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There are two large groups urethritis - infectious and noninfectious. Infectious urethritis caused by different pathogens - bacteria, gonokokkami, viruses, mycoplasmas, ureaplazmami, chlamydia, gardnerellami, trihomonadami Baktrialnye and other pathogens are specific urethritis (gonokokki, gardnerelly) and nonspecific (staphylococcus, Escherichia coli, streptococcus). The article will be reviewed urethritis caused by nonspecific bacterial flora.

Non-communicable urethritis may develop as a result of trauma urethra that may occur during cystoscopy, catheterization of the bladder, passing through the stone. Other causes could be an allergic reaction, narrowing of the urethra, the phenomenon of stagnation in the pelvic area. As a rule, the development of noncommunicable urethritis in urethra active opportunistic pathogens (particularly staphylococcus), and non-urethritis quickly transferred to the secondary non-bacterial.

Who is sick And HOW infected urethritis
Sick with urethritis can absolutely anyone. Infection occurs most often during sexual contact with a patient. It should be noted that urethritis can proceed without the expressed attitudes, imperceptibly, and the patient may not know that he is sick. However, this does not mean that all his sexual partners will also be easy to carry the disease - during the disease depends on the state of an organism and even from a number of factors. Also, be aware, symptoms do not appear immediately after sexual intercourse, but later nektoroe time (for nonspecific bacterial urethritis - from several hours to several months), which is called the incubation period.

HOW There urethra
The main manifestations of urethritis - that burning sensation, pain or mulligrubs with urination, especially at the beginning, and the allocation of the urethra. Highlight usually in the mornings, when they are nonspecific baktrialnoy infection abundant, mucous-purulent nature, blue-green color with odor.
It should be noted that men, because of anatomical features (a long and narrow urethra), earlier and more sensitive symptoms urethritis. Women also expressed less urethritis symptoms, and may even go unnoticed.
Men can celebrate conglutination morning sponges external openings of the urethra and redness. Urethritis can proceed without funding from the urethra only unpleasant sensation when urinating. Moreover, as stated above, the manifestations of urethritis may be so minor that patients do not give them value. However, this does not mean that the disease do not have to treat it “will take place by itself.”
If urethritis is usually not indicated obschevospalitelnyh symptoms - there is no increase in body temperature, weakness.

What happens if not treated
If diseased acute urethritis decided not to pay attention to the allocation, “to suffer” unpleasant sensation when urinating, and did not bother the doctor “on nothing”, then after a while - about a miracle! - All the symptoms disappear by themselves. As it turns out you can not go to the doctor, do not spend money on drugs? Not quite. Just the body was able to suppress inflammation. But never in such cases, the body can not get rid of all pathogens. They remain small, but they remain. They “save” men - in the prostate gland and seminal vesicles, women - in bartolinovyh glands, small glands before. Pathogen “wait” the first episode of hypothermia, excessive alcohol consumption, turbulent sexuality, and then it again will cause an inflammation of the urethra, but likely will not confine them, but also cause chronic prostatitis, vesiculitis, epididymitis perhaps even the threat of development in Further obturatsionnoy forms of infertility.
What does the urologist, when it addresses the patient urethritis

When applying to an oncologist to conduct a study to confirm the diagnosis. This fence and seed funding from the urethra (and in their absence - the first portion of urine samples from trehstakannoy). In the laboratory, determine the causative agent of disease, as well as its sensitivity to different groups antibakterilnyh drugs, which allows to put the final diagnosis and to appoint adequate treatment.
Additionally, the doctor conducts a series of studies to exclude the involvement of inflammation in other organs (for men - especially of the prostate and seminal vesicles, women - bladder).

HOW treated urethra
The main treatment for urethritis - is anti-bacterial therapy. There are many different drugs for each patient’s oncologist selects the most effective (and affordable), primarily based on data from laboratory studies. The total course of treatment may last from several days to several weeks, depending on the severity of the disease and its stage. Treatment is carried out, usually at home, hospitalized patients with urethritis rarely, usually with severe purulent complications.

WHAT IS gleet
If sexual contact with a sick urethritis on mucous membranes healthy person gets a small amount of the causative agent, or the agent severely weakened (for example, the uncontrolled use of antibiotics), or your body is “healthy” and “strong”, no symptoms of disease may not appear. But the agent does not perish, but will remain in the body “to wait for a suitable case to prove itself.” Then, from time to time the patient will feel unpleasant sensation when urinating in the morning to see drops in the linen selections, but these manifestations are minor and quickly disappear, those that rarely turns to the doctor with these complaints.
In another case, acute urethritis becomes chronic when the wrong or inadequate treatment. The disease runs a long time (months, years) and sooner or later, still leads the patient to see a doctor. But this happens usually when the developed complications, especially chronic prostatitis.

Also, with the long course of chronic urethritis may develop unpleasant complications such as stricture urethra - the narrowing of the urethra clearance. This is increasing pain with urination and weak stream of urine.

HOW treated gleet
Treatment of chronic urethritis goes harder and longer than acute. In addition to antibacterial therapy, it includes instillyatsii (introduction) in the urethra of drugs and the use of various means of immunotherapy (such as medication, and nemedikamendoznyh). With the development of stricture urethra use bouginage (expand) the urethra with special metal buzhami.

How to avoid urethritis
Urethritis is a group of diseases that are much easier to prevent than to cure. Since the main way of contracting the disease - sexual, then prevention is hygiene sexuality. This is a permanent sexual partners, and at random, the use of condoms.

If your spouse (husband, secretary, friend, bystanders) accidentally mentioned that with urination experienced unpleasant feelings, then refrain from sexual contact with her and persuaded to go to a urologist.

