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Bladder tamponade is a pathological condition in which the bladder cavity is completely filled with blood clots. This condition is considered by doctors as urgent, because in connection with it, urinary disorders develop, and sometimes acute urinary 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;
• neoplasms of the bladder;
• varicose veins of the urinary reservoir and prostate gland;
• damage to the prostate capsule due to the fact that the capsule burst.

Bladder cancer is a common cause.

Development mechanism

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

Pressure is constantly exerted on the muscle that relaxes the bladder, as well as on its neck. It is formed due to the fact that it is necessary to overcome the infravesicular blockage. The change in pressure within the bladder and the large volume of the prostate gland create conditions that lead to the rupture of the capsule. As a result, hematuria occurs.

Symptoms

The main manifestations of bladder tamponade will be pain when trying to urinate, the urge either does not give an effect, or a small amount of urine is released. On palpation above the pubis, a bulge is determined, this is an overflowing bladder. At the slightest pressure on it, pain occurs. A person with bladder tamponade is emotionally labile and restless.

Based on the determination of the volume of blood in the bladder, the degree of blood loss is determined. The urine contains fresh or altered blood impurities. It should be borne in mind that the tamponade of the urinary reservoir suggests bleeding. The capacity of the bladder in males 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;
• palpitations;
• weakness and apathy;
• dizziness;
• increased heart rate.

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

Anemia is one of the complications of a pathological condition

How is it diagnosed?

Bladder tamponade is determined on the basis of complaints, questioning. As a rule, the doctor finds out that there have already been cases of blood in the urine. On examination, expressed soreness when pressed in the womb, a pale and unhealthy appearance of the patient, draws on itself.

Blood is observed in the urinary fluid. When examining men with a finger through the rectum, the doctor determines the prostate gland, which is larger than normal size.

The attending physician necessarily prescribes blood and urine tests. In the general analysis of blood, there is a decrease in the level of hemoglobin, erythrocyte elements. There is also a pronounced increase in the level of leukocytes in the blood, a shift in the formula of leukocytes to the left and a high level of erythrocyte sedimentation rate. This is due to the inflammatory process in the bladder.

In the biochemical analysis of blood, the level of creatinine and uric acid increases. This is due to 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 ultrasound, you can see an enlarged prostate due to adenoma. In the urine reservoir, blood clots are observed in the form of elements of different echogenicity.

With the help of ultrasound, it is possible to assume quite accurately the amount of blood that is in the bladder cavity. But examination of the kidneys allows you to diagnose a blockage of the urinary tract above the urine reservoir itself.

On ultrasound, this obstruction will be visible as an expansion on both sides. The calyx-pelvic system and ureters expand. This type of diagnosis also detects neoplasms, if any.

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

Treatment

Therapeutic measures are of an operational nature. Distinguish between urgent and delayed surgical treatment. The urgent is to revise the urine reservoir and remove the adenoma.

Hemostatics - medications used for bleeding in various types

But the delayed one involves cleansing the bladder from blood through the urethra in parallel with antibiotic and hemostatic therapy. Lost blood replacement is also used. If the bleeding is stopped, then there is time for a full examination and delayed intervention. Tamponade is a very dangerous condition that requires immediate treatment. At the first sign, see your doctor.

15.1. RENAL COLIC

Renal colic- Acute pain syndrome resulting from a sudden disturbance of the outflow of urine from the renal calyx-pelvis system as a result of ureteral obstruction.

Etiology and pathogenesis. The most common obstacle to the passage of urine are stones of 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 with kidney tuberculosis, tumor pieces, membranes of cysts, etc. from the outside, 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 result, there is an overstretching of the ureter, renal pelvis and calyces above the site of obstruction. Muscle contractions, turning into spasm of the cups, renal pelvis and ureter in response to an obstacle, further increase the pressure in the urinary tract, which causes pyelovenous reflux, and renal hemodynamics begins to suffer. The blood supply in the kidney is disrupted, and significant interstitial edema develops, manifested by parenchymal hypoxia. Thus, the disorder of urodynamics disrupts the renal circulation, the trophism of the organ suffers. The edematous renal tissue is compressed within the surrounding dense fibrous capsule. Overstretching and compression of 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. Of the predisposing factors contributing to its occurrence, it should be noted physical stress, running, jumping, outdoor games, driving on a bad, shaky road.

renal colic is characterized by a sudden onset of severe paroxysmal pain in one of the sides of the lumbar region. It immediately reaches such intensity that patients are not able to tolerate it, behave restlessly, rush, constantly change their 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 can be localized not in the lumbar region, but in the hypochondrium or in the flank of the abdomen. Its typical irradiation is down the ureter, into the iliac and groin regions on the same side, along the inner surface of the thigh, into the testicle, the glans penis in men and into the labia majora in women. Such irradiation of pain is associated with irritation of the branches. n. genitofemoralis. A definite dependence of the localization and irradiation of pain in renal colic on the location of a stone in the urinary tract was noted. When it is located in the pelvis or the adjoining part of the ureter, the greatest intensity of pain is noted in the lumbar region and hypochondrium. As the stone passes through the ureter, the downward irradiation increases, to the genitals, thigh, groin area, and frequent urination joins.

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

Dyspeptic phenomena in the form of nausea, vomiting, stool retention and gas with bloating often accompany an attack of renal colic and require a differential diagnosis between renal colic and acute diseases of the abdominal organs. The body temperature is usually normal, but if a urinary tract infection is present, it may rise.

Having started unexpectedly, the pain can also suddenly stop due to a change in the position of the stone with a 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 dull, which then disappears or aggravates again. In some cases, the attacks can be repeated, follow one after the other at short intervals, completely exhausting the patients. In this case, the clinical picture of renal colic can change, which depends on the movement of the stone along the urinary tract. However, the attack of renal colic is not always typical, which makes it difficult to recognize.

Diagnostics renal colic and the diseases that caused it, is based on a 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 had similar attacks of pain before, whether he underwent examinations in this regard, whether there was previously a discharge of stones, whether there are other diseases of the kidneys and urinary tract.

Objective examination in some cases allows palpation of an enlarged painful kidney. On palpation at the time of an attack of renal colic, there is a sharp soreness in the lumbar region and the corresponding half of the abdomen and often moderate muscle tension. Symptoms of peritoneal irritation are not observed. The symptom of tapping in the lumbar region on the side of the attack (Pasternatsky's symptom) is positive. Changes in the urine are very characteristic of renal colic. The appearance of bloody, cloudy urine with abundant sediment or the passage of stones during or after an attack confirms renal colic. Hematuria can be of varying intensity - more often micro- and less often macroscopic. Red blood cells in urine, as a rule, are unchanged. If there is an infection in the urinary tract, leukocytes may be found in the urine.

It should be borne in mind that even in the presence of an infection in the kidney, if the lumen of the ureter is completely obturated, the composition of urine may be normal, since urine secreted only by a healthy kidney enters the bladder. In the blood, leukocytosis, an increase in ESR can be observed.

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

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

The ultrasound picture in renal colic is characterized by varying degrees of severity of the expansion of the calyx-pelvis system. The stone can be located in the pelvis, dilated parochal or prevesical ureter. With dynamic scintigraphy, there is a sharp decrease or complete absence of kidney function on the side of colic.

X-ray examination is of exceptional importance for diagnosis. An overview 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 picture, so it should be taken on a large film (30 x 40 cm). With good preparation, the overview image shows clearly defined shadows of the kidneys, the edges of the lumbar-iliac muscles. In case of renal colic, shadows of calculi may be detected on a plain radiograph in the projection of the proposed 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 the belonging of the shadow of the alleged calculus to the urinary tract, determined on the survey image, the separate state of the excretory function of each kidney, the effect 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, kink, ureteral stricture, etc.), the correct diagnosis can be made using urography. The anatomical state of the kidneys and ureters with excretory urography can be determined in cases where the kidney is functioning and excretes a contrast agent in the urine. At the height of renal colic, kidney function may be temporarily absent as a result of high pressure in the calyx-pelvic system (blocked, or "mute", 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 the installation of multispiral 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. With cystoscopy, an infringement of calculus in the intramural ureter can be seen, often the mouth is elevated, its edges are hyperemic, edematous. This swelling extends to the surrounding bladder mucosa. Sometimes in the gaping mouth it is possible to see a restrained calculus (Fig. 16, see color insert). In some cases, mucus may be released from the mouth, cloudy

urine or urine stained with blood. Determination of the function of the kidney and ureters 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 of calculus is in doubt, catheterization of the ureter is performed. In this case, the catheter can stop near the stone, or sometimes it can be passed higher. After that, survey x-rays of the corresponding section of the urinary tract are made in two projections. The diagnosis of ureterolithiasis is established if the shadows of the alleged calculus and the catheter are aligned on the images. The discrepancy between these shadows excludes the presence of calculus in the ureter. In cases where a stone can be moved upward into the pelvis with a catheter and its shadow disappears from the projection of the ureter, appearing in the kidney area, and an attack of renal colic immediately passes, the diagnosis of urolithiasis is beyond doubt. Retrograde ureteropyelography is performed to clarify the diagnosis, as well as to obtain information about the state of the renal calyx-pelvic system and the ureter.

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

Pain with appendicitis may resemble that of renal colic in the case of a high retrocecal and retroperitoneal location of the appendix. The nature of the development and the intensity of pain are important differential diagnostic signs. With appendicitis, it often develops gradually and rarely reaches such strength as with renal colic. Even in cases where the pain is severe enough, it is still bearable. Patients with acute appendicitis, as a rule, lie quietly in the chosen position. Patients with renal colic are more often restless, constantly changing body position, and do not find a place for themselves. Dysuria in acute appendicitis appears rarely, although it is possible with the pelvic appendix. A characteristic symptom of acute appendicitis is tachycardia, which almost never occurs with renal colic. Vomiting with both diseases occurs almost always, but with appendicitis it is more often single, and with renal colic it is repeated many times at the height of continuing attacks of pain. Deep palpation of the abdomen in the right iliac region with 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 resting in the lumbar region from 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.

