Urologic Emergencies

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Introduction   

Although urologic emergencies are rare, it is important for nurses to understand the subtlety of the clinical manifestations of these conditions since the complications and long-term effects can be severe. The most prevalent urologic emergencies are acute urinary retention, obstructive pyelonephritis (pyonephrosis), gross hematuria and clot retention, priapism, penile fracture, Fournier’s gangrene, and paraphimosis. Failure to properly assess, diagnose, and treat these conditions can result in renal failure, organ damage, and loss of sexual function (1).  

Acute urinary retention (AUR) is the most common cause for emergency urologic care, and 10% of men aged 70 to 79 and 30% of men aged 80 to 89 experiences at least one episode of the condition (1). AUR affects men 13 times more than women and can be a challenging condition to treat if the patient delays seeking medical care (1). 

Obstructive pyelonephritis (pyonephrosis) is a medical emergency, unlike regular pyelonephritis, which requires emergent surgery. Gross hematuria and clot retention require Foley catheterization and bladder irrigation to resolve the bleeding. Priapism can be either ischemic or non-ischemic, and if ischemic priapism is not resolved, it can result in permanent sexual dysfunction. Penile fracture is a very painful condition that is often underreported due to the male patient’s hesitation to seek medical treatment. Fournier’s gangrene affects roughly two in 100,000 males, but it carries a current mortality rate of 40% due to its quick colonization and permeation of tissues and organs (7). Paraphimosis can occur in both children and adult males and may require full circumcision to prevent future occurrences (1). 

Acute Urinary Retention 

Acute urinary retention occurs when either an extremely small amount of urine, or no urine at all, is the result of the patient’s attempt to void. The condition can occur in all age groups, but it is most present in infants and the elderly. When the ordinary flow of urine through the urinary tract is restricted, a back pressure of urine into the kidneys can occur. If this pressure is not relieved, severe damage to the organs and other tissues can result (1, 8). 

Causes can be due to acute obstruction of one of the structures somewhere in the urologic system, or from bladder contractility malfunctions. Blockages can occur in the bladder neck, urethra, or meatus and can be caused by blood clots, stones, tumors, prostate enlargement, edema, phimosis, congenital abnormalities, and malignancies. Bladder contractility issues can occur from trauma, medications (anticholinergics, sympathomimetics), and neurologic conditions. Post-surgical acute urinary retention can result from anesthesia, narcotic pain medications, constipation, and decreased mobility in 70% of patients (1). Men who have benign prostatic hypertrophy (BPH) are at increased risk for AUR due to increased prostate volume, decreased urine flow rate, and a prostate specific antigen (PSA) diagnostic of greater than 2.5 ng/mL. Additional etiologies associated with AUR are urinary tract infection, prostate cancer, bladder cancer, phimosis, paraphimosis, urolithiasis, spinal cord injury, parasite infection, colonic endometriosis, ureterocele, and dyssynergia. In women, the most common causes of AUR are pelvic organ prolapse and urethral diverticulum (1, 8). 

The symptoms associated with acute urinary retention can be difficult to detect, especially since upper urinary tract obstruction that occurs over time can be asymptomatic. The symptoms patients may experience in the presence of acute urinary retention are renal colic, flank pain, and flank pressure. The nurse should assess the location, intensity, quality, severity, and alleviating factors of the patient’s pain. The nurse should also palpate the bladder and assess for costovertebral tenderness or a palpable mass that could be the cause of the urinary retention. Nocturia, dysuria, urinary urgency and/or frequency, and decreased force of urinary stream can suggest BPH or prostatic adenocarcinoma. The patient should be monitored for fever and urine that is cloudy and foul-smelling that can indicate urinary tract infection and septicemia (1, 8).  

Prostatic malignancy is characterized by unintentional weight loss, night sweats, and hematuria. Urinary tract obstructions can also be caused by gastrointestinal complications, such as fecal impaction, bowel obstruction and colonic mass that are marked by symptoms like constipation, nausea, vomiting, and diarrhea. Postsurgical appendectomy and hysterectomy patients can experience ureteral injury. Therefore, it is important for the nurse to conduct a thorough health history and assessment on all patients with symptoms that originate from the abdominal and pelvic regions (1, 8).  

