UROLOGICAL

EMERGENCIES
For 6th Year Medical Students
 Outline

Urological
Emergency

Trauma Non-Trauma

Acute
Urinary Acute Acute Penile
Renal Ureteral Bladder Urethral Penile Testicular Urolithiasis UTI Hematuria Scrotum pain
retention

Priapism Paraphimosis
GENITOURINARY TRAUMA
Renal Trauma

• Epidemiology:

• Most commonly injured organ of GU system

• 8-10% of blunt and penetrating abdominal injuries involve

kidneys

• Penetrating injury more likely to require surgery

Renal Trauma

Mechanism of Injury:

ØPenetrating (10-20%)
ØGSW
ØStabs

ØBlunt (80-90%)
ØSudden deceleration
Ø MVAs
Ø Falls
Ø Assault
Renal Trauma

• Clinical Assessment:
• ATLS 1ry and 2ry Survey:
• Mechanism of injury
• Extent of deceleration
• Caliber
• Velocity
• Flank pain bruises / ecchymosis
• Hematuria
• Gross
• Microscopic
• Hypotension
• Investigations:
• CBC
• CT Abdmen / Pelvic with contrast (and delayed phase)
 Renal Trauma

AAST: Kidney Injury Scale (2018 revision)

Grade CT Finding

I • Subcapsular hematoma and/or parenchymal

contusion without laceration
II • Perirenal hematoma confined to Gerota fascia
• Renal parenchymal laceration ≤1 cm depth
without urinary extravasation
III • Renal parenchymal laceration >1 cm depth without
collecting system rupture or urinary extravasation.
IV • Parenchymal laceration extending into urinary
collecting system with urinary extravasation
• Renal pelvis laceration and/or complete
ureteropelvic disruption
• Segmental renal vein or artery injury
• Active bleeding beyond Gerota fascia into the
retroperitoneum or peritoneum
• Segmental or complete kidney infarction(s)
due to vessel thrombosis without active bleeding
V • Main renal artery or vein laceration or
• More than one grade of kidney injury may be present and should be classified by the higher grade
avulsion of hilum of injury.
• Devascularized kidney with active bleeding • Advance one grade for multiple injuries up to grade III
• Shattered kidney with loss of identifiable • Cor more details :
parenchymal renal anatomy See Table 8: https://www.aast.org/resources-detail/injury-scoring-scale
To see more images: https://radiopaedia.org/articles/aast-kidney-injury-scale
Renal Trauma

ØManagement of isolated renal injury:

ØConservative
Ø Bed rest until urine clears and vitals stabilize
Ø Serial CBC

ØAngio-embolization

ØDJS if urinary extravasation

ØHemodynamically unstable pts require surgery

Renal Trauma
Ureteral Trauma

ETIOLOGY
Iatrogenic Injury
Ø Open/ Laparoscopic / Robotic surgery
Gynecological (most common)
hysterectomy (54%), oophorectomy, BN suspension,
laser for endometriosis
General surgery ; colectomy, appy, bowel resection
Vascular ; aorto-iliac bypass
Urologic; ureterolithotomy, reimplant, pelvic nodes
Ø Endourology (ureteroscopy, stones)
Ureteral Trauma

ETIOLOGY
• External violence
• MVAs

• Falls

• Gun shot wounds

• Crushing blows

• Avulsions - usually in children with

hyperextended spinal Cord
Ureteral Trauma

Diagnosis
ØOn CT (Violence, MVA)

ØIntra-operative (Iatrogenic)

Ø“Missed” injuries
Ø >48 hrs post-op
Ø Persistent fever, ileus, pain, increasing Cr, urine from wound,
abscess, renal loss
Ureteral Trauma

Assessment:

• US

• IVP

• CT

• Intra-operative methylene blue

• RGP
For more imagies: https://radiopaedia.org/cases/right-ureteric-injury-from-penetrating-trauma?lang=us
Ureteral Trauma

