What can be cooked from squid: quick and tasty

Bladder cancer is the most common tumor of the urinary tract. Among malignant tumors of other organs, bladder cancer takes 7th place in men and 17th place in women. Thus, in men, neoplasms of the bladder occur up to 4-5 times more often than in women. Mostly people over 55-65 years old are ill. In Russia, from 11 to 15 thousand people fall ill annually. At the same time, the annual mortality from this disease is at least 7-8 thousand people. For comparison, in the United States, the incidence is about 60 thousand people, and the death rate is no more than 13 thousand. Such pronounced differences are due to both the imperfection of early diagnosis and the insufficient prevalence of modern and highly effective methods of treating bladder cancer in our country.

Figure 2. Prevalence of Bladder Cancer.

It is generally accepted that the main cause of bladder cancer is the effect of carcinogenic substances excreted in the urine on the bladder mucosa. The proven risk factors for malignant bladder tumor are:

• Occupational hazards (long-term work in rubber, dyeing, oil, textile, rubber, aluminum industries, etc.) - increases the risk of developing bladder cancer by up to 30 times.
• Smoking - increases the risk up to 10 times.
• Taking certain medications (phenacetin-containing analgesics, cyclophosphamide) increases the risk by 2-6 times.
• Exposure to radiation - increases the risk by 2-4 times.
• Schistosomiasis (North Africa, Southeast Asia, Middle East) - increases the risk by 4-6 times.
• Chronic cystitis, chronic stagnation of urine, bladder stones - increases the risk up to 2 times.
• Chlorinated water consumption - 2 times

There are no specific complaints specific to bladder cancer. The initial stages of bladder cancer are usually asymptomatic in most cases.

• The leading symptom is hematuria (the appearance of blood in the urine). Often, hematuria has a transient nature - it appears out of the blue and quickly disappears. The patient may not attach much importance to this. Or confine yourself to taking the "hemostatic" drug prescribed in the clinic. Meanwhile, the bladder tumor continues to develop. With profuse bleeding, bladder tamponade often occurs and, as a result, acute urinary retention.
• Dysuria (frequent and painful urination with imperative urge), a feeling of fullness in the projection of the bladder.
• Dull pain over the bosom, in the region of the sacrum, perineum (when the tumor spreads to the muscle layer).
• In advanced forms, patients are often worried about weakness, a sharp loss of body weight, fatigue, anorexia.

The diagnosis of bladder cancer is based on the collection of patient complaints, medical history and examination of the patient. The latter is given special importance. It is necessary to pay attention to the following manifestations of bladder cancer when examining a patient:

• Signs of chronic anemia (weakness, lethargy, pallor of the skin
• Swollen lymph nodes on palpation in areas of possible lymphogenous metastasis
• Definition of neoplasm by palpation of the bladder, its mobility, the presence of infiltration of surrounding tissues.
• Enlarged bladder, due to chronic or acute urinary retention
• Positive tapping symptom, palpation of enlarged kidneys (with the development of hydronephrosis, as a result of urinary retention)

Laboratory research

General urine analysis with sediment microscopy (to determine the degree and location of hematuria)

Cytological examination of urine sediment (to detect abnormal cells)

Instrumental diagnostic methods

Radiation methods are of great importance in the diagnosis of bladder tumors:

	Ultrasound (ultrasound) - to assess the location, size, structure, nature of growth and prevalence of the tumor, the area of ​​regional metastasis, the upper urinary tract, the presence or absence of hydronephrosis. This method is a screening method and is not used for mono-diagnostics.
	CT, MRI with intravenous contrast (computed tomography, magnetic resonance imaging) - determination of the extent of the tumor process and the patency of the ureters

• Excretory urography is an outdated method, but if necessary, it allows you to assess the patency of the ureters, to identify formations in the upper urinary tract and in the bladder. Currently not widely used due to the low specificity and sensitivity of the method
• CT scan of the lungs, scanning of the bones of the skeleton (osteoscintigraphy) (if metastatic lesion is suspected).

Bladder cancer must be differentiated from the following diseases: inflammatory diseases of the urinary tract, nephrogenic metaplasia, anomalies of the urinary tract, squamous cell metaplasia of the urothelium, benign epithelial formations of the urinary bladder, tuberculosis and syphilis of the genitourinary system, endometriosis, chronic bladder cystitis, metastasis of the urinary tract stomach, etc. (extremely rare).

Depending on the degree of prevalence (neglect), bladder cancer can be divided into 3 types:

• surface
• invasive
• generalized

Anticipating the consideration of the clinical forms of bladder cancer, it should be noted that the wall of this organ consists of four layers:

Epithelium (mucous membrane) - a layer that is in direct contact with urine and in which tumor growth "begins";

The submucosal connective tissue layer (lamina propria) is a fibrous plate that serves as a "base" for the epithelium and contains a large number of vessels and nerve endings;

The muscle layer (detrusor), whose function is to expel urine from the bladder;

The outer layer of the bladder wall can be represented by adventitia (in the retroperitoneal part of the organ) or the peritoneum (in the intra-abdominal part of the organ).

