Chapter 2 — Urologic Emergencies — Urology Guide for APPs

These are the diagnoses you cannot afford to miss. For each, the goal is rapid recognition, the correct immediate action, and knowing when to get the attending or the OR involved. When suspicion is high for a time-critical diagnosis (ischemic priapism, obstructed infected stone, Fournier's), act first — do not let a test delay definitive care. Torsion is the exception we handle differently: we always confirm with a scrotal ultrasound, obtained in parallel with mobilizing the OR so it costs no time (Section 2.1).

Emergency OR access at New Jersey Urology

New Jersey Urology uses its ambulatory surgery center for appropriate stable same-day cases and affiliated hospitals for emergencies requiring admission or ICU-level care.
An ambulatory surgery center is a same-day-discharge facility. A septic patient with an obstructed, infected stone needs emergent decompression plus inpatient sepsis care and goes to an affiliated hospital with urologic coverage, not an ASC.
When a patient needs an urgent procedure, call the urologist immediately so the patient is directed to the correct office, surgery center, or hospital without delay.

Time-critical emergencies at a glance

Testicular torsion: salvage falls sharply after 6 hours — confirm with Doppler US in parallel with mobilizing the OR.
Ischemic priapism > 4 hours: corporal aspiration + phenylephrine at the bedside; a compartment syndrome of the penis.
Obstructed, infected upper tract (stone + fever): emergent decompression (stent or nephrostomy) + antibiotics. Pus under pressure.
Fournier's gangrene: immediate broad-spectrum antibiotics + emergent surgical debridement.
Cauda equina / cord compression: neurosurgical emergency; retention may be the presenting sign.
Obstructing stone in a solitary kidney or with AKI: decompress.

2.1 Testicular Torsion

Torsion is twisting of the spermatic cord, strangling the testicular blood supply. The underlying anatomic predisposition is the “bell-clapper” deformity — a high investment of tunica vaginalis that leaves the testis free to rotate within the scrotum. It is a clock-driven diagnosis: the testis is a solid organ suffering ischemia, and every hour matters.

Who and how — classically an adolescent or young adult with sudden, severe unilateral scrotal pain, often with nausea and vomiting. There is a bimodal age distribution (neonates and peripubertal boys), but it can occur at any age — never dismiss it because the patient is 40. It may follow activity or minor trauma, or wake the patient from sleep.

Exam — high-riding testicle, transverse (horizontal) lie, absent cremasteric reflex (the most useful single sign — its presence makes torsion much less likely, though not impossible), diffuse tenderness, and a swollen, often erythematous hemiscrotum. A negative Prehn's sign (no relief with elevation) is suggestive but unreliable. Compare with the contralateral side.

Work-up — we always get the ultrasound — at New Jersey Urology we obtain a color Doppler scrotal ultrasound in every suspected torsion, because we must confirm the diagnosis and, in our system, the scan does not delay care. Escalate to the on-call urologist and mobilize the OR in parallel with the ultrasound — imaging and OR preparation happen at the same time, never in sequence. Look for decreased or absent intratesticular flow, a heterogeneous/hypoechoic testis (a late, ominous sign of infarction), and the “whirlpool sign” of the twisted cord. Note that a normal-appearing scan does not fully exclude intermittent torsion: if the clinical picture is convincing, explore.

Management — emergent surgical exploration through a scrotal incision with detorsion and, if viable, bilateral orchiopexy (the bell-clapper deformity is usually bilateral, so the contralateral testis must be fixed too). A non-viable testis is removed. Manual detorsion (“open-book,” typically medial-to-lateral, like opening a book) can be attempted as a temporizing bridge to the OR — success is signaled by immediate pain relief and the testis dropping into a lower, normal lie. Manual detorsion is never a substitute for surgical fixation.

Duration of torsion	Approximate salvage rate
< 6 hours	Near 100%
6–12 hours	~ 70%
12–24 hours	~ 20%
> 24 hours	< 10%

Torsion pearls

Always confirm with a scrotal ultrasound — we do not take a patient to the OR without it — but obtain it in parallel with mobilizing the OR so nothing is delayed.
The 6-hour window drives everything: near-100% salvage < 6 h, dropping substantially by 12–24 h.
A negative/normal ultrasound does not override a convincing clinical picture — intermittent torsion can have normal flow. Clinical judgment still wins.
Torsion of a testicular/epididymal appendage (“blue dot sign,” focal upper-pole tenderness, normal flow) is a benign mimic — but do not assume it without excluding true torsion.
Document the time of pain onset precisely; it is medico-legally and clinically pivotal.
Neonatal torsion is usually extravaginal and prenatal; a hard, fixed, discolored scrotum in a newborn warrants urgent evaluation.

