Emergency in Urology

Emergency in Urology
dr. Fakhri Rahman, SpU

October 24th, 2021
Outline
Obstructive uropathy
Urological Trauma
Urinary Retention
Paraphimosis
Penile Fracture
Priapism
Testicular Torsion
Obstructive Uropathy
Obstructive Uropathy
Definition:
Functional or anatomic obstruction of urinary flow at any level of
the urinary tract
Involves in 10% of the acute renal failure causes and 4% of

ESRD cases
Pathophysiology
Affecting
excretion Irreversible
Urinary Tract Tubular pressure
function and renal
Obstruction changes
renal impairment
homeostasis
Mourmouris PI, Chiras T, Papatsoris AG. Obstructive uropathy: From Etiopathology to Therapy. World J Nephrol Urol. 2014 March 3(1):1-6
RENAL
Congenital Polycystic kidney, renal cyst, peripelvic cyst, UPJO
Possible Causes of
Neoplastic Wilms tumor, RCC, multiple myeloma, transitional cell carcinoma of collective
Obstructive Uropathy system
Inflammatory TB, Echinococcus infection
Metabolic Stone
Miscellaneous Sloughed papillae, trauma, renal artery aneurysm
URETER
Congenital Stricture, ureterocele, obstructive megaureter, retrocaval ureter, prune-belly syndrome
Neoplastic Primary carcinoma of ureter metastatic carcinoma
Inflammatory TB, Amyloidosis, schistosomiasis, abscess, ureteritis cystica
Miscellaneous Retroperitoneal fibrosis, aortic aneurysm, radiation therapy, lymphocele, trauma,

urinoma, pregnancy, pelvic lipomatosis
BLADDER AND URETHRA

Congenital Posterior urethral valve, phimosis, hydrocolpos
Neoplastic Bladder cancer, prostate cancer, carcinoma of urethra, carcinoma of penis
Mourmouris PI, Chiras T, Papatsoris AG. Obstructive

Inflammatory Prostatitis, paraurethral abscess
uropathy: From Etiopathology to Therapy. World J Nephrol
Urol. 2014 March 3(1):1-6 Miscellaneous BPH, Neurogenic bladder, urethral stricture
UUO vs BUO or Solitary
Bilateral obstruction or solitary kidney

may lead to anuria
GFR significantly decreases in relevance

with the degree of obstruction due to
non-existent healthy kidney
No compensatory mechanism
Wein AJ, Kavoussi LR, Meredith F. Campbell-Walsh Urology.

12th ed. Philadelphia, PA: Elsevier Saunders, 2016.
Evaluation
History taking: Physical Examination
• Wide range symptoms, depend • General examination
on:
• Acute / chronic • Evaluate every signs related to
• Unilateral / bilateral the causes of obstructive
• Cause of obstruction (extrinsic vs uropathy
intrinsic)
• Complete / partial obstruction
• Presence or absence of infection
• Compliance of collecting system
DynaMed . Urinary tract obstruction and hydronephrosis
Supporting examinations:
Lab parameters: Imaging:
• CBC • Ultrasound
• Urinalysis • KUB radiography
• Creatinine • Renal scan
• Ureum • CT-Scan
• Electrolyte • MRI
Hydronephrosis Imaging
Ultrasound CT-Scan
Hydronephrosis. Radiopaedia.org
Emergency surgical indications
– release obstruction :
• Bilateral obstruction or unilateral obstruction in solitary kidney
• Urosepsis
• Uremia
• Hyperkalemia
• Persistent Renal Colic
• Worsening of hydronephrosis and renal impairment
Releasing options:
Upper tract  JJ Stent, Percutaneous Nephrostomy
Lower tract  Urethral catheterization, suprapubic
catheterization
Wein AJ, Kavoussi LR, Meredith F. Campbell-Walsh Urology. 12th ed. Philadelphia, PA: Elsevier Saunders, 2016.
Management of Uropathy Obstructive
Principles:
• Relief pain
• Recover or maintain renal function
• Avoid complication
Increase of the pressure within distention of ureteral wall / renal

