International Journal of Community Medicine and Public Health

Alzahrani FA et al. Int J Community Med Public Health. 2023 Dec;10(12):4972-4976

http://www.ijcmph.com

pISSN 2394-6032 | eISSN 2394-6040

Review Article

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20233515

Approach to diagnosis and treatment to urologic emergencies

Fahad Ahmed Alzahrani1*, Hatim Osama Alhelali2, Khalid Itran Alismail3, Khaled Soud Alraddadi2, Mohammed Saeed Alghamdi4, Khalid Hassan Alzhrani4, Muhammad Abdulrahman Alahmadi5, Bader Abdullah Alzahrani4, Saleh Ali Alshehri6, Nourhan Sulaiman Basyouni7, Jawad Najeeb Almarzooq8

1Department of Urology, East Jeddah Hospital, Jeddah, Saudi Arabia

2Department of Emergency Medicine, Al Madinah General Hospital, Medina, Saudi Arabia

3College of Medicine, Najran University, Najran, Saudi Arabia

4Department of Urology, King Fahad Hospital, Al Baha, Saudi Arabia

5Department of Urology, Al Madinah General Hospital, Medina, Saudi Arabia

6Department of Urology, Armed Forces Hospital Southern Region, Abha, Saudi Arabia

7College of Medicine, Hashemite University, Zarqa, Jordan

8Department of Emergency Medicine, Prince Saud bin Jalawi Hospital, Al Ahsa, Saudi Arabia

Received: 17 October 2023

Accepted: 01 November 2023

*Correspondence:

Dr. Fahad Ahmed Alzahrani,

E-mail: Dr.Fahad.az@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Acute urinary retention, which is an emergency presents a significant challenge, for healthcare providers especially among elderly men. This condition often leads to dysfunction and genital pain causing distress and anxiety for those affected. The likelihood of experiencing acute urinary retention increases with age, with men in their 70s facing a 10% risk that escalates to, over 30% in their 80s. Dealing with both dysfunction and acute pain adds complexity to the clinical management of these cases. This summary highlights the role played by emergency physicians in the management of this troubling urologic emergency. The initial approach involves conducting an evaluation that includes assessing medical history performing physical examinations and conducting relevant diagnostic tests. Promptly identifying the causes, which can range from prostatic hyperplasia and urethral strictures to infections or neurogenic conditions is crucial. Pain relief is an immediate concern, prompting the administration of analgesics to alleviate patient discomfort. Concurrently, urinary catheterization, skillfully performed by the emergency physician, effectively resolves the urinary obstruction, providing substantial relief. Referral to urologists ensures a comprehensive etiological assessment and the formulation of an individualized management plan. In summary, effectively managing retention, with associated erectile dysfunction and genital pain, requires a collaborative effort between emergency physicians and urological specialists. By identifying the cause, providing skilled pain management and expertly performing urinary catheterization emergency physicians play a crucial role in relieving patient discomfort.

Keyword: Diagnostic strategies, Emergency urology, Therapeutic approaches, Urologic, Urologic emergencies

