Acute urological emergencies Acute urological emergencies

 

Normally, adults void about 4 to 6 times/day, mostly in the daytime, totaling 700 to 2000 mL/day [60 to 100cc /hour] at 300cc bladder full we need to pee, more than 300 bladdr tart to have some discomfort and pain, more than 500 without emptying is a retention and action is needed.

Basic definition and explanation

 

Symptoms and Signs

Asymptomatic patients with renal disease may have hypertension or abnormal blood or urine findings.

They may have a family history of renal disorders (eg, polycystic disease, hereditary nephropathy).

Routine antenatal ultrasonography may detect fetal renal abnormalities.

In symptomatic patients, fever, weight loss, and malaise are common findings with renal carcinoma, advanced renal failure, and UTI.

Typically, renal symptoms include changes in

·         micturition, urinary output,

·         or appearance;

·         hematospermia in men;

·         or pain, edema,

·         and nonspecific symptoms

·         and signs related to renal insufficiency.

 

 

Frequent micturition

 without an increase in urine volume is a symptom of

·         reduced bladder filling capacity.

·          Infection,

·         foreign bodies,

·          calculi,

·         or tumors

·         may injure the bladder mucosa or underlying structures, leading to inflammatory infiltration and edema.

·         Mild stretching of the bladder, reduced bladder elasticity,

·         a pelvic mass, or a gravid uterus functionally reduces bladder capacity, resulting in pain and urgency (a compelling need to urinate).

Incontinence may occur if voiding is not immediate. Urine volume is usually small, and the desire to urinate may be almost constant until the irritative process resolves.

 

 

Polyuria (> 2500 mL/day voided) may be caused by

·         increased water intake (eg, compulsive water drinking),

·          osmotic diuresis (eg, glycosuria from uncontrolled diabetes mellitus),

·         decreased vasopressin release due to hypothalamic or posterior pituitary disease,

·         or decreased renal tubular response to ADH from hypercalcemia, K deficiency,

·          or congenital or acquired nephrogenic diabetes insipidus (NDI).

 

 

Oliguria (< 500 mL/day voided in adults or < 24 mL/kg body weight/day in young children) tends to be acute and caused by decreased renal perfusion (prerenal factors),

·         ureteral

·         or bladder outlet obstruction (postrenal factors),

·         or primary renal disease. Uremia may occur.

 

 

Anuria (< 100 mL/day voided in adults), although rare, may signal acute renal failure, the end stage of chronic progressive renal insufficiency, or, rarely, renal infarction or cortical necrosis.

 It may also be due to reversible urinary obstruction.

Prolonged anuria inevitably results in uremia.

 

 

Nocturia (voiding during the night) is an abnormal but nonspecific symptom. It may occur without disease; eg, due to excessive fluid intake in the late evening.

 It may result from urine retention secondary to bladder neck obstruction (eg, prostatism).

Less commonly, nocturia may reflect early renal disease and polyuria from a decrease in concentrating capacity or heart and liver failure without evidence of intrinsic urinary system disease.

 

 

Enuresis (bed-wetting) is physiologic during the first 2 or 3 yr of life but later becomes an increasing problem

It may be caused by delayed neuromuscular maturation of the lower urinary tract or organic disease; eg,

·         infection or distal urethral stenosis in girls,

·          posterior urethral valves in boys,

·          or neurogenic bladder in either sex.

 

 

Dysuria (painful urination) suggests irritation or inflammation in the bladder neck or urethra, usually due to bacterial infection.

 Persistent symptoms without such infection require careful evaluation of the bladder and urethra

 

Obstructive symptoms (hesitancy, straining, decrease in force and caliber of the urinary stream, terminal dribbling)

are commonly due to obstruction distal to the bladder.

 In men, such obstruction is usually due to prostatic obstruction or less often to urethral stricture or posterior urethral valves (which may be congenital in boys).

 Similar symptoms may suggest meatal stenosis in either sex.

 

 

Urinary incontinence (an uncontrollable loss of urine) may be caused by

·         exstrophy of the bladder,

·          epispadias,

·          vesicovaginal fistula,

·         ectopic ureteral orifices,

·         congenital or acquired neurogenic (peripheral neuropathy, stroke, dementia) bladder dysfunction,

·          or injuries due to prostatectomy or childbirth

 

In women, incontinence with mild physical stress (eg, coughing, laughing, running, lifting) is commonly due to urethral atrophy from a lack of estrogen or to a cystocele as a result of aging or stretching of the pelvic floor muscles during childbirth.

Loss of urine due to bladder outlet obstruction or a flaccid bladder may produce overflow incontinence when the intravesicular pressure exceeds outlet resistance.

Residual urine is always present with overflow incontinence.

 

 

Pneumaturia (the passage of gas in the urine) is rare.

It usually indicates a fistula between the urinary tract and the bowel and may be a complication of

·         diverticulitis, with abscess formation,

·         enterocolitis, colon cancer,

·         or vesicovaginal fistula.

