EMERGENCIES ALL SHOULD KNOW:ABDOMEN AND PELVIC TRAUMA (URO-GENITAL)

TRAUMA

Trauma is defined as the morbid condition of body produced by external violence. Physicians with different specialties evaluate the trauma patient, as a high level of expertise is required. Ten per cent of patients with blunt or penetrating injuries of the abdomen have associated renal trauma.Renal trauma  can be acutely life-threatening but the majority of renal injuries are mild and can be managed conservatively.

Patients admitted with severe abdominal injury and shock will need prompt resuscitation and immediate laparotomy. Patients found to have either frank haematuria or microscopic haematuria and clinical shock should  be investigated with ultrasound and contrast enhanced computed tomography(CT scan). 

The mechanism of renal injuries is classified as blunt or penetrating.Blunt trauma is usually secondary to motor vehicle accidents, falls, vehicle-associated pedestrian accidents, contact sports and assault. Traffic accidents are the major cause for almost half of blunt renal injuries.Renal lacerations and renal vascular injuries make up only 10-15% of all blunt renal injuries.Gunshot and stab wounds represent the most common causes of penetrating injuries. In most cases, they result from interpersonal violence. Renal injuries from penetrating trauma tend to be more severe and less predictable than those from blunt trauma.

Initial assessment of the trauma patient should include securing of the airway, controlling any external bleeding and resuscitation of shock as required.The medical history should be detailed, as pre-existing organ dysfunction has a profound effect on trauma patient outcome. Physical examination is the basis for the initial assessment of each trauma patient. Haemodynamic stability is the primary criterion for the management of all renal injuries.

Ultrasound scans are used in the triage of patients with blunt abdominal trauma, they can be helpful in identifying which patients require a more aggressive radiological exploration to obtain a diagnosis of certainty. . Computed tomography (CT scan) is considered the gold standard method for the radiographic assessment of stable patients with renal trauma. Computed tomography(CT scan) more accurately defines the location of injuries, easily detects contusions and devitalized segments, visualizes the entire retroperitoneum and any associated haematomas, and simultaneously provides a view of the abdomen and pelvis. IVP should be done to  establish the presence or absence of one or both of the kidneys, clearly define the renal parenchyma, and outline the collecting system

The goal of management of patients with renal injuries is to minimize morbidity and to preserve renal function. Thus, renal exploration should be undertaken selectively. A life-threatening haemodynamic instability due to renal haemorrhage is an absolute indication for renal exploration, irrespective of the mode of injury. In stable patients, supportive care with bed-rest, hydration and antibiotics is the preferred initial approach. Patients who are  treated conservatively carry a risk of presenting with complications later. This risk correlates significantly with increasing grade. 

Early complications occur within the first month after injury and can be bleeding, infection, perinephric abscess, sepsis, urinary fistula, hypertension, urinary extravasation and urinoma. Delayed complications include bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension, arteriovenous fistula, hydronephrosis  pseudoaneurysms.

A different approach is needed in children, in whom no correlation between degree of haematuria and severity of injury has been found. Some studies have stated that all children presenting after trauma with haematuria (whether microscopic or macroscopic) should be investigated with computed tomography as the likelihood of important renal injury is greater.

Children are more susceptible to renal trauma than adults. Differences in anatomy and physiology, as well as the higher incidence of pre-existing renal disease, make children more likely to sustain injury.Haematuria is an important clinical sign of renal injury. Ultrasound is considered a reliable method for screening and following the course of renal injury of paediatric patients with blunt renal trauma. Also children may develop accidental zipper entrapment  injuries to the penis which may sometimes involve urethra.

URETER INJURIES

Any external injury to the flank or back and any calamity within the bony pelvis therefore places the ureter at risk. Perhaps because of its protected location, its small size and its mobility, trauma to the ureter is relatively rare and accounts for only 1% of all urinary tract trauma.

