Urology

Question 1

DDx for microscopic/gross hematuria

Answer 1

Pre-renal:

1) Coagulation disorders, anticoagulants.
2) Pseudohematuria: beets, dyes, laxatives.

Renal:

1) stones
2) Trauma
3) Tumor
4) Infection
5) Inflammation (e.g. glomerulonephritis)
6) Vascular malformation (AVM)

Post-renal:

1) stones
2) Trauma
3) tumors
4) infections (KEEPS)

Question 2

Important Q’s on history for hematuria

Answer 2

Flank/abdominal pain vs suprapubic pain vs painless.
Dysuria, frequency, voiding changes.
Trauma hx.
Fever/chills.
Wt loss, night sweats.
Hx of stones.
RF for Ca: smoking, occupational exposures, radiation exposure.

Question 3

Labs/investigations for hematuria

Answer 3

UA + culture (infection vs nephritis).
Urinary cytology: picks up more aggressive cancers only (if negative cannot r/o malignancy as low grade tumors don’t shed cells).
CBC, PTT/INR.
Creatinine (look for renal impairment).

Question 4

List situations for when US, CT IVP (contrast), CT KUB (non-contrast) would each be first line in the context of hematuria and the pros/cons of each.

Answer 4

US: First line for microscopic hematuria or signs of upper UTI. Good for upper tract imaging when suspected renal tumors, stones in the kidneys or looking for hydronephrosis. However, will miss ureteral stones/tumors, small/flat bladder tumors and gives no functional info.

CT IVP (contrast): first line for pts with gross hematuria for upper imaging. Most sensitive for detecting GU pathology. C/I for contrast may include renal dysfunction, MM, contrast allergy, pregnancy.

CT KUB (non-contrast): 1st line for pts with renal colic. Helps to ID stone location and size and guides tx.

Question 5

Hematuria: when to refer to uro

Answer 5

Gross hematuria with no obvious cause (e.g. no overt signs infection).
Microhematuria with risk factors.
Abnormal cytology results.

Question 6

Symptoms of urothelial carcinoma

Answer 6

Main: painless gross hematuria.

Wt loss, night sweats, voiding changes.

Question 7

Investigations for suspected urothelial carcinoma

Answer 7

CT IVP: triphasic protocol to look at arterial, venous and excretory phases. (upper tract imaging).
Cystoscopy: for lower tract imaging.

Upper and lower imaging needed as everything lined with urothelium is exposed to same risk (field defect theory).

Question 8

Acute management of acute GU bleeding

Answer 8

ABC’s: stabilize.
Determine site of bleeding: CT IVP and cystopscopy.
CBI: manually irrigate all clots first then start CBI to prevent new clots from forming.

Surgical mgmt:
cystoscopy + fulguration.
Intravesicular therapies: aluminum, formalin, silver nitrate.
Hyperbaric oxygen or vascular embolization if unable to control bleeding.
Cystectomy and urinary diversion if severe/unable to control.

Question 9

4 common risk factors for urothelial malignancy

Answer 9

1) SMOKING!!
2) Occupational exposure to aniline dyes (hairdressers, leather tanners, textile workers, painters, dry cleaners).
3) Medications: phenacetin (old analgesic), cyclophosphamide.
4) Chronic cystitis: catheters, infections (associated w/ squamous cell carcinoma).

Question 10

Diagnosis of urothelial carcinoma

Answer 10

Cystoscopy and biopsy with transurethral resection of lesion and underlying detrusor muscle to stag the tumor.

Question 11

Types of urothelial tumors, grading and staging.

Answer 11

1) urothelial carcinoma: transitional cell carcinoma.
2) Adenocarcinoma: affects dome of bladder. Assocated with urachus (remnant connection to bladder).
3) SCC: associated with chronic inflammation (neurogenic bladder, indwelling catheter, bladder stones, schistosomiasis).

Grading: low grade (70%) or high grade.

Staging: Non-muscle invasive (NMIBC) T0, T1 or muscle invasive (MIBV) T2+ (T2 once muscularis propria invaded).

