Chapter 39. Genitourinary Emergencies

Oliguria or Anuria

General Considerations

It is helpful to categorize the mechanism as prerenal (eg, resulting from decreased or abnormal renal perfusion), renal (eg, resulting from intrinsic renal disease), or postrenal (eg, disease of the urinary collecting system distal to the renal parenchyma). Prerenal and postrenal causes are often suggested by the history and physical examination. Additionally, it is be helpful to determine the presence and extent of acute kidney injury (AKI) that frequently accompanies oliguria and anuria.

Prerenal Causes

Prerenal causes include hypovolemia, sepsis, and heart failure.

Renal Causes

Renal causes include tubular, glomerular, vascular, or interstitial disease.

Postrenal Causes

Supravesical Obstruction

Supravesical obstruction rarely causes oliguria or anuria, because bilateral disease is required to reduce decreased urine flow. There are two types of supravesical obstruction: (1) ureteral obstruction (usually tumor) and (2) ureteropelvic or ureterovesical obstruction.

Intravesical or Infravesical Obstruction

Intravesical or infravesical obstruction is more common than supravesical obstruction and may be from many causes (Table 39–1).

Clinical Findings

History

Obstruction

Differentiate between reduced urine output (with normal or nearly normal voiding patterns) and oliguria associated with difficult in voiding, feeling of incomplete voiding, and diminished urinary stream. The latter findings suggest obstruction.

Associated Medical Conditions

Ask about coexisting cardiac, pulmonary, renal, or other underlying disease that might contribute to renal or prerenal oliguria.

Drugs

The patient's medications might cause problems with urination or be nephrotoxic. Anticholinergics and sympathomimetics are most often the culprits of urinary retention.

Physical Examination

Vital Signs

Obtain a complete set of vital signs. Correct volume depletion, if present (Chapter 11).

General Examination

Focus on signs of cardiac, pulmonary, renal, or hepatic disease that might contribute to oliguria of a prerenal or renal origin. Look for signs of volume depletion, such as dry mucous membranes or poor skin turgor.

Abdominal Examination

Palpate the lower abdomen to determine whether a suprapubic mass, consistent with a distended bladder, is present. A distended bladder is manifested as a firm (but not hard) mass that is adjacent to the symphysis pubica and is dull to percussion.

GU Examination

Examine the prostate for masses, prostatic hypertrophy, prostatic tenderness, or prostatic dislocation (associated with trauma).

Detection of Bladder Outlet Obstruction

Bladder outlet obstruction (complete or partial) is strongly suggested by a palpable bladder in a patient who is unable to void or who has a weak urinary stream or a feeling of incomplete voiding. Severe lower abdominal pain is more likely to be present with acute obstruction and rapid bladder distention than gradually progressive obstruction.

The diagnosis may be confirmed by calculating postvoid residual using either catheter drainage, ultrasonography, or CT scanning immediately after the patient's attempt to completely empty their bladder. Diagnostic features of some of the common causes of bladder outlet obstruction are set forth in Table 39–1.

Acute Kidney Injury

Oliguria and anuria are frequently accompanied by AKI. A standardized definition as well as objective grading system for AKI has been developed to help predict outcomes and aid in treatment (Table 39–2). It is important to note that laboratory markers of AKI such as serum creatinine usually lag behind oliguria or anuria.

Treatment

Serious Underlying Disease

If the patient appears to be acutely ill, in shock, septic, in decompensated heart failure or has other serious coexisting conditions that might cause prerenal oliguria, these disorders must be evaluated and treated before those of the urinary tract.

Distended Bladder (Presumed Bladder Outlet Obstruction)

Gain Intravenous Access

Draw blood for complete blood count (CBC), electrolyte determination, and blood urea nitrogen and serum creatinine measurements.

Drain the Bladder

Urethral Catheter

Try to pass an indwelling urethral (Foley) catheter. If this maneuver is successful, drain the bladder, record the volume of urine obtained, and send a specimen for urinalysis and culture. Monitor the patient for postobstructive diuresis. Gradual bladder draining is not a proven method of decreasing bladder atony or mucosal hemorrhage. If bladder outlet obstruction is relieved by passage of a Foley catheter and is apparently due to a transient cause (eg, drugs), the catheter may be removed and the patient observed for ability to void after the effects of any drugs are presumed to have dissipated. In patients with fixed bladder outlet obstruction (eg, benign prostatic hypertrophy), leave the catheter in place, and obtain urologic consultation within 1 week. If a standard Foley catheter cannot be passed secondary to prostatic hypertrophy, reattempt passage using a coudé catheter (which has a curved tip that usually allows passage beyond the enlarged prostate). Inability to pass the catheter beyond the proximal urethra is suggestive for urethral stricture.

