L.M.Rapoport, V.V.Borisov, D.G.Tsarichenko

Bleeding in the immediate postoperative period after prostate surgery, the frequency of its occurrence does not depend on the type of adenomectomy (transurethral resection, evaporation, transvesical or retropubic adenomectomy). As a rule, it occurs at certain times after surgery (6-8, 12-14, 19-21 days) and is associated with phlebothrombosis of the pelvis, which causes the development of varicose veins of thin-walled veins of the submucosal layer of the bladder neck and prostatic urethra. A significant increase in venous pressure under conditions of venous stasis due to phlebothrombosis can lead to vein rupture and profuse bleeding. It is manifested by sharp pain due to sudden overflow of the bladder with blood, urine and blood clots, collapse and other circulatory disorders against the background of acute, sometimes very significant blood loss.

It is well known that in order to eliminate this complication it is necessary first of all to empty the bladder of blood clots, since this is what can lead to the elimination of its overdistension, reduction of the detrusor and reduction of bleeding. Final hemostasis is carried out by passing a Foley catheter through the urethra, inflating its balloon and tensioning the catheter for the purpose of prolonged compression of the bleeding vessels of the neck and prostatic bed against the background of subsequent constant drip lavage of the bladder. To quickly wash the lumen of the bladder from blood and clots, as a rule, one cystostomy drainage, even of a significant diameter, is clearly not enough. The effect is achieved by passing a special evacuation catheter No. 24-26 and even 28 CH through the urethra into the bladder, followed by the introduction of washing fluid through it and aspiration of blood and clots. This is done blindly, sometimes without taking into account the injection pressure and aspiration of the washing liquid. Excessive pressure on the piston of the Janet syringe when attempting to forcibly wash out the lumen of the bladder during tamponade is fraught with possible vesicoureteral reflux and ascending pyelonephritis, which is very dangerous in the conditions of such a complication. Excessive pressure during suction through the evacuation device, since the holes at its end are lateral, can increase bleeding. These circumstances forced us to look for more rational ways to eliminate bladder tamponade.

For this we use emergency irrigation urethrocystoscopy. It allows you to pass the instrument into the lumen of the bladder under visual control. One large hole at the end of the urethrocystoscope tube allows you to more efficiently and quickly, using a flushing system, and, if necessary, a Janet syringe, evacuate clots from the bladder and lead to its emptying. It is imperative to emphasize the need for thorough anesthesia of the anterior and posterior parts of the urethra. From our point of view, the most rational is the use of rapidly absorbed aqueous solutions of anesthetics (1-2 and even 3% lidocaine solution in an amount of at least 30-40 ml endourethral before manipulation) with the addition of a 1% solution of dioxidine and glycerin. The use of local anesthetics in gel form is less desirable because their absorption of the urethral mucosa is slower, and the quantity to reach its proximal parts is, as a rule, insufficient. The second indispensable condition for such manipulation is the relatively low perfusion pressure of the irrigation system (not higher than 50-60 cm of water column), which is a reliable prevention of vesicoureteral reflux and ascending pyelonephritis. In our observations, a 1.5% sodium chloride solution has worked well for washing the bladder lumen during tamponade. Being a weak hypertonic solution, it does not penetrate through the open vessels of the bed into the bloodstream and does not cause hypervolemia, which can occur when using isotonic solutions.

Visual control of the completeness of evacuation of blood clots from the bladder significantly increases the effectiveness of this procedure, and identification of bleeding vessels allows them to be electrocoagulated by eye to finally stop bleeding. In the event that the source of bleeding cannot be identified, or diffuse bleeding from the vessels of the bed is observed, passing a Foley catheter through the urethra into the bladder with tension on the filled catheter balloon is certainly indicated. The duration of tension should not exceed 6 hours, which prevents the development of urethritis and urethral stenosis. The described approach can be applied not only after surgery, but also in case of bladder tamponade of another nature (bladder tumor, renal bleeding). Quick and effective elimination of tamponade allows you to increase the effectiveness of treatment. The results of providing emergency care to such patients over the past 5 years (25 observations) allow us to recommend this method for widespread use.

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Bladder tamponade

Bladder tamponade is a pathological condition in which the bladder cavity is completely filled with blood clots. This condition is considered by doctors as an emergency, because in connection with it, urination disorders develop, and sometimes acute urine retention.

