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Lecture notes, cheat sheets
Urology. Cheat sheet: briefly, the most important
Directory / Lecture notes, cheat sheets Table of contents
1. Urinary tract infections. Classification, etiology, clinic, diagnostics Urinary tract infections - the state of infection of the urinary tract with microflora, which causes its inflammation. Classification. There are infections of the upper (pyelonephritis) and lower urinary tract (cystitis, prostatitis, urethritis) by the presence or absence of symptoms (symptomatic or asymptomatic bacteriuria), by the origin of the infection (community-acquired or nosocomial, complicated and uncomplicated. Uncomplicated UTIs are characterized by the absence of a violation Complicated infections are accompanied by functional or anatomical abnormalities of the upper or lower urinary tract Risk factors for complicated UTIs are anatomical and functional disorders, congenital pathology, vesicoureteral reflux, sexual life, gynecological surgery, urinary incontinence, frequent catheterizations; in men also - uncircumcised foreskin, homosexuality, benign prostatic hyperplasia, intravesical obstructions Metabolic and immunological disorders, foreign bodies in the urinary tract, calculi, urinary disorders, advanced age of the patient, spinal cord lesions and multiple sclerosis, diabetes mellitus, neutropenia, immunodeficiency, pregnancy, instrumental research methods contribute to UTI. Etiology. With uncomplicated UTI - E. Coli; in complicated UTIs, Proteus, Pseudomonas, Klebsiella, fungi are more common. The source of uropathogenic microorganisms is the intestine, anal region, vestibule of the vagina and periurethral region. Inflammation most often develops in conditions of disturbed outflow of urine in combination with a decrease in the overall reactivity of the body. There are the following types of UTIs: severe bacteriuria, small bacteriuria, asymptomatic bacteriuria and contamination. UTI is verified when the number of microbial bodies is more than 105 CFU per 1 ml in two consecutive portions of fresh urine and is confirmed by microscopic examination of urine in order to exclude vaginal contamination, in which a false positive result is often observed. Reduced diuresis and lack of fluid intake contribute to the growth of bacteria. Diagnostics. A common screening test reagent - a biochemical reagent strip - detects the presence of leukocyte esterase (pyuria) and evaluates the reactivity of nitrate reductase. A negative test strip result rules out infection. In practice, erythrocytes and leukocytes that make up the urinary sediment are lysed at a urine pH of more than 6,0, with low urine osmolarity, prolonged standing urine; therefore, false-negative results on urine microscopy are more common than false-positive results on a test strip test. Microscopic examination of the urine sediment is mandatory. The use of the phase contrast technique makes it easier to identify most cellular elements compared to light microscopy. 2. Urinary tract infections Treatment. The goals of antimicrobial treatment and prevention of UTIs are the eradication of pathogenic microorganisms from the genitourinary system and the prevention of exacerbation or reinfection. The choice of an antibiotic is based on the spectrum of action of the drug, the sensitivity of microorganisms, the pharmacokinetic and pharmacodynamic properties of the antibiotic, and side effects. According to the recommendations of the Federal Guidelines for Physicians, adult patients should be prescribed fluoroquinolones and fosfomycin trometamol (once), children - inhibitor-protected b-lactams and oral cephalosporins generations. In most cases, lower urinary tract infection is combined with neuromuscular disorders of the smooth muscle elements of the urinary tract and pelvic organs; in this case, the addition of antispasmodics to complex therapy is indicated. The herbal preparation Cyston is effective (2 tablets 2 times a day). In most cases, antibiotic therapy is indicated, except for asymptomatic bacteriuria. The goals of antibiotic therapy are: rapid resolution of symptoms, eradication of pathogens, reduction in the number of relapses and complications, and reduction in mortality. Fluoroquinolones have a bactericidal effect, have a wide range of antimicrobial activity, including against multi-resistant strains of microorganisms, have high oral bioavailability, have a fairly high half-life, create a high concentration in the urine, and penetrate well into the mucous membranes of the urogenital tract and kidneys. . The effectiveness of fluoroquinolones in UTI is 70-100%, these drugs are well tolerated. The optimal duration of treatment for acute uncomplicated cystitis according to the results of a meta-analysis is 3 days. Fluoroquinolones are the drugs of choice for the treatment of complicated and nosocomial UTIs (ciprofloxacin). Treatment of UTIL (uncomplicated infection of the lower genital tract) should be etiological and pathogenetic and should include antibiotic therapy for up to 7-10 days, the choice of drugs is carried out taking into account the isolated pathogen and antibiogram, antibiotics with bactericidal action are preferable. Comprehensive treatment should include, according to indications: 1) correction of anatomical disorders; 2) STI therapy, in which the drugs of choice are macrolides, tetracyclines, fluoroquinolones, antivirals, treatment of sexual partners; 3) postcoital prophylaxis; 4) treatment of inflammatory and dysbiotic gynecological diseases; 5) correction of unfavorable hygienic and sexual factors; 6) correction of immune disorders; 7) local therapy; 8) the use of hormone replacement therapy in patients with estrogen deficiency. 3. Acute pyelonephritis Acute pyelonephritis - non-specific infectious inflammation of the pyelocaliceal system and kidney parenchyma .. Etiology and pathogenesis. Acute pyelonephritis is the result of an ascending infection from foci of chronic inflammation in the female genital organs, lower urinary tract, less often in the large intestine; caused by Escherichia E. Coli (in most cases), Klebsiella, Proteus, Pseudomonas. The hematogenous way of development of acute pyelonephritis is less common than the ascending one; its source is an acute or subacute inflammatory process outside the urinary tract. Clinic acute pyelonephritis depends on obstruction in the urinary tract. With a non-obstructive process, the disease begins with dysuria with a rapid increase in body temperature to high numbers. Chills, pains from the affected kidney join the body temperature; chills are replaced by heavy sweat with a short-term decrease in body temperature. In obstructive acute pyelonephritis, the disease begins with a gradually increasing or acutely developed pain in the lower back from the side of the lesion, followed by the development of chills and an increase in body temperature. Diagnostics. Laboratory determined pyuria, bacteriuria. Ultrasound examination, computed tomography exclude anatomical and functional anomalies of the urinary tract. Computed tomography and magnetic resonance imaging provide information about the state of the affected kidney and surrounding tissues. Treatment. Patients should be urgently hospitalized in a urological hospital with obstruction disease, as it is necessary to restore the passage of urine. If parenteral antibiotic therapy was initially prescribed, then after 1-2 days it can be replaced with an oral regimen of the drug. Conventional therapy lasts 10-14 days. In the treatment of acute pyelonephritis, cephalosporins of the II-III generation, fluoroquinolones, inhibitor-protected aminopenicillins and aminoglycosides are most often used. Due to the resistance of many uropathogens to the most commonly used antibiotics, it becomes necessary to prescribe fluoroquinolones. Drugs from this group, united by a common mechanism of action, are characterized by a wide spectrum of antimicrobial activity and favorable pharmacokinetic properties: levofloxacin (tavanic) (500 mg 1 time per day for severe infection), gatifloxacin (400 mg), moxifloxacin (400 mg) , trovafloxacin (200 mg) for 7-10 days. Antibiotics are combined with chemotherapy drugs, at the same time they give plenty of fluids (cranberry juice), and conduct detoxification therapy. For pain in the area of the affected kidney, thermal procedures, painkillers are indicated. Nutrition should be sufficiently high-calorie (up to 2000 kcal per day), not plentiful, without limiting the intake of table salt. 4. Chronic pyelonephritis. Clinic. Diagnostics Chronic pyelonephritis observed in 35% of urological patients. Clinic. For chronic pyelonephritis, the paucity of general clinical symptoms is characteristic due to the slow, sluggish course of the inflammatory process in the interstitial tissue of the kidney. The disease is usually detected several years after cystitis or other acute process in the urinary tract. General symptoms of chronic pyelonephritis: subfebrile temperature, general weakness, fatigue, lack of appetite, nausea, vomiting, anemia, discoloration of the face, dry skin, arterial hypertension. Diagnostics. Of great importance is the detection of bacteriuria and leukocyturia, the detection of Sternheimer-Malbin cells and active leukocytes in the urine sediment. Hidden leukocyturia is detected by provocative tests (prednisolone, pyrogenal). Immunological methods for the diagnosis of chronic pyelonephritis are used, based on the detection of autoantibodies to renal antigens using the complement fixation reaction and the passive hemagglutination reaction. In patients with chronic pyelonephritis, a more pronounced violation of tubular reabsorption is found compared to glomerular filtration according to clearance tests; violation or absence of indigo carmine release during chromocystoscopy. The vertical location of the kidney, as well as an increase in its size and uneven contours, are found on an overview urogram, tomograms or sonograms of the urinary tract. Excretory urography, in addition to changing the size of the kidneys and their contours, allows you to establish the deformation of the cups and pelvis, violation of the tone of the upper urinary tract. In the later stages of the disease, deformation of the cups is noted: they become rounded, with flattened papillae and narrowed necks. Morphology. Chronic pyelonephritis is characterized by focality and polymorphism of the inflammatory process in the kidney. There are 4 stages of development of chronic pyelonephritis, in which there is a rapid and pronounced damage to the tubules compared to the glomeruli. In stage I, the glomeruli are intact, there is uniform atrophy of the collecting ducts and diffuse leukocyte infiltration of the interstitial tissue. In stage II, hyalinization of individual glomeruli occurs, tubular atrophy is even more pronounced, there is a decrease in inflammatory infiltration of the interstitial and proliferation of connective tissue. In stage III, many glomeruli die, most of the tubules are sharply expanded; in stage IV, the death of most of the glomeruli of the tubules occurs, the kidney decreases in size, is replaced by scar tissue. With bilateral chronic pyelonephritis or damage to a single kidney in the terminal stage, chronic renal failure develops. Depending on the degree of activity of the inflammatory process in the kidney in chronic pyelonephritis, the active phase of inflammation, the latent phase and the remission phase are distinguished. 5. Chronic pylonephritis Differential diagnosis. Treatment Differential diagnosis is carried out with chronic glomerulonephritis, amyloidosis of the kidneys, glomerulosclerosis, tuberculosis of the kidney, necrotic papillitis, spongy kidney, interstitial nephritis, nephrosclerosis, hypoplasia of the kidney, multicystic kidney. Treatment. Elimination of the focus of infection in the body: chronic tonsillitis, carious teeth, furunculosis, chronic constipation. If the passage of urine is disturbed, its outflow from the kidney is restored. With unilateral chronic pyelonephritis, not amenable to therapy, or pyelonephrotic wrinkling of one kidney, complicated by arterial hypertension, nephrectomy is indicated. Long-term antibacterial treatment is carried out with intermittent courses in accordance with the nature of the microflora. Antibiotics alternate with taking sulfonamides, chemotherapy drugs, derivatives of the nitrofuran series. Sequential or combined administration of antimicrobial drugs for 1,5-2 months, as a rule, allows to achieve clinical and laboratory remission in most patients with chronic pyelonephritis. Within a year after acute pyelonephritis and at least 5 years after an exacerbation of chronic pyelonephritis, anti-relapse therapy is carried out: the first 7-10 days of each month, a uroseptic is taken (1 time at night in 1/4 of the daily dose). The next 20 days - herbal preparations (diuretics, litholytics, antiseptics, anti-inflammatory, strengthening the vascular wall, improving the vitamin composition of the body). Fees are assigned for 3-6 months. Physiotherapeutic procedures of anti-inflammatory and absorbable action are also used. In some cases, the issues of surgical correction of anomalies of the urinary tract are solved. The diet excludes foods rich in extractive substances: spices, marinades, smoked meats, sausages, canned food, spices. Forecast depends on the primary or secondary nature of the lesion, the intensity of treatment, concomitant diseases. 6. Kidney abscess. kidney carbuncle kidney abscess - limited purulent inflammation, characterized by melting of the kidney tissue and the formation of a cavity filled with pus, is one of the forms of acute purulent pyelonephritis. Etiology. Kidney abscess develops as a result of purulent fusion of the parenchyma in the inflammatory infiltrate. Clinic depends on the presence and degree of violation of the passage of urine. The body temperature rises hectically, chills, sweat, headache, vomiting are observed, the pulse and respiration become more frequent, pronounced leukocytosis with a predominance of neutrophilia. The absence of hyperleukocytosis is an unfavorable sign. Diagnostics. The diagnosis is based on palpation of an enlarged painful kidney, a positive symptom of Pasternatsky, the presence of bacteriuria and pyuria, which can be significant when an abscess breaks into the renal pelvis. on excretory urography - restriction of kidney mobility at the height of inhalation and after exhalation, deformation or amputation of the calyces of the kidney, compression of the renal pelvis. Treatment surgical: decapsulation of the kidney, opening of the abscess, drainage of the cavity; in violation of the passage of urine, the operation is completed with a pyelo- or nephrostomy. Kidney carbuncle is one of the forms of acute pyelonephritis, in which a purulent-necrotic pathological process develops in a limited area of the cortical layer of the kidney. Etiology and pathogenesis. Most often, the carbuncle of the kidney occurs due to blockage of a large end vessel of the kidney by a microbial embolism that has penetrated from the focus of inflammation into the body (furuncle, carbuncle, mastitis, osteomyelitis, etc.) with blood flow. Clinic. The main signs are a sharp general weakness, pallor of the skin, a high body temperature of a hectic nature with tremendous chills and heavy sweats, oliguria, and a decrease in blood pressure. Local symptoms: tension in the muscles of the anterior abdominal wall and lower back, a sharply positive symptom of Pasternatsky, sometimes an enlarged and painful kidney is clearly palpated, but these local symptoms are not always detected. Diagnostics. The most valuable in the diagnosis of carbuncle of the kidney are x-ray, isotope and ultrasound methods of research. An overview image of the urinary tract shows an increase in the size of the kidney segment, focal bulging of its outer contour, and the disappearance of the contour of the lumbar muscle on the side of the lesion. Treatment. Massive antibiotic therapy is carried out. In the first 2-3 days of the disease, surgical treatment is performed - kidney decapsulation, excision of the carbuncle and drainage of the perirenal tissue. At the same time restore the disturbed passage of urine. With multiple carbuncles of the kidney that destroyed the entire parenchyma, and a functioning opposite kidney, nephrectomy is indicated. 7. Apostematous pyelonephritis Apostematous pyelonephritis - suppuration of the renal parenchyma with the development of multiple small pustules (apostemes) in it, is one of the late stages of acute pyelonephritis. Etiology and pathogenesis. Regardless of the location of the primary purulent focus in the body, the infection penetrates the kidney through the hematogenous route. Inflammatory infiltrates spread along the interstitial perivenous tissue, reaching the surface of the kidney in the subcapsular space. This leads to the appearance of pustules on the surface of the kidney. Unilateral apostematous pyelonephritis occurs as a result of obstruction of the upper urinary tract. A kidney affected by apostematous pyelonephritis is enlarged, stagnant-plethoric, a large number of small pustules can be seen through the fibrous capsule; with the progression of apostematous pyelonephritis, the pustules merge, forming an abscess or carbuncle; when the process spreads to the perirenal tissue, purulent paranephritis develops. Clinic disease depends on the presence and degree of violation of the passage of urine. Characterized by general weakness, pain throughout the body, loss of appetite, nausea, sometimes vomiting, dry tongue, rapid pulse corresponding to body temperature, stunning chills followed by fever up to 39-40 ° C and heavy sweats, pain in the kidney area; there are symptoms of irritation of the peritoneum, tension of the muscles of the anterior abdominal wall. It is possible to develop exudative pleurisy if the infection spreads through the lymphatic tract. The patient's condition is severe, in the later stages, the function of the kidneys is impaired, the renal-hepatic syndrome with jaundice develops. Diagnostics. The diagnosis is substantiated by laboratory and radiological data: high blood leukocytosis with a shift of the leukocyte formula to the left, bacteriuria, leukocyturia. An overview urogram reveals a curvature of the spine towards the disease and the absence of a shadow of the lumbar muscle on this side. The kidneys are enlarged. When the upper segment of the kidney is affected, effusion into the pleural cavity is determined. Excretory urography during the patient's breathing or at the height of inhalation and exhalation determines the limitation of the mobility of the affected kidney, its function is reduced. In the later stage of apostematous pyelonephritis and in violation of the passage of urine, these symptoms are more pronounced, the function of the affected kidney is sharply impaired, significant bacteriuria and leukocyturia are detected. Treatment. Surgical treatment consists in decapsulation of the kidney, opening of abscesses, drainage of the perirenal space, and in case of impaired passage of urine, the renal pelvis by imposing pyelo- or nephrostomy. Sometimes the affected kidney is removed. Broad-spectrum antibiotics, sulfonamides, nitrofurans are used. Antibiotics are changed, infusion therapy, vitamin therapy, analgesics, antispasmodics are taken. Cranberry juice, decoction of plantain, horsetail, eleutherococcus extract are also useful. 