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2MB Extra Material > Urological Emergencies > Flashcards

Urological Emergencies Flashcards

1
Q

Is Acute Urine Retention a Medical Emergency?

A

Yes

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2
Q

What is acute urine retention often a complication of?

A

Benign Prostatic Hyperplasia (BPH)

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3
Q

What is the aetiology of acute urinary retention?

A

Poorly understood.

Prostate infection 
Prostatic infarction
Bladder overdistension 
Excessive fluid intake 
Alcohol
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4
Q

How is acute urinary retention classed?

A

Spontaneous

Precipitated (triggered by an event)

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5
Q

List some events which lead to precipitated acute urinary retention?

A 
Non-prostate related surgery,
Catheterization,
Urethral instrumentation,
Alcohol, 
Anticholinergic medications 
Prostatic infarction
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6
Q

What is the classic sign of acute urinary retention?

A

Inability to pee, with increasing pain

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7
Q

How is acute urinary retention managed?

A

If painful retention with < 1 litre residue and normal serum electrolytes then trial without catheter (TWOC) during same admission.
Prescribing a uroselective alpha-blocker (Alfuzosin, Tamsulosin) before TWOC should improve chance of voiding success but evidence does not prove this

Otherwise, Catheterization

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8
Q

How does Post-obstructive diuresis present?

A

Often present in patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF, hypertension

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9
Q

How does post-obstructive diuresis occur?

A

Occurs due to solute diuresis (loss of urea, sodium and water) AND defect in concentrating ability of kidney

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10
Q

How is post-obstructive diuresis managed?

A

Monitor fluid balance and beware if urine output > 200ml/hr. Usually resolves in 24-48hr but in severe cases, may require IV fluid and sodium replacement

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11
Q

Is Haematuria self-limiting in acute urinary retention?

A

Yes, common but resolves within 24 hours

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12
Q

What are common differentials for acute loin pain?

A

Leaking AAA

Ureteric Colic secondary to calculus

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13
Q

How does ureteric colic secondary to calculus occur?

A

Mediated by prostaglandin release by the ureter in response to obstruction
Often relates to the site of stone at first presentation

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14
Q

How is ureteric colic secondary to calculus managed?

A

NSAID +/- Opiate

Tamsulosin alpha blocker can be given for small stones that are expected to pass but evidence is not strong

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15
Q

What are the chances of a calculus passing, according to their size?

A

<4mm: 80%
4-6mm: 59%
>6mm: 21%

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16
Q

When is intervention needed for ureteric colic secondary to calculus?

A

If stone hasn’t passed in 1 month then likely to require intervention as it is unlikely to pass

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17
Q

What are indications to treat urgently in renal calculus?

A

Pain unrelieved for 24-48 hours
Pyrexia, which can indicate infection
Persistent N&V
High-grade obstruction

Plan to remove stone even if small

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18
Q

Describe imaging used for renal calculi?

A

First line is KUB X-Ray
If patient is pregnant, has gynae disease or pyelonephritis, then USS
Second line is CT Stone Search or MRI

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19
Q

What is the management for ureteric colic secondary to renal calculi if NOT passed spontaneously?

A

Ureteric stent or stone fragmentation/removal if no infection

Percutaneous nephrostomy for infected Hydronephrosis i.e. a tube through the loin into kidney

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20
Q

List causes of Frank Haematuria

A 
Infection
Stones
Tumours
Benign prostatic hyperplasia (BPH)
Polycystic kidneys
Trauma
Coagulation/platelet deficiencies
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21
Q

For haematuria due to clot retention of urine, what is the management?

A

3-way irrigating haematuria catheter which you can aspirate hard and the catheter does not collapse.
Islet allows clots to pass

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22
Q

For haematuria due to clot retention of urine, what are the investigations?

A

CT Urogram and Cytoscopy

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23
Q

Describe the general presentation of testicular torsion

A

Common during puberty
Can occur with trauma or athletic activity but usually spontaneous. Adolescents often woken from sleep
Usually sudden onset of pain, sometimes previous episodes of self-limiting pain
May have nausea/vomiting or referral of pain to lower abdomen

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24
Q

What would you feel on examination with testicular torsion?

Testis, duh

A

Spasm of the cremaster muscles causing loss of the cremasteric reflex
Transverse lying of the affected testicle
Testis high in scrotum

Acute hydrocoele and oedema may obliterate landmarks, if it has been lying for hours

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25
Q

What are investigations for testicular torsion?

