UROLOGIC

EMERGENCIES
(or GENITOURINARY or UROGENITAL)

Mohamed zewita, MD
Lecturer of Urology
Port University
 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)
 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
- septicemia and urosepsis
TYPES OF UROLOGIC EMERGENCIES

 Acute Obstruction:

-renal colic
-obstructive anuria ‫انقطاع بولى حاد‬
-acute urine retention ‫احتباس بولى حاد‬
-clot retention
- obstructed tube or urinary catheter
TYPES OF UROLOGIC EMERGENCIES

 Concomitant renal obstruction and infection:

- obstructive pyelonephritis
- infected hydronephrosis
TYPES OF UROLOGIC EMERGENCIES

 Bleeding:
Hematuria

External bleeding after:

 penetrating trauma
 urologic surgery (revealed by drains)
Internal hemorrhage e.g. intra-peritoneal and retro-peritoneal
TYPES OF UROLOGIC EMERGENCIES

 Trauma:

- renal (especially major and penetrating trauma)

- bladder rupture (especially intraperitoneal)

- testicular (especially with testicular rupture)

- penile fracture
TYPES OF UROLOGIC EMERGENCIES

 Acute Vascular Conditions (mainly ischemogenic):

- testicular torsion (vein & artery)
- paraphimosis (vein & artery)
- priapism
-unilateral renal vein thrombosis or renal artery thrombosis
TYPES OF UROLOGIC EMERGENCIES

Urologic conditions with

acute changes of body fluids and electrolytes :

 Trans-urethral resection (TUR) syndrome

 Post-obstructive diuresis
TYPES OF UROLOGIC EMERGENCIES

 Relative emergencies:
 Bladder exstrophy: within 72 hours

 Tumors especially Wilms’ tumor &

testicular tumor
 UROLOGIC EMERGENCIES:
1- HEMATURIA
HEMATURIA
means the presence of more than 3 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

Hematuria may be:

 Macroscopic (Gross) hematuria


Microscopic hematuria (microhematuria)

Eumorphic & >

3 RBCs/HPF
 HEMATURIA

 Macroscopic (gross) Hematuria is an emergency with:

 clot retention

 clot colic

 hypotension and shock

 anemia necessitating blood transfusion

 obstruction of the draining tube or catheter by clots

 bleeding from a solitary kidney (critical)

= (complications or sequels of hematuria)

HEMATURIA

According to its relation to the act of micturition,

hematuria may be: THREE GLASSES TEST
 Initial

 Terminal urinary bladder

(e.g. ACTIVE BILHARZIASIS)

 Total Kidney, ureter or

urinary bladder
HEMATURIA

The presence of pain:

 Painful hematuria
 Painless hematuria: more alarming
 Painless or painful)

Severity of hematuria :
 Smoky urine
 Light hematuria
 Deep (profuse) hematuria
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

-Presence of clots = 100 % hematuria (pathognomonic)

-Associated symptoms e.g. colic, trauma, burning etc.

 HEMATURIA

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

HEMATURIA
Investigations:
Bilharzial ova, crystals
1. Urine analysis …………… pus or malignant cells
Thrombocytopenia
2. Bleeding profile …………. or ↓ prothrombin
concentration
Radio-opaque stones
3. KUB radiogram …………
PCKD, urinary stones
4. Abdominal U/S …………..
TCC of the renal
5. Intravenous urography … pelvis
Renal cell carcinoma
6. Abdominal CT .…………. or any urinary stone
During pregnancy or
7. MRI ……………………… with renal failure
8. Cystoscopy ………………. Bladder ulcer, growth
or carcinoma in situ
HEMATURIA

Treatment:
 Treatment of the cause e.g. litholapaxy orTURP
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

 UROLOGIC EMERGENCIES:
2- RENAL COLIC
Pathogenesis: Acute upper urinary tract obstruction with hyper-
peristalsis of the calyces, pelvis and/or ureter

Causes: Passage of crystals, stones, blood clots or the presence of

ureteric stricture

Site: - At the flank, radiates to the abdomen along the course of the ureter
- Referred to the ipsilateral testis, hemiscrotum or upper thigh
RENAL COLIC

