EM2 GENITOURINARY EMERGENCIES

Required Readings:

Tintinalli Chapters 91, 92, 254,

1.           Explain the following regarding the finding of meatal blood:

a.      What it is associated with including possible fracture

b.      Superiorly displaced prostate

c.       Why the patient should not be catheterized

d.      What diagnostic test is mandatory in this setting

Zen Lite

a. What it is associated with including possible fracture

Urethral injuries

pelvic fractures

b. Superiorly displaced prostate

indicates disruption of the posterior urethra

c. Why the patient should not be catheterized

to prevent the conversion of a partial urethral laceration into a complete transection

d. What diagnostic test is mandatory in this setting

retrograde urethrogram

Zen Seeker Tinitinalli EM Fifth Edition

MEATAL BLOOD

Blood at the meatus is associated with urethral injuries. Urethral injuries are almost exclusively seen in males. Posterior urethral injuries are commonly associated with pelvic fractures. A superiorly displaced prostate indicates disruption of the posterior urethra. Anterior urethral injuries are associated with straddle injuries and instrumentation.

When meatal blood is noted, a urinary catheter should not be placed in order to prevent the conversion of a partial urethral laceration into a complete transection. A retrograde urethrogram is virtually mandatory in this setting.

Ky. Tin p1711-12

a.   What it is associated with including possible fracture:  vast majority due to blunt trauma. (>80% pts with GU injuries to kidney have other concurrent injuries).  Pelvic Fx.

b.   Superiorly displaced prostate:  if riding high or boggy then there has been a disruption of membranous urethra.  Indicates disruption of posterior urethra.

c.   Why the patient should not be catheterized:  not done until urine can be examined for blood.  If blood is noted then no catheter due to concern that a partial laceration will become complete.

d.   What diagnostic test is mandatory in this setting:  (unsure) urinalysis for blood (microscopic vs. gross).  X-ray of pelvis (A-P)

Anonymous Tintinalli  pg. 1711-2

• Associated with urethral injuries. Most exclusively seen in males.

• What it is associated with including possible fracture:

  • Commonly associated with pelvic fractures.  

• Superiorly displaced prostate:

  • Indicates disruption of the posterior urethra.

• Why the patient should not be catheterized:

  • In order to prevent the conversion of a partial urethral laceration into a complete transection.

• What diagnostic test is mandatory in this setting

  • Retrograde urethrogram

Anonymous  Tintinalli  pg. 1711-2

Associated with urethral injuries. Most exclusively seen in males.

What it is associated with including possible fracture:

Commonly associated with pelvic fractures.  

Superiorly displaced prostate:

Indicates disruption of the posterior urethra.

Why the patient should not be catheterized:

In order to prevent the conversion of a partial urethral laceration into a complete transection.

What diagnostic test is mandatory in this setting

Retrograde urethrogram

Anonymous Tintinalli p 1171-1172

A)  What is associated with including possible fracture-  Blood at the meatus is associated with urethral injuries and posterior urethral injuries are commonly associated with pelvic fractures.  

B)  Superiorly displaced prostate- Superiorly displaced prostate indicates disruption of the posterior urethra.

C)  Why the patient should not be catheterized- If meatal blood is noted catheterization should not be attempted in order to prevent the conversion of a partial urethral laceration into a complete transaction.

D)  What diagnostic test is mandatory in this setting- Retrograde Urethrogram

2.           Identify the following regarding hematuria following trauma:

a.      Definition of microscopic hematuria

b.      Why two urine specimens should be obtained

c.       What isolated microscopic hematuria usually signifies

Zen Lite

a. Definition of microscopic hematuria

>5 RBCs per high-power field (hpf)

b. Why two urine specimens should be obtained

initial stream and terminal stream

• Initial hematuria- injury to the distal system (i.e., urethra or prostate)

• Terminal hematuria- bladder neck injury

c. What isolated microscopic hematuria usually signifies

• microscopic hematuria (or even no hematuria) may be seen in renovascular injuries

• Ø significant hemodynamic compromise, unlikely to represent significant blunt injury

Zen Seeker Tinitinalli EM Fifth Edition

HEMATURIA

For the purposes of trauma, microscopic hematuria is defined as more than five red blood cells (RBCs) per high-power field (hpf). A 10-mL specimen must be centrifuged for 5 min at 2000 revolutions for an accurate assessment. Gross hematuria is, of course, readily visible blood. Reddish urine does not necessarily indicate hematuria; several medications and toxic substances may cause discoloration (Table 254-3). Also, results of a dipstick evaluation may be erroneous, since myoglobin, a frequent finding in major trauma, reacts with the reagent.

TABLE 254-3         Substances and Medications Associated with Urinary Discoloration

The initially voided urine may provide clues as to the location of injury. When possible, at least two specimens (initial stream and terminal stream) should be obtained. Initial hematuria suggests injury to the distal system (i.e., urethra or prostate). Terminal hematuria suggests bladder neck injury. Continuous hematuria suggests upper renal system (bladder, ureter, or kidney) injury.

Many studies have demonstrated that, in adult patients with blunt trauma, the degree of hematuria does not correspond to the degree of injury. Gross hematuria may be seen with relatively minor renal contusions, whereas microscopic hematuria (or even no hematuria) may be seen in renovascular injuries. However, in the absence of significant hemodynamic compromise, isolated microscopic hematuria is unlikely to represent significant blunt injury. While there is no clinically validated or generally accepted upper limit of microscopic hematuria beyond which imaging is done, many physicians image patients where the degree of microscopic hematuria is >50 RBCs/hpf. A review of several major studies addressing this question concluded that isolated microscopic hematuria indicates significant injury in about 1 in 500 patients with such a finding.3 Thus, the current consensus is that adult patients with isolated microscopic hematuria do not require further imaging studies. There are three exceptions. When the mechanism of trauma involves rapid deceleration, renal pedicle injuries may ensue but can present with minimal (or even no) hematuria. Also, hematuria in a patient with even transient hypotension should not be considered an isolated finding. Finally, microscopic hematuria may be a significant finding in children, as detailed later in the text.

All patients in whom microscopic hematuria is found with concurrent nonrenal injuires and those with hemodynamic instability should have a diagnostic imaging study, as discussed below. In such patients, computed tomography (CT) is often impractical. A “one-shot” intravenous pyelogram (IVP) can be obtained in the operating room.

Gross hematuria may occur from injury virtually anywhere in the renal tract. The finding of gross hematuria mandates a diagnostic imaging study that is chosen based on other findings (Table 254-4). For example, in the presence of pelvic fractures, gross hematuria should raise the possibility of bladder or urethral injury. Almost 95 percent of bladder injuries are associated with gross hematuria.

Ky. Tin p1712

a.   Definition of microscopic hematuria:  > 5 RBCs per high-power field

b.   Why two urine specimens should be obtained:  Get initial stream and terminal stream.  Initial stream = suggests injury to distal system (urethra or prostate).  Terminal stream = bladder neck injury.  Continuous hematuria suggests upper renal system (KUB) injury.

c.   What isolated microscopic hematuria usually signifies:  renovascular injury.

Anonymous Tintinalli  pg. 1711-2

• Definition of microscopic hematuria: 

  • More than five red blood cells per high-power field.

• Why two urine specimens should be obtained:

  • Initial hematuria suggest injury to the distal system (ie: urethra/prostate).  Terminal hematuria suggests bladder neck injury.  Continuous hematuria suggests upper renal system injury (bladder, ureter, kidney).

• What isolated microscopic hematuria usually signifies

  • May be seen in renovascular injuries

  • Unlikely to represent significant blunt injury

Anonymous  Tintinalli  pg. 1711-2

Definition of microscopic hematuria:  

More than five red blood cells per high-power field.

Why two urine specimens should be obtained:

Initial hematuria suggest injury to the distal system (ie: urethra/prostate).  Terminal hematuria suggests bladder neck injury.  Continuous hematuria suggests upper renal system injury (bladder, ureter, kidney).

What isolated microscopic hematuria usually signifies

May be seen in renovascular injuries

Unlikely to represent significant blunt injury

Anonymous Tintinalli p 1712

A)  Definition of microscopic hematuria- more than five red blood cells per high power field

B)  Why two urine specimens should be obtained- The initial voided urine may provide clues as to the location of injury.  When possible, at least two specimens (initial stream and terminal stream) should be obtained.  

               1.  Initial hematuria suggests injury to the distal system (urethra or prostate)

               2.  Terminal hematuria suggests bladder neck injury

               3.  Continuous hematuria suggests upper renal system (bladder, ureter, or kidney) injury.

C)  What isolated microscopic hematuria usually signifies- revovascular injuries

3.           List the indications for imaging the kidneys using CT and identify a major disadvantage.

Zen Lite

Indications

following blunt trauma

• gross hematuria

• hematuria with multiple injuries or hemodynamic instability

• mechanisms that include rapid deceleration

major disadvantage

performed only in a stable patient

Zen Seeker Tinitinalli EM Fifth Edition

Choice of Radiographic Study for Evaluation and Staging of Renal System Injury

The following should be considered when ordering studies in the trauma patient: (1) intravenous contrast agents can cause false-positive scan results for blood; (2) the total quantity of contrast required may limit the number of contrast studies, especially with shock; (3) hypotensive patients are at risk for developing contrast-induced acute renal failure; (4) abdominal CT reveals more information but requires a hemodynamically stable condition; and (5) an intraoperative IVP during an emergency laparotomy is needed to determine the status of the contralateral kidney.

A guideline for the selection of diagnostic imaging modalities is shown in Table 254-4.

TABLE 254-4         Selection of Diagnostic Imaging for Suspected Renal System Injury

COMPUTED TOMOGRAPHY

Indications for imaging the kidneys following blunt trauma include gross hematuria, hematuria with multiple injuries or hemodynamic instability, and mechanisms that include rapid deceleration. When renal injury is suspected, CT is considered superior to other imaging modalities, including sonography, angiography, or IVP. CT is most likely to allow appropriate staging of renal injury (Table 254-2) and has several advantages. CT is a noninvasive modality with superior imaging detail that allows detection of even minor injuries and minimal extravasation, estimation of extent of hematoma, and simultaneous evaluation of other organs. The major disadvantage is that it can be performed only in a stable patient. Other disadvantages are cost and the difficulty in detecting vascular, particularly venous, injury. In children with hematuria, CT is the radiographic study of choice in evaluating renal injuries because a significant nonrenal intraabdominal injury is more likely than a renal injury.

Certain considerations should be kept in mind. Routine abdominal CT evaluation often stops at the iliac crests. In situations where renal system trauma is under consideration, the examination should be extended to the pelvis. Also, contrast enhancement is usually indicated for appropriate evaluation. Both oral and intravenous contrast material is often given when other intraabdominal trauma is under consideration. However, if enhanced CT is required to image the kidneys and collecting system appropriately, gastrointestinal contrast studies may need to be delayed to allow accurate interpretation.

Ky. Tin p1713

Indications:  Gross hematuria. Hematuria with multiple injuries or hemodynamic instability.  Rapid deceleration injuries.

Disadvantage of CT:  performed only on a stable pt.

Anonymous Tintinalli p. 1713

Indications for imaging the kidneys using CT are following blunt trauma with gross hematuria, hematuria with multiple injuries or hemodynamic instability, and mechanisms that include rapid deceleration.  The major disadvantage of CT is that it can only be performed on a stable pt.

Anonymous   p. 1713

Indications for imaging the kidneys using CT are following blunt trauma with gross hematuria, hematuria with multiple injuries or hemodynamic instability, and mechanisms that include rapid deceleration.  The major disadvantage of CT is that it can only be performed on a stable pt.

