When I started my first core surgical trainee (CST) job in urology, I had no prior exposure or experience. Quickly I realised the significant step up and responsibility involved. Covering multiple sites overnight is something that requires organisation and awareness of clinical prioritisation.
As a new trainee, it’s easy to become overwhelmed. Looking back, there are a few key lessons I wish I had known from day one: small pieces of knowledge that would have made those first few months less daunting and more efficient.
Catheterisation – giving good advice will save you time
This is likely the most common referral. Giving effective advice and starting from basic trouble shooting can prevent the need for intervention such as flexible cystoscopy. Gaining information such as where the catheter is getting stuck helps indicate whether the problem is at the prostate (more common), versus a proximal obstruction such as a stricture. Always find out how many tries have been attempted and whether a balloon has been inflated. This helps gives you an idea of the degree of urethral trauma.
Prostate problems: ensure the penis is taut to straighten the urethra and use plenty of Instillagel®. Using a silicone catheter is usually preferable, particularly a 16Fr. Often smaller, softer catheters are tried first which is an easy solution. Silicone’s firmness aids navigation through the urethra and prostate, making passage smoother and reducing the risk of trauma. A Tiemann (Coude) tip catheter can be a gamechanger in difficult catheterisations. The curved tip helps guide the catheter past the obstruction more naturally, sometimes avoiding the need for a flexible cystoscopy altogether. It’s a small adjustment in technique that can have a big impact in clinical efficiency and is always worth trying before escalating to invasive measures.
Strictures: urethral strictures will likely need intervention such as the use of a guidewire and flexible cystoscope. If the catheter feels like it is hitting a blind end, it is useful to downsize and if a 12Fr will not pass, the use of a flexible cystoscope is required to gain direct visualisation ensuring no further damage is sustained.
What takes clinical prioritisation?
Testicular torsion: Time is critical. Torsion is a urological emergency where delays can cost viability. Every suspected case should be assessed immediately. You receive many emergency referrals for testicular torsion, most of which are benign cases of epididymitis or orchitis. However, cases do occur and can have a variable presentation. Not all are classic, sudden onset severe testicular pain with vomiting. Some patients present with a delayed presentation or perhaps do not communicate the severity of their pain. It can be helpful to use the ‘twist score’ especially in younger patients or those with learning difficulties to help in decision making.
Septic stones: An obstructed infected system is a urological emergency and can deteriorate rapidly, mainly due to the kidneys receiving 25% of the cardiac output and leading to the development of sepsis. Early recognition, broad-spectrum antibiotics and urgent decompression (either via nephrostomy or stent) are essential if the patient is unwell. Patients need assessed for fitness for surgery. If patients are not fit for a general anaesthetic, nephrostomies are often considered. These cases often require coordination with radiology and senior input – act fast and escalate early.
Non-septic stones: Commonly called through to urology for ongoing outpatient management or admission. Patients who are not septic and responding well to antibiotics with no impairment in renal function do not need to be operated on overnight. For smaller, non-obstructed stones calculate the probability of stone passage using the ‘MIMIC Calculator’. This will help guide management and check your department pathway for follow up.
Retention: clot versus acute
Clot retention: Clot retention can be distressing for patients. The problem commonly occurs in a postoperative setting or patients with a known bladder malignancy as well as anticoagulated patients. Clots in a two-way catheter will continue to cause problems; prompt bladder irrigation, evacuation of clots and ensuring adequate catheter drainage are key. Manual washout with a bladder syringe until clear, increases the success of intervention. Patients often require the insertion of a three-way catheter and irrigation (or upsize..). Postoperative bleeds, such as after transurethral resection of the prostate (TURP), can respond to pressure through further inflation of the catheter balloon and traction. If there is any haemodynamic compromise, persistent bleeding despite irrigation or tension, escalate early as the patient may require emergency theatre for cystodiathermy and washout.
Acute urinary retention (AUR): Establish the urgency of the situation. Question the nature of the presentation. How long since the patient passed urine? Is the patient uncomfortable? A common referral is for a patient who has an incidental large volume on bladder scan but is comfortably asleep and has stable renal function. This is not an acute emergency. Understanding renal function in the context of acute urinary retention is essential. If renal impairment is present, this often suggests high-pressure chronic retention (HPCR). In such cases, do not be tempted to advise patients that they will be given a trial without catheter before the underlying cause, commonly benign prostatic hyperplasia (BPH), is properly addressed. Premature removal can risk recurrent retention or worsening renal function. Conversely, if renal function is normal, a cautious trial without catheter can be considered once the cause has been optimised. Always individualise care but let renal function be your guide.
Renal trauma
Renal injuries are often referred after the initial trauma assessment and management has started. Renal traumas are graded, and the majority are conservatively managed (grade I–III). Review imaging and the report; ensure a CT with a delayed phase has been performed as this will assess for injuries resulting in a urine leak. Assess the patient: review haemodynamic stability, evidence of ongoing bleeding, renal function and whether haematuria is present. If intervention is required, this requires discussion at a consultant level and will involve potential interventional radiologists.
Conclusion
Urology can be unpredictable, but a few core principles can help you stay ahead of the curve. Recognise true emergencies early, know your tools, and understand the physiological reasoning behind your decisions. If you are uncertain, the safest way forward is to discuss with your friendly urology registrar! These lessons, born from experience, will not only make you more confident but also safer and more efficient as a trainee. The learning curve in urology is steep, but with the right mindset and a few practical insights it can be very rewarding.
TAKE HOME MESSAGES
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Information is key when getting referrals. Establishing what needs done out of hours helps prioritise your work. Giving good advice for others to troubleshoot may avoid adding another patient to your ‘to see’ list.
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Recognise and act fast on true urological emergencies. Testicular torsion, septic stones and clot retention require immediate attention. Early intervention and escalation is needed.
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Think systematically, communicate clearly and escalate if unsure. Whether it’s handling renal trauma, liaising with radiology or knowing when to call for help, good judgment and teamwork is needed for patient safety.
