Surgey: Urology

🩺 Urology. Most urology is outpatient work (haematuria, LUTS, cancer), but a few emergencies must never be missed: testicular torsion, an obstructed infected kidney, acute urinary retention, priapism and Fournier's gangrene. Prostate, bladder, kidney and testicular cancer oncology is in the Urology, Skin and Other Cancers chapter; kidney stone medicine is in the Tubular Disorders, Inherited Disease and Stones chapter.
Your four questions for every patient: Is there an emergency -torsion, infected obstruction, retention, sepsis? Could this be cancer -and does the patient meet urgent referral criteria? Where is the problem (kidney, ureter, bladder, prostate, urethra, scrotum)? What does the patient need now -a catheter, drainage, antibiotics, or surgery?

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Urological Assessment

• History:
  • Storage symptoms -frequency, urgency, nocturia, urge incontinence.
  • Voiding symptoms -poor stream, hesitancy, straining, intermittency, terminal dribbling.
  • Post-micturition symptoms -feeling of incomplete emptying, post-void dribbling.
  • Haematuria (visible or not, painful or painless), loin pain, fever, sexual function, previous surgery, smoking and occupational exposures (bladder cancer), drugs (anticholinergics, diuretics, anticoagulants).
• Examination -abdomen (palpable bladder, kidneys), external genitalia, digital rectal examination (prostate -size, consistency, nodules, tenderness), neurological examination if a neurological cause is suspected.
• Bedside tests -urine dipstick and MSU, frequency–volume chart (3 days), bladder scan (post-void residual).
• Bloods -U&E (obstructive kidney injury), PSA (after counselling), FBC, CRP.
• Imaging -ultrasound of the kidneys and bladder, CT KUB (stones), CT urogram (visible haematuria), MRI prostate (suspected prostate cancer).
• Specialist tests -flexible cystoscopy (looks inside the bladder under local anaesthetic), uroflowmetry, urodynamics (bladder pressure studies).

Haematuria

• Visible haematuria -blood seen in urine; non-visible -found on dipstick (1+ or more, confirmed on repeat).
• First exclude -UTI (treat and re-test), menstruation, recent exercise, beetroot, rifampicin (red urine without blood).
• Suspected cancer referral (NICE NG12):
  • Aged 45 and over with unexplained visible haematuria without UTI, or visible haematuria that persists or recurs after successful UTI treatment.
  • Aged 60 and over with unexplained non-visible haematuria and either dysuria or a raised white cell count.
• Haematuria clinic -flexible cystoscopy plus imaging (CT urogram for visible haematuria; ultrasound often for non-visible).
• Causes -bladder cancer (smokers, painless visible haematuria), kidney cancer, upper tract urothelial cancer, prostate cancer or benign enlargement, stones, infection, trauma, glomerular disease (IgA nephropathy -with proteinuria, hypertension, low eGFR -refer to nephrology), anticoagulants (still investigate).
• Clot retention -heavy bleeding with clots blocking the bladder -three-way catheter and bladder irrigation, bladder washouts; treat the cause.
• Haemorrhagic cystitis -after cyclophosphamide or ifosfamide (mesna prevents it), radiotherapy, BK virus (after transplant).

Lower Urinary Tract Symptoms and BPH

• Benign prostatic hyperplasia (BPH) -non-cancerous enlargement of the prostate's transition zone with age; causes voiding symptoms (bladder outlet obstruction) and sometimes storage symptoms.
• Assessment (NICE CG97) -IPSS score, frequency–volume chart, urine dipstick, DRE, U&E if obstruction suspected, PSA after counselling (if cancer is a concern or it would change management).
• Conservative -reduce evening fluids, cut caffeine and alcohol, bladder training, urethral milking for post-void dribbling, review drugs.
• Medicines:

  Drug	Use	Side effects
  Alpha-blocker (tamsulosin, alfuzosin)	First-line for moderate to severe voiding symptoms; works in days	Postural hypotension, dizziness, retrograde ejaculation, floppy iris syndrome (tell the eye surgeon before cataract surgery)
  5-alpha reductase inhibitor (finasteride, dutasteride)	Enlarged prostate (over about 30 g, or PSA over 1.4) at high risk of progression; takes 6 months; reduces retention and surgery	Reduced libido, erectile dysfunction, gynaecomastia; halves PSA (double the value when interpreting)
  Combination	Bothersome symptoms with a large prostate	Both sets
  Antimuscarinic (oxybutynin, solifenacin) or mirabegron	Storage symptoms (overactive bladder) if persisting	Antimuscarinics -dry mouth, constipation, confusion in older people (anticholinergic burden), retention; mirabegron -raises BP
  Desmopressin or late-afternoon loop diuretic	Nocturnal polyuria	Desmopressin -hyponatraemia (check sodium; caution in older people)

