3 urological emergency

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  • Fowler’s syndrome (impaired relaxation of external sphincter occurring in premenopausal women, often in association with polycystic ovaries
  • Haematuria leading to clot retention Drugs: anticholinergics, sympathomimetic agents such as ephedrine in nasal decongestants Pain (adrenergic stimulation of the bladder neck) postoperative retention; sacral (S2–S4) nerve compression or damage—so-called cauda equina compression (due to prolapsed L2–L3 disc or L3–L4 intervertebral disc, trauma to the vertebrae, benign or metastatic tumours) radical pelvic surgery damaging the parasympathetic plexus (radical hysterectomy, abdominoperineal resection); pelvic fracture rupturing the urethra (more likely in men than women); neurotropic viruses involving the sensory dorsal root ganglia of S2–S4 (herpes simplex or zoster); multiple sclerosis transverse myelitis diabetic cystopathy Damage to dorsal columns of spinal cord causing loss of bladder sensation (tabes dorsalis, pernicious anaemia).
  • 3 urological emergency

    1. 1. GenitourinaryEmergencyProf. Dr. Mostafa SakrGenitourinary Surgery
    2. 2. • Urologic emergency arises when a conditionrequire rapid diagnosis and immediate treatment• Compared to other surgical fields there arerelatively few emergencies in urology
    3. 3. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal Trauma2) Ureteral Injury3) Bladder Trauma4) Urethral Injury5) Testicular Trauma
    4. 4. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal Trauma2) Ureteral Injury3) Bladder Trauma4) Urethral Injury5) Testicular Trauma
    5. 5. Hematuria• Blood in the urine• Types:– Macroscopic (frank, or gross hematuria)/Dipstick hematuria for Microscopic hematuria(the presence of > 3 red blood cells per highpower microscopic field).– Painless or painful.– Initial / Terminal / Total
    6. 6. Hematuria…• Causes– Nephrological (medical) or urological (surgical)– Medical causes:• glomerular and nonglomerular• blood dyscrasias, interstitial nephritis, and renovasculardisease– Surgical/urological nonglomerular causes:• renal tumours, urothelial tumours (bladder, ureteric, renalcollecting system), prostate cancer, bleeding from vascularbenign prostatic enlargement, trauma, renal or uretericstones, and UTI.• Haematuria in these situations is usually characterised bycircular erythrocytes and absence of proteinuria and casts.Non traumaticemergency
    7. 7. Hematuria…• Presentation:– Hematuria– Anemia: bleeding is so heavy (this is rare)– Urine retention or ureteric colic (Clot retention)• Work Up :– History– Examination– Investigation :• Urine culture• Urine cytology• Renal US• Flexible cystoscopy,• IVU or computed tomography (CT) scan in selected groups.– Treat the causeNon traumaticemergency
    8. 8. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal Trauma2) Ureteral Injury3) Bladder Trauma4) Urethral Injury5) Testicular Trauma
    9. 9. ACUTE FLANK PAIN—URETERICOR RENAL COLIC• The commonest urologic emergency.• One of the commonest causes of the “Acute Abdomen”.• Sudden onset of severe pain in the flank• Most often due to the passage of a stone formed in thekidney, down through the ureter.
