urolithiasis. syndrome of swollen scrotum
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Urolithiasis. Syndrome of swollen scrotum. Pavlo Hoschynsky. Urolithiasis. Introduction - PowerPoint PPT PresentationTRANSCRIPT
Urolithiasis. Syndrome of swollen scrotum.Pavlo Hoschynsky
Urolithiasis IntroductionUrolithiasis is increasingly recognized in pediatric patients and is
encountered in a variety of clinical settings. The wide geographic variation in the incidence of urolithiasis in childhood is related to climatic, dietary, and socioeconomic factors. Approximately 7% of urinary calculi occur in children younger than 16 years of age. Many children with stone disease have a metabolic abnormality. Revolutionary advances in the minimally invasive and noninvasive management of stone disease over the past 2 decades have greatly facilitated the ease with which stones are removed. Given the frequency with which stones recur, the development of a medical prophylactic program to prevent stone recurrences is desirable. The lifetime prevalence of kidney stone disease is estimated at 1% to 15%, with the probability of having a stone varying according to age, gender, race, and geographic location. Stone disease typically affects boys more co mmonly as much as two to three times more frequently than females. Upper urinary tract stones occur more commonly in boys than girls by a ratio of 1.4:1 to 2.1:1.
Classification of stones
Stone size:<5 mm, 5-10 mm, > 10-20 mm, > 20 mm.
Classification of stones
Stone location:upper calyx, middle calyx or lower calyx, renal pelvis, upper ureter, middle ureter or distal ureter, urinary bladder.
Location of Renal stones
Classification of stones
X-ray characteristics
Radiopaque Poor radiopaque Radiolucent
Calcium oxalate dehydrate
Magnesium ammonium phosphate
Uric acid
Calcium oxalate monohydrate
Apatite Ammonium urate
Calcium phosphates
Cystine Xanthine
2,8-dihydroxyadenine
'Drug-stones'
Stones classified according to their aetiology
Non-infection stonesCalcium oxalatesCalcium phosphatesUric acidInfection stonesMagnesium-ammonium-phosphateApatiteAmmonium urateGenetic causesCystineXanthine2,8-dihydroxyadenine'Drug stones'
Calcium oxalate monohydrates
Calcium oxalate dihydrates
Uric acid
Struvite
Cystine
High risk stone formersGeneral factors
Early onset of urolithiasis in life (especially children and teenagers)Familial stone formation
Brushite containing stones (calcium hydrogen
phosphate; CaHP04. 2H20)
Uric acid and urate containing stones
Infection stones
Solitary kidney (The solitary kidney itself does not have a particular increased risk of stone formation, but theprevention of a potential stone recurrence is of more importance)
High risk stone formers
Diseases associated with stone formation
Hyperparathyroidism
Nephrocalcinosis
Gastrointestinal diseases or disorders (i.e. jejuno-ileal bypass, intestinal resection, Crohn's disease,malabsorptive conditions)
Sarcoidosis
High risk stone formers
Genetically determined stone formation
Cystinuria (type A, B, AB)
Primary hyperoxaluria (PH)
Renal tubular acidosis (RTA) type 1
2,8-dihydroxyadenine
Xanthinuria
Lesh-Nyhan-Syndrome
Cystic fibrosis
High risk stone formers
Anatomical and urodynamic abnormalities associated with stone formation
Medullary sponge kidney (tubular ectasia)
Ureteropelvic junction (UPJ) obstruction
Calyceal diverticulum, calyceal cyst
