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2MBChB Renal > Urological Emergencies > Flashcards

Urological Emergencies Flashcards

1
Q

What is acute urinary retention?

A

A complication of benign prostatic hyperplasia (BPH).

Inability to urinate with increasing pain.

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2
Q

What is the aetiology of acute urinary retention?

A

Poorly understood.

Prostate infection.

Bladder overdistention.

Excessive fluid intake.

Alcohol.

Prostate infarction.

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3
Q

What are the indications to treat ureteric calculi urgently?

A

Pain unrelieved.

Pyrexia.

Persistent nausea/vomiting.

High-grade obstruction.

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4
Q

What is the treatment for urgent treatment of ureteric calculi?

A

Ureteric stent or stone fragmentation removal if there is no infection.

Percutaneous nephrostomy for infected hydronephrosis.

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5
Q

What are the causes of frank haematuria?

A

Infection.

Stones.

Tumours.

Benign prostatic hyperplasia (BPH).

Polycystic kidneys.

Trauma.

Coagulation/platelet deficiencies.

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6
Q

If there is frank haematuria with clot retention what would you use?

A

A 3-way irrigating haematuria catheter.

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7
Q

What investigations would you do for frank haematuria?

A

CT urogram.

Cystoscopy.

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8
Q

What are the causes of an acute scrotum?

A

Torsion of spermatic cord.

Torsion of appendix testis.

Epididymitis/epididymo-orchitis.

Inguinal hernia.

Hydrocoele.

Trauma/insect bite.

Dermatological lesions.

Inflammatory vasculitis.

Tumour.

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9
Q

What are the symptoms of torsion of the spermatic cord?

A

Most common at puberty.

Can occur with trauma or athletic activity but usually spontaneous. Adolescent often woken from sleep.

Usually sudden onset of pain, sometimes previous episodes of self-limiting pain.

May be nausea/vomiting.

May be referral of pain to lower abdomen.

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10
Q

What will you see on examination of torsion of the spermatic cord?

A

Testis high in the scrotum.

Transverse lie.

Absence of cremasteric reflex.

Acute hydrocoele and oedema may obliterate landmarks.

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11
Q

What is the treatment of torsion of the spermatic cord?

A

Prompt exploration - irreversible ischaemic injury may begin as soon as 4hrs.

2- or 3-point fixation with fine non-absorbable sutures.

If testis necrotic then remove.

MUST fix contralateral side (bell clapper deformity).

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12
Q

What are the symptoms of epididymitis?

A

Rare in children.

May be difficult to distinguish from torsion.

Dysuria/pyrexia more common.

History of UTI, urethritis, catheterisation/instrumentation.

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13
Q

On examination, what do you expect to see from epididymitis?

A

Cremasteric reflex present.

Suspect if pyuria.

Doppler – swollen epididymis, increased blood flow.

Send urine for culture + chlamydia PCR.

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14
Q

What is the treatment of epididymitis?

A

Analgesia and scrotal support.

Bed rest.

Ofloxacin 400mg/day for 14 days.

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15
Q

What is paraphimosis?

A

Painful swelling of the foreskin distal to a phimotic ring.

Often happens after foreskin retracted for catheterisation or cystoscopy and staff member forgets to replace it in its natural position.

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16
Q

What is the treatment for paraphimosis?

A

Iced glove, granulated sugar for 1-2hrs, multiple punctures in oedematous skin.

Manual compression of glans with distal traction on the oedematous foreskin

Dorsal slit.

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17
Q

What is priapism?

A

Prolonged erection (>4 hours).

Often painful and not associated with sexual arousal.

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18
Q

What is the aetiology of priapism?

A

Intracorporeal injection for ED, e.g. papaverine.

Trauma (penile/perineal).

Haematologic dyscrasias e.g. sickle cell.

Neurological conditions.

Idiopathic.

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19
Q

What is ischaemic priapism?

A

Vascular stasis in the penis and decreased venous outflow, a true compartment syndrome.

Corpora cavernosa are rigid and tender, penis often painful.

Veno-occlusive or low-low.

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20
Q

What is non-ischaemic priapism?

A

Traumatic disruption of penile vasculature results in unregulated blood entry and filling of corpora.

Fistula formation between the cavernous artery and lacunar spaces allows blood to bypass the normal helicine arteriolar bed.

Arterial or high-flow.

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21
Q

What is the treatment of ischaemic priapism?

A

Aspiration +/- irrigation with saline.

Injection of alpha-agonist.

Surgical shunt.

If been ongoing for 48-72 hours it will be unlikely to respond to intracavernosal treatment.

Specialised centres may even consider immediate placement of a penile prosthesis.

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22
Q

What is the treatment of non-ischaemic priapism?

A

Observe as may resolve spontaneously.

Selective arterial embolisation with non-permanent materials.

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23
Q

What is Fournier’s gangrene?

A

A form of necrotizing fasciitis occurring about the male genitalia.

Most commonly arises from skin, urethra or rectal region.

24
Q

What are the predisposing factors for Fournier’s gangrene?

A

Diabetes.

Local trauma.

Periurethral extravasation.

Perianal infection.

25
Q

What is the treatment for Fournier’s gangrene?

A

Antibiotics and surgical debridement.

26
Q

What is the presentation of Fournier’s gangrene?

A

Starts as cellulitis – swollen, erythematous, tender.

