Non-Traumatic

Urologic Emergencies

By Extern Worawalun Honglertnapakul

Non-Traumatic
Urologic Emergencies
 Acute ureteric obstruction
 Acute urinary retention
 Surgical anuria
 Hematuria
 Phimosis & Paraphimosis
 Acute scrotal pain
 Fournier’s gangrene
 Priaprism
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Acute ureteric
obstruction
Acute ureteric obstruction
 Incidence: adult male
 Causes:
 Acute intraluminal obstruction eg.
Calculus, blood clot, debris
 Acute extraluminal obstruction
 S&S:
 CVA tenderness
 Colicky pain
 Referred pain to ipsilateral scrotum or
glans penis / clitoris
 N/V
 Segmented bowel ileus
 Rebound tenderness
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Acute ureteric obstruction
 Complications:
 Hydronephrosis
 Infection (UTI)
 Decreased renal function
 DDx:
 Acute ureteric calculus obstruction
 Acute intraluminal & extraluminal
ureteric obstruction from other causes
 Acute flank or abdominal pain from
other causes eg. Dissecting aneurysm,
acute cholecystitis, acute pancreatitis,
acute appendicitis, torsion ovarian cyst,
ectopic pregnancy
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Acute ureteric obstruction

 Investigation:
 UA: RBC
 X-ray KUB

 IVP (sens 64%, spec 92%)

 CT scan (sens 100%, spec 92%)

 renal failure
 allergy to contrast

 U/S
 Hydronephrosis
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Acute ureteric obstruction

 Treatment:
 Symptomatic:
 Analgesics
 Alpha1-blocker eg. Doxazosin 1-2 mg

 Definitive:
 ureteroscopy
 ureterolithotomy

 ESWL (extracorporeal shockwaves

lithotripsy)

7
Acute urinary retention
Acute urinary retention

 Incidence: senile male

 Causes:
 Obstruction site lower than
bladder eg. BPH
 Sudden functional impairment of
detrusor muscle
 combination

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Acute urinary retention

 S&S
 Acute
 ปวดอยากถ่ายปัสสาวะ
 แต่ปัสสาวะไม่ออก หรือ ออกกะปริบกะปรอย

 Full bladder c tenderness

 Chronic
 Full bladder, not tender
 Overflow incontinence

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Acute urinary retention
 DDx:
 Anuria
 Chronic urinary retention

 Midline lower abdominal pain from other

causes
 Treatment:
 Symptomatic: analgesics, Foley cath.,
suprapubic cystostomy
 Definitive: treat causes

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Surgical anuria
Surgical anuria
 Definition:
 Oliguria <400 cc in 24 hr
 Medical anuria <100 cc in 24 hr

 Surgical anuria = no urine

 Causes: post renal

 Stone or any other abstruction of both
ureter
 DDx:
 Acute urinary retention
 Medical anuria eg. ATN
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 Surgical anuria
factors Surgical anuria Medical anuria
Urine None <100 cc

Onset Hours Days

History Passing stone Anemia
CA cervix Fatique
Operation in pelvic or HT
retroperitoneal area Pitting edema
Pain in renal area Nephrotoxic
Hematuria or pyuria substances
PE CVA tenderness No CVA tenderness
Mass at renal area No mass
Lab RBC in UA Anemia
Uric acid crystal Proteinuria/Cast
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Rising BUN Cr Rising BUN Cr
Surgical anuria
 Investigation
 U/S: hydronephrosis
 Plain KUB

 Cystourethroscopy & Retrograde

pyeloureterography
 Percutaneous nephrostomy (PCN) &
Anterograde pyeloureterography
 Treatment
 Drainage via Cystourethroscopy or PCN
 Definitive: treat causes eg. Remove
stone 15
Hematuria
Hematuria
 Macroscopic hematuria: gross
hematuria
 Microscopic hematuria: RBC>3/HPF
 Causes:
 Surgical diseases
 Congenital eg. ADPKD, AVM
 Infection/Inflammation eg. UTI, cystitis,
prostatitis
 FB eg. Stone
 Tumors eg. CA bladder, CA kidney, BPH
 trauma
 Medical diseases
 Coagulopathy 17

 Nephrologic diseases eg. AGN

Hematuria
 DDx:
 Hematuria
 Initial  urethra, prostate
 Terminal  bladder
 Total  kidney, ureter, bladder

