Chapter 9

Urologic Emergencies

Introduction

This chapter is designed to aid the urologist when called to the emergency room (ER) or to a hospitalized inpatient for matters worthy of immediate attention aside from urinary trauma, stones, sepsis, and sexually transmitted diseases that are topics of specific chapters covered in detail elsewhere in this manual.

Gross hematuria

Bleeding from anywhere in the urinary tract may be manifest by passage of visible blood in the urine. In anticipation of this common emergency, the urologist needs available a well-stocked equipment cart including: a variety of catheter types (e.g., coudé, Council, three-way) and sizes; filiforms and followers; sounds; guide wires; a catheter guide or stylet; and flexible cystoscope. Management involves two phases: 1) ensuring patency of urine flow and hemodynamic stability and 2) determining etiology of hematuria.

Hemodynamic stability

1. Check serial Hb/Hct. Transfuse PRN.

2. Correct coagulopathy.

Ensure patency of urine flow

1. If voiding comfortably without clot monitor for spontaneous clearance of hematuria if otherwise stable.

2. If clot present:

a. Place large bore catheter to evacuate clot.

b. Saline continuous bladder irrigation to prevent clot reaccumulation

c. Hand (Toomey syringe) evacuation of clot in low-capacity or poorly compliant bladders (e.g., postirradiation)

3. Hematuria with indwelling catheter

a. Determine appropriate catheter positioning in bladder.

1) Gently irrigate and aspirate for return of irrigant.

2) Check cystogram.

b. Replace or upsize catheter for tamponade of urethral bleeding and/or satisfactory drainage.

Determine etiology of hematuria

1. Urinalysis (UA) and culture and sensitivity (C&S) for urinary tract infection (UTI)

2. Urine cytology

3. CT urography

4. Cystoscopy

5. Angiography

Urinary retention

Relief of infravesical lower urinary tract obstruction in the difficult-to-catheterize patient is the bread and butter of bedside emergency urologic care.

Noncatheterized patient

1. History

a. Voiding difficulty

1) Benign prostatic hyperplasia (BPH)

2) Urethral stricture

b. Prior lower urinary tract trauma or surgery (e.g., transurethral resection of the prostate [TURP], radical prostatectomy)

1) Urethral stricture

2) Bladder neck contracture

3) Meatal stenosis/ balanitis xerotica obliterans (BXO)

c. History of bladder stones

d. History of sexually transmitted disease (e.g., gonorrhea)

e. Gross hematuria – clot urinary retention

f. Acute neurologic event – spinal/cerebral shock

1) Spinal cord injury

2) Cerebrovascular accident

3) Multiple sclerosis

2. Physical examination

a. Palpably distended bladder

b. Palpable urethral mass

c. Meatal fibrosis

3. Laboratory tests

a. Urinanalysis

b. Blood urea nitrogen (BUN)/creatinine

4. Management

a. Placement of well-lubricated catheter

1) Coudé tip for BPH

2) Catheter guide

b. If unsuccessful

1) Van Buren sound to identify urethral level obstruction

2) Filiforms and followers to dilate stricture

3) Cystoscopy

a) Guide wire

b) Heyman/Amplatz hollow core dilators

4) Suprapubic tube placement

Catheterized patient

Urinary retention in a patient with a Foley catheter previously inserted may be due to malpositioning of catheter (misplacement, false passage, or caudal migration) or obstruction of the catheter lumen by clot, stone, tissue, or debris.

1. History

a. Catheter previously draining well

b. Severe pain during or after placement

c. Gross hematuria

2. Physical examination

a. Excess length of catheter protruding from urethral meatus

b. Palpably distended bladder (if not, consider possible anuria)

3. Management

a. Irrigate and aspirate to remove debris or clot.

b. Cystogram to determine catheter position

c. Replace catheter (follow algorithm for noncatheterized patient).

Flank pain

A multitude of entities, both urologic and nonurologic, may be the cause of the patient presenting with acute atraumatic flank pain. A systematic evaluation will enable the prudent urologist to identify any contributing genitourinary etiologies and formulate further treatment based on this diagnosis.

Differential Diagnosis

1. Intrinsic renal/ureteral obstruction

a. Obstructing calculus

b. Hematologic/vascular

1) Blood clot

2) Papillary necrosis

c. Infectious

1) Viscous pyuria/bacteriuria

2) Fungus ball

3) Tuberculous pyelitis/ureteritis with secondary stricture of infundibula/ureters

d. Obstructing tumor

1) Transitional cell carcinoma

a) Renal pelvic/calyx

b) Ureter

c) Bladder

2) Adenocarcinoma prostate

e. Ureteral stricture

2. Extrinsic ureteral obstruction

a. Cancers and associated adenopathy

1) Endometrial

2) Ovarian

3) Breast

4) Colon

5) Sarcoma

b. Retroperitoneal fibrosis

1) Idiopathic

2) Perianeurysmal

c. Iatrogenic ligation

1) Clip

2) Stitch

3. Parenchymal bleed or rupture

a. Malignant

1) Renal cell carcinoma

2) Transitional cell carcinoma

b. Benign

1) Cyst rupture or bleed

2) Angiomyolipoma bleed

c. Adrenal hemorrhage

4. Renovascular

a. Occlusive arterial

1) Intrinsic stenosis/thrombosis (trauma)

2) Extrinsic emboli

b. Renal vein thrombosis

Evaluation

1. History

a. Duration of pain

b. Location

c. Anticoagulant use

2. Physical examination

a. Temperature and vital signs

b. Tenderness

c. Ecchymosis

d. Palpable mass

3. Laboratory tests

a. UA and C&S

b. Complete blood count (CBC) with differential

c. Basic metabolic panel (BMP)

d. Coagulation profile (Coags)

4. Imaging

a. Ultrasound

1) Hydronephrosis – nonspecific

2) Best utilized during pregnancy

b. Noncontrast CT scan of abdomen and pelvis

1) Mass

2) Adenopathy

3) Stones
Hounsfield Units (HU) may predict stone composition.
Indinavir stones are nonvisualized even on CT.

c. Contrast-enhanced CT scan of abdomen and pelvis

1) Arterial phase
Identify renovascular clot or stenosis.
Enhancing masses
Parenchymal ischemia

2) Urographic phase
Site of obstruction
Intralumenal filling defects

d. Retrograde or antegrade urography

Acute management – based on etiology

1. Obstruction

a. Monitor if stable.

b. Drainage

1) Retrograde stent

2) Antegrade nephrostomy tube or stent

c. Dilation

2. Infectious

a. Empiric antimicrobials

b. Pan culture

3. Hemorrhagic

a. Anemia: Transfuse PRN.

b. Reverse anticoagulation.

c. Endoscopic cauterization

4. Renovascular occlusion

a. Initiate anticoagulation.

b. Thrombectomy

c. Interventional radiologic treatment/angioplasty

Scrotal pain

First and foremost, a call to evaluate a patient with acute scrotal pain should lead to a prompt response owing to the possibility that the underlying condition may represent a surgically treatable emergency, namely testicular torsion. Every other cause for acute scrotal pain, aside from genital trauma, is less urgent.