Urologic Surgery and Trauma

Primary emergency considerations in urology from the critical care perspective include hemorrhagic, obstructive, infectious, and ischemic processes, in addition to a wide variety of general postoperative difficulties that may warrant emergent intervention. Oncologic emergencies also arise in urology and may require urgent critical care management. Urologic trauma (addressed in a separate section, below) encompasses a wide variety of injuries that may vary from life threatening issues to those impacting functional outcomes. Gross hematuria is an alarming symptom to the patient and the medical practitioner, and may mandate immediate critical care intervention depending on the magnitude of the hematuria and details of the individual case (1). Patients presenting with gross hematuria to the emergency center may have a defined cause (e.g., known radiation cystitis, recurrent benign prostatic hypertrophy [BPH]-related bleeding) or may be reporting a new sign not previously evaluated. Immediate urologic intervention is necessary if the patient has clot retention (unable to void or empty adequately due to the presence of clots in the bladder), is bleeding severely (which may be difficult to judge), has significant pain, is infected, has coagulopathy, or has other underlying medical factors with increased risk of further complications. Vital sign measurement, physical examination, and basic laboratory studies including complete blood count (CBC), coagulation functions, electrolyte and renal function testing, urinalysis, and culture will often answer the above questions and determine the need for immediate intervention. Palpation and percussion of the bladder may reveal bladder distention with or without tenderness. Bladder ultrasound units (BladderScan) or other readily available ultrasound instruments may rapidly answer the question of whether the bladder is distended. In the setting of gross hematuria and a distended bladder, a catheter must be inserted. Often too small a catheter is placed, which does not allow adequate irrigation of clots; clots must be fully evacuated to allow proper catheter drainage as well as to determine the degree of bleeding and continuation of bleeding. Small clots may be evacuated via an 18 to 20 French catheter; large clots require a bigger catheter (22–24 French) for satisfactory evaluation. The catheter should be irrigated to and fro with a piston syringe using 60 to 120 mL of normal saline. When no more clots can be retrieved, the irrigation efflux should become clear if bleeding is not ongoing. If the efflux remains bloody despite complete clot evacuation or if new clots continue to form, there is ongoing bleeding and input from the urologist is needed. One can change the patient to a three-way catheter in the setting of continuing bleeding in order to keep the catheter patent, but this decision is best made along with urologic consultation. There are risks involved in the implementation of continuous bladder irrigation, including bladder rupture if the outflow lumen becomes occluded without recognition and the inflow of irrigant continues. It is preferable to diagnose early with definitive intervention as cystoscopic examination and fulguration may solve the problem with less morbidity and less blood replacement than more conservative approaches. Gross hematuria in the urologic postoperative setting will be addressed in more detail below. Other hemorrhagic urologic problems requiring immediate critical care intervention include renal or perirenal bleeding (e.g., spontaneous hematoma in the anticoagulated patient or the renal tumor patient) or scrotal hematoma. Bleeding in these sites is often trauma related (see below). Urosepsis is another concern. Sepsis of the urinary tract or urogenital origin may present in a most precipitous and potentially life-threatening manner, or may be indolent (2). It is essential to understand the importance of the combination of infection and obstruction in producing a dangerous septic state. A common scenario is the patient presenting with an obstructing ureteral calculus. Typical symptoms of ureteral colic include flank pain (often radiating to the lower quadrant, and ipsilaterally to the genitalia with distal stones), irritative voiding symptoms (when the stone is distal in the intramural ureter), nausea, vomiting, or distention (due to ileus). These symptoms can be extremely distressing and require urgent medical attention, but the most critical emergency seen in such a setting occurs when these symptoms are accompanied by infection and sepsis. The combination of infection and obstruction of the urinary tract (upper or lower) is a veritable surgical emergency requiring immediate action. Septic shock may unfold rapidly in such situations with a significant mortality rate, even in the otherwise healthy host. We teach our residents that the sun should never set on an undrained, infected obstructed urinary tract. Other infectious states requiring urgent critical care intervention include renal or perirenal abscess, scrotal abscess, acute epididymo-orchitis, and Fournier gangrene (see below). Obstruction of the urinary tract and urinary retention may require critical care intervention independent of the presence or absence of hematuria or infection. Upper or lower tract obstruction can result in acute or chronic renal failure, mandating prompt drainage to control metabolic instability. Acute urinary retention with bladder distention is a miserable experience for the patient, and must be promptly relieved by introduction of a catheter into the bladder, preferably by a transurethral route, or alternatively by a suprapubic route if the urethra is impassable.