UROLOGICAL EMERGENCIES by JOHN SANDREY, M.B., CH.M., F.R.C.S

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 employed; 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. Many of the loose descriptive terms bladder growth or suprapubic cystostomy may be formerly applied to these conditions, such as necessary to control severe haemorrhage. ' uraemia,' ' pre- or post-renal anuria,' have had to be abandoned and a more workable classifica- In Women tion, based on the part of the nephron most In women, retention of urine is commonly due affected, is now being universally adopted. to urethral stricture, neoplasms infiltrating or pro- Changes taking place in the nephron are found to lapsing through the internal urinary meatus, be concentrated at three levels; the glomerular foreign bodies or sometimes hysteria. Uterine en- arterioles, the proximal renal tubules and the digtal largements such as fibroids or retroverted gravid renal tubules: uteri are, in the experience -of the writer, very i. Firstly, cortical ischaemia from vasospasm seldom the cause of acute retention of urine. may be observed when the blood pressure is Urethral stricture is a disease by no means con- greatly lowered, as in shock or cardiac failure, fined to the male sex and is often observed in when the blood volume is diminished by haemor- women after urethral trauma or infection. The rhage, as the result of nervous stimuli (' reflex condition is usually easy to treat by dilatation. anuria ') and possibly from toxaemia. Here the kidney itself is not necessarily diseased. Non-Obstructive Retention 2. In the second group the brunt of the damage Non-obstructive retention may follow pelvic is observed to fall on the proximal tubules (' upper operations or confinements (' reflex retention ') or nephron nephrosis') with marked impairment of is observed in association with various neuro- their function. Degenerative changes at this level psychiatric disorders such as hysteria, arterio- are observed in cases of renal toxaemia, eclampsia Protected by copyright. sclerosis, schizophrenia, etc. (' inhibitory re- and poisoning by heavy metals. tention '). The former state is painful, the latter 3. In this group the distal tubules are chiefly is not. These conditions usually respond to para- affected (' lower nephron nephrosis ') and the main sympathetic stimulants, and rarely require factor is obstructive. This obstruction occurs catheterization. either in the distal tubules, by casts, heme pigment or acetyl sulphonamide, or in the collecting tubules Anuria which are dilated by back pressure from an ob- Anuria can readily be distinguished from acute struction at a lower level such as a ureteric retention of urine by catheterization and finding an calculus, bladder neck obstruction, etc. empty bladder. Failure to take this elementary Cases of anuria should be investigated very precaution at the earliest possible moment in fully in order to classify them correctly at the comatose or semi-comatose patients has often been earliest possible moment. This is by no means responsible for avoidable delay in instituting treat- easy since the groups may overlap; for instance, ment. Early recognition of the anuric state is of sulphonamide anuria is often partly obstructive http://pmj.bmj.com/ the utmost importance. Any patient who, after a and partly toxic. In cases in the first and third severe operation, haemorrhage', abortion or crush groups the changes are often reversible and many injury, passes less than 500 cc. of urine in 24 hours recover with correct treatment. On the other must be kept under the closest scrutiny. hand permanent damage to the epithelium of the A wide variety of conditions, many of them proximal tubules from longstanding renal disease primarily non-renal, can give rise to oliguria or is likely in the second group and in these anuria is a

anuria. Among them may be mentioned the crush terminal event. on September 24, 2021 by guest. syndrome, 'transfusion kidney,' various anuric syndromes associated with pregnancy and abortion, Management sulphonamide anuria, poisoning with heavy metals, The management of all cases of anuria, unless anuria following shock, haemorrhage or haemolysis. the condition is obviously a terminal event, must The bedside of the anuric patient is, in fact, now be based on the assumption that the renal damage the meeting place of nearly every type of specialist, is reversible. The objects of treat-ment are to all interested in different aspects of a many-sided maintain normal water balance, electrolyte, blood problem. pressure, blood volume and haemoglobin levels, During the past decade the important