Suprapubic Catheter

If the coudé catheter is unsuccessful and a urologist is not available, insert a suprapubic catheter for temporary drainage (Chapter 7). A large (16-gauge) needle-clad catheter (eg, Intracath) will provide satisfactory emergency bladder drainage.

Treat Cystitis and Prostatitis, If Present

See Dysuria section, below.

Hospitalize Patients As Needed

Hospitalize patients who have systemic symptoms (fever, rigors, intractable emesis) and those who need additional diagnosis and treatment (eg, for management of postobstructive diuresis, azotemia, sepsis, or electrolyte abnormalities).

Bladder Not Palpable; Patient Able to Void

If the patient can void on command but continues to have subjective or objective evidence of a weak urinary stream or if the patient experiences a feeling of incomplete voiding, partial bladder outlet obstruction is likely.

Draw blood for CBC, electrolyte, blood urea nitrogen, and serum creatinine measurements. Send a urine specimen for urinalysis and culture. Treat cystitis or prostatitis, if present. If blood chemistry results and urinalysis are normal, refer the patient to a urologist. The presence of azotemia or electrolyte abnormalities indicates severe or long-standing obstructive uropathy, and the patient likely requires hospitalization.

Bladder Not Palpable; Patient Unable to Void

Consider the following in the differential diagnosis (1) intrinsic renal disease, (2) occult prerenal disease (unlikely, because most causes would be obvious on brief physical examination), (3) occult bladder outlet obstruction, or (4) supravesical obstructive uropathy (rare).

Draw blood for CBC; serum glucose, electrolyte, calcium, and phosphorus; and tests of renal and hepatic function. Obtain chest and abdominal X-rays to help evaluate the size of the kidneys and bladder. Ultrasonography is the best noninvasive test for evaluating kidney and bladder size.

Ensure adequate hydration. In an adult without obvious volume overload (eg, pulmonary or peripheral edema), give 1–2 L of fluid orally or intravenously, and observe the patient for 1–2 hours. In an individual with normal kidneys, this amount should produce a brisk flow of urine.

If anuria persists despite adequate hydration and if the bladder is not distended, the cause of the anuria is likely to be proximal to the bladder (prerenal, renal, or, rarely, bilateral ureteral obstruction). Bladder catheterization, with strict adherence to sterile technique, should be performed to confirm the lack of urine output. Hospitalize the patient for further evaluation.

Disposition

Hospitalization is required for patients with persistent unexplained anuria or severe oliguria (<500 mL/d), those with systemic symptoms, and those with markedly abnormal electrolytes or renal function.

Patients with partial bladder outlet obstruction (ie, weak urinary stream, with or without palpable bladder) should be referred to a urologist if renal function is normal or nearly normal. Asymptomatic patients with an indwelling urethral catheter should be reexamined or referred to a urologist within 1 week.

Scrotal Pain

See Table 39–3.

Essentials of Diagnosis

• Trauma is a common cause
• Infection accounts for orchitis and epididymitis
• Flank pain, hematuria, and scrotal pain usually indicates urolithiasis
• Incarcerated hernias cause scrotal pain
• Testicular torsion requires urgent diagnosis to salvage the testicle. A torsed testis may be high riding or horizontally lying; ultrasound will show diminished blood flow to the torsed testis

Clinical Findings

Trauma

(See also Chapter 26) Trauma commonly causes testicular or scrotal pain. Careful questioning may be required to elicit the circumstances under which the trauma occurred.

Viral Orchitis

Mumps virus and the enteroviruses may cause acute unilateral or bilateral orchitis. In orchitis due to mumps virus, associated parotitis is usually present.

Urolithiasis

Rarely, patients with urolithiasis present with pain localized mainly in the scrotum; however, in most cases, back or flank pain has preceded the scrotal pain, or a history of nephrolithiasis is present. In such cases, the testicle and epididymis are normal to palpation. Hematuria is an important diagnostic clue.

Incarcerated Hernia

Inguinal hernias incarcerated in the scrotum may cause scrotal pain that may be confused with testicular pain. Bowel sounds are heard in the scrotum early in incarceration; if the hernia strangulates, bowel sounds are no longer audible. Intestinal hernia into the scrotum is almost always associated with clinical findings of intestinal obstruction (Chapter 15). Ultrasonography is diagnostic.