Why is it developing?

Bladder tamponade 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.

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 larger.

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

How to diagnose?

Bladder tamponade is determined based on complaints and questioning. As a rule, the doctor finds out that there have already been cases of blood in urine. On examination, one notices pronounced pain when pressing in the pubic area, and the patient’s pale and unhealthy appearance.

There is blood in the urinary fluid. When examining men with a finger through the rectum, the doctor identifies a prostate gland that is larger than normal size.

The attending physician must prescribe blood and urine tests. In a general blood test, a decrease in the level of hemoglobin and erythrocyte elements is observed. There is also a pronounced increase in the level of leukocytes in the blood, a shift in the leukocyte count to the left and a high level of erythrocyte sedimentation rate. This happens due to the inflammatory process in the bladder.

In a biochemical blood test, the level of creatinine and uric acid increases. This is explained by the fact that against the background of acute urinary retention and prolonged tamponade, the cleansing ability of the kidneys decreases.

To diagnose tamponade, ultrasound examination of the bladder and prostate gland, as well as the upper urinary tract and kidneys, is used. On an ultrasound, you can see an enlarged prostate due to an adenoma. Blood clots in the form of elements of different echogenicity are observed in the urine reservoir.

Using ultrasound, it is possible to predict quite accurately the amount of blood that is in the cavity of the bladder. But examining the kidneys allows you to diagnose blockage of the urinary tract above the urine reservoir itself.

On ultrasound, this obstruction will be visible as expansion on both sides. The pyelocaliceal system and ureters expand. This type of diagnosis also identifies neoplasms if they are present.

Placing a catheter does not solve the problem, as it immediately becomes clogged with blood clots.

Treatment measures are operational in nature. There are urgent and delayed surgical treatment. Urgent consists of revision of the urine reservoir and removal of the adenoma.

Hemostatics are drugs used for bleeding of various types.

But delayed treatment involves clearing the bladder of blood through the urethra in parallel with antibiotic and hemostatic therapy. Replacement of lost blood is also used. If the bleeding has stopped, then there is time for a full examination and delayed intervention. Tamponade is a very dangerous condition and requires immediate treatment. At the first signs, consult a doctor.

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Urgent measures in some emergency situations in urology at the prehospital stage

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.

As can be seen from table. 1, the number of ambulance calls in Moscow for sudden diseases and syndromes in urology requiring emergency treatment increased by 5.8% from 1997 to 1999.

Renal colic

Definition. 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.

Etiology and pathogenesis

Most often, obstruction of the upper urinary tract is caused by the presence of a stone (calculus) in the ureter. Occlusion of the ureter can also occur with strictures, kinks and torsions of the ureter, with obstruction of its lumen by a blood clot, mucus or pus, caseous masses (with kidney tuberculosis), or a rejected necrotic papilla (see Table 2). Renal colic is a syndrome that only indicates involvement of the kidney or ureter in the pathological process.

Clinical picture. Renal colic is characterized by the sudden appearance of intense pain in the lumbar region, often at night, during sleep, sometimes after physical activity, long walking, bumpy driving, taking large amounts of liquid or diuretics. Typically, pain occurs in the costovertebral angle and radiates to the hypochondrium, along the ureter into the genitals, along the inner surface of the thigh. Less commonly, pain begins along the ureter, and then spreads to the lumbar region on the corresponding side and radiates to the testicle or labia majora. Atypical irradiation of pain is possible (in the shoulder, scapula, in the navel area), which is explained by the wide nerve connections of the renal nerve plexus. Paradoxical pain in the area of a healthy kidney due to reno-renal reflux is often observed. In some patients, pain prevails at the site of irradiation.

Characteristic is the restless behavior of patients who moan, rush about and take the most incredible poses, since they cannot find a position in which the intensity of the pain would decrease. Pallor and cold sweat appear. Sometimes blood pressure rises. Dysuric phenomena quite often (but not always) accompany an attack of renal colic. Dysuria is manifested by frequent, painful urination: the closer to the bladder the stone is localized, the more severe the dysuria.

Renal colic is often accompanied by nausea, repeated vomiting, stool and gas retention, bloating (gastrointestinal syndrome), which makes diagnosis difficult.