    10. 10. Renal colic….• The pain is characteristically :– very sudden onset– colicky in nature– Radiates to the groin as the stone passes into the lower ureter.– May change in location, from the flank to the groin, (the locationof pain does not provide a good indication of the position of thestone)– The patient cannot get comfortable, and may roll around inagony.– Associated with nausea / Vomiting– the pain of a ureteric stone as being worse than the pain oflabour.Non traumaticemergency
    11. 11. Renal colic….• Differential diagnoses– Leaking abdominal aortic aneurysms– Pneumonia– Myocardial infarction– Ovarian pathology (e.g., twisted ovarian cyst)– Acute appendicitis– Testicular torsion– Inflammatory bowel disease (Crohn’s, ulcerative colitis)– Diverticulitis– Ectopic pregnancy– Burst peptic ulcer– Bowel obstructionNon traumaticemergency
    12. 12. Renal colic….• Work Up :– History– Examination: patient want to move around, inan attempt to find a comfortable position.– +/- Fever– Pregnancy test– MSUNon traumaticemergency
    13. 13. Renal colic….– Radiological investigation :• KUB / Abdominal US• IVP (was)• Helical CTU– advantages over IVP:» greater specificity (95%) and sensitivity (97%) for diagnosingureteric stones» Can identify other, non-stone causes of flank pain.» No need for contrast administration.» Faster, taking just a few minutes» the cost of CTU is equivalent to that of IVU• MRI– very accurate way of determining whether or not a stone is presentin the ureter– very high costNon traumaticemergency
    14. 14. Renal colic….• Acute Management of Ureteric Stones:– Pain relief• NSAIDs• Intramuscular or intravenous injection, by mouth,or per rectum• +/- Opiate analgesics (pethidine or morphine).– ? Hyper hydration– ‘watchful waiting’ with analgesic supplements• 95% of stones measuring 5mm or less passspontaneouslyNon traumaticemergency
    15. 15. Renal colic….• Indications for Intervention to RelieveObstruction and/or Remove the Stone:– Pain that fails to respond to analgesics.– Associated fever.– Renal function is impaired because of thestone (solitary kidney obstructed by a stone,bilateral ureteric stones, or preexisting renalimpairment )– Obstruction unrelieved for > 4 weeks– Personal or occupational reasonsNon traumaticemergency
    16. 16. Renal colic….• Treatment of the Stone:– Temporary relief of the obstruction:• Insertion of a JJ stent or percutaneousnephrostomy tube.– Definitive treatment of a ureteric stone:• ESWL.• PCNL• Ureteroscopy• Open Surgery: very limited.Non traumaticemergency
    17. 17. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal Trauma2) Ureteral Injury3) Bladder Trauma4) Urethral Injury5) Testicular Trauma
    18. 18. Urinary Retention• Acute Urinary retention• Chronic Urinary retentionNon traumaticemergency
    19. 19. Acute Urinary retention• Painful inability to void, with relief of painfollowing drainage of the bladder bycatheterization.• Pathophysiology:– Increased urethral resistance, i.e., bladderoutlet obstruction (BOO)– Low bladder pressure, i.e., impaired bladdercontractility– Interruption of sensory or motor innervationsof the bladderNon traumaticemergency
    20. 20. Acute urinary retention…• Causes :– Men:• Benign prostatic enlargement (BPE) due to BPH• Carcinoma of the prostate• Urethral stricture• Prostatic abscess– Women• Pelvic prolapse (cystocoele, rectocoele, uterine)• Urethral stricture;• Urethral diverticulum;• Post surgery for ‘stress’ incontinence• pelvic masses (e.g., ovarian masses)Non traumaticemergency
    21. 21. Acute urinary retention…Causes…• Both Sex– Haematuria leading to clot retention– Drugs– Pain– Sacral nerve compression or damage(cauda equinacompression )– Radical pelvic surgery– Pelvic fracture rupturing the urethra– Neurotropic viruses involving the sensory dorsal root ganglia ofS2–S4 (herpes simplex or zoster);– Multiple sclerosis– Transverse myelitis– Diabetic cystopathy– Damage to dorsal columns of spinal cord causing loss of bladdersensation (tabes dorsalis, pernicious anaemia).Non traumaticemergency
    22. 22. Acute urinary retention…• Initial Management :– Urethral catheterisation– Suprapubic catheter ( SPC)• Late Management:– Treating the underlying causeNon traumaticemergency
    23. 23. Chronic urinary retention• Obstruction develops slowly, the bladderis distended (stretched) very graduallyover weeks/months, so pain is not afeature .• Presentation:– Urinary dribbling– Overflow incontinence– Palpable lower suprapubic massNon traumaticemergency
