Spectrum of non-traumatic urologic emergencies in eleven (11) urology centres in Ghana: a cross-sectional study

¹Department of Surgery, Korle Bu Teaching Hospital, University of Ghana, Accra, Ghana, ²Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti Region, Ghana, ³Department of Surgery, Tamale Teaching Hospital, Tamale, Northern Region, Ghana, ⁴Data Analyst, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana, ⁵37 Military Hospital, Accra, Ghana, ⁶Police Hospital, Accra, Ghana, ⁷Cape Coast Teaching Hospital, Cape Coast, Central Region, Ghana, ⁸Sogakope District Hospital, Sogakope, Ghana, ⁹Ho Teaching Hospital, Ho, Volta Region, Ghana, ¹⁰University of Health and Allied Sciences (UHAS), Ho, Volta Region, Ghana, ¹¹Koforidua Regional Hospital, Koforidua, Eastern Region, Ghana, ¹²Seventh-Day Adventist (SDA) Hospital, Kumasi, Ghana, ¹³Sunyani Government Hospital, Sunyani, Ghana, ¹⁴Kumasi South Hospital, Kumasi, Ghana, ¹⁵Wenchi Methodist Hospital, Wenchi, Ghana, ¹⁶Techiman Holy Family Hospital, Techiman, Ghana, and University of Cape Coast Medical School, Cape Coast, Central Region, Ghana

^&Corresponding author
Frank Obeng, Department of Surgery, Urology Unit, University of Health and Allied Sciences (UHAS), P.O. Box 13, Ho, Volta Region, Ghana

Introduction    

Burden of urological emergencies - global to Ghana

urological emergencies represent an important component of acute healthcare utilisation, encompassing obstructive, infective, haemorrhagic, traumatic and genital conditions in which delayed treatment may result in irreversible organ damage, sepsis, loss of sexual or reproductive function, or death. Globally, emergency urological patients comprise >2% of emergency-department presentations and up to 30% of urology admissions [1]. National French registry data covering >720 emergency departments found that urological emergencies accounted for 4.2% of all emergency presentations, approximately 591,080 visits annually, with infection, renal colic, acute urinary retention and haematuria as prominent presentations [2]. More broadly, emergency conditions impose a disproportionately high burden in low-income settings, where median emergency-condition disability-adjusted life years (DALYs) have been estimated at 47,728 per 100,000 population, compared with 25,186 and 15,691 in middle- and high-income countries, respectively [3].

Across Africa, evidence remains predominantly hospital-based but consistently demonstrates substantial urological emergency workloads. Urinary retention, infection, haematuria, ureteric obstruction, acute scrotal disease, priapism and Fournier's gangrene recur among the principal presentations [4-6]. In a six-year tertiary-centre series, urinary retention accounted for 51.7% of emergencies, followed by testicular torsion (10%), bilateral ureteric obstruction (5.4%) and priapism (5.3%); suprapubic cystostomy was the commonest operative procedure [4]. A systematic review of 30 sub-Saharan African studies involving 21,904 patients presenting with urological emergencies found that approximately 6.6% were attributable to genitourinary trauma, predominantly urethral (42.9%) and external genital injuries (25.1%). These, however, should be interpreted alongside problems of under-reporting, inadequate emergency registries, and specialist capacity [5]. Thus, the African burden encompasses both common obstructive/infective disease and potentially catastrophic traumatic and genital emergencies.

The West African literature similarly indicates a substantial but heterogeneous burden, largely derived from tertiary centres. At Dakar University Teaching Hospital, 1,237 urological emergencies were recorded over 20 months; acute urinary retention constituted 53%, genitourinary infection 16.4%, Fournier's gangrene 4.1% and priapism 1.3%, while suprapubic catheterisation was the dominant emergency procedure [6]. In Port Harcourt, Nigeria, 592 urologic emergencies constituting 3.25% of 18,194 emergency admissions were seen. Urinary retention (47.5%), haematuria (16.7%), trauma (12.0%) and testicular torsion (5.6%) predominated [7]. Collectively, these studies demonstrate a recurring West African pattern of obstruction, infection, haematuria and acute genital pathology, but also substantial institutional variation related to referral patterns, case definitions and available specialist capacity.

