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Flashcards in Urologic Emergencies Deck (37)
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1

Renal Trauma -Evaluation
What test?

CT with contrast

2

Renal Trauma -Evaluation
CT with contrast for:
3

1.Blunt Trauma with:
*Gross hematuria
*Microhematuria with shock
2.Penetrating Trauma
*Any Hematuria
3. Pediatric Trauma
*Microhematuria with >50 RBC/hpf

3

Renal Trauma - Management
1. Most is managed how?
-What does this entail? 4

2. Indications for surgical intervention? 4

1. Most managed conservatively (especially blunt)
-+/- stent,
-embolization,
-percutaneous drain or
-nephrostomy tube


2.
-Life threatening hemorrhage
-Continued bleeding
-Exploration for other injuries reveals expanding perirenal hematoma
-Repair or remove kidney

4

1. Penile fracture is usually caused by what?

2. Examples? 5

1. Usually caused by blunt trauma to erect penis causing tear in tunica albigenia

2.
-Aggressive intercourse
-Off target penetration
-Masturbation
-Falling out of bed
-Scorned lover

5

Penile fracture: Dx? 4

Dx:
-Audible snap,
-sudden detumence,
-swelling,
-bruising

6

Penile Fracture - Management
1. Conservative (nonoperative) can lead to what? 3

2. Surgical treatment? 3

1. Conservative (nonoperative) can lead to:
-Erectile Dysfunction
-Curvature
-Painful erections

2. Surgical treatment:
-Deglove penis
-Rule out urethral injury
-Close corporal tear

7

Testis Rupture
Mostly caused by what? 2

BLUNT OR PENETRATING TRAUMA
-Straddle,
-saddle horn,
-bar fight/kick

8

Testis Rupture: Diagnosis
1. Exam?

2. Scrotal US? 2 findings

1. Exam:
Scrotal swelling and echymosis


2. Scrotal Ultrasound:
-Loss of tunic continuity
-Internal echos, heterogenecity

9

1. Testis Rupture – Management?


2. Prognosis? 2


1. Surgery to debride extruded tissue and close tunic

2.
-Early (less than 3 days): 9% Orchiectomy, 80% Salvage
-Late (> 3days): 70% Orchiectomy

10

Bladder Rupture
1. What kind of trauma mostly?
2. Exztraperitoneal or Intra?

3. What is always present?

4. 90% of bladder ruptures are have associated with what?

1. Blunt >> Penetrating

2.
-60 % Extraperitoneal
-30 % Intraperitoneal
-10 % Combined

3. Hematuria always present
-95% with gross hematuria
-5% with microhematuria

4. pelvic fracture
-10% of pelvic fractures have associated bladder ruptures

11

Bladder Rupture - Intraperitoneal
1. What is it?
2. Dx? 2 Contrast where? 2

3. Management?
4. Catheter drainage alone risks what?

1. External blow, full bladder

2. CT or Cystogram:
-Contrast around bowel
-Contrast above superior acetabular line

3. Management: Surgical Repair

4. Catheter drainage alone risks chemical peritonitis

12

Bladder Rupture - Extraperitoneal
1. What is it?

2. Dx? 2

3. Sign seen with contrast?

4. Management?

5. When would you have surgery?

1. Blunt trauma with pelvic fracture

2. CT or Cystogram:
-Contrast limited to pelvis, perineum, or genitalia

3. Starburst pattern of contrast below superior acetabular line

4. Management is catheter drainage

5. Surgical repair if having surgery for other injury


13

Urethral Disruption
1. From what kind of trauma?
2. Blood where?
3. Probles with the bladder? 2
4. Genital problems?
5. Dx?

1. Blunt or penetrating trauma

2. Blood at meatus !

3. Distended bladder; unable to void

4. Genital swelling and hematoma

5. Diagnosis by RUG (Retrograde Urethrogram)

14

Urethral Disruption
Incomplete
1. What will the RUG show?
2. Management is what?

Complete
1. RUG shows what?
2. Management?

Incomplete:
1. RUG shows contrast extravasation but with contrast into bladder
2. Management is catheter drainage

Complete
1. RUG shows contrast extravasation w/o contrast into bladder (rule out poor technique)

2. Management: Suprapubic tube with:
-Early primary realignment, or
-Delayed reconstruction

15

Acute Urinary Retention
1. How will it present?
2. What will you see on the US or CT?
3. Many causes such as? 7

1. Sudden, unexpected, painful inability to void
2. Abd / pelvic mass on exam, US or CT

3. Many causes:
-BPH
-Urethral stricture
-Blood Clots
-Stone
-Drugs (antihistamines, narcotics, alpha adrenergics)
-Post op
-Overdistension

16

Acute Urinary Retention -
Management?
5

1. Urethral catheter
-Lots of lube !!
-14 French Coude tip

2. Suprapubic tube

3. Suprapubic aspiration

4. Watch for hematuria

5. Post Obstructive diuresis uncommon with acute retention & normal Cr

17

Priapism
1. What is it?

