Complications of kidney and bladder cancer. Palliative treatment of bladder cancer Bladder tamponade indications for surgery

Bladder cancer is the most common tumor of the urinary tract. Among malignant tumors of other organs, bladder cancer takes 7th place in men and 17th place in women. Thus, in men, neoplasms of the bladder occur up to 4-5 times more often than in women. Mostly people over 55-65 years old are ill. In Russia, from 11 to 15 thousand people fall ill annually. At the same time, the annual mortality from this disease is at least 7-8 thousand people. For comparison, in the United States, the incidence is about 60 thousand people, and the death rate is no more than 13 thousand. Such pronounced differences are due to both the imperfection of early diagnosis and the insufficient prevalence of modern and highly effective methods of treating bladder cancer in our country.

Figure 2. Prevalence of Bladder Cancer.

Bladder Cancer Causes

It is generally accepted that the main cause of bladder cancer is the effect of carcinogenic substances excreted in the urine on the bladder mucosa. The proven risk factors for malignant bladder tumor are:

Occupational hazards (long-term work in rubber, dyeing, oil, textile, rubber, aluminum industries, etc.) - increases the risk of developing bladder cancer by up to 30 times.
Smoking - increases the risk up to 10 times.
Taking certain medications (phenacetin-containing analgesics, cyclophosphamide) increases the risk by 2-6 times.
Exposure to radiation - increases the risk by 2-4 times.
Schistosomiasis (North Africa, Southeast Asia, Middle East) - increases the risk by 4-6 times.
Chronic cystitis, chronic stagnation of urine, bladder stones - increases the risk up to 2 times.
Chlorinated water consumption - 2 times

Bladder Cancer Symptoms

There are no specific complaints specific to bladder cancer. The initial stages of bladder cancer are usually asymptomatic in most cases.

The leading symptom is hematuria (the appearance of blood in the urine). Often, hematuria has a transient character - it appears out of the blue and quickly disappears. The patient may not attach much importance to this. Or confine yourself to taking the "hemostatic" drug prescribed in the clinic. Meanwhile, the bladder tumor continues to develop. With profuse bleeding, bladder tamponade often occurs and, as a result, acute urinary retention.
Dysuria (frequent and painful urination with imperative urge), a feeling of fullness in the projection of the bladder.
Dull pain over the bosom, in the region of the sacrum, perineum (when the tumor spreads to the muscle layer).
In advanced forms, patients are often worried about weakness, a sharp loss of body weight, fatigue, anorexia.

Diagnosis of Bladder Cancer

The diagnosis of bladder cancer is based on the collection of patient complaints, medical history and examination of the patient. The latter is given special importance. It is necessary to pay attention to the following manifestations of bladder cancer when examining a patient:

Signs of chronic anemia (weakness, lethargy, pallor of the skin
Swollen lymph nodes on palpation in areas of possible lymphogenous metastasis
Definition of neoplasm by palpation of the bladder, its mobility, the presence of infiltration of surrounding tissues.
Enlarged bladder, due to chronic or acute urinary retention
Positive tapping symptom, palpation of enlarged kidneys (with the development of hydronephrosis, as a result of urinary retention)

Laboratory research

General urine analysis with sediment microscopy (to determine the degree and location of hematuria)

Cytological examination of urine sediment (to detect abnormal cells)

Instrumental diagnostic methods

Radiation methods are of great importance in the diagnosis of bladder tumors:

	Ultrasound (ultrasound) - to assess the location, size, structure, nature of growth and prevalence of the tumor, the area of regional metastasis, the upper urinary tract, the presence or absence of hydronephrosis. This method is a screening method and is not used for mono-diagnostics.
	CT, MRI with intravenous contrast (computed tomography, magnetic resonance imaging) - determination of the extent of the tumor process and the patency of the ureters

Excretory urography is an outdated method, but if necessary, it allows you to assess the patency of the ureters, to identify formations in the upper urinary tract and in the bladder. Currently not widely used due to the low specificity and sensitivity of the method
CT scan of the lungs, scanning of the bones of the skeleton (osteoscintigraphy) (if metastatic lesion is suspected).

Differential diagnosis

Bladder cancer must be differentiated from the following diseases: inflammatory diseases of the urinary tract, nephrogenic metaplasia, anomalies of the urinary tract, squamous cell metaplasia of the urothelium, benign epithelial formations of the urinary bladder, tuberculosis and syphilis of the genitourinary system, endometriosis, chronic bladder cystitis, metastasis of the urinary tract stomach, etc. (extremely rare).

Classification of Bladder Cancer

Depending on the degree of prevalence (neglect), bladder cancer can be divided into 3 types:

surface
invasive
generalized

Anticipating the consideration of the clinical forms of bladder cancer, it should be noted that the wall of this organ consists of four layers:

Epithelium (mucous membrane) - a layer that is in direct contact with urine and in which tumor growth "begins";

The submucosal connective tissue layer (lamina propria) is a fibrous plate that serves as a "base" for the epithelium and contains a large number of vessels and nerve endings;

The muscle layer (detrusor), whose function is to expel urine from the bladder;

The outer layer of the bladder wall can be represented by adventitia (in the retroperitoneal part of the organ) or the peritoneum (in the intra-abdominal part of the organ).

