Urological trauma and emergencies

Published on 14/03/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1147 times

Chapter 19 Urological trauma and emergencies

Phillip C. Brenner

RENAL TRAUMA

Initial assessment

Penetrating. < 15% of all renal trauma, usually gunshot or knife. Will usually be explored for associated injuries. CT with contrast necessary (or intravenous pyelogram (IVP) if CT not available) to ensure contralateral kidney function and to assess disruption of urinary collecting system.

Blunt. 85% of all renal trauma. Most will be conservatively managed.

Indications of radiological imaging

• Gross haematuria
• Microscopic haematuria as well as:

• hypotension (systolic < 90 mmHg) any time since accident
• suggestive injury—fall > 3 m, flank bruising; direct blow; deceleration injury > 60 kph
• suggestive associated injury—fractured lumbar vertebrae; fractured lower ribs

• Microscopic haematuria alone followed up electively with CT kidney-ureter-bladder (KUB) with IV contrast to exclude preexisting disease (e.g. polycystic kidney)

Type of imaging

CT with contrast. Look for:

• contralateral functioning kidney
• delayed or absent function in affected kidney
• contrast extravasation.

Management

General

1. Blood and fluid replacement
2. Assessment of associated injuries
3. Conservative for stable patients with functioning kidney and minor extravasation only

Surgical exploration—acutely

• Unstable patient due to haemorrhage
• Major extravasation due to shattered or bisected kidney
• Renal pedicle disruption
• Continued subacute haemorrhage
• Urinoma with sepsis

Ureteric injury or pelviureteric disruption

Rare except in children. This is typically a deceleration injury. Diagnosed in CT KUB with IV contrast.

Rupture of bladder or posterior urethra

This is usually due to a fractured pelvis. Occasionally a stab wound or seat belt injury will rupture a full bladder.

Seat belt or knife wound

• Associated injuries may need to be explored.
• Cystogram (see below) is performed.
• Minor extraperitoneal rupture may be managed with catheter drainage alone.
• Major extraperitoneal or intraperitoneal rupture must be repaired.

Fractured pelvis

• The patient is often shocked and requires resuscitation.
• There is a tender mass suprapubically which may be a pelvic haematoma or a full bladder. Bedside ultrasound is very useful.
• There may be blood at the urethral meatus.
• Urinary retention is usually the rule, but urine may have been passed and should be examined for blood.

Management of stable patient

1. If there is no blood at the meatus, a 15 Fr or 18 Fr catheter may be gently passed. If there is no macroscopic blood, no further imaging is necessary.
2. If there is blood at the meatus, a urethrogram is performed.

a. Commonly a complete rupture of the prostatomembranous urethra will be seen. This will require exploration or suprapubic diversion. There is often associated rupture of bladder—ultrasound will identify a full bladder.
b. If the urethra is intact, the catheter is advanced into the bladder and a formal cystogram is performed.

3. Cystogram—350 mL of water-soluble contrast are instilled unless extravasation is seen. The bladder is drained and post-drainage films are examined for extravasated contrast.
4. Limited extraperitoneal rupture may occasionally be managed with catheter drainage, but most major extraperitoneal and all intraperitoneal leakages are explored and repaired.
5. CT KUB with IV contrast must be performed to exclude associated ureteric or renal injury.

Management of unstable patient

In an unstable patient who is going to laparotomy with blood at meatus:

1. A gentle attempt to pass a catheter should be made by experienced staff.
2. If the catheter enters the bladder a CT KUB with IV contrast and cystogram should be performed as time permits.

Surgical management

Surgical management will be to repair bladder, place suprapubic diversion and attempt to stent urethral disruption with urethral catheter.

Rupture of bulbar urethra

This is due to a fall-astride injury, e.g. onto the crossbar of bicycle, cutting the bulbar urethra between the pubic bone and bar. There is:

• blood at the meatus
• ‘butterfly’ bruising in perineum, and scrotal swelling
• urinary retention.

Treatment

1. Retrograde urethrogram to establish whether tear is complete.
2. Suprapubic stab cystotomy for drainage.
3. For incomplete tears, a catheter will be passed under X-ray control to try to stent the urethra.
4. Complete tears need surgical exploration and re-anastomosis either at time of injury or when bruising settles.

