Urinary system disease in children presentation

Urinary system disease

1. RADIATION DIAGNOSTICS OF
DISEASES OF THE URINARY SYSTEM IN
CHILDREN.
Syzdykova N.R.

2. METHODS OF RADIATION EXAMINATION OF THE
KIDNEYS AND URINARY TRACT
▶Ultrasound – transabdominal, transrectal and transvaginal sensors
▶ Overview radiography
▶Intravenous urography
▶Infusion urography
▶Retrograde pyelography
▶Cystography
▶Angiography
▶CT
▶MRI
▶Nephroscintigraphy

3. To diagnose kidney and urinary tract diseases in children, a complex of radiation methods is used, but the leading
method, the most widely used today, is ultrasound.
Indications for ultrasound.
1. Screening at the age of about 1-2 months of life.
2. In cases of antenatal diagnosis of kidney abnormalities immediately after discharge from the hospital, if the
severity of the baby's condition does not require assistance already in the first day of life.
3. Screening every 2 years, including mandatory examination before admission to a children's institution, sports
section, etc.
4. Unclear hyperthermia without catarrhal manifestations.
5. Dysuric disorders.
6. Changes in urine tests.
7. Lower back and/or abdominal pain.
8. Injury to the abdomen and/or lumbar region.
There are no contraindications to kidney ultrasound. With the echographic detection of pathological changes on the
part of the kidneys and urinary tract, indications are given for other research methods - primarily excretory
urography and cystography.

4. In excretory urography, a radiopaque drug is injected into the ulnar vein and X-rays are taken at certain
intervals.
Indications for excretory urographin are:
- the presence of obstructive uropathies or suspicion of them;
- traumatic kidney injuries;
- anomalies of the number, position and relative position of the kidneys or suspicion of this pathology
Contraindications to excretory urography are:
- the child's age is less than 2 weeks due to the low concentration capacity of the kidneys;
- systolic blood pressure below 70 mmHg.;
- kidney failure;
- allergic reactions to contrast agents.

5. When preparing for excretory urography,1- 2 days before the study, the individual sensitivity of the patient
to iodine should be checked.
To do this, 1 ml of the radiopaque substance verografin containing iodine is slowly injected into the vein. W
ith hypersensitivity (the appearance of itchy skin, urticaria, rhinitis, Quincke's edema, general malaise, pron
ounced tachycardia, etc.), the study is contraindicated.
During retrograde urography, when a radiopaque substance is injected into the urinary tract (after checking i
ndividual sensitivity to iodine), no special preparation of the intestine is required.
In / in 20-60 ml of iodine-containing contrast: sergozina, urografina, urotrasta.
A series of radiographs on the 1st, 5th, 10th, 20th, 45th and 60th min

6. With cystography,
a contrast agent is injected through a catheter into the bladder, an X-ray is taken with the bladder
filled, and then during the injection.
An indication for cystography is a suspicion of vesicoureteral reflux. Currently, it is miction cys
tography that is the gold standard in the diagnosis of vesicoureteral reflux.
A contraindication to performing cystography is an acute inflammatory process in the kidneys,
as well as trauma to the urethra.

7. cystography: descending and ascending. Descending cystography is performed immediately after excretory
urography. Descending cystography has a number of disadvantages: relatively low contrast of the image of
the lower urinary tract, it is difficult to detect vesicoureteral reflux. The technique of ascending cystography
consists in catheterization of the bladder and the introduction of any water-soluble or contrast gaseous drug
into it before the appearance of an imperative urge to urinate. They usually take three pictures: the first is in
the phase of urine retention. Normally, the bladder in the phase of maximum filling has a rounded, pear
-shaped or oval shape. The contours are smooth, clear. The second picture is taken at the moment of urination
- this technique is called miction cystography. It allows you to set the height of the retrograde movement of
urine from the bladder, register vesicoureteral reflux, antiperistalsis of the ureter during reflux.
In addition to obstruction, vesicoureteral reflux; non-X-ray contrast concretions and some types of neurogenic
bladder dysfunctions, with the help of cystography, it is possible to identify diverticula of the bladder wall,
ureterocele, tumors and traumatic lesions of the lower urinary tract. Cystography does not allow to diagnose
inflammatory changes in the mucous membrane of the bladder and does not replace cystoscopic examination.

8. KIDNEY ANGIOGRAPHY. A diagnostic method that allows you to assess the condition of the
renal arteries. A catheter is inserted through a puncture in the femoral artery, which is brought
along the abdominal part of the aorta to the place where the renal arteries depart from it and a
water-soluble contrast agent (40-60 ml) is injected into them. Renal angiography is performed
when: Suspected renovascular hypertension (atherosclerosis, arteritis of the renal arteries)
Planning operations for an abnormal kidney Planning of intravascular surgical interventions
(balloon dilation, embolization, stenting)

9. Overview radiography of the kidneys is a method of rapid diagnosis of a number of
pathological conditions (urolithiasis, hydronephrosis, kidney tumors, etc.), the results of which
require further clarification by other methods
2-3 days before the study, it is necessary to exclude from the diet products that promote gas
formation (milk, fruit, black bread, vinaigrettes, salads, sugar, etc.) With a tendency to flatulence, it
is advisable to prescribe activated carbon (carbolene) 1 table 4 times a day. On the eve of the study,
it is recommended to limit fluid intake from the afternoon. In the evening and in the morning, 2-3
hours before the study, the intestines are cleaned with an enema.

