the Member correspondent of the Russian Academy of Medical Science, professor E.B.Mazo, A.A.Rastaporov, E.S. Korshunova, Z.V.Chikviladze RGMU, the National scientifically-practical society of the first help Inflammatory diseases of bodies of uric system

Definition nonspecific infectious vospalenie chashechnolohanochnoj systems and parenhimy.

the Aetiology and patogenez . A sharp pyelonephritis observe at women is more often, and eto disease is shown by a fever, a body heat (38-39 and # 65392; With i above), a pain in a waist (in a side). Very often to it precedes speeded up boleznennoe in the end of the certificate mocheispuskanie (a clinical picture of a sharp cystitis). In this case the sharp pyelonephritis is a consequence of an ascending infection which obychno is presented Escherichia coli, Klebsiela, Proteus, Pseudomonas and drugimi bacteria. Patogenez diseases includes the centres chronic vospalenija in female genitals, the bottom uric ways and is more rare in thick kishechnike. Gematogennyj the way of development of a sharp pyelonephritis happens not so more often, kak ascending, and its source is sharp or podostryj inflammatory protsess out of uric ways the mastitis, a furuncle or karbunkul and others. For today polagajut, that in any case that the sharp pyelonephritis, neobhodimy contributing factors in the form of infringement gemo or urodinamiki in pochke or the top uric ways has developed.

the Clinical current a sharp pyelonephritis depends on absence or nalichija infringements of a passage of urine on the top uric ways, that is from a kidney in lohanku and further on mochetochniku. Differently, in the first case doctor SMP will be imet business with the patient, at which sharp not obstructive pyelonephritis, in the second with ostrym an obstructive pyelonephritis.

At not obstructive disease can begin with dizurii and this very day or cherez 12 days to lead to a body heat, a fever and a pain from the party porazhennoj kidneys. Important remember features sharp not obstructive pielonefrita a fever it can to be replaced down-pour then with short-term decrease temperatury bodies; The pain in lumbar area can appear during time mocheispuskanija and in that case be shown to a fever and gipertermii (puzyrnomochetochnikovyj refljuks), and after them not to repeat any more (rupture forniksa one or neskolkih cups and rezorbtsija urine fornikalnyj a reflux).

At an obstructive sharp pyelonephritis (okkljuzija mochetochnika a stone, produktami a chronic inflammation of a kidney, external sdavlenie retroperitonealnyj fibroz, the cancer of internal genitals of the man and the women increased limfouzly i etc.) disease begins with gradually accruing or sharply developed boli in a waist from defeat with the subsequent development of a fever and increase temperatury bodies.

the Diagnosis is based on anamnesis gathering (a chronic pyelonephritis, mochekamennaja illness, disease of female genitals, predstatelnoj glands, perenesennye operations on kidneys and uric ways etc.) Described above klinicheskoj a picture and data of objective inspection: conformity of frequency pulsa degrees gipertermii, shining eyes, a flush on cheeks, pure language, a pain pri palpatsii a stomach in podrebere and a positive symptom pokolachivanija on pojasnitse (a symptom Pasternatsky) from the amazed kidney.

Treatment . At suspicion or diagnosis installation the sharp pyelonephritis bolnoj should be urgently hospitalised in an urological hospital, osobenno if it is a question of the obstructive form of disease. It speaks neobhodimostju first of all to normalise a passage of urine from a kidney. The only thing, chto doctor SMP before hospitalisation can execute to establish to the woman kateter ademeure in a bladder at thorough data about puzyrnomochetochnikovom refljukse. After hospitalisation and elimination of possible causes of illness naznachajutsja antibiotics and uranoseptiki, active in the relation gramotritsatelnyh and grampolozhitelnyh microorganisms.

Definition a nonspecific sharp inflammation predstatelnoj zhelezy.

the Clinical current . Disease usually begins with speeded up boleznennogo in the end of the certificate mocheispuskanija and a body heat. Characteristic javljaetsja increase mocheispuskanija at night (57 times), small portions, with prodolzhajushchimisja desires and a pain in promezhnosti, amplifying at defekatsii. Ostryj the prostatitis, especially at persons of elderly and senile age, demands srochnoj hospitalisation in an urological hospital as quite often oslozhnjaetsja a sharp delay mocheispuskanija or incomplete oporozhneniem uric puzyrja (residual urine).

the Diagnosis of a sharp prostatitis is simple. The patient can tell, that suffers hronicheskim a prostatitis, and on the eve of the present disease has transferred pereohlazhdenie. A direct link patogeneza a prostatitis is uretroprostatichesky a reflux in reply to increase of intraurethral pressure. Predpolozhenie about the diagnosis it is possible to confirm manual rektalnym with research, kotoroe reveals increased, sharply painful prostatu, sometimes with signs fljuktuatsii in one of its shares. This research is carried out rather cautiously pri wide experience of the doctor.

