RMP is the most common tumor of the urinary tract. Among malignant tumors of other organs, RMP ranks 7th in men and 17th in women. Thus, in men, neoplasms of the bladder occur up to 4-5 times more often than in women. Mostly sick people older than 55-65 years. In Russia, from 11 to 15 thousand people fall ill every year. At the same time, the annual mortality from this disease is at least 7-8 thousand people. For comparison, in the United States, the incidence is about 60 thousand people, and the death rate is no more than 13 thousand. Such pronounced differences are due to both the imperfection of early diagnosis and the insufficient prevalence of modern and highly effective methods of treating bladder cancer in our country.
Figure 2. Prevalence of Bladder Cancer.
Causes of Bladder CancerIt is generally accepted that the main cause of bladder cancer is the effect of carcinogens excreted in the urine on the bladder mucosa. Proven risk factors for bladder cancer are:
- Occupational hazards (long-term work in the rubber, dyeing, oil, textile, rubber, aluminum industries, etc.) - increases the risk of developing bladder cancer up to 30 times.
- Smoking - increases the risk up to 10 times.
- Taking certain drugs (phenacetin-containing analgesics, cyclophosphamide) - increases the risk by 2-6 times.
- Exposure to radiation - increases the risk by 2-4 times.
- Schistosomiasis (North Africa, Southeast Asia, Middle East) - increases the risk by 4-6 times.
- Chronic cystitis, chronic stagnation of urine, bladder stones - increases the risk up to 2 times.
- The use of chlorinated water - 2 times
There are no specific complaints characteristic of bladder cancer. The initial stages of RMP occur in most cases and are completely asymptomatic.
- The leading symptom is hematuria (the appearance of blood in the urine). Often, hematuria is transient in nature - it appears on a “flat place” and quickly disappears. The patient may not attach much importance to this. Or limit yourself to taking a “hemostatic” drug prescribed in the clinic. Meanwhile, the tumor of the bladder continues to develop. With profuse bleeding, bladder tamponade often occurs and, as a result, acute urinary retention.
- Dysuria (frequent and painful urination with imperative urges), a feeling of fullness in the projection of the bladder.
- Dull pain over the womb, in the region of the sacrum, perineum (when the tumor spreads to the muscle layer).
- In advanced forms, patients are often concerned about weakness, sudden weight loss, fatigue, anorexia.
Diagnosis of bladder cancer is based on the collection of patient complaints, anamnesis of the disease and examination of the patient. The latter is of particular importance. It is necessary to pay attention to the following manifestations of RMP when examining a patient:
- Signs of chronic anemia (weakness, lethargy, pale skin
- Enlargement of lymph nodes on palpation in areas of possible lymphogenous metastasis
- Definitions of a neoplasm during palpation of the bladder, its mobility, the presence of infiltration of surrounding tissues.
- Enlarged bladder due to chronic or acute urinary retention
- Positive symptom of effleurage, palpation of the enlarged/s kidneys (with the development of hydronephrosis, as a result of urinary retention)
Laboratory research
Urinalysis with sediment microscopy (to determine the degree and location of hematuria)
Cytological examination of urine sediment (to detect abnormal cells)
Instrumental diagnostic methods
Radiation methods are of great importance in the diagnosis of bladder tumors:
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Ultrasound (ultrasound examination) - to assess the location, size, structure, nature of growth and prevalence of the tumor, the area of regional metastasis, upper urinary tract, the presence or absence of hydronephrosis. This method is screening and is not used for mono-diagnosis. |
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CT, MRI with intravenous contrast (computed tomography, magnetic resonance imaging) - determination of the extent of the tumor process and the patency of the ureters |
- Excretory urography is an outdated method, however, if necessary, it allows you to assess the patency of the ureters, to identify formations in the upper urinary tract and in the bladder. Currently not widely used due to the low specificity and sensitivity of the method.
- CT of the lungs, scanning of the bones of the skeleton (ostescintigraphy) (if a metastatic lesion is suspected).
Bladder cancer must be differentiated from the following diseases: inflammatory diseases of the urinary tract, nephrogenic metaplasia, anomalies in the development of the urinary tract, squamous metaplasia of the urothelium, benign epithelial formations of the bladder, tuberculosis and syphilis of the genitourinary system, endometriosis, chronic cystitis, metastasis to the bladder of melanoma, cancer stomach, etc. (extremely rare).
Classification of Bladder CancerDepending on the degree of prevalence (neglect), bladder cancer can be divided into 3 types:
- surface
- invasive
- generalized
Anticipating the consideration of clinical forms of bladder cancer, it should be noted that the wall of this organ consists of four layers:
Epithelium (mucosa) - a layer that is in direct contact with urine and in which tumor growth "begins";
Submucosal connective tissue layer (lamina propria) - a fibrous plate that serves as the "base" for the epithelium and contains a large number of vessels and nerve endings;
The muscular layer (detrusor), whose function is to expel urine from the bladder;
The outer layer of the bladder wall can be represented by adventitia (at the retroperitoneal part of the organ) or peritoneum (at the intra-abdominal part of the organ).
| TNM classification of bladder cancer | Histological classification |
| Tx - primary tumor cannot be assessed T0 - no evidence of primary tumor T1 - tumor invasion affects the submucosal layer T2 - tumor invasion of the muscle layer T3 - tumor invasion extends to paravesicular tissue T4 - tumor invasion extends to any of these organs - vagina, uterus, prostate gland, pelvic wall, abdominal wall. N1-3 - metastasis to regional or adjacent lymph nodes is detected M1 - metastasis to distant organs is detected |
Transitional cell carcinoma: with squamous metaplasia with glandular metaplasia with squamous and glandular metaplasia squamous Adenocarcinoma undifferentiated cancer |
| WHO classification (2004) |
MK CODESB-10 Class II - neoplasms. Block C64–C68 - Malignant neoplasms of the urinary tract. |
Flat neoplasms
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Bladder Cancer Treatment
Superficial bladder cancer
Among patients with newly diagnosed bladder cancer, 70 percent have a superficial tumor. In 30 percent of patients, there is a multifocal lesion of the bladder mucosa. In superficial cancer, the tumor is located within the epithelium of the bladder (or extends no deeper than the lamina propria) and does not affect its muscular membrane. This form of the disease has the best prognosis.
Transurethral resection of the bladder (TUR) is the main treatment for superficial bladder cancer.
Picture. Scheme - TUR Bladder
At TOUR remove all visible tumors. The exophytic component and the base of the tumor are removed separately. This technique has diagnostic and therapeutic value - it allows you to take material for histological examination (diagnosis confirmation) and remove the neoplasm within healthy tissues, which is necessary for the correct determination of the stage of the disease and the choice of further treatment tactics. In 40–80 percent of cases after transurethral resection (TUR), recurrence develops within 6–12 months, and 10–25 percent of patients develop invasive cancer. This percentage can be reduced by using photodynamic diagnosis and intravesical administration of the BCG vaccine or chemotherapy drugs (mitomycin, doxorubicin, etc.). Promising techniques for intravesical drug electrophoresis are in the development phase.
Picture. TUR Bladder. Cystoscopic picture.
Intravesical BCG therapy reduces the incidence of bladder cancer recurrence after TURBT in 32-68 percent of cases.
BCG therapy is contraindicated:- during the first 2 weeks after TUR biopsy
- in patients with macroscopic hematuria
- after traumatic catheterization
- in patients with symptoms of urinary tract infection
- bleeding (intraoperative and postoperative)
- perforation of the bladder wall (depending on the experience of the surgeon);
After TURP, it is absolutely MANDATORY to perform repeated follow-up examinations of the bladder to rule out recurrence. With multiple relapses after TUR and the detection of poorly differentiated ("evil") cancer, it is often advisable to resort to a radical operation - cystectomy (removal of the bladder) with the formation of a new bladder from the intestinal segment. Such an operation is especially effective in early forms of cancer and provides high oncological results. With adequate treatment, the 5-year survival rate for patients with superficial bladder cancer exceeds 80 percent.
Muscle-invasive bladder cancerInvasive bladder cancer is characterized by the spread of a tumor lesion to the muscular membrane and beyond the organ - to the perivesical fatty tissue or neighboring structures (in advanced cases). In this phase of the development of a bladder tumor, the likelihood of metastasis to the lymph nodes increases significantly. The main treatment for invasive bladder cancer is radical cystectomy with lymphadenectomy (removal of the bladder with peritoneum and paravesical tissue covering it as a single block, prostate with seminal vesicles, bilateral pelvic (ileo-obturator) lymphadenectomy. In case of a tumor lesion of the prostatic part of the urethra, ureterectomy is performed) ). Radical cystectomy with intestinal plasty is optimal because it allows you to save the possibility of independent urination. In a limited number of cases, TURP and open bladder resection are used to treat patients with muscle-invasive cancer. To increase the effectiveness of surgical treatment in some patients, it is advisable to prescribe antitumor chemotherapy drugs. The 5-year survival rate for patients with invasive bladder cancer averages 50-55 percent.
With the appearance of metastases (screenings of the tumor in the lymph nodes and organs), bladder cancer is called generalized (metastatic). Most often, the disease metastasizes to the regional lymph nodes, liver, lungs, and bones. Almost the only effective treatment for generalized bladder cancer that can prolong a patient's life is powerful chemotherapy with several drugs at once (methotrexate, vinblastine, doxorubicin, cisplatin, etc.). Unfortunately, all these drugs are not safe. Mortality in their application is 2-4 percent. Often it is necessary to resort to surgical treatment, the purpose of which is to prevent the patient from dying from life-threatening complications that accompany the tumor process (for example, bleeding). The 5-year survival rate for patients with advanced bladder cancer does not exceed 20 percent.
Prevention of bladder cancer- Elimination of exposure to carcinogens in the body
- To give up smoking
- Prompt treatment of urinary tract infections
- Ultrasound of the genitourinary system, general urinalysis
- Timely examination and treatment by a urologist at the first signs of dysfunction of the urinary system
Important for you:
Do not be lazy to spend ONE day (in a good clinic) ONCE a year (in a good clinic) and undergo a QUALITY dispensary examination, which necessarily includes an ultrasound of a filled bladder and a urine test. If you suddenly notice an admixture of blood in the urine, be sure to consult a competent urologist who has the opportunity and, most importantly, the desire to find out the cause of this episode. Doing the above is highly likely to help you avoid "news" like advanced bladder cancer.
Bladder bleeding is most often observed after open adenomectomy or TUR of prostate adenoma.
Intensively entering the lumen of the bladder blood after adenomectomy or TURP due to inadequate hemostasis leads to the formation of a blood clot in the bladder. The clinical picture of bladder tamponade develops.
The most common cause of bleeding from the adenoma bed is incomplete removal of adenomatous tissue, damage to the bladder neck or adenoma capsule. The cause of bleeding may also be a violation of blood clotting, therefore, in the event of bleeding after adenomectomy, a coagulogram must be performed and the concentration of D-dimers in the blood serum must be determined.
Blood clots clog the lumen of the drainage tubes, urine output stops through them, and bladder tamponade develops. Patients complain of severe pain over the womb, painful urge to urinate. A sharply painful bladder is palpated above the bosom. In the blood test, a decrease in the number of red blood cells and hemoglobin is noted. Ultrasound can confirm the presence of blood clots in the bladder.
In case of diagnosed bladder tamponade with blood clots, an attempt should be made to evacuate them with an evacuator catheter. If it is possible to evacuate blood clots from the bladder, then it is necessary to drain the bladder with a Foley catheter along the urethra, the catheter balloon is filled with 40 ml of solution and a pull is attached to the catheter, which allows you to press the bladder neck and stop the flow of blood from the adenoma bed into its lumen. It is necessary to establish a constant washing of the bladder with an antiseptic solution and to carry out hemostatic and antibacterial therapy. The tension of the catheter is removed after 24 hours, the bladder flushing system should function for 3–5 days.
If the catheter-evacuator fails to remove blood clots from the bladder, then a cystotomy should be performed. Blood clots are removed, the source of bleeding is established. When blood is received from the adenoma bed, its digital revision is performed. The remaining fragments of the adenoma lobes are removed. A Foley catheter is passed through the urethra into the bladder and its balloon is inflated in the adenoma bed until the blood supply to the bladder stops. After the operation, it is necessary to constantly wash the bladder with furacilin.
If intense bleeding after adenomectomy is not accompanied by the formation of blood clots, then this is a sign of coagulopathy bleeding and the development of DIC. The fight against such bleeding is carried out under the control of indicators of the coagulogram and D-dimers (for details on hemostatic measures for DIC, see "Acute pyelonephritis").
Bleeding after TUR of prostate adenoma is also clinically manifested by bladder tamponade. Removal of blood clots is carried out using a catheter-evacuator. Then, a resectoscope tube is passed along the urethra to examine the area of the resected adenoma in order to search for a bleeding vessel and its coagulation. After achieving good hemostasis, the bladder is drained with a Foley catheter and a constant bladder lavage is established.
According to WHO, bladder cancer accounts for 3% of all detected malignant diseases and 70% of all neoplasms of the urinary system.
Clinical and morphological classification of urinary tract cancerzyrya. According to the morphological structure, malignant tumors of the bladder with an overwhelming frequency are of epithelial origin. Transitional cell carcinoma occurs with a frequency of 80-90%, adenocarcinoma - 3%, squamous cell carcinoma - 3%, papilloma - 1%, sarcomas of various origins - 3%.
Etiology and pathogenesis. Finally, the etiology and pathogenesis of bladder cancer have not been established. Individual risk factors with a high probability of causing cancer have been identified. For example, it has been known for more than 100 years that people who work with aniline dyes are much more likely to suffer from bladder cancer. This is due to the fact that the decomposition products of aniline dyes excreted in the urine have a pronounced carcinogenic effect on the mucous membrane of the bladder. Thus, artists, painters, interior designers are at risk.
