Urologic Emergencies Flashcards
DDx for acute scrotal pain?
- testicular torsion**
- appendiceal torsion
- epididymitis
- testicular rupture
Hx for acute scrotal pain?
- need to know exact time of onset of sxs in addition to usual pain questions
- assoc sxs: fever, chills, dysuria, hematuria, d/c
- H/O trauma?
PE of acute scrotal pain?
- detailed exam of abdomen
- exam of testes, epididymis, cord and scrotal skin:
prehns sign: lifting of testicle on affected side relieves pain + for epididymitis - exam of inguinal region - hernia?
- cremasteric reflex - if absent could be torsion
- possible DRE to check prostate
W/U for acute scrotal pain?
- UA and culture
- color doppler US
Testicular torsion is a….
Urologic Emergency!!!
Hx and sxs of testicular torsion?
- hx: sudden onset of severe pain, possible inciting event (trauma) or may occur spontaneously
- sxs: lower abdominal pain, inguinal canal or testes:
pain isn’t positional, can be constant or intermittent, pain is sudden in onset: may awaken in middle of night w/ pain, may have assoc N/V
PE findings suggestive of testicular torsion?
- high riding (elevated) testis on affected side
- early on may have significant swelling
- epidiymis may be displaced and not found in its normal posterolateral position
- testicle is firm
- exquisite tenderness
- cremasteric reflex is usually absent
Dx eval of poss. testicular torsion?
- color doppler US of testicle:
can determine if there is intratesticular flow but if sure of dx don’t wait to call urologist
Tx of testicular torsion?
- emergent urologic consultation and surgery
- potential for manual detorsion:
painful
twist laterally “like opening a book”
may need to twist up to 720 degrees, if successful can give excellent relief of pain.
Still needs to have surgical exploration and orchiopexy
Acute epididymitis?
- less than 6 wks
- swelling of epididymitis w. exquisite tenderness
- +/- inguinal lymphadenopathy
- may have systemic sxs of fever, chills, irritative voiding sxs
- may be seen in combo w/ acute prostatitis
Chronic epididymitis?
- longer than 6 wks
- subtle epididymal induration and tenderness
- no irritative voiding sxs
- +/- inguinal lymphadenopathy
PE of epidiymitis?
- tenderness posterior and lateral to testis
- DRE to eval for prostatic involvement if hx suggests
- in acute cases may have swelling w/ reactive hydrocele (epididymo-orchitis)
- may have + Prehn’s sign
W/U for epididymitis?
- UA and urine culture, test for GC and chlamydia if applicable
- urethral swab if d/c present
- r/o other causes of scrotal pain: get an US to r/o torsion if acute in onset
Tx of infectious epididymitis in men younger than 35?
- etiology: consider GC and chlamydia
- Ceftriaxone 250 mg IM + doxy 1000 mg BID x 10 days
- if septic needs to be hosp for IV hydration, and IV abx
Tx of infectious epididymitis in men older than 35, hx of BPH, urethral stricture or chronic UTI?
- etiology: consider enteric gram negative bacteria
- levaquin 500 mg qday x 10 days
- out pt management
or if septic needs to be hosp for IV abx
Sx tx for epididymitis?
- NSAIDs
- scrotal elevation
- ice
Inflammatory epididymitis:
RFs
presentation
Tx?
- RFs: med rxn, prolonged sitting, vigorous exercise, trauma, autoimmune disease
- may be secondary to reflux of urine w/in ejaculatory ducts
- presentation: progressive, gradual onset of pain
- tx: scrotal elevation, warm baths, NSAIDs, tx w/ abx if uncertain of etiology
What is the appendix testis? What is an appendiceal torsion?
- appendix testis is small appendage of normal tissue that is located on upper portion of testis
- torsion occurs when this tissue twists
Epidemiology, Sxs, dx of appendiceal torsion?
- epidemiology: most cases occur b/t age 7-14YO
- sxs:
gradual onset of pain
reactive hydrocele: which may transiluminate
localized tenderness
exam of scrotal wall may reveal classic “blue dot” sign (tender blue or black spot beneath skin) - dx: US shows torsed appendage as a lesion of low echogenicity w/ a central hypoechogenic area
Tx of appendiceal torsion?
- conservative:
rest, ice, NSAID. Recovery is slow and w/ discomfort, the infarcted tissue is usually reabsorbed - surgical:
excision of appendix testis, while not necessary, is safe and quick, usually reserved for continued pain - pts can usually resume normal activity w/o pain in few days
What is a testis rupture? Etiology? Main sxs?
- rip or tear of tunica albuginea resulting in extrusion of testicular contents
- seen in blunt or penetrating trauma
- rare in sports
- Main sxs:
scrotal swelling
severe pain
ecchymosis (dramatic)
Dx and tx of Testis rupture?
