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Renal > Urology Emergencies > Flashcards

Urology Emergencies Flashcards

1
Q

what is acute urinary retention

A

inability to urinate
increasing pain
a complication with BPH

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2
Q

what causes acute urinary retention

A 
prostate infection 
bladder overdistention 
excessive fluid intake 
alcohol 
prostatic infarction

can be sponatenous or precipitated (non prostate related surgery, catheterisation, urethral instrumentation, anaesthesia, medication w/ sympathomimetic/ anticholinergic effects)

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3
Q

what is the Rx for acute urinary rentention

A

catheter
uroselective alphablocker (alfuzosin, tamsulosin)
trial without catheter (if <1 litre residue, painful, normal serum electrolytes)

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4
Q

what is post-obstructive diuresis

A

polyuric (increased urine output) response initiated by the kidneys after the relief of a substantial bladder outlet obstruction. In severe cases this condition can become pathologic, resulting in dehydration, electrolyte imbalances, and death if not adequately treated

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5
Q

who gets post obstructive diuresis

A

patients with chronic bladder outflow obstruction in associated with uraemia, oedema, CCF, hypertension

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6
Q

what causes post obstructive diuresis

A

solute diuresis (higher solute volume) retained urea, sodium and water + defect in concentrating ability of kidney

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7
Q

what is the treatment of post obstructive diuresis

A

monitor fluid balance and beware if urine output > 200 ml/hr

usually resolves in 24-48 hrs, severe cases may need IV fluid and sodium replacement

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8
Q

is haematuria common in acute urinary retention

A

yes- usually settles in 24 hrs

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9
Q

what are the differentials for acute loin pain

A

renal stones

AAA

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10
Q

what is the Rx for ureteric colic

A 
NSAID +/- opiate 
alpha blocker (tamsulosin) for small stones that are expected to pass
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11
Q

what sizes of stone are likely to pass

A

<4 mm 80%
4-6 mm 59%
>6 mm 21%

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12
Q

how long do you give a stone to pass spontaneously

A

1 month, if not then intervention

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13
Q

are renal stones radio opaque

A

90% are

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14
Q

what are the indications to treat renal stones urgently

A

pain unrelieved by analgesia
pyrexia (infection)
persistent N/V
high grade obstruction (affect urine outflow)

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15
Q

what is the urgent treatment for a renal stone

A

ureteric stent
stone fragmentation/ removal if no infection
percutaneous nephrostomy for infected hydronephrosis

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16
Q

what can cause frank haematuria

A 
infection 
stones
tumours
BPH
polycystic kidneys 
trauma 
coagulation/ platelet deficiencies
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17
Q

what investigations for frank haematuria

A

CT urogram + cystoscopy

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18
Q

what can be used to treat clot retention

A

3 way irrigating haematuria catheter

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19
Q

what is the acute scrotum presentation you should always rule out

A

torsion

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20
Q

who is torsion most common in

A

teenagers- most common at puberty

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21
Q

what can cause acute scrotum

A

Torsion of spermatic cord
Torsion of appendix testis
Epididymitis / epididymo-orchitis (infective)
Inguinal hernia
Hydrocoele can appear in relation to infection, trauma, torsion)
Trauma / insect bite
Dermatological lesions
Inflammatory vasculitis
Tumour (usually don’t present acutely but can do)

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22
Q

what is the presentation of torsion of the spermatic chord

A 
most occur spontaneously 
can occur with trauma/ athletic activity
adolescent woken from sleep 
usually sudden onset of pain 
sometime previous episode of self limiting pain 
N/V
pain can refer to lower abdomen/ groin
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23
Q

what are the clinical signs of torsion of the spermatic chord

A

testes high in scrotum
transverse lie of testes (bell clapper deformity)
absence of cremasteric reflex

acute hydrocoele + scrotal oedema

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24
Q

what is the Rx for torsion of the spermatic cord

A

prompt surgical exploration
if necrotic them removed
if bell clapper deformity must fix contralateral side aswell

