GU Emergencies

Topics
Renal Trauma
Pelvic Trauma Urethral Trauma Acute Scrotum

Kidneys
Renal Trauma

Ureteric Colic
Others

Renal Trauma
Blunt
RTA Sports Injury

Associated Injuries
Liver laceration Splenic laceration Rib fractures Pulmonary contusion Small bowel injury

Penetrating
Stab wound Gunshot

If injury is minor, consider underlying urological anomaly

Grade 1 Subcapsular haematoma

Grade 2
Perirenal haematoma

Grade 2
Laceration

Grade 3
>1 cm Laceration

Grade 4 Deep laceration

Grade 4
Contained vascular injury

Grade 5 Shattered Kidney

Grade 5 PUJ avulsion

Blunt: Management
Haemodynamically Stable
Microscopic Haematuria
No imaging necessary

Gross Haematuria
Imaging of retroperitoneum. CT. Grade Injury Managed conservatively.

Haemodynamically Unstable. Explore.

Conservative Management
Very strict Bed rest Nil PO Antibiotics Observe until urine clears

Long term problems

Rebleed within 2 weeks Hypertension

Penetrating Renal Trauma

Do not necessarily need to be explored Minor injuries posterior to mid-axillary line may be managed conservatively Anterior injuries require exploration
Related bowel injuries High risk of liver / spleen injury

Ureteric Colic
Diagnosis made on:
History
Radiating pain to groin

Urine
Microscopic haematuria

Imaging
IVP or CT KUB

Ureteric Colic
Sepsis in the presence of colic is LIFE THREATENING
Requires urgent imaging and drainage by nephrostomy

Must rule out AAA in older patient Stones less than 5 mm may pass spontaneously Most managed by simple ureteroscopy/ESWL

Renal Emergencies: Others

Renal Artery Thrombosis Renal Infarct / Emboli Acute haemorrhage
Renal Cyst (APCKD) Angiomyolipoma (AML) Renal Cell carcinoma (RCC)

Acute pain: PUJ Obstruction/ Ureterocoeles

Ureteric Injury: Iatrogenic

Gynae, General and Urological Surgery Ideally, preoperatively stented to avoid injury Or noticed intra-operatively and repaired by a Urologist Often suspected when drain output is high with little urine output or Vaginal fistula

Ureteric Injury
Management
Immediate Ultrasound and Percutaneous Nephrostomy drainage Later, antegrade ureteric stents can be placed Ultimately, open reimplantation of ureters Depending on level of injury:
Psoas hitch / Boari Flap Transuretero-ureterostomy (TUU) Ileal interposition graft

Pelvic Trauma
Bladder Injuries Urethral Injuries

Bladder Injury
Minor mucosal injuries are common Methods of Injury
Pelvic fracture
Blunt / Penetrating

Bladder Rupture
Fall on a full bladder Previous augmentation

Iatrogenic

Bladder Injury
Evaluation
Contrast Cystogram (CT) +/- Retrograde Urethrogram

Management
Extraperitoneal Bladder Injury
Catheter drainage

Intraperitoneal Bladder Injury

Surgical Exploration

Urethral Injury
90% associated with pelvic fractures Common: 10% of all pelvic fractures Suspected if:
Haematuria Unable to void Blood at meatus Perineal bruising High riding prostate

Urethral Injury
Grading
Grade 1 Grade 2 Grade 3 stretch injury Partial tear Complete tear

Location
Anterior urethra
Less common

Posterior urethra
Occur with pelvic fractures

Penile Fractures
Injury to the erect penis usually by female partner on top Audible snap and instant detumesence Rupture of Bucks fascia May have associated urethral injury Requires MRI +/- urethrogram Must be repaired ASAP

Priapism
Definition: persistent erection not accompanied by sexual desire or stimulation > 6 hours Corpora cavernosa only all age groups (including newborns) peak incidence 20 to 50yrs younger age group assoc with sickle cell usually pain (except in non-ischaemic type)

Classification
Low flow or Ischaemic (veno-occlusive)
most common Painful due to tissue ischaemia and smooth muscle hypoxia (compartment syndrome)