observa- acid-base equilibrium and general nutrition. tions of Bywaters and other British workers on the Attempts have also been made to remove excess of crush syndrome and of Trueta and his associates certain products of metabolism by means of on renal vascular ' shunts' have stimulated peritoneal dialysis or the artificial kidney with immense interest in renal physiology, both normal varying degrees of success. A high calorie, 92 POSTGRADUATE MEDICAL JOURNAL February i 95zPostgrad Med J: first published as 10.1136/pgmj.28.316.89 on 1 February 1952. Downloaded from protein-free diet, as recommended by Bull, evidence to support the view that this action can Joekes and Lowe (I949), is administered by con- be prolonged indefinitely by hormonal influences. tinuous drip through an indwelling gastric tube, Diminution or complete cessation of renal function any vomitus being filtered and returned to the is a common phenomenon after an attack of renal stomach. The daily requirements of the average colic and may last for several days. It must, patient are satisfied by the following formula: therefore, be taken into account in the interpreta- tlon of intravenous pyelograms. Glucose 400 grammes Peanut oil 10I grammes In some cases a normal kidney may be inhibited Acacia, q.s. to emulsify by an obstruction of the opposite side (' crossed' Water to I 1. (Vitamins can be added if required.) reflex anuria), Treatment is directed to removal of the cause, such as an obstruction in the ureter Surgical measures include catheterization of or a drainage tube pressing on the renal pedicle obstructed ureters and lavage of the renal pelvis after a renal operation. Attempts to interrupt the to remove accumulations of gravel, sulphonamide reflex- arc by spinal or paravertebral anaesthesia crystals or inspissated pus. Removal of calculi or where the exciting cause is not obvious have been drainage of an obstructed renal pelvis by made in cases of post-operative anuria and in the nephrostomy or pyelostomy may be necessary crush syndrome, but the results have not been when ureteric catheterization is unsuccessful in uniformly successful. restoring urinary secretion. Spinal and paravertebral anaesthesia to relieve glomerula vaso- Anuria Following Urethral Instrumentation spasm and renal decapsulation to reduce tension in Anuria may follow urethral instrumentation, upper nephron nephrosis have their advocates but especially after severe urethral trauma in the are probably of limited value. presence of an infected urine. The rapid absorp-

Apart from the types of anuria already men- tion of bacteria from the raw surface will give riseProtected by copyright. tioned there are certain well-recognized con- to septicaemia, the kidneys already damaged by ditions which are fairly common in the practice of the effects of longstanding urinary obstruction urology. bearing the brunt of the resulting systemic infection. Prevention, apart from chemotherapy, con- Calculous Anuria sists in gentleness when dilating urethral strictures, Calculous anuria is usually due to a small move- especially when infection and signs of renal damage able stone which has become impacted on its way are present. Other reminders of the absorptive down the ureter. It is often associated with a mass powers of the urethra are provided by reports from of gravel, blood clot or inspissated puis which time to time of cases of mercurial poisoning from forms a plug making a partial obstruction com- the use of mercurial solutions for bladder wash- plete. The stone itself may be small in size and outs or cystoscopy (Page and Wilson, I941), and as barely discernable in a radiogram. Complete the renal epithelium is always extensively damaged anuria will result when the blockage is bilateral or by the absorption of heavy metals, anuria' tends to

when the opposite kidney is functionless because be a prominent clinical feature. http://pmj.bmj.com/ of disease, congenital absence or reflex inhibition. Instances where anuria followed ureteric The onset is often insidious but generally follows catheterization have also been reported. Here the repeated attacks of renal colic, the site of the pain mechanism appears to have been chiefly the effect indicating the side last obstructed. A complete of reactionary oedema causing blockage of the urinary investigation is likely to reveal the cause ureter in association with absence of function or and site of the obstruction, which must be re- possibly reflex inhibition of the other side. Lastly, lieved forthwith, either by ureteric catheterization, after per-urethral resection of the prostate, anuria nephrostomy or ureterolithotomy. may