1. COMMON UROLOGICAL EMERGENCIES
(Excluding Prostate)
Dr. Utham Murali. M.S ; M.B.A.
Asso.Prof of Surgery

2. Objectives
 Introduction
 Classification
 Description – Each
 Summary

3. Introduction
Urologic emergency is one of the
most common emergencies faced in
the casualty.
Compared to other surgical fields
there are relatively few emergencies
in urology.
It includes different conditions
ranging from Kidney injury to
Testicular torsion.

4. Classification
Traumatic
Renal Trauma
Ureteral Injury
Bladder Trauma
Urethral Injury
Penile trauma
Testicular Trauma
Non traumatic
Hematuria
Renal Colic
Urinary Retention
Acute Scrotum
Paraphimosis

5. Non- Traumatic Injuries

6. 1. Haematuria - Types / Causes
 Early (Initial) : Ure.origin / Distal to ext.sph.
 Terminal : Bladder neck / Prostate origin
 Diffuse (Total) : Source in Bladder / UUT.

7. Haematuria – Work-up
History
Examination
Blood tests
Urine tests
Renal U/S
Flexible cystoscopy
IVU / CT scan
Cystoscopy - selected
Treat the cause

8. 2. Renal Colic
The commonest urologic emergency.
One of the commonest causes of the
“Acute Abdomen”.
Sudden onset of severe pain in the
flank.
Most often due to the passage of a
stone formed in the kidney, down
through the ureter.

9. Renal Colic
 When caused by acute obstruction of the renal
pelvis, is typically fixed deep in the loin and
‘bursting’ in character.
 When caused by acute ureteric obstruction
(usually by a stone), is colicky with sharp
exacerbations against a constant background.
 Is liable to be referred to the groin, scrotum or
labium as the calculus obstruction moves
distally.

10. Renal Colic – D / D
 Pyelonephritis
 Abdominal aortic aneurysm
 Appendicitis
 Biliary colic (gallstones)
 Peritonitis
 Diverticulitis
 Salpingitis
 Torsion - ovarian cyst
 Ectopic pregnancy
 Shingles

11. Renal Colic – Work up
History
Examination
Pregnancy test
MSU
X-ray KUB / U/s – Abd
IVP / CT scan

12. Renal Colic – Renal stones - Treatment
 Calculi smaller than 0.5 cm pass spontaneously
 Pain relief - NSAIDs
 IV – Fluids
 Most calculi are treated by MAT
 PCNL / ESWL / URS

13. Renal Colic – Ureteric stones - Treatment
 Oral fluids – plenty
 Pain relief - NSAIDs
 Flush therapy – IV Fluids + Diuretic
 Site of Stone

14. 3. Urinary Retention
 Painful inability to void, with relief of pain
following drainage of the bladder by
catheterization.
Pathophysiology :
 Increased urethral resistance, i.e., bladder
outlet obstruction (BOO).
 Low bladder pressure, i.e., impaired bladder
contractility.
 Interruption of sensory or motor innervations
of the bladder.

15. Urinary Retention
Men Women Both
- BOO (commonest
cause)
- Urethral stricture
- Acute urethritis or
prostatitis
- Phimosis
- Pelvic prolapse
(cystocoele, rectocoele,
uterine)
- Post surgery for ‘stress’
incontinence
- Pelvic masses (e.g.,
ovarian masses)
- Bladder neck
obstruction (rare)
- Blood clot
- Urethral calculus
- Rupture of the urethra
- Neurogenic
- Smooth muscle cell dysfn.
(associated with ageing)
- Faecal impaction
- Anal pain
(haemorrhoidectomy)
- P O analgesic treatment
- Drugs
- Spinal anaesthesia

16. Urinary Retention - MGT
Initial Management :
 Urethral catheterization
 Suprapubic catheter (SPC)
Late Management:
 Treating the underlying cause

17. 4. Acute Scrotal Conditions
Emergency situation requiring prompt
evaluation, differential diagnosis, and
potentially immediate surgical
exploration.
Testicular Torsion - Most serious.
Torsion of the Testicular and
Epididymal Appendages.
Epididymo-orchitis - Most common

18. 4-a. Torsion Testis
 Inversion of the testis - most common
predisposing cause. The testis is rotated so
that it lies transversely or upside down.
 High investment of the tunica vaginalis causes
the testis to hang within the tunica like a
“clapper in a bell”.
 Gap between epididymis & the body of the
testis permits the testis to twists over
epididymis.
 Heavy straining – vig.contraction of cremaster
– attached spirally.

