This document provides information about acute cholecystitis, cholangitis, and their management. It begins with the anatomy of the gallbladder and discusses the pathogenesis of acute cholecystitis, typically caused by gallstones obstructing the cystic duct. Signs and symptoms include right upper quadrant pain and fever. Ultrasound is often used for diagnosis. Treatment involves antibiotics, analgesia, and early cholecystectomy to remove the gallbladder. Complications of acute cholangitis from bacterial infection of the bile ducts are also reviewed.

1. Acute Cholecystitis &
Cholangitis
1

2. Gall bladder Anatomy
• Pear-shaped sac, 7 to 10 cm
long, 30 to 50 mL
• Differs histologically from
the rest of the GIT
( Lacks a muscularis mucosa
and submucosa.)
• Along with bile ducts, and
the sphincter of Oddi, Store
and regulate bile flow.
• Concentrate and store
hepatic bile and deliver bile
into the duodenum in
response to a meal.
2

3. • Could be:
 Acute or chronic inflammation
 Calculus or acalculous
• Risk factors: obstruction and bile stasis
• Bacterial growth common but secondary
3
Cholecystitis

4. Acute Cholecystitis
Pathogenesis
• Gallstones in 90% to 95% of cases.
• Obstruction of the cystic duct by a gallstone
( Only occasionally )
↓↓↓
Gallbladder distention, inflammation, and wall edema
↓↓↓
Hyperemia and patchy necrosis the mucosa
( - Ischemia and necrosis of the GB wall – 5 – 10%)
( - Gallstone is dislodged and inflammation resolves)
4

5. Pathogenesis…
When the GB remains obstructed and secondary bacterial
infection supervenes
↓↓↓
Acute gangrenous cholecystitis develops
Abscess or empyema forms within the gallbladder.
Perforation of ischemic areas (Rare)
↓↓↓
- Usually contained in the subhepatic
- Free perforation with peritonitis,
- Intrahepatic perforation with intrahepatic abscesses
- Perforation into adjacent organs (duodenum or colon)
( Cholecystoenteric Fistula)
5

6. Acute Cholecystitis: Diagnosis
History
• Compatible with chronic cholecystitis – 80%.
• Begins as an attack of biliary colic, but, more severe,
unremitting and may persist for several days.
• The pain is typically in the right upper quadrant or
epigastrium and may radiate to the right upper part of
the back or the interscapular area.
• Fever, anorexia, nausea, and vomiting
Physical Examination
• Jaundice – CBD Stones or Mirizzi’s syndrome
• Focal tenderness and guarding in the RUQ
• A mass (gallbladder and adherent Omentum), is
occasionally palpable.
• Murphy’s sign
6

7. Acute Cholecystitis: Diagnosis …
• Leukocytosis (12,000 –15,000
cells/mm3, >20,000
cells/mm3)
• Some may have a normal
WBC.
• Serum liver chemistries -
Usually normal
• Abdominal U/S
- Sensitivity and specificity of
95%.
- Presence or absence of stones,
- Thickening of the gallbladder
wall and pericholecystic fluid
- Sonographic Murphy’s sign 7

8. Acute Cholecystitis: Diagnosis …
• Elderly and diabetic patients may have a
subtle presentation
↓↓
Delay in diagnosis.
↓↓
• Increased incidence of complications
• 10-fold the mortality rate compared to that of
younger and healthier patients.
8

9. DDx
 perforated PUD
 appendicitis
 acute pancreatitis
 hepatitis
 lobar pneumonia
 pyelonephritis
 AMI
9

10. Acute Cholecystitis: Management
• IV fluids
• Antibiotics
- Cover gram-negative aerobes and anaerobes
- 3rd generation cephalosporin with good
anaerobic coverage or
- Second-generation cephalosporin combined
with metronidazole or
- Aminoglycoside with metronidazole or
- Ciprofloxacin with metronidazole
• Analgesia.
10

11. Acute Cholecystitis: Management …
• Definitive treatment – Cholecystectomy
• Timing of cholecystectomy
- Early cholecystectomy - within 2 to 3 days of
the illness Vs Interval/delayed
cholecystectomy ( 6 to 10 weeks after initial
medical treatment)
• When patients present late, or unfit for surgery,
treat with antibiotics, then cholecystectomy
scheduled for 2 months later.
11

