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Year 2 > Urological emergencies > Flashcards

Urological emergencies Flashcards

1
Q

Acute urinary retention occurs as a complication of what?

A

Benign prostatic hyperplasia

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2
Q

Define acute urinary retention

A

Inability to urinate with increasing pain

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3
Q

Make a list of factors which are associated with the aetiology of acute urinary retention

A 
Alcohol
Prostate infection
Prostate infarction
Excessive fluid intake
Bladder over distention
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4
Q

How can you categorise acute urinary retention?

A

Spontaneous

Precipitated

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5
Q

List the precipitating factors for acute urinary retention

A 
Non-prostatic surgery
Medications (anti-cholinergic, sympathomimetric)
Urethral instrumentation 
Catheterisation 
Anaesthesia
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6
Q

How is acute urinary retention managed?

A

Catheterisation

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7
Q

When should a trial without catheter be implemented in acute urinary retention? What improves success rates?

A

Painful retention with less than 1 litre residue AND normal serum electrolytes
Prescription of uroselective alpha blockers

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8
Q

List two uroselective alpha blockers

A

Alfuzosin

Tamsulosin

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9
Q

Who typically gets post-obstructive diuresis? List its associations

A

Patients with chronic bladder outflow obstruction

  • Uraemia
  • Congestive cardiac failure
  • Hypertension
  • Oedema
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10
Q

What causes post-obstructive diuresis?

A

Retention of urea, water and sodium (solute diuresis)

Problem with kidney’s concentrating of urine

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11
Q

How should post-obstructive diuresis be managed?

A

Monitor fluid balance (>200ml/l is worrying but should resolve within two days )
Severe cases require IV fluids and sodium replacement

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12
Q

Is haematuria a sign of acute urinary retention?

A

No - the whole point of retention is that you’re not passing urine HOWEVER post catheterisation haematuria is fairly common and self resolving

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13
Q

List some non urinary causes of loin pain

A

AAA
Appendicitis
Pancreatitis
Ectopic pregnancy

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14
Q

What does urinary colic occur secondary to? What mediates the pain?

A

Renal calculus

Prostaglandins released by the ureters when obstructed

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15
Q

How is renal colic managed?

A 
Analgesia (NSAIDs +/- opiates)
Alpha blocker (tamsulosin) for small stones expected to pass
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16
Q

Categorise how likely renal stones are to pass according to size

A

unlikely to pass spontaneously

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17
Q

If a stone hasn’t passed within 2 weeks then it is unlikely to pass spontaneously. T/F

A

False - within a month

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18
Q

When should renal colic be managed acutely?

A

Fever
Persistent nausea and vomiting
Unrelieved pain
High grade obstruction

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19
Q

How should renal colic be managed acutely?

A

Non infected - stent / stone fragmentation

Infected hydronephrosis - percutaneous nephrostomy

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20
Q

List some causes of frank haematuria

A 
Infection
Stones
Tumours 
Benign prostatic hyperplasia 
Polycystic kidneys 
Trauma
Coagulopathy
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21
Q

If there is clot retention in haematuria, what type of catheter should be used?

A

Three way irrigating haematuria catheter

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22
Q

How should haematuria be investigated?

A

CT urogram & cytoscopy

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23
Q

List some causes of acute scrotum

A 
Torsion (spermatic cord, appendix)
Tumour
Epididymitis
Epididymo-orchitis
Inguinal hernia 
Hydrocoele 
Trauma
Insect bite/dermatological
Inflammatory vasculitis
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24
Q

What age group typically presents with torsion of the spermatic cord?

A

Pubertal adolescents

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25
Q

What features of a history point towards torsion of the spermatic cord?

A 
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
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26
Q

What will be found on examination of someone with testicular torsion?

A

High riding testis
Transverse testi
Absent cremasteric reflex

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27
Q

What may be associated with testicular torsion?

A

Acute hydrocoele/oedema

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28
Q

How is suspected testicular torsion investigated?

A

Doppler USS can determine blood supply but first line is surgical exploration

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29
Q

How is testicular torsion managed?

A

Removal of necrotic tissue
2/3 point fixation in correct position if tissue preserved
Fix contralateral side

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30
Q

What is a bell clapper deformity?

A

Congenital deformity where testis is not properly attached to scrotum and so lies in horizontal position (higher risk of torsion)

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31
Q

What features of a history point towards testicular appendix torsion?

