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GENITOURINARY EMERGENCIES
- 1. GENITOURINARY EMERGENCIES Presenter : Dr. Athirah Binti Amran
- 2. OUTLINES 1) RENAL CALCULI 2) TESTICULAR TORSION 3) EPIDIDYMITIS 4) PRIAPISM 5) FOURNIER GANGRENE 6) HERNIA 7) HEMORRHOIDS
- 5. RISK FACTORS • Diet • Dehydration • UTI • Hypercalcemia • Gout • Pregnancy • FMH of stone • Obesity
- 6. SIGNS AND SYMPTOMS • Asymptomatic • Back pain • Renal colic • Dysuria • Hematuria • Nausea • Sweating
- 7. Investigations • UFEME • FBC • RP • Electrolytes (Ca,Mg,Po) • Uric acid • Urine c+s • Xray • Ultrasound • CT Urogram
- 9. • any HYDRONEPHROSIS causing obstructive uropathy needs intervention. • by STENTING/NEPHROSTOMY
- 10. MANAGEMENT * Majority passed out spontaneously 1) HYDRATION 2) ANALGESICS - NSAIDS (Diclofenac) - Morphine - Opiods 3) Urine alkalinizer: Ural sachet 1/1 TDS / Mist potassium citrate 10ml TDS 4) Surgery -Lithotripsy (Retrograde uretero pyeloscopic laser/shockwave/percutaneous) -Open 5) Treat other underlying causes
- 11. RED FLAGS • Fever or other features, e.g. rigors - consistent with systemic infection which can lead to life threatening sepsis (admit,drain,iv antibiotics at least 2 weeks ) • Suspected bilateral obstructing stones • Known clinically significant renal impairment • The presence of only one kidney • Pregnancy
- 12. DISCHARGE Advices: • Increase water intake • Reduce salt intake • Maintain a healthy diet • Avoid fructose-containing soft drinks • Pain management • TCA STAT if persistent pain/vomitting
- 13. SCROTAL PAIN
- 14. ORIGIN PRIMARY REFERRED testicular torsion appendicitis epididymitis bowel fournier gangrene renal colic/pyelonephritis trauma AAA skin lesion
- 15. TESTICULAR TORSION • True surgical emergency • Most common in adolescent males • Sudden onset of severe unilateral scrotal pain is testicular torsion untill proven otherwise (seconds or minutes) • Twisting of spermatic cord leads to arterial ischemia causing infarction of the testicle • +/- Associated systemic symptoms (nausea,vomitting) • Rapid recognition and treatment
- 16. Torsion of testicle Torsion of appendages
- 18. SIGNS • Hemiscrotum swelling • Redness overlying skin • Tenderness • Elevated testis • Loss of cremasteric reflex
- 19. Cremasteric Reflex • The reflex is elicited by : (1) stroking the ipsilateral inner thigh with a tongue depressor or gloved hand (2) the elevation of the testicle through contraction of the cremasteric muscle. • Afferent (sensory) : femoral branch of genitofemoral and ilioinguinal nerve • Efferent (motor): genital branch of genitofemoral branch
- 20. Investigations • FBC • UFEME • Doppler US
- 22. EPIDIDYMITIS • Most common complaint of scrotal pain • Differentiated from testicular torsion • Gradual progressive inflammatory onset of pain (hours or days) • Red ,swollen and tenderness • +/- Urinary symptoms • Duck waddle gait • Prehn’s sign : relief of pain with scrotal elevation • Investigations: UFEME ,Urine c+s , Ultrasound
- 23. RISK FACTORS • Sexually intercourse with more than one partner and not using condom • Uncircumcised • Recent surgery in urinary tract • Structural abnormalities in urinary tract • Regular use of urethral catheter
- 26. Management 1) Antibiotics 2) Analgesics 3) Scrotal support 4) Avoid physical strain
- 29. PRIAPISM
- 32. PRIAPISM LOW FLOW(Ischaemic): - Stagnant, oxygen-poor, acidic blood accumulates in the corpora, resulting in “ischemic” pain. Ischemia resulting from prolonged erection may lead to irreversible cellular damage, permanent fibrosis, and impotence. STEPWISE FASHION: therapeutic aspiration +/- irrigation /intracavernous sympathomimetic agents HIGH FLOW(Non Ischaemic): persistent painless erection continuous inflow of oxygen-rich blood through traumatic arterial- cavernosal fistulae Evidence of trauma
- 33. Ischemic priapism (low-flow priapism) • More common type. • Cause: Non-trauma, Sickle cell anemia may cause episodes of ischemic priapism, i.e. recurrent priapism (stuttering priapism). • Blood not being able to leave the penis. • Rigid penile shaft, but glans is soft. • Progressive penile pain. • May require penile aspiration (drainage of the corpora). • Mx: • Oxygenation • Analgesics (eg, intravenous morphine) • Hydration • Alkalization • Exchange transfusions • Emergent surgical decompression: Advocated by most experts when conservative management fails
