UROLOGY

(PART II)
KATHLEEN GONZALES, MD, FPUA
 UROLOGIC EMERGENCIES

ACUTE URINARY RETENTION

• Inability to void despite full bladder
• AUR can happen in men or women but more
commonly due to BPH
• Other causes may be due to poor bladder
emptying:
• Diabetic neuropathy
• Urethral stricture
• Multiple sclerosis
• Parkinson’s disease
 UROLOGIC EMERGENCIES

ACUTE URINARY RETENTION

• Medications that may precipitate AUR by decreasing
bladder contractility
• Opiates
• Anticholinergics
• B-agonists
• Can result to renal failure if not managed promptly
• Treatment : placement of urethral catheter
• BPH or urethral stricture can make catheterization difficult
• If unsuccesful, a suprapubic tube should be placed
• If with gross hematuria, continuous bladder irrigation
(cystoclysis) through a 3-way catheter is done to prevent
clot formation
 UROLOGIC EMERGENCIES

ACUTE URINARY RETENTION

• Labs: • After drainage, the cause of AUR
should be addressed
• Urinalysis – poorly emptying bladder is
prone to infection • BPH – alpha blocker, 5-ARIs
• Creatinine – to assess renal function; an • Urethral stricture - urethrotomy
elevated crea suggests that AUR has
resulted to renal dysfunction; px is at
• Narcotics and other precipitating
medications tapered or stopped
risk for postobstructive diuresis
• Constipation treated
• Post-obstructuve diuresis – excessive
• After removal of catheter , check for
urine output often caused by osmotic postvoid residual by UTZ or straight
diuresis due to retained nitrogenous cath (>150-200mL – high tendency to
waste products (200mL/h); fluid recur)
replacement (0.5mL 0.45 normal saline • Give option to maintain IFC or CIC
for every mL of urine above 200
 UROLOGIC EMERGENCIES

TESTICULAR TORSION
• One differential for acute scrotal pain
• Usually occurs in neonates or adolescent
males
• The blood supply to the testicle is
compromised due to twisting of the
spermatic cord within the tunica vaginalis
(ischemia to the epidydimis and testis)
• Risk factors:
• Undescended testis
• Testicular tumor
• “Bell-clapper deformity” – poor gubernacular
fixation of the testis to the scrotal wall
 UROLOGIC EMERGENCIES

TESTICULAR TORSION
• Clinical Hx/PE
• Sudden onset of pain at a distinct point in time
• Subsequent swelling
• Swollen, asymmetric scrotum with tender,
high-riding testicle
• Absent cremasteric reflex
• Doppler ultrasound – decreased
intratesticular blood flow relative to the
contralateral testis
• If ultrasound is not available, timely surgical
exploration shoud be considered if with high
index of suspicion
 UROLOGIC EMERGENCIES

TESTICULAR TORSION
• Golden period: within 6 hours from torsion to
salvage an ischemic testis
• Midline or bilateral transverse scrotal
incisions
• Once testis is detorsed, assess viability; fixto
the dartos fascia on medial and lateral
aspects withsmall nonabsorbable sutures
• If the testis is clearly non-viable or necrotic,
orchiectomy is done to avoid abscess
formation
 UROLOGIC EMERGENCIES

FOURNIER’S GANGRENE
• A necrotizing fascitis of the male genitalia
and perineum that can be rapidly
progressing and fatal if not treated promptly
• Mortality – 30-40%
• Risk factors:
• Urethral strictures
• Perirectal abscess
• Poor perineal hygiene
• Diabetes
• Cancer
• HIV
 UROLOGIC EMERGENCIES

FOURNIER’S GANGRENE
• Infection spreads along dartos, Scarpa’s
fascia and Colles’ fascia
• Ssx: fever, perineal and scrotal pain,
indurated tissue, cellulitis, eschars,
necrosis, flaking skin and crepitus
• Diagnosis made largely on clinical
suspicion
• Histological findings on biopsy: dermal
necrosis, vascular thrombosis, and PMN
leucocyte invasion with subcutaneous
tissue necrosis
 UROLOGIC EMERGENCIES

