Emergency Room Emergency Room UrologyUrologyUrologyUrology

Dr. Syah Mirsya Warli, SpUDr. Bungaran Sihombing,SpUDiv. of Urology, Surgery Dept.

Medical Faculty, University of Sumatera Utara

Ref :Ref :

�� Clinical Manual of Urology, (Philip M. Clinical Manual of Urology, (Philip M.

Hanno et al eds), McGrawHanno et al eds), McGraw--Hill Int ed, Hill Int ed,

33rdrd ed, 2001ed, 200133 ed, 2001ed, 2001

�� Smith’s General Urology (Tanagho & Smith’s General Urology (Tanagho &

McAninch eds), Lange Medical Books, McAninch eds), Lange Medical Books,

1515thth ed, 2000ed, 2000

Genitourinary Emergencies

�� PainPain

�� Testicular TorsionTesticular Torsion

�� Oliguria & anuriaOliguria & anuria

�� PriapismPriapism�� Testicular TorsionTesticular Torsion

�� HematuriaHematuria

�� Urinary RetentionUrinary Retention

�� PriapismPriapism

�� Foreskin Foreskin

emergenciesemergencies

Pain

Flank Pain

�� DD : calculusDD : calculus

pyelonephritispyelonephritis

renal traumarenal traumarenal traumarenal trauma

renal vein thrombosisrenal vein thrombosis

cholecystitischolecystitis

Pain

Flank Pain : Renal Colic

� Sudden onset, no relief with change of position

� Nause & vomiting

� Diagnosis studies :Diagnosis studies :

- urinalysis

- non-contrast CT scan

- plain radiograph

- white count and serum creatinin

- urine culture

- IVP

Indications for admission for renal

calculi

�� Obstructing stone in a patient with a Obstructing stone in a patient with a

solitary kidneysolitary kidney

�� Fever and infection associated with an Fever and infection associated with an

obstructing stoneobstructing stoneobstructing stoneobstructing stone

�� Inability to maintain oral hydrationInability to maintain oral hydration

�� Pain refractory to oral analgesicsPain refractory to oral analgesics

�� HighHigh--grade obstruction from a stone that is grade obstruction from a stone that is

too large to pass spontaneouslytoo large to pass spontaneously

Pain

Flank Pain : Pyelonephritis

� Onset subacute, constant

� Exacerbated by movement

� Prodrome of cystitis symptoms � clue� Prodrome of cystitis symptoms � clue

� Ask about previous history of urolithiasis,

UTI and urologic surgery

Pain

Suprapubic Pain

� DD : urinary retention, cystitis

bladder stones, gynecologic problems

interstitial cystitisinterstitial cystitis

� Retention & cystitis must be diagnosed in the

ED

� History : voiding function, gross hematuria,

urinary retention

� Palpate the bladder

� Pelvic exam in women

Testicular Torsion

�� Incidence 1: 4000Incidence 1: 4000

�� Most serious of acute problems affecting the Most serious of acute problems affecting the scrotal contentsscrotal contents

�� 2 peak incidences2 peak incidences

–– Neonatal periodNeonatal period

–– PubertyPuberty

Testicular Torsion

�� Why does it happen?Why does it happen?

–– Testes not adequately anchored to the Testes not adequately anchored to the tunica vaginalistunica vaginalistunica vaginalistunica vaginalis

Testicular Torsion

Symptom complex

� Sudden onset of severe testicular pain

� Constant & progressive

� Nausea (+)

Fever, urethral discharge, cystitis symptoms (-)� Fever, urethral discharge, cystitis symptoms (-)

Testicular Torsion

Physical examination

–– Edematous scrotumEdematous scrotum

–– Tender, swollen testisTender, swollen testis

–– Testis high in scrotum with horizontal lie Testis high in scrotum with horizontal lie –– Testis high in scrotum with horizontal lie Testis high in scrotum with horizontal lie �� classical signclassical sign

–– CremastericCremasteric reflex (reflex (--))

–– ““bell-clapper deformity” ”

–– Pain not relieved with elevation of Pain not relieved with elevation of scrotumscrotum

TORSIONTORSION

Testicular Torsion:

Diagnosis

� Doppler USG now test of choice for Dx

of torsion. Sensitivity comparable to

radioisotope scans (86%-100%) and radioisotope scans (86%-100%) and

greater specificity (100%).

� Doppler U/S is more rapid and more

available than radioisotope scans.

