Urological Emergencies

Urological emergency symptoms and Lower Urological emergencies

1. Urological Emergencies Symptoms and LUT Non-Traumatic Emergencies Presenter : Dr MANIRABONA E, MD, PG-Y2 General Surgery Supervisor : Dr NGENDAHAYO Edouard, Urologist

2. SCOPE Introduction Urological Emergency Symptoms Non Traumatic Lower urological emergencies Priapism Paraphimosis Testicular torsion Fournier’s gangrene Take Home Message References

3. INTRODUCTION Significant proportion of the urological complaints in hospitals are acute urological emergencies These complaints require immediate, often life-saving treatment either surgical or medical management In many cases there is an underlying disease that can trigger a urological complaint

4. Flank Pain regarded as Classic symptom of renal or ureteric pathology Only 50% of patients who present with flank pain have a ureteric stone confirmed on imaging studies Other 50% have non-stone-related disease and more often non-urological disease Differential diagnosis dependent on age, side of the pain and sex of the patient Roots serving pain sensation from the kidney also serve pain sensation from other organs

5. Etiologies of Flank Pain Urological causes: Ureteric stones, renal stones, infection (pyelonephritis, perinephric abscess, pyonephrosis), PUJO Medical causes : MI, Pneumonia, rib fracture, malaria, PE Gynecological and obstetric disease : Twisted ovarian cysts, ectopic pregnancy, salpingitis Other non-urological causes: Diverticulitis, IBD, PUD, gastritis

6. HEMATURIA Relatively rarely an emergency- presents as clot retention, clot colic or anemia It is such an alarming symptom Macroscopic , frank, or gross hematuria- visible to naked eyes Dipstick hematuria- detected by urine dipstick Microscopic hematuria- presence of > 3 RBCs/hpf

7. ANURIA, OLIGURIA AND INABILITY TO PASS URINE Anuria - complete absence of urine production BOO reveals percussable and palpably distended bladder U/O will resume once a catheter has bypassed obstruction and BPH is most common etiology Obstruction at level of ureters or ureteric orifices, bladder will not be palpable or percussable usually as result of locally advanced prostatic, rectal, cervical cancers Catheterization reveals no or very little urine and diuresis will not be improved

8. Oliguria- scanty urine production and more precisely less than 400 mL/day in adults and less than 1mL/kg/h in children Prerenal causes : Hypovolemia, Hypotension Renal causes : Acute vasculitis, AGN, AIN and ATN from drugs, toxins or sepsis Postrenal causes- BPH, Ureteric obstruction

9. SUPRAPUBIC PAIN Bladder overdistention may result from BOO like BPH and urethral stricture UTI is associated with urethral burning on voiding, frequent and incomplete bladder emptying Inflammatory conditions like interstitial cystitis and carcinoma Gynecological causes include endometriosis, fibroids, and ovarian pathology GIT causes include IBD and irritable bowel syndrome.

10. SCROTAL PAIN AND SWELLING Scrotal pain may arise Scrotum- testicular torsion or appendages, epididymo-orchitis Referred- Pain of ureteric colic may be referred to the testis Classic presentation of testicular torsion is sudden onset of acute pain in the hemi-scrotum Localized tenderness in the epididymis and the absence of testicular tenderness helps to distinguish epididymo-orchitis from testicular torsion

11. Acute Urinary Retention Painful inability to void relieved by bladder drainage Reduced or absent urine output with lower abdominal pain are not in itself enough to make a diagnosis of AUR Diagnosis is the presence of a large volume of urine when drained leads to resolution of pain volumes of 500–800 mL are typical but <500 mL should be questionable, Volumes >800 mL are defined as acute-on-chronic retention

12. AUR-Pathophysiology There are three broad mechanisms Increased urethral resistance : i.e. BOO Low bladder pressure: i.e. impaired bladder contractility Interruption of sensory or motor innervation of the bladder

13. Etiologies of AUR in Men Commonest cause is benign prostatic enlargement (BPE) due to benign prostatic hyperplasia (BPH) leading to BOO Less common causes include malignant prostatic enlargement, urethral stricture and rarely prostatic abscess It is either spontaneous (preceded by the presence of LUTS) or precipitated by event ( previously asymptomatic patient)

