Urology 1- 80-year-old man presented with dull aching pain in the loins. Investigations showed high urea and creatinine. Ultrasound of the abdomen showed bilateral hydronephrosis. Most common cause is: A. Stricture of urethral meatus B. Neoplasm of the bladder C. Prostatic enlargement D. Pelvic CA E. Retroperitoneal fibrosis Hydronephrosis and hydroureter can range from benign processes, such as the physiologic hydroureteronephrosis of pregnancy, to potential life-threatening situations, such as infected hydronephrosis or pyonephrosis. Although patients usually present with some signs or symptoms, hydronephrosis can be an incidental finding encountered during the evaluation of an unrelated process. If unrecognized or left untreated, hydronephrosis and hydroureter secondary to obstruction can lead to hypertension, loss of renal function, and sepsis. Consequently, all patients found to have hydronephrosis or hydroureter should undergo a thorough evaluation and should be referred to a urologist. Sex
In women, gynecologic cancers and pregnancy are common causes. As such, among younger patients (aged 20-60 y), the frequency of hydronephrosis is higher in women than in men. In men, obstruction secondary to prostatic hypertrophy and prostate cancer are the major causes of hydronephrosis. Consequently, among older patients (>60 y), the frequency of hydronephrosis is higher in men than in women.
In young adults, calculi are the most common causes of hydroureter and hydronephrosis. In children, reflux and ureteropelvic junction obstruction are common causes.
Age
Clinical History
Symptoms vary depending on whether the hydronephrosis is acute or chronic. With acute obstruction, patients may present with pain, which is usually described as severe, intermittent, and dull. Patients may describe worsening of pain with consumption of fluids. Depending on the level of hydroureter, pain may radiate to the ipsilateral testicle or labia. Often associated with nausea and vomiting, pain from an obstructed system is referred to as renal colic. A history of hematuria may herald a stone or malignancy anywhere in the urinary tract. A history of fever or diabetes adds urgency to the evaluation and treatment. A history of a solitary kidney is an emergent situation. Hydronephrosis may develop silently, without symptoms, as the result of advanced pelvic malignancy or severe urinary retention from bladder outlet obstruction. Bilateral symmetrical hydronephrosis usually suggests a cause related to the bladder, such as retention, prostatic blockage, or severe bladder prolapse.1
Physical
With severe hydronephrosis, the kidney may be palpable. With bilateral hydronephrosis, lower extremity edema may occur. Costovertebral angle tenderness on the affected side is common. A palpably distended bladder adds evidence of lower urinary tract obstruction. A digital rectal examination should be performed to assess sphincter tone and to look for hypertrophy, nodules, or induration of the prostate.
Causes A multitude of causes exist for hydronephrosis and hydroureter. Classification can be made according to the level within the urinary tract and whether the etiology is intrinsic, extrinsic, or functional.
Ureter o
o o
Intrinsic Ureteropelvic junction stricture Ureterovesical junction obstruction Papillary necrosis Ureteral folds Ureteral valves Ureteral stricture (iatrogenic) Blood clot Benign fibroepithelial polyps Ureteral tumor Fungus ball Ureteral calculus Ureterocele Endometriosis Tuberculosis Retrocaval ureter Functional Gram-negative infection Neurogenic bladder Extrinsic Retroperitoneal lymphoma Retroperitoneal sarcoma Cervical cancer Prostate cancer Retroperitoneal fibrosis Aortic aneurysm Inflammatory bowel disease Ovarian vein syndrome Retrocaval ureter Uterine prolapse Pregnancy Iatrogenic ureteral ligation Ovarian cysts Diverticulitis Tuboovarian abscess Retroperitoneal hemorrhage Lymphocele
Bladder o Intrinsic Bladder carcinoma Bladder calculi Bladder neck contracture Cystocele Primary bladder neck hypertrophy Bladder diverticula o Functional Neurogenic bladder Vesicoureteral reflux o Extrinsic - Pelvic lipomatosis Urethra o Intrinsic Urethral stricture Urethral valves Urethral diverticula Urethral atresia Labial fusion
o
Extrinsic - Benign prostatic hyperplasia and prostate cancer
2- Filling defect in IVP & hypoechoic mass in US: -Blood clots -Tumor -Uric acid stones. -IVP study done for a male & showed a filling defect in the renal pelvis non-radio opaque. U/S shows echogenic structure & hyperacoustic shadow. The most likely diagnosis is: a. Blood clot b. Tumor C. Uric acid stone d. ??? - a non opaque renal pelvis filling defect is seen on IVP.Ultrasound reveals dense echoes and acoustic shadowing.The MOST likely diagnosis is: a)blood clot b)tumor c)sloughed renal papilla d)uric acid stone e)crossing vessel
Causes
