Urologic emergencies

Question 1

Eval for renal trauma?

Answer 1

CT w/ contrast for:
1. blunt trauma w/:
gross hematuria
microhematuria w/ shock
2. penetrating trauma: any hematuria
3. ped trauma: microhematuria w/ over 50 RBC/hpf

Question 2

Management of renal trauma? Indications for surgical intervention?

Answer 2

• most managed conservatively (esp blunt): +/- stent, embolization, percutaneus drain or nephrostomy tube
• indications for surgical intervention:
• life threatening hemorrhage
• cont. bleeding
• exploration for other injuries reveals expanding perirenal hematoma
• repair or remove kidney (make sure contralateral kidney is fxnl)

Question 3

Usual causes of a penile fracture? Dx?

Answer 3

- 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
- dx:
audible snap, sudden detumence, swelling, bruising

Question 4

Management of a penile fracture?

Answer 4

conservative (nonoperative) tx can lead to:
ED
curvature
painful erections

surgical tx:
deglove penis
rule out urethral injury
close corporal tear

Question 5

Cause of testis ruptures?

Answer 5

• blunt or penetrating trauma: straddle, saddle horn, bar fight, kick
• rare in team sports

Question 6

Dx of testis rupture?

Answer 6

• exam: scrotal swelling and echymosis
• US:
  loss of tunic continuity
  internal echos, heterogenecity

Question 7

Management of testis rupture?

Answer 7

• surgery to debride extruded tissue and clos tunic
• early (less than 3 days): 9% orchiectomy, 80% salvage
• later (greater than 3 days): 70% orchiectomy

Question 8

Causes of bladder rupture? What is always present?

Answer 8

• blunt more common than penetrating
• 60% extraperitoneal
• 30% intraperitoneal
• 10% combined
• hematuria always present:
  95% w/ gross hematuria
  5% w/ microhematuria
• 90% of bladder ruptures have assoc pelvic fractures
• 10% of pelvic fractures ssoc bladder ruptures

Question 9

Cause of intraperitoneal bladder rupture? Dx? Management?

Answer 9

• external blow, full bladder
• CT or cystogram:
  contrast around bowel, contrast above superior acetabular line
• management: surgical repair
• catheter drainage alone risks chemical peritonitis

Question 10

Cause of extraperitoneal bladder rupture? Dx? Management?

Answer 10

• blunt trauma w/ pelvic fracture
• CT or cystogram:
  contrast limited to pelvis, perineuma or genitalia, starburst pattern of contrast below superior acetabular line
• management: catheter drainage, surgical repair if having surgery for other injury

Question 11

Cause of urethral disrpution? Hallmark sign? Other signs? Dx?

Answer 11

• blunt or penetrating trauma
• blood at meatus
• distended bladder, unable to void, genital swelling and hematoma
• dx by RUG

Question 12

Incomplete urethral disruption?

Answer 12

• RUG shows contrast extravasation but w/ contrast into bladder
• management is catheter drainage

Question 13

Complete urethral disruption? Management?

Answer 13

• Emergency!!
• RUG shows contrast extravasation w/o contrast into bladder (r/o poor technique)
• management:
  suprapubic tube w/
  early primary realignment or delayed reconstruction

Question 14

Sxs of acute urinary retention? Causes?

Answer 14

• sudden, unexpected, painful inability to void
• abd/pelvic mass on exam, US or CT
• causes:
  BPH
  urethral stricture
  blood clots
  stones
  drugs (antihistamines, narcotics, alpha adrenergics)
  post op
  overdistension

Question 15

Management of acute urinary retention?

Answer 15

• urethral catheter - 14 french Coude tip
• suprapubic tube
• suprapubic aspiration
• watch for hematuria
• post obstructive diuresis uncommon w/ acute retention and normal Cr

Question 16

What is a priapism?

Answer 16

• painful, prolonged (over 4 hrs) erection

Question 17

Ischemic priapism? Causes?

Answer 17

• low flow, MC form
• compartment syndrome
• causes:
  drugs (intracavernosal injections, trazadone, cocaine, PDE5 inhibitors)
  sickle cell disease
  blood dyscrasias (leukemias)
  idiopathic (30-50%)

Question 18

Nonischemic priapism? Cause?

