UROLOGICAL EMERGENCIESBy JOHN SANDREY, M.B., CH.M., F.R.C.S.

Surgeon, St. Peter's Hospital; Consultant Urologist to the Royal Navv

With the exception of acute retention of urine,urological emergencies are not common enoughfor any medical man, unless he specializes in thistype of work, to become at all familiar with them.This seems to be the main reason why so manymistakes are made in diagnosis and treatment.From the point of view of treatment urologicalemergencies can be classified under three mainheadings.

i. True surgical emergencies which requireimmediate operative treatment. These includeruptures of the ureter, bladder or urethra, spon-taneous perirenal haematoma, genital torsions ofvarious kinds, extravasation of urine, acute pyo-nephrosis, acute paraphimosis and constriction ofthe penis from any other cause.

2. Where a symptom, such as acute retention ofurine or severe and prolonged renal colic, takesprecedence over the underlying cause. Though notsurgical emergencies in the strict sense of the word,it is, nevertheless, correct to say that their propermanagement from the beginning will play a vitalrole in the patient's ultimate recovery. Prelimin-ary measures to afford relief of what is, in thefirst instance, an urgent and painful condition willoften become part of a planned attack on theunderlying cause later on. In some cases the mainsymptom alone is relieved, the underlying causebeing dealt with at some future date (e.g. whensuprapubic drainage is required to relieve re-tention of urine due to an impassible urethralstricture). In others both cause and effect can beefficiently dealt with simultaneously, as whenimmediate prostatectomy or continuous dilatationof a narrow urethral stricture are carried out incertain cases of acute retention.

3. A group of acute conditions which areusually treated conservatively in the first placealthough operative treatment may eventually beneeded. These conditions include the anurias,the more severe forms of renal haematuria andmost contusions of the kidney and the externalgenitalia.

It will be appreciated that only the salientclinical features and more important principles of

treatment can be indicated in this short review,and omissions are inevitable. The conditions foundin Groups i and 3 are usually the surgeon'sresponsibility, but the role of the family doctor inearly diagnosis and in eliminating delay in trans-ferring the patient to hospital is perhaps just asimportant. In Group 2 the general practitionerwill often institute and sometimes complete treat-ment in the patient's home. He should, therefore,be familiar with the management of such cases andprovide himself with the proper equipment neededto deal with them efficiently.

Acute retention of urine is a relatively common-place emergency which can generally be relievedpromptly by catheterization in the patient's home,difficulties only arising as a rule when severeobstructions at the bladder neck or in the urethraare encountered. As many of the patients in thiscategory are elderly and in poor physical condition,from the effects of longstanding urinary obstruc-tion, infection or intercurrent cardiovasculardisease, it is most essential that they be givenefficient treatment from the start. Catheterization,a simple enough procedure in most instances, mayunder certain circumsta-nces become a harrowingexperience for both practitioner and patient, andthe number of admissions to hospital of patientswith clot retention, false passages, urinary in-fections and unnecessary suprapubic cystotomiesbears witness to the difficulties sometimes en-countered.No practitioner need ever suffer the humiliation

of being unable to give prompt relief to a patientwith a painful distended bladder if he carries afew relatively simple items of equipment inreadiness for this type of emergency. They con-sist of:One or two catheters of the Tieman pattern

(sizes I4 and i6 charriere).A fine lumbar puncture needle (Howard Jones'

or similar pattern).Several filiform bougies.A tapered meatal dilator.A medium-sized metal bougie for pushing

90 POSTGRADUATE MEDICAL JOURNAL February 1952

foreign bodies or calculi impacted in the urethraback into the biadder.These can all be sterilized quite simply in the

home by boiling in any large dish or saucepan.Tieman's catheter (Fig. i) has many advantagesover the gum-elastic instruments generally em-ployed; it can be readily sterilized by boiling andits upturned, tapered and flexible end enables itto negotiate a distorted posterior urethra withease, whereas a more rigid gum-elastic instrumentwill often be held up and may readily causetrauma and false passages if force is used.

