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X Emergency Med Exam 2 > Urologic Emergencies > Flashcards

Urologic Emergencies Flashcards

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1
Q

When do kidney stones become symptomatic?

A

When 2-3 mm in size because obstructing the ureter

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2
Q

Types of kidney stones (nephrolithiasis)

A

Calcium salts (most common)- radiopaque
Struvite (infection)- radiopaque
Uric acid (gout)-radiolucent
Cystine-rare

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3
Q

Renal colic pain associated with kidney stones

A

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)

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4
Q

Labs and imaging for renal colic

A

UA is 75-85% hematuria
BUN/Cr for renal compromise
KUB xray but misses alot
Test of choice: non contrast CT scan

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5
Q

When do you use a renal u/s with renal colic?

A

Pregnant
Children
Pts with previous hx stones
*IDs hydronephrosis

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6
Q

What is the importance of the size of the kidney stone?

A

Size predicts spontaneous expulsion:
Most 1-4 mm will
Usually 5 and above need urologic intervention (> 9 mm only a quarter will pass)

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7
Q

Tx for renal colic

A

NSAID for pain relief
Anti nausea, abx, alpha 1 blockers
Admit if sick
JJ stent or percutaneous nephrostomy tube for temporary relief

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8
Q

Definitive tx of a ureteric stone with intractable pain and fever for 4 wks

A

ESWL (lithotripsy)
PCNL (nephrolithotomy-1 cm incision)
Ureteroscopy
Open surgery (very limited)

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9
Q

Does medical expulsion therapy help with kidney stone? (CCB, a-blockers, Flowmax)

A

<4-5 mm no benefit

5-10 mm will have increased passage (NNT 5)

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10
Q

What is acute urinary retention?

A

Painful inability to void, with relief following drainage of the bladder by catheterization

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11
Q

Causes of acute urinary retention

A

Obstructive (prostatic hyperplasia, infection prostate, constipation)
Pharm (antihistamine, decongestants, anticholinergic, narcotics)
Inflammatory
Neurogenic (spinal cord trauma/tumor, MS)

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12
Q

Diagnostics for acute urinary retention

A

Bladder us shows distention
Large amt urine post catheter placement- post void residual (PVR)
BMP maybe renal failure
UA maybe infection

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13
Q

What is an abnormal amt of post void residual vol?

A

Abnormal is >100-150 ml

Normal is <50-100 ml (judgment for 50-100)

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14
Q

Management for acute urinary retention

A

Urethral catheterization!!
Suprapubic catheter (SPC)
CBI (continuous bladder irrigation if blood clots)
Late management is treat the underlying cause

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15
Q

Discharge tx for urinary retention

A

Monitor pt for 2-4 hrs post decompression (may have post obstructive diuresis)
Discharge pt with drainage bag and f/u 3-5 days

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16
Q

Progression of UTIs when not treated

A

Cystitis
Pyelonephritis
(prostatitis)
Urosepsis

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17
Q

Most common cause of uncomplicated cystitis

A

E coli (less common are klebsiella, proteus, pseudomonas, enterococci)

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18
Q

Sxs of cystitis

A 
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)
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19
Q

How to diagnose cystitis

A

Usually clinical dx (UA and culture will just support the history and PE-but culture if high risk, male, pregnant etc)

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20
Q

When do you need a UA with cystitis?

A 
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
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21
Q

What diagnoses an infection on urine culture?

A

100,000 CFU/ml

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22
Q

Labs for cystitis

A

Microscopic urine >10 wbc/hpf
Urine dipstick shows leukocyte esterase (pyuria), nitrite (Gram - bacteria)
Usually don’t need urine culture or imaging

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23
Q

Tx for cystitis

A

Abx (Macrobid or cephalosporin usually, can be bactrim fosfomycin or augmentin)
Analgesia-phenazopyridine
Hydrate
No f/u if asymptomatic

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24
Q

What drugs are to be avoided in cystitis?

A

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)

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25
Q

When do you consider complicated cystitis?

A 
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)
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26
Q

Presentation of pyelonephritis

A 
Same UTI sxs (dysuria, frequency, urgency)
Fever, chills, rigor
N/v
Diaphoresis
Flank/abd pain
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27
Q

Labs in pyelonephritis

A 
UA: nitrates, LE, pyuria, bacteriuria, hematuria, WBC cast!
Urine C&amp;S
Cultures
CBC, pregnancy test, BMP
Maybe CT or US or CXR
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28
Q

Tx for pyelonephritis

A

Empiric therapy with usually Cipro or Levoquin (can do bactrim or cephalosporins)
Fluids and pain meds

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29
Q

What drugs are not used for pyelonephritis?

A

Macrobid b/c does not get into parenchyma

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30
Q

When to follow up for pyelonephritis

A

If new or worsening sxs

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31
Q

Risks for complication with pyelonephritis

A

Obstruction (stone, tumors)
Urologic surgeries or instrumentation
Pregnancy
DM

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32
Q

Indications for inpatient tx of pyelonephritis

A

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

33
Q

What is asymptomatic bacteriuria?

A

Common and benign
No long term harm
Only rarely treated (common pitfall of treating a nonpregnant pt with abx)

34
Q

When do you get a UA with asymptomatic bacteriuria?