A

Doppler USS which can used to aid differentials when unsure of diagnosis.
Will show if there is blood supply to the teste or not

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26
Q

What is the management of testicular torsion?

A

Prompt exploration prior to USS
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 to prevent bell clapper deformity

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27
Q

How does Torsion of Appendix present?

A

Symptoms variable – may be insidious in onset or identical to torsion of spermatic cord.
If seen early, may have localised tenderness at upper pole and “blue dot” sign
Testis should be mobile and cremasteric reflex present

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28
Q

Is Torsion of Appendix self-limiting?

A

Yes, if diagnosis confirmed then will resolve spontaneously without surgery

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29
Q

What is Epididymitis?

A

Inflammation of the epididymis tube, often caused by infection

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30
Q

How does Epididymitis present?

A

History of:
UTI,
Dysuria/Pyrexia, Urethritis, Catheterization/Instrumentation
General Unwellness

May be difficult to distinguish from Torsion
Rare in children

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31
Q

How does epididymitis present on examination?

A

Cremasteric reflex present
Suspect if pyuria
Doppler shows swollen epididymis and increased blood flow

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32
Q

What is the main investigation for epididymitis?

A

Urine for culture + Chlamydia PCR

Typically;
Young men = chlamydia
Old men = UTI

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33
Q

What is the management for epididymitis?

A

Analgesia, Scrotal support and bed rest

Ofloxacin 400mg/day for 14 days

34
Q

How does idiopathic scrotal oedema present?

A

NO FEVER
Minimal Tenderness
Possible Pruritis
Unknown cause

35
Q

How is idiopathic scrotal oedema treated?

A

Usually self-limiting
Can be treated with Fluoroquinolone for
Can be treated with Ciprofloxacin or Trimethroprim for UTI

36
Q

What is Paraphimosis?

A

Retracted foreskin which cannot be returned to its normal anatomical position creating a tight, phimotic ring

37
Q

How does paraphimosis present?

A

Painful swelling of the foreskin distal to a phimotic ring

38
Q

How does paraphimosis occur?

A

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

39
Q

What is the treatment of paraphimosis?

A 
Iced glove
Granulated sugar for 1-2hrs
Multiple punctures in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit
40
Q

What is Priapism?

A

Prolonged erection (> 4hrs), often painful and NOT associated with sexual arousal

41
Q

What is the aetiology for Priapism?

A 
Intracorporeal injection for Erectile Dysfunction, e.g. Papaverine
Trauma (penile / perineal)
Haematologic dyscrasias e.g. sickle cell
Neurological conditions
Idiopathic
42
Q

What is the classification for priapism?

A

Ischaemic (More common)

Non-ischaemic

43
Q

How does ischaemic priapism occur?

A

Vascular stasis in penis in which arterial blood can flow in but venous flow is decreased/stopped.

Corpora cavernosa are rigid and tender, penis often painful

44
Q

How does Non-Ischaemic priapism occur?

A

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

Fistula formation between cavernous artery and lacunar spaces allows blood to by-pass the normal helicine arteriolar bed

45
Q

How is priapism diagnosed?

A

Blood Aspiration from corpus cavernosum for either dark blood (low O2 and high CO2) in Ischaemic or normal arterial blood in high-flow

Colour duplex USS which will show minimal or absent flow in cavernosal arteries in low-flow ischaemic priapism and normal to high flow in non-ischaemic priapism

46
Q

What is treatment of Ischaemic Priapism?

A

Aspiration +/- irrigation with saline to take out pressure and restore normal circulation of corpus carvenosa
Injection of alpha-agonist, e.g. Phenylephrine 100-200ug every 5-10 mins up to max 1000ug
Surgical shunt
Ischaemic priapism > 48-72hrs is unlikely to respond to intracavernosal treatment

For very delayed presentation, may even consider immediate placement of a penile prosthesis

47
Q

What is treatment for Non-Ischaemic Priapism?

A

Observe, may resolve spontaneously (fibrosis lower risk due to oxygenation)

Selective arterial embolization with non-permanent materials

48
Q

What is Fournier’s Gangrene?

A

A form of necrotizing fasciitis occurring about the male genitalia which most commonly arises from an infectious skin, urethra or rectal lesion

49
Q

What are predisposing factors for Fournier’s gangrene?