12. Acute Cholecystitis: Management …
Fail to respond to initial medical therapy
↓↓ ↓↓
Those fit for Surgery Not fit for surgery
↓↓ ↓↓
Cholecystectomy Percut. cholecystostomy or
Open cholecystostomy (LA)
12

13. Acute Cholecystitis: Management …
After percutaneous or open cholecystostomy
↓ ↓
Failure to improve Respond after cholecystostomy
↓ ↓
Gangrene of the GB or Remove the tube after cholangiography
Perforation ↓
↓ Schedule for Cholecystectomy
Surgery is unavoidable.
• For the rare patients who can’t tolerate surgery,
the stones can be extracted via the
cholecystostomy tube before its removal
13

14. CHRONIC CHOLECYSTITIS
 Incompletely resolved AC
 Contracted fibrotic GB
 Dyspepsia …belching ,flatus ,abdominal bloating
,fullness epigastric burning & Nausea & Vomiting
Management
- Cholecystectomy
14

15. ACALCULAS CHOLECYSTITIS
 pts with major abdominal & thoracic surgery & TPN
 recovering from major trauma
 severe burns
Acute emphysematous cholecystitis
 serious form of Ac.
 Characterized by gas in the lumen or wall of the GB
 In the elderly pts
 25% have DM
 CF as AC but pts are more toxic
 DX ….air in the gallbladder or wall on plain abdominal
Film
15

16. INVESTIGATION AND DIAGNOSIS
1. History & P/E
2. Standard base line investigation
- CBC
- LFT
-Serum Amylase ….. Acute pancreatitis
- Blood culture
3. Plain radiography
- 10% of GS are radio opaque
-not routinely indicated
-in acutely ill pts to R/O perforated viscus
- Gas in the GB or BD
16

17. 4. ULTRASOUND
primary screening
procedure
 can show us….
 Calculi with acoustic
shadow
 thickened wall ,
 distension of GB
 localized pericholecystic
collection
 dilated CBD
17

18. 5. Oral cholecystography (OCG)
- replaced by U/S
- used to assess GB function
6. IV cholangiography
-to see extrahepatic biliary tree
-effective in jaundiced pts.
7. CT & MRI
- to R/O pancreatic head tumour
8. Scintography … to Dx acute cholecystitis
18

19. 9. PTC & ERCP
- in pts with comp. acute biliary dd. & jaundice
- clotting studies before PTC
- prophylactic antibiotics
indicated in pts.
- Known GBS with increased bilirubin >10 mg/dl
- Symptomatic pts with previous cholecystectomy
- Pts with biliary Sx & inconclusive evidence
19

20. Acute Cholangitis
• Bacterial infection superimposed on an obstruction
of the biliary tree
• Most commonly from a gallstone, but it may be
associated with neoplasm or stricture.
• Biliary tract obstruction  Elevated intraluminal
pressure Infection of bile
• Bacteria gain access to the biliary tree by retrograde
ascent from the duodenum or from portal venous
blood.
• Primary sclerosing cholangitis
- inflammation and fibrosis of the intrahepatic and
extrahepatic bile ducts (Autoimmune mechanism).
20

21. • The most common pathogens isolated in blood
cultures
• E coli (59%),
• Klebsiella species (16%),
• Pseudomonas aeruginosa (5%),
• Enterococcus species (4%).
21

22. • Ranges from mild symptoms to fulminant
overwhelming sepsis.
• History of abdominal pain or symptoms of
gallbladder colic before
• Charcot's Triad consists of fever, RUQ pain, and
jaundice.
• Reynolds Pentad - Charcot's triad + ( Mental status
changes and sepsis )
• Previous history of diagnosed Gallstones, CBD
stones
• History of Recent cholecystectomy
• Endoscopic manipulation or ERCP, cholangiogram 22

23. • CBC: Leukocytosis, 79% had a WBC greater than
10,000/mL,
• Electrolyte panel with renal function.
• Calcium level is necessary to check if pancreatitis
• LFT- Hyperbilirubinemia and increased ALP
• PT, PTT – Sepsis related DIC
• Pancreatic enzymes - elevations suggest bile duct
stones caused the cholangitis, with or without
gallstone pancreatitis.
• Biliary and blood cultures cultures
• Abdominal U/S, CT scan
23

