Urologic Emergencies Flashcards
1
Q
Non-traumatic urological emergencies
A
- Urolithiasis/Renal Colic 2. Urinary Retention
- Infections
- Hematuria
- Acute Scrotum
- Paraphimosis
- Priapism
- Fourniers gangrene
2
Q
Kidney stones
A
Accumulation of normally dissolved solids from kidney form a stone. Once 2-3mm in size become symptomatic with pain and obstructing the ureter.
3
Q
When do kidney stones become symptomatic
A
2-3 mm in size IN URETER
4
Q
Most common kidney stone
A
Calcium salts (radiopaque)
5
Q
types of stones
A
•Calcium salts- most common- radiopaque •Struvite- associated with infection-
radiopaque
•Uric acid- associated with Gout-radiolucent •Cystine- rare
6
Q
Sx of renal colic
A
- The Unilateral Flank pain is characteristically :
- Very sudden onset- Colicky
- Radiates to the groin as the stone passes into the lower ureter.
- May change in location, from the flank to the groin
- The patient cannot get comfortable, and may roll around in agony. Pain equal to labor
- Associated with nausea / Vomiting • Urinary frequency- dark urine
7
Q
PE for renal colic
A
abdomen, back, chest
Male GU
female +/- pelvic
VS - temp and BP
8
Q
Labs for renal colic
A
u/a - hematuria Bun/Cr- renal compromise KUB x-ray Non-contrast CT scan* Renal US (pregnant, children, pt w/ previous hx stones) - detects hydronephrosis
9
Q
Spontaneous expulsion chances
A
> 5-6 = urologic intervention
most are 2-4; pencil eraser diameter = 6mm
10
Q
Tx for renal colic
A
pass if <5mm; not pass if >8 mm
Pain relief, antinausea, abx, alpha 1 blockers, watchful waiting
Admit if “sick”
Temporary relief if not passing on own - insert JJ stent of percutaneous nephrostomy tube
Definitive tx (intractable pain, fever, renal function, 4 weeks) - ESWL (lithotripsy), PCNL (nephrolithotomy), ureteroscopy, open surgery
11
Q
Meds for renal colic
A
stones <4-5 mm (no benefit)
Stones 5-10 - increase passage (NNT5)
12
Q
Acute urinary retention : what is it?
A
painful inability to void, w/ relief following drainage of the bladder by cath; OBSTRUCTIVE - BPH most common (>50YO), infection of prostate, constipation
13
Q
Most common cause of acute urinary retention
A
BPH
14
Q
Causes of acute urinary retention
A
Obstruction- BPH, prostate infection, constipation
Pharm - antihistamine, decongestant, anticholinergic, narcotic
Inflammatory
Neurogenic- spinal cord trauma, tumor, MS
15
Q
Sx of acute urinary retention
A
• Abdominal distension • Bladder US shows distention • Large amount urine post catheter placement- Post Void Residual(PVR) • BMP- +/- renal failure • UA- +/- infection
16
Q
Normal bladder volume
A
<50-100 mL
17
Q
Initial management for urinary retention
A
urethral cath
Suprapubic cath (SPC)
CBI (continuous bladder irrigation) – if blood clots
18
Q
Late management for acute urinary retention
A
Treat underlying cuase
19
Q
Tx of acute urinary retention
A
monitor for 2-4 hrs post decompression
May develop post obstructive diuresis
D/c pt w/ drainage bag and f/u 3-5 days w/ urology
20
Q
Most common cause of cystitis
A
E.coli
kelbsiella, proteus miarbilis, pseudomonas, enterococci
21
Q
Sx of UTI
A
- Dysuria
- Frequency
- Urgency
- Suprapubic or abdominal pain
- Dark urine- hematuria-dehydration
- No Vaginitis or Cervicitis = likelihood 90% of UTI
- Cloudy urine= likelihood 96% of UTI
22
Q
Dx of UTI
A
CLINICAL!!!
