by hypertensive medicaments. What is your
predective diagnosisThe answer : nephrogenic hypertension. Intravenous urography, USR and angiopgraphy. must be
done to the patient.
2. The patient A, 21 years old, has pain in the right half of stomach,which is amplified with any
physical work and are accompanied with increasing of arterial pressure.
Objectively: a patient with astenic structure of the body and of average. Arterial pressure 145 and
110 mm/Hg. The stomach has correct form, the oval smooth elastic formation is palpated in the right half
of stomach and is easily dispaced up and is hidden in the right subcostae. What is your predictive
diagnosis ?
What is your clinical tactics?
The answer : Right side nephroptosis. Nephrogenic hypertension. Orthostatic intravenous
urography. Nephropexy on the right side must be done to the patient.
1. What examination it is necessary to provide at the IInd stage of diagnosis of vasorenal
hypertension?
A. Howards test.
B. Exretory urography
C. Isotopic renography
D. Kidney's angiography
E. Kidney's biopsy
The correct answer: D
2. What is necessury to provide at 3rd stage of diagnosis of vasorenal hypertension:
A: Howards and Rappoport's test
B: Zymnytskyiy's test
45
C: Zeidovych' test
D: Excretory urography
E: Kidney's angiography
The correct answer: E
Students Practical Activities:
Student must know:
1 Classification of the nephrogenic arterial hypertension.
2. Pathogenesis of the nephrogenic arterial hypertension.
3. Symptoms and clinical forms.
4. Diagnostic of the vasorenal hypertension at the 1st stage.
5. Diagnostic of the vasorenal hypertension at the 2nd stage.
6. Diagnostic of the vasorenal hypertension at the 3rd stage.
7. Differential diagnosis of the nephrogenic hypertension.
8. Treatment of the vasorenal hypertension.
9. Parenchymal hypertension. Etiology, pathogenesis.
10. Symptoms of parenchymal hypertension.
11. Diagnosis and differential diagnosis of parenchymal hypertension.
12. Treatment ofparenchymal hypertension.
Student should be able to:
1. To find out the main clinical indications of nephrogenic hypertension.
2. To ground and to formulate the clinical diagnosis.
3. To make up the program of the additional methods of the examination.
4. To conduct the differential diagnosis.
5. To ground the medicamentos treatment and indications for a surgical interference.
6. To know how to palpate the kidneys in horizontal and vertical positions, auscultation of the
abdominal aorta and projection of kidneys arteries.
Methodological Instructions to Lesson N l6 for Students
Theme: Acute renal failure.
Aim: To study symptoms, signs and laboratory findings of acute renal failure and principles of
conservative treatment.
Professional Motivation:
Acute renal failure leads to critical disorders of homeostasis, retention of protein metabolism
products in blood, changes in water-electrolyte And salt metabolism. In a great number of cases
morphological changes in kidney tissue are reversible, and recovering is possible even in serious
situations.
Basic Level:
1. Anatomy and physiology of urinary tract.
2. To take history and physical examination.
3. Etiology and pathogenesis-of acute renal failure.
4. X-Ray, instrumental, laboratory, endoscopic methods in acute renal failure diagnosis.
Students' Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. General clinical symptoms and syndroms of acute renal failure. In the initial phase are present
symptoms of the main pathology that's the reason of acute renal failure; as a result of azotemia appear
general weakness, anorexia, vomiting, maliase, disorders of consciousness, symptoms of digestive
system violation, respiratory disorders, hypoproteinemia, leucocytosis, anemia, oliguria or anuria.
Laboratory findings are: specific gravity of urine – is near 1010 within 48 hours of the onset of shock or
poisoning; urine chloride concentration fixed between 30-40 mEq/l; serum. electrolytes – sodium and:
chloride concentrations may be low, normal or high depending on salt and water intake; test of retention
– serum creatinine and urea nitrogen tend to rise together at a 1:10 ratio; others.
46
2. Etiologic classification of acute renal failure and its stages.
There are 3 types of acute renal failure: prerenal, renal and postrenal. Causes of prerenal anuria are:
hypovolemia {hemorrhage, gastrointestinal losses, pancreatitis, burns, peritonitis, traumatized tissue,
diuretic abuse, impaired cardiac function: congestive heart failure, myocardial infarction, pericardial
tamponade, acute pulmonary embolism, peripheral vasodilatation, bacteriemia, antihypertensive
medications, increased renal vascular resistanse: anesthesia, surgical operation, hepatorenal syndrome,
renal vascular obstruction, bilateral: emboism, thrombosis. Renal azotemia is a result of diseases lof
glomeruli and small blood vessels: acute poststreptococcal glomerulonephritis, systemic lupus
erythematosus, polyarteritis nodosa, serum sickness, and nephrotoxins action -exogenous (heavy metals,
carbon tetrachloride. X-ray contrast media) and endogenous (calcium, uric acid, myoglobulin,
hemoglobin). The causes of postrenal azotemia are: obstruction of ureters, bilateral (extraureteral –
tumors: cervix, prostate, endometriosis, priureteral fibrosis, ligation during pelvic operation, and
intraureteral – crystals, blood clots, pyogenic debris, stones, edema, papillary necrosis), bladder’s neck
obstruction (prostatic hypertrophy, bladder carcinoma, bladder infection, functional – neuropathy or
ganglionic blocking agents, urethral obstruction.
The clinical course of acute renal failure can be divided into 4 stages: 1) initiating or shock phase,
2) oligo-anuria – diuresis less than 300 ml, 3) normalization of diuresis, 4) recovering phase.
3. Medical tactics in patients of acute renal failure according to etiologic features and phase.
The first principle of therapy of acute renal failure is to exlude potentially reversible causes of
deteriorating renal function. Once the diagnosis of acute renal failure has been established, little specific
therapy is avaible. Dialysis for removal of toxins may occasionally be indicated. Even in the presence of
acute renal failure any prercnal factors should be corrected to improve the circulation and maximize
chances for early recovery of renal function. In the patients who remains oliguric despite correction of
prerenal factors, it has become common clinical practice to administer either mannitol or the potent loop
diuretic furosemide. The rationale for this therapy is that the combination of correction of prerenal factors
and potent diuretic therapy may induce a nonoliguric state and thus attenuate the natural history of acute
renal failure. Medical management of acute rernal failure includes: be sure all specifically treatable
causes of deteriorating renal function have been excluded, correct prerenal factors, attempt to establish a
urine output, conservative (nondialytic) treatment: decrease intake of nitrogen, water, and electrolytes to
match output, after drug therapy, provide adequate source of calories, clinical monitoring (frequency of
vital signs determined by patient status; intake and output, body weight, inspection of wounds and
intravenous sites, and physical examinations should be performed daily; biochemical monitoring
(frequency of blood urea nitrogen,' serum creatinine, electrolytes, and complete blood count
determinations will be dictated by patient status; in general, at least daily determination will be needed;
calcium, phosphorum, magnesium, and uric acid can often be determined less often; dialytic therapy.
II. Tests and Assignments for Self-assessment.
Task 1. Prove and formulate clinical diagnosis.
Student takes complains, disease and life history of the patient, physical examination,
detects main clinical signs of acute renal failure, forms diagnostic programme, formulates
diagnosis.
Questions for the student:
1. What are the clinical symptoms of urolithiasis?
2. What is the classification of acute renal failure?
3. What are the levels of urea nitrogen, creatinine, potassium and other electrolyties, uric acid,
bilirubin, protein in patients with different phases of acute renal failure and in the blood of normal
people?
Task 2. Make differential diagnosis of urolithiasis.
Student make differential diagnosis acute renal failure, using complains, disease and life history,
physical examination, laboratory and sonography signs.
Questions for the student:
1. What diseases is it necessary to make differential diagnosis with?
2. What is the medical tactics in the patients with acute renal failure?
3. What are the indications for surgical treatment or acute renal failure?
47
Multiple Choice.
Choose the correct answer/statement.
1. The cause of prerenal acute renal failure is:
A. Stone of the only kidney.
B. Haemorrhage.
C. Intoxication by heavy metals.
D. Nephrectomy of the only kidney.
E. Obstruction of the both ureters.
2. In ease of the intoxication by the heavy metals the universal antidote is:
A. Natrium tiosulphate.
B. Calcium chloride.
C. Hydrocortisone.
D. Ethylic alcohol.
Real life situations to be solved:
A. In a patient on the 2nd: day after extirpation of the uterus is the anuria, pain in the lumbar region.
What diagnostic measures are necessary to be held in this situation to form the diagnosis? What are the
surgical tactics?
B. The patient L., 62 years old, complains of the pain in the right lumbar region, nausea, vomitting,
general weakness,-absence of the urine for a 2 days. Biochemistry blood analysis: urea – 41,6 mmol/1,
creatinine – 0,46 mmol/1. On general urogram – shadow : of the stone 0,8x0,7 at the proection of the
lower part of the right ureter. From the case. history -has the urolithiasis of right kidney. What is the
primary diagnosis? What are therapeutic tactics in this case?
III. Answers to the Self-assessment:
The correct answers to the tests:
1- B;
2- A.
The correct answers to the real life situations:
A- Yatrogenic defect of the ureters, postrenal anuria, it is necessary to find the organic reason of
the obstruction by catheterization of the ureters, if it is impossible the ureterocystoneostomy is indicated;
B-stone of lower part of the right ureter, postrenal anuria, acute renal failure, is indicated the
catheterization of the right kidney, to take out the stone is necessary.
Visual aids and material tools:
1. Slides:
1. 1 Renal angiography – granular kidney (cirrhosis of the kidney).
1. 2 Retrograde ureteropyelography – granular kidney.
