Complications of kidney and bladder cancer. Urgent measures in some emergency situations in urology at the prehospital stage What may be the consequences

DEFINITION.

Hematuria - the appearance of blood in the urine - is one of the characteristic symptoms of many urological diseases. There are microscopic and macroscopic hematuria; the occurrence of intense gross hematuria often requires emergency care.

ETIOLOGY AND PATHOGENESIS.

Possible causes of hematuria are presented in table.

CAUSES OF BLEEDING FROM THE URINARY SYSTEM ORGANS

(Pytel A.Ya. et al., 1973).

CLINICAL PICTURE AND CLASSIFICATION.

The appearance of red blood cells in the urine gives it a cloudy appearance and a pink, brown-red or reddish-black color, depending on the degree of hematuria. With macrohematuria, this color is noticeable when examining urine with the naked eye; with microhematuria, a significant number of red blood cells are detected only when examining urine sediment under a microscope.

To determine the localization of the pathological process during hematuria, a three-glass test is often used, in which the patient needs to urinate successively into 3 vessels. Macrohematuria can be of three types:

1) initial (initial), when only the first portion of urine is blood-colored, the remaining portions are of normal color;

2) terminal (final), in which no blood admixture is visually detected in the first portion of urine, and only the last portions of urine contain blood;

H) total, when urine in all portions is equally colored with blood.

Possible causes of gross hematuria are presented in table.

TYPES AND CAUSES OF MACROHEMATURIA.

Often macrohematuria is accompanied by an attack of pain in the kidney area, since a clot formed in the ureter disrupts the outflow of urine from the kidney. With a kidney tumor, bleeding precedes pain (“asymptomatic hematuria”), and with urolithiasis, pain appears before the onset of hematuria. Localization of pain during hematuria also allows us to clarify the localization of the pathological process. Thus, pain in the lumbar region is characteristic of kidney diseases, and in the suprapubic region for lesions of the bladder. The presence of dysuria simultaneously with hematuria is observed when the prostate gland, bladder or posterior urethra is affected.

The shape of blood clots also allows us to determine the localization of the pathological process. Worm-shaped clots that form as blood passes through the ureter indicate a disease of the upper urinary tract. Shapeless clots are more typical for bleeding from the bladder, although they can form in the bladder when blood is released from the kidney.

DIAGNOSTIC CRITERIA.

The diagnosis of hematuria may be suspected during the first examination of the patient; urine sediment is examined for confirmation. When diagnosing hematuria, the emergency physician should obtain answers to the following questions.

1) Do you have a history of urolithiasis or other kidney diseases? Is there a history of trauma? Is the patient receiving anticoagulants? Do you have a history of blood diseases or Crohn's disease?

It is necessary to clarify the possible cause of hematuria.

2) Has the patient consumed foods (beets, rhubarb) or medications (analgin, 5-NOK) that can turn urine red?

Hematuria and urine staining of another cause are differentiated.

3) Is the discharge of blood from the urethra associated with the act of urination.

It is necessary to differentiate between hematuria and urethrorrhagia

4) Has the patient had any poisoning, blood transfusions, or acute anemia?

It is necessary to differentiate between hematuria and hemoglobinuria that occurs with massive intravascular hemolysis of red blood cells.

MAIN AREAS OF THERAPY.

If gross hematuria occurs, especially painless, immediate cystoscopy is indicated to determine the source of bleeding or at least the side of the lesion, since with tumor processes the hematuria may suddenly stop, and the opportunity to determine the lesion will be lost. The position formulated in 1950 by I. N. Shapiro that any unilateral significant renal bleeding should be considered a sign of a tumor until another cause of hematuria is discovered remains fully relevant. Only after a diagnosis has been established, or at least the side of the lesion, can the use of hemostatic agents begin.

To assess the danger of emerging hematuria, it is important to determine the level and dynamics of blood pressure, hemoglobin content, the severity of tachycardia, and determination of blood volume. It is especially important to study these indicators when, in addition to hematuria, internal bleeding is also possible (for example, with a kidney injury). Thus, treatment tactics for hematuria depend on the nature and location of the pathological process, as well as the intensity of bleeding.

1) Hemostatic therapy:

a) intravenous infusion of 10 ml of 10% calcium chloride solution;

b) administration of 100 ml of a 5% solution of e-aminocaproic acid intravenously;

c) administration of 4 ml (500 mg) of 12.5% ​​dicinone solution intravenously;

2) rest and cold on the affected area.

3) transfusion of fresh frozen plasma.

With profuse total hematuria, the bladder often fills with blood clots and independent urination becomes impossible. Bladder tamponade occurs. Patients develop painful tenesmus, and a collaptoid state may develop. Bladder tamponade requires immediate treatment. Simultaneously with the blood transfusion and hemostatic drugs, they begin to remove clots from the bladder using an evacuation catheter and a Janet syringe.

COMMON THERAPY ERRORS.

Urethrorrhagia, in which blood is released from the urethra outside the act of urination, should be distinguished from hematuria. Urethrorrhagia most often occurs when the integrity of the wall of the urethra is violated or a tumor appears in it. If there is evidence of an inflammatory process or tumor of the urethra, urgent urethroscopy and stopping bleeding by electrocoagulation or laser ablation of the affected area is necessary. If a urethral rupture is suspected, attempting to insert a catheter or other instruments into the bladder is strictly contraindicated, as this will aggravate the injury.

To avoid mistakes, remember that changes in the color of urine can be caused by taking medications or foods (beets). The occurrence of hematuria occurs with extrarenal diseases (typhoid fever, measles, scarlet fever, etc.; blood diseases, Crohn's disease, overdose of anticoagulants).

INDICATIONS FOR HOSPITALIZATION.

For gross hematuria, hospitalization is indicated. Bleeding that threatens the patient’s life and the lack of effect from conservative treatment is an indication for urgent surgical intervention (nephrectomy, resection of the bladder, ligation of the internal iliac arteries, emergency adenomectomy and others).

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As is known, the extensive spread of a bladder tumor makes radical treatment impossible, and the main goal of palliative treatment is to reduce or complete elimination painful symptoms of the disease, i.e. to improve quality of life indicators.

Palliative treatment methods:

1. Palliative surgical interventions
2. Radiation therapy
3. Chemotherapy
4. Immunotherapy

The main clinical syndromes during the progression of bladder cancer (BC):

1. Anemia
2. Intravesical obstruction syndrome
3. Chronic renal failure
4. Chronic pain syndrome

Thus, therapeutic measures against the background of the main methods of influence will also be aimed at combating pain, hematuria, acute urinary retention, blockade of the upper urinary tract, and paravesical phlegmon.

Those. the nature and extent of palliative care will be dictated by the most predominant clinical syndromes requiring emergency treatment.

Emergency conditions and their characteristics

1. Hematuria
2. Bladder tamponade
3. Acute urinary retention
4. Blockage of the upper urinary tract (hydronephrosis)
5. Pain syndrome
6. Paravesical phlegmon

The appearance of blood in the urine (hematuria), as a rule, is the first symptom that forces the patient to consult a doctor and suspect the presence of a bladder tumor.

In the early stage of the disease, hematuria may not cause much concern and sometimes it is enough to prescribe hemostatic agents (nettle decoction, dicinone) to compensate for blood loss and stop bleeding.

Two symptom complexes can determine the urgency of the situation and the need for emergency medical care for profuse hematuria - acute anemia and bladder tamponade. Intense, non-stopping conservative methods Treatment of bleeding leads to blood loss, hypovolemia and anemia.

Coagulation of blood spilled into the lumen of the bladder may be accompanied by the formation of clots that can cause bladder tamponade. If this situation occurs, it is necessary to resort to surgical treatment.

The scope of surgical intervention will be determined by the location of the tumor and the extent of the process. To do this, a high section of the bladder is performed, followed by its revision, freeing the bladder cavity from clots and restoring the passage of urine.

In case of limited cancer of the bottom and body of the bladder, resection of the bladder is performed; in case of infiltration of the ureteric opening, resection of the intramural part of the ureter is performed, followed by neoimplantation into the bladder.

In case of total damage to the bladder or the location of the tumor in the area of ​​the bladder triangle, the possibility of the need for cystectomy, a technically difficult and traumatic operation for the patient, cannot be excluded.

Cystectomy ends with bilateral ureterocutaneostomy, since increasing the volume of the operation due to the formation of an artificial reservoir for urine, given the urgency of the operation, can have a fatal outcome.

If the bladder tumor is unresectable, attempts are made to stop the bleeding with palliative measures - electrocoagulation of the tumor, ligation of both internal iliac arteries.

In specialized medical institutions, it is possible to use endovascular interventions followed by embolization of the internal iliac arteries, under angiography control. The advantage of embolization is the possibility of occlusion of the peripheral arterial bed, which eliminates the development of collaterals.

Also, the advantage of endovascular intervention is the ability, through catheterization of one of the vessels, to carry out a regional infusion of hemostatic and cytostatic drugs, against the background of which it is possible to stop ongoing bleeding.

Embolization is carried out by transfemoral catheterization according to Seldinger, selective insertion of a catheter into the internal iliac artery on one or both sides and under visual control by occlusion of all peripheral vessels.

Bleeding from the bladder neck can be established using a Foley balloon catheter: after inserting the catheter into the bladder and inflating the balloon, the outer end is fixed in a taut position to the thigh, which provides compression of the tumor. You can also use a tight tamponade of the bleeding tumor with a gauze pad to stop bleeding.

In case of disturbance of the outflow of urine associated with germination of the ureteric orifices, their infiltration and leading to the development of ureterohydronephrosis and azotemia, the patient is advised:

Percutaneous nephrostomy;
ureteral stenting;
nephrostomy placement;
excretion of the ureteric orifices onto the skin.

With complete urinary retention optimal method restoration of urinary diversion is catheterization of the bladder with an elastic catheter. If it is impossible to install an elastic catheter, it is possible to perform a trocar epicystostomy or create a suprapubic fistula. A rubber Foley catheter is inserted into the bladder through the trocar and, after filling the balloon, it is left to drain the bladder and drain urine.

Tumor growth into the pelvic organs and compression of the nerve trunks is accompanied by persistent pain, leading to the need to use analgesics and narcotic drugs.

Principles drug treatment pain syndrome are described above. It is also possible to use conductive novocaine blockades through the obturator foramen according to Stuckey, presacral blockade according to A.V. Vishnevsky, epidural denervation, resection of the presacral nerve plexus.

Although modern development Pharmacotherapy reduces this area to almost a minimum. Also, carrying out this kind of manipulation requires good skill. In case of metastatic lesions of the skeletal bones, short courses of local irradiation can be used to relieve pain.

Extraperitoneal perforation of the bladder develops in patients with advanced endophytic, infiltrating tumor due to its spontaneous or in the case of radiation disintegration. A defect in the bladder wall causes urine to leak into the peri-vesical cellular space, which is complicated by the development of paravesical phlegmon.

In this case, the optimal method of palliative care would be resection of the wall of the bladder with a disintegrating tumor and suturing of the post-resected defect.

The operation for paravesical phlegmon has two goals: urine diversion and drainage of the perovesical cellular space.

The most effective way to divert urine is an epicystomy through a “healthy” wall without signs of visible tumor invasion. When a tumor disintegrates in the area of ​​the bladder triangle, the only possible way diversion of urine to the outside is a bilateral ureterocutaneostomy.

Drainage of the paravesical tissue through the anterior abdominal wall ensures outflow from the upper parts of the retropubic space and prevesical tissue. The peri-vesical tissue, located deep in the pelvis, should be drained through the obturator foramen.

After providing primary palliative care, patients are further recommended to undergo radiation therapy with single single dose (SOD) 1.8-2.5 Gy, total focal dose (SOD)- 60-70 Gy.

Contraindication to radiation therapy is compression of the ureters, acute pyelonephritis, the presence of multiple metastases, inhibition of hematopoiesis, severe general condition of the patient.

For chemotherapy, the most commonly used cytostatics are adriamycin, thioteph, mitomycin C, cisplatin, methotrexate, vinblastine, 5-Fluorouracil. The standard treatment regimen currently is a combination of 3-4 drugs based on cisplatin and methotrexate.

The most commonly used MVAC scheme is:

Methotrexate 30 mg/m2, intravenously, on days 1, 15, 22,
Vinblastine 3 mg/m2, intravenously, on days 2, 15, 22,
Adriamycin 30 mg/m2, intravenously, on day 2,
Cisplatin 70 mg/m2, IV, on day 2.

The interval between courses is 28 days. At least 2-3 courses. The effectiveness of chemotherapy for disseminated bladder cancer is about 50-70% and its use in a palliative mode if the patient is in good condition should not be neglected by the attending physician.

Novikov G.A., Chissov V.I., Modnikov O.P.

Bladder tamponade is a pathological condition in which the bladder cavity is completely filled with blood clots. This condition is considered by doctors as an emergency, because in connection with it, urination disorders develop, and sometimes acute urine retention.

Why is it developing?

Bladder tamponade can be a consequence of diseases of the genitourinary system, as well as the result of injuries. The main reasons are:

• upper urinary tract injuries;
• neoplasms of the upper urinary tract;
• bladder neoplasms;
• varicose veins of the urinary reservoir and prostate gland;
• damage to the prostate capsule due to the capsule rupturing.

Bladder cancer is a common cause

Development mechanism

How the process develops largely depends on the origin of the pathology. For example, with a sudden rupture of the prostate capsule, the process proceeds as follows. Rupture and tension of the capsule occurs due to the growth of the prostate gland and obstruction in it.

There is constant pressure on the muscle that relaxes the bladder, as well as on the neck of the bladder. It is formed due to the fact that it is necessary to overcome infravesicular blockage. Changes in pressure inside the bladder and a large volume of the prostate gland create conditions that lead to capsule rupture. As a result, hematuria occurs.

Symptoms

The main manifestations of bladder tamponade are pain when trying to urinate, the urge either does not have an effect, or a small amount of urine is released. Upon palpation, a bulge is detected above the pubis; this is a full bladder. The slightest pressure on it causes pain. A person with bladder tamponade is emotionally labile and has restless behavior.

