Urologic Emergency

UROLOGICAL
EMERGENCY

 
Overview
Acute Urinary Retention
Fournier's Gangrene
Paraphimosis
Priaprism
Testicular Torsion

OVERVIEW

Some urological conditions have serious or life-threatening consequences and require immediate medical attention. These medical emergencies include

While these conditions are unrelated and have different symptoms, they all require urgent care. Delaying treatment in some cases can result in orchiectomy (surgical removal of testicles), permanent impotence (inability to achieve an erection), or death.

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ACUTE URINARY RETENTION

Acute urinary retention is the sudden inability to urinate and is usually symptomatic of another condition that needs treatment.

Incidence and Prevalence
Anyone can experience acute urinary retention. The causes and rate of occurrence varies greatly between genders until about age 60, when men are more often affected as a result of benign prostatic hyperplasia (BPH).

Risk Factors
Kidney stones, prostate cancer, prostatitis, and BPH are risk factors in men. Women with a history of kidney stones or urinary tract infections (UTIs), pregnant women, and those who have had recent gynecological surgery are at higher risk.

Causes
Acute urinary retention is caused by obstruction in the bladder or urethra (the tube that carries urine from the bladder outside the body), a disruption of sensory information in the nervous system (e.g., spinal cord or nerve damage), or a situation or event that causes the bladder to become distended.

Factors associated with acute urinary retention include the following:

  • alcohol consumption
  • allergy or cold medications containing decongestants or antihistamines
  • certain prescription drugs (e.g., ipratropium bromide, albuterol, epinephrine) that cause the urethra to become narrow
  • delaying urination for a long time
  • prolonged exposure to cold temperatures
  • long period of inactivity or bed rest
  • spinal cord injury/nerve damage
  • surgery (e.g., complication of anesthesia)
  • urinary system obstruction (e.g., benign prostatic hyperplasia (BPH), kidney stones)
  • urinary tract infection

Signs and Symptoms
Acute urinary retention produces severe lower abdominal pain, a distended abdomen, and/or the sudden inability to pass urine.

Complications that may develop with untreated urinary retention include bladder damage and chronic kidney failure.

Diagnosis
Diagnosis is based on a sudden lack of urinary output and bladder distention (swelling) observed during a physical examination.

Treatment
Treatment should be obtained within 5 hours of the onset of symptoms to avoid the development of complications. The underlying cause of urinary retention (e.g., kidney stones) must be diagnosed and treated as well.

A catheter (small tube) is inserted into the bladder through the urethra to drain the urine. Catheterization relieves pain and distention.

Prognosis
Depending on the underlying cause, the recurrence rate can be up to 70% within a week after initial treatment. BPH is responsible for most recurrences.

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FOURNIER'S GANGRENE

Fournier’s gangrene, sometimes called Fournier’s disease, is a bacterial infection of the skin that affects the genitals and perineum (i.e., area between the scrotum and anus in men and in women between the vulva and anus). The disease develops after a wound or abrasion becomes infected. A combination of anaerobic (living without oxygen) microorganisms (e.g., staphylococcal) and fungi (e.g., yeast) causes an infection that spreads quickly and causes destruction of skin (i.e., necrosis), subcutaneous tissue (tissue under the skin), and muscle. Staphylococcal bacteria clot the blood, depriving surrounding tissue of oxygen. The anaerobic bacteria thrive in this oxygen-depleted environment and produce enzymes (molecules that instigate chemical reactions) that further the spread of the infection. Fournier’s gangrene can be fatal if the infection enters the bloodstream.

Incidence and Prevalence
Men are ten times more likely than women to develop Fournier’s gangrene. Men aged 60-80 with a predisposing condition are most susceptible.

Women who have had an abscess (pus-producing bacterial infection) in the vaginal area, an episiotomy (a surgical incision in the vagina and perineum to prevent tearing of skin during delivery of a child), septic abortion (i.e., an abortion resulting in fever and an infection of the lining of the uterus), or hysterectomy (surgical removal of the uterus) are susceptible.

Rarely, children may develop Fournier’s gangrene as a complication in wounds that result from a burn, circumcision, or insect bite.

Risk Factors
Men with alcoholism, diabetes mellitus, leukemia, morbid obesity, and immune system disorders (e.g., HIV, Crohn’s disease), and intravenous drug users are at increased risk for developing Fournier’s gangrene. Surgery is also a risk factor.

Causes
Fournier’s gangrene develops when multiple bacteria infect the body through a wound, usually in the perineum, urethra (tube that carries urine outside the body from the bladder), or colorectal (colon and rectum) area. Existing immune system deficiencies help infection to spread quickly, producing a disease that destroys the skin and superficial and deep fascia (membranes that separate muscles and protect nerves and vessels) of the genital area. The corpora cavernosa (chambers in the penis that fill with blood to create an erection), testicles, and urethra are not usually affected.

