This Zoom call information is only good for Thursday August 20, 2020
INTRODUCTION
Unlike the other surgical specialties’ Urology does not have too many emergencies. 1 It is about 2% of the emergencies presenting to the hospitals and in the population about 1.5 per 100000. Hence most of the Urologists do not plan for emergencies and the emergencies are left to the general surgeons to treat. It is very important for the rural surgeons to know the basics in handling the Urological emergencies. In general, the Urological emergencies cause a lot of stress to the patients and require immediate relief. For instance, it is terrible to have urinary obstruction and ureteric colic could be as painful as labor pain. We have a look at some of the common ones that were presented at the annual conference of the Association of rural surgeons of India.
URINARY RETENTION
Urinary retention could be either acute or chronic. Sometimes chronic retention can present with overflow incontinence. The following table lists the various causes of retention.
Table: Causes of Urinary Retention
It is more common in men and is due to bladder outflow obstruction secondary to Prostate. Men especially in the rural areas ignore the lower urinary tract symptoms and retention comes as a surprise and is often precipitated by postponing voiding [for example while traveling]. Sometimes bleeds or prostatic infarcts or infection could be the precipitating factor. It is uncommon in women and is related to prolapsed Uterus or stones. Some factors are common to both. Most of the time simple catheterization should suffice for relieving the obstruction. Antibiotics should be given prior to the procedure that should be carried out under sterile conditions. Temporary relief could be provided using spinal or long needle to aspirate the bladder and remove as much urine as possible to get sufficient time for preparation. Plenty of lubricant should be used and curve of the urethra should be in mind to make sure the catheter is pushed gently in the correct direction.
If catheterization is not successful, then Suprapubic bladder drainage is carried out. It should be remembered that later the Urologists need to use this track for scopies especially in case of stricture urethra and hence it should be place at a sufficiently higher level above the pubic bones. Rapid decompression of the distended bladder can cause severe bleeding and hence the decompression should be slow by clamping the tubing of the Urosac.
It is important to check the hourly urine output after relieving the obstruction and replace the output with normal saline if it exceeds 200 ml per hour. This is to avoid acute renal failure and electrolyte imbalance. Serum potassium levels should also be monitored.
ACUTE LOIN PAIN Acute loin pain caused by renal or more commonly ureteric calculi are classically colicky pain radiating from the renal angle to the groin. Sometimes it could be as severe as labor pain and the patient rolls in pain trying to get some relief. Depending on the site of the stone the pain could be at the tip of the penis or in the groin alone. Presence of vomiting indicates an ongoing process and the stone could be moving down from the previous location. High grade fever with chills indicates infection in an obstructed system and is a grave emergency.
In rural areas most often a KUB X ray and ultrasound examination should suffice. Urine microscopy need not show red blood cells to diagnose a calculus. Elevated counts, ESR and a positive ‘C” reactive protein might indicate obstruction and sepsis. The following table gives the differential diagnosis
Table: Differential Diagnosis of Acute Loin Pain
Powerful pain killers and anti – inflammatory medication is necessary during the acute phase. Tamsulosin an alpha blocker could be used at a dose of 0.4 mg daily. Sodium bicarbonate could alkalinize the urine and help with dissolving uric acid stones. A bedtime dose of an antibiotic like Ciprofloxacillin would help prevent infection or be of help in infection stones.
HEMATURIA Hematuria could either be due to medical or surgical causes. The medical causes are related to either blood dyscrasias or nephrological problems like Pyelonephritis, glomerulonephritis or interstitial nephritis. The surgical causes include Renal tumours, Urothelial tumours, prostate, urinary tract calculii, urinary tract infection, Urinary tract trauma, inflammation and tuberculosis.
The type of Hematuria can give an idea about the origin. For example, initial Hematuria has urethral causes and terminal Hematuria has the bleed from bladder neck or prostate. Total Hematuria is from renal or bladder causes. Pain would be an indicator for stone disease and dysuria might mean cystitis.
Ultrasound examination is a useful diagnostic tool. KUB X ray would give an idea about stone disease.
Use of Ethamsylate or Transxemic acid might be tempting with Hematuria. However, one should remember that with bleeding from prostate, bladder etc the control of venous bleed depends on the collapsing of muscle layers and presence of clots would make the bleeding continue.
Insertion of 3-way Foley’s catheter and vigorous wash might break the clots and help evacuation. Two ml syringe fits well into the Foley’s catheter and should be used for pushing in the saline with force and for applying negative pressure.
Cystoscopy and bladder wash are a useful skill to learn. The bugbee electrode or guide wire inside a DJ stent pusher could be used for breaking the clots and for cauterizing the bleeding points under vision using the cystoscope.
