FINAL EM Urologic

Question 1

Define Renal colic

Answer 1

Nephrolithiasis-Urolithiasis “kidney stones”
*accumulation of normally dissolved solids from kidney for a stone. Become sx with pain and ureteral obstruction once 2-3 mm in size

Question 2

Types of stone, their associations, and density?

Answer 2

60-90% are radiopaque with Ca salts most common

Struvite: a/w infection, radiopaque

Uric acid: a/w gout (radiolucent)

Cystine: rare

Question 3

Hx renal colic (characteristics of pain)

Answer 3

Sudden onset, colicky
Radiates to GROIN as stone passes into lower ureter
May change in location from flank to groin
Pt constant, may roll around in agony, pain like labor
a/w N/V
Urinary frequency, tea colored urine

Question 4

What exam components are important with renal colic

Answer 4

Exam: abd, back and chest
Male GU
Female +/- pelvic
Vitals: check temp, BP

Question 5

Labs and Imaging important to Renal colic

Answer 5

UA 75-85% have hematuria (may not have if complete obstruction)
BUN/CR to determine renal compromise
KUB: misses 40% cases
NCCT (non contrast CT) scan: 94-100% specific
UTZ: preg or child, 65% show hydronephrosis

Question 6

Ddx to consider a/w renal colic

Answer 6

Acute pyelonephritis,
Papillary necrosis (sickle cell, NSAID abuse),
Appendicitis/biliary colic/bowel obstruction,
AAA,
GYN emergency ie ectopic/ovarian torsion,
Testicular torsion/epididymitis/hernia

Question 7

Size of stones related to passing ability?

Answer 7

8mm, can’t pass

in bw??

Question 8

Tx of renal colic

Answer 8

Toradol great for pain relief
Abx
Alpha 1 blockers (ie Flomax for dilation),
Possibly just watchful waiting

Temporary relief if not passing on own: Insertion of JJ stent or percutaneous nephrostomy tube

Definitive tx of ureteric stone: intractable pain, fever, renal function, 4 wk
ESWL (lithotripsy, shock waves)
PCNL (nephrolithotomy 1 cm incision)
Ureteroscopy
Open surgery – very limited

Question 9

Causes of acute urinary retention

Answer 9

a) Obstructive: BPH most common cause in M >50
b) Inflammatory: ie prostate infection
c) Neurogenic (spinal cord trauma, spinal cord tumor, MS)
d) Pharmacologic: antihistamine, anticholinergic, narcotics

Question 10

PE, Imaging, Lab findings a/w acute urinary retention

Answer 10

a) abdominal distension
b) Bladder US show distension
c) BMP: renal failure
d) infection

*need catheter ASAP, may need SPC if can’t fit cath in (ie pt has BPH)

Question 11

Initial and late mgmt of acute urinary retention, tx, discharge

Answer 11

Initial: urinary cath ASAP, potentially suprapubic (SPC)

Late: treat underlying cause

Tx: monitor 4-6 hr post decompression bc just drained a lot of water/pressure drop; may develop postobstructive diuresis

Discharge pt with drainage bag and f/u in 1-3 d

Question 12

Infections a/w UG

Answer 12

Cystitis, pyelonephritis, prostatitis, urosepsis

Question 13

Dx of infections

Answer 13

Urine culture 100,000 CFU/mL dx
(+) leukocyte esterase and nitrates

Pyuria at least 8-10 WBC/hpf
Gram stain rarely used
GC/CT enzyme assays

Question 14

Pathophysiology of cystitis

Answer 14

Pathogens from fecal flora colonize vaginal introitus, enter the urethra and bladder and stimulate a host response

*E coli (70-95% of episodes)
other: S. saphrophyticus
Less common: Proteus, Klebsiella, enterococci

Question 15

Hx consistent with Cystitis

Answer 15

Dysuria, frequency, urgency
Suprapubic or abd pain,
Dark urine/hematuria/dehydration
Low back pain

*get UA in ER??

Question 16

PE components for cystistis (4)

Answer 16

Temp
Abdomen
CVA percussion
Pelvic exam possibly

Question 17

Ddx to consider for cystitis

Answer 17

Renal calculi,
pyelonephritis,
vaginitis/vulvitis,
GC or CT (urethritis, cervicitis, PID)

Question 18

Labs a/w Cystitis

Answer 18

Urine microscopic 6-20 wbc/hpf

Urine Dipstick detects:

a) Leukocyte esterase (pyuria)
b) Nitrite (G- bacteria)
* beware of false -/+ (blood can give false nitrite positive)

Urine culture not usually indicated in routine UTI

Question 19

Imgaging for cystitis?

Answer 19

Not usually

Question 20

Tx of cystitis?