Signs and Symptoms
The early physical symptoms of Fournier’s gangrene do not always indicate the severity of the condition. Pain sometimes diminishes as the disease progresses. Symptoms are progressive and include the following:

  • Fever and lethargy (drowsiness)
  • Severe genital pain accompanied by tenderness and swelling of the penis and scrotum
  • Increasing genital pain and erythema (redness)
  • Crepitant (“spongy” to the touch) skin
  • Dead and discolored (gray-black) tissue; pus weeping from injury
  • Odor

Diagnosis
Physical examination and blood tests are necessary. A diagnosis is made on finding gangrenous (i.e., spongy, weeping, discolored) skin. A biopsy (microscopic examination of a tissue specimen) may be taken if visible symptoms are insufficient to distinguish between Fournier’s and other bacterial infections.

Treatment
Antibiotics (often double or triple drug therapy) along with aggressive surgical removal of all of the diseased tissue is required immediately for an optimal outcome.

When not treated or treated late in the disease progression, bacterial infection enters the bloodstream and can cause delirium, heart attack, respiratory failure, and death.

Complications
Incomplete debridement (surgical removal of dead tissue) allows wound infection to continueto spread. In this event, follow-up surgery is performed.

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PARAPHIMOSIS

Paraphimosis occurs when the foreskin (the fold of skin that covers the glans of an uncircumcised penis) has been retracted and narrows below the glans (head), constricting the penis lymphatic drainage causing the glans to swell. If not corrected, blood flow in the penis becomes impeded by the increasingly constricting band of foreskin, which causes further swelling of the glans. Because lack of oxygen from the reduced blood flow can cause necrosis (tissue death), paraphimosis is considered a medical emergency and requires immediate treatment.

Incidence and Prevalence
In the United States, paraphimosis occurs in about 1% of males over age 16. It can occur at any age but is most common during adolescence. Paraphimosis occurs in the elderly who need frequent catheterizations and those who have a history of poor hygiene or bacterial infections.

Risk Factors
Uncircumcised males are at risk. Piercing the penis increases the risk if the penile ring interferes with foreskin retraction or replacement over the glans, and if infection results from the piercing.

Causes
Causes include the following:

  • Bacterial infection (e.g., balanoposthitis)
  • Catheterization (i.e., if the foreskin is not returned to its original position after a urethral catheter is inserted, the glans may become swollen, which can initiate paraphimosis)
  • Poor hygiene
  • Swelling-producing injury
  • Vigorous sexual intercourse

Signs and Symptoms
Symptoms include the following:

  • Band of retracted foreskin tissue beneath the glans
  • Black tissue on the glans (indicates necrosis)
  • Erythema (redness)
  • Penile pain
  • Swollen glans (the shaft of the penis is not swollen)
  • Tenderness
  • Urinary retention (inability to urinate)

Complications
Gangrene (tissue death caused by loss of blood supply) and autoamputation (spontaneous detachment of diseased tissue) of the glans are possible complications of paraphimosis.

Diagnosis
Paraphimosis is diagnosed during a physical examination.

Treatment
Because paraphimosis can be severely painful, a pain reliever is administered before treatment. The first method of treatment after diagnosis involves manual manipulation of the penis to reduce swelling and to replace the foreskin over the glans. An ice pack may be applied to the penis (after the penis has been wrapped in plastic) to help reduce swelling.

If manual treatment is unsuccessful, the puncture technique uses a needle to drain excess edematous fluid (watery fluid in the swollen tissue) from the glans to reduce swelling.

A third option is to make a small incision in the foreskin to alleviate constriction and allow the swelling to subside. With this procedure, local anesthesia is administered to minimize discomfort.

After reduction of swelling is achieved, antibiotics are prescribed for any underlying infection.

Prognosis
Full recovery from paraphimosis is expected with prompt treatment.

Prevention
Circumcision is recommended after treatment to prevent a recurring episode.

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PRIAPISM

Priapism is a prolonged, painful penile erection that occurs when blood in the penis is "trapped," or unable to drain. The stagnant blood causes an erection that can last from hours to days. A painful erection lasting for more than 4 hours indicates priapism. If not treated promptly, scarring and permanent impotence (inability to achieve an erection) can result.

Types

Veno-occlusive (low flow)
Veno-occlusive (blocked vein) priapism develops when circulation in the penis becomes sluggish due to obstructed veins. This type usually occurs without a known cause in men who are otherwise healthy.

Arterial (high flow)
This rare, less painful type of priapism results from an injury to the penis or perineum (area between scrotum and anus) that prevents blood in the penis from circulating normally. It indicates a ruptured artery in the penis. There may be a lapse between the time of injury and onset of priapism.

  • Incidence and Prevalence
    Priapism can affect men of any age. Most veno-occlusive priapism in men with sickle cell disease occurs between ages 19-21. The rate of veno-occlusive priapism is higher in men who have malaria, leukemia, and Fabry disease.

Risk Factors
Diseases that affect blood circulation may predispose men to developing the condition. Forty-two percent of men with sickle cell disease develop veno-occlusive priapism at least once.