2. Medical cards of ambulant patients
Students Practical Activities:
Student must know:
1. Classification (etiologic and on phases) of acute renal failure.
2. Symptoms and clinical signs of acute renal failure in initiating phase.
3. Symptoms and clinical signs of acute renal failure in oligoanuric phase.
4. Differential diagnosis of acufe-'renal, failure and acute anuria.
5. Treatment of prerenal acute renal failure.
6. Treatment of renal acute renal failure.
7. Treatment ofpostrenal adute renal failure.
Students should be able to:;
1. Detect main clinical signs of acute renal failure using complains and case history.
2. Define necessary quantity and sequence of patients examination: physical, laboratory
roentgenological, endovesical.
3. Prove and formulate clinical diagnosis.
4. Make differential diagnosis,
5. Prove conservative treatment and indications for the surgical treatment treatment.
6. To estimate the levels of urea nitrogen, creatinine, potassium and other electrolytes, uric acid,
bilirubin protein in patients with different phases of acute renal failure and in the blood of normal people.
48
Methodological Instructions to Lesson 17 for Students
Theme: Acute diseases of scrotum organs.
Aim: To study symptoms, signs, principals of treatment of the patients with acute diseases of
scrotum.
Professional Motivation:
As to B. S. Hetman, 78 % of the patients with acute diseases of scrotum organs are young men at
the age from 20 to 25. It is known that in some cases acute epididimitis is complicated by orchitis that
can lead a man to infertility
Basic Level:
1. Anatomy and physiology of scrotum organs.
2. Laboratory and physical methods of examination, diaphanoscopy in diagnosis of scrotum
diseases.
3. Conservative measures of etiologic, pathogenetic and symptomatic treatment physiotherapeutic
and surgical therapy.
Students' Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
1. Etiology and pathogenesis of acute epididimitis and acute orchitis. There are 3 common causes
of epididimitis: 1) preexisting prostatitis, or prostatic infection introduced by an internal or indwelling
urethral catheter; 2) prostatectomy, particularly the transurethral type, where the ejaculatoty ducts are laid
open in prostatic fossa; the hyarostatic pressure with voiding or with physical strain may force urine
(which may contain bacteria for 8-12 weeks after the operation) dawn the was; 3) reflux of sterile urine
down the vas deferens will lead to a chemical epididymitis. In its early stages, epididymitis a cellular
inflammation, it starts in the vas deferens and descends to the lower pole of the epididymis; in the acute
stage epididymitis is swaollen and indurated, the infection spreads from the lower to the upper pole.
Microscopically changes grade from edema and infiltration with leucocytes, plasma cells, and
lymphocytes to actual abscess formation. The testis may become inflamed from; a hematogenous source.
Orchitis may occur with any infectious disease (coxsackievirus infection, dengue). Patients with mumps
parotitis excrete the virus in the urine. Therefore, it would appear that a complicating mumps epididymoorchitis may also be a descending infection. The edema which develops probably leads to death of the
spermatogenic cells from ischerraia. Primary infection of an epididymis may involve its testis by direct
extension. Grossly, in nonspecific orchitis, the testis are much enlarged, congected and tense. On section,
small abscesses may be noted. Microscopically, there is edema of the connective tissue with diffuse
neutrophilic infiltration. The seminiferous tubules also show involvement; necrosis is present In the
healed stage, the seminiferous tubules are embedded in fibrous tissue. Histologic study shows
considerable atrophy. The interstitial cells are usually present. Mumps is the most common cases of
inflammation of the testis, which occurs only after puberty. It is usually unilateral but may be bilateral.
On section because of the interstitial reaction and edema, the tubules do not extrude. Microscopically,
edema and dilatation of blood vessels are noted.
Neutrophils, lymphocytes, and macrophages are abundant. Tubular cells show varying degrees of
degeneration. In the healed stage, the testis are small and flabby. Microscopic study in this instance
shows marked tubular atrophy, although the Leudig cells are usually normal in appearance. The
epididymis usually shows similar changes.
2. General clinical symptoms,acute diseases of scrotum organs.
Epididymitis often follows severe physical strain such as lifting a heavy object. It may develop
after considerable sexual excitement. Pain develops rather suddenly in the scrotum, it may radiate along
the spermatic cord and even reach the flank; the pain is generally quite severe and the epididymis
exquisitely sensitive. Swelling is rapid and may cause the organ to become twice the of normal in the
course of 3 or 4 hours. The temperature may reach 40°C. Urethral discharge may be noted. Symptoms of
cystitis with cloudy urine may accompony the painful swelling. Clinical symptoms of acute orchitis:
onset is sudden, with pain and swelling of the testicle. The scrotum becomes reddened and edematous.
There are no urinary symptoms, as are often seen with epididymitis. Fever may reach 40°C, and
prostration may be marked. The parotitis of mumps may be present, or evidence of other infectious
49
disease may be found. One ore both testis may be enlarged and very tender. The epididymis cannot be
distinguished from the testis on palpation. The scrotal skin may be reddened. An acute trans illuminating
hydrocele may develop.
3. Proving and formulation of clinica diagnosis.
In case of acute epididymitis may be tenderness over the groin (spermatic cord) or in the lower
abdominal quadrant on the affected side, the scrotum is enlarged. The overlying skin may be reddened; if
abscess is present, the skin may appear dry, flaky and thinned; it may rupture spontaneously. Hydrocele
secondary to the inflammation may develop within a few days. The white blood count often reaches 2030 G/liter; urinalysis may or may not reveal evidence of infection. The white blood count is usually
elevated in the patients with acute orchitis. Urinalysis is usually normal, although some protein may be
found. Abnormal renal is found in patients with mumps. Microhematuria and proteinuria are common.
The specific virus can be found in the urine. Later, renal function and urine return to normal.
Key words and phrases: Acute epididymitis, acute orchitis, testis torsion, conservative treatment,
surgical therapy.
II. Tests and Assignments for Self-assesment:
1. In case of testis torsion is indicated:
A. Antibacterial therapy.
B. Urgent operation.
C. Non-urgent operation.
D. Block of spermatic cord.
E. Desintoxication and antimicrobal therapy.
2. In case of purative epididymitis is indicated:
A. Suspensorium wearing.
B. Urgent operation.
C. Planned operation.
D. Epididyectomy.
E. Winkelmann's operation.
Real-life situations to be solved:
A. Boy of 8 years old was brought to hospital with complaints of acute pain in right part of scrotum
that appeared urgent (after physical training lesson). On examination right orchis enlarged on 4 cm, is
very painful. What is the diagnosis? What are the tactics of treatment?
B. In patient 74 years old at the 8th day after prostatectomy appeared acute pain in left part of
scrotum, increased temperature to 39,2°C. Objective: left part of scrotum enlarged, hyperertiic,
tenderness. Palpated enlarged, very painful epididymis with orchis. For 4 days was held antimicrobal
therapy, improvement isn't preasent. Blood count: leucocyte – 18,0 G/l, leucocyte, related to stab
neutrophile – 24 %, erythrocyte sedimentation rate – 34 mm/h. Diagnosis? What are therapuetical
tactics?
III. Answers to the Self-assesment:
B;
D.
A. torsion of right orchis, urgent operation;
B. acute purative orcho epididymitis from the left side, hemicastration is indicated.
Task 1. Prove and formulate clinical diagnosis. Student takes complains, case and life history of the
patient, physical examination, detects main clinical signs of acute diseases of scrotum organs (orchitis,
epididymitis, orchoepidtdymitis, testis torsion), forms diagnostic program, formulates diagnosis.
Questions for the student:
1. What are the clinical symptoms of acute epididymitis?
2. What are the clinical symptoms of acute orchitis?
3. What are the clinical signs of testis torsion?
4. What are the main methods of the patients with orchoepididymitis examination?
Task 2. To make differential diagnosis.
1.
2.
50
Student makes differentional diagnosis of orchoepididymitis, using complains, disease and history,
physical examination, laboratory and diaphanoscopy signs.
Questions for the student:
1. What diseases is it necessary to make differential diagnosis with ?
2. What is the medical tactics in patients with orchoepididymitis?
3. What is the medical tactics in patients with spermatic cord torsion?
Visual aids and material tools:
1. Medical cards of ambulatory patients.
Students Practical Activities:
Student must know:
1. Etiology and pathogenesis of acute epididymitis.
2. Symptoms and clinical course of acute epididymitis.
3. Acute epididymitis diagnosis.
4. Therapy of acute epididymitis.
5. Symptoms and clinical course of acute orchitis.
6. Diagnosis of acute orchitis.
7. Differential diagnosis of acute orchitis.
9. Treatment of acute orchitis.
10. Clinical signs of testis torsion.
11. Diagnosis of testis torsion.
12. Differential diagnostic of testis torsion.
13. Principles oftestis torsion treatment.
Students should be able to:
1. Detect from case history main clinical signs of acute diseases of scrotum organs.
2. Define necessary quantity and sequence of patients examination: physical, laboratory,
endovesical.
3. Define therapy plan for the patients with orchoepididymitis, testis torsion.
4. Use diaphanoscopy and diagnostic punction of scrotum organs in examination of patients.
Methodological Instruction to Lesson 18 for Students.
Theme: Curatio of the patient.
Aim: To teach the students how to write correct history of the disease of the patient’s with
urological pathology.
Methodological Indication to Clinical Examination of Urological Patient.
1. PRAETACIO
Passport part
Date and time of entering:
Date and time of leaving:
Departament: Room #
Types of transporting ( on wheel litter, on medical chair, can walk )
Blood group: Rh factor:
Side effects of medicaments (name of medicament, character of side effect):
1.
2.
3.
4.
5.
6.
7.
8.
9.
a. Basic:
Name,Surname:
Sex:
Age:
Address:
Place of work,profession (for invalids- group of invalidity):
By whom patient was directed:
The diagnosis at admission:
Clinical diagnosis:
Final diagnosis:
51
b. Basic Complication :
c. Accompanying:
10.
Hospitalization in this year with this disease (primary, secondary, etc. )
11.
Surgical operations,types of anesthesia and post operative complications
(name of operation, year and time, type of anethesia, complications):
12.
Other types of treatment:
13.
Final of disease ( with recovery, without changes, death):
14.
Capacity for work (full, decreased, decreased at little period of time,
imposible):
15.
