EMERGENCY

UROLOGY NON
TRAUMA

1. Kidney Pain & Ureteral Pain

2. HEMATURIA

PRIAPISM

DEFINITION:
Prolonged erection.painful
no sexual excitement or desire is present.
ETIOLOGY
Idiopathic in 60% of cases
40% of cases are associated with diseases (eg,
leukemia, sickle cell disease, pelvic tumors, pelvic
infections), penile trauma, spinal cord trauma
Currently, intracavernous injection therapy for impotence
may be the most common cause.

CLASSIFICATION
high- flow
Low-flow.
HIGH FLOW PRIAPISM (NON-ISCHEMIC)
usually occurs secondary to perineal trauma

Blood-gas determination

injures the central penile arteries loss of penile blood-flow

regulation.
High oxygen level
Normal carbon dioxide levels.

Arteriography is useful to demonstrate aneurysms that

will respond to embolization
Erectile function is usually preserved.

LOW FLOW PRIAPISM (ISCHEMIC)

Patients usually present with a history of several

hours of painful erection.
The glans penis and corpus spongiosum are soft
and uninvolved in the process.
The corpora cavernosa are tense with
congested blood and tender to palpation.
The mechanism remain in debate
physiologic

obstruction of the venous drainage.

If the process continues for several days

interstitial

edema
IMPOTENCE

fibrosis

of the corpora cavernosa

Treatment

The sludged blood can then be evacuated from the corpora

cavernosa through a large needle placed through the glans.
The addition of adrenergic agents administered via intracavernous
irrigation has proved helpful.
Multiple wedges of tissue can be removed with a biopsy needle to
create a shunting fistula between the glans penis and corpora
cavernosa.
This technique, which has been very successful, provides an
internal fistula to keep the corpora cavernosa decompressed.
To maintain continuous fistula drainage, pressure should be exerted
intermittently (every 15 minutes) on the body of the penis.

If the shunt described fails, another shunting

technique may be used by anastomosing the
superficial dorsal vein to the corpora cavernosa.
Other effective shunting methods are corpora
cavernosa to corpus spongiosum shunt by
perineal anastomosis; saphenous vein to
corpora cavernosa shunt; and pump
decompression.

Hyperbaric oxygen also has been

suggested for these patients.
Treatment should not prevent aggressive
management of the priapism if the
erection persists for several hours.

Impotence is the worst sequel of priapism.

It is more common after prolonged
priapism (several days).
Early recognition (within hours) and
prompt treatment of priapism offer the best
opportunity to avoid this major problem.

PARAPHIMOSIS

Paraphimosis is the condition in which the

foreskin, once retracted over the glans, cannot
be replaced in its normal position.
The skin ring causes venous congestion leading
to edema and enlargement of the glans, which
make the condition worse.
As the condition progresses, arterial occlusion
and necrosis of the glans may occur.

The paraphimosis must be regarded as an

emergency situation: retraction of a too narrow
prepuce behind the glans penis into the glanular
sulcus may constrict the shaft and lead to
oedema.
It interferes with perfusion distally from the
constrictive ring and brings a risk of consecutive
necrosis.

Paraphimosis usually can be treated by

firmly squeezing the glans for 5 minutes to
reduce the tissue edema and decrease
the size of the glans.
The skin can then be drawn forward over
the glans.
Occasionally, the constricting ring requires
incision under local anesthesia.

TREATMENT

Consists of manual compression of the

oedematous tissue with a subsequent attempt to
retract the tightened foreskin over the glans
penis.
Injection of hyaluronidase beneath the narrow
band may be helpful to release it.
If this fails, a dorsal incision of the constrictive
ring is required. Depending on the local findings,
a circumcision is carried out immediately or can
be performed in a second session.

Phimosis

Phimosis is a condition in which the contracted

foreskin cannot be retracted over the glans.
Chronic infection from poor local hygiene is its
most common cause.
Most cases occur in uncircumcised males,
although excessive skin left after circumcision
can become stenotic and cause phimosis.

