L.M. Rapoport, V.V. Borisov, D.G. Tsarichenko
Bleeding in the immediate postoperative period after prostate surgery, the frequency of its occurrence does not depend on the type of adenomectomy (transurethral resection, evaporation, transvesical or retropubic adenomectomy). As a rule, it occurs at a certain time after the operation (6-8, 12-14, 19-21 days) and is associated with phlebothrombosis of the pelvis, which causes the development of varicose veins of the thin-walled veins of the submucosal layer of the bladder neck and the prostatic urethra. A significant increase in venous pressure in conditions of venous stasis due to phlebothrombosis can lead to rupture of veins and profuse bleeding. It is manifested by a sharp pain due to a sudden overflow of the bladder with blood, urine and blood clots, collapse and other circulatory disorders against the background of acute, sometimes very significant, blood loss.
It is well known that in order to eliminate this complication, it is first of all necessary to empty the bladder from blood clots, since it is precisely this that can lead to the elimination of its hyperextension, a reduction in the detrusor and a decrease in bleeding. The final hemostasis is carried out by holding a Foley catheter along the urethra, inflating its balloon and stretching the catheter in order to prolonged pressing of the bleeding vessels of the cervix and prostatic bed against the background of subsequent continuous drip irrigation of the bladder. For the prompt washing of the lumen of the bladder from blood and clots, as a rule, one cystostomy drainage, even of a significant diameter, is clearly not enough. The effect is achieved by holding a special evacuator catheter No. 24-26 and even 28 CH through the urethra into the bladder, followed by the introduction of a rinsing fluid through it and aspiration of blood and clots. This is done blindly, sometimes without taking into account the pumping pressure and aspiration of the flushing fluid. Excessive pressure on the plunger of Janet's syringe when attempting to forcibly launder the lumen of the bladder during tamponade is fraught with possible vesicoureteral reflux and ascending pyelonephritis, which is very dangerous in conditions of such a complication. Excessive pressure during aspiration through the tow truck, since the holes at its end are lateral, can increase bleeding. These circumstances forced us to look for more rational ways to eliminate bladder tamponade.
For this we use an emergency irrigation urethrocystoscopy. It allows the instrument to be guided into the bladder lumen under visual control. One large opening at the end of the urethrocystoscope sheath allows more efficient and faster use of the flushing system and, if necessary, the Janet syringe to evacuate clots from the bladder and lead to its emptying. The need for careful anesthesia of the anterior and posterior urethra must be emphasized. From our point of view, the most rational use of rapidly absorbed aqueous solutions of anesthetics (1-2 and even 3% lidocaine solution in an amount of at least 30-40 ml endourethrally before manipulation) with the addition of 1% dioxidine and glycerin solution. Using local anesthetics in the form of a gel is less desirable because their absorption by the urethral mucosa is slower, and the amount to reach it proximal is usually insufficient. The second prerequisite for such manipulation is a relatively low perfusion pressure of the irrigation system (no higher than 50-60 cm H2O), which is a reliable prevention of vesicoureteral reflux and ascending pyelonephritis. In our observations, for washing the lumen of the bladder with tamponade, a 1.5% solution of sodium chloride has proven itself well. Being a weak hypertonic solution, it does not penetrate through the open vessels of the bed into the bloodstream and does not cause hypervolemia, which can occur when using isotonic solutions.
Visual control of the completeness of the evacuation of blood clots from the bladder significantly increases the effectiveness of this procedure, and the identification of bleeding vessels allows them to be electrocoagulated by eye to finally stop bleeding. In the event that it is not possible to identify the source of bleeding, or diffuse bleeding from the vessels of the bed is observed, it is undoubtedly indicated to conduct a Foley catheter through the urethra into the bladder with tension of the filled balloon of the catheter. The duration of the tension should not exceed 6 hours, which prevents the development of urethritis and urethral stenosis. The described approach can be applied not only after surgery, but also for tamponade of a bladder of a different nature (bladder tumor, renal bleeding). Quick and effective elimination of the tamponade improves the effectiveness of treatment. The results of providing emergency care to such patients over the past 5 years (25 observations) make it possible to recommend this method for widespread use.
Can a person's bladder burst? It will not be possible to deliberately delay urination until the organ is overstretched and injured. The bladder is able to withstand severe stress and not burst from overflow in the absence of mechanical obstacles to urine flow. External physical influences on the abdominal wall are dangerous.