Associated symptoms:
 Hematuria
 Irritative LUTS
 GIT symptoms
 Fever
 Anuria
RENAL COLIC

Differential diagnosis:
 Biliary colic (right side, fatty dyspepsia, jaundice etc.)
 Intestinal colic ( diarrhea, tenesmus, melena etc.)
 Appendicular colic (tenderness, rebound tenderness
& rigidity at McBurny point etc.)
RENAL COLIC

Causes of persistent renal colic:

 Obstruction e.g. by impacted stone

 Urinary tract infection

 Ureteric wall edema

RENAL COLIC

Investigations:

 Urine analysis

 KUB radiography

 Abdominal ultrasonography

 ± Abdominal CT
 UROLOGIC EMERGENCIES:
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)
 OBSTRUCTIVE ANURIA
Causes:
complete obstruction of both kidneys or a solitary kidney
by:
 ureteric or renal stones
 ureteric strictures
 malignancy of the bladder, prostate, uterine cervix or
retroperitoneum infiltrating the ureters
 iatrogenic during gynecologic, obstetric or abdomino-
perineal surgery as a result of ligation of the ureters
 OBSTRUCTIVE ANURIA
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
 Late: manifestations of renal failure e.g. anorexia, nausea,
vomiting, loss of vigor, acidotic breathing, etc.
OBSTRUCTIVE ANURIA

Dangerous signs:
 Pulmonary edema (Lung)
 Pericarditis (Heart)
 Brain: encephalopathy & coma
 Bleeding tendency
 Biochemically:
hyperkalemia and serum creatinine > 10 mg/dL
(mostly indicate urgent dialysis)
OBSTRUCTIVE ANURIA

Investigations:
 Abdominal ultrasonography
 KUB radiography
 Non contrast abdominal CT or abdominal MRI
 Serum creatinine, potassium and bicarbonate
OBSTRUCTIVE ANURIA

Treatment:
 Temporary drainage of kidney/s by:
PCN, ureteric catheter or JJ stent
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
 UROLOGIC EMERGENCIES:
4- ACUTE URINARY RETENTION

Definition:
It is the inability to void in spite of full urinary
bladder and severe painful desire for voiding.
 ACUTE URINARY RETENTION
Cause/s at:
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
O RH P
Reflex retention
Hysterical retention
Hematoclpus in imperforate hymen
Phimosis
 ACUTE URINARY RETENTION

Clinical picture:
A- Symptoms:
 Inability
to micturate
 Severe desire to void
 Supra-pubic pain and agony

B- Signs:
 Supra-pubic fullness, dullness and tenderness
 Signs of the cause e.g. palpable urethral stone
or BPH
ACUTE URINARY RETENTION

Treatment:
I- Urgent measures for relief of retention e.g.:
 Urethral catheterization
 If failed or contraindicated → puncture cystostomy tube

or
 Urethral catheterization under anesthesia

II- Treatment of the cause e.g.:

 Urethral stone → disintegration
 Prostatic abscess → drainage
 BPH → medical treatment or prostatectomy
 ACUTE URINARY RETENTION

SOME PECULARITIES OF ACUTE RETENTION OF URINE due to:

1- BPH:
•Spontaneous
•Precipitated by 5 Ws (water, wine, weather, woman, withhold)
2- urethral stricture or prostate cancer infiltrating the urethra:
urethral catheterization is not feasible
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
ACUTE URINARY RETENTION

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

 ACUTE URINARY RETENTION

OBSTRUCTIVE ANURIA VERSUS ACUTE URINE RETENTION

Differentiating OBSTRUCTIE ACUTE URINE
Point ANURIA RETENTION
Patient Both render the patient unable to void
Obstruction level Supravesical Infravesical
Bladder Empty Full
Pain Renal Suprapubic, agony
Patient tolerance For few days Only for few hours
Renal function Deteriorating Normal
Needed drainage Kidney Bladder
 UROLOGIC EMERGENCIES:
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 RENAL INFECTION

