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UROLOGY > UROLOGIC EMERGENCIES > Flashcards

UROLOGIC EMERGENCIES Flashcards

1
Q

imaging for renal trauma

A

CT WITH CONTRAST

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2
Q

management of renal trauma

A
  • most are managed conservatively
    ⦁ +/- stent, embolization, percutaneous drain or nephrostomy tube
- indications for surgical intervention
⦁	life threatening hemorrhage
⦁	continued bleeding
⦁	exploration for other injuries reveals an expanding perirenal hematoma
⦁	if need to repair or remove kidney
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3
Q

indications for surgical intervention with renal trauma

A

⦁ life threatening hemorrhage
⦁ continued bleeding
⦁ exploration for other injuries reveals an expanding perirenal hematoma
⦁ if need to repair or remove kidney

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4
Q

most cases of renal trauma are managed

A

conservatively

+/- stent, embolization, percutaneous drain or nephrostomy tube

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5
Q

causes of penile fracture

A
  • usually caused by blunt trauma to an erect penis, causing a tear in the tunica albuginea (around corpus cavernosum)
⦁	aggressive intercourse
⦁	off target penetration
⦁	masturbation
⦁	falling out of bed
⦁	scorned lover
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6
Q

symptoms that may occur with penile fracture

A

difficulty urinating

may report gross hematuria (esp if urethra was also torn)

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7
Q

imaging done with penile fracture if suspicion of urethral damage, hematuria or voiding difficulty

A

retrograde urethrogram

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8
Q

conservative (nonoperative) treatment of penile fractures can lead to

A

⦁ ED
⦁ curvature
⦁ painful erections

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9
Q

surgical treatment of penile fractures

A

1) deglove the penis
2) rule out urethral injury
3) close corporal tear

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10
Q

diagnosis of testis rupture

A

physical exam & scrotal ultrasound

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11
Q

physical exam of testis rupture

A
  • scrotal swelling

- ecchymosis

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12
Q

imaging of testis rupture

A

scrotal ultrasound
⦁ loss of tunic continuity ( tunica albuginea) - so all testicular contents are floating around in the scrotum
⦁ internal echos, heterogenicity

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13
Q

loss of tunic continuity

A

testis rupture

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14
Q

MANAGEMENT OF TESTICLE RUPTURE

A
  • surgery to debride extruded tissue and close tunic
  • if surgery is done early (< 3 days) = 80% chance of salvaging testicle, 9% chance of orchiectomy
  • if surgery is done late (> 3 days) = 70% chance of needing orchiectomy
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15
Q

when should surgery for testis rupture be done with best chances of salvaging the testicle

A

< 3 days

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16
Q

bladder ruptures always have

A

hematuria

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17
Q

___________ hematuria is more common than __________ hematuria with bladder ruptures

A

gross hematuria more common (95%) than microhematuria (5%)

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18
Q

most common location of bladder rupture is

A

extraperitoneal

⦁ 60% = Extraperitoneal
⦁ 30% = Intraperitoneal
⦁ 10% = combined

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19
Q

bladder ruptures are associated with

A

pelvic fractures

90% of bladder ruptures have associated pelvic fractures

(10% of pelvic fractures have bladder ruptures)

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20
Q

bladder ruptures are most often due to

A

blunt trauma&raquo_space;> penetrating trauma

get a pelvic fracture and then end up having ruptured through the bladder

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21
Q

imaging for intraperitoneal bladder rupture

A

CT with contrast or cystogram (Xray with contrast)
⦁ see contrast around bowel
⦁ see contrast above the superior acetabular line**

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22
Q

contrast above acetabular line or around bowel

A

bladder rupture

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23
Q

management of intraperitoneal bladder rupture

A

*only surgical repair

managing with catheter drainage only = risk of chemical peritonitis

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24
Q

external blow with a full bladder = what type of bladder rupture

A

intraperitoneal

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25
Q

penetrating trauma or bladder rupture due to pelvic fracture = what type of bladder rupture

