Bladder tamponade is an indication for surgery. Urgent measures in some emergency situations in urology at the prehospital stage. Acute urinary retention

Tamponade bladder can be a consequence of diseases of the genitourinary system, as well as the result of injuries. The main reasons are:

upper urinary tract injuries;
neoplasms of the upper urinary tract;
bladder neoplasms;
varicose veins of the urinary reservoir and prostate gland;
damage to the prostate capsule due to the capsule rupturing.

Bladder cancer is a common cause

Development mechanism

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

There is constant pressure on the muscle that relaxes the bladder, as well as on the neck of the bladder. It is formed due to the fact that it is necessary to overcome infravesicular blockage. Changes in pressure inside the bladder and a large volume of the prostate gland create conditions that lead to capsule rupture. As a result, hematuria occurs.

What are the reasons for incomplete emptying of the bladder?

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

Frequent urination in men should not always be considered normal. Even if there is no frequent urge to empty the bladder unpleasant sensations, discharge and other alarming symptoms, the patient should consult a specialist.

Reasons

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

Bladder cystostomy in men

Ischuria affects men more often than women and children, so they are given a cystostomy more often. Men also experience more discomfort from it, because... their organ is arched.

Indications for its application:

Prostate diseases (adenoma or tumor). Adenoma is an indication for cystostomy in men. As it progresses, it enlarges the prostate gland and can compress the urethra. Ischuria develops. Often the adenoma degenerates into adenocarcinoma, which risks blocking the urethra.
Operations on the bladder or penis. With such interventions, it is often necessary to apply a special catheter.
Neoplasms of the bladder or pelvis have become increasingly common. Tumors are localized in different places, but the most dangerous ones are at the mouth of the ureter or urethra. If the tumor is in the place where the bladder passes into the urethra, then within a few months its growth will lead to anuria (urine will stop flowing into the bladder).
The urethra is blocked by a stone or foreign body. This is a consequence of urolithiasis. The stone can pass through the urethra for more than one day. This interferes with the flow of urine and prevents a catheter from being inserted. Rescue in cystostomy.
There is pus in the bladder, requiring it to be washed out.
The penis is injured.

Carrying out diagnostics and a therapeutic course in some cases requires installing a catheter in the patient’s bladder. Most often, the tube is inserted through the urethra, but it is also possible to place it through the abdominal wall, located in front. The catheter performs the following important functions:

removes urine;
flushes the bladder;
helps administer the medicine.

Reasons

Symptoms

The main manifestations of bladder tamponade are pain when trying to urinate, the urge either does not have an effect, or a small amount of urine is released. Upon palpation, a bulge is detected above the pubis; this is a full bladder. The slightest pressure on it causes pain. A person with bladder tamponade is emotionally labile and has restless behavior.

Based on determining the volume of blood in the bladder, the degree of blood loss is determined. Urine contains fresh or altered blood impurities. It is worth considering that tamponade of the urinary reservoir involves bleeding. The capacity of the bladder in a male is about 300 milliliters, but in fact the volume of lost blood is much greater.

Symptoms of a bladder rupture

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

pale and moist skin;
heartbeat;
weakness and apathy;
dizziness;
increase in heart rate.

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

Anemia is one of the complications of the pathological condition

Prostate adenoma: catheterization or surgery?

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

Technique for performing the procedure:

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

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

Serious complications include:

abdominal puncture;
bladder perforation;
injuries to organs located near the puncture organ;
urine entering the tissue located around the organ;
purulent-inflammatory process in the fiber.

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

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

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

They cannot refuse you surgery because of your age; the heart problem is solved together with a cardiologist and anesthesiologist during the preparation for the operation. If you are refused surgery by one specialist, find another, a third, go to a specialized clinic and regional center, today adenoma can be successfully treated at any age, a catheter with a urine bag is not a death sentence!

Suprapubic capillary puncture: indications for use

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

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

Bladder puncture technique

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

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

The doctor must make sure that the needle goes deep enough so that it cannot slip out. After this, the patient is turned over on his side and tilted slightly forward. Urine flows through a tube attached to the other end of the needle into a special tray. After the bladder is completely emptied, the needle is carefully removed and the manipulation site is treated with alcohol or sterile wipes.