• Management
• Trauma patient
• If diagnosed immediately, then surgical repair

• Iatrogenic injury
• If diagnosed immediately, then surgical repair
• If delayed diagnosis => (Urine diversion)
• DJS if ureter partially intact or NTs
• If large defect or large extravasation, then surgical repair may be preferable
Ureteral Trauma

Surgical Surgical
options Principles
Bladder Trauma

Etiology – rarely isolated

Penetrating (14%)
Operative/iatrogenic
External violence (stabs, gunshots)

Blunt (most common)

Pelvic # (83 – 95% of injuries):
MVA
Falls
Crush
Abdominal blow
Empty bladder: often extraperitoneal rupture
Full: often intra-peritoneal

Spontaneous Rupture
Rare, usually associated with pre-existing bladder pathology, chronic retention
and minor trauma
Bladder Trauma

Radiology
• Cystogram

• CT cystogram an alternative
 Bladder Trauma

Extraperitoneal Intraperitoneal
Urine Leak in the Extraperitoneal space Urine Leak in the Intraperitoneal space

More Common 1/3 (more common with the children)

Manage with catheter insertion Managed with surgical repair
Bladder Trauma

Complications
• Failure to diagnose:
• Urinoma
• Abscess
• Sepsis from infected urine

• 12% mortality usually due to other concomitant injuries

Urethral Trauma

Anatomy

• Male Urethra
1) Posterior
• prostatic
• membranous
2) Anterior
• bulbous
• penile/pendulous

• Female Urethra
•Rarely injured
Urethral Trauma

Posterior Urethra Trauma

Mechanism of injury
• Violent external force:
Strong shearing from high-speed blunt and crush injuries
High velocity penetrating trauma

– Prostatic attachments and pubo-prostatic ligaments tear with urethra

– Pelvic fracture in 90%

Urethral Trauma

Posterior Urethra Trauma

• Presentation
• Triad:
• Blood at meatus
• Inability to void/ Distended bladder
• Perirenal Butterfly Hematoma

• Gross hematuria

• Penile, scrotal and/or perineal swelling

Urethral Trauma

Posterior Urethra Trauma

Diagnostic evaluation
• Physical examination
® ABC’s, vitals and hemodynamic stability
® Blood at meatus
®DRE: high-riding prostate
®Boggy fluid collection (blood or urine) at normal prostatic site
®Imaging:
®Pelvic fracture
®Retrograde urethrogram
Urethral Trauma

• Posterior Urethra Trauma

Urethral Trauma

Posterior Urethra Trauma

Management Shouldn’t be Catheterized
by other than a specialist

• Immediate:
• SP catheter
• Primary realignment

• Delayed:
• Reconstruction
Urethral Trauma

Anterior Urethra Trauma

Mechanism
• Blunt trauma (straddle injuries or blow to perineum)
• Traumatic Catheter insertion

Diagnosis
• Physical exam
Swelling and ecchymosis of penis, scrotum and/or perineum

Blood at meatus

• Retrograde urethrogram
 Urethral Trauma

Anterior Urethra Trauma

• Retrograde urethrogram

Complete anterior urethral rupture secondary to a straddle injury. Partial anterior urethral rupture secondary to Foley
Note the venous extravasation. catheter balloon blown up in bulbous urethra.
Urethral Trauma

Anterior Urethra Trauma

Management
• Similar options to posterior

Stricture area was removed. Cut ends

of urethra were spatulated ventrally.
Urethral Trauma
Penile Trauma (Fracture)

• Traumatic: rare 1/175,000

• Injury to the erect penis
• Intercourse
• Self-inflicted
• History:
• Pop
• Pain
• Detumescence
• Swelling

• Examination:
• Eggplant deformity
• Blood at the meatus suggests urethral injury
Penile Trauma (Fracture)

