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Urology > Urologic Emergencies > Flashcards

Urologic Emergencies Flashcards

1
Q

Renal Trauma -Evaluation

What test?

A

CT with contrast

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2
Q

Renal Trauma -Evaluation
CT with contrast for:
3

A
  1. Blunt Trauma with:
    • Gross hematuria
    • Microhematuria with shock
  2. Penetrating Trauma
    • Any Hematuria
  3. Pediatric Trauma
    • Microhematuria with >50 RBC/hpf
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3
Q

Renal Trauma - Management

  1. Most is managed how?
    - What does this entail? 4
  2. Indications for surgical intervention? 4
A
  1. Most managed conservatively (especially blunt)
    - +/- stent,
    - embolization,
    - percutaneous drain or
    - nephrostomy tube
    • Life threatening hemorrhage
    • Continued bleeding
    • Exploration for other injuries reveals expanding perirenal hematoma
    • Repair or remove kidney
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4
Q
  1. Penile fracture is usually caused by what?

2. Examples? 5

A
  1. Usually caused by blunt trauma to erect penis causing tear in tunica albigenia
    • Aggressive intercourse
    • Off target penetration
    • Masturbation
    • Falling out of bed
    • Scorned lover
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5
Q

Penile fracture: Dx? 4

A

Dx:

  • Audible snap,
  • sudden detumence,
  • swelling,
  • bruising
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6
Q

Penile Fracture - Management
1. Conservative (nonoperative) can lead to what? 3

  1. Surgical treatment? 3
A
  1. Conservative (nonoperative) can lead to:
    - Erectile Dysfunction
    - Curvature
    - Painful erections
  2. Surgical treatment:
    - Deglove penis
    - Rule out urethral injury
    - Close corporal tear
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7
Q

Testis Rupture

Mostly caused by what? 2

A

BLUNT OR PENETRATING TRAUMA

  • Straddle,
  • saddle horn,
  • bar fight/kick
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8
Q

Testis Rupture: Diagnosis
1. Exam?

  1. Scrotal US? 2 findings
A
  1. Exam:
    Scrotal swelling and echymosis
  2. Scrotal Ultrasound:
    - Loss of tunic continuity
    - Internal echos, heterogenecity
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9
Q
  1. Testis Rupture – Management?

2. Prognosis? 2

A
  1. Surgery to debride extruded tissue and close tunic

2.

  • Early (less than 3 days): 9% Orchiectomy, 80% Salvage
  • Late (> 3days): 70% Orchiectomy
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10
Q

Bladder Rupture

  1. What kind of trauma mostly?
  2. Exztraperitoneal or Intra?
  3. What is always present?
  4. 90% of bladder ruptures are have associated with what?
A
  1. Blunt&raquo_space; Penetrating
    • 60 % Extraperitoneal
    • 30 % Intraperitoneal
    • 10 % Combined
  3. Hematuria always present
    - 95% with gross hematuria
    - 5% with microhematuria
  4. pelvic fracture
    - 10% of pelvic fractures have associated bladder ruptures
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11
Q

Bladder Rupture - Intraperitoneal

  1. What is it?
  2. Dx? 2 Contrast where? 2
  3. Management?
  4. Catheter drainage alone risks what?
A
  1. External blow, full bladder
  2. CT or Cystogram:
    - Contrast around bowel
    - Contrast above superior acetabular line
  3. Management: Surgical Repair
  4. Catheter drainage alone risks chemical peritonitis
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12
Q

Bladder Rupture - Extraperitoneal
1. What is it?

  1. Dx? 2
  2. Sign seen with contrast?
  3. Management?
  4. When would you have surgery?
A
  1. Blunt trauma with pelvic fracture
  2. CT or Cystogram:
    - Contrast limited to pelvis, perineum, or genitalia
  3. Starburst pattern of contrast below superior acetabular line
  4. Management is catheter drainage
  5. Surgical repair if having surgery for other injury
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13
Q

Urethral Disruption

  1. From what kind of trauma?
  2. Blood where?
  3. Probles with the bladder? 2
  4. Genital problems?
  5. Dx?
A
  1. Blunt or penetrating trauma
  2. Blood at meatus !
  3. Distended bladder; unable to void
  4. Genital swelling and hematoma
  5. Diagnosis by RUG (Retrograde Urethrogram)
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14
Q

Urethral Disruption
Incomplete
1. What will the RUG show?
2. Management is what?