Bimanual palpation reveals sharp pain in the kidney area and muscle resistance on the side of the disease. Sometimes it is possible to palpate an enlarged and painful kidney. In some cases, with renal colic, fever, chills, and leukocytosis are observed in the absence of other signs of urinary infection and acute pyelonephritis.

Making a diagnosis of “renal colic” requires an emergency physician to answer the following questions:

Do you have a history of urolithiasis or other kidney diseases (it is necessary to clarify the possible cause of renal colic)?
What are the conditions for the occurrence of pain (colic often occurs after physical exertion, bumpy driving, long walking)?
What is the nature and location of the pain (characterized by acute intense pain in the lower back, in one or another half of the abdomen)?
What is the irradiation of pain (with occlusion of the pelvis stone, pain can irradiate to the lower back and hypochondrium, with occlusion at the level of the border of the upper and middle third of the ureter - to the lower abdomen, with a lower location of the stone - to the groin area, inner thigh, genitals)?
Is there a position in which the pain is relieved (with renal colic, patients look for such a position, but cannot find it)?
Is there a urinary disorder (often accompanies renal colic)?

When treating renal colic, the doctor pursues two main goals: eliminating pain and stopping (eliminating) obstruction. If we recall the stages of the pathogenesis of PC, it becomes clear that the main drug used to relieve pain in PC, which should be in the arsenal of an emergency physician, is diclofenac sodium. The latter is an antagonist of prostaglandin synthesis, which helps to reduce filtration and, thus, intrapelvic pressure. In addition, diclofenac sodium reduces inflammation and swelling in the area of occlusion, inhibits stimulation of the smooth muscles of the ureter, which reduces or even blocks its peristalsis. These effects of diclofenac sodium lead to the relief of pain in PC, and its analgesic effect is the same as that of morphine when administered intravenously.

Diclofenac sodium is used intramuscularly, intravenously, orally, sublingually and rectally.

In addition to diclofenac sodium, indomethacin, piroxicam and other non-steroidal anti-inflammatory drugs are used.

The parenteral dosage of diclofenac sodium is 75 mg, rectal suppositories contain 100 mg of both diclofenac sodium and indomethacin (children's doses - 50 mg).

It is also advisable to use antispasmodics (no-spa, papaverine, platifilin) parenterally, preferably in combination with diclofenac sodium.

One should remember the negative effect of non-steroidal anti-inflammatory drugs on persons with diseases of the gastrointestinal tract (erosions, ulcers), especially during or immediately after their exacerbation. In this case, the drugs of choice are atropine, antidiuretics - desmopressin (a synthetic analogue of vasopressin).

Indications for hospitalization. During an attack of renal colic, patients are subject to hospitalization in urological or surgical hospitals.

Acute urinary retention

Definition. Acute urinary retention means a complete cessation of urination when the bladder is full.

Etiology and pathogenesis. Urinary retention can occur due to a number of reasons presented in table. 3.

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 diseases of the central nervous system and spinal cord, who, as a rule, are immobilized and do not experience severe pain, react differently. 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. Severe pain 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.), catheterization of the bladder 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. The most active against these pathogens are fluoroquinolones (ciprofloxacin, pefloxacin, ofloxacin etc.), the level of resistance of which is less than 3%.

As an alternative, you can use amoxicillin/clavulanate or cephalosporins of the second - third generation (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 for diagnostic or therapeutic purposes is 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. Emergency care involves 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 with warm water, by pouring water from one vessel to another (the sound of a falling stream of water can reflexively induce 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 table. 5.

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 table. 6.

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 develop painful tenesmus and may develop a collapsoid state. Bladder tamponade requires immediate treatment.

Main directions of therapy. With the development of hypovolemia and a drop in 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 table. 7.

Clinical picture. The symptoms of acute pyelonephritis consist of general and local signs of the disease. Initially, acute pyelonephritis is clinically manifested by signs of an 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, the mortality rate of which is 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 emergency medical care, Moscow

Note!

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.

www.lvrach.ru

Bladder cancer

According to WHO, bladder cancer accounts for 3% of all detected malignant diseases and 70% of all neoplasms of the urinary system.