Most research on the etiology and prevention of urinary tract stone disease has been directed toward the role of elevated urinary levels of calcium, oxalate, and uric acid in stone formation, as well as reduced urinary citrate levels. Hypercalciuria is the most common metabolic abnormality. Some cases of hypercalciuria are related to increased intestinal absorption of calcium (associated with excess dietary calcium and/or overactive calcium absorption mechanisms), some are related to excess resorption of calcium from bone (ie, hyperparathyroidism), and some are related to an inability of the renal tubules to properly reclaim calcium in the glomerular filtrate (renal-leak hypercalciuria). Magnesium and especially citrate are important inhibitors of stone formation in the urinary tract. Decreased levels of these in the urine predispose to stone formation. A low fluid intake, with a subsequent low volume of urine production, produces high concentrations of stoneforming solutes in the urine. This is an important, if not the most important, environmental factor in kidney stone formation. The exact nature of the tubular damage or dysfunction that leads to stone formation has not been characterized. The most common findings on 24-hour urine studies include hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia, and low urinary volume. Other factors, such as high urinary sodium and low urinary magnesium concentrations, may also play a role. To identify these risk factors, a 24-hour urine profile, including appropriate serum tests of renal function, uric acid, and calcium, is needed. Such testing is available from various commercial laboratories. A finding of hypercalcemia should prompt follow-up with an intact parathyroid hormone study to evaluate for primary and secondary hyperparathyroidism.
Imaging Studies
Plain abdominal radiography
o
Plain abdominal radiography (also known as a flat plate or kidney, ureter, and bladder [KUB] radiography) is useful for assessing total stone burden, as well as the size, shape, and location of urinary calculi in some patients. It is also helpful in determining the progress of the stone without the need for more expensive tests with greater radiation exposures. o Calcium-containing stones (approximately 85% of all upper urinary tract calculi) are radiopaque, but pure uric acid, indinavir-induced, and cystine calculi are relatively radiolucent on plain radiography. o When used with other imaging studies, such as a renal ultrasonography or, particularly, CT scanning, the plain film helps provide a better understanding of the size, shape, location, orientation, and composition of urinary stones revealed with these other imaging studies. This may also be helpful in planning surgical therapy and in tracking progress of the stone over time. Renal ultrasonography o Renal ultrasonography by itself is frequently adequate to determine the presence of a renal stone. The study is mainly used alone in pregnancy or in combination with plain abdominal radiography to determine hydronephrosis or ureteral dilation associated with an abnormal radiographic density believed to be a urinary tract calculus. o A stone easily identified with renal ultrasonography but not visible on the plain radiograph may be a uric acid or cystine stone, which is potentially dissolvable with urinary alkalinization therapy. o Ureteral calculi, especially in the distal ureter, and stones smaller than 5 mm are not easily observed with ultrasonography. Intravenous urography o An intravenous urography (IVU) test, also known as an intravenous pyelography (IVP), has been the standard for determining the size and location of urinary calculi up until recently. IVU provides both anatomical and functional information. o IVU is very labor intensive and is no longer the standard for the initial evaluation of a patient with a kidney stone. It may fail to reveal alternative pathology if a stone is not discovered, delaying the final diagnosis. Up to 6 hours may be required to complete the study in the presence of severe obstruction. For optimal results, IVU requires a bowel preparation. It involves intravenous injection of potentially allergic and mildly nephrotoxic contrast material. o A helical CT scan without contrast material is currently believed to be the best initial radiographic examination for acute renal colic. If positive, KUB radiography is recommended to assist in follow-up and planning. o The so-called delayed nephrogram on the IVU is one of the hallmark signs of acute urinary tract obstruction. The relative delay in penetration of intravenous contrast passing through an obstructed kidney elicits this sign. The kidney appears to develop a whitish color, and contrast appearance within the collecting system of the affected renal unit is significantly delayed. o IVU is helpful in identifying the specific problematic stone among numerous pelvic calcifications and in establishing that the other kidney is functional. These determinations are particularly helpful if the degree of hydronephrosis is mild and the non-contrast CT scan findings are not definitive. CT scanning with delayed contrast series and thin slices has reduced the need for IVU in the evaluation of problematic ureteral stones.
