Professional Documents
Culture Documents
Julian Mander
Emergencies
PAIN
Typical: Loin to groin pain
Variable severity
Episodic
Not mechanical but paroxysmal
Atypical: Anterior
Groin pain alone
Testicular pain alone
Penile tip pain alone
Associated vomiting (ongoing)
Mechanical character
Stones - Presentation - LUTS
LUTS
Irritative: Frequency
Urgency
Strangury
Burning micturition
Macroscopic haematuria
FEVER
Loin pain + fever + stone = infected obstructed kidney = commonly life threatening
MSU
U&E/Creatinine
Serum calcium/albumin uric acid
Imaging
Until recently, limited IVP with extra tomograms or delayed films as dictated by progress
Now imaging by non contrast stone CT scan as routine initial diagnostic imaging protocol.
SO
1) Do not repeat CT for the same stone – once a diagnosis is established, patients can be
managed with AXR or U/S or both.
2) Do not do CT scans for recurrent stone formers – patients can usually tell you the
diagnosis – do U/S and AXR not CT.
3) Avoid CT in children
More plain Xrays during admission and more IVPs at F/U in CT group
Stone size in mm
From Mostofavi et al : Accurate Determination of Chemical Composition of Urinary Calculi by Spiral Computerized Tomography
J Urol 159(3) March 1998 673-5
If in doubt, do AXR.
Emergency Management of Renal Colic
Most patients can be discharged home with adequate analgesia and a plan for follow up.
Analgesia:
NSAIDs after diagnosis specific for PG release shown to be associated with acute renal colic –
Oral analgesics generally not absorbed well during renal colic -> so give the patient NSAID suppositories !!
N.B Management with oral narcotics/panadeine forte/tramadol is generally inadequate and results in return to hospital.
Non Surgical Management Plan for Renal Colic
If uncomplicated, with likely spontaneous passage, review at 6 weeks with appropriate imaging, most commonly U/S +
AXR.
Note, do not encourage the patient to “drink lots to flush the stone out” – stone will pass more rapidly if patient drinks less !
6 Weeks – stone passed + pain gone + Ca/Uric acid normal -> discharge.
6 Weeks – stone not passed – no adverse features – repeat imaging at 12 weeks, adverse features increase HN refer.
Note, once the stone has passed, encouraged long term increase in fluid intake.
50% reduction in stone recurrence has been well documented if patients produce 2 li urine per 24 hours long term.
Indications for Surgical Intervention
Etiology
Catheterization
use “long term” catheter – Bard “Biocath” or Silastic (not brown latex – 3 day use max).
Suprapubic catheter
short term Bonano type – narrow gauge
make sure you aspirate urine with fine needle after LA infiltration
Acute Urine Retention ? Admission
check hourly urine output > 200 ml/hour Rx I/V fluid replacement with saline, hourly I/V to equal
hourly urine output, with 12 hourly potassium assessment (significant risk of
hypokalemia)
Note, the theoretical problem with conversion to pre renal renal failure without adequate
replacement.
Diagnosis
History – LUTS + Temp > 38 celsius
recent urological surgery or catheter, or catheter change
loin pain = either stone + infected/ obstructed
or uncomplicated pyelonephritis
Examination – Kidney tenderness
Prostate tenderness = prostatitis
BP – “septic shock” and inotropes
Investigation
MSU and blood cultures should correlate
Bloods routine + CRP
Imaging – U/S kidneys initially – hydronephrosis = infected/obst
Urosepsis - Treatment
Antibiotics
NB Take urine and blood cultures before commencing antibiotics.
Current general therapy:
Tazocin 4.5 gm t.d.s. Reduced dosage 4.5 gm b.d. if impaired renal function
Antibiotic guidelines:
Gentamicin (Gram –ve cover) single daily dose 5 – 7 mg/Kg
trough levels 12 hours post dose, with adjustment pending
+ Amox/Ampicillin (Enterococcus cover) 1gm 6 hourly
Change to less potentially toxic regimen once antibiotic sensitivities returned. Usually within 72
hours.
Etiology
Upper tract vs lower tract – most commonly lower tract origin
Young – stones
History
Painless – commonly lower urinary tract
Examination
Usually little to find – DRE in older men ? CA prostate
Investigation
MSU
Bloods – FBP U&E/Creat +/- Coag profile
Imaging U/S as starting point, unless clinically stone, then non contrast CT
Cystoscopy – GA rigid cystoscopy if urgent, or flexible cystoscopy LA if urine clears.
