Urolithiasis. Edematous Scrotum Syndrome. Traumatic injuries of Urinary system

1. "Urolithiasis. Edematous scrotum"Urolithiasis. Edematous scrotum
syndrome. Traumatic injuries of thesyndrome. Traumatic injuries of the
urinary system"urinary system"

2. Plan of the lecture:Plan of the lecture:
Etiology and pathogenesis of urolithiasis.
Clinic and diagnosis of urolithiasis.
Treatment of urolithiasis in children.
Syndrome of swollen scrotum in boys:
clinic and diagnostics, tactics of treatment.
Injuries of the testicles and scrotum.
Injuries of the kidney in children.
Injuries of the urinary tract organs in
children.

3. UrolithiasisUrolithiasis
Found in many countries. There are countries where
it is very common, but there are regions in which are
very rare.
In Ukraine endemic in urolithiasis are areas of
Donbass, Dnipropetrovsk and Kharkiv regions.
Carpathians although not endemic region in this
pathology, but its incidence in children is increasing
every year.

4. Etiology and pathogenesis of UrolithiasisEtiology and pathogenesis of Urolithiasis
 Crystallization theory:
Violation of colloidal status crystallization of urine
salts. Normally urine is an ultrafiltrate of blood plasma,
which contains large amount of mineral and organic
products metabolism, residual products of metabolism
that are in suspended form or dissolved due to the
presence of stabilizing colloids in urine. Its system may
be disrupted by changing the reaction and surface
tension of urine, difficulties outflow of urine, the
presence of bacteria in urine, leukocytes, fibrin.
Thus there is deposition of salts, crystalline particles,
which then serve as cores for future stones are formed.

5. SponsoredSponsored
Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

6. Matrix theoryMatrix theory
Basis of stone is organic core (matrix), on which are
superimposed the salt crystals. This is confirmed by
the fact, that each urinary stone consists of two
components: an organic matrix (2-3% of stone) and
the mineral, which is intimately associated with the
matrix.
Significant role in the etiology of urolithiasis play:
vitamin deficiencies, hyperparathyroidism, urinary
tract infection, violation of the urine outflow,
damage of the brain and spinal cord, damage of
skeleton, hyperthermia, a way of life.

7. Etiology and pathogenesis of UrolithiasisEtiology and pathogenesis of Urolithiasis
Very important are: metabolic disorders, diseases of
the digestive tract, especially the food, social and
living conditions.
The child's body contains more extracellular fluid,
which is easily lost during diarrhea, vomiting, fever.
Dehydration leads to oliguria and increased
concentration of urine, which promotes stone
formation.
Thus, an important factor, contributing to the
formation of stones, is urine stasis. In turn, urinary
tract stones lead to urine stasis.

8. Localization:
60-70% of urolites are localized in
renal hollow system, in 20-25% -
in the ureters, more rarely - in the
bladder and urethra.
Depending on the chemical
composition:
Organic stones
(protein, xanthine, cysteine and​​
cholesterol)
Inorganic stones
(oxalate, urate, phosphates and
carbonates).
Mixed stones

9. Clinical pictureClinical picture of Urolithiasisof Urolithiasis
Depends on the child's age, size and location of
stones. In children older, than 7 years, often the first
manifestation of urolithiasis is renal colic.
In renal colic arises anxiety child, sharp abdominal
pain accompanied by nausea and vomiting. When
pain patients twists, taking forced position. In
children under 7 years renal colic is rare due to the
fact, that they have relatively wide ureter.
Uncomplicated urolithiasis appears aching pain in
the abdomen and lumbar region. There hematuria,
especially after physical activity.

10. Clinical pictureClinical picture of Urolithiasisof Urolithiasis
The cause of hematuria is mucosal injury by
concrements, joining infections. Reliable sign of
urolithiasis is the stone in urine.
Very quickly urolithiasis is complicated by
infection and the development of pyelonephritis:
the pain does not go out, there is a fever,
frequent painful urination, thus leaving turbid
urine. The patient worsens sleep and appetite,
nausea worried, pale skin.
Another complication is hydronephrosis, that
occurs after occlusion of ureter by stone. When
occlusion two ureters or urethra occurs anuria.

11. Diagnosis ofDiagnosis of UrolithiasisUrolithiasis
Ultrasound: It identifies positive echo formation in
the projection of the urinary tract, may be
ultrasonic path. Sometimes secondary signs of
urolithiasis are defined - expansion of cup-pelvis
complex. In ureters visualization of concrements
is difficult.