When filled, the bladder stretches, the walls become thinner, it begins to protrude beyond the bony fold and becomes vulnerable to external influences... Especially if filled with urine. Due to a blow to the abdomen, falling from a height, the bladder may burst. Empty, on the contrary, is elastic and does not injure when shaken.
Consider what happens if the bladder bursts, what are the reasons for this, what symptoms will help to recognize a dangerous condition.
Classification
Bladder injuries are divided into open (as a result of injuries, road traffic accidents), closed (internal) and contusions. 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 the adjacent tissues);
- intraperitoneal (it happens more often with a filled organ, characterized by slight bleeding, the upper part of the bladder bursts, urine is poured into abdominal cavity filling the internal organs);
With fractures of the pelvic bones, the rupture can be mixed.
At closed injuries the process begins with the inner layer, then affects the muscles and, in extreme cases, the peritoneum.
Warning signs
If there is a ruptured bladder, the symptoms are very characteristic, which cannot be ignored by a conscious person:
- pain in the area below the navel, above the pubis;
- severe swelling in the groin;
- a febrile condition, accompanied by chills, deterioration in general health;
- acute urinary retention (AUR) and unsuccessful urge;
if urine is excreted, then with blood; - sometimes the pain goes to the lumbar region.
For physicians, an important diagnostic measure is the insertion of a soft catheter. At the same time, 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 is a mixture of urine, blood, and exudate.
A characteristic symptom confirming 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 (unlike anuria).
There are several reasons:
- violation of the conduction of nerve impulses;
- mechanical blockage of the urethra;
- injuries of the urinary organs;
- psychogenic urinary retention;
- poisoning with chemicals, medicines.
The doctor will carry out differential diagnostics to exclude conditions that caused acute urinary retention that are not associated with a ruptured bladder. In men, urinary retention develops due to adenoma and prostate cancer, constipation, bladder tamponade, narrowing of the urethra, neurological and infectious diseases, stones.
In women, the causes of acute urinary retention can also be pregnancy, oncology, diabetes mellitus.
Consequences
If a ruptured bladder is left untreated, the consequences for men and women are the same.
- In case of intraperitoneal injury of the organ, the poured urine is partially adsorbed, causing irritation internal organs, non-infectious inflammation and peritonitis (urinary) later.
- With extraperitoneal complete rupture, blood and urine soak the nearby fiber with the formation of urohematoma. Further, urine disintegrates, salt crystals fall out, purulent inflammation (phlegmon) of the pelvic and retroperitoneal tissues develops. The process extends to the entire wall of the organ with the transition to necrotizing cystitis.
If measures are not immediately taken to hospitalize the victim when the bladder burst, the consequences will be irreversible, up to and including death.
The process will involve blood vessels pelvis with the formation of blood clots, there will be a blockage of the artery of the lung, a heart attack of its tissues, pneumonia. Purulent pyelonephritis will develop in the pelvis, turning into acute renal failure.
Very rarely, an inflammatory process with minor ruptures leads to a slowdown in the development of a purulent-inflammatory process with the formation of abscesses in the fiber.
Treatment
Treatment of complete closed injuries is only surgical. If the bladder bursts slightly or is bruised, urine is not poured out. Layer-by-layer hemorrhages are formed with deformation of the outline of the organ.
Without treatment, incomplete rupture resolves without a trace, or leads to tissue inflammation, necrosis and the transition of the process to the stage of complete rupture with the release of urine and further, as described above. Incomplete rupture can occur from the outside when the wall of the MP is injured by bone fragments.
A bruise with an incomplete rupture is treated conservatively. Strict bed rest must be observed, medications are prescribed to eliminate inflammation, stop bleeding, antibiotics, analgesics. To prevent the development of a two-stage rupture and self-scarring of the bladder wall, a catheter with constant urine diversion is installed for 7-10 days.
Internal incomplete rupture with venous bleeding stops. When the arteries rupture, blood does not clot and tamponade develops.
Hemorrhage
Bladder tamponade, what is it? This is the state of OZM (complete cessation of its excretion) due to the filling of the MP cavity with clots of coagulated blood. The causes of hemorrhage are various: kidney and urinary tract diseases, trauma, tumors, prostate adenoma, rupture of its capsule, bleeding from varicose veins of internal organs.
