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X Emergency Med Exam 2 > Urologic Emergencies > Flashcards

Urologic Emergencies Flashcards

(79 cards)

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1
Q

When do kidney stones become symptomatic?

A

When 2-3 mm in size because obstructing the ureter

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2
Q

Types of kidney stones (nephrolithiasis)

A

Calcium salts (most common)- radiopaque
Struvite (infection)- radiopaque
Uric acid (gout)-radiolucent
Cystine-rare

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3
Q

Renal colic pain associated with kidney stones

A

Unilateral flank pain w/ very sudden onset (colicky)
Radiates to groin as stone goes to lower ureter
Pt can’t get comfortable and may roll around in agony (maybe like labor)
Associated with n/v
Urinary frequency and dark urine (blood)

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4
Q

Labs and imaging for renal colic

A

UA is 75-85% hematuria
BUN/Cr for renal compromise
KUB xray but misses alot
Test of choice: non contrast CT scan

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5
Q

When do you use a renal u/s with renal colic?

A

Pregnant
Children
Pts with previous hx stones
*IDs hydronephrosis

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6
Q

What is the importance of the size of the kidney stone?

A

Size predicts spontaneous expulsion:
Most 1-4 mm will
Usually 5 and above need urologic intervention (> 9 mm only a quarter will pass)

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7
Q

Tx for renal colic

A

NSAID for pain relief
Anti nausea, abx, alpha 1 blockers
Admit if sick
JJ stent or percutaneous nephrostomy tube for temporary relief

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8
Q

Definitive tx of a ureteric stone with intractable pain and fever for 4 wks

A

ESWL (lithotripsy)
PCNL (nephrolithotomy-1 cm incision)
Ureteroscopy
Open surgery (very limited)

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9
Q

Does medical expulsion therapy help with kidney stone? (CCB, a-blockers, Flowmax)

A

<4-5 mm no benefit

5-10 mm will have increased passage (NNT 5)

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10
Q

What is acute urinary retention?

A

Painful inability to void, with relief following drainage of the bladder by catheterization

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11
Q

Causes of acute urinary retention

A

Obstructive (prostatic hyperplasia, infection prostate, constipation)
Pharm (antihistamine, decongestants, anticholinergic, narcotics)
Inflammatory
Neurogenic (spinal cord trauma/tumor, MS)

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12
Q

Diagnostics for acute urinary retention

A

Bladder us shows distention
Large amt urine post catheter placement- post void residual (PVR)
BMP maybe renal failure
UA maybe infection

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13
Q

What is an abnormal amt of post void residual vol?

A

Abnormal is >100-150 ml

Normal is <50-100 ml (judgment for 50-100)

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14
Q

Management for acute urinary retention

A

Urethral catheterization!!
Suprapubic catheter (SPC)
CBI (continuous bladder irrigation if blood clots)
Late management is treat the underlying cause

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15
Q

Discharge tx for urinary retention

A

Monitor pt for 2-4 hrs post decompression (may have post obstructive diuresis)
Discharge pt with drainage bag and f/u 3-5 days

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16
Q

Progression of UTIs when not treated

A

Cystitis
Pyelonephritis
(prostatitis)
Urosepsis

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17
Q

Most common cause of uncomplicated cystitis

A

E coli (less common are klebsiella, proteus, pseudomonas, enterococci)

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18
Q

Sxs of cystitis

A 
Dysuria
Frequency
Urgency
Suprapubic or abd pain
Dark urine (hematuria, dehydration)
No vaginitis or cervicitis (90% chance of UTI)
Cloudy urine (96% chance of UTI)
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19
Q

How to diagnose cystitis

A

Usually clinical dx (UA and culture will just support the history and PE-but culture if high risk, male, pregnant etc)

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20
Q

When do you need a UA with cystitis?

A 
If sxs unclear 
Back pain, looks sick, male or older
Immunocompromised
Hx of multi course abx
Hx of abx resistance
Hx of multi drug allergies
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21
Q

What diagnoses an infection on urine culture?

A

100,000 CFU/ml

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22
Q

Labs for cystitis

A

Microscopic urine >10 wbc/hpf
Urine dipstick shows leukocyte esterase (pyuria), nitrite (Gram - bacteria)
Usually don’t need urine culture or imaging

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23
Q

Tx for cystitis

A

Abx (Macrobid or cephalosporin usually, can be bactrim fosfomycin or augmentin)
Analgesia-phenazopyridine
Hydrate
No f/u if asymptomatic

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24
Q

What drugs are to be avoided in cystitis?