3- a 75 year olf man came to the ER complaining of acute urine retention what will be your initial management: a)send patient immediately to OR for prostatectomy b)empty urinary bladder by folley’s catheter and tell him to come back to the clinic c)give him antibiotics because retention could be from sort of infection d)insert folly’s catheter and tell him to come back to the clinic (b & d are repeated) e)admission, investigation which include cystoscopy then.. - A 82 years old patient present with urinary retention. What is the most proper treatment in ER? -Insert Folly’s Cath then send to clinic. -Insert Folly’s Cath then send to home. -O.R. for prostatectomy. -Admission, Investigation, then do cystoscope or TRUP.
- In an 82 years old patient with acute urinary retention,the management is: a) To empty the bladder by Foley’s catheter and follow up in the clinic. b) To insert a Foley’s catheter then send the patient home to come back in the clinic. c) To admit and investigate by TURP. d) Immediate prostatectomy trans urethral resection of the prostate for benign prostate enlargement. Asymptomatic pts do not require treatment, and those with complications of urethral obstruction such as inability to urinate, renal failure, recurrent urinary tract infection, hematuria, or bladder stones clearly require surgical extirpation of the prostate, usually by transurethral resection (TURP). However, the approach to the remaining pts should be based on the degree of incapacity or discomfort from the disease and the likely side effects of any intervention. If the pt has only mild symptoms, watchful waiting is not harmful and permits an assessment of the rate of symptom progression. If therapy is desired by the pt, two medical approaches may be helpful: terazosin, an α1-adrenergic blocker (1 mg at bedtime, titrated to symptoms up to 20 mg/d), relaxes the smooth muscle of the bladder neck and increases urine flow; finasteride (5 mg/d), an inhibitor of 5 α-reductase, blocks the conversion of testosterone to dihydrotestosterone and causes an average decrease in prostate size of ~24%. TURP has the greatest success rate but also the greatest risk of complications. Transurethral microwave thermotherapy (TUMT) may be comparably effective to TURP. Direct comparison has not been made between medical and surgical management.
4- premature-ejaculation, all true except: a) most common sexual disorder in males b) uncommon in young men c) Benefits from sexual therapy involving both partners d) it benefit from anxiety Rx 5- acute GN, all is acceptable Ix (investigations) except: a) complement b) urinanalysis c) ANA d) Blood culture e) Cystoscopy 6- A 20 yr old female present with fever, loin pain & dysuria, management include all of the following except: a) urinanalysis and urine culture b) blood culture c) IVU (IVP) d) Cotrimexazole 7- Old male came with urine retention, dilated ureter and hydronephrosis, Dx is: a) Benign prostatic hyperplasia. b) Ureteric stone impaction. c) bladder tumor. 8- In Testicular torsion, all of the following are true, except: a) Very tender and progressive swelling. b) More common in young males. c) There is hematuria. d) Treatment is surgical. e) Has to be restored within 12 hours or the testis will infarct. Testicular torsion is a true urologic emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle. Though testicular torsion can occur at any
age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males; it is the most frequent cause of testicle loss in that population. Clinical History History includes a sudden onset of severe unilateral scrotal pain. Onset of pain can occur more slowly, but this is an uncommon presentation of torsion. Torsion can occur with activity, can be related to trauma in 4-8% of cases,2 or can develop during sleep. The historical features suggestive of testicular torsion include the following: o Acute onset of unilateral scrotal pain o Scrotal swelling o Nausea and vomiting: In the pediatric population, nausea and vomiting more commonly accompany acute testicular torsion and have a positive predictive value of greater than 96%. 4 o Abdominal pain (20-30%) o Fever (16%) o Urinary frequency (4%) Many patients have a history of recurrent scrotal pain that has resolved spontaneously. This history is highly suggestive of intermittent torsion and detorsion of the testicle. Patients who complain of what sounds like torsion-detorsion should be referred promptly to a urologist since patients with symptoms of intermittent torsion who electively have surgical exploration are less likely to develop subsequent torsion and loss of the testicle.5 Creagh et al reported that acute torsion developed in 10% of patients with intermittent torsion while they waited for surgery.6 Physical The physical examination is useful, but imperfect, in diagnosing acute testicular torsion. 