ACUTE UROLOGICAL CONDITIONS
Introduction
Urological conditions are frequently encountered in our clinical environment. In the emergent
setting the general surgeon is often called upon to treat these ailments. Therefore a grounding
on the common urological ailments is essential. This seminar aims to shed light on and
provide an approach to some of the acute urological conditions that we commonly encounter.
Anatomy
The kidneys are retroperitoneal organs situated on the posterior wall of the abdomen on each
side of the vertebral column, at about the level of the twelfth rib. The left kidney is slightly
higher in the abdomen than the right, due to the presence of the liver pushing the right kidney
down.
The kidneys take their blood supply directly from the aorta via the renal arteries; blood is
returned to the inferior vena cava via the renal veins. Urine (the filtered product containing
waste materials and water) excreted from the kidneys passes down the fibromuscular ureters
and collects in the bladder. The bladder muscle (the detrusor muscle) is capable of distending
to accept urine without increasing the pressure inside; this means that large volumes can be
collected (700-1000ml) without high-pressure damage to the renal system occurring. When
urine is passed, the urethral sphincter at the base of the bladder relaxes, the detrusor contracts,
and urine is voided via the urethra. The male urethra is divided into the anterior and posterior
sections by the urogenital diaphragm. The posterior urethra consists of the prostatic and the
membranous urethra. The anterior urethra consists of the bulbar and penile urethra.
Outline
1) Genitourinary Trauma
a) Renal Injuries
b) Ureteric Injuries
c) Bladder Injuries
d) Urethral Injuries
e) Penile amputation and fracture
f) Scrotal trauma
2) Acute Miscellaneous Conditions
a) Priapism
b) Acute urinary retention
c) Urolithiasis
3) Acute Scrotum
a) Testicular torsion
b) Torsion of testicular appendages
c) Epididymo-orchitis
4) Infections:
a) Acute bacterial prostatitis
b) Fournier’s gangrene
c) Emphysematous pyelonephritis
Genitourinary Trauma8,13,15,16
1
,Initial assessment of the trauma patient should include securing the airway, controlling
external bleeding, and resuscitation of shock, as per Advanced Trauma and Life Support
(ATLS) principles.
a) Renal Trauma
Renal trauma occurs in approximately 1-5% of all trauma cases. Renal injuries are classified
by their mechanism: blunt or penetrating. Blunt trauma is usually caused by motor vehicle
accidents, falls, vehicle-associated pedestrian accidents, contact sports, and assault. Traffic
accidents are the major cause of almost half the blunt renal injuries. Gunshot and stab wounds
represent the most common causes of penetrating injuries. Renal injuries from penetrating
trauma tend to be more severe and less predictable than those from blunt trauma. Bullets,
because of their higher kinetic energy, have the potential for greater parenchymal destruction
and are most often associated with multiple-organ injuries.
Renal injury scale according to the Organ Injury Scale of the American Association of
Surgery of Trauma (AAST)
Possible indicators of major renal injury include a rapid deceleration event (fall, high-speed
motor vehicle accidents) or a direct blow to the flank.
.
The following findings on physical examination could indicate possible renal involvement:
➢ haematuria
➢ flank pain
➢ flank ecchymosis
➢ flank abrasions
➢ fractured ribs
➢ abdominal distension
➢ abdominal mass
➢ abdominal tenderness
Imaging:
2
, Ultrasound(U/S): It provides a quick, non-invasive, low-cost means of detecting peritoneal
fluid collections without exposure to radiation. Ultrasound scans can detect renal lacerations
but cannot definitely assess their depth and extent and do not provide functional information
about renal excretion or urine leakage therefore U/S findings do not provide sufficient
evidence for a definite answer on the severity of renal injuries.
Computerised Tomography(CT): Computerised tomography is the gold standard method for
the radiographic assessment of stable patients with renal trauma. CT is more sensitive and
specific than intravenous pyelogram (IVP), ultrasonography or angiography. Computed
tomography more accurately defines the location of injuries, easily detects contusions and
devitalised segments, visualises the entire retroperitoneum and any associated haematomas,
and simultaneously provides a view of both the abdomen and pelvis.
