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1、Symptoms and signs of the kidney and urinary systemSlideSlide2 2Symptomsandsignsofthekidneyandurinarysystemn nAlterationsinurinecompositionAlterationsinurinecomposition(haematuria,(haematuria,proteinuria,bacteriua,proteinuria,bacteriua,leucocyturia,calculi)leucocyturia,calculi)n nDisordersofMicturat
2、ionDisordersofMicturation(frequency,(frequency,urgency,dysuria,urgency,dysuria, incontinence,incontinence, retention)retention)n nDisordersofUrinevolumeDisordersofUrinevolume(oliguria,anuria,(oliguria,anuria,polyuria)polyuria)n nLoindullpain(pyelonephritis,obstruction),Loindullpain(pyelonephritis,ob
3、struction),renalcolic(acuteobstruction)renalcolic(acuteobstruction)n nOedemaOedema(hypoalbuminaemia,saltandwater(hypoalbuminaemia,saltandwaterretention)retention) n nSymptomsofUraemiaSymptomsofUraemia(nausea,vomiting,(nausea,vomiting,lethargy)lethargy)血血 尿尿HaematuriaSlideSlide4 4Hematurian nDefiniti
4、onDefinitionn nCausesCausesn nLocalizationandpathogenesisLocalizationandpathogenesisn nAssociatedsymptomsAssociatedsymptomsn nEvaluationofHematuriaEvaluationofHematurian nCasestudyCasestudySlideSlide5 5Definitionofhematurian nMicroscopicevaluationofurinarysediment:freshlyvoidedMicroscopicevaluationo
5、furinarysediment:freshlyvoided(10ml),centrifuged(1500rpmfor5min)(10ml),centrifuged(1500rpmfor5min) urinesediment:urinesediment:RBC 3/HPonatleast2out3collectedspecimensonatleast2out3collectedspecimensnDipsticktest：freehemoglobin&myoglobinmyoglobin,needconfirmationn nTwoTypesofHematuriaTwoTypesofHemat
6、urian nGrosshematuria(1mlGrosshematuria(1ml/l):/l):brightred,tea-coloredbrightred,tea-coloredbrownorcocacolabrownorcocacolan nMicroscopichematuria:theurineisclear,RBCcanbeMicroscopichematuria:theurineisclear,RBCcanbeseenunderamicroscopeortestedinalab(byflowseenunderamicroscopeortestedinalab(byflowcy
