urology Flashcards
which is more concerning, gross or microhematuria
gross
describe an approach to hematuria
divide into:
- pre-renal
- -coagulation disorders
- -pseudohematuria (beets, dyes, laxatives) - renal
- -stones
- -trauma
- -tumours
- -infection
- -glomerulonephritis
- -vascular malformations - post renal
- -stones
- -trauma
- -tumours
- -infection
most likely cause of hematuria in age:
0-20 years
(in order of frequency)
glomerulonephritis
UTI
congenital anomalies
most likely cause of hematuria in age:
20-40 years
(in order of frequency)
UTI
stones
bladder tumour
most likely cause of hematuria in age:
40-60 years
(in order of frequency)
male–> bladder tumours, stones, UTI
female–> UTI, stones, bladder tumours
most likely cause of hematuria in age:
over 60 years
(in order of frequency)
male–> BPH, bladder tumour, UTI
female–> bladder tumour, UTI
what % chance is there that gross hematuria is a urological malignancy
25%
*gross, painless hematuria is malignancy until proven otherwise (trauma, infection, stones etc are generally symptomatic and picked upon hx)
what % chance is there that micro hematuria is a urological malignancy
5%
ddx of hematuria
most common are all pre or post renal
tumour trauma infections stones coagulopathy (doesn't cause gross hematuria)
things to ask on hx that suggest uro malignancy
weight loss night sweats flank pain N/V voiding changes
numer 1 risk factor for urothelial tumours
smoking
risk factors for urothelial tumours
smoking
occupational exposure (aniline dyes, hairdressers, painters, leather tanners)
meds (cyclophosphamide etc)
previous radiation exposure
chronic cystitis (catheters, infections)
what to ask on hx to evaluate stones
flank/abdo pain
dysuria
previous stones
what to ask on hx to evaluate uro infection
fever
chills
suprapubic or flank pain
dysuria
frequency
what investigations should you order to evaluate hematuria
- U/A and culture
- -leukocytes and nitrites suggest infection
- -dysmorphic RBCs with or without protein suggest glomerular cause or stones (maybe crystals)
- -C and S for infection - urinary cytology
- -collect specimen, more sensitive and specific depending on the grade of malignancy - CBC
- -hemoglobin and platelets (bleeding diathesis or coagulopathy?)
- -WBC for infection - PTT/INR
- -bleeding diathesis? - kidney function
what are the options for imaging the urinary tract
- ultrasound
- CT IVP/triphasic CT
- MRI
- IVP or retrograde pyelogram
- plain film KUB or CT KUB without contrast
for imaging the urinary tract:
pros of ultrasound
good for RENAL TUMOURS, STONES within kidney and hydronephrosis in the kidney
first investigation for microscopic hematuria (depends on risk category–> 40 yo or risk factors)
first step for signs of infection–> can do CT with contrast if there are findings
inexpensive and safe
for imaging the urinary tract:
cons of ultrasound
will miss ureteral stones, ureteral tumours and most small or flat bladder and renal tumours
may not differentiate blood clot from tumour in bladder or renal pelvis
no functional info
what is the first choice imaging test for patient with gross hematuria
CT IVP/triphasic CT
arterial/venous (later after injection)/excretory phase
image the ureters, kidney and bladder
contrast in the collection system can obscure views of stones tho
for imaging the urinary tract:
pros of CT IVP
most sensitive test for any GU pathology
accurate staging of renal/ureteric tumours and renal trauma
non contrast CT for patiens with renal colic
may demonstrate other disorders like abdominal aneurysm, ascesses, fluid collections, filling defects in the ureteric phase
for imaging the urinary tract:
cons of CT IVP
there can be adverse reactions to the IV contrast (allergy, nephrotoxicity)
expensive and has radiation exposure
contraindications for renal dysfunction, multiple myeloma, contrast allergy, pregnancy
can you use IVP or retrograde pyelogram for kidney tumours
no
what do you use IVP or retrograde pyelogram for
suspected stones or urothelial tumours of bladder and ureter
when do you use KUB or CT KUB without contrast in uro imaging
flank pain/renal colic–> good for ID stones (plain film will miss uric acid stones)
when do we work up hematuria
if its gross hematuria
if malignancy is suspected
if they’re symptomatic and have risk factors concerning for etiologies (i.e cancer)
hematuria in the acutely bleeding patient–> stabilize with fluids or blood and ABCs, irrigate the bladder and manage surgically
when should you refer a patient with hematuria to a urologist
any patient with gross hematuria needs both upper (radiology) and lower tract (cytoscopy) imaging
cytoscopy can be done fairly easily in the uro clinic
all patient with gross hematuria should see a urologist unless there is an obvious alternative
how you do diagnose urothelial carcinoma
cytoscopy and biopsy
what should you make sure to have done before making your uro referral for hematuria
hx px U/A urine cytology imaging to get dx as much as possible, with initial management and stabilizations of patient.