A

extraperitoneal

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26
Q

imaging for extraperitoneal bladder rupture

A
  • CT with contrast or cystogram (xray with contrast)
    ⦁ contrast is limited to the pelvis, perineum or genitalia
    ⦁ starburst pattern of contrast below the superior acetabular line
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27
Q

management for extraperitoneal bladder rupture

A
  • catheter draining

- surgical repair if having surgery for another injury

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28
Q

BLOOD AT THE MEATUS

A

URETHRAL DISRUPTION

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29
Q

urethral disruption = look for

A

blood at the meatus

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30
Q

with urethral disruption will have _________________ due to inability to void

A

distended bladder

will also have genital swelling and hematoma due to urethral disruption

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31
Q

signs/symptoms of urethral disruption

A 
blood at meatus
distended bladder
inability to void
genital swelling
hematoma
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32
Q

diagnosis of urethral disruption

A

RUG (retrograde urethrogram)

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33
Q

incomplete urethral disruption shown on RUG

A

RUG shows contrast extravasation, but some contrast still getting to the bladder

Treatment = catheter drainage

can leave catheter in, and urethra will heal around the catheter! Risk = urethra can end up attaching to the catheter as it heals if left in too long

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34
Q

management for incomplete urethral disruption

A

catheter drainage

can leave catheter in, and urethra will heal around the catheter! Risk = urethra can end up attaching to the catheter as it heals if left in too long

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35
Q

complete urethral disruption shown on RUG

A

RUG shows contrast extravasation, and NO CONTRAST INTO BLADDER (need to rule out poor technique)

treatment = suprapubic cath

36
Q

management for complete urethral disruption

A

Suprapubic tube with early primary realignment or delayed reconstruction

37
Q

MOST COMMON UROLOGIC EMERGENCY

A

ACUTE URINARY RETENTION

38
Q
  • sudden, unexpected, PAINFUL inability to void
A

ACUTE URINARY RETENTION

39
Q

causes of acute urinary retention (many)

A 
⦁	BPH
⦁	urethral stricture
⦁	blood clots
⦁	stone
⦁	drugs (antihistamines, narcotics, alpha adrenergics)
⦁	post op
⦁	overdistension

Acute urinary retention may develop immediately after general anesthesia or following acute spinal cord injury such as infarction or demyelination

neurogenic impairments
detrusor muscle insufficiency

40
Q

incidence of acute urinary retention increases with

A

age

41
Q

acute urinary retention = 13x more common in

A

men

42
Q

Acute urinary retention is most often caused by outflow obstruction due to

A

BPH

43
Q

Risk factors for Acute Urinary Retention in men with BPH

A

⦁ severity of urinary symptoms
⦁ increased prostate volume
⦁ decreased urine flow rate
⦁ PSA > 2.5

44
Q

Most common cause for acute urinary retention in women

A

pelvic organ prolapse

45
Q

Additional etiologies of Acute Urinary Retention include Neurogenic impairment & Detrusor muscle insufficiency

ex of neurogenic impairment of bladder: due to

A

neurogenic bladder
diabetes
damage to spinal cord
MS

46
Q

MANAGEMENT FOR ACUTE URINARY RETENTION

A
  • Urethral catheter (lots of lube! French tip)
  • Suprapubic tube
  • Suprapubic aspiration
  • Watch for hematuria
  • Post obstructive diuresis = uncommon with acute retention & normal creatinine (post-obstructive diuresis more likely to occur with acute retention & ABNORMAL creatinine)
47
Q
  • painful, prolonged erection > 4 hours
A

priapism

48
Q

PATHOPHYS OF AN ERECTION

A
  • begins with nitric oxide or neuroendocrine induced relaxation of smooth muscle of cavernous arteries & tissues –> increased penile blood flow
  • As the corpus cavernosum fills with blood, the veins that drain the corpus cavernosum are compressed –> maintained erection
49
Q

priapism occurs due to failure of

A

corpus cavernosum to drain

50
Q

priapism generally occurs when there is a failure of the corpus cavernosum to drain = due to

