Urological Emergencies

Question 1

Complication of BPH

Inability to urinate with increasing pain

Answer 1

Acute urinary retention

Question 2

What could cause acute urinary retention?

Answer 2

Surgery
Catheterisation
Urethral instrumentation
Anaesthesia
Medication

Question 3

Treatment for acute urinary retention

Answer 3

Catheter

If painful retention with

Question 4

Management of post-obstructive diuresis

Answer 4

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 5

Treatment for acute loin pain (e.g. caused by calculus)

Answer 5

NSAID +/- opiate
Alpha-blocker (Tamsulosin)

Indications to treat urgently:

• pain unrelieved
• pyrexia
• persistent nausea/vomitting
• high grade obstruction

If this is the case then ureteric stent or stone fragmentation/removal if no infection
-PERCUTANEOUS NEPHROSTOMY for infected hydronephrosis

Question 6

Treatment for clot

Answer 6

3-way irrigating haematuria catheter

Question 7

Investigations for frank haematuria

Answer 7

CT urogram and cystoscopy

Question 8

Usually sudden onset of pain, sometimes previous episodes of self-limiting pain
May be nausea/vomiting
May be referral of pain to lower abdomen

Answer 8

Torsion of spermatic cord

Question 9

-testis high in scrotum
transverse lie (lying -transversely instead of up and down)
-absence of cremasteric reflex

Answer 9

Torsion of spermatic cord

Question 10

Absence of which reflex in torsion of spermatic cord?

Answer 10

Absence of cremasteric reflex

Question 11

Blue dot sign

Answer 11

Torsion of appendage

Question 12

Symtpoms of torsion of appendage

Answer 12

Symptoms variable –> may be identical to torsion of cord or insidious onset

May have tenderness at upper pole and “blue dot sign”

Testis should be mobile and CREMASTERIC reflex present

Question 13

Epididymitis

Answer 13

Rare in children
May be difficult to distinguish from torsion
Dysuria / pyrexia more common
Hx of UTI, urethritis, catheterization/instrumentation

Question 14

What should you suspect if pyuria and presentation similar to torsion

Answer 14

Epididymitis

Question 15

Cremasteric reflex present
Suspect if pyuria
Doppler – swollen epididymis, increased bloodflow

Send urine for culture + Chlamydia PCR

Answer 15

Epididymitis

Question 16

What would doppler show in epididymitis?

Answer 16

Swollen spididymis and increased blood flow

Question 17

What investigations should you ask for if epididymis suspected?

Answer 17

Urine for culture and CHLAMYDIA PCR

Question 18

Treatment for epididymitis

Answer 18

Ofloxacin 400mg/day for 14 days

Question 19

Idiopathic scrotal oedema

Answer 19

Self-limiting, unknown cause, not usually associated with scrotal erythema
No fever, tenderness minimal but may be pruritis

Question 20

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

Answer 20

Paraphimosis

Question 21

Painful swelling of the foreskin distal to phimotic ring

Answer 21

Paraphimosis

Question 22

Treatment for paraphimosis

Answer 22

Iced glove, granulated sugar for 1-2hrs, multiple punctures in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit

Question 23

Priapsim

Answer 23

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

Question 24

Classification of priapism

Answer 24

Ischaemic (low flow)
Non-ischaemic (high flow)

Differentiate by aspirating 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

Question 25

Treatment for ischeamic priapism

Answer 25

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

Question 26

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

Answer 26

Fournier’s gangrene

Question 27

What is Fournier’s gangrene?

Answer 27

A form of necrotising fasciits occuring outside male genitalia

Question 28

Investigations for Fournier’s gangrene

Answer 28

Plain x-ray or USS may confirm gas in tissues

Question 29

Who doe emphysematous pyelonephritis usually affect?

Answer 29

Diabetics

Question 30

Infection of the kidneys with gas in/around kidneys

Answer 30

Emphysematous pyelonephritis

Question 31

Organism which usually causes emphysematous pyelonephritis

Answer 31

E. coli

Question 32

High WCC
High serum creatinine
Pyuria

Answer 32

Perinephric abscess

Question 33

Haematoma, subcapsular, non-expanding, no parenchymal laceration

Answer 33

Class I

Question 34

Laceration

Answer 34

Class II

Question 35

> 1cm depth, no collecting system rupture or extravasation

Answer 35

Class III

Question 36

Laceration through cortex, medulla and collecting system

Main arterial/venous injury with contained haemorrhage

Answer 36

Class IV

Question 37

Shattered kidney

Avulsion of hilum, devascularizing kidney

Answer 37

Class V

Question 38

Indications for imaging

Answer 38

Frank haematuria in adult
Frank or occult haematuria in child
Occult haematuria + shock (systolic

Question 39

Suprapubic/abdominal pain and inability to void

Suprapubic tenderness, lower abdominal bruising, guarding/rigidity, diminished bowel sounds

suggests what?

Answer 39

Bladder injury

Question 40

If there is blood at the external meatus or if the catheter doesn’t pass easily through then what should you perform?

Answer 40

Retrograde urethrogram – may well have urethral injury

Question 41

Flame shaped collection of contrast in pelvis

Answer 41

Extraperitoneal injury