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Unit 2 Emerg/Surg > L7: Urologic emergencies > Flashcards

L7: Urologic emergencies Flashcards

1
Q

How big does a stone have to be for it to be symptomatic?

A

2-3 mm

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2
Q

Most common type of stone

A

Calcium salts

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3
Q

The radiolucent stones

A

uric acid crystals from stones

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4
Q

All the radiopaque stones

A

Struvite stones from infection
Calcium salts
Crystine (usually)

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5
Q

Renal colic aka

A

urolithiasis

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6
Q

renal colic presentation

A 
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
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7
Q

Imaging for renal colic

A

KUB xray→ misses radiolucent

Non Contrast CT scan→ specific

Renal Ultrasound→ pregnant, children, hx of stones.
See most stones and hydronephrosis

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8
Q

Which stones usually pass? Which don’t?

A

Pass=<5 mm

Don’t pass= >8 mm

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9
Q

A pencil eraser has a diameter of

A

6mm

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10
Q

Watchful waiting management of renal colic

A 
Pain relief
Anti nausea
Abx
alpha 1 blockers. 
Admit if “sick”
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11
Q

Temporary relief for renal colic

A

not passing on own→ insertion of a JJ stent or percutaneous nephrostomy tube.

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12
Q

Definitive treatment for renal colic

A

Intractable pain, fever, renal function, 4 weeks:

  1. ESWL (lithotripsy- “shock waves”)
  2. PCNL (nephrolithotomy-1cm incision)
  3. Ureteroscopy
  4. Open Surgery (very limited
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13
Q

Medical expulsion system of urolithiasis

A 
CCB
alpha blockers (“flowmax”)

<4-5 mm→ no benefit
5-10 mm→ increased passage

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14
Q

Painful inability to void

A

acute urinary retention

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15
Q

Obstructive causes of urinary retention

A

BPH, men >50 (most common), Prostate infection,Constipation

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16
Q

Pharmacologic causes of urinary retention

A

antihistamine
decongestants
anticholinergic
narcotics

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17
Q

Neurogenic causes of urinary retention

A

Spinal cord trauma or tumor
MS
Cauda equina

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18
Q

Urinary retention diagnosis

A

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

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19
Q

Acute urinary retention management

A

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

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20
Q

Patients considered a “complicated” UTI

A 
Male Sex, Elderly, Children
Hospital Acquired
Pregnancy
Indwelling urinary catheter
Recent instrumentation
Functional/Anatomic abnormality
Recent antimicrobial use
Symptoms for > 7 days
DM
Immunosuppression
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21
Q

2 symptoms that really point towards UTI

A

Cloudy urine

No vaginitis or cervicitis

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22
Q

Who needs a UA, rather than a clinical diagnosis,?

A 
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
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23
Q

Treatment options for UTI

A 
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
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24
Q

Pehnazopyridine

A

analgesia for UTIs

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25
Q

Does your UTI patient need to follow up?

A

Not if they are asymptomatic after tx

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26
Q

Drugs you don’t give for UTI and the reasoning why

A

NO Fluoroquinolone(Cipro) → black box→ only if no other tx options (sinusitis, acute bacterial exacerbation of chronic bronchitis, uncomplicated UTI)

NO Amoxicillin→ resistance

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27
Q

Risk of complication from pyelonephritis

A 
DM
pregnancy
obstruction
tumors
stones
urologic surgeries or instrumentation

These patients get admitted!

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28
Q

UA of UTI

A

Urine culture 100,000 CFU/ml

Pyuria >= 10
WBC/hpf
(microscopic)

Urine Dipstick:
(+) Leukocyte esterase→ pyuria, (+)Nitrite→ G-
False (-) & (+). No imaging

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29
Q

Labs for pyelonephritis

A 
UA→ nitrates, leukocyte esterase, pyuria, bacteriuria, hematuria, WBC cast
Urine culture and sensitivities
Blood Cultures
CBC
hCG
BMP→ serum electrolytes
\+/-CT, US, CXR
30
Q

Management of pyelonephritis

A

Cipro 500mg bid x7 days
Levo 750 mg QD x5 days
Bactrim DS for 14 days
Cephalosporins 3rd gen for 10-14 days

31
Q

Admit a pyelonephritis patient if…

A

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

32
Q

Don’t give ____ for pyelonephritis

A

Macrobid (nitrofurotoin)

33
Q

Who needs you to get urine for asymptomatic bactiuria

A

pregnant, symptoms

undergoing urologic procedures

34
Q

Treatment for asymptomatic bacteriuria

A

DON’T TREAT
Antibacterial conservation and prevention of C diff

“Don’t treat the nonpregnant pt with abx”

35
Q

Causes of acute prostatitis by age group

A

<35 years→N gonorrhoeae and Chlamydia

> 35 years→ G- E coli

36
Q

Acute prostatitis presentation

A

Fever, chills
Myalgias
Pain in lower back, rectum, perineum
+/- urinary retention, dysuria

