ACUTE ABDOMEN
270 Surgical Emergencies
MANAGEMENT
1 Significantly ill patients.
(i) Includes those with vomiting, dehydration, or prostration;
those who are pregnant, very young or old; and those who are
known to have urinary tract abnormalities, e.g. a duplex system,
horseshoe kidney or renal/ureteric stones.
(ii) Commence i.v. fluids. Give gentamicin 5 mg/kg i.v. and
ampicillin 2 g i.v. q.d.s.
(iii) Refer these patients to the medical team for admission.
2 Otherwise, if the symptoms are mild, commence an oral antibiotic
depending on local prescribing policy, such as cephalexin 500 mg q.d.s, or
amoxicillin 875 mg with clavulanic acid 125 mg one tablet b.d., or
trimethoprim 300 mg once daily, all for 10 days.
3 Return the patient to the GP with a letter requesting the GP to organize a
repeat urine culture after the completion of a full antibiotic course, to ensure
that the infection has been eradicated.
4 Arrange a renal ultrasound in any male with a proven urinary tract infec-
tion, or in females with recurrent pyelonephritis and refer to urology out-
patients for follow-up.
Acute urinary retention
DIAGNOSIS
1 Predisposing factors include prostatic hypertrophy, urethral stricture, pelvic
neoplasm, anticholinergic drugs, pregnancy, local painful condition such as
genital herpes and faecal loading in the elderly.
2 Occasionally, retention is due to a neurogenic cause such as multiple
sclerosis.
3 The enlarged bladder is easily palpable, dull to percussion and is usually
painful, although in the semiconscious patient it may manifest as
restlessness.
4 Always perform a rectal examination, and assess perineal sensation and leg
ref lexes in every patient.
5 Send blood for FBC, ELFTs and blood sugar.
MANAGEMENT
1 Carefully pass a urethral catheter as a strict aseptic procedure, and send a
specimen of urine for microscopy and culture (see p. 484).
2 Refer the patient to the surgical team or gynaecology as appropriate.