FINAL EM Urologic Flashcards
Define Renal colic
Nephrolithiasis-Urolithiasis “kidney stones”
*accumulation of normally dissolved solids from kidney for a stone. Become sx with pain and ureteral obstruction once 2-3 mm in size
Types of stone, their associations, and density?
60-90% are radiopaque with Ca salts most common
Struvite: a/w infection, radiopaque
Uric acid: a/w gout (radiolucent)
Cystine: rare
Hx renal colic (characteristics of pain)
Sudden onset, colicky
Radiates to GROIN as stone passes into lower ureter
May change in location from flank to groin
Pt constant, may roll around in agony, pain like labor
a/w N/V
Urinary frequency, tea colored urine
What exam components are important with renal colic
Exam: abd, back and chest
Male GU
Female +/- pelvic
Vitals: check temp, BP
Labs and Imaging important to Renal colic
UA 75-85% have hematuria (may not have if complete obstruction)
BUN/CR to determine renal compromise
KUB: misses 40% cases
NCCT (non contrast CT) scan: 94-100% specific
UTZ: preg or child, 65% show hydronephrosis
Ddx to consider a/w renal colic
Acute pyelonephritis,
Papillary necrosis (sickle cell, NSAID abuse),
Appendicitis/biliary colic/bowel obstruction,
AAA,
GYN emergency ie ectopic/ovarian torsion,
Testicular torsion/epididymitis/hernia
Size of stones related to passing ability?
8mm, can’t pass
in bw??
Tx of renal colic
Toradol great for pain relief
Abx
Alpha 1 blockers (ie Flomax for dilation),
Possibly just watchful waiting
Temporary relief if not passing on own: Insertion of JJ stent or percutaneous nephrostomy tube
Definitive tx of ureteric stone: intractable pain, fever, renal function, 4 wk ESWL (lithotripsy, shock waves) PCNL (nephrolithotomy 1 cm incision) Ureteroscopy Open surgery – very limited
Causes of acute urinary retention
a) Obstructive: BPH most common cause in M >50
b) Inflammatory: ie prostate infection
c) Neurogenic (spinal cord trauma, spinal cord tumor, MS)
d) Pharmacologic: antihistamine, anticholinergic, narcotics
PE, Imaging, Lab findings a/w acute urinary retention
a) abdominal distension
b) Bladder US show distension
c) BMP: renal failure
d) infection
*need catheter ASAP, may need SPC if can’t fit cath in (ie pt has BPH)
Initial and late mgmt of acute urinary retention, tx, discharge
Initial: urinary cath ASAP, potentially suprapubic (SPC)
Late: treat underlying cause
Tx: monitor 4-6 hr post decompression bc just drained a lot of water/pressure drop; may develop postobstructive diuresis
Discharge pt with drainage bag and f/u in 1-3 d
Infections a/w UG
Cystitis, pyelonephritis, prostatitis, urosepsis
Dx of infections
Urine culture 100,000 CFU/mL dx
(+) leukocyte esterase and nitrates
Pyuria at least 8-10 WBC/hpf
Gram stain rarely used
GC/CT enzyme assays
Pathophysiology of cystitis
Pathogens from fecal flora colonize vaginal introitus, enter the urethra and bladder and stimulate a host response
*E coli (70-95% of episodes)
other: S. saphrophyticus
Less common: Proteus, Klebsiella, enterococci
Hx consistent with Cystitis
Dysuria, frequency, urgency
Suprapubic or abd pain,
Dark urine/hematuria/dehydration
Low back pain
*get UA in ER??
PE components for cystistis (4)
Temp
Abdomen
CVA percussion
Pelvic exam possibly
Ddx to consider for cystitis
Renal calculi,
pyelonephritis,
vaginitis/vulvitis,
GC or CT (urethritis, cervicitis, PID)
Labs a/w Cystitis
Urine microscopic 6-20 wbc/hpf
Urine Dipstick detects:
a) Leukocyte esterase (pyuria)
b) Nitrite (G- bacteria)
* beware of false -/+ (blood can give false nitrite positive)
Urine culture not usually indicated in routine UTI
Imgaging for cystitis?
Not usually
Tx of cystitis?
