references : Smith’s general urology Emil A.tanagho, jack W.McAninch ارولوژی‏ عمومی دکترناصرسیم فروش، دکتر اکبرنورعلیزاده

1. Urological Emergencies
• Smith’s general urology Emil A.tanagho, jack W.McAninch
• ‫ارولوژی‬‫دکتر‬ ،‫فروش‬ ‫دکترناصرسیم‬ ‫عمومی‬‫اکبرنورعلیزاده‬
• emedicine.medscape.com
‫خدا‬ ‫نام‬ ‫به‬

2. Classification
Traumatic
Renal Trauma
Ureteral Injury
Bladder Trauma
Urethral Injury
Penile trauma
Testicular Trauma
Non traumatic
Hematuria
Renal Colic
Urinary Retention
Acute Scrotum
Priapism

3. Renal Trauma
the most common injuries of the urinary system
Most injuries occur from motor vehicle accidents,
fights, falls, and contact sports
Deceleration
abdominal visceral injuries are present in 95% of
renal penetrating wounds.

4. Signs:
Lower rib fractures(11,12)
Deceleration
Vertebral injury
Ecchymosis in the flank or upper quadrants
of the abdomen
Gunshot
Psoas shadow, ground glass

5. Pathologic classification of renal
injuries:
 Grade 1 (the most common):
 Renal contusion or bruising of
the renal parenchyma
 Microscopic hematuria(gross
hematuria can occur rarely)

6.  Grade 2:
 Renal parenchymal laceration into the renal cortex
 Perirenal hematoma is usually small (<1cm)

7.  Grade 3:
 Renal parenchymal laceration extending through the
cortex and into the renal medulla.
 Bleeding can be significant in the presence of
largeretroperitoneal hematoma.

8.  Grade 4:
 Renal parenchymal laceration extending into the renal
collecting system; also, main renal artery thrombosis from
blunt trauma, segmental renal vein,or both; or artery injury
with contained bleeding.

9.  Grade 5:
 Multiple Grade 4 parenchymal lacerations,renal pedicle
avulsion, or both;
 main renal vein or artery injury from penetrating trauma.
Advance one grade for bilateral injury up to grade 3.

10. Indications for imaging studies:
 Any child with microscopic(>5 RBCs per high powered field or
dipstick hematuria) or macroscopic hematuria
 Macroscopic hematuria
 Microscopic hematuria a hypotensive patient (SBP <90mmHg )
 Penetrating wounds
 A history of a rapid deceleration, Falling (>4m), bicycle accident, car
accident, sports

11. Imaging studies:
 Abdominal CT with contrast media is the best imaging study to
detect and stage renal and retroperitoneal injuries.
 venous injuries
 urinary extravasation: avulsion of the renal pedicle, renal
pelvic injuries
 Decreased enhancement: arterial thrombosis, arterial spasm,
shock, renal artery injury (arteriography)
 IVP
 Arteriography(embolization)
 sonography

12. Complications:
 A. EARLY COMPLICATIONS:
 Hemorrhage is the most important immediate complication
 Urinary extravasation (urinoma) [prone to abscess
formation and sepsis]
 perinephric abscess
 B. LATE COMPLICATIONS:
 Hypertension
 hydronephrosis
 arteriovenous fistula
 Calculus formation
 pyelonephritis

13. Treatment:
 A. EMERGENCY MEASURES:
 Treatment of shock and hemorrhage, complete resuscitation,
and evaluation of associated injuries.
 B. SURGICAL MEASURES
 1. Blunt injuries
 2. Penetrating injuries

14. 1. Blunt injuries:
 98% of cases and do not usually require operation (bed rest
and hydration)
 Indications for surgery:
1. persistent retroperitoneal bleeding
2. urinary extravasation
3. evidence of nonviable renal parenchyma
4. renal pedicle injuries

15. 2. Penetrating injuries
 Grades 3,4,5 Penetrating injuries should be surgically
explored.
 Emergent laparotomy without imaging
 Renal artery injury(<8h)

17. INJURIES TO THE URETER
 is rare but may occur, usually during:
 difficult pelvic surgical procedure
 as a result of gunshot wounds
 Endoscopic basket manipulation of ureteral calculi
 Etiology:
 Gunshot (the most common penetrating trauma)
 Vertebral fractures (the most common blunt trauma)
 Hysterectomy, oophorectomy(the most common surgical injury)
 Ureteroscopy

18. INJURIES TO THE URETER
 Clinical Findings
 fever of 38.3°C–38.8°C
 flank and lower quadrant pain
 Uremia
 paralytic ileus with nausea and vomiting
 cutaneous fistula, vaginal fistula

19. Diagnosis and treatment
Imaging
 IVP
 CT scan
 Retrograde urography
treatment
 repair is in the operating room
 Delayed repair

20. INJURIES TO THE BLADDER
 Bladder injuries occur most often from external force and are
often associated with pelvic fractures.
 Pelvic fracture with hematuria bladder examination
 Pelvic and abdominal Penetrating trauma with hematuria
cystography
 Gynecologic surgery, pelvic surgery, repair of hernia
Clinical findings:
 Pelvic fracture accompanies bladder rupture in 90% of
cases.
 Pelvic fracture with supra pubic tenderness
 Patients ordinarily are unable to urinate, but when
spontaneous voiding occurs.
 gross hematuria is usually present.

