Hematuria as a manifestation of isolated urinary syndrome in children. Urinary syndrome as a sign of kidney disease

Urinary syndrome / irritable syndrome Bladder, including cases of pain during urination that are not caused by urinary infection or bladder stones. There are no exceptional symptoms, so clinical diagnosis can be quite complex.

Other names: Hypersensitive Bladder, Bladder Sick Syndrome (PBS)

Interstitial cystitis (IC) or urinary syndrome is a condition characterized by chronic or recurring pelvic pain and frequent urination.

Usually the disease is diagnosed in people over 18 years of age, although no scientific basis why IC may not be present in children.

There was a time when doctors did not believe that the disease existed, the patient had to constantly jump from one doctor to another to find relief.

The term interstitial cystitis was first introduced in 1878. The urologist first looked for "elusive ulcers" on the wall of the bladder as he stretched it out for examination with a cystoscope. The ulcer was called "Hanner's Ulcer", it was a classic type of urinary syndrome.

However, many patients who did not have an ulcer had irritable bladder symptoms and were considered psychiatric cases until 1978. In 1978, the non-ulcer type was described. It is now known that the majority of patients with urinary syndrome are of the non-ulcer type.

Symptoms range from mild discomfort to severe pain, some patients feel pressure in the pelvic area. General signs include incomplete emptying, frequency of urination, or a combination of both.

There are no symptoms for urinary syndrome, so the clinical diagnosis is quite difficult.

The change in symptoms, their severity, prompts the person to think that the problem is a combination of diseases.

The cause of urinary syndrome is little understood, and research is being done to better understand it. However, despite two decades of research, little progress has been made in understanding.

Epithelial dysfunction

Epithelial dysfunction is observed in patients with urinary syndrome. In this, the bladder urothelium (outer layer) fails in its function, which increases the abnormal permeability of solutes (such as potassium) found in the urine.

It causes inflammatory response the lower layer of the mucous membrane. Soluses can depolarize sensory nerves causing localized pain.

Mast cell activation

Mast cell activation is involved in the disorder. It initiates the release of histamine, which releases substance P (diseased neurotransmitter) and induces the proliferation of pain-sensing demyelinated C-fibers. C fibers are seen in large quantities on the late stage urinary syndrome, this explains the hypersensitivity of the bladder in patients.

Symptoms are very similar to those of tuberculosis of the genitourinary system, so more early methods treatments were aimed at eliminating this disease. But patients are not responding to TB treatment. Today there is a significant increase in awareness of the disease.

Progress in the knowledge of causes, diagnosis, treatment gives hope for The best way treatment.

There is no evidence that irritable bladder syndrome is associated with big risk cancer development. It does not affect fertility, in pregnant women it does not affect the growth of the fetus.

It is much more common in women than in men.

Symptoms

Pain

Intermittent pain or discomfort, including throbbing, burning, pressure. Pain occurs when the bladder fills with urine or empties.

  • Men also have pain when they ejaculate or when they have an orgasm. Women feel pain during menstruation or during vaginal intercourse.
  • The location of the pain can be anywhere in the lower abdomen, pelvis, urinary passage (urethra), anus, rectum.

Frequency and emptying

They usually exist together, although urgency can exist on its own without frequency. The frequency of urination increases significantly, mainly because the bladder cannot hold much urine, even if its size is normal.

If a person urinates more than 8 times, it is considered abnormal. Nighttime urination disturbs the sleep of the affected person. Some may go to the bathroom every 10-15 minutes, 40 to 60 times a day.

In a broad sense, it includes all quantitative and qualitative changes in urine, and in a narrower sense - changes in urine sediment: proteinuria, hematuria, leukocyturia. These or those combinations of these components of urine are more often observed (proteinuria with leukocyturia, proteinuria with hematuria, etc.), less often there is an "isolated" proteinuria or hematuria, when other signs are either absent, or they are expressed slightly.

Urinary syndrome is considered one of the most important signs possible violations in the urinary system, in the essence of which lies a laboratory-proven (statically reliable) and obvious deviation from the norm of the composition of urine.

Difficulties in the differential diagnosis of urinary syndrome arise mainly when it is the only manifestation pathological process. If this syndrome becomes the only manifestation of kidney disease, then in such cases a diagnosis is made - isolated urinary syndrome. Isolated urinary syndrome can occur with primary and, as well as with other kidney diseases.