- 35. Non-ischemic priapism (high-flow) • Usually caused by trauma to the penis, pelvis or perineum (straddle injury) • Excessive arterial blood flow into the penis. • Well-oxygenated corpora • Usually painless. • Erect but not fully rigid penile shaft. • May obliterate causative fistula with arterial embolization • Mx: – Locate causative fistula- obliterate by selective arterial embolization using an autologous blood clot, gelatin sponge, microcoils, or chemicals. – surgery
- 36. FOURNIER’S GANGRENE • synergistic polymicrobial necrotizing fasciitis of the perineum and genitalia with subsequent vascular thrombosis and tissue necrosis. • pain out of proportion to physical findings • elderly, diabetic, or other immuno-compromised • C/P: Perineal pain, swelling, redness, bruising, fever, vomiting, lethargy, weakness (“systemic” symptoms) • may rapidly progress to fulminant sepsis with shock
- 38. Antibiotics
- 39. HERNIA • Protrusion of organ through defect in abdominal wall • More frequently seen in ELDERLY • Strangulation can occur in : • INGUINAL • FEMORAL • OBTURATOR • UMBLICAL
- 40. SIGNS AND SYMPTOMS • Severe pain initially at the hernia site then become generalised • Persistent vomiting • Abdominal discomfort • Constipation • Recent sudden increase of lump • Rebound tenderness • Cough impulse absent • Irreducible • DULL in case of OMENTUM • RESONENT in case of GUT • SILENT ABDOMEN in case PERITONITIS (PARALYTIC ILEUS)
- 41. INCARCERATED OBSTRUCTED STRANGULATED adhesion between the sac and content of hernia viscus trapped within sac viscus trapped within sac no obstruction present of obstruction present of obstruction blood supply intact blood supply intact blood supply compromised irreducible without obstruction/strang ulation + CARDINAL SIGNS of intestinal obstruction : - pain -vomitting -abdominal distension -constipation impaired viability of bowel
- 42. • Indication for admission: 1) symptomatic irreducible 2) obstructed hernia 3) strangulated hernia 4) incarcerated hernia (Any hernia that warranted for emergency hernioplasty)
- 43. MANAGEMENT OF INCARCERATED HERNIA • 70% of incarcerated hernia can be reduced manually • Manual reduction can be attempted in less than 4- 8hours without suspicious strangulation - Place in supine position with hip padded at 30 degree with hip and knee flexed - Possible complication: 1) Intestinal rupture 2) Peritonitis 3) Testicular rupture - Post reduction: proceed for operation within 3-4 days to avoid recurrence
- 44. SURGERY: • 1. HERNIOTOMY • 2. BASSINI REPAIR • 3. LIGHT WEIGHT SYNTHETIC MESH
- 45. HEMORRHOIDS • Symptomatic anal cushions. • helps with finest and last closure of anal canal • rich blood supply with direct open into venous space • venous bleeding with bright colour? - direct anastomosis between arterial and venous system • 3 classical sites: - 3/7/11 o clock • Most common age : 45-65 years old
- 46. RISK FACTORS • Straining and constipation • Pregnancy • Obesity • Prolonged sitting • Spinal cord injury. • Rectal surgery • Episiotomy • Anal intercourse • IBD PR bleeding +>40 years OR Risk factor +< 40 years = need for referral + further workup (colonoscopy + CT)
- 49. PHYSICAL EXAMINATION - Per Abdomen - PR : check for any mass/tenderness/fluctuance - Proctoscope: importance to differentiate internal vs external hemorrhoids
- 51. Management • In ETD,Gauze soaked with D10 -hyperosmotic agent --> reduce swelling -trial manual reduction of hemorrhoids • Analgesics - Paracetamol - Ibuprofen • Stool softener -syrup lactulose 15ml ON • Bioflavonoids - T. dafflon 11/11 TDS X4/7 - T. dafflon 11/11 BD X3/7 - T. dafflon 11/11 OD X1/52 • Reduce pain • Reduce bleeding • Reduce itchiness
- 53. Banding (good for grades I to III hemorrhoids) surgical (hemorrhoidectomy) - open (miligan morgan): leave mucosa open - closed (ferguson): close mucosa with suture - indications: 1) 3rd and 4th degree hemorrhoids 2) 2nd degree that not resolve by non operative treatments 3) Fibrosed hemorrhoids
