urinary retension and pain
Acute urinary retention:
stream diminishing Analgesia, duplex scan, US, MRI
Torsion of a testicular appendage results from ischemia and infarction of an embryologic remnant. Although four possible remnants are at risk, the appendix testis and appendix epididymis account for approximately 99% of all cases. Although the blue dot sign may be visible early in the process, it eventually is obscured by edema and erythema. There are rarely any voiding symptoms or fever associated with this entity. Doppler ultrasonography typically reveals normal testicular blood flow with a small hyperechoic area adjacent to the testis. Once the diagnosis is definitively made, management is nonoperative. Analgesics and scrotal support may be useful supportive adjuncts.
Epididymitis (PID!!!!) arises from pain and swelling of the epididymis. It usually arises secondary to infection or inflammation from the urethra or bladder. If the process remains untreated, it may involve the adjacent testis and scrotum, and eventually result in abscess formation. Fever and leukocytosis are present in between 30% and 50% of cases. Doppler ultrasonography reveals normal to increased blood flow to the testis and epididymis, contrasting sharply with testis torsion. Antibiotic treatment for epididymitis depends on patient age and probable underlying pathogen. Neisseria gonorrhoeae and Chlamydia trachomatis account for most cases in men under 35, and these may be treated with intramuscular ceftriaxone plus a course of doxycycline. In men over 35, urine culture usually reveals Escherichia coli, and treatment consists of an oral fluoroquinolone for 21 days.
The most common infectious cause for acute retention is acute prostatitis. Patients typically appear sick at presentation, displaying fever, dysuria, and perineal pain. Digital rectal examination reveals an exquisitely tender, boggy prostate. Aggressive prostate may cause bacteremia, and should be avoided. Patients should begin therapy immediately, and toxic patients may need to be admitted for monitoring, fluid resuscitation, and intravenous antibiotics. If the patient is in urinary retention, a small urethral catheter should be gently inserted. Alternatively, a suprapubic catheter may be placed if patients find a urethral Foley catheter too uncomfortable. Other infectious causes of retention include urethral herpes, periurethral abscesses, and tuberculous cystitis
Neurovascular Hx: Sickle cell disease and other thromboembolic or hypercoagulable states (eg, polycythemia, thalassemia, and vasculitis) are frequently associated with priapism
obstructive, infectious, pharmacologic, and neurogenic: Neurogenic/pathic
There are many pharmacologic agents that may contribute to urinary retention. The most common group includes anticholinergics. These may act by blocking postganglionic impulses to the detrusor and inhibiting contraction. Common offending medications include atropine, oxybutynin, tolterodine, and certain antihistamines. α-Adrenergic agonists (commonly found in decongestants) including ephedrine and pseudoephedrine cause bladder neck smooth muscle contraction and subsequent retention. Psychiatric medications including phenothiazine antipsychotics and monoamine oxidase inhibitors also have anticholinergic effects and may cause acute retention. Withdrawal of the offending medication may ultimately relieve retention.
hyperplasia, tumor: painless gross hematuria
prastatic:12F/ coude decompression: palpate >1000cc in,
strictures, spasms, stones, FB,
urodynamic studies,
phimosis: unretracted/ paraphimosis: triamcinolone:
paraphimosis: block and conscious sedation and ace glans to return through the phimotic ring. Or dorsal slit and circ elective
Advanced prostate cancer, which invades the urethra or bladder neck, may also cause acute urinary retention. On rectal examination, these patients typically have nodular, indurated prostates with palpable tumor, which may extend beyond the border of the gland. They typically have elevated serum prostate-specific antigen levels, and may have undergone transrectal ultrasound-guided prostate biopsy for tissue diagnosis. They may have signs of systemic disease, including bone pain and weight loss. Treatment is by transurethral catheter placement, and urologic consultation regarding future prostate cancer therapeutic options.
Urethral strictures not infrequently present in acute retention. The stricture is a circumferential scar of the mucosa and underlying corpus spongiosum. The stricture may be anywhere from the urethral meatus back to the bladder neck. Strictures usually arise secondary to previous urethral instrumentation, perineal trauma, or urethritis, but the etiology is frequently idiopathic. The stricture may occasionally be palpable through the scrotal or perineal skin as a firm, indurated region of urethra. A small Foley catheter (12F catheter) may successfully traverse the narrowed segment. If not, the stricture may be dilated using urethral filiforms and followers up to 12F catheter for catheter placement. Alternatively, a suprapubic catheter may be placed for bladder decompression. Both of these procedures should be performed only by those experienced in these maneuvers, and urologic consultation is often prudent to avoid significant urethral trauma.
