Sepsis

Systemic Inflammatory Response Syndrome If a patient presents with at least two of the criteria listed in Table 3.5, but lacks evidence for infection, the conditions for a systemic inflammatory response syndrome (SIRS) are met. The SIRS is the uniform answer of the body to a variety of diseases such as pancreatitis, major operation, severe trauma, or ischemia. Additionally a drop in the platelet count and the antithrombin-III levels (AT-III) is usually seen (Fresenius and Heck 2001). Table 3.5....

Physical Examination 231

In emergency urology, many decision trees branch on the vital signs of blood pressure, pulse rate, respiratory rate, temperature, and general assessment of the patient (i.e., toxic or well appearing). These should be available from nursing personnel before any history taking by the doctor if not, they must be obtained quickly (and updated frequently). After the vital signs, the initial assessment follows. Although urologists will be tempted to emphasize the genitourinary physical examination,...

Special Investigations

Special investigations to be done include a full blood count, clotting profile, urea, creatinine and electro lytes, liver function tests, blood glucose, blood gases, group and screen, HIV and VDRL. Abnormal findings include anemia, thrombocytopenia, coagulopathy, hyponatremia, and raised urea and creatinine. Hypocalcemia may occur in some cases, subsequent to the chelation of ionized calcium by triglycerides liberated by bacterial lipases. Leukocytosis with a white cell count above 15,000 mm3...

Prostate Cancer

Prostate cancer is the second leading urological cancer after renal cell carcinoma associated with paraneoplas-tic syndromes. Paraneoplastic syndromes in association with prostate cancer are uncommon and include Cushing's syndrome, the inappropriate antidiuretic hormone syndrome, hypercalcemia, and hypophosphatemia (Table 14.3). Table 14.3. Most common paraneoplastic syndromes associated with prostate cancer Inappropriate antidiuretic hormone secretion

Introduction

Scrotal emergencies frequently result in a call to the urologist. It is important to remember that emergencies that involve the scrotum maybe confined to scrotal structures or referred from other sources. There are a number of differential diagnoses to consider (Table 12.1), as the scrotum itself contains numerous structures the testicles, epididymis, spermatic cord, and the scrotal tissue itself, comprised of several muscular and fascial layers. Without a thorough differential diagnosis of...

Placenta Percreta Involving Urinary Bladder

The incidence of placenta accreta is estimated from one in 540 to one in 93,000 deliveries (Smith and Ferrara 1992). Placenta percreta is a variant of placenta accreta in which chorionic villi penetrate the entire thickness of the myometrium and may involve adjacent structures. Placenta percreta involving the bladder is extremely rare (less than 60 published cases) (Washecka and Behling 2002) and is encouraged by uterine scars and cesarean section. This potentially catastrophic condition may...

General Anesthetic Agents and Neuromuscular Blocking Agents

The main agents used for induction of anesthesia are hypnotics (thiopentone, propofol, and etomidate), opioids (fentanyl), neuroleptics, and benzodiazepines (Thong and Yeow-Chan 2004). The majority of intraoperative anaphylactic reactions are caused by the neu-romuscular blocking agents commonly used to induce paralysis to facilitate endotracheal intubation or to optimize surgical exposure (Birnbaum et al. 1994). The use of intradermal skin tests for the diagnosis of IgE-mediated anaphylaxis to...

Urinary Retention After Prostatectomy

Prostate cancer treatment with curative intent can also predispose to urinary retention. Although the true incidence of bladder neck contracture following radical prostatectomy is not known, 1.3 -27 of patients will develop symptomatic BNC requiring treatment (Anger et al. 2005). Surgical technique remains a critical determinant of BNC development however, risk factors for microvascular disease such as smoking, hypertension, and diabetes mellitus also appear to play a role (Borboroglu et al....

Bladder Rupture Postaugmentation

Enterocystoplasty is a commonly utilized technique within pediatric urology as a method of both increasing vesical storage capacity and decreasing pressure transmission to the upper urinary tracts in children with inadequate bladder volumes and abnormal bladder wall dynamics. The most frequent indications for augmentation include a poorly compliant, high-pressure, low-capacity bladder secondary to spina bifida (or other spinal cord anomaly or insult), posterior ure-thral valves (PUV), or...