Drivers are at risk. This is due to the carcinogenic effect of gasoline combustion products, as well as the habit of drinking little liquid and holding urine for a long time. The risk of developing bladder cancer in smokers is 2-5 times higher. The likelihood increases with smoking experience.
There is a close relationship between malignant tumors and chronic diseases of the bladder, as well as diseases that cause urostasis: prostatic hyperplasia, urethral stricture, etc.
Symptoms. The clinical picture of bladder cancer depends on the stage of the tumor. Neoplasms T a -T 1 are usually asymptomatic. One of the first clinical manifestations is macrohematuria or microhematuria, which may appear once, and then not disturb the patient for a long time.
Massive or prolonged gross hematuria can cause bladder tamponade, a condition in which blood clots almost completely fill the bladder.
Another danger of ongoing hematuria is a decrease in hemoglobin levels and anemia of the patient. Often this life-threatening condition makes it necessary to undertake emergency surgery.
As the tumor grows, other symptoms begin to join, often associated with the addition of an infection. There may be various urination disorders - dysuria.
A sign of tumor growth into the muscle layer may be the appearance of pain over the womb. At first, it is associated with the act of urination, and then, as the muscular wall of the bladder grows and infiltration of neighboring organs, the pain becomes constant.
The growth of a bladder tumor often leads to compression of the mouths of the ureters, which disrupts the passage of urine from the kidneys. In such patients, there is a pulling pain in the lumbar region, often like renal colic. Often against this background there is an attack of acute pyelonephritis.
Diagnostics. Often, with advanced cancer, a tumor can be determined in women with bimanual palpation through the vagina and anterior abdominal wall, in men - through the rectum. In urine tests for bladder cancer, there is an increase in the number of red blood cells, in blood tests - a decrease in hemoglobin, indicating ongoing bleeding.
One of the ways to diagnose bladder cancer is a urine cytology test, which is usually performed several times. The detection of atypical cells in the urine is pathognomonic for a neoplasm of the bladder. In recent years, another laboratory diagnostic method has appeared, the so-called BTA (bladder tumor antigen) test. Using a special test strip, urine is examined for the presence of a specific antigen of a bladder tumor. This technique is usually used as a method of screening diagnostics.
Ultrasound is of great importance in the diagnosis of bladder cancer. Transabdominal examination makes it possible to detect tumors larger than 0.5 cm with a probability of 82%. The formations located on the side walls are most often visualized. When the tumor is localized in the bladder neck, the use of transrectal examination may be informative. Neoplasms of small sizes are best diagnosed using a transurethral scan, carried out by a special sensor inserted through the urethra into the bladder cavity. The disadvantage of this study is its invasiveness. It must be remembered that ultrasound of a patient with a suspected bladder tumor must necessarily include an examination of the kidneys and upper urinary tract in order to detect dilatation of the pelvicalyceal system as a sign of compression of the ureter orifice by the tumor.
Large tumors are detected by excretory urography or retrograde cystography. Sedimentary cystography according to Knise-Schober helps to increase the information content of the study. Helical and multislice contrast-enhanced computed tomography is of great importance in the diagnosis of bladder cancer. Using these techniques, it is possible to establish the size and localization of the formation, its relation to the mouths of the ureters, germination into neighboring organs, as well as the condition of the kidneys and upper urinary tract. However, this method can be used if the patient is able to accumulate a full bladder and retain urine during the study time. Another disadvantage of CT is the lack of information in identifying the depth of tumor invasion into the muscle layer due to the low possibility of visualizing the layers of the bladder wall.
Magnetic resonance imaging is also used in the diagnosis of bladder neoplasms. In contrast to CT, tumor invasion into the muscular layer of the bladder or adjacent organs can be assessed with much greater accuracy.
Despite the information content of high-tech methods, the main and final way to diagnose bladder cancer is cystoscopy with biopsy. Visualization of the tumor, the conclusion of the morphologist about the malignant nature, structure and degree of differentiation of the bladder neoplasm are leading in the choice of treatment method.
Fluorescent cystoscopy can increase the information content of cystoscopy. The peculiarity of this technique is that after treatment of the mucous membrane of the bladder with a solution of 5-aminolevulinic acid during cystoscopy using a light flux of the blue-violet part of the spectrum, the tumor tissue begins to fluoresce. This is due to the increased accumulation of the fluorescent agent by the cells of the neoplasm. The use of this technique makes it possible to detect formations of small sizes, which often cannot be detected by any other method.
Treatment. The main treatment for bladder cancer is surgery. When removing the bladder, the issue of diversion (derivation) of urine is solved. Currently, all options for operations can be divided into the following groups:
The operation, after which urine is constantly excreted and patients need a urinal, is a ureterocutaneostomy.
Operations in which internal urine diversion is used - the mouths of the ureters open into the intestine.
Operations with the creation of a reservoir from which urine is excreted at the request of the patient.
Conservative treatments for bladder cancer include: radiation therapy - remote and contact irradiation; systemic or local intravesical chemotherapy; and local immunotherapy with BCG vaccine. All of these techniques can be used as adjuvant or neoadjuvant therapy, or as palliative treatment in patients whose general condition does not allow resorting to surgery.
Tamponade of the bladder is a pathological condition in which the bladder cavity is completely filled with blood clots. This condition is considered by physicians as an emergency, because in connection with it, urination disorders develop, and sometimes acute urinary retention.
Why is it developing?
Tamponade of the bladder can be the result of diseases of the genitourinary system, as well as the result of injuries. The main reasons are:
- injuries of the upper urinary tract;
- neoplasms of the upper urinary tract;
- neoplasms of the bladder;
- varicose veins of the urinary reservoir and prostate;
- damage to the capsule of the prostate gland due to the fact that the capsule has ruptured.
Common cause is bladder cancer
Development mechanism
How it develops, the process largely depends on the origin of the pathology. For example, with a sudden rupture of the prostate capsule, the process proceeds as follows. Rupture and tension of the capsule occurs due to the growth of the prostate gland and obstruction in it.
The muscle that relaxes the bladder, as well as its neck, is constantly under pressure. It is formed due to the fact that it is necessary to overcome the infravesicular blockage. Changes in pressure inside the bladder and a large volume of the prostate gland create conditions that lead to rupture of the capsule. As a result, hematuria occurs.
Symptoms
The main manifestations of bladder tamponade will be pain when trying to urinate, the urge either does not work, or a small amount of urine is released. On palpation, a bulge is determined above the pubis, this is an overflowing bladder. The slightest pressure on it causes pain. A person with bladder tamponade is emotionally labile, his behavior is restless.
Based on the determination of the volume of blood in the bladder, the degree of blood loss is determined. In urine there are blood impurities fresh or already changed. It should be borne in mind that tamponade of the urinary reservoir involves bleeding. The capacity of the bladder in the male is about 300 milliliters, but in fact the volume of lost blood is much larger.
Therefore, a sick person has all the signs of blood loss:
- pale and moist skin;
- heartbeat;
- weakness and apathy;
- dizziness;
- increase in heart rate.
The main complaints of a patient with tamponade will be pain in the area of the urinary reservoir, inability to urinate, painful and ineffective urges, dizziness, blood in the urine.
Anemia is one of the complications of a pathological condition
How to diagnose?
Bladder tamponade is determined on the basis of complaints, questioning. As a rule, the doctor finds out that there have already been cases of blood in the urine. When examined, a pronounced soreness with pressure in the area of the womb, a pale and unhealthy appearance of the patient draws on himself.
There is blood in the urinary fluid. When examining men with a finger through the rectum, the doctor determines the prostate gland, which is larger than the normal size.
The attending physician necessarily prescribes blood and urine tests. In the general blood test, a decrease in the level of hemoglobin, erythrocyte elements is observed. There is also a pronounced increase in the level of leukocytes in the blood, a shift in the formula of leukocytes to the left and a high level of erythrocyte sedimentation rate. This happens because of the inflammatory process in the bladder.
In the biochemical blood test, the level of creatinine and uric acid increases. This is due to the fact that against the background of acute urinary retention and prolonged tamponade, the cleansing ability of the kidneys is reduced.
To diagnose tamponade, ultrasound of the bladder and prostate gland, as well as the upper urinary tract and kidneys, is used. On ultrasound, you can see an enlarged prostate due to adenoma. In the urine reservoir, blood clots are observed in the form of elements of different echogenicity.
With the help of ultrasound, it is possible to predict quite accurately the amount of blood that is in the cavity of the bladder. But examination of the kidneys allows you to diagnose blockage of the urinary tract above the urine reservoir itself.
On ultrasound, this obstruction will be seen as an enlargement on both sides. Expanding pyelocaliceal system, ureters. This type of diagnosis also determines neoplasms, if any.
Inserting a catheter does not solve the problem, as it immediately becomes clogged with blood clots.
Treatment
Therapeutic measures are operational in nature. Distinguish between urgent and delayed surgical treatment. Urgent consists in revision of the urine reservoir and removal of the adenoma.
Hemostatics - drugs used for bleeding in various types
But the delayed one involves cleansing the bladder of blood through the urethra in parallel with antibiotic and hemostatic therapy. Replacement of lost blood is also used. If the bleeding is stopped, then there is time for a full examination and delayed intervention. Tamponade is a very dangerous condition, it requires immediate treatment. Seek medical attention at the first sign.
15.1. RENAL COLIC
Renal colic- acute pain syndrome that occurs as a result of a sudden violation of the outflow of urine from the pyelocaliceal system of the kidney as a result of obstruction of the ureter.
Etiology and pathogenesis. The most common obstruction to the passage of urine are the stones of the renal pelvis and ureter, so typical renal colic is one of the reliable signs of urolithiasis. However, it can also occur with any other obturation of the ureter: blood clots, casts of urinary salts, accumulation of pus, mucus, microbes, caseous masses in case of kidney tuberculosis, pieces of a tumor, cyst membranes, etc. Severe nephroptosis with an inflection of the ureter, cicatricial narrowing and squeezing it from the outside, neoplasms or enlarged lymph nodes can also cause renal colic.
The mechanism of development of renal colic is as follows. As a result of the appearance of an obstruction to the outflow of urine, its passage from the renal pelvis is delayed, while urine formation continues. As a result, there is an overdistension of the ureter, renal pelvis and calyces above the site of obstruction. Muscle contractions, turning into a spasm of the calyces, renal pelvis and ureter in response to an obstacle, further increase the pressure in the urinary tract, in connection with which pyelovenous reflux occurs, and renal hemodynamics begin to suffer. The blood supply to the kidney is disturbed, significant interstitial edema develops, manifested by hypoxia of the parenchyma. Thus, the disorder of urodynamics disrupts the renal circulation, the trophism of the organ suffers. The edematous renal tissue is compressed inside the dense fibrous capsule surrounding it. Overstretching and compression of the nerve endings in the kidney, pelvis and ureter lead to severe paroxysmal, almost always unilateral pain in the lumbar region.
An attack of renal colic can happen unexpectedly with complete rest. Of the predisposing factors contributing to its occurrence, it should be noted physical stress, running, jumping, outdoor games, driving on a bad, bumpy road.
renal colic are characterized by sudden onset of severe paroxysmal pain in one side of the lumbar region. It immediately reaches such intensity that the patients are not able to endure it, they behave uneasily, rush about, constantly change the position of the body, trying to find relief. Excited and restless
the behavior of patients is a characteristic feature of renal colic, and in this they differ from patients with acute surgical diseases of the abdominal cavity. Sometimes pain can be localized not in the lumbar region, but in the hypochondrium or in the flank of the abdomen. Its typical irradiation is down along the ureter, into the iliac and inguinal regions on the same side, along the inner surface of the thigh, into the testicle, glans penis in men and into the labia majora in women. Such irradiation of pain is associated with irritation of the branches n. genitofemoralis. A certain dependence of the localization and irradiation of pain in renal colic on the presence of a stone in the urinary tract was noted. When it is located in the pelvis or pelvic region of the ureter, the greatest intensity of pain is noted in the lumbar region and hypochondrium. As the stone passes through the ureter, irradiation increases downward, into the genitals, thigh, inguinal region, and frequent urination joins.
The lower the stone is located in the ureter, the more pronounced dysuria.
Dyspeptic phenomena in the form of nausea, vomiting, stool retention and gas with bloating often accompany an attack of renal colic and require differential diagnosis between renal colic and acute diseases of the abdominal cavity. Body temperature is often normal, but if there is a urinary tract infection, it may increase.
Having suddenly begun, the pains can also suddenly stop due to a change in the position of the stone with a partial restoration of the outflow of urine or its discharge into the bladder. More often, however, the attack subsides gradually, the sharp pain turns into a dull one, which then disappears or becomes aggravated again. In some cases, attacks can be repeated, follow one after another at short intervals, completely exhausting the patients. In this case, the clinical picture of renal colic may change, depending on the progression of the stone along the urinary tract. However, an attack of renal colic is not always typical, which makes it difficult to recognize it.
Diagnostics of renal colic and diseases that caused it, is based on a characteristic clinical picture and modern methods of examination. A properly collected history is important. It should be found out whether the patient had similar attacks of pain before, whether he underwent examinations on this matter, whether stones were previously discharged, whether there are other diseases of the kidneys and urinary tract.
An objective examination in some cases allows you to feel the enlarged painful kidney. On palpation at the time of an attack of renal colic, there is a sharp pain in the lumbar region and the corresponding half of the abdomen and often moderate muscle tension. Symptoms of peritoneal irritation are not observed. The symptom of tapping on the lumbar region on the side of the attack (Pasternatsky's symptom) is positive. Very characteristic of renal colic are changes in the urine. The appearance of bloody, cloudy urine with copious sediment or the passage of stones during or after an attack confirms renal colic. Hematuria can be of varying intensity - more often micro- and less often macroscopic. Erythrocytes in the urine, as a rule, are unchanged. If there is an infection in the urinary tract, white blood cells may be found in the urine.
