Genitourinary Emergencies
Emergency Room UrologyDr. Syah Mirsya Warli, SpUDr. Bungaran
Sihombing,SpUDiv. of Urology, Surgery Dept.Medical Faculty,
University of Sumatera Utara
1Ref :Clinical Manual of Urology, (Philip M. Hanno et al eds),
McGraw-Hill Int ed, 3rd ed, 2001Smiths General Urology (Tanagho
& McAninch eds), Lange Medical Books, 15th ed,
20002Genitourinary EmergenciesPainTesticular
TorsionHematuriaUrinary Retention
Oliguria & anuriaPriapismForeskin emergencies
3Testicular TorsionIncidence 1: 4000Most serious of acute
problems affecting the scrotal contents2 peak incidencesNeonatal
periodPuberty
4Testicular TorsionWhy does it happen?Testes not adequately
anchored to the tunica vaginalis
5Testicular Torsion Symptom complexSudden onset of severe
testicular painConstant & progressiveNausea (+)Fever, urethral
discharge, cystitis symptoms (-)
6Testicular Torsion Physical examination Edematous
scrotumTender, swollen testisTestis high in scrotum with horizontal
lie classical signCremasteric reflex (-)bell-clapper deformity Pain
not relieved with elevation of scrotum7
TORSION
9Testicular Torsion: DiagnosisDoppler USG now test of choice for
Dx of torsion. Sensitivity comparable to radioisotope scans
(86%-100%) and greater specificity (100%). Doppler U/S is more
rapid and more available than radioisotope scans. 10Testicular
Torsion: ManagementImmediate Urologic consultation for surgical
exploration and possible bilateral orchidopexy if diagnosis is
obviousManual detorsion rotating the testicle in a medial to
lateral direction, open the book maneuverEmergent surgery is still
required to assure complete detorsion and perform contralateral
orchidopexy11In patients with consistent history and physical exam,
no cremasteric reflex, no urethral discharge, no recent urinary
tract infection a diagnosis of Testicular torsion should be
seriously considered with immediate urological consultation
U/S only has a role if diagnosis is uncertainGross
HematuriaEtiology : 1. Common cause infections, stones,
malignancies (bladder, kidney), BPH, trauma, post op 2. Less cause
radiation or chemical cystitis, sickle cell disease,
coagulopathy.12Gross HematuriaAll patients presenting with gross
hematuria must have urologic follow-up, even if the bleeding
spontaneously resolves. Bladder tumors classically bleed
intermittently and diagnosis can be delayed if patients are not
appropriately counseled
13Urinary RetentionHistory : age, general health premorbid
voiding symptoms history of urethral strictures previous episodes
of retention prior urologic manipulation or surgery (TURP, radical
prostatectomy) medication (sympathomimetics, anticholinergics)
incontinence14Estimated 10% of men in their 70s and 33% of men in
their 80s will have at least 1 episode.Urinary
RetentionEtiologyAnatomic obstruction : 1. BPH (most common) 2.
Urethral stricture 3. Bladder neck contracture 4. Prostate Ca
(uncommon)Functional obstruction : 1. Neurologic disease (CNS or
peripheral) 2. Medication side effect 3. Pain (nociceptive
retention) post op, post trauma 4. Psychogenic15Alpha adrenergics
induce bladder neck hypertonicity which can result in AUR
Urinary Retention : Management16 or 18 F Standard Urethral
Catheter, adequate lubrication of the catheterIf fails Urology
consult for SPTNo patient in retention should be instrumented,
drained, and then discharged from ED without a clear plan for
urologic follow-up16Oliguria & anuriaAnuria urine output <
50 ml / 24 hEvaluation & treatment : - Physical exam &
urethral catheterization - USG bilateral hydronephrosis no
hydronephrosis unilateral hydronephrosis17PriapismThe pathologic
prolongation of penile erection, accompanied by pain &
tendernessNot by sexual excitementNot relieved by orgasm1842% of
men with sickle cell disease will have at least 1 episode of
veno-occlusive priapismForeskin EmergenciesPhimosisThe
uncircumcised foreskin cannot be retracted over the
glansCatheterized with a coude tip19
20Foreskin EmergenciesParaphimosisThe uncircumcised foreskin has
been left in the retracted position obstruction to venous &
lymphatic drainage progressive edemaTrue urologic emergencyTh/ :
immadiate manual reductionIf fail dorsal slit21Phimosis vs.
Paraphimosis
Phimosis: inability to retract foreskinTx: dorsal slit or
circumcisionParaphimosis: foreskin retracted behind coronal groove;
tourniquet to glansTx: circumcision22Foreskin EmergenciesZipper
InjuriesCommon source of genital lacerationTh/ : adequate analgesia
& disassembly the zipperUsing a cutter median bar of the zipper
is completely cut the teeth of the zipper fall apart23Foreskin
EmergenciesExternal ringsOften used as sexual aids edema, urethral
fistula, necrosisManaged with ring cutterImmediate removal of the
object & debridement24Foreskin EmergenciesIntraurethral foreign
bodiesEvaluate radiographicallyDont catheterized place SPT if
retentionIf distal to the external sphincter object will be
palpable & can often be removed endoscopicallyIf proximal to
the sphincter open extraction25Foreskin
EmergenciesPost-circumcision complicationsHematoma drained by
removing a stitch & evacuating the clot. Replace
dressingBleeding - steady pressure 10 15 - if fail lidocaine
(1:100.000 ephinephrine) & apply pressure 10 15 more - skin
edges may be cauterized with silver nitrate sticks - significant
bleeding suture placement under penile block with
lidocaine26Foreskin EmergenciesPost-circumcision complications
Disruption of incision - if small no th/ - if major place a few
interrupted suture under penile blockInfection - uncommon &
usually minor - th/ : oral cephalosporine27the endwr 200928