Particulary notes:
Name of curator: Head of curation:
Subjective examination.
2. Querellae Aegroti
3. Anamnesis Morbi
4. Anamnesis Vitae
5. Anamnesis Communis
Respiratory system (breathing, excretion from nose, excretion of blood from nose, larynx, the pain
in region of thorax, apnoe, tussis).
Cardio-vascular system (the pain in region of heart, after sternum, palpitation, edema).
Organs of digestive system (appetite, presense of dyspepsia, pain in abdomen, its localization,
irradiation of the pain, defecatio act, excretions, their character).
Genito-urinological system – pain in lumbar region (their character, duration, appearence,
irradiation in back, sex organs, inguinal regions), suprapubical pain (character, reasons of pain, reasons
which increase or decrease the pain), uresis (free, dysuria, bradyuria, nycturia, nocturia, strangury,
pollakiuria), the pain in testis region (their appearence, duration, irradiation), women: pain in external sex
organs, excretion from vagina.
Locomotary aparatus:
Neurological system:
Objective examination.
6. State of the patient at the time of examination.
State of the patient.
Consciousness.
Possition of the patient.
Look on the face.
Constitution.
Height, mass, body temperature.
7. Examination of patients’ systems.
Skin.
Hairs cover.
Mucous membanes.
Subcutaneus.
Glandula mamaria.
Lymphatic nodes.
Muscles.
Thyroid gland.
Bones and joints.
Respiratory organs (form of thorax, type of breathing, palpation of thorax, comparative percussion
and auscultation).
Cardio-vascular organs (pulse, blood pressure, examination of heart region, epigastrial pulsation,
percussion and auscultation of the heart, functional tests).
Digestive tract (form of abdomen, superficial and deep palpation, determination of liquid in
abdominal cavity, auscultation of abdomen, examination of rectum and anus).
Genito-urological system:
52
Kidneys: form, localization, movement, surface (smooth, humping), pain, Pasternatskiy symptom.
Palpation of urinary bladder. Palpation of adenoma per rectum (sizes, surface, fluctuation).
Examination of external sex organs. Palpation of scrotum (sizes, pain of scrotum or epididimis).
Nervous system, dermographism.
8. Locus morbi.
During examination of basic urological diseases, it is necessary to do following: examination,
palpation, percussion, and auscultation.
9. Primary diagnosis.
On the baseis of querellae aegroti, basic symptoms and datas of laboratory, X-ray, instrumental
methods of examination.
10. Plan of examination.
11. Laboratory analyses.
12. X-ray examination.
View and excretory urograms, retrograde pyelography, cystography and etc.
13. Instrumental examination.
14. Biopsy, bactorio- and cytological datas.
To give short characteristic of determined changes of laboratory and instrumental methods of
examination.
15. Clinical diagnosis.
Is formed on the basis of primary diagnosis and results of laboratory and instrumental changes.
16. Differential diagnosis.
Provides with disease symptoms of which is the same.
16.
Final diagnosis.
17.
Etiology and pathogenesis.
18.
Treatment.
1. Conservative (specific, pathogenetic, symptomatical)- indications.
2. Operative: indications and preoperative preparing, type of anesthesia, discription of operation,
characteristic of macropreparations.
19.
Treatment of these patient.
20.
Diary.
21.
Graphical discription of body temperature, pulse and blood pressure.
22.
Prognosis:
1. For the life.
2. For the health.
3. For the work.
23.
Epicrisis.
Literature. Which was used during teaching disease, it’s treatment. Methodological Instructions
Lesson № l8 for Students
Theme: Urgent urology
Aim: To learn how to diagnose and to provide urgent help in case of acute urological diseases
(acute paranephritis, acute pyelonephritis, acute orhoepididimitis, acute ishuria, anuria., invagination of
funicular spermatic, kidneys pain, haematuria
Professional Motivation:
Urgent urinology is of more importance because more of population's urbanization, ecology,
increasment oftrsiumatism, numerous increasment of the patients with nephrolitiasis and oncodeaseases.
Basic Level:
1. To collect anamnesis, to recognise the syndroms of different urgent states.
2. X-ray, functional, instrumental, laboratory, endosoopic methods of the research in the
diagnostics of the urgent states.
3. The means of the etiological, patogenetic, symptomatic therapy -medical and surgical.
Student's Independent Study Program.
I. Objectives for Students' Independent Studies.
You should prepare for the practical class using the existing textbooks and lectures. Special
attention should be paid to the following:
53
1. The main symptomps and syndroms of acute urinological diseases.
Pain in lumbar region in the side of damage is observed in 80- 95 % of cases of isolated traumas of
kidney and in 10-20 % of combined injuries. It is dull or acute with irradiation in inguinal region or
external sexual organs.
The attack of acute renal pain begins owing to urether obturation by a blood clot. The pain proceeds
from 2-5 days to several weeks and gradually ceases. If bleeding is lasting, the pain continuously
increases and can entail to a shock.
In case of combined injuries the pain can prevail in other organs, therefore diagnosis of kidney
damage is settled only in several days and even weeks after trauma. Sometimes pain in a lumbar region is
result of fracture of the inferior ribs.
The injuries of kidney often is accompanied by hematuria, its duration and intensity can be various.
Degree of hematuria not always reflects the gravity of renal parenchyma damage. Hematuria not always
arises during abruption of vascular crus, renal bowl or urether, superficial rupture of renal parenchyma
and even its complete disintegration, if ureter is closed by blood clots.
Generally hematuria occurs immediately after trauma (at once or after some hours), however
sometimes secondary or late hematuria is observed, which arises in 1-2 weeks or later. In case of a
bleeding in paranephric fat tissue hematuria can be absent. The injuries of kidney often are accompanied
by hematuria, its duration and intensity can be various. Degree of hematuria not always reflects the
gravity of renal parenchyma damage. Hematuria not always arises during of abruption of vascular crus,
renal bowl or urether, superficial rupture of renal parenchyma and even its complete disintegration, if
ureter is closed by blood clots.
The important symptom of the rupture of bladder are disorders of urination. After retroperitoneal
rupture the untrue willings to urinate are observed, which are accompanied by tenesms and excretions of
insignificant amount of urine, pigmented with blood, or excretion of blood. The ischuria is possible.
During percussion above the pubis dullness appears, which has no strict border, which irradiates into the
inguinal region. In a case of intraperitoneal rupture of bladder the earliest symptom is the pain, which at
first is localized in a pubic region, and then iradiates all over the abdomen. Sometimes the pain spastic
and periodic. The signs of peritonitis occurs. There suprapubic and ingunal regions or perineum are
swelled, quite often – edema of scrotum ( in women – vulvar labii).
Clinical manifestationss of urethral injuries are typical: trauma, pain, urethrorhagia, acute ischuria,
urinary flows, hematoma of perineum and scrotum. First of all it is necessary to find out character of a
trauma: the closed damage of urethra or penetrating wound. In case of fractures of pelvic bones, after
operations on a perineum and in neighboring regions, after child birth acute ischuria also can be
observed.
2. The necessary number and sequence of the research methods: physical and laboratory.
Complete endosscopic studies are among the most precise diagnostic tests in all medicine. Any
urethral lesion ( eg, verrucae, tumors, strictures and diverticular), as well as the size and configuration of
the prostate and bladder neck, are noted before the bladder is inspected. When the bladder is entered, the
trigone is visualized and the size, shape, position, and number of ureteral orifices noted. The bladder wall
is carefully inspected for tumors, stones, diverticula, ulcers, trabeculation, hemorrhage, and edema.
For diagnosis of the closed ureters injuries excretional (infusional) urography is used. In pyelogram
one can see formless urinary flow in retroperitoneal tissue. If excretional urography does not provide the
necessary information, retrogradual uretropyelography is performed. It allows to specify state and degree
of ureter conduction ability, and also level of its)injuries. Durine radionuclide scanning or scintigraphy
attention is payed to accumulation (well-timed or late) and allocation (uniform or irregular) of
radionuclide preparation in kidney.
Retrogradual cystography help to differentiate penetrating and un penetrating, intraperitoneal and
retroperitoneal ruptures of the bladder, locate urinary flow and approximate site of rupture. The sign of
retroperitoneal rupture is accumulation of -ray contrast matter in paavesical fat tissue, intraperitoneal – in
abdominal cavity, mainly in one of lateral canals, it has form of strip with convex external and festonic
internal contours, as continuous masses above urinary bladder or in rectovesical avity. In case of
separation of urinary bladder neck on retrogradual uretrogramm one can see spreading of X-ray contrast
matter of contours of ureter near its internal foramen. If conduction of catheter through the uretra is
impossible, it is necessary to do excretorial (infusional) urography or descending cystography.
54
3. Differential diagnostics of the urgent states in the urinology with the surgical diseases ( kidney's
pain with acute appendicitis, cholecystitis, perforation of ulcer).
The isolated renal damage is necessary to differentiate with a trauma of abdominal organs
(liver, mesentery and its vessels, intestines). Most typical sign of damage of abdominal organs is the
symptom of an acute abdomen: rigid muscles of anterior abdominal wall, positive symptoms of
peritoneum irritation. Hematuria does not occur, in lateral regions of abdominal cavity (flanx) free
migrating fluid is found.
Main role in diagnostics play radionuclide methods, ultrasonic scanning.
The combined damage of kidney and organs of abdominal cavity are difficult to differentiate. In
such cases it is useful to perform laparotomy and revision of organs of abdominal cavity, than of
retroperitoneal space.
4. Indications and contraindications for conservative and surgical treatment of urgent states.
Treatment of the patients with injuries of a kidney caused by instrumental researches and
manipulations, should be conservative. In case of fast increasing of hematoma or urohematoma,
expressed hematuria, peritonitis or acute purulent pyelonephritis lumbotomy and revision of injured
kidney are necessary. The character of operation depends on damage degree.
