urological 999s!!

Question 1

eggys of uro 999s

Answer 1

acute urinary retention
acute loin pain
frank haematuria
acute scrotum
paraphimosis
priapism
fournier’s gangrene

Question 2

acute urinary retention

Answer 2

complication of BPH
inability to urinate, with increasing pain.

cause poorly understood – prostate infection, bladder overdistension, excessive fluid intake, alcohol, prostatic infarction

can separate into spontaneous and precipitated:
precipitated (triggering event) – non-prostate related surgery, catheterization or urethral instrumentation, anaesthesia, medication with sympathomimetic or anticholinergic effects

Question 3

risk factor of acute urinary retention

Answer 3

if painful retention with < 1 litre residue and normal serum electrolytes then trial without catheter (TWOC) during same admission.
prescribing a uroselective alphabocker (Alfuzosin, Tamsulosin) before TWOC improves chance of voiding success

Question 4

post-obstructive diuresis

Answer 4

often present in patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF, hypertension
diuresis due to solute diuresis (retained urea, sodium and water) + defect in concentrating ability of kidney
monitor fluid balance and beware if urine output > 200ml/hr. usually resolves in 24-48hr but in severe cases may require IV fluid and sodium replacement

Question 5

haematuria

Answer 5

not uncommon but generally settles in 24hrs

Question 6

acute loin pain

Answer 6

possibility of dx outwith urinary tract, especially AAA

yreteric colic 2ndry to calculus – pain mediated by prostaglandins released by ureter in response to obstruction

Rx – NSAID +/- opiate
- alpha-blocker (Tamsulosin) for small stones that are expected to pass

Spontaneous passage: <4mm 80%
4-6mm 59%
>6mm 21%

also relates to site of stone at first presentation
if stone hasn’t passed in 1 month then likely to require intervention

Question 7

indications and risk factors to treat cute loin pain quickly

Answer 7

pain unrelieved
pyrexia
persistent nausea/vomiting
renal impairment

rx - ureteric stent or stone fragmentation/removal if no infection, percutaneous nephrostomy for infected hydronephrosis

Question 8

frank haematuria (not surgical unless symptomatic of anaemia, coagulation) causes

Answer 8

infection
stones
tumours – esp bladder
benign prostatic hyperplasia (BPH)
polycystic kidneys
trauma
coagulation/platelet deficiencies
pelvic radiation cystitis

Question 9

clot retention and investigations

Answer 9

use a 3-way irrigating haematuria catheter
ix – CT urogram / USS + cystoscopy

Question 10

eggys of cute scrotum (s welling/pain)

Answer 10

torsion of spermatic cord
torsion of appendix testis
epididymitis / epididymo-orchitis
inguinal hernia
hydrocoele
trauma / insect bite
dermatological lesions
inflammatory vasculitis
tumour

Question 11

torsion of spermatic cord

Answer 11

most common at puberty/teenage
can occur w/ trauma or athletic activity but usually spontaneous. adolescent often woken from sleep
usually sudden onset of pain, sometimes previous episodes of self-limiting pain
may be nausea/vomiting
may be referral of pain to lower abdomen

O/E: testis high in scrotum
transverse lie
absence of cremasteric reflex

acute hydrocoele + oedema may obliterate landmarks

Question 12

investigating torsion of spermatic cord

Answer 12

Ix – Doppler USS sometimes helpful

Rx – Prompt exploration. Irreversible ischaemic injury may begin as soon as 4hrs
2 or 3-point fixation with fine non-absorbable sutures
If testis necrotic then remove
MUST fix contralateral side (bell clapper deformity)

Question 13

torsion of appendage (14 types)

Answer 13

MOST COMMON - hydratomorgany (one that sounds like morgie)

symptoms variable – may be insidious onset or identical to torsion of cord

if seen early, may have localised tenderness at upper pole and “blue dot” sign

testis should be mobile and cremasteric reflex present

if diagnosis confirmed then will resolve spontaneously without surgery

Question 14

epidymitis

Answer 14

rare in children
may be difficult to distinguish from torsion
dysuria / pyrexia more common
hx of UTI, urethritis, catheterization/instrumentation

Question 15

epididymitis o/e

Answer 15

O/E: cremasteric reflex present
suspect if pyuria
doppler – swollen epididymis, increased bloodflow
send urine for culture + Chlamydia PCR

Question 16

managing epididymitis

Answer 16

analgesia + scrotal support, bed rest
ofloxacin 400mg/day for 14 days

Question 17

idiopathical scrotal oedema

Answer 17

self-limiting, unknown cause, not usually associated w/ scrotal erythema
no fever, tenderness minimal but may be pruritus

Question 18

paraphimosis

Answer 18

painful swelling of the foreskin distal to a phimotic ring
often happens after foreskin retracted for catheterization or cystoscopy and staff member forgets to replace it in its natural position

Question 19

paraphimosis management

Answer 19

rx iced glove, granulated sugar for 1-2hrs, multiple punctures in oedematous skin
under penile block manual compression of glans with distal traction on oedematous foreskin
dorsal slit

Question 20

priapism

Answer 20

prolonged unwanted erection (>4hrs), often painful and not associated w/ sexual arousal

aetiology - intracorporeal injection for ED, e.g. papaverine
trauma (penile / perineal)
haematologic dyscrasias e.g. sickle cell
neurological conditions
idiopathic