Hematuria

Isolated glomerular hematuria can occur with primary and secondary glomerulonephritis, renal vascular disease, tubulointerstitial disease, and renal papillary necrosis. There is tubular and extrarenal hematuria, which develops with malignant tumors kidneys and urinary tract, kidney cysts, prostate adenoma,. Hematuria occurs in IgA nephropathy, thin membrane disease, and less frequently in Alport syndrome.

IgA nephropathy

IgA nephropathy can develop with Crohn's disease, adenocarcinoma of the stomach and colon, bronchitis obliterans, dermatitis herpetiformis, fungal mycosis, ankylosing spondylitis and Sjogren's syndrome, in which there is no inflammation in the glomeruli. The pathognomonic sign is IgA deposits in the mesangium, which may be combined with C3 deposits.

Clinical manifestations of IgA nephropathy are minimal. Gross hematuria occurring 24 to 48 hours after a sore throat, gastrointestinal infection, and severe physical activity- the main manifestation of nephropathy. In some patients, microhematuria is detected during a routine examination. arterial hypertension occurs in 20-30% of patients and in 10%.

IgA nephropathy flows for years. Terminal renal failure develops within 20 years in 30-50% of patients. The prognosis is worse in older men, with high proteinuria, kidney failure at the beginning of the disease, glomerulosclerosis and hyalinosis of arterioles. Microscopic examination reveals IgA and C3 deposits in the kidney, mesangial expansion due to matrix accumulation and an increase in the number of glomerular cells, in severe cases, crescents, inflammatory infiltration of the interstitium and foci of glomerulosclerosis.

There is no cure. In severe cases (rapidly progressive course, nephrotic and) recommend high doses of immunosuppressants with the obligatory consideration of the underlying disease that led to the development of IgA nephropathy.

thin membrane disease

Thin membrane disease - autosomal dominant hereditary disease- usually begins in childhood and presents with persistent or intermittent hematuria after acute respiratory infections. A morphological feature - a thin basement membrane (less than 275 nm in children and less than 300 nm in adults) - is detected by electron microscopy. The prognosis is good.

Alport syndrome

Alport syndrome is a hereditary nephropathy. The type of inheritance is dominant, linked to the X chromosome. It develops more often in men and is characterized by hematuria, proteinuria and progressive renal failure. In addition to kidney damage, 60% of patients have sensorineural deafness, and 15-30% of eye damage has bilateral anterior lenticonus. In heterozygous women, the disease occurs in mild form without kidney failure. Microscopy reveals mesangial proliferation, focal segmental nephrosclerosis, tubular atrophy, and foam cells. Electron microscopy reveals a deformed and thickened basement membrane. The progression of the syndrome in men leads to the development, in which dialysis and are indicated.

Isolated proteinuria

Isolated proteinuria without any kidney disease found in 1-10% of the population. It can be benign or permanent.

Benign isolated proteinuria

Benign isolated proteinuria can have the following variants:

  • Transient idiopathic proteinuria - detected in young people with a single urine test during preventive examinations(in the repeated protein, as a rule, it is already absent).
  • Functional proteinuria- occurs with fever, hypothermia, emotional overstrain, heart failure (presumably due to increased intraglomerular pressure and glomerular filter permeability).
  • Orthostatic proteinuria - due to a long standing position (usually does not exceed 2 g / day).

In all variants of benign isolated proteinuria, a biopsy either does not reveal any changes or reveals minor changes in the mesangium and podocytes. The prognosis is favorable.

Persistent isolated proteinuria

Permanent isolated proteinuria is characterized by the constant presence of protein in the urine, regardless of external conditions and the state of the researcher. A biopsy reveals a morphological picture of any glomerulonephritis. The most common are mesangioproliferative glomerulonephritis and focal segmental glomerulosclerosis. The prognosis for this syndrome is less favorable than for benign isolated proteinuria. Chronic renal failure develops in 20-30% of patients within 20 years, but it usually does not reach the terminal stage.

ON THE TOPIC: URINARY SYNDROME. HYPERTENSIVE SYNDROME IN RENAL DISEASES


URINARY SYNDROME

Urinary syndrome - a combination of proteinuria, not exceeding 3.5 g / day, erythrocyturia, leukocyturia and cylindruria. Some combinations of these components are more often observed (proteinuria with leukocyturia, proteinuria with erythrocyturia and cylindruria, etc.), less often there is an "isolated" proteinuria or erythrocyturia, when other signs are either absent, or they are expressed slightly.

