urological emergencies
TRANSCRIPT
Urological Emergencies• Smith’s general urology Emil A.tanagho, jack W.McAninch• اکبرنورعلیزاده دکتر فروش، دکترناصرسیم ارولوژیعمومی• emedicine.medscape.com
به نام خدا
Classification
TraumaticRenal Trauma
Ureteral Injury
Bladder Trauma
Urethral Injury
Penile trauma
Testicular Trauma
Non traumaticHematuria
Renal Colic
Urinary Retention
Acute Scrotum
Priapism
Renal Trauma
the most common injuries of the urinary systemMost injuries occur from motor vehicle accidents, fights, falls, and contact sports
Decelerationabdominal visceral injuries are present in 95% of renal penetrating wounds.
Signs:Lower rib fractures(11,12)DecelerationVertebral injuryEcchymosis in the flank or upper quadrants of the abdomen
GunshotPsoas shadow, ground glass
Pathologic classification of renal injuries: Grade 1 (the most common): Renal contusion or bruising of
the renal parenchyma Microscopic hematuria(gross
hematuria can occur rarely)
Grade 2: Renal parenchymal laceration into the renal cortex Perirenal hematoma is usually small (<1cm)
Grade 3: Renal parenchymal laceration extending through the
cortex and into the renal medulla. Bleeding can be significant in the presence of
largeretroperitoneal hematoma.
Grade 4: Renal parenchymal laceration extending into the renal
collecting system; also, main renal artery thrombosis from blunt trauma, segmental renal vein,or both; or artery injury with contained bleeding.
Grade 5: Multiple Grade 4 parenchymal lacerations,renal pedicle
avulsion, or both; main renal vein or artery injury from penetrating trauma.
Advance one grade for bilateral injury up to grade 3.
Indications for imaging studies:
Any child with microscopic(>5 RBCs per high powered field or dipstick hematuria) or macroscopic hematuria
Macroscopic hematuria Microscopic hematuria a hypotensive patient (SBP <90mmHg ) Penetrating wounds A history of a rapid deceleration, Falling (>4m), bicycle accident, car
accident, sports
Imaging studies:
Abdominal CT with contrast media is the best imaging study to detect and stage renal and retroperitoneal injuries. venous injuries urinary extravasation: avulsion of the renal pedicle, renal
pelvic injuries Decreased enhancement: arterial thrombosis, arterial spasm,
shock, renal artery injury (arteriography) IVP Arteriography(embolization) sonography
Complications: A. EARLY COMPLICATIONS:
Hemorrhage is the most important immediate complication Urinary extravasation (urinoma) [prone to abscess
formation and sepsis] perinephric abscess
B. LATE COMPLICATIONS: Hypertension hydronephrosis arteriovenous fistula Calculus formation pyelonephritis
Treatment: A. EMERGENCY MEASURES: Treatment of shock and hemorrhage, complete resuscitation,
and evaluation of associated injuries. B. SURGICAL MEASURES 1. Blunt injuries 2. Penetrating injuries
1. Blunt injuries:
98% of cases and do not usually require operation (bed rest and hydration)
Indications for surgery:
1. persistent retroperitoneal bleeding
2. urinary extravasation
3. evidence of nonviable renal parenchyma
4. renal pedicle injuries
2. Penetrating injuries
Grades 3,4,5 Penetrating injuries should be surgically explored.
Emergent laparotomy without imaging Renal artery injury(<8h)
INJURIES TO THE URETER is rare but may occur, usually during:
difficult pelvic surgical procedure as a result of gunshot wounds Endoscopic basket manipulation of ureteral calculi
Etiology: Gunshot (the most common penetrating trauma) Vertebral fractures (the most common blunt trauma) Hysterectomy, oophorectomy(the most common surgical injury) Ureteroscopy
INJURIES TO THE URETER
Clinical Findings fever of 38.3°C–38.8°C flank and lower quadrant pain Uremia paralytic ileus with nausea and vomiting cutaneous fistula, vaginal fistula
Diagnosis and treatment
Imaging IVP CT scan Retrograde urography
treatment repair is in the operating room Delayed repair
INJURIES TO THE BLADDER Bladder injuries occur most often from external force and are
often associated with pelvic fractures. Pelvic fracture with hematuria bladder examination Pelvic and abdominal Penetrating trauma with hematuria
cystography Gynecologic surgery, pelvic surgery, repair of hernia
Clinical findings: Pelvic fracture accompanies bladder rupture in 90% of
cases. Pelvic fracture with supra pubic tenderness Patients ordinarily are unable to urinate, but when
spontaneous voiding occurs. gross hematuria is usually present.
