Urology: Emergencies Flashcards
What % of all sepsis cases is urosepsis?
25%
What are the mortality rates in severe sepsis?
20-40% (severe sepsis is a critical situation)
What are most cases of urosepsis due to?
Complicated UTI
What is a complicated UTI?
Occurs in a patient with an anatomically abnormal urinary tract (stone in urinary tract, ect.) or with significant medical or surgical comorbidities
What do complicated UTI require?
- Prolonged course of antimicrobial therapy
2. May require surgical intervation
How have the rates and mortality of urosepsis changed over recent years?
- Rates have increased
- Mortality has decrease
- This suggests improved management of aptients
What special patient groups does urosepsis have a higher mortality rate in?
- Elderly patients
- Immunosuppressed patients: Diabetics, patients with HIV, Patients on chemotherapy of chronic steroids, Organ transplant recipients
* If any of these patients present with sepsis, deal with it RIGHT AWAY
What is urosepsis often due to?
Obstructive uropathy of the upper or lower urinary tract
What are 3 things that can cause obstructive uropathy of the upper or lower urinary tract?
- Blockage of ureter: Stone, tumor, extrinsic compression
- Blockage of urethra: Stricture, prostate enlargement
- Conditions resulting in poor emptying of urine: VUR or neurogenic bladder
If you have a kidney stone over 7mm that gets lodged in the ureter, what could be the potential sequelae leading to urosepsis?
It can cause proximal infection, leading to bacterial spread into the blood… urosepsis
What is VUR?
The urine flow retrograde back into the kidney
What is a neurogenic bladder?
It doesn’t squeeze right…can be caused by spina bifida, SC disease, or diabetes
What can obstructive uropathy of the upper or lower urinary tract promote?
Intravasation of bacteria into the vascular system and may induce bacteremia or sepsis
This can then lead to systemic inflammatory response syndrome (SIRS)
What are 4 major aspects of the treatment of urosepsis?
- Early goal-directed therapy
- Optimal pharmacodynamic exposure to antimicrobials both in blood and the urinary tract
- Control of complicating factors in the urinary tract
- Specific sepsis therapy
What should be the timeframe of treatment for someone presenting with urosepsis
Treatment takes place with in 3 hours
What is part of early goal-directed therapy?
- Time from admission to therapy is critical
- Fluids, fluids, fluids, ABG, maybe vasopressors and a central line….GET FLUIDS IN FAST
- IV, pH, lactate, ect.
What must done with regards to antibiotics when a patient present with urosepsis?
Blood and urine cultures….then start broad-spectrum antibiotics and then tailor then once results come in
What is involved in control of complicating factors in the urinary tract?
Stent versus nephrostomy tube
-Place a stent and foley catheter to keep urine flowing…need to divert the urine
What is one option for specific sepsis therapy?
Hydrocortisone
Why is the association of an obstructing calculus along with febrile UTI usually considered an emergency?
Because of the risk of sepsis
With obstructing calculus and febrile UTI is intervention mandatory and if so, with what?
- Intervention is mandatory in most cases
- Specifically by emplying either a nephrostomy tube or ureteral stent
What can stones do to the treatment of UTI if they are infected?
Prolong it…. (biofilm/magnesium ammonium phosphate stones)
What % of cases of urosepsis are caused by gram positive organisms?
Under 15%
What accounts for the majority of cases of urosepsis?
Gram negative bacilli
- E. Coli: 50% (remember, E. Coli doesn’t cause struvite stones though)
- Proteus: 15%
- Enterobacter: 15%
- Klebsiella: 15%
- Pseudomonas: 5%
What do pathogenic bacteria give large doses of?
Bacterial cell wall ingredients: LPS or Lipid A (endotoxin)
What are the 2 most important pro-inflammatory cytokines and what do they influence?
- TNF-alpha and IL-1
- They influence temperature regulatory centers in the hypothalamus
What binds to both latex and urothelial cells?
Type 1 fimbriae
What are type I fimbria inhibited by?
