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Flashcards in Urological Emergencies Deck (81):
1

Is Acute Urine Retention a Medical Emergency?

Yes

2

What is acute urine retention often a complication of?

Benign Prostatic Hyperplasia (BPH)

3

What is the aetiology of acute urinary retention?

Poorly understood.

Prostate infection
Prostatic infarction
Bladder overdistension
Excessive fluid intake
Alcohol

4

How is acute urinary retention classed?

Spontaneous
Precipitated (triggered by an event)

5

List some events which lead to precipitated acute urinary retention?

Non-prostate related surgery,
Catheterization,
Urethral instrumentation,
Alcohol,
Anticholinergic medications
Prostatic infarction

6

What is the classic sign of acute urinary retention?

Inability to pee, with increasing pain

7

How is acute urinary retention managed?

If painful retention with < 1 litre residue and normal serum electrolytes then trial without catheter (TWOC) during same admission.
Prescribing a uroselective alpha-blocker (Alfuzosin, Tamsulosin) before TWOC should improve chance of voiding success but evidence does not prove this

Otherwise, Catheterization

8

How does Post-obstructive diuresis present?

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

9

How does post-obstructive diuresis occur?

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

10

How is post-obstructive diuresis managed?

Monitor fluid balance and beware if urine output > 200ml/hr. Usually resolves in 24-48hr but in severe cases, may require IV fluid and sodium replacement

11

Is Haematuria self-limiting in acute urinary retention?

Yes, common but resolves within 24 hours

12

What are common differentials for acute loin pain?

Leaking AAA
Ureteric Colic secondary to calculus

13

How does ureteric colic secondary to calculus occur?

Mediated by prostaglandin release by the ureter in response to obstruction
Often relates to the site of stone at first presentation

14

How is ureteric colic secondary to calculus managed?

NSAID +/- Opiate
Tamsulosin alpha blocker can be given for small stones that are expected to pass but evidence is not strong

15

What are the chances of a calculus passing, according to their size?

<4mm: 80%
4-6mm: 59%
>6mm: 21%

16

When is intervention needed for ureteric colic secondary to calculus?

If stone hasn’t passed in 1 month then likely to require intervention as it is unlikely to pass

17

What are indications to treat urgently in renal calculus?

Pain unrelieved for 24-48 hours
Pyrexia, which can indicate infection
Persistent N&V
High-grade obstruction

Plan to remove stone even if small

18

Describe imaging used for renal calculi?

First line is KUB X-Ray
If patient is pregnant, has gynae disease or pyelonephritis, then USS
Second line is CT Stone Search or MRI

19

What is the management for ureteric colic secondary to renal calculi if NOT passed spontaneously?

Ureteric stent or stone fragmentation/removal if no infection

Percutaneous nephrostomy for infected Hydronephrosis i.e. a tube through the loin into kidney

20

List causes of Frank Haematuria

Infection
Stones
Tumours
Benign prostatic hyperplasia (BPH)
Polycystic kidneys
Trauma
Coagulation/platelet deficiencies

21

For haematuria due to clot retention of urine, what is the management?

3-way irrigating haematuria catheter which you can aspirate hard and the catheter does not collapse.
Islet allows clots to pass

22

For haematuria due to clot retention of urine, what are the investigations?

CT Urogram and Cytoscopy

23

Describe the general presentation of testicular torsion

Common during puberty
Can occur with trauma or athletic activity but usually spontaneous. Adolescents often woken from sleep
Usually sudden onset of pain, sometimes previous episodes of self-limiting pain
May have nausea/vomiting or referral of pain to lower abdomen

24

What would you feel on examination with testicular torsion?
(Testis, duh)

Spasm of the cremaster muscles causing loss of the cremasteric reflex
Transverse lying of the affected testicle
Testis high in scrotum

Acute hydrocoele and oedema may obliterate landmarks, if it has been lying for hours

25

What are investigations for testicular torsion?

Doppler USS which can used to aid differentials when unsure of diagnosis.
Will show if there is blood supply to the teste or not

26

What is the management of testicular torsion?

Prompt exploration prior to USS
Irreversible ischaemic injury may begin as soon as 4hrs
2 or 3-point fixation with fine non-absorbable sutures
If testis necrotic then remove
MUST fix contralateral side to prevent bell clapper deformity

27

How does Torsion of Appendix present?

