Emergency Urology Non Trauma

7/23/2019 Emergency Urology Non Trauma

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EMERGENCY

UROLOGY NONTRAUMA



2. HEMATURIA

1. Kidney Pain & Ureteral Pain



PRIAPISM DEFINITION: Prolonged erection.pain!l no "e#!al e#cite$ent or de"ire i" pre"ent.

ETIOLOGY Idiopat%ic in &'( o ca"e" )'( o ca"e" are a""ociated *it% di"ea"e" +eg,

le!-e$ia, "ic-le cell di"ea"e, pelic t!$or", pelic

inection"/, penile tra!$a, "pinal cord tra!$a C!rrentl0, intracaerno!" in1ection t%erap0 or i$potence

$a0 2e t%e $o"t co$$on ca!"e.



CLA33IFICATION

%ig%4 lo*

Lo*4lo*.

5IG5 FLO6 PRIAPI3M +NON4I3C5EMIC/ !"!all0 occ!r" "econdar0 to perineal tra!$a

in1!re" t%e central penile arterie" lo"" o penile 2lood4lo*reg!lation.

7lood4ga" deter$ination 5ig% o#0gen leel Nor$al car2on dio#ide leel".

Arteriograp%0 i" !"e!l to de$on"trate ane!r0"$" t%at*ill re"pond to e$2oli8ation Erectile !nction i" !"!all0 pre"ered.



LOW FLOW PRIAPISM (ISCHEMIC)

Patient" !"!all0 pre"ent *it% a %i"tor0 o "eeral%o!r" o pain!l erection.

T%e glan" peni" and corp!" "pongio"!$ are "otand !ninoled in t%e proce"".

T%e corpora caerno"a are ten"e *it%

conge"ted 2lood and tender to palpation. T%e $ec%ani"$ re$ain in de2ate

p%0"iologic o2"tr!ction o t%e eno!" drainage. I t%e proce"" contin!e" or "eeral da0"

inter"titial ede$a

i2ro"i" o t%e corpora caerno"a

IMPOTENCE



Treat$ent

T%e "l!dged 2lood can t%en 2e eac!ated ro$ t%e corporacaerno"a t%ro!g% a large needle placed t%ro!g% t%e glan".

T%e addition o adrenergic agent" ad$ini"tered ia intracaerno!"irrigation %a" proed %elp!l.

M!ltiple *edge" o ti""!e can 2e re$oed *it% a 2iop"0 needle tocreate a "%!nting i"t!la 2et*een t%e glan" peni" and corporacaerno"a.

T%i" tec%ni9!e, *%ic% %a" 2een er0 "!cce""!l, proide" aninternal i"t!la to -eep t%e corpora caerno"a deco$pre""ed.

To $aintain contin!o!" i"t!la drainage, pre""!re "%o!ld 2e e#ertedinter$ittentl0 +eer0 ; $in!te"/ on t%e 2od0 o t%e peni".



I t%e "%!nt de"cri2ed ail", anot%er "%!nting

tec%ni9!e $a0 2e !"ed 20 ana"to$o"ing t%e

"!pericial dor"al ein to t%e corpora caerno"a. Ot%er eectie "%!nting $et%od" are corpora

caerno"a to corp!" "pongio"!$ "%!nt 20

perineal ana"to$o"i"< "ap%eno!" ein to

corpora caerno"a "%!nt< and p!$pdeco$pre""ion.



50per2aric o#0gen al"o %a" 2een

"!gge"ted or t%e"e patient".

Treat$ent "%o!ld not preent aggre""ie

$anage$ent o t%e priapi"$ i t%e

erection per"i"t" or "eeral %o!r".



I$potence i" t%e *or"t "e9!el o priapi"$.

It i" $ore co$$on ater prolonged

priapi"$ +"eeral da0"/.

Earl0 recognition +*it%in %o!r"/ and

pro$pt treat$ent o priapi"$ oer t%e 2e"t

opport!nit0 to aoid t%i" $a1or pro2le$.



PARAPHIMOSIS

Parap%i$o"i" i" t%e condition in *%ic% t%e

ore"-in, once retracted oer t%e glan", cannot

2e replaced in it" nor$al po"ition. T%e "-in ring ca!"e" eno!" conge"tion leading

to ede$a and enlarge$ent o t%e glan", *%ic%

$a-e t%e condition *or"e.

A" t%e condition progre""e", arterial occl!"ion

and necro"i" o t%e glan" $a0 occ!r.



T%e parap%i$o"i" $!"t 2e regarded a" an

e$ergenc0 "it!ation: retraction o a too narro*prep!ce 2e%ind t%e glan" peni" into t%e glan!lar"!lc!" $a0 con"trict t%e "%at and lead tooede$a.

