Terms in this set (17)

The commonest urologic emergency.
One of the commonest causes of the "Acute Abdomen".
Sudden onset of severe pain in the flank
Most often due to the passage of a stone formed in the kidney, down through the ureter.

The pain is characteristically :
very sudden onset
colicky in nature
Radiates to the groin as the stone passes into the lower ureter.
May change in location, from the flank to the groin, (the location of pain does not provide a good indication of the position of the stone)
The patient cannot get comfortable, and may roll around in agony.
Associated with nausea / Vomiting
the pain of a ureteric stone as being worse than the pain of labour.

Differential diagnoses
Leaking abdominal aortic aneurysms
Myocardial infarction
Ovarian pathology (e.g., twisted ovarian cyst)
Acute appendicitis
Testicular torsion
Inflammatory bowel disease (Crohn's, ulcerative colitis)
Ectopic pregnancy
Burst peptic ulcer
Bowel obstruction

Work Up :
Examination: patient want to move around, in an attempt to find a comfortable position.
+/- Fever
Pregnancy test

Radiological investigation :
KUB / Abdominal US
IVP (was)
Helical CTU

advantages over IVP:
greater specificity (95%) and sensitivity (97%) for diagnosing ureteric stones
Can identify other, non-stone causes of flank pain.
No need for contrast administration.
Faster, taking just a few minutes
the cost of CTU is equivalent to that of IVU

very accurate way of determining whether or not a stone is present in the ureter
very high cost

Acute Management of Ureteric Stones:
Pain relief
Intramuscular or intravenous injection, by mouth, or per rectum
+/- Opiate analgesics (pethidine or morphine).
? Hyper hydration
'watchful waiting' with analgesic supplements
95% of stones measuring 5mm or less pass spontaneously

Indications for Intervention to Relieve Obstruction and/or Remove the Stone:
Pain that fails to respond to analgesics.
Associated fever.
Renal function is impaired because of the stone (solitary kidney obstructed by a stone, bilateral ureteric stones, or preexisting renal impairment )
Obstruction unrelieved for > 4 weeks
Personal or occupational reasons

Treatment of the Stone:
Temporary relief of the obstruction:
Insertion of a JJ stent or percutaneous nephrostomy tube.

Definitive treatment of a ureteric stone:
Open Surgery: very limited.
-True surgical emergency of the highest order
-Irreversible ischemic injury to the testicular parenchyma may begin as soon as 4 hours
-Testicular salvage ↓ as duration of torsion↑

-Acute onset of scrotal pain.
-Majority with history of prior episodes of severe, self-limited scrotal pain and swelling.
-Referred to the ipsilateral lower quadrant of the abdomen.
-Dysuria and other bladder symptoms are usually absent.

Physical examination:
The affected testis is high-riding Transverse orientation.
Acute hydrocele or massive scrotal edema
Cremasteric reflex is absent.
Tender larger than other side.

Adjunctive tests:
To aid in differential diagnosis of the acute scrotum.
To confirm the absence of torsion of the cord.
Doppler examination of the cord and testis :High false-positive and false-negative results

Color Doppler ultrasound:
Assessment of anatomy and determining the presence or absence of blood flow.
Sensitivity: 88.9% specificity of 98.8%
Operator dependent.

Radionuclide imaging :
Assessment of testicular blood flow.
PPV of 75%, a sensitivity of 90%, and a specificity of 89%.
False impression from hyperemia of scrotal wall.
Not helpful in Hydrocele and Hematoma

Surgical exploration:
A median raphe scrotal incision or a transverse incision.
The affected side should be examined first
The cord should be detorsed.
Testes with marginal viability should be placed in warm sponges and re-examined after several minutes.
A necrotic testis should be removed
If the testis is to be preserved, it should be placed into the dartos pouch (suture fixation)
The contralateral testis must be fixed to prevent subsequent torsion.
Persistent erection of the penis for more than 4 hours that is not related or accompanied by sexual desire.

2 Types:
- ischaemic (veno-occlusive, low flow (most common)
.Due to haematological disease, malignant infiltration of the corpora cavernosa with malignant disease, or drugs.
- nonischaemic (arterial, high flow).
.Due to perineal trauma, which creates an arteriovenous fistula.

-Primary (Idiopathic) : 30%- 50%
.Hematological disease

The diagnosis
- Usually obvious from the history
.Duration of erection >4 hours?
.Is it painful or not?.
.Previous history and treatment of priapism ?
.Identify any predisposing factors and underlying cause
- Examination
.Erect, tender penis (in low-flow priapism).
.Characteristically the corpora cavernosa are rigid and the glans is flaccid.
.Abdomen for evidence of malignant disease
.DRE: to examine the prostate and check anal tone.

