The document discusses various acute emergencies in urology, detailing conditions like acute and chronic urinary retention, acute urinary tract infections, renal stones, and hematuria through case scenarios. It emphasizes management protocols, differential diagnoses, examination techniques, and the necessity of investigations such as ultrasounds and CT scans. The document also outlines specific treatment strategies, including catheterization, pain relief measures, antibiotic use, and when to consider surgical interventions.

1. Acute Emergencies in Urology
Dr Vijayant Govinda Gupta
MBBS (UCMS)
MS (MAMC)
MCh Urology (PGI Chandigarh)

2. Retention of Urine
• Inability to pass urine
• Acute Retention - Sudden inability to pass urine usually
associated with pain
• Chronic Urinary Retention is the inability to
completely empty the bladder of urine.
• The International Continence Society defined
the Chronic retention of urine as a
nonpainful bladder that remains palpable after voiding

3. Case Scenario 1
• 65 year old hypertensive
man presented to
emergency department
with inability to pass
urine since last 6 hours.
He is complaining of
severe pain in lower
abdomen and is going to
bathroom again and
again but is not passing
even a drop of urine.

4. Acute Urinary Retention in Men
• Differential Diagnosis
– Prostate (BPH / Ca Prostate)
– Stone
– Clot Retention
– Severe Acute UTI/ Urethritis
– Urethral Stricture / Trauma / Past Surgery

5. Relevant Past History
• H/O LUTS – On Urimax since 6 months (AUR on
Treatment – Surgery)
• No H/O overflow incontinence (Acute on Chronic)
• No H/O Surgery (TURP/Urethra), Trauma,
Hematuria (Clot retention), Stone disease
• No Similar Past episode – 2 episodes of AUR
indication for surgery

6. Examination
• GCS 15, Vitals stable
• Supra pubic tenderness with bladder palpable (on
palpation and percussion)
• Penis normal, meatus normal, no Phimosis , no stone
palpable in Urethra (Always examine penis)
• No prior scar on abdomen (Examine for SPC/
Cystolithotomy / Freyers)
• Postpone DRE after catheterization

7. Investigation
• None required

8. Management
• Pain relief – Antispasmodics and Analgesics
• Prophylactic Antibiotic before Catheterization
(Floroquinolone or Aminoglycoside)
• Clean Catheterization with Foleys catheter
• Send Urine Culture and KFT

9. Catheterization Basics
• No Touch Technique
• Clean prepuce and glans with antispectic solution
• Go for 14 French
• Siliconised catheter is enough – no need for silicon
• Don’t over inflate baloon , always ensure urine free flow
• Liberally use jelly
• Ensure free flow of Urine
• No role of slow decompression
• Always fix catheter

10. Digital Rectal Examination
• Before leaving do a DRE
• See for any Prostate Abscess/ Tenderness or
Hard Prostate
• No role of PSA in AUR – False elevation. PSA
after 3 to 4 days of catheterisation.

11. Management
• Admit or discharge patient with instructions to
follow up
• One trial of voiding after 3 to 7 days of alpha
blockers can be tried
• If AUR on Medication or recurrent episodes –
work up for TURP / HOLEP

12. Case Scenario 2
• 65 year old hypertensive
and diabetic man
presented to emergency
department. Complaining
of only mild discomfort.
Going to toilet every 10
to 15 minutes and
passing only few drops of
urine. Has gone to
bathroom 20 times in 1
day.

13. Chronic Urinary Retention in Men
• Differential Diagnosis
– Prostate (BPH / Ca Prostate)
– Neurogenic Bladder
– Diabetic Cystopathy

14. Relevant Past History
• H/O LUTS – On Urimax since 6 months.
• Old Ultrasounds show increasing PVR
• H/O overflow incontinence
• No H/O Surgery (TURP/Urethra), Trauma,
Hematuria (Clot retention), Stone disease
• History of multiple AUR in the past –
Decompensated bladder

15. Examination
• GCS 15, Vitals stable
• No Supra pubic tenderness with bladder palpable (on
palpation and percussion)
• Penis normal, meatus normal, no Phimosis , no stone
palpable in Urethra (Always examine penis)
• No prior scar on abdomen (Examine for SPC/
Cystolithotomy / Freyers)
• DRE may be done