Bladder stones or bladder tumors may also cause obstructive urinary retention. A bladder stone typically forms secondary to urinary stasis (because of bladder outlet obstruction) or a foreign body in the bladder. These patients typically complain of intermittency because the stone acts as a ball valve at the bladder neck. A urethral catheter may temporarily push the stone back up into the bladder and relieve the obstruction. The bladder stone may ultimately be treated by transurethral fragmentation or open cystolithotomy for larger calculi. If the cause of the stone is an obstructing prostate adenoma, it is typically resected or excised simultaneously.
A bladder tumor may lead to urinary retention through significant hematuria and blood clot formation. A patient who presents with painless gross hematuria and clots should be suspected of harboring an underlying bladder tumor. As the clots solidify and increase in number, they may settle at the most dependent portion of the bladder (the bladder neck) and completely block outflow. Most patients have some interval of gross hematuria and pass a few clots before clot retention occurs. The best treatment for these patients is placement of a large three-way hematuria catheter for continuous bladder irrigation. Aggressive manual clot irrigation is critical to ensure adequate drainage. Patients may occasionally require urgent operative intervention for clot evacuation and fulguration of hemorrhage in anticipation of formal transurethral bladder tumor resection. Patients may bleed significantly before presentation, and routine hematocrit checks are prudent in this situation.
Less common obstructive etiologies include urethral foreign bodies, penile constricting bands, and meatal stenosis. Obstructive urinary retention in women is distinctly uncommon, but causes may include ureteroceles, urethral polyps, and urethral strictures.
Neurogenic causes of urinary retention may be broadly categorized into upper motor neuron lesions, lower motor neuron lesions, and peripheral nerve lesions. Upper motor neuron lesions include all neurologic lesions above the sacral micturition center. The most common cerebral upper motor neuron lesions include cerebrovascular accident (stroke); multiple sclerosis; and Parkinson's disease. In the suprasacral cord, tumors and spinal cord injury are frequent causes. The bladder is typically spastic, with decreased storage capacity and impaired emptying secondary to sphincter dyssynergia. Lower motor neuron lesions include spinal cord trauma below S1, spinal cord compression secondary to metastatic cancer, and multiple sclerosis. The bladder is usually hypotonic or atonic in these cases. Peripheral nerve lesions that commonly lead to urinary retention include diabetic neuropathy; intervertebral disk herniation (specifically L4-5 or L5-S1); and pelvic surgery (abdominoperineal resection for colon cancer, radical hysterectomy), which may inadvertently injure the pelvic plexus.
Treatment options for patients with neurogenic urinary retention should be individualized according to the patient's overall clinical and neurologic status. These patients frequently have complex voiding dysfunction, and urodynamic studies are often of benefit, particularly in patients with spinal cord injury. Treatment options may range from clean intermittent catheterization to bladder augmentation and catheterizable stoma creation. Suprapubic or indwelling urethral catheter placement is much less desirable in the long-term and should be reserved only for patients with a poor prognosis or those who are unable or unwilling to learn intermittent catheterization.
SummaryGenitourinary emergencies are commonly seen in the emergency room, and the primary care physician plays a vital role in the initial evaluation and treatment of each. Although genitourinary trauma is rarely life threatening, it may be the cause of significant long-term morbidity. Key clinical indicators outlined in this article (eg, inability to urinate, gross hematuria) combined with judicious use of imaging help stage the injury and allow a safe and rational approach to treatment. The acute scrotum frequently presents a challenging problem to both the emergentologist and urologist. Although epididymitis may be managed nonoperatively, there should be no delay in exploring suspected testis torsion. The conditions of the penis outlined require urgent treatment to preserve potency (priapism) and restore normal function (eg, penile amputation). Acute urinary retention has a myriad of underlying etiologies, and treatment must be individualized. Urgent bladder decompression by urethral or suprapubic catheterization provides initial relief until urologic consultation is available.
stream diminishing Analgesia, duplex scan, US, MRI
Torsion of a testicular appendage results from ischemia and infarction of an embryologic remnant. Although four possible remnants are at risk, the appendix testis and appendix epididymis account for approximately 99% of all cases. Although the blue dot sign may be visible early in the process, it eventually is obscured by edema and erythema. There are rarely any voiding symptoms or fever associated with this entity. Doppler ultrasonography typically reveals normal testicular blood flow with a small hyperechoic area adjacent to the testis. Once the diagnosis is definitively made, management is nonoperative. Analgesics and scrotal support may be useful supportive adjuncts.