10. NORMAL RADIATION ANATOMY OF THE KIDNEYS,
URINARY TRACT
During ultrasound examination, the kidney of a healthy child has an oval shape
echographically, smooth clear contours, the echogenicity of the cortical layer of the
parenchyma is lower than the echogenicity of fragments of neighboring parenchymal organs. In
newborns, the echogenicity of the cortical layer of the renal parenchyma may be higher than the
echogenicity of other organs (the kidneys look more "white"). The hypoechoic pyramids are
clearly traced, which morphologically correspond to groups of collecting tubules in the cerebral
layer of the kidney parenchyma.
USG-the size of the kidneys in children. The most stable kidney size is its length. In a newborn,
it is about 45-50 mm, by the first year of life it reaches 62 mm, then it increases by about 3 mm
per year. Thus, the length of the kidney can be roughly determined by the formula:
L = 62 + 3 x (n - 1)
where L is the length of the kidney in mm, n is the age of the child in years.

11. The mobility of the kidneys in children is echographically determined during an orthostatic
test: after marking the position of the upper pole of the kidney in the child's lying position, the
child should get up, jump a little or walk. Then, in the standing position, the location of the
kidney is determined and again a mark is made on the child's back, focusing on the upper edge
of the kidney. The distance between the marks is measured and its ratio to the child's height is
calculated: normally, the displacement of the kidney does not exceed 1.8% of the child's
height; 1.8-3.0% indicate increased mobility of the kidney; more than 3% indicate
nephroptosis. More often, increased mobility of the kidneys is determined in school-age
children with an asthenic body type, mainly in girls.
Doppler assessment of renal blood flow is widely used in kidney ultrasound, while the
visualization of the vascular pattern in the kidneys depends both on the age and physique of the
child, and on the technical capabilities of the equipment used. The larger the patient, the less
detailed it is possible to visualize both the actual structure of the renal parenchyma and the
vascular pattern.

12. During excretory urography, the contrast of the renal parenchyma is normally
observed already at the 1st minute after the administration of the contrast
agent, at the 5th-6th minute the undilated collecting system of the kidneys is
contrasted, the ureters can be traced not all at once, but by cystoids. By the
30-40 minutes, the calyx-pelvic system of the kidneys is freed from the
contrast that accumulates in the bladder. With cystography, the bladder has
smooth, clear contours, there is no casting of contrast agent into the ureters,
there are no inclusions in the lumen of the bladder and there are no defects in
its contrast.
Quantitative assessment of renal blood flow is quite complicated. In general,
children tend to increase the rate of arterial blood flow and decrease its
resistive characteristics with age. The speed and resistive characteristics of
blood flow also decrease from the main renal artery to the periphery. Attention
is drawn to the significant individual variability of indicators. Numerical
values of arterial renal blood flow are presented in the appendix.

13. Traditional radiopaque examination of urinary system in children:
a - excretory urography, the picture was taken at 6 minutes, the kidneys were clearly contrasted on
both sides, there was a little contrast preparation in the bladder;
b, c - cystography with a filled bladder (b) and during miction (c). The arrow shows the urethra

14. ANOMALIES OF THE KIDNEYS
Anomalies in the number of kidneys can be associated with both an increase and a
decrease in their number. The latter may be congenital (congenital single kidney) or
acquired (condition after nephrectomy).
The single congenital conditionally healthy kidney differs from a paired organ only in
its size: already in a newborn it is somewhat larger than the age norm, although a
significant increase in size develops later: the outstripping growth of a single kidney is
clearly noticeable by 4-5 months, when it reaches the size of a paired kidney of a
one-year-old child or exceeds them. By the age of 4-5, a single healthy kidney can reach
the size of an adult kidney. By the end of its growth, a single congenital kidney usually
reaches a size of 140-150 mm in length and 55-65 mm in thickness. The Doppler study is
characterized by an increase in the blood flow rate in the arteries of the kidney, the
resistive characteristics of arterial blood flow usually do not differ from the norm.

15. Aplasia is the congenital absence of one or both kidneys and renal
vessels. Bilateral aplasia of the kidneys is incompatible with life.
Aplasia of one kidney is relatively common - in 4-8% of patients
with kidney anomalies. It occurs due to the underdevelopment of
metanephrogenic tissue. In half of the cases, there is no
corresponding ureter on the aplasia side of the kidney, in other
cases, its distal end ends blindly.
Kidney aplasia is combined with anomalies of the genital organs in
70% of girls and in 20% of boys. In boys, the disease occurs 2 times
more often.
Information about the presence of a single kidney in a patient is
extremely important, since the development of diseases in it always
requires special treatment tactics. A single kidney is functionally
more adapted to the influence of various negative factors. With renal
aplasia, its compensatory (vicarious) hypertrophy is always
observed.
▶

16. The single kidney or aplasia:
a - excretory urography. The picture was taken 15 minutes after the administration of the contrast agent. A
slightly dilated cup-pelvic system of the right kidney is determined. There is no function of the left kidney, it is
impossible to judge the presence or absence of an organ;
b - angiography. The only left renal artery is determined (arrow)

17. Excretory urography and ULTRASOUND allow you to detect a single, enlarged kidney. A characteristic
feature of the disease is the absence of renal vessels on the side of aplasia, so the diagnosis is reliably
established on the basis of methods that allow to prove the absence of not only the kidneys, but also its
vessels (renal arteriography, multispiral computer and magnetic resonance angiography). The cystoscopy
picture is characterized by the absence of the corresponding half of the interureteral fold and the mouth of
the ureter. With a blindly ending ureter, its mouth is hypotrophied, the contraction and excretion of urine
are absent. This type of defect is confirmed by catheterization of the ureter with retrograde ureterography.