8. Infectious-toxic shock. paranephritis Infectious-toxic shock - a state of circulatory failure, which is caused by a sudden massive effect of bacterial toxins on the patient's body. Etiology. The process develops as a result of the introduction into the bloodstream of a large number of various microorganisms that form endotoxin. The impact of endotoxin on the vascular wall and the patient's body leads to shock with hypovolemia, lowering blood pressure, severe intoxication, often accompanied by acute renal failure. Clinic. Signs: stunning chills, hectic body temperature, drop in blood pressure. The patient is pale, covered with cold sweat, the pulse is frequent, weak, arterial pressure is low, the circulating blood is thickened, hyperglycemia, dysproteinemia, diselectrolytemia, acidosis, azotemia are detected. Diagnostics. The diagnosis is based on the clinical picture of laboratory data (an increase in the number of leukocytes in the blood with a shift in the leukocyte formula to the left, an increase in hematocrit, a small number of platelets, an increase in the number of erythrocytes and hemoglobin). Treatment should be intensive, massive antibiotic therapy is necessary, and with a closed focus of inflammation, its emergency drainage by surgery. Infusion therapy includes transfusion of plasma, plasma-substituting fluids, vasopressors, corticosteroids are prescribed, acid-base and electrolyte balance is corrected. Paranephritisinflammation of the peritoneal tissue. Etiology. Primary paranephritis occurs as a result of hematogenous spread of infection from the focus - furuncle, carbuncle, panaritium, tonsillitis. Secondary paranephritis is mainly a complication of a purulent-inflammatory process in the kidney, retroperitoneal tissue, and abdominal organs. Clinic. Acute paranephritis begins with a sudden rise in temperature to 38-40 ° C, accompanied by chills, the temperature is initially constant, then hectic. Pain in the lumbar region appears 1-3 days after the onset of the disease. Diagnostics. The most important diagnostic features: lower back pain, aggravated by movement, pastosity and hyperemia of the skin in the lumbar region, flatness of the waist, characteristic position of the limb, immobile infiltrate in the lumbar region, fever of the skin of the lower back, high leukocytosis, accelerated ESR, anemia. Pyuria, bacteriuria are detected On the survey urogram, the curvature of the spine or the absence of the contours of the lumbar muscle. On excretory urograms and retrograde pyelogram - displacement of the kidney, absence or sharp limitation of the mobility of the kidney on the side of the paranephritis during the patient's breathing. 9. Cystitis. Urethritis Cystitis - inflammation of the mucous membrane of the bladder, the most common disease of the urinary tract. Etiology. The infection is caused by Escherichia coli or pathogenic Staphylococcus aureus. Non-bacterial cystitis is possible with allergic conditions, complications of drug therapy. With adenovirus infections, hemorrhagic cystitis develops. Hypothermia, stressful situations, weakening of the body predispose to disease. There are acute and chronic cystitis. Clinic. Pain in the lower abdomen, spreading to the perineum, genitals, imperative urge to urinate, frequent urination with pain. Diagnostics. The diagnosis is made on the basis of complaints, discharge of cloudy urine, sometimes with blood clots, proteinuria, leukocyturia, bacteriuria, squamous epithelium, erythrocytes. When sowing urine, the growth of microflora takes place. Treatment. In acute cystitis, bed rest, baths with a warm solution of furacilin or chamomile decoction, UHF physiotherapy, microwave therapy, and plenty of fluids are prescribed; diet excludes spicy substances. Chronic cystitis - a secondary disease that complicates the course of urolithiasis, kidney tuberculosis, prostate diseases. Clinic. Pain in the lower abdomen, frequent urination with pain, urge to urinate, pus in the urine. Differential diagnosis. Differentiate with neurogenic diseases of the bladder, cystalgia. Treatment. Establish the root cause of the disease to prescribe treatment. Antibacterial therapy is carried out in combination with nitrofurans, sulfonamides. The bladder is washed with warm solutions of aseptic agents. Urethritis - inflammation of the urethra, infectious or non-infectious. Etiology. Infectious urethritis is divided into venereal (gonorrheal, trichomonas, viral) and non-venereal (staphylococcal, streptococcal, colibacillary). Clinic. Pain during urination, burning, purulent discharge from the urethra. With a torpid course, these symptoms occur after intercourse, drinking alcohol and spicy foods. With a latent course, there are no complaints. Treatment For acute urethritis, broad-spectrum antibiotics are effective; antibiotics are combined with sulfonamides. The course of treatment lasts 5-7 days, at this time sexual intercourse is excluded, a dairy and vegetable diet is prescribed. Plentiful drinking is prescribed, the use of alcoholic beverages is prohibited. 10. Stricture urethra. Prostate stones. Prostate abscess Urethral stricture - persistent narrowing of its lumen as a result of cicatricial tissue replacement, distinguish between congenital and acquired strictures. Etiology. The most common causes are inflammatory diseases (most often gonorrhea), ulceration, chemical, traumatic injuries. Narrowings of an inflammatory nature are often multiple and are located in the hanging or bulbous part of the urethra. Clinic. In the initial period, lasting several weeks, it is still impossible to detect anatomical narrowing of the lumen, and there are no clinical signs; in the second period, the thickness and shape of the urine stream changes, its strength decreases, the duration and frequency of urination increase. All symptoms gradually progress, fever and pain in the urethra periodically join. Diagnostics. The diagnosis is based on the anamnesis, the most valuable in the diagnosis is urethrography. Treatment instrumental (bougienage) or operational. Bougienage is combined with absorbable therapy (aloe extract, vitreous body, hyaluronidase preparations). Surgical intervention consists of urethrotomy and a number of other operations. prostate stones is a relatively rare disease. Etiology. Stones are formed in the follicles during inflammatory processes in the prostate gland, the stones are multiple, small in size, radiopaque. Clinic. Patients complain of pain in the sacrum, above the pubis, in the perineum, rectum, hemo-spermia. The temperature rises to 39-40 ° C when a stone is infringed in the ejaculatory duct. Treatment In case of infection, antibiotic therapy is recommended, in case of abscess formation, surgical removal of stones with opening of the abscess. prostate abscess - complication of acute prostatitis. Etiology. There is a penetration into the gland of pyogenic bacteria, especially often staphylococci. Clinic. There are general symptoms (terrific chills, fever of a hectic nature, pouring sweat, tachycardia, rapid breathing, headache, general malaise, leukocytosis with a shift of the formula to the left). Diagnostics. With the spread of the inflammatory process to the surrounding tissue, the breakthrough of the abscess to the surrounding tissue, a significant infiltration along the side walls of the rectum is determined. Treatment consists in urgent surgical intervention - opening the abscess and draining its cavity. Antibacterial, detoxification therapy is carried out. 11. Acute prostatitis Prostatitis - inflammation of the prostate gland, which can be combined with inflammation of the back of the urethra, seminal tubercle and seminal vesicles. According to the course, acute and chronic are distinguished. Etiology acute prostatitis: any pyogenic microbe (staphylococcus), getting into the prostate gland, can cause an inflammatory process in it. The ways of getting the infection into the gland are thematic (after infectious and purulent diseases), lymphogenous (with inflammatory processes in the rectum), canalicular (from the back of the urethra). Hypothermia contributes to the development of prostatitis. According to the stages of the disease, catarrhal, follicular and parenchymal acute prostatitis are distinguished. Clinic. Catarrhal prostatitis may be characterized by pollakiuria, especially at night, pain in the perineum, sacrum, and often pain at the end of urination. With follicular prostatitis, pain in the perineum and sacrum is more intense, aggravated by defecation, radiating to the anus, there is difficulty urinating, the urine stream is thin, rarely urinary retention. Body temperature from subfebrile to 38 "C. Diagnostics. The diagnosis of acute prostatitis occurs on the basis of symptoms, palpation of the prostate through the rectum, urine and blood tests. In the catarrhal form, the gland is almost not enlarged and only slightly sensitive to palpation. When follicular - moderately enlarged, distinctly painful, increased density in some areas with uneven contours. When parenchymatous - sharply tense and painful, dense consistency, the longitudinal furrow is often smoothed. With an abscess, fluctuation is determined. After palpation and secretion into the urethra, softening areas are determined. In urine tests in the second portion, a large number of purulent threads, leukocyturia, more significant in the last portions, inflammatory changes in the blood (leukocytosis with a stab shift of the formula) are determined. Treatment. Bed rest, broad-spectrum antibiotics, sulfonamides, analgesics for pain, constipation - laxatives. Locally: warm sitz baths at 38-40 ° C for 10-15 minutes and microclysters at a temperature of 39-40 ° C from 1 cup of chamomile infusion with the addition of a 1-2% solution of novocaine, sage decoction 3-4 times a day. The liquid is slowly injected into the rectum, where it is left as long as possible. The patient should take a semi-sitting or semi-lying position (the patient lies on the bed, putting pillows under his head and back). With pronounced pain and dysuria, paraprostatic novocaine blockade can be performed. The diet is milky-vegetarian, plentiful drink. With an abscess of the prostate, its opening through the perineum or rectum and its drainage is shown. 12. Chronic prostatitis Chronic prostatitis - an inflammatory disease of an infectious genesis of the parenchymal and interstitial tissue of the prostate gland, the result of acute inflammation or a primary chronic course. Epidemiology. It is detected in 8-35% of men aged 20-40. Etiology. Infection or congestion with a sedentary lifestyle, alcohol intake, masturbation, disturbed rhythm of sexual intercourse. It is characterized by foci of the lesion, the formation of infiltrates, zones of destruction and scarring. Gram-negative microbes are the most common cause. Sexual dysfunction negatively affects the course of chronic prostatitis. Classification (US National Institutes of Health, 1995). Category I. Acute bacterial prostatitis. Category II. Chronic bacterial prostatitis. Category SHA. Chronic inflammatory pelvic pain syndrome. Category SHV. Syndrome of non-inflammatory chronic pelvic pain (prostatodynia). Category IV. Asymptomatic inflammatory prostatitis. Phases of the course: the phase of active inflammation, latent and remission. Pathogenesis. Inflammatory process with the addition of autoimmune disorders. Clinic. Complaints of discomfort in the genital area, pulling pain in the sacrum, above the womb, in the perineum; increased pain at the end of intercourse or subsidence during it, difficult, frequent urination, especially in the morning, prostatorrhoea that occurs in the morning, while walking, physical exertion. It is characterized by a decrease in the tone of the excretory ducts of the prostate gland. Violation of sexual function - impotence. Diagnostics. The diagnosis is based on the patient's complaints, digital examination of the prostate gland through the rectum, analysis of the secretion of the prostate gland. For bacteriological diagnosis of prostatitis, the Meares and Stamey method is usually used, which consists in the sequential study of the first and middle portions of urine, prostatic secretion and urine obtained after prostate massage. Analysis of the secret of the prostate, obtained by massage, is not very informative. Only 20% of patients with chronic prostatitis show signs of inflammation in the secretion of the prostate gland; in other cases, normal indicators of the secret may indicate obstruction of the excretory ducts of the lobules of the organ. The diagnosis of chronic bacterial prostatitis is established if the microbial count exceeds 103/ml Ultrasound sonography is limited in information content. Uroflowmetry - a way to determine the state of urodynamics, allows you to determine the signs of infravesical obstruction. With a prolonged inflammatory process, ureteroscopy or urethrocystography is performed. Punch biopsy of the prostate allows to differentiate chronic prostatitis, cancer or benign prostatic hyperplasia. There are no clear diagnostic criteria for chronic abacterial prostatitis. 13. Chronic prostatitis. Treatment The objectives of treatment are to stop the infection, restore the immune response, and prostate function. Antibiotics are prescribed for chronic bacterial prostatitis, chronic abacterial prostatitis (category III A, if there is clinical, bacteriological, immunological evidence of prostate infection). The nature of the microflora, the sensitivity of microorganisms, side effects, the nature of previous treatment, doses and combinations of antibacterial drugs, combination with other methods of treatment are taken into account. When using cotrimoxazole, the duration of treatment is 1-2 months. In addition to antibacterial drugs, treatment includes the treatment of urethritis, agents aimed at improving microcirculation, immunomodulators, non-steroidal anti-inflammatory drugs, and physiotherapy. New approach - using a1- adrenoblockers; it is advisable to prescribe them for chronic prostatitis of the SHV category (prostatodynia), with a pronounced violation of urination and the absence of an active inflammatory process; the duration of treatment is from 1 to 6 months (doxazozin). Prostatilen, diclofenac, Wobenzym, Enerion, Gelarium, Citalopram, Pentoxifylline (phosphodiesterase inhibitor) reduce inflammation, Troxevasin, Detralex improve venous outflow. Candles "Vitaprost" of plant origin are also used. The drug contributes to the normalization of microcirculation, spermatogenesis, helps to restore the function of the prostate, increase the activity of the secretory epithelium of the acini, the disappearance of secretion stagnation, normalize the content of leukocytes in the secret, eliminate microorganisms from it, increase immunity, non-special physical resistance of the body, normalization of hemostasis; pain syndrome decreases improved sexual function (increased libido, restoration of erectile function). Physiotherapy: 1) physiotherapeutic effect daily or every other day (20 sessions); 2) impulse fluctuating stimulation; 3) sinusoidal modulated currents; 4) ultrasound therapy; 5) laser infrared transrectal irradiation; 6) finger massage. Finger massage of the prostate gland: before the massage, the patient does not completely empty the bladder, but does it after the massage to remove the pathological secret; massage is performed without tension, gradually increasing its intensity, which allows you to normalize the indicators of the secret of the prostate gland, relieve the patient of pain, improve the consistency of the gland. If pain intensifies after the massage, then this indicates the intensity of the infiltrative-cicatricial process in the prostate gland, in these cases, thermal procedures, anti-sclerotic and provocative therapy are first performed. Thermal procedures are carried out in the form of sitz baths and microclysters with chamomile, antipyrine (1 g per 50 ml of hot water). 14. Orchitis. Vesiculitis Orchitis - inflammation of the ovary. Etiology. More often it develops as a complication of an infectious disease: mumps, influenza, pneumonia, typhoid, tuberculosis, brucellosis, trauma. The infection spreads hematogenously or lymphogenously. Clinic. The disease has an acute or chronic course. In acute orchitis, there is swelling of the albuginea of the testicle, infiltration of the interstitial tissue. The testicle is tense, sharply painful on palpation, significantly enlarged in size, with a smooth surface. There are severe pains in the scrotum radiating along the spermatic cord and into the lumbosacral region, the skin of the scrotum is hyperemic, edematous, hot to the touch. Diagnostics. Diagnosis is based on clinical signs. Nonspecific orchitis must be differentiated from tuberculosis and testicular tumors, syphilitic and tuberculous orchitis. To make a diagnosis of brucellosis orchitis, anamnesis, serological reactions, and leukopenia are taken into account. In tuberculosis, the testis is usually affected secondarily. Treatment. With nonspecific acute orchitis, bed rest, a diet with the exclusion of spicy foods and alcoholic beverages, wearing a suspension, cold, novocaine blockade of the spermatic cord, and broad-spectrum antibiotics are prescribed. As acute phenomena subside, warming compresses, UHF therapy, and electrophoresis can be used. Vesiculitis (spermatocystitis) - inflammation of the seminal vesicles. Etiology. The infection enters the seminal vesicles from the back of the urethra through the ejaculatory ducts, prostate gland, rectal wall and hematogenously, the development of aseptic vesiculitis occurs with prolonged sexual abstinence. Clinic. Acute vesiculitis is manifested by pain in the perineum, rectum with irradiation to the penis, testicles, pain and painful urge during defecation. Urination is speeded up. Diagnostics. The diagnosis is based on the data of the anamnesis. Palpation of the prostate and seminal vesicles is painful, the secret of the prostate gland contains pus. Treatment. Treatment is conservative and surgical. Massive antibiotic therapy is prescribed with 2-3 broad-spectrum antibiotics in combination with nitrofurans, sulfonamides; thermal procedures (thermal baths 37-40 ° C), paraffin applications have a positive effect. Vesiculitis chronic - the outcome of acute inflammation of the seminal vesicles, develops with untimely and incomplete treatment of acute vesiculitis. Clinic. Pain in the lower back, groin, above the pubis, in the perineum, burning in the urethra, pain during orgasm, frequent erections. Diagnostics. The diagnosis is based on anamnestic data, the results of palpation of the seminal vesicles. In the secret of the prostate gland, an increased number of leukocytes, erythrocytes, oligo- or azoospermia is determined. Treatment. Long-term antibiotic therapy, massage of seminal vesicles, the use of thermal procedures; with pain - novocaine blockades, suppositories, thermal baths. 