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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5233_Библиотеки_им_академика_М_И_Перельмана.pdf
17 Urology Sheet
163
• Dipstick urinalysis, by dipping of a test strip into the urine to detect levels of
tell-tale chemicals in the urine.
• Urinalysis can also microscopy, culture and sensitivity
3. tumor markers: as PSA and acid phosphatase
Imaging
1. Ultrasound:
Can detect:
(a) Solid from cystic mass.
(b) Post voided residual in the bladder
(c) All types of stones, Radiolucent or Radio-opaque.
(d) Trans rectal U/S (TRUS): For prostatic lesions, especially if PSA is high or
abnormal prostatic outline on DRE. can provide access for biopsies.
2. Radiology
(a) KUB
• It is a plain radiography of the urinary system to detect the stones.
• Check the presence and position of catheters and stents, and obtain a preliminary view before performing other examinations.
• Bony abnormalities as spina bida and sacral agenesis, fractures of the
spine or pelvis, osteoplastic metastases (typical of prostate carcinoma),
osteolytic metastases (the majority of solid tumors), or manifestations
of hematologic disorders (sickle cell anemia, myeloma) or Paget’s
disease.
• Abnormal gas collections as gas in the renal parenchyma or collecting
system as a result of recent instrumentation or emphysematous
pyelonephritis.
(b) Intravenous pyelogram:
• Procedure: contrast (Urogran) is given lV.
• Value: diagnosis of:
1. Anatomical description of the urinary system.
2. Stones, tumors (lling defect), diagnose renal artery stenosis.
3. Differential kidney function.
• Side effects
1. Anaphylactic shock.
2. Acute renal failure (contrast nephropathy).
164
3. CT scans and MRI can also be useful inlocalizing urinary tract pathology.
4. Voiding cystourethrogram is a functional study where contrast “dye” is injected
through a catheter into the bladder and urethra. Diagnosis of Vesico-Ureteric
Reux, urethral stricture, posterior urethral valve and Urethral injuries.
5. Renal arteriography.
6. Radionuclide Imaging.
7. Surgical procedures
• Cystoscopy and biopsy.
8. Urodynamic tests.
Evaluate the storage of urine in the bladder and the ow of urine from the
bladder through the urethra. It may be performed in cases of urinary incontinence or neurological problems affecting the urinary system.
S. Anderson et al.
Hematuria
Denition: Blood in urine.
Hematuria can be classied in different ways:
Intensity
1. Gross or macroscopic hematuria: Urine is red and hematuria is visible to the
naked eye. This is a “red sign” for the patient to ask for medical advice.
2. Microscopic hematuria is detected by microscopic urine analysis (the presence
of >5 RBCs/hpf).
Origin
1. Systemic disease
2. Urinary tract pathology
Relation toMicturition
1. Total hematuria is present all over the voided urine.
2. Terminal drop hematuria, at the end of micturition
3. Initial hematuria at the beginning of micturition
17 Urology Sheet
165
Associated Symptoms
• Painless hematuria (no other urinary symptoms): Bladder cancer
• Hematuria associated with other symptoms: as in BPH and prostate cancer are
associated LUTS (Prostatism).
Etiologic
General or Systemic Causes
• Bleeding disorder: Thrombocytopenia, leukemia, hemophilia
• Liver cirrhosis
• Anticoagulants
• Hypertension
Renal Causes
(a) Nephrologic: Acute glomerulonephritis is the most common cause in children
and young adults. It is associated with proteinuria.
(b) Urologic:
• Congenital: Polycystic kidney
• Inammation: Pyelonephritis, TB.
• Trauma: Accidents, iatrogenic
• Stones
• Kidney cancer
• Vascular: Haemangioma, AV stulae
Ureteral
• Stones
• Iatrogenic trauma e.g. Uretrescopy.
• Tumors: Urothelial tumors of renal pelvis and ureter
Bladder
• Bladder cancer is the most common cause of gross hematuria in a patient above
the age of 50years.
• Cystitis: Bacterial, Bilaharzial, TB.
• Stones
• Traumas e.g. post tumor resection (TURBT).
166
Prostate
• BPH
• Prostate cancer
• Prostatitis
• Surgical: After prostatectomy
Posterior Urethra
• Inammation
• Trauma
• Tumor
Diagnosis
History
• Age: < 40years: inammation, stones >40years: tumors
• Sex: BPH, prostate cancer in elderly men
• Trauma: Violence, accidents → blunt, penetrating
• Bilharziasis and stone disease
• Systemic disease: liver cirrhosis
• Obstructive symptoms: BPH, prostate cancer
S. Anderson et al.
Physical Examination
• General: Hypertension, petechial hemorrhages
• Abdominal: Renal mass
• Genital: T.B. thickening and beading of vas
• DRE: Bladder mass, BPH, prostate cancer
Investigations
Laboratory
• Blood: CBC, liver function tests, creatinine, blood glucose
• Attention to platelets, prothrombin, clotting and coagulation times
• Urine analysis and culture
17 Urology Sheet
Radiologic
• Ultrasound: Renal masses, stones, polycystic kidneys, bladder mass
• KUB: Radio-opaque stones
• Non-contrast CT: Stone disease
• CT with contrast: kidney, ureteric, bladder and prostate cancer evaluation.