18. ▶An increase in the number of kidneys is common: one or two-sided doubling of the calyx-pelvic
system is one of the most common developmental abnormalities. Ultrasound determines the increase
in length and separation of the collecting system of the kidney. The size of the fragments of a doubled
kidney is often unequal: the upper fragment is usually smaller than the lower one. In the absence of
dilatation of the urinary tract, it is echographically impossible to trace the course of the ureters and it
is possible to differentiate the variant of the structure of the urinary tract only during excretory
urography: with complete doubling of the urinary tract, there are also 2 ureters that open into the
bladder with two mouths. With incomplete doubling, there is one split ureter (ureter fissus), the mouth
of the ureter is one.
▶For the final verification of the features of the confluence of the ureters of the doubled kidney into the
bladder, cystoscopy is performed - a visual examination of the bladder cavity using endoscopic
technique. Doubling of the kidney in itself has no clinical manifestations, occurs quite often and is
sometimes detected accidentally by ultrasound for other diseases, even in old age. However, quite
often the doubling of the collecting system of the kidney is accompanied by vesicoureteral reflux into
one or both collecting systems, obstructive uropathies of one or both fragments.

19. Kidney doubling is the most common abnormality of the number of kidneys, occurring in one case per 150
autopsies. In women, this malformation is observed 2 times more often.
As a rule, each of the halves of the doubled kidney has its own blood supply. Characteristic of such an anomaly
is anatomical-function-on asymmetry. The upper half is more likely to be less developed. The symmetry of the
organ or predominance in the development of the upper half is much less common.
Doubling of the kidney can be single- and bilateral, as well as complete and incomplete . Complete doubling
implies the presence of two cup-pelvis systems, two ureters opening with two mouths in the bladder (ureter
duplex). With incomplete doubling, the ureters eventually merge into one and open with one mouth in the
bladder (ureter fissus).
Often, a complete doubling of the kidney is accompanied by an anomaly in the development of the lower part of
one of the ureters: it was intravesical ectopia (opening in the urethra or vagina), the formation of a ureterocele or
the insolvency of the vesicoureteral junction with the development of reflux. A characteristic sign of ectopia is a
constant leakage of urine with maintained normal urination. A doubled kidney, not affected by any disease, does
not cause clinical manifestations and is found in patients with a random examination. However, it is more often
than normal, prone to various diseases, such as pyelonephritis, urolithiasis, hydronephrosis, nephroptosis,
neoplasms.
▶

20. a, b - Ultrasound: double kidney. The upper fragment is noticeably smaller than the lower one;
c, d - ultrasound: a doubled kidney, the size of the fragments is approximately equal;
e - excretory urography. Doubling of the urinary tract on the right;;
f - cystography. High (II-III degree) active vesicoureteral reflux in both fragments of the doubled left kidney
c
db
e f

21. The fusion of the kidneys can be symmetrical and asymmetrical. In the first case, the kidneys grow together
with the same poles, as a rule, the lower and extremely rarely - the upper (horseshoe-shaped kidney) or middle
sections (biscuit-shaped kidney). In the second, the fusion occurs with different poles. Depending on the fusion
option , there are:
- The horseshoe kidney is the most common fusion anomaly. In more than 90% of cases, there is a fusion of the
kidneys by the lower poles. More often, such a kidney consists of symmetrical, identical in size kidneys and is
dystopic. The size of the splicing zone, the so-called isthmus, can be very different. Its thickness, as a rule,
ranges from 1.5-3, width 2-3, length - 4-7 cm.
- The biscuit-shaped kidney is usually located below the promontorium in the pelvic area. The volume of the
parenchyma of each half of the biscuit-shaped kidney is different, which explains the asymmetry of the organ.
The ureters usually flow into the bladder in a normal place and very rarely intersect with each other.
- With the location of one kidney in a typical place, and the second, fused with it at right angles, across the spine
- the kidney is called L-shaped.
- I-shaped kidney (fusion of opposite poles with cross dystopia and caudal displacement of one of the kidneys) -
is rare.
-In cases where in the fused kidney lying on one side of the spine, the gate is directed in different directions, it is
called S-shaped

22. Scheme of variants of kidney fusion (thin vertical line conventionally denotes the spine):
a - the normal location of the kidneys;
b - horseshoe kidney;
c - biscuit-shaped kidney;
d- L- shaped kidney;
e – I - shaped kidney
b c
d e

23. S- shaped kidney L- shaped kidney I - shaped kidney

24. Clinically fused kidneys may be manifested by pain in the para-umbilical region. Due to the peculiarities
of the blood supply and innervation of the horseshoe kidney and the pressure of its isthmus on the aorta,
vena cava and solar plexus, even in the absence of pathological changes in it, can be characteristic
symptoms. With such a kidney, the appearance or intensification of pain in the navel during bending the
trunk back (Rovzing's symptom) is typical. There may be disorders of the digestive system - pain in the
epigastric region, nausea, bloating, constipation.
Ultrasound, excretory urography and multispiral CT are the main methods for diagnosing fused kidneys
and identifying their possible pathology

25. CT with contrast (frontal projection). Horseshoe kidney.
Weak vascularization of the isthmus due to the
predominance of fibrous tissue in it
Multispiral CT (axial projection).
Horseshoe kidney

