Urology Frequency of urological problems lurolithiasis (3-7% of the population) incontinence (20-70% of older women) subvesical obstruction in benign prostatic hyperplasia (50% of men) prostate cancer (the most common cancer in men, the second cause of Ca death in men). l Symptomatology of urological diseases lThe entire urogenital system should always be examined for every symptom of urological disease history of: - pain, temperature, micturition character - injuries, CNS diseases, childhood diseases the basic requirement is always - urine examination chemically, microscopically and biochemically, measuring micturition frequency and volume l Changes in urine appearance lmacroscopic hematuria (by color - intensity and age of hematuria), uretrorrhagia (bloody discharge from the urethra), pyuria (purulent, sometimes stinking urine), hemoglobinuria (urine stained with free hemoglobin in the absence of erythrocytes), pneumaturia (air in the urine when fistula between intestine and urinary tract), crystalluria (it is obligatory in older urine) chyluria (communication with the lymphatic system in filariasis, rare l Pathological changes in the amount of urine lQuantity changes Polyuria increased urine in 24 hours Beware, frequent urination is polakisuria! Oliguria drop of dispensing below 300 ml / 24 hours Anuria prerenal, renal and subrenal l Urological symptoms lstranguria (cutting during urination) urgency (urge to urinate) polakisuria (frequent urination) nocturia (nocturnal urination) anuria (absence of urine) retention (urinary retention in the bladder) incontinence (failure to retain urine) enuresis (nocturnal incontinence) residue (urine residue after urination) l Urinary disorders lIncontinence - stressful - urgent - reflective - from overflow (ischuria paradoxa) Enuresis nocturna Nykturia (release of retained urine) l Etiology of urinary disorders lUrgent urination- frequent, painful urination - inflammation, combination with tumors, foreign bodies, stones, TB, interstitial cystitis Retarded, delayed urination - benign prostatic hyperplasia Prolonged urination - a thin stream Intermittent urination - valves, stones Urination in parts - diverticulum, reflux Retention, residue - residual urine in subvesical obstruction l Pain of the urogenital system lKidney - nephralgia - how many lBladder - mostly associated with micturition disorder lUretra - rusty or burning lProstate and seminal vesicles - dull pains in the perineum, rectum and surrounding area lTesticles and epididymis - primary or secondary testalgia l Examination in urology lAnamnesis Physical exam Laboratory examination (urine and blood) Imaging methods - Ultrasonography - X-ray - Isotopes Endoscopic methods Examination of urinary tract function l Physical examination in urology lPerspective – Aspects - View tumors, cysts, abdominal wall contractions Palpation bimanual, examination of the bladder, scrotum, penis, urethra examination per rectum Percussion Listening - aneurysm l Palpation l llarger kidney tumors (bimanual palpation), lmovable kidney in ptosis, filled bladder, lchanges in penis and scrotum l C:\Obrazy\Díl 4 skripta,Olomouc,operace\Anatomická schémata\bimpalp.jpg Digital rectal examination C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\per rectum palp.jpg C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\per rectum palpace.jpg Examination per vaginam C:\Obrazy\Díl 4 skripta,Olomouc,operace\Anatomická schémata\per vaginal.jpg For women in indicated cases: Ureterolithiasis Incontinence Urinary fistula Tumors percussion lTapping - (tapottement) with the little finger – hand - edge in the lumbar region examines the sensitivity of the kidney hearing lListening is less used in urology, but it will help reveal aortic vortex in a dissecting aortic aneurysm, which may have similar symptomatology to renal colic. Differential diagnosis of pain (what is necessary to exclude ...) lIschiadic syndrome Herpes Biliary colic Abdominal colic Perinephric abscess Appendicitis Pankreatitis Gynecological diseases l C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\kostovert.úhel.jpg Laboratory examination lBiochemical urine examination (indicator papers) - pH, presence of protein, ketone bodies, bile pigments, - nitrites as indicators of bacterial infection Urinary sediment examination - Qualitative - Quantitative (Hamburger or Addis collections) Blood tests (urea, creatinine, uric acid, mineralogram, ABR, osmolarity) l Urine examination lMedium current - First current - Final current Catheterized urine (sterile collection in women) Suprapubic puncture C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\punkce mm.jpg hematuria lmacroscopic, microscopic. linitial, total and terminal lpainless, painful Hemoglobinuria Uretrorhagie l C:\Dokumenty\PowerPoint pásma\Chudobín\R_Hematur.jpg Examination of stones lAppearance lChemical examination lMineralographic examination - crystallography -Spectroscopy -X-ray