Lesson 4

Lesson 4

 

INJURIES TO THE KIDNEY & URETER

EMERGENCY DIAGNOSIS & MANAGEMENT

 

INJURIES TO THE KIDNEY

 

              

Renal trauma may manifest in a dramatic fashion for both the patient and the clinician. The incidence of renal trauma somewhat depends on the patient population being considered. Renal trauma accounts for approximately 3% of all trauma admissions and as many as 10% of patients who sustain abdominal trauma. In addition, renal trauma may occur in settings other than those thought of as a classic trauma setting. At most trauma centers, blunt trauma is more common than penetrating trauma, thereby making blunt renal injuries as much as 9 times more common than penetrating injuries. Both kidneys are at equal disposition for injury.

The approach to renal injuries has changed over time, requiring diligent attention to recent literature. Namely, the tolerance for nonoperative or expectant management has increased, even in the most seriously injured kidneys, replacing the past tendency toward aggressive renorrhaphy.

                                       

 

Injury to the kidney and ureter is damage to the organs of the upper urinary tract.

Causes

The kidneys are located in the flank (back of the upper abdomen at either side of the spinal column). They are deep in the abdomen and are protected by the spine, lower rib cage, and strong muscles of the back. This location protects the kidneys from many outside forces.

The kidneys are well-padded for a reason -- they have a large blood supply. Injury can lead to severe bleeding.

Kidneys may be injured by damage to the blood vessels that supply or drain them, including:

Aneurysm

Arterial blockage

Arteriovenous fistula

Renal vein thrombosis (clotting)

Trauma

 

Kidney injuries may also be caused by:

Angiomyolipoma, a noncancerous tumor

Autoimmune disorders

Bladder outlet obstruction

Cancer of the kidney, pelvic organs (ovaries or uterus in women), or colon

Diabetes

Excess buildup of body waste products such as uric acid (which can occur with gout or treatment of bone marrow, lymph node, or other disorders)

Exposure to toxic substances such as lead, cleaning products, solvents, fuels, or long-term use of high-dose pain medications (analgesic nephropathy)

High blood pressure and other medical conditions that affect the kidneys

Inflammation caused by immune responses to medications, infection, or other disorders

Medical procedures such as kidney biopsy, or nephrostomy tube placement

Ureteropelvic junction obstruction

Ureteral obstruction

 

The ureters are the tubes that carry urine from the kidneys to the bladder. Uretral injuries may be caused by:

Complications from medical procedures

Diseases such as retroperitoneal fibrosis, retroperitoneal sarcomas, or cancers that spread to the lymph nodes near the ureters

Kidney stone disease

Radiation to the belly area 

Trauma

Etiology

Blunt trauma directly to the abdomen, flank, or back is the most common mechanism, accounting for 80-85% of all renal injuries. Trauma may result from motor vehicle accidents, fights, falls, and contact sports. Vehicle collisions at high speed may result in major renal trauma from rapid deceleration and cause major vascular injury. Gunshot and knife wounds cause most penetrating injuries to the kidney; any such wound in the flank area should be regarded as a cause of renal injury until proved otherwise. Associ­ated abdominal visceral injuries are present in 80% of renal penetrating wounds.

 

 

 

 

 

                    

 

 

Pathology & Classification

A. Early Pathologic Findings: Lacerations from blunt trauma usually occur in the transverse plane of the kidney. The mechanism of injury is thought to be force transmitted from the center of the impact to the renal parenchyma. In injuries from rapid deceleration, the kidney moves upward or downward, causing sudden stretch on the renal pedi­cle and sometimes complete or partial avulsion. Acute thrombosis of the renal artery may be caused by an intimal tear from rapid deceleration injuries owing to the sudden stretch.

Pathologic classification of renal injuries is as fol­lows (Moore et al, 1989):

                                

 

 

Classification

1. Minor renal trauma (85% of cases)-

Renal contusion or bruising of the parenchyma is the most common lesion. Subcapsular hematoma in associa­tion with contusion is also noted. Superficial cortical lacerations are also considered minor trauma. These injuries rarely require surgical exploration.

2. Major renal trauma (15% of cases)-

Deep corticomedullary lacerations may extend into the col­lecting system, resulting in extravasation of urine into the perirenal space. Large retroperitoneal and perinephric hematomas often accompany these deep lacerations. Multiple lacerations may cause complete destruction of the kidney. Laceration of the renal pelvis without parenchymal laceration from blunt trauma is rare.

3. Vascular injury (about 1% of all blunt trauma cases)- Vascular injury

 

 

              

                       

Vascular injury of the renal pedicle is rare but may occur, usually from blunt trauma. There may be total avulsion of the artery and vein or partial avulsion of the segmental branches of these vessels. Stretch on the main renal artery without avulsion may result in renal artery thrombosis. Vascular injuries are difficult to diagnose and result in total destruction of the kidney unless the diagnosis is made promptly.

 

 

B. Late Pathologic Findings:

1. Urinoma-Deep lacerations that are not re­paired may result in persistent urinary extravasation and late complications of a large perinephric renal mass and, eventually, hydronephrosis and abscess formation.

2. Hydronephrosis-Large hematomas in the retroperitoneum and associated urinary extravasation may result in perinephric fibrosis engulfing the ureteropelvic junction, causing hydronephrosis. Fol­low-up excretory urography is indicated in all cases of major renal trauma.

3. Arteriovenous fistula-Arteriovenous fistu­las may occur after penetrating injuries but are not common.

4. Renal vascular hypertension-The blood flow in tissue rendered nonviable by injury is com­promised; this results in renal vascular hypertension in about 1% of cases. Fibrosis from surrounding trauma has also been reported to constrict the renal artery and cause renal hypertension.

Clinical Findings & Indications for Studies

Microscopic or gross hematuria following trauma to the abdomen indicates injury to the urinary tract. It bears repeating that stab or gunshot wounds to the flank area should alert the physician to possible renal injury whether or not hematuria is present. Some cases of renal vascular injury are not associated with hematuria. These cases are almost always due to rapid deceleration accidents and are an indication for intravenous urography.

 

 Hematuria

 

The degree of renal injury does not correspond to the degree of hematuria, since gross hematuria may occur in minor renal trauma and only mild hematuria in major trauma. However, not all adult patients sus­taining blunt trauma require full imaging evaluation of the kidney). Miller and McAninch (1995) made the following recommendations based on findings in over 1800 blunt renal trauma injuries: Patients with gross hematuria or microscopic hema­turia with shock (systolic blood pressure < 90 mm Hg) should undergo radiographic assessment; pa­tients with microscopic hematuria without shock need not. However, should physical examination or associated injuries prompt reasonable suspicion of a renal injury, renal imaging should be undertaken. This is especially true of patients with rapid decelera­tion trauma, who may have renal injury without the presence of hematuria.

A. Symptoms:

Acute or emergency symptoms may include:

Abdominal pain

Abdominal swelling

Back pain

Blood in the urine

Decreased alertness, including coma

Decreased urine output

Drowsiness

Fever

Flank pain, severe

Increased heart rate

Inability to urinate

Nausea, vomiting

Pale skin

Skin cool to touch

Sweating

 

Long-term (chronic) symptoms may include:

Constipation (can occur with toxic injury or lead poisoning)

Irritability

Weight loss

If only one kidney is affected and the other kidney is healthy, you may not have any symptoms.

 

B. Signs: Initially, shock or signs of a large loss of blood from heavy retroperitoneal bleeding may be noted. Ecchymosis in the flank or upper quadrants of the abdomen is often noted. Lower rib fractures are frequently found. Diffuse abdominal tenderness may be found on palpation; an "acute abdomen" indicates free blood in the peritoneal cavity. A palpable mass may represent a large retroperitoneal hematoma or perhaps urinary extravasation. If the retroperitoneum has been torn, free blood may be noted in the peri­toneal cavity but no palpable mass will be evident. The abdomen may be distended and bowel sounds absent.

Most blunt renal injuries are low-grade; therefore, they are usually amenable to treatment with observation and bed rest alone. Penetrating trauma is more likely to be associated with more severe renal injury, thus requiring a higher index of clinical awareness. Further, penetrating trauma is more often associated with other abdominal injuries requiring laparotomy, thus providing the opportunity for intraoperative renal staging and/or repair.

 

Patients with indications for emergent exploration include those with hemodynamic instability. Expanding hematomas or active hemorrhage suggests the possibility of high-grade renal injury. Patients with penetrating trauma who are stable and do not require urgent laparotomy for other possible intra-abdominal injuries may be observed without immediate renal exploration.

 

Unrelenting gross hematuria may require urgent exploration. However, the presence of a renal contusion does not typically require specific intervention. Findings from imaging studies may appear quite alarming, but most renal contusions resolve, particularly if the lesion appears to be of grade I-III.

Symptoms and Diagnosis

Symptoms of a blunt kidney injury may include pain in the upper abdomen or flank (the area between the ribs and hip), bruising of the flank, blood in the urine, marks near a kidney made by a seat belt, or pain resulting from fractures of the lower ribs. With severe kidney injuries, low blood pressure (shock) and anemia may occur if the person loses a significant amount of blood.         

