Urology is the medical specialty that deals with the urinary tract in both men and women and with the male reproductive system in men. Many urological problems are chronic, such as benign prostatic hypertrophy and urinary incontinence, and can be evaluated by a urologist in clinic. However, certain urological problems are emergencies and require prompt medical attention to ensure future health.
Even though urology is considered a surgical specialty, many urological problems—including emergencies—affect diverse organ systems. Thus, urologists must possess knowledge of internal medicine, gynecology, pediatrics, psychiatry, and more to best treat health issues. Furthermore, urologists, like all specialists, often consult with other types of physicians to provide optimal care.
According to the American Urological Association, there are seven urology subspecialties:
renal (kidney) transplantation
calculi (kidney stones)
female urology (think urinary incontinence)
neurourology (think voiding disorders and erectile dysfunction)
urologic oncology (cancer)
Here are six urological emergencies that you should know about. Being able to recognize their signs and symptoms will ensure prompt and effective treatment. Many of these conditions affect men; however, some affect both men and women.
Jokes made about priapism belie the very serious nature of this condition. Priapism is defined as an erection that lasts more than four hours, which has nothing to do with sexual stimulation. Moreover, priapism can’t be relieved by ejaculation.
The most common form is low-flow or ischemic priapism. With priapism, the cavernosal bodies, which compose the shaft of the penis, are rigid while the glans or tip is flaccid. Furthermore, the penis is exquisitely tender, which is enough reason for most men to seek immediate medical attention.
Priapism is usually caused by obstruction of venous outflow; it is essentially a compartment syndrome of the penis.
About 25 percent of priapism cases are attributable to sickle cell disease, metastatic cancer or leukemia. Misuse of drugs, like cocaine, MDMA (ecstasy), methamphetamine (crystal meth), and marijuana, can also lead to priapism. Additionally, priapism can be an adverse effect of prescription medications like calcium-channel blockers, antipsychotics and warfarin (blood thinner).
Sustained decreases in arterial flow can result in the following:
Necrosis (tissue death)
If left untreated, priapism can ruin future sexual function. Thus, swift treatment is necessary. The longer that priapism goes untreated, the greater the risk of permanent penile dysfunction. The goal of treatment is detumescence, or reduction in penile swelling.
Penile blood gases can be drawn to confirm diagnosis of priapism. Initially, priapism can be treated with the oral medications pseudoephedrine (a sympathomimetic) or baclofen (a muscle relaxer). Typically, however, these oral medications don’t work all that well so a large-gauge (18-gauge) needle is inserted into the corporal body or shaft of the penis and blood is aspirated or removed. Phenylephrine is then injected into the penis.
Pseudoephedrine, which activates the sympathetic system, is used to treat priapism because erections are mediated by parasympathetic input. Pseudoephedrine counters these parasympathetic effects. Of note, ejaculation is mediated by the sympathetic nervous system. (Medical students remember this distinction using the mnemonic “point and shoot.”)
In severe cases of priapism, a surgical shunt can be placed.
2 Testicular Torsion
Contrary to what some might have you believe, testicles can’t switch places. However, the spermatic cord, which supplies blood to the epididymis and testis, can twist.
Testicular torsion usually affects babies and adolescent boys but can occur at any age. Testicular torsion is rare in men aged 30 and older.
Two risk factors for testicular torsion include undescended testicles and testicular tumors.
Boys or men with testicular torsion experience immediate onset of sharp pain at a specific point followed by swelling of the testicle. Nausea and vomiting accompany the pain. Furthermore, boys and men who present with testicular torsion often have a history of such pain followed by repositioning of the testicle on its own.
Both this clinical history and physical examination are key in diagnosing testicular torsion. Ultrasound confirms diagnosis, but if evaluation by ultrasound is unavailable, immediate surgical exploration is necessary. In addition to confirming diagnosis, ultrasound can also rule out malignancy, which could be causing the testicular torsion.
As with priapism, time is of the essence. If surgery is performed within the first six hours, the chance of saving the testis is 80 percent. If more than 12 hours passes, the success rate for surgery drops to below 20 percent.
Surgery involves detorsion or untwisting of the testicle. Enough time is given to determine whether circulation to the testis resumes, and this revascularization is confirmed with Doppler ultrasound. In the case of necrosis of the testis, orchiectomy, or removal of the testicle, is performed.
3 Acute Urinary Retention
Acute urinary retention (AUR) occurs most commonly in men with benign prostatic hypertrophy (BPH) or enlargement of the prostate. Remember that the prostate surrounds the urethra, and its enlargement obstructs the flow of urine.
