EMERGENCIES ALL SHOULD KNOW:PRIAPISM

PRIAPISM

Priapism is a condition in which the erect penis does not return to its flaccid state, despite the absence of both physical and psychological stimulation, within four hours. Priapism is considered a medical emergency which should receive proper treatment by a qualified medical practitioner. 

The condition develops when blood in the penis becomes trapped and unable to drain. If the condition is not treated immediately, it can lead to scarring and permanent erectile dysfunction.It can occur in all age groups, including newborns.
There are two types of priapism: low-flow and high-flow; 80% to 90% of clinically presented priapisms are low flow disorders. Low-flow involves the blood not adequately returning to the body from the organ. High-flow involves a short-circuit of the vascular system partway along the organ. Treatment is different for each type. Early treatment can be beneficial for a functional recovery.

Priapus is a fertility god (greek)  represented with a disproportionately large and permanent erection.
In the normal erection process, blood flows into the penis and, usually following an orgasm, drains out of the penis without discomfort. When priapism occurs the blood is unable to drain as it would -normally occur.. Because there is little room in the penis for blood to circulate, it becomes stagnant and begins to lose oxygen. Without oxygen, red blood cells become stiff, making proper penis drainage even more problematic.

The causative mechanisms are poorly understood but involve complex neurological and vascular factors. Any bodily ailment that causes blood to thicken or causes red blood cells to lose their flexibility and mobility can lead to priapism. Priapism may be associated with blood disorders, like sickle cell disease, malaria and other conditions such as leukemia, thalassemia, and neurological diseases  such as spinal cord lesions lesions and spinal cord trauma. It has been estimated that approximately 42% of adults with sickle-cell disease will eventually develop priapism.

 Priapism can also be caused by reactions to drugs like desyrel, used to treat depression, or thorazine, used to treat certain mental illnesses ,marijuana and cocaine.The most common medications that cause priapism are intra-cavernous injections for penile doppler,or treatment of erectile dysfunction, like papaverine etc.

Potential complications include ischemia, clotting of the blood retained in the penis (thrombosis), and damage to the blood vessels of the penis which may result in an impaired erectile function or impotence. In serious cases, the ischemia may result in gangrene, which could necessitate penectomy

.Medical advice should be sought immediately for cases of erection beyond four hours and one should be honest in giving proper information about situation/drug intake if any,  leading to priapism.
 Apart from analgesics, locally Ice is applied to the penis and perineum may reduce swelling.

If there is still no relief,the treatment at this stage is to aspirate blood from the corpus cavernosum under sedation with the help of anaesthesiologist.. If this is still insufficient, then intra cavernosal injections of phenylephrine are administered. This should only be performed by a urologist/andrologist/specialist trained in the procedure, with the patient under constant ECG monitoring, as phenylephrine can cause severe hypertension, bradycardia/tachycardia,arrhythmia 
.As the complication of shortened, indurated and non-erectile penis is high in prolonged priapism, early penile prosthesis implantation can be performed. Apart from early resumption of sexual activity, early implantation can avoid the formation of dense fibrosis and hence a shortened penis.

A general rule of thumb is to pay close attention to excess swelling or pain in the penis and to seek out care sooner rather than later if you suspect something ABNORMAL.

EMERGENCIES ALL SHOULD KNOW:RENAL COLIC

RENAL COLIC


The renal colic is a pain related to stones in urinary tract, comes in waves due to ureteric peristalsis. It may come in two varieties: dull and acute; the acute variation is particularly unpleasant and is often described as one of the strongest pain sensations felt by humans (being worse than childbirth, broken bones, gunshot wounds, burns, or surgery).

Passing kidney stones can be quite painful, the experience is said to be traumatizing due to pain, and the experience of passing blood, blood clots, and pieces of the stone. The majority of renal calculi contain calcium. The pain generated by renal colic is primarily caused by dilation, stretching, and spasm because of the acute ureteral obstruction.

Depending on the sufferer's situation, surgery may be needed to remove the stone which is impacted in the  urinary passage anywhere between kidney and urethra in both males and females.One may have kidney stones in one or both  kidneys or ureters. Blood clots, ureter spasms (tightening and relaxing), and dead tissue may also block the urinary tract.The pain may start quickly, come and go, and may become worse over time. One may have any of the following:

• Severe low back, abdominal, or groin pain. The pain may be so bad that you are not able to sit still. You may have pain when you urinate. The pain may also cause you to sweat and feel like your heart is beating faster than usual.
• Nausea and vomiting.
• Feeling the need to urinate often, or right away.
• Urinating less than what is normal for you, or not at all.

Most small stones are passed spontaneously and only pain killers and anti-spasmodics are required.There is typically no antalgic position for the patient (lying down on the non-aching side etc).

Medical treatment of nephrolithiasis involves supportive care and administration of agents, such as the following:

• IV hydration
• IV narcotic analgesics
• NSAIDS 
• Uricosuric agents (eg, allopurinol)
• Antiemetics
• Antibiotics 
• Alkalinizing agents (eg, potassium citrate, sodium bicarbonate): For uric acid and cysteine calculi
• Alpha blockers (eg, tamsulosin, terazosin)
  
  
  
  
  
  The reason why kidney stones are formed is still not known in many cases. Many waste chemicals are dissolved in the urine. The chemicals sometimes form tiny crystals in the concentrated urine which clump together to form a small stone.About half of the people who have a kidney stone develop another one at a later age in life.
  