diffraction -Polarization examination l C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\weddelit krystal.jpg Urological aids and materials Marking of catheters and catheters lThe circumference of the catheter is critical to clinical use - Chariere - French – C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\char_mmtab.jpg Types of catheter C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\katetry.jpg Disposable catheters C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\thieman.jpg C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\nelaton.jpg Nelaton Thiemann Fixation of catheters C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\malecot.jpg C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\katetrves.jpg Foley C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\foleykat.jpg Woman catheterizing C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\cevkovaní ženy.jpg Man catheterizing C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\katetrizace.jpg C:\Prezentace PowerPoint\semináře PRO MEDIKY\definitivní 5 ročník 1.den\A_Pondělí\Medici\katetrizace muže.jpg Derivating performance lDrainage through the lower urinary tract catheter double pigtail lNephrostomy puncture operating lOperational derivative reconstruction The main problem of urology – drainage – impendimenta: C:\Obrazy\Descscan\kameny.tif upper urinary tract: stones external ureter oppression rarely tumors lower urinary tract: benign prostatic hypertrophy tumors urinary stones Ureter drainage lureteral catheter ureteral double (pigtail) nephrostomy stent C:\Obrazy\Descscan\doublepigobr.tif Percutaneous nephrostomy lAcute and long-term drainage lMinimally invasive procedure lOpen road to kidney lGood function control l C:\Dokumenty\Publikace knihy\obrázky\obr.19 schéma perkutánní nefrostomie.jpg Seldinger technique nephrostomy C:\Obrazy\Descscan\nefrostep1.tif C:\Obrazy\Descscan\nefrostep2.tif C:\Obrazy\Descscan\nefrostep3.tif C:\Obrazy\Descscan\nefrostep4.tif C:\Obrazy\Descscan\nefrostep5.tif puncture wire conductor dilatation nephrostomy removal of mandrene Epicystostomy C:\Dokumenty\PowerPoint pásma\Chudobín\PUNKČNÍ EPICYSTOSTOMIE.jpg Ureteral catheters C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\cevky.jpg „Double pigtail“ C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\doublepigobr.jpg C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\dobpigt.jpg C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\doublepig.jpg Wall stent C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\stentmodel.jpg C:\Obrazy\Díl 4 skripta,Olomouc,operace\kATETRY,MATERIÁL\stenty.jpg CA stenosis Endoscopy in urology Endoscopes in urology lCystoscope Uretroscope Ureterorenoscope Nephroscope Pyeloscope Retroperitoneoscope (laparoscope) Endoscope for examination of cavum serosum scroti Cystoscopy C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\cystosch.jpg Nástavec Okulár Vedení světla Optika Pracovní kanál Objektiv Otvor pro výhled Pracovní délka Nebezpečná délka Optics C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\optikpr.jpg C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\optika2.jpg Cystoscopy and uretroscopy ØCystoscopy -optics tilt angle 70 ° –- to examine the bladder ØPanendoscopy -optics tilt angle 0 ° –- for progressive examination of the urethra and ureter C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\skopie.jpg Flexible tools lCystoscope - thin tool - well flexible - without operating channel - worse orientation about location lUreterorenoscope - for diagnostics C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\flexcyst.jpg Ureterorenoscopy lAccess via urethra and bladder C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\ureteroskopie schema.jpg Cystoscopy lRight ureteral orifice C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\Cystoskopie obrazy\evicevka.jpg Cystoscopy lLeft ureteral orifice C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\Cystoskopie obrazy\USTÍ DX.jpg Cystoscopy lBladder papilloma C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\Cystoskopie obrazy\CYSTITIS.jpg Cystoscopy lCystolithisis C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\Cystoskopie obrazy\evikamech.jpg Cystoscopy lBladder tumor C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\Cystoskopie obrazy\BUL EDÉM.jpg Uretroscopy lStricture of urethra C:\Obrazy\Díl 4 skripta,Olomouc,operace\ENDOSKOPIE\Cystoskopie obrazy\BULBARNI STENOZA.jpg Ureterolithiasis C:\Obrazy\Díl 4 skripta,Olomouc,operace\Operace schemata a obrázky\Atlas operací\126-2.jpg Ureteral tumor C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\ureterkopie Tur tumoru.jpg C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\ureterkopie tumor1.jpg C:\Obrazy\kopie 95\dOPLNĚNÍ OBRÁZKŮ\ureterkopie tumor3.jpg Ureteral catheter C:\WINDOWS\TEMP\~AUT0011.bmp Urgent procedures in urology Characteristics lOften emerged from full health lSerious symptoms altering