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

Difficulties in the differential diagnosis of renal colic with perforated ulcer of the stomach and duodenum. Anamnesis and clinical picture of the disease are of great importance in such cases. A perforated ulcer is characterized by a "dagger" character of pain in the epigastric region. Typical for this disease is rare, single and not abundant 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 ulcerative history. Patients are inactive, they seem to be afraid to change the position of the body in bed. The abdominal wall in the epigastric region, and sometimes throughout the abdomen, is tense, the symptoms of peritoneal irritation are sharply expressed. The disappearance of hepatic dullness is observed, and an X-ray examination reveals free gas in the right subphrenic 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 shingles in nature. The abdomen is swollen, its soreness and muscle tension in the right hypochondrium are noted. 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 due to the fact that the clinical picture of these diseases has a lot in common: abrupt bloating, vomiting, flatulence, intestinal paresis, gas and stool retention. However, with intestinal obstruction, the patient's condition caused by intoxication is more severe. Pain with intestinal obstruction is of a cramping character, in some cases its 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 thoroughly collected history helps to establish the 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 reveals a strangled, tense, painful hernial sac.

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

Treatment. Relief of renal colic should begin with thermal treatments. 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, blood vessels of the skin and internal organs is especially clearly manifested during local thermal hydroprocedures (for example, when the lumbar region is warmed, the skin vessels, kidney vessels 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 (ciston, cystenal, phytolysin), which make it possible to relieve well renal colic.

Chlorethyl and intradermal novocaine blockade. The effect of parenterally administered drugs (excluding intravenous injections) begins to manifest itself only after 20-40 minutes, therefore, it is very rational to simultaneously carry out the rapidly manifesting properties of chloroethyl or intradermal novocaine blockade. Particular attention should be paid to paravertebral chloroethyl blockade, which is a good aid in urgent care 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 chloroethyl 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 internal organs. As you know, the sympathetic innervation of the kidney and ureter refers to the X-XI-XII thoracic and I lumbar segments of the spinal cord, projecting onto the skin as a zone from the corresponding vertebrae anteriorly through the costoiliac space onto the anterior abdominal wall.

In cases where renal colic does not stop, a novocai-new blockade of the spermatic cord in men and the round ligament of the uterus in women (Lorin-Epstein blockade) is performed, which is especially effective in localizing the stone in the lower third of the ureter.

The most effective pathogenetic treatment of renal colic in stationary conditions is the restoration of the outflow of urine from the kidney by catheterization, 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 (erythrocytes) 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 elderly people.

Classification. By the amount of blood in the urine, they are divided:

■ macrohematuria- its presence in urine is determined visually;

■ microhematuria- microscopy of the sediment of the general analysis of urine detects more than 3 erythrocytes in the field of view, and in the study of urine according to Nechiporenko - more than 1,000 erythrocytes in 1 ml of an average portion of urine.

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

Initial hematuria- blood is determined in the first portion of urine. Such hematuria occurs when the 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 bladder neck 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 parenchyma of the kidney, renal pelvis, ureter and bladder. In some cases, the source of hematuria can be identified by the shape of the clots. A worm-like blood clot, which is a cast of the ureter, is 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. Allocate hematuria glomerular and extra-glomerular genesis. In the first case, it is caused by nephrological diseases: acute glomerulonephritis, systemic lupus erythematosus, essential mixed cryoglobulinemia, hemolytic uremic syndrome, Alport disease, etc.

Hematuria extraglomerular genesis develops with diseases of the blood system (leukemia, sickle cell anemia, decreased blood clotting), taking antiplatelet agents and anticoagulants, vascular diseases (renal artery stenosis, renal artery or vein thrombosis, 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, ICD, hydronephrosis, adenoma and prostate cancer, etc.

Diagnostics. First of all, urethrorrhagia should be distinguished from hematuria. Urethrorrhagia is called the discharge of blood from the urethra, regardless of the act of urination. Blood can be discharged in drops or in a stream, 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 its sediment reveals an accumulation of hemoglobin or "pigment casts" 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 together 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 reddish-brown. Myoglobinuria is observed with a syndrome of prolonged compression, crushing of tissues and is associated with the ingress of striated muscle pigment into the urine. Admixture of blood to semen (hemospermia), giving it a color from pink to brown, may indicate inflammation of the seminal vesicles or prostate gland, seminal tubercle, or oncological lesions of the listed organs.

Further, in a patient with gross hematuria, it is necessary to visually assess the color of urine, which can change when eating certain foods (beets, rhubarb) and taking medications (nitroxoline, madder dye, senna). Depending on the amount of blood in the urine, its color changes from pale pink to deep red, cherry. Establishing 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 in hematuria are of some importance. In some cases, an admixture of blood in the urine appears after a painful attack, usually caused by a pelvis or ureter stone. In this case, blood in the urine can appear as a result of both microtraumas of the pelvis or ureter wall with a stone, and 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, the so-called painless hematuria is observed. In this case, an admixture of blood in the urine occurs against the background of subjective well-being, and pain can develop already 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 ICD, pain first occurs 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). Strengthening of dysuric phenomena or the occurrence of imperative urges during movement indicate the possible presence of a stone in the bladder. Dull pain over the bosom, 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 study in 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. Edema, increased blood pressure are signs of a probable nephrological disease, and an increase in lymph nodes is characteristic of infectious, oncological or blood diseases. Palpation of the abdomen reveals an enlarged liver, spleen, tumors of the abdominal cavity and retroperitoneal space. Male patients need a digital rectal examination and women a vaginal examination. In addition, all patients undergo an examination of the external opening of the urethra.

The presence of hematuria is confirmed by the data of the general analysis of urine and microscopy of its sediment. Additional diagnostic value are urine studies according to Nechiporenko (the content of erythrocytes in 1 ml of urine) and according to Addi-su-Kakovsky (the content of erythrocytes in the total volume of urine excreted by the patient per day). In the general analysis of urine, attention is paid to the protein content, since with severe proteinuria, the likelihood of nephrological disease is high. In doubtful cases, a proteinuria selectivity test should be performed. Microscopy of the sediment using a state-of-the-art phase contrast microscope makes it possible to establish the state of the red blood cells in the urine. When unchanged erythrocytes are detected, there is a high probability of urological disease with the location of the source of hematuria in the kidneys and urinary tract; the presence of altered erythrocytes and casts in the sediment indicates a nephrological disease. Leukocyturia and pyuria indicate a urinary tract infection. If these changes are detected in the analysis of urine, a bacteriological study is shown to determine the sensitivity to antibiotics.

An important role in the diagnosis of urological diseases that caused hematuria is played by ultrasound. It allows you to determine the shape, structure, location and size of the kidneys, the state of their calyx-pelvic systems, the presence and location of calculi, cysts, tumors, prolapse or abnormalities of the kidneys. At the same time, with the help of this method, it is possible to distinguish between a tumor and a cyst with the greatest reliability, to clarify the localization of stones in the urinary tract, including those that are radiopaque. 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. An obligatory and valuable diagnostic method for macrohematuria is cystoscopy, which makes it possible to determine the source of bleeding.

Treatment. Macrohematuria 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 (adroxone), etamzilat (dicinone), epsilon-aminocaproic acid, vicasol, tranexamic acid, vitamin C, blood plasma, etc.

The volume and nature of surgical treatment depend on the identified disease, which was the cause of hematuria.

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

15.3. ACUTE DELAYED URINARY

Acute urinary retention (ishuria)- the impossibility of an independent act of urination with an overflowing bladder. It may come on 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.

Allocate acute and chronic delay in urination. The first is manifested by the inability to urinate independently with strong urge to urinate, overflow of the bladder and bursting pains in the lower abdomen. In cases where, during urination, part of the urine is excreted, and some of it remains in the bladder, they speak of chronic urinary retention. The urine that remains in the bladder after urinating is called residual urine. Its amount can be from 50 ml to 1.5-2.0 liters, and sometimes more.

Etiology and pathogenesis. Acute urinary retention occurs as a result of urological diseases or pathological conditions that cause a violation of the innervation of the sphincter and detrusor of the bladder. Most often it develops in 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 peri-vesicular diseases in women.

Ruptured urethra and bladder often lead to urinary retention. And yet it is most often observed with benign hyperplasia (adenoma) of the prostate gland. The provoking factors of its development in this disease are spicy plentiful food, alcohol, cooling, prolonged sitting or lying, disruption of the intestines,

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

The causes of urinary retention can be diseases of the central nervous system (organic and functional) and urinary 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. Often, acute urinary retention is observed in the postoperative period, including in young people. This delay is of a reflex nature and, as a rule, disappears after spontaneous urination or several catheterizations.

Symptoms and clinical course acute urinary retention is fairly common. Patients complain of severe pain in the lower abdomen, excruciating, sterile urge to urinate, a feeling of fullness and distention of the bladder. The urgency to urinate increases and quickly becomes unbearable for patients. Their behavior is restless. Suffering from overstretching of the bladder and fruitless attempts to empty it, patients groan, take a variety of positions to urinate (lie down, kneel down, squat down), press on the bladder area, squeeze the penis. The pains then subside, then they repeat again with greater force. A similar condition never occurs with anuria or acute urinary retention caused by a violation of the innervation of the bladder.

An objective study, especially in patients with low nutrition, determines the change in the configuration of the lower abdomen. In the suprapubic region, swelling is clearly visible due to an enlarged bladder. Percussion above it is determined by a dull sound. Palpation usually produces a painful urge to urinate. Sometimes patients experience reflexive inhibition of intestinal activity with bloating.

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

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

number and 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 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 urine. In such patients, an overflowing bladder is sometimes determined visually as a round formation in the suprapubic region.

In the diagnosis of diseases of the prostate gland, 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. Violation of the act of urination with bladder stones largely depends on the location and size of the stone. When urinating, there is an intermittency and laying of a stream of urine. If a stone wedges into the inner 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 the position of the body changes, the stone can move back into the bladder, and urination in this case is restored. If the stone moves outside the bladder into the urethra and completely closes its lumen, then acute urinary retention is persistent.

