Urologic Emergencies Flashcards
Top 10 Urologic Emergencies
Renal trauma Penile fracture Testis rupture Bladder rupture Urethral disruption Acute urinary retention Priapism Acute ureteral obstruction Fournier's Gangrene Testis torsion
When should you use a CT with contrast for renal trauma?
Blunt trauma with gross hematuria or micro-hematuria with chock
Penetrating trauma with hematuria
Pediatric trauma with micro-hematuria
Management of Renal Trauma
Most managed conservatively
+/- stent
+/- embolization
+/- percutaneous drain or nephrostomy tube
Indications for Surgical Intervention
Life threatening hemorrhage
Continued bleeding
Exploration for other injuries reveals expanding peritoneal hematoma
Repair or remove kidney
Causes of Penile Fracture
Aggressive intercourse Off target penetration Masturbation Falling out of bed Scored lover
Diagnosis of Penile Fracture
Audible snap
Sudden detumesce
Swelling
Bruising
Conservative Management of Penile Fracture
Erectile dysfunction
Curvature
Painful erections
Surgical Treatment of Penile Fracture
Deglove penis
Rule out urethral injury
Close corporal tear
Causes of Testis Rupture
Blunt or penetrating trauma Straddle Saddle horn Bar fight Kick Drug deal gone bad
Exam for Testis Rupture
Scrotal swelling
Echymosis
Testis Rupture & Scrotal Ultrasound
Loss of tunic continuity
Internal echos
Heterogenecity
Management of Testis Rupture
Surgery to debride extruded tissue & close tunic
Early: salvage
late: orchiectomy
Bladder Rupture
Blunt >> Penetrating 60% extraperitoneal 30% intraperitoneal 10% combined Hematuria always present 90% have pelvic fractures
Causes of Intraperitoneal Bladder Rupture
External blow, full bladder
MVA
Diagnosing Intraperitoneal Bladder Rupture
CT or Cystogram
Contrast around bowel & above superior acetabular line
Management of Intraperitoneal Bladder Rupture
Surgical repair
Causes of Extraperitoneal
Blunt trauma with pelvic fracture
Diagnosing Extraperitoneal Bladder Rupture
CT or cystogram
Contrast limited to pelvis, perineum, or genitalia
Starburst pattern of contrast below superior acetabular line
Management of Extraperitoneal Bladder Rupture
Catheter drainage
Surgical repair IF repairing something else
Cause Urethral Disruption
Blunt or penetrating trauma
Signs/Symptoms of Urethral Disruption
Blood at meatus
Distended bladder
Genital swelling & hematoma
Diagnosis of Urethral Disruption
Retrograde Urethrogram (RUG)
Incomplete Urethral Disruption Diagnosis
RUG shows contrast extravasation but with contrast into bladder
Management of incomplete Urethral Disruption
Catheter drainage
Complete Urethral Disruption Diagnosis
RUG shows contrast extravasation without contrast into bladder
Management of Complete Urethral Disruption
Suprapubic tube with early primary realignment or delayed reconstruction
Define Acute Urinary Retention
Sudden, unexpected, painful inability to void
Causes of Acute Urinary Retention
PBH Urethral stricture Blood clots in urethra Stone in urethra Drugs: antihistamines, narcotics, alpha adrenergics Post op Overdistension
Management of Acute Urinary Retention
Urethral catheter Suprapubic tube Suprapubic aspiration Watch for hematuria Post obstructive diuresis uncommon
Define Priapism
Painful, prolonged (>4 hours) erection
Ischemic Priapism
Low flow, most common
Compartment syndrome
Multiple causes
Causes of Ischemic Priapism
Drugs: intracavernosal injections, trazadone, cocaine, PDE5 inhibitors
Sickle cell disease
Blood dycrasias (leukemia)
Idiopathic
Non Ischemic Priapism
High flow due to AV fistula
Usually due to trauma
Treatment of Priapism
Phenylephrine + 1:100,000 epinephrine solution
Surgical: Winter & Al Ghorab shunt
Diagnosis of Acute Ureteral Obstruction
Flank and/or abdominal pain: colicky, cramping Pain radiating to groin N/V UA Noncontrast abdominal/pelvic CT
UA in Acute Ureteral Obstruction
Hematuria
Pyre with epithelial
Without nitrites
Bacteria suggests contamination
Etiologies of Acute Ureteral Obstruction
Stones Clot Retroperineal fibrosis Surgical mishap Bladder outlet obstruction Malignancy: ureter, RP nodes, adjacent organs
Emergent Acute Ureteral Obstruction
Solitary kidney
Bilateral obstruction
Association infection: fever, chills, high WBC, pyuria, bacteria, hypotension, tachycardia
Non-Emergent Acute Ureteral Obstruction
Pyuria without other evidence of infection Hydronephrosis Perinephric fluid (urine) Hematuria Mildly increased creatinine
Emergent Management of Acute Ureteral Obstruction
Ureteral stent
Nephostomy tube
Stone removal with ureteroscopy (no infection present)
Ureteral stent
Requires surgery, anesthesia
Convenient but painful
Flomax reduces symptoms
Nephrostomy Tube
Provides reliable, unequivocal drainage
More comfortable
Invasive & inconvenient
Non-emergent Management of Acute Ureteral Obstruction
Toradol: IM
P.O analgesia
Tamsulosin: dilates ureter to help pass the stones
Define Fournier’s Gangrene
Necrotizing infection of skin, fat & fascia of genitalia & perineum
Mortality with Fournier’s Gangrene
20-30%
Risk Factors for Fournier’s Gangrene
Obesity DM Immunosuppression Alcoholism Malnutrition
Diagnosis of Fournier’s Gangrene
Pain Swelling Fever Musculoskeletal changes Tachycardia Tachypnea Erythema Edema Crepitus Fluctuance Discoloration Purulent drainage Foul odor X-ray, CT or US
Treatment of Fournier’s Gangrene
Wide, aggressive debridement
Broad spectrum antibiotics to cover anaerobes
Post-op wound care
Post-op Wound Care with Fournier’s Gangrene
Repeat debridement Dressing changes Wound vac Skin grafts, flaps HBO
Extravaginal Testis Torsion
Neonate with swollen, discolored scrotum Nontender, firm testis with hydrocele Cord twists above tunica vaginalis Presumed to occur in utero Salvage is rare
Intravaginal Testis Torsion
Adolescents
More common
Within tunica vaginalis
Acute scrotal and/or ipsilateral abdominal pain
Firm, tender, high riding testis with hydrocele & edema
Absent cremasteric reflex
Differential Diagnosis of Testis Torsion
Torsion of testis appendage
Epididymitis
Incarcerated hernia
Distinguishing Torsion of Testis Appendage
Blue dog sign
Tender, firm nodule
Normal US
Distinguishing Epididymitis
Doppler US: normal testis flow, increased epididymal flow
Distinguishing Incarcerated Hernia
Bowel sounds in scrotum
Gas in scrotum on US or x-ray
Intravaginal Testicular Torsion Doppler Scrotal Ultrasound
Absence of flow is 90% sensitive, 99% specific
Treatment of Intravaginal Testicular Torsion
Manual detorsion
Immediate exploration with detorsion & bilateral fixation
Orchiectomy for non-viable testis
Extravaginal Testicular Torsions Treatment
Orchiectomy with contralateral fixation