Postsurgical patients should be monitored for post-obstructive diuresis, which can occur if urine output is more than 200 cc/hour for three consecutive hours, or more than three liters in 24 hours. Post-obstructive diuresis is most commonly seen in men with chronic urinary retention and existing fluid overload, and the condition can cause solute loss that leads to hypovolemia and electrolyte imbalance. Treatment for post-obstructive diuresis is intravenous normal saline of about 75% of urinary output (1).  

The diagnostics utilized to detect acute urinary retention are bladder ultrasound, bladder scan, computed tomography (CT) urogram, and urinary catheterization. Lab studies include complete blood count (CBC), basic metabolic panel (BMP), electrolytes, blood urea nitrogen (BUN), creatinine, and urine analysis and culture (1, 8).  

Decompression of the bladder with urethral catheterization is the primary treatment for acute urinary retention. A 16 to 18 French Foley catheter is inserted, and the patient’s urine output is monitored. If Foley catheterization is unsuccessful or contraindicated, a suprapubic catheter or needle decompression of the bladder may be necessary to prevent potential bladder rupture (1, 8).  

Upper urinary tract obstruction can be relieved with cystoscopic placement of a urethral double-J stent or percutaneous placement of a nephrostomy tube into the kidney. The nurse should monitor these patients for transient hypotension and bradycardia. Once the emergent cause of the urinary retention and obstruction is resolved, the non-emergent factors can be addressed (1, 8). 

Medications that inhibit alpha-1-adrenergic receptors (tamsulosin, terazosin) and thus relax the smooth muscles of the bladder neck and prostate can improve urinary retention secondary to BPH. Other medications used to relieve urinary retention in BPH are bicalutamide, leuprolide, finasteride, and dutasteride (8). 

Failure to recognize the signs and symptoms of urine retention and obstruction in neonates can lead to renal failure and morbidity and mortality of the child. Urinary obstruction is accountable for almost 17% of all pediatric renal transplants (8).  

Obstructive Pyelonephritis (Pyonephrosis)

E-coli, Klebsiella, Proteus, Enterobacter, Pseudomonas, and Citrobacter are the bacteria that can be found in an obstructed kidney, which can cause obstructive pyelonephritis (pyonephrosis). The obstruction can be caused from a kidney stone, tumor, ureteral stricture, or congenital abnormality. E. coli is found in 80% of cases, making it the most common causative organism (1, 4, 5, 6). In obstructive pyelonephritis, the renal collecting system becomes blocked with pus, which damages the renal parenchyma and leads to loss of function of the affected kidney.

Patient symptoms may include renal colic, fever, chills, dysuria, anorexia, nausea, vomiting, costovertebral tenderness, and urinary symptoms of burning, urgency, and frequency. If sepsis is present, the nurse should assess the patient for hypotension and tachycardia and be vigilant in monitoring the patient to prevent septic shock. The nurse should anticipate the following diagnostic lab studies: CBC with differential, BMP, urine analysis and culture, lactate level, coagulation studies, blood cultures, and arterial blood gases (ABG). Diagnostic imaging includes non-contrast computed tomography of the entire genitourinary tract (abdomen and pelvis). Renal and bladder ultrasound, plain film x-ray of the abdomen, and xray of the kidneys, ureters, and bladder (KUB) are also utilized (1, 4, 5). 

Obstructive pyelonephritis requires urgent surgical intervention, unlike acute pyelonephritis that requires only medical treatment. Presurgical care includes admitting the patient to the hospital, obtaining urine and blood cultures, administering broad-spectrum intravenous antibiotics, providing fluid resuscitation, and correcting electrolyte abnormalities. The surgical goal is to decompress the obstructed kidney with a ureteral stent placed via cystoscopy. If a ureteral stent is contraindicated, a nephrostomy tube can be placed (1, 5, 6).  

Gross Hematuria and Clot Retention 

Gross hematuria is a medical emergency that can be caused by both urological and medical etiologies. Specific causes can include tumors (renal, bladder), prostate enlargement and/or cancer, renal and/or ureteral stones, trauma, urinary tract infection, nephritis, anticoagulation, and inflammation. Complications of gross hematuria are hypotension, anemia, and blood clots, which can cause obstruction and urinary retention that can lead to bladder rupture or perforation (1, 2). 

Symptoms associated with gross hematuria and clot retention are severe abdominal pain, hypertension, tachycardia, and overdistended bladder (2). The nurse should assess the patient for signs and symptoms associated with hypovolemia, electrolyte imbalance, and infection. 

