Acute Cholecystitis & Cholangitis - Tilayae.pptx

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1. Acute C holecystitis & Cholangitis 1

2. Gall bladder Anatomy Pear-shaped sac, 7 to 10 cm long, 30 to 50 mL Differs histologically from the rest of the GIT ( Lacks a muscularis mucosa and submucosa.) Along with bile ducts, and the sphincter of Oddi, Store and regulate bile flow. Concentrate and store hepatic bile and deliver bile into the duodenum in response to a meal. 2

3. Could be:  A cute or chronic inflammation  Calculus or acalculous Risk factors: obstruction and bile stasis Bacterial growth common but secondary 3 Cholecystitis

4. Acute Cholecystitis Pathogenesis Gallstones in 90% to 95% of cases. Obstruction of the cystic duct by a gallstone ( Only occasionally ) ↓↓↓ Gallbladder distention, inflammation, and wall edema ↓↓↓ H yperemia and patchy necrosis the mucosa ( - Ischemia and necrosis of the GB wall – 5 – 10%) ( - Gallstone is dislodged and inflammation resolves) 4

5. Pathogenesis… When the GB remains obstructed and secondary bacterial infection supervenes ↓↓↓ Acute gangrenous cholecystitis develops Abscess or empyema forms within the gallbladder. Perforation of ischemic areas (Rare) ↓↓↓ - Usually contained in the subhepatic - Free perforation with peritonitis, - Intrahepatic perforation with intrahepatic abscesses - Perforation into adjacent organs (duodenum or colon) ( Cholecystoenteric Fistula) 5

6. Acute Cholecystitis: Diagnosis History Compatible with chronic cholecystitis – 80%. Begins as an attack of biliary colic, but, more severe, unremitting and may persist for several days. The pain is typically in the right upper quadrant or epigastrium and may radiate to the right upper part of the back or the interscapular area. Fever, anorexia, nausea, and vomiting Physical Examination Jaundice – CBD Stones or Mirizzi’s syndrome Focal tenderness and guarding in the RUQ A mass (gallbladder and adherent Omentum), is occasionally palpable. Murphy’s sign 6

7. Acute Cholecystitis: Diagnosis … Leukocytosis (12,000 –15,000 cells/mm3, >20,000 cells/mm3) Some may have a normal WBC. Serum liver chemistries - Usually normal Abdominal U/S - Sensitivity and specificity of 95%. - Presence or absence of stones, - Thickening of the gallbladder wall and pericholecystic fluid - Sonographic Murphy’s sign 7

8. Acute Cholecystitis: Diagnosis … Elderly and diabetic patients may have a subtle presentation ↓↓ De lay in diagnosis. ↓↓ Increased incidence of complications 10-fold the mortality rate compared to that of younger and healthier patients. 8

9. DDx perforated PUD appendicitis acute pancreatitis hepatitis lobar pneumonia pyelonephritis AMI 9

10. Acute Cholecystitis: Management IV fluids Antibiotics Cover gram-negative aerobes and anaerobes 3rd generation cephalosporin with good anaerobic coverage or Second-generation cephalosporin combined with metronidazole or Aminoglycoside with metronidazole or Ciprofloxacin with metronidazole Analgesia. 10

11. Acute Cholecystitis: Management … Definitive treatment – Cholecystectomy Timing of cholecystectomy - Early cholecystectomy - within 2 to 3 days of the illness Vs Interval/delayed cholecystectomy ( 6 to 10 weeks after initial medical treatment) When patients present late, or unfit for surgery, treat with antibiotics, then cholecystectomy scheduled for 2 months later. 11

12. Acute Cholecystitis: Management … Fail to respond to initial medical therapy ↓↓ ↓↓ Those fit for Surgery Not fit for surgery ↓↓ ↓↓ Cholecystectomy Percut . cholecystostomy or Open cholecystostomy (LA) 12

13. Acute Cholecystitis: Management … After percutaneous or open cholecystostomy ↓ ↓ Failure to improve Respond after cholecystostomy ↓ ↓ Gangrene of the GB or Remove the tube after cholangiography Perforation ↓ ↓ Schedule for Cholecystectomy Surgery is unavoidable. For the rare patients who can’t tolerate surgery, the stones can be extracted via the cholecystostomy tube before its removal 13

