Pediatric Urology Emergencies

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Pediatric Urology Emergencies. Ahmed Al-Sayyad MD,FRCSC Assistant Professor-King Abdulaziz University. Pediatric Urology Emergencies. Acute scrotum GU Trauma Priapism Paraphimosis PUV Urosepsis in association of obstruction Urolithiasis. Acute scrotum. - PowerPoint PPT Presentation

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  • Pediatric Urology EmergenciesAhmed Al-Sayyad MD,FRCSC Assistant Professor-King Abdulaziz University

  • Pediatric Urology EmergenciesAcute scrotumGU TraumaPriapismParaphimosisPUVUrosepsis in association of obstructionUrolithiasis

  • Acute scrotum

    Torsion of the spermatic cord Torsion of the appendix testis Torsion of the appendix epididymis Epididymitis Epididymo-orchitis Inguinal hernia Communicating hydrocele Hydrocele Hydrocele of the cord Trauma/insect bite Dermatologic lesions Inflammatory vasculitis (Henoch-Schnlein purpura) Idiopathic scrotal edema Tumor Spermatocele Varicocele Nonurogenital pathology (e.g., adductor tendinitis)

  • Torsion of the Spermatic Cord (Intravaginal)

    Torsion of the spermatic cord is a true surgical emergency of the highest order Irreversible ischemic injury to the testicular parenchyma may begin as soon as 4 hours after occlusion of the cordIntravaginal torsion happens within the space of the tunica vaginalis; this results from lack of normal fixation of the testis and epididymis to the fascial and muscular coverings that surround the cord within the scrotum

  • Torsion of the Spermatic Cord (Intravaginal)Usually there is an acute onset of scrotal pain, but in some instances the onset appears to be more gradual A large number of boys give a history of previous episodes of severe, self-limited scrotal pain and swellingNausea and vomiting may accompany acute torsion, and some boys have pain referred to the ipsilateral lower quadrant of the abdomen Dysuria and other bladder symptoms are usually absent

  • Torsion of the Spermatic Cord (Intravaginal)Testis can be riding high in the scrotum or with transverse orientationThe absence of a cremasteric reflex is a good indicator of torsion of the cordAfter several hours an acute hydrocele or massive scrotal edema obliterates all landmarks Color Doppler examination had a diagnostic sensitivity of 88.9% and a specificity of 98.8%, with a 1% rate of false-positive resultsWhen the diagnosis of torsion of the cord is suspected, prompt surgical exploration is warranted When torsion of the spermatic cord is found, exploration of the contralateral hemiscrotum must be carried out

  • Torsion of the Testicular and Epididymal Appendages

    The appendix testis, a mllerian duct remnant, and the appendix epididymis, a wolffian remnant, are prone to torsionThe symptoms associated with torsion of an appendage are extremely variable, from an insidious onset of scrotal discomfort to an acute condition identical to that seen with torsion of the cord

  • Torsion of the Testicular and Epididymal Appendageslocalized tenderness of the upper pole of the testis or epididymis Tender nodule may be palpated. In some instances, the infarcted appendage is visible through the skin as a blue dot sign The cremasteric reflex is usually present In cases in which the inflammatory changes are more significant, scrotal wall edema and erythema may be severeColor Doppler examination may show hyperemia at the upper pole of the testis or epididymisWhen the diagnosis of torsion of an appendage is confirmed clinically or by imaging, nonoperative management allows most cases to resolve spontaneouslyLimitation of activity and administration of nonsteroidal anti-inflammatory agents are only needed

  • Perinatal Torsion of the Spermatic Cord

    Prenatal (in utero) torsion is typified by the finding at delivery of a hard, nontender testis fixed to the overlying scrotal skinThe skin is commonly discolored by the underlying hemorrhagic necrosisClassic teaching has held that testes found to be hard, nontender, and fixed to the skin at birth do not merit surgical explorationHowever, controversy has arisen regarding the need for prompt exploration of the contralateral testis

  • Perinatal Torsion of the Spermatic Cord

    Contralateral scrotal exploration traditionally has not been recommended in cases of prenatal torsion because extravaginal torsion is not associated with the testicular fixation defect (bell-clapper deformity) that is recognized as the cause of intravaginal torsion However, reports of asynchronous perinatal torsion have made the practice of avoiding prompt surgical exploration of the contralateral testis controversial

