Week 3 - I - Urological emergencies (penis stuff)

Question 1

What is the difference between acute urinary retention and chronic urinry retention? (basically) overflow incontinence)

Answer 1

Acute urinary retention (AUR) is the sudden inability to pass urine.

It is usually painful and requires emergency treatment with a urinary catheter.

Chronic urinary retention is usually nonpainful and the bladder remains palpable after voiding

Question 2

What is acute urinary retention a complication of and what is required to allow the urine to pass? Does it occur in females?

Answer 2

Acute urinary retention is usually a complication of benign prostatic hyperplasia and is an emergency requiring catheritisation

It rarely occurs in females

Question 3

After the catheter is used for drainage in acute urinary retention, the patient can be sent home with or without a catheter What drugs are prescribed for trial without a catheter? first line (give 2example drug names)

Answer 3

First line is an alpha blocker (alpha 1 adrenoreceptor antagonist) - doxazosin or tamulosin

Question 4

What is an example of a 5-alpha-reductase inhibitors that can help treat acute urinary retention by reducing the size of the prostate also?

Answer 4

Finasteride

Question 5

Because the bladders are so expanded and then size is reduced to normal there can be a little blood in the urine due to leakage of the vessels post-treatment What other complication can occur after the removal of the obstruction (reduction in size for BPH) of the urinary tract?

Answer 5

Post-obstructive diuresis

Question 6

What needs to be monitored and when should this resolve? What urine output should you be aware of in post-obstruction diuressi?

Answer 6

Monitor fluid balance and should resolve in 24-48 hours

beware if urine output > 200ml/hr.

Question 7

What is the most common cause of loin pain presenting as ureteric colic?

Answer 7

Renal calculi (kindey stones)

Question 8

Ureteric colic secondary to calculus – pain mediated by prostaglandins released by ureter in response to obstruction The treatment for the pain is usally an NSAID +/- an opiate if pain is severe What is the drug given that can help small stones expected to pass?

Answer 8

An alpha blocker

Question 9

If stone hasn’t passed in 1 month then likely to require intervention Small stones pass much more easily (<4mm diameter) - about 80% will drop through. What size of stone is it where passage is unlikely?

Answer 9

If the stone is greater than 6mm diameter and therefore unlikely to drop through

Question 10

What is the best immaging to detect renal stones?

Answer 10

Non contrast CT scan - the calcium deposits will show up white so do not want a white contrast confusing things

Question 11

What is nephrolithiasis?

Answer 11

Nephrolithiasis specifically refers to when there is the presence of stones in the kidneys

Question 12

What are indications to treat renal stones urgently?

Answer 12

Pain unrelieved, pyrexia (indicative of infection)

Persistent nausea and vomiting - indicate urgent treatment

Question 13

What is the first line treatment of renal stones in absence of infection? (for stones >5mm)

Answer 13

First line treatment is removal of the stone or stone fragmentation

* (Extracorporeal shock wave lithotripsy (ESWL) uses ultrasound to fragment the stones so they can be passed in the urine)

* (uteroscopy in pregnant women removes the stone)

Question 14

For infected hydronephrosis due to the kidney stones, what is the treatment?

Answer 14

Percutaneous nephrostomy to remove the urine

Question 15

What is the most common cause of frank haematuria?

Answer 15

Infective cystitis

Question 16

What are other causes of frank haematuria?

Answer 16

Stones, tumours, BPH, polycystic kidneys (ADPKD)

Question 17

What inevestigations are done for frank haematuria?

Answer 17

Urinalysis

* If patient >50, flexible cystocopy + CT Urogram

Question 18

If someone presents with frank haematuria then has retention due to clots, catheritisation wont work What catheter is used instead for treatment of this cot retention associated with frank haematuria?

Answer 18

Need to use a special three way irrigating haematuria catheter- then do a CT urogram

Question 19

What is the most common cause of acute scortum in a boy?

Answer 19

Hydatid of Morgagni torsion (also known as the appendix testis)

Can present with a blue dot discolouration on the scrotum

Question 20

What is another cause of acute scrotum? Most common in pubertal boys as testis have enlarged but still have a narrow ____ so more likely to twist?

Answer 20

Torsion of the spermatic cord

Question 21

How does spermatic cord torison often present?

Answer 21

Usually sudden onset of pain often waking the patient up

Associated with nausea and vomiting from the patient and pain can refer to lower abdomen

Can have previous episodes that are self limiting

Question 22

How does the presentating of epididymitis differ from spermatic cord torsion?

Answer 22

characterised by discolouration and swelling of the testis, often with fever (testicular torsion can also produce low grade fever though)

Question 23

What reflex is absent in testicular torison (of spermatic cord) but present in appendix testes torsion?

Answer 23

The cremasteric reflex (touch inner thigh and scrotum should draw up)

Question 24

Repair testis- ASAP- between 6-10 hours you may lose the testis How can ultrasound help differ between infection and torsion? (do not wait hours for an ultrasound)

Answer 24

Infection - ultrasound will be increased blood flow

Torsion on ultrasound will be decreased blood flow (if any)

Question 25

What is this showing about the position of the testis in spermatic cord torison?

