UROLOGICAL EMERGENCIES
Julian Mander
Emergencies
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Renal colic diagnosis and management
Urine Retention
Urosepsis
Haematuria
Testicular torsion
Trauma renal
bladder
urethral
Stones - Presentation - Pain
PAIN
Typical:
Loin to groin pain
Variable severity
Episodic
Not mechanical but paroxysmal
Atypical: Anterior
Groin pain alone
Testicular pain alone
Penile tip pain alone
Associated vomiting (ongoing)
Mechanical character
Stones - Presentation - LUTS
LUTS
Irritative:
Frequency
Urgency
Strangury
Burning micturition
Macroscopic haematuria
Common misdiagnosis UTI - Do MSUs if in doubt.
Stones - Presentation - Fever
FEVER
Loin pain + fever (38c) = pyelonephritis = generally not life threatening
Loin pain + fever + stone = infected obstructed kidney = commonly life threatening
Message – do ultrasound in all pyelonephritis admissions
Stones - Investigation
MSU
U&E/Creatinine
Serum calcium/albumin uric acid
Imaging
First or infrequent presentation admit to hospital until
diagnosis made
Diagnostic Imaging
Until recently, limited IVP with extra tomograms or delayed films as dictated by progress
Now imaging by non contrast stone CT scan as routine initial diagnostic imaging protocol.
BUT
CT scan has a relatively high radiation dose
SO
1) Do not repeat CT for the same stone – once a diagnosis is established, patients can be
managed with AXR or U/S or both.
2) Do not do CT scans for recurrent stone formers – patients can usually tell you the
diagnosis – do U/S and AXR not CT.
3) Avoid CT in children
4) Do not do CT in pregnancy – use U/S
CT vs IVP
Renal colic: A prospective evaluation of non-enhanced spiral CT versus
intravenous pyelography
Mendelson et al
Australasian Radiology 2003 47, 22 – 28
200 patients randomized to CT or IVP
Radiation dose CT 5 mSv vs
IVP 2.97 mSv
More plain Xrays during admission and more IVPs at F/U in CT group
CT greater diagnostic utility, but no difference in measured outcomes
66% CT diagnostic vs 41% IVP diagnostic
CT Scan
CT Scan
CT Scan
Communicating Diagnosis
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Stone size in mm
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Anatomical stone position
parenchymal
calyceal diverticulum
calyx
renal pelvis
PUJ pelvi-ureteric junction
ureter: upper 1/3, middle 1/3, lower 1/3
vesico-ureteric junction
bladder
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Stone composition
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Stone appearance – staghorn, jackstone
In addition include fever, renal function, level of pain control, comorbidities
calcium 80%
uric acid 15%
infection (struvite) 5%
CT Scan Stone Composition
From Mostofavi et al :
If in doubt, do AXR.
Accurate Determination of Chemical Composition of Urinary Calculi by Spiral Computerized Tomography
J Urol 159(3) March 1998 673-5
Emergency Management of Renal Colic
Non surgical management:
80% of 5 mm stones will pass spontaneously
50% of 8 mm stones will pass spontaneously
Uric acid stones will dissolve with urine alkalinization – NaHCO3 840 mg q.i.d.
Most patients can be discharged home with adequate analgesia and a plan for follow up.
Analgesia:
Initial I/M or I/V narcotic until diagnosis is made.
NSAIDs after diagnosis specific for PG release shown to be associated with acute renal colic –
Oral analgesics generally not absorbed well during renal colic -> so give the patient NSAID suppositories !!
Indocid suppositories 100mg 12 hourly prn
Voltaren suppositories 100mg 12 hourly prn
Oral Ibuprofen (Nurofen OTC 400mg 8 hourly OK) as backup if pain not severe
N.B Management with oral narcotics/panadeine forte/tramadol is generally inadequate and results in return to hospital.
Non Surgical Management Plan for Renal Colic
Urology referral if first presentation or problematic or expect surgery to be required.
If uncomplicated, with likely spontaneous passage, review at 6 weeks with appropriate imaging, most commonly U/S +
AXR.