Lab studies include CBC with differential, BUN and creatinine, coagulation studies, urine analysis and culture, and urine cytology. Imaging diagnostics are CT scan of the abdomen and pelvis with or without contrast, renal and bladder ultrasound, and MRI urogram. Cystoscopy is required in all patients so that any underlying causes can be determined and managed (1).  

Placement of a 22 to 24 French Foley catheter and irrigation of the bladder with saline (using a Toomey syringe) are utilized to evacuate the clots and collect the gross hematuria and dislodged clots. In the case of tenacious clots, a solution of 0.15% or 0.3% hydrogen peroxide and streptokinase can be instilled into the bladder to lyse the clots (2).  

If continued bleeding occurs, the patient’s bladder can be continuously irrigated using a three-way catheter. If the patient is taking anticoagulant therapy, this may need to be discontinued temporarily. Blood products can be administered to replace the lost blood. If the patient’s bleeding persists, a cystoscopy should be performed in a surgical setting to determine the underlying cause of the blood loss (1, 2).  

Priapism 

Priapism is a persistent penile erection that lasts for at least four hours beyond the sexual stimulation experience (1). The condition affects mostly boys aged 5 to 10 years and men aged 20 to 50 years with 1.5 cases per 100,000 males occurring per year (1). Roughly 40% of men with sickle cell disease experience at least one episode of ischemic priapism during their lives (9). Some men experience idiopathic priapism where the condition is a recurrent problem, resulting in the patient having “stuttering priapism” (9). 

Priapism occurs when the smooth muscles of the cavernous arteries and tissues of the penis relax, thus encouraging increased blood flow to the area. The corpus cavernosum engorges with blood and the veins that drain the tissue are compressed, which maintains turgidity. The turgidity remains due to the corpus cavernosum’s inability to drain because of impaired relaxation or paralysis of the cavernosal smooth muscle or occlusion of the venous outflow. Priapism can be ischemic or non-ischemic with ischemic priapism being the most common (1, 9). 

The sign and symptom of ischemic priapism is a painful, prolonged, and fully rigid erection, which is caused by the increased intracavernosal pressure that decreases arterial inflow. The patient’s penis will be tender and erythematous while the glans and corpus spongiosum are soft. The low inflow and outflow causes hypoxia, acidosis, and penile compartment syndrome. Tissue edema occurs at the four to six-hour mark and structural damage of the cavernous smooth muscle occurs after 12 hours. If the erection lasts for 12 hours, 50% of men will experience permanent erectile dysfunction (1, 9). At 24 hours, irreversible damage happens as the cavernosal smooth muscles demonstrate necrosis and fibroblast proliferation, which causes permanent erectile dysfunction in 90% of men (1, 9). After 48 hours, irreversible fibrosis of the corpus cavernosum occurs (1, 9).  

Causes of ischemic priapism are sickle cell disease (particularly in children), thalassemia, malignant tumor (leukemia, multiple myeloma), medications (sildenafil, trazodone, bupropion, alpha blockers, anticoagulants, antidepressants, and cocaine), penile injection therapy (used by men with erectile dysfunction), toxins (spider venom, rabies), total parenteral nutrition (TPN),  and neurologic shock (1, 9). Ischemic priapism is a medical emergency. 

Non-ischemic priapism is caused by a fistula between the cavernosal artery and corpus cavernosum. Fistulas are caused by blunt trauma, congenital arterial malformations, penile surgery, and needle injury that results in a hole in the caversonal artery. Consistent high inflow of blood into the corpus cavernosum without reduced outflow results in a high inflow, high outflow situation. This causes a partial, non-tender erection. Non-ischemic priapism is not a medical emergency, and it does not result in permanent damage to the penis that can negatively impact sexual function. Although the majority of non-ischemic priapism cases are the result of penile or perineal trauma, roughly 60% of non-ischemic priapism cases resolve without treatment (1, 9). 

During the assessment, the nurse should ask the patient questions related to the duration of the erection, the patient’s pain level, medications, illicit drug use (particularly cocaine), erectogenic drug use, penile and/or perineal trauma, and history of hematologic disease. Blood gases collected from the corpora cavernosum differentiate between ischemic and non-ischemic cases. Ischemic priapism is associated with dark blood with hypoxemia, hypercarbia, and acidemia while bright red blood with normal blood gas levels is associated with non-ischemic priapism. Penile doppler can also aid in diagnosis (1, 9). 

