UROLOGICAL EMERGENCIES

2.  Define common urological emergencies
that may face non urologists.
 How to diagnose these emergencies
 Initial management of these problems
for non urologists

3. 1 Loin pain
2 Retention of urine
3 Testicular pain
4 Hematuria
5 Problems with the penis
6 Problems with catheters

4.  Acute renal colic is the most
excruciatingly painful event a person can
endure .
Non traumatic
emergency

5.  Does not always present with classic history
 Classically presents with loin pain radiating
around abdomen, as stone moves down
ureter
 May get testicular/labial pain +/- strangury if
stone impacts at VUJ

6. - Reflects the somatic
sensory distribution
of the spinal level of
renal innervations
- (T1o-T12).
- Most probable
hypothesis:
Afferents from the
skin & viscera
converge on the
same neuron in the
spinal cord and
share the same
ascending neuron .

7.  Urinalysis
 CBC
 BUN & s. Creatinine
 KUB

8.  KUB

9.  Limitations
 Significant
obstruction may be
associated with little
dilatation of
collecting system.
 Relatively poor in
visualizing the ureter.
 Difficult to detect
stones < 5mm in size
 Operator and
equipment
dependent

10.  95% sensitivity
 98% specificity
 Performed in 5 min.
 Identifies radiolucent
stones .
 Identifies other causes
of flank pain.
stone

11.  Treat the symptoms –analgesia
 Blood cultures if pyrexial
Consider antibiotics
quinolone if not vomiting
gentamicin if vomiting

12.  Persistent pain .
 Ureteral obstruction from a stone in a
solitary or transplanted kidney .
 Ureteral obstruction from a stone in
presence of UTI, fever, sepsis or
pyonephrosis.
 Relative indication:
Co morbid conditions (e.g. diabetes ,
dehydration, renal failure, or any immuno
compromised state)

13. Size of Stone
< 4mm
4-6 mm
> 6mm
Management
Conservative: 90% pass
spontaneously
50% pass
spontaneously – trial
of passage
Intervention likely, only
10% pass
spontaneously

14.  Stone on KUB - No stone on KUB
 Pyrexia - No pyrexia
 Hematuria - No hematuria
 Raised creatinine - Normal creatinine

15.  NSAIDs .
 Antispasmodics ?
 Alpha blockers
 Nefedipine ?

17. • Causes :
– Men:
• Benign prostatic enlargement (BPE) due to BPH
• Carcinoma of the prostate
• Urethral stricture
• Prostatic abscess
– Women
• Pelvic prolapse (cystocoele, rectocoele, uterine)
• Urethral stricture;
• Urethral diverticulum;
• Post surgery for ‘stress’ incontinence
• pelvic masses (e.g., ovarian masses)
Non traumatic
emergency

18. • Both Sex
– clot retention
– Drugs
– Pain
– Sacral nerve compression or damage(cauda equina
compression )
– Radical pelvic surgery
– Pelvic fracture rupturing the urethra
– Neurotropic viruses involving the sensory dorsal root
ganglia of S2–S4 (herpes simplex or zoster);
– Multiple sclerosis
– Transverse myelitis
– Diabetic cystopathy
– Damage to dorsal columns of spinal cord causing loss of
bladder sensation (tabes dorsalis, pernicious anaemia).

19.  Empty bladder – Distended bladder
Painful retention – Painless retention
 Raised creatinine – Normal creatinine

20. Pain + residual >400ml
needs drainage

21.  Do it immediately
 Urethral catheter 12/14F
 Record the residual
 Two attempts then call for help
 16F SPC if urethra impassable

22.  Obstruction develops slowly, the bladder
is distended (stretched) very gradually
over weeks/months, so pain is not a
feature .
 Presentation:
› Urinary dribbling
› Overflow incontinence
› Palpable lower suprapubic mass
Non traumatic
emergency

23.  Usually associated with
› Reduced renal function.
› Upper tract dilatation
 R/x is directed to renal support.
 Bladder drainage under slow rate to
avoid sudden decompression>
hematuria.
 Late R/x of cause.