FOURNIER’S GANGRENE
• Prompt debridement of nonviable tissue –
extensive incision through the skin and
subQ going beyond the areas of
involvement until normal fascia is found
• Broad-spectrum antibiotics
• Orchiectomy is seldom needed since the
testes have separate blood supply
• Repeated debridement if needed
• Tight glucose control and adequate
nutrition to facilitate wound healing
 UROLOGIC EMERGENCIES

PRIAPISM
• Persistent erection for greater than 4 hours
unrelated to sexual stimulation
• Divided into two types:
• Low flow or Ischemic priapism: a medical emergency
• due to decreased venous outflow and sustained
decrease in arterial inflow
• Resulting to tissue hypoxia, acidosis, and edema
• High flow or Nonischemic priapism – rare and related
to penile or perineal trauma in a cavernous artery; not
painful and not related to ischemia
 UROLOGIC EMERGENCIES

PRIAPISM • Diagnosis can be confirmed with a

• Risk factors for Ischemic priapism: penile blood gas demonstrating
• Sickle cell disease hypoxic, acidotic blood
• Malignancy • Insert a large gauge needle (18
• Medications gauge) into the lateral aspect of
• Cocaine abuse one corporal body, aspirate and
irrigate both corporal bodies
• Certain antidepressants
• Total parenteral nutrition • Inject phenylephrine (200mg in 20
mL normal saline) into the
• Management – rapid detumescence
corporal bodies
to preserve future erectile function
 UROLOGIC EMERGENCIES

PRIAPISM
• If still unsuccesful, surgical shunt can be done
• Distal shunts – done in the ER with a True-cut
needle (Winter Shunt)
• Al-Ghorab shunt – also a distal shunt done in
the OR
• Proximal shunts – Grayhack’s (corporal-
saphenous vein) or Quackel’s (proximal
cavernosum-spongiosum) may be required in
refractory cases
 UROLOGIC EMERGENCIES

PARAPHIMOSIS
• Painful swelling of the foreskin distal to a
phimotic ring, occurs if the foreskin remains
retracted for a prolonged time
• Usually after the foreskin has been
traumatically reduced during an examination
• Delay can be catastrophic as penile necrosis
may occur due to ischemia
• Penile blocks, pain medications and sedation
sometimes needed before manual reduction
• Apply firm pressure to the edematous distal
penis for several minutes to reduce edema,
pull the constricting band distally
• Dorsal slit to prevent recurrence
 UROLOGIC EMERGENCIES

EMPHYSEMATOUS PYELONEPHRITIS
• Life-threatening infection that results from
complicated pyelonephritis by gas-
producing organisms
• An acute necrotizing infection of the kidney
esp in diabetic patients
• Sepsis and ketoacidosis
• Mgt: Hydration, IV antibiotics, relief of
urinary tract obstruction (Nephrostomy
tube, Nephrectomy)
 UROLOGIC INFECTIONS
CYSTITIS PYELONEPHRITIS
• Infection of the bladder with common • Bacterial infection of the kidney
manifesting as fever and flank pain
sxs of dysuria, frequency and urgency
• Urine culture (105 CFU) for a definitive • Due to ascending bacteria along the
path of ureters
diagnosis
• Urinalysis – aside from WBCs and • Can result in renal scarring
RBCs • Can lead to emphysematous
pyelonephritis with a mortality of up to
• Leukocyte esterase – marker of 30%
inflammation
• Nitrites – formed from bacterial reduction • Can develop into an abscess within the
of nitrates
renal parenchyma (renal abscess) or
between the capsule and Gerota’s
• Risk factors: female, urinary fascia(perinephric abscess)
instrumentation, urinary obstruction, • Tx: broad-spectrum antibiotics and
diabetes, neurologic bladder percutaneous drainage (if with
dysnfunction abscess)
 UROLOGIC INFECTIONS
PROSTATITIS
• Acute prostatitis – bacterial infection • Chronic prostatitis – continued
in the prostate gland lower urinary tract symptoms and
pelvic pain
• Ssx: fever, dysuria, perineal or back
discomfort • May be bacterial or nonbacterial

