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11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021
| Contributor Information
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Images from Konan PG, Vodi CC, Dekou AH, Fofana A, Gowe EE, Manzan K. BMC Urol. 2015;15:112. [Open access.] PMID: 26572222, PMCID: PMC4647508.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
In any setting, but particularly in the emergency department (ED), clinicians can encounter serious urologic conditions that require urgent diagnosis and early management to avoid severe or life-threatening complications. Review the keys to diagnosing and managing 11 urologic emergencies.
Paraphimosis
Paraphimosis occurs when the foreskin is retracted distal to the glans, causing edema and preventing replacement of the foreskin to orthotopic position.[1,2] As shown in the images above, the retracted foreskin becomes edematous and swollen, causing a pathognomonic distention with an almost blisterlike appearance behind the glans, particularly if the foreskin has been retracted for a prolonged period. If left retracted, the glans can become ischemic and eventually necrotic. The diagnosis of paraphimosis can be elusive in elderly patients with dementia, who often are unable to convey to the clinician the pain that occurs with this condition.[1]
Diagram courtesy of Josh Palka, DO (left); photograph of paraphimosis of 4 days' duration in a 45-year-old diabetic patient from Wikimedia Commons/Drvgaikwad (right).
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
The first step in reducing a paraphimosis (right) is to remove the associated edema.[1,2] This can be achieved by using firm pressure to squeeze the glans from distal to proximal; if the patient is unable to tolerate the pain, oral (PO) or intravenous (IV) pain medication can be given, or a penile block can be performed.
Once the edema has diminished, place both thumbs over the glans at position 1 in the drawing (left), with the index and middle fingers behind the retracted foreskin at position 2.[1,2] Then apply force to the glans with the thumbs while concurrently pulling the foreskin distally with the index and middle fingers, to reduce the foreskin. The use of gauze can help prevent slippage.
If manual reduction of the foreskin is unsuccessful, surgical intervention, including creation of a dorsal slit, may be required.[1,2]
If the foreskin is injured during reduction, infection is a risk, especially in patients with immune compromise or diabetes and those who abuse alcohol.[1] In these patients, close observation for signs of infection or recurrence of paraphimosis should be considered.
Adapted image courtesy of Medscape.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Priapism
The American Urological Association (AUA) defines priapism as "a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation" and lasts longer than 4 hours.[3] Many predisposing factors for priapism exist, but most cases are idiopathic or medication-related (eg, intracavernosal injections for erectile dysfunction, trazodone, cocaine), or they involve sickle cell disease or hematologic malignancies.
Priapism exists in three forms: ischemic, nonischemic, and stuttering. Ischemic (low-flow) priapism is more common and involves little or no cavernous blood outflow; nonischemic (high-flow) priapism is characterized by unregulated cavernous arterial inflow; it may resolve spontaneously and does not require urgent management.[3,4] Ischemic priapism features painful and rigid corpora but a soft glans and spongiosum.[3,4] Stuttering priapism is a term used to describe recurrent events of ischemic priapism. It is characterized by repetitive, transient, painful, self-limiting episodes of priapism and is commonly associated with hematologic disorders such as sickle cell disease.
With ischemic priapism, the rate of subsequent erectile dysfunction increases with the duration of the episode: approximately 50%, if less than 24 hours; 50-90%, if more than 24 hours; nearly 100%, if longer than 36 hours.[5,6]
Images courtesy of Medscape.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
The first stage of treating ischemic priapism consists of corporal aspiration and irrigation. (Oral medications such as pseudoephedrine are not recommended.) First, a penile anesthetic block is performed. Then, large-gauge needles can be placed at the 3 and 9 o'clock positions to aspirate the old blood and clot. Some clinicians prefer to place the needles through the glans into the corpora to aspirate, thereby creating a distal Winter shunt. Sterile normal saline may assist in diluting the blood and clots.
If this procedure is ineffective, intracavernosal injection of phenylephrine, diluted to a concentration of 100-500 µg/mL, can be used.[3] Exercise caution while injecting phenylephrine; this includes monitoring blood pressure and heart rate, particularly in individuals with cardiovascular disease (use electrocardiographic [ECG] monitoring). Avoid phenylephrine injections in patients with poorly controlled blood pressure or in those taking monoamine oxidase inhibitors (MAOIs).