It should be borne in mind that even in the presence of an infection in the kidney, if the lumen of the ureter is completely obstructed, the composition of the urine may be normal, since only urine excreted by a healthy kidney enters the bladder. In the blood, leukocytosis, an increase in ESR can be observed.
To establish the cause that caused an attack of renal colic, ultrasound, X-ray radionuclide, instrumental, endoscopic examinations and MRI are performed.
It is difficult to overestimate the importance of ultrasound, which allows you to assess the size, position, mobility of the kidneys, the width of the parenchyma.
The ultrasound picture in renal colic is characterized by varying degrees of expansion of the pelvicalyceal system. The stone can be located in the pelvis, dilated pelvic or prevesical ureter. With dynamic scintigraphy, there is a sharp decrease or complete absence of kidney function on the colic side.
X-ray examination is of exceptional importance for diagnosis. Quite informative is a survey x-ray of the urinary tract. It is important that all parts of the urinary system are in the field of view in the image, so it should be done on a large film (30 x 40 cm). With good preparation, clearly defined shadows of the kidneys, the edges of the lumbosacral muscles are visible in the overview picture. With renal colic, on a plain radiograph, shadows of calculi can be detected in the projection of the proposed location of the kidneys, ureters and bladder. Their intensity can be different and depends on the chemical composition of the stones. Radiopaque urate stones occur in up to 7-10% of cases.
Excretory urography allows you to clarify whether the shade of the alleged calculus, determined on the overview image, belongs to the urinary tract, the separate state of the excretory function of each kidney, the effect of the stone on the anatomical and functional state of the kidneys and ureters. In cases where an attack of renal colic is caused by other diseases of the urinary system (hydronephrosis, nephroptosis, inflection, stricture of the ureter, etc.), urography can be used to establish the correct diagnosis. The anatomical state of the kidneys and ureters during excretory urography can be determined in cases where the kidney is functioning and excreting a contrast agent in the urine. At the height of renal colic, the function of the kidney as a result of high pressure in the pelvicalyceal system may be temporarily absent (blocked, or "silent" kidney). In such cases, the presence of a stone, including an X-ray negative one, as well as the anatomical state of the kidneys and urinary tract, make it possible to establish multislice CT and MRI.
An important place in the diagnosis of renal colic, as well as the diseases that cause it, belongs to cystoscopy, chromocystoscopy, ureteral catheterization and retrograde ureteropyelography. With cystoscopy, the infringement of the calculus in the intramural part of the ureter can be seen, often the mouth is elevated, its edges are hyperemic, edematous. This swelling extends to the surrounding mucosa of the bladder. Sometimes it is possible to see a strangulated calculus in the gaping mouth (Fig. 16, see color insert). In some cases, mucus may be discharged from the mouth, cloudy
urine or urine stained with blood. Determination of the function of the kidney and ureters by chromocystoscopy(Fig. 14, see color insert) is the fastest, simplest and quite informative method, which is important in the differential diagnosis of renal colic with acute surgical diseases of the abdominal organs.
If a shadow suspicious of a calculus is in doubt, ureteral catheterization is performed. In this case, the catheter may stop near the stone or sometimes it can be passed higher. After that, survey x-rays of the corresponding part of the urinary tract are taken in two projections. The diagnosis of ureterolithiasis is established if the shadows of the alleged calculus and the catheter are combined on the pictures. The discrepancy between these shadows excludes the presence of a calculus in the ureter. In those cases when the stone can be moved up into the pelvis with a catheter and its shadow disappears from the projection of the ureter, appearing in the kidney area, and the attack of renal colic immediately disappears, the diagnosis of urolithiasis is beyond doubt. To clarify the diagnosis, as well as to obtain information about the state of the pyelocaliceal system of the kidney and ureter, retrograde ureteropyelography is performed.
Differential diagnosis Renal colic most often has to be carried out with acute appendicitis, cholecystitis, pancreatitis, perforated stomach and duodenal ulcers, acute intestinal obstruction, strangulated hernia, ovarian cyst torsion, ectopic pregnancy. These acute surgical diseases require urgent surgical intervention for health reasons, while with renal colic, conservative therapy is acceptable and often effective.
Pain appendicitis may resemble that of renal colic in the case of a high retrocecal and retroperitoneal location of the appendix. Important differential diagnostic features are the nature of development and intensity of pain. With appendicitis, it often develops gradually and rarely reaches such strength as with renal colic. Even in those cases when the pain is strong enough, it is still tolerable. Patients with acute appendicitis, as a rule, lie quietly in the chosen position. Patients with renal colic are more often restless, constantly change the position of the body, do not find a place for themselves. Dysuria in acute appendicitis is rare, although it is possible with the pelvic location of the appendix. A characteristic sign of acute appendicitis is tachycardia, which almost never occurs with renal colic. Vomiting in both diseases almost always occurs, but with appendicitis it is more often single, and with renal colic it is repeated many times at the height of ongoing attacks of pain. Deep palpation of the abdomen in the right iliac region in acute appendicitis causes distinct pain, positive symptoms of peritoneal irritation (Shchetkin-Blumberg, Rovsing, etc.) are determined, which are absent in renal colic. For renal colic, pain is characteristic when tapping on the lumbar region on the corresponding side (Pasternatsky's symptom), which is not observed in acute appendicitis. Acute appendicitis, as a rule, is not accompanied by changes in urine tests, while renal colic is characterized by erythrocyte- and leukocyturia, false proteinuria.
In the differential diagnosis of renal colic and acute surgical pathology of the abdominal organs, chromocystoscopy is used. In acute appendicitis, kidney function is not impaired, and 3-6 minutes after intravenous administration of 3-5 ml of a 0.4% solution of indigo carmine, streams of blue-colored urine are ejected from the mouths of the ureters (Fig. 14, see color insert). In the case of renal colic due to impaired patency of the ureter during chromocystoscopy on the affected side, the release of indigo carmine is sharply delayed or absent.
There may be difficulties in the differential diagnosis of renal colic with perforated ulcer of the stomach and duodenum. In such cases, the anamnesis and clinical picture of the disease are of great importance. A perforated ulcer is characterized by a "dagger" character of pain in the epigastric region. Typical for this disease is a rare, single and mild vomiting or its absence, in contrast to renal colic, in which vomiting is almost constant. The onset of the disease is usually preceded by a long ulcer history. Patients are inactive, they seem to be afraid to change the position of the body in bed. The abdominal wall in the epigastric region, and sometimes throughout the abdomen, is tense, symptoms of peritoneal irritation are pronounced. There is a disappearance of hepatic dullness, and an X-ray examination reveals free gas in the right subdiaphragmatic space.
Sometimes renal colic has to be differentiated from acute cholecystitis, gallstone colic, acute pancreatitis. Pain in cholecystitis and cholelithiasis colic is localized in the right hypochondrium, with pancreatitis they are often shingles. The abdomen is swollen, its soreness and muscle tension in the right hypochondrium are noted. Sometimes it is possible to feel an enlarged, painful gallbladder. Destructive forms of cholecystitis and pancreatitis are accompanied by a picture of purulent peritonitis.
It is quite difficult to distinguish renal colic from intestinal obstruction. This is due to the fact that in the clinical picture of these diseases there is a lot in common: severe bloating, vomiting, flatulence, intestinal paresis, gas and stool retention. However, with intestinal obstruction, the patient's condition due to intoxication is more severe. Pain in intestinal obstruction is cramping in nature, in some cases, through the abdominal integument, its peristalsis is visible, which is not observed in renal colic.
Clinical picture strangulated umbilical or inguinal hernia may be similar to that of renal colic. A carefully collected history helps to establish the diagnosis, since in most cases patients are aware of the existence of a hernia. Palpation examination of the anterior abdominal wall of the umbilical region and inguinal rings reveals a strangulated, tense, painful hernial sac.
Currently, the main methods of differential diagnosis of renal colic and acute surgical diseases of the abdominal cavity are radiation methods of research (ultrasound, panoramic and excretory urography, multispiral CT with contrast), MRI and chromocystoscopy, which allow in the vast majority of cases to establish the correct diagnosis.
Treatment. The relief of renal colic should begin with thermal procedures. These include: a heating pad, a hot bath (water temperature 38-40 ° C). Thermal effects intensify skin respiration, blood and lymph circulation. The friendly reaction of smooth muscles, blood vessels of the skin and internal organs is especially clearly manifested during local thermal hydroprocedures (for example, when the lumbar region is warmed, the skin vessels and kidney vessels expand at the same time, and the smooth muscles of the ureter relax).
Thermal procedures are combined with non-steroidal anti-inflammatory drugs (diclofenac 50-75 mg intramuscularly, ketorolac 10-30 mg intramuscularly), antispasmodics (baralgin, spazgan, no-shpa) and herbal preparations (cyston, cystenal, phytolysin), which allow you to stop well renal colic.
Chloroethyl and intradermal novocaine blockade. The effect of parenterally administered drugs (excluding intravenous injections) begins to appear only after 20-40 minutes, therefore it is very rational to simultaneously carry out chlorethyl or intradermal novocaine blockade that quickly manifests its properties. Paravertebral ethyl chloride blockade deserves special attention, which is a good aid in emergency care, both as an anesthetic and as a differential diagnostic test to distinguish renal colic from acute surgical diseases of the abdominal cavity. The analgesic effect of chlorethyl irrigation is explained by the effect of the thermal factor on the vegetative formations of the skin (vessels, receptors, sweat glands, papillary smooth muscles, etc.) in the Zakharyin-Ged zone, which have the same segmental autonomic sympathetic innervation as the corresponding ones interconnected with the skin. internal organs. As you know, the sympathetic innervation of the kidney and ureter refers to the X-XI-XII thoracic and I lumbar segments of the spinal cord, projecting onto the skin with a zone from the corresponding vertebrae anteriorly through the costoiliac space to the anterior abdominal wall.
In cases where renal colic does not stop, a novocaine blockade of the spermatic cord in men and round ligament of the uterus in women (Lorin-Epstein blockade) is performed, which is especially effective when the stone is localized in the lower third of the ureter.
The most effective pathogenetic treatment of renal colic in stationary conditions is the restoration of urine outflow from the kidney by catheterization, stenting of the ureter (Fig. 21, 22, see color insert) or percutaneous puncture nephrostomy.
Forecast regarding renal colic, with the timely elimination of the cause that caused it, favorable.
15.2. hematuria
Hematuria- excretion of blood (erythrocytes) in the urine, detected visually and / or by microscopic examination of the urine sediment.
Epidemiology. The prevalence of hematuria in the population reaches 4%. With age, the incidence of hematuria increases: from 1.0 to 4.0% in children to 9-13% in the elderly.
Classification. The amount of blood in the urine is divided into:
■ gross hematuria- its presence in the urine is determined visually;
■ microhematuria- with microscopy of the sediment of a general urine test, more than 3 erythrocytes are determined in the field of view, and when examining urine according to Nechiporenko, more than 1 thousand erythrocytes in 1 ml of an average portion of urine.
Depending on the presence of blood during the act of urination, which is determined visually and using a three- or two-glass urine sample, hematuria is divided into the following types.
Initial hematuria- blood is determined in the first portion of urine. Such hematuria occurs when the pathological process is localized in the urethra (trauma or iatrogenic damage to the urethra, erosive urethritis, calliculitis, hemangiomas, papillomas, urethral cancer).
Terminal hematuria - blood appears in the last portion of urine. It is characteristic of pathological processes occurring in the neck of the bladder or the prostate gland. The combination of initiation and terminal hematuria indicates damage to the prostatic urethra.
Total hematuria - all urine is stained with blood or blood is recorded in all its portions. It is observed with bleeding from the parenchyma of the kidney, renal pelvis, ureter and bladder. In some cases, the source of hematuria can be determined by the shape of the clots. Worm-like blood clots, which are casts of the ureter, are usually a sign of bleeding from the kidney, pelvis, and ureter. Shapeless blood clots are characteristic of bleeding from the bladder, although they do not exclude bleeding from the kidney with the formation of clots not in the ureter, but in the bladder.
Etiology and pathogenesis. Allocate hematuria glomerular and extraglomerular origin. In the first case, it is caused by nephrological diseases: acute glomerulonephritis, systemic lupus erythematosus, essential mixed cryoglobulinemia, hemolytic uremic syndrome, Alport disease, etc.
Hematuria extraglomerular genesis develops with diseases of the blood system (leukemia, sickle cell anemia, decreased blood clotting), taking antiplatelet agents and anticoagulants, vascular diseases (renal artery stenosis, renal artery or vein thrombosis, arteriovenous fistula) and most urological diseases.
Most often, hematuria occurs with neoplasms of the kidney, upper urinary tract, bladder, trauma, inflammatory diseases of the kidneys and urinary tract, KSD, hydronephrosis, adenoma and prostate cancer, etc.
Diagnostics. First of all, urethrorrhagia should be distinguished from hematuria. Urethrorrhagia is the discharge of blood from the urethra, regardless of the act of urination. Blood can be released drop by drop or stream, depending on the degree of bleeding, the source of which is located in the urethra.
In this case, the first portion of urine is also stained with blood (initial hematuria). This symptom indicates a disease (cancer, stone) or injury to the urethra.
Hematuria must be differentiated from hemoglobinuria and myoglobinuria.
With true hemoglobinuria the urine is reddish in color or may even be clear, and microscopy of the sediment reveals accumulations of hemoglobin or "pigmented casts" of amorphous hemoglobin. Hemoglobinuria indicates hemolysis (transfusion of incompatible blood, the effect of hemolytic poisons). The presence of "pigment casts" or casts of hemoglobin in the urine along with red blood cells is called false hemoglobinuria and is associated with partial hemolysis of red blood cells in the urine.