14. CHRONIC CHOLECYSTITIS Incompletely resolved AC Contracted fibrotic GB Dyspepsia …belching ,flatus ,abdominal bloating ,fullness epigastric burning & Nausea & Vomiting Management - Cholecystectomy 14

15. ACALCULAS CHOLECYSTITIS pts with major abdominal & thoracic surgery & TPN recovering from major trauma severe burns Acute emphysematous cholecystitis serious form of Ac. Characterized by gas in the lumen or wall of the GB In the elderly pts 25% have DM CF as AC but pts are more toxic DX ….air in the gallbladder or wall on plain abd ominal Film 15

16. INVESTIGATION AND DIAGNOSIS 1 . History & P/E 2. Standard base line investigation - CBC - LFT -Serum Amylase ….. Acute pancreatitis - Blood culture 3. Plain radiography - 10% of GS are radio opaque -not routinely indicated -in acutely ill pts to R/O perforated viscus - Gas in the GB or BD 16

17. 4. ULTRASOUND primary screening procedure can show us…. Calculi with acoustic shadow thickened wall , distension of GB localized pericholecystic collection dilated CBD 17

18. 5 . Oral cholecystography ( OCG ) - replaced by U/S - used to assess GB function 6. IV cholangiography - to see extrahepatic biliary tree -effective in jaundiced pts. 7. CT & MRI - to R/O pancreatic head tumour 8. Scintography … to Dx acute cholecystitis 18

19. 9 . PTC & ERCP - in pts with comp. acute biliary dd. & jaundice - clotting studies before PTC - prophylactic antibiotics indicated in pts . - K nown GBS with increased bilirubin >10 mg/dl - Symptomatic pts with previous cholecystectomy - Pts with biliary Sx & inconclusive evidence 19

20. Acute C holangitis B acterial infection superimposed on an obstruction of the biliary tree Most commonly from a gallstone, but it may be associated with neoplasm or stricture . Biliary tract obstruction  E levated intraluminal pressure I nfection of bile Bacteria gain access to the biliary tree by retrograde ascent from the duodenum or from portal venous blood . Primary sclerosing cholangitis  - inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts (Autoimmune mechanism). 20

21. The most common pathogens isolated in blood cultures E coli  (59%),  Klebsiella  species (16%),  Pseudomonas aeruginosa ( 5%),   Enterococcus  species (4%). 21

22.   Ranges from mild symptoms to fulminant overwhelming sepsis . History of abdominal pain or symptoms of gallbladder colic before Charcot's Triad consists of fever, RUQ pain, and jaundice . Reynolds Pentad - Charcot's triad + ( Mental status changes and sepsis ) Previous history of diagnosed Gallstones , CBD stones History of Recent cholecystectomy Endoscopic manipulation or ERCP, cholangiogram 22

23. CBC: Leukocytosis, 79% had a WBC greater than 10,000/mL, Electrolyte panel with renal function. Calcium level is necessary to check if pancreatitis LFT- H yperbilirubinemia and increased ALP PT, PTT – Sepsis related DIC Pancreatic enzymes - elevations suggest bile duct stones caused the cholangitis, with or without gallstone pancreatitis.  Biliary and blood cultures cultures Abdominal U/S, CT scan 23

24. 1. Medical Therapy B road-spectrum IV antibiotics Correction of fluid and electrolyte imbalances Analgesics 2. Surgical Therapy - Decompression and drainage of the biliary system . Endoscopic biliary drainage and decompression Surgical decompression – If endoscopic or transhepatic drainage is unsuccessful or unavailable. 24

25. Complications Liver failure,  hepatic abscesses, and micro abscesses Bacteremia (25-40 %); gram-negative sepsis Acute renal failure Catheter-related problems in patients treated with percutaneous or endoscopic drainage: Bleeding (intra-abdominally or percutaneously) Catheter-related sepsis Fistulae Bile leak (intraperitoneally or percutaneously) 25

26. Management of Urologic Emergencies Acute Scrotum Bladder and Uretheral Injury Acute Urinary Retention Phimosis and Paraphimosis Priapism and Penile Fracture 26

27. Acute SCROTUM Acute onset of scrotal pain and or swelling With or without fever Anorexia, Nausia and vomitting 27

28. Causes of Acute Scrotum Ischemia: - Torsion of the testis ( Intravaginal Vs Extravaginal ), (Prenatal or Neonatal) Appendiceal torsion ( testis or epididymis ) Testicular infarction due to other vascular insult (cord injury, thrombosis) Trauma: Testicular rupture Intratesticular hematoma, Testicular contusion Hematocele 28