• Surgery -for severe symptoms, failure of medicines, retention, recurrent UTIs, bladder stones, haematuria from the prostate, kidney damage from obstruction:
  • TURP (transurethral resection of the prostate) -risks: retrograde ejaculation (most), bleeding, infection, incontinence, erectile dysfunction, urethral stricture, TURP syndrome (absorbed glycine irrigation -hyponatraemia, confusion, fluid overload, visual disturbance; less common with bipolar TURP using saline).
  • Laser procedures (HoLEP -holmium laser enucleation, laser vaporisation), Urolift, Rezum (steam), open prostatectomy for very large glands.

Urinary Retention

• Acute urinary retention -sudden, painful inability to pass urine with a palpable, tender bladder; volume usually under about 1 litre on catheterisation.
• Causes:
  • BPH (commonest in men), urethral stricture, prostate cancer, clots, stones.
  • Drugs -anticholinergics, opioids, tricyclics, antihistamines, decongestants, alcohol, anaesthesia (after surgery).
  • Constipation, UTI, pain, immobility.
  • Neurological -cauda equina syndrome (saddle anaesthesia, back pain, leg symptoms -emergency MRI), spinal cord compression, MS, diabetes.
  • Women -pelvic masses, prolapse, post-partum, Fowler's syndrome.
• Management:
  • Urethral catheter (suprapubic if urethral fails -urology review); record the drained volume.
  • Treat causes -constipation, drugs, infection; check U&E.
  • Trial without catheter (TWOC) after starting an alpha-blocker for at least 2–3 days (improves success); if it fails -recatheterise and refer for TURP or long-term catheter.
• Chronic retention -painless, large residual volume (often over 1 litre), overflow incontinence, nocturnal enuresis.
  • High-pressure chronic retention -with hydronephrosis and kidney impairment -catheterise; watch for post-obstructive diuresis (large urine output over 200 mL/hour -replace fluids carefully, monitor U&E, sodium and potassium); usually needs TURP.
  • Low-pressure -normal kidneys -may not need a catheter; urology review.
• Haematuria after catheterisation of a chronically distended bladder is common (decompression) -usually settles.

Urinary Catheters

• Indications -retention, accurate fluid monitoring in the critically ill, perioperative use, irrigation for clots, severe incontinence with pressure sores or for palliative comfort.
• Avoid unnecessary catheters -every day adds infection risk (CAUTI); review daily and remove as soon as possible.
• Types:
  • Short-term (latex or PTFE) and long-term (silicone, changed up to every 12 weeks).
  • Three-way -irrigation for haematuria and clots.
  • Suprapubic -long-term catheterisation (fewer urethral problems), urethral stricture or trauma.
  • Intermittent self-catheterisation -neurogenic bladder, chronic retention in able patients -lower infection risk than indwelling catheters.
• Technique -consent, aseptic technique, lidocaine gel, smallest size that will drain (12–14 Ch); in men don't inflate the balloon until urine flows (inflating in the urethra causes trauma); replace the foreskin afterwards (paraphimosis).
• Problems:
  • Not draining -check for kinks, bag position, constipation; bladder washout; replace if blocked.
  • Bypassing -blockage, bladder spasm (antimuscarinic), constipation, infection.
  • CAUTI -don't dipstick catheter urine (always positive); treat only symptomatic infection -fever, loin pain, delirium, sepsis; change the catheter (if in for over 7 days) before taking a sample and starting antibiotics (NICE NG113).
  • Difficult catheterisation -don't force; urology for a coudé catheter, flexible cystoscopy-guided insertion or suprapubic catheter; suspect a stricture or false passage (bleeding).
• Suspected urethral injury (pelvic fracture, blood at the meatus) -do not pass a urethral catheter -urology review (see Urological Trauma).