If necessary, bladder puncture is repeated 2-3 times a day. If the procedure needs to be performed regularly, the bladder is punctured and a permanent catheter or drainage is left in place to remove urine. If urine is needed for testing, it is collected in a special syringe with a sterile cap. Before sending the material for testing to the laboratory, the contents are poured into a sterile tube.

Main indications for puncture:

Contraindications to catheterization/inability to remove urine through a catheter.
Injuries to the external genitalia, trauma to the urethra.
Urine collection for reliable laboratory testing.
The bladder is full, and the patient is unable to empty it independently.

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

Indications for the procedure

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

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

If the cystic formation is small and does not manifest itself in any way, patients need to be examined by ultrasound twice a year to monitor the situation.

A common unpleasant consequence of manipulation with a puncture of the urethra is urethral fever. It can occur due to bacteria entering the blood. This happens when injured medical instruments urethra. This complication is accompanied by chills and intoxication of the body. In more severe forms, urethral fever can trigger the occurrence of prostatitis, urethritis or some other serious diseases.

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

Contraindications

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

Clarification of the cause of erythrocyturia.

Better analysis of urine that is not contaminated with foreign flora of the external genital organs.

Identifying the cause of leukocyturia.

Surgery is contraindicated for:

Tamponade.
Paracystitis, acute cystitis.
Small capacity bubble.
Hernia of the inguinal canal.
Neoplasms in the bladder of a benign or malignant type.
Obesity of the third stage.
The presence of scars on the skin in the area of the intended puncture site.

Like any other invasive procedure, bladder puncture has its contraindications. These include:

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

Hemorrhagic diathesis is a contraindication to manipulation

The list of contraindications continues:

history of dissection of the anterior abdominal wall along the linea alba below the navel;
confusion, enlargement or stretching of the peritoneal organs;
the presence of inguinal or femoral hernias;
inflammation of the bladder - cystitis;
abnormalities of organs that are located in the pelvis (cysts, sprains);
infectious lesion of the skin at the puncture site.

There are cases when puncture is impossible. This procedure is prohibited to perform in case of various injuries of the bladder and its low capacity. Manipulation is not advisable for men with acute prostatitis or prostate abscesses. The procedure is prohibited for women during pregnancy. Complications during this manipulation can also occur in patients with complex forms of obesity.

Other contraindications to puncture are:

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

A cystostomy is a hollow tube through which urine is removed directly from the bladder and collected in a special bag that temporarily replaces the bladder. A regular catheter is inserted directly into the urethral canal, and a cystostomy is inserted through the peritoneal wall.

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

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

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

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

What could be the consequences?

At correct installation cystostomy and its proper use, as a rule, side effects does not arise. But the risk of complications cannot be excluded. Practicing urologists have described the following possible pathological reactions and conditions:

Allergy to tube material.
The incision site is bleeding.
The wound is rotting.
The intestines are damaged.
The bladder becomes inflamed.
The tube pulls out spontaneously.
The place where the tube is attached is irritated.
The patient may stop urinating on his own. The ability to urinate atrophies. The body does not strain; the tube does the work for it. Therefore, you should try to urinate yourself within a week after cystostomy.
Urine flows into the peritoneum.
The tube becomes clogged with blood and mucus.
The stoma hole closes.
Blood in the urine after cystostomy.
The walls of the bladder are damaged.
Suppuration around the cystostomy. Mucus or pus on the wound indicates infection. If there is no systemic inflammation, the suppuration is treated with antiseptics.

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

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

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

IMPORTANT! If the patient has polycystic disease or a formation larger than 7 cm, the puncture is considered ineffective.

Can a person's bladder burst? It will not be possible to consciously hold back urination until the organ is overstretched and injured. The bladder is able to withstand severe loads and not burst from overflow in the absence of mechanical obstacles to the drainage of urine. External physical influences on the abdominal wall are dangerous.

