GU ER Flashcards by Cierra Pennal

Microscopic Hematuria value

Laboratory diagnosis (> 3 RBC/HPF)

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Initial Hematuria

● Blood clearing at the beginning of stream or small
clots in the underwear
○ Urethral bleeding (below the bladder neck)

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Gross Hematuria

● Bright red blood throughout micturition
○ Lower tract (bladder, ureters, prostate)

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Casts, Protein, Dysmorphic RBCs

● Casts, significant proteinuria (>1,000 mg/24 hours),
dysmorphic RBCs
○ Upper tract (renal, glomerular)

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Hematuria imaging

● KUB
● Ultrasound w/ post void residual
● CT Urogram

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Cystitis Presentation

● Urgency, frequency, hesitancy, dysuria, hematuria, and/or suprapubic tenderness
● CVA tenderness may be present due to referral pain
● Vaginal discharge or irritation is more often associated with vaginitis, cervicitis, or
pelvic inflammatory disease

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Bacteriuria lab on urinalysis

○ >1 bacterium/HPF is 95% sensitive and
>60% specific to predict a positive culture
○ False positives can result with contamination
or presence of epithelial cells

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Does uncomplicated UTI need a urine culture?

maybe
○ If done, inform the Pt that you will
notify them of C&S results in afew days
to adjust the treatment if needed

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Does complicated cystitis need a urine culture?

Urine Culture – yes
○ If done, inform the Pt that you will notify them of C&S results in a few days to adjust the
treatment if needed

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Urethritis

● Dysuria with urethral discharge (can present without discharge)
○ May be secondary to urethral trauma (foley, instrumentation)
● UA/micro may reveal pyuria with or without bacteria
● Urethral swab vs “First-void” urine

ER-GU-1

“Tintinalli’s Emergency Medicine,” 9e, Tintinalli.

● If evidence of cervicitis, then think of a Chlamydia infection

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Pyelonephritis Presentation

● Flank pain, CVA tenderness, especially in
association with fever, chills, nausea,
vomiting, or prostration (feel so bad you
want to lay down)
● May or may not have coexistent
symptoms of cystitis

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Missed pyelonephritis could lead to ____

sepsis

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Nephrolithiasis presentation

● Excruciating, unilateral flank and/or mid back pain that radiates to
the ipsilateral lower quadrant, groin, testicle, or labia
○ Sx may ebb and flow and pain may cause vasovagal syncope
● Nausea/Vomiting are common
● Gross hematuria
● LUTS (typically suggests a distal ureteral stone)

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Nephrolithiasis imaging

Non-contrast CT abdomen/pelvis
(gold standard)

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Nephrolithiasis analgesia

○ Ketorolac (Toradol®) IM or IV in the ED
■ Check creatinine first
○ Opioids
■ Comparative studies show little
difference between opiates & NSAIDS

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Nephrolithiasis: admission criteria

● Intractable pain
● Intractable emesis
● Coexisting pyelonephritis/pyuria
● Documented or suspected renal dysfunction (↑
BUN or Cr levels, bilateral ureteral stones, oliguria
or anuria (very bad)
● Degree of obstruction or size of the stone
● Abnormal anatomy (solitary kidney)

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Most common cause of prerenal AKI in the ER

Dehydration

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Most common cause of intrinsic AKI in the ER

Ischemic injury, nephrotoxic drugs

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Most common cause of postrenal AKI in the ER

(obstruction to urine outflow)

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Uremia

“Urine in the blood”
● Toxic buildup of urea or other nitrogenous waste
● Develops when CrCl falls to < 10 mL/min

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Nephrotoxins – AD A CaN

○ Aminoglycosides, Beta Lactams,
Quinolones
● Diuretics
○ Loop/Thiazide (Furosemide/HCTZ)
● ACE/ARB
● Cancer drugs
● NSAIDs

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Changes associated with ↑ K+

Tall, peaked T waves with a
narrow base, shortened QT
interval, ST-segment depression

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Test of choice for urologic
imaging

U/S

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Metabolic acidosis (kidney)

