emergency room urology
TRANSCRIPT
Emergency Room Emergency Room UrologyUrologyUrologyUrology
Dr. Syah Mirsya Warli, SpUDr. Bungaran Sihombing,SpUDiv. of Urology, Surgery Dept.
Medical Faculty, University of Sumatera Utara
Ref :Ref :
�� Clinical Manual of Urology, (Philip M. Clinical Manual of Urology, (Philip M.
Hanno et al eds), McGrawHanno et al eds), McGraw--Hill Int ed, Hill Int ed,
33rdrd ed, 2001ed, 200133 ed, 2001ed, 2001
�� Smith’s General Urology (Tanagho & Smith’s General Urology (Tanagho &
McAninch eds), Lange Medical Books, McAninch eds), Lange Medical Books,
1515thth ed, 2000ed, 2000
Genitourinary Emergencies
�� PainPain
�� Testicular TorsionTesticular Torsion
�� Oliguria & anuriaOliguria & anuria
�� PriapismPriapism�� Testicular TorsionTesticular Torsion
�� HematuriaHematuria
�� Urinary RetentionUrinary Retention
�� PriapismPriapism
�� Foreskin Foreskin
emergenciesemergencies
Pain
Flank Pain
�� DD : calculusDD : calculus
pyelonephritispyelonephritis
renal traumarenal traumarenal traumarenal trauma
renal vein thrombosisrenal vein thrombosis
cholecystitischolecystitis
Pain
Flank Pain : Renal Colic
� Sudden onset, no relief with change of position
� Nause & vomiting
� Diagnosis studies :Diagnosis studies :
- urinalysis
- non-contrast CT scan
- plain radiograph
- white count and serum creatinin
- urine culture
- IVP
Indications for admission for renal
calculi
�� Obstructing stone in a patient with a Obstructing stone in a patient with a
solitary kidneysolitary kidney
�� Fever and infection associated with an Fever and infection associated with an
obstructing stoneobstructing stoneobstructing stoneobstructing stone
�� Inability to maintain oral hydrationInability to maintain oral hydration
�� Pain refractory to oral analgesicsPain refractory to oral analgesics
�� HighHigh--grade obstruction from a stone that is grade obstruction from a stone that is
too large to pass spontaneouslytoo large to pass spontaneously
Pain
Flank Pain : Pyelonephritis
� Onset subacute, constant
� Exacerbated by movement
� Prodrome of cystitis symptoms � clue� Prodrome of cystitis symptoms � clue
� Ask about previous history of urolithiasis,
UTI and urologic surgery
Pain
Suprapubic Pain
� DD : urinary retention, cystitis
bladder stones, gynecologic problems
interstitial cystitisinterstitial cystitis
� Retention & cystitis must be diagnosed in the
ED
� History : voiding function, gross hematuria,
urinary retention
� Palpate the bladder
� Pelvic exam in women
Testicular Torsion
�� Incidence 1: 4000Incidence 1: 4000
�� Most serious of acute problems affecting the Most serious of acute problems affecting the scrotal contentsscrotal contents
�� 2 peak incidences2 peak incidences
–– Neonatal periodNeonatal period
–– PubertyPuberty
Testicular Torsion
�� Why does it happen?Why does it happen?
–– Testes not adequately anchored to the Testes not adequately anchored to the tunica vaginalistunica vaginalistunica vaginalistunica vaginalis
Testicular Torsion
Symptom complex
� Sudden onset of severe testicular pain
� Constant & progressive
� Nausea (+)
Fever, urethral discharge, cystitis symptoms (-)� Fever, urethral discharge, cystitis symptoms (-)
Testicular Torsion
Physical examination
–– Edematous scrotumEdematous scrotum
–– Tender, swollen testisTender, swollen testis
–– Testis high in scrotum with horizontal lie Testis high in scrotum with horizontal lie –– Testis high in scrotum with horizontal lie Testis high in scrotum with horizontal lie �� classical signclassical sign
–– CremastericCremasteric reflex (reflex (--))
–– ““bell-clapper deformity” ”
–– Pain not relieved with elevation of Pain not relieved with elevation of scrotumscrotum
Testicular Torsion:
Diagnosis
� Doppler USG now test of choice for Dx
of torsion. Sensitivity comparable to
radioisotope scans (86%-100%) and radioisotope scans (86%-100%) and
greater specificity (100%).
� Doppler U/S is more rapid and more
available than radioisotope scans.