Magnetic Resonance Imaging(MRI): is not the first choice in managing patients with trauma
because it requires a longer imaging time, increases the cost, and limits access to patients
when they are in the magnet during the examination. MRI is therefore useful in renal trauma
only if CT is not available, in patients with iodine allergy, or in the very few cases where the
findings on CT are equivocal.
Management : Operative vs Non-Operative Approach
Operative management: A life-threatening haemodynamic instability due to renal
haemorrhage is an absolute indication for renal exploration, irrespective of the mode of
injury. Other indications include an expanding or pulsatile peri-renal haematoma identified
during exploratory laparotomy performed for associated injuries or a Grade V renal injury.
The goal of renal exploration following renal trauma is control of haemorrhage and renal
salvage. Renal reconstruction should be attempted in cases where the primary goal of
controlling haemorrhage is achieved and a sufficient amount of renal parenchyma is viable.
Renal reconstruction is feasible in most cases. The overall rate of patients who have a
nephrectomy during exploration is around 13%, usually in patients with penetrating injury,
and higher rates of transfusion requirements, haemodynamic instability, injury severity
scores, and mortality. Other intra-abdominal injuries also slightly increase the need for
nephrectomy. Mortality is associated with the overall severity of the injury and is not often a
consequence of the renal injury itself. In gunshot injuries caused by a high-velocity bullet,
reconstruction can be difficult and nephrectomy is often required.
Non-Operative management: As the indications for renal exploration become clearer, non-
operative management has become the treatment of choice for the majority of renal injuries.
In stable patients, supportive care with bed-rest, hydration, and antibiotics is the preferred
initial approach. Primary conservative management is associated with a lower rate of
nephrectomy without any increase in the immediate or long-term morbidity. The failure of
conservative therapy is low. All Grade I and II renal injuries can be managed non-
operatively, whether due to blunt or penetrating trauma. Therapy of Grade III injuries has
been controversial, but recent studies support expectant treatment. Patients diagnosed with
urinary extravasation in solitary injuries can be managed without major intervention and a
resolution rate of > 90%. Persistent bleeding is the main indication for a reconstruction
attempt. The majority of patients with Grade IV and V renal injuries present with major
associated injuries and consequently experience high exploration and nephrectomy rates.
b) Ureteral Injuries
3
Introduction
Urological conditions are frequently encountered in our clinical environment. In the emergent
setting the general surgeon is often called upon to treat these ailments. Therefore a grounding
on the common urological ailments is essential. This seminar aims to shed light on and
provide an approach to some of the acute urological conditions that we commonly encounter.
Anatomy
The kidneys are retroperitoneal organs situated on the posterior wall of the abdomen on each
side of the vertebral column, at about the level of the twelfth rib. The left kidney is slightly
higher in the abdomen than the right, due to the presence of the liver pushing the right kidney
down.
The kidneys take their blood supply directly from the aorta via the renal arteries; blood is
returned to the inferior vena cava via the renal veins. Urine (the filtered product containing
waste materials and water) excreted from the kidneys passes down the fibromuscular ureters
and collects in the bladder. The bladder muscle (the detrusor muscle) is capable of distending
to accept urine without increasing the pressure inside; this means that large volumes can be
collected (700-1000ml) without high-pressure damage to the renal system occurring. When
urine is passed, the urethral sphincter at the base of the bladder relaxes, the detrusor contracts,
and urine is voided via the urethra. The male urethra is divided into the anterior and posterior
sections by the urogenital diaphragm. The posterior urethra consists of the prostatic and the
membranous urethra. The anterior urethra consists of the bulbar and penile urethra.
Outline
1) Genitourinary Trauma
a) Renal Injuries
b) Ureteric Injuries
c) Bladder Injuries
d) Urethral Injuries
e) Penile amputation and fracture
f) Scrotal trauma
2) Acute Miscellaneous Conditions
a) Priapism
b) Acute urinary retention
c) Urolithiasis
3) Acute Scrotum
a) Testicular torsion
b) Torsion of testicular appendages
c) Epididymo-orchitis
4) Infections:
a) Acute bacterial prostatitis
b) Fournier’s gangrene
c) Emphysematous pyelonephritis
Genitourinary Trauma8,13,15,16
1
,Initial assessment of the trauma patient should include securing the airway, controlling
external bleeding, and resuscitation of shock, as per Advanced Trauma and Life Support
(ATLS) principles.
