Ureteritis is an inflammation of the ureter. Isolated process is rare, the lesion is more often associated with prolonged chronic cystitis, pyelonephritis. There are no pathognomonic symptoms, clinical manifestations are due to the underlying pathology, include pain during urination, pain in the groin and lower back, hyperthermia. Diagnosis is based on the results of imaging studies: cystoureteroscopy, CT, MRI, intravenous urography. From laboratory tests, urine and blood test are prescribed. Sometimes specific tests for tuberculosis, schistosomiasis are required. Treatment – antibacterial therapy, elimination of the supporting factor.
ICD 10
N28.8 Other specified diseases of the kidneys and ureter
Meaning
Ureteritis as a separate nosology is practically not considered by specialists. Pathology is more often identified as concomitant with instrumental urological studies conducted to diagnose kidney and bladder diseases. According to statistics, most cases of ureteritis occur after the concretion is wedged in when trying to independently withdraw, manually lowering the stone with damage to the wall. Lithotripsy with the use of modern equipment is much less complicated by the formation of the urinary tract and inflammation. In 20-30% of cases, ureteritis develops due to iatrogenic injuries during operations.
Causes
The cause of the disease correlates with the etiopathogenetic factor. Concomitant immunosuppression plays a certain role, the more the immune system suffers, the higher the probability of total damage to the urinary organs. The body’s adequate response to contact with the pathogen is disrupted in diabetes mellitus, HIV infection, and some systemic diseases. Contributing factors include taking hormonal medications, pregnancy, and old age. The main pathological processes that cause ureteritis are:
- Inflammatory diseases. Damage to the ureter can be initiated ascending (prostatitis, cystitis) or descending (pyelonephritis, pyelitis), when microorganisms are introduced into the mucous membrane with the development of secondary inflammation. Typical microflora in ascending infection are Escherichia coli and Aerobacter aerogenes – nonspecific pathogens, gonococci and candida are isolated from specific ones. Hematogenic pathogens get to the ureter from neighboring organs with diverticulitis, appendicitis, colitis.
- Iatrogenic injuries. Traumatization of the organ occurs during gynecological and abdominal operations involving the iliac vessels, during lymph dissection or suturing of the posterior leaf of the parietal peritoneum. In modern urology, damage to the ureteral wall is possible with pyeloureteroscopy and endoscopic interventions: TUR of the bladder, lithotripsy and lithoextraction. Against the background of secondary infection and contact with urine, initially aseptic inflammation becomes infectious.
- Oncology. Secondary ureteritis is caused by compression of the ureter with a tumor mass from the abdominal cavity during metastasis of ovarian cancer, Wilms tumor. Pathology is supported by tissue ischemia. Perifocal wall changes are detected around the ureteral malignant neoplasm. After undergoing radiation therapy for a tumor of the uterus, rectum, the ureter suffers from a burn, the inflammatory process aggravates the formation of stricture.
- Other diseases. Secondary infection of the ureter occurs against the background of standing concretion in any department, blockage of the lumen by a blood clot from the kidney, with a long-functioning ureteral catheter. Ureteritis accompanies urogenital schistosomiasis, tuberculosis. Malacoplakia is considered separately – a disease with an unspecified etiology, in which the granulomatous process affects the ureter in 8% of cases.
Risk factors include abnormalities in the development of the ureter: kinks, curvatures and twisting along the longitudinal axis, increasing the likelihood of recurrent urinary tract infections. Neuromuscular dysplasia is characterized by underdevelopment of the muscle layer, which causes constant stagnation of urine and indirectly – ureteritis. The functions of the ureter are impaired in Ormond’s disease (fibrous stenosing periurethritis). Narrowing of the lumen, compression and ischemia lead to nonspecific ureteritis, inadequate urodynamics.
Pathogenesis
The main function of the ureter is to transport urine from the kidneys to the bladder, preventing it from being thrown back into the upper urinary tract, which is facilitated by the structure of the organ wall. The length of the urinary tube is 25-30 cm, the diameter is variable, there are physiological constrictions at the exit from the pelvis, at the intersection with the iliac vessels, at the junction with the bladder. In these areas, inflammation is more often localized.
The inflammatory process in the ureter is accompanied by a violation of contractility (hypotension), which provokes edema, cellular infiltration. If the provoking factor (stone, clot, compression) is not eliminated at this stage, gross tissue changes appear: ulceration, cystic degeneration, desmoplastic reaction. The normal structure of cells is disrupted, fibrous processes begin to prevail, which culminate in the formation of stricture. In case of mechanical damage, acute ureteritis provokes a secondary infection.
