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Urological Emergencies for the Non-Urologist. Mr C Dawson MS FRCS Consultant Urologist Edith Cavell Hospital Peterborough. Content of the Presentation. Renal Colic Testicular Torsion Trauma Paraphimosis Priapism. Renal Colic. Does not always present with classic history

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urological emergencies for the non urologist

Urological Emergencies for the Non-Urologist

Mr C Dawson MS FRCS

Consultant Urologist

Edith Cavell Hospital

Peterborough

content of the presentation
Content of the Presentation
  • Renal Colic
  • Testicular Torsion
  • Trauma
  • Paraphimosis
  • Priapism
renal colic
Renal Colic
  • Does not always present with classic history
  • Classically presents with loin pain radiating around abdomen, as stone moves down ureter
  • May get testicular/labial pain +/- strangury if stone impacts at VUJ
renal colic4
Renal Colic
  • Full examination essential – primarily to rule out other causes for pain
  • Look for signs of Sepsis
  • Differential diagnosis includes
    • Acute Appendicitis
    • Diverticulitis
    • Salpingitis
    • Ruptured Aortic Aneurysm
    • Pyelonephritis
    • Ectopic Pregnancy
renal colic investigations
Renal Colic - Investigations
  • Routine Urinalysis – microscopic haematuria is common but not invariable
  • IVP
    • Particularly in patients over 50 (?AAA)
    • USS and KUB if contrast allergic
    • Caution in Pregnancy
  • Pregnancy Test in all fertile women of child bearing age
renal colic management
Renal Colic - Management
  • If NO signs of ureteric obstruction on IVP AND Pain free
    • Home with explanation of symptoms
    • Review after 2/52 in OPD
  • If IVP shows obstruction of ureter
    • Admit for observation
    • May still be allowed home for trial of stone passage
  • If Obstructed AND signs of Sepsis
    • Urgent Nephrostomy
renal colic management7
Size of Stone

