Urological Emergencies Flashcards
What is the most common urological emergency?
Acute urinary retention
What is acute urinary retention?
when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine.
Epidemiology of acute urinary retention?
Whilst acute urinary retention is common in men, it rarely occurs in women (incidence ratio of 13:1). It occurs most frequently in men over 60 years of age and incidence increases with age.
It has been estimated that around a third of men in their 80s will develop acute urinary retention over a five year period.
Aetiology of acute urinary retention?
In men, most commonly occurs secondary to benign prostatic hyperplasia
Other urethral obstructions; including urethral strictures, calculi, cystocele, constipation or masses. Usually post-op
Medications
Less commonly, there may be a neurological cause
In patients with predisposing causes, a simple urinary tract infection can be enough
in women postpartum: usually secondary to a combination of the above risk factors.
Which medications can cause acute urinary retention
Medications affecting nerve signals to the bladder: these include anticholinergics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines.
Acute urinary presentation typically is
subacute onset of: Inability to pass urine Lower abdominal discomfort Considerable pain or distress an acute confusional state may also be present in elderly patients
How is acute urinary retention different from chronic?
This differs from chronic urinary retention which is typically painless. In a patient with a background of chronic urinary retention, acute urinary retention may present instead with overflow incontinence.
Signs of acute urinary retention?
Palpable distended urinary bladder either on an abdominal or rectal exam
Lower abdominal tenderness
Investigations for acute urinary retention?
Patients should all be investigated with a urine sample which should be sent for urinalysis and culture. This might only be possible after urinary catheterisation.
Serum U&Es and creatinine should also be checked to assess for any kidney injury.
A FBC and CRP should also be performed to look for infection
PSA is diagnostic of acute urinary retention
false
PSA is not appropriate in acute urinary retention as it is typically elevated
To confirm the diagnosis of acute urinary retention
bladder ultrasound should be performed. A volume of >300 cc confirms the diagnosis, but if the history and examination are consistent, with an inconsistent bladder scan, there are causes of bladder scan inaccuracies and hence the patient can still have acute urinary retention.
Management of acute urinary retention?
decompressing the bladder via catheterisation
What should you measure after catheterisation in acute urinary retention? What does this indicate?
volume of urine drained in 15 minutes measured. A volume of <200 confirms that a patient does not have acute urinary retention, and a volume over 400 cc means the catheter should be left in place. In between these volumes, it depends on the case.
Further investigations after decompression of acute urinary retention?
Further investigation should be targeted by the likely cause. In reversible causes such as UTI, resolution with treatment is sufficient and further investigation is not necessary. Men not diagnosed by BPH should be further evaluated by a urologist, Patients with neurological symptoms should be evaluated by a neurologist and women with gynaecological symptoms by a gynaecologist. Where no likely cause is identified, patients should be evaluated by a urologist for anatomical and urodynamic causes.
Complications of acute urinary retention?
post-obstructive diuresis
the kidneys may increase diuresis due to the loss of their medullary concentration gradient. This can take time re-equilibrate
this can lead to volume depletion and worsening of any acute kidney injury
some patients may therefore require IV fluids to correct this temporary over-diuresis
What is Balanitis?
inflammation of the glans penis and sometimes extends to the underside of the foreskin which is known as balanoposthitis
What causes balanitis?
most common causes are infective (both bacterial and candidal) although there are a number of other autoimmune causes that are important to know
Simple hygiene is a key part of the treatment of balanitis
true
both improper washing under the foreskin and the presence of a tight foreskin can make balanitis worse
balanitis is an acute presentation
false
The presentation can either be acute or more chronic and children and adults are affected by the causes differently.
assessment of balanitis?
Most diagnoses are made clinically based on the history and examination.
The history will tell you how acute the presentation is and other key features that are important to note are whether there is itching or discharge.
In the history also look for the presence of other systemic conditions affecting the skin such as eczema, psoriasis or connective tissue diseases.