Acute pyelonephritis require hospital admission

in case of:

* Concomitant obstruction
* Conception
* Cases with solitary kidney
* Critically ill patients e.g. diabetics
ACUTE RENAL INFECTION

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

ACUTE RENAL INFECTION
Differentiating Obstructive Infected
Point Pyelonephritiis Hydronephrosis
Obstruction type Acute Chronic
Kidney palpation Not palpable May be palpable
Degree of PCS Minimal Mild, moderate
dilatation or marked
Renal cortical Within normal Thinner with
thickness variable degrees
Kidney size Within normal Enlarged with
variable degrees
Best drainage by JJ stent PCN
 UROLOGIC EMERGENCIES:
8- ANDROLOGIC EMERGENCIES

I- Phimosis
II- Paraphimosis
III- Priapism
IV- Penile fracture
V- Acute scrotum
 ANDROLOGIC EMERGENCIES:
I- PHIMOSIS

Definition: Inability to retract the prepuce

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
PHIMOSIS
 ANDROLOGIC EMERGENCIES:
II- PARAPHIMOSIS
Definition:
constriction of the glans by the retracted prepuce

Sequels:
venous congestion → edema → more constriction →
more congestion → more constriction → arterial obstruction
PARAPHIMOSIS

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
PARAPHIMOSIS

Treatment
1. Emergent 2. Emergent
Manual reduction Dorsal slit
of the prepuce of the prepuce
Incise at 12 o’clock position

3. Elective
Circumcision
 PARAPHIMOSIS

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 and removal.
o If neglected, it may lead to urethro-cutaneous fistula or even
necrosis and
sloughing of the glans.
 ANDROLOGIC EMERGENCIES:

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)
2. Non-ischemic (arterial, high flow)
3. Stuttering (intermittent)
 PRIAPISM

Causes:
I- Idiopathic: 35%
II- Drug induced:
 Penile injections of papaverine, protaglandin or phentolamine
 As a complication of PDE 5 inhibitors e.g. sildenafil
 Other drugs: antihypertensives , anticoagulants & antipsychotics
III Medical diseases:
 Blood disorders e.g. sickle cell disease and leukemia
 Spinal cord injury and multiple sclerosis
IV Scorpion bite
PRIAPISM

Pathology: (Potential sequelae)

Clotting and thrombosis of the blood retained in the penis

Damage to the blood vessels of the penis

Ischemia and fibrosis of the cavernous tissue

Permanent loss of erectile function
PRIAPISM

ONE BITER IS ENOUGH

ONE BITE IS MORE THAN ENOUGH

BE A FIGHTER NOT A BITER

PRIAPISM

Intracavernosal injection of vaso-active drug/s

o Avoid the midline; dorsally and

ventrally
o Inject into only one corpus cavernosum
 PRIAPISM

Treatment:
Early treamtnet is very important for fear of impotence
if priapism is neglected.
a. Drainage and intracavernosal vasoconstrictor injection
b. Surgical shunts:
 Corporo- corporal shunts:
- Distal shunt
- Proximal shunt
 Sapheno-corporal shunt

c. Blood transfusion
ANDROLOGIC EMERGENCIES:
IV- PENILE FRACTURE
Definition:
rupture of the tunica albuginea of the corpus cavernosum
in an erect penis
Cause:
abrupt bending of the erect penis by blunt trauma
(In the erect penis the tunica albuginea thins from 2 mm
to 0.5 - 0.25 mm and becomes more susceptible to tear)
PENILE FRACTURE
Corpus Cavernosum

____________
PENILE FRACTURE

Symptoms:
 The patient may recall hearing a cracking sound

followed by detumescence of the erect penis.