Marked pain, fever, systemic toxicity.

Swelling & crepitus of scrotum, dark purple areas.

Often marked toxicity out of proportion to the local findings.

27
Q

What are infective emergencies?

A

Emphysematous pyelonephritis.

Fournier’s gangrene.

Perinephric abscess.

28
Q

What is a perinephric abscess?

A

Usually results from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection.

Insidious onset.

1/3 are not pyrexial.

Flank mass in 1/2.

High WCC, high serum creatinine and pyuria.

29
Q

What is the treatment of perinephric abscess?

A

Antibiotics & percutaneous or surgical drainage.

30
Q

What is the investigation of choice fro suspected perinephric abscess?

A

CT.

31
Q

What is the classification for renal trauma?

A

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, devascularisng kidney.

32
Q

What are the indications for imaging renal trauma?

A

Patients presenting with:

  • Frank haematuria in an adult.
  • Frank or occult haematuria in children.
  • Occult haematuria & shock (systolic BP <90mmHg).
  • Penetrating injury with any degree of haematuria.
33
Q

What is the treatment for renal trauma?

A

Most cases can be managed non-operatively by angiography/embolisation.

Surgery if there is persistent renal bleeding, expanding perirenal haematoma or pulsatile perirenal haematoma.

Urinary extravasation, non-viable tissue, incomplete staging (can do on-table IVU).

34
Q

What are the indications of immediate repair of a bladder injury?

A

Intraperitoneal injury

Penetrating injury.

Inadequate drainage or clots in urine.

Bladder neck injury.

Rectal or vaginal injury.

Open pelvic fracture.

Pelvic fracture requiring open reduction/fixation.

Patients undergoing laparotomy for other reasons.

Bone fragments projecting into the bladder.

35
Q

What is posterior urethral injury often associated with?

A

Fracture of the pubic rami.

36
Q

What will a urethral injury look like on examination?

A

Blood at meatus.

Inability to urinate.

Palpably full bladder.

“High-riding” prostate.

Butterfly perineal haematoma.

37
Q

What is the investigation of choice for a urethral injury?

A

Retrograde urethrogram.

38
Q

What is the treatment for a urethral injury?

A

Suprapubic catheter.

Delayed reconstruction after at least 3 months.

39
Q

What is a penile fracture?

A

Typically happens during intercourse – buckling injury when the penis slips out of the vagina and strikes pubis.

Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling.

20% incidence of urethral injury (frank haematuria/blood at meatus).

40
Q

What is the treatment for penile fracture?

A

Prompt exploration and repair.

Circumcision incision with degloving of the penis to expose all 3 compartments.

41
Q

What does testicular injury present with?

A

Exquisite pain and nausea.

Swelling/bruising variable.

42
Q

What is the investigation of choice for a testicular injury?

A

USS to assess integrity/vascularity.

43
Q

What is the treatment for testicular injury?

A

Early exploration/repair improves testis salvage, reduces convalescence, better preserves fertility and hormonal function.

44
Q

What can trigger acute urinary retention?

A

Non-prostate related surgery.

Catheterisation or urethral instrumentation.

Anaesthesia.

Medication with sympathomimetic or anticholinergic effects.

45
Q

What is the treatment for acute urinary retention?

A

Catheter.

46
Q

What is the treatment for acute loin pain?

A

NSAID +/- opiate.

Alpha-blocker (tamsulosin) for small renal stones that are expected to pass.

47
Q

What is the treatment of idiopathic scrotal oedema?

A

Self-limiting, unknown cause, not usually associated with scrotal erythema.

No fever, tenderness minimal but there may be pruritis.

48
Q

How can non-ischaemic priapism be diagnosed?

A

Aspirate blood from the corpus cavernosum will be normal arterial blood.

Colour duplex USS will show normal to high flow in cavernosal arteries.

49
Q

How can ischaemic priapism be diagnosed?

A

Aspirate blood from corpus cavernosum will be dark blood, low in oxygen and high in carbon dioxide.

Colour duplex USS will show minimal or absent flow in cavernosal arteries.

50
Q

What is emphysematous pyelonephritis?

A

An acute necrotising parenchymal and perirenal infection caused by gas-forming uropathogens (usually e. coli).

Usually occurs in diabetics.

Often associated with ureteric obstruction.

51
Q

What are the symptoms of emphysematous pyelonephritis?

A

Fever.

Vomiting.

Flank pain.

52
Q

How do investigations diagnose emphysematous pyelonephritis?

A

Gas will be seen on KUB xray.

CT will define the extent of the emphysematous process.

53
Q

What is the treatment for emphysematous pyelonephritis?

A

Often requires nephrectomy.

54
Q

What is bladder injury normally associated with?

A

Pelvic fracture.

55
Q

What are the clinical features of bladder injury?

A

Suprapubic/abdominal pain & inability to void.

Suprapubic tenderness.

Lower abdominal bruising.

Guarding/rigidity.

Diminished bowel sounds.

Catheterisation will show gross haematuria in 90-100% cases.

If blood at external meatus or if the catheter doesn’t pass easily then perform retrograde urethrogram – may well have a urethral injury.

56
Q

What investigations are done for a suspected bladder injury?

A

CT cystoscopy.

57
Q

What is the treatment for a bladder injury?

A

Large-bore catheter.

Antibiotics.

Repeat cystogram in 14 days.

2MBChB Renal (20 decks)

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