Superficial bladder cancer

Among patients with newly diagnosed bladder cancer, 70 percent have a superficial tumor. In 30 percent of patients, multifocal lesions of the bladder mucosa are noted. In superficial cancer, the tumor is located within the epithelium of the bladder (or spreads no deeper than the lamina propria) and does not affect its muscular membrane. This form of the disease has the best prognosis.

Transurethral resection of the bladder (TUR) is the main treatment for superficial bladder cancer.

Drawing. Scheme - TUR of the Bladder

At TOUR remove all visible tumors. The exophytic component and the base of the tumor are removed separately. This technique has diagnostic and therapeutic value - it allows you to take material for histological examination (confirmation of the diagnosis) and remove the neoplasm within healthy tissues, which is necessary for the correct establishment of the stage of the disease and the choice of further treatment tactics. Relapse develops in 40–80 percent of cases after transurethral resection (TUR) within 6–12 months, and invasive cancer occurs in 10–25 percent of patients. This percentage can be reduced by using photodynamic diagnostics and intravesical administration of BCG vaccine or chemotherapy drugs (mitomycin, doxorubicin, etc.). Promising intravesical drug electrophoresis techniques are in the development phase.

Drawing. TUR of the Bladder. Cystoscopic picture.

Intravesical BCG therapy has been shown to reduce the recurrence rate of bladder cancer after TURP in 32-68 percent of cases.

• within the first 2 weeks after TUR-biopsy
• in patients with gross hematuria
• after traumatic catheterization
• in patients with symptoms of a urinary tract infection

• bleeding (intraoperative and postoperative)
• perforation of the bladder wall (depending on the experience of the surgeon);

After the TUR is completed, it is absolutely MANDATORY to perform repeated control examinations of the bladder to exclude a relapse. In case of multiple relapses after TUR and detection of poorly differentiated ("evil") cancer, it is often advisable to resort to a radical operation - cystectomy (removal of the bladder) with the formation of a new bladder from the segment of the intestine. Such an operation is especially effective in early forms of cancer and provides high oncological results. With adequate treatment, the 5-year survival rate for patients with superficial bladder cancer is over 80 percent.

Invasive bladder cancer is characterized by the spread of tumor lesions to the muscular membrane and outside the organ - to the peri-vesicular fatty tissue or adjacent structures (in advanced cases). In this phase of the development of a bladder tumor, the likelihood of metastasis to the lymph nodes is significantly increased. The main method of treatment of invasive bladder cancer is radical cystectomy with lymphadenectomy (removal of a single block of the bladder with the peritoneum covering it and paravesical tissue, the prostate gland with seminal vesicles, bilateral pelvic (ileo-obturator) lymphadenectomy. ). Radical cystectomy with intestinal plastic is optimal, since it allows you to preserve the ability to urinate independently. In a limited number of cases, TUR and open bladder resection are used to treat patients with muscle-invasive cancer. To increase the efficiency of surgical treatment in some patients, it is advisable to prescribe anticancer chemotherapy drugs. The 5-year survival rate for patients with invasive bladder cancer averages 50-55 percent.

When metastases appear (tumor screenings in the lymph nodes and organs), bladder cancer is called generalized (metastatic). Most often, the disease metastasizes to regional lymph nodes, liver, lungs and bones. Almost the only effective method of treating generalized bladder cancer that can prolong the patient's life is powerful chemotherapy with several drugs at once (methotrexate, vinblastine, doxorubicin, cisplatin, etc.). Unfortunately, none of these drugs are safe. The mortality rate when using them is 2-4 percent. Often it is necessary to resort to surgical treatment, the purpose of which is to prevent the patient from dying from life-threatening complications accompanying the tumor process (for example, bleeding). The 5-year survival rate for patients with advanced bladder cancer does not exceed 20 percent.

• Elimination of the effects on the body of carcinogenic substances
• To give up smoking
• Timely treatment of genitourinary infections
• Ultrasound of the genitourinary system, general urine analysis
• Timely examination and treatment by a urologist at the first signs of dysfunction of the urinary system

The main thing for you:

Do not be lazy to spend ONE day a year (in a good clinic) and undergo a QUALITY dispensary examination, which necessarily includes an ultrasound of a filled bladder and a urinalysis. If you suddenly notice an admixture of blood in the urine, be sure to seek advice from a competent urologist who has the opportunity and, most importantly, the desire to find out the cause of this episode. Compliance with the above is highly likely to allow you to avoid such "news" as advanced cancer of your bladder.

DEFINITION.

Hematuria - the appearance of an impurity of blood in the urine - is one of the characteristic symptoms of many urological diseases. Distinguish between microscopic and macroscopic hematuria; the onset of intense gross hematuria often requires urgent care.