    24. 24. Chronic urinary retention…• Usually associated with– Reduced renal function.– Upper tract dilatation• R/x is directed to renal support.• Bladder drainage under slow rate to avoidsudden decompression> hematuria.• Late R/x of cause.Non traumaticemergency
    25. 25. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal Trauma2) Ureteral Injury3) Bladder Trauma4) Urethral Injury5) Testicular Trauma
    26. 26. Acute Scrotum• Emergency situation requiring promptevaluation, differential diagnosis, andpotentially immediate surgical explorationNon traumaticemergency
    27. 27. Acute scrotum…Differential Diagnosis:Non traumaticemergency
    28. 28. Acute scrotum…Differential Diagnosis…1. Torsion of the Spermatic Cord(Intravaginal)– Most serious.1. Torsion of the Testicular and EpididymalAppendages.2. Epididymitis.– Most commonNon traumaticemergency
    29. 29. Torsion of the Spermatic Cord(A) extravaginal; (B) intravaginalNon traumaticemergency
    30. 30. Torsion of the Spermatic Cord(Intravaginal)• True surgical emergency of the highest order• Irreversible ischemic injury to the testicularparenchyma may begin as soon as 4 hours• Testicular salvage ↓as duration of torsion↑
    31. 31. Torsion of the Spermatic Cord…Presentation:• Acute onset of scrotal pain.• Majority with history of prior episodes ofsevere, self-limited scrotal pain and swelling.• N/V• Referred to the ipsilateral lower quadrant of theabdomen.• Dysuria and other bladder symptoms areusually absent.Non traumaticemergency
    32. 32. Torsion of the Spermatic Cord…Physical examination:•The affected testis ishigh- ridingTransverse orientation.•Acute hydrocele ormassive scrotal edema•Cremasteric reflex isabsent.•Tender larger than otherside.Non traumaticemergency
    33. 33. Torsion of the Spermatic Cord…Adjunctive tests:• To aid in differential diagnosis of the acutescrotum.• To confirm the absence of torsion of thecord.• Doppler examination of the cord andtestis– High false-positive and false-negative resultsNon traumaticemergency
    34. 34. Torsion of the Spermatic Cord…• Color Doppler ultrasound:– Assessment of anatomy and determining thepresence or absence of blood flow.– Sensitivity: 88.9% specificity of 98.8%– Operator dependent.
    35. 35. Torsion of the Spermatic Cord…• Radionuclide imaging :– Assessment of testicular blood flow.– PPV of 75%, a sensitivity of 90%, and aspecificity of 89%.– False impression from hyperemia of scrotalwall.– Not helpful in Hydrocele and Hematoma
    36. 36. Non traumaticemergency
    37. 37. Torsion of the Spermatic Cord…Surgical exploration:• A median raphe scrotal incision or a transverseincision.• The affected side should be examined first• The cord should be detorsed.• Testes with marginal viability should be placed inwarm sponges and re-examined after several minutes.• A necrotic testis should be removed• If the testis is to be preserved, it should be placed intothe dartos pouch (suture fixation)• The contralateral testis must be fixed to preventsubsequent torsion.Non traumaticemergency
    38. 38. Torsion of the Spermatic Cord…Non traumaticemergency
    39. 39. Epid.Orchitis• Presentation:– Indolent process.– Scrotal swelling, erythema, and pain.– Dysuria and fever is more common• P/E :– localized epididymal tenderness, a swollen and tenderepididymis, or a massively swollen hemiscrotum withabsence of landmarks.– Cremasteric reflex should be present• Urine:– pyuria, bacteriuria, or a positive urine culture(Gram-negative bacteria) .Non traumaticemergency
    40. 40. Epid.Orchitis…• Management:– Bed rest for 1 to 3 days then relativerestriction .– Scrotal elevation, the use of an athleticsupporter– parenteral antibiotic therapy should beinstituted when UTI is documented orsuspected.– Urethral instrumentation should be avoidedNon traumaticemergency
    41. 41. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal Trauma2) Ureteral Injury3) Bladder Trauma4) Urethral Injury5) Testicular Trauma
    42. 42. Priapism• Persistent erection of the penis for morethan 4 hours that is not related oraccompanied by sexual desire.Non traumaticemergency
    43. 43. Priapism…• 2 Types:– ischaemic (veno-occlusive, low flow (most common)• Due to haematological disease, malignant infiltration of thecorpora cavernosa with malignant disease, or drugs.• Painful.– nonischaemic (arterial, high flow).• Due to perineal trauma, which creates an arteriovenousfistula.• Painless• Age:– Any age– two main age groups affected are 5- to 10-year-oldboys and 20- to 50-year-old men.