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25
Q

what are the symptoms of torsion of appendage

A

may be insidious onset or identical to torsion of cord

if early may have localised tenderness at upper pole and blue dot sign (necrotic tissue showing through the skin)

testes should be mobile and cremasteric reflex should be present

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26
Q

what is the treatment for torsion of appendage

A

should resolve spontaneously without surgery

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27
Q

what are the features of epididymitis

A

rare in children
hard to distinguish from torsion
dysuria/ pyresxia more common

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28
Q

who gets epididymitis

A

people with a history of UTI, urethritis, catheterisation/ instrumentation

29
Q

what are the signs of epididymitis

A

cremasteric reflex present
suspect if pyuria (puss or WBC in urine)
doppler (swollen epididymis, increased blood flow)
do urine culture + chlamydia PCR

30
Q

what is the treatment for epidymitis

A

analgesia + scrotal support, bed rest

ofloxacin for 14 days

31
Q

what is idiopathic scrotal oedema

A

self limiting, unknown cause

32
Q

what are the symptoms of idiopathic scrotal erythema

A

no scrotal erythema
no fever
tenderness minimal
may be pruritis

33
Q

what is paraphimosis

A

painful swelling of the foreskin distal to a phimotic ring

34
Q

what causes a paraphimosis

A

often happens after foreskin is retracted for catheterisation or cytoscopy and staff members forget to replace it to its natural position

35
Q

what is the treatment for a paraphimosis

A 
iced glove 
granulates sugar for 1-2 hrs 
multiple punctures in oedematous skin 
manual compression on glans with distal traction on oedematous foreskin 
dorsal slit
36
Q

what is priaprism

A

a prolonged erection >4 hrs, often painful, not associated with sexual arousal

37
Q

what causes priapism

A 
erectile dysfunction treatments (intracorporeal injection e.g. papverine) 
trauma (penile/ perineal) 
heamatologic dyscrasias (sickle cell) 
neurological conditions 
idiopathic
38
Q

what are the types of priapism

A

ischaemic: (veno occlusive/ low flow)
- vascular stasis in penis-decreased venous outflow
- compartment syndrome
- corpora carvenosa are rigid and tender, penis painful

non ischaemic: (arterial or high flow)

  • traumatic disruption of penile vasculature = unregulated blood entry and filling or corpora
  • fistula formation can allow blood to bypass the normal helicine arteriolar bed
39
Q

how do you distinguish the forms of priapism

A

aspirate blood from corpus cavernosum:

  • dark blood, low O2, high CO2 = low flow (ischaemic)
  • normal arterial blood = high flow (non ischaemic)

colour duplex USS:

  • minimal/absent flow= ischaemic
  • normal/high flow= non ischaemic
40
Q

what is the treatment for ischaemic priapism

A

aspiration +/- irrigation with saline
injection of alpha- agonist (phenylephrine)
surgical shunt

Ischaemic priapism > 48-72hrs unlikely to respond to intracavernosal treatment- get firbsosis, permanent erectile dysfunction

For very delayed presentation, may even consider immediate placement of a penile prosthesis

41
Q

what is the treatment for non-ischaemic

A

observe - can spontaneously resolve

selective arterial embolisation with non permanent materials

42
Q

what is fourniers gangrene

A

NF occurring about the male genitalia

43
Q

what causes fourniers gangrene

A

arises from skin, urethra or rectal lesion
Predisposing factors – diabetes, local trauma, periurethral extravasation, perianal infection, alcoholic/ immunocompromised in some way
Usually a mixture of aerobes/anaerobes (gas forming organisms)
Starts as cellulitis – swollen, erythematous, tender. Marked pain, fever, systemic toxicity

44
Q

what are the symptoms of fourniers gangrene

A

swelling + crepitus of scrotum, dark purple areas

45
Q

what is the treatment for fourniers gangrene

A

antibiotics + surgical debridement
mortality 20%- higher in diabetics and alcoholics
can spread into abdominal wall