26. Hypoplasia of the kidney (dwarf kidney) is a congenital decrease in the size of the normal morphological
structure of the renal parenchyma without impairing its function. This malformation, as a rule, is combined
with an increase in contralateral kidneys. Hypoplasia is more often unilateral, much less often - it is observed
on both sides.
Unilateral renal hypoplasia may not be clinically manifested, but in an abnormal kidney, pathological
processes develop much more often. Bilateral hypoplasia is accompanied by symptoms
of arterial hypertension and renal failure, the severity of which depends on the degree of the birth defect and
complications arising mainly from the accession of infection.
The diagnosis is usually established on the basis of ultrasound diagnostics, excretory urography, CT and
radioisotope scanning
Of particular difficulty is the differential diagnosis of hypoplasia from dysplasia and wrinkled kidney as a
result of nephrosclerosis. Unlike dysplasia, this anomaly is characterized by the normal structure of the renal
vessels, the cup-pelvis system and the ureter. Nephrosclerosis is more often the outcome of chronic
pyelonephritis or develops as a result of hypertension. Cicatricial degeneration of the kidney is accompanied
by a characteristic deformation of its contour and cups.
Treatment of patients with a hypoplastic kidney is carried out with the development of pathological processes
in it.

27. An anomaly in the location of the kidney - dystopia - the presence of the kidney in an atypical anatomical area for it.
This anomaly occurs in one in 800 to 1,000 newborns. The left kidney is dystopic more often than the right.
The reason for the formation of this malformation is a violation of the movement of the kidney from the pelvis to the
lumbar region during fetal development. Dystopia is caused by fixation of the kidney in the early stages of embryonic
development by an abnormally developed vascular apparatus or insufficient growth of the ureter in length.
Depending on the level of location, thoracic, lumbar, sacroiliac and pelvic dystopia are distinguished.
Anomalies in the location of the kidneys can be unilateral and bilateral. Dystopia of the kidney without its
displacement to the opposite side is called homolateral. The dystopic kidney is located on its side, but above or below
the normal position. Heterolateral (cross) dystopia is a rare malformation detected with a frequency of
1: 10,000 autopsies. It is characterized by the displacement of the kidney to the opposite side, as a result of which both
of them are located on one side of the spine. In cross-dystopia, both ureters open in the bladder, as in the normal
location of the kidneys. The urinary triangle is preserved.

28. A ectopic kidney can be the cause of constant or periodic pain in the corresponding half of the abdomen, lumbar
region, sacrum.
An abnormally located kidney can often be felt through the anterior abdominal wall.
This anomaly is in the first place among the causes of erroneously performed surgical interventions, since the
kidney is often mistaken for a tumor, appendicular infiltrate, pathology of the female genital organs, etc. In
dystopic kidneys, pyelonephritis, hydronephrosis, urolithiasis often develop.
The greatest difficulties in making a diagnosis are caused by pelvic dystopia. This arrangement of the kidney
can be manifested by pain in the lower abdomen and simulate acute surgical pathology. Lumbar and iliac
dystopias, even if not complicated by any disease, can be manifested by pain in the corresponding area. Pain in
the most rare thoracic dystopia of the kidney is localized behind the sternum.

29. Types of renal ectopia: 1 - thoracic;
2 - lumbar; 3 - sacroiliac; 4 - pelvic;
5 - normally located left kidney
Heterolateral (cross) ectopia of
the right kidney

30. The most common malformations of the structure of the kidney parenchyma are cortical cystic lesions (multicystosis,
lycystosis and solitary kidney cyst). These anomalies are united by the mechanism of violation of their
morphogenesis, which consists in the dissonance of the connection of the primary tubules of the metanephrogenic
blastema with the metanephros duct. They differ in the timing of the violation of such a fusion during the period of
embryonic differentiation, which determines the severity of structural changes in the kidney parenchyma and the
degree of its functional insufficiency. The most pronounced changes in the parenchyma incompatible with its
function are observed in multicystic kidney disease.
The multicystic kidney is a rare anomaly characterized by multiple cysts of different shapes and sizes occupying the
entire parenchyma, with the absence of its normal tissue and underdevelopment of the ureter. Intercystic spaces are
represented by connective and fibrous tissue. The multic kidney is formed due to a violation of the connection of the
me-tanephrosis duct with the metanephrogenic blastema and the absence of the excretory laying while maintaining
the secretory apparatus of the permanent kidney in the early stages of its embryogenesis. Urine, formed, accumulates
in the tubules and, having no exit, stretches them, turning them into cysts. The contents of the cysts are usually a
clear liquid, remotely recalled urine. By the time of birth, the function of such a kidney is absent.
As a rule, multicystic kidney disease is a unilateral process, often combined with malformations of the contralateral
kidney and ureter. Bilateral multicystosis is incompatible with life.
Before the infection joins, the unilateral multicystic kidney does not manifest itself clinically and may be an
accidental finding during a dispensary examination. The diagnosis is established using sonography and X-ray
radionic methods of research with a separate determination of kidney function. Unlike from polycystosis,
multicysticism is always a one-sided process with the absence of function of the affected organ.
▶

