Urological emergencies Flashcards
Acute urinary retention:
-what are the clinical features of this? 3
Clinical features: increasing pain, inability to urinate, complication of BPH
-can be spontaneous or precipitated
what is the aetiology of acute urinary retention? 5
poorly understood:
- prostate infection
- bladder overdistension
- excessive fluid intake
- alcohol
- prostatic infarction
What are the 5 precipitating factors for acute urinary retention?
- non-prostate relating surgery
- catheterisation
- urethral instrumentation
- anaeasthesia
- medication with sympathomimetic and anticholinergic effects
what is the treatment for acute urinary retention? when is it appropriate to trial without catheter during the same admission? What is useful to prescribe before TWOC to improve the chance of voiding?
- catheter
- if painful retention with <1litre of residue and normal serum electrolytes then TWOC during same admission
- prescribing a uroselective alpha blocker before TWOC improves chance of voiding (relaxes smooth muscle)
what is post-obstructive diuresis? what is the presentation? what is the treatment?
= diuresis due to solute diuresis from retained urea/sodium/water and defect in concentrating ability of kidney
Presentation: in pt.s with chronic bladder outflow obstruction in assoc. with uraemia/oedema/CCF/hypertension
Treatment: monitor fluid balance and beware if urine output > 200ml/hr. usually resolves in 24-48hrs but in severe cases may require IV fluid/Na+ replacement
Acute loin pain:
-what is the most common reason for this?
most commonly ureteric colic 2ndry to calculus
-pain mediated by prostaglandins released by ureter in response to obstruction
(remember it could be AAA)
What is the treatment of acute loin pain?
- NSAID +/- opiate
- alpha blocker for small stones expected to pass
What is the likelihood of spontaneous passage of stone:
- <4mm
- 4-6mm
- > 6mm
what does this depend on?
How long before a stone is likely to require intervention?
Spontaneous passage of stone:
<4mm - 80%
4-6mm - 59%
>6mm - 21%
depends on the site of the stone
if the stone hasn’t passed after one month it is likely to require intervention
What are the indications to treat a urinary calculus?
- pain unrelieved
- pyrexia
- persistant nausea/vomiting
What are the treatment options for a high grade obstruction?
- Ureteric stent/stone fragmentation or removal if no infection
- percutaneous nephrostomy for infected hydronephrosis
What are the differentials for frank haematuria?
- infection
- stones
- tumours
- BPH
- polycystic kidneys
- trauma
- coagulation or platelet deficiencies
What investigations are suitable for frank haematuria? what is the management for clot retention?
Investigations:
-CT urogram and cystoscopy
Clot retention: use a 3 way irrigating haematuria catheter
what are the 10 differentials for an acute scrotum?
- Torsion spermatic cord
- Appendix testis
- epididymitis/epididymo-orchitis
- inguinal hernia
- hydrocele
- trauma
- insect bite
- dermatological lesion
- inflammatory vasculitis
- tumour
What is the presentation of a spermatic cord torsion?
- most common at puberty
- can occur due to trauma/athletic activity but is usually spontaneous
- adolescent is usually awoken from sleep
what are the four symptoms of spermatic cord torsion?
- sudden onseet pain
- sometimes previous, self-limiting episodes of pain
- may be nausea/vomiting
- pain may be referred to the lower abdomen
what are the three signs of spermatic cord torsion? what may cause the obliteration of landmarks?
- testes high in scrotum
- transverse lie
- absence of cremasteric reflex
aqua-hydrocele and oedema may obliterate landmarks
What could be useful to investigate spermatic cord torsion?
doppler USS sometimes helpful
What is the treatment for spermatic cord torsion?
prompt exploration - irreversable ischaemic injury may begin as soon as 4 hours
- 2/3 point fixation with fine non-absorbable sutures
- if testes necrotic then remove
- must fix contralateral side (bell clapper deformity)
What is torsion of appendages? what symptoms are observed? what signs? Treatment?
this is torsion of appendages (developmental remnants)
Symptoms: variable, may be insidious or identical to torsion of testes
Signs: if seen early may have localised tenderness at upper pole and ‘blue dot’ sign. Testes should be mobile and cremasteric reflex present
Treatment: if diagnosis confirmed then it will resolve spontanously without surgery
Epididymitis: what is this and what are the clinical features? What signs indicate this?
Inflammation of epididymus
Features: rare in kids, difficult to distinguish from torsion, dysuria/pyrexia common, history of UTI/urethritis/catheterisation/instrumentation
Signs: cremasteric reflex present, suspect if pyuria
What are the investigations and management for epididymitis?
Investigations:
-on doppler: swollen epididymus/increased blood flow, send urine for culture and chlamydia PCR
Treatment:
- analgesia/scrotal support
- bed rest
- oflaxacin 400mg/day 14 days
What would indicated idiopathic scotal oedema? what is the treatment?
pruritus, minimal tenderness, no fever
-self-limiting
What is paraphimosis? why does this happen?
= painful swelling of foreskin distal to phimotic ring
- usually happens after foreskin is retracted for catheterisation or cystoscopy and staff member forgets to return it to it’s natural position
What is the treatment for paraphimosis?
- iced glove
- granulated sugar for 1-2hrs
- multiple punctures in oedematous skin
- manual compression of glans with distal traction on oedematous foreskin
- dorsal slit
What is priapism?
Prolonged (more than 4 hours) erection, often painful, not assoc. with sexual arousal
What are the different aetiologies of priapism? 5
- intracorporeal injection for erectile dysfunction
- trauma (penile/perineal)
- haematological dyscrasias (e.g. sickle cell)
- neurological conditions
- idiopathic
How is priapism classified?
Ischaemic or non-ischaemic
Ischaemic (veno-occlusive or low-flow): vascular stasis in penis and decrease in venous outflow = true compartment syndrome.