Initial and Preoperative Management

If there is doubt about the diagnosis of Fournier's gangrene, imaging and laboratory studies maybe requested, but this should not delay definitive surgical management. The cause of the infection should be established, bearing in mind that urogenital causes (urethral stricture) and anorectal infections are the most common etiological factors. Passing an F16 transurethral catheter should exclude or confirm a urethral stricture, and painful digital rectal examination may indicate an ischiorectal...

Immunological Mechanism

Coombs and Gell (1975) first classified four types of hypersensitivity (immunopathologic) reactions (Table 4.2). Type I Immediate (IgE-dependent) Type II Cytotoxic (IgG, IgM-dependent) Type III Immune complexes (IgG, IgM-dependent complex) Type IV Delayed (T lymphocyte-dependent) 4.3 Clinical Presentation and Differential Diagnosis Table 4.2. Classification of hypersensitivity (Coombs and Gell 1975) Table 4.2. Classification of hypersensitivity (Coombs and Gell 1975) IgE antibodies Mast cells...

Epidemiology and Diagnosis

It is important to remember that BPH is a pathological diagnosis, and most of the patients seen in practice have clinically enlarged prostate glands but no histological confirmation of BPH. Hence the term benign prostatic enlargement (BPE) is more appropriate in those in whom tissue diagnosis is not confirmed. BPH is one of the most prevalent conditions affecting men aged 40 and above. Histological studies have shown features of BPH to be present in the prostate of approximately 60 of men aged...

Etiology

An etiological factor or factors can be identified in more than 90 of cases and should be actively sought, because it may determine the treatment and prognosis (Smith et al. 1998 Santora and Rukstalis 2001). In apparently idiopathic cases, the cause may have been overlooked or obscured by the necrotizing disease process. Any process where a virulent, synergistic infection gains access to the subcutaneous tissue of the perineum may serve as the point of origin. The cause of infection may be from...

Hyperglycemia

There are very few reports regarding the development of diabetes or worsening of preexisting diabetes in patients with renal cell carcinoma (Elias 2005 Palgon et al. 1986 Jobe et al. 1993 Callewaert et al. 1999). In one case, the patient was diagnosed with a preexisting insulin-dependent diabetes mellitus that became uncontrollable by insulin therapy. The patient underwent partial nephrectomy because of a histological papillary type and the control of his glycemia improved immediately and...

Imaging

History, physical examination and laboratory tests are usually completed by various imaging procedures. In Europe, the easiest test to access is commonly sonography in the US it is probably CT. Sonography allows the evaluation of the size and position of the kidneys, parenchymal width, and the detection of masses, calculi (especially over 3 mm) (Heinz-Peer and Helbich 2001) and calcifications. Moreover, it is possible to diagnose urinary tract dilatation and assess the grade of hydro-nephrosis....

Perioperative Cardiac Complications

Major cardiac complications presenting as myocardial infarction, myocardial ischemia, cardiac failure, or life-threatening dysrhythmias contribute significantly to perioperative morbidity and mortality. Preventive strategies are of major importance since even despite adequate treatment these events are associated with poor outcome. According to Poldermans and Boersma (2005), the incidence of a perioperative myocardial infarction is 0.185 in the United States. Approximately 50,000out of 27...

Neurological Abnormalities

All the abnormalities mentioned above have similar presentation and management in women, in fact some conditions such as MS are far more prevalent in the female population. Generally, women with voiding dysfunction in the absence of structural abnormalities of the lower urinary tract are very difficult to manage. A small group of female patients with obstructed voiding, and in some cases AUR, have been shown to have a specific electro-myographic abnormality of the striated urethral sphincter,...

Surgical Treatment 7421

When a urinary calculus requires surgery during pregnancy, the classical attitude is to ensure urine flow, with the definitive treatment undertaken after the child is born (Denstedt and Razvi 1992). Placing a double-J ureteral stent easily removes the obstruction. In very septic patients, the stent can be placed without sedation. When urine is thick, it is preferable to first position an open ureteral stent, which can be replaced after a few days with a double-J stent when the sepsis is under...