- 57. REFERENCES • Bailey & Love’s Short Practice of Surgery, 26th edition • https://www.racgp.org.au/download/documents/AFP/2011/ October/201110macneil.pdf • https://www.aafp.org/afp/2018/0201/p172.html
- 58. PRIAPISM
- 60. Ischemic priapism (low-flow priapism) • More common type. • Cause: Non-trauma, Sickle cell anemia may cause episodes of ischemic priapism, i.e. recurrent priapism (stuttering priapism). • Blood not being able to leave the penis. • Rigid penile shaft, but glans is soft. • Progressive penile pain. • May require penile aspiration (drainage of the corpora). • Mx: • Oxygenation • Analgesics (eg, intravenous morphine) • Hydration • Alkalization • Exchange transfusions • Emergent surgical decompression: Advocated by most experts when conservative management fails
- 61. Nonischemic priapism (high-flow priapism) • Usually caused by trauma to the penis, pelvis or perineum (straddle injury) • Excessive arterial blood flow into the penis. • Well-oxygenated corpora • Usually painless. • Erect but not fully rigid penile shaft. • May obliterate causative fistula with arterial embolization • Mx: – Locate causative fistula- obliterate by selective arterial
Editor's Notes
- BPH:a proliferative process of both stomal and epithelial elements of the prostate, Age dependent high risk for BPH progression (PSA levels between 1.4–10.0 g/dL, prostate volume > 30 cm3, IPSS > 13, and PVR > 350 mL)
- sudden and severe loin pain symptom-free between these episodes typically appear restless and unable to find a comfortable position
- stone less than 4 mm: passed spontaneously , no need surgery, follow up 2-3 weeks if still not passed stone more than 4mm: persist more than 6 weeks, surgery calcium containing stone visible on xray uric acid stone: radiolucency
- refers to the structural or functional changes in the urinary tract that impede normal urine flow.
- 1)why nsaid? prostaglandin cause smooth muscle spasm so diclo inhibit PG production+ longer duration ex: diclofenac :IM/IV/oral/rectal dose: 50-75mg stat may repeat 30 minutes later contra for recent MI 2) morphine 5-10mg good for any contra for nsaids/pregnant Alpha blocker for BPH: relax the muscle of the prostate and bladder neck, which allows urine to flow more easily. There are at least five medications in this category: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo) lithotripsy video: https://youtu.be/-urxndxfHns Retrograde uretero pyeloscopic laser: less than 2cm, lower pole shockwave: less than 2cm, middle and upper pole percutaneous: more than 2 cm, staghorn urine alkalinizer: make urine less acidic so prevent stone formation https://bpac.org.nz/bpj/2014/april/colic.aspx https://www.racgp.org.au/download/documents/AFP/2011/October/201110macneil.pdf
- Absolute indications are: • infection (pyonephrosis) • renal failure. Relative indications are: • ongoing or recurrent pain • stone larger than 6 mm, unlikely to pass • occupational/social. Renal colic during pregnancy The incidence of renal colic is not thought to be increased in women who are pregnant.1 However, the composition of urinary stones in women who are pregnant may be different, e.g. often containing calcium phosphate.1 Complications if renal colic does occur during pregnancy include: premature rupture of membranes, pre-term labour and delivery, pregnancy loss, mild pre-eclampsia and infection. All pregnant women with suspected renal colic should therefore be referred to an Urologist or Obstetrician.1 The possibility of ectopic pregnancy should be excluded during the history and examination. Renal and bladder ultrasound is the investigation of choice in women who are pregnant, but interpretation of imaging may be complicated if the stone is not readily visible due to hydronephrosis, which occurs naturally in up to 90% of pregnant women.1 Transvaginal ultrasonograpy, simple radiography and intravenous urography are investigations that may also be used if necessary.1 The majority of urinary stones in women who are pregnant