In regard of character of ureter damage and degree of violation of its integrity treatment can be
conservative or surgical. Conservative treatment is recommended in case of commotion and anguish of
ureter wall, in case of its damage during endoureteral manipulations. Patient is given analgetics,
antibiotics and drugs, which prevent development periureteritis and narrowings of ureter, and also
thermal procedures.
The surgical treatment consists of evacuation of urinary flow and restoring of organ integrity. It is
necessary to save the kidney. Nephrectomy is expedient only in case of complete destruction of renal
parenchime and loss of its function.
Visual aids and material tools:
1. X-ray pictures:
1. 1. X-ray pictures of nephrolitiasis.
1. 2. X-ray pictures of adenoma and cancer of prostata
1. 3. X-ray pictures of tumor of kidney's and urinam cyst.
Test and Assignments for Self-assesment.
Work 1. Conducting of the differential diagnosis.
Based on the complaints, anamnesis of the disease and life, the fact of objective examination,
laboratory, X-ray researchers, a student conduct the differential diagnosis of the patients with the kidneys
pain.
The student must answer such questions:
1. What surgical diseases will you use to conduct the differential diagnosis?
2. What additional diagnostic methods should one use with the purpouse of the differential
diagnostics?
3. What is the tactics in case of the kidney pain?
Real-life situations to be solved.
1. The patients P. 42 years old, complains of sudden pain in the right part of the stomach
localization in the right suboostal in the right limb. Objectively: a soft stomach, sensitive in the right
kidney’s projection. Pastemazkyiy's symptoms is positive in the right. Often urination. The shadows of
the subjects are not present in the urogram
What is your predective diagnosis?
What should you do to confirm the diagnosis.
The answer: Right side kidney's pain. Chromocystoscopia must be done to the patient.
Differential diagnosis must be conducted with the cholditiasis, perforation of the ulcer.
2. The patient L, 81 years old, had the complaints of the under-stomach pain, being unable to
urinate during the 24 hours. What has happened to the patient? What are the tactics? Which disease may
cause this pathology?
The answer: The patient has acute ishuria Urinary cyst is needed to be catheteriasd.
55
The Test:
1. Zeldovych’s test is used in case of:
A Broken urinary cyst.
B. Broken kidney.
C. Broken uretra
D. Trauma of uretra
E. Trauma of the scrotum organs.
The correct answer: A
2. Urgent help in case of trauma of uretra is:
A Hemostatic therapy.
В Antebacteiial therapy.
C. Kidney's catheterezation.
D. Epicystostoraia
E. Uretrotomia
The correct answer: D
Students Practical Activities:
Student must know:
1. Symptomatology and clinical course of acute urinological diseases.
2. Instrurnental methods of the diagnostics of this diseases.
3. Classification of acute pyelononephritis.
4. Diagnostics, treatment of the acute pyelonephritis.
5. Urgent help in case of kidney's pain.
6. Classification of the dosed kidney's traumata,
7. Diagnostics of the kidney's traumata
8. Cural tactics in case of the closed kidney's traumata.
9. Diagnostics and treatment of the dosed traumata of the urinary cyst.
10. Urgent help in case of the broken uretra
11. Differential diagnostic between acute ishuria and anuria
12. Diagnostics and treatmant of the funicular spermatic's mvegination.
13. Diagnostics and treatmant of the acute orhoepididimitis.
Student should be able to:
1. To find out the main clinical signs of the urgent states.
2. To confirm and to formulate the clinical diagnosis.
3. To make up the program of the additional examination methods.
4. To conduct the differential diagnostics.
5. To prescribe the medical treatment and the indications of the surgical interferens.
Methodological Instructions to Lesson 19 for Students
Theme: Concluding lesson
Aim: To determine the level of knowledges of urology and the main methods of diagnostic of
urological diseases symptoms.
Professional Motivation:
Basic Level:
1. To collect anamnesis, determine the symptoms of urological diseases.
2. X-ray,functional,instrumental,laboratory,endoscopic methods of examination in diagnostic of
urologic diseases.
3. Etiological, pathogenetic, symptomatical, operative methods of treatment.
Students' Independent Study Program.
1.
Clinical Assessment of Urological Symptoms.
2.
Instrumental Methods of Examination in Urology
3.
X-rays and radioisotopic diagnostics of urological diseases.
4.
Acute pyelonephritis.
5.
Pyonephros and paranephritis.
56
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Tuberculosis of kidneys.
Tumors of kidneys and urinary tract.
Tumors of urinary bladder.
Benign prostatic hyperplasia and cancer of prostata
Urine stones (urolithiasis)
Hydronephrosis. Nephroptosis.
Injuries of urine system
Nephrogenic arterial hypertension.
Acute renal failure.
Acute diseases of scrotum.
Urgent urology.
Tumors of genitals.
Tuberculosis of genitals.
Chronic renal failure.
Varicocele.
Chronical cystitis.
One has to master the followings methods of diagnostic of urological diseases:
1.
Cystoscopy
2.
Chromocystoscopy.
3.
Urethroscopy
4.
General and descending urography.
5.
Retrograde pyeloureterography
6.
Compression, infusion, orthostatic excretion urography.
7.
Cystography (descending, ascending, combinative, sedimentary, polycystography)
8.
Uretrography.
9.
Angiography.
10.
radiorenographic study.
11.
kidney scanning.
12.
Zeldovich’ probe.
Visual aids and material tools:
1. X-ray pictures:
1. 1. General urograms – stones of the kidney, ureter, bladder, descending of the stone with loop.
1. 2. Excretory urograms – stones of the kidney and ureter, hydronephros of I-II degree, cancer of
the kidney, cancer of the bladder, tuberculosis of the kidney.
3.3.
Ascending ureteropyelography – hydronephrosis III degree, coral-like stone of the
kidney, tumors of the kidney, abnormalities of the urinary system.
3.4.
Ascending pneumopyelography – stone of the kidney.
3.5.
Ascending pneumoureteropyelography – stone of the ureter.
3.6.
Ascending cystography – cancer of the urinary bladder.
Students Practical Activities:
Student should know
1.
The main symptoms of diseases.
2.
Characteristics of the pain at the urological diseases. Reasons and mechanism of the renal
colic.
3.
Disorders of the urination: pollakiuria (night and day), imperative feeling of urination, hard
urination: acute and chronic urine retention, ischuria paradoxa.
4.
Common and distinctive features of true enuresis and ischuria paradoxa, acute urine
retention and anuria.
5.
Quantive and qualitive changes of urine (specific weight, daily diuresis, pathological
additions).
6.
Cystoscopy and chromocystoscopy. Indications and contraindications,diagnostic value.
57
7.
Descending (excretory) and ascending urography. Indications and contraindications
diagnostic value.
8.
Pyelonephritis. Ethiology, pathogenesis, classification.
9.
Primary pyelonephritis. Clinics, diagnosis, treatment.
10. Secondary pyelonephritis. Clinics, diagnosis, treatment.
11. Pyelonephritis of pregnant women. Clinics, diagnosis, treatment.
12. Acute purulent pyelonephritis. Clinics, diagnosis, treatment.
13. Pyonephros. Clinics, diagnosis, treatment.
14. Paranephritis. Classification, clinics, diagnosis, treatment.
15. Nephroptosis. Classification, clinics, diagnosis, treatment.
16. Cystitis. Classification, clinics, diagnosis, treatment.
17. Acute orchoepididymitis. Clinics, diagnosis, treatment.
18. Spermatic cord torsion. Clinics, diagnosis, treatment.
19. Varicocele. Ethiology, mechanism. Clinics, diagnosis, treatment.
20. Renal tuberculosis. Ethiology, pathogenesis. Clinic-roentgenologycal classification.
21. Renal tuberculosis. Clinics, diagnosis.
22. Treatment and prognosis of the renal tuberculosis.
23. Prostatic tuberculosis. Clinics, diagnosis, treatment.
24. Epididymis tuberculosis. Clinics, diagnosis, treatment.
25. Urine stones. Clinics, diagnosis, treatment.
26. Differential diagnosis of the renal colic and acute diseases of abdominal organs. Treatment
of the renal colic.
27. Hydronephrosis. Clinics, diagnosis, treatment.
28. Complications of the urinary stones. Treatment.
29. Tumors of the kidney. Classification, metastasis.
30. Symptoms and clinic of renal tumors.
31. Diagnosis and treatment of the renal tumors.
32. Classification, symptoms and clinical course of cystic tumors.
33. Diagnosis and treatment of cystic tumors.
34. Penis tumors. Classification, clinics, diagnosis, treatment.
35. Testes tumors. Classification, clinics, diagnosis, treatment.
36. Symptoms and clinical course of the prostatic adenoma.
37. Diagnosis and treatment of prostatic adenoma.
38. Symptoms and clinical course of the prostatic carcinoma.
39. Diagnosis and treatment of prostatic carcinoma.
40. Closed injury to the kidney. Classification, clinics, diagnosis, treatment.
41. Closed injury to the urinary bladder. Classification, clinics, diagnosis, treatment.
42. Treatment of the closed injury to the bladder and its complications.
43. Injury to the urethra. Classification, clinical course and diagnosis.
44. Treatment of the urethra injuries. Urgent aid at the total rupture of the urethra.
45. Classification and pathogenesis of the nephrogenic arterial hypertension.
46. Etiology, pathogenesis, and classification of the prostatic cancer.
Real-life situations to be solved
1.
Patient S., at the age of 69; was admited to the urology department, his complaints are
urinary difficulty, urinary frequency, bloody urine. Was noted after urination dullness of the
percussion sound under symphisis. Pastematzkiy's symptom is negative. The urination is 4
times during the night. How is the urinary difficulty and the urinary frequency called? How is
the blood in urine called? Name of the diseases that these symptoms are typical. What does the
dullness of the percussion sound mean?
Answer: Stranguria. Hematuria. These symptoms are typical for nonmalignant hyperplasia of
prostate. Chronic urinary retention.
2.
