Transcript Urological Emergencies for the Non

Urological Emergencies for the
Non-Urologist
Mr C Dawson MS FRCS
Consultant Urologist
Edith Cavell Hospital
Peterborough
Content of the Presentation
Renal Colic
 Testicular Torsion
 Trauma
 Paraphimosis
 Priapism
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Renal Colic
Does not always present with classic
history
 Classically presents with loin pain
radiating around abdomen, as stone
moves down ureter
 May get testicular/labial pain +/strangury if stone impacts at VUJ
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Renal Colic
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Full examination essential – primarily to rule
out other causes for pain
Look for signs of Sepsis
Differential diagnosis includes
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Acute Appendicitis
Diverticulitis
Salpingitis
Ruptured Aortic Aneurysm
Pyelonephritis
Ectopic Pregnancy
Renal Colic - Investigations
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Routine Urinalysis – microscopic haematuria
is common but not invariable
IVP
– Particularly in patients over 50 (?AAA)
– USS and KUB if contrast allergic
– Caution in Pregnancy
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Pregnancy Test in all fertile women of child
bearing age
Renal Colic - Management
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If NO signs of ureteric obstruction on IVP
AND Pain free
– Home with explanation of symptoms
– Review after 2/52 in OPD
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If IVP shows obstruction of ureter
– Admit for observation
– May still be allowed home for trial of stone
passage
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If Obstructed AND signs of Sepsis
– Urgent Nephrostomy
Renal Colic - Management
Size of Stone
Management
< 4mm
Conservative: 90% pass
spontaneously
50% pass spontaneously
– trial of passage
Intervention likely, only
10% pass
spontaneously
4-6 mm
> 6mm
Testicular Torsion
Can occur at any age
 Most common in adolescents
 Occasionally seen in neonates
 In infants (and esp neonates) the
symptoms and signs are imprecise
 Prompt action required to avoid
irreversible testicular ischaemia
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Testicular Torsion
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Diagnosis usually made solely on basis
of clinical examination
– Testis usually swollen and exquisitely
tender
– Lies horizontally and retracted compared to
normal side
Testicular Torsion
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Studies have shown that only 25% of boys
presenting with acute scrotal swelling with
have torsion
No reliable diagnostic test exists
Doppler USS can effectively establish the
presence of arterial inflow
Surgical exploration remains the final arbiter,
and should not be delayed whilst waiting for
investigations
Testicular Torsion
Urological Trauma
Fortunately very rare
 Typical victims
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– Young men involved in sport (55%)
– People in RTAs (25%)
– Domestic or industrial accidents (15%)
– Victims of Assault (5%)
Urological Trauma
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Upper Urinary Tract
– Renal injuries
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Lower Urinary Tract
– Bladder
– Urethra
– External Genitalia
Urological Trauma - Overview
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Take a careful history
– Mechanism of injury (blunt trauma, penetrating
trauma)
– Velocity of injury
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Careful Assessment
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Careful Examination
ABC of Primary Survey
Baseline Investigations
Appropriate Radiology and additional imaging
Primary Survey
From ABC of Major Trauma
(chapter by Cope and
Stebbings)
Renal Trauma
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The Kidney is the most commonly injured
urological organ
Injuries can be blunt (80-90%) or penetrating
Blunt trauma occurs with upper abdominal
injury and rapid deceleration
Such injuries usually involve multiple organ
systems and patients – other injuries must be
suspected and excluded
Renal Trauma – Radiological
Assesment
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Adult patient with blunt trauma
– Visible haematuria, or microscopic
haematuria and shock - Needs
Radiological assessment
– Microscopic haematuria without shock –
radiological assessment not required
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Adult patients with penetrating trauma /
All Paediatric patients – require
radiological assessment
Renal trauma
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Radiological Assessment should begin with IVU –
Most patients adequately staged this way
CT has largely replaced the arteriogram and IVU in
the diagnosis and management of severe abdominal
or GU trauma
Patients who are haemodynamically unstable will
require immediate laparotomy
85% of blunt renal injuries require no surgery, 5-10%
require judgement and surgical exploration, 5% are
non-salvageable and require nephrectomy
Lower Urinary Tract – Bladder
and Urethra
Approx 90% of bladder injuries result
from blunt trauma
 The bladder is commonly injured in
pelvic fractures
 The bladder in a child is an abdominal
(not pelvic) organ and is more
vulnerable to injury
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Lower Urinary Tract – Bladder
and Urethra
Signs and symptoms of bladder rupture
are non specific
 Frank haematuria occurs in 95%,
m/scopic haematuria in the remainder
 Patient may complain of inability to void
 Suprapubic tenderness
 Intraperitoneal rupture (1/3 of all bladder
injuries) is common in children
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Management
of Bladder
injury
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Do NOT pass
urethral catheter if
there is blood at
meatus
Retrograde
urethrography may
be performed in
place of IVU
Urethral Injury
Commonly associated with Straddle
injuries
 Patient may be unable to void
 Most patients will have blood at meatus
and swelling/bruising of penis/scrotum
and perineum.
 Rectal examination may reveal a “highriding prostate”
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Urethral Injury
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All patients require a urethrogram
Do NOT attempt urethral catheterisation –
may convert a partial tear into a complete
rupture
If patients require immediate laparotomy then
bladder may be catheterised suprapubically
Long term sequelae of this injury include
incontinence, stricture, and impotence
Scrotal Trauma
Testes may be damaged by direct blow
 If swelling is moderate it usually settles
 Severe swelling may require exploration
to exclude testicular laceration
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Urological Trauma – further
reading
ABC of major Trauma – Edited by
Skinner et al. BMJ Publishing Group
 Renal and Ureteric Injuries – McAninch
JW in Adult and Paediatric Urology
(edited by Gillenwater)
 Genitourinary Trauma – Peters and
Sagalowsky in Campbell’s Urology
(edited by Walsh et al)
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Paraphimosis
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May result from phimosis
Commonly occurs in catheterised patients
Good catheter care prevents this problem!
May be reduced after gentle compression of
glans and distal penis
Occasionally may require surgical release of
paraphimosis under LA (or GA in children)
Priapism
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A persistent painful erection that is not related
to sexual desire
Causes
– Intracavernosal pharmacotherapy for Erectile
Dysfunction
– Idiopathic
– Penile or Spinal Cord trauma
– Assoc with Leukaemia, Sickle Cell disease or
Pelvic Trauma
Priapism
Early treatment is the key element
 Climbing stairs (arterial “steal”
phenomenon) or ice packs may resolve
 Aspiration of Corpora cavernosa may
be required
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Priapism
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Two types
 Low flow (anoxic) – blood aspirated is dark and
deoxygenated
 High flow – blood is bright red
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Infusion of alpha agonist (phenylephrine) may
be tried in low flow priapism
Surgical Shunting may be attempted as a last
resort
Summary
Renal Colic
 Testicular Torsion
 Trauma
 Paraphimosis
 Priapism
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Thank You