Based on determining the volume of blood in the bladder, the degree of blood loss is determined. Urine contains fresh or altered blood impurities. It is worth considering that tamponade of the urinary reservoir involves bleeding. The capacity of the bladder in a male is about 300 milliliters, but in fact the volume of lost blood is much larger.

Therefore, a sick person has all the signs of blood loss:

• pale and moist skin;
• heartbeat;
• weakness and apathy;
• dizziness;
• increase in heart rate.

The main complaints of a patient with tamponade will be pain in the area of ​​the urinary reservoir, inability to urinate, painful and ineffective urge, dizziness, blood in the urine.

Anemia is one of the complications of the pathological condition

How to diagnose?

Bladder tamponade is determined based on complaints and questioning. As a rule, the doctor finds out that there have already been cases of blood in urine. On examination, one notices pronounced pain when pressing in the pubic area, and the patient’s pale and unhealthy appearance.

There is blood in the urinary fluid. When examining men with a finger through the rectum, the doctor identifies a prostate gland that is larger than normal size.

The attending physician must prescribe blood and urine tests. In a general blood test, a decrease in the level of hemoglobin and erythrocyte elements is observed. There is also a pronounced increase in the level of leukocytes in the blood, a shift in the leukocyte count to the left and a high level of erythrocyte sedimentation rate. This happens due to the inflammatory process in the bladder.

In a biochemical blood test, the level of creatinine and uric acid increases. This is explained by the fact that against the background of acute urinary retention and prolonged tamponade, the cleansing ability of the kidneys decreases.

To diagnose tamponade, ultrasound examination of the bladder and prostate gland, as well as the upper urinary tract and kidneys, is used. On an ultrasound, you can see an enlarged prostate due to an adenoma. Blood clots in the form of elements of different echogenicity are observed in the urine reservoir.

Using ultrasound, it is possible to predict quite accurately the amount of blood that is in the cavity of the bladder. But examining the kidneys allows you to diagnose blockage of the urinary tract above the urine reservoir itself.

On ultrasound, this obstruction will be visible as widening on both sides. The pyelocaliceal system and ureters expand. This type of diagnosis also identifies neoplasms if they are present.

Placing a catheter does not solve the problem, as it immediately becomes clogged with blood clots.

Treatment

Treatment measures are operational in nature. There are urgent and delayed surgical treatment. Urgent consists of revision of the urine reservoir and removal of the adenoma.

Hemostatics are drugs used for bleeding of various types.

But delayed treatment involves clearing the bladder of blood through the urethra in parallel with antibiotic and hemostatic therapy. Replacement of lost blood is also used. If the bleeding has stopped, then there is time for a full examination and delayed intervention. Tamponade is a very dangerous condition and requires immediate treatment. At the first signs, consult a doctor.

Situations requiring urgent intervention occur quite often in urological practice. These include renal colic, acute pyelonephritis, urinary retention, gross hematuria. Rapid recognition and differentiated treatment of these conditions reduces the likelihood of complications and increases the duration of the effect of the therapy.

Clinical picture and diagnostic criteria

Patients suffer from bladder overflow: painful and fruitless attempts to urinate, pain in the suprapubic region; The patients' behavior is characterized as extremely restless. Patients with central diseases react differently. nervous system and spinal cord, which are usually immobilized and do not experience severe pain. When examined in the suprapubic region, a characteristic bulge is determined, caused by an overfilled bladder (“vesical ball”), which upon percussion produces a dull sound.

In order to provide the patient with timely and qualified assistance, it is necessary to clearly understand the mechanism of development of acute urinary retention in each individual case. In case of acute urinary retention, it is necessary to urgently evacuate urine from the bladder. Considering the danger of urinary tract infection in the absence of a pronounced urge to urinate, it is better to perform catheterization in a hospital setting. Severe pain caused by overdistension of the bladder is an indication for catheterization at the prehospital stage.

Bladder catheterization should be treated as a serious procedure, equating it to surgery. In patients without anatomical changes in the lower urinary tract (with diseases of the central nervous system and spinal cord, postoperative ischuria, etc.), bladder catheterization usually does not present any difficulties. For this purpose, various rubber and silicone catheters are used.

The greatest difficulty is catheterization in patients with benign prostatic hyperplasia (BPH). With BPH, the posterior urethra lengthens and the angle between its prostatic and bulbous sections increases. Given these changes in the urethra, it is advisable to use catheters with Tieman or Mercier curvature. With rough and violent insertion of a catheter, serious complications are possible: the formation of a false passage in the urethra and prostate gland, urethrorrhagia, urethral fever. Prevention of these complications is careful adherence to asepsis and catheterization techniques.

The need for catheterization often arises in elderly patients, as well as in persons with severe concomitant pathologies, including diabetes mellitus, circulatory disorders, etc. In such cases, taking into account the lack of sterile conditions in the ambulance, catheterization must be carried out antibiotic prophylaxis of urinary tract infections (UTIs).

The main causative agent of uncomplicated UTI infections is E. coli- 80 - 90%, much less often - S. saprophyticus (3-5%), Klebsiella spp., P. mirabilis etc. Fluoroquinolones (ciprofloxacin, pefloxacin, ofloxacin, etc.) are most active against these pathogens, the level of resistance of which is less than 3%.

As an alternative, you can use amoxicillin/clavulanate or cephalosporins II - III generations (cefuroxime axetil, cefaclor, cefixime, ceftibuten).

For preventive purposes, these antibacterial drugs can be used orally.

In acute prostatitis (especially those resulting in an abscess), acute urinary retention occurs due to deviation and compression of the urethra by the inflammatory infiltrate and swelling of its mucosa. Bladder catheterization is contraindicated in this disease. Acute urinary retention is one of the leading symptoms in patients with urethral trauma. In this case, catheterization of the bladder for diagnostic or therapeutic purposes is also unacceptable.

Acute urinary retention due to stones in the bladder occurs when a stone wedges into the neck of the bladder or obstructs the urethra in its various parts. Palpation of the urethra helps diagnose stones. For urethral strictures that lead to urinary retention, an attempt to catheterize the bladder with a thin elastic catheter is possible.

The cause of acute urinary retention in elderly and senile women may be uterine prolapse. In these cases, it is necessary to restore the normal anatomical position of the internal genital organs, and urination is also restored (usually without prior catheterization of the bladder).

Casuistic cases of acute urinary retention include foreign bodies in the bladder and urethra, which injure or obstruct the lower urinary tract. Immediate help is to remove foreign body; however, this manipulation can only be performed in a hospital setting.

In case of reflex urinary retention (for example, with postpartum, postoperative ischuria), you can try to induce urination by irrigating the external genitalia with warm water, by pouring water from one vessel to another (the sound of a falling stream of water can reflexively induce urination); if these methods are ineffective and there are no contraindications, 1 ml of a 1% solution of pilocarpine or 1 ml of a 0.05% solution of prozerin is administered subcutaneously; if ineffective, bladder catheterization is indicated.

Indications for hospitalization. Patients with acute urinary retention are subject to emergency hospitalization.

Gross hematuria

Definition. Hematuria - the appearance of blood in the urine - is one of the characteristic symptoms of many urological diseases. There are microscopic and macroscopic hematuria; the occurrence of intense gross hematuria often requires emergency care.

Etiology and pathogenesis. Possible causes of hematuria are presented in.

Clinical picture and classification. The appearance of red blood cells in the urine gives it a cloudy appearance and a pink, brown-red or reddish-black color, depending on the degree of hematuria.

Macrohematuria can be of three types: 1) initial (initial), when only the first portion of urine is colored with blood, the remaining portions are of normal color; 2) terminal (final), in which no blood admixture is visually detected in the first portion of urine and only the last portions of urine contain blood; H) total, when urine in all portions is equally colored with blood. Possible causes of gross hematuria are presented in.

Often macrohematuria is accompanied by an attack of pain in the kidney area, since a clot formed in the ureter disrupts the outflow of urine from the kidney. With a kidney tumor, bleeding precedes pain (“asymptomatic hematuria”), while with urolithiasis, pain appears before the onset of hematuria. Localization of pain during hematuria also allows us to clarify the localization of the pathological process. Thus, pain in the lumbar region is characteristic of kidney diseases, and in the suprapubic region - for lesions of the bladder. The presence of dysuria simultaneously with hematuria is observed when the prostate gland, bladder or posterior urethra is affected. The shape of blood clots also allows us to determine the localization of the pathological process. Worm-shaped clots that form as blood passes through the ureter indicate a disease of the upper urinary tract. Shapeless clots are more typical for bleeding from the bladder, although they can form in the bladder when blood is released from the kidney.

With profuse total hematuria, the bladder is often filled with blood clots and independent urination becomes impossible. Bladder tamponade occurs. Patients develop painful tenesmus and may develop a collapsoid state. Bladder tamponade requires immediate treatment.

Main directions of therapy. With the development of hypovolemia and falls blood pressure restoration of circulating blood volume is indicated - intravenous administration of crystalloid and colloid solutions. Hemostatic agents are not used.

Indications for hospitalization. If gross hematuria occurs, immediate hospitalization in the urology department of the hospital is indicated.

Acute pyelonephritis

Definition. Pyelonephritis is a nonspecific infectious and inflammatory process with predominant damage to the interstitial tissue of the kidneys and its pyelocaliceal system.

Etiology and pathogenesis. The causative agents of pyelonephritis can be Escherichia coli, less often - other gram-negative bacteria (for example, Pseudomonas aeruginosa), staphylococci, enterococci, etc. Possible ways kidney infections - ascending (urinogenic), hematogenous (in this case, the source of infection can be any purulent-inflammatory process in the body - otitis media, tonsillitis, mastitis, pneumonia, sepsis, etc.). Predisposing factors - immunodeficiency, urinary tract obstruction (urolithiasis, various anomalies of the kidneys and urinary tract, strictures of the ureter and urethra, prostate adenoma, etc.), instrumental studies of the urinary tract, pregnancy, diabetes, old age, etc. According to the conditions of occurrence, pyelonephritis is distinguished between primary (without any previous disorders of the kidneys and urinary tract) and secondary (arising on the basis of organic or functional processes in the kidneys and urinary tract, reducing the resistance of the renal tissue to infection and disrupting outflow of urine). In general, pyelonephritis develops more often in women, especially at a young age, which is associated with the anatomical, physiological and hormonal characteristics of the female body. In old age, the disease is more common in men due to the development of prostate adenoma.

The classification of acute pyelonephritis is presented in.

Clinical picture. The symptoms of acute pyelonephritis consist of general and local signs of the disease. Initially, acute pyelonephritis is clinically manifested by signs of an infectious disease, which often causes diagnostic errors.

General symptoms: increased body temperature, severe chills followed by profuse sweating, nausea, vomiting, inflammatory changes in blood tests.

Local symptoms: pain and muscle tension in the lumbar region on the affected side, sometimes dysuria, cloudy urine with flakes, polyuria, nocturia, pain when tapping the lower back.

During acute pyelonephritis, the stages of serous and purulent inflammation are distinguished. Purulent forms develop in 25 - 30% of patients. These include apostematous (pustular) pyelonephritis, carbuncle and kidney abscess.

Treatment algorithm for acute pyelonephritis

Full treatment is possible only in a hospital setting; at the prehospital stage, only symptomatic therapy is possible, implying the use of non-steroidal anti-inflammatory drugs and antispasmodics (see section Renal colic).

Prescribing broad-spectrum antibacterial drugs without clarifying the state of urodynamics of the upper urinary tract and restoring urine passage leads to the development of an extremely serious complication - bacteriotoxic shock, with a mortality rate of 50 - 80%.

Indications for hospitalization. Patients with acute pyelonephritis require urgent hospitalization for a detailed examination and determination of further treatment tactics.

D. Yu. Pushkar, Doctor of Medical Sciences, Professor
A. V. Zaitsev, Doctor of Medical Sciences, Professor
L. A. Aleksanyan, Doctor of Medical Sciences, Professor
A. V. Topolyansky, Candidate of Medical Sciences
P. B. Nosovitsky
MGMSU, NNPO emergency medical care, Moscow

Note!

• The effectiveness of treatment for patients with acute urological diseases depends on two factors: the quality of a set of measures aimed at normalizing vital functions, and timely delivery of the patient to a specialized hospital.
• Renal colic is a symptom complex that occurs when there is an acute (sudden) disruption of the outflow of urine from the kidney, which leads to the development of pyelocaliceal hypertension, reflex spasm of the arterial renal vessels, venous stasis and edema of the parenchyma, its hypoxia and overstretching of the fibrous capsule.
• In acute prostatitis (especially those resulting in an abscess), acute urinary retention occurs due to deviation and compression of the urethra by the inflammatory infiltrate and swelling of its mucosa.

15.1. RENAL COLIC

Renal colic- acute pain syndrome resulting from a sudden disruption of the outflow of urine from the pyelocaliceal system of the kidney as a result of obstruction of the ureter.

Etiology and pathogenesis. The most common obstacles to the passage of urine are stones in the renal pelvis and ureter, therefore typical renal colic is one of the reliable signs of urolithiasis. However, it can also occur with any other obstruction of the ureter: blood clots, casts of urinary salts, accumulation of pus, mucus, microbes, caseous masses in kidney tuberculosis, pieces of tumor, cyst membranes, etc. Severe nephroptosis with kinking of the ureter, cicatricial narrowing and compression of it externally, neoplasms or enlarged lymph nodes can also cause renal colic.

The mechanism of development of renal colic is as follows. As a result of the appearance of an obstacle to the outflow of urine, its passage from the renal pelvis is delayed, while urine formation continues. As a consequence, overdistension of the ureter, renal pelvis and calyces above the site of obstruction occurs. Muscle contractions, turning into spasms of the calyces, renal pelvis and ureter in response to an obstruction, further increase the pressure in the urinary tract, and therefore pyelovenous reflux occurs, and renal hemodynamics begin to suffer. The blood supply to the kidney is disrupted, and significant interstitial edema develops, manifested by hypoxia of the parenchyma. Thus, a disorder of urodynamics disrupts the renal circulation, and the trophism of the organ suffers. The edematous renal tissue is compressed inside the surrounding dense fibrous capsule. Overstretching and compression of the nerve endings in the kidney, pelvis and ureter lead to severe paroxysmal, almost always unilateral pain in the lumbar region.

