GU Emergencies Flashcards

1
Q

Sx’s of acute urinary retention

A

can’t pee, decreased stream, “dribble”, severe pain in lower abdomen

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2
Q

what is acute urinary retention?

A

painful inability to void

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3
Q

pathophysiology of acute urinary retention? (HINT: 3 factors)

A

increased urethral resistance
-bladder outlet obstruction

lower bladder pressure
-impaired bladder contractility

interruption of sensory and motor innervations of the bladder

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4
Q

what factors can trigger acute urinary retention?

A

Prostatitis, Narcotics, diphenhydramine (anticholinergics), Pseudoephedrine, Oxybutynin/Detrol, ETOH ingestion, anesthesia (paralyzes bladder)

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5
Q

how does prostatitis trigger acute urinary retention?

A

increases bladder outlet obstruction (M/C)

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6
Q

how do narcotics trigger acute urinary retention?

A

reduce bladder contractility

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7
Q

how does diphenhydramine trigger acute urinary retention? who does it cause retention in?

A

it’s an anticholinergic -> reduces contractility

-causes retention in older people

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8
Q

how does Pseudoephedrine trigger acute urinary retention?

A

it’s a sympathomimetic which stimulates Alpha-receptors in prostate

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9
Q

how does Oxybutynin/Detrol trigger acute urinary retention?

A

anticholinergic meds for tx of overactive bladder or bladder spasms
-can flip someone into retention

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10
Q

most common cause of acute urinary retention in men?

A

BPH

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11
Q

causes of acute urinary retention in women?

A

pelvic prolapse, urethral stricture, urethral diverticulum, post-surgery, pelvic masses that stop contractility of the bladder

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12
Q

causes of acute urinary retention in both men and women?

A

clot retention (clot off urethra), herpes zoster virus can cause the bladder to not contract

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13
Q

what is the initial management of acute urinary retention?

A

Urethral catheterization (Foley catheter) - to drain bladder

Supra Pubic Catheter (for pts that had trauma to the urethra)

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14
Q

what is late management of acute urinary retention?

A

treat the underlying cause (do this after drain the bladder)

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15
Q

what labs do you want to get for acute urinary retention?

A

UA and Cx - want to check Cr, electrolytes, see if there’s an infection

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16
Q

what are the indications for treatment for BPH?

A

incomplete bladder emptying, acute urinary retention, CRI

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17
Q

what is the FIRST LINE medical tx for BPH?

A

Alpha-1 blockers

-Terazosin, Doxazosin, Tamsulosin (M/C), Alfuzosin

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18
Q

what is the MOA of alpha-1 blockers?

A

-relax the muscle of the prostate and bladder neck -> increased urinary outflow

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19
Q

when do alpha-1 blockers begin to work?

A

quickly, within 72hrs

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20
Q

what is the M/C side effect of alpha-1 blockers?

A

orthostatic hypotension

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21
Q

which alpha-1 blockers are more likely to lower BP (cause orthostatic hypotension)? when are they taken?

A

Terazosin and Doxazosin are more likely to lower BP

Taken at Bedtime

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22
Q

when can you NOT take terazosin or doxazosin?

A

do not take terazosin or doxazosin with meds for ED like sildenafil, vardenafil, tadalafil, or avanafil

Tamsulosin and Alfuzosin don’t interact with ED meds

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23
Q

Tamsulosin has a higher incidence of what?

A

ejaculatory dysfunction

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24
Q

do Tamsulosin 0.4mg and Alfusozin need to be pirated up?

A

NO!!!

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25
Q

what are other meds to use to treat BPH?

A

5-Alpha-reductase inhibitors

Finasteride (M/C), Dutasteride

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26
Q

MOA of 5-Alpha-reductase inhibitors?

A

androgen inhibitors -> suppress growth of prostate and can cause it to shrink

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27
Q

how long does it take for Finasteride or Dutasteride to work?

A

6 months -> no indication to start in the AUR phase

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28
Q

side effects of Finasteride or Dutasteride? what can they cause? side effects resolve when?

A

decreased sex drive, difficult with erection or ejaculation, or sx’s of depression

  • can cause pts to stop taking the meds
  • side effects resolve when the med is stopped
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29
Q

what levels decrease by 50% in men who take Finasteride or Dutasteride? why is this important to remember?

A

PSA levels decrease by 50%

-important to remember if you have PSA testing to screen for prostate cancer

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30
Q

complication of acute urinary retention?

A

Post-Obstructive Diuresis

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31
Q

what is the criteria for Post-Obstructive Diuresis?

A

> 200ml/hr for 3 consecutive hrs or 3L/24hrs of urine drained

-if >1000cc in bladder and increased Cr, monitor for post-obstructive diuresis

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32
Q

pts with post-obstructive diuresis need to be kept as what?

A

need to be kept inpatient to monitor for urine output and electrolytes

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33
Q

tx for post-obstructive diuresis?

A

IVF at 75% of the cc/hr rate of diuresis

probably keep Foley in for 10-14 days

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34
Q

all men in urinary retention need what follow-up?

