Pyelonephritis in children: classification, course, diagnosis and treatment

General information about the disease

Pyelonephritis is an inflammation of the kidneys of a bacterial nature. Almost every second newborn is susceptible to this disease, because the kidneys are not yet properly formed at the time of birth. Children who underwent intensive care immediately after birth are also at risk.

This disease affects the pyelocaliceal system and the renal parenchyma (internal tissues). It is detected mainly in children under seven years of age.

The main causative agent of pyelonephritis in a child is Escherichia coli , which settles in the urinary system. Also, the disease is often provoked by coccal infection. Source: A.A. Kozlovsky Pyelonephritis in children (literature review) // Problems of health and ecology, 2009, pp. 60-66

Important ! Parents should know and promptly identify signs of pyelonephritis in their child. The disease is dangerous in its chronic form and even fatal.

Vesico-ureteral reflux

Vesico-ureteral reflux is a pathological condition characterized by the backflow of a small amount of urine into the renal pelvis. It is caused by its obstructed outflow into the bladder through the ureters.

Vesico-ureteral reflux is most often diagnosed in childhood and adolescence. Its danger lies in an acute attack with painful symptoms and quickly occurring complications. It is in childhood that there is a high risk of rapid replacement of functionally active tissues with connective tissues with pathological scarring. A number of factors predispose to pyelonephritis, including anatomical features:

• lower hydrostatic pressure (the volume of blood flowing through the kidney);
• inability to control urination in early childhood;
• lack of intimate hygiene skills;
• predisposition to weakened immunity.

Young children do not inform their parents about the first uncomfortable sensations and do not know how to interpret them. Therefore, pyelonephritis is diagnosed in them not at an early stage, but at a late stage, when severe complications have already arisen.

Another feature of the development of the disease in childhood and adolescence is the descending route of infection. Pathogenic microorganisms are transported by the blood stream from inflammatory foci formed in the upper respiratory tract. There are known cases where the trigger for pathology was carious teeth and a common ARVI.

Causes of the disease

Protozoa microorganisms, viruses, fungi, bacteria are the causative agents of inflammatory kidney diseases. In chronic forms, in some cases, a simultaneous combination of different pathogens is diagnosed.

Microorganisms can enter the kidneys:

• by blood (when an infection from another organ “spreads” throughout the body);
• through the lymph (with lymph flow, especially during stagnation in the lymphatic system);
• from the reproductive and/or urinary system (this infection occurs more often after one year and in girls).

If treatment is not started on time

Of course, failure to provide timely assistance to a child with pyelonephritis risks the development of serious complications. The most unpleasant one is a purulent abscess. It comes to this quite rarely; more often, due to self-medication or an incorrect diagnosis, sclerosis of the kidney tissue begins, and then necrosis of the tissue of these organs.

Chronic pyelonephritis, which a child suffered in childhood, can leave a mark for life and torment an adult with renal failure, hydronephrosis and arterial hypertension. Fortunately, if you do not start the process, the consequences and complications of pyelonephritis can be safely avoided.

It is worth noting that pyelonephritis can be treated for quite a long time - from two weeks to three months, even when the main symptoms and high temperature no longer make themselves felt. After a course of antibiotics and discharge from the hospital, it is important not to repeat the mistakes of many parents and not stop taking medications. Pyelonephritis is an inflammation due to an infection that does not go away immediately, but smolders gradually. If you do not “extinguish” it completely, after a certain period of time it will make itself felt again and, perhaps, the disease will become chronic. Thorough and leisurely treatment is the only possible option to treat and prevent recurrent outbreaks of the disease.

Once faced with a sudden inflammation of the kidneys in a child, parents, as a rule, begin to take a very responsible approach to ensuring that their child does not become hypothermic and run to the clinic for urine tests after the first symptoms of a cold. As experts note, pyelonephritis is not a reason to be afraid of a relapse for the rest of your life and limit your child’s bathing and playing in the fresh air. It is better to take good care of his hygiene and work closely on strengthening the immunity of the whole family. Then not a single bacteria will penetrate into the strong child’s body.

Predisposing factors:

• high aggressiveness of the microorganism, its resistance to the body’s defense mechanisms;
• abnormalities in the structure of the kidneys, causing improper outflow of urine;
• vesicoureteral reflux (when urine from the bladder flows back into the kidneys);
• stagnation of urine;
• violation of personal hygiene;
• inflammation of the genital organs;
• cystitis;
• diabetes;
• ailments that reduce immunity;
• worms;
• chronic infections;
• hypothermia;
• transfer of a child under one year to artificial feeding;
• teething.