Although most common in men with BPH, AUR can occur as a result of a variety other things that inhibit bladder emptying including the following:
Medications like opiates and anticholinergics
Blood clots secondary to hematuria
AUR often occurs in an inpatient or hospital setting when patients are taking medications that decrease bladder emptying and have limited ability to get out of bed and move around. Moreover, constipation, which is also common in hospital settings, can make urinary retention worse.
Typically, AUR is a painful condition. However, in some people with chronic decompensation of the bladder, this condition may not be painful. If left untreated, AUR can proceed to overflow incontinence, and then, after several days, to acute renal failure. Thus, AUR must be treated quickly to relieve pain and prevent complications.
Acute renal failure is first treated with placement of a urethral catheter to drain the urine. In men with BPH, a curved catheter is used because the prostatic urethra is positioned at an angle. If a urinary stricture is present, a urologist will need to relieve the AUR using cystoscopy, urethral dilators and so forth.
4 Fournier's Gangrene
Fournier’s gangrene is rare. It’s a form of necrotizing fasciitis (“flesh-eating” disease) that affects the male genitals and perineum, or strip of real estate between the scrotum and anus.
As with any necrotizing fasciitis, infection eats through the soft tissue. With Fournier’s gangrene, this infection affects the dartos, Scarpa’s and Colles’ fascias.
Fournier’s gangrene progresses rapidly, and if treatment is delayed, bad things happen.
Here are some risk factors that contribute to the development of Fournier’s gangrene:
Poor perineum hygiene
Infection with Fournier’s gangrene is pretty serious and includes the following signs and symptoms:
Crepitus (crackling under the skin)
Of note with Fournier’s gangrene, the pain described by the patient is usually out of proportion to the physical exam.
Fournier’s gangrene is treated by removal or debridement of dead or necrotic tissue as well as administration of broad-spectrum antibiotics. Typically, more than one surgery is required, and once all the dead tissue is removed, reconstructive surgery is performed. In other words, successful treatment of Fournier’s gangrene is a long process.
Because the testes have their own separate blood supply, they can usually be saved in people with Fournier’s gangrene. The testes can be tucked into a “thigh pouch” during recovery to facilitate further management.
Proper wound care and frequent dressing changes are important during recovery. Furthermore, men with diabetes should have their glucose levels controlled and receive adequate nutrition to facilitate wound healing.
Research suggests that the mortality rate of Fournier’s gangrene ranges between 20 and 40 percent.
Paraphimosis occurs only in men who are uncircumcised and thus have a foreskin. Typically, this condition occurs in men who are lying supine in bed for long periods of time like in the hospital. In this position, the foreskin naturally retracts and edema or swelling collects in the penis, and penile pain ensues. In people with altered consciousness, this pain may go unnoticed for some time until it’s too late and the penis becomes necrotic secondary to decreased blood flow to the area (ischemia).
Treatment of paraphimosis involves manual reduction of the glands, pushing it back into its normal positioning. This procedure is very painful but necessary for proper treatment. Because this reduction is pretty painful, pain medications, penile blocks, and even sedation may be necessary.
Like other conditions detailed in this article, paraphimosis is a true medical emergency which requires prompt medical attention before permanent damage transpires.
6 Emphysematous Pyelonephritis
Pyelonephritis is a urinary tract infection of the kidneys. When this infection is caused by gas-producing bacteria, it’s called emphysematous pyelonephritis. Emphysematous pyelonephritis usually occurs in people with diabetes and is usually caused by E. Coli. This infection can also spread systemically and causes sepsis, which is life threatening. All in all, emphysematous pyelonephritis is pretty scary.
People with emphysematous pyelonephritis can expect treatment with intravenous antibiotics and supportive care. Additional treatment of pyelonephritis depends on how far the infection has spread within the kidney. If the infection is confined to the parenchyma, conservative treatment may work. This conservative treatment involves placement of a nephrostomy tube to drain the pus-filled material. If infection of the kidney is more widespread and sepsis is also present, surgical removal of the kidney (nephrectomy) may be needed.
Fortunately, many of these emergency urological presentations occur infrequently. Nevertheless, all these conditions and illnesses are emergencies and require prompt medical attention. If you or a loved one suspect any of these problems, please contact emergency services and your physician immediately. With all of these conditions, time is of the essence and prompt medical attention is necessary to prevent future disability or even death.
On a final note, as previously mentioned, most of these conditions affect men. Nevertheless, acute urinary retention can also affect women, and pyelonephritis usually affects young adult women.
Even if you suspect that you may be experiencing one of these conditions and it turns out that you’re not, it’s always a good idea to follow up with a physician about the symptoms that prompted your concerns in the first place. You may also request referral to a urologist for any concerns that you may have about your urinary tract and genitals. Please remember that your physician is there to help you attain the health care that you desire and need.