Anonymous Tintinalli p 1712

A)  Indications for imaging the kidneys using CT following blunt trauma include:

             1.  Gross hematuria

             2.  Hematuria with multiple injuries or hemodynamic instability

             3.  Mechanisms that include rapid deceleration

B)  Major disadvantage to CT- it can only be performed on a stable patient

4.           Explain how cystography is and briefly how it is done.

Zen Lite

plain-film cystogram is classically used for suspected bladder injuries

~300-500mL (5 mL/kg in children) of contrast media is instilled retrograde into the bladder under gravity from 2ft (60 cm) above the pt

distended bladder view obtained

postdrainage view obtained to note any extravasation not evident on the initial film

Zen Seeker Tinitinalli EM Fifth Edition

CYSTOGRAPHY

For suspected bladder injuries, plain-film cystogram is classically used. About 300 to 500 mL (5 mL/kg in children) of contrast media is instilled retrograde into the bladder under gravity from 2 ft (60 cm) above the patient. At a height of 2 ft, the intravesical pressure generated approximates the physiologic voiding pressure. Unless adequate bladder pressure is generated, the cystogram may be falsely negative. Ideally, the procedure is performed under fluoroscopy to avoid filling the peritoneal cavity with contrast material in the event of a tear. A film of the distended bladder is taken, and a postdrainage view is obtained to note any extravasation not evident on the initial film. Some authorities suggest that the bladder be “washed out” with saline solution prior to obtaining the post-“wash-out” view.

Allowing intravenous contrast material to flow into the bladder following intravenous injection is not considered an appropriate technique,12 although some continue to advocate clamping a urinary catheter to allow antegrade filling of the bladder.13 A CT cystogram may be preferred in a patient who requires intravenous contrast-enhanced CT imaging for other indications.14 However, contrast material must still be injected retrograde.15 Postvoiding scans are generally not required, since CT allows full imaging of the retrovesicular space.

A prospective investigation studying indications for cystography in blunt trauma with hematuria or pelvic fracture concluded that it was appropriate and cost effective to restrict this procedure to patients with gross hematuria only.16 The authors contend that patients with pelvic fracture and microscopic hematuria do not routinely require cystography. 

Urethral injuries are also investigated by retrograde cystography. An unlubricated urinary catheter is placed about 2 to 3 cm into the navicular fossa of the distal urethra, and the balloon is inflated with 1 to 3 mL water. Approximately 20 to 30 mL of contrast material is injected. An oblique view is obtained. The entire length of the urethra is seen on the plain film when the x-ray is taken as the last 10 mL of the contrast solution is injected. Occasionally, a patient may be transferred from another facility with an indwelling urethral catheter in place. A retrograde urethrogram can still be performed without removing the catheter, by injecting contrast solution into the urethra through a small feeding tube placed adjacent to the urethral catheter. 

Urethral injuries should not be investigated in cases of pelvic trauma until it is certain that pelvic angiography or embolization is not required. Also, if the prostate gland was grossly displaced on rectal examination, the urethra is transected, and a retrograde study is not needed, at least not during the initial evaluation.

Ky. Tin p1713-14.  Lab manual p991-93

Use: suspected bladder injuries.  It is a film of the bladder taken with contrast material.  Look for compression or distortion of bladder.  Extravasation is seen in traumatic rupture or perforation.

Procedure:  ~300 ml contrast media instilled retrograde into bladder under gravity from 2 ft above pt (this approximates voiding pressure).  Unless adequate bladder pressure is generated, test may be falsely negative.  A film of distended bladder is taken and postdrainage view is obtained to note any extravasation not evident on initial film.

Anonymous  Tintinallip. 1713-14

Cystography is used for suspected bladder injuries (a plain film cystogram is classically used.)  About 300-500 ml of contrast media is instilled retrograde into the bladder under gravity from 2 ft above the pt.  At a height of 2 ft, the intravesical pressure generated approximates the physiologic voiding pressure.  Unless adequate bladder pressure is generated, the cystogram may be falsely negative.  A film of the distended bladder is taken, and a postdrainage view is obtained to note any extravasation not evident on the initial view.

Anonymous   p. 1713-14

Cystography is used for suspected bladder injuries (a plain film cystogram is classically used.)  About 300-500 ml of contrast media is instilled retrograde into the bladder under gravity from 2 ft above the pt.  At a height of 2 ft, the intravesical pressure generated approximates the physiologic voiding pressure.  Unless adequate bladder pressure is generated, the cystogram may be falsely negative.  A film of the distended bladder is taken, and a postdrainage view is obtained to note any extravasation not evident on the initial view.

Anonymous TIntinalli p 1713

A)  For suspected bladder injuries, plain film cystography is classically used.

B)  About 300 to 500 mL of contrast media is instilled into the bladder under gravity from 2 feet above the patient.  At a height of 2 feet the intravesical pressure generated approximates the physiological voiding pressure.  Unless adequate bladder pressure is generated the cystogram may be falsely negative.  Ideally the procedure is performed under fluoroscopy to avoid filling the peritoneal cavity with contrast material in the event of a tear.  A film of the distended bladder is taken, and a postdrainage view is obtained to note any extravasation not evident on the initial film.  

5.           For kidney injuries, identify:

a.      the significance if the kidneys are injured

b.      how often these are contusions

Zen Lite

a. the significance if the kidneys are injured

Considerable force is generally necessary to cause significant renal injury

b. how often these are contusions

92%

Zen Seeker Tinitinalli EM Fifth Edition

Kidney Injuries

The kidneys are well protected in the retroperitoneal location surrounded by bulky musculature, fascia, and lower ribs. Considerable force is generally necessary to cause significant renal injury. Fractured ribs, vertebral transverse process fractures, flank bruises or hematomas, and hematuria may indicate injury. Contusions account for most (92 percent) renal injuries, with renal lacerations (5 percent), renal pedicle injuries (2 percent), and renal ruptures or shattered kidneys (1 percent) accounting for the rest.

Ky. Tin p1714

a.   the significance if the kidneys are injured:  they are well protected retroperitoneal organs and considerable force is need to cause significant injury.  Fx ribs, vertebral transverse process fx, flank bruises or hematomas and hematuria may indicate renal injury.

b.   how often these are contusions:  92%

Anonymous Tintinalli 1714

¨      Over 90 percent of kidney injuries are constusions. 

Anonymous  Tintinalli, p. 1714:

Renal contusion accounts for over 90% of renal injuries.  

Anonymous Tintinalli p 1714

A)  The significance if the kidneys are injured- The kidneys are vary protected in their retroperitoneal location surrounded by bulky musculature, fascia, and lower ribs so if there is a kidney injury considerable force is necessary.

B)  How often these are contusions- 92%

6.           Briefly explain how the following kidney injuries are usually managed:

a.      Grade I and II

b.      Grade III and IV

Zen Lite

a. Grade I and II

nonoperatively

b. Grade III and IV

admitted to the hospital

Many nonoperatively

Conservative management includes bed rest, hydration, serial hematocrit determinations, monitoring of vital signs, and serial urine specimens to assess the degree of hematuria

The following get surg

• Uncontrolled renal hemorrhage

• Penetrating injuries

• Inadequate staging

• Multiple kidney lacerations

• Shattered (ruptured) kidney

• Avulsed major renal vessel

• Pulsatile or expanding hematoma found on abdominal exploration

• Vascular injuries found early

• Extensive extravasation

Zen Seeker Tinitinalli EM Fifth Edition

TABLE 254-2         Grading of Renal Injuries 4

Kidney

Grade I and II renal injuries (Table 254-2) are usually managed nonoperatively. If there are no other medical considerations, such patients can be treated similarly to those with isolated hematuria. Renal contusions almost always resolve without sequelae unless there is a preexisting renal lesion, such as hydronephrosis, cyst, or tumor. Almost all minor lacerations heal without sequelae with conservative management.

Patients with grade III and IV injuries should be admitted to the hospital. Most of these patients will have other compelling reasons to be admitted or be taken to the operating room. Many stable adult patients with clearly delineated grade III and even grade IV injuries can still be managed nonoperatively.20,21 Many centers attempt nonoperative management for all stable children unless the renal injury is particularly severe or the child fails conservative therapy.8,22 Exploration itself is not without consequence, since it may accentuate considerable hemorrhage. Neither the volume of blood replacement nor the degree of extravasation is an indication for exploration in itself.3 However, if exploration is undertaken for the evaluation of other injuries, repair of renal injuries is usually undertaken. If conservative management is attempted, frequent reassessment is required, and there should be a low threshold for ordering reimaging studies. Conservative management includes bed rest, hydration, serial hematocrit determinations, monitoring of vital signs, and serial urine specimens to assess the degree of hematuria. Patients with gross hematuria remain at bed rest until the gross hematuria resolves and remain at limited activity until microscopic hematuria resolves.

Indications for operative management are listed in Table 254-5.3 Renal rupture is usually explored and nephrectomy usually required. Most, but not all, penetrating injuries are explored. The only widely accepted absolute indication for surgical exploration of a renal injury is persistent retroperitoneal bleeding with hemodynamic instability. As noted, CT may allow adequate staging even for penetrating injuries.18 If the patient has other injuries warranting abdominal exploration, an intraoperative IVP may assist in determining the necessity for retroperitoneal exploration while also giving information regarding function of the contralateral kidney.

TABLE 254-5      Indications for Operative Exploration or Intervention in Renal Injury3

Uncontrolled renal hemorrhage

Penetrating injuries

Inadequate staging

Multiple kidney lacerations

Shattered (ruptured) kidney

Avulsed major renal vessel

Pulsatile or expanding hematoma found on abdominal exploration

Vascular injuries*

Extensive extravasation

* Only those found early (see the text).

Renal pedicle injuries are usually associated with multiple life- threatening injuries, and the safest surgical option is nephrectomy. In a stable patient with an isolated renal pedicle injury, repair should be undertaken within 12 h of the injury if a viable kidney is to result. Thrombosis of segmental arteries is treated conservatively.

Surgical exploration consists of preliminary vascular control, debridement, and surgical repair. Early control of the renal vessels decreases the nephrectomy rate in potentially salvageable kidneys. Nephrectomy, however, may be necessary in unstable patients.

Deb/Tint,pg.1716

Grade I and II-managed nonoperatively (renal contusions almost always resolve without sequelae, almost all minor lacerations heal without sequelae with conservative mgt.

Grade III and IV-pts should be admitted to hospital, stable adult pts with clearly delineated grade III and even grade IV can still be managed nonoperatively (bedrest, hydration, serial hct. Determinations, monitor v.s. and serial urine specimens to assess degree of hematuria, pt with gross hematuria remain on bedrest ti it resolves and remain on limited activity til microscopic hematuria resolves)/if exploration isundertaken for eval. Of other injuries, repair of renal injuries is usually undertaken

sgTint,pg.1712,1716

Table 254-2

Extravasation, def:  the escape of fluids (serum, blood , lymph) into surrounding tissues. Syn: suffusion

*Table 254-5:  Uncontrolled renal hemorrhage, penetrating injuries, inadequate staging, multiple lacerations, ruptured kidney, avulsed major renal vessel, expanding hematoma found, vascular injuries that are seen soon after the occurred,  extensive extravasation.

Anonymous Tintinalli

Grade I and II renal injuries are usually managed non-operatively.  Such patients can be treated similarly to those with isolated hematuria.  Renal contusions almost asways resolve without sequelae unless there is a preexisting renal lesion, such as hydronephrosis, cyst, or tumor.   Almost all minor lacerations heal without sequelae with conservative management.

Anonymous   Tintinalli, p. 1716:

Grade I and II renal injuries (table 254-2) are usually managed nonoperatively.  If there are no other medical considerations, such patients can be treated similarly to those with isolated hematuria.  Renal contusions almost always resolve without sequelae unless there is a preexisting renal lesion.  Almost all minor lacerations heal without sequelae with conservative management.  

Anonymous Tintinalli p 1716

A)  Grade I & II- these are usually managed nonperatively

B)  Grade III & IV- these patients should be admitted to the hospital, and depending on other injuires or severity of symptoms the majority of these can be managed nonoperatively as well.  