·         Rarely, pneumaturia may be due to gas formation from bacteriuria alone.

 

 

Abnormal color or appearance of urine has many causes. Urine may be clear during water diuresis or may be a deep yellow color when maximally concentrated due to chromogens (eg, urobilin). If excretion of food pigments (usually red urine) or drugs (brown, black, blue, green, or red) can be excluded, non-yellow urine suggests the presence of hematuria, hemoglobinuria, myoglobinuria, pyuria, porphyria, or melanoma. Cloudy urine is commonly due to precipitated amorphous phosphate salts in an alkaline urine; less frequently, it suggests pyuria due to a UTI. Milky urine may be caused by precipitated phosphates in an alkaline urine. Brick dust urine usually is produced by precipitated urates in an acid urine. Urine microscopy and chemical analysis usually identify the cause.

 

 

Hematuria (blood in the urine) can produce red to brown discoloration depending on the amount of blood present and the acidity of the urine. Slight hematuria may cause no discoloration and may be detected only by microscopy or chemical analysis. Hematuria without pain usually is due to renal, vesical, or prostatic disease. In the absence of RBC casts (which usually indicate glomerulonephritis--see Table 214-1), silent hematuria may be caused by bladder or kidney tumor. Such tumors usually bleed intermittently, and complacency must not occur if the bleeding stops spontaneously. Intermittent, recurrent hematuria may also occur in IgA nephropathy. Other causes of asymptomatic hematuria include calculi, polycystic disease, renal cysts, sickle cell disease, hydronephrosis, and benign prostatic hyperplasia. Hematuria accompanied by excruciating pain (renal colic) suggests passage of a ureteral calculus or a clot from renal bleeding. Hematuria with dysuria is also associated with bladder infections or lithiasis.

 

 

Chyluria (lymph in the urine) is produced by rupture of a lymph vessel, chiefly due to abnormal connections between obstructed retroperitoneal lymphatics and the renal collecting system or to filariasis, lymphoma, or an occult neoplasm.

 

 

Hematospermia (bloody semen) occurs in < 2% of urologic referrals. Most patients have recurrent hematospermia, although some experience it just once. It is usually idiopathic. Seminal vesiculopathy due to unidentified infection or vascular congestion may be causal. It may also be associated with prolonged sexual abstinence or with frequent or interrupted coitus. The disorder is usually benign and is rarely associated with malignancy or serious infection. Such patients should, however, be evaluated for prostatic infection or urethral strictures. Occasionally, hematospermia is due to a bleeding disorder. Treatment is empiric, unless a cause is found. Some urologists advocate a 5- to 7-day trial of tetracycline 250 mg qid followed by gentle prostatic massage.

 

 

Kidney pain usually is felt in the flank or back between the 12th rib and the iliac crest, with occasional radiation to the epigastrium. Stretching of the pain-sensitive renal capsule is the probable cause and may occur in any condition producing parenchymatous swelling (eg, acute glomerulonephritis, pyelonephritis, acute ureteral obstruction). There is often marked tenderness over the kidney in the costovertebral angle formed by the 12th rib and the lumbar spine. Inflammation or acute distention of the renal pelvis or ureter causes pain in the flank and hypochondrium, with radiation into the ipsilateral iliac fossa and often into the upper thigh, testicle, or labium. The pain is intermittent but does not completely remit between waves of colic. Chronic obstruction is usually asymptomatic.

 

 

Bladder pain is most commonly caused by bacterial cystitis; it is usually suprapubic and referred to the distal urethra during urination. Acute urinary retention causes agonizing pain, whereas chronic urinary retention due to bladder neck obstruction or neurogenic bladder usually causes little discomfort.

 

 

Prostate pain due to prostatitis may be felt as a vague discomfort or fullness in the perineal or rectal area, but prostatic disease is generally painless.

 

 

Testicular pain due to trauma or infection usually is severe.

 

 

Edema usually represents excessive extracellular water and Na due to abnormal renal excretion, but it may also be caused by heart or liver disease. Initially, edema may be evident only by weight gain but later becomes overt. Edema associated with kidney disease is sometimes noted first as facial puffiness rather than swelling in dependent or lower parts of the body. If fluid retention continues, anasarca (generalized edema) with fluid transudates (effusions) in the pleural and peritoneal cavities may occur; it is most frequently associated with continuous, heavy proteinuria (nephrotic syndrome).

 

 

Uremia (a toxic condition associated with excessive accumulation in the blood of protein metabolism by-products) occurs when GFR declines to < 10% of normal, with resultant disturbances of multiple organ systems. Weight loss, weakness, fatigue, dyspnea, anorexia, nausea and vomiting, itching, failure to grow, tetany, peripheral neuropathy, pericarditis, and convulsions are the usual symptoms and signs; most can be ameliorated or reversed by dialysis or renal transplantation and appropriate diet.