31. Polycystic kidney disease is a malformation characterized by the replacement of the renal
parenchyma with multiple cysts of various sizes. This is a difficult bilateral process, it is
often joined by chronic pyelonephritis, arterial hypertension and increasing chronic renal
failure.Polycystosis occurs quite often - 1 case per 400 autopsies. In a third of patients,
cysts in the liver are detected, but they are few in number and do not violate the function of
the organ.Pathogenetically and clinically, this anomaly is divided into polycystic kidney
disease in children and adults. For polycystosis of childhood, an autosomal recessive single
type of transmission of the disease is characteristic, for polycystosis of adults - autosomal
dominant. This anomaly in children is severe, most of them do not live to
adulthood.Polycystosis in adults has a more favorable course, manifesting itself in young or
middle age, and for many years is compensated. The average life expectancy is 45-50
years.Macroscopically, the kidneys are enlarged in size due to a variety of cysts of different
diameters, the number of functioning parenchyma is minimal. The growth of cysts causes
ischemia of unchanged renal tubules and death of renal tissue. This process is facilitated by
the joining chronic pyelonephritis and nephrosclerosis.Patients complain of pain in the
abdomen and lumbar region, weakness, fatigue, thirst, dry mouth, headache, which is
associated with chronic renal failure and increased blood pressure.
•Palpation easily determines significantly enlarged dense tuberous buds. Other complicat
ions of polycystosis are macrohematuria, suppuration and malignant cysts.
•In blood tests, anemia, an increase in the level of creatinine and urea are noted.
The diagnosis is established on the basis of ultrasound and X-ray radiation methods of r
esearch. Characteristic features are enlarged sizes of the kidney, completely represented
by cysts of different sizes, squeezing of the pelvis and calyx, the necks of which are elo
ngated, determine the medial deviation of the ureter

32. CT. Polycystic kidney disease
Excretory urogram. Polycystic kidney disease

33. Solitary kidney cyst. Malformation has the most favorable course and is characterized by the formation of one or
more cysts localized in the cortical layer of the kidney. This anomaly is equally common in persons of both sexes
and is observed mainly after 40 years.
Solitary cysts can be simple and dermoid. A solitary simple cyst can be not only congenital, but also acquired. A
congenital simple cyst develops from embryonic collecting tubules that have lost contact with the urinary tract.
The pathogenesis of its formation includes a violation of the drainage activity of the tubules with the subsequent
development of the retention process and ischemia of the renal tissue. The inner layer of the cyst is represented by
a single-layered squamous epithelium. Its contents are often serous, in 5% of cases hemorrhagic. Hemorrhage in
the cyst is one of the signs of its ma-lignization.
A simple cyst is usually a single (solitary), although there are multiple, multi-chambered, including bilateral
cysts. Their size ranges from 2 cm in diameter to giant formations with a volume of more than 1 l. Most often,
cysts are localized in one of the poles of the kidney.
Dermoid kidney cysts are extremely rare. They may contain fat, hair, teeth and bones, which are detected by
X-ray examination.
Simple cysts of small sizes are asymptomatic and are an accidental finding on examination. Clinical
manifestations begin as soon as increase in the size of the cyst, and they are associated primarily with its
complications, such as compression of the cup-pelvis system, ureter, kidney vessels, suppuration, hemorrhage and
malignancy. There may be a rupture of a large kidney cyst.

34. CT. Solitary cyst of the lower
pole of the right kidney
Multispiral CT with contrast.
Multiple segmental type of
renal arteries (1), cyst (2), and
kidney tumor

35. Selective renal arteriogram.
Solitary cyst of the lower pole
of the left kidney (arrow)

36. Hydronephrosis of the kidney is manifested by a significant expansion of the calyx system, including both
the pelvis and calyx. With a pronounced anomaly, the kidney on ultrasound may look like a thin-walled
formation, which is a conglomerate of cavities communicating with each other with liquid contents. The
parenchyma of the kidney during ultrasound is sharply thinned, loses its normal structure, its echogenicity
increases. The vascular pattern of the kidney with pronounced hydronephrotic transformation is sharply
depleted, the blood flow rate decreases, and peripheral resistance indicators increase
The causes of hydronephrotic changes are diverse. These include compression of the prilochnochny ureter by
an aberrant renal vessel. Doppler examination of renal vessels is a very informative method for diagnosing
this condition in childhood. The aberrant vessel can move away from both the aorta and the iliac artery and
is clearly visualized in the projection of the pelvioureteral articulation during ultrasound, they may look like
a collection of separate thin-walled cavities in which, during a Doppler study, the movement of stagnant
contents can be recorded

37. ANOMALIES OF THE URETERS
Malformations of the ureters account for 22% of all anomalies of the urinary system. In some cases, they are combined
with anomalies in the development of the kidneys. As a rule, anomalies of the ureters lead to a violation of urodynamics.
The following classification of malformations of the ureters has been adopted.
Anomalies in the number of ureters
■ agenesis (aplasia);
■ doubling (full and incomplete);
■
tripling.
Anomalies in the position of the ureters
■ retrocaval;
■ retroiliacal;
■
ectopia of the mouth of the ureter.

38. Agenesis (aplasia) is a congenital absence of the ureter
due to underde velopment of the ureteral germ. In some
cases, the ureter can be determined in the form of a
fibrous cord or blindly ending
process. Unilateral agenesis of the ureter is combined
with agenesis of the kidney on the same side or
multicystosis. Bilateral is extremely rare and
incompatible with life.
Diagnosis is based on the data of X-ray research
methods with contrast and nephroscintigraphy, which
allow to identify the absence of one kidney.
Characteristic cystoscopic signs are underdevelopment
or absence of half of the bladder triangle and the mouth
of the ureter on the corresponding side. With the
preserved distal part of the ureter, its opening is also
underdeveloped, although it is located in the usual place.
In this case, retrograde ureterography allows to confirm
the blind ending of the ureter.
Aplasia of the left kidney.
Blindly ending ureter

