Emergency Urology Hacks - The Practical Field Guide

Sources: Rosen's Emergency Medicine, Roberts & Hedges' Clinical Procedures in Emergency Medicine, Tintinalli's Emergency Medicine, Campbell-Walsh-Wein Urology, Brenner & Rector's The Kidney, Sabiston Textbook of Surgery, Bailey & Love's Surgery

1. TESTICULAR TORSION - The "6-Hour Clock"

The Diagnostic Table (No single finding rules it out)

Hack: Absent cremasteric reflex + high-riding transverse testicle = torsion until proven otherwise. Do NOT wait for ultrasound if clinical suspicion is high - go straight to OR.

Manual Detorsion Technique (Buys Time While Prepping OR)

1. Call urology AND prep for OR simultaneously
2. Give spermatic cord anesthesia (optional): 1% lidocaine without epinephrine, 10 mL into the cord at the external inguinal ring
3. Stand at the patient's right side (right-hand dominant)
4. Rotate the right testicle counter-clockwise (medial to lateral) - rotate 180 degrees first
5. May need 2-3 full rotations - endpoint is pain relief
6. If pain worsens, detorse in the opposite direction (some torse the other way)
7. Confirm with bedside Doppler - return of flow = success
8. Surgical exploration is still mandatory even after successful manual detorsion

Key hack: Even if manual detorsion succeeds clinically, surgical bilateral orchiopexy is still required - the risk of re-torsion is 100% without fixation.

• Rosen's Emergency Medicine, p. 1401
• Roberts & Hedges' Clinical Procedures in Emergency Medicine, p. 1302

2. PRIAPISM - Compartment Syndrome of the Penis

Distinguishing Ischemic vs. Non-Ischemic

Over one third of patients with severe priapism suffer permanent ED despite treatment - act fast.

Step-by-Step ED Management (Ischemic Priapism)

1. Pain control - parenteral opioid or light sedation
2. Trial of terbutaline: 0.25-0.5 mg SC (repeat in 15 min), or 5 mg PO
3. Intracorporal alpha-agonist injection (first-line definitive):
   • Phenylephrine: dilute to 100-500 mcg/mL, inject 1 mL into lateral corpus at 3 or 9 o'clock position using a 23-gauge butterfly needle
   • Repeat every 20 min x 3 doses max
   • Monitor BP - systemic absorption causes hypertension
   • Note: only ONE corpus needs to be accessed (they communicate)
4. If still erect: aspiration - withdraw 20-30 mL of dark blood
5. If still erect: corporal irrigation - normal saline aspirate-irrigate cycle until blood turns bright red (arterial = success)
6. Persistent erection = call urology for Winter shunt or cavernosum-spongiosum shunt
7. After resolution: wrap penis loosely in elastic bandage, 3-day oral alpha-agonist, urgent urology follow-up

Hack: The spongy urethra and glans are SOFT in priapism - only the corpora cavernosa are rigid. This confirms diagnosis. Injection at 3 or 9 o'clock avoids the dorsal neurovascular bundle.

Common causes to ask about: Sickle cell disease (highest recurrence), PDE5 inhibitor overdose, antipsychotics (especially chlorpromazine, trazodone), cocaine

• Roberts & Hedges' Clinical Procedures, p. 1306

3. ACUTE URINARY RETENTION - The Foley Is Your Friend

Common Causes by Category

• Anticholinergics (bladder relaxation)
• Tricyclics, antihistamines
• Alpha-agonists (cold/decongestant tablets, ephedrine)
• NSAIDs, calcium channel blockers (inhibit detrusor)

Hack: Always ask about recent cold/flu medications. Pseudoephedrine is a silent culprit.

ED Management

1. Catheterize immediately - 14-18 Fr Foley catheter
2. If Foley fails (stricture, false passage): try a coude-tip catheter; do NOT force
3. Suprapubic catheter if urethral access impossible
4. Rapid complete decompression is the current recommendation - the old "clamp the catheter every 500 mL" is NOT supported by evidence
5. Urine output > 200 mL/hour after decompression = post-obstructive diuresis - watch electrolytes and replace fluids if sustained
6. Leave catheter 3-7 days before voiding trial - early removal has up to 70% recurrence rate
7. Start tamsulosin 0.4 mg daily at time of catheter insertion (improves TWOC success in BPH patients)
8. Do NOT give prophylactic antibiotics for catheter insertion alone - promotes resistance
9. Check creatinine only if prolonged obstruction or pre-existing renal disease is suspected

• Uncomplicated AUR with BPH + catheter draining well = discharge with catheter and urology follow-up
• Fever, renal impairment, neurologic deficits, failed catheterization = admit

RED FLAG: AUR + saddle anesthesia + bilateral leg weakness = cauda equina syndrome - emergency MRI spine NOW.

