Urological emergencies Flashcards
Acute urinary retention occurs as a complication of what?
Benign prostatic hyperplasia
Define acute urinary retention
Inability to urinate with increasing pain
Make a list of factors which are associated with the aetiology of acute urinary retention
Alcohol Prostate infection Prostate infarction Excessive fluid intake Bladder over distention
How can you categorise acute urinary retention?
Spontaneous
Precipitated
List the precipitating factors for acute urinary retention
Non-prostatic surgery Medications (anti-cholinergic, sympathomimetric) Urethral instrumentation Catheterisation Anaesthesia
How is acute urinary retention managed?
Catheterisation
When should a trial without catheter be implemented in acute urinary retention? What improves success rates?
Painful retention with less than 1 litre residue AND normal serum electrolytes
Prescription of uroselective alpha blockers
List two uroselective alpha blockers
Alfuzosin
Tamsulosin
Who typically gets post-obstructive diuresis? List its associations
Patients with chronic bladder outflow obstruction
- Uraemia
- Congestive cardiac failure
- Hypertension
- Oedema
What causes post-obstructive diuresis?
Retention of urea, water and sodium (solute diuresis)
Problem with kidney’s concentrating of urine
How should post-obstructive diuresis be managed?
Monitor fluid balance (>200ml/l is worrying but should resolve within two days )
Severe cases require IV fluids and sodium replacement
Is haematuria a sign of acute urinary retention?
No - the whole point of retention is that you’re not passing urine HOWEVER post catheterisation haematuria is fairly common and self resolving
List some non urinary causes of loin pain
AAA
Appendicitis
Pancreatitis
Ectopic pregnancy
What does urinary colic occur secondary to? What mediates the pain?
Renal calculus
Prostaglandins released by the ureters when obstructed
How is renal colic managed?
Analgesia (NSAIDs +/- opiates) Alpha blocker (tamsulosin) for small stones expected to pass
Categorise how likely renal stones are to pass according to size
unlikely to pass spontaneously
If a stone hasn’t passed within 2 weeks then it is unlikely to pass spontaneously. T/F
False - within a month
When should renal colic be managed acutely?
Fever
Persistent nausea and vomiting
Unrelieved pain
High grade obstruction
How should renal colic be managed acutely?
Non infected - stent / stone fragmentation
Infected hydronephrosis - percutaneous nephrostomy
List some causes of frank haematuria
Infection Stones Tumours Benign prostatic hyperplasia Polycystic kidneys Trauma Coagulopathy
If there is clot retention in haematuria, what type of catheter should be used?
Three way irrigating haematuria catheter
How should haematuria be investigated?
CT urogram & cytoscopy
List some causes of acute scrotum
Torsion (spermatic cord, appendix) Tumour Epididymitis Epididymo-orchitis Inguinal hernia Hydrocoele Trauma Insect bite/dermatological Inflammatory vasculitis
What age group typically presents with torsion of the spermatic cord?
Pubertal adolescents
What features of a history point towards torsion of the spermatic cord?
Sudden onset severe pain May be woken from sleep History of trauma/sports History of previous self limiting episodes Referred pain to abdomen Nausea and vomiting
What will be found on examination of someone with testicular torsion?
High riding testis
Transverse testi
Absent cremasteric reflex
What may be associated with testicular torsion?
Acute hydrocoele/oedema
How is suspected testicular torsion investigated?
Doppler USS can determine blood supply but first line is surgical exploration
How is testicular torsion managed?
Removal of necrotic tissue
2/3 point fixation in correct position if tissue preserved
Fix contralateral side
What is a bell clapper deformity?
Congenital deformity where testis is not properly attached to scrotum and so lies in horizontal position (higher risk of torsion)
What features of a history point towards testicular appendix torsion?
Identical to testicular torsion although MAY be more insidious onset
What may be found on examination of someone with testicular appendix torsion?
