Epidemiology and management of urological emergencies in a tertiary care setting in Scandinavia | International Journal of Emergency Medicine

In this study, a majority of patients presenting to the ED with urological issues were male. Most patients were triaged to the SUT section, with the majority self-referred. One reason for some patients to not be referred to the SUT section is that urinary infections in females usually is seen as an infectious disease or internal medicine problem in Sweden. Urological symptoms such as loin pain, fever, LUTS and macroscopic hematuria were common, with UGIs being the most frequent diagnoses. A significant portion of patients required admission, particularly for UGIs and macroscopic hematuria, with a median hospital stay of 4 days. Acute radiological imaging was performed in a substantial number of patients, with CT being the most common procedure, though many exams revealed no urological pathological findings.

In contrast to other studies [6, 17] demonstrating seasonal variations in incidence of urological emergencies, our findings showed no evidence of such seasonal variation. This discrepancy may be attributed to the fact that summer in other countries are significantly hotter than in Sweden, making individuals more susceptible to dehydration during the summer months and, consequently, more prone to renal colic. Furthermore, the diagnostic agreement variability, assessed using Cohen’s kappa (κ = 0.741), indicated an elevated level of consistency between the preliminary diagnoses made by ED staff and the final diagnoses established after the evaluation of all radiological and laboratory findings.

Among the 106 patients with four or more contacts with a urological unit during the study period, recurrent presentations were predominantly due to UGIs, macroscopic hematuria, and urolithiasis. These findings align with studies showing that patients with chronic urologic conditions often experience repeated acute episodes that necessitate imaging [18], noted that recurrent stone formers benefit from CT imaging to monitor stone burden and assess for complications such as obstruction or infection, emphasizing the role of imaging in long-term management.

Interestingly, the admission rate was higher among patients who sought care independently compared to those referred by a GP in primary care. This suggests that self-referred patients may present with more severe conditions, as they often contact emergency services directly due to serious symptoms, leading to a higher proportion of severe cases in this group. However, the overall admission rate remains relatively low, with only one-fifth of patients being admitted, compared to the national average, where approximately one in three emergency visits results in hospital admission [19]. The relatively low admission rate, despite the higher number of GP referrals, may indicate that primary care providers might not always fully assess the severity of conditions before referring patients to the ED [20]. This highlights areas where the primary care system could benefit from increased capacity to manage urological emergencies [21].

To address this, targeted training programs that enhance primary care providers’ ability to diagnose, and manage such conditions, including when to appropriately refer patients to specialized care, would be beneficial. Additionally, equipping primary care facilities with essential diagnostic tools and allocating more resources to improve access to primary care physicians would allow patients to receive timely assessments, reducing unnecessary ED visits. Furthermore, improving access to specialist consultations through telemedicine or streamlined referral systems could ensure timely expert advice and reduce unnecessary ED referrals. Additionally, establishing a dedicated catheter nurse-led clinic for patients would be highly beneficial in providing specialized care, improving patient outcomes, and optimizing resource utilization. Overall, only a small proportion of ED visits lead to hospital admission. This suggests that many patients may be seeking emergency care for conditions that could have been effectively managed in a well-equipped primary care setting or through self-care.

Self-referred patients were more likely to have urolithiasis, whereas those who visited a GP before their ED visit more commonly presented with UGIs. This pattern may be influenced by differences in the perceived severity of symptoms and the urgency felt by the patients. Symptoms of urolithiasis, such as severe pain, might prompt individuals to bypass primary care and seek immediate help at the ED. In contrast, UGIs symptoms might initially seem less severe, leading patients to seek care at primary healthcare centers first, where the infection is identified and potentially escalated to the ED if necessary. Additionally, primary care providers may triage and refer UTI cases to the ED more frequently when complications or advanced care are required.

Our study reveals that almost half of all patients underwent acute imaging during their ED visit or within 4 weeks. The high proportion of normal imaging results observed in this study highlights the need for more judicious use of imaging. Over-reliance on imaging may lead to unnecessary radiation exposure [22], increased healthcare costs, and delays in clinical decision-making. Although this high rate of negative results might suggest potential overuse, 23% of cases had urolithiasis. Clinical decision tools, such as the STONE score, or other diagnostic algorithms have been validated to predict the likelihood of urolithiasis and can aid in selecting patients who would benefit most from imaging [23].

To mitigate these risks, it is crucial to establish evidence-based guidelines for when CT imaging is truly necessary [24]. While CT provides superior diagnostic accuracy, US offers a radiation-free alternative but is operator-dependent. Comparative studies, such as those by Smith-Bindman et al. [25] suggest that tailored approaches integrating clinical judgment and resource availability can optimize imaging use. Encouraging the use of alternative diagnostic methods, such as US where appropriate, and providing ongoing training for healthcare professionals in clinical decision-making may therefore improve the judicious use of imaging. Emerging technologies and AI-driven imaging algorithms may improve diagnostic accuracy further [26].

Patients with urological catheters constitute a vulnerable subgroup. This population is predominantly elderly, making them more prone to complications. The use of catheters increases the risk of infections and other complications, with nearly half of these patients requiring hospitalization. In accordance with our results, urinary catheterization is highly prevalent among patients admitted to urology departments, with up to 75% receiving a catheter during their hospital stay and around 20% already having one in place before admission [27].

The frequent need for hospital admission highlights the complexity of catheterized patients’ conditions. Additionally, nearly half of these patients received antibiotic treatment, indicating a high burden of infection or infection-related concerns in this population [28]. This underscores the need for better preventive measures, such as improved catheter care protocols, timely assessments, and judicious use of antibiotics to prevent resistance.

Our study has several strengths, being the first Scandinavian investigation regarding the epidemiology of urological emergencies. It provides valuable insights into the urological acute care landscape and related factors within the population, offering a snapshot of data that can inform public health planning and resource allocation. Moreover, with a study population of 2 433 patients, it provides a solid foundation for making further decisions regarding the development of acute care services. However, there are limitations to consider. Given the cross-sectional nature of the study, it cannot establish causal relationships, as both exposure and outcomes are measured at the same time. Additionally, the study may be influenced by biases, including selection bias that the participants included in this study may not be representative of the broader population, potentially skewing the results and limiting the generalizability of the findings.