Assess urethra:
• Urethrogram
Or
• Intraoperative cystoscopy

Rapid exploration:
• Repair of tunical defect
Penile Trauma (Fracture)

• Risks of conservative treatment:

• Deformity/curvature

• Fibrosis/plaque formation

• ED
Testicular Trauma (Fracture)

• Rare
• Mechanism
• Blunt (usually)
• Penetrating
• Presentation:
• Pain
• Swelling / Echymosis
Testicular Trauma (Fracture)

• Scrotal US:
• Hematocele
• Avascular hypoechoic area
• Tunica Albugenia Distruption

For more imaging: https://radiopaedia.org/articles/testicular-fracture

Testicular Trauma (Fracture)

• Management
• Surgical Exploration.
• Assess the testicular viability
• Debride necrotic tissue
• Repair the Tunica albuginea rupture if there is a viable testicular
tissue.
• Orchiectomy of dead testicle
Testicular Trauma (Hematocele)

• Accumulation of blood within the tunica vaginalis .

• Secondary to trauma .
• Painful swelling .
• Does not transluminate .
• Treatment : depend on the size :
• Conservative ( small )
• Surgical : large or w laceration of the Tunica Albugenia
Non-Traumatic Urologic
Emergencies
 Urolithiasis Emergencies

Indications for emergency intervention

• High grade urinary obstruction .

• Infection / Pyelonephritis
• Uncontrolled pain
• Impaired renal function
• Bilateral obstructing stones
 Urolithiasis Emergencies

Eitiology

Varies
Asymptomatic Renal colic or Pyelonephritis
 Urolithiasis Emergencies

Presentations
• Sudden onset of severe pain
• Starts in the back, radiates to
the front & to groin
• Nauseated
• Blood in urine
• Storage LUTS
• Fever
Acute Pyelonephritis
• Hypotension
 Urolithiasis Emergencies

History:
• Personal Hx:
• Age at onset
• Sex
• Occupation
• Geographic residence
• Fluid intake & Diet
• PSHx:
• Interventional procedures, surgeries
• Stone episodes / Previous stone composition

• PMHx
• Co-morbidities: PTH, Gout, bowel disease, Urinary
tract infections, renal disease
• Drug Hx: vitamins, calcium,
• Family history
 Urolithiasis Emergencies

Physical Exam:
qAppearance
q In pain
q Writhing or pacing
q Pale and sweating
q Vital signs
q Pulse, RR and BP elevated
q Temp normal
q Abdominal exam
q Tender flank and costovertebral angle
q Ext genitalia
 Urolithiasis Emergencies

Investigations:
• Labs:
• CBC
• Renal Function
• Electrolyte
• U/A +/- Urine Cultures
• Blood culture ( if infected stone)
• Pregnancy test (childbearing age female)

• Imaging:
• US + KUB
• CT abdomen / Pelvis (NO Contrast) “ Low dose CT”
You need to know about stone:
1- Location
2- Size
3- Obstructing vs non-obstructing
4- Stone density on CT
Urolithiasis Emergencies

Imaging findings:

https://radiopaedia.org/articles/abdomen-kub-view

US KUB CT Abdomen and Pelvis

 Urolithiasis Emergencies

Sites of Ureteric Stone Impaction:

Ureteropelvic junction (UPJ)

Over the iliac vessels

Ureterovesical junction (UVJ)

 Urolithiasis Emergencies

Emergency Management
qIntravenous fluids
qIntravenous Antibiotics (if infected stone)
q Always send cultures first
q Adequate narcotic analgesia
q Adequate anti-emetics
q Strain urine
q Image to define diagnosis
q Triage to urology
– in/outpatient
 Urolithiasis Emergencies

Triage Strategy

Inpatient Urology Consult Outpatient Consult

qPoor pain control qPush fluids
qInfection qOral analgesics/ anti-
emetics
qSingle/both kidneys qAlpha blocker: Tamsulosin
blocked
qStrain urine
qImpaired renal function
qReturn if uncontrolled pain
qLarge stone or fever
qCo-morbidities qFollow-up ±further imaging
 Urolithiasis Emergencies

Emergency Interventions:

?? Emergency Ureteroscopy

1-Non-infected
2- Small size
3- Distal ureteric stone

1- DJ Stent Placement (Urologist) 2- Nephrostomy Tube Placement (IR)

 Urolithiasis Emergencies

What could happen to the stone?