39. Doubling is the most common malformation of the ureters. In girls, this
anomaly occurs 5 times more often than in boys.
As a rule, during caudal migration, the ureter of the lower half of the kidney is
the first to connect to the bladder and, therefore, occupies a higher and lateral
position than the ureter of its upper half. The ureters in the pelvic regions are
mutually crossed and flow into the bladder in such a way that the mouth
of the upper one is located lower and medial, and the lower one is higher
and lateral (Weigert-Meyer law) .
Doubling of the upper urinary tract can be single- or bilateral, full (ureter
duplex) and incomplete (ureter fissus). In the case of a complete doubling, each
ureter opens with a separate mouth in the bladder. Incomplete doubling of the
upper urinary tract is characterized by the presence of two pelvises and ureters
connecting in the pelvic region and opening in the bladder with one mouth.
Weigert-Meyer law. Crossing of the
ureters and the location of their
mouths in the bladder with a
complete doubling of the urinary
tract

40. ▶The described features of the topography of the ureters with doubling of the upper urinary tract are
predisposing to the occurrence of complications. Thus, the ureter of the lower half of the kidney, which has
a higher and laterally located mouth, has a short submucosal tunnel, which is the reason for the high
frequency of vesico-ureteral-pelvic reflux into this ureter. In contrast, the mouth of the ureter of the upper
half of the kidney is often ectopic and predisposed to stenogenesis, which is the cause of the development of
hydroureteronephrosis.
▶Doubling of the ureter in the absence of a violation of urodynamics is not clinically manifested. This
anomaly can be suspected by sono-graphia, in which the doubling of the kidney is determined, and the
ureters, in the presence of expansion, can be seen in their plinth or pelvic sections. The final diagnosis is
established on the basis of excretory urography, multispiral CT with contrast, MRI and cystoscopy. In the
absence of function of one of the halves of the kidney, the diagnosis can be confirmed by antegrade or
retrograde ureteropielography.
▶Tripling the pelvis and ureters is casuistry.

41. Retrocaval ureter is a rare anomaly in which the ureter in the lumbar region goes under the vena cava and, ring-shaped around it,
returns to its previous position when it passes into the pelvic region. Compression of the ureter with the inferior vena cava leads to a
violation of the passage of urine with the development of hydroureteronephrosis and its characteristic clinical picture. To suspect this
anomaly allow ultrasound and excretory urography, which reveals the expansion of the cavity system of the kidney and ureter to its
middle third, loop-like bending and the normal structure of the ureter in the pelvic region. The diagnosis is confirmed by multispiral CT
and MRI.
Retroiliacal ureter is an extremely rare malformation in which the ureter is located behind the iliac vessels. This anomaly, like the
retrocaval ureter, leads to its obstruction with the development of hydroureteronephrosis. Surgical treatment consists in crossing the
ureter, releasing it from under the vessels and performing anthevasal ureteroanastomosis.
Ectopia of the mouth of the ureter is an anomaly characterized by an atypical intravesical arrangement of the mouths of one or both
ureters. This malformation is more common in girls and, as a rule, is combined with a doubling of the ureter and / or ureterocele. The
cause of this anomaly is a delay or violation of the separation of the ureteral germ from the Wolf duct during embryogenesis.
Intravesical types of ectopia of the mouth of the ureter include its displacement down and medially into the neck of the bladder. Such a
change in the location of the mouth, as a rule, is asymptomatic. The mouths of the ureters with their extravesical ectopia open into the
urethra, paraurethral, into the uterus, vagina, vas deferens, seminal vesicle, rectum.
The clinical picture of the extravesical ectopy of the mouth of the ureter is determined by its localization and depends on the sex. In
girls, this malformation is manifested by urinary incontinence with maintained normal urination. In boys, with the intrauterine
development of wolffs, the duct turns into a vas deferens and seminal vesicles, so the ectopic mouth of the ureter is always
located proximal to the urethral sphincter and urinary incontinence does not occur.
Diagnosis is based on the results of a comprehensive examination, including excretory urography, CT, vaginography, urethroscopy and
cystoscopy, catheterization of the ectopic mouth and retrograde ureterography.

42. Achalasia of the ureter is a neuromuscular dysplasia of its pelvic section. Underdevelopment of the ureter in this anomaly
is local in nature and does not affect its overlying departments, where they are little changed or developed normally.
From these positions, achalasia of the ureter should not be considered a stage of development of a megaureter, but one
of its varieties. As a rule, the expansion of the ureter in its pelvic region with achalasia remains at the same level throughout
life. In some cases, the overlying parts of the ureter may be involved in the pathological process for the second time as a result
of stagnation of urine in the enlarged cystoid, that is, dynamic obstruction.
The clinical picture of neuroma-cervical dysplasia of the ureter depends on the degree of its severity. With unilateral achalasia
or megaureter, the general condition remains satisfactory for a long time. Symptoms are mild or absent, which is one of the
reasons for the late diagnosis of neuromuscular dysplasia already in adulthood. The first signs of megaureter are due to the
addition of chronic pyelonephritis. There are pains in the corresponding lumbar region, fever with chills, dysuria. A severe
clinical course is observed with a bilateral megaureter. From an early age, symptoms of chronic renal malnutrition are
detected: the child's lag in physical development, reduced appetite, polyuria, thirst, weakness, fatigue.
Diagnosis of neuromuscular dysplasia is based on laboratory, radiation, urodynamic and endoscopic research methods.
Sono-graphics allows you to identify the expansion of the cup-pelvis system and the ureter in its plochanic and prevesical
sections, a decrease in the layer of the renal parenchyma. A characteristic feature of achalasia on excretory urograms is a
significant expansion of the pelvic part of the ureter with unchanged overlying parts of the urinary tract
With megaureter, there is an increase in length and a significant expansion of the ureter along the entire length with areas of
knee-like kinks.

