Urological Emergencies In Clinical Practice

Hashim Hashim, John Reynard, Nigel C. Cowan, Dan Wood and Noel Armenakas (eds.)Urological Emergencies In Clinical Practice2nd ed. 201310.1007/978-1-4471-2720-8© Springer-Verlag London 2013

Editors

Hashim Hashim, John Reynard, Nigel C. Cowan, Dan Wood and Noel Armenakas

Urological Emergencies In Clinical Practice

Editors

Hashim Hashim

Department of Urology, Bristol Urological Institute Southmead Hospital, Bristol, UK

John Reynard

Department of Urology, Nuffield Department of Surgical Sciences, Oxford University Hospitals, Oxford, UK

The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK

Nigel C. Cowan

Department of Radiology, The Churchill Hospital, Oxford, UK

Dan Wood

Department of Adolescent and Reconstructive Urology, University College London Hospitals, London, UK

Department of Urology, Great Ormond Street Hospital, London, UK

University College London, London, UK

Noel Armenakas

Department of Urology, Lenox Hill Hospital and New York Presbyterian Hospital (Cornell-Weill), New York, NY, USA

ISBN 978-1-4471-2719-2e-ISBN 978-1-4471-2720-8

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Library of Congress Control Number: 2013932850

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Contents

1 Presenting Symptoms of Urological Emergencies 1

Hashim Hashim

2 Lower Urinary Tract Emergencies 11

John Reynard

3 Nontraumatic Renal Emergencies 25

John Reynard

4 Other Infective Urological Emergencies 59

Hashim Hashim

5 Traumatic Urological Emergencies 71

Noel Armenakas

6 Scrotal and Genital Emergencies 181

John Reynard

7 Postoperative Emergencies After Urological Surgery 205

Hashim Hashim

8 Ureteric Colic in Pregnancy 223

Dan Wood

9 Management of Urological Neoplastic Conditions Presenting as Emergencies 235

Dan Wood

10 Pediatric Emergencies 247

Dan Wood

11 Common Emergency Urological Procedures 259

John Reynard and Nigel C. Cowan

Index273

Hashim Hashim, John Reynard, Nigel C. Cowan, Dan Wood and Noel Armenakas (eds.)Urological Emergencies In Clinical Practice2nd ed. 201310.1007/978-1-4471-2720-8_1© Springer-Verlag London 2013

1. Presenting Symptoms of Urological Emergencies

Hashim Hashim¹  

(1)

Department of Urology, Bristol Urological Institute, Southmead Hospital, Bristol, UK

Hashim HashimConsultant Urological Surgeon and Director of the Urodynamics Unit

Email: [email protected]

Abstract

Urological emergencies can present with several different symptoms affecting the urinary tract from the kidneys down to the urethra. It is important that clinicians and nurses are aware of these symptoms. They include flank pain, hematuria, difficulty passing urine, suprapubic pain, scrotal/testicular pain, priapism and back pain. This chapter discusses these symptoms and their potential presentations.

Keywords

Flank painsuprapubic painback paintesticular painanuriaoliguriaurinary retentionhematuriapriapism

Flank Pain

Flank pain is regarded as a classic symptom of renal or ­ureteric pathology. Indeed, it is often immediately assumed that a patient who presents with flank pain has a stone in the ureter or kidney. However, only 50% of patients who present with flank pain have a ureteric stone confirmed on imaging studies (Smith et al. 1996; Thomson et al. 2001). The other 50% have non-stone-related disease (and more often than not, non-urological disease), the differential diagnosis of which is long and dependent on the age, the side of the pain, and the sex of the patient.

The multiple causes of flank pain, to an extent, reflect the fact that the nerve roots subserving pain sensation from the kidney also subserve pain sensation from other organs. Pain sensation from the kidney primarily is transmitted via preganglionic sympathetic nerves that reach spinal cord levels T11 to L2 through the dorsal nerve roots. These same nerve roots supply pain fibers to other intra-abdominal organs. Similarly, pain derived from the T10 to T12 costal nerves can also be confused with renal colic.

