Urological Emergencies Flashcards
What can acute urinary retention be a complication of?
Benign prostatic hyperplasia
What are the symptoms of acute urinary retention?
Inability to urinate with increasing pain
What are some of the proposed aetiologies of acute urinary retention?
Prostate infection, bladder over-distension, excessive fluid intake, alcohol, prostatic infaction
What can acute urinary retention be split into?
Spontaneous (no precipitating cause) or precipitated
What are some precipitating causes of acute urinary retention?
Non-prostate related surgery, catheterisation or urethral instrumentation, anaesthesia, medication with sympathomimetic or anticholinergic effects
What is the first line treatment for acute urinary retention?
Insert a catheter
When should you do a trail without catheter in a patient with acute urinary retention?
If painful retention with <1 litre residue and normal serum electrolytes
What can improve voiding success in a trail without catheter for acute urinary retention?
Prescribing an alpha blocker (e.g alfuzosin, Tamsulosin) before starting
What are some features that may occur due to acute urinary retention?
Post-obstructive diuresis or haematuria
What patients tend to suffer from post-obstructive diuresis?
Patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF or hypertension
What causes post-obstructive diuresis?
Solute diuresis = retained urea, Na+ and K+
Defect in concentrating ability of kidney
How should patients with post-obstructive diuresis be managed?
Monitor fluid balance and beware if urine output > 200ml/hr
What is the prognosis of post-obstructive diuresis?
Usually resolves in 24-48hrs
What is the treatment for severe cases of post-obstructive diuresis?
IV fluid and sodium replacement
What is the haematuria that occur along with acute urinary retention like?
Not uncommon but usually resolves in 24hrs
What is the most common urological cause for acute loin pain?
Ureteric colic secondary to a calculus
What mediates the pain cause by a ureteric calculus?
Prostaglandins released by the ureter in response to obstruction
What is the treatment for ureteric calculi?
NSAIDs +/- opiates Alpha blocker (Tamsulosin) for small stones that are expected to pass
How common is spontaneous passage of ureteric calculi?
80% if <4mm
59% if 4-6mm
21% if >6mm
When is surgical intervention indicated for a ureteric calculus?
If it hasn’t been passed in 1 month
What are the indications that ureteric colic needs urgent treatment?
Pyrexia, pain unrelieved, persistent nausea/vomiting, high grade obstruction
What is the surgical treatment for ureteric calculi?
No infection = ureteric stent or stone fragmentation/removal
Infected hydronephrosis = percutaneous nephrostomy
What are some causes of frank haematuria?
Infection, stones, tumours, benign prostatic hyperplasia, polycystic kidneys, trauma, coagulation/platelet deficiencies
How is frank haematuria investigated?
CT urogram and cystoscopy
How should clot retention in frank haematuria be treated?
Use a 3-way irrigating haematuria catheter
What are some causes of an acute scrotum?
Torsion of the spermatic cord or appendix testis, epididymitis or epididymo-orchitis, inguinal hernia, trauma, hydrocele, insect bite, dermatological lesions, inflammatory vasculitis, tumour
At what age is torsion of the spermatic cord most common?
Puberty
What causes torsion of the spermatic cord?
Can occur with trauma or exercise
Most commonly spontaneous = teen woken from sleep
What are the symptoms of spermatic cord torsion?
Usually sudden onset pain = may have had previous episodes of self-limiting pain, nausea/vomiting, referred pain to abdomen
What may be seen on examination for a patient with torsion of the spermatic cord?
Testes high in scrotum, transverse lie, absence of cremasteric reflex
What may obliterate landmarks as a result of torsion of the spermatic cord?
Acute hydrocele and oedema
What may aid diagnosis of torsion of the spermatic cord?
Doppler US
Why does torsion of the spermatic cord need urgent exploration?
Irreversible ischaemic injury can occur as soon as 4hrs after onset
What is the treatment of spermatic cord torsion?
2 or 3 point fixation with fine non-absorbable sutures
Removes testis if necrotic
Must fix contralateral side = bell clapper deformity
What are the symptoms of appendage torsion?
