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3. E Med & Surgery > 2- Urologic Emergencies > Flashcards

2- Urologic Emergencies Flashcards

1
Q

At what size does a kidney stone become symptomatic w/ pain and obstruct the ureter?

A

≥ 2-3 mm in size

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2
Q

What is the most common composition of a kidney stone? Are they radiolucent or radiopaque?

A

Calcium salts

Radiopaque

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3
Q

Struvite stones indicate what? Are they radiolucent or radiopaque?

A

Infection

Radiopaque

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4
Q

How will a pt w/ renal colic present?

A

Sudden onset colicky unilateral flank pain w/ radiation to groin as stone passes into lower ureter (pain equal to labor), N/V, urinary frequency, hematuria

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5
Q

What is the imaging of choice for evaluating renal colic?

A

Non-contrast CT

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6
Q

What imaging is used in pregnant, children or pt w/ previous hx of stones?

A

Renal US (identifies hydronephronis, +/- stone)

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7
Q

The majority of what size kidney stones will pass spontaneously?

A

Usually pass if < 5 mm, will not pass if > 8 mm

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8
Q

What is the tx for renal colic?

A

Pain relief, anti-emetic, ABX, alpha 1 blocker, watchful waiting

Admit if “sick”

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9
Q

What are definitive txs for a ureteric stone (intractable pain, fever, renal function, 4 wks)?

A

ESWL (lithotripsy)
PCNL (nephilithotomy)
Ureteroscopy
Open surgery

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10
Q

For what size stones will medical explusion therapy (CCB, a-blocker, flowmax) have an effect?

A

5-10 mm => increased passage

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11
Q

If pt is not able to pass a stone what can provide temporary relief?

A

JJ stent

Percutaneous nephrostomy tube (common in pregnant pts)

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12
Q

Renal colic is aka what?

A

Urolithiasis

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13
Q

What is a painful inability to void w/ relief of pain following drainage of bladder by cath?

A

Acute urinary retention

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14
Q

What is the most common causes of obstructive urinary retention in men > 50 yo?

A

Prostatic Hyperplasia

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15
Q

What are the general causes of urinary retention? (4)

A

Obstructive
Pharmacologic
Inflammatory
Neurogenic (spinal cord trauma/tumor, MS)

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16
Q

What are the exam findings for pt w/ urinary retention?

A

Abdominal/bladder distention

Large amount urine in post void residual (PVR)

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17
Q

What volume of urine is concerning for urinary retention?

A

> 100-150 ml

  • <50-100 ml = normal
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18
Q

What is the initial management for acute urinary retention?

A

Urethral cath/Suprapubic cath
Continuous bladder irrigation if blood clots
Monitor pt for 24 hrs post decompression and d/c home w/ drainage bag and urology f/u in 3-5 days

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19
Q

What is the late management for acute urinary retention?

A

Tx underlying cause

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20
Q

What is the most common pathogen of uncomplicated cystitis?

A

E. coli (due to fecal flora colonization)

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21
Q

If pt presents w/ urinary sx but has no vaginitis or cervicitis on exam, are they likely to have UTI?

A

Yes! 90% likelihood

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22
Q

If pt presents w/ urinary sx and has cloudy urine, are they likely to have UTI?

A

Yes 96% likelihood

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23
Q

T or F: Cystitis is a clinical dx supported by UA, culture and hx/PE.

A

TRUE!

Always order UA if 
Sx not clear
Male, back pain, looks sick
IMC
HX multi course ABX
Hx of ABX resistance
HX of mult drug allergies
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24
Q

What are the infectious disease society of American guidelines for when to tx cystitis?

A

Urine culture ≥ 100,000 CFU/ml

+ leukocyte ester & nitrates (Pyuria)

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25
Q

When should pelvic exam be performed in pt w/ suspected cystitis?

A

Vaginal d/c, sick, return visit

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26
Q

What should be included on PE for pt w/ suspected UTI?

A

CVA percussion

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27
Q

Are Culture and imaging indicated for dx of routine UTI?

A

Not usually

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28
Q

What is the ABX tx for cystitis?

A 
Macrobid X 5 days
Bactrim DS > 3 days (don't use if high e. coli resistant strains)
Fosfomycin 3g single dose
Cephalosporins X 7 days
Aumentin x 7 days
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29
Q

What ABXs are NOT allowed in the tx of UTI?

A

Fluoroquinolone (Cipro) - black box warning (only use if no other tx options for uncomplicated UTI)
- Concern for tendon rupture (especially older pts w/ concomitant steroid use)

Amoxicillin - too much resistant

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30
Q

Who is at risk for complicated UTI?

