Transcript Pediatric Urology Emergencies

Pediatric Urology Emergencies
Ahmed Al-Sayyad MD,FRCSC
Assistant Professor-King Abdulaziz
University
Pediatric Urology Emergencies
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Acute scrotum
GU Trauma
Priapism
Paraphimosis
PUV
Urosepsis in association of obstruction
Urolithiasis
Acute scrotum
• Torsion of the spermatic cord
Torsion of the appendix testis
Torsion of the appendix epididymis
Epididymitis
Epididymo-orchitis
Inguinal hernia
Communicating hydrocele
Hydrocele
Hydrocele of the cord
Trauma/insect bite
Dermatologic lesions
Inflammatory vasculitis (Henoch-Schönlein purpura)
Idiopathic scrotal edema
Tumor
Spermatocele
Varicocele
Nonurogenital pathology (e.g., adductor tendinitis)
Torsion of the Spermatic Cord (Intravaginal)
• Torsion of the spermatic cord is a true surgical
emergency of the highest order
• Irreversible ischemic injury to the testicular
parenchyma may begin as soon as 4 hours after
occlusion of the cord
• Intravaginal torsion happens within the space of
the tunica vaginalis; this results from lack of
normal fixation of the testis and epididymis to the
fascial and muscular coverings that surround the
cord within the scrotum
Torsion of the Spermatic Cord
(Intravaginal)
• Usually there is an acute onset of scrotal pain, but in
some instances the onset appears to be more
gradual
• A large number of boys give a history of previous
episodes of severe, self-limited scrotal pain and
swelling
• Nausea and vomiting may accompany acute torsion,
and some boys have pain referred to the ipsilateral
lower quadrant of the abdomen
• Dysuria and other bladder symptoms are usually
absent
Torsion of the Spermatic Cord
(Intravaginal)
• Testis can be riding high in the scrotum or with transverse
orientation
• The absence of a cremasteric reflex is a good indicator of
torsion of the cord
• After several hours an acute hydrocele or massive scrotal
edema obliterates all landmarks
• Color Doppler examination had a diagnostic sensitivity of
88.9% and a specificity of 98.8%, with a 1% rate of falsepositive results
• When the diagnosis of torsion of the cord is suspected,
prompt surgical exploration is warranted
• When torsion of the spermatic cord is found, exploration of
the contralateral hemiscrotum must be carried out
Torsion of the Testicular and
Epididymal Appendages
• The appendix testis, a müllerian duct remnant,
and the appendix epididymis, a wolffian remnant,
are prone to torsion
• The symptoms associated with torsion of an
appendage are extremely variable, from an
insidious onset of scrotal discomfort to an acute
condition identical to that seen with torsion of
the cord
Torsion of the Testicular and
Epididymal Appendages
• localized tenderness of the upper pole of the testis or epididymis
• Tender nodule may be palpated. In some instances, the infarcted
appendage is visible through the skin as a “blue dot sign”
• The cremasteric reflex is usually present
• In cases in which the inflammatory changes are more significant,
scrotal wall edema and erythema may be severe
• Color Doppler examination may show hyperemia at the upper pole
of the testis or epididymis
• When the diagnosis of torsion of an appendage is confirmed
clinically or by imaging, nonoperative management allows most
cases to resolve spontaneously
• Limitation of activity and administration of nonsteroidal antiinflammatory agents are only needed
Perinatal Torsion of the Spermatic
Cord
• Prenatal (in utero) torsion is typified by the
finding at delivery of a hard, nontender testis
fixed to the overlying scrotal skin
• The skin is commonly discolored by the
underlying hemorrhagic necrosis
• Classic teaching has held that testes found to be
hard, nontender, and fixed to the skin at birth do
not merit surgical exploration
• However, controversy has arisen regarding the
need for prompt exploration of the contralateral
testis
Perinatal Torsion of the Spermatic
Cord
• Contralateral scrotal exploration traditionally has
not been recommended in cases of prenatal
torsion because extravaginal torsion is not
associated with the testicular fixation defect (bellclapper deformity) that is recognized as the cause
of intravaginal torsion
• However, reports of asynchronous perinatal
torsion have made the practice of avoiding