INTRODUCTION

Urologic emergencies are a subset of conditions that are known for their sudden and critical nature. These conditions encompass a range of pathologies that affect the system and nearby structures, posing complex challenges for healthcare professionals worldwide.1 While genitourinary trauma is typically not life-threatening, it can lead to long-term complications. This article outlines indicators (such as difficulty in urinating and visible blood in urine) along with the careful use of imaging techniques to determine the severity of the injury and adopt a safe and rational treatment approach. The acute scrotum often presents an issue for both emergency physicians and urologists. Although it is not congenital abnormalities present at birth or benign lesions causing parental anxiety (like benign scrotal conditions) may prompt a visit to the emergency department for evaluation.2 It's important to conduct investigations and provide management for these urgent cases to address patient and parental concerns adequately. The significance of emergencies cannot be emphasized enough. To maintain waste elimination and fluid balance our internal urinary system plays a pivotal role, making any disruption to its function a matter of grave concern. Situations such as blockage in the tract, the presence of kidney stones, injuries to the genitourinary system, and sudden inability to pass urine can cause complications.3,4 History and physical examination are very much important in order to do clinical diagnosis, whereas different modern imaging techniques is increasingly used for confirmatory diagnoses. It is advised to relived the acute urinary retention with Foley placement. Situation including penile emergencies include paraphimosis, in which foreskin of the penis is reduced, whereas other condition like penile fracture and priapism required major urologic intervention. Some other clinical condition like Fournier gangrene and testicular torsion are also an important urological emergency but they are known as scrotal emergencies which primarily requiring emergent surgery. Although painful, Nephrolithiasis is not an emergency unless there is a concern for concomitant urinary tract infection, stones obstructing both ureters or an obstructing stone in a solitary kidney.5 Understanding the epidemiology and demographics of urologic emergencies is essential for informed healthcare planning. Recent research indicates a change, in the occurrence of these conditions influenced by factors like an getting aged may increase in risk factors such as obesity and metabolic syndromes. The field of emergencies has made advancements in diagnostic methods.6,7 There are several advanced imaging techniques like computed tomography, magnetic resonance imaging, and point of care ultrasound, have easier to get improved results by improving the accuracy and speed of diagnosis. Additionally, the discovery of biomarkers shows promise in enhancing accuracy, enabling healthcare providers to make prompt and well-informed decisions. Treatment approaches for emergencies have evolved to prioritize invasive procedures. Study shows that techniques like nephrostomy, ureteral stenting, and endoscopic procedures may benefit patients by offering them reduced patient discomfort, shorter hospital stays, and faster recovery times.8-10 Moreover, the integration of robotic-assisted surgery and telemedicine has expanded access to care in underserved areas revolutionizing how urologic emergencies are managed.11 Although there have been advancements, urologic emergencies continue to present challenges. Access to care also remains unequal, creating disparities in treatment. Moreover, the increasing antibiotic resistance and the emergence of pathogens in tract infections require constant adaptation of treatment protocols. Exploring how emerging technologies like intelligence and genomic medicine impact accuracy and personalized treatment approaches is essential. Therefore, this study aims to investigate the methods and treatments for urological emergencies.

This study is done based on a search of the different literature that was conducted previously and published in different journals. The web search was conducted on September 24, 2023, in the Medline and PubMed databases. For this study, we searched necessary keywords and a combination of related terms to ensure that we captured all relevant information. The purpose of our search was to gather information about how urologic emergencies, such as retention, renal colic, testicular torsion, priapism, and Fournier gangrene, are diagnosed and treated. We also manually searched through Google Scholar by exploring the reference lists of retrieved papers. Our goal was to find insights into the epidemiology underlying causes of clinical presentation, differential diagnosis methods, investigations conducted for diagnosis purposes, treatment approaches taken by healthcare professionals, and their outcomes when dealing with emergencies. Paper from 2008 and more is added for our study, and only paper which is written in English has been taken. There were no other restrictions on participant age or type of publication.

DISCUSSION

Urinary retention is an emergency condition, in urology that often leads to consultations. As people age the likelihood of experiencing acute urinary retention increases significantly. For instance, research indicates that a man, in his seventies, faces a 10% likelihood of experiencing this condition, whereas a man in his eighties has a 30% chance of being affected. When men with dysfunction also experience genital pain, they understandably seek quick pain relief and resolution. The management of retention alongside erectile dysfunction and genital pain in elderly males is crucially important. It acknowledges the causes of this condition. Recognizes the distress and anxiety it can cause individuals. Prompt action by emergency physicians is essential to alleviate pain, identify the causes, and perform catheterization to relieve obstruction and restore normal urination. Additionally, it highlights the urgency for intervention and subsequent referral to specialists for further treatment options. While some patients may require management by urological consultants, there are cases where emergency physicians can successfully resolve the issue.

