3Stones - Presentation - Pain Typical: Loin to groin painVariable severityEpisodicNot mechanical but paroxysmalAtypical: AnteriorGroin pain aloneTesticular pain alonePenile tip pain aloneAssociated vomiting (ongoing)Mechanical character
4Stones - Presentation - LUTS Irritative: FrequencyUrgencyStranguryBurning micturitionMacroscopic haematuriaCommon misdiagnosis UTI - Do MSUs if in doubt.
5Stones - Presentation - Fever Loin pain + fever (38c) = pyelonephritis = generally not life threateningLoin pain + fever + stone = infected obstructed kidney = commonly life threateningMessage – do ultrasound in all pyelonephritis admissions
6Stones - Investigation MSUU&E/CreatinineSerum calcium/albumin uric acidImagingFirst or infrequent presentation admit to hospital until diagnosis made
7Diagnostic ImagingUntil recently, limited IVP with extra tomograms or delayed films as dictated by progressNow imaging by non contrast stone CT scan as routine initial diagnostic imaging protocol.BUT CT scan has a relatively high radiation doseSO1) Do not repeat CT for the same stone – once a diagnosis is established, patients can be managed with AXR or U/S or both.2) Do not do CT scans for recurrent stone formers – patients can usually tell you the diagnosis – do U/S and AXR not CT.3) Avoid CT in children4) Do not do CT in pregnancy – use U/S
8CT vs IVPRenal colic: A prospective evaluation of non-enhanced spiral CT versus intravenous pyelographyMendelson et al Australasian Radiology , 22 – 28200 patients randomized to CT or IVPRadiation dose CT 5 mSv vs IVP mSvMore plain Xrays during admission and more IVPs at F/U in CT groupCT greater diagnostic utility, but no difference in measured outcomes66% CT diagnostic vs 41% IVP diagnostic
12Communicating Diagnosis Stone size in mmAnatomical stone positionparenchymalcalyceal diverticulumcalyxrenal pelvisPUJ pelvi-ureteric junctionureter: upper 1/3, middle 1/3, lower 1/3vesico-ureteric junctionbladderStone composition calcium 80%uric acid 15%infection (struvite) 5%Stone appearance – staghorn, jackstoneIn addition include fever, renal function, level of pain control, comorbidities
13CT Scan Stone Composition From Mostofavi et al : Accurate Determination of Chemical Composition of Urinary Calculi by Spiral Computerized TomographyJ Urol (3) MarchIf in doubt, do AXR.
14Emergency Management of Renal Colic Non surgical management:80% of 5 mm stones will pass spontaneously50% of 8 mm stones will pass spontaneouslyUric acid stones will dissolve with urine alkalinization – NaHCO3 840 mg q.i.d.Most patients can be discharged home with adequate analgesia and a plan for follow up.Analgesia:Initial I/M or I/V narcotic until diagnosis is made.NSAIDs after diagnosis specific for PG release shown to be associated with acute renal colic –Oral analgesics generally not absorbed well during renal colic -> so give the patient NSAID suppositories !!Indocid suppositories 100mg 12 hourly prnVoltaren suppositories 100mg 12 hourly prnOral Ibuprofen (Nurofen OTC 400mg 8 hourly OK) as backup if pain not severeN.B Management with oral narcotics/panadeine forte/tramadol is generally inadequate and results in return to hospital.
15Non Surgical Management Plan for Renal Colic Urology referral if first presentation or problematic or expect surgery to be required.If uncomplicated, with likely spontaneous passage, review at 6 weeks with appropriate imaging, most commonly U/S +AXR.Note, do not encourage the patient to “drink lots to flush the stone out” – stone will pass more rapidly if patient drinks less !Imaging is not required if patient has the stone in a jar !6 Weeks – stone passed + pain gone + Ca/Uric acid normal -> discharge.6 Weeks – stone not passed – no adverse features – repeat imaging at 12 weeks, adverse features increase HN refer.12 Weeks- stone not passed – refer for surgical management.Note, once the stone has passed, encouraged long term increase in fluid intake.50% reduction in stone recurrence has been well documented if patients produce 2 li urine per 24 hours long term.
