Urological emergencies

(or GENITOURINARY or UROGENITAL)

WHAT IS MEANT BY A MEDICAL EMERGENCY?
Any acute condition or disease state that:
 is intolerable and compels the person to seek medical service urgently
 if not urgently treated, deleterious effects would develop
= cases of the casualty unit
(Attendance at any time , Admission at the same time and Attention all the time)

* Character of an emergency:
1. Acute
2. Urgent
3. Intolerable
4. Serious side effects
‫رعرض نًعاعفاخ‬ٚ ‫طرحًهٓا أ تذا‬ٚ ‫هك ف ا٘ ٔقد تشكٕ٘ حصهد يرج ٔاحذِ يش يٍ كاو ضاعّ ٔيش قادر‬ٛ‫ج‬ٚ ‫شُد‬ٛ‫انث‬
‫طرقر‬ٛ‫رج ترحجسِ فٕرا ٔترفعم ذراتعّ نحذ ي‬ٛ‫خط‬
TYPES of UROLOGIC EMERGENCIES
 Acute Infections:
- Acute infections e.g.: acute (pyelonephritis, orchitis, epididymitis, epididymo-
orchitis and prostatitis)
- Abscesses e.g. Renal, perinephric, testicular and prostatic.
- Infected urinoma
 Patient with renal trauma leading to opening in pelvi-calyceal system then
urine not pass in the ureter and go out of the kidney leading to urine
collection around the kidney.
 Only urinoma itself not indication for intervention BUT if infected , it must
be drained at once
- Septicemia and urosepsis : fatal in 30%
sepsis – urosepsis ٍ‫ أخاف يُٓا ْٗ عثارج ع‬complication ‫كم‬
Any surgical operation calssified
according to infection to :
1. Clean 2. Clean infected.
3. Infected.
 Infected wound :
‫ّ ؟؟‬ٛ‫ح ْعًهٓا فٗ انًطانك ن‬ٛ‫ٓا اٖ عًه‬ٛ‫يثال ن‬
infection ٗ‫ؤدٖ ان‬ٛ‫ ف‬stasis ‫ ٔ يٍ ثى ترعًم‬obstruction ‫ ترطثة‬stones ‫اخ‬ٛ‫الٌ يثال عًه‬
intervention ‫ نًا اجٗ اعًم‬recurrent UTIs ‫ تراعرٓا آَا ترعًم‬complications ًٍ‫ يٍ ظ‬prostate ‫ح‬ٛ‫أ يثال نًا اجهٗ اعًم عًه‬
septicemia ‫عًم‬ٚ ٗ‫ ٔ تانران‬pus enter circulation ٌ‫ أل حاجح ْرحصم ا‬infection ‫ر و اعانج‬ٛ‫ط دِ يٍ غ‬ٚ‫نهًر‬
 Acute Obstruction:
1. Renal colic )emergency َّ‫عشاٌ اقٕل ا‬persistant ٌٕ‫ك‬ٚ ‫( التذ‬
Upper UT Obstruction: kidney or ureter by stone, tumor or clot
- Leads to persistent renal colic ( emergency condition ) last for 24h don’t
respond to high dose of opioid analgesics.
persistent # ِ‫يطرجاتش كذ‬opiates ٘‫ّ انرانرّ انراتعّ َذ‬َٛ‫ َٔسٔد يرج انرا‬NSAIDs ‫تُثذا ب‬
Why is it emergency? As renal shut down occurs in 24h
2. Obstructive anuria ‫اَقطاع تٕنٗ حاد‬
- Bilateral obstruction at the same time
- ** Anuria <100ml **Oliguria 100:400ml ** Norma UOP> 400ml
3. Acute urine retention ‫احرثاش تٕنٗ حاد‬
Due to Lower UT obstruction : prostate or urethra
4. Clot retention
5. Obstructed tube or urinary catheter

 Concomitant renal obstruction and infection: (occur at the same time)

- Obstructive pyelonephritis
- Infected hydronephrosis
Obstructed pyelonephritis Infected hydronephrosis

Pathophysiology Acute obs. Followed by infection Chronic obs.then infection occurs by time

US  Minimal hydronephrosis  Moderate to severe hydronephrosis

 Preserved cortex  Atrophied cortex

TTT  JJ stent  PCN ( Percutaneous Nephrostomy)

