Urological emergencies

non-trauma
Jean Marie Niyonkuru, PGY III
Florence Umurangwa, Urologist
 PRIAPISM
• Persistent penile erection with or not sexual stimulation
• Lasting > 6 hrs
• Peak incidence in 20 – 50 years of age
• Associated with sickle cell disease in young individuals
 Erection
• Relaxation of penile smooth muscle
• Increased cavernosal arterial blood flow
• Decreased cavernosal venous outflow
• Engorment of the cavernosa
 Etiologies
Disturbance in penile detumescence
• Excess release of contractile neuro transmitters
• Malfx of intrinsic detumescence mechanism
• Obstruction of draining venule
• Prolonged cavernosal SM relaxation
 Classification
Low flow or ischmic (veno-occlusive)
• The most common
• Very painful
• Corpora cavernosa hypoxia and ischemia
Non-ischemic or high flow (arterial)
• Less common
• There is up-regulated cavernous inflow
• Usually the penis is partially rigid and painless
 Ischemic priapism
• Corporal blood is acidotic
• There is platelet aggregation + thrombus formation
• Tissue damage 2/2hypoxia
 Causes
• Intracavernosal pharmacotherapy
• Accounts 21% of cases of priapism
• Papaverine & PGE-1(Alprostadil)
• Extremely low incidence with oral agents
• Drugs
• Cocaine
• Heparin withdrawal
• Trazadone, phenothiazines
 Causes cont…
• Hyperviscosity syndrome
• Sickle cell disease
• Thrombophilia
• Lymphoma, malignant infiltration of the corpora
• Neurologic
• Very rare
• Lumbar cord compression
• CVA
• Post-trauma
• Perineum, groin or penis
 High flow priapism
• Less common
• 2/2 to penile/perineal trauma
• There uncontrolled arterial inflow
• Often has h/o on & off episods
• Normal blood gas
• Minimal risk of hypoxia and ischemia
 Management
• Treat the cause where possible
• The goal is to achieve detumescence & pain control
• Prevent further corporal damage
• Do blood gas to differentiate occlusive from non-occlusive
• Do penile color DU
 Medical amangement
• Corporal blood aspiration
• Use a 21 G needle + irrigation with phenylephrine
• Repeat this every 5 min
• Oral terbutaline 5-10mg, 36% response rate
• Hydration, oxygeneation, alkalinization if sickle cell disease
Surgical treatment
 Complications
• Corporal fibrosis and erectile dysfunction
• Early complications may include
• Acute HTN
• Palpitations
• Arrythmias
• Bleeding, Hematoma
• Infection and urethral injury
 PARAPHYMOSIS
• Trapped prepuce behind the glans penis
• Forms a tourniquet around the distal penis
• Flaccid penile shaft proximal to the tourniquet
• Engorged, edematous distal penile shaft
• Very painful
• May lead to glanular necrosis
 Causes
Iatrogenic
• Cleansing the prepuce
• Placement of the urethral catheter
• Cystoscopy
• Penile exam
• Coital trauma
• Self inflicted injuries
Treatment
 FOURNIER’S GANGRENE
• Polymicrobial necrotizing fasciitis of the perineum
• Commonly originates form
• The anorectum
• Urogenital tract
• Skin of genitalia
• Follows specific fascia planes
• Can rapidly spread within hours
• Has yield very high mortality rate
 Risk factors
• DM
• HIV/AIDS
• Malnutrition
• Obesity
• Alcoholism
• Chronic steroid use
• Malignancy
 Involved microbes
At least four germs are isolated
• E.coli
• Bacterioids
• Streptococcus
• MRSA
• Klebsiella
• Pseudomonas
• Proteus
• Claustridium
Pathogenesis
 Clinical presentation
• Insidious onset of external genitalia pruritus & discomfort
• Fever, lethargy may be present for 2-7 days
• Out of proportion of genitalia pain and tenderness
• Erythema, dusky overlying skin
• Subcutaneous crepitation, feculent odor
• Gangrene of the genitalia, pain subsides
 Differential dx
• Balanitis
• Cellulitis
• Epidydimitis
• Gas gangrene
• Orchitis complicated hernia
• Complicated hydrocele
 Investigations
• FBC
• Electrolytes
• Creatinine
• Blood sugar
• Blood/urine culture
• Coagulation profile
Imaging
 Treatment
• IVF hydration
• Monitor urine output
• Broad spectrum ATB
• Vancomycin for MRSA
• IV IG to neutralize super antigen
• Antifungal if required
• Aggressive debridement
• Preserve the testis
 ACUTE RENAL COLIC
• Known as nephrolithiasis
• Common condition affecting 5-15% in life-time
• Yearly incidence of 0.5% in NA and Europe
• Increased urinary solutes + precipitation
• Hypercalciuria
• Infection
• hypocitraturia
 Pathogenesis
• Stones formed in the renal pelvis migrates to the ureter
• Obstructing ureteral stones will lead to
• Severe excruciating flank pain
• Hydronephrosis
• Renal damage to the affected ureter
 Clinical presentation
• Sudden flank pain
• Radiation to the groin or hemiscrotum
• Colicky in nature
• May have nausea and vomiting
• Microscopic or macroscopic hematuria
• Dysura
• pollakyuria
 Diagnosis
• FBC
• UMCS
• 24 hrs urne Ca ++, phosporus, uric acid, citrate, oxalate
• Electrolytes, Ph
Imaging
 Management
• Analgesics
• Ant-emetics
• ATB
• Alpha blockers
• Surgery for stones larger than 10mm
 References
• Kessler CS, Bauml J. Non-traumatic urologic emergencies in men: a
clinical review. West JEmerg Med. 2009 Nov.
• Campbell& walsh urology text book,12ed
• Gandhi A, Hashemzehi T, Batura D. The management of acute renal
colic. Br J Hosp Med (Lond). 2019 Jan 02;80(1):C2-C6.