Ureteral stricture
Vesico-uretero-renal reflux
Horseshoe kidney
Ureterocele
Urinary diversion (via enteric hyperoxaluria)
Neurogenic bladder dysfunction
Compounds that cause drug stonesActive compounds crystallizing in urine• Allopurinol / oxypurinol
• Amoxicillin / ampicillin
• Ceftriaxone
• Ciprofloxacin
• Ephedrine
• Indinavir
• Magnesium trisilicate
• Sulfonamide
• Triamterene
Substances impairing urine composition
• Acetazolamide
• Allopurinol
• Aluminium magnesium hydroxide
• Ascorbic acid
• Calcium
• Furosemide
• Laxatives
• Methoxyflurane
• Vitamin D
Diagnostic steps in urolithiasis (UTI urinary tract infection, CT computed tomography, MR1 magnetic resonance imaging, PTH
parathyroid hormone, pC02 partial pressure of carbon dioxide)
Fig.a,b. A 17-year-old girl with cystinuria. a) Abdominal plain radiograph showing urolithiasis on the left, b) IVU showing hydronephrosis on the left due
to urolithiasis
Fig. a,b. A 4-year-old boy with incomplete RTA and hyperoxaluria, a Sonogram of right kidney showing medullary nephrocalcinosis grade III (Dick et al. 1999). b Sonogram of bladder showing an ureteral stone on the right immediately before the ureterovesical junction
An 8-year-old boy with primary hyperparathy roidism, hypercalciuria, and urinary tract infection. Ab dominal plain radiograph showing a huge ureteral stone on the left immediately before the ureterovesical junction
Bilateral Ureteric Calculus in a patient presenting with Anuria Bilateral Ureteric Calculus in a patient presenting with Anuria
Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on Gantry. These are rapidly performed and do not require contrast agents for reconstruction.
Evaluation for a suspected stone.(RBUS)-renal/bladder ultrasound
extracorporeal shockwave lithotripsy (ESWL)percutaneous nephrolithotomy -(PCNL)
Recommendations for pain relief during renal colic:-1st choice: treatment should be started with an NSAID(Diclophenac sodium, Indomethacin, Ibuprofen)-2nd choice: Hydromorphine(Pentazocine,Tramadol)-Diclofenac sodium is recommended to counteract recurrent pain after an episode ofureteral colic
For septic patients with obstructing stones, the collecting system should be urgently decompressed, using either percutaneous drainage or ureteral stenting.Definitive treatment of the stone should be delayed until sepsis is resolved.
Medical expulsive therapyAlpha-blockers (Tamsulosin, 0.4 mg, doxazosin,terazosin, alfuzosin and naftopidil)Calcium-channel blockers(nifedipine)Corticosteroids
Chemolytic dissolution of stones:-Percutaneous irrigation chemolysis-Oral Chemolysis
Methods of percutaneous irrigation chemolysis
Stone composition Refs. Irrigation solution CommentsStruviteCarbon apatite
1-6 10% Hemiacidrin with pH 3.5-4Suby's G
Combination with Shockwavelithotripsy for staghorn stonesRisk of cardiac arrest due tohypermagnesaemia
Brushite 7 HemiacidrinSuby's G
Can be considered forresidual fragments
Cystine 8-13 Trihydroxymethyl- aminomethan(THAM; 0.3 or 0.6 mol/L) with pH range8.5-9.0N-acetylcysteine (200 mg/L)
Takes significantly longertime than for uric acid stonesUsed for elimination ofresidual fragments
Uric acid 10,14-18 Trihydroxymethyl- aminomethan(THAM; 0.3 or 0.6 mol/L) with pH range8.5-9.0
Oral chemolysis is thepreferred option
The figure shows a 12 month-old child treated with the Modulith SLK (Storz Medical AG, Kreuzlingen).