46
Q

what is emphysematous pyelonephritis

A

An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E coli

Usually occurs in diabetics

47
Q

what are the symptoms of emphysematous pyelonephritis

A

Often associated with ureteric obstruction

Fever, vomiting, flank pain
See gas on KUB
CT defines extent of emphysematous process

48
Q

what is the treatment of emphysemtous pyelonephritis

A

emergency nephrectomy

49
Q

what is a perinephric abscess

A

infective emergency
Usually results from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection

50
Q

what are the features of a perinephric abscess

A

Insidious onset, approx 33% not pyrexial
Flank mass in 50%
High WCC, high serum creatinine, pyuria

51
Q

what is the treatment for a perinephric asbcess

A

Ix - CT

Rx - Antibiotics + percutaneous or surgical drainage

(infective emergency)

52
Q

what are the classifications of renal trauma

A

I Haematoma, subcapsular, non-expanding, no parenchymal laceration

II Laceration <1cm parenchymal depth without urinary extravasation

III >1cm depth, no collecting system rupture or extravasation

IV Laceration through cortex, medulla and collecting system
Main arterial/venous injury with contained haemorrhage

V Shattered kidney
Avulsion of hilum, devascularizing kidney

53
Q

when in renal trauma do you need to image

A

frank haematuria in adult
occult/frank haematuria in child
occult haematuria + shock
penetrating injury

(do CT with contrast)

54
Q

what is the treatment for renal injury

A

90% conservatively with angiography/embolisation

surgery if persistent bleeding, expanding haematoma, pulsatile haematoma, urinary extravasation, non viable tissue, incomplete staging

55
Q

what is bladder injury most commonly associated with

A

pelvic fracture

56
Q

what is the presentation of a bladder injury

A

Suprapubic/abdominal pain + inability to void
Suprapubic tenderness, lower abdominal bruising, guarding/rigidity, diminished bowel sounds
Catheterization – gross haematuria in 90-100%
If blood at external meatus or if catheter doesn’t pass easily then perform retrograde urethrogram – may well have urethral injury

57
Q

what imaging for a bladder injury

A

CT cytography

58
Q

what is the treatment for a bladder injury

A

large bore catheter to keep the bladder empty
antibiotics
repeat cystogram in 14 days

59
Q

when would you need to immediately repair a bladder injury

A 
Intraperitoneal injury
Penetrating injury
Inadequate drainage or clots in urine
Bladder neck injury
Rectal or vaginal injury
Open pelvic fracture
Pelvic fracture requiring open reduction/fixation
Patients undergoing laparotomy for other reasons
Bone fragments projecting into bladder
60
Q

what are posterior uretheral injuries associated with

A

fracture of pubic rami

61
Q

what part of urethra is most vulnerable to injury

A

bulbomembranous

62
Q

what are the signs of a urethral injury

A 
Blood at meatus
Inability to urinate
Palpably full bladder
“High-riding” prostate
Butterfly perineal haematoma
63
Q

what investigations for a urethral injury

A

retrograde urethrogram

64
Q

what is the Tx for a urethral injury

A

suprapubic catheter

delayed reconstruction after at least 3 months

65
Q

what is a penile fracture

A

Typically happens during intercourse – buckling injury when penis slips out of vagina and strikes pubis

66
Q

what are the signs of a penile fracture

A

Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling
20% incidence of urethral injury (frank haematuria/blood at meatus)

67
Q

what is the treatment for a penile fracture

A

Prompt exploration and repair

Circumcision incision with degloving of penis to expose all 3 compartments

68
Q

how does a testicular injury present

A

Usually presents with exquisite pain + nausea

Swelling / bruising variable

69
Q

what is the treatment for a testicular injury

A

USS to assess integrity / vascularity

Early exploration/repair improves testis salvage, reduces convalescence, better preserves fertility and hormonal function

Renal (27 decks)

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