Question 12

Treatment of non-muscle invasive bladder cancer

Answer 12

Transurethral resection of lesion (TURBT) but associated with hi recurrence rate.

Follow up with intravesicular chemo.
Strong indications for intra-vesicular chemo include high grade NMIBC, lamina propria invasion (T1), CIS, multi-focal NMIBC, unable to completely resect, rapid recurrence initial resection.

Options for intra-vesicular chemo:
1) BCG: bacille Calmette Guerin. Attenutated bacillus that causes and immune response in the bladder such that cytokines are released that attack cancer cells. Decreases progression of cancer. Need maintenance tx every 3 months to keep steady state.

2) Mitomycin C: Reduces recurrence risk. Give immediately post-TURBT int he OR to kill free cancer cells.

When to give radical therapy:

1) persistent CIS after intravesicular chemo.
2) extensive superficial tumors that are not amenable to resection.

Question 13

Tx of muscle invasive bladder cancer

Answer 13

1) Radical cystectomy + lymphadenectomy +/- systemic chemo: urinary diversion (ileal conduit or neobladder can be surgically created). Chemo with cisplatin/gemcitabine.
2) Palliative: may still require cystectomy tho if uncontrollable hematuria.

Question 14

DDx for a benign solid mass in the kidney

Answer 14

1) Oncocytoma: capsulated area with central scarring. Treat as RCC as difficult to differentiate on imaging.
2) Angiomyolipoma: composed of blood vessels, muscle and fat. Excise/embolise if symptomatic or if >4 cm (50% hemorrhage risk!). Follow with imaging (1-2% malignancy risk).
3) Abscess
4) Adenoma: not symptomatic, small.
5) Pseudotumor: E.g. dromedary hump, hypertrophied column of Bertin, compensatory hypertrophy. DMSA scan wil have normal uptake vs tumors have decreased uptake.

Question 15

DDx for a malignant renal mass

Answer 15

1) RCC makes up 90% of solid renal masses, 25% presents with mets.
2) Urothelial cell carcinoma: nephrourecterectomy required.
3) Metastasis: lymphoma, leukemia, lung, breast.
4) Wilm’s tumor (peds)

Question 16

Histological subtypes of RCC (4)

Answer 16

Clear cell, papillary, chromophobe, sarcomatoid.

Question 17

Typical presentation of pt with RCC.

Answer 17

1) Incidental finding: asymptomatic until late.
2) Classic triad: flank pain, hematuria, palpable mass (uncommon until late).
3) Paraneoplastic syndromes are common (20-30% of RCC)

Question 18

What are some of the common paraneoplastic syndromes associated with RCC?

Answer 18

1) hematologic: anemia, polycythemia (secondary to high EPO).
2) Hypercalcemia: PTH like substance secretion.
3) High ESR.
4) HTN: increased renin.
5) Stauffer syndrome: abnormal liver enzymes, low WBC, fevers. Reversible with treatment of RCC.

Question 19

Labs and imaging for suspected RCC

Answer 19

Labs: CBC, ESR, LE, Ca, ALP (look for bone involvement), UA.

Imaging:
CT abdo/pelvis with contrast to characterize mass, assess tumor extension, look for IVC thrombus/nodes/mets. Contralateral renal abnormalities (5% chance of cancerous lesion).
CXR for mets.
Biopsy NOT recommended.

Question 20

Tx options for RCC

Answer 20

If localized:

1) Nephrectomy.
2) Partial nephrectomy: if small tumor (<7cm), pt w/ solitary kidney/impaired RF, bilateral tumors, hereditary syndromes (Von Hippel-Lindau Syndrome).
3) Ablation therapy: radiofrequency or cryotherapy.
4) Targeted therapies: Y kinase inhibitrs, anti-VEGF mAb, mTOR inhibitors.

Metastatic RCC: nephrectomy and chemo.

Question 21

DDx flank pain

Answer 21

Life-threatening: AAA rupture, AA dissection, appendicitis, ectopic pregnancy, septic stone.