 Intense local pain
 Penile swelling
 Urethral bleeding may be present
indicating associated urethral injury
PENILE FRACTURE
Signs:
 Bruising
 Penile deformity (eggplant) by hematoma
 Palpable swelling(hematoma) and tunical defect

Investigations:
1. Penile imaging by ultrasonography or MRI
2. Urethral imaging by retrograde urethrography
Complications:
- Penile shaft curvature
- Erectile dysfunction
- Urethral stricture
PENILE FRACTURE

Treatment:
- Evacuation of the hematoma
- Repair of the tunical tear
- Repair of the urethral injury if present
( on a Foley catheter)
ANDROLOGIC EMERGENCIES:
V- ACUTE SCROTUM
It is acute scrotal pain which may be associated with
scrotal swelling.
Differential diagnosis:
1. Testicular torsion
2. Torsion of testicular appendeges
3. Mumps orchitis
4. Acute epididymitis and epididymo-orchitis
5. Trauma to the testis
6. Incarcerated inguinal hernia
 TORSION OF THE TESTIS

It is the twisting of the testis and its cord on itself

strangulating its blood supply. (inward = clockwise
for the right testis)

Types:
1. Extravaginal torsion
2. Intravaginal torsion

Etiology:
1. Lack of fixation
2. Long mesentery
3. Contraction of the
cremasteric muscle
TORSION OF THE TESTIS

Symptoms:
1. A boy, with the peak at 13 years
2. History of an exercise or a minor trauma may be present.
3. Sudden attack of acute scrotal pain
4. Gastro-intestinal symptoms may follow the testicular pain.
5. Scrotal swelling then occurs.
Signs:
1. Enlarged (swollen) tender testis
2. High-riding (elevated) testis
3. Anterior epididymis
4. No fever and no cremasteric reflex
 TORSION OF THE TESTIS

Investigations:
1. Scrotal color Doppler ultrasonography
no flow
1. Urine analysis ( epididymitis)
Treatment:
I- Manual detorsion (outward), if failed:
II- Surgical exploration for:
 Detorsion and orchiopexy (within 6 hours)
 Orchidectomy if gangrenous (to avoid antigenic reaction)
 Prophylactic orchiopexy for the other testis
 NATURE of UROLOGIC
EMERGENCIES
According to the presence or absence of pain:
 Painful conditions e.g.: infections, obstruction, ischemia
etc.

 Painless states e.g.: non obstructive acute renal failure

 Either painless or painful processes e.g.: hematuria

NATURE OF UROLOGIC EMERGENCIES

According to the presence or absence of fever:

 Febrile conditions e.g.: acute infections and
abscess formation
 Afebrile states e.g.: hematuria and trauma
NATURE OF UROLOGIC EMERGENCIES

According to time critique:

Very critical = within few hours it may lead to
irreversible organ loss
e.g.: testicular torsion, paraphimosis and
priapism

 ----------still critical !!
NATURE OF UROLOGIC EMERGENCIES

According to type of required treatment:

medications e.g. renal colic, TUR syndrome & acute
infections
 simple procedures e.g. manual testicular detorsion or
manual reduction of the prepuce in paraphimosis
urgent drainage e.g. acute urine retention, obstructive
anuria, infected hydronephrosis, abscesses and priapism
 urgent surgery e.g. penile fracture, intraperitoneal bladder
rupture or life threatening bleeding due to major renal trauma
 ALARMING POINTS
- In emergencies, dagnosis is based on suspicion.
- Urgency is badly needed in testicular torsion, paraphimosis and
priapism, otherwise !!
- Subtle trauma may be present but concealed (wait and see)
- Obstructive anuria may go silent, yet it is very critical.
- Painless hematuria is more dangerous.
- Hematuria may stop spontaneously but should be investigated
- Priapism may reflect a serious underlying disease as leukemia.
- With intracavernosal injection of vaso-active drugs, there is a risk
of priapism.
 EDUCATIONAL OBJECTIVES

To describe the:
etiology, clinical picture, investigations, risks,
complications and treatment of
some urologic complications including:
renal colic, obstructive anuria, acute retention of urine
and
andrologic emergencies (phimosis, paraphimosis,
priapism, penile fracture & acute scrotum)
 ‫خير الكالم قليل الحروف كثير القطوف بليغ األثر‬
‫وكم من كفيف بصير الفؤاد وكم من فؤاد كفيف البصر‬

‫أبو العتاهية‬