Treatment . The patient with a sharp prostatitis should be urgently gospitalizirovan in an urological hospital. It is especially important, if clinical kartina is accompanied by a fever. Treatment begins with application of antibiotics shirokogo an action spectrum. If within 12 days there is no positive dynamics, absoljutnym is troakarnoe assignment of urine from a bladder in a kind tsistostomii. Further application uranoseptikov is shown.

Definition a nonspecific inflammation of an appendage jaichka which can neredko grasp and jaichko epididimoorhit. The reason sharp epididimita javljaetsja an infection more often getting retrogradno from an urethra owing to it buzhirovanija, kateterizatsii, endoskopicheskih manipulations, etc., from prostaty, rezhe gematogenno.

the Clinical current and diagnostics . Disease can razvivatsja slowly, from pain occurrence in this or that half moshonki and posledujushchego developments of its hypostasis with increase in the size, rise in temperature tela. It there is an ambulance surgeon who defines at such bolnogo sharp morbidity even at easy palpatsii the amazed bodies.

essentially such patient is subject to hospitalisation in an urological hospital, osobenno if at manual rektalnom research the doctor defines signs hronicheskogo a prostatitis.

Treatment : antibiotics, ice, candles with diklofenakom.

Nephritic kolika (personal computer) one of the strongest and painful kinds boli which demands fast diagnostics and treatment. Risk of occurrence of the personal computer in techenie lives of 1-10 %. Naibolee the frequent reason of the personal computer is urolithic illness (MKB) in the form of stones mochetochnika or, that happens rather seldom, a cup stone (" chashechkovaya" kolika). In any case of the personal computer a consequence of sharp infringement of a passage of urine on top mochevym to ways (VMP) (chashechnolohanochnaja system and mochetochnik). From here many bolezni, both urological, and not urological, can call the personal computer in rezultate internal okkljuzii or external sdavlenija VMP: sharp and chronic pielonefrit (products of an inflammation slime, fibrin, epitely, leukocytes), a tumour pochki (gematurija in the form of clots), a kidney tuberculosis (nekroticheskaja a fabric sosochka), travma kidneys (at the expense of clots of blood or external sdavlenna VMP urogematomoj), ginekologicheskie or such diseases zabrjushinnogo spaces, as retroperitonealnyj fibroz (illness Ormonda) and other.

Patogenez the personal computer: sharp okkljuzija VMP j sharp povyshenie pressure in chashechnolohanochnoj to system j a hypostasis paren himy j a stretching of a fibrous capsule of a kidney (fig. 1). Bol at the personal computer is a consequence of hyperactivation baroretseptorov chashechnolohanochnoj sistemy and receptors of a fibrous capsule which on ThXILI segmentam a spinal cord is passed in a kind afferentnyh impulses in a bark golovnogo a brain where it is transformed as a pain.

At the heart of these stages patogeneza the personal computer lays set patofiziologicheskih protsessov. If to present patogenez the personal computer from the point of view of "pure" practice, that, vozmozhno, it is more important for the ambulance surgeon, it is possible to see, that its scheme prosta.

the Clinical current of the personal computer . At adults the pain usually arises suddenly, imeet constant and shvatkoobraznyj character, the sexual member, in a vagina and sexual lips is localised in lumbar area ili podrebere and irradiiruet on a course mochetochnika in podvzdoshnuju, pahovuju areas, v moshonku and its bodies. It is accepted schitat, that irradiatsija pains decreases with moving of a stone which in it sluchae stops in places of physiological narrowings mochetochnika lohanochnomochetochnikovom a segment (souste) more often, at a recross with podvzdoshnymi sosudami, jukstavezikalnom (predpuzyrnom) and intramuralnom (in a wall mochevogo a bubble) departments. In the latter case the pain irradiiruet in a head sexual chlena also can be accompanied speeded up and painful in the end of the certificate mocheispuskaniem.