29. Causes … Infectious conditions: - Acute epididymitis - Acute orchitis - Acute epididymorchitis - Abscess ( intratesticular , intravaginal , scrotal ) -Gangrenous infections (Fournier’s gangrene) Inflammatory conditions: Henoch-Schonlein purpura (HSP) Vasculitis of scrotal wall - Fat necrosis Hernia: - Incarcerated, strangulated inguinal hernia, with or without associated testicular ischemia 29

30. Causes …. Acute on chronic events: - Spermatocele ( rupture or hemorrhage) - Hydrocele (rupture, hemorrhage or infection) - Testicular tumor ( with rupture, hemorrhage, infarction or infection) - Varicocele 30

31. 1. Testicular Torsion Testicular Anatomy The normal testis is oriented in the vertical axis and the epididymis is above the superior pole in the posterolateral position . Tunica Vaginalis Cremasteric reflex: Stroking/pinching the inner thigh should result in elevation of > 0.5 cm of the ipsilateral testicle 31

32. 1. Testicular Torsion … Incidence 1:4000 Only 50% salvageability with testicular loss from either atrophy or ochidectomy Age - 70% occur prenatally and 30% occur postnatally Two peak periods: First year of life and at puberty 10 times more likely in an undescended testis  Left side is more commonly involved 32

33. 1. Testicular Torsion … Most torsions due to bilateral anatomic abnormality. Tunica vaginalis has a high insertion about the spermatic cord. ↓ Bell-clapper deformity ↓ Testis dangles in the scrotum and is mobile 33

34. 1.Testicular Torsion: Pathophysiology Initially venous return is obstructed and then venous thrombosis is followed by arterial thrombosis Degree of obstruction is a function of the degree of rotation 720° twist is required to compromise flow through the testicular artery and result in ischemia. Necrosis develops in testicle with complete obstruction and infarction develops after arterial thrombosis 34

35. 1. Testicular Torsion… Rapid swelling and edema of the testis and scrotum, followed by scrotal erythema Damage proportional to duration/extent of vascular obstruction Testis salvage rate ~ 100% in patients who undergo detorsion within 6 hours of the start of pain. 20% viability rate if detorsion occurs >12 hours Virtually no viability if detorsion is delayed >24 hrs 35

36. 1. Testicular Torsion … 40% report a history of similar pain that resolved spontaneously in the past The onset of pain may be preceded trauma, physical activity, or by no activity (e.g. during sleep). Typically no urinary symptoms Sudden onset of scrotal pain, but can be inguinal or lower abdominal. May be constant or intermittent. Nausea and Vomiting 36

37. 1. Testicular Torsion …. Hemiscrotum is swollen, tender, firm High-riding testis with a transverse lie is classic sign Loss of Cremasteric reflex – almost universal May see the bell-clapper deformity, with horizontal lie of the contralateral testicle Prehn’s sign: Checking for relief of scrotal pain by elevating testicle. Pain NOT relieved – Negative Prehn’s test  Testicular Torsion 37

38. 1. Testicular Torsion: Diagnosis Doppler Ultrasound Test of choice for Dx of torsion. Sensitivity comparable to radioisotope scans (86%-100%) and greater specificity (100%). More rapid and more available than radioisotope scans. testicular perfusion is the key to the ultrasound diagnosis of torsion. Tests such as nuclear testicular scans, CT or MRI, have essentially no role in the contemporary management of the acute scrotum. 38

39. 1.Testicular Torsion: Management Immediate Urologic consultation for surgical exploration and possible bilateral orchidopexy if diagnosis is obvious Manual detorsion - Only a temporizing measure. Endpoint for successful detorsion is pain relief. Most torsions occur lateral to medial, therefore detorsion should be attempted in a medial to lateral direction - “open the book” maneuver Imaging if diagnosis unclear, should NOT delay exploration if high suspicion exists 39

40. 1.Testicular Torsion: Management Sharply entering the scrotum, open the tunica vaginalis Detorse the testis and wrapp in a warm, moist gauze. The contralateral side then undergoes orchidopexy to prevent torsion on that side. The affected testis is re inspected for signs of improved perfusion (“pinking up”). 40