An attack of renal colic can occur unexpectedly with complete rest. Predisposing factors contributing to its occurrence include physical stress, running, jumping, outdoor games, driving on a bad, bumpy road.

Renal colic is characterized by suddenly appearing severe paroxysmal pain in one side of the lumbar region. It immediately reaches such intensity that patients are unable to tolerate it, they behave restlessly, rush about, continuously change body position, trying to find relief. Excited and restless

The behavior of patients is a characteristic feature of renal colic, and in this they differ from patients with acute surgical diseases of the abdominal cavity. Sometimes the pain may be localized not in the lumbar region, but in the hypochondrium or in the flank of the abdomen. Its typical irradiation is down the course of the ureter, into the iliac and inguinal regions on the same side, along the inner surface of the thigh, into the testicle, head of the penis in men and into the labia majora in women. This irradiation of pain is associated with irritation of the branches n. genitofemoralis. A certain dependence of the localization and irradiation of pain in renal colic on the location of the stone in the urinary tract has been noted. When it is located in the pelvis or pelvis of the ureter, the greatest intensity of pain is noted in the lumbar region and hypochondrium. As the stone passes through the ureter, irradiation downward into the genitals, thigh, and groin area increases, and frequent urination occurs.

The lower the stone is located in the ureter, the more pronounced the dysuria.

Dyspeptic symptoms in the form of nausea, vomiting, stool retention and gases with bloating often accompany an attack of renal colic and require differential diagnosis between renal colic and acute diseases of the abdominal organs. Body temperature is often normal, but if there is a urinary tract infection, it may increase.

Having started unexpectedly, the pain can just as suddenly stop due to a change in the position of the stone with partial restoration of the outflow of urine or its discharge into the bladder. More often, however, the attack subsides gradually, the acute pain turns into a dull pain, which then disappears or worsens again. In some cases, attacks can be repeated, following one another at short intervals, completely exhausting the patient. At the same time, the clinical picture of renal colic may vary, depending on the movement of the stone through the urinary tract. However, an attack of renal colic is not always typical, which makes it difficult to recognize.

Diagnostics renal colic and the diseases that caused it are based on the characteristic clinical picture and modern examination methods. A correctly collected anamnesis is of no small importance. It is necessary to find out whether the patient has previously had similar attacks of pain, whether he has undergone examinations about this, whether the passage of stones has previously been observed, whether there are other diseases of the kidneys and urinary tract.

An objective examination in some cases allows one to palpate an enlarged, painful kidney. On palpation at the time of an attack of renal colic, sharp pain is noted in the lumbar region and the corresponding half of the abdomen and often moderate muscle tension. There are no symptoms of peritoneal irritation. The symptom of tapping in the lumbar region on the side of the attack (Pasternatsky's symptom) is positive. Very characteristic of renal colic are changes in the urine. The appearance of bloody, cloudy urine with the presence of copious sediment or the passage of stones during or after an attack confirms renal colic. Hematuria can be of varying intensity - often micro- and less often macroscopic. Red blood cells in the urine, as a rule, appear unchanged. If there is a urinary tract infection, white blood cells may be found in the urine.

It should be borne in mind that even if there is an infection in the kidney, if the lumen of the ureter is completely obstructed, the composition of the urine may turn out to be normal, since urine secreted only by a healthy kidney enters the bladder. Leukocytosis and an increase in ESR may be observed in the blood.

To establish the cause that caused the attack of renal colic, ultrasound, X-ray radionuclide, instrumental, endoscopic examinations and MRI are performed.

It is difficult to overestimate the importance of ultrasound examination, which allows one to assess the size, position, mobility of the kidneys, and the width of the parenchyma.

The ultrasound picture of renal colic is characterized by varying degrees of severity of expansion of the pyelocaliceal system. The stone can be located in the pelvis, dilated pelvis or prevesical section of the ureter. Dynamic scintigraphy reveals a sharp decrease or complete absence of kidney function on the colic side.

X-ray examination is of exceptional importance for diagnosis. A survey x-ray of the urinary tract is quite informative. It is important that all parts of the urinary system are in the field of view in the image, so it should be taken on large film (30 x 40 cm). With good preparation, the survey image shows clearly defined shadows of the kidneys and the edges of the lumboiliac muscles. In case of renal colic, shadows of stones may be detected on a plain radiograph in the projection of the expected location of the kidneys, ureters and bladder. Their intensity can be different and depends on the chemical composition of the stones. Radiopaque urate stones occur in up to 7-10% of cases.

Excretory urography makes it possible to clarify whether the shadow of the suspected stone identified on the survey image belongs to the urinary tract, the separate state of the excretory function of each kidney, the influence of the stone on the anatomical and functional state of the kidneys and ureters. In cases where an attack of renal colic is caused by other diseases of the urinary system (hydronephrosis, nephroptosis, kinking, ureteral stricture, etc.), the correct diagnosis can be established using urography. The anatomical state of the kidneys and ureters during excretory urography can be determined in cases where the kidney is functioning and secretes a contrast agent in the urine. At the height of renal colic, kidney function as a result of high pressure in the collecting system may be temporarily absent (blocked, or “silent” kidney). In such cases, the presence of a stone, including an X-ray negative one, as well as the anatomical state of the kidneys and urinary tract, allow us to establish multislice CT and MRI.

An important place in the diagnosis of renal colic, as well as the diseases that cause it, belongs to cystoscopy, chromocystoscopy, ureteral catheterization and retrograde ureteropyelography. During cystoscopy, strangulation of a calculus in the intramural part of the ureter may be visible; often the mouth is raised, its edges are hyperemic and edematous. This swelling also extends to the surrounding bladder mucosa. Sometimes it is possible to see a strangulated calculus in the gaping mouth (Fig. 16, see color insert). In some cases, cloudy mucus may be released from the mouth

urine or blood-stained urine. Determination of kidney and ureter function by chromocystoscopy(Fig. 14, see color insert) is the fastest, simplest and most informative method, which is important in the differential diagnosis of renal colic with acute surgical diseases of the abdominal organs.

If a shadow suspicious for a stone raises doubts, catheterization of the ureter is performed. In this case, the catheter may stop near the stone or sometimes it can be passed higher. After that, survey x-rays of the corresponding part of the urinary tract are taken in two projections. The diagnosis of ureterolithiasis is established if the shadows of the suspected stone and the catheter are combined on the images. The discrepancy between the indicated shadows excludes the presence of a stone in the ureter. In cases where the catheter manages to move the stone up into the pelvis and its shadow disappears from the projection of the ureter, appearing in the kidney area, and the attack of renal colic immediately passes, the diagnosis of urolithiasis is beyond doubt. To clarify the diagnosis, as well as to obtain information about the condition of the pyelocaliceal system of the kidney and ureter, retrograde ureteropyelography is performed.

Differential diagnosis renal colic most often has to be carried out with acute appendicitis, cholecystitis, pancreatitis, perforated gastric and duodenal ulcers, acute intestinal obstruction, strangulated hernia, torsion of an ovarian cyst, and ectopic pregnancy. These acute surgical diseases require emergency surgical intervention for life-saving reasons, while for renal colic conservative therapy is acceptable and often effective.

Pain when appendicitis may resemble that of renal colic in the case of a high retrocecal and retroperitoneal location of the appendix. Important differential diagnostic features are the nature of development and intensity of pain. With appendicitis, it often develops gradually and rarely reaches such strength as with renal colic. Even in cases where the pain is quite severe, it is still tolerable. Patients with acute appendicitis, as a rule, lie quietly in the chosen position. Patients with renal colic are often restless, constantly change body position, and cannot find a place for themselves. Dysuria in acute appendicitis rarely appears, although it is possible with the pelvic location of the appendix. A characteristic sign of acute appendicitis is tachycardia, which almost never occurs with renal colic. Vomiting with both diseases almost always occurs, but with appendicitis it is often one-time, and with renal colic it is repeated many times during ongoing attacks of pain. Deep palpation of the abdomen in the right iliac region in acute appendicitis causes distinct pain, positive symptoms of peritoneal irritation (Shchetkin-Blumberg, Rovzing, etc.) are determined, which are absent in renal colic. Renal colic is characterized by pain when tapping the lumbar region on the corresponding side (Pasternatsky's symptom), which is not observed in acute appendicitis. Acute appendicitis, as a rule, is not accompanied by changes in urine tests, while renal colic is characterized by erythrocyte and leukocyturia, false proteinuria.

Chromocystoscopy is used in the differential diagnosis of renal colic and acute surgical pathology of the abdominal organs. In acute appendicitis, kidney function is not impaired, and 3-6 minutes after intravenous administration of 3-5 ml of 0.4% indigo carmine solution, streams of colored indigo are ejected from the mouths of the ureters. Blue colour urine (Fig. 14, see color insert). In the case of renal colic due to obstruction of the ureter, during chromocystoscopy on the affected side, the release of indigo carmine is sharply delayed or absent.

There may be difficulties in the differential diagnosis of renal colic with perforated ulcer of the stomach and duodenum. In such cases, the anamnesis and clinical picture of the disease are of great importance. A perforated ulcer is characterized by a “dagger-like” nature of pain in the epigastric region. Typical for this disease is rare, one-time and mild vomiting or its absence, in contrast to renal colic, in which vomiting occurs almost constantly. The onset of the disease is usually preceded by a long history of ulcers. Patients are inactive; they seem to be afraid to change their body position in bed. The abdominal wall in the epigastric region, and sometimes throughout the entire abdomen, is tense, and symptoms of peritoneal irritation are pronounced. The disappearance of hepatic dullness is observed, and X-ray examination reveals free gas in the right subdiaphragmatic space.

Sometimes renal colic has to be differentiated from acute cholecystitis, gallstone colic, acute pancreatitis. Pain with cholecystitis and gallstone colic is localized in the right hypochondrium; with pancreatitis, it is often girdling in nature. The abdomen is swollen, there is pain and muscle tension in the right hypochondrium. Sometimes it is possible to palpate an enlarged, painful gallbladder. Destructive forms of cholecystitis and pancreatitis are accompanied by a picture of purulent peritonitis.

It can be quite difficult to distinguish renal colic from intestinal obstruction. This is explained by the fact that the clinical picture of these diseases has a lot in common: severe bloating, vomiting, flatulence, intestinal paresis, gas and stool retention. However, with intestinal obstruction, the patient's condition due to intoxication is more severe. Pain due to intestinal obstruction is cramping in nature; in some cases, peristalsis is visible through the abdominal integument, which is not observed with renal colic.

Clinical picture strangulated umbilical or inguinal hernia may be similar to that of renal colic. A carefully collected anamnesis helps to establish a diagnosis, since in most cases patients are aware of the existence of a hernia. Palpation examination of the anterior abdominal wall of the umbilical region and inguinal rings allows one to detect a strangulated, tense, painful hernial sac.

Currently, the main methods of differential diagnosis of renal colic and acute surgical diseases of the abdominal organs are radiation methods studies (ultrasound, survey and excretory urography, multislice CT with contrast), MRI and chromocystoscopy, which in the vast majority of cases make it possible to establish the correct diagnosis.

Treatment. Relief of renal colic should begin with thermal procedures. These include: heating pad, hot bath (water temperature 38-40 °C). Thermal effects intensify skin respiration, blood and lymph circulation. The friendly reaction of smooth muscles, skin vessels and internal organs is especially clearly manifested during local thermal hydro procedures (for example, when warming the lumbar region, the skin vessels and kidney vessels simultaneously expand, and the smooth muscles of the ureter relax).

Thermal procedures are combined with non-steroidal anti-inflammatory drugs (diclofenac 50-75 mg intramuscularly, ketorolac 10-30 mg intramuscularly), antispasmodics (baralgin, spazgan, no-shpa) and herbal preparations (cystone, cystenal, phytolysin), which allow for good relief renal colic.

Chlorethyl and intradermal novocaine blockades. The effect of parenterally administered drugs (excluding intravenous injections) begins to manifest itself only after 20-40 minutes, so it is very rational to simultaneously carry out a chloroethyl or intradermal novocaine blockade, which quickly manifests its properties. Particular attention is paid to paravertebral chloroethyl blockade, which is a good aid in urgent care, both as an anesthetic and as a differential diagnostic test to distinguish renal colic from acute surgical diseases of the abdominal cavity. The analgesic effect of chlorethyl irrigation is explained by the effect of the thermal factor on the vegetative formations of the skin (vessels, receptors, sweat glands, papillary smooth muscles, etc.) in the Zakharyin-Ged zone, which have the same segmental vegetative sympathetic innervation as the corresponding ones interconnected with the skin internal organs. As is known, the sympathetic innervation of the kidney and ureter belongs to the X-XI-XII thoracic and I lumbar segments of the spinal cord, projecting onto the skin by the zone from the corresponding vertebrae anteriorly through the costoiliac space onto the anterior abdominal wall.

In cases where renal colic is not relieved, novocaine blockade is performed spermatic cord in men and the round ligament of the uterus in women (Lorin-Epstein block), which is especially effective when the stone is localized in the lower third of the ureter.

The most effective pathogenetic treatment of renal colic in hospital conditions is to restore the outflow of urine from the kidney through catheterization and stenting of the ureter (Fig. 21, 22, see color insert) or percutaneous puncture nephrostomy.

Forecast Regarding renal colic, with timely elimination of the cause that caused it, favorable.

15.2. HEMATURIA

Hematuria- the release of blood (red blood cells) in the urine, detected visually and/or by microscopic examination of urine sediment.

Epidemiology. The prevalence of hematuria in the population reaches 4%. With age, the incidence of hematuria increases: from 1.0 to 4.0% in children to 9-13% in the elderly.

Classification. Based on the amount of blood in the urine, they are divided into:

■ gross hematuria- its presence in urine is determined visually;

■ microhematuria- microscopy of the sediment from a general urinalysis reveals more than 3 red blood cells in the field of view, and when examining urine according to Nechiporenko, more than 1 thousand red blood cells are detected in 1 ml of the average portion of urine.

Depending on the presence of blood during the act of urination, which is determined visually and using a three- or two-glass urine sample, hematuria is divided into the following types.

Initial hematuria- blood is detected in the first portion of urine. Such hematuria occurs when a pathological process is localized in the urethra (trauma or iatrogenic damage to the urethra, erosive urethritis, calliculitis, hemangiomas, papillomas, urethral cancer).

