UROLOGIC EMERGENCIES Hakan KOYUNCU MD Asistant Profesor Yeditepe

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UROLOGIC EMERGENCIES Hakan KOYUNCU; MD Asistant Profesor Yeditepe University Medical Faculty Department of Urology

UROLOGIC EMERGENCIES Hakan KOYUNCU; MD Asistant Profesor Yeditepe University Medical Faculty Department of Urology

n 34 -yo male n Severe right sided flank pain

n 34 -yo male n Severe right sided flank pain

34 M, R flank pain n Hx n PE n urinalysis n imaging

34 M, R flank pain n Hx n PE n urinalysis n imaging

RENAL COLIC n n Stones of the urinary tract Hematoma or tissue in the

RENAL COLIC n n Stones of the urinary tract Hematoma or tissue in the ureter Upper ureter: lumbar-inguinal Lower ureter: genital n n Intermittant Not affected by body positioning Lumbar tenderness Nausea & vomiting

R: Appendicitis - Cholelithiasis n urinalysis: hematuria n KUB n IVP n Computerized Tomography

R: Appendicitis - Cholelithiasis n urinalysis: hematuria n KUB n IVP n Computerized Tomography n Pain management, hydration, hot bath n Treatment of the underlying cause n

n Solitary kidney n Ureteral stone n Hydronephrosis anuria, uremia

n Solitary kidney n Ureteral stone n Hydronephrosis anuria, uremia

n 62 yo male Severe abdominal and inguinal pain, 30 hrs in duration, “have

n 62 yo male Severe abdominal and inguinal pain, 30 hrs in duration, “have not slept for 5 min. ” n Feels like voiding every 10 -15 minutes, passes a few drops each time n n He presented to the ER of a hospital, was diagnosed as cystitis, was given a parasymphatholytic, but did not get any better.

Acute Urinary Retention Bladder neck – prostate – urethra n Usually in elderly with

Acute Urinary Retention Bladder neck – prostate – urethra n Usually in elderly with BPH n Massive hematuria, acute prostatitis, prostate abcess, stones lodged at the bladder neck/urethra, phimosis, uretral trauma n History n Suprapubic mass n Urethral catheterization n Suprapubic catheterization (cystostomy) n

47 yo diabetic n Alcohol (+) n Fever, malaise, redness and discomfort in scrotum

47 yo diabetic n Alcohol (+) n Fever, malaise, redness and discomfort in scrotum n

Fournier’s Gangrene n n n n Synergistic effect of multiple microorganisms in the urogenital/anal

Fournier’s Gangrene n n n n Synergistic effect of multiple microorganisms in the urogenital/anal region Effects soft tissue and fascia, necrosis Generally starts from genital/perineal region Uretral trauma, urinary ekstravasation, urethral instrumantation, perianal abcess and fissur are predisposing factors Immunocompromised patients (diabetes, alcoholism) Begins like cellulitis, rapidly spreads along the fascial planes Necrosis and gangrene Hypoxia anaerobic bacteria gas formation, crepitation

n n n n Malaise, discomfort Scrotal-perineal pain Redness Fever, chills, sweating, scrotal edema

n n n n Malaise, discomfort Scrotal-perineal pain Redness Fever, chills, sweating, scrotal edema Gangrene Rapid deterioration in general health Rapidly involves the abdomen and causes death

Management Bacteroides, Klebsiella, Proteus, Streptococus, Clostridium Perfringens n An avarage of 4 microorganisms per

Management Bacteroides, Klebsiella, Proteus, Streptococus, Clostridium Perfringens n An avarage of 4 microorganisms per patient n

Phimosis n Inability to retract the preputium – – – Bad hygiene-recurrent infections Uncircumsized

Phimosis n Inability to retract the preputium – – – Bad hygiene-recurrent infections Uncircumsized boys/adults Prepitual edema, redness, purulent discharge Physiologic until 3 years of age Dorsal slit or circumsition

Paraphimosis: n The foreskin, once retracted over the glans penis, cannot be replaced in

Paraphimosis: n The foreskin, once retracted over the glans penis, cannot be replaced in its normal position – Usually chr. inflammation of preputium, stricture – Lymphatic, venous, and arterial flow are compromised, leading to necrosis – Firmly squeezing glans for 5 mins. – Skin can then be drawn over the glans (lubricant) – dorsal slit, circumsition

n 42 yo male n High fever, chills, malaise, frequency, perineal pain n DRE:

n 42 yo male n High fever, chills, malaise, frequency, perineal pain n DRE: n Lab: enlarged, pain, warm prostate leucoytosis, shift to the left n culture-sensitivity

Admitted Antibiotics, NSAID Urinary retention in the evening ? ? • Suprapubic catheterisation

Admitted Antibiotics, NSAID Urinary retention in the evening ? ? • Suprapubic catheterisation

n The patients general health deteriorates on day 3, fever does not resolve

n The patients general health deteriorates on day 3, fever does not resolve

Prostate Abcess n n n n Coliform bacteria Generally urethral (ascending) Staphilococcus via hematogenous