GI: Cholecystitis, biliary colic, acute pancreatitis, diverticulitis, PUD, IBC, gastritis, infarct.

Gyne: PID, Ovarian torsion/rupture, endometriosis.

GU: renal/ureteric calculi, renal abscess, pyelonephritis, renal vein thrombosis, acute glomerulonephritis.

Question 22

Nephrolithiasis: etiology of pain + sites of obstruction

Answer 22

Acute obstruction of ureter by stone causes distension of ureter which causes pain.

Sites of impaction include: ureteropelvic junction, crossing of iliac and ureterovesicular junction.

Question 23

Labs and imaging for renal colic

Answer 23

Labs: WBC, Cr, UA/urine microscopy (bacteriuria, pyuria, pH).

CT KUB (non-contrast): picks up uric acid stones. Can infer degree of obstruction by presence of hydronephrosis.

XR KUB: 85% of stones are radio-opaque but can’t pick up uric acid stones or tell degree of obstruction.

Question 24

What are the 4 types of kidney stones

Answer 24

Calcium oxalate (most common), calcium phosphate, struvite (infection stones), uric acid stones.

Question 25

Etiology of calcium oxalate stones

Answer 25

1) Dietary hyperoxaluria (chocolate, nuts, tea, strawberries, PB, excessive dietary Ca restriction).
2) Hypercalcuria: inherited icnreased absorption, hyperPTH.
3) Dietary hypercalciuria: if increased sodium and protein intake as well.

Question 26

Etiology of calcium PO4 stones

Answer 26

Associated with metabolic abnormalities including:

1) Primary hyperparathyroidism.
2) Distal RTA
3) Hypercalcemia due to malignancy or sarcoid

Question 27

Composition and etiology of struvite (infection) stones.

Answer 27

Formed from MAP (magnesium, ammonium phosphate and Ca).
Only form if urine pH >8 which occurs with urease positive bacteria such as klebsiella, Proteus, Pseudomonus, staph. Does NOT form with E coli (not urease positive).
Forms staghorn stones.

Question 28

Etiology of uric acid stones

Answer 28

1) Persistent acidic urine (low urine volume, chronic diarrhea, excessive sweating ,dehydration).
2) Gout: hyperuricemia.
3) Excess dietary purine: meats.
4) chemotherapy for lymphoma or leukemia patients.

Question 29

4 Tx options for symptomatic urinary calculi

Answer 29

1) Acute medical tx with analgesia, anti-emetics, warm compress.
2) Retrograde ureteric stents (double J stents).
3) Percutaneous nephrostomy tubes (drain kidney proximally).
4) Removal of stone: Spontaneous passage (if <5 mm), extracorporeal shockwave lithotripsy (ESWL) if <2 cm, ureteroscopy and basket/laser or percutaneous nephrolithotomy if >2cm or staghorn calculi (risk of bleeding, renal perforation).

Question 30

Indications for emergency drainage of obstructed kidney

Answer 30

1) obstructed ureter with fever/chills, bacteriuria, elevated WBC (urosepsis risk).
2) solitary kidney
3) renal failure
4) intractable pain or n/v.
5) comorbidities: CHF, pregnant

Question 31

DDx of scrotal mass

Answer 31

1) Cele’s: hydrocele, spermatocele, hematocele, varicocele.
2) Infection: epididymitis, orchitis.
3) Torsion
4) hernia
5) malignancy

Question 32

Hx taking Q’s for scrotal mass

Answer 32

Pain, onset, firmness, STD hx, LUTs, urethreal d/c. Hx of undescended testes.

Question 33

PEx findings to look for with scrotal mass

Answer 33

Location, tenderness, transilluminance, reflexes.

Question 34

Tests for scrotal mass

Answer 34

UA: pyuria with epididymitis or orchitis.
US: sensitive and sp for testicular tumors, torsion.

Question 35

Hydrocele: What, SS, tests, mgmt

Answer 35

Collection of serous fluid that results from a defect or irritation in the tunica vaginalis. Considered ‘communicating hydrocele’ if processus vaginalis (cogenital connection between peritoneum and scrotum) is patent.