Pain
collecting system capsul
Pain medications:
NSAID  help decrease inflammation and pressure, not recommended in patients with renal insufficiency
Acetaminophen
Narcotic analgesics
Alpha-blockers (ureter relaxation, encourage urinary stone expulsion)
Corticosteroids
Surgical approach for definitive treatment  refer to urologist
Urological Trauma
Renal – Ureter – Bladder - Urethra
Urological Trauma
Trauma is defined as
physical injury or a wound to living tissue caused by an extrinsic agent
Renal
Upper trauma
urinary tract Ureter
Urological trauma
Trauma Bladder
Lower trauma
urinary tract Urethral
trauma
Kitrey ND, Djakovic N, Hallscheidt P, Kuehhas FE, Lumen N, Serafetinidis E et al.EAU Guidelines on Urological trauma. 2021
Renal Trauma
• Causes:
• Blunt injuries : MVAs, falls, sporting injuries, assault
• Penetrating injuries: stab, gunshot wounds
• Classification (AAST renal injury grading scale)
GRADE I GRADE II GRADE III
GRADE IV – Laceration extending GRADE V – Complete shattered

through collecting system kidney and avulsion of renal hilum
Imaging
• FAST (Focused assessment
with sonography for trauma)
• Abdominal and pelvis CT (IV
Contrast enhanced)
• IV Pyelography (IVP)
Indication:
(Arrow) subcapsular hematoma
• Visible hematuria
• Non-visible hematuria + one
episode of hypotension
• Penetrating trauma
• A History of rapid deceleration
injury and/or significant
associated injury
• Clinical sign suggesting renal
injury
IVP demonstrates poor visualization of left kidney
(Arrow) Laceration extending to collecting system
(post-trauma)
Kawashima A, Sandler CM, Corl FM, West OC, Tamm EP, Fishman EK et al. imaging of renal trauma: a comprehensive review. Goldman RadioGraphics;200121(3):557-74
Ureteral Trauma
• Relatively rare
• Causes:
• Penetrating injury (such as gunshot wound)
• Blunt injury (MVAs) – direct or indirect (deceleration mechanism)
• Iatrogenic injury due to various procedures
Imaging
1-shot IVP CT with IV contrast
Evaluation – Upper Urinary Tract Trauma
• Primary survery (A-B-C-D-E) – secondary survey (Head to Toe)
• Hemodynamic stabilization
• Evaluate:
• Vital signs
• Physical examinations:
• Renal trauma : flank bruising, stab wounds, bullet entry, exit wound, abdominal tenderness,
hematuria
• Ureteral trauma: flank pain, urinary incontinence, vaginal or drain urinary leakage, hematuria,
fever, uremia, urinoma
• Find the evidence of rib fracture (related with renal injuries)
• Examine the genitalia (look for blood , perineum, urethral meatus)
• Work-up: urinalysis , CBC, creatinine
• Hematuria (visible or non-visible) is the key finding
Dynamed. Renal and Ureteral trauma management
Management – Renal Trauma
Management – Ureteral Trauma
• Ureteral trauma patients often in unstable condition 
• may require emergent exploratory laparotomy (surgical exploration and repair)
• Some patients might require stenting
Pain medications:
• Fentanyl 1-2 mcg/kg IV
• Morphine 0.1 mg/kg IV
Dynamed. Ureteral trauma management
Bladder Trauma
• Primarily classified according to the location of injury:
• intra peritoneal  associated with sudden rise in intravesical pressure of a distended bladder
• Extraperitoneal  almost always associated with pelvic fractures
• combined intra-extralperitoneal
• Causes:
• Non-iatrogenic (blunt and penetrating)
• Iatrogenic (external and internal)
Dynamed. Bladder trauma management
Imaging
• FAST ultrasound
• cystogram
• CT cystogram
• CT with IV contrast • CT scan with contrast showed contrast
extravasation (arrow) from the bladder