Testicular Torsion, Epididymitis, and Torsion of the Testicular Appendages

(See Table 39–3) Torsion of a testicular appendage, epididymitis, and testicular torsion are the three most common causes of acute scrotal pain and account for approximately 85–90% of cases. Because of the urgency to diagnose and treat testicular torsion within 6 hours to prevent loss of the testis, testicular torsion must be promptly ruled out in all patients with scrotal pain. It may be difficult to distinguish from epididymitis or torsion of testicular appendages as edema and inflammation progress to involve the entire scrotal sac and contents.

Testicular Torsion

Testicular torsion tends to occur in young men and is rare in men older than 30 years; however, it can and does occur at all ages and a smaller peak also occurs in the first year of life. There is often a history of episodes of similar scrotal pain representing torsion with spontaneous repositioning of the testicle. The pain is abrupt in onset, severe, unilateral, and often associated with nausea and vomiting. Tenderness is initially noted only in the testicle; however, with persistent torsion and the resulting testicular hypoxia, pain and tenderness spread to involve contiguous intrascrotal structures.

Examination early in the illness shows an elevated testicle that is apt to have a horizontal lie (Bell clapper deformity). The epididymis may be felt in an abnormal position (eg, anteriorly) in the early stages. Later, the entire scrotal contents become swollen and tender, making the examination extremely difficult and less informative because the epididymis becomes indistinguishable from the testis on palpation.

Epididymitis

Epididymitis tends to occur in sexually active men older than 20 years and is the most common misdiagnosis for testicular torsion. There may be a history of urinary tract infection or urethritis. Pain begins gradually and is less severe than in testicular torsion. The Prehn's sign is present if the pain is reduced when the scrotum is elevated. This finding is not specific to epididymitis nor is it a reliable discriminating clinical sign. Physical examination reveals a tender epididymis, often unilateral and often with erythema and edema of the scrotal skin. Early on, the testicle may be normal or minimally tender. However, as edema worsens, the epididymis becomes indistinguishable from the testicle on palpation, and a reactive hydrocele may develop, making it difficult to differentiate epididymitis from testicular torsion. Urinalysis frequently shows pyuria and possibly bacteriuria if a concomitant urethritis or urinary tract infection is present. Doppler ultrasound shows increased blood flow to the affected testis, in contrast to the decreased blood flow seen in testicular torsion.

Torsion of Testicular or Epididymal Appendages

Of the four appendages, the appendix testis, located on the anterosuperior pole of the testis, is the most frequently (92%) torsed appendage followed by the appendix epididymis (7%), located on the head of the epididymis. Pain is usually sudden in onset and can be severe, with nausea and vomiting. Physical examination occasionally (21%) reveals a small, tender, firm nodule (“blue dot” sign), representing the infarcted appendage in the anterosuperior pole of the testis. The scrotal skin and testicle are usually normal and minimally tender. In advanced cases, marked edema and appearance of a reactive hydrocele may obscure the diagnosis of testicular torsion.

Specialized Diagnostic Tests for Differentiating Torsion From Epididymitis

These tests should not delay emergency urologic consultation and surgical treatment of patients with high probability of testicular torsion (ie, patients younger than 18 years with acute unilateral testicular pain and no signs or recent history of urinary tract infection).

Color-Flow Doppler Ultrasonography

Color-flow Doppler ultrasonography is the diagnostic study of choice in most institutions. It is widely available and has a sensitivity of 86–100% and a specificity of 100% as compared with a sensitivity of 80–100% and a specificity of 86–100% for radionucleotide imaging. The most frequent sonographic finding is absent or diminished blood flow to the affected testis, compared with the unaffected side. If the diagnosis is still unclear, then a nuclear study should be pursued. Ultrasound is more advantageous than nuclear scanning for elucidating other scrotal pathology including varicoceles, hydroceles, hernias, and masses.

Radionuclide Scan

In epididymitis, scanning of the scrotum after intravenous injection of technetium-99m sodium pertechnetate reveals increased scrotal uptake on the affected side, whereas torsion shows decreased uptake.

Treatment and Disposition

(See Table 39–3) If testicular torsion is present, obtain urgent urologic consultation, and prepare the patient for immediate surgery. Manual detorsion should be attempted if the urologist is not immediately available but definitive treatment should not be delayed. Detorsion of the testicle (either manual or surgical) must be accomplished within 6 hours to prevent testicular infarction. Torsion causes the patient's left testicle to rotate counterclockwise and the right to rotate clockwise (Figure 39–1); the affected testicle should be twisted in the opposite direction when detorsion is attempted. Because the testis affected by torsion is usually rotated a minimum of 360° (one turn), the physician should initially attempt to untwist the testicle by counter rotating it one turn. The testis will usually return to normal position on its own after this maneuver, even if it was originally twisted more than one complete revolution.