Endoscopic
• Uretrescopy: Stones and tumors of ureter
• Cystoscopy: Diagnostic and therapeutic in bladder cancer
167
Acute Urinary Retention
• Acute urinary retention (AUR) is a sudden painful inability to urinate inspite of
a full bladder due to complete obstruction of lower urinary tract.
• Relief of pain follows drainage by catheterization.
Causes
Mechanical or Obstructive
1. Bladder:- Stone, bladder neck obstruction, cancer
2. Prostate:
– BPH is the most common cause in men over 50years.
– Acute prostatitis and abscess
– Prostate cancer
3. Urethra:- Stone, stricture, urethritis, injury, Phimosis, posterior urethral valves.
4. Clot retention in severe hematuria e.g. cancer, trauma.
5. Women: pelvic masses, urethral stenosis and diverticulum, pelvic prolapse,
hysterical.
Functional andNeurogenic
1. Postoperative AUR is common:
– Pain, limited mobility, drugs, bladder nerve injury e.g. hysterectomy and
abdomin operineal resection.
168
S. Anderson et al.
2. Drugs: Anesthetics, anticholinergic, sympathomimetic
3. Neurogenic: as
– Spinal cord injury.
– Intervertebral disc prolapse.
– Multiple sclerosis.
– Transverse myelitis.
History
– Cause- related:
• A complication of BPH
• Drugs
• Urethral trauma
• Stone disease
– Suprapubic bursting pain, no urine, strong desire to urinate.
– Acute urine retention should be differentiated from obstructive anuria.
Abdominal examination: The full bladder is felt as a midline globular tender mass
in the Suprapubic region.
Genital examination: Phimosis, severe urethral meatal stenosis.
DRE: BPH, prostate cancer.
Chapter 18
Hernia Sheet
AhmedFarag, AsifMehraj, andPatrickJordan
Abstract This important sheet which is included in the Abdominal Sheet in order
to remind the Students and practicing doctors with the abdominal examination as an
integral part of the hernia sheet. We proceed to this special form of sheet If the
patient has a Swelling at the site of a hernia orice which gives an Expansile Impulse
during cough.
Keywords Hernia · Examination · Sheet · Abdomen · General · Inguinal · Femoral
· Umbilical · Obturator · lumbar
General Plan fortheHernia Sheet
This important sheet which is included in the Abdominal Sheet in order to remind
the Students and practicing doctors with the abdominal examination as an integral
part of the hernia sheet.
We proceed to this special form of sheet If the patient has a Swelling at the site
of a hernia orice which gives an Expansile Impulse during cough.
Actually according to the general “Structured” plan of examination mentioned in
the General examination sheet in this book all the areas below the diaphragm should
be examined namely the Abdomen “Front, Perineum and back” and both LLs are
part of the Local examination in addition to the Virchow and Left supraclavicular
LNs which may carry metastases from an intra-abdominal malignancy. General
A. Farag (*)
Kasr Alainy Hospital, Cairo University, Cairo, Egypt
A. Mehraj
Apollo Health City, Hyderabad, India
e-mail: Asifdr80@yahoo.com.in
P. Jordan
SPr SVUH, Dublin, Ireland
e-mail: jordanpr@tcd.ie
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_18
169© The Author(s), under exclusive license to Springer Nature
170
A. Farag et al.
examination of the patient for associated General disease which may affect the
result to operate or not to operate on such patient or may affect the healing process
and/or infection rate such as Collagen disease hidden thyrotoxicosis “a real life
scenario which may cause a thyrotoxic crisis during anesthesia if not detected preoperatively”, Anemia, Hypo-proteinaemia or organ Dysfunction or failure such as
Liver Failure or heart failure.
Seven Questions should be answered after examination of a surgical patient:
1. Is it a Hernia or not?
2. Which type of the Hernia? (Inguinal “Direct or indirect” or Femoral? Umbilical
or Para-Umbilical? Complete Reaching the bottom of the scrotum or incomplete
still in the inguinal Canal?
3. What are the contents of the hernia? “Bowel, Omentum, Tubes and or ovaries,
Sliding Bladder “As part of the wall not as content” …etc.”
4. Is it Complicated or not? If it is fully reducible it is Uncomplicated. Or not fully
reducible “i.e. complicated” and which type of complication? I.e. irreducible,
obstructed, incarcerated, Strangulated, inamed or Hydrocele of hernia Sac.
N.B.Ruptured hernia is a special complication after local trauma followed by
sudden reduction of the hernia due to rupture of its content from the intestine
which retracts into the abdominal cavity and leads to Peritonitis if undiagnosed
or suspected.