- dx: scrotal us
- tx:
referral to Urologist for scrotal exploration, pain management, IV
What are other causes of scrotal pain?
- trauma: w/ possible testicular rupture
- strangulated hernia: usually abnormal abdominal exam
- post-vasectomy problems
- mumps
- testicular cancer
- kidney stone
What is a priapism?
- erection unrelated to stimulation lasting typically longer than 4 hr
- occurs by trapping of blood in erectile bodies which can result in ischemia and infarction
Diff b/t ischemic and non-ischemic priapism?
- ischemic: MC, painful
- non-ischemic: rare, painful, usually from development of traumatic A/V fistula b/t cavernosal artery and corpus cavernosum
Etiology of priapism?
1 - primary (idiopathic)
2 - secondary:
heme, sickle cell anemia, leukemia, thalassemia, MM, TTP
Neuro (spinal shock)
tumors (mets)
perineal, penile trauma
Iatrogenic (injections - up to 25%, MC cause in adults)
drugs: antiHTN, antidepressants, anticoag, alpha blockers, cocaine)
Infection: malaria, spider toxins
metabolic disorders: gout, hemodialysis, high lipid content, TPN, diabetes, amyloidosis
Hx and PE findings of a priapism?
- hx:
presence of pain, duration, role of antecedent factors, prior episodes. Existence of etiological conditions and erectile fxn status - PE:
-insepction and palpation of penis may indicate the extent and tumescence and presence and extent of tenderness
-abdominal, perineal, and rectal exams can reveal signs of trauma or malignancy
Dx of priapism?
- CBC
- can use color duplex doppler US to dist. ischemic from nonischemic
- aspiration of blood from corpus cavernous can be eval:
if darkly colored (unoxygenated) - ischemic
if bright red (oxygenated) - nonischemic
-can do ABGs on aspirated blood
Tx of priapism?
- pain management, urgent urological consultation
- ischemic:
evacuation of blood then intracavernous injection of alpha-adrenergic sympathomimetic agent- phenylephrine (penile shaft block can be done first)
-90% of men w/ ischemic priapism lasting more than 24 hrs don’t regain ability to have sexual intercourse - nonischemic:
initially - observe, 62% spontaneously resolve, urological consult for further management as other tx can cause ED
Causes of penile fx?
- Rupture of one or both of tunica albuginea that covers the corpora cavernosa
- cause:
rapid blunt force to an erect penis:
vaginal intercourse
aggressive masturbation
Signs and sxs, dx of penile fx?
- signs and sxs: popping or cracking sound severe pain immediate loss of erection - dx: RUG if suspect urethral injury
Tx and complications of penile fx?
- tx: surgical correction
- complications:
ED
penile curvature
pain
When does paraphimosis occur?
- occurs when foreskin in uncircumcised or partially circumcised male is retracted behind glans penis, develops venous and lymphatic congestion and can’t be returned to its normal position - this is a UROLOGIC EMERGENCY
Hx and Physical findings of paraphimosis?
hx:
swelling of penis and penile pain, cause of irritability in preverbal infant, recent penile exam, foley insertion, cystoscopy
physical findings:
ensure that there is no constricting fb, edema and tenderness of glans, painful swollen retracted foreskin, penile shaft is unaffected, w/ ischemia the color of glans will change from normal pink to blue or black and will be firm rather than soft
What do you have to r/o with paraphimosis?
- r/o angioedema or constricting band
- if it is constricting band such as hair - this must be cut and removed
- pain control for pt
Noninvasive techniques for reduction in paraphimosis?
- application of lidocaine gel and ice in rubber glove
- compression bandages (applied for 20 min)
- manual compression and reduction
- osmotic agents - sugar, 50% dextrose or mannitol
- traction w/ forceps, sedation likely reqd
Invasive techniques for reduction in paraphimosis?
- puncture technique: puncture w/ small gauge needle to allow for lymph fluid to escape
- glans penis aspiration
- dorsal slit procedure (refer to urology)
Etiology of urinary retention?
- inability to voluntarily pass urine
- secondary to BPH
- uncommon in women
- 3 factors causing retention:
outflow obstruction
neuro impairment
inefficient detrusor muscle
Eval and dx of urinary retention?
- H and P: lower abdomen rectal pelvic (female) neuro exam - Dx: bladder US catheter insertion (most impt part of dx and tx) UA/culture Creatinine level: elevated then consider renal US
Tx and complications of urinary retention?
- tx: catheter - 14-16 French, self cath, SP cath, Alpha blocker meds - Tamsulosin (flomax), doxazosin (cardura) - complications: hematuria postobstructive diuresis
Labs for dysuria?
lab:
UA
- pyuria can be seen w/ UTI, chlamydia and gonococcal urethritis
- hematuria + pyuria rules out STI
- hematuria alone w/o sxs and signs of urithrolithiasis may be due to cancer and pt should have further f/u
- urine culture recommended in men w/ pyelonephritis or women w/ complicated UTI
Presentation and labs for pyelonephritis?
