Urologic emergency is one of the
most common emergencies faced in
Compared to other surgical fields
there are relatively few emergencies
It includes different conditions
ranging from Kidney injury to
8. 2. Renal Colic
The commonest urologic emergency.
One of the commonest causes of the
Sudden onset of severe pain in the
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
11. Renal Colic – Work up
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
Increased urethral resistance, i.e., bladder
outlet obstruction (BOO).
Low bladder pressure, i.e., impaired bladder
Interruption of sensory or motor innervations
of the bladder.
15. Urinary Retention
Men Women Both
- BOO (commonest
- Urethral stricture
- Acute urethritis or
- Pelvic prolapse
- Post surgery for ‘stress’
- Pelvic masses (e.g.,
- Bladder neck
- Blood clot
- Urethral calculus
- Rupture of the urethra
- Smooth muscle cell dysfn.
(associated with ageing)
- Faecal impaction
- Anal pain
- P O analgesic treatment
- Spinal anaesthesia
16. Urinary Retention - MGT
Initial Management :
Suprapubic catheter (SPC)
Treating the underlying cause
17. 4. Acute Scrotal Conditions
Emergency situation requiring prompt
evaluation, differential diagnosis, and
potentially immediate surgical
Testicular Torsion - Most serious.
Torsion of the Testicular and
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
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
Secondary hydrocele may be present.
Urine : pyuria, bacteriuria, or a positive urine
culture (Gram-negative bacteria)
Bed rest for 1 to 3 days then relative
Scrotal elevation, the use of an
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
Glans will be swollen / oedematous with severe pain
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.
25. 1. Renal Injury
The most common of all injuries to the GU
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
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
Surgery – only in 10 -20%
I Bruise / Contusion Conservative
II Breach – PCS / Rupture
– 1 branch RA
III Rupture – PCS / Renal
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.
Permanent cutaneous ureterostomy.
30. 3. Bladder Injury - Rupture
Blow, kick or fall
Road traffic accidents
Stabs, gunshot injuries
Endoscopic trauma /
I. Intraperitoneal rupture — 20%
Occurs in fully distended
bladder due to blow, kick or fall.
II. Extraperitoneal rupture—80%
Due to RTA, golf playing, fall
over the manhole.
31. Bladder Injury – C / F & Investigations
History : “Classic Triad”
- Suprapubic pain
- Difficulty passage of urine
- 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.
32. Bladder Injury - Treatment
Extravesical injury – Catheter drainage for 10
Intraperitoneal injury – Laparotomy / Repair &
- 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
- 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
III. Depending on the thickness of the urethra
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
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 /
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
Complete rupture :
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
Most commonly with sexual intercourse, but also
reported with masturbation, rolling over or falling on
Diagnosis straightforward by history and
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
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.
C. Conditions - one has to face in an emergency room.
Differential - Renal colic
Investigations / Treatment
Catheterization / SPC / Circumcision