Proteinuria. It should be remembered that also healthy people sometimes traces of protein are found in the urine, and its daily excretion at the same time reaches 60 mg. After significant muscle and emotional tension, overheating or hypothermia, the introduction of adrenaline, prolonged palpation of the kidneys, it can increase by 2-3 times, but quickly (usually after one or two days) returns to normal.

Physiological can also include orthostatic (or rather lordotic) proteinuria, which is observed in childhood and adolescence with pronounced lordosis lumbar spinal column and usually disappears by the age of 20. At the same time, protein in the urine collected immediately after a night's sleep is not detected; it appears only some time after being in a standing position. Its quantity in 58% of cases does not exceed 10 g/l and only in isolated cases reaches 100 g/l. Albumin predominates in the urine (selective proteinuria); erythrocyturia, cylindruria are absent, kidney function is not impaired. To confirm orthostatic proteinuria, an orthostatic test is performed. Orthostatic proteinuria should be differentiated from the latent form chronic glomerulonephritis(a variant with an isolated urinary syndrome - an antihypertensive stage, according to the classification of L. A. Pyriga) or pyelonephritis. The latter is evidenced by the persistence of proteinuria even after the age of twenty and the presence, along with it, of at least a slight erythrocyturia, leukocyturia and cylindruria. In difficult cases, they resort to a kidney biopsy.

In cases of prolonged, isolated proteinuria without impaired renal function, without indications of both their diseases and pathological processes leading to the development of secondary nephropathy (diffuse diseases connective tissue, diabetes, tuberculosis, syphilis, drug allergy and others), one should first of all think about the latent form of primary chronic glomerulonephritis (the variant with an isolated urinary syndrome - the anhypertensive stage) and less often about primary chronic pyelonephritis. Isolated proteinuria may be the initial and for a long time the only manifestation of primary amyloidosis and multiple myeloma. In the latter case great importance for the diagnosis, it has the detection of Bence-Jones protein in the urine and paraproteins in the blood serum and in the urine (by starch gel electrophoresis). In difficult cases, a puncture of the sternum usually resolves the issue.

Diseases in which erythrocyturia occurs can be divided into the following groups.

1. Diseases of the urinary tract: inflammatory (cystitis, prostatitis, urethritis); bladder and ureter stones; tumors (benign and malignant); traumatic injury.

Kidney disease: glomerulonephritis, interstitial nephritis, pyelonephritis; nephropathy in diffuse connective tissue diseases; kidney tuberculosis; papillary necrosis; kidney stone disease; nephrocalcinosis; "gouty" kidney; hypernephroma; polycystic; hydronephrotic transformation: kidney infarction; hepatic vein thrombosis, renal venous hypertension; kidney injury.

3. Other diseases: hemorrhagic diathesis; leukemia; erythremia and erythrocytosis; cirrhosis of the liver; mourn; bacterial endocarditis, sepsis, influenza, tonsillitis, scarlet fever and other infectious diseases; medicinal hematuria ( acetylsalicylic acid and salicylates, hexamethylenetetramine, sulfa drugs, anticoagulants, etc.); disovarian purpura.

Sometimes with the most careful clinical trial the cause of erythrocyturia (or hematuria) remains unknown. In such cases, they speak of "essential hematuria" (or erythrocyturia). This term reflects the insufficiency of the research methods that we currently have.

Leukocyturia is usually an indicator infectious process in urinary tract and kidneys (urethritis, cystitis, pyelonephritis, kidney tuberculosis), especially if it is combined with bacteriuria (over 100,000 bacteria in 1 ml of urine). However, leukocyturia and non-infectious genesis (acute glomerulonephritis, lupus nephropathy, nephrotic syndrome) can be observed. In doubtful cases, to confirm infectious nature leukocyturia shows provocative tests with pyrogenic substances and especially with prednisone.

Cylindruria is usually combined with proteinuria and erythrocyturia.

Difficulties in the differential diagnosis of the urinary syndrome arise mainly when it is the only manifestation of the pathological process. In table. 19 shows the differential diagnosis of urinary syndrome in the most common diseases.

Acute glomerulonephritis as a cause of the urinary syndrome requires clarification mainly in cases of its monosyndromic variant, specific gravity which in last years increased.




Urinary syndrome in acute glomerulonephritis is characterized by proteinuria, erythrocyturia, cylindruria, less often (in 1/3 cases) - leukocyturia. If there is a connection between the urinary syndrome and an acute infectious disease (tonsillitis, acute respiratory disease, pneumonia, scarlet fever, etc.), or exacerbation of the process in the foci chronic infection(tonsillitis, etc.) the correct interpretation of the urinary syndrome is not particularly difficult. Acute glomerulonephritis with isolated urinary syndrome (monosyndromic variant) sometimes has to be differentiated from latent, acute primary pyelonephritis, which also usually occurs after acute infectious disease or exacerbation of the process in the focus of chronic infection.

