Urology

1- 80-year-old man presented with dull aching pain in the loins. Investigations showed high
urea and creatinine. Ultrasound of the abdomen showed bilateral hydronephrosis. Most
common cause is:
A. Stricture of urethral meatus
B. Neoplasm of the bladder
C. Prostatic enlargement
D. Pelvic CA
E. Retroperitoneal fibrosis
Hydronephrosis and hydroureter can range from benign processes, such as the physiologic hydroureteronephrosis of
pregnancy, to potential life-threatening situations, such as infected hydronephrosis or pyonephrosis. Although patients
usually present with some signs or symptoms, hydronephrosis can be an incidental finding encountered during the
evaluation of an unrelated process. If unrecognized or left untreated, hydronephrosis and hydroureter secondary to
obstruction can lead to hypertension, loss of renal function, and sepsis. Consequently, all patients found to have
hydronephrosis or hydroureter should undergo a thorough evaluation and should be referred to a urologist.
Sex

In women, gynecologic cancers and pregnancy are common causes. As such, among younger patients (aged
20-60 y), the frequency of hydronephrosis is higher in women than in men.
In men, obstruction secondary to prostatic hypertrophy and prostate cancer are the major causes of
hydronephrosis. Consequently, among older patients (>60 y), the frequency of hydronephrosis is higher in men
than in women.

In young adults, calculi are the most common causes of hydroureter and hydronephrosis.
In children, reflux and ureteropelvic junction obstruction are common causes.

Age

Clinical
History

Symptoms vary depending on whether the hydronephrosis is acute or chronic.

With acute obstruction, patients may present with pain, which is usually described as severe, intermittent, and
dull. Patients may describe worsening of pain with consumption of fluids. Depending on the level of
hydroureter, pain may radiate to the ipsilateral testicle or labia. Often associated with nausea and vomiting,
pain from an obstructed system is referred to as renal colic.
A history of hematuria may herald a stone or malignancy anywhere in the urinary tract.
A history of fever or diabetes adds urgency to the evaluation and treatment.
A history of a solitary kidney is an emergent situation.
Hydronephrosis may develop silently, without symptoms, as the result of advanced pelvic malignancy or
severe urinary retention from bladder outlet obstruction.
Bilateral symmetrical hydronephrosis usually suggests a cause related to the bladder, such as retention,
prostatic blockage, or severe bladder prolapse.1

Physical

With severe hydronephrosis, the kidney may be palpable.

With bilateral hydronephrosis, lower extremity edema may occur. Costovertebral angle tenderness on the
affected side is common.
A palpably distended bladder adds evidence of lower urinary tract obstruction.
A digital rectal examination should be performed to assess sphincter tone and to look for hypertrophy, nodules,
or induration of the prostate.

Causes
A multitude of causes exist for hydronephrosis and hydroureter. Classification can be made according to the level
within the urinary tract and whether the etiology is intrinsic, extrinsic, or functional.

Ureter
o

o
o

Intrinsic
Ureteropelvic junction stricture
Ureterovesical junction obstruction
Papillary necrosis
Ureteral folds
Ureteral valves
Ureteral stricture (iatrogenic)
Blood clot
Benign fibroepithelial polyps
Ureteral tumor
Fungus ball
Ureteral calculus
Ureterocele
Endometriosis
Tuberculosis
Retrocaval ureter
Functional
Gram-negative infection
Neurogenic bladder
Extrinsic
Retroperitoneal lymphoma
Retroperitoneal sarcoma
Cervical cancer
Prostate cancer
Retroperitoneal fibrosis
Aortic aneurysm
Inflammatory bowel disease
Ovarian vein syndrome
Retrocaval ureter
Uterine prolapse
Pregnancy
Iatrogenic ureteral ligation
Ovarian cysts
Diverticulitis
Tuboovarian abscess
Retroperitoneal hemorrhage
Lymphocele

