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Emergency Room

Urology
Dr. Syah Mirsya Warli, SpU
Dr. Bungaran Sihombing,SpU
Div. of Urology, Surgery Dept.
Medical Faculty,
University of Sumatera Utara

Ref :

Clinical Manual of Urology, (Philip M.


Hanno et al eds), McGraw-Hill Int ed,
3rd ed, 2001
Smiths General Urology (Tanagho &
McAninch eds), Lange Medical Books,
15th ed, 2000

Genitourinary Emergencies

Pain
Testicular Torsion
Hematuria
Urinary Retention

Oliguria & anuria


Priapism
Foreskin
emergencies

Testicular Torsion

Incidence 1: 4000
Most serious of acute problems
affecting the scrotal contents
2 peak incidences
Neonatal period
Puberty

Testicular Torsion

Why does it happen?


Testes not adequately anchored to
the tunica vaginalis

Testicular Torsion
Symptom complex

Sudden onset of severe testicular pain


Constant & progressive
Nausea (+)
Fever, urethral discharge, cystitis symptoms (-)

Testicular Torsion
Physical examination
Edematous scrotum
Tender, swollen testis
Testis high in scrotum with
horizontal lie classical sign
Cremasteric reflex (-)
bell-clapper deformity
Pain not relieved with elevation of
scrotum

TORSION

Testicular Torsion:
Diagnosis

Doppler USG now test of choice for Dx


of torsion. Sensitivity comparable to
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,
trauma, post op
2. Less cause radiation or
chemical cystitis, sickle cell disease,
coagulopathy.

Gross Hematuria

All patients presenting with gross


hematuria must have urologic follow-up,
even if the bleeding spontaneously
resolves.
Bladder tumors classically bleed
intermittently and diagnosis can be delayed
if patients are not appropriately counseled

Urinary Retention

History :
age, general health
premorbid voiding symptoms
history 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.
2.
3.
4.

BPH (most common)


Urethral stricture
Bladder neck contracture
Prostate Ca (uncommon)

Functional obstruction :
1.
2.
3.
4.

Neurologic disease (CNS or peripheral)


Medication side effect
Pain (nociceptive retention) post op, post trauma
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
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
- USG bilateral hydronephrosis
no hydronephrosis
unilateral hydronephrosis

Priapism

The pathologic prolongation of penile


erection, accompanied by pain &
tenderness
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
edema
True urologic emergency
Th/ : immadiate manual reduction
If fail dorsal slit

Phimosis vs. Paraphimosis

Phimosis: inability to
retract foreskin
Tx: 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
zipper
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
Immediate removal of the object &
debridement

Foreskin Emergencies
Intraurethral foreign bodies

Evaluate radiographically
Dont catheterized place SPT if retention
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
- 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
suture under penile block
Infection
- uncommon & usually minor
- th/ : oral cephalosporine

the end

wr 2009