Each new portion of blood increases the number of clots. Bladder tamponade is characterized by painful and ineffectual urge to urinate, increasing pain when pressing on the suprapubic region, and nervousness of the patient. If it is possible to obtain portions of urine, then they are mixed with blood.
Despite the fact that the bladder capacity in men is 250-300 ml, blood loss during tamponade is much higher, 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 clogged with clots. It is not possible to completely empty the bladder. With an unsuccessful attempt to wash away blood clots, the treatment of tamponade is an operation.
First aid
If, as a result of an abdominal injury, the victim has characteristic symptoms (the bladder has burst, or fractures of the pelvic bones are obtained), it is necessary to urgently call the team emergency care and put an ice pack on the victim's stomach.
Sources of
- Guide to urology in 3 volumes / ed. N. A. Lopatkin. - M .: Medicine, 1998. T 3 S. 34-60. ISBN 5-225-04435-2
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 every year. 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 CausesIt 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, the 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
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 give it of great importance... 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 above 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.
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 chronic anemia(weakness, lethargy, pallor 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 enhancement (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 of the lungs, scanning of the bones of the skeleton (osteoscintigraphy) (if you suspect a metastatic lesion).
Bladder cancer must be differentiated from the following conditions: inflammatory diseases urinary tract, nephrogenic metaplasia, anomalies in the development 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 cystitis, metastasis in the bladder of melanoma, gastric cancer.
Classification of Bladder CancerDepending 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), the function of which 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 the primary tumor T1 - tumor invasion affects the submucosal layer T2 - tumor invasion of the muscle layer T3 - tumor invasion extends to the paravesicular tissue T4 - tumor invasion extends to any of these organs - vagina, uterus, prostate, 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
|
|
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 all visible tumors are removed. 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. Reducing this percentage allows the use of photodynamic diagnostics and intravesical administration of the 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
- bleeding (intraoperative and postoperative)
- perforation of the bladder wall (depending on the experience of the surgeon);
After performing the TUR, 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. Such an 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 cancerInvasive 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 for 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 bladder resection 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 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 method treatment of generalized bladder cancer, which can prolong the patient's life, is a 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 you have to resort to surgical treatment, the purpose of which is to prevent the patient from dying 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 analysis urine
- 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 a 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.
v Definition.
Acute condition of completely filling the bladder with blood clots
due to hematuria, often causing severe dysuria and cessation of the act of urination -
acute urinary retention.
v Etiology.
The cause of hematuria can be multiple diseases of the genitourinary system,
they can all be accompanied by bladder tamponade:
ª Tamponade of the bladder with massive hematuria due to upper urinary trauma
ª Tamponade of the bladder with massive hematuria due to tumors of the upper
urinary tract,
ª Tamponade of the bladder with hematuria due to a tumor of the bladder,
ª Tamponade of the bladder with prostatic hyperplasia.
§ Hematuria and tamponade due to bleeding from varicose veins
veins of the prostate and bladder neck,
§ Hematuria and tamponade due to bleeding from damaged areas
capsules of the prostate (spontaneous rupture of the capsule, self-exfoliation of hyperplastic
v Pathogenesis of development in prostatic hyperplasia.
The mechanisms of development of hematuria and tamponade in prostatic hyperplasia are as follows:
ª Hematuria from varicose veins of the prostate.
As the obstructive process in the prostate progresses and its volume increases due to
intravesical prostatic growth develops a violation of the venous outflow of blood from
organ, as a result of mechanical compression of the veins of the prostate and bladder neck. This
the condition leads to the development of varicose veins of the bladder neck with
degenerative changes in their walls. Constant loads of the detrusor and urinary neck
bladder to overcome increased resistance (bladder outlet obstruction) create
sharp changes in intravesical pressure, which, against the background of constant pressure, increased
organ on the veins contributes to the creation of micro- and then marconadry veins. Blood flows into
urine directly in the bladder. Excessive flow of blood into the bladder for
at first it is expressed in hematuria with unchanged blood, then against the background of already
existing bladder outlet obstruction, the blood begins to clot, forming clots.
Each successive turn of blood flow increases the number of blood clots in
bladder.
ª Hematuria with spontaneous rupture of the prostate capsule.