Testicular Torsion:
Management
� Immediate Urologic consultation for surgical exploration and possible bilateral orchidopexy if diagnosis is obvious
� Manual detorsion � rotating the testicle in a medial to lateral direction, “open the book” maneuver
� Emergent surgery is still required to assure complete detorsion and perform contralateral orchidopexy
Gross Hematuria
� Etiology :
1. Common cause � infections, stones,
malignancies (bladder, kidney), BPH,malignancies (bladder, kidney), BPH,
trauma, post op
2. Less common cause � radiation or
chemical cystitis, sickle cell disease,
coagulopathy.
Gross Hematuria
�� All patients presenting with gross All patients presenting with gross
hematuriahematuria must have urologic followmust have urologic follow--up, up,
even if the bleeding spontaneously even if the bleeding spontaneously
resolves. resolves. resolves. resolves.
�� Bladder tumorsBladder tumors classically bleed classically bleed
intermittently and diagnosis can be delayed intermittently and diagnosis can be delayed
if patients are not appropriately counseledif patients are not appropriately counseled
Urinary Retention
� History :
age, general health
premorbid voiding symptoms
history of urethral strictureshistory of urethral strictures
previous episodes of retention
prior urologic manipulation or surgery (TURP, radical
prostatectomy)
medication (sympathomimetics, anticholinergics)
incontinence
Urinary Retention
Etiology
� Anatomic obstruction :
1. BPH (most common)
2. Urethral stricture
3. Bladder neck contracture3. Bladder neck contracture
4. Prostate Ca (uncommon)
� Functional obstruction :
1. Neurologic disease (CNS or peripheral)
2. Medication side effect
3. Pain (nociceptive retention) � post op, post trauma
4. Psychogenic
Urinary Retention :
Management
� 16 or 18 F Standard Urethral Catheter, adequate lubrication of the catheter
� If fails � Urology consult for SPT
No patient in retention should be � No patient in retention should be instrumented, drained, and then discharged from ED without a clear plan for urologic follow-up
Oliguria & anuria
� Anuria � urine output < 50 ml / 24 h
� Evaluation & treatment :
- Physical exam & urethral catheterization- Physical exam & urethral catheterization
- USG � bilateral hydronephrosis
no hydronephrosis
unilateral hydronephrosis
Priapism
� The pathologic prolongation of penile
erection, accompanied by pain &
tendernesstenderness
� Not by sexual excitement
� Not relieved by orgasm
Foreskin Emergencies
Phimosis
� The uncircumcised foreskin cannot be
retracted over the glans
� Catheterized with a coude tip
Foreskin Emergencies
Paraphimosis
� The uncircumcised foreskin has been left in
the retracted position � obstruction to
venous & lymphatic drainage � progressive
edemaedema
� True urologic emergency
� Th/ : immadiate manual reduction
� If fail � dorsal slit
Phimosis vs. Paraphimosis
Phimosis: inability to retract foreskinTx: dorsal slit or circumcision
Paraphimosis: foreskin retracted
behind coronal groove; tourniquet to
glans
Tx: circumcision
Foreskin Emergencies
Zipper Injuries
� Common source of genital laceration
� Th/ : adequate analgesia & disassembly the
zipperzipper
� Using a cutter � median bar of the zipper
is completely cut � the teeth of the zipper
fall apart
Foreskin Emergencies
External rings
� Often used as sexual aids � edema,
urethral fistula, necrosis
Managed with ring cutter� Managed with ring cutter
� Immediate removal of the object &
debridement
Foreskin Emergencies
Intraurethral foreign bodies
� Evaluate radiographically
� Don’t catheterized � place SPT if retention
� If distal to the external sphincter � object � If distal to the external sphincter � object
will be palpable & can often be removed
endoscopically
� If proximal to the sphincter � open
extraction
Foreskin Emergencies
Post-circumcision complications
� Hematoma � drained by removing a stitch & evacuating
the clot. Replace dressing
� Bleeding� Bleeding
- steady pressure 10 – 15’
- if fail � lidocaine (1:100.000 ephinephrine) & apply
pressure 10 – 15’ more
- skin edges may be cauterized with silver nitrate sticks
- significant bleeding � suture placement under
penile block with lidocaine
Foreskin Emergencies
Post-circumcision complications
� Disruption of incision
- if small � no th/
- if major � place a few interrupted - if major � place a few interrupted
suture under penile block
� Infection
- uncommon & usually minor
- th/ : oral cephalosporine