Treatment:
extraperitoneal rupture
Indication for surgery:
1. patients who need another surgery
2. Open fractures of pelvic
3. Rupture of the rectum
4. fragment projecting into the rupture
Intraperitoneal rupture Surgical repaire
INJURIES TO THE URETHRA Urethral injuries are uncommon and occur most often in
men, usually associated with pelvic fractures or straddletype falls. They are rare in women.
INJURIES TO THE POSTERIOR URETHRA: Patients usually complain of lower abdominal pain and inability
to urinate. Blood at the urethral meatus is the single most important sign
of urethral injury. The presence of blood at the external urethral meatus
indicates that immediate urethrography is necessary to establish the diagnosis.
Treatment:
Stricture impotence incontinence
Complications:
1. Immediate management
2. Delayed urethral reconstruction
3. Immediate urethral realignment
INJURIES TO THE ANTERIOR URETHRA
Straddle injury may cause laceration or contusion of the urethra.
iatrogenic instrumentation may cause partial disruption.
Treatment: Hemostasis Cystostomy Anastomosis
INJURIES TO THE PENIS Disruption of the tunica albuginea
Disruption of the tunica albuginea of the penis (penile fracture) can occur during sexual intercourse.
At presentation,the patient has penile pain and hematoma. This injury should be surgically corrected.
Penile amputation Penile amputation involves the complete or partial severing of
the penis Amputation of the penis may be accidental but is often self-
inflicted, especially during psychotic episodes in individuals who are mentally ill.
INJURIS TO THE PENIS Penetrating injury
RUG Immediate repair Delayed repair
avulsion of the penile skin Immediate debridement and skin grafting
INJURIES TO THE TESTIS Blunt trauma to the testis causes severe pain and,
often,nausea and vomiting. Lower abdominal tenderness may be present. A hematoma may surround the testis and make delineation
of its margin difficult. If rupture has occurred, the sonogram will delineate the
injury, which should be surgically repaired. Operative indications for blunt trauma: suspicion of rupture expanding hematomas
Diagnosis:Physical exam:
Enlargement and edema of the testicle; edema involving the entire scrotum
Scrotal erythema the testis is high riding compared with the other side The cremasteric reflex is almost always absent or diminished on the
affected side Imaging studies: Imaging studies usually are not necessary. Ordering them wastes
valuable time when the definitive treatment is emergent urologic consultation for surgical management.
color Doppler ultrasonography: Absent or decreased blood flow in the affected testicle
Radionuclide Scan: demonstrate decreased uptake in the affected testicle
Testicular tortion the torsion of the spermatic cord structures and subsequent loss of
the blood supply.
Presentation: sudden onset of severe unilateral scrotal pain followed by
inguinal and/or scrotal swelling. Torsion can occur with sports or physical activity, can be related
to trauma in 4-8% of cases,or can develop spontaneously. Vomiting Fever, Dysuria, frequency are usually absent.
Treatment: Immediate surgical exploration is indicated(4h) If treatment is delayed, the patient may experience decreased fertility or may
require orchiectomy(8h) The spermatic cord is untwisted, then fix gonads to the scrotal wall
DDX Differential Diagnoses Appendicitis Fournier Gangrene Henoch-Schonlein Purpura in Emergency Medicine Hernias Scrotal Trauma Spermatocele Testicular Choriocarcinoma Testicular Seminoma Testicular Trauma Varicocele
priapism Priapism is an uncommon condition of prolonged erection. It is
usually painful for the patient, and no sexual excitement or desire is present.
A bimodal distribution has been noted, with peaks at 5-10 years and 20-50 years
Etiology: The most common cause of priapism in the pediatric
population is sickle cell disease Leukemia, trauma, idiopathic, pharmacologic Fat embolism (from multiple long-bone fractures or
intravenous infusion of lipids as part of total parenteral nutrition)
Prostate cancer, Bladder cancer (highest risk), Hematologic cancer (leukemia), Renal carcinoma, Melanoma
Classification:
High-flow priapism (nonischemic) usually occurs secondary to perineal trauma, which
injures the central penile arteries and results in loss of penile blood-flow regulation
Low-flow priapism (ischemic) presents with a history of several hours of painful
erection. The glans penis and corpus spongiosum are soft and
uninvolvedin the process
Presentation: Obvious erection is the key physical finding in any case of priapism Pain and tenderness Edema Thrombosis, fibrosis, necrosis
Diagnosis: history Physical examination CBC, hemoglobin S determination Penile blood gas (PBG) test Color-flow penile Doppler imaging
Treatment: low-flow priapism
starting with therapeutic aspiration Irrigation intracavernous injection of a sympathomimetic agent attempt to treat the underlying condition
High-flow priapism embolization of the offending vessel
Surgical treatment: A unilateral shunt is often effective
Complications: Fibrosis impotence
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