what is the imaging choice if the suspected cause of the hematuria is:
- post renal
- renal
- CT–> post renal
2. U/S–> renal
what is the workup for urothelial carcinoma
cytoscopy and biopsy
treatment of urothelial cancers
transurethral resection of the lesion and underlying detrusor muscle to stage the tumour
risk factors for urothelial tumours
SMOKING occupational exposures meds previous radiation chronic infection or inflammation irritation (i.e catheters)
ddx of urothelial tumours
urothelial carcinoma (transition cell)
adenocarcinoma (dome/trigone of bladder)
squamous cell carcinoma (associated with chronic inflammation from bladder stones, indwelling catheter etc)
most common urothelial tumour
urothelial carcinoma (transitional cell carcinoma)
what kind of urothelial tumour is associated with associated with chronic inflammation from bladder stones, indwelling catheter etc
squamous cell carcinoma
what kind of urothelial tumour is associated with dome/trigone of bladder
adenocarcinoma
how do you assess severity of a urothelial tumour
- grade–> histologic appearance is high vs low grade
- stage–>
- -non-muscle invasive bladder cancer (T1 disease) vs. muscle invasive (above T1 disease)
- -T1 involves invasion into lamina propria, T2 begins shallow muscle invasion
treatment of non-muscle invasive bladder cancer
transurethral resection of lesion
if high grade or multifocal, use more invasive measures like chemo or BCG (which we think stimulates the immune system)
consider mitomycin C to prevent recurrence
consider intravesical chemo if high grade, lamina propria invasion (T1), multifocal, carcinoma in situ, unable to completely reset or rapid recurrence after resection
- -> commonly cisplatin
- -more effective as neoadjuvant treatment
reassess response to theraoy (persistent CIS after chemo?) may need radical treatment
what agent is commonly used as intravesical chemo if bladder cancer is high grade, or multifocal or etc…
cisplatin
what might you use to try and prevent recurrence after bladder cancer resection
mitomycin C
how do you treat muscle invasive bladder cancer
radical cystectomy with or without systemic chemo–> may even be done palliatively to stop bleeding or pain
radical cystectomy is indicated if muscle invasive disease, high grade NMIBC refractory to intravesical therapy, unresectable NMIBC or palliation to control hemorrhage
requires a urinary diversion–.> ileal conduit is simple but has stoma and incontinence//neobladder has no bag, but has higher risks of complications and recurrence
ddx for benign renal mass on imaging
oncocytoma
angiomyolipoma –> fat; observable
abscess
pseudotumour –> dromedary hump, hypertrophied column of Bertin, compensatory hypertrophy
ddx for malignant renal mass on imaging
renal cell carcinoma (most common)
urothelial cell carcinoma
mets–> lymphoma/leukemia, lung, breast
Wilms tumour (kids)–> highly treatable, arises from parenchyma
what is the likely diagnosis for a central renal mass in the collecting duct
transitional cell carcinoma/urothelial cell carcinoma
lines the renal pelvis, ureters, bladder
RESECT ALL IF MALIGNANT
how are renal masses usually detected
incidentally
classic triad of symptoms of renal mass
flank pain
hematuria
palpable mass (uncommon)
what type of mass makes up 90% of malignant renal masses
renal cell carcinoma
25% present with mets
clear cell RCC is the most common subtype
where are mets commonly from if met to kidney
lymphoma
leukemia
lung
breast
investigations to work up a renal mass
CT abdo/pelvis–> characterize mass (malignany, tumour size, nodes, mets)
CXR–> assess for mets
Labs–>
- -ALP (for bone mets)
- -liver function tests (for hepatic mets or portal vein involvement)
- -calcium (good for bone mets or paraneoplastic syndrome)
- -paraneoplastic syndrome can cause other things (HTN, polycythemia, increased ESR etc)–> decreased DMSA uptake indicates real tumours, normal uptake indicates psuedotumour
biopsy–> kind of useless because we resect anyways but can help with dx
what test can be done to help distinguish between real kidney tumours and pseudotumours
decreased DMSA uptake indicates real tumours, normal uptake indicates psuedotumour
how do you treat RCC
if locally confined, can use nephrectomy or partial nephrectomy (if less than 7 cm, bilateral tumours, only one kidney, hereditary syndrome etc)
if metastatic, combine nephrectomy with targeted chemo (sunitinib)
if not surgical candidate, can try ablation but hard to tell if there is tumour left over after
what chemo agent do you use to treat metastatic RCC (in addition to nephrectomy)
sunitinib
what is the most common cause of renal colic
acute obstruction of the ureter by the stone
when do non-obstructing stones cause pain
only when occur with UTI
what size stones usually pass on their own?