• Rosen's Emergency Medicine, pp. 1408-1410

4. RENAL COLIC - Pain Control First, Then Work Up

Pain Management (The Priority)

• NSAIDs are first-line (ketorolac 15-30 mg IV) - as effective as opioids, fewer side effects, less nausea
• Opioids if NSAIDs contraindicated (renal impairment, allergy, anticoagulation)
• Antiemetics (ondansetron or metoclopramide) are often needed
• IV fluids for hydration, antiemetics, and stone passage facilitation
• Forced IV hydration does NOT speed stone passage - do not over-hydrate

Medical Expulsive Therapy (MET)

• Tamsulosin 0.4 mg daily for stones 5-10 mm - reduces ureteral smooth muscle tone and increases spontaneous passage rate
• AUA recommendation: tamsulosin for stones < 10 mm with 4-6 weeks observation
• EAU recommendation: alpha-blockers for stones > 5 mm
• Tamsulosin is superior to nifedipine for MET
• Cochrane review (67 studies, 10,509 participants): alpha-blockers increase clearance AND shorten expulsion time

When to Admit (Cannot Discharge)

• Infection + obstruction = urological emergency (urosepsis in the making) - needs urgent nephrostomy/stent
• Persistent uncontrolled pain
• Intractable vomiting
• Solitary kidney with obstruction
• Stone > 10 mm (< 1% chance of spontaneous passage)
• Bilateral obstruction

Hack: The triad of fever + flank pain + obstructed stone = urosepsis. This needs emergency decompression (nephrostomy tube or ureteral stent) within hours, not days. Antibiotics alone are insufficient.

• Brenner & Rector's The Kidney, p. 1735

5. PARAPHIMOSIS - Reduce It Before It Necroses

Reduction Steps

• Dorsal penile nerve block: inject 1% lidocaine WITHOUT epinephrine at 2 o'clock and 10 o'clock positions at the penile base, just deep to Buck's fascia (3-5 mm depth). Feel a slight "pop" through the fascia. Do not use epinephrine - causes vasoconstriction/ischemia.

• Ice pack for 3-minute increments (avoid cold injury)
• Manual palm compression of glans + foreskin for 5 minutes
• Elastic bandage wrapped from glans to base for 5-7 minutes

• Iced-glove method: Fill a large glove halfway with crushed ice + water, tie the cuff, invaginate the thumb of the glove, draw over the lubricated paraphimotic penis for 5-10 minutes. Cooling + compression reduces edema.
• Babcock clamp technique: 6-8 Babcock clamps evenly spaced on the distal foreskin straddling the phimotic ring; grasp all simultaneously and apply distal traction.
• Dundee technique: Multiple micropunctures in the edematous foreskin with a hypodermic needle, then express edema fluid manually.
• Hyaluronidase injection into the foreskin: hydrolysis of hyaluronic acid increases tissue permeability, dramatically reduces edema for easier reduction.
• Surgical dorsal slit if all else fails - call urology.
• Tintinalli's Emergency Medicine, p. 918
• Roberts & Hedges' Clinical Procedures, p. 1314

6. FOURNIER'S GANGRENE - Never Miss It

Who Gets It

Presentation (Do Not Be Fooled)

• Severe scrotal/perineal pain, often out of proportion to early skin findings
• Scrotal/genital swelling and discoloration
• Crepitus - pathognomonic (subcutaneous gas from anaerobes)
• Foul-smelling discharge
• Early cases may have nearly normal-looking skin - pain + crepitus alone should trigger surgical consult

Hack: CT pelvis/perineum with contrast detects gas in tissue planes BEFORE visible skin necrosis appears. If you suspect Fournier's and skin looks normal, get the CT.

Treatment (No Delays)

1. Broad-spectrum IV antibiotics immediately covering gram-positives, gram-negatives, and anaerobes (e.g., piperacillin-tazobactam + metronidazole, or meropenem)
2. Urgent surgical debridement - aggressive, wide margins
3. ICU-level supportive care
4. Testes and deep penile structures (beneath tunica vaginalis and Buck's fascia) are usually spared and should be preserved
5. Urethral catheter drainage is sufficient initially - suprapubic tube rarely needed acutely
6. Wound care + skin grafting after infection controlled

• Sabiston Textbook of Surgery, p. 2819

Quick Reference: Emergency Urology Red Flags

Clinical bottom line: In emergency urology, the primary mistake is delay. Testicular torsion and Fournier's gangrene both have narrow windows. Priapism causes irreversible impotence after just a few hours. When in doubt, act and call urology simultaneously - not after.