Clinical and morphological classification of bladder cancer. According to the morphological structure, malignant tumors of the bladder are overwhelmingly of epithelial origin. Transitional cell carcinoma occurs with a frequency of 80-90%, adenocarcinoma - 3%, squamous cell carcinoma - 3%, papilloma - 1%, sarcomas of various origins - 3%.

Etiology and pathogenesis. The etiology and pathogenesis of bladder cancer have not been definitively established. Individual risk factors have been identified that are highly likely to cause cancer. For example, it has been known for more than 100 years that people who work with aniline dyes are much more likely to suffer from bladder cancer. This is due to the fact that the breakdown products of aniline dyes, excreted in the urine, have a pronounced carcinogenic effect on the mucous membrane of the bladder. Thus, artists, painters, and interior designers are at risk.

Drivers are at risk. This is due to the carcinogenic effect of gasoline combustion products, as well as the habit of drinking little fluid and retaining urine for a long time. The risk of developing bladder cancer in smokers is 2-5 times higher. Moreover, the likelihood increases with smoking experience.

There is a close connection between malignant tumors and chronic diseases of the bladder, as well as diseases that cause urostasis: prostatic hyperplasia, urethral stricture, etc.

Symptoms. The clinical picture of bladder cancer depends on the stage of the tumor. Ta-T1 neoplasms are usually asymptomatic. One of the first clinical manifestations is macrohematuria or microhematuria, which may appear once and then not bother the patient for a long time.

Massive or long-lasting gross hematuria can cause bladder tamponade, a condition in which blood clots almost completely fill the bladder.

Another danger of ongoing hematuria is a decrease in hemoglobin levels and anemia of the patient. Often this life-threatening condition forces emergency surgery.

As the tumor grows, other symptoms begin to appear, often associated with an infection. Various urinary disorders - dysuria - may occur.

A sign of tumor growth into the muscle layer may be the appearance of pain above the pubis. At first it is associated with the act of urination, and then, as the muscular wall of the bladder grows and infiltrates neighboring organs, the pain becomes constant.

The growth of a bladder tumor often leads to compression of the orifices of the ureters, which interferes with the passage of urine from the kidneys. Such patients develop nagging pain in the lumbar region, often similar to renal colic. Often against this background an attack of acute pyelonephritis occurs.

Diagnostics. Often, with advanced cancer, a tumor can be identified in women by bimanual palpation through the vagina and anterior abdominal wall, in men - through the rectum. Urine tests for bladder cancer show an increase in the number of red blood cells, and blood tests show a decrease in hemoglobin levels, indicating ongoing bleeding.

One way to diagnose bladder cancer is urine cytology, which is usually performed several times. The detection of atypical cells in the urine is pathognomonic for bladder neoplasm. In recent years, another laboratory diagnostic method has appeared, the so-called BTA (bladder tumor antigen) test. Using a special test strip, urine is examined for the presence of a specific bladder tumor antigen. This technique is usually used as a screening diagnostic method.

Ultrasound diagnostics is of great importance in diagnosing bladder cancer. Transabdominal examination can detect tumors larger than 0.5 cm with a probability of 82%. The formations located on the lateral walls are most often visualized. When the tumor is localized in the bladder neck, the use of transrectal examination may be informative. Small neoplasms are best diagnosed using transurethral scanning, performed with a special sensor inserted through the urethra into the bladder cavity. The disadvantage of this study is its invasiveness. It must be remembered that an ultrasound of a patient with a suspected bladder tumor must necessarily include an examination of the kidneys and upper urinary tract in order to identify dilatation of the collecting system as a sign of compression of the ureteral orifice by the tumor.

Large tumors are detected by excretory urography or retrograde cystography. Sedimentary cystography according to Kneise-Schober helps to increase the information content of the study. Spiral and multislice computed tomography with contrast is of great importance in the diagnosis of bladder cancer. Using these techniques, it is possible to establish the size and localization of the formation, its relationship to the orifices of the ureters, germination into neighboring organs, as well as the condition of the kidneys and upper urinary tract. However, this method can be used if the patient is able to accumulate a full bladder and hold urine during the study. Another disadvantage of CT is the insufficient information content in identifying the depth of tumor invasion into the muscle layer due to the low ability to visualize the layers of the bladder wall.

