common urological emergencies
TRANSCRIPT
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Urology Emergencies
MazinFY1 Urology / Gum
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Testicular pain
• Torsion• Epididymo-orchitis• Mumps orchitis• Torsion of testicular appendages• Idiopathic scrotal oedema
• Age 13-20 common
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Testicular Torsion
• Twist in the spermatic cord with subsequent strangulation of testicular blood supply
• 1 in 4000 males younger than 25 years* • 17% of acute scrotal presentations• Commonest (90%) cause of acute scrotal pain in
adolescent (13-21y) age group• More common in patients with cryptorchidism
*Srinivasan AK et al J Urol 2007
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History• Sexual health history – recent unprotected sex• Ask young patients directly – alone
• Exam– High riding testicle, may be on its side– Red, tender, swollen– Scrotal wall edema if testicle is already dead– *Blue dot sign* in non-thick scrotums (pathognomonic)– Cremasteric reflex should be preserved
• Mgt: surgical exploration & fixation (both testicles)
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Presentation
• On examination
– Swollen– Tender– High riding– Horizontal lie– Absent cremaster reflex
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Testicular torsion• Pain to knife time is crucial• For acute testicular torsion: surgery within 6 hours of onset of
pain usually results in survival of testis, beyond 8 hours seldom
• In the adolescent all discussions of the acute scrotum start after exploration
• Ultrasound is of no diagnostic value• QEH: Age <16 years: Refer to Evelina / age >16 years: A&E
registrar to urology registrar referral• UHL: Refer to general surgery team • Testicular pain >24 hours: Doppler ultrasound is more useful
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Aetiology Intra-vaginal (Bell-Clapper)
• Tunica vaginalis completely surrounds the testis
• Absence of normal posterior anchoring allows the testicle to twist freely
• Left testis is more frequently involved
• Bilateral cases account for 2% of all torsions
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AetiologyExtra-vaginal
• Testis, epididymis, and tunica vaginalis twist on the spermatic cord
• 5% of all torsions• More common in neonates • Associated with high birth
weight
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Prognosis• Rate of Salvage
Time since onset of symptoms (Hrs)
Salvage rate
<6 85 – 97%
6-12 55 – 85%
12-24 20 – 80%
>24 <10%-
Davenport M. 1996
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Investigations
• Doppler ultrasound– Absent or decreased blood flow– Demonstrates flow in only 79-90% of
normal cases
• Radionuclide imaging– Technetium-99m pertechnetate– Decreased perfusion on symptomatic
side
None should delay surgical exploration!
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Management
• All suspected torsions need to be explored, ideally within 6 hours
• Manual de-torsion (open like a book) may be attempted
• If no torsion, close scrotum, do perform orchidopexy on same side.
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Torsion of testicular appendages
• Usually occurs in children aged 7-12 years
• Systemic symptoms are rare• Localized tenderness at upper pole
of testis• Occasionally (21%), blue dot sign is
present in light-skinned boys• Excision not mandatory if torsion
excluded
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Torsion of Testicular Appendages
Appendix Epididymis – Remnant of part of Wolffian duct
Hydatid of Morgagni – Remnant of Mullerian duct
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Epididymo-orchitis
• In young men think STI, in seniors usually associated with UTI
• Mild swelling, observations stable, afebrile: home + oral antibiotics (consider doxycycline)
• Severe swelling, high temperature, increased WBC: refer to Urology SHO for admission
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Epididymo-orchitis – Reflux of infected urine– N. Gonorrhoea or C . Trachomatis STI– Excessive straining or lifting with reflux of urine
(chemical epididymitis).– Underlying congenital or acquire urological
abnormality may predispose– Often accompanied by systemic signs and
symptoms of UTI– Pyuria, bacteriuria and leucocytosis– Urethral swab and MSU should be obtained
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Epididymo-orchitis • USS scan can differentiate from torsion but may miss
20% • If unsure - explore• Empirical antibiotics
– <35 years; Doxycycline– >35 years; Quinolone
• Minimum of 2 weeks treatment• Treat partner if Chlamydia identified• Complications; Chronic epididymitis, abscess,
infarction, chronic pain, infertility
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Scrotal swelling DDx• Tumour• o Typically present with lump attached to testis• o Prognosis usually good• · Torsion• o Testicular pain in child (<4, 12+)• o Needs surgery within 2-4 hours to salvage
testis.• o Main differentials are torsion of hydatid, or
epididymal orchitis• (infection – may take months to resolve)• · Hydrocoele• o Most idiopathic, can be a reaction to insult.
