Urological Emergencies• Smith’s general urology Emil A.tanagho, jack W.McAninch• اکبرنورعلیزاده دکتر فروش، دکترناصرسیم ارولوژیعمومی• emedicine.medscape.com

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Classification

TraumaticRenal Trauma

Ureteral Injury

Bladder Trauma

Urethral Injury

Penile trauma

Testicular Trauma

Non traumaticHematuria

Renal Colic

Urinary Retention

Acute Scrotum

Priapism

Renal Trauma

the most common injuries of the urinary systemMost injuries occur from motor vehicle accidents, fights, falls, and contact sports

Decelerationabdominal visceral injuries are present in 95% of renal penetrating wounds.

Signs:Lower rib fractures(11,12)DecelerationVertebral injuryEcchymosis in the flank or upper quadrants of the abdomen

GunshotPsoas shadow, ground glass

Pathologic classification of renal injuries: Grade 1 (the most common): Renal contusion or bruising of

the renal parenchyma Microscopic hematuria(gross

hematuria can occur rarely)

Grade 2: Renal parenchymal laceration into the renal cortex Perirenal hematoma is usually small (<1cm)

Grade 3: Renal parenchymal laceration extending through the

cortex and into the renal medulla. Bleeding can be significant in the presence of

largeretroperitoneal hematoma.

Grade 4: Renal parenchymal laceration extending into the renal

collecting system; also, main renal artery thrombosis from blunt trauma, segmental renal vein,or both; or artery injury with contained bleeding.

Grade 5: Multiple Grade 4 parenchymal lacerations,renal pedicle

avulsion, or both; main renal vein or artery injury from penetrating trauma.

Advance one grade for bilateral injury up to grade 3.

Indications for imaging studies:

Any child with microscopic(>5 RBCs per high powered field or dipstick hematuria) or macroscopic hematuria

Macroscopic hematuria Microscopic hematuria a hypotensive patient (SBP <90mmHg ) Penetrating wounds A history of a rapid deceleration, Falling (>4m), bicycle accident, car

accident, sports

Imaging studies:

Abdominal CT with contrast media is the best imaging study to detect and stage renal and retroperitoneal injuries. venous injuries urinary extravasation: avulsion of the renal pedicle, renal

pelvic injuries Decreased enhancement: arterial thrombosis, arterial spasm,

shock, renal artery injury (arteriography) IVP Arteriography(embolization) sonography

Complications: A. EARLY COMPLICATIONS:

Hemorrhage is the most important immediate complication Urinary extravasation (urinoma) [prone to abscess

formation and sepsis] perinephric abscess

B. LATE COMPLICATIONS: Hypertension hydronephrosis arteriovenous fistula Calculus formation pyelonephritis

Treatment: A. EMERGENCY MEASURES: Treatment of shock and hemorrhage, complete resuscitation,

and evaluation of associated injuries. B. SURGICAL MEASURES 1. Blunt injuries 2. Penetrating injuries

1. Blunt injuries:

98% of cases and do not usually require operation (bed rest and hydration)

Indications for surgery:

1. persistent retroperitoneal bleeding

2. urinary extravasation

3. evidence of nonviable renal parenchyma

4. renal pedicle injuries

2. Penetrating injuries

Grades 3,4,5 Penetrating injuries should be surgically explored.

Emergent laparotomy without imaging Renal artery injury(<8h)

INJURIES TO THE URETER is rare but may occur, usually during:

difficult pelvic surgical procedure as a result of gunshot wounds Endoscopic basket manipulation of ureteral calculi

Etiology: Gunshot (the most common penetrating trauma) Vertebral fractures (the most common blunt trauma) Hysterectomy, oophorectomy(the most common surgical injury) Ureteroscopy

INJURIES TO THE URETER

Clinical Findings fever of 38.3°C–38.8°C flank and lower quadrant pain Uremia paralytic ileus with nausea and vomiting cutaneous fistula, vaginal fistula

Diagnosis and treatment

Imaging IVP CT scan Retrograde urography

treatment repair is in the operating room Delayed repair

INJURIES TO THE BLADDER Bladder injuries occur most often from external force and are

often associated with pelvic fractures. Pelvic fracture with hematuria bladder examination Pelvic and abdominal Penetrating trauma with hematuria

cystography Gynecologic surgery, pelvic surgery, repair of hernia

Clinical findings: Pelvic fracture accompanies bladder rupture in 90% of

cases. Pelvic fracture with supra pubic tenderness Patients ordinarily are unable to urinate, but when

spontaneous voiding occurs. gross hematuria is usually present.