Children under 2 years of age seldom have true

phimosis; their relatively narrow preputial
opening gradually widens and allows for normal
retraction of foreskin over the glans.
Circumcision for phimosis should be avoided in
children requiring general anesthesia; except in
cases with recurrent infections, the procedure
should be postponed until the child reaches an
age when local anesthesia can be used.

Edema, erythema, and tenderness of the

prepuce and the presence of purulent discharge
usually cause the patient to seek medical
attention.
The dorsal foreskin can be slit if improved
drainage is necessary.
Circumcision, if indicated,should be done after
the infection is controlled.

TREATMENT

Treatment of phimosis in children is dependent

on the parents preferences and can be plastic
or radical circumcision after completion of the
second year of life.
Contraindications for circumcision are
coagulopathy, an acute local infection and
congenital anomalies of the penis, particularly
hypospadias or buried penis.

As a conservative treatment option of the

primary phimosis, a corticoid ointment or
cream (0.05-0.1%) can be administered
twice a day over a period of 20-30 days
This treatment has no side effects and the
mean bloodspot cortisol levels are not
significantly different from an untreated
group of patients
Agglutination of the foreskin does not
respond to steroid treatment

Urosepsis

Sepsis is a systemic response to infection.

The symptoms of SIRS which were initially
considered to be mandatory for the diagnosis of
sepsis, are now considered to be alerting
symptoms.

Pathogenesis

Micro-organisms reach the urinary tract by way

of the ascending, haematogenous, or lymphatic
routes.
The risk of bacteriaemia is increased in severe
UTIs, such as pyelonephritis and acute bacterial
prostatitis (ABP), and is facilitated by
obstruction.
A fatal outcome is described in 20-40% of all
patients.

Cytokines as markers of the septic response

They are peptides that regulate the amplitude and duration of the
host inflammatory response.
When they become bound to specific receptors on other cells,
cytokines change their behaviour in the inflammatory response.
The complex balance between pro- and anti-inflammatory
responses is modified in severe sepsis.
An immunodepressive phasis follows the initial pro-inflammatory
mechanism.
Tumour necrosis factor- (TNF-9 pt), interleukin-1 (IL-1), IL-6, and
IL-8 are cytokines that are associated with sepsis.

Procalcitonin is a potential marker of sepsis

Procalcitonin is the propeptide of calcitonin, but is devoid of
hormonal activity.
Normally in healthy humans, levels are undetectable.
During severe generalized infections (bacterial, parasitic and fungal)
with systemic manifestations, procalcitonin levels may rise to > 100
ng/mL.
High procalcitonin levels, or an abrupt increase in levels in these
patients, should prompt a search for the source of infection.
Procalcitonin may be useful in differentiating between infectious and
non-infectious causes of severe inflammatory status.

Diagnosis

Diagnosis

Acute Scrotum

Acute scrotum is a urology emergency case, most commonly

caused by torsion of the testis, torsion of the appendix testis and
epididymitis/epididymo-orchitis.
Torsion of the testis occurs most often in the neonatal period and
around puberty, while torsion of the appendix testes occurs over a
wider age range.
Acute epididymitis affects two age groups: below the age of 1 year
and between 12 and 15 years.
Acute epididymitis was found most often (37-64.6%) in boys with
acute scrotum.
One study predicted the incidence of epididymitis as about 1.2 per
1,000 male children per year.

EPIDIDYMITIS
Aetiology

Infection and inflammation of the epididymis most often result

from an ascending infection from the lower urinary tract.
Most cases of epididymitis in men younger than 35 years are due
to sexually transmitted organisms (N. gonorrhoeae and C.
trachomatis); those in children and older men are due to urinary
pathogens such as E. coli.
In homosexual men who practice anal intercourse, E. coli and
other coliform bacteria are common causative organisms.

A.