15. Cavernite. Cooperite. Epidemic Cavernite - inflammation of the cavernous bodies of the penis. Etiology. The infection can penetrate into the cavernous bodies from the outside, through the skin of the penis, from the urethra when it is inflamed, or by the hematogenous route from distant foci of inflammation, it is relatively rare. Clinic. It develops suddenly and quickly, accompanied by high body temperature, pain in the penis, painful, prolonged erections, in which the penis is curved, since the process most often develops on one side. Treatment. In case of acute cavity - massive antibacterial therapy, locally - first cold, then heat, with signs of suppuration - opening of an abscess, in chronic cavity, antibiotics and chemotherapy are used, absorbable treatment (aloe extract, vitreous body), physiotherapy. cooperite - inflammation of the Cooper (retrobulbar) gland, located near the bulbous part of the urethra. Etiology. Cooperitis is observed mainly in gonorrheal and trichomonas urethritis, less often caused by nonspecific bacterial flora. Clinic. Pain in the perineum, especially when sitting, discharge from the urethra after walking, enlargement of the gland. Diagnostics. The diagnosis is difficult due to the deep location of the gland in the thickness of the perineal tissues. For diagnostic purposes, palpation and bacterioscopy of the secretion of the gland is performed. Treatment. In the acute period of the disease - bed rest, rest, cold on the perineum, antibiotics. The abscess is opened. When acute phenomena subside, diathermy of the Cooper gland and its massage are prescribed. In chronic cooperitis - hot sitz baths, heat on the perineum. Epididymitis - inflammation of the epididymis is one of the most common diseases of the genital organs in men. Most often, men with epididymitis fall ill during the period of greatest sexual activity at the age of 20-50 years. Etiology. The etiology is infectious, most often the source of infection is nonspecific bacterial flora, gonorrhea, Trichomonas invasion, malaria, brucellosis, rarely tuberculosis, syphilis. Clinic. Acute epididymitis begins acutely with fever, severe pain, a sharp increase and induration of the epididymis, redness and swelling of the skin of the scrotum. In the blood, leukocytosis is noted with a shift of the leukocyte formula to the left, lymphopenia. Diagnostics. The diagnosis is based on the data of the anamnesis, complaints of patients, the results of examination and palpation, in chronic and recurrent epididymitis, biopsy of the epididymis, excretory urography, and examination of seminal fluid provide certain diagnostic information. Treatment. Prescribe broad-spectrum antibiotics; in case of acute dropsy of the testicular membranes, a puncture is indicated to evacuate the fluid. 16. Age-related changes in the male body A natural stage of the biological aging process is accompanied by menopause - a biochemical syndrome that occurs in adulthood and is characterized by androgen deficiency in the blood serum, accompanied by a decrease in the body's sensitivity to androgens. With age, the concentration of free testosterone (TC) in the blood plasma decreases due to the deterioration of the blood supply to the testicular tissue, as well as an increase in the level of TC - binding globulin; the concentration of biologically active TC (freely circulating fraction) decreases to a greater extent than the level of total TC. These changes are most often accompanied by an increase in estrogen levels. Clinical manifestations of hypogonadism: 1) violation of copulatory function - decreased libido, erectile dysfunction, ejaculation disorders and orgasm disorders; 2) reduced fertility of the ejaculate; 3) somatic disorders - a decrease in muscle mass and strength, osteopenia and osteoporosis, visceral obesity, gynecomastia, thinning and atrophy of the skin, anemia of varying severity; 4) vegetovascular disorders: sudden flushing of the face, neck, increased blood pressure, heart pain, dizziness, sweating; 5) psycho-emotional disorders: increased irritability, fatigue, memory and attention impairment, sleep disturbance, depression, deterioration in general well-being, decreased performance and self-esteem. Diagnostics. The level of total testosterone in the blood below 7 nmol / l is an indicator of hypogonadism; when the testosterone (TS) content is below 12 nmol/l, it is necessary to determine the concentration of luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH) and prolactin (PRL). Androgen replacement therapy (AZT) is carried out with natural TS preparations, of which Omnadren 250 has a prolonged action. The drug stimulates protein synthesis, enhances calcium fixation in the bones, increases muscle mass, affects the development and function of the external genital organs, prostate gland, seminal vesicles, secondary sexual characteristics, determines the constitution of the body and sexual behavior, activates libido and potency, stimulates spermatogenesis. Among the drugs that help maintain the synthesis and biological effects of endogenous testosterone at a normal level, antioxidants are distinguished, in particular vitamins A, E, and some trace elements (selenium). The source of natural vitamin E is Viardot's preparation. The drug is administered orally at a dose of 1,8 g / day. (2 capsules 3 times a day). It provides a 2-3 times increase in testosterone levels, increased sexual desire and libido, improves the clinical condition in patients with prostate adenoma. 17. Erectile dysfunction. Infertility in men Erectile dysfunction (ED) - inability to achieve or maintain an erection of the penis for sexual intercourse. Classification. There are 3 types of this form of ED: peripheral, spinal and supraspinal. The peripheral type is the result of damage to the sensory nerves. The spinal type of neurogenic ED develops as a result of spinal cord injury, pathology of the intervertebral discs, myelodysplasia, arachnoiditis, spinal cord tumors, and multiple sclerosis. Supraspinal neurogenic ED is the result of stroke, encephalitis, Parkinson's disease, epilepsy. Treatment. Drug therapy for ED includes drugs of central action (apomorphine), central and peripheral action (phentolamine, yohimbine) and peripheral action (sildenafil, tadalafil, vardenafil), which have the greatest effect. Drugs are rapidly absorbed from the gastrointestinal tract; fatty foods reduce the absorption of sildenafil (Viagra), vardenafil (Levitra), does not affect the absorption of tadalafil (Cialis). Vardenafil is superior to other drugs in terms of the speed of reaching the maximum concentration in the blood (on average after 30-40 minutes), which makes it possible to quickly prepare for sexual intercourse. Infertility in men - no conception for 2 years with regular sexual intercourse with a healthy woman of childbearing age without the use of contraceptive measures. Etiology. The etiological factors of infertility are: 1) secretory violation of the fertility of the ejaculate due to congenital or acquired pathology of the testicles .; 2) excretory (congenital or acquired diseases of the gonads and vas deferens lead to impaired fertility) .; 3) combined (simultaneous impact of several factors); 4) relative and discorrelative infertility that occurs with endocrinopathies or as a result of the use of corticosteroids. Clinic. Lack of conception, less often - spontaneous abortions in the wife or the birth of children with deformities. Objectively, with secretory infertility, hypogonadism of varying severity is noted. Diagnostics. The diagnosis of infertility is established on the basis of the results of the examination of the ejaculate. In the absence of pathospermia, special immunological studies and functional tests for the biological activity of spermatozoa are indicated. Treatment. Assign conservative treatment (special diet, anti-inflammatory drugs, physiotherapy methods). 18. Female Sexual Dysfunction (FSD) The female sexual response includes libido, arousal, orgasm, satisfaction. Reduced sexual desire occurs in 30% of sexually active women. Disorder of sexual arousal - the inability to achieve or maintain sexual arousal, which may be accompanied by insufficient hydration (blood filling) of the genital organs and (or) the absence of other somatic manifestations. Orgasm disorder - the inability to achieve sexual satisfaction in the presence of adequate sexual stimulation and arousal, may be primary or secondary. Pain during sexual activity. Dyspareunia is persistent or intermittent pain in the genitals during intercourse. The result of vestibulitis, vaginal atrophy, may have a psychological or physiological basis. Vaginismus is a constant or recurrent involuntary spasm of the anterior third of the vagina in response to an attempt at penetration. Allocate generalized vaginismus, which occurs in any situation, and situational. Pain syndrome outside of intercourse is a constant or recurring pain in the genital organs during non-coital sexual stimulation, the causes of which are genital trauma, endometriosis, inflammation in the genital organs. Etiology. Circulatory disorders. Syndromes of clitoral and vaginal vascular insufficiency are associated with a decrease in genital blood flow due to atherosclerosis of the ilio-hypogastric vascular bed, resulting inth vaginal dryness and dyspareunia occur. Neurological disorders: spinal cord injuries, lesions of the central and peripheral nervous system (diabetes mellitus). Endocrine disorders: disorders of the hypothalamic-pituitary system, surgical or medical castration, menopause, premature ovarian dysfunction, hormonal contraception. Diagnostics. To assess female sexual dysfunction, a study of the pelvic organs, a psychological and psychosocial study, laboratory and hormonal studies, and monitoring of sexual arousal are carried out. It is necessary to identify conditions associated with damage to the hypothalamic-pituitary system, and hormone deficiency conditions caused by menopause, chemotherapy or surgical castration, to identify drugs that can negatively affect sexual function, disorders of the emotional sphere, interpersonal relationships. Treatment. In violations associated with the period of premenopause, estrogen replacement therapy is indicated, in violation of lubrication. The drug sal-butiamine, similar in structure to thiamine, is prescribed for functional or psychogenic dysfunction. 19. Foreign bodies of the bladder, urethra, kidneys Foreign bodies of the bladder occur relatively often, more often in women. Foreign bodies are very diverse: thermometers, gauze swabs, rubber tips, elastic catheters. Etiology. Causes of foreign bodies entering the bladder: introduction of a foreign body by the patient himself for the purpose of masturbation, accidental entry of a foreign body into the bladder as a result of technical errors during instrumental manipulations, entry of a foreign body into the bladder during a gunshot wound. Clinic. Small foreign bodies may be shed during urination. Long, irregularly shaped (thermometers, pencils, pieces of glass) cause pronounced dysuria, hematuria. In the future, an infection of the bladder joins. Treatment. The foreign body of the bladder is subject to removal by endovesical or surgical means. Foreign bodies of the urethra found almost exclusively in men. Etiology. Foreign bodies often enter the urethra through its external opening, less often from the bladder. Less commonly, foreign bodies can be left after manipulations carried out for therapeutic purposes. Clinic. Foreign bodies at the time of their entry into the urethra cause pain; there is no pain symptom with a small size and a smooth surface foreign body. Prolonged stay in the urethra leads to urethritis. Later, as a result of the addition of the inflammatory process, abundant bloody-purulent discharge from the urethra appears. Diagnostics. Recognition of a foreign body of the urethra is not difficult. It is easily determined in the hanging part of the urethra or on the perineum with external probing, and in the membranous part - when examined through the rectum. Plain radiography and urethrography can be of great help in recognition. Treatment. Removal of a foreign body from the urethra. Small, round, soft foreign bodies are often spontaneously excreted from the urethra in the urine stream. Foreign bodies of the kidney get into the renal parenchyma or pyelocaliceal system with penetrating blind wounds (bullets, shot, metal fragments). Clinic. A foreign body that has entered the kidney is initially manifested by hematuria, later the foreign body either encapsulates and there are no clinical symptoms, or an inflammatory process develops around it, and pyuria appears. Treatment. In the presence of purulent inflammation, hematuria, signs of impaired renal function and passage of urine, surgical treatment is indicated - removal of a foreign body. Nephrectomy is performed if, as a result of trauma and subsequent complications, the death of the renal parenchyma has occurred and according to indications. 20. Bladder injury Bladder injury subdivided into closed (extraperitoneal and intraperitoneal) and open. Etiology. Extraperitoneal rupture of the bladder most often occurs when the pelvic bones are fractured, the degree of damage can be different: bruise, partial or complete damage to the bladder wall, complete detachment of the bladder from the urethra. Intraperitoneal rupture of the bladder occurs with an overfilled bladder as a result of a bruise or blow and with a fracture of the pelvic bones. Open injuries of the bladder - gunshot, stab, cut wounds. Clinic. Urinary dysfunction, pain and bleeding. With extraperitoneal rupture, frequent painful urge to urinate, the release of drops of blood from the urethra. Pain is determined by palpation above the womb, muscle tension in the lower parts of the anterior abdominal wall. Dullness of percussion sound above the pubis is characteristic. Diagnostics. The diagnosis is based on the data of the anamnesis, the symptoms listed above, to confirm the diagnosis, the data of catheterization, cystoscopy, cystography, excretory urography are used. The leading role in the diagnosis is played by cystography: streaks of the radiopaque substance outside the bladder are detected. Treatment. Anti-shock measures, then, with an extraperitoneal incomplete rupture of the bladder, conservative therapy is possible (ice on the stomach, hemostatic agents, a permanent catheter). In all other cases, surgical treatment is mandatory. Urethral injury are found mainly in men. Damage can be closed and open, isolated and combined, penetrating and non-penetrating. With closed injuries, the integrity of the outer integument is not violated. Etiology. The impact of an external force on the urethra or damage to it in pelvic fractures. Clinic. The most common signs of damage to the urethra are urinary retention, pain, urohematoma in the perineum. The blood loss can be significant. Treatment With a complete rupture of the urethra in fresh cases, a primary suture with epicystostomy can be applied, with late hospitalization - epicystostomy and drainage of a urohematoma. Injury to the ureters Etiology. Wounds (gunshot or stab wounds) of the ureter and closed (subcutaneous) injuries. Clinic. Hematuria, urinary retroperitoneal edema, urine discharge from the wound a few days after the injury. Diagnostics based on the clinical symptoms described above. Excretory urography reveals leakage of the radiopaque substance from the ureter into the retroperitoneal space. Treatment. Treatment is surgical, only with small partial ruptures of the ureter can be limited to leaving a permanent ureteral catheter. 21. Damage to the scrotum, penis, testis and its epididymis Scrotal injury may be open or closed. In severe cases, gangrene of the scrotum may develop. Etiology. Etiology of closed damage to the scrotum: contusion or compression. Open injuries of the scrotum can be isolated or combined with damage to other organs and tissues. Clinic. A closed injury leads to the formation of a hematoma, which can reach a large size, spread to the penis, perineum, thighs, and anterior abdominal wall. Treatment. With closed injuries of the scrotum, bed rest, wearing a suspension, local cold, antibiotic therapy are prescribed. It is necessary to open and drain the hematoma. penis injury divided into closed and open. Closed (subcutaneous) injuries: bruises, ruptures, dislocation and infringement of the penis. Open injuries - incised wounds, less often - gunshot wounds. Etiology. Bruising of the penis is the result of a traumatic force acting on a non-erect organ. Clinic. With a bruise of the penis, a sharp swelling and hematoma of the skin and subcutaneous tissue is visible without violating the integrity of the cavernous bodies. When the penis is fractured, a characteristic crunch occurs, a sharp pain, an erection stops immediately, edema quickly develops, an extensive hematoma, the penis increases in size, becomes purple-cyanotic. Treatment. With a bruise of the penis - mostly conservative (cold, rest, elevated position of the penis and scrotum), with rupture of the cavernous bodies - mainly operational (exposure and suturing of a defect in the albuginea and cavernous tissue). Damage to the testicle and its epididymis may be closed or open. Etiology. Closed injuries are caused by a blow, fall, riding or cycling. Open injuries of the testicle and its epididymis are among the most severe. Damage is cut, chipped, torn. In the most severe cases, detachment of the testicle from the spermatic cord is possible. Clinic. Sharp pain, a significant increase in the size of the scrotum, cyanosis of its skin, swelling of the testicle or epididymis, their soreness, tension. With open damage, the testicle often falls into the wound of the scrotum. Diagnostics. A massive hematoma of the scrotum makes it difficult to determine the integrity of the testicle and epididymis. The large size of the hematoma and sharp pain suggest damage not only to the scrotum, but also to the organs contained in it. Treatment. In mild cases (closed superficial injuries of the testicle and appendage - bruises, ruptures of the albuginea) without a large hematoma of the scrotum, conservative therapy is performed. Surgical intervention is resorted to with threatening bleeding and an increase in hematoma of the scrotum. Massive crushing of the testis and its epididymis require hemicasterization. 