Treatment:

extraperitoneal rupture

Indication for surgery:

1. patients who need another surgery

2. Open fractures of pelvic

3. Rupture of the rectum

4. fragment projecting into the rupture

Intraperitoneal rupture Surgical repaire

INJURIES TO THE URETHRA Urethral injuries are uncommon and occur most often in

men, usually associated with pelvic fractures or straddletype falls. They are rare in women.

INJURIES TO THE POSTERIOR URETHRA: Patients usually complain of lower abdominal pain and inability

to urinate. Blood at the urethral meatus is the single most important sign

of urethral injury. The presence of blood at the external urethral meatus

indicates that immediate urethrography is necessary to establish the diagnosis.

Treatment:

Stricture impotence incontinence

Complications:

1. Immediate management

2. Delayed urethral reconstruction

3. Immediate urethral realignment

INJURIES TO THE ANTERIOR URETHRA

Straddle injury may cause laceration or contusion of the urethra.

iatrogenic instrumentation may cause partial disruption.

Treatment: Hemostasis Cystostomy Anastomosis

INJURIES TO THE PENIS Disruption of the tunica albuginea

Disruption of the tunica albuginea of the penis (penile fracture) can occur during sexual intercourse.

At presentation,the patient has penile pain and hematoma. This injury should be surgically corrected.

Penile amputation Penile amputation involves the complete or partial severing of

the penis Amputation of the penis may be accidental but is often self-

inflicted, especially during psychotic episodes in individuals who are mentally ill.

INJURIS TO THE PENIS Penetrating injury

RUG Immediate repair Delayed repair

avulsion of the penile skin Immediate debridement and skin grafting

INJURIES TO THE TESTIS Blunt trauma to the testis causes severe pain and,

often,nausea and vomiting. Lower abdominal tenderness may be present. A hematoma may surround the testis and make delineation

of its margin difficult. If rupture has occurred, the sonogram will delineate the

injury, which should be surgically repaired. Operative indications for blunt trauma: suspicion of rupture expanding hematomas

Diagnosis:Physical exam:

Enlargement and edema of the testicle; edema involving the entire scrotum

Scrotal erythema the testis is high riding compared with the other side The cremasteric reflex is almost always absent or diminished on the

affected side  Imaging studies: Imaging studies usually are not necessary. Ordering them wastes

valuable time when the definitive treatment is emergent urologic consultation for surgical management. 

color Doppler ultrasonography: Absent or decreased blood flow in the affected testicle

Radionuclide Scan: demonstrate decreased uptake in the affected testicle

Testicular tortion the torsion of the spermatic cord structures and subsequent loss of

the blood supply.

Presentation: sudden onset of severe unilateral scrotal pain followed by

inguinal and/or scrotal swelling. Torsion can occur with sports or physical activity, can be related

to trauma in 4-8% of cases,or can develop spontaneously. Vomiting Fever, Dysuria, frequency are usually absent.

Treatment: Immediate surgical exploration is indicated(4h) If treatment is delayed, the patient may experience decreased fertility or may

require orchiectomy(8h) The spermatic cord is untwisted, then fix gonads to the scrotal wall

DDX Differential Diagnoses Appendicitis Fournier Gangrene Henoch-Schonlein Purpura in Emergency Medicine Hernias Scrotal Trauma Spermatocele Testicular Choriocarcinoma Testicular Seminoma Testicular Trauma Varicocele

priapism Priapism is an uncommon condition of prolonged erection. It is

usually painful for the patient, and no sexual excitement or desire is present.

 A bimodal distribution has been noted, with peaks at 5-10 years and 20-50 years

Etiology: The most common cause of priapism in the pediatric

population is sickle cell disease Leukemia, trauma, idiopathic, pharmacologic Fat embolism (from multiple long-bone fractures or

intravenous infusion of lipids as part of total parenteral nutrition)

Prostate cancer, Bladder cancer (highest risk), Hematologic cancer (leukemia), Renal carcinoma, Melanoma

Classification:

High-flow priapism (nonischemic) usually occurs secondary to perineal trauma, which

injures the central penile arteries and results in loss of penile blood-flow regulation

Low-flow priapism (ischemic) presents with a history of several hours of painful

erection. The glans penis and corpus spongiosum are soft and

uninvolvedin the process

Presentation: Obvious erection is the key physical finding in any case of priapism Pain and tenderness Edema Thrombosis, fibrosis, necrosis

Diagnosis: history Physical examination CBC, hemoglobin S determination Penile blood gas (PBG) test  Color-flow penile Doppler imaging

Treatment: low-flow priapism

starting with therapeutic aspiration Irrigation intracavernous injection of a sympathomimetic agent attempt to treat the underlying condition

High-flow priapism embolization of the offending vessel

Surgical treatment: A unilateral shunt is often effective

Complications: Fibrosis impotence

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