Kidney Injuries: Minor to Severe

The severity of kidney injuries varies widely. When an injury is minor, the kidney may only be bruised. When an injury is more severe, the kidney may be cut or torn (lacerated), and urine and blood may leak into the surrounding tissue. If the kidney is torn from its attachment to blood vessels, bleeding may be profuse, resulting in shock or death. Most kidney injuries result in blood in the urine.

The history of events that led to the injury, the person's symptoms, and a physical examination help doctors recognize kidney injuries. A sample of urine is taken and examined to see whether blood is present. Blood in the urine in a person with an injury to the trunk suggests that the injury involves the kidney. The blood may be visible with the naked eye (gross hematuria) or visible only using a microscope (microscopic hematuria). With penetrating injuries, the location of the wound (whether in the upper or mid part of the abdomen, back, or flank) may help doctors determine whether the kidney is involved.

 

Adults who have mild symptoms and blood in the urine that is visible only with a microscope probably have a minor bruise that will heal on its own. Further tests are usually not needed. For children, and for adults in whom doctors suspect a more serious injury, computed tomography (CT) with radiopaque dye (contrast agent) is done. Occasionally, additional imaging tests may be needed to confirm the diagnosis.

 

C. Laboratory Findings:      

   

 

Microscopic or gross hematuria is usually present. The hematocrit may be normal initially, but a drop may be found when serial studies are done. This finding represents persistent retroperitoneal bleeding and development of a large retroperitoneal hematoma. Persistent bleeding may necessitate operation.

 

D. Staging and X-Ray Findings: Staging of renal injuries allows a systematic approach to these problems. Adequate studies help define the extent of injury and dictate appropriate management.

n         (KUB): the method allows to find damage of bones, to suspect presence of retroperitoneal hematoma (contours of kidney and lumbar muscles are absent).

 

      Excretory urography gives  an opportunity to define the     side of damage, anatomical and function status of injured and opposite kidney.

 

 

            Retrograde urography 

 

 

For example, blunt trauma to the abdomen associated with gross hematuria and a normal urogram requires no additional renal stud­ies; however, nonvisualization of the kidney requires immediate arteriography or CT scan to determine whether renal vascular injury exists. Ultrasonography and retrograde urography are of little use initially in the evaluation of renal injuries.

 

 

   Ultrasound scans can detect renal lacerations but cannot definitely assess their depth and extent.

 

   CT scan

 

 

Staging begins with an abdominal CT scan, the most direct and effective means of staging renal in­juries. This noninvasive technique clearly defines parenchymal lacerations and urinary extravasation, shows the extent of the retroperitoneal hematoma, identifies nonviable tissue, and outlines injuries to surrounding organs such as the pancreas, spleen, liver, and bowel. (If CT is not avail­able, an intravenous pyelogram can be obtained.)

 

 

 

      Arteriography

 

 

Arteriography defines major arterial and parenchy­mal injuries when previous studies have not fully done so. Arterial thrombosis and avulsion of the re­nal pedicle are best diagnosed by arteriography and are likely when the kidney is not visualized on imag­ing studies. The major causes of non-visualization on an excretory urogram are total pedi­cle avulsion, arterial thrombosis, severe contusion causing vascular spasm, and absence of the kidney (either congenital or from operation).

 

 

 

 

 

X-ray signs of renal damage are weak and later spreading of X-ray contrast solution in calyces-bowling systems, subcapsular and retrorenal spreading of  X-ray contrast, deformation of renal bowl and calyces.

 

Radionuclide renal scans have been used in stag­ing renal trauma. However, in emergency manage­ment, this technique is less sensitive than arteriography or CT.

Differential Diagnosis

Trauma to the abdomen and flank areas is not al­ways associated with renal injury. In such cases, there is no hematuria, and the results of imaging studies are normal.

Complications

A. Early Complications: Hemorrhage is per­haps the most important immediate complication of renal injury. Heavy retroperitoneal bleeding may re­sult in rapid exsanguination. Patients must be observed closely, with careful monitoring of blood pressure and hematocrit. Complete staging must be done early. The size and expansion of palpable masses must be carefully monitored. Bleed­ing ceases spontaneously in 80-85% of cases. Persis­tent retroperitoneal bleeding or heavy gross hematuria may require early operation.

Urinary extravasation from renal fracture may show as an expanding mass (urinoma) in the retroperitoneum. These collections are prone to ab­scess formation and sepsis. A resolving retroperi­toneal hematoma may cause slight fever (38.3 °C [101 °F]), but higher temperatures suggest infection. A perinephric abscess may form, resulting in abdom­inal tenderness and flank pain. Prompt operation is indicated.

B. Late Complications: Hypertension, hydronephrosis, arteriovenous fistula, calculus formation, and pyelonephritis are important late complications. Careful monitoring of blood pressure for several months is necessary to watch for hypertension. At 3-6 months, a follow-up excretory urogram or CT scan should be obtained to be certain that perinephric scarring has not caused hydronephrosis or vascular compromise; renal atrophy may occur from vascular compromise and is detected by follow-up urography. Heavy late bleeding may occur 1—4 weeks after in­jury.

 

 

Treatment

A. Emergency Measures: The objectives of early management are prompt treatment of shock and hemorrhage, complete resuscitation, and evaluation of associated injuries.

B. Surgical Measures:      

1. Blunt injuries-Minor renal injuries from blunt trauma account for 85% of cases and do not usually require operation. Bleeding stops sponta­neously with bed rest and hydration. Cases in which operation is indicated include those associated with persistent retroperitoneal bleeding, urinary extravasa­tion, evidence of nonviable renal parenchyma, and renal pedicle injuries (less than 5% of all renal in­juries). Aggressive preoperative staging allows com­plete definition of injury before operation.

         

 

n     The operation should be maximum savings and directed on the decision of two tasks - stopping of bleeding and normalization of urine outflow.

 

 

 

2. Penetrating injuries-Penetrating injuries should be surgically explored. A rare exception to this rule is when staging has been complete and only minor parenchymal injury, with no urinary extravasa­tion, is noted. In 80% of cases of penetrating injury, associated organ injury requires operation; thus, renal exploration is only an extension of this procedure.

C. Treatment of Complications: Retroperi­toneal urinoma or perinephric abscess demands prompt surgical drainage. Malignant hypertension re­quires vascular repair or nephrectomy. Hydronephro­sis may require surgical correction or nephrectomy.

 

Prognosis

With careful follow-up, most renal injuries have an excellent prognosis, with spontaneous healing and return of renal function. Follow-up excretory urography and monitoring of blood pressure ensure detec­tion and appropriate management of late hydronephrosis and hypertension.

 

 

INJURIES TO THE URETER   

Ureteral injury is rare but may occur, usually dur­ing the course of a difficult pelvic surgical procedure or as a result of gunshot wounds. Rapid deceleration accidents may avulse the ureter from the renal pelvis. Endoscopic basket manipulation of ureteral calculi may result in injury. Injury to the intramural ureter during transurethral resections also may occur.

Etiology

Large pelvic masses (benign or malignant) may displace the ureter laterally and engulf it in reactive fibrosis. This may lead to ureteral injury during dis­section, since the organ is anatomically malpositioned. Inflammatory pelvic disorders may involve the ureter in a similar way. Extensive carcinoma of the colon may invade areas outside the colon wall and directly involve the ureter; thus, resection of the ureter may be required along with resection of the tu­mor mass. Devascularization may occur with exten­sive pelvic lymph node dissections or after radiation therapy to the pelvis for pelvic cancer. In these situations, ureteral fibrosis and subsequent stricture for­mation may develop along with ureteral fistulas.

  Endoscopic manipulation

 

Endoscopic manipulation of a ureteral calculus with a stone basket or ureteroscope may result in ureteral perforation or avulsion. Passage of a ureteral catheter beyond an area of obstruction may perforate the ureter. This is usually secondary to the acute in­flammatory process in the ureteral wall and sur­rounding the calculus.

Pathogenesis & Pathology

The ureter may be inadvertently ligated and cut during difficult pelvic surgery. In such cases, sepsis and severe renal damage usually occur postopera-tively. If a partially divided ureter is unrecognized at operation, urinary extravasation and subsequent buildup of a large urinoma will ensue, which usually leads to ureterovaginal or ureterocutaneous fistula formation. Intraperitoneal extravasation of urine can also occur, causing ileus and peritonitis. After partial transection of the ureter, some degree of stenosis and reactive fibrosis develops, with concomitant mild to moderate hydronephrosis.

Clinical Findings     

A. Symptoms: If the ureter has been completely or partially ligated during operation, the postoperative course is usually marked by fever of 38.3-38.8 °C (101-102 °F) as well as flank and lower quadrant pain. Such patients often experience paralytic ileus with nausea and vomiting. If ureterovaginal or cutaneous fistula develops, it usually does so within the first 10 postoperative days. Bilateral ureteral injury is mani­fested by postoperative anuria.

Ureteral injuries from external violence should be suspected in patients who have sustained stab or gun­shot wounds to the retroperitoneum. The mid portion of the ureter seems to be the most common site of penetrating injury. There are usually associated vas­cular and other abdominal visceral injuries.