U/a & Culture
23
Q
When is U/A needed
A
s/sx not clear or:
- back pain, looks sick, male, age ranges
- immunocompromised
- hx of multi courses abx
- hx antibiotic resistance
- hx of multi drug allergies
24
Q
Lab results for UTI
A
100,000 CFU/ml (culture not routine)
POS leukocyte esterase and nitrites
Pyuria >= 10 WBC/hpf
Microscopic >10 wbc/hpf
25
Tx for UTI
* Macrobid x 5 days
* Bactrim DS x 3days (Don’t use if high e.coli resistant rates)
* Fosfomycin 3g single dose
* Cephalosporins x 7days • Augmentin x 7 days
(macrobid and cephalosporins top 2)
Analgesia- Phenazopyridine
Hydration
No f/u if asymptomatic (No FLQ, no Amoxicillin)
26
PE for cystitis
▪ Temperature
▪ Abdomen
▪CVA percussion
▪May need pelvic examination- if vag d/c, sick, return visit
27
When to use FLQ
no other tx options for sinusitis, acute bacterial exacerbation of chronic bronchitis (ABECB) and uncomplicated UTI
28
Complicated cystitis etiology
```
✓Male Sex
✓Elderly
✓Hospital Acquired ✓Pregnancy
✓Indwelling urinary catheter
✓Recent instrumentation
✓Functional/Anatomic abnormality
✓Children
✓Recent antimicrobial use ✓Symptoms for > 7 days ✓Diabetes Mellitus ✓Immunosuppression
```
29
Management/tx of complicated cystitis
evaluate like pyelonephritis
| Labs and longer abx
30
Sx of pyelonephritis
* lower urinary tract symptoms. dysuria, urinary frequency, urgency
* Fever, Chills, Rigors
* Nausea/vomiting
* Diaphoresis
* Flank and/or abdominal pain
31
Labs for pyelonephritis
```
◼UA-nitrates,LE, pyuria, bacteruria, hematuria, WBC cast
◼Urine culture and sensitivities
◼Blood Cultures
◼Complete blood count ◼Pregnancy test
◼Serum electrolytes-BMP
◼Imaging possible CT or US or CXR
```
32
Pyelonephritis sign
WBC casts
33
Tx for pyelonephritis
Cipro 500mg bid for 7 days
Levo 750mg QD for 5 days
Bactrim DS for 14 days
Cephalosporins 3rd>1st Gen. for 10-14 days
```
(NO MACROBID)
Fluids
UA and CX
Pain med
f/u if recurrent or still sx
```
34
Risk factors for pyelo complications
•Obstruction-stone-tumors
•Urologic surgeries or
instrumentation •Pregnancy
•Diabetes
(admit these people)
35
Indications for admission
* 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
36
When to get a UA
Pregnant
Sx
Undergoing urologic procedures
37
Acute prostatitis causes
>35 YO: e. coli
| <35 YO: N. gonorrhoeae & Chlamydia
38
Sx of acute prostatitis
fever/chills/myalgia
pain in lower back, rectum or perineum
urinary retention, dysuria
39
Exam/Labs/RAD for prostatitis
* ABD- may be tender
* GU exam-perineal area tender
* Urethral swab if applicable
* Rectal- tender boggy prostate-DON’T MASSAGE= Bacteremia • Lab- CBC-wbc may be up, UA- Pyuria
* Rad- no imaging unless toxic
40
Tx for acute prostatitis
* Hydration Analgesics, bed rest, stool softeners
* Cipro or Levo >35 y/o (2nd line Bactrim then tetracyclines) • Tx2-4weeks
* GC/Chlamydia tx <35
* If toxic treat as Uroseptic
41
Urosepsis: what is it
Severe illness which occurs when a urinary tract infection spreads systemically
42
Presentation of urosepsis
hx of UTI, pyelo, urolithiasis, prostatitis
• Persistent symptoms of above infections
• Recent Urological procedure
• Weakness
• Confusion
• Dehydration
• Nursing home patient- common
43
SIRS criteria
```
2+ of these sx to dx urosepsis:
• Temperature >100.4 or <96.8
• WBC count >12K or <4K or 10% bands
• Tachycardia >90 bpm
• Tachypnea >20/min
Severe- AMS
• Elevated plasma Lactate > 4mmol/L
```
more criteria = mortality goes up
44
Exam/lab/RAD for urosepsis
Exam as pyelo or acute prostate
CBC, blood cx, BMP, UA, Urine Cx, lactate
CT w/ contrast - r/o stone, abscess, ddx
45
Tx for urosepsis
fluids
abx
tx shock
admit
46
Things to r/o w/ hematuria
obstruction
coagulopathy
Rhabdomyolysis
47
Exam/labs for hematuria gross or >5 RBC
```
UA
CBC
PT/INR
CK- rhabdo
CMP - kidney function
Check med list, LMP
```
48
Managmenet of hematuria
VSS/no pan or other c/o: URO w/u
abn vitals/labs or pain- ED w/u
- renal US, CT scan abd pelvic w/ contrast
- bladder US, +/- foley if retention, CBI
- treat cause
49
Torsion more common w/
undescended testis
50
Sx of torsion
```
• Sudden onset of testicular pain
- May be insidious
- May have a prior event
- Onset may be during sleep or exertion
• Swelling
