This document provides an overview of common urologic emergencies and their management. It discusses renal colic caused by kidney stones, including pain management with NSAIDs and opioids. It also covers acute urinary retention, priapism, hematuria, and anuria. For each condition, it outlines evaluation, differential diagnosis, and treatment approaches including medical expulsive therapy, ureteral stenting, and surgical procedures.

3. Ahmed Eliwa
MD Urology and Andrology
Secretary of reconstructive urologic
surgery at EUA
member or U-MERG

17. UROLOGIC PAIN
Renal colic
Acute retention
Acute scrotum
HAEMATURIA
ANURIA
PRIAPISM
PEDIATRIC UROLOGIC EMERGENCIES

19. The chief cause of pain in the
urinary tract is distention
from increased intraluminal
pressure.
The severity of the pain is
not related to the degree of
distention but to the rapidity
with which it develops.
Two other causes of renal
pain are distention of the
renal capsule and acute renal
ischemia.

20. Obstruction is influenced by:
• The degree of obstruction (partial or compete,
unilateral or bilateral)
• Chronicity (acute or chronic)
• The presence of other mitigating factors such as
urinary infection.

21. Renal
Congenital Polycystic kidney
Renal cyst
Fibrous obstruction at ureter-opelvic
junction
Aberrant vessel at ureteropelvic junction
Neoplastic Wilms' tumor
Renal cell carcinoma
Transitional cell carcinoma
Metabolic
Ureter
Congenital Stricture
Ureterocele
Ureterovesical reflux
Ureteral valve
Ectopic kidney
Retrocaval ureter
Prune-belly syndrome
Neoplastic Primary carcinoma of ureter
Metastatic carcinoma
Inflammatory Tuberculosis
Schistosomiasis
Ureteritis cystica
Endometriosis
Metabolic
Pelvic lipomatosis
Aortic aneurysm
Radiation therapy
Lymphocele
Trauma
Urinoma
Pregnancy
Bladder and Urethra
Congenital Posterior urethral valve
Phimosis
Urethral stricture
Neoplastic Bladder carcinoma
Prostate carcinoma
Miscellaneous Benign prostatic hypertrophy
Neurogenic bladder
Calculi
Calculi

22. Stones affect 1-5 % of adult populations in
industrialized nations.
10 % of Caucasian men will develop a kidney stone
by the age of 70.

23. Pathophysiology
Increases in collecting system pressure and ureteral wall tension
are proposed mechanisms of renal colic
Distention-mediated activation of renal pelvis mechanoreceptors
results in spinothalamic (pain pathway) C fiber excitation.
The mean threshold pressure to elicit this primate response was
32 mm Hg. This is similar to the 30 mmHg proposed threshold for
evoking pain in humans ( Ammons, 1992 ).
Interventions that reduce collecting system pressure should
theoretically reduce pain. NSAIDs have been demonstrated to
reduce collecting system pressure.

24. Clinical presentation.
o Severe flank pain
o sudden onset
o colicky (waves of increasing severity are followed
by a reduction in severity, but it seldom goes
away completely).
o Associated with GIT symptoms
o Inability to obtain rest, irrespective of position
o Mild tenderness on deep palpation
o Radiates to groin or scrotum in males, and groin
or vulva in females

25. Pain Pathways and Referred Pain
segments T-11 and T-12 receive sensory fibers from both
the upper ureter and testis, so distention of the upper
ureter may cause referred pain to the ipsilateral testis.
In similar manner, distention of the lower ureter may
cause referred pain to the ipsilateral scrotum

26. Differential diagnosis
Right-side flank pain
Biliary colic, cholecystitis, hepatitis, appendicitis.
Urological causes ureteric stones, renal stones, renal or
ureteric tumours, renal infection and pelviureteric junction
obstruction.
Medical causes myocardial infarction, pneumonia, rib
fracture, malaria, pulmonary embolus.
Gynaecological and obstetric diseases twisted ovarian cysts,
ectopic pregnancy, salpingitis.
Nonurological causes pancreatitis, diverticulitis, inflammatory
bowel disease, peptic ulcer disease, gastritis.

27. Approximately 50% of patients with classic symptoms
for a ureteric stone don’t have a stone confirmed on
subsequent imaging studies, nor do they physically ever
pass a stone.
In the emergency room setting, non-contrast helical
abdominal/pelvic CT has become the examination of
choice in the evaluation of flank pain and obstructive
anuria
(Niall et al. 2002; Shokeir et al. 2002, 2004; Colistro et al. 2002).
Diagnostic studies

28. • Quick and Relatively
easy to interpret
• No contrast media
• Sensitivity 95% and
specificity 98% .
• non-urologic sources
of flank pain.
NCCT
Diagnostic studies
• Can be done during the
renal colic
• Does not need intestinal
preparation
• Stone composition (HU).
• The skin-to-stone distance.
• Relationships with peri-
renal structures for PNL.

