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33 Gynecological Emergencies 353
(instruments, bottles, and so on) alone or with a partner. Always suspect that rape
may have been a causative factor. Clinically, the bleeding is obvious. Diagnosis is
by speculum examination: there is a lateral laceration, beginning at the hymen and
extending upward, and the edges are rather neat. In some cases, the tear is transmural and involves the cul-de-sac. Treatment consists of hemorrhage control and
repair of the laceration with an absorbable continuous stitch in the lithotomy position; whether to do it under local or general anesthesia depends on the extent of
the laceration and the individual patient.
Acute Abdominal Pain in the Pregnant Woman
“In men nine out of ten abdominal tumors are malignant; in women nine out of
ten abdominal swellings are the pregnant uterus.” (Rutherford Morrison, 1853–1939)
General Considerations
A consultation about abdominal pain in a pregnant or immediately postpartum woman is frequently an anxiety-provoking experience for the general surgeon. We think that the following few paragraphs will help you to approach these
difficult problems with a new understanding and confidence based on some simple concepts.
Abdominal emergencies in pregnant women pose a great challenge for the
following reasons:
The ascending uterus gradually distorts the normal abdominal anatomy,
displacing organs and thus changing the typical clinical scenario.
Physiologically, the pregnant woman is different; nausea and vomiting are
not uncommon during the first trimester, thereafter, tachycardia, mild elevation
of temperature, and leukocytosis are considered “normal.”
To a certain degree, abdominal “aches and pains” are common during
pregnancy.
When dealing with a sick pregnant woman, you automatically have two
patients; the life and well-being of the fetus have to be considered also.
When it comes to treatment, there may be a conflict of interest between the
mother and fetus. Early in pregnancy, the risk is of miscarriage, while at the end
it is premature labor; in both cases, it is hard to determine which is more risky—
surgery or nonoperative management.
Generally, acute abdominal conditions during pregnancy are either “because”
or “in spite” of pregnancy.
354 Bernard Cristalli · Moshe Schein
Abdominal emergencies specific to pregnancy are either:
Obstetric—Such as ectopic pregnancy (discussed separately in a previous
section), abortion, and septic abortion (a septic uterus may present with an impressive acute abdomen); “red degeneration” of a fibroid; abruptio placenta; rupture of uterus; and pre-eclampsia. These conditions are not further discussed.
Hey, we did not promise you a manual of obstetrics.
General—Such as acute pyelonephritis, which is more common in pregnant
women, or rupture of visceral aneurysm (e.g., splenic artery), which is rare but “typically” occurs during pregnancy. Another condition, which may be associated with
pregnancy, is spontan eou s h em at om a of t he re ct u s abdomi ni s mu s cl e. (This condition
may also develop in nonpregnant men and women, particularly in anticoagulated patients.) The hematoma originates from a ruptured branch of the inferior epigastric artery and develops deep to the muscle. On examination, a tender abdominal wall mass
is often felt; it will not disappear when the patient tenses his or her abdominal wall
(Fothergill’s sign). US or a CT can confirm the diagnosis. Treatment is conservative.
Abdominal Emergencies Randomly Developing During Pregnancy
Any abdominal emergency may occur during pregnancy. Here are a few
basic considerations:
“Think in trimesters”. During the first trimester the fetus is most susceptible
to the potential damaging effects of drugs and X-rays. Abdominal operations at
this stage may precipitate an abortion. Operations during the third trimester are
more likely to induce premature labor, posing additional risk to the mother and
fetus. Thus, surgery is best tolerated during the second trimester—if you have the
luxury of choice.
The well-being of the mother overrides that of the fetus. If maternal and
fetal distress are present simultaneously on presentation, all therapeutic efforts
should be for the benefit of the mother. A Caesarean section is considered only if
the fetus is more than 24 weeks old and in persistent distress in spite of maximal
therapy to the mother.
Pregnant women suffer from a chronic abdominal compartment syndrome
(> Chap. 40). The abdominal emergency (e.g., perforated appendicitis or intes-
tinal obstruction) will further increase the intra-abdominal pressure, reducing
venous return and cardiac output. Place such patients in a left lateral decubitus
position to shift the gravid uterus away from the compressed inferior vena cava.
