Bleeding into the lumen of the bladder after prostate surgery. Differentiated hematuria and urine staining of another cause Bladder tamponade indications for surgery

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 urinary tract cancerzyrya. According to the morphological structure, malignant tumors of the bladder with an overwhelming frequency are 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. Finally, the etiology and pathogenesis of bladder cancer have not been established. Individual risk factors with a high probability of causing cancer have been identified. 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 decomposition products of aniline dyes excreted in the urine have a pronounced carcinogenic effect on the mucous membrane of the bladder. Thus, artists, painters, 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 liquid and holding urine for a long time. The risk of developing bladder cancer in smokers is 2-5 times higher. The likelihood increases with smoking experience.

There is a close relationship 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. Neoplasms T a -T 1 are usually asymptomatic. One of the first clinical manifestations is macrohematuria or microhematuria, which may appear once, and then not disturb the patient for a long time.

Massive or prolonged 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 makes it necessary to undertake emergency surgery.

As the tumor grows, other symptoms begin to join, often associated with the addition of an infection. There may be various urination disorders - dysuria.

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

The growth of a bladder tumor often leads to compression of the mouths of the ureters, which disrupts the passage of urine from the kidneys. In such patients, there is a pulling pain in the lumbar region, often like renal colic. Often against this background there is an attack of acute pyelonephritis.

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

One of the ways to diagnose bladder cancer is a urine cytology test, which is usually performed several times. The detection of atypical cells in the urine is pathognomonic for a neoplasm of the bladder. 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 antigen of a bladder tumor. This technique is usually used as a method of screening diagnostics.

Ultrasound is of great importance in the diagnosis of bladder cancer. Transabdominal examination makes it possible to detect tumors larger than 0.5 cm with a probability of 82%. The formations located on the side walls are most often visualized. When the tumor is localized in the bladder neck, the use of transrectal examination may be informative. Neoplasms of small sizes are best diagnosed using a transurethral scan, carried out by a special sensor inserted through the urethra into the bladder cavity. The disadvantage of this study is its invasiveness. It must be remembered that ultrasound of a patient with a suspected bladder tumor must necessarily include an examination of the kidneys and upper urinary tract in order to detect dilatation of the pelvicalyceal system as a sign of compression of the ureter orifice by the tumor.

Large tumors are detected by excretory urography or retrograde cystography. Sedimentary cystography according to Knise-Schober helps to increase the information content of the study. Helical and multislice contrast-enhanced computed tomography 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 relation to the mouths 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 retain urine during the study time. Another disadvantage of CT is the lack of information in identifying the depth of tumor invasion into the muscle layer due to the low possibility of visualizing the layers of the bladder wall.

Magnetic resonance imaging is also used in the diagnosis of bladder neoplasms. In contrast to CT, tumor invasion into the muscular layer of the bladder or adjacent organs can be assessed with much greater accuracy.

Despite the information content of high-tech methods, the main and final way to diagnose bladder cancer is cystoscopy with biopsy. Visualization of the tumor, the conclusion of the morphologist about the malignant nature, structure and degree of differentiation of the bladder neoplasm are leading in the choice of treatment method.

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

Treatment. The main treatment for bladder cancer is surgery. When removing the bladder, the issue of diversion (derivation) of urine is solved. Currently, all options for operations can be divided into the following groups:

The operation, after which urine is constantly excreted and patients need a urinal, is a ureterocutaneostomy.

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

Operations with the creation of a reservoir from which urine is excreted at the request of the patient.

Conservative treatments for bladder cancer include: radiation therapy - remote and contact irradiation; systemic or local intravesical chemotherapy; and local immunotherapy with 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 resorting to surgery.

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

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

The most common cause of 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 violation of blood clotting, therefore, in the event of bleeding 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 output stops through them, and bladder tamponade develops. Patients complain of severe pain over the womb, painful urge to urinate. A sharply painful bladder is palpated above the bosom. In the blood test, a decrease in the number of red blood cells and hemoglobin is noted. Ultrasound can confirm the presence of blood clots in the bladder.

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

If the catheter-evacuator fails to remove blood clots from the bladder, then a cystotomy should be performed. Blood clots are removed, the source of bleeding is established. When blood is received from the adenoma bed, its digital revision 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 adenoma bed until the blood supply to the bladder stops. After the operation, it is necessary to constantly wash the bladder with furacilin.