Urinary Incontinence

Type	Features	Management
Stress	Leaks with coughing, sneezing, laughing, exercise; women after childbirth, menopause; men after prostatectomy	Supervised pelvic floor muscle training (at least 3 months), weight loss; duloxetine (if surgery not wanted); surgery -colposuspension, autologous sling, bulking agents (mesh tapes restricted in the UK); artificial urinary sphincter or male sling after prostatectomy
Urge (overactive bladder)	Sudden strong urge then leak, frequency, nocturia	Bladder training (at least 6 weeks), reduce caffeine; antimuscarinics (avoid oxybutynin in frail older women) or mirabegron; botulinum toxin injection into the bladder (may need self-catheterisation), sacral nerve stimulation
Mixed	Both	Treat the main component first
Overflow	Constant dribbling with a full bladder (chronic retention)	Treat the obstruction or neurological cause; catheter
Functional	Mobility or cognitive problems stop the person reaching the toilet	Toileting help, environment, treat reversible causes
Fistula	Continuous leakage (vesicovaginal -after surgery, radiotherapy, obstructed labour)	Surgical repair

• Reversible causes -UTI, constipation, drugs (diuretics, alpha-blockers in women, sedatives), delirium, hyperglycaemia, atrophic vaginitis (topical oestrogen).
• Assessment -bladder diary (at least 3 days), urine dipstick, post-void residual, pelvic examination; urodynamics before surgery (NICE NG123).
• Neurogenic bladder (spinal injury, MS, spina bifida) -protect the kidneys (high-pressure bladders cause hydronephrosis); intermittent self-catheterisation, antimuscarinics, botulinum toxin, bladder augmentation.

Stones -Surgical Management

• Renal colic -sudden severe loin-to-groin pain, restless, colicky, nausea, haematuria (dipstick positive in most).
• Imaging -non-contrast CT KUB within 24 hours (pregnant women and children -ultrasound first) (NICE NG118).
• Pain relief -NSAID (IM, oral or rectal diclofenac or ibuprofen) first; IV paracetamol if NSAIDs unsuitable; opioids as third line; no antispasmodics.
• Medical expulsive therapy -alpha-blocker (tamsulosin) for distal ureteric stones under 10 mm.
• Chance of passing -under 5 mm usually pass; over 10 mm unlikely.
• Treatment options (NICE NG118):

  Stone	Treatment
  Ureteric stone under 10 mm	Watchful waiting ± alpha-blocker; shockwave lithotripsy (SWL) or ureteroscopy if not passing or pain uncontrolled
  Ureteric stone 10–20 mm	Ureteroscopy (laser fragmentation) or SWL
  Renal stone under 10 mm	SWL; ureteroscopy if SWL unsuitable; asymptomatic small stones may be watched
  Renal stone 10–20 mm	SWL or ureteroscopy
  Renal stone over 20 mm (including staghorn)	Percutaneous nephrolithotomy (PCNL)

• Treat within 48 hours of diagnosis if pain is ongoing and not tolerated, or the stone is unlikely to pass.
• Contraindications to SWL -pregnancy, uncorrected bleeding disorder or anticoagulation, infection, distal obstruction, aortic aneurysm near the stone.
• Ureteric stents -often left after ureteroscopy; cause bladder irritation, haematuria and loin pain on voiding; must be removed or changed (a forgotten stent encrusts) -keep a stent register.
• Prevention -fluids (2.5–3 L a day), add lemon juice, avoid fizzy drinks, normal calcium intake, reduce salt; potassium citrate (calcium oxalate stones with high urine calcium), thiazides (recurrent calcium stones with hypercalciuria) -see the Stones chapter.

The Obstructed Infected Kidney

• An obstructed infected kidney is a urological emergency -pus under pressure leads to rapid sepsis and can destroy the kidney.
• Features -loin pain with fever, rigors, raised inflammatory markers, possibly AKI, and hydronephrosis on imaging; usually a stone, sometimes a tumour or stricture.
• Management:
  • Sepsis Six -blood cultures, urine culture, IV antibiotics (per local policy, e.g. gentamicin with co-amoxiclav or piperacillin–tazobactam), IV fluids, lactate, urine output.
  • Urgent decompression -percutaneous nephrostomy (radiology) or retrograde ureteric stent (theatre) -within hours.
  • Treat the stone later once the infection has settled (not at the same time).
• Other indications for urgent decompression -obstruction of a solitary kidney, bilateral obstruction, obstruction with AKI, uncontrolled pain.
• Other causes of hydronephrosis -pelvi-ureteric junction obstruction, pelvic cancers (cervix, bladder, prostate, rectum), retroperitoneal fibrosis (methysergide, IgG4 disease, aortic aneurysm), pregnancy (physiological on the right), BPH (bilateral).
• Emphysematous pyelonephritis -gas in the kidney in people with diabetes -severe sepsis; drainage or nephrectomy.
• Xanthogranulomatous pyelonephritis -chronic destructive infection with staghorn stones; nephrectomy.