Treatment of ischemic priapism includes using an 18 or 19-gauge needle placed at three or nine o’clock position during which 5 mL of blood is aspirated from the penile tissue. The smooth muscle relaxation that contributed to the disorder can be reversed with an injected solution of 1 cc of 10 mg phenylephrine diluted with 19 cc of normal saline. One cc of the solution is injected every 15 minutes and vital signs are collected during the procedure. Up to three injections of the solution may be used. If this treatment is unsuccessful, a surgical procedure where a fistula is deliberately made between the corpus cavernosa and corpus spongiosum or glans with a biopsy needle to drain the blood in the corpus cavernosa is implemented. In these instances where a shunt is implemented, success rates are 50% to 75% with a 25% to 50% likelihood of long-term erectile dysfunction (9). Other treatments include exercise, ice packs to the penis, ejaculation, and oral pseudoephedrine (1, 9).  

Treatment of non-ischemic priapism includes arterial embolization by an interventional radiologist if a fistula is present. The goal is to occlude the arteriovenous fistula (9). 

Penile Fracture 

Penile fracture is an uncommon urologic emergency in which vaginal intercourse is the most common cause followed by masturbation, penile manipulation, and injury, such as rolling over in bed onto an erect penis (1, 3). However, nurses should be aware that the incidence of penile fracture is underestimated since many patients may not seek treatment due to embarrassment (3). 

Signs and symptoms include the patient’s report of hearing a cracking noise and feeling a “pop” (when the tunica ruptures) during sexual activity followed by immediate pain and loss of erection (detumescence) during which the penis becomes edematous and ecchymotic due to hematoma formation. Patients and clinicians report that the penis resembles an eggplant after injury, hence the popular term “eggplant deformity.” Difficulty urinating and gross hematuria may also be reported (1, 3). 

Ultrasonography, MRI, and cavernosography may be utilized if the healthcare provider is uncertain if a penile fracture exists. Retrograde urethrography (RGU) is used if urethral injury is suspected. Otherwise, there are no additional diagnostics associated with penile fracture since the clinical presentation is evident (1, 3). 

Treatment for penile fracture is surgical where the tunica albuginea is closed to prevent future erectile dysfunction, curvature of the penis, and painful erections. A subcoronal degloving incision or an incision over the site of the hematoma is performed. The hematoma is drained, and the corporal bodies are repaired using either running or interrupted sutures. Any concomitant urethral injuries are performed at the same time. Postsurgical complications include premature ejaculation, erectile dysfunction, penile curvature, penile nodules, urethral stricture, hypo-desire disorder, anxiety, depression, and relationship conflict (1, 3).  

Fournier’s Gangrene 

Fournier’s gangrene is a life-threatening necrotizing infection of the abdomen and perineum that is caused by a mucosal barrier breakdown in the urethra or colon. E. coli, Klebsiella, enterococci, Bacteroides, Fusobacterium, and Clostridium are the offending agents. The infection affects both men and women, but it is most prevalent in older men (7). Additional risk factors include diabetes mellitus, HIV/AIDS, obesity, atherosclerosis, peripheral artery disease, malnutrition, prostate cancer, leukemia, alcoholism, liver disease, smoking, and renal failure. The morbidity and mortality rates associated with Fournier’s gangrene are high with the mortality rate due to sepsis being roughly 20% to 40% (1, 7). Having multiple comorbidities puts patients at higher risk, and nurses must be aware of the importance of early detection and aggressive treatment (7). 

The causative organisms release enzymes that cause tissue destruction and necrosis at a rate of one inch per hour; the gangrene spreads rapidly through the superficial and deep fascial layers in the perineal, genital, and perianal areas, causing septic shock. The gangrene can spread to the anterior abdominal wall and vital organs, causing multi-organ failure (7). 

The symptoms associated with Fournier’s gangrene occur rapidly and include blisters, bullae, edema, subcutaneous gas, subcutaneous crepitus, hypotension, fever, tachycardia, and shock. One of the earliest manifestations is pain in the genital and perianal regions with little to no cutaneous damage. The patient’s skin tone can change to one that is dusky and darker. The infection can spread particularly quickly to the labia, penis, scrotum, gluteal folds, and abdominal wall, and release a putrid odor (1, 7).  

Diagnostics include wound cultures, as well as serum glucose, C-reactive protein, sodium, potassium, and creatinine levels (1, 7). Standard radiography is used to detect the presence of subcutaneous emphysema, which 90% of patients with the condition possess (6). Ultrasonography can detect the “dirty” acoustic shadowing of subcutaneous gas in the perineum and scrotal area. CT scan and MRI determine the extent of infection, which helps the nurse plan for debridement (1, 7). 