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

Bleeding after TUR of prostate adenoma is also clinically manifested by bladder tamponade. Removal of blood clots is carried out using a catheter-evacuator. Then, a resectoscope tube is passed along the urethra to examine the area of the resected adenoma in order to search for a bleeding vessel and its coagulation. After achieving good hemostasis, the bladder is drained with a Foley catheter and a constant bladder lavage is established.

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Tamponade of the bladder

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

Why is it developing?

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

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

Common cause is bladder cancer

Development mechanism

How it develops, the process 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.

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

The main manifestations of bladder tamponade will be pain when trying to urinate, the urge either does not work, or a small amount of urine is released. On palpation, a bulge is determined above the pubis, this is an overflowing bladder. The slightest pressure on it causes pain. A person with bladder tamponade is emotionally labile, his behavior is restless.

Based on the determination of the volume of blood in the bladder, the degree of blood loss is determined. In urine there are blood impurities fresh or already changed. It should be borne in mind that tamponade of the urinary reservoir involves bleeding. The capacity of the bladder in the male is about 300 milliliters, but in fact the volume of lost blood is much larger.

Bladder rupture symptoms

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 urges, dizziness, blood in the urine.

Anemia is one of the complications of a pathological condition

How to diagnose?

Bladder tamponade is determined on the basis of complaints, questioning. As a rule, the doctor finds out that there have already been cases of blood in the urine. When examined, a pronounced soreness with pressure in the area of the womb, a pale and unhealthy appearance of the patient draws on himself.

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

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

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

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

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

On ultrasound, this obstruction will be seen as an enlargement on both sides. Expanding pyelocaliceal system, ureters. This type of diagnosis also determines neoplasms, if any.

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

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

Hemostatics - drugs used for bleeding in various types

But the delayed one involves cleansing the bladder of blood through the urethra in parallel with antibiotic and hemostatic therapy. Replacement of lost blood is also used. If the bleeding is stopped, then there is time for a full examination and delayed intervention. Tamponade is a very dangerous condition, it requires immediate treatment. Seek medical attention at the first sign.

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

Situations requiring urgent intervention are quite common 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 with an acute (sudden) violation of the outflow of urine from the kidney, which leads to the development of pyelocaliceal hypertension, reflex spasm of arterial renal vessels, venous stasis and swelling of the parenchyma, its hypoxia and overstretching of the fibrous capsule.

Etiology and pathogenesis

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

clinical picture. Renal colic is characterized by the sudden onset of intense pain in the lumbar region, often at night, during sleep, sometimes after physical exertion, long walking, bumpy driving, taking large amounts of fluids or diuretics. Usually, pain occurs in the costovertebral angle and radiates to the hypochondrium, along the ureter to the genitals, along the inner surface of the thigh. Less commonly, pain begins along the ureter, and then spreads to the lumbar region from the corresponding side and radiates to the testicle or labia majora. Atypical irradiation of pain is possible (to the shoulder, shoulder blade, to the navel), which is explained by the wide nerve connections of the renal plexus. Often there are paradoxical pains in the area of a healthy kidney due to reno-renal reflux. In some patients, pain prevails at the site of irradiation.

Characterized by restless behavior of patients who groan, rush about and take the most incredible postures, as they cannot find a position in which the intensity of pain would decrease. Appear pallor, cold sweat. Sometimes BP rises. Dysuric phenomena quite often (but not always) accompany an attack of renal colic. Dysuria is manifested by frequent, painful urination: the closer the stone is localized to the bladder, the sharper the dysuria.

Often, renal colic is accompanied by nausea, repeated vomiting, retention of stools and gases, bloating (gastrointestinal syndrome), which complicates the diagnosis.

Bimanual palpation reveals sharp pain in the kidney area, 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, there is an increase in temperature, chills, leukocytosis in the absence of other signs of urinary infection and acute pyelonephritis.

The diagnosis of "renal colic" requires the EMS doctor to answer the following questions:

Do you have a history of urolithiasis, other kidney diseases (it is necessary to clarify the possible cause of renal colic)?
What are the conditions for the onset of pain (colic often occurs after physical exertion, bumpy driving, long walking)?
What is the nature and localization of 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 calculus of the pelvis, pain can radiate 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 inguinal region, inner thigh, genitals)?
Is there a position in which the pain is relieved (in renal colic, patients look for such a position but cannot find it)?
Is there a disorder of urination (often accompanied by renal colic)?

