Urology: Stones, Haematuria and Testicular Emergencies
Urology tests stone disease, obstruction, haematuria, prostate disease, testicular emergencies and urological trauma. Many stems ask for the first-line investigation or the indication for urgent decompression.
Core rules
- Renal colic: non-contrast CT of the kidneys, ureters and bladder is first-line. NSAIDs are first-line analgesia. A distal ureteric stone below 10 mm may be managed with medical expulsive therapy such as tamsulosin.
- Obstructed infected kidney: fever, pyuria and hydronephrosis require urgent decompression by nephrostomy or JJ stent plus antibiotics; do not delay for stone removal.
- Haematuria: painless macroscopic haematuria in an adult requires CT urography and cystoscopy, not just urine culture.
- Benign prostatic hyperplasia: assess with IPSS, PSA and digital rectal examination. Surgery is indicated for retention, recurrent urinary tract infection, bladder stones or renal impairment.
- Prostate cancer: PSA plus digital rectal examination plus MRI; biopsy confirms. PSA is not diagnostic on its own and is elevated in prostatitis and benign hyperplasia.
- Testicular torsion: a clinical diagnosis; do not delay exploration for Doppler ultrasound. Bilateral fixation is performed.
- Testicular tumour: painless lump; check alpha-fetoprotein and beta-hCG; radical inguinal orchidectomy.
- Fournier gangrene: necrotising fasciitis of the perineum; urgent debridement and broad-spectrum antibiotics.
Worked example
A 45-year-old man has sudden left flank pain radiating to the groin, nausea and microscopic haematuria. CT shows a 6 mm left distal ureteric stone with mild hydronephrosis. He is afebrile with normal renal function.
Reasoning: this is uncomplicated renal colic. Give NSAIDs and consider tamsulosin. He does not need urgent decompression because there is no sepsis or obstruction with renal failure. Follow-up is arranged, with intervention if pain persists or the stone does not pass.
Traps
- Ultrasound is not the first-line investigation in acute renal colic; CT is.
- Do not give antibiotics for uncomplicated renal colic.
- A normal Doppler study does not exclude testicular torsion.
- A mildly raised PSA may be due to benign hyperplasia or prostatitis.