stones less than 4mm are 90% likely to pass
stones over 8mm are only 20% likely to pass
what are the 3 most common sites of ureteric stones
sites of physiologic narrowing–
- uretero-pelvic junction
- crossing of the iliac vessels
- uretero-vesical junction
ddx for renal colic
very broad
therefore must have diagnosis with imaging and microhematuria workup before referring to a urologist
- urgent–> AAA (rupture?), appendicitis, ectopic pregnancy, septic stone
- GI–> cholecystitis, biliary colic, diverticulitis, IBD
- gyne–> PID, ovarian torsion
- GU–> renal/ureteric calculi, pyelonephritis
- other–> lumbar disc herniation, herpes zoster
lab investigations for renal colic
CBC (WBC indicates inflammation and infection)
creatinine (renal function/obstruction)
urine micro (bacteriuria, pyuria, pH)
imaging for renal colic FIRST TEST
plain film KUB
85% of stones are radioopaque except uric acid stones (needs CT)–> there is no info about obstruction tho
which stones are NOT radio opaque
uric acid stones
struvite stones
imaging beyond plain film KUB for renal colic
CT scan without contrast or CT-KUB (fast, easy, inexpensive, gives info on obstruction)
how do you manage small stones that are asymptomatic
watchful waiting
ALPHA BLOCKERS can relax the ureter and may help with spontaneous passage
when should you refer a patient with stones to a urologist
- fever/chills, bacteriuria, high WBC or other risks of urosepsis
- obstructed ureter with diabetes
- solitary kidney
- renal failure
- significant comorbidities
how do you treat stones causing obstruction
- retrograde ureteric stents–> double J stents can be placed antegrade or retrograde under GA, and stay in place with low risk of bleeding
- percutaneous nephrostomy tubes–> placed under local anesthetis by IR after pus drained, but these have higher bleeding risks
- remove stone–> conservative passed if uncomplicated with alpha blocker, hydration, NSAIDs
- -ESWL if less than 2 cm or ureteric stone (shocks localized by xray fragment the stones)
- -ureteroscopy with basket (if stone small enough) or laser (if stone too large for basket)
- -percutaneous nephrolithotomy (for stones about 1-2 cm and/or up near the kidney or staghorn stones)–> risks include bleeding and renal perforation
what is the most common type of renal stone
calcium oxalate
risk factors for calcium oxalate stones
hypercalciuria (hyperparathyroidism or dietary intake)
high sodium or protein diet
chocolate
nuts
tea
what is the second most common type of renal stone
calcium phosphate
in what type of patients do you find calcium phosphate stones
those with metabolic abnormalities–hypercalcemia, primary hyperparathyroidism
what types of stones are associated with infectious causes
struvite stones–> forms staghorn stones
can only form if urine pH is above 8, thus usually only present with urease positive bacteria
made of Mg, ammonium phosphate, calcium
risk factors for uric acid stones
persistent acidic urine
low urine volumes
gout
excess purine in diet (meat)
how do you investigate microhematuria
repeat measurement (more than 5 red cells for HPF?)
