Urological emergencies Flashcards
acute urinary retention
the sudden inability to pass urine which causes significant pain
acute urinary retention is characterised as
spontaneous or precipitated
precipitated acute urinary retention is where
there is a triggering event i.e. non-prostate related surgery, catheterisation, urethral instrumentation, anaesthesia, medication with sympathomimetic or anti-cholinergic affects
causes of acute urinary retention in men
benign prostatic hyperplasia (most common), meatal stenosis, paraphymosis, prostate cancer
causes of acute urinary retention in woman
cysteocels (where the bladder bulges into the vagina), rectocele (where the rectum bulges into the vagina), pelvic mass (gynaecological malignancy, uterine fibrosis)
in both male and females acute urinary retention can be caused by
bladder calculi, blader cancer, faecal impacatation, GI or retro-peritoneal malignancy
infections and inflammatory causes of acute urinary retention in males
balanitits (inflammation of the glans penis), prostatitis, prostatic abscess
infections and inflammatory causes of acute urinary retention in females
acute vulvovaginitis, lichen sclerosus
infections and inflammatory causes of acute urinary retention which can occur in both males and females
schistosomiasis, cystitis, herpes simplex, peri-urethral abscess
drug related causes of acute urinary retention
anti-cholinergics, opioids, anaestheticis, alpha-adrenergic agonists, benzodiazepines
presentation of acute urinary retention
teder distended palpable bladder with inability to pass urine
management of acute urinary retention
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
what should be prescribed to increase success of trial without catheterisation
alpha blocker (tamsulosin)
how does tamsulosin work
it is a selective alpha blocker which causes relaxation of smooth muscles in the bladder neck and prostate
post obstructive diuresis
high urine output greater than 200ml per hour for more than 2 consecutive hours after an obstruction is relieved
post obstructive diuresis most often presents in patients with
chronic bladder outflow obstruction in associated with uraemia, oedema, congestive heart failure and hypertension
post-obstructive diuresis is a state of
polyuresis where there is excessive amount of water excreted in the urine after treatment of a urinary tract obstruction
diureisus is a normal physiological response
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
in post-obstructive diuresis there is a risk of
dehydration, electrolyte imbalance and hypovolaemic shock
post-obstructive diuresis usually resolves after
24-48 hours but if severe requires IV fluids and sodium replacement
acute loin pain always consider what in your differentials
diagnosis outwith the urinary tract such as AAA
acute loin pain most commonly caused by
nephrolithiasis
the urerter has 3 sites of what
constriction where it contracts smooth muscle, narrowing can occur at these sites and calculi can get lodged here:
- pelvics-ureteric junction
- pelvic brim
- vesico-ureteric orifice
the cells lining the renal tubules are predominantly
cuboidal epithelial cells
within the renal tubules what can form
crystal like structures known as calculus
if the calculus are small enough
the pass out in urine without causing any problems, but if they are large they can cause obstruction
obstruction within the tubules causes
release prostaglandisng causing pain
presentation of calculi
- acute flank pain which can radiate to the groin
- nausea,vomiting, fever
risk factors for renal stones
- white caucasian
- obesity
- high sodium and protein diet
- carbonic anhydrase inhibitors
- sodium and calcium containing medication
some of the risk factors for renal stones
increase uurianry solute concentration (sodium, calcium, oxalate) and some risk factors reducing concentrations of salt forming inhibitors (citrate and magnesium)
these combined factors cause
urine super-saturation causing the formation of calculus
types of stones
- 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
investigations for renal stones
FBCS, CRP, urinalysis
- ULTRASOND IS INITIAL IMAGING OF CHOIDE AND THEN NON-CONTRAST CT
management of renal stones
- Intra-muscular diclofenace
- tamsulosin
- stones less than 5mm usually pass spontaneously within 4 weeks
indications to urgently treat renal stones
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
non-emergency treatment of renal stones
- 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
causes f acute scotrum
- testicualr torsion
- torsion of the tesitucal appendix
- epidydymitis
- incarcerated inguinal hernia
- hydroecels
- trauma
testicular torsion most commonly occurs in who
pubertal boys
symptoms of testicualr torsion
extreme pain, nausea, vomtinting,
signs in testisuatl torsion
- loss of cremator reflex
- prehns sign negative (lifting the testes does not relieve the pain, but in epidydymitis this would receive the pain)