Medical Management of Terrorist Related Injuries

Terrorist acts frequently generate mass casualty events that overwhelm the regional health care system and cause a temporary imbalance between the sudden urgent demand for large-scale resources and expertise at a specific location and the availability of such resources (Shemer and Shapira 2001). The inundation of the medical system with hundreds of victims presents two types of challenge a medical challenge, i.e., proper medical management with accurate triage, and a logistical challenge...

Clinical Presentation

The diagnosis of Fournier's gangrene is made on clinical grounds. It is usually preceded by prodromal symptoms such as fever, prostration, nausea and vomiting, perineal discomfort, and poor glucose control in diabetics, for a period ranging from 2 to 9 days (Bahlmann et al. 1983 Paty and Smith 1992 Benizri et al. 1996 Edi-no et al. 2005). Genital and perineal discomfort worsens, leading to pain, itching, burning sensation, erythema, swelling, and eventual skin necrosis. There may be a purulent...

Clinical Presentation and Differential Diagnosis

The severity of the hypersensitivity reaction is classified into four grades (see Table 4.3) IgE- or non-IgE-mediated reactions and anaphylactoid or anaphylactic reactions, respectively, cannot be differentiated clinically. The most important clinical signs are (Chiu and Kelly 2005) Cutaneous reactions (erythema, urticaria ) and soft tissue swelling (e.g., eyelids, lips) Hypotension and tachycardia Table 4.3. Severity of immediate hypersensitivity reactions Grade 1 Only cutaneous signs diffuse...

Neuromuscular and Cutaneous Syndromes

Polyneuropathy, polymyositis, and myopathy are all known to occur with RCC. The myopathy is characterized by involvement of proximal muscles and association of elevated serum levels of creatine kinase and aldolase (Solon etal. 1994 Evans etal. 1990). In each condition, there are reports of resolution after nephrecto-my. With the development of metastatic disease, poly-myositis and polyneuromyopathy have recurred. Myasthenia gravis is an autoimmune disorder of neural conduction in which the...

Human Chorionic Gonadotropin

Elevation of human chorionic gonadotropin (hCG) associated with renal cell carcinoma RCC has been reported (McCloskey and O'Connor 1982 Golde et al. 1974 Fukutani et al. 1983). In males, clinical findings include gynecomastia, decreased libido, and elevated urine and serum hCG levels. Only a small number of cases have been reported, though there is no direct evidence of tumor production of these hormones. Gy-necomastia and increased urinary levels gonadotro-pins associated with RCC have been...

Reconstructive Surgery

Depending on the extent of skin defects, the options in reconstruction are suturing, split thickness skin grafting, or myocutaneous vascularized pedicle flaps. Small defects can be closed by primary suturing, especially where only the pliable scrotal skin is involved. Split thickness skin grafting is most often used and yields acceptable results, even in large defects (Hessel-feldt-Nielsen et al. 1986). Healthy skin from the legs, buttocks, and arms can be used, in a single or multiple...

Treatment

Acute management of autonomic dysreflexia is important to prevent complications. If untreated autonomic dysreflexia can lead to convulsions, subarachnoid hemorrhage, intracerebral bleeding, hypertensive encepha-lopathy, cardiac arrhythmias, neurogenic pulmonary edema and death (Shergill et al. 2004). The acute management aims to relieve the precipitant cause and management of symptoms to prevent potential complications. The long-term goal is to prevent recurrence of autonomic dysreflexia....

Fourniers Gangrene

Necrotizing ascending infection of the scrotal wall, or Fournier's gangrene, is a urologic emergency requiring immediate diagnosis and expedient treatment, as delayed diagnosis and treatment can result in a 50 mortality in high-risk patients such as older diabetic patients. It involves the skin, subcutaneous fat, and superficial fascia of the external genitalia and perineum. This disease process is characterized by a polymicrobial fas-ciitis involving the perineum and external genitalia. This...