If you must be a cystoscopy, bouginage or any another tool interference in urethra, then make sure that it holds a bona fide doctor. For the prevention of urethritis and cystitis in these cases are also using antibiotics.
If you have a need for a long time to wear urinary catheter, it should be changed regularly and you should (on the advice of a doctor) to take antibiotics.

Abdominal pain.
A large number of patients subjected to urological examination at the complaints of abdominal pain in his side divisions in the back. The pain associated with damage to the kidneys, may be due to various reasons. Stones located in the kidney or ureter, causing pain with urinary tract obstruction, with subsequent development of hydronephrosis.

If the pressure inside the closed urinary system and kidneys, raises strength capsules pain impulses. The stones may occur in the urinary system and reach considerable size without causing pain, if there is no obstruction or if it develops gradually (for rocks korallovidnyh, in chronic urinary infections caused by microorganisms, fissile urea).

The appearance of renal pain may result in kidney infection, acute pyelonephritis, renal or okolopochechnogo abscess. Papillary necrosis can also cause considerable pain, as well as kidney ischemia, especially if the process starts badly. In blunt trauma of the kidney may be a pain in the soft tissues of the lateral divisions of the stomach, podkapsulnaya hematoma, damage to the kidney parenchyma, and adjacent organs, and gemoperitoneum.

The pain emanating from the kidney, there was a patient in costoclavicular vertebral angle or more diffusely on the lateral surface of the body, or in the upper abdominal quadrants.
Pain in the lower divisions of the stomach may be due to urological causes, for example, delayed urine, bladder irritation or injury.

Abdominal pain neurologicheskogo character can simulate kidney. Neurologicheskimi most frequent causes of pain in the abdomen, which may be taken for pain urological origin, are zhelchnokamennaya disease, cholecystitis, diverticulitis colon, abscess in zabryushinnoy tissue and tumor located in the abdominal cavity.
Muscle pain in the back, as well as neurological pain caused by intervertebral disc lesion may resemble renal pain.

The appearance of pain and swelling in the genital region
Pain in the scrotum
Overwind testicle is the most severe of all the pathological conditions of scrotum. It is very important to diagnosis and careful attention to the patient, because the speed of treatment determines the chances of survival testicle. Start pain often severe and may be (but not necessarily) associated with physical load. If left untreated, the pain diminished somewhat, but in a few days a new rush of pain as a result of increased edema and inflammation. If left untreated, the process leads to necrosis of tissues to their fusion and formation of abscess, or to the gradual atrophy of body.
In epididymitis pain usually increases gradually initially and at first localized in zadnelateralnoy part scrotum. Young men in history often indicates infection with sexually transmitted infections, or symptoms associated urethritis. In patients younger than 35 years, the most frequent etiological factor epididimita is Chlamidia trachomatis, while the enteric bacteria (eg, E. Coli) are more frequent in patients older than 35 years of age. In the latter group, especially in men older than 50 years, symptoms of bladder neck obstruction may coexist with a clinical picture epididimita, the pathophysiologic process is a violation of the act of emptying the bladder, and as a result of infection ascending to the appendage testis. It is important to exclude a delay of urine in the bladder by palpation, percussion or other methods (ultrasonography).
In rapidly developing epididymitis symptoms such as localized pain and induration appendage with palpation can not be found, and with physical examination findings will be the same as in the later phase overwind testicle. At this stage, the study showed the intensity of the blood testis, sometimes - a trial surgery. After the end of the inflammatory process may study the velocity of blood flow, retrograde uretrografiya or cystoscopy.
When examining scrotum identified as: congestion, the appearance of the skin scrotum plots with sedentary skin, fluctuation, or the allocation of krepitatsiya pus.
Testicle tumor classically appears as a painful swelling in the testicles. In fact, in 95% of the increase is the increase in testis cancer, while the vast majority of tumors located outside the testicle are benign. At the slightest suspicion on the tumor (in the testicle or outside) the patient should be immediately sent to the urologist.
Incarcerated inguinal hernia may look like a tumor found in the scrotum. If the inspection can detect thickening of the grounds scrotum, where it will be hernial sac, down from the outer openings inguinal canal in the scrotum.
Other benign Education scrotum - gidrotsele, spermatotsele and varicocele.

Pain in the penis and urethra
The pain of the penis may occur as a result of vascular disturbances and infections. Inflammatory process, or a spectacular head preputsialny bag, called, respectively, and balanitom postitom or together (balanopostit). Treatment is carried out without difficulty by the appointment of per os antibiotic wide range activities and conduct in-depth local health events.
Balanitis xerotica obliterans - a chronic process, which can be expressed induration and chronic inflammation of the head and preputsialnogo bag.
Pain in the penis because of blood circulation may be accompanied by the appearance of zones of necrosis and ischemia in the head and more often observed in patients with diabetes.
The pain in the urethra may be described as a dizuriya or burning with urination, and be constant or occur intermittently. Urethritis may be due to chemical, traumatic or infectious factors. When infectious urethritis may be separated from the urethra.
Diseases transmitted through sexual contact ranging from large lesions of the skin (eg, kondilomy) to painful blisters on the skin of the genital organs (such as with herpes infection). Syphilis, gonorrhea and venereal inguinal limfogranulema may occur, respectively, Shankar, dizuriey or limfoadenopatiey.

The pain in the prostate gland
If you have any pain in the perineum or in the zone of the prostate to exclude infection, inflammation, tumors or neurogenic dysfunction of the body. Pain is often found in young men. Prostatodiniya - complain of pain associated with prostate gland, with no pathological changes of the body. Need advice urologist and neuropsychiatrist.

The most common etiologic factors are benign prostate hyperplasia, cancer of, stricture urethra and bladder neck contracture.

