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EMERGENCY Trauma & NON

TRAUMA
IN GENITO URINARY

Kurnia Penta seputra

Department of Urology
Saiful Anwar General Hospital / Medical Faculty Brawijaya University
Malang
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STANDARD KOMPETENSI DOKTER INDONESIA
(KKI 2012)
Tingkat kemampuan yang harus dicapai (standard
Kompetensi)
1. Mengenali dan menjelaskan
2. Mendiagnosis dan merujuk
3. Mendiagnosis, melakukan penatalaksanaan awal, dan
merujuk
A.Bukan gawat darurat
B. Gawat darurat
4. Mendiagnosis, melakukan penatalaksanaan secara mandiri
dan tuntas
A. Kompetensi yang dicapai pada saat lulus dokter
B. Profisiensi (kemahiran) yang dicapai setelah selesai internsip
dan/atau Pendidikan Kedokteran Berkelanjutan (PKB)
STANDARD KOMPETENSI DOKTER
INDONESIA

The Current Clinical Development of


22 November 2008
Trauma Care
Incidence of UG Trauma

Urogenital trauma
Bladder Genitalia
(41 cases) (11 cases) Ureter
23% 6% (5 cases)
3%

Urethral
(50 cases) Kidney
28% (72 cases)
40%
KIDNEY TRAUMA
Kidney (Renal) trauma
*Ginjal dilindungi oleh kapsul ginjal & organ sekitarnya

• Kidneys are retroperitonel organs those are protected by


surrounding organs
• Renal trauma accounts for approximately 3% of all trauma
admissions and as many as 10% of patients who sustain
abdominal trauma.
– :=3:1
– Majority of renal traumas are mild and can be managed
conservatively
– Advanced of imaging study
 more accurate staging of renal injury: decrease surgical
intervention and increase renal preservation
Epidemiology
Most of renal trauma are blunt type

Grade IV
Grade III 3%
Grade II 4% Grade V
5% 7%

Grade I
81%
Mode of Injury

Blunt In rural areas:


trauma 90-95 %

Stab wounds
Mechanism of renal Penetrating trauma
In urban:
injury up to 20 %
Gunshot wounds

Rapid deceleration
renal artery occlusion
injuries
Tapi kadang jg gada hematuri
*Ada jejas di daerah flank disertai dengan hematuria (mikroskopis/makroskopis)
 bila ada bekuan darah
-Kriteria mikrohematuri: eritrosit >5 pada hapusan
menyumbat di ureter

Diagnosis
Initial Emergency Assessment
Securing of the airway
Controlling any external bleeding
Resuscitation of shock

Decide : Haemodynamic stability !


• Initial Assessment
– History:
• Direct, witnesses or emergency personal
• Possible indicators of renal injury :
 a rapid deceleration event
 high speed motor vehicle accident
 direct blow to the flank
 penetrating (stab/gunshot) along the line of kidneys
 Urinalysis
 basic test for renal injury

 Serial Haematocrit
 indicate blood loss

 Creatinine Jelek bila <1,2

 reflects renal function prior to the injury


Imaging Examination
Bisa ukur jumlah cairan
 Cairan, cairan bebas,
1) Ultrasonography hematoma di perianal
Bisa buat liat fungsi ginjal yg sebelahnya

2) Intravenous Pyelography (IVP) Gabisa liat drajat grading dari trauma


ginjal  cmn bisa liat extravasasi
kontras

3) Computed Tomography (CT scan)


Cmn boleh kalo pasien udh stabil Tp pada trauma sering a.renalis
4) MRI vasospasme  gabisa dilewati kontras

5) Angiography u/ liat ada lesi vaskuler gk


Indication
1) Gross haematuria
2) Microscopic haematuria and shock
3) The presence of major associated injuries
4) Rapid deceleration injury
5) Penetrating wound suspected passing the
kidney
IVU (intravenous urography)

IVU revealed :
– the presence of contra lateral
Grade 3
kidney
– define the renal parenchyma
– out line the collecting system

Extravasation of contrast
CT Urography

Ginjal kedorong
keatas karena
didesak hematom
Grading and Treatment of Kidney
Trauma
• Goal of management :
– Minimize morbidity
– Preserve renal function

• The question of renal trauma management


– Explore or observe ? Ditentukan dari klinis & penunjang

Influenced by the associated abdominal injuries


Grading Renal Injury
Konservatif (tirah baring 10hr-2mgg)