Deep Vein Thrombosis and Pulmonary Embolism

Perioperative thromboembolic disease and pulmonary embolism contribute to morbidity and mortality in urological patients. Venous thromboembolism is a multifactorial disease involving clinical risk factors as well as genetic and environmental interactions. It is uncommon in the young, but after 40 years of age the incidence doubles with each decade of life. Hereditary risk factors include factor V Leiden mutation, G20210A prothrombin gene mutation, and deficiencies in protein C, protein S, and...

Pyelonephritis and Pyonephrosis

Urine With Fungal Balls

Urinary tract infection (UTI) occurs in approximately 8 of girls and 6 of boys during their first 6 years of life (Marild and Jodal 1998). Although older patients Fig. 8.16a-c. DMSA scan showing multiple photopenic areas consistent with renal scars (Courtesy H.G. Rushton) may complain of irritative voiding symptoms and thus direct clinical suspicion to the urinary tract, infants and neonates may present with only nonspecific symptoms such as poor feeding, irritability, and failure to thrive....

Physical Examination

The general appearance of the patient is one of the most important factors to consider when examining the patient. The diagnostic possibilities for a patient with ca-chexia are different than a well-nourished patient complaining of flank pain. Patients with classic colic will appear uncomfortable however, the diagnosis is not always stone disease. A similar appearance can be seen in patients with other urologic problems such as UPJ obstruction or less commonly ureteral tumors. Completely...

Unilateral Upper Urinary Tract Obstruction

One of the most common forms of failed drainage in the upper urinary tract is acute unilateral ureteral ob- Table 10.1. Etiology of upper urinary tract obstruction Intrinsic Urothelial carcinoma Fibroepithelial polyp UPJ obstruction Renal cell carcinoma Wilms tumor Cystic renal diseases Parapelvic cysts Renal artery aneurysm Retroperitoneal malignancy (primary or metastatic) Inflammatory bowel disease Trauma (ureteral ligation) Radiation therapy Lymphocele Urinoma Retroperitoneal fibrosis...

BCG Sepsis

The most serious complication of BCG therapy is generalized sepsis secondary to intravascular absorption of mycobacteria or other urinary pathogens. Traumatic catheterization, identified in more than two-thirds of such cases, is the most common etiologic factor (Lamm 1992). Severe cystitis and recent transurethral surgery (within 1 week) are other potential routes for dissemination. Fever is the most common presenting sign and typically occurs within 12 h ofBCG instillation (Pater-son and Patel...

Idiopathic Scrotal Edema

Acute idiopathic scrotal edema (AISE) is a fairly common, yet underreported cause of the acute scrotum in children, accounting for as many as 30 of patients who undergo assessment (Najmaldin and Burge 1987). It is characterized by the rapid onset of nontender, frequently unilateral scrotal and penile erythema and edema. The patient is usually afebrile and is otherwise asymptomatic, apart from the distressing appearance of the genitalia. It is usually found in prepubertal children from 5 to 11...

Diagnostic Tests and Risk Factors

There are many different diagnostic tests, including serum tryptase, plasma histamine, specific IgE-level measurements, and skin tests. However, all of these tests have their pitfalls. An elevated tryptase level 1 - 6 h after a suspected anaphylactic reaction indicates mast cell degranulation. Together with a suggestive history and clinical findings, this supports the diagnosis of anaphylaxis (Fisher and Baldo 1998). However, serum tryptase concentration may be normal even in fatal anaphylaxis....

Immediate and Nonimmediate Reactions to Contrast Media

Since their development in the 1950s tri-iodinated benzene derivates have been used for opacification of the urinary tract. The radiopacity of such compounds is produced by molecular iodine, which is attached to the benzene ring. The agents are further characterized by their ionic and nonionic side chains as well as their monomeric or dimeric ring structure. Contrast media are used in many diagnostic and in-terventional procedures, including intravenous ur-ography, CT scan, angiography,...

Urinary Tract Infection

Urinary tract infections are relatively rare in male patients, but they do represent a proportion of men attending with AUR. Many of these patients will have a degree of BOO and or LUTS, and some will be known to have incomplete bladder emptying. They are also commonly seen in BOO caused by stricture disease. The patient will typically give a history of LUTS, but associated with a short-term history of dysuria, offensive-smelling or dark cloudy urine, and suprapubic pain. Some patients may...