7 The physical examination, moreover, may be difficult to perform, as the testicle is typically very tender and patients are often in significant discomfort. The involved testicle is painful and is frequently elevated in position when compared with the other side. Horizontal lie of the testicle - While abnormal lie can help diagnose testicular torsion, fewer than 50% of cases demonstrated true horizontal lie.7 Enlargement and edema of the testicle; edema involving the entire scrotum Scrotal erythema Ipsilateral loss of the cremasteric reflex - The cremasteric reflex is almost always absent in patients with testicular torsion, and its presence may help to distinguish other causes of acute scrotal pain from testicular torsion. Case reports, however, have noted the opposite to be true. 8,9,7 Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn sign]) Fever (uncommon) Causes Congenital anomaly; bell clapper deformity Undescended testicle Sexual arousal and/or activity Trauma Testicular tumor Exercise Treatment Emergency Department Care Early diagnosis and prompt urologic consultation is essential since time is critical in salvage of the testicle. Analgesic pain relief should be administered as testicular torsion is typically very painful. Attempt manual detorsion with pain relief as the guide for successful detorsion. The procedure is similar to the "opening of a book" when the physician is standing at the patient's feet. Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting outward and laterally. o For example, in a suspected torsion of the right testicle, the physician is in front of the standing or supine patient and holds the patient's right testicle with the left thumb and forefinger. o The physician then rotates the right testicle outward 180° in a medial to lateral direction. o Rotation of the testicle may need to be repeated 2-3 times for complete detorsion and to provide pain relief to the patient. o For the patient's left testicle, the physician uses the right thumb and forefinger and rotates the patient's left testicle in an outward direction 180° from medial to lateral. o Manual detorsion is successful in 26.5% to greater than 80% of patients based upon a number of reviewed studies.2
Consultations If the clinical diagnosis of torsion is suspected, early urologic consultation is mandatory since definitive treatment is surgery for detorsion and orchiopexy or possible orchiectomy.
9- Epididymitis, one is true: a)The peak age between 12 &18. b)u/s is diagnostic. c)The scrotal contents are within normal size. d) typical iliac fossa pain. e) none of the above. - Epidydimitis: A-Common at the age 12-18 years B-Iliac fossa pain C-Scrotal content does not increase in size. D-Ultrasound will confirm the diagnosis. E-All of above Acute scrotal pain is a common complaint in the emergency room, and the diagnosis of epididymitis must be differentiated from testicular torsion, a true scrotal emergency.1 Ultrasonography is noninvasive and can help differentiate between the pathologies. One area under investigation is the ability of emergency physicians to use bedside ultrasonography to accurately diagnose patients with acute scrotal pain. Epididymitis is most often due to the retrograde extension of organisms from the vas deferens and is rarely the result of hematogenous spread. Bacterial infection results in the infiltration of WBCs into the epididymal connective tissue, with resultant congestion and edema. This inflammation can rapidly spread to the tubules, with the risk of abscess formation and necrosis of the epididymis.4,5 The causative organism is identified in 80% of patients and varies according to the age of the patient. Age Epididymitis is primarily a disease of adults, most commonly affecting males aged 19-40 years. Clinical History The progression of epididymitis usually is gradual in nature, with symptoms often peaking within 24 hours of onset. Initially, the patient may note abdominal or flank pain because cellular inflammation typically begins in the vas deferens. As the inflammation descends to the lower segment of the epididymis, the patient notes discomfort localized to the scrotum. Younger patients or any patient with a sexually transmitted epididymitis may note symptoms related to urethritis. A recent history of endourethral instrumentation or urinary tract infection is more common in older patients. Symptoms include the following: Scrotal pain and edema Urinary frequency, urgency, or dysuria Urinary retention from bladder outlet obstruction in older patients Nausea Fever and chills