the patient's condition lNeed urgent solution lOften hospitalization Symptoms lPain Abdominal symptoms Elevated temperature Bladder hematuria and tamponade Urinary retention and anuria Septic syndrome Renal colic lupper urinary tract obstruction syndrome concrement coagulum (tumor!) Necrotic tissue Caseous matter Edema in inflammation or allergy Renal colic lSymptoms lPain lMotor restlessness lNausea, vomiting, intestinal paresis lPolypnoea and bradycardia (vagus) C:\Obrazy\Medici- 5.ročník výukový blok\Obrazová data\Reif\02.bmp Renal colic lDiagnosis Finding on stomach Basic laboratory Imaging examination l - ultrasonography l - X-ray methods C:\Obrazy\Medici- 5.ročník výukový blok\Obrazová data\Reif\03.bmp Renal colic lTherapy Spasmolytics Spazmoanalgetika Antiedematics Ganglioplegics Anodynas Renal colic lComplications are the result of long-term obstruction lInflammatory complications - acute pyelonephritis to urosepse - chronic pyelonephritis with complications Hydronephrotic kidney atrophy (in long-term obstruction without infection) l Acute retention lIt is due to infravesical obstruction lbenign prostatic hyperplasia lprostate cancer lstricture and urethral valves luretrolithiasis Acute retention lHas a positive medical history (dysuria, trauma, utretra discharge) l lCrowded bladder with lower back pain Acute retention lThe distended bladder can be: hammer out feel see found sonographically find out by emptying the catheter Acute retention lTherapy lBladder catheterization: a / single l b) establishing a permanent catheter lSuprapubic evacuation puncture urine. bladder lPuncture epicystostomy lAttention! a / use a soft balloon catheter b / “Drop out twice” (e-vacuo bleeding, not all at once) Oliguria and anuria lReduction of diuresis: oliguria below 400 ml / d (20 ml / h) anuria below 100 ml / d (5 ml / hour) l Functional oliguria (benign) = dehydration in 1.well-functioning kidneys 2.with free upper urinary tract (HMC) = responds well to volumoterapy! Urosepsis lthe infectious agent primarily affects the Urogenital organ lthe disability first alters its function lsepsis is then a set of disorders and organ reactions to them, affecting even the tissues intact by the infection Urosepse - causes by frequency lpyelonephritis, pyonephrosis lEpididymitis lacute prostatitis lurethral (catheter) fever lmale genital gangrene Septic syndrome lpresence of an inflammatory deposit lseptic type of temperature ltachycardia above 90 pulses / min ltachypnoe above 20 breaths / min lOliguria lanxiety, agitation, confusion, sopor Diagnosis of urosepsis lCareful clinical examination of UGT organs lImaging methods (USG, VU, CT) clarify: - conditions of drainage. upper urinary tract - inflammatory infiltration, colitis or retention in the kidney, retroperitoneum and genital area - distinguishes between surgical, gynecological and internal sepsis Urosepsis – th lmonitoring of CVT (central vein cannulation) and lhourly diuresis (permanent catheter) lsanation of the infectious deposit (urine drainage, l abscess emptying, nephrectomy, semi-castration) lantibacterial treatment general therapy (infusion, plasmaexpanders, corticoids, acidosis correction, tenzamine in renal dose) Ø Testicle torsion lactually the torsion of sperm funicular lsudden onset in children and adolescents lshocking pain, nausea and vomiting lwithout signs of inflammation including urine lthe testicle is painful, its elevation does not bring relief lsonographically hydrocele, doppler without blood supply. C:\Obrazy\Medici- 5.ročník výukový blok\Obrazová data\Reif\07t.jpg Testicular torsion - treatment lsurgical treatment within 4-6 hours risk of necrosis: revise if in doubt Vital testis derote, necrotic remove fix even the second testicle Epididymitidis lductogenic inflammation of the epididymis lsubacute onset of swelling and pain llocal and general signs of inflammation, especially urine. honor lpyuria and leukocytosis ltesticular elevation reduces pain lsonographically affected epididymis Epididymitidis - th lwide-spectrum ATB lcorticoids to facilitate their penetration lantipyretics, antiphlogistics lscratch elevation + lining lin the case of failure surgical therapy Orchitidis lhematogenic origin (viruses, pneumococcus, brucella) lor per continuitatem from epididymis llocal and general signs of inflammation lurine without finding lelevation relieves pain lsonographically affected testis Orchititis - th lbroad spectrum antibacterial therapy lantiphlogistics and antipyretics lcalm with elevation scratch lonly in granulomatous chronic forms - semicastration Paraphimosis - characteristics lsupposes the existence of phimosis larises after dragging the foreskin behind the glans lglans swell lymphatic and venous stasis lthe strangulation strip may necrotize Paraphimosis th lpenile anesthesia (mucosal, infiltration) l"Emptying the gland" by compression lonly then the reduction discision of strangulation line lor circumcision