the Pain can be accompanied by a nausea and the vomiting which is not bringing simplification, and takzhe a delay othozhdenija gases and development pareza intestines of different degree. Harakter pains, especially in the first 1,5-2 ch, body position, any of which, as a rule, not prinosit simplification forces the patient to change. The patient rushes about, sometimes inclines a trunk, keeping ladon on a waist from a pain. At stone localisation in jukstavezikalnom otdele mochetochnika there can be false desires to defekatsii and speeded up mocheispuskanie.

the Pain at the personal computer at children of younger age is usually localised in the field of a navel, chashche is accompanied by vomiting. The child cries, is frightened. The sharp attack of pains lasts nedolgo (15-20 min), that it is possible to explain fornikalnoj nephritic rezorbtsiej urine. In this case vozmozhno rise in temperature of a body to 37,2-37,3 and # 65392; S.

the personal computer with a sharp pain in a waist develops approximately at 3 % of pregnant women in tretem a trimester. The clinical picture corresponds to obstruction localisation v top two thirds mochetochnika is more often.

personal computer Diagnostics . Personal computer recognition is based on anamnesis gathering (presence MKB or other diseases, in patogeneze which is possible development sharp obstruktsii VMP), to a disease picture, fizikalnom survey, ultrasonic issledovany (ultrasonic) of kidneys and uric ways, application radio isotope and rentgenologicheskih research methods.

In a clinical picture of the personal computer of first two hours the bradycardia and umerennoe increase of arterial pressure at the expense of the reflex mechanism can be observed, odnako these changes are changeable. In the analysis of peripheral blood can be umerennoe increase of quantity of leukocytes to 10-12х109/мл. Gematurija the most frequent symptom of the personal computer which is shown, as a rule, in a kind " more fresh" eritrotsiturii. At the same time normal indicators of the analysis of urine do not exclude the personal computer, a is faster, confirm it as it testifies to absence postuplenija urine from the blocked kidney from the party gripes at not amazed protivopolozhnoj to a kidney. As it has been specified above, one of links patogeneza pains pri the personal computer is inclusion of nervous receptors at level ThXILI, a therefore this pain can be perceived and as consequence of involving of some organov zheludochnokishechnogo a path and other urinogenital bodies which can innervirovatsja from segments of these levels of a spinal cord.

For example, the pain at the personal computer owing to a stone mochetochnika can irradiirovat in jaichko as the kidney, and mochetochnik ThXIThXII has the last innervatsiju the same level, as, and at a stone mochetochnika at level ego a recross with podvzdoshnymi vessels on the right irradiirovat in podvzdoshnuju oblast in point МсВurney, feigning an appendicitis, etc.

On the other hand, the pain owing to sharp epididimita, orhita, perekruta semennogo kanatika (jaichka) can and is frequent irradiiruet in area of a waist and on hodu mochetochnika, feigning the personal computer.

In this connection differential diagnostics of the personal computer spend with " sharp by a stomach" (an appendicitis, pechenochnaja kolika, a cholecystitis, a pancreatitis, probodnaja a stomach ulcer or 12-perstnoj kishki, intestinal impassability, a thrombosis mezenterialnyh vessels, adneksit, vnematochnaja pregnancy, perekrut kisty jaichnika), a radiculitis, intercostal nevralgiej, Herpes zoster etc. As differential diagnostics of the personal computer with bolshinstvom the specified diseases is in details resulted in textbooks on urology, pozvolim to itself to stop only on some of them.

the Intercostal neuralgia has shvatkoobraznogo no character of a pain, depends from polozhenija bodies, i.e. abates in rest and at superficial breath that does not happen pri the personal computer. Extremely seldom the personal computer arises from an opposite side in relation to okkljuzirovannomu mochetochniku. This phenomenon is described Сlаrk and Norman and named " mirror bol". Believe, that the similar phenomenon can take place at such anomalies razvitija kidneys, as podkovoobraznaja, L or Svivid a kidney, etc. Unfortunately, chuvstvitelnost and specificity of signs and personal computer symptoms make sootvetstvenno 73 % and 46 %. But it was possible to show, that predecessors of the personal computer javljajutsja sharp, long (till 10-12 ch) a pain in a stomach or a waist and mikrogematurija (at more than 10 eritrotsitah in pole sight).

ultrasonic ideal primary inspection (and dynamic supervision) patients from the personal computer, tak as it noninvasive, fast, with repetition possibility, rather nedorogoe and, that absence ionizirujushchego radiations and necessities of introduction of contrast substances ideally dlja children, pregnant women and patients with some defeats of the kidneys complicated pochechnoj by insufficiency, including in a terminal stage is important for ambulance surgeons, portable, and.