B. Signs: The acute hydronephrosis of a totally ligated ureter results in severe flank pain and abdom­inal pain with nausea and vomiting early in the post­operative course and with associated ileus. Signs and symptoms of acute peritonitis may be present if there is urinary extravasation into the peritoneal cavity. Watery discharge from the wound or vagina may be identified as urine by determining the creatinine con­centration of a small sample—urine has many times the creatinine concentration found in serum—and by intravenous injection of 10 mL of indigo carmine, which will appear in the urine as dark blue.

C. Laboratory Findings: Ureteral injury from external violence is manifested by microscopic hematuria in 90% of cases. Urinalysis and other labora­tory studies are of little use in diagnosis when injury has occurred from other causes. The serum creatinine level usually remains normal except in bilateral ureteral obstruction.

D. X-Ray Findings: Diagnosis is by excretory urography. A plain film of the abdomen may demon­strate a large area of increased density in the pelvis or in an area of retroperitoneum where injury is sus­pected. After injection of contrast material, delayed excretion is noted with hydronephrosis. Partial tran­section of the ureter results in more rapid excretion, but persistent hydronephrosis is usually present, and contrast extravasation at the site of injury is noted on delayed films.

 

  Excre­tory urogram

 

 Excre­tory urogram

 

 

In acute injury from external violence, the excre­tory urogram usually appears normal, with very mild fullness down to the point of extravasation at the ureteral transection.

Retrograde ureterography demonstrates the exact site of obstruction or extravasation.

E. Ultrasonography: Ultrasonography outlines hydroureter or urinary extravasation as it develops into a urinoma and is perhaps the best means of ruling out ureteral injury in the early postoperative period.

It has the advantages of being noninvasive and rapid.

F. Radionuclide Scanning: Radionuclide scan­ning demonstrates delayed excretion on the injured

side, with evidence of increasing counts owing to ac­cumulation of urine in the renal pelvis. Its great ben­efit, however, is in the assessment of renal function after surgical correction.

 

 

Differential Diagnosis

Postoperative bowel obstruction and peritonitis may cause symptoms similar to those of acute ureteral obstruction from injury. Fever, "acute ab­domen," and associated nausea and vomiting follow­ing difficult pelvic surgery are definite indications for screening sonography or excretory urography to establish whether ureteral injury has occurred.

Deep wound infection must be considered postoperatively in patients with fever, ileus, and localized tenderness. The same findings are consistent with urinary extravasation and urinoma formation.

Acute pyelonephritis in the early postoperative pe­riod may also result in findings similar to those of ureteral injury. Sonography is normal, and urography shows no evidence of obstruction.

Drainage of peritoneal fluid through the wound from impending evisceration may be confused with ureteral injury and urinary extravasation. The creatinine concentration of the transudate is similar to that of serum, whereas urine contains very high creatinine levels.

Complications

Ureteral injury may be complicated by stricture for­mation with resulting hydronephrosis in the area of in­jury. Chronic urinary extravasation from unrecognized injury may lead to formation of a large retroperi-toneal urinoma. Pyelonephritis from hydronephrosis and urinary infection may require prompt proximal drainage.

 

Treatment

Prompt treatment of ureteral injuries is required. The best opportunity for successful repair is in the operating room when the injury occurs. If the injury is not recognized until 7-10 days after the event and no infection, abscess, or other complications exist, immediate reexploration and repair are indicated.

 

    Nephrostomy

 

Proximal urinary drainage by percutaneous nephrostomy or formal nephrostomy should be considered if the injury is recognized late or if the patient has sig­nificant complications that make immediate recon­struction unsatisfactory. The goals of ureteral repair are to achieve complete debridement, a tension-free spatulated anastomosis, watertight closure, ureteral stenting (in selected cases), and retroperitoneal drainage.

A. Lower Ureteral Injuries: Injuries to the lower third of the ureter allow several options in management. The procedure of choice is reimplantation into the bladder combined with a psoas-hitch procedure to minimize tension on the ureteral anasto­mosis.

 Reimplantation into the bladder

 

 An antireflux procedure should be done when possible. Primary ureteroureterostomy can be used in lower-third injuries when the ureter has been ligated without transection. The ureter is usually long enough for this type of anastomosis. A bladder tube flap can be used when the ureter is shorter.

Transureteroureterostomy may be used in lower-third injuries if extensive urinoma and pelvic infec­tion have developed. This procedure allows anasto­mosis and reconstruction in an area away from the pathologic processes.

 

 Ureteroureterostomy

 

 Ureteroureterostomy

B. Mid ureteral Injuries: Midureteral injuries usually result from external violence and are best re­paired by primary ureteroureterostomy or transureteroureterostomy.

    Uretrocutaneostomy

               

C. Upper Ureteral Injuries: Injuries to the up­per third of the ureter are best managed by primary ureteroureterostomy. If there is extensive loss of the ureter, autotransplantation of the kidney can be done as well as bowel replacement of the ureter.

D. Stenting: Most anastomoses after repair of ureteral injury should be stented. The preferred tech­nique is to insert a silicone internal stent through the

 anastomosis before closure

 

.     

 Plain film (ureteral stent)

 

 

These stents have a J memory curve on each end to prevent their migration in the postoperative period. After 3-4 weeks of heal­ing, stents can be endoscopically removed from the bladder. The advantages of internal stenting are maintenance of a straight ureter with a constant cal­iber during early healing, the presence of a conduit for urine during healing, prevention of urinary ex­travasation, maintenance of urinary diversion, and easy removal.

 

 

  Reconstruction anasto­mosis

 

 

 

Prognosis

The prognosis for ureteral injury is excellent if the diagnosis is made early and prompt corrective surgery is done. Delay in diagnosis worsens the prog­nosis because of infection, hydronephrosis, abscess, and fistula formation.

 

 

 

 

 

 

 

INJURIES TO THE BLADDER & URETHRA

            

 

INJURIES TO THE BLADDER

Bladder injuries occur most often from external force and are often associated with pelvic fractures. (About 15% of all pelvic fractures are associated with concomitant bladder or urethral injuries.) latrogenic injury may result from gynecologic and other extensive pelvic procedures as well as from hernia repairs and transurethral operations.

Pathogenesis & Pathology

The bony pelvis protects the urinary bladder very well. When the pelvis is fractured by blunt trauma, fragments from the fracture site may perforate the bladder. These perforations usually result in extraperitoneal rupture. If the urine is infected, extraperitoneal bladder perforations may result in deep pelvic abscess and severe pelvic inflammation.

               Intraperitoneal disruption

 

When the bladder is filled to near capacity, a di­rect blow to the lower abdomen may result in bladder disruption. This type of disruption ordinarily is intraperitoneal. Since the reflection of the pelvic peri­toneum covers the dome of the bladder, a linear lac­eration will allow urine to flow into the abdominal cavity. If the diagnosis is not established immedi­ately and if the urine is sterile, no symptoms may be noted for several days. If the urine is infected, imme­diate peritonitis and acute abdomen will develop.

Clinical Findings

Pelvic fracture accompanies bladder rupture in 90% of cases. The diagnosis of pelvic fracture can be made initially in the emergency room by lateral com­pression on the bony pelvis, since the fracture site will show crepitus and be painful to the touch. Lower abdominal and suprapubic tenderness is usually pres­ent. Pelvic fracture and suprapubic tenderness with acute abdomen suggest intraperitoneal bladder dis­ruption.

A. Symptoms: There is usually a history of lower abdominal trauma. Blunt injury is the usual cause. Patients ordinarily are unable to urinate, but when spontaneous voiding occurs, gross hematuria is usually present. Most patients complain of pelvic or lower abdominal pain.

B. Signs: Heavy bleeding associated with pelvic fracture may result in hemorrhagic shock, usu­ally from venous disruption of pelvic vessels. Evi­dence of external injury from a gunshot or stab wound in the lower abdomen should make one sus­pect bladder injury, manifested by marked tenderness of the suprapubic area and lower abdomen. An acute abdomen indicates intraperitoneal bladder rupture. A palpable mass in the lower abdomen usually repre­sents a large pelvic hematoma. On rectal examina­tion, landmarks may be indistinct because of a large pelvic hematoma.

C. Laboratory Findings: Catheterization usu­ally is required in patients with pelvic trauma but not if bloody urethral discharge is noted. Bloody urethral discharge indicates urethral injury, and a urethrogram is necessary before catheterization. When catheterization is done, gross or, less commonly, microscopic hematuria is usually present. Urine taken from the bladder at the initial catheterization should be cultured to determine whether infection is present.

D. X-Ray Findings: A plain abdominal film generally demonstrates pelvic fractures. There may be haziness over the lower abdomen from blood and urine extravasation. An intravenous urogram should be obtained to establish whether kidney and ureteral injuries are present.

 

  Retrogradual cystography (Retroperitoneal rupture)

 

Bladder disruption is shown on cystography. The bladder should be filled with 300 mL of contrast material and a plain film of the lower abdomen ob­tained. Contrast medium should be allowed to drain out completely, and a second film of the abdomen should be obtained. The drainage film is extremely important, because it demonstrates areas of extraperitoneal extravasation of blood and urine that may not appear on the filling film. With intraperitoneal extravasation, free contrast medium is visualized in the abdomen, highlighting bowel loops.

