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Slide 1 : UROLOGIC EMERGENCIES Surgical conditions affecting the urinary system requiring emergent care JOEL PATRICK A. ALDANA, MD, MBA Clinical Associate Professor, UP College of Medicine
Slide 2 : Objective Discuss surgical conditions affecting the urinary system requiring emergent care clinical presentation pathophysiology / cause diagnostic tests principles of management
Slide 3 : Urologic Emergencies Acute urinary retention Renal colic Genitourinary trauma Anuria Penile Emergencies Acute Scrotum
Slide 4 : 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
Slide 5 : 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
Slide 6 : Pathophysiology Bladder does not contract Neurologic stimulation is impaired / absent Bladder musculature is converted to fibrous tissue
Slide 7 : 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
Slide 8 : 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
Slide 9 : Head Foot
Slide 10 : Emergent Management Urethral catheterization Suprapubic tube cystostomy
Slide 11 : 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
Slide 12 : 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
Slide 13 : 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
Slide 14 : 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
Slide 15 : 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
Slide 16 : Special Examinations CT-Scan Excretory Urography Retrograde Cystography Urethrography Arteriography Abdominal sonography Cystoscopy, retrograde pyelography
Slide 17 : Management Dependent on : Specific organ injured Mechanism of injury Degree of injury General options Surgery Observation Urinary diversion (catheterization)
Slide 18 : 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
Slide 19 : 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
Slide 20 : Classification of renal trauma Minor - 85% Grade I to III Major - 15% Grade IV-V Vascular injury - 1% Grade V
Slide 21 : Grade I renal injury: contusion
Slide 22 : Grade I renal injury: subcapsular hematoma
Slide 23 : Grade II renal injury
Slide 24 : Grade III renal injury
Slide 25 : Grade IV renal injury: injury of collecting system with extravasation of dye
Slide 26 : Grade IV renal injury: segmental vascular injury
Slide 27 : Grade V renal injury: shattered kidney
Slide 28 : Grade V renal injury: vascular pedicle injury or avulsion
Slide 29 : 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
Slide 30 : 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
Slide 31 : CT Scan Disrupted outline Perinephric collection of blood Extravasation of dye
Slide 32 : Excretory Urography (IVP) Broken 11th rib Extravasation of dye slug
Slide 33 : Ultrasound Perinephric collection of blood
Slide 34 : Arteriography Non visualization of renal parenchyma/ disrupted outline Non visualization of entire kidney
Slide 35 : 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
Slide 36 :
Slide 37 : Ureteral Trauma Rare May not present acutely Mechanisms of injury : Iatrogenic – most common Ligation or transection during surgical procedures Deceleration Penetrating wounds
Slide 38 : 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
Slide 39 : Diagnostics KUB-IVP Ultrasound Hydronephrosis Urinoma Retrograde pyelography Extravasation of dye from ureter
Slide 40 : 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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