Urinary Tract Infections

Because of anatomic, functional, and hormonal modifications, urinary tract infection is frequent during pregnancy. It can present as three different entities asymptomatic bacteriuria, acute cystitis, or acute pyelonephritis (Ovalle and Levancini 2001). Different risk factors have been discussed maternal age, socioeconomic status, antecedents of UTI, sexual intercourse, hemoglobinopathies, diabetes, immunodepression of HIV infection, multiparity, and race (Connolly and Thorpe 1999 Ovalle and...

Complications

Early complications occur within the 1st month after injury and can be bleeding, arteriovenous fistulae involving the renal artery, infection, perinephric abscess, sepsis, urinary fistula, hypertension, urinary extravasation, and urinoma. Delayed complications include bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension, arteriovenous fistula, hydronephrosis, and pseudoaneurysms. Delayed retroperitoneal bleeding usually occurs within several weeks of an injury or...

Urological Aspects of Terrorist Related Injuries

Abdome Com Pilha

A review of the literature reveals that there is a paucity of data on terrorist-related urological injuries. Important data is available from the Israeli Trauma Registry (ITR), which records all hospitalizations for physical trauma at most of the Israeli trauma centers. Unfortunately, the accumulated experience of the Israeli medical system with terrorist-related injuries during the last two decades is exceptional in duration and intensity, out-ranging any comparable practice gained elsewhere,...

Hemorrhagic Cystitis

Hemorrhagic cystitis is defined as gross hematuria secondary to diffuse inflammation of the bladder. Viral infection, radiation-induced inflammation, and chemotherapy-induced inflammation account for the majority of cases among cancer patients. While relatively un- common in patients with genitourinary malignancies, viral-mediated hemorrhagic cystitis occurs in as many as 50 of patients undergoing bone marrow transplantation (Bedi et al. 1995). The principle etiologic factor involved is the BK...

Gynecomastia

About 10 of choriocarcinoma of the testis and 15 - 20 of gonadal stroma sex cord testicular tumors induce gynecomastia through their autonomous synthesis and secretion of estrogens. Tumor estrogen production may also cause decreased libido and poor sperm quality. The diagnosis of these hormone producing tumors is usually clinically evident from the finding of a testicular swelling that might be painless or painful. Occasionally the sole presenting feature is gynecomastia or very rarely...

Radiation Cystitis

Radiation cystitis is a late complication of radiotherapy which, by definition, occurs at least 90 days after the initiation of radiation treatment but maybe delayed up to 10 years or more (Cox et al. 1995). Most patients develop severe irritative voiding symptoms however, gross hematuria dominates the clinical picture (Pas-quier et al. 2004). While any patient receiving pelvic radiotherapy is at risk, radiation cystitis is most common among those treated for prostate or cervical cancer. Three...

Solid Renal and Juxtarenal Lesions

Vincristine Syringe

The majority of solid renal or juxtarenal lesions present either prenatally or as a palpable abdominal mass in childhood. The most common renal tumor in the neonate remains congenital mesoblastic nephroma (CMN). More than 80 are diagnosed in the 1st month of life and essentially all are identified by 1 year of age (Geller et al. 1997). CMN usually presents as an asymptomatic abdominal mass however, prenatal US has also demonstrated polyhydramnios, fetal hydrops, and premature delivery in...

Intensive Care Procedures 351

Stroke Volume Variation

The use of analgetics and sedatives for the treatment of pain, anxiety, and agitation is a daily challenge in the intensive care environment. It is usually needed for the mechanically ventilated patient. To achieve a sufficient level of patient shielding while minimizing side effects and a short and cost-effective weaning period, the algorithm for analgosedation (AS) is an important task for the clinician. Emphasis should be placed on the consequent and correct implementation of a concept while...

References

Allen ZA, Merrick GS, Butler WM et al 2005 Detailed urethral dosimetry in the evaluation ofprostate brachytherapy-relat-ed urinary morbidity. Int J Radiat Oncol Biol Phys 62 981 Allgood RJ, Cook JH, Weedn RJ et al 1970 Prospective analysis of pulmonary embolism in the postoperative patient. Surgery 68 116 Andriole GL, Sandlund JT, Miser JS et al 1987 The efficacy of mesna 2-mercaptoethane sodium sulfonate as a uropro-tectant in patients with hemorrhagic cystitis receiving further...