Ascending infection towards the kidneys

Most often, pathogenic and opportunistic microorganisms enter the kidneys from the urethra through the bladder and urinary ducts. With weakened immune defenses, this process occurs at a rapid pace.

Because of the wide, short urethra, women are much more likely to have kidney damage than men. It is located very close to the vagina, anorectal area. Therefore, even with proper intimate hygiene, the risk of infectious pathogens moving towards the kidneys in women is very high.

In men, the development of the inflammatory process is usually caused by the presence of some kind of formation in the urethra, which prevents the normal flow of urine. It stagnates, which becomes a favorable environment for the proliferation of pathogenic bacteria. Men with kidney stones, proliferation of prostate tissue, urethral stricture, benign or malignant neoplasms in the organs of the urinary system are predisposed to acute pyelonephritis. Tumors and other factors that lead to narrowing of the urethra become an impetus for stagnation of urine in women.

Symptoms of the disease

Symptoms and features of acute pyelonephritis in children

Signs of the disease may vary and depend on the severity of the process, existing diseases, age and other factors. The general symptoms are:

• rise in body temperature for no apparent reason;
• drowsiness;
• weakness;
• vomit;
• decreased appetite;
• pale or gray skin;
• “bruises” under the eyes;
• pain (aching, pulling) in the lower back and/or abdomen, around the navel, which may decrease with heating;
• urinary incontinence;
• painful, frequent or, conversely, very rare urination;
• swelling on the face in the morning;
• cloudy urine that may have an unpleasant odor. Source: https://www.ncbi.nlm.nih.gov/pubmed/30592257 Leung AKC, Wong AHC, Leung AAM, Hon KL. Urinary Tract Infection in Children // Recent Pat Inflamm Allergy Drug Discov. 2019;13(1):2-18. doi: 10.2174/1872213X13666181228154940.

Signs of chronic inflammatory process in the kidneys

The chronic form of the disease is characterized by alternating remissions and exacerbations. During an exacerbation, the symptoms repeat the acute type of pyelonephritis. If a child is exposed to this chronic illness for a long time, he becomes irritable, inattentive, and gets tired quickly. Developmental delays are sometimes observed.

Symptoms of pyelonephritis

There are two forms of pyelonephritis with their inherent manifestations - acute and chronic. The acute form always occurs suddenly. The child has the following symptoms:

• a sharp increase in body temperature (up to 39-40°C);
• general weakness;
• chills;
• decreased appetite;
• nausea, vomiting;
• cloudiness and change in urine color;
• headache;
• severe pain in the lumbar back.

In some cases, the pain becomes so severe that it becomes difficult for the child to lead a normal lifestyle and even move.
The pain can be unilateral or, less commonly, bilateral. The clinic of chronic pyelonephritis manifests itself to a much lesser extent. Parents often find out that their child has an inflammatory disease during a routine urine test. The chronic course of the disease is characterized by:

• weakness and increased fatigue;
• frequent urination;
• headache;
• periodic nagging pain in the lower back, worse in the cold;
• anemia (pallor of the skin and mucous membranes, increased hair loss, brittle nail plate).

As a rule, chronic pyelonephritis is a consequence of an incompletely cured form of the disease.

Why is it difficult to diagnose pyelonephritis in infants?

The baby cannot tell the parents and the doctor about the unpleasant sensations. Therefore, parents must be very attentive. Symptoms typical for newborns include:

• frequent vomiting and regurgitation;
• sluggish sucking or complete refusal of the breast (bottle);
• cyanosis of the skin above the upper lip;
• lack of weight gain or decrease;
• dry skin;
• causeless crying and anxiety (signal pain);
• difficulty urinating (the child is worried, cries, blushes before this process);
• diarrhea;
• increased body temperature;
• sleep disturbance. Source: E.M. Pleshkova Features of pyelonephritis in infants // Bulletin of the Smolensk State Medical Academy, 2006, pp. 51-53

Clinical picture in women

The nature and severity of symptoms of acute pyelonephritis varies depending on the stage of the infectious-inflammatory process. Its acute course is characterized by the following symptoms:

• thickening, darkening of urine, the presence of blood streaks and purulent impurities in it;
• body temperature above subfebrile values, its sharp decrease and subsequent rise during the day;
• burning sensation when emptying the bladder, pain, pain;
• nausea leading to vomiting;
• headaches.

