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Flashcards in Urological emergencies Deck (103):
1

Acute urinary retention occurs as a complication of what?

Benign prostatic hyperplasia

2

Define acute urinary retention

Inability to urinate with increasing pain

3

Make a list of factors which are associated with the aetiology of acute urinary retention

Alcohol
Prostate infection
Prostate infarction
Excessive fluid intake
Bladder over distention

4

How can you categorise acute urinary retention?

Spontaneous
Precipitated

5

List the precipitating factors for acute urinary retention

Non-prostatic surgery
Medications (anti-cholinergic, sympathomimetric)
Urethral instrumentation
Catheterisation
Anaesthesia

6

How is acute urinary retention managed?

Catheterisation

7

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

8

List two uroselective alpha blockers

Alfuzosin
Tamsulosin

9

Who typically gets post-obstructive diuresis? List its associations

Patients with chronic bladder outflow obstruction
- Uraemia
- Congestive cardiac failure
- Hypertension
- Oedema

10

What causes post-obstructive diuresis?

Retention of urea, water and sodium (solute diuresis)
Problem with kidney's concentrating of urine

11

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

12

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

13

List some non urinary causes of loin pain

AAA
Appendicitis
Pancreatitis
Ectopic pregnancy

14

What does urinary colic occur secondary to? What mediates the pain?

Renal calculus
Prostaglandins released by the ureters when obstructed

15

How is renal colic managed?

Analgesia (NSAIDs +/- opiates)
Alpha blocker (tamsulosin) for small stones expected to pass

16

Categorise how likely renal stones are to pass according to size

unlikely to pass spontaneously

17

If a stone hasn't passed within 2 weeks then it is unlikely to pass spontaneously. T/F

False - within a month

18

When should renal colic be managed acutely?

Fever
Persistent nausea and vomiting
Unrelieved pain
High grade obstruction

19

How should renal colic be managed acutely?

Non infected - stent / stone fragmentation
Infected hydronephrosis - percutaneous nephrostomy

20

List some causes of frank haematuria

Infection
Stones
Tumours
Benign prostatic hyperplasia
Polycystic kidneys
Trauma
Coagulopathy

21

If there is clot retention in haematuria, what type of catheter should be used?

Three way irrigating haematuria catheter

22

How should haematuria be investigated?

CT urogram & cytoscopy

23

List some causes of acute scrotum

Torsion (spermatic cord, appendix)
Tumour
Epididymitis
Epididymo-orchitis
Inguinal hernia
Hydrocoele
Trauma
Insect bite/dermatological
Inflammatory vasculitis

24

What age group typically presents with torsion of the spermatic cord?

Pubertal adolescents

25

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

26

What will be found on examination of someone with testicular torsion?

High riding testis
Transverse testi
Absent cremasteric reflex

27

What may be associated with testicular torsion?

Acute hydrocoele/oedema

28

How is suspected testicular torsion investigated?

Doppler USS can determine blood supply but first line is surgical exploration

29

How is testicular torsion managed?

Removal of necrotic tissue
2/3 point fixation in correct position if tissue preserved
Fix contralateral side

30

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)

31

What features of a history point towards testicular appendix torsion?

Identical to testicular torsion although MAY be more insidious onset

32

What may be found on examination of someone with testicular appendix torsion?

Localised tenderness to upper pole of testis
Blue dot sign
Mobile testis
Present cremasteric reflex

33

How is torsion of the testicular appendix managed?

Will spontaneously resolve without surgery

34

How common is epididymitis in children?

Rare

35

What features of a history point towards epididymitis?

As for torsion
Dysuria
Pyrexia
History of
- UTI
- urethritis
- instrumentation/catheterisation

36

What should be found on examination of a patient with epididymitis?

Present cremasteric reflex
Pyuria (urinalysis)

37

How should suspected epididymitis be investigated?

Doppler USS (swollen epididymis + inc blood flow)
Urine culture
Chlamydial PCR

38

How is epididymitis managed?

Analgesia
Scrotal support
Bed rest
Ofloxacin 400mg/day 14 days

39

How does idiopathic scrotal oedema present?

Odema
No erythema
No fever
Minimal tenderness
Pruritis

40

How is idiopathic scrotal oedema managed?

Self limiting

41

What is paraphimosis?

Painful swelling of the foreskin distal to phimotic ring

42

What is the common iatrogenic cause of paraphimosis?

Retraction of foreskin not relocated into its natural position after catheterisation/cytoscopy

43

How can paraphimosis be managed?

Iced glove & granulated sugar
Puncture in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit

44

What is priapism?

Prolonged erection +/- pain often not associated with arousal (>4hr)

45

What are the causes of priapsim?

Iatrogenic for erectile dysfunction
Idiopathic
Neurological
Trauma (penis or perineum)
Haematologic dyscrasias (e.g sickle cell)

46

How can you classify priapism?

Ischaemic and non ischaemic

47

What is ischaemic priapism?

Veno-occlusive pathology or poor perfusion

48

How does ischaemic priapism present?

Corpus cavernosa rigid and tender
Pain

49

How does ischaemic priapsm occur?

Vascular stasis and thus decreased venous outflow (i.e compartment syndrome)

50

What is non-ischaemic priapism?

Arterial pathology or high flow

51

How does non-ischaemic priapsm occur?