High flow or Nonischaemic (arterial)

less common increased cavernous inflow usually not fully erect and painless Secondary to trauma

Low-flow priapism
Low flow or Ischaemic (veno-occlusive) most common Penis fully erect (sludging of blood within) Painful blood gases from corpora - acidosis platelet aggregation and adhesion - thrombus formation and tissue damage

Causes of low-flow priapism

Intracavernosal pharmacotherapy 21% of cases of priapism - 207 patients papaverine PGE-1 alprostadil <1% intracavernosal <0.1% intraurethral extremely low incidence with oral agents Drugs cocaine, heparin withdrawal, trazadone, phenothiazines Haemoglobinopathies / Sickle Cell disease

High-flow priapism
Nonischaemic (arterial) less common Penile, perineal or pelvic trauma uncontrolled arterial inflow directly into the penile sinusoidal spaces usually penis not fully erect and painless normal local blood gases no risk of ischaemia and subsequent fibrosis

Management of Priapism
A Urological emergency Treat causal factor where identified goal is to abort the erection, thereby preventing permanent damage to the corpora (ED) and to relieve pain. Longer duration implies greater risk of impotence Glans and corpus spongiosum rarely involved Urinalysis Haemoglobin S to outrule leukaemia Local blood gas measurments

Management of low-flow Priapism

Aspiration of the corpora with a 21G butterfly needle followed by an injection of phenylephrine (1 adrenergic agonist) every 5 minutes until detumescence Winter procedure using a Trucut needle
create a shunt between glans and corpora cavernosa

30% of Winter procedure fail

direct cavernosal-spongiosum anastomosis corpora-saphenous shunt

Management of High-flow Priapism

Ice pack arterial spasm Most cases require arteriography and embolisation of the internal pudendal artery or a branch Outcome:
Low-flow: risk of impotence/fibrosis due to ischaemia High-flow: Good prognosis

Acute Scrotum and Torsion

Testicular Torsion
Twisting of testis on its cord resulting in strangulation of its blood supply and infarction. Medially 66% 1 in 4000 males < 25 years 12 20 and perinatal, peak 14 16years (post pubertal) 80 90% acute scrotum in teenagers Left > Right Maldescent 5% Always bilateral Intravaginal and extravaginal

Pathophysiology
Bell-Clapper Theory (Intravaginal) Lack of fixation of testis and epididymis due to larger free space between parietal and visceral layers of tunica vaginalis which expands to surround the testis which is more mobile

Larger or smaller mesentery or abnormal attachment Absence of gubernaculum (Extravaginal) Cremasteric pull (spiral insertion)

Presentation
Acute pain, may be prior episodes Nausea/vomiting Lying still with legs spread Wont allow examination (too sore) Swollen erythematous scrotum High ridding transverse lie, foreshortening of cord Absent cremasteric reflex 100%

Management
Diagnosis
A Clinical Diagnosis Other Modalities
Doppler U/S (Johns Hopkins 2000 radiol 130 pts missed 2/85 followed up) reassure that its not torsion Technetium 99 vascular integrity (invasive and slow)

Management
Manual Detorsion? Still needs exploration Immediate Exploration midline incison Bilateral testicular 3-point fixation Warm sponges / necrotic--- excise

Injury
Irreversible ischaemic injury at 4 hours (Bartsch 1980) Operated < 8 hours had normal size Symptoms < 4 hours 50% normal semen analysis Puri 1985 Fertility normal (33 pts) Bilateral torsion testicular failure 60% atrophy rate at 2 years >18 yrs higher risk of loss due to delay in presenting Ischaemia reperfusion injury

Appendages
Appendix Testis mullerian duct Peak 10 12, prepubertal 50% acute scrotums Insidious onset, less pain/sickness, upper pole Tender nodule Blue Dot sign 20% Testis mobile

Appendix epididymis wolfian duct

Epididymitis
Very common In men < 30 associated with sexual activity
Often chlamydia / non-gonnococcal organism Ofloxacin / Doxycycline recommended

Older men / long term catheter users

Urinary organisms: E.Coli, Proteus, Enterococcus Treat according to MSU

Thank You! Any Questions?