Urologic Emergencies Flashcards
When do kidney stones become symptomatic?
When 2-3 mm in size because obstructing the ureter
Types of kidney stones (nephrolithiasis)
Calcium salts (most common)- radiopaque
Struvite (infection)- radiopaque
Uric acid (gout)-radiolucent
Cystine-rare
Renal colic pain associated with kidney stones
Unilateral flank pain w/ very sudden onset (colicky)
Radiates to groin as stone goes to lower ureter
Pt can’t get comfortable and may roll around in agony (maybe like labor)
Associated with n/v
Urinary frequency and dark urine (blood)
Labs and imaging for renal colic
UA is 75-85% hematuria
BUN/Cr for renal compromise
KUB xray but misses alot
Test of choice: non contrast CT scan
When do you use a renal u/s with renal colic?
Pregnant
Children
Pts with previous hx stones
*IDs hydronephrosis
What is the importance of the size of the kidney stone?
Size predicts spontaneous expulsion:
Most 1-4 mm will
Usually 5 and above need urologic intervention (> 9 mm only a quarter will pass)
Tx for renal colic
NSAID for pain relief
Anti nausea, abx, alpha 1 blockers
Admit if sick
JJ stent or percutaneous nephrostomy tube for temporary relief
Definitive tx of a ureteric stone with intractable pain and fever for 4 wks
ESWL (lithotripsy)
PCNL (nephrolithotomy-1 cm incision)
Ureteroscopy
Open surgery (very limited)
Does medical expulsion therapy help with kidney stone? (CCB, a-blockers, Flowmax)
<4-5 mm no benefit
5-10 mm will have increased passage (NNT 5)
What is acute urinary retention?
Painful inability to void, with relief following drainage of the bladder by catheterization
Causes of acute urinary retention
Obstructive (prostatic hyperplasia, infection prostate, constipation)
Pharm (antihistamine, decongestants, anticholinergic, narcotics)
Inflammatory
Neurogenic (spinal cord trauma/tumor, MS)
Diagnostics for acute urinary retention
Bladder us shows distention
Large amt urine post catheter placement- post void residual (PVR)
BMP maybe renal failure
UA maybe infection
What is an abnormal amt of post void residual vol?
Abnormal is >100-150 ml
Normal is <50-100 ml (judgment for 50-100)
Management for acute urinary retention
Urethral catheterization!!
Suprapubic catheter (SPC)
CBI (continuous bladder irrigation if blood clots)
Late management is treat the underlying cause
Discharge tx for urinary retention
Monitor pt for 2-4 hrs post decompression (may have post obstructive diuresis)
Discharge pt with drainage bag and f/u 3-5 days
Progression of UTIs when not treated
Cystitis
Pyelonephritis
(prostatitis)
Urosepsis
Most common cause of uncomplicated cystitis
E coli (less common are klebsiella, proteus, pseudomonas, enterococci)
Sxs of cystitis
Dysuria Frequency Urgency Suprapubic or abd pain Dark urine (hematuria, dehydration) No vaginitis or cervicitis (90% chance of UTI) Cloudy urine (96% chance of UTI)
How to diagnose cystitis
Usually clinical dx (UA and culture will just support the history and PE-but culture if high risk, male, pregnant etc)
When do you need a UA with cystitis?
If sxs unclear Back pain, looks sick, male or older Immunocompromised Hx of multi course abx Hx of abx resistance Hx of multi drug allergies
What diagnoses an infection on urine culture?
100,000 CFU/ml
Labs for cystitis
Microscopic urine >10 wbc/hpf
Urine dipstick shows leukocyte esterase (pyuria), nitrite (Gram - bacteria)
Usually don’t need urine culture or imaging
Tx for cystitis
Abx (Macrobid or cephalosporin usually, can be bactrim fosfomycin or augmentin)
Analgesia-phenazopyridine
Hydrate
No f/u if asymptomatic
What drugs are to be avoided in cystitis?
FLQ or Amoxicillin (too much resistance)
Black box FLQ (should be reserved for pts with no other tx options for sinusitis, acute bacterial exacerbation of chronic bronchitis and uncomplicated UTIs)
When do you consider complicated cystitis?