Urological Cancer Surgery

• Prostate cancer:
  • Diagnosis -PSA (age-specific), DRE, multiparametric MRI before biopsy, then transperineal biopsy (lower infection risk than transrectal); Gleason grade and CPG risk group (NICE NG131).
  • Low-risk -active surveillance; localised intermediate or high-risk -radical prostatectomy (usually robotic) or radiotherapy with hormone therapy.
  • Prostatectomy risks -erectile dysfunction, stress incontinence, anastomotic stricture; pelvic floor exercises, PDE5 inhibitors.
  • Metastatic -androgen deprivation (GnRH agonists -flare: give an anti-androgen first; or antagonists), novel hormone drugs, chemotherapy (see the cancer chapter).
• Bladder cancer (mostly urothelial; smoking, aromatic amines, schistosomiasis -squamous):
  • TURBT (transurethral resection of bladder tumour) for diagnosis, staging and treatment.
  • Non-muscle-invasive -TURBT, a single dose of intravesical mitomycin C after resection, then intravesical BCG for high-risk (side effects -cystitis, rarely disseminated BCG infection); regular cystoscopy surveillance.
  • Muscle-invasive -neoadjuvant chemotherapy then radical cystectomy with ileal conduit (urostomy) or neobladder, or radical radiotherapy with a radiosensitiser (bladder preservation).
• Kidney cancer (renal cell carcinoma -smoking, obesity, hypertension, VHL, dialysis):
  • Often found by chance on imaging; classic triad (haematuria, loin pain, mass) is late; left varicocele (left renal vein invasion), paraneoplastic features (polycythaemia, high calcium, hypertension).
  • Partial nephrectomy for small tumours (preserves kidney function); radical nephrectomy for larger ones; ablation or active surveillance for small masses in frail patients; tumour thrombus in the IVC may need complex surgery.
• Upper tract urothelial cancer -haematuria with a filling defect on CT urogram; nephroureterectomy (associated with Lynch syndrome).
• Penile cancer -squamous; HPV, phimosis, poor hygiene; a lump or ulcer on the glans or foreskin -urgent referral (NICE NG12).

Scrotal Swellings

Swelling	Features	Management
Testicular tumour	Hard, painless lump within the testis; can't be separated from it	Urgent ultrasound and referral (suspected cancer pathway)
Hydrocele	Fluid around the testis; transilluminates; can get above it; testis may be hard to feel	Ultrasound (exclude an underlying tumour in young men); surgery if bothersome; in infants usually resolves by 1–2 years
Epididymal cyst	Separate from and above/behind the testis; transilluminates; often multiple	Reassure; excise if large or painful
Varicocele	"Bag of worms", usually left-sided, more obvious standing, reduces lying down; dragging ache; subfertility	Reassure; embolisation or surgery if painful or fertility issue; new right-sided or non-reducing varicocele -scan for a renal or retroperitoneal mass
Inguinoscrotal hernia	Can't get above it; cough impulse; may reduce	Hernia repair (see the Hernias page)
Epididymo-orchitis	Painful, swollen, tender epididymis ± testis, gradual onset, fever, urinary symptoms	Antibiotics (see below)
Testicular torsion	Sudden severe pain, high-riding testis	Emergency surgery
Sebaceous cysts	In the scrotal skin; mobile	Excise if troublesome

• Key examination questions -can you get above it? (if not -hernia); is it separate from the testis? (epididymal cyst); does it transilluminate? (hydrocele or cyst); is it tender?
• Ultrasound for any uncertain scrotal lump -it is quick and decisive.

Testicular Torsion

• Twisting of the spermatic cord, cutting off blood supply to the testis -a surgical emergency; salvage falls sharply after 6 hours.
• Who -commonest in teenagers (12–18) and newborns; can happen at any age; "bell-clapper" deformity (testis lies horizontally and hangs freely).
• Features:
  • Sudden severe testicular pain, often waking from sleep or during exercise; may present as lower abdominal pain (always examine the testes in boys with abdominal pain).
  • Nausea and vomiting.
  • High-riding, horizontal testis, very tender, swollen; absent cremasteric reflex; pain not relieved by lifting the testis (negative Prehn's sign -unreliable).
• Management:
  • Urgent scrotal exploration -don't delay for ultrasound if clinically suspected.
  • Untwist; if viable -bilateral orchidopexy (fix both testes, since the other side has the same anatomy); if dead -orchidectomy and fix the other side.
  • Analgesia; manual detorsion ("open the book" -twist outwards) only as a temporary measure if surgery is delayed.
• Torsion of the testicular appendage (hydatid of Morgagni) -younger boys (7–12), pain at the upper pole, a "blue dot" sign, normal cremasteric reflex; settles with analgesia, but explore if torsion can't be excluded.
• Intermittent torsion -repeated short episodes of sudden pain that settle -elective bilateral orchidopexy.

