Urological Emergencies Flashcards
What is a common complication of BPH?
Acute Urinary Retention
What causes acute urinary retention?
Infection, overdistention, excessive fluid intake, alcohol, infarction
State factors that can precipitate acute urinary retention
- non-prostate related surgery
- catheterisation
- urethral instrumentation
- anaesthesia
- medication (anticholinergic/sympathomimetic)
How is acute urinary retention treated?
Catheter
In what circumstances can a catheter be removed in patients with previous acute urinary retention?
If <1 litre and normal electrolytes, can trial without a catheter but must prescribe a uroselective alpha blocker first
Name a uroselective alpha blocker
Tamulosin
What is post-obstructive diuresis?
Chronic obstruction associated with oedema, uraemia, hypertension - as a result of solute diuresis and defect in concentrating ability
How is post-obstructive diuresis treated?
Monitor fluid balance and it usually resolves in 24-48hours
What is the main concern in acute loin pain?
AAA
What is acute loin pain often due to?
Ureter colic secondary to calculus
How does the ureter respond to obstruction?
Releases prostaglandins which causes pain
State the relationship between size of stone and likelihood of passage
<4mm - 80%
4-6mm - 59%
>6mm - 21%
How is a stone treated?
NSAID +/- opiate
Alpha blocker if the stone is small and expected to pass
After how long will intervention be required for a stone?
1 month
What symptoms associated with loin pain signify treatment is urgent?
Pyrexia, pain unrelieved, persistent nausea/vomitting, high grade obstruction
How can a stone be removed?
Stent, surgical removal or nephrostomy for infected hydronephrosis
State the potential causes of frank haematuria
Infection, stones, tumours, BPH, polycystic kidneys, trauma, coagulation/platelet deficiencies (blood clot)
What investigations are done on a patient with frank haematuria?
CT urogram and cystoscopy
How is clot retention treated?
A 3 way irrigating haematuria catheter
State the causes of acute scrotum?
Torsion of spermatic cord/appendix testis Epididymitis Inguinal hernia Hydrocele Trauma Vasculitis Tumour
Describe the presentation of spermatic cord torsion
Most common in puberty, can occur during sport or spontaneously (sleep), sudden onset pain, nausea/vomiting
On examination what will be found in spermatic cord torsion?
Testes will be high in scrotum and may lie transverse, absent cremasteric reflex
What investigations are carried out in suspected torsion?
Doppler USS
How is spermatic cord torsion treated?
2-3 point fixation, remove if necrotic, fix bell clapper deformity if present on other side
Describe torsion of appendage
Variable symptoms and may have blue dot, cremasteric reflex will be present and testis mobile - should resolve spontaneously without surgery
What is epididymitis caused by?
UTI or STI
How does epididymitis present?
Dysuria/pyrexia
History of UTI
Urethritis
Post catheterisation/instrumentation
What investigation can be done in epidiymitis?
Doppler - will show swelling and increased blood flow
Urine culture & chlamydia PCR
How is epididymitis treated?
Analgesia, scrotal support and ofloxacin (14 days)
Describe idiopathic scrotal oedema
Self limiting, minimal tenderness may be itchy
What is the name given to swelling of the foreskin distal to the phimotic ring?
Paraphimosis
What causes paraphimosis?
Retraction for catheterisation/cystoscopy
How is paraphimosis treated?
Iced glove
Granulated sugar
Manual compression
Multiple punctures/slit if other options fail
State the term used to describe a prolonged erection
Priapism
After how long is an erection considered pathological?
4 hours
What causes priapism?
ED injection Trauma Sickle cell Neurological conditions Idiopathic Atherosclerosis
What are the two types of priapism?
Ischaemic
Non-ischemic
Describe ischaemic priapism
Low flow, leads to vascular stasis and decreased venous outflow - compartment syndrome
Describe non-ischaemic priapism
High flow, traumatic disruption to vasculature leads to unregulated blood entry and filling of corpora, fistula formation allows blood to by-pass arteriolar bed
What investigations are carried out in priapism?
