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Non traumatic Urological
Emergency
Prepared by: Under supervision of:
Zana Hossam Dr.Kamiran J. Sadeeq
Urological Emergency
A urology emergency refers to any urologic condition that
requires urgent medical attention from a ur...
Urological Emergency
Non traumatic
1. Hematuria
2. Ureteric Colic
3. Acute Scrotum
4. Priapism
5. Urinary Retention
6. Par...
Hematuria
Defined as the presence of the blood in urine
Macroscopic (frank or gross hematuria): Blood in the urine
which ...
Causes of hematuria:
Surgical/urological
• Stones
• UTI
• Instrumentation
• Trauma
• tumors
• BPH
• Prostatic cancer
Medic...
Workup..
History
• Onset & duration & amount(clots)
• Mesturation in female
• Hx of ingestion of substance that may cause ...
Examination
• General
• Abdominal
Investigations
• CBC
• Urinalysis
• Urine culture and cytology
• Blood urea and creatini...
Urological Emergency
Non traumatic
1. Hematuria
2. Ureteric Colic
3. Acute Scrotum
4. Priapism
5. Urinary Retention
6. Par...
ACUTE FLANK PAIN
URETERIC COLIC
• Sudden severe agonizing colicky pain, started at the loin and
radiating inferiorly and a...
ureteric colic cont…
• One of the commonest urological emergencies
• Most often due to the passage of a stone formed in th...
Causes of ureteric colic
Intraluminal obstruction
• Impacted stone
• Blood clot
• Mucosal edema
• Sloughed papilla
• Fungu...
Presentation
• The classic presentation for a patient with ureteric colic is
the sudden onset of severe pain originating i...
Presentation cont…
• Distal ureteral stones: Radiate into groin or testicle (men)
or labia majora (women)
• (the location ...
Differential diagnosis
 Acute appendicitis
 UTI (Pyelonephritis)
 Acute Cholecysititis
 Testicular torsion
 Diveticul...
Work up
• History
• Examination
• Investigation
a) FBC
b) Urinanalysis
c) Preganacy test
d) Urea and electrolyte
e) KUB
f)...
Acute mangment of ureteric colic:
• Pain relief
– NSAIDs
– Narcotic analgesics.
– Calcium channel blockers
– α1 blockers
–...
Mangment cont..
• watchful waiting with analgesic & hydration supplements
− 95% of stones measuring 5mm or less pass spont...
• Temporary relief of the obstruction:
– Insertion of a JJ stent or percutaneous nephrostomy tube.
• Definitive treatment ...
Urological Emergency
Non traumatic
1. Hematuria
2. Ureteric Colic
3. Acute Scrotum
4. Priapism
5. Urinary Retention
6. Par...
Acute scrotum
• Is an Emergency situation requiring prompt evaluation,
differential diagnosis, and sometimes immediate sur...
Differential diagnosis of acute scrotum
• Testicular torsion
• Epididymo-orchitis
• Epididymitis
• Orchitis
• Torsion of t...
Testicular torsion
• refers to the torsion of the spermatic cord structures and
subsequent loss of the blood supply to the...
• Testicular torsion is common in pt between 10-20 years
• Irreversible ischemic injury to the testicular parenchyma
may b...
Possible causes of testicular torsion
• Bell clapper deformity
• Rapid growth during puberty
• after injury to the groin
•...
Presentation
• Sudden onset of sever scrotal pain
• Pain is referred to ipsilateral lower quadrant of abdomen
• Nausea & v...
Physical examination
• Scrotal swelling & erythema on The affected side
• Acute hydrocele & massive scrotal edema
• The af...
• Often, doctors diagnose testicular torsion with just a history
& physical examination,Sometimes investigations are
neces...
Torsion of the Spermatic Cord…
Surgical exploration:
• A median raphe scrotal incision or a transverse incision.
• The aff...
Torsion of the Spermatic Cord…
Manual detorsion
• Manual detorsion of the torsed testis may be attempted but is
usually di...
Epididymo-orchitis
• Refer to inflamation of the testis & epididymis
• It is common in men aged 15-30 and in men aged over...
Causes
• UTI or mumps virus infection that spreads to the
epididymis
• Brucellosis
• Trauma or injury of the testes
• Sexu...
Signs and Symptoms
• Gradual onset
• Pain or tenderness in the scrotum, abdomen, or groin
• Redness or swelling of the scr...
Managment
– Bed rest for 1 to 3 days then relative restriction .
– Scrotal elevation, the use of an athletic supporter
– D...
Complications
• Abcess formation
• Reduced fertility in the affected testis, especially in cases
caused by the mumps virus...