With the development of obstructive process in the prostate and the development of an increase in the volume of the prostate
most often due to intravesical prostatic growth, in addition to impaired venous outflow
tension and tension of the prostate capsule develops. Constant detrusor loads and
bladder neck to overcome increased resistance (infravesical
obstruction) create sharp changes in intravesical pressure, which, against the background of constant
the pressure of the enlarged organ on the capsule contributes to the self-rupture of the capsule with
prolapse of the gland tissue into the capsule defect and the development of hematuria. Coming to
bladder blood clots, each next burst of bleeding increases
the number of clots.
v Symptoms and clinical picture.
The leading and main symptoms of bladder tamponade are:
ª Pain and painful urge to urinate with bladder tamponade
practically does not differ from that in acute urinary retention. Frequent
(pollakiuria, stranguria), painful urge to urinate is unsuccessful or
ineffective, palpation in the suprapubic region causes increased pain... Sick like
usually extremely restless.
ª Hematuria... An admixture of blood in the urine can be either fresh (unchanged blood) or
altered blood, total hematuria.
ª Acute urinary retention in the form of ineffectual and painful urges to
urination causes severe pain in the bladder area.
ª General signs of blood loss. Considering that the capacity of a man's bladder is
the average is 250-300 ml with the development of bladder tamponade, it can be assumed
minimal blood loss in the same amount. However, the amount of blood lost during
bladder tamponade is usually much larger. Depending on the degree
blood loss is noted outward signs anemia: pallor of the skin and visible
mucous,rapid pulse,tendency to hypotension etc.
v Diagnostics.
ª Complaints... Patients complain about the manifestations of the main symptoms: the absence
spontaneous urination, blood flow with urine, painful urge to
urination, general weakness, dizziness.
ª Anamnesis. During the survey, as a rule, it turns out that this hematuria is not the first and
previously there were episodes of self-limited macrohematuria. Also it turns out
a long history of symptoms of bladder outlet obstruction.
ª Inspection. Visually, the bladder, as a rule, protrudes above the bosom. Palpable
bulging over the bosom, overflowing bladder,palpation causes a sharp
soreness... From the urethra with a full bladder small
the number of blood clots or urine mixed with blood.Rectally enlarged,
tight-elastic adenomatous prostate.Pallor of the skin and visible mucous membranes,
other external signs of anemia.
ª Laboratory diagnostics. Depending on the degree of blood loss, the indicators are reduced
red blood: total red blood cell count and hemoglobin ... Blood clots in the urinary
bladder and developing against the background of this AUR cause an inflammatory reaction of the blood in the form
leukocytosis ,shift of the leukocyte formula to the left ,increased ESR .
With long-term current bladder tamponade against the background of AUR and anemia, it develops
violation of the evacuation function of the upper urinary tract, the cleansing function decreases
kidney that is expressed azotemia- blood creatinine can reach values of 150 μmol / l and
higher, urea - over 10 mmol / l, residual nitrogen - over 50 - 60 mg%.
ª Ultrasound diagnostics.
§ Ultrasound scanning of the bladder and prostate. Besides the increased
adenomatous prostate in the bladder is determined a large number of clots
blood performing all congested bladder in the form of education
mixed echogenicity. Sometimes it is possible to visualize a capsule defect with
an adjacent blood clot... In terms of the size and volume of education, you can
approximately determine the amount of blood loss.
§ Ultrasound scanning of the kidneys and upper urinary tract. Allows you to diagnose
sometimes associated with bladder tamponade supravesical
obstruction in the form of bilateral dilatation of the upper urinary tract. Dilatation degree
can reach considerable sizes: the ureter is up to 3-4 cm, the pelvis is up to 4-5 cm,
ª Treatment.
Developing and continuing tamponade of the bladder is an indication for
surgical treatment - revision of the bladder, transvesical adenomectomy.
− Delayed surgical treatment.
On the background hemostatic,antibacterial and blood substitute therapy
produce washing of the bladder from clots through the urethral catheter.
Successful completion of the last and no ongoing bleeding gives
time for systemic examination of the patient and preparation for delayed
surgical intervention.
− Urgent surgical treatment.
Failure to wash tamponade (clots), re-development of tamponade and
ongoing massive bleeding is an indication for urgent
surgical intervention: revision of the bladder and adenomectomy.