Terminal hematuria - blood appears in the last portion of urine. It is characteristic of pathological processes occurring in the neck of the bladder or prostate gland. The combination of initial and terminal hematuria indicates damage to the prostatic urethra.

Total hematuria - all urine is stained with blood or blood is recorded in all its portions. It is observed with bleeding from the kidney parenchyma, renal pelvis, ureter and bladder. In some cases, the source of hematuria can be determined by the shape of the clots. Worm-shaped blood clots, which are a cast of the ureter, are usually a sign of bleeding from the kidney, pelvis and ureter. Shapeless blood clots are characteristic of bleeding from the bladder, although they do not exclude bleeding from the kidney with the formation of clots not in the ureter, but in the bladder.

Etiology and pathogenesis. Isolate hematuria glomerular And extraglomerular origin. In the first case, its cause is nephrological diseases: acute glomerulonephritis, systemic lupus erythematosus, essential mixed cryoglobulinemia, hemolytic-uremic syndrome, Al-port disease, etc.

Hematuria extraglomerular origin develops with diseases of the blood system (leukemia, sickle cell anemia, decreased blood clotting), taking antiplatelet agents and anticoagulants, vascular diseases (renal artery stenosis, thrombosis of the renal artery or vein, arteriovenous fistula) and most urological diseases.

Most often, hematuria occurs with neoplasms of the kidney, upper urinary tract, bladder, trauma, inflammatory diseases of the kidneys and urinary tract, urolithiasis, hydronephrosis, adenoma and prostate cancer, etc.

Diagnostics. First of all, urethrorrhagia should be distinguished from hematuria. Urethrorrhagia is the discharge of blood from the urethra, regardless of the act of urination. Blood may be released in drops or streams depending on the degree of bleeding, the source of which is located in the urethra.

In this case, the first portion of urine is also stained with blood (initial hematuria). This symptom indicates a disease (cancer, stone) or injury to the urethra.

Hematuria must be differentiated from hemoglobinuria and myoglobinuria.

With true hemoglobinuria the urine is reddish in color or may even be clear, and microscopy of the sediment reveals hemoglobin accumulations or “pigment casts” consisting of amorphous hemoglobin. Hemoglobinuria indicates hemolysis (transfusion of incompatible blood, the action of hemolytic poisons). The presence of “pigment casts” or casts of hemoglobin in the urine along with red blood cells is called false hemoglobinuria and is associated with partial hemolysis of red blood cells in the urine.

Myoglobinuria - the presence of myoglobin in the urine; at the same time it turns red-brown. Myoglobinuria is observed in the syndrome of prolonged compression, tissue crushing and is associated with the ingress of striated muscle pigment into the urine. Blood mixed with semen (hemospermia), giving it a pink to brown color may indicate inflammation of the seminal vesicles or prostate gland, seminal tubercle, or oncological lesions of these organs.

Next, in a patient with gross hematuria, it is necessary to visually assess the color of urine, which may change when eating certain foods (beets, rhubarb) and taking medicines(nitroxoline, madder, senna). Depending on the amount of blood in the urine, its color changes from pale pink to deep red, cherry. Determining the nature of hematuria: initial, terminal or total- may indicate the localization of the pathological process. With severe hematuria, blood clots may form. The worm-like shape of such clots indicates their formation in the upper urinary tract, and the formation of large shapeless clots occurs in the bladder.

The presence and nature of pain due to hematuria are of particular importance. In some cases, blood in the urine appears after a painful attack, usually caused by a stone in the pelvis or ureter. In this case, blood in the urine can appear as a result of both microtrauma of the wall of the pelvis or ureter with a stone, as well as ruptures of the fornix and the development of fornical bleeding against the background of acute obstruction of the ureter. With tumors of the kidneys and upper urinary tract, so-called painless hematuria is observed. In this case, the admixture of blood in the urine occurs against the background of subjective well-being, and pain can develop against the background of hematuria, which is associated with a violation of the outflow of urine from the upper urinary tract due to blood clots obstructing the ureter.

Thus, with urolithiasis, pain first appears in the corresponding half of the lumbar region, and then hematuria, and, conversely, with a kidney tumor, total gross hematuria first appears, and then an attack of pain.

Dysuria accompanying hematuria may indicate inflammation of the bladder (hemorrhagic cystitis). Increased dysuric symptoms or the occurrence of imperative urges during movement indicate the possible presence of a stone in the bladder. Dull pain above the pubis, dysuria

and hematuria are characteristic of muscle-invasive bladder cancer. The intensity of hematuria does not always correlate with the severity of the disease that caused the appearance of this symptom.

An objective examination of patients with hematuria may reveal hemorrhagic rashes on the skin and mucous membranes, indicating possible diseases of the hemostatic system, hemorrhagic fever with renal syndrome. Swelling and increased blood pressure are signs of a probable nephrological disease, and enlarged lymph nodes are characteristic of infectious, oncological diseases or blood diseases. Palpation of the abdomen reveals an enlarged liver, spleen, tumor of the abdominal organs and retroperitoneal space. Male patients should undergo a digital rectal examination, and female patients a vaginal examination. In addition, all patients undergo an examination of the external urethral meatus.

The presence of hematuria is confirmed by data from a general urine analysis and microscopy of its sediment. Urinalysis according to Nechiporenko (the content of red blood cells in 1 ml of urine) and according to Addi-su-Kakovsky (the content of red blood cells in the total volume of urine excreted by the patient per day) have additional diagnostic value. In a general urine test, attention is paid to the protein content, since with severe proteinuria there is a high probability of nephrological disease. In doubtful cases, it is necessary to perform a proteinuria selectivity study. Sediment microscopy using a modern phase contrast microscope allows one to determine the status of red blood cells in the urine. If unchanged red blood cells are detected, there is a high probability of a urological disease with the source of hematuria located in the kidneys and urinary tract; the presence of altered red blood cells and casts in the sediment indicates a nephrological disease. Leukocyturia and pyuria indicate a urinary tract infection. If these changes are detected in a urine test, a bacteriological study with determination of sensitivity to antibiotics is indicated.

Ultrasound plays an important role in the diagnosis of urological diseases that cause hematuria. It allows you to determine the shape, structure, location and size of the kidneys, the condition of their pyelocaliceal systems, the presence and location of stones, cysts, tumors, prolapse or abnormalities of the kidneys. Moreover, using this method, you can most reliably distinguish between a tumor and a cyst, and clarify the localization of stones in the urinary tract, including radiopaque ones. When the bladder is full, the prostate gland and its pathology (adenoma, cancer, prostatitis, abscess, stones), the walls of the bladder and the contents of its cavity (tumor, stones, diverticulum) are well defined. Currently, ultrasound and other modern diagnostic methods (survey and intravenous urography, angiography, CT, MRI, scintigraphy, urethrocystoscopy, ureteropyeloscopy) almost always make it possible to establish not only the source of hematuria, but also the disease that caused it. A mandatory and valuable diagnostic method for gross hematuria is cystoscopy, which makes it possible to determine the source of bleeding.

Treatment. Gross hematuria is an indication for emergency hospitalization of the patient in a urological hospital. Conservative therapy is carried out in parallel with the examination. More often, hematuria is not intense and stops on its own. For treatment, conventional hemostatic agents are used: calcium preparations, carbazochrome (adroxon), etamzilate (dicinone), epsilon-aminocaproic acid, vikasol, tranexamic acid, vitamin C, blood plasma, etc.

The volume and nature of surgical treatment depend on the identified disease that caused the hematuria.

Forecast for hematuria is determined by the severity of the disease that caused it.

15.3. ACUTE URINARY RETENTION

Acute urinary retention (ischuria)- inability to urinate independently when the bladder is full. It can occur suddenly or occur against the background of previous dysuric phenomena, such as frequent, difficult urination, sluggish, thin stream of urine, a feeling of incomplete emptying of the bladder after urination, etc.

Highlight acute And chronic urinary retention. The first is manifested by the inability to urinate independently with a strong urge to urinate, an overflowing bladder and bursting pain in the lower abdomen. In cases where, when urinating, part of the urine is excreted, but some of it remains in the bladder, we speak of chronic urinary retention. Urine that remains in the bladder after urination is called residual urine. Its quantity can be from 50 ml to 1.5-2.0 l, and sometimes more.

Etiology and pathogenesis. Acute urinary retention occurs as a result of urological diseases or pathological conditions that cause disruption of the innervation of the sphincter and detrusor of the bladder. Most often it develops with a number of diseases and injuries of the genitourinary organs. The main ones include:

■ diseases of the prostate gland - benign hyperplasia, cancer, abscess, sclerosis, prostatitis;

■ bladder - stones, tumors, diverticula, trauma, bladder tamponade, urinary infiltration;

■ urethra - strictures, stones, damage;

■ penis - gangrene, cavernitis;

■ some paravesical diseases in women.

Ruptures of the urethra and bladder often lead to urinary retention. And yet, most often it is observed with benign prostatic hyperplasia (adenoma). Provoking factors for its development in this disease are spicy rich food, alcohol, cooling, prolonged sitting or lying down, disruption of the intestines,

especially constipation, forced delay of urination when the bladder is full, physical fatigue and other factors. All this leads to stagnation of blood in the pelvis, swelling of the enlarged prostate gland and even more pronounced compression of the urethra.

The causes of urinary retention may be diseases of the central nervous system (organic and functional) and genitourinary organs. Diseases of the central nervous system include tumors of the brain and spinal cord, tabes dorsalis, traumatic injuries with compression or destruction of the spinal cord. Acute urinary retention is often observed in postoperative period, including persons young. This delay is reflexive in nature and, as a rule, goes away after spontaneous urination or several catheterizations.

Symptoms and clinical course acute urinary retention is quite typical. Patients complain of severe pain in the lower abdomen, painful, fruitless urge to urinate, a feeling of fullness and distension of the bladder. The strength of the imperative urge to urinate increases and quickly becomes unbearable for patients. Their behavior is restless. Suffering from overdistension of the bladder and fruitless attempts to empty it, patients groan, take a variety of positions to urinate (lie down, kneel, squat), put pressure on the bladder area, and squeeze the penis. The pain either subsides or recurs with greater force. A similar condition never occurs with anuria or acute urinary retention caused by impaired innervation of the bladder.

An objective examination, especially in patients with low nutrition, reveals a change in the configuration of the lower abdomen. In the suprapubic region, swelling is clearly visible due to the enlarged bladder. Percussion reveals a dull sound above it. Palpation, as a rule, causes a painful urge to urinate. Sometimes patients experience reflex inhibition of intestinal activity with bloating.

Diagnostics Acute urinary retention and the diseases that caused it are based on the characteristic complaints of patients and the clinical picture. When collecting anamnesis, it is important to pay attention to the nature of urination before the development of ischuria (free or difficult). It is necessary to clarify the time of onset of the disease and its course. In cases where this is not the first time this condition has developed, you should find out the methods of treatment used and its results. When questioning, it is important to obtain from the patient information about the amount of urine during urination before the delay, its type (transparency, presence of blood) and the time of the last urination.

The most common cause of acute urinary retention in older men is benign prostatic hyperplasia. As the tumor grows, the prostatic part of the urethra is compressed, bent, its lumen narrows, and lengthens, which creates an obstacle to the outflow of urine and contributes to the development of urine retention. Acute urinary retention can occur at any stage of this disease, including

including in the first, when the clinical picture is still poorly expressed. In such cases, it occurs against the background of relative well-being; the content of 400-500 ml of urine in the bladder already causes a painful urge to urinate. When the disease develops gradually, the capacity of the bladder increases markedly. It can contain up to 1-2 liters or even more of urine. In such patients, a full bladder is sometimes detected visually as a round formation in the suprapubic region.

In the diagnosis of prostate diseases, the main place belongs to its digital examination through the rectum, ultrasound, x-ray examination and determination of the level of prostate-specific antigen.

Bladder and urethral stones are often the cause of acute urinary retention. Impaired urination due to bladder stones largely depends on the location and size of the stone. When urinating, there is intermittency and blocking of the urine stream. If a stone wedges into the internal opening of the urethra and completely closes it, acute urinary retention develops. This condition occurs more often when the patient empties the bladder while standing. When changing the position of the body, the stone may move back into the bladder, and urination in this case is restored. If the stone moves beyond the bladder into the urethra and completely closes its lumen, then acute urinary retention can be persistent.

Ruptures of the urethra, post-traumatic strictures and narrowings of other origins are often complicated by acute urinary retention. The diagnosis in such cases is established on the basis of anamnesis, urethrography and urethroscopy (Fig. 3, see color insert).

Acute urinary retention can be caused by tumors of the bladder and urethra. A villous, floating tumor located at the neck of the bladder can close the internal opening of the urethra and cause urinary retention. In case of bladder cancer, the cause of urinary retention can be either growth of the bladder neck by a tumor or massive bleeding with the formation of blood clots. It should also be borne in mind that blood in the bladder with the formation of clots is not only observed with tumors, but can also occur with severe renal bleeding and bleeding from the prostate gland.

Acute urinary retention can develop due to diseases and spinal cord injury.

Differential diagnosis acute urinary retention should be performed with anuria. In both conditions, the patient does not urinate. However, with acute urinary retention, the bladder is full, the patient feels bursting pain in the lower abdomen and a strong urge to urinate, but cannot urinate due to an obstruction in the neck of the bladder or urethra. With anuria, urine does not flow from the kidneys and upper urinary tract into the bladder, it is empty, and there is no urge to urinate.

Treatment. Providing emergency care to patients with acute urinary retention involves evacuating it from the bladder. Emptying

the bladder is possible by three methods: catheterization, suprapubic capillary puncture and trocar epicystostomy.

The most common and less traumatic method is catheterization of the bladder with soft elastic catheters. It should be borne in mind that in a significant number of cases, acute urinary retention can be eliminated by catheterization of the bladder alone or by leaving a permanent catheter in place for a short time. If urination is not restored, repeat catheterization may be necessary. The presence of purulent inflammation of the urethra (urethritis), inflammation of the epididymis (epididymitis), the testicle itself (orchitis), as well as prostate abscess is a contraindication for catheterization. It is also contraindicated in case of urethral rupture. Catheterization of the bladder is performed in compliance with the rules of asepsis. Attempts to forcefully insert the catheter should be avoided, as this may cause injury to the prostate gland and urethra. As a result of such catheterization, urethrorrhagia or the development of urethral fever with an increase in body temperature to 39-40 ° C are possible.