You should be aware of:
Acute appendicitis. You are commonly called to “exclude acute appen-
dicitis” in a pregnant woman. Address the problem as discussed in > Chap. 28;
although the cecum is usually fixed in place, it may be displaced by the gravid
uterus, and the omentum is “lifted” away and thus may not provide “walling-
33 Gynecological Emergencies 355
off” protection to the perforated appendix, making free perforation more likely.
US may help in excluding acute cholecystitis and ovarian or uterine causes of
pain and may document an enlarged appendix. CT is not advisable because of
the risks of irradiation of the fetus. Diagnostic laparoscopy or laparoscopic appendectomy during pregnancy have been reported safe to both mother and fetus
but still remain somewhat controversial, particularly in late pregnancy. If you
choose to operate, tilt the table to the left and place a muscle-splitting incision di-
rectly over the point of maximal tenderness, wherever it is (it may be higher than
usual). And, remember that the “best” treatment of acute appendicitis occurring
early in pregnancy may be nonoperative—with antibiotics (see > Chap. 28).
Acute cholecystitis. It is easily recognized clinically and ultrasonographically
(> Chap. 20.1) during pregnancy. During the first trimester, try conservative man-
agement, delaying the operation to the second trimester. If it occurs during the
third trimester, try to postpone the operation, if possible, until after delivery. Laparoscopic cholecystectomy appears safe during pregnancy. Inflate the abdomen
with the lowest pressure possible and rotate the table well to the left to decrease
compression of the inferior vena cava by the uterus. When cholecystectomy is required late in pregnancy (when the uterus fills the entire abdominal cavity), we
prefer an open approach through a small subcostal incision. This is perhaps the
place to mention the HELLP Syndrome (hemolysis, elevated liver enzymes, and low
platelet count). It is a relatively rare syndrome that may develop in a pre- eclamptic,
preterm, patient and be confused with acute biliary disease (even “mild” HELLP
may stretch the liver capsule, producing severe right upper quadrant pain). Liver
hemorrhage and hematoma and even liver rupture are serious complications of
the HELLP syndrome and represent surgical emergencies; the child should be
promptly delivered and the liver managed based on trauma principles. In the unstabl e, coag ul opa th ic patient , t he liver s hou ld be p ac ke d (> Chap . 39). Think about
HELLP: a misguided cholecystectomy may kill the mother and baby.
Intestinal obstruction: sigmoid or cecal volvulus is more common during
late pregnancy. The displacement of abdominal structures during pregnancy may
also shift long-standing adhesions, producing small bowel obstruction or volvulus. Pregnancy tends to cloud presenting features and impedes early diagnosis.
Notice that a few plain abdominal X-rays, with or without Gastrografin (> Chaps.
4 and 21), are entirely safe even in early pregnancy. So, if you suspect a large or
small bowel obstruction, do not hesitate. Remember that intestinal strangulation
threatens the life of the mother and her child. This is no time for timidity.
Trauma in Pregnancy
The management of abdominal trauma in pregnancy is identical to the management in the nonpregnant woman (> Chaps. 38 and 39), except that in preg-
nancy there is concern for two patients—the mother and the fetus. Remember that
356 Bernard Cristalli · Moshe Schein
the pregnant woman has a marked increase in blood volume, a fact that tends to
mask or delay clinical features of hypovolemic shock. Assessment of the fetal sta-
tus either by Doppler or by continuous cardiotocodynamometry is mandatory
when the clinical circumstances permit. The major clinical concerns in the injured
pregnant female are uterine rupture and abruptio placentae. The former condition
is suggested by abdominal tenderness and signs of peritoneal irritation, sometimes in conjunction with palpable fetal parts or inability to palpate the fundus.
The latter is suggested by vaginal bleeding and uterine contractions. When the
fetus is in jeopardy, a rapid Caesarean section is usually in the best interests of
both the mother and fetus.
The “Postpartum” Period
Abdominal emergencies are notoriously difficult to diagnose during the
early postpartum or post-Caesarean section period. Abdominal pain and gastrointestinal symptoms are commonly attributed to “afterpain” and fever or systemic
malaise to “residual endometritis.” In addition, at this stage the abdominal wall is
maximally stretched and redundant, such that guarding and other peritoneal signs
may be missing. “Things move around” the abdomen during delivery, and a loop
of bowel may be twisted or caught. We have treated perforated acute appendicitis,
perforated peptic ulcer, and acute cholecystitis during the early postpartum days.