prompt surgical exploration of the contralateral
testis controversial
Perinatal Torsion of the Spermatic
Cord
• Prompt exploration of suspected postnatal torsion of the
spermatic cord is indicated (in conjunction with
exploration of the contralateral testis) when the patient's
general condition and anesthetic considerations allow for
a safe procedure
• Exploration, when elected, should be carried out through
an inguinal incision to allow for the most efficacious
treatment of other potential or unexpected causes of
scrotal swelling
• If torsion is confirmed, contralateral scrotal exploration
with testicular fixation should be carried out
• The most effective and safest form of testicular fixation
involves dartos pouch placement
Priapism
• Priapism is a persistent penile erection of at least 4 hours in
duration that continues beyond and is unrelated to sexual
stimulation .There are three subtypes:
• Ischemic (veno-occlusive, low-flow) priapism is characterized by
little or no cavernous blood flow, and cavernous blood gases are
hypoxic, hypercapnic, and acidotic. The corpora are rigid and tender
to palpation
• Nonischemic (arterial, high-flow) priapism is caused by unregulated
cavernous arterial inflow. Typically, the penis is neither fully rigid
nor painful. There is often a history of antecedent trauma resulting
in a cavernous artery–corpora cavernosa fistula
• Stuttering (intermittent) priapism is a recurrent form of ischemic
priapism with painful erections with intervening periods of
detumescence
Priapism
• The most common cause of priapism in children is sickle cell disease
• Priapism typically occurs during sleep, when mild hypoventilatory
acidosis depresses oxygen tension and pH in the corpora. The pain
experienced is a sign of ischemia
• On examination, there is typically significant corporal engorgement
with sparing of the glans penis
• Medical therapy, including exchange transfusion, hydration,
alkalinization, pain management with morphine, and oxygen should
be started
• Intracavernous irrigation with a sympathomimetic agent, such as
phenylephrine will be the next step. General anesthesia or
intravenous sedation will be necessary.
• If irrigation and medical therapy are unsuccessful, a corporoglanular
shunt should be considered
Priapism
• For stuttering priapism, administration of an oral αadrenergic agent (pseudoephedrine) once or twice
daily is first-line therapy. If this treatment is
unsuccessful, an oral β agonist (terbutaline) is
recommended; a GnRH analog plus flutamide is
recommended as third-line therapy
• Nonischemic (high-flow) priapism most commonly
follows perineal trauma, such as a straddle injury, that
results in laceration of the cavernous artery
• Spontaneous resolution may occur. If not, angiographic
embolization is indicated
Paraphimosis
• Paraphimosis develops when the tip of the
foreskin retracts proximal to the coronal sulcus
and becomes fixed in position
• Severe edema of the foreskin occurs within
several hours, depending on the tightness of the
tip of the foreskin
• In most cases, manual compression of the
glans with placement of distal traction on the
edematous foreskin allows reduction of the
paraphimotic ring
Renal Trauma
• The pediatric kidney is believed to be more
susceptible to trauma because of a decrease in
the physical renal protective mechanisms
• hematuria is very unreliable in determining who
to screen for renal injuries
• Indeed, some studies have failed to find any
evidence of either gross or microscopic
hematuria in up to 70% of children sustaining
grade 2 or higher renal injury
Indications for Imaging
• A significant deceleration or high-velocity injury such as
one sustained in a high-speed motor vehicle accident, a
pedestrian/bicycle-motor vehicle accident, a fall from more
than 15 feet, or a strike to the abdomen or flank with a
foreign object (e.g., football helmet, baseball bat)
• Significant trauma that has resulted in fractures of thoracic
rib cage, spine, pelvis, or femur, or bruising of the
torso/perineum, or signs of peritonitis
• Gross hematuria
• Microscopic hematuria (<50 red blood cells per highpowered field) associated with shock (systolic blood
pressure less than 90 mm Hg)
• penetrating injuries
Imaging