Epididymo-orchitis

• Infection or inflammation of the epididymis (± testis) -gradual onset of pain and swelling, tenderness, fever, urinary symptoms or urethral discharge; cremasteric reflex present; pain may ease with lifting (positive Prehn's sign).
• Causes by age (BASHH):
  • Under 35 or sexually active -Chlamydia trachomatis and Neisseria gonorrhoeae.
  • Over 35, low STI risk -enteric organisms (E. coli) -with urinary obstruction, recent instrumentation or catheters.
  • Mumps orchitis -teenagers and young men a few days after parotitis; may cause subfertility.
  • Others -TB (chronic, "beaded" vas), amiodarone (non-infective, head of epididymis), Behçet's.
• Investigations -urine NAAT for chlamydia and gonorrhoea, urethral swab, MSU; ultrasound if diagnosis unclear (exclude torsion, abscess, tumour).
• Treatment:
  • Probable STI -ceftriaxone 1 g IM (gonorrhoea) plus doxycycline 100 mg twice daily for 10–14 days; contact tracing and partner notification; refer to sexual health.
  • Probable enteric organism -ofloxacin or levofloxacin for 14 days (or per sensitivities); investigate for outflow obstruction.
  • Analgesia, scrotal support, rest.
• Complications -abscess, testicular infarction, chronic pain, subfertility.
• In a young man with sudden pain -torsion until proven otherwise; if in doubt, explore.

Testicular Cancer

• The commonest cancer in men aged 15–45; very curable even when spread.
• Risk factors -undescended testis (cryptorchidism -even after orchidopexy), previous testicular cancer, family history, Klinefelter syndrome, infertility.
• Types:
  • Seminoma -30s–40s; very radiosensitive; PLAP may be raised; AFP is never raised (if AFP is raised it is a non-seminoma).
  • Non-seminomatous germ cell tumours (teratoma, embryonal, yolk sac, choriocarcinoma) -20s–30s; AFP and/or beta-hCG raised.
  • Leydig cell tumours -may cause gynaecomastia; lymphoma -older men (over 60).
• Features -a painless, hard lump in the testis; dragging or ache; gynaecomastia (hCG); back pain from para-aortic nodes; breathlessness from lung metastases.
• Investigation -scrotal ultrasound; tumour markers (AFP, beta-hCG, LDH) before and after surgery; CT chest, abdomen and pelvis for staging.
• Treatment:
  • Radical inguinal orchidectomy (through the groin, not the scrotum -avoids spreading to scrotal lymph drainage); offer a testicular prosthesis.
  • Offer sperm banking before treatment.
  • Then surveillance, chemotherapy (BEP -bleomycin, etoposide, cisplatin -bleomycin lung toxicity), radiotherapy (seminoma), or retroperitoneal lymph node dissection.
• Lymph drainage of the testis is to the para-aortic nodes (not inguinal); scrotal skin drains to inguinal nodes.

Foreskin and Penile Problems

• Phimosis -a tight foreskin that can't be pulled back:
  • Physiological in young boys (usually resolves by adolescence) -no treatment needed; don't force retraction.
  • Pathological -scarring, often from lichen sclerosus (balanitis xerotica obliterans -white, scarred foreskin) or recurrent balanitis -topical steroids, circumcision.
• Paraphimosis -the foreskin is retracted and stuck behind the glans, which swells -an emergency (risk of glans ischaemia):
  • Often after catheterisation or examination when the foreskin is not replaced.
  • Analgesia (penile block), compression, ice, granulated sugar to reduce swelling, manual reduction; dorsal slit or circumcision if this fails.
• Balanitis -inflammation of the glans -candida (diabetes -check glucose), bacterial, irritant, STIs; hygiene, treat the cause; circumcision for recurrent cases.
• Erectile dysfunction -often an early sign of cardiovascular disease (check BP, lipids, HbA1c); also neurological, hormonal (testosterone), drugs (beta-blockers, thiazides, SSRIs, finasteride), psychological; PDE5 inhibitors (sildenafil, tadalafil) -never with nitrates (severe hypotension).
• Peyronie's disease -fibrous plaque in the penis causing curvature and painful erections; associated with Dupuytren's contracture; wait for the disease to stabilise (12 months); surgery if curvature prevents intercourse.
• Hypospadias -the urethral opening on the underside of the penis in boys -don't circumcise (foreskin used for repair); surgical repair in infancy.
• Undescended testis -refer by 3 months if bilateral or not descended (or at birth if bilateral non-palpable -consider disorders of sex development); orchidopexy by 6–12 months to reduce cancer risk and improve fertility (see the Paediatric Surgery chapter).

