1. Urology emergencies include testicular torsion, epididymo-orchitis, renal colic, urinary retention, and haematuria. 2. Testicular torsion requires urgent surgical exploration within 6 hours to salvage the testis. Epididymo-orchitis is usually treated with antibiotics but may require admission. 3. Renal colic from stones is initially managed conservatively but larger or obstructing stones may require shockwave lithotripsy or ureteroscopy. Urinary retention can often be managed with catheterization.

1. Urology Emergencies
Mazin
FY1 Urology / Gum

2. Testicular pain
• Torsion
• Epididymo-orchitis
• Mumps orchitis
• Torsion of testicular appendages
• Idiopathic scrotal oedema
• Age 13-20 common

3. Testicular Torsion
• Twist in the spermatic cord with subsequent
strangulation of testicular blood supply
• 1 in 4000 males younger than 25 years*
• 17% of acute scrotal presentations
• Commonest (90%) cause of acute scrotal pain in
adolescent (13-21y) age group
• More common in patients with cryptorchidism
*Srinivasan AK et al J Urol 2007

4. History
• Sexual health history – recent unprotected sex
• Ask young patients directly – alone
• Exam
– High riding testicle, may be on its side
– Red, tender, swollen
– Scrotal wall edema if testicle is already dead
– *Blue dot sign* in non-thick scrotums (pathognomonic)
– Cremasteric reflex should be preserved
• Mgt: surgical exploration & fixation (both testicles)

5. Presentation
• On examination
– Swollen
– Tender
– High riding
– Horizontal lie
– Absent cremaster reflex

6. Testicular torsion
• Pain to knife time is crucial
• For acute testicular torsion: surgery within 6 hours of onset
of pain usually results in survival of testis, beyond 8 hours
seldom
• In the adolescent all discussions of the acute scrotum start
after exploration
• Ultrasound is of no diagnostic value
• QEH: Age <16 years: Refer to Evelina / age >16 years: A&E
registrar to urology registrar referral
• UHL: Refer to general surgery team
• Testicular pain >24 hours: Doppler ultrasound is more
useful

7. Aetiology
Intra-vaginal (Bell-Clapper)
• Tunica vaginalis completely
surrounds the testis
• Absence of normal posterior
anchoring allows the testicle to
twist freely
• Left testis is more frequently
involved
• Bilateral cases account for 2% of
all torsions

8. Aetiology
Extra-vaginal
• Testis, epididymis, and
tunica vaginalis twist on the
spermatic cord
• 5% of all torsions
• More common in neonates
• Associated with high birth
weight

9. Prognosis
• Rate of Salvage
Time since onset
of symptoms (Hrs)
Salvage rate
<6 85 – 97%
6-12 55 – 85%
12-24 20 – 80%
>24 <10%-
Davenport M. 1996

10. Investigations
• Doppler ultrasound
– Absent or decreased blood flow
– Demonstrates flow in only 79-90% of
normal cases
• Radionuclide imaging
– Technetium-99m pertechnetate
– Decreased perfusion on symptomatic
side
None should delay surgical exploration!

11. Management
• All suspected torsions need to be explored,
ideally within 6 hours
• Manual de-torsion (open like a book) may be
attempted
• If no torsion, close scrotum, do perform
orchidopexy on same side.

12. Torsion of testicular appendages
• Usually occurs in children aged 7-12
years
• Systemic symptoms are rare
• Localized tenderness at upper pole
of testis
• Occasionally (21%), blue dot sign is
present in light-skinned boys
• Excision not mandatory if torsion
excluded

13. Torsion of Testicular Appendages
Appendix Epididymis – Remnant
of part of Wolffian duct
Hydatid of Morgagni – Remnant
of Mullerian duct

14. Epididymo-orchitis
• In young men think STI, in seniors usually
associated with UTI
• Mild swelling, observations stable, afebrile:
home + oral antibiotics (consider doxycycline)
• Severe swelling, high temperature, increased
WBC: refer to Urology SHO for admission