16. Investigation
• None required

17. Emergency Management
• No requirement of Pain relief
• Prophylactic Antibiotic before Catheterization
(Floroquinolone or Aminoglycoside)
• Clean Catheterization with Foleys catheter
• Watch for Hematuria – Retention volume may be
more than a litre

18. Management
• Admit or discharge patient with instructions to
follow up
• No benefit of trial of voiding
• Candidates for surgery – higher chances of
failure of symptoms if NGB/Cystopathy

19. Case Scenario 3
• 65 year old hypertensive and
diabetic man presented to
emergency department.
Complaining of severe burning
in penis. Going to toilet every
10 to 15 minutes and passing
only few drops of urine. Has
gone to bathroom 20 times in 1
day. Also complaining of blood
drops.
• On Examination – No Bladder
Palpable

20. Acute UTI
• Differential Diagnosis
– Prostatitis / Abscess
– Urethritis/ Cystitis / Stricture
– Stone in Bladder/ Strangury
– Clot/Mass in UB
– UTI in CKD (Anuria)

21. Examination
• GCS 15, Vitals stable
• No Supra pubic tenderness no bladder palpable (on
palpation and percussion)
• Penis normal, meatus normal, no Phimosis , no stone
palpable in Urethra (Always examine penis)
• Prior scar on abdomen of SPC (Past history of Stricture and
OIU
• DRE Tender

22. Investigation
• Order Ultrasound
– Bladder wall, Thickness, Mass, Stone
– Stone may be seen in prostatic fossa , VUJ
• Urine Routine – Full Field Pus Cells
• KFT – may be deranged

23. Emergency Management
• No emergent role of catheterization
• Start
– Analgesics
– Antibiotics
– Antispasmodics
– Fluid management
– Alpha Blockers
• Treat Pathology
– CLT if Stone
– OIU and placement of catheter if stricture

24. Management
• If Prostatitis and more than 2 episodes a year,
may benefit from surgery

25. Renal Stones
• Stones in the kidneys can present in many
ways
– Pain
• Colic – Loin to Groin
• Constant Discomfort – Stretch Pain
– Fever – Pyelonephritis / Pyonephrosis
– Uremia – Obstructive Uropathy
– Hematuria
– Cystitis/ Strangury/Retention

26. Case Scenario 4
• 18 year old female
presented to Emergency
with pain in Right Iliac
Fossa for few hours.
• Pain is colicky in nature
and radiating to the
urethra. Vomited gastric
contents twice after pain
onset.
• Passed a few drops of
blood with urine.

27. Differential Diagnosis
• Ureteric Colic
• Appendicitis
• Salpingitis
• Ovulation pain
• Dysmenorrhea
• Typhoid/Colitis
• UTI

28. Relevant History
• Past History of Stones
• No history of Fever
• No Diarrhea/ altered bowel habits
• LMP
• History of sexual intercourse

29. Examination
• In ureteric colic abdomen rarely has signs
• Maybe some tenderness but usually no rebound
• No features of peritonitis
• Flank tenderness may be present if pyonephrosis
/ pyelonephritis

30. Emergency management
• Stabilize patient
– Start fluids
– Analgesics, Antibiotics and PPI

31. Investigation
• Ultrasound is the Initial Investigation of Choice in
the acute emergency setting
• Full Bladder if possible
• Can rule out appendicitis
• Indirect signs like fullness of PCS, HDUN
• Stone may also be visualised

32. Adjunct findings
• Urine routine may show some RBS’s
• TLC is rarely elevated

33. NCCT KUB
• Investigation of Choice for Ureteric Calculi
once USG is done
• Size, Shape, Location, Number, Kidney Status

34. Surgery
1. Infected obstructed kidney = surgical emergency
2. Pain uncontrolled despite PR NSAIDS
3. Stone clearly too large to pass > 7mm
4. CKD
5. Solitary kidney – risk obstructive uropathy