When filled, the bladder stretches, the walls become thinner, it begins to protrude beyond the bone and becomes vulnerable to external influences. Especially if it's filled with urine. A blow to the stomach or a fall from a height can cause the bladder to burst. Empty, on the contrary, is elastic and is not injured by shaking.

Let's consider what happens if the bladder bursts, for what reasons this happens, what symptoms will help recognize a dangerous condition.

Classification

Bladder injuries are divided into open (as a result of wounds, road accidents), closed (internal) and bruises. Internal complete bladder rupture is classified into 2 types:

extraperitoneal (accompanied by heavy bleeding, damaged bottom part organ, urine is poured into adjacent tissues);
intraperitoneal (happens more often when the organ is full, characterized by minor bleeding, the upper part of the bladder bursts, urine pours into the abdominal cavity, flooding the internal organs);

With fractures of the pelvic bones, the gap can be mixed.

With closed injuries, the process begins with the inner layer, then affects the muscles and, in extreme cases, the peritoneum.

Warning signs

If a bladder rupture occurs, the symptoms are very characteristic and impossible for a conscious person to ignore:

pain in the area below the navel, above the pubis;
severe swelling in the groin;
feverish state accompanied by chills, deterioration of general health;
acute urinary retention (AUR) and ineffective urge;
if urine is excreted, it is with blood;
sometimes the pain goes to the lumbar region.

For doctors, an important diagnostic step is the insertion of a soft catheter. There will be almost no urine, despite the patient’s prolonged absence of urination. Or the fluid is much larger than the capacity of the bladder and is a mixture of urine, blood and exudate.

A characteristic symptom confirming an intraperitoneal rupture of the bladder will be acute pain when pressing on the anterior abdominal wall, if the hand is quickly removed.

Acute urinary retention

This is an unpredictable condition in which it is impossible to empty the bladder on your own due to frequent urges to do so (difference from anuria).

There are several reasons:

disruption of nerve impulses;
mechanical blockage of the urethra;
injuries of the urinary organs;
psychogenic urinary retention;
poisoning with chemicals and medications.

The doctor will conduct a differential diagnosis to exclude conditions that caused acute urinary retention that are not associated with bladder rupture. In men, urinary retention develops as a result of prostate adenoma and cancer, constipation, bladder tamponade, narrowing of the lumen of the urethra, neurological and infectious diseases, and stones.

In women, the causes of acute urinary retention can also be pregnancy, oncology, diabetes mellitus.

Consequences

If a ruptured bladder is left untreated, the consequences are the same for men and women.

In case of intraperitoneal injury to an organ, the urine that is released is partially adsorbed and causes irritation. internal organs, non-infectious inflammation and peritonitis (urinary) in the future.
With an extraperitoneal complete rupture, blood and urine permeate the nearby tissue to form a urohematoma. Next, the urine breaks down, salt crystals fall out, and purulent inflammation (phlegmon) of the pelvic and retroperitoneal tissues develops. The process spreads to the entire wall of the organ with transition to necrotizing cystitis.

If measures are not immediately taken to hospitalize the victim when the bladder bursts, the consequences will be irreversible, including death.

The process will involve the blood vessels of the pelvis with the formation of blood clots, blockage of the lung artery, infarction of its tissues, and pneumonia. Purulent pyelonephritis will develop in the pelvis, turning into acute renal failure.

Very rarely, the inflammatory process with minor ruptures leads to a slowdown in the development of the purulent-inflammatory process with the formation of ulcers in the tissue.

Treatment

Treatment of complete closed injuries is only surgical. If the bladder bursts slightly or a bruise occurs, urine does not flow beyond its boundaries. Layer-by-layer hemorrhages are formed with deformation of the outlines of the organ.

Without treatment, an incomplete rupture resolves without a trace, or leads to tissue inflammation, necrosis and the transition of the process to the stage of complete rupture with the release of urine and further, as described above. An incomplete rupture can occur from the outside when the wall of the bladder is injured by bone fragments.

