Urology Emergencies

MazinFY1 Urology / Gum

Testicular pain

• Torsion• Epididymo-orchitis• Mumps orchitis• Torsion of testicular appendages• Idiopathic scrotal oedema

• Age 13-20 common

Testicular Torsion

• Twist in the spermatic cord with subsequent strangulation of testicular blood supply

• 1 in 4000 males younger than 25 years* • 17% of acute scrotal presentations• Commonest (90%) cause of acute scrotal pain in

adolescent (13-21y) age group• More common in patients with cryptorchidism

*Srinivasan AK et al J Urol 2007

History• Sexual health history – recent unprotected sex• Ask young patients directly – alone

• Exam– High riding testicle, may be on its side– Red, tender, swollen– Scrotal wall edema if testicle is already dead– *Blue dot sign* in non-thick scrotums (pathognomonic)– Cremasteric reflex should be preserved

• Mgt: surgical exploration & fixation (both testicles)

Presentation

• On examination

– Swollen– Tender– High riding– Horizontal lie– Absent cremaster reflex

Testicular torsion• Pain to knife time is crucial• For acute testicular torsion: surgery within 6 hours of onset of

pain usually results in survival of testis, beyond 8 hours seldom

• In the adolescent all discussions of the acute scrotum start after exploration

• Ultrasound is of no diagnostic value• QEH: Age <16 years: Refer to Evelina / age >16 years: A&E

registrar to urology registrar referral• UHL: Refer to general surgery team • Testicular pain >24 hours: Doppler ultrasound is more useful

Aetiology Intra-vaginal (Bell-Clapper)

• Tunica vaginalis completely surrounds the testis

• Absence of normal posterior anchoring allows the testicle to twist freely

• Left testis is more frequently involved

• Bilateral cases account for 2% of all torsions

AetiologyExtra-vaginal

• Testis, epididymis, and tunica vaginalis twist on the spermatic cord

• 5% of all torsions• More common in neonates • Associated with high birth

weight

Prognosis• Rate of Salvage

Time since onset of symptoms (Hrs)

Salvage rate

<6 85 – 97%

6-12 55 – 85%

12-24 20 – 80%

>24 <10%-

Davenport M. 1996

Investigations

• Doppler ultrasound– Absent or decreased blood flow– Demonstrates flow in only 79-90% of

normal cases

• Radionuclide imaging– Technetium-99m pertechnetate– Decreased perfusion on symptomatic

side

None should delay surgical exploration!

Management

• All suspected torsions need to be explored, ideally within 6 hours

• Manual de-torsion (open like a book) may be attempted

• If no torsion, close scrotum, do perform orchidopexy on same side.

Torsion of testicular appendages

• Usually occurs in children aged 7-12 years

• Systemic symptoms are rare• Localized tenderness at upper pole

of testis• Occasionally (21%), blue dot sign is

present in light-skinned boys• Excision not mandatory if torsion

excluded

Torsion of Testicular Appendages

Appendix Epididymis – Remnant of part of Wolffian duct

Hydatid of Morgagni – Remnant of Mullerian duct

Epididymo-orchitis

• In young men think STI, in seniors usually associated with UTI

• Mild swelling, observations stable, afebrile: home + oral antibiotics (consider doxycycline)

• Severe swelling, high temperature, increased WBC: refer to Urology SHO for admission

Epididymo-orchitis – Reflux of infected urine– N. Gonorrhoea or C . Trachomatis STI– Excessive straining or lifting with reflux of urine

(chemical epididymitis).– Underlying congenital or acquire urological

abnormality may predispose– Often accompanied by systemic signs and

symptoms of UTI– Pyuria, bacteriuria and leucocytosis– Urethral swab and MSU should be obtained

Epididymo-orchitis • USS scan can differentiate from torsion but may miss

20% • If unsure - explore• Empirical antibiotics

– <35 years; Doxycycline– >35 years; Quinolone

• Minimum of 2 weeks treatment• Treat partner if Chlamydia identified• Complications; Chronic epididymitis, abscess,

infarction, chronic pain, infertility

Scrotal swelling DDx• Tumour• o Typically present with lump attached to testis• o Prognosis usually good• · Torsion• o Testicular pain in child (<4, 12+)• o Needs surgery within 2-4 hours to salvage

testis.• o Main differentials are torsion of hydatid, or

epididymal orchitis• (infection – may take months to resolve)• · Hydrocoele• o Most idiopathic, can be a reaction to insult.

~10% recur• o US if testes not palpable or to confirm

diagnosis• o Aetiology:• o young - patent processus• o old - fluid forms in scrotum

• · Epididymal Cysts• o Can be excised, but frequently recur• o Often multiple small cysts as well as presenting

lump• o Main differential – spermatocoele.• · Varicocoele• o Look like hernia, but no cough impulse, tend to go

if patient supine.• o More common on the left.• o Can be caused by renal tumour• o Consider surgery:• o Embolise• o Laparascopic• o Open - least chance of recurrence• o Pain may persist after surgery• · Haematoma• o Should be history of trauma• · Inflammation• · Hernia

Renal stones

• Obstructed infected kidney loses function in 3 days• Simple renal stones: 5-6 mm, distal ureter, normal

U&Es, normal other kidney: Home (analgaesia + tamsulosin) – outpatient clinic in 3 weeks

