Emergent Urological Conditions Flashcards
What are the principle types of Urologic Emergencies?
Testicular torsion (rupture, fracture, dislocation) Priapism Paraphimosis Urinary obstruction Fornier's Gangrene
What are the types of testicular torsion?
Intravaginal (cord twists within tunica vaginalis)
Extravaginal (Cord and tunica twist together, newborns)
What are the predisposing factors for testicular torsion?
Undescended testis
Bell clapper deformity
What is the typical age of testicular torsion?
12-18 years old but may occur at any age
How does testicular torsion present?
Acute onset of severe testicular pain.
What are the physical findings associated with testicular torsion?
Tender, firm, high riding testicle
Absent cremasteric reflex
Thick knotted spermatic cord
Pain not relieved by elevation of testicle
How is testicular torsion diagnosed?
clinically
What is the differential diagnosis for severe testicular pain?
Torsion (acute and abrupt in onset)
Epididymitis (more chronic and gradual)
What modalities my aid in the diagnosis of torsion?
Ultrasound may be used to check blood flow with doppler.
What is the treatment for Testicular torsion?
Immediate surgical exploration with with detorsion, and bilateral orchiopexy.
What is the timeframe of testicular torsion?
Most are viable if detorsed within 6 hours. Few are viable after 24 hours
What should you do for torsion if an operating room is not immediately available?
Attempt manual detorsion through the Scrotum. Follow that up with scheduled orchiopexy.
What is paraphimosis?
When the foreskin gets trapped behind the glans resulting in necrosis of the glans.
What should be done to treat paraphimosis?
Manual reduction –> dorsal slit –> emergent circumcision
What should be done before attempting to manually reduce a paraphimosis?
topical anesthetic, penile block, pain medication, or sedation.
What is the technique for manually reducing paraphimosis?
Squeeze out any edema
put index and forefinger on either side of the constricting skin, then push down with thumbs on glans.
If there is cutaneous compromise during reduction of the phimosis/paraphimosis what complication may occur?
Fournier’s Gangrene
How do you treat ureteral obstruction with sepsis?
Drain with nephrostomy tube, administer antibiotics, then relieve the obstruction after the infection has resolved.
How do you manage high grade ureteral obstruction?
Place a ureteral stent, place a nephrostomy tube, remove the cause of the obstruction promptly.
How do you manage bladder outlet obstruction with significant urinary retention?
Drain with catheter or SP tube.
Why is ambiguous genitalia considered a urologic emergency?
Because conditions causing ambiguous genitalia can also cause fluid and electrolyte abnormalities
What is post obstructive diuresis?
The polyuria that results from relieving complete obstruction of the urinary system.
What are the pathophysiologic causes of post obstructive diuresis?
Osmotic diuresis - accumulation of urea, most common Physiologic - Release of fluid and Na Neph DI - Impaired tubular concentrating Impaired proximal tubule Na resorption Circulating hormones - i.e. ANP
What is the usual course of post obstructive diuresis?
post obstructive diuresis is usually self limiting and lasts for less than 48 hours
What is the cause of post obstructive diuresis?
Impaired proximal tubular reabsorption of sodium causes salt diuresis
What are the complications post obstructive diuresis > 48 hours?
hypovolemia
hyponatremia
hypokalemia
hypomagnesemia
What tests should be ordered for post obstructive diuresis?
BUN/Cr
electrolytes (including Mg)
What are the criteria for discharge for post obstructive diuresis?
- Short duration of symptoms
- No elevation in BUN/Cr
- No electrolyte abnormalities
- No change in mental status
- Patient can drink fluids
- Stable condition and vital signs
If patient does not meet any of the above criteria then admit
How do you treat post obstructive diuresis?
- Increase oral intake
- If oral intake is inadequate give 1ml 1/2 NS for every mL lost
- Replace electrolytes as needed
- Be cautious of overhydrating.