Magnetic resonance imaging is also used in the diagnosis of bladder tumors. Unlike CT, tumor invasion into the muscle layer of the bladder or adjacent organs can be assessed with much greater accuracy.

Despite the informative nature of high-tech methods, the main and final method for diagnosing bladder cancer is cystoscopy with biopsy. Visualization of the tumor, a morphologist's conclusion about the malignant nature, structure and degree of differentiation of the bladder neoplasm are leading in the choice of treatment method.

Fluorescence cystoscopy can increase the information content of cystoscopy. The peculiarity of this technique is that after treating the mucous membrane of the bladder with a solution of 5-aminolevulinic acid during cystoscopy using light from the blue violet part of the spectrum, the tumor tissue begins to fluoresce. This is due to increased accumulation of fluorescent agent by neoplasm cells. The use of this technique makes it possible to identify small formations that often cannot be detected by any other method.

Treatment. The main treatment for bladder cancer is surgery. When the bladder is removed, the issue of urine diversion is resolved. Currently, all operation options can be divided into the following groups:

An operation after which urine is constantly released and patients need a urinal is ureterocutaneostomy.

Operations in which internal urinary diversion is used - the mouths of the ureters open into the intestine.

Operations involving the creation of a reservoir from which urine is released at the request of the patient.

Conservative methods of treating bladder cancer include: radiation therapy - external and contact irradiation, systemic or local intravesical chemotherapy and local immunotherapy with the BCG vaccine. All of these techniques can be used as adjuvant or neoadjuvant therapy, or as palliative treatment in patients whose general condition does not allow surgical intervention.

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Hematuria.

Hematuria is the presence of blood in the urine. In cases where the presence of blood in the urine is determined by eye, we speak of macrohematuria, and when red blood cells are detected using a microscope, we speak of microhematuria.

Etiology. The causes of hematuria are quite varied and numerous. Most urological diseases can cause hematuria. However, most often it is observed with tumors of the kidney, ureter and bladder, urolithiasis, inflammation and damage to the urinary organs. For blood to appear in the urine, the integrity of a blood vessel or vessels communicating with the urinary tract must be disrupted. This can occur in any organ of the urinary system. Determining blood in the urine is important, firstly, because such patients often need emergency care, and secondly, because hematuria is often the first sign of urological cancer.

Clinic. Urine is very sensitive to blood staining. Even one drop of blood per 150 ml of urine is enough to change its color and raise the suspicion of blood.

The admixture of blood in urine can occur in various phases of urination - at the beginning, end or throughout the entire act. If the urine is stained with blood only at the beginning of urination (in the 1st portion), and its subsequent portions are without visible blood, then they speak of initial, or initial, hematuria. Staining with blood only the last portions of urine is called final, or terminal, hematuria, but if blood uniformly stains the entire stream of urine, i.e., all its portions, then we are talking about complete, or total, hematuria. A three-glass test plays an important role in determining the type of hematuria.

The type of hematuria allows you to roughly determine the part of the urinary tract from where the bleeding occurs. The initial (initial) form of hematuria indicates the localization of the pathological process in the peripheral part of the urethra. However, localization of the pathological process in the same parts can also cause terminal hematuria. In such cases, blood enters the urine because at the end of urination there is a significant contraction of the muscles of the perineum and bladder. Often with initial hematuria, spontaneous bleeding from the external opening of the urethra occurs. This happens with damage to the urethra, with polyps and papillomas of the hanging part of the urethra, with caruncles (small vascular benign neoplasms in the urethra) in women.

Terminal hematuria is one of the main symptoms of disease of the bladder neck, disease of the prostate gland, seminal tubercle, stones and tumors of the bladder. It occurs when the detrusor muscle contracts sharply at the end of urination. As a result, when the bladder neck or posterior urethra is damaged, injury to these parts occurs, which leads to bleeding. This form of hematuria is equally common in both men and women.

Total hematuria poses a serious problem regarding the correct recognition of the main causes of its occurrence. It can be due to the release of blood from the bladder, ureters, renal pelvis or the kidneys themselves. The intensity of urine staining with blood may vary.

Table. Types of hematuria depending on the source and causes. (V. Yu. Lelyuk, V. I. Voshchula, V. S. Pilotovich, T. E. Bileichik, 2006)

It is very important to know whether bleeding is preceded by pain in the lumbar region or whether this pain occurs after the bleeding. Hematuria that occurs after an attack of lower back pain usually indicates urolithiasis, while total painless hematuria usually occurs with cancer of the urinary organs.