Bladder
o Intrinsic
Bladder carcinoma
Bladder calculi
Bladder neck contracture
Cystocele
Primary bladder neck hypertrophy
Bladder diverticula
o Functional
Neurogenic bladder
Vesicoureteral reflux
o Extrinsic - Pelvic lipomatosis
Urethra
o Intrinsic
Urethral stricture
Urethral valves
Urethral diverticula
Urethral atresia
Labial fusion

Extrinsic - Benign prostatic hyperplasia and prostate cancer

2- Filling defect in IVP & hypoechoic mass in US:

-Blood clots
-Tumor
-Uric acid stones.
-IVP study done for a male & showed a filling defect in the renal pelvis non-radio opaque. U/S
shows echogenic structure & hyperacoustic shadow. The most likely diagnosis is:
a. Blood clot
b. Tumor
C. Uric acid stone
d. ???
- a non opaque renal pelvis filling defect is seen on IVP.Ultrasound reveals dense echoes and
acoustic shadowing.The MOST likely diagnosis is:
a)blood clot
b)tumor
c)sloughed renal papilla
d)uric acid stone
e)crossing vessel

Causes

Most research on the etiology and prevention of urinary tract stone disease has been directed toward the role of
elevated urinary levels of calcium, oxalate, and uric acid in stone formation, as well as reduced urinary citrate
levels.
Hypercalciuria is the most common metabolic abnormality. Some cases of hypercalciuria are related to
increased intestinal absorption of calcium (associated with excess dietary calcium and/or overactive calcium
absorption mechanisms), some are related to excess resorption of calcium from bone (ie,
hyperparathyroidism), and some are related to an inability of the renal tubules to properly reclaim calcium in
the glomerular filtrate (renal-leak hypercalciuria).
Magnesium and especially citrate are important inhibitors of stone formation in the urinary tract. Decreased
levels of these in the urine predispose to stone formation.
A low fluid intake, with a subsequent low volume of urine production, produces high concentrations of stoneforming solutes in the urine. This is an important, if not the most important, environmental factor in
kidney stone formation.
The exact nature of the tubular damage or dysfunction that leads to stone formation has not been characterized.
The most common findings on 24-hour urine studies include hypercalciuria, hyperoxaluria, hyperuricosuria,
hypocitraturia, and low urinary volume. Other factors, such as high urinary sodium and low urinary
magnesium concentrations, may also play a role. To identify these risk factors, a 24-hour urine profile,
including appropriate serum tests of renal function, uric acid, and calcium, is needed. Such testing is available
from various commercial laboratories. A finding of hypercalcemia should prompt follow-up with an intact
parathyroid hormone study to evaluate for primary and secondary hyperparathyroidism.