 Bleeding:
 Hematuria
- Emergency if : Deep, profuse, associated with blood clots
‫ الزو عهطٕل‬retention ‫ر نذرجّ ذكٌٕ جهطاخ ف ذعًم‬ٛ‫ُسف كر‬ٚ acute urinary retention ٌ‫ا‬ٛ‫ ع‬-
.ٖ‫ انهٗ يٕجٕدج د‬clots ٗ‫افع‬
 External bleeding after:
 Penetrating trauma ‫اخ فٕرا‬ٛ‫ذخم عًه‬ٚ
- Trauma of kidney divided into 5 stages but 4&5 are life threatening
 Urologic surgery (revealed by drains)
ٔ ‫قح‬ٚ‫ف تأ٘ غر‬ٚ‫ ٔ الزو أقف انُس‬life threatening condition ‫ذ ٔصم ل‬ٚ‫ف شذ‬ٚ‫ط فحصم َس‬ٚ‫ح نًر‬ٛ‫تُعًم عًه‬
.‫ف‬ٚ‫ح عشاٌ أقف انُس‬ٛ‫ أثُاء انعًه‬nephrectomy ‫يًكٍ ذٕصم اٌ عًم‬
 Internal hemorrhage e.g. intra-peritoneal and retro-peritoneal

 Trauma:
- Renal (especially major and penetrating trauma)

- Bladder rupture (especially intraperitoneal)

- Testicular (especially with testicular rupture)

- Penile fracture

 Acute Vascular Conditions (mainly ischemogenic):

 Testicular torsion (vein & artery)
 Paraphimosis (vein & artery)
 Priapism
- Sustained erection> 4h
- 2 Types : Ischemic ( with severe pain ) & Non ischemic ( no pain)
‫ح‬ٚ‫ٍ نغا‬ٚ‫ر‬ٛ‫حصم فٗ ضٍ يٍ أل االغفال انصغ‬ٛ‫ ت‬ischemic priapism ْٕ ‫جٗ فٗ االضرقثال‬ْٛ ٗ‫ انه‬-
thrombosis in penile ‫ ذعًم‬sickle cell ‫ٍ يرشخص ب‬ُٛ‫ ض‬4 ٔ‫ ا‬3 ِ‫جٗ غفم عُذ‬ٚ ٍ‫ يًك‬،‫انكثار‬
drainage of penis ‫ ذقفم ال‬shaft
 Unilateral renal vein thrombosis or renal artery thrombosis

 Urologic conditions with acute changes of body fluids and electrolytes :

 Trans-urethral resection (TUR) syndrome
 Post-obstructive diuresis

 Relative emergencies: ٙ‫ قذ يُقذر تص يش دنٕقر‬ٙ‫ُْعًهٓا تذر٘ عه‬

 Bladder exstrophy: must treated within 72 hours
 Tumors especially Wilms’ tumor & testicular tumor: immediate
intervention because of spontaneous rupture
  UROLOGIC EMERGENCIES:
 1- HEMATURIA
 Means the presence of more than 3 -5 RBCs / HPF in a
centrifuged urine specimen.!!! (urine sediment)
 Hematuria may be a symptom, a sign or an investigation finding
but is not a literal complaint !
 Hematuria may be:
 Macroscopic (Gross) hematuria(bloody urine)
Eumorphic &
 Microscopic hematuria (microhematuria) (no complain) >3
RBCs/HPF
 Macroscopic (gross) Hematuria is an emergency with:
 Clot retention
 Clot colic (blood clot obstruct ureter)
 Hypotension and shock in cases of ruptured Tumors e.g.
Angiomyolipoma (very vascular tumor may spontaneously
rupture if > 4 cm)
 Anemia necessitating blood transfusion (on doing CBC during
evacuation find HB 3 or 4 which is incompatible with life)
** HB > 4 = compatible with life. ** HB ≤ 4 = incompatible with life.
 Obstruction of the draining tube or catheter by clots
 Bleeding from a solitary kidney (critical)
= (complications or sequels of hematuria)
Evaluation of hematuria:
History :
- Initial or terminal red discoloration of urine means hematuria
- Total red discoloration of urine may be due to other causes e.g. foods, drinks or drugs
( red or coca cola or tea like color )
- Presence of clots = 100 % hematuria (pathognomonic)
- Associated (upper & lower) symptoms e.g. colic, trauma, burning, dysuria etc.
Clinical examination : may suspect or detect the cause of hematuria:
1. General examination e.g.: bleeding tendency
2. Abdominal examination e.g.: PCKD or Wilms’ tumor
3. Digital rectal examination e.g.: BPH or bladder cancer
Investigations:

NOTES
 On doing CT or MRI
must be done with
contrast ??
- Because of urological
tumors (TCC) is flat
tumor not appear
without contrast so
we do with contast to
see small filling
defect.

Treatment:
 Treatment of the cause e.g. litholapaxy or TURP
(Tumor →Nephrectomy ''' Bladder tumor →TURP ''' Stones →Endoscopy)
 Measures for sequels of hematuria e.g.:
1- Clot retention:
e.g. evacuation, continuous bladder wash etc.
2- Life threatening profuse hematuria:
e.g. blood transfusion, angio-embolization etc.
3- Long standing hematuria e.g. supplementation
  2- RENAL COLIC
 Pathogenesis: Acute upper urinary tract obstruction with hyper- peristalsis (of
smooth muscles ) of the calyces, pelvis and/or ureter to overcome obstruction.
 Causes: Passage of crystals, stones, blood clots or the presence of ureteric stricture
 Site:
- At the flank, (in renal angle) radiates to the abdomen along the course of the ureter
- Referred to the ipsilateral testis, hemiscrotum or upper inner thigh
 Nature : colicky, Increased with diuresis, decreased with analgesia.
 Associated symptoms:
 Hematuria
 Irritative LUTS
 GIT symptoms
 Fever
 Anuria
 Differential diagnosis: Very Important
 Biliary colic (right side (RT hypochondrium) , fatty dyspepsia, jaundice etc.)
 Intestinal colic (diarrhea, tenesmus, melena etc.)
 Appendicular colic (RT iliac fossa , tenderness, rebound tenderness & rigidity at
McBurny point etc.)
 Causes of persistent renal colic:
 Obstruction e.g. by impacted stone ( in the same place with back pressure in 2
imaging study sequential between them at least 1 month)
 Urinary tract infection→ only in case of inspissated pus.
 Ureteric wall edema
 Investigations:
 Urine analysis
 KUB radiography
 Abdominal ultrasonography
 ± Abdominal CT

 3- OBSTRUCTIVE ANURIA

 Definition:
Urine output between zero and 100 mL. / 24 hours in adults
or Daily urine output less than 1 mL / kg in infants,
0.5 mL /kg in children and
100 mL in adults
  Synonyms:
* Post-renal anuria * Surgical anuria * Calcular anuria (If due to stones)

 One of emergency if not treated leads to renal failure :

o Pre renal; Hge or burn leads to severe hypotension and shock leads to ATN
o Renal; autoimmune diseases ( SLE , RA, GN , Ig Nephropathy)
o Post renal; obstruction of ureter in one side if one kidney and both sides in 2
kidney→→ surgical emergency
 Causes: complete obstruction of both kidneys or a solitary kidney by:
 Ureteric or renal stones.
 Ureteric strictures (normal ureter 4mm -never cause anuria except impacted
stone even if small or with infection which cause edema in wall of ureter) .
 Malignancy of the bladder, prostate, uterine cervix or retroperitoneum
infiltrating the ureters.
 Iatrogenic during gynecologic, obstetric (vaginal hysterectomy)or abdomino-
perineal surgery as a result of ligation of the ureters.
 History:
 No urination and no desire for it
 Renal pain
 History of recent pelvic operation e.g. gynecologic, obstetric, rectal cancer
surgery or even TVP
 Examination:
 Early: the patient looks normal but biochemically is not (no symptoms but
creatinine (2- 2.5- 3) then become (4, 5, 6, 7,) with:
 Late: manifestations of renal failure e.g. anorexia, nausea,vomiting, loss of
vigor, acidotic breathing, Muddy face, puffy eye. etc.