22. Kidney damage Kidney damagecan be closed (subcutaneous) and open; the right kidney is damaged more often than the left one due to its lower location. Etiology. A closed kidney injury occurs as a result of a rough blunt blow or a sharp compression, but an indirect effect is also possible (falling from a height, shaking the body). Open injuries are the result of a gunshot wound or received with a piercing and cutting tool. Kidney ruptures include: 1) damage to the fatty and fibrous capsule with the formation of a hematoma in the perirenal tissue; 2) subcapsular rupture of the kidney parenchyma without violating the integrity of the calyces and pelvis with the formation of a subcutaneous hematoma; 3) damage to the parenchyma with a violation of the integrity of the cups and pelvis with the formation of urohematoma and urinary infiltration with total hematuria; 4) crushing of the kidney, accompanied in some cases by damage to the peritoneum; 5) complete separation of the kidney from the gate and isolated damage to the renal vessels while maintaining the integrity of the kidney itself with the development of extensive hematomas. Clinic. The main signs of kidney damage are pain, swelling in the kidney area (perirenal hematoma), hematuria, with open injuries, additional urine output from the wound. In mild forms, the condition of patients is satisfactory, in severe forms, shock, anemia, and peritonitis develop. With superficial damage, there is local pain, a small perirenal hematoma, unexpressed hematuria, the general condition of the patient is satisfactory, the prognosis is favorable. With subcapsular injuries - local pain, significant hematuria, no hematoma in the perirenal space, shallow shock, general satisfactory condition. Diagnostics. When examining the lower back, a hematoma is determined, palpation is a dense formation located in the lumbar region, tension in the muscles of the abdominal wall and lower back. The degree of intensity of bleeding from the kidney can be judged not only by the nature of urine staining, but also by the formation of clots and their shape. Excretory urography is indicated for all types of trauma. If there is no kidney function, then retrograde pyelography is performed. Both methods detect streaks of radiopaque material outside the pelvicalyceal system. Treatment. In case of minor injuries (bruise, rupture of the capsule), conservative treatment is carried out: strict bed rest for 2 weeks, antibacterial, hemostatic therapy. Signs of rupture of the kidney parenchyma require surgical intervention. 23. Urogenital fistulas in women. Torsion of the spermatic cord. paraphimosis Urogenital fistulas in women - pathological communication between the urinary and genital organs. Etiology. Genitourinary fistulas occur mainly due to damage to the urinary organs during childbirth, obstetric and gynecological operations, rarely due to domestic trauma and gunshot wounds, purulent fusion, tumor germination, radiation therapy. The most common are vesicovaginal fistulas. Clinic. With all types of fistulas, urinary incontinence develops, complete or partial. Treatment. The main method of treatment is surgical, which restores voluntary urination in a natural way. As a rule, plastic surgery is performed 4-6 months after the onset of the fistula, uretero-vaginal fistulas are operated on no later than 1,5-2 months after their formation. Torsion of the spermatic cord it is observed in children, young men and in 60-70-year-old men, it is more often unilateral, more often there is a volvulus of an abnormally located testicle. Etiology. They predispose to the absence of normal fixation of the testicle (lack of Gunter's ligament with cryptorchidism or late descent of the testicle into the scrotum), congenital non-fusion of the epididymis with the testicle when they are located separately; malignancy of the testicle detained in the abdominal cavity; Inguinal-scrotal hernia due to the sudden release of the viscera into the hernial sac. The most common causes are trauma, severe physical stress, and a sharp blood filling of the genital organs. Clinic. The disease begins with pain in the lower abdomen, in the groin; gradually pains are localized in the testicle. Treatment operational. paraphimosis - infringement of the glans penis by the narrowed skin ring of the foreskin pulled back. Etiology. Long foreskin with a narrow preputial opening (phimosis) or balanoposthitis (inflammatory process of the glans penis and foreskin). Clinic. As a result of the ring-shaped infringement of the head of the penis by the foreskin, the blood supply is upset, the head and the inner leaf of the foreskin swell, which become painful when touched, its mucous membrane ulcerates, with untimely treatment, inflammation of the strangulated head of the penis and necrosis of the self-infringing ring of the foreskin develop, even gangrene of the glans penis . Treatment. In all cases of uncomplicated phimosis, an attempt is made to reposition the head as follows: the head of the penis is lubricated with vaseline oil, the penis I, II are tightly covered with the fingers of the left hand, and the head of the penis is pushed into the pinching ring with fingers I, II, III of the right hand. 24. Kidney tuberculosis Tuberculosis of the kidney - secondary organ tuberculosis, which usually develops many years after the primary clinical manifestations of tuberculosis. Etiology. Tuberculous mycobacteria penetrate the kidneys mainly by the hematogenous route, less often by the lymphogenous route. Clinic. Symptoms of the disease are closely related to the stage and form of the disease. In subclinical forms of tuberculosis of the kidney, patients complain only of general malaise, subfebrile body temperature and dull pain in the lumbar region, sweating, especially in the morning, loss of appetite, weight loss, decreased performance. In the presence of pyonephrosis, a septic course is observed with high fever and tremendous chills. Information is provided by a positive result of a bacteriological examination of urine, as well as the appearance of leukocyturia with an acidic urine reaction. Diagnostics. The main means of early diagnosis of tuberculous lesions of the kidneys should be considered a bacteriological examination of sterile urine obtained from a patient with tuberculosis. 5-10 days before urine culture, it is necessary to stop treatment with anti-tuberculosis drugs, it is desirable to make three cultures of morning urine. They also carry out a provocative tuberculin test, a tuberculin immunochemical test. Tuberculosis is characterized by an acid reaction of urine, slight proteinuria (0,033-0,99 g/l), leukocyturia, and slight erythrocyturia. Plain radiograph establishes the presence of petrificates in the parenchyma. Nephrotuberculosis according to the clinical and radiological classification is divided into the following stages: 1) non-destructive (infiltrative); 2) initial destruction (papillitis, small cavity); 3) limited destruction (large cavities in one of the three renal segments); 4) subtotal or total destruction (polycavernous process in two renal segments, pyonephrosis, total nephrolithia of the kidney). Treatment. The options are: 1) exclusively drug therapy is carried out with non-destructive forms, tuberculous papillitis, a small single cavity; 2) patients with tuberculosis of one or both kidneys are subject to long-term drug therapy as a preparation for organ-preserving surgery, the nature of which is specified after a certain period of conservative treatment; 3) mandatory organ-preserving surgical interventions; 4) nephrectomy, nephroureterectomy; 5) plastic corrective operations. According to WHO recommendations (2000), drug therapy includes a combination of isoniazid + rifampicin + pyrazinamide (or ethambutol) for 4-6 months. Treatment is combined with complex vitamin therapy. 25. Tuberculosis of the penis, prostate, seminal vesicles, testis and its appendages Tuberculosis of the penis is a rare disease. Etiology. Hematogenous route of spread of tuberculosis infection. Clinic. The appearance of tubercles on the glans penis, which merge into large vesicles, turn into ulcers, bleed easily, inguinal-femoral lymph nodes are enlarged. Diagnostics. The following signs of tuberculosis allow suspecting tuberculosis: ulceration on the open surface of the head of the penis, multiple ulcerations, duration of the course, spontaneous remissions, healing of some ulcers and the formation of others. Treatment. Specific anti-tuberculosis chemotherapy in most cases leads to recovery. Tuberculosis of the prostate and seminal vesicles most often accompanies tuberculosis of the kidney, testis and its epididymis. Clinic. Initial focal changes in the prostate gland are asymptomatic. With extensive infiltrates and cavities in the gland, patients complain of pain in the perineum and rectum. Diagnostics. The diagnosis is based on data from a digital examination of the prostate gland (small-nodular tuberosity of its surface, large dense nodes, softening areas) and urethrography, which reveals cavities in the gland. Differential diagnosis. Tuberculosis of the prostate and seminal vesicles should be differentiated from a tumor with a denser consistency; with prostate adenoma, when the gland is symmetrical, its consistency is densely elastic, urination disorders are more pronounced. Treatment. Treatment is mainly conservative: combined chemotherapy. Tuberculosis of the testis and its epididymis Etiology. Most often, the infection spreads by the lymphohematogenous route from the prostate gland. Clinic. Tuberculosis of the epididymis often has a chronic course. A small seal appears in the epididymis, which gradually increases without sharp subjective sensations. Diagnostics. Consolidation, enlargement and tuberosity of the epididymis, dense, well-shaped vas deferens, fistula on the skin of the scrotum, coming from the epididymis, characteristic palpation changes in the prostate gland indicate a tuberculous lesion. Differential diagnosis. Differential diagnosis is carried out with specific epididymitis, tumor, syphilis of the testis or its epididymis. Treatment. Intensive anti-tuberculosis therapy followed by epididymectomy. When the testicle is involved in the process, an additional resection of the testicle or hemicasterization is performed in case of total damage to the testicle. 26. Tuberculosis of the bladder, urethra, ureter Bladder tuberculosis begins in the mouth of the ureter with the formation of deep ulcers. Etiology. As a result of the lymphogenous introduction of tuberculosis infection into the bladder, areas of focal hyperemia, rashes of tuberculous tubercles, ulcerations, scars at the site of their formation appear on its mucous membrane. Clinic. The main symptom is dysuria of varying intensity. Urination is frequent, painful, accompanied by terminal hematuria. The capacity of the bladder gradually decreases, its walls thicken and are replaced by scar tissue. Diagnostics. Cystoscopy: tuberculous tubercles, ulcers and cicatricial changes in the mucous membrane, located mainly in the region of the mouth of the ureter of the more affected kidney, and cystography: deformed contours of the wrinkled bladder, beveling of one of its side walls, decrease in volume, often with signs of vesicoureteral reflux . Treatment. Specific chemotherapy is carried out simultaneously with the treatment of tuberculosis of the kidney and ureter. With a cicatricial-wrinkled bladder, they resort to its intestinal plastics. Tuberculosis of the urethra - a rare but serious complication of tuberculosis of the kidney, bladder and prostate. It is characterized by the formation of multiple strictures in different parts of the urethra. Clinic. Difficulty urinating, formation of urethral urinary fistulas. Diagnostics. Bacteriological examination of urine and discharge from the fistulas of the urethra, urethrography, which reveals a characteristic pattern of clearly defined narrowing of the urethra. Treatment. Systematic bougienage of the canal under the protection of specific chemotherapy, in advanced cases - the imposition of a suprapubic fistula, followed by plastic surgery. Tuberculosis of the ureter always a consequence of kidney tuberculosis. With the transition of the tuberculous process to the ureter, specific ulcers appear on its mucous membrane, with a tendency to rapid scarring, leading to a persistent narrowing of the lumen of the ureter in the pelvic region and in the area of its anastomosis with the pelvis. Clinic. Dull pain in the lumbar region, sometimes attacks of renal colic due to obstruction of the lumen of the ureter in places of specific damage by a blood clot or detritus. Diagnostics. The diagnosis is based on the data of excretory urography: clearness, a symptom of a string, when the ureter loses its inherent bends and pulls up the wall of the bladder; due to cicatricial changes, hydroureteronephrosis develops. Treatment Anti-tuberculosis therapy is combined with glucocorticoids, ureteral bougienage. Irreversible cicatricial strictures of the ureter require surgical treatment. 27. Urolithiasis, etiology, clinic, diagnosis, complications Urolithiasis (nephrolithiasis) - the most common urological pathology, common in all geographical areas ... Etiology. Kidney stones are formed as a result of the crystallization of supersaturated urine as a result of the precipitation of salts on a protein basis. Among the endogenous factors in the development of urolithiasis, a large role is played by hyperparathyroidism, trauma of tubular bones (increased serum calcium), impaired liver function, and digestive organs. Contribute to the formation of kidney stones developmental anomalies and congenital malformations of the kidneys and urinary tract, inflammatory strictures, urodynamic disorders, pyelonephritis, spinal cord injury, paraplegia. Lack of dietary vitamins A, B, D is accompanied by excessive excretion of calcium oxalate in the urine, which can contribute to the formation of stones. According to the chemical composition, stones are inorganic (urates, phosphates, oxalates, carbonates, xanthine, cysteine, indigo, sulfur) and organic (bacterial, fibrin, amyloid). Clinic. Symptoms of urolithiasis depend on the size and location of the stone, concomitant congenital malformations and anomalies, and complications. The main symptoms of urolithiasis: pain in the lumbar region with irradiation along the ureter, hematuria, excretion of salts and stones, fever, chills, nausea, vomiting, flatulence, dysuric disorders. Pain in the lumbar region is a common symptom, the pain is dull and sharp. Dull pain is characteristic of sedentary stones, it is constant, aggravated by movement, excessive fluid intake. Acute pain in the lumbar region radiates along the ureter, accompanied by dysuric disorders, restlessness, sometimes fever and chills. The duration of renal colic is different, after the passage of stones, salts, the pain stops. Hematuria appears as a result of damage to the mucous membrane of the urinary tract, pyelonephritis or venous stasis in the kidney, increases by the end of the day with movements. Diagnostics based on the study of complaints and data from a comprehensive urological study. The leading importance is attached to the survey radiograph of the urinary organs, excretory urography, tomography, urine examination. Complications urolithiasis: pyelonephritis, hydronephrosis, pyonephrosis, apostematous pyelonephritis, carbuncle, kidney abscess, anuria, oliguria, renal failure. The possibility of developing complications requires a detailed study of the function of each kidney. In 10% of cases, kidney stones are X-ray negative, so retrograde pyelography is performed. 28. Urolithiasis, differential diagnosis, treatment Differential diagnosis. Differential diagnosis in renal colic should be carried out with acute appendicitis, acute cholecystitis, pancreatitis, perforated gastric ulcer, intestinal obstruction, ectopic pregnancy, adnexitis, sciatica, tumor, kidney tuberculosis, hydronephrosis, abnormal development of the kidneys. Treatment. Treatment of urolithiasis is symptomatic: medication, instrumental, surgical, combined. Conservative treatment includes antispasmodics, analgesics, anti-inflammatory drugs, prevention of relapses and complications of nephrolithiasis (diet therapy, urine acidity control, vitamin therapy, spa treatment), creating the possibility of dissolving stones, especially urates. With uric acid stones, it is necessary to limit meat food, with phosphates - milk, vegetables, fruits, with oxalates - lettuce, sorrel, other vegetables and milk. In the treatment of urolithiasis, food should be complete, varied and fortified with a limited amount for uric acid stones of the liver, kidneys, brains, meat broths; with phosphates - milk, vegetables, fruits, with oxalates - sorrel, spinach, milk. An attack of renal colic is stopped with hot baths (38-40 ° C), heating pads, antispasmodic drugs in combination with analgesics, novocaine blockade of the spermatic cord or round uterine ligament in women, in some cases - ureteral catheterization. With small stones and sand in the urinary tract, a tincture of the fruits of ammi tooth (1 tablespoon 3 times a day), kellin (0,04 g 3 times a day), avisan (0,05 g 3 times a day) are recommended. day). To dissolve oxalate stones, a powder of pyridoxine, magnesia, calcium phosphate is recommended, used 3 times a day with plenty of liquid. Oxalaturia decreases with the use of Almagel. To dissolve mixed stones, a citrate mixture is recommended 1-3 times a day. Chemotherapeutic and antibacterial drugs alternate with diuretic, antiseptic and antispasmodic agents of plant origin: infusion of corn stigmas, parsley, horsetail, wild rose, eucalyptus leaves, tripoli, etc. Boric acid, benzoic acid with ammonium chloride are used to acidify urine. Stones of the kidneys, ureters, bladder and urethra are subject to surgical treatment if they lead to a significant decrease in kidney function, are accompanied by bouts of pain, hematuria, exacerbations of pyelonephritis, hydronephrosis, anuria and oliguria. Restorative operations include pyelolithotomy, pyelonephrolithotomy, nephrolithotomy with drainage of the kidney, resection of the ureteropelvic segment, ureterolithotomy, and cystolithotomy. 