A 
Diabetes 
Local trauma 
Periurethral extravasion 
Perianal infection 
Alcohol
50
Q

Describe the progression for Fournier’s gangrene?

A

Starts as cellulitis – swollen, erythematous, tender.
Then marked pain, fever, systemic toxicity, spreads rapidly into abdominal wall
Then swelling and crepitus of scrotum, dark purple areas

Often marked toxicity out of proportion to the local findings

51
Q

Investigations for Fournier’s Gangrene?

A

Plain X-ray or USS may confirm gas in tissues if unsure

52
Q

How is Fournier’s Gangrene treated?

A

Antibiotics

Surgical Debridement

53
Q

What is Emphysematous pyelonephritis?

A

An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E coli

54
Q

Who does Emphysematous pyelonephritis classically effect?

A

Usually occurs in diabetics

Often associated with ureteric obstruction

55
Q

What are symptoms of Emphysematous pyelonephritis

A

Fever
Vomiting
Flank Pain

56
Q

What are investigations for Emphysematous pyelonephritis?

A

KUB X-Ray which shows Gas

CT defines extent of emphysematous process

57
Q

How is Emphysematous pyelonephritis usually treated?

A

Nephrectomy

58
Q

How does Peripnephric Abscess occur?

A

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

59
Q

What are symptoms of perinephric abscess?

A 
Insidious onset in around 33% 
NOT PYREXIAL 
Flank mass in 50% Flank swelling can be seen 
High WCC
High serum creatinine, Pyuria
60
Q

What are investigations for perinephric abscess?

A

CT

61
Q

What is treatment for perinephric abscess?

A

Antibiotics

Percutaneous/Surgical Drainage

62
Q

What are the Levels of the Trauma Renal Classification?

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, devascularizing kidney

63
Q

What are indications for imaging in renal trauma?

A

Frank haematuria in adult
Frank or occult haematuria in child
Occult haematuria + shock (systolic <90mmHg at any point)
Penetrating injury with any degree of haematuria

64
Q

What is the main investigation for renal trauma?

A

Contrast CT

65
Q

How is Renal Trauma treated?

A

98% of blunt renal injuries can be managed non-operatively with angiography/embolization

Surgery is indicated in:

  • Persistent renal bleeding
  • Expanding perirenal haematoma
  • Pulsatile perirenal haematoma
  • Urinary extravasation, - Non-viable tissue, incomplete staging (can do on-table IVU)
66
Q

What is bladder injury commonly associated with?

A

Pelvic fracture

67
Q

How does bladder injury tend to present?

A 
Suprapubic/abdominal pain AND inability to void
Suprapubic tenderness
Lower abdominal bruising
Guarding/rigidity
Diminished bowel sounds
Gross haematuria in 90-100%
68
Q

What is the main imaging for Bladder Injury?

A

CT Cystography

Flame-shaped collection of contrast shows extraperitoneal injury

69
Q

What is the treatment for bladder injury?

A

Large-bore catheter. If blood at external meatus or if catheter doesn’t pass easily then perform retrograde urethrogram as patient may well have urethral injury - check bladder integrity
Antibiotics

Repeat cystogram in 14 days

70
Q

What are indications for immediate repair of the bladder?

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 bladder
71
Q

What is posterior urethral injury often associated with?

A

Fracture of pubic rami

72
Q

What is seen on examination of urethral injury?

A 
Blood at meatus
Inability to urinate
Palpably full bladder
“High-riding” prostate - boggy space where prostate ought to be, i.e. high riding 
Butterfly perineal haematoma
73
Q

What is the main investigation for urethral injury?

A

Retrograde Urethrogram

No Contrast in bladder

74
Q

What is the treatment for urethral injury?

A

Suprapubic catheter

Delayed reconstruction after at least 3 months

75
Q

How does Penile Fracture typically occur?

A

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

76
Q

What is a penile fracture?

A

Tearing of the corpus Cavernosum

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

77
Q

What is a typical history of penile fracture?

A

Intercourse

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

78
Q

What is the treatment for penile fracture?

A

Prompt exploration and repair

Circumcision incision with degloving of penis to expose all 3 compartments

79
Q

How does Testicular Injury present?

A

Usually presents with exquisite pain and nausea

Swelling / bruising variable

80
Q

What is the investigation of testicular injury?

A

USS to assess integrity/vascularity

81
Q

What is the treatment for testicular injury?

A

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

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