Pyelitis

Pyelitis (from the Greek pyelos- pelvis), inflammation of the renal pelvis. Experimental observations and pathological-anatomical research have shown, however, that the inflammatory process as a rule is not limited to the pelvis and that along with it to a greater or lesser degree the parenchyma of the kidney is also affected. This gave some authors (Kuster, Ultzmann) reason to speak not of P., but of pyelonephritis, since this term indicates simultaneous involvement of both the pelvis and the kidney, while emphasizing that the predominant process is in the pelvis. Most authors, however, still use the old term P. as a purely clinical concept for designating those cases in which damage to the renal parenchyma cannot be detected by ordinary research methods (absence of protein in the urine, normal kidney function) and when the disease does not proceed too severely. Pyelonephritis is the term used for cases of disease when simultaneous damage to kidney tissue can be clinically recognized by the presence of protein, renal formed elements in the urine, and by decreased function of the given kidney. In those cases where the inflammatory process is localized predominantly in the renal parenchyma and to a lesser degree the pelvis is affected, it is customary to speak of nephropyelitis. Thus P., pyelonephritis, and nephropyelitis represent different stages of the inflammatory process of the upper urinary organs. Pyelonephrosis represents a further stage of the inflammatory process, characterized by the formation in the kidney of cavities filled with purulent content. Some authors give the terms pyelonephritis and nephropyelitis a different meaning, emphasizing not this or that degree of involvement of the pelvis and kidney, but the direction of spread of the inflammatory process, namely in ascending infection, when first the pelvis is affected, and then the inflammatory process spreads to the renal parenchyma, they speak of pyelonephritis, while in cases of descending infection, when the renal tissue is primarily affected and secondarily the pelvis, they speak of nephropyelitis. Often, however, the inflammatory process affects not only the upper urinary tract (pelvis), but also the bladder, and we then have to deal with a systemic disease. In such cases, it is customary to speak of pyelocystitis or cystopyelitis. Word formation by authors is either based on the principle of direction of spread of the process, with pyelocystitis implying a descending process (from the pelvis to the bladder) and cystopyelitis an ascending one, or based on the principle of predominance of clinical symptoms. When symptoms from the pelvis predominate, these authors speak of pyelocystitis, while when symptoms from the bladder predominate, they speak of cystopyelitis. P. is the most common surgical disease of the urinary organs, second in frequency only to inflammatory processes of the bladder. Women suffer from P. more often than men. This difference is particularly pronounced in children under five years of age and in adults from 20 to 40 years. This difference is somewhat erased in both sexes after 40 years, when men suffer from P. significantly more often than before this age. According to Julich's data, out of 170 cases of P., 140 were in women and 30 in men. In Kretschmer's 200 cases, 61% were women and 39% men. In Hellstrom's 398 cases of P., pyelonephritis, and pyelocystitis, there were 334 women and 64 men. According to Necker's collective statistics, for 1,296 women there were 462 men. According to Lenhartz, adult women were ill in 90%, according to Lindemann in 64.5%, girls according to Meyer in 70%, according to Kossel in 90%. The predominance of P. in women is explained by anatomical-topographical and functional peculiarities of the sexual and urinary system, especially in connection with the period of sexual life. The right side, especially in women, is affected significantly more often than the left. In men, the predominance of the right side is less pronounced. According to Zangemeister, P. in pregnant women was on the right in 67%, on the left in 13%, and on both sides in 20%. Bilateral P. occurs significantly less often than unilateral. In the vast majority of cases, the inflammatory process in P. is caused by bacteria or their toxins. In rare cases, P. can be caused by toxins excreted through the kidneys after taking cantharidin, turpentine, and other poisonous preparations. In some cases, aseptic pyurias are observed, the nature of which is not yet fully clarified. The infectious agent can enter the pelvis and kidney by the following routes: hematogenous, urogenous, and lymphogenous. The hematogenous route is simultaneously descending for the urinary system. Bacteria that have entered the bloodstream after passing through the renal glomeruli and tubules can initially cause an inflammatory process in the pelvis, which can later spread to the lower urinary tract - the ureter and bladder. Hematogenous infection of the pelvis can occur with any infectious disease (typhoid, paratyphoid, influenza, diphtheria, dysentery, etc.) or in the presence of a chronic infectious focus in the body (furuncle, osteomyelitis, tonsillitis, carious teeth, etc.). The urogenous route is an ascending (ascending) route for the urinary system, since the infectious agent, initially located in the bladder, can be thrown back during antiperistaltic contractions of the ureter by the so-called reflux from the bladder into the pelvis or spread per continuitatem, affecting the mucous membrane of the ureter, starting from the ureteral orifice and reaching the mucous membrane of the pelvis. The lymphogenous route. Through the work of Franke, the presence of anastomoses between the lymphatic vessels of the ascending and cecum (with the vermiform appendix) and the lymphatic vessels of the right kidney and pelvis has been proven; through these anastomoses, enterogenous infection can pass from the intestine into the pelvis. Such penetration is usually preceded by disorders of intestinal activity in the form of constipation or diarrhea, facilitating the penetration of the infectious agent (usually E. coli) from the intestine into the lymphatic vessels. Infection can enter the pelvis also along the lymphatic pathways located in the connective tissue along the ureter (outside it), both from an affected bladder and in inflammatory diseases of the appendages in women (parametritis) and in prostatitis and vesiculitis in men. Finally, infection can also spread along the lymphatic vessels located in the wall of the ureter itself. The lymphogenous route of infection for the urinary system, like the hematogenous one, is descending. Hematogenous and lymphogenous infection are defined as endogenous infection in contrast to urogenous, which is exogenous. Bacteriology of P. The most frequent causative agent of P. is the bacillus coli (E. coli). It is especially often found in women and girls (up to 90% of cases). Second in frequency is the staphylococcus. On Julich's material, it was found in 23.2%, in Necker's in 30%, in Wossidlo's in 34%. When considering only men with P., the percentage of staphylococcus increases significantly, reaching on Necker's material 58%, while E. coli in men was found only in 28.6%. Thus, in P. in women, first place is taken by E. coli, and in men by staphylococcus. Third place is occupied by streptococcus, then comes Proteus. The gonococcus is in last place. Mixed infection is relatively common, and along with staphylococcus, streptococcus, and other types of bacteria, E. coli is found. Subsequently, E. coli can completely displace the original causative agent. The nature of the causative agent, along with other factors, to some extent depends on the severity of the clinical course of P. Among the numerous strains of E. coli, the hemolytic ones are more pathogenic. Proteus causes a particularly deep process (with ulcers of the mucosa), while a frequent tendency for P. to transition to pyelonephritis and pyonephrosis is observed with streptococcal infection. Staphylococcal infection usually proceeds relatively mildly. Factors contributing to the development of P. The mere entry of bacteria into the pelvis is not yet sufficient for the development of an inflammatory process on the mucosa. The bacteria that have entered can be expelled from there by peristaltic contractions of the pelvis with urine, causing only bacteriuria, and not the phenomena of P. For the bacteria that have entered to settle on the mucosa, penetrate its thickness, and cause inflammation, the presence of certain favorable circumstances is required, and first of all - stagnation of urine in the pelvis, as occurs in pyelectasis, hydronephrosis, or a descended kidney. The second contributing factor is trauma to the kidney area, either direct trauma to the mucosa (by a stone). In rarer cases, the appearance of infection is facilitated by impaired circulation in the kidney and pelvis, as occurs in nephroptosis when the renal vessels are twisted. Finally, the development of P. is connected with the general weakening of the body, the virulence of the infection, the number of bacteria, and the duration of their entry into the pelvis. Pathological anatomy. The pathological-anatomical picture in P. depends primarily on the nature of the process. In acute P., the mucous membrane of the pelvis shows all signs of acute inflammation - redness, looseness, swelling, hemorrhages, sometimes necrosis of tissue with ulcerations.