 Characteristics of blood clot

 เส้นกลมเล็ก kidney
 เส้นกลมใหญ่ ureter
 ไม่แน่นอน เป็นก้อน เป็นแผ่น bladder
 Painful urination
 Initial  distal urethra
 Terminal  bladder eg. Acute
18
hemorrhagic cystitis
Hematuria
 Approaches:
 True hematuria
 Persistent hematuria
 Location
 IVP
 Cystoscopy, Retrograde pyelography
 Treatment:
 Clot retention  Acute urinary retention
 Intermittent cath c irrigation
 Continuous bladder irrigation
 Massive blood loss  shock
 Resuscitation
 Definitive: treat causes 19
Phimosis

Paraphimosis
Phimosis & Paraphimosis
 Phimosis: the
prepuce of an
uncircumcised
male cannot be
fully retracted
 Paraphimosis: the
prepuce becomes
trapped behind the
glans penis, and ca
nnot be pulled back
to its normal flaccid
position covering th
e glans penis
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Phimosis

 Physiologic phimosis:
 96% of male infants
 Pathologic (true) phimosis:
 1% of 14 yrs old male
 Causes:
 Congenital

 Acquired
 Tearing and inflammation of prepuce
 Chronic balanoposthitis
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Phimosis
 Complications:
 Paraphimosis
 Acute balanoposthitis
 Chronic balanoposthitis 
Balanitis Xerotica Obliterans
 Risk for STD
 Risk for premalignant lesions

 Treatment
 Topicalsteroid or NSAIDS
 Circumcision
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Paraphimosis
 S&S:
 Venous & lymphatic congestion of
glans penis
 Inflammation
 Difficult urination

 Treatment of paraphimosis
 Reduction
 Elastic bandage
 Tourniquet c needle
 Dorsal slit

 circumcision 24
Acute scrotal pain
Acute scrotal pain
 Incidence: teenage & young adult
male
 Causes:
 Testes eg. Torsion spermatic cord,
tosion testicular appendages, acute
epididymitis
 Scrotum eg. Necrotizing fasiitis
(Fournier’s gangrene)
 Adjacent organ eg. Incarcerated/
strangulated inguinal hernia
 Radiating pain eg. Ureteric stone
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Acute scrotal pain

 Emergency:
 Torsion spermatic cord
 Incarcerated/ strangulated inguinal
hernia
 Acute necrotizing fasciitis

 Not emergancy:
 Torsiontesticular appendages
 Acute epididymitis

 Acute hydrocele
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 Clinical Torsion Torsion Acute Incarcerated
features spermatic cord appendage epididymitis inguinal
testis hernia

Age Preadolescence Preadolescenc Adolescence, Infancy

incidence e; younger than young adult
torsion testis

Onset of Sudden, Sudden, Gradual, Sudden,

pain severe moderate; may become severe;
localized to severe; increase
upper pole of when testis
early on limited
testis lifted
to epididymis
(blue dot) and cord

History Trauma to Trauma to Concurrent UTI Prematurity;

scrotum, scrotum or urethritis, hernia noted
cryptorchidism, recent urologic on prior
previous attack instrumentation examination
of similar pain 28
 Clinical Torsion Torsion Acute Incarcerated
features spermatic cord appendage epididymitis inguinal
testis hernia

Groin No, No No yes

swelling except in case of
cryptorchidism
Mobility of Movable testis; Fix at upper Movable testis; Fix at groin
mass increase of pain pole of testis relief of pain
when lifted when lifted
(Prehn’s sign)

Overlying No, initially No, initially Yes no

skin Yes, after Yes, after
redness several hours several hours
but located to
proximal
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scrotum
 Clinical Torsion Torsion Acute Incarcerated
features spermatic appendage epididymitis inguinal
cord testis hernia

Associated RLQ abdominal Fever,dysuria Signs of

features pain, nausea, UA: pyuria, bowel
vomiting bacteriuria obstruction,
Spermatic cord: billous
CBC:
thickening but vomiting
leukocytosis
not tender Spermatic cord:
exquisitively
tender

Position of Lies transverse, Normal Normal Normal

testis high in scrotum

Cremasteric Absence Present Present present

reflex 30
 Diseases Radionuclide scan or
color-coded duplex U/S

Torsion spermatic cord Testis/epididymis: decreased uptake

Scrotal skin: normal uptake; later may
increase uptake

Torsion appendage testis Testis/epididymis: normal uptake c

localized area of increase uptake near
upper pole

Acute epididymitis Testis/epididymis: increased uptake

Scrotal skin: increased uptake

Incarcerated inguinal hernia Testis/epididymis: normal uptake

Scrotal skin: normal uptake
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Torsion spermatic cord
 Risks:
 Bell Clapper