Epididymitis (PID!!!!) arises from pain and swelling of the epididymis. It usually arises secondary to infection or inflammation from the urethra or bladder. If the process remains untreated, it may involve the adjacent testis and scrotum, and eventually result in abscess formation. Fever and leukocytosis are present in between 30% and 50% of cases. Doppler ultrasonography reveals normal to increased blood flow to the testis and epididymis, contrasting sharply with testis torsion. Antibiotic treatment for epididymitis depends on patient age and probable underlying pathogen. Neisseria gonorrhoeae and Chlamydia trachomatis account for most cases in men under 35, and these may be treated with intramuscular ceftriaxone plus a course of doxycycline. In men over 35, urine culture usually reveals Escherichia coli, and treatment consists of an oral fluoroquinolone for 21 days.
The most common infectious cause for acute retention is acute prostatitis. Patients typically appear sick at presentation, displaying fever, dysuria, and perineal pain. Digital rectal examination reveals an exquisitely tender, boggy prostate. Aggressive prostate may cause bacteremia, and should be avoided. Patients should begin therapy immediately, and toxic patients may need to be admitted for monitoring, fluid resuscitation, and intravenous antibiotics. If the patient is in urinary retention, a small urethral catheter should be gently inserted. Alternatively, a suprapubic catheter may be placed if patients find a urethral Foley catheter too uncomfortable. Other infectious causes of retention include urethral herpes, periurethral abscesses, and tuberculous cystitis
Neurovascular Hx: Sickle cell disease and other thromboembolic or hypercoagulable states (eg, polycythemia, thalassemia, and vasculitis) are frequently associated with priapism
obstructive, infectious, pharmacologic, and neurogenic: Neurogenic/pathic
There are many pharmacologic agents that may contribute to urinary retention. The most common group includes anticholinergics. These may act by blocking postganglionic impulses to the detrusor and inhibiting contraction. Common offending medications include atropine, oxybutynin, tolterodine, and certain antihistamines. α-Adrenergic agonists (commonly found in decongestants) including ephedrine and pseudoephedrine cause bladder neck smooth muscle contraction and subsequent retention. Psychiatric medications including phenothiazine antipsychotics and monoamine oxidase inhibitors also have anticholinergic effects and may cause acute retention. Withdrawal of the offending medication may ultimately relieve retention.
hyperplasia, tumor: painless gross hematuria
prastatic:12F/ coude decompression: palpate >1000cc in,
strictures, spasms, stones, FB,
urodynamic studies,
phimosis: unretracted/ paraphimosis: triamcinolone:
paraphimosis: block and conscious sedation and ace glans to return through the phimotic ring. Or dorsal slit and circ elective
Advanced prostate cancer, which invades the urethra or bladder neck, may also cause acute urinary retention. On rectal examination, these patients typically have nodular, indurated prostates with palpable tumor, which may extend beyond the border of the gland. They typically have elevated serum prostate-specific antigen levels, and may have undergone transrectal ultrasound-guided prostate biopsy for tissue diagnosis. They may have signs of systemic disease, including bone pain and weight loss. Treatment is by transurethral catheter placement, and urologic consultation regarding future prostate cancer therapeutic options.
Urethral strictures not infrequently present in acute retention. The stricture is a circumferential scar of the mucosa and underlying corpus spongiosum. The stricture may be anywhere from the urethral meatus back to the bladder neck. Strictures usually arise secondary to previous urethral instrumentation, perineal trauma, or urethritis, but the etiology is frequently idiopathic. The stricture may occasionally be palpable through the scrotal or perineal skin as a firm, indurated region of urethra. A small Foley catheter (12F catheter) may successfully traverse the narrowed segment. If not, the stricture may be dilated using urethral filiforms and followers up to 12F catheter for catheter placement. Alternatively, a suprapubic catheter may be placed for bladder decompression. Both of these procedures should be performed only by those experienced in these maneuvers, and urologic consultation is often prudent to avoid significant urethral trauma.