Complaints of sexual organs
Orhialgiya
In addition to the above-mentioned pathological changes (pain or swelling in the scrotum), patients may complain of chronic perezhayuschiysya or discomfort, pain in the testicles of different expressiveness. In the absence of any correlation between the complaints and the results of physical examination to think of such pathological states as varicocele, orchitis, atrophy of testicles, as reflected pain or mental illness.

Mikropenis
Penis, which is less than the size of more than 2 Sigma (2 medium-sized Quadratic deviation), is called mikropenis. Normally a baby’s penis - 1.5, see A child 2-4 years old is 3.3 cm, an adult - 12,4 cm. If inadequate response to the length of the penis the patient should be referred to a counselor or a urologist.

Sexual Disorders
Complaints relating to sexual dysfunction may include loss of Libido. Erectile Dysfunction, ejaculation disorder, pain in the genital region and the deformation of the penis during sexual intercourse.
Loss of libido can have psychological causes, and may be associated with endocrine system disorders. For a correct assessment of the causes of loss of Libido or impotence associated with a weak erection, it is necessary to compile a complete general and neurological histories, as well as to conduct appropriate laboratory examination.

Gemospermiya
Blood in the ejaculate is found very often and usually do not indicate the presence of a malignant process, but a cause of great excitement in the patient. It should conduct a psychological interview, but reappears in the blood - to send to the consultation to the urologist to exclude rare but very serious disease (chronic infection, tumor, etc.).

Prostate cancer in the currently occupies at 1 - 2 nd place in the structure of morbidity and 2 - 3rd place in the structure of mortality from cancer among men in most developed countries. Current methods of diagnosis and treatment of prostate cancer can provide early detection and effective treatment of this disease.

Cancer of the prostate (FPW) - one of the most frequent malignant tumors in men middle-aged and older. More than 80% of cases is under the age of 65. Currently in the USA FPW - this is the most common form of cancer among men in 1996 identified 317 000 new patients who have died - 41 400.

The likelihood of the development of microscopic FPW for life is 30%, while the probability of death - 3%. A great influence on the incidence has geographical location and race. The highest incidence of more than 100 per 100 000 population, marked by black men in the U.S., and they FPW develops at a younger age. The low incidence is found in Asia and Africa, where it is ten times lower than in North America and Northern Europe.

Important is the fact that the migration of Chinese and Japanese in the U.S. leads to a considerable increase in the incidence of these groups. Thus, when the incidence in China 1,2 - 1,7 per 100 000 population, the frequency of cancer among the Chinese who moved to the U.S., reaching 28 per 100 000 population, which spoke of the impact of environmental factors and life.

However, the frequency of latent FPW virtually identical in all populations studied, and found at autopsy in 10 - 15% of men who died of various causes, while those over 60 years this figure reaches 30%. FPW incidence in Russia is 9, 3 per 100 000 population (world standard, 1995).

In addition to age, an important risk factor for FPW is heredity. In the presence of prostate cancer among blood relatives the risk increases by 2 - 3 times, about 9% of the FPW is due to genetic causes. They noted the relationship between illness and consumption of foods rich in animal fats. Risk factors are overweight. Geographical prevalence of prostate cancer correlates with the incidence of malignant tumors of the breast and colon cancer.

In the diet of residents of Asian countries, where prevalence is low FPW, contains a lot of vitamin A and estrogens of plant origin, which neutralize effect of androgens on the prostate gland. For other data, has a protective effect of vitamin E reduces the risk of cancer by 35%. We study the role of infectious factors, such as herpes virus, cytomegalovirus.

It was found that patients with prostate cancer, sexually transmitted diseases are sick, their wives are sick of cervical cancer. It is shown that over 50% of prostate tumors containing human papillomavirus. The question of increased risk in people who have contact with cadmium, the nuclear power plants.

Important role in the development of hormonal status plays FPW. Testosterone and its more powerful metabolite dihydrotestosterone, formed in the tissue of the prostate by the enzyme 5a-reductase, necessary for normal growth and development of the prostate. Hormone hypothesis development FPW confirmed hormonal success, the possibility of cancer in animals as a result of long-term exposure to androgens.

In addition, prostate cancer does not develop in men castrated prior to the completion of sexual development, and very rarely - if insufficient enzyme 5a-reductase.

Pathological Anatomy.

Up to 70% of the FPW is developing in the peripheral zone, about 10 - 15% of tumors located in the central zone, while in other cases - in the transitional zone of the prostate. Approximately 15 - 30% of men older than 50 years show FPW, which has no clinical manifestations or latent cancer. Typically, this small, well-differentiated tumors less than 0.5 cm3, with the increase is accompanied by loss of differentiation characteristics. In addition, it was found that 10% of tumors with a small amount of 0,5% from 1 cm3 invaziruyut in the capsule.

Recently, for the histological classification is widely used Gleason (1966), five different gradations, and based on the extent of the tumor cells in a distinct ferruginous structures.

Graduation 1: a tumor composed of small uniform glands with minimal changes in the nuclei.

Graduation 2: a tumor composed of clusters of glands are still separated by stroma, but located close to each other.

Graduation 3: The tumor consists of glands of different size and structure and, as a rule, infiltrative stromal and surrounding tissue.

Graduation 4: The tumor is composed of clearly atypical cells and infiltrative surrounding tissue.

Graduation 5: tumor is an undifferentiated layers of atypical cells.
Because the FPW is often heterogeneous structure, for the calculation of points on the Gleason summarize two of the greatest importance for graduation. The resulting number of points is an important prognostic sign. Patients with scores of less than 4 FPW metastatic to the 2, 1% per year, between 5 and 7 - to 5.4% and a 7 - to 13,5% of cases.