~10% recur• o US if testes not palpable or to confirm
diagnosis• o Aetiology:• o young - patent processus• o old - fluid forms in scrotum
• · Epididymal Cysts• o Can be excised, but frequently recur• o Often multiple small cysts as well as presenting
lump• o Main differential – spermatocoele.• · Varicocoele• o Look like hernia, but no cough impulse, tend to go
if patient supine.• o More common on the left.• o Can be caused by renal tumour• o Consider surgery:• o Embolise• o Laparascopic• o Open - least chance of recurrence• o Pain may persist after surgery• · Haematoma• o Should be history of trauma• · Inflammation• · Hernia
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Renal stones
• Obstructed infected kidney loses function in 3 days• Simple renal stones: 5-6 mm, distal ureter, normal
U&Es, normal other kidney: Home (analgaesia + tamsulosin) – outpatient clinic in 3 weeks
• Complex renal stones: Size >6mm, proximal ureter, moderate hydronephrosis, deranged renal function: refer to Urology SHO for admission
• Obstructed infected kidney: high temperature, observations: non-stable: consider nephrostomy
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Stones
• Formation of calculi in renal tract• Ratio Male 3: Female 1• 20 – 50 years old, 10% caucasian males• RF
– Westerners, warm climates, occupation, FHx, diet, seasonal, medical conditions, anatomical deformities
– Supersaturation / crystalisation
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Stones: Composition and lucency
• Calcium Oxalate (<85%)• Calcium Phosphate/oxalate (~15%)• Uric Acid (10%)• Struvite (<20%)• Cysteine (1%)• Indinavir
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Stones: Differential diagnosis
• Acute Pyelonephritits• Ruptured AAA• Appendicitis• Other renal condition• UTI• Ruptured ectopic pregnancy
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History
• Loin to groin pain, N&V, haematuria, ureteric irritation (T12-L2), urgency, frequency, UTI
• Examination: Full abdo & external genitalia• Absence of peritonitis• Temp, chills, rigors, ?urosepsis• *Retrosternal appendix can cause same pain
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Workup
• Don’t bother with plain films – need CT KUB• Or IVU (conta in: *Contrast allergy, Metformin,
asthmatics*)• Urinalysis & MSU• Pregnancy test• Bloods• ?Metabolic screen (calcium, uric acid)
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KUB
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IVU
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CT KUB
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Conservative management
• Renal calculi– Asymptomatic, small, peripheral, associated
medical problems
• Ureteric calculi– <5mm, asymptomatic, no radiological signs of
obstruction
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Mgt• Increase oral fluids (IV), antiemetics• Analgaesics (morphine, NSAIDs)• Conservative Medical expulsive therapy (Tamsulosin)• Shock wave lithotripsy (ESWL)• Flexible cystoscopy / Ureteroscopy• Percutaneous surgery (PCNL) / nephrostomy +/- ureteric stent
insertion• Correct metabolic abnormality• Treat infection promptly• Reduce calcium intake (Thiazide diuretics for idiopathic
hypercalcaemia)• Urinary alkalisation (eg. Sodium bicarbonate in water)
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Extracorporeal Shock Wave Lithotripsy
• Stone absorbs energy• Cavitation effect• Fractures stones• Sand like material as end
product
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Lithotripsy
• Shock waves• Perspex lens• Focused on stone• Fragments pass• 3 treatments if no progress
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Ureteroscopy
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Urinary retention
• Acute over distension injuries produce lasting bladder dysfunction
• Residual volume <1L, normal kidney functions: Home, urology clinic (consider TWOC clinic beforehand if no prior symptoms)
• Residual volume >1L, deranged kidney function: Refer to urology SHO for admission
• Remember that the role of DRE for diagnosis of prostate cancer; do not do PSA test in acute situation
• Default optimal catheter size is 16 Fr silicone
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History
• Inability to void• Long journey prior• Abdo pain improves with catheter
• Chronic urinary retention -> bedwetting -> overflow
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Ask
• Painful / painless• Inability to void?• Precipitated?
– (alcohol, surgery, constipation, UTI)• Back pain – neurology ?cord compression• Background LUTS• DRE (prostate / rectum) – tumour
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Examination
• Examination:
– General
– Bladder palpable? Scars?
– Meatus/genitalia
– DRE (prostate/rectum)
– Neurology
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Workup
• Catheterise urgently• Urethral vs SPC• Document residual volume• Strict input / output Diuresis (>200 ml/h
over 24 h)• U&E – check PSA (NOT acutely)• Renal function tests• Alpha blocker?
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Catheter problems
• Catheter to be changed in casualty with a single dose of antibiotic
• Urology assistance via SHO is for failed catheter by skilled practitioner, fever, bleeding or escaped suprapubic catheter
• Only a small number of these patients require admission
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Haematuria
• Common diagnostic yield: infections, stones, malignancy• Microscopic haematuria: 2ww outpatient one stop
haematuria clinic• Frank haematuria• Mild, rose colour, non-obstructing, no clots, stable,
normal haemoglobin: 2ww one stop• Severe, clots, red wine colour, deranged haemoglobin: 3
way catheter 22 Fr, start irrigation, refer to urology SHO for admission
• Please send for MSU culture and sensitivity
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WorkupVisible vs Non visible
History:
Painful vs Painless
Where in stream?
How heavy? Clots?
Duration. Other symptoms
Smoking? Occupation? DHx (warfarin etc)
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Examination
• General:
Well or Unwell?
Shock? (BP/pulse/urine OP/CRT)
Temperature
Bladder palpable?
DRE
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HaematuriaInvestigations:
Urinalysis/MSU
Bloods (FBC/UE/clotting)
?PSA
?imaging
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Workup Management:
Resuscitate?
Catheterise – Size?
Washouts/irrigate
Fluids/blood tx?
Definitive investigation – cystoscopy/USS
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Fournier's gangrene
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Urosepsis Sepsis +/- septic shock
Often diabetic/elderly/catheter
Bloods, MSU/CSU, ABG, blood cultures
Resuscitate – ABC, fluids, Oxygen
Close observation
IV broad spectrum antibiotics
Early USS +/- nephrostomy
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Post-Operative Patients
• If a patient attends with post-operative problems or complications, the relevant specialty SHO should be informed and they should discuss with their registrar directly