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Pediatric Urology Emergencies


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Title: Pediatric Urology Emergencies

Pediatric Urology Emergencies
  • Ahmed Al-Sayyad MD,FRCSC
  • Assistant Professor-King Abdulaziz University

Pediatric Urology Emergencies
  • Acute scrotum
  • GU Trauma
  • Priapism
  • Paraphimosis
  • PUV
  • Urosepsis in association of obstruction
  • Urolithiasis

Acute scrotum
  • Torsion of the spermatic cordTorsion of the
    appendix testisTorsion of the appendix
    l herniaCommunicating hydroceleHydroceleHydroce
    le of the cordTrauma/insect biteDermatologic
    lesionsInflammatory vasculitis (Henoch-Schönlein
    purpura)Idiopathic scrotal edemaTumorSpermatoce
    leVaricoceleNonurogenital pathology (e.g.,
    adductor tendinitis)

Torsion of the Spermatic Cord (Intravaginal)
  • Torsion of the spermatic cord is a true surgical
    emergency of the highest order
  • Irreversible ischemic injury to the testicular
    parenchyma may begin as soon as 4 hours after
    occlusion of the cord
  • Intravaginal torsion happens within the space of
    the tunica vaginalis this results from lack of
    normal fixation of the testis and epididymis to
    the fascial and muscular coverings that surround
    the cord within the scrotum

Torsion of the Spermatic Cord (Intravaginal)
  • Usually there is an acute onset of scrotal pain,
    but in some instances the onset appears to be
    more gradual
  • A large number of boys give a history of
    previous episodes of severe, self-limited scrotal
    pain and swelling
  • Nausea and vomiting may accompany acute torsion,
    and some boys have pain referred to the
    ipsilateral lower quadrant of the abdomen
  • Dysuria and other bladder symptoms are usually

Torsion of the Spermatic Cord (Intravaginal)
  • Testis can be riding high in the scrotum or with
    transverse orientation
  • The absence of a cremasteric reflex is a good
    indicator of torsion of the cord
  • After several hours an acute hydrocele or
    massive scrotal edema obliterates all landmarks
  • Color Doppler examination had a diagnostic
    sensitivity of 88.9 and a specificity of 98.8,
    with a 1 rate of false-positive results
  • When the diagnosis of torsion of the cord is
    suspected, prompt surgical exploration is
  • When torsion of the spermatic cord is found,
    exploration of the contralateral hemiscrotum must
    be carried out

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Torsion of the Testicular and Epididymal
  • The appendix testis, a müllerian duct remnant,
    and the appendix epididymis, a wolffian remnant,
    are prone to torsion
  • The symptoms associated with torsion of an
    appendage are extremely variable, from an
    insidious onset of scrotal discomfort to an acute
    condition identical to that seen with torsion of
    the cord

Torsion of the Testicular and Epididymal
  • localized tenderness of the upper pole of the
    testis or epididymis
  • Tender nodule may be palpated. In some
    instances, the infarcted appendage is visible
    through the skin as a blue dot sign
  • The cremasteric reflex is usually present
  • In cases in which the inflammatory changes are
    more significant, scrotal wall edema and erythema
    may be severe
  • Color Doppler examination may show hyperemia at
    the upper pole of the testis or epididymis
  • When the diagnosis of torsion of an appendage is
    confirmed clinically or by imaging, nonoperative
    management allows most cases to resolve
  • Limitation of activity and administration of
    nonsteroidal anti-inflammatory agents are only

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Perinatal Torsion of the Spermatic Cord
  • Prenatal (in utero) torsion is typified by the
    finding at delivery of a hard, nontender testis
    fixed to the overlying scrotal skin
  • The skin is commonly discolored by the underlying
    hemorrhagic necrosis
  • Classic teaching has held that testes found to be
    hard, nontender, and fixed to the skin at birth
    do not merit surgical exploration
  • However, controversy has arisen regarding the
    need for prompt exploration of the contralateral

