UROLOGIC EMERGENCIES

Hakan KOYUNCU;MDAsistant Profesor

Yeditepe University Medical FacultyDepartment of Urology

34-yo male Severe right sided flank pain

34 M, R flank pain

Hx PE urinalysis imaging

RENAL COLIC

Stones of the urinary tract Hematoma or tissue in the ureter Upper ureter: lumbar-inguinal Lower ureter: genital

Intermittant Not affected by body positioning Lumbar tenderness Nausea & vomiting

R: Appendicitis - Cholelithiasis urinalysis: hematuria

KUB IVP Computerized Tomography

Pain management,hydration, hot bath Treatment of the underlying cause

Solitary kidney Ureteral stone Hydronephrosis anuria, uremia

62 yo male

Severe abdominal and inguinal pain, 30 hrs in duration, “have not slept for 5 min.”

Feels like voiding every 10-15 minutes, passes a few drops each time

He presented to the ER of a hospital, was diagnosed as cystitis, was given a parasymphatholytic, but did not get any better.

Acute Urinary Retention

Bladder neck – prostate – urethra Usually in elderly with BPH Massive hematuria, acute prostatitis, prostate

abcess, stones lodged at the bladder neck/urethra, phimosis, uretral trauma

History Suprapubic mass Urethral catheterization Suprapubic catheterization (cystostomy)

47 yo diabetic Alcohol (+) Fever, malaise,

redness and discomfort in scrotum

Fournier’s Gangrene

Synergistic effect of multiple microorganisms in the urogenital/anal region

Effects soft tissue and fascia, necrosis Generally starts from genital/perineal region Uretral trauma, urinary ekstravasation, urethral

instrumantation, perianal abcess and fissur are predisposing factors

Immunocompromised patients (diabetes, alcoholism) Begins like cellulitis, rapidly spreads along the fascial planes Necrosis and gangrene Hypoxia anaerobic bacteria gas formation, crepitation

Malaise, discomfort Scrotal-perineal pain Redness Fever, chills, sweating, scrotal edema Gangrene Rapid deterioration in general health Rapidly involves the abdomen and causes

death

Management Bacteroides, Klebsiella, Proteus, Streptococus,

Clostridium Perfringens An avarage of 4 microorganisms per patient

Phimosis

Inability to retract the preputium– Bad hygiene-recurrent infections– Uncircumsized boys/adults– Prepitual edema, redness, purulent

discharge– Physiologic until 3 years of age– Dorsal slit or circumsition

Paraphimosis:

The foreskin, once retracted over the glans penis, cannot be replaced in its normal position– Usually chr. inflammation of preputium,

stricture– Lymphatic, venous, and arterial flow are

compromised, leading to necrosis

– Firmly squeezing glans for 5 mins.– Skin can then be drawn over the glans

(lubricant)– dorsal slit, circumsition

42 yo male High fever, chills, malaise,

frequency, perineal pain

DRE: enlarged, pain, warm prostate

Lab: leucoytosis, shift to the left

culture-sensitivity

AdmittedAntibiotics, NSAID Urinary retention in the evening ????

•Suprapubic catheterisation

The patients general health deteriorates on day 3, fever does not resolve

Prostate Abcess

Coliform bacteria Generally urethral (ascending) Staphilococcus via hematogenous route Diabetes, immune compromised, urethral

trauma, prostate biopsy Pollakiuria, disuria, acute urinary retention;

fever, malaise Usually excacerbation of symptoms after acute

prostatitis DRE: fluctuation Lab: pyuria, leucocytosis

TRUS: definitive diagnosis Drainage Antibiotics Suprapubik catheterization

Telephone: 15 yo male Enlargement and pain in L testis

Testicular Torsion Newborn – adolesents %50 uykuda olur Usually anomaly of tuniga vaginalis or the

spermatic cord Pain-sudden onset, skrotal edema,

enlargement and redness, nausea, vomiting

PE: usually retracted,Loss of cremasteric reflexIncreased pain with testicular elevation (Prehn)

Epidydimis may be palpated in an abnormal location – early sign

Leucocytosis within a few hours Doppler US or nuclear scan Manuel de-torsion (inside out) (local anest) Eksploration !!! 5-6 hrs

35 yo male Errection for 4 hrs in duration, pain

Perineal trauma? Blood gas: high 02 & low CO2

Priapism

Etiology:– Most frequent: intracavernosal injection– Idiopathic– Disease (leucemia, sickle cell disease,..)

Obstruction of venous drainage, c.c.’da pooling of viscous low oxygenated blood in corpus cavernosum edema, fibrosis, erectile dysfunction

Increase venous outflow Find out underlying reason-if possible Non-surgical management first:

– Aspiration – Alfa adrenergikc agonist injection

• (phenephrine, 10mg/ml, diluted in 19 ml saline)

If non-surgical tx fails:– Distal or proximal shunt

TRAUMA

GU tract in 10% of all traumas Kidney is the most commonly involved

organ–   Suspect GU taruma when: – Hematuria – Descelerating injury – Penetrating abdominal or flank injury – Echimosis of the flank

Bladder & Urethra

– Suspect trauma in the presence of: – Blood at the urethral meatus– DRE: “prostate displaced superiorly "– Hematuria– Penetrating abdominal, pelvic or genital

injury– Anterior pelvic fracture – Open pelvic fracture – Perineal laseration

Renal Trauma

Blunt : (85 -90% ) – vehicle accident, fall, rapid

deceleration, iatrogenic

Penetrating : Gunshot and (85-90 % associated with intraabdominal or thoracic injury)

Renal Trauma - Diagnosis

History PE (lumbar echimosis, pain with

palpation) Hematuria

– (Renal vascular injury - 36 % not associated with hematuria)

Variable clinical presentation (asymptomatic-shock)

American Association for the Surgery of Trauma

Organ Injury Severity Scale for the Kidney

Grade Tip Tanım1 kontüzyon Mikroskobik ya da gross hematuri, ürolojik

incelemeler normal

hematom SubKapsuler, genişlemeyenparankimal hasar yok

2 hematom Genişlemeyen perirenal hematom , renal retroperitona sınırlı

laserasyon <1-cm derinlikte parenkimal korteks hasarı,üriner ekstravazasyon yok

3 laserasyon >1-cm derinlikte parenkimal korteks hasarı,üriner ekstravazasyon yok

4 laserasyon Medulla ve toplayıcı sisteme ulaşan parenkim hasarı

vasküler Renal arter ve vende hemoraji içeren hasar

5 laserasyon Tamamen parçalanmış Böbrek

vasküler Renal hilusun ayrılması

Radiologic Imaging

KUB (loss of psoas or renal contour) IVU (delayed renal function,

nonhomogenous collecting system) USG (lumbar hematoma and urinoma

lokalizasyonu) Computerized Tomography Renal angiography

Expectant Management:

Hemodynamically stable, well defined and non-expanding injury on CT scan

88 % patienst are observed

If there is associated gross hematuria, admit and observe

Surgery :

Absolute Indication – Persistant renal bleeding– Expanding perirenal hematoma– Perirenal hematoma with pulsation

Relative indication – Urinary extravasation– Inability in proper staging– Delayed arterial injury

Urethral Injury

A partial rupture could be a complete rupture during catheterisation!

A urethrogram should be performed

In the presence of urethral disruption, a suprapubic catheter should be placed.

THANK YOU