29. Coral stones of the kidneys, stones of the ureters, stones of the bladder, stones of the urethra Coral kidney stones - a special form of nephrolithiasis, in which the stone is a cast of the pyelocaliceal system, most often occurs in women aged 20-50 years. Etiology. The causes are similar to those in the formation of ordinary kidney stones, but differ in a greater frequency of phosphaturia and oxaluria. Clinic. A discrepancy between clinical manifestations and anatomical and functional changes in the kidney is characteristic. With coral-like stones, pain is insignificant or absent, which leads to a latent course of the disease, the development of deep, sometimes irreversible changes. Treatment surgical and conservative, the latter is of leading importance, pyelolithomy is more often performed, in exceptional cases it becomes necessary to remove the kidney. ureteral stones are descended kidney stones, there are single, multiple, one- and two-sided, oblong, calculi with a smooth or rough surface about 10 mm in size. Clinic Ureteral stones are more often manifested by renal colic, the duration of which depends on the size and shape of the stones, the level of the stone. After the stone has passed, the pain disappears. As the stone moves along the ureter, dysuric phenomena increase. Diagnostics. The diagnosis is based on the study of the patient's complaints, X-ray data. Stones of the bladder are primary, but more often descend from the kidney. In the bladder, stones grow, significantly increasing in size. Bladder stones are multiple or solitary, most often mixed in composition. Clinic. Pain and dysuric disorders; the pain is acute, especially at the time of infringement of the stone in the neck of the bladder. After the elimination of the infringement of the stone, terminal hematuria is noted. Dull pain in the region of the bladder on motion, especially in the evening. Complications. Bladder stones are always complicated by cystitis, which is difficult to treat if there is a violation of bladder emptying. urinary tract stones enter the urethra during urination. Clinic. Difficulty intermittent urination, urinary incontinence, pain in the perineum, pelvis, hematuria, pyuria. Etiology and pathogenesis. In the occurrence and development of kidney tumors, trauma, chronic inflammatory diseases, the effect of chemicals on the kidney tissue, radiation exposure, and hormonal influences are important. Benign neoplasms are rare, accounting for only 6% of tumors of the renal parenchyma, and have no independent clinical significance. 30. Kidney adenocarcinoma Classification. Tumors of the renal parenchyma are divided into the following types. 1. Benign tumors: adenoma, lipoma, fibroma, leiomyoma, hemangioma, dermoids, etc. 2. Malignant tumors: adenocarcinoma, sarcoma, mixed tumor. 3. Secondary (metastatic) kidney tumor. According to the TNM system, the tumor is divided into the following stages: 1) T1 - tumor within the renal capsule; 2) T2 - the tumor grows into the fibrous capsule of the kidney; 3) T3 - involvement of the vascular pedicle of the kidney or perirenal fatty capsule; 4) T4 - germination of the tumor in neighboring organs; 5) Nx - it is impossible to assess the state of regional lymph nodes before surgery; 6) N1 - metastases in regional lymph nodes are determined by X-ray or radioisotope methods; 7) M0 - distant metastases are not determined; 8) M1 - single distant metastasis; 9) M2 - multiple distant metastases. Metastasis of kidney cancer can manifest itself with clinical signs before the detection of the primary tumor focus, metastases can also appear late - several years after the removal of the kidney affected by cancer. Metastases to the lungs can regress after removal of the primary focus. The main sources of metastatic kidney tumors are tumors of the adrenal gland, lungs, and thyroid gland. Clinic. There are three periods in the development of adenocarcinoma: 1) latent, hidden; 2) the period of appearance of local symptoms - hematuria, pain, enlargement of the kidney; 3) a period of rapid tumor growth, the addition of symptoms of metastases, an increase in anemia and cachexia. Blood in the urine appears suddenly (excretion of worm-like blood clots 6-7 cm long), is observed with one or two urination and suddenly stops. Less often, it lasts for several days, and repeated hematuria may appear after a few days or weeks. Intense bleeding from the kidney can cause tamponade (blockade) of the bladder and acute urinary retention. Diagnostics. Of the diagnostic measures, cystoscopy is performed at the height of hematuria. To determine from which ureter blood is secreted, the leading methods in the diagnosis of a kidney tumor are computed tomography, excretory urography. Treatment - surgical, nephrectomy is performed with the removal of perirenal and retroperitoneal tissues with regional lymph nodes. Combined treatment (surgical and radiation) increases the survival rate of patients. 31. Adenosarcoma of the kidney. Tumor of the pelvis and ureter Adenosarcoma of the kidney (Wilms tumor) occurs at the age of 2-5 years, grows rapidly, reaches large sizes. Histologically, Wilms' tumor in 95% of cases is an adenosarcoma, in which undifferentiated cells of an embryonic nature are determined. Clinic. In the early stage, Wilms' tumor is manifested by common symptoms: weakness, malaise, pale skin, subfebrile temperature, lack of appetite, stunted growth, irritability. Diagnosticsin the early period is difficult due to the absence of characteristic symptoms. Recognition of a tumor in children is based on its probing in the subcostal-lumbar region. Treatment Wilms' tumor is complex: irradiation in the pre- and postoperative periods, nephrectomy, chemotherapy. Tumor of the pelvis - are relatively rare, at the age of 40-60 years, more often in men. Allocate benign (papilloma, angioma) and malignant (papillary cancer, squamous cell carcinoma, muco-glandular cancer, sarcoma) tumors. Tumor metastases spread through the lymphatic vessels of the submucosal layer to the ureter and bladder. Clinic. The leading symptom of a tumor of the pelvis is recurrent total hematuria. Pain in the lumbar region (dull or acute) is observed at the height of hematuria. The kidney does not increase in size and is not palpable. Diagnostics. The diagnosis is based on data from a cytological examination of urine, cystoscopy (the side of the lesion, the size and localization of the underlying tumor and metastases are specified). On the excretory urogram, defects in the filling of the shadow of the pelvis, pyelectasis are clearly visible. When making a diagnosis, computed urography is informative. Treatment - surgical: nephroureterectomy with partial resection of the bladder wall. In the pre- and postoperative periods, external beam radiation therapy is prescribed. After the operation, patients are subject to dispensary observation. Cystoscopy is done 2-3 times a year for the purpose of early detection of recurrence. Tumors of the ureter occur in 1% of all tumors of the kidneys and upper urinary tract. Clinic. Hematuria and pain. During the period of hematuria, the pain becomes paroxysmal. Diagnosticsureteral tumors is based on history data, results of cytological examination of urine sediment, cystoscopy, excretory urography and retrograde pyeloureterography. In the urine sediment, atypical cells are determined, with cystoscopy, a tumor is visible at the mouth of the ureter or a bulging of the bladder mucosa in the mouth area. With excretory urography, a decrease in the secretory and excretory function of the kidneys and ureterohydronephrosis are noted. Treatmentsurgical. Along with nephruretectomy and partial resection of the ureter, ureterocystoneostomy and intestinal ureteroplasty are used. 32. Tumors of the bladder and urethra Tumors of the bladder observed most often in men. Etiology unknown. Bladder cancer can develop as a result of metabolic disorders in the body, the formation of carcinogenic compounds, exposure to viruses. Classification. Epithelial tumors of the bladder are divided into benign (adenoma, endometrioma, papilloma) and malignant (papillary, solid and glandular cancers, chorionepithelioma, hypernephroma). A cancerous tumor can be localized in any part of the bladder, but most often in the region of the urinary triangle, ureter orifices, bladder neck and diverticula, it grows into neighboring organs, causes ureterohydronephrosis, vesico-rectal and vesico-vaginal fistulas and abdominal cavity carcinomatosis . International classification of bladder cancer according to the TNM system: 1) T1 - the tumor infiltrates the subepithelial connective tissue without spreading to the muscle tissue; a soft, freely displaceable tumor is palpated bimanually; 2) T2 - the tumor infiltrates the superficial muscle layer; a movable seal of the bladder wall is palpated bimanually; 3) T3 - the tumor infiltrates the deep muscle layer; a mobile, dense or tuberous tumor is palpated bimanually; 4) T4 - the tumor grows into the pelvic tissue or neighboring organs; on bimanual examination, it is fixed to the pelvic wall or passes to the prostate gland, vagina or abdominal wall; 5) Nx - the state of the lymph nodes before the operation cannot be assessed; 6) N1 - metastases in regional lymph nodes are determined by X-ray or radioisotope methods; 7) M0 - distant metastases were not found; 8) M1 - there are metastases to distant organs. Clinic. Hematuria is the most common. Total hematuria lasts several hours or 1-2 days and also suddenly stops. After an indefinite time, hematuria recurs. Treatment The leading role belongs to surgical methods: 1) endovesical, transurethral, electrocoagulation; 2) radical resection of the bladder; 3) extirpation of the bladder. Diversion of urine is carried out in the intestine, on the skin. Tumors of the urethra are divided into benign (papillomas, polyps, condylomas, fibromas, myomas, neurofibromas, angiomas) and malignant (squamous keratinizing and non-keratinizing cancers, adenocarcinomas). The stages of urethral cancer are determined according to the international TNM classification. 33. Tumors of the urethra in women and men Benign tumors of the urethra in women. Clinic. Benign tumors of the urethra in women in some cases are asymptomatic and are detected during preventive examinations, in others they are accompanied by burning, pain in the canal, dysuric disorders and the appearance of spotting. Treatment benign tumors of the urethra in women surgical. Tumors on a long narrow stalk coagulate. Neoplasms on a wide basis are excised. Malignant tumors of the urethra in women are found after 40 years, manifested by pain, dysuria. Clinic. Pain in the canal of a permanent nature, after urination there is a burning sensation. Large tumors make it difficult to urinate or cause urinary incontinence. Ulcerated forms of cancer are accompanied by spotting or urethrorrhagia. Diagnostics is based on the study of complaints, data of examination and palpation of the urethra through the vagina. With ureteroscopy and cystoscopy, the degree of prevalence of the tumor process is determined. Treatment tumors of the urethra surgical in combination with radiation therapy. Tumors of the urethra are observed in men different ages. Clinic. Tumors growing near the external opening of the urethra do not have subjective manifestations; papillomas, polyps growing in the lumen of the urethra are accompanied by bleeding, suppuration, and in the future - a violation of the act of urination. Pain is not noted. Treatment surgical. Benign tumors located near the external opening of the urethra are removed under local anesthesia, benign tumors located in the spongy part are resected with a part of the urethra. Malignant tumors of the urethra in men are rare, grow slowly, grow into the prostate gland, perineum, metastasize to the lymph nodes of the retroperitoneal space. Clinic. In advanced cases, there is germination in the perineum, discharge from the external opening of the urethra, dysuric disorders, spraying of the urine stream during urination, sometimes priapism appears. Metastasis to the lymph nodes of the retroperitoneal space leads to swelling of the scrotum. Treatmentcancer of the urethra in men - combined surgery and radiation. In some cases, it becomes necessary to amputate the penis. 34. Prostate cancer Epidemiology. This malignant neoplasm is most common in men. Etiology. Violation of the exchange of sex hormones, a violation of the ratio between androgens and estrogens due to increased activity of the hypothalamic-pituitary system. Classification. An international classification of prostate cancer has been adopted depending on its size, damage to the lymphatic vessels and the presence of metastases: 1) T1 - the tumor occupies less than half of the prostate gland; 2) T2 - the tumor occupies half of the prostate gland or more, but does not cause its enlargement or deformation; 3) T3 - the tumor leads to an increase or deformation of the prostate gland, but does not go beyond its limits; 4) T4 - the tumor grows into the surrounding tissues or organs; 5) Nx - it is impossible to assess the state of regional lymph nodes; 6) N1 - the presence of metastases in the iliac and inguinal lymph nodes; 7) M0 - no distant metastases; 8) M1 - bone metastases; 9) M2 - metastases in other organs with or without bone involvement. Clinic.. At the beginning of the disease, the reason for going to the doctor is erectile dysfunction, later urination disorders are detected. There may be pain in the perineum, sacrum, anus, lower back, hips. Diagnostics. A digital examination reveals a bumpy, irregularly shaped prostate without a clear outline. The median sulcus disappears. In the gland, infiltrates passing to the pelvic wall are determined. Cystoscopy in the initial stages of prostate cancer may not detect changes in the bladder. Treatment. For prostate cancer, surgical, hormonal and combined methods of treatment are used. Surgical treatment is radical and palliative. Radical prostatectomy is one of the main treatments for localized prostate cancer and is performed using a retropubic or transperineal approach or laparoscopically. Quality of life after RP. Full continence is restored after 6 weeks. Phosphodiesterase type 5 inhibitors (sildenafil) are used to improve erection. Palliative surgery for prostate cancer is used to divert urine. Hormone therapy is indicated for most patients. Under the influence of hormone therapy, the tumor undergoes regression, metastases resolve. Patients with prostate cancer without treatment die after 1-2 years from the moment the first symptoms of the disease appear, with hormone therapy, life expectancy increases to 3 years or more. 35. Adenoma of the prostate. Etiology, pathogenesis, clinic, diagnostics Prostate adenoma grows from the rudiments of the paraurethral glands and is located in the submucosal layer of the urethra. Etiology and pathogenesis. Etiology and pathogenesis are not fully understood. The main theory is the theory of male aging, there is evidence in favor of the estrogen theory, the theory of embryonic awakening, inflammation, the role of oxidoreductases and tissue growth factors. Proven leading role a1- adrenoreceptors, the stimulation of which increases the tone of the smooth muscle elements of the bladder neck, prostatic urethra and prostate gland. Their activation leads to the development of a dynamic component of infravesical obstruction. The growth of the paraurethral glands is accompanied by compression and atrophy of the prostate parenchyma. Under the influence of adenoma, the shape of the gland changes: it becomes round, pear-shaped, consists of 3 lobes that cover the urethra and deform its lumen, the adenoma is surrounded by connective tissue. The share of the gland can, like a valve, block the internal opening of the urethra and cause stagnation of urine in the bladder, upper urinary tract, and kidneys. The lumen of the ureter in prostate adenoma is expanded up to the pelvis. The disease ends with the development of bilateral pyelonephritis, chronic renal failure. Circulatory disorders in the bladder neck and prostate gland and hypoxia lead to a decrease in the level of tissue metabolism with a decrease in the contractility of the detrusor., Clinic. Symptoms of the disease depend on the degree of violation of the contractile function of the bladder, in connection with this, three stages are distinguished. In the first stage, the adenoma is manifested by frequent urination, especially at night. The first stage lasts 1-3 years, there is no residual urine, the gland is enlarged, dense elastic consistency, its boundaries are clearly defined, the median sulcus is well palpable, palpation of the gland is painless. In the second stage, residual urine appears; sometimes the urine is cloudy or mixed with blood, acute urinary retention is observed, symptoms of chronic renal failure are added. In the third stage, the bladder is greatly stretched, urine that is cloudy or mixed with blood is excreted drop by drop; weakness, weight loss, poor appetite, anemia, dry mouth, constipation Diagnostics. On palpation, the gland is enlarged, densely elastic, hemispherical. Cystoscopy shows the diverticula of the bladder and its trabecularity, which sometimes makes the orifices of the ureters difficult to detect. Excretory urography reveals functional and morphological changes in the kidneys and ureters. Radionuclide methods are used to study the function of the kidney, to determine the amount of residual urine. Informative echography. 