Urologic Emergencies Flashcards
Differential Diagnosis of Acute Scrotal Pain
Testicular torsion
Appendiceal torsion
Epididymitis
Testicular rupture
History of Acute Scrotal Pain
Good pain history Fever/chills Dysuria/hematuria Discharge H/O trauma
Describe a Positive Prehn’s Sign
Lifting of testicle on affected side relieves pain
Physical Exam Inclusions
Abdominal exam Exam of testes, epididymis, cord, and scrotal skin Exam of inguinal region Cremasteric reflex Possible DRE to check prostate
Work Up of Acute Scrotal Pain
UA and culture
Color doppler ultrasound
History of Testicular Torsion
Sudden onset
Possible inciting event or occur spontaneously
Symptoms of Testicular Torsion
Lower abdominal pain, inguinal canal or testes
N/V (+/-)
Physical Exam Findings for Testicular Torsion
High-riding testis on affected side Significant swelling Epididymis may be displaced and not found in normal position Testicle is firm Exquisite tenderness Cremasteric reflex absent
Diagnostic Evaluation of Testicular Torsion
Color doppler US of testicle
Treatment of Testicular Torsion
Emergent urologic consultation
Manual detorsion
Orchiopexy
Describe Manual Detorsion
Twist laterally “like opening a book”
May need to twist 720 degrees
Acute Epididymitis
Less than 6 weeks
Swelling of epididymis with exquisite tenderness
+/- inguinal lymphadenopathy
Systemic symptoms: fever/chills, irritative voiding symptoms
+/- acute prostatitis
Chronic Epididymitis
6+ weeks
Subtle epididymal induration and tenderness
No irritative voiding symptoms
+/- inguinal lymphadenopathy
Physical Exam Findings in Epididymitis
Tenderness posterior and lateral to the testis
DRE to evaluate prostate
Acute: reactive hydrocele
Positive Prehn’s sign
Work Up of Epididymitis
UA and urine culture
+/- GC and chlamydia
Urethral swab if discharge present
Rule out other causes of scrotal pain
Etiology of Epididymitis in Men Younger than 35 Years Old
Gonococcal
Clamydia
Treatment of Epididymitis in Men Younger than 35 Years Old
Ceftriaxone 250 mg IM +
Doxycycline 100 mg BID x 10 days
Etiology of Older Men or History of BPH, Urethral Stricture, or Chronic UTI
Enteric gram negative bacteria
Treatment of Older Men or History of BPH, Urethral Stricture, or Chronic UTI
Levaquin 500 mg QD x 10 days
Symptomatic Treatment of Epididymitis
NSAIDs
Scrotal elevation
Ice
Risk Factors for Inflammatory Epididymitis
Medication reaction Prolonged sitting Vigorous exercise Trauma Autoimmune disease
Presentation of Inflammatory Epididymitis
Progressive, gradual onset of pain
Treatment of Inflammatory Epididymitis
Scrotal elevation
Warm baths
NSAIDs
Define Appendix Testis
Small appendage of normal tissue that is usually located on the upper portion of the testis
Symptoms of Appendiceal Testis
Gradual onset of pain
Reactive hydrocele (transilluminate)
Localized tenderness
Classic “blue dot” sign
Diagnosis of Appendiceal Testis
US shows tossed appendage as a lesion of low echogenicity with central hypoechogenic area
Conservative Treatment of Appendiceal Testis
Rest Ice NSAIDs Slow recovery with discomfort Infarcted tissue usually reabsorbed
Surgical Treatment of Appendiceal Testis
Excision of appendix testis
Define Testis Rupture
Rip or tear in the tunica albuginea resulting in extrusion of testicular contents
Main Symptoms of Testis Rupture
Scrotal swelling
Severe pain
Ecchymosis
Diagnostics for a Testis Rupture
Scrotal US
Treatment of Testis Rupture
Referral to urologist for scrotal exploration
Pain management
IV
Other Causes of Scrotal Pain
Trauma Strangulated hernia Post-vasectomy problems Mumps Testicular cancer Kidney stone
Define Priapism
Erection unrelated to stimulation lasting typically longer than 4 hours
Pathophysiology of Priapism
Trapping of blood in the erectile bodies which can result in ischemia and infarction
Ischemic Priapism
Most common
Painful
Non-Ischemic Priapism
Rare
Painful
Usually development of traumatic A/V fistula between cavernosal artery and corpus cavernosum
Etiology of Priapism
Idiopathic Sickle cell anemia Leukemia Thalassemia MM TTP Spinal shock Metastatic cancers Perineal, pelvic, or penile trauma Iatrogenic Drugs Infection Metabolic disorders
Drug Classes that can Cause Priapism
Anticoagulants Anti-hypertensives Anti-depressants PDE5 inhibitors Intracavernous injections Alpha-blockers Cocaine
Metabolic Disorders that can Cause Priapism
Gout Hemodialysis High lipid content Total parenteral nutrition DM Amyloidosis
History of Priapism
Presence of pain
Duration, role of antecedent factors, prior episodes
Existence of etiological conditions
Existence of erectile function status
Physical Exam Findings of Priapism
Extent of tumescence and presence and extent of tenderness
Abdominal, perirenal, and rectal exams can reveal signs of trauma or malignancy
Diagnosis of Priapism
CBC
Color doppler US to distinguish ischemic from non-ischemic
Evaluation of aspirated blood
Treatment of Priapism
Pain management
Urgent urological consultation
Treatment of Ischemic Priapism
Evacuation of blood
Intracavernous injection of alpha-adrenergic sympathomimetic agent
Treatment of Non-Ischemic Priapism
Observation
Urological consult
Define Penile Fracture
Rupture of one or both of the tunica albuginea that covers the corpora cavernosa
Cause of a Penile Fracture