Myoglobinuria - the presence of myoglobin in the urine; at the same time it is painted in red-brown color. Myoglobinuria is observed in the syndrome of prolonged compression, crushing of tissues and is associated with the ingestion of the pigment of striated muscles into the urine. Admixture of blood to semen (hemospermia), giving it a pink to brown coloration, may indicate inflammation of the seminal vesicles or prostate gland, seminal tubercle, or oncological lesions of these organs.
Next, in a patient with gross hematuria, it is necessary to visually assess the color of urine, which can change when eating certain foods (beets, rhubarb) and taking medications (nitroxoline, madder dye, senna). Depending on the amount of blood in the urine, its color changes from pale pink to deep red, cherry. Establishing the nature of hematuria: initial, terminal or total- can indicate the localization of the pathological process. With severe hematuria, blood clots may form. The worm-like shape of such clots indicates their formation in the upper urinary tract, and the formation of large shapeless clots occurs in the bladder.
The presence and nature of pain in hematuria are of some importance. In some cases, an admixture of blood in the urine appears after a painful attack, usually caused by a stone in the pelvis or ureter. In this case, blood in the urine can appear as a result of both microtrauma of the wall of the pelvis or ureter with a stone, and ruptures of the fornixes and the development of fornic bleeding against the background of acute obstruction of the ureter. With tumors of the kidneys and upper urinary tract, the so-called painless hematuria is observed. In this case, the admixture of blood in the urine occurs against the background of subjective well-being, and pain can develop already against the background of hematuria, which is associated with a violation of the outflow of urine from the upper urinary tract due to blood clots obstructing the ureter.
Thus, with KSD, pain first occurs in the corresponding half of the lumbar region, and then hematuria, and, conversely, with a kidney tumor, total macrohematuria appears first, and then an attack of pain.
Dysuria accompanying hematuria may indicate inflammation of the bladder (hemorrhagic cystitis). Increased dysuric phenomena or the occurrence of imperative urges during movement indicate the possible presence of a stone in the bladder. Dull pain over the womb, dysuria
and hematuria are characteristic of muscle-invasive bladder cancer. The intensity of hematuria does not always correlate with the severity of the disease that caused the appearance of this symptom.
An objective study in patients with hematuria can reveal hemorrhagic rashes on the skin and mucous membranes, indicating possible diseases of the hemostasis system, hemorrhagic fever with renal syndrome. Edema, increased blood pressure are signs of a probable nephrological disease, and swollen lymph nodes are characteristic of infectious, oncological diseases or blood diseases. Palpation of the abdomen reveals an increase in the liver, spleen, a tumor of the abdominal cavity and retroperitoneal space. Male patients should have a digital rectal examination and women a vaginal examination. In addition, all patients undergo an examination of the external opening of the urethra.
The presence of hematuria is confirmed by the data of a general analysis of urine and microscopy of its sediment. Urinalysis according to Nechiporenko (the content of red blood cells in 1 ml of urine) and according to Addy-su-Kakovsky (the content of red blood cells in the total volume of urine excreted by the patient per day) have additional diagnostic value. In the general analysis of urine, attention is paid to the protein content, since with severe proteinuria there is a high probability of nephrological disease. In doubtful cases, it is necessary to perform a study on the selectivity of proteinuria. Sediment microscopy using a modern phase contrast microscope allows you to establish the status of red blood cells in the urine. If unchanged erythrocytes are detected, there is a high probability of a urological disease with the location of the source of hematuria in the kidneys and urinary tract; the presence of altered erythrocytes and cylinders in the sediment indicates a nephrological disease. Leukocyturia and pyuria are indicative of a urinary tract infection. If these changes are detected in the urine test, a bacteriological study is indicated to determine sensitivity to antibiotics.
An important role in the diagnosis of urological diseases that caused hematuria is played by ultrasound. It allows you to determine the shape, structure, location and size of the kidneys, the state of their pelvicalyceal systems, the presence and location of stones, cysts, tumors, prolapse or anomalies of the kidneys. At the same time, using this method, with the greatest reliability, it is possible to distinguish between a tumor and a cyst, to clarify the localization of stones in the urinary tract, including radiopaque ones. When the bladder is full, the prostate gland and its pathology (adenoma, cancer, prostatitis, abscess, stones), the walls of the bladder and the contents of its cavity (tumor, stones, diverticulum) are well defined. Currently, ultrasound and other modern diagnostic methods (survey and intravenous urography, angiography, CT, MRI, scintigraphy, urethrocystoscopy, ureteropyeloscopy) almost always make it possible to establish not only the source of hematuria, but also the disease that caused it. A mandatory and valuable diagnostic method for gross hematuria is cystoscopy, which makes it possible to determine the source of bleeding.
Treatment. Gross hematuria is an indication for emergency hospitalization of the patient in a urological hospital. Conservative therapy is carried out in parallel with the examination. Most often, hematuria is not intense and stops on its own. Conventional hemostatic agents are used for treatment: calcium preparations, carbazohrom (adroxon), etamsylate (dicinone), epsilon-aminocaproic acid, vikasol, tranexamic acid, vitamin C, blood plasma, etc.
The volume and nature of surgical treatment depend on the identified disease that caused hematuria.
Forecast with hematuria is determined by the severity of the disease that caused it.
15.3. ACUTE URINARY RETENTION
Acute urinary retention (ischuria)- the impossibility of an independent act of urination with an overflowing bladder. It can come on suddenly or occur against the background of previous dysuric phenomena, such as rapid, difficult urination, sluggish, thin urine stream, a feeling of incomplete emptying of the bladder after urination, etc.
Allocate sharp and chronic urinary retention. The first is manifested by the impossibility of independent urination with a strong urge to it, overflow of the bladder and arching pains in the lower abdomen. In cases where, during urination, part of the urine is excreted, and some of it remains in the bladder, they speak of chronic urinary retention. The urine that remains in the bladder after urination is called residual urine. Its quantity can be from 50 ml to 1.5-2.0 liters, and sometimes more.
Etiology and pathogenesis. Acute urinary retention occurs as a result of urological diseases or pathological conditions that cause a violation of the innervation of the sphincter and detrusor of the bladder. Most often, it develops in a number of diseases and injuries of the genitourinary organs. The main ones include:
■ diseases of the prostate - benign hyperplasia, cancer, abscess, sclerosis, prostatitis;
■ bladder - stones, tumors, diverticula, injuries, bladder tamponade, urinary infiltration;
■ urethra - strictures, stones, damage;
■ penis - gangrene, cavernitis;
■ some perivesical diseases in women.
Ruptures of the urethra and bladder often lead to urinary retention. And yet, most often it is observed with benign prostatic hyperplasia (adenoma). The provocative factors of its development in this disease are spicy abundant food, alcohol, cooling, prolonged sitting or lying, disruption of the intestines,
especially constipation, forced delay in urination when the bladder is full, physical fatigue and other factors. All this leads to stagnation of blood in the pelvis, swelling of the enlarged prostate gland and even more pronounced squeezing of the urethra.
The causes of urinary retention can be diseases of the central nervous system (organic and functional) and urinary organs. Diseases of the central nervous system include tumors of the brain and spinal cord, dorsal tabes, traumatic injuries with compression or destruction of the spinal cord. Often, acute urinary retention is observed in the postoperative period, including in young people. This delay is reflex in nature and, as a rule, disappears after self-urination or several catheterizations.
Symptoms and clinical course acute urinary retention are quite typical. Patients complain of severe pain in the lower abdomen, painful, fruitless urge to urinate, a feeling of fullness and bursting of the bladder. The strength of the imperative urge to urinate increases and quickly becomes unbearable for patients. Their behavior is restless. Suffering from overdistension of the bladder and fruitless attempts to empty it, patients groan, take a variety of positions to urinate (lie down, kneel, squat), put pressure on the bladder area, squeeze the penis. The pains then subside, then repeat again with greater force. Such a condition never occurs with anuria or acute urinary retention caused by a violation of the innervation of the bladder.
In an objective study, especially in patients with reduced nutrition, a change in the configuration of the lower abdomen is determined. In the suprapubic region, swelling is clearly visible due to the enlarged bladder. Percussion above it is determined by a dull sound. Palpation, as a rule, causes an agonizing urge to urinate. Sometimes patients experience reflex inhibition of intestinal activity with bloating.
Diagnostics acute urinary retention and the diseases that caused it are based on the characteristic complaints of patients and the clinical picture. It is important when taking an anamnesis to pay attention to the nature of urination before the development of ischuria (free or difficult). It is necessary to clarify the time of onset of the disease, its course. In cases where such a condition does not develop for the first time, it is necessary to find out the methods of treatment used and its results. When questioning, it is important to obtain from the patient information about the amount of urine during urination before the delay, its type (transparency, the presence of blood) and the time of the last urination.
The most common cause of acute urinary retention in older men is benign prostatic hyperplasia. As the tumor grows, the prostatic urethra is compressed, bent, its lumen narrows, lengthens, which creates an obstacle to the outflow of urine and contributes to the development of its retention. Acute urinary retention can occur at any stage of the disease, including
including in the first, when the clinical picture is still poorly expressed. In such cases, it occurs against the background of relative well-being, the content of 400-500 ml of urine in the bladder already causes painful urge to urinate. When the disease develops gradually, the capacity of the bladder increases markedly. It can contain up to 1-2 liters and even more urine. In such patients, an overfilled bladder is sometimes determined visually as a rounded formation in the suprapubic region.
In the diagnosis of prostate diseases, the main place belongs to its digital examination through the rectum, ultrasound, X-ray examination and determination of the level of prostate specific antigen.
Bladder and urethral stones are often the cause of acute urinary retention. Violation of the act of urination with bladder stones largely depends on the location and size of the stone. When urinating, there is discontinuity and laying of the urine stream. If the stone is wedged into the internal opening of the urethra and completely closes it, an acute urinary retention develops. This condition is observed more often when the patient empties the bladder while standing. When changing the position of the body, the stone can move back into the bladder, and urination in this case is restored. If the stone is displaced outside the bladder into the urethra and completely closes its lumen, then acute urinary retention is persistent.
Urethral ruptures, post-traumatic strictures, and narrowing of other origins are often complicated by acute urinary retention. The diagnosis in such cases is established on the basis of the history, urethrography and ureteroscopy (Fig. 3, see color insert).
Acute urinary retention can be caused by tumors of the bladder and urethra. A villous, floating tumor located in the neck of the bladder can close the internal opening of the urethra and cause urinary retention. In bladder cancer, the cause of urinary retention can be both the germination of the bladder neck by a tumor, and massive bleeding with the formation of blood clots. It should also be borne in mind that blood in the bladder with the formation of clots is not only observed with tumors, but can also occur with severe kidney bleeding and bleeding from the prostate gland.
Acute urinary retention can develop with diseases and spinal cord injury.
Differential diagnosis acute urinary retention should be carried out with anuria. In both cases, the patient does not urinate. However, with acute urinary retention, the bladder is full, the patient feels bursting pains in the lower abdomen and a strong urge to urinate, but cannot urinate due to an obstruction in the bladder neck or urethra. With anuria, urine does not flow from the kidneys and upper urinary tract to the bladder, it is empty, there is no urge to urinate.
Treatment. The provision of emergency care to patients with acute urinary retention consists in its evacuation from the bladder. Emptying
bladder is possible by three methods: catheterization, suprapubic capillary puncture and performing trocar epicystostomy.
The most common and least traumatic method is bladder catheterization with soft elastic catheters. It should be borne in mind that in a significant number of cases, acute urinary retention can be eliminated by catheterization of the bladder alone or by leaving a permanent catheter for a short time. If the act of urination is not restored, it may be necessary to repeat the catheterization. The presence of purulent inflammation of the urethra (urethritis), inflammation of the epididymis (epididymitis), the testicle itself (orchitis), and prostate abscess is a contraindication for catheterization. It is also contraindicated in case of rupture of the urethra. Bladder catheterization is performed in compliance with the rules of asepsis. Attempts to forcibly pass the catheter should be avoided, as this causes injury to the prostate gland and urethra. As a result of such catheterization, urethrorrhagia or the development of urethral fever with an increase in body temperature up to 39-40 ° C are possible.
In cases where bladder catheterization with a soft catheter fails or is contraindicated, the patient should be referred to a hospital for catheterization with a metal catheter, bladder puncture, or trocar epicystostomy.
Forecast with acute urinary retention, it is favorable, since it can always be eliminated by one of the above methods, which cannot be said about the reasons that caused it. Stable recovery of urination occurs only as a result of radical treatment of the disease that led to acute urinary retention.
15.4. ANURIA
Anuria- stopping the flow of urine from the upper urinary tract to the bladder. It occurs as a result of a violation of the excretion of urine by the renal parenchyma or due to obstruction of the ureters.
Classification. Anuria is divided into arenal, prerenal, renal and postrenal.
Arenal anuria occurs in the absence of kidneys. This condition may be congenital (renal aplasia) or caused by the removal of a single or only functioning kidney.
Prerenal (vascular) anuria due to impaired hemodynamics and a decrease in the total volume of circulating blood, which is accompanied by renal vasoconstriction and a decrease in renal circulation.
Renal (parenchymal) anuria due to toxic damage to the renal tissue or chronic kidney disease.
Postrenal (obstructive) anuria develops as a result of obstruction of the ureters or ureter of a single kidney.