A certain role is assigned to the uropathogenic microflora, typical of chronic pyelonephritis and cystitis, which actively multiplies in stagnant urine. Under normal conditions, a special layer (glycocalyx) protects the mucous membrane from its aggressive effects. If its integrity is violated, inflammation develops. Concomitant ischemia aggravates the condition. In urogenital schistosomiasis, the parasite invades the wall of the bladder or ureter. The vital activity of the helminth leads to an acute inflammatory reaction, squamous metaplasia, hydroureter.
Classification
Ureteritis can be primary (on the background of traumatization) or secondary, developing with another pathology. There are unilateral and bilateral pathological processes. Bilateral lesion is more typical for tuberculosis and schistosomiasis. Inflammation can be acute, caused by obstruction by a stone, tumor or clot, or chronic, accompanying long-term pyelonephritis, cystitis. Histological classification is based on the features of cellular changes:
- Cystic. Thin-walled cysts with transparent contents are visualized on the mucosa lined with normal urothelium. Sometimes the process is so pronounced that cystic lesions can be considered during ureteroscopy.
- Follicular. Due to the accumulation of lymphocytes on the mucous membrane, many lymphoid polyps are formed, which give the surface a heterogeneous appearance (granularity, granulation).
- Glandular. Pathological changes include the formation of rounded cavities as in the cystic form, but with an apical (glandular) orientation.
- Metaplastic. The appearance of atypical (prismatic) cells producing mucin is characteristic. This form is considered as a risk factor for the development of carcinoma, although there is no convincing evidence of dependence.
- Granulomatous. A secondary lesion of the urinary canal is detected due to the spread of the granulomatous process to it in tuberculosis or amyloidosis.
Symptoms
There are no specific clinical manifestations, the symptoms reflect the provoking pathology. Common signs include painful sensations in the projection of the ureter, frequent urge to urinate. If ureteritis occurs with inflammation of the kidney, pain in the lumbar region is initially detected. With cystitis, dysuria is primary, heaviness in the lower abdomen, then pain appears in the inguinal zone on the affected side. Body temperature is elevated, patients complain of weakness, there is cephalgia, myalgia.
In urolithiasis, the severity of pain correlates with the degree of violation of urinary outflow. Acute renal pain with irradiation in the groin, frequent urge to urinate indicates the independent discharge of the concretion. When the ureter is completely blocked, hydronephrosis, purulent pyelonephritis joins within a few hours. The stuck concretion is indicated by a pronounced increase in temperature, stunning chills, pouring sweat.
In case of ureteral injury, there is always a connection with surgery, diagnostic procedure, urological manipulation. If not all layers of the organ are damaged, the pain is moderate, localized in the groin or abdomen. Typically, the appearance of urine with blood, frequent urge, urination in small portions. Severe pain during palpation of the kidney, hyperthermia are suspicious of ureteral ligation, and the appearance of a tumor–like formation is due to urohematoma due to channel crossing.
Tuberculous ureteritis, ureteral lesion in retroperitoneal fibrosis and amyloidosis are always secondary, proceed asymptomatically until a significant obstruction appears that prevents normal urodynamics. Ureteral tumors behave similarly. The trouble can be suspected by an unexplained increase in temperature, hematuria, asthenia. At night, there is increased sweating (hyperhidrosis).
Complications
The main complication of ureteritis is the formation of stricture, leading to a gradual hydronephrotic transformation of the kidney. With a relatively compensated narrowing, urinary tract infections recur. In 25-50% of patients without treatment, acute purulent pyelonephritis develops, which can provoke kidney carbuncle, paranephritis, urosepsis. Due to the constant stagnation of urine, the multiplication of microbial pathogens and the presence of exfoliated epithelium, stones can form.
The greatest severity is the bilateral lesion of the ureters. Gradual obliteration of organs contributes to the progression of renal failure. Injury to the canal wall, wedging of the concretion with concomitant pronounced inflammatory process can result in necrosis of all layers and the formation of a fistula. The accumulation of urine in the retroperitoneal tissue forms a urohematoma, and then a urinary phlegmon. Adverse outcomes associated with high mortality are necrosis of adipose tissue, peritonitis.
Diagnostics
Hematuria and pain in the lumbar region are the most common signs for which clinical and urological diagnostics are carried out. A patient with unclear complaints of pain in the lower abdomen and inguinal region is examined by a surgeon. With stable forms of ureteritis, a phthisiourologist’s consultation is necessary. Ultrasound to assess the urinary canal is not informative, but can be used to identify the primary pathological process in the abdominal cavity, kidneys, ovaries. The examination algorithm for urethritis includes:
- Laboratory diagnostics. In urine tests, there are erythrocytes, leukocytes, and bacteria. Accumulations of salts indicate nephrolithiasis, dysmetabolic nephropathy. With severe inflammation, the blood test shows accelerated ESR, a shift of the leukocyte formula to the left. Sowing urine on the flora allows you to determine the pathogen, sensitivity to antibacterial drugs. According to the indications, tests are prescribed to detect tuberculosis infection, schistosomiasis. The level of urea and creatinine in the blood is evaluated to exclude chronic kidney disease.