Grade I and II are managed conservatively


*Grade 2&3 udh harus antibiotika
Grade III and IV injuries are now managed conservatively
Operative: salvage or nephrectomy
Conservative management

Observation
• T
N
Exploration
Hb
Hematuria
Flank mass 
Complication
• Early complication • Late complication

⇛ Bleeding/delayed bleeding ⇛ Delayed bleeding


⇛ Infection ⇛ Hydronephrosis
⇛ Perinephric abscess ⇛ Urolithiasis
⇛ Sepsis ⇛ Chronic
⇛ Urinary fistula pyelonephritis
⇛ Urinary extravasations ⇛ Hydronephrosis Akibat
darah
clotting

⇛ Urinoma ⇛ Hypertension
⇛ Hypertension Akibat vasospasme
a.renalis ⇛ AV Fistula
⇛ Pseudoaneurysms
URETERAL TRAUMA
Etiology

Gynecologic: 73% (247 cases )

Iatrogenic: 75%
General surgery: 14% (46 cases)
(340 cases )

Ureteral urological surgery: 14% (47 cases)


Blunt: 18%
injuries
(81 cases)
(452 cases)
Penetrating: 7%
(31 cases)

(Dobrowolski et, BJU Int 2002, 89 : 748-751)


Location of Injury

(Dobrowolski et, BJU Int 2002, 89 : 748-751


Diagnosis
Should be suspected for ureteral trauma :
In all cases of penetrating abdominal injury (especially gunshot
wounds)
Deceleration trauma
Signs of upper tract obstruction, urinary fistula
Sepsis after trauma
Flank pain Akibat pasase urin ke buli gakda
Vaginal leakage After gynecological pelvic surgery
Septic
Suspected ureteral injury durante operation
inject methylene blue I.V.
IVP
Masukin endoscopi ke ureter  suntikan kontras
Retrograde pyelography  xray liat extravasasi kontras
Management
1. Partial injuries (grade 1 and 2)
Ureteral stenting antegrade or retrograde ( 3 weeks)
Nephrostomy to divert urine
Both need fluoroscopic guidance
Grade 2 and 3 detected at surgery (iatrogenic)
Primary closure and stent
Placement a non suction drain peri ureteral
Indwelling catheter for 2-3 days to avoid reflux
during voiding
2. Complete Tears :
Principles of repair for grade 3-5 :
Debridement of ureteral ends to fresh tissue
Spatulation of ureteral ends
Placement of internal stent
Watertight closure of reconstructed ureter with
absorbable suture
Placement of external, non-suction drain
Isolation of injury with peritoneum or omentum
Prevention ureteral injury before
operation
IVP, before :
– Gynecological malignancy operation
– Advanced endometriosis
– Pelvic inflammatory disease
Introducing
Careful dissection, identified ureter
No panic in case of arterial bleeding during dissection
Use a traumatic vascular clamp
Bladder Trauma
ETIOLOGY
Dinding buli jadi tipis

• Full bladder is vulnerable for trauma


• Trauma patients 10% involving genitourinary
tract
• 2% of abdominal injury requiring surgical repair
involve bladder
• Blunt trauma accounts for 67-86%
• Penetrating trauma accounts for 14-33%
• In 70-97% of bladder injuries: (pelvic fracture
+)
• In pelvic fracture: (30% bladder injury +)
CLASSIFICATION OF BLADDER INJURY
BASED ON THE TYPE OF TRAUMA

CLASSIFICATION OF ASSOCIATED
INJURY
MECHANISM OF INJURY
INJURIES
Blunt pelvic trauma with Pelvic fractures
Extra
laceration by bone fragments(s)
peritoneal (80- Other long bone
Shearing at ligamentous
90%) fractures
attachment(S)
Blunt trauma
High velocity blunt lower High rate of associated
Intraperitoneal abdominal trauma intra-abdominal
(10-20%) High intravesical pressure with rupture injuries
at dome High mortality

Direct injury to the bladder wall Associated injury to


Penetrating ohter organs is
trauma common
DIAAGNOSIS
 Gross haematuria 82%
 Abdominal tenderness 62%
 Inability to avoid
 Bruises over the suprapubic region
 Swelling in the perineum, scrotum and thighs,
as well as a long the anterior abdominal wall
due to urine extravasations
 An urethral catheter does not return urine
Pake kateter  masukin kontras  foto sesudah & sebelum kontras  bedakan intra/retroperitoneak

Cystography
• Is considered as standard
diagnostic procedure?
• Accuracy rate 85–100%
• Injected contrast identified
outside the bladder
• Instillation of 350 ml
contrast media with gravity
• Exposing film :
Plain film
Filled film
Post drainage film