Penile fracture in a 32-year-old man. Image from Ozcan S, Akpinar E. Cases J. 2009;2:8065. [Open access.] PMID: 19830047, PMCID: PMC2740298.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Penile Fractures
Penile fractures occur when the corpus cavernosum is traumatically ruptured, commonly during vigorous sexual activity when the penis slips out and strikes either the partner's perineum or pubic bone.[7,8] Patients may report an audible "pop," pain, and immediate detumescence (due to disruption of the tunica albuginea). Subsequent penile swelling, ecchymosis due to hematoma formation between the skin and the tunica albuginea, and deviation toward the side opposite the fracture result in the characteristic "eggplant" deformity (shown).[7,8]
Gross blood at the meatus, difficulty voiding, or hematuria on urinalysis suggests concomitant urethral injury, which occurs in approximately 10-20% of cases of penile fracture.[7,8]
If the diagnosis is uncertain, penile ultrasonography (US) or magnetic resonance imaging (MRI) can be performed. Surgical exploration and repair of the disrupted corpus cavernosum can reduce the penile curvature, recovery time, and subsequent morbidity (eg, painful erection or erectile dysfunction).[7,8]
Post-debridement photograph in a patient with Fournier gangrene. Image courtesy of Josh Palka, DO.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Fournier Gangrene
Fournier gangrene is a necrotizing fasciitis of the perineal, genital, or perianal region that is most commonly caused by Escherichia coli, Bacteroides species, Streptococcus pyogenes, or Staphylococcus aureus. Particularly susceptible patients include those with diabetes, alcoholism, or other immune compromise. A hallmark of Fournier gangrene is rapid progression from cellulitis to necrotizing fasciitis, spreading along fascial planes.[9]
On examination, patients with Fournier gangrene typically demonstrate a grayish hue to the affected tissues, similar to dirty dishwater; a foul odor; and palpable crepitus, signifying air within the tissues. Pain out of proportion to the examination findings can be seen, as well.[9,10]
Treatment includes prompt administration of broad-spectrum antibiotics and aggressive surgical debridement of necrotic tissue.[9,10] In most cases, a second, or even a third, assessment is required 24-48 hours after the initial debridement. Despite aggressive modern management, the mortality associated with this condition remains as high as 15-50%.[11,12]
Retrograde urethrogram showing a complete disruption of the urethra in a trauma patient. Image courtesy of Medscape.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Urethral Injuries
Urethral injuries involve partial or complete disruption of the urethra; they are categorized as either anterior or posterior, with the latter almost always occurring in the setting of traumatic pelvic fractures.[13] Clinicians should suspect urethral injury in trauma patients who present with blood at the urethral meatus, genital or perineal hematoma, penile fracture, penetrating penile injury, a high-riding prostate on digital rectal examination, pelvic fracture, an inability to void, or a distended bladder.
Before placement of a urinary catheter in such patients, retrograde urethrography should be performed. Use of a Foley catheter to perform a retrograde pyelogram can potentially lead to further urethral injury.[13]
Images from Sun Z, Xie M, Xiang F, et al. PLoS One. 2015;10(9):e0138523. [Open access.] PMID: 26382244, PMCID: PMC4575189.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Testicular Emergencies
Testicular torsion
The gray-scale (left) and color Doppler (right) sonograms above provide a comparison between a normal testicle (top row) and a torsed testicle (bottom row). The normal testicle (top row) has a homogeneous echotexture and a normal testicular contour (top left and right), as well as a good intratesticular blood flow signal (top right). The torsed testicle (bottom row) is swollen and twisted, with a heterogeneous echotexture (bottom left and right); no intratesticular blood flow signal is seen (bottom right).
Testicular torsion is a surgical emergency requiring intervention within 6 hours of symptomatic onset to avoid loss of testicular viability.[14] The diagnosis is made on clinical grounds, although scrotal Doppler US can be diagnostic.
If intraoperative confirmation of torsion is obtained and the testicle is viable, a bilateral orchiopexy should be performed. In as many as 80% of patients, the bell-clapper deformity, which increases torsion risk, exists bilaterally.[14] If the testicle is nonviable, orchiectomy and contralateral orchiopexy should be performed.
Images from Thinyu S, Muttarak M. Biomed Imaging Interv J. 2009;5(1):e2. [Open access.] PMID: 21611024, PMCID: PMC3097754.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Testicular rupture
Testicular rupture (ie, disruption within the tunica albuginea) results from blunt trauma in about 75% of cases. Testicular rupture should be considered in all cases of blunt injuries to the groin because external signs—ecchymosis and swelling—do not correlate well with actual injury.[8] In equivocal cases, imaging such as testicular US should be performed to exclude rupture.
The above sonograms were obtained from a 20-year-old patient who presented with a 1-day history of painful swelling of the right hemiscrotum after sustaining scrotal trauma while playing football. (A) The longitudinal sonogram shows an indistinct testicular contour (arrows), an acute hyperechoic intratesticular hematoma (H), and a hematocele (asterisk). (B) The color Doppler sonogram reveals no vascularity in the intratesticular hematoma (H).
Prompt surgical exploration and repair of the tunica albuginea are vital in testicular rupture. When exploration and repair occur within 3 days of the injury, testicular salvage rates exceed 90%.[8]
Image courtesy of Josh Palka, DO.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Kidney Injury
The abdominopelvic contrast CT scan above was obtained in a 67-year-old male pedestrian victim of an automobile accident. In addition to other polytrauma, this delayed CT scan reveals a right grade IV kidney laceration with penetration through the collecting system and active extravasation of contrast material from the posterior right kidney.
The kidney is the genitourinary organ most commonly injured in the setting of trauma, predominantly from blunt trauma.[15] Hematuria may or may not be present, but even if present, its severity does not correlate with the severity of the kidney injury.
