Flashcards in Urological emergencies Deck (103):
Acute urinary retention occurs as a complication of what?
Benign prostatic hyperplasia
Define acute urinary retention
Inability to urinate with increasing pain
Make a list of factors which are associated with the aetiology of acute urinary retention
Excessive fluid intake
Bladder over distention
How can you categorise acute urinary retention?
List the precipitating factors for acute urinary retention
Medications (anti-cholinergic, sympathomimetric)
How is acute urinary retention managed?
When should a trial without catheter be implemented in acute urinary retention? What improves success rates?
Painful retention with less than 1 litre residue AND normal serum electrolytes
Prescription of uroselective alpha blockers
List two uroselective alpha blockers
Who typically gets post-obstructive diuresis? List its associations
Patients with chronic bladder outflow obstruction
- Congestive cardiac failure
What causes post-obstructive diuresis?
Retention of urea, water and sodium (solute diuresis)
Problem with kidney's concentrating of urine
How should post-obstructive diuresis be managed?
Monitor fluid balance (>200ml/l is worrying but should resolve within two days )
Severe cases require IV fluids and sodium replacement
Is haematuria a sign of acute urinary retention?
No - the whole point of retention is that you're not passing urine HOWEVER post catheterisation haematuria is fairly common and self resolving
List some non urinary causes of loin pain
What does urinary colic occur secondary to? What mediates the pain?
Prostaglandins released by the ureters when obstructed
How is renal colic managed?
Analgesia (NSAIDs +/- opiates)
Alpha blocker (tamsulosin) for small stones expected to pass
Categorise how likely renal stones are to pass according to size
unlikely to pass spontaneously
If a stone hasn't passed within 2 weeks then it is unlikely to pass spontaneously. T/F
False - within a month
When should renal colic be managed acutely?
Persistent nausea and vomiting
High grade obstruction
How should renal colic be managed acutely?
Non infected - stent / stone fragmentation
Infected hydronephrosis - percutaneous nephrostomy
List some causes of frank haematuria
Benign prostatic hyperplasia
If there is clot retention in haematuria, what type of catheter should be used?
Three way irrigating haematuria catheter
How should haematuria be investigated?
CT urogram & cytoscopy
List some causes of acute scrotum
Torsion (spermatic cord, appendix)
What age group typically presents with torsion of the spermatic cord?
What features of a history point towards torsion of the spermatic cord?
Sudden onset severe pain
May be woken from sleep
History of trauma/sports
History of previous self limiting episodes
Referred pain to abdomen
Nausea and vomiting
What will be found on examination of someone with testicular torsion?
High riding testis
Absent cremasteric reflex
What may be associated with testicular torsion?
How is suspected testicular torsion investigated?
Doppler USS can determine blood supply but first line is surgical exploration
How is testicular torsion managed?
Removal of necrotic tissue
2/3 point fixation in correct position if tissue preserved
Fix contralateral side
What is a bell clapper deformity?
Congenital deformity where testis is not properly attached to scrotum and so lies in horizontal position (higher risk of torsion)
What features of a history point towards testicular appendix torsion?
Identical to testicular torsion although MAY be more insidious onset
What may be found on examination of someone with testicular appendix torsion?
Localised tenderness to upper pole of testis
Blue dot sign
Present cremasteric reflex
How is torsion of the testicular appendix managed?
Will spontaneously resolve without surgery
How common is epididymitis in children?
What features of a history point towards epididymitis?
As for torsion
What should be found on examination of a patient with epididymitis?
Present cremasteric reflex
How should suspected epididymitis be investigated?
Doppler USS (swollen epididymis + inc blood flow)
How is epididymitis managed?
Ofloxacin 400mg/day 14 days
How does idiopathic scrotal oedema present?
How is idiopathic scrotal oedema managed?
What is paraphimosis?
Painful swelling of the foreskin distal to phimotic ring
What is the common iatrogenic cause of paraphimosis?
Retraction of foreskin not relocated into its natural position after catheterisation/cytoscopy
How can paraphimosis be managed?
Iced glove & granulated sugar
Puncture in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
What is priapism?
Prolonged erection +/- pain often not associated with arousal (>4hr)
What are the causes of priapsim?
Iatrogenic for erectile dysfunction
Trauma (penis or perineum)
Haematologic dyscrasias (e.g sickle cell)
How can you classify priapism?
Ischaemic and non ischaemic
What is ischaemic priapism?
Veno-occlusive pathology or poor perfusion
How does ischaemic priapism present?
Corpus cavernosa rigid and tender
How does ischaemic priapsm occur?
Vascular stasis and thus decreased venous outflow (i.e compartment syndrome)
What is non-ischaemic priapism?
Arterial pathology or high flow
How does non-ischaemic priapsm occur?