Cystography
Extraperitoneal Bladder Rupture Intraperitoneal Bladder Rupture
CT cystography – Extraperitoneal Bladder Rupture CT cystography – Intraperitoneal Bladder Rupture
Evaluation – Bladder Trauma
• Primary survery (A-B-C-D-E) – secondary survey (Head to Toe)
• Hemodynamic stabilization
• Evaluate:
• History: abdominal and/or pelvic pain ; anuria, dysuria and/or hematuria
• Vital signs
• Physical examinations:
• Pelvic instability, abdominal tenderness
• Gross hematuria
• Work-up: urinalysis , CBC, creatinine
Management – Bladder Trauma
Pain medications: Fentanyl 1-2 mcg/kg IV ; Morphine 0.1 mg/kg IV
Prophylactic antibiotics: recommended for bladder ruptures
• Fluoroquinolone (or 3rd gen cephalosporine) and metronidazole 500 mg IV/8-h
Specific management
a) Bladder contusions (no urine extravasation)
• Supportive care
• Placement of foley catheter for continuous drainage of the bladder
b) Extraperitoneal bladder ruptures
• Expectant management with continuous bladder drainage
• Prophylactic antibiotics
• Coexisting rectal, vaginal, or bladder neck injury requires surgical repair
c) Intraperitoneal bladder ruptures
• Operative repair (due to risk of peritonitis)
Urethral Trauma
• Can be first classified based on location:
• Anterior
• Posterior
• Most common location of urethral trauma : bulbar part
Etiology
Traumatic Non Traumatic
• Blunt/penetrating trauma • Iatrogenic i.e. transurethral

• Motor vehicle trauma instrumentation, improper urethral
• Straddle injuries catheterization, forced removal of urethral
catheter
• Pelvic fractures – most common in
posterior urethral trauma
AAST Urethral Injury Scale
Imaging
Retrograde Urethrography (RUG)
Urethral injury and rupture of corpus cavernosum in Urethral injury and rupture of posterior urethra
retrograde urethrogram in retrograde urethrogram
U: Urethra; CC: Corpus Cavernosum
Evaluation
• History of trauma, mechanism of injury

History • Symptoms: urinary retention, bloody urethra, hematuria, dysuria
• Blood from meatus urethra

• Distended bladder
Physical Examination • Butterfly hematoma
• Rectal touche: high-riding prostate, rectal laceration
• Retrograde urethrogram (gold standard): extravasation to

Work-up cavernous body/perineum
• Cystourethroscopy, USG
Management
Anterior Posterior
• Immediate exploration and • Early urethral management (less
urethral reconstruction than 3 weeks)
• Urinary diversion : • Immediate urethroplasty (<48
hours) – not recommended
transurethral/suprapubic
• Early urethroplasty (2 days-6
weeks)
• Early re-alignment
• Deferred management (after 3
months)
Urethral Trauma Management-
EAU Guidelines Figure
Urinary Retention
Urinary Retention
Definition: The inability to voluntarily pass an adequate amount of urine
Classification based on the anatomical etiology
Supravesica
Vesica
Infravesica
Differential Diagnosis
Supravesica Vesica Infravesica
• Diabetes mellitus • Bladder cancer • Prostatic obstruction

(neuropathy) • Bladder stone (BPH, Cancer,
• Trauma (iatrogenic / non • Clot retention Prostatitis)
iatrogenic) • Drugs • Bladder neck contracture
• Other neurological • Urethral stricture
disease • Urethral compression
• Phimosis / Paraphimosis
• Drugs
Acute vs Chronic Urinary Retention
• Pain
• Less pain / no pain
• Pain • > 800 ml / > 1000 ml
• Pain • Hesitancy
• Overflow incontinence
Evaluation
• History taking  REMEMBER DIFFERENTIAL DIAGNOSIS
• Exam:
• Physical exam:
• Bladder: tender, palpable (≥200 ml), percussable bladder
suprapubically (≥ 150 ml)
• Digital rectal exam (DRE)
• Anal tone and bulbocavernous reflex (BCR)  possibility of
neurogenic bladder (bladder underactivity)
• Prostate size / contour / pain
• External genitalia
Full Bladder Blood Clot
Very useful
examination! •Bladder ultrasound
Other exam
• Prostate ultrasound
• Laboratorium: Ur/Cr, urinalysis
• Renal ultrasound  upper tract dysfunction
• MRI  concern of acute spinal injury
• PSA (only for man)  deferred during AUR / after catheterization
• Retrograde urethrography / bipolar (if stricture is suspected)
Urinary
Diversion
• Transurethral
• Suprapubic
• Percutaneous
• Open
Picture from: https://community.paraplegie.ch/en/wiki-en/bladder-