Renal colic

Clinical presentation

• Severe flank pain radiating around to groin, testis or labia.
• Patient rolls around unable to find comfortable position, sweats and may be pale, sometimes vomits.
• Low stones present with ill-defined lower pain and extreme desire to pass urine with empty bladder. (May present with ‘retention’ but there is no urine in bladder.)
• Microscopic or macroscopic haematuria is present in over 90% of cases.
• Stone will be seen on X-ray in 85%.

Note: Ureter runs across tip of transverse processes of L2– L5, upper and lower sacroiliac joint and next to ischial spine. Ureteric orifice is medial, near coccyx.

• Patient has often had renal colic before. In older patients with first episode, suspect aortic aneurysm.

Initial assessment

1. Exclude: (a) peritonitis (rigid abdomen); (b) fever; (c) urinary retention.
2. Administer analgesia: (a) IV morphine or pethidine; (b) antiemetic metoclopramide or procholorperazine; (c) indomethacin 100 mg suppository; (d) hyoscine 20 mg IV may help less severe pain.
3. Test for haematuria.
4. Non-contrast CT KUB to identify stone and plain X-ray to see if it is radio-opaque (i.e. calcium) or radiolucent (i.e. uric acid).

Indications for admission

• Absolute: (a) ongoing or unrelieved pain; (b) fever > 37.5°C; (c) anuria or serum creatinine > 0.20 mmol/L; (d) known solitary kidney
• Relative: (a) stone > 8 mm seen on KUB; (b) diabetes; (c) background renal compromise; (d) re-presentation with pain

If admitted, non-contrast CT is performed on a semi-urgent basis.

Notes on renal calculi

Stones:

• < 5 mm—90% likelihood of passing without intervention.
• > 10 mm—10% likelihood of passing spontaneously.

Renal calculi:

• < 2 cm are often treated with lithotripsy.
• Larger renal calculi will best be cleared with percutaneous nephrolithotomy.

Ureteric calculi:

• Most will pass spontaneously.
• In lower half of ureter, may be removed with ureteroscope.
• In upper half, are pushed back into kidney for lithotripsy.

Differential diagnosis

• If non-contrast CT KUB fails to show a stone, consider herpes zoster in L1 nerve root distribution.
• Disc injury with nerve root compression and referred pain.
• Aortic abdominal aneurysm.

Editor’s comment

Beware radiation load (cumulative) of repeated CTs in patients with recurrent renal colic (see Chapter 4, ‘Diagnostic imaging in emergency patients’).

Urinary retention

• Acute retention most commonly occurs in elderly males.
• The patient complains of severe pain and inability to pass urine.
• Bladder is palpable and percussible.
• Urinary retention is confirmed with bladder scanner/ultrasound.

Common causes

• Primary prostatic obstruction.
• Urethral stricture.
• Bladder neck stenosis, following trans-urethral resection of prostate.
• Recent instrumentation.
• Clot retention.
• Retention in young patient—consider drugs, i.e. anticholinergics, alpha-adrenergics (phenylephrine) or recreational (Ecstasy).
• Painless retention—consider neurological lesion, particularly corda equina compression. In patients with malignancy, check anal tone, perianal sensation and power in lower limbs.

Treatment

1. Attempt to pass soft 15 Fr or 18 Fr catheter.

a. Measure and note volume of retention.
b. Send urine for culture and sensitivity.
c. Urinalysis. If no urine returned through catheter, either bladder is not in correct position or bladder is empty. Confirm with ultrasound or bladder scanner.

2. Clot retention.

a. If postoperative, heavy haematuria or suggestion of clots—attempt to pass 22 Fr, 3-way irrigating haematuria catheter.
b. If unable to pass urethral catheter, place suprapubic catheter; introducer to be used only by experienced staff.
c. Send off full blood count, group-and-hold, and anticoagulants.

3. Suprapubic catheter.

a. Confirm bladder full by percussion and/or bladder scanner.
b. Check for anticoagulant (warfarin) therapy.
c. Infiltrate spot 2 finger breadths above pubis in midline with local anaesthetic.
d. Confirm presence of full bladder by passing 22-gauge spinal tap needle—urine must be demonstrated before passing trocar of suprapubic catheter.
e. Pass trocar at right angle to skin and drain urine.
f. Ensure suprapubic catheter is sutured to skin at all points or it will immediately fall out on transfer to ward.

Common misdiagnoses

• Pelvic haematoma will present as a suprapubic mass and retention, but the bladder is empty and no urine will be obtained by suprapubic puncture.
• Lower abdominal peritonitis will give impression of retention. Bladder is empty due to anuria. Irrigation of 50 mL of fluid in and out of catheter will confirm correct position and an empty bladder.
• Lower abdominal mass such as diverticular phlegmon, ruptured aortic aneurysm or pelvic malignancy.