Answer 25

The testis lie higher up in the scrotum

Question 26

If the testis become necrotic in testicular torsion, what is the treatment?

Answer 26

Treatment would require removal of the testis

Question 27

What is the most common cause of epididymitis?

Answer 27

Chlamydial infection

Question 28

What is the difference in the ages affected by testicular torsion and epididymitis?

Answer 28

Testicular torsion - occurs in puberty commonly

Epididymitis - young adult

Question 29

The cremasteric reflex is present in epididymitis What does the blood flow usually show on ultrasound? What factor indicates epididymitis over testicular torsion?

Answer 29

Ultrasound shows increased blood flow in epididymitis

Decreased in testicular torison

Also in epididymitis patient will present with a fever

Question 30

Epididymitis vs appenidx testes vs spermatic cord torsion

Cremasteric reflex Fever Pain Ultrasound

Answer 30

* Epididymitis - Cremasteric reflex present, fever, pain, ultrasound shows increased blood flow, discolouration and swelling of testis

* Appendix testis torsion - cremasteric reflex present, pain, normal ultrasound, blue dot disclouration

* Spermatic cord torsion - creasteric reflex absent, low grade fever, pain to abdomen, US shows decreeased blood flow, testes lie higher up in scrotum

Question 31

Analgesia + scrotal support, bed rest are the supportive treatment for epididymitis What treatment is given if sexual infection is not suspected?
What is the treatment for chlamydia?

Answer 31

Give oflaxacin or ciprofloxacin

For chlamydia - treatment is azithromyicn (or doxcycline)

Question 32

Red, inflamed looking scrotum. Not sore but often Itchy. It is self limiting What is this?

Answer 32

Idiopathic scrotal oedema

Question 33

What is a tight foreskin in front of the glans known as? What is a tight retracted foreskin known as that is unable to be put back in place?

Answer 33

Inf ront of glans -Phimosis

Behind glans - Paraphimosis

Often happens after foreskin retracted for catheterization or cystoscopy and staff member forgets to replace it in its natural position

Question 34

What is the usual treatment of paraphimosis?

Answer 34

Iced glove and manually compress glans so prepuce can go back forward

Question 35

Last line treatment where nothing else works for the paraphimosis, what is done to divided the ring?

Answer 35

Dorsal slit on the wring and probably circumsize after this

Question 36

Prolonged erection (> 4hrs), often painful and not associated with sexual arousal What is this known as?

Answer 36

Pripasim

Question 37

Priapism can typically be seen after an injection for erectile dysfunction eg with papaverine How are injections for ED given?

Answer 37

Intracoporeal injection (this is a third line treatment - 1st line is treat cause, 2nd line is 5-phosphodiesterase)

Injects into the corpus cavernosum

Question 38

What is the treatment of priapsim? (first line is something with paharmacological) want to reduce blood in penis

Answer 38

Aspirtaion + irrigation with saline

And an alpha agonist - phenylephrine (causes vasoconstriction)

Question 39

A form of necrotizing fasciitis occurring about the male genitalia Most commonly arises from skin, urethra or rectal region What is this?

Answer 39

Fourniere’s gangrene

Question 40

What are predisposing factors to fournier’s gangrene?

Answer 40

Diabetes and local trauma

Question 41

What does the scrotum usually feel/look like in Fourniere’s gangrene?

Answer 41

Swollen scrotum that looks dark blue/purple and feels like a crepitus

Question 42

How does the necrotizing fasciits in fourniere’s angrene spread? What is the treatment?

Answer 42

Spreads via fascal planes

Treat with IV antibiotics and surgical debridement of the necrosed issues

Question 43

Necrotizing of the renal parenchyma with characteristic gas formation within or around the kidneys What is this known as?

Answer 43

Emphysematous pyelonephritis

Question 44

What is the usual organism causing emphysematous pyelonephritis?

Answer 44

E.coli - Usually occurs in diabetics

Question 45

What would be used to describe the kidneys in emphysematous polynephritis on abdominal xray? (the appearacne)

Answer 45

A mottled appearance of the kidneys

Can see the mottled appearance on CXR here

Question 46

Usually results from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection What is this? (what is treatment - same as all abscesses)

Answer 46

This is a perinephric abscess, treat with antibiotics and drainage

Question 47

What is the usual cause of a perinephric abscess?

Answer 47

Rupture of a cortical abscesss into the perinephric space

Question 48

There are 5 ways to grade renal trauma What are the five ways?

Answer 48

* I Haematoma, no parenchymal laceration

* II Laceration 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

Question 49

Fracture of what is commonly associated with bladder innjury? What are the symptoms of bladder injury?

Answer 49

A pelvic fracture

Suprapubic tenderness, lower abdominal bruising, guarding/rigidity, diminished bowel sounds

Catheterization – gross haematuria in 90-100%

Question 50

Typically happens during intercourse – buckling injury when penis slips out of vagina and strikes pubis Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling What is this?

Answer 50

Penis fracture