A

impaired relaxation

or paralysis of cavernosal smooth muscle

or occlusion of venous outflow

51
Q

2 types of priapism

A

ischemic & non-ischemic

52
Q

most common form of priapism

A

ischemic

53
Q

which form of priapism is not generally related to permanent ED

A

non-ischemic

54
Q

form of priapism with low flow

form of priapism with high flow

A

ischemic = low flow

non-ischemic = high flow

55
Q

form of priapism with compartment syndrome

A

ischemic

irreversible damage is seen after 24 hrs

a serious condition that occurs when there’s a large amount of pressure inside a muscle compartment = can lead to serious / irreversible damage

56
Q

causes of ischemic priapism

A

⦁ drugs (intracavernosal injections, trazadone, cocaine, PDE5 inhibitors)
⦁ sickle cell disease
⦁ blood dyscrasias (leukemia)
⦁ idiopathic (30-50%)

57
Q

form of priapism that is usually due to trauma

A

non-ischemic

58
Q

most common cause of ischemic priapism

A

idiopathic

59
Q

AV fistula form of priapism

A

non-ischemic

60
Q

if priapism lasts for > 24 hrs = 90% of men will experience

A

permanent ED

61
Q

physical exam for ischemic priapism

A

men will present with erythematous, tender and fully erect corpus cavernosum with a soft glans & corpus spongiosum (not due to sexual arousal)

62
Q

priapism treatment

A

o RX
- phenylephrine & flush with epinephrine

o Surgical
- winter shunt - use biopsy needles to create shunt between corpus cavernosum & glans –> drain

  • El Ghorab shunt - cut incision into tunica albuginea and drain
63
Q

congenital testicular torsion

A 
⦁	neonate with swollen, discolored scrotum (hemorrhagic necrosis)
⦁	nontender, firm testis with hydrocele
⦁	cord twists above the tunica vaginalis
⦁	presumed to occur in utero
⦁	salvage = rare
64
Q

acquired testicular torsion

A

⦁ typically in adolescents
⦁ more common
⦁ within tunica vaginalis
⦁ Acute scrotal and/or ipsilateral abdominal pain
⦁ firm, tender, high riding testis with hydrocele & edema
⦁ Absent cremasteric reflex

65
Q

absent cremasteric reflex

A

testicular torsion

66
Q

blue dot on scrotum

A

testicular torsion

67
Q

TESTICULAR TORSION VS EPIDIDYMITIS VS INCARCERATED HERNIA

A

TESTICULAR TORSION

  • blue dot sign
  • tender, firm nodule
  • normal ultrasound

EPIDIDYMITIS
- doppler US shows normal testis flow, but increased epididymal flow

INCARCERATED HERNIA

  • bowel sounds in scrotum
  • gas in scrotum on US or xray
68
Q

management for testicular torsion

A
  • manual detorsion (rotate externally / laterally - as spermatic cord always twists inward) - so fix it by opening like a book - always to the outside
  • immediate exploration with detorsion & bilateral fixation; orchiectomy for nonviable testes
69
Q

most common treatment for testicular torsion

A

orchiopexy (bilateral fixation of testes in scrotum)

as manual detorsion often fails due to associated pain

70
Q

ACUTE URETERAL OBSTRUCTION SYMPTOMS

A
  • Flank and/or abdominal pain
    ⦁ colicky, cramping
    ⦁ unable to lay still or find a comfortable position
    ⦁ non-positional! kind of vague flank/abdominal pain - not able to point to where it is
  • Pain radiation to groin
  • Nausea / Vomiting
71
Q

LABS FOR ACUTE URETERAL OBSTRUCTION (stones)

A

o UA
⦁ hematuria = present with 85% of stones
⦁ pyuria with epithelials, without nitrites, and bacteria suggests contamination

UA = should have microscopic or gross hematuria. Nitrites if infectious.

