Urological emergencies Flashcards
How does acute urinary retention present?
Inability to urinate
Increasing pain
What condition is acute urinary retention a complication of?
Benign prostatic hyperplasia
What is the treatment for acute urinary retention?
Catheter
What are the indications for trial without catheter following catheterisation to treat acute urinary retention?
>1 litre residue
Normal serum electrolytes
What drug may be prescribed to try and improve success of trial without catheter following catherisation for acute urinary retention?
Alpha blocker - relaxes smooth muscle in the bladder wall
Why might haematuria occur following acute urinary retention?
Decompression of bladder may cause some bleeding
When is post-obstructive diuresis usually present?
In patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF, hypertension
What causes post-obstructive diuresis?
Solute diuresis (retained urea, sodium and water) and defect in concentrating ability of kidney
How should post-obstructive diuresis be managed?
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
What differential for acute loin pain outwith the urinary tract should always be remembered?
AAA
What is the gold-standard investigation for looking at kidney stones?
Non-contrast CT
What causes the pain in ureteric obstruction by a renal stone?
Prostaglandin release in response to obstruction
What is the treatment for small kidney stones?
NSAIDs
Opiate
Alpha blocker (if expected to pass spontaneously)
What signs would indicate urgent treatment for renal calculi required?
Pain unrelieved
Pyrexia
Persistent nausea/vomiting
High-grade obstruction
What is the treatment for significant renal calculi?
Ureteric stent or stone fragmentation/removal if no infection
Percutaneous nephrostomy for infected hydronephrosis: drain infected urine first, deal with stone later
What are the causes of frank haematuria?
Infection
Stones
Tumours
Benign prostatic hyperplasia (BPH)
Polycystic kidneys
Trauma
Coagulation/platelet deficiencies
What is the most common cause of haematuria?
Infection
What treatment should be used if a patient is passing clots followed by an inability to urinate?
3-way irrigating haematuria catheter to perform bladder washout and remove clots
When is torsion of spermatic cord most common?
Puberty
How does testicular torsion present?
Sudden onset pain
May be predisposed by previous episodes of self-limiting pain
May be nauseous
Referred pain to abdomen
Usually spontaneous, but can be brought on by trauma or sports
What is the treatment for testicular torsion?
2 or 3-point fixation with fine non-absorbable sutures
If testis necrotic then remove
MUST fix contralateral side (bell clapper deformity)
What imaging is used to investigate testicular torsion?
Doppler ultrasound
What signs on examination indicate testicular torsion?
Testis high in scrotum
Transverse lie
Absence of cremasteric reflex
Which testicular pathology is indicated by a ‘blue dot’ sign?
Testicular appendage torsion
What is epididymitis?
Inflammation of the epididymis at the back of the testicle
What symptoms are more likely to be present in epididymitis that would distinguish it from testicular torsion?
Dysuria
Fever
What may be in the history of a patient presenting with epididymitis?
UTI
Urethritis
Catheterization/instrumentation
What would be seen on examination and imaging with epididymitis?
Cremasteric reflex present
Pyuria
Doppler – swollen epididymis, increased bloodflow
What investigations should be sent off with epididymitis?
Urine for culture
PCR for chlamydia
What is the treatment for epididymitis?
Analgesia and scrotal support
Bed rest
Ofloxacin 400mg/day for 14 days
What is paraphimosis?
Painful swelling of the foreskin distal to a phimotic ring
How does paraphimosis often occur?
Often happens after foreskin retracted for catheterization or cystoscopy and staff member forgets to replace it in its natural position
What is the treatment for paraphimosis?
Iced glove, granulated sugar for 1-2hrs, multiple punctures in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit
What is the diagnosis here?
Paraphimosis
What is priapism?
Prolonged erection (> 4hrs), often painful and not associated with sexual arousal
How can priapism be classed?
Ischaemic
Non-ischaemic
What is the cause of ischaemic priapism?