If the patient is found to be distressed an in-jection of morphia on arrival at the house will allayanxiety and enable arrangements to be made forcatheterization under proper aseptic conditions.Furthermore a quiet relaxed patient will be moreco-operative than one who is restless and appre-hensive. Intravenous pethidine (50 to I00 mg.)may be a boon when dealing with refractorypatients.

Preliminary questioning may yield valuable in-formation; for instance, the patient may be awareof the fact that he has a stricture or else may admitto having recently introduced a foreign body alongthe urethra. He may perhaps describe what isobviously a recent attack of renal colic, thusindicating the possibility of a calculus obstructingthe urethra.

Examination of the patient will not only confirrnthat the bladder is distended but may sometimesbring other important facts to light, for example ameatal stricture or a perineal abscess, if present,will be obvious on external examination.Where the cause is not apparent, an attempt

should be made to pass a Tieman's catheter. Ifthis is successful the prostate and bladder baseshould be carefully palpated per rectum after thebladder has been completely emptied and beforethe catheter is removed. In most cases a smoothbi-lobed enlargement of the prostate gland will bereadily appreciated, and this type of case shouldbe sent to hospital where, if conditions arefavourable and the patient a ' good risk,' im-mediate prostatectomy is generally regarded as thebest form of treatment. About 20 per cent. of allprostatic obstructions, however, are due to malig-nant disease. In such cases the gland is found tobe stony hard, irregular and its borders ill-defined;the catheter should then be tied in for a week andfull doses of stilboestrol (30 to 6o mg. daily)administered. The ' boggy ' sensation of aprostatic abscess may be detected and when such acollection is at all large, adequate drainage fromthe perineum must be provided.When a urethral stricture is present the passage

of the catheter is obstructed in the bulb, usuallyI0 to 12 cm. from the external meatus. Some-

FIG. I.-Tieman's catheter.

times the stricture is of ' wide bore,' the attack ofretention being due to congestion from alcohol,cold, etc. In these cases a small Tieman'scatheter will usually pass with ease. Generally,however, the stricture is contracted and un-yielding and, in these, infinite patience and gentle-ness will be necessary to coax the finest filiformbougie through its narrow lumen. When this issuccessful urine will pass drop by drop alongsidethe instrument. After retention has been relievedcontinuous dilatation of the stricture can be carriedout by substituting larger and larger instruments.This type of retention may be complicated by aperiurethral abscess or by gangrenous cellulitis ofthe perineum. A profound toxaemia, rapidly fatalin untreated cases, usually accompanies the moresevere forms of suppuration in this area. Treat-ment, by free incision of the affected subcutaneoustissues, urinary diversion by perineal or suprapubiccystostomy and chemotherapy, is urgently re-quired in these cases.

Suprapubic puncture is an alternative methodwhen catheterization fails. It is also sometimesemployed as a routine procedure, in cases of simpleprostatic obstruction in order to avoid the risk ofcatheter infection, by those who practise theWilson Hey technique of 'immediate ' aseptic'prostatectomy in such circumstances. The punc-ture is made with a very fine spinal needle im-mediately above the symphysis pubis and thebladder emptied as completely as possible. Inorder to prevent leakage of urine from the punctureinto the prevesical space the stylet should be re-inserted immediately before withdrawal and thesite of puncture firmly compressed for a fewmoments after removal of the needle. Thedangers of prevesical cellulitis following thismethod are greatly increased when the urine isheavily infected. If this complication is feared,arrangements should be made to provide moreadequate suprapubic drainage with the leastpossible delay. Injuries to the peritoneum or gutare rare and are only likely in very obese patients.

Certain types of retention require sp'ecialtreatment.

Clot RetentionClot retention, where the outlet of the'bladder

is blocked by blood-clot, may follow urethraltrauma or may be spontaneous, the latter beingdue as a rule to a vesical neoplasm. Evacuation of

SANDREY: Urological Emergencies

the clot through a large metal catheter by means ofa syringe or Bigelow's evacuator is usually success-ful, but cystoscopic diathermy to a bleedingbladder growth or suprapubic cystostomy may benecessary to control severe haemorrhage.

