Postgrad Med J: first published as 10.1136/pgmj.28.316.89 on 1 February 1952. Downloaded from UROLOGICAL EMERGENCIES By JOHN SANDREY, M.B., CH.M., F.R.C.S. Surgeon, St. Peter's Hospital; Consultant Urologist to the Royal Navv With the exception of acute retention of urine, treatment can be indicated in this short review, urological emergencies are not common enough and omissions are inevitable. The conditions found for any medical man, unless he specializes in this in Groups i and 3 are usually the surgeon's type of work, to become at all familiar with them. responsibility, but the role of the family doctor in This seems to be the main reason why so many early diagnosis and in eliminating delay in trans- mistakes are made in diagnosis and treatment. ferring the patient to hospital is perhaps just as From the point of view of treatment urological important. In Group 2 the general practitioner emergencies can be classified under three main will often institute and sometimes complete treat- headings. ment in the patient's home. He should, therefore, i. True surgical emergencies which require be familiar with the management of such cases and immediate operative treatment. These include provide himself with the proper equipment neededProtected by copyright. ruptures of the ureter, bladder or urethra, spon- to deal with them efficiently. taneous perirenal haematoma, genital torsions of Acute retention of urine is a relatively common- various kinds, extravasation of urine, acute pyo- place emergency which can generally be relieved nephrosis, acute paraphimosis and constriction of promptly by catheterization in the patient's home, the penis from any other cause. difficulties only arising as a rule when severe 2. Where a symptom, such as acute retention of obstructions at the bladder neck or in the urethra urine or severe and prolonged renal colic, takes are encountered. As many of the patients in this precedence over the underlying cause. Though not category are elderly and in poor physical condition, surgical emergencies in the strict sense of the word, from the effects of longstanding urinary obstruc- it is, nevertheless, correct to say that their proper tion, infection or intercurrent cardiovascular management from the beginning will play a vital disease, it is most essential that they be given role in the patient's ultimate recovery. Prelimin- efficient treatment from the start. Catheterization, ary measures to afford relief of what is, in the a simple enough procedure in most instances, may http://pmj.bmj.com/ first instance, an urgent and painful condition will under certain circumsta-nces become a harrowing often become part of a planned attack on the experience for both practitioner and patient, and underlying cause later on. In some cases the main the number of admissions to hospital of patients symptom alone is relieved, the underlying cause with clot retention, false passages, urinary in- being dealt with at some future date (e.g. when fections and unnecessary suprapubic cystotomies suprapubic drainage is required to relieve re- bears witness to the difficulties sometimes en- tention of urine due to an impassible urethral countered. stricture). In others both cause and effect can be No practitioner need ever suffer the humiliation on September 24, 2021 by guest. efficiently dealt with simultaneously, as when of being unable to give prompt relief to a patient immediate prostatectomy or continuous dilatation with a painful distended bladder if he carries a of a narrow urethral stricture are carried out in few relatively simple items of equipment in certain cases of acute retention. readiness for this type of emergency. They con- 3. A group of acute conditions which are sist of: usually treated conservatively in the first place or of the Tieman pattern although operative treatment may eventually be One two catheters needed. These conditions include the anurias, (sizes I4 and i6 charriere). the more severe forms of renal haematuria and A fine lumbar puncture needle (Howard Jones' most contusions of the kidney and the external or similar pattern). genitalia. Several filiform bougies. It will be appreciated that only the salient A tapered meatal dilator. clinical features and more important principles of A medium-sized metal bougie for pushing 90 POSTGRADUATE MEDICAL JOURNAL February 1952Postgrad Med J: first published as 10.1136/pgmj.28.316.89 on 1 February 1952. Downloaded from foreign bodies or calculi impacted in the urethra back into the biadder. These can all be sterilized quite simply in the home by boiling in any large dish or saucepan. Tieman's catheter (Fig. i) has many advantages FIG. I.