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Renal and Urology > Urological emergencies > Flashcards

Urological emergencies Flashcards

1
Q

acute urinary retention

A

the sudden inability to pass urine which causes significant pain

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2
Q

acute urinary retention is characterised as

A

spontaneous or precipitated

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3
Q

precipitated acute urinary retention is where

A

there is a triggering event i.e. non-prostate related surgery, catheterisation, urethral instrumentation, anaesthesia, medication with sympathomimetic or anti-cholinergic affects

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4
Q

causes of acute urinary retention in men

A

benign prostatic hyperplasia (most common), meatal stenosis, paraphymosis, prostate cancer

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5
Q

causes of acute urinary retention in woman

A

cysteocels (where the bladder bulges into the vagina), rectocele (where the rectum bulges into the vagina), pelvic mass (gynaecological malignancy, uterine fibrosis)

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6
Q

in both male and females acute urinary retention can be caused by

A

bladder calculi, blader cancer, faecal impacatation, GI or retro-peritoneal malignancy

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7
Q

infections and inflammatory causes of acute urinary retention in males

A

balanitits (inflammation of the glans penis), prostatitis, prostatic abscess

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8
Q

infections and inflammatory causes of acute urinary retention in females

A

acute vulvovaginitis, lichen sclerosus

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9
Q

infections and inflammatory causes of acute urinary retention which can occur in both males and females

A

schistosomiasis, cystitis, herpes simplex, peri-urethral abscess

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10
Q

drug related causes of acute urinary retention

A

anti-cholinergics, opioids, anaestheticis, alpha-adrenergic agonists, benzodiazepines

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11
Q

presentation of acute urinary retention

A

teder distended palpable bladder with inability to pass urine

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12
Q

management of acute urinary retention

A

immediate and complete bladder decompression using a catheter, if painful retention with less than 1 litre residue and normal serum electrolytes trial without cathetersitation is carried out during the same admission

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13
Q

what should be prescribed to increase success of trial without catheterisation

A

alpha blocker (tamsulosin)

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14
Q

how does tamsulosin work

A

it is a selective alpha blocker which causes relaxation of smooth muscles in the bladder neck and prostate

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15
Q

post obstructive diuresis

A

high urine output greater than 200ml per hour for more than 2 consecutive hours after an obstruction is relieved

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16
Q

post obstructive diuresis most often presents in patients with

A

chronic bladder outflow obstruction in associated with uraemia, oedema, congestive heart failure and hypertension

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17
Q

post-obstructive diuresis is a state of

A

polyuresis where there is excessive amount of water excreted in the urine after treatment of a urinary tract obstruction

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18
Q

diureisus is a normal physiological response

A

to help eliminate excessive volume and solutes which accumulated during the prolonged obstruction but the diuresis should resolve after solute and volume have been normalised but in POD the kidney continues to eliminated fluid after homeostasis has been achieved

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19
Q

in post-obstructive diuresis there is a risk of

A

dehydration, electrolyte imbalance and hypovolaemic shock

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20
Q

post-obstructive diuresis usually resolves after

A

24-48 hours but if severe requires IV fluids and sodium replacement

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21
Q

acute loin pain always consider what in your differentials

A

diagnosis outwith the urinary tract such as AAA

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22
Q

acute loin pain most commonly caused by

A

nephrolithiasis

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23
Q

the urerter has 3 sites of what

A

constriction where it contracts smooth muscle, narrowing can occur at these sites and calculi can get lodged here:

  1. pelvics-ureteric junction
  2. pelvic brim
  3. vesico-ureteric orifice
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24
Q

the cells lining the renal tubules are predominantly

A

cuboidal epithelial cells

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25
Q

within the renal tubules what can form

A

crystal like structures known as calculus

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26
Q

if the calculus are small enough

A

the pass out in urine without causing any problems, but if they are large they can cause obstruction

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27
Q

obstruction within the tubules causes

A

release prostaglandisng causing pain

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28
Q

presentation of calculi

A
  • acute flank pain which can radiate to the groin

- nausea,vomiting, fever

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29
Q

risk factors for renal stones

A
  • white caucasian
  • obesity
  • high sodium and protein diet
  • carbonic anhydrase inhibitors
  • sodium and calcium containing medication
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30
Q

some of the risk factors for renal stones

A

increase uurianry solute concentration (sodium, calcium, oxalate) and some risk factors reducing concentrations of salt forming inhibitors (citrate and magnesium)