16Indications for Surgical Intervention 1. Infected obstructed kidney = surgical emergency2. Pain uncontrolled despite PR NSAIDS3. Stone clearly too large to pass > 8mm4. Significant CRF creatinine >2005. Solitary kidney – risk obstructive uropathy
17Acute Urine RetentionSudden inability to pass urine – usually associated with pain, unless neuropathic cause.EtiologyNeuropathic – painless – MS, spinal cord compressionMechanical – Benign prostatic obstruction - most common+/- precipitating event – post op narcotics/mobilizationUTIoverstretch – long travel timesdrugs - anticholinergics?? constipationBladder neck dyssernergia – young men withprecipitating event eg UTIMalignant prostatic obstruction/ other malignancyUrethral strictureUrethral stone – rareFunctional – psychological/psychiatric background
18Acute Urine Retention - Treatment CatheterizationUrethral Foley catheteruse 16F or 18F for adequate long term drainageuse “long term” catheter – Bard “Biocath” or Silastic (not brown latex – 3 day use max).do not use force – urethral trauma – convert to suprapubicSuprapubic cathetershort term Bonano type – narrow gaugelong term – 16F Foley via “Add A Cath”midline 1cm above pubic symphysismake sure you aspirate urine with fine needle after LA infiltration
19Acute Urine Retention ? Admission Should depend on renal functionCreatinine < 200home with urology followup, and continence clinic appointment for assistance with bag management.Creatinine > 200admit for management post obstructive diuresischeck hourly urine output > 200 ml/hour Rx I/V fluid replacement with saline, hourly I/V to equalhourly urine output, with 12 hourly potassium assessment (significant risk of hypokalemia)Note, the theoretical problem with conversion to pre renal renal failure without adequate replacement.Note also admission pending co-morbidities.
20UrosepsisSepticaemia originating from the urinary tract, usually Gram negativeDiagnosisHistory – LUTS + Temp > 38 celsiusrecent urological surgery or catheter, or catheter changeloin pain = either stone + infected/ obstructedor uncomplicated pyelonephritisExamination – Kidney tendernessProstate tenderness = prostatitisBP – “septic shock” and inotropesInvestigationMSU and blood cultures should correlateBloods routine + CRPImaging – U/S kidneys initially – hydronephrosis = infected/obst
21Urosepsis - Treatment Antibiotics NB Take urine and blood cultures before commencing antibiotics.Current general therapy:Tazocin 4.5 gm t.d.s Reduced dosage 4.5 gm b.d. if impaired renal functionAntibiotic guidelines:Gentamicin (Gram –ve cover) single daily dose 5 – 7 mg/Kgtrough levels 12 hours post dose, with adjustment pending+ Amox/Ampicillin (Enterococcus cover) 1gm 6 hourlyChange to less potentially toxic regimen once antibiotic sensitivities returned. Usually within 72 hours.Treat obstucted kidneysEither urgent Cysto/JJ stent if fit for GAor Radiological insertion of nephrostomy tubeSupportive therapy – ICU and inotropes – BP and renal function? Steroids and other therapies
22Macroscopic Haematuria EtiologyUpper tract vs lower tract – most commonly lower tract originYoung – stonesOld – males most common cause is BPHfemales most common cause is UTI/haemorrhagic cystitisCancer is the major concernPost urological surgeryHistoryPainless – commonly lower urinary tractLoin pain associated – usually upper tract origin – stones/tumoursLUTS UTI symptoms – haemorrhagic cystitis (and VUJ stones)
23Macroscopic Haematuria ExaminationUsually little to find – DRE in older men ? CA prostateInvestigationMSUBloods – FBP U&E/Creat +/- Coag profileImaging U/S as starting point, unless clinically stone, then non contrast CTCystoscopy – GA rigid cystoscopy if urgent, or flexible cystoscopy LA if urine clears.TreatmentTreat pathologyRarely life threatening unless uro-arterial fistulaAdmit depending on circumstances, predicted pathologyN.B. Catheterization is not necessary unless patient is in clot retention.(and can aggravate and perpetuate the presenting problem !!)
24Management of Clot Retention History of heavy frank haematuria then painful inability to voidCommonly tender palpable bladder22F 3 way Foley catheterSyringe bladder vigorously with sterile saline to break up andwash out clot – use at least 500mlRun bladder washout flat out until certain cleared, then slow to keepurine roseIf failure to wash out clot, or washout clotting off – requires emergencycystoscopy under anaestheticCheck Hb +/- coag profile
25Testicular TorsionIncidence: Cumulative incidence 1 in 4,000 males by the age of 25 yearsTwo age peaks: 1) 1st year of life2) early adolescence65% of cases present between ages 12 and 18 yearsEtiology: 90% “bell clapper” congenital anatomical arrangement.History: sudden onset of severe testicular pain and associated testicular swelling, usually presenting a short time afteronset.Examination: tender, swollen, “high riding” testicle, lying transversely.Patients usually afebrileDifferential diagnosis in adults usually orchitis – preceding LUTS for several days, slower onset of pain and laterpresentation, commonly with a fever.Differential diagnosis in children: torsion Hydatid of Morgagni or appendix testis andacute idiopathic scrotal oedema AISE (average age 6 years, unknown cause).
