UROGENITAL

EMERGENCIES

DIVISION OF UROLOGY, DEPARTMENT OF SURGERY

MEDICAL FACULTY
HASANUDDIN UNIVERSITY
MAKASSAR
2020
PHIMOSIS AND PARAPHIMOSIS
 PHIMOSIS

The contracted foreskin or

prepuce can not be retracted
over the glans

PARAPHIMOSIS

The foreskin, once retracted

over the glans, can not be
replaced in its normal position
 PHIMOSIS

Etiology :
1.Congenital abnormality
2.Inflammation due to infection
3.Traditional circumcise
•Emergency 
posthitis or
balanoposthitis

•Delayed to treat 
urinary extravasation
(penis, scrotum, perineum)
 TREATMENT
1. No infection : circumcision (dorsumcision –
circumcision)
2. Phimosis with infection and urinary
extravasation :
• Dorsumsicion / a dorsal slit
• Inserted catheter
• Multiple incision on urinary infiltrate
• Antibiotic – anti inflammation- analgetic
• Definitive operation / circumcision when
infection and inflammation have subsided
 If More
the than one or progresses
condition two hours 
Painful
arterial
oedema and impossible
occlusion
and and to retract
necrosis
enlargement of theof
PARAPHIMOSIS the prepuce glans
 TREATMENT

1. Early Stage : Conservative

• Pull the prepuce down
over the glans
• If successful 
circumcision should be
done after inflammation
has subsided
 TREATMENT

2. Late Stage : Surgical

• If conservative
unsuccessful
• A dorsal slit  release the
constriction
• Returned to normal
condition  circumcision
 CIRCUMCISION

The operation is carried out of prepuce,

skin and mucosa which covered up the
glans penis
ADVANTAGES OF CIRCUMCISION

1. It’s a great satisfaction to know that he is a

religious
2. Adequate penile hygiene  prevent to infection
& penis carcinoma
3. Prevent to cervix ca. for his wife.
4. Carcinoma of the cervix is less frequent in
women whose husbands have been circumcised
5. The circumcised penis seems courageous
 INDICATION

1.To make adequate penile cleanliness and good

hygiene and can be maintained to prevent
infection and penile cancer
2. Religious and cultural reasons
3. Medical: redundant prepuce, phimosis, paraphimosis,
recurrent posthitis/balanoposthitis
CONTRAINDICATION

Hypospadia

Epispadia

Chordee penis
 TECHNIQUE
CIRCUMCISION
1. DORSAL SLIT CIRCUMCISION
(DORSUMCISION – CIRCUMCISION)

2. SLEEVE TYPE CIRCUMCISION

3. GUILOTINE TYPE CIRCUMCISION

GUILLORONE
1. Sterile minor surgery set
PREPARATION
2. Antiseptic solution, Betadine
3. Procain / xylocain 1-2%
4. Adrenalin / antihistamine
5. 5 ml syringe
6. 3/0 absorbable suture / cat gut
7. Size 7-8 surgical glove
8. Sterile gauze
DESINFECTION
DRAPPING
DORSAL SLIT CIRCUMCISION
(DORSUMCISION – CIRCUMCISION)
SLEEVE TYPE CIRCUMCISION
GUILOTINE TYPE CIRCUMCISION
GUILLORONE
TECHNIQUE TO MAKE SYMMETRICAL AND BALANCE OF PENIS

• Dorsal and ventral skin and

mucosa on mid line are
approximated and sutured.
Retracted to ventral and
dorsal
• Lateral skin and mucosa
(right and left side) are
approximated with
continuous or interrupted
suture of plain no 3/0 cat gut
1. Hemorrhages
2. Infection
3. If excision of the skin is
abundant :
The wound is opened
He will feel pain when the
penis is erection
4. Urethral fistel  injury to
urethra when mucosa
corona is excised
MANAGEMENT POST CIRCUMCISION

• Antibiotic, analgesic and anti

inflammation drugs
• The wound must be free water or
urine
• Keep the external genitalia area clean
• If there are hemorrhages, back to
doctor
PRIAPISM
• Painful persistent of penile erection without
sexual stimulation or desire sexual intercourse
• > 4 hours
• Classified:
• ischaemic (low flow)  more common and urological
emergency
• non ischaemic (high flow)
• Any age group but between 5 - 10 years in
children and 20 - 50 years in adults
Etiology :

1. Obstruction of the venous drainage

a. Tumor around the base of the penis
b. Venous thrombosis in blood disease (sickle
cell anemia, leucaemic)
c. Primary carcinoma of the corpora cavernosa
d. Penile trauma  thrombosis of the dorsal
vein of the penis
2. Neurogenic stimulus
• Cerebro spinal syphilis or tbc
• Injury to the brain or spinal cord
3. Medication. Oral or intra cavernous injection
therapy for impotence
Classification
Low flow or • Most common
• Penis Fully Erect
Ischaemic • Painful sec to tissue ischaemia and smooth
muscle hypoxia (compartmen syndrome)
(veno- • Blood gases from corpora  acidosis, hypoxia,
hypercapnia

occlusive) • Emergency management required

• Less common
High flow / •
•
Due to penile, perineal or pelvic trauma
Usually penis not fully erect and painless
non ischaemic •
•
Normal local blood gas
No risk of ischemia and subsequent fibrosis
(arterial)
Penile Diagnostic
• Aspirate from cavernosum tested for ABG
• Color Duplex Ultrasound  can be used as an
alternative to aspiration and ABG
• Ultrasound  can diagnose anatomical
abnormalities associated with non ischaemic
variety
• Penile arteriography
TREATMENT