 

 

  Retrogradual cystography (Intraperitoneal rupture)

 

                 Retrogradual cystography (Intraperitoneal rupture)

 

 

CT cystography is an excellent method for detect­ing bladder rupture; however, retrograde filling of the bladder with 300 mL of contrast medium is nec­essary to distend the bladder completely.

    

 

 Incomplete distention with consequent missed diagnosis of blad­der rupture often occurs when the urethral catheter is clamped during standard abdominal CT scan with in­travenous contrast injection.

 

E. Instrumental Examination: If urethral in­jury is suspected (bloody discharge), a urethrogram should be obtained before any attempt is made to catheterize the patient. If there is no evidence of ure­thral injury, catheterization can be safely accom­plished.

Cystoscopy is not indicated, since bleeding and clots obscure visualization and prevent accurate diag­nosis.

 

 

Differential Diagnosis

Abdominal trauma with hematuria may cause in­jury to the kidney and ureter as well as the bladder. A urogram is indicated for all patients with trauma-re­lated hematuria. Associated injuries to the pelvic ves­sels and bowel also should be considered.

The urethra may be injured as well as the bladder; this possibility should be considered in any patient with blunt trauma and pelvic fractures. Urethrogra-phy demonstrates disruption of the urethra.

Complications

A pelvic abscess may develop from extraperitoneal bladder rupture; if the urine becomes infected, the pelvic hematoma becomes infected too.

Intraperitoneal bladder rupture with extravasation of urine into the abdominal cavity causes delayed peritonitis.

Partial incontinence may result from bladder injury when the laceration extends into the bladder neck. Meticulous repair may ensure normal urinary control.

 

 

Treatment

A. Emergency Measures: Shock and hemor­rhage should be treated.

B. Surgical Measures: A lower midline ab­dominal incision should be made.

 Suprapubic cystostomy

 

 As the bladder is approached in the midline, a pelvic hematoma, which is usually lateral, should be avoided. Entering the pelvic hematoma can result in increased bleeding from release of tamponade and in infection of the hematoma, with subsequent pelvic abscess. The blad­der should be opened in the midline and carefully in­spected. After repair, a suprapubic cystostomy tube is usually left in place to ensure complete urinary drainage and control of bleeding.

1. Extraperitoneal rupture-  Extraperitoneal rup­ture should be repaired intravesically. As the bladder is opened in the midline, it should be carefully in­spected and lacerations closed from within. Polyglycolic acid or chromic absorbable sutures should be used.

 

 

 Juncture by two-row catgut junctures.

 

 

 

   Perivesical space is drainage through obturatorial foramen or ischiorectal space.

 

 

 

 Drainage through obturatorial foramen

 

Extraperitoneal bladder lacerations occasionally extend into the bladder neck and should be repaired meticulously. Fine absorbable sutures should be used to ensure complete reconstruction so that the patient will have urinary control after injury. Such injuries are best managed with indwelling urethral catheterization and suprapubic diversion.

Peritoneotomy should be done and the intraabdominal fluid inspected before the procedure is completed. If abdominal fluid is bloody, complete abdominal ex­ploration should be done to rule out associated in­juries.

2. Intraperitoneal rupture Intraperitoneal blad­der ruptures should be repaired via a transperitoneal approach after careful transvesical inspection and clo­sure of any other perforations.

 Transperitoneal approach

 

 

The peritoneum must be closed carefully over the area of injury. The bladder is then closed in separate layers by absorbable suture. All extravasated fluid from the peritoneal cavity should be removed before closure. At the time of clo­sure, care should be taken that the suprapubic cystostomy is in the extraperitoneal position.

 

3. Pelvic fracture Stable fracture of the pubic rami is usually present. In such cases, the patient can be ambulatory within 4-5 days without damage or difficulty. Unstable pelvic fractures requiring exter­nal fixation have a more protracted course.

 

4. Pelvic hematoma There may be heavy un­controlled bleeding from rupture of pelvic vessels even if the hematoma has not been entered at opera­tion. At exploration and bladder repair, packing the pelvis with laparotomy tapes often controls the prob­lem. If bleeding persists, it may be necessary to leave the tapes in place for 24 h and operate again to re­move them. Embolization of pelvic vessels with Gelfoam or skeletal muscle under angiographic con­trol is useful in controlling persistent pelvic bleeding.

C. Medical Measures: The patient whose cystogram shows only a small degree of extravasation can be managed by placing a urethral catheter into the bladder, without operation or suprapubic cystostomy. The urine must be free of infection. Corriere and Sandier (1988) have reported success with such man­agement. Careful observation is necessary because of the potential for pelvic hematoma infection, continued bleeding from the bladder, and clot retention.

Prognosis

With appropriate treatment, the prognosis is excel­lent. The suprapubic cystostomy tube can be re­moved within 10 days, and the patient can usually void normally. Patients with lacerations extending into the bladder neck area may be temporarily incon­tinent, but full control is usually regained. At the time of discharge, urine culture should be performed to determine whether catheterassociated infection requires further treatment.

 

 

INJURIES TO THE URETHRA

 

Urethral injuries are uncommon and occur most often in men, usually associated with pelvic fractures or straddle-type falls. They are rare in women.

Various parts of the urethra may be lacerated, tran­sected, or contused. Management varies according to the level of injury. The urethra can be separated into 2 broad anatomic divisions: the posterior urethra, consisting of the prostatic and membranous portions, and the anterior urethra, consisting of the bulbous and pendulous portions.

INJURIES TO THE POSTERIOR URETHRA

Etiology

The membranous urethra passes through the urogenital diaphragm and is the portion of the posterior urethra most likely to be injured. The urogenital di­aphragm contains most of the voluntary urinary sphincter. It is attached to the pubic rami inferiorly, and when pelvic fractures occur from blunt trauma, the membranous urethra is sheared from the prostatic apex at the prostatomembranous junction. The ure­thra can be transected by the same mechanism at the interior surface of the membranous urethra.

Pathogenesis & Pathology

Injuries to the posterior urethra commonly occur from blunt trauma and pelvic fractures. The urethra usually is sheared off just proximal to the urogenital diaphragm, and the prostate is displaced superiorly by the developing hematoma in the periprostatic and perivesical spaces.

Clinical Findings

 

A. Symptoms: Injuries that cause significant damage to the urethra may lead to urinary strictures or obstructions. As a result, a person may experience a variety of symptoms, including:

Weak or slow urine stream

Dribbling

Urinary frequency

Urgency to urinate

Nocturia, a condition in which a person has to urinate frequently during the nighttime

Urinary retention

 

B. Signs: Blood at the urethral meatus is the sin­gle most important sign of

 urethral injury              .

 

 

The impor­tance of this finding cannot be overemphasized, be­cause an attempt to pass a urethral catheter may result in infection of the periprostatic and perivesical he­matoma and conversion of an incomplete laceration to a complete one. The presence of blood at the external urethral meatus indicates that immediate urethrography is necessary to establish the diagnosis.

Suprapubic tenderness and the presence of pelvic fracture are noted on physical examination. A large developing pelvic hematoma may be palpated. Peri-neal or suprapubic contusions are often noted. Rectal examination may reveal a large pelvic hematoma with the prostate displaced superiorly.

 

 

 

 

 

Rectal exami­nation can be misleading, however, because a tense pelvic hematoma may resemble the prostate on pal­pation. Superior displacement of the prostate does not occur if the puboprostatic ligaments remain in­tact.

 

 

Partial disruption of the membranous urethra (currently 10% of cases) is not accompanied by prostatic displacement.

 

C. Laboratory Findings: Anemia due to hem­orrhage may be noted. Urine usually cannot be ob­tained initially, since the patient should not void and catheterization should not be attempted.

 

D. X-Ray Findings: Fractures of the bony pelvis are usually present. A urethrogram (using 20-30 mL of watersoluble contrast material) shows the site of extravasation at the prostatomembranous junction.

 

 Fractures of the bony pelvis

 

 

        Urethrogram

 (free extravasation of contrast material)

 

 

   Urethrogram

 (free extravasation of contrast material)

Or­dinarily, there is free extravasation of contrast material into the perivesical space. Incomplete prostatomembranous disruption is seen as minor ex­travasation, with a portion of contrast material passing into the prostatic urethra and bladder.

 

E. Instrumental Examination: The only in­strumentation involved should be for urethrography. Catheterization or urethroscopy should not be done, because these procedures pose an increased risk of hematoma, infection, and further damage to partial urethral disruptions.

 

Differential Diagnosis

Bladder rupture may be associated with posterior urethral injuries. An intravenous urogram should be considered part of the assessment. Delayed films should be obtained to demonstrate the bladder and note extravasation. Cystography cannot be done preoperatively, since a urethral catheter should not be passed. Careful evaluation of the bladder at operation is necessary. The anterior portion of the urethra may be injured as well as the prostatomembranous urethra.