After gynaecological pelvic surgery, if any woman who complains of flank pain, develops vaginal leakage of urine or becomes septic should also be suspected of having injury to the ureter or bladder and should be investigated appropriately.Ureteral trauma should be suspected in all cases of penetrating abdominal injury Once recognized, they can be managed with ureteral stenting or by placement of a nephrostomy tube to divert urine.

Upper third: Uretero-ureterostomy

Transuretero-ureterostomy

Ureterocalycostomy

Middle third: Uretero-ureterostomy

Transuretero-ureterostomy

Boari flap and reimplantation 

Lower third: Direct reimplantation

Psoas hitch

Blandy cystoplasty

Complete: Ileal interposition

Autotransplantation 

URINARY BLADDER INJURIES

Lower urinary tract injury may be caused by either blunt, penetrating, or iatrogenic trauma. About 10% of trauma patients will manifest genitourinary tract involvement. About 70-97% of patients with bladder injuries from blunt trauma have associated pelvic fractures Traumatic forces may be transferred to the urinary bladder by the seatbelt and injuries usually occur in the patient with a full bladder. The two most common sign and symptoms are gross haematuria (82%) and abdominal tenderness (62%) in patients with major bladder injuries . Other findings may include the inability to void, bruises over the

suprapubic region and abdominal distension . Extravasation of urine may result in swelling in the perineum,Cystography is accepted as the most accurate  radiological study for diagnosing bladder.

Most patients with extraperitoneal rupture can be managed safely by catheter drainage only, Intraperitoneal ruptures occurring after blunt trauma should always be managed by surgical exploration.

URETHRAL INJURIES

The male urethra is divided into the anterior and posterior sections by the urogenital diaphragm. The posterior

urethra consists of the prostatic and the membranous urethra. The anterior urethra consists of the bulbar and

penile urethra. Only the posterior urethra exists in the female; 

Injuries to the posterior urethra occur with pelvic fractures, which are commonly caused by road traffic accidents, crush injuries or falls from height.

                                

The severe shearing forces necessary to fracture the pelvis are transmitted to the prostato-membranous junction, resulting in disruption of the prostate from its connection to the anterior urethra at the prostatic apex. 

Retrograde urethrography and magnetic resonance imaging have been correlated with this location of the injury . An accurate knowledge of the functional anatomy of the sphincter mechanism is essential to the success of posterior urethral surgery.Thus, clinical management can be advised accordingly:

• Type I no treatment required

• Types II and III can be managed conservately with suprapubic cystostomy (SPC) or urethral catheterisation.

• Types IV and V will require open or endoscopic treatment, primary or delayed.

• Type VI requires primary open repair.

 It has been shown that the more proximal the injury, the greater the risk of incontinence, impotence and stricture formation in the long follow up.These can occur involving the urethra, as well as being iatrogenic injuries caused by endoscopic instrumentation or during surgery for vaginal repair. 

Another less frequent cause of blunt anterior urethral trauma occurs in association with ruptures of the corpora cavernosa, which usually occur with an erect penis, often during intercourse. In these injuries, the urethra is involved in 20% of the cases. 

In females, urethral and bladder neck damageoccur quite often due to ischaemic injury during obstructed labour.

 Intraluminal stimulation of the urethra with foreign objects have also been implicated for urethral injuries.Iatrogenic urethral injuries caused by instrumentation are also one of the  common causes of urethral trauma.

Urethral ischaemic injuries related to cardiac bypass procedures are not infrequent and can result in long and fibrotic strictures.

 In conscious patient, a thorough voiding history should be obtained to establish the time of last urination, force of urinary stream, painful urination and presence of haematuria. Retrograde urethrography is considered the gold standard for evaluating urethral injury . A scout film

should be performed first.

