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Flashcards in Urologic emergencies Deck (33)
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1

Eval for renal trauma?

CT w/ contrast for:
1. blunt trauma w/:
gross hematuria
microhematuria w/ shock
2. penetrating trauma: any hematuria
3. ped trauma: microhematuria w/ over 50 RBC/hpf

2

Management of renal trauma? Indications for surgical intervention?

- most managed conservatively (esp blunt): +/- stent, embolization, percutaneus drain or nephrostomy tube
- indications for surgical intervention:
- life threatening hemorrhage
- cont. bleeding
- exploration for other injuries reveals expanding perirenal hematoma
*repair or remove kidney (make sure contralateral kidney is fxnl)

3

Usual causes of a penile fracture? Dx?

- usually caused by blunt trauma to erect penis causing tear in tunica albigenia:
aggressive intercourse
off target penetration
masturbation
falling out of bed
scorned lover
- dx:
audible snap, sudden detumence, swelling, bruising

4

Management of a penile fracture?

conservative (nonoperative) tx can lead to:
ED
curvature
painful erections

surgical tx:
deglove penis
rule out urethral injury
close corporal tear

5

Cause of testis ruptures?

- blunt or penetrating trauma: straddle, saddle horn, bar fight, kick
- rare in team sports

6

Dx of testis rupture?

- exam: scrotal swelling and echymosis
- US:
loss of tunic continuity
internal echos, heterogenecity

7

Management of testis rupture?

- surgery to debride extruded tissue and clos tunic
- early (less than 3 days): 9% orchiectomy, 80% salvage
- later (greater than 3 days): 70% orchiectomy

8

Causes of bladder rupture? What is always present?

- blunt more common than penetrating
- 60% extraperitoneal
- 30% intraperitoneal
- 10% combined
- hematuria always present:
95% w/ gross hematuria
5% w/ microhematuria
- 90% of bladder ruptures have assoc pelvic fractures
- 10% of pelvic fractures ssoc bladder ruptures

9

Cause of intraperitoneal bladder rupture? Dx? Management?

- external blow, full bladder
- CT or cystogram:
contrast around bowel, contrast above superior acetabular line
- management: surgical repair
- catheter drainage alone risks chemical peritonitis

10

Cause of extraperitoneal bladder rupture? Dx? Management?

- blunt trauma w/ pelvic fracture
- CT or cystogram:
contrast limited to pelvis, perineuma or genitalia, starburst pattern of contrast below superior acetabular line
- management: catheter drainage, surgical repair if having surgery for other injury

11

Cause of urethral disrpution? Hallmark sign? Other signs? Dx?

- blunt or penetrating trauma
- blood at meatus
- distended bladder, unable to void, genital swelling and hematoma
- dx by RUG

12

Incomplete urethral disruption?

- RUG shows contrast extravasation but w/ contrast into bladder
- management is catheter drainage

13

Complete urethral disruption? Management?

- Emergency!!
- RUG shows contrast extravasation w/o contrast into bladder (r/o poor technique)
- management:
suprapubic tube w/
early primary realignment or delayed reconstruction

14

Sxs of acute urinary retention? Causes?

- sudden, unexpected, painful inability to void
- abd/pelvic mass on exam, US or CT
- causes:
BPH
urethral stricture
blood clots
stones
drugs (antihistamines, narcotics, alpha adrenergics)
post op
overdistension

15

Management of acute urinary retention?

- urethral catheter - 14 french Coude tip
- suprapubic tube
- suprapubic aspiration
- watch for hematuria
- post obstructive diuresis uncommon w/ acute retention and normal Cr

16

What is a priapism?

- painful, prolonged (over 4 hrs) erection

17

Ischemic priapism? Causes?

- low flow, MC form
- compartment syndrome
- causes:
drugs (intracavernosal injections, trazadone, cocaine, PDE5 inhibitors)
sickle cell disease
blood dyscrasias (leukemias)
idiopathic (30-50%)

18

Nonischemic priapism? Cause?

- high flow due to AV fistula
- usually due to trauma

19

Tx of priapism?

- pharm: inject phenylephrine 5 - 1mg q 10 min
- flush w/ 1:100,000 epi soln
- surgical if pharm doesn't work:
winter shunt
or
al ghorab shunt

20

Dx acute ureteral obstruction?

- flank and/or abd pain:
colicky, cramping - unable to lay still or find comfortable position, non-positional
- pain radiation to groin
- N/V
- UA: hematuria prsent w/ 85% of stones
pyuria w/ epithelials, w/o nitrites, bacteria suggests contamination
- noncontrast abd/pelvic CT:
all stones seen, pleboliths can be misleading

21

Etiologies of acute ureteral obstruction?

- stones
- clot
- retroperineal fibrosis
- surgical mishap
- bladder outlet obstruction
- malignancy (ureter, RP nodes, adjacent organs)

22

What are signs of emergent ureteral obstruction?

- solitary kidney
- bilateral obstruction
- assoc infection:
fever/chills
high WBCs
pyuria, bacteruria
hypotension, tachycardia

23

Signs of non-emergent acute ureteral obstruction?

- pyuria w/o other evidence of infection (pos. nitrites, bacteruria)
- hydronephrosis
- perinephric fluid: urine
- hematuria
- mildly increased Cr

24

Emergent management of acute ureteral obstruction?

- ureteral stent:
reqrs surgery, anesthesia, convenient but potentially painful, flomax reduces sxs
- nephrostomy tube:
provides reliable, unequivocal drainage, more comfortable, invasive and inconvient
- stone removal w/ ureteroscopy delayed til after infection has resolved

25

Non-emergent management of acute ureteral obstruction?

- toradol
- p.o. analgesia
- tamsulosin (flomax) - may help w/ sxs
- stone 4 mm or less will most likely pass

26

What is Fournier's gangrene? RFs?

- necrotizing infection of skin, fat, and fascia of genitalia and perineum
- synergistic infection w/ multiple aerobic and anerobic bugs
- 20-30% mortality
- RFs:
obesity
DM
immunosupression
alcoholism
malnutrition

27

Dx fournier's gangrene?

- hx: pain, swelling, fever
- exam:
fever, MS changes, tachycardia, tachypnea
- erythema, edema, crepitus, fluctuance, discoloration (purple, black), purulent drainage, foul odor
- soft tissue gas on xray, CT or US

28

Tx of fourneir's gangrene?

- wide, aggressive debridement
- broad spectrum abx to cover GP, GN and anerobes
- post op wound care:
repeat debridement
dressing changes
HBO
wound vac
skin grafts, flaps

29

Extravaginal testis torsion?

- neonate w/ swollen, discolored scrotum (hemorrhagic necrosis)
- nontender, firm testis w/ hydrocele
- cord twists above tunica vaginalis
- presumed to occur in utero
- salvage is rare

30

Intravaginal testis torsion?

- typically in adolescents
- more common
- w/in tunica vaginalis
- acute scrotal and/or ipsilateral abd pain
- firm, tender, high riding, testis w/ hydrocele and edema
- absent cremasteric reflex