A

FLQ or Amoxicillin (too much resistance)
Black box FLQ (should be reserved for pts with no other tx options for sinusitis, acute bacterial exacerbation of chronic bronchitis and uncomplicated UTIs)

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25
When do you consider complicated cystitis?
``` Male or elderly Hospital acquired Pregnancy Indwelling urinary cath Recent instrumentation Functional.anatomic abnormality Children Recent abx use Sxs > 7days DM Immunosuppression (evaluate like pyelo-labs and longer abx) ```
26
Presentation of pyelonephritis
``` Same UTI sxs (dysuria, frequency, urgency) Fever, chills, rigor N/v Diaphoresis Flank/abd pain ```
27
Labs in pyelonephritis
``` UA: nitrates, LE, pyuria, bacteriuria, hematuria, WBC cast! Urine C&S Cultures CBC, pregnancy test, BMP Maybe CT or US or CXR ```
28
Tx for pyelonephritis
Empiric therapy with usually Cipro or Levoquin (can do bactrim or cephalosporins) Fluids and pain meds
29
What drugs are not used for pyelonephritis?
Macrobid b/c does not get into parenchyma
30
When to follow up for pyelonephritis
If new or worsening sxs
31
Risks for complication with pyelonephritis
Obstruction (stone, tumors) Urologic surgeries or instrumentation Pregnancy DM
32
Indications for inpatient tx of pyelonephritis
Inability to maintain oral hydration or take oral meds Compliance risk Uncertainty about diagnosis High fevers, severe disability or uncontrolled pain Risk factors for complications
33
What is asymptomatic bacteriuria?
Common and benign No long term harm Only rarely treated (common pitfall of treating a nonpregnant pt with abx)
34
When do you get a UA with asymptomatic bacteriuria?
If they have sxs, are pregnant or are undergoing urologic procedures
35
Etiology of acute prostatitis
>35 usually gram - (E coli) | <35 is N gonorrhoeae and Chlamydia
36
Presentation of prostatitis
Fever, chills, myalgias Pain in lower back, rectum or perineum May have urinary retention or dysuria
37
PE for prostatitis
Abd may be tender GU exam may have perianal area tender Urethral swab if applicable Tender boggy prostate (don't massage b/c that can cause bacteremia)
38
Labs for prostatitis
CBC may have increased WBCs UA shows pyuria No imaging unless a toxic pt
39
Tx of prostatitis
Hydration, analgesics, bed rest, stool softeners Abx (Cipro or levo if >35- then bactrim or tetracyclines for 2-4 wks) Treat as uroseptic if toxic
40
What is urosepsis?
Severe illness that occurs when UTI spreads systemically
41
Presentation of urosepsis
``` May have history of recent UTI, pyelo, urolithiasis or prostatitis Persistent sxs of above infections Recent urological procedure Weakness, confusion, dehydration Common in nursing home pts! ```
42
What in the exam of urosepsis indicates systemic inflammatory response syndrome (SIRS)?
``` 2 or more: Temp>100.4 or <96.8 WBC count >12K or <4K or 10% bands >90 bpm >20 breaths/min Severe AMS (elevated plasma lactate >4 mmol/L) ```
43
Labs and diagnostics for urosepsis
CBC, blood cultures, BMP, UA, cultures, lactate | CT w/o contrast to r/o stone, abscess etc.
44
Tx for urosepsis
Fluids, abx | Treat shock and admit
45
What must be ruled out with gross hematuria?
Obstruction Coagulopathy Rhabdomyolysis
46
How to quantify hematuria
Gross of >5 RBC on UA
47
What to be checked with hematuria
Medication list (anything new or stopped recently) LMP PT/INR, CK, CMP
48
What to do with hematuria if normal vitals, labs, no pain or other complaints
Uro workup
49
What to do with hematuria is abnormal vitals, labs or pain
ED work up Renal u/s, CT scan, abd pelvic with contrast Bladder u/s maybe foley if retention (CBI) Tx of cause
50
Presentation of testicular torsion
Sudden onset of testicular pain (may be insidious, may have prior event)--maybe during sleep or exertion Swelling May have abd pain, n/v
51
What exam to do with testicular torsion?
``` NPO Sedate pt if in too much pain Swollen, firm and tender hemiscrotum High riding testis with transverse lie Possible loss of cremasteric reflex Blue dot sign: torsion of appendix testis ```
52