With severe kidney damage, the pain radiates, is felt in the lumbar region, and intensifies with pressure.

Classification of the disease

Consequences and complications

The cause of complications is late seeking medical help, as well as improper treatment. Acute pyelonephritis is especially dangerous for pregnant women and people with diabetes. The disease develops rapidly in them, and many pharmacological drugs with antibacterial effects are contraindicated. In such cases, adequate therapy with gentle agents under close medical supervision is required.

The more severe the inflammation, the higher the likelihood of sepsis. Pathogenic microorganisms quickly grow and multiply, and the infectious process spreads to healthy kidney structures. Toxic products of their vital activity accumulate in the systemic bloodstream. Blood poisoning occurs - a life-threatening condition that, if not treated promptly, can result in death.

Diagnosis of pilonephritis

The disease is diagnosed by laboratory and instrumental methods:

• cumulative samples;
• general urine analysis;
• urine culture;
• biochemical and clinical blood tests;
• biochemistry of urine;
• blood pressure control;
• Ultrasound;
• radiography;
• MRI;
• ;
• and others as prescribed by a doctor. Source: A.I. Safina Pyelonephritis of young children: modern approaches to diagnosis and treatment // Practical Medicine, 2012, No. 7(62), pp. 50-56

Infectious agents

The most common infectious agent of acute pyelonephritis is Escherichia coli. It is a gram-negative rod-shaped bacterium that lives in the lower intestine. The development of the inflammatory process can be provoked by the following microorganisms:

• staphylococci;
• Proteus;
• Klebsiella;
• enterococci;
• pseudomonas;
• streptococci;
• Pseudomonas aeruginosa.

A disease caused by the introduction of pathogenic or opportunistic fungi into the renal structures is diagnosed much less frequently.

In case of ascending infection in the urine, E. coli is especially often detected by biochemical methods or microscopy. But if surgical intervention, traumatic injury and medical manipulation led to pathology, then Klebsiella, Proteus, and Pseudomonas aeruginosa are detected.

Treatment options

Important! You cannot use traditional methods and take medications uncontrollably. Therapy should be prescribed and supervised only by a physician.

Acute form of the disease

With pyelonephritis of this form in children, diet and bed rest are important. Adjusting the diet is aimed at reducing the load on the kidneys. Drug treatment is also carried out with antibacterial drugs, uroseptics, antispasmodics, antipyretics, etc. Treatment takes about a month or two, hospitalization may be recommended. Source: S.V. Maltsev, A.I. Safina Treatment of pyelonephritis in children // Practical Medicine, 2007, No. 5(24), pp. 20-24

During the period of remission, the child should be observed by a pediatrician, nephrologist, and undergo tests with a specified regularity.

Chronic form of the disease

The therapy is similar to that used for acute pyelonephritis. It includes the use of diet, medications, and for a number of anomalies, surgery is indicated. During the period of remission, anti-relapse measures are prescribed (uroseptics, antibiotics, herbal medicine, etc.).

Treatment methods for acute pyelonephritis

When determining individual therapeutic tactics, the doctor takes into account the nature and severity of the symptoms of acute pyelonephritis, the severity, age of the patient, and the presence of concomitant diseases.

Treatment is outpatient only for pathology detected at an early stage of development. In other cases, the patient is hospitalized for therapy under the supervision of medical personnel. This is also necessary if there are signs of general intoxication of the body - fever, chills, nausea, vomiting, and a dangerous drop in blood pressure.

The leading method of treatment is a course of antibiotics. To increase the effectiveness of therapy, you must adhere to the following medical recommendations:

• frequent consumption of water acidified with lemon juice, weakly brewed tea to force the elimination of pathogenic bacteria in the urine;
• compliance with bed rest to minimize the risk of spread of the infectious process to healthy tissues and organs;
• optimal temperature conditions, absence of drafts;
• emptying the bladder as often as possible, which often requires taking diuretic (diuretic) drugs.

Simultaneously with acute pyelonephritis, the pathology that caused its development is treated. Treatment of gynecological diseases, prostatitis, prostatic hyperplasia is performed. It is aimed at the rehabilitation of chronic infectious and inflammatory foci of any location and (or) restoration of optimal urine outflow.