• Spontaneous passage.

• 15-30% of symptomatic stone will require surgeries.

• Stone < 7 mm to be given 4-8 weeks to pass on their own with

alpha blocker and pain medication.

• Stone >10 mm unlikely to pass spontaneously .

 Urolithiasis Emergencies

Definite stone management

qExpectant management
qEndoscopic urology
qPercutaneous urology
qExtracorporeal shockwave lithotripsy (ESWL)
qOpen, Laparoscopic or Robotic Surgery
• Nephrolithotomy
• Pyelolithotomy
• Ureterolithotomy
• Cystolithotomy
Urolithiasis Emergencies

Percutaneous nephrolithotomy

ESWL Endoscopic laser lithotripsy

 UTI

Discussed in 4th year lecture

• ALSO READ: Urology (House officer series) Fifth edition.

Chapter 17
ACUTE URINARY RETENTION

Decreased urine output

Causes:
• Acute renal failure
Usually have some urine output (oliguric)
Renovascular occlusion

• Obstruction
Urinary retention
Upper tract obstruction in a solitary kidney
Bilateral upper tract obstruction
ACUTE URINARY RETENTION

Causes
Outflow obstruction: Loss of bladder innervation
• Prostate • Spinal cord injury, disc
BPH, prostate cancer, herniation
prostatitis
• Stroke
• DM
• Urethra
• Post-pelvic surgery
Stricture, traumatic disruption
Pharmacologic
• Calculus/clot/foreign body • Anticholinergics
at bladder neck or urethra • Narcotics
• OTC cold medications
 ACUTE URINARY RETENTION

Assessment
• History:
• Inability to urinate
• May have suprapubic and/ or flank pain (acute)
• Physical Exam:
• Palpable and/or percussable bladder
• Assess for purulent/bloody meatal discharge
• DRE:
• Examine prostate
• Anal sphincter tone
• Focused neurological exam
• Labs:
• Elevated Creatinine

• Imaging:
• Distended Bladder
• US: R/O hydronephrosis (may not be present early on)
ACUTE URINARY RETENTION

Management
Catheterization:
• Urethral vs suprapubic
• R/O urethral disruption in trauma patients

Send urine for analysis; C&S

Consider CBC, BUN, Creat, electrolytes, ultrasound, cystoscopy as indicated
Observe for post-obstructive diuresis
Start on alpha-blockers
Trial of voiding if otherwise stable
Address cause of retention accordingly
ACUTE URINARY RETENTION

Suprapubic Catheter
Urethral (Foley) Catheter
 ACUTE URINARY RETENTION

Postobstructive Diuresis

Management:

Careful fluid and electrolyte (Na) replacement

Monitor patient

Monitor urine output

 Gross Hematuria

Clot retention
History:
• Gross vs Microscopic
• Onset, duration, recurrence, ..etc
• Associated symptoms:
• Flank pain
• Storage LUTS: Frequency, Urgency, Nocturia, Dysuria (FUND)
• Voiding LUTS: Weak stream, Intermittency, Straining, Incomplete Emptying (WISE)
• Urinary retention / passing clots
• Associated Activity ( Menses, Extrenous exercise)
• Risk Factors
• Red Urine Causes (Dietary or medication e.g. phenazopyridine)
• Prior urological disease and intervention
 Gross Hematuria

Clot retention
Examination:
• Vital Signs
• Low Blood Pressure
• Tachycardia
• Fever

