Urological emergency symptoms and Lower Urological emergencies

1. Urological Emergencies
Symptoms and LUT Non-
Traumatic Emergencies
Presenter : Dr MANIRABONA E, MD, PG-Y2 General Surgery
Supervisor : Dr NGENDAHAYO Edouard, Urologist

2. SCOPE
• Introduction
• Urological Emergency Symptoms
• Non Traumatic Lower urological emergencies
1. Priapism
2. Paraphimosis
3. Testicular torsion
4. Fournier’s gangrene
• Take Home Message
• References

3. INTRODUCTION
• Significant proportion of the urological complaints in hospitals
are acute urological emergencies
• These complaints require immediate, often life-saving treatment
either surgical or medical management
• In many cases there is an underlying disease that can trigger a
urological complaint

4. Flank Pain
• regarded as Classic symptom of renal or ureteric pathology
• Only 50% of patients who present with flank pain have a ureteric stone confirmed
on imaging studies
• Other 50% have non-stone-related disease and more often non-urological
disease
• Differential diagnosis dependent on age, side of the pain and sex of the patient
• Roots serving pain sensation from the kidney also serve pain sensation from
other organs

5. Etiologies of Flank Pain
• Urological causes: Ureteric stones, renal stones, infection
(pyelonephritis, perinephric abscess, pyonephrosis), PUJO
• Medical causes : MI, Pneumonia, rib fracture, malaria, PE
• Gynecological and obstetric disease: Twisted ovarian cysts,
ectopic pregnancy, salpingitis
• Other non-urological causes: Diverticulitis, IBD, PUD,
gastritis

6. HEMATURIA
• Relatively rarely an emergency- presents as
clot retention, clot colic or anemia
• It is such an alarming symptom
• Macroscopic, frank, or gross hematuria-
visible to naked eyes
• Dipstick hematuria- detected by urine dipstick
• Microscopic hematuria- presence of > 3
RBCs/hpf

7. ANURIA, OLIGURIA AND INABILITY TO
PASS URINE
Anuria- complete absence of urine production
• BOO reveals percussable and palpably distended bladder
• U/O will resume once a catheter has bypassed obstruction and BPH is most
common etiology
• Obstruction at level of ureters or ureteric orifices, bladder will not be palpable or
percussable usually as result of locally advanced prostatic, rectal, cervical
cancers
• Catheterization reveals no or very little urine and diuresis will not be improved

8. Oliguria- scanty urine production and more precisely less than
400 mL/day in adults and less than 1mL/kg/h in children
• Prerenal causes : Hypovolemia, Hypotension
• Renal causes : Acute vasculitis, AGN, AIN and ATN from drugs,
toxins or sepsis
• Postrenal causes- BPH, Ureteric obstruction

9. SUPRAPUBIC PAIN
• Bladder overdistention may result from BOO like BPH and urethral
stricture
• UTI is associated with urethral burning on voiding, frequent and
incomplete bladder emptying
• Inflammatory conditions like interstitial cystitis and carcinoma
• Gynecological causes include endometriosis, fibroids, and ovarian
pathology
• GIT causes include IBD and irritable bowel syndrome.

10. SCROTAL PAIN AND SWELLING
Scrotal pain may arise
• Scrotum- testicular torsion or appendages, epididymo-orchitis
• Referred- Pain of ureteric colic may be referred to the testis
• Classic presentation of testicular torsion is sudden onset of acute
pain in the hemi-scrotum
• Localized tenderness in the epididymis and the absence of testicular
tenderness helps to distinguish epididymo-orchitis from testicular
torsion

11. Acute Urinary Retention
• Painful inability to void relieved by bladder drainage
• Reduced or absent urine output with lower abdominal pain are not in
itself enough to make a diagnosis of AUR
• Diagnosis is the presence of a large volume of urine when drained
leads to resolution of pain
• volumes of 500–800 mL are typical but <500 mL should be
questionable, Volumes >800 mL are defined as acute-on-chronic
retention

12. AUR-Pathophysiology
There are three broad mechanisms
• Increased urethral resistance : i.e. BOO
• Low bladder pressure: i.e. impaired bladder contractility
• Interruption of sensory or motor innervation of the bladder

13. Etiologies of AUR in Men
• Commonest cause is benign prostatic enlargement (BPE)
due to benign prostatic hyperplasia (BPH) leading to BOO
• Less common causes include malignant prostatic
enlargement, urethral stricture and rarely prostatic abscess
• It is either spontaneous (preceded by the presence of LUTS)
or precipitated by event ( previously asymptomatic patient)

