urological emergencies

Question 1

what events can cause precipitated acute urinary retention?

Answer 1

non-prostate related surgery, catheterisation or urethral instrumentation, anaesthesia, medication with sympathomimetic or anticholinergic effects

Question 2

what is post-obstructive diuresis?

Answer 2

Diuresis due to solute diuresis (retained urea, sodium and water) + defect in concentrating ability of kidney
Often present in patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF, hypertension

Question 3

what is the management of post-obstructive diuresis?

Answer 3

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 4

what is it important to rule out in a patient presenting with acute loin pain?

Answer 4

AAA

Question 5

how long should you wait to see if a renal stone passes itself before intervening?

Answer 5

1 month
(unless there is extreme pain, renal impairment or infection)

Question 6

what is the most common cause of spermatic cord torsion?

Answer 6

spontaneous - adolescent suddenly woken in their sleep with severe pain

Question 7

what is the management of spermatic cord torsion?

Answer 7

• 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 8

what is epididymitis?

Answer 8

Inflammation of the testis and epididymis secondary to infection

Question 9

what are the investigations for epididymitis?

Answer 9

Cremasteric reflex present
Suspect if pyuria
Doppler – swollen epididymis, increased bloodflow
Send urine for culture + Chlamydia PCR

Question 10

what is the management for epididymitis?

Answer 10

Analgesia + scrotal support, bed rest
Ofloxacin 400mg/day for 14 days

Question 11

what is paraphimosis?

Answer 11

Painful swelling of the foreskin distal to a phimotic ring
foreskin stuck back

Question 12

what is a cause of paraphimosis in hospital?

Answer 12

after foreskin retracted for catheterization or cystoscopy and staff member forgets to replace it in its natural position

Question 13

what is the management of paraphimosis?

Answer 13

• Under penile block, manual compression of glans with distal traction on oedematous skin
• If fails - dorsal slit

Question 14

what is priapism?

Answer 14

Prolonged unwanted erection (> 4hrs), often painful and not associated with sexual arousal

Question 15

what can cause priapism?

Answer 15

• Intracorporeal injection for ED, e.g. papaverine
• Trauma (penile / perineal)
• Haematologic dyscrasias e.g. sickle cell
• Neurological conditions
• Idiopathic

Question 16

what is ischaemic priapism?

Answer 16

(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

Question 17

what is non ischaemic priapism?

Answer 17

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 18

what is the treatment of ischaemic priapism?

Answer 18

Aspiration +/- irrigation with saline
injection of alpha-agonist, e.g. phenylephrine 100-200ug every 5-10 mins up to max 1000ug
Surgical shunt

in delayed presentation (>48 hours) can consider penile prosthesis

Question 19

what is the treatment of non-ischaemic priapism?

Answer 19

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

Question 20

what is fournier’s gangrene?

Answer 20

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

Question 21

what are predisposing factors for fournier’s gangrene?

Answer 21

diabetes, local trauma, periurethral extravasation, perianal infection

Question 22

what is the presentation of fournier’s gangrene?

Answer 22

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 23

what is the treatment of fournier’s gangrene?

Answer 23

Plain X-ray or USS may confirm gas in tissues
Antibiotics + surgical debridement
Mortality 20%, higher in diabetics and alcoholics

Question 24

what is emphysematous pyelonephritis?

Answer 24

An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E coli, usually seen in diabetics

Question 25

what is the presentation of emphysematous pyelonephritis?

Answer 25

Often associated with ureteric obstruction Fever, vomiting, flank pain See gas on KUB

Question 26

what causes a perinephric abscess?

Answer 26

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

Question 27

what are the classifications of renal trauma?

Answer 27

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

Question 28

what are indications for imaging in renal injury?

Answer 28

Frank haematuria in adult Frank or occult haematuria in child Occult haematuria + (systolic <90mmHg at any point) Penetrating injury with any degree of haematuria do CT with contrast

Question 29

what is the presentation of bladder injury?

Answer 29

Suprapubic/abdominal pain + inability to void Suprapubic tenderness, lower abdominal bruising, guarding/rigidity, diminished bowel sounds

Question 30

what are indications for immediate repair of bladder injury?

Answer 30

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 otherwise - catheter + antibiotics

Question 31

what is the presentation of urethral injury?

Answer 31

Blood at meatus Inability to urinate Palpably full bladder “High-riding” prostate Butterfly perineal haematoma often associated with fracture of pubic rami

Question 32

what are the investigations and management of urethral injury?

Answer 32

retrograde urethrogram suprapubic catheter, delayed reconstruction after at least 3 months

Question 33

describe penile fracture

Answer 33

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)

Question 34

what is the management of penile fracture?

Answer 34

Prompt exploration and repair Circumcision incision with degloving of penis to expose all 3 compartments