Traumatic disruption of vasculature causes unregulated blood entry and thus filling of the corpora
Where does a fistula form in non-ischaemic priapsm?
Between cavernous artery and lacunar spaces (blood by passes normal helicine arteriolar bed)
How is priapsm investigated?
Aspirate blood from corpus cavernosum
Colour duplex USS
How would aspirated blood from the corpus cavernosum differ between ischaemic and non-ischaemic priapsm?
Ischaemic - dark blood (high CO2 low O2)
Non ischaemic - bright blood (low CO2 high O2)
What would a colour duplex USS show in priapsm?
Ischaemic - minimal/absent flow in cavernosal arteries
Non ischaemic - normal to high flow
How is ischaemic priapsm treated?
Aspirate +/- irrigate with saline
Inject alpha agonist (phenylephrine)
When will ischaemic priapsm not respond to treatment?
48-72 hours after onset - necrosis
Can place penile prosthesis
How is non-ischaemic priapsm treated?
Observe for spontaneous resolution
Selective arterial embolisation with non permanent materials
What is fournier's gangrene?
Necrotising fasciitis of the male genitalia
Where does fournier's gangrene originate from?
What are the predisposing factors to fourniers gangrene?
What pathogens usually cause fournier's gangrene?
How does fournier's gangrene present?
Cellulitis (erythema, swelling, tenderness) --> Severe pain, fever and systemic upset
Swelling & crepitus of scrotum
Dark purple areas
Findings seem out of proportion to what can be clinically seen
How might fournier's gangrene be investigated?
Looking for gas in tissues
How is fournier's gangrene treated?
Antibiotics and debridement
Who dies more often from fournier's gangrene?
What is emphysematous pyelonephritis?
Acute necrotising parenchymal & perirenal infection caused by gas forming uropathogens
What is the commonest cause of emphysematous pyelonephritis?
How does emphysematous pyelonephritis present?
Who is at high risk of emphysematous pyelonephritis? What is it associated with?
How is emphysematous pyelonephritis diagnosed?
KUB (plain film) will show gas
CT shows extent of emphysema
How is emphysematous pyelonephritis treated?
Nephrectomy commonly required
What causes perinephric abscess?
Rupture of acute cortical abscess into perinephric space
Haematogenous seeding from sites of infection
How does perinephric abscess present?
Mass in flank
What are the characteristic blood results of a perinephric abscess? What urine result?
High white cell count
High serum creatinine
How is a perinephric abscess investigated?
How is a perinephric abscess treated?
Antibiotics + percutaneous/surgical drainage
Describe the classifications of renal trauma
Type I - haematoma, subcapsular, non expanding, no parenchymal laceration
Type II - laceration 1cm, no collecting system rupture or extravasation
Type IV - laceration through cortex, medulla and collecting system, main arterial/venous injury with contained haemorrhage
Type V - shattered kidney, avulsion of hilum, devascularisation
What are the indications for imaging renal trauma?
Gross haematuria in adult
Gross or microscopic haematuria in child
Microscopic haematuria with shock (
How is kidney trauma investigated?
How is kidney trauma managed?
Most blunt injuries are non-operatively managed
What are the indications for surgical management of renal trauma?
Extravasation of urine
What is bladder injury associated with?
How does bladder injury present?
Inability to void
How does bladder injury present on examination?
Lower abdominal bruising
Diminished bowel sounds
When bladder injuries are catheterised what will be seen?
What is the indication for a retrograde urethrogram?
Blood at the external meatus
Catheter not passing through easily
(suggest urethral injury)
How should bladder injury be investigated?
What will be present on CT scan if there is intraperitoneal bladder injury?
Flame shaped collection of contrast within pelvis
How are bladder injuries managed?
Large bore catheter
Repeat cystogram in two weeks
When should the bladder be surgically repaired?
Bladder neck injury
Clots in urine
Inadequate urine drainage
Open pelvic fracture
Bone fragments in bladder
What is posterior urethral injury associated with?
Fractured pubic rami
What is the most vulnerable part of the urethra?
Bulbomembranous junction (between urogenital diaphragm and puboprostatic ligaments)
What are the signs and symptoms of urethral injury?
Blood at meatus
High riding prostate (fracture) on PR exam
Butterfly perineal haematoma
How is urethral injury investigated?
How is urethral injury treated?
Reconstruction after at least 3 months of healing
When does a penile fracture typically occur?
During intercourse - penis slips from vagina and buckles against pubis
What is the typical history of a penile fracture?
Cracking or popping sound (jesus fucking christ) --> pain
Is urethral injury associated with penile fracture?
Yes about 20% of cases have urethral injury - frank haematuria and blood at external meatus
How are penile fracture managed?
Exploration and repair (circumcision excision and degloving)
How does testicular injury present?
Pain + nausea
How are testicular injuries investigated?
USS (assess integrity and vascularity)