Concerning ureteric trauma, which of the following is true?
A retrograde pyelogram is the most sensitive test for ureteral injury. Partial injuries can be primarily repaired, although all devitalized tissue must be debrided to avoid delayed tissue breakdown and urinoma formation. Ureteral stents should be placed in this situation to facilitate healing without stricture. Midurethral level injuries can be treated with a ureteroureterostomy if a spatulated, tension-free repair can be achieved. For longer defects, the bladder can be mobilized and brought up to the psoas muscle (psoas hitch). For additional length, a tubularized flap of bladder (Boari flap) can be created and anastomosed to the remaining ureter.
Treatment of acute urinary retention may include all of the following EXCEPT:
Treatment should include placement of a urethral catheter as quickly as possible. However, benign prostatic hyperplasia (BPH) or urethral strictures often make the placement of a catheter difficult. For men with BPH, a coude (French for curved) catheter is helpful in negotiating past the angulation in the prostatic urethra. Placement of a suprapubic tube approximately two fingerbreadths above the pubic symphysis may be needed. If hematuria is the cause of retention, continuous bladder irrigation often is necessary to prevent clot formation. Fluid replacement typically is 0.5 mL of 0.45 normal saline for every 1 mL of urine output above 200 mL in 1 hour, although sodium and potassium supplementation requirements depend on the electrolyte status of the patient.
Regarding testicular torsion, which of the following is FALSE?
Risk factors for torsion include undescended testis, testicular tumor, and a "bell-clapper" deformity-poor gubernacular fixation of the testicles to the scrotal wall. The diagnosis is made by clinical history and examination, but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow relative to the contralateral testis. Immediate surgical exploration can salvage an ischemic testis. More than 80% of testes can be salvaged if surgery is performed within 6 hours; this rate decreases to <20% as time lapses beyond 12 hours. At the time of surgery, the contralateral testes must also be explored and fixed to the dartos fascia due to the possibility that the same anatomic defect allowing torsion exists on the contralateral side.
All of the following are true concerning priapism EXCEPT:
Priapism is a persistent erection for more than 4 hours unrelated to sexual stimulation. Risk factors include sickle cell disease or trait, malignancy, medications, cocaine abuse, certain antidepressants, and total parenteral nutrition. Low-flow priapism can be confirmed with a penile blood gas of the cavernosal bodies demonstrating hypoxic, acidotic blood. Injection of phenylephrine (up to 200 mg in 20 mL normal saline) into the corporal bodies may be required.
Which of the following is true concerning BPH?
Besides voiding symptoms, consequences of BPH include gross hematuria, infections due to incomplete emptying, bladder calculi, and urinary retention. Over time, incomplete emptying may lead to chronic bladder overdistention that can result in a de-functionalized bladder. Medical treatment of BPH is usually the first step. Alpha blockers act on a-receptors in the smooth muscle of the prostate and decrease its tone. Transurethral resection of the prostate is the mainstay of endoscopic surgical BPH treatment. It is extremely effective at improving flow and decreasing residual urine. Complications are rare but include incontinence and excessive fluid absorption of the hypotonic irrigating solution used during resection, resulting in the transurethral resection syndrome. It is due to hyponatremia and fluid overload, and although rare, can result in death. Mental status changes and pulmonary edema are managed by diuresis and sodium supplementation with hypertonic saline in severe cases. Because of these rare, but potentially dangerous side effects, laser or electrovaporization of the prostate has grown popular. It is associated with very limited fluid absorption, and saline can be used because there is no monopolar electrocautery.