urological emergencies

Question 1

what is acute urinary retention?

Answer 1

a complication of BPH
inability to urinate with increasing pain

can be caused by prostate infection, bladder overdistension, excess fluid intake, alcohol, prostatic infarction, an anaesthetic, anti muscarinic meds

Question 2

what is post obstructive diuresis?

Answer 2

often present in patients with chronic bladder outflow obstruction in association with uraemia, oedema, CCF and hypertension

Question 3

what can cause acute loin pain?

Answer 3

remember AAA
ureteric colic secondary to calculus- pain mediated by prostaglandins released by ureter in response to obstruction

Question 4

what is used for small kidney stones?

Answer 4

NSAIDs +/- opiates
alpha blockers (tamsulosin) for small stones expected to pass

Question 5

what are some indications for urgent kidney stone treatment?

Answer 5

pain unrelieved
pyrexia
persistant nausea/vomiting
renal impairment

Question 6

how are severe kidney stones treated?

Answer 6

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

Question 7

what can cause visible haematuria?

Answer 7

infection
stones
tumours (esp. bladder)
BPH
polycystic kidneys

Question 8

what is the referral pathway for macrohaematuria?

Answer 8

2 week wait
same day if- symptomatic anaemia, coag/platlet deficiency, peliv radiation cystitis

Question 9

what can cause an acute scrotum?

Answer 9

Torsion of spermatic cord
Torsion of appendix testis
Epididymitis / epididymo-orchitis
Inguinal hernia
Hydrocoele
Trauma / insect bite
Dermatological lesions
Inflammatory vasculitis
Tumour

Question 10

what are the features of testicular torsion?

Answer 10

most common at puberty/teenage
no known trigger
adolescents usually woken from sleep
sudden onset of pain, N+V, pain referral to lower abdo
O/E- testes high in scrotum, transverse lie, acute hydrocele

Question 11

when can irreparable damage occur in testicular torsion?

Answer 11

4 hrs after torsion

Question 12

what is the treatment for testicular torsion?

Answer 12

Prompt exploration. Irreversible ischaemic injury may begin as soon as 4hrs
3-point fixation with fine non-absorbable sutures
If testis necrotic then remove
MUST fix contralateral side (bell clapper deformity)

Question 13

what are the symptoms of appendage torsion?

Answer 13

Symptoms variable – may be insidious onset or identical to torsion of cord
If seen early, may have localised tenderness at upper pole and “blue dot” sign
Testis should be mobile and cremasteric reflex present

Question 14

how is torsion of appendage resolved?

Answer 14

spontaneously

Question 15

what are the features of epididymitis?

Answer 15

rare in children
May be difficult to distinguish from torsion
Dysuria / pyrexia more common
Hx of UTI, urethritis, catheterization/instrumentation

Question 16

what is seen O/E in epididymitis?

Answer 16

Cremasteric reflex present
Suspect if pyuria
Doppler – swollen epididymis, increased bloodflow
Send urine for culture + Chlamydia PCR

Question 17

how is epididymitis treated?

Answer 17

analgesia+scrotal support, bed rest
ofloxacin 400mg/day for 14 days

Question 18

what are the features of idiopathic scrotal oedema?

Answer 18

Self-limiting, unknown cause, not usually associated with scrotal erythema
No fever, tenderness minimal but may be pruritis

Question 19

what is paraphimosis?

Answer 19

surgical emergency
Painful swelling of the foreskin distal to a phimotic ring
Often happens after foreskin retracted for catheterization or cystoscopy and staff member forgets to replace it in its natural position

Question 20

how is paraphimosis treated?

Answer 20

Under penile block Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit

Question 21

what is priapism?

Answer 21

Prolonged unwanted erection (> 4hrs), often painful and not associated with sexual arousal

Question 22

what causes priapism?

Answer 22

Intracorporeal injection for ED, e.g. papaverine
Trauma (penile / perineal)
Haematologic dyscrasias e.g. sickle cell
Neurological conditions
Idiopathic

Question 23

what are the features of non-ischaemic priapism?

Answer 23

Observe, may resolve spontaneously
Selective arterial embolization with non-permanent materials

Question 24

what is the treatment of an ischaemic priapism?

Answer 24

Aspiration +/- irrigation with saline
Injection of alpha-agonist, e.g. phenylephrine 100-200ug every 5-10 mins up to max 1000ug
Surgical shunt
Ischaemic priapism > 48-72hrs unlikely to respond to intracavernosal treatment
For very delayed presentation, may even consider immediate placement of a penile prosthesis

Question 25

what is fourniers gangrene?

Answer 25

A form of necrotizing fasciitis occurring about the male genitalia

Question 26

what predisposes to fourniers gangrene?

Answer 26

diabetes, local trauma, periurethral extravasation, perianal infection

Question 27

what are the features of fourniers gangrene?

Answer 27

cellulitis
swelling and crepitus of scrotum, dark purple areas

Question 28

what is the treatment for fourniers gangrene?

Answer 28

Antibiotics + surgical debridement
Mortality 20%, higher in diabetics and alcoholics

Question 29

what is emphysematous phylonephritis?

Answer 29

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

Question 30

who is usually affected by emphysematous pyelonephritis?

Answer 30

diabetics

Question 31

at are the symptoms of emphysematous pyelonephritis?

Answer 31

Often associated with ureteric obstruction
Fever, vomiting, flank pain
See gas on KUB
CT defines extent of emphysematous process

requires ITU support. If not settling needs nephrectomy

Question 32

what are the features of a perinephric abcess?

Answer 32

Usually results from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection
Insidious onset, approx 33% not pyrexial
Flank mass in 50%
High WCC, high serum creatinine, pyuria

treated with abx

Question 33

what is a class 1 renal trauma?

Answer 33

Haematoma, subcapsular, non-expanding, no parenchymal laceration

Question 34

what are the features of a class 2 trauma?

Answer 34

Laceration <1cm parenchymal depth without urinary extravasation

Question 35

what are the features of a class 3 trauma?

Answer 35

> 1cm depth, no collecting system rupture or extravasation

Question 36

what are the features of a class 4 trauma?

Answer 36

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

Question 37

what are the features of a class 5 trauma?

Answer 37

Shattered kidney
Avulsion of hilum, devascularizing kidney

Question 38

what are renal traumas imaged?

Answer 38

Frank haematuria in adult
Frank or occult haematuria in child
Occult haematuria + (systolic <90mmHg at any point)
Penetrating injury with any degree of haematuria

Ix – CT with contrast

Question 39

how are blunt renal images treated?

Answer 39

98% of blunt renal injuries can be managed non-operatively with angiography/embolization

Surgery - Persistent renal bleeding, expanding perirenal haematoma, pulsatile perirenal haematoma
Urinary extravasation, non-viable tissue, incomplete staging (can do on-table IVU)

Question 40

what are the features of a bladder injury?

Answer 40

commonly associated with a pelvic fracture
suprapubic/abdo pain and inability to void
lower abdo bruising, guarding/rigidity
catheterisation needed
treated with abx

Question 41

what are the features of a penile fracture?

Answer 41

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
20% incidence of urethral injury (frank haematuria/blood at meatus)