Answer 20

Abx: 
FQ 3d
Macrobid (Nitrofurantoin) 5d
Bactrim x3d (high e coli resistant rates)
Augmentin x 7-10d
Cephalosporins x 7-10 d

Analgesia: phenazopyridine (pyridium) – SE orange urine

Hydration

Question 21

F/u for cystitis?

Answer 21

Non if asymp

If sx persists, w/u the ddx

Question 22

Etiology of complicated cystitis

Answer 22

a) Assoc w/ condition that increases risk of failing therapy;
b) Present the same, work up the same
c) UTIs in these pts need longer tx, cultures, closure f/u and search for ddx if not rapidly improving

Question 23

Complicated Cystitis etiology

Answer 23

Male, Elderly, children
Urban ER
Hospital acquired, recent abx
Pregnancy, immunosuppression
Indwelling urinary catheter, recent instrumentation
Functional/anatomic abn
Sx >7d
DM

Question 24

Define pyelonephritis

Answer 24

Infectious inflammatory dz involving kidney parenchyma and renal pelvis

Question 25

Agents causing pyelonephritis

Answer 25

E coli >90%, enterobacter, Klebsiella, Proteus, Pseudomonas, Enterococcus

Question 26

S/Sx Pyelonephritis

Answer 26

Fevers, chills, rigors NV, diaphoresis Flank/abd pain Lower UTI sx: dysuria, freq, urge

Question 27

PE pyelonephritis

Answer 27

Vitals Abd, chest, GU CVA tenderness Pelvic/rectal exam??

Question 28

Ddx pyelonephritis

Answer 28

Acute cystitis, perinephric abscess, urolithiasis, ectopic preg, PID, acute prostatitis, acute epididymitis, appendicitis, pneumonia

