UROLOGIC EMERGENCIES

1. UROLOGIC EMERGENCIES Hakan KOYUNCU;MDAssociate Professor Yeditepe University Medical Faculty Department of Urology

2. 34-yo male • Severe right sided flank pain

3. 34 M, R flank pain • Hx • PE • urinalysis • imaging

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

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

9. Solitary kidney • Ureteral stone • Hydronephrosis anuria, uremia

11. 62 yo male • Severe abdominal and inguinal pain, 30 hrs in duration, “have not slept for 5 min.” • Feels like voiding every 10-15 minutes, passes a few drops each time • He presented to the ER of a hospital, was diagnosed as cystitis, was given a parasymphatholytic, but did not get any better.

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

18. 47 yo diabetic • Alcohol (+) • Fever, malaise, redness and discomfort in scrotum

22. Fournier’s Gangrene • 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

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

25. Management • Bacteroides, Klebsiella, Proteus, Streptococus, Clostridium Perfringens • An avarage of 4 microorganisms per patient

27. Phimosis • 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

28. Paraphimosis: • 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

29. 42 yo male • High fever, chills, malaise, frequency, perineal pain • DRE: enlarged, pain, warm prostate • Lab: leucoytosis, shift to the left • culture-sensitivity

30. AdmittedAntibiotics, NSAID Urinary retention in the evening ???? • Suprapubic catheterisation

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

32. Prostate Abcess • 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

33. TRUS: definitive diagnosis • Drainage • Antibiotics • Suprapubik catheterization

34. Telephone: • 15 yo male • Enlargement and pain in L testis

36. Testicular Torsion • 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)

37. 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

44. 35 yo male Errection for 4 hrs in duration, pain • Perineal trauma? • Blood gas: high 02 & low CO2

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

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

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

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

49. Renal Trauma - Diagnosis • History • PE (lumbar echimosis, pain with palpation) • Hematuria • (Renal vascular injury - 36 % not associated with hematuria) • Variable clinical presentation (asymptomatic-shock)

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