In the treatment of renal colic, the doctor pursues two main tasks: the elimination of pain and the stop (liquidation) of the 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-shpa, papaverine, platifilin) parenterally, preferably in combination with sodium diclofenac.

It should be remembered the negative impact of non-steroidal anti-inflammatory drugs on persons with diseases of the gastrointestinal tract (erosion, 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 the act of urination with a full bladder.

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

Clinical presentation and diagnostic criteria

Patients suffer from overfilling of the bladder: there are painful and fruitless attempts to urinate, pain in the suprapubic region; the patient's behavior is characterized as extremely restless. Patients with diseases of the central nervous system and spinal cord react differently, who, as a rule, are immobilized and do not experience severe pain. When viewed in the suprapubic region, a characteristic bulge is determined due to an overflowing bladder (“vesical ball”), which, on percussion, gives a dullness of sound.

In order to provide the patient with timely and qualified assistance, it is necessary to clearly understand the mechanism for the development of acute urinary retention in each individual case. With acute urinary retention, it is urgent to evacuate urine from the bladder. Given the risk of urinary tract infection in the absence of a pronounced urge to urinate, catheterization is best done in a hospital setting. Severe pain syndrome due to overdistension of the bladder is an indication for catheterization at the prehospital stage.

Bladder catheterization should be treated as a major procedure, equating it with 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 is usually not difficult. Various rubber and silicone catheters are used for this purpose.

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 Timan or Mercier curvature. With the rough and violent introduction of the 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 observance of asepsis and catheterization techniques.

The need for catheterization often occurs in elderly patients, as well as in people with severe comorbidities, including diabetes mellitus, circulatory disorders, etc. In such cases, given the lack of sterile conditions in the SMP machine, catheterization should be carried out antibiotic prophylaxis of urinary tract infections (UTIs).

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

Alternatively, amoxicillin/clavulanate or II-III generation cephalosporins (cefuroxime axetil, cefaclor, cefixime, ceftibuten) can be used.

These antibiotics can be taken orally as a preventive measure.

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

Acute urinary retention with stones in the bladder occurs when the stone is wedged into the neck of the bladder or obturates the urethra in its various departments. Palpation of the urethra helps to diagnose stones. With strictures of the urethra, which led 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 that injure or obstruct the lower urinary tract. Emergency care is to remove the foreign body; however, this manipulation can only be performed in a hospital setting.

In the 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 into another (the sound of a falling stream of water can reflexly 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; with inefficiency, catheterization of the bladder is indicated.

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

Gross hematuria

Definition. Hematuria - the appearance of an admixture 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 erythrocytes in the urine gives it a cloudy appearance and a pink, brown-red or reddish-black color, depending on the degree of hematuria.

Gross hematuria can be of three types: 1) initial (initial), when only the first portion of urine is stained with blood, the remaining portions are of a normal color; 2) terminal (final), in which no blood impurities are visually detected in the first portion of urine and only the last portions of urine contain blood; H) total, when the urine in all portions is equally colored with blood. Possible causes of gross hematuria are presented in Table. 6.

Often, gross hematuria is 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. In kidney tumors, bleeding precedes pain (“asymptomatic hematuria”), while in urolithiasis, pain occurs before the onset of hematuria. Localization of pain in hematuria also allows you to clarify the localization of the pathological process. So, 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 with damage to the prostate gland, bladder or posterior urethra. The shape of blood clots also allows you to determine the localization of the pathological process. Worm-like clots that form as blood passes through the ureter indicate an upper urinary tract disease. Shapeless clots are more characteristic of bleeding from the bladder, although they may form in the bladder when blood is released from the kidney.

The main directions of therapy. With the development of hypovolemia and a drop in blood pressure, restoration of the volume of circulating blood is shown - intravenous administration of crystalloid and colloid solutions. Hemostatic agents are not used.

Indications for hospitalization. If macrohematuria occurs, immediate hospitalization in the urological department of the hospital is indicated.