assess for proteinuria (if normal, likely not renal cause)
send for micro for closer assessment
renal U/S
refer to urologist for cystoscopy
describe a diagnostic approach to a scrotal mass
- infectious–> PAINFUL
- -epididymitis or orchitis - anatomic
- -hydrocele, varicocele, spermatocele
- -testicular torsion or torsion of appendix testis - malignant
- -testis tumour
what investigations should you do in someone with a scrotal mass
- U/A–> pyuria with epididymitis/orchitis
2. U/S–> very sensitive and specific for testicular tumours
what is epididymitis
infectious scrotal mass
common in young adults (under 35) and is often associated with STI or babies with UTI or older men with BPH UTIs
older than 35 years, usually e coli
presents with tender, indurated (hardened) epididymis
how does acute epididymitis present
acute pain, testicular swelling, erythema, hardening with or without dysuria, fever, pyuria
investigate with CBC, U/A for pyuria, consider doppler U/S
how do you treat acute epididymitis
NSAIDs
abx for 4 weeks
ice prn
what virus is associated with orchitis
mumps–> can lead to sterility
can also be associated with other viruses
how does orchitis present
swollen and very tender testicles, often bilaterally
what is a hydrocele
fluid within the layers of the tunica vaginalis at a certain point
is a communicating hydrocele if the processus vaginalis is patent
how does a hydrocele typically present
painless
transilluminates
testicle palpation is difficult
how do you treat a hydrocele
none required, may do for cosmetic reason
what is a spermatocele
aneurysmal blowout of the epididymis (dilation of the tubule)
how does a spermatocele usually present
typically painless
transilluminates
can palpate testicle separate from mass
how do you treat a spermatocele
none required as they generally dont grow or cause problems, may treat for cosmetic reasons
what is a varicocele
most are left sided in the pampiniform plexus, which drains the testicle
can lead to male factor infertility, but most men have normal fertility
how does a varicocele usually present
typically asymptomatic
increases with standing or valsalva
palpated as “bag of worms”/spaghetti in the scrotum/cord
treatment for varicocele
surgical or sclerotherapy
what is the most common age group to present with testicular torsion
12-18 year olds
why do we care about testicular torsion
surgical emergency requiring surgical scrotal exploration as there is 6 hours to prevent irreversible testicular ischemia
how does testicular torsion present on physical exam
associated with bell clappers deformity and high riding horizontal testicle
often has absent cremasteric reflex
Prehn sign–> relief of pain when supporting scrotum (suggests epididymitis)
investigations for testicular torsion
U/A to rule out pyuria for epididymitis
doppler to clarify diagnosis
treatment for testicular torsion
surgical detorsion and orchidoplexy (fix the testicle in the scrotum)
how does torsion of appendix testis present
may mimic testicular torsion but commonly has a blue dot sign
uncommon in older men
testes may be inflamed and tender at appendix but not likely elevated or horizontal
investigations for torsion of appendix testis
U/A to rule out epididymitis
dopple to assess perfusion
treatment for torsion of appendix testis
conservative, symptom management and urological assessment
how does testicular cancer usually present
as painless mass in young healthy men aged 15-35 found on self exam
on px–> hard, irregular, doesn’t transilluminate, B symptoms
what are the types of testicular cancer
primary vs secondary
primary is germ cell vs non germ cell
germ cell is non seminoma versus seminoma
investigations for testicular cancer
- bHCG–> produced by choriocarcinoma and some seminomas
- alpha fetoprotein–> produced by yolk sac, embryonal carcinoma, teratocarcinoma
- LDH–> correlated with tumor volume
- scrotal U/S and CT abdo pelvis
- CXR and CT head for mets
- CT for staging
treatment rates for testicular cancer
cure rates are very good
germ cell tumours are highly chemosensitive
radical orchiectomy (ALWAYS via the inguinal canal retroperitoneal, not the scrotum)
where do seminoma germ cell tumours originate
germinal epithelium of the seminiferous tubules
older and middle aged patients, less aggressive
what are the types of non-seminoma germ test testicular cancers
embryonal carcinoma
teratoma or teratocarcinoma
choriocarcinoma
yolk sac tumour
list the two types of non germ cell testicular cancers
leydig cell tumour
sertoli cell tumour
what are the two most common types of secondary testicular cancer
lymphoma
leukemia
what innervates the detrusor muscle
parasympathetics S234 via the pelvic splanchnic nerve to cause urination
what innervates the trigone
sympathetics T11-L1, L2 via the hypogastric nerves to cause the detrusor relaxation and bladder neck constriction
how many sphincters does the male urethra have? female?