35. Case Scenario 5
• 18 year old male
presented to
Emergency with
anorexia, lethargy and
nausea. No pain
• History of pain in flank
and past history of
renal stones
• Has not passed urine
for 3 days

36. Differential Diagnosis
• Obstructive Uropathy
• ESRD

37. Investigation
• Ultrasound – Bilateral HDUN, UB Empty
• Creatinine 7.5
• Hyponatremia and Hyperkalemia
• ABG reveals acidosis

38. NCCT KUB
• Investigation of Choice for Obstructive
Uropathy
• Bilateral VUJ Calculi

39. Emergency management
• Nephrology review
• Consider for Emergency Dialysis to correct
electrolyte abnormalities and acidosis
• Cystoscopy plus URS plus Bilateral DJ Stenting
– Do minimum and rapidly
– CKD predisposes to bleeding
– Poor vision and ureteric edema

40. Post Obstructive Diuresis
Once Obstruction is relieved patient may go into
Diuresis
• Watch for Urine Output
• Replace 2/3rd output with half saline
• Monitor Electrolytes 6 hourly in first 48 hours
• Monitor decline in creatinine
• Adequate nutrition
• Maintain dialysis access, may require one or two
more sessions if obstruction long standing

41. Case Scenario 6
• 48 year old male
presented to
Emergency with
anorexia, lethargy high
grade fever.
• Complaining of mild
discomfort in left flank
• No history of stones
• O/E Flank tenderness

42. Differential Diagnosis
• Pyelonephritis – Infection of renal
parenchyma
• Pyonephrosis – Pus collection in PCS

43. Investigation
• Ultrasound – Left Hydronephrosis with
Multiple stones and Internal Echoes
• Creatinine 1.5, Uncontrolled Diabetes
• Urine Routine reveals Pus Cells

44. CECT KUB
• If Creatinine allows a CECT is better
• Can provide date in evolving abscesses,
parenchyma enhancement, XGPN, Parenchym
function, fistula, lymph nodes etc

45. Emergency management
• Internal Drainage vs External Drainage
• Both are comparable
• PCN
– Giant hydronephrosis
– Thick Pus
– Air in system
– Solitary Kidney
– Too Sick to move to OT
– Internal Drainage fails
• DJ Stent
Preferable in times of endourology
Comparable outcomes

46. Hematuria
• Blood in urine in called hematuria
• Visible blood is Gross Hematuria
• Microscopic Hematuria is not always
pathological

47. Case Scenario 8
• 68 year old male
presented to
Emergency with gross
painless hematuria
since 3 days
• Patient is Chain
Smoker
• No Pain, No Burning,
Associated with clots

48. Differential Diagnosis
• Ca UB / Upper Tract TCC
• Coagulopathy
• Prostatic Bleed (Prostatic Piles)
• Pain/Dysuria
– UTI
– Trauma
– Stones
– Renal Origin Bleed

49. Relevant History
• Pain – Flank or Suprapubic
•
• Any history of Anticoagulation
• Dysuria / Stones ??

50. Examination
• Check for GCS / Hypotension / Tachycardia
• Check for bladder – Clot retention

51. Emergency management
• Stabilize patient
– Start fluids
– Analgesics, Antibiotics and PPI
• To catheterize and start irrigation
– Not in every case
– If hemodynamics stable, no clot retention, passing
urine then can wait till investigation is over

52. Investigation
• Ultrasound is the Initial Investigation of Choice
in the acute emergency setting
• Full Bladder – Will demonstrate mass and
clots
• Always evaluate upper tracts
• A CECT is always required in Hematuria

53. Management
• Cystoscopy with clot evacuation plus minus
TURBT always
• Sessile lesions common, also helps evaluate
the prostate
• If no mass always wait for ureteric efflux –
may show hematuria – then ureteroscopy

54. • Cystoscopy may be delayed in suspected cases
of coagulopathy where USG and CT are
normal
• If recurrent hematuria even after tapering
anticoagulants consider cystoscopy

55. Many More – Limited Time
• Acute Scrotum
– Epidydmoorchitis
– Torsion
– Trauma
• Urological Trauma
• Urethral Stricture and Pelvic Fracture
• Penile Fracture