When choosing the most effective antibiotic for a particular patient, the doctor is guided by the results of bacteriological urine culture. Its effect can be enhanced by drugs from other clinical and pharmacological groups, for example, antimicrobial agents, uroseptics, including those with herbal active ingredients. Self-selection of antibiotics is ineffective, since pathogenic bacteria gradually develop resistance (resistance) to such medications. And this will lead to the progression of the disease and the development of complications.

If conservative therapy is ineffective and a large purulent focus has formed in the renal structures, surgical treatment is performed. The doctor chooses the most gentle method, aimed at excision of the minimum possible amount of tissue. Only in emergency situations associated with irreversible damage to the organ is it completely removed.

The help of surgeons is often required to eliminate the cause of inflammatory kidney damage. For example, with a pronounced narrowing of the urethra, proliferation of prostate tissue, or the presence of a neoplasm.

Advantages of SM-Clinic

“SM-Clinic” is one of the best specialists in St. Petersburg, doctors with high qualifications and significant experience. We have created comfortable conditions for small patients, diagnostics are carried out quickly and accurately, and treatment is prescribed based on individual characteristics. In case of hospitalization, children are offered comfortable rooms.

You can make an appointment with a pediatric nephrologist by phone.

Sources:

1. A.A. Kozlovsky. Pyelonephritis in children (literature review) // Problems of health and ecology, 2009, pp. 60-66.
2. EAT. Pleshkova. Features of pyelonephritis in infants // Bulletin of the Smolensk State Medical Academy, 2006, pp. 51-53.
3. A.I. Safina. Pyelonephritis in young children: modern approaches to diagnosis and treatment // Practical Medicine, 2012, No. 7(62), pp. 50-56.
4. S.V. Maltsev, A.I. Safina. Treatment of pyelonephritis in children // Practical Medicine, 2007, No. 5(24), pp. 20-24.
5. https://www.ncbi.nlm.nih.gov/pubmed/30592257 Leung AKC, Wong AHC, Leung AAM, Hon KL. Urinary Tract Infection in Children // Recent Pat Inflamm Allergy Drug Discov. 2019;13(1):2-18. doi: 10.2174/1872213X13666181228154940.

The information in this article is provided for reference purposes and does not replace advice from a qualified professional. Don't self-medicate! At the first signs of illness, you should consult a doctor.

Diagnosis and treatment of pyelonephritis in children in outpatient practice

Diagnosis and treatment of urinary tract infections and pyelonephritis in children is one of the pressing problems of pediatrics; they are among the most common infectious diseases and are widely encountered in pediatric outpatient practice.

Table 1. Diary of the rhythm of spontaneous urination (sample of management)

Table 2. Differential diagnosis of enuresis

Urinary tract infection

(UTI) is their bacterial infection at any level, be it the bladder (cystitis), the renal pelvis (pyelitis) or the renal parenchyma (pyelonephritis).

Pyelonephritis

(PN) is a nonspecific, acute or chronic microbial inflammation in the interstitial tissue of the kidneys and the pyelocaliceal system involving tubules, blood and lymphatic vessels in the pathological process.

The importance of the problem of pyelonephritis is due to factors such as:

• high prevalence
  . Due to the fact that UTIs in children are not subject to mandatory registration, their incidence is not precisely known. It can be assumed that many cases, mainly in infants, remain unrecognized or the diagnosis is made erroneously. PN ranks second in frequency of occurrence after acute respiratory diseases. The prevalence of UTIs, including PN, according to various sources, ranges from 15 to 22 per 1000 children, and with a comprehensive survey, 200-400. In the structure of diseases of the urinary system, PN ranks first, accounting for 70% of nephrological pathologies;
• the possibility of recurrence and progression of the process
  . The risk of UTI recurrence is high and, according to various sources, is up to 80%, decreasing by approximately 20% after each subsequent relapse. The greatest number of relapses occur during the first 6 months after the infection. They are often caused by a microorganism of a different species or serotype;
• risk of complications with the development of arterial hypertension and chronic renal failure
  . PN ranks third among the causes leading to chronic renal failure (CRF). In the development of complications, late diagnosis of urological pathology in patients with UTI is of great importance;
• reproductive dysfunction and decreased quality of life
  . In case of infertility, the frequency of UTIs in patients reaches 40-50%. Infectious diseases of the urethra (urethritis) and genital organs (for example, epididymitis, prostatitis) are much more common in adults and are usually sexually transmitted. It should be noted that in the practice of a pediatric urologist-andrologist, adolescents with sexual disorders (erectile dysfunction, ejaculation, orgasm, spermatogenesis) and psychosomatic disorders arising in connection with this (depression and hypochondria, hysterical and impulsive reactions) are increasingly encountered.