Quite often, blood in the urine is observed with urolithiasis. Intense hematuria can occur with a neoplasm in the urinary system. In these cases, it often occurs as if in the midst of complete health, suddenly, in the absence of other visible signs of illness. She is called asymptomatic. For tumors of the kidneys and bladder, hematuria is one of the leading signs of the disease.

Hematuria of tumor origin can be significant, in these cases the formation of a large number of blood clots is observed. They can overfill the bladder, causing tamponade. The passage of clots through the ureter often leads to renal colic. Bladder tumors are often the cause of hematuria. In this case, hematuria can appear unexpectedly, “in the midst of complete health,” as with kidney tumors.

Inflammatory processes of the kidneys and bladder themselves rarely cause significant bleeding. However, moderate “touching” with minor tinting of urine is common.

Diagnosis. The purpose of diagnosis is to determine the source of bleeding. To accurately determine the source of bleeding, a detailed examination of the patient is necessary.

As a rule, the examination begins with an ultrasound examination of the kidneys, bladder, and prostate gland. In some cases, this is enough to determine the pathology. However, there are often cases when the source of bleeding is not determined during ultrasound examination. In such situations, cystoscopy is a mandatory study.

Cystoscopy allows you to determine the source of bleeding if it is localized in the bladder, as well as the release of blood from the mouths of the ureters if the cause of bleeding is in the kidney or ureter. By seeing which orifice the blood is coming from, you can find out which side attention should be focused on during further examination. Therefore, any hematuria, including the so-called asymptomatic, is a direct indication for immediate cystoscopy, especially in cases where it is impossible to perform an ultrasound or it is uninformative.

In the examination of patients with hematuria, X-ray and radioisotope research methods, computed and magnetic resonance imaging, and transurethral ureteropyeloendoscopy are widely used.

ACUTE URINARY RETENTION - the inability to urinate independently when the bladder is full. Urinary retention should be distinguished from anuria, in which urination does not occur due to the lack of urine in the bladder.

Etiology. Acute urinary retention is caused by:

Most often, acute urinary retention develops with diseases and injuries of the genitourinary organs. These include diseases of the prostate gland (adenoma, cancer, abscess, acute prostatitis), bladder (stones, tumors, injuries, bladder tamponade), urethra (strictures, stones, injuries), penis (gangrene).

disturbances of the innervation of the bladder, its sphincters and urethra;

consequences of mechanical obstructions to urination caused by various diseases of the bladder, prostate and urethra;

traumatic injuries of the bladder and urethra;

psychogenically caused acute urinary retention.

The causes of urinary retention can be diseases of the central nervous system (organic and functional) and diseases of the genitourinary organs. Diseases of the central nervous system include tumors of the brain and spinal cord, tabes dorsalis, traumatic injuries with compression or destruction of the spinal cord, and hysteria.

Acute urinary retention is often observed in the postoperative period, including in young people. This urinary retention is of a reflex nature and, as a rule, is completely eliminated after several catheterizations.

The clinical picture of acute urinary retention is quite typical. Patients complain of severe pain in the lower abdomen (suprapubic region), frequent painful, fruitless urge to urinate, a feeling of fullness and distension of the bladder. The strength of the imperative urge to urinate increases and quickly becomes unbearable for patients. Their behavior is restless. Suffering from overdistension of the bladder and fruitless attempts to empty it, patients groan, take a variety of positions to urinate (kneel, squat), put pressure on the bladder area, and squeeze the penis. When examining the suprapubic region, a swelling in the form of a spherical body, which is called the “vesical ball,” clearly appears. Palpation, as a rule, causes a painful urge to urinate.

Diagnosis of the causes of acute urinary retention is based primarily on fairly characteristic complaints and clinical picture. Most often, especially in older men, the cause of acute urinary retention is prostate adenoma. In the diagnosis of prostate adenoma, an important place belongs to the examination of the prostate gland through the rectum. Adenoma is characterized by enlargement of the gland while maintaining a dense elastic consistency and smooth surface.