Complications

Stricture, impotence, and incontinence as compli­cations of prostatomembranous disruption are among the most severe and debilitating mishaps that result from trauma to the urinary system. Stricture follow­ing primary repair and anastomosis occurs in about one-half of cases. If the preferred suprapubic cystostomy approach with delayed repair is used, the in­cidence of stricture can be reduced to about 5%.

The incidence of impotence after primary repair is 30-80% (mean, about 50%). This figure can be re­duced to 10-15% by suprapubic drainage with de­layed urethral reconstruction.

Incontinence in primary reanastomosis is noted in one-third of patients. Delayed reconstruction reduces the incidence to less than 5%.

 

Treatment

A. Emergency Measures: Shock and hemor­rhage should be treated.

B. Surgical Measures: Urethral catheterization should be avoided.

1. Immediate management-Initial manage­ment should consist of suprapubic cystostomy to pro­vide urinary drainage.

      Suprapubic cystostomy

 

A midline lower abdominal in­cision should be made, care being taken to avoid the large pelvic hematoma. The bladder and prostate are usually elevated superiorly by large periprostatic and perivesical hematomas. The bladder often is distended by a large volume of urine accumulated during the period of resuscitation and operative preparation. The urine is often clear and free of blood, but gross hematuria may be present. The bladder should be opened in the midline and carefully inspected for lacerations. If a laceration is present, the bladder should be closed with absorbable suture material and a cystostomy tube in­serted for urinary drainage. This approach involves no urethral instrumentation or manipulation. The suprapubic cystostomy is maintained in place for about 3 months. This allows resolution of the pelvic hematoma, and the prostate and bladder will slowly return to their anatomic positions.

 

Incomplete laceration of the posterior urethra heals spontaneously, and the suprapubic cystostomy can be removed within 2-3 weeks. The cystostomy tube should not be removed before voiding cystourethrography shows that no extravasation persists.

2. Urethral reconstruction-

 

Urethral reconstruction

 

 

                                         

                                                                                                         Urethral reconstruction

 

Reconstruction of the urethra after prostatic disruption can be under­taken within 3 months, assuming there is no pelvic abscess or other evidence of persistent pelvic infec­tion. Before reconstruction, a combined cystogram and urethrogram should be done to determine the ex­act length of the resulting urethral stricture. This stricture usually is 1-2 cm long and situated immedi­ately posterior to the pubic bone. The preferred ap­proach is a single-stage reconstruction of the urethral rupture defect with direct excision of the strictured area and anastomosis of the bulbous urethra directly to the apex of the prostate. A 16F silicone urethral catheter should be left in place along with a suprapu­bic cystostomy. Catheters are removed within a month, and the patient is then able to void.

Surgical Therapy

When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm.

The traditional intervention for men with posterior urethral injury secondary to pelvic fracture is placement of a suprapubic catheter for bladder drainage and subsequent delayed repair. This is the safest approach because it establishes urinary drainage and does not require either urethral manipulation or entrance into the hematoma caused by the fracture of the pelvis. This allows a formal repair to be carried out several weeks later under controlled circumstances and after resolution of the hematoma. The suprapubic catheter can be safely placed either percutaneously or via an open approach with a small incision. Ultrasound guidance can aid in the percutaneous approach. Some advocate immediate realignment through a number of different techniques, although much controversy exists on this topic.

Ultimate repair of the posterior urethral injury can be performed 6-12 weeks after the event, after the pelvic hematoma has resolved and the patient's orthopedic injuries have stabilized. It is often carried out via a perineal approach, and repair consists of mobilizing the urethra distally to allow a direct anastomosis after excision of the stricture. To prevent tension on the anastomosis, the distal urethra can be mobilized to the penoscrotal junction. Further length can be achieved with division of the septum between the corpora cavernosa and with inferior pubectomy. A urethral catheter is left indwelling to stent the repair, and the suprapubic catheter may be removed. Transpubic approaches for this repair have also been described and may be useful in men with fistulous tracts complicating a membranous urethral injury. Combining a perineal and abdominal approach with pubectomy provides maximum exposure of the prostatic apex.

Early realignment of posterior urethral injuries is also a treatment option. This has been performed at the time of injury, using interlocking sounds or by passage of catheters from both retrograde and antegrade approaches. Also, direct suture repair has been attempted in the immediate postinjury period. Another approach could be careful insertion of a urethral catheter under fluoroscopic guidance by a urologist experienced in that approach. These approaches have the disadvantage of possible entrance into and contamination of the pelvic hematoma with ensuing hemorrhage and sepsis.

 

Early endoscopic realignment (within 1 week postinjury) using a combined transurethral and percutaneous transvesical approach may be safer. If performed 5-7 days postinjury, the pelvic hematoma has stabilized and hemorrhage is less of a concern. The patient's overall condition has usually improved by this time, and sepsis is less of a concern. Ultimate outcomes and benefits of this approach remain controversial.

Bulbar urethral injuries often manifest months to years following blunt perineal trauma. The presentation for these injuries is often that of decreased stream and voiding symptoms. The diagnosis of urethral stricture is then made with urethrography and cystoscopy. These strictures may be managed with excision of the stricture and end-to-end anastomosis via a perineal approach. Most are short (< 2 cm). Longer strictures may require flaps (penile fasciocutaneous) or grafts (buccal mucosa) to achieve a tensionless anastomosis.

Penetrating anterior urethral injuries should be explored. The area of injury should be examined, and devitalized tissue should be debrided carefully to minimize tissue loss. Defects of up to 2 cm in the bulbar urethra and up to 1.5 cm in the penile urethra can be repaired primarily via a direct anastomosis over a catheter with fine absorbable suture. This is the preferred method of repair for these injuries. Longer defects should never be repaired emergently; they should be reconstructed at an interval following the injury to allow for resolution of other injuries and proper planning of the tissue transfers required for the repair. Urinary diversion can be accomplished with a suprapubic catheter during this interval.

Female urethral injuries are uncommon but deserve special consideration. The mechanism involves shearing of the urethra away from the pubic symphysis by the pelvic fracture and can be associated with significant vaginal and bladder injury.

 

Blood is often found in the vaginal vault on pelvic examination, and passage of a urethral catheter is impossible or yields no urine. Urethrography is difficult to obtain; the diagnosis is often clinical. Concomitant bladder injury must often be ruled out with CT cystography. These women commonly have multiple injuries, and the management approach must reflect this.

 

Bladder drainage must be established; the easiest and fastest method is placement of a suprapubic catheter followed by delayed evaluation and reconstruction. If the patient is being explored for other injuries or if a percutaneous suprapubic catheter cannot be safely placed, cystotomy with antegrade urethral catheter may provide for early definitive repair and minimize further morbidity. Careful follow-up is needed to manage any resulting incontinence or gynecologic disturbance.

 

 

 

 Urethral reconstruction prostatomembranous part of the urethra

 

3. Immediate urethral realignment-Some surgeons prefer to realign the urethra immediately. Direct suture reconstruction of the prostatomembranous disruption in the acute injury is extremely diffi­cult. Persistent bleeding and surrounding hematoma create technical problems. The incidence of stricture, impotence, and incontinence appears to be higher than with immediate cystostomy and delayed recon­struction. However, several authors have reported success with immediate urethral realignment.

C. General Measures: After delayed recon­struction by a perineal approach, patients are allowed ambulation on the first postoperative day and usually can be discharged within 3 days.

D. Treatment of Complications: Approxi­mately 1 month after the delayed reconstruction, the urethral catheter can be removed and a voiding cys­togram obtained through the suprapubic cystostomy tube. If the cystogram shows a patent area of recon­struction free of extravasation, the suprapubic cathe­ter can be removed; if there is extravasation or stric­ture, suprapubic cystostomy should be maintained. A follow-up urethrogram should be obtained within 2 months to watch for stricture development.

Stricture, if present (< 5%), is usually very short, and urethrotomy under direct vision offers easy and rapid cure.

The patient may be impotent for several months after delayed repair. Impotence is permanent in about 10% of patients. Implantation of a penile prosthesis is indicated if impotence is still present 2 years after reconstruction.

Incontinence seldom follows transpubic or perineal reconstruction. If present, it usually resolves slowly.

Prognosis

If complications can be avoided, the prognosis is excellent. Urinary infections ultimately resolve with appropriate management.

 

INJURIES TO THE ANTERIOR URETHRA

Etiology The anterior urethra is the portion distal to the urogenital diaphragm. Straddle injury may cause lacera­tion or contusion of the urethra. Self-instrumentation or iatrogenic instrumentation may cause partial dis­ruption.

Pathogenesis & Pathology

A. Contusion: Contusion of the urethra is a sign of crush injury without urethral disruption. Perineal hematoma usually resolves without complications.

B. Laceration: A severe straddle injury may re­sult in laceration of part of the urethral wall, allowing extravasation of urine. If the extravasation is unrec­ognized, it may extend into the scrotum, along the penile shaft, and up to the abdominal wall. It is lim­ited only by Colics' fascia and often results in sepsis, infection, and serious morbidity.