    44. 44. Priapism…• Causes:– Primary (Idiopathic) : 30%- 50%– Secondary:• Drugs• Trauma• Neurological• Hematological disease• Tumors• MiscellaneousNon traumaticemergency
    45. 45. Priapism…• The diagnosis– Usually obvious from the history• Duration of erection >4 hours?• Is it painful or not?.• Previous history and treatment of priapism ?• Identify any predisposing factors and underlying cause– Examination• Erect, tender penis (in low-flow priapism).• Characteristically the corpora cavernosa are rigid andthe glans is flaccid.• Abdomen for evidence of malignant disease• DRE: to examine the prostate and check anal tone.Non traumaticemergency
    46. 46. Priapism…• Investigations:– CBC (white cell count and differential, reticulocytecount)– Hemoglobin electrophoresis for sickle cell test– Urinalysis including urine toxicology– Blood gases taken from either corpora,• low-flow (dark blood; pH <7.25 (acidosis); pO2<30mmHg (hypoxia); pCO2 >60mmHg (hypercapnia))• high-flow (bright red blood similar to arterial blood atroom temperature; pH = 7.4; pO2 >90mmHg; pCO2<40mmHg)Non traumaticemergency
    47. 47. Priapism…– Colour flow duplex ultrasonography incavernosal arteries:• Ischaemic (inflow low or nonexistent)• Nonischaemic (inflow normal to high).– Penile pudendal arteriography
    48. 48. Priapism…• Treatment:– Depends on the type of priapism.– Conservative treatment should first be tried– Medical treatment– Surgical treatment.– Treatment of underlying cause• →→ It is important to warn all patientswith priapism of the possibility ofimpotence.Non traumaticemergency
    49. 49. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal injuries2) Ureteral injuries3) Bladder injuries4) Urethral Injuries5) Testicular injuries
    50. 50. RENAL INJURIES• The kidneys relatively protected fromtraumatic injuries.• Considerable degree of force is usuallyrequired to injure a kidney.Traumaticemergency
    51. 51. • Mechanisms and cause:– Blunt• direct blow or acceleration/ deceleration (roadtraffic accidents, falls from a height, fall onto flank)– Penetrating• knives, gunshots, iatrogenic, e.g., percutaneousnephrolithotomy (PCNL)
    52. 52. Renal injuries…• Indications for renal imaging:– Macroscopic hematuria– Penetrating chest, flank, and abdominal wounds– Microscopic [>5 red blood cells (RBCs) per highpowered field] or dipstick hematuria ahypotensive patient (SBP <90mmHg )– A history of a rapid acceleration or deceleration– Any child with microscopic or dipstick hematuriawho has sustained trauma.Traumaticemergency
    53. 53. Renal injuries…• What Imaging Study?– IVU:• replaced by the contrast-enhanced CT scan• On-table IVU if patient is transferred immediatelyto the operating theatre without having had a CTscan and a retroperitoneal haematoma is found,– Spiral CT: does not allowaccurate stagingTraumaticemergency
    54. 54. Renal injuries…– Renal US:• Advantages:– can certainly establish the presence of two kidneys– the presence of a retroperitoneal hematoma– power Doppler can identify the presence of blood flow in therenal vessels.• Disadvantages:– cannot accurately identify parenchymal tears, collectingsystem injuries, or extravasations of urine until a later stagewhen a urine collection has had time to accumulate.– Contrast-enhanced CT:• the imaging study of choice• accurate, rapid, images other intra-abdominalstructuresTraumaticemergency
    55. 55. Renal injuries…• Staging (Grading)• American Association for the Surgery ofTrauma Organ Injury Severity ScaleTraumaticemergency
