Bladder Trauma
Although the bladder is an abdominal organ in children, bladder trauma is a relatively rare event, occurring in approximately 5 - 7 of pediatric patients assessed for trauma McAleer et al. 1993 . Pelvic fracture, and other concomitant injuries, is associated with bladder rupture in more than 95 of cases. Blunt trauma, secondary to motor vehicle collisions, is the most common cause of bladder rupture in both the pediatric and adult trauma populations Hochberg and Stone 1993 . Depending on the...
Postoperative Urinary Retention
One of the most common presentations of AUR is postoperative UR. This is surprisingly common and can occur associated with up to 23 of anesthetic procedures, with an especially high prevalence in those undergoing epidural or spinal anesthetic Dolin and Cashman 2005 Kim et al. 2006 . It is more likely to occur in patients undergoing major abdominal, pelvic, or lower limb surgery, and is also more likely in those patients receiving opiate analgesia. The precise mechanism of postoperative UR is...
Risk Factors for Urosepsis
Predisposing primary diseases such as advanced age, diabetes mellitus, malignancy, cachexia, immunodeficiency, radiotherapy, cytostatic therapy obstructive uropathy e.g., urethral stricture, benign prostatic hyperplasia BPH , carcinoma of the prostate, urolithia- Precapillary sphincters shut the capillary bed, the blood rushes via precapillary arterial-venous shunts gas exchange and removal of metabolites, e.g., lactate, cease Hyperventilation induces respiratory alkalosis The patient is warm...
Tumors
Any mass originating from the testicle must be presumed to be testicular cancer until otherwise proven, because of the explosive growth and metastatic potential of germ cell testicular cancers. While rare, testis cancers are the most common solid tumor of young adult males. Germ cell tumors make up approximately 95 of all testis tumors and are seminoma, yolk sac, choriocarcinoma, embryonal, and teratoma. Stromal testis tumors are rare and are found almost exclusively in prepubertal individuals....
Scrotal Masses
Inguinal hernias may also present acutely and, if incarcerated, do represent a true surgical emergency. If manual reduction is unsuccessful, ischemic necrosis of the contents of the hernia is a significant concern, and therefore, emergent hernia repair is necessary. Examination will demonstrate an inguinoscrotal mass with a thickened spermatic cord Fig. 8.46 . Occasionally the underlying blood supply to the testis may become compromised and US will not be able to distinguish if concomitant...
Torsion of Testicular Appendages
The most common testicular appendage susceptible to torsion is the appendix testis, which is a remnant of the Mullerian duct. Presentation is usually the same as that for testicular torsion. Patients are most often adolescents and present with the sudden onset of orchalgia. Occasionally, early in the course of the process, before edema has developed, it is possible to palpate the twisted appendage as a small 3- to 5-mm tender area or mass close to the upper pole of the testis. Also, rarely, a...
Spermatocele
Spermatocele is defined as a painless, sperm-containing mass in the caput of the epididymis. They generally occur in middle-aged men and are never seen in children. This lesion is generally not painful and is palpable above the testicle, which is usually palpable. They can reach a massive size and extend up to the external ring. A not uncommon presentation is to have the patient come to the office complaining of the feeling of having a third testicle. Spermatoceles can be thought of diverticula...
Hernia
An inguinal hernia may present as a scrotal mass secondary to loops of bowel within the scrotum. Exam will reveal peristalsis of the scrotum and auscultation will reveal bowel sounds. Direct inguinal hernias result from an acquired weakness in the transversalis fascia at Hesselbach's triangle, bounded by the inguinal ligament, the exterior border of the rectus muscle, and the inferior epigastric vessels, and the peritoneum rarely outpouches beyond the area of the external ring thus scrotal...
Epididymitis 1
Epididymitis is an inflammatory reaction of the epididymis to one of several infectious agents or to local trauma. Acute epididymitis may present at any age, with a sudden onset of pain and swelling of the epididymis in the scrotum. Epididymitis can present in a sexually transmitted form or one associated with urinary tract infections and prostatitis. Thus, eliciting a specific history of sexual exposure or of prior genitourinary tract disease is crucial for diagnosis and appropriate treatment....