male–> 2
female–> 1
how are the male urethral sphincters innervated
internal INvoluntary sphincter–> sympathetic L1/2
external voluntary sphincter–> pudendal nerve from S234
(prostatic, membranous, bulbar and penile parts to the urethra)
how does bladder filling work
as bladder fills–> sympathetic reflex is initiated to keep you dry via stimulation of alpha adrenergic receptors at the bladder neck/internal sphincter and beta-3 receptors in the detrusor muscle to inhibit contraction
also direct inhibition of the detrusor motor neurons in the sacral spinal cord
with gradual increase in urethral pressure, the pudendal nerve activates the external sphincter
formation of a mucosal seal
how does bladder emptying work
increased bladder pressure gives the sense of distension and needing to void
coordination of the detrusor contraction and external sphincter relaxation is managed by the pontine micturition center which inhibits the steady state of continence
also needs relaxation of the internal sphincter in men and absence of any obstruction
define neurogenic bladder
dysfunction of the urinary bladder due to neurologic dysfunction or insult
define spastic bladder–what causes it?
UMN lesion
no normal signal from the brain inhibiting emptying so the bladder will reflexively empty on its own with filling
loss of voluntary control of micturition
may be due to cerebral injury (stroke, tumour) causing detrusor overactivity
may be due to basal ganglia disease (i.e parkinsons) leading to detrusor overactivity and short contractions and urge incontinence
may be due to suprasacral spinal cord damage above T6–> reflex micturition with detrusor-sphincter dyssyngergy leading to overactivity
may be due to suprasacral spinal cord damage below T6–> reflex micturition with detrusor-sphincter synergy leading to overflow incontinence
define flaccid bladder–what causes it?
LMN lesion
atonic with overflow incontinence or need for catheterization
sacral spinal cord damage–> i.e pelvic fracture–> causes acontractile bladder and poor bladder sensation
peripheral nerve damage–> i.e diabetes or pelvic surgery
what are the two types of voiding dysfunction
failure to store (incontinence)–detrusor overactivity or outlet incompetence
failure to void (retention)–ie LNM lesion –detrusor underactivity or outlet obstruction (i.e BPH, uretheral stricture)
define urge incontinence
involuntary loss with strong desire to void
etiology of urge incontinence
stone
UTI
tumour
overactive bladder
investigations for urge incontinence
hx/px
urodynamics
UA
urine cx
maybe U/S
treatment for urge incontinence
treat underlying cause
timed voiding (every 2 hours to prevent overfilling)
bladder training via biofeedback exercises
meds–> anticholinergics for the bladder, TCAs
surgical–> bladder pacemaker or augmentation (to increase storage capacity) or even urinary diversion
etiology of stress urinary incontinence
urinary retention or detrusor overactivity with increased abdo pressure
may involve intrinsic sphincter deficiency
may involve uretheral hypermobility (often related to weak pelvic floor muscles)
risk factors for stress urinary incontinence
obesity
female
pregnancy and vaginal deliveries
hysterectomy
prostatectomy
strenuous activity
treatment for stress urinary incontinence
kegel exercises or bladder training with biofeedback exercises
meds–> alpha agonist (TCA or SSRIs) to increase sphincter tone, estrogen
periurethral collagen injections for urethral stability
pessaries (for prolapse)
surgery (bladder neck suspension or urethral slings, artificial sphincter that can be pump controlled in the scrotum)
what is overflow incontinence and how do you treat it
obstruction–> treat underlying cause
acontractile bladder/atonic bladder–> can result from overstretching
can treat with timed voiding, clean intermittent catheterization, indwelling or suprapubic cathether
what is a pneumonic to remember the causes of transient urinary incontinence
DIAPERS
what does the DIAPERS mnemonic stand for
causes of transient urinary incontinence
Delirium (cognitive dysfunction can lead to functional incontinence)
Infection
Atrophic vaginitis (may be post menopausal)
Pharmaceuticals (diuretics, anticholinergics–impair contraction, narcotics–impair contraction, alpha agonists–increased sphincter tone, alpha blockers–lead to stress incontinence
Excessive urine production (i.e diuretics, diabetes)
Restricted mobility
Stool impaction (constipation impairs bladder function and is especially relevant in elderly patients)
describe the questions included in a focused voiding issue history
urgency, frequency, dysuria
fluid intake
associated with valsalva?