Ruptures of the urethra, post-traumatic strictures and narrowing of other origins are often complicated by acute urinary retention. The diagnosis in such cases is established on the basis of anamnesis data, 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 in the neck of the bladder can close the inner opening of the urethra and cause urinary retention. In bladder cancer, urinary retention can be caused by both the proliferation of the bladder neck by a tumor and 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 with diseases and injuries of the spinal cord.

Differential diagnosis acute urinary retention should be carried out with anuria. And with that, and with another condition, the patient does not urinate. However, with acute urinary retention, the bladder is full, the patient feels bursting pains in the lower abdomen and strong urge to urinate, but cannot urinate due to an obstruction in the bladder neck or urethra. With anuria, urine does not flow from the kidneys and upper urinary tract into the bladder, it is empty, there is no urge to urinate.

Treatment. The provision of emergency care for patients with acute urinary retention consists in its evacuation from the bladder. Emptying

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

The most frequent and less traumatic method is bladder catheterization 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 an indwelling catheter for a short time. If the act of urination is not restored, it may be necessary to re-catheterize. The presence of purulent inflammation of the urethra (urethritis), inflammation of the epididymis (epididymitis), the testicle itself (orchitis), as well as an abscess of the prostate gland is a contraindication for catheterization. It is contraindicated in the case of a ruptured urethra. Bladder catheterization is performed in compliance with the rules of asepsis. Attempts to forcefully insert the catheter should be avoided as this can injure 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 fails or is contraindicated, the patient should be referred to a 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 that led to acute urinary retention

15.4. ANURIA

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

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

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

Prerenal (vascular) anuria caused by a violation of 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 due to toxic damage to the kidney 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. The main reasons prerenal anuria are cardiogenic or traumatic shock, embolism and renal thrombosis

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 caused by exposure to the kidney of toxic substances: 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, a syndrome of prolonged compression, and nontraumatic, associated with muscle damage during prolonged alcohol or drug coma. Renal anuria can be caused by acute glomerulonephritis, lupus nephritis, chronic pyelonephritis with wrinkling of the kidneys, etc.

Postrenal anuria develops as a result of impaired outflow of urine from the kidneys due to obstruction of the ureter (s) with stones, tumors of the upper urinary tract, bladder, prostate, compression of them by neoplasms of female genital organs, metastatic enlarged lymph nodes and other formations, as well as due to cicatricial strictures and obliteration ureters. With this type of anuria, there is a sharp expansion of the ureters and pelvis with pronounced interstitial edema of the renal parenchyma. If the outflow of urine is restored quickly enough, the changes in the kidneys are reversible, however, 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, imbalance in water and electrolyte balance, intoxication and uremia (see chapter 13.1).

Diagnostics and differential diagnostics are carried out on an emergency basis. First of all, anuria should be distinguished from acute urinary retention. The latter is characterized by the fact that there is urine in the bladder, moreover, it is overflowing, which is why the 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. Finally, palpation and percussion over the bosom, ultrasound and catheterization of the bladder make it possible to distinguish between these two conditions.

After the diagnosis of anuria is confirmed, you should find out its cause. First of all, it is necessary to carry out differential diagnosis of post-renal anuria from its other types. For this purpose, 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 expansion of the calyx-pelvic system. An even more objective test is bilateral ureteral catheterization. With the free passage of the ureteral catheters to the pelvis and in the absence of urine flow through them, postrenal anuria can be rejected with confidence. On the contrary, if the catheter detects an obstacle along the ureter (s), you should try to push it higher, thereby eliminating the cause of the anuria.

The final diagnosis is assisted by multispiral CT, MRI, renal angiography, and renal scintigraphy. These methods provide information about the state of the vascular bed of the kidney (prerenal form), its parenchyma (renal form) and ureteral patency (postrenal form).

Treatment should be aimed at eliminating the cause that caused the development of anuria. In case of shock, the main one is therapy 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, they must be removed by washing the stomach and intestines. Unithiol is a universal antidote for poisoning with heavy metal salts.

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

The indication for hemodialysis is an increase in the potassium content of more than 7 mmol / l, urea up 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 prophylactic hemodialysis, which prevents the development of severe metabolic complications.

Forecast favorable for the rapid elimination of 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. TORTURE OF THE SEED ROOM AND EGGS

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

Etiology and pathogenesis. Distinguish between extravaginal and intravaginal testicular torsion.

Extravaginal testicular torsion it is usually observed in children under one year old 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 than the testicle.

Much more often observed intravaginal torsion, due to the anatomical and functional characteristics of the child's body and therefore

more common in children than in adults. Intravaginal torsion is facilitated by the relatively long length of the spermatic cord in children, combined with its high connection with the vaginal membrane, stronger than in adults, the contractile ability of the muscle supporting the testicle, as well as weak fixation of the epididymis to the skin of the scrotum. The subsequent obstruction 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 injury. The main symptom of the onset 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 palpable at the upper edge of the scrotum, which is associated with a 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 join.

Diagnostics and differential diagnostics. In addition to clinical manifestations in this pathology, it is necessary to take into account the data of the anamnesis. The presence in the past of sudden pain in the testicle, which disappeared on its own, should suggest a predisposition to torsion. Testicular torsion, mistaken for inflammation and treated conservatively, always ends in organ necrosis.

Differentiate testicular torsion primarily with acute epididymitis and orchitis. With these diseases, there are all the signs of acute inflammation: testicular enlargement, scrotal edema, hyperemia of its skin and high body temperature.

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 onset of torsion, testicular viability is restored, otherwise testicular necrosis develops, followed by its atrophy.

15.6. PRIAPISM

Priapism- an acute disease consisting in a prolonged pathological erection without sexual desire and sexual satisfaction. An erection can last from several hours to several days, does not go away after intercourse and does 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. Priapism is caused by: 1) pathology of the nervous system and psychogenic disorders; 2) intoxication; 3) hematological diseases; 4) local factors. The former include diseases leading to the stimulation of the corresponding areas of the spinal cord and brain (trauma, tumors, dorsal tabes, multiple sclerosis, meningitis, etc.), hysteria, neurasthenia, psychoneurosis on the basis of erotic fantasies. The second - poisoning with chemicals, drugs, alcohol intoxication. The third group of factors is made up of diseases

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

Classification. Priapism is classified as 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 blood flow rate decreases sharply and can completely stop. As a result, ischemia occurs, fibrosis of the corpora cavernosa and organic erectile dysfunction develop. Already after 12 hours, changes appear in the tissues, and after 24 hours irreversible consequences occur.

Non-ischemic(arterial, high-flow) priapism occurs when the penis or perineum is traumatized with damage to the arteries, as a result of which an arterio-lacunar fistula is formed. With this type of priapism, tissue trophic disturbances are insignificant.

Relapsing(intermittent, or recurrent) priapism is an ischemic variant. It is characterized by an undulating course: long periods of painful erection are replaced 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 comes on suddenly and can continue for a long time, completely exhausting the patient. A pathological erection is accompanied by severe pain in the penis, sacral region. The penis becomes tense, sharply painful, its skin becomes cyanotic. The direction of the penis is arcuate, at an acute angle to the abdomen. The head of the penis and the spongy body of the urethra are soft, relaxed. Urination is not impaired. The development of priapism is determined by the inadequacy of the inflow and outflow of blood into the corpora cavernosa.

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

Diagnostics based on patient complaints and examination. In the differential diagnosis of ischemic and non-ischemic priapism, Doppler and gas measurements of blood aspirated from the corpora cavernosa are used. With arterial priapism, the echographic picture will indicate a violation of the integrity of the arteries of the penis. The oxygen partial pressure and blood pH do not change. Veno-occlusive priapism is characterized by hypoxia and acidosis. Long-term local hypoxia of the 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.Emergency conservative therapy includes

sedative and analgesic drugs, anticoagulants, local hypothermia, antibiotic and anti-inflammatory therapy, as well as drugs that improve microcirculation and rheological properties of blood; a-adrenomimetics are administered intracavernously.

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

Forecast favorable in terms of eliminating the disease and questionable with respect to erectile function. With the development of organic impotence, they resort to falloprosthetics.

15.7. INJURIES OF THE Urogenital Organs

Damage to the genitourinary system accounts for 1.5-3% in the total structure of injuries of all human organs. In peacetime, 75-80% of victims suffer from injuries during road traffic accidents and falls from a height. In 60-70% of cases, injuries are combined or multiple, for the most part there are damage to the kidneys and urinary tract.

Classification. Localization distinguishes trauma to the kidneys, ureters, bladder, urethra and male genital organs.

Depending on the presence of a wound channel that communicates the damage zone with the external environment, closed and open injury.

Injuries can be isolated, multiple and combined. Isolated injury of 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 region, for example, an injury to the kidney and abdominal organs. Combined simultaneous injuries to organs located in different anatomical regions are considered, for example, damage to the bladder and traumatic brain injury.

Depending on the severity of the urinary trauma, 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 occurs most often and accounts for about 60-65% of the structure of damage to the urinary system. In peacetime, closed kidney injuries prevail, and in wartime - open kidney injuries.

Etiology and pathogenesis. Closed kidney damage usually occurs as a result of the application of force to the lower back or abdomen 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 parenchyma of the kidney, surrounded by a dense fibrous capsule. Direct impact and detonation of the fluid inside the organ lead to rupture of the fibrous capsule and renal parenchyma. In a domestic environment, injury often occurs as a result of a fall by the lumbar region on a protruding solid object. The rupture of an organ occurs as a result of a direct impact and the damaging action of adjacent bone structures - the ribs and the spine.

Kidney damage can occur as a result of minimally invasive and endoscopic methods of diagnosis and treatment of urological diseases, which are now widespread. First of all, they are associated with careless or erroneous actions of the doctor. After remote shock wave nephrolithotripsy, subcapsular hematomas are often diagnosed, and the hematuria that always occurs after it may be the result of not only the damaging effect on the urothelium of the stone and its fragments, but also ruptures of the fornix. Injury of the renal parenchyma can be observed during ureteral catheterization (stenting), ureteroscopy, nephroscopy, nephrobiopsy, and even with perirenal blockade.