Diagnosis is usually delayed and so is the treatment. Be aware.
Six men give a doctor less to do than one woman (a Spanish proverb).
Urological Emergencies
Jack Baniel
Urology is not associated with many emergencies. Actually, one of the main
advantages enjoyed by the senior urologist is that most of our surgery is elective,
and unlike his or her fellow general surgeon, nights may be spent out of the
operating room (OR) and in the warm bed. Most acute urological problems are
managed in the emergency room (ER) with the help of other disciplines. I discuss
here those common scenarios that a general surgeon may encounter, and solve,
while the urologist slumbers.
Acute Renal Colic
Renal colic is quite easy to diagnose and usually involves intrinsic obstruction of the renal pelvis or ureter by a stone. The classic complaint is of acute flank
pain in a restless patient. The pain radiates from the back forward, is spasmodic,
and is recurrent. It is often associated with nausea and, less frequently, vomiting.
The pain is caused by the dilatation of the urinary tract proximal to the stone. As
the stone travels down the ureter by force of the forward pressure caused by the
urine flow, the location of the pain changes, radiating toward the lower abdomen,
inguinal area, and then the genitalia. As the stone reaches the lower ureter, the
patient will complain of frequency and urgency, and then all abates as the stone is
expelled into the bladder. Thus, one may trace the advancement of the stone by the
patient’s complaints. Stones need to pass three narrowings in the collecting system
on their way to the bladder: the uretropelvic junction, the iliac vessels, and the
vesicoureteral junction. These points are where calculi usually get stuck.
The most important factors to assess in this situation are the stone’s width
and its location within the urinary system. Most stones less than 5 mm in size
and those in the lower ureter (beyond the iliac vessels) should be expelled spontaneously (80–90%) and thus are managed expectantly. Larger stones and those
34
Jack Baniel
Department of Urology, Beilinson Hospital, Rabin Medical Center, Petach Tikva 49100, Israel
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_34, © Springer-Verlag Berlin Heidelberg 2010
357
358 Jack Baniel
higher in the ureter need to be manipulated out. Most stones that pass spontaneously do so within 3–4 weeks.
Diagnosis
Most stones are radiopaque and thus a regular plain abdominal X-ray is the
initial diagnostic step. Looking at the X-ray, we use the rule of 4 S’s: when searching
for stones check that the side corresponds to the pain, that the skeleton does not
hold surprises (metastasis), and that there are no suspicious silhouettes (tumor).
Noncontrast computed tomography (NCCT) is the gold standard in the
diagnosis of stones in the ER setting. NCCT may diagnose all stones regardless
of their composition (uric acid, etc.). Ultrasound is helpful in the assessment of
hydronephrosis and obstruction: urine flow into the bladder is visualized by
urine jets in the bladder; its absence is a surrogate marker of obstruction.
Management
The pain of ureteric colic is mediated by prostaglandins and therefore, intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) are the drug of choice in
the management of pain. Fluids are given to increase diuresis and force the stone
down the ureter, and smooth muscle relaxants (e.g., intravenous papaverine) also
have merit in alleviating acute pain. Steroids and calcium channel blockers have
been tried in the past with minimal value. Lately, tamsulosin, an alpha-adrenergic
blocker used for prostatism, has been found to facilitate stone expulsion.
Remember: on initial assessment of the patient, look for signs of infection
or renal dysfunction. These along with intractable pain are indications for
h o s pitalization.
Laboratory tests should include a complete blood count and those for creatinine and electrolytes. Some patients presenting with renal colic will be septic
or in severe renal failure (beware patients with a single kidney). These patients
must be admitted to the hospital and have emergency decompression of the collecting system as the penalty for delay in treatment may be death from sepsis.
Decompression may be done by insertion of a self-retaining stent (JJ) (now, you
will have to call your urologist) or by percutaneous nephrostomy by the radiologist. The available options to get rid of the obstructing ureteral stone disease are
(usually) to insert a stent and fragment the stone later (shock wave lithotripsy) or
to perform immediate ureteroscopy and stone fragmentation with laser.
Ureteroscopy is the definitive solution for most lower ureteral stones. Stones in
the upper ureter or in the renal pelvis are usually fragmented by ESWL (external
shock wave lithotripsy).
