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EMed Exam 2 > Urologic Emergencies > Flashcards

Urologic Emergencies Flashcards

1
Q

Non-traumatic urological emergencies

A
  1. Urolithiasis/Renal Colic 2. Urinary Retention
  2. Infections
  3. Hematuria
  4. Acute Scrotum
  5. Paraphimosis
  6. Priapism
  7. Fourniers gangrene
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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.

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3
Q

When do kidney stones become symptomatic

A

2-3 mm in size IN URETER

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4
Q

Most common kidney stone

A

Calcium salts (radiopaque)

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5
Q

types of stones

A

•Calcium salts- most common- radiopaque •Struvite- associated with infection-
radiopaque
•Uric acid- associated with Gout-radiolucent •Cystine- rare

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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
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7
Q

PE for renal colic

A

abdomen, back, chest
Male GU
female +/- pelvic
VS - temp and BP

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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
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9
Q

Spontaneous expulsion chances

A

> 5-6 = urologic intervention

most are 2-4; pencil eraser diameter = 6mm

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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

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11
Q

Meds for renal colic

A

stones <4-5 mm (no benefit)

Stones 5-10 - increase passage (NNT5)

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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

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13
Q

Most common cause of acute urinary retention

A

BPH

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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

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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
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16
Q

Normal bladder volume

A

<50-100 mL

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17
Q

Initial management for urinary retention

A

urethral cath
Suprapubic cath (SPC)
CBI (continuous bladder irrigation) – if blood clots

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18
Q

Late management for acute urinary retention

A

Treat underlying cuase

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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

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20
Q

Most common cause of cystitis

A

E.coli

kelbsiella, proteus miarbilis, pseudomonas, enterococci

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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
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22
Q

Dx of UTI

A

CLINICAL!!!

U/a & Culture

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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
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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

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25
Q

Tx for UTI

A
  • 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)

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26
Q

PE for cystitis

A

▪ Temperature
▪ Abdomen
▪CVA percussion
▪May need pelvic examination- if vag d/c, sick, return visit

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27
Q

When to use FLQ

A

no other tx options for sinusitis, acute bacterial exacerbation of chronic bronchitis (ABECB) and uncomplicated UTI

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28
Q

Complicated cystitis etiology

A 
✓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
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29
Q

Management/tx of complicated cystitis

A

evaluate like pyelonephritis

Labs and longer abx

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30
Q

Sx of pyelonephritis

A
  • lower urinary tract symptoms. dysuria, urinary frequency, urgency
  • Fever, Chills, Rigors
  • Nausea/vomiting
  • Diaphoresis
  • Flank and/or abdominal pain
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31
Q

Labs for pyelonephritis

A 
◼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
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32
Q

Pyelonephritis sign

A

WBC casts

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33
Q

Tx for pyelonephritis

A

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
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34
Q

Risk factors for pyelo complications

A

•Obstruction-stone-tumors
•Urologic surgeries or
instrumentation •Pregnancy
•Diabetes

(admit these people)

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35
Q

Indications for admission

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
36
Q

When to get a UA

A

Pregnant
Sx
Undergoing urologic procedures

37
Q

Acute prostatitis causes

A

> 35 YO: e. coli

<35 YO: N. gonorrhoeae & Chlamydia

38
Q

Sx of acute prostatitis

A

fever/chills/myalgia
pain in lower back, rectum or perineum
urinary retention, dysuria

39
Q

Exam/Labs/RAD for prostatitis

A
  • 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
Q

Tx for acute prostatitis

A
  • 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
Q

Urosepsis: what is it

A

Severe illness which occurs when a urinary tract infection spreads systemically

42
Q

Presentation of urosepsis

A

hx of UTI, pyelo, urolithiasis, prostatitis
• Persistent symptoms of above infections
• Recent Urological procedure
• Weakness
• Confusion
• Dehydration
• Nursing home patient- common