medications
neurological deficits (MS, spinal cord injuries, paresthesias)
diseases like diabetes
what investigations should be done to investigate voiding problems
- UA or serum creatinine
- voiding diary and post void residual
- urine cytology (if there are irritative voiding symptoms)
- urodynamics if refractory to treatment (i.e flow)
- cytoscopy
- renal US
indications for uro referral with voiding problem
hx or px suggests neuro disease
hematuria, recurrent UTIs, bladder stones, renal insufficiency
persistent incontinence, especially post op or once underlying causes are corrected.
what are the symptoms associated with storage issues
irritative
frequency, urgency, nocturia
what are the symptoms associated with obstructive voiding problems
hesitancy
slow stream
stuttering stream
dribbling
what are symptoms of uncomplicated BPH
microhematuria
NOT usually dysuria and incontinence
ddx of lower urinary tract symptoms (LUTS) in older men
- prostate–> BPH, cancer, prostatitis
- bladder–> cystitis, bladder tumour, bladder stone
- urethra–> urethral stricture, meatal stenosis, phimosis
- neurologic–> parkinson’s, stroke, spinal cord disease
- Other–> diabetes, sleep apnea, meds, pelvic mass
what are the two main types of tissue in the prostate
stroma (smooth muscle and collagen)
epithelium
where does BPH occur
the transition zone
where does prostate cancer most often occur
peripheral zones
what is BPH
involves growth of the stromal component of the prostate , via increased alpha 1 receptors increasing smooth muscle tone
size and degree of outlet obstruction doesnt fully correlate with degree of symptoms
complications of BPH
urinary retention
atonic bladder
renal failure and blockage
recurrent UTIs
bladder stones
hematuria
alpha blocker size effects
dizziness
fatigue
nasal congestion
retrograde ejaculation
5-ARI side effects
ED
decreased libido
decreased volume of ejaculation (not common)
management of BPH–> lifestyle
decrease fluids, caffeine, alcohol, decongestants, lose weight, exercise
how do you manage BPH
- lifestyle mods
- phytotherapy (i.e saw palmetto)
- alpha blockers
- 5 ARIs (prevent formation of 5-DHT)–> can decrease size and PSA and rate of surgery
- anticholinergics if there is lots of overactivity
- surgery–> TURP, MIS, green light to vaporize prostate, open prostatectomy
what is TURP
trans urethral resection of the prostate
involves electrocautery resection endoscopically
can cause bleeding, perforation, and some electrolyte imbalances
what are some MIS options for BPH management
injections like botox, photodynamic therapy, needle ablation, high intensity U/S, microwave tx etc…
when is surgery for BPH indicated
mainly if symptoms are refractory to medical therapies (i.e having recurrent UTI, retention, hematuria, renal impairment etc)
if the prostate is small and the PSA is low… how do you treat BPH
alpha blocker
if the prostate is large and the PSA is high… how do you treat BPH
combination
what are potential causes of gross hematuria after injury
renal
ureteric
bladder
urethral injury
what is the most commonly injured organ in GU trauma
kidney
10% of all serious injuries in the abdomen have associated renal injury
variable etiology depending on the area–> rural is 90% blunt trauma, whereas urban is less blunt trauma and more penetrating trauma
how do you work up a possible GU trauma
if penetrating trauma–everyone should get a CT
if blunt trauma–imaging with if….