Priapism and Penile Fracture

• Priapism -a persistent, often painful erection lasting more than 4 hours, not linked to sexual stimulation.
• Ischaemic (low-flow) priapism -the common and dangerous type -painful, rigid shaft with a soft glans; blood is trapped and deoxygenated; an emergency (risk of permanent erectile dysfunction):
  • Causes -sickle cell disease, intracavernosal injections for ED, PDE5 inhibitors (rarely), antipsychotics, trazodone, alpha-blockers, cocaine and cannabis, leukaemia, spinal cord injury.
  • Corporal blood gas -dark blood, low oxygen, high CO₂, acidosis.
  • Management -analgesia, penile block, aspiration of blood from the corpora ± saline irrigation, then intracavernosal phenylephrine (an alpha-agonist -monitor BP and heart rate); surgical shunt if this fails; sickle cell -also standard sickle crisis treatment with haematology.
• Non-ischaemic (high-flow) priapism -usually after perineal or penile trauma (arterial fistula); painless, partially rigid; bright red oxygenated blood on aspiration -not an emergency; may resolve or need selective embolisation.
• Penile fracture -rupture of the tunica albuginea during an erection (vigorous intercourse) -a "snap", immediate loss of erection, pain, rapid swelling and bruising ("aubergine" deformity) -emergency surgical repair; check for urethral injury (blood at the meatus, retention).

Fournier's Gangrene

• Necrotising fasciitis of the perineum, scrotum and genitals -a surgical emergency with high mortality.
• Risk factors -diabetes, obesity, alcohol excess, immunosuppression, older men; perianal abscesses, urethral strictures or trauma, recent urological or perianal surgery. SGLT2 inhibitors have been linked with rare cases (MHRA warning).
• Mixed organisms -aerobic and anaerobic bacteria (polymicrobial).
• Features:
  • Severe pain out of proportion to the visible signs (early).
  • Swelling, redness, then dusky or black skin, crepitus (gas), foul-smelling discharge.
  • Fever, sepsis and shock, rapidly spreading.
• Management:
  • Sepsis Six; broad-spectrum IV antibiotics (e.g. piperacillin–tazobactam with clindamycin -reduces toxin production -per local policy; add MRSA cover if needed).
  • Urgent radical surgical debridement -repeated "second-look" operations; faecal diversion (colostomy) or suprapubic catheter in some.
  • Don't delay surgery for imaging (CT may show gas if the diagnosis is uncertain).
  • ICU care; glucose control; later reconstruction (skin grafts, flaps).

Urological Trauma

• Kidney injury -blunt (most) or penetrating trauma; loin bruising, haematuria (amount doesn't match severity), lower rib fractures.
  • CT with contrast (including delayed phase) in stable patients with visible haematuria, or non-visible haematuria with shock, or significant mechanism.
  • Most managed conservatively (bed rest, monitoring, transfusion); angioembolisation for ongoing bleeding; surgery (nephrectomy) if unstable.
• Ureteric injury -usually iatrogenic (gynaecological, colorectal or vascular surgery); may present late with loin pain, fever, urinary leak or fistula; stents, repair or reimplantation.
• Bladder injury -often with pelvic fractures:
  • Extraperitoneal (commonest) -catheter drainage for about 10–14 days.
  • Intraperitoneal (full bladder, blow to the abdomen) -urine in the abdomen (ascites, raised creatinine from reabsorption) -surgical repair.
  • CT cystogram confirms.
• Urethral injury:
  • Posterior (membranous) -pelvic fractures; blood at the meatus, inability to void, a high-riding prostate on DRE, perineal or scrotal bruising.
  • Anterior (bulbar) -straddle injuries (falling astride a bar); "butterfly" perineal bruising.
  • Do not pass a urethral catheter -retrograde urethrogram first; suprapubic catheter if needed; later urethral repair.
• Testicular trauma -ultrasound; exploration and repair for rupture (a tear in the tunica albuginea) -early surgery saves the testis.