The vessels are dilated, the wall of the pelvis is infiltrated with leukocytes. The mucous membrane is covered with purulent discharge. In chronic P., the mucous membrane is thickened, whitish-gray or brown in color, the number of vessels is reduced. In some areas, the mucous membrane is scarred. In prolonged processes, all layers of the pelvis are changed [see separate table (pp. 155-156), Fig. 5]. The infiltrated areas contain a large number of lymphocytes and plasma cells. Along with anatomical changes in P., a disturbance of the motor function of the pelvis is observed. The pelvis becomes atonic, its peristalsis is disrupted, and urine is poorly emptied from the pelvis. Histologically, the following forms of P. are distinguished: pyelitis simplex (redness and swelling of the mucous membrane), p. haemorrhagica (in case of hemorrhages), p. purulenta (with a large amount of purulent discharge), p. ulcerosa (with a tendency to ulcerations), p. pseudomembranacea, p. papillaris or polyposa (with a tendency to overgrowth of the mucous membrane), p. gravis, s. cystica. In p. follicularis, round cell accumulations resembling lymph follicles are found under the mucous membrane. In ascending pyelonephritis, the inflammatory process spreads from the mucous membrane of the pelvis to the renal parenchyma, either along the urinary tubules due to urine stagnation in the pelvis and increased intrapelvic pressure (ascending infection), or along the lymphatic vessels of the kidney. Voelcker distinguishes, from the pathogenetic point of view, two main forms of P.-infectious P. and dilatational P.-depending on whether the pelvis was dilated before the infection appeared or not. When P. (infectious) transitions to pyelonephritis, destruction of renal tissue occurs first in the area of the pyramid apices, and the cavity of the kidney expands mainly due to the expansion of the calyces, while the pelvis itself does not expand. Subsequently, the newly formed individual cavities increase in size and a picture of pyonephrosis results. In dilatational P., infection enters the primarily dilated pelvis with little changed calyces. In the first case, we have primary infection and secondarily occurring expansion of the kidney cavity, in the second case-primary expansion (of the pelvis) and secondarily occurring infection. Clinical classification of P. Depending on the nature of the clinical course, acute and chronic P. are distinguished. Acute P., in turn, can be primary if it occurs in previously healthy people without apparent cause, and secondary when a causal relationship between P. and a preceding general infectious disease (typhoid, influenza, etc.) can be established, or when there is already a lesion of the urinary system before the appearance of P. (stone, neoplasm, stricture, hypertrophy of the prostate, etc.). Due to the difference in the clinical course of P. in patients depending on age, sex, moments related to sexual life, P. in adults, in infants and children, in pregnant women and defloration P. are distinguished. Symptoms. Acute P. begins with a sudden rise in temperature, which is sometimes preceded by chills. The general condition is severely disturbed, weakness, malaise, headache, shallow and rapid breathing, frequent pulse, nausea, sometimes vomiting appear. The tongue is coated. Patients with acute P., especially in cases of hematogenous infection, give the impression of patients with symptoms of severe general infection. The general phenomena are explained both by the absorption of bacteria and their toxins by the mucous membrane of the inflamed pelvis, and by the entry of bacteria directly into the circulatory system by the so-called pyelovenous reflux. The absorption of toxins and pyelovenous reflux is facilitated by increased intrapelvic pressure, which occurs due to difficult outflow of urine from the pelvis because of swelling of the mucous membrane in the pelvic part of the ureter and reduction of its lumen. In mild cases, the temperature lasts 4-6 days and the general condition is less disturbed; in severe cases, when the inflammatory process involves the renal parenchyma (pyelonephritis), the temperature, reaching 40°, can last 14 days or more. The temperature fluctuations can reach two or more degrees during the day. In some cases, the temperature curve is intermittent-after 4-5 days of normal or subfebrile temperature, it rises again to 39-40° and remains at this level. In some cases, acute P. begins with general malaise and a slight rise in temperature, and only after several days does chills and a sharp rise in temperature occur. If the local symptoms (pain in the renal region, dysuria) are not pronounced and the urine does not attract attention, patients with acute P. often give rise to an erroneous diagnosis-abdominal typhoid, pneumonia, malaria-depending on the general symptoms and the nature of the temperature curve. Pain is the second main symptom of acute P. It is acute or dull in character and is localized either from the back to the area of the XII rib or in the hypochondrium. In hematogenous infection, sharp stabbing pains can occur immediately as a result of sudden infectious embolism. Dull, pressing pains of a longer duration occur either as a result of stretching of the pelvis due to insufficient outflow of urine or as a result of tension of the renal capsule. The described pains can radiate from the renal region downward into the abdomen along the course of the ureter. In addition to independent pains, pains caused by tapping the kidney area from the back (Pasternatsky's symptom) and tenderness on palpation of the kidney from the abdominal wall are observed in acute P. The latter is often tense. The third and most essential symptom in acute P. are changes in the urine. The urine in P. is turbid due to the bacteria and pus contained in it. Bacteria can be contained in the urine of pyelitics in large quantities, especially in hematogenous infection, already at the stage when the number of leukocytes is still small. In the first days of the disease, the amount of pus increases. Macroscopically, the urine becomes diffusely turbid, and upon standing, a small sediment consisting of leukocytes forms. Sometimes the urine can contain a small macroscopic amount of blood. Microscopically, erythrocytes are found significantly more often (up to 25%). The amount of pus can change sharply during P. depending on the conditions of outflow of