Recreational or "party" drug use (e.g., cocaine, ecstasy, marijuana) is a risk factor. An overdose of injectable medication such as papaverine and phentolamine (Regitine®) for erectile dysfunction is also a risk factor. Men with sickle cell disease, leukemia, malaria, and Fabry disease are predisposed to priapism. Alcohol consumption, androgenic steroids (used to increase muscle size), anticoagulants (Coumadin®, Warfilone®), and antihypertensives (Prazosin®) increase risk. Prolonged sexual activity is also a risk factor.

Causes
Priapism may develop as a result of prolonged sexual activity. Other causes include the following:

  • black widow spider bites
  • carbon monoxide poisoning
  • erectile dysfunction [link to ED section] injection therapy (if amount of medication injected exceeds prescribed dose)
  • penile or perineal injury (e.g., perineal trauma against the top tube of a bicycle)
  • prescription antidepressive drugs trazodone (Desyrel®) and chlorpromazine (Compazine® , Serentil®)
  • spinal cord trauma
  • tumor

Signs and Symptoms
A painful penile erection that lasts 4 hours or more, and a soft glans (head) with a hard shaft are signs of priapism.

Diagnosis
Diagnosis includes a patient history and a physical examination to detect an injury or underlying problem.

In veno-occlusive priapism, angiography may be used to help locate blocked veins. Angiography uses a special dye injected into the bloodstream to enable the physician to see blockages on x-ray.

Doppler sonogram (digital images of ultrasound echos that detect the characteristic sound of poor blood flow) may be used to diagnose high- or low-flow priapism.

Treatment
There are several forms of treatment. Ice packs are applied to the penis and perineum to reduce swelling. Walking up a flight of stairs is sometimes effective, because mild exercise may divert blood flow to other areas of the body. The underlying injury (ruptured artery) causing arterial priapism is treated by surgical ligation (tying off the artery) to restore normal blood flow.

Intracavernous injection
Low-flow priapism is treated with vasoconstrictive medications injected into the corpora cavernosa (two chambers in the penis that fill with blood to create an erection) to narrow the veins and cause swelling to subside. Alpha agonists terbutaline (Adrenalin®, Alupent®) and phenylephrine (Neo-Synephrine®) are commonly used.

Puncture
After numbing the area, a needle is used to drain the blood from the corpora cavernosa to allow the swelling to subside.

Surgical shunt
For veno-occlusive priapism, a surgical shunt (passageway) may be inserted to divert blood flow and reestablish circulation. The underlying cause is treated when disease is present (e.g., leukemia, sickle cell disease).

Prognosis
The prognosis is good for both types of priapism when the condition is resolved quickly. When treatment is delayed, penile scarring and permanent impotence can result.

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TESTICULAR TORSION

Testicular torsion is a disorder in which the testicles rotate (twist) and strangle the spermatic cord (blood vessels, lymphatic vessels, nerves, and the vas deferens [duct that carries sperm from the body]), stopping the blood supply to the testicles. Torsion can cause atrophy (shrinkage), necrosis (tissue death), and may require orchiectomy (surgical removal of the testicles) if not treated promptly. Torsion often occurs during sleep.

Incidence and Prevalence
Testicular torsion primarily affects infants in the first year of life and adolescent boys age 12-18, although it can occur at any age. Males with cryptorchidism (one or both testicles not descended into scrotum) develop testicular torsion more often than the general population.

Risk Factors
Injury to the scrotum or groin and vigorous physical activity are risk factors.

Causes
Injury to the scrotum can initiate a muscle spasm that cause the testicles to twist. Some cases result from inadequate connective tissue that "anchors" the testicle within the scrotum. Many cases are idiopathic (no known cause).

Signs and Symptoms
Symptoms include the following:

  • Blood in semen
  • Lower abdominal pain
  • Lump in testicle
  • Nausea and vomiting
  • Sudden, severe testicular pain, followed by diminishing pain after several hours (after necrosis begins to set in)
  • Redness of scrotum
  • Swelling of one testicle

Diagnosis
A patient history and physical examination is usually sufficient to diagnose testicular torsion. Testicular torsion exhibits similar symptoms (e.g., testicular pain and swelling) to epididymitis (inflammation of the tubule where sperm is stored); diagnostic tests may be necessary.

Color Doppler sonography (color printout of an ultrasound echo test) is used to identify the absence of blood flow typically found in a twisted testicle, which distinguishes the condition from epididymitis.

Urinalysis (analyzing chemical composition of urine) can be used to rule out bacterial infections. Surgical exploration may be necessary if diagnosis cannot be made using other methods.

Treatment
Treatment involves detorsion (untwisting), manually if possible and surgically if necessary. Surgical detorsion requires anesthesia followed by an incision in the scrotum. The testicles are untwisted and evaluated for necrosis. Dead tissue is removed; removal of one or both testicles may be necessary. If necrosis has not occurred, the healthy testicle(s) are then sutured (stitched) to the scrotal wall to avoid recurrence.

Prognosis
If torsion is diagnosed and treated within 5-6 hours, the prognosis is good. The more time that elapses before resolution worsens the prognosis. After 18-24 hours, necrosis usually develops and indicates orchiectomy (removal of the affected testicle).

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