Acute Conditions in Urology & Scrotal Swellings

1. Acute Conditions in Urology& Scrotal Swellings Done by: Khadija S. El-Hammasi Supervised by: Dr. Yhaya Elshebiny

3. Acute Conditions in Urology • Acute Urological conditions: • Urolithiasis (Calculus Disease) • Trauma of Genitourinary system • Infection of Genitourinary system • Testicular torsion • Priapism • Phimosis & Paraphimosis

4. -Incidence: 1% of the population. Causes of calculi formation: 1.Primary (idiopathic) 2.Secondary due to stasis  Infection  Metabolic disorders (cystinuria) -Types of the calculi: 1.Calcium oxalate (75%) 2. Phosphate (15%) 3. Urate (5%) 4.Cystine (2%) 5. Xanthine & pyruvate (rare) Urolithiasis (Calculus Disease)

5. - Factors predispose to the development of renal stones? 1.Recent reduction in fluid intake 2. Increased exercise with dehydration 3.Medications that cause hyperuricemia (high uric acid) 4.History of gout • Symptoms: • Asymptomatic • Renal colic is what brings pts to the ER • a collection of symptoms that occur as the stone is in transit from the kidney to the bladder. This may result in partial or complete urinary obstruction. • These symptoms include • Sudden onset of severe colicky pain that originates in the flank and may radiate to the lower abdomen, groin or testes (labia) depending on the site

6. Cont… • The pain may be associated with nausea and vomiting • Symptoms of irritative bladder such as increased frequency and urgency the stone is in the distal ureter • Symptoms of UTI • Hematuria O/E: • Pt is rolling on bed or pacing • Vitals: important to take T. it defines your management. • T is high obstructive pyelonephritis  PCN or DJ stent • Tenderness overlying the stone

7. Investigations: • CBC  WBC> 15,000/cm² • RFT & electrolytes. Impaired RFT is a contraindication for IVU • Urine analysis & microscopy. • KUB: 90% of stones are radio-opaque. (urate & cystien stones are radiolucent) • U/S • Emergency IVU: to detect site of obstruction. • CT scan • MRU (in case of pregnant women) • Radio nuclear study  To confirm diagnosis  To evaluate kidney function

8. Nephrolithiasis Renal Calculi • Only The Radioopaque (i.e. White) calculi are seen

9. Ureteric and Bladder Calculi • Only The Radioopaque (i.e. White) calculi are seen

10. Intravenous Urography= IVUNORMAL • Minor calyx • Major calyx • Ureter • Bladder

11. IVU; Ureteric calculus with minor obstructive changes

12. Treatment: For acute symptoms (renal colic) Conservative management: • relive pain e.g. pethidine / NSAID • admit to hospital  if persistent colic  fever  Renal failure Antispasmodics e.g. desmopressin to inhibit uretric peristalsis relief the renal colic • bed rest, IV fluid • collect urine to retrieve calculus for analysis • check radiograph to asses progress of stones. • Broad spectrum antibiotic after urine sample is obtained. (in case of infection)

13. Cont… Further management depends on • Response to analgesia • Size of the stone • <4mm will pass spontaneously.(50% of stone 4-6 mm will pass spontaneously) • Stone >6mm requires removal. • Presence of infection/obstruction decompression • Percutaneous nephrostomy (PCN) • DJ stent

14. Stone management: • ESWL: -Kidney  stones 0.5 – 2.5 cm +/- DJ stint. -Ureter  stones 0.5 – 2.5 cm +/- DJ stint for stones located in the upper & middle part of the ureter (possible lower). • Percutaneous nephrolithotomy • Uretric stone • Bladder  resectoscope sheath, broken up with forceps and washed out • Open surgery: • Ureterolithotomy( stone >5mm, or in the ureter) • Pyelolithiotomy • Nephrolithotomy (stones pushed into the renal pelvis)

15. Trauma of Genitourinary system • Upper tract (kidney & ureter) • Lower tract (bladder, urethra, scrotum).

16. Kidney Trauma • Most common injuries of urinary system. • Most injuries occur from car accident or sport • >50% occur in males <30 yrs • F:M is 1:4 • Pts with renal abnormalities are more prone to renal injuries Causes: • Blunt trauma directly to abdomen, flank or back.(80-85%) • Penetrating injuries: gunshot& knife wounds

17. Classification and Management of Renal Injuries

18. Types of Renal Injuries

19. History: • H/O trauma • Pain localized to flank or abdomen. • Hematuria. • Abdominal distention + nausea & vomiting(retroperitoneal bleeding) O/E: • Vitals: low BP & rapid pulse Shock • Bruising over the ribs posteriorly, evidence of penetrating injury • Lower rib fractures. • Diffuse abdominal tenderness and guarding. • Mass (represent retroperitoneal hematoma or urinary extravasations). • Exclude pneumothorax or bleeding into the chest and peritoneum

20. Who to investigate? • Penetrating injury to the flanks • Rapid deceleration injuryrenal vascular injury • Blunt injury associated with hematuria, tenderness, rib fracture Investigations: • CBC  dropping Hb bleeding • Cross matching • Urine analysis • RFT  IVU is needed • X-ray. • U/S • CT  the gold standard (adequately stage 85% of renal injuries). • Excretory urograph (IVU) in case of emergency • Arteriography: detect arterial thrombosis & avulsion of renal pedicle.