The probability of local spread of tumor for 10 years, depending on the number of points on the Gleason presented in the table.

Clinic.

Current possibilities of diagnosis FPW identify disease in its early stages, but more than 50 - 70% of patients at the time of diagnosis reveal III - IV stage of disease. FPW a long time may be asymptomatic, the appearance of clinical manifestations often shows far gone process. One of the first symptoms are a violation of an act of urination: a fast, sometimes painful urination, vyalaya stream, difficulty in beginning urination, a feeling of incomplete emptying of the bladder in 20% of cases there is an acute delay in the urine, although possible and urinary incontinence. In addition, more pronounced in the local spread of tumor may occur gematuriya, pain in the perineum and the lobkom, symptoms sdavleniya ureter, urinary infection, impotence, gematospermiya.

Locally distributed FPW can affect the distal rectum department and cause symptoms such as constipation, tenezmy and bleeding from the rectum. In the presence of metastases in regional lymph nodes may cause edema scrotum, lower extremities. Characteristic gematogennymi metastases for FPW are metastases in the pelvic bones, lumbo-sacral spine, with the possible development of paraplegia.

Diagnosis.

Paltseva study of the prostate through the rectum is a simple, cheap and quite effective method of diagnosing prostate cancer. The sensitivity of this method is 80%, and specificity to 50%. Signs of the FPW are rocky areas of tissue density in the prostate, its asymmetry, immobility due to the seam with the surrounding tissues, palpiruemye seminal vesicles (a symptom of “bull horns”). Differential diagnosis should be carried out with stones, prostate adenoma, particularly in the fibrous form granulematoznym prostatitis, tuberculosis. The most marked underestimation of the stage, because small, located in the front offices of prostate tumors are usually not palpiruyutsya. When cytological study of biopsy of the prostate nodular education, identified with the finger rectally study, 40 - 50% are cancer.
Studies in recent years suggest that a laboratory is essential to define the serum prostate specific antigen (PSA). PSA - this glycoprotein involved in the diluted semen. In raising its level of above 6 ng / ml in one third of men find FPW. PSA in serum in the form of free and associated with a1-himotripsinom forms. In patients with adenoma of the prostate is dominated by increased levels of free PSA, and cancer patients - related. Determination of levels of PSA - this is the most effective method of identifying FPW during mass surveys, the diagnostic value of the method increases when used in combination with finger rectal study. In addition, to improve the clinical relevance of this method is defined indicators such as index or PSA density (the correlation between serum levels of PSA and the size of the prostate, with PSA less than 0.15, the index tumor, probably clinically insignificant), the age norms (the so - as PSA levels rise with age). Moreover, noting the relationship of PSA and the incidence of breast cancer patients: PSA levels are 10 - 20 ng / ml showed germination capsules, levels above 40 ng / ml - the existence of metastases. It turned out that the definition of multiple levels of PSA can be used to assess the effectiveness of treatment. Convincing data on the importance of PSA suggest that with increasing levels of PSA and the lack of pathology in the finger rectally study shows the implementation of transrektalnoy ultrasonic tomography prostate and, if necessary, multifokalnoy puncture biopsy of the prostate.
An important diagnostic method is transrektalnoe ultrasound of the prostate, allowing the identification of tumor up to 1 cm in diameter. With UZT assess the prevalence of bladder cancer, germination in the capsule, the relationship with bladder and rectum. The most valuable method is the ability to monitor the advancement of the needle puncture biopsy in the performance. Magnetic resonance imaging and computed tomography are also used to study prostate, but their effectiveness does not exceed UZT results and the simplicity and safety of ultrasound allows deservedly take its lead method.
So far there is no single opinion on the feasibility of a screening FPW. The existence of simple survey techniques (finger rectal study, the definition of PSA), the identification of tumors at an early stage where possible to completely cure the patient, certainly an advantage of screening. However, there is also the view that early detection of hidden running FPW is not appropriate. Prolonged life expectancy of patients with asymptomatic FPW compared with clinical may be due to slow tumor growth, and its early detection can lead to giperdiagnostike and giperlecheniyu. Older men positive effect of screening may not be as significant as that of younger patients, as well as the likelihood of significant progression of the disease from them below. In addition, the effectiveness of screening for a reduction in mortality has not been proven.

Treatment.

