History and exam
Key diagnostic factors
common
history of vesicoureteral reflux (VUR)
Plays a key role in the pathogenesis of renal infection and chronic renal damage. It is associated with urinary tract infection (UTI) in children and also occurs because of anatomic abnormalities in children without UTI.[11] In addition, enuresis, or bedwetting, has been described as a presenting symptom of VUR in children who have daytime incontinence.[38]
history of acute pyelonephritis
Chronic pyelonephritis often develops as an outcome of inadequately treated or recurrent acute pyelonephritis.[12]
history of renal obstruction
This may occur due to congenital or anatomic urinary tract abnormalities, benign prostatic hypertrophy, or renal stones (e.g., staghorn calculi).
Other diagnostic factors
common
female sex
Recurrent UTIs, xanthogranulomatous pyelonephritis (XGP), and emphysematous pyelonephritis (EPN) occur predominantly in women; men tend to have VUR.
nausea
Patients may have symptoms of the underlying cause (e.g., UTI).
elevated blood pressure
Hypertension occurs late in the course of the disease.
children and infants (risk of VUR)
VUR usually occurs in infants and children.
uncommon
adults (risk of XGP and EPN)
XGP and EPN occur in older adults, who are more likely to have concurrent medical problems. XGP occurs with prolonged renal obstruction and infection. Proteus species are the causative pathogens in 60% of cases.[16] High levels of HbA1c and impaired host immune mechanisms are thought to predispose diabetic patients to EPN.[19]
weight loss
More common in XGP.
fatigue
Patients may have symptoms of the underlying cause (e.g., UTI).
malaise
Patients may have symptoms of the underlying cause (e.g., UTI).
cloudy urine
Patients may have symptoms of the underlying cause (e.g., UTI).
fever
More common in acute infections and EPN.
back/flank pain and tenderness
More common in acute infections and EPN.
Risk factors
strong
acute pyelonephritis
Chronic pyelonephritis often develops as an outcome of inadequately treated or recurrent acute pyelonephritis.[12]
vesicoureteral reflux
Plays a key role in the pathogenesis of renal infection and chronic renal damage. It is associated with urinary tract infection (UTI) in children and also occurs because of anatomic abnormalities in children without UTI.[11]
obstruction
This may occur due to renal stones, such as staghorn calculi, which often predispose to chronic infection and may be a factor in xanthogranulomatous pyelonephritis (XGP), congenital or anatomic urinary tract abnormalities, or benign prostatic hypertrophy.
renal calculi
Some renal stones, such as staghorn calculi, are large, porous stones with bacteria interspersed within the mineral matrix. The large size makes the stones difficult to treat, and the bacterial integration in the stone matrix makes eradication of potential recurrent infections with antibiotics difficult to impossible.
diabetes mellitus
This condition is a risk factor for infection, and poorly controlled diabetes mellitus increases morbidity and mortality in severe infection.[26][27] Poorly controlled diabetes mellitus, high levels of HbA1c, and impaired host immune mechanisms are thought to predispose to emphysematous pyelonephritis.[19]
weak
neurogenic bladder
Neurogenic bladder is a nonspecific term for voiding dysfunction due to an overactive or underactive bladder. There are many etiologies for neurogenic bladder, ranging from damage to the spinal cord caused by trauma or congenital abnormalities (such as meningomyelocele) to autonomic dysfunction from diabetes mellitus or alcohol, or it may occur in some people with aging. Inadequate emptying of the bladder may predispose to developing infection in the urine. The degree of risk depends on the severity of the problem.
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