ED Urology. Dr Dan Morrissy

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Urology for junior ED doctors. Dr Dan Morrissy

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ED Urology. Dr Dan Morrissy

  1. 1. ADVENTURES IN EMERGENCY MEDICINE UROLOGY Daniel Morrissy DO
  2. 2. TODAY’S TOPICS • Infection • Renal/ureteral Calculi • Urinary Retention
  3. 3. URINARY TRACT INFECTIONS • Diagnosis and treatment is dependent on the age, sex and commorbities of the patient
  4. 4. SIGNS AND SYMPTOMS OF UTI • Dysuria • Urgency • Frequency • Polyuria • Suprapubic tenderness • Flank Pain • Fever
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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)
  11. 11. MALE UTI • Differentiate Sexually transmitted disease from UTI • Prostatitis • Epididimitis • Epiditimo-orchitis • Orchitis
  12. 12. RENAL CALCULI
  13. 13. RENAL CALCULI
  14. 14. 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
  15. 15. DIFFERENTIAL DIAGNOSIS
  16. 16. 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
  17. 17. TREATMENT • Pain Control – NSAIDS, Narcotics • Anti-emetics as needed • IV Fluids??? • Medical Expulsive Therapy – Calcium Channel Blockers, Steroids, Alphaadrenergic Blockers • Tamsulosin 0.4mg daily x 4 weeks (44% more likely to pass)
  18. 18. 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?
  19. 19. 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
  20. 20. ACUTE URINARY RETENTION
  21. 21. ACUTE URINARY RETENTION • Inability to pass urine voluntarily • Distending bladder causing extreme discomfort
  22. 22. ETIOLOGY • Pharmacological • Neurological • Infectious/Inflammatory • Obstruction What is the most common presentation in the emergency department?
  23. 23. PHARMACOLOGICAL CAUSES • Increased sphincter tone or prolonged bladder immotillity • Antiarrhythmics • Anticholinergics • Antidepressants • Antihistamines • Antihypertensives • Antiparkinsonians • Antipsychotics • Muscle Relaxants • Sympathomimetics • Etc…….
  24. 24. 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
  25. 25. INFECTIOUS CAUSES • Urethritis, Prostatitis, Severe Vulvovaginitis • Genital Herpes – involving the Sacral nerves
  26. 26. OBSTRUCTIVE CAUSES • Intrinsic – BPH, bladder stones, blood clots • Extrinsic – Masses, cystocele, rectocele
  27. 27. Women Men Obstructive – Cystocele, tumor Obstructive – BPH, Meatal stenosis, Phimosis/paraphimosis, tumor Infectious Infectious Operative Operative
  28. 28. 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
  29. 29. 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?
  30. 30. 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?
  31. 31. TYPES OF CATHETERS Foley Cathetyer Coude Catheter When do you use each catheter? Triple lumen catheter
  32. 32. BLADDER IRRIGATION • What fluid do you use?
  33. 33. 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?
  34. 34. 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.
  35. 35. 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
  36. 36. 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?
  37. 37. QUESTIONS?

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