Operation: percutaneous nephrolithotomy■ Rarely used in pediatric surgery■ Utilize a nephroscope or ureteroscope■ Extract with visualization■ Break larger stones using ultrasonographyOperation: open stone removal■ Rarely necessary, only when urinary calculi are not amenable to ESWLor PL■ Make an incision below the 12th rib■ Expose the kidney and the ureter■ Open the renal pelvis and extract the stone (or ureter in the case of aureteral stone)■ Wash the entire calyx system■ Suture the pyelon or the ureterPostoperative care■ Ureter drain for 2–5 days with an antegrade contrast X-ray before drainremoval■ Antibiotic therapy as prophylaxis in cases of vesicoureteral reflux■ Urine culture once a month■ UltrasonographyPrognosis■ Stone recurrence is rare if urine is sterile and an obstruction does notoccur
Medical treatment of recurrent stones
Scrotal Pain and Swelling Outline
Embryology and anatomy Causes of Pain and Swelling
Torsion, Epididymitis, Orchitis, Trauma History, Physical, Radiologic Exams, Labs
Causes of Swelling Hydrocele, Varicocele, Spermatocele, Tumor,
Idiopathic
Embryology
Descent of testes at 32-40 wks gestation Descends within processes vaginalis
Outpouching of peritoneal cavity Tunica vaginalis is potential space that remains
after closure of process vaginalis
Anatomy Spermatic cord –testicular vessels, lymph, vas
deferens Epididymis - sperm formed in testicle and undergo
maturation, stored in lower portion Vas Deferens – muscular action propels sperm up and
out during ejaculation Gubernaculum – fixation point for testicle to
tunica vaginalis Tunica Vaginalis – potential space
Encompasses anterior 2/3’s of testicle Tunica albuginea is inner layer opposing testis
Anatomy – Nuts and Bolts
AnteriorPosterior
Causes of Pain and Swelling
Pain Testicular torsion Torsion of appendix testis Epididymitis Trauma Orchitis and Others
Swelling Hydrocele Varicocele Spermatocele Tumor
Torsion Inadequate fixation of testes to tunica vagnialis
at gubernaculum Torsion around spermatic cord
Venous compression to edema to ischemia
Epidemiology
Accounts for 30% of all acute scrotal swelling Bimodal ages – neonatal (in utero) and pubertal
ages 65% occur in ages 12-18yo
Incidence 1 in 4000 in males <25yo Increased incidence in puberty due to inc weight
of testes
Predisposing Anatomy
Bell-clapper deformityTesticle lacks normal
attachment at vaginalis Increased mobilityTranverse lie of testesTypically bilateralPrevalence 1/125
Torsion: Clinical Presentation
Abrupt onset of pain – usually testicular, can be lower abdominal, inguinalOften < 12 hrs durationMay follow exercise or minor traumaMay awaken from sleep
Cremasteric contraction with nocturnal stimulation in REM
Up to 8% report testicular pain in past
Torsion: Examination
Edematous, tender, swollen Elevated from shortened spermatic cord
Horizontal lie common (PPV 80%) Reactive hydrocele may be present
Cremasteric reflex absent in nearly all (unreliable in <30mo old) (PPV 95%)
Prehn’s sign elevation relieves pain in epididymitis and not torsion is unreliable
Intermittent Torsion
Intermittent pain/swelling with rapid resolution (seconds to minutes)
Long intervals between symptoms PE: testes with horizontal lie, mobile testes,
bulkiness of spermatic cord (resolving edema) Often evaluation is normal – if suspicious need
GU followup
Diagnosis – “Time is Testicle”
Ideally -- prompt clinical diagnosis Imaging
Color doppler – decreased intratesticular flow False + in large hydrocele, hematoma Sens 69-100% and Spec 77-100% Lower sensitivity in low flow pre-pubertal testes
Nuclear Technetium-99 radioisotope scan Show testicular perfusion 30 min procedure time Sens and spec 97-100%
Acute torsion L testis Dec blood flow on L
Late torsion on R Inc blood flow around
but dec flow w/in testis
Images - Torsion
Decreased echogenicity
and size of right testicle
Nuclear medicine scan
shows "rim sign“ =no flow
to testicle and swelling
Management
Detorsion within 6hr = 100% viability Within 12-24 hrs = 20% viability After 24 hrs = 0% viability
Surgical detorsion and orchiopexy if viable Contralateral exploration and fixation if bell-clapper deformity
Orchiectomy if non-viable testicle
Never delay surgery on assumption of nonviability as prolonged symptoms can represent periods of intermittent torsion
Intravaginal torsion with ischemia in a adolescent boy.