Perinatal Torsion of the Spermatic Cord
  • Contralateral scrotal exploration traditionally
    has not been recommended in cases of prenatal
    torsion because extravaginal torsion is not
    associated with the testicular fixation defect
    (bell-clapper deformity) that is recognized as
    the cause of intravaginal torsion
  • However, reports of asynchronous perinatal
    torsion have made the practice of avoiding prompt
    surgical exploration of the contralateral testis

Perinatal Torsion of the Spermatic Cord
  • Prompt exploration of suspected postnatal torsion
    of the spermatic cord is indicated (in
    conjunction with exploration of the contralateral
    testis) when the patient's general condition and
    anesthetic considerations allow for a safe
  • Exploration, when elected, should be carried out
    through an inguinal incision to allow for the
    most efficacious treatment of other potential or
    unexpected causes of scrotal swelling
  • If torsion is confirmed, contralateral scrotal
    exploration with testicular fixation should be
    carried out
  • The most effective and safest form of testicular
    fixation involves dartos pouch placement

  • Priapism is a persistent penile erection of at
    least 4 hours in duration that continues beyond
    and is unrelated to sexual stimulation .There are
    three subtypes  
  • Ischemic (veno-occlusive, low-flow) priapism is
    characterized by little or no cavernous blood
    flow, and cavernous blood gases are hypoxic,
    hypercapnic, and acidotic. The corpora are rigid
    and tender to palpation   
  • Nonischemic (arterial, high-flow) priapism is
    caused by unregulated cavernous arterial inflow.
    Typically, the penis is neither fully rigid nor
    painful. There is often a history of antecedent
    trauma resulting in a cavernous arterycorpora
    cavernosa fistula   
  • Stuttering (intermittent) priapism is a recurrent
    form of ischemic priapism with painful erections
    with intervening periods of detumescence

  • The most common cause of priapism in children is
    sickle cell disease
  • Priapism typically occurs during sleep, when mild
    hypoventilatory acidosis depresses oxygen tension
    and pH in the corpora. The pain experienced is a
    sign of ischemia
  • On examination, there is typically significant
    corporal engorgement with sparing of the glans
  • Medical therapy, including exchange transfusion,
    hydration, alkalinization, pain management with
    morphine, and oxygen should be started
  • Intracavernous irrigation with a sympathomimetic
    agent, such as phenylephrine will be the next
    step. General anesthesia or intravenous sedation
    will be necessary.
  • If irrigation and medical therapy are
    unsuccessful, a corporoglanular shunt should be

  • For stuttering priapism, administration of an
    oral a-adrenergic agent (pseudoephedrine) once or
    twice daily is first-line therapy. If this
    treatment is unsuccessful, an oral ß agonist
    (terbutaline) is recommended a GnRH analog plus
    flutamide is recommended as third-line therapy
  • Nonischemic (high-flow) priapism most commonly
    follows perineal trauma, such as a straddle
    injury, that results in laceration of the
    cavernous artery
  • Spontaneous resolution may occur. If not,
    angiographic embolization is indicated

  • Paraphimosis develops when the tip of the
    foreskin retracts proximal to the coronal sulcus
    and becomes fixed in position
  • Severe edema of the foreskin occurs within
    several hours, depending on the tightness of the
    tip of the foreskin
  • In most cases, manual compression of the glans
    with placement of distal traction on the
    edematous foreskin allows reduction of the
    paraphimotic ring

Renal Trauma
  • The pediatric kidney is believed to be more
    susceptible to trauma because of a decrease in
    the physical renal protective mechanisms
  • hematuria is very unreliable in determining who
    to screen for renal injuries
  • Indeed, some studies have failed to find any
    evidence of either gross or microscopic hematuria
    in up to 70 of children sustaining grade 2 or
    higher renal injury

Indications for Imaging
  • A significant deceleration or high-velocity
    injury such as one sustained in a high-speed
    motor vehicle accident, a pedestrian/bicycle-motor
    vehicle accident, a fall from more than 15 feet,
    or a strike to the abdomen or flank with a
    foreign object (e.g., football helmet, baseball
  • Significant trauma that has resulted in fractures
    of thoracic rib cage, spine, pelvis, or femur, or
    bruising of the torso/perineum, or signs of
  • Gross hematuria
  • Microscopic hematuria (lt50 red blood cells per
    high-powered field) associated with shock
    (systolic blood pressure less than 90 mm Hg)
  • penetrating injuries