Traumatic disruption of vasculature causes unregulated blood entry and thus filling of the corpora

52

Where does a fistula form in non-ischaemic priapsm?

Between cavernous artery and lacunar spaces (blood by passes normal helicine arteriolar bed)

53

How is priapsm investigated?

Aspirate blood from corpus cavernosum
Colour duplex USS

54

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)

55

What would a colour duplex USS show in priapsm?

Ischaemic - minimal/absent flow in cavernosal arteries
Non ischaemic - normal to high flow

56

How is ischaemic priapsm treated?

Aspirate +/- irrigate with saline
Inject alpha agonist (phenylephrine)
Surgical shunt

57

When will ischaemic priapsm not respond to treatment?

48-72 hours after onset - necrosis
Can place penile prosthesis

58

How is non-ischaemic priapsm treated?

Observe for spontaneous resolution
Selective arterial embolisation with non permanent materials

59

What is fournier's gangrene?

Necrotising fasciitis of the male genitalia

60

Where does fournier's gangrene originate from?

Skin
Urethral/rectal region

61

What are the predisposing factors to fourniers gangrene?

Diabetes
Trauma
Periurethral extravasation
Perianal infection

62

What pathogens usually cause fournier's gangrene?

Coliforms
Anaerobes

63

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

64

How might fournier's gangrene be investigated?

Plain x-ray
USS

Looking for gas in tissues

65

How is fournier's gangrene treated?

Antibiotics and debridement

66

Who dies more often from fournier's gangrene?

Diabetics
Alcoholics

67

What is emphysematous pyelonephritis?

Acute necrotising parenchymal & perirenal infection caused by gas forming uropathogens

68

What is the commonest cause of emphysematous pyelonephritis?

E.coli

69

How does emphysematous pyelonephritis present?

Fever
Vomiting
Flank pain

70

Who is at high risk of emphysematous pyelonephritis? What is it associated with?

Diabetics
Ureteric obstruction

71

How is emphysematous pyelonephritis diagnosed?

KUB (plain film) will show gas
CT shows extent of emphysema

72

How is emphysematous pyelonephritis treated?

Nephrectomy commonly required

73

What causes perinephric abscess?

Rupture of acute cortical abscess into perinephric space
Haematogenous seeding from sites of infection

74

How does perinephric abscess present?

Insidious onset
With/without pyrexia
Mass in flank

75

What are the characteristic blood results of a perinephric abscess? What urine result?

High white cell count
High serum creatinine

Pyuria

76

How is a perinephric abscess investigated?

CT

77

How is a perinephric abscess treated?

Antibiotics + percutaneous/surgical drainage

78

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

79

What are the indications for imaging renal trauma?

Gross haematuria in adult
Gross or microscopic haematuria in child
Microscopic haematuria with shock (

80

How is kidney trauma investigated?

Contrast CT

81

How is kidney trauma managed?

Most blunt injuries are non-operatively managed
Angiography/embolisation

82

What are the indications for surgical management of renal trauma?

Persistant bleeding
Expanding haematoma
Pulsatile haematoma
Extravasation of urine
Non-viable tissue
Incomplete staging

83

What is bladder injury associated with?

Pelvic fracture

84

How does bladder injury present?

Suprapubic/abdominal pain
Inability to void

85

How does bladder injury present on examination?

Suprapubic tenderness
Lower abdominal bruising
Guarding
Diminished bowel sounds

86

When bladder injuries are catheterised what will be seen?

Gross haematuria

87

What is the indication for a retrograde urethrogram?

Blood at the external meatus
Catheter not passing through easily
(suggest urethral injury)

88

How should bladder injury be investigated?

CT cystography

89

What will be present on CT scan if there is intraperitoneal bladder injury?

Flame shaped collection of contrast within pelvis

90

How are bladder injuries managed?

Large bore catheter
Antibiotics
Repeat cystogram in two weeks

91

When should the bladder be surgically repaired?

Intraperitoneal injury
Penetrating injury
Bladder neck injury
Clots in urine
Inadequate urine drainage
Open pelvic fracture
Bone fragments in bladder

92

What is posterior urethral injury associated with?

Fractured pubic rami

93

What is the most vulnerable part of the urethra?

Bulbomembranous junction (between urogenital diaphragm and puboprostatic ligaments)

94

What are the signs and symptoms of urethral injury?

Blood at meatus
Anuria
Full bladder
High riding prostate (fracture) on PR exam
Butterfly perineal haematoma

95

How is urethral injury investigated?

Retrograde urethrogram

96

How is urethral injury treated?

Suprapubic catheter
Reconstruction after at least 3 months of healing

97

When does a penile fracture typically occur?

During intercourse - penis slips from vagina and buckles against pubis

98

What is the typical history of a penile fracture?

Cracking or popping sound (jesus fucking christ) --> pain
Rapid detumescence
Swelling
Discolouration

99

Is urethral injury associated with penile fracture?

Yes about 20% of cases have urethral injury - frank haematuria and blood at external meatus

100

How are penile fracture managed?

Exploration and repair (circumcision excision and degloving)

101

How does testicular injury present?

Pain + nausea
Swelling
Bruising

102

How are testicular injuries investigated?

USS (assess integrity and vascularity)

103

How are testicular injuries managed?

Early exploration and repair - decreases removal and convalesecne , increases preservation of fertility and hormonal function

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