Urological Conditions at a Glance

Condition	Key clues	Management
Visible haematuria	Age 45 or over, painless, smoker	Suspected cancer referral -cystoscopy and CT urogram
BPH	Poor stream, nocturia, smooth enlarged prostate	Alpha-blocker ± 5-ARI; TURP or laser
Acute retention	Painful palpable bladder, anticholinergic drug	Catheter, alpha-blocker, TWOC
High-pressure chronic retention	Painless large residual, AKI, hydronephrosis	Catheter, watch for post-obstructive diuresis
Stress incontinence	Leaks on coughing	Pelvic floor training; surgery
Urge incontinence	Sudden urge then leak	Bladder training; mirabegron or antimuscarinic; botox
Ureteric stone	Loin-to-groin pain, haematuria	NSAID, CT KUB, tamsulosin, ureteroscopy
Obstructed infected kidney	Stone, fever, hydronephrosis	Antibiotics and urgent nephrostomy or stent
Testicular torsion	Sudden pain, high-riding testis, no cremasteric reflex	Immediate exploration, bilateral orchidopexy
Epididymo-orchitis	Gradual pain, urinary symptoms, discharge	Ceftriaxone plus doxycycline, or ofloxacin
Testicular cancer	Hard painless testicular lump in a young man	Ultrasound, markers, inguinal orchidectomy
Paraphimosis	Swollen glans with a retracted foreskin	Reduce urgently
Ischaemic priapism	Painful rigid erection over 4 hours, sickle cell	Aspiration, phenylephrine
Fournier's gangrene	Perineal pain out of proportion, crepitus, diabetes	Antibiotics and urgent debridement
Urethral injury	Pelvic fracture, blood at the meatus	No urethral catheter; urethrogram; suprapubic catheter

Spot the Diagnosis

Clue	Diagnosis
Painless visible haematuria in a 66-year-old ex-smoker	Bladder cancer until proven otherwise
Non-visible haematuria with proteinuria and hypertension in a 30-year-old after a sore throat	IgA nephropathy -nephrology
Dizziness on standing after starting a drug for prostatic symptoms	Alpha-blocker
PSA halved after 6 months of a new prostate drug	5-alpha reductase inhibitor
Confusion and sodium 118 during TURP	TURP syndrome
Painful inability to pass urine after starting amitriptyline	Drug-induced acute urinary retention
Urinary retention with saddle anaesthesia and back pain	Cauda equina syndrome
Urine output 400 mL/hour after catheterising a 1.8 L residual	Post-obstructive diuresis
Fever and confusion in a man with a long-term catheter	CAUTI -change the catheter, culture, antibiotics
Leaks when laughing after three vaginal deliveries	Stress incontinence
Loin-to-groin pain with a 4 mm distal ureteric stone	Likely to pass -NSAID and tamsulosin
Fever, rigors and hydronephrosis behind a ureteric stone	Obstructed infected kidney -urgent nephrostomy
Gas in the kidney of a woman with poorly controlled diabetes	Emphysematous pyelonephritis
Kidney mass with a new left varicocele	Renal cell carcinoma (left renal vein)
Cystitis after bladder instillation treatment for cancer	Intravesical BCG
Scrotal swelling that transilluminates and the testis can't be felt separately	Hydrocele
Lump above and separate from the testis that transilluminates	Epididymal cyst
"Bag of worms" in the left scrotum disappearing on lying down	Varicocele
Sudden testicular pain waking a 14-year-old, high-riding testis	Testicular torsion -explore now
Upper-pole pain with a blue dot in a 9-year-old	Torsion of the testicular appendage
Gradual testicular pain with dysuria and discharge in a 24-year-old	Epididymo-orchitis (chlamydia or gonorrhoea)
Testicular swelling a week after parotitis	Mumps orchitis
Hard painless testicular lump with raised AFP	Non-seminomatous germ cell tumour
Swollen glans after catheterisation with the foreskin pulled back	Paraphimosis
White scarred tight foreskin in an adult	Lichen sclerosus (pathological phimosis)
Painful erection for 6 hours in a man with sickle cell disease	Ischaemic priapism
A "snap" and rapid penile swelling during intercourse	Penile fracture
Penile curvature and Dupuytren's contracture	Peyronie's disease
Perineal crepitus and black skin in a man with diabetes	Fournier's gangrene
Blood at the meatus and a high-riding prostate after a pelvic fracture	Posterior urethral injury

Exam-style Scenarios

1. A 15-year-old boy wakes at 4 am with sudden severe pain in his left testis and vomits. The left testis is high and horizontal, very tender, and the cremasteric reflex is absent.
Answer: Testicular torsion.

• Immediate urology referral for scrotal exploration -don't wait for ultrasound; keep nil by mouth; analgesia.
• Untwist; bilateral orchidopexy if viable; orchidectomy if non-viable, fixing the other side.
• Explain the time-critical nature (best salvage within 6 hours) and consent for possible orchidectomy.

2. A 78-year-old man had a hip replacement 2 days ago. He hasn't passed urine for 10 hours and has lower abdominal pain. A bladder scan shows 950 mL. He takes oxybutynin and morphine.
Answer: Acute urinary retention (post-operative, drug-related, likely BPH).