SS: non-tender, cystic intrascrotal mass (unable to palpate testicle!). Transilluminates

Do US to r/o tumor.

Surgery indicated if symptomatic, very large or for cosmetic purposes. Surgery better option than I+D (higher infxn/bleeding risk).

Question 36

Epididymitis/orchitis: etiology, symptoms, investigations, mgmt

Answer 36

Epididymitis: STI or E coli.
Orchitis: mumps, infection from urinary tract.

SS: PAIN! Epididymitis- tender, indurated epididymis. Orchitis- swollen, tender, testicles, often bilateral.

Cremasteric reflex PRESENT (stroke thigh and watch for contraction of cremasteric muscle).
Positive Prehn’s sign: lifting testis alleviates pain.

Investigations: CBC, UA showing pyuria.

Abx x4 wks, NSAIDs and ice PRN.

Question 37

Spermatocele: what, SS, investigations/mgmt

Answer 37

Cystic dilation of epididymal tubule due to obstruction (sperm and fluid).

SS: non-tender, cystic mass, able to palpate testicle separate from mass, transilluminates.

US to r/o tumor.

No tx required unless for cosmesis.

Question 38

Hematocele: what, SS, mgmt

Answer 38

Trauma with blood present in the tunica vaginalis.

SS: tender, no transillumination.

Do US to exclude # of testis.

Tx: Ice packs, analgesia, surgical repair.

Question 39

Indirect inguinal hernia: what, SS, tx

Answer 39

Protrusion of abdominal contents through inguinal canal into the scrotum.

SS: pain with straining, lifting, if strangulated. Testis separable from hernia. Small bulge that increases in size with gravity/valsalva. No transillumination.

Tx: surgical repair.

Question 40

Testicular torsion: what, SS, mgmt

Answer 40

Twisting of testicle causes venous occlusion/engorgement and arterial ischemia/infarct.

SS: acute severe scrotal pain, swelling, retracted and horizontal testis. Negative cremasteric reflex and Prehn’s sign.
Bell clapper deformity (2 turns of cord to completely obstruct arterial flow.

Only do Doppler US if diagnosis unclear (loo for decreased flow of teticular artery.
Detort: like opening a book (untwist outward), buys some time before OR (use lidocaine without epi).
Do exploration and bilateral orchidopexy within 4-6 hrs to preserve testicle.

Question 41

Varicocele: what, SS, tx

Answer 41

Dilation and tortuosity of pampiniform plexus. Incompetent valves in testicular veins (90% are left sided!). Associated with male infertility due to increased temperature of scrotum.

SS: bag of worms cosmetically, non-tender, no transillumination, increases in size with valsalva, decreases in size when supine.

Tx with surgical ligation or angiographic sclerosis if impaired sperm, pain or for cosmesis.

Question 42

Primary vs secondary testicular cancers

Answer 42

Primary testis cancer:
1) Germ cell tumor (95%):
Non-seminoma: embryonal, teratoma, choriocarcinoma, yolk sac tumor.
Seminoma.

2) non-germ cell tumors: Leydig cell tumors or Sertoli cell tumors.

Secondary testicular cancers: Lymphoma or leukemia.

Question 43

Symptoms of testicular tumors

Answer 43

Painless, intratesticular mass discovered on self-exam. Increased size of testicle.
Age 15 - 35. 
Does not transilluminate. 
Feels hard and irregular. 
Constitutional symptoms.

Question 44

RF for testicular tumors

Answer 44

Cryptorchidism, atrophy, HIV, infertility, famHx.

Question 45

Labs for ?testicular tumor

Answer 45

bHCG and alpha fetoprotein: both produced by non-seminomatous tumors.

LDH: correlates with tumor bulk

Question 46

Imaging for ?testicular tumor

Answer 46

Scrotal US: look for hypoechoic mass.

CXR, CT abdo/pelvis: look for mets for staging.

Question 47

Tx for testicular tumor

Answer 47

Radical orchiectomy: always via INGUINAL approach NEVER scrotal.
Note that lymphatic spread goes to retroperitoneal lymph nodes, not to inguinal lymph nodes as is for the scrotum.

