Symptoms of pyelonephritis

Symptoms of acute pyelonephritis (or exacerbation of chronic) are often characterized by a sudden onset of the disease with the development of a triad of signs:

• an increase in body temperature (up to 38-40 °C, sometimes higher) with stunning chills and profuse sweating;
• pain of varying intensity in the lumbar region (unilateral or bilateral), which intensifies with palpation, walking, and tapping in the area of the kidney projection (pain in the lateral parts of the abdomen is possible);
• pyuria (leukocyturia).

In some cases, more often in women, acute pyelonephritis begins with acute cystitis (frequent and painful urination, pain in the bladder, terminal hematuria). Other symptoms of acute myelonephritis: general fatigue, weakness, muscle and headaches, loss of appetite, nausea, vomiting. Purulent forms (apostematous nephritis, carbuncle, kidney abscess, necrotic papillitis) are more common in acute pyelonephritis that occurs against the background of urinary tract obstruction, diabetes mellitus, immunosuppressive therapy, etc. (5-20%). In obstructive pyelonephritis, pain in the lumbar region is intense and bursting, there are often pronounced signs of general intoxication, an increase in the level of nitrogenous waste in the blood, jaundice is possible.

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Symptoms of chronic pyelonephritis

Chronic pyelonephritis may be an outcome of acute pyelonephritis (in 40-50% of cases with obstructive pyelonephritis, in 10-20% - with gestational). It is possible to develop gradually, gradually, often starting in childhood (more often in girls). The patient may not be bothered by anything or have general complaints of weakness, increased fatigue, sometimes subfebrile temperature, chills (long after colds), aching pain in the lumbar region, pain in the right side with right-sided pyelonephritis, urinary disorders (polyuria or nocturia), the appearance of pastosity of the eyelids in the morning, increased blood pressure (hypertension is initially transient, then becomes stable and high).

Often the only symptoms of chronic pyelonephritis are:

• isolated urinary syndrome (minor bacteriuria, leukocyturia);
• decreased relative density of urine;
• anemia that is difficult to treat (in the absence of signs of renal failure, it is caused by prolonged intoxication).

Sometimes latent chronic pyelonephritis first manifests itself clinically with symptoms of chronic renal failure. Paleness, dry skin, nausea, vomiting, nosebleeds appear. Patients lose weight, anemia increases; pathological elements disappear from the urine. The rate of progression of chronic renal failure is determined by:

• activity of the infectious process;
• virulence of the pathogen;
• severity of hypertension and other factors.

In the absence of structural abnormalities and metabolic disorders, disease progression to the terminal stage of chronic renal failure is rarely observed (2-3%) [Massry S., 1983]. Recurrent pyelonephritis significantly more quickly leads to a decrease in renal function: 10 years after diagnosis, normal renal function is observed in only 20% of patients.

An important role in the chronicity of the disease is given to disturbances in the passage of urine (vesicoureteral reflux, nephrolithiasis, etc.).

In elderly patients, the symptoms of chronic pyelonephritis may be varied - from low-symptom or asymptomatic latent urinary infection, isolated intoxication syndrome, severe anemia to severe bacteremic shock with sudden collapse, signs of disseminated intravascular coagulation (DIC), septicemia, acute acid-base balance disorders. Urogenic acute pyelonephritis often begins immediately with the development of purulent inflammation.

The frequency of purulent forms, according to morphological studies, approaches 25% in men and 15% in women. Manifestations of intoxication may be accompanied by changes in the leukocyte formula and an increase in ESR. Differential diagnostic difficulties often arise when assessing the activity of the process in elderly people due to the fact that pyelonephritis develops or worsens against the background of polyorgan senile pathology, manifestations of systemic vascular diseases, tumor processes or metabolic disorders. In weakened cachectic patients, even purulent pyelonephritis complicated by paranephritis may be virtually asymptomatic or manifest itself as intoxication syndrome and anemia.

Symptoms of pyelonephritis during pregnancy

Acute pyelonephritis of pregnant women (including exacerbation of chronic pyelonephritis) occurs in approximately 10% of cases. Most often (about 80%) exacerbations develop in the second trimester (at 22-28 weeks) of pregnancy, less often in the third trimester. Among the risk factors for the development of pyelonephritis during pregnancy, the most significant are:

• asymptomatic bacteriuria not treated before pregnancy (30-40% of women);
• malformations of the kidneys and urinary tract (6-18%);
• stones in the kidneys and ureters (about 6%);
• reflux at various levels of the urinary tract;
• chronic kidney disease, etc.

The development of gestational pyelonephritis is facilitated by urodynamic disorders caused by pregnancy:

• hyperprogestinemia and associated hypotension, dilation of the renal pelvis and ureters already in the early stages of pregnancy;
• pressure of the uterus on the urinary tract, increasing as the pregnancy progresses;
• borderline and pathological variants of pregnancy (large fetus, polyhydramnios, multiple pregnancy, narrow pelvis).

In the postpartum period, the risk of developing pyelonephritis remains high for another 2-3 weeks (usually on the 4th, 6th, 12th days after delivery), while the dilation of the upper urinary tract persists. Acute pyelonephritis in pregnant women and women in labor is characterized by a sudden onset, high body temperature, chills, and severe intoxication. As the disease progresses, the general symptoms of pyelonephritis are combined with local pain in the lumbar region on the affected side. If the therapy is ineffective, pain continues to increase, and signs of intoxication increase, it is necessary to exclude purulent forms: apostematous nephritis, renal carbuncle, inflammation of the perirenal tissue. With these forms, septic shock and acute renal failure may develop. Pyelonephritis in pregnant women can also occur with mild symptoms, the so-called “latent” form (especially in women who received antibacterial therapy during pregnancy), which makes it difficult to diagnose the disease.