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* Urological Emergencies *Non-Traumatic -DrTabaKhan FY1 RenalColic: TesticularTorsion: AcuteUrinaryRetention: •Definitionandcauses •Definitionandriskfactors •Causes •Clinicalpresentation •Signsandsymptoms •Clinicalpresentation •Diagnosis(imagingstudiessuchas •Diagnosis(ultrasound) •Initialmanagement CTscan) •Emergencysurgicalintervention •Catheterizationtechniques •Managementandpaincontrol Hematuria: BladderOutletObstruction: Urosepsis: •Typesofhematuria(macroscopic •Causes(prostatichypertrophy, •Definitionandpathophysiology vs.microscopic) urethralstricture) •Causes(traumatic,infectious, •Signsandsymptoms •Clinicalpresentation neoplastic) •Diagnosis(blood cultures,imaging) •Evaluationanddiagnostic •Initialmanagement •Antibiotictherapyandsupportive procedures •Urodynamicstudies care T opics tobe covered: PenileFracture: Fournier'sGangrene: BladderRupture: •Causesandriskfactors •Definitionandetiology •Traumaticvs.non-traumaticcauses •Signsandsymptoms •Clinicalfeatures •Clinicalpresentation •Diagnosis(clinicalandimaging) •Diagnosticapproach •Diagnosis(imagingstudies) •Surgicalintervention •debridementagementand •Surgicalrepair Priapism: GenitourinaryTrauma: Paraphimosis: •Ischemicvs.non-ischemicpriapism •Mechanismsofinjury •Definitionandcauses •Causesandriskfactors •Typesofinjuries(renal,bladder, •Clinicalpresentation •Managementstrategies(aspiration, urethral) •Reductiontechniques shunts, medication) •Diagnosticapproachand imaging •Complicationsandfollow-upcare •SurgicalinterventionsCase1 CaseScenario:A 45-year-oldmanpresentstotheemergencydepartmentwithexcruciatingleft-sided flankpain. What isthelikely diagnosis? Options: A) Appendicitis B)RenalColicdue toa kidneystone C)Pancreatitis D) Cholecystitis Renal Colic CaseScenario:A 45-year-oldmanpresentstotheemergencydepartmentwithexcruciatingleft-sided flankpain, radiatingtothegroin.Hedescribesthepainasintermittentandsharp. Thereisno associatedhematuria,but hefeelsnauseous.Question:Whatisthelikely diagnosis? Options: A) Appendicitis B) Renal Colicdue to akidney stone C)Pancreatitis D) CholecystitisRenal StonesCase2 CaseScenario:A17-year-oldmalepresentsurgentlywithsevereunilateraltesticularpain.Question:Given themostlikelydiagnosis,whichofthefollowingreflexesabnormalitiesis likelyto bepresent? • Options: • A.PresentBabinskiReflex • B.AbsentBabinskiReflex • C.AbsentCremastericReflex • D.PresentCremastericReflex • E.PresentMorrowReflexT esticular T orsion CaseScenario:A17-year-oldmalepresentsurgentlywithsevereunilateraltesticularpainthat started suddenly.Thereis nohistoryoftrauma,andthepainis notrelievedbyrest.Onexamination,theaffected testicle is swollenandtender.Question: Giventhe mostlikely diagnosis,whichofthe followingreflexes abnormalitiesis likelyto bepresent? • Options: • A. PresentBabinski Reflex • B. Absent Babinski Reflex • C.AbsentCremastericReflex • D. Present CremastericReflex • E. PresentMorrowReflex T esticular T orsion ClinicalPresentation: • Severeunilateraltesticularpain • Not improvedonelevatingthe testes(Prehn’sSign-+inepididymo-orchitis) • Canbe intermittentor constant • +/-Nausea& vomiting • Scrotalswelling/ oedema/ Erythema • High Ridingtestes • Lossof cremastericreflex • Elevationof testesontouching medialthigh RiskFactors: • 12–25 yearolds • PreviousTorsionorFamilyHistory • Undescendedtestes • “bell-clapper deformity”(horizontallyingtestes,increasedmobilityoftunica vaginalis) Testicular T orsion Investigations: Management: 4 –6 HOURWINDOW Nil bymouth,inpreparationforsurgery !!CLINICALDIAGNOSIS!!DONOTDELAY SURGICALEXPLORATION Analgesiaas required Urgentsenior urologyassessment Ultrasoundcanbe usedtoinvestigateinunclear Surgicalexplorationof thescrotum cases:Dopplerusedtodiagnosepoorblood flow. Orchiopexy Rule outinfection: Orchidectomy Bloods– inflammatorymarkers /U&Es Urinalysis / MCS Urethralswabsetc.Case3 CaseScenario: A60-year-oldmale presentswith suddeninability topass urine.Question: Whatcouldbethelikely cause,and howshouldyouapproachthispatient? • Options: • A)Urinary tractinfection • B)ProstaticHypertrophy • C)Bladder stones • D)Urethralstricture Acute Urinary Retention CaseScenario: A60-year-oldmale presentswith suddeninability topass urine, accompaniedby lowerabdominaldiscomfort.Hedenies anyrecent infections. Question:Whatcouldbethelikely cause, andhowshouldyouapproachthispatient? • Options: • A)Urinary tractinfection • B)ProstaticHypertrophy • C)Bladder stones • D)Urethralstricture Acute Urinary Retention CaseScenario: A60-year-oldfemale presentswith suddeninability topass Question:Whatcouldbethelikely cause, andhowshouldyouapproachthispatient?ions. Acute Urinary Retention CaseScenario: A60-year-oldfemale presentswith suddeninability topass urine, accompaniedby lowerabdominaldiscomfort.Shedenies anyrecent infections.The painis situated inthe suprapubic region,with noradiation. Sheadmits shehas beenunable tourinefor24 hoursdespite thesensation tovoid.Shehas apast medical historyof hypertension,hypercholesterolaemiaand depression.Onexamination:HR110, RR25, BP 120/89, T36.7. Tendernessinthe suprapubicregionwith apalpable bladder Question:Whatcouldbe thelikely cause,andhowshouldyouapproachthispatient? • Options: • A. Tamsulosin • B.Ramipril • C. Atorvastatin • D. Amitriptyline • E.Amlodipine Acute Urinary Retention CaseScenario: A60-year-oldfemale presentswith suddeninability topass urine, accompaniedby lowerabdominaldiscomfort.Shedenies anyrecent infections.The painis situated inthe suprapubic region,with noradiation. Sheadmits shehas beenunable tourinefor24 hoursdespite thesensation tovoid.Shehas apast medical historyof hypertension,hypercholesterolaemiaand depression.Onexamination:HR110, RR25, BP 120/89, T36.7. Tendernessinthe suprapubicregionwith apalpable bladder Question:Whatcouldbe thelikely cause,andhowshouldyouapproachthispatient? • Options: • A. Tamsulosin • B.Ramipril • C. Atorvastatin • D. Amitriptyline • E.AmlodipineAcute Urinary Retention Acute Urinary Retention Symptoms: Investigations •AcutePain- Suprapubic, severe,discomfort • Bladder Scan: o Measureofvolume ofurine retainedpost- •Inability tomicturate- urgepresent void(normal<400mL) •Supra-pubic tenderness o >1L– possibilityofhigh-pressurechronic •Palpablebladder retention •DRE– faecal impaction/Prostate • Bloods: o Inflammatory markers:infection? enlargement(?constipation) •Pyrexia/ diaphoresis(infection?) o Renalfunction(U&Es): renal consequence? •Catheterised?-> Clotretention? • UltrasoundUrinary Tract Haematuria? o Visualisethe urinary tracttolook for signs ofHydronephrosis Acute Urinary Retention !!!CATHETERISE!!! Start Tamsulosin: Alpha- MonitorforOutput& Post- Providesinstantrelief by blocker – relaxes contraction obstructiondiuresis: draining urinedirectly of bladder wall/prostateto •Loss oftheintramedullary fromthebladder allow urine flow (SEs: concentrationgradientfrom REMEMBER: Measure hypotension) prolongedretention. thevolume/ outputafter Reverse any identified insertingthecatheter causes: •WorsensAKI •Patientswithoutput medicationssible >200mL/h shouldreceive IV fluids toreplace losses Treat active infections (UTIs): Urine MCS / urinalysisCase4 CaseScenario:A35-year-oldfemalepresentswithvisible bloodinherurine.Question:Whatshouldbeyour initial step inevaluatingthis patient,andwhy? • Options: • A)Cystoscopy • B)CTscan • C)Urinalysis • D)RenalbiopsyHematuria CaseScenario:A35-year-oldfemalepresentswithvisible bloodinherurine,noticedduringthe lasttwo this patient,andwhy?atedpainduringurination.Question:Whatshouldbeyourinitial stepin evaluating • Options: • A)Cystoscopy • B)CTscan • C)Urinalysis • D)RenalbiopsyHematuria Visible haematuria: bloodis visible inthe urine,colouringit