7、tometry).cytometry).SlideSlide6 6Pseudohematurian nMenstruatingfemaleMenstruatingfemalen nPigmenturia:Pigmenturia:presenceofcoloredsubstanceintheurine.presenceofcoloredsubstanceintheurine.n nEndogenous:myoglobin(breakdownofmuscle;Endogenous:myoglobin(breakdownofmuscle;pink,red,brownorblack)Hemoglobu
8、linpink,red,brownorblack)Hemoglobulinn nExogenousExogenousn nDrugs:phenytoinDrugs:phenytoin(redurine),(redurine),rifampinrifampin(yellow-(yellow-orangetored),orangetored),metronidazole,nitrofurantoinmetronidazole,nitrofurantoin(brown)(brown),warfain,warfainn nFoods:beetrootsFoods:beetroots(red),(red
9、),berries,rhubarbberries,rhubarb(yellowto(yellowtobrownorred)brownorred)SlideSlide7 7CausesofHematuria n nKidneyandurinarytractdiseasesKidneyandurinarytractdiseases n nGlomerulonephritis(GN):Glomerulonephritis(GN):IgAnephropathy,MembranoproliferativeIgAnephropathy,MembranoproliferativeGN,CrescenticG
10、N,FSGS,RenalvasculitisGN,CrescenticGN,FSGS,Renalvasculitis. .Lupusnephritis,Lupusnephritis,Schonlein-Henochnephritis,Schonlein-Henochnephritis,acuteacutePoststreptococcalGNPoststreptococcalGNn nInfection:Infection:Pyelonephritis,Cystitis,Urethritis,prostatitis,TBPyelonephritis,Cystitis,Urethritis,pr
11、ostatitis,TBn nStone:Stone:kidney,Ureter,bladder,urethrakidney,Ureter,bladder,urethran nTumors:Tumors:kidney,Ureter,bladder,prostatekidney,Ureter,bladder,prostaten nHereditarydisease:Alpertssyndrome,ThinglomerularbasementHereditarydisease:Alpertssyndrome,Thinglomerularbasementmembranenephropathy,Pol
12、ycystickidneydiseasemembranenephropathy,Polycystickidneydiseasen nRenalvesseldiseases:Renalvesseldiseases: Arterialemboliorthrombosis,RenalveinArterialemboliorthrombosis,Renalveinthrombosis,Arterialorvenousmalformationthrombosis,Arterialorvenousmalformationn nOthers:Interstitialnephritis,papillaryne
13、crosis,traumaOthers:Interstitialnephritis,papillarynecrosis,traumaSlideSlide8 8CausesofHematurian nSystemicdiseasesSystemicdiseasesn ns systemiccoagulationdisorders:TTP,plateletdefect,ystemiccoagulationdisorders:TTP,plateletdefect,coagulationproteindeficiency,therapeuticanticoagulationcoagulationpro