Clinical Findings

 

A. Symptoms: There is usually a history of a fall, and in some cases a history of instrumentation. Bleeding from the urethra is usually present. There is local pain into the perineum and sometimes massive perineal hematoma. If voiding has occurred and ex­travasation is noted, sudden swelling in the area will be present. If diagnosis has been delayed, sepsis and severe infection may be present.

 

B. Signs: The perineum is very tender, and a mass may be found. Rectal examination reveals a nor­mal prostate. The patient usually has a desire to void, but voiding should not be allowed until assessment of the urethra is complete. No attempt should be made to pass a urethral catheter, but if the patient's bladder is overdistended, percutaneous suprapubic cystostomy can be done as a temporary procedure.

When presentation of such injuries is delayed, there is massive urinary extravasation and infection in the perineum and the scrotum. The lower abdomi­nal wall may also be involved. The skin is usually swollen and discolored.

C. Laboratory Findings: Blood loss is not usually excessive, particularly if secondary injury has occurred. The white count may be elevated with in­fection.

 

D. X-Ray Findings: A urethrogram, with instil­lation of 15-20 mL of water-soluble contrast mater­ial, demonstrates extravasation and the location of in­jury.

    Urethrogram (demonstrates extravasation and the location of in­jury)

A contused urethra shows no evidence of extravasation.

E. Instrumental Examination: If there is no evidence of extravasation on the urethrogram, a ure­thral catheter may be passed into the bladder. Ex­travasation is a contraindication to further instrumen­tation at this time.

Differential Diagnosis

Partial or complete disruption of the prostatomem-branous urethra may occur if pelvic fracture is pres­ent. Urethrography usually demonstrates the location and extent of extravasation and its relationship to the urogenital diaphragm.

Complications

Heavy bleeding from the corpus spongiosum in­jury may occur in the perineum as well as through the urethral meatus. Pressure applied to the perineum over the site of the injury usually controls bleeding. If hemorrhage cannot be controlled, immediate oper­ation is required.

The complications of urinary extravasation are chiefly sepsis and infection. Aggressive debridement and drainage are required if there is infection.

Stricture at the site of injury is a common compli­cation, but surgical reconstruction may not be re­quired unless the stricture significantly reduces uri­nary flow rates.

Treatment

A. General Measures: Major blood loss usu­ally does not occur from straddle injury. If heavy bleeding does occur, local pressure for control, fol­lowed by resuscitation, is required.

B. Specific Measures:

1. Urethral contusion The patient with ure­thral contusion shows no evidence of extravasation, and the urethra remains intact. After urethrography, the patient is allowed to void; and if the voiding oc­curs normally, without pain or bleeding, no addi­tional treatment is necessary. If bleeding persists, urethral catheter drainage can be done.

 

   Urethral catheter

 

 

2. Urethral lacerations. Instrumentation of the urethra following urethrography should be avoided. A small midline incision in the suprapubic area read­ily exposes the dome of the bladder so that a suprapubic cystostomy tube can be inserted, allowing complete urinary diversion while the urethral lacera­tion heals.

 

 PERCUTANEOUS CYSTOSTOMY

 

                                                                                         PERCUTANEOUS CYSTOSTOMY

 

Percutaneous cystostomy may also be used in such injuries. If only minor extravasation is noted on the urethrogram, a voiding study can be performed within 7 days after suprapubic catheter drainage to search for extravasation. In more exten­sive injuries, one should wait 2-3 weeks before do­ing a voiding study through the suprapubic catheter. Healing at the site of injury may result in stricture formation. Most of these strictures are not severe and do not require surgical reconstruction. The suprapu­bic cystostomy catheter may be removed if no ex­travasation is documented. Follow-up with documen­tation of urinary flow rates will show whether there is urethral obstruction from stricture.

3. Urethral laceration with extensive uri­nary extravasation- After major laceration, urinary extravasation may involve the perineum, scrotum, and lower abdomen. Drainage of these areas is indi­cated. Suprapubic cystostomy for urinary diversion is required. Infection and abscess formation are com­mon and require antibiotic therapy.

4. Immediate repair-Immediate repair of ure­thral lacerations can be performed, but the procedure is difficult and the incidence of associated stricture is high.

C. Treatment of Complications: The main complication following reconstruction of posterior injuries is recurrent stricture. When managed with standard urethroplasty techniques, recurrent stricture requiring major repeat operation should be observed in only 1%-2% of patients, although 10%-15% may require either dilation or incision of a short recurrence.

 

Endoscopic realignment by experienced physicians appears to produce similar results. When performed at 5-7 days postinjury, rare infectious complications occur despite the presence of the organized pelvic hematoma.

 

Continence rates approach 100% in all series, particularly if the bladder neck is not involved. Potency status is probably related to the extent of the injury itself rather than the management of the problem. Several series have demonstrated only a small group of men losing erectile capabilities following the urethroplasty when they are potent following the actual injury.

Complications of reconstruction of anterior urethral injuries are similar to those observed in posterior urethral repairs.

 

Prognosis

Urethral stricture is a major complication but in most cases does not require surgical reconstruction. If, when stricture resolves, urinary flow rates are poor and urinary infection and urethral fistula are present, reconstruction is required.

 

 

 

 

 

NONSPECIFIC INFECTIONS OF THE EPIDIDYMIS

 

ACUTE EPIDIDYMITIS                              

Etiology                            

Although occasional cases of epididymal in­flammation are caused by trauma or reflux of sterile urine from the urethra through the vas deferens, most leases can be divided into 2 groups: (1) a sexually transmitted form associated with urethritis and com­monly caused by C trachomatis and N gonorrhoeae (singly or in combination), and (2) a primarily non-sexually transmitted form associated with urinary tract infections and prostatitis and caused mainly by Enterobacteriaceae or Pseudomonas. The hydrostatic pressure associated with voiding or physical strain may force urine containing pathogens from the urethra or prostate up the ejaculatory ducts and through the vas deferens to reach the epididymis, or infection may reach the epididymis through the perivasal lymphatics. Recurrent epididymitis in a young boy suggests the possibility of ureteral drainage into a seminal vesicle.

Tuberculous epididymitis now occurs infrequently in the USA; however, it is common in areas where pul­monary tuberculosis is still a public health problem.

Pathogenesis & Pathology

In its early stages, epididymitis is a cellular in­flammation (cellulitis). It generally begins in the vas deferens and descends to the lower pole of the epididymis.

In the acute stage, the epididymis is swollen and indurated. The infection spreads from the lower to the upper pole. On section, small abscesses may be seen. The tunica vaginalis often secretes serous fluid (in­flammatory hydrocele), which may become purulent. The spermatic cord becomes thickened. The testis be­comes swollen secondarily from passive congestion but rarely becomes involved in the infectious process.

Histologically, changes range from edema and infiltration with neutrophils, plasma cells, and lym­phocytes to actual abscess formation. The tubular epithelium may show necrosis. The infection may re­solve completely without residual injury, but peritubular fibrosis often develops and occludes the ducts. Bilateral epididymitis may result in sterility or low levels of fertility.

Clinical Findings

A. Symptoms: Epididymitis may follow severe physical strain (eg, lifting a heavy object) or consider­able sexual excitement. The patient may have experi­enced signs or symptoms of urethritis or prostatitis. At times, pathogens from the urethra or prostate are transmitted to the epididymis as a consequence of urethral instrumentation orprostatic surgery. Postpros-tatectomy bacterial epididymitis may evolve unless the urine is kept sterile throughout prostatectomy and the convalescent period.

Pain that is usually quite severe develops sud­denly in the scrotum and may radiate along the sper­matic cord and even reach the flank. The epididymis is exquisitely sensitive. Swelling is rapid and may cause the organs to double their normal size in the course of 3-4 hours. The temperature may reach 40 °C (104 °F). Urethral discharge may be seen. Symptoms of cystitis or prostatitis, with cloudy urine, may accompany the painful scrotal swelling.

 

 

B. Signs: There may be tenderness over the groin (spermatic cord) or in the lower abdominal quadrant on the affected side. The scrotum usually is enlarged, and the overlying skin may be reddened. If an abscess is present, the overlying skin may appear dry, flaky, and thinned; the abscess may rupture spontaneously. Early in the course of acute epididymitis, the enlarged, indu­rated, tender epididymis may be distinguished from the testis; but after a few hours, the testis and epididymis typically become one mass.

 

The spermatic cord is thickened by edema; a reactive hydrocele secondary to the inflammation may develop within a few days. Urethral discharge may be seen.

Palpation of the prostate may reveal changes suggesting acute or chronic prostatitis. The prostate should not be massaged during acute epididymitis, because the epididymitis may worsen.

C. Laboratory Findings: The hemogram typi­cally shows marked elevation of the white blood cell count, with a shift to the left. In preschool children, epididymitis is frequently associated with urinary tract infection due to coliform organisms or Pseudomonas; therefore, urinalysis and urine culture are important in the diagnosis of these children. The cause of epididymitis can be differentiated by examination of Gramstained smears or cultures of a midstream urine specimen and a urethral specimen. If coliform bac­teria, Pseudomonas, N gonorrhoeae, or C trachomatis is found, a presumptive diagnosis of epididymitis due to that organism is justified.