Regardless of the result of manual detorsion, emergency surgery is indicated to perform detorsion—if necessary—and to secure the testicle. Without surgery, torsion may occur again at any time.

In patients with suspected epididymitis or orchitis, urologic consultation should be sought if the diagnosis is in doubt. If epididymitis is present, see Chapter 42 for treatment. Torsion of the testicular appendage (after testicular torsion is excluded) is managed with bed rest, scrotal elevation, analgesics, and follow-up care within 1–2 days. Surgical excision is often needed for adequate pain control.

Painless Scrotal Mass Lesions

See Table 39–4.

Essentials of Diagnosis

• Malignancy is often painless
• A tense hydrocele or a firm spermatocele must be differentiated from a tumor. Ultrasound is the diagnostic study of choice
• Sudden onset of a varicocele in an older male may be a late sign of a renal tumor

General Considerations

Conditions causing painless (relatively painless) scrotal swelling are not true emergencies, although testicular tumors are life-threatening and require urgent evaluation (within a few days). Table 39–4 sets forth helpful diagnostic features of conditions associated with painless scrotal swelling. Patients with newly diagnosed testicular enlargement or mass lesions should be referred to a urologist.

Dysuria

Essentials of Diagnosis

• Painful urination that represents acute inflammation of the urethra, bladder, or prostate
• Frequency and urgency may also be present
• Workup should be guided by other associated symptoms, ie, hematuria or discharge
• Urinalysis or sexually transmitted disease testing usually confirms the diagnosis

General Considerations

Common causes of dysuria and their associated clinical findings are given in Table 39–5. Urethral diverticula, urolithiasis, endocervical gonorrhea, balanitis, and urethral warts are uncommon causes of dysuria.

Clinical Findings

Dysuria in Males

Urethritis

In males, urethritis is a much more common cause of dysuria than is urinary tract infection. Attempt to express urethral discharge by milking the urethra, and send the material for culture and smear. If no discharge can be obtained, sample the anterior 2–3 cm (¾–1 3/16 in) of the urethra with a calcium alginate, Dacron, or cotton swab, or wire loop and send the swab for PCR or culture for Neisseria gonorrhoeae and Chlamydia trachomatis. Do not use a wood-handled cotton swab, because wood is toxic to the Chlamydia organism. The presence of more than 5 leukocytes per × 400 field indicates urethritis; the presence of intracellular diplococci (gram-negative if a Gram stain was done)—especially without other bacteria—indicates gonococcal urethritis. See Chapter 42 for treatment of gonorrhea and nongonococcal urethritis.

Dysuria without evidence of urethral or urinary tract inflammation (<5 white blood cells per × 100 field, negative culture) is rare in men and may represent low-grade infection. Treatment for urethritis is usually indicated.

Prostatitis

If no evidence of urethritis is found, obtain a midstream clean-voided urine specimen. Polymorphonuclear neutrophils in the urine in the absence of urethritis are diagnostic of urinary tract inflammation. Prostatitis (either alone or associated with urinary tract infection) may be excluded by rectal examination. For further information on treatment, see Chapter 42.

Urinary Tract Infection

Leukocytes, usually with bacteria, are found on microscopic examination of a midstream urine specimen. Urine dip reagent strips that test for the presence of leukocyte esterase and nitrite are equivalent to the urine sediment analysis at detecting pyuria when both are positive. They are increasingly being used as a screening tool and often eliminate the need for microscopic examination. Culture usually shows bacteria of a single species (usually >105 colony-forming units per milliliter but occasionally only 102–104, especially with certain organisms [eg, Candida species or enterococci]). Note: Urinary tract infection is unusual in men younger than 60 years unless associated urinary tract abnormalities are present or the patient engages in anal intercourse.

Local Causes

Inspect the penis and urethral meatus for balanitis and intrameatal pathologic structures (warts, herpetic ulcers) that are commonly associated with dysuria. Urethral strictures often cause dysuria, and patients may describe a split or intermittent urinary stream.

Dysuria in Females

Collection of Urine

Obtain an uncontaminated urine specimen for microscopic analysis. Contamination of the specimen is usually indicated by the presence of squamous (vaginal) epithelial cells visible microscopically (eg, ≥5 cells per × 100 field); if these are seen, discard the specimen and obtain another uncontaminated specimen. Proper collection techniques for adults are as follows:

Midstream Clean-Voided Urine

This method of collection is satisfactory in most cases but requires a cooperative patient and some coordination.

Catheterization

A small, straight (9 F) catheter should be used for quick “in and out” catheterization, because it is more comfortable than the 14–19 F Foley-type catheter. Contamination may occur.

