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Year 2 > Urological emergencies > Flashcards

Urological emergencies Flashcards

(103 cards)

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1
Q

Acute urinary retention occurs as a complication of what?

A

Benign prostatic hyperplasia

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2
Q

Define acute urinary retention

A

Inability to urinate with increasing pain

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3
Q

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

A 
Alcohol
Prostate infection
Prostate infarction
Excessive fluid intake
Bladder over distention
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4
Q

How can you categorise acute urinary retention?

A

Spontaneous

Precipitated

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5
Q

List the precipitating factors for acute urinary retention

A 
Non-prostatic surgery
Medications (anti-cholinergic, sympathomimetric)
Urethral instrumentation 
Catheterisation 
Anaesthesia
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6
Q

How is acute urinary retention managed?

A

Catheterisation

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7
Q

When should a trial without catheter be implemented in acute urinary retention? What improves success rates?

A

Painful retention with less than 1 litre residue AND normal serum electrolytes
Prescription of uroselective alpha blockers

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8
Q

List two uroselective alpha blockers

A

Alfuzosin

Tamsulosin

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9
Q

Who typically gets post-obstructive diuresis? List its associations

A

Patients with chronic bladder outflow obstruction

  • Uraemia
  • Congestive cardiac failure
  • Hypertension
  • Oedema
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10
Q

What causes post-obstructive diuresis?

A

Retention of urea, water and sodium (solute diuresis)

Problem with kidney’s concentrating of urine

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11
Q

How should post-obstructive diuresis be managed?

A

Monitor fluid balance (>200ml/l is worrying but should resolve within two days )
Severe cases require IV fluids and sodium replacement

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12
Q

Is haematuria a sign of acute urinary retention?

A

No - the whole point of retention is that you’re not passing urine HOWEVER post catheterisation haematuria is fairly common and self resolving

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13
Q

List some non urinary causes of loin pain

A

AAA
Appendicitis
Pancreatitis
Ectopic pregnancy

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14
Q

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

A

Renal calculus

Prostaglandins released by the ureters when obstructed

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15
Q

How is renal colic managed?

A 
Analgesia (NSAIDs +/- opiates)
Alpha blocker (tamsulosin) for small stones expected to pass
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16
Q

Categorise how likely renal stones are to pass according to size

A

unlikely to pass spontaneously

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17
Q

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

A

False - within a month

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18
Q

When should renal colic be managed acutely?

A

Fever
Persistent nausea and vomiting
Unrelieved pain
High grade obstruction

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19
Q

How should renal colic be managed acutely?

A

Non infected - stent / stone fragmentation

Infected hydronephrosis - percutaneous nephrostomy

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20
Q

List some causes of frank haematuria

A 
Infection
Stones
Tumours 
Benign prostatic hyperplasia 
Polycystic kidneys 
Trauma
Coagulopathy
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21
Q

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

A

Three way irrigating haematuria catheter

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22
Q

How should haematuria be investigated?

A

CT urogram & cytoscopy

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23
Q

List some causes of acute scrotum

A 
Torsion (spermatic cord, appendix)
Tumour
Epididymitis
Epididymo-orchitis
Inguinal hernia 
Hydrocoele 
Trauma
Insect bite/dermatological
Inflammatory vasculitis
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24
Q

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

A

Pubertal adolescents

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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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