2.2 Priapism

Priapism is a persistent erection (> 4 hours) unrelated to sexual stimulation. Distinguish the two types immediately, because management is opposite. Ischemic (low-flow) priapism is a compartment syndrome of the corpora cavernosa: blood stagnates, becomes hypoxic and acidotic, smooth muscle becomes ischemic, and after ~24–48 hours irreversible corporal fibrosis and permanent erectile dysfunction follow.

Know the real causes — it is almost never the PDE5 inhibitor Despite the reputation, oral PDE5 inhibitors (sildenafil, tadalafil) are a very rare cause of true ischemic priapism. Do not anchor on the Viagra/Cialis history. The actual culprits, in practice: intracavernosal injection therapy (Trimix) is the leading cause we see, followed by sickle cell disease and cocaine/illicit stimulant use. So the history that matters is: injection therapy (what, how much, when), sickle cell/hemoglobinopathy, and drug use — ask about these explicitly and early. Other causes to keep in mind: leukemia and other hematologic malignancy, certain psychotropics (trazodone, chlorpromazine), and perineal/genital trauma (which causes the non-ischemic type).
Feature	Ischemic (low-flow) — EMERGENCY	Non-ischemic (high-flow)
Pain	Painful, rigid	Usually painless, not fully rigid
Mechanism	Veno-occlusive; compartment syndrome	Arterial fistula, usually after blunt perineal/straddle trauma
Onset	Often abrupt; after injection therapy	Often delayed days after trauma
Cavernosal blood gas	Hypoxic, acidotic, dark blood (pO2 < 30, pCO2 > 60, pH < 7.25)	Well-oxygenated, bright red (arterial values)
Action	Aspirate + phenylephrine at bedside; emergent	Not emergent; observe / selective arterial embolization

Ischemic priapism — bedside management, step by step

Have the patient come to the office immediately if it is open; if the office is closed, send the patient to the ER. This is a procedure you can and should do in the office or at the bedside in the ER. It does not require the OR. Take a targeted history first (Trimix/injection use, sickle cell disease, cocaine) and screen for a hemoglobinopathy when the cause is not obvious.

Put the patient on a cardiac monitor — you will be giving intracavernosal phenylephrine, so continuous heart-rate and blood-pressure monitoring is mandatory.
Treat the pain: hydromorphone (Dilaudid) 1 mg IV is our standard.
Perform a penile block — we use a combination of lidocaine and bupivacaine (Marcaine) for immediate onset plus lasting anesthesia. Do the block before you stick the corpora; the procedure is otherwise very painful.
Aspirate and irrigate at the bedside: insert a 16-gauge angiocath into the corpus cavernosum (lateral, at roughly the 3 or 9 o'clock position), aspirate the dark, sludgy blood to decompress, and irrigate with saline until the aspirate returns bright red. Because the corpora communicate, a single side is usually sufficient.
Inject dilute intracavernosal phenylephrine (e.g., 100–500 mcg) every 3–5 minutes, alternating with aspiration/irrigation, until detumescence. Watch the monitor — hypertension, reflex bradycardia, and headache are the expected adverse effects.
Send a cavernosal blood gas if the diagnosis is at all in doubt (dark, hypoxic, acidotic confirms ischemic).
If bedside aspiration/irrigation plus phenylephrine fails, escalate for a surgical shunt (distal shunt first — e.g., Winter/Ebbehoj/Al-Ghorab — before proximal).

Priapism pearls

Any ischemic priapism > 4 hours is an emergency — irreversible corporal fibrosis and ED risk rise with duration. Beyond ~36–48 hours, counsel honestly that the goal shifts toward pain relief and future prosthesis candidacy.
Priapism comes to the office immediately when it is open; if the office is closed, send the patient to the ER. Treat it in the office or at the bedside — monitor, Dilaudid, penile block, 16-G angiocath aspiration/irrigation, phenylephrine. Do not default to the OR.
Phenylephrine is the intracavernosal agent of choice due to near-pure alpha-1 activity; monitor BP/HR throughout. Avoid in patients with severe uncontrolled cardiovascular disease without careful monitoring.
Because Trimix is the most common cause we see, every patient started on injection therapy must be counseled up front: an erection lasting > 4 hours means come in immediately.
Stuttering priapism (recurrent, self-limited) — common in sickle cell — warrants follow-up and a prevention plan.
In sickle cell patients, treat the priapism directly; hydration, oxygen, and transfusion are supportive but must NOT delay aspiration and phenylephrine.