Dangerous signs: Very Important

 Pulmonary edema (Lung)
 Pericarditis (Heart)
 Brain: encephalopathy & coma
 Bleeding tendency
 Biochemically: hyperkalemia > 7 and serum creatinine > 10 mg/dL
(mostly indicate urgent dialysis)
NOTE === Normal K in blood 3.5 : 5
 Investigations: NOT do Urine Analysis in Anuria ‫ش أصال‬ٛ‫و ْٕ يف‬
 Abdominal ultrasonography
 KUB radiography
 Non contrast abdominal CT or abdominal MRI
 Serum creatinine, potassium and bicarbonate
 Treatment: (Diversion)
 Temporary drainage of kidney/s by: PCN (preferred if there’s pus or marked
hydronephrosis & unfit for anathesia), ureteric catheter or JJ stent ( preferred in
cases not exceed 24 hrs , no infection, creatinine isn’t markedly elevated).
 Temporary dialysis until the condition of the patient is maximized
 Later, treat the cause if treatable and and the patient can withstand the required
intervention
 Permanent kidney/s drainage or permanent dialysis if treatment is not feasible
e.g. advanced prostate cancer

 4- ACUTE URINARY RETENTION

 Definition:
It is the inability to void in spite of full urinary bladder and
severe painful desire for voiding.
 Cause/s at: Infra-vesical
1. External urethral meatus e.g. meatal stenosis (hypospadic or orthotopic)
2. Urethra e.g. Impacted urethral stone
Impermeable urethral stricture
Posterior urethral distraction injury
Posterior urethral valve
3. Prostate e.g. BPH, prostate cancer and prostatic abscess
4. Bladder neck e.g. stone, polyp or tumor
5. Occasions e.g. Obstructed urethral catheter
Reflex retention
Hysterical retention
Hematoclpus in imperforate hymen
Phimosis
 Clinical picture:
A- Symptoms:
 Inability to micturate
 Severe desire to void
 Supra-pubic pain, very rigid and agony
 B- Signs:
 Supra-pubic fullness, dullness and tenderness
 Signs of the cause e.g. palpable urethral stone or BPH
 Treatment:
I- Urgent measures for relief of retention e.g.:
 Urethral catheterization
 If failed or contraindicated → puncture cystostomy tube (supra-pubic drainage)
or
 Urethral catheterization under anesthesia
II- Treatment of the cause e.g.:
 Urethral stone → disintegration
 Prostatic abscess → drainage
 BPH → medical treatment or prostatectomy

** In bladder cancer:
In satge 4, invasion to ant. abd. wall occurs so you can’t do spra-pubic drainage and do surgery
called Urethral catheterization under anesthesia

SOME PECULARITIES OF ACUTE RETENTION OF URINE due to:

1- BPH:
• Spontaneous ; mostly need intervention operation
• Precipitated by 5 Ws (water, wine, weather, woman, withhold)
2- Urethral stricture or prostate cancer infiltrating the urethra:
urethral catheterization is not feasible and do Perminant supra pubic tube with consent
3- Prostate cancer: bilateral orchiectomy may abolish retention
4- Bladder cancer: bilateral PCNs
5- due to intra-thecal morphia: concealed if urologically, urethral catheterization is
otherwise indicated
DIFFERENTIAL DIAGNOSIS OF NON VOIDING PATIENT
1- Anuria (empty bladder)
2- Retention of urine
3- Intra-peritoneal bladder rupture (empty bladder)
4- Coma
5- Acute stage of spinal cord trans-section
 ‫الجدول ده اتذكر فوق قبل كده‬

5- ACUTE RENAL INFECTION (besides renal & peri-renal abscesses)

 Acute pyelonephritis = acute infection of a normal kidney
 Obstructive pyelonephritis = acute infection of an acutely obstructed kidney
 Infected hydronephrosis = acute infection of a chronically obstructed kidney

Acute pyelonephritis require hospital admission in case of:

* Concomitant obstruction
* Conception
* Cases with solitary kidney
* Critically ill patients e.g. diabetics
Acute pyelonephritis, obstructive pyelonephritis and infected hydronephrosis
All cause:
 High grade fever, severe renal pain and tenderness
 Require broad spectrum parentral antibiotics
However, obstruction essentially requires drainage
  8- ANDROLOGIC EMERGENCIES
I- Phimosis
II- Paraphimosis
III- Priapism
IV- Penile fracture
V- Acute scrotum