14、teindeficiency,therapeuticanticoagulationn nInfectiousdiseases:SBE,severeinfectiousdiseaseInfectiousdiseases:SBE,severeinfectiousdiseasen nMalignantHTN,DN,AmyloidosisMalignantHTN,DN,Amyloidosisn nPhysicalinjuryandchemicaltoxicationPhysicalinjuryandchemicaltoxicationn nvigorousexercise:vigorousexerci
15、se:marathonrunningmarathonrunningnNutcrackersyndromenIdiopathichematuriaSlideSlide9 9LocalizationofHematurian nGlomerularHematuriaGlomerularHematurian nFromtherenalparenchymaFromtherenalparenchyman nNon-glomerularHematuriaNon-glomerularHematurian nFromtherenalpelvis,Fromtherenalpelvis,ureters,bladde
16、r,orurethraureters,bladder,orurethra(urinarytractbleeding)(urinarytractbleeding)SlideSlide1010GlomerularHematurian nGNortubulointerstitialnephritisGNortubulointerstitialnephritisn nPathogenesisPathogenesisn nSmallbreaksintheGBMSmallbreaksintheGBMn nRuptureoftubularbasementmembraneRuptureoftubularbas
17、ementmembranen nDysmorphichematuriaDysmorphichematuria（80%80%) )n nFragmented,distortedRBC,knoblikeFragmented,distortedRBC,knoblikeprojections(passingthroughgapsofprojections(passingthroughgapsofGBM)GBM)n nThedegreeofdysmorphismmaybeThedegreeofdysmorphismmaybeinfluencedbytheurineosmolality,PHininflu
18、encedbytheurineosmolality,PHinthetubuleandthetimefrompassageofthetubuleandthetimefrompassageofurineurinen nOtherclues:Otherclues: significantproteinuriasignificantproteinuria(1g/d),(1g/d),redcellcasts,redcellcasts,hypertensionandedemahypertensionandedemaSlideSlide1111Non-glomerularHematurian nInfect
19、ion,tumor,stone,Infection,tumor,stone,traumaortraumaorarteriovenousmalformationsarteriovenousmalformationsn nDuetoinflammationofmucosa,Duetoinflammationofmucosa,disruptionofsmallvesselsanddisruptionofsmallvesselsanderosionofurinarytracterosionofurinarytractn nUniformbioconcaveshapeUniformbioconcaves