37
Q

Acute prostatitis on exam

A

+/Tender abdomen

GU: Perineal area tender
→ +/- urethral
swab

DRE→ Tender boggy prostate→ don’t massage, risk of bacteremia

38
Q

Acute prostatitis labs

A

CBC→ elevated WBC
UA→ pyuria
Only imaging if toxic

39
Q

Acute prostatitis treatment

A

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

40
Q

Severe illness when UTI spreads systemically

A

Urosepsis

41
Q

Urosepsis history and presentation

A

SIRS

Hx UTI, pyelonephritis, urolithiasis, prostatitis→ persistent sx

Recent Urological procedure

Weakness, Confusion, Dehydration

Nursing home patient (common)

42
Q

Urosepsis exam/diagnostics

A

Exam as Pyelonephritis or Acute Prostate

CBC, Blood cultures, BMP, UA, Urine cultures, Lactate

CT w/ contrast→ r/o stone, abscess

Evaluate for SIRS

43
Q

Criteria for Systemic Inflammatory response syndrome

A

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

44
Q

Urosepsis treratment

A

Fluids
Abx
Treat shock
Admit

45
Q

Hematuria that needs to go to the ED

A

Gross, or >5 RBC UA → ED

> 3 RBC on UA and abnormal vitals, labs, or pain

46
Q

Hematuria workup in the ED (gross, >5 RBC)

A

Rule out obstruction, coagulopathy, rhabdomyolysis

UA, CBC< PT/INR, CK, CMP

Check medication list, LMP

47
Q

what do you do with a patient with Gross hematuria and >3 RBC?

A
  1. Normal vitals, labs, no pain, no comorbidities→ urology
  2. Abnormal vitals, labs, or pain→ ED→ renal amd bladder US, CT abdomen/pelvis w/ contrast, retention→ foley catheter, continuous bladder irrigation
48
Q

Rotation of testis within tunica→ twisting→ compromised blood flow

More common undescended testis

A

Acute testicular torsion

49
Q

Testicular torsion presentation

A 
Sudden onset of testicular pain
\+/- prior event, insidious onset
\+/-Onset  during sleep or exertion
Swelling
\+/- Abdominal pain, N/V
50
Q

Exam/diagnostics for testicular torsion

A

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

51
Q

Testicular torsion management

A

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

52
Q

“Retrograde spread” of infected urine down the vas deferens

A

Acute epididymitis

53
Q

Causes of acute epididymitis by age group

A 
< 35 year→  Chlamydia, GC
> 35 yo→ 
E coli, Enterococci
Pseudomonas
Proteus
54
Q

Acute epididymitis presentation

A 
Scrotal pain, swelling and tenderness→ relieved with testicle elevation
Lower abd or perineal pain
\+/- urethral discharge
\+/- UTI symptoms
\+/- fever, chills
55
Q

Acute epididymitis on exam

A

Testicle red, swollen warm, tender
Testicular lump
Inguinal LAD
Intact cremasteric reflex

56
Q

Acute epididymitis labs

A

CBC, UA
Gonorrhea and Chlamydia testing
Doppler US→ r/o torsion. Tumor, +/- increased blood flow to epididymis

57
Q

Who gets admitted with acute epididymitis?

A

Systemic signs on CBC

58
Q

General care for acute epididymitis

A

Bedrest, Scrotal elevation with ice
Pain meds
Stool softeners

59
Q

Treatment of acute epidymitis

A

<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

60
Q

Why is paraphimosis an emergency?

A

arterial compromise to the glans

61
Q

Risk for/history of paraphimosis

A

Elderly or very young

Frequent catheterization

Poor hygiene
Retracted foreskin not replaced

Risk: Sexual activity or genital piercings

62
Q

Paraphimosis management

A 
Attempt to reduce by pushing on glans while pulling on foreskin
Manual glands compression
Sugar Lidocaine wrap
Emergent dorsal slit in foreskin
Urology STAT
63
Q

Priapism is an erection greater than _____ most common in _____

A

4 hours

20-40 years

64
Q

Workup for priapism

A

Trauma, new drugs? (antipsychotics and antidepressants most common)

Penile shaft firm, glans is soft

CBC, UA if able

65
Q

Priapism management

A

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

66
Q

Differentials for paraphimosis (pics on slide)

A

Infections:
balanoposthitis (glans + foreskin)

balanitis (glans)

67
Q

Necrotizing fasciitis infection of the perineum involving penis,
scrotum, perineum, abdominal wall

A

Fournier’s gangrene

68
Q

Fournier’s gangrene is caused by

A

Staph
Strep
E coli
Clostridium

high mortality

69
Q

Comorbidities/risks of Fournier’s gangrene

A

DM (most common)

Alcoholism

Immunosuppression

Liver disease

Trauma to ano-urogential, perineal area

Preexisting perineal/rectal infections

70
Q

Fournier’s gangrene on exam

A 
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
71
Q

Fournier’s gangrene labs

A

Septic workup→ CBC, CMP, blood culture, coags, wound cultures, UA, lactate
Contrast CT scan

72
Q

Fournier’s gangrene management

A

NPO
IV Fluids, IV Pressors
IV Antibiotics
Call surgeon→ Surgical Debridement

Unit 2 Emerg/Surg (8 decks)

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