Urethral Trauma
The majority of posterior urethral injuries are associated with blunt trauma and shearing forces secondary to pelvic fracture. Complete evaluation of the urinary tract is necessary, as 10 -30 of boys with posterior urethral injuries will also have an associated bladder perforation Baskin and McAninch 1993 . Urethral and bladder neck injuries in females, although quite rare, are typically associated with pelvic fractures and anterior vaginal wall lacerations. Any patient presenting with a...
Varicocele
Varicocele is defined as a dilation of the pampiniform plexus of the veins within and surrounding the spermatic cord secondary to absent or incompetent venous values, which are congenital or acquired, respectively. Varicoceles maybe visible, nonvisible but palpable the classic sign is the so-called scrotal bag of worms, referring to vermiform appearance of the dilated veins , or nonvisible and nonpalpable. Both adults and children present as a scrotal emergency with a varicocele. Varicoceles...
Pseudohermaphroditism
Pediatric urologic emergencies fortunately remain rare occurrences within the emergency department of a hospital or ambulatory care center. More commonly, congenital anomalies noted at birth, or benign lesions that prompt significant parental anxiety such as benign scrotal conditions , often result in a visit to the emergency department for evaluation. These urgencies nonetheless require both the appropriate investigations and management in order to allay patient and parental concern. The...
Exstrophy
Bladder exstrophy represents one of the most significant neonatal urologic anomalies a family may face. It has an overall incidence of 1 in 50,000 births and occurs in a 3-6 1 male to female ratio Engel 1974 Ives et al. 1980 . Cloacal exstrophy occurs even more rarely, with a reported incidence of up to 1 in 400,000 Engel 1974 . However, the incidence appears to be decreasing as more and more patients are being diagnosed prenatally with subsequent parental termination of pregnancy. A number of...
Intravaginal
In this type of torsion, the spermatic cord twists inside the tunica vaginalis. This is thought to occur because of an abnormal attachment of the spermatic cord to the testis, which allows the testis to turn easily within the scrotum. This anatomic relationship, in which the testicle has a transverse lie, is termed the bell-clapper deformity Fig. 12.3 . This horizontal lie is a risk factor for torsion. Generally, intravaginal torsion occurs in children as well as adults, but usually in...
Noncontrast Helical AbdominalPelvic CT
In the emergency room setting, noncontrast helical abdominal pelvic CT has become the examination of choice in the evaluation of flank pain and obstructive anuria Niall et al. 2002 Shokeir et al. 2002, 2004 Coli-stro et al. 2002 . Introduced by Smith and colleagues in 1995, noncontrast CT is quick, relatively easy to interpret, and obviates risks associated with the use of contrast media Smith et al. 1999 . Noncontrast CT is the gold standard in the detection of urinary calculi with an...
i
Continue p-blockers, Dosage 0 if applicable Statins Epiduralcatheter Start p-blocker-therapy or consult cardiologist Perioperative arrhythmias are caused by physiologic and pathologic disturbances or by pharmacologic drug effects. Physiologic disturbances include hypoxemia, hypercapnia, acidosis, hypotension, hypovolemia, electrolyte imbalances, adrenergic stimulation light anesthesia , vagal stimulation, and mechanical irritation chest tube, pulmonary artery catheter . Pathologic cardiac...
Comparison of Temporary Drainage Techniques
Despite limited options, the method for urgent decompression of the obstructed urinary tract is controversial. Proponents of percutaneous nephrostomy suggest that drainage is improved with the larger sized nephro-stomy tube and that complications related to manipulation of a stent across the area of blockage are eliminated i.e., ureteral perforation . In addition, percutaneous nephrostomy can be performed under local anesthesia, which is a true benefit for many patients. In some institutions...
Paraphimosis and Phimosis
Paraphimosis is a frequently encountered condition in the pediatric emergency department. Because of their age and lack of understanding, children have a tendency to neglect to reduce their foreskin following retraction at the time of micturition. Occasionally medical personnel will cause an iatrogenic paraphimosis by inadvertently leaving the foreskin retracted following insertion of an indwelling urethral catheter. Subsequent edema and venous congestion proximally could lead to decreased...