7.           Explain what is meant by penile “fracture”, signs and symptoms, and how it is treated.

Zen Lite

Traumatic rupture of the corpus cavernosum of the penis

S/S

• cracking sound is heard

• followed by penile pain

• immediate detumescence

• rapid swelling

• discoloration

• distention

Tx

immediate surgical evacuation of blood clot and repair of the torn tunica albuginea of the corpus cavernosum and urethra

Zen Seeker Tinitinalli EM Fifth Edition

Injuries to the Penis

Self-inflicted injuries of the penis include vacuum cleaner injuries and blade injuries. Vacuum cleaners cause extensive injury to the glans penis and some loss of the urethra, requiring debridement of devitalized tissue and reconstruction. Blade injuries range from superficial lacerations to complete amputation. Amputation of the penis is managed by reimplantation or local repair. Reimplantation is preferable if the distal penis is in satisfactory condition, and the ischemia time is less than 12 to 18 h. Loss of penile skin by avulsion injury or burns is managed by split-thickness skin grafts after the denuded penis is clean and uninfected. The avulsed skin should not be reapplied, for it invariably becomes necrotic and infected and must be subsequently removed.

Traumatic rupture of the corpus cavernosum of the penis or fracture of the penis occurs when the erect penis impacts forcibly on a hard object (sexual partner´s pubis or the floor), receives a direct blow, or is subjected to abnormal bending. A cracking sound is heard, followed by penile pain, immediate detumescence, rapid swelling, discoloration, and distention. Urethral injuries may accompany penile ruptures. Penile ruptures are managed by immediate surgical evacuation of blood clot and repair of the torn tunica albuginea of the corpus cavernosum and urethra.

FRACTURE OF THE PENIS

An acute tear or rupture of the corpus cavernosa tunica albuginea is rare but easily diagnosed. The penis is acutely swollen, discolored, and tender. The history is of trauma during intercourse or other sexual activity, when a sudden “snapping sound” occurs. Even though the urethra is infrequently injured, a retrograde urethrogram may be necessary to assure urethral integrity. Surgical treatment consists of hematoma evacuation and suture apposition of the disrupted tunica albuginea.

Deb/Tint.pg 1717

Fx of penis is traumatic rupture of corpus cavernosum of penis when the erect penis impacts forcibly on a hard object, receives a direct blow, or is subjected to abnormal bending

SX-(don’t read if your squeamish-ouch!) a cracking sound is heard, followed by penile pain, immediate detumescence, rapid swelling, discoloration and distention

TX-immediate surgical evacuation of blood clot and repair of torn tunica albuginea of the corpus cavernosum and urethra.

Sg Tint.pg 634

Penile Fracture, def:  acute  rupture of the corpus cavernosum  tunica albuguinea.  History of trauma during intercourse or other sexual activity, when sudden "snapping" sound occurs.

Signs/Symptoms:  Acute swelling, discoloration, and tenderness.  Urethral injuries can accompany penile ruptures.  

Tx:  Surgical removal of clot, repair of urethra (if involved) and suture apposition of torn tunica albuginea of the corpus cavernosum

Anonymous Tintinalli 1717

• Penile fracture is a term used to describe the traumatic rupture of the corpus cavernosum of the penis and occurs when the erect penis impacts forcibly on a hard object (sexual partner’s pubis or the floor), receives a direct blow (not my choice of words), or is subjected to abnormal bending.

• A cracking sound is heard, followed by penile pain, immediate detumescence, rapid swelling, discoloration, and distention.  Urethral injuries may accompany penile ruptures.  

• These injuries are managed by immediate surgical evacuation of blood clots and repair of the torn tunica albuginea of the corpus cavernosum and urethra.

Anonymous  

Happens when erect penis impacts forcibly on hard object (partners pubis, floor), or receives a direct blow or is subjected to abnormal bending. A cracking sound is heard, followed by penile px, immediate loss of erection (detumescence), rapid swelling, discoloration and distention.

Immediate surgical evacuation of blood clot and repair or torn tunica albuginea of the corpus cavernosum and urethra is required. Tintinalli pg 1717

Anonymous Tintinalli p 1717

A)  Penile Fracture- traumatic rupture of the corpus cavernosum, occurring when the erect penis impacts forcibly on a hard object (sexual partners pubis) receives a direct blow, or is subjected to

abnormal bending.

B)  Signs and Symptoms Include:

             1.  cracking sound heard followed by penile pain

             2.  Immediate detumescence

             3.  Rapid swelling

             4.  Discoloration

             5.  Distention

C)  Treatment- Penile ruptures are managed by immediate surgical evacuation of blood clot and repair of the torn tunica albuginea of the corpus cavernosum and urethra.  

8.           Explain how to manage a zipper injury to the penis.

Zen Lite

Mineral oil and lidocaine

or wire-cutting or bone-cutting pliers are used to divide the median bar (or diamond) of the zipper, which causes the zipper to fall apart

Zen Seeker Tinitinalli EM Fifth Edition

Zipper injury to the penis is caused when the penile skin is trapped in the trouser zipper. Mineral oil and lidocaine infiltration are useful in freeing the penile skin from the zipper. Otherwise, wire-cutting or bone-cutting pliers are used to divide the median bar (or diamond) of the zipper, which causes the zipper to fall apart, freeing the penile skin.

Contusions of the perineum or penis, which can result from straddle or toilet seat injuries, are treated conservatively with cold packs, rest, and elevation. If the patient is unable to void, catheter drainage is elected.

Deb/Tint.pg.1717

Mineral oil and lidocaine infiltration are useful in freeing penile skin from zipper, otherwise the jaws of life-wire cutting or bone cutting pliers are used to divide the median bar of the zipper which causes the zipper to fall apart.

Sg Tint.pg.1717

Lubricant and lidocaine to ease skin from zipper, or pry zipper open (ouch)

Anonymous Tintinalli 1717

Mineral oil and lidocaine infiltration are useful in freeing the penile skin from the zipper.  In some cases, wire-cutting or bone-cutting pliers are used to cut the zipper and free the penile skin.

Anonymous  Tintinalli pg 1717

(gently)Mineral oil and lidocaine can be tried in attempt to “set the penis free” , wire cutters or bone cutters (pliers) are used to divide the median  bar (or diamond) of the zipper, so it will separate, freeing the penile skin.

Anonymous Tintinalli p 1717

A)  Mineral oil and lidocaine infiltration are useful in freeing the penile skin from the zipper.  If the penile tissue cannot be freed wire cutting or bone cutting pliers are used to divide the median bar of the zipper.  

9.           Briefly describe the following disorders and how they are managed:

a.      Simple scrotal abscess of a hair follicle

b.      Fournier’s gangrene

c.       Phimosis

d.      Paraphimosis

e.      Orchitis

Zen Lite

a. Simple scrotal abscess of a hair follicle

• hair-follicle scrotal-wall abscess - incision and drainage

• Contiguous involvement scrotal skin by inflammatory mass in the testis or epididymis -ultrasound, retrograde urethrogram, refer urologist

b. Fournier’s gangrene

polymicrobial, synergistic infection of the subcutaneous tissues that originates from one of three sites: skin, urethra, or rectum

• fluid resuscitation

• gram-positive, gram-negative, and anaerobic antibiotic coverage

• wide surgical debridement

• sometimes in conjunction with pre- and postoperative hyperbaric oxygen therapy

c. Phimosis

inability to retract the foreskin proximally and posterior to the glans penis

• Hemostatic dilation of the preputial ostium relieves the urinary retention

• dorsal slit or circumcision

d. Paraphimosis

inability to reduce the proximal edematous foreskin distally over the glans penis into its naturally occurring position

urologic emergency

• compression of the glans for several minutes to reduce edema and allow for successful reduction

• Tightly wrapping the glans with a ×2-inch elastic bandage for 5 min is one method to reduce edema

• several puncture wounds with a small needle (22 to 25 g) can help edema fluid be expressed out

• local anesthetic block

• local infiltration of the constricting band with 1% plain lidocaine followed by superficial vertical incision of the band will decompress the glans

e. Orchitis

inflammation of the testicle

symptomatic and disease-specific with urologic F/U

Zen Seeker Tinitinalli EM Fifth Edition

SCROTAL ABSCESS

The important distinction with a scrotal abscess is whether the phlegmon is localized to the scrotal wall, i.e., simple hair follicle abscess, or involves, and even perhaps originates from, infection in one of the primary intrascrotal organs, i.e., testis, epididymis, bulbous urethra. This distinction can be very difficult late in the course of the disease process when a scrotal mass may be the only discernible finding.

A simple hair-follicle scrotal-wall abscess can be managed by incision and drainage. Oftentimes wound care can be simplified by circumferential excision of the entire roof of the abscess. This allows access for wound care and sitz baths and assures healing from the base outward. Antibiotics are rarely needed in an immunocompetent male.

Contiguous involvement of the scrotal skin by an inflammatory mass in the testis or epididymis is best evaluated by ultrasound. A retrograde urethrogram will delineate the integrity of the urethra. Definitive care of any complex abscesses should be directed by a urologist.

FOURNIER´S GANGRENE

Fournier´s gangrene is a polymicrobial, synergistic infection of the subcutaneous tissues that originates from one of three sites: skin, urethra, or rectum. This infectious process typically begins as a benign infection or simple abscess that quickly becomes virulent, especially in an immunocompromised host, and leads to end-artery thrombosis in the subcutaneous tissue that promotes widespread necrosis of previously healthy tissue (Fig. 91-4).

A patient with Fournier´s gangrene of the scrotum. Note the sharp demarcation of gangrenous changes and the marked edema of the scrotum and the penis.

The diabetic male seems to be most at risk. Prompt recognition of Fournier´s gangrene in its early stages should prevent extensive tissue loss that accompanies delayed diagnosis. Aggressive fluid resuscitation; gram-positive, gram-negative, and anaerobic antibiotic coverage; and wide surgical debridement sometimes in conjunction with pre- and postoperative hyperbaric oxygen therapy are the mainstays of treatment. Urologic consultation is often required when periurethral abscess is the inciting event, or when other etiologies have secondarily invaded the urinary tract and supravesical urinary drainage is needed. It is imperative that emergency physicians maintain a very high index of suspicion for this entity in immunocompromised patients who present complaining of scrotal, rectal, or any genitalia pain out of proportion to their physical examination findings. Surgical consultation is strongly recommended in all such patients, rather than deciding on symptomatic treatment and discharge from the emergency department.

Phimosis and paraphimosis. (The lower figure depicts the
method of reduction.)

PHIMOSIS

Phimosis is the inability to retract the foreskin proximally and posterior to the glans penis (Fig. 91-5). Causes include infection, poor hygiene, or previous preputial injury with scarring. Scarring at the tip of the foreskin can occlude the preputial meatus, infrequently causing urinary retention. Hemostatic dilation of the preputial ostium relieves the urinary retention until definitive dorsal slit or circumcision can be done.

PARAPHIMOSIS

Paraphimosis is the inability to reduce the proximal edematous foreskin distally over the glans penis into its naturally occurring position (Fig. 91-5). The resulting glans edema and venous engorgement can progress to arterial compromise and gangrene.

Paraphimosis is a true urologic emergency. Paraphimosis can often be reduced by compression of the glans for several minutes to reduce edema and allow for successful reduction of the foreskin back over the now smaller glans. Tightly wrapping the glans with a ×2-inch elastic bandage for 5 min is one method to reduce edema. Infrequently, several puncture wounds with a small needle (22 to 25 g) can help edema fluid be expressed out the glans. A local anesthetic block of the penis is also helpful if the patient cannot tolerate the pain of compression. If these methods are unsuccessful, local infiltration of the constricting band with 1% plain lidocaine followed by superficial vertical incision of the band will decompress the glans and allow foreskin reduction. This procedure should be done by an emergency physician unless a urologist is immediately available.

ORCHITIS

Isolated orchitis, or inflammation of the testicle, is quite rare. It usually occurs in conjunction with other systemic diseases, such as mumps, other viral illnesses, or syphilis. Orchitis usually presents as bilateral testicular tenderness and swelling over a few days´ duration. Treatment is symptomatic and disease-specific with urologic follow-up.

