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Year 2 Clinical > Urological Emergencies > Flashcards

Urological Emergencies Flashcards

1
Q

Common cause of acute urinary retention?

A

Complication of BPH/BNH

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2
Q

Aetiology of acute urinary retention?

A 
Unclear:
• Prostate infection
• Bladder over-distension
• Excessive fluid intake
• Alcohol
• Prostatic infection
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3
Q

Classifications of acute urinary retention?

A

Spontaneous

Precipitated (i.e: there is a triggering event):
• Non-prostate related surgery
• Catheterisation or urethral instrumentation
• Anaesthesia
• Medication with sympathomimetic or anti-cholinergic effects

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4
Q

Presentation of acute urinary retention?

A

Inability to urinate, with increasing pain

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5
Q

Mx of acute urinary retention?

A

CATHETERISATION

If painful retention with <1L residue and normal serum electrolytes then:
• Trial without catheter (TWOC) during the same admission
• Prescribing a uroselective α-blocker (Tamsulosin) before TWOC improves chances of voiding

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6
Q

Occurrence of post-obstructive diuresis?

A

Often presents in patients with chronic bladder outflow obstruction in assoc. with uraemia, oedema, CCF and hypertension

Diuresis occurs due to solute diuresis (retention of urea, Na+ and water) AND due to a defect in the conc. ability of the kidney

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7
Q

Monitoring and Mx of post-obstructive diuresis?

A

Usually resolves in 24-48 hours

Monitor fluid balance and beware if urine ouput > 200 ml/hr

Severe cases may require IV fluid and Na+ replacement

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8
Q

Time period for haematuria?

A

Not uncommon but generally settles in 24 hours

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9
Q

Causes of acute loin pain?

A

Renal calculi

Causes outwith the urinary tract:
• AAA

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10
Q

Ix for renal stones?

A

X-ray (often seen near the transverse processes of vertebrae)

CT-KUB (kidneys, ureters, bladder)

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11
Q

Treatment of renal calculi?

A

NSAID (pain is mediated by PGs released by the ureter in response to obstruction) +/- opiate

α-blocker (Tamsulosin) for small stones that are expected to pass

If stone has not passed in 1 months, likely to require further intervention

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12
Q

Indications to treat renal calculi urgently?

A

Pain that is unrelieved with analgesia

Pyrexia (indicates infected urine above the stone)

Persistent N&V

High-grade obstruction

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13
Q

Urgent Mx options for renal calculi?

A

If no infection - ureteric stent or stone fragmentation/removal

For infected hydronephrosis - percutaneous nephrostomy

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14
Q

Causes of frank haematuria?

A

Infections and stones

Tumours and BPH

Coagulation/platelet deficiencies

Polycystic kidneys

Trauma

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15
Q

Ix with frank haematuria?

A

CT urogram + cystoscopy

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16
Q

How to treat clot retention with frank haematuria?

A

Use 3-way irrigating haematuria catheter

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17
Q

Ix for frank haematuria?

A

CT urogram + cystoscopy

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18
Q

Occurrence of torsion of the spermatic cord?

A

Most common at puberty; it may occur with trauma or athletic activity but it is usually spontaneous

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19
Q

Presentation of torsion of the spermatic cord?

A

Adolescent often woken from sleep by sudden onset pain; they may have had previous episodes of self-limiting pain
Pain may be referred to lower abdomen

May have N&V

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20
Q

Examination of torsion of the spermatic cord?

A

Testis high in the scrotum

Transverse lie

Absence of the cremasteric reflex (cremaster muscle does not pull the testis upwards)

Acute hydrocoele + oedema can obliterate landmarks

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21
Q

Ix for torsion of the spermatic cord?

A

Mainly a clinical diagnosis and exploration should not be delayed (irreversible ischaemic injury may begin as soon as 4 hours)

Doppler USS is sometime helpful

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22
Q

Mx for torsion of the spermatic cord?

A

2 or 3 point fixation with fine, non-absorbable sutures

If testis is necrotic, then remove

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23
Q

Most common underlying cause of torsion of the spermatic cord?

A

Congenital issue known as bell-clapper deformity; this is why, during treatment, the contralateral side must be fixed

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24
Q

Symptoms of torsion of an appendage?

A

Symptoms are variable; it may be insidious onset or identical to torsion of a cord

Early presentation may have localised tenderness at the upper pole and “blue dot” sign

Testis should be mobile and cremasteric reflex is present

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25
Q

Mx of torsion of an appendage?

A

If diagnosis has been confirmed then it will resolve spontaneously without surgery

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26
Q

Occurrence of epididymitis?

A

Rare in children

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27
Q

Presentation of epididymitis?

A

May be difficult to distinguish from torsion

Dysuria/pyrexia are more common in this

Typically have a history of UTI, urethritis, catheterisation/instrumentation

28
Q

Examination of epididymitis?

A

Cremasteric reflex is present

Suspicious of this is there is pyuria

29
Q

Ix for epididymitis?

A

Doppler shows a swollen epididymis and increased blood flow

Send urine for culture and Chlamydia PCR

30
Q

Mx for epididymitis?

A

Analgesia, scrotal support and bed rest

Ofloxacin 400mg/day for 14 days

31
Q

Aetiology of idiopathic scrotal oedema?

A

Unknown cause

32
Q

Presentation of idiopathic scrotal oedema?