29. Exceptions are calculi composed of protease inhibitors
(Indinavir)
Secondary CT signs of obstruction
Ureteral dilatation
Nephromegaly
Perinephric stranding
NCCT
Diagnostic studies

34. Ultrasonography
• Hydronephrosis as a reflection of the degree of
obstruction.
• The method of choice in the pediatric
• Poor technique to demonstrate stones in the ureter
KUB
• Demonstrate radio-opaque urinary tract stones In
combination with ultrasonography, KUB the number, size,
form and position of the stones.
KUB and US
Diagnostic studies

38. IVU

42. Management of pain
Management of obstruction
Definitive management of the stone

43. Non-steroidal anti-inflammatory drugs (NSAIDs)
Narcotic analgesics.
Combination of NSAIDs and Narcotics analgesics
Pain Management

44. Reduction in both RBF and intrapelvic pressure (25% to 58%
reductions in renal pelvic pressure).
Perlmutter et al, 1993.
NSAIDs directly inhibit the synthesis of prostaglandins, thereby
decreasing activation of pain receptors.
NSAID can be given intravenously, orally, or by suppository.
They are inexpensive and generally well tolerated.
Side effects : gastrointestinal disturbances, qualitative platelet
dysfunction, and renal functional impairment.
Pain Management
NSAID

47. Opioid analgesics are effective for the treatment of renal colic.
They are used when the pain is not controlled adequately with
NSAIDs or as an adjunct to NSAID therapy.
Side effects include nausea, emesis, constipation, drowsiness,
respiratory depression, and hypotension.
Intravenous administration is preferred because of rapid onset
and the ability to titrate the dose based on the patients
response.
Pain Management

49. Other Drugs
• α-1 blockers
• Calcium channel blockers
• Antispasmodics
• Transcutaneous electrical nerve stimulation, Acupuncture,
Regional nerve block
• Nitrites
The role of hydration in pain management and stone
passage was recently evaluated. There is no difference in
pain score or rate of spontaneous stone passage with forced
hydration compared to minimal hydration.

50. Indications
1. Complete ureteral obstruction (unilateral or bilateral)
2. Obstruction with infection
3. Obstruction with acute renal failure
4. Obstruction in a solitary native kidney
5. Obstruction in a renal allograft
6. Obstruction in a pregnant female
Management of Obstruction
Urgent Intervention

51. Acute Intervention
• URS
• Ureteric stenting
• PCN
• ESWL

52. Definitive management of stone disease
Medical Expulsive Therapy (MET)
ESWL
URETEROSCOPY and URETERIC STENTING
PCNL
SURGERY

53. An option if reasonable chance of spontaneous stone passage, controllable
pain, adequate renal function, and no evidence of sepsis.
Calcium channel blockers and α-1 blockers ± corticosteroids.
Meta-analytic studies showed that a 65% greater likelihood of
spontaneous stone passage as compared to those not receiving such
therapy.
Side effects of α-1 blocker dizziness, nasal congestion, ejaculatory
disturbances, and hypotension.
Patients who will do cataract surgery should inform their ophthalmologist
that they are on α-1A blocker (floppy iris syndrome).
Medical Expulsive Therapy (MET)

54. ESWL

55. URS AND URETERIC STENTING

59. Inability to pass urine, associated with
suprapubic pain & discomfort
It is a condition seen predominantly in men and
rarely in women
Often patients have a history of symptoms of
outflow obstruction.
If in doubt, perform ultrasonography of the
bladder.

60. Physical examination
o Abdomen
o Perineum
o Rectal
o Urethral
o Perform ultrasound of bladder

61. Causes
o Benign prostatic hyperplasia
o Prostatic abscess
o Prostate carcinoma
o Urethral trauma and stricture
o Stone impacted in urethra
o Neurological disorders
o Postoperative

62. Management
Urethral catheterization can be done by average-sized
urethral catheter.
Failed or difficult urethral catheter suprapubic catheter
should be inserted.

