L7: Urologic emergencies Flashcards
1
Q
How big does a stone have to be for it to be symptomatic?
A
2-3 mm
2
Q
Most common type of stone
A
Calcium salts
3
Q
The radiolucent stones
A
uric acid crystals from stones
4
Q
All the radiopaque stones
A
Struvite stones from infection
Calcium salts
Crystine (usually)
5
Q
Renal colic aka
A
urolithiasis
6
Q
renal colic presentation
A
Unilateral Flank pain Very sudden onset, colicky Stone passes to lower ureter→ radiate to groin Change location flank→ groin Restless, move, roll around N/V Dark urine, frequency
7
Q
Imaging for renal colic
A
KUB xray→ misses radiolucent
Non Contrast CT scan→ specific
Renal Ultrasound→ pregnant, children, hx of stones.
See most stones and hydronephrosis
8
Q
Which stones usually pass? Which don’t?
A
Pass=<5 mm
Don’t pass= >8 mm
9
Q
A pencil eraser has a diameter of
A
6mm
10
Q
Watchful waiting management of renal colic
A
Pain relief Anti nausea Abx alpha 1 blockers. Admit if “sick”
11
Q
Temporary relief for renal colic
A
not passing on own→ insertion of a JJ stent or percutaneous nephrostomy tube.
12
Q
Definitive treatment for renal colic
A
Intractable pain, fever, renal function, 4 weeks:
- ESWL (lithotripsy- “shock waves”)
- PCNL (nephrolithotomy-1cm incision)
- Ureteroscopy
- Open Surgery (very limited
13
Q
Medical expulsion system of urolithiasis
A
CCB alpha blockers (“flowmax”)
<4-5 mm→ no benefit
5-10 mm→ increased passage
14
Q
Painful inability to void
A
acute urinary retention
15
Q
Obstructive causes of urinary retention
A
BPH, men >50 (most common), Prostate infection,Constipation
16
Q
Pharmacologic causes of urinary retention
A
antihistamine
decongestants
anticholinergic
narcotics
17
Q
Neurogenic causes of urinary retention
A
Spinal cord trauma or tumor
MS
Cauda equina
18
Q
Urinary retention diagnosis
A
Abdominal distension
Bladder US→ distention
Normal <50-100 ml → clinical judgement
Abnormal >100-150 ml
Catheter placement→ large amount of urine→ Post Void Residual(PVR)
BMP- +/- renal failure
UA- +/- infection
19
Q
Acute urinary retention management
A
Initial Management :
1 Urethral catheterization
2. Suprapubic catheter ( SPC)
3. CBI Continuous Bladder Irrigation→ if blood clots
Late Management:
Treating the underlying cause
Monitor 2-4 hrs post decompression→ +/- develop post obstructive diuresis
Discharge pt with drainage bag and follow up 3-5 days→ Urology
20
Q
Patients considered a “complicated” UTI
A
Male Sex, Elderly, Children Hospital Acquired Pregnancy Indwelling urinary catheter Recent instrumentation Functional/Anatomic abnormality Recent antimicrobial use Symptoms for > 7 days DM Immunosuppression
21
Q
2 symptoms that really point towards UTI
A
Cloudy urine
No vaginitis or cervicitis
22
Q
Who needs a UA, rather than a clinical diagnosis,?
A
s/sx not clear Back pain Looks sick Male Age ranges Immunocompromised Hx multi courses ABX or resistance Hx multidrug allergies \+/- No U/A in low risk patients, call in RX
23
Q
Treatment options for UTI
A
Macrobid (nitrofurantoin) x 5 days Bactrim DS x 3 days (CI: high e.coli resistant) Fosfomycin 3g single dose Cephalosporins x 7days Augmentin x 7 days
24
Q
Pehnazopyridine
A
analgesia for UTIs
25
Does your UTI patient need to follow up?
Not if they are asymptomatic after tx
26
Drugs you don't give for UTI and the reasoning why
NO Fluoroquinolone(Cipro) → black box→ only if no other tx options (sinusitis, acute bacterial exacerbation of chronic bronchitis, uncomplicated UTI)
NO Amoxicillin→ resistance
27
Risk of complication from pyelonephritis
```
DM
pregnancy
obstruction
tumors
stones
urologic surgeries or instrumentation
```
These patients get admitted!
