Surgey: Urology

• Bladder and prostate: Urological Assessment | Haematuria | Lower Urinary Tract Symptoms and BPH | Urinary Retention | Urinary Catheters | Urinary Incontinence
• Kidney and ureter: Stones — Surgical Management | The Obstructed Infected Kidney | Urological Cancer Surgery
• Scrotum and penis: Scrotal Swellings | Testicular Torsion | Epididymo-orchitis | Testicular Cancer | Foreskin and Penile Problems | Priapism and Penile Fracture | Fournier's Gangrene | Urological Trauma
• Revision: Urological Conditions at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Urology — page 8 of the Surgery chapter. 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?

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

• 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

• 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