It interere" *it% per!"ion di"tall0 ro$ t%econ"trictie ring and 2ring" a ri"- o con"ec!tienecro"i".



Parap%i$o"i" !"!all0 can 2e treated 20ir$l0 "9!ee8ing t%e glan" or ; $in!te" to

red!ce t%e ti""!e ede$a and decrea"et%e "i8e o t%e glan".

T%e "-in can t%en 2e dra*n or*ard oert%e glan".

Occa"ionall0, t%e con"tricting ring re9!ire"inci"ion !nder local ane"t%e"ia.



TREATMENT

Con"i"t" o $an!al co$pre""ion o t%eoede$ato!" ti""!e *it% a "!2"e9!ent atte$pt to

retract t%e tig%tened ore"-in oer t%e glan"

peni".

In1ection o %0al!ronida"e 2eneat% t%e narro*2and $a0 2e %elp!l to relea"e it.

I t%i" ail", a dor"al inci"ion o t%e con"trictie

ring i" re9!ired. Depending on t%e local inding",a circ!$ci"ion i" carried o!t i$$ediatel0 or can

2e peror$ed in a "econd "e""ion.



P%i$o"i"

P%i$o"i" i" a condition in *%ic% t%e contracted

ore"-in cannot 2e retracted oer t%e glan".

C%ronic inection ro$ poor local %0giene i" it"$o"t co$$on ca!"e.

Mo"t ca"e" occ!r in !ncirc!$ci"ed $ale",

alt%o!g% e#ce""ie "-in let ater circ!$ci"ion

can 2eco$e "tenotic and ca!"e p%i$o"i".



C%ildren !nder = 0ear" o age "eldo$ %ae tr!ep%i$o"i"< t%eir relatiel0 narro* prep!tial

opening grad!all0 *iden" and allo*" or nor$alretraction o ore"-in oer t%e glan".

Circ!$ci"ion or p%i$o"i" "%o!ld 2e aoided inc%ildren re9!iring general ane"t%e"ia< e#cept in

ca"e" *it% rec!rrent inection", t%e proced!re"%o!ld 2e po"tponed !ntil t%e c%ild reac%e" anage *%en local ane"t%e"ia can 2e !"ed.



Ede$a, er0t%e$a, and tenderne"" o t%eprep!ce and t%e pre"ence o p!r!lent di"c%arge

!"!all0 ca!"e t%e patient to "ee- $edicalattention.

T%e dor"al ore"-in can 2e "lit i i$proeddrainage i" nece""ar0.

Circ!$ci"ion, i indicated,"%o!ld 2e done atert%e inection i" controlled.



TREATMENT

Treat$ent o p%i$o"i" in c%ildren i" dependent

on t%e parent"> preerence" and can 2e pla"tic

or radical circ!$ci"ion ater co$pletion o t%e

"econd 0ear o lie.

Contraindication" or circ!$ci"ion are

coag!lopat%0, an ac!te local inection and

congenital ano$alie" o t%e peni", partic!larl0%0po"padia" or 2!ried peni".



A" a con"eratie treat$ent option o t%epri$ar0 p%i$o"i", a corticoid oint$ent or

crea$ +'.';4'.(/ can 2e ad$ini"tered

t*ice a da0 oer a period o ='4?' da0"

T%i" treat$ent %a" no "ide eect" and t%e

$ean 2lood"pot corti"ol leel" are not

"igniicantl0 dierent ro$ an !ntreated

gro!p o patient"

Aggl!tination o t%e ore"-in doe" not

re"pond to "teroid treat$ent



Uro"ep"i"

3ep"i" i" a "0"te$ic re"pon"e to inection.

T%e "0$pto$" o 3IR3 *%ic% *ere initiall0

con"idered to 2e @$andator0> or t%e diagno"i" o"ep"i", are no* con"idered to 2e alerting

"0$pto$".



Pat%ogene"i"

Micro4organi"$" reac% t%e !rinar0 tract 20 *a0o t%e a"cending, %ae$atogeno!", or l0$p%aticro!te".

T%e ri"- o 2acteriae$ia i" increa"ed in "eereUTI", "!c% a" p0elonep%riti" and ac!te 2acterialpro"tatiti" +A7P/, and i" acilitated 20

o2"tr!ction. A atal o!tco$e i" de"cri2ed in ='4)'( o allpatient".