• Complex renal stones: Size >6mm, proximal ureter, moderate hydronephrosis, deranged renal function: refer to Urology SHO for admission

• Obstructed infected kidney: high temperature, observations: non-stable: consider nephrostomy

Stones

• Formation of calculi in renal tract• Ratio Male 3: Female 1• 20 – 50 years old, 10% caucasian males• RF

– Westerners, warm climates, occupation, FHx, diet, seasonal, medical conditions, anatomical deformities

– Supersaturation / crystalisation

Stones: Composition and lucency

• Calcium Oxalate (<85%)• Calcium Phosphate/oxalate (~15%)• Uric Acid (10%)• Struvite (<20%)• Cysteine (1%)• Indinavir

Stones: Differential diagnosis

• Acute Pyelonephritits• Ruptured AAA• Appendicitis• Other renal condition• UTI• Ruptured ectopic pregnancy

History

• Loin to groin pain, N&V, haematuria, ureteric irritation (T12-L2), urgency, frequency, UTI

• Examination: Full abdo & external genitalia• Absence of peritonitis• Temp, chills, rigors, ?urosepsis• *Retrosternal appendix can cause same pain

Workup

• Don’t bother with plain films – need CT KUB• Or IVU (conta in: *Contrast allergy, Metformin,

asthmatics*)• Urinalysis & MSU• Pregnancy test• Bloods• ?Metabolic screen (calcium, uric acid)

KUB

IVU

CT KUB

Conservative management

• Renal calculi– Asymptomatic, small, peripheral, associated

medical problems

• Ureteric calculi– <5mm, asymptomatic, no radiological signs of

obstruction

Mgt• Increase oral fluids (IV), antiemetics• Analgaesics (morphine, NSAIDs)• Conservative Medical expulsive therapy (Tamsulosin)• Shock wave lithotripsy (ESWL)• Flexible cystoscopy / Ureteroscopy• Percutaneous surgery (PCNL) / nephrostomy +/- ureteric stent

insertion• Correct metabolic abnormality• Treat infection promptly• Reduce calcium intake (Thiazide diuretics for idiopathic

hypercalcaemia)• Urinary alkalisation (eg. Sodium bicarbonate in water)

Extracorporeal Shock Wave Lithotripsy

• Stone absorbs energy• Cavitation effect• Fractures stones• Sand like material as end

product

Lithotripsy

• Shock waves• Perspex lens• Focused on stone• Fragments pass• 3 treatments if no progress

Ureteroscopy

Urinary retention

• Acute over distension injuries produce lasting bladder dysfunction

• Residual volume <1L, normal kidney functions: Home, urology clinic (consider TWOC clinic beforehand if no prior symptoms)

• Residual volume >1L, deranged kidney function: Refer to urology SHO for admission

• Remember that the role of DRE for diagnosis of prostate cancer; do not do PSA test in acute situation

• Default optimal catheter size is 16 Fr silicone

History

• Inability to void• Long journey prior• Abdo pain improves with catheter

• Chronic urinary retention -> bedwetting -> overflow

Ask

• Painful / painless• Inability to void?• Precipitated?

– (alcohol, surgery, constipation, UTI)• Back pain – neurology ?cord compression• Background LUTS• DRE (prostate / rectum) – tumour

Examination

• Examination:

– General

– Bladder palpable? Scars?

– Meatus/genitalia

– DRE (prostate/rectum)

– Neurology

Workup

• Catheterise urgently• Urethral vs SPC• Document residual volume• Strict input / output Diuresis (>200 ml/h

over 24 h)• U&E – check PSA (NOT acutely)• Renal function tests• Alpha blocker?

Catheter problems

• Catheter to be changed in casualty with a single dose of antibiotic

• Urology assistance via SHO is for failed catheter by skilled practitioner, fever, bleeding or escaped suprapubic catheter

• Only a small number of these patients require admission

Haematuria

• Common diagnostic yield: infections, stones, malignancy• Microscopic haematuria: 2ww outpatient one stop

haematuria clinic• Frank haematuria• Mild, rose colour, non-obstructing, no clots, stable,

normal haemoglobin: 2ww one stop• Severe, clots, red wine colour, deranged haemoglobin: 3

way catheter 22 Fr, start irrigation, refer to urology SHO for admission

• Please send for MSU culture and sensitivity

WorkupVisible vs Non visible

History:

Painful vs Painless

Where in stream?

How heavy? Clots?

Duration. Other symptoms

Smoking? Occupation? DHx (warfarin etc)

Examination

• General:

Well or Unwell?

Shock? (BP/pulse/urine OP/CRT)

Temperature

Bladder palpable?

DRE

HaematuriaInvestigations:

Urinalysis/MSU

Bloods (FBC/UE/clotting)

?PSA

?imaging

Workup Management:

Resuscitate?

Catheterise – Size?

Washouts/irrigate

Fluids/blood tx?

Definitive investigation – cystoscopy/USS

Fournier's gangrene

Urosepsis Sepsis +/- septic shock

Often diabetic/elderly/catheter

Bloods, MSU/CSU, ABG, blood cultures

Resuscitate – ABC, fluids, Oxygen

Close observation

IV broad spectrum antibiotics

Early USS +/- nephrostomy

Post-Operative Patients

• If a patient attends with post-operative problems or complications, the relevant specialty SHO should be informed and they should discuss with their registrar directly