Urological Emergencies Flashcards
how does acute urinary retention present?
inability to urinate with increasing pain
what common condition can cause acute urinary retention?
BPH
what can acute urinary retention be separated in to?
spontaneous and precipitated
when would acute urinary retention be precipitated?
- non-prostate related surgery
- catheterization
- anaesthesia
- medication with sympathomimetric or anticholinergeric effects
when should trial without catheter be used in acute urinary retention?
if painful retention with
what can be prescribed to improve chance of successful voiding before trial without catheter in acute urinary retention?
prescribing a uroselective alphablocker
examples of uroselective alpha-blocker?
Tamsulosin, alfuzosin
in what patients does post-obstructive diuresis often present in?
patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF, hypertension
what is the diuresis due to in post-obstructive diuresis?
due to solute diuresis (retained urea, sodium and water) and defect in concentrating ability of kidney
in post-obstructive diuresis what should you make sure urine output doesnt exceed?
> 200 ml/hr
how long does post-obstructive diuresis take to resolve?
24-48 hours
what treatment may be required in post-obstructive diuresis in a severe case?
IV fluid and sodium replacement
most common cause for ureteric colic?
calculus
what mediates the pain in ureteric colic?
release of prostaglandins by ureter in response to obstruction
for a small stone, what is the treatment?
NSAIDS +/- opiate
alpha-blocker
stone expected to pass
what is the chance of a stone
80%
what is the chance of a stone 4-6mm spontaneously passing?
59%
what is the chance of a stone > 6mm spontaneously passing?
21%
intervention is likely required if a ureteric stone hasnt passed within what time length?
a month
what is the best diagnostic investigation when investigating renal calculus ?
non-contrast CT
what are the indications that a renal calculus needs to be treated urgently?
- pain unrelieved
- pyrexia
- persistent nausea/vomitting
- high-grade obstruction
how is a renal stone managed surgically in the absence of infection ?
ureteric stent or stone fragmentation/removal
how is a renal stone managed surgically if there is an infected hydronephrosis?
percutaneous nephrostomy for infected hydronephrosis
at what age is torsion of the spermatic cord most common?
at puberty
how does torsion of the spermatic cord present?
sudden onset of pain, may be nausea/vomitting, lower abdo pain
what can precipitate a torsion of the spermatic cord?
trauma or athletic activity
what will you find on examintion of the teste in a torsion of the spermatic cord?
- testis high in scrotum
- testis lying transversely
- absence of cremasteric reflex
what is the managment of a torsion of the spermatic cord?
urgent surgical exploration.
what happens if a torsion of spermatic cord is not recognised/treated?
irreversible ischaemic injury begins as soon as 4hrs
how may a torsion of appendage present and appear on examintion?
- symptoms variable - may be insidious onset or same as torsion of cord.
- ma have localised tenderness at upper pole and blue dot sign
is the cremasteric reflex present in torsion of appendage?
yes
managment of torsion of appendage?
will resolve spontaneously without surgery
presentation of epididymitis?
similar to torsion. dysuria/pyrexia more common.
is the cremateric reflex present in epididymitis?
reflex present
what can been seen in a doppler of epididymitis?
swollen epididymis, increased bloodflow
what tests should be done in suspected epididymitis?
send urine for culture and chlamydia PCR
what can precipitate epididymitis?
history of UTI, urethritis, catheterization/instrumentation
conservative management of epididymitis?
- analgesia, scrotal support, bed rest
medical managment of epididymitis?
- ofloxacin 400mg/day for 14 days
is idiopathic scrotal oedema usually associated with erythema?
no
what would you expect on examination of idiopathic scrotal odema?
odema around scrotum, no eythema, no fever, minimal tenderness
how is idiopathic scrotal oedema managed?
it is self-limiting
what is paraphimosis?
painful swelling of the foreskin distal to a phimotic ring
when does paraphimosis usually occur?
often happens after foreskin is retracted for catheterization or cystoscopy and staff member forgets to pull foreskin back into its natural position
what is priapism?
prolonged erection (>4hrs) often painful and not associated with sexual arousal
aetiology of priapism?