ultrasonic in seroshkalnom a mode reveals stones in chashechnolohanochnoj to system, and glavnoe in lohanochnomochetochnikovom a segment and intramuralnom department mochetochnika. Transrektalnoe and trasvaginalnoe ultrasonics allow to visualise konkrementy in jukstavezikalnom department mochetochnika. Stone revealing hardly more low lohanochnomochetochnikovogo a segment can be carried out at pieloureteroektazii. Ultrasonic legko reveals (kaliko) pieloektaziju. However expansion chashechnolohanochnoj systems zavisit from completeness of obstruction and its duration (1,5-2 ch). Moreover, expansion chashechnolohanochnoj systems can be a consequence puzyrnomochetochnikovolohanochnogo a reflux, is long existing chronic pielonefrita, numerous personal computers in the anamnesis and other reasons. Such picture nabljudajut is much more rare, that is why expansion lohanki and-or cups (for example, pri intranephritic lohanke) a real sign of the personal computer.

Thus, diagnostic tactics at the personal computer develops of two etapov. The f irst dostatsionarnyj the most responsible and quite often difficult: it raspoznavanie a problem of the ambulance surgeon or the one who renders it. In it sluchae at the disposal of the doctor:

the anamnesis (numerous nephritic gripes in the past owing to nefrolitiaza with othozhdeniem konkrementov, occurrence of pains after jolty driving, run, employment sportom, physical activity, plentiful drink or on the contrary sharp restriction pitevogo a mode, stay in conditions of a heat of environment, upotreblenija in food of considerable quantities " salt" products, meat uraty, chocolate oksalaty, molochnorastitelnyh phosphates);

a clinical picture of disease (behaviour of the patient, the opened palm with storony waists, dizurija, specific irradiatsija pains, dispepsicheskie projavlenija);

data of the general survey (presence of postoperative hems traces appendektomii, holetsistektomii, apropos perforativnoj stomach ulcers or 12-perstnoj kishki, intestinal impassability, etc. Facilitate the emergency period differentsialnoj diagnostics of the personal computer with a choice of means of its knocking over);

given fizikalnogo inspections (a positive symptom pokolachivanija pojasnitsy from pains);

express diagnostics mikrogematurii.

we Will hope, that in the near future ambulance surgeons will have in svoem the order the portable device for ultrasonic, having seized which job, they rasshirjat the " fasts" diagnostic possibilities, including or, maybe, v the first turn of the personal computer.

the Second stage should not call stationary diagnostics of the personal computer big trudnostej.

personal computer Treatment carries out two primary goals : elimination of a pain and a stop ili obstruction liquidation. If to recollect stages patogeneza the personal computer, it becomes clear, that glavnym a medicine of the fast medical help for knocking over of pains at the personal computer javljaetsja diklofenak sodium. Last is the antagonist of synthesis prostaglandinov, that promotes decrease in a filtration and, thus, vnutrilohanochnogo pressure. Besides, diklofenak sodium reduces an inflammation and otek in a zone okkljuzii, ingibiruet stimulation of smooth muscles mochetochnika, that snizhaet or even blocks it peristaltiku. These effects diklofenaka sodium privodjat to pain knocking over at the personal computer, and it analgetichesky the effect is identical with takovym at morfina at its intravenous introduction.

Diklofenak sodium apply intramuscularly, intravenously, peroralno, sublingvalno and rektalno.

Except diklofenaka sodium, use indometacin, piroksikam and others nesteroidnye anti-inflammatory preparations.

Parenteralnaja the dosage diklofenaka sodium makes 75 mg, rektalnye svechi contain 100 mg of a preparation as diklofenaka sodium, and indometacin (children`s dozy 50 mg).

it is necessary to remember negative influence not steroid anti-inflammatory preparatov at persons with diseases zheludochnokishechnogo a path (erosion, an ulcer), osobenno during the period or immediately after their aggravation. In this case on the foreground skoroj the help leave atropine, platifillin, antidiuretiki desmopressin (synthetic analog vazopressina). At confidence of the personal computer diagnosis it is not necessary to forget about warm vanne.

Gematurija the pathological symptom characterised by an impurity of blood in urine. Prichiny nephritic bleedings are presented in table 1.

Distinguish gematuriju micro-and macroscopical.

