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Urological Emergencies Flashcards

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1
Q

Is Acute Urine Retention a Medical Emergency?

A

Yes

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2
Q

What is acute urine retention often a complication of?

A

Benign Prostatic Hyperplasia (BPH)

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3
Q

What is the aetiology of acute urinary retention?

A

Poorly understood.

Prostate infection 
Prostatic infarction
Bladder overdistension 
Excessive fluid intake 
Alcohol
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4
Q

How is acute urinary retention classed?

A

Spontaneous

Precipitated (triggered by an event)

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5
Q

List some events which lead to precipitated acute urinary retention?

A 
Non-prostate related surgery,
Catheterization,
Urethral instrumentation,
Alcohol, 
Anticholinergic medications 
Prostatic infarction
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6
Q

What is the classic sign of acute urinary retention?

A

Inability to pee, with increasing pain

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7
Q

How is acute urinary retention managed?

A

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

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8
Q

How does Post-obstructive diuresis present?

A

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

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9
Q

How does post-obstructive diuresis occur?

A

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

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10
Q

How is post-obstructive diuresis managed?

A

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

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11
Q

Is Haematuria self-limiting in acute urinary retention?

A

Yes, common but resolves within 24 hours

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12
Q

What are common differentials for acute loin pain?

A

Leaking AAA

Ureteric Colic secondary to calculus

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13
Q

How does ureteric colic secondary to calculus occur?

A

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

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14
Q

How is ureteric colic secondary to calculus managed?

A

NSAID +/- Opiate

Tamsulosin alpha blocker can be given for small stones that are expected to pass but evidence is not strong

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15
Q

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

A

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

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16
Q

When is intervention needed for ureteric colic secondary to calculus?

A

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

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17
Q

What are indications to treat urgently in renal calculus?

A

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

Plan to remove stone even if small

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18
Q

Describe imaging used for renal calculi?

A

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

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19
Q

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

A

Ureteric stent or stone fragmentation/removal if no infection

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

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20
Q

List causes of Frank Haematuria

A 
Infection
Stones
Tumours
Benign prostatic hyperplasia (BPH)
Polycystic kidneys
Trauma
Coagulation/platelet deficiencies
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21
Q

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

A

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

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22
Q

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

A

CT Urogram and Cytoscopy

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23
Q

Describe the general presentation of testicular torsion

A

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

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24
Q

What would you feel on examination with testicular torsion?

Testis, duh

A

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

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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

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