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

Open injuries - knife or gunshot - are usually multiple in nature.

Classification. Clinical and anatomical classification of closed kidney injuries is based on the severity of the organ injury. Distinguish bruises and breaks kidneys (Fig. 67, see color insert). The contusion is characterized by a sharp concussion (contusion) of the organ without rupture of the parenchyma of the kidney, its capsule and cavity system. Clinically significant damage to the kidney is observed only with its ruptures, from microscopic tears of the parenchyma and fornix to crushing of the organ. From this point of view, the appearance of subcapsular and perirenal hematomas, as well as hematuria, is always a consequence of, even if insignificant, 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 kidney capsule with the formation of a perinephral hematoma;

v- internal rupture of the parenchyma and fornix, opening into the cavity system of the kidney (hematuria);

G- Penetrating rupture of the capsule, parenchyma and cavity system of the kidney with the formation of perirenal urohematoma (hematuria);

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

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

Rice. 15.1. Types of kidney rupture

The most severe forms of kidney damage are its crushing, that is, the formation of multiple organ ruptures that penetrate into the calyx-pelvic system with possible separation of the parenchyma (pole) sections, and rupture (detachment) 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 damage to the kidney and the presence of injuries to other organs. Patients complain of pain in the lumbar region and / or in the abdomen, aggravated by deep breathing, bloating, nausea, vomiting, general weakness. Total hematuria is observed with severe kidney damage (Fig. 15.1, c-f). Macrohematuria serves as a sign of the severity of organ damage, in turn being one of the determining factors of the severity of the victim's condition. At the same time, in some cases, the degree of hematuria does not correspond to the degree of kidney damage. With small fornical ruptures, persistent pronounced hematuria can be observed, and, conversely, with crushing of the kidney, hematuria

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

The rupture of a vascular-rich parenchymal organ, such as the kidney, is accompanied by signs of internal bleeding. In combination with severe hematuria, it can quickly lead to anemization and a serious condition of the patient, which is manifested by pallor of the skin, cold sweat, tachycardia, a decrease in blood pressure, and an increase in retroperitoneal urohematoma. An objective examination on the skin of the abdomen and lumbar region may reveal abrasions, hemorrhages, tissue edema, as well as swelling in this area caused by a large urohematoma. The location and course of the wound channel with the outflow of urine from it makes it possible to suspect an open kidney injury. Palpation of the chest and spine can be accompanied by sharp pain due to the fracture of these bone formations. On palpation of the abdomen, pain and protective tension of the muscles on the side of the lesion are determined, and with large urohematomas, a rounded formation in the hypochondrium and lumbar region.

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

Diagnostics. In diagnostics, attention is paid to the type and nature of the injury, its objective local and general manifestations. In blood tests, a decrease in the number of erythrocytes and hemoglobin is determined, at a later date from the moment of injury, leukocytosis joins. In the analysis of urine, red blood cells cover the entire field of view. The total renal function makes it possible to assess the determination of residual nitrogen, urea and serum creatinine, which is especially important to know in case of damage to a single kidney and planning of surgical treatment.

Radiation methods are the main ones in making the diagnosis of a ruptured kidney. They allow, firstly, to determine the degree of kidney damage, and secondly

rykh, to assess the separate function of the damaged and contralateral kidneys, thirdly, to monitor the dynamics of the wound process in order to diagnose complications early and correct them in a timely manner. The most affordable, minimally invasive and fastest method for diagnosing kidney damage - Ultrasound. With its help, you can identify sub-capsular and perirenal uro-hematomas (Fig.15.2), determine the size, deformation of the contours of the kidney, parenchymal defects, deformation of the calyx-pelvic system, the degree of its ectasia, detect clots

Rice. 15.2. Sonogram. Perirenal urohematoma (arrow)

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

blood. Comparison of the ultrasound results with the anamnesis, physical examination data and the severity of bleeding often makes it possible to establish a diagnosis and, in a serious condition of the patient, proceed to an emergency operation without other examination methods.

In all cases, patients with suspected renal injury should perform plain radiography abdominal and retroperitoneal space. With its help, it is possible to identify scoliosis, the absence of the contour of the kidney and the psoas major muscle, fractures of the lower ribs, transverse processes of the vertebrae and pelvic bones. Excretory urography allows you to detect deformation and squeezing of the cups and pelvis, contrast streaks on the affected side (Fig.15.3), to assess the function of the damaged and contralateral kidneys, which is important in determining

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

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

research methods. It can be used to clarify the degree of kidney damage, if excretory urography is not informative and CT, MRI and angiography are unavailable due to the urgency of the situation or their absence in this hospital.

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

Rice. 15.4. CT with contrast, frontal projection. Ruptured left kidney (arrow)

Rice. 15.5. Contrast-enhanced CT, axial projection. Extravasation of contrast medium due to rupture of the left kidney

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

Kidney angiography allows, in addition to diagnosing damage to the

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

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

Rice. 15.6. Contrast-enhanced multispiral CT:

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

Rice. 15.7. Kidney angiograms:

a- ruptures of the 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 is indicated for small ruptures of an organ with subcapsular or perirenal hematoma up to 300 ml in volume and moderate hematuria (see Fig. 15.1, a-c). Prescribe strict bed rest for two weeks, cold to the lumbar region, hemostatic, antibacterial and improving microcirculation in the kidney. In the course of treatment, constant dynamic monitoring is required, including an assessment of the state of hemodynamics, blood and urine tests, and ultrasound monitoring. It should be remembered about the possibility of the so-called two-stage organ damage, which means rupture of the fibrous capsule over the subcapsular hematoma with renewed 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 10-15% of patients with severe kidney injury. 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 perrenal hematoma with the formation of a perinephral 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 ones include percutaneous puncture and drainage of hematoma or post-traumatic perirenal abscess; laparoscopic (lumboscopic) suturing of a ruptured kidney or nephrectomy, evacuation and drainage of the hematoma; arteriography and selective embolization of a bleeding renal vessel.

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

Even now, nephrectomy is most often performed with kidney injury. It is performed in approximately 50% of patients who undergo emergency lumbotomy (laparotomy) for organ rupture. The kidney is removed in the event of a 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 rapidly increasing, life-threatening bleeding, especially with associated injuries. In some cases, in district and small city hospitals, nephrectomy is performed without proper revision 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 concomitant intraperitoneal injuries. During the operation, the revision of the kidney is mandatory if there is a growing retroperitoneal hematoma of large size. If nephrectomy is planned after revision of the retroperitoneal space and kidney, it is necessary to assess 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 emergency cases 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 to the kidney, it is necessary to take into account the cavitation effect of a bullet, a fragment, that is, concussion, crushing of the parenchyma due to the impact of a pulsating cavity. In such cases, surgical treatment of the wound channel is necessary, including, in addition to stopping bleeding, excision of non-viable tissues and removal of foreign bodies.

Forecast depends on the degree of kidney damage and the correct treatment. Conservative therapy for small breaks and organ-preserving surgical treatment make the prognosis for the anatomical and functional state of the kidney favorable. With pronounced organ ruptures and massive bleeding, the prognosis for the patient's life is determined by timely surgical intervention.

15.7.2. Damage to the ureters

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

Etiology and pathogenesis. Open injuries of the ureters are extremely rare, as a rule, 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 from all combat injuries of the genitourinary system during the period of modern hostilities. Not much more often observed and closed damage to the ureters as a result of external influences due to their anatomical and topographic 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 areiatrogenic character, that is, it occurs as a result of accidental damage during surgery. Ligation, dissection, or transection of the ureter is most commonly seen during obstetric-gynecological and surgical procedures. Damage to it as a result of endourological diagnostic and therapeutic interventions (ureteroscopy, stenting and ureteral catheterization) should be regarded as a complication during manipulation.

Symptoms and clinical course. Ureteral injuries are manifested by pain in the lumbar region associated with impaired outflow of urine from the corresponding kidney, and short-term hematuria. With open wounds, trauma to the ureter is almost always combined and manifests itself as a clinic of retroperitoneal urinary leakage or urine leakage from the wound.

The symptomatology of iatrogenic ureteral injuries depends on the nature of their damage. The dressing is accompanied by a clinical picture of renal colic. Ureteral lesions not detected during surgery are manifested by the release of urine through drains from the abdominal cavity or retroperitoneal space already in the first hours after the operation. The outflow 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, followed by the development of urosepsis. A formidable symptom of ureteral obstruction is post-renal anuria. It can occur in patients with ureteral obstruction of a solitary kidney or with bilateral ureteral injury.

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

Rice. 15.8. Antegrade pyeloureterogram on the right.

Extravasation of contrast medium (arrow) as a result of injury to the parochal ureter

the damaged ureter is not secreted. Catheterization the ureter allows you to establish the degree and localization of its damage.

At Ultrasound revealing hydrouretero-nephrosis when ligating the ureter or the presence of fluid (urine) in the paranephral tissue and abdominal cavity.

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

Treatment damage to the ureters depends on their type, location and time elapsed since the injury. When open

injuries require urine diversion by puncture nephrostomy and drainage of urinary leakage. After the wound has healed, an operation is performed to restore the patency of the ureter. The marginal injuries of the ureter, which occurred as a result of endourological operations, close independently after the stent is inserted.

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, with more extensive defects or ligation of the ureter, resection of its altered areas is performed with ureterouretero or ureterocystoanastomosis. If iatrogenic damage to the ureter is not noticed during surgery, the outcome may be urinary leakage, peritonitis, cicatricial narrowing, and ureterovaginal fistulas. In such cases, and especially with the development of postrenal anuria, percutaneous puncture non-frostomy with drainage of urinary streaks is indicated. Later, depending on the length and localization of narrowing or obliteration of the ureter, reconstructive operations are performed: uretero-ureteroanastomosis, ureterocystoanastomosis (Fig. 52, 53, see color insert), and with extended or bilateral narrowings - intestinal ureteral plastic ( fig. 54, 55, see color insert).