A bruise with an incomplete rupture is treated conservatively. Strict bed rest must be observed, medications are prescribed to eliminate inflammation, stop bleeding, antibiotics, and analgesics. To prevent the development of a two-stage rupture and independent scarring of the bladder wall, a catheter with permanent urine drainage is installed for 7-10 days.

Internal incomplete rupture with venous bleeding stops. When the arteries rupture, the blood does not clot and tamponade develops.

Hemorrhages

Bladder tamponade, what is it? This is a state of AUR (complete cessation of its excretion) due to the filling of the MP cavity with clots of coagulated blood. The causes of hemorrhage are various: diseases of the kidneys and urinary tract, trauma, tumors, prostate adenoma, rupture of its capsule, bleeding from varicose veins of internal organs.

Each new portion of blood increases the number of clots. Bladder tamponade is characterized by a painful and unsuccessful urge to urinate, increasing pain when pressing on the suprapubic area, and patient nervousness. If you manage to get portions of urine, they are mixed with blood.

Despite the fact that the capacity of the bladder in men is 250-300 ml, blood loss during tamponade is much greater, which is manifested by obvious anemia (pallor of the skin, rapid heartbeat, increased blood pressure, dizziness).

By introducing a catheter it is possible to partially alleviate the patient's condition, but the lumen of the tube also becomes clogged with clots. It is not possible to completely empty the bladder. If an attempt to wash away blood clots is unsuccessful, treatment for tamponade is surgery.

First aid

If, as a result of an abdominal injury, the victim exhibits characteristic symptoms (the bladder has burst, or the pelvic bones are fractured), it is necessary to urgently call an emergency team, and the victim should put an ice pack on the stomach.

Sources

Guide to urology in 3 volumes / ed. N. A. Lopatkin. – M.: Medicine, 1998. T 3 P. 34-60. ISBN 5-225-04435-2

Situations requiring urgent intervention occur quite often in urological practice. These include renal colic, acute pyelonephritis, urinary retention, gross hematuria. Rapid recognition and differentiated treatment of these conditions reduces the likelihood of complications and increases the duration of the effect of the therapy.

Clinical picture and diagnostic criteria

Patients suffer from bladder overflow: painful and fruitless attempts to urinate, pain in the suprapubic region; The patients' behavior is characterized as extremely restless. Patients with central diseases react differently. nervous system and spinal cord, which are usually immobilized and do not experience severe pain. When examined in the suprapubic region, a characteristic bulge is determined, caused by an overfilled bladder (“vesical ball”), which upon percussion produces a dull sound.

In order to provide the patient with timely and qualified assistance, it is necessary to clearly understand the mechanism of development of acute urinary retention in each individual case. In case of acute urinary retention, it is necessary to urgently evacuate urine from the bladder. Considering the danger of urinary tract infection in the absence of a pronounced urge to urinate, it is better to perform catheterization in a hospital setting. Expressed pain syndrome, caused by overdistension of the bladder, is an indication for catheterization at the prehospital stage.

Bladder catheterization should be treated as a serious procedure, equating it to surgery. In patients without anatomical changes in the lower urinary tract (with diseases of the central nervous system and spinal cord, postoperative ischuria, etc.), bladder catheterization usually does not present any difficulties. For this purpose, various rubber and silicone catheters are used.

The greatest difficulty is catheterization in patients with benign prostatic hyperplasia (BPH). With BPH, the posterior urethra lengthens and the angle between its prostatic and bulbous sections increases. Given these changes in the urethra, it is advisable to use catheters with Tieman or Mercier curvature. With rough and violent insertion of a catheter, serious complications are possible: the formation of a false passage in the urethra and prostate gland, urethrorrhagia, urethral fever. Prevention of these complications is careful adherence to asepsis and catheterization techniques.

The need for catheterization often arises in elderly patients, as well as in persons with severe concomitant pathologies, including diabetes mellitus, circulatory disorders, etc. In such cases, taking into account the lack of sterile conditions in the ambulance, catheterization must be carried out antibiotic prophylaxis of urinary tract infections (UTIs).