19. Torsion Testis
 It is most common between 10 and 25 yrs.
 Symptoms vary with the degree of torsion.
 Signs related to Torsion –
Deming’s / Angell’s / Prehn’s sign
 Right testis rotates in clockwise direction
where as Left testis rotates in anticlockwise.
 Doppler ultrasound scan - confirm the absence
of the blood supply to the affected testis.
 If there is any doubt about the diagnosis, the
scrotum should be explored.

20. Torsion Testis
 Prompt exploration, untwisting and fixation is
the only way to save the torted testis.
 The patient should be counselled and
consented for orchidectomy before exploration.
 The anatomical abnormality is bilateral and the
contralateral testis should also be fixed.
 Other structure in scrotum which can undergo
torsion is ‘Appendage of testis’.

21. 4-b. Epididymo-orchitis - Acute
 Infection reaches the epididymis via the vas.
 Mode of infection.
 Dysuria & fever is more common
 Scrotal swelling / tender & thickened
epididymis.
 Secondary hydrocele may be present.
 Urine : pyuria, bacteriuria, or a positive urine
culture (Gram-negative bacteria)

22. Epididymo-orchitis
Bed rest for 1 to 3 days then relative
restriction.
Scrotal elevation, the use of an
athletic supporter.
Parenteral antibiotic therapy should
be instituted when UTI is
documented or suspected.
Reassurance – required.

23. 5. Paraphimosis
 Inability to place back the retracted prepucial
skin over the glans.
 Constriction ring proximal - to corona & prepuceal
skin.
 Glans will be swollen / oedematous with severe pain
and tenderness.
 Icebags, gentle manual reduction and injection of a
solution of hyaluronidase in normal saline may help
to reduce the swelling.
 If manipulation fails circumcision is done.

24. Traumatic Injuries

25. 1. Renal Injury
 The most common of all injuries to the GU
system.
 Blunt trauma 80-85%
- Motor vehicle accidents, fights, falls, sports
vehicle collision at high speed.
 Penetrating : Associated abdominal visceral
injuries 10 - 20%
- Gunshot wounds
- Stab wounds

26. Renal Injury – C / F & Grading
 Pain : localized to one flank area or over the
abdomen.
 Gross or microscopic hematuria / Delayed.
 Ecchymosis in the flank or upper quadrants
of the abdomen.
 Lower ribs or transverse process fracture.
 Palpable mass : large retroperitoneal
hematoma or urinary extravasation.
 Generalized peritonitis / FO – Shock.

27. Renal Injury – Management
 IVU – High Dose.
 U/S – Abdomen.
 RFT / Grouping / X-matching
 Contrast-enhanced CT
 Initially Conservative
 Surgery – only in 10 -20%
Types Treatment
I Bruise / Contusion Conservative
II Breach – PCS / Rupture
– 1 branch RA
Conservative /
Nephrectomy
III Rupture – PCS / Renal
substance
Nephrectomy

28. 2. Ureteric Injury – Causes
 External Trauma (20%)
- After external violence are rare (<1%)
- 10 - 28% have associated renal injuries
- 5% have associated bladder injuries
 Surgical Injury (80%)
- Pelvic surgical procedure – TAH
- Endoscopic manipulation, etc.

29. Ureteric Injury – Treatment
 Repair when injury occurs.
 Tension-free spatulated anastomosis,closure,
ureteral stenting, RP - drainage.
 Primary closure of partial transection of the
ureter. Direct ureter to ureter anastomosis.
 Reimplantation of the ureter into the bladder
(ureteroneocystostomy), either using a psoas
hitch or a Boari flap.
 Transureteroureterostomy.
 Permanent cutaneous ureterostomy.