15.7.3. Bladder injury

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

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

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

Etiology and pathogenesis. Closed bladder injuries in most cases (70-80%) are the result of pelvic fractures. With this mechanism of injury, extraperitoneal ruptures prevail, which occur as a result of sudden movement of the vesicoprostatic and lateral ligaments of the bladder. Sharp tension of dense anatomical structures, such as its ligaments, leads to rupture of the more pliable soft-elastic bladder wall. 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 a hydrodynamic shock against the wall of an overflowing bladder. Such damage occurs even with a minimal traumatic effect on the lower abdomen (sudden blow) with a relaxed anterior abdominal wall.

Damage to the bladder, like the ureters, is often iatrogenic in nature. Especially often his injuries occur during obstetric-hynecological operations.

Symptoms and clinical course. For bladder injuries NS painful sensations in the lower abdomen, which are especially pronounced with fractures of the pelvic bones, are characteristic. Vivid symptoms of bone trauma, especially with the development of a state of shock, masks the manifestations of intrapelvic organ damage, including damage to the urinary bladder. It should be remembered that in patients with fractures of the pelvic bones, ruptures of the bladder and / or membranous urethra most often occur. These injuries should first of all be excluded when examining such victims. The acute abdomen clinic is the main manifestation of intraperitoneal bladder rupture. The presence of a large amount of urine in the abdominal cavity causes the 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 abdomen. As a result, he 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 defect formed. Despite the increased urgent urge, 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 with an admixture of blood through the urethra.

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

Diagnostics. Taking anamnesis allows you to establish the nature of the injury (hitting a vehicle, falling from a height, a strong blow to the abdomen). The patient's condition is severe, tenderness and protective tension of the muscles of the anterior abdominal wall are determined by palpation. With intraperitoneal rupture, pronounced symptoms of peritoneal irritation, intestinal paresis are determined. Rectal digital examination allows to exclude the rupture of the rectum, to reveal its pastiness and overhang of the anterior wall caused by urine flow. Women need to have a vaginal examination.

Ultrasound with 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 of it.

Bladder catheterization and retrograde cystography are one of the main and most reliable methods for diagnosing bladder ruptures. First, you should make sure that there is no injury to the urethra, since it is contraindicated to carry instruments along it. 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 large amounts of urine mixed with blood, exceeding the maximum capacity of the bladder (sometimes 1 liter or more);

■ a discrepancy between the volume of fluid injected and removed through the catheter (Zeldovich's symptom).

Bladder catheterization is performed on an X-ray table, so that after evaluating its results, you can go directly to retrograde cystography. Before it begins, a plain X-ray of the pelvic region is performed, which makes it possible to determine the nature and degree of bone damage. The features of performing retrograde cystography are as follows:

■ high concentration of the injected 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 the removed contrast agent.

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

Signs of penetrating extra-peritoneal rupture of the bladder

rye are the deformation of its walls and the leakage of a radiopaque substance beyond its limits (Fig. 15.9). With intraperitoneal ruptures, shapeless streaks of contrast agent are determined in the abdominal cavity.

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

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

Rice. 15.10. Methods for drainage of pelvic tissue through a suprapubic wound (1), obturator opening (2) and perineum (3)

Treatment. In case of non-penetrating ruptures of the bladder, an indwelling catheter is installed for 3-5 days, hemostatic and antibiotic therapy is prescribed. Penetrating ruptures require urgent surgical intervention. The existing bladder defects are sutured with a double-row continuous-knot vicryl suture, urinary leaks are widely drained in the pelvic cavity, and in case of 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 extraperitonization of the bladder in order to separate the sutured wound of the bladder from the abdominal cavity. Drainage of the small pelvis is carried out through the suprapubic wound, the MacWarter-Buyalsky obturator and the perineum (Fig. 15.10). The operation ends with epicystostomy, which is a universal and most reliable method of urine diversion. Drainage with a urethral catheter is possible if no more than a day has passed since the moment of injury and qualified postoperative observation 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 found in men. Recently, in connection with the widespread introduction of endourological interventions, iatrogenic injuries of the urethra have become more frequent.

Etiology and pathogenesis. In theory, any part of the urethra can be damaged. In practice, there are mainly injuries of two of its sections: perineal - with a direct impact and membranous - with a fracture of the pelvic bones.

The anterior urethra (hanging, perineal and bulbous) is more often damaged by direct traumatic effects: falling by the perineum on solid objects (edge ​​of a bench, fence, well hatch cover, bicycle frame), 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. Injuries to the posterior urethra in fractures of the pelvic bones are often combined with ruptures of other adjacent organs (bladder, rectum) and are accompanied by a severe, often shock patient. As a rule, with a fracture of the pelvic bones, the membranous (membranous) part of the urethra is damaged. This department is not closed by the corpora cavernosa and consists only of the mucous and submucosal layer, surrounded by connective tissue and the ligamentous apparatus of the pelvis. Fracture of the anterior pelvic half-ring is accompanied by a sharp stretching and tearing of its ligaments with rupture of the poorly protected membranous urethra. In some cases, damage occurs with displaced bone fragments.

Damage to the urethra is rare in women. Their causes are fractures of the pelvic bones, household trauma, sexual intercourse, complicated childbirth.

Classification. Distinguish open and closed trauma to the urethra. Depending on the localization, lesions are isolated front or rear department of the urethra.

Clinical and anatomical classification:

Non-penetrating tears (tears of a part of the urethral wall): internal (from the side of 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 the therapeutic tactics, since conservative therapy is carried out for non-penetrating breaks, and surgical treatment for penetrating breaks.

Symptoms and clinical course. The victims complain of pain in the perineum, in the lower abdomen, in the penis, sharply increasing when trying to urinate. Pain is especially pronounced and multifactorial in fractures of the pelvic bones and associated damage to the intrapelvic organs. A characteristic symptom of damage to the urethra 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 ruptures of the urethra. Retention of urine is accompanied by strong urging, attempts to urinate are unsuccessful, while urine is poured into the paraurethral tissues and surrounding cellular spaces. Subsequently, urinary leakage develops, and when it becomes infected, urinary cellulitis and urosepsis.

Diagnostics. The general condition of the patient with isolated lesions suffers little. Local manifestations come to the fore: pain in the area of ​​the damaged part of the urethra, urethrorrhagia and urinary disorders. On examination, bruising, cyanosis of the skin of the perineum, scrotum and penis, edema of the tissues surrounding the urethra are noted. In the area of ​​the external opening of the urethra - clotted blood. The severe condition of the victims is observed with ruptures of the urethra associated with fractures of the pelvic bones and combined damage to the intrapelvic organs. Many patients go into shock. They are pale, adynamic, inadequate, frequent pulse and hypotension are noted.

X-ray establishes the localization and severity of fractures of the pelvic bones. Retrograde urethrography is the main method for diagnosing urethral rupture. It allows you to determine the localization and degree of damage to the urethra. With penetrating injuries, an X-ray contrast agent is found outside the urethra in the form of shapeless streaks (Fig. 15.11). If its rupture is complete, extravasation is more pronounced, while there is no contrasting of the urethra

Rice. 15.11. Retrograde urethrogram. Radiopaque contrast agent leaks as a result of rupture of the membranous urethra (arrow)

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

Bladder catheterization for the purpose of diagnosing a rupture of the urethra is not very informative, it can lead to infection and transfer of a non-penetrating rupture to a penetrating one.

Treatment. The tactics of treating urethral ruptures depends on the severity of the condition of the victims, the degree of damage and the time elapsed since the moment of injury. Conservative treatment is carried out with non-penetrating ruptures and consists in the appointment of anesthetic drugs, hemostatic and antibacterial therapy.

Penetrating breaks are an indication for emergency surgery. In all cases, it is necessary to divert urine by epicystostomy and drain the paraurethral urinary leaks. The operation can be extended in

execution account the primary suture of the urethra. Such tactics are possible under the following conditions: 1) if no more than 12 hours have passed since the moment of injury; the general condition of the victim is stable (no shock); there is a qualified team of urologists with experience in urethral surgery. The operation consists in perineotomy, revision and debridement of the wound, refreshing 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 ruptures of the urethra are strictures and obliteration of the urethra. They develop in all patients with penetrating wounds, with the exception of those who have had a primary urethral suture.

15.7.5. Urethral strictures and obliterations

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

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

Rice. 15.12. Retrograde urethrogram. Perineal urethral stricture (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. Due to their education, they are divided into: post-inflammatory, chemical and post-traumatic. Postinflammatory drugs prevailed before the introduction of antibiotic therapy. They are more often localized in the anterior urethra and, as a rule, are not isolated. Currently, most

cases there are post-traumatic strictures and obliteration of the urethra.

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

With obliteration of the urethra, independent urination is impossible, the patient has a permanent suprapubic urinary fistula for urine diversion, in which a Foley or Pezzer catheter is installed.

Diagnosis is based on urethrography(fig. 15.12) and ureteroscopy(Fig. 3, see color insert). With the help of these studies, the lo-

calization, length and severity of narrowing. Retrograde urethrography in combination with antegrade cystourethrography makes it possible to assess the size of the obliterated 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 operational. Conservative

Rice. 15.13. Retrograde urethrogram with antegrade cystourethrogram. Contrast agent defect as a result of obliteration of the membranous urethra (arrow)

consists in the bougienage of the urethra. This method has been used since ancient times. It is palliative and indicated for short (no more than 1 cm) contractions. Bougie is the forcible passage of specially designed for this purpose rigid instruments, called bougie, through the scar-narrowed areas of the urethra. Bougies have an increasing size (diameter) and can be elastic and metal (see Ch. 4, Fig. 4.42) To make the bougie pass easier and reduce pain, a special gel with anesthetic and antiseptic (ins-tillagel, catejel) is injected into the urethra ... In some cases, anesthesia is used. Bougie of the urethra requires caution, since it is performed blindly, and can be accompanied by a number of complications: ruptures of the unchanged wall, formation of a false passage, urethrorrhagia, urethral fever and the development of epididymitis and orchitis. Bougienage is supplemented with the appointment 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 elimination of urinary leakage, perifocal inflammation and consolidation of pelvic fractures. The operation is performed endoscopically or openly. Endoscopic surgery consists of an internal optical (under visual control) urethrotomy (Fig. 4, see color insert) and recanalization of the urethra. It is used for non-extended (up to 2 cm), including multiple narrowings of the urethra. It is a palliative intervention, since the scar

any 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, tightly fitting to the walls of the urethra, does not allow the scar tissue to narrow its lumen (Fig. 15.14).