14. Etiologies of AUR in Women AUR is less common than it is in men Causes include pelvic prolapse (cystocele, rectocele, uterine) Pelvic masses (e.g. ovarian masses) Prolapsing organ directly compressing the urethra; urethral stricture and urethral diverticulum

15. Causes in Either Sex Hematuria leading to clot retention and postoperative retention Pain- Adrenergic stimulation of the bladder neck Sacral (S2–S4) nerve compression Damage-so-called cauda equina compression Prolapsed L2–L3 disk or L3–L4 intervertebral disk Trauma to the vertebrae Benign or metastatic tumors

16. Neurological Causes of Urinary Retention History of constipation and associated back pain Nighttime back pain and sciatica Spinal tumor or cauda equina compression from a prolapsed intervertebral disk Inability to feel bladder is full and urethral voiding Difficulty in knowing passage of feces or flatus Males loose erection ability and orgasm

17. Is It Acute or Chronic Retention ? Elderly men whose urinary retention not aware- bladder filling or emptying Chronic urinary retention with maintained voiding and bladder volume > 800 mL and intravesical pressure >30 cm H2O associated hydronephrosis Bladder is insensitive to gross distention, voiding continues without sensation of incomplete emptying Sudden inability to pass urine is termed acute on chronic urinary retention Foley catheter and urine volume <800mL or more

18. Urinary Retention-Initial Management Urethral catheterization is the mainstay of initial management of urinary retention Pain from overdistended bladder become improved SPC is requires once urethral catheter failed and in every procedure urine volume must be recorded Urine volume helps diagnosis confirmation and determines subsequent management

19. NON-TRAUMATIC UROLOGIC EMERGENCIES IN MEN PRIAPISM Persistent and painful erection >4hrs not related to sexual arousal nor relieved by sexual intercourse Classified into low-flow and high-flow priapism

20. PRIAPISM Low-flow or ischemic priapism results from decreased venous and lymphatic drainage of the corpus cavernosum High-flow priapism is less likely to be ischemic and most often caused by traumatic arterial laceration Main complication of priapism is erectile dysfunction due to inflammation and fibrosis of the corpus cavernosum

21. Etiologies of Priapism Most cases of low-flow priapism in adults are secondary to pharmacotherapy or drug abuse Drug of abuse such as alcohol, cocaine for heavy users Anti HTN drugs like CCBs, prazosin and hydralazine Psychiatric medications, trazodone, chlorpromazine, thioridazine Erectile dysfunction medications like sildenafil, vardenafil, and tadalafil

22. Other causes of low-flow priapism include Blood dyscrasias Hypercoagulable states such as sickle cell disease, thalassemia polycythemia and vasculitis Most common cause of high-flow priapism regardless of age is arteriovenous fistula formation secondary to perineal trauma

23. Pathophysiology Low-flow priapism Sludging of red blood cells clogs the spaces of the corpus cavernosum leading to impaired drainage of blood Impaired venous outflow can also lead to thrombosis and further ischemia from remaining stagnant blood High-flow priapism Arteriovenous shunt following perineal trauma causes abnormally high flow of blood through the corpus cavernosum

24. Diagnosis Erect, tender penis and soft glans unrelated to sexual arousal High-flow state is usually less painful and carries smaller risk of ischemia with recent history of perineal trauma Definitive distinction between high- flow and low-flow is made by penile blood gas analysis from corpus cavernosum Color duplex ultrasonography to differentiate flow patterns CBC, Coagulation studies and Hb Electrophoresis

25. Management First step is hydration and analgesia Ischemic priapism : terbutaline sulfate SC (0.25 to 0.5 mg) every 30min PRN Aspiration of cavernosal blood and direct caversonal injection of phenylephrine (100- 200 mg every 5-10 min with max of 1000 mg) High-flow priapism arterial blood flow is intact, selective arterial embolization using an autologous clot is highly effective

