Urological Emergencies Flashcards
What is the most common urological emergency?
Acute urinary retention
What is acute urinary retention?
when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine.
Epidemiology of acute urinary retention?
Whilst acute urinary retention is common in men, it rarely occurs in women (incidence ratio of 13:1). It occurs most frequently in men over 60 years of age and incidence increases with age.
It has been estimated that around a third of men in their 80s will develop acute urinary retention over a five year period.
Aetiology of acute urinary retention?
In men, most commonly occurs secondary to benign prostatic hyperplasia
Other urethral obstructions; including urethral strictures, calculi, cystocele, constipation or masses. Usually post-op
Medications
Less commonly, there may be a neurological cause
In patients with predisposing causes, a simple urinary tract infection can be enough
in women postpartum: usually secondary to a combination of the above risk factors.
Which medications can cause acute urinary retention
Medications affecting nerve signals to the bladder: these include anticholinergics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines.
Acute urinary presentation typically is
subacute onset of: Inability to pass urine Lower abdominal discomfort Considerable pain or distress an acute confusional state may also be present in elderly patients
How is acute urinary retention different from chronic?
This differs from chronic urinary retention which is typically painless. In a patient with a background of chronic urinary retention, acute urinary retention may present instead with overflow incontinence.
Signs of acute urinary retention?
Palpable distended urinary bladder either on an abdominal or rectal exam
Lower abdominal tenderness
Investigations for acute urinary retention?
Patients should all be investigated with a urine sample which should be sent for urinalysis and culture. This might only be possible after urinary catheterisation.
Serum U&Es and creatinine should also be checked to assess for any kidney injury.
A FBC and CRP should also be performed to look for infection
PSA is diagnostic of acute urinary retention
false
PSA is not appropriate in acute urinary retention as it is typically elevated
To confirm the diagnosis of acute urinary retention
bladder ultrasound should be performed. A volume of >300 cc confirms the diagnosis, but if the history and examination are consistent, with an inconsistent bladder scan, there are causes of bladder scan inaccuracies and hence the patient can still have acute urinary retention.
Management of acute urinary retention?
decompressing the bladder via catheterisation
What should you measure after catheterisation in acute urinary retention? What does this indicate?
volume of urine drained in 15 minutes measured. A volume of <200 confirms that a patient does not have acute urinary retention, and a volume over 400 cc means the catheter should be left in place. In between these volumes, it depends on the case.
Further investigations after decompression of acute urinary retention?
Further investigation should be targeted by the likely cause. In reversible causes such as UTI, resolution with treatment is sufficient and further investigation is not necessary. Men not diagnosed by BPH should be further evaluated by a urologist, Patients with neurological symptoms should be evaluated by a neurologist and women with gynaecological symptoms by a gynaecologist. Where no likely cause is identified, patients should be evaluated by a urologist for anatomical and urodynamic causes.
Complications of acute urinary retention?
post-obstructive diuresis
the kidneys may increase diuresis due to the loss of their medullary concentration gradient. This can take time re-equilibrate
this can lead to volume depletion and worsening of any acute kidney injury
some patients may therefore require IV fluids to correct this temporary over-diuresis
What is Balanitis?
inflammation of the glans penis and sometimes extends to the underside of the foreskin which is known as balanoposthitis
What causes balanitis?
most common causes are infective (both bacterial and candidal) although there are a number of other autoimmune causes that are important to know
Simple hygiene is a key part of the treatment of balanitis
true
both improper washing under the foreskin and the presence of a tight foreskin can make balanitis worse
balanitis is an acute presentation
false
The presentation can either be acute or more chronic and children and adults are affected by the causes differently.
assessment of balanitis?
Most diagnoses are made clinically based on the history and examination.
The history will tell you how acute the presentation is and other key features that are important to note are whether there is itching or discharge.
In the history also look for the presence of other systemic conditions affecting the skin such as eczema, psoriasis or connective tissue diseases.
Describe the frequency, acute/chronic presentation and features of Candidiasis as a cause of balanitis
Very common Acute
Usually occurs after intercourse and associated with itching and white non-urethral discharge
Describe the frequency, acute/chronic presentation and features of Dermatitis (contact or allergic) as a cause of balanitis
Very common Acute
Itchy, sometimes painful and occasionally associated with a clear non-urethral discharge. Often there is no other body area affected
Describe the frequency, acute/chronic presentation and features of Dermatitis (eczema or psoriasis) as a cause of balanitis
Very common Both
Very itchy but not associated with any discharge and there will be a medical history of an inflammatory skin condition with active areas elsewhere on the body
Describe the frequency, acute/chronic presentation and features of Dermatitis (eczema or psoriasis) as a cause of balanitis
Very common Both Very itchy but not associated with any discharge and there will be a medical history of an inflammatory skin condition with active areas elsewhere on the body
Describe the frequency, acute/chronic presentation and features of bacterial infection as a cause of balanitis
Common Acute Painful and can be itchy with yellow non-urethral discharge and most often due to Staphylococcus spp.
Describe the frequency, acute/chronic presentation and features ofAnaerobic infection as a cause of balanitis
Common Acute May be itchy but is most associated with a very offensive yellow non-urethral discharge
Describe the frequency, acute/chronic presentation and features of lichen planus as a cause of balanitis
Uncommon Both May be itchy, the main diagnostic feature is the presence of Wickham’s striae and violaceous papules