A 
Men
Elderly
Hospital acquired
Pregnancy
Indwelling urinary cath/recent instrumentation
Children
Recent ABX use
DM/IMC
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31
Q

A complicated UTI is evaluated/tx similar to what?

A

Pyelonephritis. Labs and longer ABX

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32
Q

What is an ascending infectious inflammatory process involving the kidney parenchyma and renal pelvis?

A

Pyelonephritis

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33
Q

A pt w/ pyelonehpritis will present w/ lower UTI sx + what?

A

Fever, chills, rigors OR
N/V OR
Diaphoresis OR
Flank and/or abdominal pain

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34
Q

What do you specifically expect to look for on UA of pt w/ suspected pyelonephritis?

A

WBC casts

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35
Q

What ABX is NOT used in the TX of pyelonephritis?

A

Macrobid

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36
Q

Empiric therapy options for pyelonephritis include what?

A

Cipro 500 mg BID x 7 day
Levo 750 QD x 5 days
Bactrim DC x 14 days
Cephalosporins 3rd > 1 st gen for 10-14 days

37
Q

When would you admit a pt w/ pyelonephritis?

A 
Obstruction (stones, tumor)
Urologic surgeries/instrumentation
Pregnancy
DM
Unable to tolerate POs
Compliance risk
38
Q

Are pts w/ asymptomatic bacteriuria often tx?

A

No. Want to prevent antimicrobial resistance and C. diff

39
Q

When do you tx pt w/ asymptomatic bacteriuria?

A

Pregnant, sxs, undergoing urologic procedure

40
Q

If pt w/ cystitis/pyelo sx and positive blood on UA. What rare complication do you want to be sure to R/O?

A

AAA

Often present w/ “and” complaints
- CP, ABD/neck/head/leg pain, renal failure, CVA

41
Q

In pts < 35 yo that are dx w/ acute prostatitis, what is the most common bacterial etiology?

A

N gonorrhoeae and chlamydia

42
Q

In pts > 35 yo that are dx w/ acute prostatitis, what is the most common bacterial etiology?

43
Q

How will a pt w/ prostatitis present?

A

Fever, chills, myalgia
Pain to low back, rectum, perineum
+/- urinary retention, dysuria

44
Q

What will DRE show for pt w/ prostatitis?

A

Tender boggy prostate.

45
Q

What should be avoided on DRE in Pt w/ suspected prostatitis?

A

Do not massage prostate => Bacteremia

46
Q

Is imaging typically required for evaluation of prostatitis?

A

Only if toxic appearing

47
Q

What will UA show for pt w/ prostatitis?

A

Pyuria (pus in the urine)

48
Q

What is the tx for prostatitis?

A

> 35 yo - Cipro or Lev > 2-4 wks

< 35 yo - TX GC/Chlamydia

49
Q

What is urosepsis?

A

Severe illness that occur when a UTI spread systemically

50
Q

DX of urosepsis requires 2+ sx. What are the sx?

A 
Temp > 100.4 or <96.8
WBC > 12K or <4K w/ 10% bands
Tachycardia
Tachypnea
AMA (elevated lactate > 4 mmol/L)
51
Q

Urosepsis in common in what pts?

A

Nursing home resident
Recent/persisting UTI, pyelonephritis, prostatitis
Recent urological procedures

52
Q

How will a pt w/ urosepsis present?

A

Weakness, confusion, dehydration

53
Q

What is the tx for urosepsis?

A

Fluids, ABX, tx shock, admit

54
Q

When pt presents to ED w/ hematuria. What three dx must you work up/ rule out?

A

Obstruction
Coagulopathy
Rhabdomyolysis

55
Q

If pt w/ gross hematuria or RBC > 5 what is the workup?

A

Check labs, med list, LMP, Uro eval

56
Q

What lab will help determine if pt is in Rhabdo?

57
Q

If pt w/ gross hematuria or RBC > 3 and normal vitals what is the workup?

A

If normal vitals => urine work up

58
Q

If pt w/ gross hematuria or RBC > 3 and abnormal vitals/labs/pain what is the workup?

A
  • Renal US, CT abd pelvic w/ contrast
  • Bladder US, +/- foley if retention, continuous bladder irrigation
  • Tx any found cause
59
Q

If testicular torsion is detorsed by 6 hrs what is the salvage rate?

60
Q

Pt w/ suspected testicular torsion presents in extreme abdominal pain and N/V. Exam for pt may show what?

A

High riding testis w/ transverse lie (bell clapper deformity)
Blue dot sign
+/- loss of cremasteric reflex

61
Q

What is blue dote sign in a pt w/ testicular torsion?