bowel/indwelling-catheter
Urethral Catheterization
• Urethra
• Male: 18-20 cm;
average meatus 24 Fr;
prostatic urethra 32 Fr;
bladder neck 28 Fr
• Female: 4 cm
• Contraindication
• Absolute:
• urethral injury;
• history of bladder neck
closure
Wein AJ, Kavoussi LR, Meredith F. Campbell-Walsh Urology. 12th ed. Philadelphia, PA: Elsevier Saunders, 2016.
Urethral Catheter
Number of
ports Type
Wein AJ, Kavoussi LR, Meredith F. Campbell-Walsh Urology. 12th ed. Philadelphia, PA:
Elsevier Saunders, 2016.
Urethral Catheter
Size -
Material
Latex – 2 weeks
Silicone – 4 weeks
Gross Hematuria with Clot Retention
Gross hematuria : presence of visible blood in the urine
• Should be distinguished from other causes:
• Myoglobinuria
• Hemoglobinuria
• Drugs (Rifampicin)
• Dietary causes (beets)
Amount of blood in the bladder > ability of the urinary urokinase

Urinary clots
Outflow blockage
Management :
• Placement of large urethral catheter ( 22 Fr or larger)
• Irrigation with 0.9% normal saline and catheter tipped syringe
If the obstruction still occurs,
• Cystoscopy and clot evacuation in the operative setting
Once urine has cleared:
continuous bladder irrigation (CBI) with 0.9% normal saline through a three way catheter, titrated to achieve clear or very light pink urine
Purpose  prevent further clotting
Paraphimosis
Paraphimosis
Definition
When tight and/or phimotic foreskin is
retracted over the glans penis and cannot
be returned into the normal position.
Tight ring proximal to the edema and necrosis of the

progressive venous congestion
corona ulceration glans penis.
Atlas of Male Genitourethral Surgery: The Illustrated Guide, 1st ed. 2014
Management
• The foreskin should be pulled back into the normal anatomic
position
• Reduce the edema between the phimotic ring and the corona by
gentle manual compression or placing ice
If cannot be reduced manually:

• A ring block or penile nerve block using 1% lidocaine is
performed.
• A 25-gauge then puncture the edematous tissue (red arrow)
in several places to allow fluid to drain.
• Digital pressure is then applied to the edematous foreskin
until the fluid has drained out.
Manual Reduction
Surgical Approach
Failure of manual compression  surgical intervention
Penile Fracture
Penile Fracture
• Rupture of tunica albuginea in penis
• Occurs  the penis is buckled during
sexual intercourse
• The penis inadvertently impacts against the
pubic bone or perineum.
• There are also cases of men forcibly
snapping the penis during masturbation in c. tunica albuginea
order to produce rapid detumescence
Evaluation
• Patient history
• Find out the mechanism of injury
• The classic presentation for a penile fracture:
• Sudden severe penile pain
• A simultaneous ‘cracking’ or ‘popping’ sound
• Immediate detumescence and the inability to carry on with
sexual intercourse.
• Gross swelling and haematoma of the penis (‘Aubergine sign’
or ‘Eggplant sign’)
• Suspected urethral injury when blood appears at the
urethral meatus.
• Physical Examination:
• Swollen and bruising penis
• limited to the penis if Buck’s fascia is intact
Extensive hematoma and bruising with a classic “Aubergine sign”
• may extend to the scrotum, perineum and lower abdominal wall if Buck’s fascia is or swelling restricted to the penile shaft “ Eggplant sign”
breached.
• A tender, palpable defect may be felt over the ruptured area of the tunica
albuginea
• The commonest site of injury is ventro-lateral  the tunica albuginea is thinnest
• There may be blood at the urethral meatus, haematuria, pain on voiding, or
urinary retention  if the urethra is also injured
Rees RW, Brown G, Dorkin T, Lucky M, Pearcy R, Shabbir M, Shukla CJ, Summerton DJ, Muneer A. BJU Int. 2018 Jul;122(1):26-8
MRI – Penile Fracture
Imaging
Ultrasonography of the penis may help identify both the
location and extent of the tunical rupture.
Cavernosography – Penile Fracture
Rees RW, Brown G, Dorkin T, Lucky M, Pearcy R, Shabbir M, Shukla CJ, Summerton DJ, Muneer A. BJU Int. 2018 Jul;122(1):26-8
Gupta N, Goyal P, Sharma K, et al. Transl Androl Urol. 2017;6(3):580-4
Guler, Ibrahim et al. The value of magnetic resonance imaging in the diagnosis of penile fracture. International braz j. 2015; 44(2): 325-8. 5538.IBJU.2015.02.20.
Management
• An urgent exploration and repair of the tunica
albuginea  prevent later penile curvature and
erectile dysfunction
• For a high index of suspicion for a urethral injury,
either an on-table urethrogram or a flexible
cystoscopy can be performed to visualize the extent
of the urethral injury
Priapism
Priapism
• A persistent penile erection with a duration of longer than 4
hours in the absence of sexual stimulation and persists despite
ejaculation.
• Priapism is classified as,
• ischemic (low flow)
• nonischemic (high flow)
• intermittent (stuttering)
• The longer the duration, the greater the degree of smooth
muscle dysfunction due to necrosis  cavernosal fibrosis.
Hatzimouratidis K, F. Giuliano, I. Moncada, A. Muneer, A. Salonia, P. Verze et al. EAU guideline on sexual and reproductive health. 2021
Classification
Low flow High flow
Ischemic Non ischemic
Venous obstruction Increase arterial flow
Pain>> Pain<<
Penile blood abnormality Penile blood within normal
More common Less common
Associated with systemic disorder (hematologic Associated with trauma