14. Etiologies of AUR in Women
• AUR is less common than it is in men
• Causes include pelvic prolapse (cystocele, rectocele, uterine)
• Pelvic masses (e.g. ovarian masses)
• Prolapsing organ directly compressing the urethra; urethral
stricture and urethral diverticulum

15. Causes in Either Sex
• Hematuria leading to clot retention and postoperative retention
• Pain- Adrenergic stimulation of the bladder neck
• Sacral (S2–S4) nerve compression
• Damage-so-called cauda equina compression
1. Prolapsed L2–L3 disk or L3–L4 intervertebral disk
2. Trauma to the vertebrae
3. Benign or metastatic tumors

16. Neurological Causes of Urinary Retention
• History of constipation and associated back pain
• Nighttime back pain and sciatica
• Spinal tumor or cauda equina compression from a prolapsed
intervertebral disk
• Inability to feel bladder is full and urethral voiding
• Difficulty in knowing passage of feces or flatus
• Males loose erection ability and orgasm

17. Is It Acute or Chronic Retention ?
• Elderly men whose urinary retention not aware- bladder filling or emptying
• Chronic urinary retention with maintained voiding and bladder volume >
800 mL and intravesical pressure >30 cm H2O associated hydronephrosis
• Bladder is insensitive to gross distention, voiding continues without
sensation of incomplete emptying
• Sudden inability to pass urine is termed acute on chronic urinary retention
• Foley catheter and urine volume <800mL or more

18. Urinary Retention-Initial Management
• Urethral catheterization is the mainstay of initial management of
urinary retention
• Pain from overdistended bladder become improved
• SPC is requires once urethral catheter failed and in every
procedure urine volume must be recorded
• Urine volume helps diagnosis confirmation and determines
subsequent management

19. NON-TRAUMATIC UROLOGIC EMERGENCIES IN
MEN
PRIAPISM
• Persistent and painful
erection >4hrs not related to
sexual arousal nor relieved by
sexual intercourse
• Classified into low-flow and
high-flow priapism

20. PRIAPISM
• Low-flow or ischemic priapism results from decreased venous
and lymphatic drainage of the corpus cavernosum
• High-flow priapism is less likely to be ischemic and most often
caused by traumatic arterial laceration
• Main complication of priapism is erectile dysfunction due to
inflammation and fibrosis of the corpus cavernosum

21. Etiologies of Priapism
Most cases of low-flow priapism in adults are secondary to
pharmacotherapy or drug abuse
• Drug of abuse such as alcohol, cocaine for heavy users
• Anti HTN drugs like CCBs, prazosin and hydralazine
• Psychiatric medications, trazodone, chlorpromazine, thioridazine
• Erectile dysfunction medications like sildenafil, vardenafil, and tadalafil

22. Other causes of low-flow priapism include
• Blood dyscrasias
• Hypercoagulable states such as sickle cell disease, thalassemia
polycythemia and vasculitis
• Most common cause of high-flow priapism regardless of age is
arteriovenous fistula formation secondary to perineal trauma

23. Pathophysiology
Low-flow priapism
• Sludging of red blood cells clogs the spaces of the corpus cavernosum
leading to impaired drainage of blood
• Impaired venous outflow can also lead to thrombosis and further ischemia
from remaining stagnant blood
High-flow priapism
Arteriovenous shunt following perineal trauma causes abnormally high flow
of blood through the corpus cavernosum

24. Diagnosis
• Erect, tender penis and soft glans unrelated to sexual arousal
• High-flow state is usually less painful and carries smaller risk of ischemia
with recent history of perineal trauma
• Definitive distinction between high- flow and low-flow is made by penile
blood gas analysis from corpus cavernosum
• Color duplex ultrasonography to differentiate flow patterns
• CBC, Coagulation studies and Hb Electrophoresis

25. Management
• First step is hydration and analgesia
• Ischemic priapism : terbutaline sulfate SC (0.25 to 0.5 mg) every
30min PRN
• Aspiration of cavernosal blood and direct caversonal injection of
phenylephrine (100- 200 mg every 5-10 min with max of 1000 mg)
• High-flow priapism arterial blood flow is intact, selective arterial
embolization using an autologous clot is highly effective

