Dr. Syah Mirsya Warli, SpU Dr. Bungaran Sihombing,SpU Div. of Urology, Surgery Dept. Medical Faculty, University of Sumatera Utara

Transcription

1 Emergency Room Urology Dr. Syah Mirsya Warli, SpU Dr. Bungaran Sihombing,SpU Div. of Urology, Surgery Dept. Medical Faculty, University of Sumatera Utara

2 Ref : Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3 rd ed, 2001 Smith s General Urology (Tanagho & McAninch eds), Lange Medical Books, 15 th ed, 2000

3 Genitourinary Emergencies Pain Testicular Torsion Hematuria Urinary Retention Oliguria & anuria Priapism Foreskin emergencies

4 Testicular Torsion Incidence 1: 4000 Most serious of acute problems affecting the scrotal contents 2 peak incidences Neonatal period Puberty

5 Testicular Torsion Why does it happen? Testes not adequately anchored to the tunica vaginalis

6 Testicular Torsion Symptom complex Sudden onset of severe testicular pain Constant & progressive Nausea (+) Fever, urethral discharge, cystitis symptoms (-)

7 Testicular Torsion Physical examination Edematous scrotum Tender, swollen testis Testis high in scrotum with horizontal lie classical sign Cremasteric reflex (-) bell-clapper deformity Pain not relieved with elevation of scrotum

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9 TORSION

10 Testicular Torsion: Diagnosis Doppler USG now test of choice for Dx of torsion. Sensitivity comparable to radioisotope scans (86%-100%) and greater specificity (100%). Doppler U/S is more rapid and more available than radioisotope scans.

11 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

12 Gross Hematuria Etiology : 1. Common cause infections, stones, malignancies (bladder, kidney), BPH, trauma, post op 2. Less common cause radiation or chemical cystitis, sickle cell disease, coagulopathy.

13 Gross Hematuria All patients presenting with gross hematuria must have urologic follow-up, even if the bleeding spontaneously resolves. Bladder tumors classically bleed intermittently and diagnosis can be delayed if patients are not appropriately counseled

14 Urinary Retention History : age, general health premorbid voiding symptoms history of urethral strictures previous episodes of retention prior urologic manipulation or surgery (TURP, radical prostatectomy) medication (sympathomimetics, anticholinergics) incontinence

15 Urinary Retention Etiology Anatomic obstruction : 1. BPH (most common) 2. Urethral stricture 3. 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

16 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 instrumented, drained, and then discharged from ED without a clear plan for urologic follow-up

17 Oliguria & anuria Anuria urine output < 50 ml / 24 h Evaluation & treatment : - Physical exam & urethral catheterization - USG bilateral hydronephrosis no hydronephrosis unilateral hydronephrosis

18 Priapism The pathologic prolongation of penile erection, accompanied by pain & tenderness Not by sexual excitement Not relieved by orgasm

19 Foreskin Emergencies Phimosis The uncircumcised foreskin cannot be retracted over the glans Catheterized with a coude tip

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21 Foreskin Emergencies Paraphimosis The uncircumcised foreskin has been left in the retracted position obstruction to venous & lymphatic drainage progressive edema True urologic emergency Th/ : immadiate manual reduction If fail dorsal slit

22 Phimosis vs. Paraphimosis Phimosis: inability to retract foreskin Tx: dorsal slit or circumcision Paraphimosis: foreskin retracted behind coronal groove; tourniquet to glans Tx: circumcision

23 Foreskin Emergencies Zipper Injuries Common source of genital laceration Th/ : adequate analgesia & disassembly the zipper Using a cutter median bar of the zipper is completely cut the teeth of the zipper fall apart

24 Foreskin Emergencies External rings Often used as sexual aids edema, urethral fistula, necrosis Managed with ring cutter Immediate removal of the object & debridement

25 Foreskin Emergencies Intraurethral foreign bodies Evaluate radiographically Don t catheterized place SPT if retention If distal to the external sphincter object will be palpable & can often be removed endoscopically If proximal to the sphincter open extraction

26 Foreskin Emergencies Post-circumcision complications Hematoma drained by removing a stitch & evacuating the clot. Replace dressing Bleeding - steady pressure if fail lidocaine (1: ephinephrine) & apply pressure more - skin edges may be cauterized with silver nitrate sticks - significant bleeding suture placement under penile block with lidocaine

27 Foreskin Emergencies Post-circumcision complications Disruption of incision - if small no th/ - if major place a few interrupted suture under penile block Infection - uncommon & usually minor - th/ : oral cephalosporine

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