Deb/Tint.pg 633

Scrotal abscess-if the phlegmon is localized to the scrotal wall, managed by incision and drainage, often wound care can be simplified by circumferential excision of entire roof of the abscess.  Antibiotics rarely needed

Fournier’s gangrene-polymicrobial synergistic infection of subc. tissues that originates from one of three sites-skin urethra, or rectum, begins as benign infection or abscess that quickly becomes virulent, leads to end-artery thrombosis in subc. tissue that promotes widespread necrosis/tx-prompt recognition to prevent extensive tissue loss, aggressive fluid resuscitation, gram pos,neg, and anaerobic antibiotic coverage, and wide surgical debridement sometimes in conjunction with pre and postop hyperbaric oxygen therapy

Phimosis-inability to retract foreskin proximally and posterior to glans penis/tx by definitive dorsal slit or circumcision

Paraphimosis-inability to reduce proximal edematous foreskin distally over the glans penis into its naturally occurring position/tx-true urologic emergency, reduced by compression of glans for several minutes to reduce edema and allow successful reduction, tightly wrapping glans with a X2-inch elastic bandage for 5 min. is one method to reduce edema, if unsuccessful, local infiltration of constricting band with lidocaine followed by superficial vertical incision of band will decompress the glans and allow reduction of foreskin.

Orchitis-(pg.637) inflammation of testicle/tx-symptomatic and disease specific with urologic followup.

Sg Tint

Anonymous Tintinalli 633-637

•        Simple scrotal abscess of a hair follicle - can be managed by incision and drainage.  Wound care can be simplified by circumferential excision of the entire roof of the abscess.  This allows access for wound care and sitz baths and assures healing from the base outward.  Antibiotics are rarely needed in the immunocompetent patient.

•        Fournier’s gangrene - is a polymicrobial synergistic infection of the subcutaneous tissues that originates from one the three sites: skin, urethra, or rectum.  The infection process typically begins as a benign infection or simple abscess and quickly turns virulent, especially in an immunocomprimised patient, and leads to end artery thrombosis in the subcutaneous tissue that promotes widespread necrosis of previously healthy tissue.  Rapid diagnosis in its early stages should prevent extensive tissue loss that accompanies delayed diagnosis.  Treatment involves aggressive fluid resuscitation, gram+, gram-, and anaerobic antibiotic coverage, wide surgical debridement sometimes with pre and postoperative hyperbaric oxygen therapy.

•        Phimosis - is the inability to retract the foreskin proximally and posterior to the glans penis.  Causes include infection, poor hygiene, or previous preputial injury with scarring.  Hemostatic dilation of the preputial ostium relieves urinary retention until definitive dorsal slit or circumcision can be done.

•        Paraphimosis - is the inability to reduce the proximal edematous foreskin distally over the glans penis into in naturally occurring position.  The edema and venous engorgement can progress into arterial compromise and gangrene.  Paraphimosis is a true urologic emergency.  Compression of the glans for several minutes to reduce edema and allow for successful reduction of the foreskin back over the now smaller glans.  One method of accomplishing this is by wrapping the glans with a 2-inch elastic bandage for 5 min. to reduce edema.  Infrequently, small punctures with a needle can help edema fluid be expressd out of the glans.  A local anesthetic block is helpful for pain control.   If these methods are unsuccessful, 1% lidocaine followed by superficial vertical incision of the bad will decompress the glans and allow foreskin reduction.  This should be done by ER physician unless a urologist is immediately available.

•        Orchitis - usually occurs in conjunction with other systemic diseases such as mumps, other viral illnesses, or syphilis.  It usually presents as bilateral testicular tenderness and swelling over a few days duration.  Treatment is symptomatic and disease-specific with urologic follow-up.

Anonymous  Tintinalli pgs 633-637

Simple scrotal abscess of a hair follicle - abscess localized to the wall of scrotum. I&D (incision and drainage) performed or circumferential excision for easier access for wound care: sitz baths and healing from deep to superficial layer. Rarely are anti-biotics needed.

Fournier’s gangrene - polymicrobial synergistic infection. Originates from either skin, urethra or rectum. Typically begins as benign process or abscess - quickly becomes virulent, especially in immuno-compromised host. Leads to artery thrombosis in subQ-tissue that promotes widespread necrosis (picture pg. 633). Diabetic male most at risk. Prompt recognition in early stages should prevent extensive tissue loss (that accompanies delayed diagnosis). Aggressive fluid replacement, AB that covers G+, G- and anaerobic given. Wide surgical debridement sometimes in conjunction with pre-post hyperbaric O₂ therapy. Urologic consult with urethral involvement if supra vesicular            urine drainage needed. Be aware of scrotal, rectal or any genital px that is out of proportion to PE findings!

Phimosis - inability to retract foreskin back over glans penis. Causes: infection, poor hygiene, previous injury or scarring. Treatment: dorsal slit, circumcision.

Paraphimosis - Inability/failure to reduce the proximal foreskin back to original position distal over glans penis, resulting in glans edema and engorgement - can lead to compromise and gangrene. This is a true urologic emergency! Compression of the glans, wrapping the glans with 2” tape x5 min., several puncture wounds in glans occasionally release enough pressure/fluid for glans size reduction. Local anesthetic block for pt px control. If unsuccessful, local anesthetic and small surgical incision vertically in foreskin band will decompress the glans and allow reduction. Should be done by ED MD unless urologist immediately available.

Orchitis - Inflammation of testicle - usually occurs in conjunction with other systemic dz (ie. mumps, viral illness or syphilis). Usually presents as bilat. testicular tenderness and swelling  x few days. Treatment for symptoms and specific dz. Urologic F/U

Anonymous Tintinalli p 633

A)  Simple scrotal abscess of a hair follicle- this abscess is localized in the scrotal wall and can be managed simply by incision and drainage.  Often times wound care can be simplified by total excision of the entire roof of the abscess.  

B)  Fournier’s Gangrene- this is a polymicrobial synergistic infection of the subcutaneous tissues that originates from the skin, urethra or rectum.  This infection typically begins as a simple abscess or benign infection and quickly becomes virulent.  Aggressive fluid resuscitation along with gram negative, gram positive, and anaerobe antibiotic coverage, wide surgical debridement sometimes in conjunction with pre and postoperative hyperbolic oxygen therapy are the mainstays of treatment.

C)  Phimosis- This is the inability to retract the foreskin proximally and posterior to the glans penis.  Hemostatic dilation of the preputial ostium relieves urinary retention until definitive dorsal slit or circumcision can be done.

D)  Paraphimosis- This is the inability to reduce the proximal edematous foreskin distally over the glans penis into its naturally occurring position.  This is a true urologic emergency and can often be reduced by:

             1.  Applying compression to the glans for several minutes to reduce edema and allow for successful

                 reduction of the foreskin.  

             2.  Infrequently several puncture wounds made to the glans with a small 22 to 25 gauge needle allow for

                 fluid to be expressed out of the glans allowing enough reduction in edema to reduce the foreskin.  A local

                 anesthetic block should be performed if this method is utilized.  

             3.  If these methods are not successful, local infiltration of the constriction band with with 1% plain

                  lidocaine followed by superficial vertical incision will decompress the glans and allow reduction.

E)  Orchitis- isolated inflammation of the testicle is quite rare and often occurs in conjunction with other systemic illnesses.  Treatment is symptomatic and disease specific with urologic follow up.

10.       Define priapism and how it typically presents.  List common causes.  Identify the medication that is used first-line for treatment.

Zen Lite

urologic emergency that presents as a painful, hard, pathologic erection in which both corpora cavernosa are engorged c stagnant blood

Reversible Causes

• Sickle cell anemia

• Iatrogenic injection of PGE1, papaverine, or phentolamine for impotence

• Leukemic infiltration

Nonreversible Causes

• Idiopathic

• High spinal cord lesion

• Medications (phenothiazines, hydralazine, prazosin)

Tx:

Terbutaline, 0.25-0.5mg SQ deltoid muscle

Zen Seeker Tinitinalli EM Fifth Edition

PRIAPISM

Priapism is a urologic emergency that presents as a painful, hard, pathologic erection in which both corpora cavernosa are engorged with stagnant blood. Even though the glans penis and the corpus spongiosum are characteristically soft and uninvolved, urinary retention may develop. Impotence has been reported to occur in 35 percent of cases who have sustained erections for prolonged periods of time; thus, expedient treatment and early urologic consultation is required. The potential for medical-legal liability mandates meticulous documentation in these cases.

A large number of cases of priapism in adults are pharmacologically related, either to intracavernosal injection for impotence or oral agents for hypertension or mental disorders. Most cases of priapism in children are due to hematologic disorders, usually sickle cell disease. Case reports have attempted to relate a variety of other drugs, metabolic conditions, and trauma to priapism, although the pathophysiologic mechanisms are speculative in most cases.

Priapism is classified into high-flow (nonischemic) priapism and low-flow (ischemic) priapism. The former is rare, most often nonpainful, and usually results from traumatic fistulae between the cavernosal artery and the corpus cavernosum. The latter is more common, is usually quite painful, and is diagnosed by the aspiration of dark acidic intracavernosal blood from the corpus cavernosum.

Low-flow priapism is further categorized as reversible or nonreversible depending upon etiology and the response to medical treatment (Table 91-1). Regardless of specific etiology, initial therapy with terbutaline, 0.25 to 0.5 mg subcutaneously in the deltoid area, repeated in 20 min as needed, is the most effective therapy. Traditional therapies of sedation or ice water enemas are ineffective. Pseudoephedrine 60 to 120 mg orally has been reported effective in some cases that present early (less than 4h). Priapism due to sickle cell disease is most consistently reversed by simple or exchange transfusion. Corporal aspiration followed by irrigation (either with plain saline or with α-adrenergic agonists, i.e., phenylephine (neosynephrine)) is the primary treatment method for persistent priapism. The urologic consultant usually performs this procedure, but if one is not readily available, the emergency physician may need to intervene. Reversible priapism may respond to these treatments, while nonreversible priapism usually does not respond and requires surgery.

TABLE 91-1      Causes and Treatment of Low-Flow Ischemic Priapism

Reversible Causes

A. Sickle cell anemia

Treatment: Terbutaline, 0.25-0.5 mg subcutaneously in the deltoid muscle; packed red blood cell transfusion; hydration and alkalization may be beneficial

B. Iatrogenic injection of PGE1, papaverine, or phentolamine for impotence

Treatment: Terbutaline, 0.25-0.5 mg subcutaneously in the deltoid muscle; aspirate 30-70 mL corporal blood, then inject 30-70 mL phenylephrine 20 mg/mL (10 mg in 500 mL normal saline), maximum dose = 1500 mg

C. Leukemic infiltration

Treatment: Terbutaline, 0.25-0.5 mg subcutaneously in the deltoid muscle; specific chemotherapy

Nonreversible Causes

A. Idiopathic

B. High spinal cord lesion

C. Medications (phenothiazines, hydralazine, prazosin)

Treatment of all nonreversible causes: Terbutaline, 0.25-0.5 mg subcutaneously in the deltoid muscle; corporal aspiration, phenylephrine instillation; heparin irrigation; shunt surgery

Deb/Tint.pg 634

Priapism is urologic emergency, presents as painful, hard, pathologic erection in which both corpora cavernosa are engorged with stagnant blood, there is high-flow (nonischemic) and low-flow (ischemic) priapism/high flow is rare usually cause by traumatic fistulae between cavernosal artery and corpus cavernosum/low flow has reversible causes (sickle cell anemia, iatrogeinic injection of PGE1, papaverine, or phentolamine for impotence, or leukemic infiltration) nonreversible causes (idiopathic, high spinal cord lesion, or meds-phenothiazines, hydralazine, or prazosin)/Tx-initial therapy with terbutaline 0.25 to 0.5mg subc. repeated q 20 min. as needed is most effective therapy.

Sg Tint.p634 ( Priapism added to chart in question 4)

Anonymous Tintinalli 634

• Priapism is a painful hard, pathologic erection in which both corpora cavernosa are engorged with stagnant blood.  This a urologic emergency.