In the treatment of FPW is now used by virtually all the special effects techniques used in oncology - surgical, radiation, hormonal, medicinal. The choice of treatment depends primarily on the incidence of bladder cancer.
In the treatment of localized FPW (T1-2) uses the following methods: temporizing tactics, radiation therapy, surgical treatment. Temporizing tactic often used in stage T1 (tumor not detected clinically, discovered by accident when microscopic examination), in patients older forms with well differentiated tumors. In stage T1a (tumor takes less than 5% rezitsirovannogo material) picture of the progressive disease develops in over 10 years at 6% of patients. As a regular definition of PSA levels.
However, localized forms of prostate cancer is more common active therapeutic approach, including the use of radiation therapy or surgery.
When radiation therapy patients FPW most commonly used static mnogopolnoe and / or rotating teleirradiation, rarely - interstitial - with the use of radioactive isotopes (gold-198, iodine-125). When the effects of interstitial radiotherapy in the first phase of the implementation of appropriate pelvic limfadenektomii. Shown better results when combined with radiation therapy with local microwave hyperthermia. When radiation therapy is very important most accurate topometriya, as well as taking stock of adequate doses - at least 65 - 70 Gy. Such potential complications of radiation therapy as proktity and cystitis occur in 5 - 20%, urinary incontinence, impotence, and 30%. In recent proliferation of so-called conformal radiation therapy, which is using new technology provides more accurate beam focusing. In general, the results of radiotherapy are comparable with the results of surgical treatment and are discussed in detail in a special article of this issue.
According to most urologists, the best method of treatment is limited FPW Radical prostatektomiya. This operation is useful in cases where the patient’s life expectancy is at least 10 years. This operation is performed, usually pozadilobkovym access involves removal of the prostate, together with the capsule, seminal vesicles, prostatic part of urethra, bladder neck, regional lymph nodes. The advantages of radical prostatektomii are the complete removal of the tumor, the exact definition of stage of disease, concomitant treatment of prostate adenoma, reliable suppression of PSA levels below the sensitivity of the qualitative analysis. The disadvantages include postoperative mortality (0 to 5%) and complications such as impotence (50 - 70%), anastomotic stricture uretralnogo (5 - 17%), urinary incontinence (3 - 36%).
It also examines the local impact of such methods as cryotherapy, laser therapy, treatment of high-intensity focused ultrasound. The preliminary results allow to consider the proposed method is effective.
In the treatment of place-distributed FPW (stage T3), in which the tumor sprouts from the capsule gland, preferred methods of radiation exposure in combination with hormonal. There have been reports on the preoperative hormonal (usually maximal androgenic blockade), which leads to the reduction of endocrine stage and makes possible the implementation of the radical operation (this method is under study).
Most of the patients at the time of diagnosis FPW have distant metastases, according to some sources, this figure reaches 50 - 70%. Unlike the limited, local spread of 70% of patients with disseminated FPW die within 5 years. Since 1941, when Huggins and Hodges first described the effect of surgical castration (bilateral orhidektomii) and estrogen therapy in patients with metastatic prostate cancer, androgen blockade is the main principle of treatment of patients with metastatic tumor processes. The use of estrogens is accompanied by a number of serious complications, such as an increase in blood coagulability with venous thrombosis, cardiovascular disorders. Widespread antiandrogens, is preferable to direct action, ie, by blocking androgen receptors specifically in the tissue of the prostate. The gold standard in the treatment of metastatic FPW is now considered a complete or maximal androgenic blockade, consisting of surgical castration or medication, which is achieved by using drug-hormone analogues rilizing lyuteoniziruyuschego pituitary hormone (zoladeks) in combination with antiandrogen direct action (kasodeks, flyutamid) . The problem of androgenic blockade is discussed by us in a special article of this issue.
The failure of hormonal FPW attributed partly to the fact that approximately 20 - 30% of patients with tumors initially sensitive to endocrine treatment, but in other cases gormonorezistentnost develops after an average of 36 months after starting treatment. In such cases, resort to polychemotherapy, the effectiveness of which is 20 - 40%, the most effective drugs are adriamycin, and platinum derivatives. Also for the treatment of disseminated FPW used drugs such as suramin, an inhibitor of epidermal growth factor and Insulin; gormonotsitostatik - estramustina phosphate; liarozol - medication, delaying the destruction of Retinoic acid and thus prolonged the antiproliferative effect of retinoic acid. To deal with bone pain was successfully applied metastron (aqueous solution of chloride of strontium-89), introduced the patient intravenously 1 every 3 - 6 months.
Thus, the use of the whole range of therapeutic interventions allows hope to achieve favorable results in treating patients FPW in various stages of the disease, but a number of unresolved issues proves the need for further study on this issue.

Introduction.

Since UTI doctor faces an almost daily basis. Diagnosis and treatment of this disease is fully within the competence of doctors.
Recent studies have revealed significant differences in the tactics of the doctors in the UTI. There are different, sometimes conflicting views on diagnostic criteria, examination techniques, tools and destination of first choice drugs in the event of a relapse, as well as the duration of treatment.
Despite the fact that research in this field is satisfied, but many, it is impossible to give clear and consistent recommendations are equally applicable in all cases. However, the available knowledge allows to some extent standardizes the management of patients who go to the doctor for the UTI. Suggested recommendations feasible in practice.
Where there are contradictions, it is indicated. The physician can determine the tactics of reference.

Recommendations
Prerequisites

The physician should have the following aids:
• test strips for determining the presence of nitrites in urine;
• centrifuge at a speed of rotation of 2000 rpm;
• microscope (preferably with a 400-fold increase);
• A means for collecting and shipping urine sowing.
From organizational points necessary to identify the following:
• assistant practice should be instructed and trained in such a way that it could give patients instructions and explanations, and independently perform laboratory examination
• Patients should receive oral or written information that they should either go to the reception with a full bladder, or immediately after urination bring to the study fresh urine.

