UROLOGIC EMERGENCIES. Dr Alison Rutledge

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1 UROLOGIC EMERGENCIES Dr Alison Rutledge

2 Plumbing Problems

3 Common problems Acute urinary retention IDC insertion Haematuria Acute scrotal pain Renal colic UTIs Trauma Other bits and bobs

4 Urinary retention Acute very painful, sudden inability to void Chronic insidious onset, relatively painless Aim of history and examination is to confirm diagnosis and identify cause / precipitating factors examination + bladder scan

5 Causes Bladder outlet obstruction Prostate BPH, CaP, prostatitis Urethra stricture, clot, UTI Bladder stone, tumour Extrinsic pelvic mass, pelvic organ prolapse Neurological Spinal cord Autonomic / peripheral nerves Medications Post-op

6 Immediate Rx Insert IDC Record volume drained FBE / UEC / CSU

7 Reasons to admit Obstructive renal failure Clot retention Sepsis Spinal cord compression

8 Discharge plan Address any precipitating factors IDC education + supplies Commence tamsulosin Arrange TOV Referral to CAPAC Community nursing for TOV 5-7 days Follow-up with urology if required

9 Getting a catheter in Size Fr in males 12 Fr in females Fr in haematuria/clot retention Shape 2-way normal tip 3-way normal tip Coude tip SPC

10 Coude tip

11 Men Lubrication +++ Use a bigger catheter Don t inflate balloon until urine draining and advanced to hilt Shouldn t need to use force Always reposition foreskin Caution urethral injury, recent surgery

12 Females Positioning Lighting Exposure Have an assistant Picture!!

13 Can t catheterise? Patient not relaxed Urethral stricture Bladder neck stricture

14 SPC Use ultrasound guidance Caution if prior lower abdominal or pelvic surgery Use spinal needle to aspirate prior to insertion

15 Trial of void Remove early Encourage oral intake ~200mL/hour Measure volume and post-void residual A good result is voiding > 200mL with < 100mL post-void residual Interpret in clinical context If fails TOV IDC/ISC + urology review

16 Haematuria An alarming symptom to most patients! Most can be managed as outpatients BUT all need appropriate follow-up 20-25% of patients with macrohaematuria have malignancy A single episode warrants urology referral

17 Causes Urologic Malignancy Infective Urolithiasis Other eg. RTx cystitis, trauma, post-procedure Medical Contributing factors Anti-coagulation

18 Describing haematuria

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20 ED management Resuscitation as required FBE / UEC / coags (G+H) MSU UA + MCS Treat identifiable causes MSU CT KUB Consider anticoagulation

21 3-way IDC Do they need a catheter? Hx: large clots, ease of urination, retention Ex: palpable bladder, heavy bleeding PVR on bladder scan Don t bother with 2-way or < 20Fr Must have bladder washout and CBI commenced

22 Bladder irrigation

23 Reasons to admit Clot retention Heavy bleeding Haemodynamically unstable Requiring transfusion Relative: Renal failure Coagulopathy / anticoagulant Rx Social reasons Significant co-morbidities

24 Discharge plan Encourage oral hydration Return if retention, fever, worsening sx, pain Withhold anticoagulation if able Prompt outpatient urology review MSU Urine cytology x 3 Upper tract imaging

25 Testicular torsion Acute scrotal pain Epididymo-orchitis Appendiceal torsion Inguinal hernia Testicular tumour Referred pain

26 How to tell the difference Testicular torsion Age 10-20s 20+ Onset Sudden Gradual Nature Severe Aching Associated sx O/E Nausea/vomiting High-riding Tender ++ Epididymo-orchitis Dysuria, frequency, urgency Epididymis > testicle Normal lie Ix: FBE/UEC, UA/MSU/urine PCR USS only on urology advice

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30 Appendiceal torsion

31 Epididymo-orchitis

32 Renal colic Sudden onset, waves of pain, restless, referred to groin/genitalia Associated nausea/vomiting, urinary sx O/E: mild tenderness to deep palpation UA: blood

33 ED management Treat symptoms Confirm diagnosis Determine disposition conservative v intervention outpatient v inpatient

34 Treat symptoms Analgesia Regular paracetamol NSAIDs oral or PR indomethacin Opioids only if necessary Nausea Hydration IV fluids

35 Confirm diagnosis CT KUB (Renal USS) XR KUB FBE / UEC UA / MSU

36 Reasons to admit Infection / fevers / urosepsis Renal impairment or deteriorating renal function Solitary kidney Transplant kidney Bilateral ureteric calculi

37 Reasons to admit Failed conservative management Severe uncontrolled pain Ureteric stone > 6mm Proximal stone Staghorn calculi Extremes of age

38 Chance of passage Depends on size: <2 mm: 95% 2-4 mm: 80% 4-6 mm 60% 6-9 mm: 50% Depends on position VUJ: 80% proximal: 50%

39 Discharge plan Regular analgesia Commence tamsulosin Strain urine Follow-up with GP 3-4 weeks Repeat imaging Refer to urologist if required Return if worsening pain / fevers

40 Surgical treatment Relief of obstruction CE + ureteric stent Percutaneous nephrostomy Definitive treatment Ureteroscopy +/- laser ESWL PCNL

41 Ureteric stent

42 Stent irritation Common post ureteric stent Haematuria, frequency, urgency, flank pain Ix: UTI (UA / MSU) Migration (XR KUB) Obstruction (USS / CT) Rx: Simple analgesia Tamsulosin Ditropan

43 UTIs Acute uncomplicated UTI: No urinary tract abnormalities No renal disease No significant comorbidities Cultures + renal USS recommended:? Pyelonephritis Unresolving 2/52 Atypical symptoms Recurrent UTIs Men Pregnancy

44 Complicated UTIs Abnormal genitourinary tract IDC, stent, bladder outlet obstruction Renal impairment Renal transplant Underlying disease Diabetes Immunosuppression

45 When to scan Urosepsis Hx renal calculi Hx urologic surgery Immunosuppression Failed antibiotic therapy Renal failure Any complicated UTI

46 CAUTI Colonisation expected Treat if symptomatic Short-term IDC remove if possible, send MSU Long-term IDC/SPC change, send CSU from new catheter Avoid unwarranted IDC

47 Trauma - kidney Blunt direct blow, deceleration; penetrating Most managed conservatively

48 Trauma - urethral Blood at meatus Do not attempt IDC insertion prior to urethrogram Haematuria All cases should be discussed with urology Have a high index of suspicion Ask for delayed phase if having CT abdo/pelvis

49 Extra bits and pieces

50 Post-TRUS sepsis 1-2% despite prophylactic abx Usually short-lived rigor and fever often normal by ED presentation All should be discussed with urology Most require admission for IV abx

51 Priapism Significant risk of impotence if prolonged Self injection of intra-corporeal agents Ischaemic v non-ischaemic Rx: Dorsal penile block Aspiration Intra-corporeal injection

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53 Fournier s gangrene

54 Fournier s gangrene Necrotizing fasciitis of perineal, perianal, genital regions Can extend to abdominal wall Risk factors: age, diabetes, immunocompromised

55 Paraphimosis

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57 Penile fracture