In WomenIn women, retention of urine is commonly due

to urethral stricture, neoplasms infiltrating or pro-lapsing through the internal urinary meatus,foreign bodies or sometimes hysteria. Uterine en-largements such as fibroids or retroverted graviduteri are, in the experience -of the writer, veryseldom the cause of acute retention of urine.Urethral stricture is a disease by no means con-fined to the male sex and is often observed inwomen after urethral trauma or infection. Thecondition is usually easy to treat by dilatation.

Non-Obstructive RetentionNon-obstructive retention may follow pelvic

operations or confinements (' reflex retention ') oris observed in association with various neuro-psychiatric disorders such as hysteria, arterio-sclerosis, schizophrenia, etc. (' inhibitory re-tention '). The former state is painful, the latteris not. These conditions usually respond to para-sympathetic stimulants, and rarely requirecatheterization.

AnuriaAnuria can readily be distinguished from acute

retention of urine by catheterization and finding anempty bladder. Failure to take this elementaryprecaution at the earliest possible moment incomatose or semi-comatose patients has often beenresponsible for avoidable delay in instituting treat-ment. Early recognition of the anuric state is ofthe utmost importance. Any patient who, after asevere operation, haemorrhage', abortion or crushinjury, passes less than 500 cc. of urine in 24 hoursmust be kept under the closest scrutiny.A wide variety of conditions, many of them

primarily non-renal, can give rise to oliguria oranuria. Among them may be mentioned the crushsyndrome, 'transfusion kidney,' various anuricsyndromes associated with pregnancy and abortion,sulphonamide anuria, poisoning with heavy metals,anuria following shock, haemorrhage or haemolysis.The bedside of the anuric patient is, in fact, nowthe meeting place of nearly every type of specialist,all interested in different aspects of a many-sidedproblem.

During the past decade the important observa-tions of Bywaters and other British workers on thecrush syndrome and of Trueta and his associateson renal vascular ' shunts' have stimulatedimmense interest in renal physiology, both normal

and abnormal, with the result that our conceptionof renal failure has had to undergo profoundmodification. Many of the loose descriptive termsformerly applied to these conditions, such as' uraemia,' ' pre- or post-renal anuria,' have hadto be abandoned and a more workable classifica-tion, based on the part of the nephron mostaffected, is now being universally adopted.Changes taking place in the nephron are found tobe concentrated at three levels; the glomerulararterioles, the proximal renal tubules and the digtalrenal tubules:

i. Firstly, cortical ischaemia from vasospasmmay be observed when the blood pressure isgreatly lowered, as in shock or cardiac failure,when the blood volume is diminished by haemor-rhage, as the result of nervous stimuli (' reflexanuria ') and possibly from toxaemia. Here thekidney itself is not necessarily diseased.

2. In the second group the brunt of the damageis observed to fall on the proximal tubules (' uppernephron nephrosis') with marked impairment oftheir function. Degenerative changes at this levelare observed in cases of renal toxaemia, eclampsiaand poisoning by heavy metals.

3. In this group the distal tubules are chieflyaffected (' lower nephron nephrosis ') and the mainfactor is obstructive. This obstruction occurseither in the distal tubules, by casts, heme pigmentor acetyl sulphonamide, or in the collecting tubuleswhich are dilated by back pressure from an ob-struction at a lower level such as a uretericcalculus, bladder neck obstruction, etc.

Cases of anuria should be investigated veryfully in order to classify them correctly at theearliest possible moment. This is by no meanseasy since the groups may overlap; for instance,sulphonamide anuria is often partly obstructiveand partly toxic. In cases in the first and thirdgroups the changes are often reversible and manyrecover with correct treatment. On the otherhand permanent damage to the epithelium of theproximal tubules from longstanding renal diseaseis likely in the second group and in these anuria is aterminal event.