Etiology and pathogenesis. Main reasons prerenal anuria are cardiogenic or traumatic shock, embolism and renal thrombosis
vessels, collapse, heart failure, pulmonary embolism, that is, conditions accompanied by a decrease in cardiac output. Even a short-term decrease in blood pressure below 80 mm Hg. Art. leads to a sharp reduction in blood flow in the kidney due to the activation of shunts in the juxtamedullary zone, ischemia of the renal parenchyma occurs and, against its background, rejection of the epithelium of the proximal tubules up to acute tubular necrosis.
Renal anuria caused by exposure to the kidney of toxic substances: salts of mercury, uranium, cadmium, copper. A pronounced nephrotoxic effect is characteristic of poisonous mushrooms and some drugs. X-ray contrast agents have nephrotoxic properties, which requires their careful use in patients with impaired renal function. Hemoglobin and myoglobin, circulating in the blood in large quantities, can also lead to the development of renal anuria due to massive hemolysis caused by transfusion of incompatible blood, and hemoglobinuria. Causes of myoglobinuria can be traumatic, such as prolonged pressure syndrome, and non-traumatic, associated with muscle damage during prolonged alcohol or drug coma. Renal anuria can cause acute glomerulonephritis, lupus nephritis, chronic pyelonephritis with wrinkling of the kidneys, etc.
Postrenal anuria develops as a result of a violation of the outflow of urine from the kidneys due to obstruction of the ureter(s) by stones, tumors of the upper urinary tract, bladder, prostate, squeezing them with neoplasms of the female genital organs, metastatically enlarged lymph nodes and other formations, as well as due to cicatricial strictures and obliteration ureters. With this type of anuria, there is a sharp expansion of the ureters and pelvis with a pronounced interstitial edema of the renal parenchyma. If the outflow of urine is restored quickly enough, the changes in the kidneys are reversible, however, with a long-term obstruction, severe circulatory disorders of the kidneys develop, which can result in an irreversible condition - tubular necrosis.
Symptoms and clinical course anuria is characterized by increasing azotemia, impaired water and electrolyte balance, intoxication and uremia (see chapter 13.1).
Diagnosis and differential diagnosis carried out on an emergency basis. First of all, anuria should be distinguished from acute urinary retention. The latter is characterized by the fact that there is urine in the bladder, moreover, it is full, which is why patients behave extremely restlessly: they rush about in fruitless attempts to urinate. With anuria, there is no urine in the bladder, patients do not feel the urge to urinate and behave calmly. Finally, these two conditions can be distinguished by palpation and percussion over the womb, ultrasound and catheterization of the bladder.
Once the diagnosis of anuria is confirmed, its cause should be investigated. First of all, it is necessary to conduct a differential diagnosis of post-renal anuria from its other types. For this purpose, an ultrasound of the kidneys is performed, which allows you to confirm or exclude the fact of bilateral obstruction.
ureters by the presence or absence of expansion of the pelvicalyceal system. An even more objective test is bilateral ureteral catheterization. With free passage of ureteral catheters to the pelvis and in the absence of urine output through them, postrenal anuria can be safely rejected. On the contrary, if the catheter detects an obstruction along the ureter(s), you should try to move it higher, thereby eliminating the cause of anuria.
Multispiral CT, MRI, renal angiography, and renal scintigraphy help to establish the final diagnosis. These methods provide information about the state of the vascular bed of the kidney (prerenal form), its parenchyma (renal form) and ureteral patency (postrenal form).
Treatment should be aimed at eliminating the cause that caused the development of anuria. In shock, the main therapy is aimed at normalizing blood pressure and replenishing the volume of circulating blood. It is advisable to introduce protein solutions and large molecular weight dextrans. In case of poisoning with nephrotoxic poisons, it is necessary to remove them by washing the stomach and intestines. A universal antidote for poisoning with salts of heavy metals is unitiol.
In the case of postrenal obstructive anuria, therapy should be aimed at early restoration of urine outflow: catheterization, stenting of the ureters, percutaneous puncture nephrostomy.
The indication for hemodialysis is an increase in the content of potassium more than 7 mmol / l, urea up to 24 mmol / l, the appearance of symptoms of uremia: nausea, vomiting, lethargy, as well as hyperhydration and acidosis. Currently, early or even preventive hemodialysis is increasingly being used, which prevents the development of severe metabolic complications.
Forecast favorable with the rapid elimination of the cause of anuria. Mortality depends on the severity of the underlying disease that caused its development. Complete recovery of renal function is observed in 35-40% of cases.
15.5. TWIST OF THE SPERM AND TESTICLE
One of the most common acute pathological conditions, especially in childhood, is testicular torsion, which leads to squeezing of blood vessels with the development of organ necrosis.
Etiology and pathogenesis. Distinguish between extravaginal and intravaginal testicular torsion.
Extravaginal testicular torsion It is usually observed in children under one year old and is associated with increased mobility of the spermatic cord and testis at this age. If testicular torsion occurred in the prenatal period, then after the birth of a child, an increase in the corresponding half of the scrotum and the presence of a tumor-like formation in it, which is much larger than the testicle, are noted.
Much more commonly seen intravaginal torsion, due to the anatomical and functional characteristics of the child's body and therefore
more common in children than in adults. Intravaginal torsion is facilitated by the relatively large length of the spermatic cord in children, combined with its high connection with the vaginal membrane, stronger than in adults, the contractility of the muscle that supports the testicle, as well as weak fixation of the epididymis to the skin of the scrotum. Following torsion, impaired patency of the venous and arterial vessels of the testis leads to congestion, thrombosis, and necrosis.
In most cases, testicular torsion is preceded by physical stress or trauma. The main symptom of the onset of testicular torsion is sudden severe pain in the testicle and the corresponding half of the scrotum, which may be accompanied by nausea and vomiting. The testicle is usually palpated at the upper edge of the scrotum, which is associated with shortening of the spermatic cord. Sometimes with torsion, the appendage is located in front of the testicle, and the spermatic cord is thickened. Subsequently, swelling and hyperemia of the scrotum join.
Diagnosis and differential diagnosis. In addition to clinical manifestations in this pathology, it is necessary to take into account the history data. The presence in the past of sudden pain in the testicle, which disappeared on its own, should suggest a predisposition to torsion. Testicular torsion, mistaken for inflammation and treated conservatively, always ends in necrosis of the organ.
Differentiate testicular torsion primarily with acute epididymitis and or-hit. With these diseases, there are all signs of acute inflammation: testicular enlargement, swelling of the scrotum, hyperemia of her skin and high body temperature.
Treatment and prognosis. Treatment of testicular torsion should be prompt and urgent. In cases where surgical correction was performed no later than 3-6 hours after the onset of torsion, the viability of the testicle is restored, otherwise testicular necrosis develops, followed by testicular atrophy.
15.6. PRIAPISM
Priapism- an acute disease, consisting in a long-term pathological erection without sexual desire and sexual satisfaction. An erection can last from several hours to several days, not pass after sexual intercourse and not end with ejaculation and orgasm. The prevalence of this disease, according to the literature, is from 0.1 to 0.5%.
Etiology and pathogenesis. Priapism is caused by: 1) pathology of the nervous system and psychogenic disorders; 2) intoxication; 3) hematological diseases; 4) local factors. The former include diseases that lead to stimulation of the corresponding areas of the spinal cord and brain (trauma, tumors, spinal cord, multiple sclerosis, meningitis, etc.), hysteria, neurasthenia, psychoneurosis based on erotic fantasies. The second - poisoning with chemicals, drugs, alcohol intoxication. The third group of factors are diseases
blood systems (sickle cell anemia, leukemia). And finally, local factors include intracavernous administration of vasoactive drugs, phimosis, paraphimosis, cavernitis, tumors and injuries of the penis, etc.
Classification. Priapism is divided into ischemic, non-ischemic and recurrent.
Ischemic(veno-occlusive, low-flow) priapism occurs in 95% of cases of all variants of this disease. With veno-occlusive priapism, the blood flow velocity decreases sharply and may stop completely. As a result, ischemia occurs, fibrosis of the cavernous bodies and organic erectile dysfunction develop. After 12 hours, changes in the tissues appear, and after 24 hours, irreversible consequences occur.
non-ischemic(arterial, high-flow) priapism occurs when the penis or perineum is traumatized with damage to the arteries, resulting in the formation of an arterio-lacunar fistula. With this type of priapism, violations of tissue trophism are insignificant.
recurrent(intermittent, or recurrent) priapism is an ischemic variant. It is characterized by an undulating course: long periods of painful erection are replaced by its decline. Recurrent priapism is more common in diseases of the central nervous system, mental disorders and blood diseases.
Symptoms and clinical course. Priapism comes on suddenly and can last for a long time, completely exhausting the patient. Pathological erection is accompanied by severe pain in the penis, sacral region. The penis becomes tense, sharply painful, its skin becomes bluish. The direction of the penis is arcuate, at an acute angle to the abdomen. The head of the penis and the spongy body of the urethra are soft, relaxed. Urination is not disturbed. The development of priapism is determined by the inadequacy of the inflow and outflow of blood into the cavernous bodies.
Clinical manifestations of priapism may develop several hours after the injury and are characterized by an inferior erection. However, when stimulated, a full erection develops. Unlike ischemic priapism, non-ischemic priapism can also occur in a painless form, and can also stop on its own or after intercourse. The presence or absence of pain in the penis is one of the diagnostic features that distinguish veno-occlusive priapism from arterial.
Diagnostics based on the patient's complaints and examination. In the differential diagnosis of ischemic and non-ischemic priapism, data from Dopplerography and gasometry of blood aspirated from the cavernous bodies are used. With arterial priapism, the echographic picture will indicate a violation of the integrity of the arteries of the penis. The partial pressure of oxygen and the pH of the blood do not change. Venous occlusive priapism is characterized by hypoxia and acidosis. Prolonged local hypoxia of the cavernous tissue is a damaging factor leading to its sclerosis and the development of erectile dysfunction.
Treatment.Priapism refers to urgent pathological conditions and requires emergency hospitalization.Emergency conservative therapy includes
sedative and analgesic drugs, anticoagulants, local hypothermia, antibiotic and anti-inflammatory therapy, as well as drugs that improve microcirculation and blood rheology; a-agonists are administered intracavernously.
Surgery produce with the ineffectiveness of conservative therapy. It is aimed at restoring the outflow of blood from the penis by applying vascular shunts. The most widely used incision of the cavernous bodies, their aspiration followed by perfusion, spongio-cavernous and saphenocavernous anastomosis, which consists in directly connecting the cavernous body and the great saphenous vein of the thigh (vena saphena magna).
Forecast favorable in terms of elimination of the disease and doubtful in relation to erectile function. With the development of organic impotence resort to phalloprosthesis.
15.7. INJURIES OF THE URINARY ORGANS
Injuries to the genitourinary system account for 1.5-3% of the total structure of injuries of all human organs. In peacetime, their cause in 75-80% of the victims is damage during traffic accidents and falls from a height. In 60-70% of cases, injuries are combined or multiple; for the most part, damage to the kidneys and urinary tract occurs.
Classification. Distinguish according to localization injuries of the kidneys, ureters, bladder, urethra and male reproductive organs.
Depending on the presence of a wound channel that communicates the damage zone with the external environment, closed and open injury.
Injuries can be isolated, multiple and combined. Isolated an injury to one organ of the genitourinary system is considered multiple - when, in addition to an injury to the genitourinary organs, there are injuries to other organs within the same anatomical region, for example, injury to the kidney and abdominal organs. Combined considered simultaneous damage to organs located in different anatomical areas, such as damage to the bladder and traumatic brain injury.
Depending on the severity of the injury to the genitourinary organs, there may be light, medium and heavy in relation to body cavities - penetrating and non-penetrating, depending on the affected side one- and bilateral.
15.7.1. Kidney damage
Epidemiology. Kidney injury is the most common and accounts for about 60-65% in the structure of damage to the organs of the urinary system. In peacetime, closed injuries prevail, and in wartime, open injuries of the kidneys.
Etiology and pathogenesis. Closed kidney injuries, as a rule, occur as a result of the application of force to the lumbar or abdomen in the form
impact or crush. The hydrodynamic factor also plays a role in the rupture mechanism, due to the significant predominance of the liquid component (blood, lymph, urine) in the kidney parenchyma, surrounded by a dense fibrous capsule. Direct impact and detonation of the fluid inside the organ lead to rupture of the fibrous capsule and kidney parenchyma. In domestic conditions, injury often occurs due to a fall in the lumbar region on a protruding solid object. The rupture of the organ occurs as a result of a direct blow and the damaging effect of the adjacent bone structures - the ribs and spine.
Kidney injuries can occur as a result of minimally invasive and endoscopic methods for the diagnosis and treatment of urological diseases, which are currently widespread. First of all, they are associated with careless or erroneous actions of the doctor. After remote shock wave nephrolithotripsy, subcapsular hematomas are often diagnosed, and the hematuria that always occurs after it can be the result of not only the damaging effect on the urothelium of the stone and its fragments, but also fornix ruptures. Injury to the renal parenchyma can be observed during catheterization (stenting) of the ureter, ureteroscopy, nephroscopy, nephrobiopsy, and even with pararenal blockade.
Kidney diseases (tumor, cyst, hydronephrosis) make it more susceptible to various traumatic effects. Severe damage to a pathologically altered kidney can occur even with minimal trauma.
Open injuries - knife or gunshot - are usually multiple.
Classification. The clinical and anatomical classification of closed kidney injuries is based on the severity of the organ injury. Distinguish bruises and breaks kidneys (Fig. 67, see color insert). A bruise is characterized by a sharp concussion (contusion) of the organ without ruptures of the parenchyma of the kidney, its capsule and cavitary system. Clinically significant damage to the kidney is observed only when it breaks, from microscopic tears of the parenchyma and fornices to crushing of the organ. From these positions, the appearance of subcapsular and perirenal hematomas, as well as hematuria, is always the result of even minor, but ruptures of the parenchyma.