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

As an alternative, you can use amoxicillin/clavulanate or cephalosporins II - III generations (cefuroxime axetil, cefaclor, cefixime, ceftibuten).

For preventive purposes, these antibacterial drugs can be used orally.

In acute prostatitis (especially those resulting in an abscess), acute urinary retention occurs due to deviation and compression of the urethra by the inflammatory infiltrate and swelling of its mucosa. Bladder catheterization is contraindicated in this disease. Acute urinary retention is one of the leading symptoms in patients with urethral trauma. In this case, catheterization of the bladder with diagnostic or therapeutic purpose also unacceptable.

Acute urinary retention due to stones in the bladder occurs when a stone wedges into the neck of the bladder or obstructs the urethra in its various parts. Palpation of the urethra helps diagnose stones. For urethral strictures that lead to urinary retention, an attempt to catheterize the bladder with a thin elastic catheter is possible.

The cause of acute urinary retention in elderly and senile women may be uterine prolapse. In these cases, it is necessary to restore the normal anatomical position of the internal genital organs, and urination is also restored (usually without prior catheterization of the bladder).

Casuistic cases of acute urinary retention include foreign bodies in the bladder and urethra, which injure or obstruct the lower urinary tract. Urgent Care consists of removing the foreign body; however, this manipulation can only be performed in a hospital setting.

In case of reflex urinary retention (for example, with postpartum, postoperative ischuria), you can try to induce urination by irrigating the external genitalia warm water, by pouring water from one vessel to another (the sound of a falling stream of water can reflexively cause urination); if these methods are ineffective and there are no contraindications, 1 ml of a 1% solution of pilocarpine or 1 ml of a 0.05% solution of prozerin is administered subcutaneously; if ineffective, bladder catheterization is indicated.

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

Gross hematuria

Definition. Hematuria - the appearance of blood in the urine - is one of the characteristic symptoms of many urological diseases. There are microscopic and macroscopic hematuria; the occurrence of intense gross hematuria often requires emergency care.

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

Clinical picture and classification. The appearance of red blood cells in the urine gives it a cloudy appearance and a pink, brown-red or reddish-black color, depending on the degree of hematuria.

Macrohematuria can be of three types: 1) initial (initial), when only the first portion of urine is colored with blood, the remaining portions are of normal color; 2) terminal (final), in which no blood admixture is visually detected in the first portion of urine and only the last portions of urine contain blood; H) total, when urine in all portions is equally colored with blood. Possible causes of gross hematuria are presented in.

Gross hematuria is often accompanied by an attack of pain in the kidney area, since a clot formed in the ureter disrupts the outflow of urine from the kidney. With a kidney tumor, bleeding precedes pain (“asymptomatic hematuria”), while with urolithiasis, pain appears before the onset of hematuria. Localization of pain during hematuria also allows us to clarify the localization of the pathological process. Thus, pain in the lumbar region is characteristic of kidney diseases, and in the suprapubic region - for lesions of the bladder. The presence of dysuria simultaneously with hematuria is observed when the prostate gland, bladder or posterior urethra is affected. The shape of blood clots also allows us to determine the localization of the pathological process. Worm-shaped clots that form as blood passes through the ureter indicate a disease of the upper urinary tract. Shapeless clots are more typical for bleeding from the bladder, although they can form in the bladder when blood is released from the kidney.

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

Main directions of therapy. With the development of hypovolemia and falls blood pressure restoration of circulating blood volume is indicated - intravenous administration of crystalloid and colloid solutions. Hemostatic agents are not used.

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

Acute pyelonephritis

Definition. Pyelonephritis is a nonspecific infectious and inflammatory process with predominant damage to the interstitial tissue of the kidneys and its pyelocaliceal system.