20、hapeisoisomorphicmorphic( (80%80%normomorphic)normomorphic)nOtherclinicalclues:loinpain,:loinpain,superpubicpain,passageofsuperpubicpain,passageofclots(notbeencounteredinpatientswithglomerulardisease)DetectionMethodnflowcytometry:automatedmethodnuncentrifugeduninesamplesnScreenlargenumbersofsamplesi
21、nashorttimensamplesofparticularcomplexityforwhichamicroscopicanalysisispreferablenphasecontrastmicroscopy:observerdependentThree-glasstestn n grosshematuriawithnormomorphicerythrocyturia, n nInthefirstInthefirst10-1510-15mlurine:themlurine:theurethraurethran nInthefinal10-30mlurine:asmallInthefinal1
22、0-30mlurine:asmallhemorrhagefromthetrigoneregionhemorrhagefromthetrigoneregionofthebladderofthebladdern nInallthreesamples:thekidneyorInallthreesamples:thekidneyorprofusebleedingfromthebladderprofusebleedingfromthebladderSlideSlide1313SlideSlide1414AssociatedsymptomsnPain:loindullpain(kidneystone),a
23、cutecolic(kidney,loindullpain(kidneystone),acutecolic(kidney,ureterstone)ureterstone)nFrequency,Urgencyanddysuria:cystitis,cystitis,urethritis,urethritis,p pyelonephritis,prostatitis,TB,tumoryelonephritis,prostatitis,TB,tumornAbdomenalmass: :renaltumor,polycystickidneydiseaserenaltumor,polycystickid
24、neydiseasenBleedingtendency: :hematologicdisordershematologicdisordersn nFever:Fever:acuteacutep pyelonephritis,TByelonephritis,TBnHTN,edema,proteinuria: :GNGNnChyluria(whitemilkyurine):filariasis,TB,tumornAsymptomic: :IgAnephropathy,TBMnephropathy,tumorIgAnephropathy,TBMnephropathy,tumorSlideSlide1
25、515Historytakingn nRuleoutpseudohematuria(drug,food,menstruation)Ruleoutpseudohematuria(drug,food,menstruation)n nPatternofhematuriaPatternofhematurian nBleedingofotherorgans:coagulationdisturbanceBleedingofotherorgans:coagulationdisturbancen nPasthistoryofthekidney,urinarytractandprostate:HTN,Pasth
26、istoryofthekidney,urinarytractandprostate:HTN,proteinuria,edema,renaldysfunctionproteinuria,edema,renaldysfunctionnFrequency,Urgencyanddysurian nHistoryofdrugingestion:analgesics,antibiotics,Historyofdrugingestion:analgesics,antibiotics,anticoaulantsanticoaulantsn nvigorousexercise,urethralcatheteri