24. 1. Medical Therapy
• Broad-spectrum IV antibiotics
• Correction of fluid and electrolyte imbalances
• Analgesics
2. Surgical Therapy - Decompression and drainage of
the biliary system.
• Endoscopic biliary drainage and decompression
• Surgical decompression – If endoscopic or
transhepatic drainage is unsuccessful or
unavailable.
24

25. Complications
• Liver failure, hepatic abscesses, and micro
abscesses
• Bacteremia (25-40%); gram-negative sepsis
• Acute renal failure
• Catheter-related problems in patients treated
with percutaneous or endoscopic drainage:
• Bleeding (intra-abdominally or percutaneously)
• Catheter-related sepsis
• Fistulae
• Bile leak (intraperitoneally or percutaneously)
25

26. Management of Urologic Emergencies
• Acute Scrotum
• Bladder and Uretheral Injury
• Acute Urinary Retention
• Phimosis and Paraphimosis
• Priapism and Penile Fracture
26

27. Acute SCROTUM
• Acute onset of scrotal pain and or swelling
• With or without fever
• Anorexia, Nausia and vomitting
27

28. Causes of Acute Scrotum
• Ischemia:
- Torsion of the testis ( Intravaginal Vs Extravaginal ),
(Prenatal or Neonatal)
- Appendiceal torsion ( testis or epididymis )
- Testicular infarction due to other vascular insult
(cord injury, thrombosis)
• Trauma:
- Testicular rupture
- Intratesticular hematoma,
- Testicular contusion
- Hematocele
28

29. Causes …
• Infectious conditions:
- Acute epididymitis
- Acute orchitis
- Acute epididymorchitis
- Abscess (intratesticular,
intravaginal, scrotal )
-Gangrenous infections
(Fournier’s gangrene)
• Inflammatory conditions:
- Henoch-Schonlein purpura
(HSP)
- Vasculitis of scrotal wall
- Fat necrosis
• Hernia:
- Incarcerated, strangulated
inguinal hernia, with or
without associated testicular
ischemia
29

30. Causes ….
• Acute on chronic events:
- Spermatocele ( rupture or hemorrhage)
- Hydrocele (rupture, hemorrhage or infection)
- Testicular tumor ( with rupture, hemorrhage,
infarction or infection)
- Varicocele
30

31. 1. Testicular Torsion
Testicular Anatomy
• The normal testis is oriented
in the vertical axis and the
epididymis is above the
superior pole in the
posterolateral position.
• Tunica Vaginalis
• Cremasteric reflex:
Stroking/pinching the inner
thigh should result in
elevation of > 0.5 cm of the
ipsilateral testicle
31

32. 1. Testicular Torsion …
• Incidence 1:4000
• Only 50% salvageability with testicular loss from
either atrophy or ochidectomy
• Age - 70% occur prenatally and 30% occur
postnatally
• Two peak periods: First year of life and at
puberty
• 10 times more likely in an undescended testis
 Left side is more commonly involved
32

33. 1. Testicular Torsion …
• Most torsions due to
bilateral anatomic
abnormality.
• Tunica vaginalis has a
high insertion about the
spermatic cord.
↓
Bell-clapper deformity
↓
Testis dangles in the
scrotum and is mobile
33

34. 1.Testicular Torsion: Pathophysiology
• Initially venous return is obstructed and then
venous thrombosis is followed by arterial
thrombosis
• Degree of obstruction is a function of the degree
of rotation
• 720° twist is required to compromise flow
through the testicular artery and result in
ischemia.
• Necrosis develops in testicle with complete
obstruction and infarction develops after arterial
thrombosis
34

35. 1. Testicular Torsion…
• Rapid swelling and edema of the testis and
scrotum, followed by scrotal erythema
• Damage proportional to duration/extent of
vascular obstruction
• Testis salvage rate
- ~ 100% in patients who undergo detorsion within
6 hours of the start of pain.
- 20% viability rate if detorsion occurs >12 hours
- Virtually no viability if detorsion is delayed >24 hrs
35

