Urinary Emergencies Flashcards
What is Acute Urinary Retention and what is it often a complication of?
Inability to urinate
with increasing pain on peeing
Complication of BPH
What can precipitate urinary retention?
- non-prostate related surgery
- catheterisation
- urethral anaesthesia
- medication with sympathetic/anticholinergic effects (blocks ACh)
How is urinary retention treated when a patient is admitted?
catheterisation
Can also do a “Trial without a Catheter” in the same admission if:
- painful retention
- < 1 litre residue
- serum electrolytes normal
What can improve the chance of voiding in a trial without a catheter?
introduction of alpha blocker drugs beforehand
e.g. Alfuzosin, Tamsulosin
What is a Post-obstructive diuresis and why does it occur?
excessive passing of urine after removal of a
chronic bladder outflow obstruction
Why is excessive urine passed in post obstructive diuresis?
- retained urea, sodium and water
AND defect in concentrating ability of kidney
Why should urine output be monitored regularly in post-obstructive diuresis?
If urine output > 200ml/hr
Pt may require IV fluid and sodium replacement
What differential diagnosis should you always consider in acute loin pain?
Leaking AAA
What mediates the pain in a ureteric obstruction caused by a calculus?
prostaglandins released by ureter to say it is obstructed
What treatment can be given for renal stones which are causing acute loin pain?
- NSAID +/- opiate
- alpha-blocker (Tamsulosin) for small stones that are expected to pass
Under what size are most renal stones expected to pass?
<4mm
After what length of time will a stone require intervention if it has not been passed?
1 month
What type of scan is best to view renal calculi and is therefore the most diagnostic?
Non-contrast CT
What symptoms would indicate that the renal stone should be treated urgently?
- Pain unrelieved
- Pyrexia
- Persistent nausea/vomiting
- High-grade obstruction
How are renal stones removed urgently?
- ureteric stent to allow them to pass more easily
- stone fragmentation (to make them smaller)
- percutaneous nephrostomy for infected hydronephrosis
What can cause macroscopic or FRANK haematuria?
- Infection
- Stones
- Tumours
- BPH
- Polycystic kidneys
- Trauma
- Coagulation/platelet deficiencies
How can a clot be removed if it is the cause of frank haematuria?
3 way irrigating haematuria catheter
- stiffer than normal catheter
=> can withstand the suction which aims to remove the clot
What investigations can be used in frank haematuria?
CT urogram
cystoscopy
Who usually suffers from testicular torsion and what can predispose to this?
Most common at puberty
Can occur after trauma or athletic activity
Teen often woken from sleep in pain
What is the normal presenting complaint in testicular torsion?
- Sudden onset of pain
- sometimes previous episodes of self-limiting pain
- nausea/vomiting
- Referral of pain to lower abdomen
What is usually found on examination of a patient with testicular torsion?
- Testis high in scrotum
- Lie transversely
- absence of cremasteric reflex
What is the cremasteric reflex?
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
What complications of testicular torsion can make it difficult to visualise and obliterate landmarks?
Acute hydrocoele
oedema
What investigation can be used to visualise the blood supply to the testis believed to be affected?
Doppler USS
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
What is Bell Clapper Deformity?
Both testes lie transversely
=> predisposing the patient to torsion
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
Torsion of an appendage can present very similarly to torsion of the testes themselves. TRUE/FALSE?
TRUE
If appendage torsion is caught early, how may it present?
localised tenderness at upper pole
“blue dot” sign
How can a testicular and appendage torsion be differentiated?
Appendage torsion involves mobile testis and intact cremasteric reflex
Torsion of an appendage can resolve spontaneously without surgery. TRUE/FALSE?
TRUE
What rare condition presents in a similar way to testicular torsion?
epididymitis
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
What investigations may be used to diagnose epididymitis?
Doppler
- swollen epididymis
- increased blood flow
Send urine for culture + Chlamydia PCR (STI causes)
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
Idiopathic scrotal oedema is NOT usually associated with any erythema. TRUE/FALSE?
TRUE
does not really cause any additional symptoms except sometimes itching
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)
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
What is priapism?
- prolonged erection (> 4hrs)
- painful
- not associated with sexual arousal
What can cause priapism?
Intracorporeal injection for Erectile Dysfunction (no longer a Tx option) Trauma (penile or perineal) Sickle cell Neurological conditions Idiopathic
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)
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
How is ischaemic priapism treated?
- Aspiration +/- irrigation with saline
- Injection of alpha-agonist to reduce inflow
- Surgical shunt
What can be considered if ischaemic priapism has presented extremely late?
immediate placement of a penile prosthesis
If non-ischaemic priapism does not respond spontaneously, what treaments can be used?
Selective arterial embolization
What is Fournier’s Gangrene?
necrotizing fasciitis occurring about the male genitalia
Usually skin in the urethra or rectal region
Who is predisposed to fournier’s gangrene?
- diabetes
- local trauma
- perianal infection
What type of microbes are found in Fournier’s gangrene?
- mixture of aerobes/anaerobes
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
What do investigations of Fournier’s gangrene show?
Plain X-ray or US may confirm gas in tissues
What is used to Treat Fournier’s Gangrene?
Antibiotics and surgical debridement
What is the mortality rate for Fournier’s gangrene?
20%
but higher if diabetic/alcoholic
Is Emphysematous pyelonephritis an infective emergency?
YES
What is Emphysematous pyelonephritis?
acute necrotizing parenchymal and peri-renal infection
caused by gas-forming uropathogens,
- usually E coli
What other conditions is Emphysematous pyelonephritis linked to?
Usually occurs in diabetics
Often associated with ureteric obstruction
What three main symptoms do patients experience in emphysematous pyeonephritis?
Fever, vomiting, flank pain
What causes a perinephric abscess?
- rupture of acute cortex abscess into the perinephric space
OR - infection travelled in the bloodstream to site
How should a perinephric abscess be investigated and treated?
Ix: CT
Tx: Antibiotics + percutaneous/surgical drainage
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
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
How are blunt renal injuries managed non-operatively?
angiography
embolization
When is surgery required in renal/urological trauma?
Persistent renal bleeding
expanding perirenal haematoma
pulsatile perirenal haematoma
Bladder injuries are commonly caused by what other trauma?
pelvic fracture
What are the main presenting complaint in bladder injury?
Suprapubic/abdominal pain + inability to void
Catheterisation after a bladder injury usually results in gross haematuria. TRUE/FALSE?
TRUE
some catheters wont go in due to urethral injury
If a catheter cannot be passed in easily after a bladder injury, what must you do first?
retrograde urethrogram – may well have urethral injury
What sign shows an extraperitoneal injury on a CT scan?
flame-shaped collection of contrast in pelvis
How is a bladder injury treated?
Large-bore catheter
Antibiotics
Repeat cystogram in 14 days
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
Fracture of the pubic rami can cause what structure to be damaged?
Posterior urethral injury
How does a posterior urethral injury usually present?
Blood at meatus Inability to urinate Palpably full bladder “High-riding” prostate Butterfly perineal haematoma
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
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
How is a penile fracture treated?
Prompt exploration and repair
Circumcision incision with degloving of penis to expose all 3 compartments
What symptoms are consistent with a testicular injury?
pain + nausea
How are testicular injuries investigated and managed?
ix: US to assess integrity / remaining blood supply
Early exploration/repair
- to preserve fertility, hormonal function etc