- -gross hematuria
- -microhematuria plus shock
- -microhematuria with acceleteration/deceleration…but honestly everyone gets a CT
what imaging should be done for a GU trauma
CT IVP with contrast… “delayed” films if preferred
single shot film at 10 minutes post injection with 2cc/kg IV contrast…allows safe avoidance of renal exploitation and is highly specific for urinary extravasation
what are absolute indications for surgical treatment of GU trauma
- high grade renal injury–> nephrectomy or repair; kidney repair with sutures is actually quite effective
- vascular injury in one kidney–> vascular repair
- penetrating renal injuries
relative indications for surgical treatment of GU trauma
- persistent bleeding more than 2 units a day
- devitalized segment with urinary extravasation
- renal pelvis or ureter injury
- significant vein or artery thrombosis
what is the AAST organ injury severity scale for the kidney
- grade 1–> bruise in the subcapsule
- grade II–> perinephric hematoma with laceration less than 1 cm
- grade III—> hematoma with deeper laceration as far as the pyramids
- grade IV–> stretch injury with some thrombosis and deep laceration, likely extravasation
- grade V–> complete fractionation of kidney and separation of the hilum
how should you manage a person who had a bike accident and presents stable but with gross hematuria
bed rest and monitoring of blood and hgb
abx to manage urine extravasation
radiographic embolization
urinary diversion–> ureteral stenting and nephrostomy drainage
surgery (reconstruction or nephrectomy) usually only if unstable
what is the etiology of blunt bladder trauma
rare
often associated with severe or high energy injuries
often associated with urethral rupture and pelvic fracture
posterior urethral injuries occur most often in pelvic fractures between the prostatic and pelvic urethra (indicated by high riding prostate)
physical signs of bladder trauma
95% have gross hematuria (may have micro)
usually gross painless hematuria after trauma with normal kidneys is a bladder injury
adbo pain and tenderness
abdo bruising
urethral catheter does not return urine–> double check all suspected ureter/urethra injuries with a CT with contrast just in case–if the foley isnt draining, its probably not in the right place other wise its likely a urethral injury
signs also include no urine output, fever, peritonitis, increased BUN or creatinine
investigations for bladder trauma
plain cystography with contrast to check for extravastion is very accurat when done properly—> look for extra peritoneal and intraperitoneal contrast
drainage films to check for adequate filling
CT cystography is preferred with dilute contrast
when do posterior urethral injuries commonly happen?
in pelvic fractures with tearing between the prostatic and pelvic urethra (especially saddle fractures/pubic rami fractures)
happens more often in males
associated with bladder rupture sometimes, and rectal injury with urethral-rectal fistula rarely
how do you diagnose posterior urethral injury?
blood at meatus in 50%
high riding prostate
inability to urinate and place urethral catheter is classic
investigate with retrograde urethrogram
treatment for posterior urethral injury
if unable to place a foley, can place suprapubic catheter for drainage, wait and inspect for injury, and then surgically re-establish the connection later
how are most kidney injuries treated
non operatively
indications for kidney operation after trauma
grade V renal injury
persistent bleeding
suspected ureter or collecting system injury
incomplete staging and already having a lap
what should you do for a patient if they have a pelvic fracture?
CT cystogram
how do you manage most extraperitoneal bladder ruptures
conservatively
but consider treating extraperitoneal bladder ruptures OPEN, especially if undergoing lap and definitely if undergoing pelvic ORIF
what should you do for a patient presenting with hematemesis
check for hemodynamic stability before doing upper endoscopy (if unstable, resuscitate and consult surgery/IR until they are stable)
if a source is not IDed but bleeding continues, attempt enteroscopy or angiography, then eventually laparoscopy
if source not IDed but bleeding is minimal, evaluate for obscure bleeding
what should you do for a patient presenting with melena
check for hemodynamic stability before doing colonoscopy
if source not IDed but bleeding continues, attempt enteroscopy or angiography before colonoscopy
if source not IDed but bleeding is minimal, perform colonoscopy then evaluate for obscure bleeding
if bleeding continues without an IDed source, try deep small bowel enteroscopy, Meckel’s scan or laparoscopy
what do you do for a patient presenting with hematochezia
check for hemodynamic stability before doing upper colonoscopy
if source not IDed and bleeding continues, attempt deep small bowel enteroscopy, Meckel’s scan or laparoscopy
what are the major pathologies associated with/causing upper GI bleeding
- ulcerative
- -PUD
- -esophagitis - portal HTN
- -esophageal varices - arterial, venous, other vascular malformations
- trauma or post-surgical
- -mallory weiss tear
- -post gastric/duodenal polypectomy - tumours
how do you manage an upper GI bleed
- CBC, lytes, coag studies, liver enzymes, albumin/BUN/creatinine
- obtain type and screen or type and crossmatch while attempting hemodynamic stabilization
- NG lavage if the source of the bleeding is unclear (helps clean the stomach too before endoscopy)
- monitor ABCDEs and vitals and urine output and NG output
- NPO and establish IV access and supplemental O2
- transfuse if necessary
- consult GI and surgery and IR
what are the major causes of lower GI bleeding
- anatomic
- -diverticulosis - vascular
- -hemorrhoids, ischemia - inflammatory
- -infectious or IBD - ulcerous
- neoplastic
- -polyp or carcinoma
how do upper GI bleeds present
hematemesis and melena
if brisk bleeding it can be hematochezia, hypotension and tachycardia
how does a lower GI bleed present
BRBPR if transverse colon or beyond
may present with melena quite proximal