ETIOLOGY AND PATHOGENESIS.

Possible causes of hematuria are presented in table.

CAUSES OF BLEEDING FROM THE ORGANS OF THE URINARY SYSTEM

(Pytel A.Ya. et al., 1973).

CLINICAL PICTURE AND CLASSIFICATION.

The appearance of red blood cells in the urine gives it a cloudy appearance and pink, brown-red or reddish-black color, depending on the degree of hematuria. With macrohematuria, this color is noticeable when examining urine with the naked eye, with microhematuria, a significant number of red blood cells is detected only when examining urine sediment under a microscope.

To find out the localization of the pathological process in hematuria, a three-glass test is often used, while the patient needs to urinate sequentially into 3 vessels. Macrohematuria can be of three types:

1) initial (initial), when only the first portion of urine is colored with blood, the remaining portions are of normal color;

2) terminal (final), in which in the first portion of urine, no blood impurities are visually detected, and only the last portions of urine contain blood;

H) total, when the urine in all portions is equally colored with blood.

Possible causes of gross hematuria are presented in table.

TYPES AND CAUSES OF MACROHEMATURIA.

Often, gross hematuria is accompanied by an attack of pain in the kidney area, since a clot formed in the ureter interferes with the outflow of urine from the kidney. In kidney tumors, bleeding precedes pain ("asymptomatic hematuria"), and in urolithiasis, pain occurs before hematuria begins. Localization of pain in hematuria also makes it possible to clarify the localization of the pathological process. So, pain in the lumbar region is typical for kidney disease, and in the suprapubic region for lesions of the bladder. The presence of dysuria simultaneously with hematuria is observed with damage to the prostate gland, bladder or posterior urethra.

The shape of the blood clots also allows you to determine the localization of the pathological process. Worm-like clots that form when blood passes through the ureter indicate an upper urinary tract disease. Formless clots are more common in bleeding from the bladder, although they may form in the bladder when blood is excreted from the kidney.

DIAGNOSTIC CRITERIA.

The diagnosis of hematuria can be suspected at the first examination of the patient, urine sediment is examined for confirmation. When diagnosing hematuria, an ambulance doctor should receive answers to the following questions.

1) Is there a history of urolithiasis, other kidney diseases? Is there a history of trauma? Is the patient receiving anticoagulants? Is there a history of blood diseases, Crohn's disease.

It is necessary to clarify the possible cause of hematuria.

2) Whether the patient has consumed foods (beets, rhubarb) or drugs (analgin, 5-NOK) that can stain urine red

Differentiated hematuria and urine staining of another cause.

3) Whether the discharge of blood from the urethra is associated with the act of urination.

It is necessary to differentiate hematuria and urethrography.

4) Has the patient had any poisoning, blood transfusions, or acute anemia.

It is necessary to differentiate hematuria and hemoglobinuria that occurs with massive intravascular hemolysis of erythrocytes.

BASIC DIRECTIONS OF THERAPY.

If gross hematuria occurs, especially painless, immediate cystoscopy is indicated to establish the source of bleeding or at least the side of the lesion, since with tumor processes hematuria may suddenly stop, and the opportunity to determine the lesion will be lost. The position, formulated in 1950 by I. N. Shapiro, that any one-sided significant renal bleeding should be considered a sign of a tumor, until another cause of hematuria is found, remains fully relevant. Only after the diagnosis or at least the side of the lesion is established, the use of hemostatic agents can begin.

To assess the danger of hematuria that has arisen, it is important to determine the level and dynamics of blood pressure, hemoglobin content, the severity of tachycardia, and the determination of the BCC. It is especially important to study these indicators when, in addition to hematuria, internal bleeding is also possible (for example, with kidney injury). Thus, the tactics of treatment for hematuria depends on the nature and localization of the pathological process, as well as the intensity of bleeding.

1) Hemostatic therapy:

a) intravenous infusion of 10 ml of 10% calcium chloride solution;

b) the introduction of 100 ml of a 5% solution of e-aminocaproic acid in / in;

c) introduction of 4 ml (500 mg) of 12.5% ​​solution of dicinone intravenously;

2) rest and cold on the affected area.

3) transfusion of fresh frozen plasma.

With profuse total hematuria, the bladder is often filled with blood clots and it becomes impossible to urinate independently. There is a tamponade of the bladder. Patients develop painful tenesmus, a collaptoid state may develop. Bladder tamponade requires immediate treatment. Simultaneously with the transfusion of blood and hemostatic drugs, they begin to remove clots from the bladder using a catheter-evacuator and Janet's syringe.

COMMON ERRORS IN THERAPY.

