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

UROLOGIC EMERGENCIES

Hakan KOYUNCU;MDAsistant Profesor

Yeditepe University Medical Faculty

Department of Urology


Urologic emergencies

  • 34-yo male

  • Severe right sided flank pain


34 m r flank pain

34 M, R flank pain

  • Hx

  • PE

  • urinalysis

  • imaging


Renal colic

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


Urologic emergencies

  • R: Appendicitis - Cholelithiasis

  • urinalysis: hematuria

  • KUB

  • IVP

  • Computerized Tomography

  • Pain management,hydration, hot bath

  • Treatment of the underlying cause


Urologic emergencies

  • Solitary kidney

  • Ureteral stone

  • Hydronephrosis anuria, uremia


Urologic emergencies

  • 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

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)


Urologic emergencies

  • 47 yo diabetic

  • Alcohol (+)

  • Fever, malaise, redness and discomfort in scrotum


Fournier s gangrene

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


Urologic emergencies

  • 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

Management

  • Bacteroides, Klebsiella, Proteus, Streptococus, Clostridium Perfringens

  • An avarage of 4 microorganisms per patient


Phimosis

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

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


Urologic emergencies

  • 42 yo male

  • High fever, chills, malaise, frequency, perineal pain

  • DRE: enlarged, pain, warm prostate

  • Lab: leucoytosis, shift to the left

  • culture-sensitivity


Admitted antibiotics nsaid urinary retention in the evening

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

  • Suprapubic catheterisation


Urologic emergencies

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


Prostate abcess

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


Urologic emergencies

  • TRUS: definitive diagnosis

  • Drainage

  • Antibiotics

  • Suprapubik catheterization


Urologic emergencies

  • Telephone:

  • 15 yo male

  • Enlargement and pain in L testis


Testicular torsion

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)


Urologic emergencies

  • 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

35 yo male Errection for 4 hrs in duration, pain

  • Perineal trauma?

  • Blood gas: high 02 & low CO2


Priapism

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


Urologic emergencies

  • 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

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

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

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

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

American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney


Radiologic imaging

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

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

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

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.


Urologic emergencies

THANK YOU


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