30. 3. Bladder Injury - Rupture
 Blow, kick or fall
 Road traffic accidents
 Stabs, gunshot injuries
 Endoscopic trauma /
Others
 Diathermy
 Instrumentations
I. Intraperitoneal rupture — 20%
 Occurs in fully distended
bladder due to blow, kick or fall.
II. Extraperitoneal rupture—80%
common.
 Due to RTA, golf playing, fall
over the manhole.
Causes Types

31. Bladder Injury – C / F & Investigations
 History : “Classic Triad”
- Suprapubic pain
- Difficulty passage of urine
- Hematuria
 Investigations :
- Plain X-ray shows ground glass appearance.
- Peritoneal tap is done to confirm urine.
- Cystogram: C-ARM image intensifier easily.
- U/S abdomen to look for other injuries
- CT scan abdomen.
Extraperitoneal Intraperitoneal

32. Bladder Injury - Treatment
 Extravesical injury – Catheter drainage for 10
days
 Intraperitoneal injury – Laparotomy / Repair &
Bladder drainage.
- Bladder tear is sutured in two layers using vicryl.
- Peritoneal wash is given.
- Malecot’s catheter is placed from above as SPC.
- Prevesical space and peritoneal cavity are
drained.
- Foley’s catheter from below is also passed.
 Adequate specific antibiotics - to prevent sepsis.

33. 4. Urethral Injury - Types
 Depending on site of rupture:
1. Rupture of the membranous urethra.
2. Rupture of the bulbous urethra.
 II. Depending on circumference of the urethral wall
involved:
1. Complete.
2. Incomplete.
 III. Depending on the thickness of the urethra
involved:
1. Total.
2. Partial.

34. Urethral Injury – Ant. Urethra
 Usually, due to a fall astride a projecting
object, like in sailing ships, cycling, over
loose manhole cover, gymnasium.
 Clinical features: “Triad”
1. Blood in external meatus
2. Perineal haematoma
3. Retention of urine
 Investigations – Condition is diagnosed
clinically.
X-ray pelvis, and U/S abdomen.

35. Urethral Injury – Ant. Urethra
 Patient should be told not to try to pass urine, if
passed, then extravasation of urine occurs.
 In OT, one attempt of urethral catheterization is
tried gently. If able to pass a catheter, then it is
left in place.
 If catheter fails to pass, SPC is done.
 Bulbous urethra is exposed through perineal
midline incision and tear is sutured with an
indwelling Foley’s catheter.
 If suturing is not possible (sometimes), then
perineal urethrostomy is done.

36. Urethral Injury – Post. Urethra
 It is associated with pelvic #, commonly due to
RTA. Also occur during instrumentation / Calculus
passage and catheterisation. In prolonged labour,
due to pressure on the urethra by foetal head.
 Blood in external meatus.
 Failure or difficulty in passing urine.
 Extravasation - urine to scrotum / perineum /
abd.wall.
 FO – Shock & other injuries.
 On P/R exam. prostate may be felt high or may
not be palpable at all. Signifies “floating prostate”.

37. Urethral Injury – Post. Urethra
 X - ray pelvis to see for fracture.
 U/S abdomen to see pelvis and other injuries.
 Urethrogram is done to see the site and type
of tear.
Complete rupture :
Railroad technique.
In-complete rupture :
Mitchell approach - SPC.
Blandy approach - Open.

38. 5. Penile Injury
 Avulsion of skin of penis – “Zipper Injuries”
 Industrial accidents / Gun - shot wounds
Fracture of penis
 Disruption of the tunica albuginea with rupture of
corpus cavernosum.
 Most commonly with sexual intercourse, but also
reported with masturbation, rolling over or falling on
erect penis.
 Diagnosis straightforward by history and
examination.
 Cracking sound + Bruising + / - Urethral injury.
 Should be promptly explored and surgically repaired.

39. 6. Testicular Injury - Haematocele
 Due to rupture of one of the vessels in the tunica
causing bleeding into the sac.
 Often it may occur following aspiration of a
hydrocele.
 Pain / swelling / Bruising / Testis not palpable:
surround by hematoma.
 U/S of scrotum is done - to find out the viability.
 Treatment : The scrotum is explored.

40. Summary
 Classification
 C. Conditions - one has to face in an emergency room.
 Differential - Renal colic
 Investigations / Treatment
 Catheterization / SPC / Circumcision

41. References