Urological Emergencies

 

  • Testicular Torsion
  • Ureteric Colic (Renal stones)

The following notes look at the main clinical treatment and management of each emergency:

Testicular torsion

  • This is described as acute pain due to the twisting of the spermatic cord supplying one of the tests - thus cutting off blood supply. (This is mainly twisting of the pampiniform plexus of veins)
  • The main aim is to recognise the torsion in patients early and take to surgery
  • Symptoms/Signs include:
    • Sudden onset of pain in one testis, making walking uncomfortable
    • Abdominal pain
    • Nausea and vomiting
    • May be a fever and raised WBC count
      • This could lead you to suspect an infection, but your priority remains with the testicular torsion
  • Inflammation around testis
    • Testis will normally lie higher and transversally
  • The main ages in which torsion occurs is 11-30 years
  • Treatment involves surgical exploration and then untwisting of the testis
    • If colour returns testis then leave and tie to the wall of the scrotum
      • Must also tie the other testis
  • If colour does not return and stays black – perform a orchiectomy
    • Must still remember to tie the other testis
  • One of the major differentials for testicular torsion is epididymo-orchitis
    • In clinical practice there is one sign, which is often used to help differentiate the two conditions, this is known as Prehns sign -  "the physical lifting of the testicles relieves the pain of epididymitis but not pain caused by testicular torsion"
      • It should be noted that this is not always the case in clinical practice and a doppler ultrasound is a much better way of making the diagnosis

Ureteric colic

  • This is the process of formation and excretion of a kidney stone that predisposes for many reasons
  • Manly occurs in males between 30-40 years old, although suspect stone in anyone under 60 with suspected symptoms
    • Symptoms/signs:
      • Pain comes in waves (Like any colic pain)
      • Patient won’t be able to keep still
      • Abdominal pain - Loin-to-groin
      • Haematuria
  • Main choice of investigation is a CT looking for a stone
  • Blood count and Urinary dipstick should also be done looking for infection and blood in the urine.
  • Treatment is aimed at symptom relief with the use of NSAIDs - typically diclofenac - with waiting for the stone to paass. However, there are certain situations when intervention is required to remove the stone via:
    • extracorporeal shock wave lipotripsy (ESWL)
    • Percutaneous nephrostomy
  • Situations in which intervention may be required includes:
    • Change in renal function
    • Poor renal function
    • Stones >0.5cm
    • Only one kidney present
    • Infection +/- sepsis
  • DDx could include:
    • Ruptured AAA, always suspect in patients over 60
    • Pyelonephritis
    • Pancreatitis