Urethrorrhagia, in which blood is excreted from the urethra outside the act of urination, should be distinguished from hematuria. Urethrorrhagia often occurs when the integrity of the wall of the urethra is violated or a tumor appears in it. If there is evidence of an inflammatory process or a tumor of the urethra, urgent urethroscopy and stopping bleeding by electrocoagulation or laser ablation of the affected area are necessary. In case of suspicion of urethral rupture, an attempt to insert a catheter or other instruments into the bladder is categorically contraindicated, as this contributes to increased trauma.

In order to avoid mistakes, it should be remembered that a change in the color of urine can be caused by taking medications or food (beets). The occurrence of hematuria occurs in extrarenal diseases (typhoid fever, measles, scarlet fever, etc.; blood diseases, Crohn's disease, with an overdose of anticoagulants).

INDICATIONS FOR HOSPITALIZATION.

With gross hematuria, hospitalization is indicated. Bleeding that threatens the patient's life and the lack of effect of conservative treatment is an indication for urgent surgical intervention (nephrectomy, resection of the bladder, ligation of the internal iliac arteries, emergency adenomectomy, and others).

2050 0

As you know, the extensive spread of bladder tumors makes radical treatment impossible, and the main goal of palliative treatment is to reduce or completely eliminate the painful symptoms of the disease, i.e. to improve the quality of life indicators.

Palliative treatment methods:

1. Palliative surgery
2. Radiation therapy
3. Chemotherapy
4. Immunotherapy

The main clinical syndromes in the progression of bladder cancer (bladder cancer):

1. Anemia
2. Syndrome of intravesical obstruction
3. Chronic renal failure
4. Chronic pain syndrome

Thus, therapeutic measures against the background of the main methods of exposure will also be aimed at combating pain syndrome, hematuria, acute urinary retention, blockade of the upper urinary tract, paravesical phlegmon.

Those. the nature and scope of palliative care will be dictated by the most prevalent clinical syndromes requiring emergency treatment.

Emergency conditions and their characteristics

1. Hematuria
2. Tamponade of the bladder
3. Acute urinary retention
4. Blockade of the upper urinary tract (hydronephrosis)
5. Pain syndrome
6. Paravesical phlegmon

The appearance of blood in the urine (hematuria) is usually the first symptom that prompts the patient to see a doctor and suspect the presence of a bladder tumor.

In the early stage of the disease, hematuria may not cause much concern, and sometimes it is enough to prescribe hemostatic agents (nettle decoction, dicinone) to compensate for blood loss and stop bleeding.

Two symptom complexes can determine the urgency of the situation and the need for urgent medical care for profuse hematuria - acute anemia and bladder tamponade. Intense bleeding that does not stop with conservative methods of treatment leads to blood loss, hypovolemia and anemia.

The clotting of blood poured into the lumen of the bladder may be accompanied by the formation of clots that can cause bladder tamponade. In the event of this situation, one has to resort to surgical treatment.

The scope of the surgical impact will be determined by the localization of the tumor and the extent of the process. For this, a high section of the bladder is performed, followed by its revision, freeing the bladder cavity from clots and restoring the passage of urine.

With limited cancer of the bottom and the body of the bladder, resection of the bladder is performed, with infiltration of the ureteral opening, the intramural ureter is resected, followed by neoimplantation into the bladder.

With total damage to the bladder or the location of the tumor in the bladder triangle, the possibility of the need for cystectomy, a technically difficult and traumatic operation for the patient, is not excluded.

Cystectomy ends with bilateral ureterocutaneostomy, since an increase in the volume of the operation due to the formation of an artificial reservoir for urine, given the urgency of the operation, can be fatal.

In the case of unresectability of the bladder tumor, attempts are made to stop bleeding by palliative measures - electrocoagulation of the tumor, ligation of both internal iliac arteries.

In specialized medical institutions, it is possible to use endovascular interventions with subsequent embolization of the internal iliac arteries, under the control of angiography. The advantage of embolization is the possibility of occlusion of the peripheral arterial bed, which excludes the development of collaterals.

Also, the advantage of endovascular intervention is the possibility, due to catheterization of one of the vessels, to conduct regional infusion of hemostatic and cytostatic drugs, against which it is possible to stop ongoing bleeding.

Embolization is carried out by transfemoral Seldinger catheterization, selective introduction of a catheter into the internal iliac artery from one or both sides and under visual control by occlusion of all peripheral vessels.

Bleeding from the bladder neck can be established using a Foley balloon catheter: after the catheter is inserted into the bladder and the balloon is inflated, the outer end is fixed in a taut position towards the thigh, which provides compression of the tumor. Also, to stop bleeding, you can use a tight tamponade of the bleeding tumor with a gauze swab.

In the case of a violation of the outflow of urine associated with the germination of the mouths of the ureters, their infiltration and leading to the development of ureterohydronephrosis and azotemia, the patient is shown:

Imposition of percutaneous nephrostomy;
ureteral stenting;
imposition of a nephrostomy;
removal of the orifices of the ureters to the skin.