Causes

This list of causes of flank pain is not exhaustive. Some of these alternative causes may seem bizarre, but we have seen examples of all of these conditions, which were initially referred to us as ureteric stone pain, but where the final diagnosis was some other cause.

Pain on Either Side

Urological causes: ureteric stones, renal stones, renal or ureteric tumors, renal infection (pyelonephritis, perinephric abscess, pyonephrosis), pelviureteric junction obstruction

Medical causes of flank pain: myocardial infarction, pneumonia, rib fracture, malaria, pulmonary embolus

Gynecological and obstetric disease: twisted ovarian cysts, ectopic pregnancy, salpingitis

Other non-urological causes: pancreatitis, diverticulitis, inflammatory bowel disease, peptic ulcer disease, gastritis

Right-Side Flank Pain

Biliary colic, cholecystitis, hepatitis, appendicitis

When flank pain has a urological origin, it occurs as a consequence of distention of the renal capsule by inflammatory or neoplastic disease (pain of constant intensity) or as a consequence of obstruction to the kidney (pain of fluctuating intensity). In the case of ureteric obstruction by a stone, pain also arises as a consequence of obstruction to the kidney and from localized inflammation within the ureter.

Characteristics of flank pain due to ureteric stones: this pain is typically of sudden onset, located below the costovertebral angle of the twelfth rib and lateral to the sacrospinalis muscle, and it radiates anteriorly to the abdomen and inferiorly to the ipsilateral groin. The intensity may increase rapidly, reaching a peak within minutes or may increase more slowly over the course of 1–2 h. The patient cannot get ­comfortable and tries to move in an attempt to relieve the pain. The pain is not exacerbated by movement or posture. Associated symptoms, occurring with variable frequency include nausea, vomiting, and hematuria.

Patients with pathology that irritates the peritoneum (i.e., peritonitis) usually lie motionless/still. Any movement, or palpation, exacerbates the pain. Patients with renal colic try to move around to find a more comfortable position. The pain may radiate to the shoulder tip or scapula if there is irritation of the diaphragm (the sensory innervation of which is by the phrenic nerve, spinal nerve root C4). Shoulder-tip pain is not a feature of urological disease.

Hematuria

While hematuria is only relatively rarely an emergency (presenting as clot retention, clot colic, or anemia), it is such an alarming symptom that it may cause a patient to present to the emergency department.

Blood in the urine may be seen with the naked eye (variously described as macroscopic, frank, or gross hematuria) or may be detected on urine dipstick (dipstick hematuria) or by microscopic examination of urine (microscopic hematuria, defined as the presence of >3 red blood cells per high-power microscopic field). Just 5 mL of blood in 1 L of urine is visible with the naked eye. Dipstick tests, for blood in the urine, test for hemoglobin rather than intact red blood cells. A cause for the hematuria cannot be found in a substantial proportion of patients despite investigations in the form of flexible cystoscopy, renal ultrasonography, intravenous urography (IVU), or computed tomogram urography (CTU). No cause for the hematuria is found in approximately 50% of patients with macroscopic hematuria and 60–70% of patients with microscopic hematuria (Khadra et al. 2000).

Hematuria has nephrological (medical) or urological (surgical) causes. Medical causes are glomerular and non-­glomerular, for example, blood dyscrasias, interstitial nephritis, and renovascular disease. Glomerular hematuria results in dysmorphic erythrocytes (distorted during their passage through the glomerulus), red blood cell casts, and proteinuria, while non-glomerular hematuria (bleeding from a site in the nephron distal to the glomerulus) results in circular erythrocytes, the absence of erythrocyte casts, and the absence of proteinuria.

Surgical/urological non-glomerular causes include renal tumors, urothelial tumors (bladder, ureteric, renal collecting system), prostate cancer, bleeding from vascular benign prostatic enlargement, trauma, renal or ureteric stones, and urinary tract infection. Hematuria in these situations is usually characterized by circular erythrocytes and absence of proteinuria and casts.

Hematuria can be painless or painful. It can occur at the beginning of the urinary stream, at the end of the urinary stream, or be present throughout the stream. Hematuria at the beginning of the stream may indicate urethral or prostatic pathology. Hematuria at the end of the stream may indicate prostatic urethra or bladder neck pathology, and that present throughout the stream of urine may indicate renal or bladder pathology.

