Urology

UROLOGICAL EMERGENCY

Dr.Mahmoud AL-Habashneh General Surgeon & Urologist Royal Medical Services

DEFINITION

Urologic emergency arises when a condition require rapid diagnosis and immediate treatment Compared to other surgical fields there are relatively few emergencies in urology

Urological Emergencies

Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal Trauma Ureteral Injury Bladder Trauma Urethral Injury Testicular Trauma

Urological Emergencies

Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal Trauma Ureteral Injury Bladder Trauma Urethral Injury Testicular Trauma

Hematuria

Blood in the urine Types: Macroscopic ( frank, or gross hematuria)/ Dipstick hematuria / Microscopic hematuria ( the presence of >3 red blood cells per high power microscopic field). Painless or painful. Initial / Terminal / Total

Hematuria… Causes Nephrological (medical) or urological (surgical) Medical causes: glomerular and nonglomerular blood dyscrasias, interstitial nephritis, and renovascular disease Surgical/urological nonglomerular causes: renal tumours, urothelial tumours (bladder, ureteric, renal collecting system), prostate cancer, bleeding from vascular benign prostatic enlargement, trauma, renal or ureteric stones, and UTI. Haematuria in these situations is usually characterised by circular erythrocytes and absence of proteinuria and casts.
Non traumatic emergency



Hematuria… Presentation: Hematuria Anemia: bleeding is so heavy (this is rare) Urine retention or ureteric colic (Clot retention) Work Up : History Examination nvestigation : All patients Urine culture and cytology Renal US Flexible cystoscopy, IVU or computed tomography (CT) scan in selected groups. Treat the cause

Non traumatic emergency

Urological Emergencies
Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal Trauma Ureteral Injury Bladder Trauma Urethral Injury Testicular Trauma


ACUTE FLANK PAIN—URETERIC OR RENAL COLIC The commonest urologic emergency.One of the commonest causes of the “Acute Abdomen”. Sudden onset of severe pain in the flankMost often due to the passage of a stone formed in the kidney, down through the ureter.

Renal colic…. The pain is characteristically : very sudden onset colicky in nature Radiates to the groin as the stone passes into the lower ureter. May change in location, from the flank to the groin, (the location of the pain does not provide a good indication of the position of the stone) The patient cannot get comfortable, and may roll around in agony. Associated with nausea / Vomiting the pain of a ureteric stone as being worse than the pain of labour.
Non traumatic emergency


Renal colic…. Differential diagnoses Leaking abdominal aortic aneurysmsPneumoniaMyocardial infarction Ovarian pathology (e.g., twisted ovarian cyst)Acute appendicitis Testicular torsionInflammatory bowel disease (Crohn’s, ulcerative colitis)DiverticulitisEctopic pregnancy Burst peptic ulcerBowel obstruction Non traumatic emergency


Renal colic…. Work Up : History Examination: patient want to move around, in an attempt to find a comfortable position. +/- Fever Pregnancy test MSU
Non traumatic emergency



Renal colic…. Radiological investigation : KUB / Abdominal US IVP (was) Helical CTU advantages over IVP: greater specificity (95%) and sensitivity (97%) for diagnosing ureteric stones Can identify other, non-stone causes of flank pain. No need for contrast administration. Faster, taking just a few minutes the cost of CTU is equivalent to that of IVU MRI very accurate way of determining whether or not a stone is present in the ureter very high cost
Non traumatic emergency


Renal colic…. Acute Management of Ureteric Stones: Pain relief NSAIDs Intramuscular or intravenous injection, by mouth, or per rectum +/- Opiate analgesics (pethidine or morphine).? Hyper hydration ‘watchful waiting’ with analgesic supplements 95% of stones measuring 5mm or less pass spontaneously Non traumatic emergency


Renal colic…. Indications for Intervention to Relieve Obstruction and/or Remove the Stone: Pain that fails to respond to analgesics. Associated fever. Renal function is impaired because of the stone (solitary kidney obstructed by a stone, bilateral ureteric stones, or preexisting renal impairment ) Obstruction unrelieved for >4 weeks Personal or occupational reasons
Non traumatic emergency