Concepts

Acute painful frequent urination (OBCHM) a clinical syndrome which is characterized by the presence of one or more of the following symptoms: dizuriya, stranguriya, pollakiuriya, irresistible urge to urination, gematuriya, pain in the bladder and pain in the waist.
A study of urine means a microscopic examination of urine sediment, if necessary supplemented by nitrite test, which may be Semiquantitative culture.
Sowing - incubation of the material, after which make the calculation and identification of microorganisms in bacteriological laboratories. This study can expand the definition of resistance. Sowing is the “gold standard”.
Under further examination include:
• a general survey of the abdominal cavity and pelvis, particular attention is drawn to the kidneys and bladder, external genital examination, if necessary, vaginal and / or a manual rectal examination;
• Additional screening: indications for sonography of kidneys and urinary tract, then, if necessary intravenoznaya pyelography (EMU), in exceptional cases, a survey technician.
Because individual circumstances vary, it is impossible to give general recommendations on further examination.
Acute uretralny syndrome diagnosed in the presence of complaints of OBCHM, in the absence of UTI. This syndrome is not considered in this standard.
Significant asymptomatic bacteriuria - the existence of at least 105 bacteria per 1 ml of urine in the absence of complaints. In a narrow sense it is a UTI.
Major diseases and conditions that contribute to the UTI, divided as follows.
• 1. Delay of urine in the urinary tract after urinating (stasis), due to:
• obstruction (retention), particularly in diseases of the prostate, stones in the urinary tract, congenital anomalies and neurogenic bladder;
• incomplete emptying, in particular with a lazy bladder syndrome, neurogenic bladder, tsistotsele and diverticulitis;
• reverse the movement of urine in the urinary tract, particularly in congenital disorders, reflux and stenosis.
• 2. Sources of infection in the urinary tract: bladder diverticulum, urinary tract stones, indwelling catheter.
• 3. Reduced resistance, the local (in particular, after radiotherapy, and sometimes in women after menopause due to atrophy or mukozy submukozy) or total (in particular, after the treatment of cytostatic drug, with leukemia and diabetes in old age).
About complications say if UTI is accompanied by fever up to 38,5 ° C or above (with or without chill or nausea), or cramps, which may indicate the presence of stones in the urinary tract. When a fever should be suspected invasive infection, which may be localized in the renal pelvis, and bladder. Invasive infections of the upper and lower divisions of the urinary tract can not be distinguished from each other only on the basis of clinical picture.

Recommendations for the diagnosis
History

When it comes to non-pregnant healthy women of reproductive age have symptoms characteristic of the syndrome OBCHM, the probability of UTI is 64%. Greater accuracy when using only data history can not be achieved.
Complaints OBCHM not necessarily occur in every case of UTI. Suspicion that the patient suffers from UTI, may also occur in the presence of impairment or the more general symptoms such as fever, which have not yet found an explanation. In such cases, the probability of UTI can not be expressed in percentage terms.

Investigation of urine

The diagnosis set for the study of urine. Criteria for UTI is the presence of at least 105 colony forming units (CFU) of bacteria in 1 ml of fresh urine, the test is determining. Explore fresh urine. If you are not able immediately to undertake a study, the urine can be used to store a maximum of 24 hours in a refrigerator at a temperature no higher than 10 ° C. When urine is stored at room temperature over 2 h, the probability lozhnootritsatelnogo the results of a study of sediment becomes too large due to leykotsitoliza, after 24 h nitrite test becomes false-positive due to bacterial growth.
A child who still could not urinate on the request, after ablution genitals clean water put mochesobiratelny bag, and then every 10 min is necessary to check whether there is already urine. Patients in other categories, you can not give instructions on the washing of the genitals: confirmed that this measure improves the accuracy of diagnosis.
The large number of epithelial cells in urine may hinder microscopic examination (see “Sediment”) in determining the number of epithelial cells not care what portion of urine is studied: the so-called average or the other.
Catheterization and puncture suprapubikalnaya shown only in cases where the required purity and accuracy of diagnosis. In practice, family doctor seldom required.
Nitrite test. White test strips are immersed in urine, while it is desirable that the latter was in the bladder at least 4 h. In the presence of nitrite in a 30 with a painting, which can vary from pale pink to krasnosirenevogo. Every painting is a positive result. The number of false-positive results are so few that, based on the results of this test may be diagnosed with UTI. Number lozhnootritsatelnyh results significantly.
Other strips. Diagnostic value leykotsitnyh strip has not yet been clarified. Other studies using strips (pH, protein, erythrocytes, etc.) do not affect the tactics of treatment, therefore, such studies are not recommended.
Residue. 10 ml urine is centrifuged for 3-5 min at the rotating speed of 2000 rpm. They carry out microscopic examination of wet unpainted product with 400-fold increase. The discovery of at least 20 bacteria in the field of view is a positive result, confirming the diagnosis of UTI. Most also show leukocytes, which is a sign of inflammation.
Sometimes, in particular because of the presence of epithelial cells, crystals, or detritus, bacteria in the draft are not visible or not. Then, as a diagnostic feature, you can use the presence of leukocytes (Piura). The result is positive, if in the field of view there is at least 5 leukocytes, which confirms the diagnosis.
The results of the survey draft, even if it contains, for example, cylinders or groups of leukocytes did not allow for localization of infection.
If the study did not find violations of sediment, while the clinical data make it possible to suspect UTI, you should repeat the nitrite test and explore the draft, obtained from a new, fresh, portions of urine.
Thus, begin with a microscopic study of sediment, and then, if necessary, to comply with nitrite test. The presence of at least 20 bacteria in the field of view allows sufficient certainty to the diagnosis. Only the identification of Piura (at least 5 leukocytes in the field of view) gives a somewhat lower confidence. If research results are negative, whereas the clinical picture still points to the UTI, the study repeated with a new portion of the urine, or go to the next stage, details are described in “Treatment”.

Further examination

In some cases the positive result of a study of urine is the basis for the general and supplementary examinations (see the “terms”). Recommendations are listed in the section “Treatment”.
How much expansion should be further examination (manual examination, ultrasonography (USG), EMU, a survey specialist), depends on the situation, while playing the role of such factors as age, history, concomitant diseases.