For specification of localisation of a source of a bleeding test is carried out two-and trehstvorchataja: thus to the patient suggest to urinate consistently in dva or three glasses.

1) Individual (initial) when blood paints only pervaja a portion of urine, other portions of normal colour.

2) Terminal (final) at which urine in the first portion vizualno it is not found out blood impurity and only last portions of urine soderzhat blood.

3) Total when urine in all portions is equally painted krovju.

In case of an impurity of blood urine gets red colour of various intensity ot colours " meat pigwashes" to temnovishnevogo. But degree krovopoteri is impossible otsenivat on urine colouring, since The maintenance of blood of 1 ml in 1 l of urine already gives it krasnyj colour.

Intensity of a bleeding is defined by presence of blood clots, degree krovopoteri a haemoglobin indicator, and is more exact gematokrita. Scarlet blood, vydeljajushchajasja with urine, testifies to a proceeding bleeding.

In cases when urine gets brown colouring, it is necessary to consider, that krovotechenie has stopped, and urine colouring is caused by dissolution blood sgustkov urine. The putrefactive smell speaks about stagnation of urine and joining infektsii.

it is necessary to remember, that colour of urine can vary at reception various lekarstvennyh preparations and foodstuff; from pyramidon pink colour, 5-NOK shafrannozheltyj, from a rhubarb and senny brown, from purgena, at alkaline reaction mochi crimson, from fenolftaleina and beets red, from a madder krasilnoj burovatokrasnyj.

From gematurii it is necessary to distinguish gemoglobinuriju thus bloody okraska urine depends on disintegration in blood eritrotsitov and allocation with urine gemoglobina which is in it in the form of cylinders.

Colour of urine at gemoglobinurii does not change even at its long standing, in to time as at gematurii eritrotsity quickly settle on a bottom of a vessel and top sloi urine get normal yellowish colouring.

gemoglobinurija it is observed after transfusion of incompatible blood, at otravlenii by aniline, mushrooms, potassium chloride, karbolovoj acid, dlitelnom cooling and extensive burns.

the Impurity mioglobina in urine gives it krasnoburuju colouring. Mioglobin fiber, blizky on structure to haemoglobin, gets to blood from the smashed muscles at so-called " krashsindrome" (long squeezing and razmozzhenie fabrics), since Its molecule v three times is less than haemoglobin, it easily gets into urine.

Top Ichesky diagnostics is helped by character of blood clots. Clots cherveobraznoj forms specify in a bleeding from the top departments of uric ways and formirovanie them in mochetochnike. However formation of such clots probably in prosvete urethras after travmaticheski vypolnenoj kateterizatsii a bladder at bolnogo with an adenoma predstatelnoj glands.

Shapeless clots are more often formed in a bladder. For topicheskogo diagnoza pains in lumbar area which are caused sharp narusheniem a passage of urine from a kidney by the formed clots matter.

the Combination of two symptoms gematurii and pains allows to differentiate novoobrazovanie kidneys from nefrolitiaza.

At nefrolitiaze gematurija arises not so much as a result of a trauma urotelija lohanki konkrementom, how much as a result of integrity infringement fornikalnyh venoznyh textures at sharp increase vnutrilohanochnogo pressure. T.o. gematurija at nefrolitiaze arises after p ristupom pains (nephritic gripes), t.e. After restoration of a passage of urine on the top uric ways.

At a kidney tumour gematurija appears suddenly and can stop samostojatelno. As a rule, it is painless, however at okkljuzii mochetochnika sgustkami pain blood arise after gematuriej.

At initsialnoj gematurii urine is painted by blood in the first portion, that svidetelstvuet about presence of pathological process in an urethra.

It is necessary to distinguish initsialnuju gematuriju from uretrorragii, at which blood vydeljaetsja from an urethra out of the certificate mocheispuskanija.

At character specification gematurii at women it is necessary to exclude bleedings iz genitals. In such cases investigate an average portion of urine at samostojatelnom mocheispuskanii or the urine received from a bubble by kateterizatsii.

Gematurija at the women, coinciding on time with predmenstrualnym the period, dolzhna to suggest about a bladder endometriosis.

At terminal gematurii urine is painted by blood last portion, that svidetelstvuet about process presence in a back urethra or in a bladder. Such gematurija it is more often observed at a sharp cystitis, a prostatitis, a stone and a tumour mochevogo a bubble.

