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Urinary Emergencies Flashcards

1
Q

What is Acute Urinary Retention and what is it often a complication of?

A

Inability to urinate
with increasing pain on peeing

Complication of BPH

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2
Q

What can precipitate urinary retention?

A
  • non-prostate related surgery
  • catheterisation
  • urethral anaesthesia
  • medication with sympathetic/anticholinergic effects (blocks ACh)
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3
Q

How is urinary retention treated when a patient is admitted?

A

catheterisation

Can also do a “Trial without a Catheter” in the same admission if:

  • painful retention
  • < 1 litre residue
  • serum electrolytes normal
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4
Q

What can improve the chance of voiding in a trial without a catheter?

A

introduction of alpha blocker drugs beforehand

e.g. Alfuzosin, Tamsulosin

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5
Q

What is a Post-obstructive diuresis and why does it occur?

A

excessive passing of urine after removal of a

chronic bladder outflow obstruction

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6
Q

Why is excessive urine passed in post obstructive diuresis?

A
  • retained urea, sodium and water

AND defect in concentrating ability of kidney

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7
Q

Why should urine output be monitored regularly in post-obstructive diuresis?

A

If urine output > 200ml/hr

Pt may require IV fluid and sodium replacement

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8
Q

What differential diagnosis should you always consider in acute loin pain?

A

Leaking AAA

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9
Q

What mediates the pain in a ureteric obstruction caused by a calculus?

A

prostaglandins released by ureter to say it is obstructed

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10
Q

What treatment can be given for renal stones which are causing acute loin pain?

A
  • NSAID +/- opiate

- alpha-blocker (Tamsulosin) for small stones that are expected to pass

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11
Q

Under what size are most renal stones expected to pass?

A

<4mm

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12
Q

After what length of time will a stone require intervention if it has not been passed?

A

1 month

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13
Q

What type of scan is best to view renal calculi and is therefore the most diagnostic?

A

Non-contrast CT

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14
Q

What symptoms would indicate that the renal stone should be treated urgently?

A
  • Pain unrelieved
  • Pyrexia
  • Persistent nausea/vomiting
  • High-grade obstruction
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15
Q

How are renal stones removed urgently?

A
  • ureteric stent to allow them to pass more easily
  • stone fragmentation (to make them smaller)
  • percutaneous nephrostomy for infected hydronephrosis
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16
Q

What can cause macroscopic or FRANK haematuria?

A
  • Infection
  • Stones
  • Tumours
  • BPH
  • Polycystic kidneys
  • Trauma
  • Coagulation/platelet deficiencies
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17
Q

How can a clot be removed if it is the cause of frank haematuria?

A

3 way irrigating haematuria catheter
- stiffer than normal catheter
=> can withstand the suction which aims to remove the clot

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18
Q

What investigations can be used in frank haematuria?

A

CT urogram

cystoscopy

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19
Q

Who usually suffers from testicular torsion and what can predispose to this?

A

Most common at puberty
Can occur after trauma or athletic activity
Teen often woken from sleep in pain

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20
Q

What is the normal presenting complaint in testicular torsion?

A
  • Sudden onset of pain
  • sometimes previous episodes of self-limiting pain
  • nausea/vomiting
  • Referral of pain to lower abdomen
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21
Q

What is usually found on examination of a patient with testicular torsion?

A
  • Testis high in scrotum
  • Lie transversely
  • absence of cremasteric reflex
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22
Q

What is the cremasteric reflex?

A

Stroking of the skin of the inner thigh causes the cremaster muscle to contract and pull the testicle up toward the inguinal canal on the same side

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23
Q

What complications of testicular torsion can make it difficult to visualise and obliterate landmarks?

A

Acute hydrocoele

oedema

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24
Q

What investigation can be used to visualise the blood supply to the testis believed to be affected?

