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Flashcards in Urologic Emergencies ER Med Deck (59):
1

Acute scrotal pain
DDx? 4

1. Testicular torsion
2. Appendiceal torsion
3. Epididymitis
4. Testicular rupture

2

For Urologic emergencies what should our physical exam consist of? 6

1. Detailed exam of the abdomen
2. Exam of the testes, epididymis, cord and scrotal skin
3. Prehn’s sign? Lifting of testicle on affected side relieves pain? + more likely epididymitis
4. Exam of inguinal region
5. Cremasteric reflex
6. Possible digital rectal exam to check prostate

3

Work up: For UE? 2

1. UA and culture

2. Color Doppler ultrasound

4

Testicular torsion is a urologic emergency
1. History? 2
2. Pain where? 3
3. Symptoms? 4

1. History:
-sudden onset severe pain.
-Possible inciting event (trauma) or may occur spontaneously

2.
- lower abdominal pain,
-inguinal canal or
-testes

3. Symptoms:
-Pain is not positional, can be constant or intermittent
-Pain is sudden in onset
-May awaken in the middle of the night with pain
-May have associated nausea and vomiting

5

Physical exam suggestive of testicular torsion
6

1. High-riding (elevated) testis on the affected side
2. Early on may have significant swelling
3. Epididymis may be displaced and not found in it’s normal posterolateral position
4. Testicle is firm
5. Exquisite tenderness
6. Cremasteric reflex is usually absent

6

Diagnostic evaluation for TT?

Color Doppler US of the testicle
-can determine if there is intratesticular flow but if sure of the diagnosis don’t wait to call urologist

7

Treatment of testicular torsion
2

1. Emergent urologic consultation and surgery

2. Potential for manual detorsion

8

TT: Potential for manual detorsion
1. Painful?
2. Twist laterally “like what?
3. May need to twist up to____ degrees
4. If successful, prognosis?
5. Still needs to have what? 2

1. yes!

2. opening a book”

3. 720

4. can give excellent relief of pain

5.
-surgical exploration and
-orchiopexy

9

Epididymitis may be acute or chronic
1. Signs of acute? 5
2. Chronic? 4

Acute
1. 6 weeks
2. Subtle epididymal induration and tenderness
3. No irritative voiding symptoms
4. +/- inguinal lymphadenopathy

10

Epididymitis: Physical exam
4

1. Tenderness posterior and lateral to the testis
2. DRE to evaluate for prostatic involvement if history suggests
3. In acute cases may have swelling with a reactive hydrocele (epididymo-orchitis)
4. May have a positive Prehn’s sign

11

Epididymitis: Work Up
5

1. UA and urine culture,
2. test for GC and chlamydia if applicable
3. Urethral swab if discharge present
4. Rule out other causes of scrotal pain
5. Get an ultrasound to rule out torsion if acute in onset

12

Infectious Epididymitis: Treatment

Younger Men less than 35
1. Etiology?
2. Tx?
3. If septic needs what?

Older men or history of BPH, Urethral stricture, chronic UTI
1. Etiology?
2. Tx?
3. What kind of management?

1. Consider GC and Chlamydia
2. Ceftriaxone 250mg IM and Azithro 1000mg/Doxy 100mg BID x 10 days
3. Needs to be hospitalized for IV hydration and abs

1. Consider enteric gram - bacteria
2. Levaquin 500mg qday X10 days
3. OUtpatient

13

Epididymitis symptomatic treatment
3

1. NSAIDs
2. Scrotal elevation
3. Ice

14

Inflammatory Epididymitis
1. Risk factors? 5
2. May be secondary to what?
3. Presentation?
4. Tx?

1. Risk factors:
-medication reaction,
-prolonged sitting,
-vigorous exercise,
-trauma,
-autoimmune disease

2. May be secondary to a reflux of urine within the ejaculatory ducts

3. Presentation: progressive, gradual onset of pain

4. Treatment:
Scrotal elevation, warm baths, NSAIDs

15

Appendiceal (appendix testis) torsion
What is this?

1. The appendix testis is a small appendage of normal tissue that is usually located on the upper portion of the testis.
2. Torsion of an appendage occurs when this tissue twists.

16

Torsion of the appendiceal testis
1. What ages commonly?
2. Symptoms? 4
3. Dx?