In cases where bladder catheterization with a soft catheter cannot be performed or is contraindicated, the patient should be sent to the hospital for catheterization with a metal catheter, bladder puncture or trocar epicystostomy.

Forecast in case of acute urinary retention, it is favorable, since it can always be eliminated by one of the above methods, which cannot be said about the reasons that caused it. Stable restoration of urination occurs only as a result of radical treatment of the disease leading to acute urinary retention

15.4. ANURIA

Anuria- stopping the flow of urine from the upper urinary tract into the bladder. It occurs as a result of a violation of the excretion of urine by the renal parenchyma or due to obstruction of the ureters.

Classification. Anuria is divided into arenal, prerenal, renal and postrenal.

Arenal anuria occurs in the absence of kidneys. This condition may be congenital (renal aplasia) or caused by the removal of a single or only functioning kidney.

Prerenal (vascular) anuria is caused by impaired hemodynamics and a decrease in the total volume of circulating blood, which is accompanied by renal vasoconstriction and a decrease in renal circulation.

Renal (parenchymal) anuria caused by toxic damage to renal tissue or chronic kidney disease.

Postrenal (obstructive) anuria develops as a result of obstruction of the ureters or ureter of a single kidney.

Etiology and pathogenesis. Main reasons prerenal anuria are cardiogenic or traumatic shock, embolism and renal thrombosis

blood vessels, collapse, heart failure, pulmonary embolism, that is, conditions accompanied by a decrease in cardiac output. Even a short-term decrease in blood pressure below 80 mm Hg. Art. leads to a sharp reduction in blood flow in the kidney due to the activation of shunts in the juxtamedullary zone, ischemia of the renal parenchyma occurs and, against its background, rejection of the epithelium of the proximal tubules up to acute tubular necrosis.

Renal anuria is caused by exposure to toxic substances on the kidney: salts of mercury, uranium, cadmium, copper. A pronounced nephrotoxic effect is characteristic of poisonous mushrooms and some drugs. X-ray contrast agents have nephrotoxic properties, which requires careful use in patients with impaired renal function. Hemoglobin and myoglobin, circulating in the blood in large quantities, can also lead to the development of renal anuria due to massive hemolysis caused by transfusion of incompatible blood and hemoglobinuria. The causes of myoglobinuria can be traumatic, for example, prolonged compartment syndrome, and non-traumatic, associated with muscle damage during prolonged alcoholic or drug coma. Renal anuria can be caused by acute glomerulonephritis, lupus nephritis, chronic pyelonephritis with kidney shrinkage, etc.

Postrenal anuria develops as a result of a violation of the outflow of urine from the kidneys due to obstruction of the ureter(s) by stones, tumors of the upper urinary tract, bladder, prostate gland, compression of them by neoplasms of the female genital organs, metastatically enlarged lymph nodes and other formations, as well as due to cicatricial strictures and obliteration ureters. With this type of anuria, a sharp dilation of the ureters and pelvis occurs with pronounced interstitial edema of the renal parenchyma. If the outflow of urine is restored quickly enough, the changes in the kidneys are reversible, but with long-term obstruction, severe circulatory disorders of the kidneys develop, which can result in an irreversible condition - tubular necrosis.

Symptoms and clinical course anuria is characterized by increasing azotemia, water-electrolyte imbalance, intoxication and uremia (see Chapter 13.1).

Diagnosis and differential diagnosis carried out on an emergency basis. First of all, it is necessary to distinguish anuria from acute urinary retention. The latter is characterized by the fact that there is urine in the bladder, moreover, it is full, which is why patients behave extremely restlessly: they rush about in fruitless attempts to urinate. With anuria, there is no urine in the bladder, patients do not feel the urge to urinate and behave calmly. These two conditions can be definitively distinguished by palpation and percussion over the pubis, ultrasound and catheterization of the bladder.

Once the diagnosis of anuria is confirmed, its cause should be found out. First of all, it is necessary to carry out a differential diagnosis of post-renal anuria from its other types. For this purpose, an ultrasound of the kidneys is performed, which allows you to confirm or exclude the fact of bilateral obstruction.

ureters by the presence or absence of dilation of the collecting system. An even more objective test is bilateral ureteral catheterization. If ureteral catheters are freely passed to the pelvis and in the absence of urine discharge through them, postrenal anuria can be confidently rejected. On the contrary, if the catheter detects an obstacle along the ureter(s), you should try to move it higher, thereby eliminating the cause of anuria.

Multislice CT, MRI, renal angiography and renal scintigraphy help to definitively establish the diagnosis. These methods provide information about the state of the vascular bed of the kidney (prerenal form), its parenchyma (renal form) and patency of the ureters (postrenal form).

Treatment should be aimed at eliminating the cause that caused the development of anuria. In case of shock, the main therapy is aimed at normalizing blood pressure and replenishing the volume of circulating blood. It is advisable to introduce protein solutions and large molecular dextrans. In case of poisoning with nephrotoxic poisons, it is necessary to remove them by washing the stomach and intestines. A universal antidote for poisoning with heavy metal salts is unithiol.

In the case of postrenal obstructive anuria, therapy should be aimed at early restoration of urine outflow: catheterization, ureteral stenting, percutaneous puncture nephrostomy.

Indications for hemodialysis are an increase in potassium content to more than 7 mmol/l, urea to 24 mmol/l, the appearance of symptoms of uremia: nausea, vomiting, lethargy, as well as overhydration and acidosis. Currently, they are increasingly resorting to early or even preventive hemodialysis, which prevents the development of severe metabolic complications.

Forecast favorable for quickly eliminating the cause of anuria. Mortality depends on the severity of the underlying disease that caused its development. Complete restoration of renal function is observed in 35-40% of cases.

15.5. Torsion of the spermatic cord and testis

One of the most common acute pathological conditions, especially in childhood, is testicular torsion, which leads to compression of blood vessels with the development of organ necrosis.

Etiology and pathogenesis. There are extravaginal and intravaginal testicular torsion.

Extravaginal testicular torsion It is usually observed in children under one year of age and is associated with increased mobility of the spermatic cord and testicle at this age. If testicular torsion occurred in the prenatal period, then after the birth of the child there is an increase in the corresponding half of the scrotum and the presence of a tumor-like formation in it, significantly larger in size than the testicle.

Much more common intravaginal torsion, due to the anatomical and functional characteristics of the child’s body and therefore

occurring more often in children than in adults. Intravaginal torsion is facilitated by the relatively large length of the spermatic cord in children in combination with high connection it with the tunica vaginalis, stronger contractility of the muscle supporting the testicle than in adults, as well as weak fixation of the epididymis to the skin of the scrotum. Following torsion, disruption of the patency of the venous and arterial vessels of the testicle leads to congestion, thrombosis and necrosis.

In most cases, testicular torsion is preceded by physical stress or trauma. The main symptom of testicular torsion is sudden severe pain in the testicle and the corresponding half of the scrotum, which may be accompanied by nausea and vomiting. The testicle is usually palpated at the upper edge of the scrotum, which is associated with shortening of the spermatic cord. Sometimes, with torsion, the epididymis is located in front of the testicle, and the spermatic cord is thickened. Subsequently, swelling and hyperemia of the scrotum are added.

Diagnosis and differential diagnosis. Besides clinical manifestations with this pathology, it is necessary to take into account the anamnesis data. A history of sudden testicular pain that went away on its own should suggest a predisposition to torsion. Testicular torsion, mistaken for inflammation and treated conservatively, always ends in necrosis of the organ.

Testicular torsion is differentiated primarily from acute epididymitis and orchitis. With these diseases there are all the signs of acute inflammation: testicular enlargement, swelling of the scrotum, hyperemia of its skin and heat bodies.

Treatment and prognosis. Treatment of testicular torsion should be prompt and urgent. In cases where surgical correction was performed no later than 3-6 hours after the occurrence of torsion, the viability of the testicle is restored, otherwise testicular necrosis develops, followed by its atrophy.

15.6. PRIAPISM

Priapism- an acute disease consisting of prolonged pathological erection without sexual desire and sexual satisfaction. An erection can last from several hours to several days, not go away after sexual intercourse and not end with ejaculation and orgasm. The prevalence of this disease, according to the literature, is from 0.1 to 0.5%.

Etiology and pathogenesis. The occurrence of priapism is caused by: 1) pathology of the nervous system and psychogenic disorders; 2) intoxication; 3) hematological diseases; 4) local factors. The first include diseases that lead to stimulation of the corresponding areas of the spinal cord and brain (trauma, tumors, tabes dorsalis, multiple sclerosis, meningitis, etc.), hysteria, neurasthenia, psychoneurosis due to erotic fantasies. To the second - poisoning chemicals, medications, alcohol intoxication. The third group of factors consists of diseases

blood systems (sickle cell anemia, leukemia). And finally, local factors include intracavernous administration of vasoactive drugs, phimosis, paraphimosis, cavernitis, tumors and injuries of the penis, etc.

Classification. Priapism is divided into ischemic, non-ischemic and recurrent.

Ischemic(veno-occlusive, low-flow) priapism occurs in 95% of cases of all variants of this disease. With veno-occlusive priapism, the speed of blood flow decreases sharply and may stop completely. As a result, ischemia occurs, fibrosis of the cavernous bodies and organic erectile dysfunction develop. Within 12 hours, changes in tissues appear, and after 24 hours, irreversible consequences occur.

Non-ischemic(arterial, high-flow) priapism occurs when there is trauma to the penis or perineum with damage to the arteries, resulting in the formation of an arterio-lacunar fistula. With this type of priapism, tissue trophic disturbances are insignificant.

Recurrent(intermittent, or recurrent) priapism is a variant of ischemic. It is characterized by a wave-like course: long periods of painful erection are followed by its decline. Recurrent priapism is more common in diseases of the central nervous system, mental disorders and blood diseases.

Symptoms and clinical course. Priapism occurs suddenly and can last for a long time, completely exhausting the patient. Pathological erection is accompanied by severe pain in the penis and sacral region. The penis becomes tense, sharply painful, its skin acquires a bluish tint. The direction of the penis is arched, at an acute angle to the abdomen. The head of the penis and the spongy body of the urethra are soft and relaxed. Urination is not impaired. The development of priapism is determined by the inadequacy of the inflow and outflow of blood into the cavernous bodies.

Clinical manifestations of priapism can develop several hours after the injury and are characterized by incomplete erection. However, with stimulation, a full erection develops. Unlike ischemic priapism, non-ischemic priapism can occur in a painless form, and can also stop on its own or after sexual intercourse. The presence or absence of pain in the penis is one of the diagnostic signs that distinguishes veno-occlusive priapism from arterial priapism.

Diagnostics based on the patient’s complaints and examination. In the differential diagnosis of ischemic and non-ischemic priapism, data from Dopplerography and gasometry of blood aspirated from the cavernous bodies are used. With arterial priapism, the echographic picture will indicate a violation of the integrity of the arteries of the penis. The partial pressure of oxygen and blood pH do not change. Veno-occlusive priapism is characterized by hypoxia and acidosis. Prolonged local hypoxia of cavernous tissue is a damaging factor leading to its sclerosis and the development of erectile dysfunction.

Treatment.Priapism is an urgent pathological condition and requires emergency hospitalization.Urgent conservative therapy includes

sedatives and analgesics, anticoagulants, local hypothermia, antibiotic and anti-inflammatory therapy, as well as drugs that improve microcirculation and rheological properties of blood; α-adrenergic agonists are administered intracavernosally.

Surgery produced when conservative therapy is ineffective. It is aimed at restoring blood flow from the penis by applying vascular shunts. The most widely used are incision of the corpora cavernosa, their aspiration followed by perfusion, spongio-cavernous and saphenocavernous anastomosis, which consists of directly connecting the corpus cavernosa and the great saphenous vein of the thigh. (vena saphena magna).

Forecast favorable in terms of eliminating the disease and questionable in relation to erectile function. With the development of organic impotence, they resort to penile prosthetics.

15.7. INJURIES OF THE GINOROGENITAL ORGANS

Injuries to the genitourinary system account for 1.5-3% of the total structure of injuries to all human organs. In peacetime, their cause in 75-80% of victims is injuries during road accidents and falls from a height. In 60-70% of cases, injuries are combined or multiple; for the most part, injuries to the kidneys and urinary tract occur.

Classification. According to localization they distinguish injuries of the kidneys, ureters, bladder, urethra And male genital organs.

Depending on the presence of a wound channel connecting the damaged area with external environment, highlight closed And open injuries.

Injuries can be isolated, multiple or combined. Isolated An injury to one organ of the genitourinary system is considered; multiple - when, in addition to injury to the genitourinary organs, there are injuries to other organs within the same anatomical area, for example, injury to the kidney and abdominal organs. Combined simultaneous injuries to organs located in different anatomical areas are considered, for example, damage to the bladder and traumatic brain injury.

Depending on the severity of injuries to the genitourinary organs, there may be light, medium And heavy, in relation to body cavities - penetrating And non-penetrating, depending on the side of the lesion - one- And bilateral.

15.7.1. Kidney damage

Epidemiology. Kidney injury is the most common and accounts for about 60-65% of the structure of injuries to the organs of the urinary system. In peacetime, closed kidney injuries predominate, and in wartime, open kidney injuries predominate.

Etiology and pathogenesis. Closed kidney injuries usually occur as a result of the application of force to the lumbar or abdominal area in the form of

impact or squeezing. The hydrodynamic factor also plays a role in the rupture mechanism, due to the significant predominance of the liquid component (blood, lymph, urine) in the kidney parenchyma, surrounded by a dense fibrous capsule. Direct impact and detonation of the fluid inside the organ lead to rupture of the fibrous capsule and parenchyma of the kidney. In domestic conditions, injury often occurs as a result of a fall with the lumbar region onto a protruding solid object. Organ rupture occurs as a result of a direct impact and the damaging effect of nearby bone structures - the ribs and spine.

