6.2 Genitourinary Emergencies: Infection, Obstruction, and the Scrotal Clock

Urinary Infection: UTI to Urosepsis

Uncomplicated urinary tract infection (UTI) presents with dysuria, frequency, urgency, and suprapubic discomfort, with pyuria and nitrites on urinalysis. Pyelonephritis adds fever, flank pain, costovertebral-angle (CVA) tenderness, and systemic signs (nausea, vomiting, rigors) — it is an upper-tract infection of the renal parenchyma.

The dangerous endpoint is urosepsis: a urinary-source infection that triggers sepsis. Screen with the systemic markers — tachycardia, hypotension, altered mentation, and a rising lactate. Treatment follows the sepsis bundle: obtain blood and urine cultures before antibiotics, give broad-spectrum antibiotics within 1 hour, and deliver a 30 mL/kg crystalloid bolus for hypotension or lactate ≥4 mmol/L. The classic test trap is the elderly patient whose only UTI sign is acute confusion (delirium); treat the infection, do not dismiss the mental-status change.

Renal Calculi and Acute Kidney Injury

Renal calculi (kidney stones) classically cause sudden, severe, colicky flank pain radiating to the groin, with hematuria and a writhing, restless patient who cannot find a comfortable position (contrast this with peritonitis, where patients lie still). Non-contrast CT is the imaging gold standard. Stone size predicts passage: stones <5 mm pass spontaneously >75% of the time, 5-10 mm about 50%, and >10 mm less than 25%. Management of an uncomplicated stone is analgesia (NSAIDs/opioids), antiemetics, hydration, and medical expulsive therapy (an alpha-blocker such as tamsulosin) for distal stones.

The emergency is the obstructing, infected stone (pyonephrosis) — fever plus obstruction. This combination causes rapidly progressive urosepsis and demands urgent decompression (ureteral stent or percutaneous nephrostomy) along with antibiotics; antibiotics alone will not clear pus behind an obstruction.

Acute kidney injury (AKI) is staged by KDIGO criteria — a rise in serum creatinine of ≥0.3 mg/dL within 48 hours, a 1.5× baseline rise within 7 days, or urine output <0.5 mL/kg/h for 6+ hours. Causes are prerenal (hypovolemia, sepsis), intrinsic (acute tubular necrosis, nephrotoxins, contrast), and postrenal (obstruction — including bilateral stones or retention). Watch for hyperkalemia: peaked T waves on ECG signal life-threatening potassium and call for calcium, insulin/glucose, and albuterol.

The Scrotal Clock and Priapism

Testicular torsion is the can't-miss GU diagnosis: the spermatic cord twists, strangling blood supply. It presents with abrupt, severe unilateral scrotal pain, often nausea/vomiting, a high-riding testicle with a horizontal lie, and an absent cremasteric reflex (a concerning finding, not a stand-alone exclusion test). Testicular salvage is time-sensitive, with the best chance when detorsion occurs within about 4–6 hours of symptom onset. Do not let imaging delay surgery — emergent urology consult is the priority; color Doppler ultrasound can support the diagnosis, but preserved flow does not exclude early, partial, or intermittent torsion, and manual detorsion ('open-book,' medial-to-lateral) is only a temporizing bridge to the OR.

Epididymitis more often develops gradually and may improve with elevation, but neither pain relief nor an intact reflex reliably excludes torsion. Equivocal acute scrotal pain still needs urgent assessment.

Urinary retention — the painful inability to void with a palpable distended bladder — is relieved by catheterization; decompress and watch for post-obstructive diuresis.

Priapism is a prolonged erection unrelated to stimulation. Ischemic (low-flow) priapism is painful, rigid, and a compartment-syndrome emergency — beyond 4 hours it threatens permanent erectile dysfunction. Treatment is corporal aspiration and intracavernosal injection of phenylephrine (an alpha-agonist). Non-ischemic (high-flow) priapism is non-painful, not emergent, and often managed with observation.

Nursing Priorities and Disposition

The emergency nurse's role in GU complaints is to risk-stratify quickly, control pain and nausea, and recognize the few presentations that cannot wait. For renal colic, an organized approach pays off:

1. Pain and nausea control first — NSAIDs (e.g., ketorolac) are first-line and often outperform opioids for ureteral colic; add an antiemetic for vomiting.
2. Obtain a urinalysis and beta-hCG — hematuria supports the diagnosis, but its absence does not exclude a stone; always rule out pregnancy in a person of childbearing potential with flank pain, because an ectopic can masquerade as renal colic.
3. Identify red flags for admission — uncontrolled pain, intractable vomiting, a single or transplanted kidney, acute kidney injury, and especially fever (infection behind an obstruction). About 3% of stone patients require admission for pain, obstruction, sepsis, or dehydration.

For urinary infection, the disposition pivot is systemic involvement: simple cystitis goes home on oral antibiotics, while pyelonephritis with vomiting or dehydration, or any sign of urosepsis, is admitted for IV therapy. Older adults and immunocompromised or pregnant patients have a lower threshold for admission.

Catheterization pearls matter for retention: relieve the distended bladder, but anticipate post-obstructive diuresis (large urine output afterward) and hematuria if a chronically distended bladder is decompressed. Document the residual volume drained.

Throughout, the emergency nurse keeps the organ-salvage clock in view: torsion and infected obstruction are the items that turn a routine GU visit into a true emergency.