Urologic Emergencies Flashcards
(93 cards)
1
Q
Differential Diagnosis of Acute Scrotal Pain
A
Testicular torsion
Appendiceal torsion
Epididymitis
Testicular rupture
2
Q
History of Acute Scrotal Pain
A
Good pain history Fever/chills Dysuria/hematuria Discharge H/O trauma
3
Q
Describe a Positive Prehn’s Sign
A
Lifting of testicle on affected side relieves pain
4
Q
Physical Exam Inclusions
A
Abdominal exam Exam of testes, epididymis, cord, and scrotal skin Exam of inguinal region Cremasteric reflex Possible DRE to check prostate
5
Q
Work Up of Acute Scrotal Pain
A
UA and culture
Color doppler ultrasound
6
Q
History of Testicular Torsion
A
Sudden onset
Possible inciting event or occur spontaneously
7
Q
Symptoms of Testicular Torsion
A
Lower abdominal pain, inguinal canal or testes
N/V (+/-)
8
Q
Physical Exam Findings for Testicular Torsion
A
High-riding testis on affected side Significant swelling Epididymis may be displaced and not found in normal position Testicle is firm Exquisite tenderness Cremasteric reflex absent
9
Q
Diagnostic Evaluation of Testicular Torsion
A
Color doppler US of testicle
10
Q
Treatment of Testicular Torsion
A
Emergent urologic consultation
Manual detorsion
Orchiopexy
11
Q
Describe Manual Detorsion
A
Twist laterally “like opening a book”
May need to twist 720 degrees
12
Q
Acute Epididymitis
A
Less than 6 weeks
Swelling of epididymis with exquisite tenderness
+/- inguinal lymphadenopathy
Systemic symptoms: fever/chills, irritative voiding symptoms
+/- acute prostatitis
13
Q
Chronic Epididymitis
A
6+ weeks
Subtle epididymal induration and tenderness
No irritative voiding symptoms
+/- inguinal lymphadenopathy
14
Q
Physical Exam Findings in Epididymitis
A
Tenderness posterior and lateral to the testis
DRE to evaluate prostate
Acute: reactive hydrocele
Positive Prehn’s sign
15
Q
Work Up of Epididymitis
A
UA and urine culture
+/- GC and chlamydia
Urethral swab if discharge present
Rule out other causes of scrotal pain
16
Q
Etiology of Epididymitis in Men Younger than 35 Years Old
A
Gonococcal
Clamydia
17
Q
Treatment of Epididymitis in Men Younger than 35 Years Old
A
Ceftriaxone 250 mg IM +
Doxycycline 100 mg BID x 10 days
18
Q
Etiology of Older Men or History of BPH, Urethral Stricture, or Chronic UTI
A
Enteric gram negative bacteria
19
Q
Treatment of Older Men or History of BPH, Urethral Stricture, or Chronic UTI
A
Levaquin 500 mg QD x 10 days
20
Q
Symptomatic Treatment of Epididymitis
A
NSAIDs
Scrotal elevation
Ice
21
Q
Risk Factors for Inflammatory Epididymitis
A
Medication reaction Prolonged sitting Vigorous exercise Trauma Autoimmune disease
22
Q
Presentation of Inflammatory Epididymitis
A
Progressive, gradual onset of pain
23
Q
Treatment of Inflammatory Epididymitis
A
Scrotal elevation
Warm baths
NSAIDs
24
Q
Define Appendix Testis
A
Small appendage of normal tissue that is usually located on the upper portion of the testis
25
Symptoms of Appendiceal Testis
Gradual onset of pain
Reactive hydrocele (transilluminate)
Localized tenderness
Classic "blue dot" sign
26
Diagnosis of Appendiceal Testis
US shows tossed appendage as a lesion of low echogenicity with central hypoechogenic area
27
Conservative Treatment of Appendiceal Testis
```
Rest
Ice
NSAIDs
Slow recovery with discomfort
Infarcted tissue usually reabsorbed
```
28
Surgical Treatment of Appendiceal Testis
Excision of appendix testis
29
Define Testis Rupture
Rip or tear in the tunica albuginea resulting in extrusion of testicular contents
30
Main Symptoms of Testis Rupture
Scrotal swelling
Severe pain
Ecchymosis
31
Diagnostics for a Testis Rupture
Scrotal US
32
Treatment of Testis Rupture