TESTES AND EPIDIDYMIS

Torsion

Testicular torsion is commonest at puberty: 75% of cases are under 20 years of age. It rarely occurs in a normal testicle. Predisposing causes are congenital and developmental abnormalities of the testicle.

Presentation

• Sudden onset of agonising testicular pain, nausea and vomiting.
• The testicle is swollen and exquisitely tender.
• The cord is short and the testicle is drawn up.
• Pain is increased by elevation of the testicle.
• Testis is difficult to examine.

Investigation

Ultrasound ± doppler does not fully exclude torsion.

Treatment

• Urgent surgical exploration—testicle is untwisted and, if viable, orchidopexy is performed.
• Gangrenous testicles are removed. Orchidopexy should be carried out on the unaffected testicle to prevent future torsion.

Acute epididymo-orchitis

This must be distinguished from torsion.

Presentation

Severe pain and swelling of the testis and epididymis is often associated with recent prostatitis and urethritis, instrumentation of the urethra and open prostatectomy. Pyrexia may be present. The testicle and epididymis are swollen and tender. There is often a secondary hydrocoele.

Investigations

• Urinalysis for leucocytes and nitrites
• Microscopy and culture of urine
• Urinary polymerase chain reaction (PCR) for chlamydia and gonorrhoea
• Doppler ultrasound to demonstrate normal blood flow within testis

Treatment

1. Antibiotics, bed rest and scrotal support
2. Mild cases as outpatients, with ciprofloxacin 500 mg twice daily or amoxycillin/clavulinic acid duo forte
3. Severe cases as inpatients with ampicillin and gentamicin

Scrotal trauma

Testicular rupture, as evidenced by severe swelling and bruising, must be explored. Ultrasound is mandatory if conservative management is considered.

Soft tissue swelling or pampiniform plexus trauma may be managed conservatively.

Phimosis and paraphimosis

If unsure if paraphimosis exists, ask the patient whether he is circumcised. Paraphimosis does not occur in circumcised males.

Phimosis

Inability to retract foreskin. May result in ballooning of foreskin, retention and underlying pus (balanitis).

Treatment

Urgent circumcision. In some circumstances an incision of foreskin only may be performed in the emergency department. This is done on the dorsal aspect (dorsal slit) with local infiltration or penile block.

Paraphimosis

The foreskin has been retracted and is unable to be replaced, causing swelling of glans. Often occurs after catheterisation when the foreskin is left retracted.

Treatment

Gentle prolonged pressure on glans may reduce swelling enough to reduce foreskin; surgical intervention is necessary if foreskin cannot be reduced.

Priapism or prolonged erection

Causes

• Arterial: self-injection with prostaglandin or papaverine
• Venous: haematological disorders, e.g. sickle cell trait, leukaemia, antipsychotic medication, neoplasm or trauma

Presentation

• Idiopathic—prolonged painful erection; may be associated with difficulty voiding.
• If arterial, glans will be engorged; in venous obstruction, glans is soft.

Treatment

1. Oral pseudoephedrine 60 mg is effective in mild cases where self-injection is cause.
2. More severe: 23 Fr butterfly into corpora cavernosa—aspirate 25–30 mL blood, note if blood is bright red (arterial) or dark (venous stasis).
3. Leave butterfly in and administer:

• ephedrine 30 mg/mL diluted with 9 mL normal saline—give 0.5 mL doses until erection subsides; monitor blood pressure, pulse and ECG
or
• adrenaline 1 mL 1:10,000 diluted with 9 mL normal saline—give 0.5 mL increments.

Fractured penis

Traumatic rupture of the corpus cavernosum.

Presentation

The patient hears a loud snap like the breaking of a glass rod, associated with a direct injury to the erect penis. The penis collapses immediately and develops a large swelling on the affected side. On rare occasions, the urethra may be ruptured.

Management

Urgent admission to hospital for the surgical repair of the ruptured corpus cavernosum.

Complications

Without repair, some 50% of patients will suffer impotence and a greater percentage will have traumatic curvature of the penis.