26Testicular TorsionTesticular torsion is a clinical diagnosis, and if diagnosed, be taken to theatre as a surgical emergency.Testicular U/S will delay diagnosis and should not be called for – the urology registrar should be called to assess theurgently and if not available the consultant should be called.The on call urology registar should assess the case clinically, urgently, and if they still have doubts (often misguided),then request U/S, then take the consequences of delay if they are wrong.If the U/S is correct and delays theatre, (which is then clearly unnecessary) then nothing is lost.If patients are taken to theatre with the wrong diagnosis, then little is lost and registrars should learn.BUT if there is a delay in taking patients to theatre because U/S is done, then testicles are lost.Senior radiologists agree with this policy and feel that diagnosis of torsion is a clinical diagnosis.Torted testicles can be recovered if detorted surgically within 6 hours (4 – 8 hours), and in some cases 12 hours.Surgery: bilateral orchidopexy through a midline scrotal incision using non absorbable suture material (3/0 Prolene).Investigations that can be done: testicular U/S with doppler, nuclear scan technetium-99m pertechnetate
27Trauma - Renal Blunt vs penetrating trauma Blunt trauma most common with high velocity MVALow velocity trauma – more commonly underlying abnormal kidneyPenetrating injury generally stab wounds and gunshotBlunt traumaSurgical exploration uncommon 2.6% of 913 cases in San FranciscoIncreasing use of radiological embolization and urological stentsPenetrating traumaCommonly require exploration42% stab wounds explored76% of gunshot wounds explored
30Renal Trauma - Presentation Obvious trauma – assess trauma potentialFrank haematuria common 80% to 94% of cases (but not always)N.B. especially renal pedicle injury in children and young adultsdeceleration injury with no haematuriaPenetrating trauma – poor correlation of degree of haematuria andseverity of injuryHypotensionearly may be associated with loss from other injuriesdeceptive absence of hypotension in children
31Renal Trauma - ImagingCT scan – multi phase – non contrast, contrast arterial and venousphases and pyelographic phase.If haemodynamically stableNote importance of contrast study in assessing that pedicle intactIntra-operative one shot IVPWhen patient haemodynamically unstable and emergency surgerynecessary, this allows assessment of pedicle integrity in presenceof identifiable non expanding peri-nephric haematomaFollow up imaging – pending initial staging – especially urinomadevelopment in stage IV injury at 48 hours
32Renal Trauma - Surgery Absolute indications Severe blood loss with haemodynamic instability, not suitable forembolizationRenal pedicle avulsion ? Time limitsUreteric avulsionRelative indicationsNonviable tissue – if large segments of ischaemic tissue ? %vs risk of delayed haemorrageUrinary extravasationCalyceal injury vs ureteric avulsionJJ stenting with radiological drainage perc drain
36Renal Trauma – Secondary Haemorrhage 2 – 36 days post injuryMost often arteriovenous fistula or pseudo-aneurysm13% - 25% with grade III and IV injuriesRx most commonly selective embolization currently
37Renal Trauma - Hypertension Incidence 0.3% - 0.9%Earliest 37 days, but up to decades after injuryAverage 34 monthsEtiology – more likely in more severe injuries grade IVPage kidney parenchymal compression by fibrosisRenal artery stenosis, post intimal injuryArterio-venous fistulasDiagnosisRegular blood pressure monitoring in high grade injuries? 6 monthly lifelong
38Trauma - Bladder Uncommon Etiology Iatrogenic most common – urology/gynaecologySpontaneous – rare in abnormal bladders eg clam cystoplastyIntoxicated – alcohol abuse with fall onto full bladderpresent with pain, unable to void or haematuriaTraumatic – blunt trauma with high velocity MVAstrong association with pelvic fracture (85% of ruptures)Classification – Extraperitoneal vs Intraperitoneal (10% combination)Imaging diagnosisCT delayed post contrast phase in major traumaCystogram in iatrogenic/spontaneous/intoxicated groups
39Bladder Trauma Treatment Extraperitoneal ruptureUrethral catheter drainage (18F catheter)Duration pending mechanism and severity of injury5 days up to 3 weeksRepeat cystogram prior to catheter removalIntraperitoneal ruptureTraditionally surgical repairMore recently, conservative, with catheter drainage and follow upcystogram
40“Anterior” Urethral Trauma EtiologyMost commonly iatrogenic – forced catheterization with stricture“Fall astride” injuryHistoryHistory of trauma, blood at urethral meatus and urine retentionExaminationBlood at urethral meatusInvestigationUsually nil for iatrogenicUrethrogram for fall astride injuriesTreatmentNil if voiding OK for iatrogenic injury and catheter not requiredCystoscopy/ endourological management in some casesSurgical repair of fall astride anterior urethral injury for complete rupturerelatively easy surgery, catheter 3 weeks post op