Classification of kidney ruptures (Fig. 15.1):
a- external rupture of the kidney parenchyma with the formation of a subcapsular hematoma;
b- external rupture of the parenchyma and the capsule of the kidney with the formation of a perinephric hematoma;
in- internal rupture of the parenchyma and fornixes, opening into the cavitary system of the kidney (hematuria);
G- penetrating rupture of the capsule, parenchyma and cavitary system of the kidney with the formation of pararenal urohematoma (hematuria);
d- crushing of the kidney: multiple penetrating ruptures of the capsule, parenchyma and cavitary system of the kidney with the formation of pararenal urohematoma (hematuria);
e- detachment of the vascular pedicle with crushing of the kidney parenchyma.
Rice. 15.1. Types of kidney ruptures
The most severe forms of damage to the kidney are its crushing, that is, the formation of multiple ruptures of the organ penetrating into the pelvicalyceal system with possible separation of parenchyma sections (poles), and rupture (rupture) of the vascular pedicle. The latter has no clinical significance, since it is almost always combined with no less severe damage to other organs, which makes this kind of damage incompatible with life.
Symptoms and clinical course. The clinical picture depends on the degree of damage to the kidney and the presence of injuries to other organs. Patients complain of pain in the lumbar region and / or in the abdomen, aggravated by deep breathing, bloating, nausea, vomiting, general weakness. Total hematuria is observed with severe kidney damage (Fig. 15.1, c-f). Gross hematuria is a sign of the severity of organ damage, in turn being one of the determining factors in the severity of the victim's condition. However, in some cases, the degree of hematuria does not correspond to the degree of kidney damage. With small fornic ruptures, persistent pronounced hematuria can be observed, and, conversely, with crushing of the kidney, hematuria
may be insignificant or absent as a result of tamponade of the abdominal system with blood clots and / or damage to the pelvis, ureter and its vascular pedicle.
The rupture of a parenchymal organ rich in vessels, which is the kidney, is accompanied by signs of internal bleeding. In combination with severe hematuria, it can quickly lead to anemia and a serious condition of the patient, which is manifested by pallor of the skin, cold sweat, tachycardia, lowering blood pressure, and an increase in retroperitoneal urohematoma. An objective examination on the skin of the abdomen and lumbar region can reveal abrasions, hemorrhages, swelling of tissues, as well as swelling in this area due to a large urohematoma. The location and course of the wound channel with the outflow of urine from it make it possible to suspect an open kidney injury. Palpation of the chest and spine may be accompanied by severe pain due to a fracture of these bone formations. On palpation of the abdomen, pain and protective tension of the muscles on the side of the lesion are determined, and with large urohematomas, a rounded formation in the hypochondrium and lumbar region is determined.
Long-term complications of closed kidney injuries are organized hematoma, squeezing the kidney, stone formation, hydronephrosis, arterial hypertension, etc.
Diagnostics. In the diagnosis, attention is paid to the type and nature of the injury, its objective local and general manifestations. In blood tests, a decrease in the number of erythrocytes and hemoglobin is determined, and leukocytosis joins at a later date from the moment of injury. In the analysis of urine, erythrocytes cover the entire field of view. The total kidney function can be assessed by the determination of residual nitrogen, urea and serum creatinine, which is especially important to know in case of damage to a single kidney and planning surgical treatment.
Radiation methods are the main ones in the diagnosis of kidney rupture. They allow, firstly, to determine the degree of damage to the kidney, and secondly,
Firstly, to evaluate the separate function of the damaged and contralateral kidneys; thirdly, to monitor the dynamics of the wound process in order to diagnose complications early and make their timely correction. The most affordable, minimally invasive and rapid method for diagnosing kidney damage - ultrasound. It can be used to identify subcapsular and pararenal urohematomas (Fig. 15.2), to determine the size, deformation of the contours of the kidney, parenchyma defects, deformation of the pyelocaliceal system, the degree of its ectasia, to detect clots
Rice. 15.2. Sonogram. Perinephric urohematoma (arrow)
Rice. 15.3. Excretory urogram. Contrast leakage (arrow) due to right kidney rupture
blood. Comparison of ultrasound results with anamnesis, physical examination data, and the severity of bleeding often makes it possible to establish a diagnosis and, in a serious condition of the patient, proceed with an emergency operation without other methods of examination.
In all cases, patients with suspected kidney injury should have plain radiography abdominal cavity and retroperitoneal space. It can be used to detect scoliosis, the absence of the contour of the kidney and psoas major, fractures of the lower ribs, transverse processes of the vertebrae and pelvic bones. Excretory urography allows you to detect deformation and compression of the calyces and pelvis, leakage of contrast on the side of the lesion (Fig. 15.3), assess the function of the damaged and contralateral kidney, which is important in determining
scope of emergency surgery. Its use is limited in cases of combined injuries and in patients with shock and unstable hemodynamics (systolic pressure below 90 mm Hg).
Currently retrograde ureteropyelography in the diagnosis of kidney damage is used extremely rarely due to the emergence of new methods.
research methods. It can be used to clarify the degree of kidney damage, if excretory urography is not informative and CT, MRI and angiography are unavailable due to the urgency of the situation or their absence in this hospital.
The most informative methods for diagnosing kidney damage are CT and MRI. With the introduction of radiopaque substances into the vein, as a rule, the need to use other radiation methods is eliminated. CT and MRI provide the highest degree of accuracy in assessing anatomical details
Rice. 15.4. CT with contrast, frontal projection. Rupture of the left kidney (arrow)
Rice. 15.5. CT with contrast, axial view. Extravasation of contrast medium as a result of rupture of the left kidney
injured kidney. In the practice of emergency care, their accuracy reaches 98%. CT makes it possible to visualize damage to the parenchyma (Fig. 15.4) and kidney vessels, segments of the organ deprived of blood supply, and to detect even small urinary streaks containing a radiopaque substance (extravasates) (Fig. 15.5), as well as trauma to other parenchymal organs. CT and MRI can detect damage to the kidney as a result of endourological interventions (Fig. 15.6).
Renal angiography allows, in addition to diagnosing damage to
vessels and parenchyma of the kidney to perform a medical procedure - selective embolization of a bleeding vessel (Fig. 15.7).
Radioisotope scanning in the system of emergency diagnosis of renal injuries is less informative than radiation methods, it requires a lot of time and special conditions. This method is more appropriate for assessing the consequences of a kidney injury and their functional state.
Rice. 15.6. Multislice CT with contrast:
a- frontal projection; b- axial projection. Perforation of the renal parenchyma with a ureteral stent (arrow)
Rice. 15.7. Renal angiograms:
a- ruptures of the renal tissue with streaks of contrast agent; b- selective embolization of bleeding vessels (arrow)
Treatment. Treatment tactics depend on the degree of kidney damage. Conservative therapy indicated for small organ ruptures with subcapsular or pararenal hematoma up to 300 ml and moderate hematuria (see Fig. 15.1, a-c). Strict bed rest is prescribed for two weeks, cold on the lumbar region, hemostatic, antibacterial and microcirculation-improving drugs in the kidney. In the process of treatment, constant dynamic monitoring is required, including an assessment of the state of hemodynamics, blood and urine tests, and ultrasound monitoring. It should be remembered about the possibility of the so-called two-stage damage to the organ, which means the rupture of the fibrous capsule over the subcapsular hematoma with the resumption of bleeding from the damaged parenchyma into the retroperitoneal tissue. Such a gap can occur if the patient does not comply with bed rest.
Surgery 10-15% of patients with severe kidney damage are required. Emergency surgery is indicated:
■ with increasing internal bleeding and / or profuse hematuria;
■ large and multiple ruptures of the parenchyma with the formation of hematomas (urohematomas) with a volume of more than 300 ml;
■ combined damage to the kidney and other internal organs requiring urgent revision;
■ infection of a perirenal hematoma with the formation of a perirenal abscess.
Elective surgeries are performed for long-term complications of closed kidney injuries.
Surgical interventions for kidney injury are divided into minimally invasive and open.
Minimally invasive ones include percutaneous puncture and drainage of a hematoma or post-traumatic perirenal abscess; laparoscopic (lumboscopic) suturing of a ruptured kidney or nephrectomy, evacuation and drainage of a hematoma; arteriography and selective embolization of a bleeding renal vessel.
Open surgery (Fig. 67, see color inset) includes suturing of a ruptured renal parenchyma with or without nephrostomy, kidney resection, and nephrectomy.
Even at present, nephrectomy is most often performed in case of kidney injury. It is carried out by approximately 50% of patients who undergo an emergency lumbotomy (laparotomy) for a ruptured organ. The kidney is removed in case of rupture of the vascular pedicle, multiple and deep wounds of the parenchyma, impossibility of performing a good revision and organ-preserving treatment due to rapidly increasing, life-threatening bleeding, especially with associated injuries. In some cases, in district and small city hospitals, nephrectomy is performed without proper revision of the kidney and assessment of the degree of its damage during laparotomy undertaken for intraperitoneal injuries.
A full urological examination may not be possible due to the need for an emergency laparotomy for associated intraperitoneal injuries. During the operation, the revision of the kidney is required if there is a growing large retroperitoneal hematoma. If a nephrectomy is planned after revision of the retroperitoneum and kidney, the function of the opposite kidney should be assessed. First of all, it is necessary to determine the presence of the organ by palpation through the parietal peritoneum, and also to establish its functional viability. In emergency cases on the operating table, this can be done in one of two ways: excretory urography or indigo carmine test (intravenous administration of a dye with clamping of the ureter of the injured kidney and monitoring its flow through the catheter from the bladder).
With gunshot wounds to the kidney, it is necessary to take into account the cavitation effect of a bullet, a fragment, that is, concussion, crushing of the parenchyma due to the impact of a pulsating cavity. In such cases, surgical treatment of the wound canal is necessary, including, in addition to stopping bleeding, excision of non-viable tissues and removal of foreign bodies.
Forecast depends on the degree of damage to the kidney and the correct treatment. Conservative therapy for small gaps and organ-preserving surgical treatment make the prognosis for the anatomical and functional state of the kidney favorable. With severe ruptures of the organ and massive bleeding, the prognosis for the patient's life is determined by timely surgical intervention.
15.7.2. Damage to the ureters
Epidemiology. Injuries to the ureters due to their anatomical structure are observed quite rarely. In the structure of damage to the organs of the urinary system, they account for no more than 1% of cases.
Etiology and pathogenesis. open injuries of the ureters are extremely rare, as a rule, are the result of stab or gunshot wounds and almost always have a combined character. Gunshot wounds of the ureters occur in 3.3-3.5% of all combat injuries of the genitourinary system during modern hostilities. Not much more common and closed damage to the ureters as a result of external influence due to their anatomical and topographic features (depth of location, protection by muscle and bone structures, size, elasticity, mobility). Such an injury can occur as a result of damage to the ureters by bone fragments due to a fracture of the posterior semiring of the pelvis. In peacetime, the vast majority of injuries to the ureters areiatrogenic nature, that is, it occurs as a result of accidental damage during surgical interventions. Ligation, incision, or transection of the ureter is most commonly seen during obstetric and gynecological and surgical procedures. Damage to it as a result of endourological diagnostic and therapeutic interventions (ureteroscopy, stenting and catheterization of the ureter) should be regarded as a complication when performing manipulations.
Symptoms and clinical course. Damage to the ureter is manifested by pain in the lumbar region associated with a violation of the outflow of urine from the corresponding kidney, and short-term hematuria. With open wounds, trauma to the ureter almost always has a combined character and is manifested by a clinic of retroperitoneal urinary leakage or leakage of urine from the wound.
Symptoms of iatrogenic injuries of the ureters depend on the nature of their damage. Ligation is accompanied by a clinical picture of renal colic. Damage to the ureter not detected during surgery is manifested by the release of urine through drainage from the abdominal cavity or retroperitoneal space already in the first hours after surgery. The outflow of urine into the abdominal cavity is manifested by symptoms of incipient peritonitis: irritation of the peritoneum and intestinal paresis. Non-drained or poorly drained urinary streaks become infected with the formation of retroperitoneal urinary phlegmon with subsequent development of urosepsis. A formidable symptom of ureteral obstruction is post-renal anuria. It can occur in patients with obstruction of the ureter of a single kidney or with bilateral damage to the ureters.
Diagnostics. In blood tests, leukocytosis is noted with a shift of the formula to the left, an increase in the level of creatinine and urea, and fresh red blood cells are determined in urine tests. When a liquid suspicious of urine is excreted through the drainage, the content of urea and creatinine in it is determined, and also carried out sample with indigo carmine. To do this, 5 ml of 0.4% indigo carmine is injected intravenously and the color of the released liquid is controlled. Staining it in blue indicates damage to the ureter. Chromocystoscopy establishes that indigo carmine from the mouth
Rice. 15.8. Antegrade pyeloureterogram on the right.
Extravasation of contrast agent (arrow) as a result of damage to the pelvic ureter
the damaged ureter is not allocated. catheterization ureter allows you to establish the degree and localization of its damage.
At ultrasound hydroureteronephrosis is detected when the ureter is ligated or the presence of fluid (urine) in the perirenal tissue and abdominal cavity.
Suspicion of damage to the ureter is an indication for emergency excretory urography or CT with intravenous contrast, and if necessary - retrograde ureteropyelography. A characteristic sign of the intersection or marginal damage to the ureter is the extravasation of the radiopaque substance (Fig. 15.8), and during ligation, the absence of its release.
Treatment damage to the ureters depends on their type, location and time elapsed since the injury. When open
Injuries require diversion of urine by puncture nephrostomy and drainage of urinary leakage. After the wound has healed, an operation is performed to restore the patency of the ureter. Marginal damage to the ureter, which occurred as a result of endourological operations, after the installation of the stent, closes on its own.