• Single-Shot Intravenous Pyelography Is useful in the unstable
patient requiring emergent laparotomy
• Once the patient is stabilized in the operating room, single-shot
intravenous pyelography (IVP) (2 mL/kg intravenous bolus of
contrast agent) with the radiograph taken 10 to 15 minutes after
injection may be of benefit
• Use of Arteriography is useful in patients with persistent or delayed
hemorrhage which usually arises from the development of
arteriovenous fistulas or pseudoaneurysm
• Approximately 25% of patients with grade 3 to grade 4 renal
trauma, managed in a nonoperative fashion, will develop persistent
or secondary (delayed) hemorrhage
• RGP +\- DJ indications after renal trauma: (1) to rule out the
presence of a partial/total ureteral disruption and (2) to aid in the
management of a symptomatic urinoma
Renal pedicle injury
Involving artery and vein
With hematoma
Delayed imaging
Injury to collecting system
with extravasation
Delayed imaging
Renal pelvis injury with leak of urine
Management
• Majority of renal injuries can be managed
conservatively
• Bed rest till urine is clear
• Frequent vitals and Hb checking
• Urine racking
• Follow up imaging after discharge
Absolute indications for exploration
• Persistent renal bleeding
• Pulsatile, expanding or uncontained
hematoma
• Avulsion of the main renal artery or vein
Relative indications for exploration
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Significant (25%-50%) non-viable tissue
Urinary extravasation
Arterial thrombosis
Penetrating trauma
Surgical approach
• The goals of operative therapy are hemorrhage
control and renal tissue preservation
• Midline incision, look for other injuries, central
control of vessels
• Renal exploration, débridement of nonviable
tissue, hemostasis by individual suture ligation of
bleeding vessels, watertight closure of the
collecting system, and coverage or
approximation of the parenchymal defect
URETEROPELVIC JUNCTION
DISRUPTION
• Disruption of the UPJ is most commonly caused by accelerationdeceleration injuries
• The majority of patients sustaining a UPJ disruption will present
with vascular instability, requiring emergent laparotomy with the
patient unable to undergo preoperative imaging
• Emergent exploratory laparotomy for coexisting intra-abdominal
injury is usually necessary and exploration fails to reveal the
presence of a retroperitoneal hematoma
• Because of the frequent association of this injury with lifethreatening trauma the diagnosis of a UPJ disruption is delayed for
more than 36 hours in more than 50% of patients
• Patients will eventually come to attention due to CT abnormalities
found during the workup of persistent postoperative fever, chronic
flank pain, continued ileus, or sepsis
URETEROPELVIC JUNCTION
DISRUPTION
• Three classic findings on triphasic CT are associated with UPJ disruption:
(1) good renal contrast agent excretion with medial extravasation of
contrast agent in the perirenal and upper ureteral area; (2) absence of
parenchymal lacerations; and (3) no visualization of the ipsilateral distal
ureter
• In the clinically stable patient in whom the diagnosis is made within 5 days
after the traumatic insult it is preferred to proceed to immediate surgical
repair with débridement of any devitalized tissue, spatulation and
reanastomosis of the ureter over a stent
• In patients with a delayed diagnosis of 6 or more days it is preferred to
place a nephrostomy tube and allow the patient and injury to stabilize for
12 weeks
• The combination of remaining renal function and the length of the surgical
defect allow the surgeon to make the proper surgical planning
URETERAL TRAUMA
• Ureteral perforation after ureteroscopy can
almost invariably be managed with stenting
• If recognized at the time of surgery, ureteral
contusions secondary to a high-velocity gunshot
wound or inadvertent ligation of the ureter
should be treated by removal of any offending
clip or ligature and placement of a ureteral stent
for 6 to 8 weeks
• if the diagnosis of a traumatic ureteral injury is
made within the first 5 days after the insult, we
prefer to proceed with immediate surgical repair
URETERAL TRAUMA
• If the patient is hemodynamically unstable and unable to
tolerate the additional operative time required for ureteral