PRIAPISM Priapism is defined as erections lasting longer than 4 hours and it could be ischemic or non – ischemic. While the former is painful the latter [non – ischemic] is due to increased blood flow and is neither painful nor very rigid like the former. The problem with Priapsim is that if it lasts for over 24 hours irreversible damage could occur.
Reversible is caused by Intra caverouns injections, sickle cells, leukemic infiltrations, etc. Irreversible causes are idiopathic, substance abuse & some medications like anti-depressants, anti HT, trauma, AV fistula.
A simple way of treating involves aspiration and irrigation with sympathomimetics medicines like epinephrine, adrenaline, phenlyepherine, etc using thick needle. Caverno – glandular shunts may be required and a simple method involves the use of biopsy gun.
Penile fractures especially in the elderly are not uncommon especially when they engage in sexual activity with the young. Treatment involves evacuation of the hematoma and suturing as soon as possible.
ACUTE SCROTUM Acute scrotal conditions are common and usually present late. However, in conditions like torsion of the spermatic cord, testis or its appendages require early diagnosis and immediate surgical treatment. Irreversible ischemia can occur as early as 4 hours. However, the most common presentation is epididymitis which for which high index of suspicion is required in the post-operative period. Bed rest and injectable antibiotics and IG scrotal dressing and elevation of the scrotum are necessary for Epidimoorchitis.
The Classical presentation is acute scrotal pain but can have lower quadrant pain, dysuria and Irritative symptoms. Often there is previous history of similar pain. Testis is higher, cremasteric reflex is absent, Prehn’s sign is positive [lifting < pain in epidymitis]. There may be acute hydrocele. Manual de-torsion may be tried. Ultrasound is often diagnostic. Not necessary to wait for other tests. Both testes are fixed in Dartos pouch.
URINARY TRACT TRAUMA Kidney is well protected and 95% of the time conservative treatment should suffice. Antibiotics and sufficient rest for 3 weeks should suffice. Only persistent bleeding warrants surgical exploration. Expanding or pulsatile hematoma on ultrasound examination is an indication for surgical exploration, in rural setting Nephrectomy is the most simple and safe option when other kidney is normal.
Ureteric injuries due to external trauma are very rare. Most common cause is intra-operative injury. Gynecological surgeries, URS, LSCS, laparoscopic surgeries and even orthopedic surgeries can cause ureteric injuries. High index of suspicion is necessary for diagnosis during surgeries. Ileus, fever, sepsis, prolonged drainage, flank pain, mass, ureter in HPE specimen, etc have led to diagnosis in the post-operative period.
DJ, stenting, partial transection and anastamosis direct U – U anastamosis, re-implantation +/- Psoas hitch / Boari flap, trans uretero - ureterostomy, ileal replacement and auto - transplant and even nephrectomy have been performed to correct the damages that occur.
Unfortunately, iatrogenic bladder injuries are the most common ones. The common ones are common procedures are TURBT, Bx, TURP, Cystolitholapaxy, LSCS and even THR. Blunt trauma with full bladder especially deceleration injuries are not uncommon. Injury can rarely occur after augmentation and with penetration injuries. The perforation could either be intra peritoneal or Extraperitoneal.
For diagnosis the Classic triad is blood in the penis, difficulty to void and supra pubic tenderness. Bladder drainage might suffice for minor extra peritoneal perforation but a formal three-layered repair and bladder drainage for a month required for others. The anterior urethral injuries are rare. They occur with direct injuries, penile fracture and rarely with catheter balloon injuries. Swelling and hematoma is the common presentation and SPC diversion and primary repair is required for treatment. Posterior urethral injuries are associated with pelvic fractures and up to 20% can have bladder injuries. Blood at the meatus and high riding prostate is seen with the common type 3 [75%] injuries. The type 2 injuries are less common [25%].
The treatment is SPC and at a later time do a definite repair. Although some do repair after 2 to 6 weeks the longer wait would ensure better results because the blood supply.
URO – SEPSIS Although many consider Urology procedures a semi – sterile one Uro sepsis is a serious life-threatening condition. It is generally caused by gram negative organisms and urinary symptoms with fever should be considered a serious condition. Combination of third generation Cephalosporins and Aminoglycosides are started even before cultures are ready. Relieving obstruction is the key to improvement. With severe sepsis the regular ICU treatment with inotropes etc are necessary. Urine cultures are important and are taken before starting the antibiotic therapy.
Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope.
indicates a Peer-Reviewed Article
LECTURE: Urology Emergencies for Rural Surgeons, Thursday, August 20, 2020
This Zoom call information is only good for Thursday August 20, 2020
INTRODUCTION
Unlike the other surgical specialties’ Urology does not have too many emergencies. 1 It is about 2% of the emergencies presenting to the hospitals and in the population about 1.5 per 100000. Hence most of the Urologists do not plan for emergencies and the emergencies are left to the general surgeons to treat. It is very important for the rural surgeons to know the basics in handling the Urological emergencies. In general, the Urological emergencies cause a lot of stress to the patients and require immediate relief. For instance, it is terrible to have urinary obstruction and ureteric colic could be as painful as labor pain. We have a look at some of the common ones that were presented at the annual conference of the Association of rural surgeons of India.
URINARY RETENTION
Urinary retention could be either acute or chronic. Sometimes chronic retention can present with overflow incontinence. The following table lists the various causes of retention.
Table: Causes of Urinary Retention
It is more common in men and is due to bladder outflow obstruction secondary to Prostate. Men especially in the rural areas ignore the lower urinary tract symptoms and retention comes as a surprise and is often precipitated by postponing voiding [for example while traveling]. Sometimes bleeds or prostatic infarcts or infection could be the precipitating factor. It is uncommon in women and is related to prolapsed Uterus or stones. Some factors are common to both. Most of the time simple catheterization should suffice for relieving the obstruction. Antibiotics should be given prior to the procedure that should be carried out under sterile conditions. Temporary relief could be provided using spinal or long needle to aspirate the bladder and remove as much urine as possible to get sufficient time for preparation. Plenty of lubricant should be used and curve of the urethra should be in mind to make sure the catheter is pushed gently in the correct direction.
If catheterization is not successful, then Suprapubic bladder drainage is carried out. It should be remembered that later the Urologists need to use this track for scopies especially in case of stricture urethra and hence it should be place at a sufficiently higher level above the pubic bones. Rapid decompression of the distended bladder can cause severe bleeding and hence the decompression should be slow by clamping the tubing of the Urosac.
It is important to check the hourly urine output after relieving the obstruction and replace the output with normal saline if it exceeds 200 ml per hour. This is to avoid acute renal failure and electrolyte imbalance. Serum potassium levels should also be monitored.
ACUTE LOIN PAIN
Acute loin pain caused by renal or more commonly ureteric calculi are classically colicky pain radiating from the renal angle to the groin. Sometimes it could be as severe as labor pain and the patient rolls in pain trying to get some relief. Depending on the site of the stone the pain could be at the tip of the penis or in the groin alone. Presence of vomiting indicates an ongoing process and the stone could be moving down from the previous location. High grade fever with chills indicates infection in an obstructed system and is a grave emergency.
In rural areas most often a KUB X ray and ultrasound examination should suffice. Urine microscopy need not show red blood cells to diagnose a calculus. Elevated counts, ESR and a positive ‘C” reactive protein might indicate obstruction and sepsis. The following table gives the differential diagnosis
Table: Differential Diagnosis of Acute Loin Pain
Powerful pain killers and anti – inflammatory medication is necessary during the acute phase. Tamsulosin an alpha blocker could be used at a dose of 0.4 mg daily. Sodium bicarbonate could alkalinize the urine and help with dissolving uric acid stones. A bedtime dose of an antibiotic like Ciprofloxacillin would help prevent infection or be of help in infection stones.
HEMATURIA
Hematuria could either be due to medical or surgical causes. The medical causes are related to either blood dyscrasias or nephrological problems like Pyelonephritis, glomerulonephritis or interstitial nephritis. The surgical causes include Renal tumours, Urothelial tumours, prostate, urinary tract calculii, urinary tract infection, Urinary tract trauma, inflammation and tuberculosis.
The type of Hematuria can give an idea about the origin. For example, initial Hematuria has urethral causes and terminal Hematuria has the bleed from bladder neck or prostate. Total Hematuria is from renal or bladder causes. Pain would be an indicator for stone disease and dysuria might mean cystitis.
Ultrasound examination is a useful diagnostic tool. KUB X ray would give an idea about stone disease.
Use of Ethamsylate or Transxemic acid might be tempting with Hematuria. However, one should remember that with bleeding from prostate, bladder etc the control of venous bleed depends on the collapsing of muscle layers and presence of clots would make the bleeding continue.
Insertion of 3-way Foley’s catheter and vigorous wash might break the clots and help evacuation. Two ml syringe fits well into the Foley’s catheter and should be used for pushing in the saline with force and for applying negative pressure.