will pass spontaneously, so management is generally watchful waiting with appropriate pain management. Of the stones that do not pass during pregnancy, many will pass after delivery; usually within the first month.1 Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided during the first and third trimester of pregnancy due to potentially teratogenic adverse effects early in pregnancy and an increased risk of miscarriage or premature closure of the ductus arteriosus later in pregnancy.1 Short-term oral morphine can be used if required for ongoing pain.6, 12 There is no evidence of alpha-blockers causing teratogenicity.6 Urinary stone passage may be accelerated by the off-label use of doxazosin if the potential benefits of an early stone passage, which will reduce the need for analgesia, outweighs any risks.1, 6 If the urinary stone does not pass or if there are signs of infection, then management depends on the clinical situation, e.g. the stage of pregnancy. Temporary drainage of the ureter with delayed stone treatment, urgent or definitive stone treatment via ureteroscopy, may be considered
- Examples of foods rich in oxalate include: tea, chocolate, spinach, beetroot, rhubarb, peanuts, cola and supplementary vitamin C purine-rich meat (e.g. red meat and offal) and seafood (e.g. shellfish and oily fish)
- it is important to consider acute GU pathology in any male patient presenting with seem_x0002_ingly isolated pain to the aforementioned anatomic regions. For instance, always consider GU condi_x0002_tions in the differential for any male with a present_x0002_ing complaint of abdominal, inguinal, or flank pain
- lack of firm testicular attachment by the tunica vaginalis subjects it to potential horizontal or vertical rotation around or within the spermatic cord, resulting in testicular torsion. tend to writhe on the gurney or pace about the examination room as they cannot find a position of comfort.
- Missed or delayed diagnosis of testicular torsion threatens testicular viability and future fertility
- intermittent and colicky ? rapid onset and offset due to torsion and detorse spontaneously
- age: >13 years old natural progression is to initially affect only the epididymis and then progress to the ipsilateral testicle as well (epididymo-orchitis) constant and progressive pain:inflammatory process minimize activity, as the slightest degree of movement may exacerbate their pain, while rest and elevation bring relief urinary symptoms: hematuria/dysuria/urgency/frequency/hesitancy +/- systemic sx: fever,malaise, nausea(but usually in advanced degree of infection
- •Practicing safe sex •Treating sexual partners as a contact to epididymitis •Repeat screening for STI ~ 2 months after initial testing for re-infection •Abstain from sex until the individual & sex partners have completed treatment
- Involuntary, prolonged >4H Unrelated to sexual stimulation Unrelieved by ejaculation
- PREDISPOSING FACTORS • Diabetes mellitus • Chronic alcoholism • Malnutrition • Obesity • Liver cirrhosis • Poor personal hygiene • Immunosuppression: • Chronic steroid use • Organ transplantation • Chemotherapy for malignancy • HIV/AIDS • Tuberculosis • Syphilis
- Normal weakness; found in everyone and related to the anatomical configuration of the area such a place where vessel or viscus enters or leaves the abdomen / where there are no muscles, only scar tissue (e.g. umbilicus) / muscles fail to overlap Abnormal weakness; congenital or acquired as a result of trauma or disease.
- *strangulation: redness and swelling plan for immediate surgery
- DIFFER THROMBOSIS INTERNAL VS EXTERNAL HEMORRHOIDS? BOTH WILL PRESENT WITH PAINFUL RECTAL BLEEDING AND ITCHINESS DO PROCTOSCOPE , SEE THE ORIGIN
- pcm 1g qid ibuprofen 200mg od
- sitz bath: water +baking soda/salt --> reduce pain witch hazel(astringents) zinc oxide (protectants) phenylephrine ( decongestants) corticosteroids
- banding: within two to three days of symptom onset achieve symptom relief
- transillumination: shine light through posterior scrotal wall
- Involuntary, prolonged >4H Unrelated to sexual stimulation Unrelieved by ejaculation