Suprapubic Aspiration

(See Chapter 7) Suprapubic aspiration is useful in special situations (eg, for infants) and is associated with a very low contamination rate.

Clinical Differentiation of Causes of Dysuria in Women

Dysuria-Frequency Syndrome (Urethral Syndrome) and Urinary Tract Infection

These conditions are characterized by dysuria without vaginal symptoms (eg, discharge) and by pyuria (<5 white cells per × 400 field). If bacteria are seen in the urinary sediment, urinary tract infection is a more likely diagnosis than urethral syndrome. Occasionally women with dysuria-frequency syndrome may have no pyuria.

Local Causes

If results on urinalysis are normal, if vaginal symptoms associated with dysuria are present, or if pain is felt outside the urinary tract (external dysuria), perform a pelvic examination to look for vaginitis, genital herpes, or a urethral caruncle. Urethral caruncle is found in postmenopausal woman and is a small, nontender red lesion resembling a strawberry on the dorsal aspect of the urethral meatus. In addition, it is helpful to culture endocervical mucus for gonococci, because gonococcal infection in women may be associated with dysuria.

Dysuria Associated with Hematuria in Either Sex

The presence of large numbers of erythrocytes in the urine in either sex should suggest hemorrhagic cystitis, concomitant urolithiasis, or urethral manipulation (see Hematuria section, below).

Treatment and Disposition

Treat the various causes of dysuria as follows:

Urinary Tract Infections

For treatment of cystitis, pyelonephritis, and urethral syndrome, see Chapter 42.

Gonorrhea

See Chapter 42.

Vaginitis

See Chapter 42.

Prostatitis

See Chapter 42.

Other Conditions

Patients with other conditions (eg, urethral stricture or diverticulum) should be referred to a urologist or gynecologist for evaluation.

Atraumatic Hematuria

Essentials of Diagnosis

• Hematuria is often an early sign of genitourinary cancer
• Hematuria with associated flank or groin pain is suggestive of urolithiasis
• Dysuria and frequency may accompany hematuria of an infectious cause

General Considerations

Common causes of hematuria (microscopic defined as >3 red blood cells per high-power field) and their associated clinical findings are set forth in Table 39–6. See Chapter 26 for management of hematuria associated with trauma or genitourinary manipulation. In all cases of atraumatic hematuria, nonglomerular diseases including infection account for 25% of cases, stones account for 20% of cases, cancer accounts for 12% of cases, and 10% of cases have an unknown cause.

Renal vein thrombosis, renal arterial embolization, drug-induced (cyclophosphamide, penicillins) interstitial cystitis, glomerular diseases, abdominal aortic aneurysm, and malignancy are less common causes of hematuria. In the elderly, painless gross hematuria is malignancy until proven otherwise.

Clinical Findings

History

Hematuria associated with abdominal or flank pain and tenderness suggests urolithiasis or, less commonly, reno-vascular disease. Diagnostic clues may come from timing of the hematuria. Initial, terminal, or total stream hematuria suggests bleeding from the following respective areas: anterior urethral, posterior urethra to trigone, or bladder sources or beyond.

Hematuria associated with dysuria and urinary urgency and frequency suggests hemorrhagic cystitis (drug-induced, infectious, or idiopathic). Systemic conditions associated with hematuria include thrombotic thrombocytopenic purpura, Henoch-Schönlein purpura, sickling hemoglobinopathies, excessive anticoagulation therapy, or coagulopathies.

Bleeding from other perineal areas, especially menstrual flow, may be mistaken for hematuria.

Physical Examination

Examine the external genitalia for local causes of hematuria (eg, intraurethral trauma). Examine the abdomen, back, and pelvis for tenderness and evidence of trauma.

In males, perform a rectal examination for evaluation of the prostate after a urine specimen has been obtained, because prostatic manipulation can induce pyuria.

Laboratory Examination

Urinalysis

Perform urinalysis to confirm the diagnosis of hematuria. Carefully performed microscopic examination of a freshly voided midstream urine specimen is essential to the evaluation of hematuria; look especially for erythrocyte casts, which suggest glomerulonephritis. In men, fractionate urinalysis (initial, midstream, and terminal specimens) is also helpful in localizing the source of hematuria.

Other Laboratory Tests

Further laboratory testing (except possibly urine culture) is not usually needed for bacterial hemorrhagic cystitis. Patients with urolithiasis may require baseline serum electrolyte determinations and renal function tests. Patients in whom a bleeding disorder is suspected or the cause of hematuria is unknown should have the following laboratory examinations: CBC with differential; prothrombin time, partial thromboplastin time, and international normalization ratio; serum electrolytes; and renal function.