Cytokines as markers of the septic response T%e0 are peptide" t%at reg!late t%e a$plit!de and d!ration o t%e

%o"t inla$$ator0 re"pon"e. 6%en t%e0 2eco$e 2o!nd to "peciic receptor" on ot%er cell",

c0to-ine" c%ange t%eir 2e%aio!r in t%e inla$$ator0 re"pon"e. T%e co$ple# 2alance 2et*een pro4 and anti4inla$$ator0

re"pon"e" i" $odiied in "eere "ep"i". An i$$!nodepre""ie p%a"i" ollo*" t%e initial pro4inla$$ator0

$ec%ani"$.

T!$o!r necro"i" actor4 +TNF4B pt/, interle!-in4 +IL4/, IL4&, andIL4 are c0to-ine" t%at are a""ociated *it% "ep"i".



Procalcitonin is a potential marker of sepsis Procalcitonin i" t%e propeptide o calcitonin, 2!t i" deoid o

%or$onal actiit0. Nor$all0 in %ealt%0 %!$an", leel" are !ndetecta2le. D!ring "eere generali8ed inection" +2acterial, para"itic and !ngal/

*it% "0"te$ic $anie"tation", procalcitonin leel" $a0 ri"e to ''ng$L.

5ig% procalcitonin leel", or an a2r!pt increa"e in leel" in t%e"epatient", "%o!ld pro$pt a "earc% or t%e "o!rce o inection.

Procalcitonin $a0 2e !"e!l in dierentiating 2et*een inectio!" andnon4inectio!" ca!"e" o "eere inla$$ator0 "tat!".



Diagno"i"



Ac!te 3crot!$

Ac!te "crot!$ i" a !rolog0 e$ergenc0 ca"e, $o"t co$$onl0ca!"ed 20 tor"ion o t%e te"ti", tor"ion o t%e appendi# te"ti" andepidid0$iti"epidid0$o4orc%iti".

Tor"ion o t%e te"ti" occ!r" $o"t oten in t%e neonatal period and

aro!nd p!2ert0, *%ile tor"ion o t%e appendi# te"te" occ!r" oer a*ider age range.

Ac!te epidid0$iti" aect" t*o age gro!p": 2elo* t%e age o 0earand 2et*een = and ; 0ear".

Ac!te epidid0$iti" *a" o!nd $o"t oten +?4&).&(/ in 2o0" *it%ac!te "crot!$.

One "t!d0 predicted t%e incidence o epidid0$iti" a" a2o!t .= per,''' $ale c%ildren per 0ear.



EPIDIDYMITIS

Aetiology

Inection and inla$$ation o t%e epidid0$i" $o"t oten re"!ltro$ an a"cending inection ro$ t%e lo*er !rinar0 tract.

Mo"t ca"e" o epidid0$iti" in $en 0o!nger t%an ?; 0ear" are d!eto "e#!all0 tran"$itted organi"$" +N. gonorrhoeae and C.trachomatis/< t%o"e in c%ildren and older $en are d!e to !rinar0pat%ogen" "!c% a" E. coli.

In %o$o"e#!al $en *%o practice anal interco!r"e, E. coli andot%er colior$ 2acteria are co$$on ca!"atie organi"$".



A. PRESENTATION AND FINDINGS

Patient" *it% epidid0$iti" pre"ent *it% "eere "crotal pain t%at$a0 radiate to t%e groin or lan-.

3crotal enlarge$ent d!e to t%e inla$$ation o t%e

epidid0$i"te"ti" or a reactie %0drocele $a0 deelop rapidl0. On p%0"ical e#a$ination, an enlarged and red "crot!$ i" pre"ent,

and it i" oten diic!lt to di"ting!i"% t%e epidid0$i" ro$ t%e te"ti"d!ring t%e ac!te inection.

A t%ic-ened "per$atic cord can occa"ionall0 2e palpated. Urinal0"i" t0picall0 de$on"trate" 67C" and 2acteria in t%e !rine

or !ret%ral di"c%arge. 3er!$ 2lood anal0"i" oten reeal" le!-oc0to"i".



B. RADIOLOGIC IMAGING

Fre9!entl0, it i" diic!lt to di"ting!i"% epidid0$iti" ro$ ac!tete"tic!lar tor"ion 2a"ed on t%e %i"tor0 and p%0"ical e#a$inationalone +Petrac- and 5aee8, BB=/.

3crotal Doppler !ltra"onograp%0 or radion!clide "canning can 2e

!"ed to conir$ t%e diagno"i" +Paltiel et al, BB/. T%e pre"ence o 2lood lo* in t%e te"ti" on Doppler !ltra"onograp%0

or !pta-e o t%e tracer" into t%e center o t%e te"ti" on radion!clide"canning r!le" o!t tor"ion.