Referral to urologist for scrotal exploration
Pain management
IV
33
Other Causes of Scrotal Pain
```
Trauma
Strangulated hernia
Post-vasectomy problems
Mumps
Testicular cancer
Kidney stone
```
34
Define Priapism
Erection unrelated to stimulation lasting typically longer than 4 hours
35
Pathophysiology of Priapism
Trapping of blood in the erectile bodies which can result in ischemia and infarction
36
Ischemic Priapism
Most common
| Painful
37
Non-Ischemic Priapism
Rare
Painful
Usually development of traumatic A/V fistula between cavernosal artery and corpus cavernosum
38
Etiology of Priapism
```
Idiopathic
Sickle cell anemia
Leukemia
Thalassemia
MM
TTP
Spinal shock
Metastatic cancers
Perineal, pelvic, or penile trauma
Iatrogenic
Drugs
Infection
Metabolic disorders
```
39
Drug Classes that can Cause Priapism
```
Anticoagulants
Anti-hypertensives
Anti-depressants
PDE5 inhibitors
Intracavernous injections
Alpha-blockers
Cocaine
```
40
Metabolic Disorders that can Cause Priapism
```
Gout
Hemodialysis
High lipid content
Total parenteral nutrition
DM
Amyloidosis
```
41
History of Priapism
Presence of pain
Duration, role of antecedent factors, prior episodes
Existence of etiological conditions
Existence of erectile function status
42
Physical Exam Findings of Priapism
Extent of tumescence and presence and extent of tenderness
| Abdominal, perirenal, and rectal exams can reveal signs of trauma or malignancy
43
Diagnosis of Priapism
CBC
Color doppler US to distinguish ischemic from non-ischemic
Evaluation of aspirated blood
44
Treatment of Priapism
Pain management
| Urgent urological consultation
45
Treatment of Ischemic Priapism
Evacuation of blood
| Intracavernous injection of alpha-adrenergic sympathomimetic agent
46
Treatment of Non-Ischemic Priapism
Observation
| Urological consult
47
Define Penile Fracture
Rupture of one or both of the tunica albuginea that covers the corpora cavernosa
48
Cause of a Penile Fracture
Rapid blunt force to an erect penis
Vaginal intercourse
Aggressive masturbation
49
Signs and Symptoms of Penile Fracture
Popping or cracking sound
Severe pain
Immediate loss of erection
50
Diagnostics of a Penile Fracture
Retrograde urethrogram (RUG)
51
Treatment of a Penile Fracture
Surgical correction
52
Complications of a Penile Fracture
ED
Penile curvature
Pain
53
Describe Paraphimosis
Foreskin in uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion and cannot be returned to its normal position
54
History with a Paraphimosis
Swelling of penis and penile pain
Cause of irritability in preverbal infant
Recent penile exam, foley insertion, cystoscopy
55
Physical Findings with a Paraphimosis
```
Ensure no constricting FB
Edema and tenderness of the glans
Painful swollen retracted foreskin
Penile shaft unaffected
Ischemic: blue or black, firm
```
56
Non-Invasive Techniques for Reduction of a Paraphimosis
```
Ice
Compression bandages
Osmotic agents
Manual compression and reduction
Traction with forceps
```
57
Invasive Techniques for Reduction of a Paraphimosis
Glans penis aspiration
| Dorsal slit procedure
58
Define Urinary Retention
Inability to voluntarily pass urine
59
3 Factors Causing Retention
Outflow obstruction
Neurologic impairment
Inefficient detrusor muscle
60
Diagnosing Urinary Retention
```
H&P
Bladder US
Catheter insertion
UA/culture
Creatinine level
```
61
Treatment of Urinary Retention
Catheter
| Alpha-blocker meds
62
Alpha-blocker Medications that help in Urinary Retention
Tamsulosin (Flomax)
| Doxazosin (Cardura)
63
Complications of Urinary Retention
Hematuria
| Postobstructive diuresis
64
Labs to Diagnose Dysuria
UA
| Urine culture
65
Pyuria on UA can be seen with what infections?