Etiology and pathogenesis. The causative agents of pyelonephritis can be Escherichia coli, less often - other gram-negative bacteria (for example, Pseudomonas aeruginosa), staphylococci, enterococci, etc. Possible ways of infection of the kidneys are ascending (urinogenic), hematogenous (in this case, the source of infection can be any purulent-inflammatory process in body - otitis media, tonsillitis, mastitis, pneumonia, sepsis, etc.). Predisposing factors - immunodeficiency, obstruction of the urinary tract (urolithiasis, various anomalies of the kidneys and urinary tract, strictures of the ureter and urethra, prostate adenoma, etc.), instrumental studies of the urinary tract, pregnancy, diabetes mellitus, old age, etc. According to the conditions occurrences are distinguished between primary pyelonephritis (without any previous disorders of the kidneys and urinary tract) and secondary (arising on the basis of organic or functional processes in the kidneys and urinary tract, reducing the resistance of the kidney tissue to infection and disrupting the outflow of urine). In general, pyelonephritis develops more often in women, especially at a young age, which is associated with the anatomical, physiological and hormonal characteristics of the female body. In old age, the disease is more common in men due to the development of prostate adenoma.

The classification of acute pyelonephritis is presented in.

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

General symptoms: increased body temperature, severe chills followed by profuse sweating, nausea, vomiting, inflammatory changes in blood tests.

Local symptoms: pain and muscle tension in the lumbar region on the affected side, sometimes dysuria, cloudy urine with flakes, polyuria, nocturia, pain when tapping the lower back.

During acute pyelonephritis, the stages of serous and purulent inflammation are distinguished. Purulent forms develop in 25 - 30% of patients. These include apostematous (pustular) pyelonephritis, carbuncle and kidney abscess.

Treatment algorithm for acute pyelonephritis

Full treatment is possible only in a hospital setting; at the prehospital stage, only symptomatic therapy is possible, implying the use of non-steroidal anti-inflammatory drugs and antispasmodics (see section Renal colic).

Prescribing broad-spectrum antibacterial drugs without clarifying the state of urodynamics of the upper urinary tract and restoring urine passage leads to the development of an extremely serious complication - bacteriotoxic shock, with a mortality rate of 50 - 80%.

Indications for hospitalization. Patients with acute pyelonephritis require urgent hospitalization for a detailed examination and determination of further treatment tactics.

D. Yu. Pushkar, Doctor of Medical Sciences, Professor
A. V. Zaitsev, Doctor of Medical Sciences, Professor
L. A. Aleksanyan, Doctor of Medical Sciences, Professor
A. V. Topolyansky, Candidate of Medical Sciences
P. B. Nosovitsky
MGMSU, NNPO ambulance medical care, Moscow

Pay attention!

The effectiveness of treatment for patients with acute urological diseases depends on two factors: the quality of a set of measures aimed at normalizing vital functions, and timely delivery of the patient to a specialized hospital.
Renal colic is a symptom complex that occurs when there is an acute (sudden) disruption of the outflow of urine from the kidney, which leads to the development of pyelocaliceal hypertension, reflex spasm of the arterial renal vessels, venous stasis and edema of the parenchyma, its hypoxia and overstretching of the fibrous capsule.
In acute prostatitis (especially those resulting in an abscess), acute urinary retention occurs due to deviation and compression of the urethra by the inflammatory infiltrate and swelling of its mucosa.

DEFINITION.

Hematuria - the appearance of blood in the urine - is one of the characteristic symptoms of many urological diseases. There are microscopic and macroscopic hematuria; the occurrence of intense gross hematuria often requires emergency care.

ETIOLOGY AND PATHOGENESIS.

Possible causes of hematuria are presented in table.

CAUSES OF BLEEDING FROM THE URINARY SYSTEM ORGANS

(Pytel A.Ya. et al., 1973).

Causes of hematuria	Pathological changes in the kidney, blood diseases and other processes
Congenital diseases	Cystic diseases of the pyramids, papillary hypertrophy, nephroptosis, etc.
Mechanical	Trauma, stones, hydronephrosis
Hematological	Blood coagulation disorders, hemophilia, sickle cell anemia, etc.
Hemodynamic	Disorders of the blood supply to the kidney (venous hypertension, infarction, thrombosis, phlebitis, aneurysms), nephroptosis
Reflex	Vasoconstrictor disorders, shock
Allergic	Glomerulonephritis, arteritis, purpura
Toxic	Medicinal, infectious
Inflammatory	Glomerulonephritis (diffuse, focal), pyelonephritis
Tumor	Benign and malignant neoplasms
“Essential”

CLINICAL PICTURE AND CLASSIFICATION.