22. Arteriogram following blunt abdominal trauma shows acute renal artery thrombosis of left kidney.

23. Contrast Enhanced CT:Renal Laceration Small perirenal hematoma Renal laceration

24. managenent: • Patient is not stable • Emergency measure: • Treat shock & hemorrhage. • Complete resuscitation & evaluation of associated injuries. • Surgery: • Indications: Shock, persistent hematuria. • Can vary from Simple suture of laceration to partial or total nephrectomy. • Patient is stable • Keep under observation • Investigate & treat accordingly (table)

25. Ureteric trauma • rare • Causes: 1. Large pelvic mass that displace the ureter laterally. 2.Surgical procedure: e.g. Gynecological procedure in female (hysterectomy)& Endoscopic manipulation of ureteral calculus. 3.Stap wound Symptoms: • Fever (post operatively) • Flank & lower abdominal pain • Nausea & vomiting. • Anuria ( post operative bilateral ureteral injury).

26. Signs: ▪Signs of acute peritonitis may be present due to urinary extravasations into the peritoneal cavity. Investigations: ▪Catheterization: microscopic heamaturia ▪Excretory urography (IVU): delayed excretion of contrast due to hydronephrosis. ▪U/S: detect hydroureter or urinary extravasation. ▪CT scan Treatment: ▪Immediate re-exploration & repair. ▪Stinting.

27. Stab wound of right ureter shows extravasation on intravenous urogram.

28. Anuria • Absence of urinary output • Causes • Underperfusion of the kidneys e.g. shock or dehydration • Sepsis • Bilateral ureteric obsruction • Tumors of the pelvis or retro peritoneum  chronic • Retroperitonial obstruction  progressive • Bilateral stones causing obstruction  acute

29. Cont… Management: • History, examination • KUB • U/S • IVU • CT • Observation • PCN • DJ stenting • Treat the undelyig cause

30. Bladder Trauma • Mostly due to external force like urological procedure (bladder tumor) iatrogenic • 90% associated with pelvic fracture • Penetrating injury • Indirect trauma to the lower abdomen with distended kidney • Trauma to the bladder may lead to intra or extraperitonial extravasation

31. History: • H/O lower abdominal trauma. • H/O alcohol consumption followed by lower abdominal trauma • Patient unable to urinate • Gross hematuria (with spontaneous voiding) • Usually pelvic or lower abdominal pain. O/E: • Signs of shock. • Lower abdominal & suprapubic tenderness • Palpable mass (in case of pelvic hematoma). Investigations: • X-ray: for pelvic fracture. • IVU: to detect any ureteric or kidney injuries or bladder leak. • CT scan • Cystography: detect extraperitoneal extravasation of blood & urine. This is the procedure of choice to R/O bladder injury

32. Contrast Enhanced CT: Traumatic Urinary Bladder Injury Rupture of bladder with extravasation of urine intothe peritoneal cavity Cystogram demonstrating extravastion

33. Treatment: • Emergency measure: treat shock & hemorrhage • Conservative & catheter drainage • The majority of cases will require surgical intervention* • Intraperitoneal extravasation • Laparoscopy or laparotomy (lower midline abdominal incision.) • Suction of urine and irrigation • Repair • Urethral and Suprapubic catheters are inserted to ensure complete urinary drainage & control of bleeding. • 1-2 weeks later a cystogram is done • Extraperitoneal extravasation • Repair the tear • SPC and urethral cath • Drainage Cath in the retropubic space. Left for 10- 14 days

34. Acute Urinary Retention • Inability to empty the bladder • 10% of pt with BPH present with acute urinary retention • Causes: • In males the most common cause is prostatic obstruction that may be precipitated by alcohol, anticholinergic drugs, constipation, infection, anaesthetics • Urethral stricture • Bladder tumor, stone or any other cause of bladder outlet obstruction • In a female, a gravid uterus may lead to retention

35. History • Inability to pass urine for several hours • Severe suprapubic pain • Abdominal distension • +/- H/O BPH • D/H: anticholinergics, alcohol • H/O UTI, constipation • O/E • Pt unable to stay still • Bladder may be palpable • PR: enlarged prostate that is pushed down size may be exaggerated • Refluxes of lower limb and perianal sensation R/O prolapsed lumber disc