  
  
  A stone that is stuck in a kidney may cause pain in the side of the abdomen.This is a severe pain which comes and goes and is caused by a stone that passes into the ureter (the tube that leads from the kidney to the bladder). The stone becomes stuck. The ureter squeezes the stone towards the bladder, which causes intense pain in the side of the abdomen. The pain may spread down into the lower abdomen or groin. The patient  may sweat or feel sick due to the pain.One may also see blood in  urine (urine turns red) caused by a stone rubbing against the inside of the ureter.Urine infections are more common in people with kidney stones. Infections can cause fever, pain on passing urine and increased frequency of passing urine.

 One is  more likely to form a stone if urine is concentrated. For example, if you exercise vigorously, if you live in a hot climate or if you work in a hot environment when you may lose more fluid as sweat and less as urine.

You are also more prone to develop kidney stones if you have:

• Recurrent urine or kidney infections.
• A kidney with scars or cysts on it.
• A close relative who has had a kidney stone.

The following are the battery of tests done if a person is having renal colic:

• Blood tests: routine blood tests,serum urea,creatinine  to know the function of kidneys,etc.
• Urine sample: A sample of your urine is collected and sent to a lab for tests for any infections.
• Renal ultrasound: A renal ultrasound is a test using sound waves to look at your kidneys. An ultrasound may show if you have a kidney stone or other problems that are causing your pain.
• Computed tomography scan: A computed tomography (CT) scan is a special x-ray using a computer to take pictures of your urinary tract. A CT scan may be done to check for stones and their size. A CT scan may also be done to check for other causes of your pain.
• KUB x-ray: A KUB  x-ray is a picture of your kidneys (K), ureters (U), and bladder (B).
• Intravenous pyelogram: An intravenous pyelogram (IVP) is an x-ray of your kidneys, ureters, and bladder. Dye is put into your IV before the pictures are taken.  People who are allergic to shellfish may be allergic to some dyes. You may need to have more than one x-ray over short periods of time during your IVP.
•    An analysis of the stone if you pass it out. To catch a stone, pass urine through gauze, a tea strainer or a filter    such as a coffee filter.

• The location and characteristics of pain in is related to site of stone in urinary tract:
  • Stones obstructing ureteropelvic junction: Mild to severe deep flank pain without radiation to the groin; irritative voiding symptoms (eg, frequency, dysuria); suprapubic pain, urinary frequency/urgency, dysuria, stranguria, bowel symptoms
  • Stones within ureter: Abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen; radiation to testicles or vulvar area; intense nausea with or without vomiting
  • Upper ureteral stones: Radiate to flank or lumbar areas
  • Midureteral calculi: Radiate anteriorly and caudally
  • Distal ureteral stones: Radiate into groin or testicle (men) or labia majora (women)
  • Stones passed into bladder: Mostly asymptomatic; rarely, positional urinary retention

• Management:
• Some stones that form and stick in the kidney do not cause symptoms or any harm. They can just be left if they are small. Sometimes you may be offered medicines to help the small stone pass through, such as  tamsulosin.
• The size of the stone is an important predictor of spontaneous passage. A stone less than 4 mm in diameter has an 80% chance of spontaneous passage; this falls to 20% for stones larger than 8 mm in diameter. However, stone passage also depends on the exact shape and location of the stone and the specific anatomy of the upper urinary tract in the particular individual.

       

Some stones become stuck in a ureter or kidney and cause persistent symptoms or problems. In these cases, the pain usually becomes severe and you may need to be admitted to hospital. There are various treatment options which include the following:

• Ureteroscopy is another treatment that may be used. In this procedure, a thin telescope either (flexible or rigid) is passed up into the ureter via the urethra and bladder. Once the stone is seen, a laser (or other form of energy) is used to break up the stone. This technique is suitable for most types of stone. The stone removal is followed by the  placement of DJ(Internal ureteral) stents which form a coil at either end, One coil forms in the renal pelvis and the other in the bladder. Stents are available in lengths from 20-30 cm and in 3 widths from 4.6F to 8.5F. The stents allow proper functioning of kidneys and are later removed usually after 4 weeks by a minor procedure.

• Extracorporeal shock wave lithotripsy (ESWL). This uses high-energy shock waves which are focused on to the stones from a machine outside the body to break up stones. You then pass out the tiny broken fragments when you pass urine.

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• Percutaneous nephrolithotomy (PCNL) is used for some select stones not suitable for ESWL. A nephroscope (a thin telescope-like instrument) is passed through the skin and into the kidney. The stone is broken up and the fragments of stone are removed via the nephroscope. This procedure is usually done under general anaesthetic.

About half of people who have a kidney stone develop another one within 10 years. Sometimes stones can be prevented from forming.f you have had one stone, you are less likely to have a recurrence if you drink plenty of fluid, mainly water, throughout the day (and night). The aim is to keep the urine dilute. (Your urine is more dilute if it is clear of colour rather than a dark yellow colour.) To do this, you should drink between two and three litres a day (unless your doctor advises otherwise if you have other medical problems). If you work or live in a hot environment, you should drink even more.

• A dietitian may advise people with calcium oxalate stones to reduce the oxalate content of their diet. This may include reducing rhubarb, coffee and spinach.
• Uric acid stones can be prevented with a medicine.

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PRIAPISM

ACUTE URINE RETENTION

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

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.