ManagementThe management of all cases of anuria, unless

the condition is obviously a terminal event, mustbe based on the assumption that the renal damageis reversible. The objects of treat-ment are tomaintain normal water balance, electrolyte, bloodpressure, blood volume and haemoglobin levels,acid-base equilibrium and general nutrition.Attempts have also been made to remove excess ofcertain products of metabolism by means ofperitoneal dialysis or the artificial kidney withvarying degrees of success. A high calorie,

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protein-free diet, as recommended by Bull,Joekes and Lowe (I949), is administered by con-tinuous drip through an indwelling gastric tube,any vomitus being filtered and returned to thestomach. The daily requirements of the averagepatient are satisfied by the following formula:

Glucose 400 grammesPeanut oil 10I grammesAcacia, q.s. to emulsifyWater to I 1. (Vitamins can be added if required.)

Surgical measures include catheterization ofobstructed ureters and lavage of the renal pelvisto remove accumulations of gravel, sulphonamidecrystals or inspissated pus. Removal of calculi ordrainage of an obstructed renal pelvis bynephrostomy or pyelostomy may be necessarywhen ureteric catheterization is unsuccessful inrestoring urinary secretion. Spinal and para-vertebral anaesthesia to relieve glomerula vaso-spasm and renal decapsulation to reduce tension inupper nephron nephrosis have their advocates butare probably of limited value.Apart from the types of anuria already men-

tioned there are certain well-recognized con-ditions which are fairly common in the practice ofurology.

Calculous AnuriaCalculous anuria is usually due to a small move-

able stone which has become impacted on its waydown the ureter. It is often associated with a massof gravel, blood clot or inspissated puis whichforms a plug making a partial obstruction com-plete. The stone itself may be small in size andbarely discernable in a radiogram. Completeanuria will result when the blockage is bilateral orwhen the opposite kidney is functionless becauseof disease, congenital absence or reflex inhibition.The onset is often insidious but generally followsrepeated attacks of renal colic, the site of the painindicating the side last obstructed. A completeurinary investigation is likely to reveal the causeand site of the obstruction, which must be re-lieved forthwith, either by ureteric catheterization,nephrostomy or ureterolithotomy.

Reflex AnuriaReflex anuria is essentially a protective mechan-

ism whereby, under certain circumstances, renalsecretion is inhibited. It occurs particularly whena ureter is blocked, but may be reproduced ex-perimentally by various stimuli of widely differentkinds. It is brought about, in the first instance,by a local nervous reflex resulting in corticalischaemia of the kidney from vasospasm and de-viation of the blood flow through the kidney bymeans of the 'shunt' mechanism. There is

evidence to support the view that this action canbe prolonged indefinitely by hormonal influences.Diminution or complete cessation of renal functionis a common phenomenon after an attack of renalcolic and may last for several days. It must,therefore, be taken into account in the interpreta-tlon of intravenous pyelograms.

In some cases a normal kidney may be inhibitedby an obstruction of the opposite side (' crossed'reflex anuria), Treatment is directed to removalof the cause, such as an obstruction in the ureteror a drainage tube pressing on the renal pedicleafter a renal operation. Attempts to interrupt thereflex- arc by spinal or paravertebral anaesthesiawhere the exciting cause is not obvious have beenmade in cases of post-operative anuria and in thecrush syndrome, but the results have not beenuniformly successful.

Anuria Following Urethral InstrumentationAnuria may follow urethral instrumentation,

especially after severe urethral trauma in thepresence of an infected urine. The rapid absorp-tion of bacteria from the raw surface will give riseto septicaemia, the kidneys already damaged bythe effects of longstanding urinary obstructionbearing the brunt of the resulting systemic infec-tion. Prevention, apart from chemotherapy, con-sists in gentleness when dilating urethral strictures,especially when infection and signs of renal damageare present. Other reminders of the absorptivepowers of the urethra are provided by reports fromtime to time of cases of mercurial poisoning fromthe use of mercurial solutions for bladder wash-outs or cystoscopy (Page and Wilson, I941), and asthe renal epithelium is always extensively damagedby the absorption of heavy metals, anuria' tends tobe a prominent clinical feature.

