Haematuria and Urological Emergencies Flashcards
definition of haematuria
blood in the urine
- either microscopic or macroscopic
what is the diagnosis quota for haematuria
presence of 5 or more RBC per high-power field in 3 of 3 consecutive specimens obtained at least one week apart
what are the 2 categories of haematuria
visible/macroscopic/gross haematuria
non-visible/microscopic/dip-stick positive haematuria
what are the 2 categories of microscopic haematuria
symptomatic; hesitancy, frequency, urgency, dysuria
or
asymptomatic - incidental finding
what else can cause urine to be red that is not blood from urinary tract
Menstrual bleeding
Food - beetroot, blackberries, rhubarb
Myoglobin in urine - destruction of muscles, Crush syndrome
Drugs - Nitrofurantoin, Rifampicin, Chloroquine
Toxins - lead, mercury
what can cause brown coloured urine
urobilonogen in urine - hemolysis, liver dysfunction
porphyria
what can make people prone to bleeding
blood thinners - warfarin, heparin, aspirin
bleeding disorders
what percentage of people with frank haematuria will have cancer
20-30%
what percentage of people with microscopic haematuria will have cancer
asymptomatic + malignancy
- 2.6%
risk factors for malignancy
smoking history occupational exposure to chemical or dyes Hx of gross haematuria Age > 40 Hx of urological disorder/disease Hx of irritative voiding symptoms Hx of UTI Analgesic abuse
common infections that can cause blood in the urine
urethritis prostatitis cystitis ureteritis pyelonephritis glomerulonephritis
how can stones cause blood in the urine
kidney/ureter stones
on the way down can scratch mucous lining and cause bleeding
what Sx does renal tumour presents with
Haematuria - 50-60%
Pain - 40%
Kidney mass - 30-40%
Triad
how do tumours of urinary tract present
Haematuria - 75-85%
Retention of urine
Urinary irritative symptoms
Loin pain
what are the 2 types of cancers common in urology system
Renal Cell Carcinoma
Transition cell carcinoma
what is Sport haematuria
renal/bladder trauma from contact sports/running
what is the pathogenesis of sport haematuria
vasoconstriction of renal vessel
- hypoxic damage to nephrones
constriction of efferent glomerular arteriole
- increased filtration pressure
what is decompression haematuria
patient with retention, drained to quickly then some blood vessels with get broken and you get haematuria
what is pneumaturia
passage of gas mixed with urine, and may be as a result of a fistula between the bowel and the bladder
see bubbles in the urine
what is faecaluria
presence of fecal matter in the urine
What should be considered in the Hx of haematuria
Trauma Age Gender Nature of haematuria Smoking Occupation Country Urological Hx FH of malignancy Hx of bleeding disorders Phenacetin abuse Concomitant treatment e.g. Warfarin Recent symptoms suggesting UTI
what can the nature of the blood in the urine appear
dark red with clots
fresh red blood
dark red with wormlike clots with colic loin pain - ?