2.3 Fournier's Gangrene

Fournier's is a necrotizing soft-tissue infection of the perineum, scrotum, and abdominal wall — typically polymicrobial (aerobes + anaerobes) with synergistic gangrene that dissects rapidly along fascial planes. Mortality is substantial and driven almost entirely by delay to debridement.

Recognize — pain out of proportion to the visible exam is the earliest and most important clue. Look for crepitus, dusky or necrotic skin, bullae, a foul “dishwater” odor, and systemic toxicity (fever, tachycardia, hypotension, confusion). Skin findings lag the underlying fascial necrosis — the disease is always worse than it looks. In practice a CT has often already been obtained by the time you are called, and it will usually show gas tracking in the subcutaneous tissue and along the fascial planes.

Do not let normal labs reassure you — the white count may be normal or even low in a septic, immunosuppressed, or diabetic patient. Labs do not grade the acuity of this disease — the exam and your suspicion do.

Risk factors — diabetes (the dominant one), obesity, immunosuppression, alcohol use disorder, malnutrition, chronic steroid use, and recent instrumentation or perineal trauma/abscess.

Act — this is a surgical emergency. Immediate broad-spectrum antibiotics covering gram-positives, gram-negatives, and anaerobes (e.g., a carbapenem or piperacillin-tazobactam, plus vancomycin/linezolid for MRSA, plus clindamycin for antitoxin effect), aggressive fluid resuscitation and sepsis care, and emergent surgical debridement — often repeated. Do not wait for imaging if the diagnosis is clinically evident; CT may show fascial gas but a negative CT never rules it out.

The one rule

Suspicion alone is enough to call the surgeon. Every hour of delay to debridement measurably increases mortality. If you are wondering whether this could be Fournier's, escalate now.

2.4 Obstructing Stone with Infection (Obstructive Pyelonephritis / Urosepsis)

An obstructing ureteral stone plus infection is the true stone emergency. This is a closed-space infection: pus under pressure behind an obstruction will not clear with antibiotics alone, because the antibiotic cannot reach it and the pressure drives bacteria into the bloodstream. Patients can look deceptively well and then crash within hours.

Clues — fever, rigors, flank pain, tachycardia, hypotension, confusion (especially in the elderly), pyuria/positive culture, leukocytosis, and hydronephrosis with a stone on non-contrast CT.

Management — resuscitate, obtain blood and urine cultures, start broad-spectrum antibiotics, and arrange EMERGENT decompression — a retrograde ureteral stent or a percutaneous nephrostomy tube. Either is acceptable; choose based on patient stability, anatomy, and available resources. Definitive stone treatment is deferred until the infection is controlled — do NOT attempt to laser the stone during a septic episode.

This patient goes to the HOSPITAL — not to our ASC

Disposition first: the septic patient with an obstructed, infected stone needs emergent decompression and inpatient sepsis care — IV antibiotics, monitoring, and often an ICU bed. Send the patient to an affiliated hospital with urologic coverage and arrange decompression there. This is not an ASC case.
Never try to definitively treat the stone in the septic patient — manipulating an infected system worsens bacteremia. Drain, treat the infection, come back in a few weeks for the stone.
Escalate immediately for: fever with an obstructing stone, AKI, a solitary or transplanted kidney with obstruction, bilateral obstruction, or intractable pain/vomiting.

2.5 Acute Urinary Retention (AUR)

Presentation — sudden inability to void with a painful, palpable, distended bladder; the bladder scan shows a large volume (often > 500–1,000 mL). Distinguish this from chronic retention, which is painless, insidious, associated with overflow incontinence and very large volumes, and carries a real risk of renal insufficiency.

Precipitants — most commonly BPH in older men; also anticholinergics, antihistamines, decongestants (alpha-agonists), opioids, constipation/fecal impaction, UTI/prostatitis, alcohol, postoperative states and anesthesia, urethral stricture, clot retention, and neurologic disease. In women, retention is much less common — think prolapse, neurologic disease, pelvic mass, or Fowler's syndrome.