Mannose
What does P-fimbriae bind to?
A urothelial cell surface receptor
-This is referred to as the P-blood group antigen present in the majority of the world population and located on the urothelial cells as well
What 2 types of cells are activated by the ingestion of bacteria and by stimulation through cytokines secreted by CD4T cells?
Macrophages and dendritic cells (these are up-regulated and down-regulated depending on a variety of factors
What do CD4 helper cells cause?
An antiinflammatory immune suppression
What are 3 acute phase proteins produced by the liver (and triggered in the inflammatory casacade)?
- CRP
- Alpha-1-antitrypsin
- Complement factors
What cells release nitric oxide and what does this lead to?
Endogenous endothelial cells….this leads to decreased vascular tone
What is included in the evaluation of the patient with complicated UTI?
- Expeditious evaluation to limit short term and long-term morbidity and mortality
- Accurate History & Physical
- UA & Urine culture is mandatory
- Assess patient’s general medical status (hematologic profiles and complete serum chemistries), BP, Pulse
- Imaging study should be mandatory, to discern whether other complicating issues exist (US or CT)
If urosepsis is suspected early (in the first hour) what is mandatory?
Supportive therapy with stabilization of BP and sufficient tissue oxygenation
-IV fluids, O2, central line for vasopressors
What can US tell us with regards to urosepsis?
It can show hydronephrosis on one kidney to help determine which side if affected
What can CT tell us with regards to urosepsis?
Where the stone actually is
What are steps for urosepsis management?
- Clinic aspect indicative for severe sepsis
- Sepsis criteria positive: Hypotensive, Tachy, Febrile
- Initial oxygen and fluid resuscitation
- Signs and symptoms indicative for urosepsis (urinary analysis and cultures)
- Sonographic evaluation of uro-genital area (imaging)
- Early goal directed therapy and empirical antibiotic therapy
- If indicated, radiographic evaluation of uro-genital tract ( if bladder is distended, put a foley in)
- Control/elimination of complicating factor
- Specific sepsis therapy, if necessary
What is early goal directed therapy guidelines?
- CVP 8-12mmHg
- MAP 65-90mmHg
- CVO2 greater than or equal to 70%
What is done for early goal directed therapy?
- Antibiotics
- Fluids
- Tissue O2
What are critical steps in the successful management of a patient with severe urosepsis?
- Early tissue oxygenation
- Appropriate initial antibiotic therapy
- Rapid identification and control of the septic focus in the urinary tract
* Interdisciplinary approach is necessary to achieve this goal
What does early goal-directed therapy involve?
Adjustment of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand
In the study presented, what was the in-hospital mortality in the group assigned to EGDT versus the group asssigned to standard therapy?
30.5% versus 46.5%
Does early goal-directed therapy provide significant benefits with respect to outcome in patients with severe sepsis and septic shock?
Yes
What was seen in patients assigned to EGDT during the 7-72 hour interval?
- Higher mean central venous oxygen saturation
- Lower lactate concentration
- Lower base deficit
- Higher pH
- Lower APACHE II scores (indicates less severe organ dysfunction)
If you are obtaining consent for a stent placement, what else should you obtain consent for?
A nephrostomy tube
Why is it important to insert a foley with a JJ stent?
To help whisk away the infection once urine starts flowing
What does the SVO2 give an estimate of and what does this indirectly correlate with?
It gives an estimate of the oxygen saturation of blood returning to the right side of the heart, which indirectly correlates with tissue oxygen extraction, and the balance between system oxygen delivery and demand
What portends to increased morbidity and mortality in early sepsis?
The presence of a low SVO2
What does EGDT provide?
Significant benefits with respect to outcome in patients with severe sepsis and septic shock
What is the standard practice for a uroseptic patient +/- comorbid conditions on the verge of crashing?
Nephrostomy tube placement
What are some perks of nephrostomy tube placement for patients with urosepsis?
- Can be placed with local anesthesia
2. Larger bore drainage tube (8-12 french versus 6 french for JJ) for thick, insupissated purulent drainage
What are 5 things in the summary of urosepsis recommendations?