A

Not usually assoc. with scrotal erythema

No fever

Tenderness is minimal but may have pruritus

33
Q

Mx of idiopathic scrotal oedema?

A

Self-limiting

34
Q

What is a paraphimosis?

A

Painful swelling of the foreskin distal to the phimotic ring

Often happens when the foreskin is retracted for catheterisation or cystoscopy and staff membrane forgets to replace it in its natural position

35
Q

Mx of paraphimosis?

A

Iced glove
Granulated sugar for 1-2 hours

Multiple punctures in oedematous skin

Manual compression of glans with distal traction of oedematous foreskin

Dorsal slit

36
Q

What is a priapism?

A

Prolonged erection (>4 hours); it is often painful and is not assoc. with sexual arousal

37
Q

Aetiology of priapism?

A

Intracorporeal injection for ED

Trauma (penile/perineal)

Haematologic dyscrasias, e.g: sickle cell

Neurological conditions

Idiopathic

38
Q

Classifications of priapism?

A

Ischaemic (veno-occlusive or low flow)

Non-ischaemic (arterial or high flow)

39
Q

Pathophysiology of ischaemic priapism?

A

Vascular stasis in penis and decreased venous outflow (a true compartment syndrome)

40
Q

Presentation of ischaemic priapism?

A

Corpora cavernosa are often rigid and render and the penis is often painful

41
Q

Pathophysiology of non-ischaemic?

A

Traumatic disruption of penile vasculature results in unregulated blood entry and filling of the corpora

OR

Fistula formation between the cavernous artery and lacunar spaces allows blood to bypass the normal helicine arteriolar bed

42
Q

Ix for priapism?

A

Aspirate blood from the corpus cavernosum - should be dark with:
• Low O2 and high CO2 in low-flow
• Normal arterial blood in high-flow

Colour duplex USS:
• Minimal/absent flow in cavernosal arteries in low-flow
• Normal-high flow in non-ischaemic priapism

43
Q

Treatment of ischaemic priapism?

A

Aspiration +/- irrigation with saline

Injection of α-agonist (phenylephrine)

Surgical shunt

For a very delayed presentation, may even consider immediate placement of a penile prosthesis

44
Q

Treatment of non-ischaemic priapism?

A

Observe, as it may resolve spontaneously

Selective arterial embolisation with non-permanent materials

45
Q

What is Fournier’s gangrene?

A

Form of necrotising fasciitis occurring around the male genitalia, usually arising from the skin, urethra or rectal region

Usually, there is a mixture of aerobes/anaerobes

46
Q

Predisposing/risk factors for Fournier’s gangrene?

A

Diabetes

Local trauma

Periurethral extravasation

Peri-anal infection

47
Q

Presentation of Fournier’s gangrene?

A

Begins as a cellulitis, i.e: swollen, erythematous, tender and painful with fever and systemic toxicity

Followed by development of dark purple areas, swelling, scrotal crepitus

Marked toxicity that is OUT OF PROPORTION to the local findings

48
Q

Diagnosis of Fournier’s gangrene?

A

Plain X-ray or USS may show gas in tissues

49
Q

Treatment of Fournier’s gangrene?

A

Antibiotics + surgical debridement

50
Q

Mortality of Fournier’s gangrene?

A

20% higher than in diabetics and alcoholics

51
Q

What is emphysematous pyelonephritis?

A

Acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E.coli

It is an infective emergency

52
Q

Occurrence of emphysematous pyelonephritis?

A

Often occurs in diabetics

53
Q

Presentation of emphysematous pyelonephritis?

A

Fever, vomiting and loin pain

54
Q

Diagnosis of emphysematous pyelonephritis?

A

Gas may be seen on CT KUB (helps define extent of emphysematous process)

55
Q

Treatment of emphysematous pyelonephritis?

A

Often requires nephrectomy

56
Q

What is a perinephric abscess?

A

Caused by:
• Rupture of an acute cortical abscess into the perinephric space
• Haematogenous seeding from sites of infection

57
Q

Presentation of perinephric abscess?

A

50% have a flank mass

58
Q

Diagnosis of perinephric abscess?

A

High WCC and serum creatinine

Pyuria

59
Q

Ix for perinephric abscess?

A

CT scan

60
Q

Management of perinephric abscess?

A

Antibiotics + percutaneous/surgical drainage

61
Q

Classification of renal trauma?

A

I - haematoma, subcapsular, non-expanding, no parenchymal laceration

II - laceration <1cm parenchymal depth without urinary extravasation

III - >1cm depth, no collecting system rupture or extravasation

IV - laceration through cortex, medulla and collecting system; main arterial/ venous injury with contained haemorrhage

V - shattered kidney, avulsion of hilum, devascularizing kidney

62
Q

Indications for imaging with renal trauma?

A

Frank haematuria in an adult OR frank/occult haematuria in a child

Occult haematuria + shock (systolic <90mmHg)

Penetrating injury with any degree of haematuria

63
Q

Investigations for renal trauma?

A

CT with contrast

64
Q

Management of renal trauma?

A

Most blunt renal injuries can be managed non-operatively

Angiography/ embolisation

65
Q

When is surgery for renal trauma indicated?

A

Persistent renal bleeding, expanding perirenal haematoma, pulsatile perirenal haematoma

Urinary extravasation, non-viable tissue, incomplete staging

Year 2 Clinical (119 decks)

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