Abx: FQ 3d Macrobid (Nitrofurantoin) 5d Bactrim x3d (high e coli resistant rates) Augmentin x 7-10d Cephalosporins x 7-10 d
Analgesia: phenazopyridine (pyridium) – SE orange urine
Hydration
F/u for cystitis?
Non if asymp
If sx persists, w/u the ddx
Etiology of complicated cystitis
a) Assoc w/ condition that increases risk of failing therapy;
b) Present the same, work up the same
c) UTIs in these pts need longer tx, cultures, closure f/u and search for ddx if not rapidly improving
Complicated Cystitis etiology
Male, Elderly, children Urban ER Hospital acquired, recent abx Pregnancy, immunosuppression Indwelling urinary catheter, recent instrumentation Functional/anatomic abn Sx >7d DM
Define pyelonephritis
Infectious inflammatory dz involving kidney parenchyma and renal pelvis
Agents causing pyelonephritis
E coli >90%, enterobacter, Klebsiella, Proteus, Pseudomonas, Enterococcus
S/Sx Pyelonephritis
Fevers, chills, rigors
NV, diaphoresis
Flank/abd pain
Lower UTI sx: dysuria, freq, urge
PE pyelonephritis
Vitals
Abd, chest, GU
CVA tenderness
Pelvic/rectal exam??
Ddx pyelonephritis
Acute cystitis, perinephric abscess, urolithiasis, ectopic preg, PID, acute prostatitis, acute epididymitis, appendicitis, pneumonia
Lab findings re pyelonephritis
UA: nitrates, LE, bacteruria, hematuria, WBC casts Urine C&S Blood cultures CBC Preg test Serum electrolytes, BMP
Imaging for pyelonephritis
*may or may not need
CT scan, UTZ
When does one need inpt mgmt for pyelonephritis
a) Inability to maintain oral hydration or take oral meds
b) Compliance risk
c) Uncertainty about dx
d) High fevers, severe disability or uncontrolled pain
e) risk factors for complications (obstruction, uro surgeries or instrumentation, DM, preg…)
Tx of pyelonephritis
10-14d
Inpt: inability to take oral, severe illness
Outpt: pt who can take oral abx
Empiric (no bactrim or macrobid/nitro)
1st: cephalosporins (Cephalexin)
2nd: FQ
* other: ampicillin + gentamicin are reasonable if enterococcus is suspected
Fluids, pain meds
Uncomplicated pyelonephritis f/u and prognosis
Prompt dx and tx carry good prognosis
Acute Prostatitis cause
Acute bacterial infection of prostate
> 35 yr usually G- E coli
<35 yr usually due to GC and CT
Hx, s/sx, labs PROSTATITIS
Fever, chills, myalgias
Pain in lower back, rectum or perineum
May have urinary retention, dysuria
Abd: may be tender
GU: Perineal area tender (urethral swab if applicable)
Rectal: tender boggy prostate (do NOT massage bc can cause Bacteremia)
Lab: CBC (WBC may be elevated), UA shows Pyuria
Imaging: none unless toxic
Tx of prostatitis
Hydration, analgesics, bed rest, stool softeners
ABX
Cipro>35, CT/GC tx <35
If toxic tx as UROSEPTIC
Define urosepsis
Severe illness which occurs when UTI spreads systemically
Hx Urosepsis
May report recent UTI, pyelonephritis, urolithiasis, prostatitis
- Persistent sx of above infections
- Weakness, confusion, dehydration
- Often seen in NURSING HOME pt
Important lab values indicative of SIRS
TEMP: >100.4 OR 12K or 4mmol/L (not part of SIRS?)