repair or if the ureteral injury is too extensive to allow for a
direct anastomosis, tie off the damaged ureter, place a
large clip at the proximal end and insert PCN
• The type of delayed ureteral repair to be used is based on
the location and the extent of ureteral damage
• Options include: ureteral anastomosis to the renal pelvis,
primary ureteroureterostomy, transureteroureterostomy,
ureteral reimplantation with or without a psoas hitch, ileal
ureter, autotransplantation and nephrectomy
BLADDER INJURIES
• The urinary bladder is well protected from external
trauma by the bony confines of the pelvis
• The majority results from blunt trauma which
include motor vehicle accidents,falls and assaults
• They are frequently associated with multiple organ
trauma, with an average of three coexisting organ
injuries and a mortality rate of 20%
• Absolute indications for bladder imaging after blunt
abdominal trauma are currently limited to two
indications: (1) the presence of gross hematuria
coexisting with a pelvic fracture and (2) inability to void
Classification
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Bladder contusion
Extraperitoneal bladder rupture
Intraperitoneal bladder rupture
Combination of intraperitoneal and
extraperitoneal ruptures
BLADDER INJURIES
• Traumatic bladder lacerations in children are approximately
two times more likely to extend through the bladder neck
compared with adults
• The diagnosis of a traumatic bladder injury should be
assessed by either standard or CT cystography
• The amount instilled within the bladder should, at a
minimum, be equal to one half of the estimated bladder
capacity for age
• All patients with traumatic bladder lacerations, either
extraperitoneal or intraperitoneal, should initially be
treated with intravenous antibiotics with oral antibiotic
therapy continued for 48 hours after removal of bladder
catheters
Intra and extra peritoneal bladder rupture
BLADDER INJURIES
• In extraperitoneal bladder injury, consideration for open
surgical intervention should be given if a bony spicule is
found to protrude into the bladder on CT evaluation or if
concern for a bladder neck laceration is present
• If these two complications are not present, management
by an indwelling urethral catheter can be considered
• Urinary drainage via the bladder catheter is maintained for
7 to 10 days, and a cystogram should be obtained to verify
healing of the injury before catheter removal
• In intraperitoneal bladder injuries, open surgical repair of
the laceration is the recommended treatment modality
URETHRAL INJURIES
• Classified into 2 broad categories based
on the anatomical site of the trauma
• Mechanism of injury include: blunt trauma
such as MVA or falls, penetrating injuries,
straddle injuries and Iatrogenic injury like
traumatic catheter placement
• Posterior urethral injuries commonly
associated with pelvic fractures
• Anterior urethral injuries come from blunt
trauma to the perineum (straddle injuries)
URETHRAL INJURIES
• children with a posterior urethral injury will differ from
adults with this injury in four ways
• First, a pelvic fracture is more likely to be unstable and
associated with a severely and permanently displaced
prostatic urethra.
• Second, the severe displacement of the prostate off the
pelvic floor makes a complete posterior urethral disruption
more common in boys than men
• Third, in children, concurrent bladder and urethral injuries
may occur in up to 20% of the patients
• Fourth, in prepubertal girls, pelvic fractures are four times
more likely to be associated with a urethral injury than in
adult women
URETHRAL INJURIES
• Radiographic or cystoscopic evaluations to rule
out this injury are mandatory in the following
circumstances:
• (1) when the patient presents with the classic
triad of findings of a perineal/penile hematoma,
blood at the meatus/vaginal introitus, and
inability to void
• 2) when one or more pubic rami are fractured or
symphyseal diastases are present
• (3) when radiographic findings suggest a bladder
neck injury
Diagnosis
• Symptoms include hematuria or inability to void
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Physical examination may reveal blood at the meatus or
a high-riding prostate gland upon rectal examination.
