UROLOGY - Urological Emergencies (for Healthcare Students)

Summary

This video provides an essential overview for junior doctors and medical students on the top five urological emergencies: renal tract calculi, testicular torsion, acute urinary retention, priapism, and paraphimosis. It covers their pathophysiology, clinical presentation, diagnostic approaches, and management strategies. Emphasizing quick recognition and intervention, the video offers valuable insights into handling these urgent cases effectively. By focusing on common urological conditions encountered in both medical rotations and finals, the content ensures junior doctors are well-equipped to manage these critical situations in emergency settings.

Takeaways

• 😀 Renal tract calculi can lead to sepsis, hydronephrosis, and acute kidney injury, and should be managed promptly with pain relief, rehydration, and antibiotics if septic.
• 😀 Renal stones can be made of calcium oxalate, phosphate, or urate, with less common types like cysteine and xanthine stones, and require imaging (CTKUB or ultrasound) to assess size and location.
• 😀 Small stones under 5mm may pass spontaneously, while stones between 5mm and 10mm may be treated with alpha blockers. Larger stones require shockwave lithotripsy or ureteroscopy.
• 😀 Large or staghorn renal calculi are managed with percutaneous nephrolithotomy, and metabolic investigations should be considered to prevent recurrence.
• 😀 Testicular torsion is a surgical emergency that can lead to testicular necrosis if not managed within six hours. Early detection is key, and management includes scrotal exploration and fixation of the testicle.
• 😀 Acute urinary retention can be caused by conditions like BPH, infection, or constipation and presents with suprapubic pain, inability to void, and possibly signs of infection.
• 😀 Management of acute urinary retention includes catheterization and addressing the underlying cause, with close monitoring of renal function.
• 😀 Priapism is a painful, prolonged erection lasting more than 4 hours and can be ischemic (due to reduced venous outflow) or non-ischemic (due to high arterial inflow).
• 😀 Ischemic priapism requires emergency treatment with blood aspiration and vasoconstrictive injections, while non-ischemic priapism is often managed conservatively.
• 😀 Phimosis involves the inability to retract the foreskin due to fibrosis or infection, while paraphimosis occurs when the foreskin is retracted but cannot be returned, causing vascular compromise and requiring urgent intervention.
• 😀 Management of phimosis may include circumcision, while paraphimosis can be treated with manual reduction, dorsal slit, or emergency circumcision if needed.

Q & A

What are the main causes of renal tract calculi?

Renal tract calculi can be caused by various factors, including high levels of calcium oxalate, calcium phosphate, urate, cysteine, or xanthine. Risk factors include gout, metabolic disorders, dehydration, and low fluid intake.

How is a renal tract calculus identified and managed?

Renal tract calculi are often identified using imaging techniques such as a CT KUB without contrast, which helps visualize the stone's size and location. Management includes analgesia, hydration, and, in some cases, surgical intervention like shock wave lithotripsy or ureteroscopy, depending on the stone's size and location.

What are the signs of testicular torsion and how is it diagnosed?

Testicular torsion presents with sudden, severe unilateral testicular pain, often radiating to the abdomen or groin, along with swelling, erythema, and tenderness. Diagnosis is clinical, but blood tests (including clotting screens) are essential pre-operatively. A Doppler ultrasound may also be used if needed.

What is the significance of a blue dot sign in testicular torsion?

The blue dot sign indicates a twisted appendage of Morgagni, which can present in testicular torsion. It appears as a bluish discoloration visible through the scrotal skin, suggesting ischemia in the twisted appendage rather than torsion of the testicle itself.

How is acute urinary retention treated?

Acute urinary retention is treated with catheterization if the bladder contains more than 400 mL of urine and the patient is symptomatic. The underlying cause, such as infection, constipation, or BPH, should also be addressed. Ongoing management includes monitoring renal function and educating the patient on catheter care.

What is the difference between ischemic and non-ischemic priapism?

Ischemic priapism is caused by reduced venous outflow, leading to blood stagnation in the penis, which can cause pain and permanent erectile dysfunction. Non-ischemic priapism is caused by excessive arterial blood flow, often due to trauma or congenital abnormalities, and typically does not require urgent intervention.

What is the first-line investigation for priapism?

The first-line investigation for priapism is cavernosal blood gas analysis, which helps differentiate between ischemic and non-ischemic priapism. The color of the blood—dark for ischemic or bright red for non-ischemic—can confirm the diagnosis.

What are the management options for priapism?

Management of ischemic priapism involves aspiration of blood from the cavernosa and flushing with saline, followed by intracavernosal injections of vasoconstrictors like phenylephrine. Non-ischemic priapism is often managed conservatively unless symptoms persist or worsen.

What is phimosis and how is it treated?

Phimosis is the inability to retract the foreskin over the glans penis due to inflammation, scarring, or congenital abnormalities. In children under two years, it is usually managed conservatively, but if recurrent infections or complications occur, circumcision may be required.

What is the difference between phimosis and paraphimosis?

Phimosis is the inability to retract the foreskin over the glans penis, while paraphimosis occurs when the foreskin is retracted but cannot be returned to its normal position, leading to restricted blood flow, edema, and potential necrosis. Paraphimosis is an emergency requiring manual reduction or surgical intervention.