TNM classification of bladder cancer

Histological classification

Th - primary tumor cannot be assessed
T0 - no data on primary tumor
T1 - tumor invasion affects the submucosa
T2 - tumor invasion of the muscle layer
T3 - tumor invasion extends to paravesicular tissue
T4 - tumor invasion extends to any of these organs
- vagina, uterus, prostate gland, pelvic wall, abdominal wall.
N1-3 - metastasis to regional or adjacent lymph nodes is detected
M1 - metastasis to distant organs is detected

Transitional cell carcinoma:
with squamous metaplasia
with glandular metaplasia
with squamous and glandular metaplasia
Squamous
Adenocarcinoma
Undifferentiated cancer

WHO classification (2004)

MK CODESB-10 Class II - neoplasms.
Block C64-C68 - malignant neoplasms of the urinary tract.

Flat neoplasms

hyperplasia (no atypia or papillary elements)
reactive atypia
atypia with unknown malignant potential
urothelial dysplasia
urothelial carcinoma in situ

Papillary neoplasms

urothelial papilloma (benign neoplasm)
papillary tumor of the urothelium with low malignant potential (POUNZP)
papillary urothelial carcinoma of low grade
high-grade papillary urothelial carcinoma

C67 - malignant neoplasm:
C67.0 - bladder triangle;
C67.1 - domes of the bladder;
C67.2 - Lateral wall of the bladder;
C67.3 - Anterior wall of the bladder;
C67.4 - posterior wall of the bladder;
C67.5 - Bladder neck; internal urethral opening;
C67.6 - Ureteral foramen;
C67.7 - Primary urinary duct (urachus);
C67.8 - involvement of the bladder, extending beyond one
and more of the above localizations;
C67.9 - Bladder, unspecified

Bladder Cancer Treatment

Superficial bladder cancer

Among patients with newly diagnosed bladder cancer, 70 percent have a superficial tumor. In 30 percent of patients, there is a multifocal lesion of the mucous membrane of the bladder. In superficial cancer, the tumor is located within the epithelium of the bladder (or spreads no deeper than the lamina propria) and does not affect its muscular membrane. This form of the disease has the best prognosis.

Transurethral resection of the bladder (TUR) is the main treatment for superficial bladder cancer.

Drawing. Scheme - TUR of the Bladder

At TOUR remove all visible tumors. The exophytic component and the base of the tumor are removed separately. This technique has diagnostic and therapeutic value - it allows you to take material for histological examination (confirmation of the diagnosis) and remove the neoplasm within healthy tissues, which is necessary for the correct establishment of the stage of the disease and the choice of further treatment tactics. Relapse develops in 40–80 percent of cases after transurethral resection (TUR) within 6–12 months, and invasive cancer occurs in 10–25 percent of patients. This percentage can be reduced by using photodynamic diagnostics and intravesical administration of BCG vaccine or chemotherapy drugs (mitomycin, doxorubicin, etc.). Promising intravesical drug electrophoresis techniques are in the development phase.

Drawing. TUR of the Bladder. Cystoscopic picture.

Intravesical BCG therapy has been shown to reduce the recurrence rate of bladder cancer after TURP in 32-68 percent of cases.

BCG therapy is contraindicated:

within the first 2 weeks after TURB biopsy
in patients with gross hematuria
after traumatic catheterization
in patients with symptoms of a urinary tract infection

Complications of TUR of the bladder:

bleeding (intraoperative and postoperative)
perforation of the bladder wall (depending on the experience of the surgeon);

After the TUR is completed, it is absolutely MANDATORY to perform repeated control examinations of the bladder to exclude a relapse. In case of multiple relapses after TUR and detection of poorly differentiated ("evil") cancer, it is often advisable to resort to a radical operation - cystectomy (removal of the bladder) with the formation of a new bladder from the segment of the intestine. This operation is especially effective in early forms of cancer and provides high oncological results. With adequate treatment, the 5-year survival rate for patients with superficial bladder cancer exceeds 80 percent.

Muscle-invasive bladder cancer

Invasive bladder cancer is characterized by the spread of tumor lesions to the muscular membrane and outside the organ - to the peri-vesicular fatty tissue or adjacent structures (in advanced cases). In this phase of the development of a bladder tumor, the likelihood of metastasis to the lymph nodes is significantly increased. The main method of treatment of invasive bladder cancer is radical cystectomy with lymphadenectomy (removal of a single block of the bladder with the peritoneum covering it and paravesical tissue, the prostate gland with seminal vesicles, bilateral pelvic (ileo-obturator) lymphadenectomy. ). Radical cystectomy with intestinal plastic is optimal, since it allows you to preserve the ability to urinate independently. In a limited number of cases, TUR and open resection of the bladder are used to treat patients with muscle-invasive cancer. To increase the efficiency of surgical treatment in some patients, it is advisable to prescribe anticancer chemotherapy drugs. The 5-year survival rate for patients with invasive bladder cancer averages 50-55 percent.

When metastases appear (tumor screenings in the lymph nodes and organs), bladder cancer is called generalized (metastatic). Most often, the disease metastasizes to regional lymph nodes, liver, lungs and bones. Almost the only effective treatment for generalized bladder cancer that can prolong the patient's life is powerful chemotherapy with several drugs at once (methotrexate, vinblastine, doxorubicin, cisplatin, etc.). Unfortunately, none of these drugs are safe. The mortality rate when using them is 2-4 percent. Often it is necessary to resort to surgical treatment, the purpose of which is not to allow the patient to die from life-threatening complications accompanying the tumor process (for example, bleeding). The 5-year survival rate for patients with advanced bladder cancer does not exceed 20 percent.

