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MANAGEMENT OF UROLOGICAL EMERGENCIESMakarand Khochikar
Everywhere USG instead of US, Chief of Urology, Shri Siddhi Vinayak Ganapati Cancer Hospital, Miraj.
Urologists over the period of time have enjoyed their on call duty hours for not being as busy as their surgeon colleagues. Having said that they do face a constant flow of following emergencies on their on call days. If you look at the statistics of accident and emergency departments, urological emergencies account for 20% of their workload.
• Acute renal/ureteric colic : Typically patients come with acute loin pain, which may be radiating to groin. Patient might give history of passing few stones in the past. Clinical examination may not be of much help barring tenderness in the loin. Microscopic or gross haematuria is always a feature of renal/ureteric colic. Immediate management includes pain relief and adequate hydration. Injectable pethidine, diclofenac sodium can relieve the pain immediately but the patients do need them on regular basis for at least first 24-48 hours. Rectal suppositories of diclofenac sodium are very effective and the effect can last for as long as 8-10 hours. Debate would continue as to what is ideal imaging in this situation (US and KUB Vs IVU), but I personally prefer an emergency IVU if the patient’s renal function is normal and if he is not asthmatic and allergic to contrast. IVU gives you information about the anatomy as well as function of the urinary tract and small stones in the ureter are well seen on IVU. The western world is slowly moving towards spiral CT which is quicker to perform and can detect very small intraureteric calculi. The subsequent treatment of the stones would depend on the size and the site of the stone and degree of obstruction. There are AUA guidelines for what is the best way of treating the stones according to site and size of the stone.
• Acute urinary retention : In young patients one should look for severe phimosis, impacted stone in the urethra or urethral stricture. In elderly patients prostatic enlargement is the commonest cause in men and urethral stenosis in women. I personally prefer to insert 14/16 F Foley catheter through suprapubic route (SPC) by means of disposable trocar and canula. One could opt for per urethral catheterisation in this situation, but I feel SPC is easier to manage, less cumbersome and the urethra remains untouched if you are contemplating TUR/urethrotomy in future. Again there is lot of controversy as to whether one should deflate the bladder with slow decompression or let it drain straightaway. I have not found much difference in this as long as you are aware that haematuria can occur at times after sudden decompression of bladder, but is rarely catastrophic. An emergency KUB and USG can give you some idea of cause of urinary retention and subsequent management depends on the causative factor.
One should not forget that constipation, use of anticholinergic drugs, infection can lead to acute urinary retention. Retention following abdominal surgery, cataract surgery is also commonly seen in absence of any urinary symptoms prior to surgery. If you correct the constipation, stop the anticholinergic and treat the infection if any and then give them a trial without catheterisation (TWOC), patients should be able to void satisfactorily.
Patients who have severe back pressurechanges due to outlet obstruction can go into severe hyponatraemia, hypokalaemia and diuresis following bladder decompression. It is safer to have a venous access in these patients and if they have excessive diuresis then it should be replaced by IV fluids preferably by electrolytes. Glucose can induce more diuresis.
•Haematuria with or without clot retention : Haematuria if massive can occur from a kidney tumour (RCC, TCC), renal trauma, bladder tumour, AV malformations and can even come from enlarged prostate. IVU and USG can be complementary to each other in this situation. The treatment would depend on its aetiology. If the patient comes with clot retention, then he should have a 20/22 F three way Foley catheter and bladder can be washed and irrigated through this. If one fails to wash the bladder then it is advisable to take him to the theatre and wash the bladder under anaesthesia.