Etiology and pathogenesis

According to most studies, UTIs in children are caused by Escherichia
coli
.
Other gram-negative pathogens are Klebsiella
spp.,
Enterobacter
spp.,
Proteus
spp.
and Pseudomonas
spp.
There are also gram-positive microorganisms: enterococci, Streptococcus agalactiae
- in newborns,
Staphylococcus saprophyticus
- in adolescents who are sexually active.
In most cases, infection occurs via an ascending route: from the urethra to the bladder - with cystitis, from the ureter to the kidney - with pyelonephritis. This is typical for children of absolutely all age groups. The hematogenous route is extremely rare, usually in newborns with sepsis caused by Staphylococcus aureus
. Bacteremia is more likely a complication of UTI. With an intact kidney, the inflammatory process (IP) cannot occur independently. The pathogenesis of UTI is based on the confrontation between the pathogen and the defense reactions of the macroorganism. The latter include:

• bactericidal properties of the secretion of urinary tract epithelial cells; glycoproteins that prevent bacteria from attaching to the mucosa;
• components of humoral and cellular immunity (IgG and IgA in urine, neutrophils and macrophages);
• periodic complete emptying of the bladder (the presence of residual urine in it not only does not promote the growth of bacteria, but also interferes with local defense mechanisms).

Failure of the protective properties of the kidney can occur only under the condition of structural-cellular, anatomical or functional disorders of varying severity in the urinary system. They entail a disruption of the normal outflow of urine, the creation of a “situation of tension” and lead to gradual overstretching of the urinary tract, which, in turn, leads to a decrease in tone, a slowdown in the flow of urine at various levels, its stasis, and disruption of the secretory and excretory functions of the kidney.

A pathogen that has penetrated the renal parenchyma causes a pronounced inflammatory response aimed at preventing the spread of infection. It is the inflammatory response that causes such systemic and local symptoms of PN as fever, intoxication and pain when tapping in the costovertebral angle. Nephrosclerosis can be a consequence of inflammation. The stated considerations about the etiopathogenesis of chronic PN in children are of great importance, since from these positions the futility of various treatment methods and methods of conservative antibacterial therapy without identifying the root causes of PN is obvious. Some children are sometimes treated unsuccessfully in outpatient clinics for chronic PN for years. Long-term antibacterial treatment is not only unable to suppress the inflammatory process in such cases, but leads to a gradual deterioration of the situation. Thus, the short-term antibacterial effect is replaced by the resistance of the microflora to the drugs used, and primary moderate anatomical and functional disorders quite quickly turn into pronounced and irreversible forms.

Based on the results of clinical, laboratory and instrumental research methods, the form of PN is identified.

Primary PN

– a microbial inflammatory process in the interstitium and pyelocaliceal system of the kidney, in which, under modern conditions, the causes contributing to its development are not identified.

Secondary PN

– a microbial-inflammatory process in the interstitium and pyelocaliceal system of the kidney, developing against the background of anomalies in the development of the organs of the urinary system, functional and organic urodynamic disorders, metabolic disorders, and dysplasia of renal tissue. Numerous studies have proven that in 80% of children, PN occurs secondary to mechanical or dynamic obstruction.

Factors and conditions predisposing to the development of UTI

For the differential diagnosis of various forms of UTI, in our opinion, the identification and correct assessment of factors that may predispose to the occurrence of infection are of particular importance:

• burdened obstetric and gynecological history of the mother
  (preeclampsia, threat of miscarriage, anemia, chronic diseases of the genitals, gestational renal failure and cystitis, oligohydramnios). The complicated course of labor (premature, rapid, delayed, infected, bleeding during childbirth) is also of great importance. These pathological conditions lead to the formation of morphofunctional immaturity, the development of intrauterine infection, acute and chronic hypoxia of the fetus and newborn, underlying neurogenic bladder dysfunction, vesicoureteral reflux, and enuresis. According to our data, indications of PN during pregnancy were present in 10% of patients, and diseases of the urinary system in close relatives were identified in 50% of children;
• the presence of malnutrition and rickets
  , which reduce the resistance and reactivity of the body in children of the first year of life. Predisposes to the introduction of infection into the urinary tract and the development of PN in infants, physiological imperfections of the body's enzymatic systems;
• anatomical and physiological features of the urinary system of infants
  , leading to urinary stasis (intrarenal location of the pelvis, tortuous hypotonic ureters, physiological immaturity of their neuromuscular apparatus, etc.), with an established infection, contribute to the development of PN;
• Any conditions that prevent the bladder from emptying completely
  carry a risk of developing a UTI. These include constipation, neurogenic bladder dysfunction and other urinary disorders. You should always ask about the latter (which is often forgotten to do). It is necessary to learn to ask parents active questions to identify the quantitative and qualitative characteristics of urination in a child.