Urological Emergency
Non traumatic
1. Hematuria
2. Ureteric Colic
3. Acute Scrotum
4. Priapism
5. Urinary Retention
6. Par...
Priapism
Priapism is an involuntary, prolonged,persistant erection of
penis lasting for more than 4 hours unrelated to sex...
Types of Priapism
Ischemic (Veno-occlusive,low-flow) Priapism
• This condition is generally painful
• Due to haematologica...
Causes of priapism
• Primary (Idiopathic) : 30%- 50%
• Secondary:
• Drugs
• Trauma
• Prolonged sexual activity
• Neurologi...
Diagnosis
– Usually obvious from the history
• Duration of erection >4 hours?
• Is it painful or not?.
• Previous history ...
Investigations:
– CBC (white cell count and differential, reticulocyte count)
– Hemoglobin electrophoresis for sickle cell...
Managment
Depened on the type of priapism:-
Low flow priapism
• Supportive care
• Intracavernosal phenylephrine is the dru...
Mangment cont…
High-Flow Priapism
• Conservative
• Blood aspiration is not helpful for the treatment of arterial priapism
...
Follow-up
after successful treatment follow up should include modification of risk
factors in order to avoid a new event a...
Urological emergency
Urological emergency
Urological emergency
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Urological emergency

Urological Emergency

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Urological emergency

  1. 1. Non traumatic Urological Emergency Prepared by: Under supervision of: Zana Hossam Dr.Kamiran J. Sadeeq
  2. 2. Urological Emergency A urology emergency refers to any urologic condition that requires urgent medical attention from a urologist or an emergency room and immediate treatment Compared to other surgical fields there are relatively few emergencies in urology
  3. 3. Urological Emergency Non traumatic 1. Hematuria 2. Ureteric Colic 3. Acute Scrotum 4. Priapism 5. Urinary Retention 6. Paraphimosis 7. Anuria 8. Pyonephrosis 9. Fournier’s Gangrene Traumatic 1. Renal Injury 2. Ureteral Injury 3. Bladder Injury 4. Urethral Injury 5. Testicular Injury
  4. 4. Hematuria Defined as the presence of the blood in urine Macroscopic (frank or gross hematuria): Blood in the urine which is seen with the naked eye Microscopic (dipstick hematuria): is the presence of >3 red blood cells per high-power microscopic field
  5. 5. Causes of hematuria: Surgical/urological • Stones • UTI • Instrumentation • Trauma • tumors • BPH • Prostatic cancer Medical • Glomerular causes • Non glomerular causes • Interstitial nephritis • Renovascular hypertension • Blood disorders Drugs • blood thinners(heprin,warfarin) • sulfa-containing drug others
  6. 6. Workup.. History • Onset & duration & amount(clots) • Mesturation in female • Hx of ingestion of substance that may cause red discoloration of urine • Painful or painless • Intial , Terminal , Total • Fever, abdominal pain, dysuria, frequency, urgency • Hx of drug intake • Hx of travel to endemic area of malaria or schistosoma • Hx of TB of any part of body • Hx of instrumentaion or biopsy • Hx of bleeding disorder • Hx of heavy exercise
  7. 7. Examination • General • Abdominal Investigations • CBC • Urinalysis • Urine culture and cytology • Blood urea and creatinine • KUB • US • Flexible cystoscopy • IVU and CT in selected group Treatment of hematuria is according to the cause
  8. 8. Urological Emergency Non traumatic 1. Hematuria 2. Ureteric Colic 3. Acute Scrotum 4. Priapism 5. Urinary Retention 6. Paraphimosis 7. Anuria 8. Pyonephrosis 9. Fournier’s Gangrene
  9. 9. ACUTE FLANK PAIN URETERIC COLIC • Sudden severe agonizing colicky pain, started at the loin and radiating inferiorly and anteriorly caused by ureteral obstraction & its associated with nausea, vomiting, and urinary symptoms like hematuria or dysuria, there is No aggravating or relieving factors, The pain makes the patient rolling to get comfortable
  10. 10. ureteric colic cont… • One of the commonest urological emergencies • Most often due to the passage of a stone formed in the kidney, down through the ureter • One of the commonest cause of acute abdomen
  11. 11. Causes of ureteric colic Intraluminal obstruction • Impacted stone • Blood clot • Mucosal edema • Sloughed papilla • Fungus ball in debilitated or diabetic patients Intramural obstruction • Stricture • Malignancy Extramural obstruction • Ureteral ligation in gynecologic & pelvic surgery • Local extension of Ca. prostate or cervix causing pressure on one or both ureteric orifices. • Compression from an abscess or inflammatory mass • Pelvic hematoma following trauma • Retroperitoneal fibrosis. • pregnancy.