Imaging Studies

Plain abdominal radiography

Plain abdominal radiography (also known as a flat plate or kidney, ureter, and bladder [KUB]
radiography) is useful for assessing total stone burden, as well as the size, shape, and location of
urinary calculi in some patients. It is also helpful in determining the progress of the stone without
the need for more expensive tests with greater radiation exposures.
o Calcium-containing stones (approximately 85% of all upper urinary tract calculi) are
radiopaque, but pure uric acid, indinavir-induced, and cystine calculi are relatively radiolucent
on plain radiography.
o When used with other imaging studies, such as a renal ultrasonography or, particularly, CT scanning,
the plain film helps provide a better understanding of the size, shape, location, orientation, and
composition of urinary stones revealed with these other imaging studies. This may also be helpful in
planning surgical therapy and in tracking progress of the stone over time.
Renal ultrasonography
o Renal ultrasonography by itself is frequently adequate to determine the presence of a renal stone.
The study is mainly used alone in pregnancy or in combination with plain abdominal radiography to
determine hydronephrosis or ureteral dilation associated with an abnormal radiographic density
believed to be a urinary tract calculus.
o A stone easily identified with renal ultrasonography but not visible on the plain radiograph may
be a uric acid or cystine stone, which is potentially dissolvable with urinary alkalinization
therapy.
o Ureteral calculi, especially in the distal ureter, and stones smaller than 5 mm are not easily observed
with ultrasonography.
Intravenous urography
o An intravenous urography (IVU) test, also known as an intravenous pyelography (IVP), has been the
standard for determining the size and location of urinary calculi up until recently. IVU provides both
anatomical and functional information.
o IVU is very labor intensive and is no longer the standard for the initial evaluation of a patient
with a kidney stone. It may fail to reveal alternative pathology if a stone is not discovered, delaying
the final diagnosis.
Up to 6 hours may be required to complete the study in the presence of severe obstruction.
For optimal results, IVU requires a bowel preparation.
It involves intravenous injection of potentially allergic and mildly nephrotoxic contrast
material.
o A helical CT scan without contrast material is currently believed to be the best initial radiographic
examination for acute renal colic. If positive, KUB radiography is recommended to assist in follow-up
and planning.
o The so-called delayed nephrogram on the IVU is one of the hallmark signs of acute urinary tract
obstruction. The relative delay in penetration of intravenous contrast passing through an obstructed
kidney elicits this sign. The kidney appears to develop a whitish color, and contrast appearance within
the collecting system of the affected renal unit is significantly delayed.
o IVU is helpful in identifying the specific problematic stone among numerous pelvic calcifications and
in establishing that the other kidney is functional. These determinations are particularly helpful if the
degree of hydronephrosis is mild and the non-contrast CT scan findings are not definitive. CT
scanning with delayed contrast series and thin slices has reduced the need for IVU in the evaluation of
problematic ureteral stones.

3- a 75 year olf man came to the ER complaining of acute urine retention what will be your
initial management:
a)send patient immediately to OR for prostatectomy
b)empty urinary bladder by folleys catheter and tell him to come back to the clinic
c)give him antibiotics because retention could be from sort of infection
d)insert follys catheter and tell him to come back to the clinic (b & d are repeated)
e)admission, investigation which include cystoscopy then..
- A 82 years old patient present with urinary retention. What is the most proper treatment in
ER?
-Insert Follys Cath then send to clinic.
-Insert Follys Cath then send to home.
-O.R. for prostatectomy.
-Admission, Investigation, then do cystoscope or TRUP.

- In an 82 years old patient with acute urinary retention,the management is:

a) To empty the bladder by Foleys catheter and follow up in the clinic.
b) To insert a Foleys catheter then send the patient home to come back in the clinic.
c) To admit and investigate by TURP.
d) Immediate prostatectomy
trans urethral resection of the prostate for benign prostate enlargement.
Asymptomatic pts do not require treatment, and
those with complications of urethral obstruction such as inability to urinate, renal failure, recurrent urinary tract
infection, hematuria, or bladder stones clearly require surgical extirpation of the prostate, usually by transurethral
resection (TURP). However, the approach to the remaining pts should be based on the degree of incapacity or
discomfort from the disease and the likely side effects of any intervention. If the pt has only mild symptoms, watchful
waiting is not harmful and permits an assessment of the rate of symptom progression. If therapy is desired by the pt, two
medical approaches may be helpful: terazosin, an 1-adrenergic blocker (1 mg at bedtime, titrated to symptoms up to 20
mg/d), relaxes the smooth muscle of the bladder neck and increases urine flow; finasteride (5 mg/d), an inhibitor of 5
-reductase, blocks the conversion of testosterone to dihydrotestosterone and causes an average decrease in prostate size
of ~24%. TURP has the greatest success rate but also the greatest risk of complications. Transurethral microwave
thermotherapy (TUMT) may be comparably effective to TURP. Direct comparison has not been made between medical
and surgical management.