Features of the mon clinic in children with urological pathology

The clinical picture of PN is polymorphic, can be quite blurred and change with age. The main symptom complex of PN is fever, chills, pain in the lumbar region, dysuria. The tendency of the disease to have a latent course over a long period, the large compensatory capabilities of the child’s body in general and the urinary system in particular are the reason for the late detection of not only its chronic, but sometimes acute forms, when one of the manifestations may be recurrent leukocyturia, detected by chance. The only, fairly constant and early symptom in such cases – repeated abdominal pain – is most often assessed by the doctor as an attack of acute appendicitis.

Most often, chronic PN in children manifests itself clinically at the age of 5-7 years. In fact, for most of them the disease begins in early childhood. Often infants are already affected by it, but diagnosing the disease presents significant difficulties due to the nonspecificity of the symptoms of the disease.

In infants, the clinical picture, as a rule, does not have symptoms characteristic of urinary tract inflammation. In newborns and infants aged 90 days. Symptoms such as drowsiness, excitability, sluggish sucking, vomiting, diarrhea, apnea, fever or hypothermia, and longer-lasting jaundice are often diagnosed. Sometimes you can identify indications of disturbances in the rhythm and nature of urination. Although these symptoms are nonspecific, since general analysis and urine culture have become a mandatory part of the workup to exclude sepsis in the setting of fever, misdiagnosis is rarely made. In children under 90 days of age. with fever of unknown origin, UTI is detected in 5-10% of cases. In children from 90 days. up to 2-3 years, fever, general symptoms, abdominal discomfort, gastrointestinal disorders are often found with PN, and the only sign of cystitis may be frequent and painful urination. In children who can speak and use the potty independently, the diagnosis is easier. With cystitis, all or many of the typical symptoms are present (painful, frequent, involuntary urination, urgency, discomfort in the suprapubic region, bedwetting, low-grade fever). In case of PN, high fever, severe intoxication, vomiting, abdominal or lower back pain are often diagnosed. Symptoms of damage to both the upper and lower urinary tracts may be present simultaneously, but in 1/3 of cases in children with manifestations of PN there are no symptoms of cystitis.

Diagnostics

The research algorithm for suspected PN includes an analysis of the patient’s complaints, a thorough collection of anamnesis (attention is paid to the premorbid background, the course of pregnancy, pedigree, the presence of metabolic disorders in family members) and clinical and laboratory data. The standards for paraclinical research in children with PN were compiled taking into account Order No. 151 of the Ministry of Health of the Russian Federation dated May 7, 1998 “On temporary industry standards for the scope of medical care for children.” Mandatory research methods are carried out for all patients, additional ones - for special indications. In patients with a predominance of severe leukocyturia

in combination with urination disorders and abdominal pain, congenital kidney pathology is most often detected - hydronephrosis, duplication of the kidneys and ureters, megaureter. Therefore, in such cases, the most informative are excretory urography and voiding cystography, which immediately make it possible to identify these developmental anomalies and refer the child for surgical treatment to a urological hospital. In the absence of pathology, they move on to radioisotope research methods to identify urodynamic disorders, and then to functional methods of examining the lower urinary tract.

In the group of patients in whom the predominant symptom is urinary disorders

in combination with leukocyturia, vesicoureteral reflux or various forms of bladder dysfunction, which are based on urodynamic disorders, are most often diagnosed. The latter are the main factor in the pathogenesis of PN in children who do not have developmental defects, when the kidneys and urinary tract are formed correctly. The leading role in the examination of patients in this group is taken by the assessment of the urodynamics of the upper and lower urinary tracts, in particular the determination of the rhythm of spontaneous urination, uroflowmetry and retrograde cystometry, radioisotope renography (Table 1).