PRESENTATION AND FINDINGS

Patients with epididymitis present with severe scrotal pain that

may radiate to the groin or flank.
Scrotal enlargement due to the inflammation of the
epididymis/testis or a reactive hydrocele may develop rapidly.
On physical examination, an enlarged and red scrotum is present,
and it is often difficult to distinguish the epididymis from the testis
during the acute infection.
A thickened spermatic cord can occasionally be palpated.
Urinalysis typically demonstrates WBCs and bacteria in the urine
or urethral discharge.
Serum blood analysis often reveals leukocytosis.

B. RADIOLOGIC IMAGING

Frequently, it is difficult to distinguish epididymitis from acute

testicular torsion based on the history and physical examination
alone (Petrack and Hafeez, 1992).
Scrotal Doppler ultrasonography or radionuclide scanning can be
used to confirm the diagnosis (Paltiel et al, 1998).
The presence of blood flow in the testis on Doppler ultrasonography
or uptake of the tracers into the center of the testis on radionuclide
scanning rules out torsion.
On scrotal ultrasonography, patients with epididymitis commonly
have an enlarged epididymis with increased blood flow.

C. MANAGEMENT

Oral antibiotic treatment is directed against specific causative

organisms, as mentioned in the previous sections on urethritis and
UTI.
In addition, bed rest, scrotal elevation, and the use of nonsteroidal
anti-inflammatory agents are helpful in reducing the duration of the
symptoms.
In patients with epididymitis caused by sexually transmitted
organisms, treatment of their sexual partners is recommended to
prevent reinfection.
Open drainage is indicated in cases in which an abscess develops.

Antibiotic treatment, although often started, is not

indicated in most cases unless urinalysis and urine
culture show a bacterial infection.
Epididymitis is usually self-limiting and with supportive
therapy (i.e.minimal physical activity and analgesics)
heals without any sequelae.
However, bacterial epididymitis can be complicated by
abscess or necrotic testis and surgical exploration is
required.
Surgical exploration is done in equivocal cases and in
patients with persistent pain.

Testicular torsion

The duration of symptoms is shorter in

testicular torsion (69% present within 12
hours) compared to torsion of the
appendix testes (62%) and acute
epididymitis (31%)

Diagnosis
Epididymitis

Testicular torsion

1.

In the early phase, location of the

pain, experience a tender
epididymitis,

1.

2.

An abnormal position of the testis

rare
The cremasteric reflex : positive
Fever occurs often in epididymitis
(11-19%).
A positive urine culture is only
found in a few patients with
epididymitis.

2.

3.
4.
5.

3.
4.

5.

More likely to have a tender

testicle and patients with torsion
of the appendix testis feel
isolated tenderness of the
superior pole of the testis.
More frequent
Negative
The classical sign of a blue dot
was found only in 10-23%
patients with torsion of the
appendix testis
An abnormal urinalysis does not
exclude testicular torsion.

Doppler ultrasound is useful to evaluate an

acute scrotum, with a sensitivity of 63.6-100%
and a specificity of 97-100%, and a positive
predictive value of 100% and negative predictive
value 97.5%
Better results were reported using highresolution ultrasonography (HRUS) for direct
visualization of the spermatic cord twist with a
sensitivity of 97.3% and a specificity of 99%

These investigations may be used when

diagnosis is less likely and if torsion of the testis
still cannot be excluded from history and
physical examination.

This should be done without inordinate delays

for emergent intervention.

Treatment

Manual detorsion of the testis is done without anaesthesia.

It should initially be done by outwards rotation of the testis unless
the pain increases or if there is obvious resistance.
Success is defined as the immediate relief of all symptoms and
normal findings at physical examination
Doppler ultrasound may be used for guidance.
Bilateral orchiopexy is still required after successful detorsion.
This should not be done as an elective procedure, but rather
immediately following detorsion.
One study reported residual torsion during exploration in 17 out of
53 patients, including 11 patients who had reported pain relief after
manual detorsion.