UROLOGICAL EMERGENCIES Flashcards
What are the main urological emergencies?
Acute urinary retention
Renal colic
Testicular torsion
Paraphimosis
Priapism
Who is normally affected by acute urinary retention?
Elderly men
What are the four major categories of causes of acute urinary retention?
Obstructive
Inflammatory
Neurological
Over-distension - leading to bladder not contracting properly
What are the obstructive causes of urinary retention?
Mechanical obstruction:
BPH
Urethral stricture
Constipation
Pelvic mass
Dynamic obstruction:
Increase in smooth muscle tone due to postoperative pain and drugs
What are the inflammatory causes of acute urinary retention?
UTI
Prostatitis
What are the neurological causes of acute urinary retention?
Spinal cord injury
Multiple sclerosis
Pelvic surgery
What are some causes of over-distention of the bladder which can lead to the bladder no longer able to contract properly and hence lead to acute urinary retention?
Post-anaesthesia
High alcohol intake
Drugs:
- ephedrine, pseudoephedrine
- Antidepressants
What are the clinical features of acute urinary retention?
Central lower abdominal pain
Anuria
Palpable bladder
How do we treat acute retention?
Urgent urethral catheterisation
What must you do once urethral catheterisation of a patient with acute urinary retention has happened?
Record the urine drained in the first 10-15 minutes
What is the normal volume drained from the bladder through urethral catheterisation following acute urinary retention?
Less than 1 litre
If more than 1 litre is drained from someone with urinary retention, what might this indicated?
More chronic retention
How should you treat a patient with urinary retention in whom urethral catheterisation fails?
Admit urgently for consideration of a suprapubic catheter.
Once a patient who presents with acute urinary retention has been catheterised, what investigations and management should be done for them?
Renal function blood tests
Start alpha blocker
TWOC after 2-3 days of alpha blocker
How should a patient with acute urinary retention who fails a TWOC be managed?
Long-term catheter
OR
Prostatic surgery
What are the features of chronic urinary retention?
Build up of more than 1 litre
Less pain than acute
Nocturnal enuresis
Overflow incontinence
Is chronic or acute urinary retention more likely to cause abnormal renal function?
Chronic - in these cases immediate catheterisation is required
How do we treat chronic urinary retention?
Catheter
TWOC not appropriate management
Should undergo elective prostatic surgery or have long term catheter.
What is renal colic?
Pain caused by kidney stones
What are the clinical features of renal colic?
Severe sudden onset-pain
Starts in the flank
Radiates around the front to the groin and sometimes scrotum or labia
Nausea and vomiting
Visible haematuria
Unable to find a comfortable position and therefore appear restless
Often nil on examination
What is the cause of the pain in renal colic?
Dilatation, stretching and spasm caused by acute ureteral obstruction.
What investigations should be done for someone who presents with signs and symptoms consistent with renal colic?
Urinalysis - blood (if not blood is found, strongly consider alternative diagnosis)
U&Es
Pregnancy test in women of childbearing age
Non-contract CT abdo-pelvis
How do you treat a patient with renal colic?
Resuscitation with fluids
Anti-emetics
Analgesia (NSAIDs should be tried before opiate based)
If small enough wait for stone to pass.
If larger - number of option including endoscopic or surgical extraction, or shock wave treatment to break up stone.
Below what size of kidney stone is there a 90% chance of spontaneously passing it?
4mm
Above what size of kidney stone is there only a 20% chance of spontaneously passing it?
6mm
What are the complications of kidney stones?
Obstructive renal failure
Severe pyelonephrtitis
What is testicular torsion?
Twisting of the spermatic cord, which impedes blood flow to the testis and impairs venous drainage. This results in oedema, ischaemia and necrosis.
What are the peak ages of incidence for testicular torsion?
1-2 years old
Late teenage years
Testicular torsion is very rare in the over 40s
What is the most common cause of testicular torsion?
Malformed tunica vaginalis - bell-clapper deformity. The tunica vaginalis extends over the whole testis rather than just the upper pole.
What are the clinical features of testicular torsion?
Pain
Very quick in onset
Previous episodes of pain indicating intermittent torsion
Swelling
Erythema
Testicle lying horizontally, sitting high in the scrotum
Absent cremasteric reflex
What investigations should be done for someone who presents with signs and symptoms consistent with testicular torsion?
Urinalysis - normal
Colour flow Doppler USS - poor or absent blood flow
Remember that time is key to management of this, so if the diagnosis is highly likely then surgery should not be delayed for investigations.
How is testicular torsion managed?
Testicle is detorted surgically and then fixed to the scrotal wall.
If testis is not salvageable, an orchidectomy is performed.
Other testicle should also be examined and fixed if bell-clapper deformity is bilateral.
What percentage of testes will be salvaged if surgery is performed 8 hours after onset of pain?
65%
What is paraphimosis?
Foreskin becomes fixed in the retracted position and cannot be reduced therefore constricting venous return from glans penis and resulting in swelling of glans.
What is the condition known to precipitate paraphimosis?
Phimosis
What is the most common cause of paraphimosis?
Iatrogenic - medical staff fail to replace the foreskin following urethral catheterisation.
What are the complications of untreated paraphimosis?
Ulceration and necrotic changes in the preputial skin and glans penis.
What are the management option for paraphimosis?
Adequate analgesia - may involve penile nerve block
Manual decompression should be tried first - reduce oedema enough to replace foreskin over glans
Dorsal slit in the preputial skin.
Formal circumcision is definitive management - usually performed after dorsal slit to allow oedema to decrease.
What is priapism?
Penile erection persisting beyond or unrelated to sexual stimulation.
What are the two types of priapism?
Low-flow or ischaemic
High-flow or non-ischaemic
What is the aetiology of low flow priapism?
Decreased venous and lymphatic drainage of corpus cavernosae
What is the aetiology of high flow priapism?
Unregulated arterial blood flow often related to trauma.
What is the main complication of priapism?
Erectile dysfunction often as a result of thrombosis, further ischaemia and subsequent fibrosis
What are the haematological causes of priapism?
Sickle cell disease
Leukaemia
Thrombophilia
What are the neurological causes of priapism?
Spinal cord compression
What are the drugs related causes of priapism?
Drugs for ED:
Intracavernosal papaverine
Intracavernosal prostaglandin E1
Intraurethral alprostadil
Other drugs:
Antihypertensives
Antipsychotics
Antidepressants
Alcohol and cocaine
What are the causes of high-flow priapism?
Perineal or penile trauma (commonly straddle type injuries) producing a cavernosal artery laceration, subsequent arteriovenous fistula and thus unregulated arterial blood flow.
How do you definitively distinguish between high-flow and low-flow priapism?
Penile blood gas aspirated from corpus cavernosum.
How do we treat low-flow priapism?
Aspiration and irrigation of corpora
Intracavernosal injection of phenylephrine (required cardiac monitoring)
If unsuccessful - surgical shunt between corpora cavernosa and spongiosa
How do we treat high-flow priapism?
This is less urgent
Normally cases can be observed prior to arteriography and selective embolisation with good functional outcomes.