pink,red,ordarkbrown Non-visiblehaematuria:bloodis presentin theurineon urinalysis,butnotvisible. This canbe furthercategorised into: • Symptomaticnon-visiblehaematuria:haematuria (confirmedonurinalysis/microscopy)presentswith associatedsymptoms,suchassuprapubicpainorrenal colic • Asymptomaticnon-visiblehaematuria:haematuria (confirmedonurinalysis/microscopy)withnoassociated symptomHematuria Investigations: Urinalysis Bloods-includingPSAifappropriate Flexiblecystoscopy USS CTUrogram Management: Treatunderlyingpathology Washoutandirrigation Rigid cystoscopyCase5 Case Scenario: A 28-year-old male presents to the A&E with swellingof the penis. Question: What isthe likely diagnosis, and howshould it bemanaged? Options: A) PenileFracture B) Priapism C) Peyronie's Disease D) ParaphimosisPenile Fracture Case Scenario: A 28-year-old male presents to the A&E with sudden, severe pain and swelling of the penis after an episode ofvigorous sexual activity. Hereports hearing a popping sound. Question: What isthe likely diagnosis, and howshould it bemanaged? Options: A)Penile Fracture B) Priapism C) Peyronie's Disease D) ParaphimosisPenile Fracture SOS Traumatic rupture of corpus cavernosa and tunica albuginea in an erect penis. • Ages: 30-40yrs • Predilection: Right sided damage • Forceful thrusting to the pubicsymphysis orperineum • Popping sensation or hearing a“snap”, with immediate pain, swelling, and detumescence. Symptoms: • Penile Swelling • Discoulouration ("Aubergine Sign") • "Rolling Sign"Penile Fracture Investigations: • ClinicalDiagnosis • Pre-opbloods • Cavernosographyor USS • RetrogradeUrethrography (voidingdifficulties/bloodat themeatus) Management: • Analgesia • Surgicalexplorationandrepair(<1 week) • Absitinence • Monitoring(>1week)Case 6 Case Scenario: A 60-year-old male presents with severe pain in thegenital. Question: What condition are you likely dealing with, and what are the critical steps in management? Options: A) Epididymo-orchitis B) Fournier's Gangrene C) Genital Herpes D) CellulitisFournier's Gangrene Case Scenario: A 60-year-old diabetic male presents with severe pain, swelling, and redness in the genital and perineal region. He appears systemically unwell. Question: What condition are you likely dealing with, and what are the critical steps in management? Options: A) Epididymo-orchitis B)Fournier's Gangrene C) Genital Herpes D) CellulitisFournier's Gangrene • Necrotising fasciitis thataffects theperineum • Mortality rate of 20-40%. • Monomicrobial ora polymicrobial: GroupA streptococcus,C. Perfringes,and E.Coli. • Anatomic barriers to the spread ofinfection include thedartos fascia ofthepenis and scrotum, Colles fascia ofthe perineum, and Scarpa fascia oftheanterior abdominal wall. As a result, the testes andepididymis arecommonly not affected bythe fasciitis. • Risk Factors: ▪ Diabetes mellitus ▪ Excess alcoholintake ▪ Poor nutritionalstate ▪ Excess steroid use ▪ Haematologicalmalignancies ▪ Recent traumaFournier's Gangrene Diagnosis: Management: • Clinical Diagnosis • Thedefinitive management:urgent surgical debridement • Routinebloods andblood cultures • HbA1C orBMs • Tissue histology and culture • CTimaging • Fluid culture (if any pus) • Broad-spectrum antibiotics • HDU/ITU admission • Further surgical relooks and debridement • Secondary closure with skin grafts -early involvement of plastic surgeonsis key Case 7 Case Scenario: A 42-year-old male presents to the emergency room with a painful, prolonged erection that has persisted for several hours without sexual stimulation. Question: Which ofthe followinganatomical structures isresponsible in the process ofa penile erection? Options: A. Corpus Callosum B. Corpus Luteum C. Corpus Cavernosum D. Corpus Spongiosum E. Glans Case 7 Case Scenario: A 42-year-old male presents to the emergency room with a painful, prolonged erection