Prevention of bladder cancer

Elimination of the effects on the body of carcinogenic substances
To give up smoking
Timely treatment of genitourinary infections
Ultrasound of the genitourinary system, general urine analysis
Timely examination and treatment by a urologist at the first signs of dysfunction of the urinary system

The main thing for you:

Do not be lazy to spend ONE day a year (in a good clinic) and undergo a QUALITY dispensary examination, which necessarily includes an ultrasound of a filled bladder and urinalysis. If you suddenly notice an admixture of blood in the urine, be sure to seek advice from a competent urologist who has the opportunity and, most importantly, the desire to find out the cause of this episode. Compliance with the above is highly likely to allow you to avoid such "news" as advanced cancer of your bladder.

2050 0

As you know, the extensive spread of bladder tumors makes radical treatment impossible, and the main goal of palliative treatment is to reduce or completely eliminate the painful symptoms of the disease, i.e. to improve the quality of life indicators.

Palliative treatment methods:

1. Palliative surgery
2. Radiation therapy
3. Chemotherapy
4. Immunotherapy

The main clinical syndromes in the progression of bladder cancer (bladder cancer):

1. Anemia
2. Intravesical obstruction syndrome
3. Chronic renal failure
4. Chronic pain syndrome

Thus, therapeutic measures against the background of the main methods of exposure will also be aimed at combating pain syndrome, hematuria, acute urinary retention, blockade of the upper urinary tract, paravesical phlegmon.

Those. the nature and scope of palliative care will be dictated by the most prevalent clinical syndromes requiring emergency treatment.

Emergencies and their characteristics

Emergency conditions:

1. Hematuria
2. Tamponade of the bladder
3. Acute urinary retention
4. Blockade of the upper urinary tract (hydronephrosis)
5. Pain syndrome
6. Paravesical phlegmon

The appearance of blood in the urine (hematuria) is usually the first symptom that prompts the patient to see a doctor and suspect the presence of a bladder tumor.

In the early stage of the disease, hematuria may not cause much concern, and sometimes it is enough to prescribe hemostatic agents (nettle decoction, dicinone) to compensate for blood loss and stop bleeding.

Two symptom complexes can determine the urgency of the situation and the need for urgent medical care for profuse hematuria - acute anemia and bladder tamponade. Intense bleeding that does not stop conservative methods of treatment leads to blood loss, hypovolemia and anemia.

The clotting of blood poured into the lumen of the bladder may be accompanied by the formation of clots that can cause bladder tamponade. In the event of this situation, you have to resort to surgical treatment.

The scope of the surgical impact will be determined by the localization of the tumor and the extent of the process. For this, a high section of the bladder is performed, followed by its revision, freeing the bladder cavity from clots and restoring the passage of urine.

With limited cancer of the bottom and the body of the bladder, resection of the bladder is performed, with infiltration of the ureteral opening, the intramural ureter is resected, followed by neoimplantation into the bladder.

With total damage to the bladder or the location of the tumor in the bladder triangle, the possibility of the need for cystectomy, a technically difficult and traumatic operation for the patient, is not excluded.

Cystectomy ends with bilateral ureterocutaneostomy, since an increase in the volume of the operation due to the formation of an artificial reservoir for urine, given the urgency of the operation, can be fatal.

In the case of unresectability of the bladder tumor, attempts are made to stop bleeding by palliative measures - electrocoagulation of the tumor, ligation of both internal iliac arteries.

In specialized medical institutions, it is possible to use endovascular interventions with subsequent embolization of the internal iliac arteries, under the control of angiography. The advantage of embolization is the possibility of occlusion of the peripheral arterial bed, which excludes the development of collaterals.

Also, the advantage of endovascular intervention is the possibility, due to catheterization of one of the vessels, to conduct regional infusion of hemostatic and cytostatic drugs, against which it is possible to stop ongoing bleeding.

Embolization is carried out by transfemoral Seldinger catheterization, selective introduction of a catheter into the internal iliac artery from one or both sides and under visual control by occlusion of all peripheral vessels.

Bleeding from the bladder neck can be established using a Foley balloon catheter: after inserting the catheter into the bladder and inflating the balloon, the outer end is fixed in a taut position to the thigh, which provides compression of the tumor. Also, to stop bleeding, you can use a tight tamponade of the bleeding tumor with a gauze swab.

In the case of a violation of the outflow of urine associated with the germination of the mouths of the ureters, their infiltration and leading to the development of ureterohydronephrosis and azotemia, the patient is shown:

Imposition of percutaneous nephrostomy;
ureteral stenting;
imposition of a nephrostomy;
removal of the orifices of the ureters to the skin.

With complete urinary retention, the best method of restoring urine diversion is bladder catheterization with an elastic catheter. If it is impossible to install an elastic catheter, it is possible to perform trocar epicystostomy or superimposition of a suprapubic fistula. A rubber Foley catheter is inserted through the trocar into the bladder, and after filling the balloon, it is left to drain the bladder and urine outflow.

The growth of the tumor into the pelvic organs and compression of the nerve trunks is accompanied by persistent pain syndrome, leading to the need to use analgesics and drugs.

The principles of drug treatment of pain syndrome are outlined by us above. It is also possible to use conduction novocaine blockades through the obturator hole according to Stuckey, presacral blockade according to A.V. Vishnevsky, epidural denervation, resection of the presacral nerve plexus.

Although the modern development of pharmacotherapy, this direction is reduced to almost a minimum. Also, carrying out this kind of manipulation requires a good skill. In case of metastatic lesions of the bones of the skeleton, it is possible to use short courses of local irradiation to relieve pain.