- intracorporeal injection
- trauma
- haematologic dyscasias
- neurological condition
- idiopathic
classifications of priapism?
ischaemic and non-ischaemic
how does an ischaemic priapism occur?
veno-occlusion or low flow leading to vascular stasis
how do corpora cavernosa feel?
rigid and tender
how does a non-ischaemic priapism occur?
traumatic disruption of penile vasculature resulting in unregulated blood entry and filling of corpora
in non-ischaemic priapism what allows blood to by-pass the normal helicine arteriolar bed?
fistula formation between the cavernous artery and lacunar spaces
how is priapism diagnosed?
aspirate blood from corpus cavernosum
what is the profile of the blood aspirated in an ischaemic priapism?
dark, low oxygen, high carbon dioxide
what is the profile of the blood aspirated in a non-ischaemic priapism?
normal arterial blood
treatment of ischaemic priapism?
aspiration +/- irrigation with saline. injection of alpha-antagonist 100-200 ug every 5-10 mins up to a max of 1000ug- if not resolved : surgical stunt
how is ischaemic priapism treated?
observe, may resolve spontaneously. selective arterial embolization with non-permanent materials
after how many hours of ischaemic priapism will it be unlikely to be helped by intracavernosal treatment?
more than 48-72 hours
for delayed presentation of ischaemic priapism, what could be considered?
immediate placement of a penile prosthesis
what is Fournier’s gangrene?
a form a necrotizing fasciitis occurring about the male genitalia.
where does Fournier’s gangrene most commonly arise from in the male genitalia?
skin, urethra or rectal region
what are the predisposing factors of Fourneir’s gangrene?
- diabetes
- local trauma
- periurethral extravasation
- perianal infection
organisms causing Fourniers gangrene?
usually a mixture of aerobes and anaerobes
what is the presentation of Fourniers gangrene?
- start as cellulitis: swollen, erythematous, tender, pain, fever, systemic upset
what can be seen on examination of Fourniers gangrene?
-swollen, eythematous, tender, marked pain, fever. crepitus of scrotum, dark purple areas.
what investigations can be used to confirm gas in the tissues in Fournier’s gangrene?
plain x-ray and USS
managment of Fournier’s gangrene?
surgical debridement and antibiotics
what is emphysematous pyelonephritis?
an acute necrotizing parenchymal and perirenal infection
what pathogen usually causes emphysematous pyelonephritis?
E.coli
what disease is associated with emphysematous pyelonephritis?
diabetes
what problem is associated with emphysematous pyelonephritis?
ureteric obstruction
how does emphysematous pyelonephritis present?
fever, vomitting, flank pain
what scan is used to define the extend of the emphysematous process in emphysematous pyelonephritis?
CT
what is often required to treat emphysematous pyelonephritis?
nephrectomy
what does a perinephric abscess usually result from?
from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
approx what percentage of patients with perinerphric absess are not pyrexial?
33%
in what percent of patients with a perinephric abscess is there a flank mass?
in 50%
what test results would be expected in peinephric abscess?
high WCC, high serum creatinine, pyuria
management of perinephric abscess?
antibiotics and percutaneous or surgical drainage
in renal trauma, what is a type I classification?
- haematoma, subcapsular, non-expanding, no parenchymal laceration
type II classification in renal trauma?
laceration
type III classification in renal trauma?
> 1cm depth, no collecting system rupture or extravasation
type IV classification in renal trauma?
laceration through cortex, medulla and collecting system. main arterial/venous injury with contained haemorrhage
type V classification in renal trauma?
shattered kidney, avulsion of hilium, devascularized kidney
what type of fracture is commonly associated with bladder injury?
pelvic fracture
what is posterior urethral injury often associated with?
fracture of pubic rami
what fixes the posterior urethra in place?
fixed at urogenital diaphragm and puboprostatic ligaments
what part of the of the posterior urethra is most vulnerable to injury?
bulbomembranous junction
what will you find on examination in urethral injury?
- blood at meatus
- inability to urinate
- palpably full bladder
- high riding prostate
- butterfly perineal haematoma
investigation for urethral injury?
retrograde urethrogram
management of urethral injury?
- suprapubic catheter
- delayed reconstruction after at least 3 months
when does a penile fracture typically happen?
during intercourse - buckling injury when penis slips out of vagina and strikes pubis
what is experienced when a penile fracture occurs?
cracking or popping sound followed by pain, discolouration and swelling
what is there a 20% incidence of in penile fractures?
urethral injury
management of penile fracture?
prompt exploration and repair. circumcision incision with degloving of penis to expose all 3 compartments
how does testicular injury usually present?
exquisite pain and nausea
what investigation is done in testicular injury?
USS to assess integrity/vascularity
managment of testicular injury?
early exploration/repair
