6 Urologic Emergencies and Urolithiasis

Question 1

What treatment woudl you give for your patient with obstructive stone with a fever?

Answer 1

1. Drain (Nephrostomy tube, or ureteral stent)

2. IV antibiotics

Question 2

Prehn’s Sign

Answer 2

elevation of the teste

if pain relief: + finding for epididymitis

if no pain relief: suggests testicular torsion

Question 3

Fournier’s Gangrene

Answer 3

Necrotizing fasciitis of male genitalia and perineum

• subcutaneous tissues
• rapidly advancing

Question 4

Fournier’s Gangrene: risk factors

Answer 4

• Diabetes
• Alcohol abuse
• Immunocompromised

Question 5

Fournier’s Gangrene: keys of the presentation

Answer 5

• foul odor
• fever
• Gas in subcutaneous tissues (crepitus)***

Question 6

Fournier’s Gangrene: Tx

Answer 6

IV antibiotics (aerobic and anerobic)

Question 7

Priapism: duration

Answer 7

> 4 hours

Question 8

Priapism: causes

Answer 8

1. Sickle cell trait and disease
2. Trazodone
3. Cocaine
4. ED drugs (ex. Papaverine/Prostaglandin E1/Phentolamine) (PDE-5 inhibitors)

Question 9

Priapism: complications

Answer 9

• ischemia/hypoxia
• Progressive cavernosal fibrosis
• ED

Question 10

Priapism: TX

Answer 10

18 gauge needle into the corpus cavernosum –>aspirate!

• Give phenylephrine
• Last resort–>shunt

Question 11

Which is an emergency: Paraphimosis or phimosis?

Answer 11

Paraphimosis because foreskin (prepuce) gets stuck proximal to the glans

Question 12

Most common stone type?

Answer 12

calcium oxalate

• radio-opaque
• Resistant to dissolution
• MCC is dehydration

Question 13

Uric Acid stone

Answer 13

• radiolucent
• Forms in acidic urine <6
• Dissolves readily if urine pH is increased (alkalinized)

Question 14

Magnesium Ammonium phosphate (struvite, triple phosphate)

Answer 14

• Caused by UTI
• Radio-opaque
• Forms in alkaline urine
• Dissolved with acidification of the urine

(staghorn calculi)

Question 15

Cystine Stones

Answer 15

• Genetic defect: autosomal recessive

- Dissolves in alkaline environement

Question 16

Matrix stones

Answer 16

• caused by Proteus infection

- Radiolucent

Question 17

Ammonium acid urate stone

Answer 17

• Associated with UTI and laxative use

- Radiolucent

Question 18

Protease inhibitor stone

Answer 18

• HIV drug (ex. Indinavir)

- Radiolucent

Question 19

Name two substances that inhibit crystal formation?

Answer 19

Citrate (complexes with calcium)

Urea (increases solubility of uric acid)

Question 20

Medications causing Urolithiasis

Answer 20

1. Vitamin C
2. Vitamin D
3. Triamterene (K+ sparing diuretic)
4. Protease inhibitors
5. Furosemide (increases urinary calcium excretion)

Question 21

Urolithiasis: presentation

Answer 21

Pain

• Flank
• Radiation
• Colic (variable intensity, waves of intensity)
• N/V
• Hematuria

Question 22

Urolithiasis: Physical exam

Answer 22

1. Fever
2. Hyperkinetic
3. CVA tenderness

Question 23

Stones smaller than _____ will be passable on their own

Answer 23

<5mm

Question 24

Name some treatment options for urolithiasis in the lower tract (bladder, urethra)

Answer 24

1. Extracorporeal Shock Wave Lithotripsy
2. Dissolve
3. Cystourethroscopy/cystolitholapaxy

Question 25

Urolithiasis: candidates for passage

Answer 25

- normal renal function - pain is controlled - Able to take things by mouth - No infection

Question 26

Treatment for stone passage

Answer 26

1. Fluids by mouth 2. Analgesics by mouth 3. Alpha-blocker (ex. tamsulosin) 4. Periodic imaging to assess for hydronephrosis

Question 27

If a patient has a uric acid stone, how much do you need to alkalinize the urine?

Answer 27

- Sodium bicarb by mouth - Potassium citrate by mouth - pH needs to be greater than 6.5 (can take 3 months to work)

Question 28

How are Cystine stones dissolved

Answer 28

Alkalinize urine to above 7.5! Potassium citrate by mouth

Question 29

How are struvite (calcium phosphate) stones dissolved

Answer 29

irrigation with acidic solution (Renacidin)

Question 30

Pros and Cons of Extracorporeal Shock Wave Lithotripsy

Answer 30

Pros: outpatient, non-invasive, sedation (not general anesthesia) Cons: stone fragments are not removed

Question 31

Extracorporeal shock wave lithotripsy: contraindications

Answer 31

- pregnancy - coagulopathy - UTI - Renal artery aneurysm - Abdominal aortic aneurysm others: - cystine stones - chronic pancreatitis/pancreatic calcifications - distal obstruction

Question 32

What size must the stone be to use ESWL?

Answer 32

<2cm also, must be visible on fluoroscopy

Question 33

How long is an ESWL done for and what else needs to be monitored?

Answer 33

- Treatment for 60-90 minutes | - EKG (to avoid inducing dysrhythmias)

Question 34

Steinstrasse (urolithiasis complication)

Answer 34

"street of stones" largest stone falls to bottom and blocks exit of the smaller stones

Question 35

ESWL complications

Answer 35

- renal hematoma - retroperitoneal hematoma - Steinstrasse - Pain - Ecchymosis

Question 36

Percutaneous Nephrolithotomy: indications

Answer 36

Large stone >2cm

Question 37

Prevention of future stones

Answer 37

1. Fluid intake: urine volume 2500 mL/day 2. Fluids with citrate 3. No soda! 4. Low animal protein 5. Low sodium 6. Low oxalate (beets, spinach, chocolate, liver, strawberries) 7. Avoid high doses of Vitamin C and D

Question 38

To prevent future stones, reduce PRAL

Answer 38

PRAL - potential renal acid load - High PRAL lowers citrate in urine :( - Limit intake of cheese and egg yolks

Question 39

Name medications important in preventing future stones

Answer 39

1. Potassium citrate 2. Thiazide 3. Allopurinol 4. Pyridoxine (B6)

Question 40

Potassium citrate

Answer 40

corrects acidosis -Decreases urinary calcium Side effects: hyperkalemia, peptic ulcers

Question 41

Explain how Thiazides can help prevent future calcium stones

Answer 41

- Correct acidosis | - Increases calcium reabsorption/decreases calcium excretion

Question 42

Explain how Pyridoxine (B6) helps prevent urolithiasis

Answer 42

Pyridoxine is involved in oxalate metabolism

Question 43

Explain how Cholestyramine helps prevent future stones

Answer 43

binds bile acids decreasing absorption of oxalate

Question 44

Thiols: Tiopronin and D-Penicillamine

Answer 44

treatment for cystinuria