Urological Emergencies Monthira Tanthanuch Div. Of Urology, Dept. of Surgery, Fac. of Medicine, Prince of Songkla Univ.
Urological Emergencies
• Trauma • Non trauma
Trauma
Renal injury Ureteral injury Bladder injury Urethral injury Penile injury Scrotal and testicular injury
Non trauma Failure of drainage upper & lower urinary tract Infection pyelonephritis, pyonephrosis, renal abscess cystitis, periuretral abscess, epididymo-orchitis prostatitis, prostatic abscess Fournier#s gangrene Torsion of the testis and testicular appendages Paraphimosis Priapism
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Urological Emergency in Trauma
Injuries to the Genitourinary Tract •
~ 10 % of trauma case at ER involve
•
Emergency diagnosis and treatment
the GU tract
Initial Assessment • Control bleeding and shock
• Resuscitation
ABCD
Renal Injury
Renal injury
Most common ~80 % have associate with other organs injuries Amount of hematuria does not correlate to severity of injury Blunt injury Penetrating injury 80-85 % of renal inj. case 5.4 % significant conservative Rx
15-20 % of renal inj. case 64 % significant surgical Rx
Mechanism of injury
Blunt injury
Mechanism of injury
Penetrating injury
Degree of injury AAST : The American Association for the Surgery of Trauma
Minor ; Grade I, II
; ~85 % of cases
Major ; Grade III, IV, V ; ~15 % of cases, (vascular ~1% of blunt trauma case)
Grade I : Contusion or subcapsular
hematoma without parenchymal laceration : microscopic/gross hematuria : normal image study
Grade II : Nonexpanding, perirenal hematoma or cortical laceration less than 1 cm deep without urinary extravasation
Grade III : Parenchymal laceration extending more than 1 cm into the cortex without urinary extravasation
Grade IV : Parenchymal laceration extending through the corticomedullary junction and into the collecting system
Grade V : Multiple major laceration -> Shattered kidney : Thrombosis of the main renal artery : Avulsion of the main renal artery and/or vein
Blunt renal injury
Indicators for major injury Rib or vertebral body fractures Flank ecchymosis Abdominal tenderness/ distension Multiple organ injuries AUA instructional course 2001 ,Anaheim California
Blunt renal injury
Hematuria First void urine Test by microscopic analysis or dipstick test More than 5 RBC/hpf (may absence in vascular injury)
Penetrating renal injury
Higher index of suspicious Wound at flank, lower chest, abdomen Any degree of hematuria require immediately imaging study Blast effect from GSW
AUA instructional course 2001 ,Anaheim California
When is imaging indicated ?
Penetrating trauma Blunt trauma with gross hematuria Blunt trauma with microscopic hematuria with shock (SBP < 90 mmHg) Decelerating injury
Type of imaging
IVP : standard, single shot, intraoperative (2 mg/kg of contrast, 10 min film)
Abdominal CT scan : evaluate associated organ injuries, staging, devitalized segment Renal angiography : identify pedicle injury, assessment of persistent or delayed bleeding > embolization
IVP
Scout IVP ;
fracture, calculi
5 min film ; function, leakage
30 min film ; function, leakage, bladder
Abdominal CT Scan
Renal angiography
Treatment of renal injury
Minor injury : conservative treatment Bed rest Hydration Antibiotics (V/S, hematuria, mass, serial Hct in the first 24 - 48 hours)
Indication for explor lap in renal injury
Hemodynamic instability Renovascular injury (within 12 hours) ; with
preservation rate 14 - 29% even prompt Dx and repair
Penetrating injury, especially GSW UPJ disruption Large non-viable parenchyma Infection of hematoma or urinoma
Proximal vascular control
Exposure of renal fossa after vascular control
Debridement of devitalized tissue Homeostasis Closure of the collecting system Coverage of the parenchymal defect
Blunt renal injury
Penetrating renal injury
Ureteral Injury
Ureteral Injury Least common ( 30 % Early phase Non specific signs
Delayed phase Prolonged ileus Urinary leakage Urinary obstruction Anuria Sepsis
Injury assessment Intraoperative diagnosis Visual inspection Dye Delayed diagnosis IVP RP ; Retrograde pyelography
AAST severity scale for the ureter
Principal of management
Bladder Injury
Bladder Injury 15 % of pelvic fracture case has bladder / urethral injury 90 % of bladder injury has fracture pelvis
Mechanism of injury
Classification of bladder injury
AAST severity scale for the bladder
AIS-90 : American Association for Automotive Medicine, 1990
Diagnosis History of lower abdominal trauma Complaint of suprapubic pain & tenderness Unable to void ( low urine output ) Gross hematuria
Guideline for imaging
Pelvic fracture + Gross hematuria : Absolute Pelvic fracture + Micro hematuria : Relative Gross hematuria + NO pelvic fracture : Relative Atypical : Abd distension, ileus, inc BUN / Cr
Cystography
Using at least 350 ml of 30 % of contrast via urethral catheterization Film ; AP, oblique Film ; empty bladder
Extraperitoneal rupture
Flame - shape extravasation Tear drop deformity of bladder (pelvic hematoma) 89 - 100 % associated with pelvic fracture
Intraperitoneal rupture
Extravasation of contrast outlining loops of bowel, filling lumbar gutter
Treatment of bladder injury
Bladder contusion Foley catheter drainage for a few days Penetrating injury Surgical exploration and repair bladder
