Urological Emergencies

Question 1

how does acute urinary retention present?

Answer 1

inability to urinate with increasing pain

Question 2

what common condition can cause acute urinary retention?

Answer 2

BPH

Question 3

what can acute urinary retention be separated in to?

Answer 3

spontaneous and precipitated

Question 4

when would acute urinary retention be precipitated?

Answer 4

• non-prostate related surgery
• catheterization
• anaesthesia
• medication with sympathomimetric or anticholinergeric effects

Question 5

when should trial without catheter be used in acute urinary retention?

Answer 5

if painful retention with

Question 6

what can be prescribed to improve chance of successful voiding before trial without catheter in acute urinary retention?

Answer 6

prescribing a uroselective alphablocker

Question 7

examples of uroselective alpha-blocker?

Answer 7

Tamsulosin, alfuzosin

Question 8

in what patients does post-obstructive diuresis often present in?

Answer 8

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

Question 9

what is the diuresis due to in post-obstructive diuresis?

Answer 9

due to solute diuresis (retained urea, sodium and water) and defect in concentrating ability of kidney

Question 10

in post-obstructive diuresis what should you make sure urine output doesnt exceed?

Answer 10

> 200 ml/hr

Question 11

how long does post-obstructive diuresis take to resolve?

Answer 11

24-48 hours

Question 12

what treatment may be required in post-obstructive diuresis in a severe case?

Answer 12

IV fluid and sodium replacement

Question 13

most common cause for ureteric colic?

Answer 13

calculus

Question 14

what mediates the pain in ureteric colic?

Answer 14

release of prostaglandins by ureter in response to obstruction

Question 15

for a small stone, what is the treatment?

Answer 15

NSAIDS +/- opiate
alpha-blocker
stone expected to pass

Question 16

what is the chance of a stone

Answer 16

80%

Question 17

what is the chance of a stone 4-6mm spontaneously passing?

Answer 17

59%

Question 18

what is the chance of a stone > 6mm spontaneously passing?

Answer 18

21%

Question 19

intervention is likely required if a ureteric stone hasnt passed within what time length?

Answer 19

a month

Question 20

what is the best diagnostic investigation when investigating renal calculus ?

Answer 20

non-contrast CT

Question 21

what are the indications that a renal calculus needs to be treated urgently?

Answer 21

• pain unrelieved
• pyrexia
• persistent nausea/vomitting
• high-grade obstruction

Question 22

how is a renal stone managed surgically in the absence of infection ?

Answer 22

ureteric stent or stone fragmentation/removal

Question 23

how is a renal stone managed surgically if there is an infected hydronephrosis?

Answer 23

percutaneous nephrostomy for infected hydronephrosis

Question 24

at what age is torsion of the spermatic cord most common?

Answer 24

at puberty

Question 25

how does torsion of the spermatic cord present?

Answer 25

sudden onset of pain, may be nausea/vomitting, lower abdo pain

Question 26

what can precipitate a torsion of the spermatic cord?

Answer 26

trauma or athletic activity

Question 27

what will you find on examintion of the teste in a torsion of the spermatic cord?

Answer 27

- testis high in scrotum - testis lying transversely - absence of cremasteric reflex

Question 28

what is the managment of a torsion of the spermatic cord?

Answer 28

urgent surgical exploration.

Question 29

what happens if a torsion of spermatic cord is not recognised/treated?

Answer 29

irreversible ischaemic injury begins as soon as 4hrs

Question 30

how may a torsion of appendage present and appear on examintion?

Answer 30

- symptoms variable - may be insidious onset or same as torsion of cord. - ma have localised tenderness at upper pole and blue dot sign

Question 31

is the cremasteric reflex present in torsion of appendage?

Answer 31

yes

Question 32

managment of torsion of appendage?

Answer 32

will resolve spontaneously without surgery

Question 33

presentation of epididymitis?

Answer 33

similar to torsion. dysuria/pyrexia more common.

Question 34

is the cremateric reflex present in epididymitis?

Answer 34

reflex present

Question 35

what can been seen in a doppler of epididymitis?

Answer 35

swollen epididymis, increased bloodflow

Question 36

what tests should be done in suspected epididymitis?

Answer 36

send urine for culture and chlamydia PCR

Question 37

what can precipitate epididymitis?

Answer 37

history of UTI, urethritis, catheterization/instrumentation

Question 38

conservative management of epididymitis?

Answer 38

- analgesia, scrotal support, bed rest

Question 39

medical managment of epididymitis?

Answer 39

- ofloxacin 400mg/day for 14 days

Question 40

is idiopathic scrotal oedema usually associated with erythema?

Answer 40

no

Question 41

what would you expect on examination of idiopathic scrotal odema?

Answer 41

odema around scrotum, no eythema, no fever, minimal tenderness

Question 42

how is idiopathic scrotal oedema managed?

Answer 42

it is self-limiting

Question 43

what is paraphimosis?

Answer 43

painful swelling of the foreskin distal to a phimotic ring

Question 44

when does paraphimosis usually occur?

Answer 44

often happens after foreskin is retracted for catheterization or cystoscopy and staff member forgets to pull foreskin back into its natural position

Question 45

what is priapism?

Answer 45

prolonged erection (>4hrs) often painful and not associated with sexual arousal

Question 46

aetiology of priapism?

Answer 46

- intracorporeal injection - trauma - haematologic dyscasias - neurological condition - idiopathic

Question 47

classifications of priapism?

Answer 47

ischaemic and non-ischaemic

Question 48

how does an ischaemic priapism occur?

Answer 48

veno-occlusion or low flow leading to vascular stasis

Question 49

how do corpora cavernosa feel?

Answer 49

rigid and tender

Question 50

how does a non-ischaemic priapism occur?

