Urological Emergencies Flashcards
Is Acute Urine Retention a Medical Emergency?
Yes
What is acute urine retention often a complication of?
Benign Prostatic Hyperplasia (BPH)
What is the aetiology of acute urinary retention?
Poorly understood.
Prostate infection Prostatic infarction Bladder overdistension Excessive fluid intake Alcohol
How is acute urinary retention classed?
Spontaneous
Precipitated (triggered by an event)
List some events which lead to precipitated acute urinary retention?
Non-prostate related surgery, Catheterization, Urethral instrumentation, Alcohol, Anticholinergic medications Prostatic infarction
What is the classic sign of acute urinary retention?
Inability to pee, with increasing pain
How is acute urinary retention managed?
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
How does Post-obstructive diuresis present?
Often present in patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF, hypertension
How does post-obstructive diuresis occur?
Occurs due to solute diuresis (loss of urea, sodium and water) AND defect in concentrating ability of kidney
How is post-obstructive diuresis managed?
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
Is Haematuria self-limiting in acute urinary retention?
Yes, common but resolves within 24 hours
What are common differentials for acute loin pain?
Leaking AAA
Ureteric Colic secondary to calculus
How does ureteric colic secondary to calculus occur?
Mediated by prostaglandin release by the ureter in response to obstruction
Often relates to the site of stone at first presentation
How is ureteric colic secondary to calculus managed?
NSAID +/- Opiate
Tamsulosin alpha blocker can be given for small stones that are expected to pass but evidence is not strong
What are the chances of a calculus passing, according to their size?
<4mm: 80%
4-6mm: 59%
>6mm: 21%
When is intervention needed for ureteric colic secondary to calculus?
If stone hasn’t passed in 1 month then likely to require intervention as it is unlikely to pass
What are indications to treat urgently in renal calculus?
Pain unrelieved for 24-48 hours
Pyrexia, which can indicate infection
Persistent N&V
High-grade obstruction
Plan to remove stone even if small
Describe imaging used for renal calculi?
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
What is the management for ureteric colic secondary to renal calculi if NOT passed spontaneously?
Ureteric stent or stone fragmentation/removal if no infection
Percutaneous nephrostomy for infected Hydronephrosis i.e. a tube through the loin into kidney
List causes of Frank Haematuria
Infection Stones Tumours Benign prostatic hyperplasia (BPH) Polycystic kidneys Trauma Coagulation/platelet deficiencies
For haematuria due to clot retention of urine, what is the management?
3-way irrigating haematuria catheter which you can aspirate hard and the catheter does not collapse.
Islet allows clots to pass
For haematuria due to clot retention of urine, what are the investigations?
CT Urogram and Cytoscopy
Describe the general presentation of testicular torsion
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
What would you feel on examination with testicular torsion?
Testis, duh
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
What are investigations for testicular torsion?
Doppler USS which can used to aid differentials when unsure of diagnosis.
Will show if there is blood supply to the teste or not
What is the management of testicular torsion?
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
How does Torsion of Appendix present?
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
Is Torsion of Appendix self-limiting?
Yes, if diagnosis confirmed then will resolve spontaneously without surgery
What is Epididymitis?
Inflammation of the epididymis tube, often caused by infection
How does Epididymitis present?
History of:
UTI,
Dysuria/Pyrexia, Urethritis, Catheterization/Instrumentation
General Unwellness
May be difficult to distinguish from Torsion
Rare in children
How does epididymitis present on examination?
Cremasteric reflex present
Suspect if pyuria
Doppler shows swollen epididymis and increased blood flow
What is the main investigation for epididymitis?
Urine for culture + Chlamydia PCR
Typically;
Young men = chlamydia
Old men = UTI
What is the management for epididymitis?
Analgesia, Scrotal support and bed rest
Ofloxacin 400mg/day for 14 days
How does idiopathic scrotal oedema present?
NO FEVER
Minimal Tenderness
Possible Pruritis
Unknown cause
How is idiopathic scrotal oedema treated?
Usually self-limiting
Can be treated with Fluoroquinolone for
Can be treated with Ciprofloxacin or Trimethroprim for UTI
What is Paraphimosis?
Retracted foreskin which cannot be returned to its normal anatomical position creating a tight, phimotic ring
How does paraphimosis present?
