Emergency Urology

Thurtle, David, Biers, Suzanne, Sut, Michal, Armitage, James

• Publisher: tfm Publishing Ltd
• Year: 2017
• ISBN:
  9781910079430
• Topic: Medicine
• Subtopic: Urology

Urology is a specialty that notoriously receives little attention in medical school, yet it makes up a sizeable portion of the workload in emergency departments and also in primary care. Urological emergencies can often be managed simply but require the appropriate knowledge and skills. Emergency urology is often covered very superficially alongside general surgery or in excessive detail within voluminous urology textbooks. This book is different: it will consist of concise, well-structured chapters, with an accessible and easily digestible style. The content will be clinically-based and will include a number of clinical photographs and radiological investigations. This book will appeal to all doctors, including those rotating through surgical and emergency medicine specialties, and those clinicians approaching professional examinations worldwide. Medical students on urology or emergency medicine placements, who are studying for their exams will also find it invaluable. In addition, primary care doctors, specialty nurses in urology and nurses in the emergency department may also appreciate the clinically relevant content of the book. The authors are all dedicated to education and teaching, and have published extensively. In addition, they run a successful emergency urology course in Cambridge, popular with clinicians and senior students alike.

Chapter 1

Assessing the Unwell Urological Patient

David Thurtle and Suzanne Biers

The approach to a new urological patient should be structured and concise. This approach should include initial resuscitation if necessary, and an assessment of the urgency or severity of the patient’s condition. Thereafter, a basic urological history, examination and initial investigations will help in accurately diagnosing and treating the patient.

ABCDE

Any acutely unwell or unstable patient should undergo initial rapid assessment and resuscitation using the ABCDE principles prior to formal assessment and investigation of urological problems, which can continue once the patient’s condition is stable and safe. The full ABCDE approach, suggested by the Resuscitation Council, is available in Appendix 2 (pages 185–190).

HISTORY

Common urological emergency presentations include voiding difficulty or urinary retention, pain and bleeding. It is important to be able to recognise and relate symptoms to potential pathology. Obtaining a ‘baseline’ urological history will be useful in evaluating the current condition and will help direct long-term management.

Urinary symptoms

Lower urinary tract symptoms (LUTS) may be acute or longstanding. It is important to determine a patient’s previous urinary tract function to contextualise their acute symptoms and obtain a diagnosis. LUTS are broadly categorised into storage and voiding symptoms (Table 1.1). Make a direct enquiry into these symptoms (see Box 1.1 for a comprehensive tick box to follow when assessing LUTS), establish the timeframe of symptoms and any recent change.

Table 1.1 The classification of lower urinary tract symptoms.

Storage	Voiding	Infective
•Urgency •Frequency •Urinary incontinence •Nocturia	•Straining •Incomplete bladder emptying •Terminal dribble •Hesitancy •Intermittent or slow stream •Double-voiding	•Frequency •Urgency •Altered urine colour or smell •Dysuria

Box 1.1 Common lower urinary tract symptoms to enquire about in a urological history.

•Daytime frequency: number of times passing urine during the day – has this changed?

•Nocturia: number of times the patient wakes at night to pass urine – has this changed?

•Hesitancy: difficulty in initiating the void, or straining to void?

•Flow: weak, strong, intermittent?

•Incomplete emptying: the sensation of not emptying the bladder completely.

•Double voiding: urinating twice in quick succession. May be a sign of incomplete bladder emptying especially if the second void volume is reasonable.

•Strangury: pain or spasm at the end or immediately after voiding.

•Urgency: unable to hold on to urine/a strong desire to go to the toilet, which is difficult to defer.

•Urgency incontinence: involuntary leak of urine if unable to reach the toilet in time (triggers can include cold weather, going from sitting to standing, key in the door lock).

•Stress urinary incontinence: urine leak with cough, sneeze or exertion.

•Dysuria: stinging or burning on passing urine.

•Haematuria: blood in the urine.

•Pneumaturia: air bubbles in the urine (specific enquiry if a patient reports recurrent UTIs and has a history of previous pelvic cancer, surgery or radiotherapy). Indicates a possible fistula between the bowel and bladder or, less commonly, infection with gas-producing bacteria.

An acute onset of storage symptoms such as urinary frequency and urgency are often caused by urinary tract infection. Be vigilant for ‘red flag’ symptoms that may indicate the presence of significant underlying pathology (see Box 1.2). Urinary incontinence is the involuntary leakage of urine. Most commonly it is reported as a chronic symptom; however, new-onset incontinence (day or night) can be related to an overflow incontinence associated with urinary retention and occasionally associated upper urinary tract obstruction and renal impairment. It is helpful to categorise the type of incontinence:

•Stress incontinence: leakage associated with raised intra-abdominal pressure such as cough.

•Urgency incontinence: associated with a strong desire to void that cannot be deferred.

•Mixed incontinence: a combination of stress and urge urinary incontinence.

•Continuous incontinence: can be caused by a urinary tract fistula such as a vesicovaginal fistula.

•Overflow incontinence: more common in men and occurs in those with chronic urinary retention.

•Nocturnal enuresis/incontinence: in males this is a significant symptom and should alert you to the possible diagnosis of high-pressure chronic retention.

Box 1.2 Red flag-type symptoms that should alert the clinician to a possible significant pathology.

•Visible painless haematuria.

•Pelvic pain.

•Back or bone pain.

•New-onset lower limb weakness.

•Unexplained weight loss.

•Palpable pelvic mass.

Pain

A large proportion of urological presentations will be with pain. The Site, Onset, Character, Radiation, Alleviating factors, Timing, Exacerbating factors and associated Symptoms are important to establish (SOCRATES). Both loin pain and scrotal pain will often be presumed to be of urological origin, hence the focus on these below. Remember the concept of referred pain, which is commonly misleading in urological conditions (Box 1.3).

Box 1.3 Referred pain.

Referred pain relates to a pain felt at a distant site from the place of development. The sensation of pain from urological organs is often referred due to the embryological origin of these organs:

•Kidney pain: radiates to the back or hypochondrium.

•Ureteric pain: varies more than renal pain, and can be felt in the back, towards the abdomen or groins and in the external genitalia.

•Bladder pain: can be felt suprapubically or deeper in the pelvis. Some men report bladder pain referred to the tip of the penis with retention or infection.

•Prostate pain: often described as lower back pain, perineal, scrotal or abdominal pain; it is also sometimes described as penile tip pain.

•Penile pain: may be referred from the bladder. Pain from the penis itself is usually well localised.

•Testicular pain: pain can be referred from the distal ureters to the testes; pain originating from the testes is often felt in the lower abdomen on the ipsilateral side. If the pain is referred from the ureter, the testes are typically not tender on palpation.

This phenomenon is partly why a genital examination should be performed on male patients presenting with lower abdominal pain, and an abdominal examination performed on those with testicular pain.

Loin pain

The most common causes of acute loin pain are ureteric colic and pyelonephritis, but the differential diagnosis is wide. Ureteric colic tends to come on within seconds or minutes, coming in waves of severe pain and the patient often reports being unable to get comfortable in any position. This colicky pain is often referred to the groi...