At total gematurii urine is painted by blood in all portions that can be obuslovleno localisation of pathological process either in a kidney, or in mochetochnike, or in a bladder.

it is the Most frequent the reasons total gematurii the tumour, a stone, a trauma pochki are, the bladder tumour, is more rare good-quality giperplazija prostaty, tuberkulez than a bladder and a kidney, a pyelonephritis, nekroz nephritic sosochkov, nefroptoz, vennaja a nephritic hypertensia, gidronefroticheskaja transformation, etc. Essentsialnaja gematurija unites a number of statuses at which it is unknown etiologija, patogenez, and klinikorentgenologicheskie and morphological researches ne allow to find out the reason kro votechenija (tab. 2).

For definition of tactics of treatment of the patient in a hospital the big role prinadlezhit to gathering of the analysis and survey of the patient at a pre-hospital stage.

It is necessary to find out occurrence conditions gematurii, its degree, character and dlitelnost, time of its occurrence to or after an attack nephritic gripes, presence v to urine of clots of blood, their form, presence or absence of a pain and dizurii at mocheispuskanii. The termination gematurii not always is a recover sign ili of a stop of development of illness.

Gematurija is an absolute indicator for hospitalisation of the patient in statsionar (in particular, in urological branch).

After installation of the preliminary diagnosis it is necessary to begin haemostatic and protivovospalitelnuju therapy.

Treatment. At a massive bleeding with education shapeless sgustkov the sharp delay of urine owing to tamponady a bladder is possible. Neobhodimo to establish urethral kateter and to wash a bladder from clots with pomoshchju a syringe Jean or to use evakuatorom. Haemostatic therapy sostoit in intravenous introduction etamzilata, acids aminokapronovoj, etc. Etamzilat enter intravenously 2-4 ml in one stage, or it is possible to enter kapelno, adding to usual solutions for infuzy. Aminokapronovaja acid is appointed intravenously and inside. For fast effekta enter intravenously sterile 5 %-s` rastvor a preparation on an isotonic solution of sodium of chloride kapelno to 100 ml. Primenenie r-ra acids aminokapronovoj can be combined with solution injection gljukozy, gidrolizatov, antishock solutions. At gematurii, connected with primeneniem geparina, appoint protamina sulphate v/v strujno or kapelno, 1 mg nejtralizuet approximately 85 ED geparina.

This suddenly come absence of the certificate mocheispuskanija at overflowed mochevom a bubble and a painful desire.

the sclerosis of a neck of a bladder, an alien body, a stone and urethra rupture, novoobrazovanie the bottom uric ways can be Reasons OZM an adenoma predstatelnoj glands, a cancer prostaty, sharp prostatit. Be more rare reasons OZM diseases i damages of the central nervous system (a tumour, a trauma etc.) can .

OZM reflex character takes place after operations, especially at children is more often. Sleduet to remember frequent occurrence OZM, mainly at elderly men, posle injections of atropine or its derivatives. In this case OZM is a consequence snizhenija of a tone detruzora, more often at already available urological disease, naprimer, at an adenoma predstatelnoj gland.

the Clinical picture . The patient is disturbed, the sensation raspiranija vnizu a stomach feels strong pains in nadlobkovoj of area, painful desires to mocheispuskaniju.

At survey at patients of an asthenic constitution define a symptom " ball" in nadlobkovoj areas. Perkutorno over a bladder a stupid sound. Palpatsija boleznennaja izza a strong desire to mocheispuskaniju.

Diagnostics first of all is based on anamnesis data, survey bolnogo. At interrogation it is important to pay attention to how the patient to OZM was wetted, kakogo colours was wetting, whether it kakielibo accepted the preparations promoting zaderzhke of urine. The doctor should specify all moments which could lead dannomu to a status. The knowledge of the reasons and patogeneza OZM will help to develop most pravilnoe the decision in each concrete case.

Differential diagnostics . It is very important to differentiate OZM from anurii. At OZM the patient disturb painful desires to mocheispuskaniju, and at anurii they are not present, palpatsija nadlobkovoj area does not call sharp morbidity, tak as a bladder empty.

It is impossible to forget about such kind of a delay of urine, as " paradoxical ischuria", at kotoroj the bladder is overflowed, the patient cannot independently empty mochevoj a bubble, but thus urine is involuntarily allocated with drops. If at such bolnogo to let out urine urethral kateterom, podtekanie urine on kakoeto time prekrashchaetsja (until the bladder again will not be overflowed).

