UROLOGIC EMERGENCIES Flashcards
(86 cards)
1
Q
imaging for renal trauma
A
CT WITH CONTRAST
2
Q
management of renal trauma
A
- most are managed conservatively
⦁ +/- stent, embolization, percutaneous drain or nephrostomy tube
- indications for surgical intervention ⦁ life threatening hemorrhage ⦁ continued bleeding ⦁ exploration for other injuries reveals an expanding perirenal hematoma ⦁ if need to repair or remove kidney
3
Q
indications for surgical intervention with renal trauma
A
⦁ life threatening hemorrhage
⦁ continued bleeding
⦁ exploration for other injuries reveals an expanding perirenal hematoma
⦁ if need to repair or remove kidney
4
Q
most cases of renal trauma are managed
A
conservatively
+/- stent, embolization, percutaneous drain or nephrostomy tube
5
Q
causes of penile fracture
A
- usually caused by blunt trauma to an erect penis, causing a tear in the tunica albuginea (around corpus cavernosum)
⦁ aggressive intercourse ⦁ off target penetration ⦁ masturbation ⦁ falling out of bed ⦁ scorned lover
6
Q
symptoms that may occur with penile fracture
A
difficulty urinating
may report gross hematuria (esp if urethra was also torn)
7
Q
imaging done with penile fracture if suspicion of urethral damage, hematuria or voiding difficulty
A
retrograde urethrogram
8
Q
conservative (nonoperative) treatment of penile fractures can lead to
A
⦁ ED
⦁ curvature
⦁ painful erections
9
Q
surgical treatment of penile fractures
A
1) deglove the penis
2) rule out urethral injury
3) close corporal tear
10
Q
diagnosis of testis rupture
A
physical exam & scrotal ultrasound
11
Q
physical exam of testis rupture
A
- scrotal swelling
- ecchymosis
12
Q
imaging of testis rupture
A
scrotal ultrasound
⦁ loss of tunic continuity ( tunica albuginea) - so all testicular contents are floating around in the scrotum
⦁ internal echos, heterogenicity
13
Q
loss of tunic continuity
A
testis rupture
14
Q
MANAGEMENT OF TESTICLE RUPTURE
A
- surgery to debride extruded tissue and close tunic
- if surgery is done early (< 3 days) = 80% chance of salvaging testicle, 9% chance of orchiectomy
- if surgery is done late (> 3 days) = 70% chance of needing orchiectomy
15
Q
when should surgery for testis rupture be done with best chances of salvaging the testicle
A
< 3 days
16
Q
bladder ruptures always have
A
hematuria
17
Q
___________ hematuria is more common than __________ hematuria with bladder ruptures
A
gross hematuria more common (95%) than microhematuria (5%)
18
Q
most common location of bladder rupture is
A
extraperitoneal
⦁ 60% = Extraperitoneal
⦁ 30% = Intraperitoneal
⦁ 10% = combined
19
Q
bladder ruptures are associated with
A
pelvic fractures
90% of bladder ruptures have associated pelvic fractures
(10% of pelvic fractures have bladder ruptures)
20
Q
bladder ruptures are most often due to
A
blunt trauma»_space;> penetrating trauma
get a pelvic fracture and then end up having ruptured through the bladder
21
Q
imaging for intraperitoneal bladder rupture
A
CT with contrast or cystogram (Xray with contrast)
⦁ see contrast around bowel
⦁ see contrast above the superior acetabular line**
22
Q
contrast above acetabular line or around bowel
A
bladder rupture
23
Q
management of intraperitoneal bladder rupture
A
*only surgical repair
managing with catheter drainage only = risk of chemical peritonitis
24
Q
external blow with a full bladder = what type of bladder rupture
A
intraperitoneal
25
penetrating trauma or bladder rupture due to pelvic fracture = what type of bladder rupture
extraperitoneal
26
imaging for extraperitoneal bladder rupture
- CT with contrast or cystogram (xray with contrast)
⦁ contrast is limited to the pelvis, perineum or genitalia
⦁ starburst pattern of contrast below the superior acetabular line
27
management for extraperitoneal bladder rupture
- catheter draining
| - surgical repair if having surgery for another injury
28
BLOOD AT THE MEATUS
URETHRAL DISRUPTION
29
urethral disruption = look for
blood at the meatus
30
with urethral disruption will have _________________ due to inability to void
distended bladder
will also have genital swelling and hematoma due to urethral disruption
31
signs/symptoms of urethral disruption
```
blood at meatus
distended bladder
inability to void
genital swelling
hematoma
```
32
diagnosis of urethral disruption
RUG (retrograde urethrogram)
33
incomplete urethral disruption shown on RUG
RUG shows contrast extravasation, but some contrast still getting to the bladder
Treatment = catheter drainage
can leave catheter in, and urethra will heal around the catheter! Risk = urethra can end up attaching to the catheter as it heals if left in too long
34
management for incomplete urethral disruption
catheter drainage
can leave catheter in, and urethra will heal around the catheter! Risk = urethra can end up attaching to the catheter as it heals if left in too long
35
complete urethral disruption shown on RUG
RUG shows contrast extravasation, and NO CONTRAST INTO BLADDER (need to rule out poor technique)
treatment = suprapubic cath
36
management for complete urethral disruption
Suprapubic tube with early primary realignment or delayed reconstruction
37
**MOST COMMON UROLOGIC EMERGENCY**
ACUTE URINARY RETENTION
38