Complete

  1. RUG shows what?
  2. Management?
A

Incomplete:

  1. RUG shows contrast extravasation but with contrast into bladder
  2. Management is catheter drainage

Complete
1. RUG shows contrast extravasation w/o contrast into bladder (rule out poor technique)

  1. Management: Suprapubic tube with:
    - Early primary realignment, or
    - Delayed reconstruction
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15
Q

Acute Urinary Retention

  1. How will it present?
  2. What will you see on the US or CT?
  3. Many causes such as? 7
A
  1. Sudden, unexpected, painful inability to void
  2. Abd / pelvic mass on exam, US or CT
  3. Many causes:
    - BPH
    - Urethral stricture
    - Blood Clots
    - Stone
    - Drugs (antihistamines, narcotics, alpha adrenergics)
    - Post op
    - Overdistension
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16
Q

Acute Urinary Retention -
Management?
5

A
  1. Urethral catheter
    - Lots of lube !!
    - 14 French Coude tip
  2. Suprapubic tube
  3. Suprapubic aspiration
  4. Watch for hematuria
  5. Post Obstructive diuresis uncommon with acute retention & normal Cr
17
Q

Priapism

1. What is it?

A

Painful, prolonged (>4 hours) erection

18
Q

Priapism

  1. What is the most common form?
  2. How will it present?
  3. Multiple causes? 4
  4. What is the other form?
    - Usually due to what?
A
  1. Ischemic (Low flow; most common form)
  2. Compartment syndrome
  3. Multiple causes:
    - Drugs (intracavernosal injections (MC), trazadone, cocaine, PDE5 inhibitors)
    - Sickle Cell Disease
    - Blood dyscrasias (leukemia)
    - Idiopathic (30-50%)
  4. Non Ischemic
    (High flow due to AV fistula)
    -Usually do to trauma
19
Q

Priapism - Treatment
1. Pharmacologic? 2

  1. Surgical option? 2
A
  1. Pharmacologic
    - Inject Phenylephrine .5 – 1mg q 10 min
    - Flush with 1:100,000 epinephrine solution
  2. Surgical
    - Winter shunt
    - Al Ghorab shunt
20
Q

Acute Ureteral Obstruction: Diagnosis? 5

A
  1. Flank and/or abd pain
  2. Pain radiation to groin
  3. Nausea, vomiting
  4. UA
  5. Noncontrast Abd/pelvic CT
21
Q

Acute Ureteral Obstruction
1. How will the flank or abdominal pain present? 3

  1. What will the UA show? 2
  2. What will the noncontrast and/pelvic CT show? 2
A
    • Colicky, cramping
    • Unable to lay still or find comfortable position
    • Non positional !
    • Hematuria present with 85% of stones
    • Pyuria w/ epithelials, w/o nitrites, bacteria suggests contamination
    • All stones are seen
    • Pleboliths can be misleading
22
Q

Acute Ureteral Obstruction

Etiologies? 6

A
  1. Stones
  2. Clot
  3. Retroperineal Fibrosis
  4. Surgical mishap
  5. Bladder outlet obstruction
  6. Malignancy (ureter, RP nodes, adjacent organs)
23
Q

Acute Ureteral Obstruction
1. Emergent situations? 3

  1. Nonemergent? 5
A
    • Solitary kidney
    • Bilateral obstructin
    • Associated infection
    • Pyuria without other evidence of infection (pos. nitrites, bacteruria, etc)
    • Hydronephrosis
    • Perinephric fluid (urine)
    • Hematuria
    • Mildly increased Cr
24
Q

Acute Ureteral Obstruction

What will an associated infection show? 4

A
  1. Fever/chills
  2. High WBC
  3. Pyuria, bacteruria
  4. Hypotension, tachycardia
25
Q