Extraperitoneal perforation of the bladder develops in patients with advanced endophytic, infiltrating tumor due to its spontaneous or in the case of radiation decay. A defect in the bladder wall causes urine to leak into the peri-vesicular cellular space, which is complicated by the development of paravesical phlegmon.

In this case, the optimal method of palliative care will be resection of the bladder wall with a disintegrating tumor and suturing of the post-resected defect.

The operation for paravesical phlegmon has two goals: urine diversion and drainage of the peri-vesical cellular tissue space.

The most effective way of urine diversion is epicystomy through a “healthy” wall without signs of visible tumor invasion. With a disintegrating tumor in the region of the bladder triangle, the only possible way to divert urine to the outside is bilateral ureterocutaneostomy.

Drainage of peri-vesicular tissue through the anterior abdominal wall provides outflow from the upper portions of the retropubic space and pre-vesicular tissue. Peripubular tissue located deep in the pelvis should be drained through the obturator opening.

After the provision of primary palliative care in the future, patients are shown radiation therapy with single single dose (ROD) 1.8-2.5 Gy, total focal dose (SOD)- 60-70 Gr.

Contraindication to radiation therapy is the compression of the ureters, acute pyelonephritis, the presence of multiple metastases, inhibition of hematopoiesis, the severe general condition of the patient.

For chemotherapy, cytostatics are most often used - adriamycin, thiotef, mitomycin C, cisplatin, methotrexate, vinblastine, 5-fluorouracil. The standard treatment regimen is currently a combination of 3-4 drugs based on cisplatin and methotrexate.

The most commonly used scheme is MVAC:

Methotrexate 30 mg / m2, IV, on days 1,15,22,
Vinblastine 3 mg / m2, i.v., on days 2,15,22,
Adriamycin 30 mg / m2, i.v., on day 2,
Cisplatin 70 mg / m2, IV, on day 2.

The interval between courses is 28 days. At least 2-3 courses. The effectiveness of chemotherapy for disseminated bladder cancer is about 50-70% and its use in a palliative mode with a good patient's condition should not be neglected by the attending physician.

Novikov G.A., Chissov V.I., Modnikov O.P.

According to the 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 cancernothing. By 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. Certain risk factors have been identified that are most likely to cause cancer. For example, it has been known for over 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 decay products of aniline dyes excreted in the urine have a pronounced carcinogenic effect on the mucous membrane of the bladder. Thus, artists, painters, and interior designers are at risk.

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

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

Symptoms. The clinical presentation 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 gross hematuria or microhematuria, which may appear once, and then not bother 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 anemization of the patient. Often, this life-threatening condition forces you to take emergency surgery.

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

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

The proliferation of a tumor of the bladder often leads to compression of the orifices 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 of the type of 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 the anterior abdominal wall, in men - through the rectum. In urine tests for bladder cancer, an increase in the number of red blood cells is noted, in blood tests - a decrease in hemoglobin levels, indicating ongoing bleeding.

One way to diagnose bladder cancer is through a urine cytology test, which is usually done several times. The detection of atypical cells in the urine is pathognomonic for the neoplasm of the bladder. In recent years, another laboratory diagnostic method has appeared, the so-called BTA (bladder tumor antigen) test. With the help of 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 screening diagnostic method.

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

Large tumors are detected by excretory urography or retrograde cystography. Sedimentary cystography according to Kneise-Schober helps to increase the information content of the study. Contrast-enhanced spiral and multislice computed tomography is of great importance in the diagnosis of bladder cancer. With the help of these techniques, it is possible to establish the size and localization of the formation, its relation to the orifices of the ureters, invasion 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 content 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. Unlike CT, tumor invasion into the muscle layer of the bladder or adjacent organs can be estimated with much greater accuracy.

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

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 the 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 allows you to detect small formations, which often cannot be detected by any other method.

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

An operation, after which urine is constantly excreted and patients need a urine bag, is ureterocutaneostomy.

Operations that use internal urine diversion - the mouths of the ureters open into the intestines.

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 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.

The human body is an intelligent and fairly balanced mechanism.

Among all infectious diseases known to science, infectious mononucleosis has a special place ...

The world has known about the disease, which official medicine calls "angina pectoris" for a long time.

Mumps (scientific name - mumps) is an infectious disease ...

Hepatic colic is a typical manifestation of gallstone disease.

Cerebral edema is a consequence of excessive stress on the body.

There are no people in the world who have never had ARVI (acute respiratory viral diseases) ...

A healthy human body is able to assimilate so many salts obtained with water and food ...

Knee bursitis is a common condition among athletes ...

Bladder tamponade

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

Why is it developing?

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

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

Bladder cancer is a common cause.

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. The rupture and tension of the capsule occurs due to the growth of the prostate gland and obstruction in it.

Pressure is constantly exerted on the muscle that relaxes the bladder, as well as on its neck. It is formed due to the fact that it is necessary to overcome the infravesicular blockage. The change in pressure within the bladder and the large volume of the prostate gland create conditions that lead to the 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 give an effect, or a small amount of urine is released. On palpation above the pubis, a bulge is determined, this is an overflowing bladder. At the slightest pressure on it, pain occurs. A person with bladder tamponade is emotionally labile and restless.