Acute pyelonephritis

Definition. Pyelonephritis is a nonspecific infectious and inflammatory process with a primary lesion of the interstitial tissue of the kidneys and its pelvicalyceal 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 kidney infection are ascending (urinogenic), hematogenous (in this case, any purulent-inflammatory process in body - otitis media, tonsillitis, mastitis, pneumonia, sepsis, etc.). Predisposing factors - immunodeficiency, urinary tract obstruction (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 occurrence, 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, which reduce the resistance of the renal tissue to infection and disrupt the outflow of urine) are distinguished. 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 older 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. 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: fever, 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 side of the lesion, sometimes dysuria, cloudy urine with flakes, polyuria, nocturia, pain when tapping on 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.

Algorithm for the treatment of acute pyelonephritis

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

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

Indications for hospitalization. Patients with acute pyelonephritis need 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 service, Moscow

Note!

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

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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 with an overwhelming frequency are 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. Finally, the etiology and pathogenesis of bladder cancer have not been established. Individual risk factors with a high probability of causing cancer have been identified. 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 decomposition products of aniline dyes excreted in the urine have a pronounced carcinogenic effect on the mucous membrane of the bladder. Thus, artists, painters, interior designers are at risk.

There is a close relationship 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 disturb the patient for a long time.

Massive or prolonged 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 makes it necessary to undertake emergency surgery.

As the tumor grows, other symptoms begin to join, often associated with the addition of an infection. There may be various urination disorders - dysuria.

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

Treatment. The main treatment for bladder cancer is surgery. When removing the bladder, the issue of diversion (derivation) of urine is solved. Currently, all options for operations can be divided into the following groups:

The operation, after which urine is constantly excreted and patients need a urinal, is a ureterocutaneostomy.

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

Operations with the creation of a reservoir from which urine is excreted at the request of the patient.

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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, they talk about macrohematuria, and when red blood cells are detected using a microscope, microhematuria.

Etiology. The causes of hematuria are quite diverse 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. In order for blood to appear in the urine, a violation of the integrity of the blood vessel or vessels communicating with the urinary tract is necessary. It can occur in any organ of the urinary system. The determination of blood in the urine is important, firstly, because such patients often need emergency care, and secondly, because hematuria is often the first sign of oncourological diseases.

Clinic. Urine is very sensitive to staining with blood. Even one drop of blood per 150 ml of urine is enough to change its color and suggest blood impurities.

The admixture of blood to urine can occur in various phases of urination - at the beginning, end or throughout the entire act. If urine is stained with blood only at the beginning of urination (in the 1st portion), and its subsequent portions without visible blood, then they speak of or initial, hematuria. Blood staining of only the last portions of urine is called final, or terminal, hematuria, but if the blood evenly stains the entire stream of urine, that is, all of its portions, then we are talking about complete, or total, hematuria. An important role in determining the type of hematuria has a three-cup test.

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, the localization of the pathological process in the same departments 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, there is also an independent release of blood from the external opening of the urethra. 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 bladder neck disease, diseases of the prostate gland, seminal tubercle, with stones and tumors of the bladder. It occurs when, at the end of the act of urination, the detrusor is sharply reduced. As a result, when the neck of the bladder or the posterior urethra is affected, trauma occurs to these departments, which leads to the release of blood. This form of hematuria is equally common in both men and women.

Total hematuria presents a serious problem in terms of correct recognition of the main causes of its occurrence. It can be with the release of blood from the bladder, ureters, renal pelvis, or the kidneys themselves. The intensity of urine staining with blood can be different.

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

It is very important to know whether pain in the lumbar region precedes bleeding or whether these pain sensations occur after bleeding. Hematuria that occurs after an attack of pain in the lower back, as a rule, speaks of urolithiasis, total painless hematuria - as a rule, occurs in oncological diseases of the urinary organs.

Quite often, the admixture of blood to the urine is observed in urolithiasis. Intense hematuria can occur with a neoplasm in the urinary system. In these cases, it often occurs as if in full health, suddenly, in the absence of other visible signs of illness. She is called asymptomatic. With 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 it to tamponade. The passage of clots through the ureter often leads to renal colic. Often the cause of hematuria are bladder tumors. In this case, hematuria may appear unexpectedly, “among full health”, as with kidney tumors.

Inflammatory processes of the kidneys and bladder by themselves rarely cause significant bleeding. However, moderate "tinting" with slight coloring of the urine is common.