34 Urological Emergencies 359
Torsion of Testis (see also > Chap. 35)
As a general surgeon, you will see most “acute scrotal conditions” well before
the urologist; some may present as depicted in > Fi g. 34.1. Torsion of the spermatic
cord is the most dramatic “acute scrotum”; it requires emergency management,
and if missed the testis will be lost. It commonly occurs in young boys but may
appear at all ages, even in the neonate.
As the testis descends through the inguinal canal, it pushes ahead of it a
sliver of peritoneum. As the testis reaches the scrotum, the peritoneum is sealed
off, and only the part attached to the lower pole of the testis is left; this actually
fixes the lower testicular pole to the scrotal wall. But, the peritoneum may adhere
higher around the spermatic cord and wrap the entire testis within an isolated
peritoneal sac. In this situation, the testis may rotate, twist itself around its vessels within the tunica vaginalis (the retained part of the peritoneum), and cause
acute ischemia. This anomaly occurs equally on both sides of the scrotum.
Medical literature from the 1960s reporting on this phenomenon observed a high
frequency of delay in diagnosis and a very high orchiectomy rate. With more attention paid to the clinical symptoms and the adoption of an aggressive operative approach, most torted testes can be saved.
The classic symptoms are acute unilateral scrotal pain, swelling, nausea,
and vomiting, without fever or urinary symptoms. Usually, there are difficulties
in gait as the patient wishes to keep his legs apart to avoid pressure on the scrotum. Often, the presentation is not so clear, and pain and swelling are the only
signs. The most common differential diagnoses are inflammatory intrascrotal
conditions (e.g., epididymitis, orchitis), but in the young torsion is more frequent
Fig. 34.1. “What’s that? A watermelon?”
360 Jack Baniel
than inflammation. Torsion of a testicular appendage may also occur and confuse the examining physician. The testis has two appendages, emanating from
the testis itself at the lower pole and from the epididymis. If they twist around
their origin, a large scrotal swelling occurs that is very painful. In this case, the
testis itself is normal. On examination, one may see a local enlargement called a
“blue dot.”
Signs of spermatic cord torsion on examination include a high-riding testis,
transverse lie, a negative dartos sign (normally, stroking the thigh elevates the
testis), and local pain and sensitivity.
The diagnosis may be assisted by a Doppler ultrasound, which may show
reduced testicular perfusion—an indication for exploration. Equivocal ultrasound results along with indicative signs and symptoms warrant surgical exploration. The testis may withstand 4–6 hrs of ischemia, after which there are
irreversible changes that result in atrophy. Practically, accurate assessment of
time of onset of the torsion is usually difficult; thus, the recommendation is to
explore the affected testis whenever signs are significant.
Exploration is performed trans-scrotally; the exposed testis is “untorted”
and wrapped in warm pads. If blood flow returns (as seen by a pinkish color), the
testis is fixed with nonabsorbable sutures to the scrotal wall at least at three
places. If blood flow does not return, the testis must be removed. It is accepted
that if left in situ the atrophic testis may produce autoantibodies, damaging the
contralateral testis and causing infertility. At the same procedure, the contralat-
eral testis must be explored as well and fixed as a prophylactic measure. Being
“aggressive enough,” one may expect a negative exploration in up to one-third of
patients.
Acute Retention of Urine
You will often have to deal with acute urinary retention in the ER or in your
postoperative patients. Most patients with retention are men who suffer from benign prostatic hypertrophy (BPH) who give a history of lower urinary tract symptoms (LUTS), such as urgency, nocturia, double micturition, hesitancy, and the
like. Other possible etiologies include urethral stricture and neurological disease
(e.g., multiple sclerosis). Retention is manifested by severe lower abdominal pain,
inability to void, and (not surprisingly) agitation. In some BPH patients, retention
is precipitated by sympatomimetic drugs (ephedrine for flu) or anticholinergics
(psychiatric drugs).
34 Urological Emergencies 361
Management
Relief of this situation is by simple insertion of a urethral (Foley) catheter.
The rule in this case is to insert a catheter with a moderate caliber but not too large
as it may have to stay in place for some time. A good choice is a 16F Foley catheter.
