No abstract

We report the atypical case of a nondiabetic 66-year old male with severe abdominal pain and vomiting who was found to have emphysematous cystitis. Of all gas-forming infections of the urinary tract emphysematous cystitis is the most common and the least severe. The major risk factors are diabetes mellitus and urinary tract obstruction. Most frequent causative pathogens are Escherichia coli and Klebsiella pneumoniae. The clinical presentation is nonspecific and ranges from asymptomatic urinary tract infection to urosepsis and septic shock. The diagnosis is made by abdominal imaging. Treatment consists of broad-spectrum antibiotics, bladder drainage, and management of the risk factors. Surgery is reserved for severe cases. Overall mortality rate of emphysematous cystitis is 7%. Immediate diagnosis and treatment is necessary because of the rapid progression to bladder necrosis, emphysematous pyelonephritis, urosepsis, and possibly fatal evolution.

Even 32 years after its first introduction shockwave lithotripsy (SWL) remains a matter of discussion and controversy. Since the first SWL in 1980, millions of treatments have been performed worldwide. To this day SWL remains the least invasive of all stone treatments and is considered the treatment modality of first choice for the majority of urinary stones. Despite the massive scale on which SWL is performed in a wide range of indications, complication rate has always remained very low and usually limited to minor side effects and complications. The introduction of affordable multifunctional lithotripters has made SWL available to more and more departments of urology worldwide. Still many centers are disappointed with the treatment results and concerned about the adverse tissue effects. In this SWL proves to be the victim of its uninvasiveness and its apparent ease of practice. Urologists need proper skill and experience; however, to adequately administer shockwaves in order to improve outcome. This aspect is too often minimized and neglected. Apart from this the power of shockwaves often is underestimated by operators of shockwave machines. Basic knowledge of the physics of shockwaves could further reduce the already minimal adverse tissue effects. Good training and coaching in the administration of shockwaves would no doubt lead to a renaissance of SWL with better treatment results and minimal adverse tissue effects.

Intravenous administration of a combination of alfentanil and propofol via a PCA device is an elegant, reliable, and safe method of analgesosedation for SWL. Patient satisfaction is high, and side effects are uncommon. Faster turnover of patients is possible.

We consider our hypothesis proved that a continuous tramadol drip is a safe and valuable analgesic regimen in renal colic.