L7: Urologic emergencies Flashcards
How big does a stone have to be for it to be symptomatic?
2-3 mm
Most common type of stone
Calcium salts
The radiolucent stones
uric acid crystals from stones
All the radiopaque stones
Struvite stones from infection
Calcium salts
Crystine (usually)
Renal colic aka
urolithiasis
renal colic presentation
Unilateral Flank pain Very sudden onset, colicky Stone passes to lower ureter→ radiate to groin Change location flank→ groin Restless, move, roll around N/V Dark urine, frequency
Imaging for renal colic
KUB xray→ misses radiolucent
Non Contrast CT scan→ specific
Renal Ultrasound→ pregnant, children, hx of stones.
See most stones and hydronephrosis
Which stones usually pass? Which don’t?
Pass=<5 mm
Don’t pass= >8 mm
A pencil eraser has a diameter of
6mm
Watchful waiting management of renal colic
Pain relief Anti nausea Abx alpha 1 blockers. Admit if “sick”
Temporary relief for renal colic
not passing on own→ insertion of a JJ stent or percutaneous nephrostomy tube.
Definitive treatment for renal colic
Intractable pain, fever, renal function, 4 weeks:
- ESWL (lithotripsy- “shock waves”)
- PCNL (nephrolithotomy-1cm incision)
- Ureteroscopy
- Open Surgery (very limited
Medical expulsion system of urolithiasis
CCB alpha blockers (“flowmax”)
<4-5 mm→ no benefit
5-10 mm→ increased passage
Painful inability to void
acute urinary retention
Obstructive causes of urinary retention
BPH, men >50 (most common), Prostate infection,Constipation
Pharmacologic causes of urinary retention
antihistamine
decongestants
anticholinergic
narcotics
Neurogenic causes of urinary retention
Spinal cord trauma or tumor
MS
Cauda equina
Urinary retention diagnosis
Abdominal distension
Bladder US→ distention
Normal <50-100 ml → clinical judgement
Abnormal >100-150 ml
Catheter placement→ large amount of urine→ Post Void Residual(PVR)
BMP- +/- renal failure
UA- +/- infection
Acute urinary retention management
Initial Management :
1 Urethral catheterization
2. Suprapubic catheter ( SPC)
3. CBI Continuous Bladder Irrigation→ if blood clots
Late Management:
Treating the underlying cause
Monitor 2-4 hrs post decompression→ +/- develop post obstructive diuresis
Discharge pt with drainage bag and follow up 3-5 days→ Urology
Patients considered a “complicated” UTI
Male Sex, Elderly, Children Hospital Acquired Pregnancy Indwelling urinary catheter Recent instrumentation Functional/Anatomic abnormality Recent antimicrobial use Symptoms for > 7 days DM Immunosuppression
2 symptoms that really point towards UTI
Cloudy urine
No vaginitis or cervicitis
Who needs a UA, rather than a clinical diagnosis,?
s/sx not clear Back pain Looks sick Male Age ranges Immunocompromised Hx multi courses ABX or resistance Hx multidrug allergies \+/- No U/A in low risk patients, call in RX
Treatment options for UTI
Macrobid (nitrofurantoin) x 5 days Bactrim DS x 3 days (CI: high e.coli resistant) Fosfomycin 3g single dose Cephalosporins x 7days Augmentin x 7 days
Pehnazopyridine
analgesia for UTIs
Does your UTI patient need to follow up?
Not if they are asymptomatic after tx
Drugs you don’t give for UTI and the reasoning why
NO Fluoroquinolone(Cipro) → black box→ only if no other tx options (sinusitis, acute bacterial exacerbation of chronic bronchitis, uncomplicated UTI)
NO Amoxicillin→ resistance
Risk of complication from pyelonephritis
DM pregnancy obstruction tumors stones urologic surgeries or instrumentation
These patients get admitted!