Bladder neck stenosis, a large prostate, or urethral stricture may make it difficult
to pass through the urethra. If insertion of a regular Foley fails, one may use a 14F
Tieman Foley that has a special tip and an angle with a better chance of negotiating the bends and curves of the urethra. Third-line catheters are tougher and
transparent, with a Tieman tip and no balloon and are of different calibers. Failure
of all these measures would necessitate the insertion of a cystostomy tube (supra-
pubic catheter). In most cases, we would first insert a large-bore needle in the
midline above the pubic bone, and when urine pours out, we thread the cystostomy kit du jour into the bladder. Caution must be practiced if the patient has had
prior surgery in the area, in which case cystostomy is best done under ultrasound
guidance. Of course, renal function must be assessed as some patients may have
chronic retention, causing renal failure.
It is very important to measure urine output for 2–3 hrs after insertion of a
catheter. A common occurrence is postobstruction diuresis with output of very
large amounts of urine. The pathophysiological basis for the polyuria is an acute
washout of solutes that, due to retention, were not excreted properly, as in a hyperosmolar state. Other reasons are inability of the medulla to conserve water
due to loss of urea and pseudo-diabetes insipidus, a temporary incapacity of antidiuretic hormone (ADH) receptors in the distal nephron. This situation is life
threatening, especially in older patients, due to fluid and electrolyte imbalance.
A patient with postobstruction diuresis (>200 ml/h) has to be hospitalized. Urine
output is measured every hour and intravenous fluids (0.45% saline) are given.
To avoid “chasing your tail,” initially 80% of the voided volume is replaced; as
urine output decreases, replacement is given at 50% of the voided volume.
Usually, this is a self-limiting situation that should resolve within 24 hrs.
Urological Trauma
Kidney
Renal injuries may be blunt or penetrating, and they are commonly associated with motor vehicle accidents, falls from heights, and assaults. An important
consideration is to check whether a deceleration injury is involved (fall from a
height especially) as this may cause an arterial intimal tear leading to renal artery
thrombosis, which is a real emergency. Otherwise, a tendency to conservative
management has emerged over the years in all renal injuries.
362 Jack Baniel
The conservative approach to stab and low-velocity gunshot wounds
emerged in South Africa. It was there that physicians managing masses of injured patients in cramped ERs first noticed that many of those with extensive
renal injuries waiting for their turn for surgery survived without surgical exploration. The kidney has good recuperation potential, and most injuries heal with
minor sequelae. Associated urine leaks are easily managed with drainage, which
may be either internal via a stent diverting urine from the kidney to the bladder
or by a percutaneous nephrostomy tube. Obviously, penetrating injuries are
commonly associated with injuries to other nearby structures according to site
of e ntr y.
The hallmark of renal injury is hematuria. Microhematuria is defined as >5
RBCs/HPF (red blood cells/high power field). We do not need to tell you what
gross, macroscopic hematuria is, right?
Which patients need renal imaging?
Blunt trauma with gross hematuria
Blunt trauma with microscopic hematuria and shock (blood pressure
<90 mmHg measured at any time since the trauma occurred)
Penetrating trauma: all patients with penetrating wounds in the anatomical
vicinity of the kidneys
Pediatric patients: use imaging more liberally because kids are more sus-
ceptible to significant renal trauma
The preferred imaging study is contrast-enhanced CT. Most spiral CTs are
performed in a 2- to 3-min sequence and reveal an arterial and a venous phase.
Urine excretion and possible injury to the collecting system may be seen only at
10 min; thus, a delayed image must be taken at 10 min as well.
Important findings are:
Medial perinephric hematoma—suggesting vascular injury
Medial extravasation of urine—uretropelvic junction avulsion
Lack of contrast enhancement of the kidney—arterial injury
IVP (intravenous pyelogram) has been abandoned and is used for only
one indication—a “single-shot” intraoperative IVP. If at laparotomy and with-
out prior imaging a surgeon encounters an unexpected retroperitoneal, perinephric hematoma, the surgeon may order an IVP to assess the kidney. A single
film is obtained 10 min after an intravenous push of 2 ml/kg contrast media.
A kidney that looks normal may be left alone. Similarly, in an emergency neph-
rectomy it is always comforting to know that the contralateral kidney is intact.
(Of course, in some developing regions IVP continues to play the role of the
poor person’s CT).
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