Immediate management — prompt bladder decompression with a urethral catheter (16–18 Fr; use a coudé tip if a large prostate makes passage difficult). Record the drained volume — it drives the next decisions. There is no need to clamp the catheter intermittently; complete drainage is safe and standard. If urethral catheterization fails, escalate for cystoscopic guidewire-assisted placement or a suprapubic tube (Chapter 14).

After decompression — watch for these three things

Post-obstructive diuresis: high-volume retention (often > 1,000–1,500 mL) can be followed by brisk diuresis. Monitor urine output, orthostatic vitals, and electrolytes; replace fluids if output is high (e.g., > 200 mL/hr) with signs of volume depletion. Most is physiologic and self-limited; a minority is pathologic and needs replacement.
Hematuria ex vacuo: decompression hematuria is common, usually mild and self-limiting. Do not panic; do not clamp.
Renal function: check a creatinine. Obstructive uropathy can present as AKI and usually improves after drainage.

Next steps — start an alpha-blocker (e.g., tamsulosin 0.4 mg daily) to improve the odds of a successful trial without catheter (TWOC). The patient must take it for a minimum of 3 days before an AM trial; confirm the patient is moving their bowels and treat constipation before catheter removal. Use polyethylene glycol 3350 (MiraLAX) for maintenance; when a patient is significantly backed up, consider magnesium citrate orally or a Fleet-type sodium-phosphate enema from below after checking the safety contraindications in Chapter 14. Stop the offending medication. Remember our position: an alpha-blocker is a bridge, not a life sentence — a man who fails a voiding trial, or who recurs, needs a definitive procedure (Chapter 4).

2.6 Gross Hematuria with Clot Retention

Problem — clots obstruct the bladder outlet, causing painful retention that a standard catheter cannot drain. Small-bore catheters simply clog.

Management — place a large-bore three-way catheter (20–24 Fr), manually irrigate with a catheter-tip (Toomey) syringe to evacuate every clot you can, then start continuous bladder irrigation (CBI) with normal saline titrated to keep the effluent light pink. Check CBC and coagulation studies, review anticoagulants and antiplatelets, and resuscitate/transfuse as needed. Persistent bleeding or inability to clear clots warrants cystoscopy with clot evacuation and fulguration in the OR.

Start a 5-ARI immediately — do not wait

For gross hematuria with clots (especially prostatic bleeding), start finasteride or dutasteride right away. 5-alpha-reductase inhibitors acutely reduce bleeding by suppressing VEGF and the prostate's microvascular density.
This is not a “start it later at follow-up” drug in this setting — begin it as part of the acute management, alongside catheter drainage and CBI.

Do not forget the cause

Clot retention is a symptom, not a diagnosis. Once the patient is stable, every episode of gross hematuria still needs a full evaluation — cystoscopy and upper-tract imaging (Chapter 3). Anticoagulation does not explain it away.

2.7 Paraphimosis

Definition — the retracted foreskin cannot be reduced back over the glans. The constricting band causes venous and lymphatic congestion, progressive edema, and — if prolonged — arterial compromise and glanular necrosis. It is most often iatrogenic: a foreskin retracted for catheterization or an exam and never returned.

Management — reduce it promptly. Apply firm, steady circumferential compression to the glans for several minutes to squeeze out edema (this is the key step and requires patience — set a timer). Then push the glans backward with your thumbs while drawing the foreskin forward over it. Adjuncts: ice, an osmotic agent (granulated sugar wrapped in gauze for 1–2 hours), a penile block, or multiple puncture holes in the edematous foreskin to let fluid escape. If reduction fails, a dorsal slit is required.

Prevention is the whole lesson

ALWAYS return the foreskin to its natural position after any catheterization, cystoscopy, or genital exam. This is the single most preventable urologic emergency, and it is on us when it happens.

2.8 Penile Fracture

Recognize — rupture of the tunica albuginea of an erect penis. There is a characteristic audible “crack” or “pop” during intercourse (classically with the partner on top, or a forceful bending), immediate loss of erection (detumescence), sharp pain, rapid swelling, and an “eggplant deformity” from a large hematoma. If Buck's fascia is intact the hematoma stays confined to the penile shaft; if it ruptures, blood tracks into the scrotum and perineum in a butterfly pattern.

Associated urethral injury — occurs in roughly 10–20% and is more common in bilateral corporal injury. Ask about, and look for, blood at the meatus, gross hematuria, and inability to void — these raise the concern and should be discussed with the operating physician before catheterization.