UA of UTI
Urine culture 100,000 CFU/ml
Pyuria >= 10
WBC/hpf
(microscopic)
Urine Dipstick:
(+) Leukocyte esterase→ pyuria, (+)Nitrite→ G-
False (-) & (+). No imaging
Labs for pyelonephritis
UA→ nitrates, leukocyte esterase, pyuria, bacteriuria, hematuria, WBC cast Urine culture and sensitivities Blood Cultures CBC hCG BMP→ serum electrolytes \+/-CT, US, CXR
Management of pyelonephritis
Cipro 500mg bid x7 days
Levo 750 mg QD x5 days
Bactrim DS for 14 days
Cephalosporins 3rd gen for 10-14 days
Admit a pyelonephritis patient if…
Inability to maintain oral hydration or take oral medications
Compliance risk
Uncertainty about diagnosis
High fevers
severe disability or uncontrolled pain
Risk factors for complications
Don’t give ____ for pyelonephritis
Macrobid (nitrofurotoin)
Who needs you to get urine for asymptomatic bactiuria
pregnant, symptoms
undergoing urologic procedures
Treatment for asymptomatic bacteriuria
DON’T TREAT
Antibacterial conservation and prevention of C diff
“Don’t treat the nonpregnant pt with abx”
Causes of acute prostatitis by age group
<35 years→N gonorrhoeae and Chlamydia
> 35 years→ G- E coli
Acute prostatitis presentation
Fever, chills
Myalgias
Pain in lower back, rectum, perineum
+/- urinary retention, dysuria
Acute prostatitis on exam
+/Tender abdomen
GU: Perineal area tender
→ +/- urethral
swab
DRE→ Tender boggy prostate→ don’t massage, risk of bacteremia
Acute prostatitis labs
CBC→ elevated WBC
UA→ pyuria
Only imaging if toxic
Acute prostatitis treatment
Hydration Analgesics, bed rest, stool softeners
Cipro or Levo >35 y/o (2nd line Bactrim 3rd tetracyclines)
GC/Chlamydia tx <35
Toxic→ treat as Uroseptic
Severe illness when UTI spreads systemically
Urosepsis
Urosepsis history and presentation
SIRS
Hx UTI, pyelonephritis, urolithiasis, prostatitis→ persistent sx
Recent Urological procedure
Weakness, Confusion, Dehydration
Nursing home patient (common)
Urosepsis exam/diagnostics
Exam as Pyelonephritis or Acute Prostate
CBC, Blood cultures, BMP, UA, Urine cultures, Lactate
CT w/ contrast→ r/o stone, abscess
Evaluate for SIRS
Criteria for Systemic Inflammatory response syndrome
2 or more of the following:
Temperature >100.4 or <96.8
WBC count >12K or <4K or 10% bands
Tachycardia >90 bpm
Tachypnea >20/min
Severe- Altered mental status,
Elevated plasma Lactate > 4mmol/L
Urosepsis treratment
Fluids
Abx
Treat shock
Admit
Hematuria that needs to go to the ED
Gross, or >5 RBC UA → ED
> 3 RBC on UA and abnormal vitals, labs, or pain
Hematuria workup in the ED (gross, >5 RBC)
Rule out obstruction, coagulopathy, rhabdomyolysis
UA, CBC< PT/INR, CK, CMP
Check medication list, LMP
what do you do with a patient with Gross hematuria and >3 RBC?