Treatment . Urgent action is urgent oporozhnenie mochevogo a bubble. At a pre-hospital stage it can be carried out by kateterizatsii a bladder elastic kateterom or nadlobkovoj punktsiej.

If OZM proceeds more than two days, it is expedient to leave kateter in mochevyh ways with purpose of preventive antibacterial therapy.

Contra-indication to kateterizatsii a bladder are: sharp uretrit and epididimit (orhit), a sharp prostatitis and-or an abscess prostaty, an urethra trauma.

In case there is at least one of the listed factors, neobhodimo to resort to a capillary puncture of a bladder.

each time the ambulance surgeon solves the Question on hospitalisation of the patient individualno. At available difficulties of the first kateterizatsii, signs uretrorragii, a sharp inflammation of an urethra, bodies moshonki and predstatelnoj glands, travme urethras, the impossibility of carrying out katetera (more than two attempts nedopustimo) accepts urgent hospitalisation in urological branch.

In case of OZM after introduction of medicines or reflex character the question mozhet to be solved towards polyclinic patronirovanija.

Basic rules kateterizatsii are specified in section " Anury". From ispolzovanija metal katetera at a pre-hospital stage follows vozderzhatsja. A capillary puncture of a bladder in a peace time carry out tolko in a hospital urological or surgical.

Definition absence of urine in a bladder.

Classification .

Allocate four forms anurii:

1. Arenalnaja anurija (renoprivnaja) at congenital aplazii both kidneys, at sluchajnom or deliberate removal both (or unique functioning) pochek.

2. Prerenalnaja anurija mechanisms of its development:

decrease in warm emission (kardiogennyj a shock, a heart heart attack);

system vazodilatatsija (a sepsis, nejrogennyj a shock);

gipovolemija and sharp decrease in volume of circulating blood (krovopoterja, plazmopoterja (at extensive burns), degidratatsija (at vomiting, a diarrhoeia, forsirovannom diureze), occurrence " the third spaces" (at sekvestratsii zhidkosti in a belly cavity astsit, in hypodermic kletchatku hypostases and other reasons).

Patogenez infringements of general haemodynamics and circulation with sharp obedneniem nephritic blood circulation induce afferentnuju vazokonstriktsiju with pereraspredeleniem (shunting) of a nephritic blood-groove, an ischemia korkovogo a layer and snizheniem speeds klubochkovoj filtrations in a kidney. At aggravation nephritic ishemii prerenalnaja anurija can pass in renalnuju at the expense of ischemic nekroza epitelija nephritic izvityh kanaltsev.

3. Renalnaja anurija it is in most cases called sharp kanaltsevym nekrozom, prichinami which can be more often:

Other reasons renalnoj anurii sharp and chronic terminal nephritic nedostatochnost owing to glomerulonefrita, malignant arterial gipertenzii, gemorragicheskoj fevers with a nephritic syndrome and Other

4. postrenalnaja anurija sharp infringement of outflow of urine from kidneys in uric puzyr. It is so-called sharp supravezikalnaja retentsija the urine, arising in rezultate okkljuzii the top uric ways from both parties. In case of unique ili it is unique a functioning kidney such form anurii arises, as sledstvie obturatsii it mochetochnika.

the Most frequent reason postrenalnoj anurii urolithic illness, preimushchestvenno in the form of stones mochetochnika. This circumstance has served osnovaniem to call such form anurii obturatsionnoj or ekskretornoj, in that vremja as prerenalnuju and renalnuju forms named sekretornymi. Among others prichin, leading postrenalnoj anurii, it is possible to allocate external sdavlenie mochevyh ways at retroperitonealnom fibroze, a uterus cancer, jaichnikov and others.

the Clinical picture . Early symptoms anurii are always connected from it prichinoj: Disease or aggravation of chronic defeats of bodies serdechnososudistoj systems, a trauma, reception casually or with the suicide purpose neizvestnyh or obviously dangerous medicines or substances, an aggravation already known hronicheskih diseases urolitiaza, gouts, diseases of bodies of a small basin and t. d.

Among signs of a clinical current anurii it is possible to allocate :

• infringement vodnoelektrolitnogo an exchange
• infringement kislotnoosnovnogo statuses
• defeat of the central nervous system (an uraemic intoxication)
• accruing azotemija
• defeat of lungs
• sharp bacterial and not bacterial inflammations of bodies.

