Urology Emergencies

Mazin
FY1 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
 Aetiology
Extra-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 Salvage rate

of symptoms (Hrs)
<6 85 – 97%

6-12 55 – 85%

12-24 20 – 80%

>24 <10%-

Davenport M. 1996
 Investigations
None should delay surgical exploration!

• 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
 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 • · Epididymal Cysts
testis • o Can be excised, but frequently recur
• o Prognosis usually good • o Often multiple small cysts as well as
• · Torsion presenting lump
• o Testicular pain in child (<4, 12+) • o Main differential – spermatocoele.
• o Needs surgery within 2-4 hours to salvage • · Varicocoele
testis. • o Look like hernia, but no cough impulse,
• o Main differentials are torsion of hydatid, or tend to go if patient supine.
epididymal orchitis • o More common on the left.
• (infection – may take months to resolve) • o Can be caused by renal tumour
• · Hydrocoele • o Consider surgery:
• o Most idiopathic, can be a reaction to insult. • o Embolise
~10% recur • o Laparascopic
• o US if testes not palpable or to confirm • o Open - least chance of recurrence
diagnosis • o Pain may persist after surgery
• o Aetiology: • · Haematoma
• o young - patent processus • o Should be history of trauma
• o old - fluid forms in scrotum • · 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
 Workup
 Visible 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
 Haematuria
Investigations:
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