Urological Emergencies for the Urological Emergencies for the Non-UrologistNon-Urologist

Mr C Dawson MS FRCSMr C Dawson MS FRCSConsultant UrologistConsultant UrologistEdith Cavell HospitalEdith Cavell Hospital

PeterboroughPeterborough

Content of the PresentationContent of the Presentation

Renal ColicRenal Colic Testicular TorsionTesticular Torsion TraumaTrauma ParaphimosisParaphimosis PriapismPriapism

Renal ColicRenal Colic

Does not always present with classic Does not always present with classic historyhistory

Classically presents with loin pain Classically presents with loin pain radiating around abdomen, as stone radiating around abdomen, as stone moves down uretermoves down ureter

May get testicular/labial pain +/- May get testicular/labial pain +/- strangury if stone impacts at VUJstrangury if stone impacts at VUJ

Renal Colic Renal Colic

Full examination essential – primarily to rule Full examination essential – primarily to rule out other causes for painout other causes for pain

Look for signs of SepsisLook for signs of Sepsis Differential diagnosis includesDifferential diagnosis includes

– Acute AppendicitisAcute Appendicitis– DiverticulitisDiverticulitis– SalpingitisSalpingitis– Ruptured Aortic AneurysmRuptured Aortic Aneurysm– PyelonephritisPyelonephritis– Ectopic PregnancyEctopic Pregnancy

Renal Colic - InvestigationsRenal Colic - Investigations

Routine Urinalysis – microscopic haematuria Routine Urinalysis – microscopic haematuria is common but not invariableis common but not invariable

IVPIVP– Particularly in patients over 50 (?AAA)Particularly in patients over 50 (?AAA)– USS and KUB if contrast allergicUSS and KUB if contrast allergic– Caution in PregnancyCaution in Pregnancy

Pregnancy Test in all fertile women of child Pregnancy Test in all fertile women of child bearing agebearing age

Renal Colic - ManagementRenal Colic - Management

If NO signs of ureteric obstruction on IVP If NO signs of ureteric obstruction on IVP AND Pain freeAND Pain free– Home with explanation of symptomsHome with explanation of symptoms– Review after 2/52 in OPDReview after 2/52 in OPD

If IVP shows obstruction of ureterIf IVP shows obstruction of ureter– Admit for observationAdmit for observation– May still be allowed home for trial of stone May still be allowed home for trial of stone

passagepassage If Obstructed AND signs of SepsisIf Obstructed AND signs of Sepsis

– Urgent NephrostomyUrgent Nephrostomy

Renal Colic - ManagementRenal Colic - Management

Size of StoneSize of Stone

< 4mm< 4mm

4-6 mm4-6 mm

> 6mm> 6mm

ManagementManagement

Conservative: 90% pass Conservative: 90% pass spontaneouslyspontaneously

50% pass spontaneously 50% pass spontaneously – trial of passage– trial of passage

Intervention likely, only Intervention likely, only 10% pass 10% pass spontaneouslyspontaneously

Testicular TorsionTesticular Torsion

Can occur at any ageCan occur at any age Most common in adolescentsMost common in adolescents Occasionally seen in neonatesOccasionally seen in neonates In infants (and esp neonates) the In infants (and esp neonates) the

symptoms and signs are imprecisesymptoms and signs are imprecise Prompt action required to avoid Prompt action required to avoid

irreversible testicular ischaemiairreversible testicular ischaemia

Testicular TorsionTesticular Torsion

Diagnosis usually made solely on basis Diagnosis usually made solely on basis of clinical examinationof clinical examination– Testis usually swollen and exquisitely Testis usually swollen and exquisitely

tendertender– Lies horizontally and retracted compared to Lies horizontally and retracted compared to

normal sidenormal side

Testicular TorsionTesticular Torsion

Studies have shown that only 25% of boys Studies have shown that only 25% of boys presenting with acute scrotal swelling with presenting with acute scrotal swelling with have torsionhave torsion

No reliable diagnostic test existsNo reliable diagnostic test exists Doppler USS can effectively establish the Doppler USS can effectively establish the

presence of arterial inflowpresence of arterial inflow Surgical exploration remains the final arbiter, Surgical exploration remains the final arbiter,

and should not be delayed whilst waiting for and should not be delayed whilst waiting for investigationsinvestigations