In Ghana, published evidence remains limited and institution-specific. At Komfo Anokye Teaching Hospital, a prospective study of 206 adults with urinary retention found 172 (83.5%) had acute urinary retention; among men, benign prostatic enlargement was the leading cause (58.1%), followed by urethral stricture (14.7%), prostate cancer (13.1%) and traumatic urethral injury (13.1%) [8]. More recently, a five-year study at Cape Coast Teaching Hospital involving 500 emergency patients identified genitourinary infection (66.2%) as the leading presentation, followed by urinary retention (10.6%), haematuria (5.6%), renal colic (4.2%), epididymo-orchitis (3.8%), Fournier's gangrene (2.2%) and priapism (2.0%) [9]. The contrasting Ghanaian patterns underscore important institutional heterogeneity. At the national level, Ghana performed an estimated 112,036 emergency operations annually, equivalent to 416 per 100,000 population, although urological procedures were not separately quantified [10].

Overall, the evidence suggests that urological emergencies constitute a substantial global acute-care burden; the wider emergency burden is disproportionately high in resource-constrained settings; African and West African studies demonstrate considerable hospital-level urological emergency activity; and Ghanaian studies confirm an important but incompletely characterised burden [1-10]. Ghana nevertheless lacks a geographically distributed, multicentre assessment of the volume, diagnostic spectrum, underlying conditions, interventions and outcomes of urological emergencies. This evidence gap limits service planning, resource allocation, specialist training and referral-pathway development and provides a strong rationale for the present multicentre investigation.

The aim of this study was to describe the spectrum of non-trauma urologic emergencies presented across various urologic centres in Ghana. The specific objectives were to identify the top five urologic emergencies, how they present, and the management modalities applied to them, as well as the outcomes of those management modalities. By achieving these objectives, the study aims to provide a robust evidence base that can inform clinical guidelines, enhance training programs, and improve patient care and outcomes.

Methods     

Study design: this study utilised a retrospective cross-sectional design to analyse data on non-trauma urologic emergencies for the period spanning January 1, 2017, to December 31, 2017. The year 2017 was selected due to the relative completeness and availability of data.

Study setting and population

Setting: this study targeted fifteen (15) urology centres affiliated with the Ghana Association of Urological Surgeons (GAUS). The selected centres include the available tertiary and regional hospitals spread across all major geopolitical zones of Ghana, ensuring a broad national representation. However, only eleven (11) out of the fifteen (15) centres successfully submitted data. These included teaching hospitals such as Korle-Bu, Komfo Anokye, Tamale, Cape Coast, Sunyani, and Ho Teaching Hospitals; 37 Military Hospital, Koforidua Regional Hospital, Wenchi Methodist Hospital, Sogakope District Hospital, Seventh-Day Adventist Hospital (Kumasi), and Kumasi South Hospital. The others (non-respondents) were Police Hospital, Accra, Margaret-Marquart Hospital, Kpando, and Techiman Catholic Hospital.

Participants: we included all patients who presented with non-trauma-related urologic emergencies between January 1 and December 31, 2017, at the eleven responding urologic centres. Eligible participants were identified from emergency room logs, surgical wards, minor procedure theatres, and operative theatre registers. Inclusion criteria were: Male or female patients of any age presenting with an acute non-traumatic urologic condition requiring urgent urological or surgical intervention. Exclusion criteria included: Patients with trauma-related urologic conditions and elective urologic admissions or procedures.

Variables

Key variables extracted included: independent variables: demographics (age, sex), type of urologic emergency (e.g., acute urinary retention, priapism, Fournier's gangrene), interventions administered (e.g. catheterization, cystostomy, debridement). The dependent variables included: outcomes (e.g., recovery, discharge home after treatment, referrals to higher centres, surgical complications, death). Each case was categorized into predefined diagnostic and procedural groups for uniform analysis.

Inclusion and exclusion criteria: all patients presenting with non-trauma urologic emergencies during the study period were included. Non-trauma urologic emergencies were defined as urologic conditions not related to external physical injury, requiring urgent or emergency urologic intervention. Exclusion criteria included trauma-related urologic emergencies and incomplete or illegible records.

Data sources/measurement: data were collected retrospectively from multiple sources, including emergency department records, urology ward admission logs, operating theatre registers, procedure books (for both major and minor surgeries), and discharge summaries. Trained clinical research assistants at each centre used a standardized data abstraction form designed by the GAUS research committee to ensure consistency. Ambiguous cases were discussed with the lead investigators for resolution.

