Urological Emergencies Ian Smith Urology Registrar Spot Diagnosis

Urological Emergencies Ian Smith Urology Registrar

Spot Diagnosis?

Penis Fracture • Usually during intercourse. • No official classification. • History - exaggerated bend on erect penis, sometimes aware of snap, painful and instant detumescence (loss of erection)

• Relatively common.

Anatomical Detail

Outer superficial layer continuous with superficial subdermal layer of scrotum

Bucks Fascia encloses penis. Attaches to perineal membrane

Management

• Exploration is the rule. Very few treated conservatively

• Why? • Urethral injury • Scar and plaque formation • Curved penis (cordee) • Erectile dysfunction

Spot Diagnosis ?

Fourniers Gangrene • Necrotizing fasciitis of scrotum, perineum, abdominal wall

• RF’s - Age, diabetes, immunocompromised state

• Polymicrobial • Sepsis - multi organ failure - death. • 25% idiopathic

Management Similar tissue planes

Gangrene to extend up to supra pubic space

Spot Diagnosis?

Renal Colic • Vast majority straight forward • Exceptions are • solitary kidney • bilateral obstruction • worsening renal function • Fever

What is connection?

Stone + Fever = urological emergency

• Only a small percentage of renal colic presentations

• RF’s - Diabetes, intercurrent UTI.

Nephrostomy inserted under LA

1

Renal Trauma • Mechanisms and cause: –Blunt

• direct blow or acceleration/ deceleration (road traffic accidents, falls from a height, fall onto flank)

–Penetrating

• knives, gunshots, iatrogenic, e.g., percutaneous (PCNL)

Classification

Pseudo aneurysm G3

Grade 5

Is classification important? Stable vs Unstable only relevant classification Does patient have 2 kidneys

Management

• Stable conservative. Unstable explore (which usually means nephrectomy)

• Many go careers without doing this • Most conservatively managed since CT • Impressive the way kidneys heal. • Collecting system injury - stent • Why - try to prevent urinoma, aid closure of defect.

• Can get HT - page kidney

Blunt scrotal trauma

• Straddle injuries • Sporting injuries - hockey, cricket • Assult

Normal Anatomy Epididymis

Corpora cavernosa

Fluid within tunica vaginalis

Whats injured? Extra scrotal - soft tissue Intrascrotal but extratesticular - dartos Intra testicular - Need ultrasound to confirm

Normal Scrotal wall injury

Testicular rupture with haematocele

Management

Acute Retention • Acute urinary retention is painful • Think of this before you call. • 3 questions • Why is this person in retention • How long do I leave catheter in • Why am I unable to catheterise this person

Men

Bladder factors - Neurological central, peripheral - Drugs anticholinergics - Diseases ie Diabetes, MS - Chronic obsrtuction - Acute retention Outlet Factors - Prostate - Strictures (POST SURGICAL)

Women

Bladder Factors - The majority - Often post surgical, post partum Outlet - Less common - Always think cervical cancer

Duration Catheter • At least 3 days. Men should be started on alpha blocker.

• Keep on permanent drainage for 24 hours then to flip flow valve

• Trial of void should be supervised with accurate post void residuals. Dont do this on a weekend.

Failed TOV? • Should be taught intermittent clean self catheterisation till we can determine cause.

• Has this patient had previous urological intervention (TURP, Radiotherapy, Prostatectomy)

• Urodynamics - functional assessment of bladder.

Cant catheterise? • Patient not relaxed - tensing sphincter • Urethral stricture • Bladder neck stricture (post surgical) • Prostate (least common) • Call us if you can’t get a catheter in

Questions