Urological Emergencies Flashcards
Presentation of acute urinary retention
Inability to urinate with increasing pain
What is acute urinary retention a complication of?
BPH
Treatment of acute urinary retention?
Catheterisation
If painful retention with
Trial without catheter (TWOC)
What should be prescribed before TWOC for best chance of success?
Uroselective alphablocker (Alfuzosin, Tamsulosin)
Why do patients get postobstructive diuresis?
Solute diuresis (retained irea, sodium & water) + defect in concentrating ability of kidney
How long does post-obstructive diuresis take to resolve?
Approx. 24 hrs
Potential diagnosis of loin pain outwith urinary tract
AAA
Muscular pain
What causes pain in ureteric colic secondary t calculus?
Pain mediated by prostaglandins released by ureter in response to obstruction
Treatment of ureteric colic
NSAID +/- opiate
Alphablocker (tamsulosin) for small stones that are expected to pass
What are the indications to treat ureteric colic urgently
Pain unrelieved
Pyrexia
Persistant nausea/vomiting
High-grade obstruction
Treatment of urgent stones in the abscence of infection
Ureteric stent or stone fragmentation/removal
Treatment for infected hydronephrosis
Percutaneous nephrostomy
Causes of frank haematuria
Infection Stones Tumours BPH Polycystic kidneys Trauma Coagulation/platelet deficiencies
Investigation of frank haematuria?
CT urogram + cystoscopy
Causes of acute scrotal pain
Torsion of spermatic cord Torsion of appendix testis Epidymitis/epididymo-orchitis Inguinal hernia Hydrocoele Trauma/insect bite Dermatological lesions Inflammatory vasculitis Tumour
When is torsion of the spermatic most common?
Puberty
Presentation of torsion fo spermatic cord
Sudden onset pain
(sometimes previous episodes of self-limiting pain)
Referra of pain to lower abdomen
May be nausea/vomtiting
Examination findings of testicular torsion
Testis high in scrotum
Transverse lie
Abscence of cremasteric reflex
(Acute hydrocoele + oedema may obliterate landmarks)
Investigation of testicular torsion
Doppler USS
Treatment of testicular torsion
Prompt exploration (
Why must the contralateral side be fixed in testicular torsion
Bell clapper deformity
What is the blue dot sign indicative of?
Torsion of appendage of testis
If there is a torsion of the appendage of testis is the cremasteric reflex present?
Yes
What features of a history would suggest epididymitis rather than testicular torsion?
Hx of UTI, uretheritis, catherterization/instrumentation
Examination findings of epidiymitis
Cremasteric refle present
Pyuria
Doppkler findings od epididymitis
Swollen epididymis
Increased blood flow
Investigations for epididymitis
urine for culture + Chlamydia PCR
Treatment of epididymitis
Analgesia + scrotal support
Ofloxacin for 14 days
s idiopathic scrotal oedema associated with erythema?
Not usually
What is paraphimosis?
Painful swelling of the foreskin distal to a phimotic ring
What does paraphimosis usually occur after?
Foreskin retracted for surgery or ytoscopy and staff member forgets to replace it in its natural replacement
Treatment of paraphimosis
Iced glove
Granulated sugar for 1-2 hrs
Multiple punctures in oedematous skin
What is priapism?
Prolonged erection (>4hrs) often painful and not asociated with sexual arousal
Causes of paraphimosis
Intracorporeal injection for ED
Trauma
Haematologic dyscrasias
Neurological conditions
Pathogenesis of ischaemic (low flow) paraphimosis
Vascular stasis in penis - decreased venous outflow - compartment syndrome
Pathogenesis of non-ischaemic (high flow) paraphimosis
Traumatic disruption of penile vasculature results in unregulated blood entry
How can different types of paaphimosis be distinguished
Aspirated blood
Duplex USS
Treatment of ischaemic paraphimosis
Apiraation +/_ irrigation with saline
Injection of alpha-agonist (e.g. phenyl epinephrine) Surgical shunt
Treatment for very delayed presentation of ischaemic priapism
Consider immediate placement of penile prosthesis
Treatment of non-ischaemic priapism
Observe - may resolve spontaneously
What is Fourneirs gangrene?
A form of necrotizing fasciitis occuring about the male genitalia
Predisposing factors to fourneir’s gangrene
Diabetes
Local trauma
Periurethral etravasation
Perianal infection
What does fourniers gangrene start as?
Cellulitis (swollen, erythematous, tednder, marked pain, fever, systemic toxicity)
Presentation of Fourneir’s gangrene?
Swelling + crepitus of scorum
Dark purple aras
often marked toxicity out of proporion of local findgins
Investigations of Fourneir’s gangrene
X-ray or USS (confirm gas is tissues)
Treatment of Fourneir’s gangrene
Antibiotics + surgical debridement
Mortality from Fournier’s gangrene is 20% higher in which 2 groups
Diabetics
Alcoholics
What is emphysematous pyelonephritis?
An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens
What is most common causal organism in emphysematous pyelonephritis?
E. coli
Why group is most prone to emphysematous pyelonephritis?
Diabetics
What is emphysematous pyelonephritis often associated with?
Ureteric obstruction
Clinical presentation of emphysematous pyelonephritis
Fever
Vomiting
Flank pain
Investigations for emphysematous pyelonephritis
X-ray (see gas_
CT (defines extent of ephysematous process)
Treatment of emphysematous pyelonephritis
Often nephrectomy
What is the most likely causes of perinephric abscess?
Rupture of acute cortical abscess into the perinephric space OR haematogenous seeding from sites of infection
Investibgation for perinephric abscess
CT
will also be high WCC, high serum creatinine, pyuria
Treatment of perinephric abscess
Antibiotics + percutaneous or surgical drainage
What is grade I renal trauma?
Haematoma, subcapsular, non-expanding, no parechymal laceration
What is grade II renal trauma?
Laceration
What is grade III renal truma?
> 1cm depth of parenchymal laceration, no collecting system rupture of extravasation
What is grade IV renal trauma?
Laceration through corte, medulla and collecting system
Main arterial/venous injury with contained haemorrhage
What is grade V renal trauma?
Shattered kidney
Avulsion of hilum, devascularizing kidney
Indications for imaging in renal trauma
Frank haematuria in adult
Frank or occult haematuria in child
Occult haematuria + shock
Penetrating injury with any degree of haematuria
What is the first line investigation for renal truma
CT with contrast
What would indicate that surgery is needed in renal trauma?
Persistent renal bleeding, expanding perirenal haematoma, pulsatile perirenal haematoma, urinary extravasation, non-viable tissue, incomplete staging
Which fracture is bladder injury commonly associated with?
Pelvic fracture
Clinical presentation of bladder injry
Suprapubic/abdominal pain Inability to void Suprapubic tenderness Lower abdo bruising Guarding/rigidity Diminished bowel sounds
Imaging for bladder injury
CT cystography
Management of bladder injury
Large bore catheter
Antibiotics
Repeat cystogram in 14 days
What is posterior urethral injury often associated with?
Fracture of pubic rami
Which part of the urethra is most prone to injury
Bulbomembranous junction
Clinical findings of 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 months
What is the most common cause of penile fracture?
Sex buckling injury as penis slips out of agina and strikes pubis
Clinical presentation of penile fracture
Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling
Treatment of penile fracture
Prompt exploration & repair
Circumcision incision with degloving to expose all 3 compartments
Investigaion of choice for testicular injury
USS to asses integrity/vascularity