Describe the frequency, acute/chronic presentation and features of Candidiasis as a cause of balanitis
Very common Acute
Usually occurs after intercourse and associated with itching and white non-urethral discharge
Describe the frequency, acute/chronic presentation and features of Dermatitis (contact or allergic) as a cause of balanitis
Very common Acute
Itchy, sometimes painful and occasionally associated with a clear non-urethral discharge. Often there is no other body area affected
Describe the frequency, acute/chronic presentation and features of Dermatitis (eczema or psoriasis) as a cause of balanitis
Very common Both
Very itchy but not associated with any discharge and there will be a medical history of an inflammatory skin condition with active areas elsewhere on the body
Describe the frequency, acute/chronic presentation and features of Dermatitis (eczema or psoriasis) as a cause of balanitis
Very common Both Very itchy but not associated with any discharge and there will be a medical history of an inflammatory skin condition with active areas elsewhere on the body
Describe the frequency, acute/chronic presentation and features of bacterial infection as a cause of balanitis
Common Acute Painful and can be itchy with yellow non-urethral discharge and most often due to Staphylococcus spp.
Describe the frequency, acute/chronic presentation and features ofAnaerobic infection as a cause of balanitis
Common Acute May be itchy but is most associated with a very offensive yellow non-urethral discharge
Describe the frequency, acute/chronic presentation and features of lichen planus as a cause of balanitis
Uncommon Both May be itchy, the main diagnostic feature is the presence of Wickham’s striae and violaceous papules
Describe the frequency, acute/chronic presentation and features of lichen sclerosis as a cause of balanitis
Rare Chronic May be itchy, associated with white plaques and can cause significant scarring
also known as balanitis xerotica obliterans
Describe the frequency, acute/chronic presentation and features of Plasma cell balanitis of Zoon as a cause of balanitis
Rare Chronic Not itchy with clearly circumscribed areas of inflammation
Describe the frequency, acute/chronic presentation and features of circinate balanitis as a cause of balanitis
Uncommon Both Not itchy and not associated with any discharge. The key feature is painless erosions and it can be associated with reactive arthritis
Most causes of balanitis occur in adults and children. Which are more common in adults?
Circinate
Lichen Planus
Investigations Balanitis
The majority of conditions are diagnosed clinically based on the history and physical appearance of the glans penis.
In the cases of suspected infective causes a swab can be taken for microscopy and culture which may demonstrate bacteria or Candida albicans.
When there is a doubt about the cause and there is extensive skin change, then a biopsy can be helpful in confirming the diagnosis.
general tx balanitis
There are three things which form the basis of management of all causes of balanitis; gentle saline washes, ensuring to wash properly under the foreskin, and in the case of more severe irritation and discomfort then 1% hydrocortisone can be used for a short period.
When the cause is not clear, these measures can often resolve the condition alone.
Bacterial balanitis is most often due to? how is this tx
Bacterial balanitis is most often due to Staphylococcus spp. or Group B Streptococcus spp. and can be treated with oral flucloxacillin or clarithromycin if penicillin allergic.
Anaerobic balanitis is managed
with saline washing and can also be managed with topical or oral metronidazole if not settling.
Dermatitis and circinate balanitis are managed with
mild potency topical corticosteroids (e.g. hydrocortisone)
Lichen sclerosus and plasma cell balanitis of Zoon are managed with
high potency topical steroids (e.g. clobetasol).
Circumcision can help in the case of lichen sclerosus.
How is candidiasis balanitis mx
In the case of candidiasis the treatment is with topical clotrimazole which has to be applied for two weeks to fully treat the infection.
Circumcision for religious or cultural reasons is not available on the NHS.
true
The medical benefits of routine circumcision remain controversial although some evidence has emerged that it:
reduces the risk of penile cancer
reduces the risk of UTI
reduces the risk of acquiring sexually transmitted infections including HIV
true
Medical indications for circumcision
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
It is important to exclude what prior to circumcision
hypospadias
foreskin may be used in surgical repair.
