UROLOGIC EMERGENCIES

Hakan KOYUNCU;MD
Associate Professor
Yeditepe University Medical Faculty
Department of Urology
 34-yo male
 Severe right sided flank pain
34 M, R flank pain

 Hx
 PE
 urinalysis
 imaging
RENAL COLIC

 Stones of the urinary tract

 Hematoma or tissue in the ureter
 Upper ureter: lumbar-inguinal
 Lower ureter: genital

 Intermittant
 Not affected by body positioning
 Lumbar tenderness
 Nausea & vomiting
 R: Appendicitis - Cholelithiasis
 urinalysis: hematuria

 KUB
 IVP
 Computerized Tomography

 Pain management,hydration, hot bath

 Treatment of the underlying cause
 Solitary kidney
 Ureteral stone
 Hydronephrosis anuria, uremia
 62 yo male

 Severe abdominal and inguinal pain, 30 hrs

in duration, “have not slept for 5 min.”
 Feels like voiding every 10-15 minutes,
passes a few drops each time

 He presented to the ER of a hospital, was

diagnosed as cystitis, was given a
parasymphatholytic, but did not get any
better.
Acute Urinary Retention
 Bladder neck – prostate – urethra
 Usually in elderly with BPH
 Massive hematuria, acute prostatitis, prostate
abcess, stones lodged at the bladder
neck/urethra, phimosis, uretral trauma

 History
 Suprapubic mass
 Urethral catheterization
 Suprapubic catheterization (cystostomy)
 47 yo diabetic
 Alcohol (+)
 Fever, malaise,
redness and
discomfort in
scrotum
 Fournier’s Gangrene

 Synergistic effect of multiple microorganisms in the

urogenital/anal region
 Effects soft tissue and fascia, necrosis
 Generally starts from genital/perineal region
 Uretral trauma, urinary ekstravasation, urethral instrumantation,
perianal abcess and fissur are predisposing factors
 Immunocompromised patients (diabetes, alcoholism)
 Begins like cellulitis, rapidly spreads along the fascial planes
 Necrosis and gangrene
 Hypoxia  anaerobic bacteria  gas formation, crepitation
 Malaise, discomfort
 Scrotal-perineal pain
 Redness
 Fever, chills, sweating, scrotal edema
 Gangrene
 Rapid deterioration in general health
 Rapidly involves the abdomen and causes death
 Management
 Bacteroides, Klebsiella, Proteus, Streptococus,
Clostridium Perfringens
 An avarage of 4 microorganisms per patient
 Phimosis

 Inability to retract the preputium

– Bad hygiene-recurrent infections
– Uncircumsized boys/adults
– Prepitual edema, redness, purulent discharge
– Physiologic until 3 years of age
– Dorsal slit or circumsition
Paraphimosis:

 The foreskin, once retracted over the glans

penis, cannot be replaced in its normal position
– Usually chr. inflammation of preputium,
stricture
– Lymphatic, venous, and arterial flow are
compromised, leading to necrosis

– Firmly squeezing glans for 5 mins.

– Skin can then be drawn over the glans
(lubricant)
– dorsal slit, circumsition
 42 yo male
 High fever, chills, malaise, frequency,
perineal pain

 DRE: enlarged, pain, warm prostate

 Lab: leucoytosis, shift to the left

 culture-sensitivity
Admitted
Antibiotics, NSAID
Urinary retention in the evening ????