41. 2. Torsion of Appendage Torsion of appendages is more common than testicular torsion Testicular and Epididymal appendages are vestigial remnants of the wolffian and mullerian ducts respectively Most frequent in preadolescent males 3-13yrs Cause unclear Twisting causes obstruction, edema and then painful necrosis 41

42. Testicular Torsion Vs Torsion of Appendix Testis 42

43. 2. Torsion of Appendage Discrete, painful testicular mass Symptoms less severe than torsion. No nausea, vomiting, or fevers Transillumination of scrotum may reveal the cyanotic appendage as a pathognomonic blue dot U/S should reveal normal to increased blood flow 43

44. 2. Torsion of Appendage: Management Scrotal Support Pelvic rest Analgesia Expect resolution of symptoms in 7-10 days with degeneration of appendages 44

45. 3. Epididymitis Average age 25 years Most common misdiagnosis for testicular torsion Rarely affects a prepubertal child without an underlying urinary tract infection Result of retrograde ascent of urethral and bladder pathogens Peritubular fibrosis may develop and occlude the ductules, if bilateral may lead to sterility 45

46. Epididymitis In men > 40 yrs, E. coli is the predominant pathogen. P seudomonas , and gram positive cocci. A ssociated w/ underlying urologic pathology -- Recent GU tract manipulation or bacterial prostatitis . In men < 40 , Chlamydia and N. gonorrhea are the major pathogens 46

47. Epididymitis Gradual Scrotal pain, peaks over days Low grade fever, average 38 degrees C Cremasteric reflex usually preserved Due to inflammatory nature of pain, may have some transient pain relief from scrotal elevation (Prehn’s Test Positive) Localized epididymal swelling initially, then may progress to single, large testicular mass Urethral discharge and voiding symptoms may be present 47

48. Epididymitis Pyuria and bacteriuria on U/A Urethral discharge should be examined for gram stain and culture Leukocytosis between 10,000 - 30,000 cells/ml Torsion should not be excluded by pyuria , fever, or dysuria . An equivocal exam demands Imaging. U/S with increased or normal testicular blood flow is c/w epididymitis 48

49. Epididymitis: Management Sexually acquired: Ceftriaxone 250 mg IM and Doxycycline 100 mg PO bid x 10d. Treat sexual partners. Nonsexually acquired: TMP-SMX or Fluoroquinolone x 14d. Check urine C&S. Bed rest, scrotal support, analgesics, sitz baths, and Urology follow up 49

50. Complications of Epididymitis Infertility - Sexually transmitted epididymitis Abscess - Gonococcal epididymitis Chronic epididymitis U/S indicated if no response to medical therapy 50

51. Orchitis Acute infection of the testis Rare without initial epididymitis, Consider testicular tumor. Bacterial infection secondary to spread from epididymitis of E. coli, Klebsiella, Pseudomonas Viral orchitis – Mumps. - 4-6 days after onset of parotitis usually. - 50 % of involved testes atrophy but infertility rare Syphilis Treatment: Antibiotics for bacterial orchitis and local scrotal measures for viral orchitis 51

52. Testicular Tumor Testicular CA – Most common cause of malignancy to afflict young men Average age of incidence is 32 Years DDx: Epididymitis and torsion Increased incidence with cryptorchidism in bilateral testes Majority are Seminomas , then embryonal cell CA and teratomas 52

53. Testicular Tumor Classic presentation – Painless, firm testicular mass Acute hemorrhage within the tumor can lead to acute scrotal pain (10%) Ultrasound – Distinct Intratesticular Mass CXR if suspect Metastases Treatment: Immediate Urology referral. Radical orchidectomy. Cisplatin chemotherapy and Radiation for seminomas. 53

54. Trauma to scrotum Blunt injury may result in:  Testicular rupture,  Intratesticular hematoma,  Testicular contusion (bruising) or  Hematocele (Blood collection within the TV space). O nly testicular rupture requires surgical repair . Large or painful hematoceles may benefit from drainage. 54

55. Scrotal Wall Infections 55

56. Strangulated Inguinal Hernia 56

57. Bladder Injury protected position of the bladder deep in the bony pelvis Bladder injuries after blunt or penetrating trauma are rare, (< 2% of abdominal injuries requiring surgery) Usually associated with other severe injuries 83- 100% have pelvic fracture, and 6-10% of patients with pelvic fracture have bladder injuries. 57