Special Studies

A CT scan may be necessary for the evaluation of urolithiasis, trauma, tumors, and other causes. Compared with ultrasound, CT scanning is a better diagnostic study for evaluation of intra-abdominal pathology and tumors, especially those that are less than 3 cm in size. In pregnant females, ultrasound is the test of choice for evaluating hematuria.

Cystoscopy is essential for evaluation of bladder or urethral hematuria due to tumors and other causes. It may also be helpful for localizing hematuria of the upper genitourinary tract to one side or the other. The need for cytoscopy should be determined by the consulting urologist.

Other studies such as radionuclide scans or angiograms may be needed in special situations, but urologic consultation should be obtained before these studies are requested.

Treatment and Disposition

Treat the various causes of hematuria as follows:

Trauma

See Chapter 26.

Urinary Tract Infection

See Chapter 42.

Suspected Tumor

Refer the patient to a urologist for evaluation. Consider hospitalization in order to expedite diagnostic procedures.

Urolithiasis

See below.

Glomerulonephritis

Hospitalize the patient, and obtain consultation with a nephrologist.

Prostatitis

See Chapter 42.

Urethral Strictures and Foreign Bodies

Refer the patient to a urologist.

Unknown Cause

Patients with hematuria of an unknown cause need urgent urologic consultation.

1This chapter is a revision of the chapter by Charles F. McCuskey, MD, from the 6th edition.

Urolithiasis (Renal Colic)

Essentials of Diagnosis

• Patients usually present with sudden onset of unilateral flank pain that may radiate to the ipsilateral lower quadrant, groin, scrotum, or labia
• Hematuria is present in approximately 90% of cases
• Spiral CT scan is the diagnostic study of choice but KUB, intravenous pyelogram, and ultrasound may also be used

General Considerations

Patients with stones in the urinary tract commonly present to the emergency department. Stones usually form in the renal pelvis, and symptoms occur with passage of the stone into the ureter, as the result of infection, or both. The incidence of stones is highest among whites with a peak incidence between ages 20 and 50 years, and the male to female ratio is 3:1. Bladder stones are less common, and patients may present with hematuria or intermittent urinary obstruction.

Clinical Findings

Symptoms and Signs

The initial symptom is usually acute, unilateral flank pain (stones near kidney) that rapidly becomes excruciating, radiating to the ipsilateral lower quadrant and often referred to the ipsilateral groin, testicle, or labia (stones near ureterovesical junction). The pain may cause vasovagal syncope; occasionally patients are asymptomatic except for hematuria. Eliciting a history of pain that shifts anteriorly and inferiorly from the flank as the stone moves distally in the urinary tract may be helpful in differentiating renal colic from other types of abdominal pain.

Some patients note gross hematuria. Nausea and vomiting are frequent. If complicating infection is present, signs and symptoms of pyelonephritis also may be present. Inquire about a history of similar attacks or a pre-disposing condition (eg, previous documented urolithiasis, gout, hypercalcemia).

Vital signs are usually normal in the absence of infection, although bradycardia from vagal hypertonicity or tachycardia from pain may be seen. Some degree of ileus is usually present. Tenderness over the affected kidney (costovertebral angle tenderness) and ureter can be elicited.

Laboratory Findings

Obtain a urinalysis. Hematuria (gross or microscopic) is present in approximately 90% of cases. Occasionally a patient presents with pain and no hematuria. A urine or serum human chorionic gonadotropin level should be obtained in all females of child-bearing age. Urine culture should be sent if an infected stone is suspected by bacteriuria and fever. Blood urea nitrogen and serum creatinine levels are usually normal. Although they will not change the emergency department management, calcium, magnesium, phosphorus, and uric acid levels may be helpful to the urologist in assessing for metabolic causes of stone formation.

Imaging

Imaging studies should be performed during the first episode of suspected renal colic or if the diagnosis is uncertain. Patients with recurrent stones with typical historical and physical examination consistent with urolithiasis may be managed symptomatically without any diagnostic studies unless obstruction or infection is of concern.

Unenhanced Helical (Spiral) CT

(see Figure 39–2) Helical CT scan is widely used and currently the study of choice for the diagnosis of renal colic. Not only is it accurate, but it is less time consuming, no contrast is required, and additional intra-abdominal information may be obtained. It has a sensitivity of 98%, a specificity of 97%, and positive and negative predictive values of 100 and 97%, respectively. It does not provide information regarding the functional status of the kidney. Even without contrast an aortic aneurysm may be seen; therefore, the helical CT scan is the preferred imaging choice for an elderly patient.