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  • Single-Shot Intravenous Pyelography Is useful in
    the unstable patient requiring emergent
  • Once the patient is stabilized in the operating
    room, single-shot intravenous pyelography (IVP)
    (2 mL/kg intravenous bolus of contrast agent)
    with the radiograph taken 10 to 15 minutes after
    injection may be of benefit
  • Use of Arteriography is useful in patients with
    persistent or delayed hemorrhage which usually
    arises from the development of arteriovenous
    fistulas or pseudoaneurysm
  • Approximately 25 of patients with grade 3 to
    grade 4 renal trauma, managed in a nonoperative
    fashion, will develop persistent or secondary
    (delayed) hemorrhage
  • RGP \- DJ indications after renal trauma (1) to
    rule out the presence of a partial/total ureteral
    disruption and (2) to aid in the management of a
    symptomatic urinoma

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Renal pedicle injury
Involving artery and vein
With hematoma
Delayed imaging
Injury to collecting system with extravasation
Delayed imaging
Renal pelvis injury with leak of urine
  • Majority of renal injuries can be managed
  • Bed rest till urine is clear
  • Frequent vitals and Hb checking
  • Urine racking
  • Follow up imaging after discharge

Absolute indications for exploration
  • Persistent renal bleeding
  • Pulsatile, expanding or uncontained hematoma
  • Avulsion of the main renal artery or vein

Relative indications for exploration
  • Significant (25-50) non-viable tissue
  • Urinary extravasation
  • Arterial thrombosis
  • Penetrating trauma

Surgical approach
  • The goals of operative therapy are hemorrhage
    control and renal tissue preservation
  • Midline incision, look for other injuries,
    central control of vessels
  • Renal exploration, débridement of nonviable
    tissue, hemostasis by individual suture ligation
    of bleeding vessels, watertight closure of the
    collecting system, and coverage or approximation
    of the parenchymal defect

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  • Disruption of the UPJ is most commonly caused by
    acceleration-deceleration injuries
  • The majority of patients sustaining a UPJ
    disruption will present with vascular
    instability, requiring emergent laparotomy with
    the patient unable to undergo preoperative
  • Emergent exploratory laparotomy for coexisting
    intra-abdominal injury is usually necessary and
    exploration fails to reveal the presence of a
    retroperitoneal hematoma
  • Because of the frequent association of this
    injury with life-threatening trauma the diagnosis
    of a UPJ disruption is delayed for more than 36
    hours in more than 50 of patients
  • Patients will eventually come to attention due to
    CT abnormalities found during the workup of
    persistent postoperative fever, chronic flank
    pain, continued ileus, or sepsis

  • Three classic findings on triphasic CT are
    associated with UPJ disruption (1) good renal
    contrast agent excretion with medial
    extravasation of contrast agent in the perirenal
    and upper ureteral area (2) absence of
    parenchymal lacerations and (3) no visualization
    of the ipsilateral distal ureter
  • In the clinically stable patient in whom the
    diagnosis is made within 5 days after the
    traumatic insult it is preferred to proceed to
    immediate surgical repair with débridement of any
    devitalized tissue, spatulation and reanastomosis
    of the ureter over a stent
  • In patients with a delayed diagnosis of 6 or more
    days it is preferred to place a nephrostomy tube
    and allow the patient and injury to stabilize for
    12 weeks
  • The combination of remaining renal function and
    the length of the surgical defect allow the
    surgeon to make the proper surgical planning

  • Ureteral perforation after ureteroscopy can
    almost invariably be managed with stenting
  • If recognized at the time of surgery, ureteral
    contusions secondary to a high-velocity gunshot
    wound or inadvertent ligation of the ureter
    should be treated by removal of any offending
    clip or ligature and placement of a ureteral
    stent for 6 to 8 weeks
  • if the diagnosis of a traumatic ureteral injury
    is made within the first 5 days after the insult,
    we prefer to proceed with immediate surgical

