Urological Emergencies for the Non-Urologist Mr C Dawson MS FRCS Consultant Urologist Edith Cavell Hospital Peterborough

Content of the Presentation Renal Colic Testicular Torsion Trauma Paraphimosis Priapism

Renal Colic Does not always present with classic history Classically presents with loin pain radiating around abdomen, as stone moves down ureter May get testicular/labial pain +/- strangury if stone impacts at VUJ

Renal Colic Full examination essential – primarily to rule out other causes for pain Look for signs of Sepsis Differential diagnosis includes Acute Appendicitis Diverticulitis Salpingitis Ruptured Aortic Aneurysm Pyelonephritis Ectopic Pregnancy

Renal Colic - Investigations Routine Urinalysis – microscopic haematuria is common but not invariable IVP Particularly in patients over 50 (?AAA) USS and KUB if contrast allergic Caution in Pregnancy Pregnancy Test in all fertile women of child bearing age

Renal Colic - Management If NO signs of ureteric obstruction on IVP AND Pain free Home with explanation of symptoms Review after 2/52 in OPD If IVP shows obstruction of ureter Admit for observation May still be allowed home for trial of stone passage If Obstructed AND signs of Sepsis Urgent Nephrostomy

Renal Colic - Management Size of Stone < 4mm 4-6 mm > 6mm Management Conservative: 90% pass spontaneously 50% pass spontaneously – trial of passage Intervention likely, only 10% pass spontaneously

Testicular Torsion Can occur at any age Most common in adolescents Occasionally seen in neonates In infants (and esp neonates) the symptoms and signs are imprecise Prompt action required to avoid irreversible testicular ischaemia

Testicular Torsion Diagnosis usually made solely on basis of clinical examination Testis usually swollen and exquisitely tender Lies horizontally and retracted compared to normal side

Testicular Torsion Studies have shown that only 25% of boys presenting with acute scrotal swelling with have torsion No reliable diagnostic test exists Doppler USS can effectively establish the presence of arterial inflow Surgical exploration remains the final arbiter, and should not be delayed whilst waiting for investigations

Testicular Torsion

Urological Trauma Fortunately very rare Typical victims Young men involved in sport (55%) People in RTAs (25%) Domestic or industrial accidents (15%) Victims of Assault (5%)

Urological Trauma Upper Urinary Tract Lower Urinary Tract Renal injuries Lower Urinary Tract Bladder Urethra External Genitalia

Urological Trauma - Overview Take a careful history Mechanism of injury (blunt trauma, penetrating trauma) Velocity of injury Careful Assessment Careful Examination ABC of Primary Survey Baseline Investigations Appropriate Radiology and additional imaging

Primary Survey From ABC of Major Trauma (chapter by Cope and Stebbings)

Renal Trauma The Kidney is the most commonly injured urological organ Injuries can be blunt (80-90%) or penetrating Blunt trauma occurs with upper abdominal injury and rapid deceleration Such injuries usually involve multiple organ systems and patients – other injuries must be suspected and excluded

Renal Trauma – Radiological Assesment Adult patient with blunt trauma Visible haematuria, or microscopic haematuria and shock - Needs Radiological assessment Microscopic haematuria without shock – radiological assessment not required Adult patients with penetrating trauma / All Paediatric patients – require radiological assessment

Renal trauma Radiological Assessment should begin with IVU – Most patients adequately staged this way CT has largely replaced the arteriogram and IVU in the diagnosis and management of severe abdominal or GU trauma Patients who are haemodynamically unstable will require immediate laparotomy 85% of blunt renal injuries require no surgery, 5-10% require judgement and surgical exploration, 5% are non-salvageable and require nephrectomy

Lower Urinary Tract – Bladder and Urethra Approx 90% of bladder injuries result from blunt trauma The bladder is commonly injured in pelvic fractures The bladder in a child is an abdominal (not pelvic) organ and is more vulnerable to injury

Lower Urinary Tract – Bladder and Urethra Signs and symptoms of bladder rupture are non specific Frank haematuria occurs in 95%, m/scopic haematuria in the remainder Patient may complain of inability to void Suprapubic tenderness Intraperitoneal rupture (1/3 of all bladder injuries) is common in children

Management of Bladder injury Do NOT pass urethral catheter if there is blood at meatus Retrograde urethrography may be performed in place of IVU

Urethral Injury Commonly associated with Straddle injuries Patient may be unable to void Most patients will have blood at meatus and swelling/bruising of penis/scrotum and perineum. Rectal examination may reveal a “high-riding prostate”

Urethral Injury All patients require a urethrogram Do NOT attempt urethral catheterisation – may convert a partial tear into a complete rupture If patients require immediate laparotomy then bladder may be catheterised suprapubically Long term sequelae of this injury include incontinence, stricture, and impotence

Scrotal Trauma Testes may be damaged by direct blow If swelling is moderate it usually settles Severe swelling may require exploration to exclude testicular laceration

Urological Trauma – further reading ABC of major Trauma – Edited by Skinner et al. BMJ Publishing Group Renal and Ureteric Injuries – McAninch JW in Adult and Paediatric Urology (edited by Gillenwater) Genitourinary Trauma – Peters and Sagalowsky in Campbell’s Urology (edited by Walsh et al)

Paraphimosis May result from phimosis Commonly occurs in catheterised patients Good catheter care prevents this problem! May be reduced after gentle compression of glans and distal penis Occasionally may require surgical release of paraphimosis under LA (or GA in children)

Priapism A persistent painful erection that is not related to sexual desire Causes Intracavernosal pharmacotherapy for Erectile Dysfunction Idiopathic Penile or Spinal Cord trauma Assoc with Leukaemia, Sickle Cell disease or Pelvic Trauma

Priapism Early treatment is the key element Climbing stairs (arterial “steal” phenomenon) or ice packs may resolve Aspiration of Corpora cavernosa may be required

Priapism Two types Low flow (anoxic) – blood aspirated is dark and deoxygenated High flow – blood is bright red Infusion of alpha agonist (phenylephrine) may be tried in low flow priapism Surgical Shunting may be attempted as a last resort

Summary Renal Colic Testicular Torsion Trauma Paraphimosis Priapism

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