develop from laking of the blood by hypo- on September 24, 2021 by guest. tonic lotion used for irrigation, intravascular Reflex Anuria haemolysis giving rise to lower nephron nephrosis Reflex anuria is essentially a protective mechan- as in the ' transfusion kidney.' ism whereby, under certain circumstances, renal secretion is inhibited. It occurs particularly when Injuries to the Genito-Urinary Organs a ureter is blocked, but may be reproduced ex- These give rise to an interesting and varied perimentally by various stimuli of widely different group of lesions which includes open wounds, sub- kinds. It is brought about, in the first instance, cutaneous injuries (contusions of the kidney and by a local nervous reflex resulting in cortical testicle, ruptures of the ureter, bladder and ischaemia of the kidney from vasospasm and de- urethra), surgical accidents (damage to the ureter viation of the blood flow through the kidney by or bladder during pelvic operations, perforations of means of the 'shunt' mechanism. There is the ureter, bladder or urethra by instruments of February T 95 2 SANDREY: Urological Emergencies 931Postgrad Med J: first published as 10.1136/pgmj.28.316.89 on 1 February 1952. Downloaded from various kind used for diagnosis or treatment). may accidentally clamp or divide it when dealing These are mostly serious injuries often complicated with large or adherent pelvic tumours or when re- by involvement of important neighbouring struc- secting the pelvic colon, or may perforate it from tures. They will present many diagnostic prob- within by means of ureteric catheters, by over- lems and as many of the cases will require opera- vigorous dilatation of a ureteral stricture or by tive treatment their management can only be forcible attempts to extract calculi with wire properly carried out in hospital. The mechanism, ' baskets' or similar instruments. Treatment con- the resulting lesion and the processes of repair will sists of immediate end-to-end suture of a severed vary greatly at different levels in the urogenital ureter if the injury is recognized at the time. tract. Where some time has elapsed it is sometimes possible to anastomose the damaged ureter to the Kidney bladder or bowel, although in most cases, especially The kidney is usually injured by a force applied where a urinary fistula has developed, the results to its anterior surface through the soft tissues of of conservative operations are unsatisfactory. the anterior abdominal wall which crushes it When the kidney of the opposite side is sound, against the unyielding structures posteriorly. The nephrectomy is usually the best form of treatment. injury is often trivial, the direction rather than the severity of the force determining the resulting renal Bladder lesion. This is almost invariably a deep fissure of The bladder may be ruptured from without by the parenchyma radiating out from the hilum and missiles, kicks or blows or by violent lateral com- involving the softer medulla more extensively than pression in association with injuries of the pelvic the firmer cortex. This gives rise to intrapelvic girdle. It may also be accidentally incised by the haemorrhage manifested by haematuria or, less surgeon in performing any pelvic operation, commonly, to perirenal haemorrhage with the especially when the pre-operative precaution ofProtected by copyright. formation of a haematoma around the kidney. emptying the bladder by means of a catheter has Haemorrhage will cease spontaneously and spon- been omitted. Intravesical surgical manipulations taneous cure with a variable amount of scarring at of any kind, rough instrumentation, over-disten- the site of the lesion will take place in approxi- sion, excessive diathermy, etc., may perforate or mately 90 per cent. of these injuries. In the re- actually burst the bladder from within. Spon- maining io per cent. operative interference will be taneous rupture of the over-distended bladder can necessary, either to control severe haemorrhage or readily occur when its wall has been weakened by to deal with associated intraperitoneal lesions such disease, especially ulceration of any kind, although as ruptured spleen, liver or gut. in some of the cases reported (Beresford-Jones, Treatment is, therefore, in the first place, al- 194I, and others) the wall of the viscus was ap- ways expectant, but in view of the possibility that parently normal before rupture. The diagnosis of nephrectomy may have to be urgently undertaken, ruptured bladder is notoriously difficult chiefly it is essential to establish the presence of a sound because typical symptoms and signs are late in kidney on the opposite side, either by intravenous appearing and are often effectively masked in the http://pmj.bmj.com/ or retrograde pyelography, at the earliest possible earlier stages by shock and associated injuries. moment. This becomes a matter of great practical Cystoscopy and cystography are valuable aids to importance when it is remembered that an en- diagnosis, but whenever there is any doubt ex- larged kidney is more vulnerable to trauma than a ploration of the bladder should be undertaken as normal one, and that a common cause of renal soon as conditions permit. Suture of the rent and enlargement is compensatory hypertrophy due to adequate drainage, not only of the bladder but