Question 48

Mgmt of cryptorchidism in infants

Answer 48

Abnormal location of testes somewhere along the normal path of descent: external inguinal ring > inguinal canal > abdominal.

Perform orchiopexy.

Prognosis: reduced fertility, increased malignancy risk, increased risk of torsion.

Question 49

Describe the innervation of the bladder + sphincters

Answer 49

Detrusor muscle: S234 (muscarinic receptors) cause contraction. Beta3 SNS receptors on detrusor inhibit detrusor contraction.

Trigone: SNS L1 - L2 (alpha receptors), relax bladder neck.

Internal sphincter (male): PNS S234.

External sphincter: somatic/voluntary S234 (pudendal). Forms urethral mucosal seal as bladder fills in women.

Question 50

Role of CNS in bladder control

Answer 50

Cortex: in storage mode, inhibits reflexive bladder emptying.

Pontine micturition center: inhibits steady state spinal reflex of continence. Cortex communicates with PMC when it is time to void and activates detrusor, inhibits sphincter contraction.

Question 51

Effects of LMN leson below S2 on voiding

Answer 51

Causes flaccidity of bladder.
No bladder tone (no sacral reflex and lose communication to PMC).
Bladder fills until it overflows (overflow incontinence). Bladder fills but is in storage mode with no sensation of high volume.

Occurs with sacral spinal cord damage or peripheral nerve damage.

Question 52

Effects of UMN lesion above pons to bladder

Answer 52

Get spastic bladder.
Normal function of brain is to inhibit reflexive bladder emptying. Dysfunction results in loss of voluntary control of micturition but PSNS intact.

Get detrusor overactivity with continuous contraction.

Cerebral injury (e.g. stroke, tumor, brain injury) -> detrusor overactivity/urge incontinence.

Basal ganglia disease (e.g. Parkinsons): Detrusor overactivity with urge incontinence but contractions are short and relaxation of external sphincter is slowed. Get urgency/urge incontinence but with slow flow.

Question 53

Difference between UMN between pons - T6 and between T6 - sacral spine

Answer 53

Both: no communication between PMC and sacral area. Sacral reflex intact and no way for brain to inhibit SNS/somatic contraction of sphincters.

Above T6: destrusor-sphincter dysnergia with urgency incontinence but variable/slow stream.

Below T6: reflexive micturition but with detrusor-sphincter synergia.

Question 54

Describe the DDx for urge incontinence

Answer 54

Stones, UTI, tumor, overactive bladder

Question 55

Management of urge incontinence

Answer 55

Treat underlying cause.
Conservative mgmt: timed voiding, bladder training (biofeedback).

Medical mgmt: 
Anticholinergics: e.g. oxybutynin. 
Alpha-agonists: e.g. TCAs, imipramine. 
B3 agonists: inhibit detrusor contraction. 
Botox injections into bladder muscle. 

Surgical mgmt (rare): 
Bladder augmentation or urinary diversion.

Question 56

Etiology and RF for stress incontinence

Answer 56

Increased abdominal pressure, internal sphincter deficiency, urethral hypermobility.

RF: obesity, female, pregnancy, vaginal deliveries, hysterectomy, prostatectomy.

Question 57

Management of stress incontinence

Answer 57

Conservative mgmt: Kegel exercises, biofeedback, pessaries to support bladder.

Medical:
Alpha agonists (TCA, SSRI, pesudoephedrine): all increase sphincter tone and bladder outflow resistance.
Estrogen creams/pill.
Periurethral collagen injection.

Surgical mgmt:
Urethral sling, artificial sphincter.

Question 58

mgmt of overflow incontinence

Answer 58

If due to obstruction: treat underlying cause.

Acontractile bladder (storage mode):

1) Timed voiding, double voiding.
2) Clean intermittent catheterization.
3) Indwelling or suprapubic catheter as last resort.