A radical method of treating narrowing and obliteration is resection of the urethra. The operation consists in complete excision of the scar tissue and stitching of the mobilized unchanged ends. This operation is easily performed when the narrowing is localized in the anterior (perineal) part of the urethra (Holtsov's urethral resection). It is much more difficult to perform resection of the

Rice. 15.14. Plain radiograph. Urethral endoprosthesis (stent) (arrow)

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

Forecast with timely performed radical surgical treatment, favorable. Patients with narrowing of the urethra should be under constant supervision of a urologist due to the high risk of recurrent strictures. Erectile dysfunction develops in half of patients with post-traumatic obliteration of the posterior urethra and after operations to restore its patency.

15.7.6. Damage to the external male genital organs

Injuries to the male external genitalia can be open or closed. Open more often observed in wartime or as a result of animal bites (Fig. 82, see color insert) or stab wounds. Traumatic amputation of the genitals is the result of accidental injury or deliberate injury. The causes of closed injuries are blows to this area, falls on the perineum and sexual excesses.

Closed penile injuries are divided into bruises, ruptures of the tunica albuginea, dislocations and infringement of it by pressing ring-shaped objects. The most common rupture of the dense tunica albuginea of ​​an erect penis occurs as a result of forced intercourse. The characteristic crunch and strong pain that occurs during this has led to the fact that this type of injury is called a fracture of the penis. 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 prompt and consists in evacuating the hematoma and suturing the rupture of the tunica albuginea with vicryl ligatures. Patients should be monitored by a urologist due to the risk of fibrotic changes in the corpora cavernosa, curvature of the penis and weakening of erection.

Closed trauma to the organs of the scrotum develops as a result of a direct traumatic effect on them: a kick, a ball, a fall on a bicycle frame, a fall from a height. There is severe pain, tissue swelling with the formation of a hematoma. The rupture of the testicular capsule causes hemorrhage in the testicular membrane (hematocele), causing a sharp increase in the scrotum and a change in its color. Sometimes, trauma to the scrotum can dislocate the testicle or dislocate it under the skin of adjacent areas. The most dangerous is the recruitment of the testicle, since the occlusion of the vessels feeding it leads to rapid necrosis of the organ.

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

Surgery indicated for ruptures of the tunica albuginea, the formation of large hematomas and torsion of the testicles. The operation consists in evacuating the hematoma, stopping bleeding, excising non-viable tissues and parenchyma, suturing the tunica albuginea and draining the scrotal cavity. When twisting, the testicle is turned in the opposite direction and fixed in the correct position. Orchiectomy is indicated only when the organ is not viable as a result of torsion and ischemia of the vascular pedicle or crushing of the testicle.

15.7.7. Foreign bodies of the urethra and bladder

Etiology and pathogenesis. Foreign bodies of the urethra and bladder are rare. 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 trauma, and secondly, because, being in the lumen of the urethra or bladder, they have a permanent damaging action. In the urethra, they are found extremely rarely and only in men, and into the bladder through the urethra they are more often found in women.

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

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

■ the 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 bougie, catheters, urinary drains, stone extractors, etc.).

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

Diagnostics. In the analyzes, leukocyturia and hematuria are noted. The diagnosis is made 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 extracting a foreign object during the process of 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 a urethro or cystotomy with the extraction of a 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 stop 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 is kidney injury 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 ruptured kidneys?

16. What is meant by iatrogenic damage to the ureters?

17. Give the classification of bladder ruptures.

18. Describe Zeldovich's symptom.

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

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

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

Clinical Objective 1

A 28-year-old patient was admitted to the admission department of a general hospital with complaints of severe paroxysmal pain in the right lumbar region radiating downward to the groin, the right half of the scrotum, along the inner thigh. The attacks are accompanied by frequent urination, nausea, and there was repeated vomiting. The pain started three hours ago after riding a motorbike on a shaky road. Twice in the last six months I have noticed similar attacks, which were not so intense and disappeared after taking no-shpa. On examination, he behaves restlessly, literally rushes about the emergency room, not finding a place for himself from pain. The abdomen is not swollen, soft, painful in the right hypochondrium. There are no symptoms of peritoneal irritation. Positive symptom of Pasternatsky. The general analysis of blood and urine are normal.

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

Clinical Objective 2

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

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

Clinical Objective 3

A 68-year-old patient was admitted on an emergency basis with complaints of the inability to urinate independently with a strong urge, bursting pains in the lower abdomen. The above complaints appeared suddenly, 6 hours ago. From the anamnesis it is known that the patient has been disturbed by frequent, difficult urination, weakening of the urine stream for two years. Recently, periodically noted an admixture of blood in the urine, pain in the lower abdomen, "laying" a stream of urine when changing the position of the body. In the analysis of urine, 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 0.8 x 1.2 cm are located. on the sonogram.

Establish a diagnosis and choose treatment tactics.

Clinical Objective 4

A 17-year-old patient was admitted to the hospital 4 hours after the injury - falling from a height onto the edge of the box with the left half of the body. Complains of pain in the left half of the lower back and abdomen, weakness, blood in the urine. The skin is pale, covered with cold sweat. Pulse 110 beats / min, BP = 90/65 mm Hg. Art. In the area of ​​the left hypochondrium, a painful formation is palpated, the lower edge of which is determined 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 to choose?

Clinical Objective 5

The patient, 43 years old, was taken to the emergency room after he was beaten in the street. On examination, there are many bruises and abrasions in the lower abdomen. Objective research is difficult due to the fact that when trying to put the patient to bed, due to a sharp increase in pain, he again takes an upright position. On palpation - a sharp soreness and symptoms: irritation of the peritoneum throughout the abdomen. The urge to urinate is more frequent. When trying to urinate, drops of urine with blood are noted.

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

Clinical Objective 6

A 28-year-old patient was admitted on an emergency basis with complaints of the inability to urinate independently, the release of blood from the external opening of the urethra. Upon questioning, it became known that 4 hours ago in the courtyard he stepped on the half-open cover of the well hatch, having fallen into the well with one foot, was hit in the crotch by the edge of the unfolded cover. After that, severe pain and profuse discharge of blood from the external opening of the urethra appeared, which decreased over time. Attempts to urinate were unsuccessful. Seek medical help. On examination, there is a hematoma and swelling in the perineal region, clotted blood in the area of ​​the external opening of the urethra.

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

Rice. 15.15. Retrograde urethrogram

patient 22 years old

Clinical Objective 7

A 22-year-old patient was admitted as planned with complaints of difficulty urinating, weak urine stream pressure. Deterioration of urination is noted within 6 months after the injury to the perineum (fell on the bike frame), after which bleeding from the external opening of the urethra was observed. The patient underwent retrograde urethrography (Fig. 15.15).

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

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;
• neoplasms of the bladder;
• varicose veins of the urinary reservoir and prostate gland;
• damage to the prostate capsule due to the fact that the capsule burst.

Bladder cancer is a common cause.

Development mechanism

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

Pressure is constantly exerted on the muscle that relaxes the bladder, as well as on its neck. It is formed due to the fact that it is necessary to overcome the infravesicular blockage. The change in pressure within the bladder and the large volume of the prostate gland create conditions that lead to the rupture of the capsule. As a result, hematuria occurs.

What are the reasons for incomplete emptying of the bladder?

Incomplete emptying of the bladder is felt mainly in diseases of the lower parts of not only the urinary but also the reproductive system in women and men.

Frequent urination in a man should not always be considered the norm. Even if the frequent urge to empty the bladder is not accompanied by discomfort, discharge and other alarming symptoms, the patient should consult a specialist.

Causes

All causes of frequent urination in men can be divided into 2 groups. The first includes physiological, in most cases associated with errors in diet or stress. The second group includes pathological causes associated with various diseases of the genitourinary and other systems.

Bladder cystostomy in men

Ishuria is more common among men than women and children, so they are given cystostomy more often. The discomfort from her in men is also greater, because their organ is curved in an arcuate manner.

Indications for its imposition:

• Diseases of the prostate (adenoma or tumor). Adenoma is an indication for cystostomy in men. It, as it progresses, enlarges the prostate gland and can compress the urethra. Ishuria develops. Often, an adenoma degenerates into adenocarcinoma, which risks blocking the urethra.
• Operations on the urinary tract or penis. With such interventions, it is often necessary to impose a special catheter.
• Neoplasms of the bladder or small pelvis are becoming more common. Tumors are localized in different places, but the most dangerous are in the mouth of the ureter or urethra. If the tumor is in the place where the urethra passes into the urethra, then within a few months its growth will lead to anuria (urine will stop flowing into the bladder).
• The urethra is blocked by a calculus or foreign body. This is a consequence of urolithiasis. The stone can pass through the urethra for more than one day. This interferes with the flow of urine and prevents the catheter from being inserted. Salvation in cystostomy.
• Pus in the bladder requiring flushing.
• The penis is injured.

Diagnostics and therapeutic course in some cases requires the installation of a catheter in the patient's bladder. Most often, the tube is inserted through the urethra, but it can also be placed through the anterior abdominal wall. The catheter performs such important functions:

• removes urine;
• flushes the bladder;
• helps injecting the medicine.

Causes

Symptoms

The main manifestations of bladder tamponade will be pain when trying to urinate, the urge either does not give an effect, or a small amount of urine is released. On palpation above the pubis, a bulge is determined, this is an overflowing bladder. At the slightest pressure on it, pain occurs. A person with bladder tamponade is emotionally labile and restless.

Based on the determination of the volume of blood in the bladder, the degree of blood loss is determined. The urine contains fresh or altered blood impurities. It should be borne in mind that the tamponade of the urinary reservoir suggests bleeding. The capacity of the bladder in males is about 300 milliliters, but in fact the volume of lost blood is much larger.