Kidney damage can occur as a result of minimally invasive and endoscopic methods for diagnosing and treating urological diseases, which are now widely used. First of all, they are associated with careless or erroneous actions of the doctor. After external shock wave nephrolithotripsy, subcapsular hematomas are often diagnosed, and the hematuria that always occurs after it can be a consequence of not only the damaging effect of the stone and its fragments on the urothelium, but also ruptures of the fornix. Injury to the renal parenchyma can be observed during catheterization (stenting) of the ureter, ureteroscopy, nephroscopy, nephrobiopsy, and even during perinephric block.

Kidney diseases (tumor, cyst, hydronephrosis) make it more susceptible to various traumatic influences. Severe damage to a pathologically altered kidney can occur even with minimal trauma.

Open injuries - knife or gunshot - are usually multiple.

Classification. The clinical and anatomical classification of closed kidney injuries is based on the severity of the organ injury. Distinguish bruises And ruptures buds (Fig. 67, see color insert). A bruise is characterized by a sharp shock (contusion) of the organ without rupture of the kidney parenchyma, its capsule and the abdominal system. Clinically significant damage to the kidney is observed only when it ruptures, from microscopic tears of the parenchyma and fornix to crushing of the organ. From this point of view, the appearance of subcapsular and perinephric hematomas, as well as hematuria, is always a consequence of even minor ruptures of the parenchyma.

Classification of kidney ruptures (Fig. 15.1):

A- external rupture of the renal parenchyma with the formation of a subcapsular hematoma;

b- external rupture of the parenchyma and capsule of the kidney with the formation of a perinephric hematoma;

V- internal rupture of the parenchyma and fornixes, opening into the abdominal cavity system of the kidney (hematuria);

G- penetrating rupture of the capsule, parenchyma and abdominal cavity system of the kidney with the formation of perinephric urohematoma (hematuria);

d- crushing of the kidney: multiple penetrating ruptures of the capsule, parenchyma and abdominal cavity system of the kidney with the formation of perinephric urohematoma (hematuria);

e- separation of the vascular pedicle with crushing of the renal parenchyma.

Rice. 15.1. Types of kidney ruptures

The most severe forms of damage to the kidney are its crushing, that is, the formation of multiple ruptures of the organ penetrating into the pyelocaliceal system with possible separation of sections of the parenchyma (pole), and rupture (severance) of the vascular pedicle. The latter has no clinical significance, since it is almost always combined with equally severe damage to other organs, which makes this kind of damage incompatible with life.

Symptoms and clinical course. The clinical picture depends on the degree of kidney damage and the presence of injuries to other organs. Patients complain of pain in the lumbar region and/or abdomen, aggravated by deep breathing, bloating, nausea, vomiting, and general weakness. Total hematuria is observed with severe kidney damage (Fig. 15.1, c-e). Gross hematuria serves as a sign of the severity of organ damage, in turn being one of the determining factors in the severity of the victim’s condition. However, in some cases the degree of hematuria does not correspond to the degree of kidney damage. With small fornical ruptures, persistent severe hematuria may be observed, and, conversely, with crushing of the kidney, hematuria

may be insignificant or absent as a result of tamponade of the abdominal system with blood clots and/or damage to the pelvis, ureter and its vascular pedicle.

Rupture of a parenchymal organ rich in blood vessels, such as the kidney, is accompanied by signs of internal bleeding. In combination with severe hematuria, it can quickly lead to anemia and a serious condition of the patient, which is manifested by pallor of the skin, cold sweat, tachycardia, decreased blood pressure, and an increase in retroperitoneal urohematoma. An objective examination of the skin of the abdomen and lumbar region may reveal abrasions, hemorrhages, tissue swelling, as well as bulging in this area due to urohematoma large sizes. The location and course of the wound channel with the flow of urine from it allows us to suspect open kidney damage. Palpation of the chest and spine may be accompanied by severe pain due to fracture of these bone formations. Palpation of the abdomen reveals pain and protective muscle tension on the affected side, and with large urohematomas, a round formation in the hypochondrium and lumbar region.

Long-term complications of closed kidney injuries are an organized hematoma that compresses the kidney, stone formation, hydronephrosis, arterial hypertension, etc.

Diagnostics. In diagnosis, attention is paid to the type and nature of the injury, its objective local and general manifestations. Blood tests determine a decrease in the number of red blood cells and hemoglobin, in more late dates from the moment of injury, leukocytosis occurs. In a urine test, red blood cells cover the entire field of view. Total renal function can be assessed by determining residual nitrogen, urea and serum creatinine, which is especially important to know when a single kidney is damaged and planning surgical treatment.

Radiation methods are the main ones in diagnosing renal rupture. They allow, firstly, to determine the degree of damage to the kidney, and secondly,

firstly, to evaluate the separate function of the damaged and contralateral kidneys, and thirdly, to monitor the dynamics of the wound process in order to early diagnose complications and make their timely correction. The most accessible, minimally invasive and quick method diagnosis of kidney damage - Ultrasound. With its help, you can identify sub-capsular and perinephric uro-hematomas (Fig. 15.2), determine the size, deformation of the contours of the kidney, parenchymal defects, deformation of the pyelocaliceal system, the degree of its ectasia, and detect clots

Rice. 15.2. Sonogram. Perinephric urohematoma (arrow)

Rice. 15.3. Excretory urogram. Contrast leakage (arrow) due to rupture of the right kidney

blood. Comparison of ultrasound results with medical history, physical examination data and the severity of bleeding often makes it possible to establish a diagnosis and, if the patient’s condition is serious, proceed to emergency surgery without other examination methods.

In all cases, patients with suspected renal injury should undergo plain radiography abdominal cavity and retroperitoneal space. It can be used to identify scoliosis, absence of a kidney contour and large psoas muscle, fractures of the lower ribs, transverse processes of the vertebrae and pelvic bones. Excretory urography allows you to detect deformation and compression of the calyces and pelvis, contrast leaks on the affected side (Fig. 15.3), assess the function of the damaged and contralateral kidneys, which is important when determining

volume of emergency surgical intervention. Its use is limited in cases of combined injuries and in victims with shock and unstable hemodynamics (systolic pressure below 90 mm Hg).

Currently retrograde ureteropyelography in the diagnosis of kidney damage is used extremely rarely due to the emergence of new me-

research methods. It can be used to clarify the degree of kidney damage when excretory urography is uninformative and CT, MRI and angiography are unavailable due to the emergency of the situation or their absence in a given hospital.

The most informative methods for diagnosing kidney damage are CT and MRI. When X-ray contrast agents are injected into a vein, as a rule, the need to use other radiation methods is eliminated. CT and MRI provide the highest degree of accuracy in assessing anatomical details

Rice. 15.4. CT with contrast, frontal projection. Left kidney rupture (arrow)

Rice. 15.5. CT with contrast, axial projection. Extravasation of contrast material due to rupture of the left kidney

injured kidney. In emergency care practice, their accuracy reaches 98%. CT allows you to visualize damage to the parenchyma (Fig. 15.4) and vessels of the kidney, organ segments deprived of blood supply, and detect even small urinary streaks containing X-ray contrast agent (extravasates) (Fig. 15.5), as well as injury to other parenchymal organs. CT and MRI can detect kidney damage resulting from endourological interventions (Fig. 15.6).

Renal angiography allows, in addition to diagnosing damage to co-

vessels and kidney parenchyma, perform a therapeutic procedure - selective embolization of a bleeding vessel (Fig. 15.7).

Radioisotope scanning in the emergency diagnostic system of renal injuries is less informative than radiation methods, requires a lot of time and special conditions. This method is more appropriate for assessing the consequences of kidney injury and their functional state.

Rice. 15.6. Multislice CT with contrast:

A- frontal projection; b- axial projection. Perforation of the renal parenchyma with a ureteral stent (arrow)

Rice. 15.7. Renal angiograms:

A- ruptures of renal tissue with leaks of contrast agent; b- selective embolization of bleeding vessels (arrow)

Treatment. Therapeutic tactics depend on the degree of kidney damage. Conservative therapy indicated for small ruptures of the organ with a subcapsular or perinephric hematoma with a volume of up to 300 ml and moderate hematuria (see Fig. 15.1, a-c). Strict bed rest is prescribed for two weeks, cold on the lumbar region, hemostatic, antibacterial and drugs that improve microcirculation in the kidney. During treatment, constant dynamic monitoring is required, including assessment of hemodynamic status, blood and urine tests and ultrasound monitoring. One should remember about the possibility of so-called two-stage organ damage, which means rupture of the fibrous capsule over the subcapsular hematoma with resumption of bleeding from the damaged parenchyma into the retroperitoneal tissue. Such a rupture can occur if the patient does not comply with bed rest.

Surgery required in 10-15% of patients with severe kidney damage. Emergency surgery is indicated:

■ with increasing internal bleeding and/or profuse hematuria;

■ large and multiple ruptures of the parenchyma with the formation of hematomas (urohematomas) with a volume of more than 300 ml;

■ combined damage to the kidney and other internal organs requiring urgent revision;

■ infection of a perinephric hematoma with the formation of a perinephric abscess.

Planned operations are performed for long-term complications of closed kidney injuries.

Surgical interventions for kidney injury are divided into minimally invasive and open.

Minimally invasive include percutaneous puncture and drainage of a hematoma or post-traumatic perinephric abscess; laparoscopic (lumboscopic) suturing of a kidney rupture or nephrectomy, evacuation and drainage of the hematoma; arteriography and selective embolization of the bleeding vessel of the kidney.

Open surgical interventions (Fig. 67, see color insert) include suturing the rupture of the renal parenchyma with or without nephrostomy, kidney resection and nephrectomy.

Even today, in case of kidney injury, nephrectomy is most often performed. It is performed in approximately 50% of patients who undergo emergency lumbotomy (laparotomy) for organ rupture. The kidney is removed in case of rupture of the vascular pedicle, multiple and deep wounds of the parenchyma, the impossibility of performing a good revision and organ-preserving treatment due to the rapidly increasing life-threatening bleeding, especially with combined injuries. In some cases, in regional and small city hospitals, nephrectomy is performed without proper inspection of the kidney and assessment of the degree of its damage during laparotomy undertaken for intraperitoneal injuries.

A complete urological examination may not be possible due to the need for emergency laparotomy for associated intraperitoneal injuries. During the operation, revision of the kidney is mandatory if there is a growing retroperitoneal hematoma of large size. If nephrectomy is planned after revision of the retroperitoneum and kidney, it is necessary to evaluate the function of the opposite kidney. First of all, it is necessary to determine the presence of an organ by palpation through the parietal peritoneum, and also be sure to establish its functional viability. IN in case of emergency on the operating table this can be done in one of two ways: excretory urography or indigo carmine test (intravenous administration of a dye with clamping of the ureter of the injured kidney and monitoring its flow through the catheter from the bladder).

In case of gunshot wounds of the kidney, it is necessary to take into account the cavitation effect of a bullet or fragment, that is, concussion, crushing of the parenchyma due to the impact of the pulsating cavity. In such cases, surgical treatment of the wound canal is necessary, including, in addition to stopping bleeding, excision of non-viable tissue and removal of foreign bodies.

Forecast depends on the degree of kidney damage and proper treatment. Conservative therapy for small ruptures and organ-preserving surgical treatment make the prognosis for the anatomical and functional state of the kidney favorable. In case of severe organ ruptures and massive bleeding, the prognosis for the patient’s life is determined by timely surgical intervention.

15.7.2. Ureteral injuries

Epidemiology. Injuries to the ureters due to their anatomical structure are observed quite rarely. In the structure of injuries to the organs of the urinary system, they account for no more than 1% of cases.

Etiology and pathogenesis. Open Injuries to the ureters are extremely rare; as a rule, they are the result of knife or gunshot wounds and are almost always of a combined nature. Gunshot wounds of the ureters occur in 3.3-3.5% of cases of all combat injuries to the genitourinary system during modern combat operations. Not much more often observed and closed damage to the ureters as a result of external influence due to their anatomical and topographical features (depth of location, protection by muscle and bone structures, size, elasticity, mobility). Such an injury can occur as a result of damage to the ureters by bone fragments due to a fracture of the posterior semi-ring of the pelvis. In peacetime, the vast majority of ureteral injuries are caused byiatrogenic nature, that is, it occurs as a result of accidental damage during surgical interventions. Ligation, incision, or transection of the ureter is most commonly observed during obstetrics, gynecology, and surgery. Damage to it as a result of endourological diagnostic and therapeutic interventions (ureteroscopy, stenting and catheterization of the ureter) should be regarded as a complication when performing manipulations.

Symptoms and clinical course. Damage to the ureter is manifested by pain in the lumbar region associated with impaired outflow of urine from the corresponding kidney, and short-term hematuria. In open wounds, ureteral injury is almost always combined and manifests itself as a retroperitoneal urinary leak or leakage of urine from the wound.

The symptoms of iatrogenic ureteral injuries depend on the nature of their damage. The dressing is accompanied by a clinical picture of renal colic. Damage to the ureter that was not detected during surgery is manifested by the release of urine through drains from the abdominal cavity or retroperitoneal space already in the first hours after surgery. The leakage of urine into the abdominal cavity is manifested by symptoms of incipient peritonitis: irritation of the peritoneum and intestinal paresis. Undrained or poorly drained urinary leaks become infected with the formation of retroperitoneal urinary phlegmon with the subsequent development of urosepsis. A serious symptom of ureteral obstruction is post-renal anuria. It can occur in patients with ureteral obstruction of a single kidney or with bilateral ureteral damage.

Diagnostics. In blood tests, leukocytosis with a shift of the formula to the left, an increase in the level of creatinine and urea are noted, in urine tests fresh red blood cells are determined. When fluid suspicious for urine is released through the drains, the content of urea and creatinine in it is determined, and sample with indigo carmine. To do this, 5 ml of 0.4% indigo carmine is injected intravenously and the color of the released liquid is monitored. Its blue color indicates damage to the ureter. Chromocystoscopy establishes that indigo carmine from the mouth

Rice. 15.8. Antegrade pyeloureterogram on the right.

Extravasation of contrast agent (arrow) due to damage to the pelvic ureter

the damaged ureter is not isolated. Catheterization ureter allows you to determine the degree and location of its damage.

