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Flashcards in Urologic Emergencies Deck (93):
1

Differential Diagnosis of Acute Scrotal Pain

Testicular torsion
Appendiceal torsion
Epididymitis
Testicular rupture

2

History of Acute Scrotal Pain

Good pain history
Fever/chills
Dysuria/hematuria
Discharge
H/O trauma

3

Describe a Positive Prehn's Sign

Lifting of testicle on affected side relieves pain

4

Physical Exam Inclusions

Abdominal exam
Exam of testes, epididymis, cord, and scrotal skin
Exam of inguinal region
Cremasteric reflex
Possible DRE to check prostate

5

Work Up of Acute Scrotal Pain

UA and culture
Color doppler ultrasound

6

History of Testicular Torsion

Sudden onset
Possible inciting event or occur spontaneously

7

Symptoms of Testicular Torsion

Lower abdominal pain, inguinal canal or testes
N/V (+/-)

8

Physical Exam Findings for Testicular Torsion

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

Diagnostic Evaluation of Testicular Torsion

Color doppler US of testicle

10

Treatment of Testicular Torsion

Emergent urologic consultation
Manual detorsion
Orchiopexy

11

Describe Manual Detorsion

Twist laterally "like opening a book"
May need to twist 720 degrees

12

Acute Epididymitis

Less than 6 weeks
Swelling of epididymis with exquisite tenderness
+/- inguinal lymphadenopathy
Systemic symptoms: fever/chills, irritative voiding symptoms
+/- acute prostatitis

13

Chronic Epididymitis

6+ weeks
Subtle epididymal induration and tenderness
No irritative voiding symptoms
+/- inguinal lymphadenopathy

14

Physical Exam Findings in Epididymitis

Tenderness posterior and lateral to the testis
DRE to evaluate prostate
Acute: reactive hydrocele
Positive Prehn's sign

15

Work Up of Epididymitis

UA and urine culture
+/- GC and chlamydia
Urethral swab if discharge present
Rule out other causes of scrotal pain

16

Etiology of Epididymitis in Men Younger than 35 Years Old

Gonococcal
Clamydia

17

Treatment of Epididymitis in Men Younger than 35 Years Old

Ceftriaxone 250 mg IM +
Doxycycline 100 mg BID x 10 days

18

Etiology of Older Men or History of BPH, Urethral Stricture, or Chronic UTI

Enteric gram negative bacteria

19

Treatment of Older Men or History of BPH, Urethral Stricture, or Chronic UTI

Levaquin 500 mg QD x 10 days

20

Symptomatic Treatment of Epididymitis

NSAIDs
Scrotal elevation
Ice

21

Risk Factors for Inflammatory Epididymitis

Medication reaction
Prolonged sitting
Vigorous exercise
Trauma
Autoimmune disease

22

Presentation of Inflammatory Epididymitis

Progressive, gradual onset of pain

23

Treatment of Inflammatory Epididymitis

Scrotal elevation
Warm baths
NSAIDs

24

Define Appendix Testis

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