Bladder rupture symptoms

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

• pale and moist skin;
• palpitations;
• weakness and apathy;
• dizziness;
• increased heart rate.

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

Anemia is one of the complications of a pathological condition

Prostate adenoma: catheterization or surgery?

With an overflowing bladder, it is quite easy to carry out medical manipulations, because the organ is greatly stretched, which means that its size is increased. In addition, the anterior wall of the bladder is not protected - it is not covered by the peritoneum, but only adjoins the abdominal muscles.

Technique for performing the procedure:

1. The patient lies down on the operating table, the medical staff fixes his legs, arms, slightly lifts him in the pelvic area.
2. To prevent infection with pathogenic bacteria, the puncture area is thoroughly disinfected with a special solution. If there is a hairline at the puncture site, then in advance (before the puncture) this area is shaved.
3. Next, the doctor palpates the patient to determine the highest point of the organ and its approximate location, after which he anesthetizes with novocaine 0.5%, injecting a solution 4 cm above the pubic symphysis.
4. After the onset of anesthesia, a puncture is performed using a 12 cm needle, the diameter of which is 1.5 mm. The needle is slowly inserted through the anterior abdominal wall, piercing all layers, eventually reaching the organ wall. Puncturing it, the needle is deepened by 5 cm and the urinary fluid is withdrawn.
5. After complete emptying, the needle is carefully removed so as not to cause bleeding, then the bladder cavity is washed with an antibacterial solution.
6. The puncture area is disinfected and covered with a special medical bandage.

The development of specific complications after a puncture is a rare occurrence. However, if medical workers neglected the rules of asepsis, then it is likely that pathogenic microorganisms penetrate, leading to inflammation.

Serious complications include:

• puncture of the abdominal cavity;
• perforation of the bladder;
• trauma to organs located near the puncture organ;
• the ingress of urine into the fiber, which is located around the organ;
• purulent-inflammatory process in the fiber.

Despite the possible complications and risks, puncture is sometimes the only method of helping the patient. The quality of its implementation and the postoperative period of the patient depends almost entirely on the experience of the surgeon.

Bladder catheterization is a temporary measure for adenoma if there are complications (infections) or the need to flush the bladder and drain urine after transurethral resection (TUR). It is the gold standard for treating adenoma when residual urine occurs.

Adenoma cannot be treated with catheterization, if conservative treatment (drugs such as doxazosin and finasteride, herbal medicine) does not give an effect, it is necessary to decide on the operation. Depending on the volume of the prostate, minimally invasive laser (vaporization and enucleation) and standard (TUR) operations can be performed.

You cannot refuse an operation because of your age; a heart problem is solved together with a cardiologist and an anesthesiologist, in preparation for the operation. If one specialist denied you an operation, find another, a third, contact a specialized clinic and regional center, today adenoma is successfully treated at any age, a catheter with a urine collection bag is not a sentence!

Suprapubic capillary puncture: indications for use

Suprapubic capillary puncture is performed when the bladder overflows, in case of acute urinary retention, when the patient is unable to empty naturally. This manipulation is resorted to when it is impossible to release urine from the bladder using a catheter. More often, such a procedure is necessary for trauma to the external genital organs and the urethra, in particular, with burns, in the postoperative periods. In addition, suprapubic puncture is performed for diagnostic purposes to collect high-quality urine tests.

This manipulation allows you to obtain a pure material for medical research. The urine samples do not come into contact with the external genitalia. This allows you to create the most accurate picture of the pathology than with analyzes using a catheter. Capillary puncture is considered a reliable method for examining urine in newborns and young children.

Bladder puncture technique

Before carrying out the manipulation, medical workers prepare the puncture area: the hair is shaved off, the skin is disinfected. In some cases, the patient is examined with an ultrasound machine to pinpoint the location of the urinary tract. The surgeon can examine the patient and, without special equipment, determine the boundaries of the overfilled bladder.

For the operation, the patient must lie on his back. General anesthesia is not practiced during this procedure; the puncture area is anesthetized with drugs for local anesthesia. Then a special long needle is inserted under the skin to a depth of 4-5 centimeters above the pubic joint. The needle penetrates the skin, abdominal muscles, pierces the walls of the bladder.

The physician should make sure that the needle is inserted deep enough and cannot slip out. After this, the patient is turned over to one side and tilted slightly forward. Through a tube attached to the other end of the needle, urine flows into a special tray. After the bladder is completely empty, the needle is carefully removed, and the manipulation site is treated with alcohol or sterile wipes.

If necessary, the puncture of the bladder is repeated 2-3 times a day. If the procedure is to be performed regularly, the bladder is punctured and an indwelling catheter or drain is left to drain urine. If urine is needed for analysis, it is collected in a special syringe with a sterile cap. Before sending the material for research to the laboratory, the contents are poured into a sterile test tube.

The main indications for puncture:

1. Contraindications to catheterization / inability to drain urine through a catheter.
2. External genital trauma, trauma to the urethra.
3. Collection of urine for reliable laboratory research.
4. The bladder is full and the patient is unable to empty it on his own.

Suprapubic puncture is a safe method for examining urinary fluid in young children and toddlers. Often, patients themselves prefer puncture of an organ, since when using a catheter, the likelihood of injury is much higher.

Indications for the procedure

Suprapubic (capillary) puncture of the bladder can be performed with two purposes - therapeutic, that is, therapeutic, and diagnostic. In the first case, the puncture is performed to empty the organ in order to avoid rupture due to excessive accumulation of urine.

The diagnostic purpose is to take a urine sample. But this method is used quite rarely, although an analysis taken in this way is much more informative than one obtained by self-urination or catheterization.

If the cystic formation is small and does not manifest itself in any way, patients need to be examined for ultrasound 2 times a year to control the situation.

A frequent unpleasant consequence of manipulation with a puncture of the urethra is urethral fever. It can occur when bacteria enter the bloodstream. This happens when the urethra is injured by medical instruments. This complication is accompanied by chills and intoxication of the body. In more severe forms, urethral fever can trigger prostatitis, urethritis, or some other serious illness.

In addition, incorrect or too hasty manipulation can lead to false canal moves. There is a risk of urine leaking into the abdominal cavity and tissue. In order to prevent unwanted leakage, health workers are advised to insert the needle not at a right angle, but obliquely.

Contraindications

Indications for puncture of the bladder are all those cases when the patency of the urethra is impaired and there is an acute retention of urine. For example, with injuries and burns of the genitals.

Operation is contraindicated for:

• Tamponade.
• Paracystitis, acute cystitis.
• Small bubble capacity.
• Hernia of the inguinal canal.
• Neoplasms in the bladder of a benign or malignant type.
• Stage III obesity.
• The presence of scars on the skin in the area of ​​the proposed puncture site.

Like any other invasive procedure, a puncture of the bladder has its own contraindications. These include:

• insufficient fullness - if the organ is empty or even half full, puncture is strictly prohibited, since there is a high risk of complications;
• pathological blood clotting - coagulopathy;
• period of bearing the child;
• the patient has hemorrhagic diathesis.

Hemorrhagic diathesis - a contraindication to manipulation

The list of contraindications continues:

• a history of dissection of the anterior abdominal wall along the white line below the navel;
• mixing, enlargement or stretching of the peritoneal organs;
• the presence of inguinal or femoral hernias;
• inflammation of the bladder - cystitis;
• anomalies of organs located in the small pelvis (cysts, sprains);
• an infectious lesion of the skin at the puncture site.

There are times when a puncture is impossible. This procedure is forbidden to perform with various injuries of the bladder and its small capacity. Manipulation is undesirable for men with acute prostatitis or prostate abscesses. The procedure is prohibited for women during pregnancy. Complications during this manipulation can occur in patients with complex forms of obesity.

Other contraindications for puncture are:

• acute cystitis and paracystitis;
• bladder tamponade;
• neoplasms of the genitourinary organs (malignant and benign);
• purulent wounds in the area of ​​the operation;
• inguinal hernia;
• scars in the puncture area;
• suspicion of displacement of the bladder.

A cystostomy is a hollow tube that drains urine directly from the bladder and collects it in a bag that temporarily replaces the urinary tract. A conventional catheter is inserted directly into the urethral canal, and a cystostomy is inserted through the peritoneal wall.

Such a catheter is necessary when the urinary tract does not empty, although it is full. This happens when:

• A conventional catheter cannot be inserted.
• It is believed that the patient will have difficulty urinating for a long time, and a cystostomy is placed for a long time.
• A patient has acute ischuria (urinary retention)
• The urethra (urethra) is damaged due to pelvic trauma, medical or diagnostic procedures, or during intercourse.
• It is necessary to determine the daily volume of urine, but you cannot put a regular catheter through the urethra.

Cystostomy eliminates the manifestation of many diseases when urination is impossible. But she does not cure them, but restores the outflow of urine.

With an empty bladder or half empty, the procedure is prohibited, as the risk of consequences increases;

What are the consequences?

With the correct installation of the cystostomy and its correct use, as a rule, there are no side effects. But the risk of complications cannot be ruled out. Practicing urologists describe the following possible pathological reactions and conditions:

• Allergy to tube material.
• The incision site is bleeding.
• The wound decays.
• The intestines are damaged.
• The bladder becomes inflamed.
• The tube is pulled out spontaneously.
• The place where the tube is attached is irritated.
• The patient may stop urinating himself. Ability to urinate atrophies. The body does not strain, the tube works for it. Therefore, you need to try to urinate yourself within a week after cystostomy.
• Urine flows into the peritoneum.
• The tube is clogged with blood, mucus.
• The opening of the stoma grows.
• Blood in urine after cystostomy.
• The walls of the bladder are damaged.
• Suppuration around the cystostomy. Mucus or pus on the wound indicates infection. If there is no systemic inflammation, suppuration is treated with antiseptics.

Puncture of a kidney cyst is an operation carried out in accordance with all the necessary rules for conducting interventions in the human body. The procedure is performed only in a clinical setting, after which the patient is in the hospital for 3 days under the supervision of medical personnel. Usually, after this therapy, the patient recovers quickly and safely.