  12. 12. Presentation • The classic presentation for a patient with ureteric colic is the sudden onset of severe pain originating in the flank and radiating inferiorly and anteriorly • Stones obstructing ureteropelvic junction: Mild to severe deep flank pain without radiation to the groin • Upper ureteral stones: Radiate to flank or lumbar areas • Midureteral calculi: Radiate anteriorly and caudally
  13. 13. Presentation cont… • Distal ureteral stones: Radiate into groin or testicle (men) or labia majora (women) • (the location of the pain does not provide accurate information about the position of the stone) • The patient cannot get comfortable, and may roll around in agony. • Associated with nausea / Vomiting • Usually afebrile • Ureteric colic is one of worst pain that the pt suffer from
  14. 14. Differential diagnosis  Acute appendicitis  UTI (Pyelonephritis)  Acute Cholecysititis  Testicular torsion  Diveticulitis  Acute pancreatitis  Inflamtory bowel disease  Bowel obstraction  Ectopic pregnancy  Complicated ovarian cyst
  15. 15. Work up • History • Examination • Investigation a) FBC b) Urinanalysis c) Preganacy test d) Urea and electrolyte e) KUB f) US g) IVP h) Helical CT
  16. 16. Acute mangment of ureteric colic: • Pain relief – NSAIDs – Narcotic analgesics. – Calcium channel blockers – α1 blockers – Corticosteroids. • IV access & Adequate hydration • Anti emetic if there is sever vomiting • Antibiotics if there is fever or you suspect an infection
  17. 17. Mangment cont.. • watchful waiting with analgesic & hydration supplements − 95% of stones measuring 5mm or less pass spontaneously • Indications for Intervention to Relieve Obstruction : 1. Pain unrelieved by analgesia. 2. Signs & symptoms of sepsis. 3. Persistent nausea & vomiting. 4. High grade obstruction. 5. Bilateral ureteral obstruction 6. Solitary kidney 7. Obstraction unrelieved > 4 weeks
  18. 18. • Temporary relief of the obstruction: – Insertion of a JJ stent or percutaneous nephrostomy tube. • Definitive treatment of a ureteric stone: – Observation – ESWL. – Ureteroscope – PCNL – Open Surgery: very limited
  19. 19. Urological Emergency Non traumatic 1. Hematuria 2. Ureteric Colic 3. Acute Scrotum 4. Priapism 5. Urinary Retention 6. Paraphimosis 7. Anuria 8. Pyonephrosis 9. Fournier’s Gangrene
  20. 20. Acute scrotum • Is an Emergency situation requiring prompt evaluation, differential diagnosis, and sometimes immediate surgical exploration
  21. 21. Differential diagnosis of acute scrotum • Testicular torsion • Epididymo-orchitis • Epididymitis • Orchitis • Torsion of testicular appendages • Tosrion of epididymal appendages • Strangulated inguinal hernia • Abcess • Traumatic rupture • Traumatic hematoma
  22. 22. Testicular torsion • refers to the torsion of the spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle. This is a true urological emergency; early diagnosis and treatment are vital to saving the testicle and preserving future fertility
  23. 23. • Testicular torsion is common in pt between 10-20 years • Irreversible ischemic injury to the testicular parenchyma may begin as soon as after 6 hours • Testicular salvage decrease as duration of torsion increase Testicular torsion: (A) extravaginal; (B) intravaginal
  24. 24. Possible causes of testicular torsion • Bell clapper deformity • Rapid growth during puberty • after injury to the groin • vigorous physical activiry & sport injury • Cold climate (winter syndrome)
  25. 25. Presentation • Sudden onset of sever scrotal pain • Pain is referred to ipsilateral lower quadrant of abdomen • Nausea & vomiting • Mild pyrexia • Dysuria but other bladder symptoms are usually absent. • There is quite often a history of previous, brief episodes of similar pain.
  26. 26. Physical examination • Scrotal swelling & erythema on The affected side • Acute hydrocele & massive scrotal edema • The affected testis is high riding with Transverse orientation • Cremasteric reflex is -ve. • Prehns sign -ve
  27. 27. • Often, doctors diagnose testicular torsion with just a history & physical examination,Sometimes investigations are necessary to confirm a diagnosis or to help identify another cause for the symptoms these investigation include : • Urinanalysis • Blood studies • Doppler examination of cord and testis • Color doppler US • Radionuclide imaging
  28. 28. 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.