• DRE: indurated and tender gland • Culture pre and post-prostatic

massage urine
• 4-6 week course of antibiotic therapy
• Bacterial form - treated with
(quinolone)
prolonged course of antibiotics
• If no improvement in 48 hours,
• Nonbacterial form – biofeedback,
imaging should be considered to rule
physical therapy, anti-inflammatory
out prostatic abscess (transurethral
unroofing or drainage)
 UROLOGIC INFECTIONS

EPIDIDYMO-ORCHITIS
• Typically the result of bacterial infection
originating in the urinary tract
• Ssx: unilateral painful swelling of the epididymis
and/or testis, fever, erythematous scrotum,
elevated WBC
• Onset is not a sudden as torsion
• Treatment: oral antibiotics if not markedly febrile
• Hospitalization and IV antibiotics may be
required if with high fever, markedly elevated
WBC, hemodynamically unstable
• Intratesticular abscess may require exploration
and orchiectomy (tunical albuginea is not
compliant)
 LOWER URINARY TRACT OBSTRUCTION

BENIGN PROSTATIC HYPERPLASIA

• Consequences: gross hematuria,
infections due to incomplete
• Clinical diagnosis describing urinary emptying, bladder calculi, and AUR
symptoms attributable to obstruction by
the prostate • Medical treatment:
• Ssx: frequency, urgency, hesitancy, slow • alpha blockers - act on alpha
stream, and/or nocturia receptors in the smooth muscle of
prostate and decrease its tone
• IPSS (International Prostate Scoring (Tamsulosin, Terazosin, Alfusozin)
System)
FUNWISR • 5-ARIs – block the conversion of
testosterone to the more potent
given points from 0-5 dihydrotestosterone; shrink the
0-7 : Mild symptoms prostate over several months
8-19: Moderate symptoms • Used singly or in combination
20-35: Severe symptoms • If medical treatment fails, surgical
intervention is indicated
 LOWER URINARY TRACT OBSTRUCTION

BENIGN PROSTATIC HYPERPLASIA

• Surgical therapies:
• Transurethral Resection of the Prostate (TURP)
– mainstay of endoscopic surgical BPH
treatment
• Complications: incontinence, TUR syndrome
(due to hyponatremia and fluid overload)
managed by diuresis, hypetonic saline (3%)
• Laser vaporization of prostate – reduced
complications due to limited fluid absorption,
less bleeding
• Open Prostatectomy – when the prostate is
very enlarged (>100g)
 LOWER URINARY TRACT OBSTRUCTION

URETHRAL STRICTURE
• May result from scarring due to infectious
urethritis, prior instrumentation, trauma or
cancer
• Urethral carcinoma is very rare
• Diagnosis is by retrograde urethrogram
(RUG) or cystoscopy
• Treatment: Dilation or transurethral incision or
visual internal urethrotomy
• For recurrent or long strictures – open
surgical excision and repair
UPPER URINARY TRACT OBSTRUCTION

• Hallmmark of partial or complete upper urinary

tract obstruction is hydroureteronephrosis (HN)
• Seen on CT, and may may range from mild to
severe
• Obstruction may be intrinsic (calculi, ureteral
tumors) or extrinsic compression (intra-abdominal
tumor, iliac aneurysm, gravid uterus)
• Contralateral kidney will compensate so serum
creatinine may not be initially elevated
• Complete occlusion can cause permanent
dysfunction within 2 weeks
UPPER URINARY TRACT OBSTRUCTION

• Tx of ureteral obstruction : endoscopic

placement of a ureteral stent,
percutaneous nephrostomy,
intracorporeal lithotripsy, extracorporeal
lithotripsy
• Ureteral or DJ stent – temporary plastic
tube with curls on each end; stents
allow flow both through the lumen and
around it
• Must be changed every 3-6 months to
prevent encrustation
 UROLITHIASIS

• Urinary calculous disease

• May affect up to 10% of the population over
the course of a lifetime
• Calculi – crystalline aggregates of one or
more components, most commonly calcium
oxalate
• Other components: calcium phosphate,
magnesium ammonium phosphate (struvite),
uric acid, cystine
• Noncontrast CT scans – study of choice to
evaluate calculi
 UROLITHIASIS