Answer 50

traumatic disruption of penile vasculature resulting in unregulated blood entry and filling of corpora

Question 51

in non-ischaemic priapism what allows blood to by-pass the normal helicine arteriolar bed?

Answer 51

fistula formation between the cavernous artery and lacunar spaces

Question 52

how is priapism diagnosed?

Answer 52

aspirate blood from corpus cavernosum

Question 53

what is the profile of the blood aspirated in an ischaemic priapism?

Answer 53

dark, low oxygen, high carbon dioxide

Question 54

what is the profile of the blood aspirated in a non-ischaemic priapism?

Answer 54

normal arterial blood

Question 55

treatment of ischaemic priapism?

Answer 55

aspiration +/- irrigation with saline. injection of alpha-antagonist 100-200 ug every 5-10 mins up to a max of 1000ug- if not resolved : surgical stunt

Question 56

how is ischaemic priapism treated?

Answer 56

observe, may resolve spontaneously. selective arterial embolization with non-permanent materials

Question 57

after how many hours of ischaemic priapism will it be unlikely to be helped by intracavernosal treatment?

Answer 57

more than 48-72 hours

Question 58

for delayed presentation of ischaemic priapism, what could be considered?

Answer 58

immediate placement of a penile prosthesis

Question 59

what is Fournier's gangrene?

Answer 59

a form a necrotizing fasciitis occurring about the male genitalia.

Question 60

where does Fournier's gangrene most commonly arise from in the male genitalia?

Answer 60

skin, urethra or rectal region

Question 61

what are the predisposing factors of Fourneir's gangrene?

Answer 61

- diabetes - local trauma - periurethral extravasation - perianal infection

Question 62

organisms causing Fourniers gangrene?

Answer 62

usually a mixture of aerobes and anaerobes

Question 63

what is the presentation of Fourniers gangrene?

Answer 63

- start as cellulitis: swollen, erythematous, tender, pain, fever, systemic upset

Question 64

what can be seen on examination of Fourniers gangrene?

Answer 64

-swollen, eythematous, tender, marked pain, fever. crepitus of scrotum, dark purple areas.

Question 65

what investigations can be used to confirm gas in the tissues in Fournier's gangrene?

Answer 65

plain x-ray and USS

Question 66

managment of Fournier's gangrene?

Answer 66

surgical debridement and antibiotics

Question 67

what is emphysematous pyelonephritis?

Answer 67

an acute necrotizing parenchymal and perirenal infection

Question 68

what pathogen usually causes emphysematous pyelonephritis?

Answer 68

E.coli

Question 69

what disease is associated with emphysematous pyelonephritis?

Answer 69

diabetes

Question 70

what problem is associated with emphysematous pyelonephritis?

Answer 70

ureteric obstruction

Question 71

how does emphysematous pyelonephritis present?

Answer 71

fever, vomitting, flank pain

Question 72

what scan is used to define the extend of the emphysematous process in emphysematous pyelonephritis?

Answer 72

CT

Question 73

what is often required to treat emphysematous pyelonephritis?

Answer 73

nephrectomy

Question 74

what does a perinephric abscess usually result from?

Answer 74

from rupture of an acute cortical abscess into the perinephric space or from haematogenous seeding from sites of infection

Question 75

approx what percentage of patients with perinerphric absess are not pyrexial?

Answer 75

33%

Question 76

in what percent of patients with a perinephric abscess is there a flank mass?

Answer 76

in 50%

Question 77

what test results would be expected in peinephric abscess?

Answer 77

high WCC, high serum creatinine, pyuria

Question 78

management of perinephric abscess?

Answer 78

antibiotics and percutaneous or surgical drainage

Question 79

in renal trauma, what is a type I classification?

Answer 79

- haematoma, subcapsular, non-expanding, no parenchymal laceration

Question 80

type II classification in renal trauma?

Answer 80

laceration

Question 81

type III classification in renal trauma?

Answer 81

>1cm depth, no collecting system rupture or extravasation

Question 82

type IV classification in renal trauma?

Answer 82

laceration through cortex, medulla and collecting system. main arterial/venous injury with contained haemorrhage

Question 83

type V classification in renal trauma?

Answer 83

shattered kidney, avulsion of hilium, devascularized kidney

Question 84

what type of fracture is commonly associated with bladder injury?

Answer 84

pelvic fracture

Question 85

what is posterior urethral injury often associated with?

Answer 85

fracture of pubic rami

Question 86

what fixes the posterior urethra in place?

Answer 86

fixed at urogenital diaphragm and puboprostatic ligaments

Question 87

what part of the of the posterior urethra is most vulnerable to injury?

Answer 87

bulbomembranous junction

Question 88

what will you find on examination in urethral injury?

Answer 88

- blood at meatus - inability to urinate - palpably full bladder - high riding prostate - butterfly perineal haematoma

Question 89

investigation for urethral injury?

Answer 89

retrograde urethrogram

Question 90

management of urethral injury?

Answer 90

- suprapubic catheter | - delayed reconstruction after at least 3 months

Question 91

when does a penile fracture typically happen?

Answer 91

during intercourse - buckling injury when penis slips out of vagina and strikes pubis

Question 92

what is experienced when a penile fracture occurs?

Answer 92

cracking or popping sound followed by pain, discolouration and swelling

Question 93

what is there a 20% incidence of in penile fractures?

Answer 93

urethral injury

Question 94

management of penile fracture?

Answer 94

prompt exploration and repair. circumcision incision with degloving of penis to expose all 3 compartments

Question 95

how does testicular injury usually present?

Answer 95

exquisite pain and nausea

Question 96

what investigation is done in testicular injury?

Answer 96

USS to assess integrity/vascularity

Question 97

managment of testicular injury?

Answer 97

early exploration/repair