Abdominal or flank pain Bilateral epididymal involvement (10%) Urethral discharge Physical Edematous tender epididymis: Early on, in cases without significant testicular involvement, tenderness may be clearly localized to the epididymis. Erythematous edematous scrotum Scrotal abscess o Scrotal fluctuance o Scrotal fixation to underlying epididymis Reactive hydrocele Prehn sign: This has been used to distinguish epididymitis from testicular torsion. Classically, scrotal elevation decreases pain in epididymitis and not in torsion. However, the Prehn sign is not reliable for distinguishing epididymitis from testicular torsion. Urethral discharge (10%) Fever or other constitutional symptoms with progression of disease
Causes Epididymitis most often is due to the retrograde extension of bacterial organisms from the vas deferens. o Prepubertal males - Coliform bacteria (E coli) o Sexually active males -C trachomatis is the most common organism followed by N gonorrhoeae o Older males - Coliform bacteria most common, sexually transmitted diseases less common Less common causes of epididymitis include the following: o Chemical epididymitis due to the reflux of sterile urine o Boys with epididymitis due to a postinfectious inflammatory reaction to pathogens, such as M pneumoniae, enteroviruses, and adenoviruses o Candidal epididymitis in immunocompromised patients (AIDS) o Epididymitis as an extrapulmonary manifestation of tuberculosis o Epididymitis secondary to exposure to amiodarone therapy or prostate brachytherapy
10- benign prostatic hyperplasia, all are true except: a) prostitis b) nocturia c) diminished size and strength of stream d) haematuria e) urine retention - BPH all true except: 1) Prostits 2) Noctouria 3) Haematouria 4) Urine retention 5) Diminished size &strength of stream -Benign prostatic hypertrophy can present with all, EXCEPT: a) Nocturia. b) Hematuria. c) urinary retention. d) poor stream. e) prostatitis. 11- Patient oliguria one contraindicated: a) l.V. ringer lactate b) I.V.P 12- A no.20 French catheter is: a) 20 cm long b) 20 mm in circumference c) 20 dolquais (French measurement) in diameter d) 20 mm in diameter e) 20 mm in radius
French catheter scale
Sizing scale of the French catheter system The French scale or French gauge system (most correctly abbreviated as Fr, but also often abbreviated as FR or F) is commonly used to measure the size (diameter) of a catheter. 1 Fr = 0.33 mm, and therefore the diameter of the catheter in millimeters can be determined by dividing the French size by 3: D (mm) = Fr/3 or Fr = D (mm) × 3 For example, if the French size is 9, the diameter is 3 mm. Note that the French scale is a measurement of the diameter, not the circumference (diameter × π). An increasing French size corresponds to a larger-diameter catheter. This is contrary to needle-gauge size, where the diameter is 1/gauge, and where the larger the gauge the narrower the bore of the needle. The Stubs Iron Wire Gauge system is also commonly used in a medical setting, and is in fact more common for measuring needles, even though many find the Stubs system to be more confusing because the scale is non-linear and inversely proportional. The French gauge was devised by Joseph-Frédéric-Benoît Charrière, a 19th-century Parisian maker of surgical instruments, who defined the "diameter times 3" relationship. In some countries (especially French-speaking), this unit is called Charriere and abbreviated as Ch. Size correspondence French Diameter Diameter Gauge (mm) (inches) 3 1 0.039 4 1.35 0.053 5 1.67 0.066 6 2 0.079 7 2.3 0.092 8 2.7 0.105 9 3 0.118 10 3.3 0.131 11 3.7 0.144 12 4 0.158 13 4.3 0.170 14 4.7 0.184 15 5 0.197 16 5.3 0.210 17 5.7 0.223 18 6 0.236 19 6.3 0.249 20 6.7 0.263 22 7.3 0.288 24 8 0.315 26 8.7 0.341 28 9.3 0.367 30 10 0.393 32 10.7 0.419 34 11.3 0.445
13- Concerning urinary calculi, which one of the follwing is true? a) 50% are radiopaque b) 75% are calcium oxalate stones c) An etiologic factor can be defined in 80% of cases d) A 4-mm stone will pass 50% of the time e) Staghorrn calculi are usually symptomatic