 If posterior urethral injury is suspected, a suprapubic catheter is inserted; a simultaneous cystogram and ascending urethrogram can be carried out at a later date to assess the site, severity and length of the urethral injury.The potential early complications of acute urethral injuries include strictures and infections. After the patient has adequately recovered from any associated injuries, and the urethral injury has stabilized, the urethra can be thoroughly re-evaluated radiographically and, when necessary, the appropriate reconstructive procedure planned. It is important to make a distinction between posterior urethral stricture and a subprostatic pelvic fracture urethral distraction defect, as the principles of their surgical management are entirely different. Erectile dysfunction occurs in 20-60% of patients after traumatic posterior urethral rupture. Partial tears of the posterior urethra can be managed in most cases with a suprapubic or urethral catheter.The treatment options available include primary realignment, immediate open urethroplasty, delayed primary urethroplasty, delayed urethroplasty and delayed endoscopic incision.

The incidence of genital trauma is higher in men than in women, not only because of anatomical differences but also due to increased exposure to violence, performance of aggressive sports and motor vehicle accidents. blow to the erect penis may cause penile fracture, frequently occurring during consensual intercourse, the penis slips out of the vagina and strikes against the symphysis

pubis or perineum.

Testicular rupture is found in approximately 50% of blunt traumas to the scrotum. Off-road

bicycling and motorbike riding, especially on bikes with a dominant petrol tank, accidents from in-line hockey skating and rugby footballers have been associated with blunt testicular trauma . Any kind of full contact sports, without the use of necessary protective aids, may be associated with genital trauma.

Besides these risk groups, self-mutilation of the external genitalia have also been reported in psychotic patients and transsexuals .The presence of subcutaneous haematoma, without rupturing of the cavernosal tunica albuginea and no immediate detumescence of the erect penis, does not require surgical intervention.

 In the case of penile fracture, immediate surgical intervention with closure of the tunica albuginea is recommended. Blunt trauma to the scrotum can cause significant haematocele without testicular rupture. In cases of testicular rupture, surgical exploration with excision of necrotic testicular tubules and closure of the tunica albuginea is mandatory.
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• RENAL COLIC

  PRIAPISM

  ACUTE URINE RETENSION

  SEVERE PALLOR

  ABSCESS

  ANIMAL BITES

  POISONING

  BURNS

  SEIZURES

  PARALYTIC STROKE

  ANY PREGNANCY RELATED EVENT

  SUDDEN LOSS OR IMPAIRMENT OF VISION

  SUDDEN HEAD ACHE AND VOMITING

  HIGH GRADE FEVER

  NON-RESPONSIVENESS

  VIOLENT BEHAVIOUR

  SUDDEN CALF PAIN

  SEVERE BREATHLESSNESS

BUCCAL MUCOSAL GRAFT URETHROPLASTY FOR PROXIMAL BULBAR STRICTURE

A 45y man presented with obstructive urinary symptoms and previous history of endoscopic treatment for urethral stricture. Examination was unremarkable. RGU reveales a proximal bulbar urethral stricture, which was confirmed on cystourethroscopy. Buccal mucosal graft urethroplasty was done in a single sitting. Patient was discharged in a stable condition. He was asymptomatic with good flow at 1 year follow up.

EMERGENCIES ALL SHOULD KNOW:TESTICULAR TORSION

TESTICULAR TORSION

Sudden testicular pain could be because of the twisting of the spermatic cord.

 The spermatic cord carries the blood vessels to the testis. The twisting can knock off the blood flow to the testis and render the testis blood less( ischemic).This results in acute pain. The patient becomes incapacitated.

Sometimes the torsion is characteristically intermittent ; with episodes of  pain coming and going.

The necessity of diagnosing this condition early is very important as with every passing hour the testis becomes more and more devitalized.

In the initial few hours; we can resort to restoration of the rotated testis preferably under sedation with the help of anaesthesiologist ( either manually or by scrotal exploration).

The basic reason for the torsion is supposed to be inadequate fixation of the testis to the scrotal wall( clapper bell deformity).So whenever a person strains with this deformity, the spermatic cord tends to rotate onto itself leading to the ischemia and pain.

If the ischemia persists for a longer time:

1)either   because of the delay in patient reporting to health care professionals

2) or wrong or delay in diagnosis

Then the devitalisation of the testis will happen progressively. As the deformity happens in bilateral testes; the recommended  strategy is bilateral orchiopexy ( to prevent the rotation again in future by fixing the testis to the scrotal wall).

Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood. If treated either manually or surgically within six hours, there is a high chance (approx. 90%) of preserving the testicle. At 12 hours the rate decreases to 50%; at 24 hours it drops to 10%, and after 24 hours the rate of preservation approaches 0.

Clinically the patient has typically severe pain with no fever. He will not have any urinary symptoms( this history will exclude epididymo-orchitis( infective aetiology): a condition which mimics the torsion).There is antecedent trauma or straining leading to acute onset of the pain.

The scrotum is swollen and very tender to touch.The testis is usually high lying with axis horizontal.

We on a slightest suspicion seek for USG Doppler scrotum to know the vascularity of the testis or any compromise of it.

If any ambiguity is present we usually go for Testicular  scan .The radio nuclear scan shows the void of any activity in the center of the testis because of the  lack of vascularity. This almost always confirms the diagnosis.
Torsion is most frequent among adolescents with about 65% of cases presenting between 12 – 18 years of age.but it can occur at any age, including infancy.

Torsion of testicular appendix is a  type of torsion and is the most common cause of acute scrotal pain in boys ages 7–14. Its appearance is similar to that of testicular torsion but the onset of pain is more gradual.Unlike other torsions,the cremasteric reflex is still active. Typical treatment involves the use of over-the-counter analgesics and the condition resolves within 2–3 days.

EMERGENCIES ALL SHOULD KNOW:PARAPHIMOSIS

PARAPHIMOSIS

Paraphimosis is a condition where the foreskin becomes trapped behind the glans penis, and cannot be reduced (that is, pulled back to its normal flaccid position covering the glans penis). If this condition persists for several hours or there is any sign of a lack of blood flow, paraphimosis should be treated as a medical emergency, as it can result in gangrene of tip of penis due to compromise in its blood supply.It is seen in un-cicumcised patients.This is different from phimosis where the fore skin cannot be pulled back.

 The foreskin may be retracted during penile examination, penile cleaning, urethral catheterization, or cystoscopy procedures,or at the time of sexual intercourse, sometimes in in local infection,bad local hygiene,etc. The foreskin if left retracted for a long period, causes edema  of the foreskin tissue  (swollen with fluid),and forms a tight constricting band  which makes subsequent reduction of the foreskin difficult.

Paraphimosis can be avoided by bringing the foreskin back into its reduced position after retraction is no longer necessary.If one falls asleep with the fore skin retracted and neglects the area ,it may cause more oedema,change of colour of tip of penis from pink to blue and severe pain by morning especially in phimosis patients.One should not delay even one such episode, as it recurs and causes gangrene.

 Phimosis (both pathologic and normal childhood physiologic forms) is a risk factor for paraphimosis. Physiologic phimosis resolves naturally as a child matures, but it may be advisable to treat  pathologic phimosis via long-term stretching or elective surgical techniques (such as preputioplasty to loosen the pruptial orifice or circumcision to excise the foreskin tissue.)

Paraphimosis can often be effectively treated by manual manipulation of the swollen foreskin tissue. You can most of the times bring the fore skin back yourself.It is like getting a tight ring off your finger with the help of lubricants.This involves compressing the glans and moving the foreskin back to its normal position, usually with the aid of a lubricant, or cold compressions. If this fails, the tight edematous band of tissue can be relieved surgically with a dorsal slit or circumcision. 
An alternative method, the Dundee technique, entails placing multiple punctures in the swollen foreskin with a fine needle, and then expressing the edema fluid by manual pressure. Sometimes,hyaluronidase injection into edematous prepuce  is effective in reducing edema and allowing foreskin to be easily reduced.I
According to Ghory and Sharma, treatment by circumcision may be definitive  to be performed by a urologist. Other experts recommend delaying elective circumcision until after paraphimosis has been resolved.