Iatrogenic injuries of the ureter, diagnosed during surgery, are subject to immediate correction, which depends on the type of damage. The marginal defect of the ureter is sutured with interrupted vicryl sutures; in case of more extensive defects or ligation of the ureter, resection of its altered sections is performed with ureterouretero or ureterocystoanastomosis. If iatrogenic damage to the ureter is not seen during surgery, it can result in urinary leakage, peritonitis, cicatricial narrowing, and ureterovaginal fistulas. In such cases, and especially with the development of postrenal anuria, percutaneous puncture nephrostomy with drainage of urinary streaks is indicated. In the future, depending on the length and localization of the narrowing or obliteration of the ureter, reconstructive and restorative operations are performed: ureteroureteroanastomosis, ureterocystoanastomosis (Fig. 52, 53, see color insert), and with extended or bilateral narrowing - intestinal plastic of the ureters ( Fig. 54, 55, see color insert).
15.7.3. Bladder injury
Bladder injury refer to severe injuries of the abdomen and pelvis. The severity of the condition of the victims and the outcomes of treatment are determined not so much by bladder injuries, but by their combination with injuries to other organs and dangerous complications caused by leakage of urine into the surrounding tissues and the abdominal cavity.
Classification. Bladder injuries are divided into closed and open, insulated and combined. They can be non-penetrating and penetrating when all layers of the bladder wall are damaged and urine is excreted outside of it. In peacetime, closed bladder injuries predominate. They can be intraperitoneal, extraperitoneal and combined, when there is a simultaneous intra- and extraperitoneal rupture of the bladder.
Epidemiology. The frequency of bladder injuries in closed abdominal trauma ranges from 3 to 16%. In most cases, extraperitoneal organ ruptures are observed.
Etiology and pathogenesis. Closed injuries of the bladder in most cases (70-80%) are the result of fractures of the pelvic bones. With this mechanism of injury, extraperitoneal ruptures prevail, which occur as a result of sudden displacement of the vesico-prostatic and lateral ligaments of the bladder. The sharp tension of dense anatomical formations, which are its ligaments, leads to a rupture of the more pliable soft-elastic wall of the bladder. Direct damage to its wall by displaced bone fragments is also possible. Intraperitoneal injuries have a different mechanism of development. The rupture occurs as a result of a hydrodynamic impact on the wall of an overflowing bladder. Such damage occurs even with minimal traumatic impact on the lower abdomen (sudden impact) with a relaxed anterior abdominal wall.
Injuries to the bladder, as well as to the ureters, are often iatrogenic in nature. Especially often his injuries occur during obstetric and gynecological operations.
Symptoms and clinical course. For bladder injuries X typical pain in the lower abdomen, which is especially pronounced in fractures of the pelvic bones. Vivid symptoms of bone injury, especially with the development of a state of shock, mask the manifestations of intrapelvic organ damage, including bladder damage. It should be remembered that in patients with pelvic fractures, ruptures of the bladder and / or membranous urethra most often occur. These injuries should be excluded in the first place when examining such victims. The clinic of an acute abdomen is the main manifestation of intraperitoneal rupture of the bladder. The presence of a large amount of urine in the abdominal cavity causes a characteristic symptom of "roly-poly". An attempt to lay the victim leads to a sharp increase in pain throughout the abdomen, which is associated with irritation of a large number of nerve endings due to movement
fluid in the upper abdomen. As a result, he tends to assume a vertical position.
Penetrating ruptures of the bladder are always accompanied by urination disorders, the severity of which is directly related to the degree of the defect formed. Despite frequent urgent urges, independent urination is impossible. An attempt to urinate leads to the movement of urine outside the organ, accompanied by a sharp increase in pain and the absence or minimal release of it with an admixture of blood through the urethra.
With late treatment and injuries not recognized in time, severe septic complications develop: with extraperitoneal damage - pelvic phlegmon, and with intraperitoneal damage - diffuse urinary peritonitis.
Diagnostics. Taking an anamnesis allows you to establish the nature of the injury (hit by a vehicle, falling from a height, a strong blow to the abdomen). The patient's condition is severe, pain and protective tension of the muscles of the anterior abdominal wall are determined by palpation. With intraperitoneal rupture, pronounced symptoms of peritoneal irritation, intestinal paresis are determined. Rectal digital examination allows to exclude ruptures of the rectum, to reveal its pastosity and overhang of the anterior wall, caused by leakage of urine. Women need to have a vaginal examination.
ultrasound with intraperitoneal rupture of the bladder, it allows to identify free fluid in the abdominal cavity with poor visualization of an insufficiently filled bladder. Extraperitoneal rupture is characterized by deformation of the bladder wall and the presence of fluid outside it.
Bladder catheterization and retrograde cystography is one of the main and most reliable methods for diagnosing bladder ruptures. You should first make sure that there is no injury to the urethra, since it is contraindicated to pass instruments through it. Signs of damage to the bladder during its catheterization are:
■ the absence or small amount of urine in the bladder of a patient who has not urinated for a long time;
■ excretion of a large amount of urine mixed with blood, exceeding the maximum capacity of the bladder (sometimes 1 liter or more);
■ discrepancy between the volume of fluid injected and excreted through the catheter (Zeldovich's symptom).
Bladder catheterization is performed on an X-ray table, so that after evaluating its results, immediately proceed to retrograde cystography. Before it begins, a survey radiography of the pelvic region is performed, which allows you to determine the nature and extent of bone damage. Features of performing retrograde cystography are as follows:
■ high concentration of injected contrast agent to avoid loss of information as a result of its dissolution in large quantities
Rice. 15.9. Retrograde cystogram. Extraperitoneal bladder rupture
fluid contained in the abdominal cavity;
■ tight filling of the bladder with the introduction of at least 300 ml of radiopaque substance;
■ assessment of the volume of the excreted contrast agent.
Radiographs are performed in the following sequence: in direct, semi-lateral (lateroposition) projection, after palpation of the bladder area and after its emptying.
Signs of a penetrating extraperitoneal rupture of the bladder
rya are the deformation of its walls and the leakage of the radiopaque substance beyond its limits (Fig. 15.9). With intraperitoneal ruptures, shapeless streaks of contrast agent are determined in the abdominal cavity.
Excretory urography in case of bladder injuries, it is not very informative due to insufficient contrasting of the bladder on a descending cystogram, however, in some cases it is advisable to perform it in order to exclude damage to the kidneys and upper urinary tract. Reliable information can be obtained from CT, especially with retrograde contrasting of the bladder.
Cystoscopy with ruptures of the bladder due to its insufficient filling, pain syndrome and hematuria, it is uninformative.
Rice. 15.10. Methods for draining the pelvic tissue through the suprapubic wound (1), the obturator foramen (2) and the perineum (3)
Treatment. With non-penetrating ruptures of the bladder, a permanent catheter is installed for 3-5 days, hemostatic and antibacterial therapy is prescribed. Penetrating ruptures require emergency surgery. The existing defects of the bladder are sutured with a double-row continuous-nodal vicryl suture, urinary streaks are widely drained in the pelvic cavity, and in case of an intraperitoneal rupture, the abdominal cavity is sanitized and drained if less than 12 hours have passed since the injury. If more than 12 hours have passed since the injury h and there is urinary peritonitis, it is advisable to perform extraperitonization of the bladder in order to separate the sutured bladder wound from the abdominal cavity. Drainage of the small pelvis is carried out through the suprapubic wound, the obturator foramen according to McWorter-Buyalsky and the perineum (Fig. 15.10). The operation is completed with epicystostomy, which is the universal and most reliable method of urine diversion. Drainage with a urethral catheter is possible if no more than a day has passed since the injury and qualified postoperative monitoring is provided. This type of drainage of the bladder in women is more justified.
15.7.4. Urethral injury
Due to the anatomical structure of the urethra, in clinical practice, damage to the urethra is mainly found in men. Recently, due to the widespread introduction of endourological interventions, iatrogenic damage to the urethra has become more frequent.
Etiology and pathogenesis. Theoretically, any part of the urethra can be damaged. In practice, damage to its two sections is mainly found: perineal - with a direct blow and membranous - with a fracture of the pelvic bones.
The anterior urethra (hanging, perineal and bulbous section) is more often damaged by direct traumatic impact: falling by the perineum on hard objects (edge of a bench, fence, manhole cover, bicycle frame), posterior sections (membranous and prostatic) - due to fracture of the pelvic bones. That is why ruptures of the anterior urethra are, as a rule, isolated in a relatively satisfactory condition of the victim. Injuries to the posterior urethra in pelvic fractures are often combined with ruptures of other nearby organs (bladder, rectum) and are accompanied by a severe, often shock, condition of the patient. As a rule, with a fracture of the pelvic bones, the membranous (webbed) section of the urethra is damaged. This section is not closed by the cavernous bodies and consists only of the mucous and submucosal layer, surrounded by connective tissue and ligamentous apparatus of the pelvis. Fracture of the anterior pelvic half ring is accompanied by a sharp stretching and tearing of its ligaments with a rupture of the poorly protected membranous urethra. In some cases, damage by displaced bone fragments occurs.
Injuries to the urethra are rare in women. Their causes are fractures of the pelvic bones, domestic trauma, sexual intercourse, complicated childbirth.
Classification. Distinguish open and closed urinary tract injury. Depending on the localization, damage is distinguished front or rear section of the urethra.
Clinical and anatomical classification:
Non-penetrating ruptures (tears of part of the wall of the urethra): internal (from the side of the mucous membrane); external (from the side of the fibrous membrane).
Penetrating breaks:
full (circular);
incomplete (rupture of one of its walls).
Such a division is very important for determining treatment tactics, since non-penetrating ruptures are treated conservatively, and penetrating ruptures are treated surgically.
Symptoms and clinical course. Victims complain of pain in the perineum, lower abdomen, in the penis, which sharply increase when trying to urinate. Pain is especially pronounced and multifactorial in case of fractures of the pelvic bones and combined damage to the intrapelvic organs. A characteristic symptom of damage to the urethra is urethrorrhagia (bleeding of blood from the external opening of the urethra outside the act of urination). With non-penetrating ruptures, when the act of urination is preserved, urethrorrhagia is combined with initial hematuria. Urination is impossible with complete penetrating ruptures of the urethra. Urinary retention is accompanied by strong urges, attempts to urinate are unsuccessful, while urine is poured into the paraurethral tissues and surrounding cellular spaces. Subsequently, urinary stagnation develops, and when it becomes infected, urinary phlegmon and urosepsis develop.
Diagnostics. The general condition of the patient with isolated injuries suffers little. Local manifestations come to the fore: pain in the area of the damaged urethra, urethrorrhagia and impaired urination. On examination, there are bruises, cyanosis of the skin of the perineum, scrotum and penis, swelling of the tissues surrounding the urethra. In the area of the external opening of the urethra - gore. The serious condition of the victims is observed with ruptures of the urethra associated with fractures of the pelvic bones and combined damage to the intrapelvic organs. Many patients go into shock. They are pale, adynamic, inadequate, there is a frequent pulse and hypotension.
Radiography establishes the localization and severity of fractures of the pelvic bones. Retrograde urethrography is the main method for diagnosing urethral ruptures. It allows you to determine the location and extent of damage to the urethra. With penetrating injuries, the radiopaque substance is found outside the urethra in the form of shapeless streaks (Fig. 15.11). If its rupture is complete, extravasation is more pronounced, while there is no contrasting of the urethra
Rice. 15.11. Retrograde urethrogram. Leakage of radiopaque substance due to rupture of the membranous urethra (arrow)
proximal to the site of damage and the contrast agent does not enter the bladder.
Bladder catheterization for the purpose of diagnosing urethral rupture is uninformative, it can lead to infection and transfer of a non-penetrating rupture to a penetrating one.
Treatment. The tactics of treating urethral ruptures depend on the severity of the condition of the victims, the degree of damage and the time elapsed since the injury. Conservative treatment is carried out with non-penetrating ruptures and consists in the appointment of painkillers, hemostatic and antibacterial therapy.
Penetrating ruptures are an indication for emergency surgery. In all cases, it is necessary to divert urine by epicystostomy and drain paraurethral urinary streaks. The operation can be expanded for
execution score primary urethral suture. Such tactics are possible under the following conditions: 1) if no more than 12 hours have passed since the moment of injury; the general condition of the victim is stable (no shock); there is a qualified team of urologists with experience in performing operations on the urethra. The operation consists in perineotomy, revision and debridement of the wound, refreshment and mobilization of the ends of the damaged urethra and the formation of a urethro-urethroanastomosis on a catheter inserted into the bladder cavity (preferably on a two-way drainage system).
Complications ruptures of the urethra are strictures and obliterations of the urethra. They develop in all patients with penetrating wounds, with the exception of those who have had a primary urethral suture.
15.7.5. Strictures and obliterations of the urethra
Urethral stricture called the narrowing of its lumen as a result of replacement of the wall of the urethra with scar tissue. Obliteration complete replacement of the urethral site with scar tissue is considered.
Strictures and obliterations of the urethra due to their prevalence, the presence of urinary fistulas, the tendency to rapid recurrence and high
Rice. 15.12. Retrograde urethrogram. Perineal urethral stricture (arrow)
the frequency of development of erectile dysfunction are a complex medical and social problem.
Etiology and pathogenesis. Distinguish congenital and acquired constriction of the urethra. The latter are much more common. Due to their formation, they are divided into: post-inflammatory, chemical and post-traumatic. Post-inflammatory diseases predominated before the introduction of antibiotic therapy. They are more often localized in the anterior urethra and, as a rule, are not single. At present, most
cases there are post-traumatic strictures and obliteration of the urethra.