-corpora cavernosa are rigid and tender, penis often painful
Non-ischaemic (arterial or high-flow): traumatic dysruption of penile vasculature results in unregulated blood entry and filling of corpora cavernosa.
- fistula formtion between cavernous artery and lacunar spaces allows blood to bypass normal helicin arteriolar bed
- painless, not fully rigid
How is priapism diagnosed?
Aspiration blood from corpus cavernosum:
- ischaemic = dark blood, high CO2, low 02
- Non-ischaemic = normal blood
Colour duplex USS:
- ischaemic = minimal/absent flow
- non-ischaemic = normal/high flow
how is priapism treated?
non-ischaemic = observe, may resolve spontaneously, selective arterial embolisation with non-permenant materials
ischaemic = aspiration +/- irrigation with saline
- injection alpha agonist (phenylepiphrine 100-200nanog) every 5-10mins up to max 1’000nanog
- surgical shunt
- if >48-72hrs = unlikely to respond to intracavernosal treatment. For v. delayed presentation, may even consider immediate placement of penile prosthesis
What is fornier’s gangrene?
Form of necrotising fasciitis occuring around the male genitalia
- most commonly arises from skin/urethra/rectal region
- usually a mix of aerobes and anaerobes
What are predisposing factors for forniers gangrene?
- Diabetes
- Local trauma
- periurethral extravasation
- perianal infection
Describe the clinical features of fornier’s gangrene?
Starts as cellulitis - swollen, erythematous, tender, marked pain, fever and systemic toxicity
Leads to swelling and crepitus of scrotum, dark purple areas
Marked toxicity out of proportion with to local findings
what is the investigation, treatment and prognosis of forniers gangrene?
Investigation: plain xray or USS may confirm gas in tissues
Treatment: abiotics and surgical debridement
Prognosis: mortality 20%, higher in diabetics and alcoholics
what two infective emergencies can affect the urological system?
- emphysematous pyelonephritis
- perinephric abscess
What is emphysematous pyelonephritis?
morbid infection of kidneys with characteristic gas formation within/around the kidney
What are the: clinical features investigation management of emphysematous pyelonephritis?
Clinical features:
- usually occurs in diabetics
- often assoc. with ureteric obstruction
- fever
- vomiting
- flank pain
Investigations:
- see gas on KUB xray
- CT defines extent of emphysematous process
Treatment:
-often requires nephrectomy
Perinephric abscess - how does this arise?
- usually from rupture of acute cortical abscesses into perinephric spaces
- also from haematogenous seeding from infection sites
What are the: clinical features investigation management of perinephric abscess?
Clinical features:
- insidious onset
- approx. 33% not pyrexial
- flank mass in 50%
- high WCC and creatinine
- pyuria
Investigation: CT
Treatment: abiotics and percutaneous or surgical drainage
Renal trauma -how is this classified?
I to V on how damaged kidneys are
Renal trauma - what is the imaging method of choice? what are the 4 indications for imaging?
CT scan
Indications:
- frank haematuria in adult
- frank or occult haematuria in child
- occult haematuria and shock (systolic <90mmHg)
- penetrating injury with any degree of haematuria
what proportion renal trauma can be managed non-operatively and what options are available for this?
What complications of renal trauma need to be managed surgically?
98% blunt injuries managed non-operatively with angiography/embolisation
Surgery for persistant renal bleeding, expanding perirenal haematoma, pulsatile perirenal haematoma:
-urinary extravasation, non-viable tissue
Bladder injury:
- what is this commonly assoc. with?
- what are the symptoms?
commonly assoc. with pelvic fracture
Symptoms:
- suprapubic/abdo pain and inability to void
- lower abdo bruising
- guarding/rigidity
- diminished bowel sounds
- gross haematuria on catheterisation
What sign would prompt you to think of bladder injury? what investigation is necessary?
- blood at urethral meatus (or if catheter does not pass easily)
- perform retrograde urethrogram (urethral injury)
what imaging and treatment is appropriate for bladder injury?
imaging: CT cystoscopy
- extraperitoneal injury - flame shaped collection of contrast in pelvis
Treatment:
-large bore catheter, abiotics, repeat cystogram in 14days
What are the indications for immediate repair of bladder injury?
- intraperitoneal injury
- penetrating injury
- inadequate drainage/clots in urine
- bladder neck injury
- rectal or vaginal injury
- open pelvic fracture/ fracture need ORIF
- pt.s undergoing laparotomy for other reasons
- bone fragments projecting into bladder
Urethral injury:
- posterior urethral injury is usually assoc with what?
- where is most vulnerable for posterior urethral injury?
- often assoc. with pubic rami fracture
- posterior urethra is fixed at urogenital diaphragm and puboprostatic ligament so bulbomembranous junction most vulnerable.
what are the signs of urethral injury?
blood at meatus inability to urinate palpably full bladder high riding prostate butterfly perineal haematoma
what is the investigation and treatment for urethral injury?
investigation:
-retrograde urethrogram
Treatment:
-suprapubic catheter and delayed reconstruction after 3mths at least
What is a penile fracture? what is the clinical presentation?
=buckling injury when penis slips out of vagina and strike pubis
- cracking/popping sound followed by pain, rapid tumescence, discolouration and swelling
- 20% incidental urethral injury (frank haematuria/blood at meatus)
What is the treatment for penile fracture?
prompt exploration and repair, circumcision incision with degloving of penis to expose all three compartments
Testicular injury:
- clinical features
- investigations
- treatment
Clinical features:
- exquisite pain/nausea
- swelling
- bruising
Investigations:
-USS to assess integrity/vascularity
Treatment:
-early exploration/repair improves chance of salvaging testes, reduces recovery time, better preserves fertility/hormonal function
