Urology Emergencies Flashcards
what is acute urinary retention
inability to urinate
increasing pain
a complication with BPH
what causes acute urinary retention
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)
what is the Rx for acute urinary rentention
catheter
uroselective alphablocker (alfuzosin, tamsulosin)
trial without catheter (if <1 litre residue, painful, normal serum electrolytes)
what is post-obstructive diuresis
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
who gets post obstructive diuresis
patients with chronic bladder outflow obstruction in associated with uraemia, oedema, CCF, hypertension
what causes post obstructive diuresis
solute diuresis (higher solute volume) retained urea, sodium and water + defect in concentrating ability of kidney
what is the treatment of post obstructive diuresis
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
is haematuria common in acute urinary retention
yes- usually settles in 24 hrs
what are the differentials for acute loin pain
renal stones
AAA
what is the Rx for ureteric colic
NSAID +/- opiate alpha blocker (tamsulosin) for small stones that are expected to pass
what sizes of stone are likely to pass
<4 mm 80%
4-6 mm 59%
>6 mm 21%
how long do you give a stone to pass spontaneously
1 month, if not then intervention
are renal stones radio opaque
90% are
what are the indications to treat renal stones urgently
pain unrelieved by analgesia
pyrexia (infection)
persistent N/V
high grade obstruction (affect urine outflow)
what is the urgent treatment for a renal stone
ureteric stent
stone fragmentation/ removal if no infection
percutaneous nephrostomy for infected hydronephrosis
what can cause frank haematuria
infection stones tumours BPH polycystic kidneys trauma coagulation/ platelet deficiencies
what investigations for frank haematuria
CT urogram + cystoscopy
what can be used to treat clot retention
3 way irrigating haematuria catheter
what is the acute scrotum presentation you should always rule out
torsion
who is torsion most common in
teenagers- most common at puberty
what can cause acute scrotum
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)
what is the presentation of torsion of the spermatic chord
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
what are the clinical signs of torsion of the spermatic chord
testes high in scrotum
transverse lie of testes (bell clapper deformity)
absence of cremasteric reflex
acute hydrocoele + scrotal oedema
what is the Rx for torsion of the spermatic cord
prompt surgical exploration
if necrotic them removed
if bell clapper deformity must fix contralateral side aswell
what are the symptoms of torsion of appendage
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
what is the treatment for torsion of appendage
should resolve spontaneously without surgery
what are the features of epididymitis
rare in children
hard to distinguish from torsion
dysuria/ pyresxia more common
who gets epididymitis
people with a history of UTI, urethritis, catheterisation/ instrumentation
what are the signs of epididymitis
cremasteric reflex present
suspect if pyuria (puss or WBC in urine)
doppler (swollen epididymis, increased blood flow)
do urine culture + chlamydia PCR
what is the treatment for epidymitis
analgesia + scrotal support, bed rest
ofloxacin for 14 days
what is idiopathic scrotal oedema
self limiting, unknown cause
what are the symptoms of idiopathic scrotal erythema
no scrotal erythema
no fever
tenderness minimal
may be pruritis
what is paraphimosis
painful swelling of the foreskin distal to a phimotic ring
what causes a paraphimosis
often happens after foreskin is retracted for catheterisation or cytoscopy and staff members forget to replace it to its natural position
what is the treatment for a paraphimosis
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
what is priaprism
a prolonged erection >4 hrs, often painful, not associated with sexual arousal
what causes priapism
erectile dysfunction treatments (intracorporeal injection e.g. papverine) trauma (penile/ perineal) heamatologic dyscrasias (sickle cell) neurological conditions idiopathic
what are the types of priapism
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
how do you distinguish the forms of priapism
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
what is the treatment for ischaemic priapism
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
what is the treatment for non-ischaemic
observe - can spontaneously resolve
selective arterial embolisation with non permanent materials
what is fourniers gangrene
NF occurring about the male genitalia
what causes fourniers gangrene
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
what are the symptoms of fourniers gangrene
swelling + crepitus of scrotum, dark purple areas
what is the treatment for fourniers gangrene
antibiotics + surgical debridement
mortality 20%- higher in diabetics and alcoholics
can spread into abdominal wall
what is emphysematous pyelonephritis
An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E coli
Usually occurs in diabetics
what are the symptoms of emphysematous pyelonephritis
Often associated with ureteric obstruction
Fever, vomiting, flank pain
See gas on KUB
CT defines extent of emphysematous process
what is the treatment of emphysemtous pyelonephritis
emergency nephrectomy
what is a perinephric abscess
infective emergency
Usually results from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
what are the features of a perinephric abscess
Insidious onset, approx 33% not pyrexial
Flank mass in 50%
High WCC, high serum creatinine, pyuria
what is the treatment for a perinephric asbcess
Ix - CT
Rx - Antibiotics + percutaneous or surgical drainage
(infective emergency)
what are the classifications of renal trauma
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
when in renal trauma do you need to image
frank haematuria in adult
occult/frank haematuria in child
occult haematuria + shock
penetrating injury
(do CT with contrast)
what is the treatment for renal injury
90% conservatively with angiography/embolisation
surgery if persistent bleeding, expanding haematoma, pulsatile haematoma, urinary extravasation, non viable tissue, incomplete staging
what is bladder injury most commonly associated with
pelvic fracture
what is the presentation of a bladder injury
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
what imaging for a bladder injury
CT cytography
what is the treatment for a bladder injury
large bore catheter to keep the bladder empty
antibiotics
repeat cystogram in 14 days
when would you need to immediately repair a bladder injury
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
what are posterior uretheral injuries associated with
fracture of pubic rami
what part of urethra is most vulnerable to injury
bulbomembranous
what are the signs of a urethral injury
Blood at meatus Inability to urinate Palpably full bladder “High-riding” prostate Butterfly perineal haematoma
what investigations for a urethral injury
retrograde urethrogram
what is the Tx for a urethral injury
suprapubic catheter
delayed reconstruction after at least 3 months
what is a penile fracture
Typically happens during intercourse – buckling injury when penis slips out of vagina and strikes pubis
what are the signs of a penile fracture
Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling
20% incidence of urethral injury (frank haematuria/blood at meatus)
what is the treatment for a penile fracture
Prompt exploration and repair
Circumcision incision with degloving of penis to expose all 3 compartments
how does a testicular injury present
Usually presents with exquisite pain + nausea
Swelling / bruising variable
what is the treatment for a testicular injury
USS to assess integrity / vascularity
Early exploration/repair improves testis salvage, reduces convalescence, better preserves fertility and hormonal function
