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Emergency Med Exam 4 > GU ER > Flashcards

GU ER Flashcards

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1
Q

Microscopic Hematuria value

A

Laboratory diagnosis (> 3 RBC/HPF)

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2
Q

Initial Hematuria

A

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

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3
Q

Gross Hematuria

A

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

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4
Q

Casts, Protein, Dysmorphic RBCs

A

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

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5
Q

Hematuria imaging

A

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

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6
Q

Cystitis Presentation

A

● 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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7
Q

Bacteriuria lab on urinalysis

A

○ >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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8
Q

Does uncomplicated UTI need a urine culture?

A

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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9
Q

Does complicated cystitis need a urine culture?

A

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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10
Q

Urethritis

A

● 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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11
Q

Pyelonephritis Presentation

A

● 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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12
Q

Missed pyelonephritis could lead to ____

A

sepsis

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13
Q

Nephrolithiasis presentation

A

● 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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14
Q

Nephrolithiasis imaging

A

Non-contrast CT abdomen/pelvis
(gold standard)

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15
Q

Nephrolithiasis analgesia

A

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

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16
Q

Nephrolithiasis: admission criteria

A

● 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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17
Q

Most common cause of prerenal AKI in the ER

A

Dehydration

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18
Q

Most common cause of intrinsic AKI in the ER

A

Ischemic injury, nephrotoxic drugs

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19
Q

Most common cause of postrenal AKI in the ER

A

(obstruction to urine outflow)

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20
Q

Uremia

A

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

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21
Q

Nephrotoxins – AD A CaN

A

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

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22
Q

Changes associated with ↑ K+

A

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

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23
Q

Test of choice for urologic
imaging

A

U/S

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24
Q

Metabolic acidosis (kidney)

A

○ 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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25
Q

Metabolic alkalosis (renal)

A

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

26
Q

Hyponatremia (normal 135-145 mEq/L)

A

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)

27
Q

Treatment of hyponatremia

A

IV fluids, slowly raise sodium levels

28
Q

Hypernatremia

A

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

29
Q

Hypernatremia treatment

A

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

30
Q

Hypokalemia

A

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

31
Q

Treatment of hypokalemia

A

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

32
Q

Hyperkalemia

A

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

33
Q

Hyperkalemia Treatment

A

● 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

34
Q

Acute Prostatitis presentation

A

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

35
Q

PE for prostatitis

A

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

36
Q

Acute Prostatitis workup

A

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

● NO PSA
● Possible post void residual (PVR)

37
Q

Acute Prostatitis treatment

A

● 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

38
Q

Acute Urinary Retention presentation

A

● 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.

39
Q

Risk Factors for Acute Urinary Retention

A

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

40
Q

Pharmacologic Agents Associated
with Urinary Retention

A

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

41
Q

Acute Urinary Retention workup

A

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

42
Q

Treatment for Acute Urinary Retention

A

● 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

43
Q

Medications from Acute Urinary Retention

A

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

44
Q

Scrotal Abscess workup

A

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

45
Q

Fournier’s Gangrene

A

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

46
Q

Risk Factors for Fournier’s Gangrene

A

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

47
Q

Fournier’s Gangrene treatment

A

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

48
Q

Epididymitis presentation

A

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

49
Q

Treatment of epididimytis

A

● 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

50
Q

Ischemia can occur after ____ hours with testicular torsion

A

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

51
Q

Balanoposthitis

A

Inflammation of the glans and foreskin

52
Q

Cause/Risk factors of Balanoposthitis

A

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

53
Q

Balanoposthitis treatment

A

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

54
Q

Phimosis treatment

A

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

55
Q

Entrapment Injuries

A

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

56
Q

Entrapment Injuries treatment

A

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

57
Q

Penile Fracture

A

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

58
Q

Causes of Penile Fracture

A

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

59
Q

Penile Fracture treatment

A

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

60
Q

Priapism causes: low flow (ischemic)

A

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

61
Q

Priapism causes: high flow (non-ischemic)

A

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

Emergency Med Exam 4 (5 decks)

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