21. Treatment:
extraperitoneal rupture
Indication for surgery:
1. patients who need another surgery
2. Open fractures of pelvic
3. Rupture of the rectum
4. fragment projecting into the rupture
Intraperitoneal rupture
 Surgical repaire

22. INJURIES TO THE URETHRA
 Urethral injuries are uncommon and occur most often in
men, usually associated with pelvic fractures or straddletype falls.
 They are rare in women.
 INJURIES TO THE POSTERIOR URETHRA:
 Patients usually complain of lower abdominal pain and inability
to urinate.
 Blood at the urethral meatus is the single most important sign
of urethral injury.
 The presence of blood at the external urethral meatus
indicates that immediate urethrography is necessary to
establish the diagnosis.

23. Treatment:
 Stricture
 impotence
 incontinence
Complications:
1. Immediate management
2. Delayed urethral reconstruction
3. Immediate urethral realignment

24. INJURIES TO THE ANTERIOR URETHRA
 Straddle injury may cause laceration or contusion of the
urethra.
 iatrogenic instrumentation may cause partial disruption.
Treatment:
 Hemostasis
 Cystostomy
 Anastomosis

25. INJURIES TO THE PENIS
 Disruption of the tunica albuginea
 Disruption of the tunica albuginea of the penis (penile
fracture) can occur during sexual intercourse.
 At presentation,the patient has penile pain and hematoma.
 This injury should be surgically corrected.
 Penile amputation
 Penile amputation involves the complete or partial severing of
the penis
 Amputation of the penis may be accidental but is often self-
inflicted, especially during psychotic episodes in individuals
who are mentally ill.

26. INJURIS TO THE PENIS
 Penetrating injury
 RUG
 Immediate repair
 Delayed repair
 avulsion of the penile skin
Immediate debridement and skin grafting

27. INJURIES TO THE TESTIS
 Blunt trauma to the testis causes severe pain and,
often,nausea and vomiting.
 Lower abdominal tenderness may be present.
 A hematoma may surround the testis and make delineation of
its margin difficult.
 If rupture has occurred, the sonogram will delineate the
injury, which should be surgically repaired.
 Operative indications for blunt trauma:
 suspicion of rupture
 expanding hematomas

28. Diagnosis:
Physical exam:
 Enlargement and edema of the testicle; edema involving the entire
scrotum
 Scrotal erythema
 the testis is high riding compared with the other side
 The cremasteric reflex is almost always absent or diminished on
the affected side
Imaging studies:
 Imaging studies usually are not necessary. Ordering them wastes
valuable time when the definitive treatment is emergent urologic
consultation for surgical management.
 color Doppler ultrasonography: Absent or decreased blood flow in the
affected testicle
 Radionuclide Scan: demonstrate decreased uptake in the affected
testicle

29. Testicular tortion
 the torsion of the spermatic cord structures and subsequent loss of
the blood supply.
Presentation:
 sudden onset of severe unilateral scrotal pain followed by
inguinal and/or scrotal swelling.
 Torsion can occur with sports or physical activity, can be related
to trauma in 4-8% of cases,or can develop spontaneously.
 Vomiting
 Fever, Dysuria, frequency are usually absent.

30. Treatment:
 Immediate surgical exploration is indicated(4h)
 If treatment is delayed, the patient may experience decreased fertility or
may require orchiectomy(8h)
 The spermatic cord is untwisted, then fix gonads to the scrotal wall
 DDX
 Differential Diagnoses
 Appendicitis
 Fournier Gangrene
 Henoch-Schonlein Purpura in Emergency Medicine
 Hernias
 Scrotal Trauma
 Spermatocele
 Testicular Choriocarcinoma
 Testicular Seminoma
 Testicular Trauma
 Varicocele

31. priapism
 Priapism is an uncommon condition of prolonged erection. It is
usually painful for the patient, and no sexual excitement or desire
is present.
 A bimodal distribution has been noted, with peaks at 5-10 years
and 20-50 years
 Etiology:
 The most common cause of priapism in the pediatric
population is sickle cell disease
 Leukemia, trauma, idiopathic, pharmacologic
 Fat embolism (from multiple long-bone fractures or
intravenous infusion of lipids as part of total parenteral
nutrition)
 Prostate cancer, Bladder cancer (highest risk), Hematologic
cancer (leukemia), Renal carcinoma, Melanoma

32. Classification:
 High-flow priapism (nonischemic)
 usually occurs secondary to perineal trauma, which
injures the central penile arteries and results in loss of
penile blood-flow regulation
 Low-flow priapism (ischemic)
 presents with a history of several hours of painful erection.
 The glans penis and corpus spongiosum are soft and
uninvolvedin the process

33. Presentation:
 Obvious erection is the key physical finding in any case of priapism
 Pain and tenderness
 Edema
 Thrombosis, fibrosis, necrosis
Diagnosis:
 history
 Physical examination
 CBC, hemoglobin S determination
 Penile blood gas (PBG) test
 Color-flow penile Doppler imaging

34. Treatment:
 low-flow priapism
 starting with therapeutic aspiration
 Irrigation
 intracavernous injection of a sympathomimetic agent
 attempt to treat the underlying condition
 High-flow priapism
 embolization of the offending vessel
 Surgical treatment:
 A unilateral shunt is often effective
 Complications:
 Fibrosis
 impotence

35. Thanks for your attention…