65. Complications
False passage & urethral injury
Hemorrhage from urethral injury or bladder
mucosa
Late: urethral stricture

66. Treatment of the cause of retention
TUR-P
VIU
Urethroplasty

67. Definition
o Pathologic prolongation of penile erection,
accompanied by pain not related to sexual
excitement and not relieved by orgasm (more than
4 hours).
o Low or High flow

68. Low-flow priapism High-flow priapism
Intracorporeal drug injection
Arterio-venous fistula (secondary
penile or perineal trauma)Oral medications (anticoagulants)
Sickle cells disease (recurrent
priapism)
Leukaemia
Fat embolus
Spinal cord lesion
Autonomic neuropathy
Malignant penile inflammation
Causes and classification of low- and high-flow priapism

69. Sequelae
Edema of the trabeculae, stasis, thrombosis occludes
the venous drainage; also intracorporal hypoxia,
hypercarbia, acidosis.
Vascular thrombosis and fibrosis of erectile tissues
leading to impotence in 50% of patients, regardless of
treatment.

70. A. Ischemic priapism.
History
Physical examination (painful erection that does not involve the glans).
complete blood count
corporal aspirate (color, consistency, corporal blood gas)
penile duplex Doppler ultrasound
B. Arterial priapism.
History (perineal trauma is almost always reported by patients)
Physical examination (partial, nonpainful erection).
Duplex Doppler ultrasound localization of the arterial-lacunar fistula.
DIAGNOSIS

71. A. Ischemic priapism.
Aspiration 16- to 18-gauge needle is inserted
α-Agonist injection
Phenylephrine (1 mL or 1 mg of phenylephrine is drawn up and mixed with 9
mL of normal saline for injection). Inject 0.3 to 0.5 mL of this mixture.
Allow 10 to 15 minutes between repeat injections. Maximum dose is 1.5 mg.
Management of sickle cell disease associated priapism are oxygenation,
hydration, alkalinization, and exchange transfusions to increase the hematocrit
value to >30%.
Nasal O2 with sickle cell disease to keep saturation above 92%.
Management

72. Surgical shunting.
If no resolution of the ischemic priapism can be achieved,
surgical shunts such as the Winter procedure are
indicated

74. ξ Treatment
PRIAPISM
ASPIRATION;
MONITORING OF
INTRACAVERNOUS
PRESSURE [ICP] &
BLOOD GASES
ICP <40 mmHg FOR 10
min [RESOLVED]
NON-ISCHAEMIC ISCHAEMIC
pH <7.25
PO2 <30
PCO2 >60
ASPIRATION &
IRRIGATION TO RESTORE
NORMAL BLOOD GASES
ICP <40 mmHg for
10 min
[RESOLVED]
INSTILLATION OF
DILUTED
EPINEPHRINE
LESS THAN 24
HOURS’
DURATION
MORE THAN 24
HOURS’
DURATION
ICP >50 mmHg UNILATERAL
SMALL SHUNT
ICP <40 mmHg for
10 min
[RESOLVED]
ICP >50 mmHg
BILATERAL, MULTIPLE, LARGE SHUNTS UNTIL ICP <40
mmHg for 10 min

75. ξ Treatment
B.
Management Plan for Secondary Priapism
** In younger [<20 yrs] patients, many urologists would delay invasive treatment
up to 7-14 days
SPECIFIC
TREATME
NT FOR
SECONDA
RY
PRIAPISM
MALIGNAN
T
POST-
TRAUMAT
IC
SICKLE
CELL
DISEASE
CHEMOTHERAP
Y
RADIOTHERAP
Y
HYDRATION,
ALKALINIZA
TION
ANALGESIA
[12 HRS]
HIGH
FLOW
NO
RESPONS
E
LOW
FLOW
TREAT AS
PER
IDIOPAT
HIC
RESOLUTI
ON
NO
RESPONS
E
HYPER-
TRANSFUS
ION [24
HRS]
RESOLUTI
ON
NO **
RESPONS
E
ASPIRATI
ON/IRRIG
ATION
SHUNTIN
G
PROCEDUR
E

76. Acute Scrotum
Torsion: testicular and appendages
Epididymitis
Trauma
Testicular tumor [with acute bleeding]

78. Symptom
Sudden onset of severe testicular pain ,constant and
progressive, often associated with nausea.
Usually pubertal and teenage boys.
Physical exam: Testicle high in scrotum, horizontal lie, absent
cremasteric reflex, no relief with elevated of the testis.