Intraperitoneal bladder rupture


Treatment
. Blunt trauma with extraperitoneal rupture :
Catheter drainage
- 86% ruptured bladder healed in 10 days
- 100% healed in 3 weeks
Surgical intervention
- debridemant and closure
- healed faster
2. Blunt trauma intraperitoneal rupture :
Always manage by surgical exploration
Abdominal organ should be inspected and urinoma must be drained
3. Penetrating injuries :
Should undergo emergency exploration and repair
URETHRAL TRAUMA
Etiology :
Pelvic fracture
Male : 3,5 – 19% Karena uretra lebih panjang dr ♀

Female : 0 – 6%
In 10 – 17% associated with bladder rupture
In 8% associated with rectal fistula
Modus of pelvic fracture :
Blunt trauma : 90 %
Traffic accidents (70%)
Fall from a leight (25%)
In 27% as associated with multi organ injuries
DIAGNOSIS
• Triad signs of urethral disruption :
– Blood at the urethral meatus (positive in 37-93%
cases)
– Inability to urinate
– Palpably full bladder
• The signs of pelvic fracture clinically and
radiographically
• High riding prostate (complete urethral
disruption) Lakukan RT  cek prostat melayang gk

 only in 34%  pelvic haematoma obscures the prostatic contour


POSTERIOR URETHRAL INJURY
Management
• Initial management :
– Resuscitation of the patient for associated
possibly life threatening injuries
• Definitive treatment of posterior urethral
injuries is remains controversial due to :
– Variety of injury patterns
– Associated injuries
– Treatment potions availability
*trauma uretra:
-anterior
-posterior
Urethral catheterization is contraindicated
Masukin kontras ke uretra  foto  ekstravasasi

Urethrography
• Technique :
– A 14-Fr foley catheter is
placed 1-2 cm into the
fossa navicularis
 inflate the balloon with 1-2
ml water
– Introduce 10 ml 30% /
anna contrast solution with
catheter tip syringe
– Films taken in the lateral
decubitus position
– Study under fluoroscopy
when available

Contrast extravasation on urethrography


Complication of Posterior Urethral
Injury
• Erectile dysfunction :
 13 – 30% (catheter only)
 48 – 78% (open repair)
• Incontinence Terjadi bila ruptur kena spinchter uretra eksterna
• Stricture Akibat scar
Anterior Urethral Injury
• Rare: 10% of lower urinary tract injuries
(Mitchell, BJU: 40, 648, 1968)
• Mostly isolated injury
• Etiology :
– Straddle injury
– Penetrating/gunshot
– Intercourse related injury Fraktur penis, robekan pada tunica albugenia
Anterior urethral Injury

• Iatrogenic
• Straddle Injury
• Bulbous Urethral
crushed (pressed)
between pubic bone
and hard object
• Butterfly hematoma
Positive causative factor

 Blood in the meatus


 Large haematoma or swelling in the
perineum / scrotum

Urethrography
Management Anterior Urethral Injury

• Blunt Trauma :
– Suprapubic catheter: 4 weeks
 urethrography
– Urethral catheterization Dengan endoscopi
– Large haematoma/swelling
 multiple incisions

• Open / penetrating injury :


– Immediate exploration
• Urethral suturing
– Perioperative antibiotic
– Cystourethrography after 2 weeks
Acute scrotum
ANATOMY
Tingkat kemampuan SKDI 2012
Learning Objective
• At the end of medical school, the student should
be able to
• Describe 6 conditions that may produce acute scrotal pain or
swelling.
• Distinguish, through the history, physical examination and
laboratory testing, testicular torsion, torsion of testicular
appendices, epididymitis, testicular tumor, scrotal trauma
and hernia.
• Appropriately order imaging studies to make the diagnosis of
the acute scrotum.
• Determine which acute scrotal conditions require emergent
surgery and which may be handled less emergently or
electively.
*acute scrotum yg blm sexual aktif  curiga torsio
*acute scrotum yg udh sexual aktif  curiga orchitis

Intrascrotal
• Pain
Acute scrotum
• Swelling
(emergency case)
• Acute onset

Potential for
testicular loss &
Infertility
nyeri mendadak disertai mual muntah & menjalar