• May have abdominal pain- nausea vomiting
```
51
PE for torsion
```
NPO
sedate pt - difficult due to pain
swollen, firm, tender hemiscrotum
high riding testis w/ transverse lie
possible loss of cremasteric reflex
BLUE DOT SIGN - torsion of the appendix testis
```
52
Labs for torsion
IMMEDIATE doppler testicular US
| UA/CBC, pre-op labs
53
Tx for testicular torsion
call urology stat
Sedate pt, attempt manual detorse - turned medially to laterally "opening of book" - may require 360 degree detorse until pain gone
54
Epididymitis cause
“Retrograde spread” of infected urine down the vas deferens = Inflammation of Epididymis
55
Causes of epidiymitis
<35 YO: chlamydia, GC
| >35 YO: e.coli, enterococci, pseudomonas, proteus
56
Hx of epididymitis
* Scrotal pain, swelling and tenderness
* Relieved with testicle elevation (Prehn's)
* May have urethral discharge and uti s/sx • Lower abd or perineal pain
* May have fever chills
57
PE for epididymitis
* Testicle red, swollen warm, tender
* Testicular lump
* Inguinal lymphadenopathy
* Cremastric reflex- intact
58
Labs/Rad for epidiymitis
* CBC if systemic signs, going to be admited • UA
* Test for gonorrhea and Chlamydia
* Doppler US. r/o Torsion or tumor
* May see incr flow to epididymis
59
Tx for epididymitis
rest, scrotal elevation w/ ice
abx - base don age, MSM
Pain meds- analgesics
stool softener
60
epididymitis <35 YO
Ceftriaxone IM in a single dose PLUS Doxycycline for 10 days
61
MSM epididymitis
Ceftriaxone IM in a single dose PLUS Levofloxacin for 10 days
62
>35 YO epididymitis
Levofloxacin x 10 days
63
What is paraphimosis
Foreskin becomes retracted behind glans of penis and cannot be placed over glans; MEDICAL EMERGENCY
64
PE of paraphimosis
Elderly or very young from frequent catheterization, poor hygiene, or retracted foreskin “not replaced”
Sexual activity/piercing
Pain tenderness redness or retracted foreskin and glans
65
Tx of paraphimosis
* Attempt to reduce by pushing on glans while pulling on foreskin
* Glands compression-manual
* Sugar Lidocaine wrap
* Emergent dorsal slit in foreskin
* Urology stat
66
What is priapism
Persistent erection of the penis for more than 4 hours that is not related or accompanied by sexual desire
67
Most common to have priapism
age 30-40 YO
68
Etiologies of priapism
acute low flow (most common) - drugs, blood disorders (Sickle cell, spinal trauma, unknwon)
- veno-occlusive
- if > several hours- painful
- corpora cavernosa -f ully rigid
- failure of blood to leave corporal bodies
High flow - rare, blunt trauma- painless, partially rigid
69
Fully rigid
acute low flow
70
Painless
High flow priapism
71
Drugs associated w/ priapism
antipsychotics
| antidepressant
72
Tx for priapism
```
Sudafed po (terbutaline-SQ to decrease inflow of blood to penis)
Aspirate corpora cavernosa w/ butterfly needle (3 and 9 oclock; aspirate 20-100 cc)
```
Phenylephrine injected into corpora cavernosa (250-500 mcg)
Urology
73
SE of priapism
impotence
| fibrosis
74
Fourniers gangrene: what is it?
Necrotizing fasciitis infection of the perineum involving penis, scrotum, perineum, abdominal wall
75
Causes of fournier's gangrene
staph
strep
e.coli
clostiridium
76
Risk factors for fournier's gangrene
* Diabetes mellitus (most common)
* Alcoholism
* Immunosuppression (HIV,cancer)
* Liver disease
* Trauma to ano-urogential, perineal area
* Preexisting perineal/rectal infections
77
Most common risk factor for fournier's gangrene
DM
78
Hx/PE for fourniers gangrene
* Varies from slow to rapid course(cm/hr)
* Starts with redness next to port of entry
* Localized pain swelling discoloration of affected area (POOP, POEM)
* Fever, lethargy, toxic appearing(SWOS)
* Subcutaneous crepitation over area
* Putrid or feculent odor
79
labs/rad of fourniers gangrene
* Septic work up- cbc,cmp,blood culture, coags, wound cultures, UA, lactate
* Call Surgeon
* NPO
* IV Fluids- IV Pressors
* IV Antibiotics
* Contrast CT scan
80
Tx of fournier's gangrene
surgical debridement
81
never give for simple UTI
Cipro
82
Never give w/ pyelonephritis
Macrobid
83
Risk of tendon rupture in elderly
steroids + cipro
84
Sudden death risk
bactrim + ACE/ARB
85
Epididmyitis must get US
r/o torsion; torsion lawsuit
