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UROLOGIC EMERGENCIES Surgical conditions affecting the urinary system requiring emergent care JOEL PATRICK A. ALDANA, MD, MBA
Clinical Associate Professor, UP College of Medicine |
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Objective Discuss surgical conditions affecting the urinary system requiring emergent care
clinical presentation
pathophysiology / cause
diagnostic tests
principles of management |
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Urologic Emergencies Acute urinary retention
Renal colic
Genitourinary trauma
Anuria
Penile Emergencies
Acute Scrotum
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Acute Urinary Retention Most common urologic emergency
Inability to pass urine (from a full bladder)
Pathophysiology : Failure to empty
Bladder outlet is obstructed
Bladder does not contract
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Clinical Conditions Congenital anomalies blocking the urethra
Posterior urethral valve (boys)
Prolapsing urethrocoele (girls)
Tight or small opening of the prepuce
Phimosis
Enlarged prostate blocking the urethra
Benign prostatic hyperplasia, Prostate carcinoma
Urethral canal closed by fibrotic scar tissue
Urethral stricture / stenosis
Urethra disrupted by trauma with hematoma constricting the proximal part
Urethral trauma |
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Pathophysiology Bladder does not contract
Neurologic stimulation is impaired / absent
Bladder musculature is converted to fibrous tissue
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Clinical Conditions Neurologic stimulation is impaired / absent
Spinal cord compression
Spinal cord trauma / transection
Peripheral neuropathy (herpes zoster, diabetic neuropathy-cystopathy)
Bladder musculature is converted to fibrous tissue
Longstanding diabetic cystopathy
Prolonged bladder outlet obstruction |
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Clinical Presentation Hypogastric mass = distended bladder
Pinpoint opening of the prepuce with inability to retract it, ballooning of the prepuce
Signs of urethral injury :
Blood per urethral meatus
Perineal hematoma
Neurologic impairment
Lower extremity paralysis/ paresis, lax anal sphincter tone |
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Emergent Management Urethral catheterization
Suprapubic tube cystostomy |
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Renal colic 2nd most common ER call to the urologist
Pathophysiology of the pain :
Stretching of the renal capsule
Spastic contraction of the ureter
Inflammation of the renal capsule
Etiology / Clinical conditions :
Obstructing urinary stones, usually ureteral
Pyelonephritis |
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Clinical Presentation Pain
Writhing, colicky vs dull, steady
Hand on the side, above the waist, thumb pointing towards the umbilicus, other digits pointing to the back
Restless
Costovertebral angle tenderness
Fever
Nausea / vomiting
Urinary frequency and urgency |
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Management Diagnostic
Urinalysis, urine culture/sensitivity
Imaging studies
CT stonogram (spiral CT)
KUB-IVP / plain KUB xray
KUB ultrasound
Therapeutic
Parenteral pain reliever – most important
Antispasmodics / muscle relaxants
Antibiotics covering for gram negative microbes |
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Genitourinary trauma 10% of all injuries in the E.R.
Presents in many ways depending on:
Specific organ injured
Mechanism of injury
Degree of injury |
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Clinical presentation Hemorrhagic shock
Blunt abdominal injury
Acute abdomen (Tender abdomen with guarding)
Flank / abdominal contusions and hematoma
Pelvic fracture / deformity
Penetrating injury : wounds to the torso/back
Hematuria : gross or microscopic
Perineal hematoma
Gross injury to the genitalia
Normal physical exam findings |
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Special Examinations CT-Scan
Excretory Urography
Retrograde Cystography
Urethrography
Arteriography
Abdominal sonography
Cystoscopy, retrograde pyelography |
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Management Dependent on :
Specific organ injured
Mechanism of injury
Degree of injury
General options
Surgery
Observation
Urinary diversion (catheterization)
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Renal Trauma Most commonly injured genitourinary organ
Pathophysiology :
Blunt injury :
80-85% of cases
Direct impact, deceleration with traction of vessels, shearing injury
Penetrating injury |
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Clinical presentation Flank / back contusion / hematoma
Posterior lower rib fracture
Wound to the back or flank
Hematuria
Hypotension
Clinical findings of other related organ injuries |
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Classification of renal trauma Minor - 85%
Grade I to III
Major - 15%
Grade IV-V
Vascular injury - 1%
Grade V
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Grade I renal injury: contusion |
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Grade I renal injury: subcapsular hematoma |
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Grade II renal injury |
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Grade III renal injury |
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Grade IV renal injury: injury of collecting system with extravasation of dye |
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Grade IV renal injury: segmental vascular injury |
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Grade V renal injury: shattered kidney |
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Grade V renal injury: vascular pedicle injury or avulsion |
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Diagnostics : Renal Trauma Urinalysis – only to check for microhematuria
Hematocrit – to gauge and monitor blood loss
Imaging studies are most useful
CT scan – test of choice for grading of injury
Excretory urography (IVP) – 2nd best, checks function of 1 kidney
KUB ultrasound
Angiography – for vascular injuries |
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Diagnostic Imaging Features Disrupted outline of the kidney
Enlargement of the kidney
Perinephric fluid (blood) collection
Extravasation/spillage of the dye
Poor visualization / nonvisualization of the kidney |
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CT Scan Disrupted outline Perinephric collection of blood Extravasation of dye |
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Excretory Urography (IVP) Broken 11th rib Extravasation of dye slug |
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Ultrasound Perinephric collection of blood |
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Arteriography Non visualization of renal parenchyma/ disrupted outline Non visualization of entire kidney |
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Therapy : Renal Trauma ABC of resuscitation
Minor injuries (Grade 1-3): conservative (nonsurgical)
Bed rest
Hydrate
Transfuse
Close watch
Major injuries (Grade 4-5) : surgical intervention
Nephrorrhaphy
Partial nephrectomy
Nephrectomy
Vascular repair |
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Ureteral Trauma Rare
May not present acutely
Mechanisms of injury :
Iatrogenic – most common
Ligation or transection during surgical procedures
Deceleration
Penetrating wounds |
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Pathophysiology Clinical Presentation Injury Fibrosis/Scarring Hematuria Urinoma Bleeding into
ureteral lumen Urine spillage Urine peritonitis Nausea
Vomiting
Fever
Abdominal distention
Abdominal pain
Abdominal tenderness Fistula Stricture Urine leakage from wound site/vagina Flank/RLQ pain
Flank mass
Flank tenderness
Fever Hydronephrosis |
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Diagnostics KUB-IVP
Ultrasound
Hydronephrosis
Urinoma
Retrograde pyelography Extravasation of dye from ureter |
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Treatment : Surgical Immediate recognition and repair
Definitive treatment
Anastomose the injured ends
Reimplant into the bladder
Divert the urine
Stenting
Tube nephrostomy
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