- sudden, unexpected, PAINFUL inability to void
ACUTE URINARY RETENTION
39
causes of acute urinary retention (many)
```
⦁ BPH
⦁ urethral stricture
⦁ blood clots
⦁ stone
⦁ drugs (antihistamines, narcotics, alpha adrenergics)
⦁ post op
⦁ overdistension
```
Acute urinary retention may develop immediately after general anesthesia or following acute spinal cord injury such as infarction or demyelination
neurogenic impairments
detrusor muscle insufficiency
40
incidence of acute urinary retention increases with
age
41
acute urinary retention = 13x more common in
men
42
Acute urinary retention is most often caused by outflow obstruction due to
BPH
43
Risk factors for Acute Urinary Retention in men with BPH
⦁ severity of urinary symptoms
⦁ increased prostate volume
⦁ decreased urine flow rate
⦁ PSA > 2.5
44
Most common cause for acute urinary retention in women
pelvic organ prolapse
45
Additional etiologies of Acute Urinary Retention include Neurogenic impairment & Detrusor muscle insufficiency
ex of neurogenic impairment of bladder: due to
neurogenic bladder
diabetes
damage to spinal cord
MS
46
MANAGEMENT FOR ACUTE URINARY RETENTION
- Urethral catheter (lots of lube! French tip)
- Suprapubic tube
- Suprapubic aspiration
- Watch for hematuria
- Post obstructive diuresis = uncommon with acute retention & normal creatinine (post-obstructive diuresis more likely to occur with acute retention & ABNORMAL creatinine)
47
- painful, prolonged erection > 4 hours
priapism
48
PATHOPHYS OF AN ERECTION
- begins with nitric oxide or neuroendocrine induced relaxation of smooth muscle of cavernous arteries & tissues --> increased penile blood flow
- As the corpus cavernosum fills with blood, the veins that drain the corpus cavernosum are compressed --> maintained erection
49
priapism occurs due to failure of
corpus cavernosum to drain
50
priapism generally occurs when there is a failure of the corpus cavernosum to drain = due to
impaired relaxation
or paralysis of cavernosal smooth muscle
or occlusion of venous outflow
51
2 types of priapism
ischemic & non-ischemic
52
most common form of priapism
ischemic
53
which form of priapism is not generally related to permanent ED
non-ischemic
54
form of priapism with low flow
| form of priapism with high flow
ischemic = low flow
non-ischemic = high flow
55
form of priapism with compartment syndrome
ischemic
irreversible damage is seen after 24 hrs
a serious condition that occurs when there’s a large amount of pressure inside a muscle compartment = can lead to serious / irreversible damage
56
causes of ischemic priapism
⦁ drugs (intracavernosal injections, trazadone, cocaine, PDE5 inhibitors)
⦁ sickle cell disease
⦁ blood dyscrasias (leukemia)
⦁ idiopathic (30-50%)
57
form of priapism that is usually due to trauma
non-ischemic
58
most common cause of ischemic priapism
idiopathic
59
AV fistula form of priapism
non-ischemic
60
if priapism lasts for > 24 hrs = 90% of men will experience
permanent ED
61
physical exam for ischemic priapism
men will present with erythematous, tender and fully erect corpus cavernosum with a soft glans & corpus spongiosum (not due to sexual arousal)
62
priapism treatment
o RX
- phenylephrine & flush with epinephrine
o Surgical
- winter shunt - use biopsy needles to create shunt between corpus cavernosum & glans --> drain
- El Ghorab shunt - cut incision into tunica albuginea and drain
63
congenital testicular torsion
```
⦁ neonate with swollen, discolored scrotum (hemorrhagic necrosis)
⦁ nontender, firm testis with hydrocele
⦁ cord twists above the tunica vaginalis
⦁ presumed to occur in utero
⦁ salvage = rare
```
64
acquired testicular torsion
⦁ typically in adolescents
⦁ more common
⦁ within tunica vaginalis
⦁ Acute scrotal and/or ipsilateral abdominal pain
⦁ firm, tender, high riding testis with hydrocele & edema
⦁ Absent cremasteric reflex
65
absent cremasteric reflex
testicular torsion
66
blue dot on scrotum
testicular torsion
67
TESTICULAR TORSION VS EPIDIDYMITIS VS INCARCERATED HERNIA
TESTICULAR TORSION
- blue dot sign
- tender, firm nodule
- normal ultrasound
EPIDIDYMITIS
- doppler US shows normal testis flow, but increased epididymal flow
INCARCERATED HERNIA
- bowel sounds in scrotum
- gas in scrotum on US or xray
68
management for testicular torsion
- manual detorsion (rotate externally / laterally - as spermatic cord always twists inward) - so fix it by opening like a book - always to the outside
- immediate exploration with detorsion & bilateral fixation; orchiectomy for nonviable testes
69
most common treatment for testicular torsion
orchiopexy (bilateral fixation of testes in scrotum)
| as manual detorsion often fails due to associated pain
70
ACUTE URETERAL OBSTRUCTION SYMPTOMS
- Flank and/or abdominal pain
⦁ colicky, cramping
⦁ unable to lay still or find a comfortable position
⦁ non-positional! kind of vague flank/abdominal pain - not able to point to where it is
- Pain radiation to groin
- Nausea / Vomiting
71
LABS FOR ACUTE URETERAL OBSTRUCTION (stones)
o UA
⦁ hematuria = present with 85% of stones
⦁ pyuria with epithelials, without nitrites, and bacteria suggests contamination
UA = should have microscopic or gross hematuria. Nitrites if infectious.