DEFINITION.
Hematuria - the appearance of an impurity of blood in the urine - 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.
CAUSES OF BLEEDING FROM THE ORGANS OF 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 |
Injuries, calculi, hydronephrosis |
|
Hematological |
Disorders of the blood coagulation system, hemophilia, sickle cell anemia, etc. |
|
Hemodynamic |
Disorders of the kidney blood supply (venous hypertension, heart attack, thrombosis, phlebitis, aneurysms), nephroptosis |
|
Reflex |
Vasoconstrictor disorders, shock |
|
Allergic |
Glomerulonephritis, arteritis, purpura |
|
Toxic |
Medicinal, infectious |
|
Inflammatory |
Glomerulonephritis (diffuse, focal), pyelonephritis |
|
Tumor |
Benign and malignant neoplasms |
|
"Essential" |
CLINICAL PICTURE AND CLASSIFICATION.
The appearance of red blood cells in the urine gives it a cloudy appearance and pink, brown-red or reddish-black color, depending on the degree of hematuria. With macrohematuria, this color is noticeable when examining urine with the naked eye, with microhematuria, a significant number of red blood cells is detected only when examining urine sediment under a microscope.
To find out the localization of the pathological process in hematuria, a three-glass 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 colored with blood, the remaining portions are of normal color;
2) terminal (final), in which in the first portion of urine, no blood impurities are visually detected, 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 gross hematuria |
Causes of macrohematter |
|
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 interferes with the outflow of urine from the kidney. In a kidney tumor, bleeding precedes pain (“asymptomatic hematuria”), and 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.
DIAGNOSTIC CRITERIA.
The diagnosis of hematuria can be suspected at the first examination of the patient, urine sediment is examined for confirmation. When diagnosing hematuria, an ambulance doctor should receive answers to the following questions.
1) Is there a history of urolithiasis, other kidney diseases? Is there a history of trauma? Is the patient receiving anticoagulants? Is there a history of blood diseases, Crohn's disease.
It is necessary to clarify the possible cause of hematuria.
2) Did the patient eat foods (beets, rhubarb) or medicines(analgin, 5-NOK), which can stain urine red
Differentiated hematuria and urine staining of another cause.
3) Whether the discharge of blood from the urethra is associated with the act of urination.
It is necessary to differentiate hematuria and urethrography.
4) Did the patient have any poisoning, blood transfusions, or acute anemia.
It is necessary to differentiate hematuria and hemoglobinuria arising from massive intravascular hemolysis of erythrocytes.
BASIC DIRECTIONS OF THERAPY.
In the event of gross hematuria, especially painless, immediate cystoscopy is indicated to establish the source of bleeding or at least the side of the lesion, since with tumor processes hematuria may suddenly stop, and the opportunity to determine the lesion will be lost. The position, formulated in 1950 by I. N. Shapiro, that any one-sided significant renal bleeding should be considered a sign of a tumor, until another cause of hematuria is found is fully retained its relevance. Only after the diagnosis or at least the side of the lesion has been established, the use of hemostatic agents can begin.
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 the BCC. It is especially important to study these indicators when, in addition to hematuria, internal bleeding is also possible (for example, with 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 in / in;
c) the introduction of 4 ml (500 mg) of 12.5% solution of dicinone 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 it becomes impossible to urinate independently. There is a tamponade of the bladder. Patients develop painful tenesmus, a collaptoid state may develop. Bladder tamponade requires immediate treatment measures... Simultaneously with the transfusion of blood and hemostatic drugs, they begin to remove clots from the bladder using a catheter-evacuator and Janet's syringe.
COMMON ERRORS IN THERAPY.
Urethrorrhagia should be distinguished from hematuria, in which blood is excreted 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 appears in it. If there is data on inflammatory process or a tumor of the urethra, urgent urethroscopy and stopping bleeding by electrocoagulation or laser ablation of the affected area are necessary. In case of suspicion of urethral rupture, an attempt to insert a catheter or other instruments into the bladder is categorically contraindicated, as this increases the injury.
In order to avoid mistakes, it should be remembered that a change in the color of urine can be caused by taking drugs or food (beets). The onset 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 surgery (nephrectomy, resection of the bladder, ligation of the internal iliac arteries, emergency adenomectomy, and others).