During the rehabilitation period, there may be an increase in body temperature and swelling in the puncture area, which quickly pass. Since the whole process is controlled by an ultrasound machine, miscalculations are excluded - puncture of the pelvis, large blood vessels. However, complications can still be observed:

• bleeding into the renal cavity;
• opening of bleeding into cyst capsules;
• the onset of purulent inflammation due to infection of the cyst, kidney;
• organ puncture;
• violation of the integrity of nearby organs;
• allergy to sclerosing solution;
• pyelonephritis.

IMPORTANT! If the patient has polycystic disease, or education more than 7 cm, puncture is considered ineffective.

2050 0

As you know, the extensive spread of bladder tumors makes radical treatment impossible, and the main goal of palliative treatment is to reduce or completely eliminate the painful symptoms of the disease, i.e. to improve the quality of life indicators.

Palliative treatment methods:

1. Palliative surgery
2. Radiation therapy
3. Chemotherapy
4. Immunotherapy

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

1. Anemia
2. Syndrome of intravesical obstruction
3. Chronic renal failure
4. Chronic pain syndrome

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

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

Emergencies and their characteristics

1. Hematuria
2. Tamponade of the bladder
3. Acute urinary retention
4. Blockade of the upper urinary tract (hydronephrosis)
5. Pain syndrome
6. Paravesical phlegmon

The appearance of blood in the urine (hematuria) is usually the first symptom that prompts the patient to see 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 urgent medical care for profuse hematuria - acute anemia and bladder tamponade. Intense bleeding that does not stop conservative methods of treatment leads to blood loss, hypovolemia and anemia.

Coagulation of blood poured into the lumen of the bladder can be accompanied by the formation of clots that can cause bladder tamponade. In the event of this situation, you have to resort to surgical treatment.

The scope of the surgical impact will be determined by the localization of the tumor and the extent of the process. For 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.

With limited cancer of the bottom and body of the bladder, resection of the bladder is performed, with infiltration of the ureteral opening, the intramural ureter is resected, followed by neoimplantation into the bladder.

With total damage to the bladder or the location of the tumor in the bladder triangle, the possibility of the need for cystectomy, a technically difficult and traumatic operation for the patient, is not excluded.

Cystectomy ends with bilateral ureterocutaneostomy, since an increase in the volume of the operation due to the formation of an artificial reservoir for urine, given the urgency of the operation, can be fatal.

In the case of unresectability of the bladder tumor, attempts are made to stop bleeding by palliative measures - electrocoagulation of the tumor, ligation of both internal iliac arteries.

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

Also, the advantage of endovascular intervention is the possibility, due to catheterization of one of the vessels, to conduct regional infusion of hemostatic and cytostatic drugs, against which it is possible to stop ongoing bleeding.

Embolization is carried out by transfemoral Seldinger catheterization, selective introduction of a catheter into the internal iliac artery from 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 the catheter is inserted into the bladder and the balloon is inflated, 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 swab to stop bleeding.

In the case of a violation of the outflow of urine associated with the germination of the mouths of the ureters, their infiltration and leading to the development of ureterohydronephrosis and azotemia, the patient is shown:

Imposition of percutaneous nephrostomy;
ureteral stenting;
imposition of a nephrostomy;
removal of the orifices of the ureters to the skin.

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

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

We have outlined the principles of drug treatment for pain syndrome above. It is also possible to use conduction novocaine blockades through the obturator hole according to Stuckey, presacral blockade according to A.V. Vishnevsky, epidural denervation, resection of the presacral nerve plexus.

Although the modern development of pharmacotherapy, this direction is reduced to almost a minimum. Also, carrying out this kind of manipulation requires a good skill. In case of metastatic lesions of the bones of the skeleton, it is possible to use short courses of local irradiation 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 decay. A defect in the bladder wall causes urine leakage into the peri-vesical cellular space, which is complicated by the development of paravesical phlegmon.

In this case, the optimal method of palliative care will be resection of the bladder wall 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 peri-vesical cellular tissue space.

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

Drainage of peri-vesicular tissue through the anterior abdominal wall provides outflow from the upper portions of the retropubic space and pre-vesicular tissue. Peripubular tissue located deep in the pelvis should be drained through the obturator opening.

After the provision of primary palliative care in the future, patients are shown radiation therapy with single single dose (ROD) 1.8-2.5 Gy, total focal dose (SOD)- 60-70 Gr.

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

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

The most commonly used scheme is MVAC:

Methotrexate 30 mg / m2, IV, on days 1,15,22,
Vinblastine 3 mg / m2, i.v., on days 2,15,22,
Adriamycin 30 mg / m2, i.v., 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 with a good patient's condition should not be neglected by the attending physician.

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

Situations requiring urgent intervention are quite common 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 presentation and diagnostic criteria

Patients suffer from overflow of the bladder: painful and fruitless attempts to urinate appear, pain in the suprapubic region; the patient's behavior is characterized as extremely restless. Patients with diseases of the central nervous system and spinal cord, who, as a rule, are immobilized and do not experience severe pain, react differently. When viewed in the suprapubic region, a characteristic swelling is determined due to an overflowing bladder ("bubble ball"), which, when percussed, gives a dull sound.

In order to provide the patient with timely and qualified assistance, it is necessary to clearly understand the mechanism for the 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. Given the danger of urinary tract infection in the absence of a pronounced urge to urinate, catheterization is best done in a hospital setting. Severe pain syndrome caused by overstretching of the bladder is an indication for catheterization at the prehospital stage.

Bladder catheterization should be treated as a serious procedure, equating it with an operation. 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 is usually not difficult. Various rubber and silicone catheters are used for this purpose.

The greatest difficulty is catheterization in patients with benign prostatic hyperplasia (BPH). With BPH, the posterior urethra is lengthened and the angle between the prostatic and bulbous parts of it increases. Given these changes in the urethra, it is advisable to use catheters with a Timan or Mercier curvature. With the rough and forced introduction of the 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 a careful adherence to asepsis and catheterization technique.

The need for catheterization often arises in elderly patients, as well as in persons with severe concomitant pathology, including diabetes mellitus, circulatory disorders, etc. antibiotic prophylaxis of urinary tract infections (UTI).

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

Alternatively, amoxicillin / clavulanate or II-III generation cephalosporins (cefuroxime axetil, cefaclor, cefixime, ceftibuten) can be used.

For prophylaxis, these antibacterial drugs can be used orally.

In acute prostatitis (especially with an outcome in an abscess), acute urinary retention occurs due to deviation and compression of the urethra by an inflammatory infiltrate and edema 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 with 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 to diagnose stones. With urethral strictures leading 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 prolapse of the uterus. 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 that injure or obstruct the lower urinary tract. Emergency care is to remove the foreign body; however, this manipulation can only be performed in a hospital setting.

In the case of reflex urinary retention (for example, with postpartum, postoperative ischuria), you can try to induce urination by irrigating the external genital organs with warm water, by pouring water from one vessel into another (the sound of a falling stream of water can reflexively cause 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 proserin is administered subcutaneously; if ineffective, bladder catheterization is indicated.

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

Macrohematuria

Definition. Hematuria - the appearance of an impurity of blood in the urine - is one of the characteristic symptoms of many urological diseases. Distinguish between microscopic and macroscopic hematuria; the onset of intense gross hematuria often requires urgent care.

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

Clinical presentation and classification. The appearance of red blood cells in the urine gives it a cloudy appearance and 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 in the first portion of urine there is no visual impurity of blood, and only the last portions of urine contain blood; H) total, when the urine in all portions is equally colored with blood. Possible causes of gross hematuria are presented in.

Often, gross hematuria is accompanied by an attack of pain in the kidney area, since a clot formed in the ureter interferes with the outflow of urine from the kidney. In a kidney tumor, bleeding precedes pain ("asymptomatic hematuria"), whereas in urolithiasis, pain occurs before the onset of hematuria. Localization of pain in hematuria also makes it possible to clarify the localization of the pathological process. So, pain in the lumbar region is characteristic of kidney disease, and in the suprapubic region - for lesions of the bladder. The presence of dysuria simultaneously with hematuria is observed with damage to the prostate gland, bladder or posterior urethra. The shape of the blood clots also allows you to determine the localization of the pathological process. Worm-like clots that form when blood passes through the ureter indicate an upper urinary tract disease. Shapeless clots are more common in bleeding from the bladder, although they may form in the bladder when blood is excreted from the kidney.

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

The main directions of therapy. With the development of hypovolemia and a drop in blood pressure, restoration of the volume of circulating blood is shown - intravenous administration of crystalloid and colloidal solutions. Hemostatic agents are not used.

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

Acute pyelonephritis

Definition. Pyelonephritis is a nonspecific infectious and inflammatory process with a predominant lesion of 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. organism - otitis media, tonsillitis, mastitis, pneumonia, sepsis, etc.). Predisposing factors - immunodeficiency, urinary tract obstruction (urolithiasis, various abnormalities of the kidneys and urinary tract, strictures of the ureter and urethra, prostate adenoma, etc.), instrumental examinations of the urinary tract, pregnancy, diabetes mellitus, old age, etc. occurrences distinguish between primary pyelonephritis (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, which reduce the resistance of the kidney tissue to infection and disrupt the 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.

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

General symptoms: fever, 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 side of the lesion, sometimes dysuria, cloudy urine with flakes, polyuria, nocturia, soreness when tapping in the lower back.

During acute pyelonephritis, 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.

Algorithm for the treatment of 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 specifying the state of urodynamics of the upper urinary tract and restoring the passage of urine 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 need 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 of emergency medical care, Moscow

Note!

• The effectiveness of the treatment of patients with acute urological diseases depends on two factors: the quality of the complex of measures aimed at normalizing vital functions, and the timely delivery of the patient to a specialized hospital.
• Renal colic is a symptom complex that occurs with an acute (sudden) violation 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 with an outcome in an abscess), acute urinary retention occurs due to deviation and compression of the urethra by an inflammatory infiltrate and edema of its mucosa.