 The next acute symptom patient present with is an acute scrotum. So it can be a torsion of appendix, torsion of spermatic cord or torsion of the testis. It can be infections like epidemitis, epidemocritis, all this can be easily ruled out with a simple ultrasonography and a history taking. History generally with epidemitis and epidemocritis is a long standing really it will take about 3 to 4 days. Secondary factors like diabetes or immunosuppression might be the cause. Unlike in torsion of spermatic cord or torsion of testis where the patient is young male, adolescent male with an acute history or acute spontaneous onset of testicular pain. Rare causes can still be vascularities or dermatological lesions which will make acute scrotum. So the first investigation of choice in acute scrotum is a duplex ultrasound of scrotum. If the diagnosis is clinically suspicious, yes we do not delay the patient for any investigation. The colonopulore ultrasound has the maximum sensitivity of 88% and the specificity of 98%. Yes, here you can see the reduced blood supply to the testis and also you can make out the twist or the torsion of the spermatic cord just before the junction where the blood supply has stopped. So surgical exploration is very important. One is to diagnose the problem, de-rotate the testis and make sure that it is not any other problem in the form of epidemocritis. Occasionally we may find on table that we have taken the patient into war with the primary diagnosis of torsion but may land up in acute epidemocritis. But yes, still that is okay but we can manage with antibiotics but we have not missed out torsion and lost his testis. So an acute epidemocritis generally is an endurance process where he has a scrotum swelling, erythema, pain and generally they have very severe tenderness and the cremastic reflex is present in epidemocritis whereas it is lost in torsion. Here the management is bed rest, scrotal support, parenteral antibiotics with IV after her diagnosing is DI and any urethral instrumentation, per urethral instrumentation catheterization should be avoided in epidemocritis. Suppose you have a large epidemocritis with retention, the preferred mode of drainage would be an SPC over foley's catheter. The next emergency where we are called is preapism. It is persistent erection of penis for more than 4 hours that is not related with a sexual desire. It can be ischemic or a non-ischemic, generally ischemic preapisms are painful whereas a non-ischemic preapisms are painless. Now the role of urologist to treat is a preapism is more in ischemic where we have to act very fast within 6 hours to drain the blood. The diagnosis for ischemic and non-ischemic is first is clinical. The next thing is we draw a corporal blood and check his ABG, if the partial pressure of oxygen in the ABG is lesser than 30, we diagnose it as an ischemic preapism versus a non-ischemic preapism where the partial pressure of oxygen is more than 90 millimeters of mercury. So this we have to diagnose because the mode of therapy or mode of treatment is completely different. Other causes for preapism include drugs, some trauma, hematological disease like sickle cell disease and tumor. The diagnosis is usually obvious from the history and the duration of erection should be more than 4 hours. Painful or not is because we have to differentiate between ischemic and non-ischemic preapism. And the previous history of and treatment of preapism is also important because early in sickle cell disease, these patients have repeated episodes of preapism. Yes, that indicates that it is again an ischemic type of preapism which has to be treated immediately. So treatment depends on the type of preapism as I told initially, many of the time it is a conservative treatment where if it is an ischemic preapism, we inject phenyl effrin. We drain the blood, inject multiple episodes of phenyl effrin in the dose of 100 to 500 micrograms diluted phenyl effrin up to 1 hour. See the response, generally 80 to 90 percent they respond and then we manage accordingly. Suppose it fails then there is a surgical option where we shunt the blood in the form of shunts. The next form of urological emergencies are trauma. The most important ones and the most common ones are the renal trauma, bladder trauma and the urethral injuries. Urethral injuries are rare, usually we get on-table calls for urethral injuries otherwise in emergencies the renal trauma and the bladder trauma are very common and very important to know how we do the manage. It can be blunt or penetrating, a direct blow or exhilaration or deceleration injuries to the kidney can cause this. A penetrating with injury with knives and got shot or heterogenic, yes can cause this type of renal trauma. Indications for renal imaging, the best imaging is contrast and then CECT abdomen and pelvis with delayed phase if the patient is hemodynamically stable. So microscopic hematuria, penetrating injuries associated, hypertensive patient which has been resuscitated, rapid exhilaration or deceleration injury in the history or any child with a microscopic hematuria with a trauma, blunt injury abdomen warrants any renal imaging. Non-contrast imagery is inferior, yes contrast CECT abdomen is accurate, rapid and images other than and it images all other organs also for management. So generally we try to grade these renal injuries from right from sub-scapular hematoma up to renal avulsion, the highest grade is vascular pedicle avulsion, grade 4 involves the collecting system injury. So generally we can classify in this group and up to grade 1 to 4 still there is role for non-exploratory laparotomy provided we have sufficient ICU backup and monitoring system and grade 5 of ascorb injury, yes we have a role for nephrectomy. So these are the images, the right kidney has a small laceration of the upper pole of the kidney, these type of injuries are generally monitored and they settle they do not require any exploratory laparotomy and procedure. 95% of the images, 95% of the injuries are managed conservatively of the penetrating injuries of isolated kidney then 50% are still managed conservatively we just monitor their hemoglobin, their urine outputs and their general condition without intervening them. Bedrest, IV antibiotics and vital signs monitoring hemoglobin are the key 4 indicators where which tells that the patient is not deteriorating. Surgical exploration is limited only for patients we have persistent bleeding or hypotensive persistent hypotensive they are expanding there is expanding perinatal hematoma on follow or there is a pulsatile perinatal hematoma. The next form of injuries are in the form of bladder injuries where it can be a penetrating or a blunt injury, rarely spontaneous ruptures can happen in very in cases of benign enlargement of prostate where the bladder has severe excessive filling pressures. This type of injuries can be classified into intraperitoneal and extaperitone why this classification is important because almost all the extaperitoneal perforations the second pictures the second picture shows the contrast these are CT's histogram where we have passed the catheter and filled the contrast and then taken a CT is not a delayed phase the dye has gone beyond the bladder but still it is contained inside the peritoneum. So these are the injuries where which can be managed almost 95% conservatively we just have to place a catheter monitor them for 2 to 4 weeks unlike this type of injury where the bladder has been injured and the whole dye is passing in the whole abdomen. The problem here is the urine keeps leaking into the peritoneum keeps getting absorbed into the peritoneum it causes raised creatinine it can cause peritonitis these injuries have to be treated surgically. So generally with intraperitoneal rupture patients will have abdominal pain abdominal peritoneitis raised in creatinine sometimes occasionally hypertension with associated other abdominal injuries but with extaperitoneal injuries they do have a supra pubic type of pain sometimes more frightening on look but there generally be a extaperitoneal injury. Yes of course all the patients almost all will have hematuria. So bladder trauma do a CT's histogram if he is stable if it is intraperitoneal will have to go and close it if it is an extaperitoneal yes only catheter drainage is sufficient.