  • If the patient is hemodynamically unstable and
    unable to tolerate the additional operative time
    required for ureteral repair or if the ureteral
    injury is too extensive to allow for a direct
    anastomosis, tie off the damaged ureter, place a
    large clip at the proximal end and insert PCN
  • The type of delayed ureteral repair to be used is
    based on the location and the extent of ureteral
  • Options include ureteral anastomosis to the
    renal pelvis, primary ureteroureterostomy,
    transureteroureterostomy, ureteral reimplantation
    with or without a psoas hitch, ileal ureter,
    autotransplantation and nephrectomy

  • The urinary bladder is well protected from
    external trauma by the bony confines of the
  • The majority results from blunt trauma which
    include motor vehicle accidents,falls and
  • They are frequently associated with multiple
    organ trauma, with an average of three coexisting
    organ injuries and a mortality rate of 20
  • Absolute indications for bladder imaging after
    blunt abdominal trauma are currently limited to
    two indications (1) the presence of gross
    hematuria coexisting with a pelvic fracture and
    (2) inability to void

  • Bladder contusion
  • Extraperitoneal bladder rupture
  • Intraperitoneal bladder rupture
  • Combination of intraperitoneal and
    extraperitoneal ruptures

  • Traumatic bladder lacerations in children are
    approximately two times more likely to extend
    through the bladder neck compared with adults
  • The diagnosis of a traumatic bladder injury
    should be assessed by either standard or CT
  • The amount instilled within the bladder should,
    at a minimum, be equal to one half of the
    estimated bladder capacity for age
  • All patients with traumatic bladder lacerations,
    either extraperitoneal or intraperitoneal, should
    initially be treated with intravenous antibiotics
    with oral antibiotic therapy continued for 48
    hours after removal of bladder catheters

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Intra and extra peritoneal bladder rupture
  • In extraperitoneal bladder injury, consideration
    for open surgical intervention should be given if
    a bony spicule is found to protrude into the
    bladder on CT evaluation or if concern for a
    bladder neck laceration is present
  • If these two complications are not present,
    management by an indwelling urethral catheter can
    be considered
  • Urinary drainage via the bladder catheter is
    maintained for 7 to 10 days, and a cystogram
    should be obtained to verify healing of the
    injury before catheter removal
  • In intraperitoneal bladder injuries, open
    surgical repair of the laceration is the
    recommended treatment modality

  • Classified into 2 broad categories based on the
    anatomical site of the trauma
  • Mechanism of injury include blunt trauma such as
    MVA or falls, penetrating injuries, straddle
    injuries and Iatrogenic injury like traumatic
    catheter placement
  • Posterior urethral injuries commonly associated
    with pelvic fractures
  • Anterior urethral injuries come from blunt trauma
    to the perineum (straddle injuries)

  • children with a posterior urethral injury will
    differ from adults with this injury in four ways
  • First, a pelvic fracture is more likely to be
    unstable and associated with a severely and
    permanently displaced prostatic urethra.
  • Second, the severe displacement of the prostate
    off the pelvic floor makes a complete posterior
    urethral disruption more common in boys than men
  • Third, in children, concurrent bladder and
    urethral injuries may occur in up to 20 of the
  • Fourth, in prepubertal girls, pelvic fractures
    are four times more likely to be associated with
    a urethral injury than in adult women

  • Radiographic or cystoscopic evaluations to rule
    out this injury are mandatory in the following
  • (1) when the patient presents with the classic
    triad of findings of a perineal/penile hematoma,
    blood at the meatus/vaginal introitus, and
    inability to void
  • 2) when one or more pubic rami are fractured or
    symphyseal diastases are present
  • (3) when radiographic findings suggest a bladder
    neck injury

  • Symptoms include hematuria or inability to void
  • Physical examination may reveal blood at the
    meatus or a high-riding prostate gland upon
    rectal examination. Extravasation of blood along
    the fascial planes of the perineum is another
    indication of injury to the urethra
  • The diagnosis is made by performance of a
    retrograde urethrogram
  • "Pie in the sky" findings revealed by cystogram
    usually indicate urethral disruption