Renal colic…. Treatment of the Stone: Temporary relief of the obstruction: Insertion of a JJ stent or percutaneous nephrostomy tube. Definitive treatment of a ureteric stone: ESWL. PCNL Ureteroscopy Open Surgery: very limited.
Non traumatic emergency

Urological Emergencies

Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal Trauma Ureteral Injury Bladder Trauma Urethral Injury Testicular Trauma

Urinary Retention

Acute Urinary retention Chronic Urinary retention
Non traumatic emergency

Acute Urinary retention

Painful inability to void, with relief of pain following drainage of the bladder by catheterization. Pathophysiology: Increased urethral resistance, i.e., bladder outlet obstruction (BOO) Low bladder pressure, i.e., impaired bladder contractility Interruption of sensory or motor innervations of the bladder
Non traumatic emergency


Acute urinary retention… Causes : Men:Benign prostatic enlargement (BPE) due to BPH Carcinoma of the prostateUrethral strictureProstatic abscess Women Pelvic prolapse (cystocoele, rectocoele, uterine)Urethral stricture;Urethral diverticulum; Post surgery for ‘stress’ incontinence pelvic masses (e.g., ovarian masses) Non traumatic emergency


Acute urinary retention…Causes… Both SexHaematuria leading to clot retentionDrugs PainSacral nerve compression or damage(cauda equina compression )Radical pelvic surgeryPelvic fracture rupturing the urethra Neurotropic viruses involving the sensory dorsal root ganglia of S2–S4 (herpes simplex or zoster); Multiple sclerosisTransverse myelitis Diabetic cystopathy Damage to dorsal columns of spinal cord causing loss of bladder sensation (tabes dorsalis, pernicious anaemia). Non traumatic emergency


Acute urinary retention… Initial Management : Urethral catheterisation Suprapubic catheter ( SPC) Late Management: Treating the underlying cause
Non traumatic emergency

Chronic urinary retention

Obstruction develops slowly, the bladder is distended (stretched) very gradually over weeks/months, so pain is not a feature . Presentation: Urinary dribbling Overflow incontinence Palpable lower suprapubic mass
Non traumatic emergency



Chronic urinary retention… Usually associated with Reduced renal function. Upper tract dilatation R/x is directed to renal support. Bladder drainage under slow rate to avoid sudden decompression> hematuria. Late R/x of cause.
Non traumatic emergency

Urological Emergencies

Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal Trauma Ureteral Injury Bladder Trauma Urethral Injury Testicular Trauma

Acute Scrotum

Emergency situation requiring prompt evaluation, differential diagnosis, and potentially immediate surgical exploration
Non traumatic emergency

Acute scrotum…Differential Diagnosis: Non traumatic emergency

Acute scrotum…Differential Diagnosis… Torsion of the Spermatic Cord (Intravaginal) Most serious. Torsion of the Testicular and Epididymal Appendages. Epididymitis. Most common
Non traumatic emergency

Torsion of the Spermatic Cord

(A) extravaginal; (B) intravaginal
Non traumatic emergency

Torsion of the Spermatic Cord (Intravaginal)

True surgical emergency of the highest order Irreversible ischemic injury to the testicular parenchyma may begin as soon as 4 hoursTesticular salvage ↓ as duration of torsion↑

Torsion of the Spermatic Cord… Presentation: Acute onset of scrotal pain. Majority with history of prior episodes of severe, self-limited scrotal pain and swelling. N/V Referred to the ipsilateral lower quadrant of the abdomen. Dysuria and other bladder symptoms are usually absent.
Non traumatic emergency

Torsion of the Spermatic Cord… Physical examination:

The affected testis is high- riding Transverse orientation. Acute hydrocele or massive scrotal edema Cremasteric reflex is absent. Tender larger than other side. Prehns sign Positiv. Manual detortion.

Non traumatic emergency

Torsion of the Spermatic Cord… Adjunctive tests: To aid in differential diagnosis of the acute scrotum. To confirm the absence of torsion of the cord. Doppler examination of the cord and testis High false-positive and false-negative results
Non traumatic emergency


Torsion of the Spermatic Cord… Color Doppler ultrasound: Assessment of anatomy and determining the presence or absence of blood flow. Sensitivity: 88.9% specificity of 98.8% Operator dependent.