hematuria is coming from upper urinary tract
- blood from kidney, down the ureter
what are the timing stages of bleeding and what can it suggest
initial/start of void - suggest bleeding is coming from urethra or prostate gland
terminal/end of void
total/throughout void
what is seen in Egypt land water that can cause urinary problems
schistosoma
what flower is seen in china and can cause urinary problems
Aristolochia
what drug can cause Transition cell cancer if abused
phenacetin
Ix of haematuria
urinalysis
culture and sensitivity
cytology
tenderness in abdo
mass in abdo
prostate exam
frank haematuria urinary uregency + frequency smoker female - aged 24 sexually active USS + cytology normal
Diagnosis
UTI
frank haematuria urinary uregency + frequency smoker female - aged 40 paraplegic bladder stones USS + Cytology normal
Diagnosis
SCC in the bladder
frank haematuria urinary uregency + frequency smoker female - aged 60 USS normal cytology suspicious
Cancer
what is acute urinary retensiont and what causes it commonly
inability to urinate with increasing pain
complication of BPH
what are precipitated/triggering events of acute urinary retention
- non-prostate related surgery,
- catheterization or urethral instrumentation
- anaesthesia
- medication with sympathomimetic or anticholinergic effects
Tx of acute urinary retention
Catheter
Alpha blocker - Tamsulosin
who gets post-obstructive diuresis (peeing more)
chronic bladder outflow obstruction in association with uraemia, oedema, CCF, hypertension
Mx of post-obstructive diuresis
monitor fluid balance
beware urine output > 200ml/hf
usually resolves in 24-48hrs
if severe IV fluid and sodium replacement
DDx of acute loin pain
Ureteric colic secondary to calculus
Tx of stones that do not require surgery
NSAID +/- opiate
Alpha-blocker (Tamsulosin) for small stone expected to pass
what are the sizes of stones that are likely to pass themselves and what size is not
6mm 21%
at what point if a stone hasn’t passed then intervention is required
1 month
what are indications to treat stones urgently
pain unrelieved
pyrexia
persistent nausea/vomiting
high-grade obstruction
Tx for stones that require surgery
ureteric stent or stone fragmentation/removal if no infection
percutaneous nephrostomy for infected hydronephrosis
what can cause frank haematuria
Infection Stones Tumours Benign prostatic hyperplasia (BPH) Polycystic kidneys Trauma Coagulation/platelet deficiencies
Ix for frank haematuria
CT urogram + cystoscopy
what are acute causes of scrotum pain
Torsion of spermatic cord Torsion of appendix testis Epididymitis / epididymo-orchitis Inguinal hernia Hydrocoele Trauma / insect bite Dermatological lesions Inflammatory vasculitis Tumour
what are features of a torsion of spermatic cord
- Most common at puberty
- Can occur with trauma or athletic activity but usually spontaneous. Adolescent often woken from sleep
Usually sudden onset of pain, sometimes previous episodes of self-limiting pain
May be nausea/vomiting
May be referral of pain to lower abdomen
Ix for torsion of spermatic cord
Doppler USS
Tx for torsion of spermatic cord
- Prompt exploration
- 2 or 3-point fixation with fine non-absorbable sutures
- If testis necrotic then remove
- MUST fix contralateral side (bell clapper deformity)
how long does it take necrosis to begin in torsion of spermatic cord
4 hours
what is the ‘blue dot’ sign a sign for
torsion of appendage
what is Epididymitis
inflammation of the epididymis. The epididymis is a tube located at the back of the testicles that stores and carries sperm
what does a Hx of epididymitis commonly
Dysuria / pyrexia more common
Hx of UTI, urethritis, catheterization/instrumentation
Ix for Epididymitis
Doppler USS
send urine for culture + chlamydia PCR
Tx for Epididymitis
Analgesia + scrotal support, bed rest
Ofloxacin 400mg/day for 14 days
Swelling, with no fever, mild tenderness and some pruritis the scrotal region - diagnosis?
idiopathic scrotal oedema
what is paraphimosis and when does it happen
Painful swelling of the foreskin distal to a phimotic ring
Often happens after foreskin retracted for catheterization or cystoscopy and staff member forgets to replace it in its natural position
Tx for paraphimosis
Iced glove, granulated sugar for 1-2hrs, multiple punctures in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit
what is priapism
Prolonged erection (> 4hrs), often painful and not associated with sexual arousal
what can cause priapism
Intracorporeal injection for ED, e.g. papaverine Trauma (penile / perineal) Haematologic dyscrasias e.g. sickle cell Neurological conditions Idiopathic
what are the classifications of priapism
Ischaemic
Non-ischaemic
what happens in ischaemic priapism
Vascular stasis in penis and decreased venous outflow, a true compartment syndrome.
corpus cavernosum is rigid and tender, penis often painful
what happens in non-ischaemic priapism
Traumatic disruption of penile vasculature results in unregulated blood entry and filling of corpora.