Treatment
Treat pathology
Rarely life threatening unless uro-arterial fistula
Admit depending on circumstances, predicted pathology
History: sudden onset of severe testicular pain and associated testicular swelling, usually presenting a short time
after
onset.
• Differential diagnosis in adults usually orchitis – preceding LUTS for several days, slower onset of pain and later
presentation, commonly with a fever.
Testicular torsion is a clinical diagnosis, and if diagnosed, be taken to theatre as a surgical emergency.
Testicular U/S will delay diagnosis and should not be called for – the urology registrar should be called to assess the
urgently and if not available the consultant should be
called.
The on call urology registar should assess the case clinically, urgently, and if they still have doubts (often misguided),
then request U/S, then take the consequences of delay if they are
wrong.
• If the U/S is correct and delays theatre, (which is then clearly unnecessary) then nothing is lost.
• If patients are taken to theatre with the wrong diagnosis, then little is lost and registrars should learn.
• BUT if there is a delay in taking patients to theatre because U/S is done, then testicles are lost.
• Senior radiologists agree with this policy and feel that diagnosis of torsion is a clinical diagnosis.
• Torted testicles can be recovered if detorted surgically within 6 hours (4 – 8 hours), and in some cases 12 hours.
• Surgery: bilateral orchidopexy through a midline scrotal incision using non absorbable suture material (3/0 Prolene).
• Investigations that can be done: testicular U/S with doppler, nuclear scan technetium-99m pertechnetate
Trauma - Renal
Blunt trauma
Surgical exploration uncommon 2.6% of 913 cases in San Francisco
Increasing use of radiological embolization and urological stents
Penetrating trauma
Commonly require exploration
42% stab wounds explored
76% of gunshot wounds explored
Renal Trauma Staging
Renal Trauma Staging
Renal Trauma - Presentation
Hypotension
early may be associated with loss from other injuries
deceptive absence of hypotension in children
Renal Trauma - Imaging
Absolute indications
Severe blood loss with haemodynamic instability, not suitable for
embolization
Renal pedicle avulsion ? Time limits
Ureteric avulsion
Relative indications
Nonviable tissue – if large segments of ischaemic tissue ? %
vs risk of delayed haemorrage
Urinary extravasation
Calyceal injury vs ureteric avulsion
JJ stenting with radiological drainage perc drain
Renal Trauma - Algorithms
Renal Trauma - Algorithms
Renal Trauma - Algorithms
Renal Trauma – Secondary Haemorrhage
Diagnosis
Regular blood pressure monitoring in high grade injuries
? 6 monthly lifelong
Trauma - Bladder
Uncommon
Etiology
Iatrogenic most common – urology/gynaecology
Spontaneous – rare in abnormal bladders eg clam cystoplasty
Intoxicated – alcohol abuse with fall onto full bladder
present with pain, unable to void or haematuria
Traumatic – blunt trauma with high velocity MVA
strong association with pelvic fracture (85% of ruptures)
Imaging diagnosis
CT delayed post contrast phase in major trauma
Cystogram in iatrogenic/spontaneous/intoxicated groups
Bladder Trauma Treatment
Extraperitoneal rupture
Urethral catheter drainage (18F catheter)
5 days up to 3 weeks
Intraperitoneal rupture
Traditionally surgical repair
Etiology
Most commonly iatrogenic – forced catheterization with stricture
“Fall astride” injury
History
History of trauma, blood at urethral meatus and urine retention
Examination
Blood at urethral meatus
Investigation
Usually nil for iatrogenic
Urethrogram for fall astride injuries
Treatment
Nil if voiding OK for iatrogenic injury and catheter not required
Cystoscopy/ endourological management in some cases
Surgical repair of fall astride anterior urethral injury for complete rupture
relatively easy surgery, catheter 3 weeks post op
Urethrogram – Anterior Urethral Trauma
“Posterior” Urethral Trauma
Etiology
Most commonly iatrogenic – no Rx or endourological/
catheterization
Associated significant pelvic injury – high level trauma potential
Clinical findings
Blood at meatus + urine retention
Investigation
Urethrogram +/- CT abdomen & pelvis
Management – surgical
Timing pending other injuries suprapubic catheterization common