43. Vesicoureteral reflux. The main method of radiation diagnosis of vesicoureteral reflux (VUR) in children is
cystography. If the injection of contrast agent into the ureters and above is determined only during the injection,
they talk about active reflux, if there is already a casting at the stage of filling the bladder, about passive reflux.
A 4-power classification of VUR is usually used:
Grade I - VUR into the distal parts of the undilated ureter;
Grade II - VUR in undilated urinary tract, including the calyxal kidney system;
Grade III - pronounced dilation of the calyx-pharyngeal system, dilation and tortuosity of the ureter;
Grade IV - pronounced dilatation of the urinary tract throughout, the ureters are sharply convoluted.
Often the degree of reflux appears to be intermediate and formulations such as "VUR II-III degrees" are used

44. a - right-sided passive vesicoureteral reflux of the III degree;
b - bilateral passive vesicoureteral reflux: on the right of the III degree, on the left of the II degree;
c - bilateral active vesicoureteral reflux: on the right of the II degree, on the left of the III-IV degree, hyporeflective bladder;
d - bilateral active vesicoureteral reflux: on the right of the II degree, on the left of the III degree

45. ACQUIRED DISEASES OF URINARY SYSTEM
Pyelonephritis is an infectious and inflammatory kidney disease with a predominant lesion of the
cup-pelvis system, tubulointerstitial tissue and subsequent involvement of the glomerular apparatus in the
process.
Epidemiology. Pyelonephritis is the most common inflammatory disease of the urinary system: it accounts
for 65-70% of cases. In children, pyelonephritis occurs in one person out of 200.
Etiology and pathogenesis. The causative agents of pyelonephritis can be endogenous (internal)
or exogenous (penetrating from the environment) microorganisms. The most common are Escherichia coli,
Proteus, staphylococcus, enterococcus, Pseudomonas aeruginosa and Klebsiella. Perhaps the development
of pyelonephritis with the participation of viruses, fungi, mycoplasmas.\
Classification. According to the clinical course, acute, chronic and recurrent pyelonephritis are
distinguished.

46. Diagnostics. Examination of patients with pyelonephritis includes the collection of complaints, anamnesis,
physical examination, after which they proceed to special diagnostic methods.
In a laboratory study, a pronounced leukocytosis (up to 30-40 thousand) is noted in a blood test with a
significant neutrophilic shift in the leukocyte formula to the left to young forms, an increase in ESR to 40-80 mm
/ h. However, a clear dependence of changes in peripheral blood on the severity of clinical manifestations is not
always observed: in severe course of the disease, as well as in weakened patients, leukocytosis can be moderate,
insignificant or absent, sometimes leukopenia is noted.
Characteristic signs of acute pyelonephritis in the study of urine sediment are proteinuria, leukocyturia and
significant (true) bacteriuriya, especially if they are detected simultaneously. False proteinuria in the
inflammatory process in the kidney is caused by decay when blood elements enter the urine and in most cases
does not exceed 1.0 g / l (from traces to 0.033-1.0 g / l). It is represented mainly by albumins, less often by
gammaglobulins. Leukocyturia (pyuria) is the most characteristic sign of pyelonephritis. It often reaches a
significant severity (leukocytes cover the entire field of view or are detected in clusters) and may be absent only
with the localization of the inflammatory process only in the cortical substance of the kidney or with obturation
of the ureter. With pyelonephritis, erythrocyturia (microhematuria) can be observed, less often - macrohematuria
(with necrosis of the renal papillae, calculous pyelonephritis). The severe course of the disease is accompanied
by cylindruria (granular and waxy cylinders). Bacteriuria is found in most cases, however, like leukocyturia, it is
intermittent in nature, so repeated studies of urine for microflora are important. To confirm pyelonephritis, only
the presence of true bacteriuria is important, implying the presence of at least 50-100 thousand microbial bodies
in 1 ml of urine.

47. Ultrasound of the kidneys is highly accurate in identifying the size of the kidney, the heterogeneity of its structure,
the deformation of the cup-pelvis system, the presence of pyonephrosis and the state of the perirenal fatty tissue. A
decrease in kidney mobility in combination with its increase is the most important ultrasound sign of acute
pyelonephritis, and the expansion of the cup-pelvis system testifies in favor of the obstructive (secondary) nature of
the disease.
With the help of sonography, focal changes (usually hypoechoic areas) are detected in the kidney parenchyma and
in paranephrium, resulting from their purulent lesion.
Overview and excretory urography allows you to establish the cause and level of obstruction of the urinary tract. In
the first 3-4 days, acute pyelonephritis may not be accompanied by leukocyturia. In such cases, it is especially
difficult to diagnose primary pyelonephritis, since there are no signs of impaired outflow of urine from the kidney.
In such patients, excretory urography with the performance of images on inhalation and exhalation on one film has
a great diagnostic value: it allows you to identify a limitation of kidney mobility on the side of the lesion.
▶

48. Sonographic signs of chronic pyelonephritis are a decrease in the size of the kidney, deformation of its
contours and the cup-pelvis system, which indicates wrinkling of the organ.
One of the main methods for diagnosing chronic pyelonephritis is excretory urography. The X-ray
picture is characterized by polymorphism. Radiological signs characteristic of this disease are a decrease in
the tone of the calyx, pelvis and upper third of the ureter in the form of their moderate expansion, the
appearance of a symptom of the edge of the lumbar muscle (at the point of contact of the pelvis and ureter
with the edge of m. psoas, an even flattening of their contour is observed). Over time, various deformations of
the calyxes develop: they acquire a mushroom-shaped, club-shaped shape, shift, their necks lengthen and
narrow, the papillae are smoothed.