Extravasation of blood along the fascial planes of the
perineum is another indication of injury to the urethra
• The diagnosis is made by performance of a retrograde
urethrogram
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"Pie in the sky" findings revealed by cystogram usually
indicate urethral disruption
Management
• The traditional intervention for patients with
posterior urethral injury secondary to pelvic
fracture is placement of a suprapubic catheter
for bladder drainage and subsequent delayed
repair
• The suprapubic catheter can be safely placed
either percutaneously or via an open approach
with a small incision
• Ultimate repair can be performed 6-12 weeks
after the event, after the pelvic hematoma has
resolved and the patient's orthopedic injuries
have stabilized
Management
• An attempt at primary realignment of the
distraction with a urethral catheter is reasonable
in stable patients either acutely or within several
days of injury (ie, 5-7 d post injury)
• When the urethral catheter is removed after 4 to
6 weeks, it is imperative to retain a suprapubic
catheter because most patients will, despite
realignment, develop posterior urethral stenosis
Management
• Placement of a catheter across a urethral
disruption injury may rarely allow healing without
stricture but in most patients, mild stenosis 1 to 2
cm in length develops
• Incomplete urethral tears are best treated by
stenting with a urethral catheter
• There is no evidence that a gentle attempt to
place a urethral catheter can convert an
incomplete into a complete transection
Management
• In cases of female urethral disruption related to
pelvic fracture, most authorities suggest
immediate primary repair, or at least urethral
realignment over a catheter, to avoid
subsequent urethrovaginal fistulas or urethral
obliteration
• Concomitant vaginal lacerations must also be
closed acutely to prevent vaginal stenosis.
Delayed reconstruction is problematic because
the female urethra is too short (about 4 cm) to
be amenable to anastomotic repair when it
becomes embedded in scar
Management
• Penetrating anterior urethral injuries should be explored
• The area of injury should be examined, and devitalized
tissue should be debrided carefully to minimize tissue
loss
• Defects of up to 2 cm in the bulbar urethra and up to 1.5
cm in the penile urethra can be repaired primarily via a
direct anastomosis over a catheter with fine absorbable
suture.
• Longer defects should never be repaired emergently;
Urinary diversion with a suprapubic catheter is
performed till time of delayed reconstruction
Testicular Trauma
• Testicular injuries can be divided into 3
broad categories based on the mechanism
of injury
• (1) blunt trauma
• (2) penetrating trauma
• (3) degloving trauma
Testicular Trauma
• Testicular rupture or fractured testis refers to a
rip or tear in the tunica albuginea resulting in
extrusion of the testicular contents
• Blunt trauma accounts for approximately 85% of
cases, and penetrating trauma accounts for 15%
• As many as 80% of hematoceles (blood in the
tunica vaginalis) are associated with testicular
rupture
Clinical diagnosis
• Patients typically present to ER with a straightforward
history of injury
• Symptoms include extreme scrotal pain, frequently
associated with nausea and vomiting
• Physical examination often reveals a swollen, severely
tender testicle with a visible hematoma
• Scrotal or perineal ecchymosis may be present
• When evaluating a patient with a clinical history of only
minor trauma, do not overlook the possibility of testicular
torsion or epididymitis
Clinical diagnosis
• For penetrating injuries, determine the entrance and exit
sites of the wound.
• Screening urinalysis is important to rule out urinary tract
infection or epididymo-orchitis
• Scrotal ultrasound imaging with Doppler studies is
valuable for diagnosing and staging testicular injuries
• The presence of a disrupted tunica albuginea is
pathognomonic for testicular rupture
Management
• Institute conservative treatment for
patients with minor trauma in which the
testes are spared and the scrotum has not
been violated
• The usual treatment consists of scrotal
support, nonsteroidal anti-inflammatory
medications, ice packs, and bed rest for
24-48 hours
Indications for scrotal exploration
• Uncertainty in diagnosis after appropriate
clinical and radiographic evaluations
• Disruption of the tunica albuginea
• Large hematocele
• Absence of blood flow on scrotal
ultrasound images with Doppler studies
scrotal exploration
• Clinical hematoceles that are expanding or of
considerable size (eg, 5 cm or larger) should be
explored
• Collections of smaller size are also often
explored, because it has been shown that such
practice allows for more optimal pain control and
shorter hospital stays
• If the testis is fractured, testicular debridement
and surgical closure of the tunica albuginea are
necessary
Thank You