Prostate Abcess n n n n Coliform bacteria Generally urethral (ascending) Staphilococcus via hematogenous route Diabetes, immune compromised, urethral trauma, prostate biopsy Pollakiuria, disuria, acute urinary retention; fever, malaise Usually excacerbation of symptoms after acute prostatitis DRE: fluctuation Lab: pyuria, leucocytosis

n TRUS: definitive diagnosis n Drainage n Antibiotics n Suprapubik catheterization

n TRUS: definitive diagnosis n Drainage n Antibiotics n Suprapubik catheterization

n Telephone: n 15 yo male n Enlargement and pain in L testis

n Telephone: n 15 yo male n Enlargement and pain in L testis

Testicular Torsion n n Newborn – adolesents %50 uykuda olur Usually anomaly of tuniga

Testicular Torsion n n Newborn – adolesents %50 uykuda olur Usually anomaly of tuniga vaginalis or the spermatic cord Pain-sudden onset, skrotal edema, enlargement and redness, nausea, vomiting PE: usually retracted, Loss of cremasteric reflex Increased pain with testicular elevation (Prehn)

n n n Epidydimis may be palpated in an abnormal location – early sign

n n n Epidydimis may be palpated in an abnormal location – early sign Leucocytosis within a few hours Doppler US or nuclear scan Manuel de-torsion (inside out) (local anest) Eksploration !!! 5 -6 hrs

35 yo male Errection for 4 hrs in duration, pain n Perineal trauma? n

35 yo male Errection for 4 hrs in duration, pain n Perineal trauma? n Blood gas: high 02 & low CO 2

Priapism Etiology: – Most frequent: intracavernosal injection – Idiopathic – Disease (leucemia, sickle cell

Priapism Etiology: – Most frequent: intracavernosal injection – Idiopathic – Disease (leucemia, sickle cell disease, . . ) n Obstruction of venous drainage, c. c. ’da pooling of viscous low oxygenated blood in corpus cavernosum edema, fibrosis, erectile dysfunction n

Increase venous outflow n Find out underlying reason-if possible n Non-surgical management first: –

Increase venous outflow n Find out underlying reason-if possible n Non-surgical management first: – Aspiration – Alfa adrenergikc agonist injection n • (phenephrine, 10 mg/ml, diluted in 19 ml saline) n If non-surgical tx fails: – Distal or proximal shunt

TRAUMA GU tract in 10% of all traumas n Kidney is the most commonly

TRAUMA GU tract in 10% of all traumas n Kidney is the most commonly involved organ – Suspect GU taruma when: – Hematuria – Descelerating injury – Penetrating abdominal or flank injury – Echimosis of the flank n

Bladder & Urethra – – – – Suspect trauma in the presence of: Blood

Bladder & Urethra – – – – Suspect trauma in the presence of: Blood at the urethral meatus DRE: “prostate displaced superiorly " Hematuria Penetrating abdominal, pelvic or genital injury Anterior pelvic fracture Open pelvic fracture Perineal laseration

Renal Trauma n Blunt : (85 -90% ) – vehicle accident, fall, rapid deceleration,

Renal Trauma n Blunt : (85 -90% ) – vehicle accident, fall, rapid deceleration, iatrogenic n Penetrating : Gunshot and (85 -90 % associated with intraabdominal or thoracic injury)

Renal Trauma - Diagnosis History n PE (lumbar echimosis, pain with palpation) n Hematuria

Renal Trauma - Diagnosis History n PE (lumbar echimosis, pain with palpation) n Hematuria n – (Renal vascular injury - 36 % not associated with hematuria) n Variable clinical presentation (asymptomaticshock)

American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney

American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney Grade Tip Tanım 1 kontüzyon Mikroskobik ya da gross hematuri, ürolojik incelemeler normal hematom Sub. Kapsuler, genişlemeyen parankimal hasar yok hematom Genişlemeyen perirenal hematom , renal retroperitona sınırlı laserasyon <1 -cm derinlikte parenkimal korteks hasarı, üriner ekstravazasyon yok 3 laserasyon >1 -cm derinlikte parenkimal korteks hasarı, üriner ekstravazasyon yok 4 laserasyon Medulla ve toplayıcı sisteme ulaşan parenkim hasarı vasküler Renal arter ve vende hemoraji içeren hasar laserasyon Tamamen parçalanmış Böbrek vasküler Renal hilusun ayrılması 2 5

Radiologic Imaging n n n KUB (loss of psoas or renal contour) IVU (delayed

Radiologic Imaging n n n KUB (loss of psoas or renal contour) IVU (delayed renal function, nonhomogenous collecting system) USG (lumbar hematoma and urinoma lokalizasyonu) Computerized Tomography Renal angiography

Expectant Management: n Hemodynamically stable, well defined and non-expanding injury on CT scan n

Expectant Management: n Hemodynamically stable, well defined and non-expanding injury on CT scan n 88 % patienst are observed n If there is associated gross hematuria, admit and observe

Surgery : Absolute Indication – Persistant renal bleeding – Expanding perirenal hematoma – Perirenal

Surgery : Absolute Indication – Persistant renal bleeding – Expanding perirenal hematoma – Perirenal hematoma with pulsation n Relative indication – Urinary extravasation – Inability in proper staging – Delayed arterial injury n

Urethral Injury n A partial rupture could be a complete rupture during catheterisation! n

Urethral Injury n A partial rupture could be a complete rupture during catheterisation! n A urethrogram should be performed n In the presence of urethral disruption, a suprapubic catheter should be placed.

THANK YOU

THANK YOU