One of the most dangerous displays of infringement vodnoelektrolitnogo an exchange javljaetsja giperkaliemija concentration increase kalija in whey to level more 5, 5 mekv/l that observe at giperkatabolicheskih processes when accumulation kalija a consequence not only blockade nephritic ekskretsii, but also its consequence postuplenija from nekrotizirovannyh muscles, gemolizirovannyh eritrotsitov. In it sluchae dangerous to a life giperkaliemija (more than 7 mekv/l) can develop in the first sutki illnesses.

Metabolic giperhloremichesky atsidoz arises in most cases, as sledstvie decrease in level of bicarbonates of blood to 13-15 mol/l. At expressed narushenijah kislotnoosnovnogo statuses arises " big noisy" breath Kussmaulja and other signs of defeat TSNS.

Azotemija a cardinal sign anurii, and its expressiveness reflects its weight techenija. At heavy hyperhydration the uraemic hypostasis of lungs, projavljajushchijsja progressing respiratory insufficiency develops.

Diagnostics . The main thing in success of liquidation anurii early diagnostics, and hotja this condition for almost all urgent statuses, in this case it opredeljaet emergency hospitalisation in profile branch of hospital, emergency neobhodimost in a hemodialysis (etilenglikol, heavy metals) and many other things, chto allows to warn destructive processes in kidneys, heavy sufferings bolnogo and quite often to rescue his life. That is why the ambulance surgeon at the slightest podozrenijah on anuriju should hospitalise the patient immediately.

Such suspicion arises after the collected anamnesis; Expressed atsidoz with vysokim anionnym deficiency develops owing to infringement of deducing by kidneys sulfatov and phosphates, and also for the bill ketoatsidoticheskoj (diabetic and alkogolnoj) a coma, an intoxication alcohol substitutes (metanol, etilenglikol), pri a shock, a poisoning okisju carbon etc., and in any case of definition nalichija urine in a bladder. It is important in all cases, but especially, when soznanie the patient " it is entangled", memory " blear", an explanation of relatives not clearly and t.p. For differential diagnostics with a sharp delay of urine carry out kateterizatsiju a bladder. It is ideal to apply kateter with a cylinder (№ 14-16,18 po SHareru), to leave it in uric ways for supervision for possible pojavleniem wet, that helps as in to, and hospital the periods with tactics lechenijah. Kateterizatsiju carry out delicately, in sterile gloves, since Any travma urethras at infitsirovanii can lead so-called " rezorbtivnoy" lihoradke and uretritu.

For the decision of a question on the form anurii it is necessary to find out, whether was vozdejstvija nefrotoksicheskih factors; it is necessary to know about presence of diseases, privodjashchih to anurii (urolithic illness, disease predstatelnoj glands, ginekologicheskie diseases, heart diseases etc.) Whether was episodes pochechnoj gripes.

At survey of the patient it is necessary to pay attention to presence free zhidkosti and presence of massive hypostases to measure arterial pressure (at level AD below 70 mm hg can develop prerenalnaja anurija). Auskultatsija can vyjavit presence of damp mixed rattles over all surface of lungs, esli there is an uraemic hypostasis of lungs, rentgenologicheski the symptom " is characterised mnozhestvennymi oblakovidnymi infiltratami in both lungs; butterflies".

the Leading part in revealing giperkaliemii and the level control kalija belongs biohimicheskomu to monitoring and an electrocardiogram. elektrokardiografija allows to reveal giperkaliemiju on high, narrow, pointed positive teeth T, postepennomu to shortening of an electric systole zheludochkov interval QТ (fig. 1), s possible delay atrioventrikuljarnoj and vnutrizheludochkovoj conductivity and sklonnosti to sinusovoj a bradycardia.

Treatment . We will repeat, that at the diagnosis anurija success of treatment - in ekstrennoj hospitalisation. However in a case prerenalnoj its form arising kak a consequence kardiogennogo of a shock or a collapse, - the ambulance surgeon can and objazan to try to direct the efforts to maintenance of warm activity, sosudistogo a peripheral tone on purpose to stabilise or even is admissible (in zavisimosti from the diagnosis) to raise arterial pressure. It is natural, that in it sluchae the patient hospitalise with proceeding drop introduction necessary rastvorov. In a case postrenalnoj anurii emergency hospitalisation in urologicheskuju clinic is shown, and at renalnoj anurii owing to a poisoning - emergency washing of a stomach on a probe or "restaurant" way, and takzhe introduction of antipillboxes is possible do it at precisely established poisonous substance.

Opublikovano from the permission administrations  Russian Medical Zhurnala.