Urological Emergencies Flashcards
What is acute urinary retention a complication of
BPH
What is acute urinary retention
Inability to urinate with increasing pain
What are some of the causes of acute urinary retention
Prostate infection bladder overdistension excessive fluid intake alcohol prostatic infarction
What is meant by precipitated urinary retention
Triggering event- non prostate related surgery, catheterisation or urethral instrumentation
anaesthesia
medication with sympathomimetic or anticholinergic effects
What is the treatment for a person in acute urinary retention
Prescribe a uroselective alpha blocker (Alfuzosin, Tamsulosin) before inserting a catheter
What patients may develop post-obstructive diuresis
Patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF or hypertension
How does ureteric colic arise
Pain mediated by prostaglandins released by ureter in response to obstruction
What are some indications to treat ureteric colic urgently
Pain unrelieved
Pyrexia
Persisitent nausea/ vomiting
High grade obstruction
What is the treatment for renal colic if urgent treatment is required
Ureteric stent or stone fragmentation/ removal if no infection
Percutaneous nephrostomy for infected hydronephrosis
What can cause frank haematuria
Infection stones tumours BPH Polycystic kidneys trauma coagulation / platelet deficiencies
What investigations should be carried out for frank haematuria
CT urogram and cystoscopy
What should be used for clot retention
A 3 way irrigating haematuria catheter
What are some causes of acute scrotum issues
Torsion of speramtic cord Torsion of appendix testis Epididymitis / epidiymo-orchitis Inguinal hernia Hydroceoele Trauma / insect bite Dermatological lesions Inflammatory vasculitis Tumour
What age are most patients who present with torsion of the spermatic cord
Mostly in puberty
What are some causes of torsion of the spermatic cord
Trauma
Athletic activity but usually spontaneous
What are some signs and symptoms of torsion of the spermatic cord
Sudden onset of pain
May be nausea/ vomiting
referred pain to lower abdomen
What are some findings on examination of a patient with spermatic cord
Absence of the cremasteric reflex
transverse lie
testis high in scrotum
What investigation is sometimes useful for torsion of the spermatic cord
Doppler USS
What is the treatment for testicular torsion
Irreversible ischaemic injury may occur as soon as 4 hours therefore we need to act FAST.
2 or 3 point fixation with fine non-absorbable sutures
if testis is necrotic - must be removed
MUST fix contralateral side (bell clapper deformity)
What might be seen if caught early in a torsion of appendage
Blue dot sign
What reflex should be present in an appendage torsion
Cremasteric reflex
What is the treatment for torsion of appendage
Nothing - will resolve spontaneously
What is epididymitis sometimes difficult to distinguish from
Torsion
What is more commonly seen in epididymitis
Dysuria / pyrexia
What are the findings of an examination in a patient with epididymitis
Cremasteric reflex present
Swollen epididymis and increased blood flow on doppler
What is the treatment for epididymitis
Analgesia and scrotal support, bed rest
Ofloxacin 400mg/day for 14 days
What are some of the signs and symptoms of idiopathic scrotal oedema
Self limiting - unknown cause - not usually associated with scortal erythema
no fever
tenderness minimal
may be pruritus
What are some of the signs Paraphimosis
Painful swelling of the foreskin distal to a phimotic ring
What are some of the causes of paraphimosis
Retraction of foreskin for catheterisation or cystoscopy and staff forget to replace it in its natural position
What is the treatment for paraphimosis
Iced glove, granulated surfer for 1-2 hours
multiple punctures in oedematous skin
manual compression of glans with distal traction on oedematous foreskin
Dorsal slit
What is Priapism
Prolonged erection >4hours
Often painful and not associated with sexual arousal
What is the aetiology of priapism
Intracorporeal injection for ED Trauma (penile / perinea) Haematologic dyscrasias e.g. sickle cell Neurological conditions Idiopathic
What can cause true compartment syndrome of the penis
Vascular stasis in penis and decreased venous outflow
What is meant by ischaemic priapism
Veno-occlusive or low-flow priapism
What is meant by non-ischaemic priapism
Arterial or high flow priapism
What might traumatic disruption of penile vasculature result in
unregulated blood entry and filling of corpora
What might be seen on a colour duplex USS in 1 low flow and 2 high flow priapism
Minimal or absent flow in cavernosal arteries in low-flow
Normal to high flow in non-ischaemic priapism
Describe the appearance of aspirated blood from the corpus cavernosium in low flow priapism
Dark blood, low O2 and high CO2
Describe the appearance of aspirated blood from the corpus cavernosium in high flow priapism
Normal arterial blood in high flow
What is the treatment for ischaemic priapism with early presentation
Aspiration +/- irrigation with saline
Injection of alpha-agonist e.g. phenylephrine 100-200g every 5-10 mins up to a max of 1000g
Surgical Shunt