Testicular Torsion:

Management

� Immediate Urologic consultation for surgical exploration and possible bilateral orchidopexy if diagnosis is obvious

� Manual detorsion � rotating the testicle in a medial to lateral direction, “open the book” maneuver

� Emergent surgery is still required to assure complete detorsion and perform contralateral orchidopexy

Gross Hematuria

� Etiology :

1. Common cause � infections, stones,

malignancies (bladder, kidney), BPH,malignancies (bladder, kidney), BPH,

trauma, post op

2. Less common cause � radiation or

chemical cystitis, sickle cell disease,

coagulopathy.

Gross Hematuria

�� All patients presenting with gross All patients presenting with gross

hematuriahematuria must have urologic followmust have urologic follow--up, up,

even if the bleeding spontaneously even if the bleeding spontaneously

resolves. resolves. resolves. resolves.

�� Bladder tumorsBladder tumors classically bleed classically bleed

intermittently and diagnosis can be delayed intermittently and diagnosis can be delayed

if patients are not appropriately counseledif patients are not appropriately counseled

Urinary Retention

� History :

age, general health

premorbid voiding symptoms

history of urethral strictureshistory of urethral strictures

previous episodes of retention

prior urologic manipulation or surgery (TURP, radical

prostatectomy)

medication (sympathomimetics, anticholinergics)

incontinence

Urinary Retention

Etiology

� Anatomic obstruction :

1. BPH (most common)

2. Urethral stricture

3. Bladder neck contracture3. Bladder neck contracture

4. Prostate Ca (uncommon)

� Functional obstruction :

1. Neurologic disease (CNS or peripheral)

2. Medication side effect

3. Pain (nociceptive retention) � post op, post trauma

4. Psychogenic

Urinary Retention :

Management

� 16 or 18 F Standard Urethral Catheter, adequate lubrication of the catheter

� If fails � Urology consult for SPT

No patient in retention should be � No patient in retention should be instrumented, drained, and then discharged from ED without a clear plan for urologic follow-up

Oliguria & anuria

� Anuria � urine output < 50 ml / 24 h

� Evaluation & treatment :

- Physical exam & urethral catheterization- Physical exam & urethral catheterization

- USG � bilateral hydronephrosis

no hydronephrosis

unilateral hydronephrosis

Priapism

� The pathologic prolongation of penile

erection, accompanied by pain &

tendernesstenderness

� Not by sexual excitement

� Not relieved by orgasm

Foreskin Emergencies

Phimosis

� The uncircumcised foreskin cannot be

retracted over the glans

� Catheterized with a coude tip

Foreskin Emergencies

Paraphimosis

� The uncircumcised foreskin has been left in

the retracted position � obstruction to

venous & lymphatic drainage � progressive

edemaedema

� True urologic emergency

� Th/ : immadiate manual reduction

� If fail � dorsal slit

Phimosis vs. Paraphimosis

Phimosis: inability to retract foreskinTx: dorsal slit or circumcision

Paraphimosis: foreskin retracted

behind coronal groove; tourniquet to

glans

Tx: circumcision

Foreskin Emergencies

Zipper Injuries

� Common source of genital laceration

� Th/ : adequate analgesia & disassembly the

zipperzipper

� Using a cutter � median bar of the zipper

is completely cut � the teeth of the zipper

fall apart

Foreskin Emergencies

External rings

� Often used as sexual aids � edema,

urethral fistula, necrosis

Managed with ring cutter� Managed with ring cutter

� Immediate removal of the object &

debridement

Foreskin Emergencies

Intraurethral foreign bodies

� Evaluate radiographically

� Don’t catheterized � place SPT if retention

� If distal to the external sphincter � object � If distal to the external sphincter � object

will be palpable & can often be removed

endoscopically

� If proximal to the sphincter � open

extraction

Foreskin Emergencies

Post-circumcision complications

� Hematoma � drained by removing a stitch & evacuating

the clot. Replace dressing

� Bleeding� Bleeding

- steady pressure 10 – 15’

- if fail � lidocaine (1:100.000 ephinephrine) & apply

pressure 10 – 15’ more

- skin edges may be cauterized with silver nitrate sticks

- significant bleeding � suture placement under

penile block with lidocaine

Foreskin Emergencies

Post-circumcision complications

� Disruption of incision

- if small � no th/

- if major � place a few interrupted - if major � place a few interrupted

suture under penile block

� Infection

- uncommon & usually minor

- th/ : oral cephalosporine

wr 2009