At Ultrasound hydrouretero-nephrosis is detected during ligation of the ureter or the presence of fluid (urine) in the perinephric tissue and abdominal cavity.

Suspicion of ureteral injury is an indication for emergency excretory urography or CT with intravenous contrast, and if necessary - retrograde ureteropyelography. A characteristic sign of intersection or marginal damage to the ureter is extravasation of X-ray contrast agent (Fig. 15.8), and during ligation - the absence of its release.

Treatment ureteral injuries depend on their type, location and time elapsed since the injury. When open

injuries require diversion of urine by puncture nephrostomy and drainage of urinary leakage. After the wound has healed, an operation is performed to restore the patency of the ureter. Marginal damage to the ureter that occurred as a result of endourological operations closes on its own after the stent is installed.

Iatrogenic ureteral injuries diagnosed during surgery are subject to immediate correction, which depends on the type of injury. The marginal defect of the ureter is sutured with interrupted vicryl sutures; in case of more extensive defects or ligation of the ureter, resection of its altered areas with ureterouretero or ureterocystoanastomosis is performed. If iatrogenic damage to the ureter is not noticed during surgery, its outcome may be urinary leakage, peritonitis, cicatricial narrowing and ureterovaginal fistulas. In such cases, and especially with the development of postrenal anuria, percutaneous puncture nephrostomy with drainage of urinary leaks is indicated. Subsequently, depending on the extent and localization of narrowings or obliterations of the ureter, reconstructive operations are performed: ureteroureteroanastomosis, ureterocystoanastomosis (Fig. 52, 53, see color insert), and in case of extended or bilateral narrowings - intestinal plastic surgery of the ureters ( Fig. 54, 55, see color insert).

15.7.3. Bladder damage

Bladder damage refer to severe injuries of the abdomen and pelvis. The severity of the condition of the victims and the outcome of treatment are determined not so much by damage to the bladder, but by their combination with injuries to other organs and dangerous complications caused by the flow of urine into the surrounding tissues and the abdominal cavity.

Classification. Bladder injuries are divided into closed And open, isolated And combined. They can be non-penetrating And penetrating, when all layers of the bladder wall are damaged and urine is released outside of it. In peacetime, closed bladder injuries predominate. They can be intraperitoneal, extraperitoneal And combined, when there is simultaneous intra- and extraperitoneal rupture of the bladder.

Epidemiology. The incidence of bladder injuries in closed injury abdomen ranges from 3 to 16%. In most cases, extraperitoneal ruptures of the organ are observed.

Etiology and pathogenesis. Closed injuries to the bladder in most cases (70-80%) are the result of fractures of the pelvic bones. With this mechanism of injury, extraperitoneal ruptures predominate, which occur as a result of sudden movement of the vesicoprostatic and lateral ligaments of the bladder. A sharp tension of dense anatomical formations, such as its ligaments, leads to rupture of the more pliable soft-elastic wall of the bladder. Direct damage to its wall by displaced bone fragments is also possible. Intraperitoneal injuries have a different mechanism of development. The rupture occurs as a result of hydrodynamic impact on the wall of the overfilled bladder. Such damage occurs even with minimal traumatic impact on the lower abdomen (sudden blow) with a relaxed anterior abdominal wall.

Damage to the bladder, as well as to the ureters, is often iatrogenic in nature. His injuries occur especially often during obstetric and gynecological operations.

Symptoms and clinical course. For bladder injuries X Characterized by pain in the lower abdomen, which is especially pronounced with fractures of the pelvic bones. The vivid symptoms of bone injury, especially with the development of a shock state, masks the manifestations of intrapelvic organ damage, including damage to the bladder. It should be remembered that in patients with pelvic bone fractures, ruptures of the bladder and/or membranous urethra most often occur. These injuries should first be excluded when examining such victims. The clinical picture of an acute abdomen is the main manifestation of intraperitoneal rupture of the bladder. Availability large quantity urine in the abdominal cavity causes a characteristic symptom of “vanka-vstanka”. An attempt to lay the victim down leads to a sharp increase in pain throughout the abdomen, which is associated with irritation of a large number of nerve endings due to movement

fluid into the upper abdominal cavity. As a result, it tends to take a vertical position.

Penetrating ruptures of the bladder are always accompanied by urination disorders, the severity of which is directly related to the degree of the resulting defect. Despite the increased urgency, independent urination is impossible. An attempt to urinate leads to the movement of urine outside the organ, accompanied by a sharp increase in pain and the absence or minimal release of it mixed with blood through the urethra.

With late presentation and injuries not recognized in time, severe septic complications develop: with extraperitoneal damage - pelvic phlegmon, and with intraperitoneal damage - diffuse urinary peritonitis.

Diagnostics. Taking an anamnesis allows you to establish the nature of the injury (collision by a vehicle, fall from a height, strong blow to the abdominal area). The patient's condition is serious; palpation reveals pain and protective tension in the muscles of the anterior abdominal wall. With an intraperitoneal rupture, pronounced symptoms of peritoneal irritation and intestinal paresis are determined. Rectal digital examination allows you to exclude ruptures of the rectum, identify its pastiness and overhang of the anterior wall caused by urine leakage. Women should undergo a vaginal examination.

Ultrasound in case of intraperitoneal rupture of the bladder, it allows to identify free fluid in the abdominal cavity with poor visualization of an insufficiently filled bladder. An extraperitoneal rupture is characterized by deformation of the bladder wall and the presence of fluid outside it.

Bladder catheterization and retrograde cystography are one of the main and most reliable methods for diagnosing bladder ruptures. You should first make sure that there is no trauma to the urethra, since passing instruments through it is contraindicated. Signs of damage to the bladder during catheterization are:

■ absence or small amount of urine in the bladder of a patient who has not urinated for a long time;

■ excretion of a large amount of urine mixed with blood, exceeding the maximum capacity of the bladder (sometimes 1 liter or more);

■ discrepancy between the volume of fluid introduced and discharged through the catheter (Zeldovich’s symptom).

Bladder catheterization is performed on an X-ray table, so that after assessing its results, immediately proceed to retrograde cystography. Before it begins, a survey x-ray of the pelvic area is performed, which allows one to determine the nature and extent of bone damage. Features of performing retrograde cystography are as follows:

■ high concentration of the administered contrast agent to avoid loss of information as a result of its dissolution in large quantities

Rice. 15.9. Retrograde cystogram. Extraperitoneal bladder rupture

fluid contained in the abdominal cavity;

■ tight filling of the bladder with the introduction of at least 300 ml of X-ray contrast agent;

■ assessment of the volume of removed contrast agent.

Radiographs are performed in the following sequence: in a direct, semi-lateral (lateral position) projection, after palpation of the bladder area and after emptying it.

Signs of penetrating extraperitoneal rupture of the bladder are

This is caused by deformation of its walls and leakage of the radiopaque substance beyond its boundaries (Fig. 15.9). With intraperitoneal ruptures, shapeless streaks of contrast material are detected in the abdominal cavity.

Excretory urography in case of damage to the bladder, it is not very informative due to insufficient contrast of the bladder on the descending cystogram, but in some cases it is advisable to perform it to exclude damage to the kidneys and upper urinary tract. Reliable information can be obtained using CT, especially with retrograde contrast enhancement of the bladder.

Cystoscopy for ruptures of the bladder due to insufficient filling, pain and hematuria, it is not very informative.

Rice. 15.10. Methods for draining pelvic tissue through the suprapubic wound (1), obturator foramen (2) and perineum (3)

Treatment. For non-penetrating bladder ruptures, a permanent catheter is installed for 3-5 days, and hemostatic and antibacterial therapy is prescribed. Penetrating ruptures require emergency surgical intervention. The existing bladder defects are sutured with a double-row continuous interrupted vicryl suture, the urinary leaks in the pelvic cavity are widely drained, and in case of an intraperitoneal rupture, the abdominal cavity is sanitized and drained if less than 12 hours have passed since the injury. If more than 12 hours have passed since the injury h and urinary peritonitis occurs, it is advisable to perform extraperitonealization of the bladder in order to separate the sutured wound of the bladder from the abdominal cavity. Drainage of the pelvis is carried out through the suprapubic wound, the obturator foramen according to McWhorter-Buyalsky and the perineum (Fig. 15.10). The operation is completed with epicystostomy, which is a universal and most reliable method of urine diversion. Drainage with a urethral catheter is possible if no more than 24 hours have passed since the injury and qualified postoperative supervision is provided. This type of bladder drainage in women is more justified.

15.7.4. Damage to the urethra

Due to the anatomical structure of the urethra, in clinical practice, damage to the urethra is mainly encountered in men. Recently, due to the widespread introduction of endourological interventions, iatrogenic injuries to the urethra have become more frequent.

Etiology and pathogenesis. Theoretically, any part of the urethra can be damaged. In practice, damage to two of its sections is mainly encountered: the perineal - in case of a direct blow, and the membranous - in case of a fracture of the pelvic bones.

The anterior urethra (hanging, perineal and bulbous sections) is more often damaged by direct traumatic effects: falling with the perineum onto hard objects (edge ​​of a bench, fence, well manhole cover, bicycle frame), the posterior sections (membranous and prostatic) - due to a fracture of the pelvic bones. That is why ruptures of the anterior urethra are, as a rule, isolated in nature with a relatively satisfactory condition of the victim. Damage to the posterior urethra due to fractures of the pelvic bones is often combined with ruptures of other nearby organs (bladder, rectum) and is accompanied by a severe, often shock, condition of the patient. As a rule, when the pelvic bones are fractured, the membranous (membranous) part of the urethra is damaged. This section is not covered by the corpora cavernosa and consists only of the mucous and submucosal layer, surrounded by connective tissue and the ligamentous apparatus of the pelvis. A fracture of the anterior pelvic semiring is accompanied by a sharp stretch and separation of its ligaments with rupture of the poorly protected membranous urethra. In some cases, damage occurs from displaced bone fragments.

Injuries to the urethra in women are rare. Their causes are fractures of the pelvic bones, domestic trauma, sexual intercourse, and complicated childbirth.

Classification. Distinguish open And closed urethral trauma. Depending on the location, damage is distinguished front or rear urethral department.

Clinical and anatomical classification:

Non-penetrating ruptures (tears of part of the urethral wall): internal (from the mucous membrane); external (from the side of the fibrous membrane).

Penetrating breaks:

full (circular);

incomplete (rupture of one of its walls).

This division is very important for determining treatment tactics, since for non-penetrating ruptures conservative therapy is carried out, and for penetrating ruptures - surgical treatment.

Symptoms and clinical course. Victims complain of pain in the perineum, lower abdomen, and penis, which sharply intensifies when trying to urinate. Pain is especially pronounced and multifactorial in nature with fractures of the pelvic bones and combined damage to intrapelvic organs. A characteristic symptom of urethral damage is urethrorrhagia (bleeding from the external opening of the urethra outside the act of urination). With non-penetrating ruptures, when the act of urination is preserved, urethrorrhagia is combined with initial hematuria. Urination is impossible with complete penetrating urethral ruptures. Urinary retention is accompanied by a strong urge, attempts to urinate are unsuccessful, while urine is poured into the paraurethral tissue and surrounding cellular spaces. Subsequently, urinary leakage develops, and when it becomes infected, urinary phlegmon and urosepsis develop.

Diagnostics. The general condition of the patient with isolated injuries suffers little. Local manifestations come to the fore: pain in the area of ​​the damaged urethra, urethrorrhagia and difficulty urinating. On examination, bruising, cyanosis of the skin of the perineum, scrotum and penis, and swelling of the tissues surrounding the urethra are noted. There is dried blood in the area of ​​the external opening of the urethra. The serious condition of victims is observed in cases of urethral ruptures associated with fractures of the pelvic bones and combined damage to intrapelvic organs. Many patients develop a state of shock. They are pale, adynamic, inadequate, with a rapid pulse and hypotension.

Radiography establishes the location and severity of pelvic bone fractures. Retrograde urethrography is the main method for diagnosing urethral ruptures. It allows you to determine the location and degree of damage to the urethra. With penetrating injuries, a radiopaque substance is detected outside the urethra in the form of shapeless streaks (Fig. 15.11). If its rupture is complete, extravasation is more pronounced, and there is no contrast of the urethra

Rice. 15.11. Retrograde urethrogram. X-ray contrast agent leakage due to rupture of the membranous urethra (arrow)

proximal to the site of injury and the contrast agent does not enter the bladder.

Catheterization of the bladder for the purpose of diagnosing urethral rupture is not very informative and can lead to infection and conversion of a non-penetrating rupture to a penetrating one.

Treatment. The treatment tactics for urethral ruptures depend on the severity of the condition of the victims, the degree of damage and the time that has passed since the injury. Conservative treatment is carried out for non-penetrating ruptures and consists of prescribing painkillers, hemostatic and antibacterial therapy.

Penetrating ruptures serve as an indication for emergency surgery. In all cases, it is necessary to divert urine through epicystostomy and drainage of paraurethral urinary leaks. The operation can be expanded beyond

progress count primary urethral suture. Such tactics are possible under the following conditions: 1) if no more than 12 hours have passed since the injury; the general condition of the victim is stable (no shock); There is a qualified team of urologists with experience in performing operations on the urethra. The operation consists of perineotomy, revision and sanitation of the wound, refreshment and mobilization of the ends of the damaged urethra and the formation of a urethro-urethroanastomosis on a catheter inserted into the bladder cavity (preferably on a two-way drainage system).

Complications Urethral ruptures are strictures and obliterations of the urethra. They develop in all patients with penetrating wounds, with the exception of those who have undergone a primary urethral suture.

15.7.5. Strictures and obliterations of the urethra

Urethral stricture is called a narrowing of its lumen as a result of replacement of the wall of the urethra with scar tissue. Obliteration complete replacement of the urethral area with scar tissue is considered.

Strictures and obliterations of the urethra due to their prevalence, the presence of urinary fistulas, the tendency to rapid recurrence and high

Rice. 15.12. Retrograde urethrogram. Stricture of the perineal urethra (arrow)

The incidence of erectile dysfunction is a complex medical and social problem.

