Urological Emergencies Flashcards by Hannah Farquhar

What is a common complication of BPH?

Acute Urinary Retention

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What causes acute urinary retention?

Infection, overdistention, excessive fluid intake, alcohol, infarction

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State factors that can precipitate acute urinary retention

non-prostate related surgery
catheterisation
urethral instrumentation
anaesthesia
medication (anticholinergic/sympathomimetic)

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How is acute urinary retention treated?

Catheter

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In what circumstances can a catheter be removed in patients with previous acute urinary retention?

If <1 litre and normal electrolytes, can trial without a catheter but must prescribe a uroselective alpha blocker first

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Name a uroselective alpha blocker

Tamulosin

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What is post-obstructive diuresis?

Chronic obstruction associated with oedema, uraemia, hypertension - as a result of solute diuresis and defect in concentrating ability

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How is post-obstructive diuresis treated?

Monitor fluid balance and it usually resolves in 24-48hours

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What is the main concern in acute loin pain?

AAA

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What is acute loin pain often due to?

Ureter colic secondary to calculus

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How does the ureter respond to obstruction?

Releases prostaglandins which causes pain

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State the relationship between size of stone and likelihood of passage

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

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How is a stone treated?

NSAID +/- opiate

Alpha blocker if the stone is small and expected to pass

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After how long will intervention be required for a stone?

1 month

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What symptoms associated with loin pain signify treatment is urgent?

Pyrexia, pain unrelieved, persistent nausea/vomitting, high grade obstruction

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How can a stone be removed?

Stent, surgical removal or nephrostomy for infected hydronephrosis

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State the potential causes of frank haematuria

Infection, stones, tumours, BPH, polycystic kidneys, trauma, coagulation/platelet deficiencies (blood clot)

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What investigations are done on a patient with frank haematuria?

CT urogram and cystoscopy

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How is clot retention treated?

A 3 way irrigating haematuria catheter

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State the causes of acute scrotum?

Torsion of spermatic cord/appendix testis
Epididymitis 
Inguinal hernia 
Hydrocele 
Trauma 
Vasculitis 
Tumour

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Describe the presentation of spermatic cord torsion

Most common in puberty, can occur during sport or spontaneously (sleep), sudden onset pain, nausea/vomiting

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On examination what will be found in spermatic cord torsion?

Testes will be high in scrotum and may lie transverse, absent cremasteric reflex

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What investigations are carried out in suspected torsion?

Doppler USS

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How is spermatic cord torsion treated?

2-3 point fixation, remove if necrotic, fix bell clapper deformity if present on other side

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Describe torsion of appendage

Variable symptoms and may have blue dot, cremasteric reflex will be present and testis mobile - should resolve spontaneously without surgery

What is epididymitis caused by?

UTI or STI

How does epididymitis present?

Dysuria/pyrexia History of UTI Urethritis Post catheterisation/instrumentation

What investigation can be done in epidiymitis?

Doppler - will show swelling and increased blood flow | Urine culture & chlamydia PCR

How is epididymitis treated?

Analgesia, scrotal support and ofloxacin (14 days)

Describe idiopathic scrotal oedema

Self limiting, minimal tenderness may be itchy

What is the name given to swelling of the foreskin distal to the phimotic ring?

Paraphimosis

What causes paraphimosis?

Retraction for catheterisation/cystoscopy

How is paraphimosis treated?

Iced glove Granulated sugar Manual compression Multiple punctures/slit if other options fail

State the term used to describe a prolonged erection

Priapism

After how long is an erection considered pathological?