Treatment. Emergency treatment measures for acute urinary retention include urgent emptying of the bladder. Urinary retention is dangerous for patients not only because it causes excruciating pain, painful urges, and discomfort, but also because it can lead to serious complications - inflammation of the bladder, kidneys, a sharp change in the condition of the bladder wall, and its thinning.

Emptying the bladder is possible by three methods: bladder catheterization, suprapubic (capillary) puncture and epicystostomy. The most common and practically safe method is catheterization of the bladder with soft rubber catheters. In a significant number of cases, acute urinary retention can be eliminated by bladder catheterization alone. The presence of purulent inflammation of the urethra (urethritis), inflammation of the epididymis (epididymitis), the testicle itself (orchitis), as well as prostate abscess is a contraindication for catheterization. It is not indicated for urethral trauma. It is very important to prevent urinary infection during catheterization. All objects that come into contact with the patient's urinary tract - instruments, underwear, dressings, solutions that are injected into the bladder and urethra - must be sterile. Forcible insertion of a catheter is unacceptable, since this causes injury to the urethra and after such catheterization, bleeding from the urethra (urethrorrhagia) or an increase in body temperature to 39-40 ° C with chills (urethral fever) is possible. To prevent urethral fever before catheterization and for one to two days after it, antibiotics and uroantiseptics are prescribed for prophylactic and therapeutic purposes. A metal catheter for bladder catheterization can be used with experience. Any rough and violent insertion of a metal catheter can lead to damage to the urethra, sometimes with the formation of false passages.

Technique for catheterization of the bladder with a soft catheter. The procedure is carried out under aseptic conditions. Hands are washed and treated with antiseptic. The external opening of the urethra is treated with furatsilin solution. In men, the procedure is performed with the patient lying on his back with his legs slightly apart. The catheter is pre-lubricated with sterile glycerin or petroleum jelly. The penis is taken with the left hand near the head so that it is convenient to open the external opening of the urethra. The catheter is inserted with the right hand using tweezers very smoothly, while the penis is pulled onto the catheter. The patient is asked to take several deep breaths, at the height of inspiration, when the muscles that close the entrance to the urethra relax, while continuing to apply gentle pressure, a catheter is inserted. Its presence in the bladder is indicated by the release of urine. If the catheter cannot be inserted, then if resistance is felt, do not apply force, because This could result in serious injury. In this case, you should resort to catheterization of the bladder with a metal catheter.

Technique for catheterization of the bladder with a metal catheter.

The first stage - the catheter is placed along the midline of the abdomen with the beak down and inserted to the membranous part of the urethra.

The second stage - the catheter is lifted and its beak is passed into the membranous part of the urethra.

the third stage - the catheter is deflected downwards and, holding it through the perineum, is passed through the prostatic part of the canal into the bladder.

In cases where bladder catheterization fails or is contraindicated (for stones, urethral injuries), one should resort to suprapubic capillary or trocar puncture of the bladder. If necessary, capillary puncture is repeated. Usually the need for this arises 10-12 hours after the previous puncture. If there is a need for repeated and prolonged drainage of the bladder, an epicystostomy should be applied. Epicystostomy (suprapubic vesical fistula) for acute urinary retention should be performed only according to strict indications. Absolute indications are ruptures of the bladder and urethra, as well as acute urinary retention, occurring with the phenomenon of azotemia and urosepsis. Epicystostomy is also indicated when other methods of unloading the bladder are ineffective, as the first stage of surgical treatment for prostate adenoma, if radical treatment is impossible.

ANURIA - complete cessation of urine flow into the bladder. In this case, the patient does not urinate and does not experience the urge to urinate.

There are three main forms of anuria:

Prerenal (hemodynamic), caused by acute renal circulatory disorders

renal, (parenchymal), caused by damage to the renal parenchyma

postrenal (obstructive), developing as a result of acute disruption of the outflow of urine from the kidneys

In the first two forms, urine is not produced by the kidneys. In the postrenal form, urine formation occurs, but urine does not enter the bladder due to an obstruction in the upper urinary tract. If a single kidney is removed, so-called arenal anuria develops.

This division of acute renal failure is of great practical importance, since therapeutic measures for different types of anuria differ. In urological practice, we often encounter cases that arise as a result of acute disturbances in the outflow of urine from the upper urinary tract into the bladder, the so-called excretory (obstructive, surgical) or postrenal anuria.