Etiology and pathogenesis. Distinguish congenital And acquired narrowing of the urethra. The latter are much more common. Based on their formation, they are divided into: post-inflammatory, chemical And post-traumatic. Post-inflammatory diseases prevailed before the introduction of antibiotic therapy. They are more often localized in the anterior urethra and, as a rule, are not isolated. Currently in most

Post-traumatic strictures and obliteration of the urethra occur in cases.

Symptoms and clinical course. The main manifestation of urethral strictures is difficulty urinating. The pressure of the urine stream decreases as the disease progresses and the degree of narrowing of the lumen of the urethra increases. With strictures located in the posterior parts of the urethra, the urine stream is weak, falls vertically, and the time of urination is prolonged. A characteristic symptom of narrowing of the anterior sections is splashing of a stream of urine.

When the urethra is obliterated, independent urination is impossible; the patient has a permanent suprapubic vesical fistula in which a Foley or Pezzer catheter is installed to drain urine.

The diagnosis is made based on urethrography(Fig. 15.12) and urethroscopy(Fig. 3, see color insert). With the help of these studies, local

calization, extent and severity of narrowing. Retrograde urethrography in combination with antegrade cystourethrography makes it possible to assess the size of the obliterated area of ​​the urethra (Fig. 15.13).

Differential diagnosis narrowing of the urethra in men should be carried out with diseases that are also characterized by difficulty urinating - benign hyperplasia, sclerosis, prostate cancer, anomalies, stones, urethral tumors.

Treatment can be conservative and operative. Conservative

Rice. 15.13. Retrograde urethrogram with antegrade cystourethrogram. Contrast defect due to obliteration of the membranous urethra (arrow)

consists of dilating the urethra. This method has been used since ancient times. It is palliative and indicated for short (no more than 1 cm) narrowings. Bougienage involves forcibly passing rigid instruments specially designed for this purpose, called bougies, through scar-narrowed areas of the urethra. Bougies have an increasing size (diameter) and can be elastic and metal (see Chapter 4, Fig. 4.42) To make the bougie easier and the pain reduced, a special gel with an anesthetic and antiseptic is injected into the urethra (instillagel, kategel) . In some cases, anesthesia is used. Bougienage of the urethra requires caution, as it is performed blindly, and can be accompanied by a number of complications: ruptures of the unchanged wall, the formation of a false tract, urethrorrhagia, urethral fever and the development of epididymitis and orchitis. Bougienage is supplemented with the prescription of anti-inflammatory and absorbable drugs.

Surgery. A planned operation to restore the patency of the urethra in patients with post-traumatic strictures and obliterations of the urethra is performed 4-6 months after the elimination of urinary leakage, perifocal inflammation and consolidation of pelvic bone fractures. The operation is performed endoscopically or open method. Endoscopic surgery consists of internal optical (under visual control) urethrotomy (Fig. 4, see color insert) and recanalization of the urethra. It is used for short (up to 2 cm), including multiple narrowings of the urethra. It is a palliative intervention, since the scar

The tissue is not completely removed. In order to prevent relapses after endoscopic dissection of the stricture, a special endoprosthesis (stent) is installed in the urethra. It is a spring that, fitting tightly to the walls of the urethra, does not allow scar tissue to narrow its lumen (Fig. 15.14).

A radical method of treating narrowings and obliterations is urethral resection. The operation consists of complete excision of scar tissue and suturing of its mobilized, unchanged ends. This operation is easily performed when the narrowing is localized in the anterior (perineal) section of the urethra (Holtzov urethral resection). It is much more difficult to perform resection for

Rice. 15.14. Survey radiograph. Endoprosthesis (stent) of the urethra (arrow)

days of the urethra, for which special instruments and surgical techniques are used. For more extensive narrowings, cutaneous or buccal (part of the buccal mucosa) urethroplasty is performed.

Forecast if radical surgical treatment is performed in a timely manner, favorable. Patients with narrowing of the urethra should be under constant supervision of a urologist due to the high risk of recurrence of strictures. Half of the patients with post-traumatic obliteration of the posterior urethra and after operations to restore its patency develop erectile dysfunction.

15.7.6. Damage to the external male genitalia

Damage to the male external genitalia can be open or closed. Open are more often observed in war time or arise as a result of an animal bite (Fig. 82, see color insert) or stab wounds. Traumatic amputation of the genital organs occurs as a result of accidental injuries or intentional mutilation. The causes of closed injuries are blows delivered to this area, falls on the perineum and sexual excesses.

Closed injuries to the penis are divided into bruises, ruptures of the tunica albuginea, dislocations and pinching by pressing ring-shaped objects. The most common rupture of the dense tunica albuginea of ​​the erect penis occurs as a result of forced sexual intercourse. The characteristic crunch and severe pain that occurs during this process have led to the fact that this type of injury is called a penile fracture. Severe bleeding from the corpora cavernosa is accompanied by the formation of extensive subcutaneous hematomas and, in combination with a defect in the tunica albuginea, leads to curvature of the organ (Fig. 83, see color insert).

Treatment is surgical and consists of evacuating the hematoma and suturing the rupture of the tunica albuginea with vicryl ligatures. Patients should be under the supervision of a urologist due to the risk of fibrotic changes in the cavernous bodies, curvature of the penis and weakened erection.

Closed injury to the scrotal organs develops as a result of direct traumatic effects on them: being kicked, hit by a ball, falling onto a bicycle frame, falling from a height. Severe pain and tissue swelling occur with the formation of a hematoma. Rupture of the testicular capsule causes hemorrhage into the membranes of the testicle (hematocele), causing a sharp increase in the scrotum and a change in its color. Sometimes an injury to the scrotum can cause the testicle to dislocate or become displaced under the skin of nearby areas. Testicular torsion is the most dangerous, since the resulting occlusion of the vessels feeding it leads to rapid necrosis of the organ.

Subcutaneous hematoma and hematocele make the diaphanoscopy symptom negative. Ultrasound allows visualization of intratesticular hematomas, testicular fragmentation and parenchymal protrusion through defects in the tunica albuginea.

Surgery indicated for ruptures of the tunica albuginea, the formation of large hematomas and testicular torsion. The operation consists of evacuation of the hematoma, stopping bleeding, excision of non-viable tissue and areas of parenchyma, suturing of the tunica albuginea and drainage of the scrotal cavity. When torsion occurs, the testicle is turned into reverse side and fix it in the correct position. Orchiectomy is indicated only if the organ is not viable as a result of torsion and ischemia of the vascular pedicle or crushed testicle.

15.7.7. Foreign bodies of the urethra and bladder

Etiology and pathogenesis. Foreign bodies of the urethra and bladder are uncommon. They should be regarded as one of the types of traumatic damage to these organs, firstly, because in some cases they get there as a result of injury, and secondly, because, being in the lumen of the urethra or bladder, they cause constant damage action. They are found extremely rarely in the urethra and only in men, and they more often enter the bladder through the urethra in women.

Foreign bodies can enter the urinary tract as a result of:

■ bladder injuries (bone fragments, fragments of wounding objects, bullets, etc.);

■ introduction of foreign bodies by the patients themselves: children, persons with mental disorders, during self-catheterization or masturbation (pencils, glass rods, hairpins, beads, thermometers, etc.).

■ instrumental interventions and operations on the urethra and bladder (gauze balls, napkins, broken parts of bougies, catheters, bladder drains, stone extractors, etc.).

Symptoms and clinical course depend on the size, shape, configuration and duration of presence of objects in the urinary tract. Patients are concerned about pain in the urethra and suprapubic region, frequent painful urination, and blood in the urine. Over time, foreign bodies become infected and cause urethritis or cystitis.

Diagnostics. The tests show leukocyturia and hematuria. The diagnosis is established on the basis of sonography, survey and excretory urography, retrograde urethro- and cystography, CT and MRI. Urethrocystoscopy allows you to finally verify the presence, location and nature of the object located in the lower urinary tract.

Treatment. All foreign bodies must be removed either endoscopically or by open surgery. The conditions for removing a foreign object during urethrocystoscopy are its size and shape, allowing it to pass through the urethra, or the possibility of fragmentation to the appropriate size. Open surgery consists of urethro- or cystotomy with removal of the foreign body and drainage of the bladder.

Control questions

1. What are the causes of renal colic and the mechanism of its development?

2. How is the differential diagnosis of renal colic and acute surgical diseases of the abdominal cavity carried out?

3. How to relieve renal colic?

4. List the types of hematuria. What is its difference from urethrorrhagia?

5. What is the algorithm for examining a patient with gross hematuria?

6. What diseases are most often complicated by acute urinary retention?

7. How to distinguish anuria from acute urinary retention?

8. List the types of anuria.

9. How is the differential diagnosis of postrenal anuria carried out?

10. How is the differential diagnosis of testicular torsion and acute orchitis carried out?

11. What are the etiology and pathogenesis of priapism?

12. What are the mechanisms of kidney damage?

13. How are kidney injuries classified?

14. What is the importance of x-ray methods in the diagnosis of kidney damage?

15. What is the indication for surgical treatment for renal ruptures?

16. What is meant by iatrogenic ureteral injuries?

17. Give a classification of bladder ruptures.

18. Describe Zeldovich’s symptom.

19. What is the main method for diagnosing penetrating bladder ruptures?

20. Which parts of the urethra and by what mechanism of injury are damaged most often?

21. What methods of treatment of injuries and post-traumatic strictures of the urethra are currently used?

Clinical task 1

A 28-year-old patient was taken to the emergency department of a multidisciplinary hospital with complaints of severe paroxysmal pain in the right lumbar region radiating down to the groin area, the right half of the scrotum, and along the inner thigh. The attacks are accompanied by frequent urination, nausea, and repeated vomiting. The pain started three hours ago after riding a motorcycle on a bumpy road. Twice over the past six months I have noticed similar attacks, which were not so intense and went away after taking no-shpa. Upon examination, he behaves restlessly, literally rushing around the emergency room, unable to find a place for himself because of the pain. The abdomen is not swollen, soft, painful in the right hypochondrium. There are no symptoms of peritoneal irritation. Positive Pasternatsky symptom. General analysis blood and urine are normal.

Establish a preliminary and differential diagnosis. What is the examination plan to establish a final diagnosis? How to stop an attack? Choose further treatment tactics.

Clinical task 2

A 50-year-old patient was admitted to the urology clinic on an emergency basis with complaints of urine stained with blood, with worm-shaped clots, and pain in the right lumbar region of a bursting nature. From the anamnesis it is known that episodes of hematuria were noted three times over the past 6 months. Lower back pain on the right appeared about 3 months ago and was regarded as a manifestation of osteochondrosis. He was treated as an outpatient. Ultrasound of the kidneys revealed dilations of the pyelocaliceal system and the upper third of the ureter on the right. In laboratory tests: blood test (hemoglobin 100 g/l, red blood cells 3.2 x 10 12, leukocytes 8.0 x 10 9), blood biochemistry (urea 12 mmol/l, creatinine 120 μmol/l), urine test (red blood cells cover all fields of view). Excretory urography was performed. The shadows of contrasting stones are not detected, the function of the left kidney is not impaired. On the right, there is a slowdown in the release of the contrast agent, expansion of the pyelocaliceal system of the kidney and ureter to the middle third, where a filling defect is determined.

Establish a preliminary diagnosis. Choose a tactic for further examination and treatment of the patient.

Clinical task 3

A 68-year-old patient was admitted as an emergency with complaints of the inability to urinate independently with a strong urge and bursting pain in the lower abdomen. The above complaints appeared suddenly, 6 hours ago. From the anamnesis it is known that the patient has been bothered by frequent, difficult urination and weakened urine stream for two years. IN Lately periodically notes blood in the urine, pain in the lower abdomen, and a “blocking” stream of urine when changing body position. In a urine test, red blood cells cover all fields of view. According to ultrasound, an enlarged prostate gland and a rounded hyperechoic formation with an acoustic shadow in the projection of the prostatic urethra of 0.8 x 1.2 cm are located. On a survey radiograph of the urinary tract in the area of ​​the pubic symphysis, an oval contrast shadow of the same dimensions as on the sonogram.

Establish a diagnosis and choose treatment tactics.

Clinical task 4

A 17-year-old patient was taken to the hospital 4 hours after an injury - a fall from a height onto the edge of a box with the left half of the body. Complains of pain in the left half of the lower back and abdomen, weakness, and blood in the urine. The skin is pale and covered with cold sweat. Pulse 110 beats/min, blood pressure = 90/65 mm Hg. Art. A painful formation is palpated in the area of ​​the left hypochondrium, the lower edge of which is located at the level of the navel. There are no symptoms of peritoneal irritation.

What is the preliminary diagnosis? What methods can be used to clarify it? What treatment tactics should I choose?

Clinical task 5

A 43-year-old patient was brought to the emergency room after being beaten on the street. Upon examination, many bruises and abrasions are noted in the lower abdomen. An objective examination is difficult due to the fact that when trying to lay the patient down, due to a sharp increase in pain, he again assumes a vertical position. On palpation - sharp pain and symptoms: irritation of the peritoneum throughout the abdomen. The urge to urinate is increased. When trying to urinate, drops of urine containing blood are noted.

What is the preliminary diagnosis and what should be done to clarify it? What will be the treatment tactics?

Clinical task 6

A 28-year-old patient was admitted as an emergency with complaints of the inability to urinate independently and bleeding from the external opening of the urethra. Upon questioning, it became known that 4 hours ago in the yard, he stepped on a half-open well hatch cover, fell with one foot into the well, and was hit in the crotch by the edge of the unfolded cover. After which severe pain and copious discharge of blood from the external opening of the urethra appeared, which decreased over time. Attempts to urinate were unsuccessful. Contacted for medical care. Upon examination, there is a hematoma and swelling in the perineal area, dried blood in the area of ​​the external opening of the urethra.

Make a diagnosis. What are the tactics of examination and treatment?

Rice. 15.15. Retrograde urethrogram

patient 22 years old

Clinical task 7

A 22-year-old patient was admitted as planned with complaints of difficulty urinating and weak urine flow. Worsening of urination was noted within 6 months after a perineal injury (fell on a bicycle frame), after which bleeding was observed from the external opening of the urethra. The patient underwent retrograde urethrography (Fig. 15.15).

What is determined on a urethrogram? Establish a diagnosis and choose treatment tactics.