Male or elderly Hospital acquired Pregnancy Indwelling urinary cath Recent instrumentation Functional.anatomic abnormality Children Recent abx use Sxs > 7days DM Immunosuppression (evaluate like pyelo-labs and longer abx)
Presentation of pyelonephritis
Same UTI sxs (dysuria, frequency, urgency) Fever, chills, rigor N/v Diaphoresis Flank/abd pain
Labs in pyelonephritis
UA: nitrates, LE, pyuria, bacteriuria, hematuria, WBC cast! Urine C&S Cultures CBC, pregnancy test, BMP Maybe CT or US or CXR
Tx for pyelonephritis
Empiric therapy with usually Cipro or Levoquin (can do bactrim or cephalosporins)
Fluids and pain meds
What drugs are not used for pyelonephritis?
Macrobid b/c does not get into parenchyma
When to follow up for pyelonephritis
If new or worsening sxs
Risks for complication with pyelonephritis
Obstruction (stone, tumors)
Urologic surgeries or instrumentation
Pregnancy
DM
Indications for inpatient tx of pyelonephritis
Inability to maintain oral hydration or take oral meds
Compliance risk
Uncertainty about diagnosis
High fevers, severe disability or uncontrolled pain
Risk factors for complications
What is asymptomatic bacteriuria?
Common and benign
No long term harm
Only rarely treated (common pitfall of treating a nonpregnant pt with abx)
When do you get a UA with asymptomatic bacteriuria?
If they have sxs, are pregnant or are undergoing urologic procedures
Etiology of acute prostatitis
> 35 usually gram - (E coli)
<35 is N gonorrhoeae and Chlamydia
Presentation of prostatitis
Fever, chills, myalgias
Pain in lower back, rectum or perineum
May have urinary retention or dysuria
PE for prostatitis
Abd may be tender
GU exam may have perianal area tender
Urethral swab if applicable
Tender boggy prostate (don’t massage b/c that can cause bacteremia)
Labs for prostatitis
CBC may have increased WBCs
UA shows pyuria
No imaging unless a toxic pt
Tx of prostatitis
Hydration, analgesics, bed rest, stool softeners
Abx (Cipro or levo if >35- then bactrim or tetracyclines for 2-4 wks)
Treat as uroseptic if toxic
What is urosepsis?
Severe illness that occurs when UTI spreads systemically
Presentation of urosepsis
May have history of recent UTI, pyelo, urolithiasis or prostatitis Persistent sxs of above infections Recent urological procedure Weakness, confusion, dehydration Common in nursing home pts!
What in the exam of urosepsis indicates systemic inflammatory response syndrome (SIRS)?
2 or more: Temp>100.4 or <96.8 WBC count >12K or <4K or 10% bands >90 bpm >20 breaths/min Severe AMS (elevated plasma lactate >4 mmol/L)
Labs and diagnostics for urosepsis
CBC, blood cultures, BMP, UA, cultures, lactate
CT w/o contrast to r/o stone, abscess etc.
Tx for urosepsis
Fluids, abx
Treat shock and admit
What must be ruled out with gross hematuria?
Obstruction
Coagulopathy
Rhabdomyolysis
How to quantify hematuria
Gross of >5 RBC on UA
What to be checked with hematuria
Medication list (anything new or stopped recently)
LMP
PT/INR, CK, CMP
What to do with hematuria if normal vitals, labs, no pain or other complaints
Uro workup
What to do with hematuria is abnormal vitals, labs or pain
ED work up
Renal u/s, CT scan, abd pelvic with contrast
Bladder u/s maybe foley if retention (CBI)
Tx of cause
Presentation of testicular torsion
Sudden onset of testicular pain (may be insidious, may have prior event)–maybe during sleep or exertion
Swelling
May have abd pain, n/v
What exam to do with testicular torsion?
