Urological Emergencies and Outflow Tract Obstruction

Question 1

Define acute urinary retention?

Answer 1

Inability to urinate with increasing pain

Question 2

What is acute urinary retention often a complication of?

Answer 2

Benign prostatic hyperplasia

Question 3

First treatment of acute urinary retention?

Answer 3

Need a catheter

Question 4

With acute loin pain as well as urinary tract what other causes should you consider?

Answer 4

AA
Malignancy
Ovarian/ testicular Torsion
Ectopic pregnancy
GI cause
Lower resp pain

Question 5

Intense loin to groin pain suggests?

Answer 5

Renal colic

Question 6

Treatment of renal colic?

Answer 6

NSAIDS e.g. diclofenac
Small stones < 0.5cm diameter usually pass spontaneously if hydration is maintained
Larger stones may need intervention

Question 7

Indications to treat renal colic urgently?

Answer 7

Pain is unrelieved by medication, pyrexia, persistent nausea/ vomiting, high grade obstruction

Question 8

Frank haematuria =

Answer 8

Bladder cancer until proven otherwise

Question 9

What must be ruled out in acute scrotum?

Answer 9

Testicular torsion

Question 10

Testicular torsion peaks at what age?

Answer 10

13-15yo

Question 11

Presentation of testicular torsion?

Answer 11

sudden, severe unilateral scrotal pain, associated vomiting

Question 12

Only way to confirm something is testicular torsion or not?

Answer 12

Scrotal exploration

If torsion can untwist

Question 13

What can mimic testicular torsion in slightly younger boys?

Answer 13

Torsion of the appendix testes (hydatid of Morgani)

Question 14

Presentation of torsion of appendix testes?

Answer 14

Similar to testicular torsion potentially slightly less severe
There will be the blue dot sign

Question 15

Blue dot sign?

Answer 15

Torsion of the appendix testes

Question 16

Treatment of torsion of appendix testes?

Answer 16

Supportive

Question 17

Describe benign prostatic hyperplasia?

Answer 17

This occurs often in men over 60 yo and aetiology not fully understood. Microscopically hyperplasia affects the glandular and connective tissue elements of the prostate.
Enlargement of the gland stretches and distorts the urethra obstructing bladder flow.

Question 18

Describe symptoms men with benign prostatic hyperplasia may complain of?

Answer 18

When bladder is filling: frequency, urgency, nocturia
When trying to pass urine: hesitancy, poor flow intermittent flow, sensation of incomplete emptying, post micturition dribbling

Question 19

What suggest high pressure chronic retention in those with BPH?

Answer 19

bedwetting

Question 20

Red flag signs in suspected BPH that may actually suggest bladder cancer?

Answer 20

Haematuria
Suprapubic pain
Recurrent UTIs

Question 21

With suspected BPH what should you make sure to ask about?

Answer 21

Pain in back and neurological symptoms

Need to rule out cauda equina etc

Question 22

Describe exam and investigations for BPH?

Answer 22

Abdo exam > enlarged bladder
DRE > Benign prostate characteristically feels smooth
Investigations: urine culture, serum PSA, renal function, US, pressure flow studies of bladder emptying

Question 23

Medical management of BPH?

Answer 23

Alpha blockers e.g. tamsulosin act to relax prostate and bladder smooth muscle
5 alpha reductase inhibitors e.g. finasteride which block conversion of testosterone to dihydrotestosterone the androgen primarily responsible for prostatic growth and enlargement
Anticholinergics which inhibit bladder smooth muscle contraction
Beta agonist inhibits bladder smooth muscle contraction

Question 24

Describe surgical treatment of BPH?

Answer 24

Transurethral resection of prostate gland or holmium laser enucleation of prostate

Question 25

Priorities in acute retention or retention with overflow in BPH?

Answer 25

Relieve pain and catheterise the bladder

Question 26

3 things that can promote stone formation?

Answer 26

Urinary stasis, infection and indwelling catheters

Question 27

Stones form if stone forming substances _________

Answer 27

reach high enough concentrations to crystallise out of solution

Question 28

Most common stones?

Answer 28

Calcium stones

Question 29

Predisposing factors to calcium stones?

Answer 29

Low urine volume high urine calcium and oxalate Low urine citrate (citrate usually helps inhibit stone formation)

Question 30

Hypercalciuria occurs in _________ of patients with stones and usually idiopathic and due to ________

Answer 30

65% | increased intestinal calcium absorption

Question 31

Urate stones form in what type of urine?

Answer 31

Acidic urine

Question 32

Why may you get acidic urine and urate stones?

Answer 32

May be idiopathic Due to enzyme defects Rapid cell turnover/ death e.g. malignancy and chemo Loss of alkaline bowel contents in diarrhoea, ileostomy, or laxative abuse

Question 33

UTI stones are composed of ________ usually due to infection with __________

Answer 33

magnesium, ammonium phosphate with varying amounts of calcium Proteus

Question 34

Why do cystine stones form?

Answer 34

Due to autosomal recessive defect in the dibasic amino acid transporter which reduces cystine reabsorption causing cystinuria

Question 35

What kidney diseases are associated with stones?

Answer 35

PKD, Medullary sponge kidney and renal tubular acidosis

Question 36

Drugs associated with kidney stones?

Answer 36

Loops, antacids, vit d and c, acetazolamide and theophylline

Question 37

Presentation of renal stones?

Answer 37

``` asymptomatic often Pain: renal colic Haematuria UTI Urinary tract obstruction ```

Question 38

Calculi get stuck at 3 predictable sites which are ________

Answer 38

pelviureteric junction pelvic brim (where ureter kind of turns as goes over the pelvis) vesicoureteric junction

Question 39

Investigations for stones?

Answer 39

``` XR US Contrast CT Check for UTI Check renal function ```

Question 40

Stones _____ usually pass spontaneously

Answer 40

less than 0.5cm in diameter

Question 41

Long term treatment of calcium stones?

Answer 41

Decrease calcium, sodium and animal protein in diet and maintain hydration

Question 42

Long term treatment of urate stones?

Answer 42

Investigate if underlying cause, decrease dietary purines (eg. red meats) increase urine alkalisation with sodium bicarbonate or potassium citrate, allopurinol to inhibit rate production

Question 43

Long term treatment of cystine stones?

Answer 43

Good fluid intake, alkalisation of urine with sodium bicarbonate

Question 44

Acute pain relief for renal colic?

Answer 44

NSAIDS- diclofenac

Question 45

Bladder stones are usually associated with ______ and present with _______

Answer 45

Bacteruira | Frequency dysuria and haematuria

Question 46

Presence of renal stones is usually checked for with?

Answer 46

USS