Urological Emergencies Flashcards
What is acute urinary retention a complication of?
BNH
What are the symptoms of acute retention?
inability to urinate with increasing pain
What can cause acute urinary retention?
prostate infection, bladder overdistension, excessive fluid intake, alcohol, antimuscarinic drugs
What is the treatment for acute retention?
catheterisation
What can be prescribed to imrpvoe chance of voiding success following acute retention?
uroselective alphablocker- alfuzosin; tamsulosin
When can trial withou catheter be trailled during same admission as acute retention?
less than 1 litre residue and normal electrolytes
What is post-obstructive diuresis?
poly-uric state post the relief of a urinary tract obstruction- defect in concentrating ability of the kidney
What is the treatmnet for post-obstructive diuresis?
monitor fluid blaance, usually resolves within 24-48hrs
How long does it take haematuria after acute retention to resolve?
24 hours
What is a differential in acute loin pain outwith urinary tract?
AAA
What mediates the pain with ureteric colic?
prostaglandins released by the ureter in response to obstruction
What is the treatment for acute loin pain?
NSAIDs +/- opiate
What drug may be given for stones that are expected to pass?
alphablockers
What is the chance of a stone less than 4mm of spontaneous passage?
80%
What is the chance of a stone between 4-6mm of spontaneous passage?
59%
What is the chance of a stone greater than 6mm of spontaneous passage?
21%
In addition to he size of the stone, what also impacts chance of spontaneous passage?
site of stone at first presentation
After what length of time if the stone has not passed is it unlikley to do so?
1 month
What are the indications to treat acute loin pain urgently?
pain unrelieved, pyrexia, persistnet N&V; high-grade obstruction
What is urgent treatmnet for acute loin pain if no infection?
ureteric stent or stone fragmentation/removal
What is the urgent treatmnet for acute loin pain with infection?
percutaneous nephrostomy
What are teh causes of frank haematuria?
infection; stones; tumours; BNH; polycystic kidneys; trauma; coag/plateley deficiencies
What is the treatment if a clot is causing acute retention?
using a 3-way irrigating haematuria catheter
What is the investigation for frank haematuria?
CT urogram and cystoscopy
What are teh causes of acute scrotum?
torsion of spermatic cord; torsion of appendix testis; epididymitis; inguinal hernia; hydrocele; trauma/insect bite; derm; inflam vasculitis; tumour
When is testicular torsion most common?
puberty
What is the typical onset of pain with testicular torsion?
woken from sleep
What is the presentation of testicular torsion?
sudden onset pain; seomtimes previous self-limiting pain; may have N and V; reffered to lower abdo
What is seen on exam with testicular torsion?
testis high in scrotum; transverse lie and absence of cremasteric reflex
What is the investigation for testicular torsion?
doppler USS
What is the treatment for testciular torsion?
prompt exploration and 2/3 point fixation with non-absorbable sutures, and fix contralateral side
How soon can irreversbile ischaemia begin with testicular torsion?
4 hours
What is seen on torsion of appendage?
loacalised tenderness at upper pole and blue dot sign
What is seen on exam of torsion of appendage?
testis mobile and cremasteric reflec present
what is the treatment for torsion of appendage?
reoslves spontaneously
What symptoms are seen more in epididymitis compared with torsion?
dysuria and pyrexia
What is typically seen in the patient history of those with epididymitis?
hx of UTI, urethritisi, catheterisation/instrumentation
What is seen on exam with epididymitis?
cremasteric reflex present; pyrexia; doppler- increased bloodflow and swollen epididymis
What is the invesigations for epididymitis?
doppler USS and urine culture and chlamydia PCR
What is the treatment for epididymitis?
analgesia and scrotal support; ofloxacin
What is idiopathic scrotal oedema?
self-limiting; no erythema or fever, child is usually happy
What is paraphimosis?
painful swelling of the foreskin distal to a phimotic ring
When does paraphimosis occur?
after foreskin retracted and not replaced in natural position
What is the treatment for paraphimosis?
iced glove; granulated sugar; mulitple punctures in oedematous skin; manual compression of glans with distal traction; dorsal slit
What is priapism?
prolonged erection (>4hrs)
What can cause priapism?
intracorporeal injection for ED; trauma; haematologic- sickle cell; neuro; idiopathic
What are the 2 types of priapism?
ischaemic and non-ischaemic
What happens with ischaemic priapism?
vascular stasis in penis and decreased venous outflow- compartment syndrome
What happens with non-ischaemic priapism?
traumatic disruption of penile vasculature results in unregulated blood entry and filling of corpora
What is the investigation of priapism?
aspirate blood from corpus cavernosum and doppler USS
What would indicate low-flow priapism on blood aspirate?
dark blood, low O2 and high CO2
What is seen with low-flow on USS ?
minimal or absent flow in cavernosal arteries
What is the treatmnet for ischaemic priapism?
aspiration +/- irrigation with saline; injection of alpha agonist; surgical shunt
After what time period is ischaemic priapism unlikely to respond?