Manual Detorsion
If presents before swelling Appropriate sedation In 2/3rds of cases testes
torses medially, 1/3rd lateral Success if pain relief, testes
lowers in scrotum Still need surgical fixation
Torsion: Special Considerations
Adolescents may be embarrassed and not seek care until late in course
Torsion 10x more likely in undescended testicle Suspicious if empty scrotum, inguinal pain/swelling
Adult Emergency Physicians accurate in bedside US diagnoses with sens of 95% and specificity of 94% (missed 1 epididymitis, no torsion)Blavis M., Emergency Evaluation of Patients Presenting with A Cute Scrotum, Academy of Emergency Medicine. Jan 2001
Neonatal Torsion
70% prenatal, 30% post-natal Post-natal typically 7-10 days after birth Unrelated to gestation age, birth weight Post-natal presents in typical fashion
Doppler U/S and radionucleotide scans less accurate with low blood flow in neonates
Surgical intervention if post-natal Prenatal torsion presents with painless testicular
swelling, rare testicular viability Rare intervention in prenatal torsion
Perinatal torsion
Torsion of Appendix Testis
Appendix testis Small vestigial structure,
remnant of Mullerium duct Pedunculated, 0.3cm long
Other appendix structures
Prepubertal estrogen may
enlarge appendix and cause
torsion
Torsion of Appendix Testis
Peak age 3-13 yo (prepubertal) Sudden onset, pain less severe Classically, pain more often in abd or groin Non-tender testicle
Tender mass at superior or inferior pole May be gangrenous, “blue-dot” (21% of cases) Normal cremasteric reflex, may have hydrocele Inc or normal flow by doppler U/S
Torsion of Appendix Testis
Blue dot of gangrenous
appendix testis
Testicular AppendagesAppendix testis
Appendix epididymis
Torsion of Appendix Testis
Management supportive analgesics, scrotal support to relieve swelling
Surgery for persistent pain no need for contralateral exploration
Epididymitis
Inflammation of epididymis Subacute onset pain, swelling localized to epididymis,
duration of days With time swelling and pain less localized
Testis has normal vertical lie Systemic signs of infection
inc WBC and CRP, fever + in 95%
Cremasteric reflex preserved Urinary complaints: discharge/dysuria PPV 80%
Epididymitis
Scrotum has overlying erythema, edema in 60% Normal vertical
lie
Epididymitis
Sexually active malesChlamydia > N. gonorrhea > E. coli
Less commonly pseudomonas (elderly) and tuberculosis (renal TB)
Young boys, adolescents often post-infectious (adenovirus) or anatomic Reflux of sterile urine through vas into epididymis 50-75% of prepubertal boys have anatomic cause by
imaging
Etiologies of Epididymitis
Epididymitis Diagnosis Leukocytosis on UA in ~40% of patients PCR Chlamydia + in 50%, GC + in 20% of
sexually active 95% febrile at presentation Doppler and Nuclear imaging show increased flow If hx consistent with STD, CDC recommends:
Cx of urethral discharge, PCR for C and G Urine culture and UA Syphilis and HIV testing
Laboratory Adjuncts Studies of acute phase reactants: CRP, IL-1, IL-6
Documented epididymitis have 4 fold increase in CRP compared to testicular torsion
PPV 94% and NPV 94% (inc 2 fold) Testicular tumor showed no increase in CRP
Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of A Cute Scrotum, Journal of Urology. Feb 2001.