Acute primary pyelonephritis is characterized by less pronounced proteinuria (up to 0.5 g / day), the predominance of leukocyturia over erythrocyturia with quantitative research urinary sediment, the presence of epithelial, leukocyte and granular casts, often - bacteriuria.

If with a monosyndromic variant acute glomerulonephritis severe erythrocyturia and pain in the lumbar region are observed, nephrolithiasis should be excluded, which is characterized by more intense, usually paroxysmal pain, dysuria, positive symptom Pasternapsky. In the study of urine, a change in the reaction is determined, the presence of a large non-cellular sediment, the prevalence of erythrocyturia with very slight proteinuria. Of particular importance are the methods of X-ray examination (general view or tomography of the kidneys, excretory urography and according to indications - retrograde pyelography), allowing in most cases to identify the calculus. Radioindication study, in particular renography, may have diagnostic value only in cases of violation of the outflow of urine from the kidneys, in which there is a change in the excretory segment of the renographic curve.

If the urinary syndrome occurs in connection with a previous infection and is characterized by severe erythrocyturia, uroberculosis and a kidney tumor should be assumed.

For tuberculosis of the kidney, in addition to indications of extrarenal tuberculosis in history, a predominance of erythrocyturia and especially leukocyturia with slight proteinuria is characteristic. Urine cultures on special media, biological tests for tuberculosis, and x-ray examination, with the help of which changes in the shape and size of the affected kidney, its abdominal sections, as well as foci of destruction are detected. The differential diagnostic capabilities of radioindication methods, in particular scanography, should also be used,

Renal tumor can be ruled out on the basis of radiopaque studies, including selective renal arteriography, as well as renal scanography, which can detect a tumor. small sizes. Of lesser diagnostic value is the presence of fermenturia, an increase in ESR, and sometimes an increase in the level of hemoglobin and erythrocytes in peripheral blood.

After an intercurrent infection, urinary syndrome may first appear as a proteinuric stage of renal amyloidosis. A feature of the urinary syndrome in renal amyloidosis is the combination of proteinuria with scanty urine sediment (“empty” sediment). An increase in erythrocyturia or the appearance of hematuria is observed with thrombosis of the veins of the kidneys, which is not always accompanied by pain.

Amyloidosis is also evidenced by the presence of diseases that cause it (tuberculosis, bronchiectasis, osteomyelitis, etc.). However, it is necessary to take into account the possibility of an erased course of the latter, in particular bronchiectasis. With the aim of differential diagnosis tests for amyloidosis should be carried out (with methylene blue, congoroth, Evans blue), the data of which are only relevant when positive results, electrophoretic study of blood plasma and urine proteins, biopsy of the gum margin or mucous membrane of the rectum, subcutaneous fatty tissue of the anterior abdominal wall and kidneys.

Chronic glomerulonephritis as a cause of urinary syndrome does not present difficulties for correct interpretation if there is a history of indications of acute glomerulonephritis.

Violations in the work of the urinary system, changes in the composition of urine, its quantity and quality in the complex are called urinary syndrome. In addition, problems with the frequency of urination and other symptoms may occur. At first, when the disease is just beginning to develop, a person does not feel its influence, only with the course of the disease, some of its signs make themselves felt.

You can determine the problem by passing a urine test: often deviations from the norm of red blood cells, white blood cells or protein can occur in its sediment. Let's consider this pathology in more detail.

Main problems

Urinary syndrome in adults is accompanied by a number of characteristic features, some of which may indicate the presence of other diseases. Most often, these symptoms indicate the presence of an excess of any elements in the blood. For example, such problems can be the first signal of kidney disease or other pathologies. However, timely diagnosis and treatment will allow you to get rid of the development of diseases in time and prevent the deterioration of the urinary tract and other organs. In any case, no matter what the deviations are, they cannot be ignored.

The presence of blood in the urine may indicate urinary syndrome

Among all forms of manifestation of the urinary syndrome, several of the most basic can be distinguished:

  • The presence of blood in the urine. Sometimes this sign is visible even to the naked eye. In other cases, blood can be detected only by passing the necessary tests.
  • The presence of protein. Only protein or protein casts may be detected.
  • The manifestation of leukocyturia - an increased number of leukocytes in the urine.
  • A salt precipitate is observed - oxalates, urates and phosphates.
  • Presence of intestinal bacteria skin, external genitalia. It is important to follow the rules for passing urine for bakposev. Recommendations are given by the attending physician.