58. Bladder Injury… Most (95%- 100%) of patients with bladder injury will have gross hematuria, Only 5% have had only microscopic hematuria Gross hematuria is felt to be associated with more significant injuries (rupture), while microhematuria has been seen more commonly with bladder contusion . 58

59. Bladder Injury … 59

60. Bladder Injury… Major diagnostic goals in patients with Bladder Injury: 1.Determine if urethral injury is present 2. Determine if bladder rupture is present, Classify it as intraperitoneal (which requires exploration and repair) or extraperitoneal (which can usually be managed by bladder drainage alone). 3. Determine if renal injuries are associated and if they require surgical exploration 60

61. Bladder Injury… Evaluation Local Signs and Symptoms Lower abdominal pain, tenderness, and bruising Urethral catheter does not return urine. Fever, absence of voiding, peritoneal irritation, and elevated BUN Blood at the Urethral Meatus - 10-17% of patients with bladder injuries will have associated urethral rupture. 61

62. Bladder Injury … Evaluation … CBC, BgRh, U/A Abdominal Ultrasound/ CT Scan Retrograde urethrogram Retrograde cystography/Static Cystography Computed Tomography (CT) Cystography 62

63. Bladder Injury: MANAGEMENT Intraperitoneal Ruptures 25% of all bladder injuries Combined with extraperitoneal rupture in another 12% Caused by rapidly rising intraperitoneal pressure causing the bladder to burst (Dome) Operative repair with two-layer closure with absorbable suture. If conservative management is attempted, persistent urinary leakage can ensue, with consequent and often fatal peritonitis. 63

64. Bladder Injury… 2. Extraperitoneal Ruptures Found alone in 62% of cases In combination with intraperitoneal ruptures in another 12%. Result from direct laceration, usually by bone spicules from the fractured pelvis. They can most commonly be managed with catheter drainage alone, 64

65. 2. Extraperitoneal Ruptures … Contraindications for conservative Management - Bone fragment projecting into the rupture, open pelvic fracture, and Rectal Perforation If clots obstruct the urinary catheter within 48 hours of injury Undergoing laparotomy for other reasons 65

66. Uretheral Trauma Management 66

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68. Etiologies of Uretheral Injury 68

69. 1. Anterior urethral injuries Blunt Trauma Bulbar urethra - the most common site injured. Penetrating injuries of the penile or bulbar urethra - Rare. Insertion of foreign bodies Penile fractures – 10 - 20 % of anterior injuries. Urethral Instrumentation - affect all segments of the anterior urethra 69

70. 2. Posterior urethral injuries M ost often related to pelvic fractures ~ 72% Iatrogenic posterior injuries - Irradiation or surgery to the prostate - 3-25% C rush or deceleration impact injury  Detachments of the perineal membrane and puboprostatic ligaments B ulbomembranous junction , just distal of the external urethral sphincter. Direct transection of the urethra by a bony fragment - Rare 70

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72. 2. Posterior urethral injuries … Injuries of the bladder neck and prostate - Rare. They mostly occur at the anterior midline of both the bladder neck and prostatic urethra. Complete transection of the bladder neck or an avulsion of the anterior part of the prostate Penetrating injuries of the pelvis, perineum or buttocks 72

73. Morbidities of Uretheral Injuries Strictures Incontinence and Erectile Dysfunction (ED) 73

74. Urethral injuries in females V ery rare - Pelvic Fracture Usually a partial longitudinal tear of the anterior wall. Complete avulsion- Extremely rare. 74

75. Diagnosis Clinical signs and symptoms Blood at the meatus An inability to void Haematuria and pain on urination Urinary extravasation and bleeding A ‘high-riding’ prostate D ifficulty or an inability to pass a urethral catheter 75

76. Diagnosis … Further diagnostic techniques Retrograde urethrography Ultrasound CT & MRI Cystoscopy 76

77. Management C ontroversial Lack of well-conducted clinical trials to provide a high level of evidence. 77

78. Anterior urethral injuries Blunt anterior urethral injuries Acute or early urethroplasty – not indicated. Therapeutic options: 1. ( A trial of ) early endoscopic realignment with transurethral catheterization 2. Suprapubic diversion Urinary diversion should be maintained:  F or2 weeks for partial rupture  For 3 Weeks for complete rupture 78