urine from the affected pelvis. When the pelvis empties freely, the urine is more turbid than when outflow is impaired. When temporary obstruction occurs due to edema of the pelvic part of the ureter, the urine can become clear, because the patient excretes urine from the bladder that has come there only from the healthy kidney. During the period of clear urine appearance in acute P., the temperature usually rises and pains in the area of the affected kidney intensify. The general condition also worsens. The protein content in the urine in P. is explained by the presence of pus and erythrocytes and usually does not exceed 0.1%. An increase in the amount of protein indicates damage to the renal parenchyma (pyelonephritis). The reaction of the urine depends on the nature of the infection. In colibacillary infection, the urine reaction is acidic, in staphylococcal infection and in the presence of Proteus, it is alkaline. The amount of urine is reduced in the first days, which is explained in part by the high temperature, and in part by urine stagnation and the resulting decrease in the functional activity of the kidneys (degenerative-toxic damage to the secreting renal epithelium). Subsequently, polyuria occurs. The increase in the amount of urine and the significant decrease in its specific gravity are explained by damage to the cerebral layer of the kidney and a decrease in the function of reabsorption of urinary water. Chronic P. can appear either completely unnoticed by the patient or develop as a result of a preceding acute P. The general condition in chronic P. is usually not disturbed, the temperature remains normal, and pains are as a rule absent. The only symptom that allows one to suspect the presence of a chronic inflammatory process in the pelvis is the presence of pus and bacteria in the urine. Sometimes chronic P. can periodically exacerbate and during this period give a picture typical of acute P. Chronic P. always requires searching for a cause in the anatomical and functional peculiarities of the urinary tract, which create unfavorable conditions for healing the inflammatory process in the pelvis. In chronic P., one must always remember the possibility of a tuberculous process in the kidney or the presence of a stone in the urinary tract. Defloration P. In some women, symptoms of acute P. occur several days after the first sexual intercourse. Most authors (Wildbolz, Rovsing) believe that the sites of rupture of the hymen are the port of entry for infection. Infection thus enters the pelvis by the hematogenous route. Some authors (Sippel), however, believe that the process of defloration itself is not guilty in the appearance of P., and that during vigorous sexual intercourse in some women, various bacteria can be introduced into the female ureter by the movements of the penis. This phenomenon is usually observed in women with a narrow entrance to the vagina, a high perineum, and a deeply located external urethral orifice in the vulva. According to this view, infection enters the pelvis by the urogenous route. The gonococcus is only exceptionally the causative agent of such P. Usually, intestinal bacilli are found in the urine.

The clinical picture is the same as in ordinary acute pyelitis. Postoperative pyelitis is sometimes observed after surgical intervention on the intestine, after appendectomy, after operations on the urinary bladder, after ureteral transplantation, after gynecological operations, etc. Pyelitis often appears after catheterization of the urinary bladder, especially when repeatedly performed due to urine retention in the postoperative period. Infection in postoperative pyelitis enters the renal pelvis either by the urogenic or lymphogenous route. Diagnosis. Recognition of acute pyelitis is easy in cases where the characteristic triad of symptoms is present—pain in the renal region, elevated temperature, and pus in the urine. However, this symptom complex appears comparatively rarely simultaneously. In the first days of the disease, pain in general or pain with characteristic localization may be absent. The phenomena of general infection or intoxication come to the forefront. In such cases, the disease can be recognized if pus and bacteria are found in the urine being examined. If, along with general symptoms, abdominal pain appears without the localization characteristic of kidney disease, diagnostic errors are possible. Depending on the localization of the pain, acute appendicitis, cholecystitis, or acute disease of the appendages in women may be mistakenly diagnosed. Error can be avoided only by timely microscopic and bacterioscopic examination of the urine for the presence of blood, pus, and bacteria. In those cases where, after several days from the onset of the disease, either independent pain in the renal region or pain on palpation of the kidney or a positive Pasternatsky symptom appears, the diagnostic thought is directed toward kidney disease. And in these cases too, only the finding of pus and bacteria confirms the assumption of pyelitis. Thus, urine examination plays a leading role in the recognition of pyelitis. However, it should be remembered that sometimes the results of a single urine examination may be negative. If urine for examination is taken during the obstruction of the diseased kidney, the urine may not contain pathological elements. Therefore, when pyelitis is suspected, urine should be examined repeatedly. For women, urine for examination should be taken with a catheter to avoid the accidental entry of secretions from the genital organs into the urine container. In men, urine for examination should be obtained by the two-glass test. In pyelitis, both portions are equally turbid. To avoid diagnostic error in men, the prostate gland and seminal vesicles should be examined. Acute prostatitis can give the same general picture of the disease as acute pyelitis, and the urine, as in pyelitis, can be purulent in both portions. The history can also assist in the diagnosis of acute pyelitis. If the onset of this disease was preceded by symptoms of acute cystitis or the introduction of instruments for diagnostic or therapeutic purposes (catheter, bougie, etc.), the recognition of pyelitis is significantly facilitated. With an acute onset of the disease and localization of pain in the renal region, differentiation must be made between acute pyelitis, pyelonephritis, and paranephritis. In paranephritis, the