Let's consider each form of manifestation in more detail.

Blood in the urine - hematuria

The presence of blood may indicate various diseases, including infections. Symptoms often indicate a concomitant disease - if a person feels pain during urination, then it is likely that you can diagnose:

  • urolithiasis;
  • thrombosis of blood vessels in the kidneys;
  • renal colic;
  • kidney tuberculosis.

Kidney tuberculosis can lead to urinary syndrome

If there is no pain during urination, then nephropathy is probably the cause of the urinary syndrome. To diagnose hematuria, it is necessary to collect morning urine. It is worth considering that girls who have menstruation during this period need to prevent discharge from entering the urine by using a tampon.

If blood in the urine is found in children, especially in infants, hospitalization is necessary, since small children may have such dangerous diseases like neoplasms, thrombosis, sepsis.

Proteinuria

If protein is found in the urine, this does not always mean that the patient is sick. Proteinuria can be benign if the protein was found in the urine only once, and if repeated analyzes similar problem did not occur. There are also two other types of benign proteinuria:

  • Functional. In this case, the protein can be found at elevated temperature body, after hypothermia, stress.
  • Orthostatic. If the patient is constantly on his feet, for example, at work, then protein can be detected in his urine.

In all of the above cases, benign proteinuria is not dangerous, however, if the patient has the same protein level after several tests, this indicates malignant proteinuria. In this case, it is likely that the following can be diagnosed:

  • cystinosis;
  • diabetes;

At diabetes often protein in the blood

  • dystrophy;
  • metal poisoning.

Cylindruria - cylindrical squirrels

If cylindrical elements of the protein rock were found in the urine, special shape which is caused by certain disorders in the body, this indicates a number of diseases. For example:

  • Waxy. These proteins may indicate the presence inflammatory processes in the kidneys or lesions within them.
  • Hyaline. The most common proteins that are found in many diseases. For a more specific diagnosis, additional diagnostics will be needed.
  • False. May be a signal for problems with the urinary tract.
  • Grainy. Often found in the urine with lesions of the tubules of the kidneys.

Leukocyturia

In the urine of any person contains leukocytes, but their excess often indicates inflammation in the urinary tract. If, along with leukocyturia, hematuria or proteinuria is observed, diseases such as pyelonephritis, lupus or tubulo-interstitial nephritis are possible. Also, such test results may indicate rejection of the donor kidney by the body if a transplant has taken place. Urinary syndrome is a common occurrence with this surgical intervention.

The urine of any person contains leukocytes, but their excess often indicates inflammation in the urinary tract

If leukocyturia is the only problem identified in the analysis, then the diagnosis may reveal:

  • rejection of a donor kidney;
  • problems with genitourinary system, often - injuries;
  • inflammatory processes;
  • pregnancy;
  • fever
  • tuberculosis;
  • various kinds of infections.

To collect urine for analysis, women need an average portion of urine after a morning shower - this will protect the collected material from getting leukocytes from the vagina into it.

Other diseases

Salts in the urine may be higher than normal if the patient is taking medications or certain foods. Urate in the urine is not dangerous unless it precipitates. In the case where persistent sediment is observed, there is a possibility that over time stones may form in the kidneys due to nephropathy. If phosphates were found, it is possible that there is an infection in the body.

In addition, there is also the problem of urination - it also makes you aware of the urinary syndrome in children and adults. There are several types of this problem:

  1. Dysuria. Most commonly seen in infections main symptom her - frequent urination with pain and burning.
  2. Polyuria is an increase in the rate of diuresis. Indicates inflammation of the bladder or other disorders.
  3. Oliguria - a decrease in the daily rate of urine. May be a signal for kidney failure or other kidney pathologies.
  4. Nocturia is a disorder in which the volume of nighttime urine is much larger than the daily volume.

Conclusion

The causes of urinary syndrome can be very different - from small problems with the body, to pathologies internal organs. In any case, urine tests, which let you know about problems when exceeding the norms, should be the reason for complex diagnostics and start treatment.

Inflammatory processes in the urinary system and kidneys are a dangerous thing. Treatment of urinary syndrome depends on the factors that caused it. But therapy must be carried out as quickly as possible. Therefore, if you find signs of this disease, contact your doctor immediately, and do not self-medicate, which can aggravate the situation.