Andrew Siegel MD 8/29/2020
Unlike some other surgical specialties, the field of urology does not involve too many true emergencies. The aim of today’s entry is to provide practical information on 10 urological emergencies that you or a family member might experience at some time. Today’s entry does not address blunt and sharp trauma to the genital/urinary organs from falls, motor vehicle accidents, and gunshots.
- Kidney stones, a.k.a. “renal or ureteral colic”
Kidney stones are common maladies, especially prevalent in the hot summer months when dehydration is more likely to occur and the dissolved salts in the urine tend to solidify. When a stone moves from the kidney and lodges in the ureter (tubular structure that conducts urine from kidney to bladder) it often causes an obstruction, manifesting with severe pain, inability to get comfortable in any position, nausea and vomiting, a condition known as renal or ureteral colic. Although many stones ultimately will pass spontaneously– depending on their size, shape and one’s anatomy–some will require a urological procedure to remove the stone and alleviate the obstruction.
2. Blood-borne urinary infection, a.k.a. “urosepsis”
Urosepsis is a serious, potentially life-threatening infection that starts in the urinary tract and becomes systemic (enters the bloodstream), requiring urgent attention. Aside from painful urination and urinary symptoms, urosepsis may cause back pain, fever, shaking chills, malaise, fatigue, breathing difficulties, rapid heart rate and decreased blood pressure. There are many underlying causes, a common one being an infected, obstructing kidney stone. At times, urosepsis can progress to septic shock, multi-organ shutdown and failure and occasional death. This emergency mandates hospital admission, resuscitation with intravenous fluids, broad-spectrum antibiotics, imaging studies and often ICU admission for careful monitoring. If the cause is a urinary tract obstruction, e.g. from a urinary tract stone, the obstruction will need to be alleviated once the clinical situation is stabilized.
3. Can’t pee, a.k.a. “acute urinary retention”
When one cannot urinate, the bladder distends and typically causes severe pain, urgency to urinate and a distended lower abdomen. Although much more common in men, it can also occur in women. Causes of acute urinary retention include urinary obstruction from an enlarged prostate or urethral scarring, severe bladder prolapse in a female, and a bladder that fails to contract properly. It is often precipitated by over-the-counter cold or allergy medications and is also a common occurrence following any kind of surgery in those with pre-existing urinary difficulties. In any case, it requires alleviation of the acute obstruction with a urinary catheter placed in the bladder via the urethra, or if not possible, via a tube placed in the bladder via the lower abdomen. If the retention does not resolve spontaneously, an evaluation is important to seek the underlying cause so that treatment can be directed appropriately. The situation will often resolve with medication, but at times will require surgery.
4. Urinary bleeding/clotting, a.k.a. “hematuria“/”clot retention”
Blood in the urine (hematuria) can occur for a variety of different reasons. Urinary tract bleeding requires an evaluation with imaging and cystoscopy (visual inspection of the bladder with a small flexible scope) to determine the source of the bleeding. If significant urinary tract bleeding occurs, clotting will occur with the potential for the clots to coalesce and obstruct the outflow of urine, resulting in clot retention. This causes urinary urgency and a painful distension of the lower abdomen, similar to acute urinary retention. The initial management is the placement of a large diameter urinary catheter into the bladder and manual irrigation and flushing of the clots. If irrigation fails to improve the situation, a visit to the operating room is often required to evacuate clots, determine the source of the bleeding, and to correct the problem that caused the bleeding.
5. Twisted testes, a.k.a. “testes torsion”
Testes torsion is twisting of the cord of tissue (spermatic cord) that contains the testes blood vessels. Torsion can compromise blood flow and may lead to strangulation and death of the testes if not promptly addressed. The testicle can spin 360°, 720° or any conceivable amount. Torsion typically causes acute onset of pain and swelling in the testicle, often with radiation of the pain to the groin and lower abdomen as well as causing the testes to ride high in the scrotal sac because of foreshortening of the spermatic cord. It can easily be confused with appendicitis when it involves the right testicle. Although torsion may occur at any age, it is most common among adolescents, typically shortly after puberty. Torsion is a surgical emergency because if the testicle is not untwisted on a timely basis it can perish. When diagnosed expeditiously, the testes can be untwisted and surgically fixated to prevent recurrent episodes. Time is of the essence and it is for this reason that testicular pain needs to be urgently evaluated.
