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Urology for junior ED doctors. Dr Dan Morrissy
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Daniel Morrissy DO
ADVENTURES IN EMERGENCY MEDICINE UROLOGY
TODAY’S TOPICS
• Infection
• Renal/ureteral Calculi
• Urinary Retention
URINARY TRACT INFECTIONS
• Diagnosis and treatment is dependent on the age, sex and commorbities of the patient
SIGNS AND SYMPTOMS OF UTI
• Dysuria
• Urgency
• Frequency
• Polyuria
• Suprapubic tenderness
• Flank Pain
• Fever
DIAGNOSTIC TESTS
• Urine Culture = Gold standard
• Urine Dipstick
• Nitrite –High Specificity, moderate sensitivity (gram negatives)
• Leukesterase – less specific, moderate sensitivity
• Hematuria – very sensitive, Low specificity
• Urine Microscopy
• Gram stain sensitive above <105 cfu/mL
SUSPECTED LOWER UTI IN NONPREGNANT FEMALE
• Absence of vaginal itch or discharge
• Multiple symptoms present = treat (nitrofurantoin or TMP-SMX)
• Few symptoms + Dipstick positive = Treat
• Symptoms + negative or equivocal dipstick = Offer empiric therapy and investigate further if still symptomatic
SUSPECTED UPPER UTI – NONPREGNANT FEMALE
• Signs of UTI with fever, flank pain, systemic inflammatory response
• Urine culture recommended
• Quinolones recommended
• Admission for systemic disease/ unwell
PREGNANT WOMEN
• Symptomatic Bacturia
• Treat with appropriate antibiotic
• Urine culture should be sent
• Follow up culture in 7 days after completion should be done
• Asymptomatic Bacturia
• Urine culture to determine treatment – NOT dipstick
• If culture positive confirm with second and treat
CATHETER ASSOCIATED UTI
• Signs of UTI without other identifiable source
• <103 cfu/mL of 1 or more bacterial species in urine specimen where catheter has been changed in last 48 hrs
• Replace catheter if in place >2 weeks to onset of symptoms
• Obtain culture prior to antibiotics from new catheter or midstream urine
• Pyuria alone cannot differentiate colonization vs infection
• Absence of pyuria suggests alternative diagnosis
• Empiric use of quinalones then guided by culture
CHILDREN• Age - Dramatic decrease in prevalence after 1 year
• 0-2 months
• 2 month – 2 years
• 2-6 years
• >6 years
• Females greater than males
• Uncircumcised greater than circumcised
• Specimens should be straight cath or suprapubic aspiration if unable to control urine or significant external irritation (urine bags are not recommended, only helpful if cx neg)
• Culture is gold standard
• Urinalysis can guide initiation of antibiotics (50,000 CFU/ml)
MALE UTI• Differentiate Sexually transmitted disease from UTI
• Prostatitis
• Epididimitis
• Epiditimo-orchitis
• Orchitis
RENAL CALCULI
RENAL CALCULI
ETIOLOGY OF STONE FORMATION• Dependant on type of Stone
• Calcium 75% (oxalate > phosphate)
• Struvite 15% (Urease-producing bacteria – proteus, klebsiella, Pseudomonas, staph)
• Uric Acid 6% (Low urine pH, Low output, high uric acid level)
• Combination of high concentrations of stone-forming salts and insufficient inhibitory proteins
DIFFERENTIAL DIAGNOSIS
DIAGNOSITIC STUDIES
• Urinalysis (check for blood, rule out infection)
• Labs – CBC?, Urea??, Cr???
• Radiographic studies – KUB (60% of stones visible), Intravenous pyelogram
• Ultrasound - Pregnacy/children
• Non-Enhanced CT Abd/Pelvis
• MRI
TREATMENT
• Pain Control – NSAIDS, Narcotics
• Anti-emetics as needed
• IV Fluids???
• Medical Expulsive Therapy – Calcium Channel Blockers, Steroids, Alpha-adrenergic Blockers
• Tamsulosin 0.4mg daily x 4 weeks (44% more likely to pass)
HEY DOC?
