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