Blood aspirate, duplex colour USS
How can ischaemic priapism be treated?
Aspiration and irrigation with saline
Injection of alpha agonist
Surgical shunt
How is non-ischaemic priapism treated?
May resolve spontaneously if not arterial embolisation of damaged vessel
What is the name given to necrotising fasciitis that arises from the skin/urethra/rectal region?
Fournier’s Gangrene
What are the risk factors for Fournier’s gangrene?
Diabetes
Trauma
Extravasation
Infection
What is the progression of fournier’s gangrene?
Cellulitis –> swelling, dark purple areas –> toxicity
Describe the features of x-ray/USS of fourniers gangrene
Gas in tissues
How is fournier’s gangrene treated?
Antibiotics and debridement
What is emphysematous pyelonephritis?
Acute necrotising infection caused by gas forming uropathogens e.g. e.coli
Who is most affected by emphysematous pyelonephritis?
Diabetics associated with ureteric obstruction
How does emphysematous pyelonephritis present?
Fever, vomiting, flank pain
What investigations are done on emphysematous pyelonephritis?
CT
X-ray - gas
What treatment is often required in emphysematous pyelonephritis?
Nephrectomy if antibiotics and drainage fails
How does a perinephric abscess often arise?
- Rupture of an acute cortical abscess into the perinephric space
- Haematogenous spread of infection
How does a perinephric abscess present?
Insidious onset, pyrexia, 50% flank mass,
What will biochemistry of a patient with a perinephric abscess show?
High WCC, serum creatinine and pyuria
How is a perinephric abscess diagnosed and treated?
CT scan
Antibiotics or drainage
What are the 5 classes of kidney trauma?
I - haematuria
II - laceration <1cm
III - >1cm laceration but no rupture or extravasation
IV - laceration through cortex, medulla and collecting system, main arterial/venous injury with contained haemorrhage
V - shattered kidney
What are the indications for imaging in kidney trauma?
Frank haematuria/occult in children
Occult haematuria and shock
Penetrating injury
How is renal trauma investigated?
CT with contrast
How is renal trauma treated?
Most can be managed by angiography and embolisation
Surgery - persistent bleeding, expanding haematuria, pulsatile haematoma, urinary extravasation, non-viable tissue
What is bladder trauma associated with?
Pelvic fracture
How does bladder trauma present?
Suprapubic/abdominal pain, inability to void, suprapubic tenderness, lower abdominal bruising, guarding/rigidity, diminished bowel sounds
What indicated urethral injury?
Blood at external meatus
Catheter does not pass easily
How is badder trauma investigated?
CT cystography
How will extraperitoneal injury appear on imaging?
Flame shaped collection of contrast in pelvis
State the treatment for bladder trauma
Large bore catheter and antibiotics - repeat cystogram in 14 days
What merits immediate repair in bladder trauma?
Intraperitoneal injury Penetrating injury Inadequate drainage/clots in urine Bladder neck/rectal/vaginal injury Open pelvic fracture Bone fragments into the bladder
What is posterior urethral injury often associated with?
Fracture of the pubic rami
Why is the bubomembranous junction the most vulnerable?
Fixed at urogenital diaphragm and puboprostatic ligaments
In urethral trauma what clinical features will be present?
Blood at meatus, inability to urinate, full palpable bladder, high-riding prostate, perineal haematoma (butterfly appearance)
How is urethral injury investigated?
Retrograde urethrogram
How is urethral injury treated?
Suprapubic catheter and delayed reconstruction
How does penile trauma most commonly occur?
Usually during intercourse, bucking injury when penis slips out of vagina and strikes pubis
Describe the process of penile trauma
Crack/pop followed by detumescence and discolouration
How is penile trauma managed?
Prompt exploration and repair but circumcision incision with degloving to expose all 3 compartments
How does testicular trauma present?
Exquisite pain and nausea sometimes with associated swelling and bruising
Describe the management of testicular trauma
USS to assess integrity and vascularity followed by surgical repair