Treatment

It is impossible to give recommendations are applicable in all situations, the proposed tactics should be considered as a basis.
Complaints OBCHM in the absence of UTI, patients often make. In this case we are talking about acute uretralnom syndrome, which in this standard is not considered.
Asymptomatic bacteriuria usually do not require treatment; exceptions discussed below.
If the control is shown after treatment of UTI, it is, in principle, be made a day after the treatment.
There are several categories of patients with UTI.
1. Non-pregnant patients older than 12 years if no complications or evidence of the existence of a main disease or condition, you can assign a choice of trimethoprim (trimopan, triprim) (1 times a day, 300 mg), sulfametizol (Rufol) (2 times a day 1000 mg) or nitrofurantoin (APO-nitrofurantoin) (4 times daily 50 mg), all preparations appointed within 3 days.
The advantage of treatment sulfonilamidami is its low cost, but it must reckon with the fact that some micro-organisms, mainly E. coli, have shown resistance to drugs in this group.
Short course of treatment preference for the fact that patients adhere to treatment more easily, as well as low-cost, side effects and effectiveness of the suppression of colonization in the intestine. The three-day better than the one-day courses, as well as in the latter case, the probability of recurrence, but a one-day treatment has its advantages.
The control is not necessary, if the complaint disappeared.
If a patient’s complaints persist, then again perform a study of urine, with positive results shall appoint another tool of first choice. Control is also not necessary, if the complaints disappear. If not, conduct further research, including seed treatment shall appoint, with the results.
When the negative result of the second and perhaps third study of urine, it is necessary to act as the Acute uretralnom syndrome, as already mentioned, in this standard, such cases are not considered.
When complications are also conducting a further survey and make seed. At the same time appoint amoxicillin (gonoform) 3 times per day to 375 mg until the results of seeding. Future Tactics is defined seeding results, taking into account the clinical picture and the overall data, and possibly additional testing.
Tactics during relapses is the same as the first infection. If within a year the patient UTI occurs more than 3 times, carry out further examination, perhaps the appointment of a preventive treatment for a period of 3-6 months with the use of trimethoprim 100 - 150 mg at night or nitrofurantoina 50 - 100 mg at night.
With regard to nursing women should be made the following clarifications:
• the recommended drugs are amoxicillin (3 times a day, 375 mg for 3 days);
• the continuing complaints and the positive result of the second study a urine culture.
2. Pregnant women appoint amoxicillin 3 times a day, 375 mg for 3-7 days. After the treatment is always carried out a study of urine control, with positive results is always carried out seeding. After recovery for the entire period of pregnancy each month exploring urine to detect signs of infection; recommended Semiquantitative culture. If you find information fektsiyu control, then re-designate treatment.
3. Children under the age of 12 are seeding, a general survey and an intensive monitoring treatment efficacy.
Usually assigned to children under 5 years of amoxicillin 25 mg / kg / day in three admission, children 6-12 years - 6-9 mg trimethoprim / kg / day in two steps, the duration of treatment is 3-7 days.
The younger the child, the more likely to have underlying disorders that have not yet been identified, so the decision on the supplementary examination (ultrasound, EMU) should be taken as soon as possible, however, clear indications for additional screening to be determined.
If you decided not to conduct additional surveys, the monthly recovery after six months investigating the presence of urine infection.
If you control the infection is detected, it should be treated and an additional survey.
4. UTI male patients over 12 years of age are most likely associated with prostatitis. We recommend further examination. Designate the choice of one of the following means: 1 trimethoprim once daily or 300 mg of amoxicillin 3 times a day, 375 mg, both drugs for 10-14 days.
After the treatment should be control study of urine. If the infection persists, produce seed.
5. Patients with low resistance (the elderly, diabetics, in-patient with indwelling catheter, or without it) in the first instance may be designated by the treatment described in paragraph 1. This is especially true in cases where the occurrence of the disease play a role of the aging process.
If complaints persist, as well as the fever and / or general malaise with no apparent complaints of violation of urination, then a positive result of the study, urine culture should be performed. In some cases it is desirable to begin treatment before the results become known for planting. You can assign amoxicillin 3 times daily or 375 mg of doxycycline (vibramitsin, unidoks, solyutab) 1 times a day, 100 mg (on the first day of 200 mg).
Note. Treatment hinolonami (eg norfloksatsinom [nolitsin, norbaktin]) or Cephalosporins may be appointed only on the basis of the results of sowing and of resistance. The use of these funds, therefore, possible only in the second or third instance.

Informing patients

In most cases, patients give health advice to increase urine production, regular emptying of the bladder, are advised not to postpone urination when the urge, the bladder is completely emptied, cleaned perinealnuyu area to prevent contamination vulvovaginalnoe, make urination after sexual intercourse.
Studies have not shown a clear relationship between lifestyle, body hygiene and the prevention of urinary tract infections and their recurrences. But still seems a reasonable recommendation is to drink a lot and well empty the bladder.

Many parents are convinced that the little boy’s genitals do not require special care, and sometimes even ashamed to discuss these issues. Such a position could lead to serious trouble - not recognized in time intimate illness may hurt auknutsya when the child grows. What should draw the attention of the parents that this does not happen, the doctor advises a Moscow hospital # 14 Igor SOKOLOV.