36. Arenoma of the prostate. Differential diagnosis, treatment Differential diagnosis carried out with prostatitis, abscess, cancer, bladder neck sclerosis and neurogenic bladder disorders. Complications of prostate adenoma: acute urinary retention, bladder tamponade with blood clots, renal failure. Treatment. Limiting the effect of androgens on the prostate gland is achieved by centrally acting drugs that block the synthesis of testosterone by the testicles at the hypothalamic-pituitary level or prevent androgenic action at the level of the prostate gland. The first group of drugs includes analogues of luteinizing hormone, releasing hormone (LHRH, goserelin, leuprolide, buserelin), estrogens and gestogens (gestonorone caproate); the second group is represented by non-steroidal androgen receptor antagonists (flutamide, bicalutamide). Drugs with both central and peripheral androgenic effects include cyproterone, megestrol. 5-a-reductase blockers (peripheral anti-androgenic effect) of plant (Seronoa repens) and synthetic origin (finasteride) are widely used. Possible adverse reactions when taking finasteride: impotence, decreased libido, decreased ejaculate volume, which become less significant over time. Less often, yohimbine-a-blocker of central and peripheral action is used, which promotes dilatation of arteries and arterioles and thereby increases blood flow to the cavernous bodies of the penis. a blockers1-adrenergic receptors - first-line drugs in the treatment of BPH: terazosin, omnic, doxazosin. The purpose of a-blockers is based on the development of a pathological process: the formation of urethral obstruction due to an increase in the prostate gland in size with a gradual narrowing of the lumen of the urethra, an increase in the tone of the smooth muscle fibers of the prostate gland, posterior urethra, bladder neck and a violation of the energy metabolism of the detrusor (mitochondral insufficiency). The drugs interrupt the effect of mediators of the sympathetic nervous system on smooth muscles, thereby eliminating the hypertonicity of the smooth muscles of the stroma, which makes it possible to reduce the dynamic component of infravesical obstruction, improve the bioenergetics of the detrusor, and restore its contractility. Unlike herbal preparations and 5-a-reductase inhibitors, they begin to act quickly. Selective blockers of a1-adrenergic receptors with a selective urological effect, such as tamsulosin, have the least effect on blood pressure (does not require special hemodynamic control). 37. Tumors of the testicle and penis Among all malignant tumors, testicular tumors make up 1-2%. Etiology. Dishormonal disorders, cryptorchidism, testicular ectopia, trauma to the scrotum and testicle, testicular hypoplasia contribute to the development of this disease. For testicular tumors, the international TNM classification is used. 1) T1 - the tumor does not go beyond the albuginea and does not violate the shape and size of the testicle; 2) T2 - the tumor, without going beyond the albuginea, causes an increase and deformation of the testicle; 3) T3 - the tumor grows into the albuginea and spreads to the epididymis; 4) T4 - the tumor spreads beyond the testicle and epididymis, germinates the scrotum, spermatic cord; 5) Nx - it is impossible to assess the state of regional lymph nodes; 6) N1 - regional lymph nodes are not palpable, but are determined radiologically; 7) N2 - regional metastases are palpable; 8) M0 - no distant metastases; 9) M1 - metastases in distant lymph nodes; 10) M2 - metastases in distant organs; 11) M3 - metastases in distant lymph nodes and distant organs. Treatment with seminoma of the testis combined. Surgical treatment is of leading importance, while chemo- and radiation therapy is auxiliary. During the operation, the testicle with membranes is removed. Tumors of the penis are benign and malignant. Of the benign tumors, non-viral papillomas are the most common. Classification. Cancer otadia are classified according to the international TNM system: 1) T1 - a tumor no larger than 2 cm without infiltration of the underlying tissues; 2) T2 - a tumor ranging in size from 2 to 5 cm with slight infiltration; 3) T3 - a tumor of more than 5 cm or any size with deep infiltration, including the urethra; 4) T4 - a tumor that grows into neighboring tissues; 5) N0 - lymph nodes are not palpable; 6) N1 - displaced lymph nodes on one side; 7) N2 - displaced lymph nodes on both sides; 8) N3 - non-displaceable lymph nodes; 9) M0 - there are no signs of distant metastases; 10) M1 - distant metastases are present. Diagnostics. The main role in the recognition of the disease belongs to the biopsy. Treatment. In the early stages of cancer, radiation therapy or organ-preserving operations (circumcision, resection of the head) are performed, in the later stages - amputation of the penis. 38. Kidney aplasia. Hypoplasia of the kidney. Kidney dystopia. Accessory kidney Aplasia of the kidney - an anomaly in the development of the kidney, which is a fibrous tissue with randomly arranged tubules, no glomeruli, no pelvis, ureter, renal arteries in their infancy. Clinic. Sometimes there are complaints of pain in the abdomen associated with compression of the nerve endings in the aplastic kidney by a growing fibrous tissue; the kidney may be the cause of arterial hypertension. Treatment. If aplasia is the cause of hypertension or persistent pain, then nephrectomy is performed, the prognosis is favorable. Hypoplasia of the kidney - reduction of the kidney caused by congenital circulatory disorders. Hypoplastic dysplasia of the kidneys is usually the result of a viral disease in the perinatal period, combined with anomalies of the urinary tract. Clinic. Nephropathy develops according to the type of glomerulonephritis, nephrotic syndrome. At school age, it is manifested by growth retardation, hypertension, a decrease in tubular-type renal function, the development of chronic renal failure (chronic renal failure), typically the addition of a urinary tract infection. Treatment. With unilateral hypoplasia of the kidney, causing hypertension - nephrectomy, with bilateral - kidney transplantation. Uncomplicated unilateral hypoplasia does not require treatment. kidney dystopia - the result of a delay in rotation and movement of the kidney from the pelvis to the lumbar region during embryonic development. The dystopic kidney has a lobed structure, is inactive, and the vessels are short. Clinic. Dull pain during physical exertion, according to the localization of the dystopic kidney, the result of a violation of the passage of urine is the development of hydronephrosis, pyelonephritis, urolithiasis, tuberculosis. Diagnostics. The basis of diagnosis is the data of angiography of the kidney, excretory urography, scanning, ultrasound. Differential diagnosis. Differential diagnosis with kidney tumor, nephroptosis, intestinal tumors. Treatment. With uncomplicated dystopia, no treatment is required; surgical operations are used for hydronephrosis, urolithiasis, and tumors. Accessory kidney located below normal, has its own blood circulation and ureter. Clinic. Pain, dysuric disorders, changes in urine tests with the development of pyelonephritis, hydronephrosis or urolithiasis in such a kidney. On palpation in the iliac region, a tumor-like formation is determined. Treatment. A normally functioning accessory kidney does not require treatment. Indications for surgical intervention: hydronephrosis, tumor, urolithiasis, ectopia of the ureteral orifice of the accessory kidney. 39. Horseshoe kidney. Doubling of the kidney. Spongy kidney. Polycystic kidney disease horseshoe kidney - fusion of the kidneys with the lower or upper poles, the pelvis is located on the anterior surface, the ureters are short, they bend over the lower poles of the kidney, the isthmus often consists of fibrous tissue Clinic. Symptoms of the disease are absent for a long time, a horseshoe-shaped kidney is found by chance, sometimes there are aching pains in the lower back, in the navel in the supine position. In connection with the violation of the passage of urine at the site of the inflection of the ureter through the isthmus, pyelonephritis, hydronephrosis may occur. Treatment. With an uncomplicated horseshoe kidney, treatment is not carried out. Surgical intervention is indicated in case of development of hydronephrosis, urolithiasis. Doubling of the kidney - a frequent anomaly in which the kidney is enlarged in size, often has a lobed structure, the upper pelvis is reduced, the lower one is enlarged. The ureters of the double pelvis are located nearby and flow into the bladder next to or with one trunk, open into the bladder with one mouth. Clinic. Symptoms of the disease appear in the case of infection, stones, or wrinkling of the kidney in violation of urodynamics. Treatment in the absence of complications, it is not indicated, the examination is carried out in case of infection, hydronephrosis, stone formation and hypertension. Surgical intervention is used for stones, hydronephrosis, nephrosclerosis. spongy kidney - an anomaly of the medulla of the kidney, in which in the renal pyramids the collecting ducts expand and form many small cysts with a diameter of 3-5 mm. Clinic. For a long time, the disease is not clinically manifested. In connection with the stagnation of urine, the addition of infection and the formation of calculi, there is a dull paroxysmal pain in the kidney area, hematuria, pyuria. Treatment carried out with the complication of the anomaly with pyelonephritis and urolithiasis. Polycystic kidney disease - an anomaly in the development of the kidneys, which is characterized by the replacement of the renal parenchyma with multiple cysts of various sizes, there is always a bilateral process. Etiology. Violation of the embryonic development of the kidneys, in which the rudiments of the excretory and secretory apparatus of the kidney are abnormally connected; improper formation of the nephron makes it difficult for the outflow of primary urine, due to increased pressure, the tubules expand with the subsequent formation of cysts; the inflammatory process plays an important role. Often cysts are found in the liver. Clinic. In infancy, the first sign of polycystic kidneys is an increase in the abdomen and the detection of tumor-like formations palpated at the site of the kidneys. In the children's type of polycystosis, fibrosis is detected in the liver. Treatment. Conservative (antibacterial therapy, treatment of chronic renal failure, hemodialysis) and operational (opening and emptying of cysts). 40. Kidney cysts. Doubling of the ureters. Neuromuscular dysplasia of the ureter There are multicystic kidneys, solitary and dermoid kidney cysts. Multicystic kidney is a total replacement of the parenchyma with cysts and obliteration of the ureter. Clinic. Often, the pain syndrome in the opposite kidney comes to the fore: a tumor-like formation is determined by palpation. Bilateral multicystosis is incompatible with life. Diagnostics. The diagnosis is made on the basis of angiography data: the renal arteries are thinned, avascular zones, there is no nephrophase. On the urogram, scanogram, the function of the kidney is reduced or absent, in the opposite kidney there are signs of vicarious hypertrophy. Differential diagnosis is carried out with a tumor of the kidneys, polycystic. Treatment. Surgical treatment: removal of the kidney when hypertension is attached. Solitary kidney cysts are superficial and localized within the parenchyma. Etiology. Congenital cysts as a result of pyelonephritis, tuberculosis, when urinary retention occurs as a result of inflammation and obliteration of the tubules. As the cyst grows, atrophy of the kidney parenchyma occurs. Clinic. Dull pain in the lumbar region, hematuria, hypertension. Treatment surgical - complete or partial excision of cysts. Forecast favorable. Dermoid cyst is a rare anomaly. Clinic. Clinically more often it is not manifested, it is found by chance. Treatment. Surgical treatment: removal of the dermoid cyst, kidney resection or nephrectomy. Doubling of the ureters observed with doubled pelvis, isolated one- and two-sided doubling, complete and incomplete doubling of the ureters. With complete doubling, the ureters are located side by side and open with two holes, with incomplete duplication, they open in the bladder with one hole. Clinic. Symptoms of a double ureter are caused by impaired urination, stagnation of urine in the upper urinary tract, pyelonephritis. Treatment surgical. Neuromuscular dysplasia of the ureter - congenital dilatation of the ureter without mechanical obstruction to the outflow of urine. Etiology. The main cause of the pathology is congenital neuromuscular disorders in the terminal ureter, which are accompanied by a violation of the contractile function of the ureter. Clinic. A long time can be asymptomatic. Constant stagnation of urine leads to infection of the ureter, dull and paroxysmal pain appears, body temperature periodically rises, with a bilateral process, signs of CRF appear. Treatment surgical. 41. Hydronephrosis. Hydroureteronephrosis Hydronephrosis - a disease characterized by a progressively increasing expansion of the pelvis and calyces with atrophy of the renal parenchyma. Etiology hydronephrosis: various changes in the ureteropelvic segment both from the outside and in the ureter itself, common causes are additional vessels to the lower pole of the kidney, kinks of the ureter, its narrowing due to the inflammatory process, developmental anomalies. Acquired narrowing of the ureter occurs due to the long stay of stones in it. Classification. Primary (or congenital) developing due to an anomaly of the upper urinary tract; secondary (or acquired) as a complication of any disease (urolithiasis, damage to the urinary tract, tumors of the pelvis). There are stages of hydronephrosis: 1) expansion mainly of the pelvis with minor changes in the renal parenchyma (pyeloectasia); 2) expansion of the renal calyx (hydrocalicosis) with a decrease in the thickness of the kidney parenchyma; 3) a sharp atrophy of the renal parenchyma, the transformation of the kidney into a thin-walled bag. Clinic. Clinical manifestations of hydronephrosis develop slowly, there are no symptoms characteristic only of hydronephrosis. The most common symptom is pain, which can be dull, aching, intense due to a significant increase in intra-renal pressure. Diagnostics. The diagnosis is based on the data of the anamnesis and objective examination. Chromocis toscopy allows you to identify the side of the lesion by the absence of release of indigo carmine from the mouth of the ureter. Plain urography diagnoses an increase in the size of the kidney, sometimes the smoothness of the contours of the psoas muscle on the side of the lesion. Excretory urography clarifies the condition of the kidney and ureter Treatment only operational; conservative treatment is allowed only with an uncomplicated course that does not impair the performance of patients, without significant impairment of kidney function and the patient's condition. In this case, anti-inflammatory therapy is performed. Surgical treatment consists of reconstructive surgery, nephrostomy or pyelostomy Hydroureteronephrosis - expansion of the ureter, pelvis and calyces with a gradual decrease in kidney function and parenchyma atrophy, develops with congenital and acquired ureteral obstructions. Clinic. For a long time, it can be asymptomatic, it is diagnosed by chance during an examination for urolithiasis to determine the cause of CRF. Pain complaints. Diagnostics. The diagnosis is based on the data of excretory urography, with chronic renal failure retrograde urography. Treatment surgical, the operation consists in removing the obstruction, resection of the ureter, removal of the kidney and ureter. 42. Ureterocele Ectopia of the ureteral orifice. Bladder exstrophy. bladder diverticulum ureterocele - a combination of stenosis of the cystic end of the ureter with a poorly developed connective tissue apparatus of the bladder in this place, the overlying part of the ureter is stretched by urine, turns into a cyst and extends into the bladder in the form of a tumor up to 10 cm in size. Etiology. Etiology - congenital neuromuscular weakness of the submucosal layer of the intramural ureter in combination with the narrowness of its mouth. Clinic. The disease can be asymptomatic for a long time, complaints appear when urination is disturbed due to the large size of the ureterocele or the disease is complicated by pyelonephritis and ureterohydronephrosis, spontaneous pain in the lumbar region, renal colic, leukocyturia appear. Treatment. Treatment is surgical and consists in excision of the ureterocele. Ectopia of the ureteral orifice - an anomaly of development in which the mouth of the ureter opens outside the bladder. In girls, it can open in the urethra, on the eve of the vagina, in boys - in the back of the urethra, seminal vesicles. Often observed with doubling of the ureters. Clinic. Urinary incontinence is noted with normal urination in girls, in boys - dysuria, pyuria, pain in the pelvic region. Treatment. The treatment is surgical, the prognosis is favorable. Bladder exstrophy - congenital absence of the anterior wall of the bladder, defect of the pyramidal muscles and skin, splitting of the urethra and divergence of the pubic bones. Underdevelopment of the testicles, bilateral cryptorchidism, aplasia of the prostate gland, in girls - splitting of the clitoris, fusion of the large and small labia, vaginal underdevelopment. The urethra is absent. Treatment operative: restoration of the bladder or transplantation of the ureters into the colon. bladder diverticulum - protrusion of the wall of the bladder. Congenital diverticula are solitary, located on the posterolateral wall, connected to the main cavity of the bladder with a long neck. Clinic. Patients note a feeling of incomplete emptying of the bladder, double urination, cloudy urine. Hematuria is common due to ulcerative hemorrhagic cystitis. Sometimes there is pain in the lumbar region, the cause of which is occlusion of the ureter by a diverticulum. Diagnostics. The diagnosis is based on complaints, cystography, excretory urography, ultrasound. Treatment surgical if diverticula are the cause of cystitis and urinary retention. 