Instances where anuria followed uretericcatheterization have also been reported. Here themechanism appears to have been chiefly the effectof reactionary oedema causing blockage of theureter in association with absence of function orpossibly reflex inhibition of the other side. Lastly,after per-urethral resection of the prostate, anuriamay develop from laking of the blood by hypo-tonic lotion used for irrigation, intravascularhaemolysis giving rise to lower nephron nephrosisas in the ' transfusion kidney.'

Injuries to the Genito-Urinary OrgansThese give rise to an interesting and varied

group of lesions which includes open wounds, sub-cutaneous injuries (contusions of the kidney andtesticle, ruptures of the ureter, bladder andurethra), surgical accidents (damage to the ureteror bladder during pelvic operations, perforations ofthe ureter, bladder or urethra by instruments of

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SANDREY: Urological Emergencies

various kind used for diagnosis or treatment).These are mostly serious injuries often complicatedby involvement of important neighbouring struc-tures. They will present many diagnostic prob-lems and as many of the cases will require opera-tive treatment their management can only beproperly carried out in hospital. The mechanism,the resulting lesion and the processes of repair willvary greatly at different levels in the urogenitaltract.

KidneyThe kidney is usually injured by a force applied

to its anterior surface through the soft tissues ofthe anterior abdominal wall which crushes itagainst the unyielding structures posteriorly. Theinjury is often trivial, the direction rather than theseverity of the force determining the resulting renallesion. This is almost invariably a deep fissure ofthe parenchyma radiating out from the hilum andinvolving the softer medulla more extensively thanthe firmer cortex. This gives rise to intrapelvichaemorrhage manifested by haematuria or, lesscommonly, to perirenal haemorrhage with theformation of a haematoma around the kidney.Haemorrhage will cease spontaneously and spon-taneous cure with a variable amount of scarring atthe site of the lesion will take place in approxi-mately 90 per cent. of these injuries. In the re-maining io per cent. operative interference will benecessary, either to control severe haemorrhage orto deal with associated intraperitoneal lesions suchas ruptured spleen, liver or gut.

Treatment is, therefore, in the first place, al-ways expectant, but in view of the possibility thatnephrectomy may have to be urgently undertaken,it is essential to establish the presence of a soundkidney on the opposite side, either by intravenousor retrograde pyelography, at the earliest possiblemoment. This becomes a matter of great practicalimportance when it is remembered that an en-larged kidney is more vulnerable to trauma than anormal one, and that a common cause of renalenlargement is compensatory hypertrophy due todisease or congenital absence on the opposite side.All patients treated conservatively should be keptin hospital at least three weeks as repair of renalparenchyma is a slow process and the danger ofsecondary haemorrhage is not past until the end ofthat time. It is always advisable to make certainby means of intravenous pyelography that renalfunction has returned to normal and that there isno obstruction to the renal pelvis by scarring beforereturning the patient to work.

UreterThe ureter, owing to its deep position in the

body, is rarely injured except by the surgeon. He

may accidentally clamp or divide it when dealingwith large or adherent pelvic tumours or when re-secting the pelvic colon, or may perforate it fromwithin by means of ureteric catheters, by over-vigorous dilatation of a ureteral stricture or byforcible attempts to extract calculi with wire' baskets' or similar instruments. Treatment con-sists of immediate end-to-end suture of a severedureter if the injury is recognized at the time.Where some time has elapsed it is sometimespossible to anastomose the damaged ureter to thebladder or bowel, although in most cases, especiallywhere a urinary fistula has developed, the resultsof conservative operations are unsatisfactory.When the kidney of the opposite side is sound,nephrectomy is usually the best form of treatment.