If urodynamic disorders are detected, voiding cystography is performed. If vesicoureteral reflux is detected, the child must be hospitalized in the urology department. Treatment of functional urinary disorders is carried out on an outpatient basis.

enuresis are included in a separate clinical group

, which is often accompanied by chronic PN or combined with congenital malformations of the urinary system. This statement is illustrated by the results of a clinical study conducted over the past 5 years at the Saratov Regional Children's Clinical Hospital. 379 patients with enuresis aged 5-17 years (63% boys and 37% girls) were examined. At the same time, 53% of patients in the study group had urinary tract infection, including chronic PN (44%). Chronic PN was combined with cystitis in 17% of cases and occurred with equal frequency in boys and girls. Lower urinary tract inflammation was more common in girls (85%) (p

The group of patients with primary monosymptomatic enuresis included children whose only manifestation of the disease was involuntary urination during sleep. The most significant factors shaping bladder dysfunction and enuresis were the average effective volume of the bladder, the number of urinations per day, the delay in the formation of “mature” volitional control of urination, imperative urges (p

• high frequency of episodes of enuresis during the night (more than twice);
• intermittent nature of the course with an increase in the frequency of enuresis against the background of manifest manifestations or exacerbation of UTI;
• secondary origin of enuresis (after stable, at least 6 months, “mature” volitional control of urination);
• enuresis in children over 4-5 years of age with maximum deviations in the formation of “mature” volitional control of urination;
• leukocyturia and unmotivated rises in temperature in the first year of life and at the time of examination;
• enuresis in combination with imperative urination syndrome;
• signs of organic syndrome of damage to the central nervous system of a traumatic nature (birth, household, etc.)

Treatment

There are two clear directions in the problem of UTI and PN: diagnosing the causes of their development and choosing effective methods for treating the disease. Treatment of UTIs begins with their prevention, which comes down to identifying and eliminating predisposing factors; unfortunately, they are often discovered only during examination for an existing disease. Treatment of PN should be comprehensive, long-term, personalized and include the following aspects:

• elimination of microbial inflammatory process in renal tissue;
• normalization of the functional state of the kidneys;
• restoration of urodynamics of the lower and upper urinary tracts;
• elimination of metabolic disorders, stimulation of regenerative processes and reduction of sclerotic processes in renal tissue.

The basic principle of UTI treatment is the immediate prescription of antibacterial drugs in accordance with the sensitivity of the pathogen. The most important goal of antibacterial therapy is eradication of the pathogen, preventing the transition from the acute stage to the chronic stage and reducing the frequency of relapses. The duration of antibacterial therapy should be optimal to completely suppress the activity of the pathogen. For empirical antibacterial therapy of PN on an outpatient basis, we give preference to oral forms of “protected” penicillins and third-generation cephalosporins that have a bactericidal effect, such as the original drug Augmentin (amoxicillin clavulanate) and Suprax (cefixime). The results of the studies ARMID (2000-2001) and ALEXANDER (1992 to the present) showed that Augmentin, unlike ampicillin, is highly active against major pathogens. It creates sufficient concentrations of the drug at the site of infection, maintains an overwhelming concentration of the drug for the required time, which ensures reliable eradication. Cefixime is an oral semisynthetic antibiotic with a broad spectrum of action, practically not inferior to third-generation parenteral cephalosporins. For children from 6 months to 12 years of age, cefixime (Suprax) is available in the form of a suspension (8 mg/kg), for children over 12 years of age and adults - in capsules of 400 mg. The drug has a prolonged effect and can be prescribed once a day. The average course of treatment is 6-7 days. For uncomplicated UTI, nitrofuran derivatives Furagin and Furamag (furazidine potassium salt and basic magnesium carbonate) were used for long-term anti-relapse therapy, as well as to potentiate the action of antibiotics. The concentration of Furamag in urine is 3 times higher than that of Furagin, and the toxicity is 8.3 times lower than that of Furadonin. Resistance to Furamag develops much more slowly than to other antibacterial drugs. Furamag has high bioavailability. The herbal preparation Canephron N has proven itself well in the treatment of UTIs and PN. Thanks to the pharmacological properties of the components of Canephron N (centaury, lovage, rosemary), its effect is multidirectional and multifaceted (diuretic, anti-inflammatory, antispasmodic, antimicrobial, vasodilator, nephroprotective). The drug can be used both as monotherapy for uncomplicated UTIs and as part of complex long-term anti-relapse therapy for PN, vesicoureteral reflux and metabolic nephropathies.