24.  High Pressure CR
 Painless Incontinent
 Raised Cr
 Bilateral
hydronephrosis
 Catheterise
 Monitor output
 Check U&E
 Low Pressure CR
 Painless
 Dry
 Normal Cr
 Distended bladder
normal kidneys
 Do nothing
urgently!

26. Epididymitis
Torsion
Hydrocele
VaricoceleBlue
dot
sign
Torsio
n of
append
ix
epididy
mis

27. (A) extravaginal (B) intravaginal

28.  Can occur at any age
 Most common in adolescents
 Occasionally seen in neonates
 In infants & neonates the symptoms and
signs are imprecise
 Prompt action required to avoid
irreversible testicular ischemia

29.  Diagnosis
usually made
solely on basis
of clinical
examination
 It is high
 It is swollen
but
 Not necessarily
painful

31.  Color Doppler ultrasound:
› Assessment of anatomy and determining the
presence or absence of blood flow.
› Sensitivity: 88.9% specificity of 98.8%
› Operator dependent.

32.  If you have time Scrotal ultrasound scan
 If you don’t have time explore the
scrotum
You only have 6 hours

34. 1
2
3
4
Minor twist-viable
Major twist- ? viable
Major twist-viable!
Major twist-necrotic

36.  Presentation:
 Indolent process.
 Scrotal swelling, erythema, and pain.
 Dysuria and fever is more common
 P/E :
› localized epididymal tenderness, a swollen and tender
epididymis, or a massively swollen hemiscrotum with
absence of landmarks.
› Cremasteric reflex should be present
 Urine:
› pyuria, bacteriuria, or a positive urine culture(Gram-
negative bacteria) .
Non traumatic
emergency

37.  Management:
› Bed rest for 1 to 3 days then relative
restriction .
› Scrotal elevation
› Parenteral antibiotic therapy
› Urethral instrumentation should be avoided

39.  Definition :
presence of blood in the urine.
 The passage of blood in the urine is
always alarming and investigation is
warranted.
Non traumatic
emergency

40.  Hematuria.
 Hemoglobinuria, myoglobinuia.
 Anthrocyanin in beets and blackberries.
 Chronic lead and mercury poisoning.
 Phenolphthalein (in bowel evacuants).
 Phenothiazines (compazine).
 Rifampicin.

41. MACROSCOPIC
MICROSCOPIC
SYMPTOMATIC
ASYMPTOMATIC
INITIAL
TERMINAL
TOTAL

42.  Microscopic examination :
 Urine dipsticks test :
-Urine dipsticks test for hem
(i.e. they test for presence of
hemoglobin & myoglobin in
urine ).
- Hem catalyses the oxidation
of orthotolidine by organic
peroxidase producing a blue
coloured compound.
-Dipsticks are capable of
detecting the presence of
hemoglobin from 1 or 2 RBCs.

43.  False positive results :
Myoglobinuria,
Bacterial peroxidases,
Povidine & hypochlorite.
• False negative results (rare):
Reducing agents ( e.g. ascorbic acid which
prevents oxidation of orthotolidine).

44.  Age and sex.
 Smoking.
 History of schistomiasis in endemic areas.
 Occupational exposure to carcinogens.
 Drugs e.g. NSAID, Cyclophosphamides.
 Pain, fever, dysuria, frequency.
 History of recent throat pain suggests post
infectious g.n.
 Information about exercise, menstruation, recent
catheterization or passage of calculi.

45.  Diagnoses
 Urothelial cancer
 UTI/STI
 Stone disease
 Decision
 Pain on voiding?
 Are there clots?
 Are they voiding?
Clinical/DRE
Temperature
Urinalysis
MSU/cytology
Bloods/PSA
IVU/UTUSS
Cystoscopy

46. Physiologic phimosis Pathologic phimosis Pathological
phimosis showing a
thickened indurated
phimotic band.
Non traumatic
emergency

47. Paraphimosis. Venous
return from the glans is impaired
and the prepuce is
edematous and engorged distal to
the phimotic ring
Sustained gentle
pressure is required
in order to reduce
the edematous
foreskin over the
glans

48.  The term “Priapism” is derived from
Priapus, the Greek god of fertility.
 An erection lasting longer than 4 h that is
not associated with sexual stimulation
Non traumatic
emergency