The appearance of red blood cells in the urine gives it a cloudy appearance and a pink, brown-red or reddish-black color, depending on the degree of hematuria. With macrohematuria, this color is noticeable when examining urine with the naked eye; with microhematuria, a significant number of red blood cells are detected only when examining urine sediment under a microscope.

To determine the localization of the pathological process during hematuria, a three-glass test is often used, in which the patient needs to urinate successively into 3 vessels. Macrohematuria can be of three types:

1) initial (initial), when only the first portion of urine is blood-colored, the remaining portions are of normal color;

2) terminal (final), in which no blood admixture is visually detected in the first portion of urine, and only the last portions of urine contain blood;

H) total, when urine in all portions is equally colored with blood.

Possible causes of gross hematuria are presented in table.

TYPES AND CAUSES OF MACROHEMATURIA.

Types of gross hematuria	Causes of macrohematteria
Initial	Damage, polyp, cancer, inflammation in the urethra.
Terminal	Diseases of the bladder neck, posterior urethra and prostate gland.
Total	Tumors of the kidney, bladder, adenoma and prostate cancer, hemorrhagic cystitis, etc.

The shape of blood clots also allows us to determine the localization of the pathological process. Worm-shaped clots that form as blood passes through the ureter indicate a disease of the upper urinary tract. Shapeless clots are more typical for bleeding from the bladder, although they can form in the bladder when blood is released from the kidney.

DIAGNOSTIC CRITERIA.

The diagnosis of hematuria may be suspected during the first examination of the patient; urine sediment is examined for confirmation. When diagnosing hematuria, the emergency physician should obtain answers to the following questions.

1) Do you have a history of urolithiasis or other kidney diseases? Is there a history of trauma? Is the patient receiving anticoagulants? Do you have a history of blood diseases or Crohn's disease?

Need clarification possible reason hematuria.

2) Did the patient consume foods (beets, rhubarb) or medicines(analgin, 5-NOK), which can turn urine red

Hematuria and urine staining of another cause are differentiated.

3) Is the discharge of blood from the urethra associated with the act of urination.

It is necessary to differentiate between hematuria and urethrorrhagia

4) Has the patient had any poisoning, blood transfusions, or acute anemia?

It is necessary to differentiate between hematuria and hemoglobinuria that occurs with massive intravascular hemolysis of red blood cells.

MAIN AREAS OF THERAPY.

If gross hematuria occurs, especially painless, immediate cystoscopy is indicated to determine the source of bleeding or at least the side of the lesion, since with tumor processes the hematuria may suddenly stop, and the opportunity to determine the lesion will be lost. The position formulated in 1950 by I. N. Shapiro that any unilateral significant renal bleeding should be considered a sign of a tumor until another cause of hematuria is discovered remains fully relevant. Only after a diagnosis has been established, or at least the side of the lesion, can the use of hemostatic agents begin.

To assess the danger of emerging hematuria, it is important to determine the level and dynamics of blood pressure, hemoglobin content, the severity of tachycardia, and determination of blood volume. It is especially important to study these indicators when, in addition to hematuria, internal bleeding is also possible (for example, with a kidney injury). Thus, treatment tactics for hematuria depend on the nature and location of the pathological process, as well as the intensity of bleeding.

1) Hemostatic therapy:

a) intravenous infusion of 10 ml of 10% calcium chloride solution;

b) administration of 100 ml of a 5% solution of e-aminocaproic acid intravenously;

c) administration of 4 ml (500 mg) of 12.5% dicinone solution intravenously;

2) rest and cold on the affected area.

3) transfusion of fresh frozen plasma.