Based on the determination of the volume of blood in the bladder, the degree of blood loss is determined. The urine contains fresh or altered blood impurities. It should be borne in mind that the tamponade of the urinary reservoir suggests bleeding. The capacity of the bladder in males 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;
palpitations;
weakness and apathy;
dizziness;
increased heart rate.

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

Anemia is one of the complications of a pathological condition

How is it diagnosed?

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. On examination, expressed soreness when pressed in the bosom, a pale and unhealthy appearance of the patient, draws on itself.

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

The attending physician must prescribe blood and urine tests. In the general analysis of blood, 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 is due to the inflammatory process in the bladder.

In the biochemical analysis of blood, 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 decreases.

To diagnose tamponade, ultrasound examination 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 assume quite accurately the amount of blood that is in the bladder cavity. But examination of the kidneys allows you to diagnose a blockage of the urinary tract above the urine reservoir itself.

On ultrasound, this obstruction will be visible as an expansion on both sides. The calyx-pelvic system and ureters expand. This type of diagnosis also detects neoplasms, if any.

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

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

Hemostatics - medications used for bleeding in various types

But the delayed one involves cleansing the bladder from blood through the urethra in parallel with antibiotic and hemostatic therapy. Lost blood replacement 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 that requires immediate treatment. At the first sign, see your doctor.

2pochki.com

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 you can see from the 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 renal arterial vessels, venous stasis and edema of the parenchyma, its hypoxia and overstretching of the fibrous capsule.

Etiology and pathogenesis

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

The clinical picture. Renal colic is characterized by the sudden appearance of intense pain in the lumbar region, often at night, during sleep, sometimes after physical exertion, long walking, shaking 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. Possible atypical irradiation of pain (in the shoulder, scapula, in the navel), which is explained by the wide nerve connections of the renal plexus. Paradoxical pain in the area of a healthy kidney due to reno-renal reflux is often observed. In some patients, pain prevails at the site of irradiation.

The restless behavior of patients is characteristic, who groan, rush and take the most incredible postures, since they cannot find a position in which the intensity of pain would decrease. Paleness, cold sweat appear. Blood pressure sometimes 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, stool and gas retention, bloating (gastrointestinal syndrome), which complicates the diagnosis.

Bimanual palpation reveals a sharp soreness in the kidney area, muscle resistance on the side of the disease. Sometimes it is possible to feel 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:

Is there 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, shaking 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 (when the pelvis is occluded by calculus, pain can be irradiated to the lower back and hypochondrium, when occluded at the border of the upper and middle third of the ureter - to the lower abdomen, with a lower stone location - to the groin, 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 urinary disorder (often accompanied by renal colic)?

In the treatment of renal colic, the doctor pursues two main tasks: the elimination of pain and the arrest (elimination) 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 doctor, is sodium diclofenac. The latter is an antagonist of prostaglandin synthesis, which helps to reduce filtration and, thus, intralocal pressure. In addition, diclofenac sodium reduces inflammation and edema in the occlusion zone, 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 diclofenac sodium.

It should be remembered about the negative effect 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 complete cessation of the act of urination when the bladder is full.

Etiology and pathogenesis. The delay in urination can occur due to a number of reasons presented in table. 3.

Clinical presentation and diagnostic criteria

Patients suffer from overflow 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, who, as a rule, are immobilized and do not experience severe pain, react differently. When viewed in the suprapubic region, a characteristic swelling is determined due to an overflowing bladder ("bubble ball"), which, when percussed, gives a dull 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. In case of acute urinary retention, it is necessary to urgently evacuate urine from the bladder. Given the danger of urinary tract infection in the absence of a pronounced urge to urinate, catheterization is best done in a hospital setting. Severe pain syndrome caused by overstretching of the bladder is an indication for catheterization at the prehospital stage.

Bladder catheterization should be treated as a serious procedure, equating it with an operation. 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 is lengthened and the angle between the prostatic and bulbous parts of it increases. Given these changes in the urethra, it is advisable to use catheters with a Timan or Mercier curvature. With a rough and forcible introduction of a catheter, serious complications are possible: the formation of a false passage in the urethra and prostate gland, urethrorrhagia, urethral fever. Prevention of these complications is a careful adherence to asepsis and catheterization technique.

The need for catheterization often arises in elderly patients, as well as in persons with severe concomitant pathology, including diabetes mellitus, circulatory disorders, etc. In such cases, given the absence of sterile conditions in the EMS machine, it is necessary to carry out antibiotic prophylaxis of urinary tract infections (UTI).

The main causative agent of uncomplicated MEP infections is E. coli - 80 - 90%, much less often - S. saprophyticus (3-5%), Klebsiella spp., P. mirabilis, etc. Fluoroquinolones (ciprofloxacin, pefloxacin, ofloxacin and others), the level of resistance of which is less than 3%.

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

For prophylaxis, these antibacterial drugs can be used orally.

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 edema of its mucous membrane. Bladder catheterization is contraindicated in this disease. Acute urinary retention is one of the leading symptoms in patients with urethral trauma. In this case, catheterization of the bladder for diagnostic or therapeutic purposes is also unacceptable.

Acute urinary retention with stones in the bladder occurs when a stone wedges into the neck of the bladder or obstructs the urethra in its various parts. Palpation of the urethra helps to diagnose stones. With urethral strictures leading 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 prolapse of the uterus. 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 genital organs with warm water, by pouring water from one vessel into another (the sound of a falling stream of water can reflexively cause urination); if these methods are ineffective and there are no contraindications, 1 ml of a 1% solution of pilocarpine or 1 ml of a 0.05% solution of proserin is administered subcutaneously; if ineffective, bladder catheterization is indicated.