Associated symptoms help determine the cause. Associated renal angle pain suggests a renal or ureteric source for the hematuria, whereas suprapubic pain suggests a bladder source. Painless frank hematuria is not infrequently due to bladder cancer.

As stated above, while patients sometimes present acutely to their family doctors or to hospital emergency departments with hematuria, it is seldom a urological emergency, unless the bleeding is so heavy that the patient has become anemic as a consequence (this is rare) or the bladder or a ureter has become blocked by clots (in which case, the patient presents with retention of urine or with ureteric colic, which may mimic that due to a stone).

We investigate all patients with hematuria and recommend, as a bare minimum, urine culture and cytology, renal ultrasonography, and flexible cystoscopy, with more complex investigations such as an IVU or CTU in selected groups.

Anuria, Oliguria, and Inability to Pass Urine

Anuria is defined as complete absence of urine production and usually indicates obstruction to the urinary tract. The level of obstruction may be at the outlet of the bladder or at the level of the ureters bilaterally. Unrelieved bilateral urinary tract obstruction leads rapidly to acute renal failure, which may have very serious consequences (e.g., hyperkalemia, fluid overload).

If the level of obstruction is at the outlet of the bladder, abdominal examination will reveal a percussable and palpably distended bladder. Urine will be present in the bladder on catheterization, and urine output will resume once a catheter has bypassed the obstruction. The commonest cause is benign prostatic enlargement and less commonly malignant enlargement of the prostate.

If the obstruction is at the level of the lower ureters or ureteric orifices, the bladder will not be palpable or percussable. Catheterization will reveal no, or a very low, volume of urine in the bladder, and there will be no improvement in urine output or of renal function post-catheterization. Causes include locally advanced prostate cancer, extensive involvement of the trigone of the bladder by bladder cancer, and locally advanced cervical or rectal cancer. Rectal or vaginal examination may reveal a cervical, prostatic, or rectal cancer, and cystoscopic examination of the bladder may demonstrate a bladder cancer.

Bilateral obstruction higher up the ureters may be due to extensive lymph node metastases to the pelvic and para-­aortic nodes from distant malignancy, retroperitoneal fibrosis, and rarely bilateral ureteric stones. Evidence of a malignancy elsewhere may be found on clinical examination. The diagnosis is usually made on the basis of excluding obstruction at the outlet of the bladder and in the lower ureters and by radiographic imaging (ultrasound and abdominal CT).

Oliguria is scanty urine production and more precisely is defined as urine production of less than 400 mL/day in adults and less than 1 mL/kg of bodyweight per hour in children. The causes are prerenal (e.g., hypovolemia, hypotension), renal (e.g., acute vasculitis, acute glomerular lesions, acute interstitial nephritis, and acute tubular necrosis from nephrotoxic drugs, toxins, or sepsis), and postrenal causes (as for anuria, but where the degree of obstruction has not yet reached a level critical enough to stop urine production completely).

Suprapubic Pain

Suprapubic pain can be caused by overdistention of the bladder and inflammatory, infective, and neoplastic conditions of the bladder. All such conditions may present as an emergency. Bladder overdistention may result from bladder outflow obstruction, for example, by an enlarged prostate or urethral stricture. Painful inability to empty the bladder is defined as urinary retention.

Urinary tract infection is usually associated with urethral burning or scalding on voiding; frequent, low-volume voiding; and a feeling of incomplete bladder emptying with an immediate desire to void again. The urine may be offensive to smell.

Inflammatory conditions of the bladder such as interstitial cystitis can also cause suprapubic pain, as can carcinoma in-situ. Gynecological causes of suprapubic pain include endometriosis, fibroids, and ovarian pathology. Gastrointes­tinal causes of suprapubic pain include inflam­matory and neoplastic bowel disease and irritable bowel syndrome.

Scrotal Pain and Swelling

Scrotal pain may arise as a consequence of pathology within the scrotum itself (e.g., torsion of the testicles or its appendages, epididymo-orchitis), or it may be referred from disease elsewhere (e.g., the pain of ureteric colic may be referred to the testis).