that has persisted for several hours without sexual stimulation. Question: Which ofthe followinganatomical structures isresponsible in the process ofa penile erection? Options: A. Corpus Callosum B. Corpus Luteum C. Corpus Cavernosum D. Corpus Spongiosum E. Glans Case 7 Case Scenario: A 42-year-old male presents to the emergency room with a painful, prolonged erection that has persisted for several hours without sexual stimulation. Question: What type of priapism is likely, and what are the immediate management steps? Options: A) Ischemic Priapism B) Non-ischemic Priapism C) Venous Leakage Priapism D) Traumatic Priapism Priapism Case Scenario: A 42-year-old male presents to the emergency room with a painful, prolonged erection that has persisted for several hours without sexual stimulation. Question: What type of priapism islikely, and what are theimmediate management steps? Options: A)Ischemic Priapism B) Non-ischemic Priapism C) Venous Leakage Priapism D) Traumatic Priapism Priapism Low Flow/ Ischaemic: • Veno-occlusive • Blockage of venous drainage • Causes: iatrogenic, sickle cell disease*, haematological disorder High Flow/ Non - Ischaemic: • Unregulated cavernous arterial inflow • Rapid arterial entry & slowexit • Causes: sexual stimulation, trauma Priapism Corporeal blood gas: Management: • Immediate:Corporeal Aspiration • SurgicalManagement–surgicalshunt • Prognosis:90%of caseswithpriapismlasting>24hoursdonot regainthe abilitytohaveintercourse. •Management = Penileprosthesisinsertion Routine Bloods: • FBC • CRP/ ESR • Coagulationscreen • U&Es& Boneprofile • Haemoglobinelectrophoresis (+/- drug screen) ?SpinalInjury • PR examination • Imaging(CT/ MRI) Case 8 CaseScenario:A 12-year-oldmalepresentstothe emergencyroomwithcomplaintsof painand swellingof thepenis.Question:Whatisthelikely diagnosis,andwhat stepsshould be takenfor immediatemanagement? Options: A) Phimosis B)Balanitis C)Paraphimosis D) Fournier'sGangrene Paraphimosis Case Scenario: A 12-year-old male presents totheemergency roomwith complaints of pain and swelling ofthe penis. He recently underwent catheterization fora medical procedure. On examination, there isnoticeable edema oftheglans with theforeskin tightly retracted behind it. Question: What is thelikely diagnosis, and what steps should betaken forimmediate management? Options: A) Phimosis B) Balanitis C) Paraphimosis D) Fournier's Gangrene Paraphimosis Tightrestrictivebandaroundthe foreskinthatpreventsits retractionoverthe glans Theforeskingetsstuck! Theglansbecomesoedematousdue to blockedvenousreturn Penileischaemia&riskofinfection Management: •Reducedas soonas possiblewith analgesia(penileblock) manualreduction dextrose-soakedgauze Dundeetechnique (puncture using needles&drainingfluid) •DefinitiveManagement–Circumcision COMMONCATHETERISSUESFORFY s “Can youhelp, MrX’scatheter “Doctor,my patient’scatheterhas isn’tdraining?” stoppedworking!” Catheters 1.Checkthereare no‘external’blockages: Isthecathetertwisted, kinked, accidentallyclamped? 2.Checkforobvious‘internal’blockages?: Isthereobvioussludge/debris blockingthetubing? Haematuria/ clots? 3.Ask thenursestoperformabladder scan: Helpsdifferentiateblockedcathetervs lowurineoutput. 4.Ask thenursestoflushthecatheter: Ifresistance,couldindicateblockage.Canalsohelp dislodge& breakblockages.But canalsocausefurther blockageslateron… 5.ChangethecatheterforlargerlumenOR3 WayCatheter BYPASSING CATHETER • Couldpotentiallybeblocked(follow “Doctor,my patient’s blockedcathetersteps) catheteris le"king. • Lumenofcatheteristoosmall- considerinsertingawiderbore catheter • Checkballoonis fullyinflated • Ifpatientis wearingalegbag,is this belowbladderlevel? AnyQs?Feedback? Finish.References • https://www.ncbi.nlm.nih.gov/books/NBK530989/ LearningObjectivesforApril122023:Common CatheterProblemsforJrDrs Urology AnatomyRefresher–Urinary Tract