15. Epididymo-orchitis
– Reflux of infected urine
– N. Gonorrhoea or C . Trachomatis STI
– Excessive straining or lifting with reflux of urine
(chemical epididymitis).
– Underlying congenital or acquire urological
abnormality may predispose
– Often accompanied by systemic signs and
symptoms of UTI
– Pyuria, bacteriuria and leucocytosis
– Urethral swab and MSU should be obtained

16. Epididymo-orchitis
• USS scan can differentiate from torsion but may miss
20%
• If unsure - explore
• Empirical antibiotics
– <35 years; Doxycycline
– >35 years; Quinolone
• Minimum of 2 weeks treatment
• Treat partner if Chlamydia identified
• Complications; Chronic epididymitis, abscess,
infarction, chronic pain, infertility

17. Scrotal swelling DDx
• Tumour
• o Typically present with lump attached to
testis
• o Prognosis usually good
• · Torsion
• o Testicular pain in child (<4, 12+)
• o Needs surgery within 2-4 hours to salvage
testis.
• o Main differentials are torsion of hydatid, or
epididymal orchitis
• (infection – may take months to resolve)
• · Hydrocoele
• o Most idiopathic, can be a reaction to insult.
~10% recur
• o US if testes not palpable or to confirm
diagnosis
• o Aetiology:
• o young - patent processus
• o old - fluid forms in scrotum
• · Epididymal Cysts
• o Can be excised, but frequently recur
• o Often multiple small cysts as well as
presenting lump
• o Main differential – spermatocoele.
• · Varicocoele
• o Look like hernia, but no cough impulse,
tend to go if patient supine.
• o More common on the left.
• o Can be caused by renal tumour
• o Consider surgery:
• o Embolise
• o Laparascopic
• o Open - least chance of recurrence
• o Pain may persist after surgery
• · Haematoma
• o Should be history of trauma
• · Inflammation
• · Hernia

18. Renal stones
• Obstructed infected kidney loses function in 3 days
• Simple renal stones: 5-6 mm, distal ureter, normal
U&Es, normal other kidney: Home (analgaesia +
tamsulosin) – outpatient clinic in 3 weeks
• Complex renal stones: Size >6mm, proximal ureter,
moderate hydronephrosis, deranged renal function:
refer to Urology SHO for admission
• Obstructed infected kidney: high temperature,
observations: non-stable: consider nephrostomy

19. Stones
• Formation of calculi in renal tract
• Ratio Male 3: Female 1
• 20 – 50 years old, 10% caucasian males
• RF
– Westerners, warm climates, occupation, FHx, diet,
seasonal, medical conditions, anatomical
deformities
– Supersaturation / crystalisation

20. Stones: Composition and lucency
• Calcium Oxalate (<85%)
• Calcium Phosphate/oxalate (~15%)
• Uric Acid (10%)
• Struvite (<20%)
• Cysteine (1%)
• Indinavir

21. Stones: Differential diagnosis
• Acute Pyelonephritits
• Ruptured AAA
• Appendicitis
• Other renal condition
• UTI
• Ruptured ectopic pregnancy

22. History
• Loin to groin pain, N&V, haematuria, ureteric
irritation (T12-L2), urgency, frequency, UTI
• Examination: Full abdo & external genitalia
• Absence of peritonitis
• Temp, chills, rigors, ?urosepsis
• *Retrosternal appendix can cause same pain

23. Workup
• Don’t bother with plain films – need CT KUB
• Or IVU (conta in: *Contrast allergy, Metformin,
asthmatics*)
• Urinalysis & MSU
• Pregnancy test
• Bloods
• ?Metabolic screen (calcium, uric acid)

24. KUB

25. IVU

26. CT KUB

27. Conservative management
• Renal calculi
– Asymptomatic, small, peripheral, associated
medical problems
• Ureteric calculi
– <5mm, asymptomatic, no radiological signs of
obstruction