Bias: to reduce selection and misclassification bias, all records within the defined period and criteria were exhaustively reviewed. Centres were provided with a uniform data extraction template; Missing data were excluded from individual analyses but noted in the results; independent reviewers performed cross-checking to validate the accuracy of extraction.

Data collection tool: each centre used a standardized Microsoft Excel spreadsheet developed for the study. To ensure consistency and accuracy, each centre received an orientation on uniform data entry practices and a designated data coordinator responsible for supervision and data integrity. All data were anonymized before being transferred for central analysis.

Data collection: the data collection process was standardized across centres. Training/repeated briefing sessions were held to ensure precision in abstraction, entry, and terminology usage. Data coordinators at each site oversaw the process and ensured adherence to the protocol.

Sample size and sampling: this was a census-based study of all eligible cases during the calendar year 2017. No prior sample size calculation was performed, as the aim was to describe the full national spectrum of non-trauma urologic emergencies over the twelve months, across the targeted 15 GAUS centres.

Quantitative variables: quantitative variables such as age and case volume per diagnosis were summarized using means, standard deviations, and medians as appropriate. Diagnostic categories were treated as categorical variables, while frequencies and percentages were computed for nominal outcomes.

Data analysis/statistical methods: descriptive statistics (means, medians, frequencies, proportions, percentages) were calculated to summarize demographic characteristics, emergency presentations, intervention type, and outcome. This constituted the socio-demographic analysis. Comparative analyses, bivariate analyses, multivariate analyses, and geospatial distribution analyses were conducted to explore trends in diagnosis, interventions, and outcomes across sites. Results were presented in tables, bar/pie charts, and spatial distribution maps to aid interpretation. All analyses were conducted using SPSS version 20.0 (IBM Corp., Armonk, NY, USA). A 5% level of significance was used.

Ethical considerations: ethical approval was obtained from the Ethical Review Committee of Ho Teaching Hospital (protocol ID: HTH-REC (06) FC_2025). The study was based entirely on existing medical records without direct patient interaction or intervention. All data were anonymised prior to analysis, and the ethics committee waived the requirement for individual informed consent due to the retrospective nature of the study.

Results     

Participants: the response rate for the study was 11 out of the 15 GAUS centres across Ghana, so we present the data for the 11 centres that responded. These included the teaching hospitals, namely Korle-Bu, Komfo Anokye, Tamale, Cape Coast, Sunyani, and Ho Teaching Hospitals; 37 Military Hospital, Koforidua Regional Hospital, Wenchi Methodist Hospital, Seventh Day Adventist Hospital, Kumasi, and Sogakope District Hospital.

Socio-demographic analysis: a total of 3,281 non-trauma urologic emergency cases were analysed from the 12 centres that provided complete datasets. The mean age of patients was 57.2 years (SD = 25.0), with a range spanning from 1 year to 102 years, reflecting the wide age distribution of urologic emergencies. The male-to-female ratio was approximately 4:1, indicating a higher prevalence of urologic emergencies among males. The patients' occupations varied widely, with a considerable proportion being retirees. Other common occupations included farmers, traders, and civil servants, highlighting the socio-economic diversity of the patient population.

Descriptive analysis: the spectrum of non-trauma urologic emergencies presented across various urologic centres in Ghana is shown in Figure 1 and Table 1. The cases include a diverse range of conditions, with the top 5 most common being lower urinary tract obstruction (LUTO) 43.8%), severe haematuria (16.3%), acute scrotum (6.6%), priapism (5.7%), and Fournier's gangrene (4.8%). Less common causes included pelvic prolapse, spinal cord compression and anaemia from metastasised prostate cancer, stuck catheter, penile fracture, and penile amputation (which are all captured under the 'others' category). Komfo Anokye Teaching Hospital topped in terms of case-loads: 618 cases (18.71%), with 4.07% mortality, but Korle-Bu Teaching Hospital topped in receiving the severest of cases (429 cases (13.07%) with 10.25% mortality) (Table 1). Table 2 shows the aetiologies of the top 5 non-trauma urologic emergency cases. Lower urinary tract obstruction (LUTO) was due to benign prostatic hyperplasia (BPH), 720 (49.2%) in older males, and urethral strictures (417 (28.8%) in younger males. These patients presented with acute urinary retention, dysuria, and suprapubic pain. Diagnosis was based on thorough clinical history, clinical examination, and, in some cases, ultrasound scan.