management of testicualr torsion
emergency surgery as ultrasound is not always diagnostic
what is important about contralateral testes in testicualr torsion
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
torsion of the testicular appendage is
twisting of the testicular appendix around its own axis
torsion of the testicular appendage is
completely self-limiting however, you must rule out testicualr torsion
symptoms of torsion of the testicualr appendage
pain, swelling, blue dot sign, the cremaster reflex is PRESENT
epidydymitis
usually a sexually transmitted infection of the epididymis
2 most common organisms causing epidydymitis
- neisseria gonorrhoea
- chlamydia trachomatis
presentation of epidydymitis
scrotal pain, fever, dysuria and erythema
what sign differentiates epidydymitis from testicualr torsion
preens sign which is positive in epidydymitis, when you elevate the testis the pain is relieved
diagnosis of epidydymitis
doppler ultrasound to rule out testicualr torsion, urine culture and chlamydia PCR
treatment of epidydymitis
ofloxacin 400mg/day for 14 days analgesia and bed rest and scrotal elevation
phimosis
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
paraphymosis occurs when
a tight prepuce (foreskin) is retracted and unable to be replaced as the glans swells
treatment of paraphymosis
iced glove, manual decompression of glans and last line is dorsal incision if this fails
priapism
prolonged erection which lasts longer than 4 hours it is often painful and is not associated with sexual arousal
priapism can be
low flow of high flow piapism
low flow priapism
- painful
- ischaemic corpora= dark blood on corporal aspiration
- no evidence of trauma
high flow priapism
- not painful
- well-oxygenated corpora
- evidence of trauma
diagnosis of priapism
aspiration of blood from the corpus cavernous and a colour duplex ultrasound
treatment of non-ischaemic priapism
observe as usually resolves spontaneously if not selective arterial embolisation with non-pernament materials
treatment of ischaemic priapism
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
fournies gangrene
type of necrotising fasciitis occurring at the male genitalis
fournies gangrene most commonly arises from
the skin, urethra or rectal region
who is at increased risk of mourners gangrene
diabetics, local trauma, peri- urethral extravasation, peri-anal infection
fournies gangrene is usually caused by a mixture of
aerobes and anaerobes
fournies gangrene begins as
cellulitis with redness, pain and fever and then it causes dark purple areas and crepitus of the scrotum
treatment of mourners gangrene
iv fluid and surgical debridement
emphysematous pyelonephritis
acute necrotising parenchymal and peri- renal infection caused by gas forming uropathogens usually E.coli
emphysematous pyelonephritis usually occurs in
diabetics and is often associated with a urinary obstruction
symptoms of emphysematous pyelnephritis
fever, vomiting, flank pain, gas seen on KUB X-ray, CT shows extent of emphysematous process
peri-nephric abscess
usually results from rupture of an acute cortical abscess into the peri-nephric space or from haematogneous spread
peri-nephric abscess onset
is insidious with one third not having a fever, 50% have a flank mass, high WCC and creatinine in serum is high
diagnosis of a peri-nephric abscess
CT
Treatment of a peri-nephric abscess
IV antibiotics and percutaneous drainage
renal trauma classification
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
investigation of renal trauma
CT CONTRAST
Treatment of renal trauma
majority are managed with angiography and embolisation but for persistent bleeding, expanding or pulsatile peri-renal haematoma requires surgery
bladder injury commonly is associated with
a pelvic fracture
presentation of bladder trauma
supra-pubic pain, distended bladder inability to void
in bladder trauma
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
investigations for bladder trauma
CT cystography
treatment of bladder trauma
IV antibiotics, large bore catheter and repeat ct CYSTOGRAPHY IN 2 WEEEKS
indications for immediate repair of bladder trauma
- intra-peritoneal injury/ penetrating injury
- inadequate urinary drainage or clots in urine
- bladder neck or vaginal injury
- open pelvic fracture
urethral injury
posterior urethral injury is often associated with fracture of the pubic rami,
most vulnerable part of the urethra in trauma
bulbomembranous junction
signs of urethral trauma
blood at the meatus, inability to urinate, palpable bladder, high-riding prostate, butterfly peri-renal heamatoma
investigation of urethral trauma
retrograde urethrogram
treatment of urethral injury
supra-pubic catheter and delayed repair after 3 months §
penile fracture classical occurs
during sex
during a penile fracture
a cracking sound followed by pain, scrotal swelling and discolouration is heard
in a penile fracture there is
20% incidence of a urethral injury
treatment of a penile fracture
emergency surgery