A

a Urology follow-up

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35
Q

what trial should AUR pts get?

A

a voiding trial in 3-7 days

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36
Q

sx’s of nephrolithiasis?

A

writhing in pain - can’t sit still

unremarkable abdominal exam

pain refers to genitals

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37
Q

what is the GOLD STANDARD imaging to dx nephrolithiasis?

A

CT scan of the abdomen and pelvic w/out IV contrast

38
Q

when is U/S used to dx nephrlithiasis?

A

pregnant pts

39
Q

what stones can KUB X-ray not dx?

A

uric acid stones

40
Q

sx’s of kidney stone at the UPJ?

A

mild to severe deep flank pain w/out radiation to groin (pain coming from the kidney)

41
Q

sx’s of kidney stone in ureter?

A

Abrupt severe colicky pain in flank and ipsilateral lower abdomen

May radiate to testicles or vulvar area, NAUSEA!!!

42
Q

when do you get the radiation of pain to the groin in nephrolithiasis?

A

when the stone is in the ureter you get radiation of pain to groin area

43
Q

sx’s of kidney stone in mid ureter?

A

Radiates anteriorly

  • may mimic appendicitis if on right
  • may mimic diverticulitis if on left
44
Q

sx’s of kidney stone in distal ureter and UVJ?

A
  • Pain radiates to groin and testicle in male, labia majora in female
  • At UVJ may have cystitis symptoms
45
Q

sx’s of kidney stone in bladder?

A

rarely symptomatic, but can cause cystitis like sx’s or urinary retention

46
Q

at what size will kidney stones NOT pass on its own?

A

stones >6mm - stones this size of greater won’t pass on its own

47
Q

what is the conservative tx for nephrolithiasis?

A
  • use alpha blockers and analgesics
  • LOTS OF FLUIDS - 2L/DAY
  • STRAIN THE URINE
  • if evidence of UTI, treat with abx
48
Q

risk factors of calcium oxalate stones?

A

dehydration, hypercalciuria, hyperoxaluria

49
Q

risk factors of uric acid stones?

A

highly acidic urine, persistent metabolic acidosis, hyperuricemia leading to hyperuricosuria, urine pH < 5.5

50
Q

risk factors of struvite stones?

A

UTIs with urease-producing bacteria (PROTEUS), Urea -> NH4 + OH- causes urine pH to rise

STAGHORN CALCULI - usually found after recurrent infection

51
Q

what type of kidney stones can you dissolve and with what?

A

uric acid stones -> use Potassium Citrate and try and alkalinize the urine

52
Q

when is ESWL use for tx of kidney stones?

A

for < 3cm stones in the kidney

uses shock wave to break up stone into smaller fragments

53
Q

when is Uretoscopy and Laser Lithotripsy used for tx of kidney stones?

A

Cystoscopy into Ureter and break up stone with Laser

For stone suck in the ureter

54
Q

when is Percutaneous Nephrolithotomy used for tx of kidney stones?

A

large stones in kidney -> STAGHORN CALCULI

55
Q

when are ureteral stents used for tx of kidney stones?

A

Used when pt has stone and has infection/sepsis/fever/pyonephrosis and don’t want to break up the stone

56
Q

what requires urgent intervention for kidney stones?

A
  • Obstructed upper tract with signs of infection and/or sepsis
  • Renal deterioration or bilateral hydronephrosis
  • Intractable N/V
  • Pain refractory to analgesic
  • Stone in solitary kidney
57
Q

what is the highest morbidity and mortality with in kidney stones?

A

with the combination of urinary tract obstruction and upper UTI

58
Q

when do you admit a patient with kidney stones?

A
  • PO analgesics are insufficient
  • Intractable vomiting
  • Obstructing in solitary or transplanted kidney
  • Bilateral ureteral obstruction
  • Sepsis, Fever, Pyonephrosis
  • Renal failure
  • Immunocompromised state
59
Q

what is the management of acute renal stones?

A
  • Placement of a ureteral stent/percutaneous nephrostomy tube to decompress the kidney
  • Does not involve breaking up the stone as bacteria are often housed w/in the stone and can worsen urosepsis
60
Q

main ways to prevent future kidney stones?

A

Increased fluid intake (2L/day) and low salt diet

For CaOx stones -> Increased dietary citrate - 2 table spoons pure lemon juice a day
-citrate can prevent CaOx deposition in the kidney

61
Q

what kidney stones does citrate (2 tblspns pure lemon juice/day) prevent the recurrence of? how do the prevent it?

A

CaOx stones -> prevents their deposition in the kidney

62
Q

what is Fournier’s Gangrene?

A

a synergistic polymicrobial necrotizing fasciitis of the perineum and genitalia

63
Q

sx’s of Fournier’s Gangrene?

A

erythematous, edematous scrotum that is tender to mild palpation

+ odor, + necrosis on scrotum and penile shaft

64
Q

who should you always inspect the genitals in? checking for?

A

diabetics, immunocompromised pts

checking for Fournier’s Gangrene

65
Q

can tx be delayed for Fournier’s Gangrene?