Causes of severe haematuria included bleeding BPH (303(56.3%), bladder cancer (61(11.3%), and prostate cancer (CaP) 39 (7.2%). Patients in this category presented with gross haematuria, clots in urine, and associated anaemia in severe cases, and the diagnoses were made using urinalysis, cystoscopy, and imaging studies. Acute Scrotum was due to epididymo-orchitis (92 (42.2%), testicular torsion (85 (39.2%), and scrotal abscesses (21 (9.6%), with patients presenting with acute scrotal pain, swelling, and erythema. Clinical examination, Doppler ultrasound, and laboratory tests were the main diagnostic tools. Priapism resulted from sickle cell disease (77 (40.3%), aphrodisiacs (52 (27.2%) and idiopathic causes (9 (4.7%). Patients presented with prolonged, painful erection (mostly purposeless) and unrelieved by ejaculation and were diagnosed by clinical history and examination. Lastly, Fournier's Gangrene, a fulminant polymicrobial infection, was precipitated or predisposed by trauma, diabetes, and immunosuppression. Symptoms included severe pain, swelling, and necrosis of the perineum and genitalia. The diagnostic tools included clinical history and examination, laboratory tests, and imaging.

Management Strategies for the Top 5 Non-Trauma Urologic emergencies were tailored to the specific diagnoses and severity of the condition. For lower urinary tract obstruction (Table 3), initial management was urgent catheterisation to relieve urinary retention. In 2017, 1,294 catheterization procedures (1,096 urethral and 198 suprapubic) were recorded for lower urinary tract obstruction, representing 96.2% of 1,345 LUTO procedures (Table 3). Using the Ghana Statistical Service GLSS7 projected 2017 population of 28,956,587 (Annex 1) [11], this corresponds to a crude annual procedural rate of 4.47 catheterizations per 100,000 population (44.7 per million). Using the estimated male population of 14.03 million (48.5% of the total population; (see GLSS7 projections under Annex 1), the corresponding male-population rate was 9.22 per 100,000 males per year (92.2 per million males (Table 3 and Annex 1). These rates are based on the participating-hospital dataset extrapolated against the national population and should therefore be interpreted as population-referenced procedural rates rather than national incidence rates.

Additional medical management for LUTO included alpha-blockers and 5-alpha reductase inhibitors for BPH, while surgical management was transurethral resection of the prostate (TURP) or open prostatectomy, urethral dilation, and bladder neck incision. The management of LUTO was associated with a crude mortality rate of 1.3% (Table 3 and Table 4). Severe haematuria was initially managed by bladder irrigation to clear clots. Subsequent definitive management was by fulguration, cystoscopy plus biopsy, and tumour resection (transurethral resection of bladder tumour, or radical cystectomy plus urinary diversion) for malignancies. The crude mortality rate for severe haematuria was 3%. Non-torsion acute scrotum (Table 3 and Table 4) was initially managed with pain management and scrotal elevation. Antibiotics were given for infections. Incision and drainage were done for abscesses. For testicular torsions, surgical intervention included emergency scrotal exploration and detorsion (plus bilateral orchidopexy). The crude mortality rate for the acute scrotum (Table 3 and Table 4) was 1%.

The initial management of Priapism was the aspiration of the deoxygenated corporal blood. Medical intervention was through intracavernosal injection of sympathomimetics (e.g., phenylephrine). Surgical management, including shunt procedures, was done for refractory cases. Priapism was self-resolving in 3% of cases, while 1% of patients declined treatment. Finally, Fournier's Gangrene was managed with broad-spectrum antibiotics, aggressive fluid resuscitation, and urgent debridement of necrotic tissue. Critically ill patients were managed in the intensive care unit (ICU). The Crude mortality rate for Fournier's gangrene was 3% (Table 3 and Table 4). The overall discharge rate exceeded 97.3% nationally, while overall mortality stood at 2.7%, with significant inter-diagnostic variation.

Bivariate analysis: bivariate analysis showed strong associations between outcomes and diagnosis (χ² = 76.02, p < 0.001), outcomes and management modality (χ² = 48.6, p < 0.001), and outcomes versus treatment facility (χ² = 216.79, p < 0.001). For instance, patients with lower urinary tract obstruction had high discharge rates, while mortality was more common in urosepsis and post-operative emergencies. Effective interventions such as antibiotics for epididymo-orchitis and Glanulo-cavernosal (GC) shunting for priapism were linked to better outcomes, whereas dialysis and Androgen Deprivation Therapy (ADT) for advanced malignancy were associated with higher death rates. Diagnoses also varied significantly by hospital (χ² = 2650.95, p < 0.001), reflecting regional differences in referral patterns and case complexity. Facilities like Ho and Koforidua had high discharge rates, while Korle-Bu and Komfo Anokye recorded more deaths, likely due to case severity.