Treatment for Fournier’s gangrene includes broad spectrum antibiotics, hemodynamic stabilization, and extensive surgical debridement and drainage of the wounds. Complete removal of the necrotic tissue as soon as possible is required to prevent the spread of infection. The surgical interventions include cystostomy, colostomy, orchiectomy, and skin grafting. Most patients require multiple reconstructive procedures. Hyperbaric oxygen therapy, negative pressure wound therapy, and vacuum-assisted devices can reduce the amount of debridement required (1, 7).  

Complications can include permanent colostomies and catheters, decreased fertility, sexual and urologic disabilities, and parathesias (1, 7). 

Paraphimosis 

Paraphimosis occurs when the foreskin of an uncircumcised or partially circumcised male retracts behind the coronal sulcus of the glans penis and becomes stuck. When the foreskin remains retracted for an extended period of time, venous and lymphatic outflow is obstructed, which leads to edema. In a matter of just hours, this situation can lead to necrosis, infarction, gangrene, and autoamputation of the glans (1).  

The greatest risk factor for paraphimosis is phimosis. Uncircumcised infants and young boys have a prepuce opening that is smaller than the coronal sulcus that can lead to paraphimosis. The condition can also occur when a caregiver or the patient retracts the foreskin for cleaning or urination and then neglects to return it to back to its original anatomical position. Paraphimosis can also occur in adolescent and adult men who have traumatized the area as the result of a genital piercing (1).  

The signs and symptoms of paraphimosis are penile pain, swelling of the foreskin and glans, constricted band of tissue at the coronal sulcus, flaccid penile shaft, and discoloration of the penis. The nurse should assess the penis for any constricting foreign body, such as clothing, rubber band, hair, ring, or metal piercing. Urinary obstruction, bladder distention, retention, and tenderness may also be evident (1).  

Treatment includes managing pain by applying topical lidocaine, injecting local bupivacaine or lidocaine (without epinephrine), or preparing the patient for dorsal penile nerve block. Younger boys may also require intranasal or intravenous opioids, light sedation, and local anesthesia since their fear and anxiety may be overwhelming. Epinephrine and ice are contraindicated since they can cause vasoconstriction and ischemia (1). 

Once the patient is anesthetized, the healthcare provider can squeeze the glans, foreskin, and shaft in a closed fist for five minutes to reduce swelling. If the area is still very edematous, an osmotic dehydrating agent of granulated sugar, 20% mannitol, or 50% dextrose can be applied, as well as compression bandages. Once the swelling has decreased, the healthcare provider can apply lubricant to the area and gently push the glans while pulling the foreskin over the glans. If this is not successful, a dorsal slit can be made in the foreskin to reduce the edema. Sutures are then applied to the incision (1). 

Patients should not retract the foreskin for seven days and should avoid forceful retraction in the future. The area should be cleaned with water and bacitracin applied to the foreskin without retracting it. These patients should be encouraged to undergo an elective, permanent dorsal slit surgery or full circumcision to prevent future paraphimosis (1).  

Patient Education 

Patients who experience urologic emergencies should be taught the importance of catheter care, urine output monitoring, wound care, and symptoms to report to the healthcare provider, such as fever, gross hematuria, blocked Foley, worsening pain, and medication side effects. If patients are prescribed antibiotics, they should be reminded to complete the entire course and not to stop treatment before the entire prescription is utilized. These patients should also be taught the importance of adhering to follow-up plans and discharge instructions (1, 7, 8). 

If patients experience mental health challenges due to their diagnosis, the nurse should ensure that they are referred to the appropriate mental health resource. It is important that nurses treat all patients who experience urological emergencies with dignity, respect, and compassion since these conditions can cause many patients to feel embarrassed. 

Conclusion

Although urologic emergencies are not common, the side effects associated with them can be very serious. It is important for nurses to thoroughly assess and monitor patients suspected of sustaining a urologic emergency, especially since some signs and symptoms associated with these conditions may not be evident or may erroneously be attributed to other conditions. Nurses should treat all patients who sustain a urologic emergency with respect, a non-judgmental attitude, and compassion since some of these injuries have a sexual component. Teaching patients self-care measures and the importance of seeking medical care are also important steps to take. 

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