Urology rotation: high-yield survival guide

1. The commonest things you will see

2. Emergencies: know these cold

1. Infected obstructed kidney
   • Fever/sepsis plus obstructing ureteric stone or hydronephrosis.
   • Requires urgent drainage by ureteric stent or nephrostomy plus antibiotics.
   • Do not treat as “just renal colic.”
2. Testicular torsion
   • Sudden unilateral scrotal pain, high-riding/horizontal testis, nausea/vomiting.
   • Urgent urology review and exploration if suspicion is high. Imaging should not delay definitive action in a convincing case.
   • Acute-scrotum ultrasound is useful, but clinical urgency matters. Campbell-Walsh-Wein Urology, p. 535.
3. Acute urinary retention
   • Relieve obstruction with catheterization, then investigate the cause.
   • Be cautious in urethral trauma, prior urethral reconstruction, or difficult catheterization.
4. Fournier gangrene
   • Severe genital/perineal pain, swelling, skin discoloration or crepitus, systemic toxicity.
   • Resuscitation, broad-spectrum antibiotics, urgent debridement.
5. Priapism
   • Painful rigid erection lasting >4 hours is presumed ischemic priapism until proven otherwise.
   • Emergency due to time-dependent corporal ischemia and erectile dysfunction risk.
   • Nonischemic priapism is often trauma-related and less urgent, but must be distinguished correctly.
6. Gross hematuria with clot retention
   • Ensure drainage, use large-bore/3-way catheter as appropriate, irrigate when trained, escalate for cystoscopic clot evacuation if needed.
7. GU trauma
   • Blood at the meatus, pelvic fracture, perineal hematoma, inability to void: suspect urethral injury.
   • Do not blindly pass a urethral catheter before appropriate assessment.
   • Gross hematuria after pelvic trauma warrants evaluation for urinary tract injury.

3. Imaging you will repeatedly be asked to interpret

• CT KUB / noncontrast CT: stone size, location, degree of obstruction, perinephric stranding.
• Renal ultrasound: hydronephrosis, renal mass, bladder volume, post-void residual.
• Scrotal Doppler ultrasound: testicular blood flow, torsion, epididymitis, testicular mass.
• CT urogram: upper-tract assessment in selected hematuria work-ups.
• Multiparametric prostate MRI: prostate lesion/risk assessment before targeted biopsy in many pathways.
• KUB X-ray: follow radiopaque stones/stents when appropriate.

4. Procedures to watch or assist with

• Foley catheter insertion and removal
• Coude catheter use
• Three-way catheter and bladder irrigation
• Flexible cystoscopy
• Ureteroscopy with laser lithotripsy and stent placement
• Ureteric stent removal
• TURP/TURBT observation
• TRUS-guided or transperineal prostate biopsy
• Circumcision, hydrocelectomy, orchidopexy

• Cystoscopy: inspect urethra/bladder, investigate hematuria, resect bladder tumors.
• Ureteroscopy: visualize/treat ureteric or renal stones.
• Ureteric stent: internally drain an obstructed upper tract.
• Percutaneous nephrostomy: external renal drainage, often in obstructed infection or when retrograde stenting is unsuitable.
• TURP/HoLEP: relieve bladder outlet obstruction from BPH.
• TURBT: diagnose and treat visible bladder tumors.

5. Daily ward-round checklist

• Why are they admitted or postoperative?
• Any fever, sepsis markers, AKI, falling hemoglobin, worsening pain?
• Urine output over 24 hours and current creatinine?
• Is a catheter/stent/nephrostomy present? Why, how long, and is it functioning?
• Is there hematuria or clots?
• What cultures are pending and are antibiotics appropriate?
• What imaging is available and what is the plan for the obstruction/mass/stone?
• What is the discharge endpoint: voiding independently, successful trial without catheter, antibiotics plan, stent plan, follow-up?

6. Questions consultants commonly ask

• Stone: size, side, level, obstruction, infection, creatinine, pain control
• Retention: PVR, catheter output, suspected cause, medication triggers, renal function
• Hematuria: gross vs microscopic, clots, anticoagulation, smoking history, imaging/cystoscopy plan
• BPH: LUTS severity, PVR, recurrent retention/UTIs/hematuria/stones/renal impairment
• Scrotal pain: onset, laterality, nausea, urinary symptoms, exam, Doppler result
• Post-op: procedure, drain/catheter/stent status, urine appearance, Hb, creatinine, fever, next step

7. Less common but high-impact topics

• Testicular tumor: painless intratesticular mass is malignant until proven otherwise. Avoid trans-scrotal biopsy.
• Renal cell carcinoma: incidental renal mass, hematuria, paraneoplastic features.
• Upper-tract urothelial carcinoma: hematuria with renal pelvis/ureter lesion.
• Urethral stricture: weak stream, recurrent retention/UTIs, traumatic catheter history.
• Neurogenic bladder: spinal cord injury, MS, diabetic neuropathy, chronic retention, recurrent UTI.
• Vesicoureteral reflux and PUJ obstruction: common pediatric teaching topics.
• Posterior urethral valves: important cause of male pediatric bladder outlet obstruction.
• Peyronie disease and erectile dysfunction: sexual health needs sensitive, nonjudgmental communication.
• Male infertility: semen analysis basics, varicocele, endocrine and obstructive causes.
• Renal trauma: grade injury, hemodynamic stability, delayed bleeding/urine leak.
• Adrenal incidentaloma: determine hormonal activity and malignancy risk.
• Urologic reconstruction and urinary diversion: ileal conduit, continent pouch, neobladder.