Question 21

classification of priapism

Answer 21

ischaemic (veno-occlusive or low-flow).
Vascular stasis in penis and decreased venous outflow, a true compartment syndrome.
Corpora cavernosa are rigid and tender, penis often painful

Non-ischaemic (arterial or high-flow)
Traumatic disruption of penile vasculature results in unregulated blood entry and filling of corpora.
Fistula formation between cavernous artery and lacunar spaces allows blood to by-pass the normal helicine arteriolar bed

Question 22

diagnosis of priapism

Answer 22

aspirate blood from corpus cavernosum – dark blood, low O2, high CO2 in low-flow
- normal arterial blood in high-flow

Colour duplex USS - minimal or absent flow in cavernosal arteries in low-flow, - normal to high flow in non-ischaemic priapism

Question 23

treating priapism

Answer 23

ISCHAEMIC - Aspiration +/- irrigation with saline
- Injection of alpha-agonist, e.g. phenylephrine
100-200ug every 5-10 mins up to max 1000ug
- Surgical shunt
- Ischaemic priapism > 48-72hrs unlikely to
respond to intracavernosal treatment
- For very delayed presentation, may even
consider immediate placement of a penile
prosthesis

NON-ISCHAEMIC - Observe, may resolve spontaneously
- Selective arterial embolization with non-
permanent materials

Question 24

fournier’s gangrene

Answer 24

form of necrotizing fasciitis occurring about the male genitalia
most commonly arises from skin, urethra or rectal region

predisposing factors – diabetes, local trauma, periurethral extravasation, perianal infection
usually a mixture of aerobes/anaerobes
starts as cellulitis – swollen, erythematous, tender. Marked pain, fever, systemic toxicity
swelling + crepitus of scrotum, dark purple areas
often marked toxicity out of proportion to the local findings

Question 25

fourniers gangrene investigating treating risking

Answer 25

diagnose: plain X-ray or USS may confirm gas in tissues
treat: Antibiotics + surgical debridement
risk: ortality 20%, higher in diabetics and alcoholics

Question 26

emphysematous pyelonephritis (infective emergencies)

Answer 26

acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E coli
usually occurs in diabetics
often associated with ureteric obstruction
fever, vomiting, flank pain
see gas on KUB
CT defines extent of emphysematous process

requires ITU support. If not settling needs nephrectomy

Question 27

perinephric abscess

Answer 27

usually results from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
insidious onset, approx 33% not pyrexial
flank mass in 50%
high WCC, high serum creatinine, pyuria

ix - CT

rx - antibiotics + percutaneous or surgical drainage

Question 28

trauma (renal classification)

Answer 28

I haematoma, subcapsular, non-expanding, no parenchymal laceration

II laceration <1cm parenchymal depth without urinary extravasation

III >1cm depth, no collecting system rupture or extravasation

IV laceration through cortex, medulla and collecting system
main arterial/venous injury with contained haemorrhage

V shattered kidney
avulsion of hilum, devascularizing kidney

Question 29

indications for imaging

Answer 29

frank haematuria in adult
frank or occult haematuria in child
occult haematuria + (systolic <90mmHg at any point)
penetrating injury with any degree of haematuria

Question 30

ix rx for renal trauma

Answer 30

ix – CT with contrast

rx – 98% of blunt renal injuries can be managed non-operatively
angiography/embolization

surgery - persistent renal bleeding, expanding perirenal haematoma, pulsatile perirenal haematoma
urinary extravasation, non-viable tissue, incomplete staging (can do on-table IVU)

Question 31

bladder injury

Answer 31

commonly assoc. w/ pelvic fracture
suprapubic/abdominal pain + inability to void
suprapubic tenderness, lower abdominal bruising, guarding/rigidity, diminished bowel sounds
catheterization – gross haematuria in 90-100%
if blood at external meatus or if catheter doesn’t pass easily then perform retrograde urethrogram – may well have urethral injury

Question 32

diagnose manage bladder injnury

Answer 32

imaging – CT cystography

extraperitoneal injury – flame-shaped collection of contrast in pelvis
Rx Large-bore catheter
Antibiotics
Repeat cystogram in 14 days

Question 33

indications for immediate repair of bladder injury

Answer 33

intraperitoneal injury
penetrating injury
inadequate drainage or clots in urine
bladder neck injury
rectal or vaginal injury
open pelvic fracture
pelvic fracture requiring open reduction/fixation
patients undergoing laparotomy for other reasons
bone fragments projecting into bladder

Question 34

urethral injury

Answer 34

posterior urethral injury often associated with fracture of pubic rami
post. urethra fixed at urogenital diaphragm and puboprostatic ligaments, so bulbomembranous junction most vulnerable

Question 35

urethral injury o/e

Answer 35

blood at meatus
inability to urinate
palpably full bladder
“high-riding” prostate
butterfly perineal haematoma

Question 36

ix and rx urethral injury

Answer 36

ix retrograde urethrogram

rx suprapubic catheter
delayed reconstruction after at least 3 months

Question 37

penile fracture in a nutshell

Answer 37

typically happens during intercourse – buckling injury when penis slips out of vagina and strikes pubis
cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling
20% incidence of urethral injury (frank haematuria/blood at meatus)

rx - prompt exploration and repair
circumcision incision with degloving of penis to expose all 3 compartments

Question 38

testicular injury in a nutshell

Answer 38

usually presents with exquisite pain + nausea
swelling / bruising variable

ix USS to assess integrity / vascularity

rx early exploration/repair improves testis salvage, reduces convalescence, better preserves fertility and hormonal function