-CBC (white cell count and differential, reticulocyte count)
-Hemoglobin electrophoresis for sickle cell test
-Urinalysis including urine toxicology
-Blood gases taken from either corpora,
. low-flow (dark blood; pH <7.25 (acidosis); pO2 <30mmHg (hypoxia); pCO2 >60mmHg (hypercapnia))
. high-flow (bright red blood similar to arterial blood at room temperature; pH = 7.4; pO2 >90mmHg; pCO2 <40mmHg)
-Colour flow duplex ultrasonography in cavernosal arteries:
. Ischaemic (inflow low or nonexistent)
. Nonischaemic (inflow normal to high).
-Penile pudendal arteriography

-Depends on the type of priapism.
- Conservative treatment should first be tried
-Medical treatment
-Surgical treatment.
-Treatment of underlying cause
**→→ It is important to warn all patients with priapism of the possibility of impotence.
The kidneys relatively protected from traumatic injuries.
Considerable degree of force is usually required to injure a kidney.

Mechanisms and cause:
direct blow or acceleration/ deceleration (road traffic accidents, falls from a height, fall onto flank)
knives, gunshots, iatrogenic, e.g., percutaneous nephrolithotomy (PCNL)

Indications for renal imaging:
-Macroscopic hematuria
-Penetrating chest, flank, and abdominal wounds
-Microscopic [>5 red blood cells (RBCs) per high powered field] or dipstick hematuria a hypotensive patient (SBP <90mmHg )
-A history of a rapid acceleration or deceleration
-Any child with microscopic or dipstick hematuria who has sustained trauma.

What Imaging Study?
replaced by the contrast-enhanced CT scan
On-table IVU if patient is transferred immediately to the operating theatre without having had a CT scan and a retroperitoneal haematoma is found,
-Spiral CT: does not allowaccurate staging

-Renal US:
can certainly establish the presence of two kidneys
the presence of a retroperitoneal hematoma
power Doppler can identify the presence of blood flow in the renal vessels.
cannot accurately identify parenchymal tears, collecting system injuries, or extravasations of urine until a later stage when a urine collection has had time to accumulate.
-Contrast-enhanced CT:
the imaging study of choice
accurate, rapid, images other intra-abdominal structures

Staging (Grading)
American Association for the Surgery of Trauma Organ Injury Severity Scale
5 grades
1. subcapsular hematoma
2. superficial tear
3. deep tear
4. deep tear+extravasation +- renal artery thrombosis
5. shattered kidney - vascular avulsion

1. Conservative:
-Over 95% of blunt injuries
-50% of renal stab injuries and 25% of renal gunshot wounds (specialized center).
.Wide Bore IV line.
. IV antibiotics.
.Bed rest
. serial CBC (Htc)
.F/up US &/or CT.
.2-3 wks.

2. Surgical exploration:
- Persistent bleeding (persistent tachycardia and/or hypotension failing to respond to appropriate fluid and blood replacement
- Expanding perirenal haematoma (again the patient will show signs of continued bleeding)
- Pulsatile perirenal haematoma
- The ureters are protected from external trauma by surrounding bony structures, muscles and other organs

Causes and Mechanisms :
- External Trauma
- Internal Trauma

External Trauma:
- Rare
- Severe force is required
- Blunt or penetrating.
- Blunt external trauma severe enough to injure the ureters will usually be associated with multiple other injuries
- Knife or bullet wound to the abdomen or chest may damage the ureter, as well as other organs.

Internal Trauma
- Uncommon, but is more common than external trauma
- Surgery:
. Hysterectomy, oophorectomy, and sigmoidcolectomy
. Ureteroscopy
. Caesarean section
. Aortoiliac vascular graft placement,
. Laparoscopic procedures,
. Orthopedic operations

Requires a high index of suspicion
1. An ileus: the presence of urine within the peritoneal cavity
2. Prolonged postoperative fever or overt urinary sepsis
3. Persistent drainage of fluid from abdominal or pelvic drains, from the abdominal wound, or from the vagina.
4. Flank pain if the ureter has been ligated
5. An abdominal mass, representing a urinoma
6. Vague abdominal pain
7. The pathology report on the organ that has been removed may note the presence of a segment of ureter!

Treatment options:
- JJ stenting
- Primary closure of partial transection of the ureter
- Direct ureter to ureter anastomosis
- Reimplantation of the ureter into the bladder (ureteroneocystostomy), either using a psoas hitch or a Boari flap
- Transureteroureterostomy
- Autotransplantation of the kidney into the pelvis
- Replacement of the ureter with ileum
- Permanent cutaneous ureterostomy
- Nephrectomy