disease or congenital absence on the opposite side. also of the paravesical tissues, are the main on September 24, 2021 by guest. All patients treated conservatively should be kept principl 's of treatment. in hospital at least three weeks as repair of renal parenchyma is a slow process and the danger of Urethra secondary haemorrhage is not past until the end of The urethra may be ruptured completely or that time. It is always advisable to make certain partially, the latter type of injury being due as a by means of intravenous pyelography that renal rule to the surgeon causing ' false passages' by function has returned to normal and that there is burrowing with the point of an instrument either no obstruction to the renal pelvis by scarring before in the spongy tissue of the bulb or in the sub- returning the patient to work. mucosa of the prostatic urethra. Such injuries may cause severe haemorrhage, clot retention, Ureter infection (periurethral suppuration) or extravasa- The ureter, owing to its deep position in the tion of urine. body, is rarely injured except by the surgeon. He Complete ruptures are found at two classica I 94 POSTGRADUATE MEDICAL JOURNAL February 1952 Postgrad Med J: first published as 10.1136/pgmj.28.316.89 on 1 February 1952. Downloaded from sites, eitherjust below the triangular ligament where contusion of the testicle may be caused by kicks, they are caused by falls astride or other injunres to crushes *or missiles; the careless tapping of a the perineum, or immediately above the triangular hydrocoele may produce the same result. The ligament in,association with fractures of the pelvic resulting haematoma when not too large will sub- girdle. At either site there is wide separation of side rapidly with rest elevation, cold applications, the torn ends and reconstructive surgery at the etc. More severe injuries will often rupture the earliest possible moment is essential in order to testis and produce a large haematoma within the secure union without excessive scar formation. tunica vaginalis (haematocoele). Operative treat- The distal type of rupture is best dealt with by ment is indicated in the latter type of injury with end-to-end suture from the perineum, the proximal the object of turning out the clot and suturing the by retrograde catheterization and weight extension. rent in the visceral layer of the tunica in order to Urinary diversion by suprapubic cystostomy is prevent subsequent atrophy of the testis. necessary in both cases while healing is taking Contusions of the penis usually affect the erect place. organ (e.g. ' faux pas de coit '), and may result in dislocation, fracture or haematoma within the Male Genitalia sheath of the corpus cavernosum. When the The male genitalia, owing to their exposed latter type of injury is severe removal of the clot position, are very vulnerable. Typical lesions are and suture of the sheath may be indicated. the result of contusions, open wounds or avulsion Avulsion of the genitalia may occur in factories injuries. Because of the great vascularity of the when the patient's clothes are caught up in rotating parts, genital wounds bleed profusely. In ad- belts. dition, nervous shock is often a striking phenomenon in these cases, so that the patient is Paraphimosis frequently found in a profound state of collapse Protected by copyright. out of all proportion to the severity of the local Paraphimosis is treated by manual reduction or lesion. incision of the constriction with subsequent cir- Treatment should in the first place be confined cumcision to enlarge the preputial opening after to the control of haemorrhage, the relief of tension the oedema has subsided. Strangulation by rubber by evacuation of retained blood clot and the pro- bands or metal rings applied to the flaccid organ vision of free drainage. No tissue should be cut by sexual perverts or to control enuresis will often away unless it is frankly non-viable. Healing is cause gangrene before the constricting agent can rapid and much can be done to remedy defects be removed and subsequent skin grafting may be subsequently by plastic surgery. The familiar necessary. http://pmj.bmj.com/ on September 24, 2021 by guest. 1%