Diagnosis. The purpose of diagnosis is to determine the source of bleeding. To accurately establish 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, prostate gland. In some cases, this is enough to determine the pathology. However, it is not uncommon for cases when an ultrasound examination does not determine the source of bleeding. In such situations, a mandatory study is cystoscopy.

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 from which mouth the blood is being released, you can find out which side 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 ultrasound or it is not informative.

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

ACUTE RETENTION OF URINATION - the impossibility of an independent act of urination with an overflowing bladder. Urinary retention should be distinguished from anuria, in which urination does not occur due to the absence of urine in the bladder.

Etiology. Acute urinary retention is caused by:

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

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

consequences of mechanical obstruction to urination due to various diseases of the bladder, prostate and urethra;

traumatic injuries of the bladder and urethra;

psychogenic 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, dorsal tabes, traumatic injuries with compression or destruction of the spinal cord, hysteria.

Often, acute urinary retention is observed in the postoperative period, including in young people. Such urinary retention is reflex in nature and, as a rule, after several catheterizations, it is completely eliminated.

The clinic 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 bursting of the bladder. The strength of the imperative urge to urinate increases, quickly becomes unbearable by 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 down, squat), put pressure on the bladder area, squeeze the penis. When examining the suprapubic region, a swelling in the form of a spherical body, which is called the "vesical ball", is clearly visible. Palpation, as a rule, causes an agonizing urge to urinate.

Diagnosis of the causes of acute urinary retention is based primarily on sufficiently characteristic complaints and the 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 study of the prostate gland through the rectum. Adenoma is characterized by an increase in the gland with the preservation of a densely elastic consistency and a smooth surface.

Treatment. Urgent therapeutic measures for acute urinary retention are urgent emptying of the bladder. Urinary retention is dangerous for patients not only because it causes excruciating pain, painful urges, 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, its thinning.

Emptying the bladder is possible in three ways: bladder catheterization, suprapubic (capillary) puncture, and epicystostomy. The most common and practically safe method is bladder catheterization with soft rubber catheters. In a significant number of cases, acute urinary retention can be eliminated by catheterization of the bladder alone. The presence of purulent inflammation of the urethra (urethritis), inflammation of the epididymis (epididymitis), the testicle itself (orchitis), and prostate abscess is a contraindication for catheterization. It is not indicated for trauma to the urethra. It is very important during catheterization to carry out the prevention of urinary infection. All items in contact with the patient's urinary tract - instruments, underwear, dressings, solutions that are introduced into the bladder and urethra must be sterile. Forcible insertion of the 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) are possible. To prevent urethral fever before catheterization and within one or 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 forceful insertion of a metal catheter can lead to damage to the urethra, sometimes with the formation of false passages.

Technique of catheterization of the bladder with a soft catheter. The procedure is carried out under aseptic conditions. Hands are washed and treated with an antiseptic. The external opening of the urethra is treated with a solution of furacilin. In men, the procedure is performed in the position of the patient on his back with slightly apart legs. The catheter is pre-lubricated with sterile glycerin or vaseline oil. 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 with the help of tweezers very smoothly, while the penis is, as it were, pulled onto the catheter. The patient is offered to take several deep breaths, at the height of inspiration, when the muscles that close the entrance to the urethra relax, continuing to exert gentle pressure, a catheter is inserted. Its presence in the bladder is evidenced by the excretion of urine. If the catheter cannot be inserted, then if resistance is felt, no effort should be applied, because. this could result in serious injury. In this case, you should resort to catheterization of the bladder with a metal catheter.

Technique of 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 occurs 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) with acute urinary retention should be applied 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 it is impossible to carry out radical treatment.

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

There are three main forms of anuria:

Prerenal (hemodynamic), due to acute violation of renal circulation

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

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

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

Such a division of acute renal failure is of great practical importance, since therapeutic measures for different types of anuria differ. In urological practice, it is more common to encounter cases that arise as a result of an acute violation of 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 a decrease in 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 mm Hg. and below, which is accompanied by a violation of general hemodynamics and circulation. Due to the impoverishment of the renal circulation, a redistribution (shunting) of the renal blood flow occurs, leading to ischemia of the cortical layer of the kidney and a decrease in the glomerular filtration rate. With aggravation of renal ischemia, prerenal acute renal failure can turn into renal due to ischemic necrosis of the epithelium of the renal convoluted tubules.