72
Q

IMAGING FOR ACUTE URETERAL OBSTRUCTION (stones)

A

⦁ non-contrast abdomen/pelvic CT: all stones are seen. Pleboliths can be misleading (calcifications within a vein - of no clinical importance)

73
Q

ETIOLOGIES OF ACUTE URETERAL OBSTRUCTION

A

⦁ stones
⦁ clot
⦁ retroperianal fibrosis
⦁ surgical misshap (ex: clamp/cut ureter instead of renal artery)
⦁ bladder outlet obstruction
⦁ malignancy (ureter, renalpelvic nodes, adjacent organs)

74
Q

EMERGENT ACUTE URETERAL OBSTRUCTION

A 
⦁	solitary kidney
⦁	bilateral obstruction
⦁	associated infection 
	- fever/chills
	- high WBC
	- pyuria, bacteruria
	- hypotension / tachycardia
75
Q

NON-EMERGENT ACUTE URETERAL OBSTRUCTION

A 
⦁	pyuria without other evidence of infection (such as positive nitrites, bacteriuria, etc)
⦁	hydronephrosis
⦁	perinephric fluid (urine)
⦁	hematuria
⦁	mildly increased creatinine
76
Q

In the acute phase of obstruction, the rise in intrarenal pressure will reduce GFR and renal plasma flow
- this in turn will

A

reduce the urinary concentrating mechanism –> results in decreased renal function

  • Long term obstruction may result in irreversible hypertrophy of ureteral musculature with the associated development of fibrous bands that may cause a kink to develop in the ureter
77
Q

LABS FOR ACUTE URETERAL OBSTRUCTION (not just stones)

A

CBC
BUN / Creatinine
electrolytes
UA

78
Q

IMAGING OF CHOICE FOR ACUTE URETERAL OBSTRUCTION (not stones)

A

CT Urogram with contrast

    • if creatinine too high = Non-contrast CT scan
79
Q

MANAGEMENT FOR ACUTE URETERAL OBSTRUCTION

A 
EMERGENT MANAGEMENT
o Ureteral stent 
⦁	requires surgery &amp; anesthesia
⦁	Convenient but potentially painful
⦁	Flomax reduces symptoms

o Nephrostomy tube
⦁ provides reliable drainage
⦁ more comfortable
⦁ invasive & inconvenient

o Stone removal with ureteroscopy is delayed until after infection is resolved

NON-EMERGENT MANAGEMENT
o Toradol
o PO analgesia
o Tamsulosin (alpha blocker - dilates smooth muscles)

80
Q

Necrotizing infection of skin / fat / fascia of genitalia & perineum

A

FOURNIER’S GANGRENE

81
Q

causative agent of Fournier’s gangrene is usually a

A

mucosal barrier breakdown in the urethra or colon

82
Q

RISK FACTORS FOR FOURNIER’S GANGRENE

A 
⦁	obesity
⦁	DM
⦁	immunosuppression
⦁	alcoholism
⦁	malnutrition
83
Q

Fournier’s gangrene bugs

A
  • mixture of facultative aerobic & anerobic organisms

⦁ E. coli, klebsiella, enterococci, bacteroides, fusobacterium, clostridium

84
Q

diagnosing Fournier’s gangrene

A

HX = pain, swelling, fever

PE
⦁ fever, MS changes, tachycardia, tachypnea
⦁ erythema, edema, crepitus, fluctuance
⦁ discoloration (purple, black), purulent drainage, foul odor

IMAGING = soft tissue gas on CT, Xray, or US

85
Q

imaging for Fournier’s gangrene = will see

A

soft tissue gas on CT, Xray, or US

86
Q

treatment of Fournier’s gangrene

A
  • wide, aggressive debridement
  • broad spectrum antibiotics to cover GP / GN / anaerobes
    ⦁ according to medscape = Cipro & Clinda (GP & anaerobes)
- Post-op wound care
⦁	repeat debridement
⦁	dressing changes
⦁	Hyperbaric oxygen
⦁	wound vac
⦁	skin grafts / flaps

UROLOGY (12 decks)

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