Emergency urology: the six-hour decisions
What the exam tests
Time-critical decisions: torsion, obstructed infected kidney, priapism, acute retention and the acute scrotum. The examiner wants the next action, not a differential list.
Core rules
- Testicular torsion: salvage falls sharply after six hours. Exploration is a clinical decision; a Doppler showing flow does not exclude intermittent torsion and must not delay surgery. Fix both testes.
- Obstructed infected kidney: decompress immediately by nephrostomy or stent plus antibiotics. Delay causes septic death.
- Ischaemic priapism is painful, rigid and low-flow. Aspirate and give intracavernosal phenylephrine; if that fails, surgical shunt within 36 to 48 hours. Non-ischaemic priapism is painless, often post-traumatic, and managed by observation or embolisation.
- Acute urinary retention: catheterise and record the residual. If catheterisation fails, place a suprapubic catheter. Watch for post-obstructive diuresis and arrange a trial without catheter after treating precipitants.
- Paraphimosis: reduce with compression and local anaesthesia; a dorsal slit is the fallback. Never leave it unreduced.
- For necrotising infection and major trauma, the emergency principle is source control before definitive reconstruction.
Worked example
A 24-year-old presents with four hours of sudden severe scrotal pain and vomiting; the testis is high and the cremasteric reflex is absent. Reasoning: the history alone justifies exploration. Theatre is booked immediately for bilateral scrotal exploration and fixation; ultrasound is not required and would waste salvage time.
Traps
Waiting for imaging in torsion; giving antibiotics but not draining an obstructed infected kidney; using corporal aspiration alone for late priapism; forgetting to fix the contralateral testis.