Tachycardia >90 bpm
Tachypnea >20 rpm
Urosepsis: Exam/Lab/RAD
PE: as Pyelonephritis or Acute Prostate
CBC, Blood cultures, BMP, UA, urine cultures, Lactate
CT to r/o stone, abscess, ddx
*Note: when getting blood cultures, just always get a lactate; lactate has to be on ice though so let nursing know ahead of time so they only have to stick pt once
Urosepsis ddx/tx
Sepsis if SIRS + infection
Etiology broad: abd/pelvic, brain, skin, resp, heart
Tx: FLUIDS, ABX, tx the shock, ADMIT
What constitutes an acute scrotum
Acute testicular torsion
Acute epididymitis
Etiology of testicular torsion…
Congenital lack of posterior fixation permitting rotation of testis w/in tunica vaginals
1/4000 M, most common 12-18, 10x more common if person has undescended testis
results in twisting of testis and compromised blood flow (more than 6hr, will result in sterility on that side)
H/PE findings consistent with Testicular torsion
SUDDEN onset testicular pain – may be insidious, may have prior event, onset may be during sleep or exertion
Swelling, May have abd pain, N/V (exam difficult to do bc of pain, may need to sedate patient)
PE:
- Swollen, firm, tender hemiscrotum
- High riding testis with transverse lie - ”red clapper deformity”
- Possible loss of cremasteric reflex
- Blue dot sign – torsion of the appendix testis
Dx testing and Tx of testicular torsion
UA/CBC preop labs NOT HELPFUL
STAT Doppler UTZ testicular shows decreased or absent flow to affected side
HAVE to untorse! Call urology STAT for surgery (pin down testes) after sedating pt and manually detorsing
*Testical turned medial to lateral like “opening a book”; may require 180-360 turn
What causes epididymitis
Retrograde spread of infected urine down the vas deferens = inflammation of epididymis
- > 35 due to E coli, enterococci, Pseudomonas, Proteus
- <35 due to CT, GC
Hx consistent with Epididymitis
Scrotal pain, swelling, tenderness relieved with testicle elevation (positive phren sign)
May have urethral dc and UTI s/sx
Low abd or perineal pain; may have fever/chills
PE: red, swollen, warm and tender testicle; testicular lump, inguinal LAD, INTACT cremasteric reflex (this may be absent in testicular torsion)
Labs/imaging Epididymitis
CBC is systemic signs
UA (swab before)
Test for GC, CT
Doppler US to r/o Torsion or Tumor; may see increased flow to epididymis
Ddx Epididymitis
Torsion, orchitis, trauma, tumor, abscess, UTI, varicocele, hydrocele
Tx Epididymitis
Bedrest, scrotal elevation with ice
ABX:
if STD then Rocephin and then Doxy;
if UTI then Cipro or Augmentin
Pain meds, stool softeners
Definition of paraphimosis
Foreskin becomes retracted behind glans of penis and cannot be placed over glans TRUE EMERGENCY bc arterial compromise to the glans may occur
H&P of paraphimosis
Elderly or very young due to freq cath, poor hygiene or retracted foreskin that was not replaced
*sexual activity or genital piercings are risk
Pain,tenderness and redness to retrated foreskin and glans
“PARAphimosis is a PARAmedic emergency, Phimosis is not”
Ddx paraphimosis
Phimosis, balanoposthitis and balanitis, trauma
Tx paraphimosis
Attempt to reduce by pushing on glans while pulling on foreskin
Glands compression – manual
Emergent dorsal slit in foreskin
Urology STAT
What is priapism
Persistent erection of the penis for >4hr that is not related to or accompanied by sexual desire
Most common in age 30-40
How to manage priarism
- Warn all pt with priapism the possibility of impotence, fibrosis
- Sudafed po
- Terbutaline SQ to decrease inflow of blood to penis
- Aspirate corpora w/ butterfly needle (2 and 10 oclock, aspirate 20-30cc till bright red arterial blood)
- Phenylephrine injected directly into corpora cavernosa 250-500 mcg
- Urology
*acute low flow most common; due to drugs, blood d/o, sickle cell, spinal trauma, veno occlusion
What is fourniers gangrene
Necrotizing infection of the perineum involving penis, scrotum, perineum, abdominal wall (30% mortality!!)
Cause: staph, strep, e coli, clostridium
*gets bad fast, may see black eschar, feel crepitus if palpate
Associations with fourniers gangrene
DM (most common) Alcoholism Immunosuppression (HIV, CA) Liver dz Trauma to ano/UG, perineal area Pre-existing perineal/rectal infections
Course of fourniers gangrene
Varies from slow to rapid
Starts with redness next to port of entry
Localized pain, swelling, discoloration of affected area
Fever, lethargy, toxic appearing
Subq crepitus over area
Putrid or feculent odor
w/u and mgmt of Fourniers Gangrene
Get septic work-up:
CBC, CMP, Blood culture, Coags, wound cultures, UA, lactate, Contrast CT scan
*call surgery STAT, surgical debridement
*ABX combo: PCN/FLagyl/Gentamicin
FLUIDS