Torsion of the Spermatic Cord… Radionuclide imaging : Assessment of testicular blood flow. Sensitivity of 90%, and a specificity of 89%. False impression from hyperemia of scrotal wall. Not helpful in Hydrocele and Hematoma


Non traumatic emergency


Torsion of the Spermatic Cord…Surgical exploration: A median raphe scrotal incision or a transverse incision. The affected side should be examined first The cord should be detorsed. Testes with marginal viability should be placed in warm sponges and re-examined after several minutes. A necrotic testis should be removed If the testis is to be preserved, it should be placed into the dartos pouch (suture fixation) The contralateral testis must be fixed to prevent subsequent torsion.
Non traumatic emergency

Torsion of the Spermatic Cord… Non traumatic emergency

Epid.Orchitis
Presentation: Indolent process. Scrotal swelling, erythema, and pain. Dysuria and fever is more common P/E : localized epididymal tenderness, a swollen and tender epididymis, or a massively swollen hemiscrotum with absence of landmarks. Cremasteric reflex should be present Urine: pyuria, bacteriuria, or a positive urine culture(Gram-negative bacteria) .
Non traumatic emergency


Epid.Orchitis… Management: Bed rest for 1 to 3 days then relative restriction . Scrotal elevation, the use of an athletic supporter parenteral antibiotic therapy should be instituted when UTI is documented or suspected. Urethral instrumentation should be avoided
Non traumatic emergency

Urological Emergencies

Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal Trauma Ureteral Injury Bladder Trauma Urethral Injury Testicular Trauma

Priapism

Persistent erection of the penis for more than 4 hours that is not related or accompanied by sexual desire.
Non traumatic emergency


Priapism… 2 Types: ischaemic (veno-occlusive, low flow (most common) Due to haematological disease, malignant infiltration of the corpora cavernosa with malignant disease, or drugs. Painful. nonischaemic (arterial, high flow). Due to perineal trauma, which creates an arteriovenous fistula. Painless Age: Any age two main age groups affected are 5- to 10-year-old boys and 20- to 50-year-old men.

Priapism… Causes: Primary (Idiopathic) : 30%- 50% Secondary: Drugs Trauma Neurological Hematological disease Tumors Miscellaneous

Non traumatic emergency

Priapism… The diagnosis Usually obvious from the history Duration of erection >4 hours? Is it painful or not?. Previous history and treatment of priapism ? Identify any predisposing factors and underlying cause Examination Erect, tender penis (in low-flow priapism). Characteristically the corpora cavernosa are rigid and the glans is flaccid. Abdomen for evidence of malignant disease DRE: to examine the prostate and check anal tone.
Non traumatic emergency


Priapism… Investigations: CBC (white cell count and differential, reticulocyte count) Hemoglobin electrophoresis for sickle cell test Urinalysis including urine toxicology Blood gases taken from either corpora, low-flow (dark blood; pH <7.25 (acidosis); pO2 <30mmHg (hypoxia); pCO2 >60mmHg (hypercapnia)) high-flow (bright red blood similar to arterial blood at room temperature; pH = 7.4; pO2 >90mmHg; pCO2 <40mmHg)
Non traumatic emergency



Priapism… Colour flow duplex ultrasonography in cavernosal arteries: Ischaemic (inflow low or nonexistent) Nonischaemic (inflow normal to high). Penile pudendal arteriography

Priapism… Treatment:Depends on the type of priapism. Conservative treatment should first be triedMedical treatmentSurgical treatment.Treatment of underlying cause→→ It is important to warn all patients with priapism of the possibility of impotence. Non traumatic emergency

Urological Emergencies

Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal injuries Ureteral injuries Bladder injuries Urethral Injuries Testicular injuries