urine as a rule does not contain pus. Acute pyelitis can be distinguished from pyelonephritis by the amount of protein contained in the urine and the presence of formed elements. If the amount of protein exceeds 1-1.5% and cylinders and renal epithelium are found in the urine, it can be concluded that not only the mucous membrane of the renal pelvis but also the renal parenchyma is affected. Cystoscopy and catheterization of the ureters are as a rule unnecessary for the recognition of acute pyelitis. These methods play a primary role in the diagnosis of chronic pyelitis. Chronic pyelitis often manifests as a single symptom—pyuria. The general condition of patients may not be disturbed, pain may be absent, and the temperature remains normal. Palpation of the kidneys may give negative results. The inflammatory process in the urinary system is discovered as a result of urine examination. Topical diagnosis is possible only with the help of cystoscopy and catheterization of the ureters. These methods should be used in men after excluding total urethritis and an inflammatory process in the sex glands. Even cystoscopy alone in some cases makes it possible to determine the side of the lesion. In these cases, inflammatory changes are visible in the area of the ureteral orifice on the corresponding side. The orifice is often eroded, hyperemic, and edematous, while the mucous membrane of the urinary bladder in the remaining areas remains unchanged. Sometimes it is possible to see, when examining the area of the ureteral orifice, how a turbid stream of urine is ejected from the orifice of the affected side. When pyelitis and cystitis exist simultaneously, simple cystoscopy gives no results, and in such cases it is necessary to resort to the most important method of investigation—catheterization of the ureters. Chromocystoscopy after the introduction of indigocarmine shows in uncomplicated cases of pyelitis (e.g., in the absence of signs of pyelectasis) normal or slight delay in the excretion of colored urine from the affected side. Significant delay makes one suspect deeper pathological changes either on the part of the renal pelvis and ureter (atony, hydronephrosis, or hydroureter) or on the part of the renal parenchyma (pyelonephritis, tuberculosis of the kidney, pyonephrosis, etc.). Catheterization of the ureters makes it possible to obtain urine separately from each kidney and, by chemical (for protein), microscopic, and bacteriological examination, to determine the side of the lesion. In addition, catheterization of the ureters makes it possible to determine certain anatomical features of the affected side—narrowing of the ureter, dilatation of the renal pelvis with residual urine in the pelvis. Simple X-ray examination can reveal the presence of a stone in the renal pelvis or ureter that does not cause pain but maintains the symptoms of pyelitis. Pyelography shows the anatomical (morphological) picture of the renal pelvis and ureter—whether the renal pelvis is normally positioned (nephroptosis with kinking of the ureter, dystopia, etc.), whether the renal pelvis is of normal size or dilated, whether there is narrowing of the ureter or compression of it by an accessory renal vessel, etc. All the mentioned details are extremely important from the point of view of therapy in each case of chronic pyelitis. The systematic application of all the research methods mentioned makes possible an exhaustive diagnosis of pyelitis. In each individual case, one should strive, as far as possible, to clarify the etiology of the disease, determine the causative agent of the infectious process, and reveal the normal or pathological condition of the urinary system in terms of both anatomical and functional features. It is especially important to determine the presence of a primary inflammatory focus in the urinary system and the presence of a mechanical obstacle to the outflow of urine. From the point of view of differential diagnosis, special research methods (chromocystoscopy, catheterization of the ureters, pyelography, etc.) make it possible to isolate cases of chronic pyelitis from the total number of cases of renal pyuria—pyonephroses and tuberculosis of the kidney. In pyonephroses, one often sees on cystoscopy the excretion of a purulent 'sausage' from the ureteral orifice. Indigocarmine is not excreted at all by such a kidney. Pyelography shows the presence of one large cavity or multiple communicating cavities. It is more difficult to differentiate between chronic pyelitis and the initial form of tuberculosis of the kidney in the absence of specific changes from the side of the urinary bladder (tubercles, ulcers, bullous edema). The absence of flora in the urine obtained from the diseased kidney, the acidic reaction of the latter, a somewhat larger amount of protein than corresponds to the pus contained in the urine, positive results when the urine is inoculated into a guinea pig, and finally, the eroded contours of the calices minores and the straight, elongated ureter without physiological curves on the pyeloureterogram speak for tuberculosis of the kidney. The prognosis in pyelitis is generally favorable. In most cases, acute pyelitis ends in recovery. The disease takes a prolonged course in the presence of predisposing factors of a general and local nature. The outcome depends on the type of flora and its virulence, on the nature of the primary infectious focus, on the condition of the organism, on the one-sided or two-sidedness of the lesion, on the presence of obstacles to the outflow of urine from the renal pelvis, etc. Under unfavorable conditions, the inflammatory process can progress, passing into nephropyelitis or even pyonephrosis. Chronic pyelitis always has a certain anatomical or functional basis, and therefore the prognosis depends on the possibility of eliminating the causes that maintain the infection. In rare cases, with very virulent infection and unfavorable general and local factors, the outcome can also be fatal. Prevention of pyelitis with exogenous infection consists in maximum observance of asepsis during instrumental manipulations of a diagnostic and therapeutic nature (catheterization and irrigation of the bladder and renal pelvis, pyelography, etc.). In infants, careful care is necessary for preventive purposes (see below). In recurrent pyelitis with focal infection, it is necessary to eliminate the primary focus. Treatment.