On "crotal !ltra"onograp%0, patient" *it% epidid0$iti" co$$onl0%ae an enlarged epidid0$i" *it% increa"ed 2lood lo*.



C. MANAGEMENT

Oral anti2iotic treat$ent i" directed again"t "peciic ca!"atieorgani"$", a" $entioned in t%e preio!" "ection" on !ret%riti" andUTI.

In addition, 2ed re"t, "crotal eleation, and t%e !"e o non"teroidalanti4inla$$ator0 agent" are %elp!l in red!cing t%e d!ration o t%e"0$pto$".

In patient" *it% epidid0$iti" ca!"ed 20 "e#!all0 tran"$ittedorgani"$", treat$ent o t%eir "e#!al partner" i" reco$$ended topreent reinection.

Open drainage i" indicated in ca"e" in *%ic% an a2"ce"" deelop".



Anti2iotic treat$ent, alt%o!g% oten "tarted, i" notindicated in $o"t ca"e" !nle"" !rinal0"i" and !rinec!lt!re "%o* a 2acterial inection.

Epidid0$iti" i" !"!all0 "el4li$iting and *it% "!pportiet%erap0 +i.e.$ini$al p%0"ical actiit0 and analge"ic"/

%eal" *it%o!t an0 "e9!elae. 5o*eer, 2acterial epidid0$iti" can 2e co$plicated 20

a2"ce"" or necrotic te"ti" and "!rgical e#ploration i"re9!ired.

3!rgical e#ploration i" done in e9!iocal ca"e" and inpatient" *it% per"i"tent pain.



Te"tic!lar tor"ion

T%e d!ration o "0$pto$" i" "%orter in

te"tic!lar tor"ion +&B( pre"ent *it%in =%o!r"/ co$pared to tor"ion o t%e

appendi# te"te" +&=(/ and ac!te

epidid0$iti" +?(/



Diagno"i"Epidid0$iti" Te"tic!lar tor"ion

. In t%e earl0 p%a"e, location o t%epain, e#perience a tenderepidid0$iti",

=. An a2nor$al po"ition o t%e te"ti"rare

?. T%e cre$a"teric rele# : po"itie

). Feer occ!r" oten in epidid0$iti"

+4B(/.;. A po"itie !rine c!lt!re i" onl0

o!nd in a e* patient" *it%epidid0$iti".

. More li-el0 to %ae a tenderte"ticle and patient" *it% tor"iono t%e appendi# te"ti" eeli"olated tenderne"" o t%e

"!perior pole o t%e te"ti".=. More re9!ent

?. Negatie

). T%e cla""ical "ign o a @2l!e dot>*a" o!nd onl0 in '4=?(patient" *it% tor"ion o t%eappendi# te"ti"

;. An a2nor$al !rinal0"i" doe" note#cl!de te"tic!lar tor"ion.



Doppler !ltra"o!nd i" !"e!l to eal!ate anac!te "crot!$, *it% a "en"itiit0 o &?.&4''(and a "peciicit0 o B4''(, and a po"itie

predictie al!e o ''( and negatie predictieal!e B.;(

7etter re"!lt" *ere reported !"ing %ig%4re"ol!tion !ltra"onograp%0 +5RU3/ or direct

i"!ali8ation o t%e "per$atic cord t*i"t *it% a"en"itiit0 o B.?( and a "peciicit0 o BB(



T%e"e ine"tigation" $a0 2e !"ed *%endiagno"i" i" le"" li-el0 and i tor"ion o t%e te"ti"

"till cannot 2e e#cl!ded ro$ %i"tor0 andp%0"ical e#a$ination.

T%i" "%o!ld 2e done *it%o!t inordinate dela0"

or e$ergent interention.



Treat$ent

Man!al detor"ion o t%e te"ti" i" done *it%o!t anae"t%e"ia. It "%o!ld initiall0 2e done 20 o!t*ard" rotation o t%e te"ti" !nle""

t%e pain increa"e" or i t%ere i" o2io!" re"i"tance. 3!cce"" i" deined a" t%e i$$ediate relie o all "0$pto$" and

nor$al inding" at p%0"ical e#a$ination Doppler !ltra"o!nd $a0 2e !"ed or g!idance. 7ilateral orc%iope#0 i" "till re9!ired ater "!cce""!l detor"ion. T%i" "%o!ld not 2e done a" an electie proced!re, 2!t rat%er

i$$ediatel0 ollo*ing detor"ion.

One "t!d0 reported re"id!al tor"ion d!ring e#ploration in o!t o;? patient", incl!ding patient" *%o %ad reported pain relie ater$an!al detor"ion.

Emergency Urology Non Trauma

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