< 4mm

4-6 mm

> 6mm

Management

Conservative: 90% pass spontaneously

50% pass spontaneously – trial of passage

Intervention likely, only 10% pass spontaneously

Renal Colic - Management
testicular torsion
Testicular Torsion
  • Can occur at any age
  • Most common in adolescents
  • Occasionally seen in neonates
  • In infants (and esp neonates) the symptoms and signs are imprecise
  • Prompt action required to avoid irreversible testicular ischaemia
testicular torsion9
Testicular Torsion
  • Diagnosis usually made solely on basis of clinical examination
    • Testis usually swollen and exquisitely tender
    • Lies horizontally and retracted compared to normal side
testicular torsion10
Testicular Torsion
  • Studies have shown that only 25% of boys presenting with acute scrotal swelling with have torsion
  • No reliable diagnostic test exists
  • Doppler USS can effectively establish the presence of arterial inflow
  • Surgical exploration remains the final arbiter, and should not be delayed whilst waiting for investigations
urological trauma
Urological Trauma
  • Fortunately very rare
  • Typical victims
    • Young men involved in sport (55%)
    • People in RTAs (25%)
    • Domestic or industrial accidents (15%)
    • Victims of Assault (5%)
urological trauma13
Urological Trauma
  • Upper Urinary Tract
    • Renal injuries
  • Lower Urinary Tract
    • Bladder
    • Urethra
    • External Genitalia
urological trauma overview
Urological Trauma - Overview
  • Take a careful history
    • Mechanism of injury (blunt trauma, penetrating trauma)
    • Velocity of injury
  • Careful Assessment
    • Careful Examination
    • ABC of Primary Survey
    • Baseline Investigations
    • Appropriate Radiology and additional imaging
renal trauma
Renal Trauma
  • The Kidney is the most commonly injured urological organ
  • Injuries can be blunt (80-90%) or penetrating
  • Blunt trauma occurs with upper abdominal injury and rapid deceleration
  • Such injuries usually involve multiple organ systems and patients – other injuries must be suspected and excluded
renal trauma radiological assesment
Renal Trauma – Radiological Assesment
  • Adult patient with blunt trauma
    • Visible haematuria, or microscopic haematuria and shock - Needs Radiological assessment
    • Microscopic haematuria without shock – radiological assessment not required
  • Adult patients with penetrating trauma / All Paediatric patients – require radiological assessment
renal trauma18
Renal trauma
  • Radiological Assessment should begin with IVU – Most patients adequately staged this way
  • CT has largely replaced the arteriogram and IVU in the diagnosis and management of severe abdominal or GU trauma
  • Patients who are haemodynamically unstable will require immediate laparotomy
  • 85% of blunt renal injuries require no surgery, 5-10% require judgement and surgical exploration, 5% are non-salvageable and require nephrectomy
lower urinary tract bladder and urethra
Lower Urinary Tract – Bladder and Urethra
  • Approx 90% of bladder injuries result from blunt trauma
  • The bladder is commonly injured in pelvic fractures
  • The bladder in a child is an abdominal (not pelvic) organ and is more vulnerable to injury
lower urinary tract bladder and urethra20
Lower Urinary Tract – Bladder and Urethra
  • Signs and symptoms of bladder rupture are non specific
  • Frank haematuria occurs in 95%, m/scopic haematuria in the remainder
  • Patient may complain of inability to void
  • Suprapubic tenderness
  • Intraperitoneal rupture (1/3 of all bladder injuries) is common in children
management of bladder injury
Management of Bladder injury
  • Do NOT pass urethral catheter if there is blood at meatus
  • Retrograde urethrography may be performed in place of IVU
urethral injury
Urethral Injury
  • Commonly associated with Straddle injuries
  • Patient may be unable to void
  • Most patients will have blood at meatus and swelling/bruising of penis/scrotum and perineum.
  • Rectal examination may reveal a “high-riding prostate”
urethral injury23
Urethral Injury
  • All patients require a urethrogram
  • Do NOT attempt urethral catheterisation – may convert a partial tear into a complete rupture
  • If patients require immediate laparotomy then bladder may be catheterised suprapubically
  • Long term sequelae of this injury include incontinence, stricture, and impotence
scrotal trauma
Scrotal Trauma
  • Testes may be damaged by direct blow
  • If swelling is moderate it usually settles
  • Severe swelling may require exploration to exclude testicular laceration
urological trauma further reading
Urological Trauma – further reading
  • ABC of major Trauma – Edited by Skinner et al. BMJ Publishing Group
  • Renal and Ureteric Injuries – McAninch JW in Adult and Paediatric Urology (edited by Gillenwater)
  • Genitourinary Trauma – Peters and Sagalowsky in Campbell’s Urology (edited by Walsh et al)
paraphimosis
Paraphimosis
  • May result from phimosis
  • Commonly occurs in catheterised patients
  • Good catheter care prevents this problem!
  • May be reduced after gentle compression of glans and distal penis
  • Occasionally may require surgical release of paraphimosis under LA (or GA in children)
priapism
Priapism
  • A persistent painful erection that is not related to sexual desire
  • Causes
    • Intracavernosal pharmacotherapy for Erectile Dysfunction
    • Idiopathic
    • Penile or Spinal Cord trauma
    • Assoc with Leukaemia, Sickle Cell disease or Pelvic Trauma
priapism28
Priapism
  • Early treatment is the key element
  • Climbing stairs (arterial “steal” phenomenon) or ice packs may resolve
  • Aspiration of Corpora cavernosa may be required
priapism29
Priapism
  • Two types
    • Low flow (anoxic) – blood aspirated is dark and deoxygenated
    • High flow – blood is bright red
  • Infusion of alpha agonist (phenylephrine) may be tried in low flow priapism
  • Surgical Shunting may be attempted as a last resort
summary
Summary
  • Renal Colic
  • Testicular Torsion
  • Trauma
  • Paraphimosis
  • Priapism