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==Overview== | ==Overview== | ||
Pyelonephritis is usually an ascending [[urinary tract infection]] that has reached the ''pyelum'' ([[Renal pelvis|pelvis]]) of the [[kidney]] (''nephros'' in [[Greek language|Greek]]). If the infection is severe, the term "urosepsis" is used interchangeably ([[sepsis]] being a [[systemic inflammatory response syndrome]] due to infection). It requires [[antibiotic]]s as therapy, and treatment of any underlying causes to prevent recurrence. It is a form of [[nephritis]]. It can also be called ''pyelitis''.<ref name=Ramakrishnan>{{cite journal | author=Ramakrishnan K, Scheid DC | title=Diagnosis and management of acute pyelonephritis in adults | journal=Am Fam Physician | year=2005 | pages=933-42 | volume=71 | issue=5 | id=PMID 15768623 | url=http://www.aafp.org/afp/20050301/933.html}}</ref> | Pyelonephritis is usually an ascending [[urinary tract infection]] that has reached the ''pyelum'' ([[Renal pelvis|pelvis]]) of the [[kidney]] (''nephros'' in [[Greek language|Greek]]). If the infection is severe, the term "urosepsis" is used interchangeably ([[sepsis]] being a [[systemic inflammatory response syndrome]] due to infection). It requires [[antibiotic]]s as therapy, and treatment of any underlying causes to prevent recurrence. It is a form of [[nephritis]]. It can also be called ''[[pyelitis]]''.<ref name="Ramakrishnan">{{cite journal | author=Ramakrishnan K, Scheid DC | title=Diagnosis and management of acute pyelonephritis in adults | journal=Am Fam Physician | year=2005 | pages=933-42 | volume=71 | issue=5 | id=PMID 15768623 | url=http://www.aafp.org/afp/20050301/933.html}}</ref> | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
The epidemiology and demographics demonstrate that: <ref name="pmid12848468">{{cite journal| author=Foxman B, Brown P| title=Epidemiology of urinary tract infections: transmission and risk factors, incidence, and costs. | journal=Infect Dis Clin North Am | year= 2003 | volume= 17 | issue= 2 | pages= 227-41 | pmid=12848468 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12848468 }} </ref><ref>{{cite journal |author=Czaja CA, Scholes D, Hooton TM, Stamm WE |title=Population-based epidemiologic analysis of acute pyelonephritis |journal=Clin. Infect. Dis. |volume=45 |issue=3 |pages=273-80 |year=2007 |pmid=17599303 |doi=10.1086/519268}}</ref><ref name="pmid9606306">{{cite journal| author=Kurowski K| title=The woman with dysuria. | journal=Am Fam Physician | year= 1998 | volume= 57 | issue= 9 | pages= 2155-64, 2169-70 | pmid=9606306 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9606306 }} </ref><ref name="pmid15206056">{{cite journal| author=Hooton TM, Besser R, Foxman B, Fritsche TR, Nicolle LE| title=Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy. | journal=Clin Infect Dis | year= 2004 | volume= 39 | issue= 1 | pages= 75-80 | pmid=15206056 | doi=10.1086/422145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15206056 }} </ref><ref name="pmid8824972">{{cite journal| author=Ikäheimo R, Siitonen A, Heiskanen T, Kärkkäinen U, Kuosmanen P, Lipponen P et al.| title=Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women. | journal=Clin Infect Dis | year= 1996 | volume= 22 | issue= 1 | pages= 91-9 | pmid=8824972 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8824972 }} </ref><ref name="pmid17599303">{{cite journal| author=Czaja CA, Scholes D, Hooton TM, Stamm WE| title=Population-based epidemiologic analysis of acute pyelonephritis. | journal=Clin Infect Dis | year= 2007 | volume= 45 | issue= 3 | pages= 273-80 | pmid=17599303 | doi=10.1086/519268 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17599303 }} </ref> | The epidemiology and demographics demonstrate that:<ref name="pmid12848468">{{cite journal| author=Foxman B, Brown P| title=Epidemiology of urinary tract infections: transmission and risk factors, incidence, and costs. | journal=Infect Dis Clin North Am | year= 2003 | volume= 17 | issue= 2 | pages= 227-41 | pmid=12848468 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12848468 }} </ref><ref>{{cite journal |author=Czaja CA, Scholes D, Hooton TM, Stamm WE |title=Population-based epidemiologic analysis of acute pyelonephritis |journal=Clin. Infect. Dis. |volume=45 |issue=3 |pages=273-80 |year=2007 |pmid=17599303 |doi=10.1086/519268}}</ref><ref name="pmid9606306">{{cite journal| author=Kurowski