Trauma and Emergency Urology
Core concepts
Emergency urology requires rapid triage and damage-control thinking. In renal trauma, most injuries are managed nonoperatively when the patient is hemodynamically stable; staging uses CT with contrast. In bladder trauma, distinguish extraperitoneal from intraperitoneal rupture: intraperitoneal rupture requires operative repair, while many extraperitoneal ruptures are managed with catheter drainage. Urethral injury should be suspected with blood at the meatus, perineal hematoma, or high-riding prostate; perform retrograde urethrography before catheterization. Testicular trauma may require exploration for rupture. Fournier's gangrene is a necrotizing fasciitis requiring urgent debridement and broad-spectrum antibiotics. Ureteral injury after pelvic surgery is often recognized late. Know the management of priapism, obstructing infected stones, and acute urinary retention.
Traps
Questions test the first step in suspected urethral injury - imaging before catheterization. Do not miss intraperitoneal bladder rupture (needs surgery) versus extraperitoneal (often catheter). In Fournier's gangrene, delay in debridement is the key error. Hemodynamic instability in renal trauma mandates intervention, not observation.
Worked example / rule of thumb
A patient with pelvic fracture and blood at the meatus: perform retrograde urethrography before attempting catheterization. Rule of thumb: suspect urethral injury, image first, catheterize never blindly.
Urologic Imaging, Diagnostics and Perioperative Care
Core concepts
This domain tests appropriate imaging selection and safe perioperative care. Know the strengths of modalities: ultrasound for screening and renal evaluation, CT urography for hematuria and stones, MRI for soft tissue and staging, and nuclear medicine for function (diuretic renography, renal scintigraphy). Understand radiation exposure and the principle of ALARA. Recognize when contrast is contraindicated: metformin-related concerns, renal impairment, and allergy. For hematuria evaluation, risk-stratify patients and choose imaging plus cystoscopy appropriately. Perioperative care includes antibiotic prophylaxis, venous thromboembolism risk assessment, and management of anticoagulation. Know the significance of post-void residual, urine cytology, and PSA as screening tools with their limitations. Understand enhanced recovery principles and the management of common postoperative complications.
Traps
Questions test the most appropriate imaging rather than the most sensitive, and the timing of prophylaxis. Do not order CT urography indiscriminately in low-risk hematuria. Distinguish screening from diagnostic tests and know that cytology has low sensitivity for low-grade tumors.
Worked example / rule of thumb
A patient with visible hematuria and risk factors: evaluate with CT urography and cystoscopy. Rule of thumb: choose the study that answers the clinical question with the least risk, and give prophylaxis within 60 minutes of incision.