27、zationvigorousexercise,urethralcatheterizationn nFamilyhistoryofrenaldisease,hematuria,deafnessandFamilyhistoryofrenaldisease,hematuria,deafnessandpolycystickidneydiseasepolycystickidneydisease SlideSlide1616EvaluationofHematurian nHistoryandphysicalexamHistoryandphysicalexamn nExcludepseudohematuri
28、a,vigorousexerciseExcludepseudohematuria,vigorousexercisen nLabtests:urinalysis,phasecontrastmicroscopyandotherbloodtestsLabtests:urinalysis,phasecontrastmicroscopyandotherbloodtestsn nNephrologicorUrologicevaluationNephrologicorUrologicevaluationn nSpecialexaminationsSpecialexaminationsn nUltrasoun
29、dUltrasoundn nUrineculture,UrinecytologyUrineculture,Urinecytologyn nIntravenouspyelogram(IVP)Intravenouspyelogram(IVP)n nCTCT/CTU/CTU,MRI,Angiography(arteriovenousmalformation),Radionuclidescans,MRI,Angiography(arteriovenousmalformation),Radionuclidescansn nCystoscopyandretrogradepyelogramsCystosco
30、pyandretrogradepyelogramsn nRenalbiopsyRenalbiopsyn nFollow-upFollow-upn nsubtleglomerularortubulointerstitialdiseasesubtleglomerularortubulointerstitialdiseasen nsmallarteriovenousmalformations,smallstonesmallarteriovenousmalformations,smallstoneSlideSlide1717病例一病例一n n男性，男性，男性，男性，1616岁岁岁岁n n发热、咽痛、流
31、涕发热、咽痛、流涕发热、咽痛、流涕发热、咽痛、流涕n n2 2天后出现肉眼血尿天后出现肉眼血尿天后出现肉眼血尿天后出现肉眼血尿n n尿常规：尿常规：尿常规：尿常规：RBC250/RBC250/ l ln n进一步检查：进一步检查：进一步检查：进一步检查：n n尿沉渣镜检：尿沉渣镜检：尿沉渣镜检：尿沉渣镜检：RBCRBC满视野，满视野，满视野，满视野，100100异型异型异型异型SlideSlide1818n n血尿与全身疾病及呼吸道感染的时间关系血尿与全身疾病及呼吸道感染的时间关系血尿与全身疾病及呼吸道感染的时间关系血尿与全身疾病及呼吸道感染的时间关系n n急性链球菌感染后肾小球肾炎急性链球菌
32、感染后肾小球肾炎：感染后感染后感染后感染后10101414天天天天出现血尿出现血尿出现血尿出现血尿n nIgAIgA肾病：肾病：肾病：肾病：上呼吸道症状与血尿几乎同时发生，上呼吸道症状与血尿几乎同时发生，上呼吸道症状与血尿几乎同时发生，上呼吸道症状与血尿几乎同时发生，一般不超过一般不超过一般不超过一般不超过3 3天天天天。SlideSlide1919病例二病例二n n男性，男性，男性，男性，2222岁岁岁岁n n因乏力、食欲不振就诊，发现血尿、蛋白尿、肾因乏力、食欲不振就诊，发现血尿、蛋白尿、肾因乏力、食欲不振就诊，发现血尿、蛋白尿、肾因乏力、食欲不振就诊，发现血尿、蛋白尿、肾功能差，诊为功能