With profuse total hematuria, the bladder is often filled with blood clots and independent urination becomes impossible. Bladder tamponade occurs. Patients develop painful tenesmus, and a collaptoid state may develop. Bladder tamponade requires immediate treatment. Simultaneously with the blood transfusion and hemostatic drugs, they begin to remove clots from the bladder using an evacuation catheter and a Janet syringe.

COMMON THERAPY ERRORS.

Urethrorrhagia, in which blood is released from the urethra outside the act of urination, should be distinguished from hematuria. Urethrorrhagia most often occurs when the integrity of the wall of the urethra is violated or a tumor appears in it. If there is evidence of an inflammatory process or tumor of the urethra, urgent urethroscopy and stopping bleeding by electrocoagulation or laser ablation of the affected area is necessary. If a urethral rupture is suspected, attempting to insert a catheter or other instruments into the bladder is strictly contraindicated, as this will aggravate the injury.

To avoid mistakes, remember that a change in the color of urine can be caused by taking medicines or food products (beets). The occurrence of hematuria occurs with extrarenal diseases ( typhoid fever, measles, scarlet fever, etc.; blood diseases, Crohn's disease, overdose of anticoagulants).

INDICATIONS FOR HOSPITALIZATION.

For gross hematuria, hospitalization is indicated. Bleeding that threatens the patient’s life and the lack of effect from conservative treatment is an indication for urgent surgical intervention (nephrectomy, resection of the bladder, ligation of the internal iliac arteries, emergency adenomectomy and others).

Bladder bleeding is most often observed after open adenomectomy or TUR of prostate adenoma.

Blood intensively entering the lumen of the bladder after adenomectomy or TUR of the prostate due to inadequate hemostasis leads to the formation of a blood clot in the bladder. The clinical picture of bladder tamponade develops.

Most common cause bleeding from the adenoma bed is incomplete removal of adenomatous tissue, damage to the bladder neck or adenoma capsule. The cause of bleeding may also be a blood clotting disorder, therefore, if bleeding occurs after adenomectomy, a coagulogram must be performed and the concentration of D-dimers in the blood serum must be determined.

Blood clots clog the lumen of the drainage tubes, urine flow through them stops, and bladder tamponade develops. Patients complain about severe pain above the womb, painful urge to urinate. A sharply painful bladder is palpated above the pubis. A blood test shows a decrease in the number of red blood cells and hemoglobin. An ultrasound can confirm the presence of blood clots in the bladder.

If bladder tamponade with blood clots is diagnosed, an attempt should be made to evacuate them with an evacuation catheter. If it is possible to evacuate blood clots from the bladder, then it is necessary to drain the bladder with a Foley catheter through the urethra, the catheter balloon is filled with 40 ml of solution and a traction is attached to the catheter, which allows you to press the neck of the bladder and stop the flow of blood from the adenoma bed into its lumen. It is necessary to establish constant lavage of the bladder antiseptic solution and carry out hemostatic and antibacterial therapy. The tension on the catheter is released after 24 hours; the bladder flushing system should function for 3–5 days.

If the evacuation catheter fails to remove blood clots from the bladder, then a cystotomy must be performed. Blood clots are removed and the source of bleeding is determined. When blood flows from the adenoma bed, a digital inspection is performed. The remaining fragments of the adenoma lobes are removed. A Foley catheter is passed through the urethra into the bladder and its balloon is inflated in the bed of the adenoma until blood flow into the bladder stops. After surgery, constant rinsing of the bladder with furatsilin is necessary.

If intense bleeding after adenomectomy is not accompanied by the formation of blood clots, then this is a sign of coagulopathic bleeding and the development of DIC syndrome. The fight against such bleeding is carried out under the control of coagulogram parameters and D-dimers (for details on hemostatic measures for DIC syndrome, see “Acute pyelonephritis”).

Bleeding after TUR of prostate adenoma is also clinically manifested by bladder tamponade. Blood clots are removed using an evacuation catheter. Then a resectoscope tube is passed through the urethra to examine the area of the resected adenoma in order to search for a bleeding vessel and coagulate it. After good hemostasis is achieved, the bladder is drained with a Foley catheter and continuous lavage of the bladder is established.