Acute Ureteral Obstruction
What ARE NOT CRITICAL FACTORS!?
2

A

STONE SIZE AND LOCATION

26
Q

Acute Ureteral Obstruction: Emergent Management

3

A
  1. Ureteral stent
  2. Nephrostomy tube
  3. Stone removal with ureteroscopy delayed til after infection is resolved
27
Q

Ureteral stent

  1. Requires what?
  2. Disadvantage?
  3. What drug will reduce symptoms?

Nephrostomy

  1. Advantages? 2
  2. Disadvantage? 2
A

Ureteral stent

  1. Requires surgery, anesthesia
  2. Convenient but potentially painful
  3. Flomax reduces symptoms

Nephrostomy tube

    • Provides reliable, unequivocal drainage
    • More comfortable
  2. Invasive and inconvient
28
Q

Acute Ureteral Obstruction: Non-emergent Management

3

A
  1. Toradol!!
  2. P.O. analgesia
  3. Tamsulosin
29
Q

Fournier’s Gangrene

  1. What is it?
  2. Mortality?
  3. Risk factors? 5
A
  1. Necrotizing infection of skin, fat and fascia of genitalia and perineum
    - Synergistic infection with multiple aerobic and anerobic bugs

2 .20-30 % mortality !

  1. Risk Factors:
    - Obesity
    - Diabetes Mellitus
    - Immunosupressoin
    - Alcoholism
    - Malnutrition
30
Q

Fournier’s Gangrene Dx

  1. Hx? 3
  2. Exam? 7
  3. Imaging?
A
  1. Hx:
    - Pain,
    - swelling,
    - fever
  2. Exam:
    - Fever,
    - MS changes,
    - tachycardia, tachypnea
    - Erythema, edema,
    - crepitus, fluctuance,
    - discoloration (purple, black),
    - purlulent drainage, foul odor !!
  3. Soft Tissue Gas on Xray, CT or US
31
Q

Fournier’s Gangrene
1. Treatment? 2

  1. Post op wound care? 5
A
  1. Wide, aggressive debridement
  2. Broad spectrum antibiotics to cover GP, GN and anerobes
  3. Post op wound care:
    - Repeat debridement
    - Dressing changes
    - HBO
    - Wound Vac
    - Skin grafts, flaps
32
Q

Testis Torsion
1. Extravaginal testis torsion will present how? 3

  1. Presumed to occur where?
  2. Prognosis?
A

Extravaginal

    • Neonate with swollen, discolored scrotum (hemorrhagic necrosis)
    • Nontender, firm testis with hydrocele
    • Cord twists above tunica vaginalis
  2. Presumed to occur in utero
  3. Salvage is rare
33
Q 
Testis Torsion
Intravaginal
1. Typically in what age group?
2. More or less common?
3. Within the what?
4. Will present how? 3
A

Intravaginal

  1. Typically in adolescents
  2. More common
  3. Within tunica vaginalis
    • Acute scrotal and/or ipsilateral abd pain
    • Firm, tender, high riding testis w/ hydrocele and edema
    • Absent cremasteric reflex
34
Q

Testis Torsion – Differential Diagnosis

3

A
  1. Torsion of testis appendage
  2. Epididymitis
  3. Incarcerated hernia
35
Q

How will the following present:

  1. Torsion of testis appendage? 3
  2. Epididymitis? 2
  3. Incarcerated hernia? 2
A
    • Blue dot sign
    • Tender, firm nodule
    • Normal ultrasound
    • Doppler US shows normal testis flow,
    • increased epididymal flow
    • Bowel sounds in scrotum
    • Gas in scrotum on US or xray
36
Q

Testis Torsion - Intravaginal
1. Dx?

  1. Management? 3
A
  1. Doppler Scrotal ultrasound
    - Absence of flow is 90% sensitive, 99% specific for torsion
    • Manual detorsion (rotate externally, laterally)
    • Immediate Exploration with detorsion and bilateral fixation;
    • orchiectomy for nonviable testis
37
Q

Testis Torsion - Extravaginal

Management?

A
  1. Orchiectomy with contralateral fixation most common

- Timing is controversial due to anesthetic risk

Urology (12 decks)

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