Management of Non-Traumatic Urological Emergencies at Souro Sanou University Teaching Hospital of Bobo-Dioulasso (Burkina Faso) ()
1. Introduction
A urological emergency is a critical clinical situation in the urological system that requires an urgent therapeutic intervention [1] . There are several non- traumatic pathologies of the urinary tract in both sexes that can affect the normal functioning of the urinary system. These may require urgent intervention to alleviate symptoms, restore normal anatomy and physiology or prevent further damage to the system. Urological emergencies can be traumatic or not. Kesler and Bauml [2] in a clinical review found priapism, paraphimosis, testicular torsion and fournier’s gangrene to be the four most common non traumatic urologic emergencies. In France, at the Pitié-Salpêtrière Hospital in Paris, 15.6% of hospital admissions were for non-traumatic urological emergencies [1] . In Spain Muntaner et al., [3] reported 1504 urological emergencies in one-year retrospective study; they found that the most common diagnosis in both males and females was renal colic, urinary retention, cystitis and hematuria. In Africa, Avakoudjo [4] in Benin found that non-traumatic urological emergencies account for 92.7% of all urological emergencies. Likewise, Halidou in Niger [5] found 89.7% of all urological emergencies and Fall [6] in Dakar reported 94.6%. In Burkina Faso, a study conducted by Zango et al. [7] in 2010 found that non- traumatic urological emergencies accounted for 93.3% of all emergency surgical admissions at the University Hospital Yalgado Ouedraogo in Ouagadougou. The purpose of this study is to retrospectively study the pattern of presentation and management of non-traumatic urological emergencies at the Souro Sanou University Hospital in Bobo Dioulasso with the view to improve the management of such cases in the future.
2. Patients and Methods
This was a cross-sectional retrospective study of medical records of all the patients who were managed for non-traumatic urological emergencies in Souro Sanou Teaching Hospital from January 1, 2017, to December 31, 2020. The data were retrieved from case notes, registers in accident and emergency, theatre, out-patient unit, and wards and were transferred to a proforma form. Detailed information about the patients was retrieved such as biodata, presenting complaints, clinical evaluation findings, diagnoses and treatment outcomes. Case notes with incomplete information and duplicates were excluded. Descriptive statistics were presented in the form of frequencies, percentages, and proportions for categorical variables. Data analysis was carried out using Epi info 7.2.2.2 French version 2017. The study has been performed with the approval of a medical ethics committee.
3. Results
During the 4 year study period, 584 patients were admitted to the surgical emergency department for non-traumatic urological emergencies accounting for 6.3% of all surgical emergencies seen. Non-traumatic urological emergencies accounted for 90.8% of all urological emergencies with an annual frequency of 146 cases per year. The male-to-female ratio was 9.2:1. The mean age of the patients was 51.9 ± 23.9 years with the ages ranging from 1 year to 107 years. The modal age group was 61 - 80 years (37.5%) and most of the patients (52.6%) were farmers or breeders, followed by those working in the informal sector (10.6%) and students (10.3%). Slightly more than half (52%) of the patients came from urban areas. The majority of the patients (69.5%) were referred from other healthcare facilities.
Forty-five per cent of the patients presented within 48 hours of symptoms. The symptoms were sudden in onset in 26% of the patients, and many of them (41.6%) presented with difficulties with micturition followed by hematuria (18.4%). Table 1 gives the distribution of patients according to clinical data.
Background history of prostate tumors (22.1%), urinary schistosomiasis (4.3%) and recurrent urinary tract infections (2.6%) has been reported in our patients; in addition, 2.4% of patients had sickle cell disease.
On admission, 154 patients (26.4%) showed signs of disease progression with the majority having clinical anemia (40.9%) and deterioration of the general clinical condition (34.4%) (Figure 1).
Laboratory investigations were performed on 369 patients (63.2%). Leukocytosis was found in 109 patients (18.7%) and anaemia in 105 patients (17.9%). The HIV serology came back positive in 8 patients (1.4%). ECBU was deranged in 59 patients (15.4%) and Escherichia coli was the most commonly found pathogen during urine culture (40.6%) followed by Klebsiella pneumoniae (17%). Radiological examinations were carried out in 52.9% of the patients and ultrasound was the most commonly requested examination (81.2%), followed by CT scan (22%).
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Table 1. Distribution of patients according to clinical aspects.
The most common diagnosis was urine retention (42.9%), followed by urinary tract infections (22.5) and hematuria (16.9%). Table 2 gives the distribution of the different diagnoses.
Intensive care admission was necessary for 4.9% of the patients for resuscitation and intensive monitoring. Blood was transfused for 12.7% of the patients. Antibiotic therapy was given based on the diagnosis made, the associated
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Figure 1. Distribution of patients according to signs of severity observed on admission.
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Table 2. Distribution of patients according to the different diagnosis.
complications and the culture and sensitivity results. It was prescribed in 25.5% of the patients for curative purposes and in 9.6% of the patients for prophylactic purposes.
The surgical intervention offered depends on the diagnosis and the severity of the patient condition. Five hundred and twenty-five (89.9%) of the patients had one surgical intervention or the other as depicted in Table 3.
The outcome was favorable in the majority of patients (95.5%). However, complications were noted in 5.5% of patients which include hemorrhagic shock (1.5% of cases), septic shock (1.4% of cases), gross hematuria (0.8%) and renal failure (0.8% of cases).