BladderThe bladder may be ruptured from without by

missiles, kicks or blows or by violent lateral com-pression in association with injuries of the pelvicgirdle. It may also be accidentally incised by thesurgeon in performing any pelvic operation,especially when the pre-operative precaution ofemptying the bladder by means of a catheter hasbeen omitted. Intravesical surgical manipulationsof any kind, rough instrumentation, over-disten-sion, excessive diathermy, etc., may perforate oractually burst the bladder from within. Spon-taneous rupture of the over-distended bladder canreadily occur when its wall has been weakened bydisease, especially ulceration of any kind, althoughin some of the cases reported (Beresford-Jones,194I, and others) the wall of the viscus was ap-parently normal before rupture. The diagnosis ofruptured bladder is notoriously difficult chieflybecause typical symptoms and signs are late inappearing and are often effectively masked in theearlier stages by shock and associated injuries.Cystoscopy and cystography are valuable aids todiagnosis, but whenever there is any doubt ex-ploration of the bladder should be undertaken assoon as conditions permit. Suture of the rent andadequate drainage, not only of the bladder butalso of the paravesical tissues, are the mainprincipl 's of treatment.

UrethraThe urethra may be ruptured completely or

partially, the latter type of injury being due as arule to the surgeon causing ' false passages' byburrowing with the point of an instrument eitherin the spongy tissue of the bulb or in the sub-mucosa of the prostatic urethra. Such injuriesmay cause severe haemorrhage, clot retention,infection (periurethral suppuration) or extravasa-tion of urine.

Complete ruptures are found at two classica I

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94 POSTGRADUATE MEDICAL JOURNAL February 1952

sites, eitherjust below the triangular ligament wherethey are caused by falls astride or other injunres tothe perineum, or immediately above the triangularligament in,association with fractures of the pelvicgirdle. At either site there is wide separation ofthe torn ends and reconstructive surgery at theearliest possible moment is essential in order tosecure union without excessive scar formation.The distal type of rupture is best dealt with byend-to-end suture from the perineum, the proximalby retrograde catheterization and weight extension.Urinary diversion by suprapubic cystostomy isnecessary in both cases while healing is takingplace.

Male GenitaliaThe male genitalia, owing to their exposed

position, are very vulnerable. Typical lesions arethe result of contusions, open wounds or avulsioninjuries. Because of the great vascularity of theparts, genital wounds bleed profusely. In ad-dition, nervous shock is often a strikingphenomenon in these cases, so that the patient isfrequently found in a profound state of collapseout of all proportion to the severity of the locallesion.

Treatment should in the first place be confinedto the control of haemorrhage, the relief of tensionby evacuation of retained blood clot and the pro-vision of free drainage. No tissue should be cutaway unless it is frankly non-viable. Healing israpid and much can be done to remedy defectssubsequently by plastic surgery. The familiar

contusion of the testicle may be caused by kicks,crushes *or missiles; the careless tapping of ahydrocoele may produce the same result. Theresulting haematoma when not too large will sub-side rapidly with rest elevation, cold applications,etc. More severe injuries will often rupture thetestis and produce a large haematoma within thetunica vaginalis (haematocoele). Operative treat-ment is indicated in the latter type of injury withthe object of turning out the clot and suturing therent in the visceral layer of the tunica in order toprevent subsequent atrophy of the testis.

Contusions of the penis usually affect the erectorgan (e.g. ' faux pas de coit '), and may result indislocation, fracture or haematoma within thesheath of the corpus cavernosum. When thelatter type of injury is severe removal of the clotand suture of the sheath may be indicated.Avulsion of the genitalia may occur in factorieswhen the patient's clothes are caught up in rotatingbelts.

ParaphimosisParaphimosis is treated by manual reduction or

incision of the constriction with subsequent cir-cumcision to enlarge the preputial opening afterthe oedema has subsided. Strangulation by rubberbands or metal rings applied to the flaccid organby sexual perverts or to control enuresis will oftencause gangrene before the constricting agent canbe removed and subsequent skin grafting may benecessary.

1%

¶ 3 4 . 7 .3 . i.