28
UA of UTI
Urine culture 100,000 CFU/ml
Pyuria >= 10
WBC/hpf
(microscopic)
Urine Dipstick:
(+) Leukocyte esterase→ pyuria, (+)Nitrite→ G-
False (-) & (+). No imaging
29
Labs for pyelonephritis
```
UA→ nitrates, leukocyte esterase, pyuria, bacteriuria, hematuria, WBC cast
Urine culture and sensitivities
Blood Cultures
CBC
hCG
BMP→ serum electrolytes
+/-CT, US, CXR
```
30
Management of pyelonephritis
Cipro 500mg bid x7 days
Levo 750 mg QD x5 days
Bactrim DS for 14 days
Cephalosporins 3rd gen for 10-14 days
31
Admit a pyelonephritis patient if...
Inability to maintain oral hydration or take oral medications
Compliance risk
Uncertainty about diagnosis
High fevers
severe disability or uncontrolled pain
Risk factors for complications
32
Don't give ____ for pyelonephritis
Macrobid (nitrofurotoin)
33
Who needs you to get urine for asymptomatic bactiuria
pregnant, symptoms
| undergoing urologic procedures
34
Treatment for asymptomatic bacteriuria
DON'T TREAT
Antibacterial conservation and prevention of C diff
"Don’t treat the nonpregnant pt with abx"
35
Causes of acute prostatitis by age group
<35 years→N gonorrhoeae and Chlamydia
>35 years→ G- E coli
36
Acute prostatitis presentation
Fever, chills
Myalgias
Pain in lower back, rectum, perineum
+/- urinary retention, dysuria
37
Acute prostatitis on exam
+/Tender abdomen
GU: Perineal area tender
→ +/- urethral
swab
DRE→ Tender boggy prostate→ don’t massage, risk of bacteremia
38
Acute prostatitis labs
CBC→ elevated WBC
UA→ pyuria
Only imaging if toxic
39
Acute prostatitis treatment
Hydration Analgesics, bed rest, stool softeners
Cipro or Levo >35 y/o (2nd line Bactrim 3rd tetracyclines)
GC/Chlamydia tx <35
Toxic→ treat as Uroseptic
40
Severe illness when UTI spreads systemically
Urosepsis
41
Urosepsis history and presentation
*SIRS*
Hx UTI, pyelonephritis, urolithiasis, prostatitis→ persistent sx
Recent Urological procedure
Weakness, Confusion, Dehydration
Nursing home patient (common)
42
Urosepsis exam/diagnostics
Exam as Pyelonephritis or Acute Prostate
CBC, Blood cultures, BMP, UA, Urine cultures, Lactate
CT w/ contrast→ r/o stone, abscess
*Evaluate for SIRS*
43
Criteria for Systemic Inflammatory response syndrome
2 or more of the following:
Temperature >100.4 or <96.8
WBC count >12K or <4K or 10% bands
Tachycardia >90 bpm
Tachypnea >20/min
Severe- Altered mental status,
Elevated plasma Lactate > 4mmol/L
44
Urosepsis treratment
Fluids
Abx
Treat shock
Admit
45
Hematuria that needs to go to the ED
Gross, or >5 RBC UA → ED
>3 RBC on UA and abnormal vitals, labs, or pain
46
Hematuria workup in the ED (gross, >5 RBC)
Rule out obstruction, coagulopathy, rhabdomyolysis
UA, CBC< PT/INR, CK, CMP
Check medication list, LMP
47
what do you do with a patient with Gross hematuria and >3 RBC?