Risk factors associated with the development of hypovolemia and a decrease in circulating blood volume are:

traumatic shock;

crushing and necrosis of muscles (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 detachment of the placenta against the background of nephropathy, eclampsia, postpartum hemorrhage, etc.);

myocardial infarction (cardiogenic shock).

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

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

Violation of 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 (OKN). 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 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 ureteral obstruction 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, which develops 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 in the normalization of water and electrolyte disturbances, the restoration of general hemodynamics, the elimination of renal ischemia, and the elimination of hyperazotemia.

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

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

With obstructive (postrenal) anuria, the leading measures are aimed at restoring the disturbed passage of urine: ureteral catheterization, percutaneous puncture nephrostomy under ultrasound control, open nephrostomy. Catheterization of the ureters, as a rule, is a palliative intervention that allows you to short-term eliminate anuria, improve the condition of patients and provide the necessary examination to clarify the nature and localization of obstruction.

DEFINITION.

Hematuria - the appearance of an admixture 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

(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, papilla hypertrophy, nephroptosis, etc.
Mechanical	Trauma, concretions, hydronephrosis
Hematological	Blood coagulation disorders, hemophilia, sickle cell anemia, etc.
Hemodynamic	Kidney blood supply disorders (venous hypertension, heart attack, thrombosis, phlebitis, aneurysms), nephroptosis
reflex	Vasoconstrictor disorders, shock
allergic	Glomerulonephritis, arteritis, purpura
toxic	medical, infectious
Inflammatory	Glomerulonephritis (diffuse, focal), pyelonephritis
Tumor	Benign and malignant neoplasms
“Essential”

CLINICAL PICTURE AND CLASSIFICATION.

The appearance of erythrocytes in the urine gives it a cloudy appearance and a pink, brown-red or reddish-black color, depending on the degree of hematuria. With gross hematuria, 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 the urine sediment under a microscope.

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

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

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

H) total, when the 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 macrohematuria	Causes of macrohematuria
Initial	Damage, polyp, cancer, inflammation in the urethra.
Terminal	Diseases of the bladder neck, posterior urethra and prostate.
Total	Tumors of the kidney, bladder, adenoma and prostate cancer, hemorrhagic cystitis, etc.

Often, gross hematuria is 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 kidney tumors, bleeding precedes pain (“asymptomatic hematuria”), and with urolithiasis, pain occurs before the onset of hematuria. Localization of pain in hematuria also allows you to clarify the localization of the pathological process. So, 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 with damage to the prostate gland, bladder or posterior urethra.

The shape of blood clots also allows you to determine the localization of the pathological process. Worm-like clots that form as blood passes through the ureter indicate an upper urinary tract disease. Shapeless clots are more characteristic of bleeding from the bladder, although they may form in the bladder when blood is released from the kidney.

DIAGNOSTIC CRITERIA.

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

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

It is necessary to clarify the possible cause of hematuria.

2) Whether the patient has consumed foods (beets, rhubarb) or drugs (analgin, 5-NOC) that can color urine red

Differentiated hematuria and urine staining of another cause.

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

It is necessary to differentiate hematuria and urethrorhagia

4) Whether the patient had poisoning, blood transfusions, whether there is acute anemia.

It is necessary to differentiate hematuria and hemoglobinuria that occurs with massive intravascular hemolysis of erythrocytes.

MAIN DIRECTIONS OF THERAPY.

If gross hematuria occurs, especially painless, immediate cystoscopy is indicated to establish the source of bleeding, or at least the side of the lesion, since hematuria may suddenly stop during tumor processes, and the ability to determine the lesion will be lost. The position formulated in 1950 by IN Shapiro fully retains its relevance, that any unilateral significant renal bleeding should be considered a sign of a tumor until another cause of hematuria is found. Only after the diagnosis is established, or at least the side of the lesion, can the use of hemostatic agents be started.

To assess the risk of hematuria that has arisen, it is important to determine the level and dynamics of blood pressure, hemoglobin content, the severity of tachycardia, and the determination of BCC. 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, the tactics of treatment for hematuria depends on the nature and localization 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) the introduction of 100 ml of a 5% solution of e-aminocaproic acid IV;

c) introduction of 4 ml (500 mg) of 12.5% solution of dicynone IV;

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 therapeutic measures. Simultaneously with the transfusion of blood and hemostatic drugs, they begin to remove clots from the bladder using an evacuator catheter and Janet's syringe.

