1. Emergency Room Urology
Dr. Syah Mirsya Warli, SpU
Dr. Bungaran Sihombing,SpU
Div. of Urology, Surgery Dept.
Medical Faculty,
University of Sumatera Utara

2. Ref :
Clinical Manual of Urology, (Philip M. Hanno et al eds), McGraw-Hill Int ed, 3rd ed, 2001
Smith’s General Urology (Tanagho & McAninch eds), Lange Medical Books, 15th ed, 2000

3. Genitourinary Emergencies
Pain
Testicular Torsion
Hematuria
Urinary Retention
Oliguria & anuria
Priapism
Foreskin emergencies

4. Pain Flank Pain DD : calculus pyelonephritis renal trauma
renal vein thrombosis
cholecystitis

5. Pain Flank Pain : Renal Colic
Sudden onset, no relief with change of position
Nause & vomiting
Diagnosis studies :
- urinalysis
- non-contrast CT scan
- plain radiograph
- white count and serum creatinin
- urine culture
- IVP

6. Indications for admission for renal calculi
Obstructing stone in a patient with a solitary kidney
Fever and infection associated with an obstructing stone
Inability to maintain oral hydration
Pain refractory to oral analgesics
High-grade obstruction from a stone that is too large to pass spontaneously

7. Pain Flank Pain : Pyelonephritis
Onset subacute, constant
Exacerbated by movement
Prodrome of cystitis symptoms  clue
Ask about previous history of urolithiasis, UTI and urologic surgery

8. Pain Suprapubic Pain DD : urinary retention, cystitis
bladder stones, gynecologic problems
interstitial cystitis
Retention & cystitis must be diagnosed in the ED
History : voiding function, gross hematuria,
urinary retention
Palpate the bladder
Pelvic exam in women

9. Testicular Torsion Incidence 1: 4000
Most serious of acute problems affecting the scrotal contents
2 peak incidences
Neonatal period
Puberty

10. Testicular Torsion Why does it happen?
Testes not adequately anchored to the tunica vaginalis

11. Testicular Torsion Symptom complex
Sudden onset of severe testicular pain
Constant & progressive
Nausea (+)
Fever, urethral discharge, cystitis symptoms (-)

12. Testicular Torsion Physical examination
Edematous scrotum
Tender, swollen testis
Testis high in scrotum with horizontal lie  classical sign
Cremasteric reflex (-)
“bell-clapper deformity”
Pain not relieved with elevation of scrotum

14. TORSION

15. Testicular Torsion: Diagnosis
Doppler USG now test of choice for Dx of torsion. Sensitivity comparable to radioisotope scans (86%-100%) and greater specificity (100%).
Doppler U/S is more rapid and more available than radioisotope scans.

16. Testicular Torsion: Management
Immediate Urologic consultation for surgical exploration and possible bilateral orchidopexy if diagnosis is obvious
Manual detorsion  rotating the testicle in a medial to lateral direction, “open the book” maneuver
Emergent surgery is still required to assure complete detorsion and perform contralateral orchidopexy
In patients with consistent history and physical exam, no cremasteric reflex, no urethral discharge, no recent urinary tract infection a diagnosis of Testicular torsion should be seriously considered with immediate urological consultation
U/S only has a role if diagnosis is uncertain

17. Gross Hematuria Etiology : 1. Common cause  infections, stones,
malignancies (bladder, kidney), BPH,
trauma, post op
2. Less common cause  radiation or
chemical cystitis, sickle cell disease,
coagulopathy.

18. Gross Hematuria
All patients presenting with gross hematuria must have urologic follow-up, even if the bleeding spontaneously resolves.
Bladder tumors classically bleed intermittently and diagnosis can be delayed if patients are not appropriately counseled

19. Urinary Retention History : age, general health
premorbid voiding symptoms
history of urethral strictures
previous episodes of retention
prior urologic manipulation or surgery (TURP, radical
prostatectomy)
medication (sympathomimetics, anticholinergics)
incontinence
Estimated 10% of men in their 70s and 33% of men in their 80s will have at least 1 episode.

20. Urinary Retention Etiology
Anatomic obstruction :
1. BPH (most common)
2. Urethral stricture
3. Bladder neck contracture
4. Prostate Ca (uncommon)
Functional obstruction :
1. Neurologic disease (CNS or peripheral)
2. Medication side effect
3. Pain (nociceptive retention)  post op, post trauma
4. Psychogenic
Alpha adrenergics induce bladder neck hypertonicity which can result in AUR

21. Urinary Retention : Management
16 or 18 F Standard Urethral Catheter, adequate lubrication of the catheter
If fails  Urology consult for SPT
No patient in retention should be instrumented, drained, and then discharged from ED without a clear plan for urologic follow-up

22. Oliguria & anuria Anuria  urine output < 50 ml / 24 h
Evaluation & treatment :
- Physical exam & urethral catheterization
- USG  bilateral hydronephrosis
no hydronephrosis
unilateral hydronephrosis

23. Priapism
The pathologic prolongation of penile erection, accompanied by pain & tenderness
Not by sexual excitement
Not relieved by orgasm
42% of men with sickle cell disease will have at least 1 episode of veno-occlusive priapism

24. Foreskin Emergencies Phimosis
The uncircumcised foreskin cannot be retracted over the glans
Catheterized with a coude tip

26. Foreskin Emergencies Paraphimosis
The uncircumcised foreskin has been left in the retracted position  obstruction to venous & lymphatic drainage  progressive edema
True urologic emergency
Th/ : immadiate manual reduction
If fail  dorsal slit

27. Phimosis vs. Paraphimosis
Phimosis: inability to retract foreskin
Tx: dorsal slit or circumcision
Paraphimosis: foreskin retracted behind coronal groove; tourniquet to glans
Tx: circumcision

28. Foreskin Emergencies Zipper Injuries
Common source of genital laceration
Th/ : adequate analgesia & disassembly the zipper
Using a cutter  median bar of the zipper is completely cut  the teeth of the zipper fall apart

29. Foreskin Emergencies External rings
Often used as sexual aids  edema, urethral fistula, necrosis
Managed with ring cutter
Immediate removal of the object & debridement

30. Foreskin Emergencies Intraurethral foreign bodies
Evaluate radiographically
Don’t catheterized  place SPT if retention
If distal to the external sphincter  object will be palpable & can often be removed endoscopically
If proximal to the sphincter  open extraction

31. Foreskin Emergencies Post-circumcision complications
Hematoma  drained by removing a stitch & evacuating the clot. Replace dressing
Bleeding
- steady pressure 10 – 15’
- if fail  lidocaine (1: ephinephrine) & apply
pressure 10 – 15’ more
- skin edges may be cauterized with silver nitrate sticks
- significant bleeding  suture placement under
penile block with lidocaine

32. Foreskin Emergencies Post-circumcision complications
Disruption of incision
- if small  no th/
- if major  place a few interrupted suture under penile block
Infection
- uncommon & usually minor
- th/ : oral cephalosporine

33. the end
wr 2009