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Bladder tamponade

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

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;
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 has restless behavior.

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.

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

The attending physician necessarily prescribes blood and urine tests. In the general analysis of blood, there is a decrease in the level of hemoglobin, erythrocyte elements. There is also a pronounced increase in the level of leukocytes in the blood, a shift in the leukocyte formula 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 increases, uric acid... 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-pelvis system, ureters expand. This type of diagnosis also identifies 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.

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

Situations requiring urgent intervention are quite common in urological practice. These include renal colic, acute pyelonephritis, urinary retention, gross hematuria. Rapid recognition and differentiated treatment of these conditions reduces the likelihood of complications and increases the duration of the effect of the therapy.

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

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, when its lumen is obstructed by 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. For renal colic 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 nerve plexus. Paradoxical pain in the area of a healthy kidney due to reno-renal reflux is often observed. In some patients, pain prevails at the site of irradiation.

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 palpate an enlarged and painful kidney. In some cases, with renal colic, there is an increase in temperature, chills, leukocytosis in the absence of other signs of urinary infection and acute pyelonephritis.

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

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 (with occlusion of the pelvis with calculus, the irradiation of pain in the lower back and hypochondrium is possible, with occlusion at the border of the upper and middle third of the ureter - in the lower abdomen, with a lower location of the stone - in 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 an 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 ambulance doctor medical care is diclofenac sodium. 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 sodium diclofenac.

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. When viewed in the suprapubic region, a characteristic swelling is determined due to overcrowded bladder("Bubble ball"), which, when percussed, produces 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). In BPH, the posterior urethra is lengthened and the angle between the prostatic and bulbose portions 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. 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, amoxicillin / clavulanate or II-III generation cephalosporins (cefuroxime axetil, cefaclor, cefixime, ceftibuten) can be used.

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

Acute urinary retention 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 with irrigation of the external genital organs 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 stained 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. 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 anomalies of the kidneys and urinary tract, strictures of the ureter and urethra, prostate adenoma, etc.), instrumental studies of the urinary tract, pregnancy, diabetes mellitus, old age, etc. occurrence 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, reducing the resistance of the kidney tissue to infection and disrupting the outflow of urine). In general, pyelonephritis develops more often in women, especially at a young age, which is associated with the anatomical, physiological and hormonal characteristics of the female body. In old age, the disease is more common in men due to the development of prostate adenoma.

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

The clinical picture. Symptoms of acute pyelonephritis consist of general and local symptoms of the disease. Initially, acute pyelonephritis is clinically manifested by signs infectious disease, which is often the cause of 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 affected side, 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

Moscow State University of Medicine and Dentistry, NNPO of Emergency Medicine, 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 mucosa.

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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 urinary 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 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.

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, there is an increase in the number of red blood cells, 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. V last years another laboratory diagnostic method 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.

Of great importance in the diagnosis of bladder cancer is ultrasound diagnostics... 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 with 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 a suspected bladder tumor must 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. Spiral and multislice computed tomography with contrast has 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 assessed 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 about the malignant nature, structure and degree of differentiation of the neoplasm of the bladder are the leading ones in the choice of the method of treatment.

Fluorescence 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 makes it possible 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 collection 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 radiation, 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.

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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 emergency care, and secondly, because hematuria is often the first sign of urological cancers.

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.

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, if 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 can 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, after several catheterizations, it is completely eliminated.

The clinic of acute urinary retention is quite typical. Patients complain of severe pain in the lower abdomen (suprapubic region), frequent painful, sterile urge to urinate, a feeling of fullness and distention of the bladder. The strength of the urge 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 characteristic 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. The adenoma is characterized by an enlargement of the gland while maintaining a dense elastic consistency and a smooth surface.

Treatment. Urgent therapeutic measures in case of acute urinary retention, they consist in urgent emptying of the bladder. Urinary retention 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 cystic 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 infections during catheterization. All items in contact with the patient's urinary tract - instruments, underwear, dressings, solutions that are injected into the bladder and urethra - must be sterile. Forced insertion of a catheter is unacceptable, since this inflicts injury on 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 for one to two days after it, antibiotics and uroantiseptics are prescribed for prophylactic and therapeutic purposes. A metal catheter for bladder catheterization can be used with experience. Any rough and forced insertion of a metal catheter can damage the urethra, sometimes with the formation of false passages.

Technique of bladder catheterization 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 on 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 apply 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, urine formation occurs, but urine does not enter the bladder due to an obstruction in the upper urinary tract. If a single kidney is removed, 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 accompanied by the development of hypovolemia and a decrease in the volume of circulating blood are:

traumatic shock;

crush injury 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 electrolyte loss (vomiting, diarrhea, intestinal fistulas);

severe infectious diseases;

bacterial shock;

obstetric complications (septic abortion, premature placental abruption on the background of 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 the direct toxic effect of chemical compounds and drugs. Among more than 100 known nephrotoxins, one of the first places is occupied by drugs, mainly aminoglycoside antibiotics, the use of which in 10-15% of cases leads to moderate, and in 1-2% - to severe acute renal failure. Of 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 the control of ultrasound, 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.

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, external signs of anemia are noted: 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.

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

Blood intensively entering the lumen of the bladder after adenomectomy or TUR of the prostate, due to inadequate hemostasis, leads to the formation of a blood clot in the bladder. The clinical picture of bladder tamponade develops.

The most common cause of bleeding from the adenoma bed is incomplete removal of adenomatous tissue, damage to the bladder neck or adenoma capsule. The cause of bleeding can also be a violation of blood coagulability, therefore, if bleeding occurs after adenomectomy, a coagulogram must be performed and the concentration of D-dimers in the blood serum must be determined.

Blood clots clog the lumen of the drainage tubes, urine flow stops through them, and tamponade of the bladder develops. Patients complain of severe pain above the bosom, painful urge to urinate. A sharply painful bladder is palpable above the bosom. In the analysis of blood, a decrease in the number of erythrocytes and hemoglobin is noted. An ultrasound scan can confirm the presence of blood clots in the bladder.

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

If a catheter evacuator fails to remove blood clots from the bladder, then a cystotomy should be performed. The blood clots are removed, and the source of bleeding is established. When blood comes from the bed of the adenoma, its digital revision is performed. The remaining fragments of the adenoma lobes are removed. A Foley catheter is passed through the urethra into the bladder and its balloon is inflated in the adenoma bed until the blood flow to the bladder stops. After the operation, constant flushing of the bladder with furacilin is necessary.

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

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

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 urinary 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. 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.

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, there is an increase in the number of red blood cells, 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 with 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 a suspected bladder tumor must 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.

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 collection 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.

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 runs the risk of 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 a 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 to administer 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 in the presence of residual urine.

Adenoma cannot be treated with catheterization if conservative treatment(drugs such as doxazosin and finasteride, herbal medicine) do 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.

They 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 is overflowing, 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 pure 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 the 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 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 purpose 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 leakage into abdominal cavity and fiber. 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, puncture of the bladder 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. It is forbidden to perform this procedure for 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 trauma, medical or diagnostic procedures, or during intercourse.
It is necessary to determine the daily volume of urine, but it is impossible to 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 - a puncture of the pelvis, large blood vessels... However, complications can still be observed:

bleeding into the renal cavity;
opening of bleeding into the cyst capsule;
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 the formation is more than 7 cm, puncture is considered ineffective.

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