Urological Emergencies Flashcards
Common cause of acute urinary retention?
Complication of BPH/BNH
Aetiology of acute urinary retention?
Unclear: • Prostate infection • Bladder over-distension • Excessive fluid intake • Alcohol • Prostatic infection
Classifications of acute urinary retention?
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
Presentation of acute urinary retention?
Inability to urinate, with increasing pain
Mx of acute urinary retention?
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
Occurrence of post-obstructive diuresis?
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
Monitoring and Mx of post-obstructive diuresis?
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
Time period for haematuria?
Not uncommon but generally settles in 24 hours
Causes of acute loin pain?
Renal calculi
Causes outwith the urinary tract:
• AAA
Ix for renal stones?
X-ray (often seen near the transverse processes of vertebrae)
CT-KUB (kidneys, ureters, bladder)
Treatment of renal calculi?
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
Indications to treat renal calculi urgently?
Pain that is unrelieved with analgesia
Pyrexia (indicates infected urine above the stone)
Persistent N&V
High-grade obstruction
Urgent Mx options for renal calculi?
If no infection - ureteric stent or stone fragmentation/removal
For infected hydronephrosis - percutaneous nephrostomy
Causes of frank haematuria?
Infections and stones
Tumours and BPH
Coagulation/platelet deficiencies
Polycystic kidneys
Trauma
Ix with frank haematuria?
CT urogram + cystoscopy
How to treat clot retention with frank haematuria?
Use 3-way irrigating haematuria catheter
Ix for frank haematuria?
CT urogram + cystoscopy
Occurrence of torsion of the spermatic cord?
Most common at puberty; it may occur with trauma or athletic activity but it is usually spontaneous
Presentation of torsion of the spermatic cord?
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
Examination of torsion of the spermatic cord?
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
Ix for torsion of the spermatic cord?
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
Mx for torsion of the spermatic cord?
2 or 3 point fixation with fine, non-absorbable sutures
If testis is necrotic, then remove
Most common underlying cause of torsion of the spermatic cord?
Congenital issue known as bell-clapper deformity; this is why, during treatment, the contralateral side must be fixed
Symptoms of torsion of an appendage?
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
Mx of torsion of an appendage?
If diagnosis has been confirmed then it will resolve spontaneously without surgery
Occurrence of epididymitis?
Rare in children
Presentation of epididymitis?
May be difficult to distinguish from torsion
Dysuria/pyrexia are more common in this
Typically have a history of UTI, urethritis, catheterisation/instrumentation
Examination of epididymitis?
Cremasteric reflex is present
Suspicious of this is there is pyuria
Ix for epididymitis?
Doppler shows a swollen epididymis and increased blood flow
Send urine for culture and Chlamydia PCR
Mx for epididymitis?
Analgesia, scrotal support and bed rest
Ofloxacin 400mg/day for 14 days
Aetiology of idiopathic scrotal oedema?
Unknown cause
Presentation of idiopathic scrotal oedema?
Not usually assoc. with scrotal erythema
No fever
Tenderness is minimal but may have pruritus
Mx of idiopathic scrotal oedema?
Self-limiting
What is a paraphimosis?
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
Mx of paraphimosis?
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
What is a priapism?
Prolonged erection (>4 hours); it is often painful and is not assoc. with sexual arousal
Aetiology of priapism?
Intracorporeal injection for ED
Trauma (penile/perineal)
Haematologic dyscrasias, e.g: sickle cell
Neurological conditions
Idiopathic
Classifications of priapism?
Ischaemic (veno-occlusive or low flow)
Non-ischaemic (arterial or high flow)
Pathophysiology of ischaemic priapism?
Vascular stasis in penis and decreased venous outflow (a true compartment syndrome)
Presentation of ischaemic priapism?
Corpora cavernosa are often rigid and render and the penis is often painful
Pathophysiology of non-ischaemic?
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
Ix for priapism?
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
Treatment of ischaemic priapism?
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
Treatment of non-ischaemic priapism?
Observe, as it may resolve spontaneously
Selective arterial embolisation with non-permanent materials
What is Fournier’s gangrene?
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
Predisposing/risk factors for Fournier’s gangrene?
Diabetes
Local trauma
Periurethral extravasation
Peri-anal infection
Presentation of Fournier’s gangrene?
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
Diagnosis of Fournier’s gangrene?
Plain X-ray or USS may show gas in tissues
Treatment of Fournier’s gangrene?
Antibiotics + surgical debridement
Mortality of Fournier’s gangrene?
20% higher than in diabetics and alcoholics
What is emphysematous pyelonephritis?
Acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E.coli
It is an infective emergency
Occurrence of emphysematous pyelonephritis?
Often occurs in diabetics
Presentation of emphysematous pyelonephritis?
Fever, vomiting and loin pain
Diagnosis of emphysematous pyelonephritis?
Gas may be seen on CT KUB (helps define extent of emphysematous process)
Treatment of emphysematous pyelonephritis?
Often requires nephrectomy
What is a perinephric abscess?
Caused by:
• Rupture of an acute cortical abscess into the perinephric space
• Haematogenous seeding from sites of infection
Presentation of perinephric abscess?
50% have a flank mass
Diagnosis of perinephric abscess?
High WCC and serum creatinine
Pyuria
Ix for perinephric abscess?
CT scan
Management of perinephric abscess?
Antibiotics + percutaneous/surgical drainage
Classification of renal trauma?
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
Indications for imaging with renal trauma?
Frank haematuria in an adult OR frank/occult haematuria in a child
Occult haematuria + shock (systolic <90mmHg)
Penetrating injury with any degree of haematuria
Investigations for renal trauma?
CT with contrast
Management of renal trauma?
Most blunt renal injuries can be managed non-operatively
Angiography/ embolisation
When is surgery for renal trauma indicated?
Persistent renal bleeding, expanding perirenal haematoma, pulsatile perirenal haematoma
Urinary extravasation, non-viable tissue, incomplete staging