Bladder stones or bladder tumors may also cause obstructive urinary retention. A bladder stone typically forms secondary to urinary stasis (because of bladder outlet obstruction) or a foreign body in the bladder. These patients typically complain of intermittency because the stone acts as a ball valve at the bladder neck. A urethral catheter may temporarily push the stone back up into the bladder and relieve the obstruction. The bladder stone may ultimately be treated by transurethral fragmentation or open cystolithotomy for larger calculi. If the cause of the stone is an obstructing prostate adenoma, it is typically resected or excised simultaneously.
A bladder tumor may lead to urinary retention through significant hematuria and blood clot formation. A patient who presents with painless gross hematuria and clots should be suspected of harboring an underlying bladder tumor. As the clots solidify and increase in number, they may settle at the most dependent portion of the bladder (the bladder neck) and completely block outflow. Most patients have some interval of gross hematuria and pass a few clots before clot retention occurs. The best treatment for these patients is placement of a large three-way hematuria catheter for continuous bladder irrigation. Aggressive manual clot irrigation is critical to ensure adequate drainage. Patients may occasionally require urgent operative intervention for clot evacuation and fulguration of hemorrhage in anticipation of formal transurethral bladder tumor resection. Patients may bleed significantly before presentation, and routine hematocrit checks are prudent in this situation.
Less common obstructive etiologies include urethral foreign bodies, penile constricting bands, and meatal stenosis. Obstructive urinary retention in women is distinctly uncommon, but causes may include ureteroceles, urethral polyps, and urethral strictures.
Neurogenic causes of urinary retention may be broadly categorized into upper motor neuron lesions, lower motor neuron lesions, and peripheral nerve lesions. Upper motor neuron lesions include all neurologic lesions above the sacral micturition center. The most common cerebral upper motor neuron lesions include cerebrovascular accident (stroke); multiple sclerosis; and Parkinson's disease. In the suprasacral cord, tumors and spinal cord injury are frequent causes. The bladder is typically spastic, with decreased storage capacity and impaired emptying secondary to sphincter dyssynergia. Lower motor neuron lesions include spinal cord trauma below S1, spinal cord compression secondary to metastatic cancer, and multiple sclerosis. The bladder is usually hypotonic or atonic in these cases. Peripheral nerve lesions that commonly lead to urinary retention include diabetic neuropathy; intervertebral disk herniation (specifically L4-5 or L5-S1); and pelvic surgery (abdominoperineal resection for colon cancer, radical hysterectomy), which may inadvertently injure the pelvic plexus.
Treatment options for patients with neurogenic urinary retention should be individualized according to the patient's overall clinical and neurologic status. These patients frequently have complex voiding dysfunction, and urodynamic studies are often of benefit, particularly in patients with spinal cord injury. Treatment options may range from clean intermittent catheterization to bladder augmentation and catheterizable stoma creation. Suprapubic or indwelling urethral catheter placement is much less desirable in the long-term and should be reserved only for patients with a poor prognosis or those who are unable or unwilling to learn intermittent catheterization.
SummaryGenitourinary emergencies are commonly seen in the emergency room, and the primary care physician plays a vital role in the initial evaluation and treatment of each. Although genitourinary trauma is rarely life threatening, it may be the cause of significant long-term morbidity. Key clinical indicators outlined in this article (eg, inability to urinate, gross hematuria) combined with judicious use of imaging help stage the injury and allow a safe and rational approach to treatment. The acute scrotum frequently presents a challenging problem to both the emergentologist and urologist. Although epididymitis may be managed nonoperatively, there should be no delay in exploring suspected testis torsion. The conditions of the penis outlined require urgent treatment to preserve potency (priapism) and restore normal function (eg, penile amputation). Acute urinary retention has a myriad of underlying etiologies, and treatment must be individualized. Urgent bladder decompression by urethral or suprapubic catheterization provides initial relief until urologic consultation is available.
posted by PainNP @ 4:34 PM
0 comments