2 3a

FIG. 2.-Longstanding torsion of spermatic cord; note secondary hydroceleand atrophy of testis

February 1952 SANDREY: Urological Emergencies 95

Genital TorsionsGenital torsions are commoner than is generally

supposed and may affect the spermatic cord, thetestis or the stalked hydatid of Morgagni. Twistsof the spermatic cord are apt to occur during lateadolescence and are perhaps the commonest causeof testicular atrophy (Fig. 2). The aetiology isunknown, but excessive mobility of the testiclewithin the scrotum undoubtedly plays an im-portant part. The onset is generally characteristic,with sudden pain and moderate swelling associatedwith mild fever. In spite of the fact that theentire testicle is enlarged the condition is oftenmistaken for epididymitis and treated as such, andwhen bilateral involvement occurs this may haveserious consequences, leading not only to.sterilitybut to eunuchodism. As degenerative changes inthe testicular epithelium will commence within a.few hours of torsion it is imperative that explora-tion be undertaken immediately, hence thesupreme importance of early diagnosis. Operativetreatment consists of untwisting the torsion,everting the tunica and stitching the edges to theback of the scrotum to prevent further attacks. Asthe condition is frequently bilateral it is usual tofix both testicles through a midline scrotal-splittingincision.

Torsion of the testis alone may occur when themesorchium is long; This may take place withinthe tunica when the testis is in the scrotum, but ismore often found in association with imperfectdescent. Torsion of an intra-abdominal testis hasbeen mistaken for an acute abdomen, and nearly50 per cent. of such organs are the site of tumourformation. Torsion of the hydatid of Morgagni,though not serious in itself, is often followed bytesticular pain of a persistent character (' testicu-lar neuralgia') which is not always relieved byremoval of the subsequent cyst or even by or-chidectomy.

Spontaneous Perirenal HaematomaSpontaneous perirenal haematoma is a con

dition which always arouses great clinical interest-because of its dramatic features. Spontaneousbleeding may take place into the perirenal or sub-capsular spaces as a result of renal or adrenaldisease, diseases of the renal blood vessels or blooddyscrazias. No determining cause can be found inabout 25 per cent. of the cases but trauma must,of course, be carefully excluded before any case ofrenal haemorrhage is classified under this heading.The onset is usually abrupt with severe abdominaland lumbar pain, together with increasing symp-toms and signs of internal haemorrhage. Thedifferential diagnosis from other forms of ab-dominal emergency is not easy. The mortality ishigh because of the frequent delay in recognizingthe condition. Treatment usually takes the formof rapid nephrectomy although bleeding cansometimes be controlled by more conservativemeasures such as packing, ligature or suture.Severe Renal Haematuria

Severe renal haematuria may be caused bytumours of the kidney or renal pelvis, hypertensivegranular red kidney or renal purpura (essentialrenal haematuria). Where bleeding from any ofthese conditions is severe enough to threaten thepatient's life, nephrectomy may become a matterof extreme urgency and the objects of an in-vestigation of such cases should be not only toreveal the site and the cause of the bleeding butalso the state of the kidney on the opposite side.

Acute PyonephrosisAn acute pyonephrosis arises when a ful-

minating infection with pyogenic bacteria takesplace in an obstructed renal pelvis. If this con-dition is not promptly relieved by drainage ornephrectomy there is always a very real danger ofa senous and often fatal septicaemia.

BIBLIOGRAPHY

BERESFORD-JONES, A. B. (194I), Brit. Y. Siurg., 24, 154.BULL, G. M., JOEKES, A. M., and LOWE, K. G. (I949), Lantcet,

ii, 229.

BYWATERS, E. G. L., and BEALI, D. (I941), Brit. med. Y., i, 427.

PAGE, B. H., and WILSON, C. (I940), Latncet, i, 640.TRUETA, J., BARCLAY, A. E., DANIEL, P. M., FRANKLIN,

K. J., and PRICHARD, M. M. L. (I947), 'Studies of theRenal Circulation,' Blackwell Scientific Publications, Oxford.