43
Q

SIRS criteria

A 
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
Q

Exam/lab/RAD for urosepsis

A

Exam as pyelo or acute prostate
CBC, blood cx, BMP, UA, Urine Cx, lactate
CT w/ contrast - r/o stone, abscess, ddx

45
Q

Tx for urosepsis

A

fluids
abx
tx shock
admit

46
Q

Things to r/o w/ hematuria

A

obstruction
coagulopathy
Rhabdomyolysis

47
Q

Exam/labs for hematuria gross or >5 RBC

A 
UA
CBC
PT/INR
CK- rhabdo
CMP - kidney function
Check med list, LMP
48
Q

Managmenet of hematuria

A

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
Q

Torsion more common w/

A

undescended testis

50
Q

Sx of torsion

A 
• 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
Q

PE for torsion

A 
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
Q

Labs for torsion

A

IMMEDIATE doppler testicular US

UA/CBC, pre-op labs

53
Q

Tx for testicular torsion

A

call urology stat
Sedate pt, attempt manual detorse - turned medially to laterally “opening of book” - may require 360 degree detorse until pain gone

54
Q

Epididymitis cause

A

“Retrograde spread” of infected urine down the vas deferens = Inflammation of Epididymis

55
Q

Causes of epidiymitis

A

<35 YO: chlamydia, GC

>35 YO: e.coli, enterococci, pseudomonas, proteus

56
Q

Hx of epididymitis

A
  • 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
Q

PE for epididymitis

A
  • Testicle red, swollen warm, tender
  • Testicular lump
  • Inguinal lymphadenopathy
  • Cremastric reflex- intact
58
Q

Labs/Rad for epidiymitis

A
  • 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
Q

Tx for epididymitis

A

rest, scrotal elevation w/ ice
abx - base don age, MSM
Pain meds- analgesics
stool softener

60
Q

epididymitis <35 YO

A

Ceftriaxone IM in a single dose PLUS Doxycycline for 10 days

61
Q

MSM epididymitis

A

Ceftriaxone IM in a single dose PLUS Levofloxacin for 10 days

62
Q

> 35 YO epididymitis

A

Levofloxacin x 10 days

63
Q

What is paraphimosis

A

Foreskin becomes retracted behind glans of penis and cannot be placed over glans; MEDICAL EMERGENCY

64
Q

PE of paraphimosis

A

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
Q

Tx of paraphimosis

A
  • 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
Q

What is priapism

A

Persistent erection of the penis for more than 4 hours that is not related or accompanied by sexual desire

67
Q

Most common to have priapism

A

age 30-40 YO

68
Q

Etiologies of priapism

A

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
Q

Fully rigid

A

acute low flow

70
Q

Painless

A

High flow priapism

71
Q

Drugs associated w/ priapism

A

antipsychotics

antidepressant

72
Q

Tx for priapism

A 
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
Q

SE of priapism

A

impotence

fibrosis

74
Q

Fourniers gangrene: what is it?

A

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

75
Q

Causes of fournier’s gangrene

A

staph
strep
e.coli
clostiridium

76
Q

Risk factors for fournier’s gangrene

A
  • Diabetes mellitus (most common)
  • Alcoholism
  • Immunosuppression (HIV,cancer)
  • Liver disease
  • Trauma to ano-urogential, perineal area
  • Preexisting perineal/rectal infections
77
Q

Most common risk factor for fournier’s gangrene

A

DM

78
Q

Hx/PE for fourniers gangrene

A
  • 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
Q

labs/rad of fourniers gangrene

A
  • 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
Q

Tx of fournier’s gangrene

A

surgical debridement

81
Q

never give for simple UTI

A

Cipro

82
Q

Never give w/ pyelonephritis

A

Macrobid

83
Q

Risk of tendon rupture in elderly

A

steroids + cipro

84
Q

Sudden death risk

A

bactrim + ACE/ARB

85
Q

Epididmyitis must get US

A

r/o torsion; torsion lawsuit

EMed Exam 2 (6 decks)

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