• Common causes include:  pharmacologically related either by intracavernosal injection for impotence or oral agents for HTN or mental disorders.  In children most cases are caused by a hematologic disorder, like sickle cell disease.

• Terbutaline 0.25mg to 0.5mg subq in the deltoid area repeated in 20 min is the most effective therapy.

Anonymous  

Urological emergency that usually presents as a painful, hard, pathologic erection in which both corpora cavernosa are engorged with stagnant blood.

Common causes- adults mostly pharmacologically related (intracavernosal injection for impotence, oral agents for HTN or psych drugs). In children usually due to hematologic disorders, esp. sickle cell disease. (Tintinalli, p. 634)

Anonymous Tintinalli p 634

A)  Priaprism- this is a urologic emergency that presents as a painful, hard, pathologic erection in which both corpa cavernosa are engorged with stagnant blood.

B)  Common causes of priaprism include:

1.  Pharmacologically related side effect of hypertensive or mental illness medications

2.  Hematologic disorders:  sickle cell disease

3.  Metabolic causes

4.  Trauma

C)  Medication used first line- Terbutaline 0.25-0.5 mg subcutaneously in the deltoid repeated every 20 minutes as needed is the most effective therapy and utilized regardless of etiology.

11.       Identify or describe the following regarding testicular torsion:

a.      At what age it most commonly occurs

b.      What frequently precedes the torsion

c.       How it presents

d.      Manual detorsion

Zen Lite

a. At what age it most commonly occurs

• puberty in conjunction with maximal hormonal stimulation

• it may occur at any age

b. What frequently precedes the torsion

athletic event, strenuous physical activity, or trauma just prior to the onset of scrotal pain

c. How it presents

• occurs suddenly

• is severe

• usually felt in one of the following

  • either lower ABD quadrant

  • inguinal canal

  • testis

• not positional in nature

d. Manual detorsion

initially be done in a medial→lateral

detorsion is a painful

done in a manner similar to opening a book

Zen Seeker Tinitinalli EM Fifth Edition

TESTICULAR TORSION

The differential diagnosis of acute scrotal pain includes testicular torsion, torsion of the appendix testis, appendix epididymis, and epididymitis. Testicular torsion must be the primary consideration (Fig. 91-7). While the peak incidence of intravaginal torsion occurs at puberty in conjunction with maximal hormonal stimulation, it may occur at any age.

Torsion of the testis or spermatic cord results from bilateral maldevelopment of fixation between the enveloping tunica vaginalis and the posterior scrotal wall. Characteristically, the at- risk testis is aligned along a horizontal rather than a vertical axis. The axis of alignment can be determined only with the patient in an upright position, and even then the determination may be difficult.

Frequently there is a history of an athletic event, strenuous physical activity, or trauma just prior to the onset of scrotal pain. However, a fair number occur during sleep. Unilateral cremaster muscle contraction results in testicular torsion. The pain usually occurs suddenly, is severe, and is usually felt in either lower abdominal quadrant, the inguinal canal, or the testis. While the pain may be constant or intermittent, it is not positional in nature as testicular torsion is primarily an ischemic event that becomes inflammatory only after the testis has infarcted.

In obvious cases of testicular torsion, emergent urologic consultation and surgical exploration are recommended. The often quoted 4-h warm-ischemia time for testicular salvage comes from controlled animal studies and cannot be extrapolated to clinical medicine. There are no readily available clinical or laboratory parameters to judge either the degree or the duration of testicular ischemia. Therefore, no matter how long the patient has been symptomatic and no matter what the presenting physical examination suggests, if testicular torsion cannot be excluded by history and physical examination, emergency scrotal exploration is the definitive diagnostic test and procedure of choice.

Color-flow duplex Doppler ultrasound and radionuclide scintigraphy are two imaging modalities used to evaluate patients with indeterminate clinical presentations. Both may be useful, but their routine clinical use is limited by timely availability and operator experience in interpreting the images. These studies are considered “positive” for testicular torsion when they demonstrate absent or clearly reduced blood flow to the painful side when compared to the opposite testicle, and “negative” when flow is normal or increased. Both studies have nearly identical reported sensitivity (80 to 90 percent) and specificity (75 to 95 percent) for testicular torsion. Ultrasound has the advantage of demonstrating scrotal anatomy (which may indicate alternate diagnosis) but has the disadvantage of the greater number of indeterminate results when compared to scintigraphy. Within these limitations, both modalities may be useful when promptly available for patients with unclear clinical presentations but should never delay attempted manual detorsion and scrotal exploration.

While awaiting transportation of the patient to the operating room, the emergency physician should attempt manual detorsion of the affected testis. Most testes torse in a lateral to medial fashion. Therefore, detorsion should initially be done in a medial to lateral motion. It must be explained to the patient that detorsion is a painful procedure and while local anesthesia of the affected spermatic cord can initially make the patient more comfortable, it also removes an important endpoint of the detorsion maneuver, i.e., relief of pain. Detorsion is done in a manner similar to opening a book (Fig. 91-8). If one were to stand at the patient´s feet, the patient´s right testis would be rotated in a counterclockwise fashion (Fig. 91-9); the patient´s left testis in a clockwise fashion (Fig. 91-10). Any relief of pain is a positive endpoint. A worsening of the patient´s pain would dictate that detorsion be done in the opposite direction. Successful detorsion converts an emergent procedure to an elective one, but one that must be done to correct a potential bilateral anatomic disaster. The timing of the elective surgical correction should depend on the patient´s compliance and responsibility.

Testicular detorsion. This procedure is best done standing at the foot of or on the right side of the patient´s bed. The torsed testis is detorsed in a fashion similar to opening a book (Fig. 91-8). That is, the patient´s right testis is rotated counterclockwise (Fig. 91-9), the left testis is roated clockwise (Fig. 91-10).

Young boys may present to the emergency department with nonspecific abdominal pain suggestive of gastroenteritis only to return one to two days later with testicular torsion. Whether these patients had undisclosed testicular torsion at their initial evaluation is not known, but emergency physicians must think about testicular torsion in the differential diagnosis of any male presenting with a complaint of abdominal pain!

Brent Tin 635, CMDT 906

a.   Although peak incidence occurs at puberty in conjunction with maximal hormonal stimulation, it can also occur at any age.

b.   Frequently there is a HX of an athletic event, strenuous physical activity, or trauma just prior to the onset of scrotal pain.  However, it can occur during sleep.

c.   Presents with severe pain that occurs suddenly in the lower abdominal quadrant, the inguinal canal, or the testis.  Pain may be constant or intermittent and isn’t positional in nature.  Inflammation may be a result of infarction of the testis.  Exam reveals a painful testis that may have a “high lie” in relation to the other testis.

d.   Most testes torse in the lateral to medial fashion.  Therefore, manual detorsion should initially be done in a medial to lateral motion.  Standing @ the patient’s feet, the right testis would be rotated in a counterclockwise direction and the left testis in a clockwise direction.  Increasing pain would indicate that detorsion be done in the opposite direction.  If manual detorsion is successful, patient still needs elective surgery to correct anatomy.  If unsuccessful, an emergent urology consult for surgery is necessary.

Jam, Tint 635

a.   At what age it most commonly occurs - peak incidence at puberty in conjunction with maximal hormonal stimulation, but may occur at any age

b.   What frequently precedes the torsion - hx of an athletic event, strenuous physical activity, or trauma

c.   How it presents - pain usually occurs suddenly, is severe, and is usually felt in either lower abdominal quadrant, the inguinal canal, or the testis. Young boys may present with nonspecific abdominal pain suggestive of gastroenteritis.

d.   Manual detorsion - most testes torse in a lateral to medial fashion, so detorsion should initially be done in a medial to lateral motion. Anesthesia is not given because the endpoint of detorsion is relief of pain. Standing at the patients’s feet, the right testis is rotated in a counterclockwise fashion; the left one in a clockwise direction. If pain worsens, turn in the opposite direction.

Anonymous Tintinalli 635

• At what age it most commonly occurs - puberty, although it can occur at any age

• What frequently precedes the torsion - there is often a history of athletic event, strenuous physical activity, or trauma just prior to the development of scrotal pain.

• How it presents - usually presents with the above hx followed by sudden onset of pain that is severe and usually felt in either lower abd quadrant, the inguinal canal or the testis.  The pain may be constant or intermittent, but is not positional. This is a urologic emergency.

• Manual detorsion - Is done while awaiting urology.  Most torsions are in a lateral to medial fashion.  Detorsion should initially be done in a medial to lateral motion.  This is a painful procedure and must be explained to the patient.  Relief of pain is a positive endpoint.  An increase in pain indicates detorsion needs to done in the opposite direction.  Successful detorsion converts  emergent surgical procedure into an elective one.

Anonymous  

Age it most commonly occurs- most occur at puberty with maximal hormonal stimulation.

What frequently precedes the torsion-there is frequently a history of an athletic event or strenuous physical activity or trauma just prior to the event. May occur during sleep as well.

How it presents-The pain occurs suddenly, is severe and is felt in either lower abdominal quadrant. It is usually constant pain and not affected by position change( as it is ischemic in nature)

Manual detorsion-Most testes torse lateral to medial therefore detorsion should initially be done medial to lateral. Tintinalli 635

Anonymous Tintinalli p 635

A)  At what age it most commonly occurs- peak incidence at puberty in conjunction with maximal hormonal stimulation

B)  What frequently precedes the torsion- Frequently history of an athletic event, strenuous physical activity, or trauma prior to onset of scrotal pain.

C)  How it presents- Onset of scrotal pain after one of these athletic or strenuous activities that may be constant or intermittent.  This is not positional in nature as it is an ischemic event.  The testicle effected will often be higher in the scrotum that the unaffected side and extremely painful to touch.

D)  Manual Detorsion- While awaiting surgical intervention the emergency physician should attempt manual detorsion.  Most testes torse in a lateral to medial fashion.  Therefore, detorsion should be attempted in a medial to lateral motion.  It must be explained to the patient that this is an extremely painful procedure.  Any relief of the pain is a positive end point.

12.       Explain the following regarding epididymitis:

a.      How the onset of pain differs from testicular torsion

b.      Common cause under age 40

c.       Common cause over age 40

d.      What other cause to consider in gay men  Dropped 2004

e.      What typically relieves the pain

Zen Lite

a. How the onset of pain differs from testicular torsion

usually more gradual than that of testicular torsion because of its inflammatory etiology

b. Common cause under age 40

STDs

c. Common cause over age 40

urinary pathogens (Escherichia coli, Klebsiella)

d. What other cause to consider in gay men

fungal infection of the lower urinary tract in addition to the more common STDs

e. What typically relieves the pain

• narcotics

• may note transient relief pn in recumbent position c scrotal elevation

Zen Seeker Tinitinalli EM Fifth Edition

EPIDIDYMITIS

The onset of pain in epididymitis or epididymo-orchitis is usually more gradual than that of testicular torsion because of its inflammatory etiology. Bacterial infection is the most common cause and tends to be age-dependent. In young boys with documented epididymitis or epididymo-orchitis, congenital anomalies of the lower urinary tract in addition to chemical epididymitis secondary to retrograde reflux of sterile urine into the globus minor (tail of the epididymis) must be considered. In patients less than 40 years of age, epididymitis is primarily due to sexually transmitted diseases (STDs) or their complications, i.e., urethral stricture. In gay men with epididymitis or epididymo-orchitis, fungal infection of the lower urinary tract in addition to the more common STD organisms must be considered. In patients over 40 years of age, epididymitis is caused by common urinary pathogens such as Escherichia coli and Klebsiella. These patients will most often have pyuria on urinalysis, but the absence of white cells or bacteria does not exclude the diagnosis. Older men with epididymitis due to infected urine must be evaluated for the cause of their lower urinary tract infection, i.e., benign prostatic hypertrophy (BPH) or urethral stricture disease. Oftentimes the answer may be found by passing a 14F or 16F Foley or Coudé catheter into the bladder. Easy passage precludes a stricture. A large residual urine should alert the physician to outlet obstruction as the cause of the patient´s infection.