26. Paraphimosis Foreskin becomes fixed in the retracted position and cannot be reduced Impaired venous return from the glans, edema, induration, ischemia and necrosis of gland

27. Etiologies Most common cause of paraphimosis is previous phimosis Iatrogenic Poor urogenital hygiene Chronic balanoposthitis Genital piercing

28. Diagnosis Patients present with edema and pain of the glans and the inability to pull back the retracted foreskin Diagnosis is straightforward as non-retractable foreskin and the resulting edema are easily visualized It is important to distinguish various infections and strictures of the penis Balanitis is an infection of the glans only Balanoposthitis is an infection of the glans and the foreskin

29. Management Goals to treatment of paraphimosis are to relieve pain and prevent further ischemia to the glans Manual reduction of the foreskin should be attempted Dorsal slit procedure entails incising the fibrotic ring of the prepuce Circumcision is the definitive treatment of paraphimosis

30. Testicular Torsion It results from a twisting of the spermatic cord Impaired blood flow to the testis and venous drainage resulting in edema, ischemia and necrosis First peak at age 1-2 years old and the second higher peak in adolescence Time is testicle

31. Pathophysiology Malformation that allows testicle to rotate more freely around the spermatic cord Malformed tunica vaginalis extends over the whole testicle Testicle is horizontally fixed “ bell-clapper deformity ” present in 12% Strong cremasteric reflex during nocturnal erections

32. Diagnosis Acute scrotal pain and swelling and associated nausea and vomiting High-riding testicle and an absent cremasteric reflex Negative Prehn’s sign Urinalysis and Ultrasonography

33. Management Testicular torsion salvage rates over time Emergent surgery to detorse the affected testicle Attachment to the scrotal wall Procedure is also done on the unaffected testicle

34. Fournier’s gangrene Necrotizing fasciitis of external genitalia, perineal or perianal region Polymicrobial from GIT or GU Affects all ages and both genders Life threatening with a mortality rate of 13-22%

35. ETIOLOGIES 50-60% of infections stem from lower GIT or GU source Risk Factors : HIV, DM, alcohol, perineal trauma, etc. Organisms include E. coli , bacteroides and staphylococci Most likely culprit for an infection of colorectal origin is clostridium

36. Pathophysiology It begins locally with skin infection and spreads down the fascial plane It results into inflammation and ischemia then necrosis later Low oxygen content and necrosis potentiate the effects of the anaerobic bacteria and cause rapid dissemination of the infection

37. Diagnosis Patients present with genital induration, pain, erythema and crepitus Diagnosis is straightforward when the lesions are found Plain radiograph or CT may demonstrate air in the perineal tissues Retrograde urethrogram reveals suspected periurethral infection Perirectal infection source suspected proctoscopy may be revealing

38. Management It relies on an aggressive medical and surgical approach Rapid fluid resuscitation and broad spectrum ATB Surgical debridement, aggressive wound care and redebridement SPC and Fecal diversion may be needed Genital skin is highly elastic and grafts are not required unless over 60% of the skin is removed

39. Take Home Message UE delays in treatment may lead to permanent damage Priapism focus is on diagnosis and distinguishing high-flow from low-flow forms as latter requires emergent treatment Paraphimosis is straightforward diagnosis ,various methods of reduction and circumcision Testicular torsion diagnosis is heavily clinical and salvage of testicle is decreasing with time to treatment Fournier’s gangrene is potentially fatal, aggressive medical and surgical therapy improve chances of survival and outcome

40. References Non-Traumatic Urologic Emergencies in Men: A Clinical Review Jesse Brown VA Medical Center, Department of Emergency Medicine, Chicago, IL, University of Illinois at Chicago, Chicago, IL Urological Emergencies In Clinical Practice-Springer-Verlag London (2013) Hashim Hashim M.D., FEBU, FRCS ( Urol ) (auth.), John Reynard, Nigel C. Cowan, Dan Wood, Noel Armenakas (eds.)- Lue-Smith and Tanagho's General Urology -McGraw-Hill Medical (2012) Jack W. McAninch , Tom F