- Instrumental diagnostics. Cystoureteroscopy confirms a change in the inner layer of the ureteral canal: hyperemia of the urothelium, cysts, edema. There is a violation of the integrity of the wall, ulcerative lesions. The hypotension of the ureter is judged by the intensity of urine ejected into the bladder. CT and MRI visualize anomalies in the structure of the canal, make it possible to establish its relationship with the surrounding structures. Tumors and strictures are clearly distinguishable on tomograms. Specific tuberculous inflammation is manifested by ragged thickenings, filling defects, calcification.
Differential diagnosis is carried out with infiltrative forms of urothelial cancer, which have a number of similar endoscopic manifestations with ureteritis: superficial spread, thickening, edema. In all doubtful cases – if tuberculosis, amyloidosis or a tumor is suspected, a biopsy of the suspicious area with further morphological examination is indicated. The outflow of urine is prevented by stones, neoplasms, polyps, which are detected using one of the imaging methods.
Treatment
The treatment plan depends on the type of inflammation, clinical and laboratory data. Pay attention to the results of cultural analyses. The drug is chosen taking into account the sensitivity of the microflora. The duration of the course is variable, determined individually. The inflammation is stopped or reduced after the elimination of the supporting factor. Possible treatment options are conservative therapy, surgical intervention with antimicrobial therapy.
Conservative therapy
With urethritis of inflammatory genesis without aggravating aspects (tumor, stricture, concretion), medication is indicated. The drug is often chosen empirically. With tuberculosis, schistosomiasis, specialized therapy is required. Patients are recommended to strengthen the drinking regime, exclude extractive broths, spicy and salty dishes from the diet. Alcohol and spices are unacceptable. The treatment plan includes the following medications:
- Antimicrobials and NSAIDs. They suppress the microbial flora, prevent the further spread of the inflammatory process. After the relief of acute ureteritis and pyelonephritis, the need for elective surgery is considered to eliminate conditions predisposing to recurrent infections. Treatment regimens include fluoroquinolones, cephalosporins, aminoglycosides, etc. NSAIDs enhance the effect of antibiotics, have antipyretic and analgesic effects.
- Antispasmodics and drugs that improve blood circulation. Antispasmodic drugs eliminate the manifestations of dysuria, increase the diameter of the ureter. This contributes to the independent discharge of small concretions, sand. Under the influence of medications, calcium ions and a number of enzymes are blocked, which leads to muscle relaxation. Means for improving blood circulation resolve ischemia, improve microcirculation, create conditions for optimal concentration of the antibiotic in the affected area.
Surgical treatment
The purpose of radical surgery is to eliminate the cause that supports ureteritis. Palliative intervention is recommended in case of a serious condition of the patient. Two-stage approaches to treatment have been developed, in which, after the restoration of urodynamics with the help of artificial drains, inflammation is suppressed by antibiotic therapy. With the normalization of clinical and laboratory parameters, they proceed to the second stage. Subsequently, drains are removed, independent urination is restored. Types of surgical aids for ureteritis:
- Nephrostomy or stenting. Produced to normalize the outflow of urine. At the same time, massive antibacterial, anti-inflammatory therapy is prescribed to relieve inflammation, urethral drainage is removed to prevent reflux. A stent-type catheter is carried to the renal pelvis through the ureter, bypassing the blocking concretion. Additionally, litolytic drugs are used. If the size of the stone does not decrease, the question of how to eliminate it (lithotripsy, ureterolithotomy) is decided.
- Other operations. With local necrosis, fistula, stricture, it is necessary to restore the integrity and functionality of the ureter. To do this, plastic surgery is performed with excision of the altered area and subsequent anastomosis of the canal sections. The choice of intervention modification depends on the localization and extent of the pathological process.
Prognosis and prevention
The prognosis of ureteritis with concomitant pyelonephritis, cystitis after adequate antibacterial therapy is good, the reverse development of pathological changes occurs. In tuberculosis of the genitourinary system with the involvement of the ureters, the outcome is more favorable in the case of unilateral lesion, absence of signs of CRF. Urethral stricture increases the risk of recurrent infections, hydronephrosis, and chronic renal failure.
Preventive measures include timely detection and treatment of diseases of the urogenital tract, preventive administration of antibiotics and uroseptics before and after endoscopic diagnostic procedures, follow-up by a urologist with laboratory monitoring. Patients with diseases of the urogenital sphere are subject to dispensary registration, which implies taking tests, undergoing ultrasound every 6-12 months.