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ORIGINAL ARTICLE
Year : 2021 | Volume
: 24
| Issue : 3 | Page : 400-405
Urological emergencies in a Nigerian teaching hospital: Epidemiology and treatment
CJ Okeke1, AO Obi2, CA Odoemene2, RW Ojewola3, EN Afogu4, C Odo4, UU Ogbobe4
1 Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital, Ebonyi State; Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital; Department of Surgery, Ebonyi State University Abakaliki, Ebonyi State, Nigeria
3 Department of Surgery, Lagos University Teaching Hospital; Department of Surgery, College of Medicine University of Lagos, Idi-Araba, Surulere, Lagos, Nigeria
4 Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital, Ebonyi State, Nigeria
Correspondence Address:
Dr. C J Okeke
Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/njcp.njcp_393_20
Abstract
Background: Urological emergencies constitute a significant part of emergency presentations in various referral centers. Data on the prevalence of these emergencies in West African sub-region are sparse. Objective: The study is aimed at determining the pattern of urological emergencies in our center and is geared towards bridging the gap in knowledge of the epidemiology of urological emergencies in this sub-region as a means of achieving efficient use of scarce resources. Subjects and Methods: It was a retrospective study of all urological emergency cases that presented over six years in a Federal University Teaching Hospital in Nigeria. Data were collected from emergency register and theatre logs. Data analysis was done using SPSS version 25. Results: A total of 267 patients presented with urological emergencies during the period of study with 258 (96.6%) men and 9 (3.4%) women. The mean age of the patients was 50.6 ± 20.8 years. Urinary retention was the most common urological emergency accounting for 159 (59.6%) cases followed by Fournier's gangrene 23 (8.6%) and testicular torsion 23 (8.6%). Bladder and ureteral injuries accounted for 5 (55.6%) of the urological emergency presentations in women while both injuries accounted for only 4 (1.6%) in men (P = 0.000). Urethral catheterization was the most commonly performed procedure 139 (52.1%), followed by percutaneous suprapubic cystostomy (SPC) 31 (11.6%). Conclusion: Urological emergencies have varying presentations in both sexes. Urinary retention, and acute scrotum were the most common urological emergencies in our facility. This knowledge can be used in emergency preparedness planning which involves personnel training and resource allocation.
Keywords: Epidemiology, Nigeria, urological emergencies
Introduction 
Urological emergencies are a vital part of urological practice. These emergencies can be traumatic or non-traumatic, and any sex or age can present with urological emergency.[1] The patterns of disease presentation vary from region to region.[2],[3],[4] Surgical conditions account for 28 to 32% of the global burden of disease.[5] Five billion people do not have access to safe and affordable surgical care. Low-income and middle-income countries (LMICs) are the worst hit as nine out of ten people in these regions cannot access primary surgical care.[6] There is an inherent difficulty in measuring the surgical, particularly urological burden of disease in sub-Saharan Africa. Diseases are underestimated because of the inherent peculiarities of the sub-region: poverty is endemic, low literacy levels, cultural beliefs and general mistrust of healthcare coupled with lack of universal health insurance.[6],[7],[8],[9] All these keep patients away from hospitals. Hence, late presentation with advanced disease is the norm.[10] Many hospitals in this region are underfunded and have human and infrastructural deficits for surgical delivery.[6],[11],[12] Knowledge of disease prevalence will assist in the allocation of these scarce resources for effective and efficient surgical care delivery. The study is geared towards bridging the gap in knowledge of the epidemiology of urological emergency in this sub-region as a means towards achieving efficient use of scarce resources.
Subjects and Methods Ethical approval was obtained from the hospital ethics and research committee.
This was a retrospective six-year hospital-based study of patients presenting with urological emergencies at a Federal University Teaching Hospital in Southeast Nigeria. Theatre and emergency records were used to retrieve data. The institution is the only referral facility in the state and serves neighboring states of Imo, Benue, Enugu, Cross River, and Abia.
Data retrieved included age, sex, diagnosis and treatment offered. These data were filled in a proforma and coded. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. was used for analysis. Variables were presented as frequencies and percentages for categorical data, while continuous data were presented as means and standard deviation. Chi-square test was used for comparing categorical variables. Statistical significance was set at P value of less than 0.05.