Patient P., 36 years complains on intensive pain in the left abdominal and right below the
rib cage, a frequent urinatory. She feals sick a day ago after a very tired some travel
58
(vibrations). On examination stomach normal soft, in accordance to the left part under the rib
cage. Symptom Pasternatskiy’s positive on the left part. Approximate diagnosis? What should
be done to give exact diagnosis?
Answer: Left sided Renal colic. Chromocystoscopy should be done.
3.
Patient S., 28 years. During intravenous infusion of 76% urographine (3 ml), troubles on
voumiting, headache, and apnoe. What does it mean? Your tactics?
Answer: Alergical reaction on iodcontent preparation. To stopped inffusion of urographyne, it is
necessary to inffuse Natrium Thyosulfate.
4.
Patient K., at the age of 67, complaints of pain at the right lumbar with raising of
temperature 39 °С and chill, the fact from her anamnesis (life history) is that she is suffering
with stone in right kidney during 12 years. From chromocystoscopy, it is noted that thick pus is
coming from right ureteric orifice. Objective: right kidney is bulged, painful. Symptom of
Pastematzkiy is positive. What is a diagnosis? What is a tactics of treatment?
Answer: Stone in right kidney. Right pyelonephros. Nephrectomy should be done for the patient.
5.
Patient C., at the age of 54, complaints on periodical dysuria which brings pain and
problem during urine excretion. Usage of uroseptics didn't bring any improvement. What type
of disease gives this type of symptoms? What should we do for absolute diagnosis for this
patient?
Answer: Tuberculosis; normal ulcer, cancer of urinary bladder. We must do cystoscopy.
6.
Patient K., at the age of 54, complaints on pain left side back in the region of kidney, urine
with blood since a week. Examination. of left side it is noted thick round structure 10*14 cm
with out pain when it is touched. What is the diagnosis? What methods should be used to put a
correct diagnosis?
Answer: Tumour of left kidney. Patient should be done ultrasound screening. Excretory urography.
7.
Patient M., at the. age of 44; during cystoscopy investigation-tumour 1,5/2 cm is noted
with elements of necrosis, diameter of tumour is large. What is a diagnosis? What is a tactics of
doctor in polyclinic, treatment of this patient?
Answer: Tumour of urinary bladder. Patient should be sent to special urological department,
necessary to provide transvasical resection of urinary bladder and next we should do radiational therapy.
8.
Patient K., at the age of 74, admitted with complaints of excretion of urine in drops, with
out sensation of urinary secretion, thirst and weakness. Objective: above the lap when the
percussive sound is dumb and when touched it is painful. Symptom of. Pastematzkiy is
doubling in two sides, prostate is bulged 6/6,5 cm, elastic, between two doles it is smooth. What
is your diagnosis? What should we have to do to the patient to confirm diagnosis and tactics in
treatment?
Answer: bening prostatic hyperplasia we should put a permanent catheter if the patient is doing
well, we should do prostatectomy.
9.
Patient K., at the age of 74, admitted with complaints of excretion of urine in drops, with
out sensation of urinary secretion, blood of urine, thirst and weakness. Objective: above the lap
when the percussive sound is dumb and when touched it is painful. Symptom of Pasternatzkiy
is doubling in two sides, prostate is bulged 6/6,5 cm, bumpy. What is your diagnosis? What
should we have to do to the patient to confirm diagnosis and tactics in treatment?
Answer: cancer of prostate, we should keep permanent catheter if the patient is doing well, we
should do orchepididimectomy and hormones. X-ray treatment.
10.
Patient S., 52 years old, complains on intensive pain in right iliac and lumbal regions,
painful excretion of urine. Region of right ureter is tenderness, Pasternatski’y symptom present
on the right side. No shades was found on urogram. What is the preliminary diagnosis? What i|
the differential diagnosis? What method is necessary to held to specify the diagnosis?
Answer: renal colic on the right side; appendicite; chromocystoscopy, ultrasonography, retrograde
pneumoweteropyelography.
11.
The patient was brought to the hospital with multiply traumas. In the left lumbar region
hematoma may be found. Hematuria. Pulse 94/min, blood pressure 105/70 mm Hg. What is the
previous diagnosis? What methods of examination are necessary in this case
Answer: closed renal rupture; urography and excretory urography are useful.
59
12.
Patient K., 34 years old, crashed by car. At the causality ward fracture of the pelvis was
found. Urethrorrhage. What is the previous diagnosis? What methods of examination is
indicated in this case?
Answer: Urethrorhagia. suspicion on the rupture of urethra. Ascending urethrocystography is
needed.
13.
The young person after therapeutic deprivation left 14 kg. Now he complains of weak,
dull pain in the right hypogasfrium and in the lumbar region after physical work. What do you
think about this clinical case? What methods of examination are useful in this situation?
Answer: nephroptosis of the right kidney, excretory orthostatic urography.
14.
The patients P. 24 years old, often has complaints on headaches, lumbar pain, increased
arterial pressure 180 and 120 mm/Hg, that cannot be corrected by hypertensive medicaments.
What is your predective diagnosisThe answer: nephrogenic hypertension. Intravenous urography, USR and angiopgraphy. must be
done to the patient.
15.
In the patient on the 2nd: day after extirpation of the uterus is the anuria, pain in the lumbar
region. What diagnostic measures are necessary to held in this situation to form the diagnosis?
What is the surgical tactics?
Ansewer: Yatrogenic defect of the ureters, postrenal anuria, it is necessary to find the organic
reason of the obstruction by catheterization of the ureters, if it is impossible the ureterocystoneostomy is
indicated.
16.
Boy of 8 years old was brought to hospital with complaints on acute pain in right part of
scrotum that appeared urgent (after physical training lesson). On examination right orchis
enlarged on 4 cm, is very painful. What is the diagnosis? What is the tactics?
Answer: torsion of right orchis, urgent operation.
17.
The patients P. 42 years old, troubles on sudden pain in the right part of the stomach
localization in the right suboostal in the right limb. Objectivelly: a solf stomach, sensible in the
right kidney’s projection. Pastemazkyiy's symptoms is positive in the right. Often urination.
The shadows of the suspect are not present on the urogram. What is your predective diagnosis?
What should you do to confirm the diagnosis.
The answer: Right side kidney's pain. Chromocystoscopia must be done to the patient
The tests.
Causes of renal anuria.
A. Incompatible blood transfusion.
B. Shock, collapse.
C. Gall-stones in ureters.
D. Ureters'bandaging during gynaecologic operations.
E. Nephrectomy of solitary kidney.
What is the physiological capacity of urinary bladder?
A. 100-150 ml.
B. 400-450 ml
C. 200-250 ml.
D. 300-400 ml.
E. 500-600 ml.
What of this preparation must be used for excretory urography?
A. Iodlipole
B. Urographyne
C. Barium
D. Bilitrast
E. Bilignost
First change in urine which will prove acute hematogenic first pyelonephritis:
A. Bacteriuria.
B. Leukocyturia.
C. Proteinuria.
D. Haematuria.
60
E. Hyaline casts.
Cystoscopic signs of pyelonephros are:
A. Hyperemia of left ureteric orifice.
B. Secretion of blood of the ureteric orifice.
C. Suppuration of the ureteric orifice.
D. Deformation of the ureteric orifice.
E. Ureterocele.
Symptom of tuberculosis in urine-excretory system which is noted in urography is:
A: deposits of calcium in kidney.
B: shadow in renal pelvis projection.
C: increase of kidney in size.
D: smoothing of transverse muscle.
E: decrease of kidney's size.
What is the main character of tumour of Williams?
A. Non-malignant.
B. Embrional adenocarcinoma of kidney.
C. Metastasis of kidney's tumour.
D. Angiosarcoma of kidney.
E. Dermoid of kidney.
Main symptom of urinary tract's tumour in retrograde cystography is:
A. Deffect wall of urinary bladder.
B. Calcium deposits.
C. Diverticulum of urinary bladder.
D. Microcyst.
E. Before bladder.
Main characteristic symptom of benign prostatic hyperplasia in excretory urography is:
A. Chain shaped urinary canal
B. Structure of ureter.
C. Bent urinary tract in 1/3 part
D. Symptom «fishhook».
E. Symptom «lion's face».
What method of examination gives the complete information of carcinoma prostatic glands?
A. -Function of prostate.
B. Doppler graphy.
C. Retrograde cystography.
D. Cystoscopy.
E. Cystography.
The method to confirm renal colic is:
A. Urography.
B. Ultrasonography..
C. Chromocystoscopy.
D. Cystoscopy.
E. Retrograde pyelography.
In patient with closed renal rupture and shock the emergency measures are:
A. Nephrectomy.
B. Nephropyelostomy.
C. Treat shock and hemorrhage.
D. Infusion of the opiates.
E. Treatment of the secondery infection.
What disease may be found by Zeidovich test?
A. Rupture of the bladder.
B. Rupture of the liver.
C. Rupture of the urethra.
D. Rupture of the kidney.
E. Rupture of the ureter.
61
The sign of the 1 stage of hydronephrosis on excretory urogram is:
A. Dilatation of the upper calix.
B. Enlargement of the pyelos and calix.
C. Enlargement of the pyelos.
D. Amputation of the calix.
What is necessury to provide at 3rd stage of diagnosis of vasorenal hypertension:
A. Howards and Rappoport's test
B. Zymnytskyiy's test
C. Zeidovych' test
D. Excretory urography
E. Kidney's angiography
The cause of prerenal acute renal failure is:
A. Stone of the only kidney.
B. Haemorrhage.
C. Intoxication by heavy metals.
D. Nephrectomy of the only kidney.
E. Obstruction of the both ureters.
In case of purative epididymitis is indicated:
A. Suspensorium wearing.
B. Urgent operation.
C. Planned operation.
D. Epididyectomy.
E. Winkelmann's operation.
Urgent help in case of trauma of uretra is:
A Hemostatic therapy.
В Antebacteiial therapy.
C. Kidney's catheterezation.
D. Epicystostoraia
E. Uretrotomia
Student should be able to:
1.
To find main symptoms of urological diseases.
2.
To make diagnosis and differential diagnosis.