COMMON THERAPY ERRORS.

From hematuria should be distinguished urethrorrhagia, in which blood is released from the urethra outside the act of urination. Urethrorrhagia often occurs when the integrity of the wall of the urethra is violated or a tumor develops in it. If there is evidence of an inflammatory process or tumor of the urethra, urgent ureteroscopy and bleeding control by electrocoagulation or laser ablation of the affected area is necessary. In case of suspected rupture of the urethra, an attempt to pass a catheter or other instruments into the bladder is strictly contraindicated, since this contributes to an increase in injury.

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

INDICATIONS FOR HOSPITALIZATION.

With gross hematuria, hospitalization is indicated. Life-threatening bleeding and the lack of effect of conservative treatment is an indication for urgent surgical intervention (nephrectomy, resection of the bladder, ligation of the internal iliac arteries, emergency adenomectomy, and others).

Can a human bladder burst? It will not be possible to deliberately delay urination until overstretching and injuring the organ. The bladder is able to withstand severe loads and not burst from overflow in the absence of mechanical obstacles to urine diversion. External physical effects on the abdominal wall are dangerous.

When filling, the bladder stretches, the walls become thinner, it begins to protrude beyond the limits of the bone womb and becomes vulnerable to external influences. Especially if filled with urine. Due to a blow to the stomach, falling from a height, the bladder can burst. Empty, on the contrary, is elastic and is not injured when shaken.

Consider what will happen if the bladder bursts, for what reasons this happens, what symptoms will help to recognize a dangerous condition.

Classification

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

extraperitoneal (accompanied by profuse bleeding, the lower part of the organ is damaged, urine is poured into adjacent tissues);
intraperitoneal (it happens more often when the organ is full, it is characterized by slight 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, which a person in the mind cannot ignore:

pain in the area below the navel, above the pubis;
severe swelling in the groin;
febrile state, accompanied by chills, deterioration in general well-being;
acute urinary retention (AUR) and ineffectual urges;
if urine is excreted, then with blood;
sometimes the pain goes to the lumbar region.

For doctors, an important diagnostic measure is the introduction of a soft catheter. In this case, there will be almost no urine, despite the long absence of urination in the patient. Either the fluid is much larger than the capacity of the bladder and it 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 not possible to empty the bladder on its own with frequent urges to this (unlike anuria).

There are several reasons:

violation of the conduction of nerve impulses;
mechanical blockage of the urethra;
urinary tract injuries;
psychogenic urinary retention;
poisoning with chemicals, medicines.

The doctor will conduct a differential diagnosis to exclude conditions that caused acute urinary retention, not associated with rupture of the bladder. In men, urinary retention develops due to adenoma and prostate 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.

Effects

If a ruptured bladder is not treated, the consequences are the same for men and women.

With an intraperitoneal injury to an organ, the outflowing urine is partially adsorbed, causing irritation of the internal organs, non-infectious inflammation and peritonitis (urinary) in the future.
With an extraperitoneal complete rupture, blood and urine infiltrate the nearby fiber with the formation of a urohematoma. Further, the disintegration of urine occurs, the precipitation of salt crystals, purulent inflammation (phlegmon) of the pelvic and retroperitoneal tissues develops. The process extends to the entire wall of the organ with the transition to necrotic cystitis.

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

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

Very rarely, the inflammatory process with minor gaps leads to a slowdown in the development of the purulent-inflammatory process with the formation of abscesses in the fiber.

Treatment

Treatment of complete closed injuries is only surgical. If the bladder has burst slightly or a bruise has occurred, urine does not pour out of it. Layered hemorrhages are formed with deformation of the outlines of the organ.

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

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

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

hemorrhages

Tamponade of the bladder, what is it? This is a state of OZM (complete cessation of its excretion) due to the filling of the MP cavity with clotted blood clots. The causes of hemorrhage are different: 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. Tamponade of the bladder is characterized by painful and ineffectual urge to urinate, aggravated pain with pressure on the suprapubic region, and patient's nervousness. If you manage to get portions of urine, then 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, palpitations, increased blood pressure, dizziness).

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

First aid

If, as a result of an abdominal injury, the victim shows characteristic symptoms (the bladder burst, or fractures of the pelvic bones are obtained), it is urgent to call an emergency team, and put an ice pack on the victim's stomach.

Sources

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