Therapeutic measures in P. can be divided into the following 4 main groups: 1) dietetic-medication, 2) local-instrumental, 3) vaccine therapy and 4) surgical treatment. Each of the listed methods has both its indications and contraindications, and the success of treatment depends on the timeliness and correctness of application of one or another method in each individual case. In acute P., treatment is predominantly dietetic-medication. Patients should remain in bed. For pain relief, heat in the form of hot water bottles or compresses is applied to the kidney area, both from the side of the loin and from the front. Some authors recommend the use of diathermy. For severe pains not relieved by heat, narcotics should be resorted to. Among the latter, a particularly beneficial effect is attributed to intramuscular injection of papaverine (2-3 times a day, 0.04 each) (Necker and others). It acts not only symptomatically, reducing pain, but also helps to eliminate spasm in the upper urinary tract, which delays the excretion of purulent urine from the renal pelvis. Febrile patients should follow a diet. Food should be non-irritating and easily digestible by the intestine. The activity of the latter should be carefully monitored. This is especially important in cases of enterogenous infection. In such cases, laxatives and high enemas should be resorted to. For vigorous excretion of urine from the renal pelvis, abundant drinking (up to 8-10 glasses a day) is recommended. However, the goal of such irrigation of the renal pelvis from above is achieved only in cases where there is no retention of urine in the upper urinary tract, when the natural outflow from the renal pelvis is not impaired. In cases of severe infection accompanied by vomiting and oliguria, repeated use of drip enemas of 5-10% glucose (2-3 liters a day) is recommended. To worsen the conditions for the development of bacteria in the urinary tract, it is recommended to change the reaction of urine depending on the nature of the infection, either by oxidizing it or by alkalinizing it. Alkalinization of urine is advisable in cases of colibacillary infection. It is achieved by taking potassium citrate, sodium citrate, sodium bicarbonate, or magnesium oxide internally. Rehn advises intravenously every other day 50 cm³ of a 4% solution of sodium bicarbonate. Oxidation of urine is recommended for coccal infection (staphylococcus and streptococcus). For this purpose, patients are given carbolic acid, phosphoric acid, or hydrochloric acid. The desired reaction of urine should also be maintained by appropriate food. Alkaline reaction is achieved by consuming milk, cheese, potatoes, white bread, macaroni, beans, peas, etc., and acidic reaction by consuming meat, fish, eggs, lard, black bread, rice, oatmeal, etc. Some (Meyer-Betz, Haas) propose for the purpose of maximum oxidation of urine to limit the amount of fluid introduced per day to 600 cm³. This amount includes 300 cm³ of acid lemonade according to the following prescription: dilute phosphoric acid 15%-50.0, raspberry syrup 50.0, distilled water 1000.0. At the same time, patients take 3.0 of urotropine and 4.0 of sodium salicylate or aspirin per day. In addition, patients receive a light bath once a day. By restricting fluid intake and applying heat procedures, it is possible to achieve significant oxidation of urine. Such a regime lasts for 3-4 days in a row. Some authors (Casper) advise alternating two-day periods of fluid restriction with similar periods of vigorous diuresis. Other authors (Weskmann, Blum) recommend alternating periods of urine oxidation and alkalinization. Medicinal treatment aims to weaken the growth and virulence of bacteria. The main means is urotropine and its derivatives. Since urotropine acts only in an acidic urine reaction, it is not recommended to prescribe large amounts of fluid or alkaline water simultaneously with urotropine. For vigorous action, adults should be prescribed up to 3.0 of urotropine per day. In addition to urotropine, salol is widely used in the treatment of P. at 0.5-three times a day. Its use is especially indicated in colibacillary P. Recently, intravenous administration of disinfectants has been widely used: neosalvarsan, urotropine, cilotropine, tripaflavin, collargol, etc. Neosalvarsan is administered every 3 days at 0.15. Favorable results from this drug are explained by the action of the cleaving formaldehyde. Positive results in coccal infections, neosalvarsan usually gives after 2-3 infusions. In colibacillary P., the effect of neosalvarsan is less favorable. Urotropine is administered in a 40% solution in an amount of 5 cm³ daily. In the same doses with the same intervals, cilotropine is administered (5 cm³ of cilotropine contain 2.0 urotropine, 0.8 sodium salicylate, 0.2 sodium salicylate caffeine). Collargol, electragol and other colloidal silver preparations are usually used in severe septic forms of P. and pyelonephritis. The action of these preparations is explained by their bactericidal properties, which manifest not only locally in the kidney and renal pelvis, but also in the blood. Tripaflavin and other aniline group drugs (acriflavine, etc.) give more favorable results in alkaline urine and in septic coliform infection. Tripaflavin is administered in a 1/2-2% solution, starting from 5 to 10 cm³ every two days. All the listed drugs can manifest their action mainly in cases where there is no retention of urine in the renal pelvis and when the pathological process is not too deep. Local-instrumental treatment has limited indications in acute P. and wide application in chronic and subacute cases. Some authors (Pasteau) propose for the purpose of strengthening peristaltic contractions of the ureter and renal pelvis to maximally fill the bladder through a catheter with a weak solution of argentic nitrate and then quickly empty it, thus causing the vesico-renal reflex. Schott-muller for the same purpose instills 100 cm³ of 2% argentic nitrate into the bladder. After 5 min. the solution is released and the bladder is washed with physiological solution. The most essential method for treating inflammations of the renal pelvis is washing its cavity with medicinal substances or introducing a catheter a demeure for drainage. In acute P., ureteral catheterization is indicated only in cases where dietetic-medication treatment remains ineffective, the temperature remains high, general phenomena do not weaken, and the ineffectiveness of conservative therapy can be explained by insufficient outflow of urine from the affected renal pelvis. In such cases, sometimes a single catheterization is sufficient for the acute phenomena to disappear. In cases of urine retention in the renal pelvis, it is advisable to leave the catheter for a day or two. In chronic cases, it is recommended to wash the renal pelvis through an introduced catheter or instill small amounts of concentrated solutions into it. Before washing, the renal pelvis is allowed to empty and only then is washing begun. The medicinal substance (argentic nitrate from 1:1,000 to 1/4-1/2% solution) is introduced slowly and carefully, avoiding any stretching of the renal pelvis and the appearance of pain. After emptying the renal pelvis of the introduced solution, washing is repeated several times. For instillations, a stronger solution of argentic nitrate (1%) is introduced after preliminary emptying of the renal pelvis and washing its cavity with an indifferent solution. After the introduction of the medicinal substance, the ureteral catheter is removed. Washing of the renal pelvis is usually done every 3 days. With a catheter left a demeure, washings are done 1-2 times a day. The solutions used should be at body temperature; ureteral catheters should not be too thin-No. 6 according to Char. Washings of the renal pelvis should be preferred in cases of P. with residual urine when there is some dilation of the renal pelvis, while instillations should be resorted to in cases of a normal, non-dilated renal pelvis. Vaccine therapy. Opinions in the literature regarding the benefits of vaccine therapy in P. are contradictory. Its use is indicated only in chronic cases. Preference should be given to autovaccine. Vaccine therapy by no means should exclude the simultaneous application of other methods of treatment. Recently, works on the treatment of P. with bacteriophage have appeared. The latter is administered orally, parenterally or subcutaneously. Some authors (Rubritius) introduced bacteriophage directly into the renal pelvis. Surgical treatment. P., not accompanied by gross lesions of the renal parenchyma, or in cases where the infection secondarily joined a significantly dilated renal pelvis (infected hydronephrosis), as a rule, does not require surgical intervention. It should be resorted to only in cases where ordinary ureteral catheterization fails to eliminate the stagnation of purulent urine in the renal pelvis, fails to achieve a decrease in temperature and improvement in the general condition. In such cases, pyelostomy is indicated for the drainage of urine from the renal pelvis through a drain.