Labs for testicular torsion
Stat doppler testicular u/s (decreased or absent flow to affected side)
53
Tx of testicular torsion
Call urology stat (needs testicular fixation even if detorsed) Attempt to manually detorse (each testicle is turned medially to laterally like opening a book-maybe 360 degrees)
54
Etiology fo epididymitis
<35 probably chlamydia, GC | >35 probably E coli, enterococci, psuedomonas, proteus
55
What must be done with epididymitis to r/o?
U/s to r/o torsion or tumor | Also test of G&C, UA and CBC if systemic signs
56
Presentation of epididymitis
``` Scrotal pain, swelling and tenderness Relieved with testicle elevation May have urethral discharge and UTI sxs Lower abd or perineal pain Fever chills ```
57
What is seen in epididymitis on exam?
``` Testicle is red, swollen, warm and tender Testicular lump Inguinal LAD Cremasteric reflex intact Positive prehns ```
58
Tx of epididymitis
Bed rest, scrotal elevation with ice Abx Pain meds analgesics Stool softeners
59
Abx tx for acute epididymitis mostly caused by G&C (<35 YO)
Cetriaxone IM single dose AND Doxy x 10 days
60
Abx tx for acute epididymitis mostly caused by G&C and enteric organisms (MSM)
Ceftriaxone IM single dose AND Levofloxacin x 10 days
61
Abx tx for acute epididymitis probably caused by enteric organisms (>35 YO)
Levofloxacin x 10 days
62
What is paraphimosis?
Foreskin becomes retracted behind glans of penis and cannot be placed over glans *true emergency b/c arterial compromise can occur
63
Common cause of paraphimosis
Elderly or very young from frequent caths, poor hygiene or retracted foreskin not replaced (sexual activity or genital piercings also pose a risk)
64
PE of paraphimosis
Pain tenderness and redness to retracted foreskin and glans
65
Tx for paraphimosis
Attempt to reduce by pushing on glans while pulling on foreskin Glands compression-manual Sugar lidocaine wrap to reduce swelling Emergent dorsal slit in foreskin (not common) Urology STAT
66
Differentials for paraphimosis
Phimosis Balanoposthitis (give antifungal cream and Keflex) Balanitis (due to yeast and tender everywhere) Trauma
67
Priapism
Persistent erection of penis for more than 4 hrs that is not related to sexual desire (30-40 YO)
68
Types of priapism
``` Acute low flow (most common type-drugs, sickle cell, spinal trauma or idiopathic) High flow (rare, blunt trauma-painless, partially rigid) ```
69
How does acute low flow priapism happen?
Veno-occlusive Painful if > several hours Corpora cavernosa is fully rigid Failure of blood to leave corporal bodies
70
Most common drugs causing priapism
Antipsychotics or antidepressants (trazadone i think?)
71
Tx for priapism
Best within 12-24 hrs (possible impotence or fibrosis) Sudafed PO Terbutaline SQ to decrease blood to penis Aspirate corpora cavernosa with butterfly needle (3 and 9 o clock, 20-100 cc til bright red arterial blood) Phenylephrine directly into corpora cavernosa (250-500 mcg)
72
What is Fourniers gangrene?
Necrotizing fascitis infection of the perineum involving penis, scrotum, perineum and abd wall
73
Common causes of Fourniers gangrene
Staph, strep, E coli, clostridium
74
Risk factors for Fourniers gangrene
DM (most common!!!) Alcoholism Immunosuppression (HIV, CA) Liver disease Trauma to ano-urogential or perianal area Preexisitng perineal or rectal infections
75
Presentation of Fourniers gangrene
``` Can be slow or rapid Redness next to port of entry is start Localized pain swelling or discoloration of affected area-pain out of proportion or out of erythemic margins Fever, lethargy, toxic SubQ crepitation over area Putrid or feculent odor ```
76
Labs and tx for Fourniers gangrene
Septic work up (CBC, CMP, culture, coags, wound cultures, UA, lactate) Call surgeon to drain NPO, IVF, IV pressors, IV abx, contrast CT Surgical debridement
77
Older pts on steroids?
No steroid b/c might rupture tendon
78
What must be done if anything other than simpe UTI?
Look down south
79
Bactrim + Ace/ARB=
Sudden death (hyperkalemia)

X Emergency Med Exam 2 (6 decks)

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