Symptoms variable – may be insidious in onset or identical to torsion of spermatic cord.
If seen early, may have localised tenderness at upper pole and “blue dot” sign
Testis should be mobile and cremasteric reflex present

28

Is Torsion of Appendix self-limiting?

Yes, if diagnosis confirmed then will resolve spontaneously without surgery

29

What is Epididymitis?

Inflammation of the epididymis tube, often caused by infection

30

How does Epididymitis present?

History of:
UTI,
Dysuria/Pyrexia, Urethritis, Catheterization/Instrumentation
General Unwellness

May be difficult to distinguish from Torsion
Rare in children

31

How does epididymitis present on examination?

Cremasteric reflex present
Suspect if pyuria
Doppler shows swollen epididymis and increased blood flow

32

What is the main investigation for epididymitis?

Urine for culture + Chlamydia PCR

Typically;
Young men = chlamydia
Old men = UTI

33

What is the management for epididymitis?

Analgesia, Scrotal support and bed rest
Ofloxacin 400mg/day for 14 days

34

How does idiopathic scrotal oedema present?

NO FEVER
Minimal Tenderness
Possible Pruritis
Unknown cause

35

How is idiopathic scrotal oedema treated?

Usually self-limiting
Can be treated with Fluoroquinolone for
Can be treated with Ciprofloxacin or Trimethroprim for UTI

36

What is Paraphimosis?

Retracted foreskin which cannot be returned to its normal anatomical position creating a tight, phimotic ring

37

How does paraphimosis present?

Painful swelling of the foreskin distal to a phimotic ring

38

How does paraphimosis occur?

Often happens after foreskin retracted for catheterization or cystoscopy and staff member forgets to replace it in its natural position

39

What is the treatment of paraphimosis?

Iced glove
Granulated sugar for 1-2hrs
Multiple punctures in oedematous skin
Manual compression of glans with distal traction on oedematous foreskin
Dorsal slit

40

What is Priapism?

Prolonged erection (> 4hrs), often painful and NOT associated with sexual arousal

41

What is the aetiology for Priapism?

Intracorporeal injection for Erectile Dysfunction, e.g. Papaverine
Trauma (penile / perineal)
Haematologic dyscrasias e.g. sickle cell
Neurological conditions
Idiopathic

42

What is the classification for priapism?

Ischaemic (More common)
Non-ischaemic

43

How does ischaemic priapism occur?

Vascular stasis in penis in which arterial blood can flow in but venous flow is decreased/stopped.

Corpora cavernosa are rigid and tender, penis often painful

44

How does Non-Ischaemic priapism occur?

Traumatic disruption of penile vasculature results in unregulated blood entry and filling of corpora.

Fistula formation between cavernous artery and lacunar spaces allows blood to by-pass the normal helicine arteriolar bed

45

How is priapism diagnosed?

Blood Aspiration from corpus cavernosum for either dark blood (low O2 and high CO2) in Ischaemic or normal arterial blood in high-flow

Colour duplex USS which will show minimal or absent flow in cavernosal arteries in low-flow ischaemic priapism and normal to high flow in non-ischaemic priapism

46

What is treatment of Ischaemic Priapism?

Aspiration +/- irrigation with saline to take out pressure and restore normal circulation of corpus carvenosa
Injection of alpha-agonist, e.g. Phenylephrine 100-200ug every 5-10 mins up to max 1000ug
Surgical shunt
Ischaemic priapism > 48-72hrs is unlikely to respond to intracavernosal treatment

For very delayed presentation, may even consider immediate placement of a penile prosthesis

47

What is treatment for Non-Ischaemic Priapism?

Observe, may resolve spontaneously (fibrosis lower risk due to oxygenation)

Selective arterial embolization with non-permanent materials

48

What is Fournier's Gangrene?

A form of necrotizing fasciitis occurring about the male genitalia which most commonly arises from an infectious skin, urethra or rectal lesion

49

What are predisposing factors for Fournier's gangrene?

Diabetes
Local trauma
Periurethral extravasion
Perianal infection
Alcohol

50

Describe the progression for Fournier's gangrene?

Starts as cellulitis – swollen, erythematous, tender.
Then marked pain, fever, systemic toxicity, spreads rapidly into abdominal wall
Then swelling and crepitus of scrotum, dark purple areas

Often marked toxicity out of proportion to the local findings

51

Investigations for Fournier's Gangrene?

Plain X-ray or USS may confirm gas in tissues if unsure

52

How is Fournier's Gangrene treated?