With complete urinary retention, the best method of restoring urine diversion is bladder catheterization with an elastic catheter. If it is impossible to install an elastic catheter, it is possible to perform trocar epicystostomy or superimposition of a suprapubic fistula. A rubber Foley catheter is inserted through the trocar into the bladder, and after filling the balloon, it is left to drain the bladder and urine outflow.

The growth of the tumor into the pelvic organs and compression of the nerve trunks is accompanied by persistent pain syndrome, leading to the need to use analgesics and drugs.

We have outlined the principles of drug treatment for pain syndrome above. It is also possible to use conductive novocaine blockades through the obturator hole according to Stuckey, presacral blockade according to A.V. Vishnevsky, epidural denervation, resection of the presacral nerve plexus.

Although the modern development of pharmacotherapy, this direction is reduced to almost a minimum. Also, carrying out this kind of manipulation requires a good skill. In case of metastatic lesions of the bones of the skeleton, it is possible to use short courses of local irradiation to relieve pain.

Extraperitoneal perforation of the bladder develops in patients with advanced endophytic, infiltrating tumor due to its spontaneous or in the case of radiation decay. A defect in the bladder wall causes urine to flow into the peri-vesicular cellular space, which is complicated by the development of paravesical phlegmon.

In this case, the optimal method of palliative care will be resection of the bladder wall with a disintegrating tumor and suturing of the post-resected defect.

The operation for paravesical phlegmon has two goals: urine diversion and drainage of the peri-vesical cellular tissue space.

The most effective way of urine diversion is epicystomy through a “healthy” wall without signs of visible tumor invasion. With a disintegrating tumor in the region of the bladder triangle, the only possible way to divert urine to the outside is bilateral ureterocutaneostomy.

Drainage of peri-vesicular tissue through the anterior abdominal wall provides outflow from the upper portions of the retropubic space and pre-vesicular tissue. Peripubular tissue located deep in the pelvis should be drained through the obturator opening.

After the provision of primary palliative care in the future, patients are shown radiation therapy with single dose (ROD) 1.8-2.5 Gy, total focal dose (SOD)- 60-70 Gr.

Contraindication to radiation therapy is the compression of the ureters, acute pyelonephritis, the presence of multiple metastases, inhibition of hematopoiesis, the severe general condition of the patient.

For chemotherapy, cytostatics are most often used - adriamycin, thiotef, mitomycin C, cisplatin, methotrexate, vinblastine, 5-fluorouracil. The standard treatment regimen is currently a combination of 3-4 drugs based on cisplatin and methotrexate.

The most commonly used scheme is MVAC:

Methotrexate 30 mg / m2, IV, on days 1,15,22,
Vinblastine 3 mg / m2, i.v., on days 2,15,22,
Adriamycin 30 mg / m2, i.v., on day 2,
Cisplatin 70 mg / m2, IV, on day 2.

The interval between courses is 28 days. At least 2-3 courses. The effectiveness of chemotherapy for disseminated bladder cancer is about 50-70% and its use in a palliative mode with a good patient's condition should not be neglected by the attending physician.

Novikov G.A., Chissov V.I., Modnikov O.P.

Situations requiring urgent intervention are quite common in urological practice. These include renal colic, acute pyelonephritis, urinary retention, gross hematuria. Rapid recognition and differentiated treatment of these conditions reduces the likelihood of complications and increases the duration of the effect of the therapy.

Clinical presentation and diagnostic criteria

Patients suffer from overflow of the bladder: there are painful and fruitless attempts to urinate, pain in the suprapubic region; the patient's behavior is characterized as extremely restless. Patients with diseases of the central nervous system and spinal cord, who, as a rule, are immobilized and do not experience severe pain, react differently. When viewed in the suprapubic region, a characteristic swelling is determined due to an overflowing bladder ("bubble ball"), which, when percussed, gives a dull sound.

In order to provide the patient with timely and qualified assistance, it is necessary to clearly understand the mechanism for the development of acute urinary retention in each individual case. In case of acute urinary retention, it is necessary to urgently evacuate urine from the bladder. Given the danger of urinary tract infection in the absence of a pronounced urge to urinate, catheterization is best done in a hospital setting. Severe pain syndrome caused by overstretching of the bladder is an indication for catheterization at the prehospital stage.

Bladder catheterization should be treated as a serious procedure, equating it with an operation. In patients without anatomical changes in the lower urinary tract (with diseases of the central nervous system and spinal cord, postoperative ischuria, etc.), bladder catheterization is usually not difficult. Various rubber and silicone catheters are used for this purpose.

The greatest difficulty is catheterization in patients with benign prostatic hyperplasia (BPH). With BPH, the posterior urethra is lengthened and the angle between the prostatic and bulbous parts of it increases. Given these changes in the urethra, it is advisable to use catheters with a Timan or Mercier curvature. With the rough and forced introduction of the catheter, serious complications are possible: the formation of a false passage in the urethra and prostate gland, urethrorrhagia, urethral fever. Prevention of these complications is a careful adherence to asepsis and catheterization technique.