- Normal vitals, labs, no pain, no comorbidities→ urology
- Abnormal vitals, labs, or pain→ ED→ renal amd bladder US, CT abdomen/pelvis w/ contrast, retention→ foley catheter, continuous bladder irrigation
Rotation of testis within tunica→ twisting→ compromised blood flow
More common undescended testis
Acute testicular torsion
Testicular torsion presentation
Sudden onset of testicular pain \+/- prior event, insidious onset \+/-Onset during sleep or exertion Swelling \+/- Abdominal pain, N/V
Exam/diagnostics for testicular torsion
Sedate pt (pain) for exam
Swollen, firm & tender hemiscrotum
High riding testis with transverse lie
+/-loss of cremasteric reflex
Blue dot sign→ torsion of the appendix testis
Doppler testicular Ultrasound→ decreased or absent flow to affected side
UA,CBC, preop labs→ not helpful acutely
Testicular torsion management
NPO
Call Urology stat→ testicular fixation
(even if detorsed in ED)
Sedate pt, attempt to manually detorse
Turn testicle medially to laterally→ ”opening of book” technique
Up to 360 degree detorse→ until pain gone
“Retrograde spread” of infected urine down the vas deferens
Acute epididymitis
Causes of acute epididymitis by age group
< 35 year→ Chlamydia, GC > 35 yo→ E coli, Enterococci Pseudomonas Proteus
Acute epididymitis presentation
Scrotal pain, swelling and tenderness→ relieved with testicle elevation Lower abd or perineal pain \+/- urethral discharge \+/- UTI symptoms \+/- fever, chills
Acute epididymitis on exam
Testicle red, swollen warm, tender
Testicular lump
Inguinal LAD
Intact cremasteric reflex
Acute epididymitis labs
CBC, UA
Gonorrhea and Chlamydia testing
Doppler US→ r/o torsion. Tumor, +/- increased blood flow to epididymis
Who gets admitted with acute epididymitis?
Systemic signs on CBC
General care for acute epididymitis
Bedrest, Scrotal elevation with ice
Pain meds
Stool softeners
Treatment of acute epidymitis
<35 years (G+C)
Ceftriaxone IM single dose +
doxycycline x 10 days
<35 years (G+C + enteric) + MSM
Ceftriaxone IM single dose + Levofloxacin x 10 days
> 35 years (enteric)
Levofloxacin x 10 days
Why is paraphimosis an emergency?
arterial compromise to the glans
Risk for/history of paraphimosis
Elderly or very young
Frequent catheterization
Poor hygiene
Retracted foreskin not replaced
Risk: Sexual activity or genital piercings
Paraphimosis management
Attempt to reduce by pushing on glans while pulling on foreskin Manual glands compression Sugar Lidocaine wrap Emergent dorsal slit in foreskin Urology STAT
Priapism is an erection greater than _____ most common in _____
4 hours
20-40 years
Workup for priapism
Trauma, new drugs? (antipsychotics and antidepressants most common)
Penile shaft firm, glans is soft
CBC, UA if able
Priapism management
Within 12-24 hours:
Sudafed po
Terbutaline-SQ Decrease inflow of blood to penis
Aspirate corpora cavernosum with butterfly needle: 3 o’clock + 9 o’clock→ 20-100 cc until bright red arterial blood
Phenylephrine 250-500 mcg injected directly into corpora cavernosa
Urology
Warn pt of possible impotence, fibrosis
Differentials for paraphimosis (pics on slide)
Infections:
balanoposthitis (glans + foreskin)
balanitis (glans)
Necrotizing fasciitis infection of the perineum involving penis,
scrotum, perineum, abdominal wall
Fournier’s gangrene
Fournier’s gangrene is caused by
Staph
Strep
E coli
Clostridium
high mortality
Comorbidities/risks of Fournier’s gangrene
DM (most common)
Alcoholism
Immunosuppression
Liver disease
Trauma to ano-urogential, perineal area
Preexisting perineal/rectal infections
Fournier’s gangrene on exam
Slow or rapid course(cm/hr) Starts: redness next to port of entry Localized pain swelling discoloration of affected area Pain out of proportion Pain outside of erythema margins Fever, lethargy, toxic appearing(SWOS) Subcutaneous crepitation Putrid/feculent odor
Fournier’s gangrene labs
Septic workup→ CBC, CMP, blood culture, coags, wound cultures, UA, lactate
Contrast CT scan
Fournier’s gangrene management
NPO
IV Fluids, IV Pressors
IV Antibiotics
Call surgeon→ Surgical Debridement