1. Epidemiology: Most cases occur between age 7-14YO

2. Symptoms:
-Gradual onset of pain
-Reactive hydrocele—which may transilluminate
-Localized tenderness
-Examination of scrotal wall may reveal classic “blue dot” sign (a tender blue or black spot beneath the skin)

3. Dx: US shows torsed appendage as a lesion of low echogoenicity with a central hypoechogenic area

17

Torsion of the appendiceal testis
1. Conservative tx? 3
2. Surgical
-When?
-When do pts usually resume normal activity?

Conservative:
1.
-Rest, ice and NSAIDs
-Recovery is slow and with discomfort
-The infarcted tissue is usually reabsorbed

2. Surgical:
-Excision of the appendix testis, while not necessary, is safe and quick, usually reserved for continued pain
-Patients can usually resume normal activity without pain in a few days

18

Testis Rupture
1. What is it?
2. When is it seen?
3. Main symptoms? 3

1. Rip or tear in the tunica albuginea resulting in extrusion of testicular contents
2. Seen in blunt or penetrating trauma- Rare in sports

3. Main symptoms
-Scrotal swelling
-Severe pain
-Ecchymosis

19

Testis Rupture
1. Dx?
2. Tx? 3

1. Diagnostics
Scrotal ultrasound

2. Treatment
-Referral to Urologist for scrotal exploration
-Pain management
-IV

20

Other causes of scrotal pain
6

1. Trauma—with possible testicular rupture
2. Strangulated hernia—usually abnormal abdominal exam
3. Post-vasectomy problems
4. Mumps
5. Testicular cancer
6. Kidney stone

21

Priapism
1. What is it?
2. Occurs how?

1. Definition: erection unrelated to stimulation lasting typically longer then 4 h

2. Occurs by trapping of blood in the erectile bodies which can result in ischemia and infarction

22

Priapism can be ischemic or non-ischemic

1. What makes them different?

2. Nonischemic is from what?

1.
Ischemic
-Most common, painful
Non-ischemic
-Rare, painful,


2.
-usually from development of a traumatic A/V fistula between cavernosal artery and corpus cavernosum

23

What are two common causes to remember with priapism?

1. Sickle cell dz
2. Iatrogenic (injections often)

24

Priapism:
1. Hx? 3
2. PE? 2

History:
1. Presence of pain
2. Duration, role of antecedent factors, prior episodes
3. Existence of etiological conditions and erectile function status

PE
1. Inspection and palpation of the penis may indicate the extent of tumescence and the presence and extent of tenderness
2. Abdominal, perineal and rectal exams can reveal signs of trauma or malignancy

25

Priapism
Dx? 3

1. CBC

2. Can use color duplex doppler ultrasound to distinguish ischemic vs. nonischemic

3. Aspiration of blood from corpus cavernosum can be evaluated

26

Priapism: Aspiration of blood from corpus cavernosum can be evaluated
1. If darkly colored?
2. If bright red?
3. Can do what on aspirated blood?

1. If darkly colored (unoxygenated)—ischemic
2. If bright red (oxygenated)—nonischemic
3. Can do ABGs on aspirated blood

27

Priapism
1. Tx? 2
2. Ischemic?

3. 90% of men with ischemic priapism > what time period do not regain the ability to have sexual intercourse?

1. Treatment:
-pain management,
-urgent urological consultation

2. Ischemic:
-Evacuation of blood then intracavernous injection of alpha-adrenergic sympathomimetic agent—phenylephrine (penile shaft block can be done first)‏
-
3. 24 h

28

Priapism: Non ischemic?
1. Initial management?
2. Prognosis?
3. Further management?

Treatment—nonischemic
1. Initial management is observation
2. 62% spontaneously resolve
3. Urological consult for further management as other treatments can cause erectile dysfunction

29

1. Penile Fracture is what?

2. Cause? 3

1. Rupture of one or both of the tunica albuginea that covers the corpora cavernosa

2. Cause
-Rapid blunt force to an erect penis
-Vaginal intercourse
-Aggressive masturbation

30

Penile Fracture
1. Signs and symptoms? 3
2. Dx? 1

1. Signs & Symptoms
-Popping or cracking sound
-Severe pain
-Immediate loss of erection

2. Diagnostics
-RUG (retrograde urethrogram) if suspect urethral injury

31

Penile Fracture
1. Tx?
2. Complications? 3

1. Treatment
Surgical correction

2. Complications
-Erectile dysfunction
-Penile curvature
-Pain

32

Paraphimosis
is what?