• Abdomen:
• Abdominal mass
• CVA tenderness
• Bladder Fullness

• DRE:
• Prostate volume
• Prostate nodule

• Genitalia:
• Masses
• Narrow meatus
 Gross Hematuria

Clot retention
Investigation:
• Blood tests :
• CBC, Renal Function, Coagulation profile

• Urine Culture (if suspected infection)

• Formal Evaluation once reasonable

• PSA (based on patient’s age, risk factor, and desire for screening)
• Urine Cytology
• Imaging
• Ultrasound
• CT urogram/ MR urogram
• Retrogradrade urgogram
• Cystoscopy
 Gross Hematuria

Clot retention

• Management:
• ABC
• Clot evacuation
• 3-ways Catheter
• Continuous bladder irrigation(CBI)
• Blood transfusion if needed
 ACUTE SCROTAL PAIN

Differential diagnosis of scrotal swelling

Acute Painful Chronic painless

Infection/inflammation: Scrotal edema

epididymitis Hernia
epididymo-orchitis Hydrocele
Trauma Varicocele
Torsion of testis or appendages Spermactocele
Epididymal cyst
Tumors
Scrotal anatomy
Scrotal anatomy
 Scrotal Exam

• Examine standing, if possible

• In a warm room
• Palpation:
• Inspection • Examine normal side first
• Including posterior aspect • Gently
• Palpation: • Between thumb (front) and
• Testes fingers, especially index
• Number (behind)
• Size
• Consistency • Roll/slip side to side
• Epididymides • Don’t squeeze
• Presence
• Fullness • Transillumination.
• Tenderness
• Cords
• Vasa
• Varicocele
 Scrotal Exam

WITH ANY SCROTAL LUMP

• Is it confined to scrotum?
• Can you get above it?
• Does it transilluminate?
• Does it have an expansile cough impulse?
• Are the testes palpable?
• Is it reducible?
• Describe it like any other lump:
• Position, color, temperature, tenderness, shape, size, surface,
composition
ACUTE SCROTAL PAIN
 ACUTE SCROTAL PAIN

Testicular abnormalities
 ACUTE SCROTAL PAIN

Testicular Torsion
• A true surgical emergency

• Usually in children and adolescents

• Irreversible ischemic injury to parenchyma may

begin as soon as 4 hours after onset

• May result from lack of normal fixation of

appropriate portion of testis coverings that
surround the cord (bell-clapper deformity)
 ACUTE SCROTAL PAIN

Testicular Torsion

• History
• Classic presentation:
• Acute scrotal pain
• May have history of prior episodes of severe, self-limited
scrotal pain and swelling
• Exam:
• Absent cremasteric reflex
• Horizontal lie of testicle
• Diagnosis:
• Clinical
• May need to confirm absence of torsion if suspect other
ultrasound diagnoses that do not require surgery
 ACUTE SCROTAL PAIN

Testicular Torsion

• Doppler US
 ACUTE SCROTAL PAIN

Testicular Torsion

• Management:
• Scrotal exploration:
• Detorsion
• Orchidopexy if viable
• Orchiectomy if not
• Contralateral orchidopexy
• Bell-clapper
 ACUTE SCROTAL PAIN

Acute Epididymo-Orchitis

• Acute infection of the epididymis and testis.

• Rare before puberty .
• Predisposing factors:
Ø UTI => (usually Elderly)
Ø Sexually transmitted diseases=> (Usually young)
Ø Instrumentation
Ø 50% unknown cause
 ACUTE SCROTAL PAIN

Acute Epididymo-Orchitis

• Hx
• Sudden, progressive pain and swelling .
• Fever and rigors (can be sever)
• Symptoms of UTI .
• Symptoms of bladder outlet obstruction .
• Instrumentation of the urethra .
• P/E:
• Thickened & tender epididymis
• Hydrocele can be present .
 ACUTE SCROTAL PAIN