  • Perinatal Torsion of the Spermatic Cord

    Prompt exploration of suspected postnatal torsion of the spermatic cord is indicated (in conjunction with exploration of the contralateral testis) when the patient's general condition and anesthetic considerations allow for a safe procedureExploration, when elected, should be carried out through an inguinal incision to allow for the most efficacious treatment of other potential or unexpected causes of scrotal swelling If torsion is confirmed, contralateral scrotal exploration with testicular fixation should be carried out The most effective and safest form of testicular fixation involves dartos pouch placement

  • PriapismPriapism is a persistent penile erection of at least 4 hours in duration that continues beyond and is unrelated to sexual stimulation .There are three subtypes: Ischemic (veno-occlusive, low-flow) priapism is characterized by little or no cavernous blood flow, and cavernous blood gases are hypoxic, hypercapnic, and acidotic. The corpora are rigid and tender to palpation Nonischemic (arterial, high-flow) priapism is caused by unregulated cavernous arterial inflow. Typically, the penis is neither fully rigid nor painful. There is often a history of antecedent trauma resulting in a cavernous arterycorpora cavernosa fistula Stuttering (intermittent) priapism is a recurrent form of ischemic priapism with painful erections with intervening periods of detumescence

  • PriapismThe most common cause of priapism in children is sickle cell diseasePriapism typically occurs during sleep, when mild hypoventilatory acidosis depresses oxygen tension and pH in the corpora. The pain experienced is a sign of ischemia On examination, there is typically significant corporal engorgement with sparing of the glans penisMedical therapy, including exchange transfusion, hydration, alkalinization, pain management with morphine, and oxygen should be startedIntracavernous irrigation with a sympathomimetic agent, such as phenylephrine will be the next step. General anesthesia or intravenous sedation will be necessary.If irrigation and medical therapy are unsuccessful, a corporoglanular shunt should be considered

  • PriapismFor stuttering priapism, administration of an oral -adrenergic agent (pseudoephedrine) once or twice daily is first-line therapy. If this treatment is unsuccessful, an oral agonist (terbutaline) is recommended; a GnRH analog plus flutamide is recommended as third-line therapyNonischemic (high-flow) priapism most commonly follows perineal trauma, such as a straddle injury, that results in laceration of the cavernous arterySpontaneous resolution may occur. If not, angiographic embolization is indicated

  • ParaphimosisParaphimosis develops when the tip of the foreskin retracts proximal to the coronal sulcus and becomes fixed in position Severe edema of the foreskin occurs within several hours, depending on the tightness of the tip of the foreskin In most cases, manual compression of the glans with placement of distal traction on the edematous foreskin allows reduction of the paraphimotic ring

  • Renal TraumaThe pediatric kidney is believed to be more susceptible to trauma because of a decrease in the physical renal protective mechanismshematuria is very unreliable in determining who to screen for renal injuries Indeed, some studies have failed to find any evidence of either gross or microscopic hematuria in up to 70% of children sustaining grade 2 or higher renal injury

  • Indications for Imaging

    A significant deceleration or high-velocity injury such as one sustained in a high-speed motor vehicle accident, a pedestrian/bicycle-motor vehicle accident, a fall from more than 15 feet, or a strike to the abdomen or flank with a foreign object (e.g., football helmet, baseball bat) Significant trauma that has resulted in fractures of thoracic rib cage, spine, pelvis, or femur, or bruising of the torso/perineum, or signs of peritonitis Gross hematuria Microscopic hematuria (

  • ImagingSingle-Shot Intravenous Pyelography Is useful in the unstable patient requiring emergent laparotomyOnce the patient is stabilized in the operating room, single-shot intravenous pyelography (IVP) (2 mL/kg intravenous bolus of contrast agent) with the radiograph taken 10 to 15 minutes after injection may be of benefit Use of Arteriography is useful in patients with persistent or delayed hemorrhage which usually arises from the development of arteriovenous fistulas or pseudoaneurysmApproximately 25% of patients with grade 3 to grade 4 renal trauma, managed in a nonoperative fashion, will develop persistent or secondary (delayed) hemorrhage RGP +\- DJ indications after renal trauma: (1) to rule out the presence of a partial/total ureteral disruption and (2) to aid in the management of a symptomatic urinoma

  • Renal pedicle injuryInvolving artery and veinWith hematoma

  • Injury to collecting system with extravasationDelayed imaging

  • Renal pelvis injury with leak of urineDelayed imaging

  • Management Majority of renal injuries can be managed conservatively Bed rest till urine is clear Frequent vitals and Hb checkingUrine racking Follow up imaging after discharge

  • Absolute indications for explorationPersistent renal bleeding Pulsatile, expanding or uncontained hematomaAvulsion of the main renal artery or vein

  • Relative indications for explorationSignificant (25%-50%) non-viable tissueUrinary extravasation Arterial thro