According to the recommendations of the European Association of Urology, treatment of overactive bladder in patients with UTI and PN as monotherapy or in combination with metabolic agents is carried out using oxybutynin, an antimuscarinic drug. Among the antimuscarinic drugs on the Russian market, Driptan is the only one officially approved for use in children over 5 years of age. The maximum effectiveness of the drug was observed in patients with complete urinary urgency syndrome (p

Correction of secondary mitochondrial dysfunction in patients with PN involves the use of drugs such as coenzyme Q 10 (Kudesan, cytochrome C), lipoic acid, nicotinamide, vitamins A, E, C, dimephosphone, L-carnitine (Elkara). L-carnitine is a natural substance produced by the body, having a mixed amino acid derivative structure, related to B vitamins. Carnitine directly or indirectly participates in the metabolism of fatty acids, glucose, ketone bodies and amino acids, contributing to the process of energy formation. Elkar is used in a dosage of 20-30 mg/kg/day, for at least 1 month.

The use of immunomodulatory therapy for pyelonephritis in children helps to reduce the duration of the active period of the disease and the length of the patient's stay in the hospital (Tebloeva L.T., Kirillov V.I., 2001), reducing the risk of relapse of pyelonephritis (Gadzhialieva M.M., 2001). For this purpose, Viferon (recombinant human interferon alpha-2) is used. Viferon is prescribed depending on age: Viferon-1 (150 IU) is prescribed rectally to children under 7 years of age. Viferon-2 (500 IU) is prescribed to children over 7 years of age. During treatment with Viferon, we noted a pronounced positive effect in the younger age group (up to 7 years).

In 20 adolescents over 14 years of age with recurrent pyelonephritis and persistent, treatment-resistant dysuric disorders, a search was undertaken for new methods of immunocorrection, which determined the possibility of using the drug recombinant interferon alpha-2 Genferon in suppositories. The drug also contains anesthesin and taurine. The drug was used according to the following regimen: 1 suppository (500,000 IU) 2 times a day rectally for 10 days, then 1 suppository (500,000 IU) 2 times a week for 5 weeks. Control was carried out according to such parameters as the activity of pyelonephritis, the severity of dysuric phenomena and imperative urination syndrome, immediately after the end of the course of treatment and after 3 months. At the end of the full course of treatment, a positive result was observed in 87% of patients: for 3 months there were no exacerbations of PN, patients noted a significant decrease and disappearance of dysuria, imperative urges, and improved well-being.

The effect of Genferon on the adaptive function of the bladder detrusor is probably due to its constituent taurine, which acts as a neurotransmitter that inhibits synaptic transmission, plays a large role in lipid metabolism, and helps optimize energy and metabolic processes.

In conclusion, it should be noted that there is no universal protocol for the management of patients with UTI. Observation and treatment are tailored individually, taking into account factors that accelerate the progression of the disease.

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Questions and answers

Question: Is it possible to carry out treatment simultaneously according to therapeutic and gynecological treatment programs? What will be the results and the planned cost of treatment? Answer: We consider a person as a whole and treat not the disease, but the sufferer (sick)! We provide a combination of therapeutic and gynecological treatment programs. And in fact, we always adjust the treatment program taking into account concomitant diseases of the genitourinary, cardiovascular, neuroendocrine, respiratory systems, and gastrointestinal tract. The procedures are combined in such a way that each subsequent one potentiates (strengthens) the effect of the previous ones. The cost of a combined (combined) treatment program, as a rule, exceeds the cost of the main treatment program by no more than 15%. Sincerely, Chief Physician of the Resort Clinic for Women's Health, Ph.D. honey. Sciences O.Yu. Ermolaev.

Question: What documents are required for treatment? Answer: It is advisable to have copies of the results of a previously conducted clinical and laboratory examination (copies of ultrasound, x-ray, computer, laboratory and other studies), copies of consultations of other specialists, copies of epicrisis (conclusions) of surgical and conservative treatment. In other words, the most complete amount of medical information about your health status. If necessary or desired, it is possible to perform a clinical and laboratory examination in our Clinic.

Question: Is it possible to issue a sick leave certificate at the Clinic for the period of treatment? Answer: At the Women's Health Resort Clinic, sick leave (sick leave) is not issued.