Multivariate analysis: multivariate logistic regression identified urosepsis (aOR = 2.33, p = 0.003), upper urinary tract obstruction (aOR = 2.52, p = 0.001), and post-operative emergencies (aOR = 2.06, p = 0.011) as independent predictors of mortality when compared to acute scrotum. Conversely, diagnoses like priapism and intra-operative emergencies had no significant adjusted odds ratio) of mortality risk. Those patients presenting with urosepsis, upper urinary tract obstruction, or post-operative emergencies had the highest adjusted odds of death, controlling for diagnosis category. Other diagnoses showed variability but did not independently predict mortality with statistical significance.

Geospatial distributional analysis: geospatial mapping (Table 1 and Figure 2) showed case clustering around major tertiary centres - Komfo Anokye, Korle-Bu, Ho, and Koforidua - with higher death counts at the major centres. Diagnosis types and outcomes varied regionally, with Volta Region (Ho and Sogakope) recording high case volumes but zero or minimal mortality, while Greater Accra showed higher mortality rates, especially in haematuria-related emergencies (Table 1 and Figure 2).

Discussion     

This national audit of 3,281 non-traumatic urological emergency presentations across eleven urologic centres in Ghana represents one of the most geographically distributed multicentre datasets reported from sub-Saharan Africa. Lower urinary tract obstruction (LUTO) and severe haematuria were the predominant emergency categories, accounting for 43.8% and 16.3%, respectively. The predominance of urinary retention/obstructive disease is consistent with reports from several African settings, including Nigeria, Burkina Faso and Senegal, although the relative proportions vary substantially between populations and health systems [6-20].

The overall outcome was favourable, with >97% of patients discharged after treatment and an overall mortality of 2.7%. This compares favourably with the substantial morbidity reported for severe urological emergencies in resource-constrained settings. However, direct comparisons of mortality are difficult because previous studies have differed considerably in case mix, referral patterns and inclusion criteria [12,15,20]. The favourable overall outcome nevertheless demonstrates that most non-traumatic urological emergencies can be successfully managed when appropriate emergency urological services are available.

Patients in our cohort had a wide age distribution, with a mean age of 57.2 ± 25.0 years. This closely resembles the mean age of 56.6 years reported in Burkina Faso by Traore et al. [15] and 57.8 years reported from Casablanca by Larrache et al. [13], while the Nigerian series of Okeke et al. [12] reported a mean age of approximately 58 years. These broadly similar age distributions suggest that urological emergencies in African tertiary and regional hospitals disproportionately affect middle-aged and older adults, reflecting the contribution of prostate disease, urethral stricture, malignancy, and other age-associated urological conditions.

There was a marked male predominance of approximately 4:1 in our cohort. This is consistent with the male predominance reported across African urological-emergency series, although the magnitude varies considerably: Traore et al. reported a sex ratio of 12.05:1 in Burkina Faso, while Larrache et al. reported a male-to-female ratio of approximately 2.5:1 in Morocco [13,15]. The male predominance in our cohort is plausibly related to the large contribution of prostate-related disease, male urethral stricture, priapism and acute scrotal conditions. It is therefore more appropriately interpreted as a consequence of the diagnostic composition of the emergency cohort rather than simply a general sex difference in emergency healthcare utilisation.

Lower urinary tract obstruction was the dominant emergency category, accounting for 43.8% of presentations. This finding is highly consistent with several African reports. Traore et al. found urinary retention in 48.3% of emergencies in Burkina Faso, while Hamza et al. reported urinary retention in 51.7% of cases in Nigeria [15,20]. In contrast, renal colic predominated in the Indian series of Talreja et al., accounting for 24.2% of emergency presentations [16], illustrating the substantial geographical variation in urological emergency profiles. The French national registry likewise demonstrated a different pattern, with renal colic, acute urinary retention and haematuria constituting the principal male urological emergencies, while cystitis, pyelonephritis and renal colic predominated among women [2].