Note, do not encourage the patient to “drink lots to flush the stone out” – stone will pass more rapidly if patient drinks less !
Imaging is not required if patient has the stone in a jar !
6 Weeks – stone passed + pain gone + Ca/Uric acid normal -> discharge.
6 Weeks – stone not passed – no adverse features – repeat imaging at 12 weeks, adverse features increase HN refer.
12 Weeks- stone not passed – refer for surgical management.
Note, once the stone has passed, encouraged long term increase in fluid intake.
50% reduction in stone recurrence has been well documented if patients produce 2 li urine per 24 hours long term.
Indications for Surgical Intervention
1. Infected obstructed kidney = surgical emergency
2. Pain uncontrolled despite PR NSAIDS
3. Stone clearly too large to pass > 8mm
4. Significant CRF creatinine >200
5. Solitary kidney – risk obstructive uropathy
Acute Urine Retention
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Sudden inability to pass urine – usually associated with pain, unless neuropathic cause.
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Etiology
Neuropathic – painless – MS, spinal cord compression
Mechanical – Benign prostatic obstruction - most common
+/- precipitating event – post op narcotics/mobilization
UTI
overstretch – long travel times
drugs - anticholinergics
?? constipation
Bladder neck dyssernergia – young men with
precipitating event eg UTI
Malignant prostatic obstruction/ other malignancy
Urethral stricture
Urethral stone – rare
Functional – psychological/psychiatric background
Acute Urine Retention - Treatment
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Catheterization
Urethral Foley catheter
use 16F or 18F for adequate long term drainage
use “long term” catheter – Bard “Biocath” or Silastic (not brown latex – 3 day use max).
do not use force – urethral trauma – convert to suprapubic
Suprapubic catheter
short term Bonano type – narrow gauge
long term – 16F Foley via “Add A Cath”
midline 1cm above pubic symphysis
make sure you aspirate urine with fine needle after LA infiltration
Acute Urine Retention ? Admission
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Should depend on renal function
Creatinine < 200
home with urology followup, and continence clinic appointment for assistance with bag management.
Creatinine > 200
admit for management post obstructive diuresis
check hourly urine output > 200 ml/hour Rx I/V fluid replacement with saline, hourly I/V to equal
hourly urine output, with 12 hourly potassium assessment (significant risk of hypokalemia)
Note, the theoretical problem with conversion to pre renal renal failure without adequate replacement.
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Note also admission pending co-morbidities.
Urosepsis
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Septicaemia originating from the urinary tract, usually Gram negative
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Diagnosis
History – LUTS + Temp > 38 celsius
recent urological surgery or catheter, or catheter change
loin pain = either stone + infected/ obstructed
or uncomplicated pyelonephritis
Examination – Kidney tenderness
Prostate tenderness = prostatitis
BP – “septic shock” and inotropes
Investigation
MSU and blood cultures should correlate
Bloods routine + CRP
Imaging – U/S kidneys initially – hydronephrosis = infected/obst
Urosepsis - Treatment
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Antibiotics
NB Take urine and blood cultures before commencing antibiotics.
Current general therapy:
Tazocin 4.5 gm t.d.s.
Reduced dosage 4.5 gm b.d. if impaired renal function
Antibiotic guidelines:
Gentamicin (Gram –ve cover) single daily dose 5 – 7 mg/Kg
trough levels 12 hours post dose, with adjustment pending
+ Amox/Ampicillin (Enterococcus cover) 1gm 6 hourly
Change to less potentially toxic regimen once antibiotic sensitivities returned. Usually within 72 hours.