Acute Epididymo-Orchitis

• Investigation:
• Urine analysis +/- CS
• Urethral Swab C/S
• Nucleic acid amplification testing (NAAT) urine or
body fluid

• Doppler US:
 ACUTE SCROTAL PAIN

Acute Epididymo-Orchitis
• Management:
Ø Bed rest
Ø Scrotal support
Ø Analgesia
ØAnti inflammatory
Ø Antibiotics
Ø Based on the Causating organism
Ø Chlamydia: Doxycycline or Azithromycin
Ø Gonorrhea: Cephalosporin
Ø E. Coli: Cephalosporin, Quinolone
 Fournier’s Gangrene

Definition

• Necrotizing fasciitis of male genitalia

Fournier’s Gangrene

Pathogenesis
Associated with:
• Urethral stricture
• Instrumentation
• Extravasation

Predisposing factors:
• DM
• Local trauma
• Periurethral extravasation of urine
• Peri-rectal or perianal infection
• Surgery (circumcision or hernia repair)
Fournier’s Gangrene

Pathogenesis
• Spread:
Through Buck’s and along Dartos (penis and scrotum), Colle’s (perineum),
and Scarpa’s (anterior abdominal wall)

• Pathogens:
Multiple organisms (synergistic infection) including anaerobes
E. coli, Klebsiella, enterococcus, Bacteroides, fusobacterium, Clostridia,
microaerophilic strep
 Fournier’s Gangrene

Clinical presentation
• Symptoms and Signs:
Initially cellulitis-like
Pain and fever prominent with systemic toxicity
Swelling
Crepitus

• Investigations:
Plain X-ray
• May show air
CT
Fournier’s Gangrene

Management
• IV fluids
• IV broad-spectrum antibiotics
• IV Immunoglobulin may be needed
• Surgical debridement
• SP diversion if urethral trauma or extravasation
• Hyperbaric O2 (rarely needed)

• Prognosis:
• Mortality 20% (but higher with DM, EtOH, colorectal source)
 Scrotal / penile Edema

Similar to edema else where in the body

• Associate with:
• LL edema
• Anasarca
• Pelvic LND
• Management:
• Scrotal elevation
• Treat volume overload
 Acute penile pain

Paraphimosis
Paraphimosis Phimosis

Painful swelling of the retracted foreskin behind the penile A narrowing or constriction of the distal penile fore- skin that
corona prevents its normal retraction over the glans.
It can cause Balanoposthitis (inflammation of the glans and
prepuce)

Image from: https://emedicine.medscape.com/article/777539-overview

 Acute penile pain

Priapism

• Abnormal Prolonged penile erection ( > 4 hrs) in the absence

of Sexual stimulation.
Ischemic (Venous) Non-Ischemic (Arterial)
Due to impaired venous drainage Due to increase arterial flow
Associated with Acidosis in penile blood gas Associated with Trauma
PAINFULL Painless
Real Emergency Could resolve Sponatnoeusly
 Acute penile pain

Ischemic Priapism
• Causes:
• Sickle cell disease
• Malignancy
• leukemia/lymphoma
• primaryor metastatic penile cancer
• pelvic mass)
• Drugs
• PDE-5 inhibitors
• intracavernosal injections
• Trazodone
• Cocaine
• Alpha blockers
• Total parenteral nutrition
Acute penile pain

Ischemic Priapism

• Management:
• Aspiration / Irrigation
(Penile Block)
• Intracorporal Phenylephrine Injection
(Monitor Heart rate and BP)
• Surgical Shunting if failed to respond
Additional readings

• 4th year lectures; Urolithiasis, UTI, Scrotal pathology

• Urology (House officer series) Fifth edition. Chapter 1, 4, 6, 7
9,10, 13, 14, 17, 20 and 36 +pages 217-218
• AUA Medical Students curriculum.
‫ﺷﻜﺮا ﻟﻜﻢ‬