Epididymitis causes lower abdominal, inguinal canal, scrotal, or testicular pain alone or in combination. The retrograde progression of infection from the prostatic urethra to the epididymis explains the location and progression of pain. Patients with epididymitis are more prone to lower urinary tract irritative voiding symptoms and may note transient relief of their pain in the recumbent position with scrotal elevation, due to the inflammatory nature of the disease. Initially, isolated firmness and nodularity of the affected globus minor is noted on examination. As the disease progresses, the sulcus between the epididymis and testis becomes obliterated, and the inflammatory epididymal mass may become contiguous with the testis, producing a large, tender scrotal mass (epididymo-orchitis) that cannot be differentiated from testicular torsion or carcinoma. At this stage the patient may appear toxic and require admission for IV antibiotic therapy (see Table 91-2). Adjunctive diagnostic modalities such as color-flow duplex Doppler sonography or radionuclide scintigraphy will demonstrate increased or preserved blood flow to the testes.

Admission criteria for epididymitis include fever with elevated white blood cell count and subjective toxicity, all of which can be indicative of epididymal or testicular abscess formation. A urologist will dictate inpatient management, which should include: (1) absolute bedrest for the first 24 to 48 h, with scrotal elevation and ice application (10 to 15 min every 4 to 6 h) to the involved testis/epididymis; (2) nonsteroidal anti- inflammatory drugs (NSAIDs); (3) intravenous antibiotics based on etiology (Table 91-2); and (4) narcotics for pain control, with concomitant stool softeners. These measures will prevent further progression of the inflammatory process. Once the bedridden patient is pain-free, he should begin ambulation with a scrotal supporter, being careful not to lift heavy objects or strain when having a bowel movement, both of which will increase intraabdominal pressure and exacerbate the inflammatory cycle. Any significant deviation from this plan will prolong the recovery period. Outpatient management is identical to inpatient management except that oral antibiotics are prescribed initially for 10 to 14 days. A urologist will need to reevaluate the patient in five to seven days and then ultimately decide when the patient may return to work based on his job description, i.e., a sedentary worker would be able to return sooner than a laborer.

Brent Tin 636

a. Pain is usually more gradual due to its inflammatory etiology.

b. <40 y/o = STD’s or their complications (urethral stricture)

c. >40 y/o = urinary pathogens such as E. coli and Klebsiella

d. Fungal infection in addition to STD’s

e. A recumbent position with scrotal elevation may provide transient relief of their pain.

Jam, Tint 636

a.   How the onset of pain differs from testicular torsion - more gradual than torsion because epididymitis is an inflammatory process

b.         Common cause under age 40 - STDs or their complications, like urethral strictures

c.   Common cause over age 40 - urinary pathogens like E. coli and klebsiella

d.   What other cause to consider in gay men - fungal infection

e.   What typically relieves the pain - transient relief of pain in recumbent position with scrotal elevation

Anonymous Tintinalli 636

• How the onset of pain differs from testicular torsion - onset of pain is more gradual than with torsion.  

• Common cause under age 40 - STD’s are the most common cause in this age group.

• Common cause over age 40 - Common urinary pathogens are the most common cause in this age group.  Pathogens include E. coli, and Klebsiella.

• What other cause to consider in gay men - In gay men, you must consider fungal infection of the lower urinary tract in addition to the more common STD organisms.

• What typically relieves the pain - Narcotic are used for pain control.  Transient relief of pain can be achieved in the recumbent position with elevation of the scrotum.

Anonymous  

a.  How the onset of pain differs from testicular torsion

Pain of epididymitis has more gradual onset than that of testicular torsion secondary to inflammatory etiology.

b.  Common cause under age 40

Under age 40, common cause of epididymitis is sexually transmitted infections (STIs)

c.  Common cause over age 40

Over age 40, epididymitis is caused by common urinary pathogens such as E. coli and Klebsiella.  Consider sexual activity, of course, when determining any individual’s risk.

d.  What other cause to consider in gay men

In gay men with epididymitis, consider fungal infection of the lower urinary tract, in addition to the more common STIs.  

e.  What typically relieves the pain

These patients may note transient relief of pain in the recumbent position with scrotal elevation due to inflammatory nature of disease

Anonymous Tintinalli p 636

A)  How the onset of pain differs from testicular torsion- this is usually a more gradual onset that that of testicular torsion because of its inflammatory etiology rather than ischemic etiology.  

B)  Common cause under age 40- sexually transmitted diseases

C)  Common cause over age 40- urinary pathogens such as Escherichia coli and Kleisbella

D)  What other causes to consider in gay men- fungal infection of the lower genital tract in addition to common STD symptoms

E)  What typically relieves the pain- recumbency with scrotal elevation

13.       Identify possible causes of urinary retention and why a detailed medication history is so important.

Zen Lite

• Meatal stenosis

• Urethral stricture

• Bladder neck contracture

• BPH

ask about OTC cold and dietary medications, as sympathomimetic agonists may cause outlet obstruction due to muscle-constricting effect on abundant α-agonistic fibers in the bladder neck

Zen Seeker Tinitinalli EM Fifth Edition

Urinary Retention

Obstructive uropathy causes a wide expanse of signs and symptoms. Overt urinary retention represents one end of the spectrum, while symptoms of insidious overflow incontinence will often fool an unsuspecting examiner. Prior to acquiring a detailed genitourinary history, questions regarding chronic systemic medical illnesses or carcinomas that have as sequelae sensory or motor neurogenic side effects or complications must be addressed. A detailed medication history, including over-the-counter cold and dietary medications, will often reveal the ingestion of a sympathomimetic agonist that has secondarily caused outlet obstruction due to its muscle-constricting effect on the abundant α-agonistic fibers in the bladder neck. Inconvenient, and therefore infrequent, voiding during a prolonged car trip by a vacationing patient with borderline obstructive symptoms may be just enough to result in urinary retention.

A thorough voiding history begins with questions regarding problems holding or initiating the urinary stream, voiding completely with one continuous stream rather than starting and stopping of the stream, a feeling of complete bladder emptying as opposed to incomplete emptying and postvoid residual, and the relative frequency of nocturia. Ultrasonography is a noninvasive, accurate way to determine the postvoid residual. Most men do not void as well or completely empty their bladders when sitting down to urinate, which happens most often during the night. Infrequent ejaculation may lead to secondary prostatic congestion and subsequent spurious symptoms of irritation and outlet obstruction. Unless specific questions are asked about the latter circumstances, these easily treatable causes of obstructive symptoms can be missed.

The most difficult evaluation involves the patient with silent prostatism. Historically, voiding symptoms have gradually worsened over the years, but at such a pace that the patient often makes adjustments and then perceives each worsening state as “normal” for him. The ultimate result is retention, with a large palpable bladder and often 1600 to 2000 mL residual urine. An intact sensory examination, anal sphincter, and bulbocavernosus reflex differentiate chronic outlet obstruction from the sensory or motor neurogenic bladder and spinal cord compression.

Intraurethral causes of urinary retention are the same as those of outlet obstruction (Table 91-3). Appropriate physical examination requires inspection of the meatus for stenosis; palpation of the entire urethral length for masses or fistulas consistent with urethral stricture disease or abscess formation; lower abdominal examination for palpation of a suprapubic mass; and rectal examination to evaluate anal sphincter tone and the size and consistency of the prostate. Outlet obstruction due to a large intravesical prostate can result in a palpably normal prostate on rectal examination. Similarly, rectal examination in a patient in urinary retention may initially reveal a spuriously enlarged, nodular prostate that will shrink considerably once bladder decompression is achieved.

TABLE 91-3 Etiology of Outlet Obstruction

Meatal stenosis

Urethral stricture

Bladder neck contracture

Benign prostatic hyperplasia

Brent Tin 639

-neurogenic bladder  -bladder neck contacture

-meatal stenosis        -BPH

-urethral stricture

Med Hx, including OTC and dietary meds, is important in order to check for the ingestion of a sympathomimetic agonist, which can cause obstruction due to its muscle-constricting effect on the bladder neck.

Jam, Tint 639

•     Causes - meatal stenosis, urethral stricture (from a complication of an STD, masses, or fistulas), bladder neck contracture, BPH, foreign body, chronic systemic illnesses, carcinoma, infrequent ejaculation (may lead to secondary prostatic congestion)

•     Ask about all meds including OTC cold and dietary. Sympathomimetic agonists may secondarily cause outlet obstruction due to their muscle-constricting effect on the abundant α-agonistic fibers in the bladder neck

Anonymous      Tintinalli 639    

• Urinary retention seems to be caused by obstruction of urinary outlet.  There are several possible causes or etiologies for an obstruction.  

• Outlet obstruction can be caused by:

  • Meatal stenosis

  • Urethral stricture

  • Bladder neck contracture

  • BPH

  • Medications

• It is important to obtain a detailed medication history including OTC cold and dietary medications.  This information will often reveal the ingestion of a sympathomimetic agonist that has secondarily caused outlet obstruction due to its muscle-constricting effect on the abundant alpha-agonistic fibers in the bladder neck.

Anonymous  Tintinalli p. 639

Causes: Inconvenient, and infrequent voiding during prolong periods with borderline obstructive symptoms may be just enough to result in urinary retention. Problems holding or initiating the urinary stream, chronic systemic medical illness or CA that may have a sequelae sensory or motor neurogenic side effect.

Med Hx: include OTC cold and dietary meds will often reveal the ingestion of a sympathomimetics agonist that has secondarily caused outlet obstruction due to its muscle-constricting effect on the abundant Alpha-agonistic fibers in the bladder neck.

Anonymous Tintinalli p 639

A)  Possible causes of urinary retention include:

             1.  Intraurethral Causes:  meatal stenosis, urethral stricture, bladder neck contracture, & benign prostatic

                  hyperplasia

B)  Why a detailed history is so important- often detailed medical and pharmacologic history reveals ingestion of a sympathomimetic agonist that has secondarily caused outlet obstruction due to its muscle constricting effect on the abundant alpha-agonistic fibers in the bladder neck.

14.       Explain how to relieve urinary retention in the ED.  Identify who should receive antibiotics and with whom the patient should follow-up.  

Zen Lite

urethral catheter alleviates pn and urinary retention

initiation of antibiotic therapy depends on presence of infected urine and length time catheter left indwelling.

all must F/U c urologist

Zen Seeker Tinitinalli EM Fifth Edition

Most patients with bladder outlet obstruction are in distress, and passage of a urethral catheter alleviates both their pain and their urinary retention. Copious intraurethral lubrication must be used, and if attempts at passage of a straight 16F Foley catheter fail, a 16F Coudé catheter should be passed. Be certain to pass either catheter to its fullest extent, obtaining a free flow of urine, and only then inflate the catheter balloon. This will prevent balloon inflation in the prostatic urethra. If the catheter drainage holes become obstructed with lubricating jelly, gentle irrigation with sterile saline or water will quickly establish urinary drainage. Spontaneous, complete drainage of a distended bladder can be accomplished rapidly without the need for repeated clamping of the catheter. Occasionally, when a bladder has been chronically distended, bladder mucosal edema develops. Rapid decompression following catheter placement may result in transient gross hematuria. The transient hematuria is usually self-limited, of little consequence, and responds to orally induced diuresis. Postmicturitional or bladder decompression syncope is rare and should be treated symptomatically.

The catheter should be left indwelling and connected to a portable leg drainage bag. The patient or his family must be instructed in the care and drainage of this simple device. The initiation of antibiotic therapy depends on the presence or absence of infected urine and on the length of time catheter will be left indwelling. The patient or a family member should be instructed on Foley balloon deflation, should it become necessary to remove the catheter because of bladder spasms that are not responsive to oral anticholinergic medication.