6. Genital flesh-eating infection, a.k.a. necrotizing fasciitis,” a.k.a. “Fournier’s gangrene”
This is a rare, rapidly-developing soft tissue infection of the male genitals, perineum (area between scrotum and anus) or peri-anal region that has a high mortality rate. It usually involves multiple bacteria that interact in such a way to produce a combined effect greater than the sum of their separate effects. Over 90% of patients with Fournier’s gangrene are diabetic, elderly, alcoholic or otherwise immune-compromised. It rapidly progresses from cellulitis (red and swollen skin) to necrotizing fasciitis (death of deeper tissues) along fascial tissue planes and requires broad-spectrum intravenous antibiotics and aggressive surgical debridement (removal of dead tissue) on an emergency basis that can be extremely disfiguring. Multiple return trips to the operating room are often necessary for further debridement, and if the patient survives, skin grafting will likely be needed to cover the tissue defect resulting from the infection.
7. Can’t get it down, a.k.a. “priapism”
This is a persistent, typically painful penile erection that lasts beyond 4 hours, continuing after or unrelated to sexual stimulation. It can be idiopathic (no underlying predisposing cause), or due to a variety of underlying conditions including: perineal trauma, medications (vasodilator penile injections therapy for erectile dysfunction; trazodone; cocaine), hematological disorders (sickle cell disease), and hematological malignancies. Priapism may be ischemic (low blood flow) caused by blood clotting within the erectile chambers or non-ischemic (high blood flow) caused by unregulated arterial inflow into the erectile chambers. Prompt treatment is important to return the penis to flaccid status and prevent permanent erectile dysfunction. Treatment may involve aspiration, irrigation and/or injection of medication into the erectile chambers of the penis. If ineffective, surgery is often necessary. High flow priapism can be effectively treated in interventional radiology with embolization (injecting a material that occludes an artery) of the unregulated arterial inflow.
8. Broken penis, a.k.a. “penile fracture”
During sexual intercourse, she “zigs” and he “zags” with the penis forcibly striking her pubic bone or perineum, rupturing the tough outer sheath of one of both of the erectile chambers. This may also occur when rolling over or falling onto the erect penis, walking into a wall in a poorly illuminated room, forcible masturbation, etc. Penile fracture causes a classic and dramatic scene in which an audible pop occurs with the rupture, followed by acute pain, rapid loss of erection, and purplish discoloration, bruising and extreme swelling of the penis, as the blood within the erectile chambers escapes through the rupture site, similar to a blow-out of a car tire. The penis often appears like an eggplant after a fracture. MRI is useful to demonstrate the precise site, extent and anatomy of the fracture. Penile fractures need to be promptly repaired in the operating room to maintain future erectile function and minimize scarring of the erectile chambers that could result in penile angulation with erections.
9. Foreskin won’t go back into position, a.k.a. “paraphimosis”
In this situation the foreskin of the penis is pulled back to expose the head of the penis but cannot be repositioned. In time, the foreskin swells and constricts the head of the penis and if left in this position, can compromise the blood flow to the head of the penis. Fixing this is a bit brutal but effective: the initial step is to firmly squeeze the head of the penis to reduce the swelling, and once the swelling is diminished the second step is to manually retract the foreskin using a pushing (the penile head)-pulling (the foreskin) technique. If ineffective, surgical intervention may be required.
10. Snapped banjo string, a.k.a. “lacerated frenulum”
The penile frenulum (“banjo string”) anchors the underside of the head of the penis to the penile shaft. When the penile frenulum is too thick, short or tight, it is prone to injury. Frenulum injury may occur with sexual intercourse or with masturbation. The tension of a short and thick frenulum is increased substantially with an erection and the possibility of trauma further increases with sexual intercourse that creates shearing and stress forces on the penis. When a frenulum is torn, it causes acute pain and bleeding and because of the hardy nerve and blood supply to this little structure, the pain can be significant and the bleeding profuse. The bleeding usually responds to direct pressure and the tear will eventually heal. However, if frenulum injury recurs, it may require surgery.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States. His latest book is: Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families.
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Our Greatest Wealth Is Health 