Question 59

Causes of transient urinary incontinene (DIAPERS)

Answer 59

Delirium,
Infection (bladder irritation),
Atrophic vaginitis (if postmenopausal),
Pharmaceutical/polypharmacy: anticholinergics, sedatives, narcotics, alpha agonist, CCB.
Excessive urine production: Diuretics, untreated DM.
Restricted mobility.
Stool impaction/constipation.

Question 60

What are LUTs seen with bladder outlet obstruction?

Answer 60

Obstructive voiding symptoms: hesitancy, slow stream, stuttering/dribbling, straining to void, sense of incomplete bladder emptying, double voiding, post-void dribble.

Irritative (storage) symptoms: frequency, urgency, nocturia.

Hematuria, dysuria, incontinence.

Note that size and degree of bladder outlet obstruction does not relate to severity of LUTS.

Question 61

DDx for bladder outlet obstruction

Answer 61

1) Prostate: BPH, prostate Ca, prostatitis.
2) Bladder: cystitis, bladder tumor, bladder stone.
3) Urethra: urethral stricture, meatal stenosis, phimosis.
4) Neurologic: Parkinsons, stroke, Alzheimers, spinal cord disease.
5) other: DM, sleep apnea, medication, diet, distal ureteral stone, pelvic mass.

Question 62

What is BPH?

Answer 62

Growth of stromal component of prostate in the transitional zone. Increased alpha-1A receptors results in increased smooth muscle tone.

Question 63

Complications of BPH (5)

Answer 63

1) Urinary retention: acute/chronic.
2) Renal failure
3) Recurrent UTIs
4) Bladder stones
5) hematuria.

Question 64

Management of BPH: lifestyle & medical options (inc SE).

Answer 64

Lifestyle: decrease fluid intake, decrease caffeine and alcohol. Time diuretics. Exercise, wt loss, diet.

Alpha blockers: decrease sphincter tone to allow voiding. E.g. can use tamsulosin, terazosin, silodosin.
SE: retrograde ejaculation, orthostatic hypotension, dizziness, asthenia, nasal congestion, syncope.

5-a reductase inhibitors: E.g finasteride, dutasteride. Inhibit the conversion of testosterone to DHT. DHT normally promotes release of growth factors that increase cell growth in the prostate. Works best in large prostates. Slower onset of action than alpha blockers.
SE: ED, decreased libido, decreased ejaculate vol, gynecomastia.

If prostate small and PSA low: alpha blocker monotherapy.

If prostate large and PSA high: alpha blocker and 5a reductase inhibitor dual therapy.

Question 65

Surgical options for BPH

Answer 65

1) Transurethral resection (TURP): gold standard. Complications = bleeding, perforation, TUR syndrome (high vol, low Na).
2) Minimally invasive therapy.
3) Great light laser therapy.
4) Open prostatectomy for large prostates.

Question 66

Indications for surgical mgmt of BPH

Answer 66

1) symptoms refractive to medical therapy.
2) recurrent UTI.
3) Urinary retention.
4) recurrent hematuria.
5) renal impairment.
6) bladder calculi

Question 67

DDx for firm prostate nodule on DRE

Answer 67

1) Prostate Ca.
2) BPH
3) Calculi
4) Infarct
5) cyst
6) TB: chronic granulomatous prostatitis.
7) scar from previous TURP or biopsy.

Question 68

How to interpret PSA

Answer 68

Normal for small amounts to be find in the blood. In older men, higher PSA can still be within normal range.

In general: PSA <10 low risk, 10-20 intermediate risk, >20 high risk. Overall, PSA velocity is a better measure for prostate cancer.

PSA is sensitive but not specific. Increases with infection, BPH, infarction, instrumentation, inflammation and prostate Ca.

Higher pretest probability of prostate cancer with elevated PSA if there are RF: African/Fijian descent, famHx, increased age, previous abnormal biopsy.

Question 69

How to stage prostate cancer

Answer 69

Prostate Ca = a multifocal heterogenous cancer with multiple tumors in a single gland with each having its own genetic signature and behaviour, thus staging is done through looking at multiple samples.