Occurs when the foreskin in the uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion and cannot be returned to its normal position—THIS IS A UROLOGIC EMERGENCY

33

Paraphimosis
1. Hx? 3
2. PE? 5

1. History
-Swelling of the penis and penile pain
-Cause of irritability in preverbal infant
-Recent penile exam, Foley insertion, cystoscopy

2. Physical findings
-Ensure that there is no constricting foreign body
-Edema and tenderness of the glans
-Painful swollen retracted foreskin
-Penile shaft is unaffected
-With ischemia the color of the glans will change from normal pink to blue or black and will be firm rather then soft

34

Paraphimosis
1. R/O what?
2. If it is a contricting band such as hair?
3. Make sure to do what for the pt?

1. R/O angioedema or constricting band

2. If it is a constricting band such as a hair this must be cut and removed

3. Pain control for the patient

35

Paraphimosis: noninvasive techniques for reduction 5

1. Ice
2. Compression bandages
3. Osmotic agents
4. Manual compression and reduction
5. Traction with forceps

36

Paraphimosis: Invasive techniques for reduction
3

1. Puncture technique
2. Glans penis aspiration
3. Dorsal slit procedure

37

Describe the following:
1. Puncture technique?
2. Glans penis aspiration?
3. Dorsal slit procedure?

1. Puncture of the glans with a small gauge needle to allow for lymph fluid to escape
2. aspiration of blood and then foreskin is reduced
3. Cut it

If all the above have failed. Done by urology unless in a rural area and you are it!

38

Urinary Retention
1. What is it?
2. Secondary to?
3. Uncommon in who?
4. 3 factors causing retention?

1. Inability to voluntarily pass urine
2. Secondary to BPH
3. Uncommon in women
4. 3 factors causing retention
-Outflow obstruction
-Neurologic impairment
-Inefficient detrusor muscle

39

Urinary Retention
1. Hx and PE
-What may you find on PE? 4
2. DX? 4

1. Evaluation: History and Physical exam
-Lower abdomen
-Rectal exam
-Pelvic exam (female)
-Neurologic exam

2. Diagnostics
-Bladder ultrasound
-Catheter insertion
-UA/Culture
-Creatinine level

40

Urinary retention
Creatinine is Elevated…. consider what?

Renal Ultrasound

41

Urinary Retention
1. Tx options? 4
2. Complications? 2

Treatment
1. Catheter
-14-16 French
-Self cath
-SP cath
-Alpha-blocker meds….Tamsulosin (Flomax), doxazosin (Cardura)

2. Complications
-Hematuria
-Postobstructive diuresis

42

Dysuria
Lab- UA
1. Pyuria can be seen with? 2
2. What rules out an STI?
3. Hematuria alone without symptoms and signs of uritholiasis may be due to?

4. Urine culture recommended in men with ___________ or women with ______________?

1. Pyuria can be seen with
-UTI,
-chlamydia and gonococcal urethritis

2. Hematuria + pyuria rules out STI

3. Hematuria alone without symptoms and signs of uritholiasis may be
--due to cancer and the patient should have further follow up

4. pyelonephritis, complicated UTI

43

Pyelonephritis
1. Presentation? 5
2. Labs?4

1. Presentation:
-Flank pain, abdominal and pelvic pain
-Nausea and vomiting
-Fever > 99.8F
-May have costovertebral angle tenderness
-+/- symptoms of cystitis

2. Labs:
-UA may show white cell casts,
-send urine for culture & sensitivities
-CBC
-Pregnancy test in females

44

Pyelonephritis - treatment
1. Mild to moderate illness? 3
2. Severe illness requiring hospitalization? 4

1. Mild to moderate illness:
-Can rehydrate and give a parenteral dose of antibiotics in ER and observe for 8-12 hours
-IV antibiotic—ceftriaxone
- d/c on fluoroquinolone x 7d

2. Severe illness requiring hospitalization:
-High fever, pain, marked debility
-Inability to maintain oral hydration or take oral meds
-Pregnancy
-Concerns about patient compliance

45

Nephrolithiasis
1. Presentation? 3
2. DDx? 5

Presentation:
1. Colicky flank pain
-Varying from mild ache to very intense
2. Migrates as stone moves down ureter—radiation
3. Hematuria: common but may be absent in up to 20% of patients

2. Differential Diagnosis
-Ectopic pregnancy
-Acute intestinal obstruction or appendicitis
-aortic aneurysm
-Persons seeking narcotics
-Renal infarct