Acute scrotum ≈ Acute abdomen


Both conditions are guided by similar management
principles:
 The patient history and physical examination are key
to the diagnosis and often guide decision making
regarding whether or not surgical intervention is
appropriate.
 Imaging studies should complement, but not
replace.
 When making a decision for conservative (non-
surgical) the provider must balance the potential
morbidity of surgical exploration against the
potential cost of missing a surgical diagnosis.
 A negative exploration rate is acceptable to
minimize the risk of missing a critical surgical
diagnosis.
Causes of Acute Scrotal Pain and Swelling
Ischemia: Torsion of the testis
Appendiceal torsion
Testicular infarction due to other vascular insult (cord injury, thrombosis)

Trauma: Testicular rupture


Intratesticular hematoma, testicular contusion
Hematocele
Infectious Acute epididymitis, Acute orchitis, Acute epididymoorchitis
conditions: Abscess (intratesticular, intravaginal, scrotal cutaneous cysts)
Gangrenous infections (Fournier’s gangrene)
Inflammatory Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall
conditions: Fat necrosis, scrotal wall

Hernia: Incarcerated, strangulated inguinal hernia, with or without associated


testicular ischemia
Acute on Spermatocele: rupture or hemorrhage
chronic events: Hydrocele: rupture, hemorrhage or infection
Testicular tumor with rupture, hemorrhage, infarction
Varicocele: infection
=varises pada p.d vena Nyerinya nyeri kemeng
*torsio  nyerinya nyeri tajam mendadak
PAINLESS SWELLING
• Hernias
• Hydrocele Cairan didalam rongga
• Testicular masses
• Lymphedema
• Post-surgical scrotal wall edema
• Testicular tumors
AGE FACTOR

Can occur in any age group !

• Neonates: extravaginal torsion


• Childhood and preadolescene:
intravaginal testicular torsion,
appendiceal testis torsion
• Epididymitis in the sexually active
patient
TESTICULAR TORSION

*UDT  resiko torsio ↑  karena testis gk terfixir sempurna


Acute scrotal swelling in
children indicates torsion of the
testes until proven otherwise.
Predisposition

The “bell clapper


deformity,” results in a
transverse as opposed
to longitudinal lie of
Ada rongga
the affected testes.

This congenital
abnormality is present
in approximately 12% Testis seharusnya terfixir  tp ini gk
nempel dinding  resiko kplintir
of human male
Bell clapper deformity and testicular
torsion
Extravaginal torsion

In neonates, the testicle frequently has not yet


descended into the scrotum, after which it
becomes attached within the tunica vaginalis.

This increased mobility of the testicle predisposes


it to torsion (extravaginal testicular torsion).
During testis torsion, the testicle
twists spontaneously on the
spermatic cord

venous occlusion and


engorgement

Experimental evidence indicates that


720° twist is required to compromise
with subsequent arterial ischemia flow through the testicular artery and
and infarction. result in ischemia.

*Pemeriksaan berdiri celana dipelorotkan:


1. Inspeksi: posisi testis kanan kiri simetris gk
2. Letak testis gmn? (vertikal/horizontal)
3. Kremaster reflek (dgn kapas digoreskan di paha dalam  N:testis gerak ke atas akibat kontraksi m.kremaster)
4. Prehn test  testis diangkat, pada orkitis nyeri akan berkurang, pada torsio tetep nyeri
Testis torsion is the most common cause of
testis loss in the US.
The incidence in males <25 years old is
approximately 1:4000.
Torsion more often involves the left testicle.

Among neonatal testicular torsion cases, 70%


occur prenatally and 30% occur postnatally.

*biasanya pada musim dingin soalnya m.kremaster kontraksi


The testis salvage rate
• in patients who undergo
Approaches detorsion within 6 hours of the
100% start of pain.

• if detorsion occurs >12 hours;


There is only a
20% viability rate

• if detorsion is delayed >24


Virtually no hours
viability

You have 6-8 hours to prevent


testicular loss !!!
Clinical Symptoms
Rapid onset of severe testicular pain and swelling.
The onset of pain may be preceded trauma, physical
activity, or by no activity (e.g. during sleep).

It most often occurs in children or adolescents, but


this diagnosis should be considered in evaluating
men with scrotal pain of any age, as it may
occasionally occur in men 40-50 years old.
Clinical Signs
The classic physical examination findings with testis torsion are
an exquisitely tender testicle with a high, horizontal lie.
• Normally the testicle has a vertical lie within the tunica vaginalis of the
scrotum – that is, the longitudinal axis of the testis is oriented vertically.