Gleason score: TRUS guided biopsy used to take 12 samples from prostate, then histology graded out of 5. A summation of the most common and second most common Gleason scores are added together for a total score out of 10. The cancer can then be stratified such that:
Low risk: GS 2-6
Intermediate: 7
High risk: 8-10.

Overall high risk individual: PSA >20, GS 8-10, >T3.

Further stage with bone scan (main), CT abdo/pelvis and CXR.

Question 70

Management of localized disease

Answer 70

1) Active surveillance: done for GS <6. Monitor with periodic DREs and PSA with repeat biopsies.
2) Radical prostatectomy: complicated by bleeding, damage to obturator nerve, rectal injury or damage to ureters. Serious long term complications include incontinence and erectile dysfunction.
3) Radiation therapy: can do brachytherapy or external beam. Complicated by radiation exposure to bladder and rectum (acute and chronic effects), urinary incontinence and erectile dysfunction.

Question 71

Describe the use of hormonal therapy in prostate ca

Answer 71

MOA: inhibit testosterone promoted growth of prostate Ca. However, may progress to castration resistant cancer.

LHRH analogues: inhibit LH and thus, reduce T. Takes 2-3 weeks to reach castration levels. Initially have flare of T due to agonist activity but over time receptors will be desensitized and LH secretion decreases.

Anti-androgens: bind to androgen receptors and prevent DHT from binding. Used with LHRH analogues to prevent flare.

GnRH antagonists: Directly inhibit GnRH-R in the pituitary. No initial flare and thus get LH secretion decrease immediately.

Question 72

Rental trauma: epidemiology, investigations, mgmt

Answer 72

Most common area of urinary tract injury. 10% of all serious abdominal injuries have associated renal injury.

Investigations:
CT with contrast and delayed film.
Only do ‘one shot’ intraoperative IVP if there isn o pre-existing w/u of the pt- highly specific for urinary extravasation and confirms existence of other kidney.

Indications for CT: Everyone with penetrating trauma. Blunt trauma pt if they have gross hematuria or microhematuriw with shock or acceleration/deceleration injury.

Mgmt: Most kidneys treated non-operatively. Close observation (bed rest, serial Hb, antibiotics if urinary extravasation).

May require: radiographic embolization, urinary diversion (ureteral stenting, nephrostomy drainage).

Surgery: for renal preservation, reconstruction or nephrectomy. Indicated if Grade 5 renal injury, persistent bleeding, suspected ureter or collecting system injury. Incomplete staging and already having a laparotomy, grade 4 vein or artery thrombosis (nephrectomy).

Most penetrating renal injuries will need surgery.

Question 73

Bladder trauma: etiology, SS, imaging, mgmt

Answer 73

Rare.
Associated with high E injuries.
Bladder rupture may occur with blunt trauma (intraperitoneal or retroperitoneal leak).
Associated with urethral rupture and pelvic fractures (get CT cystogram if pelvic #).

SS: suspicion of cases of penetrating trauma based on trajectory.
Gross hematuria in 95%.
Microhematuria only if minimal injury (insignificant injury to bladder).
Abdominal pain/tenderness/bruising.
Uretheral catheter does NOT return urine.
Delayed: fever, no urine output, peritoneal signs, high BUN/Cr.

Imaging:
1) Plain cystography: must be done accurately with 30% contrast and adequate filling (if not done correctly get false negatives).

2) CT cystography: preferred but must be retrograde filling and dilute contrast.

Mgmt: conservative treatment if extraperitoneal ruptures. Consider treating if undergoing laparotomy and definitely if undergoing pelvic ORIF.

Question 74

Posterior urethra trauma: etiology, SS, imaging, mgmt

Answer 74

Associated with pelvic fractures, bladder ruptures. Urethral-rectal fistula with 8% of rectal injuries.

SS: blood at meatus, high-riding prostate, inability to urinate or place catheter.

Imaging: retrograde urethrogram (look for disruption of contrast in urethra).

Mgmt: place open suprapubic catheter (unable to get foley in). Inspect/repair bladder for associated injury.