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Treat obstucted kidneys
Either urgent Cysto/JJ stent if fit for GA
or Radiological insertion of nephrostomy tube
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Supportive therapy – ICU and inotropes – BP and renal function
? Steroids and other therapies
Macroscopic Haematuria
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Etiology
Upper tract vs lower tract – most commonly lower tract origin
Young – stones
Old – males most common cause is BPH
females most common cause is UTI/haemorrhagic cystitis
Cancer is the major concern
Post urological surgery
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History
Painless – commonly lower urinary tract
Loin pain associated – usually upper tract origin – stones/tumours
LUTS UTI symptoms – haemorrhagic cystitis (and VUJ stones)
Macroscopic Haematuria
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Examination
Usually little to find – DRE in older men ? CA prostate
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Investigation
MSU
Bloods – FBP U&E/Creat +/- Coag profile
Imaging U/S as starting point, unless clinically stone, then non contrast CT
Cystoscopy – GA rigid cystoscopy if urgent, or flexible cystoscopy LA if urine clears.
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Treatment
Treat pathology
Rarely life threatening unless uro-arterial fistula
Admit depending on circumstances, predicted pathology
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N.B. Catheterization is not necessary unless patient is in clot retention.
(and can aggravate and perpetuate the presenting problem !!)
Management of Clot Retention
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History of heavy frank haematuria then painful inability to void
Commonly tender palpable bladder
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22F 3 way Foley catheter
Syringe bladder vigorously with sterile saline to break up and
wash out clot – use at least 500ml
Run bladder washout flat out until certain cleared, then slow to keep
urine rose
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If failure to wash out clot, or washout clotting off – requires emergency
cystoscopy under anaesthetic
Check Hb +/- coag profile
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Testicular Torsion
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Incidence: Cumulative incidence 1 in 4,000 males by the age of 25 years
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Two age peaks: 1) 1st year of life
2) early adolescence
65% of cases present between ages 12 and 18 years
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Etiology: 90% “bell clapper” congenital anatomical arrangement.
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History: sudden onset of severe testicular pain and associated testicular swelling, usually presenting a short time after
onset.
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Examination: tender, swollen, “high riding” testicle, lying transversely.
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Patients usually afebrile
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Differential diagnosis in adults usually orchitis – preceding LUTS for several days, slower onset of pain and later
presentation, commonly with a fever.
Differential diagnosis in children: torsion Hydatid of Morgagni or appendix testis and
acute idiopathic scrotal oedema AISE (average age 6 years, unknown cause).
Testicular Torsion
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Testicular torsion is a clinical diagnosis, and if diagnosed, be taken to theatre as a surgical emergency.
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Testicular U/S will delay diagnosis and should not be called for – the urology registrar should be called to assess the
urgently and if not available the consultant should be called.
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The on call urology registar should assess the case clinically, urgently, and if they still have doubts (often misguided),
then request U/S, then take the consequences of delay if they are wrong.
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If the U/S is correct and delays theatre, (which is then clearly unnecessary) then nothing is lost.
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If patients are taken to theatre with the wrong diagnosis, then little is lost and registrars should learn.
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BUT if there is a delay in taking patients to theatre because U/S is done, then testicles are lost.
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Senior radiologists agree with this policy and feel that diagnosis of torsion is a clinical diagnosis.
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Torted testicles can be recovered if detorted surgically within 6 hours (4 – 8 hours), and in some cases 12 hours.
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Surgery: bilateral orchidopexy through a midline scrotal incision using non absorbable suture material (3/0 Prolene).
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Investigations that can be done: testicular U/S with doppler, nuclear scan technetium-99m pertechnetate
Trauma - Renal
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Blunt vs penetrating trauma
Blunt trauma most common with high velocity MVA
Low velocity trauma – more commonly underlying abnormal kidney
Penetrating injury generally stab wounds and gunshot
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Blunt trauma
Surgical exploration uncommon 2.6% of 913 cases in San Francisco
Increasing use of radiological embolization and urological stents
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Penetrating trauma
Commonly require exploration
42% stab wounds explored
76% of gunshot wounds explored
Renal Trauma Staging
Renal Trauma Staging
Renal Trauma - Presentation
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Obvious trauma – assess trauma potential
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Frank haematuria common 80% to 94% of cases (but not always)
N.B. especially renal pedicle injury in children and young adults
deceleration injury with no haematuria
Penetrating trauma – poor correlation of degree of haematuria and
severity of injury
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Hypotension
early may be associated with loss from other injuries
deceptive absence of hypotension in children
Renal Trauma - Imaging
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CT scan – multi phase – non contrast, contrast arterial and venous
phases and pyelographic phase.
