S.P. Elliott, J.W. McAninch
Compared to other surgical fields there are relatively few emergencies in urology. For this reason we maybe-come unaccustomed to caring for the acutely ill patient. Therefore, it is important to keep certain guiding principles in mind when confronted with a patient with an emergent urologic condition.
First, remember that emergencies in urology are rarely life-threatening. Even some of the most concerning conditions such as pyonephrosis or renal trauma are urgent but usually not emergent. Remembering this principle will prevent one from making rushed decisions about management. Important questions to consider before acting are:
1. Is the patient well enough to undergo an operation?
2. Will an operation improve the situation or is a minimally invasive approach or patience a better course of action?
3. Have you considered possible concomitant pathology or injuries?
4. Should you involve a general surgeon, internist, or intensivist in the patient's care?
5. Would additional imaging be helpful?
By no means should an urgent problem go untreated but taking a couple of minutes to think through these questions could avoid misguided therapy.
Second, as mentioned above, avail yourself of imaging of the genitourinary tract. Radiology should be considered an extension of the physical exam in urology since many of the structures are difficult to examine by palpation. Contrast-enhanced computerized tomography of the abdomen and pelvis with delayed imaging of the urinary collection system plays a critical role in the evaluation and management of abdominal trauma involving the urinary system, ultrasound is often indispensable in the differentiation of orchitis and testicular torsion, and a cystogram diagnoses a bladder perforation as intraperitoneal or extraperitoneal. In each of these examples, findings on radiographic imaging will significantly alter one's choice of management. The urologist should be familiar with the options for imaging and the interpretation of those images.
Third, and perhaps most important, do not be afraid to involve other urologists or other services in the care of the patient, particularly if you are unfamiliar with the management of the acutely ill patient. As alluded to above, many of us have an office-based practice and perform mostly short-stay surgery. If one is uncomfortable managing an acutely ill patient one should not allow pride to prevent one from consulting a colleague early in the patient's hospital course.
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