- Obtain cultues
- Initiate early goal directed therapy
- Start broad spectrum antibiotics
- Alleviate obstruction/complicated factors
- Specific sepsis therapy
What is in the DDx for acute scrotum?
- Testicular torsion
- Torsion of appendix testis or epididymal appendage
- Epididymitis/Epididymoorchitis
- Testicular rupture
What is testicular torsion?
Torsion of the spermatic cord
What patient population is testicular torsion most seen in?
Males 12-18
What is the characteristic presentation of testicular torsion?
Acute onset of severe testicular pain with or without swelling (also nausea and vomiting)
What is pathognomonic for torsion of appendix testis or epididymal appendage?
Small firm nodule of “blue dot sign”
What is a description of the pain in epididymitis/epidiymoorchitis?
- Onset of pain is gradual and progresses from mild to more intense
- 1-2 weeks of unilateral progressive testicular pain
What is the most important factor in warranting immediate surgical exploration for testicular torsion?
- Level of suspicion based on the history
- Need to get the testicle detorsed in 6 hours or less
If you suspect a testicular torsion, what can you try right away?
An “open book” detorsion
When must the testicles be detorsed by to remain viable?
6 HOURS
What test must be done with testicular torsion?
A stat scrotal duplex sonogram
What must be performed in the near future to prevent further episodes of testicular torsion (even if the testicle is detorsed)?
A bilateral orchiopexy (suture the testicle to the scrotum)
What are findings seen with testicular torsion?
- Horizontal lie of testicle
- Absent cremasteric reflex
- No pain relief with elevation of the testicle
- Thick or knotted spermatic cord
What is the presenting symptom with testicular torsion?
Acute onset of severe pain with or without swelling
-May also present with GI symptoms (nausea and vomiting)
When will you think epidiymitis over testicular torsion?
When the onset of pain is gradual and progressed from mild to more severe
What can you do if you have an internal testicular torsion?
Try an open book detorsion before US
-If good blood flow is present, can wait to do other things
What age group are intravaginal torsions seen?
Older
What age group are extravaginal tosions seen?
In newborns due to the bell clapper deformity
What are you checking for on US in testicular torsion?
Blood flow
What else can included in the DDx for testicular torsion?
Acute epididymitis/orchitis
Is testicular torsion a true surgical emergency?
YES… 6 hours for viability
What is seen in epididymitis?
A swollen and heterogeneous epididymis
-Also hydrocele and scrotal wall thickening is seen (inflammatory hydrocele)
What is seen on color doppler US in epidiymitis?
Increased flow to the epididymis
What is fractured in a testicular rupture?
The tunica albuginea (fibrous capsule)
What does fracture of the tunica albuginea in testicular rupture lead to?
Extrusion of the seminiferious tubules
you need to debride this and then suture it back together
What setting does testicular rupture occur in?
The setting of blunt trauma
What can testicular rupture affect?
Fertility and endocrine function
Usually okay long term because of the other testicle
What is seen on US in testicular rupture?
Heterogeneous echotexture
If surgical repaire is done with in 72 hours what is the testicular salvage rate in testicular rupture?
80-90%
Why is prompt surgery required in testicular rupture?
To avoid testicular loss, infection, infertility, and chronic pain
What is the presentation of a penile fracture?
- Popping or cracking sound
- Significant pain
- Immediate flaccidity
- Skin hematoma of various sizes
- Symptoms are similar to a common bruising or contusion of the penis
What is a penile fracture associated with?
An erection
What are 2 “buzz words” associated with penile fracture?
Throckmortons sign and Eggplant deformity
What is a penile fracture?
A traumatic rupture of tunica albuginea and the tumescent corpora cavernosa due to the nonphysiological bending of the penile shaft, presenting with or without rupture of corpus spongiosum and urethra
Is penile fracture a common injury?