1. Ice bag, sedative and anticoagulants are tried first,

may induce subsidence of the erection
2. Epidural / spinal or general anesthesia can also be
used
3. Corporal aspiration
4. Anti androgenic treatment with stilbestrol 5 mg t.i.d.
for a few days may help in mild cases
5. Surgery :
a. A shunting fistula between the glans penis and
corpora cavernosa
b. Corpora cavernosa-saphenous shunt
TESTICULAR TORSION
• Twisting of the spermatic
cord leading to decreased
blood flow to the testicle
resultin ischaemic,
infarction and tissue
necrosis
• Urological emergency 
early diagnosis and
treatment are vital to
saving the tersticle and
future fertility
ETIOLOGY
Predispose factors :
1. Cryptorchismus
• Abscens of Gubernaculum
• High mobility of testicle
• Abscens of tunica vaginalis
2. Hydrocele
• High mobility of testicle intravaginal
3. Cremaster muscle spasm
4. Bell clapper deformity
• The testicle, epididymis and cord completely surrounded by
the tunica vaginalis
INITIATING FACTOR

1. Cremaster muscle suddenly contraction :

• Cough
• Sudden cold weather
2. Over physical exercise / activity
3. Trauma
4. Sometime occurs during sleep
PATHOLOGY & PATHOGENESIS
• Extravaginal
The entire testis and its covering tunica vaginalis
within the scrotum  twisting of the spermatic
cord near the external inguinal ring
• Intravaginal
Bell clapper deformity, in this case twisting of
spermatic cord intra vaginally
 Right testis : clockwise
 Left rotate : counter clockwise
 Predispose factors

Initiating factors

Venous occlusion

1-2 hours

Oedema / swelling

3-4 hours

Arterial occlusion

6-12 hours

Testicle necrosis
/ infarct
CLINICAL FINDING
• Sudden acute pain
• Referred pain
• Swelling and oedematous
• Nausea and vomiting
• Cremaster reflex  absent
• Pathognomonic sign :
Deming’s sign : higher position
Angle’s sign : horizontal position
Prehn’s sign : Pain not relieved on elevation of
scrotum
Diagnosis
 History
Physical exam
Color doppler ultrasonography :
sensitivity 90%
specificity 99%
false positive 1%
Normal Ultrasound and Doppler
Findings
• Color Doppler should reveal bilaterally
symmetric and relatively uniform flow through
both testicles and epididymies
Ultrasound for Testicular Torsion

• Early stages  scrotal contents may have a

normal sonographic appearance
• After 4-6 hours  testis becomes swollen
and hypoechoic
• After 24 hours  testis become
heterogenous as a result of hemorrhage,
infarction, necrosis and vascular congestion
• Spermatic cord immediately cranial to the
testis and epididymis is twisted, causing
characteristic torsion knot or whirlpool
pattern
Differential Diagnosis
Hydrocele
• transsillumination test (+)

Hernia
• Testis & epididymis normal
• Enlargement extend up into the groin
• Gastro intestinal symptoms usually predominat

Acute epididymitis or orchio-epididymitis

• The history of infection, fever and pus in the urine
• Prehn’s sign (-)

Testicle tumor
- Very hard
- Painless
Management
• Detorsion within 6hr = 100% viability
• Within 12-24 hrs = 20% viability
• After 24 hrs = 0% viability

• Surgical detorsion and orchiopexy if viable

• The contra lateral testis should be explored also and fixation to
the inner layer of wall scrotal skin
• Orchiectomy if non-viable testicle

• Never delay surgery on assumption of

nonviability as prolonged symptoms can
represent periods of intermittent torsion
Manual Detorsion
• If presents before swelling
• Appropriate sedation
• Apply ‘open book’ rotation (The
left testis is rotated clockwise
and the right one counter
clockwise)
• Success if pain relief, testicles
lowers in scrotum
• Still need surgical fixation
PROGNOSIS
• Detorsion within 5-6 hours : good result

• Detorsion within 12-15 hours : recovery is about 70-

90% but the seminiferous tubulues may already
become infarct

• Detorsion is delayed beyond 24 hours : infarct/necrosis

 orchidectomy
 URINARY
RETENTION
 DEFINITION

The inability to discharge all or part of the

urine from the bladder

URINARY
RETENTION

The most common emergency cases in

urology
 ETIOLOGY

Urinary retention which is caused

by obstruction on the urinary
1. Obstruction tract distal to the bladder neck

2. Non Obstruction
Urinary retention which is caused by
power dysfunction of the bladder
musculature or atonia detrussor
muscle
 ACUTE URINARY RETENTION

 Intense pain in the supra pubic region

 Usually a precipitating cause for the acute : for

URINARY instance : alcohol drink, adrenergic drugs,
RETENTION sudden fluid over load obstruction

 A moderately distanded bladder, tension and

tenderness on palpation (contraction and spasm
of bladder musculature)

 Volume urine in the bladder slightly higher than

normal about 500-600 ml on catheterization
 ACUTE ON CHRONIC URINARY
RETENTION

 Minimal discomfort in the lower abdomen

URINARY
RETENTION  A very large bladder that is not tender to
palpation  extend until to umbilicus

 Volume urine in the bladder very large, may be

about 2000-3000 ml

 May be paradoxic incontinence is present

1. Relief of obstruction
 Any causative underlying condition
urinary, drainage should merit first
attention
 Urethral catheter inserts to the bladder
 If it fails, supra pubic catheterization
(cystostomy)  opened cystostomy or
closed cystostomi
 Treatment of the main causes of obstruction and stasis (BPH, urethral,
stricture, prostate ca., etc)

 Eradication of infection (with antibiotics)

THANK YOU