12. Plain or excretory
urography: X-ray-
positive stones
(phosphates,
carbonates, oxalates)
are defined as
shadows. In urograms
also is determined the
expansion rate of
urinary tract and their
patency.
Urinalysis: hematuria,
leukocyturia, salts.

13. Treatment ofTreatment of UrolithiasisUrolithiasis
Conservative: the introduction of analgesics and
antispasmodics, non-steroidal anti-inflammatory
drugs. Assign thermal treatments (bath, hot
water bottle), novocaine blockade of the
spermatic cord or the round ligament of the
uterus. During prolonged colic catheterization of
the ureter is indicated. It is recommended to
drink plenty of fluids. Physiotherapy treatment
(Diathermy, Vibrotherapy) is applied.
If you can not obtain a discharge of stones with
conservative methods, the method of
extracorporeal lithotripsy is used.

14. Treatment ofTreatment of UrolithiasisUrolithiasis
With the ineffectiveness of all these methods is
carried out surgical treatment, whose purpose is not
only to remove the stones, but also eliminating the
causes of urostasis.
After removal of urolites treatment should be aimed
at preventing stone formation: diet, vitamins,
mineral water, spa treatment.
Equally important in the prevention of urolithiasis is
treatment of pyelonephritis.

15. Syndrome of swollen scrotum
is a group of acute illnesses of the testicles and
appendages, requiring urgent surgery.
For a long time, various acute diseases of the
scrotum was united in diagnosis of "acute
orchitis" and treated conservatively. This tactic
resulted in a high frequency of hypoplasia or
atrophy of the testes and in the future - to
violations of reproductive function.
1) Torsion of the spermatic cord.
2) Torsion of hydatis testicles.
3) Acute orchiepididymitis. 4) Injuries of the
testicles.

16. Torsion of the spermatic cord
Most commonly occurs in children under 1 year
and in the pubertal age (90%).
The cause of spermatic cord torsion (SCT) is a
sharp reduction of muscle, that raises the testicle,
the fibers of which have a spiraling motion.
Preferably there intravaginal torsion (inside the
vaginal membrane testes), but in children under 1
year is more common testicular torsion with
shells (extravaginal form).
Crucial importance in the etiopathogenesis of
torsion has morphological immaturity of the
spermatic cord.

17. Complications of SCTComplications of SCT
Acute impairment of blood and lymph
circulation and development of the hemorrhagic
infarct of testis.
Irreversible pathological changes in the testis
occurs very quickly, and after 6-10 hours after
torsion occurs necrosis.
Immune reactions, resulting SCT, can lead to
dysfunction also healthy (contralateral) testis.

18. Clinic of SCTClinic of SCT
In patient occurs acute pain in the affected part
of the scrotum, sometimes align also general
complaints - fainting, pale skin, cold sweat,
nausea.
Pain can irradiate in the inguinal area.
On examination, swelling and redness of skin
scrotum are marked, in palpation is defined
enlarged, dense, sharply painful testicle.
Spermatic cord is thickened and compacted.
Location of testicle is changed - toned to the
top of scrotum.

19. Diagnosis of SCTDiagnosis of SCT
Diafanoskopy (ray bright light)- testicle not
enlightened
Ultrasound, Doppler of testicle and spermatic
cord vessels - venous stasis, depleted blood
circulation, induration of testicles are defined.
The differential diagnosis must spend with
tumors also other acute diseases of the testes.

20. Treatment of SCTTreatment of SCT
 Surgery, should be performed immediately upon
diagnosis or even with suspected it.
 Access is scrotal or inguinal. After untwisting the
spermatic cord (detorsion), novocaine blockade of it
and warming of testicle by damp cloth with warm
solution are conducted.
 The viability of testicle (color, luster membranes) is
evaluated, testis is fixed by sutures to separate
membranes of scrotum, scrotum is drained by a rubber
drainage.
 If necrotic testicle, orchidektomy is performed, then
fixation the opposite testicle is carried out.
 Anti-inflammatory drugs, vitamins A, E, C, Heparin,

21. Testicular hydatis torsionTesticular hydatis torsion
More common occurs in boys aged 4 to 15 years.
Morhanyi’s hydatis are derivatives of primary
genital ducts (Volf’s and Muller’s). There are 5
kinds of hydatis. Its sizes may be from 2 to 10
mm in diameter.
Hydatis can subverted around the leg, which
leads to ischemia, infection and necrosis.
Inflammation from hydatis goes on testicle and its
shells. Without surgery occurs atrophy of testicle.
Rarely cystic degeneration and malignancy of
hydatis are observed.