A

NO!!! DO NOT DELAY TX -> HIGH MORTALITY RATE

66
Q

Labs for Fournier’s Gangrene?

A

Sepsis Workup

  • WBC (high WBC)
  • CMP (glucose may be high if diabetic)
  • Lactate
  • Blood Cx
67
Q

risk factors of Fournier’s Gangrene?

A
  • Perineal or genital skin infections
  • Urethral stricture
  • Piercing or cocaine injection
  • STIs
  • Paraphimosis

Causative event is a mucosal breakdown in the urethra or colon

68
Q

what is the M/C organism for Fournier’s Gangrene?

A

E. Coli

69
Q

how many organisms do you usually see from cx for Fournier’s Gangrene?

A

3

70
Q

other organisms for Fournier’s Gangrene?

A

Klebsiella, B. fragilis, Strep, Staph, Pseudomonas, C. Perfringes

71
Q

dx of Fournier’s Gangrene?

A

Clinical DX (have a high clinical suspicion)

Surgical Consult Stat!!!!
-need debridement of all necrotic tissue ASAP

Imaging

  • good for atypical presentations -X-rays - air in tissues
  • US - differentiate intrascrotal abnormality, thickening, gas, in scrotal wall
  • CT or MRI - r/o retroperitoneal or intra-abdominal process
72
Q

what MUST NOT be delayed in dx/tx of Fournier’s Gangrene?

A

Surgical Consult for Early Debridement

73
Q

tx for Fournier’s Gangrene?

A

Surgical Consult for Early Debridement

Hemodynamic stabilization - IVF

Abx (ZOSYN + VANCO + CLINDAMYCIN)

Hyperbaric Oxygen (no clear evidence on effectiveness)

PLASTICS

74
Q

what abx treat Fournier’s Gangrene?

A

ZOSYN + VANCO + CLINDAMYCIN

Clindamycin targets antitoxin effects of the toxin elaborating strains of strep and staph

75
Q

what does Hyperbaric Oxygen do for tx of Fournier’s Gangrene?

A

No clear evidence on effectiveness

Neutralizes anaerobes, increases fibroblast proliferation, promotes angiogenesis

76
Q

high clinical index of suspicion of Fournier’s Gangrene in who?

A

DM, immunocompromised, alcoholics

77
Q

what urologic diseases are Urologic Emergencies?

A

Testicular Torsion, Priapism, Penile Fracture, Paraphimosis, Fournier’s Gangrene

78
Q

sx’s of Testicular Torsion? Labs?

A

Rapid onset of severe pain either from trauma, physical activity or none whatsoever

At 12-24 hours, whole scrotum appears as a confluent mass

Afebrile, no irritative voiding symptoms

Normal UA and WBC

79
Q

what test confirms dx of testicular torsion?

A

US with Doppler -> assesses arterial flow w/in the affected testis

80
Q

when does Priapism result?

A

when there is impaired drainage and relaxation of smooth muscle of cavernous arteries and tissues in penis

81
Q

what is Ischemic Priapism?

A
  • Men present with erythematous painful erect corpus cavernosum
  • The increase arterial flow results in hypoxia, acidosis, and eventually penile compartment syndrome
82
Q

Ischemic Pripism seen in who?

A

Sickle cell, Drugs, Neurogenic shock

83
Q

what is Non-Ischemic Priapism? Occurs in?

A

Less common and result of a fistula b/w the cavernosal artery and corpus cavernosum, resulting in consistently high in flow of blood

Occurs in: Needle injury, trauma, congenital arterial malformations

84
Q

what is the treatment for Priapism?

A
  • Analgesia
  • CALL UROLOGY
  • Corporal aspiration followed by irrigation w/alpha-adrenergic agonists (Phenylephrine)
85
Q

Sick Cell pts with priapism need what tx?

A

Sickle Cell need exchange transfusion as well as adequate hydration and analgesia

86
Q

what is a penile fracture?

A

The tunica albuginea of one or both corpus cavernosa ruptures due to direct trauma to the erect penis

87
Q

what is the most common cause of penile fracture? other causes?

A

sexual intercourse = M/C cause

other causes: animal bites, stabbing, bullet wounds, and self-mutilation

88
Q

sx’s of penile fracture?

A

acutely swollen, discolored, and tender penis

89
Q

tx of penile fracture?

A

CALL UROLOGY

Retrograde urethrogram to assess the urethra

Surgery to remove hematoma and suture the tunica albuginea

90
Q

tx of paraphimosis?

A

Pain control, topical lidocaine (NO EPI as can worsen vasoconstriction and ischemia)

Urology consult to attempt manual reduction and if not successful, surgical

91
Q

sx’s of paraphimosis?

A

foreskin of uncircumcised male becomes retraced behind the coronal sulcus of the glans of the penis

-get venous and lymphatic outflow obstructed, edema worsens, blood flow can become obstructed and result in skin necrosis, gangrene, or even auto-amputation

92
Q

common causes of priapism?

A

Many cases are pharmacologically related to intracavernosal injection of vasoactive substances for impotence, calcium channel blockers and erectile dysfunction meds