No… approximately 1 in 175,000 hospital care emergencies (not including notable number of patients not seeking for medical care due to embarrassment or fear)
Is surgical repair required in penile fracture?
YES
Why is surgical repair required?
To help reduce the risk of ED and permanent penile curvature
How long can surgical repair be delayed in penile fracture?
For up to 2 weeks with conservative therapy devoid of urethral injury
In the western hemisphere, when does penile fracture usually occur?
-Penile fracture usually occurs during sexual intercourse when the penis slips out of the vagina and strikes the perineum or the pubic symphysis
What are other potential causes of penile fracture?
Industrial accidents, masturbation, gunshot wounds, or any other mechanical trauma that causes forcible breaking of an erect penis
What is a common cause of penile fracture in Middle Eastern Countries?
Penile manipulation to achieve detumescence
What are some rare etiologies of penile fracture?
Turning over in bed, a direct blow, forced bending, or hastily removing or applying clothing when the penis is erect.
What is urethral injury usually elucidated by in penile fractures?
Blood at meatus, hematuria, difficulty urinating
Bilateral fracture- 10-20% of cases RUG should then be performed
After surgery for penile fracture, how long until the penis can be used?
4-6 weeks, until it heals (how sad)
What is paraphimosis?
When the foreskin gets stuck behind the glands
Who does paraphimosis happen to?
Only uncircumcised males (duh)
Why should paraphimosis be reduced immediately?
To prevent necrosis
How do you reduce paraphimosis?
- Squeeze out edema by holding a firm grip on the edematous tissue
- Attempt to reduce (pull it down)
If attempts at reducing paraphimosis are unsuccessful, what might the patient need?
A dorsal slit
What is the most common cause of paraphimosis?
Iatrogenic: When medical personnel forget to reduce the foreskin after instrumentation of catheterization of the urethra
What is the pathology of paraphimosis?
-The retracted foreskin initially blocks lymphatic drainage from the distal penis, progressively causing further edema of the retracted foreskin. If the foreskin remains retracted and the edema continuous, venous obstruction followed by arterial flow are expected within hours to days
What is Fournier’s Gangrene?
Abrupt onset, rapidly progressive necrotizing fasciitis involving the perineum and genitalia
In Fournier’s Gangrene, where does infection normally spread?
Along the dartos fascia, colle’s fascia, and scarpa’s fascia (because these layers are contiguous)
What are RF for Fournier’s Gangrene?
DM, alcohol abuse, immunocompromised state
What is the average number of days between symptom onset and patient presentation in Fournier’s Gangrene?
5 days
What is the diagnosis of Fournier’s Gangrene based off of?
PAIN in the penis of scrotum out of proportion to exam, fevers, crepitus, black eschar, foul odor.
What can be seen on imaging in Fournier’s Gangrene?
Gas in the Sub-Q tissues
What is diagnosis of Fournier’s Gangrene based off it?
Clinical Suspicion
What can cause Fournier’s Gangrene and what is the most commonly cultured organism?
Aerobes and anaerobes
-E. Coli
Does Fournier’s Gangrene have a high mortality rate?
Yes
Are patients with Fournier’s Gangrene normally obese?
Yes
What is the average number of bacteria present per case of Fournier’s Gangrene?
4 different bacteria
What is treatment for Fournier’s Gangrene?
- Broad spectrum IV antibiotics
- EGDT
- Wide surgical debridement of necrotic tissue
What else is helpful to inhibit the growth of and kill the anerobic bacteria in Fournier’s Gangrene?
Hyperbaric oxygen therapy
What is the overall mortality rate with Fournier’s Gangrene and what is the mortality rate is sepsis is already present at the time of initial hospital admission?
40% and 78%
What is priapism?
Persistent erection that continues beyond 4 hours or is unrelated to sexual stimulation (a prolonged, painful, fully rigid erection)
What is arterial (high-flow) priapism usually secondary to?
Trauma or rupture of a cavernous artery and unregulated flow into the lacunar spaces
Is arterial (high-flow) priapism painful?
