Urologic emergencies
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UROLOGIC EMERGENCIES. Hakan KOYUNCU;MD Asistant Profesor Yeditepe University Medical Faculty Department 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

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UROLOGIC EMERGENCIES

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UROLOGIC EMERGENCIES

Hakan KOYUNCU;MDAsistant Profesor

Yeditepe University Medical Faculty

Department 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 reflex

    Increased 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


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


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