A/8. Urological emergency Flashcards
Total urinary retention def
acute onset suprapubic discomfort with the desire, but inability, to urinate
Total urinary retention etiology
More common in men due to
* BPH
* prostate cancer
* urethral stricture
* Other causes include:
*neurological disorders
*blood clot obstructing lower urinary
tract
*and infection
Total urinary retention treatment
- Perform suprapubic catheterization when trans-urethral catheterization is contraindicated.
- 3-7 days course with alpha-blockers can rapidly relief the obstruction in patients with BPH
trans-urethral catheterization is
contraindicated in?
what to do instead?
Perform suprapubic catheterization when transurethral CI
- urethral trauma
- urethral stricture
- lower urinary tract infection
how ro relief the obstruction in patients with BPH
3-7 days course with alpha-blockers can rapidly relief obstruction
terazosin (Hytrin),
doxazosin (Cardura),
tamsulosin (Flomax),
alfuzosin (Uroxatral),
and silodosin
Total urinary retention must be differenciated from
acute anuria
( Urine output < 0.5 ml/kg/h) seen with AKI
Renal colic def
acute onset abdominal pain due to kidney stone
Renal colic Symptoms
typically, pain starts in the flank and radiates around the abdomen,
and it can radiate into
the testes in men and
the labia in women
Renal colic diagnostics
- Definitive diagnosis by stone visualization with low-dose CT (1st line), US, or X-ray.
- Abdominal examination is frequently unremarkable, which may help to exclude
other differential diagnoses (acute appendicitis, peritonitis, diverticulitis,
salpingitis, ruptured AAA). - If urinalysis doesn’t show microscopic hematuria, an alternative diagnosis should
be considered.
Treatment Renal colic
Initial treatment for all patients should include
* IV fluids, analgesics, antiemetics.
* Definitive treatment is stone removal; approach guided by stone characteristics (location, size, type).
* Acute intervention is indicated in cases of ‘obstructive pyelonephritis’ -
*patient presenting with acute-onset flank pain, fever, N/V, increased inflammatory markers and
stone visible on CT.
*Treat acutely with..
-urine deviation (Double-J stent, percutaneous nephrostomy)
-antibiotics
-relieving the obstruction
-supportive
when is acute intervention indicated in which case of renal colic?
how is it treated?
in cases of ‘obstructive pyelonephritis
patient presenting with
* acute-onset flank pain
* fever
* N/V
* increased inflammatory markers
* and stone visible on CT.
*Treat acutely with..
-urine deviation (Double-J stent, percutaneous nephrostomy)
-antibiotics
-relieving the obstruction
-supportive
Testicular torsion def
results from inadequate fixation of the lower pole of the testis to the tunica vaginalis
If fixation is absent or insufficient, the testis may twist on the
spermatic cord, potentially producing ischemia from reduced arterial inflow and venous outflow obstruction.
Testicular torsion Etiology
commonly presents in males 12-18 years old;
after an inciting event (trauma,
vigorous physical activity) or spontaneously
Testicular torsion symptoms
acute, severe pain,
high-riding testis,
and absent cremasteric reflex. (Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal.)
Testicular torsion diagnostic
- mainly clinical
- may be supported by color Doppler US in equivocal cases.
Testicular torsion treatment
- orchiopexy within 6 hours (testis is directed back to place and secured to the scrotal wall). Orchiopexy should be bilateral (contralateral testis is at risk for subsequent torsion)
*Perform manual detorsion if surgical option is unavailable in time frame - if testis is not viable > orchiectomy
Acute scrotal pain (differential diiagnosis)
- testicular torsion,
- epididymitis/orchitis
- hernia,
- infection (prostatitis, testicular abscess)
timeframe for orchiopexy
within 6 hours
Priapism def
persistent erection (>4 hrs) of the penis that’s not associated with sexual stimulation or
desire
Priapism types
- Ischemic priapism (low-flow)
- Non-ischemic priapism (high-flow) - less common
Ischemic priapism (low-flow) def
results in what
- is prolonged erection(>4hrs)
- impaired relaxation and paralysis of cavernosal smooth muscle.
- Results in compartment
syndrome, with increasing hypoxia and acidosis in the cavernous tissue.
Ischemic priapism (low-flow) results in what syndrome
- Results in compartment
syndrome,
with increasing hypoxia
and acidosis in the cavernous tissue.
Non-ischemic priapism (high-flow) def
occurs less commonly than ischemic priapism and
is
usually the result of a fistula between the cavernosal artery and corpus cavernosum.
not an emergency usually
Priapism etiology
- idiopathic
- sickle cell disease (risk of recurrent priapism)
- drug-induced (sildenafil,
trazodone, alpha-blockers, cocaine)
Priapism Diagnostics
- made clinically;
- may use US
- cavernosal blood gas analysis (blood aspirated from the corpora cavernosum for a blood gas analysis to differentiate between ischemic and
non-ischemic priapism).
cavernosal blood gas analysis
(blood aspirated from the corpora cavernosum for a blood gas analysis to differentiate between ischemic and
non-ischemic priapism).
Priapism treatment
- 1st line :
*intracavernosal phenylephrine injection (alpha-agonist > vasoconstriction)
OR
*aspiration of blood from corpus cavernosum (with/without saline irrigation) - 2nd line :
*shunting (surgical fistula is created between the corpus cavernosum
and the corpus spongiosum, glans penis, or one of the penile veins)
Paraphimosis def
retracted foreskin in an uncircumcised man that can’t be returned to normal position.
Paraphimosis pathology
Impairment of lymphatic and venous flow from the constricting ring of foreskin
causes
venous engorgement of the glans penis with swelling; ultimately, arterial flow to the glans penis becomes compromised.
If paraphimosis is not corrected in a timely fashion, the most common outcome is
necrosis.
In rare cases, penile necrosis, infarction of the glans, gangrene, and
autoamputation may occur
Paraphimosis etiology
- complication of phimosis, iatrogenic (following catheterization)
- trauma (vigorous sexual intercourse, piercing)
Diagnostics Paraphimosis
made clinically
Paraphimosis Treatment:
- Conservative: manual reduction with adequate pain control (topical anesthesia,
local infiltration of anesthesia, or regional blocks) - Surgical :
*dorsal slit reduction surgery ( incision of the constricting band) if manual reduction fails or penile ischemia occurs
*OR circumcision
Spinal cord compression Often presents to urologists because
metastatic prostate cancer is one of the most common
causes
Spinal cord compression
Symptoms
acute-onset neurological abnormalities
Spinal cord compression diagnosis
MRI
Spinal cord compression TREATMENT
- high-dose IV corticosteroids,
- pain control
- DVT prophylaxis
- radiation therapy if tumor is known to be radiation-sensitive
- spinal cord decompression surgery
*Supporting team should include oncologist, neurologist, spinal orthopedic surgeon