○ Loss of HCO3

or increase in acid concentration
■ Failure of kidney to excrete acids (renal disease)
■ Formation of excess acid (DKA, lactic acidosis)
■ Loss of base from bodily fluids (severe diarrhea)

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Metabolic alkalosis (renal)

○ Increase in HCO3 or loss of excess H+
■ Ingestion of alkali drugs (sodium bicarb)
■ Excessive vomiting

Hyponatremia (normal 135-145 mEq/L)

To much water in the system (SIADH, Addison’s Dz)
Loss of salt (diarrhea or vomiting)
● Moderate – Na+ <130 mEq/L
○ HA, nausea, disorientation, confusion, agitation, ataxia, areflexia
● Severe – Na+ <120 mEq/L
○ Intractable vomiting, seizure, coma, respiratory arrest (brain stem
herniation)

Treatment of hyponatremia

IV fluids, slowly raise sodium levels

Hypernatremia

To much sodium (typically from diet, primary aldosteronism) or loss of water
● Nausea, vomiting, lethargy, weakness, increase thirst, polyuria
● Hypotension, tachycardia, altered mental status
● If untreated, shock, seizure, coma

Hypernatremia treatment

● Treat shock and volume deficits with (0.9%) saline or LR
● Treat underlying condition (DM, vomiting, diarrhea)
● Possible dialysis (life threatening, like salt ingestion)

Hypokalemia

● K + <3.5 mEq/L
○ Sx usually start a 2.5 mEq/L
○ T-wave depression, U-wave

Treatment of hypokalemia

● Mild – >3.0 mEq/L → PO supplementation
● IV Potassium Chloride (KCl)
● Monitor ECG
● Likely need Mg2+ (tends to come with low K+
)

Hyperkalemia

● K + >5.5 mEq/L
○ Cardiac dysrhythmias, neuromuscular dysfunction, weakness,
paresthesias, areflexia, GI effects
● Labs/special tests
○ ECG (peaked T-waves)
electrolytes, ABG

Hyperkalemia Treatment

● Potassium lowering agents
○ Nebulized Albuterol
○ IV Glucose (D50W) with IV Insulin
○ Diuretics
○ Kayexalate
● IV Calcium Gluconate is used to stabilize cardiac membranes.
This acts quickly and can be life-saving

Acute Prostatitis presentation

● Low back, perineal, suprapubic or genital discomfort
● LUTS with urinary hesitancy
● Painful ejaculation, painful defecation
● Fever and chills

PE for prostatitis

● “Boggy” prostate
● Tender/painful with palpation
○ “Chandelier Sign”

Acute Prostatitis workup

● Urine Culture
○ >35 yo – E. Coli >
Pseudomonas, Klebsiella
○ < 35 yo or MSM –
Gonorrhea/Chlamydia
■ Consider urethral swab

● NO PSA
● Possible post void residual (PVR)

Acute Prostatitis treatment

● Fluoroquinolone x 2 weeks
○ Cipro 500 mg PO BID
■ F/U with PCP
● SMZ/TMP PO BID x 2 weeks
● Fosfomycin 3 gm QD x 7 days, then
3 gm every 48 hrs x 6 weeks

Acute Urinary Retention presentation

● Older male (>70 years)
● LUTS with urinary hesitancy
● Painful inability to pass urine
● Lower abdominal pain and distension
● Hypertension or tachycardia (may
resolve after decompression)
● Fever, tachycardia, tachypnea &
hypotension suggest infection or sepsis.

Risk Factors for Acute Urinary Retention

● Hx of BPH, prostate infection, prostate or
bladder cancer/surgery
● Anatomical abnormalities
● Neurogenic
● Medications

Pharmacologic Agents Associated
with Urinary Retention

α-Adrenergic agents
Amphetamines*
Anesthesia agents*
Anticholinergics*
Antihistamines
Antiparkinsonian
agents
Antipsychotic agents
Carbamazepine
Decongestants
Hydralazine
Muscle relaxants
Opiates
SSRI
TCA

Acute Urinary Retention workup

● Urinalysis
● Culture (if indicated)
● BMP/CMP (renal function)
● CBC (if suspect infection)
● Ultrasound, Bladder scan
○ Normal bladder capacity 300-600 mL