 Undescended testis
 Ectopic testis 32
Torsion spermatic cord

 Testicular infarction in 2 hr
 Irreversible ischemia in 6 hr
 Golden period
 Complete infarction in 24 hr
 Treatment:
 Detorsion: lateral rotation
 Definitive: orchiopexy both sides,
orchidectomy
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Acute epididymitis

 Treatment:
 Bed rest, avoid strenuous exercise
 Analgesics, NSAIDS, local
anesthesia
 Lift testis

 ATB cover gram negative

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Torsion testicular appendages

 Treatment
 Symptomatic: analgesics, warm
compression

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Incarcerated/ strangulated
inguinal hernia
 Treatment:
 Surgery
 Herniorrhaphy
 Hernioplasty

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Fournier’s gangrene
Fournier’s gangrene

 Necrotizing soft tissue infection

or necrotizing fasciitis of
genitalia, perineum, or perianal
area
 Life threatening infection
 Characteristics
 Systemic toxicity
 Rapid progression

 Mortality rate = 25-100% 38

Fournier’s gangrene
 Incidence
 Teenage male
 U/D eg. alcoholism, DM
 Sources of infection
 Urogenital (45%) eg. Urethral
stricture c periurethral abscesses,
epididymo-orchitis, post surgical
procedures, instrumentation
 Anorectal (33%) eg. Perirectal
abscesses, post anorectal surgical
procedures
 Dermal (21%)

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Fournier’s gangrene
 Polymicrobial infection
 Escherichia coli
 Bacteroides
 Streptococcal species
 Staphylococci
 Peptostreptococci
 Clostridia
 Synergistic necrotizing fasciitis
 Patho: infective obliterative
thromboarteritis of
subcutaneous arteries 40
Fournier’s gangrene

 Virulence factors cause

 Vascular thrombosis
 Gram negative septicemia

 Direct tissue damage/necrosis

 Gas formation

 Counteract host defense

mechanism

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Fournier’s gangrene

 S&S:
 Systemic toxicity: high grade fever
or hypothermia, tachycardia,
vascular volume depletion, mental
status change, organ failure,
septicemia
 Local: nonspecific inflammatory
signs, skin discoloration, crepitus
 Persistent or progression of
inflammatory process
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Fournier’s gangrene
 Investigation:
 Lab, hemoculture
 U/S, CT, MRI

 Treatment:
 Systemic resuscitation
 ATB: broad spectrum triple drugs
regimen eg.
 Semisynthetic penicillin or vancomycin
 Aminoglycosides or 3rd gen
cephalosporins
 Metronidazole or clindamycin

 Aggressive debridement (radical) 43

Fournier’s gangrene

Multiple Limited Aggressive

incisions excision of debridement
+ necrotic on
ATB tissue emergency
basis

Mortality rate 100% 70% 10%

 Mortality rate depends on

aggressiveness of operation
intervention
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Priaprism
Priaprism
 Persistent abnormal erection of
penis, accompanied by pain and
tenderness, resulting from a
pathological condition rather
than sexual desire
 Incidence: all age group
 Child: leukemia, sickle cell
disease
 After puberty: unknown cause
 Senile: malignant neoplasm
46
Priaprism
 Causes:
 Primary(idiopathic) 60%
 Secondary:
 Thromboembolic (sickle cell anemia,
leukemia,fat emboli)
 Trauma to perineum and genitalia
 Neurogenic (spinal cord lesion,
anesthesia)
 Malignant penile infiltration (prostatic
cancer, bladder cancer)
 Oral medications (chlopromazine,
trazodone, sildenafil) 47
Priaprism

 Pathophysiology:
 Low-flow (veno-occlusive,
ischemic) most common
 Venous congestion
 Hypoxia of corpora cavernosa

 Ischemic pain

 High-flow (non ischemic) from

perineal or genital trauma
 Cavernous artery injury
 Malignant cell infiltration
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Priaprism

 Low-flow type is a true emergency

 Blood gas
 Color-coded duplex scan

 Treatment
 Low-flow: good result if < 12 hr
 Needle
 Phenylephrine

 Shunt

 High-flow:angiographic embolization
 Malignant: treat cause
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The
end
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