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

Macrohematuria

Definition. Hematuria - the appearance of an impurity of blood in the urine - is one of the characteristic symptoms of many urological diseases. Distinguish between microscopic and macroscopic hematuria; the onset of intense gross hematuria often requires urgent care.

Etiology and pathogenesis. Possible causes of hematuria are presented in table. 5.

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

Macrohematuria can be of three types: 1) initial (initial), when only the first portion of urine is colored with blood, the remaining portions are of normal color; 2) terminal (final), in which the first portion of urine does not visually detect blood impurities 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 interferes with the outflow of urine from the kidney. In a kidney tumor, bleeding precedes pain ("asymptomatic hematuria"), whereas in urolithiasis, pain occurs before the onset of hematuria. Localization of pain in hematuria also makes it possible to clarify the localization of the pathological process. So, pain in the lumbar region is typical for kidney disease, 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 the blood clots also allows you to determine the localization of the pathological process. Worm-like clots that form when blood passes through the ureter indicate an upper urinary tract disease. Shapeless clots are more common in bleeding from the bladder, although they may form in the bladder when blood is excreted from the kidney.

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

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 colloidal solutions. Hemostatic agents are not used.

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

Acute pyelonephritis

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

Etiology and pathogenesis. The causative agents of pyelonephritis can be Escherichia coli, less often other gram-negative bacteria (for example, Pseudomonas aeruginosa), staphylococci, enterococci, etc. organism - otitis media, tonsillitis, mastitis, pneumonia, sepsis, etc.). Predisposing factors - immunodeficiency, urinary tract obstruction (urolithiasis, various abnormalities 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. occurrences distinguish between primary pyelonephritis (without any previous disorders of the kidneys and urinary tract) and secondary (arising on the basis of organic or functional processes in the kidneys and urinary tract, which reduce the resistance of the kidney tissue to infection and disrupt the outflow of urine). In general, pyelonephritis develops more often in women, especially at a young age, which is associated with the anatomical, physiological and hormonal characteristics of the female body. In old age, the disease is more common in men due to the development of prostate adenoma.

The classification of acute pyelonephritis is presented in table. 7.

The clinical picture. Symptoms of acute pyelonephritis consist of general and local symptoms 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, soreness when tapping in the lower back.

During acute pyelonephritis, 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, implying the use of non-steroidal anti-inflammatory drugs and antispasmodics (see section Renal colic).

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

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

D. Yu. Pushkar, Doctor of Medical Sciences, Professor A. V. Zaitsev, Doctor of Medical Sciences, Professor L. A. Aleksanyan, Doctor of Medical Sciences, Professor A. V. Topolyansky, Candidate of Medical Sciences P. B. Nosovitsky

MGMSU, NNPO of emergency medical care, 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 renal arterial vessels, venous stasis and edema 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 edema of its mucous membrane.

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Bladder cancer

According to the 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. By 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. Certain risk factors have been identified that are most likely to cause cancer. For example, it has been known for over 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 decay products of aniline dyes excreted in the urine have a pronounced carcinogenic effect on the mucous membrane of the bladder. Thus, artists, painters, and interior designers are at risk.

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

Symptoms. The clinical presentation of bladder cancer depends on the stage of the tumor. Ta-T1 neoplasms are usually asymptomatic. One of the first clinical manifestations is gross hematuria or microhematuria, which may appear once, and then not bother 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 anemization of the patient. Often, this life-threatening condition forces you to take emergency surgery.

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

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

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

An operation, after which urine is constantly excreted and patients need a urine bag, is ureterocutaneostomy.

Operations that use internal urine diversion - the mouths of the ureters open into the intestines.

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 speak of macrohematuria, and when erythrocytes are detected using a microscope - microhematuria.

Etiology. The causes of hematuria are quite varied and numerous. Most urological diseases can be the cause of 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. Determination of blood in urine is important, firstly, because such patients often require urgent care, and secondly, because hematuria is often the first sign of urological cancer.

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

The admixture of blood to urine can occur in various phases of urination - at the beginning, end, or throughout the entire act. or initial, hematuria. Staining with blood only the last portions of urine is called the final, or terminal, hematuria, but if the blood evenly stains the entire stream of urine, that is, all its portions, then we are talking about complete, or total, hematuria. The three-glass test has an important role in determining the type of hematuria.

The type of hematuria allows you to roughly determine the section of the urinary tract, 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 injuries of 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, prostate disease, seminal tubercle, 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 damaged, these parts are injured, which leads to the release of blood. This form of hematuria is equally common in both men and women.

Total hematuria is a serious problem in terms of correctly recognizing the underlying causes of its occurrence. It can be when blood is released from the bladder, ureters, renal pelvis, or the kidneys themselves. The intensity of blood staining of urine may vary.

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

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

Quite often, an admixture of blood to urine is observed with urolithiasis. Intense hematuria can occur with a neoplasm in the urinary system. In these cases, it often arises, as it were, in full health, suddenly, in the absence of other visible signs of the disease. It is called asymptomatic. In kidney and bladder tumors, 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 overflow the bladder, causing tamponade. The passage of clots through the ureter often leads to renal colic. Often, tumors of the bladder are also the cause of hematuria. In this case, hematuria may appear unexpectedly, "in the midst of complete health," as in kidney tumors.

Inflammatory processes of the kidneys and bladder alone rarely cause significant bleeding. However, mild "undercutting" with slight coloration of urine is common.