Clinical manifestation

Urologic emergencies cover a range of conditions each, with its specific signs and symptoms. It is crucial to understand these presentations in order to make timely diagnoses. Recent studies have shed light on the characteristics and trends associated with emergencies providing a more nuanced understanding of these critical situations. One noticeable trend in the manifestation of emergencies is the impact of changes. As the population ages, there are implications for the prevalence and symptoms of urologic emergencies.12 Older individuals are particularly vulnerable to conditions like tract blockage caused by prostatic hyperplasia (BPH) or kidney stones.13 These patients may experience recurring tract infections, blood in the urine (hematuria) or sudden inability to urinate. There are other types of injury including Posterior urethral injuries that occur within the urethra from the bladder to the perineum, which damages these viscera. These injuries are often caused by trauma, such as car accidents, falls, or crushing incidents.14 It is common for injuries to be accompanied by fractures, affecting 10% to 20% of patients who experience this type of injury. Another potential complication arising from injuries is bladder rupture, which happens when broken bones or substantial impacts tear or puncture the bladder. Signs of injuries may involve the presence of blood at the opening of the penis (meatus) blood, in the urine (hematuria), and bruising or swelling in the perineum or scrotum. These signs suggest damage to the possible leakage of urine into surrounding tissues. Additionally, a noticeable sign of injury is an elevated prostate position, where it shifts upward and deviates from its usual location. This can be detected through an examination or observed using an ultrasound. A high-riding prostate suggests that the urethra has been wholly torn or detached from the bladder. Understanding the connection between aging and urologic emergencies is vital for healthcare professionals. It helps them recognize the importance of screening and personalized interventions for adults. Additionally, the prevalence of lifestyle-related risk factors has changed the landscape of emergencies. Specifically, obesity increases the risk of tract obstruction and complications during procedures. Healthcare providers need to be attentive in evaluating these risk factors during assessments, as addressing them can significantly impact disease prevention and management.15 When it comes to diagnosing emergencies, symptom assessment plays a role. Recent research emphasizes the significance of a history and physical examination. Patients often experience a combination of symptoms, including flank pain, visible or microscopic blood in urine, inability to urinate and fever. These symptoms may also be present in urologic conditions, highlighting the importance of a comprehensive diagnostic approach. Furthermore, there are gender variations, in how these emergencies manifest clinically that have garnered attention. In the field of urology, recent research has shed light on differences in the occurrence of emergency cases between males and females. For example, men are likely to face retention often caused by conditions like BPH or other anatomical factors.16,17 On the other hand, women commonly encounter tract infections and pelvic discomfort. These distinctions based on gender hold significance in terms of diagnosis and treatment because they can help doctors determine which specific tests or interventions would be most suitable for each patient's sex.