Kidney lacerations are graded on a scale from I (least severe) to V (most severe). Surgical exploration should be prompted by the presence of grade V lacerations, an expanding or pulsatile retroperitoneal hematoma, or a life-threatening hemorrhage thought to be renal in origin.[13,15]
Images courtesy of Josh Palka, DO.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Obstructed Pyelonephritis
A 74-year-old woman presented with acute-onset right flank pain, pyrexia (40.8°C), and tachycardia. Laboratory results included a serum lactic acid level of 7.8 mg/dL and 10-20 white blood cells (WBCs) in the urine with positive nitrite. An abdominopelvic CT scan without contrast (shown) revealed a distal 6-mm obstructive right ureteral stone (arrow). The patient underwent emergency decompression with placement of a ureteral stent. After stent placement, purulent material, which had been dammed behind the stone, could be seen draining into the bladder through the stent (inset).
In general, most ureteral calculi pass spontaneously, without any need for intervention.[16] However, stones that are associated with infection and cause obstruction may result in irreversible kidney damage and sepsis if not managed expeditiously. Treatment involves emergency decompression with placement of either a retrograde ureteral stent or a percutaneous nephrostomy tube.[16]
Image courtesy of Josh Palka, DO.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Bladder Injury
The sagittal image above was obtained from a patient with a distended bladder who was involved in a motor vehicle accident. Extravasation of contrast medium from the bladder can be seen.
Bladder injuries most often occur in the setting of trauma with associated pelvic fractures, or may result from blunt trauma to the lower abdomen when the bladder is distended, as in motor vehicle accidents when the patient is wearing a lap seat belt.[13,17] Bladder injuries manifest as contusions, as well as extraperitoneal injuries (60%), intraperitoneal injuries (30%), or mixed extraperitoneal and intraperitoneal injuries (≤10%).[13,17] Common presentations of bladder injuries include gross hematuria, suprapubic discomfort, tenderness, bruising, and inability to void.[17]
Delayed diagnosis and management of bladder injury can lead to the development of abdominal ascites, ileus, and increasing levels of blood urea nitrogen and creatinine because of reabsorption.
Image courtesy of Josh Palka, DO.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
These images are from a 34-year-old woman who presented after being stabbed in the pelvis with a steak knife. (The stab wound is in the area of extravasation [arrows] on the lateral aspect of the bladder.) She had associated gross hematuria after a Foley catheter was placed. A CT cystogram was obtained, revealing extraperitoneal bladder injury. The injury was managed conservatively with an indwelling Foley catheter for 2 weeks and subsequently resolved.
Intraperitoneal injuries necessitate surgical exploration and repair of the bladder in two to three layers.[8,17] Extraperitoneal injuries can be managed conservatively with an indwelling Foley catheter as long as there is no concomitant bladder neck injury, vaginal/rectal injury, or bone fragments in (or entrapment of) the bladder wall, and as long as the catheter adequately drains the bladder.[8,17]
Images from Wikimedia Commons/James Heilman, MD.
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Acute Urinary Retention
These CT scans, obtained from the same patient, demonstrate the presence of a prostatic abscess (red arrows) causing urinary retention signaled by a distended bladder (blue arrows).
Acute urinary retention is one of the most frequent conditions encountered by urologists. Patients typically present with severe suprapubic or lower abdominal pain. Emergency management first involves decompressing and draining the bladder with either urethral or suprapubic catheterization and then treating the underlying cause.[8,18,19] If acute urinary retention is left untreated, worsening kidney function, infection, bladder dysfunction, and kidney failure can ensue.[8,18,19]
Common causes of acute urinary retention include obstruction due to benign prostatic hyperplasia (BPH) (the most common cause[19]) or pelvic or urogenital masses, iatrogenic urethral trauma from attempted Foley catheter insertion, certain medications (eg, antihistamines, sedatives), urethral strictures, hematuria and clot retention, and neurologic conditions.[8,18,19]
Images courtesy of Josh Palka, DO (left, center) and from Wikimedia Commons/James Heilman, MD (right).
11 Urologic Emergencies You Need to Know
Josh Palka, DO | September 3, 2021 | Contributor Information
Occasionally, as in some patients with BPH, a standard Foley catheter cannot be placed. An alternative option is to attempt Foley catheterization with a Coudé catheter (left).[20] The angled or curved tip of the Coudé catheter allows it to navigate the anatomic angulation caused by the enlarged prostate. During insertion, the tip is pointed upward; the balloon port is oriented in the same plane as the tip, so if the balloon port is up, the tip is also pointed upward within the body.[20]
If placement of the Foley or Coudé catheter is unsuccessful, cystoscopy may be required to assess the cause of the obstruction. Sometimes, the obstruction is due to urethral stricture or a bladder neck contracture. Urethral dilators (center) can be advanced over a wire placed through the cystoscope to dilate the tract so that it can accommodate a Foley catheter (also placed over a wire). At times, neither option is possible, and placement of a suprapubic tube (right) is required.
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Josh Palka, DO
Detroit Medical Center
Detroit, MI
Disclosure: Josh Palka, DO, has disclosed no relevant financial relationships.
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References
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