3.
To determine treatment tactics at urological diseases.
4.
To know the methodic and to give interpretation ofdiagnostical methods.
References:
a) basic literature:
1. Donald R. Smith, M. D. General Urology, 11-th edition, 1984.
2. Official Journal of the European Association of Urology /2002-2005/.
3. Urological Guidelines (European Assosiation of Urology) Health Care Office /august 2004
edition/.
4. Scientific Foundations of Urology. Third Edition 1990. Edited by Geoffrey D. Chisholm and
William R. Fair, MD. Heinemann Medical Books, Oxford.
5. O. F. Vozianov, O. V. Lyulko. Urology. – Kyiv: Vischa shkola, 1993.
6. Urology edited by N. A. Lopatkin, Moscow, 1982.
b) supplementary literature:
1. Urinary Tract Infection and Inflamation / Jackson E. Fowler, JR. MD. Year Book Medical
Publishers, Chicago 1989.
2. European Urology Supplements /2002-2005/.
3. Urological Oncology. Editors J. Lorens, J. Dembowski, R. Zdrojowy /Dolnoslaskie
wydawnictwo edukacyyne, Wroclaw 2002, 2003/.
4. European Urology via www. eropeanurology. com
62
5. Urology The Gold Jounal /www. goldjournal/net/. Methodological Instructions to Independent
Study
Theme: CYSTITES
Aim: learn clinic, diagnostics and principles of treatment of cystites.
Professional motivation: cystitis 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, xrays 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
63
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, cyclophosphamide), 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 enterovcsical 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, rafcgraphic 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
64
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?
Methodological Instructions to Independent Study
Theme: CHRONIC RENAL FAILURE
Aim: learn clinic, diagnostics and principles of treatment of chronic renal failure..
65
Professional motivation: chronic renal failure is the consequence of large variety of urologic
disorders and is considered as particular pathologic state, demanding special forms of treatment.
Basic level:
1. Anatomy: structure and blood supply of kidney.
2. Pathology: etiology and pathogenesis of chronic renal failure. Pathomorphological logycal
changes of kidney attached to chronic renal failure. Evaluation of macro- and micropreparation.
3. Propedeutics: symptomatology of chronic renal failure, clinical and laboratory diagnostics.
4. Pharmacology: medicines, used in treatment of patients with chronic renal failure. Prescription
of recepts.
5. X-ray study and radiology: methods of X-ray examination, used in diagnostics of chronic renal
failure.
6. Operation surgery: principles of operations, used for treatment of patients with chronic renal
failure.
Student’s Independent Study Program
Student should know:
- etiology and pathogenesis of chronic renal failure;
- classification of chronic renal failure;
- clinic and diagnostics of chronic renal failure;
- principles of chronic renal failure treatment.
Student should be able to:
- prepare the plan of clinical, laboratory, instrumental, X-ray examination of patients with chronic
renal failure;
evaluate laboratory and endovesical findings, results of X-ray
examination;
- prescribe individual treatment for the patient with chronic renal failure.
Materials for students independent study:
Etiology & Pathogenesis:
A variety of disorders are associated to chronic renal failure. Either a primary renal
glomerulonephritis, pyelonephritis, congenital hypoplasia or a secondary one (eg, a kidney affectedly
systemic process such as diabetes, lupus erythematosus) may be responsible. Miner physiologic
alterations secondary to dehydration or hypertension often put patient into uncompensated clinical
uremia.
Clinical Findings:
Symptoms such as pruritus, generalized malaise, lassitude, loss of libido, nausea, and altered
behavior often occure. Symptoms of a multisystem disorder (eg, arthritis in lupus erythematosus) may be
present. Most of patients with renal failure have elevated blood pressure secondary to volume overload
and overhydration. Occasionally, hyperreninemic alterations may be present. However, the blood
pressure may be normal or low if patients are on a very low sodium diet or have marked salt-losing
tenderness. The pulse rate is rapid as manifestations of anemia,:metabolic acidosis. Clinical findings of
uremick carditis, neurologic findings, and peripheral neuropathy are often present Palpable kidneys
suggest polycystic disease, ofthalmoscopic examination may show hypertensive diabetic retinopathy.
Alterations involving the coma have been associated with metabolic disorders.
Laboratory Findings:
Urine composition-The urine volume depending on the severity and type of renal disease.
Quantitatively normal amounts of urine can be associated with polycystic forms of disease. Daily salt
losses become more fixed, and a state of sodium retention occurs soon after. Proteinuria may be variable
but often is not excessive when the GFR is severely reduced.
Blood studies-Anemia is the rule, but the hematocrit may be normal in polycystic disease. Platelet
dysfunction or thrombasthenia is characterized by abnormal bleeding times. Platelet counts and
prothrombin content are normal. Severe abnormalities in serum electrolytes and mineral metabolism
66
become manifest when the GFR drops below 30 mL/min. Progressive reduction of buffer stores and an
inability to excrete titrable acids results in progressive acidosis characterized by reduced serum
bicarbonate and compensatory respiratory hyperventilation. The metabolic acidosis of uremia is
associated with an ion gap. Hyperkalemia is not usually seen. Patients with interstitial diseases,
nephropathy, and diabetic may develop hyperchloremic metabolic acidosis with hyperkalemia (renal
tubular acidosis) even when the GFR is over 30 mL/min. Multiple factors lead to an increase in serum
phosphate and a decrease in calcium. Uric acid levels are frequently elevated due to reduced renal
excretion.
X-Ray Findings:
Infusion nephrotomograms are required if the serum creatinine is 3 mg/dL or more. They will
usually reveal small kidneys, congenital hypoplasia, polycystic disease, or some other structional
disorder. Bone x-rays may show retarded growth or osteitis fibrosa. Soft calcification may be present.
Renal sonograms are helpful in determining renal cortical thickness and in localizing tissue for cutaneous
renal biopsy.
Renal Biopsy:
Renal biopsies may not reveal pathologycal changes except end stage scarring and
glomerulosclerosis. There may be pronounced vascular changes: thickening of the media, fragmentation
of fibers, and intimal proliferation, which may be attached to uremic hypertension or due to arteriolar
sclerosis. Appropriate examination by light microscopy, immunofluorescence, and electron microscopy is
also indicated.
Treatment
Management should be conservative until it becomes impossible for patients to continue their
customary life-slyles. Conservative management includes restriction of dietary protein and potassium as
well as close sodium balance in the diet so that patients do not retain sodium or become sodium depleted.
Use of bicarbonate can be helpful when moderate acidemia occurs. Transfusions may be helpful, but
fresh blood should be used to avoid excessive release of potassium. Prevention of possible uremic
osteodystrophy requires close attention to calcium and phosphorus balance; phosphate-retaining antacids
and administration of calcium or vitamin D may be needed to maintain the balance. Extreme care must be
paid to this management, however, because if the Ca x P product is greater than 65 mg/dL, metastatic
calcifications can occur.
A. Chronic Peritoneal Dialysis: Chronic peritoneal dialysis is used electively or when
circumstances (ie, no available vascular access) prohibit chronic hemodialysis. Improved soft catheter's
(Tenckhoff) can be used repeatedly. In comparison to hemodialysis, small molecules (such as creatinine
and urea) are cleared less effectively than larger molecules (vitamin 612), but excellent treatment can be
accomplished. Either intermittent thrice-weekly treatment (IPPD) or chronic ambulatory peritoneal
dialysis (CAPD) is possible. With the latter, the patient performs 3-5 daily exchanges using 1-2 L of
dialysate at each exchange. Bacterial contamination and peritonitis are becoming Jess common with
improvements in technology.
B. Chronic Hemodialysis: Chronic hemodialysis using semipermeable dialysis membranes is now
widely performed. Access to the vascular system is by means of Scribner shunts, arteriovenous fistulas,
and grafts. The actual dialyzers may be of a parallel plate, coil, or hollow fiber type. Body solutes and
excessive body fluids can be easily cleared by using dialysate fluids of known chemical composition.
Treatment is intermittent-usually 3-5 hours 3 times weekly. It may be given in a kidney center, a
satellite unit, or the home. Very ill patients or those who for any reason cannot be trained in the use of the
equipment with an assistant require treatment in a dialysis center. Home dialysis is optimal because it
provides greater scheduling flexibility and is generally more comfortable and convenient for the patient,
but only 30% of dialysis patients meet the medical and training requirements for this type of therapy.
More widespread use of dialytic techniques has permitted greater patient mobility. Treatment on
vacations and business trips can be provided by prior arrangement.
Materials for the self-assesment:
1. Etiology, pathogenesis of chronic renal failure.
2. Classification of chronic renal failure.
67
3. Symptomatology of chronic renal failure.
4. Diagnostics of chronic renal failure.
5. Differential diagnostics between acute and chronic renal failure.
6. Conservative treatment of chronic renal failure.
7. Chronic Peritoneal Dialysis.
8. Chronic Hemodialysis.
9. Indications and contraindications for renal transplantation.
10. Prognosis in case of chronic renal failure.
Tests for the self-assesment:
Real life situation to be solved:
32 years woman, was hospitalized in urology department with the complaints on dull pains in right
lumbal region thirstness, headaches, often urination, weakness.
Anamnesis: 3 years ago survived left nephrectomy because of secondary renal sclerosis, renal
hypertension.
Objective examination: skin surface is clean, pale. Body temperature – 37,6 oC, puls – 88,
rhythmical. Blood pressure – 180/110 Hg. Data of palpation: abdominal pain in region of right kidnee.
1. Previous diagnosis?
2. Plan of examination?
3. Treatment?
Differential diagnosis?METHODICAL INSTRUCTION
FOR STUDENTS INDEPENDENT STUDY
Theme: VARICOCELE
Aim: learn clinic, diagnostics and principles of treatment of varicocele.
Professional motivation: Varicocele is common in young men and consists of dilatation of the
pampiniform plexus above the testis, 12,4% cases of varicocele occur in teenagers (under 17 years), that
play importent role in their following development.