Variable = may be insidious onset or identical to cord torsion, if seen early may have localised tenderness at upper pole and blue dot sign
What would be seen on examination of a patient with appendage torsion?
Testes mobile and cremasteric reflex present
What is the treatment for torsion of the appendage?
Resolves spontaneously without surgery
What are the features of idiopathic scrotal oedema?
Self limiting and of unknown cause = not associated with scrotal erythema, no fever, minimal tenderness but may have pruritic
What age group is epididymitis rare in?
Children
What is epididymitis difficult to distinguish from?
Torsion
What are the symptoms of epididymitis?
Dysuria and pyrexia common, suspect if pyuria
History of UTI, urethritis or catheterisation/instrumentation
What may be seen on examination of epididymitis?
Cremasteric reflex present, swollen epididymis and increased bloodflow seen on Doppler US
What investigations are done for epididymitis?
Send urine for culture and chlamydia PCR
What is the treatment for epididymitis?
Analgesia, scrotal support and bed rest
Ofloxacin 400 mg/day for 14 days
What is paraphimosis?
Painful swelling of the foreskin of the phimotic ring
What is a common cause of paraphimosis?
Often happens after foreskin is retracted for catheterisation or cystoscopy and staff member forgets to replace it in its normal position
How is paraphimosis treated?
Iced glove, granulated sugar for 1-2hrs, multiple punctures in oedematous skin
Manual compression of glans with distal retraction on oedematous foreskin, dorsal slit
What is priapism?
Prolonged erection = >4hrs, often painful and not associated with arousal
What causes priapism?
Intra-corporeal injection for ED, penile/perineal trauma, idiopathic, haematological dyscrasius (e.g sickle cell), neurological disease
What are the two kinds of priapism?
Ischaemic (veno-occlusive/low flow)
Non-ischaemic (arterial/high flow)
What causes ischaemic priapism?
Vascular stasis in penis and decreased venous outflow = true compartment syndrome
What are some features of ischaemic priapism?
Corpora cavernosa are rigid and tender, penis often painful
What occurs in non-ischaemic priapism?
Traumatic disruption of penile vasculature results in unregulated blood entry and filling of corpora
What does fistula formation between cavernous artery and lacunar spaces allow in non-ischaemic priapism?
Allows blood to bypass the normal helicine arteriolar bed
What is the blood aspirate like for ischaemic priapism?
Dark blood, low O2 and high CO2
What is the blood aspirate like for non-ischaemic priapism?
Normal arterial blood
What investigations are done for priapism?
Aspirate of blood from corpus cavernosum
Colour duplex US of cavernosal arteries
What is the colour duplex US result in priapism?
Ischaemic = minimal/absent flow Non-ischaemic = normal/high flow
How is ischaemic priapism treated?
Aspiration +/- irrigation with saline
Injection of alpha agonist = phenylephrine 100-200 micrograms every 5-10 mins
Surgical shunt
How does delayed presentation affect ischaemic priapism management?
If over 48-72hrs then unlikely to respond to intra-cavernosal treatment = consider immediate placement of penile prosthesis
What is the treatment for non-ischaemic priapism?
Observe as may resolve spontaneously
Selective arterial embolization with non-permanent materials
What is Fournier’s gangrene?
Form of necrotising fasciitis that affects the male genitalia = usually a mixture of anaerobes and aerobes
What areas are commonly affected by Fournier’s gangrene?
Skin, urethra or rectal region
What are the risk factors for Fournier’s gangrene?
Diabetes, local trauma, periurethra extravasation, perianal infection
Mortality 20% higher in diabetics and alcoholics
How does Fournier’s gangrene start?
Starts as cellulitis = swollen, erythematous, tender, marked pain, fever, systemic toxicity
What are the symptoms of Fournier’s gangrene?
Swelling and crepitus of scrotum, dark purple areas, often marked toxicity out of proportion with local findings
What investigations can be done for Fournier’s gangrene?
Plain x-ray and USS may show gas in tissues
What is emphysematous pyelonephritis?
