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ED Urology. Dr Dan Morrissy
- 1. ADVENTURES IN EMERGENCY MEDICINE UROLOGY Daniel Morrissy DO
- 2. TODAY’S TOPICS • Infection • Renal/ureteral Calculi • Urinary Retention
- 3. URINARY TRACT INFECTIONS • Diagnosis and treatment is dependent on the age, sex and commorbities of the patient
- 4. SIGNS AND SYMPTOMS OF UTI • Dysuria • Urgency • Frequency • Polyuria • Suprapubic tenderness • Flank Pain • Fever
- 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. 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. 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. 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. 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. 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. MALE UTI • Differentiate Sexually transmitted disease from UTI • Prostatitis • Epididimitis • Epiditimo-orchitis • Orchitis
- 12. RENAL CALCULI
- 13. RENAL CALCULI
- 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
- 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. 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. 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. 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
- 21. ACUTE URINARY RETENTION • Inability to pass urine voluntarily • Distending bladder causing extreme discomfort
- 22. ETIOLOGY • Pharmacological • Neurological • Infectious/Inflammatory • Obstruction What is the most common presentation in the emergency department?
- 23. PHARMACOLOGICAL CAUSES • Increased sphincter tone or prolonged bladder immotillity • Antiarrhythmics • Anticholinergics • Antidepressants • Antihistamines • Antihypertensives • Antiparkinsonians • Antipsychotics • Muscle Relaxants • Sympathomimetics • Etc…….
- 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. INFECTIOUS CAUSES • Urethritis, Prostatitis, Severe Vulvovaginitis • Genital Herpes – involving the Sacral nerves
- 26. OBSTRUCTIVE CAUSES • Intrinsic – BPH, bladder stones, blood clots • Extrinsic – Masses, cystocele, rectocele
- 27. Women Men Obstructive – Cystocele, tumor Obstructive – BPH, Meatal stenosis, Phimosis/paraphimosis, tumor Infectious Infectious Operative Operative
- 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. 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. 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. TYPES OF CATHETERS Foley Cathetyer Coude Catheter When do you use each catheter? Triple lumen catheter
- 32. BLADDER IRRIGATION • What fluid do you use?
- 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. 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. 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. 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. QUESTIONS?