a) Renal Trauma
Renal trauma occurs in approximately 1-5% of all trauma cases. Renal injuries are classified
by their mechanism: blunt or penetrating. Blunt trauma is usually caused by motor vehicle
accidents, falls, vehicle-associated pedestrian accidents, contact sports, and assault. Traffic
accidents are the major cause of almost half the blunt renal injuries. Gunshot and stab wounds
represent the most common causes of penetrating injuries. Renal injuries from penetrating
trauma tend to be more severe and less predictable than those from blunt trauma. Bullets,
because of their higher kinetic energy, have the potential for greater parenchymal destruction
and are most often associated with multiple-organ injuries.
Renal injury scale according to the Organ Injury Scale of the American Association of
Surgery of Trauma (AAST)
Possible indicators of major renal injury include a rapid deceleration event (fall, high-speed
motor vehicle accidents) or a direct blow to the flank.
.
The following findings on physical examination could indicate possible renal involvement:
➢ haematuria
➢ flank pain
➢ flank ecchymosis
➢ flank abrasions
➢ fractured ribs
➢ abdominal distension
➢ abdominal mass
➢ abdominal tenderness
Imaging:
2
, Ultrasound(U/S): It provides a quick, non-invasive, low-cost means of detecting peritoneal
fluid collections without exposure to radiation. Ultrasound scans can detect renal lacerations
but cannot definitely assess their depth and extent and do not provide functional information
about renal excretion or urine leakage therefore U/S findings do not provide sufficient
evidence for a definite answer on the severity of renal injuries.
Computerised Tomography(CT): Computerised tomography is the gold standard method for
the radiographic assessment of stable patients with renal trauma. CT is more sensitive and
specific than intravenous pyelogram (IVP), ultrasonography or angiography. Computed
tomography more accurately defines the location of injuries, easily detects contusions and
devitalised segments, visualises the entire retroperitoneum and any associated haematomas,
and simultaneously provides a view of both the abdomen and pelvis.
Magnetic Resonance Imaging(MRI): is not the first choice in managing patients with trauma
because it requires a longer imaging time, increases the cost, and limits access to patients
when they are in the magnet during the examination. MRI is therefore useful in renal trauma
only if CT is not available, in patients with iodine allergy, or in the very few cases where the
findings on CT are equivocal.
Management : Operative vs Non-Operative Approach
Operative management: A life-threatening haemodynamic instability due to renal
haemorrhage is an absolute indication for renal exploration, irrespective of the mode of
injury. Other indications include an expanding or pulsatile peri-renal haematoma identified
during exploratory laparotomy performed for associated injuries or a Grade V renal injury.
The goal of renal exploration following renal trauma is control of haemorrhage and renal
salvage. Renal reconstruction should be attempted in cases where the primary goal of
controlling haemorrhage is achieved and a sufficient amount of renal parenchyma is viable.
Renal reconstruction is feasible in most cases. The overall rate of patients who have a
nephrectomy during exploration is around 13%, usually in patients with penetrating injury,
and higher rates of transfusion requirements, haemodynamic instability, injury severity
scores, and mortality. Other intra-abdominal injuries also slightly increase the need for
nephrectomy. Mortality is associated with the overall severity of the injury and is not often a
consequence of the renal injury itself. In gunshot injuries caused by a high-velocity bullet,
reconstruction can be difficult and nephrectomy is often required.
Non-Operative management: As the indications for renal exploration become clearer, non-
operative management has become the treatment of choice for the majority of renal injuries.
In stable patients, supportive care with bed-rest, hydration, and antibiotics is the preferred
initial approach. Primary conservative management is associated with a lower rate of
nephrectomy without any increase in the immediate or long-term morbidity. The failure of
conservative therapy is low. All Grade I and II renal injuries can be managed non-
operatively, whether due to blunt or penetrating trauma. Therapy of Grade III injuries has
been controversial, but recent studies support expectant treatment. Patients diagnosed with
urinary extravasation in solitary injuries can be managed without major intervention and a
resolution rate of > 90%. Persistent bleeding is the main indication for a reconstruction
attempt. The majority of patients with Grade IV and V renal injuries present with major
associated injuries and consequently experience high exploration and nephrectomy rates.
b) Ureteral Injuries
3
