Emergency Medicine Board Review 2014 GU

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Emergency Medicine Board Review 2014 GU

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Emergency Medicine Board Review 2014 GU

  1. 1. PENIS AND RENAL STUFF BOARD REVIEW Derek Orchard PGY 4 EMERGENCY MEDICINE
  2. 2. GAME PLAN • Male GU Diseases • Polycystic Kidney Disease • Kidney Stones This is going to be concise and to the point board review.
  3. 3. ANATOMY
  4. 4. BALANITIS/BALANOPOSTHITIS • Balanitis = Glans • Posthitis = Foreskin • Think: Uncircumcised, DM, Poor Hygiene, Obesity (picture Rundio) • Clinical: itching, discharge, redness, pain • Treatment • Hygiene • Topical Antifungal • +/- antibacterial
  5. 5. PHIMOSIS VS PARAPHIMOSIS • Phimosis • 2/2 recurrent balanitis, inadequate circumcision • Tx • Nonobstructive: Urology Follow-up • Obstructive: place urinary catheter (may have to place suprapubic), consult Urology, Circumcision • Paraphimosis • PARAmedics • Tx • Reduce it manually • Circumcision
  6. 6. EPIDIDYMITIS & ORCHITIS • Ascending infection • Most are STD related • Chemical epididymitis is due to reflux • Older men with BPH, Stricture or CA • Clinical: progressive pain, swelling, erythema, dysuria, fever, discharge • Phren’s sign • Clinical Dx with US and UA • TX: Think 35!!! • <35 Chlamydia/Gonorrhea – Doxy 14 days + Ceftriaxone • >35 E. coli – Cipro, Bactrim
  7. 7. PRIAPISM • Low Flow (more common) vs High Flow (rare) • High Flow – Trauma (rupture of cavernous artery), AV fistula • Low Flow • Medications – Viagra, Trazadon • Sickle Cell Disease • Malignancy • Cord Injury • DX: Clinical, Blood Gas • TX • Terbutaline, Pseudoephedrine, Ice, Phenylephrine, Aspiration • Sickle Cell: Exchange transfusion • Urology Consultation
  8. 8. PENILE FRACTURE • Not Ortho • Urologic Emergency • Traumatic tear of tunica albuginea • Exclude urethral injury with retrograde urethrogram • Management • Immediate Surgical Repair
  9. 9. TORSION • Bimodal • Highest Risk @ 1yr (undescended testicle, Bell clapper deformity) • During puberty • Child with abdominal pain/nausea --- Examine the testicles! • Time is Testicle • 6 hours!!! • Ultrasound – GO with the EXAM, not the US!!! • Manual de-torsion • Immediate Urology
  10. 10. FOURNIER’S GANGRENE • Necrotizing infection of the scrotum and perineum • Rapidly Progressive • DM, Immunocompromised, Recent trauma • Dx: Clinical, XR, CT • Management • Surgical Emergency • Abx, Hyperbaric oxygen
  11. 11. POLYCYSTIC KIDNEY DISEASE • Autosomal Dominant, multiple kidney cysts • Cysts can become infected and bleed • Associated with Liver Cysts and Cerebral Aneurysm • Clinical: Flank Pain, Hematuria, Hypertension • DX • Renal Insuffciency • CT scan, Ultrasound • Tx: Blood Pressure Control and Nephrology Referral
  12. 12. NEPHROLITHIASIS • Age 20-50 • Recurrence is common • < 5mm 90% pass rate • Stone Type • Calcium Oxalate – MC 80% • Struvite – 2nd most common • Majority of staghorn calculi, Proteus • Uric Acid • Radiolucent • Gout, Leukemia, Tumor Lysis
  13. 13. NEPHROLITHIASIS • Diagnosis • R/O AAA • US – Hydro • UA – Hematuria • CT • Most Common Sites of Impaction • Ureterovesical Junction • Ureteropelvic Junction • Pelvic Brim
  14. 14. MANAGEMENT • No obstruction or infection • IVF, Analgesia, +/- alpha blockers, CCB • Obstruction • May require surgical measures and lithotripsy • Obstruction + Infection • Emergent Decompression
  15. 15. ACUTE RENAL FAILURE • Rapid Decline in GFR • 50% increase in Cr from baseline • 3 Types • PRErenal • INTRINSIC • POSTrenal
  16. 16. PRERENAL • Think >>>>>> SHOCK • Decreased effective blood volume • Sepsis, burns, anaphylaxis, low albumin states, decreased cardiac output,….. • Kidney • Reabsorbs water and salt • Concentrated Urine and Low urine Na
  17. 17. INTRINSIC RENAL FAILURE • Intrinsic damage to the kidney/renal tubule: • Can’t Concentrate pee and Reabsorb Na • Acute Tubular Necrosis (ATN) • 90% • Prolonged prerenal injury, Nephrotoxins, Others • Rhabdomyolysis • Myoglobin injures renal tubules, especially in an acidic environment • Bicarb (for exam) • Aggressive Hydration • Hypo K+ can cause and lead to Hyper K+
  18. 18. POST-RENAL FAILURE • Obstruction to urine flow VS
  19. 19. WORKUP • Cr, Lytes, CK • Check the pee • UA, Urine Lytes, Osmolality • Foley • +/- Ultrasound/CT/Finger
  20. 20. PRE VS POST VS INTRINSIC Test PRErenal POSTrenal Intrinsic Ur Osmolality >500 <400 <300 Ur Na <20 >40 >40 FENa (%) <1 >2 >2 • • • • • BUN:Cr >20 High CK, Blood in UA, No RBC Renal Tubular/Muddy Brown casts Eosinophilia, White cell casts RBC casts, Proteinuria • • • • • PRErenal Rhabdo ATN AIN Acute Glomerulonephritis
  21. 21. REVIEW • Balanitis – Glans • Paraphimosis – PARAmedics • Epididymitis/Orchitis – Think 35 • Priapism – Low Flow, Drugs or Sickle Cell • Torsion – 6 hours • Fournier’s Gangrene – Surgery • Polycystic Kidney Disease – Cerebral Aneurysms • Kidney Stones - < 5mm, r/o AAA

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