Treatment of bladder injury
Intraperitoneal rupture Surgical exploration and repair bladder Extraperitoneal rupture Foley catheter drainage for 10-14 days Open repair : patient require surgery for other organ injury : large amount of extravasation
Urethral Injury
Mechanism of urethral injury
Anterior urethral injury
Posterior urethral injury
AAST severity scale for the urethra
Anterior urethral injury
Diagnosis Hemorrhage in Buck#s fascia : Sleeve appearance Hemorrhage in Colles# fascia : Butterfly appearance Bleeding per meatus : Injury from open wound
Anterior urethral injury
Buck#s fascia
Colles# fascia
Treatment of anterior urethral injury
Posterior urethral injury
> 90 % of case has pelvic fracture ~ 10 % of pelvic fracture has post urethral inj Diagnosis Bleeding per meatus Unable to void Floating prostate
(puboprostatic ligament)
Urethrography 25 ml contrast , film : 30 degree oblique position
Partial tear
Complete tear
Treatment of posterior urethral injury
Partial tear gentle attempt to pass urethral cath and retain for 7 - 10 days Complete tear Initial management : suprapubic cystostomy for 3 month Treatment of stricture urethra : open surgery, endoscopic
Penile injury
Fracture Gangrene Avulsion Amputation
Penile Injury Possible urethral injury -> urethrogram in suspected case
Penile fracture Disrupt of tunica albuginia during erection Snap sound, sudden pain, flaccid, hematoma Surgery
Penile gangrene Obstructing rings placed around base of penis Remove foreign body
Total avulsion Machinery injury Debridement & STSG Amputation Reconstruction
Scrotal Injury Hematoma Hematocele Avulsion
Scrotal Injury
Hematoma (subcut.) R/O testicular rupture Conservative Rx : elevation , ice/warm , anal. Large expanding : evacuation Hematocele Bleed in tunica vaginalis 80 % ass with testicular rupture Large expanding : evacuation Avulsion Debridement & groin implantation
Testicular Injury
Testicular rupture Scrotal hematoma Explor scrotum in questionable case Testicular dislocation Empty scrotum after trauma Reduction Explor : Failure reduction, R/O rupture testis, R/O torsion testis
Non trauma Torsion of the testis and testicular appendages Fournier#s gangrene Paraphimosis Priapism
Testicular torsion : twist of the testicle and strangle the spermatic cord : cut of blood supply : necrosis, atrophy
Signs & symptoms : sudden severe testicular pain : swelling and axis changing of testis : nausea and vomiting
Investigation : Doppler sonography identify the absence of blood flow : Urinalysis to rule out bacterial infections
Treatment
: Detorsion & orchiopexy : Orchiectomy
Fournier’s Gangrene (Necrotizing fasciitis) fasciitis) : fulminant , rapidly progressing subcutaneous infection of perineum area : 20 – 25 % mortality rate
Fournier’s Gangrene : Mixed aerobic and anaerobic bacteria : Mechanism of infection local trauma, extension from urinary tract infection, extension from perianal, perianal, periurethral, periurethral, or ischiorectal infection
Fournier’s Gangrene : Delayed treatment bacterial infection spread into bloodstream and cause multiple organ failure : Risk factors alcoholism, diabetes mellitus (DM), leukemia, morbid obesity, immune system disorders
Signs & symptoms : Crepitant skin (spongy to the touch) : Severe genital pain, sign of inflammation : Dead and discolored (grey(grey-black) tissue, pus : Fever & drowsiness : Foul smell
Treatment : hemodynamic stabilization : parenteral broadbroadspectrum antibiotics : surgical debridement
Paraphimosis
: Swelling of the glans after retracted prepuce in uncircumcised penis : the constricted band obstructs blood flow and cause tissue necrosis
Causes of Paraphimosis
Catheterization
Bacterial infection (balanoposthitis (balanoposthitis) balanoposthitis) Poor hygiene Vigorous sexual intercourse
Signs & symptoms : Band of retracted foreskin tissue beneath the glans : Penile pain : Swelling of the glans
Treatment Manual reduction
Dorsal slit / circumcision
Priapism : Prolonged, painful penile erection : Occurs when blood in the penis is trapped or unable to drain
Painful erection lasting for more than 4 hours : Priapism
Classification VenoVeno-occlusive (low flow) : circulation in penis becomes sluggish : high incidence in sickle cell anemia, leukemia, malaria, colonic cancer Arterial (high flow) : rare : less painful type of priapism : result from injury to the penis or perineum area that cause rupture of artery in the penis
Risk factors of priapism : Disease that affect blood circulation (sickle cell anemia, leukemia, malaria) : Cancer e.g., colonic cancer Drug : Party drug use (cocaine, marijuana) : Injected drug use for erectile dysfunction (papaverine, papaverine, phentolamine) phentolamine)
: Antidepressive drugs (trazodine,chlorpromazine) trazodine,chlorpromazine) : Alcohol consumption, androgenic steroids
Risk factors of priapism Other : animal bite
black widow spider
: prolonged sexual activity : perineal trauma
scorpion
Priapism Signs & symptoms : Painful penile erection lasts 4 hours or more
Investigation : For underlying disease : Doppler ultrasonogram (low flow / high flow)
Treatment
corpus cavernosum – corpus spongiosum
Distal shunt
Proximal shunt
CavernosoCavernoso-venous shunt
Saphenous vein