Differential Diagnosis

Tuberculous epididymitis seldom is associated with pain or significant fever. The epididymis usually is distinguishable from the testis on palpation. ' 'Bead­ing" of the vas deferens may be observed. Induration of the prostate and a thickened ipsilateral seminal vesi­cle usually are found in tuberculous epididymitis. The diagnosis can be established by finding tubercle bacilli in cultures of the urine or prostatic fluid.

Testicular tumors generally cause painless swell­ing of the affected testis; on occasion, however, acute hemorrhage within the tumor may cause sudden distention of the tunica albuginea and pain. Careful palpation generally detects a mass separate from a normal epididymis rising from the testicle. Prostatic examina­tion and urinalysis are normal.

 

     Scrotal ultrasonoraphy

 

 

Scrotal ultrasonoraphy may be helpful in differential diagnosis. If the diagnosis is still in doubt, surgical exploration is man­datory.

         Differential Diagnosis

 

    

 

Torsion of the spermatic cord occurs primarily in prepubertal boys but occasionally may be seen in young adults. In men 30 years of age or older, epididy­mitis is common but torsion of the spermatic cord occurs infrequently. In the early phase of torsion, the epididymis may be palpated anterior to the testis. The testis is apt to be retracted. Later, however, the testis and epididymis become one enlarged, tender mass. Prehn's sign (when the scrotum is gently lifted onto the symphysis, pain due to epididymitis is re­lieved but that due to torsion is worsened) may be helpful in the differential diagnosis but is not totally reliable. Use of the Doppler stethoscope or radionuclide scanning may confirm the diagnosis of epididymitis but should not be allowed to delay surgi­cal exploration of possible torsion.

      

Torsion of the appendages of the testis or epididymis occurs occasionally in prepubertal boys. These pedunculated bodies may become twisted, caus­ing localized pain and swelling. In the early stages, palpation discloses a tender nodule of the upper pole of the testicle; the epididymis is normal. Later, the entire testis becomes swollen, making the differential diag­nosis between epididymitis and torsion of the cord or its rudimentary appendages difficult. Early surgery is necessary in this case, since torsion of the cord must be treated promptly.

Testicular trauma may simulate acute epididymitis in every way, but the history of injury and the absence of pyuria or abnormal urethral discharge will help in differentiation.

      USI    (testicular trauma)

 

Mumps orchitis usually is accompanied by parotitis. There are no urinary symptoms, and the urinary sediment is free of excessive numbers of white cells and bacteria. If diagnosis and appropriate therapy are delayed, an abscess may form and drain spontane­ously through the scrotum; it may require surgical drainage.

Complications

Epididymal abscess may extend into and destroy the testis (epididymo-orchitis), but this is rare. Chronic epididymitis may evolve.

Prevention

In order to prevent recurrence of sexually trans­mitted forms of epididymitis, infected sexual partners must be identified and treated. Identification and treatment of underlying causes of urinary tract infec­tions and prostatitis can prevent non-sexually trans­mitted forms of epididymitis. Recurrent acute attacks may indicate the need for ipsilateral vasoligation.

Treatment

A. Specific Measures: Sexually transmitted acute epididymitis occurs mainly in young adults in association with urethritis without underlying genitourinary disease or abnormalities. For treatment, tetracycline hydrochloride, 500 mg orally 4 times daily for 21 days, or doxycycline, 100 mg orally twice daily for 21 days, is recommended. Alternative treatment for gonococcal urethritis and epididymitis is ampicil-lin, 500 mg orally 4 times daily for 21 days, or a 10-day course of a parenteral second- or third-generation cephalosporin. For nongonococcal urethritis and epididymitis, alternative therapy may consist of eryth-romycin, 500 mg orally 4 times daily for 21 days.

Non-sexually transmitted acute epididymitis is most often a consequence of infection with Enterobacteriaceae or Pseudomonas, especially in middle-aged or older men. Prompt treatment with antimicrobial drugs selected on the basis of culture and sensitivity tests is indicated. Provided that the pathogens are sus­ceptible to these drugs, trimethoprim-sulfamethoxa-zole (trimethoprim, 160 mg, and sulfamethoxazole, 800 mg) orally twice daily for 4 weeks, is recom­mended, especially if an underlying bacterial prosta­titis is suspected. The patient should be evaluated for underlying genitourinary tract disease.

B. General Measures: Bed rest is necessary dur­ing the acute phase (3-4 days). Support for the en­larged, heavy testicle partially relieves the discomfort; the more roomy athletic supporter is preferred to stan­dard scrotal supports. Local injection of 20 mL of 1% lidocaine or other local anesthetic agent into the sper­matic cord at the pubic tubercle (just above the testicle) may produce marked relief of pain and discomfort. This may be repeated on a daily basis as needed. Oral analgesics and antipyretics are usually indicated. In the early phase, an ice bag helps prevent swelling. After­ward, local heat affords comfort and probably hastens resolution of the inflammatory process.

Sexual activity or physical strain may exacerbate the infection and worsen the symptoms and therefore should be avoided.

Prognosis

When diagnosed promptly and treated appropri­ately, acute epididymitis usually resolves slowly with­out complications. Complete resolution of pain and symptoms often takes up to 2 weeks, and 4 or more weeks may be required for the epididymis to return to normal size and consistency. Complications are un­usual, although lowered fertility and even sterility may ensue, especially when the process is bilateral.

 

CHRONIC EPIDIDYMITIS

Chronic epididymitis usually represents the irre­versible end stage of a severe acute epididymitis that has been followed by frequent mild attacks.

In chronic epididymitis, fibroplasia leads to indu­ration of part or all of the organ. Histologically, the scarring is extensive and tubular occlusion is com­mon. The tissues are infiltrated with lymphocytes and plasma cells.

Except during a mild exacerbation, at which time variable degrees of local discomfort are the rule, chronic epididymitis is not associated with specific symptoms. The patient may notice a lump in the scrotum.

The epididymis usually is thickened and some­what enlarged; it may or may not be tender. It is easily distinguished from the testis on palpation. The sper­matic cord is often thickened, and the diameter of the vas deferens may be increased. The prostate may be firm or may contain areas of fibrosis. When chronic epididymitis is associated with chronic prostatitis, the prostatic expressate shows excessive numbers of in­flammatory cells. The voided urine may show pyuria, and cultures may be positive for an underlying prosta­titis or urinary tract infection.

Tuberculous epididymitis mimics nonspecific chronic epididymitis in every way. Beading of the vas deferens, thickening of the ipsilateral seminal vesicle, and the finding of ' 'sterile'' pyuria and tubercle bacilli in the urine generally make the diagnosis of tubercu­lous epididymitis. Urograms may show typical changes associated with tuberculous involvement of the urinary tract. Cystoscopy may reveal ulcers involv­ing the bladder lining.

Testicular tumors may present as a "lump in the testicle". Careful palpation, however, will show a thickened epididymis or a hard, insensitive testicular I tumor.

Except in infants and elderly men, tumors of the epididymis are rare. Differentiation from chronic epididymitis ultimately may be made only by the sur­gical pathologist.

If chronic epididymitis is bilateral, sterility or relative infertility may result.

When it is suspected that an exacerbation of chronic epididymitis is associated with active bacterial infection, the use of appropriate antibacterial agents is indicated. However, the scarring associated with chronic epididymitis can impede diffusion of the anti­microbial agents into the tissues. Appropriate treat­ment of underlying urinary tract infection or pros­tatitis is always indicated. At times, vasoligation on the affected side may prevent recurrent bouts of as­cending epididymitis. Surgical excision of the epididymis and attached vas deferens may prove necessary.

Except for recurring pain and the threat of infertil­ity (when involvement is bilateral), chronic epiditiymitis is of little consequence. Once the stage of diffuse fibrosis is reached, little can be done other than epididymectomy to resolve the problem.

 

 

 

NONSPECIFIC INFECTIONS OF THE TESTIS

ACUTE ORCHITIS

Etiology

Inflammation of the testis may occur as a result of hematogenous spread of various systemic infectious diseases. It is thought that orchitis without epididymitis originates in this way.

Epididymoorchitis, a fearful complication of mumps, is generally seen only in adolescent boys and young men. The factors that predispose to this compli­cation are unknown; however, mumps orchitis occurs in 20-35% of cases of mumps in males in this age range and is bilateral in 10%, The onset is usually 3-4 days after the development of parotitis.

Tuberculous orchitis may result from hematoge­nous spread of tubercle bacilli from a pulmonary focus of infection or, more commonly, by direct extension from tuberculous epididymitis.

The testis may be involved in syphilis; gummas with large areas of necrosis occasionally complicate advanced stages of syphilis.

Granulomatous orchitis, a nonspecific inflam­matory process in the testis, occurs occasionally in middle-aged and older men. It apparently is of nonin-fectious origin. Evidence suggests that it is an autoim­mune disease which represents a granulomatous re­sponse to spermatozoa.

Pathogenesis & Pathology      

On gross inspection, the testis involved by nonspecific orchitis is variably enlarged, congested, and tense; on section, small abscesses may be seen.