36. 1. Testicular Torsion …
• 40% report a history of similar pain that
resolved spontaneously in the past
• The onset of pain may be preceded trauma,
physical activity, or by no activity (e.g. during
sleep).
• Typically no urinary symptoms
• Sudden onset of scrotal pain, but can be
inguinal or lower abdominal.
• May be constant or intermittent.
• Nausea and Vomiting
36

37. 1. Testicular Torsion ….
• Hemiscrotum is swollen, tender,
firm
• High-riding testis with a transverse
lie is classic sign
• Loss of Cremasteric reflex – almost
universal
• May see the bell-clapper deformity,
with horizontal lie of the
contralateral testicle
• Prehn’s sign: Checking for relief of
scrotal pain by elevating testicle.
• Pain NOT relieved – Negative
Prehn’s test
 Testicular Torsion
37

38. 1. Testicular Torsion: Diagnosis
• Doppler Ultrasound
- Test of choice for Dx of torsion.
- Sensitivity comparable to radioisotope scans (86%-100%)
and greater specificity (100%).
- More rapid and more available than radioisotope scans.
- testicular perfusion is the key to the ultrasound diagnosis
of torsion.
- Tests such as nuclear testicular scans, CT or MRI, have
essentially no role in the contemporary management of
the acute scrotum.
38

39. 1.Testicular Torsion: Management
• Immediate Urologic consultation
for surgical exploration and
possible bilateral orchidopexy if
diagnosis is obvious
• Manual detorsion - Only a
temporizing measure. Endpoint for
successful detorsion is pain relief.
• Most torsions occur lateral to
medial, therefore detorsion should
be attempted in a medial to lateral
direction - “open the book”
maneuver
• Imaging if diagnosis unclear, should
NOT delay exploration if high
suspicion exists
39

40. 1.Testicular Torsion: Management
• Sharply entering the scrotum,
open the tunica vaginalis
• Detorse the testis and wrapp in a
warm, moist gauze.
• The contralateral side then
undergoes orchidopexy to
prevent torsion on that side.
• The affected testis is re inspected
for signs of improved perfusion
(“pinking up”).
40

41. 2. Torsion of Appendage
• Torsion of appendages is more
common than testicular torsion
• Testicular and Epididymal
appendages are vestigial
remnants of the wolffian and
mullerian ducts respectively
• Most frequent in preadolescent
males 3-13yrs
• Cause unclear
• Twisting causes obstruction,
edema and then painful
necrosis
41

42. Testicular Torsion Vs Torsion of Appendix Testis
42

43. 2. Torsion of Appendage
• Discrete, painful testicular mass
• Symptoms less severe than
torsion.
• No nausea, vomiting, or fevers
• Transillumination of scrotum may
reveal the cyanotic appendage as a
pathognomonic blue dot
• U/S should reveal normal to
increased blood flow
43

44. 2. Torsion of Appendage: Management
• Scrotal Support
• Pelvic rest
• Analgesia
• Expect resolution of symptoms in 7-10 days
with degeneration of appendages
44

45. 3. Epididymitis
• Average age 25 years
• Most common misdiagnosis for testicular torsion
• Rarely affects a prepubertal child without an
underlying urinary tract infection
• Result of retrograde ascent of urethral and
bladder pathogens
• Peritubular fibrosis may develop and occlude the
ductules, if bilateral may lead to sterility
45

46. Epididymitis
• In men > 40 yrs, E. coli is the predominant
pathogen.
• Pseudomonas, and gram positive cocci.
• Associated w/ underlying urologic pathology --
Recent GU tract manipulation or bacterial
prostatitis.
• In men < 40, Chlamydia and N. gonorrhea are
the major pathogens
46

47. Epididymitis
• Gradual Scrotal pain, peaks over days
• Low grade fever, average 38 degrees C
• Cremasteric reflex usually preserved
• Due to inflammatory nature of pain, may have
some transient pain relief from scrotal elevation
(Prehn’s Test Positive)
• Localized epididymal swelling initially, then may
progress to single, large testicular mass
• Urethral discharge and voiding symptoms may
be present
47