A

If they have sxs, are pregnant or are undergoing urologic procedures

35
Q

Etiology of acute prostatitis

A

> 35 usually gram - (E coli)

<35 is N gonorrhoeae and Chlamydia

36
Q

Presentation of prostatitis

A

Fever, chills, myalgias
Pain in lower back, rectum or perineum
May have urinary retention or dysuria

37
Q

PE for prostatitis

A

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)

38
Q

Labs for prostatitis

A

CBC may have increased WBCs
UA shows pyuria
No imaging unless a toxic pt

39
Q

Tx of prostatitis

A

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

40
Q

What is urosepsis?

A

Severe illness that occurs when UTI spreads systemically

41
Q

Presentation of urosepsis

A 
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!
42
Q

What in the exam of urosepsis indicates systemic inflammatory response syndrome (SIRS)?

A 
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)
43
Q

Labs and diagnostics for urosepsis

A

CBC, blood cultures, BMP, UA, cultures, lactate

CT w/o contrast to r/o stone, abscess etc.

44
Q

Tx for urosepsis

A

Fluids, abx

Treat shock and admit

45
Q

What must be ruled out with gross hematuria?

A

Obstruction
Coagulopathy
Rhabdomyolysis

46
Q

How to quantify hematuria

A

Gross of >5 RBC on UA

47
Q

What to be checked with hematuria

A

Medication list (anything new or stopped recently)
LMP
PT/INR, CK, CMP

48
Q

What to do with hematuria if normal vitals, labs, no pain or other complaints

A

Uro workup

49
Q

What to do with hematuria is abnormal vitals, labs or pain

A

ED work up
Renal u/s, CT scan, abd pelvic with contrast
Bladder u/s maybe foley if retention (CBI)
Tx of cause

50
Q

Presentation of testicular torsion

A

Sudden onset of testicular pain (may be insidious, may have prior event)–maybe during sleep or exertion
Swelling
May have abd pain, n/v

51
Q

What exam to do with testicular torsion?

A 
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
52
Q

Labs for testicular torsion

A

Stat doppler testicular u/s (decreased or absent flow to affected side)

53
Q

Tx of testicular torsion

A

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)

54
Q

Etiology fo epididymitis

A

<35 probably chlamydia, GC

>35 probably E coli, enterococci, psuedomonas, proteus

55
Q

What must be done with epididymitis to r/o?

A

U/s to r/o torsion or tumor

Also test of G&C, UA and CBC if systemic signs

56
Q

Presentation of epididymitis

A 
Scrotal pain, swelling and tenderness
Relieved with testicle elevation
May have urethral discharge and UTI sxs
Lower abd or perineal pain
Fever chills
57
Q

What is seen in epididymitis on exam?

A 
Testicle is red, swollen, warm and tender
Testicular lump
Inguinal LAD
Cremasteric reflex intact
Positive prehns
58
Q

Tx of epididymitis

A

Bed rest, scrotal elevation with ice
Abx
Pain meds analgesics
Stool softeners

59
Q

Abx tx for acute epididymitis mostly caused by G&C (<35 YO)

A

Cetriaxone IM single dose AND Doxy x 10 days

60
Q

Abx tx for acute epididymitis mostly caused by G&C and enteric organisms (MSM)

A

Ceftriaxone IM single dose AND Levofloxacin x 10 days

61
Q

Abx tx for acute epididymitis probably caused by enteric organisms (>35 YO)

A

Levofloxacin x 10 days

62
Q

What is paraphimosis?

A

Foreskin becomes retracted behind glans of penis and cannot be placed over glans
*true emergency b/c arterial compromise can occur

63
Q

Common cause of paraphimosis

A

Elderly or very young from frequent caths, poor hygiene or retracted foreskin not replaced (sexual activity or genital piercings also pose a risk)

64
Q

PE of paraphimosis

A

Pain tenderness and redness to retracted foreskin and glans

65
Q

Tx for paraphimosis

A

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

66
Q

Differentials for paraphimosis

A

Phimosis
Balanoposthitis (give antifungal cream and Keflex)
Balanitis (due to yeast and tender everywhere)
Trauma

67
Q

Priapism

A

Persistent erection of penis for more than 4 hrs that is not related to sexual desire (30-40 YO)

68
Q

Types of priapism

A 
Acute low flow (most common type-drugs, sickle cell, spinal trauma or idiopathic)
High flow (rare, blunt trauma-painless, partially rigid)
69
Q

How does acute low flow priapism happen?

A

Veno-occlusive
Painful if > several hours
Corpora cavernosa is fully rigid
Failure of blood to leave corporal bodies

70
Q

Most common drugs causing priapism

A

Antipsychotics or antidepressants (trazadone i think?)

71
Q

Tx for priapism

A

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)

72
Q

What is Fourniers gangrene?

A

Necrotizing fascitis infection of the perineum involving penis, scrotum, perineum and abd wall

73
Q

Common causes of Fourniers gangrene

A

Staph, strep, E coli, clostridium

74
Q

Risk factors for Fourniers gangrene

A

DM (most common!!!)
Alcoholism
Immunosuppression (HIV, CA)
Liver disease
Trauma to ano-urogential or perianal area
Preexisitng perineal or rectal infections

75
Q

Presentation of Fourniers gangrene

A 
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
76
Q

Labs and tx for Fourniers gangrene

A

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

77
Q

Older pts on steroids?

A

No steroid b/c might rupture tendon

78
Q

What must be done if anything other than simpe UTI?

A

Look down south

79
Q

Bactrim + Ace/ARB=

A

Sudden death (hyperkalemia)

X Emergency Med Exam 2 (6 decks)

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