Emergency Room

Urology

Dr. Syah Mirsya Warli, SpU

Div. of Urology, Surgery Dept.
Medical Faculty,
University of Sumatera Utara
Ref :

 Clinical Manual of Urology, (Philip M.

Hanno et al eds), McGraw-Hill Int ed,
3rd ed, 2001
 Smith’s General Urology (Tanagho &
McAninch eds), Lange Medical Books,
15th ed, 2000
 Genitourinary Emergencies

 Pain  Oliguria & anuria

 Testicular Torsion  Priapism
 Hematuria  Foreskin
 Urinary Retention emergencies
Pain in the urinary tract
FLANK PAIN
 DD : calculus
pyelonephritis
renal trauma
renal vein thrombosis
cholecystitis
 Pain in the urinary tract
RENAL COLIC
 Sudden onset, no relief with change of position
 Nause & vomiting
 Diagnosis studies :
- urinalysis
- non-contrast CT scan
- plain radiograph
- white count and serum creatinin
- urine culture
- IVP
Indications for admission for renal calculi

 Obstructing stone in a patient with a

solitary kidney
 Fever and infection associated with an
obstructing stone
 Inability to maintain oral hydration
 Pain refractory to oral analgesics
 High-grade obstruction from a stone that is
too large to pass spontaneously
 Pain in the urinary tract
PYELONEPHRITIS
 Onset subacute, constant
 Exacerbated by movement
 Prodrome of cystitis symptoms  clue
 Ask about previous history of urolithiasis,
UTI and urologic surgery
 Pain in the urinary tract
SUPRAPUBIC PAIN
 DD : urinary retention, cystitis
bladder stones, gynecologic problems
interstitial cystitis
 Retention & cystitis must be diagnosed in the
ED
 History : voiding function, gross hematuria,
history of urinary retention
 Palpate the bladder
 Pelvic exam in women is often critical
Testicular Torsion

 Incidence 1: 4000
 Most serious of acute problems affecting the
scrotal contents
 2 peak incidences
– Neonatal period
– Puberty
 Testicular Torsion

 Why does it happen?

– Testes not adequately anchored to the
tunica vaginalis
 Testicular Torsion
Symptom complex
 Sudden onset of severe testicular pain
 Constant & progressive
 Nausea (+)
 Fever, urethral discharge, cystitis symptoms (-)
 Testicular Torsion
Physical examination

– Edematous scrotum
– Tender, swollen testis
– Testis high in scrotum with horizontal lie
 classical sign
– Cremasteric reflex (-)
– “bell-clapper deformity”
– Pain not relieved with elevation of
scrotum
TORSION
 Testicular Torsion:
Diagnosis

 Doppler USG now test of choice for Dx

of torsion. Sensitivity comparable to
radioisotope scans (86%-100%) and
greater specificity (100%).
 Doppler U/S is more rapid and more
available than radioisotope scans.
 Testicular Torsion:
Management

 Immediate Urologic consultation for

surgical exploration and possible bilateral
orchidopexy if diagnosis is obvious
 Manual detorsion  rotating the testicle in
a medial to lateral direction, “open the
book” maneuver
 Emergent surgery is still required to assure
complete detorsion and perform
contralateral orchidopexy
GROSS HEMATURIA

 Etiology :
1. Common cause  infections, stones,
malignancies (bladder, kidney), BPH,
trauma, post op
2. Less common cause  radiation or
chemical cystitis, sickle cell disease,
GNtis, coagulopathy, GI or gynecologic
 GROSS HEMATURIA

 All patients presenting with gross

hematuria must have urologic follow-up,
even if the bleeding spontaneously
resolves. Bladder tumors classically bleed
intermittently and diagnosis can be delayed
if patients are not appropriately counseled
 Urinary Retention
 History :
age, general health
premorbid voiding symptoms
history of urethral strictures
previous episodes of retention
prior urologic manipulation or surgery (TURP, radical
prostatectomy)
medication (sympathomimetics, anticholinergics)
incontinence
 Urinary Retention
Etiology
 Anatomic obstruction :
1. BPH (most common)
2. Urethral stricture
3. Bladder neck contracture
4. Prostate Ca (uncommon)
 Functional obstruction :
1. Neurologic disease (CNS or peripheral)
2. Medication side effect
3. Pain (nociceptive retention)  post op, post trauma
4. Psychogenic
 Urinary Retention :
Management
 16 or 18 F Standard Urethral
Catheter, adequate lubrication of the
catheter
 If fails  Urology consult for SPT
 No patient in retention should be
instrumented, drained, and then
discharged from ED without a clear
plan for urologic follow-up
Oliguria & anuria

 Anuria  urine output < 50 ml / 24 h

 Evaluation & treatment :
- Physical exam & urethral catheterization
- USG  bilateral hydronephrosis
no hydronephrosis
unilateral hydronephrosis
Priapism

 The pathologic prolongation of penile

erection, accompanied by pain &
tenderness
 Not by sexual excitement
 Not relieved by orgasm
Foreskin Emergencies
Phimosis
 The uncircumcised foreskin cannot be
retracted over the glans
 Catheterized with a coude tip
Foreskin Emergencies
Paraphimosis
 The uncircumcised foreskin has been left in
the retracted position  obstruction to
venous & lymphatic drainage  progressive
edema
 True urologic emergency
 Th/ : immadiate manual reduction
 If fail  dorsal slit
Phimosis vs.
Paraphimosis

Phimosis: inability to Paraphimosis: foreskin retracted

retract foreskin behind coronal groove; tourniquet to
Tx: dorsal slit or glans
circumcision Tx: circumcision
Foreskin Emergencies
Zipper Injuries
 Common source of genital laceration
 Th/ : adequate analgesia & disassembly the
zipper
 Using a cutter  median bar of the zipper
is completely cut  the teeth of the zipper
fall apart
Foreskin Emergencies
External rings

 Often used as sexual aids  edema,

urethral fistula, necrosis
 Managed with ring cutter
 Immediate removal of the object &
debridement
 Foreskin Emergencies
Intraurethral foreign bodies
 Evaluate radiographically
 Don’t catheterized  place SPT if retention
 If distal to the external sphincter  object
will be palpable & can often be removed
endoscopically
 If proximal to the sphincter  open
extraction
 Foreskin Emergencies
Post-circumcision complications

 Hematoma  drained by removing a stitch & evacuating

the clot. Replace dressing
 Bleeding
- steady pressure 10 – 15’
- if fail  lidocaine (1:100.000 ephinephrine) & apply
pressure 10 – 15’ more
- skin edges may be cauterized with silver nitrate sticks
- significant bleeding  suture placement under
penile block with lidocaine
Foreskin Emergencies
Post-circumcision complications

 Disruption of incision
- if small  no th/
- if major  place a few interrupted
suture under penile block
 Infection
- uncommon & usually minor
- th/ : oral cephalosporine
wr 2009