• Acute Scrotum : Acute testicular pain with/without testicular swelling is the commonest emergency in paediatric age group and adolescent group. The differential diagnosis is
- Testicular torsion
- Twisted hydatid cyst of Morgagni
- Epididymo-orchitis
• Testicular torsion is characterised by acute onset of pain, exacerbation of pain if any attempt of touching/lifting the scrotum is made (Prehn’s sign), uplifting of scrotal contents on affected side, inability to differentiate between testis and cord structures and contralateral ‘bell clapper’ testis. In contrast, epididymoorchitis is of gradual onset and invariably associated with raised temperature and white cell count and often have associated urinary tract infection. Twisted hydatid cyst of Morgagni is very commonly seen in the western world. If the diagnosis is not clear on clinical examination, I would always suggest an emergency exploration. None of the investigations (US, nuclear medicine scan, colour doppler) are of any help in differentiating these conditions and only exploration would give you a correct answer. It is advisable to consent the patient for bilateral exploration, bilateral scrotal fixation of testes (in case of torsion) and possible orchidectomy if there is gangrene of testis. If one is not sure of the adequacy of blood supply to the testis, I would recommend the use of hot water saline packs and gentle incision on tunica albugenia. If there is bleeding at the edges of tunica albugenia then it is worth saving the testicle. Sometimes, you might come across a testicular tumour presenting as testicular mass and acute pain. US scan would certainly help in confirming a diagnosis in this situation.
• Fracture Pelvis with bladder and urethral injuries : Injury to the pelvic organs can be a cause of worry, with fracture pelvis. One can escape any significant damage, or with minor haematoma, but bladder disruption or intraperitoneal rupture can be fatal. High riding prostate, with bladder pushed upwards is a sign of disruption of bladder. Intraperitoneal rupture of bladder can occur in patients with full bladder at the time of trauma. Blood discharge per urethra signifies urethral injury. Standard teaching supports the view that no attempt should be made to catheterise these patients. However I would completely disagree with this (so as most of the trauma units). A water soluble contrast ascending urethrogram done in the emergency room, would tell you if there is any urethral injury. If the urethra is intact, and no extravasation, one could insert a Foley catheter. This would drain the bladder effectively and help in assessing the urine output, which again is vital. If there is some urethral injury (extravasation of contrast), one must defer catheterisation and insert a suprapubic catheter. If facilities or expertise is not available, it is safe to do suprapubic cystostomy. Further management of urethral rupture can be done at the time of exploration of pelvic fracture by the orthopaedic surgeons. It can also be done, once fracture pelvis is dealt with (delayed repair). But, in my experience the extensive fibrosis one come across at the time of delayed repair can be troublesome. Intraperitoneal bladder rupture needs exploration and repair.
• Anuria : Anuria is defined as no urine output through the urinary tract. This can result from variety of causes. One should look for a palpable bladder in clinical examination. If the bladder is empty, look for the degree of hydration, collect blood for renal parameters and electrolytes. A KUB X-ray and US scan would certainly tell us about the aetiology of anuria. If there is no significant dilatation of the upper tracts and bladder is empty, it could well be a prerenal factor in which case a nephrologist’s help is warranted. In case of obstructed renal unit an emergency percutaneous nephrostomy should be inserted under local anaesthetic. Emergency double J stenting through the cystoscope is another option. In early obstruction one may not see a significant dilatation in the upper tracts on US, wherein Resistive Index (RI) on colour doppler would help. If RI is more than 0.7 then it might be suggestive of obstruction.
• Priapism : Priapism is painful, sustained erection of penis. With the advent of use of intracavernosal injections (PGE2 alpha, papavarine, phentolamine etc.), intraurethral PGE 2 installations (MUSE) for erectile failure, the number of patients with priapism are more frequently seen in the middle of the night in accident and emergency department. Priapism can be high flow low flow. Patients who have AV malformations in the corpora cavernosa usually have a very high flow priapism. Priapism induced by vasoactive drugs is usually of a low flow type. Patients with sickle cell disease, leukaemia, myeloproliferative disorders, and patients on parenteral nutrition therapy can also present with low flow priapism. Antipsychotic drugs such as trazodone can also induce priapism. pH of the aspirated blood from corpora would certainly differentiate between high flow and low flow priapism. Low pH and bright red colored aspirate suggests high flow priapism as against dark red venous blood and high pH suggests low flow priapism. If the patient with priapism induced by intracavernosal injections arrives within 3 hours of onset of priapism, then it usually gets deflated by simple aspiration of stagnated blood from corpora cavernosa. At times one might have to wash and irrigate the corporal sinusoids with saline and sympathomimetic drugs such as adrenaline, phenylephrine. If it does not respond to this treatment or if the priapism is of more than 3 hours duration, then shunt procedures are warranted. Patients with neurogenic impotence are likely to develop priapism. Patients with high flow priapism need angiography and selective embolisation of the AV malformations.