4- premature-ejaculation, all true except:

a) most common sexual disorder in males
b) uncommon in young men
c) Benefits from sexual therapy involving both partners
d) it benefit from anxiety Rx
5- acute GN, all is acceptable Ix (investigations) except:
a) complement
b) urinanalysis
c) ANA
d) Blood culture
e) Cystoscopy
6- A 20 yr old female present with fever, loin pain & dysuria, management include all of the
following except:
a) urinanalysis and urine culture
b) blood culture
c) IVU (IVP)
d) Cotrimexazole
7- Old male came with urine retention, dilated ureter and hydronephrosis, Dx is:
a) Benign prostatic hyperplasia.
b) Ureteric stone impaction.
c) bladder tumor.
8- In Testicular torsion, all of the following are true, except:
a) Very tender and progressive swelling.
b) More common in young males.
c) There is hematuria.
d) Treatment is surgical.
e) Has to be restored within 12 hours or the testis will infarct.
Testicular torsion is a true urologic emergency and must be differentiated from other complaints of testicular pain
because a delay in diagnosis and management can lead to loss of the testicle. Though testicular torsion can occur at any

age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males; it is the most frequent
cause of testicle loss in that population.
Clinical
History
History includes a sudden onset of severe unilateral scrotal pain.
Onset of pain can occur more slowly, but this is an uncommon presentation of torsion.
Torsion can occur with activity, can be related to trauma in 4-8% of cases,2 or can develop during sleep.
The historical features suggestive of testicular torsion include the following:
o Acute onset of unilateral scrotal pain
o Scrotal swelling
o Nausea and vomiting: In the pediatric population, nausea and vomiting more commonly accompany
acute testicular torsion and have a positive predictive value of greater than 96%. 4
o Abdominal pain (20-30%)
o Fever (16%)
o Urinary frequency (4%)
Many patients have a history of recurrent scrotal pain that has resolved spontaneously. This history is highly
suggestive of intermittent torsion and detorsion of the testicle. Patients who complain of what sounds like
torsion-detorsion should be referred promptly to a urologist since patients with symptoms of intermittent
torsion who electively have surgical exploration are less likely to develop subsequent torsion and loss of the
testicle.5 Creagh et al reported that acute torsion developed in 10% of patients with intermittent torsion while
they waited for surgery.6
Physical
The physical examination is useful, but imperfect, in diagnosing acute testicular torsion. 7
The physical examination, moreover, may be difficult to perform, as the testicle is typically very tender and
patients are often in significant discomfort.
The involved testicle is painful and is frequently elevated in position when compared with the other side.
Horizontal lie of the testicle - While abnormal lie can help diagnose testicular torsion, fewer than 50% of cases
demonstrated true horizontal lie.7
Enlargement and edema of the testicle; edema involving the entire scrotum
Scrotal erythema
Ipsilateral loss of the cremasteric reflex - The cremasteric reflex is almost always absent in patients with
testicular torsion, and its presence may help to distinguish other causes of acute scrotal pain from testicular
torsion. Case reports, however, have noted the opposite to be true. 8,9,7
Usually, no relief of pain upon elevation of scrotum (elevation may improve the pain in epididymitis [Prehn
sign])
Fever (uncommon)
Causes
Congenital anomaly; bell clapper deformity
Undescended testicle
Sexual arousal and/or activity
Trauma
Testicular tumor
Exercise
Treatment
Emergency Department Care
Early diagnosis and prompt urologic consultation is essential since time is critical in salvage of the testicle.
Analgesic pain relief should be administered as testicular torsion is typically very painful.
Attempt manual detorsion with pain relief as the guide for successful detorsion. The procedure is similar
to the "opening of a book" when the physician is standing at the patient's feet.
Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting
outward and laterally.
o For example, in a suspected torsion of the right testicle, the physician is in front of the standing or
supine patient and holds the patient's right testicle with the left thumb and forefinger.
o The physician then rotates the right testicle outward 180 in a medial to lateral direction.
o Rotation of the testicle may need to be repeated 2-3 times for complete detorsion and to provide pain
relief to the patient.
o For the patient's left testicle, the physician uses the right thumb and forefinger and rotates the patient's
left testicle in an outward direction 180 from medial to lateral.
o Manual detorsion is successful in 26.5% to greater than 80% of patients based upon a number of
reviewed studies.2

Consultations
If the clinical diagnosis of torsion is suspected, early urologic consultation is mandatory since definitive treatment is
surgery for detorsion and orchiopexy or possible orchiectomy.