1. Normal vitals, labs, no pain, no comorbidities→ urology
2. Abnormal vitals, labs, or pain→ ED→ renal amd bladder US, CT abdomen/pelvis w/ contrast, retention→ foley catheter, continuous bladder irrigation
48
Rotation of testis within tunica→ twisting→ compromised blood flow
More common undescended testis
Acute testicular torsion
49
Testicular torsion presentation
```
Sudden onset of testicular pain
+/- prior event, insidious onset
+/-Onset during sleep or exertion
Swelling
+/- Abdominal pain, N/V
```
50
Exam/diagnostics for testicular torsion
Sedate pt (pain) for exam
Swollen, firm & tender hemiscrotum
High riding testis with transverse lie
+/-loss of cremasteric reflex
Blue dot sign→ torsion of the appendix testis
Doppler testicular Ultrasound→ decreased or absent flow to affected side
UA,CBC, preop labs→ not helpful acutely
51
Testicular torsion management
NPO
Call Urology stat→ testicular fixation
(even if detorsed in ED)
Sedate pt, attempt to manually detorse
Turn testicle medially to laterally→ ”opening of book” technique
Up to 360 degree detorse→ until pain gone
52
“Retrograde spread” of infected urine down the vas deferens
Acute epididymitis
53
Causes of acute epididymitis by age group
```
< 35 year→ Chlamydia, GC
> 35 yo→
E coli, Enterococci
Pseudomonas
Proteus
```
54
Acute epididymitis presentation
```
Scrotal pain, swelling and tenderness→ relieved with testicle elevation
Lower abd or perineal pain
+/- urethral discharge
+/- UTI symptoms
+/- fever, chills
```
55
Acute epididymitis on exam
Testicle red, swollen warm, tender
Testicular lump
Inguinal LAD
Intact cremasteric reflex
56
Acute epididymitis labs
CBC, UA
Gonorrhea and Chlamydia testing
Doppler US→ r/o torsion. Tumor, +/- increased blood flow to epididymis
57
Who gets admitted with acute epididymitis?
Systemic signs on CBC
58
General care for acute epididymitis
Bedrest, Scrotal elevation with ice
Pain meds
Stool softeners
59
Treatment of acute epidymitis
<35 years (G+C)
Ceftriaxone IM single dose +
doxycycline x 10 days
<35 years (G+C + enteric) + MSM
Ceftriaxone IM single dose + Levofloxacin x 10 days
>35 years (enteric)
Levofloxacin x 10 days
60
Why is paraphimosis an emergency?
arterial compromise to the glans
61
Risk for/history of paraphimosis
Elderly or very young
Frequent catheterization
Poor hygiene
Retracted foreskin not replaced
Risk: Sexual activity or genital piercings
62
Paraphimosis management
```
Attempt to reduce by pushing on glans while pulling on foreskin
Manual glands compression
Sugar Lidocaine wrap
Emergent dorsal slit in foreskin
Urology STAT
```
63
Priapism is an erection greater than _____ most common in _____
4 hours
20-40 years
64
Workup for priapism
Trauma, new drugs? (antipsychotics and antidepressants most common)
Penile shaft firm, glans is soft
CBC, UA if able
65
Priapism management
Within 12-24 hours:
Sudafed po
Terbutaline-SQ Decrease inflow of blood to penis
Aspirate corpora cavernosum with butterfly needle: 3 o’clock + 9 o’clock→ 20-100 cc until bright red arterial blood
Phenylephrine 250-500 mcg injected directly into corpora cavernosa
Urology
Warn pt of possible impotence, fibrosis
66
Differentials for paraphimosis (pics on slide)
Infections:
balanoposthitis (glans + foreskin)
balanitis (glans)
67
Necrotizing fasciitis infection of the perineum involving penis,
scrotum, perineum, abdominal wall
Fournier's gangrene
68
Fournier's gangrene is caused by
Staph
Strep
E coli
Clostridium
*high mortality*
69
Comorbidities/risks of Fournier's gangrene
DM (most common)
Alcoholism
Immunosuppression
Liver disease
Trauma to ano-urogential, perineal area
Preexisting perineal/rectal infections
70
Fournier's gangrene on exam
```
Slow or rapid course(cm/hr)
Starts: redness next to port of entry
Localized pain swelling discoloration of affected area
Pain out of proportion
Pain outside of erythema margins
Fever, lethargy, toxic appearing(SWOS)
Subcutaneous crepitation
Putrid/feculent odor
```
71
Fournier's gangrene labs
*Septic workup*→ CBC, CMP, blood culture, coags, wound cultures, UA, lactate
Contrast CT scan
72
Fournier's gangrene management
NPO
IV Fluids, IV Pressors
IV Antibiotics
Call surgeon→ Surgical Debridement