K| title=The woman with dysuria. | journal=Am Fam Physician | year= 1998 | volume= 57 | issue= 9 | pages= 2155-64, 2169-70 | pmid=9606306 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9606306 }} </ref><ref name="pmid15206056">{{cite journal| author=Hooton TM, Besser R, Foxman B, Fritsche TR, Nicolle LE| title=Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy. | journal=Clin Infect Dis | year= 2004 | volume= 39 | issue= 1 | pages= 75-80 | pmid=15206056 | doi=10.1086/422145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15206056 }} </ref><ref name="pmid8824972">{{cite journal| author=Ikäheimo R, Siitonen A, Heiskanen T, Kärkkäinen U, Kuosmanen P, Lipponen P et al.| title=Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women. | journal=Clin Infect Dis | year= 1996 | volume= 22 | issue= 1 | pages= 91-9 | pmid=8824972 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8824972 }} </ref><ref name="pmid17599303">{{cite journal| author=Czaja CA, Scholes D, Hooton TM, Stamm WE| title=Population-based epidemiologic analysis of acute pyelonephritis. | journal=Clin Infect Dis | year= 2007 | volume= 45 | issue= 3 | pages= 273-80 | pmid=17599303 | doi=10.1086/519268 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17599303 }} </ref> | ||
*Urinary tract infections are the most frequent [[bacterial infection]] in women with at least half the women by age 32 report at least one episode. | *[[Urinary tract infections]] are the most frequent [[bacterial infection]] in women with at least half the women by age 32 report at least one episode. | ||
*Females are more commonly affected with pyelonephritis than males. | *Females are more commonly affected with pyelonephritis than males. | ||
*Pyelonephritis is not as common as cystitis. The ratio being around 1 is to 28. | *Pyelonephritis is not as common as [[cystitis]]. The ratio being around 1 is to 28. | ||
*Pyelonephritis effects 120-130 [[incidence|cases annually]] per 100,000 women and 30-40 cases per 100,000 men. | *Pyelonephritis effects 120-130 [[incidence|cases annually]] per 100,000 women and 30-40 cases per 100,000 men. | ||
*The incidence of Pyelonephritis in 15-34 year old women is 25 cases per 10,000 women annually . | *The incidence of Pyelonephritis in 15-34 year old women is 25 cases per 10,000 women annually . | ||
==Historical Perspective== | ==Historical Perspective== | ||
[[Urinary tract infections]] have been described since ancient times with the first documented description in the Ebers Papyrus dated to | [[Urinary tract infections]] have been described since ancient times with the first documented description in the Ebers Papyrus dated to 1550 BC. In 1836, three cases of severe lower urinary tract symptoms without the presence of a [[bladder stone]] were described a surgeon from Philadelphia named Joseph Parrish.<ref name=abc> Interstitial Cystitis. Wikipedia.https://en.wikipedia.org/wiki/Interstitial_cystitis#History Accessed on February 8, 2016</ref> | ||
==Classification== | ==Classification== | ||
| Line 28: | Line 28: | ||
==Pathophysiology== | ==Pathophysiology== | ||
Pyelonephritis results from infection of the renal parenchyma that can result either from an ascending infection from the urethra, bladder or ureter or by a descending | Pyelonephritis results from infection of the renal parenchyma that can result either from an ascending infection from the [[urethra]], [[Urinary bladder|bladder]] or [[ureter]] or by a descending infection from the blood. Immunosuppressed patients of any kind are more prone to getting infections and thus pyelonephritis.<ref name="pmid10969044">{{cite journal| author=Hooton TM| title=Pathogenesis of urinary tract infections: an update. | journal=J Antimicrob Chemother | year= 2000 | volume= 46 Suppl A | issue= | pages= 1-7 | pmid=10969044 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10969044 }} </ref><ref name="pmid15768623">{{cite journal| author=Ramakrishnan K, Scheid DC| title=Diagnosis and management of acute pyelonephritis in adults. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 5 | pages= 933-42 | pmid=15768623 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15768623 }} </ref> | ||
==Causes== | ==Causes== | ||