The need for catheterization often arises in elderly patients, as well as in persons with severe concomitant pathology, including diabetes mellitus, circulatory disorders, etc. In such cases, given the absence of sterile conditions in the EMS machine, it is necessary to carry out antibiotic prophylaxis of urinary tract infections (UTI).

The main causative agent of uncomplicated MEP infections is E. coli- 80 - 90%, much less often - S. saprophyticus (3-5%), Klebsiella spp., P. mirabilis and others. The most active to these pathogens are fluoroquinolones (ciprofloxacin, pefloxacin, ofloxacin, etc.), the level of resistance of which is less than 3%.

Alternatively, amoxicillin / clavulanate or II-III generation cephalosporins (cefuroxime axetil, cefaclor, cefixime, ceftibuten) can be used.

For prophylaxis, these antibacterial drugs can be used orally.

In acute prostatitis (especially with an outcome in an abscess), acute urinary retention occurs due to deviation and compression of the urethra by an inflammatory infiltrate and edema of its mucosa. Bladder catheterization is contraindicated in this disease. Acute urinary retention is one of the leading symptoms in patients with urethral trauma. In this case, catheterization of the bladder for diagnostic or therapeutic purposes is also unacceptable.

Acute urinary retention with stones in the bladder occurs when a stone wedges into the neck of the bladder or obstructs the urethra in its various parts. Palpation of the urethra helps to diagnose stones. With urethral strictures leading to urinary retention, an attempt to catheterize the bladder with a thin elastic catheter is possible.

The cause of acute urinary retention in elderly and senile women may be prolapse of the uterus. In these cases, it is necessary to restore the normal anatomical position of the internal genital organs, and urination is also restored (usually without prior catheterization of the bladder).

Casuistic cases of acute urinary retention include foreign bodies in the bladder and urethra that injure or obstruct the lower urinary tract. Emergency care is to remove the foreign body; however, this manipulation can only be performed in a hospital setting.

In the case of reflex urinary retention (for example, with postpartum, postoperative ischuria), you can try to induce urination by irrigating the external genital organs with warm water, by pouring water from one vessel into another (the sound of a falling stream of water can reflexively cause urination); if these methods are ineffective and there are no contraindications, 1 ml of a 1% solution of pilocarpine or 1 ml of a 0.05% solution of proserin is injected subcutaneously; if ineffective, bladder catheterization is indicated.

Indications for hospitalization. Patients with acute urinary retention are subject to emergency hospitalization.

Macrohematuria

Definition. Hematuria - the appearance of an impurity of blood in the urine - is one of the characteristic symptoms of many urological diseases. Distinguish between microscopic and macroscopic hematuria; the onset of intense gross hematuria often requires urgent care.

Etiology and pathogenesis. Possible causes of hematuria are presented in.

Clinical presentation and classification. The appearance of red blood cells in the urine gives it a cloudy appearance and pink, brown-red or reddish-black color, depending on the degree of hematuria.

Macrohematuria can be of three types: 1) initial (initial), when only the first portion of urine is colored with blood, the remaining portions are of normal color; 2) terminal (final), in which in the first portion of urine, no blood impurities are visually detected and only the last portions of urine contain blood; H) total, when the urine in all portions is equally colored with blood. Possible causes of gross hematuria are presented in.

Often, gross hematuria is accompanied by an attack of pain in the kidney area, since a clot formed in the ureter interferes with the outflow of urine from the kidney. In a kidney tumor, bleeding precedes pain ("asymptomatic hematuria"), whereas in urolithiasis, pain occurs before the onset of hematuria. Localization of pain in hematuria also makes it possible to clarify the localization of the pathological process. So, pain in the lumbar region is typical for kidney disease, and in the suprapubic region - for lesions of the bladder. The presence of dysuria simultaneously with hematuria is observed with damage to the prostate gland, bladder or posterior urethra. The shape of the blood clots also allows you to determine the localization of the pathological process. Worm-like clots that form when blood passes through the ureter indicate an upper urinary tract disease. Formless clots are more common in bleeding from the bladder, although they may form in the bladder when blood is excreted from the kidney.

With profuse total hematuria, the bladder is often filled with blood clots and independent urination becomes impossible. There is a tamponade of the bladder. Patients develop painful tenesmus, and a collaptoid state may develop. Bladder tamponade requires immediate treatment.

The main directions of therapy. With the development of hypovolemia and a drop in blood pressure, restoration of the volume of circulating blood is shown - intravenous administration of crystalloid and colloidal solutions. Hemostatic agents are not used.

Indications for hospitalization. If gross hematuria occurs, immediate admission to the urology department of the hospital is indicated.

Acute pyelonephritis

Definition. Pyelonephritis is a nonspecific infectious and inflammatory process with a predominant lesion of the interstitial tissue of the kidneys and its pyelocaliceal system.