Testicular TorsionTesticular Torsion

Urological TraumaUrological Trauma

Fortunately very rareFortunately very rare Typical victimsTypical victims

– Young men involved in sport (55%)Young men involved in sport (55%)– People in RTAs (25%)People in RTAs (25%)– Domestic or industrial accidents (15%)Domestic or industrial accidents (15%)– Victims of Assault (5%)Victims of Assault (5%)

Urological TraumaUrological Trauma

Upper Urinary TractUpper Urinary Tract– Renal injuriesRenal injuries

Lower Urinary TractLower Urinary Tract– BladderBladder– UrethraUrethra– External GenitaliaExternal Genitalia

Urological Trauma - OverviewUrological Trauma - Overview

Take a careful historyTake a careful history– Mechanism of injury (blunt trauma, penetrating Mechanism of injury (blunt trauma, penetrating

trauma)trauma)– Velocity of injuryVelocity of injury

Careful AssessmentCareful Assessment– Careful ExaminationCareful Examination– ABC of Primary SurveyABC of Primary Survey– Baseline InvestigationsBaseline Investigations– Appropriate Radiology and additional imagingAppropriate Radiology and additional imaging

Primary SurveyPrimary Survey

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

Renal TraumaRenal Trauma

The Kidney is the most commonly injured The Kidney is the most commonly injured urological organurological organ

Injuries can be blunt (80-90%) or penetratingInjuries can be blunt (80-90%) or penetrating Blunt trauma occurs with upper abdominal Blunt trauma occurs with upper abdominal

injury and rapid decelerationinjury and rapid deceleration Such injuries usually involve multiple organ Such injuries usually involve multiple organ

systems and patients – other injuries must be systems and patients – other injuries must be suspected and excludedsuspected and excluded

Renal Trauma – Radiological Renal Trauma – Radiological AssesmentAssesment

Adult patient with blunt traumaAdult patient with blunt trauma– Visible haematuria, or microscopic Visible haematuria, or microscopic

haematuria and shock - haematuria and shock - NeedsNeeds Radiological assessmentRadiological assessment

– Microscopic haematuria without shock – Microscopic haematuria without shock – radiological assessment radiological assessment not requirednot required

Adult patients with penetrating trauma / Adult patients with penetrating trauma / All Paediatric patients – require All Paediatric patients – require radiological assessmentradiological assessment

Renal traumaRenal trauma

Radiological Assessment should begin with IVU – Radiological Assessment should begin with IVU – Most patients adequately staged this wayMost patients adequately staged this way

CT has largely replaced the arteriogram and IVU in CT has largely replaced the arteriogram and IVU in the diagnosis and management of severe abdominal the diagnosis and management of severe abdominal or GU traumaor GU trauma

Patients who are haemodynamically unstable will Patients who are haemodynamically unstable will require immediate laparotomyrequire immediate laparotomy

85% of blunt renal injuries require no surgery, 5-10% 85% of blunt renal injuries require no surgery, 5-10% require judgement and surgical exploration, 5% are require judgement and surgical exploration, 5% are non-salvageable and require nephrectomynon-salvageable and require nephrectomy

Lower Urinary Tract – Bladder Lower Urinary Tract – Bladder and Urethraand Urethra

Approx 90% of bladder injuries result Approx 90% of bladder injuries result from blunt traumafrom blunt trauma

The bladder is commonly injured in The bladder is commonly injured in pelvic fracturespelvic fractures

The bladder in a child is an abdominal The bladder in a child is an abdominal (not pelvic) organ and is more (not pelvic) organ and is more vulnerable to injuryvulnerable to injury

Lower Urinary Tract – Bladder Lower Urinary Tract – Bladder and Urethraand Urethra

Signs and symptoms of bladder rupture Signs and symptoms of bladder rupture are non specificare non specific

Frank haematuria occurs in 95%, Frank haematuria occurs in 95%, m/scopic haematuria in the remainderm/scopic haematuria in the remainder

Patient may complain of inability to voidPatient may complain of inability to void Suprapubic tendernessSuprapubic tenderness Intraperitoneal rupture (1/3 of all bladder Intraperitoneal rupture (1/3 of all bladder

injuries) is common in childreninjuries) is common in children

Management Management of Bladder of Bladder injuryinjury Do NOT pass Do NOT pass

urethral catheter if urethral catheter if there is blood at there is blood at meatusmeatus