In our cohort, the principal causes of LUTO were BPH, urethral stricture, and prostate cancer, reflecting the importance of urethro-prostatic disease in Ghanaian emergency urology. This pattern is consistent with the Ghanaian experience reported by Yenli et al. [8] and with findings from Nigeria and Morocco [12,13]. The prominence of retention is clinically important because delayed presentation may convert potentially manageable lower urinary tract symptoms into acute retention requiring emergency decompression. In resource-constrained settings, patients may subsequently remain dependent on indwelling catheters while awaiting definitive treatment, increasing the risks of infection, recurrent obstruction, impaired quality of life and economic burden. Catheterisation was consequently the dominant intervention for LUTO. In the present dataset, 1,294 LUTO-related catheterisations were recorded, comprising 1,096 urethral and 198 suprapubic catheterisations and representing approximately 96.2% of the LUTO procedures recorded. This is consistent with the central role of urinary decompression reported in Ghana and elsewhere in Africa [8,13,15,20-25]. Traore et al. and Fall et al. reported suprapubic cystostomy as their most frequently performed operative procedure; whereas Hamza et al. reported successful urethral catheterisation in most patients with retention, with suprapubic cystostomy being the commonest operative procedure [6,15,20].

In the present study, the 1,294 catheterisations correspond to an estimated 4.47 LUTO-related catheterisation procedures per 100,000 population/year, or 9.22 per 100,000 males/year using the estimated male population as the denominator. This population-based procedural metric is not directly comparable with the 9.6% prevalence of long-term catheter users among Tanzanian urology outpatients reported by Ndomba et al. [25]. This is because the latter measures catheter-user prevalence rather than annual procedure frequency. The Ghana finding nevertheless highlights the substantial procedural burden generated by late presentation with obstructive disease.

These findings support the need for earlier recognition and treatment of lower urinary tract symptoms, particularly among men at risk of BPH, prostate cancer and urethral stricture. Public-health education should encourage men to seek assessment at the stage of progressive LUTS rather than waiting until complete urinary retention develops. Early presentation could permit medical or elective surgical management and potentially reduce emergency catheterisation, prolonged catheter dependence, and associated infectious and economic consequences.

Severe haematuria was the second most frequent emergency category, accounting for 16.3% of presentations. Bleeding BPH, prostate cancer and bladder cancer constituted the principal underlying conditions in our cohort. The prominence of haematuria is consistent with the broad spectrum of haemorrhagic emergencies described in African urological practice, although the relative frequency varies between settings [2,12,13,15]. The Moroccan series of Larrache et al. reported haematuria in 7.68% of urological emergencies, with bladder tumours accounting for most cases, while the Burkina Faso series reported total haematuria in 7.28%, with bladder tumour as the principal cause [13,15]. The higher proportion observed in our cohort may therefore reflect differences in case ascertainment, referral patterns, and underlying disease prevalence.

Acute scrotum accounted for 6.6% of emergencies in our study and comprised principally epididymo-orchitis, testicular torsion and scrotal abscess. This burden is clinically important because testicular torsion is time-sensitive and delay can result in irreversible testicular loss [17,18]. The spectrum observed in our cohort is consistent with African reports documenting testicular torsion among the important acute scrotal emergencies, although the proportions vary according to age structure, referral pathways and whether cases are managed at peripheral or specialist centres [17,18]. Emergency management appropriately included antibiotics and analgesia for infective disease, drainage or debridement for abscess and necrotising disease, and detorsion with bilateral orchidopexy. Orchidectomy was done in cases of testicular necrosis.

Priapism accounted for 191 cases (5.7%), making it another important component of the Ghanaian emergency urological workload. Priapism requires prompt treatment because prolonged ischaemic priapism can result in corporal smooth-muscle necrosis, fibrosis, and permanent erectile dysfunction [19,24]. The Nigerian series by Hamza et al. reported priapism in approximately 5.3-5.4% of urological emergencies, providing a particularly close regional comparator [20]. In our cohort, sickle-cell disease accounted for 75.8% of identified causes, consistent with the importance of haemoglobinopathy-related ischaemic priapism in West Africa. Ahmed et al. in a dedicated Nigerian series from Zaria, similarly found that 82.5% of patients with ischaemic priapism had sickle-cell anaemia and demonstrated substantial erectile morbidity associated with delayed presentation [19].