26. Paraphimosis
• Foreskin becomes fixed in the
retracted position and cannot be
reduced
• Impaired venous return from the
glans, edema, induration,
ischemia and necrosis of gland

27. Etiologies
• Most common cause of paraphimosis is previous phimosis
• Iatrogenic
• Poor urogenital hygiene
• Chronic balanoposthitis
• Genital piercing

28. Diagnosis
• Patients present with edema and pain of the glans and the inability to pull
back the retracted foreskin
• Diagnosis is straightforward as non-retractable foreskin and the resulting
edema are easily visualized
• It is important to distinguish various infections and strictures of the penis
• Balanitis is an infection of the glans only
• Balanoposthitis is an infection of the glans and the foreskin

29. Management
• Goals to treatment of paraphimosis
are to relieve pain and prevent
further ischemia to the glans
• Manual reduction of the foreskin
should be attempted
• Dorsal slit procedure entails incising
the fibrotic ring of the prepuce
• Circumcision is the definitive
treatment of paraphimosis

30. Testicular Torsion
• It results from a twisting of the
spermatic cord
• Impaired blood flow to the testis
and venous drainage resulting in
edema, ischemia and necrosis
• First peak at age 1-2 years old and
the second higher peak in
adolescence
• Time is testicle

31. Pathophysiology
• Malformation that allows testicle to rotate more freely around the
spermatic cord
• Malformed tunica vaginalis extends over the whole testicle
• Testicle is horizontally fixed “bell-clapper deformity” present in 12%
• Strong cremasteric reflex during nocturnal erections

32. Diagnosis
• Acute scrotal pain and swelling and associated nausea and vomiting
• High-riding testicle and an absent cremasteric reflex
• Negative Prehn’s sign
• Urinalysis and Ultrasonography

33. Management
Testicular torsion salvage rates
over time
• Emergent surgery to detorse the
affected testicle
• Attachment to the scrotal wall
• Procedure is also done on the
unaffected testicle

34. Fournier’s gangrene
• Necrotizing fasciitis of external
genitalia, perineal or perianal
region
• Polymicrobial from GIT or GU
• Affects all ages and both genders
• Life threatening with a mortality
rate of 13-22%

35. ETIOLOGIES
• 50-60% of infections stem from lower GIT or GU source
• Risk Factors : HIV, DM, alcohol, perineal trauma, etc.
• Organisms include E. coli, bacteroides and staphylococci
• Most likely culprit for an infection of colorectal origin is clostridium

36. Pathophysiology
• It begins locally with skin infection and spreads down the fascial plane
• It results into inflammation and ischemia then necrosis later
• Low oxygen content and necrosis potentiate the effects of the
anaerobic bacteria and cause rapid dissemination of the infection

37. Diagnosis
• Patients present with genital induration, pain, erythema and crepitus
• Diagnosis is straightforward when the lesions are found
• Plain radiograph or CT may demonstrate air in the perineal tissues
• Retrograde urethrogram reveals suspected periurethral infection
• Perirectal infection source suspected proctoscopy may be revealing

38. Management
• It relies on an aggressive medical and surgical approach
• Rapid fluid resuscitation and broad spectrum ATB
• Surgical debridement, aggressive wound care and redebridement
• SPC and Fecal diversion may be needed
• Genital skin is highly elastic and grafts are not required unless over 60% of
the skin is removed

39. Take Home Message
• UE delays in treatment may lead to permanent damage
• Priapism focus is on diagnosis and distinguishing high-flow from low-flow forms as latter
requires emergent treatment
• Paraphimosis is straightforward diagnosis ,various methods of reduction and circumcision
• Testicular torsion diagnosis is heavily clinical and salvage of testicle is decreasing with
time to treatment
• Fournier’s gangrene is potentially fatal, aggressive medical and surgical therapy improve
chances of survival and outcome

40. References
1. Non-Traumatic Urologic Emergencies in Men: A Clinical Review Jesse Brown VA Medical
Center, Department of Emergency Medicine, Chicago, IL, University of Illinois at Chicago,
Chicago, IL
2. Urological Emergencies In Clinical Practice-Springer-Verlag London (2013) Hashim Hashim
M.D., FEBU, FRCS (Urol) (auth.), John Reynard, Nigel C. Cowan, Dan Wood, Noel Armenakas
(eds.)-
3. Lue-Smith and Tanagho's General Urology-McGraw-Hill Medical (2012) Jack W. McAninch,
Tom F