72
IMAGING FOR ACUTE URETERAL OBSTRUCTION (stones)
⦁ non-contrast abdomen/pelvic CT: all stones are seen. Pleboliths can be misleading (calcifications within a vein - of no clinical importance)
73
ETIOLOGIES OF ACUTE URETERAL OBSTRUCTION
⦁ stones
⦁ clot
⦁ retroperianal fibrosis
⦁ surgical misshap (ex: clamp/cut ureter instead of renal artery)
⦁ bladder outlet obstruction
⦁ malignancy (ureter, renalpelvic nodes, adjacent organs)
74
EMERGENT ACUTE URETERAL OBSTRUCTION
```
⦁ solitary kidney
⦁ bilateral obstruction
⦁ associated infection
- fever/chills
- high WBC
- pyuria, bacteruria
- hypotension / tachycardia
```
75
NON-EMERGENT ACUTE URETERAL OBSTRUCTION
```
⦁ pyuria without other evidence of infection (such as positive nitrites, bacteriuria, etc)
⦁ hydronephrosis
⦁ perinephric fluid (urine)
⦁ hematuria
⦁ mildly increased creatinine
```
76
In the acute phase of obstruction, the rise in intrarenal pressure will reduce GFR and renal plasma flow
- this in turn will
reduce the urinary concentrating mechanism --> results in decreased renal function
- Long term obstruction may result in irreversible hypertrophy of ureteral musculature with the associated development of fibrous bands that may cause a kink to develop in the ureter
77
LABS FOR ACUTE URETERAL OBSTRUCTION (not just stones)
CBC
BUN / Creatinine
electrolytes
UA
78
IMAGING OF CHOICE FOR ACUTE URETERAL OBSTRUCTION (not stones)
CT Urogram with contrast
* - if creatinine too high = Non-contrast CT scan
79
MANAGEMENT FOR ACUTE URETERAL OBSTRUCTION
```
EMERGENT MANAGEMENT
o Ureteral stent
⦁ requires surgery & anesthesia
⦁ Convenient but potentially painful
⦁ Flomax reduces symptoms
```
o Nephrostomy tube
⦁ provides reliable drainage
⦁ more comfortable
⦁ invasive & inconvenient
o Stone removal with ureteroscopy is delayed until after infection is resolved
NON-EMERGENT MANAGEMENT
o Toradol
o PO analgesia
o Tamsulosin (alpha blocker - dilates smooth muscles)
80
Necrotizing infection of skin / fat / fascia of genitalia & perineum
FOURNIER'S GANGRENE
81
causative agent of Fournier's gangrene is usually a
mucosal barrier breakdown in the urethra or colon
82
RISK FACTORS FOR FOURNIER'S GANGRENE
```
⦁ obesity
⦁ DM
⦁ immunosuppression
⦁ alcoholism
⦁ malnutrition
```
83
Fournier's gangrene bugs
- mixture of facultative aerobic & anerobic organisms
| ⦁ E. coli, klebsiella, enterococci, bacteroides, fusobacterium, clostridium
84
diagnosing Fournier's gangrene
HX = pain, swelling, fever
PE
⦁ fever, MS changes, tachycardia, tachypnea
⦁ erythema, edema, crepitus, fluctuance
⦁ discoloration (purple, black), purulent drainage, foul odor
IMAGING = soft tissue gas on CT, Xray, or US
85
imaging for Fournier's gangrene = will see
soft tissue gas on CT, Xray, or US
86
treatment of Fournier's gangrene
- wide, aggressive debridement
- broad spectrum antibiotics to cover GP / GN / anaerobes
⦁ according to medscape = Cipro & Clinda (GP & anaerobes)
```
- Post-op wound care
⦁ repeat debridement
⦁ dressing changes
⦁ Hyperbaric oxygen
⦁ wound vac
⦁ skin grafts / flaps
```
