urological 999s!! Flashcards
eggys of uro 999s
acute urinary retention
acute loin pain
frank haematuria
acute scrotum
paraphimosis
priapism
fournier’s gangrene
acute urinary retention
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
risk factor of acute urinary retention
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
post-obstructive diuresis
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
haematuria
not uncommon but generally settles in 24hrs
acute loin pain
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
indications and risk factors to treat cute loin pain quickly
pain unrelieved
pyrexia
persistent nausea/vomiting
renal impairment
rx - ureteric stent or stone fragmentation/removal if no infection, percutaneous nephrostomy for infected hydronephrosis
frank haematuria (not surgical unless symptomatic of anaemia, coagulation) causes
infection
stones
tumours – esp bladder
benign prostatic hyperplasia (BPH)
polycystic kidneys
trauma
coagulation/platelet deficiencies
pelvic radiation cystitis
clot retention and investigations
use a 3-way irrigating haematuria catheter
ix – CT urogram / USS + cystoscopy
eggys of cute scrotum (s welling/pain)
torsion of spermatic cord
torsion of appendix testis
epididymitis / epididymo-orchitis
inguinal hernia
hydrocoele
trauma / insect bite
dermatological lesions
inflammatory vasculitis
tumour
torsion of spermatic cord
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
investigating torsion of spermatic cord
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)
torsion of appendage (14 types)
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
epidymitis
rare in children
may be difficult to distinguish from torsion
dysuria / pyrexia more common
hx of UTI, urethritis, catheterization/instrumentation
epididymitis o/e
O/E: cremasteric reflex present
suspect if pyuria
doppler – swollen epididymis, increased bloodflow
send urine for culture + Chlamydia PCR
managing epididymitis
analgesia + scrotal support, bed rest
ofloxacin 400mg/day for 14 days
idiopathical scrotal oedema
self-limiting, unknown cause, not usually associated w/ scrotal erythema
no fever, tenderness minimal but may be pruritus
paraphimosis
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
paraphimosis management
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
priapism
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
classification of priapism
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
diagnosis of priapism
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
treating priapism
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
fournier’s gangrene
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
fourniers gangrene investigating treating risking
diagnose: plain X-ray or USS may confirm gas in tissues
treat: Antibiotics + surgical debridement
risk: ortality 20%, higher in diabetics and alcoholics
emphysematous pyelonephritis (infective emergencies)
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
perinephric abscess
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
trauma (renal classification)
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
indications for imaging
frank haematuria in adult
frank or occult haematuria in child
occult haematuria + (systolic <90mmHg at any point)
penetrating injury with any degree of haematuria
ix rx for renal trauma
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)
bladder injury
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
diagnose manage bladder injnury
imaging – CT cystography
extraperitoneal injury – flame-shaped collection of contrast in pelvis
Rx Large-bore catheter
Antibiotics
Repeat cystogram in 14 days
indications for immediate repair of bladder injury
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
urethral injury
posterior urethral injury often associated with fracture of pubic rami
post. urethra fixed at urogenital diaphragm and puboprostatic ligaments, so bulbomembranous junction most vulnerable
urethral injury o/e
blood at meatus
inability to urinate
palpably full bladder
“high-riding” prostate
butterfly perineal haematoma
ix and rx urethral injury
ix retrograde urethrogram
rx suprapubic catheter
delayed reconstruction after at least 3 months
penile fracture in a nutshell
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
testicular injury in a nutshell
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