9- Epididymitis, one is true:

a)The peak age between 12 &18.
b)u/s is diagnostic.
c)The scrotal contents are within normal size.
d) typical iliac fossa pain.
e) none of the above.
- Epidydimitis:
A-Common at the age 12-18 years
B-Iliac fossa pain
C-Scrotal content does not increase in size.
D-Ultrasound will confirm the diagnosis.
E-All of above
Acute scrotal pain is a common complaint in the emergency room, and the diagnosis of epididymitis must be
differentiated from testicular torsion, a true scrotal emergency.1 Ultrasonography is noninvasive and can help
differentiate between the pathologies. One area under investigation is the ability of emergency physicians to use bedside
ultrasonography to accurately diagnose patients with acute scrotal pain.
Epididymitis is most often due to the retrograde extension of organisms from the vas deferens and is rarely the result of
hematogenous spread. Bacterial infection results in the infiltration of WBCs into the epididymal connective tissue, with
resultant congestion and edema. This inflammation can rapidly spread to the tubules, with the risk of abscess formation
and necrosis of the epididymis.4,5 The causative organism is identified in 80% of patients and varies according to the age
of the patient.
Age
Epididymitis is primarily a disease of adults, most commonly affecting males aged 19-40 years.
Clinical
History
The progression of epididymitis usually is gradual in nature, with symptoms often peaking within 24 hours of onset.
Initially, the patient may note abdominal or flank pain because cellular inflammation typically begins in the vas
deferens. As the inflammation descends to the lower segment of the epididymis, the patient notes discomfort localized
to the scrotum. Younger patients or any patient with a sexually transmitted epididymitis may note symptoms related to
urethritis. A recent history of endourethral instrumentation or urinary tract infection is more common in older patients.
Symptoms include the following:
Scrotal pain and edema
Urinary frequency, urgency, or dysuria
Urinary retention from bladder outlet obstruction in older patients
Nausea
Fever and chills
Abdominal or flank pain
Bilateral epididymal involvement (10%)
Urethral discharge
Physical
Edematous tender epididymis: Early on, in cases without significant testicular involvement, tenderness may be
clearly localized to the epididymis.
Erythematous edematous scrotum
Scrotal abscess
o Scrotal fluctuance
o Scrotal fixation to underlying epididymis
Reactive hydrocele
Prehn sign: This has been used to distinguish epididymitis from testicular torsion. Classically, scrotal elevation
decreases pain in epididymitis and not in torsion. However, the Prehn sign is not reliable for distinguishing
epididymitis from testicular torsion.
Urethral discharge (10%)
Fever or other constitutional symptoms with progression of disease

Causes
Epididymitis most often is due to the retrograde extension of bacterial organisms from the vas deferens.
o Prepubertal males - Coliform bacteria (E coli)
o Sexually active males -C trachomatis is the most common organism followed by N gonorrhoeae
o Older males - Coliform bacteria most common, sexually transmitted diseases less common
Less common causes of epididymitis include the following:
o Chemical epididymitis due to the reflux of sterile urine
o Boys with epididymitis due to a postinfectious inflammatory reaction to pathogens, such as M
pneumoniae, enteroviruses, and adenoviruses
o Candidal epididymitis in immunocompromised patients (AIDS)
o Epididymitis as an extrapulmonary manifestation of tuberculosis
o Epididymitis secondary to exposure to amiodarone therapy or prostate brachytherapy