Basic level:
1. Anatomy: structure of testical veins, ways of venous outflow from testis and kidney.
2. Pathology: pathologycal changes in external genitalia attached to varicocele.
3. Propedeutics: symptomatology of dilatation of the pampiniform plexus above the testis, clinical
diagnostics of varicocele.
4. Pharmacology: treatment of patients with varicocele. Prescription of recepts.
5. Operation surgery: principles of operations, used for treatment of patients with varicocele.
Student’s Independent Study Program:
Student should know:
- pathogenesis of varicocele;
- classification of varicocele;
- clinic and diagnostics of varicocele;
- principles of varicocele treatment.
Student should be able to:
- prepare the plan of clinical, laboratory, X-ray examination of patients with varicocele;
- examine the patient with varicocele.
- prescribe treatment of varicocele.
Materials for students independent study:
Varicocele is common in young men and consists of dilatation of the pampiniform plexus above the
testis, with the left side most commonly affected. These veins drain into the internal spermatic vein in the
region of the internal inguinal ring. The internal spermatic vein passes lateral to the vas deferens at the
internal inguinal ring and, on the left side, drains into the renal vein. On the right it empties into the vena
cava.
68
Incompetent valves are more common in the left internal spermatic vein, This condition, combined
with the effect of gravity, may lead to poor drainage of the pampiniform plexus, the veins of which
gradually undergo dilation and elongation. The area may be painful, particularly in sexually continent
men. Sexual activity (including masturbation) may relieve symptoms.
The sudden development of a varicocele in an older man is sometimes a late sign of renal
tumorwhen tumor cells have invaded the renal vein, thereby occluding the spermatic vein.
Examination of a man with varicocele when he is upright reveals a mass of dilated, tortuous veins
lying. posterior to and above the testis, It may extend up to the external inguinal ring and is often tender.
The degree of dilatation can be increased by the Valsalva maneuver. In the recumbent position, venous
disten-tion abates. Testicular atrophy from impaired circulation may be present.
No treatment is required unless the varicocele is thought to contribute to infertility or is painful or
so large as to disturb the patient. A scrotal support will often relieve discomfort. The most useful surgical
procedure is ligation of the internal spermatic veins at the internal inguinal ring. This can be done as an
outpatient procedure. Recently, percutaneous methods, eg. balloon catheter, sclerosing fluids, have been
used to occlude the veins. This is particularly useful when the infertile patient is undergoing percutaneous
internal spermatic venography. One or both veins can be occluded as indicated (Formanek et al, 1981;
Reidl, Lunglmayr, and Stacki, 1981; Walsh and White, 1981).
Materials for the self-assesment:
1. Pathogenesis of varicocele.
2. Anatomy of testical veins.
3. Symptomatology and clinical course of varicocele.
4. Classification of varicocele.
5. Diagnostics of varicocele.
6. Differential diagnostics between congenital and acute varicocele.
7. Principles of varicocele treatment.
8. Indications for arteriography for diagnostics of varicocele.
9. Varicocele of children.
Tests for the self-assesment:
1.
2.
3.
varicocele.
4.
of varicocele.
Factors, leading to varicocele.
Complications of varicocele.
Indications for operational treatment of
Methods of operations, used for treatment
Tasks for the self-assesment.
15 years boy, was hospitalized in urology department with the complaints on dilatation of left part
of scrotum, dull pains in inguinal region, especially after physic load..
Objective examination: left part of scrotum is dilatated, in stand position veins are palpable, veins
are empty, when patient is leying, positive orthostatic symptom.
1. Previous diagnosis?
2. Plan of examination?
Treatment?METHODICAL INSTRUCTION
FOR STUDENTS INDEPENDENT STUDY
Theme: TUMOURS OF GENERATIVE ORGANS.
Aim: learn clinic, diagnostics and principles of treatment of tumors of generative organs.
Professional motivation: tumours of generative organs freaquency varies from 1 % up to 5 % of
all neoplasms of men.
69
Basic level:
1. Anatomy: structure and blood supply of male generative organs.
2. Pathology: etiology and pathogenesis of tumors of male generative organs. Pathomorphological
of tumors of male generative organs. Evaluation of macro- and micropreparation.
3. Propedeutics: symptomatology of tumors of generative organs, clinical and laboratory
diagnostics.
4. Pharmacology: medicines, used in treatment of patients with tumors of generative organs.
Prescription of recepts.
5. X-ray study and radiology: methods of X-ray examination, used in diagnostics of tumors of
generative organs. Methods of radiology treatment.
6. Operation surgery: principles of operations, used for treatment of patients with tumors of
generative organs.
Student’s independent study program:
Student should know:
- etiology and pathogenesis of tumors of generative organs;
- classification of tumors of generative organs;
clinic and diagnostics of tumors of generative organs;
peculiarities of laboratory, instrumental, X-ray examination of patients with tumors of
generative organs;
- principles of treatment of tumors of generative organs.
Student should be able to:
- prepare the plan of clinical, laboratory, instrumental, X-ray examination of patients with tumors
of generative organs;
evaluate laboratory and endovesical findings, results of X-ray
examination;
- prescribe individual treatment for the patient with tumors of generative organs.
Materials for students independent study:
Penis cancer.
Etiology & Pathogenesis: The causes of penis carcinoma are poorly understood. Phimosis,
accompanied by accumulated smegma in the preputial sac and frequently associated with chronic
inflammation, has long been thought to be the most probable etiologic factor. Recent experimental work
suggests, however, that if human smegma has carcinogenic potential, its potential is weak and is
influenced by genetic factors. Owing to the high incidence of sexually transmitted disease in patients
with penis cancer, syphilis and gonorrhea have been implicated as causative factors, but continuing
studies suggest that neither is a predisposing factor.
Early malignant changes occurring within the der-mis have been labeled by some as erythroplasia
of Queyrat and by others as Bowen's disease. Erythroplasia presents as a small, bright red spot that
slowly progresses into a sharply defined, glistening, velvety lesion, while Bowen's disease is usually drier
in appearance and is often crusted and ulcerated. However, the 2 conditions have similar histopathologic
findings and may be clinically indistinguishable. In both, thickened epidermis is replaced by atypical
cells that form a plaquelike acanthosis. Hypokeratosis and fewer multinucleated and malignant
dyskeratotic cells distinguish erythroplasia from Bowen's disease.
Clinical Findings: The most common complaint is the lesion itself, which may be ulcerative, or
fungating in appearance. Other symptoms may include penis discharge, local pain and problems
associated with urination (frequency, dysuria, urgency, or incontinence). Confirmation of the exact nature
of the lesion is biopsy.
Inguinal lymphadenopathy is present in more than 50% of patients. However, in most instances, the
lymph nodes are soft in consistency and only represent response to the infected primary lesion. The lymf
nodes occasionally are hard and matted together.
70
Laboratory Findings: Leukocytosis, a frequent finding, usually secondary to local infection.
Hypercalcemia, associated with localized carcinoma of the penis and cured by removal of the tumor.
X-Ray Findings: Lymphangiography identify metastases to the inguinal lymph nodes, but
applicability in this disease is limited by advanced age of the patient.
Differential Diagnosis
Syphilitic chancre may simulate a small ulcerating epithelioma. Darkfield examination should
reveal Treponemapallidum. In case of doubt, biopsy is indicated.
Chancroid sometimes causes confusion in diagnosis, It is ordinarily a rapidly spreading, painful,
ulcerative lesion. Complement fixation tests or findings of Haemophilus ducreyi on smears from the
lesion are diagnostic.
Condylomata acuminata are soft, warty growths, caused by a virus that is usually transmitted
sexually. They are usually not invasive. If any doubl exists, a biopsy should be performed.
Treatment
Treatment of patients with penis carcinoma is best carried out in stages. After the primary lesion
has been treated and the patient has recovered, attention is directed toward control of the regional lymph
nodes. Penis carcinoma usually spreads in an orderly, step-wise fashion by embolization through the
lymphatics, not by lymphatic permeation orvenous dissemination
Small lesions (< 3 cm) without evidence of me-asis can be destroyed by megavoltage x-ray (50005700 rads in 3-5 weeks). However, even though results of radiotherapy have been satisfactory, the long
interval of time required tc deliver the therapy, the slow rate of regression of the tumor after treatment
has been completed, and the weeks of discomfort while the radiation reaction is; subsiding prove major
disadvantages to the elderly, debilitated patient. Consequently, surgery is frequently the simplest, safest,
most time-saving and cost-effective way to manage the primary tumor. Radiotherapy is best reserved for
young patients with small lesions.
Tumor of testis.
Clinical Findings:A painless testicular mass must be considered cancer until proved
otherwise. Unfortunately, despite attempts to expand awareness among young men and to
teach self-examination, delay in making an early correct diagnosis remains common.
Symptoms: By far the most common presenting complaint is a painless enlargement of the
testis, which occurs in 65% of patients and is sometimes described as a sense of "heaviness. "
Since metastases are already present at diagnosis in 32% of patients, up to 14% present with
complaints secondary to the metastatic tumor The most common, back pain, is usually the result of
enlarged retroperitoneal lymph nodes, Other symptoms are vague abdominal pain, anorexia, nausea,
vomiting, and weightless, probably the result of large tumor masses; cough and dyspnea, when present,
may reflect large parenchyffli pulmonary metastases or irritation of the tradw bronchial tree by nodal
masses. Up to 8% of patients present with no symptoms at all, in which case the tumor may be
discovered incidentally after traumaw during sexual activity.
Materials for the self-assesment:
1. Etiology, pathogenesis of tumors of male generative organs.
2. Classification of tumors of generative male organs.
3. Symptomatology of tumors of generative male organs.
4. Diagnostics of tumors of generative male organs.
5. Differential diagnostics of tumors of male generative organs.
6. Treatment of tumors of male generative organs.
Tests for the self-assesment:
1.
Factors, leading to tumors of generative
organs.
2.
Classification of tumors of generative
organs.
3.