Etiology and pathogenesis. The causative agents of pyelonephritis can be Escherichia coli, less often other gram-negative bacteria (for example, Pseudomonas aeruginosa), staphylococci, enterococci, etc. organism - otitis media, tonsillitis, mastitis, pneumonia, sepsis, etc.). Predisposing factors - immunodeficiency, urinary tract obstruction (urolithiasis, various abnormalities of the kidneys and urinary tract, strictures of the ureter and urethra, prostate adenoma, etc.), instrumental studies of the urinary tract, pregnancy, diabetes mellitus, old age, etc. occurrences distinguish between primary pyelonephritis (without any previous disorders of the kidneys and urinary tract) and secondary (arising on the basis of organic or functional processes in the kidneys and urinary tract, which reduce the resistance of the kidney tissue to infection and disrupt the outflow of urine). In general, pyelonephritis develops more often in women, especially at a young age, which is associated with the anatomical, physiological and hormonal characteristics of the female body. In old age, the disease is more common in men due to the development of prostate adenoma.

The classification of acute pyelonephritis is presented in.

The clinical picture. Symptoms of acute pyelonephritis consist of general and local symptoms of the disease. Initially, acute pyelonephritis is clinically manifested by signs of an infectious disease, which often causes diagnostic errors.

General symptoms: fever, severe chills, followed by profuse sweating, nausea, vomiting, inflammatory changes in blood tests.

Local symptoms: pain and muscle tension in the lumbar region on the side of the lesion, sometimes dysuria, cloudy urine with flakes, polyuria, nocturia, soreness when tapping in the lower back.

During acute pyelonephritis, stages of serous and purulent inflammation are distinguished. Purulent forms develop in 25 - 30% of patients. These include apostematous (pustular) pyelonephritis, carbuncle and kidney abscess.

Algorithm for the treatment of acute pyelonephritis

Full treatment is possible only in a hospital setting; at the prehospital stage, only symptomatic therapy is possible, implying the use of non-steroidal anti-inflammatory drugs and antispasmodics (see section Renal colic).

Prescribing broad-spectrum antibacterial drugs without specifying the state of urodynamics of the upper urinary tract and restoring the passage of urine leads to the development of an extremely serious complication - bacteriotoxic shock, with a mortality rate of 50 - 80%.

Indications for hospitalization. Patients with acute pyelonephritis require urgent hospitalization for a detailed examination and determination of further treatment tactics.

D. Yu. Pushkar, Doctor of Medical Sciences, Professor
A. V. Zaitsev, Doctor of Medical Sciences, Professor
L. A. Aleksanyan, Doctor of Medical Sciences, Professor
A. V. Topolyansky, candidate of medical sciences
P. B. Nosovitsky
MGMSU, NNPO of emergency medical care, Moscow

Note!

• The effectiveness of the treatment of patients with acute urological diseases depends on two factors: the quality of the complex of measures aimed at normalizing vital functions, and the timely delivery of the patient to a specialized hospital.
• Renal colic is a symptom complex that occurs with an acute (sudden) violation of the outflow of urine from the kidney, which leads to the development of pyelocaliceal hypertension, reflex spasm of renal arterial vessels, venous stasis and edema of the parenchyma, its hypoxia and overstretching of the fibrous capsule.
• In acute prostatitis (especially with an outcome in an abscess), acute urinary retention occurs due to deviation and compression of the urethra by an inflammatory infiltrate and edema of its mucosa.

v Definition.

Acute condition of completely filling the bladder with blood clots

due to hematuria, often causing severe dysuria and cessation of the act of urination -

acute urinary retention.

v Etiology.

The cause of hematuria can be multiple diseases of the organs of the genitourinary system,

they can all be accompanied by bladder tamponade:

ª Tamponade of the bladder with massive hematuria due to upper urinary trauma

ª Tamponade of the bladder with massive hematuria due to tumors of the upper

urinary tract,

ª Tamponade of the bladder with hematuria due to a tumor of the bladder,

ª Tamponade of the bladder with prostatic hyperplasia.

§ Hematuria and tamponade due to bleeding from varicose veins

veins of the prostate and bladder neck,

§ Hematuria and tamponade due to bleeding from damaged areas

capsules of the prostate (spontaneous rupture of the capsule, self-exfoliation of hyperplastic

v Pathogenesis of development in prostatic hyperplasia.

The mechanisms of development of hematuria and tamponade in prostatic hyperplasia are as follows:

ª Hematuria from varicose veins of the prostate.