A further notable finding was that 27.2% of priapism cases were attributed to sex-enhancing medications, including sildenafil and locally available aphrodisiac preparations. This finding warrants attention because the use of unregulated or poorly supervised sexual-enhancement products may contribute to preventable emergency presentations. Management in our cohort involved the established emergency approaches of corporal aspiration, intracavernosal sympathomimetic therapy, and shunt procedures where required. These approaches are consistent with contemporary management principles described by Alnajjar and Muneer [24] and with the Nigerian experience reported by Ahmed et al. [19].

Fournier's gangrene was less frequent but clinically important because of its potential lethality. In our cohort, 157 cases were recorded, and mortality was approximately 3%. The underlying causes included urological, anorectal, and cutaneous sources, diabetes and other conditions, although a substantial proportion remained unspecified. This contrasts with the Burkina Faso experience reported by Traore et al. in which urological causes accounted for 36.6% of Fournier's gangrene cases and overall mortality was 24.4% in a dedicated series of external-genital gangrene [15]. The markedly lower mortality in our overall cohort may reflect earlier recognition, differences in disease severity, access to resuscitation and repeated debridement, or differences in case ascertainment. Nevertheless, Fournier's gangrene remains an emergency requiring aggressive resuscitation, broad-spectrum antimicrobial therapy and prompt, often repeated, surgical debridement.

Finally, upper urinary tract obstruction, urosepsis and postoperative and intraoperative complications constituted additional important components of the emergency workload. Their presence across geographically diverse participating hospitals reinforces the need for urological emergency services capable of managing not only retention and haematuria but also obstructive, infective, genital and iatrogenic emergencies. The substantial variation in emergency patterns reported across Ghana, West Africa, North Africa, India, Europe and Israel indicates that urological emergency profiles are strongly influenced by disease epidemiology, referral pathways, healthcare access and local treatment practices [2,6,12,13,15,16,20,21]. The present multicentre Ghanaian dataset therefore provides an important national benchmark against which future changes in emergency presentation, intervention and outcome can be assessed.

Bivariate analyses confirmed significant associations between diagnosis and outcomes (χ² = 76.02, p < 0.001), as well as between management approaches and outcomes within major conditions such as LUTO (χ² = 48.6, p < 0.001), underscoring the importance of diagnosis-specific management and timely intervention in emergency urological care. Similar relationships between the type of emergency, treatment requirements, and clinical outcomes have been described in African emergency-urology series [6,12,15,20].

Notably, multivariate logistic regression identified urosepsis (aOR = 2.33), upper urinary tract obstruction (aOR = 2.52), and post-operative emergencies (aOR = 2.06) as independent predictors of mortality after adjustment for confounders. These findings are clinically plausible because infective and obstructive emergencies can progress rapidly to systemic illness and organ dysfunction, while postoperative emergencies may represent complications requiring urgent recognition and intervention. Previous African emergency-urology studies have similarly demonstrated substantial morbidity associated with severe obstructive, infective and postoperative conditions, although direct comparison of adjusted effect estimates is limited because most published audits have not used multivariable mortality models [6,12,13,15,20]. On the other hand, priapism and intra-operative emergencies were not independent predictors of mortality in our cohort; they are rather morbidity-related diseases. The relatively favourable mortality associated with priapism is consistent with the predominantly survivable nature of the condition when timely treatment is provided, although delayed treatment carries a major risk of permanent erectile dysfunction [19,24].

The geospatial analysis demonstrated marked variation in the distribution of cases and deaths between participating hospitals. Korle-Bu and Komfo Anokye recorded the highest absolute numbers of deaths, consistent with their roles as major tertiary referral centres receiving patients from wide catchment areas. However, absolute mortality counts should not be interpreted as evidence of poorer hospital performance without adjustment for case volume, disease severity and referral status. Similarly, the relatively high case volumes but low mortality observed at Ho Teaching Hospital and District Hospital-Sogakope should be interpreted cautiously, as the present study did not directly measure referral delay, disease severity at presentation, triage performance or treatment availability. The geographical variation nevertheless highlights the importance of referral pathways and differences in emergency-urological service capacity across health systems: issues also recognised in African urological-emergency literature [4,6,12,15,20].

The spectrum of acute scrotal pathology (6.6%) and priapism (5.7%) in this cohort is consistent with previous African emergency-urology reports [16,18,19]. Acute scrotal emergencies require rapid assessment because testicular torsion is time-dependent, and delayed intervention may result in testicular loss [17,18]. Similarly, ischaemic priapism requires urgent treatment to prevent corporal fibrosis and subsequent erectile dysfunction [19,24]. The absence of a statistically significant independent mortality association for these conditions in our multivariable model should therefore not be interpreted as evidence that they are clinically less urgent; rather, mortality is an inappropriate sole measure of outcome for conditions in which organ preservation and functional outcomes are important.

