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

2. Content of the Presentation
Renal Colic
Testicular Torsion
Trauma
Paraphimosis
Priapism

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Testicular Torsion

12. 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%)

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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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”

23. 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

24. 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

25. 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)

26. 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)

27. 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

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

29. 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

30. Summary
Renal Colic
Testicular Torsion
Trauma
Paraphimosis
Priapism

31. Thank You