Results During the six-year study period, two hundred and sixty-seven (267) patients presented for emergency urological service in our institution. Two hundred and fifty-eight (96.6%) were men, while nine (3.4%) were women with a male-to-female ratio of 28.6:1.
The mean age of the patients was 50.6 ± 20.8 years, while the ages ranged from 4 to 100 years. [Figure 1] shows the age distribution of all patients; 12 (4.5%) were children while 255 (95.5%) were adults. One hundred and forty-two patients (53.1%) were above 50 years while 125 (46.9%) were below 50 years of age. The mean age of patients with Fournier's gangrene was 42.6 years, acute urinary retention 61.3 years, acute on-chronic retention 51.2 years, testicular torsion 24.0 years as shown in [Table 1]. [Table 1] also shows the distribution of various urological emergencies in all patients.
Urinary retention was the most common urological emergency, accounting for 159 (59.6%) cases followed by Fournier's gangrene 23 (8.6%), testicular torsion 23 (8.6%) and scrotal trauma 17 (6.4%). A total of 132 patients (49.4%) had acute urinary retention (AUR), while 27 patients (10.1%) had acute on-chronic urinary retention. One woman (0.8%) had AUR while 131 men (99.2%) had AUR (P = 0.000). [Figure 2] depicts the distribution of emergencies in both men and women. Benign prostatic enlargement (BPE) was responsible for AUR in 89 (67.4%), urethral stricture in 37 (28.0%) and cancer of the prostate 3 (2.3%) as shown in [Figure 3]a. Conversely, urethral stricture, BPE and cancer of the prostate were responsible for 18 (66.7%), 8 (29.6%) and 1 (3.7%) of acute on-chronic urinary retention respectively as shown in [Figure 3]b. Bladder and ureteral injuries accounted for 5 (55.6%) of the urological emergency presentation in women while both injuries accounted for 4 (1.6%) in men (P = 0.000) as shown in [Figure 2]. Two (66.7%) of the bladder injuries in men were due to blunt abdominal trauma while 3 (100%) of the bladder injuries in women were following pelvic surgery. (P = 0.000). Two (66.7%) of ureteral injuries occurred in women (P = 0.000). Urethral catheterization was the most commonly performed procedure 139 (52.1%) followed by percutaneous suprapubic cystostomy (SPC) in 31 (11.6%). Orchidopexy and wound debridement accounted for 21 (7.9%) and 23 (8.6%) respectively Details of other intervention are as shown in [Figure 4].
Figure 2: Bar chart showing the sex distribution of the emergencies seen
Figure 3: (a) Pie chart depicting the causes of acute urinary retention. (b) Pie chart showing the causes of acute on-chronic urinary retention
Figure 4: Bar chart showing the distribution of the procedures that were performed Discussion The mean age of the patients in this study was 50.6 years. Most patients presented with urinary retention due to prostate disease, and this disease occurs commonly in men above 50 years. This age distribution is similar to the finding of Dejinnin et al.[1] in Cotonou but slightly lower than values from other west African countries.[2],[4],[12]
The male-to-female ratio of 28.6:1 was similar to the findings of Yenli et al.[13] in Ghana. In their study, the male-to-female ratio was 25.1:1 This gender difference can be accounted for by the huge prevalence of benign prostatic enlargement (BPE) in our study which is a problem peculiar to older men globally.[14],[15],[16] Urinary retention was the most common presentation in our study. One hundred and fifty-nine (59.6%) patients presented with urinary retention. This is similar to the finding by Fall et al.[4] in Senegal, where they noted a 60.7% prevalence of urinary retention in their series. Diallo et al.[3] in Guinea reported a higher prevalence of 73.9%. In contrast, Martin et al.[2] in France reported a lower prevalence in urinary retention of 24.11%. The reason for this marked difference between continents borders on health care financing, poverty, and illiteracy.[8],[17],[18],[19] Acute urinary retention (AUR) was the most common cause of urinary retention in our study accounting for 83% of urinary retention. This is in keeping with earlier studies in Ghana and Senegal.[4],[13] Yenli et al.[13] found that 83. 5% of urinary retention was due to AUR. Acute on-chronic urinary retention (CUR) accounted for 27 (17%) of urinary retention. A similar value was also corroborated by other authors who found a prevalence of CUR ranging from 12.6% to 16.5%.[4],[13] The three most common causes of AUR in this study were benign prostatic enlargement (BPE), urethral stricture, and cancer of the prostate. This is similar to other studies.