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Table 3. Distribution of patients according to the different procedures performed.
Most of the patients (61.3%) were managed and discharged from the hospital however, 22 patients (3.8%) died, 32.9% were transferred to other units and 1% left against medical advice. The average length of hospital stay was 5.1 ± 7.5 days with a range of 3 hours and 71 days.
4. Discussion
In our study, non-traumatic urological emergencies accounted for 90.8% of all urological emergencies, which underscores the importance of this entity; this same observation has been made by other authors in Africa [4] [6] [7] . The average age of our patients was 51.9 ± 23.9 years and the modal age group was 61 to 80 years. This could be due to the fact that the commonest presentation was urine retention and prostatic hyperplasia was the commonest background pathology which is commonly seen among men above 50 years. Avakoudjo [4] in Benin, Fall [6] in Senegal and Kambou [8] in Burkina found the average ages of their patients to be 61, 59 and 58.8 years respectively in their series. Almost half of the patients (45%) presented 48 hours after the onset of symptoms. This could be probably due to difficulties in getting access to health services, lack of knowledge of the early symptoms and signs of some of these emergency conditions, waste of time by patronage to traditional health practitioners and self-medica- tion.
The male sex was predominant in our series as reported by many studies [6] [7] [9] . This could be explained by the high incidence of urethro-prostatic pathologies in males on the one hand and the fact that pathologies of the female urinary tract are generally seen and taken care of in the gynaecology department.
The commonest reason for the presentation was acute retention of urine. It is the most common urological emergency due to the extreme pain caused by the inability to empty the bladder. Several authors in their series have made the same reports [4] [7] [10] [11] . Gross hematuria was the second emergency presentation because of the high level of fear and concern the patient and their relative usually have on the sight of blood in the urine. Referrals were also prompt in patients with hematuria because of what the fear that the rapid loss of blood may cause to the hemodynamic stability of the patients.
Radiological evaluation plays a significant role in the diagnosis and treatment of these patients. In our study, 52.9% of the patients had one radiological evaluation or the other. Ultrasound, a quick, easily accessible and inexpensive examination, was the most commonly performed (81.2%) radiological investigation. This may be due to the fact that the majority of patients are farmers/breeders who are poor and cannot afford more sophisticated radiological examinations. Moreover, most of the diagnoses can be reached with USS hence there may be no need for costly radiological evaluation especially when all investigations are paid by the patient out-of-pocket.
The commonest diagnosis was retention of urine (42.9%) followed by urogenital infections (22.5). These results are similar to those of several authors. Tfeil et al. [12] in Mauritania found 60.5% of their patients presented with urine retention and 16.75% urogenital infection. For Owon’Abessolo et al. in Cameroon, Diabate et al. in Senegal and Bobo Diallo et al. in Guinea, hematuria was the commonest diagnosis followed by urine retention [13] [14] [15] . On the other hand, for Mondet et al. in France, urinary retention was the second most common cause of urological emergencies behind low back pain [4] . This could be explained by the rather early presentation to hospitals in France at the slightest symptoms of dysuria, whereas African patients because of socio-economic, cultural and poor access to health services often present late with complications such as urine retention and sepsis.
The management of the patients depends on the working diagnosis. Thus, patients with urine retention were relieved by urethral catheterization or suprapubic cystostomy if urethral catheterization failed or was contraindicated. Therefore, urethral was the most frequently performed emergency procedure in several African series [6] [14] [15] .
Urogenital infections (22.5%) were the second most frequent presentation in our study usually in the form of gangrene of the external genitalia and epididymoorchitis as in the studies by Tfeil et al. and Tengue et al. [12] [16] . The majority of gangrene of the external genitalia occurs in elderly patients with numerous comorbidities (arterial hypertension, diabetes and severe acute malnutrition) or sexually transmitted infections (human immunodeficiency virus). The treatment is based on bi- or tri-antibiotic therapy associated with surgical debridement and systematic treatment against tetanus (anti-tetanus serum and anti-tetanus vaccine). This treatment approach has been reported in several studies [17] [18] .
Hematuria was the third most common presentation of non-traumatic urological emergencies in our study. This could be explained by the fact that Burkina Faso is a schistosomiasis endemic country. The management of these patients requires the placement of a three-way urinary catheter and the initiation of continuous bladder irrigation with normal saline to wash out any clots in the bladder. If the haemorrhage affects the haemodynamic stability of the patients, a blood transfusion may be indicated. In our series, a blood transfusion was necessary in 12.5% of our patients.
The short-term outcome was satisfactory in 95.5% of patients. The mortality rate was 3.8%. This could be due to the fact that most of the patients seen were elderly with many comorbidities. In addition, delayed presentation; poor referral system; and poor overall healthcare services associated with many logistic issues that prevent prompt and adequate resuscitation and proper treatment may be responsible for this high mortality rate.
Retrospective nature of the study with it inherent shortcomings was one of the key limitations of the study. Incomplete records and missing records are other well-known limitations of retrospective study which we also observed in our study. Finally, failure to come back for follow-up makes it difficult to ascertain treatment outcomes.
5. Conclusion
Non-traumatic urological emergencies constitute a significant portion of all emergency surgical presentations in our setting. Urinary retention was the most common urological emergency. Delays in presentation, poor logistic protocol causing a delay in resuscitation and background comorbidities were responsible for the high mortality rate recorded. However, for patients who were seen and treated early in the course of the disease, the management outcome used to be satisfactory.