• Urethral catheter; record residual; check U&E; treat constipation and pain.
• Stop oxybutynin, reduce opioids where possible; start tamsulosin.
• Trial without catheter after 2–3 days on the alpha-blocker; if it fails -recatheterise and refer to urology.

3. A 42-year-old woman has left loin pain, temperature 39°C and rigors. CRP 280, creatinine 140. CT KUB shows a 7 mm left proximal ureteric stone with hydronephrosis.
Answer: Obstructed infected kidney -a urological emergency.

• Sepsis Six -blood and urine cultures, IV antibiotics (per local policy), IV fluids, lactate, catheter.
• Urgent decompression -percutaneous nephrostomy or retrograde ureteric stent within hours.
• Definitive stone treatment (ureteroscopy) only after the infection has settled.

4. A 27-year-old man notices a painless hard lump in his right testis. He had an orchidopexy as a child. Ultrasound shows a solid intratesticular mass. AFP is normal; beta-hCG is mildly raised.
Answer: Testicular cancer (probable seminoma -normal AFP).

• Suspected cancer pathway; tumour markers (AFP, hCG, LDH) before surgery; CT chest, abdomen and pelvis.
• Offer sperm banking; radical inguinal orchidectomy (not scrotal); offer a prosthesis.
• MDT for surveillance, carboplatin or radiotherapy depending on stage; follow-up markers and imaging.

5. A 58-year-old man with type 2 diabetes on an SGLT2 inhibitor has 2 days of severe perineal and scrotal pain. The scrotum is red, swollen and dusky with crepitus. HR 125, BP 85/50, lactate 5.
Answer: Fournier's gangrene with septic shock.

• Sepsis Six and resuscitation; broad-spectrum IV antibiotics including clindamycin; stop the SGLT2 inhibitor; check ketones and glucose.
• Emergency radical surgical debridement (urology ± general surgery) -don't delay for imaging; planned second looks.
• ICU care, glucose control, and later reconstruction.

Key Points

• Visible haematuria aged 45 or over (no UTI) -suspected cancer referral for cystoscopy and CT urogram.
• BPH -alpha-blocker first; 5-ARI for large prostates (halves PSA, takes 6 months).
• Tell the eye surgeon about tamsulosin (floppy iris syndrome).
• TURP -retrograde ejaculation is common; TURP syndrome causes hyponatraemia.
• Acute retention -catheter, review drugs and constipation, alpha-blocker before trial without catheter.
• Retention with saddle anaesthesia -cauda equina -emergency MRI.
• High-pressure chronic retention -watch for post-obstructive diuresis.
• Don't dipstick catheter urine; change the catheter before culture and antibiotics.
• Stress incontinence -pelvic floor training; urge -bladder training, then mirabegron or antimuscarinic.
• Renal colic -NSAID first; CT KUB within 24 hours; tamsulosin for distal stones under 10 mm.
• Stones over 20 mm in the kidney -PCNL.
• An obstructed infected kidney needs urgent drainage plus antibiotics.
• Can't get above a scrotal swelling -hernia; transilluminates -hydrocele or cyst; hard and part of the testis -cancer.
• Testicular torsion -explore immediately, fix both testes.
• Epididymo-orchitis under 35 -ceftriaxone plus doxycycline; over 35 -think enteric organisms.
• Testicular cancer -inguinal orchidectomy; sperm banking; AFP never raised in pure seminoma.
• Always replace the foreskin after catheterisation -paraphimosis is an emergency.
• Ischaemic priapism -aspirate and give phenylephrine.
• Fournier's gangrene -pain out of proportion; urgent debridement.
• Blood at the meatus after pelvic fracture -no urethral catheter.

Guidelines and Further Reading

• NICE NG12: Suspected cancer -recognition and referral
• NICE CG97: Lower urinary tract symptoms in men
• NICE NG123: Urinary incontinence and pelvic organ prolapse in women
• NICE NG118: Renal and ureteric stones -assessment and management
• NICE NG113: Urinary tract infection (catheter-associated) -antimicrobial prescribing
• NICE NG131: Prostate cancer -diagnosis and management
• NICE NG2: Bladder cancer -diagnosis and management
• BASHH: UK national guideline for the management of epididymo-orchitis
• British Association of Urological Surgeons (BAUS): Patient information and guidance on urological emergencies
• European Association of Urology (EAU) Guidelines: Urological trauma; Priapism; Testicular cancer
• MHRA: SGLT2 inhibitors -reports of Fournier's gangrene
• BNF -for current doses