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  • The traditional intervention for patients with
    posterior urethral injury secondary to pelvic
    fracture is placement of a suprapubic catheter
    for bladder drainage and subsequent delayed
  • The suprapubic catheter can be safely placed
    either percutaneously or via an open approach
    with a small incision
  • Ultimate repair can be performed 6-12 weeks after
    the event, after the pelvic hematoma has resolved
    and the patient's orthopedic injuries have

  • An attempt at primary realignment of the
    distraction with a urethral catheter is
    reasonable in stable patients either acutely or
    within several days of injury (ie, 5-7 d post
  • When the urethral catheter is removed after 4 to
    6 weeks, it is imperative to retain a suprapubic
    catheter because most patients will, despite
    realignment, develop posterior urethral stenosis

  • Placement of a catheter across a urethral
    disruption injury may rarely allow healing
    without stricture but in most patients, mild
    stenosis 1 to 2 cm in length develops
  • Incomplete urethral tears are best treated by
    stenting with a urethral catheter
  • There is no evidence that a gentle attempt to
    place a urethral catheter can convert an
    incomplete into a complete transection

  • In cases of female urethral disruption related to
    pelvic fracture, most authorities suggest
    immediate primary repair, or at least urethral
    realignment over a catheter, to avoid subsequent
    urethrovaginal fistulas or urethral obliteration
  • Concomitant vaginal lacerations must also be
    closed acutely to prevent vaginal stenosis.
    Delayed reconstruction is problematic because the
    female urethra is too short (about 4 cm) to be
    amenable to anastomotic repair when it becomes
    embedded in scar

  • Penetrating anterior urethral injuries should be
  • The area of injury should be examined, and
    devitalized tissue should be debrided carefully
    to minimize tissue loss
  • Defects of up to 2 cm in the bulbar urethra and
    up to 1.5 cm in the penile urethra can be
    repaired primarily via a direct anastomosis over
    a catheter with fine absorbable suture.
  • Longer defects should never be repaired
    emergently Urinary diversion with a suprapubic
    catheter is performed till time of delayed

Testicular Trauma
  • Testicular injuries can be divided into 3 broad
    categories based on the mechanism of injury
  • (1) blunt trauma
  • (2) penetrating trauma
  • (3) degloving trauma

Testicular Trauma
  • Testicular rupture or fractured testis refers to
    a rip or tear in the tunica albuginea resulting
    in extrusion of the testicular contents
  • Blunt trauma accounts for approximately 85 of
    cases, and penetrating trauma accounts for 15
  • As many as 80 of hematoceles (blood in the
    tunica vaginalis) are associated with testicular

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Clinical diagnosis
  • Patients typically present to ER with a
    straightforward history of injury
  • Symptoms include extreme scrotal pain, frequently
    associated with nausea and vomiting
  • Physical examination often reveals a swollen,
    severely tender testicle with a visible hematoma
  • Scrotal or perineal ecchymosis may be present
  • When evaluating a patient with a clinical
    history of only minor trauma, do not overlook the
    possibility of testicular torsion or epididymitis

Clinical diagnosis
  • For penetrating injuries, determine the entrance
    and exit sites of the wound.
  • Screening urinalysis is important to rule out
    urinary tract infection or epididymo-orchitis
  • Scrotal ultrasound imaging with Doppler studies
    is valuable for diagnosing and staging testicular
  • The presence of a disrupted tunica albuginea is
    pathognomonic for testicular rupture

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  • Institute conservative treatment for patients
    with minor trauma in which the testes are spared
    and the scrotum has not been violated
  • The usual treatment consists of scrotal support,
    nonsteroidal anti-inflammatory medications, ice
    packs, and bed rest for 24-48 hours

Indications for scrotal exploration
  • Uncertainty in diagnosis after appropriate
    clinical and radiographic evaluations
  • Disruption of the tunica albuginea
  • Large hematocele
  • Absence of blood flow on scrotal ultrasound
    images with Doppler studies

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scrotal exploration
  • Clinical hematoceles that are expanding or of
    considerable size (eg, 5 cm or larger) should be
  • Collections of smaller size are also often
    explored, because it has been shown that such
    practice allows for more optimal pain control and
    shorter hospital stays
  • If the testis is fractured, testicular
    debridement and surgical closure of the tunica
    albuginea are necessary

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