Doppler Epididymitis
Left Epididymitis Inc blood flow in
and around left testis
Epididymitis Treatment
Sexually active treat with Ceftriaxone/Doxycycline or Ofloxacin
Pre-pubertal boysTreat for co-existing UTI if presentSymptomatic tx with NASIDs, restReferral all to GU for studies to rule out VUR,
post urethral valves, duplications Negative culture has 100% NPV for anomaly
Orchitis
Inflammation/infection of testicle Swelling pain tenderness, erythema and shininess to
overlying skin
Spread from epididymitis,
hematogenous, post-viral Viral: Mumps, coxsackie,
echovirus, parvovirus Bacterial: Brucellosis
Mumps Orchitis
Extremely rare if vaccinated 20-30% of pts with mumps, 70% unilateral, rare
before puberty Presents 4-6 days after mumps parotitis Impaired fertility in 15%, inc risk if bilateral
Trauma
Result of testicular compression against the pubis bone, from direct blow, or straddle injuries
Extent depends on location of rupture Tunica albuginea ruptures (inner layer of tuncia vaginalis)
allows intratesticular hematoma to rupture into hematocele Rupture of tunica vaginalis allow blood to collect under
scrotal wall causing scrotal hematoma Doppler often sufficient to assess extent Surgery for uncertain dx, tunica albuginea rupture,
compromised doppler flow
Testicular Hematoma
Blood as a filling
defect in testis
Other Causes of Pain Incarcerated inguinal hernia Henoch-Schonlein Purpura
Vasculitis of testicular vessels Rarely presents with only scrotal pain
Referred pain Retrocecal appendix, urolithiasis, lumbar/sacral nerve injury
Non specific scrotal pain Minimal pain, nl exam – return immediately for inc symptoms
Scrotal Swelling
Hydrocele Varicocele Spermatocele Testicular Cancer
Hydrocele
Fluid accumulation
in potential space of
tunica vaginalis May be primary from
patent PV or secondary
to torsion/epididymitis
Hydrocele
Transilluminating
anterior cystic
mass
Hydrocele
Mass increases in size during day or with crying and decreases at night if communicating
If non-communicating and <1 yo follow If communicating (enlarging), scrotum tense
(may impair blood flow) requires repair Unlikely to close spontaneously and predisposes to
hernia
Varicocele
Collection dilated veins in
pampiniform plexus
surrounding spermatic cord More common on left side
R vein direct to IVC L vein acute angle to renal vein
~20% of all adolescent males
Varicocele
Often asymptomatic or c/o dull ache/fullness upon standing
Spermatic cord has ‘bag of worms’ appearance that increased with standing/valsalva
If prepubertal, rapidly enlarging, or persists in supine position rule out IVC obstruction
Most management conservatively Surgery if affected testis < unaffected testis volume
Spermatocele
Painless sperm containing
cyst of testis, epipdidymis Distinct mass from testis
on exam Transilluminates Do not affect fertility Surgery for pain relief only
Testicular Cancer
Most common solid tumor in 15-30 yo males20% of all cancers in this group
Painless massRapidly growing germ cell tumors may cause
hemorrhage and infarctionPresent as firm massTypically do not transilluminate
Diagnostic imaging with U/S initially
Acute Idiopathic Scrotal Edema
Scrotal skin red and tender underlying testis normal no hydrocele
Erythema extends off
scrotum onto perineum Empiric tx, cause unknown
Antihistamine, steroids Resolves w/in 48-72hrs
Conclusions Clinical history and careful exam are key factors in
formulating accurate differential Imaging and labs useful adjuncts in unclear cases
U/S superior to nuclear imaging if time essential
TIME IS TESTICLE Early surgical intervention and GU involvement
Swelling without pain, usually less time sensitive diagnostically
References
Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum, European J. of Ped. Surgery. Oct 2004.
Blavis M., Emergency Evaluation of Patients Presenting with Acute Scrotum, Academy of Emergency Medicine. Jan 2001
Doehn C., Value of Acute Phase Proteins in the Differential Diagnosis of Acute Scrotum, Journal of Urology. Feb 2001.
Kaplan G., Scrotal Swelling in Children. Pediatrics in Review. Sep 2000.
Luzzi GA. Acute Epididymitis. BJU International. May 2001. Fleisher G, Ludwig S, Henretig F. Textbook of Pediatric Emergency
Medicine. 2006.