Ultrasound

Renal ultrasound may be useful to detect stones or hydronephrosis but is not as sensitive (64%) as helical CT or intravenous pyelogram, particularly for detection of small stones. It may be of value in patients with a history of hypersensitivity to intravenous contrast and with radiolucent stones. Pregnant women and pediatric patients should be evaluated with ultrasound as the first screening modality.

Intravenous Pyelogram

An intravenous pyelogram has a 90% sensitivity for detecting urolithiasis or the related obstruction as well as for assessing functional status and visualization of the entire urinary tract. Caution: This method is relatively contraindicated in the following settings: (1) patients with creatinine above 1.4 mg/dL, (2) elderly patients with proteinuria and elevated creatinine, and (3) patients with documented allergy to contrast media unless they are premedicated with antihistamines and steroids.

KUB

KUB, a study of the kidneys, urethras, and bladder, is less than 70% sensitive but may be useful because 90% of calculi are radiopaque. When the stone is visualized on KUB, its progress can usually be followed on subsequent KUBs.

Treatment

About 90% of renal stones are passed spontaneously. The likelihood of renal stone passage decreases with increasing stone size. Stones larger than 6 mm will pass without intervention in only 10% of patients. Basic treatment is as follows:

Provide Analgesia

Begin analgesics as soon as the diagnosis has been established with reasonable certainty. Opioids and antiemetics are mainstays of therapy. Ketorolac is as equipotent as mild narcotic analgesics. Ketorolac provides analgesia, and given its antiprostaglandin effects, it can decrease the inflammatory response, promote relaxation of the ureteral spasm, and alleviate capsular distention. Most comparison studies show little difference between opiates and NSAIDs with a trend toward fewer complications with the NSAIDs. For patients who are not hospitalized, an antiemetic, an anti-inflammatory agent, and a narcotic may be required for control of pain and emesis.

Ensure Adequate Hydration

Although authorities usually recommend drinking 2–3 L of fluid per day, this is probably of more value in preventing the formation of more stones than in facilitating passage of an existing stone.

Medical Expulsive Therapy

The use of medication to expidite passage of the stone should be considered. Corticosteroids, calcium channel blockers and alpha-blockers, such as terazosin, and the alpha-1 selective blocker tamsulosin, can promote relaxation of ureteral musculature to aid in the passage of stones.

Strain Urine

Patients with their first episode of urolithiasis or those who pass stones of unknown composition should strain their urine through a urine strainer or a coffee filter and submit the stone for chemical analysis.

Prevention

Specific preventive therapy can be recommended after the composition of the stone has been determined by chemical analysis.

Disposition

Patients with any of the following conditions require hospitalization:

• Intractable pain
• Intractable emesis
• Coexisting pyelonephritis
• Documented or suspected renal dysfunction (elevated blood urea nitrogen or serum creatinine levels, bilateral ureteral stones, oliguria or anuria, hydronephrosis)

Patients who do not require hospitalization should be referred to a urologist within 24–48 hours for further evaluation and treatment.

Diseases of the Male Genitourinary System

Torsion of the Testicle

Essentials of Diagnosis

• Rare in males older than 30 years but occurs at all ages
• The testicle may be high riding with “bell clapper'' deformity
• Detorsion must occur within 6 hours for testicular salvage
• Attempt manual detorsion
• Color-flow Doppler ultrasound demonstrates diminished blood flow to affected testis

Clinical Findings

Testicular torsion has a bimodal incidence with peaks occurring in neonates and pubescent males; however, it can occur in all age groups. Torsion of the testicular or epididymal appendages can also present as acute unilateral scrotal pain. Of the four appendages, the appendix testis becomes torsed the most often (99%) and usually requires only supportive care.

The history for testicular torsion is most often a sudden onset of moderate to severe, unilateral scrotal pain. Patients may recount similar episodes that resolved spontaneously in the past. On physical examination, the testis can be high-riding with a transverse rather than vertical lie, slightly larger than the unaffected testis, and diffusely tender and erythematous. An absent cremasteric reflex on the affected side is the most sensitive physical finding. Nausea, vomiting, and abdominal pain may occur as a result of the ischemia.

Epididymitis, orchitis, neoplasms, peritonitis, hernia, abdominal aortic aneurysm, Fournier gangrene, and other scrotal diseases need to be considered in the differential diagnosis (see Table 39–3). Urinalysis is usually normal. Color-flow Doppler ultrasonography or radionucleotide scanning may confirm the diagnosis.

Epididymitis and orchitis may be confused with torsion of the testicle; helpful differentiating features are discussed in the section on scrotal pain and in Table 39–3. The diagnosis may be confirmed by Doppler ultrasound examination or radionuclide scanning.