• Paraphimosis : In this condition the foreskin when retracted backwards, remains in that position for some time resulting in to swelling of the prepucial skin and thus inability to bring it back to its normal position. The longer you leave this foreskin in retracted position, the more it gets swollen and infected. Attempts of reducing this paraphimosis with ‘squeeze technique’ by using plenty of lubrication often succeeds. Failing which dorsal slit or perhaps emergency circumcision is necessary.
• Septicaemia and septic shock : About 2-3% of patients who have undergone transrectal prostatic biopsy (TRUS Bx) do present with septicaemia with or without urinary tract infection, despite good antibiotic cover and aseptic precautions. These patients need blood culture, urine culture and need to be treated with intravenous antibiotics. Patients with pyonephrosis, pyelonephritis, perinephric abscess, infectedobstructed kidneys also can present with septicaemia. They again need to be treated with intravenous antibiotics and if the kidney is obstructed, need emergency percutaneous nephrostomy drainage.
• Hypovolaemic shock : Only urological condition one should be aware of in dealing with unexplained hypovolaemic shock is rupture of angiomyolipoma (AML) of kidney. Typically patients have tuberous sclerosis and might have been diagnosed as a case of AML in the past. Emergency US or CT scan is helpful to arrive at the diagnosis. If the AML is less than 5 cm in diameter, then it can be selectively embolised and anything bigger than 5 cm would perhaps need emergency nephrectomy to save the patient. One should not forget that AML is bilateral and in these situations it is wiser to selectively embolise the opposite site at later date to prevent this catastrophic bleeding.
• Impending paraplegia due to carcinoma of prostate : Patients with advanced prostatic carcinoma who have metastatic deposits in the lumbar spine may present with impending paraplegia as an emergency. If the patient has not had any hormone manipulation in the past, then emergency bilateral orchidectomy gives excellent results. If the patient already had hormone manipulation in the past then one could offer radiation to the metastatic deposit. This also gives very good result and avoids major neurodeficit. Steroids (oral/injectable) can help in this situation.
• Foreign bodies in penis, urethra, rectum : Occasionally a urologist is called to attend a patient with foreign bodies in the genital tract. This could result from sexual deprivation, sexual perversion and invariably these patients have underlying psychological disorder. Most of these foreign bodies need to be removed under general anaesthetic. All these patients need psychosexual counseling and perhaps therapy to treat the underlying disorder.
• Blocked catheters and non deflatable Foley balloons : Patients with long term catheters do call at accident and emergency department with this problem. Catheter can get blocked with debri, blood clots or with formation of bladder calculi in these patients. One should make an attempt to flush the bladder with normal saline with aseptic precautions and under antibiotic cover. If there is difficulty in unblocking the catheter, one should look for any bladder calculi which can develop in these patients. Nondeflatable Foley balloon is always challenging to treat. One could try and overinflate the balloon with saline which works in fair number of patients. Failing which, one could try to use metal stillete of ureteric catheter to unblock the balloon channel of the catheter. If this fails then one could try and puncture the balloon through rectal route in men and vaginal route in women. If all these options fail then our radiologist friend could help in deflating the balloon under ultrasound guidance. One should resist any temptation of injecting ether in the Foley balloon to overinflate and burst it. This results in to sudden increase in the intravesical pressure as ether is volume expander and even lead to chemical cystitis. Small fragments of balloon can remain in the bladder once it gets burst, which can cause recurrent infections and stone formation.
(This format of the text has deliberately avoided the conventional references and cross reference as they would appear in a standard article. This article is a practical guide of how to approach a urological emergency, rather than to bombard the readers with purely theoretical aspect of it. Views expressed in this article are of Author’s own and are result of his last twelve years of urological experience which he had during the course of working in Indian as well as British urology units.)
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