As the obstructive process in the prostate progresses and its volume increases due to

intravesical prostatic growth develops a violation of the venous outflow of blood from

organ, as a result of mechanical compression of the veins of the prostate and bladder neck. This

the condition leads to the development of varicose veins of the bladder neck with

degenerative changes in their walls. Constant detrusor and urinary neck loads

bladder to overcome increased resistance (bladder outlet obstruction) create

sharp changes in intravesical pressure, which, against the background of constant pressure, increased

organ on the veins contributes to the creation of micro- and then marconadry veins. Blood flows into

urine directly in the bladder. Excessive flow of blood into the bladder for

at first it is expressed in hematuria with unchanged blood, then against the background of

existing bladder outlet obstruction, the blood begins to clot, forming clots.

Each successive turn of blood flow increases the number of blood clots in

bladder.

ª Hematuria with spontaneous rupture of the prostate capsule.

As the obstructive process develops in the prostate and the development of an increase in the volume of the prostate

most often due to intravesical prostatic growth, in addition to impaired venous outflow

tension and tension of the prostate capsule develops. Constant detrusor loads and

bladder neck to overcome increased resistance (infravesical

obstruction) create sharp changes in intravesical pressure, which, against the background of constant

the pressure of the enlarged organ on the capsule contributes to the self-rupture of the capsule with

prolapse of the gland tissue into the capsule defect and the development of hematuria. Coming to

bladder blood clots, each next burst of bleeding increases

the number of clots.

v Symptoms and clinical picture.

The leading and main symptoms of bladder tamponade are:

ª Pain and painful urge to urinate with tamponade of the bladder

practically does not differ from that in acute urinary retention. Frequent

(pollakiuria, stranguria), painful urge to urinate is unsuccessful or

ineffective, palpation in the suprapubic region causes increased pain... Sick like

usually extremely restless.

ª Hematuria... The admixture of blood in the urine can be either fresh (unchanged blood) or

altered blood, total hematuria.

ª Acute urinary retention in the form of ineffectual and painful urges to

urination causes severe pain in the bladder area.

ª General signs of blood loss. Considering that the capacity of a man's bladder is

the average is 250-300 ml with the development of bladder tamponade, it can be assumed

minimal blood loss in the same amount. However, the amount of blood lost during

bladder tamponade is usually much larger. Depending on the degree

blood loss, external signs of anemia are noted: pallor of the skin and visible

mucous,rapid pulse,tendency to hypotension etc.

v Diagnostics.

ª Complaints... Patients complain of manifestations of the main symptoms: absence

spontaneous urination, blood flow with urine, painful urge to

urination, general weakness, dizziness.

ª Anamnesis. In the course of the survey, as a rule, it turns out that this hematuria is not the first and

previously there were episodes of self-limited macrohematuria. Also it turns out

a long history of symptoms of bladder outlet obstruction.

ª Inspection. Visually, the bladder, as a rule, protrudes above the bosom. Palpable

bulging over the bosom, overflowing bladder,palpation causes a sharp

soreness... From the urethra with a full bladder small

the number of blood clots or urine mixed with blood.Rectally enlarged,

tight-elastic adenomatous prostate.Pallor of the skin and visible mucous membranes,

other external signs of anemia.

ª Laboratory diagnostics. Depending on the degree of blood loss, the indicators are reduced

red blood: total red blood cell count and hemoglobin ... Blood clots in the urinary

bladder and developing against the background of this AUR cause an inflammatory reaction of the blood in the form

leukocytosis ,shift of the leukocyte formula to the left ,increased ESR .

With long-term current bladder tamponade against the background of AUR and anemia, it develops

violation of the evacuation function of the upper urinary tract, the cleansing function decreases

kidney that is expressed azotemia- blood creatinine can reach values ​​of 150 μmol / l and

higher, urea - over 10 mmol / l, residual nitrogen - over 50 - 60 mg%.

ª Ultrasound diagnostics.

§ Ultrasound scanning of the bladder and prostate. Besides the increased

adenomatous prostate in the bladder is determined a large number of clots

blood performing all congested bladder in the form of education

mixed echogenicity. Sometimes it is possible to visualize a capsule defect with

an adjacent blood clot... In terms of the size and volume of education, you can

approximately determine the amount of blood loss.

§ Ultrasound scanning of the kidneys and upper urinary tract. Allows you to diagnose

sometimes associated with bladder tamponade supravesical

obstruction in the form of bilateral dilatation of the upper urinary tract. Dilatation degree

can reach considerable sizes: the ureter is up to 3-4 cm, the pelvis is up to 4-5 cm,

ª Treatment.

Developing and continuing tamponade of the bladder is an indication for

surgical treatment - revision of the bladder, transvesical adenomectomy.

− Delayed surgical treatment.

On the background hemostatic,antibacterial and blood substitute therapy

produce washing of the bladder from clots through the urethral catheter.

Successful completion of the last and no ongoing bleeding gives

time for systemic examination of the patient and preparation for delayed

surgical intervention.

− Urgent surgical treatment.

Failure to wash tamponade (clots), re-development of tamponade and

ongoing massive bleeding is an indication for urgent

surgical intervention: revision of the bladder and adenomectomy.