 

 

Hypertension may be secondary to renal disease (eg, vascular anomalies or occlusion, glomerulonephritis, progressive renal failure). However, <= 5% of adult hypertension is due to renovascular causes (with major renal artery or segmental artery obstruction and demonstrable increased renin secretion from the obstructed side).

 

 

Skin changes may include pallor, suggesting anemia, commonly associated with renal disease; excoriations, suggesting pruritus; and infections (eg, carbuncles, cellulitis), which may be due to glomerulonephritis. Skin lesions from vasculitis or endocarditis may suggest a possible cause of renal disease.

 

 

Retinal abnormalities on ophthalmoscopy may include hemorrhages, exudates, and papilledema as signs of cerebral edema associated with malignant hypertension or metabolic abnormalities.

 

 

 

Other abnormalities suggesting urinary system disease include stomatitis; an ammoniacal breath odor; and enlargement of the kidneys, bladder, or prostate on palpation.

 

 

Acute retention of urine

In the remainder of this article we cover four urological emergencies that you might come across where emergency management decisions do make a difference.


Male catheterisation model (ADAM, ROUILLY)

Torsion of the testicle

The diagnosis of testicular torsion should be considered in any man presenting with testicular pain. The patient's age will give you some guide to the likely cause: torsion usually occurs in adolescents and is rare in men over 20; in older men the cause is more likely to be epididymoorchitis. Don't forget that children localise pain poorly; the testicles must always be examined in any child presenting with abdominal pain. It is often difficult to exclude torsion confidently, and most urologists will have a low threshold for performing a scrotal exploration. Remember too that 10% of testicular tumours can present with acute testicular pain.

The typical symptoms of torsion are sudden onset severe testicular pain +/- lower abdominal pain +/- vomiting. It is not uncommon for young boys to be woken suddenly at night with this pain. There may be a history of similar milder episodes due to intermittent twisting and untwisting of the testicle. On examination the testis may lie higher in the scrotum (twisting of the cord essentially shortens it and therefore elevates the testicle); the testicle may also lie horizontally. The testicle is usually swollen and exquisitely tender. Epididymitis rather than torsion is suggested if the pain is relieved by elevation of the affected testicle (a positive Prehn's sign), but this test is of dubious reliability. The presence of dysuria and blood/protein in the urine points more towards a diagnosis of infection. Doppler ultrasound may assist in the diagnosis, but if there is still sufficient clinical doubt then discretion is the better part of valour and the patient will need exploring. If there is any doubt about the diagnosis (and there usually is) keep the patient "nil by mouth" and get a senior urological or surgical opinion urgently. Remember that torsion of the testis cuts off the blood supply to the testis and therefore every minute of delay will increase the ischaemic damage that may render the testis non-viable. Tissue necrosis occurs after 6-8 hours.

Spinal cord compression

One of the commonest causes of cord compression is metastatic prostate cancer. Missing the diagnosis of cord compression can be a disaster. Symptoms are often rapidly progressive and are rarely reversible. Prompt diagnosis and decompression by surgery or radiotherapy is the only way to minimise subsequent disability. The diagnosis of prostate cancer or another malignancy with a tendency to boney metastases may have been made already. (Though it sounds crazy, if you remember these as the 5 B's of bostate, breast, byroid, bidney and bronchus you will never forget them.) When cord compression occurs as a primary presentation the diagnosis can be very difficult.

The typical patient is an old man with prostate cancer "off his legs." It is easy to assume that this is just due to general decline, but, though this may be true, the diagnosis of cord compression must always be considered. Specific symptoms to ask for are:

Carry out a neurological examination and look specifically for:

If you think there is any suggestion of cord compression get a senior opinion urgently and request a CT or MRI scan. Corticosteroids may reduce oedema of the cord. In metastatic prostate cancer some kind of androgen deprivation, if not commenced already, will also be necessary.

Features of spinal cord compression

Possible history of metastatic cancer
"Off legs"
Sensory level
Symptoms and signs of abnormal lower limb neurology
New urinary symptoms
Loss of bulbocavernosus reflex

Renal colic - special cases

As a surgical or urological house officer you will probably admit one patient with renal colic almost every time you are on call. With the registrar in theatre or clinic, it may be some time before anyone else sees them. Most of these patients just need analgesia initially and can be treated expectantly, but a few special cases exist.

Ruptured urethra

In a major trauma case where the more senior people do the "glamorous" stuff at the top end like central lines and chest drains, the house officer will probably be asked to put in the catheter. Remember, however, that fractured pelvis is a common occurrence in major trauma and that around 10% of patients with a fractured pelvis will have an associated urethral injury, usually in the membranous urethra. Catheterising a patient with a urethral injury may convert a partial rupture into a complete one and should therefore only be done, if at all, by an experienced person. The features to look out for are:

Top tips

Testicular pain is due to torsion until proven otherwise

Beware the elderly man "off legs" - think spinal cord compression

Obstructed infected kidneys need urgent decompression

Rupture of the urethra is common in pelvic fracture

"Old men don't get renal colic" - think aneurysm