Fistula formation between cavernous artery and lacunar spaces allows blood to by-pass the normal helicine arteriolar bed
Ix of priapism and what results would indicate what type of priapism
Aspirate blood from corpus cavernosum
– dark blood, low O2 , high CO2 in low-flow
- normal arterial blood in high-flow
Colour duplex USS
- minimal or absent flow in cavernosal arteries in low-flow
- normal to high flow in non-ischaemic priapism
Tx of ischaemic priapism
Aspiration +/- irrigation with saline
Injection of alpha-agonist
Surgical shunt
Tx of non-schaemic priapism
Observe, may resolve spontaneously
Selective arterial embolization with non-permanent materials
what is Fournier’s gangrene
form of necrotizing fasciitis occurring about the male genitalia
Most commonly arises from skin, urethra or rectal region
what are predisposing factors for Fournier’s gangrene
diabetes
local trauma
periurethral extravasation perianal infection
how does Fournier’s gangrene first start
as cellulitis
- swollen, erythematous, tender
- marked pain, fever, systemic toxicity
how does Fournier’s gangrene progressive
Swelling + crepitus of scrotum, dark purple areas
Ix of Fournier’s gangrene
Plain X-ray or USS may confirm gas in tissues
Tx of Fournier’s gangrene
Antibiotics and surgical debridement
what is Emphysematous pyelonephritis
severe, necrotizing infection of the renal parenchyma
caused by gas-forming uropathogens, usually E coli
how does Emphysematous pyelonephritis present and what is it associated with
fever, vomiting, flank pain
associated with diabetes and ureteric obstruction
Ix of Emphysematous pyelonephritis
KUB - see gas
CT
Tx of Emphysematous pyelonephritis
nephrectomy
what causes a perinephric abscess
results from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
features of perinephric abscess
high WCC
high serum creatinine
pyuria
IX of perinephric abscess
CT
Tx of perinephric abscess
Antibiotics + percutaneous or surgical drainage
what are the 5 levels of renal trauma
I Haematoma, subcapsular, non-expanding, no parenchymal laceration
II Laceration 1cm depth, no collecting system rupture or extravasation
IV Laceration through cortex, medulla and collecting system
Main arterial/venous injury with contained haemorrhage
V Shattered kidney
Avulsion of hilum, devascularizing kidney
what are indications for imaging in trauma
Frank haematuria in adult
Frank or occult haematuria in child
Occult haematuria + shock (systolic
what is the gold standard Ix for kidney trauma
CT with contrast
what is features of bladder injury and what is it associated with
Suprapubic/abdominal pain + inability to void
Suprapubic tenderness, lower abdominal bruising, guarding/rigidity, diminished bowel sounds
Associated with pelvic fracture and catheterisation
Ix for bladder injury
CT cystography
how does an extraperitoneal injury appear in a contrast of the pelvis
as a flame-shaped collection
Tx for bladder injury
Large-bore catheter
Antibiotics
Repeat cystogram in 14 days
how can the urethra be injured
fracture of pubic rami
what is seen O/E to urethral injury
Blood at meatus Inability to urinate Palpably full bladder “High-riding” prostate Butterfly perineal haematoma
what is Ix for urethral injury
retrograde urethrogram
Tx of urethral injury
Suprapubic catheter
MOI of penile fracture
happens during intercourse – buckling injury when penis slips out of vagina and strikes pubis
Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling
Tx for penile fracture
Prompt exploration and repair
Circumcision incision with degloving of penis to expose all 3 compartments
presentation of testicular injury
presents with extremely pain and nausea
swelling/bruising variable
Ix of testicular injury
USS
when is early exploration/repair important in testicular injury
improves testis salvage, reduces convalescence, better preserves fertility and hormonal function
