Urological emergencies Flashcards
A man presents with an inability to urinate and increasing abdominal pain.
Acute urinary retention
How do you manage acute urinary retention?
Immediate catheterisation
What drug could you prescribe before removal of the catheter, after acute urinary retention?
Alpha blocker
A patient presents with acute pain going from his loin to his groin. What is the most likely diagnosis?
Renal calculus
What is the treatment for renal colic due to a small calculus?
NSAID +/- opiate Alpha blocker (tamsulosin) for small stones that are expected to pass.
Why would you want to know if a renal stone was radio opaque or radio lucent?
For effective follow up .
If a stone hasn’t passed in …… then it is unlikely to and will probably need intervention.
1 month
A patient presents with severe unremmiting loin pain radiating to his groin. He is pyrexic and vomiting. What do you do?
Likely to a large renal calculus.
Ureteric stent or stone fragmentation/removal
How would you treat an infected hydronephrosis?
Percutaneous nephrostomy
How do you treat frank haematuria with cot retention
3 way irrigating haematuria catherter
How would you investigate a patient with frank haematuria.
CT urogram + cystoscopy
A teenage boy presents with severe pain in his testicles. He said it came on suddenly.
Torsion of the spermatic cord.
What investigation may be useful in a suspected testicular torison?
Doppler ultrasound scan
How do you treat testicular torsion?
Surgical treatment. 2 or 3 point fixation with fine non absorbale sutures.
A teenage boy presents with testicular pain that has got worse over the last day. The tenderness is worst at the upper pole. The testes are mobile and the cremateric reflex is present.
Torsion of the appendage
What is the treatment of a torsion of the appendage?
Diagnosis confirmed it is not testicular torsion. It will resolve spontaneously without surgery.
Describe the cremasteric reflex.
Stroking the superior and medial part of the thigh with the 3rd finger regardless of the direction of stroke results in an immediate contraction of the cremaster muscle that pulls up the ipsilateral testis.
A 25 year old man presents with severe testicular pain and dysuria. The cremasteric reflex is present but urine dipstick reveals pyuria.
Epidymitis
What investigations should be ordered if you suspect epidymitis?
Doppler scan (swollen epididymis with increased blood flow) Send urine for culture and chlamydia screen.
What is the treatment for epididymitis?
Analgesia, scrotal support and bed rest.
Ofloxacin 400mg/day for 14 days.
Is idiopathic scrotal oedema in babies dangerous?
No, it is usually self limiting.
How is paraphimosis commonly caused?
If the foreskin has been retracted for catheterization or cytoscopy and a staff member fails to replace it in its natural position.
A 76 year old man presents with a painful penis. One examination the tip of the penis is red and swollen. He had a cystoscopy 3 days ago.
Paraphimosis.
What is paraphimosis?
Painful swelling of the foreskin distal to a phimotic ring
How do you treat paraphimosis?
Mannual manipulation with an iced glove.
Multiple punctures in swollen foreskin.
Mannual compression of glan with distal traction on oedematous foreskin.
A man presents saying he has had an erection for the last 13 hours.
Pripism
What causes priapism?
Ischaemic: Vascular stasis in penis and decreased venous outflow (a compartment syndrome)
Non ischaemic: Traumatic disruption of penile vasuclature results in unregulated blood entry to the penis and filling of the corpora.
Fistula formation between cavernous artery and lacumar spaces allows blood to by pass the normal helicine arteriolar bed.
How do you investigate priapism?
Aspirate blood from the corpus cavernosum.
Colour duplex ultrasound scan.
How do you treat ischaemic priapism?
Aspiration of blood and irrigation with saline.
Injection of an alpha agonist such as pheylephrine 100 - 200ug every 5 - 10 mins.
How do you treat non ischamic priapism?
Obsesrve as it may resolve spontaneously.
Selective arterial embolization with non permanent materials.
A 64 year old diabetic patient complains of sever pain around his genitalia. On examination the scrotum looks red but not overly swollen.
Forniers gangrene (necrotising fasciitis of the skin around the male genitalia.)
How do you treat forniers gangerne.
Debridement and antibiotics
What organism usually causes emphysematous pyelonephritis?
E coli
What investigation would you order is you suspected emphysematous pyelonephritis?
CT
How do you treat emphysematous pyelonephritis?
Nephrectomy
What causes a perinephric abscess?
Rupture of an acute cortical abscess into the perinephric space of from haematogenous seeding from sights of infection.
The blood results return for a patient who presented with a mass in the flank region. He has a high WCC, high serum creatine and pyuria.
Perinephric abscess
What investigation woull you want if you suspected a perinephric abscess?
CT
How do you treat a perinephric abscess?
Antibiotic + percutaneous surgical drainage.
In a patient who has experienced trauma; what are signs would lead to to image the kidneys?
Frank haematuria in an adult
Frank or occult haematuria is a child.
Occult haemiaturia and schock.
Penetrating injury with any degree of haematuria.
How would you image if you suspected trauma to the kidneys?
CT with contrast.
What sign would you expect to see on contrast CT if a patient ha sustained a bladder injury?
Flame shaped collection of contrast in pelvis.
How do you investigate suspected bladder trauma?
CT cystography.
After following of his bike a patient has suprapubic tenderness, lower abdominal brusing and rigidity.
Bladder trauma
How do you treat a bladder injury?
Large bore catheter
Antibiotics
Repeat cystogram in 14 days.
What fracture puts you most at risk of a urethral injury?
Pubic rami fracture
A patient who was in a RTA has an inability to urinate, a palpable full bladder and butterfly perineal heamatoma. What do you suspect an what investigation do you order?
Urethral injury
Retrograde urethrogram
On inserting a catheter in a patient who has been in an RTA you see blood and the catheter is hard to insert.
Urethral injury. Stop and order a retrograde urethrogram.
How do you treat a penile fracture?
Prompt exploration and repair.
Circumcison incision with degloving of penis to expose all 3 compartments.
What is a bell clapper deformity?
Testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels.
What is emphysematous pyelonephritis?
A severe infection of the renal parenchyma that causes gas accumulation in the tissues (see the image below). EPN is common in persons with diabetes, often has a fulminating course, and can be fatal if not recognized and treated promptly.