Acute necrotising parenchymal and perirenal infection = caused by gas forming uropathogens (usually E.coli)
What patient group are most at risk of emphysematous pyelonephritis?
Diabetics
What are the features of emphysematous pyelonephritis?
Often associated with ureteric obstruction, fever, vomiting, flank pain, gas on KUB
How is emphysematous pyelonephritis investigated and treated?
Investigation = CT defines extent of process Treatment = often requires nephrectomy
What causes a perinephric abscess?
Rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
What are the features of a perinephric abscess?
Insidious onset, 66% pyrexial, flank mass in 50%, high white cell count and serum creatine, pyuria
How are perinephric abscesses investigated and treated?
Investigation = CT Treatment = antibiotics and percutaneous/surgical drainage
What is stage I renal trauma?
Haematoma, subcapsular, non-expanding, no parenchymal laceration
What is stage II renal trauma?
Laceration <1cm parenchymal depth without urinary extravasation
What is stage III renal trauma?
> 1cm depth, no collecting system rupture or extravasation
What is stage IV renal trauma?
Laceration through cortex, medulla and collecting system, main arterial/venous injury with contained haemorrhage
What is stage V renal trauma?
Shattered kidney, avulsion of hilum (devascularises kidney)
What are the indications for doing imaging in renal trauma?
Frank haematuria in adult, frank or occult haematuria in child, occult haematuria and shock (<90mmHg systolic at any point), penetrating injury with any degree of haematuria
How is renal trauma investigated?
CT with contrast
How are blunt renal injuries managed?
98% can be managed non-operatively = angiography or embolization
What are the indications for surgery in renal trauma?
Persistent renal bleeding, expanding perirenal haematoma, pulsatile perirenal haematoma, urinary extravasation, non-viable tissue, incomplete staging
What are bladder injuries commonly associated with?
Pelvic fracture
What are the symptoms of bladder injuries?
Suprapubic/abdominal pain and inability to void = may also have lower abdominal bruising, guarding/rigidity, diminished bowel sounds
What does catherization of patients with bladder injury show?
Haematuria in 90-100%
When should a retrograde urethrogram be done in a patient with a bladder injury?
If there is blood at the external meatus or if the catheter doesn’t pass easily = may have urethral injury
How does an extraperitoneal bladder injury appear on imaging?
Flame shaped collection of contrast in pelvis
What is the treatment for bladder injuries?
Large bore catheter, antibiotics, repeat cystogram in 14 days
What are the indications for immediate repair of bladder injuries?
Intraperitoneal or penetrating injury
Inadequate drainage or clots in urine
Bladder neck, vaginal or rectal injury
Open pelvic fracture or fracture requiring open fixation
Patients undergoing laparotomy for other reasons
Bone fragments projecting into bladder
What are posterior urethral injuries associated with?
Fracture to the pubic rami
Why is the bulbomembranous junction of the urethra most vulnerable to injury?
Posterior urethra fixed at urogenital diaphragm and puboprostatic ligaments
What observations may be seen in a urethral injury?
Blood at meatus, inability to urinate, palpably full bladder, high riding prostate, butterfly perineal haematoma
What investigation is done for urethral injuries?
Retrograde urethrogram
How are urethral injuries treated?
Suprapubic catheter, delayed construction after at least 3 months
When do penile fractures occur?
usually during intercourse = buckling injury when penis slips out of vagina and strikes pubis
What are the symptoms of penile fractures?
Crackling/popping sound followed by pain, rapid detumescence, discolouration and swelling
What often occurs alongside a penile fracture?
20% have urethral injury = frank haematuria or blood at meatus
How are penile fractures treated?
Prompt exploration and repair, circumcision incision with degloving of penis to expose all three compartments
How do testicular injuries present?
Exquisite pain and nausea = swelling and bruising are variable
How are testicular injuries investigated?
USS to assess integrity/vascularity
How are testicular injuries treated?
Early exploration and repair = improves testis salvage, reduces convalescence, better preserves fertility and hormonal function