36. Investigations • CBC WBC (UTI, prostatitis) • MSU UTI • PSA Ca or prostatitis • U/S bladder and prostate • X-ray • IVU  filling defect • Treatment • Aim is to relieve the pain • Analgesia, short course of alpha adrenergic blocker • Catheterization: urethral or SPC • After 4-7 days, trail to void at the hospital • Treat the underlying condition • BPH • Voiding medication • Unable to void TURP

37. Urethral Injury • The most common cause is iatrogenic (catheter, cystoscopy) • 30% pelvic fractures are associated with urethral injuries • Not a common injury. More in in males. Rare in females • If a urethral injury is suspected, DO NOT insert a urethral cath • Retrograde urethrogram is the investigation of choice. It delineates the severity of the injury • If there is extravasation, SPC is inserted for 3weeks. A cystourethrogram is then done to ensure resolution

39. Scrotal trauma • This is usually occurs in sport injuries or violence. • Trauma maybe result in bleeding into the layer of tunica vaginalis resulting in hematocele. • Symptoms& signs: -Sever pain -Scrotal swelling +/- ruptured testis -Bruising -Tender enlarged testis. • Investigation: -U.S. - CT scan • Treatment: -Bed rest. -Surgical exploration may be require to evacuate hematocele & repair a split in the tunica albuginea.

40. Genitourinary Infection *Include: -Pyelonephritis -Cystitis -Prostatitis -Epedidemo-orchitis *Risk Factors: -Vesicoureteric reflux -Obstruction -Neurogenic bladder -Pregnancy -DM

41. Pyelonephritis -Bacterial infection of one or both kidneys. -Most common organism is E-coli. -Symptoms: 1.Loin pain 2.Dysuria & Frequency 3.Fever & rigors -Lab findings: 1.Leukocytosis 2.pyuria, bacteruria & microscopic Hematouria 3.>100,000 colonies/ml in urine culture

42. CT Right kidney is markedly enlarged andhas a wedge-shaped area of low attenuation

43. *Radiological findings: -IVU  renal enlargement -U/S  dilated collecting system from obstruction, presence of urinary stones or renal abscess - CT scan *Tx: -I.V Abx +/- nephrostomy

44. Cystitis -Common organism is E-coli. -Bladder infection -Symptoms: 1.Irritative Sx (Dysuria, frequency & urgency) 2. Hematuria 3. Suprapubic pain & tenderness -Lab findings: 1.Pyuria, bacteruria + hematuria -Radiological investigation is limited to cases where renal infection is suspected -Tx Abx

45. Prostatitis -Commonly in young males -Common organism is E-coli, Pseudomonas -Sigh & Symptoms: 1.Fever 2.Low back pain, perenial pain 3.Bladder irritation & outflow obstruction 4.Tender, warm, large & firm prostate on PR examination -Lab findings: 1.Pyuria, bacteruria + microscopic hematuria *Tx I.V Abx

46. ParaPhimosis • Paraphimosis occurs when the foreskin has been retracted and narrows below the glans, constricting the lymphatic drainage and causing the glans to swell. • If not corrected, blood flow in the penis becomes impeded by the increasingly constricting band of foreskin, which causes further swelling of the glans. Because lack of oxygen from the reduced blood flow can cause tissue death (necrosis) • paraphimosis is considered a medical emergency and requires immediate treatment.

47. Causes: • Bacterial infection (e.g., balanoposthitis) • Catheterization (i.e., if the foreskin is not returned to its original • position after a urethral catheter is inserted, the glans may become swollen, which can initiate paraphimosis) • Poor hygiene • Swelling-producing injury • Vigorous sexual intercourse • Symptoms and Signs : • Inability to urinate (urinary retention) • Penile pain • Swollen glans (the shaft of the penis is not swollen) • Redness, Black tissue on the glans (indicates necrosis • Band of retracted foreskin tissue beneath the glans • Tenderness

48. Diagnosis • Paraphimosis is diagnosed during physical examination. • Treatment • Injection of hyaluronidase with lidocane followed by gentel pressure. This usually results in reduction • Failure  incision of he constricting band • Circumcision to prevent reoccurrence

49. Priapism -Persistent, painful erection. -Causes: 1.Idiopathic 2. Leukemia, sickle cell dx 3.Pelvic malignancy 4.Pt on hemodialysis -Tx: 1.Aspiration of blood from the corpora cavernosa 2.Anastomosis of the great saphenous vein to the engorged corpora cavernosa thus establishing venous drainage of the corpora

50. Phimosis • Phimosis is the inability to retract the prepuce (foreskin) of penis over the shaft due to a narrow opening.Phimosis can be congenital or acquired:- In acquired phimosis there is chronic inflammation of the tip of the penis and prepuce (fore skin) or there are adhesions between glans & prepuce or due to malignancy. In congenital causes it is present since birth. Phimosis is usually caused by thickening and repeated inflammation of the foreskin.