5. Is there a cause of increased intra-abdominal pressure? Including extra-
abdominal causes like chronic cough or an associated intra-abdominal pathology.
6. If the patient t for surgery or not.
7. Other Hernias “other hernia orices”.
During the Clinical examination in such sheet we leave the General examination to
the end.
Present History
• Age: Certain Hernias are common at a certain age group e.g. Umbilical hernia in
the newborn babies or infants as compared to para-Umbilical hernias and direct
Hernia at an older age groups.
• Sex: Femoral hernias are more common in females than males.
• Occupation: Hard labor is associated with more hernias due to repeated indirect
trauma by lifting heavy weights.
• Special Habits of medical Importance: Such as chronic smoking associated
with chronic cough which repeatedly increase Intra-abdominal pressure.
Complaint: A swelling at the site of a hernia orice which increase on standing and
decreases or disappears on Lying down is a hernia till prove otherwise.
18 Hernia Sheet
171
Usually painless if uncomplicated however it may be painful at the start or later
on when becomes markedly enlarged “dragging pain”, or later on when complicated
“Obstruction, inammation or strangulation.
Present History
• Onset “Mode of onset and was it associated with trauma or inammation”:
• Sudden and was associated with indirect trauma such as lifting a heavy weight or
during an attack of cough and at this point it may cause sharp pain which draws
the patient’s attention to the swelling.
• Signs of Inammation “Local or Systemic” may be due to inammation of the
coverings such as wearing an ill tted truss “Hernia Belt” or due to inammation
of the contents such as Salpingitis, Diverticulitis, Appendicitis Known as
Amyand’s Hernia or Meckel’s diverticulitis called Littre hernia.
• Course: May be stationary but usually progressive “Slow or fast”.
• Duration: Variable.
Screening for the Symptoms of other Systems such as Cardinal Manifestations of
Intestinal obstruction namely Colics, Distension, Vomiting “Projectile due to
Mechanical obstruction” and absolute constipation which is manifested as “failure
to pass Gases or stools despite the desire to do so” In upper small bowel obstruction
the Vomiting is more Pronounced with less distension “upper abdominal” and less
obvious and late absolute constipation specially early while vomiting is late in distal
small bowel obstruction or in Colonic obstruction in a hernia “Rare” which distension and absolute constipation is more apparent. I.e. In proximal small bowel
obstruction vomiting is more pronounced and precedes other obstructive symptoms.
In distal bowel obstruction, abdominal distension is more prominent and precedes
other obstructive symptoms.
Clinical manifestations of strangulation “Tense and Tender Hernia”. Strangulation
is usually associated with Intestinal obstruction except when the contents are
Omentum, Ovary and/or Fallopian tube, Appendix, Meckel’s diverticulum or only
part of the bowel wall sparing the bowel Lumen for passage of the intestinal contents called Richter Hernia.
Urinary Symptoms suggestive of a sliding urinary bladder in the hernia namely
increase in the size of the hernia before micturition and decrease in its size after
micturition and sense of the need for micturition during Local examination of
the hernia.
Manifestations of Liver, Kidney, Cardiac, respiratory Problems, Dysfunction or
failure and manifestations suggestive of Collagen disease.
172
A. Farag et al.
Past History
• Medical history:
• Of Systemic diseases such as DM “Type and doses Of insulin and other oral
hypoglycemic drugs, which indicates severity of DM”, Collagen disease, ciga-
rette smoking “Number of Packets, which indicates the type of habituation e.g.
heavy smoking with more than a packet per day. Those affects wound healing
especially when skin aps are needed to raise during surgery as during dermo-
lipectomy, during incisional hernia repair. Anticoagulation treatment past or
present for a history suggestive of DVT or recent Angina or cerbro-vascular dis-
ease or after recent Coronary stents. History suggestive of advanced vital organ
dysfunction or organ failure.
• Surgical History:
• Previous abdominal operation which may lead to incisional hernia even at the
port site of laparoscopic or Robotic surgery, though more common after Open
surgery or Phantom hernias after extended subcostal, bilateral subcostal inci-
sions or Mercedes Benz upper abdominal incision. They are not true hernias “i.e.
no sac or defect” but they result from cutting of the intercostal nerves and sub-
costal nerve supplying the upper abdominal muscle “Paralytic hernia.
• History of allergies to foods and/or Medications.
Family History
Hernias are more common in some families due to congenitally weal Mesenchyme.
General Examination
Is very important to answer the question number 6 is the patient t or not?
For Symptoms of anemias, Hypoproteinaemias and collagen disease which may
affect infection rate and wound healing. And for the signs of a hidden more dangerous disease like thyrotoxicosis or arrhythmias not reported by the patients during
history taking.
And for symptoms suggestive of vital organ dysfunctions, which may affect the
decision for surgery or the need to take special precautions before, during or after
surgery.