14- Screening program for prostatic Ca, the following is true: - Tumor marker (like PSA) is not helpful - PR examination is the only test to do - Early detection does not improve over all survival -……………… Screening Advances in transrectal ultrasound (TRUS) and prostate-specific antigen (PSA) monitoring have allowed for enhanced detection of nonpalpable tumors. Much controversy currently exists over whether men over age 50 should be encouraged to undergo screening. While available data show a decrease in the mortality rate of prostate cancer, there is as yet little evidence that screening has been the cause of this change. Even so, the realities of clinical practice are that the combination of digital rectal examination and serum PSA monitoring is the most effective screening protocol. 15- 35 Y/O presented with left iliac pain and dysuria, management include all the following except: • blood C+S. • microscopy of urine. • IVP. • urine C+S. • norfloxacin. 16- Laprascopy could be used in all, except: a) Infertility b) Intestinal obstruction c) primary amenorrhea 17- Infertility, all true, except: a) Male factor present 24% b) Normal semen analysis is >20,000,000 c) Idiopathic infertility is 27% d) High prolactin could be a cause eInfertility is defined as the inability to achieve pregnancy after one year of unprotected intercourse. An estimated 15% of couples meet this criterion and are considered infertile, with approximately 35% due to female factors alone, 30% due to male factors alone, 20% due to a combination of female and male factors, and 15% unexplained. Conditions of the male that affect fertility are still generally underdiagnosed and undertreated. Causes of infertility in men can be explained by deficiencies in sperm formation, concentration (eg, oligospermia [too few sperm], azoospermia [no sperm in the ejaculate]), or transportation. This general division allows an appropriate workup of potential underlying causes of infertility and helps define a course of action for treatment. Normal ejaculate volume ranges from 1.5 to 5 mL and has a pH level of 7.05-7.8. The seminal vesicles provide 4080% of the semen volume, which includes fructose for sperm nutrition, prostaglandins and other coagulating substances, and bicarbonate to buffer the acidic vaginal vault. Normal seminal fructose concentration is 120-450 mg/dL, with lower levels suggesting ejaculatory duct obstruction or absence of the seminal vesicles. The prostate gland contributes approximately 10-30% (0.5 mL) of the ejaculate. Products include enzymes and proteases to liquefy the seminal coagulum. This usually occurs within 20-25 minutes. The prostate also secretes zinc, phospholipids, phosphatase, and spermine. The testicular-epididymal component includes sperm and comprises about 5% of the ejaculate volume. An estimated 10-15% of couples are considered infertile, defined by the World Health Organization (WHO) as the absence of conception after at least 12 months of unprotected intercourse. In American men, the risk correlates to approximately 1 in 25. Low sperm counts, poor semen quality, or both account for 90% of cases; however, studies of infertile couples without treatment reveal that 23% of these couples conceive within 2 years, and 10% more conceive within 4 years. Even patients with severe oligospermia (<2 million sperm/mL) have a 7.6% chance of conception within 2 years
o
Sperm density: Normal sperm density is greater than 20 million sperm/mL, or greater than 50-60 million total sperm. Oligospermia is defined as fewer than 20 million sperm/mL, severe oligospermia is less than 5 million/mL, and azoospermia is defined as no sperm present. To verify azoospermia, the semen should be centrifuged and evaluated under a light microscope for the presence of sperm. Patients with azoospermia should have a postejaculatory urine sample analyzed for sperm, should be evaluated for ejaculatory duct obstruction, and should undergo a hormonal evaluation.
18- RTA with urethral bleeding. Step of management: a) Insert foley’s cath b) Stabilize the pelvis c) Insert suprapubic cath Treatment Prehospital Care
Address acute life-threatening conditions. Be very aware that the amount of force necessary to cause a significant pelvic fracture is likely to have caused other significant injuries. Application of an external compression device to a grossly unstable pelvis will provide mechanical stabilization while controlling hemorrhage from the fracture site. A sheet or one of a variety of inexpensive, commercial products may be used.10 Avoid excessive movement of the pelvis. Obtain large-bore intravenous (IV) access, and administer analgesia and fluids in accordance with local protocols. Closely monitor vital signs.
19- A patient with gross hematuria after blunt abdominal trauma has a normal-appearing cystogram after the intravesical instillation of 400 ml of contrast. You should next order: a. A retrograde urethrogram. b. An intravenous pyelogram. c. A cystogram obtained after filling, until a detrusor response occurs. d. A voiding cystourethrogram. e. A plain film of the abdomen after the bladder is drained.
Injuries to the Kidney Essentials of Diagnosis 1. 2. 3. 4.
History or evidence of trauma, usually local. Hematuria. Flank mass. Failure to opacify the kidney or extravasation of urine on excretory urography.