• How Long does it take for stones to pass?
• What size stone requires Urology consultation?
• What can the patient do to prevent future stone formation?
INDICATIONS OF ADMISSION/ INTERVENTION
• Obstruction with infection
• Intractable pain with refractory vomiting
• Impending renal failure
• Severe dehydration
• Single kidney or transplant
• Bilateral obstruction
• Urinary Extravasation
ACUTE URINARY RETENTION
ACUTE URINARY RETENTION
• Inability to pass urine voluntarily
• Distending bladder causing extreme discomfort
ETIOLOGY
• Pharmacological
• Neurological
• Infectious/Inflammatory
• Obstruction
What is the most common presentation in the emergency department?
PHARMACOLOGICAL CAUSES• Increased sphincter tone or prolonged bladder immotillity
• Antiarrhythmics
• Anticholinergics
• Antidepressants
• Antihistamines
• Antihypertensives
• Antiparkinsonians
• Antipsychotics
• Muscle Relaxants
• Sympathomimetics
• Etc…….
NEUROLOGIC CAUSES• Diabetic Cystopathy
• Upper Motor Neuron Lesions – Multiple Sclerosis, Parkinson’s disease, Trauma, Stroke, neoplasms
• Lower motor Neuron Lesions – Spinal cord tumors, epidural abcesses, trauma
INFECTIOUS CAUSES• Urethritis, Prostatitis, Severe Vulvovaginitis
• Genital Herpes – involving the Sacral nerves
OBSTRUCTIVE CAUSES• Intrinsic – BPH, bladder stones, blood clots
• Extrinsic – Masses, cystocele, rectocele
Women Men
Obstructive – Cystocele, tumor Obstructive – BPH, Meatal stenosis, Phimosis/paraphimosis, tumor
Infectious Infectious
Operative Operative
LABORATORY TESTING• Urinalysis – MOST IMPORTANT
• Hematuria
• Infection
• Electrolytes, Urea, Creatinine – Evaluate renal function in setting of prolonged obstruction
• CBC – Select patients with serious infection, hematologic disorders or hypovolemia
IMAGING STUDIES• Bladderscan – bladder volume
• Renal Ultrasound – Hydronephrosis, stone, obstruction
• Bladder ultrasound – Bladder masses,stone, free fluid, volume
Does the degree of hydronephrosis correlate with serum creatinine?
TREATMENT
• Immediate and complete decompression of the bladder through urinary catheterization
• Complications – Hematuria, hypotension, post-obstructive diuresis(Which patients are at risk?), infection.
What is the proper technique?
TYPES OF CATHETERS
Foley Cathetyer Coude Catheter Triple lumen catheter
When do you use each catheter?
BLADDER IRRIGATION
• What fluid do you use?
RELATIVE CONTRAINDICATIONS TO CATHETER PLACEMENT
• Pelvic trauma with blood at meatus
• Penile deformity
• Perineal hematoma
• Known impassible catheterization
• History of known recent prostate or bladder neck surgery
When do you call the Urologist?
SUPRAPUBIC CATHETERS INDICATIONS
• Failure of Urethral catheter in Acute Urinary Retention
• Contraindication to urethral catheterization
• Major Urethral Trauma and no Urologist Available
Use ultrasound to help ensure proper placement.
DISPOSITION
• DISCHARGE if Successful catheterization
• Leave catheter in for BPH (70% recurrence rate)
• Place a leg bag
• Prescribe Alpha Blocker (Tamulosin)
• ADMIT - If any of the following present:
• Severe infection
• Significant comorbidity
• Impaired Renal function
• Neurological deficits
• Catheter complications
SPECIAL CONSIDERATIONS
• Antibiotics – Only if treating infection
• How long should the catheter stay in? BPH vs precipitated?
• Should you test the foley balloon prior to insertion?
• What should the balloon be filled with? Why?
QUESTIONS?