• Inteventions:
• Underlying causes • DJ stent or percutaneous nephrostomy
• Hypercalciuria due to placement
hyperparathyroidism, sarcoidosis, “renal
leaks”, or idiopathic overabsorption of
• Ureteroscopy (URS), Intracorporeal
lithotripsy (ICL)
calcium
• After gastric bypass – prone to oxalate • Percutaneous nephrostolithotomy
stones (PCNL)
• Gout pxs are at risk for uric acid stones • Extracorporeal lithotripsy (ESWL)
• Calculi up to 6mm – may try medical • Complications:
expulsive therapy • URS may lead to strictures
• Calculi >7mm are more likely to become • PCNL may cause significant bleeding,
impacted, so intervention may be needed hydrothorax
• ESWL may cause renal hematomas
 RETROPERITONEAL FIBROSIS

• A process resulting in encasement of the ureters,

along with the great vessels, in a dense fibrotic mass
• Imaging demonstrates medially displaced ureters with
a homogenous plaque-like mass in the
retroperitoneum
• May occasionally be a neoplastic process such as
histiocytosis or lymphoma, but most are idiopathic
• Medications may be precipitating factors:
methysergide, methyldopa, beta blockers
• Bilateral ureteral stent or PCN may provide temporary
relief of obstruction
• Corticosteroids to relieve inflammation
• Surgical ureterolysis usually required
 PEDIATRIC UROLOGY

URETEROPELVIC JUNCTION
OBSTRUCTION
• Most common cause of
• Open pyeloplasty – gold standard
especially in infants
hydronephrosis found on prenatal
ultrasound • Recent advances introduced
Laparoscopic or Robotic pyeloplasty
• Intrinsic causes : adynamic or stenotic for faster recovery time and
segment of proximal ureter impairing decreased postoperative pain
flow of urine into the ureter and
causes dilatation of the collecting • Endopyelotomy – endoscopic
system approach ; “cut to the light”
approach (lateral incision into the
• Renal nuclear scans – diagnostic affected ureteral segment with a
modality of choice; delayed clearance laser or cold knife)
of contrast or radiotracer implies
obstruction
 PEDIATRIC UROLOGY

VESICOURETERAL REFLUX (VUR)

• Second most common cause of
hydronephrosis after UPJO
• 2/3 of infants presenting with recurrent
UTI may be found with VUR
• A congenital anomaly caused by
insufficient intramural tunneling of the
distal ureter
• Primary complication is the development
of recurrent episodes of pyelonephritis
which can cause cumulative damage
through scarring
 PEDIATRIC UROLOGY

VESICOURETERAL REFLUX (VUR)

• Diagnosis: Voiding cystourethrogram
(VCUG)
• VUR is graded according to International
Classification System
• Gr I and II : spontaneously resolve
• Gr III and IV: 30-50% will resolve
• Gr V: 9% will resolve
• Mgt: Antibiotic prophylaxis, Ureteral
reimplantation, submucosal injection of
bulking agents at the ureteral orifice
 PEDIATRIC UROLOGY

URETEROCOELES
• Cystic dilatation of the terminal ureter thought to
result from a persistent membrane between the
ureteral bud and the urogenital sinus
• Associated with duplicated collecting system and
ectopic ureteral location
• May present with hydronephrosis and pyelonephritis
• A large prolapsing ureterocoele can cause bladder
outlet obstruction
• Diagnosis: cystoscopy, VCUG, or IVP
• Mgt: Endoscopic incision of the ureterocoele;
heminephrectomy if nonfunctioning duplicated
system
 PEDIATRIC UROLOGY

POSTERIOR URETHRAL VALVES (PUV)

• Tissue folds located in the prostatic urethra which
cause bladder outlet obstruction
• A damaging cause of bilateral hydronephrosis in a
newborn boy
• Diagnosis: VCUG which shows poor bladder
emptying and a dilated posterior urethra
• Tx: cystoscopic ablation or resection of valve
• Even after ablation, pxs may still have a
significant risk of renal failure depending on the
degree of prenatal obstruction
• Most serious outcome of PUV is pulmonary
hypoplasia due to intrauterine oligohydramnios
 THANK YOU
KATHLEEN R. GONZALES, MD, FPUA