Urogenital complaints are common presentations to emergency departments and EMS providers. Although not the typical focus of prehospital education and planning, these clinical scenarios represent a potentially growing number of calls as more and more members of the public rely on EMS as their entry into the health care safety net. Despite the fact that these conditions are not the typical focus of EMS physicians and providers, appropriate care and attention can significantly impact the quality of care that these patients receive. In some cases, the prehospital patient encounter provides the needed clues to the diagnosis and proper management that would not otherwise be apparent. Even in cases where field care is not potentially definitive, attention to detail in the field and carefully relaying observations can speed diagnostic confirmation and intervention in the emergency department.

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  List common causes of hematuria in prehospital patients.

  
  
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  Describe the initial prehospital evaluation and management of urogenital trauma.

  
  
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  Describe the initial prehospital evaluation and management of priapism.

  
  
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  Describe the initial prehospital evaluation and management of victims of sexual assault.

  
  
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  Describe common complications of urological procedures affecting prehospital patient care (Foley/suprapubic catheters, nephrostomy tubes, kidney transplant, failure of dialysis catheters (ie, venous air embolism).

  
  
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  Discuss flank pain.

The kidneys are the filter systems of the blood. They receive nearly 25% of the cardiac output, filtering 180L per day though only approximately 1L/day is excreted as urine. The bladder stores urine in a low-pressure system with a normal capacity of 400 to 500cc. Injury or dysfunction of the mechanism of the filter or bladder can lead to significant illness.

Etiologies of hematuria are wide and varied. The most common causes are related to urogenital trauma, infection, nephritis, kidney stones, and tumors. It is important to note that medications may induce a red discoloration to the urine which may be mistaken for hematuria. These medications include but are not limited to sulfonamides, quinine, rifampin, and phenytoin. Posttraumatic hematuria may be secondary to renal or bladder injury. Infectious causes include hemorrhagic cystitis. Nephritis, kidney stones, and tumors are other causes. For the patient with flank pain that radiates into the groin (especially those with a history of renal colic) analgesia with narcotics and ketorolac may be appropriate in the prehospital setting. For older patients with no renal colic history the ketorolac should be omitted due to the potential for abdominal aortic aneurism to be masquerading as renal colic.

Patients with urinary retention typically present with acute lower abdominal pain and distention with an inability to urinate. In men older than 50 years of age, the most common cause is prostate hypertrophy. Other causes of urinary retention include obstructive, infectious and inflammatory, pharmacologic, neurologic, or other. Other common causes include prostatitis, cystitis, urethritis, and vulvovaginitis, and medication-induced urinary retention from anticholinergic and α-adrenergic agonist medications. Neurologic causes such as cortical, spinal, or peripheral nerve lesions may be the causation.

A history and a focused physical examination provide significant insight into the etiology of the patient’s pain. The patient may have obvious distension of the lower abdomen and tenderness to palpation. Confirmation of a distended bladder is easily done with bedside ultrasound. One of the most common and easiest methods to measure bladder volume is the prolate ellipsoid equation: volume = length × width × height × 0.52. The diagnosis of urinary retention is defined as postvoid residual greater than 100 cc. This can be measured using a small ultrasound machine or passing a catheter into the bladder to collect the remaining urine.

Treatment is immediate decompression of the bladder with a straight catheter. Depending on the etiology of the urinary retention, a Foley catheter may need to be left in place until further diagnostic studies can be done. Pain medication should be strongly considered for treatment in the prehospital phase of care.

Torsion most commonly presents in puberty and occurs in 1 in 4000 per 25,000 males per year before the age of 25.^1–3 Torsion may be associated with trauma; however, this is not necessarily the case. Torsion of the testes is a urologic emergency. Patients typically have an acute onset of pain and nausea or vomiting secondary to pain. Patients may also complain of referred abdominal pain. The position of the testicle will be high and will lie in the transverse position of the affected testis. There will also be an abnormal cremasteric reflex.

Diagnosis is one made by clinical history and the physical examination. If a torsed testicle is suspected, an immediate detorsion of the testicle is necessary. If the testicle is not detorsed within 6 hours,^4,5 there is a high likelihood that the testicle may have irreversible ischemic. Manual detorsion using the “opening of a book” technique. Place the patient in the supine position or standing position. Manual detorsion of the testicle involves twisting outward and laterally. The testicle should be rotated outward 180° in a medial-to-lateral direction. Lateral rotation of the torsion has been described in up to a third of testicular torsions. Testicles may retorse after detorsion. In these cases surgical intervention is required.

Rotation of the testicle may need to be repeated two to three times for complete detorsion. Pain relief serves as a guide to successful detorsion. Resolution of the transverse lie of the testis to a longitudinal orientation, lower position of the testis in the scrotum, and return of normal arterial pulsations detected with a Doppler stethoscope are indicators of a successful detorsion.