[12],[20],[21],[22] The prevalence of BPE as a cause of AUR in this study was 67.4%. This is close to the 64% prevalence reported by Ikuerowo et al.[21] in Lagos. In civilized countries, the prevalence of BPE as a cause of acute urinary retention is 44%.[23] This variability in prevalence between these two societies can be explained by illiteracy and poverty and absence of health insurance which make patients present late with complications Literacy level in Nigeria is low hence, these patients are ignorant of the significance of their symptoms and therefore pay no attention to them, with AUR heralding the diagnosis of BPE.[8],[24] Poverty is endemic as 70% of Nigerians live on less than $1 daily.[17] Even though the cost of treatment in Nigerian government hospitals is subsidized, most patients may only be able to afford the first dose of treatment and abandon treatment because of the inability to continue to fund the cost of treatment.[25]
In Nigeria, out-of-pocket financing accounts for as high as 68% of total health expenditure.[18],[19] Health insurance covers the civil servants, which is a fraction of the population, and this financing is without full coverage.[25]
Acute scrotum accounted for 68 (25.5%) of emergency urological presentations. Fournier's gangrene and testicular torsion were the most common forms of presentation. The prevalence of Fournier's gangrene was noted to be 8.6%. This is significantly higher than what was reported by authors from neighboring countries, where they reported prevalence ranging from 1.8% to 4.1%.[3],[4] This pathology was, however, not noted in a study in France.[2] The regional differences in the incidence of this pathology could be explained by the difference in health-seeking behavior. There seems to be a taboo ascribed to urogenital disease, so most patients use traditional medicine initially only to present at a later stage with a florid disease.[12]
Testicular torsion accounted for 23 (8.6%) of emergency presentations and 23 (33. 8%) of acute scrotum. This is slightly lower than 9.8% prevalence reported in Abuja by Atim et al. in Gwagwalada, Nigeria.[26] It is also lower than the 50.6% prevalence of this pathology as a cause of acute scrotum as noted by Mbibu et al. in Zaria, Nigeria.[27] The difference in prevalence between these geographical regions of the country cannot be elucidated from this study.
Bladder and ureteral injuries accounted for 5 (55.5%) of female presentation to the emergency. Similar injuries accounted for 4 (1.6%) of male presentation. (P = 0.000). Of the bladder injuries in women, 100% was iatrogenic while in men, two (66.7%) were due to blunt abdominal trauma. Two (66.7%) of ureteral injuries occurred in women, and these were due to pelvic surgery. This wide gender variability in the etiology of injuries in these pelvic organs can be accounted for by the high incidence of injuries to these organs during gynecologic surgeries in our region.[28],[29]
Urethral catheterization accounted for 139 (52.1%) of the procedures performed. This is similar to the 54.3% that was reported in Guinea by Diallo et al.[3] but slightly lower than earlier studies in neighboring West African countries.[12],[13],[20] Suprapubic cystostomy was employed to relieve urinary retention in 31 (11.6%) of patients, this rate is lower than what was reported in Kano, Nigeria where up to 39% of urinary retention was relieved by suprapubic cysytostomy[22] Close to half of retentions (42%) relieved by percutaneous SPC were due to BPE. This rate could however be further reduced if there were coude-tip urethral catheters which make urethral catheterization more successful in patients with BPE.[30]
Wound debridement accounted for 23 (8.6%) of the procedures done. This is higher than the 2.4% recorded in Guinea.[3] This difference can be explained by the high incidence of Fournier's gangrene in our study compared to theirs and also because the same treatment may be offered for scrotal injury.
Conclusion Urological emergencies have varied presentations in both sexes. Urinary retention, Fournier's gangrene, testicular torsion, and scrotal injuries were the most common urological emergencies in our facility. This knowledge can be used in emergency preparedness planning which involves personnel training and resource allocation.
Acknowledgements
Many thanks to Dr Chidimma Ogechukwu Ezeilo for her meticulous technical input.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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