Diagnosis. The purpose of the diagnosis is to determine the source of bleeding. For an accurate determination of the source of bleeding, a detailed examination of the patient is necessary.

As a rule, the examination begins with an ultrasound examination of the kidneys, bladder, and prostate gland. In some cases, this is enough to determine the pathology. However, it is not uncommon for an ultrasound examination to 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 discharge of blood from the orifices of the ureters, if the cause of bleeding is in the kidney or ureter. Having seen from which mouth the blood is released, you can find out on which side attention should be focused 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 uninformative.

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

ACUTE DELAYED 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 a lack 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 gland (adenoma, cancer, abscess, acute prostatitis), bladder (stones, tumors, trauma, bladder tamponade), urethra (strictures, stones, trauma), penis (gangrene).

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

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

traumatic injuries of the bladder and urethra;

psychogenically caused acute urinary retention.

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

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

The clinic of acute urinary retention is quite typical. Patients complain of severe pain in the lower abdomen (suprapubic region), frequent painful, sterile urge to urinate, a feeling of fullness and distention of the bladder. The strength of the urgency to urinate increases, quickly becomes unbearable for patients. Their behavior is restless. Suffering from overstretching of the bladder and fruitless attempts to empty it, patients moan, take a variety of positions to urinate (kneel, squat), press on the bladder area, squeeze the penis. When examining the suprapubic region, a swelling in the form of a spherical body, which is called a "bubble ball", clearly appears. Palpation usually produces a painful urge to urinate.

Diagnosis of the causes of acute urinary retention is based primarily on fairly typical complaints and clinical presentation. 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 enlargement of the gland while maintaining a dense elastic consistency and a smooth surface.

Treatment. Urgent therapeutic measures for acute urinary retention are the urgent emptying of the bladder. Retention of urine is dangerous for patients not only because it causes excruciating pain, painful desires, discomfort, but also because it can lead to serious complications - inflammation of the bladder, kidneys, a sharp change in the state 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 bladder catheterization alone. The presence of purulent inflammation of the urethra (urethritis), inflammation of the epididymis (epididymitis), the testicle itself (orchitis), as well as an abscess of the prostate gland is a contraindication for catheterization. It is not indicated for trauma to the urethra. It is very important to prevent urinary infection during catheterization. All items in contact with the patient's urinary tract - tools, underwear, dressings, solutions that are injected into the bladder and urethra - must be sterile. Forced insertion of a catheter is unacceptable, since this inflicts trauma 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 to two days after it, antibiotics and uroantiseptics are prescribed for prophylactic and therapeutic purposes. A metal catheter for bladder catheterization can be used with experience. Any rough and forced insertion of a metal catheter can damage the urethra, sometimes with the formation of false passages.

Bladder catheterization technique 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 furacilin solution. In men, the procedure is performed with the patient supine with legs slightly apart. The catheter is pre-lubricated with sterile glycerin or liquid paraffin. The penis is taken with the left hand near the head so that it is convenient to open the external opening of the urethra. The catheter is inserted with the right hand using tweezers very smoothly, while the penis is, as it were, pulled over the catheter. The patient is offered to take several deep breaths, at the height of inhalation, when the muscles that close the entrance to the urethra relax, while continuing to exert gentle pressure, a catheter is inserted. Its presence in the bladder is evidenced by the release of urine. If the catheter cannot be inserted, then if you feel resistance, you should not use force, 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 its beak down and inserted up 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 downward and, holding it through the perineum, is passed through the prostate part of the canal into the bladder.

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

ANURIA - complete cessation of the flow of urine into 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 impairment of renal circulation

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

postrenal (obstructive), which develops 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 arena anuria develops.

This division of acute renal failure is of practical importance, since therapeutic measures for different types of anuria differ. In urological practice, it is often necessary to meet with cases arising from 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 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 depletion of the renal blood circulation, a redistribution (shunting) of the renal blood flow occurs, leading to ischemia of the renal cortex and a decrease in the glomerular filtration rate. With exacerbation of renal ischemia, prerenal ARF 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;

crush and muscle necrosis (cruch syndrome);

electrical injury;

burns and frostbite;

operating injury (shock);

blood loss;

anaphylactic shock;

transfusion of incompatible blood;

peritonitis;

acute pancreatitis, pancreatic necrosis;

acute cholecystitis;

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

severe infectious diseases;

bacterial shock;

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

myocardial infarction (cardiogenic shock).

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

Abnormal fluid 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.

Reasons for renal anuria:

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

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

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

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

Causes of postrenal anuria.

Acute urinary tract obstruction (occlusion): bilateral ureteral obstruction, 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 ARF 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-electrolyte disturbances, restoration of general hemodynamics, elimination of renal ischemia, 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 "Artificial kidney" apparatus. Various types of dialysis therapy are used: hemodialysis, hemofiltration, hemodiafiltration, ultrafiltration, as well as hemosorption and plasmapheresis.

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

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

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

Bladder cancer is a common cause.

Development mechanism

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

What are the reasons for incomplete emptying of the bladder?

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

Frequent urination in a man should not always be considered the norm. Even if the frequent urge to empty the bladder is not accompanied by discomfort, discharge and other alarming symptoms, the patient should consult a specialist.

Causes

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

Bladder cystostomy in men

Ishuria is more common among men than women and children, so they are given cystostomy more often. The discomfort from her in men is also greater, because their organ is curved in an arcuate manner.