Surgical intervention should still be resorted to in cases where prolonged healing is unattainable due to a constant anatomical cause that disrupts the normal outflow of urine from the pelvis, as occurs in strictures of the ureter, fixed kinks of it, nephroptosis, or the presence of a stone in the pelvis. In these cases, the aim of the surgical intervention is to eliminate the aforementioned anatomical obstacles. Given that the intestine is often the source of recurrent infection, Lichtenberg advises performing decapsulation in addition to the main operation, thereby disrupting the connection between the lymphatic pathways of the intestine and the kidney. Treatment for individual clinical forms differs little from the therapy of ordinary cases. Pyelitis in pregnancy is the most frequent complication of pregnancy affecting the urinary organs. It occurs on average in 1%; however, this percentage refers only to severe cases requiring hospital treatment; if mild cases are also considered, the frequency of pyelitis in pregnancy, according to some authors (Boeminghaus and others), reaches 10%. Primigravidas contract the disease more often than multigravidas (according to Zangemeister, 3 times more often). Some authors (Stoeckel) point out that women of an infantile-hypoplastic type are particularly predisposed to this disease. Pyelitis often recurs with a new pregnancy (thus, the case of Legueu is particularly characteristic - a complication of pyelitis during 13 pregnancies). Naujoks, noting the relative frequency of recurrent pyelitis, explains it by pregnancies following one another quickly (as prevention, he recommends preventing them). As a rule, pyelitis appears in the second half of pregnancy, in rarer cases in the first months of pregnancy. Right-sided pyelitis in pregnant women is observed significantly more often than left-sided (according to Zangemeister, 3 times more often). In rarer cases, pyelitis is bilateral. Some authors (Bazy, Goppert and others) see a connection between pyelitis in pregnancy and pyelitis experienced in childhood. During pregnancy, in the opinion of these authors, an old dormant inflammatory process in the pelvis flares up. The majority of authors, however, deny such a connection, since pregnancy itself creates favorable conditions for the development of pyelitis. The main predisposing factor for the development of infection in the upper urinary tracts during pregnancy is the observed dilation and atony of the pelvis and ureter, especially in the second half of pregnancy, and consequently the stasis (retention) of urine there. Pregnancy almost like an experiment reveals the etiological significance of the factor of insufficient urine outflow for the development and existence of pyelitis. The frequency of dilation of the upper urinary tracts on the right during pregnancy reaches, on clinical material, according to Olshausen 50%, according to Lachs 75% on the right and 50% on the left, according to Weibel 40%, and on autopsy material according to Hirsch based on 300 autopsies - 30%. However, at present we have a more precise and objective criterion than old clinical observations for the anatomical and functional state of the upper urinary tracts during pregnancy, based on ascending or intravenous pyelography. The application of these methods has confirmed the existence in the second half of pregnancy of dilation of the upper urinary tracts, especially on the right, in most women. Several theories exist regarding the causes of dilation and atony of the upper urinary tracts during pregnancy. Stoeckel believes that the atony of the urinary tracts, like the atony of the intestine, is the result of the body's intoxication during the period of pregnancy. Sellheim explains the condition of the urinary tracts during pregnancy by their stretching (Weiterstellung), analogous to other hollow organs, due to the process of progressive growth. However, most authors tend to explain the dilation of the urinary tracts by the mechanical pressure of the pregnant uterus on the ureters at the level of the linea innominata. The predominant compression of the right ureter is explained by the frequently observed rotation of the pregnant uterus to the right around its long axis (Rechtsdrehung). The theory of mechanical compression of the ureter is confirmed by the following factors. During catheterization of the right ureter, a clearly perceptible obstacle is often encountered at the 13th cm (at the level of the linea innominata), which is particularly easily overcome if the pregnant uterus is slightly lifted through the abdominal wall and displaced to the left with the hands. After the tip of the ureteral catheter passes above the linea innominata, urine begins to be excreted through the catheter in rapid succession. Finally, pyelography, especially intravenous, in which any artificial mechanical influences are excluded, clearly shows that the existing dilation of the urinary tracts (pelvis and ureter) sharply ceases at the level of the linea innominata. The cited anatomical and functional changes are observed on the right during pregnancy even in the absence of an inflammatory process in the urinary tracts. Thus, pregnancy creates favorable conditions for the development of bacteria that have entered the pelvis by one way or another. Most often, the intestinal bacillus (76-79%) is found in the urine in pyelitis of pregnancy. However, some authors (Latzko and others) found staphylococci or streptococci in the urine in the first days of the disease and only later the intestinal bacillus. This circumstance gave these authors reason to consider the intestinal bacillus only as an additional infection that suppresses the growth of the primary one. The paths by which bacteria enter the pelvis in pregnant women are the same as outside of pregnancy. It is possible that the lymphogenous path is somewhat more often a conductor of infection, since pregnant women often suffer from constipation (Stoeckel, Latzko and others.). The urogenic path can be assumed to be less often responsible, since cystitis during pregnancy is relatively rare (Latzko). In each individual case, it is often impossible to determine by which path the infection entered the pelvis. The clinical picture of pyelitis in pregnant women, both in the onset of the disease and in its symptoms, differs little from ordinary acute pyelitis. However, pains in the renal region even with some elevation of temperature do not yet indicate the presence of pyelitis. These pains are the result of the compression of the ureter by the pregnant uterus, disruption of the outflow of urine from the pelvis, and the appearance of acute stasis phenomena in the upper urinary tracts. An increase in intrapelvic pressure, however, can cause the so-called pyelovenous reflux with the entry of some amount of uninfected urine from the pelvis into the circulatory system. The body reacts to the urine that has entered the bloodstream with temperature fluctuations. The clinical phenomena take a more acute course when some infection has localized in the upper urinary tracts. Pains in the renal region can be severe, temperature reaches 40° and higher; both at the onset of the disease and in the further course, chills and vomiting are often observed. The general condition of patients is severe. Such an acute course is explained, on the one hand, by the worsening of the outflow of urine from the pelvis not only due to the compression of the ureter by the pregnant uterus but also due to the narrowing of the lumen of the adjacent pelvic part of the ureter as a result of the inflammatory process, and on the other hand by the increase in intrapelvic pressure and the entry into the bloodstream of the infection residing in the pelvis via pyelovenous reflux. The urine in pyelitis contains a large number of pus cells and bacteria. During complete cessation of outflow from the diseased pelvis, the urine can be clear and contain neither pus nor bacteria. These periods of clear urine coincide with periods of worsening general condition, intensification of pains, and elevation of temperature. Pyelitis during pregnancy, as a rule, takes a protracted course. Periods of relatively good health alternate with exacerbation of all the characteristic manifestations of pyelitis, which is explained by the alternation of favorable and unfavorable conditions for the outflow of urine from the pelvis. However, pus and bacteria are present in the urine throughout the entire pregnancy, and only the elimination of predisposing factors associated with the pregnancy itself - whether it is normal delivery or artificial termination of pregnancy - leads to the cure of pyelitis. In regard to the treatment of pyelitis in pregnancy, we are in relatively favorable conditions since the predisposing and aggravating factors are known. First of all, one should strive to improve the outflow of urine from the pelvis, and secondly, try to affect the infection with the help of disinfectant drugs. To eliminate the pressure of the pregnant uterus on the ureters, it is recommended to lay the patient on the healthy side. Disinfectants should be administered intravenously (40% urotropin or cylotropin). In milder cases, it is possible to achieve improvement in the general condition, decrease in temperature, and alleviation of pains by using these means with a general appropriate regimen [bed rest, diet, regular emptying of the bowels (according to Stoeckel, 2 times a day high enemas for several days), heat on the kidney area, etc.].