EMPTY basket.
To ensure that the boy’s all right, you should feel his scrotum. The best way to do this when the child is calm, is full and is to start a conversation. Keep hands in warm water and wipe dry - if inspected cold hands, the muscles reflexly reduced testis and can “limp”. The left hand keep scrotum, but it felt right delicately. If the testicle in the scrotum, you’re sure to find it. Male sex glands initially formed near the kidneys, but also in the maternal womb gradually descend through the inguinal canal at the bottom of scrotum. But at any point on this long journey, they can “stick”. The condition, when the scrotum is not one or both testicles, the doctors called kriptorhizmom. In premature infants kriptorhizm considered normal. By the end of the first year of life in 80% of stray testicle does falls into scrotum. Sometimes young boys found a so-called false kriptorhizm: testicle is located in the scrotum, but with a reduction of muscles, raised testicle, it periodically pull up. And parents do not find it on the ground, raise the alarm. But kriptorhizm distinguish the true from the false, to determine the size of inguinal rings and the size of the testicles may be just a doctor. It is therefore not ленитесь once again show the son of children’s surgeon. Indeed kriptorhizm - is not just a cosmetic defect, but also the disease is fraught with serious complications. Already at the age of five in the “getting stuck” testicle begins dystrophic changes, sometimes in the future could lead to infertility. Over time, undescended testis have been increasingly harmful effects, and the 20-40 years it may develop cancer. In addition, the abdominal cavity, where the testicle moves freely, it can happen overwind. A location of testis in inguinal canal has its denials. Parents should keep in mind about these complications and to know their signs. Disease begins with sudden sharp pains in the abdomen and pahu. Then the temperature rises, vzduvaetsya stomach, and begins vomiting. If you have suspicious symptoms should immediately call “ambulance”, a child with legs bent at the knees to lay on the bed. At the bottom of your stomach, put the bubble on the rocks. Boys with kriptorhizmom to a year should observe a surgeon and a children’s endocrinologist. To accelerate the lowering of testicle in scrotum, often appoint stimulants. Already by the second month of life the child begins to give an oily solution of vitamin E for 5-10 mg / day. Mothers who breast feed, except for enriched nutritional doctors recommend taking extra vitamins A, B1, C, E and D. “Iskusstvennikam” is a mixture enriched with vitamins. After a year, if the egg does not fall, except for vitamin E designate another child vitamins C and E in doses appropriate to the age. Older children by checking their hormonal background, sometimes appoint hormones. But this is not a panacea: kriptorhizm healed in only 80-90% of cases. In addition, any hormone therapy is always fraught with unpredictable consequences. And before you accept it, it must be good to think about. Most surgeons believe that the best method of treatment is kriptorhizma operation. If you make it in time, recovery is guaranteed. Older children operated on in 5-7 years, but recently the age batten down to 2-3 years, which helps prevent dystrophic changes. If the testicle is located close to the scrotum, there is only one operation. And if it is raised high, then lower it in two stages.

Adversary “proboscis”

Phimosis - another extremely intimate common disease causing genuine concern of parents. A sick child in the flesh severely reduced, which prevents exposure of the head of the penis. Phimosis often passes itself: a young boys head is not normally grows together with the inner surface of the flesh, and to five years, they separated from each other. But sometimes self becomes impossible. More often it is due to inflammation. The point is that between the head and the foreskin has a layer of fat - smegma. Mixed with urine, it has become infected and cause inflammation. After this form adhesions and scarring, which can be removed only by surgery. Another reason for phimosis - Education stones appearing at a standstill smegmy. When expressed phimosis foreskin hanging with the head of the penis in the form of a “hobotka. When a child mochitsya, “proboscis” under pressure inflates the urine and sometimes resembles a ball. Sometimes a baby is difficult to urinate, have to retch. This urine is allocated a thin trickle. Narrowing foreskin difficult urination, resulting in increased pressure in the urinary tract. This, in turn, leads to serious diseases such as pyelonephritis and hydronephrosis. Permanent natuzhivanie increases the pressure in the abdominal cavity, causing a hernia, you may receive or prolapsed rectum. In a very narrow hole foreskin may infringe the head of the penis - parafimoz accompanied by severe pain and progressive edema of the penis. Infringement requires immediate surgical intervention, because it can lead to gangrene head. The task of the parents - to prevent scarring and spaek. This is easily done by observing the elementary rules of hygiene. Accustom the boy to hold morning and evening toilet exterior genitals. Several times a week after bathing delay the flesh toward the root of the penis and remove smegmu a sterile cloth, then lubricate the surface of sterile sticks together vazelinovym oil. If the inflammation does there, be sure to make twice-daily baths with a weak solution margantsovki. Typically, these activities are simple enough to prevent the bonding head and the foreskin. If, however, to five years of your efforts have failed, you should go to a surgeon. Do not be afraid: no one will soon operate the hapless boy. First, the doctor will try to separate the foreskin from the head of a special metal probe. This manipulation is carried out several times, and in the intervals should be regularly uncover “all the way” and routine hygiene activities. However, if the child pronounced phimosis with scars and adhesions to release the head of the probe can not. Launched phimosis can be cured only by surgery. However, it can be done without waiting for five years - at the request of the parents or with a very narrow “hobotke” inhibiting urination. Foreskin is removed under general anesthesia, and after the operation to the line of stitches put gauze roll. Mom, caring for baby, must be that at the time of urination brassard not namokala. For this purpose you can use a wide receiver to tight pristavlyayut to the head of the penis when a child mochitsya. And, of course, careful toilet genitals.

NATURE OF ERROR

Gipospadiya - a rare disease in which the external urethra opening is not located in the center of the head of the penis, and either on its lower part or on the body of the penis, and sometimes even in the scrotum. Read gipospadiyu easy - just to look at the boy’s sexual organs. In addition to misuse of the urethra openings, the child is curved penis. Frequent urination disorders, because of what the boy did not mochitsya standing and sitting, with the jet spray of urine. Children are afraid to use public toilets, soon aware of their physical disability. Therefore, if you want a child growing up without the complex, to solve this problem not only with doctors, but also to psychologists. Sick boys must necessarily operate. Sometimes surgery is done in two phases, the first straightened the penis, and then forming the urethra. To take the plastic skin from the penis, with the perineum, with the scrotum or thigh. Now increasingly used prosthetic urethra, and this operation is done in one step. After her baby mochitsya through the catheter. And my mom, being in the hospital with the baby, should follow the catheter, so as not to leak urine, that it does not fall and did not overwind. The skin around it should handle margantsovkoy, podsushivat paste Lassara and regularly change the gauze swabs. A urinal must be changed on a daily basis sterile.