Treatment of disorder
Fig. 1 Structure of urinary passage (quoted from homepage of Japanese Urological Association
Pyelonephritis is the disease where virus infects to kidney.
s shown in fig.1, urine produced at kidney flows through kidney pelvis and urinary duct, pooled at bladder and then discharged out through urethral tube. And this urinary passage, or urinal pathway, is biologically clean in nature, but virus breaks in and infected case is called as infection of the urinary tract. Depend on the position where virus in infected, they are generally grouped into lower tract infection and upper tract infection. Lower tract infection is the infection disease which occur at urinal passage or bladder. Most of them are bladder inflammation. On the other hand, upper tract infection is the infection disease which occur on kidney pelvis or kidney. Most of them are diagnosed as Pyelonephritis. Disease, which virus is propagated in kidney pelvis and inflammation is expanded to kidney, is called as Pyelonephritis.
Fig. 2 Escherichia Coli (quote from HP of Kanagawa Institute of Health)
Pyelonephritis is developed by virus, break in from the exit of urethral tube, has reached to kidney pelvis by tracking back in urinary passage.
Generally speaking, invaded virus to urinary passage is discharged out of body by bladder emptying, and exterminated by immunity, so that Pyelonephritis is hardly developed. But when basic disease (generally compromised condition like, benign prostatic hypertrophy, neurogenic bladder, stone in the ureter, malignancy of urinary tract, urinary placement of catheter or diabetes, steroid internal use) is developed, there might be the case where pyelonephritis is repeated. This is called as complicated pyelonephritis. Foreign object like stone in the ureter or urinary placement of catheter easily become the hotbed of bacteria growing so that the disease becomes easy to recur. As a fundamental treatment, there is a case where these foreign objects are removed.
On the other hand, pyelonephritis with no entire body disease or abnormality in urinary passage is called as simple pyelonephritis. Most of the acutely developed acute pyelonephritis is a simple one.
The offending bacterium of the complexed pyelonephritis is a wide ranging, so that other than bacteria in intestines like bacterium coli (fig.2) or genus klebsiella and genus proteus, bacterium like Pseudomonas aeruginosa or Enterobacter, Enterococcus, staphylococcal bacterium are the causes of this disease. On the other hand, 70% of the cause for simple pyelonephritis is bacterium coli. And genus klebsiella and genus proteus may become the cause.
Primary symptoms are pain on the back or lower back, high fever, bladder inflammation symptom (miction pain, frequent micturition, feeling of residual urine, etc).
There are two kinds of pyelonephritis, the one is an acute pyelonephritis which is developed precipitously and the other is chronic pyelonephritis which recurs several times, and symptoms are different each other. In case of acute pyelonephritis, in addition to miction pain, frequent micturition, feeling of residual urine as well as bladder inflammation, constitutional symptom like attack of fever or general feeling of malaise, digestive symptom like pains on the back or lower back, feeling of sickness, and emesis can be found. In case of child or elderly person, altered mentation can be seen due to dehydration. Also, there is a case which is life-threatening when bacteria is spread out to entire body from kidney through the blood flow (blood poisoning), and develops blood pressure drop (blood poisoning shock), acute kidney failure or failure of multiple organs.
On the other hand, in case of chronic pyelonephritis, no symptom appears in most of the cases. Even when symptom appears, they are mild pain on the lower back, mild fever, lost of appetite like mild ones. But when symptoms are getting worse precipitously, symptom like acute pyelonephritis appears. When the cause of chronic pyelonephritis is in vesicoureteral regurgitation (pooled urine in the bladder reversely flow to urinary duct or kidney), there might be the case where pyelonephritis recurred several times so that kidney function falls to a low level, or to be a renal hypertension.
Analysis of urine, blood test and ultrasonography (echo) are conducted. Firstly, analysis of urine is conducted to confirm the existence of white blood cell or bacteria. In case when white blood cells exist over certain numbers, provability of infection of the urinary tract becomes high, and also when there are pathognomonic symptom for pyelonephritis like fever attack or pain on the back, it is diagnosed as acute pyelonephritis. On the other hand, even there is no fever or pains on the lower back if the person has affected by bladder inflammation or acute pyelonephritis in the past, chronic pyelonephritis is suspected. Urine bacterial cultivation test is conducted to specify the kind of disease germ collaterally with urine test. This is the inevitable test to investigate antibiotic sensitivity.