Retrograde Retrograde urethrography may urethrography may be performed in be performed in place of IVUplace of IVU

Urethral InjuryUrethral Injury

Commonly associated with Straddle Commonly associated with Straddle injuriesinjuries

Patient may be unable to voidPatient may be unable to void Most patients will have blood at meatus Most patients will have blood at meatus

and swelling/bruising of penis/scrotum and swelling/bruising of penis/scrotum and perineum.and perineum.

Rectal examination may reveal a “high-Rectal examination may reveal a “high-riding prostate”riding prostate”

Urethral InjuryUrethral Injury

All patients require a urethrogram All patients require a urethrogram Do NOT attempt urethral catheterisation – Do NOT attempt urethral catheterisation –

may convert a partial tear into a complete may convert a partial tear into a complete rupturerupture

If patients require immediate laparotomy then If patients require immediate laparotomy then bladder may be catheterised suprapubicallybladder may be catheterised suprapubically

Long term sequelae of this injury include Long term sequelae of this injury include incontinence, stricture, and impotenceincontinence, stricture, and impotence

Scrotal TraumaScrotal Trauma

Testes may be damaged by direct blowTestes may be damaged by direct blow If swelling is moderate it usually settlesIf swelling is moderate it usually settles Severe swelling may require exploration Severe swelling may require exploration

to exclude testicular lacerationto exclude testicular laceration

Urological Trauma – further Urological Trauma – further readingreading

ABC of major Trauma – Edited by ABC of major Trauma – Edited by Skinner et al. BMJ Publishing GroupSkinner et al. BMJ Publishing Group

Renal and Ureteric Injuries – McAninch Renal and Ureteric Injuries – McAninch JW in Adult and Paediatric Urology JW in Adult and Paediatric Urology (edited by Gillenwater)(edited by Gillenwater)

Genitourinary Trauma – Peters and Genitourinary Trauma – Peters and Sagalowsky in Campbell’s Urology Sagalowsky in Campbell’s Urology (edited by Walsh et al)(edited by Walsh et al)

ParaphimosisParaphimosis

May result from phimosisMay result from phimosis Commonly occurs in catheterised patientsCommonly occurs in catheterised patients Good catheter care prevents this problem!Good catheter care prevents this problem! May be reduced after gentle compression of May be reduced after gentle compression of

glans and distal penisglans and distal penis Occasionally may require surgical release of Occasionally may require surgical release of

paraphimosis under LA (or GA in children)paraphimosis under LA (or GA in children)

PriapismPriapism

A persistent painful erection that is not related A persistent painful erection that is not related to sexual desireto sexual desire

CausesCauses– Intracavernosal pharmacotherapy for Erectile Intracavernosal pharmacotherapy for Erectile

DysfunctionDysfunction– IdiopathicIdiopathic– Penile or Spinal Cord traumaPenile or Spinal Cord trauma– Assoc with Leukaemia, Sickle Cell disease or Assoc with Leukaemia, Sickle Cell disease or

Pelvic TraumaPelvic Trauma

PriapismPriapism

Early treatment is the key elementEarly treatment is the key element Climbing stairs (arterial “steal” Climbing stairs (arterial “steal”

phenomenon) or ice packs may resolvephenomenon) or ice packs may resolve Aspiration of Corpora cavernosa may Aspiration of Corpora cavernosa may

be requiredbe required

PriapismPriapism

Two typesTwo types Low flow (anoxic) – blood aspirated is dark and Low flow (anoxic) – blood aspirated is dark and

deoxygenateddeoxygenated High flow – blood is bright redHigh flow – blood is bright red

Infusion of alpha agonist (phenylephrine) may Infusion of alpha agonist (phenylephrine) may be tried in low flow priapismbe tried in low flow priapism

Surgical Shunting may be attempted as a last Surgical Shunting may be attempted as a last resortresort

SummarySummary

Renal ColicRenal Colic Testicular TorsionTesticular Torsion TraumaTrauma ParaphimosisParaphimosis PriapismPriapism

Thank YouThank You