22. Hydatis looks like a rounded formation purplish or
bluish color on the stem, which is attached to the
testicles

23. Clinic of testicular hydatis torsionClinic of testicular hydatis torsion
Complaints of pain in the affected part of the
scrotum. Locally reveal edema and hyperemia of
the corresponding half of the scrotum. In
palpation is determined the increased testicle,
near the upper pole of it palpable dense, sharply
painful knot. Sometimes it shows through the
scrotum, dark color.
Diagnosis
based on the data of ultrasound and
diafanoskopy. Sometimes is performed testicular
membranes puncture, thus getting turbid liquid.

24. Treatment of testicular hydatisTreatment of testicular hydatis
torsiontorsion
Surgical. Involves the removal hydatis,
drainage of testicle membranes. Novocaine
blockade of the spermatic cord is performed.
After surgery anti-inflammatory and metabolic
drugs (Aevit, Nicotinic acid, 5% Aminocapronic
acid, Nimesulide, Kvartsetin) are prescribed.

25. OOrchitisrchitis
This is an acute inflammation of the testicle,
which is caused by infection, trauma, and other
factors. There are specific and nonspecific
orchitis.
Specific orchitis develops under the influence of
pathogen, tropic to testicular tissue (mumps,
tuberculosis, hepatitis, etc.).
Etiologic factor is infection. In the pathogenesis
are important also autoimmune reactions.
Pathogen effect on spermatogenic epithelium.
Affects parenchymal and interstitial cells.

26. OrchitisOrchitis
Swelling of the testicle tissue leads to ischemia it
and at the future - to atrophy.
Clinic. It starts acutely, there is pain that gives
back to perineum, lower abdomen. Testicle
becomes dense, enlarged, painful. Later there is
swelling and redness of the scrotum.
Conservative treatment: antibiotics, compresses,
glucocorticoids, Aspirin. Suspensory is imposed. In
the presence of fluid under the testicular shells is
performed surgery - decompression of testicles.
The operation is carried out in the urgent manner.
More often orchitis is a complication of hydatis

27. Algorithm of urgent actions in syndromeAlgorithm of urgent actions in syndrome
of swollen scrotum:of swollen scrotum:
Preoperative preparation: administration of analgesics.
Surgical intervention: access (often - scrotal), detorsion
of testis, removing of hydatis, drainage of testicular
membranes, spermatic cord blockade with 0.25% Sol.
Novocaine + Hydrocortisone administration.
Postoperative treatment: antibiotics, metabolic drugs -
Trental, vitamins A, E, antioxidants, Kvartsetin.
Untimely and inadequate treatment, refusal of
emergency operations may lead to ischemia and atrophy
of testes, chronic dropsy, obstruction of vas deferens.
Later it leads to male infertility.

28. Injury of the scrotum and testiclesInjury of the scrotum and testicles
There are open and closed injuries. By type:
contusion, rupture, dislocation and compression of
the testicle. Upon impact the scrotum and testicles
there is swelling of tissues, in severe cases -
hemorrhage or hematoma.
The extreme degree of testicular rupture is crushing
or separation of it from the spermatic cord.
One of the rare variants injury is testicular dislocation
(one or two) that can be found in the inguinal canal,
under the skin of the abdomen, thighs, perineum.
Open injuries: torn, chopped, sliced and bitten​​
wounds.

29. ClinicClinic
Depends on the nature of the damage. In closed injuries
there are swelling and hemorrhage of soft tissues,
increasing and tenderness of testis and epididimus,
thickening and tenderness of spermatic cord. When
bleeding into the tissues of scrotum or testicles is
determined hematocele or scrotal hematoma,
sometimes is defined fluctuation. Scrotum may be
increased in size by 3-5 times. In open injuries is
visible wound of scrotum and testicles. Gaps of
testicles and applications is usually accompanied by
varying degrees of traumatic shock. When testicular
dislocation is empty scrotum, the testicles are
determined abroad.

30. TreatmentTreatment
In closed injuries - bed rest, cold on the scrotum,
imposing of suspensory. Later is prescribed
thermal and physiotherapy. In the presence of
hematoma is revealed draining, transmitting
hemostasis. At slaughter - novocaine blockade of
the spermatic cord is performed. When break of
testis - emergency operation - suturing of tunica
albuginea and drainage. In open injuries - revision
of wound, primary surgical treatment, necrectomy,
suturing the testicle and scrotum with the
drainage. When crushing or separation of testis
orchidektomy is indicated. To all children with

31. Injury ofInjury of kidney
Arises as a result of closed injury of the lumbar
region (face, falling from height, compression).
The kidneys in children are more prone to injury
because the musculoskeletal system provides
enough protection function and kidney fairly
mobile.
About 20% of injuries occur when renal
pathology (tumors, hydronephrosis, etc.).
There are open and closed injuries of kidneys.