> 48-72hrs
What is the treatment for non-ischaemic priapism?
may resolve spontaneously; selective arterial embolization with non-oermanent materials
What is Fournier’s gangrene?
a form of necrotisiing fasciitis occuring about the male genitalia
What are the risk factors for Fournier’s gangrene?
DM; local trauma; peri-urethral extravasation and peri-anal infection
What does Fournier’s start as?
cellulitis
What are the signs of Fournier’s gangrene?
swollen; erythematous, tender, marked pain, fever, systemic toxicity, crepitus of scrotum; dark purple areas
What is the investigation of Fournier’s gangrene?
plain xray or USS- gas in tissues
What is the rteatment for Fournier’s?
antibiotics and surgical debridement
What is emphysematous pyelonephritis?
an acute necrotisiing parenchymal and perirenal infection caused by gas-forming uropathogens usually E.coli
Who does emphysematous pyelonephritis occur in?
DM
What are the symptoms of emphysematous pyelonephritis?
fever, vomiting, flank pain, often assoc with ureteric obstruction
What are the investigations of emphysematous pyelonephritis?
gas on xray; CT
What is the treatment for emphysematous pyelonephritis?
often requires nephrectomy
What does a perinephric abscess usually result from?
a rupture of an acute cortical abscess into the perinephric space or from haematogenous spread
What are the signs of perinephric abscess?
flank mass; high WBC; high creat; pyuria
What is the investigation of perinephric abscess?
CT
Waht is the treatmnet for perinephric abscess?
antibiotics and percut or surgical drainage
What is 1 in classification of kidney trauma?
haematoma; subcapsular; non-expanding, no parenchymal laceration
What is 2 in classification of kidney trauma?
laceration <1cm parenchymal depth without urinary extravasation
What is 3 in classification of kidney trauma?
> 1cm depth, no collecting system rupture or extravasation
What is 4 in classification of kidney trauma?
laceration thorugh cortex, medulla nd collecting system, main arterial/venous injury with contained haemorrhage
What is 5 on kidney trauma?
shattered kidney; avulsion of hilum devascularising kidney
What are the indications for imagin with suspected kidney trauma?
frank haematuria in adult; frank or occult haematuria in child; occult haematuria and shock in adult; penetrating injury with any haematuria
What is the investiagtion for kidney trauma?
CT with contrast
What are the indications for treatmnet with kidney trauma?
persistent renal bleeding; expanding/pulsatile perirenal haematoma; urinary extravasation, non-viable tissue
What is the non-surgical tx of kidney trauma?
angiography/embolisation
What is bladder injury commonly associated with?
pelvic fracture
Waht are the symptoms of bladder injury?
suprapubic/abdo painand tenderness and inability to void, lower abdo bruising, guarding, decreased bowel sounds
What is seen on catheterisation with bladder injury?
frank haematuria
What should be done if there is blood at the external meatus or catheter doesnt pass easily?
retrograde urethrogram
What is the imaging for bladder injury?
CT cystography
What is seen on CT cystography with extraperitoneal bladder injury?
flame-shaped collection of contrast in pelvis
What is the treatment for bladder injuries?
large bore catheter; antibiotics; repeat cystogram in 14 dayas
What are the indications for immediate repair with bladder injuries?
intraperitoneal injury; penetrating injury; inadequte drainage; bladder neck injury; rectal or vaginal injury; open pevlic fracture or fracture requiring ORIF; bone fragments projecting into bladder
What is posterior urethral injury often associated with?
fracture of pubic rami
What is seen on exam with urethral injury?
blood at meatus; inability to urinate; palpably full bladder; high riding prostate on PR; butterfly perineal haematoma
What is the investigation of urethral injury?
retrograde urethrogram
What is the treatment of urethral injury?
suprapubic catheter; delayed reconstruction after 3 month
When does penile fracture occur?
during intercourse; buckling injury when penis slips out of vagina and strikes pubis
What are the syptoms of penile fracture?
cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling
What is the treatmnet of penile fracture?
prompt exploration and repair; circumcision incision with degloving of penis to expose all 3 compartments
What does testicular injury usually present with?
exquisite pain and nausae; swelling and bruising
What is the investigation of testicular injury?
USS- integrity and vascularitiy
What is the treatment for testicular injury?
early exploration/repair improves testis salvage, reduces convalescence