(Vaccinotherapy is applied by almost no one due to questionable results, while regarding the recently proposed neosalvarsan, a final judgment cannot be made due to the small number of observations.) If this treatment does not yield success within 3-4 days, it is necessary to eliminate urine stagnation in the pelvis by catheterization of the ureter. Through the inserted catheter, the pus-retained urine is emptied from the pelvis. The intrapelvic pressure sharply decreases, the conditions for pyelovenous reflux * and absorption from the side of the pelvic mucosa are eliminated, and the condition of patients improves markedly within the first day. Sometimes a single catheterization is sufficient for all acute phenomena to disappear immediately. In cases of pyelitis in pregnant women, it is rarely necessary to resort to washing out the pelvis or instilling stronger solutions into it. Steckel advises resorting to local treatment - washing out the affected pelvis with a 2% solution of boric acid - only after the failure of the treatment mentioned above. Sometimes a catheter can be left in the pelvis for several hours or for a day. In case of recurrence of acute phenomena, ureteral catheterization must be repeated. Such treatment, being to a certain extent causal, makes it possible in almost all cases of pyelitis in pregnant women to achieve good results and carry the pregnancy to term. With rational instrumental treatment, we almost have no indications for artificial interruption of pregnancy in pyelitis. However, such cases still occur, just as cases of spontaneous abortions and premature births are observed. For example, in Albeck's 52 cases, 1 spontaneous abortion occurred, in 9 - premature births, and in 5 - it was necessary to interrupt the pregnancy; in Naujoks' 81 cases, 3 spontaneous abortions were observed, 34 premature births at 7-9 months, and 1 time it was necessary to induce premature labor. Finally, there are also such rarer severe cases in which hepatic syndrome develops and it becomes necessary to resort to abortion (Fruhanholz). However, a certain part of these cases can, with a certain degree of probability, be attributed to diagnostic errors (appendicitis, typhoid, pneumonia) or to untimely application of radical treatment (ureteral catheterization). On the other hand, the failure of pyelitis treatment by catheterization may indicate that we are dealing not with pyelitis, but with a deeper purulent process in the renal parenchyma, in which improvement in urine outflow from the pelvis does not affect the course of the purulent process in the renal parenchyma. In these cases, one cannot expect good results from artificial termination of pregnancy in relation to the renal process. In such patients, it becomes necessary to resort to surgical intervention on the kidney (nephrotomy, nephrectomy, etc.). Such surgical treatment, according to Steckel, makes it possible to preserve the pregnancy in most cases. The course of pyelitis is still favorable in the vast majority of cases, the development of pyonephrosis, the formation of stones on the basis of pyelitis is extremely rare, and fatal outcomes after it are also rare (e.g., Opitz, Naujoks, and others), which resulted from kidney insufficiency or general septic infection. - In rarer cases, pyelitis may occur for the first time sub or post partum, and in such cases it deserves the greatest attention, as it may serve as a cause for the spread of infection from the urinary system to the genital system. Hence it follows that all obstetric operations undertaken in pyelitis must be carried out with maximum caution, and similarly in the postpartum period, the possibility of the presence of pyelitis must be taken into account in the differential diagnosis. From the point of view of prevention, pregnant women should regularly visit the consultation, periodically undergo urine tests, carefully monitor the hygiene of the external genital organs and perineum, and observe the function of the intestines.

1. Gottlieb. Pyelitis in children. The concept of 'P. in children' does not fully coincide with what in adults is called inflammation of the renal pelvis. Observed by Goschler (1871), Huttenbrenner (1876), and later by Hirschsprung (1883), this disease was described by Escherich in 1894 under the name of colicystitis. Subsequent authors (Holt, Hutinel, Goppert, Filatov) established that the inflammatory process is not limited to the bladder but also spreads to the renal pelvis, i.e., that it is a matter of colicystitis and colipyelitis. Finally, in view of the fact that the main symptom of the disease—purulent urine—does not even give precise indications on microscopic examination as to the localization of the process, Kleinschmidt proposed using the term pyuria, which is generally accepted in pediatrics. As doctors began to pay more attention to the nature of urine in various diseases in children, it became clear that pyuria is a frequent phenomenon in children; it particularly often accompanies intestinal disorders and influenza infection. P. most often occurs between the ages of ¹/₂ year and 2 years, with girls suffering much more often than boys. Cases of P. have been described even in newborns (Sauer, Runge), and out of 27 cases, 18 were boys. In general, the age and sex of the child play a major role in the frequency of the disease; thus, according to Bloch's material, he encountered: Age Total Girls Boys % boys Under 1 year .... 291 275 25.5 10.1 Noggerath and Eckstein give figures of 537 in girls and 166 (23.7%) in boys. American authors indicate up to 42.5% in boys. As for the time of year, which according to some authors influences the frequency of P. in children, one must above all consider the epidemics of intestinal and influenza diseases, which are accompanied by P. The influence of constitutional factors, especially the exudative diathesis, is undoubtedly present, although the influence of this anomaly is apparently exaggerated by some authors (Birkg—100%). The neuroarthritic diathesis also noticeably influences the frequency of P., appearing as a predisposing factor (Filatov, Rudnev). The method of feeding in itself plays no role (Finkelstein), but since nutritional disorders are more frequent and take a more severe form in artificially fed children, it must be taken into account. Among the clinical forms of P., two are distinguished. In some cases (more often in girls over 2 years), the disease usually begins some time after some acute illness as a new acute infectious process: a sharp rise in temperature, often to 40°, with fluctuations or of the continuous type, chills or even convulsive seizures, severe general condition, vomiting, frequent painful urination, or frequent but fruitless urges. In other cases, the disease begins insidiously, without sharp phenomena, with an irregular type of temperature, and the child becomes capricious, irritable, and loses appetite. Urination is frequent. Very characteristic of P. is the pallor of the skin, often with a yellowish tinge, sometimes reaching actual jaundice. With progressive weight loss, very poor appetite, and digestive