32. Classification of renal injuriesClassification of renal injuries
I deg. - Damage of parenchyma without evidence of
accumulation of fluid (blood, urine) in capsule or
around it.
II deg. - Partial damage with little accumulation of
fluid under the capsule or around it (urohematoma).
III deg. - Rupture of the kidney with significant
accumulation of fluid around the kidney.
IV deg. - Crushing of kidney while maintaining a
connection with parts of it and maintaining
circulation.
V deg. - Damage of the vascular pedicle, ureter

33. І ІІІ V

34. Clinic of renal injuriesClinic of renal injuries
The main symptoms - gross hematuria, pain, signs
of shock, swelling in the lumbar region, in upper
and lateral abdomen. Expression of hematuria
depends on the severity and nature of the
damage. Pain is dull, sometimes has the character
of renal colic. Pain may be accompanied by
muscle tension of the abdominal wall, signs of
peritoneal irritation.
 Diagnosis
In urgent is performed excretory urography,
ultrasonography and, if necessary - CT. At the
same time is determined the degree of damage

35. Antegrade pyelography. SeparationAntegrade pyelography. Separation
of ureterof ureter

36. Excretory urography. RuptureExcretory urography. Rupture
of the right kidneyof the right kidney

37. Excretory urography. Right-Excretory urography. Right-
sided urohematomasided urohematoma

38. Treatment of kidney injuryTreatment of kidney injuryMust be as organic preservative. In injuries of the
I-II degrees without hemodynamic disturbances is
prescribed bed rest to stop hematuria, antibiotics
and haemostatic therapy.
Surgical intervention is carried out in injury of the
III-V degrees, with an increasing urohematoma,
continued bleeding, prolonged hematuria,
infection of paranefron, the occurrence of ureteral
obstruction. The operation is aimed to remove
urohematoma, suturing breaks, drainage of the
renal pelvis and paranefron.
Nephrectomy is performed only in the case of
renal blood flow violation (injury of 5 degree).

39. Damage of uretersDamage of ureters
Belong to a very rare injury. Detected by excretory
urography. Treatment exclusively surgical and
depends on the type of injury.
Damage of the bladder
intraperitoneal extraperitoneal
Resulting from compression of the lower body,
kick or fall from a height in a crowded bladder.
Damage arising from fractures of the pelvis by
displaced fragments or with penetrating wounds of
the perineum.

40. Bladder Injuries ClinicBladder Injuries Clinic
Intra-abdominal injury: are present peritoneal
symptoms - abdominal pain, vomiting, muscle tension o
anterior abdominal wall, peritoneal irritation symptoms,
blunting in cape places of abdomen with percussion.
Urination disorders - frequent urge release drops of
bloody urine, patient can not urinate self. When bladder
catheterization is observed gross hematuria.
Extraperitoneal damage: signs of peritonitis are not
pronounced, disturbing pain under pubis by palpation
and muscle tension. Painful urination, stands a small
amount of urine, colored with blood. To confirm the
diagnosis is used cystography.

41. Treatment of bladder injuriesTreatment of bladder injuries
Surgical
When intraabdominal - laparotomy, is
examined the upper and posterior wall of the
bladder. Gaps are stitched of two rows ketgut
seams. Must carry out sanitation of the
abdominal cavity and epiсystostomy.
When extraperitoneal injuries also is imposed
epicystostoma.

42. Injury of urethraInjury of urethra
Arises in impact perineum to a solid object or
bone fractures of the pelvis. Preferably is
damaged posterior urethra. There are penetrating
and non-penetrating gaps.
Clinic is characterized by bleeding from urethra,
perineal hematoma, urinary retention, where there
is a feeling of fullness. Urine penetrates soft
tissues, urinary abscess may occur. With the
spread it to the pelvis condition of child much
worse. For diagnosis is used retrograde
urography, with visible contrast penetration
beyond the urethra.

43. Treatment of the urethra injuriesTreatment of the urethra injuries
Begins with antishock measures. Bladder
catheterization is contraindicated.
Emergency operation is conducted: imposing
epicystostoma, drainage of paraurethral
hematoma. Later - suturing of breaks urethra.
Often after such injuries occur stricture of
urethra channel that require bouginage. In the
ineffectiveness of the treatment is carried out
complex plastic surgery to restore patency of
the urethra.

44. Cystouretrography.Cystouretrography.
Stenosis of urethraStenosis of urethra