Tumors

Appendix Testis

Any mass originating from the testicle must be presumed to be testicular cancer until otherwise proven, because of the explosive growth and metastatic potential of germ cell testicular cancers. While rare, testis cancers are the most common solid tumor of young adult males. Germ cell tumors make up approximately 95 of all testis tumors and are seminoma, yolk sac, choriocarcinoma, embryonal, and teratoma. Stromal testis tumors are rare and are found almost exclusively in prepubertal individuals....

Epididymitis

Epididymitis is an inflammatory reaction of the epididymis to one of several infectious agents or to local trauma. Acute epididymitis may present at any age, with a sudden onset of pain and swelling of the epididymis in the scrotum. Epididymitis can present in a sexually transmitted form or one associated with urinary tract infections and prostatitis. Thus, eliciting a specific history of sexual exposure or of prior genitourinary tract disease is crucial for diagnosis and appropriate treatment....

Varicocele

Varicocele is defined as a dilation of the pampiniform plexus of the veins within and surrounding the spermatic cord secondary to absent or incompetent venous values, which are congenital or acquired, respectively. Varicoceles maybe visible, nonvisible but palpable the classic sign is the so-called scrotal bag of worms, referring to vermiform appearance of the dilated veins , or nonvisible and nonpalpable. Both adults and children present as a scrotal emergency with a varicocele. Varicoceles...

Noncontrast Helical Abdominal Pelvic CT

Upper Urinary Tract Urothelial Carcinoma

In the emergency room setting, noncontrast helical abdominal pelvic CT has become the examination of choice in the evaluation of flank pain and obstructive anuria Niall et al. 2002 Shokeir et al. 2002, 2004 Coli-stro et al. 2002 . Introduced by Smith and colleagues in 1995, noncontrast CT is quick, relatively easy to interpret, and obviates risks associated with the use of contrast media Smith et al. 1999 . Noncontrast CT is the gold standard in the detection of urinary calculi with an...

Urinary Retention

Where Hymen Female With Photos

The majority of newborns will void within the first 8 h of life, though some may void up to 24 h following birth Mesrobian et al. 2004 . If more than 24 h elapses, obstruction must be considered and investigated accordingly. Furthermore, a complete newborn physical ex- Fig. 8.31. VCUG demonstrating posterior urethral valves in a newborn male with a known prenatal history of bilateral hy-droureteronephrosis and bladder wall thickening. Fig. 8.31. VCUG demonstrating posterior urethral valves in a...

Cardiac Failure Treatment Instant

Fluid Chart For Dialysis Patients

Continue p-blockers, Dosage 0 if applicable Statins Epiduralcatheter Start p-blocker-therapy or consult cardiologist Perioperative arrhythmias are caused by physiologic and pathologic disturbances or by pharmacologic drug effects. Physiologic disturbances include hypoxemia, hypercapnia, acidosis, hypotension, hypovolemia, electrolyte imbalances, adrenergic stimulation light anesthesia , vagal stimulation, and mechanical irritation chest tube, pulmonary artery catheter . Pathologic cardiac...

Comparison of Temporary Drainage Techniques

Despite limited options, the method for urgent decompression of the obstructed urinary tract is controversial. Proponents of percutaneous nephrostomy suggest that drainage is improved with the larger sized nephro-stomy tube and that complications related to manipulation of a stent across the area of blockage are eliminated i.e., ureteral perforation . In addition, percutaneous nephrostomy can be performed under local anesthesia, which is a true benefit for many patients. In some institutions...

Paraphimosis and Phimosis

Boy Phimosis

Paraphimosis is a frequently encountered condition in the pediatric emergency department. Because of their age and lack of understanding, children have a tendency to neglect to reduce their foreskin following retraction at the time of micturition. Occasionally medical personnel will cause an iatrogenic paraphimosis by inadvertently leaving the foreskin retracted following insertion of an indwelling urethral catheter. Subsequent edema and venous congestion proximally could lead to decreased...