Treatment for Acute Urinary Retention

● Catheterization
○ Pro-Tip: if straight cath fails in
men, then us a 16 or 18 French
Coude’ tip catheter
○ Do NOT cath if suspected urethral trauma
○ Do NOT force with suspected prostatitis
● Monitor urine output
○ “Post obstructive diuresis” long standing obstruction
■ >400 mL output, replace 1⁄2 the amount with IV fluids
● Re-Exam after decompression of the bladder
○ Any unresolved mass or problem not previously felt

Medications from Acute Urinary Retention

● Remove offending medications
● α-adrenergic receptor blocker – Tamsulosin (Flomax®) Alfuzosin (Uroxatral®)

Scrotal Abscess workup

Causes
● Infected hair follicle, penetrating trauma
Diagnosis
● U/S
Treatment
● I&D, wound care, sitz baths,
● Antibiotics not typically needed with “simple follicle” abscess

Fournier’s Gangrene

Polymicrobial, synergistic, infective necrotizing
fasciitis of the perineal, genital, or perianal area

Risk Factors for Fournier’s Gangrene

● Males >45 yo (Females 10-25% of cases)
● Immunocompromised
● Diabetes – uncontrolled
● ETOH or drug abuse

Fournier’s Gangrene treatment

Prompt recognition and urology consult
● Aggressive fluid resuscitation
● IV antibiotics – cover for gram-positive, gram-negative, anaerobes
○ Piperacillin-tazobactam, or imipenem, or meropenem (PULL OUT THE
BIG GUNS)
○ PLUS Vancomycin – MRSA coverage
● Urology consult, admit to ICU

Epididymitis presentation

● Lower abdominal, inguinal, scrotal, or testicular pain
alone or in combination
● Enlarged, painful, posterior testicle, tender with
palpation
● Prehn’s sign - not to reliable

Treatment of epididimytis

● Gonorrhea & Chlamydia
○ Ceftriaxone 250 mg IM once, AND Doxycycline 100 mg PO BID x 10 days
● Gram Negative Bacteria
○ Levofloxacin QD x 10 days
○ SMX/TMP BID x 10 days

Ischemia can occur after ____ hours with testicular torsion

4
Time between symptom onset and surgery should be <6 hours

Balanoposthitis

Inflammation of the glans and foreskin

Cause/Risk factors of Balanoposthitis

● Inadequate hygiene, opportunistic infection
(Candida, staph/strep or mixed flora)
● Diabetes or immunocompromised

Balanoposthitis treatment

● Topical antifungals, good hygiene. Recurrent cases do well with combination
antifungal/steroid creams. Occasionally topical antibiotics

Phimosis treatment

● Topical corticosteroids BID x 1-2 months
● Daily manual retraction
● Circumcision

Entrapment Injuries

Risk similar to that of paraphimosis
● Hair, string, wire, or rings become
wrapped around the penis
● Edema of the glans cause venous
engorgement, resulting in arterial
compromise and gangrene

Entrapment Injuries treatment

Removal of foreign body
● Lubrication, compression of the penis, cutting the object
● Ice packs can help decrease inflammation and edema
● Surgical removal if edema prevents access to the constricting source

Penile Fracture

Surgical Emergency
● Rupture of the tunica albuginea due to
direct trauma to the erect penis
● May result in partial or complete urethral
rupture (18%) or deep dorsal vein injury

Causes of Penile Fracture

● Most common cause is sexual intercourse
● Animal bites, stabbing, bullet wounds,
self-mutilation

Penile Fracture treatment

○ Urology consult
■ Evacuation of hematoma
■ Suturing of the disrupted tunica albuginea
■ Surgery within 8 hours
● Delayed Tx may result in impotence

Priapism causes: low flow (ischemic)

○ Meds (antipsychotics, antidepressants, methylphenidate,
injectable ED medications), outflow obstruction (bladder tumors,
thromboembolic), sickle-cell, idiopathic
○ In children, sickle cell anemia most common

Priapism causes: high flow (non-ischemic)

○ Results from traumatic fistula between the cavernosal artery and the
corpus cavernosum
○ Straddle injuries

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GU ER Flashcards

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