79. Other studies:
Color Doppler ultrasound:
Doppler US scan—not indicated in the diagnosis of torsion (due to significant
false-positive and false-negative results), but more useful for confirmation of
absence of torsion if surgery not deemed necessary.
Nuclear scanning

80. T O R S I O N E P I D I D Y M I tS
AGE PUBERTY TO 4TH DECADE,
MOST COMMON AGE 12-18
PUBERTY TO 8TH
DECADE
ONSET ACUTE MAY BE GRADUAL
NAUSEA COMMON NONE
PAIN SEVERE SEVERE
PYREXIA ABSENT OFTEN PRESENT
URINALYSIS NORMAL PYURIA COMMON
MANUAL
SCROTAL
ELEVATION
PAIN CONSTANT PAIN DECREASED
TESTICULAR
POSTIION
ELEVATED NORMAL

81. TREATMENT
All patients should undergo immediate scrotal exploration to
do de-torsion & fix testicle in scrotum
Orchiectomy If unviable gangrenous testis
Fixation of contralateral testicle.

82. Presence of blood in urine, which should always be considered
as a symptom of serious disease until proven otherwise:
Based on microscopy
Gross: visible to the unaided eye
Microscopic: more than three RBCs per HPF
Based on timing
Initial: source distal to external sphincter
Terminal: source in proximal urethra or bladder neck
Total: source in bladder or upper urinary tract

83. False haematuria
discoloration of urine from pigments, such as food coloring
and myoglobin
Factitious haematuria
presence of RBCs in urine from a source outside the urinary
tract

84. Urologic
Calculi
Benign prostate hypertrophy
Infection
Neoplasms
Urethral stricture
Abdominal aorta aneurysm

85. Important causes
HTN
Haematologic
Congenital and acquired coagulopathies
Therapeutic anticoagulation
Sickle cell disease or trait

86. Investigation
History
Examination
Renal function
Urine microscopy & culture

87. Urological investigations
Radiological imaging
Ultrasound [preferred screening in most patients]
Intravenous urography
CT scan with contrast
Retrograde pyelography
Cysto-urethroscopy with biopsy
Urine cytology
Renal biopsy

88. Management
Maintain intravascular volume
Evacuate clots
History, physical exam, laboratory studies & radiographs
Admission

89. Oliguria urine output of less 400 mL/24 h
Anuria urine output less than 50cc 24 hours
The urologist is called upon to treat or exclude all types of
obstructive uropathy in the anuric patient. The work-up
should be promptly, almost always within 24 hrs of
presentation.
Prerenal
Renal
Post-renal

90. Prerenal <20 >500 >20
Renal >40 <350 <20
Postrenal
Acute <20 >500 >20
Chronic >40 <350 <20

91. Urologic Causes :
Kidney
– Urolithiasis – pelvis– Ureteropelvic junction obstruction
Ureter
– Urolithiasis –Retroperitoneal fibrosis (idiopathic, drugs,
rradiation) -tumor
Bladder
– Neurogenic bladder – Bladder neck obstruction
– Transitional cell carcinoma
Urethra
– Stricture
– BPH or Prostate cancer

92. Symptoms of Uremia
Hypertension and peripheral edema
Nausea, vomiting, and upper gastrointestinal bleeds
Mental status changes, encephalopathy, coma, and seizures.
Bleeding and anemia.
Hyponatremia, hyperkalemia, hypermagnesemia,
hypocalcemia, and hyperuricemia.
Pruritus in the arms and legs.

93. Systematic approach
Physical exam
urethral catheterization.
Plain film [KUB].
Ultrasonography.
Non-contrast pelvi-abdominal CT.
cystoscopy & urethral catheterization.

94. Systematic approach
Ultrasonography
Bilateral hydronephrosis: Proceed to
cystoscopy, ureteral catheterization &
nuclear scan, and decompress the better
side initially with a percutaneous
nephrostomy.
No hydronephrosis: Obstructive uropathy
is very unlikely in this setting. Evaluation
with nuclear renal scan; arteriography is
scan shows absent perfusion.

96. Adrenal
CAH and Intersex
Adrenal Hemorrhage
presents as an adrenal
mass.
Birth trauma, neonatal
asphyxia, septicemia, or
coagulopathies.
If adrenal insufficiency
necessitates temporary
steroid replacement.

97. Kidney
Anomalies
Calculi
Cystic Renal Lesions
Solid Renal Lesions
Pyelonephritis and
Pyonephrosis.

98. Bladder
Exstrophy
Urinary Retention
Urethra
Posterior urethral valve
Urethral stricture

99. External Genitalia
Circumcision Injuries
Paraphimosis and Phimosis
Testicular Torsion
Epididymitis