In children paraphimosis may also present as obstructive voiding symptoms and acute urinary retention. Because of extreme pain, patients need support from anaesthesiologist in the form of local anaesthetic cream,jelly,injection or sedation with local penile block to relieve pain of manipulation or  surgery (circumcision).

EMERGENCIES ALL SHOULD KNOW::ACUTE TUBULAR NECROSIS (ACUTE RENAL SHUT DOWN)

ACUTE TUBULAR NECROSIS (ACUTE RENAL SHUT DOWN)

 is a medical condition involving the death of tubular cells that  transport urine to the ureters.Tubular cells continually replace themselves and if the cause of ATN is removed then recovery is likely. ATN is commonly defined as an abrupt decline in renal function, manifested by acute elevation in plasma blood urea nitrogen (BUN) and serum creatinine, occurring in hours to days to weeks.The presence of "muddy brown casts" of epithelial cells found in the urine during urinalysis is pathognomonic for ATN.

It may be classified as either toxic or ischemic. Toxic ATN occurs when the tubular cells are exposed to a nephrotoxic substance  Ischemic ATN occurs when the tubular cells do not get enough oxygen, a condition that they are highly sensitive and susceptible to, due to their very high metabolism.

Toxic ATN can be caused by free hemoglobin or myoglobin, by medication such as  aminoglycosides,  drugs such as cisplatin,amphoterecin, or by intoxication with ethylene glycol etc.Toxic ATN is characterized by proximal tubular epithelium necrosis, Necrotic cells fall into the tubule lumen, obturating it, and determining acute renal failure.Ischemic ATN can be caused when the kidneys are not sufficiently perfused for a long period of time as in renal artery stenosis or during shock. Hypoperfusion can also be caused by embolism of the renal arteries. Ischemic ATN specifically causes skip lesions through the tubules.

There are other causes like mis-matched blood transfusion,iodine-contrast induced reaction,extensive muscle damage,septic shock , diabetics.


The symptoms are common to any acute renal shut down like, nausea,vomiting,generalised swelling,decreased/no urine out put,delirium,coma etc.
The following tests confirm the diagnosis of ATN:

• BUN and serum creatinine
• Fractional excretion of sodium
• Kidney biopsy
• Urinalysis
• Urine sodium
• Urine specific gravity and osmolarity urine

In most people, ATN is reversible. The goal of treatment is to prevent life-threatening complications of acute kidney failure.Treatment focuses on preventing the excess buildup of fluids and wastes, while allowing the kidneys to heal. Patients should be watched closely for deterioration of kidney function.

Treatment can include:

• Identifying and treating the underlying cause of the problem
• Restricting fluid intake to a volume equal to the volume of urine produced
• Taking medications to help control potassium levels in the bloodstream
• Medicines taken by mouth or through an IV to help remove excess fluid from the body
• Most of the times there may be a block in the ureters due to necrotic material from kidney.This is managed by placing a DJ stent to allow proper functioning of kidneys.This is done by a urologist under anaesthesiologist cover. 
• 

Temporary dialysis can remove toxins and excess fluids. This can make  the kidney failure easier to control. Dialysis may not be necessary for all people, but is often lifesaving.

Dialysis may be needed in the following cases:

• Decreased mental status
• Fluid overload
• Increased potassium levels
• Pericrditis
• To remove toxins that are dangerous to the kidneys
• Total lack of urine production
• Uncontrolled buildup of nitrogen waste products

There is less urine for a few days to 6 weeks,and this may be followed by a period of high urine output (diuretic phase). This occurs because the healed and newly functioning kidneys try to clear the body of fluid and waste.

One or two days after  urine out put  increases, symptoms reduce and test results begin to return to normal.

At the time of Blood transfusions blood should be  crossmatched by two people  to reduce the risk of incompatibility reactions.Control the diseases like as diabetes, liver disorders, and cardiac disorders to reduce the risk of acute tubular necrosis.Drink a lot of fluids after having any radiocontrast dyes to allow them to be removed from the body and reduce the risk of kidney damage.