Rapid blunt force to an erect penis
Vaginal intercourse
Aggressive masturbation
Signs and Symptoms of Penile Fracture
Popping or cracking sound
Severe pain
Immediate loss of erection
Diagnostics of a Penile Fracture
Retrograde urethrogram (RUG)
Treatment of a Penile Fracture
Surgical correction
Complications of a Penile Fracture
ED
Penile curvature
Pain
Describe Paraphimosis
Foreskin in uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion and cannot be returned to its normal position
History with a Paraphimosis
Swelling of penis and penile pain
Cause of irritability in preverbal infant
Recent penile exam, foley insertion, cystoscopy
Physical Findings with a Paraphimosis
Ensure no constricting FB Edema and tenderness of the glans Painful swollen retracted foreskin Penile shaft unaffected Ischemic: blue or black, firm
Non-Invasive Techniques for Reduction of a Paraphimosis
Ice Compression bandages Osmotic agents Manual compression and reduction Traction with forceps
Invasive Techniques for Reduction of a Paraphimosis
Glans penis aspiration
Dorsal slit procedure
Define Urinary Retention
Inability to voluntarily pass urine
3 Factors Causing Retention
Outflow obstruction
Neurologic impairment
Inefficient detrusor muscle
Diagnosing Urinary Retention
H&P Bladder US Catheter insertion UA/culture Creatinine level
Treatment of Urinary Retention
Catheter
Alpha-blocker meds
Alpha-blocker Medications that help in Urinary Retention
Tamsulosin (Flomax)
Doxazosin (Cardura)
Complications of Urinary Retention
Hematuria
Postobstructive diuresis
Labs to Diagnose Dysuria
UA
Urine culture
Pyuria on UA can be seen with what infections?
UTI
Chlamydia urethritis
Gonococcal urethritis
Hematuria + Pyuria on UA Rules Out
STI
Painless Hematuria Potentially Indicates
Cancer
When is a urine culture recommended with dysuria?
Men with pyelonephritis
Women with a complicated UTI
Presentation of Pyelonephritis
Flank pain Abdominal pain Pelvic pain N/V Fever >99.8 May have CVA tenderness \+/- cystitis symptoms
Labs for Pyelonephritis
UA
CBC
Pregnancy test
Treatment of Mild to Moderate Pyelonephritis
Rehydrate and give parenteral dose of antibiotics in ED
Observe for 8-12 hours
IV ceftriaxone
Oral fluoroquinolone x 7 days
Treatment of Severe Pyelonephritis
Hospitalization High fever Pain Marked debility Inability to maintain oral hydration or take oral meds Pregnancy Concerns about patient compliance
Presentation of Nephrolithiasis
Colicky flank pain
Hematuria
Diagnostics of Nephrolithiasis
Abdominal plain films
Usually non-contrast helical CT scan
US: patient who need to avoid radiation
Conservative Treatment of Nephrolithiasis
Pain medication
Stone less than 10 mm, tamsulosin (Flomax)
Hydration
Strain urine
When is an urgent urological consult warranted?
Urosepsis
Acute renal failure
Anuria
Unyielding pain, N/V
Epidemiology of Blunt Trauma to the Urogenital Region
MVA
Falls from heights
Direct blows to the torso or external genitalia
Injuries to the female genitalia (pelvic fractures, physical or sexual assault)
Testicular injuries
Initial Management of Genitourinary Trauma
Identification and stabilization of life-threatening injuries
Rarely life-threatening
Secondary Survey of GU Trauma for Both Genders
Inspect perineum and external genitalia
Blood on underwear
Folds of buttocks for perineal lacerations (pelvic fracture)
Rectal exam
What are we looking for with a rectal exam in a GU trauma?
Sphincter tone
Presence of blood
Position of prostate
Secondary Survey of GU Trauma for Males
Examine scrotum for bruising or testicular rupture
Look for blood at penile meatus
Secondary Survey of GU Trauma for Females
Vaginal introitus for lacerations or hematoma
Bimanual exam if suspicion of pelvic trauma, hematoma, or bruising
Any sign of vaginal blood, need a speculum exam to look for vaginal laceration
When should you suspect a urethral injury?
Blood at urethral meatus Gross hematuria Inability to void Absent or abnormally positioned prostate Ecchymosis or hematoma of penis, scrotum or perineum Plain films reveal a pelvic fracture
What must be done prior to insertion of a foley catheter in GU trauma?
Retrograde urethrogram (RUG)
When should you evaluate for bladder rupture?
Foley catheter has been placed and there is gross hematuria or pelvic fracture with microscopic hematuria
What tests can evaluate for a bladder rupture?
Retrograde cystography
Retrograde CT cystography
Define Bladder Contusion
Partial thickness injury to the bladder wall without rupture
When does an intraperitoneal rupture occur?
Blunt force injury to the lower abdomen with a full bladder
What does an intraperitoneal rupture result in?
Rupture of the bladder dome followed by extravasation of urine into the peritoneal cavity
When does an extraperitoneal rupture occur?
In association with pelvic fractures
When should you suspect renal injuries?
Bruising, pain, or tenderness of the flank or abdomen Posterior rib or spine fractures Hematuria (gross or microscopic) Shock Fever, flank mass
Work Up of Renal Injuries
UA
Renal imaging
Indications for Renal Imaging
Penetrating trauma
Lower rib fracture
Gross hematuria
Blunt trauma with microscopic hematuria plus shock
Clinical signs indicating abdominal organ injury or significant deceleration injury