Traumatic Urological Emergencies

RENAL INJURIES URETERIC INJURIES BLADDER INJURIES URETHRAL INJURIES TESTICULAR INJURIES PENILE INJURIES PENILE FRACTURE

RENAL INJURIES

The kidneys relatively protected from traumatic injuries. Considerable degree of force is usually required to injure a kidney.
Traumatic emergency


Mechanisms and cause: Blunt direct blow or acceleration/ deceleration (road traffic accidents, falls from a height, fall onto flank) Penetrating knives, gunshots, iatrogenic, e.g., percutaneous nephrolithotomy (PCNL)

Renal injuries… Indications for renal imaging: Macroscopic hematuria Penetrating chest, flank, and abdominal wounds Microscopic [>5 red blood cells (RBCs) per high powered field] or dipstick hematuria a hypotensive patient (SBP <90mmHg ) A history of a rapid acceleration or deceleration Any child with microscopic or dipstick hematuria who has sustained trauma.
Traumatic emergency



Renal injuries… What Imaging Study? IVU: replaced by the contrast-enhanced CT scan On-table IVU if patient is transferred immediately to the operating theatre without having had a CT scan and a retroperitoneal haematoma is found, Spiral CT: does not allow accurate staging
Traumatic emergency


Renal injuries… Renal US: Advantages: can certainly establish the presence of two kidneys the presence of a retroperitoneal hematoma power Doppler can identify the presence of blood flow in the renal vessels. Disadvantages: cannot accurately identify parenchymal tears, collecting system injuries, or extravasations of urine until a later stage when a urine collection has had time to accumulate. Contrast-enhanced CT: the imaging study of choice accurate, rapid, images other intra-abdominal structures
Traumatic emergency


Renal injuries… Staging (Grading) American Association for the Surgery of Trauma Organ Injury Severity Scale
Traumatic emergency


Renal injuries… Management: Conservative: Over 95% of blunt injuries 50% of renal stab injuries and 25% of renal gunshot wounds (specialized center). Include: Wide Bore IV line. IV antibiotics. Bed rest serial CBC (Htc) F/up US &/or CT. 2-3 wks.
Traumatic emergency


Renal injuries… Surgical exploration: Persistent bleeding (persistent tachycardia and/or hypotension failing to respond to appropriate fluid and blood replacement Expanding perirenal haematoma (again the patient will show signs of continued bleeding) Pulsatile perirenal haematoma
Traumatic emergency



Urological Emergencies
Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal injuries Ureteral injuries Bladder injuries Urethral Injuries Testicular injuries

URETERIC INJURIES

The ureters are protected from external trauma by surrounding bony structures, muscles and other organs Causes and Mechanisms : External Trauma Internal Trauma
Traumatic emergency


Ureteric injuries… External Trauma: Rare Severe force is required Blunt or penetrating. Blunt external trauma severe enough to injure the ureters will usually be associated with multiple other injuries Knife or bullet wound to the abdomen or chest may damage the ureter, as well as other organs.
Traumatic emergency


Ureteric injuries… Internal Trauma Uncommon, but is more common than external trauma Surgery: Hysterectomy, oophorectomy, and sigmoidcolectomy Ureteroscopy Caesarean section Aortoiliac vascular graft placement, Laparoscopic procedures, Orthopedic operations
Traumatic emergency


Ureteric injuries… Diagnosis: Requires a high index of suspicion Intraoperative: Late: 1. An ileus: the presence of urine within the peritoneal cavity 2. Prolonged postoperative fever or overt urinary sepsis 3. Persistent drainage of fluid from abdominal or pelvic drains, from the abdominal wound, or from the vagina. 4. Flank pain if the ureter has been ligated 5. An abdominal mass, representing a urinoma 6. Vague abdominal pain 7. The pathology report on the organ that has been removed may note the presence of a segment of ureter!
Traumatic emergency



Ureteric injuries… Treatment options: JJ stenting Primary closure of partial transection of the ureter Direct ureter to ureter anastomosis Reimplantation of the ureter into the bladder (ureteroneocystostomy), either using a psoas hitch or a Boari flap Transureteroureterostomy Autotransplantation of the kidney into the pelvis Replacement of the ureter with ileum Permanent cutaneous ureterostomy Nephrectomy
Traumatic emergency

