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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

UROLOGIC EMERGENCIES

Hakan KOYUNCU;MDAsistant Profesor

Yeditepe University Medical Faculty

Department of Urology

slide3
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
slide10
R: Appendicitis - Cholelithiasis
  • urinalysis: hematuria
  • KUB
  • IVP
  • Computerized Tomography
  • Pain management,hydration, hot bath
  • Treatment of the underlying cause
slide11
Solitary kidney
  • Ureteral stone
  • Hydronephrosis anuria, uremia
slide14
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)
slide22
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
slide28
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
slide34
42 yo male
  • High fever, chills, malaise, frequency, perineal pain
  • DRE: enlarged, pain, warm prostate
  • Lab: leucoytosis, shift to the left
  • culture-sensitivity
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
slide38
TRUS: definitive diagnosis
  • Drainage
  • Antibiotics
  • Suprapubik catheterization
slide39
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)

slide46
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
slide52
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)
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.
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