Painful swelling of the foreskin distal to a phimotic ring
How does paraphimosis occur?
Often happens after foreskin retracted for catheterization or cystoscopy and staff member forgets to replace it in its natural position
What is the treatment of paraphimosis?
Iced glove Granulated sugar for 1-2hrs Multiple punctures in oedematous skin Manual compression of glans with distal traction on oedematous foreskin Dorsal slit
What is Priapism?
Prolonged erection (> 4hrs), often painful and NOT associated with sexual arousal
What is the aetiology for Priapism?
Intracorporeal injection for Erectile Dysfunction, e.g. Papaverine Trauma (penile / perineal) Haematologic dyscrasias e.g. sickle cell Neurological conditions Idiopathic
What is the classification for priapism?
Ischaemic (More common)
Non-ischaemic
How does ischaemic priapism occur?
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
How does Non-Ischaemic priapism occur?
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
How is priapism diagnosed?
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
What is treatment of Ischaemic Priapism?
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
What is treatment for Non-Ischaemic Priapism?
Observe, may resolve spontaneously (fibrosis lower risk due to oxygenation)
Selective arterial embolization with non-permanent materials
What is Fournier’s Gangrene?
A form of necrotizing fasciitis occurring about the male genitalia which most commonly arises from an infectious skin, urethra or rectal lesion
What are predisposing factors for Fournier’s gangrene?
Diabetes Local trauma Periurethral extravasion Perianal infection Alcohol
Describe the progression for Fournier’s gangrene?
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
Investigations for Fournier’s Gangrene?
Plain X-ray or USS may confirm gas in tissues if unsure
How is Fournier’s Gangrene treated?
Antibiotics
Surgical Debridement
What is Emphysematous pyelonephritis?
An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E coli
Who does Emphysematous pyelonephritis classically effect?
Usually occurs in diabetics
Often associated with ureteric obstruction
What are symptoms of Emphysematous pyelonephritis
Fever
Vomiting
Flank Pain
What are investigations for Emphysematous pyelonephritis?
KUB X-Ray which shows Gas
CT defines extent of emphysematous process
How is Emphysematous pyelonephritis usually treated?
Nephrectomy
How does Peripnephric Abscess occur?
Usually results from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
What are symptoms of perinephric abscess?
Insidious onset in around 33% NOT PYREXIAL Flank mass in 50% Flank swelling can be seen High WCC High serum creatinine, Pyuria
What are investigations for perinephric abscess?
CT
What is treatment for perinephric abscess?
Antibiotics
Percutaneous/Surgical Drainage
What are the Levels of the Trauma Renal Classification?
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
What are indications for imaging in renal trauma?
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
What is the main investigation for renal trauma?
Contrast CT
How is Renal Trauma treated?
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)
What is bladder injury commonly associated with?
Pelvic fracture
How does bladder injury tend to present?
Suprapubic/abdominal pain AND inability to void Suprapubic tenderness Lower abdominal bruising Guarding/rigidity Diminished bowel sounds Gross haematuria in 90-100%
What is the main imaging for Bladder Injury?
CT Cystography
Flame-shaped collection of contrast shows extraperitoneal injury
What is the treatment for bladder injury?
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
What are indications for immediate repair of the bladder?
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
What is posterior urethral injury often associated with?
Fracture of pubic rami
What is seen on examination of urethral injury?
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
What is the main investigation for urethral injury?
Retrograde Urethrogram
No Contrast in bladder
What is the treatment for urethral injury?
Suprapubic catheter
Delayed reconstruction after at least 3 months
How does Penile Fracture typically occur?
Typically happens during intercourse – buckling injury when penis slips out of vagina and strikes pubis
What is a penile fracture?
Tearing of the corpus Cavernosum
Associated with 20% incidence of urethral injury (frank haematuria/blood at meatus)
What is a typical history of penile fracture?
Intercourse
Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling
What is the treatment for penile fracture?
Prompt exploration and repair
Circumcision incision with degloving of penis to expose all 3 compartments
How does Testicular Injury present?
Usually presents with exquisite pain and nausea
Swelling / bruising variable
What is the investigation of testicular injury?
USS to assess integrity/vascularity
What is the treatment for testicular injury?
Early exploration/repair which improves testis salvage, reduces convalescence, better preserves fertility and hormonal function