Localised tenderness to upper pole of testis
Blue dot sign
Mobile testis
Present cremasteric reflex
How is torsion of the testicular appendix managed?
Will spontaneously resolve without surgery
How common is epididymitis in children?
Rare
What features of a history point towards epididymitis?
As for torsion Dysuria Pyrexia History of - UTI - urethritis - instrumentation/catheterisation
What should be found on examination of a patient with epididymitis?
Present cremasteric reflex
Pyuria (urinalysis)
How should suspected epididymitis be investigated?
Doppler USS (swollen epididymis + inc blood flow)
Urine culture
Chlamydial PCR
How is epididymitis managed?
Analgesia
Scrotal support
Bed rest
Ofloxacin 400mg/day 14 days
How does idiopathic scrotal oedema present?
Odema No erythema No fever Minimal tenderness Pruritis
How is idiopathic scrotal oedema managed?
Self limiting
What is paraphimosis?
Painful swelling of the foreskin distal to phimotic ring
What is the common iatrogenic cause of paraphimosis?
Retraction of foreskin not relocated into its natural position after catheterisation/cytoscopy
How can paraphimosis be managed?
Iced glove & granulated sugar
Puncture in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit
What is priapism?
Prolonged erection +/- pain often not associated with arousal (>4hr)
What are the causes of priapsim?
Iatrogenic for erectile dysfunction Idiopathic Neurological Trauma (penis or perineum) Haematologic dyscrasias (e.g sickle cell)
How can you classify priapism?
Ischaemic and non ischaemic
What is ischaemic priapism?
Veno-occlusive pathology or poor perfusion
How does ischaemic priapism present?
Corpus cavernosa rigid and tender
Pain
How does ischaemic priapsm occur?
Vascular stasis and thus decreased venous outflow (i.e compartment syndrome)
What is non-ischaemic priapism?
Arterial pathology or high flow
How does non-ischaemic priapsm occur?
Traumatic disruption of vasculature causes unregulated blood entry and thus filling of the corpora
Where does a fistula form in non-ischaemic priapsm?
Between cavernous artery and lacunar spaces (blood by passes normal helicine arteriolar bed)
How is priapsm investigated?
Aspirate blood from corpus cavernosum
Colour duplex USS
How would aspirated blood from the corpus cavernosum differ between ischaemic and non-ischaemic priapsm?
Ischaemic - dark blood (high CO2 low O2)
Non ischaemic - bright blood (low CO2 high O2)
What would a colour duplex USS show in priapsm?
Ischaemic - minimal/absent flow in cavernosal arteries
Non ischaemic - normal to high flow
How is ischaemic priapsm treated?
Aspirate +/- irrigate with saline
Inject alpha agonist (phenylephrine)
Surgical shunt
When will ischaemic priapsm not respond to treatment?
48-72 hours after onset - necrosis
Can place penile prosthesis
How is non-ischaemic priapsm treated?
Observe for spontaneous resolution
Selective arterial embolisation with non permanent materials
What is fournier’s gangrene?
Necrotising fasciitis of the male genitalia
Where does fournier’s gangrene originate from?
Skin
Urethral/rectal region
What are the predisposing factors to fourniers gangrene?
Diabetes
Trauma
Periurethral extravasation
Perianal infection
What pathogens usually cause fournier’s gangrene?
Coliforms
Anaerobes
How does fournier’s gangrene present?
Cellulitis (erythema, swelling, tenderness) –> Severe pain, fever and systemic upset
Swelling & crepitus of scrotum
Dark purple areas
Findings seem out of proportion to what can be clinically seen
How might fournier’s gangrene be investigated?
Plain x-ray
USS
Looking for gas in tissues
How is fournier’s gangrene treated?
Antibiotics and debridement
Who dies more often from fournier’s gangrene?
Diabetics
Alcoholics
What is emphysematous pyelonephritis?