10- benign prostatic hyperplasia, all are true except:

a) prostitis
b) nocturia
c) diminished size and strength of stream
d) haematuria
e) urine retention
- BPH all true except:
1) Prostits
2) Noctouria
3) Haematouria
4) Urine retention
5) Diminished size &strength of stream
-Benign prostatic hypertrophy can present with all, EXCEPT:
a) Nocturia.
b) Hematuria.
c) urinary retention.
d) poor stream.
e) prostatitis.
11- Patient oliguria one contraindicated:
a) l.V. ringer lactate
b) I.V.P
12- A no.20 French catheter is:
a) 20 cm long
b) 20 mm in circumference
c) 20 dolquais (French measurement) in diameter
d) 20 mm in diameter
e) 20 mm in radius

French catheter scale

Sizing scale of the French catheter system

The French scale or French gauge system (most correctly abbreviated as Fr, but also often abbreviated as FR or F) is
commonly used to measure the size (diameter) of a catheter. 1 Fr = 0.33 mm, and therefore the diameter of the catheter
in millimeters can be determined by dividing the French size by 3:
D (mm) = Fr/3
or
Fr = D (mm) 3
For example, if the French size is 9, the diameter is 3 mm. Note that the French scale is a measurement of the diameter,
not the circumference (diameter ).
An increasing French size corresponds to a larger-diameter catheter. This is contrary to needle-gauge size, where the
diameter is 1/gauge, and where the larger the gauge the narrower the bore of the needle.
The Stubs Iron Wire Gauge system is also commonly used in a medical setting, and is in fact more common for
measuring needles, even though many find the Stubs system to be more confusing because the scale is non-linear and
inversely proportional.
The French gauge was devised by Joseph-Frdric-Benot Charrire, a 19th-century Parisian maker of surgical
instruments, who defined the "diameter times 3" relationship.
In some countries (especially French-speaking), this unit is called Charriere and abbreviated as Ch.
Size correspondence
French
Diameter
Diameter
Gauge
(mm)
(inches)
3
1
0.039
4
1.35
0.053
5
1.67
0.066
6
2
0.079
7
2.3
0.092
8
2.7
0.105
9
3
0.118
10
3.3
0.131
11
3.7
0.144
12
4
0.158
13
4.3
0.170
14
4.7
0.184
15
5
0.197
16
5.3
0.210
17
5.7
0.223
18
6
0.236
19
6.3
0.249
20
6.7
0.263
22
7.3
0.288
24
8
0.315
26
8.7
0.341
28
9.3
0.367
30
10
0.393
32
10.7
0.419
34
11.3
0.445

13- Concerning urinary calculi, which one of the follwing is true?

a) 50% are radiopaque
b) 75% are calcium oxalate stones
c) An etiologic factor can be defined in 80% of cases
d) A 4-mm stone will pass 50% of the time
e) Staghorrn calculi are usually symptomatic

14- Screening program for prostatic Ca, the following is true:

- Tumor marker (like PSA) is not helpful
- PR examination is the only test to do
- Early detection does not improve over all survival
-
Screening
Advances in transrectal ultrasound (TRUS) and prostate-specific antigen (PSA) monitoring have
allowed for enhanced detection of nonpalpable tumors. Much controversy currently exists over
whether men over age 50 should be encouraged to undergo screening. While available data show a
decrease in the mortality rate of prostate cancer, there is as yet little evidence that screening has
been the cause of this change. Even so, the realities of clinical practice are that the combination of
digital rectal examination and serum PSA monitoring is the most effective screening protocol.
15- 35 Y/O presented with left iliac pain and dysuria, management include all the following
except:
blood C+S.
microscopy of urine.
IVP.
urine C+S.
norfloxacin.
16- Laprascopy could be used in all, except:
a) Infertility
b) Intestinal obstruction
c) primary amenorrhea
17- Infertility, all true, except:
a) Male factor present 24%
b) Normal semen analysis is >20,000,000
c) Idiopathic infertility is 27%
d) High prolactin could be a cause
eInfertility is defined as the inability to achieve pregnancy after one year of unprotected intercourse. An estimated
15% of couples meet this criterion and are considered infertile, with approximately 35% due to female factors
alone, 30% due to male factors alone, 20% due to a combination of female and male factors, and 15%
unexplained. Conditions of the male that affect fertility are still generally underdiagnosed and undertreated.
Causes of infertility in men can be explained by deficiencies in sperm formation, concentration (eg, oligospermia
[too few sperm], azoospermia [no sperm in the ejaculate]), or transportation. This general division allows an
appropriate workup of potential underlying causes of infertility and helps define a course of action for treatment.
Normal ejaculate volume ranges from 1.5 to 5 mL and has a pH level of 7.05-7.8. The seminal vesicles provide 4080% of the semen volume, which includes fructose for sperm nutrition, prostaglandins and other coagulating
substances, and bicarbonate to buffer the acidic vaginal vault. Normal seminal fructose concentration is 120-450
mg/dL, with lower levels suggesting ejaculatory duct obstruction or absence of the seminal vesicles. The prostate
gland contributes approximately 10-30% (0.5 mL) of the ejaculate. Products include enzymes and proteases to
liquefy the seminal coagulum. This usually occurs within 20-25 minutes. The prostate also secretes zinc,
phospholipids, phosphatase, and spermine. The testicular-epididymal component includes sperm and comprises
about 5% of the ejaculate volume.
An estimated 10-15% of couples are considered infertile, defined by the World Health Organization (WHO) as the
absence of conception after at least 12 months of unprotected intercourse. In American men, the risk correlates to
approximately 1 in 25. Low sperm counts, poor semen quality, or both account for 90% of cases; however, studies
of infertile couples without treatment reveal that 23% of these couples conceive within 2 years, and 10% more
conceive within 4 years. Even patients with severe oligospermia (<2 million sperm/mL) have a 7.6% chance of
conception within 2 years

Sperm density: Normal sperm density is greater than 20 million sperm/mL, or greater than 50-60
million total sperm. Oligospermia is defined as fewer than 20 million sperm/mL, severe
oligospermia is less than 5 million/mL, and azoospermia is defined as no sperm present. To verify
azoospermia, the semen should be centrifuged and evaluated under a light microscope for the
presence of sperm. Patients with azoospermia should have a postejaculatory urine sample
analyzed for sperm, should be evaluated for ejaculatory duct obstruction, and should undergo a
hormonal evaluation.

18- RTA with urethral bleeding. Step of management:

a) Insert foleys cath
b) Stabilize the pelvis
c) Insert suprapubic cath
Treatment
Prehospital Care

Address acute life-threatening conditions. Be very aware that the amount of force necessary to cause a
significant pelvic fracture is likely to have caused other significant injuries.
Application of an external compression device to a grossly unstable pelvis will provide mechanical
stabilization while controlling hemorrhage from the fracture site. A sheet or one of a variety of inexpensive,
commercial products may be used.10
Avoid excessive movement of the pelvis.
Obtain large-bore intravenous (IV) access, and administer analgesia and fluids in accordance with local
protocols.
Closely monitor vital signs.

19- A patient with gross hematuria after blunt abdominal trauma has a normal-appearing
cystogram after the intravesical instillation of 400 ml of contrast. You should next order:
a. A retrograde urethrogram.
b. An intravenous pyelogram.
c. A cystogram obtained after filling, until a detrusor response occurs.
d. A voiding cystourethrogram.
e. A plain film of the abdomen after the bladder is drained.

Injuries to the Kidney

Essentials of Diagnosis
1.
2.
3.
4.

History or evidence of trauma, usually local.

Hematuria.
Flank mass.
Failure to opacify the kidney or extravasation of urine on excretory urography.

General Considerations
Renal injury is uncommon but potentially serious and often accompanied by multisystem trauma. The most common
causes are athletic, industrial, or automobile accidents. The degree of injury may range from contusion to laceration of
the parenchyma or disruption of the renal pedicle.