Usually it is NOT PAINFUL
What does arterial (high-flow) priapism result from?
Penetrating penile trauma or a blunt perineal injury (AV malformation from trauma/ect.)
Is arterial (high-flow) priapism common?
No it is rare
How do you fix arterial (high-flow) priapism and what is the consequence of this?
You embolize the arteries
-The patient will become impotent (penile prosthetic?)
What is the most common type of priapism?
Ischemic (low-flow)
What is the pathophysiology of ischemic (low-flow) priapism?
- Decreased venous outflow
- Increased intracavernosal pressure
- Erection
- Decreased arterial inflow
- Stasis of blood
- Local hypoxia and local acidosis
What 2 things are seen with priapism?
- Progressive cavernosal fibrosis
2. ED
What % of men with priapism over 24 hours develop severe ED?
90%
What % of men develop ED even with early intervention?
50%
-NEED TO DECOMPRESS THE PENIS
If you get blood from a needle drain of the penis and it is hypoxic and acidotic, what does those mean and what do you need to do?
- Ishcemic (low-flow) priapism
- Get arterial blood flowing
What are 6 causes of priapism?
- Sickle Cell Disease and Sickle Cell Trait (the RBCs get stuck)
- Malignant infiltration of the corpora: Leukemia
- TPN: 20% lipid infusion
- Medications: Trazodone, Phenothiazines, Cocaine
- ED medications (Injection therapies)
- Spinal or general anesthesia (Usually self-limiting)
Do oral ED medications cause priapism?
No, those are okay… usually the injectibles can cause it (can be iatrogenic)
What is the first thing to do when treating priapism?
Establish ischemic versus non-ischemic
How do you tell if its ischemic or non-ischemic?
If there is pain or non
-Ischemic is painful, non-ischemic is not painful
What is the PO2, PCO2, and pH in a cavernosal blood gas (first corporal aspirate) in ischemic priapism?
PO2: Under 30
PCO2: Over 60
pH: Under 7.25 (7)
What 5 things are done for a patient with sickle cell and ischemic priapism?
- IV hydration
- Alkalization with bicarbonate in IV fluids
- Analgesia/pain control
- Oxygen (facemask or NC)
- Hemoglobin electrophoresis
What do you want to keep the hemoglobin at and why in priapism (Sickle Cell)?
- Transfuse to keep hemoglobin over 10g/dL
- This should reduce hemoglobin S to under 30%
- If not anemic, then consider performing an exchange transfusion
In a sickle cell patient, what factors do they want to avoid to prevent priapism?
Factors that precipitate sickling:
-Dehydration, cold, hypoxia
What are 5 steps in the procedure for ischemic priapism?
- Penile ring block with 1% Lidocaine
- Corporal aspiration and irrigation with 18 or 19 gauge needle inserted at 9 or 3 o’clock position at base of penis and blood aspirated from corpora
- Irrigate with sterile, injectable normal saline into corpora with 10-20ml syringe
- Phenylephrine – 1%, mix 0.5cc with 9.5cc normal saline
- 500mcg/mL – 1mL injected every 5 minutes until detumescence achieved. Max 2000mcg
What do we need to monitor patients for during a procedure for priapism and why?
-Put on heart monitor to look for:
1. Tachycardia
2. Reflex bradycardia
3. Arrhythmia
Because we give them phenylephrine (which is a vasoconstrictor)
What happens if there is no detumesence after 1 hour?
Then you proceed with a surgical shunt (this is unusual though)
Why can’t you place the aspiration needle at the 6 or 12 o’clock position when treating priapism?
Because this is where the nerve, artery, vein and urethra lie
What do you have to be careful of when aspirating a priapism?
-The needle must not become dislodged during irrigation/aspiration as it will likely cause hematoma
Are urologic emergencies common?
No, urologic emergencies are fairly uncommon, by high mortality and morbidity rates can occur if no recognized and treated in a timely fashion
What are recognition and quick intervention the key to in urological emergencies?
To preserve tissue, fertility, erections, and LIFE