Acute necrotising parenchymal & perirenal infection caused by gas forming uropathogens
What is the commonest cause of emphysematous pyelonephritis?
E.coli
How does emphysematous pyelonephritis present?
Fever
Vomiting
Flank pain
Who is at high risk of emphysematous pyelonephritis? What is it associated with?
Diabetics
Ureteric obstruction
How is emphysematous pyelonephritis diagnosed?
KUB (plain film) will show gas
CT shows extent of emphysema
How is emphysematous pyelonephritis treated?
Nephrectomy commonly required
What causes perinephric abscess?
Rupture of acute cortical abscess into perinephric space
Haematogenous seeding from sites of infection
How does perinephric abscess present?
Insidious onset
With/without pyrexia
Mass in flank
What are the characteristic blood results of a perinephric abscess? What urine result?
High white cell count
High serum creatinine
Pyuria
How is a perinephric abscess investigated?
CT
How is a perinephric abscess treated?
Antibiotics + percutaneous/surgical drainage
Describe the classifications of renal trauma
Type I - haematoma, subcapsular, non expanding, no parenchymal laceration
Type II - laceration 1cm, no collecting system rupture or extravasation
Type IV - laceration through cortex, medulla and collecting system, main arterial/venous injury with contained haemorrhage
Type V - shattered kidney, avulsion of hilum, devascularisation
What are the indications for imaging renal trauma?
Gross haematuria in adult
Gross or microscopic haematuria in child
Microscopic haematuria with shock (
How is kidney trauma investigated?
Contrast CT
How is kidney trauma managed?
Most blunt injuries are non-operatively managed
Angiography/embolisation
What are the indications for surgical management of renal trauma?
Persistant bleeding Expanding haematoma Pulsatile haematoma Extravasation of urine Non-viable tissue Incomplete staging
What is bladder injury associated with?
Pelvic fracture
How does bladder injury present?
Suprapubic/abdominal pain
Inability to void
How does bladder injury present on examination?
Suprapubic tenderness
Lower abdominal bruising
Guarding
Diminished bowel sounds
When bladder injuries are catheterised what will be seen?
Gross haematuria
What is the indication for a retrograde urethrogram?
Blood at the external meatus
Catheter not passing through easily
(suggest urethral injury)
How should bladder injury be investigated?
CT cystography
What will be present on CT scan if there is intraperitoneal bladder injury?
Flame shaped collection of contrast within pelvis
How are bladder injuries managed?
Large bore catheter
Antibiotics
Repeat cystogram in two weeks
When should the bladder be surgically repaired?
Intraperitoneal injury Penetrating injury Bladder neck injury Clots in urine Inadequate urine drainage Open pelvic fracture Bone fragments in bladder
What is posterior urethral injury associated with?
Fractured pubic rami
What is the most vulnerable part of the urethra?
Bulbomembranous junction (between urogenital diaphragm and puboprostatic ligaments)
What are the signs and symptoms of urethral injury?
Blood at meatus Anuria Full bladder High riding prostate (fracture) on PR exam Butterfly perineal haematoma
How is urethral injury investigated?
Retrograde urethrogram
How is urethral injury treated?
Suprapubic catheter
Reconstruction after at least 3 months of healing
When does a penile fracture typically occur?
During intercourse - penis slips from vagina and buckles against pubis
What is the typical history of a penile fracture?
Cracking or popping sound (jesus fucking christ) –> pain
Rapid detumescence
Swelling
Discolouration
Is urethral injury associated with penile fracture?
Yes about 20% of cases have urethral injury - frank haematuria and blood at external meatus
How are penile fracture managed?
Exploration and repair (circumcision excision and degloving)
How does testicular injury present?
Pain + nausea
Swelling
Bruising
How are testicular injuries investigated?
USS (assess integrity and vascularity)
How are testicular injuries managed?
Early exploration and repair - decreases removal and convalesecne , increases preservation of fertility and hormonal function