Indications for its imposition:

Diseases of the prostate (adenoma or tumor). Adenoma is an indication for cystostomy in men. It, as it progresses, enlarges the prostate gland and can compress the urethra. Ishuria develops. Often, an adenoma degenerates into adenocarcinoma, which risks blocking the urethra.
Surgery on the urinary tract or penis. With such interventions, it is often necessary to impose a special catheter.
Neoplasms of the bladder or small pelvis are becoming more common. Tumors are localized in different places, but the most dangerous are in the mouth of the ureter or urethra. If the tumor is in the place where the urethra passes into the urethra, then within a few months its growth will lead to anuria (urine will stop flowing into the bladder).
The urethra is blocked by a calculus or foreign body. This is a consequence of urolithiasis. The stone can pass through the urethra for more than one day. This interferes with the flow of urine and prevents the catheter from being inserted. Salvation in cystostomy.
Pus in the bladder requiring flushing.
The penis is injured.

Diagnostics and therapeutic course in some cases requires the installation of a catheter in the patient's bladder. Most often, the tube is inserted through the urethra, but it can also be placed through the anterior abdominal wall. The catheter performs such important functions:

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

Causes

Symptoms

Based on the determination of the volume of blood in the bladder, the degree of blood loss is determined. The urine contains fresh or altered blood impurities. It should be borne in mind that the tamponade of the urinary reservoir suggests bleeding. The capacity of the bladder in males 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;
palpitations;
weakness and apathy;
dizziness;
increased heart rate.

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

Anemia is one of the complications of a pathological condition

Prostate adenoma: catheterization or surgery?

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

Technique for performing the procedure:

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

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

Serious complications include:

puncture of the abdominal cavity;
perforation of the bladder;
trauma to organs located near the puncture organ;
the ingress of urine into the fiber, which is located around the organ;
purulent-inflammatory process in the fiber.

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

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

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

You cannot refuse an operation because of your age; a heart problem is solved together with a cardiologist and an anesthesiologist, in preparation for the operation. If one specialist denied you an operation, find another, a third, contact a specialized clinic and regional center, today adenoma is successfully treated at any age, a catheter with a urine collection bag is not a sentence!

Suprapubic capillary puncture: indications for use

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

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

Bladder puncture technique

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

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

The physician must make sure that the needle is inserted deep enough and cannot slip out. After this, the patient is turned over to one side and tilted slightly forward. Through a tube attached to the other end of the needle, urine flows into a special tray. After the bladder is completely empty, the needle is carefully removed, and the manipulation site is treated with alcohol or sterile wipes.

If necessary, the puncture of the bladder is repeated 2-3 times a day. If the procedure is to be performed regularly, the bladder is punctured and an indwelling catheter or drain is left to drain urine. If urine is needed for analysis, it is collected in a special syringe with a sterile cap. Before sending the material for research to the laboratory, the contents are poured into a sterile test tube.

The main indications for puncture:

Contraindications to catheterization / inability to drain urine through a catheter.
External genital trauma, trauma to the urethra.
Collection of urine for reliable laboratory research.
The bladder is full and the patient is unable to empty it on his own.

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

Indications for the procedure

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

The diagnostic goal is to take a urine sample. But this method is used quite rarely, although an analysis taken in this way is much more informative than one obtained by self-urination or catheterization.

If the cystic formation is small and does not manifest itself in any way, patients need to be examined for ultrasound 2 times a year to control the situation.

A frequent unpleasant consequence of manipulation with a puncture of the urethra is urethral fever. It can occur when bacteria enter the bloodstream. This happens when the urethra is injured by medical instruments. This complication is accompanied by chills and intoxication of the body. In more severe forms, urethral fever can trigger prostatitis, urethritis, or some other serious illness.

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

Contraindications

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

Clarification of the cause of erythrocyturia.

More qualitative analysis of urine, uncontaminated by extraneous flora of the genital external organs.

Identification of the cause of leukocyturia.

Operation is contraindicated for:

Tamponade.
Paracystitis, acute cystitis.
Small bubble capacity.
Hernia of the inguinal canal.
Neoplasms in the bladder of a benign or malignant type.
Stage III obesity.
The presence of scars on the skin in the area of the proposed puncture site.

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

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

Hemorrhagic diathesis - a contraindication to manipulation

The list of contraindications continues:

a history of dissection of the anterior abdominal wall along the white line below the navel;
mixing, enlargement or stretching of the peritoneal organs;
the presence of inguinal or femoral hernias;
inflammation of the bladder - cystitis;
anomalies of organs located in the small pelvis (cysts, sprains);
an infectious lesion of the skin at the puncture site.

There are times when a puncture is impossible. This procedure is forbidden to perform with various injuries of the bladder and its small capacity. Manipulation is undesirable for men with acute prostatitis or prostate abscesses. The procedure is prohibited for women during pregnancy. Complications during this manipulation can occur in patients with complex forms of obesity.

Other contraindications for puncture are:

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

A cystostomy is a hollow tube that drains urine directly from the bladder and collects it in a bag that temporarily replaces the urinary tract. A conventional catheter is inserted directly into the urethral canal, and a cystostomy is inserted through the peritoneal wall.

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

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

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

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

What are the consequences?

With the correct installation of the cystostomy and its correct use, as a rule, there are no side effects. But the risk of complications cannot be ruled out. Practicing urologists describe the following possible pathological reactions and conditions:

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

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

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

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

IMPORTANT! If the patient has polycystic disease, or education more than 7 cm, puncture is considered ineffective.