    56. 56. Renal injuries…• Management:– Conservative:• Over 95% of blunt injuries• 50% of renal stab injuries and 25% of renalgunshot wounds (specialized center).• Include:– Wide Bore IV line.– IV antibiotics.– Bed rest– serial CBC (Htc)– F/up US &/or CT.– 2-3 wks.Traumaticemergency
    57. 57. Renal injuries…• Surgical exploration:– Persistent bleeding (persistent tachycardiaand/or hypotension failing to respond toappropriate fluid and blood replacement– Expanding perirenal haematoma (again thepatient will show signs of continued bleeding)– Pulsatile perirenal haematomaTraumaticemergency
    58. 58. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal injuries2) Ureteral injuries3) Bladder injuries4) Urethral Injuries5) Testicular injuries
    59. 59. URETERIC INJURIES• The ureters are protected from externaltrauma by surrounding bony structures,muscles and other organs• Causes and Mechanisms :– External Trauma– Internal TraumaTraumaticemergency
    60. 60. Ureteric injuries…• External Trauma:– Rare– Severe force is required– Blunt or penetrating.– Blunt external trauma severe enough to injurethe ureters will usually be associated withmultiple other injuries– Knife or bullet wound to the abdomen or chestmay damage the ureter, as well as otherorgans.Traumaticemergency
    61. 61. Ureteric injuries…• Internal Trauma– Uncommon, but is more common than externaltrauma– Surgery:• Hysterectomy, oophorectomy, and sigmoidcolectomy• Ureteroscopy• Caesarean section• Aortoiliac vascular graft placement,• Laparoscopic procedures,• Orthopedic operationsTraumaticemergency
    62. 62. Ureteric injuries…• Diagnosis:– Requires a high index of suspicion– Intraoperative:– Late:• 1. An ileus: the presence of urine within the peritoneal cavity• 2. Prolonged postoperative fever or overt urinary sepsis• 3. Persistent drainage of fluid from abdominal or pelvicdrains, from the abdominal wound, or from the vagina.• 4. Flank pain if the ureter has been ligated• 5. An abdominal mass, representing a urinoma• 6. Vague abdominal pain• 7. The pathology report on the organ that has been removedmay note the presence of a segment of ureter!Traumaticemergency
    63. 63. Ureteric injuries…• Treatment options:– JJ stenting– Primary closure of partial transection of the ureter– Direct ureter to ureter anastomosis– Reimplantation of the ureter into the bladder(ureteroneocystostomy), either using a psoas hitch ora Boari flap– Transureteroureterostomy– Autotransplantation of the kidney into the pelvis– Replacement of the ureter with ileum– Permanent cutaneous ureterostomy– NephrectomyTraumaticemergency
    64. 64. Ureteric injuries…Traumaticemergency
    65. 65. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal injuries2) Ureteral injuries3) Bladder injuries4) Urethral Injuries5) Testicular injuries
    66. 66. BLADDER INJURIES• Causes:– Iatrogenic injury• Transurethral resection of bladder tumour (TURBT)• Cystoscopic bladder biopsy• Transurethral resection of prostate (TURP)• Cystolitholapaxy• Caesarean section, especially as an emergency• Total hip replacement (very rare)– Penetrating trauma to the lower abdomen or back– Blunt pelvic trauma—in association with pelvic fracture or‘minor’ trauma in the inebriated patient– Rapid deceleration injury—seat belt injury with full bladderin the absence of a pelvic fracture– Spontaneous rupture after bladder augmentationTraumaticemergency
    67. 67. Types of PerforationA-intraperitonealperforationthe peritoneumoverlying thebladder, has beenbreached along withthe wall of thebladder, allowingurine to escape intothe peritoneal cavity.Traumaticemergency