COMMON POSTOPERATIVE PROBLEMS

Extracorporeal shock-wave lithotripsy (ESWL)

• Most commonly, patients will present with pain and haematuria and will require narcotic analgesia only.
• Plain X-ray of kidney-ureter-bladder (KUB) is relevant to establish size of stone fragment that is passing down ureter, or presence of Steinstrasse (series of stone fragments in a line).
• Measure diameter of largest fragment in millimetres.
• Fever > 38°C is an absolute indication for admission and indicates an infected, obstructed system requiring decompression by a double-J stent or nephrostomy.
• Anuria or raised creatinine due to bilateral disease or solitary kidney is similarly an emergency requiring admission.

Treatment

1. Morphine or pethidine IV.
2. Maxolon or stemetil, rectal indomethacin 100 mg (if no history of peptic ulcer).
3. Buscopan IV.
4. Urinalysis for blood, and for microscopy, culture and sensitivity.
5. Plain X-ray (KUB).
6. If pain-free, discharge with indomethacin suppositories 100 mg twice daily (if no history of ulcer) and Panadeine Forte.

Prostate biopsy

This is performed in the office under ultrasound control or day only procedure. Needle is passed transrectally and hence is prone to sepsis which may be life-threatening.

Complications

• Sepsis. Patients with any fever > 37.5°C must be admitted for intravenous ampicillin and gentamicin (or ciprofloxacin if allergic to penicillin). Take three blood cultures, and urine culture, and transfer to intensive care unit if there are signs of hypotension or anuria.
• Haematuria. Only requires treatment if it precipitates retention or is massive. Use a 22 Fr three-way irrigation catheter.
• Retention. Usually due to preexisting prostatism. Pass a small (14 Fr or 12 Fr) Foley catheter. If this is not possible, use a small suprapubic stab catheter (12 Fr).

Haematuria

Causes

• Bacterial cystitis
• Stones
• Trauma
• Postoperative malignancy
• Drug-induced (warfarin)
• Medical
• Glomerulonephritis
• Vascular, arterial or venous

History

• Recent urological surgery, complicated by secondary haemorrhage, is common and will often be accompanied by heavy bleeding and clots, requiring insertion of irrigation catheter.

Full blood count, group-and-hold, and anticoagulants are performed.

• Haematuria associated with dysuria, frequency, suggestive of bacterial cystitis.

Send mid-stream urine (MSU), urinary PCR for chlamydia, gonococcus, and treat presumptively with norfloxacin.

Review with results of microurine. Norfloxacin 400 mg bd.

• Haematuria associated with loin pain, suggestive of renal calculus.

Non-contrast CT KUB.

• Gross painless haematuria suggestive of transitional cell carcinoma of the bladder or carcinoma of the kidney.

Send urine for culture.

Admit if bleeding is heavy with clots and impeding micturition; otherwise may be discharged for CT scan pre-post CT KUB, pre-post IV contrast, and ultrasound of the kidneys and bladder.

• Tea-coloured or brown haematuria.

Check serum creatinine for upper renal causes of blood. Check history of long distance running or trauma.

Non-contrast CT KUB to exclude stone. If no stone or other cause, proceed to contrast study to find intrinsic renal lesion, such as arterial or venous thrombosis, particularly if patient has atrial fibrillation.

Check if patient is taking warfarin.

Prostate specific antigen (PSA) is usually reserved for elective investigation of prostatic disease. PSA can be performed in patients presenting with acute urinary retention. A low level will tend to show low risk of prostate cancer but an elevated reading may be due to urinary retention, infection or catheterisation and thus is not helpful.

Approximate risk of prostate cancer in a 60-year-old man:

• PSA 0–4.5

Risk equivalent to that of general population
• PSA 4.5–10

25% risk of prostate cancer
• PSA 10–20

50% risk of prostate cancer
• PSA > 20

90% risk of prostate cancer

Needs urological consult if PSA rises and PSA fractionated.

RECOMMENDED READING

Gillenwater J.Y., et al. Adult and pediatric urology. Vol. 1. Mosby Year Book, St Louis, 1996.

Gillenwater J.Y., et al. Adult and pediatric urology. Vol. 3. Mosby Year Book, St Louis, 2001.

Hinman F. Atlas of urologic surgery, 2nd edn. Philadelphia: WB Saunders; 1992.

McAninch J.W., editor. Traumatic and reconstructive urology. Philadelphia: WB Saunders, 1996.

MacFarlane M.J. Urology for the house officer, 2nd edn. Baltimore: Williams and Wilkins; 2000.

Related posts:

Default ThumbnailAortic and vascular emergencies Default ThumbnailHand injuries and care Default ThumbnailEmergency gynaecology Envenomation Electrical injuries Geriatric care