43. Diseases of the urethra. Hypospadias. epispadias Urinary duct obstruction - congenital vesico-umbilical fistula. Clinic. There is a discharge of urine and serous fluid from the navel, and granulation tissue develops around the fistula. Treatment. In newborns, the toilet of the navel is carried out. Congenital valves of the urethra - semilunar, membranous or funnel-shaped folds of the mucous membrane, located in the back of the urethra. Clinic. Clinically manifested by difficulty urinating, an increase in the bladder. Treatment. Surgical treatment: excision of the valve. Congenital diverticula of the urethra - a bag-shaped depression of the lower wall, communicating with the urethra with a narrow neck. Clinic. Purulent urine accumulates in large diverticula. Treatment. Surgical treatment. Hypospadias - abnormal development of the urethra, there is no posterior wall of the urethra. Clinic. With hypospadias of the head, the urethra opens immediately behind it on the posterior surface of the penis with a pinpoint or wide slit-like opening, with scrotum - along the midline of the scrotum, with perineal hypospadias - on the perineum behind the scrotum. Treatment. Treatment - operational, is carried out in three stages. Stage I - excision of the notochord, alignment of the penis and the creation of excess skin for plastic surgery of the urethra. II and III stages - the creation of the urethra. epispadias - congenital splitting of the anterior wall of the urethra. There are 3 degrees of epispadias: 1) with epispadias of the head, only a part of the urethra corresponding to the head of the penis is split; 2) with penile epispadias of the penis, the urethra is split along the anterior wall of the entire penis or on a certain segment of it; 3) with total epispadias, the upper wall of the urethra appears to be split throughout, including the sphincter area. The penis is underdeveloped, curved upward and adjacent to the skin of the abdomen. The split foreskin hangs down. Clinic. The main complaints about the inconvenience of the act of urination, urinary incontinence, curvature of the penis. Treatment. Treatment - surgical in early childhood before the onset of an erection, epispadias of the head does not require treatment. 44. Short frenulum of the foreskin. Phimosis. Anorchism. Monorchism Short frenulum of the foreskin - a congenital defect that prevents the mobility of the foreskin. Promotes the accumulation of smegma, the development of inflammation. Clinic. Pain during erection, with tears, bleeding is noted. Diagnostics. Diagnosis is not difficult, based on history and examination. Treatment. Toilet of the foreskin, surgical lengthening of the frenulum. Phimosis - congenital or acquired narrowing of the opening of the foreskin, preventing the exposure of the glans penis. Etiology. Congenital narrowing (physiological phimosis) is caused by epithelial gluing of the inner layer of the foreskin with the glans penis. As the child grows under the influence of spontaneous erections and smegma pressure, by the age of 3-6 years, physiological phimosis completely eliminates itself. Due to the narrowing of the foreskin, the external opening of the urethra is reduced to a point size. Acquired phimosis develops as a result of diseases of the penis, edema or infiltration of the glans penis or foreskin in acute balanoposthitis or trauma and cicatricial changes. Clinic. Difficulty urinating. Urine enters the preputial sac, and it swells at the time of urination, this can cause urinary retention in the bladder, which leads to its infection, the formation of calculi, the development of cystourethritis, cystopyelitis. Infection of the prepuce sac leads to the formation of stones, exacerbates the narrowing of the opening of the foreskin. Treatment. In infants and preschool children, the narrowed foreskin is expanded in a blunt way (using a grooved probe) and baths with aseptic solutions are prescribed. With elongation and sclerotic changes, the foreskin ring is circumcised. If the foreskin is not elongated, then its dissection is permissible. With secondary phimosis, a circular circumcision of the foreskin is performed. Prevention phimosis - hygiene of the preputial sac. Anorchism - Absence of both testicles. Rare malformation. Clinic. Absence of testicles in the scrotum and inguinal canal, signs of hypogonadism. Diagnostics according to the indicated clinical symptoms and the exclusion of bilateral abdominal cryptorchidism. Treatment. Replacement hormone therapy. Monorchism - one congenital testicle. The anomaly is associated with impaired embryogenesis of the final kidney and gonad. Clinic. One testicle, epididymis and spermatic cord are missing, the scrotum is underdeveloped; in some cases, the only testicle is not lowered, hypogonadism is possible. Treatment. With a normal second testicle, a silicone prosthesis is implanted. 45. Cryptorchidism. hypogonadism Cryptorchidism - undescended testicles into the scrotum. Etiology. The delay occurs due to the general endocrine underdevelopment of the body or mechanical obstacles. Classification. According to the mechanism of testicular delay, the following forms of undescended are distinguished: 1) true cryptorchidism (intrauterine retention of the testicle at one of the stages of its descent from the lower pole of the primary kidney to the bottom of the scrotum); 2) false cryptorchidism (the testicle is completely lowered, but due to the enlarged inguinal ring and increased tone of the cremaster muscles, it is pulled up and is almost constantly located in the inguinal canal; 3) incomplete or delayed testicular descent (absence of the testicles in the scrotum after birth, but then in the first weeks or months of life without any therapeutic measures, they completely descend into the scrotum); 4) ectopia or dystopia (displacement of the testicle away from its physiological path of descent). There are the following types of cryptorchidism: 1) true cryptorchidism; 2) false cryptorchidism; 3) ectopia; 4) mixed and other types of testicular descent disorders. Clinic. Signs of testicular retention in the abdominal cavity are usually absent, but at an older age, pulling pain may appear due to torsion of the mesentery of the testicle and aggravated by exercise, which is typical for the inguinal cryptorchidism. Inguinal cryptorchidism causes pain from compression of the testicle during physical exertion, coughing, walking, and may be accompanied by a hernia. Diagnostics based on clinical data. With anorchism, elements of the spermatic cord are felt in the scrotum. The appendage, the external opening of the inguinal canal is normal, with abdominal creep-torchism (unlike anorchism), these elements are not present in the scrotum, the external opening of the inguinal canal is usually narrowed or overgrown. In difficult cases, pneumoperitoneum and scintigraphy are used to recognize abdominal cryptorchidism. Treatment. Of the drugs, drugs are used that stimulate the function of the hypothalamic-pituitary system, regulate the function and histochemical processes of the testicle (tocopherol acetate), activate the synthesis of steroid hormones (ascorbic acid), components of the formation of nuclear structures during cell division of the spermatogenic epithelium (retinol), activators of oxidative - recovery processes (vitamin P and galascorbin), neurotrophic factor (thiamine). Hypogonadism - a significant decrease in the size of the testicles. Clinic. Signs of eunuchoidism: underdevelopment of the penis and prostate, obesity, sparse facial and pubic hair, thin voice. Treatment. Gonadotropic hormone of the anterior pituitary gland - prolan A - synthetic androgens are used: testosterone, methyltestosterone or testosterone-propionate in tablet form or in injectable form. 46. Klinefelter's syndrome. Shereshevsky-Turner syndrome. Spermatocele. Dropsy of testicular membranes and spermatic cord Klinefelter syndrome - a kind of hypogonadism, characterized by congenital degeneration of the tubular epithelium of the testicles with a preserved structure of interstitial hormoneocytes. Etiology. It develops due to a chromosomal abnormality (in the presence of an additional X chromosome). Clinic. According to the clinical appearance, 2 varieties of Klinefelter's syndrome are distinguished - endomorphic and exomorphic. In the first form, the genitals are developed correctly, but there are signs of gynecomastia and some stunting. Diagnostics. In special studies, normal and somewhat reduced levels of 17-ketosteroids and relative hyperestrogenism, increased excretion of follitropin are found. Elements of spermatogenesis are absent, azoospermia. Treatment begin in early childhood, use vitamin and hormonal preparations, as with cryptorchidism. Shereshevsky-Turner syndrome - a congenital type of hypogonadism, due to a change in the chromosome set. Treatment of this phenotype in men is aimed at correcting growth and hormonal stimulation of the development of the genital organs. Spermatocele - cystic tumor located paratesticular or paraepididymal. Cystic formations can be congenital and acquired. Congenital cysts are formed from embryonic remnants, acquired cysts develop from traumatized tubular elements. Clinic. Spermatocele is a spherical single or multi-chamber elastic painless formation, palpable near the epididymis or testicle, grows slowly, there are no complaints. Treatmentoperative - exfoliation under local anesthesia. Dropsy of testicular membranes and spermatic cord - accumulation of fluid in the cavity of the vaginal membrane of the testicle. Etiology. Acquired dropsy of the testicles is the result of inflammatory diseases of the epididymis, trauma; congenital - the result of non-closure of the vaginal process of the peritoneum after the descent of the testicle into the scrotum. Clinic. The formation of a pear-shaped swelling in the scrotum, facing downwards, contributes to the accumulation of fluid in the testicular membranes, with dropsy of the membranes of the spermatic cord, the swelling penetrates the inguinal canal, forming an hourglass-type dropsy or a multi-chamber dropsy. The skin of the scrotum is freely taken into the fold, the testicle is usually not possible to probe, the hernia is excluded when probing the inguinal ring. Treatment. Reactive dropsy of the testicles in acute epididemitis, orchitis requires complete rest, wearing a suspension, antibiotic therapy. 47. Hematuria Hematuria - a pathological symptom characterized by the admixture of blood in the urine. Etiology. Causes of renal bleeding (A. Ya. Pytel et al., 1973). 1. Pathological changes in the kidney. 2. Congenital. 3. Mechanical. 4. Hemodynamic. 5. Hematological. 6. Reflex. 7. Allergic. 8. Toxic. 9. Inflammatory. 10. Tumor. 11. Essential. Clinic. There are microscopic and macroscopic hematuria. Macroscopic hematuria can be of three types: 1) initial, when only the first portion of urine is stained with blood; 2) final, in which no blood impurities are visually detected in the first portion of urine, and only the last portions of urine contain blood; 3) total, when urine in all portions is equally colored with blood. The degree of blood loss is not assessed by the color of urine, since the content of 1 ml of blood in 1 liter of urine already gives it a red color. Additional diagnostic research and differential diagnostics. The frequency of bleeding is determined by the presence of blood clots; the degree of blood loss - in terms of hemoglobin, more precisely - hematocrit. Scarlet blood in the urine suggests ongoing bleeding. The brown color of urine, due to the dissolution of blood clots, indicates the cessation of bleeding. A putrid odor indicates stagnation of urine and infection. The color of urine changes when taking various medications and foods. Hematuria must be distinguished from hemoglobinuria - with this symptom, the bloody color of the urine is explained by the breakdown of red blood cells in the blood and the excretion of hemoglobin in the urine, which is in it in the form of cylinders. The presence of myoglobin in the urine gives it a reddish-brown color. Myoglobin is a protein that has features similar in composition to hemoglobin. Topical diagnosis is based on the nature of the clots. The worm-like shape of the clots indicates that the bleeding comes from the upper urinary tract and their formation (clots) in the ureter. The formation of such clots is possible in the lumen of the urethra after a traumatically performed bladder catheterization in a patient with prostate adenoma. Shapeless clots often form in the bladder. Treatment. Hospitalization is mandatory if hematuria is detected. Hemostatic therapy consists of intravenous administration of etamsylate (2-4 ml at once or drip), aminocaproic acid (intravenous 5% solution of the drug in isotonic sodium chloride solution, drip up to 100 ml). 48. Acute retention of urine. Anuria Acute urinary retention - sudden absence of the act of urination with an overflowing bladder and a painful urge. Etiology. Prostate adenoma, prostate cancer, bladder neck sclerosis, foreign body, stone, urethral rupture, neoplasm of the lower urinary tract. Clinic. The patient has anxiety, severe pain in the suprapubic region, painful urge to urinate, a feeling of fullness in the lower abdomen. Differential diagnosis. It is necessary to differentiate AUR from anuria, in which there is no pain. One should not forget about this type of urinary retention, such as paradoxical ischuria, in which the bladder is full, the patient cannot empty the bladder on his own, urine is involuntarily excreted in drops. Treatment. Urgent action - urgent emptying of the bladder. If AUR lasts more than two days, it is justified to leave the catheter in the urinary tract with the appointment of prophylactic antibiotic therapy. Anuria - Absence of urine in the bladder. Classification. There are several types of anuria. 1. Arenal anuria (renoprival) in case of congenital aplasia of both kidneys. 2. Prerenal anuria develops as a result of reduced cardiac output, systemic vasodilation, hypovolemia and a sharp decrease in circulating blood volume, dehydration, and the appearance of a third space. 3. Renal anuria is caused by acute tubular necrosis, the causes of which may be: 1) renal ischemia; 2) nephrotoxic factors; 3) other causes of renal anuria - acute and chronic renal failure. 4. Postrenal anuria is an acute violation of the outflow of urine from the kidneys to the bladder. Diagnostics. At the slightest suspicion of anuria, the patient should be hospitalized. Severe acidosis with a high anion deficiency develops as a result of a violation of the excretion of sulfates and phosphates by the kidneys, also due to ketoacidotic coma, intoxication with alcohol surrogates, in shock, carbon monoxide poisoning. Differential diagnosis. Bladder catheterization is performed - a catheter with a balloon (No. 14-16, 18 according to Sharière) is used, which are left in the bladder to monitor the possible appearance of urine. Treatment. At the prehospital stage, it is necessary to ensure the maintenance of cardiac activity, peripheral vascular tone. With postrenal anuria, hospitalization is carried out in a urological clinic, with renal anuria due to poisoning, there is a need for emergency gastric lavage, the introduction of antidotes with a precisely established toxic substance. 49. Renal colic, etiology, pathogenesis, clinic Renal colic - an acute pain attack caused by a sharp violation of the outflow of urine from the kidney and hemodynamics in it. Etiology. ureteral stones; tumor, blood clots, mucus, pus suddenly occluding the lumen of the urinary tract and disrupting the passage of urine. Pathogenesis. Acute occlusion of the upper urinary tract, a sharp increase in pressure in the pyelocaliceal system, swelling of the parenchyma, stretching of the fibrous capsule of the kidney. Pain is a consequence of hyperactivation of the baroreceptors of the pelvicalyceal system and receptors of the fibrous capsule. Clinic. An attack of acute pain in the lower back and lateral parts of the abdomen with severe irradiation to the inner surface of the thigh, inguinal region and genitals. Renal colic can occur at any time of the day, an attack occurs suddenly, develops very quickly. The irradiation of pain depends on the localization of the calculus in the urinary tract that caused their occlusion. With a stone that caused occlusion of the pelvis, pain radiates to the lower back and hypochondrium. The nature of the pain (especially in the first 1,5-2 hours) makes the patient change the position of the body, any of which does not bring relief. The patient rushes about, sometimes tilts the body, holding the palm on the lower back from the side of pain. Renal colic with acute low back pain may develop in pregnant women in the third trimester. At the height of renal colic, moderate arterial hypertension is noted. Sometimes the pain causes fainting. Dysuria is characteristic but inconsistent. Easily caused symptom Pasternatsky (slight tapping on the lumbar region). In the presence of a single kidney, anuria or oliguria may occur. Tongue coated with white; the abdomen is involved in the act of breathing. Often, with renal colic, symptoms characteristic of acute diseases of the abdominal organs are observed: symptoms of peritoneal irritation may appear (Shchetkin-Blumberg symptom, Rovsing). In more than half of cases, renal colic is accompanied by an increase in body temperature, which is caused by pyelovenous reflux as a result of the penetration of urine into the blood stream. The duration of an attack of renal colic ranges from several minutes to several hours. Diagnostics. Recognition of PC is based on anamnesis data (the presence of urolithiasis or other diseases in the pathogenesis of which acute obstruction of the upper urinary tract may develop), the clinic of the disease, on a physical examination, ultrasound examination of the kidneys and urinary tract, radioisotope and radiological research methods. Ultrasound is the ideal initial examination. Transrectal and transvaginal ultrasound allows visualization of stones in the juxtavesical ureter. Ultrasound easily detects pyelectasis. 