Symptoms and clinical course. The main manifestation of urethral strictures is difficulty urinating. The pressure of the urine stream decreases as the disease develops and the degree of narrowing of the urethral lumen increases. With strictures located in the posterior urethra, the urine stream is weak, falls vertically, the time of urination is lengthened. A characteristic symptom of narrowing of the anterior sections is spraying of the urine stream.
With obliteration of the urethra, independent urination is impossible, the patient has a permanent suprapubic vesical fistula in which a Foley or Pezzer catheter is installed to divert urine.
Diagnosis is based on urethrography(Fig. 15.12) and ureteroscopy(Fig. 3, see color insert). With the help of these studies, lo-
calization, length and severity of narrowing. Retrograde urethrography in combination with antegrade cystourethrography makes it possible to estimate the size of the obliterated area of the urethra (Fig. 15.13).
Differential diagnosis narrowing of the urethra in men should be carried out with diseases that are also characterized by difficulty urinating - benign hyperplasia, sclerosis, prostate cancer, anomalies, stones, tumors of the urethra.
Treatment may be conservative or operative. conservative
Rice. 15.13. Retrograde urethrogram with antegrade cystourethrogram. Contrast defect due to obliteration of the membranous urethra (arrow)
consists in bougienage of the urethra. This method has been used since ancient times. It is palliative and is indicated for short (no more than 1 cm) constrictions. Bougienage consists in forcibly carrying out hard instruments specially designed for this purpose, which are called bougie, through the scar-narrowed areas of the urethra. The bougie has an increasing size (diameter) and can be elastic and metal (see Ch. 4, Fig. 4.42) To make the bougie go easier and reduce pain, a special gel with an anesthetic and antiseptic is injected into the urethra (instillagel, catedzhel) . In some cases anesthesia is used. Urethral bougienage requires caution, as it is performed blindly, and may be accompanied by a number of complications: ruptures of the unchanged wall, the formation of a false passage, urethrorrhagia, urethral fever, and the development of epididymitis and orchitis. Bougienage is supplemented with the appointment of anti-inflammatory and absorbable drugs.
Surgery. A planned operation to restore the patency of the urethra in patients with post-traumatic strictures and obliterations of the urethra is performed 4-6 months after the elimination of urinary streaks, perifocal inflammation and consolidation of pelvic fractures. The operation is performed endoscopically or openly. Endoscopic surgery consists of internal optical (under visual control) urethrotomy (Fig. 4, see color insert) and urethral recanalization. It is used for non-extended (up to 2 cm), including multiple narrowing of the urethra. It is a palliative intervention, since scarring
the tissue is not completely removed. In order to prevent recurrence after endoscopic dissection of the stricture, a special endoprosthesis (stent) is installed in the urethra. It is a spring, which, tightly adhering to the walls of the urethra, does not allow scar tissue to narrow its lumen (Fig. 15.14).
Resection of the urethra is a radical treatment for narrowing and obliteration. The operation consists in the complete excision of the scar tissue and the stitching together of its mobilized unchanged ends. This operation is easily performed when the narrowing is localized in the anterior (perineal) section of the urethra (resection of the urethra according to Holtsov). Much more difficult to resect
Rice. 15.14. Plain radiograph. Endoprosthesis (stent) of the urethra (arrow)
days of the urethra, for which special tools and surgical techniques are used. With more extended narrowings, skin or buccal (a section of the buccal mucosa) plastic surgery of the urethra is performed.
Forecast with timely performed radical surgical treatment is favorable. Patients with narrowing of the urethra should be under the constant supervision of a urologist due to the high risk of recurrence of strictures. Half of the patients with post-traumatic obliteration of the posterior urethra and after operations to restore its patency develop erectile dysfunction.
15.7.6. Damage to the external male genital organs
Damage to the male external genital organs can be open and closed. open are more often observed in wartime or result from animal bites (Fig. 82, see color insert) or stab wounds. Traumatic amputation of the genital organs is the result of accidental injury or deliberate mutilation. The causes of closed injuries are blows applied to this area, falls on the perineum and sexual excesses.
Closed injuries of the penis are divided into bruises, ruptures of the albuginea, dislocations and infringements by its pressing ring-shaped objects. The most common rupture of the dense protein membrane of the erect penis, which occurs as a result of forced intercourse. The characteristic crunch and severe pain that occurs at the same time led to the fact that this type of injury is called a penile fracture. Severe bleeding from the cavernous bodies is accompanied by the formation of extensive subcutaneous hematomas and, in combination with a defect in the albuginea, leads to a curvature of the organ (Fig. 83, see color insert).
Treatment is surgical and consists in evacuating the hematoma and suturing the rupture of the albuginea with vicryl ligatures. Patients should be under the supervision of a urologist due to the risk of fibrous changes in the cavernous bodies, curvature of the penis and weakening of erection.
Closed injury of the scrotum develops as a result of a direct traumatic impact on them: a kick, a ball, a fall on a bicycle frame, a fall from a height. There is severe pain, swelling of tissues with the formation of a hematoma. The rupture of the testicular capsule causes hemorrhage in the testicular membranes (hematocele), causing a sharp increase in the scrotum and a change in its color. Sometimes trauma to the scrotum can lead to a dislocation of the testicle or its displacement under the skin of adjacent areas. Testicular torsion is the most dangerous, since the resulting occlusion of the blood vessels that feed it leads to rapid necrosis of the organ.
Subcutaneous hematoma and hematocele make a negative symptom of diaphanoscopy. Ultrasound can visualize intratesticular hematomas, testicular fragmentation, and protrusion of the parenchyma through defects in the albuginea.
Surgery indicated for ruptures of the albuginea, the formation of large hematomas and testicular torsion. The operation consists in evacuating the hematoma, stopping bleeding, excising non-viable tissues and parenchyma, suturing the albuginea of the testicle and draining the scrotal cavity. When twisted, the testicle is turned in the opposite direction and fixed in the correct position. Orchiectomy is indicated only when the organ is not viable as a result of torsion and ischemia of the vascular pedicle or testicular crush.
15.7.7. Foreign bodies of the urethra and bladder
Etiology and pathogenesis. Foreign bodies of the urethra and bladder are rare. They should be regarded as one of the types of traumatic damage to these organs, firstly, because in some cases they get there as a result of trauma, and secondly, because, being in the lumen of the urethra or bladder, they have a permanent damaging action. In the urethra, they are found extremely rarely and only in men, and they enter the bladder through the urethra more often in women.
Foreign bodies can enter the urinary tract as a result of:
■ bladder injuries (bone fragments, fragments of injuring objects, bullets, etc.);
■ the introduction of foreign bodies by the patients themselves: children, persons with mental disorders, during self-catheterization or masturbation (pencils, glass rods, hairpins, beads, thermometers, etc.).
■ instrumental interventions and operations on the urethra and bladder (gauze balls, napkins, broken parts of bougie, catheters, bladder drains, stone extractors, etc.).
Symptoms and clinical course depend on the size, shape, configuration and prescription of objects in the urinary tract. Patients are concerned about pain in the urethra and suprapubic region, frequent painful urination, blood in the urine. Over time, foreign bodies become infected and become the causes of urethritis or cystitis.
Diagnostics. The analysis noted leukocyturia and hematuria. The diagnosis is established on the basis of sonography, survey and excretory urography, retrograde urethro- and cystography, CT and MRI. Urethrocystoscopy allows you to finally verify the presence, location and nature of the object located in the lower urinary tract.
Treatment. All foreign bodies must be removed either endoscopically or by open surgery. The conditions for extracting a foreign object during urethrocystoscopy are its size and shape, allowing it to pass through the urethra, or the possibility of fragmentation to the appropriate size. An open operation consists of a urethro- or cystotomy with removal of the foreign body and drainage of the bladder.
test questions
1. What are the causes of renal colic and the mechanism of its development?
2. How is the differential diagnosis of renal colic and acute surgical diseases of the abdominal cavity carried out?
3. How to stop renal colic?
4. List the types of hematuria. How is it different from urethrorrhagia?
5. What is the algorithm for examining a patient with gross hematuria?
6. What diseases are most often complicated by acute urinary retention?
7. How to distinguish anuria from acute urinary retention?
8. List the types of anuria.
9. How is the differential diagnosis of postrenal anuria performed?
10. How is testicular torsion and acute orchitis differentiated?
11. What is the etiology and pathogenesis of priapism?
12. What are the mechanisms of kidney damage?
13. How are kidney injuries classified?
14. What is the importance of X-ray methods in the diagnosis of kidney damage?
15. What is an indication for surgical treatment for ruptured kidneys?
16. What is meant by iatrogenic injuries of the ureters?
17. Give a classification of bladder ruptures.
18. Describe Zeldovich's symptom.
19. What is the main diagnostic method for penetrating bladder ruptures?
20. What parts of the urethra and under what mechanism of injury are most often damaged?
21. What methods of treatment of injuries and post-traumatic strictures of the urethra are currently used?
Clinical task 1
A 28-year-old patient was taken to the emergency department of a multidisciplinary hospital with complaints of severe paroxysmal pain in the right lumbar region radiating down to the inguinal region, the right half of the scrotum, along the inner surface of the thigh. Attacks are accompanied by frequent urination, nausea, and repeated vomiting. The pains started three hours ago after riding a motorcycle on a bumpy road. Twice during the last six months he noted similar attacks, which were not so intense and disappeared after taking no-shpa. On examination, he behaves uneasily, literally rushing around the emergency room, unable to find a place for himself from pain. The abdomen is not swollen, soft, painful in the right hypochondrium. There are no symptoms of peritoneal irritation. Positive symptom of Pasternatsky. General analysis of blood and urine are normal.
Establish a preliminary and differential diagnosis. What is the examination plan for establishing the final diagnosis? How to stop an attack? Choose tactics of further treatment.
Clinical task 2
A 50-year-old patient was admitted to the urology clinic on an emergency basis with complaints of urine stained with blood, with worm-shaped clots, pain in the right lumbar region of a bursting nature. From the anamnesis it is known that episodes of hematuria were noted three times during the last 6 months. Pain in the lower back on the right appeared about 3 months ago and were regarded as manifestations of osteochondrosis. Treated on an outpatient basis. Ultrasound of the kidneys revealed expansion of the pyelocaliceal system and the upper third of the ureter on the right. In laboratory tests: blood test (hemoglobin 100 g / l, erythrocytes 3.2 x 10 12, leukocytes 8.0 x 10 9), blood biochemistry (urea 12 mmol / l, creatinine 120 μmol / l), urinalysis (erythrocytes cover all fields of view). Performed excretory urography. Shadows of contrasting calculi are not determined, the function of the left kidney is not impaired. On the right, slowing down the release of a contrast agent, expansion of the pelvicalyceal system of the kidney and ureter to the middle third, where the filling defect is determined.
Establish a preliminary diagnosis. Choose the tactics of additional examination and treatment of the patient.
Clinical task 3
A 68-year-old patient was admitted on an emergency basis with complaints of the impossibility of independent urination with a strong urge, bursting pains in the lower abdomen. The above complaints appeared suddenly, 6 hours ago. From the anamnesis it is known that the patient has been troubled by frequent, difficult urination, weakening of the urine stream for two years. Recently, periodically notes the admixture of blood in the urine, pain in the lower abdomen, "laying" of the urine stream when changing the position of the body. In the analysis of urine, erythrocytes cover all fields of view. According to ultrasound data, an enlarged prostate gland and a rounded hyperechoic formation with an acoustic shadow in the projection of the prostatic urethra 0.8 x 1.2 cm are located. on the sonogram.
Establish a diagnosis and choose a treatment strategy.
Clinical task 4
A 17-year-old patient was taken to the hospital 4 hours after an injury - a fall from a height onto the edge of a box with the left half of the body. Complains of pain in the left half of the lower back and abdomen, weakness, blood in the urine. The skin is pale, covered with cold sweat. Pulse 110 beats / min, blood pressure = 90/65 mm Hg. Art. In the region of the left hypochondrium, a painful formation is palpated, the lower edge of which is determined at the level of the navel. There are no symptoms of peritoneal irritation.
What is the preliminary diagnosis? What methods can be used to refine it? What treatment tactics to choose?
Clinical task 5
A 43-year-old patient was taken to the emergency room after being beaten on the street. On examination, there are many bruises and abrasions in the lower abdomen. An objective examination is difficult due to the fact that when you try to lay the patient down, he again assumes a vertical position due to a sharp increase in pain. On palpation - a sharp pain and symptoms: irritation of the peritoneum throughout the abdomen. The urge to urinate is increased. When trying to urinate, drops of urine with blood are noted.
What is the preliminary diagnosis and what should be done to clarify it? What will be the treatment strategy?
Clinical task 6
A 28-year-old patient was admitted on an emergency basis with complaints of the impossibility of independent urination, bleeding from the external opening of the urethra. Upon questioning, it became known that 4 hours ago in the courtyard he stepped on a half-open cover of a well hatch, fell into the well with one foot, and received a blow in the crotch with the edge of the unfolded cover. Then there was severe pain and copious discharge of blood from the external opening of the urethra, which decreased over time. Attempts to urinate were unsuccessful. Asked for medical help. On examination, there is a hematoma and swelling in the perineum, gore in the area of the external opening of the urethra.
Set the diagnosis. What is the tactics of examination and treatment?
Rice. 15.15. Retrograde urethrogram
patient 22 years old
Clinical task 7
A 22-year-old patient was admitted in a planned manner with complaints of difficulty urinating, weak pressure of the urine stream. Deterioration of urination is noted within 6 months after a perineal injury (fell on a bicycle frame), after which bleeding from the external opening of the urethra was observed. The patient underwent retrograde urethrography (Fig. 15.15).
What is determined on the urethrogram? Establish a diagnosis and choose a treatment strategy.