Question 29

Lab findings re pyelonephritis

Answer 29

``` UA: nitrates, LE, bacteruria, hematuria, WBC casts Urine C&S Blood cultures CBC Preg test Serum electrolytes, BMP ```

Question 30

Imaging for pyelonephritis

Answer 30

*may or may not need CT scan, UTZ

Question 31

When does one need inpt mgmt for pyelonephritis

Answer 31

a) Inability to maintain oral hydration or take oral meds b) Compliance risk c) Uncertainty about dx d) High fevers, severe disability or uncontrolled pain e) risk factors for complications (obstruction, uro surgeries or instrumentation, DM, preg…)

Question 32

Tx of pyelonephritis

Answer 32

10-14d Inpt: inability to take oral, severe illness Outpt: pt who can take oral abx Empiric (no bactrim or macrobid/nitro) 1st: cephalosporins (Cephalexin) 2nd: FQ * other: ampicillin + gentamicin are reasonable if enterococcus is suspected Fluids, pain meds

Question 33

Uncomplicated pyelonephritis f/u and prognosis

Answer 33

Prompt dx and tx carry good prognosis

Question 34

Acute Prostatitis cause

Answer 34

Acute bacterial infection of prostate >35 yr usually G- E coli <35 yr usually due to GC and CT

Question 35

Hx, s/sx, labs PROSTATITIS

Answer 35

Fever, chills, myalgias Pain in lower back, rectum or perineum May have urinary retention, dysuria Abd: may be tender GU: Perineal area tender (urethral swab if applicable) Rectal: tender boggy prostate (do NOT massage bc can cause Bacteremia) Lab: CBC (WBC may be elevated), UA shows Pyuria Imaging: none unless toxic

Question 36

Tx of prostatitis

Answer 36

Hydration, analgesics, bed rest, stool softeners ABX Cipro>35, CT/GC tx <35 If toxic tx as UROSEPTIC

Question 37

Define urosepsis

Answer 37

Severe illness which occurs when UTI spreads systemically

Question 38

Hx Urosepsis

Answer 38

May report recent UTI, pyelonephritis, urolithiasis, prostatitis * Persistent sx of above infections * Weakness, confusion, dehydration * Often seen in NURSING HOME pt

Question 39

Important lab values indicative of SIRS

Answer 39

TEMP: >100.4 OR 12K or 4mmol/L (not part of SIRS?) Tachycardia >90 bpm Tachypnea >20 rpm

Question 40

Urosepsis: Exam/Lab/RAD

Answer 40

PE: as Pyelonephritis or Acute Prostate CBC, Blood cultures, BMP, UA, urine cultures, Lactate CT to r/o stone, abscess, ddx *Note: when getting blood cultures, just always get a lactate; lactate has to be on ice though so let nursing know ahead of time so they only have to stick pt once

Question 41

Urosepsis ddx/tx

Answer 41

Sepsis if SIRS + infection Etiology broad: abd/pelvic, brain, skin, resp, heart Tx: FLUIDS, ABX, tx the shock, ADMIT

Question 42

What constitutes an acute scrotum

Answer 42

Acute testicular torsion | Acute epididymitis

Question 43

Etiology of testicular torsion…

Answer 43

Congenital lack of posterior fixation permitting rotation of testis w/in tunica vaginals 1/4000 M, most common 12-18, 10x more common if person has undescended testis results in twisting of testis and compromised blood flow (more than 6hr, will result in sterility on that side)

Question 44

H/PE findings consistent with Testicular torsion

Answer 44

SUDDEN onset testicular pain – may be insidious, may have prior event, onset may be during sleep or exertion Swelling, May have abd pain, N/V (exam difficult to do bc of pain, may need to sedate patient) PE: * Swollen, firm, tender hemiscrotum * High riding testis with transverse lie - ”red clapper deformity” * Possible loss of cremasteric reflex * Blue dot sign – torsion of the appendix testis

Question 45

Dx testing and Tx of testicular torsion

Answer 45

UA/CBC preop labs NOT HELPFUL STAT Doppler UTZ testicular shows decreased or absent flow to affected side HAVE to untorse! Call urology STAT for surgery (pin down testes) after sedating pt and manually detorsing *Testical turned medial to lateral like “opening a book”; may require 180-360 turn

Question 46

What causes epididymitis

Answer 46

Retrograde spread of infected urine down the vas deferens = inflammation of epididymis * >35 due to E coli, enterococci, Pseudomonas, Proteus * <35 due to CT, GC

Question 47

Hx consistent with Epididymitis

Answer 47

Scrotal pain, swelling, tenderness relieved with testicle elevation (positive phren sign) May have urethral dc and UTI s/sx Low abd or perineal pain; may have fever/chills PE: red, swollen, warm and tender testicle; testicular lump, inguinal LAD, INTACT cremasteric reflex (this may be absent in testicular torsion)

Question 48

Labs/imaging Epididymitis

Answer 48

CBC is systemic signs UA (swab before) Test for GC, CT Doppler US to r/o Torsion or Tumor; may see increased flow to epididymis

Question 49

Ddx Epididymitis

Answer 49

Torsion, orchitis, trauma, tumor, abscess, UTI, varicocele, hydrocele

Question 50

Tx Epididymitis

Answer 50

Bedrest, scrotal elevation with ice ABX: if STD then Rocephin and then Doxy; if UTI then Cipro or Augmentin Pain meds, stool softeners

Question 51

Definition of paraphimosis

Answer 51

Foreskin becomes retracted behind glans of penis and cannot be placed over glans TRUE EMERGENCY bc arterial compromise to the glans may occur

Question 52

H&P of paraphimosis

Answer 52

Elderly or very young due to freq cath, poor hygiene or retracted foreskin that was not replaced *sexual activity or genital piercings are risk Pain,tenderness and redness to retrated foreskin and glans “PARAphimosis is a PARAmedic emergency, Phimosis is not”

Question 53

Ddx paraphimosis

Answer 53

Phimosis, balanoposthitis and balanitis, trauma

Question 54

Tx paraphimosis

Answer 54

Attempt to reduce by pushing on glans while pulling on foreskin Glands compression – manual Emergent dorsal slit in foreskin Urology STAT

Question 55

What is priapism

Answer 55

Persistent erection of the penis for >4hr that is not related to or accompanied by sexual desire Most common in age 30-40

Question 56

How to manage priarism

Answer 56

1. Warn all pt with priapism the possibility of impotence, fibrosis 2. Sudafed po 3. Terbutaline SQ to decrease inflow of blood to penis 4. Aspirate corpora w/ butterfly needle (2 and 10 oclock, aspirate 20-30cc till bright red arterial blood) 5. Phenylephrine injected directly into corpora cavernosa 250-500 mcg 6. Urology *acute low flow most common; due to drugs, blood d/o, sickle cell, spinal trauma, veno occlusion

Question 57

What is fourniers gangrene

Answer 57

Necrotizing infection of the perineum involving penis, scrotum, perineum, abdominal wall (30% mortality!!) Cause: staph, strep, e coli, clostridium *gets bad fast, may see black eschar, feel crepitus if palpate

Question 58

Associations with fourniers gangrene

Answer 58

``` DM (most common) Alcoholism Immunosuppression (HIV, CA) Liver dz Trauma to ano/UG, perineal area Pre-existing perineal/rectal infections ```

Question 59

Course of fourniers gangrene

Answer 59

Varies from slow to rapid Starts with redness next to port of entry Localized pain, swelling, discoloration of affected area Fever, lethargy, toxic appearing Subq crepitus over area Putrid or feculent odor

Question 60

w/u and mgmt of Fourniers Gangrene

Answer 60

Get septic work-up: CBC, CMP, Blood culture, Coags, wound cultures, UA, lactate, Contrast CT scan *call surgery STAT, surgical debridement *ABX combo: PCN/FLagyl/Gentamicin FLUIDS