48. Epididymitis
• Pyuria and bacteriuria on U/A
• Urethral discharge should be
examined for gram stain and
culture
• Leukocytosis between 10,000 -
30,000 cells/ml
• Torsion should not be excluded
by pyuria, fever, or dysuria.
• An equivocal exam demands
Imaging.
• U/S with increased or normal
testicular blood flow is c/w
epididymitis
48

49. Epididymitis: Management
• Sexually acquired: Ceftriaxone 250 mg IM and
Doxycycline 100 mg PO bid x 10d. Treat sexual
partners.
• Nonsexually acquired: TMP-SMX or
Fluoroquinolone x 14d. Check urine C&S.
• Bed rest, scrotal support, analgesics, sitz
baths, and Urology follow up
49

50. Complications of Epididymitis
• Infertility - Sexually transmitted epididymitis
• Abscess - Gonococcal epididymitis
• Chronic epididymitis
• U/S indicated if no response to medical
therapy
50

51. Orchitis
• Acute infection of the testis
• Rare without initial epididymitis, Consider testicular
tumor.
• Bacterial infection secondary to spread from
epididymitis of E. coli, Klebsiella, Pseudomonas
• Viral orchitis – Mumps.
- 4-6 days after onset of parotitis usually.
- 50% of involved testes atrophy but infertility rare
• Syphilis
• Treatment: Antibiotics for bacterial orchitis and local
scrotal measures for viral orchitis
51

52. Testicular Tumor
• Testicular CA – Most common cause of malignancy
to afflict young men
• Average age of incidence is 32 Years
• DDx: Epididymitis and torsion
• Increased incidence with cryptorchidism in
bilateral testes
• Majority are Seminomas, then embryonal cell CA
and teratomas
52

53. Testicular Tumor
• Classic presentation – Painless, firm testicular
mass
• Acute hemorrhage within the tumor can lead to
acute scrotal pain (10%)
• Ultrasound – Distinct Intratesticular Mass
• CXR if suspect Metastases
• Treatment: Immediate Urology referral.
• Radical orchidectomy.
• Cisplatin chemotherapy and Radiation for
seminomas.
53

54. Trauma to scrotum
• Blunt injury may result in:
Testicular rupture,
 Intratesticular hematoma,
 Testicular contusion (bruising) or
 Hematocele (Blood collection within the TV
space).
• Only testicular rupture requires surgical repair.
• Large or painful hematoceles may benefit from
drainage.
54

55. Scrotal Wall Infections
55

56. Strangulated Inguinal Hernia
56

57. Bladder Injury
• protected position of the bladder deep in the
bony pelvis
• Bladder injuries after blunt or penetrating
trauma are rare, (< 2% of abdominal injuries
requiring surgery)
• Usually associated with other severe injuries
• 83- 100% have pelvic fracture, and 6-10% of
patients with pelvic fracture have bladder
injuries.
57

58. Bladder Injury…
• Most (95%- 100%) of patients with bladder injury
will have gross hematuria,
• Only 5% have had only microscopic hematuria
• Gross hematuria is felt to be associated with more
significant injuries (rupture), while
• microhematuria has been seen more commonly
with bladder contusion .
58

59. Bladder Injury …
59

60. Bladder Injury…
• Major diagnostic goals in patients with Bladder
Injury:
1.Determine if urethral injury is present
2. Determine if bladder rupture is present,
• Classify it as intraperitoneal (which requires
exploration and repair) or
• extraperitoneal (which can usually be managed
by bladder drainage alone).
3. Determine if renal injuries are associated and if
they require surgical exploration
60

61. Bladder Injury…
Evaluation
• Local Signs and Symptoms
- Lower abdominal pain, tenderness, and
bruising
- Urethral catheter does not return urine.
- Fever, absence of voiding, peritoneal irritation,
and elevated BUN
• Blood at the Urethral Meatus
- 10-17% of patients with bladder injuries will
have associated urethral rupture. 61

62. Bladder Injury …
Evaluation …
• CBC, BgRh, U/A
• Abdominal Ultrasound/ CT Scan
• Retrograde urethrogram
• Retrograde cystography/Static Cystography
• Computed Tomography (CT) Cystography
62