What is priapism
persistent penile erection, typically defined as lasting longer than 4 hours and is not associated with sexual stimulation
Priapism can be described as either? Describe
Priapism can be described as either ischaemic or non-ischaemic with both categories having a different pathophysiology.
Ischaemic priapism is typically due to impaired vasorelaxation and therefore reduced vascular outflow resulting in congestion and trapping of de-oxygenated blood within the corpus cavernosa.
Non-ischaemic priapism is due to high arterial inflow, typically due to fistula formation often either as the result of congenital or traumatic mechanisms.
Epidemiology of priapism?
Age at presentation has a bimodal distribution, with peaks between 5-10 years and 20-50 years of age
incidence has been estimated at up to 5.34 per 100,000 patient-years
Causes of priapism?
Idiopathic
Sickle cell disease or other haemoglobinopathies
Erectile dysfunction medication (e.g. Sildenafil and other PDE-5 inhibitors), this also includes intracavernosal injected therapies.
Other drugs both prescribed (anti-hypertensives, anticoagulants, antidepressants etc) and recreational (specifically cocaine, cannabis and ecstasy).
Trauma
Presentation priapism?
A persistent erection lasting over 4 hours
Pain localised to the penis - Patients may, more rarely, present with either a non-painful erection or an erection that is not fully rigid: these are both suggestive of non-ischaemic priapism.
Often a history of either known haemoglobinopathy or use of certain medications
History of trauma to the genital or perineal region: also suggestive of non-ischaemic priapism.
Which investigation differentiates between 2 types of priapism? What would this show?
Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic:
in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased.
Diagnosis of priapism is clinical
true
investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.
Investigations in priapism?
Cavernosal blood gas analysis
Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis.
A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
Ischaemic priapism is a medical emergency
true
delayed treatment can lead to permanent tissue damage and long-term erectile dysfunction.
Outline mx ischaemic priapism?
If the priapism has lasted longer than 4 hours
first-line treatment is aspiration of blood from the cavernosa, this is often combined with injection of a saline flush to help clear viscous blood that has pooled.
If aspiration and injection fails, then intracavernosal injection of a vasoconstrictive agent such as phenylephrine is used and repeated at 5 minute intervals.
If medical therapy fails then surgical options can be considered.
Outline mx non ischaemic priapism?
Non-ischaemic priapism is not a medical emergency and is normally suitable for observation as a first-line option.
What is testicular torsion
twist of the spermatic cord resulting in testicular ischaemia and necrosis.
testicular torsion most common?
males aged between 10 and 30 (peak incidence 13-15 years)
testicular torsion testis is retracted downwards
false
retracted upwards
Which reflex is lost in TT
cremasteric reflex
What is Prehn’s sign
elevation of the testis does not ease the pain in testicular torsion
How doe sTT present?
pain is usually severe and of sudden onset
the pain may be referred to the lower abdomen
nausea and vomiting may be present
on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
cremasteric reflex is lost
elevation of the testis does not ease the pain (Prehn’s sign)
testicular torsion mx
treatment is with urgent surgical exploration
Why are both testes fixed in TT?
condition of bell clapper testis is often bilateral
risk factors for TT?
abnormal testicular lie
What is Epididymo-orchitis
infection of the epididymis +/- testes resulting in pain and swelling.
Causes of Epididymo-orchitis
most commonly caused by local spread of infections from the genital tract (such as Chlamydia trachomatis and Neisseria gonorrhoeae) or the bladder.
In EO The most important differential diagnosis is
testicular torsion
This needs to be excluded urgently to prevent ischaemia of the testicle.
factors suggesting testicular torsion vs EO
patients < 20 years, severe pain and an acute onset
Features of Epididymo-orchitis
unilateral testicular pain and swelling
urethral discharge may be present, but urethritis is often asymptomatic
Epididymo-orchitis mx
if the organism is unknown BASHH recommend: ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
further investigations following treatment are recommended to exclude any underlying structural abnormalities