33、差，诊为功能差，诊为功能差，诊为“ “尿毒症尿毒症尿毒症尿毒症” ”，开始血液透析治疗。，开始血液透析治疗。，开始血液透析治疗。，开始血液透析治疗。n n伴耳聋伴耳聋伴耳聋伴耳聋n n一个舅舅、一个舅舅、一个舅舅、一个舅舅、2 2个堂兄均为尿毒症个堂兄均为尿毒症个堂兄均为尿毒症个堂兄均为尿毒症诊断诊断AlportSyndrome(XD)SlideSlide2020病例三病例三n n女性女性女性女性 1515岁，体型偏瘦岁，体型偏瘦岁，体型偏瘦岁，体型偏瘦n n肉眼血尿，反复发作，多在运动后出现肉眼血尿，反复发作，多在运动后出现肉眼血尿，反复发作，多在运动后出现肉眼血尿，反复发作，多在运动后出现
34、n n尿沉渣镜检：尿沉渣镜检：尿沉渣镜检：尿沉渣镜检：RBCRBC满视野，满视野，满视野，满视野，9090正常形态正常形态正常形态正常形态SlideSlide2121n n双肾静脉彩超：左肾静脉近双肾静脉彩超：左肾静脉近双肾静脉彩超：左肾静脉近双肾静脉彩超：左肾静脉近肾门处内径增宽，腹主动脉肾门处内径增宽，腹主动脉肾门处内径增宽，腹主动脉肾门处内径增宽，腹主动脉与肠系膜上动脉夹角处左肾与肠系膜上动脉夹角处左肾与肠系膜上动脉夹角处左肾与肠系膜上动脉夹角处左肾静脉管腔受压，内径变细。静脉管腔受压，内径变细。静脉管腔受压，内径变细。静脉管腔受压，内径变细。n n诊断：诊断：诊断：诊断：n胡桃夹现象胡
35、桃夹现象尿频、尿急、尿痛尿频、尿急、尿痛Frequentmicturition,urgentmicturitionandpainonmicturition(symptomofbladderirritation)协和医院协和医院肾内科肾内科李明喜李明喜SlideSlide2323尿频、尿急、尿痛尿频、尿急、尿痛n n定义、分类定义、分类定义、分类定义、分类n n机制机制机制机制n n常见疾病常见疾病常见疾病常见疾病n n病例讨论病例讨论病例讨论病例讨论SlideSlide2424定义定义n nFrequencyFrequencyn n排尿次数增多。正常成人白天排尿排尿次数增多。正常成人白天排尿排
36、尿次数增多。正常成人白天排尿排尿次数增多。正常成人白天排尿3 3 3 35 5 5 5次，夜间排尿次，夜间排尿次，夜间排尿次，夜间排尿0 0 0 02 2 2 2次。次。次。次。 每次尿量每次尿量每次尿量每次尿量200200200200400ml400ml400ml400ml。n nUrgencyUrgencyn n尿意一来即要排尿的感觉，不能控制尿意一来即要排尿的感觉，不能控制尿意一来即要排尿的感觉，不能控制尿意一来即要排尿的感觉，不能控制, , , , 每次尿量均较正常少。每次尿量均较正常少。每次尿量均较正常少。每次尿量均较正常少。n nOdynuriaOdynurian n排尿时或刚结束
37、尿道、耻骨上区、会阴疼痛感，主要为刺痛排尿时或刚结束尿道、耻骨上区、会阴疼痛感，主要为刺痛排尿时或刚结束尿道、耻骨上区、会阴疼痛感，主要为刺痛排尿时或刚结束尿道、耻骨上区、会阴疼痛感，主要为刺痛或灼痛。或灼痛。或灼痛。或灼痛。 n n三者合称膀胱刺激征或尿路刺激征三者合称膀胱刺激征或尿路刺激征三者合称膀胱刺激征或尿路刺激征三者合称膀胱刺激征或尿路刺激征SlideSlide2525Mechanismsoffrequencyn炎炎症症性性刺刺激激：膀膀膀膀胱胱胱胱内内内内有有有有炎炎炎炎症症症症时时时时、神神神神经经经经感感感感受受受受阈阈阈阈限限限限降降降降低低低低，尿意中枢一直处于兴奋状态，导
38、致尿频。尿意中枢一直处于兴奋状态，导致尿频。尿意中枢一直处于兴奋状态，导致尿频。尿意中枢一直处于兴奋状态，导致尿频。n膀膀胱胱容容量量减减小小：包包包包括括括括膀膀膀膀胱胱胱胱内内内内占占占占位位位位性性性性病病病病变变变变及及及及挛挛挛挛缩缩缩缩膀膀膀膀胱胱胱胱，引引引引起起起起每每每每次次次次排排排排尿尿尿尿量量量量减减减减少少少少，排排排排尿尿尿尿次次次次数数数数增增增增多多多多，可可可可不不不不伴伴伴伴尿尿尿尿急急急急和和和和尿痛。尿痛。尿痛。尿痛。n n神神神神经经经经系系系系统统统统病病病病变变变变：膀膀膀膀胱胱胱胱高高高高反反反反应应应应性性性性而而而而出出出出现现现现尿尿尿尿频
39、频频频，可可可可伴伴伴伴尿尿尿尿急急急急，但无尿痛。但无尿痛。但无尿痛。但无尿痛。n下尿路梗阻下尿路梗阻：排尿困难，排尿费力。：排尿困难，排尿费力。：排尿困难，排尿费力。：排尿困难，排尿费力。SlideSlide2626UrinaryFrequencyclassificationbycausesn n生理性尿频：饮水过多、精神紧张、气侯变化等可以改变排尿的频率。生理性尿频：饮水过多、精神紧张、气侯变化等可以改变排尿的频率。生理性尿频：饮水过多、精神紧张、气侯变化等可以改变排尿的频率。生理性尿频：饮水过多、精神紧张、气侯变化等可以改变排尿的频率。n n病理性尿频：病理性尿频：病理性尿频：病理性尿