46

1. Nephrolithiasis may lead to what? 2

2. Diagnosis? 3

1.
-persistent renal obstruction,
-which could cause permanent renal damage if left untreated….hydronephrosis

2.
-Abdominal plain films
-Usually non-contrast helical CT scan
-US in pts who need to avoid radiation

47

Treatment of nephrolithiasis
-Many patients can be managed conservatively with pain medication and hydration until the stone passes. How should we manage if they arent going right to surgery?
2

Urgent urological consult is warranted in patients with what? 4

1. They should be straining their urine
2. If the stone is

48

Initial management of genitourinary trauma?
3

1. Focus on rapid identification and stabilization of life-threatening injuries

2. Genitourinary trauma is rarely life-threatening although a shattered kidney or major renal vascular laceration can pose a threat to life or to the kidney itself

3. Once the patient is stabilized evaluation for genitourinary injury is undertaken

49

GU trauma assessment: secondary survey
1. Inspect what? 2
2. Look for blood where?
3. Look in the folds of the buttocks for what? What would this indicate?
4. Rectal exam for? 3

1. Inspect
-perineum and
-external genitalia

2. Look for blood on the underwear

3. Look in the folds of the buttocks for perineal lacerations which may indicate a pelvic fracture

4. Rectal exam
-Sphincter tone
-Presence of blood
-Position of prostate

50

1. What is the most common type of injury? 2

2. Most common site of urethral injury

1.
-Avulsion of the puboprostatic ligament then
-stretching of the membranous urethra

2. can result in a partial or complete disruption of the urethra at it’s weakest point, the bulbomembranous junction

51

GU Trauma assessment: Secondary survey
1. Males? 2
2. Females? 3

Males
1. Examination of scrotum for bruising or testicular rupture
2. Look for blood at the penile meatus

Females
1. Check the vaginal introitus for lacerations or hematoma
2. Any suspicion of pelvic trauma/hematoma/bruising do a bimanual exam to evaluate for vaginal blood
3. Any sign of vaginal blood will need a speculum exam to rule out vaginal laceration

52

Urethral and bladder injuries
Suspect a urethral injury if?
6

1. Blood at urethral meatus
2. Gross hematuria
3. Inability to void
4. Absent or abnormally positioned prostate
5. Ecchymosis or hematoma of the penis, scrotum or perineum
6. Plain films reveal a pelvic fracture

53

Urethral and bladder injuries
1. Prior to inserting a Foley catheter a what must be done to evaluate the integrity of the urethra?

2. The procedure is deferred only if what?

1. retrograde urethrogram (RUG)

2. pelvic angiography is being done to control pelvic hemorrhage

54

Urethral and bladder injuries
Management:
1. In the presence of gross hematuria without other signs of urethral injury? 2
2. If a Foley catheter has been placed and there is gross hematuria or a pelvic fracture with microscopic hematuria (RBCs>25 per HPF)?

1.
-Foley catheter may be inserted
-Any resistance abort the attempt and do a RUG

2.
evaluate for bladder rupture with retrograde cystography or retrograde CT cystography

55

Bladder injuries
1. What are contusions?
2. Intraperitoneal rupture
-Occurs how?
-Results in?

3. Exztraperitoneal rupture?
-Occurs in association with what?
-Injury force causes what?
-What is an issue if we have bony fragments?

1. Contusions—partial thickness injuries to the bladder wall without rupture
2. Intraperitoneal rupture
-Occurs from blunt force injury to the lower abdomen w/ a full bladder
-Results in rupture of the bladder dome followed by extravasation of urine into the peritoneal cavity

3. Extraperitoneal rupture
-Occurs in association w/ pelvic fractures
-Injury force causes rupture of the anterior or anterior-lateral wall
-Sometimes bony fragments impale the bladder

56

All patients with a pelvic fracture or gross hematuria should have a what to rule out bladder rupture?

cystogram

57

Suspect renal injuries when:
5

1. Bruising, pain or tenderness of the flank or abdomen
2. Posterior rib or spine fractures
3. Hematuria (gross or microscopic)
4. Shock
5. Fever, flank mass (urinoma)

58

Renal injuries work up? 2

UA
Renal imaging (CT scan)

59

Renal imaging (CT scan) is indicated in patients who have the following? 5

1. Penetrating trauma
2. Lower rib fracture
3. Gross hematuria
4. Blunt trauma w/ microscopic hematuria plus shock
5. All clinical signs indicating abdominal organ injury or significant deceleration injury