Urological Emergencies

Smiths general urology Emil A.tanagho, jack W.McAninch

emedicine.medscape.com

Classification
Traumatic
Renal Trauma
Ureteral Injury
Bladder Trauma
Urethral Injury
Penile trauma
Testicular Trauma

Non
traumatic
Hematuria
Renal Colic
Urinary Retention
Acute Scrotum
Priapism

Renal Trauma
the most common injuries of the urinary system
Most injuries occur from motor vehicle accidents,
fights, falls, and contact sports
Deceleration
abdominal visceral injuries are present in 95% of
renal penetrating wounds.

Signs:
Lower rib fractures(11,12)
Deceleration
Vertebral injury
Ecchymosis in the flank or upper quadrants
of the abdomen
Gunshot
Psoas 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 38.3C38.8C
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:
1. Immediate management
2. Delayed urethral reconstruction
3. Immediate urethral realignment

Complications:
Stricture
impotence
incontinence

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 selfinflicted, 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

Thanks for your attention