 I- PHIMOSIS
 Definition: Inability to retract the prepuce
- Intact prepuce (at penile shaft) which is removed in circumcision, in
newborn smegma (which is infection) accumulates under it and if not
removed infection spread along penis.
- If it isn’t removed urine is collected in closed space causing urine retention.
 Etiology: Narrow preputial opening or adhesions between the prepuce and glans.
It may be congenital or acquired
 Clinical picture:
1. Difficulty of micturition
2. Narrow urine stream
3. Ballooning of the prepuce during micturition
4. It is an emergency if it caused acute urine retention
 Treatment: Circumcision

 II- PARAPHIMOSIS
 Definition: constriction of the glans by the retracted prepuce
 Sequels: venous congestion → edema → more constriction → more
congestion → more constriction → arterial obstruction
 Clinical picture:
* occurs with retraction of the
prepuce for any purpose
– especially if it is narrow – and
not returned again or removed
(iatrogenic)
* The bare glans acquires edema,
congestion, swelling and later
becomes bluish and may get
gangrenous and slough
DD: Hair tie
o This is an occasional emergency where fallen hair/s encircles the
coronal sulcus, and is spontaneously tied and constricts the glans.
o It is encountered in already circumcised infants, young boys and
those who are mentally retarded.
o The glans becomes edematous, congested and ischemic.
o It requires urgent untying in situ and removal (under anesthesia and child is
completely sedated).
o Using magnifying loop before removal to show if completely cut then remove it and
sterile in its space and using catheter, wait 10- 14 day to know outcome until edema
subside .
o If neglected, it may lead to urethro-cutaneous fistula or even necrosis and sloughing
of the glans.

 III- PRIAPISM
 Definition: It is a persistent, painful and purposeless erection that lasts more than
four hours without a sexual desire
 Types:
1. Ischemic (veno-occlusive, low flow) = emergency (full erection, pain, very hard)
2. Non-ischemic (arterial, high flow) = not emergency (no pain not fully erected)
3. Stuttering (intermittent)
 Causes:
I. Idiopathic: 35%
II. Drug induced:
a. Penile injections of papaverine, protaglandin or phentolamine
b. As a complication of PDE 5 inhibitors( in erectile dysfunction) e.g. sildenafil
c. Other drugs: antihypertensives , anticoagulants & antipsychotics
III. Medical diseases:
a. Blood disorders e.g. sickle cell disease and leukemia
b. Spinal cord injury and multiple sclerosis
IV. Scorpion bite

 Pathology: (Potential sequelae) whatever the cause, the same mechanism.

 Clotting and thrombosis of the blood (in venous drainage) retained in the penis
 Damage to the blood vessels of the penis
 Ischemia and fibrosis of the cavernous tissue (as citrate is released due to stasis)
 Permanent loss of erectile function
NOTE
 4 : 8 hrs all sequelae is presented and patient can be treated without any problem
 8 : 12hrs = 30% erectile dysfunction
 >12hrs = 90%
 >24hrs = 100%
.ّٛ‫ك قع‬ٛ‫رفع عه‬ْٛ ‫ّ تكذِ ٔاال‬ٛ‫حصهّ يشكهّ ذًع‬ْٛ ٕ‫ّ عشاٌ ن‬ٚ‫شُد اْى حاجّ ذطانّ تقانّ قذ ا‬ٛ‫هك انث‬ٛ‫ج‬ٚ ‫عشاٌ كذِ نًا‬

 Treatment:
Early treamtnet is very important for fear of impotence if priapism is neglected.
a. Drainage and intracavernosal vasoconstrictor injection
- Aspirate 50ml of blood from each corpus cavernosum through wide bore syringe
until become fresh blood.
- If erection persists; injection of vasoactive material (phenylephrine) dilute
ampule on 10 cm every 4 min evacuate blood inject 1 cm.
- If erection disappear it’s called detumescence.
- Keep under observation
b. Surgical shunts: If ampule finish but sustained erection do shunt
 Corporo- corporal shunts:
 Distal shunt
 Proximal shunt
 Sapheno-corporal shunt
Once patient do shunt →→ erectile dysfunction for life.
c. Blood transfusion