- flank pain, abdominal and pelvic pain
- N/V
- fever over 99.8F
- may have CVA tenderness
- +/- sxs of cystitis
labs:
- UA may show white cell casts, send urine for culture and sensitivites
- CBC
- preg test for females
Tx for mild to moderate pyelo?
- can rehydrate and give a parenteral dose of abx in ER and observe for 8-12 hrs
- IV abx: ceftriaxone
- d/c on fluoroquinolone x 7 days
What defines a severe pyelo that reqrs hosp?
- high fever, pain, marked debility
- inability to maintain oral hydration or take oral meds
- preg
- concerns about pt compliance
Presentation of nephrolithiasis?
- colicky flank pain:
varying from mild ache to very intense - migrates as stone moves down ureter (radiation)
- hematuria: common but may be absent in up to 20% of pts, will be microscopic
DDx for colicky flank pain and hematuria?
- nephrolithiasis
- ectopic preg
- acute intestinal obstruction or appendicitis
- aortic aneurysm
- persons seeking narcotics
- renal infarct
What can nephrolithiasis lead to if left untx?
- may lead to persistent renal obstruction, which could cause permanent renal damage if left untx = hydronephrosis
Dx of nephrolithiasis?
- abdominal plain films (uric acid won’t show)
- usually non-contrast helical CT
- US in pts who need to avoid radiation
Tx of nephrolithiasis?
- many pts can be managed conservatively w/ pain meds and hydration until the stone passes:
they should be straining their urine, if stone is less than 10 mm an alpha blocker such as flomax (tamsulosin) may help stone passage
When is urgent urological consult warranted in pts?
- urosepsis
- acute renal failure
- anuria
- unyielding pain, N/V
Epidemiology of GU trauma?
- 10% of pts admitted to trauma service sustain injuries to GU tract
- 80% result from blunt trauma:
MVA
falls from heights
direct blows to torso or genitalia - injuries to female genitalia:
often assoc w/ pelvic fx
can be result of physical or sexual assault - 85% of testicular injuries are result of blunt trauma
Initial management of GU trauma?
- focus on rapid ID and stabilization of life threatening injuries
- rarely life threatening although shattered kidney or major renal vascular laceration can pose a threat to life or to kidney itself
- once pt is stabilized eval for GU injury is undertaken
secondary survey for GU trauma?
- inspect perineum and external genitalia
- look for blood in underwear
- look in folds of buttocks for perineal lacerations which may indicate a pelvic fx
- rectal exam:
sphincter tone
presence of blood
position of prostate - riding high or boggy: disruption of membranous urethra
MC site of urethral injury?
- avulsion of puboprostatic ligament then stretching of membranous urethra can result in a partial or complete disruption of the urethra at its weakest pt, the bulbomembranous junction
GU trauma assessment - secondary survey specifically for males?
- exam of scrotum for brusing or testicular rupture
- look for blood at penile meatus
GU trauma assessment - secondaray survey specifically for females?
- check vaginal introitus for lacerations or hematoma
- any suspicion of pelvic trauma/hematoma/bruising do a bimanual exam to eval for vaginal blood
- any sign of vaginal blood will need speculum exam to r/o 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 pelvic fx
What should be done b/f inserting foley cath in GU injuries?
- RUG must be done to eval integrity of urethra
- procedure is deferred only if pelvic angiography is being done to control pelvic hemorrhage
When can a foley cath be inserted b/f RUG?
- in presence of gross hematuria w/o other signs of urethral injury
- any resistance abort attempt and do a RUG
What should be done if a foley cath has been placed and there is gross hematuria or pelvic fx w/ microscopic hematuria (RBCs more than 25/HPF)?
- eval for bladder rupture W/ retrograde cystography or retrograde CT cystography
Diff types of bladder injuries?
- contusions: partial thickness injuries to bladder wall w/o rupture
- intraperitoneal rupture: occurs from blunt force injury to lower abdomen w/ full bladder, results in rupture of bladder dome followed by extravasation of urine into peritoneal cavity
- extraperitoneal rupture: occurs in assoc w/ pelvic fx, injury force causes rupture of anterior or anterior-lateral wall, sometimes bony fragments impale bladder
What should all pts w/ pelvic fx or gross hematuria have done?
- cystogram to R/O bladder rupture
When should you suspect renal injuries?
- bruising, pain or tenderness of flank or abdomen
- posterior rib or spine fx
- hematuria (Gross or Microscopic)
- shock
- fever, flank mass (urinoma)
W/U for renal injuries?
- UA
- renal imaging (CT) is indicated in pts who have:
penetrating trauma
lower rib fx
gross hematuria
blunt trauma w/ microscopic hematuria + shock,
all clinical signs indicating abdominal organ injury or sig deceleration injury