condition), pharmacologic agent and
malignancy
Differential diagnosis
Management - Treatment of ischaemic priapism
BAUS Section of Andrology Genitourethral Surgery, Muneer A, Brown G, Dorkin T, Lucky M, Pearcy R, Shabbir M, Shukla CJ, Rees RW, Summerton DJ. BJU Int. 2018 Jun;121(6):835-839.
Aspiration
Aspiration of blood from the corpus cavernosum can
be performed using a 21-G butterfly needle directly
into the corpus cavernosum or inserted into the
corpus cavernosum through the glans penis.
• Aspirate until the penis is flaccid

• Inject more phenylephrine and cap
the needle/ syringe for a few minutes.
• Perform a few cycles of aspiration and
injection of phenylephrine, and if no
sustained detumescence is achieved,
move to irrigation.
Injection of Sympathomimetic
• The instillation of α adrenergic agonists  induce contraction of the corpus
cavernosum and the helicine arteries  reduce the volume of stagnated blood 
relieve the pressure on the subtunical venules  detumescence.
• Administer 1000 μg per injection for a patient with a fully rigid erection and using lower
doses (250–500 μg) for men with an erection that is just about penetration hardness
• Inject the phenylephrine slowly and repeat at 5–10 min intervals
• Careful monitoring of the patient’s blood pressure is required as the adrenergic effects
of the drug on the systemic circulation can lead to systemic hypertension
Shunt
The Ebbehoj A Winter The T-shunt
procedure shunt
Inserts a No 11
Creates a shunt blade through the
Similar to the
glans penis
between the Ebbehoj
Rotates this 90°
glans penis and procedure
away from the
the corporal except that a urethral meatus
head by Tru-Cut needle is
inserting a No 11 inserted into the Failure to achieve
scalpel through glans and corpus detumescence
the glans penis cavernosum leads to the surgeon
and into the tip attempting the same
of the corpus procedure on the
cavernosum. opposite side
Garcia MM, Shindel AW, Lue TF. BJUI 2008; 102(11): 1754–64
Assessment
• Doppler ultrasound  show poor perfusion in the

corpus cavernosum
• Aspirating blood from the corpus cavernosum
which is typically hypoxic and acidotic.
Non-Ischaemic Priapism
• The initial management can be conservative.

• If a fistula is demonstrated then duplex compression of the fistula can
be performed.
• Failure of resolution  refer to a specialist for superselective
arteriography and embolization
Testicular Torsion
Testicular Torsion
• Characterized by a sudden onset of severe pain in the hemi-
scrotum which often radiates to the lower abdomen or flank.
Types:
A. Extravaginal
B. Intravaginal
Testicular blood vessels are twisted Impaired venous Hemorrhagic Necrosis of the
relative to the tunica vaginalis outflow infarction testicle
Clinical Features
• Unilateral inguinal and/or scrotal swelling
• The testicle may be lying in an abnormal
position – high in the scrotum and/or
horizontal.
• Transillumination negative
• Absent of cremasteric reflex
• Phren sign negative – (Pain does not relieve
after the elevation of the scrotum)
Acute scrotal pain
–
Elevate the scrotum
negative Positive
Testicular Epididymitis
Torsion
Ekstravaginal Torsio Intravaginal Torsio
• In neonates, extravaginal torsion predominates, with More common in older children and adults
the entire cord, including the processus vaginalis,
twisting
• Poor prognosis
The bell-clapper deformity  abnormal fixation

of the tunica vaginalis to the testicle 
in increased mobility of the testicle within the
tunica vaginalis
Callewaert PR, Van Kerrebroeck P. Eur J Pediatr. 2010;169(6):705–12.