Management — urgent surgical exploration and repair — notify the on-call urologist and prepare the OR. Early repair (within 24 hours) produces markedly better outcomes than delayed or conservative management, which risks penile curvature, fibrotic plaques, and erectile dysfunction. This is a clinical diagnosis; imaging (ultrasound or MRI) is only needed when the presentation is atypical and must not delay the OR.

2.9 Genitourinary Trauma

Renal trauma

Image when: gross hematuria; microscopic hematuria WITH shock (SBP < 90); a significant deceleration mechanism (fall from height, high-speed MVC) even without hematuria; or penetrating injury near the flank. The imaging study is a CT abdomen/pelvis with IV contrast INCLUDING delayed (excretory-phase) images — without the delayed phase you will miss a collecting-system injury or urinary extravasation.
Management: the large majority of blunt renal injuries — including many high-grade ones — are managed non-operatively with bed rest, serial hematocrits, and observation. Absolute indications for exploration are hemodynamic instability from renal bleeding, an expanding or pulsatile retroperitoneal hematoma, and renal pedicle avulsion. Angioembolization is often the better answer for ongoing bleeding in a stable patient.
Grading (AAST I–V): I contusion/subcapsular hematoma; II superficial laceration < 1 cm; III laceration > 1 cm without collecting-system involvement; IV laceration into the collecting system or a segmental vascular injury; V shattered kidney or renal pedicle/hilar avulsion.

Bladder trauma

Suspect with: pelvic fracture plus gross hematuria — this combination mandates a CT cystogram (retrograde-filled, not just a clamped Foley on a routine CT, which misses injuries).
Extraperitoneal rupture (more common, associated with pelvic fracture): usually managed with catheter drainage alone for 2–3 weeks, then a cystogram before removal.
Intraperitoneal rupture (a burst injury of the dome, often from a blow to a full bladder): requires surgical repair — urine in the peritoneum causes chemical peritonitis and metabolic derangement.

Urethral trauma

Suspect with: blood at the urethral meatus (the classic sign), inability to void, a high-riding or non-palpable prostate, or perineal/scrotal butterfly hematoma after pelvic trauma or a straddle injury.
Keep this in proportion. True urethral disruption is rare — it belongs to major pelvic-fracture trauma, not to everyday urology. We do not routinely order retrograde urethrograms, and blood at the meatus in a patient who yanked out his own catheter is not a urethral injury work-up (Chapter 14 — replace the Foley; it tamponades the bleeding).
In the genuine high-energy pelvic-fracture patient: do not force a catheter, and call. Posterior (membranous) injuries accompany pelvic fractures; anterior (bulbar) injuries follow straddle mechanisms. Management is suprapubic diversion with delayed reconstruction, or primary realignment in selected cases — a physician decision, not an APP one.

Testicular trauma

Scrotal ultrasound for suspected rupture (loss of the normal contour, heterogeneous parenchyma, disrupted tunica albuginea). Explore if the tunica is breached — early repair salvages the testis in the large majority; delayed exploration does not.

Didactics

2.1 Testicular Torsion

2.2 Priapism

Ischemic priapism — bedside management, step by step

2.3 Fournier's Gangrene

2.4 Obstructing Stone with Infection (Obstructive Pyelonephritis / Urosepsis)

2.5 Acute Urinary Retention (AUR)

2.6 Gross Hematuria with Clot Retention

2.7 Paraphimosis

2.8 Penile Fracture

2.9 Genitourinary Trauma

Renal trauma

Bladder trauma

Urethral trauma

Testicular trauma

Clinical Pathway

The classic patient

The anatomy

Pitfalls

Approximate salvage by duration of torsion

What it drives

Findings that support torsion

Pitfalls

our practice rule

What to look for on the scan

Next

Why

Pitfalls

Features

Pitfalls

Signs it worked

Pitfalls

The operation

Pearls

Pitfalls

What ischemic priapism is

Ask explicitly and early

Other causes to keep in mind

Pitfalls

The profile

Action

The profile

Action

Mandatory

Where this happens

Our standard

Sequence

Technique

Why one side is enough

Dosing

Watch the monitor

Why phenylephrine

Pitfalls

Ischemic values

Sequencing

Order of shunts

Prevention

Duration counseling

Special situations

Pitfalls

What it is

Look for

Pitfalls

Why

Pitfalls

Risk factors

The rule

Regimen from the chapter

What runs alongside

Expect

In practice

Pitfalls

Why it is different

Clues

New Jersey Urology emergency route

Stable urgent cases

Orders

Choosing it

Choosing it

The rule