Inflammatory evidence, such as leukocyte increment, left transition of the core, CRP or procalcitonin (PCT) elevation, elevated sedimentation rate, can be seen with the blood test. It is important to take 2 sets of blood culture test in suspecting the existence of bacteremia with having clinical condition of leukocyte increment or increase of breathing or pulse rate. In case bacterium is found in blood culture test, provability for blood poisoning is high, so that it may accompanied with shock, thus it is necessary to pay attention to hemodynamic status.
At the abdominal ultrasonography (fig.3), check whether there is any urinal transit disorder at first. At the kidney ultrasonography, kidney has already been in inflammation so that there may appear low echo region which is indicating edema/micro abscess at cortex and medullary boarder area. Abdominal contrast enhanced CT can evaluate kidney abscess, perinephric abscess, and emphysematous pyelonephritis. In the contrast enhanced CT observation, in addition to the kidney inflammation, it may find the density increase in the surrounding adipose tissue, thickened Gerota fascia, and cuneiformist – echymotic contrast defective area in the renal stroma. Critical and special clinical condition like hydronephrotic kidney, abscess formation, or aerogenesis, it is necessary to diagnose promptly and expeditiously, and if necessary, urological procedure (drainage) should be taken.
• Fig. 3 Ultrasonography
• Fig. 4 CT
Because the cause of disease is bacteria infection, treatment is primarily drug therapy using antibacterial drug. In case body condition is relatively in good and mild, symptom will promptly improve by prompt antibacterial drug treatment. Treatment period is normally in 1 to 2 weeks, but urine test is conducted after certain period (approximately 1 to 2 weeks) to confirm the recurrence existence or non-existence after the treatment is completed. During the treatment, it is necessary to have a complete rest and enough rehydration. When symptom does not improve, admission to hospital is considered.
In case of severely diseased like, strong fever attack level, unable to take water or meal enough, blood pressure drops, or entire body condition is worse, course of injection of antibacterial drug treatment is conducted upon hospitalization. When fever has been settled, it is able to change into oral treatment. In case when urinal baseline disease is found, it is necessary to take that treatment as well.
Antibacterial drug like beta-lactam agent or quinolones drug are useful. Switching timing from injection drug to oral drug is 24 hours later from remission of symptom like decline of fever, and dosage period is targeted in total 14 days.
In case when urinal baseline disease is left as it is, the provability of recurring pyelonephritis is getting higher. There is a case where urinal baseline disease is treated at the same time of pyelonephritis treatment, but most of them wil be started after when inflammation has ceased.
At the time when treatment for acute pyelonephritis starts, in case no offending bacterium has identified, treatment will be proceeded with using antibacterial drug, effective for broader range of bacteria. When offending bacteria has identified, the treatment continues with altering to that particularly effective drug. To suppress a symptom, there may use anti-inflammatory analgesic. Normally, symptom may become ceased in 4 to 7 days, but treatment will continue for 1 to 2 weeks. And also, even after when treatment is completed. Another test will be conducted to check recurrence of the disease, with 1 to 2 weeks interval.
Besides, the most careful point on the treatment is the dosage of the drugs. Don’t stop taking drugs without asking even after the symptom has ceased. Even after the symptom has ceased, bacteria is still alive and remains in the body so that if drugs has taken inadequately enough, bacteria will be reproduced then symptoms recur or transfer to chronic stage. Prescribed drug should be taken till its end.
In case of chronic pyelonephritis, as the same as acute pyelonephritis, antibacterial drug is used for the treatment. In case the disease is repeating the recurrence, since no abnormal reaction occur at urinal test, even when the symptom has been ceased, drug taking should be continued for another one month or over. Then, in case when pyelonephritis turns into chronic one due to the cause of possessed baseline disease, it is necessary to have treatment for this baseline disease.
Naturally, pyelonephritis is developed when bacteria breaks into the bladder in antiseptic condition, then the proliferative bacteria in bladder reaches to kidney pelvis or kidney. Firstly, it is important to keep genitals clean to prevent bacteria breaks in the bladder. Also, for female case, as urinal tube is shorter than male, bacteria may easily break into bladder so that taking lots of shower or bath is effective. And for female, it is important to exchange sanitary napkins or pantiliner often and taking care of sweeping out after bowel motion.
It is important to flushing bacteria in the urethral tube out with urine for bacteria not to break in. For that purpose, it is effective to take water a lot, and not to hold urine in the bladder without holding urine. When holding off on a trip to the bathroom, bacteria may grow up so that it is important to go to bathroom and try to discharge urine even without a desire to urinate.