    68. 68. B- extraperitonealperforationthe peritoneum is intactand urine escapes intothe space around thebladder, but not intothe peritoneal cavity.Traumaticemergency
    69. 69. Bladder injuries…• Presentation:– Recognized intraoperatively– The classic triad of symptoms and signs thatare suggestive of a bladder rupture• suprapubic pain and tenderness, difficulty orinability in passing urine, and haematuriaTraumaticemergency
    70. 70. Bladder injuries…• Management:– Extraperitoneal• Bladder drainage +++++• Open repair +++– Intra peritoneal :• open repair…why?– Unlikely to heal spontaneously.– Usually large defects.– Leakage causes peritonitis– Associated other organ injury.Traumaticemergency
    71. 71. Urological Emergencies1) Non traumatic1. Hematuria2. Renal Colic3. Urinary Retention4. Acute Scrotum5. Priapism2) Traumatic1) Renal injuries2) Ureteral injuries3) Bladder injuries4) Urethral Injuries5) Testicular injuries
    72. 72. URETHRAL INJURIES• ANTERIOR URETHRAL INJURIES• POSTERIOR URETHRAL INJURIESTraumaticemergency
    73. 73. ANTERIOR URETHRALINJURIES• Rare• Mechanism:– The majority a result of a straddle injury inboys or men.– Direct injuries to the penis– Penile fractures– Inflating a catheter balloon in the anteriorurethra– Penetrating injuries by gunshot wounds.
    74. 74. Ant. Urethral injuries…• Symptoms and signs:– Blood at the end of the penis– Difficulty in passing urine– Frank hematuria– Hematoma may around the site of the rupture– Penile swellingTraumaticemergency
    75. 75. Ant. Urethral injuries…• Diagnosis:– Retrograde urethrography• Contusion: no extravasation of contrast:• Partial rupture : extravasation of contrast, withcontrast also present in the bladder:.• Complete disruption: no filling of the posteriorurethra or bladderTraumaticemergency
    76. 76. Ant. Urethral injuries…• Management– Contusion• A small-gauge urethral catheter for one week– Partial Rupture of Anterior Urethra• No urethral catheterization• Majority can be managed by suprapubic urinary diversion forone week• Penetrating partial disruption (e.g., knife, gunshot wound),primary (immediate) repair.– Complete Rupture of Anterior Urethra• patient is unstable a suprapubic catheter.• patient is stable, the urethra may either be immediately repairedor a suprapubic catheter– Penetrating Anterior Urethral Injuries• generally managed by surgical debridement and repairTraumaticemergency
    77. 77. POSTERIOR URETHRALINJURIES• Great majority of posterior urethral injuriesoccur in association with pelvic fractures• 10% to 20% have an associated bladderrupture• Signs– Blood at the meatus, gross hematuria, andperineal or scrotal bruising.– High-riding prostate
    78. 78. • Classification of posterior urethral injuries– type I:(rare )• stretch injury with intact urethra– type II : (25%)• partial tear but some continuity remains)– type III:(75%)• complete tear with no evidence of continuity– In women, partial rupture at the anteriorposition is the most common urethral injuryassociated with pelvic fracture.Traumaticemergency
    79. 79. Traumaticemergency
    80. 80. • Management:– Stretch injury (type I) and incomplete urethraltears (type II) are best treated by stenting witha urethral catheter.– Type III• Patient is at varying risk of urethral stricture,urinary incontinence, and erectile dysfunction (ED)• Initial management with suprapubic cystotomy andattempting primary repair at 7 to 10 days afterinjury.Traumaticemergency
    81. 81. Thank you…

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