40、频：n n每次尿量正常，每次尿量正常，每次尿量正常，每次尿量正常，全日总尿量增多全日总尿量增多全日总尿量增多全日总尿量增多：糖尿病、尿崩症、：糖尿病、尿崩症、：糖尿病、尿崩症、：糖尿病、尿崩症、ARFARFARFARF恢复期恢复期恢复期恢复期n n每次尿量减少，每次尿量减少，每次尿量减少，每次尿量减少，全日总尿量正常或减少全日总尿量正常或减少全日总尿量正常或减少全日总尿量正常或减少：n n肾脏疾病：肾结核、肾盂肾炎、多囊肾等；肾脏疾病：肾结核、肾盂肾炎、多囊肾等；肾脏疾病：肾结核、肾盂肾炎、多囊肾等；肾脏疾病：肾结核、肾盂肾炎、多囊肾等；n n膀膀膀膀胱胱胱胱及及及及尿尿尿尿道道道道疾疾疾疾病
41、病病病：急急性性膀膀胱胱炎炎、尿尿道道炎炎、前前列列腺腺增增生生症症。膀膀膀膀胱胱胱胱结结结结石石石石和和和和膀膀膀膀胱结核所致的挛缩膀胱、膀胱肿瘤、尿道狭窄等。胱结核所致的挛缩膀胱、膀胱肿瘤、尿道狭窄等。胱结核所致的挛缩膀胱、膀胱肿瘤、尿道狭窄等。胱结核所致的挛缩膀胱、膀胱肿瘤、尿道狭窄等。 n n继继继继发发发发于于于于泌泌泌泌尿尿尿尿系系系系邻邻邻邻近近近近器器器器官官官官疾疾疾疾患患患患：盆盆盆盆腔腔腔腔及及及及会会会会阴阴阴阴邻邻邻邻近近近近器器器器官官官官炎炎炎炎症症症症、肿肿肿肿块块块块，盆盆盆盆腔腔腔腔内内内内肿瘤、增大的子宫肿瘤、增大的子宫肿瘤、增大的子宫肿瘤、增大的子宫(
42、( ( (如妊娠如妊娠如妊娠如妊娠) ) ) )压迫亦常引起尿频。压迫亦常引起尿频。压迫亦常引起尿频。压迫亦常引起尿频。 n n神经源性膀胱。神经源性膀胱。神经源性膀胱。神经源性膀胱。MechanismsofOdynurian炎炎症症的的的的膀膀膀膀胱胱胱胱自自自自主主主主或或或或不不不不自自自自主主主主的的的的收收收收缩缩缩缩、痉痉痉痉挛挛挛挛n n尿液流经尿液流经尿液流经尿液流经发炎发炎发炎发炎的尿道的尿道的尿道的尿道n n尿尿尿尿路路路路阻阻阻阻塞塞塞塞或或或或尿尿尿尿道道道道异异异异物物物物：从从从从膀膀膀膀胱胱胱胱颈颈颈颈至至至至外外外外尿尿尿尿道道道道口口口口任任任任何何何何部部部
43、部位位位位的的的的阻阻阻阻塞塞塞塞均均均均可可可可造造造造成成成成尿尿尿尿痛痛痛痛，可不伴有炎症性疾病可不伴有炎症性疾病可不伴有炎症性疾病可不伴有炎症性疾病n n重重重重度度度度血血血血尿尿尿尿或或或或尿尿尿尿液液液液酸酸酸酸度度度度过过过过高高高高偶偶偶偶尔尔尔尔也也也也可可可可产产产产生尿痛生尿痛生尿痛生尿痛SlideSlide2727SlideSlide2828CausesofOdynurian膀胱、尿道感染：细菌膀胱、尿道感染：细菌(TB)、支原体、病毒、寄生虫支原体、病毒、寄生虫支原体、病毒、寄生虫支原体、病毒、寄生虫n前列腺疾病前列腺疾病（炎症、增生）（炎症、增生）（炎症、增生）（
44、炎症、增生）n阴道炎：阴道炎：细菌、真菌、原虫、病毒细菌、真菌、原虫、病毒细菌、真菌、原虫、病毒细菌、真菌、原虫、病毒n n女性雌激素缺乏女性雌激素缺乏女性雌激素缺乏女性雌激素缺乏n n间质性膀胱炎间质性膀胱炎间质性膀胱炎间质性膀胱炎n n化学刺激：清洁剂化学刺激：清洁剂化学刺激：清洁剂化学刺激：清洁剂n n尿路梗阻尿路梗阻尿路梗阻尿路梗阻n n系统性疾病：系统性疾病：系统性疾病：系统性疾病：ReitersyndromeReitersyndrome、BehcetsyndromeBehcetsyndrome、CrohndiseaseCrohndiseasen n膀胱肿瘤膀胱肿瘤膀胱肿瘤膀胱肿瘤S
45、lideSlide2929Urinaryurgencyn n有尿痛有尿痛有尿痛有尿痛n n见见见见于于于于泌泌尿尿道道炎炎症症。特特特特别别别别是是是是膀膀膀膀胱胱胱胱三三三三角角角角区区区区粘粘粘粘膜膜膜膜发发发发炎炎炎炎，小小小小量量量量尿尿尿尿液液液液充充充充盈，即可刺激发生尿急，尿痛。盈，即可刺激发生尿急，尿痛。盈，即可刺激发生尿急，尿痛。盈，即可刺激发生尿急，尿痛。n n粘粘粘粘膜膜膜膜无无无无重重重重要要要要病病病病变变变变，但但但但尿尿成成分分发发生生明明显显的的变变化化，如如如如感感感感染染染染性性性性尿尿尿尿液液液液，较强的酸碱度变化，对粘膜都有较强的刺激，较强的酸碱度变化，