Most of cases of Pyelonephritis are caused by ''[[escherichia coli]] ("E. coli")'', a bacterium found in the lower [[gastrointestinal tract]]. Other causes of Pyelonephritis include | Most of cases of Pyelonephritis are caused by ''[[escherichia coli]] ("E. coli")'', a bacterium found in the lower [[gastrointestinal tract]]. Other causes of Pyelonephritis include [[medications]], [[diabetes]],, iatrogenic causes, [[endometriosis]], [[pelvic inflammatory disease]], [[urinary obstruction]], and [[bladder incontinence]].<ref name="pmid15768623">{{cite journal| author=Ramakrishnan K, Scheid DC| title=Diagnosis and management of acute pyelonephritis in adults. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 5 | pages= 933-42 | pmid=15768623 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15768623 }} </ref><ref name="pmid8413414">{{cite journal| author=Stamm WE, Hooton TM| title=Management of urinary tract infections in adults. | journal=N Engl J Med | year= 1993 | volume= 329 | issue= 18 | pages= 1328-34 | pmid=8413414 | doi=10.1056/NEJM199310283291808 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8413414 }} </ref> | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Pyelonephritis must be differentiated from other causes of [[dysuria]] such as [[cystitis]], [[urethritis]], [[prostatitis]], [[vulvovaginitis]], [[urethral stricture]]s or diverticula, [[benign prostatic hyperplasia]] and [[neoplasm]]s such as [[renal cell carcinoma]] and cancers of the bladder, prostate, and penis. It must also be differentiated from the causes of [[flank pain]] including [[ovarian torsion]], [[Ovarian cyst|ruptured ovarian cyst]], [[ectopic pregnancy]], liver ischemia, [[rib fracture]] or an [[abscess]] of the underlying structures.<ref name="pmid9606306">{{cite journal| author=Kurowski K| title=The woman with dysuria. | journal=Am Fam Physician | year= 1998 | volume= 57 | issue= 9 | pages= 2155-64, 2169-70 | pmid=9606306 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9606306 }} </ref><ref name="pmid11989635">{{cite journal| author=Bremnor JD, Sadovsky R| title=Evaluation of dysuria in adults. | journal=Am Fam Physician | year= 2002 | volume= 65 | issue= 8 | pages= 1589-96 | pmid=11989635 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11989635 }} </ref> | |||
==Risk Factors== | ==Risk Factors== | ||
Common risk factors in the development of pyelonephritis include urinary catheters, bladder stones, [[diabetes]], [[pregnancy]], [[catheterization]], bowel [[incontinence]], old age, and immobility.<ref name="pmid15768623">{{cite journal| author=Ramakrishnan K, Scheid DC| title=Diagnosis and management of acute pyelonephritis in adults. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 5 | pages= 933-42 | pmid=15768623 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15768623 }} </ref> | Common risk factors in the development of pyelonephritis include urinary catheters, [[bladder stones]] and [[kidney stones]], [[diabetes]], [[pregnancy]], [[catheterization]], bowel [[incontinence]], old age, and immobility.<ref name="pmid15768623">{{cite journal| author=Ramakrishnan K, Scheid DC| title=Diagnosis and management of acute pyelonephritis in adults. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 5 | pages= 933-42 | pmid=15768623 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15768623 }} </ref> | ||
==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
Pyelonephritis has to be treated with medications immediately after drawing urine samples. Many complications can result as a result of Pyelonephritis and include | Pyelonephritis has to be treated with medications immediately after drawing urine samples. Many complications can result as a result of Pyelonephritis and include [[Sepsis]], [[Pyonephrosis]], [[perinephric abscess]], [[renal failure]] and even death. | ||
==Diagnosis== | ==Diagnosis== | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
A detailed history is the most important step to begin dealing with any medical condition. Patients with Pyelonephritis have a typical history of fever, dysuria and flank pain. | A detailed history is the most important step to begin dealing with any medical condition. Patients with Pyelonephritis have a typical history of [[fever]], [[dysuria]] and [[flank pain]]. Long term history of known anatomical abnormality in the urinary tract or presence of [[Diabetes mellitus|diabetes]] or any [[immunocompromised]] condition may also be helpful in the diagnosis. | ||
===Physical Examination=== | ===Physical Examination=== | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