A

Doppler USS

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25
When treating testicular torsion, both sides require fixation, even if this has not occurred bilaterally. TRUE/FALSE?
TRUE | don't want to risk it occurring on the opposite side
26
What is Bell Clapper Deformity?
Both testes lie transversely | => predisposing the patient to torsion
27
What is Torsion of an appendage?
Torsion of an appendix on the testis Appendages are common but have no function Torsion of an appendage can still be very painful
28
Torsion of an appendage can present very similarly to torsion of the testes themselves. TRUE/FALSE?
TRUE
29
If appendage torsion is caught early, how may it present?
localised tenderness at upper pole | “blue dot” sign
30
How can a testicular and appendage torsion be differentiated?
Appendage torsion involves mobile testis and intact cremasteric reflex
31
Torsion of an appendage can resolve spontaneously without surgery. TRUE/FALSE?
TRUE
32
What rare condition presents in a similar way to testicular torsion?
epididymitis
33
How do the presentations of testicular torsion and epididymitis differ?
Epididymitis usually also present with: - Dysuria (pain on peeing) - pyrexia Hx of STI/ UTI/ catheterisation
34
What investigations may be used to diagnose epididymitis?
Doppler - swollen epididymis - increased blood flow Send urine for culture + Chlamydia PCR (STI causes)
35
What treatment can be given in epididymitis?
Analgesia + scrotal support bed rest If STI is the cause: Ofloxacin 400mg/day for 14 days If UTI is the cause: Ciprofloxacin or Trimethoprim in some cases
36
Idiopathic scrotal oedema is NOT usually associated with any erythema. TRUE/FALSE?
TRUE does not really cause any additional symptoms except sometimes itching
37
What is a paraphimosis?
- Painful swelling of the foreskin distal to a phimotic ring | - Happens after foreskin retracted and not replaced into its natural position (e.g. catheterisation)
38
How can a paraphimosis be treated?
- Ice - sugar (to draw fluid out by osmosis) - multiple punctures in oedematous skin to let fluid out - Manual compression of glans to force fluid out - Dorsal slit to relieve pressure
39
What is priapism?
- prolonged erection (> 4hrs) - painful - not associated with sexual arousal
40
What can cause priapism?
``` Intracorporeal injection for Erectile Dysfunction (no longer a Tx option) Trauma (penile or perineal) Sickle cell Neurological conditions Idiopathic ```
41
Describe the difference between ischaemic and non-ischaemic priapism?
Ischaemic (veno-occlusive or LOW-FLOW) Vascular stasis in penis and decreased venous outflow => COMPARTMENT SYNDROME => Corpora cavernosa are rigid and tender Non-ischaemic (arterial or HIGH-FLOW) Trauma disrupts penile blood vessels => unregulated blood entry (too much)
42
How can ischaemic/non-ischaemic priapism be diagnosed?
Blood aspirate - dark blood = low O2 => LOW FLOW => ischaemic Colour duplex US - minimal/ absent blood flow => LOW-FLOW
43
How is ischaemic priapism treated?
- Aspiration +/- irrigation with saline - Injection of alpha-agonist to reduce inflow - Surgical shunt
44
What can be considered if ischaemic priapism has presented extremely late?
immediate placement of a penile prosthesis
45
If non-ischaemic priapism does not respond spontaneously, what treaments can be used?
Selective arterial embolization
46
What is Fournier's Gangrene?
necrotizing fasciitis occurring about the male genitalia | Usually skin in the urethra or rectal region
47
Who is predisposed to fournier's gangrene?
- diabetes - local trauma - perianal infection
48
What type of microbes are found in Fournier's gangrene?
- mixture of aerobes/anaerobes
49
What local signs are significatn indications of Fournier's Gangrene?
Swelling + crepitus of scrotum (gas) dark purple areas marked toxicity out of proportion to the local findings
50
What do investigations of Fournier's gangrene show?
Plain X-ray or US may confirm gas in tissues
51
What is used to Treat Fournier's Gangrene?
Antibiotics and surgical debridement
52
What is the mortality rate for Fournier's gangrene?
20% | but higher if diabetic/alcoholic
53
Is Emphysematous pyelonephritis an infective emergency?
YES
54
What is Emphysematous pyelonephritis?
acute necrotizing parenchymal and peri-renal infection caused by gas-forming uropathogens, - usually E coli
55
What other conditions is Emphysematous pyelonephritis linked to?
Usually occurs in diabetics | Often associated with ureteric obstruction
56
What three main symptoms do patients experience in emphysematous pyeonephritis?
Fever, vomiting, flank pain
57
What causes a perinephric abscess?
- rupture of acute cortex abscess into the perinephric space OR - infection travelled in the bloodstream to site
58
How should a perinephric abscess be investigated and treated?
Ix: CT Tx: Antibiotics + percutaneous/surgical drainage
59
Describe the progression of renal trauma classifications
Classifications 1-5 Stage 1 = subcapsular haematoma Stage 3 = no rupture into collecting system Stage 5 = Shattered kidney and Avulsion of hilum
60
What indicates imaging is required in renal trauma?
- Macroscopic haematuria in adult - Macroscopic OR occult haematuria in child - Occult haematuria + shock (systolic <90mmHg) - Penetrating injury with any degree of haematuria
61
How are blunt renal injuries managed non-operatively?
angiography | embolization
62
When is surgery required in renal/urological trauma?
Persistent renal bleeding expanding perirenal haematoma pulsatile perirenal haematoma
63
Bladder injuries are commonly caused by what other trauma?
pelvic fracture
64
What are the main presenting complaint in bladder injury?
Suprapubic/abdominal pain + inability to void
65
Catheterisation after a bladder injury usually results in gross haematuria. TRUE/FALSE?
TRUE | some catheters wont go in due to urethral injury
66
If a catheter cannot be passed in easily after a bladder injury, what must you do first?
retrograde urethrogram – may well have urethral injury
67
What sign shows an extraperitoneal injury on a CT scan?
flame-shaped collection of contrast in pelvis
68
How is a bladder injury treated?
Large-bore catheter Antibiotics Repeat cystogram in 14 days
69
What reasons would warrant immediate repair of a bladder injury?
``` Intraperitoneal injury Bladder neck injury Rectal or vaginal injury Open pelvic fracture Bone fragments projecting into bladder ```
70
Fracture of the pubic rami can cause what structure to be damaged?
Posterior urethral injury
71
How does a posterior urethral injury usually present?
``` Blood at meatus Inability to urinate Palpably full bladder “High-riding” prostate Butterfly perineal haematoma ```
72
What investigations and treatment should be completed in a posterior urethral injury?
Retrograde urethrogram ``` Suprapubic catheter (as urethra is injured) - Delayed reconstruction after at least 3 months ```
73
When does a penile fracture usually occur?
during intercourse – buckling injury when penis slips out of vagina and strikes pubis Cracking or popping sound followed by pain, discolouration and swelling
74
How is a penile fracture treated?
Prompt exploration and repair | Circumcision incision with degloving of penis to expose all 3 compartments
75
What symptoms are consistent with a testicular injury?
pain + nausea
76
How are testicular injuries investigated and managed?
ix: US to assess integrity / remaining blood supply Early exploration/repair - to preserve fertility, hormonal function etc

RENAL (24 decks)

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