-Tieman's catheter. over the gum-elastic instruments generally em- ployed; it can be readily sterilized by boiling and its upturned, tapered and flexible end enables it times the stricture is of ' wide bore,' the attack of to negotiate a distorted posterior urethra with retention being due to congestion from alcohol, ease, whereas a more rigid gum-elastic instrument cold, etc. In these cases a small Tieman's will often be held up and may readily cause catheter will usually pass with ease. Generally, trauma and false passages if force is used. however, the stricture is contracted and un- If the patient is found to be distressed an in- yielding and, in these, infinite patience and gentle- jection of morphia on arrival at the house will allay ness will be necessary to coax the finest filiform anxiety and enable arrangements to be made for bougie through its narrow lumen. When this is catheterization under proper aseptic conditions. successful urine will pass drop by drop alongside Furthermore a quiet relaxed patient will be more the instrument. After retention has been relieved co-operative than one who is restless and appre- continuous dilatation of the stricture can be carried hensive. Intravenous pethidine (50 to I00 mg.) out by substituting larger and larger instruments. may be a boon when dealing with refractory This type of retention may be complicated by a patients. periurethral abscess or by gangrenous cellulitis of Preliminary questioning may yield valuable in- the perineum. A profound toxaemia, rapidly fatal formation; for instance, the patient may be aware in untreated cases, usually accompanies the more of the fact that he has a stricture or else may admit severe forms of suppuration in this area. Treat-Protected by copyright. to having recently introduced a foreign body along ment, by free incision of the affected subcutaneous the urethra. He may perhaps describe what is tissues, urinary diversion by perineal or suprapubic obviously a recent attack of renal colic, thus cystostomy and chemotherapy, is urgently re- indicating the possibility of a calculus obstructing quired in these cases. the urethra. Suprapubic puncture is an alternative method Examination of the patient will not only confirrn when catheterization fails. It is also sometimes that the bladder is distended but may sometimes employed as a routine procedure, in cases of simple bring other important facts to light, for example a prostatic obstruction in order to avoid the risk of meatal stricture or a perineal abscess, if present, catheter infection, by those who practise the will be obvious on external examination. Wilson Hey technique of 'immediate ' aseptic' Where the cause is not apparent, an attempt prostatectomy in such circumstances. The punc- should be made to pass a Tieman's catheter. If ture is made with a very fine spinal needle im- this is successful the prostate and bladder base mediately above the symphysis pubis and the should be carefully palpated per rectum after the bladder emptied as completely as possible. Inhttp://pmj.bmj.com/ bladder has been completely emptied and before order to prevent leakage of urine from the puncture the catheter is removed. In most cases a smooth into the prevesical space the stylet should be re- bi-lobed enlargement of the prostate gland will be inserted immediately before withdrawal and the readily appreciated, and this type of case should site of puncture firmly compressed for a few be sent to hospital where, if conditions are moments after removal of the needle. The favourable and the patient a ' good risk,' im- dangers of prevesical cellulitis following this mediate prostatectomy is generally regarded as the method are greatly increased when is the urine on September 24, 2021 by guest. best form of treatment. About 20 per cent. of all heavily infected. If this complication is feared, prostatic obstructions, however, are due to malig- arrangements should be made to provide more nant disease. In such cases the gland is found to adequate suprapubic drainage with the least be stony hard, irregular and its borders ill-defined; possible delay. Injuries to the peritoneum or gut the catheter should then be tied in for a week and are rare and are only likely in very obese patients. full doses of stilboestrol (30 to 6o mg. daily) Certain types of retention require sp'ecial administered. The ' boggy ' sensation of a treatment. prostatic abscess may be detected and when such a collection is at all large, adequate drainage from Clot Retention the perineum must be provided. Clot retention, where the outlet of the'bladder When a urethral stricture is present the passage is blocked by blood-clot, may follow urethral of the catheter is obstructed in the bulb, usually trauma or may be spontaneous, the latter being I0 to 12 cm. from the external meatus. Some- due as a rule to a vesical neoplasm. Evacuation of February 1952 SANDREY: Urological Emergencies 9I Postgrad Med J: first published as 10.1136/pgmj.28.316.89 on 1 February 1952. Downloaded from the clot through a large metal catheter by means of and abnormal, with the result that our conception a syringe or Bigelow's evacuator is usually success- of renal failure has had to undergo profound ful, but cystoscopic diathermy to a bleeding modification.