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Flashcards in UROLOGICAL EMERGENCIES Deck (50)
1

What are the main urological emergencies?

Acute urinary retention

Renal colic

Testicular torsion

Paraphimosis

Priapism

2

Who is normally affected by acute urinary retention?

Elderly men

3

What are the four major categories of causes of acute urinary retention?

Obstructive

Inflammatory

Neurological

Over-distension - leading to bladder not contracting properly

4

What are the obstructive causes of urinary retention?

Mechanical obstruction:

BPH

Urethral stricture

Constipation

Pelvic mass


Dynamic obstruction:

Increase in smooth muscle tone due to postoperative pain and drugs

5

What are the inflammatory causes of acute urinary retention?

UTI

Prostatitis

6

What are the neurological causes of acute urinary retention?

Spinal cord injury

Multiple sclerosis

Pelvic surgery

7

What are some causes of over-distention of the bladder which can lead to the bladder no longer able to contract properly and hence lead to acute urinary retention?

Post-anaesthesia

High alcohol intake

Drugs:
- ephedrine, pseudoephedrine
- Antidepressants

8

What are the clinical features of acute urinary retention?

Central lower abdominal pain

Anuria

Palpable bladder

9

How do we treat acute retention?

Urgent urethral catheterisation

10

What must you do once urethral catheterisation of a patient with acute urinary retention has happened?

Record the urine drained in the first 10-15 minutes

11

What is the normal volume drained from the bladder through urethral catheterisation following acute urinary retention?

Less than 1 litre

12

If more than 1 litre is drained from someone with urinary retention, what might this indicated?

More chronic retention

13

How should you treat a patient with urinary retention in whom urethral catheterisation fails?

Admit urgently for consideration of a suprapubic catheter.

14

Once a patient who presents with acute urinary retention has been catheterised, what investigations and management should be done for them?

Renal function blood tests

Start alpha blocker

TWOC after 2-3 days of alpha blocker

15

How should a patient with acute urinary retention who fails a TWOC be managed?

Long-term catheter

OR

Prostatic surgery

16

What are the features of chronic urinary retention?

Build up of more than 1 litre

Less pain than acute

Nocturnal enuresis

Overflow incontinence

17

Is chronic or acute urinary retention more likely to cause abnormal renal function?

Chronic - in these cases immediate catheterisation is required

18

How do we treat chronic urinary retention?

Catheter

TWOC not appropriate management

Should undergo elective prostatic surgery or have long term catheter.

19

What is renal colic?

Pain caused by kidney stones

20

What are the clinical features of renal colic?

Severe sudden onset-pain

Starts in the flank

Radiates around the front to the groin and sometimes scrotum or labia

Nausea and vomiting

Visible haematuria

Unable to find a comfortable position and therefore appear restless

Often nil on examination

21

What is the cause of the pain in renal colic?

Dilatation, stretching and spasm caused by acute ureteral obstruction.

22

What investigations should be done for someone who presents with signs and symptoms consistent with renal colic?

Urinalysis - blood (if not blood is found, strongly consider alternative diagnosis)

U&Es

Pregnancy test in women of childbearing age

Non-contract CT abdo-pelvis

23

How do you treat a patient with renal colic?

Resuscitation with fluids

Anti-emetics

Analgesia (NSAIDs should be tried before opiate based)

If small enough wait for stone to pass.

If larger - number of option including endoscopic or surgical extraction, or shock wave treatment to break up stone.

24

Below what size of kidney stone is there a 90% chance of spontaneously passing it?

4mm

25

Above what size of kidney stone is there only a 20% chance of spontaneously passing it?

6mm

26

What are the complications of kidney stones?

Obstructive renal failure

Severe pyelonephrtitis

27

What is testicular torsion?

Twisting of the spermatic cord, which impedes blood flow to the testis and impairs venous drainage. This results in oedema, ischaemia and necrosis.

28

What are the peak ages of incidence for testicular torsion?

1-2 years old

Late teenage years

Testicular torsion is very rare in the over 40s

29

What is the most common cause of testicular torsion?

Malformed tunica vaginalis - bell-clapper deformity. The tunica vaginalis extends over the whole testis rather than just the upper pole.

30

What are the clinical features of testicular torsion?

Pain

Very quick in onset

Previous episodes of pain indicating intermittent torsion

Swelling

Erythema

Testicle lying horizontally, sitting high in the scrotum

Absent cremasteric reflex

31

What investigations should be done for someone who presents with signs and symptoms consistent with testicular torsion?

Urinalysis - normal

Colour flow Doppler USS - poor or absent blood flow

Remember that time is key to management of this, so if the diagnosis is highly likely then surgery should not be delayed for investigations.

32

How is testicular torsion managed?

Testicle is detorted surgically and then fixed to the scrotal wall.

If testis is not salvageable, an orchidectomy is performed.

Other testicle should also be examined and fixed if bell-clapper deformity is bilateral.

33

What percentage of testes will be salvaged if surgery is performed 8 hours after onset of pain?

65%

34

What is paraphimosis?

Foreskin becomes fixed in the retracted position and cannot be reduced therefore constricting venous return from glans penis and resulting in swelling of glans.

35

What is the condition known to precipitate paraphimosis?

Phimosis

36

What is the most common cause of paraphimosis?

Iatrogenic - medical staff fail to replace the foreskin following urethral catheterisation.

37

What are the complications of untreated paraphimosis?

Ulceration and necrotic changes in the preputial skin and glans penis.

38

What are the management option for paraphimosis?

Adequate analgesia - may involve penile nerve block

Manual decompression should be tried first - reduce oedema enough to replace foreskin over glans

Dorsal slit in the preputial skin.

Formal circumcision is definitive management - usually performed after dorsal slit to allow oedema to decrease.

39

What is priapism?

Penile erection persisting beyond or unrelated to sexual stimulation.

40

What are the two types of priapism?

Low-flow or ischaemic

High-flow or non-ischaemic

41

What is the aetiology of low flow priapism?

Decreased venous and lymphatic drainage of corpus cavernosae

42

What is the aetiology of high flow priapism?

Unregulated arterial blood flow often related to trauma.

43

What is the main complication of priapism?

Erectile dysfunction often as a result of thrombosis, further ischaemia and subsequent fibrosis

44

What are the haematological causes of priapism?

Sickle cell disease

Leukaemia

Thrombophilia

45

What are the neurological causes of priapism?

Spinal cord compression

46

What are the drugs related causes of priapism?

Drugs for ED:

Intracavernosal papaverine

Intracavernosal prostaglandin E1

Intraurethral alprostadil


Other drugs:

Antihypertensives

Antipsychotics

Antidepressants

Alcohol and cocaine

47

What are the causes of high-flow priapism?

Perineal or penile trauma (commonly straddle type injuries) producing a cavernosal artery laceration, subsequent arteriovenous fistula and thus unregulated arterial blood flow.

48

How do you definitively distinguish between high-flow and low-flow priapism?

Penile blood gas aspirated from corpus cavernosum.

49

How do we treat low-flow priapism?

Aspiration and irrigation of corpora

Intracavernosal injection of phenylephrine (required cardiac monitoring)

If unsuccessful - surgical shunt between corpora cavernosa and spongiosa

50

How do we treat high-flow priapism?

This is less urgent

Normally cases can be observed prior to arteriography and selective embolisation with good functional outcomes.