79. Anterior urethral injuries … Penetrating anterior urethral injuries Immediate exploration and Debridement. Spatulation of the urethral ends and primary anastomosis - defects 1.5 cm in the penile urethra and 2-3 cm in the bulbar urethra, L arger defects or apparent infection,  a staged repair with urethral marsupialization and a suprapubic catheter Peri- and post-operative antibiotic treatment is necessary. 79

80. Posterior urethral injuries Blunt posterior urethral injuries Complete Vs Partial Timing • Immediate: < 48 hours after injury • Delayed primary: 2 days to 2 weeks after injury • Deferred: > 3 months after injury 80

81. Posterior urethral injuries Immediate Management U rinary diversion • To monitor urinary output • To treat symptomatic retention • To minimize urinary extravasation and its secondary effects, such as infection and fibrosis . Attempt at urethral catheterization by experienced hands if SPC not possible/difficult 81

82. Partial posterior urethral rupture Suprapubic or urethral catheter Urethrography - at 2-weekly intervals until healing has occurred. A residual or subsequent stricture should be managed with: • Internal urethrotomy if it is short and non-obliterative; • Anastomotic urethroplasty - long and dense, complete obliteration or failed internal urethrotomy 82

83. Complete posterior urethral rupture Acute treatment options: • Immediate realignment: - Apposition of the urethral ends over a catheter; - To correct severe distraction injuries rather than to prevent a stricture • Immediate urethroplasty: - Suturing of urethral ends - Difficult and not recommended 83

84. Delayed primary treatment Delayed treatment options: 1. Delayed primary realignment - Performed within 14 days (i.e. before fibrosis begins) 2. Delayed primary urethroplasty - Performed no later than 14 days after the initial injury Only a few reports have been published in the literature Not recommended. 84

85. Deferred treatment 1 . Deferred urethroplasty Procedure of choice for the treatment of posterior urethral distraction defects. Excellent outcome 2. Deferred endoscopic optical incision For short, non-obliterative strictures following realignment or urethroplasty, 85

86. Penetrating posterior urethral injuries Immediate exploration by retropubic route and primary repair or realignment. Life-threatening associated injuries:  Suprapubic diversion with delayed abdominoperineal urethroplasty In the case of rectal injury, a diverting colostomy. 86

87. Female urethral injuries Immediate exploration and primary repair: Proximal Disruptions – Retropubic approach Mid-urethral Disruptions - Transvaginal approach Distal urethral injuries - Managed vaginally by primary suturing and closure of the vaginal laceration. 87

88. Acute Urinary Retention 88

89. 89 Introduction Urinary obstruction is a common cause of acute and chronic renal failure. A wide variety of pathological processes, intrinsic and extrinsic to the urinary system, can cause obstruction. Symptoms and signs of obstruction are often mild, occurring over long periods of time and requiring a high index of suspicion for diagnosis.

90. 90 Causes Infants and children Urethral and bladder outlet obstruction Urethral atresia Phimosis Meatal stenosis P osterior urethral valves Calculus Blood clot Neurogenic bladder (meningomyelocele) Ureterocele

91. 91 Adults Urethral and bladder outlet obstruction Phimosis Stricture Trauma, Blood clot Calculi BPH, Prostatic or Bladder Ca Carcinoma of cervix or colon Neurogenic bladder

92. 92 Clinical Presentation Hx P/E Imaging

93. 93 Management 1. Medical Therapy Analgesics Antibiotics Other medications: Prazosin 2. Surgical Therapy The goal of surgical intervention is to completely relieve the urinary tract obstruction. Point of obstruction should be identified A. Urethral catheterization A urethral catheter (size 8F-24F) May need to perform urethral dilation, cystoscopy , or both to pass the catheter. Indwelling / clean intermittent catheterization. If blood is present at the urethral meatus after pelvic trauma and suspicion of urethral injury exists, retrograde urethrography needs to be performed to rule out urethral injury . B. Suprapubic Cystostomy

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95. 95 Suprapubic Cystostomy: Percutaneously (at the bedside) Open Cystostomy (in the operating room). A suprapubic tube is placed ~ 2 finger-breadths above the pubic symphysis. Ultrasound guidance should be used for bedside procedures to ensure proper placement without injury to adjacent structures. In patients with previous abdominal surgery, adhesions and scar tissue may have changed the normal bowel location , so an open approach may be preferred.

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97. Other Urologic Emergencies Phimosis and Paraphimosis Priapism Penile Fracture 97