A

Torsion of the appendix testis

62
Q

What dx is needed immediately for pt w/ suspected testicular torsion?

A

Doppler US

63
Q

What is the tx for testicular torsion?

A

Urology STAT => testicular fixation (even if detorsed in ED)

Definitive tx: Manual detorsion (medial to lateral/ “opening of book” technique)

64
Q

What is retrograde spread of infected urine down the vas deferens?

A

Epididymitis

65
Q

What is the most common cause of epididymitis in M < 35 yo?

A

GC, Chlamydia

66
Q

What is the most common cause of epididymitis in M > 35 yo?

A

E. coli, Enterococci, Pseudomonas, Proteus

67
Q

Pt presents w/ scrotal pain and swelling, lower abdominal/perineal pain, +/- fever, UTI sx. You suspect epididymitis. What exam findings would support your dx?

A

Pain is relieved w/ testicle elevation
Cremastric reflex is intact
Inguinal lymphadenopathy

68
Q

What labs/imaging are needed for evaluated epididymitis?

A

UA
Test GC/Chlamydia
Doppler US to r/o torsion or tumor
CBC/admit if systemic sx

69
Q

What is the tx for epididymitis?

A 
Bedrest
Scrotal elevation w/ ice
ABX
Analgesics
Stool softeners
70
Q

For acute epididymitis most likely caused by GC/chlamydia (<35 y/o) what is the ABX tx?

A

Ceftriaxone IM x1 +

Doxycycline x 10 days

71
Q

For acute epididymitis most likely caused by GC/chlamydia AND enteric organisms (MSM) what is the ABX tx?

A

Ceftriaxone IM x1 +

Levofloxacin x 10 days

72
Q

For acute epididymitis most likely caused by enteric organisms (>35 yo) what is the ABX tx?

A

Levofloxacin x 10 days

73
Q

What is foreskin that becomes retracted behind the glans of penis and can’t be replaced over the glans?

A

Paraphimosis

74
Q

Is paraphimosis or phimosis an emergency?

A

Paraphimosis b/c possible arterial compromise

*Think “Para” as in Paramedic

75
Q

How will paraphimosis present?

A

Pain, tenderness, redness to retracted foreskin and glans

76
Q

What is the tx for paraphimosis?

A
  • Attempt manual gland compression (reduce by pushing on glans while pulling on foreskin)
  • If unsuccessful sugar lidocaine wrap, emergent dorsal slit in foreskin
  • Urology Stat
77
Q

Balanoposthitis/blantitis are due to infection of the glands most commonly in uncircumcised men. Which is describes an infection in peds vs adults?

A 
Balanoposthitis = peds
Balantitis = adults
78
Q

What is a persistent erection of the penis > 4 hrs that is NOT accompanied by sexual desire?

79
Q

Acute low flow causes of priapism are most common. Pt presents w/ fully rigid penis (glans soft), +/- painful. What are possible causes?

A

Drugs, blood disorders (sickle cell), spinal trauma, idiopathic

80
Q

High flow causes of priapism are RARE. Pt presents w/ partially rigid penis that is painless. What are possible causes?

81
Q

What antidepressant causes priapism?

A

Trazadone

*Antidepressants and antipsychotics are most common drugs to cause priapism)

82
Q

What is the risk associated w/ priapism?

A

Impotence and fibrosis

83
Q

What is the tx for priapism?

A
  • Terbuatline SQ (decrease inflow of blood to penis)
  • Aspirate corpus cavernosa w/ butterfly needle (3 & 9 o’ clock position)
  • Phenylephrine injection in corpora cavernosa
  • Urology
84
Q

What is necrotizing fasciitis infection of the perineum involving the penis, scrotum, perineum, and abdominal wall?

A

Fourniers gangrene

85
Q

What are the most common pathogens of fourniers gangrene

A

Staph
Strep
E. coli
Clostridium

86
Q

What is the common RF for Fourniers gangrene?

A 
DM (most common)
Alcoholism/liver disease
IMC
Trauma
Preexisting perineal/rectal infections
87
Q

Pt presents w/ fever, toxic appearing and perineal POOP. You suspect fourniers gangrene. What exam findings would support your dx?

A

Localized pain, swelling, discoloration to affected area
Redness next to port of entry
Subcutaneous crepitation over affected areas
Putrid odor

88
Q

What is the work up for Fourniers gangrene?

A 
Septic work up
Surgery consult
NPO &amp; IVF
IV ABX
Contrast CT
89
Q

What is the tx for Fourniers gangrene?

A

Surgical debridement

3. E Med & Surgery (19 decks)

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