NPO Sedate pt if in too much pain Swollen, firm and tender hemiscrotum High riding testis with transverse lie Possible loss of cremasteric reflex Blue dot sign: torsion of appendix testis
Labs for testicular torsion
Stat doppler testicular u/s (decreased or absent flow to affected side)
Tx of testicular torsion
Call urology stat (needs testicular fixation even if detorsed)
Attempt to manually detorse (each testicle is turned medially to laterally like opening a book-maybe 360 degrees)
Etiology fo epididymitis
<35 probably chlamydia, GC
>35 probably E coli, enterococci, psuedomonas, proteus
What must be done with epididymitis to r/o?
U/s to r/o torsion or tumor
Also test of G&C, UA and CBC if systemic signs
Presentation of epididymitis
Scrotal pain, swelling and tenderness Relieved with testicle elevation May have urethral discharge and UTI sxs Lower abd or perineal pain Fever chills
What is seen in epididymitis on exam?
Testicle is red, swollen, warm and tender Testicular lump Inguinal LAD Cremasteric reflex intact Positive prehns
Tx of epididymitis
Bed rest, scrotal elevation with ice
Abx
Pain meds analgesics
Stool softeners
Abx tx for acute epididymitis mostly caused by G&C (<35 YO)
Cetriaxone IM single dose AND Doxy x 10 days
Abx tx for acute epididymitis mostly caused by G&C and enteric organisms (MSM)
Ceftriaxone IM single dose AND Levofloxacin x 10 days
Abx tx for acute epididymitis probably caused by enteric organisms (>35 YO)
Levofloxacin x 10 days
What is paraphimosis?
Foreskin becomes retracted behind glans of penis and cannot be placed over glans
*true emergency b/c arterial compromise can occur
Common cause of paraphimosis
Elderly or very young from frequent caths, poor hygiene or retracted foreskin not replaced (sexual activity or genital piercings also pose a risk)
PE of paraphimosis
Pain tenderness and redness to retracted foreskin and glans
Tx for paraphimosis
Attempt to reduce by pushing on glans while pulling on foreskin
Glands compression-manual
Sugar lidocaine wrap to reduce swelling
Emergent dorsal slit in foreskin (not common)
Urology STAT
Differentials for paraphimosis
Phimosis
Balanoposthitis (give antifungal cream and Keflex)
Balanitis (due to yeast and tender everywhere)
Trauma
Priapism
Persistent erection of penis for more than 4 hrs that is not related to sexual desire (30-40 YO)
Types of priapism
Acute low flow (most common type-drugs, sickle cell, spinal trauma or idiopathic) High flow (rare, blunt trauma-painless, partially rigid)
How does acute low flow priapism happen?
Veno-occlusive
Painful if > several hours
Corpora cavernosa is fully rigid
Failure of blood to leave corporal bodies
Most common drugs causing priapism
Antipsychotics or antidepressants (trazadone i think?)
Tx for priapism
Best within 12-24 hrs (possible impotence or fibrosis)
Sudafed PO
Terbutaline SQ to decrease blood to penis
Aspirate corpora cavernosa with butterfly needle (3 and 9 o clock, 20-100 cc til bright red arterial blood)
Phenylephrine directly into corpora cavernosa (250-500 mcg)
What is Fourniers gangrene?
Necrotizing fascitis infection of the perineum involving penis, scrotum, perineum and abd wall
Common causes of Fourniers gangrene
Staph, strep, E coli, clostridium
Risk factors for Fourniers gangrene
DM (most common!!!)
Alcoholism
Immunosuppression (HIV, CA)
Liver disease
Trauma to ano-urogential or perianal area
Preexisitng perineal or rectal infections
Presentation of Fourniers gangrene
Can be slow or rapid Redness next to port of entry is start Localized pain swelling or discoloration of affected area-pain out of proportion or out of erythemic margins Fever, lethargy, toxic SubQ crepitation over area Putrid or feculent odor
Labs and tx for Fourniers gangrene
Septic work up (CBC, CMP, culture, coags, wound cultures, UA, lactate)
Call surgeon to drain
NPO, IVF, IV pressors, IV abx, contrast CT
Surgical debridement
Older pts on steroids?
No steroid b/c might rupture tendon
What must be done if anything other than simpe UTI?
Look down south
Bactrim + Ace/ARB=
Sudden death (hyperkalemia)