After venous outflow is occluded, there is swelling and


occlusion of arterial flow.
• Early on, one may be able to palpate the torsed cord and the testis below it;
• later in the course, however, progressive edema and inflammation ensues,
such that after 12-24 hours,
• the entire hemiscrotum appears as a confluent mass without identifiable
landmarks. At this stage, the physical examination may be indistinguishable
from that seen with epididymoorchitis.
*Orchitis:
-ada riwayat demam
-ada riwayat mumps/parotitis
Clinical Signs

Importantly, with torsion, signs of infection are usually


absent:

• patients are usually afebrile,


• free of irritative voiding symptoms such as dysuria,
• And normal urinalysis and normal white blood cell count.

In later torsion, however, an elevated WBC may be


seen in response to the inflammation
Clinical Signs
In one study of 523 patients presenting to the
Emergency Department with acute scrotum, no single
clinical finding had 100% sensitivity for the presence
of testicular torsion, but all patients with testicular
torsion had 1 or more of the following

• Nausea or vomiting
• Pain duration of less than 24 hours
• High position of the testis
• Abnormal cremasteric reflex

Beni-Israel et a, Am J Emerg Med 2010l


Ngecek ada vaskularisasi kedalam testis apa gak

Doppler Ultrasonography

Torsio  darah jd gabisa msk

Remember, testicular perfusion is the key to the ultrasound


diagnosis of torsion.
Treatment

With a high degree of suspicion, one


may reasonably recommend surgical
exploration without delay as testicular
torsion is a true vascular emergency

Exploration:
• After sharply entering the scrotum, the tunica
vaginalis opened, the testis detorsed and
wrapped in a warm, moist gauze.
• The contralateral side then undergoes
orchidopexy to prevent torsion on that side.
• The affected testis is reinspected for signs of
improved perfusion (“pinking up”)
Tunica albugenia testis di fiksasi ke tunica dartos biar gk mluntir lagi

Testis sbelahnya di orchidopexy jg u/ preventif


Viable testis
Late Testicular torsion
Histopathology testiscular torsion
TORSION OF TESTICULAR APPENDAGES

• Vestigial remnants of wolffian duct-appendix


epididymus
• Vestigial remnants of mullerian duct-appendix
testis
• Both located near the head of the epididymus,
cause identical symptoms
• No risk to testicular viability
TORSION OF TESTICULAR APPENDAGES

• Typically pre-pubertal kids


• Pain appears acutely or sub-acutely and may
be mild or severe
• “Blue dot” sign (early) is pathognomonic
• Patients can pinpoint the area of pain
• With time edema, hydrocele, thickening of
tunica vaginalis and reactive epididymitis
appear making the diagnosis more difficult
TORSION OF TESTICULAR APPENDAGES

• Sonography may be helpful, do not confuse


with epididymitis (rare with normal UA)
• Exploration may be required for diagnostic
uncertainly
• Management is expectant (anti-
inflammatories, scrotal support)
• Operation is reserved for chronic pain
EPIDIDYMITIS/ORCHITIS

• Rare in childhood
• Occurs in association with
urinary tract infection
• Evaluate for possible
urogenital anomaly
(ectopic ureter)
• In the absence of UTI’s,
epididymitis has been
known to occur in boys
with severe voiding
dysfunction

*Terapi;
-dikasih antibiotik golongan quinolon selama 4-6mgg
-scrotal support (pake sempak yg lbi kecil ukurannya  agar terfixir mengurangi nyeri)
Cont….
• Usually adolescent, sexually active male
• Symptoms are gradual
• Associated pyuria, dysuria, flank pain, fever
• Sonography is helpful in making the diagnosis
• Causes: Chlamydia trachomatis, Ureoplasma
urealyticum, Neisseria gonorrhea
Doppler Ultrasonography

A
B
Hypervascularization in the epididimis (in acute epididimitis, A) or in
testicular area (in acute orchitis, B)
DIAGNOSIS OF SELECTED CONDITIONS
RESPONSIBLE FOR THE ACUTE SCROTUM

Onset of Cremasteric
Condition Age Tenderness Urinalysis Treatment
symptoms reflex

Testicular Surgical
Acute Early puberty Diffuse Negative Negative
torsion exploration

Appendiceal Localized to Bed rest and


Sub acute Prepubertal Negative Positive
torsion upper pole scrotal elevation

Positive or
Epididymitis Insidious Adolescence Epididymal Positive Antibiotics
negative
TRAUMA
• Infrequent
• History of direct hit to scrotal area
• May range from normal exam to diffusely
enlarged scrotum with echymoses and loss of
anatomic landmarks
• Many patients presents with torsion after acute
trauma
• Testicular rupture requires immediate exploration
• Hematomas are managed expectantly
Upper Urinary Obstruction
Organs that involve in urinary
Urinary tract consist of

Kidney: parenchyma
pelvicaliceal
Ureter
Bladder
urethra
Pathophysiology Urinary Tract Obstruction (“Symptoms”)

Structure Alteration Symptoms of Urinary tract Abnormality

• Infection (pyonephrosis): fever, pyuria


• Renal failure: oliguria, anuria, acidosis, weakness,
pale.