If urinary retention has been chronic or insidious, postobstructive diuresis may occur secondary to osmotic diuresis or interstitial tubular dysfunction. Postobstructive diuresis may occur in the presence of normal BUN and creatinine levels and may become an emergency if the patient suddenly becomes hypovolemic or hypotensive without warning. Thus, close monitoring of urine output is essential, with appropriate fluid replacement. For these reasons, all patients with chronic or insidious obstructive voiding symptoms and urinary retention should either be observed for 4 to 6 h or be admitted, with particular attention paid to hourly intake, urinary output, vital signs, and urine and serum electrolytes. Osmotic diuresis will dissipate or the dysfunctional tubules will recover within 24 to 48 h. In all cases of urinary retention, consultation and follow-up with a urologist for a complete genitourinary evaluation are necessary.

Brent Tin 639-40

Urinary retention is relieved by insertion of an indwelling 16F Foley or coudé catheter.  Antibiotics should be considered depending on the presence or absence of infected urine and the length of time the catheter will be left indwelling.  A follow-up and consultation with an urologist is necessary.

Jam, Tint 639-640

• To relieve: pass a urethral catheter with copious intraurethral lubrication. If attempts with a 16F Foley catheter fail, then a 16F Coudé should be passed. Catheter must go in to fullest extent, obtaining a free flow of urine, before inflating catheter balloon. If cath drainage holes become clogged with lubricant, irrigate with sterile saline.

• Antibiotics depend on presence or absence of infected urine and the length of time catheter will be left indwelling.

• Follow up with urologist for complete GU eval

Anonymous Tintinalli 639-640

Patients with bladder outlet obstruction are in distress, and passage of a urethral catheter alleviates both their pain and their urinary retention.  A 16F foley catheter is used first, if the foley catheter fails, then a 16f Coude catheter should be use.   Once there is a free flow of urine the catheter balloon is inflated.    

Antibiotic therapy depends on the presence or absence of infected urine and the duration in which the catheter will be left indwelling.

Anonymous   tintinalli, pg.  639.

-Most pts with bladder outlet obstruction are in distress, and passage of a urethral catheter alleviates both their pain and their urinary retention.  Copious intraurethral lubrication must be     used, and if attempts at passage of a straight 16F Foley catheter fail, a 16F Coude catheter should be passed.  Be certain to pass either catheter to its fullest extent, obtaining a free flow of urine, and only then inflate the balloon.  

-Initiation of antibiotic therapy depends on the presence or absence of infected urine and on the length of time the catheter will be left indwelling.  

-In all cases of urinary retention, consultation and follow-up with a urologist for a complete genitourinary evaluation are necessary.

Anonymous Tintinalli p 640

A)  Catheterization will relieve pain and alleviate retention

B)  The initiation of antibiotic therapy depends on the presence of infected urine upon initial caterterization, and the length of time the catheter is in place.  Follow up with a urologist is necessary.

15.       Identify risk factors and predisposing factors for kidney and ureteral stones in adults.

Zen Lite

• ♂:♀   3:1

• 30's-50's

• genetic predisposition

• hereditary diseases (e.g., renal tubular acidosis, hyperparathyroidism, and cystinuria)

• mountainous, desert, or tropical regions

• sedentary jobs

• warmest 3 months of year

• S.E. region US

• protease inhibitor indinavir sulfate (HIV)

• Diuretic use

<16y/o (7% all cases)

• 1:1 sex

• metabolic abnormalities 50%

• urologic anomalies 20%

• infection 15%

• immobilization syndrome 5%

• idiopathic

Zen Seeker Tinitinalli EM Fifth Edition

RENAL AND URETERAL STONES

Epidemiology

Urologic stone disease is a common condition with an incidence estimated as high as 12 percent.1 Stones occur three times more often in males, usually in the third to fifth decades of life.2 There is a genetic predisposition to stone development, and some hereditary diseases (e.g., renal tubular acidosis, hyperparathyroidism, and cystinuria) increase the frequency of kidney stones.2

Lifestyle factors may also augment stone growth. Patients in mountainous, desert, or tropical regions and those in sedentary jobs suffer a higher frequency of stone disease.2 There is also an increased incidence during the warmest 3 months of the year for any geographic location.2 In the United States the southeast region has a higher incidence than the remainder of the country.3 Finally, increased water intake is associated with a decreased incidence of calculi.4

Some medications predispose to stone disease. Most recently, the protease inhibitor indinavir sulfate, used to treat HIV infection, has been associated with a 4 percent incidence of symptomatic urolithiasis. Diuretic use has also been shown to increase the prevalence of renal stones.3

Children under 16 years of age constitute approximately 7 percent of all cases of renal stones.2 Unique to this age group is a 1:1 sex distribution.2,5 The most common causes in this age group involve metabolic abnormalities (50 percent), urologic anomalies (20 percent), infection (15 percent), and immobilization syndrome (5 percent).2 The remainder are diagnosed as idiopathic.

Brent Tin 641, CMDT 916

-M>F

-30-50 y/o

-genetic predisposition

-hereditary diseases such as renal tubular acidosis, hyperparathyroidism, and cystinuria.

-geographic factors such as areas of high humidity and elevated temp.

-↑’d risk during warmest 3 mos of the year

-↑’d water intake is associated with ↓’d incidence

-meds such as diuretics and indinavir sulfate

-past Hx of stones (recurrence rate of 50% @5yrs)

Jam, Tint 640

•     Stones occur 3x more often in males, usually in 3^rd to 5^th decade

•     genetic predisposition

•     hereditary diseases - renal tubular acidosis, hyperparathyroidism, and cystinuria

•     lifestyle factors - living in mountainous, desert, tropical regions, or southeast U.S., sedentary jobs

•     warmest 3 months of the year in any geographic location

•     medications - indinavir sulfate for HIV, diuretics

•     decreased water intake

Anonymous Tintinalli 640

            Predisposing Factors:

• Genetic predisposition

• Hereditary diseases (e.g. renal tubular acidosis, hyperparathyroidism, and cystinuria)

• Medications: protease inhibitor (indinavir sulfate) and diuretics

            Risk Factors:

• Male gender -  experience 3 times the stones as females

• Age - increased incidence in 3^rd to 5^th decade

• Geographic region, people in mountainous, desert, and tropical regions have a higher incidence

• Sedentary job

• Warmer months of the year regardless of geographic location

• Decreased water intake

Anonymous  Tintinalli, p.640

Male: Female = 3:1

HX of stone

Genetic predisposition

Hereditary diseases - renal tubular acidosis, hyperparathyroidism, cystinuria

Lifestyle factors - reside in mountainous, desert, or tropical regions; sedentary jobs; low water intake.

Medications - diuretics, protease inhibitor (indinavir sulfate)

Age -  7% of children under 16 with 1:1 distribution between the sexes; common causes include: metabolic abnormalities (50%), urologic anomalies (20%), infection (15%), immobilization syndrome (5%), and idiopathic (10%).

Anonymous Tintinalli p 640

A)  Risk factors and predisposing factors include:

             1.  Genetic predisposition

             2.  Hereditary Diseases- renal tubular acidosis, hyperparathyroidism, cystinuria

             3.  Lifestyle factors:  mountainous, desert, or tropical regions; those with sedentary jobs, increased incidence  

                  during the warmest three months of the year;

             4.  Medications:  protease inhibitors used to treat HIV

16.       Identify how often kidney stone recur.  Dropped 2004

Zen Lite

up to 33% in 1 yr

~50% in 5 yrs

Zen Seeker Tinitinalli EM Fifth Edition

In patients with a history of a kidney stone, up to a third suffer recurrence within 1 year, with the recurrence rate at 5 years near 50 percent.2 This is probably because the underlying abnormality that created the first stone is still present.

Paul, Tintinalli pg 640

In patients with a history of a kidney stone, up to a third suffer recurrence within 1 year, with the recurrence rate at 5 years near 50%.

Greg  Tintinalli, p. 640.

1/3 of  pts w/ a hx of a kidney stones will have a recurrence w/in one year, recurrence rate at 5 years is nearly 50%.  This is likely due to a chronic underlying pathology.

Anonymous Tintinalli 640

            One-year recurrence rate is up to 1/3 of patients with a kidney stone history.

            Five-year recurrence rate is nearly 50%

Anonymous   Tininalli chap. 92 pg. 640

In a patient with a hx of kidney stones, up to 1/3 suffer recurrence within one year, and up to 50% within 5 years.

Anonymous Tintinalli p 640

A)  Up to 1/3 suffer recurrence within one year, with recurrence rate at five years near 50%.

17.        List the different kinds of stones and identify which type is most common.

Zen Lite

75% calcium c oxalate, phosphate, or both

10% magnesium- ammonium-phosphate (struvite).

10% uric acid- uroliths

5% cystine and other uncommon minerals

Zen Seeker Tinitinalli EM Fifth Edition

Pathophysiology

The precise cause of urinary stones is unknown. Theories regarding urinary calculi formation include urinary supersaturation of solute followed by crystal precipitation, or a decrease in the normal urinary proteins that inhibit crystal growth. Urinary stasis from physical anomaly, neurogenic bladder, or catheter placement, and the presence of foreign bodies (e.g., surgical suture) may provide the environment for stone growth.

Approximately 75 percent of calculi are composed of calcium, occurring in conjunction with oxalate, phosphate, or a combination of both.2 These stones may develop as a result of increased urinary excretion of a given solute. Calcium excretion is elevated in conditions such as high dietary calcium intake, immobilization syndrome, or hyperparathyroidism. Oxalate excretion is enhanced in patients with bowel disease (e.g., Crohn´s disease or ulcerative colitis) and as a result of small- bowel bypass surgery. Ten percent of stones are magnesium- ammonium-phosphate (struvite).2 These stones are often associated with infection by urea-splitting bacteria and are the most common cause of staghorn calculi. Staghorn calculi are large stones that form a cast of the renal pelvis. Antibiotics are ineffective, since there is poor penetration into the calculus. Uric acid causes 10 percent of uroliths.2 Cystine and other uncommon minerals comprise the remainder.2

Paul, Tintinalli pg 640

• Approximately 75% of calculi are composed of calcium occurring in conjunction with oxalate, phosphate, or a combination of both.  Calcium excretion is elevated in conditions such as high dietary calcium intake, immoblizataion sydrome, or hyperparathyroidism.  Oxalate excretion is enhance in patients with bowel disease (Crohn’s or ulcerative colitis) or as a result of small bowel bypass surgery.

• 10% of stones are magnesium-ammonium-phosphate (struvite).  Often associated with infection by urea-splitting bacteria.

• Uric acid causes 10% of uroliths.

• Cystine and other uncommon minerals comprise the remainder

Greg  Tintinalli, p. 640.

-75% of all stones are composed of calcium, occurring in conjunction with oxalate, phosphate, or a combination of both.  These stones may develop as a result of increased urinary excretion of a given solute.  Calcium excretion is elevated in conditions such as high dietary calcium intake, immobilization syndrome, or hyperparathyroidism.  Oxalate excretion is enhanced in patients with bowel disease and as a result of small-bowel bypass surgery.

-10% of stones are magnesium-ammonium-phosphate (struvite).  These stones are often associated with infection by urea-splitting bacteria and are the most common cause of staghorn calculi.

-10% of stones are caused by uric acid.

-The remainder is cystine and other uncommon minerals.

Anonymous Tintinalli 640, Noble1373

            Calcium oxalate - most common

            Calcium phosphate

            Uric Acid

            Cystine

            Struvite

Anonymous  Tintinalli p. 640

-Calcium containing stones account for 75% of all stones and are generally composed of a mixture of calcium oxalate and calcium phosphate (with the oxalate stones being more common than the phosphate).

-Ten percent of stones are magnesium-ammonium-phosphate (struvite).

-Uric acid causes 10% of uroliths.

-Cystine and other uncommon minerals comprise the remainder.