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FIG. 2.-Longstanding torsion of spermatic cord; note secondary hydrocele and atrophy of testis February 1952 SANDREY: Urological Emergencies 95 Postgrad Med J: first published as 10.1136/pgmj.28.316.89 on 1 February 1952. Downloaded from Genital Torsions Spontaneous Perirenal Haematoma Genital torsions are commoner than is generally Spontaneous perirenal haematoma is a con supposed and may affect the spermatic cord, the dition which always arouses great clinical interest- testis or the stalked hydatid of Morgagni. Twists because of its dramatic features. Spontaneous of the spermatic cord are apt to occur during late bleeding may take place into the perirenal or sub- adolescence and are perhaps the commonest cause capsular spaces as a result of renal or adrenal of testicular atrophy (Fig. 2). The aetiology is disease, diseases of the renal blood vessels or blood unknown, but excessive mobility of the testicle dyscrazias. No determining cause can be found in within the scrotum undoubtedly plays an im- about 25 per cent. of the cases but trauma must, portant part. The onset is generally characteristic, of course, be carefully excluded before any case of with sudden pain and moderate swelling associated renal haemorrhage is classified under this heading. with mild fever. In spite of the fact that the The onset is usually abrupt with severe abdominal entire testicle is enlarged the condition is often and lumbar pain, together with increasing symp- mistaken for epididymitis and treated as such, and toms and signs of internal haemorrhage. The when bilateral involvement occurs this may have differential diagnosis from other forms of ab- serious consequences, leading not only to.sterility dominal emergency is not easy. The mortality is but to eunuchodism. As degenerative changes in high because of the frequent delay in recognizing the testicular epithelium will commence within a. the condition. Treatment usually takes the form few hours of torsion it is imperative that explora- of rapid nephrectomy although bleeding can tion be undertaken immediately, hence the sometimes be controlled by more conservative supreme importance of early diagnosis. Operative measures such as packing, ligature or suture. treatment consists of untwisting the torsion, Severe Renal Haematuria everting the tunica and stitching the edges to the Severe renal haematuria may be caused byProtected by copyright. back of the scrotum to prevent further attacks. As tumours of the kidney or renal pelvis, hypertensive the condition is frequently bilateral it is usual to granular red kidney or renal purpura (essential fix both testicles through a midline scrotal-splitting renal haematuria). Where bleeding from any of incision. these conditions is severe enough to threaten the Torsion of the testis alone may occur when the patient's life, nephrectomy may become a matter mesorchium is long; This may take place within of extreme urgency and the objects of an in- the tunica when the testis is in the scrotum, but is vestigation of such cases should be not only to more often found in association with imperfect reveal the site and the cause of the bleeding but descent. Torsion of an intra-abdominal testis has also the state of the kidney on the opposite side. been mistaken for an acute abdomen, and nearly 50 per cent. of such organs are the site of tumour Acute Pyonephrosis formation. Torsion of the hydatid of Morgagni, An acute pyonephrosis arises when a ful- though not serious in itself, is often followed by minating infection with pyogenic bacteria takes testicular pain of a persistent character (' testicu- place in an obstructed renal pelvis. If this con- http://pmj.bmj.com/ lar neuralgia') which is not always relieved by dition is not promptly relieved by drainage or removal of the subsequent cyst or even by or- nephrectomy there is always a very real danger of chidectomy. a senous and often fatal septicaemia.

BIBLIOGRAPHY BERESFORD-JONES, A. B. (194I), Brit. Y. Siurg., 24, 154. PAGE, B. H., and WILSON, C. (I940), Latncet, i, 640. BULL, G. M., JOEKES, A. M., and LOWE, K. G. (I949), Lantcet, TRUETA, J., BARCLAY, A. E., DANIEL, P. M., FRANKLIN, on September 24, 2021 by guest. ii, 229. K. J., and PRICHARD, M. M. L. (I947), 'Studies of the BYWATERS, E. G. L., and BEALI, D. (I941), Brit. med.Y., i, 427. Renal Circulation,' Blackwell Scientific Publications, Oxford.