Vascular stasis in penis and decreased venous outflow, a true compartment syndrome
What signs on examination would indicate an ischaemic priapism?
Corpora cavernosa are rigid and tender, penis often painful
What is the pathology in non-ischaemic priapism?
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
How can priapism be diagnosed?
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
How is non-ischaemic priapism treated?
Observe, may resolve spontaneously
Selective arterial embolization with non-permanent materials
What is Fournier’s gangrene?
A form of necrotizing fasciitis occurring about the male genitalia
Most commonly arises from skin, urethra or rectal region
What are some predisposing factors to Fournier’s gangrene?
Diabetes
Local trauma
Periurethral extravasation
Perianal infection
How does Fournier’s gangrene present?
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
What increases mortality in Fournier’s?
Mortality 20% increased in alcoholics and diabetics
What is the treatment for Fournier’s?
Antibiotics and surgical debridement
What is emphysematous pyelonephritis?
An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens
What is the most common causative organism in emphysematous pyelonephritis?
E. Coli
In which patients does emphysematous pyelonephritis usually occur?
Diabetic patients
Associated with ureteric obstruction
How does emphysematous pyelonephritis present?
Fever
Vomiting
Flank pain
What signs on imaging would indicate emphysematous pyelonephritis?
Gas on Xray
CT to see extent of emphysematous process
How is emphysematous pyelonephritis usually treated?
Nephrectomy
How does a perinephric abscess occur?
From rupture of an acute cortical abscess into the perinephric space
From haematogenous seeding from sites of infection
How does perinephric abscess present?
Insidious onset, approx 33% not pyrexial
Flank mass in 50%
Pyruria
What blood tests are raised in perinephric abscess?
White cell count
Serum createnine
What imaging is used in perinephric abscess?
CT
What is the treatment for perinephric abscess?
Antibiotics and percutaneous or surgical drainage
What is class 1 renal trauma?
Haematoma:
Subcapsular
Non-expanding
No parenchymal laceration
What is class 2 renal trauma?
Laceration <1cm parenchymal depth without urinary extravasation
What is class 3 renal trauma?
>1cm depth, no collecting system rupture or extravasation
What is class 4 renal trauma?
Laceration through cortex, medulla and collecting system
Main arterial/venous injury with contained haemorrhage
What is class 5 renal trauma?
Shattered kidney
Avulsion of hilum, devascularizing kidney
What are the indications for renal imaging following trauma?
Frank haematuria in adult
Frank or occult haematuria in child
Occult haematuria + shock (systolic <90mmHg at any point)
Penetrating injury with any degree of haematuria
What imaging is used to view the kidneys following trauma?
Contrast CT
What fracture is bladder injury commonly associated with?
Pelvic fracture
How does bladder injury present?
Suprapubic/abdominal pain
Inability to void
Suprapubic tenderness
Lower abdominal bruising
Guarding/rigidity
Diminished bowel sounds
What sign on imaging indicates extraperitoneal injury?
Flame-shaped collection of contrast in pelvis
What would indicate urethral injury?
Blood at external urethral meatus
Catheter doesn’t pass easily
What is the treatment for extraperitoneal injury?
Large-bore catheter
Antibiotics
Repeat cystogram in 14 days
What fracture is a posterior urethral injury associated with?
Fracture of pubic rami
What would indicate a posterior urethral injury on examination?
Blood at meatus
Inability to urinate
Palpably full bladder
“High-riding” prostate
Butterfly perineal haematoma
What imaging is used to investigate posterior urethral injury?
Retrograde urethrogram
What is the treatment for posterior urethral injury?
Suprapubic catheter
Delayed reconstruction after at least 3 months
How does testicular injury present?
Exquisite pain
Nausea
Swelling / bruising variable
What imaging is used to investigate testicular injury?
Ultrasound to assess integrity/vascularity
What is the treatment for testicular injury?
Early exploration/repair improves testis salvage, reduces convalescence, better preserves fertility and hormonal function