UTI
Chlamydia urethritis
Gonococcal urethritis
66
Hematuria + Pyuria on UA Rules Out
STI
67
Painless Hematuria Potentially Indicates
Cancer
68
When is a urine culture recommended with dysuria?
Men with pyelonephritis
| Women with a complicated UTI
69
Presentation of Pyelonephritis
```
Flank pain
Abdominal pain
Pelvic pain
N/V
Fever >99.8
May have CVA tenderness
+/- cystitis symptoms
```
70
Labs for Pyelonephritis
UA
CBC
Pregnancy test
71
Treatment of Mild to Moderate Pyelonephritis
Rehydrate and give parenteral dose of antibiotics in ED
Observe for 8-12 hours
IV ceftriaxone
Oral fluoroquinolone x 7 days
72
Treatment of Severe Pyelonephritis
```
Hospitalization
High fever
Pain
Marked debility
Inability to maintain oral hydration or take oral meds
Pregnancy
Concerns about patient compliance
```
73
Presentation of Nephrolithiasis
Colicky flank pain
| Hematuria
74
Diagnostics of Nephrolithiasis
Abdominal plain films
Usually non-contrast helical CT scan
US: patient who need to avoid radiation
75
Conservative Treatment of Nephrolithiasis
Pain medication
Stone less than 10 mm, tamsulosin (Flomax)
Hydration
Strain urine
76
When is an urgent urological consult warranted?
Urosepsis
Acute renal failure
Anuria
Unyielding pain, N/V
77
Epidemiology of Blunt Trauma to the Urogenital Region
MVA
Falls from heights
Direct blows to the torso or external genitalia
Injuries to the female genitalia (pelvic fractures, physical or sexual assault)
Testicular injuries
78
Initial Management of Genitourinary Trauma
Identification and stabilization of life-threatening injuries
Rarely life-threatening
79
Secondary Survey of GU Trauma for Both Genders
Inspect perineum and external genitalia
Blood on underwear
Folds of buttocks for perineal lacerations (pelvic fracture)
Rectal exam
80
What are we looking for with a rectal exam in a GU trauma?
Sphincter tone
Presence of blood
Position of prostate
81
Secondary Survey of GU Trauma for Males
Examine scrotum for bruising or testicular rupture
| Look for blood at penile meatus
82
Secondary Survey of GU Trauma for Females
Vaginal introitus for lacerations or hematoma
Bimanual exam if suspicion of pelvic trauma, hematoma, or bruising
Any sign of vaginal blood, need a speculum exam to look for vaginal laceration
83
When should you suspect a urethral injury?
```
Blood at urethral meatus
Gross hematuria
Inability to void
Absent or abnormally positioned prostate
Ecchymosis or hematoma of penis, scrotum or perineum
Plain films reveal a pelvic fracture
```
84
What must be done prior to insertion of a foley catheter in GU trauma?
Retrograde urethrogram (RUG)
85
When should you evaluate for bladder rupture?
Foley catheter has been placed and there is gross hematuria or pelvic fracture with microscopic hematuria
86
What tests can evaluate for a bladder rupture?
Retrograde cystography
| Retrograde CT cystography
87
Define Bladder Contusion
Partial thickness injury to the bladder wall without rupture
88
When does an intraperitoneal rupture occur?
Blunt force injury to the lower abdomen with a full bladder
89
What does an intraperitoneal rupture result in?
Rupture of the bladder dome followed by extravasation of urine into the peritoneal cavity
90
When does an extraperitoneal rupture occur?
In association with pelvic fractures
91
When should you suspect renal injuries?
```
Bruising, pain, or tenderness of the flank or abdomen
Posterior rib or spine fractures
Hematuria (gross or microscopic)
Shock
Fever, flank mass
```
92
Work Up of Renal Injuries
UA
| Renal imaging
93
Indications for Renal Imaging
Penetrating trauma
Lower rib fracture
Gross hematuria
Blunt trauma with microscopic hematuria plus shock
Clinical signs indicating abdominal organ injury or significant deceleration injury