Urinalysis and urine culture | [[Urinalysis]] and [[urine culture]] are done to help diagnose pyelonephritis on first interaction. A combination of leukocyte esterase test and nitrite test (with either of the two test being positive) is considered to be very effective with a sensitivity ranging from 75-84 and a specificity ranging from 82-98 percent.<ref name="pmid15768623">{{cite journal| author=Ramakrishnan K, Scheid DC| title=Diagnosis and management of acute pyelonephritis in adults. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 5 | pages= 933-42 | pmid=15768623 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15768623 }} </ref> | ||
==Treatment== | ==Treatment== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Pyelonephritis is usually an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney (nephros in Greek). If the infection is severe, the term "urosepsis" is used interchangeably (sepsis being a systemic inflammatory response syndrome due to infection). It requires antibiotics as therapy, and treatment of any underlying causes to prevent recurrence. It is a form of nephritis. It can also be called pyelitis.[1]
Epidemiology and Demographics
The epidemiology and demographics demonstrate that:[2][3][4][5][6][7]
- Urinary tract infections are the most frequent bacterial infection in women with at least half the women by age 32 report at least one episode.
- Females are more commonly affected with pyelonephritis than males.
- Pyelonephritis is not as common as cystitis. The ratio being around 1 is to 28.
- Pyelonephritis effects 120-130 cases annually per 100,000 women and 30-40 cases per 100,000 men.
- The incidence of Pyelonephritis in 15-34 year old women is 25 cases per 10,000 women annually .
Historical Perspective
Urinary tract infections have been described since ancient times with the first documented description in the Ebers Papyrus dated to 1550 BC. In 1836, three cases of severe lower urinary tract symptoms without the presence of a bladder stone were described a surgeon from Philadelphia named Joseph Parrish.[8]
Classification
Pyelonephritis can be classified based on the duration of infection and the aetiology into the following categories.[9][10]
- Acute complicated pyelonephritis
- Acute Complicated Pyelonephritis
- Chronic Pyelonephritis
- Emphysematous Pyelonephritis
- Xanthogranulomatous Pyelonephritis
Pathophysiology
Pyelonephritis results from infection of the renal parenchyma that can result either from an ascending infection from the urethra, bladder or ureter or by a descending infection from the blood. Immunosuppressed patients of any kind are more prone to getting infections and thus pyelonephritis.[11][12]
Causes
Most of cases of Pyelonephritis are caused by escherichia coli ("E. coli"), a bacterium found in the lower gastrointestinal tract. Other causes of Pyelonephritis include medications, diabetes,, iatrogenic causes, endometriosis, pelvic inflammatory disease, urinary obstruction, and bladder incontinence.[12][13]
Differential Diagnosis
Pyelonephritis must be differentiated from other causes of dysuria such as cystitis, urethritis, prostatitis, vulvovaginitis, urethral strictures or diverticula, benign prostatic hyperplasia and neoplasms such as renal cell carcinoma and cancers of the bladder, prostate, and penis. It must also be differentiated from the causes of flank pain including ovarian torsion, ruptured ovarian cyst, ectopic pregnancy, liver ischemia, rib fracture or an abscess of the underlying structures.[4][14]
Risk Factors
Common risk factors in the development of pyelonephritis include urinary catheters, bladder stones and kidney stones, diabetes, pregnancy, catheterization, bowel incontinence, old age, and immobility.[12]
Natural History, Complications, and Prognosis
Pyelonephritis has to be treated with medications immediately after drawing urine samples. Many complications can result as a result of Pyelonephritis and include Sepsis, Pyonephrosis, perinephric abscess, renal failure and even death.
Diagnosis
History and Symptoms
A detailed history is the most important step to begin dealing with any medical condition. Patients with Pyelonephritis have a typical history of fever, dysuria and flank pain. Long term history of known anatomical abnormality in the urinary tract or presence of diabetes or any immunocompromised condition may also be helpful in the diagnosis.