General Considerations Renal injury is uncommon but potentially serious and often accompanied by multisystem trauma. The most common causes are athletic, industrial, or automobile accidents. The degree of injury may range from contusion to laceration of the parenchyma or disruption of the renal pedicle.
Clinical Findings Symptoms and Signs 1. Gross hematuria following trauma means injury to the urinary tract. 2. Pain and tenderness over the renal area may be significant but could be due to musculoskeletal injury. 3. Hemorrhagic shock may result from renal laceration and lead to oliguria. 4. Nausea, vomiting, and abdominal distention (ileus) are the rule. 5. Physical examination may reveal ecchymosis or penetrating injury in the costovertebral angle or flank. 6. Extravasation of blood or urine may produce a palpable flank mass. 7. Other injuries should be sought.
Laboratory Findings 1. 2.
Serial hematocrit determinations will give clues to persistent bleeding. Hematuria is to be expected, but the absence of hematuria does not exclude renal injury (as in renal vascular injury).
Imaging Studies 1.
A plain film may reveal obliteration of the psoas shadow; this suggests the presence of a retroperitoneal hematoma or urinary extravasation. Bowel gas may be displaced from the area. Evidence of transverse vertebral process fractures or rib fracture may be noted. In the past the excretory urogram was used for evaluating renal trauma. Excretory urograms may show a normal kidney if it is mildly contused or may show extravasation of contrast medium if the kidney is lacerated. Nonfunction suggests injury to the vascular pedicle. The excretory urogram should demonstrate that the contralateral kidney is normal.
2.
CT scan with intravenous contrast medium is now the method of choice for staging a patient with hemodynamically stable renal trauma. CT scans may miss urinary extravasation if performed too rapidly following intravenous contrast administration—before the contrast is excreted into the collecting system and ureter.
3.
If renal vascular damage is suspected and the patient's condition is stable, preoperative renal angiography may facilitate planning of renovascular reconstruction or permit arterial stenting. In special circumstances, selective renal artery embolization may control segmental arterial bleeding.
Renal imaging is indicated in 1. any adult with gross hematuria or microscopic hematuria with shock. 2. with deceleration injuries 3. children with any hematuria > 50 red blood cells per high-power field.
Differential Diagnosis Bony fractures or contusion of soft tissues in the region of the kidney may cause confusion. Hematuria might be secondary to vesical injury. The absence of a perirenal mass (ie, hematoma or urinoma) or contrast extravasation on urograms or CT scan would rule out significant trauma.
Complications Early 1.
2. 3.
The most serious complication is continued perirenal hemorrhage, which may be fatal. Serial hematocrit, blood pressure, and pulse determinations are essential. Serial CT scans may also be useful. Evidence of an enlarging flank mass implies persistent bleeding. In most cases, bleeding stops spontaneously, probably as a result of tamponade by the perirenal fascia. Delayed bleeding 1 or 2 weeks later is rare. Infection of the perirenal hematoma may occur.
Late
Ultrasound should be obtained 1–3 months after surgery to look for progressive hydronephrosis from ureteral obstruction. The blood pressure should be checked at regular intervals, because hypertension may be a late sequela.
Treatment 1. 2. 3. 4. 5. 6. 7.
Treat shock and hemorrhage with fluids and transfusion. Most patients with blunt renal trauma stop bleeding and heal spontaneously. Bed rest is indicated until hematuria resolves. If bleeding persists, laparotomy is indicated. Penetrating renal trauma requires exploration. Lacerations may be sutured, the collecting system closed, and urinary extravasation drained. Nephrectomy or partial nephrectomy may be necessary to remove devitalized tissue and secure the collecting system. 8. Late complications may occur. 9. Perinephric abscess should be drained. 10. Hypertension due to renal ischemia requires vascular reconstruction or nephrectomy.
Prognosis Most injured kidneys heal spontaneously, though the patient must be examined at intervals for the onset of hypertension due to renal ischemia or progressive hydronephrosis due to secondary ureteral stricture. Many patients with genitourinary trauma have associated injuries. In most cases, death is due to associated injury rather than renal injury.
20- The most likely cause of gross hematuria in a 35-year-old man is: a) cystitis b) ureteral calculi c) renal carcinoma d) prostatic carcinoma e) bladder carcinoma