49.  Venous, low flow.
 Cessation of arterial
inflow serves to create
an acidotic and
hypoxic condition in
the penis.
 Increased
intracorporeal
pressure similar to the
compartment
syndrome.
 Arterial , high flow
 Unregulated arterial
inflow
 Ischemic  Non ischemic

50.  Idiopathic 50%.
 Intracavernosal inj.
 Antidepressant
Antipsychotics,
chlorpromazine,
phenothiazine.
 Antihypertensives ;
hydralazine, prazozine
 High fat content of TPN
 Cocaine and alcohol
 Direct trauma to penis,
perineum or pelvis
arterial rupture and
increased arterial
inflow.
 Ischemic  Non ischemic

51.  Sickle cell anemia.
 Leukemia.
 Neurologic :
lumber spinal stenosis,
cerebrovascular disease,
seizure disorders.
 Neoplasm: Ca bladder, Ca
prostate, metastatic renal
cell carcinoma
infiltrate and obstruct
venous drainage. (This type
of priapism is usually
treated with chemotherapy
or radiotherapy).
 Trauma to penis, perineum
or pelvis
arterial rupture and
increased intracorporeal
arterial inflow.
 Ischemic  Non ischemic
T

52. Aspiration of corporeal blood
For ABG
 Dark venous blood
 PH <7.25
 PO2 <30 mmHg
 PCO2 > 60 mm Hg
 CBC for leukemia
 Sickle C test
 Doppler U/S
 No cavernous arterial flow
 Bright arterial blood
 PH >7.3
 PO2 >50 mm Hg
 PCO2 < 40 mm Hg
 Ruptured cavernosal artery
with unregulated blood flow
pooling.
 Laboratory testing
 Ischemic
 Non ischemic

53.  History:
Duration and quality of erection .
Pain or no pain.
Medication and recreational drugs
Sickle cell anemia or hypercoagulable state.
 Physical examination :
- Rigid painful erection with a softer glans with
ischemic priapism
- Semirigid painless penis often with non ischemic
priapism
- Signs of genital or perineal trauma
- Signs of lymphadenopathy

54.  Penile nerve block : Inject lidocaine 1% at the
base of the penis at the 3 o’clock and 9 o’clock
positions.
 Insert an 18-gauge or 20-gauge butterfly needle into
one of the corpora cavernosa (2 o’clock or 10 o’clock
positions). Attach to a large syringe.
 Aspiration : Aspirate 50 mL (it may be necessary
to milk the penis). Dark blood is aspirated initially.
 If this does not lead to detumescence, then another 50
mL is aspirated from the contralateral corpus. Then
apply manual pressure to the penis for few minutes.

55.  Irrigation: If failure, then another 50 mL should
be aspirated from the corpora and irrigate
with 30–40 mL warm, sterile heparinised
saline solution (5000 U/L) and then aspirate
another 30–40 mL.
 Infusion: If failure, apply a tourniquet to the base of
the penis. Inject 200 μg of Phenylephrine (a1 agonist,
vasoconstrictor),50-100 μg Ephedrine, 20-80 μg Nor
adrenaline or 10-20 μg Adrenaline into the corpora.
Need to measure blood pressure, pulse rate every 5
minutes and to have electrocardiogram monitoring.

56.  Wait for 5–10 minutes; if this
fails, then repeat the
injection with another 200 μg
of phenylephrine. If this fails,
then consider another 500 μg
of phenylephrine.
If phenylephrine is not
available, then adrenaline 10–
20 μg every 5 minutes could
be used
 If failure, Surgery : Distal
shunt, if fails : Proximal
shunt

57.  1 Aspiration for diagnosis. Do not use
sympathomimetics
 2 Observation
 3 Embolization
 4 Surgery, aided by intraoperative Doppler
ultrasound

59. Blocked catheter
 Change the catheter don’t wash it out
 Send a CSU
 ? Start antibiotics
 Admit if pyrexial
Non traumatic
emergency

60. Urine bypassing the catheter
 Wash the bladder out
 Start anticholinergic drugs
Non traumatic
emergency