The classic presentation of testicular torsion is one of sudden onset of acute pain in the hemi-scrotum, sometimes waking the patient from sleep. It may radiate to the groin and/or the loin. There may be a history of mild trauma to the testis in the hours before the acute onset of pain. Similar episodes may have occurred in the past, with spontaneous resolution of the pain, suggesting torsion with spontaneous detorsion. Patients will be in considerable pain. They may have a slight fever. They do not like the testis being touched and will find it difficult to walk and to get up on the examination couch, as movement exacerbates the pain. The testis is usually swollen, very tender to touch, and may appear abnormally tense (if the patient lets you squeeze it!). It may be high riding (lying at a higher than normal position in the scrotum) and may lie horizontally due to twisting of the cord with difficulty in feeling the cord. The testis may feel hard, and there may be scrotal wall erythema.

Epididymo-orchitis may present with similar symptoms. The localization of tenderness in the epididymis and the absence of testicular tenderness may help to distinguish epididymo-orchitis from testicular torsion, but in many cases, it is difficult to make a precise diagnosis on clinical grounds alone, and often testicular exploration is the only way of establishing the diagnosis with certainty.

Other scrotal pathology may present as acute scrotal swelling leading to emergency presentation. Rarely testicular tumors present as an emergency with rapid onset (days) of scrotal swelling. Very rarely they present with advanced metastatic disease (see Chap. 9).

Priapism

Priapism is a painful persistent prolonged erection not related to sexual stimulation. Its causes are summarized in Chap. 6. Knowledge of these causes allows appropriate questions to be asked during history taking. The two broad ­categories of priapism are low-flow (most common) and high-flow. Low-flow priapism is essentially due to hematological disease, malignant infiltration of the corpora cavernosa with malignant disease, or drugs. High-flow priapism is due to perineal trauma, which creates an arteriovenous fistula. It is painless, unlike low-flow priapism, where ischemia of the erectile tissue causes pain.

The diagnosis of priapism is usually obvious from the history and examination of the erect, tender penis (in low-flow priapism). Characteristically, the corpora cavernosa are rigid, and the glans is flaccid. Examine the abdomen for evidence of malignant disease and perform a digital rectal examination to examine the prostate and check anal tone.

Back Pain and Urological Symptoms

Occasionally, patients with urological disease present with associated back pain. In some cases, this may be the very first symptom of urological disease, and it may be so severe that the patient may present acutely to the emergency department. In general terms, there are two broad categories of disease that may present with back pain and urological symptoms: neurological conditions and malignant conditions of urological or non-urological origin.

Neurological Disease

Patients with neurological disease may present with both back pain and disturbed lower urinary tract, disturbed bowel, and disturbed sexual function. Such conditions include spinal cord and cauda equina tumors and prolapsed intervertebral discs. In all of these conditions, back pain is the most common early presenting symptom. It is usually gradual in onset and progresses slowly but relentlessly. Associated symptoms suggestive of a neurological cause for the pain include pins and needles in the hands or feet, weakness in the arms (cervical cord) or legs (lumbosacral spine), urinary symptoms such as hesitancy and a poor urinary flow, constipation, loss of erections, and seemingly bizarre symptoms, such as loss of sensation of orgasm or absent ejaculation. From time to time, the patient may present in urinary retention. It is all too easy to assume that this is due to prostatic obstruction if a focused neurological ­history is not sought and a focused neurological examination is not performed.

Malignant Disease

Malignant tumors may metastasize to the vertebral column, where they may compress the spinal cord (spinal cord compression) or the nerve roots that comprise the cauda equina. Examples include urological malignancies such as prostate cancer and non-urological malignancies such as lung cancer. In so doing, they may cause both back pain and disturbed urinary, bowel, and sexual function. The pain of vertebral metastases may be localized to the area of the involved vertebra but may also involve adjacent spinal nerve roots, causing radicular pain. Interscapular pain that wakes the patient at night is characteristic of a metastatic deposit in the thoracic spine.

The physical sign of spinal cord compression is a sensory level, but this tends to occur late in the day in the course of the condition. Remember, however, that a normal neurological examination does not exclude a diagnosis