8. Practical points that make you useful

• Always examine the catheter system before calling it “blocked.”
• Record urine output accurately, especially after relieving retention or obstruction.
• Never force a difficult catheter.
• In a stone patient, fever plus obstruction is the key danger combination.
• In acute scrotum, torsion is the diagnosis you cannot miss.
• In painless gross hematuria, think malignancy until the work-up proves otherwise.
• Know whether the patient has a stent, when it was inserted, and the removal/exchange plan.
• Ask patients about anticoagulants, antiplatelets, diabetes medications, allergies, prior pelvic surgery, radiation, and sexual/voiding function when relevant.

9. One-minute pre-round reading list

1. Urinary retention and catheterization
2. BPH/LUTS and PVR
3. Ureteric stones and obstructed infected system
4. Hematuria work-up
5. Acute scrotum/testicular torsion
6. UTI in men and catheter-associated infection
7. Bladder cancer and TURBT
8. Prostate cancer basics
9. Postoperative care after TURP, TURBT, ureteroscopy, nephrectomy
10. GU trauma principles

Recent guidelines to use on urology rotation

Stones / urolithiasis

1. EAU Guidelines on Urolithiasis 2026
   • Most current broad international reference, including diagnosis, renal colic, medical expulsive therapy, SWL, ureteroscopy, PCNL, infection, pregnancy, pediatric stones, and metabolic prevention.
   • The 2026 update revised recommendations for renal colic, MET, SWL, URS, PCNL, antithrombotic management, radiation protection, and calcium-stone disorders. See the EAU 2026 guideline and pocket guide.
2. AUA Surgical Management of Kidney and Ureteral Stones Guideline 2026
   • Current US guide for procedural selection.
   • High-yield: for adult renal stones >2 cm, recommend PCNL first line. Procedure choice otherwise depends on stone size, site, anatomy, patient preference, likelihood of stone-free status, stent requirement, anesthesia risk, and potential need for repeat procedures. Read the AUA surgical stones guideline.
3. AUA Medical Management of Kidney Stones Guideline 2026
   • Current US guide for metabolic work-up, diet, medications, and follow-up in adults and children.
   • Emphasizes evaluation, individualized dietary/pharmacologic prevention, monitoring for recurrence and adverse effects, and the systemic associations of stone disease. See the AUA medical stone guideline.

• Obstructed infected system = emergency: urgent collecting-system drainage plus antibiotics.
• NSAIDs are generally first-line analgesia for renal colic when not contraindicated.
• Consider conservative management only when symptoms are controlled, renal function is safe, and there is no sepsis, solitary-kidney concern, refractory pain, or persistent obstruction.
• For recurrent/high-risk stone formers: obtain stone analysis when available and consider metabolic evaluation including 24-hour urine testing.
• Prevention is tailored to stone type and urinary abnormalities, not simply “drink more water.”

Hematuria

1. AUA/SUFU Microhematuria Guideline, 2020 amended 2025
   • This is the key current US guideline for microscopic hematuria. Read the AUA/SUFU microhematuria guideline.
   • Definition: microhematuria is >3 RBC/high-power field on microscopy from one properly collected urine specimen.
   • Do not use dipstick alone as the diagnosis. Confirm with microscopy.
   • First look for reversible/non-malignant causes: UTI, menstruation or gynecologic bleeding, stones, BPH, recent instrumentation, renal disease. Repeat urinalysis after the cause has resolved.
2. Risk-stratified evaluation
   • Risk is based on age/sex, smoking exposure, degree and persistence of hematuria, prior gross hematuria, and urothelial-cancer risk factors.
   • Additional risk factors include irritative LUTS, prior pelvic radiation, cyclophosphamide/ifosfamide exposure, occupational aromatic-amine/benzene exposure, Lynch syndrome or urothelial-cancer family history, and chronic indwelling urinary foreign body.
   • Low/negligible risk: repeat urinalysis within 6 months rather than immediate cystoscopy or imaging.
   • Persistent hematuria on repeat testing: reclassify and proceed with risk-based work-up.
   • Intermediate risk: generally cystoscopy plus renal ultrasound.
   • High risk: cystoscopy plus axial upper-tract imaging, usually CT urography if appropriate; MR urography is an alternative when CT contrast/radiation is unsuitable.
3. Gross hematuria
   • This is not addressed by the microhematuria risk pathway in the same way.
   • A history of gross hematuria generally warrants complete evaluation with cystoscopy, upper-tract imaging with CT or MR urography, and urine cytology, per the AUA hematuria teaching summary.

One-line ward answers

• “A stone with fever, sepsis, AKI, solitary kidney, or uncontrolled pain needs urgent senior/urology review, and infected obstruction needs drainage.”
• “Microhematuria is >3 RBC/HPF, confirmed on microscopy, then evaluated after excluding transient causes using AUA risk stratification.”
• “Painless gross hematuria is malignancy until proven otherwise: cystoscopy plus upper-tract imaging.”