46、对粘膜都有较强的刺激，较强的酸碱度变化，对粘膜都有较强的刺激，较强的酸碱度变化，对粘膜都有较强的刺激，n n膀胱结石或异物膀胱结石或异物膀胱结石或异物膀胱结石或异物刺激刺激刺激刺激n n无尿痛无尿痛无尿痛无尿痛n n由于神经性因素，致使排尿反射不正常。由于神经性因素，致使排尿反射不正常。由于神经性因素，致使排尿反射不正常。由于神经性因素，致使排尿反射不正常。SlideSlide3030伴随症状伴随症状n n伴发热、脓尿见于尿路化脓性感染伴发热、脓尿见于尿路化脓性感染伴发热、脓尿见于尿路化脓性感染伴发热、脓尿见于尿路化脓性感染n n伴血尿见于感染（伴血尿见于感染（伴血尿见于感染（伴血尿见于感染（
47、TBTB）、膀胱肿瘤、结石）、膀胱肿瘤、结石）、膀胱肿瘤、结石）、膀胱肿瘤、结石n n中年男性以上尿频伴进行性排尿困难，见于前列腺增生中年男性以上尿频伴进行性排尿困难，见于前列腺增生中年男性以上尿频伴进行性排尿困难，见于前列腺增生中年男性以上尿频伴进行性排尿困难，见于前列腺增生n n伴神经系统疾病，见于神经源性膀胱伴神经系统疾病，见于神经源性膀胱伴神经系统疾病，见于神经源性膀胱伴神经系统疾病，见于神经源性膀胱SlideSlide3131查体要点查体要点n n重点检查腹部：腹部肿物、肾脏肿大、膀胱肿大重点检查腹部：腹部肿物、肾脏肿大、膀胱肿大重点检查腹部：腹部肿物、肾脏肿大、膀胱肿大重点检查腹部
48、：腹部肿物、肾脏肿大、膀胱肿大n n肋脊角压痛及肾区叩击痛肋脊角压痛及肾区叩击痛肋脊角压痛及肾区叩击痛肋脊角压痛及肾区叩击痛n n老年男性：前列腺指检老年男性：前列腺指检老年男性：前列腺指检老年男性：前列腺指检n n疑有遗传性肾炎：听力及眼科检查疑有遗传性肾炎：听力及眼科检查疑有遗传性肾炎：听力及眼科检查疑有遗传性肾炎：听力及眼科检查SlideSlide3232实验室检查实验室检查n n尿常规、尿沉渣红细胞形态分析尿常规、尿沉渣红细胞形态分析尿常规、尿沉渣红细胞形态分析尿常规、尿沉渣红细胞形态分析n n清洁中段尿细菌清洁中段尿细菌清洁中段尿细菌清洁中段尿细菌/ /真菌培养真菌培养真菌培养真菌培
49、养n n尿找尿找尿找尿找TBTB菌菌菌菌n n影像学：影像学：影像学：影像学：B B超、腹部平片、超、腹部平片、超、腹部平片、超、腹部平片、IVPIVPn n膀胱镜检查膀胱镜检查膀胱镜检查膀胱镜检查SlideSlide3333病例讨论病例讨论n n女性女性女性女性 5050岁岁岁岁 体型偏胖体型偏胖体型偏胖体型偏胖 糖尿病糖尿病糖尿病糖尿病7 7年年年年n n一年前尿频、尿急无尿痛，两月前尿常规正常，一年前尿频、尿急无尿痛，两月前尿常规正常，一年前尿频、尿急无尿痛，两月前尿常规正常，一年前尿频、尿急无尿痛，两月前尿常规正常，B B超示双肾大小形态超示双肾大小形态超示双肾大小形态超示双肾大小形态
50、正常，膀胱残余尿正常，膀胱残余尿正常，膀胱残余尿正常，膀胱残余尿200cc200ccn n诊断？诊断？诊断？诊断？n n糖尿病糖尿病糖尿病糖尿病 n n神经源性膀胱神经源性膀胱神经源性膀胱神经源性膀胱n n近近近近2 2周发烧（周发烧（周发烧（周发烧（T:38T:38c c) )、尿频、尿急加重伴尿痛、腰痛，尿常规、尿频、尿急加重伴尿痛、腰痛，尿常规、尿频、尿急加重伴尿痛、腰痛，尿常规、尿频、尿急加重伴尿痛、腰痛，尿常规 ：Leu500/ulLeu500/ul、Ery50/ulEry50/ul，尿沉渣，尿沉渣，尿沉渣，尿沉渣RBCRBC形态正常；血形态正常；血形态正常；血形态正常；血WBCWB
51、C及其分类升及其分类升及其分类升及其分类升高。查体高。查体高。查体高。查体:T:37.5:T:37.5c c，双肋脊角压痛，双肾区叩击痛阳性。，双肋脊角压痛，双肾区叩击痛阳性。，双肋脊角压痛，双肾区叩击痛阳性。，双肋脊角压痛，双肾区叩击痛阳性。n n诊断？诊断？诊断？诊断？n n糖尿病糖尿病糖尿病糖尿病 神经源性膀胱神经源性膀胱神经源性膀胱神经源性膀胱n n泌尿系感染泌尿系感染泌尿系感染泌尿系感染 急性肾盂肾炎急性肾盂肾炎急性肾盂肾炎急性肾盂肾炎n n外院予头孢菌素治疗，外院予头孢菌素治疗，外院予头孢菌素治疗，外院予头孢菌素治疗，2 2天后出现四肢、躯干皮肤红斑疹、天后出现四肢、躯干皮肤红斑疹、天后出现四肢、躯干皮肤红斑疹、天后出现四肢、躯干皮肤红斑疹、血嗜酸细胞增高，停用头孢菌素，来我院就诊。血嗜酸细胞增高，停用头孢菌素，来我院就诊。血嗜酸细胞增高，停用头孢菌素，来我院就诊。血嗜酸细胞增高，停用头孢菌素，来我院就诊。n n诊断？诊断？诊断？诊断？n n药疹药疹药疹药疹n n下一步检查及治疗？下一步检查及治疗？下一步检查及治疗？下一步检查及治疗？n n主诉？主诉？主诉？主诉？SlideSlide3434SlideSlide3535