  29. 29. Torsion of the Spermatic Cord… Manual detorsion • Manual detorsion of the torsed testis may be attempted but is usually difficult because of acute pain during manipulation. • Nonoperative detorsion is not a substitute for surgical exploration • it can protect testicular viability in cases of surgical delay, and also provides significant pain relief. • If manual detorsion is successful (ie, confirmed by color Doppler sonogram in a patient with complete resolution of symptoms), the patient must undergo definitive surgical fixation of the testes before leaving the hospital
  30. 30. Epididymo-orchitis • Refer to inflamation of the testis & epididymis • It is common in men aged 15-30 and in men aged over 60. It does not common before puberty.. • risk of getting epididymo-orchitis is increased if the pt have a catheter or other instruments inserted into the urethra.
  31. 31. Causes • UTI or mumps virus infection that spreads to the epididymis • Brucellosis • Trauma or injury of the testes • Sexually transmitted infections such as gonorrhea or Chlamydia • Urine that flows backward from urethra to the epididymis • Medications such as amiodarone
  32. 32. Signs and Symptoms • Gradual onset • Pain or tenderness in the scrotum, abdomen, or groin • Redness or swelling of the scrotum • Discharge from the penis or blood in urine or semen • Dysuria & Fever are more common than testicular torsion • Cremastric reflex is +ve • Prehns sign is +ve
  33. 33. Managment – Bed rest for 1 to 3 days then relative restriction . – Scrotal elevation, the use of an athletic supporter – Do not lift heavy objects – NSAIDs , such as ibuprofen, help decrease swelling,pain & fever. – antibiotic therapy should be instituted when UTI or STD is documented or suspected – Urethral instrumentation should be avoided – Surgery may be needed if the condition gets worse. Surgery to drain an abscess may be needed. Surgery to remove part or all of epididymis or testicle may be requirred
  34. 34. Complications • Abcess formation • Reduced fertility in the affected testis, especially in cases caused by the mumps virus. • An ongoing (chronic) inflammation occasionally develops. • Rarely, serious damage to the testis may occur and result in dead tissue (gangrene) in the testis that needs to be removed surgically
  35. 35. Urological Emergency Non traumatic 1. Hematuria 2. Ureteric Colic 3. Acute Scrotum 4. Priapism 5. Urinary Retention 6. Paraphimosis 7. Anuria 8. Pyonephrosis 9. Fournier’s Gangrene
  36. 36. Priapism Priapism is an involuntary, prolonged,persistant erection of penis lasting for more than 4 hours unrelated to sexual stimulation and unrelieved by ejaculation. It occur at any age & the 2 main age groupes are:- 5-10 years old 20-50 years old
  37. 37. Types of Priapism Ischemic (Veno-occlusive,low-flow) Priapism • This condition is generally painful • Due to haematological disease, malignant infiltration of the corpora cavernosa with malignant disease, or drugs. Non Ischaemic (arterial, high flow) Priapism • This type of priapism is generally not painful and may manifest in an episodic manner • Due to perineal trauma, which creates an arteriovenous fistula
  38. 38. Causes of priapism • Primary (Idiopathic) : 30%- 50% • Secondary: • Drugs • Trauma • Prolonged sexual activity • Neurological • Hematological disease • Tumors • Carbon monoxide poisoning • widow spider bite
  39. 39. 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.
  40. 40. 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) – Colour flow duplex ultrasonography in cavernosal arteries – Penile pudendal arteriography
  41. 41. Managment Depened on the type of priapism:- Low flow priapism • Supportive care • Intracavernosal phenylephrine is the drug of choice and first-line treatment for low-flow priapism • aspiration of the corpora cavernosa followed by saline irrigation and, if necessary, injection of an alpha-adrenergic agonist • If the above interventions are unsuccessful, a diluted solution of phenylephrine may be used for irrigation • If medical treatment fails, the condition warrants surgical intervention.
  42. 42. Mangment cont… High-Flow Priapism • Conservative • Blood aspiration is not helpful for the treatment of arterial priapism • Selective arterial embolisation • Surgical management – Selective ligation of the fistula through a transcorporeal approach under the guidance of colour duplex US is possible It is important to warn all patients with priapism of the possibility of impotence.
  43. 43. Follow-up after successful treatment follow up should include modification of risk factors in order to avoid a new event and assessment of erectile function, Penile fibrosis is usually easily identified with clinical examination of the penis & to identify signs of recurrence especially after embolisation. Prognosis The prognosis is good for both types of priapism when the condition is resolved quickly. When treatment is delayed, penile scarring and permanent impotence can result.

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