•Suprapubic catheterisation
 The patients general health
deteriorates on day 3, fever does not
resolve
Prostate Abcess
 Coliform bacteria
 Generally urethral (ascending)
 Staphilococcus via hematogenous route
 Diabetes, immune compromised, urethral trauma,
prostate biopsy
 Pollakiuria, disuria, acute urinary retention; fever,
malaise
 Usually excacerbation of symptoms after acute
prostatitis
 DRE: fluctuation
 Lab: pyuria, leucocytosis
 TRUS: definitive diagnosis
 Drainage
 Antibiotics
 Suprapubik catheterization
 Telephone:
 15 yo male
 Enlargement and pain in L testis
 Testicular Torsion
 Newborn – adolesents
 %50 uykuda olur
 Usually anomaly of tuniga vaginalis or the
spermatic cord
 Pain-sudden onset, skrotal edema,
enlargement and redness, nausea, vomiting
 PE: usually retracted,
Loss of cremasteric reflex
Increased pain with testicular elevation
(Prehn)
 Epidydimis may be palpated in an abnormal
location – early sign
 Leucocytosis within a few hours
 Doppler US or nuclear scan
 Manuel de-torsion (inside out) (local anest)
 Eksploration !!!
 5-6 hrs
35 yo male
Errection for 4 hrs in duration,
pain

 Perineal trauma?
 Blood gas: high 02 & low CO2
Priapism
 Etiology:
– Most frequent: intracavernosal injection
– Idiopathic
– Disease (leucemia, sickle cell disease,..)
 Obstruction of venous drainage, c.c.’da pooling
of viscous low oxygenated blood in corpus
cavernosum edema, fibrosis, erectile
dysfunction
 Increase venous outflow
 Find out underlying reason-if possible
 Non-surgical management first:
– Aspiration
– Alfa adrenergikc agonist injection
• (phenephrine, 10mg/ml, diluted in 19 ml saline)
 If non-surgical tx fails:
– Distal or proximal shunt
 TRAUMA

 GU tract in 10% of all traumas

 Kidney is the most commonly involved organ
– Suspect GU taruma when:
– Hematuria
– Descelerating injury
– Penetrating abdominal or flank injury
– Echimosis of the flank
Renal Trauma
 Blunt : (85 -90% )
– vehicle accident, fall, rapid deceleration,
iatrogenic

 Penetrating : Gunshot and (85-90 %

associated with intraabdominal or thoracic
injury)
Renal Trauma - Diagnosis

 History
 PE (lumbar echimosis, pain with palpation)
 Hematuria
– (Renal vascular injury - 36 % not associated with
hematuria)
 Variable clinical presentation
(asymptomatic-shock)
 Radiologic Imaging
 KUB (loss of psoas or renal contour)
 IVU (delayed renal function,
nonhomogenous collecting system)
 USG (lumbar hematoma and urinoma
lokalizasyonu)
 Computerized Tomography
 Renal angiography
 American Association for the Surgery of Trauma

Organ Injury Severity Scale for the Kidney

Grade Tip Tanım

1 kontüzyon Mikroskobik ya da gross hematuri, ürolojik
incelemeler normal
hematom SubKapsuler, genişlemeyen
parankimal hasar yok
2 hematom Genişlemeyen perirenal hematom , renal
retroperitona sınırlı
laserasyon <1-cm derinlikte parenkimal korteks
hasarı,üriner ekstravazasyon yok
3 laserasyon >1-cm derinlikte parenkimal korteks
hasarı,üriner ekstravazasyon yok
4 laserasyon Medulla ve toplayıcı sisteme ulaşan parenkim
hasarı
vasküler Renal arter ve vende hemoraji içeren hasar

5 laserasyon Tamamen parçalanmış Böbrek

vasküler Renal hilusun ayrılması

Expectant Management:

 Hemodynamically stable, well defined and

non-expanding injury on CT scan

 88 % patienst are observed

 If there is associated gross hematuria,

admit and observe
Surgery :

 Absolute Indication
– Persistant renal bleeding
– Expanding perirenal hematoma
– Perirenal hematoma with pulsation
 Relative indication
– Urinary extravasation
– Inability in proper staging
– Delayed arterial injury
 Bladder & Urethra

– Suspect trauma in the presence of:

– Blood at the urethral meatus
– DRE: “prostate displaced superiorly "
– Hematuria
– Penetrating abdominal, pelvic or genital injury
– Anterior pelvic fracture
– Open pelvic fracture
– Perineal laseration
Urethral Injury

 A partial rupture could be a complete rupture

during catheterisation!

 A urethrogram should be performed

 In the presence of urethral disruption, a

suprapubic catheter should be placed.
THANK YOU