Treatment and Disposition

Provide Analgesia

Parenteral narcotic analgesics usually are required.

Prepare for Surgery

Give nothing orally, obtain blood for CBC and renal function tests, and begin an intravenous infusion.

Obtain Immediate Urologic Surgical Consultation

If a delay in urologic consultation is anticipated, attempt manual detorsion as discussed earlier in this chapter. Testicular salvage approaches 100% if detorsion (manual or surgical) is performed within 6 hours.

Epididymitis

See Chapter 42.

Orchitis

Orchitis is commonly associated with epididymitis. It usually has an infectious cause, for example, from viral, bacterial, or mycobacterial agents. Viral orchitis is most often due to mumps. The orchitis commonly presents 5 days after the parotitis. Mumps orchitis may result in atrophy. If the diagnosis is in doubt or specific treatment appears warranted, obtain urologic consultation. Symptomatic relief may be achieved with recumbency and analgesics.

Priapism

Clinical Findings

Priapism is a persistent involuntary, painful erection, unrelated to sexual stimulation and unrelieved by ejaculation. About 25% of cases are associated with leukemia, metastatic carcinoma, or sickling hemoglobinopathies. If the medical history is unclear, consider a CBC and sickling test. Alcohol, marijuana, cocaine, and now MDMA (Ecstasy) are among some of the recreational drugs known to induce priapism, but many prescription drugs are culprits as well. Regardless of treatment, there is a high incidence of corporal fibrosis and erectile dysfunction.

Treatment

Management is mainly to provide analgesia and hydration and to abort the erection to prevent permanent damage. Several modalities can be attempted, but success is often limited. Ice packs have limited success. Hydration, oxygenation, and sometimes exchange transfusion is necessary for sickle cell patients. Terbutaline, either subcutaneous or oral, has had some favorable results. Corporal aspiration and irrigation with a phenylephrine solution can be used and is more effective than systemic sympathomimetic therapy but should be done in conjunction with urologic consultation.

Disposition

Hospitalize all patients with persistent priapism or those with serious underlying disease (sickling hemoglobinopathy, leukemia). Obtain urgent urologic consultation.

Fournier Gangrene

Essentials of Diagnosis

• Necrotizing fasciitis of the perineum
• Fever, pain, edema, and erythema of the scrotum are typically present
• Chiefly affects diabetic males

Fournier gangrene is a necrotizing fasciitis of the perineum that primarily affects diabetic males aged 20–50 years. Patients typically present with fever, pain, edema, and erythema of the scrotum or penis. The most common causes are infection and trauma. Aerobes or anaerobes may be the causative infectious agents. A CT scan often shows the infection to have spread beyond what is clinically apparent on the skin. Treatment includes antibiotic therapy, wide surgical incision, and drainage. Mortality is approximately 60–70%.

Phimosis and Paraphimosis

Essentials of Diagnosis

• Chronic balanoposthitis, due to a bacterial or fungal infection, is a risk factor for phimosis (inability to retract the foreskin)
• Physiologic phimosis is normal in the first few years of life
• Paraphimosis (retracted, constricted foreskin proximal to the glans) may cause necrosis to the glans and urethra if not treated

Phimosis is a fibrous constriction of the foreskin preventing retraction; it is often associated with balanitis and may cause urinary retention. Phimosis or paraphimosis rarely results from chronic balanoposthitis, which is categorized as either irritant or infectious. Balanoposthitis is inflammation of the glans penis and the prepuce. Treatment for acute irritant balanoposthitis is sitz baths, cleansing with the foreskin retracted, and 0.5% hydrocortisone cream. Candidal infections are the most common infectious cause and are treated with good hygiene and topical antifungal cream. Phimosis without balanitis may be an indication for elective circumcision, but it is not an emergency. Surgical correction should not be attempted in the emergency department.

Paraphimosis occurs when the retracted foreskin develops a fixed constriction proximal to the glans. The penis distal to the constricting foreskin may become swollen and painful, or even gangrenous, and urinary retention may result. Attempt manual reduction: Squeeze the glans firmly for 5–10 minutes to reduce its size. Then move the prepuce distally while the glans is pushed proximally. Additionally ice, sugar and multiple punctures to the glans with a small bore needle have each been described and reported to be successful. If manual reduction is unsuccessful, a dorsal slit of the foreskin is necessary (Figures 39–3 and 39–4). Refer the patient to a urologist for elective circumcision to reduce risk of recurrence. In addition, a complication of the Plastibell device for pediatric circumcision occurs if the ring inadvertently slips behind the glans, creating a paraphimosis and causing penile ischemia. The ring should be removed immediately.