A

Identical to testicular torsion although MAY be more insidious onset

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32
Q

What may be found on examination of someone with testicular appendix torsion?

A

Localised tenderness to upper pole of testis
Blue dot sign
Mobile testis
Present cremasteric reflex

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33
Q

How is torsion of the testicular appendix managed?

A

Will spontaneously resolve without surgery

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34
Q

How common is epididymitis in children?

A

Rare

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35
Q

What features of a history point towards epididymitis?

A 
As for torsion
Dysuria
Pyrexia 
History of 
  - UTI
  - urethritis
  - instrumentation/catheterisation
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36
Q

What should be found on examination of a patient with epididymitis?

A

Present cremasteric reflex

Pyuria (urinalysis)

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37
Q

How should suspected epididymitis be investigated?

A

Doppler USS (swollen epididymis + inc blood flow)
Urine culture
Chlamydial PCR

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38
Q

How is epididymitis managed?

A

Analgesia
Scrotal support
Bed rest
Ofloxacin 400mg/day 14 days

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39
Q

How does idiopathic scrotal oedema present?

A 
Odema 
No erythema
No fever 
Minimal tenderness
Pruritis
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40
Q

How is idiopathic scrotal oedema managed?

A

Self limiting

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41
Q

What is paraphimosis?

A

Painful swelling of the foreskin distal to phimotic ring

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42
Q

What is the common iatrogenic cause of paraphimosis?

A

Retraction of foreskin not relocated into its natural position after catheterisation/cytoscopy

43
Q

How can paraphimosis be managed?

A

Iced glove & granulated sugar
Puncture in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit

44
Q

What is priapism?

A

Prolonged erection +/- pain often not associated with arousal (>4hr)

45
Q

What are the causes of priapsim?

A 
Iatrogenic for erectile dysfunction
Idiopathic
Neurological 
Trauma (penis or perineum)
Haematologic dyscrasias (e.g sickle cell)
46
Q

How can you classify priapism?

A

Ischaemic and non ischaemic

47
Q

What is ischaemic priapism?

A

Veno-occlusive pathology or poor perfusion

48
Q

How does ischaemic priapism present?

A

Corpus cavernosa rigid and tender

Pain

49
Q

How does ischaemic priapsm occur?

A

Vascular stasis and thus decreased venous outflow (i.e compartment syndrome)

50
Q

What is non-ischaemic priapism?

A

Arterial pathology or high flow

51
Q

How does non-ischaemic priapsm occur?

A

Traumatic disruption of vasculature causes unregulated blood entry and thus filling of the corpora

52
Q

Where does a fistula form in non-ischaemic priapsm?

A

Between cavernous artery and lacunar spaces (blood by passes normal helicine arteriolar bed)

53
Q

How is priapsm investigated?

A

Aspirate blood from corpus cavernosum

Colour duplex USS

54
Q

How would aspirated blood from the corpus cavernosum differ between ischaemic and non-ischaemic priapsm?

A

Ischaemic - dark blood (high CO2 low O2)

Non ischaemic - bright blood (low CO2 high O2)

55
Q

What would a colour duplex USS show in priapsm?

A

Ischaemic - minimal/absent flow in cavernosal arteries

Non ischaemic - normal to high flow

56
Q

How is ischaemic priapsm treated?

A

Aspirate +/- irrigate with saline
Inject alpha agonist (phenylephrine)
Surgical shunt

57
Q

When will ischaemic priapsm not respond to treatment?

A

48-72 hours after onset - necrosis

Can place penile prosthesis

58
Q

How is non-ischaemic priapsm treated?

A

Observe for spontaneous resolution

Selective arterial embolisation with non permanent materials

59
Q

What is fournier’s gangrene?

A

Necrotising fasciitis of the male genitalia

60
Q

Where does fournier’s gangrene originate from?

A

Skin

Urethral/rectal region

61
Q

What are the predisposing factors to fourniers gangrene?

A

Diabetes
Trauma
Periurethral extravasation
Perianal infection

62
Q

What pathogens usually cause fournier’s gangrene?

A

Coliforms

Anaerobes

63
Q

How does fournier’s gangrene present?

A

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

64
Q

How might fournier’s gangrene be investigated?

A

Plain x-ray
USS

Looking for gas in tissues

65
Q

How is fournier’s gangrene treated?

A

Antibiotics and debridement

66
Q

Who dies more often from fournier’s gangrene?