Favorito LA, Cavalcante AG, Costa WS. Int Braz J Urol. 2004;30(5):420–4.
How to Assess the Viability of Testis
during Surgery
80-100% decrease in volume and production
Grimsby GM, Schlomer BJ, Menon VS, Ostrov L, Keays M, Sheth KR, et al. Prospective evaluation of predictors of testis atrophy after surgery for testis torsion in children. Urology 2018;116:150–5
Diagnosis - Imaging
• To differentiate with other acute scrotum  Doppler USG or penile
scintigraphy
The absence of blood

flow in the testicle
Management
Prompt restoration of blood flow to the ischemic testicle 

emergency scrotal exploration under general anesthesia
Both testicles are then fixed in the scrotum by

Untwisting of the spermatic cord suturing the tunica albuginea to the dartos
muscle
Surgical management
Management
• Manual detorsion should be attempted if surgery is

not an immediate option or while preparations for
surgical exploration are being made, but should not
replace surgical exploration
• Orchidectomy only done if there is subsequently no
sign of perfusion after scrotal exploration
• The testes can be salvaged for up to 6 hours after
torsion
Acknowledgement
• dr. Claudio Agustino
THANK YOU

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dr. Fakhri Rahman, SpU

Involves in 10% of the acute renal failure causes and 4% of

Congenital Stricture, ureterocele, obstructive megaureter, retrocaval ureter, prune-belly syndrome

Neoplastic Primary carcinoma of ureter metastatic carcinoma

Inflammatory TB, Amyloidosis, schistosomiasis, abscess, ureteritis cystica

Miscellaneous Retroperitoneal fibrosis, aortic aneurysm, radiation therapy, lymphocele, trauma,

BLADDER AND URETHRA

Mourmouris PI, Chiras T, Papatsoris AG. Obstructive

Bilateral obstruction or solitary kidney

GFR significantly decreases in relevance

Wein AJ, Kavoussi LR, Meredith F. Campbell-Walsh Urology.

Increase of the pressure within distention of ureteral wall / renal

Surgical approach for definitive treatment  refer to urologist

• Classification (AAST renal injury grading scale)

GRADE IV – Laceration extending GRADE V – Complete shattered

• Some patients might require stenting

Dynamed. Bladder trauma management

• Blunt/penetrating trauma • Iatrogenic i.e. transurethral

• History of trauma, mechanism of injury

• Blood from meatus urethra

• Retrograde urethrogram (gold standard): extravasation to

Classification based on the anatomical etiology

Supravesica Vesica Infravesica

• Diabetes mellitus • Bladder cancer • Prostatic obstruction

Picture from: https://community.paraplegie.ch/en/wiki-en/bladder-

Amount of blood in the bladder > ability of the urinary urokinase

Tight ring proximal to the edema and necrosis of the

If cannot be reduced manually:

Failure of manual compression  surgical intervention

Cavernosography – Penile Fracture

Ischemic Non ischemic

Venous obstruction Increase arterial flow

Penile blood abnormality Penile blood within normal

More common Less common

Associated with systemic disorder (hematologic Associated with trauma

• Aspirate until the penis is flaccid

• Inject the phenylephrine slowly and repeat at 5–10 min intervals

• Doppler ultrasound  show poor perfusion in the

• The initial management can be conservative.

The bell-clapper deformity  abnormal fixation

Callewaert PR, Van Kerrebroeck P. Eur J Pediatr. 2010;169(6):705–12.

80-100% decrease in volume and production

The absence of blood

Prompt restoration of blood flow to the ischemic testicle 

Both testicles are then fixed in the scrotum by

• Manual detorsion should be attempted if surgery is

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