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31
Q

these combined factors cause

A

urine super-saturation causing the formation of calculus

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32
Q

types of stones

A
  • calcium oxalate (most common) and are radiopaque and more likely to form in acidic urine
  • calcium phosphate are radiopaque and most likely to form in alkaline urine
  • struvite are common in chronic UTIS and contain magnesium ammonia and phosphate and are radioopaue
  • uric acid stones are radiolucent
  • cystine stones are very rare and are radiopaque
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33
Q

investigations for renal stones

A

FBCS, CRP, urinalysis

- ULTRASOND IS INITIAL IMAGING OF CHOIDE AND THEN NON-CONTRAST CT

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34
Q

management of renal stones

A
  • Intra-muscular diclofenace
  • tamsulosin
  • stones less than 5mm usually pass spontaneously within 4 weeks
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35
Q

indications to urgently treat renal stones

A

pain unrelieved, persistent causes, vomiting, high- grade obstruction
- ureteric obstruction
- renal abnormality such as horseshoe kidney
- previous renal transplant
URETERIC OBSTRUCTION CAUSED BY STONE COMBINDE WITH INFECTION IS A SURGICAL EMERGENCY options include nephrostomy tube insertion of ureteric catheter or ureteric stent

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36
Q

non-emergency treatment of renal stones

A
  • shock wave lithotripsy
  • ureteroscopy (indicated in individuals where shock wave lithotripsy is contra-indicated i.e. pregnant females and in complex stone disease). In most cases a stent is left in situ for 4 weeks after the procedure
  • percutaneous nephroplithotomy
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37
Q

causes f acute scotrum

A
  • testicualr torsion
  • torsion of the tesitucal appendix
  • epidydymitis
  • incarcerated inguinal hernia
  • hydroecels
  • trauma
38
Q

testicular torsion most commonly occurs in who

A

pubertal boys

39
Q

symptoms of testicualr torsion

A

extreme pain, nausea, vomtinting,

40
Q

signs in testisuatl torsion

A
  • loss of cremator reflex

- prehns sign negative (lifting the testes does not relieve the pain, but in epidydymitis this would receive the pain)

41
Q

management of testicualr torsion

A

emergency surgery as ultrasound is not always diagnostic

42
Q

what is important about contralateral testes in testicualr torsion

A

if the person has a bell clapper deformity (tunica vaginlais joins high on the spermatic cord) the contra-lateral testes must also be corrected as there is increased risk of testicualr torsion

43
Q

torsion of the testicular appendage is

A

twisting of the testicular appendix around its own axis

44
Q

torsion of the testicular appendage is

A

completely self-limiting however, you must rule out testicualr torsion

45
Q

symptoms of torsion of the testicualr appendage

A

pain, swelling, blue dot sign, the cremaster reflex is PRESENT

46
Q

epidydymitis

A

usually a sexually transmitted infection of the epididymis

47
Q

2 most common organisms causing epidydymitis

A
  • neisseria gonorrhoea

- chlamydia trachomatis

48
Q

presentation of epidydymitis

A

scrotal pain, fever, dysuria and erythema

49
Q

what sign differentiates epidydymitis from testicualr torsion

A

preens sign which is positive in epidydymitis, when you elevate the testis the pain is relieved

50
Q

diagnosis of epidydymitis

A

doppler ultrasound to rule out testicualr torsion, urine culture and chlamydia PCR

51
Q

treatment of epidydymitis

A

ofloxacin 400mg/day for 14 days analgesia and bed rest and scrotal elevation

52
Q

phimosis

A

almost all boys have a retractable foreskin at birth, the inner foreskin is attached to the glans, foreskin adhesions then breakdown and the process of retraction is spontaneous and requires no manipulation which is called physiological phimosis, phimosis is not a problem unless it uses urinary obstruction haeamturia or local pain

53
Q

paraphymosis occurs when

A

a tight prepuce (foreskin) is retracted and unable to be replaced as the glans swells

54
Q

treatment of paraphymosis

A

iced glove, manual decompression of glans and last line is dorsal incision if this fails

55
Q

priapism

A

prolonged erection which lasts longer than 4 hours it is often painful and is not associated with sexual arousal