4 hours

What causes priapism?

``` ED injection Trauma Sickle cell Neurological conditions Idiopathic Atherosclerosis ```

What are the two types of priapism?

Ischaemic | Non-ischemic

Describe ischaemic priapism

Low flow, leads to vascular stasis and decreased venous outflow - compartment syndrome

Describe non-ischaemic priapism

High flow, traumatic disruption to vasculature leads to unregulated blood entry and filling of corpora, fistula formation allows blood to by-pass arteriolar bed

What investigations are carried out in priapism?

Blood aspirate, duplex colour USS

How can ischaemic priapism be treated?

Aspiration and irrigation with saline Injection of alpha agonist Surgical shunt

How is non-ischaemic priapism treated?

May resolve spontaneously if not arterial embolisation of damaged vessel

What is the name given to necrotising fasciitis that arises from the skin/urethra/rectal region?

Fournier's Gangrene

What are the risk factors for Fournier's gangrene?

Diabetes Trauma Extravasation Infection

What is the progression of fournier's gangrene?

Cellulitis --> swelling, dark purple areas --> toxicity

Describe the features of x-ray/USS of fourniers gangrene

Gas in tissues

How is fournier's gangrene treated?

Antibiotics and debridement

What is emphysematous pyelonephritis?

Acute necrotising infection caused by gas forming uropathogens e.g. e.coli

Who is most affected by emphysematous pyelonephritis?

Diabetics associated with ureteric obstruction

How does emphysematous pyelonephritis present?

Fever, vomiting, flank pain

What investigations are done on emphysematous pyelonephritis?

CT | X-ray - gas

What treatment is often required in emphysematous pyelonephritis?

Nephrectomy if antibiotics and drainage fails

How does a perinephric abscess often arise?

- Rupture of an acute cortical abscess into the perinephric space - Haematogenous spread of infection

How does a perinephric abscess present?

Insidious onset, pyrexia, 50% flank mass,

What will biochemistry of a patient with a perinephric abscess show?

High WCC, serum creatinine and pyuria

How is a perinephric abscess diagnosed and treated?

CT scan | Antibiotics or drainage

What are the 5 classes of kidney trauma?

I - haematuria II - laceration <1cm III - >1cm laceration but no rupture or extravasation IV - laceration through cortex, medulla and collecting system, main arterial/venous injury with contained haemorrhage V - shattered kidney

What are the indications for imaging in kidney trauma?

Frank haematuria/occult in children Occult haematuria and shock Penetrating injury

How is renal trauma investigated?

CT with contrast

How is renal trauma treated?

Most can be managed by angiography and embolisation | Surgery - persistent bleeding, expanding haematuria, pulsatile haematoma, urinary extravasation, non-viable tissue

What is bladder trauma associated with?

Pelvic fracture

How does bladder trauma present?

Suprapubic/abdominal pain, inability to void, suprapubic tenderness, lower abdominal bruising, guarding/rigidity, diminished bowel sounds

What indicated urethral injury?

Blood at external meatus | Catheter does not pass easily

How is badder trauma investigated?

CT cystography

How will extraperitoneal injury appear on imaging?

Flame shaped collection of contrast in pelvis

State the treatment for bladder trauma

Large bore catheter and antibiotics - repeat cystogram in 14 days

What merits immediate repair in bladder trauma?

``` Intraperitoneal injury Penetrating injury Inadequate drainage/clots in urine Bladder neck/rectal/vaginal injury Open pelvic fracture Bone fragments into the bladder ```

What is posterior urethral injury often associated with?

Fracture of the pubic rami

Why is the bubomembranous junction the most vulnerable?

Fixed at urogenital diaphragm and puboprostatic ligaments

In urethral trauma what clinical features will be present?

Blood at meatus, inability to urinate, full palpable bladder, high-riding prostate, perineal haematoma (butterfly appearance)

How is urethral injury investigated?

Retrograde urethrogram

How is urethral injury treated?

Suprapubic catheter and delayed reconstruction

How does penile trauma most commonly occur?

Usually during intercourse, bucking injury when penis slips out of vagina and strikes pubis

Describe the process of penile trauma

Crack/pop followed by detumescence and discolouration

How is penile trauma managed?

Prompt exploration and repair but circumcision incision with degloving to expose all 3 compartments

How does testicular trauma present?

Exquisite pain and nausea sometimes with associated swelling and bruising

Describe the management of testicular trauma

USS to assess integrity and vascularity followed by surgical repair