What is the treatment for ischaemic priapism after 48-72 hours (late presentation)
It is unlikely to respond to intracavernosal treatment
Consider immediate placement of a penile prosthesis for very delayed presentation
What is the treatment for non-ischaemic priapism
Observe - may resolve spontaneously
Selective arterial embolisation with non-permanent materials
What is Fournier’s gangrene
A form of necrotising fasciitis occurring about the male genitalia
Where does Fournier’s gangrene most commonly arise
From skin, urethra or rectal region
What are predisposing factors to Fournier’s gangrene
Diabetes
local trauma
periurethral extravasation
perianal infection
What causes Fournier’s gangrene
A mixture of aerobes / anaerobes
Describe the onset of Fournier’s gangrene
Starts as cellulitis - swollen erythematous, tender
Marked pain, fever, systemic toxicity
Swelling and crepitus of scrotum, dark purple areas
Often marked toxicity out of proportion to the local findings
What investigation may confirm las in tissues
Plain X-Ray or USS
What is the treatment for Fournier’s gangrene
Antibiotics and surgical debridement
What is the prognosis for Fournier’s gangrene
Mortality 20% but higher in diabetics and alcoholics
What is Emphysematous pyelonephritis
An acute necrotising parenchymal and peritoneal infection caused by gas-forming uropathogens, usually Ecoli
What patients are most likely to develop Emphysematous pyelonephritis
Diabetics
What is Emphysematous pyelonephritis associated with
ureteric obstruction
What ares one of the symptoms of Emphysematous pyelonephritis
fever, vomiting, flank pain
What investigation is most useful in Emphysematous pyelonephritis and what does it tell us
CT
Defines extent of emphysematous process
What is often the treatment for Emphysematous pyelonephritis
Nephrectomy
What does a perinephric abscess usually result from
rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
What would the blood results show in a patient with a perinephric abscess
High WCC
High serum creatinine
pyuria
What is the treatment for perinephric abscess
Antibiotics and percutaneous or surgical drainage
How can we classify renal trauma
1: Hameatoma, subcapsular, non-expanding, no parenchymal laceration
2: Laceration 1cm depth, no collecting system rupture or extravasation
4: Laceration through cortex, medulla and collecting system. Main arterial / venous injury with contained haemorrhage
5: Shattered kidney. Avulsion of hilum, devascularising kidney
What are some of the indications of imaging
Frank haematuria in an adult
Frank or occult haematuria in child
Occult haematuira + shock
Penetrating injury with any degree of haematuria
What is the investigation of choice
CT with contrast
What is the treatment for blunt trauma kidney injuries
98% can be managed non-operatively
Angiography / embolisation
When is surgery required for kidney injuries
Persistent renal bleeding, expanding perirenal haematoma Pulsatile perirenal haematoma Urinary extravasation non-viable tissue incomplete staging (can do on table IVU)
What is a bladder injury commonly associate with
Pelvic fracture
What are some of the signs and symptoms of a bladder injury
Suprapubic / abdominal pain + inability to void Suprapubic tenderness lower abdominal bruising guarding/rigidity diminished bowel sounds
What should be performed if a catheter does not easily pass or if there is blood at the external meatus
A retrograde urethrogram as they may well have a urethral injury
What is the best imaging technique for a bladder injury
CT cystography
What is the treatment for a bladder injury
Large-bore catheter
Antibiotics
Repeat cystogram in 14 days
What are some indications for an immediate repair of a bladder injury
Intraperitoneal injury penetrating injury Inadequate drainage or clots in urine Bladder neck injury Rectal or vaginal injury Open pelvic fracture Pelvic fracture requiring open reduction/ fixation Patients undergoing laparotomy for other reasons Bone fragments projecting into bladder
What is a urethral injury often associated with
fracture of the pubic rami
What are some of the findings on examination of a urethral injury
Blood at meatus Inability to urinate Palpably full bladder High -riding prostate Butterfly perineal haematoma
What investigation is best for a urethral injury
Retrograde urethrogram
What is the treatment for a urethral injury
Suprapubic catheter
Delayed reconstruction after at least 3 months
How does a penile fracture usually arise
Typically during intercourse - buckling injury when penis slips out of vagina and strikes pubis
What is the normal presenting complaint of a patient with a penile fracture
Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling
What is the treatment for a penile fracture
Prompt exploration and repair
Circumcision incision with degloving of penis to expose all 3 compartments
How do testicular injuries usually present
Exquisite pain and nausea
swelling / bruising variable
What is the investigation of choice for a testicular injury
USS to assess integrity / vascularity
What is the treatment for a testicular injury
Early exploration / repair improves testis salvage,
reduces convalescence,
better preserves fertility and hormonal function