28. Mgt
• Increase oral fluids (IV), antiemetics
• Analgaesics (morphine, NSAIDs)
• Conservative Medical expulsive therapy (Tamsulosin)
• Shock wave lithotripsy (ESWL)
• Flexible cystoscopy / Ureteroscopy
• Percutaneous surgery (PCNL) / nephrostomy +/- ureteric
stent insertion
• Correct metabolic abnormality
• Treat infection promptly
• Reduce calcium intake (Thiazide diuretics for idiopathic
hypercalcaemia)
• Urinary alkalisation (eg. Sodium bicarbonate in water)

29. Extracorporeal Shock Wave Lithotripsy
• Stone absorbs energy
• Cavitation effect
• Fractures stones
• Sand like material as end
product

30. Lithotripsy
• Shock waves
• Perspex lens
• Focused on stone
• Fragments pass
• 3 treatments if no progress

31. Ureteroscopy

32. Urinary retention
• Acute over distension injuries produce lasting
bladder dysfunction
• Residual volume <1L, normal kidney functions:
Home, urology clinic (consider TWOC clinic
beforehand if no prior symptoms)
• Residual volume >1L, deranged kidney function:
Refer to urology SHO for admission
• Remember that the role of DRE for diagnosis of
prostate cancer; do not do PSA test in acute
situation
• Default optimal catheter size is 16 Fr silicone

33. History
• Inability to void
• Long journey prior
• Abdo pain improves with catheter
• Chronic urinary retention -> bedwetting ->
overflow

34. Ask
• Painful / painless
• Inability to void?
• Precipitated?
– (alcohol, surgery, constipation, UTI)
• Back pain – neurology ?cord compression
• Background LUTS
• DRE (prostate / rectum) – tumour

35. Examination
• Examination:
– General
– Bladder palpable? Scars?
– Meatus/genitalia
– DRE (prostate/rectum)
– Neurology

36. Workup
• Catheterise urgently
• Urethral vs SPC
• Document residual volume
• Strict input / output  Diuresis (>200 ml/h
over 24 h)
• U&E – check PSA (NOT acutely)
• Renal function tests
• Alpha blocker?

37. Catheter problems
• Catheter to be changed in casualty with a
single dose of antibiotic
• Urology assistance via SHO is for failed
catheter by skilled practitioner, fever, bleeding
or escaped suprapubic catheter
• Only a small number of these patients require
admission

38. Haematuria
• Common diagnostic yield: infections, stones,
malignancy
• Microscopic haematuria: 2ww outpatient one stop
haematuria clinic
• Frank haematuria
• Mild, rose colour, non-obstructing, no clots, stable,
normal haemoglobin: 2ww one stop
• Severe, clots, red wine colour, deranged haemoglobin:
3 way catheter 22 Fr, start irrigation, refer to urology
SHO for admission
• Please send for MSU culture and sensitivity

39. Workup
Visible vs Non visible
History:
Painful vs Painless
Where in stream?
How heavy? Clots?
Duration. Other symptoms
Smoking? Occupation? DHx (warfarin etc)

40. Examination
• General:
Well or Unwell?
Shock? (BP/pulse/urine OP/CRT)
Temperature
Bladder palpable?
DRE

41. Haematuria
Investigations:
Urinalysis/MSU
Bloods (FBC/UE/clotting)
?PSA
?imaging

42. Workup
 Management:
Resuscitate?
Catheterise – Size?
Washouts/irrigate
Fluids/blood tx?
Definitive investigation – cystoscopy/USS

43. Fournier's gangrene

44. Urosepsis
 Sepsis +/- septic shock
 Often diabetic/elderly/catheter
 Bloods, MSU/CSU, ABG, blood cultures
 Resuscitate – ABC, fluids, Oxygen
 Close observation
 IV broad spectrum antibiotics
 Early USS +/- nephrostomy

45. Post-Operative Patients
• If a patient attends with post-operative
problems or complications, the relevant
specialty SHO should be informed and they
should discuss with their registrar directly