50. Renal colic. Differential diagnosis and treatment Differential diagnosis. Renal colic must be differentiated from acute cholecystitis with localization of pain in the right hypochondrium. Hepatic colic is characterized by irradiation of pain in the region of the nipple of the right mammary gland, in the right shoulder blade, shoulder, neck; they increase with inhalation and palpation of the gallbladder area, light tapping along the right costal arch, which is not observed with renal colic. With hepatic colic, a phrenicus symptom is detected, in the right hypochondrium, stiffness of the muscles of the anterior abdominal wall and sometimes signs of peritoneal irritation are determined, while these symptoms are absent in renal colic. Differentiating between renal colic and acute appendicitis can be difficult, especially when the process is retrocecal. In acute appendicitis, pain usually occurs in the epigastric region (Kocher's symptom), and then localized in the right iliac region, where stiffness of the muscles of the anterior abdominal wall, slight abdominal distension are determined by palpation, symptoms of peritoneal irritation may appear. In acute appendicitis, vomiting appears long after the onset of pain; in renal colic, these symptoms appear almost simultaneously. If acute appendicitis cannot be completely excluded in renal colic, then laparoscopy or even laparotomy is performed. With renal colic, the intensity of pain is much greater. Difficulties may arise in the differential diagnosis of intestinal 50б obstruction and renal colic. Signs such as the absence of stools, non-excretion of gases, sharp pains throughout the abdomen can be observed with renal colic, although they are characteristic of intestinal obstruction. Vomiting is characteristic of both intestinal obstruction and renal colic. With difficulties in recognizing renal colic and intestinal obstruction, one has to resort to additional research methods. Pain in intestinal obstruction is excruciating, incessant, captures the entire abdomen, peristalsis is preserved, increased at the onset of the disease. Treatment renal colic involves the elimination of pain and the elimination of obstruction. Pain can be relieved by diclofenac sodium, which is an antagonist of prostaglandin synthesis, which helps to reduce filtration and thus intrapelvic pressure; and also reduces inflammation and swelling in the area of occlusion, inhibits stimulation of the smooth muscles of the ureter, which blocks its peristalsis. The analgesic effect is the same as that of morphine when administered intravenously. Parenteral dosage 75 mg, rectal suppositories contain 100 mg. With renal colic, thermal procedures, painkillers, novocaine blockade of the spermatic cord in men and blockade of the round ligament of the uterus in women or intra-pelvic blockade according to Shkolnikov are also shown. 51. Nephroptosis. Etiology, classification, clinic Nephroptosis (prolapsed kidney, wandering kidney) - a pathological condition in which the kidney leaves its bed and in a vertical position is displaced beyond the limits of physiological mobility. It occurs mainly in women aged 25-40 years, more often on the right. Etiology. The main role is played by factors leading to significant changes in the ligamentous apparatus of the kidney (infectious diseases, weight loss) and to a decrease in the tone of the anterior abdominal wall during pregnancy or for other reasons. Trauma (fall from a height, blow to the lumbar region, sudden lifting of weight), leading to overstretching or rupture of the ligamentous apparatus, can contribute to the development of nephroptosis. The more frequent occurrence of nephroptosis in women is due to their constitutional feature (wider pelvis), right-sided nephroptosis is observed more often. Classification. Nephroptosis can be fixed and mobile. There are three stages of nephroptosis. At stage I, on inspiration, the lower pole of the kidney is palpated, but on inspiration, it goes into the hypochondrium. At stage II, the entire kidney leaves the hypochondrium in the vertical position of the patient, and its rotation around the vascular pedicle is significant. At stage III, the kidney completely leaves the hypochondrium, shifts into the large or small pelvis. At this stage, a fixed kink of the ureter may occur, leading to expansion of the pelvicalyceal system. At stages II and II, stretching and torsion of the vascular renal pedicle occurs with a decrease in its lumen. Clinic. Complaints may be absent, and the mobile kidney is detected by chance. Clinical manifestations of nephroptosis without disturbance of hemodynamics and urodynamics are scarce. In the initial stage, patients complain of small dull pains in the lumbar region in the vertical position of the body and during physical exertion. Reduction of pain occurs in the position on the sore side, while lying on the healthy side, patients feel heaviness or dull pain in the opposite side of the lower back or abdomen. At stage II, the pain intensifies somewhat, spreads throughout the abdomen with irradiation to the back, the region of the bladder, stomach, and sometimes acquires the character of renal colic. Proteinuria and erythrocyturia may be detected as a result of damage to the fornic veins due to increased pressure in the venous system. At the III stage of nephroptosis, the intensity of pain increases sharply, they become constant, lead to mental depression, appetite disappears, headaches, dyspepsia, fatigue, irritability appear. With the development of pyelonephritis in the lowered kidney, the body temperature rises. There are also changes in the urine characteristic of pyelonephritis: leukocyturia, bacteriuria. Over time, kidney function decreases sharply, which contributes to the development of arterial hypertension. 52. Nephroptosis. Complications, differential diagnosis, treatment, prevention Complications. Hydronephrosis and hydroureter as a result of kinks of the ureter, fixed by scar bands, accessory vessels. A frequent complication of nephroptosis is venous hypertension in the kidney, manifested by hematuria, which occurs during physical exertion and disappears at rest, in the horizontal position of the patient. Another common complication of nephroptosis is pyelonephritis, which greatly complicates the course of nephroptosis. Arterial hypertension is another severe complication of nephroptosis: when the kidney is lowered, the angle of origin of the renal artery and vein changes sharply, the vessels stretch, lengthen, their diameter greatly decreases, tears of the intima and the internal elastic membrane of the renal artery occur, followed by the development of scarring processes - fibromuscular disc -plasia of the renal artery with the development of renovascular hypertension. Nephroptosis can also lead to fore bleeding. Diagnostics. When making a diagnosis, the presence of an injury in the anamnesis, the relationship of pain with the vertical position of the patient and physical activity, episodes of pyelonephritis, hematuria, and high blood pressure are taken into account. Palpation of the kidney is carried out not only in the horizontal, but also in the vertical position of the patient, in which in most cases it is possible to palpate the lowered kidney. Refinement of the diagnosis is assisted by instrumental and radiological methods of investigation. Excretory urography in the horizontal and vertical position of the patient allows you to determine the degree of their displacement and functional ability, ultrasound is performed. Renal angiography, duplex examination of the vessels of the kidney can reveal fibromuscular changes in the renal artery. To clarify the functional state of the kidney, isotope renography and kidney scintigraphy are used. Treatment. Conservative therapy consists in the appointment of antispasmodic, analgesic, anti-inflammatory drugs, warm baths, the horizontal position of the patient. Early appointment of a bandage ensures the prevention of the progression of nephroptosis and its complications. The bandage should be put on only in a horizontal position, in the morning, before getting out of bed, on the exhale. In addition, a special set of gymnastic exercises will not be superfluous to strengthen the muscles of the anterior abdominal wall. Prevention. Elimination of sharp physical efforts, repeated injuries of the renal region, prolonged physical work in a vertical or half-bent position of the body. Of great importance for the prevention of nephroptosis is the control of body weight, especially in asthenic constitution, when an increase in body weight should be recommended. 53. Necrosis of renal papillae Necrosis of the renal papillae (necrotizing papillitis) - severe disease of the medullary substance of the kidney. Etiology. Necrosis of the papillae is due to the peculiarities of the blood supply to this section, circulatory disorders in the medulla of the kidney, impaired venous outflow, impaired passage (pelvic-noxal-caliceal hypertension, inflammatory diseases of the kidneys), and the presence of pelvic-renal reflux. Necrotic changes cause coagulating staphylococci. Primary necrosis develops without previous inflammatory changes, secondary necrosis is a complication of pyelonephritis. Clinic. The main symptoms of necrotic papillitis: renal colic, pyuria, hematuria, excretion of necrotic masses in the urine (late symptom); common symptoms include headache, fever, arterial hypertension, and renal failure. Diagnostics. The diagnosis consists of a complex of studies, including an analysis of the general clinical signs of the disease, laboratory, radiological and morphological methods. An overview picture of the urinary system sometimes allows you to establish the presence of small calcified shadows, which is due to calcifications with a characteristic structure of necrotic masses of the renal papilla (their shape is triangular), which repeat the outlines of the renal papilla. Excretory urography and retrograde urography are performed in different projections, reveal characteristic signs (narrowing of the fornic zone of the calyces, smeared contours of the papillae ("moth eaten"), later on ring shadow; the rejected papilla, located in the calyx or pelvis, is presented on the urogram as a filling defect, often triangular in shape). Differential diagnosis. Differential diagnosis is carried out with pelvic-renal refluxes, anomalies of the medullary substance of the kidney (spongy kidney, kidney dysplasia), chronic and acute pyelonephritis, kidney tuberculosis, hydronephrosis, nephrolithiasis, papillary tumors of the pelvicalyceal system. Treatment Indications for surgical intervention are acute pyelonephritis, not amenable to treatment with conservative measures (restoration of the passage of urine by catheterization of the ureters and subsequent antibiotic therapy) within 1-2 days from the moment of its occurrence, occlusion of the pelvis and ureter with necrotic masses, profuse hematuria. Nephrectomy is indicated only in case of total necrosis of the medullary substance and symptoms of acute purulent pyelonephritis, and only in case of satisfactory function of the contralateral kidney. In all other cases, organ-preserving operations are performed: nephrostomy, removal of necrotic masses, kidney resection with profuse hematuria. 54. Retroperitoneal fibrosis, renal reflux, vesicoureteral reflux Retroperitoneal fibrosis characterized by progressive compression of the ureters by fibrous tissue. Etiology. Inflammatory diseases of the female genital organs, pancreatitis, lymphangitis, drug-induced retroperitoneal arteritis, trauma with the formation of retroperitoneal hematoma. Clinic. Pain in the lumbar region, in the lower abdomen, weight loss, subfebrile condition, anemia, increased ESR. Treatment surgical, the effectiveness depends on the early detection of the disease and the degree of renal failure. Pelvic-renal reflux - reverse flow of the contents of the pelvis and calyces into the renal tissue and its vessels. Etiology. The main reason is a sudden increase in intrapelvic pressure as a result of blockage or dyskinesia of the upper urinary tract. Pelvic-renal refluxes are fornikal (rupture of the fornix) and tubular (penetration of the contents of the pelvis into the renal tissue through the collecting ducts). The penetration of infected urine into the renal tissue leads to the development of pyelonephritis and sclerosis of the renal parenchyma. Treatment. Elimination of the underlying disease, restoration of urinary tract urodynamics and normal urine passage. Vesicoureteral reflux - Return of urine into the ureter. Etiology. The main one is the failure of the closing apparatus of the mouth of the ureter due to cicatricial and ulcerative changes in the bladder, neurogenic disorders of the act of urination, and congenital failure. Clinic. A characteristic symptom of vesicoureteral reflux is the appearance of pain in the kidney at the time of urination. Sometimes there is a two-act urination: a few minutes after emptying the bladder, patients are able to re-excrete the same amount of urine. The clinical course of vesicoureteral reflux is characterized by a progressive increase in retention changes in the ureter and pelvicalyceal system to the formation of large hydroureteronephrosis. Treatment. The initial forms of active vesicoureteral reflux are amenable to reverse development. Advanced forms of reflux, complicated by dilatation of the upper urinary tract and pyelonephritis, require surgical correction. With normal bladder capacity, ureterocystone anastomosis is resorted to using the anti-reflux technique; with a cicatricial-wrinkled bladder, intestinal plasty of the bladder is performed with transplantation of the ureter into an intestinal graft. 55. Overactive bladder Overactive bladder (OAB) - a symptom complex, including the occurrence of a strong sudden urge to urinate (urgency); imperative urinary incontinence; nocturia, pollaki-uria. The following types of detrusor overactivity are distinguished: 1) phase hyperactivity: a wave characteristic of involuntary contraction of the detrusor is determined, which can lead to urinary incontinence; 2) terminal hyperactivity: the only involuntary contraction of the detrusor that occurs when the bladder is filled to cystometric volume. The patient cannot suppress the involuntary contraction, as a result of which urine is not retained; 3) incontinence with detrusor overactivity: incontinence due to involuntary contraction of the detrusor. Etiopathogenesis. According to the etiology, detrusor hyperactivity is divided into: 1) neurogenic - the patient has a neurological pathology; 2) idiopathic - the cause of hyperactivity is not clear. According to the pathogenesis, OAB can be the result of a disruption in the activity of the nervous system or myogenic disorders. Depending on the level of damage to various parts of the nervous system, neurogenic dysfunctions are divided into groups. Supraspinal neurologic urinary disorders usually do not affect the urinary reflex. These injuries include stroke, brain tumor, бmultiple sclerosis, hydrocephalus, Parkinson's disease. Suprasacral neurological disorders of urination occur in patients with spinal cord injuries, multiple sclerosis, and myelodysplasia. Sacral neurological disorders of urination occur with a herniated disc, diabetic neuropathy, multiple sclerosis, tumors of the spine, with extensive surgical interventions in the pelvic area. There are two types of myogenic disorders - a decrease in the excitability threshold and the propagation of a depolarization wave, which lead to a coordinated contraction of the detrusor and the development of OAB. Treatment. Non-pharmacological, medical, surgical. The main goal of drug treatment of detrusor hyperactivity is to reduce its contractile activity and increase the functional capacity of the bladder. Tolterodine (Detrusitol, Detrol) - M-cholinergic blocker, reduces the frequency of urination and episodes of urinary incontinence, contributes to the disappearance of dysuric phenomena, an increase in the volume of urination. Oxybutynin (Dripton, Ditropan) is an anticholinergic blocker with a mixed type of action (2,5-5 mg 3-4 times a day), it can be used intravesically or in the form of rectal suppositories, there are transdermal forms (prescribed once every 2 weeks) . 56. Enuresis, varicocele Enuresis - Bedwetting, or involuntary urination during sleep, occurs mainly in boys 2-15 years old. Etiology. One of the causes of enuresis is the weakness of the urinary reflex, due to congenital anomalies or congenital insufficiency of the neuromuscular apparatus of the bladder. Enuresis can be promoted by reflex influences emanating from other organs where pathological processes are localized. Clinic. Involuntary urination can occur every night, every other night, or less frequently. It can be one or more times a night. Enuresis can occur with remissions, relapses are usually associated with fatigue, past infections and mental trauma. Diagnostics Violation of various parts of the nervous system and the neuromuscular apparatus of the bladder is revealed. Knee, Achilles and medioplantar reflexes are impaired. Vegetative changes in the nervous system are manifested by persistent dermographism, marbling of the skin of the extremities. Extremities cold and wet. Neurotic changes are manifested by the lability of the emotional sphere. X-ray examination reveals non-fusion of the arches of the lumbar and sacral vertebrae, on cystograms - leakage of a contrast agent from the bladder into the back of the urethra. According to electromyography, the biopotentials of the bladder and sphincters are determined. Treatment you need to start with suggestive therapy in combination with the appointment of tonic drugs. Varicocele - varicose veins of the spermatic cord, which occurs most often in young men. Etiology. The disease develops as a result of a violation of the outflow from the left testicular vein as a result of its stenosis or thrombosis or inferior vena cava. It is more often observed on the left, where the testicular vein flows into the renal vein. A symptom of venous stasis in the kidney is the expansion of the veins of the spermatic cord. Clinic. Unpleasant sensations in the scrotum, pulling pains in the testicles, inguinal regions, aggravated by physical exertion, sexual arousal, sexual function may be reduced, oligospermia and infertility may develop. The corresponding half of the scrotum is enlarged, on palpation, vine-shaped nodular-dilated veins of the spermatic cord are determined, and the testicle gradually atrophies. Treatment. To eliminate symptomatic varicocele that has developed as a result of renal vein stenosis, the testicular vein is ligated, anastomosis is performed between the testicular and common iliac veins.
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