Loin pain

•LUTS consist of storage and voiding


problems
•Acute urinary retention
•Hematuria

*Upper: diatas buli


*Lower: buli kebawah
CLASSIFICATION OF OBSTRUCTIVE UROPATHY

U.T.O

UPPER TRACT LOWER TRACT

ACUTE CHRONIC

UNEQUIVOCAL

EQUIVOCAL
U.T.O.: Urinary Tract Obstruction
ACUTE OBSTRUCTION

ETIOLOGY

• Stone
• Sloughed renal papillae
• Blood clot
• Acute retroperitoneal pathology
• Accidental ureteric ligation

*anuria: urin produksi <200cc/24jam


Etiologi obstruksi sal. kemih
1.27.00

ACUTE OBSTRUCTION

PATHOPHYSIOLOGY

• Intrarenal pressure

• Renal blood flow (RBF)

• Glomerular filtration rate (GFR)

• Tubular function

• Obstructive atrophy
Sumber: Smith & Tanagho’s 18th
Functional changes during and following Upper Urinary Tract
Obstruction

Campbell Walsh 10th


Sumber: Campbell Walsh 10th
SYMPTOMS & SIGNS

• Asymptomatic (incidental)
• Symptoms:

– Acute or chronic
– Uni or bi-lateral
– In or ex-trinsic
– Complete or partial

– Flank pain
– Nausea, vomiting, fever, chilling, anuria
UPPER TRACT OBSTRUCTION

INVESTIGATION
1. IVP
2. USG
3. RADIONUCLIDE (RENOGRAM)
4. CT
Sumber: Basuki B. Purnomo, Dasar-dasar Urologi, 2011
IVP
USG
RENOGRAM

Figure : The effect of obstruction on the renogram curve. A, mild obstruction;


b, moderate obstruction;c, high-grade obstruction.
CT-SCAN
UPPER TRACT OBSTRUCTION

• Indications of emergency drainage


• Types of urinary drainage
• Considerations in:
– type of the procedure
– timing
UPPER TRACT OBSTRUCTION

• Types of emergency drainage


– External:
Nephrostomy
• Open
• Percutaneous (PNS)
– Internal
• Double-J stenting
UPPER TRACT OBSTRUCTION

• Considerations in:
– type of the procedure
• Degree of dilatation
• Patient condition --- positioning
• Local or general/regional anesthesia
• Drainage only or definitive treatment
– timing
UPPER TRACT OBSTRUCTION

• Indications of emergency drainage


– Obstructive anuria
– Urosepsis caused by
• Pyonephrosis
• Infected Hydronephrosis
Anuria
• Treatment :
Should know the cause
Pre renal, Renal or Post Renal.
• Post Renal Obstruction.
Release the obstruction by
1. open nephrostomy or percutan.
2. Dj Sten ( endoscopy)
Nephrostomy
Double DJ Stent
Urosepsis
• Sepsis from urinary tract as a source of infection
• Diagnosis :
Ax, Physical exam, Lab, Rx, Urine and blood culture
• Treatment : multimodalities
Antibiotic, supportive, surgery.

Prevent from shock septic.


Retentio Urine
• Acut : Can’t to void , Bladder full, painful with
a great desire to micturition
• Chronic : some time pinless, no desire to
micturition, weak urine flow
The cause : Obstruction (Clot, Stone, Prostate,
phimosis, pharaphimosis,etc) and Bladder
disfunction.
Treatment : Catheterization
Urethral catheterization
Suprapubic catheterization (cystostomy)
CONCLUSION

• Upper Tract Obstruction may be acute or chronic, uni or


bilateral, unequivocal or equivocal
• Unequivocal diagnosed by imaging technique
• Equivocal obstruction requires functional and urodynamic
assessment
• Emergency drainage is indicated when there are
obstructive anuria and pyonephrosis
• Hemodialysis is needed if indicated and should be
discussed appropriately