Clinical Findings
Symptoms and Signs
1. Gross hematuria following trauma means injury to the urinary tract.
2. Pain and tenderness over the renal area may be significant but could be due to musculoskeletal injury.
3. Hemorrhagic shock may result from renal laceration and lead to oliguria.
4. Nausea, vomiting, and abdominal distention (ileus) are the rule.
5. Physical examination may reveal ecchymosis or penetrating injury in the costovertebral angle or flank.
6. Extravasation of blood or urine may produce a palpable flank mass.
7. Other injuries should be sought.

Laboratory Findings
1.
2.

Serial hematocrit determinations will give clues to persistent bleeding.

Hematuria is to be expected, but the absence of hematuria does not exclude renal injury (as in renal vascular
injury).

Imaging Studies
1.

A plain film may reveal obliteration of the psoas shadow; this suggests the presence of a retroperitoneal hematoma
or urinary extravasation. Bowel gas may be displaced from the area. Evidence of transverse vertebral process
fractures or rib fracture may be noted.
In the past the excretory urogram was used for evaluating renal trauma. Excretory urograms may show a normal
kidney if it is mildly contused or may show extravasation of contrast medium if the kidney is lacerated.
Nonfunction suggests injury to the vascular pedicle. The excretory urogram should demonstrate that the
contralateral kidney is normal.

2.

CT scan with intravenous contrast medium is now the method of choice for staging a patient with
hemodynamically stable renal trauma. CT scans may miss urinary extravasation if performed too rapidly
following intravenous contrast administrationbefore the contrast is excreted into the collecting system and ureter.

3.

If renal vascular damage is suspected and the patient's condition is stable, preoperative renal angiography may
facilitate planning of renovascular reconstruction or permit arterial stenting. In special circumstances, selective
renal artery embolization may control segmental arterial bleeding.

Renal imaging is indicated in

1. any adult with gross hematuria or microscopic hematuria with shock.
2. with deceleration injuries
3. children with any hematuria > 50 red blood cells per high-power field.

Differential Diagnosis
Bony fractures or contusion of soft tissues in the region of the kidney may cause confusion.
Hematuria might be secondary to vesical injury. The absence of a perirenal mass (ie, hematoma or urinoma) or contrast
extravasation on urograms or CT scan would rule out significant trauma.

Complications
Early
1.

2.
3.

The most serious complication is continued perirenal hemorrhage, which may be fatal. Serial hematocrit, blood
pressure, and pulse determinations are essential. Serial CT scans may also be useful. Evidence of an enlarging flank
mass implies persistent bleeding. In most cases, bleeding stops spontaneously, probably as a result of tamponade by
the perirenal fascia.
Delayed bleeding 1 or 2 weeks later is rare.
Infection of the perirenal hematoma may occur.

Late

Ultrasound should be obtained 13 months after surgery to look for progressive hydronephrosis from ureteral
obstruction. The blood pressure should be checked at regular intervals, because hypertension may be a late sequela.

Treatment
1.
2.
3.
4.
5.
6.
7.

Treat shock and hemorrhage with fluids and transfusion.

Most patients with blunt renal trauma stop bleeding and heal spontaneously.
Bed rest is indicated until hematuria resolves.
If bleeding persists, laparotomy is indicated.
Penetrating renal trauma requires exploration.
Lacerations may be sutured, the collecting system closed, and urinary extravasation drained.
Nephrectomy or partial nephrectomy may be necessary to remove devitalized tissue and secure the collecting
system.
8. Late complications may occur.
9. Perinephric abscess should be drained.
10. Hypertension due to renal ischemia requires vascular reconstruction or nephrectomy.

Prognosis
Most injured kidneys heal spontaneously, though the patient must be examined at intervals for the onset of hypertension
due to renal ischemia or progressive hydronephrosis due to secondary ureteral stricture. Many patients with
genitourinary trauma have associated injuries. In most cases, death is due to associated injury rather than renal injury.

20- The most likely cause of gross hematuria in a 35-year-old man is:
a) cystitis
b) ureteral calculi
c) renal carcinoma
d) prostatic carcinoma
e) bladder carcinoma