Ureteric injuries… Traumatic emergency

Urological Emergencies
Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal injuries Ureteral injuries Bladder injuries Urethral Injuries Testicular injuries

BLADDER INJURIES

Causes:Iatrogenic injuryTransurethral resection of bladder tumour (TURBT)Cystoscopic bladder biopsyTransurethral resection of prostate (TURP)CystolitholapaxyCaesarean section, especially as an emergency Total hip replacement (very rare)Penetrating trauma to the lower abdomen or backBlunt pelvic trauma—in association with pelvic fracture or ‘minor’ trauma in the inebriated patientRapid deceleration injury—seat belt injury with full bladder in the absence of a pelvic fractureSpontaneous rupture after bladder augmentation Traumatic emergency

Types of Perforation

A-intraperitoneal perforation the peritoneum overlying the bladder, has been breached along with the wall of the bladder, allowing urine to escape into the peritoneal cavity.
Traumatic emergency


B- extraperitoneal perforation the peritoneum is intact and urine escapes into the space around the bladder, but not into the peritoneal cavity.
Traumatic emergency



Bladder injuries… Presentation: Recognized intraoperatively The classic triad of symptoms and signs that are suggestive of a bladder rupture suprapubic pain and tenderness, difficulty or inability in passing urine, and haematuria
Traumatic emergency


Bladder injuries… Management:Extraperitoneal Bladder drainage +++++ Open repair +++Intra peritoneal : open repair…why? Unlikely to heal spontaneously. Usually large defects. Leakage causes peritonitis Associated other organ injury. Traumatic emergency

Urological Emergencies

Non traumatic Hematuria Renal Colic Urinary Retention Acute Scrotum Priapism Traumatic Renal injuries Ureteral injuries Bladder injuries Urethral Injuries Testicular injuries

URETHRAL INJURIES

ANTERIOR URETHRAL INJURIES POSTERIOR URETHRAL INJURIES
Traumatic emergency

ANTERIOR URETHRAL INJURIES

Rare Mechanism: The majority a result of a straddle injury in boys or men. Direct injuries to the penis Penile fractures Inflating a catheter balloon in the anterior urethra Penetrating injuries by gunshot wounds.



Ant. Urethral injuries… Symptoms and signs: Blood at the end of the penis Difficulty in passing urine Frank hematuria Hematoma may around the site of the rupture Penile swelling
Traumatic emergency


Ant. Urethral injuries… Diagnosis: Retrograde urethrography Contusion: no extravasation of contrast: Partial rupture : extravasation of contrast, with contrast also present in the bladder:. Complete disruption: no filling of the posterior urethra or bladder
Traumatic emergency


Ant. Urethral injuries… Management Contusion A small-gauge urethral catheter for one week Partial Rupture of Anterior Urethra No urethral catheterization Majority can be managed by suprapubic urinary diversion for one week Penetrating partial disruption (e.g., knife, gunshot wound), primary (immediate) repair. Complete Rupture of Anterior Urethra patient is unstable a suprapubic catheter. patient is stable, the urethra may either be immediately repaired or a suprapubic catheter Penetrating Anterior Urethral Injuries generally managed by surgical debridement and repair
Traumatic emergency

POSTERIOR URETHRAL INJURIES

Great majority of posterior urethral injuries occur in association with pelvic fractures 10% to 20% have an associated bladder rupture Signs Blood at the meatus, gross hematuria, and perineal or scrotal bruising. High-riding prostate


Classification of posterior urethral injuries type I:(rare ) stretch injury with intact urethra type II : (25%) partial tear but some continuity remains) type III:(75%) complete tear with no evidence of continuity In women, partial rupture at the anterior position is the most common urethral injury associated with pelvic fracture.
Traumatic emergency

Traumatic emergency

Management: Stretch injury (type I) and incomplete urethral tears (type II) are best treated by stenting with a urethral catheter. Type III Patient is at varying risk of urethral stricture, urinary incontinence, and erectile dysfunction (ED) Initial management with suprapubic cystotomy and attempting primary repair at 7 to 10 days after injury.
Traumatic emergency

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