Cystoscopy and bladder wash are a useful skill to learn. The bugbee electrode or guide wire inside a DJ stent pusher could be used for breaking the clots and for cauterizing the bleeding points under vision using the cystoscope.
PRIAPISM
Priapism is defined as erections lasting longer than 4 hours and it could be ischemic or non – ischemic. While the former is painful the latter [non – ischemic] is due to increased blood flow and is neither painful nor very rigid like the former. The problem with Priapsim is that if it lasts for over 24 hours irreversible damage could occur.
Reversible is caused by Intra caverouns injections, sickle cells, leukemic infiltrations, etc. Irreversible causes are idiopathic, substance abuse & some medications like anti-depressants, anti HT, trauma, AV fistula.
A simple way of treating involves aspiration and irrigation with sympathomimetics medicines like epinephrine, adrenaline, phenlyepherine, etc using thick needle. Caverno – glandular shunts may be required and a simple method involves the use of biopsy gun.
Penile fractures especially in the elderly are not uncommon especially when they engage in sexual activity with the young. Treatment involves evacuation of the hematoma and suturing as soon as possible.
ACUTE SCROTUM
Acute scrotal conditions are common and usually present late. However, in conditions like torsion of the spermatic cord, testis or its appendages require early diagnosis and immediate surgical treatment. Irreversible ischemia can occur as early as 4 hours. However, the most common presentation is epididymitis which for which high index of suspicion is required in the post-operative period. Bed rest and injectable antibiotics and IG scrotal dressing and elevation of the scrotum are necessary for Epidimoorchitis.
The Classical presentation is acute scrotal pain but can have lower quadrant pain, dysuria and Irritative symptoms. Often there is previous history of similar pain. Testis is higher, cremasteric reflex is absent, Prehn’s sign is positive [lifting < pain in epidymitis]. There may be acute hydrocele. Manual de-torsion may be tried. Ultrasound is often diagnostic. Not necessary to wait for other tests. Both testes are fixed in Dartos pouch.
URINARY TRACT TRAUMA
Kidney is well protected and 95% of the time conservative treatment should suffice. Antibiotics and sufficient rest for 3 weeks should suffice. Only persistent bleeding warrants surgical exploration. Expanding or pulsatile hematoma on ultrasound examination is an indication for surgical exploration, in rural setting Nephrectomy is the most simple and safe option when other kidney is normal.
Ureteric injuries due to external trauma are very rare. Most common cause is intra-operative injury. Gynecological surgeries, URS, LSCS, laparoscopic surgeries and even orthopedic surgeries can cause ureteric injuries. High index of suspicion is necessary for diagnosis during surgeries. Ileus, fever, sepsis, prolonged drainage, flank pain, mass, ureter in HPE specimen, etc have led to diagnosis in the post-operative period.
DJ, stenting, partial transection and anastamosis direct U – U anastamosis, re-implantation +/- Psoas hitch / Boari flap, trans uretero - ureterostomy, ileal replacement and auto - transplant and even nephrectomy have been performed to correct the damages that occur.
Unfortunately, iatrogenic bladder injuries are the most common ones. The common ones are common procedures are TURBT, Bx, TURP, Cystolitholapaxy, LSCS and even THR. Blunt trauma with full bladder especially deceleration injuries are not uncommon. Injury can rarely occur after augmentation and with penetration injuries. The perforation could either be intra peritoneal or Extraperitoneal.
For diagnosis the Classic triad is blood in the penis, difficulty to void and supra pubic tenderness. Bladder drainage might suffice for minor extra peritoneal perforation but a formal three-layered repair and bladder drainage for a month required for others.
The anterior urethral injuries are rare. They occur with direct injuries, penile fracture and rarely with catheter balloon injuries. Swelling and hematoma is the common presentation and SPC diversion and primary repair is required for treatment.
Posterior urethral injuries are associated with pelvic fractures and up to 20% can have bladder injuries. Blood at the meatus and high riding prostate is seen with the common type 3 [75%] injuries. The type 2 injuries are less common [25%].
The treatment is SPC and at a later time do a definite repair. Although some do repair after 2 to 6 weeks the longer wait would ensure better results because the blood supply.
URO – SEPSIS
Although many consider Urology procedures a semi – sterile one Uro sepsis is a serious life-threatening condition. It is generally caused by gram negative organisms and urinary symptoms with fever should be considered a serious condition. Combination of third generation Cephalosporins and Aminoglycosides are started even before cultures are ready. Relieving obstruction is the key to improvement. With severe sepsis the regular ICU treatment with inotropes etc are necessary. Urine cultures are important and are taken before starting the antibiotic therapy.
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