A

Diabetics

Alcoholics

67
Q

What is emphysematous pyelonephritis?

A

Acute necrotising parenchymal & perirenal infection caused by gas forming uropathogens

68
Q

What is the commonest cause of emphysematous pyelonephritis?

A

E.coli

69
Q

How does emphysematous pyelonephritis present?

A

Fever
Vomiting
Flank pain

70
Q

Who is at high risk of emphysematous pyelonephritis? What is it associated with?

A

Diabetics

Ureteric obstruction

71
Q

How is emphysematous pyelonephritis diagnosed?

A

KUB (plain film) will show gas

CT shows extent of emphysema

72
Q

How is emphysematous pyelonephritis treated?

A

Nephrectomy commonly required

73
Q

What causes perinephric abscess?

A

Rupture of acute cortical abscess into perinephric space

Haematogenous seeding from sites of infection

74
Q

How does perinephric abscess present?

A

Insidious onset
With/without pyrexia
Mass in flank

75
Q

What are the characteristic blood results of a perinephric abscess? What urine result?

A

High white cell count
High serum creatinine

Pyuria

76
Q

How is a perinephric abscess investigated?

A

CT

77
Q

How is a perinephric abscess treated?

A

Antibiotics + percutaneous/surgical drainage

78
Q

Describe the classifications of renal trauma

A

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

79
Q

What are the indications for imaging renal trauma?

A

Gross haematuria in adult
Gross or microscopic haematuria in child
Microscopic haematuria with shock (

80
Q

How is kidney trauma investigated?

A

Contrast CT

81
Q

How is kidney trauma managed?

A

Most blunt injuries are non-operatively managed

Angiography/embolisation

82
Q

What are the indications for surgical management of renal trauma?

A 
Persistant bleeding
Expanding haematoma
Pulsatile haematoma
Extravasation of urine 
Non-viable tissue
Incomplete staging
83
Q

What is bladder injury associated with?

A

Pelvic fracture

84
Q

How does bladder injury present?

A

Suprapubic/abdominal pain

Inability to void

85
Q

How does bladder injury present on examination?

A

Suprapubic tenderness
Lower abdominal bruising
Guarding
Diminished bowel sounds

86
Q

When bladder injuries are catheterised what will be seen?

A

Gross haematuria

87
Q

What is the indication for a retrograde urethrogram?

A

Blood at the external meatus
Catheter not passing through easily
(suggest urethral injury)

88
Q

How should bladder injury be investigated?

A

CT cystography

89
Q

What will be present on CT scan if there is intraperitoneal bladder injury?

A

Flame shaped collection of contrast within pelvis

90
Q

How are bladder injuries managed?

A

Large bore catheter
Antibiotics
Repeat cystogram in two weeks

91
Q

When should the bladder be surgically repaired?

A 
Intraperitoneal injury
Penetrating injury
Bladder neck injury
Clots in urine 
Inadequate urine drainage
Open pelvic fracture
Bone fragments in bladder
92
Q

What is posterior urethral injury associated with?

A

Fractured pubic rami

93
Q

What is the most vulnerable part of the urethra?

A

Bulbomembranous junction (between urogenital diaphragm and puboprostatic ligaments)

94
Q

What are the signs and symptoms of urethral injury?

A 
Blood at meatus
Anuria
Full bladder
High riding prostate (fracture) on PR exam
Butterfly perineal haematoma
95
Q

How is urethral injury investigated?

A

Retrograde urethrogram

96
Q

How is urethral injury treated?

A

Suprapubic catheter

Reconstruction after at least 3 months of healing

97
Q

When does a penile fracture typically occur?

A

During intercourse - penis slips from vagina and buckles against pubis

98
Q

What is the typical history of a penile fracture?

A

Cracking or popping sound (jesus fucking christ) –> pain
Rapid detumescence
Swelling
Discolouration

99
Q

Is urethral injury associated with penile fracture?

A

Yes about 20% of cases have urethral injury - frank haematuria and blood at external meatus

100
Q

How are penile fracture managed?

A

Exploration and repair (circumcision excision and degloving)

101
Q

How does testicular injury present?

A

Pain + nausea
Swelling
Bruising

102
Q

How are testicular injuries investigated?

A

USS (assess integrity and vascularity)

103
Q

How are testicular injuries managed?

A

Early exploration and repair - decreases removal and convalesecne , increases preservation of fertility and hormonal function

Year 2 (72 decks)

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