Answer 18

• high flow due to AV fistula

- usually due to trauma

Question 19

Tx of priapism?

Answer 19

• pharm: inject phenylephrine 5 - 1mg q 10 min
• flush w/ 1:100,000 epi soln
• surgical if pharm doesn’t work:
  winter shunt
  or
  al ghorab shunt

Question 20

Dx acute ureteral obstruction?

Answer 20

• flank and/or abd pain:
  colicky, cramping - unable to lay still or find comfortable position, non-positional
• pain radiation to groin
• N/V
• UA: hematuria prsent w/ 85% of stones
  pyuria w/ epithelials, w/o nitrites, bacteria suggests contamination
• noncontrast abd/pelvic CT:
  all stones seen, pleboliths can be misleading

Question 21

Etiologies of acute ureteral obstruction?

Answer 21

• stones
• clot
• retroperineal fibrosis
• surgical mishap
• bladder outlet obstruction
• malignancy (ureter, RP nodes, adjacent organs)

Question 22

What are signs of emergent ureteral obstruction?

Answer 22

• solitary kidney
• bilateral obstruction
• assoc infection:
  fever/chills
  high WBCs
  pyuria, bacteruria
  hypotension, tachycardia

Question 23

Signs of non-emergent acute ureteral obstruction?

Answer 23

• pyuria w/o other evidence of infection (pos. nitrites, bacteruria)
• hydronephrosis
• perinephric fluid: urine
• hematuria
• mildly increased Cr

Question 24

Emergent management of acute ureteral obstruction?

Answer 24

• ureteral stent:
  reqrs surgery, anesthesia, convenient but potentially painful, flomax reduces sxs
• nephrostomy tube:
  provides reliable, unequivocal drainage, more comfortable, invasive and inconvient
• stone removal w/ ureteroscopy delayed til after infection has resolved

Question 25

Non-emergent management of acute ureteral obstruction?

Answer 25

• toradol
• p.o. analgesia
• tamsulosin (flomax) - may help w/ sxs
• stone 4 mm or less will most likely pass

Question 26

What is Fournier’s gangrene? RFs?

Answer 26

• necrotizing infection of skin, fat, and fascia of genitalia and perineum
• synergistic infection w/ multiple aerobic and anerobic bugs
• 20-30% mortality
• RFs:
  obesity
  DM
  immunosupression
  alcoholism
  malnutrition

Question 27

Dx fournier’s gangrene?

Answer 27

• hx: pain, swelling, fever
• exam:
  fever, MS changes, tachycardia, tachypnea
• erythema, edema, crepitus, fluctuance, discoloration (purple, black), purulent drainage, foul odor
• soft tissue gas on xray, CT or US

Question 28

Tx of fourneir’s gangrene?

Answer 28

• wide, aggressive debridement
• broad spectrum abx to cover GP, GN and anerobes
• post op wound care:
  repeat debridement
  dressing changes
  HBO
  wound vac
  skin grafts, flaps

Question 29

Extravaginal testis torsion?

Answer 29

• neonate w/ swollen, discolored scrotum (hemorrhagic necrosis)
• nontender, firm testis w/ hydrocele
• cord twists above tunica vaginalis
• presumed to occur in utero
• salvage is rare

Question 30

Intravaginal testis torsion?

Answer 30

• typically in adolescents
• more common
• w/in tunica vaginalis
• acute scrotal and/or ipsilateral abd pain
• firm, tender, high riding, testis w/ hydrocele and edema
• absent cremasteric reflex

Question 31

DDx of testis torsion?

Answer 31

• torsion of testis appendage: blue dot sign, tender, firm nodule, normal US
• epididymitis: doppler US shows normal testis flow, increased epididymal flow
• incarcerated hernia:
  bowel sounds in scrotum, gas in scrotum on US or xray
• testicular torsion: doppler would show no flow

Question 32

Dx and tx of intravaginal testis torsion?

Answer 32

• doppler scrotal US: absence of flow is 90% sensitive, 99% specific for torsion
• manual detorsion (rotate externally, laterally)
• immediate exploration w/ detorsion and bilateral fixation, orchiectomy for noviable testis

Question 33

Tx of extravaginal testis torsion?

Answer 33

• orchiectomy w/ contralateral fixation MC

- timing is controversial due to anesthetic risk