49. Cystitis is an infectious and inflammatory disease of the bladder wall with a predominant lesion of its mucous membrane.
Etiology and pathogenesis. The most common cause of cystitis is a bacterial infection. In addition, the causative agents of
the disease can be viruses, mycoplasma, chlamydia, fungi. Most often, in patients with cystitis in the urine, Escherichia
coli, staphylococcus, enterobacter, Proteus, Pseudomonas aeruginosa, Klebsiella are determined. The leading microbial
pathogen in acute cystitis is E. coli (80-90% of observations), which is explained by the high pathogenic and adaptive
capabilities of this microorganism (the phenomenon of adhesion, high reproduction rate, the production of ammonia,
which weakens the immune system and disrupts the function of smooth muscle fibers of the urinary tract).
Diagnostics. The rapid onset of the disease with characteristic symptoms can immediately suspect acute cystitis. In clinical
and biochemical blood tests, pathological changes, as a rule, are not observed.
The urine is cloudy, with a smell. In the study, its reaction is often alkaline, a large number of leukocytes and bacteria are
always determined, erythrocytes, epithelium, cylinders may be present, false proteinuria is noted, that is, due to the
breakdown of a large number of blood cells.
It is important to note that in acute cystitis, invasive diagnostic methods, primarily cystoscopy, are
contraindicated. Firstly, this procedure does not carry significant information, secondly, in the presence of acute
inflammation, it is extremely painful and, thirdly, can lead to reinfection and / or aggravate the course of the infectious
process. Cystoscopy is possible and indicated for chronic cystitis, with its help, areas of hyperemia, a pronounced vascular
pattern , fibrinous overlays, ulcers, leukoplakia, stones, etc. can be detected.
Cystitis echographically manifests itself in the form of thickening of the mucous membrane of the bladder, the appearance
of a dispersed suspension in its lumen. With a Doppler study, it is sometimes possible to fix an increase in the vascular
pattern in the bladder wall

50. a - cystitis. Thickening of the bladder wall and fine
suspension in the lumen;
b - cystoureteritis. Swelling of the mucosa of the distal
ureters (arrows);

51. renal colic in children is rare. The cause of renal colic is
concretions or dense clots that obstruct the urinary tract. The most
common localization of the obstacle is the pelvioureteral joint or
the distal (pre-bubble, intramural) part of the ureter. When the
concretion is localized in the projection of the pelvioureteral joint,
not only a block of the urinary tract often occurs, but also
manifestations of obstructive pyelonephritis in the form of swelling
of the pelvic mucosa. The concretion on ultrasound is detected as a
dense inclusion of various sizes and shapes with an acoustic
shadow. It is the presence of an acoustic shadow that is the criterion
for an echographic conclusion about the presence of a concretion,
and not just a dense inclusion (clot). In the Doppler study, the
concretion has a bright multicolored color due to the Doppler
shimmering artifact

52. Radiologically, concretions can be
diagnosed already at the survey
radiography, as well as at the stages of
excretory urography in the form of
dense shadows.
a - during an overview radiography of
the abdominal cavity, the shadow of
the concretion (arrow) in the
projection of the left kidney is
determined;
b - during excretory urography, the
shadow of the concretion (arrow) in
the lower group of cups on the left is
determined;
c- during the survey radiography, a
dubious contrast of the left (oval) and
the shadow of the concretions is
determined significantly above the
projection of the kidney.

53. Acute glomerulonephritis occurs relatively often in childhood, but, unfortunately, it does not always have any
characteristic radiation signs. Ultrasound is practically the only method of radiation evaluation of the kidneys in
glomerulonephritis. In the severe course of the disease, an increase in the size of the kidneys, an increase in the
echogenicity of the parenchyma, a depletion of the vascular pattern mainly in the projection of the cortical layer
of the renal parenchyma and a variety of violations of the quantitative characteristics of arterial renal blood flow
are characteristic. Glomerulonephritis is the only indication for nephrobiopsy in children's practice in order to
determine the activity of the process and resolve the issue of patient management tactics.
Acute renal failure is one of the most severe conditions in pediatric intensive care. Of the methods of radiation
diagnostics, only ultrasound can really be used to assess the state of the kidneys in children with acute renal
failure: excretory urography and CT are uninformative with a critical decrease or absence of kidney
function. Multiple organ changes in acute renal failure are often found on the part of almost all organs and
systems, which forces the radiologist to sometimes conduct multiple studies. Most often, changes in the form of a
dispersed suspension in the lumen of the gallbladder and/ or swelling of its walls and perifocal tissues are detected
in children with acute renal failure. Significant changes in the pancreas are often detected in the form of an
increase in its size and changes in echogenicity. Characteristic of liver failure are signs of liquid contents in the
pleural cavities, abdominal cavity, less often - in the pericardial cavity. There may be areas of hypoventilation in
the dorsal parts of the lungs. In boys, the general edematous syndrome is often accompanied by the development
of pronounced swelling of the soft tissues of the scrotum and / or dropsy of the testicular membranes. In young
children, an echographic assessment of brain structures and cerebral hemodynamics is possible.