Ways of metastases spreading in caseof
tumors of male generative organs.
71
4.
5.
In diagnostics of tumors of generative
organs are helpful:
general examination and palpation;
laboratory examination;
X-ray examination;
Cytology examination;
Diafanoskopy.
What diseases should you to differentiate
with tumors of generative organs?
6.
Radial and chemotherapy of tumors of
male generative organs.
7.
Surgical
treatment
of
tumors
of
generative organs.
Real life situation to be solved:
37 years man, was hospitalized in urology department with the complaints on increasing of right
testis.
Objective examination: skin surface is clean, pale. Body temperature – 36,8 oC, puls – 82,
rhythmical. Signs of gynecomasty are present.
Data of palpation: right testis is enlarged, with crooked surface.
1. Previous diagnosis?
2. Plan of examination?
Differential diagnosis?Methodological Instructions to Independent Study
Theme: TUBERCULOSIS OF MALE GENERATIVE ORGANS
Aim: learn clinic, diagnostics and principles of treatment of tuberculosis of male generative organs.
Professional motivation: Tuberculosis of male is one of the most frequent pathology in urologic
practice.
Basic level:
1. Anatomy: structure and blood supply of male generative organs.
2. Pathology: etiology and pathogenesis of tuberculosis of male generative organs.
Pathomorphological changes in generative organs. Evaluation of macro- and micropreparation.
3. Propedeutics: symptomatology of tuberculosis of generative organs, clinical and laboratory
diagnostics.
4. Pharmacology: medicines, used in treatment of patients with tuberculosis of generative organs.
Prescription of recepts.
5. X-ray study and radiology: methods of X-ray examination, used in diagnostics of tuberculosis of
generative organs. Methods of radiology treatment.
6. Operation surgery: principles of operations, used for treatment of patients with tuberculosis of
generative organs.
Student’s independent study program:
Student should know:
- etiology and pathogenesis of tuberculosis of generative organs;
- classification of tuberculosis of generative organs;
clinic and diagnostics of tuberculosis of generative organs;
peculiarities of laboratory, instrumental, X-ray examination of patients with
tuberculosis of generative organs;
- principles of etiological, pathogenetic, symptomatic and operational treatment of tuberculosis
of generative organs.
72
Student should be able to:
- prepare the plan of clinical, laboratory, instrumental, X-ray examination of patients with
tuberculosis of generative organs;
evaluate laboratory and endovesical findings, results of X-ray
examination;
- prescribe individual treatment for the patient with tuberculosis of generative organs.
Materials for students independent study:
Etiology & Pathogenesis:
The infecting organism is Mycobacterium tuberculosis, which reaches the genitourinary organs by
the hematogenous route from the lungs. The primary site is often not symptomatic or apparent. The
kidney and possibly the prostate are the primary sites of tuberculous infection in the genitourinary tract.
All other genitourinary organs become involved either by ascent (prostate to bladder) or descent (kidney
to bladder; prostate to epididymis). The testis may become involved by direct extension from epididymal
infection.
Clinical Findings:
Tuberculosis of the genitourinary tract should be considered in the presence of any of the following
situations: (1) chronic cystitis that refuses to respond to adequate therapy, (2) the finding of pus without
bacteria in a methylene blue stain or culture of the urinary sediment, (3) gross or microscopic hematuria,
(4) a nontender, enlarged epididymis with a beaded or thickened vas, (5) a chronic draining scrotal sinus,
or (6) induration or nodulation of the prostate and thickening of one or both seminal vesicles (espeeiallj
in a young man). A history of present or past tuberculosis elsewhere in the body should cause the ptmi-1
cian to suspect tuberculosis in the genitourinary iraa when signs or symptoms are present.
The diagnosis rests upon the demonstrationt tubercle bacilli in the urine by culture. The extenic the
infection is determined by (1) the palpable findings in the epididymides, vasa deferentia, prostate.
seminal vesicles; (2) the renal and ureteral lesionss revealed by excretory urograms; (3) involvemento the
bladder as seen through the cystoscope; (4) lit degree of renal damage as measured by loss of fiction; and
(5) the presence of tubercle bacilli in ones both kidneys.
A thickened, now or only slightly tender epididymis may be discovered. The vas delerens often is
thickened and beat chronic draining sinus through the scrotal skin is almost pathognomonic of
tuberculous epididymitis. In the more advanced stages, the epididymis cannot be differentiated from the
testis upon palpation. This may mean that the testis has been directly invaded by (he epididymal abscess.
Hydrocele occasionally accompanies tuberculous epididymitis. The "idiopathic" hydrocele should
be lapped so that underlying pathologic changes, if present, can be evaluated (epididymitis, testicular
tumor). Involvement of the penis and urethra is rare.
Prostate and seminal vesicles: these organs may be normal to palpation. Ordinarily, however, the
tuberculous prostate shows areas of induration. The involved vesicle is usually indurated, enlarged, and
fixed. If epididymitis is present, the lateral vesicle usually shows changes as well.
Laboratory Findings:
Persistent pyuria without organisms on culture on the smear stained with methylene blue means
tuberculosis until proved otherwise. Acid-fast stains on the concentrated sediment from a 24-hour
specimen are positive in at least 60% of cases. However, this must be corroborated by a positive culture.
About 15-20% of patients with tuberculosis have secondary pyogenic infection; the clue ("sterile" pyuria)
is thereby obscured. If clinical response to adequate treatment fails and pyuria persists, tuberculosis must
be ruled out by bacteriologic and
If tuberculosis is suspected, perform the tuberculin test. A positive test, particularly in an adult, is
diagnostic.
X-Ray Findings:
A chest film feat shows evidence of tuberculosis should cause the pliysieian to suspect tuberculosis
of the urogenital tract in the presence of urinary signs and symptoms. A plain "to of ihe abdomen may
show enlargement of one titoey or obliteration of the renal and psoas shadows to to perinephric abscess.
Punctate calcification in fc renal parenchyma may be due to tuberculosis.
73
Renal stones are found in 10% of cases. Calcification of the ureter may be noted, but this is rare
(Fig 6-3). Small prostatic stones the size of grape seeds in the region of the pubic symphysis are
ordinarily not due to tuberculosis, but large calcific bodies may be.
Instrumental Examination:
Thorough cystoscopic study is indicated even when the offending organism has been found in the
urine and excretory urograms show the typical renal lesion. This will clearly demonstrate the extent of
the disease. Cystoscopy may reveal the typical tubercles or ulcers of tuberculosis. Biopsy can be done if
necessary. Severe contracture of the bladder may be noted. A cystogram may reveal ureteral reflux. A
clean specimen of urine should also be obtained for further study.
Differential Diagnosis:
Chronic nonspecific cystitis or pyelonephritis may mimic tuberculosis perfectly,
especially since 15-20% of cases of tuberculosis are secondarily invaded by pyogenic
organisms. If nonspecific infections do not respond to adequate therapy, a search for tubercle
bacilli should be made. Painless epididymitis points to tuberculosis. Cystoscopic
demonstration of tubercles and ulceration of the bladder wall means tuberculosis. Urograms
are usually definitive.
Acute or chronic nonspecific epididymiti s may be confused with tuberculosis, since the onset of
tuberculosis is occasionally quite painful. It is rare to have palpatory changes in the seminal vesicles with
nonspecific epididymitis, but these are almost routine findings in tuberculosis of the epididymis. The
presence of tubercle bacilli on a culture of the urine is diagnostic. On occasion, only the pathologist can
make the diagnosis by microscopic study of the surgically removed epididymis.
Amicrobic cystitis usually has an acute onset and is often preceded by a urethra! discharge.
"Sterile" pyuria is found, but tubercle bacilli are absent.
Materials for the self-assesment:
1Etiology, pathogenesis of tuberculosis of male generative organs.
2Classification of tuberculosis of generative male organs.
3. Symptomatology of tuberculosis of generative male organs.
4 Diagnostics of tuberculosis of generative male organs.
5. Differential diagnostics of tuberculosis of male generative organs.
6. Treatment of tuberculosis of male generative organs.
Tests for the self-assesment:
1.
of generative organs.
2.
male generative organs.
3.
generative organs.
4.
with tuberculosis of generative organs?
5.
male generative organs.
6.
generative organs.
Infecting microorganism of tuberculosis
Ways of infectional contamination of
Classification
of
tuberculosis
of
What diseases should you to differentiate
Conservative treatment of tuberculosis of
Surgical treatment of tuberculosis of
Real life situation to be solved:
46 years man, was hospitalized in urology department with the complaints on pain and fealing of
pressure in perineal region, pain increases during defecation, urine was with pus.
Objective examination: skin surface is clean, pale. Body temperature – 37,7 oC, puls – 94,
rhythmical. During manual examination of prostatic gland plain painless infiltrates were discovered,
located in both lobes of the gland.
1.
Previous diagnosis?
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2.
Plan of examination?
References:
a) basic literature:
1. Donald R. Smith, M. D. General Urology, 11-th edition, 1984.
2. Official Journal of the European Association of Urology /2002-2005/.
3. Urological Guidelines (European Assosiation of Urology) Health Care Office /august 2004
edition/.
4. Scientific Foundations of Urology. Third Edition 1990. Edited by Geoffrey D. Chisholm and
William R. Fair, MD. Heinemann Medical Books, Oxford.
5. O. F. Vozianov, O. V. Lyulko. Urology. – Kyiv: Vischa shkola, 1993.
6. Urology edited by N. A. Lopatkin, Moscow, 1982.
b) supplementary literature:
1. Urinary Tract Infection and Inflamation / Jackson E. Fowler, JR. MD. Year Book Medical
Publishers, Chicago 1989.
2. European Urology Supplements /2002-2005/.
3. Urological Oncology. Editors J. Lorens, J. Dembowski, R. Zdrojowy /Dolnoslaskie wydawnictwo
edukacyyne, Wroclaw 2002, 2003/.
4. European Urology via www. eropeanurology. com
5. Urology The Gold Jounal /www. goldjournal/net/.
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