The causes of prerenal anuria are decreased cardiac output, acute vascular insufficiency, hypovolemia and a sharp decrease in circulating blood volume. This leads to a long-term and sometimes short-term decrease in blood pressure to 80-70 mmHg. and lower, which is accompanied by a violation of general hemodynamics and circulation. Due to depletion of renal circulation, redistribution (shunting) of renal blood flow occurs, leading to ischemia of the renal cortex and a decrease in glomerular filtration rate. As renal ischemia worsens, prerenal acute renal failure can develop into renal acute renal failure due to ischemic necrosis of the epithelium of the renal convoluted tubules.

Risk factors accompanied by the development of hypovolemia and a decrease in circulating blood volume are:

traumatic shock;

crushing and muscle necrosis (cruch syndrome);

electrical injury;

burns and frostbite;

surgical trauma (shock);

blood loss;

anaphylactic shock;

transfusion of incompatible blood;

peritonitis;

acute pancreatitis, pancreatic necrosis;

acute cholecystitis;

dehydration and loss of electrolytes (vomiting, diarrhea, intestinal fistulas);

severe infectious diseases;

bacterial shock;

obstetric complications (septic abortion, premature placental abruption due to nephropathy, eclampsia, postpartum hemorrhage, etc.);

myocardial infarction (cardiogenic shock).

Abnormal fluid loss through the skin (excessive sweating due to fever, exercise, and burns);

Abnormal fluid losses through the kidneys (diuretic therapy, diabetes insipidus, renal pathology with polyuria, adrenal insufficiency and uncompensated diabetes mellitus);

Disturbance in the flow of fluid into the body.

Causes of renal anuria:

1) In 75% of cases, renal acute renal failure is caused by acute tubular necrosis (ATN). There are two types of OKN:

Ischemic acute tubular necrosis, complicating shock (cardiogenic, hypovolemic, anaphylactic, septic), coma, dehydration.

Nephrotoxic acute tubular necrosis, resulting from the direct toxic effect of chemical compounds and drugs. Among more than 100 known nephrotoxins, one of the first places is occupied by drugs, mainly aminoglycoside antibiotics, the use of which in 10-15% of cases leads to moderate, and in 1-2% to severe acute renal failure. Of the industrial nephrotoxins, the most dangerous are salts of heavy metals (mercury, copper, gold, lead, barium, arsenic) and organic solvents (glycols, dichloroethane, carbon tetrachloride).

2) In 25% of cases, renal acute renal failure is caused by inflammation in the renal parenchyma and interstitium (acute and rapidly progressive glomerulonephritis, acute interstitial nephritis).

Causes of postrenal anuria.

Acute obstruction (occlusion) of the urinary tract: bilateral obstruction of the ureters, and in patients with chronic kidney disease, unilateral obstruction of the ureter is sufficient. The most common cause is urolithiasis. Other causes include retroperitoneal fibrosis and retroperitoneal tumors. The mechanism of development of postrenal acute renal failure is associated with afferent renal vasoconstriction, developing in response to a sharp increase in intratubular pressure with the release of angiotensin II and thromboxane A2.

Treatment in cases of prerenal or renal anuria consists mainly of normalizing water and electrolyte disturbances, restoring general hemodynamics, eliminating renal ischemia, and eliminating hyperazotemia.

Detoxification therapy includes transfusion of a 10-20% glucose solution to 500 ml with an adequate amount of insulin, 200 ml of a 2-3% sodium bicarbonate solution. The administration of solutions should be combined with gastric lavage and siphon enemas.

An important method of therapy is extracorporeal hemocorrection. The most commonly used is acute hemodialysis using the Artificial Kidney machine. Various types of dialysis therapy are used: hemodialysis, hemofiltration, hemodiafiltration, ultrafiltration, as well as hemosorption and plasmapheresis.

In case of obstructive (postrenal) anuria, the leading measures are aimed at restoring the impaired passage of urine: catheterization of the ureters, percutaneous puncture nephrostomy under ultrasound control, open nephrostomy. Catheterization of the ureters, as a rule, is a palliative intervention that allows for the short-term elimination of anuria, improving the condition of patients and providing the necessary examination to clarify the nature and localization of obstruction.