56
Q

priapism can be

A

low flow of high flow piapism

57
Q

low flow priapism

A
  • painful
  • ischaemic corpora= dark blood on corporal aspiration
  • no evidence of trauma
58
Q

high flow priapism

A
  • not painful
  • well-oxygenated corpora
  • evidence of trauma
59
Q

diagnosis of priapism

A

aspiration of blood from the corpus cavernous and a colour duplex ultrasound

60
Q

treatment of non-ischaemic priapism

A

observe as usually resolves spontaneously if not selective arterial embolisation with non-pernament materials

61
Q

treatment of ischaemic priapism

A

aspiration +/- irrigation with saline, injection of alpha agonist (Phenylephrine) 100-200 micrograms every 5-10 mins up to max of 1000 micrograms
- surgical shunt if person presents after 48 hours from onset

62
Q

fournies gangrene

A

type of necrotising fasciitis occurring at the male genitalis

63
Q

fournies gangrene most commonly arises from

A

the skin, urethra or rectal region

64
Q

who is at increased risk of mourners gangrene

A

diabetics, local trauma, peri- urethral extravasation, peri-anal infection

65
Q

fournies gangrene is usually caused by a mixture of

A

aerobes and anaerobes

66
Q

fournies gangrene begins as

A

cellulitis with redness, pain and fever and then it causes dark purple areas and crepitus of the scrotum

67
Q

treatment of mourners gangrene

A

iv fluid and surgical debridement

68
Q

emphysematous pyelonephritis

A

acute necrotising parenchymal and peri- renal infection caused by gas forming uropathogens usually E.coli

69
Q

emphysematous pyelonephritis usually occurs in

A

diabetics and is often associated with a urinary obstruction

70
Q

symptoms of emphysematous pyelnephritis

A

fever, vomiting, flank pain, gas seen on KUB X-ray, CT shows extent of emphysematous process

71
Q

peri-nephric abscess

A

usually results from rupture of an acute cortical abscess into the peri-nephric space or from haematogneous spread

72
Q

peri-nephric abscess onset

A

is insidious with one third not having a fever, 50% have a flank mass, high WCC and creatinine in serum is high

73
Q

diagnosis of a peri-nephric abscess

A

CT

74
Q

Treatment of a peri-nephric abscess

A

IV antibiotics and percutaneous drainage

75
Q

renal trauma classification

A

1= haematoma, sub-capsular, non-expanding, no parenchymal laceration
2= laceration less than 1cm of parenchymal depth without utinary involvement
3= laceration greater than 1cm parenchymal depth, no collecting system rupture of extravasation
4= laceration greater through cortex, medulla and collecting system but haemorrhage is contained
5=shattered kidney, avulsion of the hilum, devascularisation of kidney

76
Q

investigation of renal trauma

A

CT CONTRAST

77
Q

Treatment of renal trauma

A

majority are managed with angiography and embolisation but for persistent bleeding, expanding or pulsatile peri-renal haematoma requires surgery

78
Q

bladder injury commonly is associated with

A

a pelvic fracture

79
Q

presentation of bladder trauma

A

supra-pubic pain, distended bladder inability to void

80
Q

in bladder trauma

A

catheterisation shows gross haematuria, if there is blood at the external meatus or if the catheter does not pass easily this could indicate a urethral injury so stop what you are doing and get a retrograde urethrogram

81
Q

investigations for bladder trauma

A

CT cystography

82
Q

treatment of bladder trauma

A

IV antibiotics, large bore catheter and repeat ct CYSTOGRAPHY IN 2 WEEEKS

83
Q

indications for immediate repair of bladder trauma

A
  • intra-peritoneal injury/ penetrating injury
  • inadequate urinary drainage or clots in urine
  • bladder neck or vaginal injury
  • open pelvic fracture
84
Q

urethral injury

A

posterior urethral injury is often associated with fracture of the pubic rami,

85
Q

most vulnerable part of the urethra in trauma

A

bulbomembranous junction

86
Q

signs of urethral trauma

A

blood at the meatus, inability to urinate, palpable bladder, high-riding prostate, butterfly peri-renal heamatoma

87
Q

investigation of urethral trauma

A

retrograde urethrogram

88
Q

treatment of urethral injury

A

supra-pubic catheter and delayed repair after 3 months §

89
Q

penile fracture classical occurs

A

during sex

90
Q

during a penile fracture

A

a cracking sound followed by pain, scrotal swelling and discolouration is heard

91
Q

in a penile fracture there is

A

20% incidence of a urethral injury

92
Q

treatment of a penile fracture

A

emergency surgery

Renal and Urology (51 decks)

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