disorders, the child quickly becomes cachectic. In prolonged cases in artificially fed children, other purulent processes develop (pyoderma, otitis, pneumonia). In the blood, there is usually a decrease in hemoglobin and red blood cells, leukocytosis, neutrophilia, and a shift to the left. The urine is cloudy as soon as it leaves the bladder, and upon standing gives a typical purulent sediment; this cloudiness does not disappear entirely even upon filtration (bacteria); the reaction is usually acidic (pH up to 5.5). Under the microscope, an increased number of leukocytes (sometimes the entire field of view is covered with them), lying in clumps of 20-50. Depending on the course of the disease, individual portions of urine may be completely clear; therefore, to avoid error, urine should be collected for 24 hours or at least several portions. In addition to leukocytes, the urine contains a small amount of red blood cells, cells of the urinary tract, mucus, and a large number of bacteria of the coli type. Protein is usually present in small amounts (up to 0.05 according to Brandberg). The duration of the febrile period in the first form is 2-4 weeks, and in the second form it is very indefinite, on average up to 2 months. The disease gradually subsides, the urine becomes clear, the pus decreases and disappears completely; the general condition improves, and the child returns to normal. Recurrences (20%) are characteristic, under the influence of intercurrent infections (most often influenza) or weakening of immunity due to one or another, often insignificant, reasons. Sometimes, however—rarely—P. takes a chronic form, subsiding in the summer months and resuming in the autumn after the first influenza disease. Pathogenesis. The occurrence of P. in childhood can follow the same three paths as in adults. Each of these forms has its advocates. Undoubtedly, in individual cases, each of these three paths occurs, but the most frequent in girls under 2-3 years of age is apparently the ascending path, while in boys the hematogenous path is relatively more common. The basis for this is the anatomical conditions in the form of the great width and shortness of the urethra in girls, through which the intestinal bacillus more easily penetrates in early age due to frequent contamination with feces. This fact of the influence of anatomical conditions on the genesis of P. is further confirmed by the greater frequency of P. of colibacillary origin in women (90%) compared to men, as well as the frequency of pyelitis in children with developmental defects of the urinary tract. The hematogenous path of pyelitis gives greater mortality, and the statistics provided by Bloch indirectly indicate the predominance of this path in boys. 1 Total Recovered Improved Not recovered Died Boys Girls 75 216 32 137 7 26 11 23 25 (33.3%) 30 (13.8%) Finally, one cannot exclude another path of formation of P.—the occurrence of the process due to the development of microbes constantly present in the urinary tract, which enter through the urethra when general or local immunity is reduced under the influence of some general infection (influenza), similar to the appearance of otitis, pneumonia, pyoderma in weakened young children. The descriptions provided by American authors of kidney lesions in P. in the form of fine-mesh nephritis are based only on autopsy results of children who died from various diseases but gave signs of P. during life. The clinical picture shows that only severe, prolonged hematogenous P. have the renal tissue as their primary localization, while the phenomena in the renal pelvis, if discovered at autopsies, are of secondary origin. In older children, one must also consider P. as a consequence of foreign bodies (stones in the urethra, bladder, and renal pelvis, pinworms, and accidentally introduced foreign bodies in the urethra). The reaction of urine in these P. is usually alkaline. Pathological-anatomical changes in P. are most often observed in the mucous membrane of the renal pelvis and partially in the ureters and bladder, consisting of more or less significant hyperemia with an increased amount of mucus on the surface; sometimes purulent deposits and pinpoint hemorrhages are found. In a large number of cases, nothing can be noted macroscopically, and only microscopic examination reveals a focal, small-cell infiltration of the mucous membrane of the pelvis. The diagnosis in the acute form is made without difficulty on the basis of the symptoms mentioned (painful urination, general phenomena), and examination of the urine confirms the conclusions. It is more difficult to make a diagnosis in the second form of the disease, where often only repeated examination of urine and blood and the possibility of excluding other purulent infections leads one to favor P. It is very important to consider damage to the renal tissue (red blood cells and protein in significant amounts, granular casts, functional kidney tests). It is necessary to differentiate the colibacillary process from tuberculosis of the kidneys. Finally, one must keep in mind the extremely rare gonorrheal lesions of the urinary tract in childhood. The prognosis is most often favorable if it is possible to improve the nutrition and immunity of the patient. One must keep in mind the complication of pyelonephritis and the possibility of sepsis. Prevention of P. consists of increasing immunity, especially during the reparative period after intestinal disorders and general infections. Great importance is attached to adequate nutrition (vitamins) and sufficient intake of fluids, as well as proper care for the child with the use of air and sun. Some importance is also attached to the preventive administration of small doses of salol or urotropin during the reparative period. Therapy aims to 1) eliminate intoxication, 2) influence the multiplication of bacteria, and 3) increase immunity to Bact. coli. The first is achieved by prescribing abundant drinking, which promotes diuresis and enhanced excretion of toxins and inflammatory products. The qualitative (women's milk, vitamins) and quantitative composition of food also has great importance in this regard, but the difficulty is almost always the existing anorexia. The sugar diet according to Aron also sometimes gives good results.

For the purpose of affecting bacteria, disinfectants for urine have been proposed: Salol, Urotropin, Helmitol, Hippol, and others, but the results of their application are unreliable. Treatment with alkalis (Potassium citrate, etc.) until the urine is alkalized (McDonald) with the aim of limiting the development of Bact. coli does not achieve its purpose. Bladder irrigations have no basis in childhood, as the matter is usually not about cystitis. Attempts to treat the patient by raising specific immunity through vaccination or better autovaccination have not yet given definite results; further study of the ways and methods of specific therapy is necessary. For now, one has to resort to non-specific methods of treatment, raising immunity, protein therapy, or better hemotherapy with proper nutrition and care and symptomatic treatment.