63. Bladder Injury: MANAGEMENT
1. Intraperitoneal Ruptures
• 25% of all bladder injuries
• Combined with extraperitoneal rupture in
another 12%
• Caused by rapidly rising intraperitoneal pressure
causing the bladder to burst (Dome)
• Operative repair with two-layer closure with
absorbable suture.
• If conservative management is attempted,
persistent urinary leakage can ensue, with
consequent and often fatal peritonitis.
63

64. Bladder Injury…
2. Extraperitoneal Ruptures
• Found alone in 62% of cases
• In combination with intraperitoneal ruptures in
another 12%.
• Result from direct laceration, usually by bone
spicules from the fractured pelvis.
• They can most commonly be managed with
catheter drainage alone,
64

65. 2. Extraperitoneal Ruptures …
• Contraindications for conservative Management
- Bone fragment projecting into the rupture,
- open pelvic fracture, and
- Rectal Perforation
- If clots obstruct the urinary catheter within 48
hours of injury
- Undergoing laparotomy for other reasons
65

66. Uretheral Trauma
Management
66

67. 67

68. Etiologies of Uretheral Injury
68

69. 1. Anterior urethral injuries
 Blunt Trauma
• Bulbar urethra - the most common site injured.
 Penetrating injuries of the penile or bulbar
urethra - Rare.
 Insertion of foreign bodies
 Penile fractures – 10 - 20% of anterior injuries.
 Urethral Instrumentation - affect all segments
of the anterior urethra
69

70. 2. Posterior urethral injuries
• Most often related to pelvic fractures ~ 72%
• Iatrogenic posterior injuries - Irradiation or
surgery to the prostate - 3-25%
• Crush or deceleration impact injury
 Detachments of the perineal membrane
and puboprostatic ligaments
• Bulbomembranous junction, just distal of the
external urethral sphincter.
• Direct transection of the urethra by a bony
fragment - Rare
70

71. 71

72. 2. Posterior urethral injuries …
• Injuries of the bladder neck and prostate - Rare.
• They mostly occur at the anterior midline of both
the bladder neck and prostatic urethra.
• Complete transection of the bladder neck or an
avulsion of the anterior part of the prostate
• Penetrating injuries of the pelvis, perineum or
buttocks
72

73. Morbidities of Uretheral Injuries
• Strictures
• Incontinence and
• Erectile Dysfunction (ED)
73

74. Urethral injuries in females
• Very rare -
• Pelvic Fracture
• Usually a partial longitudinal tear of
the anterior wall.
• Complete avulsion- Extremely rare.
74

75. Diagnosis
• Clinical signs and symptoms
• Blood at the meatus
• An inability to void
• Haematuria and pain on urination
• Urinary extravasation and bleeding
• A ‘high-riding’ prostate
• Difficulty or an inability to pass a urethral
catheter
75

76. Diagnosis …
• Further diagnostic techniques
Retrograde urethrography
• Ultrasound
• CT & MRI
• Cystoscopy
76

77. Management
• Controversial
• Lack of well-conducted clinical trials
to provide a high level of evidence.
77

78. Anterior urethral injuries
Blunt anterior urethral injuries
• Acute or early urethroplasty – not indicated.
• Therapeutic options:
1. ( A trial of ) early endoscopic realignment with
transurethral catheterization
2. Suprapubic diversion
Urinary diversion should be maintained:
 For2 weeks for partial rupture
 For 3 Weeks for complete rupture
78

79. Anterior urethral injuries …
Penetrating anterior urethral injuries
• Immediate exploration and Debridement.
• Spatulation of the urethral ends and primary
anastomosis - defects 1.5 cm in the penile
urethra and 2-3 cm in the bulbar urethra,
• Larger defects or apparent infection,
 a staged repair with urethral marsupialization
and a suprapubic catheter
• Peri- and post-operative antibiotic treatment is
necessary.
79

80. Posterior urethral injuries
Blunt posterior urethral injuries
• Complete Vs Partial
• Timing
• Immediate: < 48 hours after injury
• Delayed primary: 2 days to 2 weeks after injury
• Deferred: > 3 months after injury
80