Overall, this study supports data-driven triage, strengthened regional emergency-urological capacity and standardised management pathways for the principal urological emergencies encountered in Ghana. The marked variation in emergency patterns and outcomes across hospitals further supports the need for coordinated referral systems and appropriate distribution of specialist expertise and resources [1,4,6,20]. Experience during the COVID-19 pandemic also demonstrated how disruption or delay in access to emergency urological care can alter presentation patterns and potentially compromise time-sensitive management, particularly for conditions such as testicular torsion [21,22]. These observations reinforce the importance of maintaining timely access to emergency urological assessment even during health-system disruptions.

Limitations: the retrospective nature of the study and reliance on available records may have introduced bias, including underreporting of cases and variability in data quality across centres. Additionally, the exclusion of trauma-related urologic emergencies limits the generalizability of findings to trauma contexts. Future studies should consider a prospective design and include trauma-related emergencies for a comprehensive understanding of urologic emergencies. Colics due to urolithiasis are becoming commonplace in Ghana as well, and new prospective data collection to capture that is needed. Our study may have missed most of that.

Conclusion     

Lower urinary tract obstruction is the most common non-trauma urologic emergency in Ghana, accounting for nearly half of the cases. Severe haematuria is the second. Effective management and favourable outcomes are achievable with appropriate interventions. The study underscores the importance of learning from local data to inform healthcare policies, improve clinical practice, and enhance patient outcomes. In line with the data, we recommend prioritising early referral systems, expanding training in minimally invasive urologic care, creating harmonised national urologic emergency guidelines to entrench our gains, and establishing a national electronic urology registry for prospective data collection, real-time analysis, and decision support. The substantial LUTO-related catheterisation rate provides some evidence that, as a health system, we ought to start embarking on targeted public health education to encourage men to seek healthcare early if with LUTO, and to adhere to prescribed medications. The concurrent need to educate men with acute scrotal pain, and those with priapism to report early (to safeguard organ preservation); whilst discouraging the use of aphrodisiacs to help reduce the rates of aphrodisiac-related priapic episodes, can also not be overemphasized.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

James Edward Mensah, Roland Azorliade, Edwin Mwintiereh Ta-ang Yenli, Setsoafia Afetsi Yao Humphrey-Ackumey, Ben Adusei, Azue-In-Yeng Luke Zakpaa, Alvin Asante-Asamani, Habib Ahmed, John Tampuori, Mahamudu Ayamba Ali, Frank Yirenkyi, John Boakye Addae, Charles Kwame Adofo, Alexander Egote, Samuel Amanamah, Boateng Bosomtwi, Clement Nabare, Patrick Opoku Manu Maison, and Frank Obeng contributed to conceptualization, data collection, and regional coordination of the study across their respective centres. Frank Obeng, Aishah Fadilah Adamu, Roland Azorliade, and Edwin Mwintiereh Ta-ang Yenli led the design of the study, compiled and cleaned national data, and drafted the initial manuscript. Frank Obeng served as the overall study coordinator, contributed to data collection, data analysis, manuscript supervision, and final critical review and submission. All authors contributed to data verification, interpretation of findings, and critical revision of the manuscript for important intellectual content. All authors have read and approved the final version of this manuscript.

Acknowledgments     

Special thanks to all contributors from various centres and institutions, including Prof. G.O. Klufio (deceased), Prof. J.E. Mensah, Dr. R. Azorliade, and others. Their supervision, feedback, and institutional support were invaluable to the successful completion of this study.

Tables and figures     

Table 1: summary of non-trauma urologic emergencies managed across eleven urologic centres in Ghana in 2017

Table 2: spectrum of specific diagnoses and relative contribution of specific conditions within major urological emergency categories among participating hospitals in Ghana.

Table 3: distribution of interventions performed for major urological emergency presentations among participating hospitals in Ghana

Table 4: clinical outcomes and post-treatment states of patients presenting with major urological emergencies

Figure 1: spectrum and frequency distribution of non-trauma urologic emergencies reported across eleven urologic centres in Ghana, 2017

Figure 2: geographic distribution of participating hospitals and urological emergency presentations across Ghana

Annex     

Annex 1: supplementary material

References