If haemodynamically stable
Note importance of contrast study in assessing that pedicle intact
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Intra-operative one shot IVP
When patient haemodynamically unstable and emergency surgery
necessary, this allows assessment of pedicle integrity in presence
of identifiable non expanding peri-nephric haematoma
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Follow up imaging – pending initial staging – especially urinoma
development in stage IV injury at 48 hours
Renal Trauma - Surgery
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Absolute indications
Severe blood loss with haemodynamic instability, not suitable for
embolization
Renal pedicle avulsion ? Time limits
Ureteric avulsion
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Relative indications
Nonviable tissue – if large segments of ischaemic tissue ? %
vs risk of delayed haemorrage
Urinary extravasation
Calyceal injury vs ureteric avulsion
JJ stenting with radiological drainage perc drain
Renal Trauma - Algorithms
Renal Trauma - Algorithms
Renal Trauma - Algorithms
Renal Trauma – Secondary Haemorrhage
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2 – 36 days post injury
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Most often arteriovenous fistula or pseudo-aneurysm
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13% - 25% with grade III and IV injuries
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Rx most commonly selective embolization currently
Renal Trauma - Hypertension
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Incidence 0.3% - 0.9%
Earliest 37 days, but up to decades after injury
Average 34 months
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Etiology – more likely in more severe injuries grade IV
Page kidney parenchymal compression by fibrosis
Renal artery stenosis, post intimal injury
Arterio-venous fistulas
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Diagnosis
Regular blood pressure monitoring in high grade injuries
? 6 monthly lifelong
Trauma - Bladder
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Uncommon
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Etiology
Iatrogenic most common – urology/gynaecology
Spontaneous – rare in abnormal bladders eg clam cystoplasty
Intoxicated – alcohol abuse with fall onto full bladder
present with pain, unable to void or haematuria
Traumatic – blunt trauma with high velocity MVA
strong association with pelvic fracture (85% of ruptures)
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Classification – Extraperitoneal vs Intraperitoneal (10% combination)
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Imaging diagnosis
CT delayed post contrast phase in major trauma
Cystogram in iatrogenic/spontaneous/intoxicated groups
Bladder Trauma Treatment
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Extraperitoneal rupture
Urethral catheter drainage (18F catheter)
Duration pending mechanism and severity of injury
5 days up to 3 weeks
Repeat cystogram prior to catheter removal
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Intraperitoneal rupture
Traditionally surgical repair
More recently, conservative, with catheter drainage and follow up
cystogram
“Anterior” Urethral Trauma
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Etiology
Most commonly iatrogenic – forced catheterization with stricture
“Fall astride” injury
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History
History of trauma, blood at urethral meatus and urine retention
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Examination
Blood at urethral meatus
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Investigation
Usually nil for iatrogenic
Urethrogram for fall astride injuries
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Treatment
Nil if voiding OK for iatrogenic injury and catheter not required
Cystoscopy/ endourological management in some cases
Surgical repair of fall astride anterior urethral injury for complete rupture
relatively easy surgery, catheter 3 weeks post op
Urethrogram – Anterior Urethral Trauma
“Posterior” Urethral Trauma
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Etiology
Most commonly iatrogenic – no Rx or endourological/
catheterization
Associated significant pelvic injury – high level trauma potential
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Clinical findings
Blood at meatus + urine retention
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Investigation
Urethrogram +/- CT abdomen & pelvis
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Management – surgical
Timing pending other injuries suprapubic catheterization common
Endourological re-alignment (flexi scope via suprapubic tract and
optical urethrotome up urethra, with passage “glide” wire)
Significant incidence of subsequent stricture – role of self dilatn
Membranous urethroplasty – advanced surgical technique
Urethrogram – Posterior Urethral Trauma