81. Posterior urethral injuries
Immediate Management
• Urinary diversion
• To monitor urinary output
• To treat symptomatic retention
• To minimize urinary extravasation and its
secondary effects, such as infection and
fibrosis.
• Attempt at urethral catheterization by
experienced hands if SPC not
possible/difficult
81

82. Partial posterior urethral rupture
• Suprapubic or urethral catheter
• Urethrography - at 2-weekly intervals until
healing has occurred.
• A residual or subsequent stricture should be
managed with:
• Internal urethrotomy if it is short and non-
obliterative;
• Anastomotic urethroplasty - long and dense,
complete obliteration or failed internal
urethrotomy
82

83. Complete posterior urethral rupture
• Acute treatment options:
• Immediate realignment:
- Apposition of the urethral ends over a catheter;
- To correct severe distraction injuries rather than to
prevent a stricture
• Immediate urethroplasty:
- Suturing of urethral ends
- Difficult and not recommended
83

84. Delayed primary treatment
• Delayed treatment options:
1. Delayed primary realignment
- Performed within 14 days
(i.e. before fibrosis begins)
2. Delayed primary urethroplasty
- Performed no later than 14 days after the initial
injury
- Only a few reports have been published in the
literature
- Not recommended.
84

85. Deferred treatment
1. Deferred urethroplasty
• Procedure of choice for the treatment of
posterior urethral distraction defects.
• Excellent outcome
2. Deferred endoscopic optical incision
• For short, non-obliterative strictures following
realignment or urethroplasty,
85

86. Penetrating posterior urethral injuries
• Immediate exploration by retropubic route
and primary repair or realignment.
• Life-threatening associated injuries:
 Suprapubic diversion with delayed
abdominoperineal urethroplasty
• In the case of rectal injury, a diverting
colostomy.
86

87. Female urethral injuries
Immediate exploration and primary repair:
• Proximal Disruptions – Retropubic approach
• Mid-urethral Disruptions - Transvaginal
approach
• Distal urethral injuries - Managed vaginally by
primary suturing and closure of the vaginal
laceration.
87

88. Acute Urinary Retention
88

89. 89
Introduction
• Urinary obstruction is a common cause of acute
and chronic renal failure.
• A wide variety of pathological processes,
intrinsic and extrinsic to the urinary system, can
cause obstruction.
• Symptoms and signs of obstruction are often
mild, occurring over long periods of time and
requiring a high index of suspicion for diagnosis.

90. 90
Causes
• Infants and children
– Urethral and bladder outlet obstruction
• Urethral atresia
• Phimosis
• Meatal stenosis
• Posterior urethral valves
• Calculus
• Blood clot
• Neurogenic bladder (meningomyelocele)
• Ureterocele

91. 91
• Adults
–Urethral and bladder outlet obstruction
•Phimosis
•Stricture
•Trauma, Blood clot
•Calculi
•BPH, Prostatic or Bladder Ca
•Carcinoma of cervix or colon
•Neurogenic bladder

92. 92
Clinical Presentation
• Hx
• P/E
• Imaging

93. 93
Management
1. Medical Therapy
• Analgesics
• Antibiotics
• Other medications: Prazosin
2. Surgical Therapy
• The goal of surgical intervention is to completely relieve the urinary tract
obstruction.
• Point of obstruction should be identified
A. Urethral catheterization
– A urethral catheter (size 8F-24F)
– May need to perform urethral dilation, cystoscopy, or both to pass the
catheter.
– Indwelling / clean intermittent catheterization.
– If blood is present at the urethral meatus after pelvic trauma and
suspicion of urethral injury exists, retrograde urethrography needs to be
performed to rule out urethral injury.
B. Suprapubic Cystostomy

94. 94

95. 95
Suprapubic Cystostomy:
• Percutaneously (at the bedside)
• Open Cystostomy (in the operating room).
• A suprapubic tube is placed ~2 finger-breadths
above the pubic symphysis.
• Ultrasound guidance should be used for bedside
procedures to ensure proper placement without
injury to adjacent structures.
• In patients with previous abdominal surgery,
adhesions and scar tissue may have changed
the normal bowel location, so an open approach
may be preferred.

96. 96

97. Other Urologic Emergencies
• Phimosis and Paraphimosis
• Priapism
• Penile Fracture
97