Tasty Morsels of EM 124 – #FRCEM Urological bits and bobs

23 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

no big guidelines here so this is mainly the OHEM 4th and Rosen’s 8th

What causes urinary retention?

  • Males
    • BPH or cancer
    • stricture
    • post op
  • Females
    • big retroverted gravid uterus
    • pelvic masses or prolapses
    • MS
    • genital HSV (through pain and autonomic disturbance of the bladder)
  • Drugs
    • anticholinergics
    • alcohol
  • Others
    • Cord compression
    • constipation
    • stone in the urethra/bladder neck

What is a post obstructive diuresis?

  • there are lots of older men with chronic retention who have massive bladders and lots of hydronephrosis and elevated creatinines
  • this is fixed with a catheter but patients can start peeing massively following this
  • historically (like with all manner of drains) it was suggested that clamping at a litre might be a good idea. it probably isn’t
  • better idea is to monitor output (Rosen’s suggests 200ml/hr as a threshold to admit) and keep up with it after the initial decompression and keep an eye on the sodium. Hypotension is common and easily responds to fluid.

What is TURP syndrome?

  • a post op complication due to the glycine based fluid used to irrigate the bladder during and after the TURP.
  • it can cause fluid overload and glycine can cause some neuro effects also.
  • presents with either SOB or confusion, coma, seizures
  • low sodium can be a problem and if very severe give hypertonic as always but the low sodium is not all that is going on.
  • glycine can also cause a raised osmolar gap

Tell me about the acute scrotum?

  • Causes
    • torsion
    • epididymitis
    • orchitis
    • torsion of appendix testis
    • tumour
    • hernia
  • Torsion
    • peak incidence at 1 year and puberty
    • the cremasteric reflex is normally absent in almost half of young kids. That being said if it’s present it’s probably reassuring
    • can occur with trauma (and of course pain is blamed on the trauma…)
    • surgical referral the priority (not ultrasound!)
    • if middle of nowhere and forced to blindly untwist then remember to “open the book” ie rotate away from the midline as most will tort inwards
    • ultrasound is less sensitive in kids as the prepubertal testicle has less flow
  • Torsion of the appendage
    • milder symptoms
    • slower onset
    • self limiting in that the appendage necroses and is absorbed
  • Epididymitis
    • infected by retrograde flow down the vas defrens
    • the usual split is <35 having more STIs, and >35 having more enteric organisms
    • believe it or not amiodarone is thought to be a non infectious cause
  • Trauma
    • the big thing here is rupture which is usually clinically impressive but the ultrasound is needed to tell if repair is needed. If the tunica albuginea is ruptured then repair likely improves salvage rate


Priapism is covered elsewhere

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