Painful, prolonged (>4 hours) erection

18

Priapism
1. What is the most common form?
2. How will it present?

3. Multiple causes? 4



4. What is the other form?
-Usually due to what?

1. Ischemic (Low flow; most common form)

2. Compartment syndrome

3. Multiple causes:
-Drugs (intracavernosal injections (MC), trazadone, cocaine, PDE5 inhibitors)
-Sickle Cell Disease
-Blood dyscrasias (leukemia)
-Idiopathic (30-50%)

4. Non Ischemic
(High flow due to AV fistula)
-Usually do to trauma

19

Priapism - Treatment
1. Pharmacologic? 2

2. Surgical option? 2

1. Pharmacologic
-Inject Phenylephrine .5 – 1mg q 10 min
-Flush with 1:100,000 epinephrine solution

2. Surgical
-Winter shunt
-Al Ghorab shunt

20

Acute Ureteral Obstruction: Diagnosis? 5

1. Flank and/or abd pain
2. Pain radiation to groin
3. Nausea, vomiting
4. UA
5. Noncontrast Abd/pelvic CT

21

Acute Ureteral Obstruction
1. How will the flank or abdominal pain present? 3

2. What will the UA show? 2

3. What will the noncontrast and/pelvic CT show? 2

1.
-Colicky, cramping
-Unable to lay still or find comfortable position
-Non positional !

2.
-Hematuria present with 85% of stones
-Pyuria w/ epithelials, w/o nitrites, bacteria suggests contamination

3.
-All stones are seen
-Pleboliths can be misleading

22

Acute Ureteral Obstruction
Etiologies? 6

1. Stones
2. Clot
3. Retroperineal Fibrosis
4. Surgical mishap
5. Bladder outlet obstruction
6. Malignancy (ureter, RP nodes, adjacent organs)

23

Acute Ureteral Obstruction
1. Emergent situations? 3

2. Nonemergent? 5

1.
-Solitary kidney
-Bilateral obstructin
-Associated infection

2.
-Pyuria without other evidence of infection (pos. nitrites, bacteruria, etc)
-Hydronephrosis
-Perinephric fluid (urine)
-Hematuria
-Mildly increased Cr

24

Acute Ureteral Obstruction
What will an associated infection show? 4

1. Fever/chills
2. High WBC
3. Pyuria, bacteruria
4. Hypotension, tachycardia

25

Acute Ureteral Obstruction
What ARE NOT CRITICAL FACTORS!?
2

STONE SIZE AND LOCATION

26

Acute Ureteral Obstruction: Emergent Management
3

1. Ureteral stent
2. Nephrostomy tube
3. Stone removal with ureteroscopy delayed til after infection is resolved

27

Ureteral stent
1. Requires what?
2. Disadvantage?
3. What drug will reduce symptoms?

Nephrostomy
1. Advantages? 2
2. Disadvantage? 2

Ureteral stent
1. Requires surgery, anesthesia
2. Convenient but potentially painful
3. Flomax reduces symptoms




Nephrostomy tube
1.
-Provides reliable, unequivocal drainage
-More comfortable
2. Invasive and inconvient

28

Acute Ureteral Obstruction: Non-emergent Management
3

1. Toradol!!

2. P.O. analgesia

3. Tamsulosin

29

Fournier’s Gangrene
1. What is it?
2. Mortality?
3. Risk factors? 5

1. Necrotizing infection of skin, fat and fascia of genitalia and perineum
-Synergistic infection with multiple aerobic and anerobic bugs

2 .20-30 % mortality !

3. Risk Factors:
-Obesity
-Diabetes Mellitus
-Immunosupressoin
-Alcoholism
-Malnutrition

30

Fournier’s Gangrene Dx
1. Hx? 3
2. Exam? 7
3. Imaging?

1. Hx:
-Pain,
-swelling,
-fever

2. Exam:
-Fever,
-MS changes,
-tachycardia, tachypnea
-Erythema, edema,
-crepitus, fluctuance,
-discoloration (purple, black),
-purlulent drainage, foul odor !!

3. Soft Tissue Gas on Xray, CT or US