Antibiotics
Surgical Debridement

53

What is Emphysematous pyelonephritis?

An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens, usually E coli

54

Who does Emphysematous pyelonephritis classically effect?

Usually occurs in diabetics
Often associated with ureteric obstruction

55

What are symptoms of Emphysematous pyelonephritis

Fever
Vomiting
Flank Pain

56

What are investigations for Emphysematous pyelonephritis?

KUB X-Ray which shows Gas
CT defines extent of emphysematous process

57

How is Emphysematous pyelonephritis usually treated?

Nephrectomy

58

How does Peripnephric Abscess occur?

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

59

What are symptoms of perinephric abscess?

Insidious onset in around 33%
NOT PYREXIAL
Flank mass in 50% Flank swelling can be seen
High WCC
High serum creatinine, Pyuria

60

What are investigations for perinephric abscess?

CT

61

What is treatment for perinephric abscess?

Antibiotics
Percutaneous/Surgical Drainage

62

What are the Levels of the Trauma Renal Classification?

I: Haematoma, subcapsular, non-expanding, no parenchymal laceration

II: Laceration <1cm parenchymal depth without urinary extravasation

III: >1cm depth, no collecting system rupture or extravasation

IV: Laceration through cortex, medulla and collecting system
Main arterial/venous injury with contained haemorrhage

V: Shattered kidney
Avulsion of hilum, devascularizing kidney

63

What are indications for imaging in renal trauma?

Frank haematuria in adult
Frank or occult haematuria in child
Occult haematuria + shock (systolic <90mmHg at any point)
Penetrating injury with any degree of haematuria

64

What is the main investigation for renal trauma?

Contrast CT

65

How is Renal Trauma treated?

98% of blunt renal injuries can be managed non-operatively with angiography/embolization

Surgery is indicated in:
- Persistent renal bleeding
- Expanding perirenal haematoma
- Pulsatile perirenal haematoma
- Urinary extravasation, - Non-viable tissue, incomplete staging (can do on-table IVU)

66

What is bladder injury commonly associated with?

Pelvic fracture

67

How does bladder injury tend to present?

Suprapubic/abdominal pain AND inability to void
Suprapubic tenderness
Lower abdominal bruising
Guarding/rigidity
Diminished bowel sounds
Gross haematuria in 90-100%

68

What is the main imaging for Bladder Injury?

CT Cystography

Flame-shaped collection of contrast shows extraperitoneal injury

69

What is the treatment for bladder injury?

Large-bore catheter. If blood at external meatus or if catheter doesn’t pass easily then perform retrograde urethrogram as patient may well have urethral injury - check bladder integrity
Antibiotics

Repeat cystogram in 14 days

70

What are indications for immediate repair of the bladder?

Intraperitoneal injury
Penetrating injury
Inadequate drainage or clots in urine
Bladder neck injury
Rectal or vaginal injury
Open pelvic fracture
Pelvic fracture requiring open reduction/fixation
Patients undergoing laparotomy for other reasons
Bone fragments projecting into bladder

71

What is posterior urethral injury often associated with?

Fracture of pubic rami

72

What is seen on examination of urethral injury?

Blood at meatus
Inability to urinate
Palpably full bladder
“High-riding” prostate - boggy space where prostate ought to be, i.e. high riding
Butterfly perineal haematoma

73

What is the main investigation for urethral injury?

Retrograde Urethrogram
No Contrast in bladder

74

What is the treatment for urethral injury?

Suprapubic catheter
Delayed reconstruction after at least 3 months

75

How does Penile Fracture typically occur?


Typically happens during intercourse – buckling injury when penis slips out of vagina and strikes pubis

76

What is a penile fracture?

Tearing of the corpus Cavernosum
Associated with 20% incidence of urethral injury (frank haematuria/blood at meatus)

77

What is a typical history of penile fracture?

Intercourse
Cracking or popping sound followed by pain, rapid detumescence, discolouration and swelling

78

What is the treatment for penile fracture?

Prompt exploration and repair
Circumcision incision with degloving of penis to expose all 3 compartments

79

How does Testicular Injury present?

Usually presents with exquisite pain and nausea
Swelling / bruising variable

80

What is the investigation of testicular injury?

USS to assess integrity/vascularity

81

What is the treatment for testicular injury?

Early exploration/repair which improves testis salvage, reduces convalescence, better preserves fertility and hormonal function