urological emergencies Flashcards
what usually causes acute urinary retention?
complication of BPH
types of acute urinary retention?
spontaneous
precipitated
what can cause precipitating AUR?
non-prostate related surgery catheterization urethral instrumentation anaesthesia medication with anticholinergic effect (reduces bladder contraction)
how is AUR managed?
put in a catheter (usually in urethra, or suprapubic if cant get it into urethra)
management without catheter?
if retension with <1L residue and normal serum electrolytes then trial without catheter
prescribe a uroselective alphablocker (alfuzosin) before the trial without catheter (improves change of voiding success)
how does post-obstructive diuresis present and how is it managed?
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non urological causes of loin pain?
AAA
what usually causes acute loin pain?
ureteric colic due to calculus
- pain mediated by release of prostaglandins by ureter in response to obstruction
how is acute loin pain managed?
NSAIDs +/- opiates
alpha blocker for small stones expected ot pass
chance of spontaneous passage of stones?
<4mm = 80% 4-6 = 59 >6 = 21
how long do you give for stones to pass before making plans to remove them?
1 month
indications for urgent removal of kidney stones?
pain unrelieved
pyrexia (infection)
persistent nausea/vomiting
high grade obstruction
how can stones be removed?
ureteric stent or stone fragmentation/removal if no infection
percutaneous nephrostomy for infected hydronephrosis
causes of frank haematuria?
infection (common) stones tumours benign prostatic hyperplasia polycystic kidneys trauma coagulation/platelet deficiencies
how is clot retention (blockage of ureters due to clot) managed?
3 way irrigating haematuria catheter
how is frank haematuria investigated?
CT urogram + cystoscopy
causes of acute scrotum?
torsion of spermatic cord/appendix testis epididymis/epididymo-orchitis inguinal hernia hydrocele trauma/insect bites dermatological lesions inflammatory vasculitis tumour
typical story of torsion of spermatic cord?
teenage boy
can occur with trauma/athletic activity
usually spontaneous
often woken from sleep with sudden onset severe pain
may have has previous episodes of self limiting pain
may have nausea/vomiting
pain can refer to lower abdomen
examination findings of torsion of spermatic cord?
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how is torsion of spermatic cord investigated?
Doppler US
how is torsion of spermatic cord managed?
2 or 3 point fixation with non-absorbable sutures
if testis is necrotic then remove
must fix contralateral side incase it happens to other side (correct bell clapper deformity)
how does torsion of appendage present?
may be insidious onset or identical to cord torsion but usually less severe
may have localised tenderness at upper pole and “blue dot” sign if seen early
testis should be mobile and cremasteric reflex present
how is torsion of appendage managed?
will resolve spontaneously without surgery
how does epididymitis present?
may present similar to torsion
rare in children
dysuria/pyrexia
history of UTI, urethritis, catheterization/instrumentation
examination findings of epididymitis?
creamsteric reflex present
pyuria
swollen epididymis and increased bloodflow on doppler
can show chlamydia on PCR
how is epididymitis managed?
analgesia + scrotal support
bed rest
ofloxacin 400mg/day for 14 days
what is idiopathic scrotal oedema?
self limiting scrotal oedema of unknown cause
no fever, tenderness or redness
may be itchy
what is paraphimosis?
painful swelling of the foreskin distal to phimotic ring
often happens after foreskin retracted for catheterization or cystoscopy and staff forget to put it back to normal position
how is paraphimosis managed?
iced glow granulated sugar for 1-2 hrs multiple punctures in oedematous skin manual compression of glans with distal traction on oedematous foreskin dorsal slit
what is priapism?
prolonged erection (>4 hrs) not associated with sexual arousal often painful
what can cause priapism?
injection for ED trauma haematologic dyscrasias (e.g sickle cell) neurological problem idiopathic
classification of priapism?
ischaemic
- vascular stasis in penis(true compartment syndrome)
- corpora cavernosa (rigid, tender, painful)
what can cause non-ischaemic priapism?
traumatic disruption of penile vasculature - leads to unregulated blood entry and filling of corpora
fistula then form between cavernous artery and lacunar spaces which allows blood to by-pass the normal helicine arteriolar bed
how is priapism diagnosed?
aspirate from corpus cavernosum (dark blood, low O2, high CO2 in low flow, normal blood in high flow)
colour duplex US (minimal/absent flow in cavernosal arteries in low flow, normal/high flow in non-ischaemic priapism)
how is priapism managed?
ischaemic = aspiration +/- irrigation with saline
injection of alpha agonist
surgical shunt
- unlikely to respond to treatment after 48-72 hrs
non-ischaemic = observe, can resolve spontaneously, selective arterial embolization with permanent materials)
what is Fournier’s gangrene?
form of necrotising fasciitis occurring around male genitalia
usually arises from skin, urethra or rectal region
predisposing factors on Fournier’s gangrene?
diabetes
local trauma
periurethral extravasation
perianal infection
what usually causes fourniers gangrene?
mix of aerobes/anaerobes
starts as cellulitis
how does fourniers gangrene present?
starts as cellulitis swollen, erythematous, tender genitalia marked pain, fever and systemic toxicity swelling and crepitus of scrotum dark purple areas X ray may show gas in tissues
how is fourniers gangrene managed?
antibiotics + surgical devridement
what is emphysematous pyelonephritis?
acute necrotising parenchymal and perineal infection caused by gas forming uropathogens, usually E coli
infective emergency
features of emphysematous pyelonephritis?
usually in diabetics
often associated with ureteric obstruction
fever, vomiting, flank pain
gas seen on X ray
how is erythematous pyelonephritis managed?
often needs nephrectomy
what usually causes perinephric abscess and how does it present?
rupture of acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
insidious onset
most are pyrexial but not all
flank mass can be felt in 50%
diagnosis of perinephric abscess?
high WCC
high creatinine
pyuria
CT
management of perinephric abscess?
antibiotics + percutaneous/surgical drainage
5 classifications of renal trauma?
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indications for imaging?
frank haematuria in adults
frank or occult haematuria in child
occult haematuria + shock
penetrating injury with any haematuria
how is blunt renal injury investigated and managed?
CT with contrast
most can be managed non-operatively
angiography/embolization
surgery done if persistent bleeding, expanding haematoma etc)
what usually causes bladder injury and how does it present?
pelvic fracture suprapubic/abdominal pain + inability to void lower abdominal bruising guarding/rigidity diminished bowel sounds
how is bladder injury managed?
catheterization
- retrograde urethrogram if blood at external meatus or catheter doesn’t pass easily (may have urethral injury)
antibiotics
repeat cystogram in 14 days
what usually causes
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