Physical Examination
Laboratory Findings
Urinalysis and urine culture are done to help diagnose pyelonephritis on first interaction. A combination of leukocyte esterase test and nitrite test (with either of the two test being positive) is considered to be very effective with a sensitivity ranging from 75-84 and a specificity ranging from 82-98 percent.[12]
Treatment
Medical Treatment
Treatment of Pyelonephritis is usually medical. In case of any risk factors like catheters or obstructing stones or masses, the management includes removing the risk factors to prevent further progress of the disease and the pathogen accumulation.
Surgery
In recurrent infections, additional investigations may identify an underlying abnormality. Occasionally, surgical intervention is necessary to improve chances of recurrence.
References
- ↑ Ramakrishnan K, Scheid DC (2005). "Diagnosis and management of acute pyelonephritis in adults". Am Fam Physician. 71 (5): 933–42. PMID 15768623.
- ↑ Foxman B, Brown P (2003). "Epidemiology of urinary tract infections: transmission and risk factors, incidence, and costs". Infect Dis Clin North Am. 17 (2): 227–41. PMID 12848468.
- ↑ Czaja CA, Scholes D, Hooton TM, Stamm WE (2007). "Population-based epidemiologic analysis of acute pyelonephritis". Clin. Infect. Dis. 45 (3): 273–80. doi:10.1086/519268. PMID 17599303.
- ↑ 4.0 4.1 Kurowski K (1998). "The woman with dysuria". Am Fam Physician. 57 (9): 2155–64, 2169–70. PMID 9606306.
- ↑ Hooton TM, Besser R, Foxman B, Fritsche TR, Nicolle LE (2004). "Acute uncomplicated cystitis in an era of increasing antibiotic resistance: a proposed approach to empirical therapy". Clin Infect Dis. 39 (1): 75–80. doi:10.1086/422145. PMID 15206056.
- ↑ Ikäheimo R, Siitonen A, Heiskanen T, Kärkkäinen U, Kuosmanen P, Lipponen P; et al. (1996). "Recurrence of urinary tract infection in a primary care setting: analysis of a 1-year follow-up of 179 women". Clin Infect Dis. 22 (1): 91–9. PMID 8824972.
- ↑ Czaja CA, Scholes D, Hooton TM, Stamm WE (2007). "Population-based epidemiologic analysis of acute pyelonephritis". Clin Infect Dis. 45 (3): 273–80. doi:10.1086/519268. PMID 17599303.
- ↑ Interstitial Cystitis. Wikipedia.https://en.wikipedia.org/wiki/Interstitial_cystitis#History Accessed on February 8, 2016
- ↑ Wang HD, Zhu XF, Xu X, Li GZ, Liu N, He F; et al. (2017). "Emphysematous Pyelonephritis Treated with Vacuum Sealing Drainage". Chin Med J (Engl). 130 (2): 247–248. doi:10.4103/0366-6999.198021. PMID 28091422.
- ↑ Upasani A, Barnacle A, Roebuck D, Cherian A (2016). "Combination of Surgical Drainage and Renal Artery Embolization: An Alternative Treatment for Xanthogranulomatous Pyelonephritis". Cardiovasc Intervent Radiol. doi:10.1007/s00270-016-1522-z. PMID 28028578.
- ↑ Hooton TM (2000). "Pathogenesis of urinary tract infections: an update". J Antimicrob Chemother. 46 Suppl A: 1–7. PMID 10969044.
- ↑ 12.0 12.1 12.2 12.3 Ramakrishnan K, Scheid DC (2005). "Diagnosis and management of acute pyelonephritis in adults". Am Fam Physician. 71 (5): 933–42. PMID 15768623.
- ↑ Stamm WE, Hooton TM (1993). "Management of urinary tract infections in adults". N Engl J Med. 329 (18): 1328–34. doi:10.1056/NEJM199310283291808. PMID 8413414.
- ↑ Bremnor JD, Sadovsky R (2002). "Evaluation of dysuria in adults". Am Fam Physician. 65 (8): 1589–96. PMID 11989635.