Histologically, edema of the connective tissue and diffuse infiltration by neutrophils are characteristic. The seminiferous tubules also may be involved, and frank necrosis may be present. The seminiferous tubules are replaced by caseous tubercles in tubercu­lous orchitis and by an infiltrate of mononuclear cells (plasma cells, lymphocytes, multinucleated giant cells, and epithelioid cells) in nonspecific granuloma-tous orchitis. The outline of the seminiferous tubules remains, but spermatogenic activity is absent. In the healed stage, the seminiferous tubules and the intersti­tial cells usually are preserved.

Mumps is the most common infectious cause of orchitis. Interestingly, mumps orchitis occurs only in postpubertal males. Grossly, the testis is greatly en­larged and bluish in color. On section, because of the interstitial reaction and edema, the tubules do not ex­trude. Histologically, edema and dilatation of blood vessels are observed; neutrophils, lymphocytes, and macrophages are abundant; and tubular cells show varying degrees of degeneration. In the healed stage, the testis is small and soft. Histologic study at this stage shows marked tubular atrophy but preservation of the interstitial cells of Leydig. The epididymis often is similarly involved.

Clinical Findings

A. Symptoms: The onset of mumps orchitis is sudden; it usually occurs about 3 -4 days after the onset of parotitis. The scrotum becomes erythematous and edematous. Unlike the findings in epididymitis, uri­nary symptoms characteristically are absent. Fever may reach 40 °C (104 °F), and prostration may be marked.

 

 

  Scrotal ultrasonoraphy

 

 

B. Signs: The parotitis of mumps may be present, or evidence of other infectious disease may be found.

      

 

 One or both testicles are enlarged and very tender. Often the epididymis cannot be distinguished from the testis by palpation. The scrotal skin may be reddened. An acute hydrocele that transilluminates may develop.

 

  USI (ACUTE ORCHITIS)

 

 

C. Laboratory Findings: The hemogram usu­ally shows leukocytosis. Mild proteinuria and microhematuria have been described, but the urinalysis usually is normal. During acute episodes of viral or­chitis, the infective organism can be recovered from the urine.

 

Differential Diagnosis

When seen early, acute epididymitis easily is distinguished from acute orchitis because only the epididymis is involved in the inflammatory reaction. Later, as passive congestion of the testicle develops, the differentiation between epididymitis and orchitis becomes more difficult. The presence of urethral discharge and pyuria, positive results of urine and prostatic fluid cultures, and the absence of a gener­alized infectious disease suggest epididymitis, not orchitis.

 

Differential Diagnosis

 

 

Torsion of the spermatic cord at times presents difficulty in the differential diagnosis. During the early stages of torsion, the epididymis is felt anterior to the testis. Absence of laboratory and physical findings suggesting an infectious disease tends to rule out or­chitis.

 

   Hydrocele

 

  Hydrocele (diaphanoscopy)

 

Nonspecific granulomatous orchitis easily is con­fused with testicular tumors on the basis of clinical findings. The differentiation usually is made by the surgical pathologist following radical orchiectomy.

Posttraumatic rupture of the testis and acute hemorrhage into the testis due to minor trauma are conditions that must be distinguished from orchitis. Spontaneous hemorrhage into the testicle may occur in men with polyarteritis nodosa. Orchiectomy is often required because these conditions cannot be distinguished from testicular tumors.

Complications

Spermatogenesis is irreversibly damaged in about 30% of testes involved in mumps orchitis. Marked atrophy of the affected testis is the rule. If both testes are involved, permanent sterility may result, but androgenic function usually is maintained.

Prevention

Live attenuated mumps virus vaccine is highly effective in preventing parotitis and complicating or­chitis; it is recommended for all susceptible persons over age 1 year. The incidence of mumps orchitis may possibly be reduced by the administration of mumps hyperimmune globulin, 20 mL, during the incubation period or very early stages of the disease. Routine administration of estrogens or corticosteroids to all postpubertal males who develop mumps has been suggested as prophylaxis against orchitis; however, the efficacy of this practice is controversial.

Treatment

 

A. Specific Measures: Orchitis due to bacterial infections should be treated with appropriate antimi­crobial drugs, but these drugs are useless against mumps orchitis. Rapid resolution of swelling and re­lief of pain often results after infiltration of the sper­matic cord immediately superior to the involved testis with 20 mL of 1% lidocaine. This also may protect spermatogenic activity by improving the blood supply to the testicle. In proved cases of nonspecific granu­lomatous orchitis, the use of corticosteroids is indi­cated.

Empirical therapy should be given to all patients with epididymo-orchitis before culture/NAAT results are available. The antibiotic regimen chosen should be determined in the light of the immediate tests (urethral or FPU smear, urinalysis) as well as age, sexual history including insertive anal intercourse, any recent instrumentation or catheterisation and any known urinary tract abnormalities.

Antibiotics may need to be varied according to local knowledge of antibiotic sensitivities and changed once the results of cultures and sensitivities are known.

For epididymo-orchitis most probably due to any sexually transmitted pathogen: ceftriaxone 250 mg intramuscularly single dose, plus doxycycline 100 mg by mouth twice daily for 10-14 days.

If it is most probably due to chlamydia or other nongonococcal organisms (ie where gonorrhoea is considered unlikely as microscopy is negative for Gram-negative intracellular diplococci and no risk factors for gonorrhoea are identified) consider: doxycycline 100 mg by mouth twice daily for 10-14 days or ofloxacin 200 mg by mouth twice daily for 14 days.

For epididymo-orchitis most probably due to enteric organisms: ofloxacin 200 mg by mouth twice daily for 14 days or ciprofloxacin 500 mg by mouth twice daily for 10 days.

Corticosteroids have been used in the treatment of acute epididymo-orchitis but have not been shown to be of benefit.

In those with severe epididymo-orchitis or features suggestive of bacteraemia, inpatient management of fluid and electrolyte balance is required. Intravenous broad-spectrum therapy directed towards coliforms and Pseudomonas aeruginosa should be considered: cefuroxime 1.5 g three times daily with or without gentamicin for 3-5 days until fever subsides; in those with severe allergy to penicillin, use ciprofloxacin 500 mg twice daily.

For epididymo-orchitis of all causes where the patient is allergic to cephalosporins and/or tetracyclines: ofloxacin 200 mg by mouth twice daily for 14 days.

Adjunctive therapy

Supportive therapy: Reduce physical activity; provide scrotal support and elevation; use ice packs, anti-inflammatory agents, and analgesics, including nerve blocks; avoid urethral instrumentation; use sitz baths

 

B. General Measures: Bed rest is necessary dur­ing the acute phase of orchitis. Local heat is helpful and may relieve the pain. Support to the organ affords comfort; a towel placed under the scrotum or the use of an athletic supporter may be helpful. Medication for relief of pain and fever is advised.

 

Complications

Complications are more often seen in patients with uropathogen-related epididymo-orchitis than sexually transmitted infection-associated epididymo-orchitis.

Reactive hydrocele.

Abscess formation and infarction of the testicle (both are rare).

Infertility - the relationship between epididymo-orchitis and infertility is poorly understood. Men who present with obstructive azoospermia are usually found to have epididymal obstruction when explored for sperm retrieval, which may be a consequence of previous infection.

Mumps epididymo-orchitis can lead to testicular atrophy. Of those with bilateral orchitis, 13% will have reduced fertility.

Prognosis

Bilateral orchitis may result in irreversible dam­age to spermatogenesis and permanent sterility. The acute phase of mumps orchitis lasts for about 1 week. Noticeable atrophy may occur in 1 or 2 months.

 

 

 

Testicular torsion

Testicular torsion is the most important differential diagnosis. It is a surgical emergency, should be considered in all patients and should be excluded first (testicular salvage is essential within 6 hours and becomes decreasingly likely with time).

Differentiation between epididymo-orchitis and testicular torsion on clinical examination may be difficult and, if any doubt exists, then urgent surgical exploration is advocated.

 

Torsion is more common in men who are younger than 20 years but it can occur at any age.

A painful swollen testicle in an adolescent boy or a young man should be managed as torsion until proven otherwise.

Torsion is more likely if the onset of pain is acute (typically around four hours at presentation) and the pain is severe.

 

 

References:

 

a) basic literature:

1. Donald R. Smith, M.D. General Urology, 11-th edition, 1984, p. 498-502, 279-297

2. Official Journal of the European Association of Urology /2002-2007/.

3. Urological Guidelines (European Assosiation of Urology) Health Care Office /august 2004 edition/.

4. Urology edited by N.A.Lopatkin, Moscow, 1982, p. 395-407, 110-146,

 

b) supplementary literature:

1. Urinary Tract Infection and Inflamation / Jackson E. Fowler, JR. MD. Year Book Medical Publishers, Chicago 1989.

2. European Urology Supplements /2002-2007/.

3. Scientific Foundations of Urology. Third Edition 1990. Edited by Geoffrey D. Chisholm and William R. Fair, MD. Heinemann Medical Books, Oxford, p.136-141,

4. European Urology via www.eropeanurology.com

5. Urology The Gold Jounal /www.goldjournal/net/.