Management

The management of cases has advanced significantly in recent years thanks to progress in medical technology, surgical techniques, and a growing focus on minimally invasive procedures. These developments aim to enhance care, improve outcomes, and lessen the impact of urological emergencies on patients and healthcare systems. One notable trend in managing these emergencies is the increasing emphasis on interventions. Procedures like nephrostomy and ureteral stenting have gained recognition for treating tract blockages. They offer benefits such as reduced complications, shorter hospital stays, and faster patient recovery. When kidney stones create an effect on the kidney, extracorporeal shock wave lithotripsy (ESWL) and laser lithotripsy is the best procedures that assist in minimizing the need for surgery and its associated risks.9,18 These minimally invasive approaches have transformed the landscape of urologic emergency management, prioritizing patient comfort and safety. Critical condition like renal bleeding which may be an impact of secondary to accidental or iatrogenic trauma and neoplastic disease requires very extensive take care of the patient as well as expeditious assessment and treatment. Currently conservative, surgical, and radiological approaches are to the management of this challenging problem. Moreover, bladder hemorrhage due to hemorrhagic cystitis, bladder cancer, and infection represents a significant problem in current practice.19 Advances in technology have changed the management options, and again, we have explored the literature in order to determine the optimum treatment approaches. The incorporation of technology in surgery is a significant advancement in treating complex cases like genitourinary trauma. Robotic-assisted surgical systems provide surgeons with improved precision, agility, and visualization capabilities. This technology has made it possible to perform procedures in previously considered difficult or inaccessible situations. For instance, renal and bladder surgeries are now commonly conducted using assistance, offering patients the advantages of incisions, reduced blood loss, and faster recovery times. Antibiotic stewardship plays a role in emergency management, especially when dealing with urinary tract infections (UTIs).20 Given the increasing prevalence of resistance, it has become essential to tailor regimens based on culture and sensitivity testing to minimize complications and enhance patient care. Recent studies found the significance of selecting antibiotics based on microbial susceptibility profiles, which helps to optimize treatment outcomes while minimizing the development of resistance. The field of telemedicine and digital health solutions has revolutionized the way urologic emergencies are managed by introducing approaches to healthcare delivery.21 These technologies have expanded access to care in remote or underserved areas. Telemedicine platforms enable consultations that facilitate interventions while alleviating the strain on emergency departments. Furthermore, digital health tools enable healthcare providers to remotely monitor patients with urologic emergencies remotely, facilitating ongoing care and follow-up. However, it's very essential to address the legal concerns that may arise by using telemedicine. This includes safeguarding patient privacy, obtaining consent, and adhering to standards. The approach to managing emergencies has evolved to focus on care that optimizes patient well-being. In times, there has been a shift toward putting patients at the center of healthcare. This means that healthcare providers not only focus on the aspects of a condition but also take into account the values and preferences of each individual. A key aspect of managing emergencies is to assess the level of risk involved, which helps determine actions to be taken. Different clinicians use tools and indicators to evaluate how serious a condition is and what impact may need to happen on the potential complications. This information then guides decisions about the type and level of care needed. Among all the approaches, using a risk-based approach, resources can be allocated effectively to ensure that patients receive the level of care. Acting promptly is crucial in managing emergencies, with advancements in diagnostic techniques such as non-contrast CT scans aiding in faster identification of these emergencies. Once diagnosed, it is important to administer medical treatment to alleviate symptoms, prevent complications, and improve the patient's quality of life. The management of emergencies extends beyond the phase, emphasizing the significance of follow-up care and rehabilitation.22 Defined follow-up protocols have gained recognition for monitoring complications, addressing postoperative concerns, and offering guidance on lifestyle adjustments to prevent recurrence. Tailored rehabilitation programs play a role in restoring function and overall quality of life. Prevention plays a role in our approach, especially when it comes to conditions influenced by lifestyle factors. Lately, we've been focusing on educating patients about risk factors and early signs so they can be more proactive. Healthcare providers trying to actively promote health by providing necessary guidance and preventive measures, including making dietary changes to prevent kidney stones or adopting a healthier lifestyle to reduce the risk of urinary tract infections. Recently, healthcare systems have also embraced quality improvement efforts where they constantly evaluate their practices compared with the approaches and implement evidence-based guidelines.23 These initiatives aim to ensure care, minimize variations in practice, and ultimately improve patient outcomes. Recent studies have highlighted the impact of these quality improvement initiatives leading to efficient and effective management of urologic emergencies.

CONCLUSION

The management of emergencies has seen advancements focusing on reducing invasiveness, optimizing antibiotic usage, and utilizing telemedicine and digital health tools. It is important to understand that urologic emergencies during sensitive situations require diagnosis and prompt treatment to prevent serious complications and improve patient outcomes. Over time, the management of these emergencies has evolved with advancements evidence evidence-based practices and improved knowledge. This includes the use of procedures, robotic-assisted surgeries, and tailored antibiotic treatments as part of emergency care. However, it is crucial for healthcare professionals to adapt evidence-based strategies to each urologic emergency while prioritizing patient well-being and efficient healthcare delivery. There are a lot of technology which is evolving and still continues to grow and becoming advance our understanding will go deeper, and it becomes increasingly important to consider approaches that are relevant to the characteristics of each urologic emergency.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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