Common Problems in Urology

Transcription

1 Common Problems in Urology 1. Renal Colic Outline 2. Urinary Retention 3. Acute Scrotum Supanut Lumbiganon, MD. Renal colic The most common urologic emergency O Sudden increase of pressure in the urinary tract and the ureteral wall. O Pain comes in waves and does not decrease if you change positions. O One of the most painful experiences, similar to giving birth 1

2 Typical characteristic O Very sudden onset O Colicky in nature O Radiates to the groin as the stone passes into the lower ureter. O May change in location, from the flank to the groin O The patient cannot get comfortable, and may roll around in agony. O Associated with nausea / Vomiting Investigations O History + Physical examinations O UA, Urine pregnancy test O CBC O Imaging O Film KUB O U/S abdomen O IVP O CT KUB +/- Abdomen Renal colic?? Really?? Loin pain pyrexia and stone PUJ stone Diverticula disease AAA A possible stone on a KUB necessitates an IVU for anatomical delineation... or a non-contrast CT Differential diagnosis O Acute appendicitis O Ovarian pathology Diverticulitis O Ectopic pregnancy O Bowel obstruction O Abdominal aortic aneurysms O Testicular torsion O Burst peptic ulcer O Pneumonia O Myocardial infarction O Inflammatory bowel disease (Crohn s, ulcerative colitis) PUJ stone IVU does give you information about function 2

3 Indications for Intervention to Relieve Obstruction and/or Remove the Stone Dilated PC system Non-function or pyrexia demand a nephrostomy O Pain that fails to respond to analgesics. O Associated fever, pyonephrosis O Renal function is impaired because of the stone O Obstruction unrelieved for >4 weeks O Personal or occupational reasons Treatment of the Stone O Temporary relief of the obstruction: O Insertion of a JJ stent or percutaneous nephrostomy tube. O Definitive treatment of a ureteric stone: O ESWL. O PCNL O Ureteroscopy O Open Surgery: very limited. Acute Management of Ureteric Stones Pain relief O NSAIDs O Intramuscular or intravenous injection, by mouth, or per rectum O +/- Opiate analgesics (pethidine or morphine). Hyper hydration watchful waiting with analgesic supplements O 95% of stones measuring 5mm or less pass spontaneously Urinary retention O Acute Urinary retention O Chronic Urinary retention 3

4 Acute Urinary retention O Painful inability to void, with relief of pain following drainage of the bladder by catheterization. O Pathophysiology : O Increased urethral resistance, i.e., bladder outlet obstruction (BOO) O Low bladder pressure, i.e., impaired bladder contractility O Interruption of sensory or motor innervations of the bladder O Acute urinary retention Both Sex O Haematuria leading to clot retention O Drugs O Pain O Sacral nerve compression or damage(cauda equina compression ) O Radical pelvic surgery O Pelvic fracture rupturing the urethra O Multiple sclerosis O Transverse myelitis O Diabetic cystopathy O Damage to dorsal columns of spinal cord causing loss of bladder sensation (tabes dorsalis, pernicious anaemia). Acute urinary retention O Causes : O Men: O Benign prostatic enlargement O Carcinoma of the prostate O Urethral stricture O Prostatic abscess O Women O Pelvic prolapse (cystocoele, rectocoele, uterine) O Urethral stricture; O Urethral diverticulum; O Post surgery for stress incontinence O pelvic masses (e.g., ovarian masses) Acute urinary retention O Initial Management : O Urethral catheterization O Suprapubic catheter ( SPC) O Late Management: O Treating the underlying cause Chronic urinary retention O Obstruction develops slowly, the bladder is distended (stretched) very gradually over weeks/months, so pain is not a feature. O Presentation: O Urinary dribbling O Overflow incontinence O Palpable lower suprapubic mass 4

5 Differential Diagnosis 1. Torsion of the Spermatic Cord O Most serious. 2. Torsion of the Testicular and Epididymal Appendages. 3. Epididymitis. O Most common Chronic urinary retention O Usually associated with O Reduced renal function. O Upper tract dilatation O Treatment is directed to renal support. O Bladder drainage under slow rate to avoid sudden decompression> hematuria. O Treatment of cause. Torsion of the Spermatic Cord (Intravaginal) O True surgical emergency of the highest order O Irreversible ischemic injury to the testicular parenchyma may begin as soon as 4 hours O Testicular salvage as duration of torsion Acute Scrotum O Emergency situation requiring prompt evaluation, differential diagnosis, and potentially immediate surgical exploration Presentation: O Acute onset of scrotal pain. O Majority with history of prior episodes of severe, self-limited scrotal pain and swelling. O N/V O Referred to the ipsilateral lower quadrant of the abdomen. O Dysuria and other bladder symptoms are usually absent. 5

6 Testicular torsion Adjunctive tests: O To aid in differential diagnosis of the acute scrotum. O To confirm the absence of torsion of the cord. O Doppler examination of the cord and testis O High false-positive and false-negative results 3 Physical examination: Color Doppler ultrasound: The affected testis is highriding Transverse orientation. Acute hydrocele or massive scrotal edema Cremasteric reflex is absent. Tender larger than other side. Prehns sign -ve. O Manual detortion. O Assessment of anatomy and determining the presence or absence of blood flow. O Sensitivity: 88.9% specificity of 98.8% O Operator dependent. Signs O Prehn +ve = decrease pain when elevate testis suspected epididymitis O Dresner s sign = dark blue spot at scrotal sac suspected tortion testicular appendix O Swollen O Hydrocele O Absent blood flow O Robinowitz s signs = absent of cremasteric reflex suspected testicular tortion 6

7 Radionuclide imaging : Torsion of the Spermatic Cord O Assessment of testicular blood flow. O PPV of 75%, a sensitivity of 90%, and a specificity of 89%. O False impression from hyperemia of scrotal wall. O Not helpful in Hydrocele and Hematoma Torsion of the Spermatic Cord Surgical exploration: O A median raphe scrotal or a transverse incision. O Affected side to be examined first O The cord should be detorsed. O Testes with marginal viability should be placed in warm sponges and re-examined after few minutes. O A necrotic testis should be removed O If the testis is to be preserved, placed into the dartos pouch (suture fixation) O The contralateral testis must be fixed to prevent subsequent torsion. TORSION Minor twist-viable Major twist-viable! Lithotomy Position 1 3 Major twist-? viable Major twist-necrotic 2 4 O In the seventeenth century, Frr Jacques gained great fame as a `stone-cutter` or `lithotomist`. He travelled through Europe, practising a bladder-stone removal technique that became the golden standard for a long time. 7