Anonymous TIntinalli p 640-641

A)  Types of urinary stones include:

1. Approximately 75% of calculi are composed of calcium occurring in conjunction with oxylate, phosphate, or both.

2. Struvate stones (magnesium-ammonium-phosphate) make up about 10% of stones

3. Staghorn Calculi- large calculi that form a cast of the renal pelvis

4. Uric acid causes 10%

5. Cysteine and other uncommon minerals comprise the remainder

18.       Identify the most common locations for stones to lodge.

Zen Lite

• renal calyx

• ureteropelvic junction (where the ureter passes over the pelvic brim and arches over the iliac vessels)

• ureterovesical junction (UVJ)

Zen Seeker Tinitinalli EM Fifth Edition

Passage of stones through the urinary tract may be slowed or halted by areas of anatomic narrowing or bending. Progressing proximally to distally, common areas of impaction include the renal calyx, ureteropelvic junction (where the ureter passes over the pelvic brim and arches over the iliac vessels), and the ureterovesical junction (UVJ). The UVJ has the smallest diameter of the urinary tract and is a common location for impacted stones. The posterior pelvis in women, especially where the ureter is crossed anteriorly by the pelvic blood vessels and broad ligament, may slow the passage of a calculus.

If a stone causes acute ureteral obstruction, after an initial rise of renal blood flow and intraureteral pressure, both parameters decline. Concurrently, there is a proportional increase in renal blood flow to the contralateral kidney. These effects are reversible in acute unilateral obstruction if the obstruction is relieved. However, after prolonged obstruction (several weeks), irreversible renal damage occurs.2 The contralateral kidney is usually able to maintain excretory requirements throughout the course. Therefore, blood urea nitrogen and creatinine levels do not rise even though there is only one functional kidney.

Paul, Tintinalli pg 641

Common areas of impaction include the renal calyx, ureteropelvic junction (where the ureter passes over the pelvic brim and arches over the iliac vessels), and the ureterovesical junction (UVJ).  The UVJ has the smallest diameter of the urinary tract and is a common location for impacted stones.  The posterior pelvis in women, especially where the ureter is crossed anteriorly by the pelvic blood vessels and broad ligament, may slow the passage of a calculus.

Greg  Tintinalli, p. 641.

Passage of stones is slowed by areas of anatomical narrowing/bending.  From proximal to distal, common sites of impaction include the renal calyx, ureteropelvic junction (where the ureter passes over the pelvic brim and arches over the iliac vessels), and the ureterovesical junction (UVJ).  The UVJ has the smallest diameter of the urinary tract and is a common location fro impacted stones.

Anonymous Tintinalli 641

            Locations for stones to lodge are proximal to distal:

• Renal calyx

• Ureteropelvic junction

• Uretervesical junction  more common site of lodging of a stone

Anonymous  

Passage of stones through the urinary tract may be slowed or halted by areas of anatomic narrowing or bending.  Progressing proximally to distally, common areas of impaction include the renal calyx, uretero-pelvic junction (where the ureter passes over the pelvic brim and arches over the iliac vessels), and the ureterovesical junction (UVJ).  The UVJ has the smallest diameter of the urinary tract and is a common location for impacted stones.  The posterior pelvis in women, especially where the ureter is crossed anteriorly by the  pelvic blood vessels and broad ligament, may slow the passage of a calculus.  (Tintinalli p. 641)

Anonymous Tintinalli p 641

A)  Progressing proximally to distally common areas of stone impaction include:

             1.  Renal calyx

             2.  Ureteropelvic junction (where the ureter passes over the pelvic brim and arches over the iliac vessels

             3.  Uretovesicular junction

19.       Identify the factors that predict whether or not a stone will pass on its own.

Zen Lite

size

• <4mm pass 90%

• 4-6mm 50%

• >6mm 10%

shape

• Bizarrely shaped or irregular stones ↓ rate

location

• proximal ureter 20%

• middle ureter 50%

• distal ureter 70%

degree of ureteral obstruction

• complete ↓ rate than partial

Zen Seeker Tinitinalli EM Fifth Edition

The probability of spontaneous passage of stones is determined by multiple factors, including size, shape, location, and degree of ureteral obstruction. Stones with diameters less than 4 mm will pass in approximately 90 percent of cases, while 50 percent of stones 4 to 6 mm in diameter pass, and only 10 percent of stones exceeding 6 mm pass spontaneously.2 Bizarrely shaped or irregular stones with spicules and sharp edges will have a lower passage rate. Rates of passage based on the location of the stone at first diagnosis are approximately 20, 50, and 70 percent for the proximal, middle, and distal ureter, respectively.6 Finally, with complete obstruction there is a lower rate of spontaneous passage than if the blockage is partial.

Paul, Tintinalli pg 641

The probability of spontaneous passage of stones is determined by multiple factors, including size, shape, location, and degree of ureteral obstruction.  Stones with diameters less than 4 mm will pass in approximately 90% of cases, while 50% of stones 4-6 mm in diameter pass, and only 10% of stones exceeding 6 mm pass spontaneously.  Bizarrely shaped or irregular stones with spicules and sharp edges will have a lower passage rate.  Rates of passage based on location at first diagnosis are approximately 20% for proximal, 50% for middle, and 70% for distal ureter.  Complete obstruction lowers rate of spontaneous passage than if blockage partial.

Greg  Tintinalli, p. 641.

Spontaneous passage of stones is determined by size, shape, location, and degree of obstruction.

-Stones w/ diameters < 4mm will pass in approx. 90% of cases.

-Stones w/ diameters 4-6mm will pass in 50% of cases.

-Stones w/ diameters >6mm will pass in only 10%

-Odd shaped stones will have a lower passage rate.

-Rates of passage based on location of stone at first dx are approx 20, 50, and 70% for the proximal, middle, and distal ureter, respectively.

-Complete obstruction has a lower passage rate than partial obstruction.

Anonymous

• Probability of spontaneous passage of stones is determined by multiple factors including size, shape, location, and degree of ureteral obstruction.

• Stones <4mm diameter pass in 90% of cases, 4-6mm in 50% of cases, >6mm only 10% will pass.

• Bizarre shaped or irregular stones with spicules and sharp edges will have lower passage rate.

• Rates of passage based on location of stone at first diagnosis are 20, 50, and 70% for proximal, middle, distal ureter respectively.

• Complete obstruction has lower rate of spontaneous passage than partial.

Anonymous  

a. Size.

-Diameter < 4 mm will pass in 90% of cases.

-Diameter 4 - 6 mm will pass in 50% of cases.

-Diameter > 6 mm will pass in only 10% of cases.

b. Shape.

-Bizarre shape or stones with spicules and sharp edges have lower passage rates.

c. Location.

-Proximal Ureter:  20%

-Middle Ureter:  50%

-Distal Ureter:  70%

d. Degree of ureteral obstruction.

-Complete obstruction has lower rate of spontaneous passage. (Tintinalli  pp. 640-641)

Anonymous Tintinalli p 641

A)  Factors predicting stone passage:

             1.  Size of stone

             2.  Shape of stone

             3.  Location of stone

             4.  Degree of ureteral obstruction

20.       Describe the typical presentation of kidney stones in the adult.

Zen Lite

• sedentary or at rest

• acute onset of severe pn

  • originates in either flank

  • radiates anteroinferiorally around the ABD

  • progresses toward the ipsilateral testicle or labia majora

• nausea

• vomiting

• diaphoresis

• unable to find a comfortable position

• anxious

• pacing

• reluctant to lie still “writhing of renal colic”

Zen Seeker Tinitinalli EM Fifth Edition

Clinical Features

Uroliths may be asymptomatic until there is at least partial obstruction of the urinary tract. The usual episode occurs while the patient is sedentary or at rest. Patients describe the acute onset of severe pain. Although subacute presentations occur, the usual rapidity of symptom onset is in contradistinction to many other diagnoses that may be considered.

Typically the pain originates in either flank, radiates anteroinferiorally around the abdomen, and progresses toward the ipsilateral testicle or labia majora. The discomfort can be extreme in intensity and may be associated with nausea, vomiting, or diaphoresis. Patients may be unable to find a comfortable position to relieve their symptoms. Consequently, they are sometimes anxious, pacing, and reluctant to lie still on the examining table. The “writhing of renal colic” is a useful point in the construction of a differential diagnosis.

The characteristic radiating pattern of renal colic pain results from autonomic nerve fibers serving both the kidney and respective gonad. However, atypical presentations with pain referral patterns to the hip, thigh, or knee are rarely reported.2 As a stone progresses to the mid-ureter, anterior abdominal pain may radiate back toward the flank. With passage near the bladder, the patient may develop urinary frequency and urgency. Symptoms can be remarkably episodic due to intermittent obstruction of the urinary tract. If the stone passes or the obstruction is temporarily relieved, the patient will have immediate relief of symptoms.

Patients are frequently cool and diaphoretic, and a history of fever is unusual. Its presence should prompt a thorough investigation for urinary tract infection or other causes of febrile illness.

In children, symptoms can vary with age. Older children are more likely to present in similar fashion to the adult. Younger children may have a more nonspecific presentation, such as abdominal or pelvic pain. Although renal colic is rare in infants, symptoms may be mistakenly attributed to intestinal colic.5 Overall, 20 to 30 percent of children may have only painless hematuria.2

Patients with known stone disease may present after treatment with extracorporeal shock wave lithotripsy (ESWL). ESWL fractures stones into small particles using focused sound waves. The resulting “sludge” is passed in the urine. When there are large fragments, an acute episode of renal colic occurs. The presentation is identical to “de novo” episodes of renal colic.

Paul, Tintinalli pg 641

Uroliths may be asymptomatic until there is at least partial obstruction of the urinary tract.  Episode usually occurs while the patient is sedentary or at rest.  Patients describe the acute onset of severe pain.  Typically the pain originates in either flank, radiates anteroinferiorally around the abdomen, and progresses toward the ipsilateral testicle or labia majora.  The discomfort can be extreme in intensity and may be associated with nausea, vomiting, or diaphoresis.  Patients may be unable to find a comfortable position to relieve their symptoms.  They may be anxious, pacing, and reluctant to lie still.  “writhing of renal colic”.  As stone progresses to the mid-ureter, anterior abdominal pain may radiate back toward the flank.  With passage near the bladder, the patient may develop urinary frequency and urgency.  Symptoms can be remarkably episodic due to intermittent obstruction of the urinary tract.  If the stone passes or the obstruction is temporarily relieved, the patient will have immediate relief of symptoms.  Patients are frequently cool and diaphoretic, and history of fever is unusual.  

In children, symptoms vary with age.  Older children are more likely to present in similar fashion to the adult.  Younger children may have a more nonspecific presentation, such as abdominal or pelvic pain.  Although renal colic is rare in infants, symptoms may be mistakenly attributed to intestinal colic.  Overall, 20-30% of children may have only painless hematuria.

Greg  Tintinalli, p.641.  

-The usual episode occurs while at rest.  Pts describe an acute onset of severe pain.

-Typically the pain originates in either flank, radiates anteroinferiorlly around the abdomen, and progresses toward the ipsilateral testicle or labia majora.

-Discomfort can be extreme in intensity and may be assoc. w/ nausea, vomiting, or diaphoresis, fever is unusual.

-Pts may be unable to find a comfortable position to relieve their symptoms, and may be anxious, pacing or reluctant to lie still on the exam table.  The “writhing of renal colic” is a useful point in the construction of a ddx.

Anonymous

Uroliths may be asymptomatic until at least partial obstruction of urinary tract. Usual episode occurs at rest and is described as acute onset of severe pain. Pain originates in either flank, radiates anterioinferiorally around the abdomen, and progresses toward ipsilateral testicle or labia majora. Discomfort may be extreme in intensity and may be associated with N/V or diaphoresis. Sometimes anxious, pacing, and reluctant to sit on exam table because they are unable to find a comfortable position (“writhing of renal colic”). As stone progresses to mid-ureter, anterior abdominal pain may radiate back toward the flank. With passage near bladder, may develop urinary frequency and urgency. Symptoms can be episodic due to intermittent obstruction of urinary tract. If stone passes or obstruction temporarily relieved, patient will have immediate relief.

Atypical presentations with pain referral patterns to hip, thigh, or knee rarely reported. Patients are frequently cool and diaphoretic, but history of fever is unusual and should prompt investigation for UTI or other causes.

Anonymous  Tintinalli  pp. 640-641

Typical pain orginates in either flank, radiates anteroinferiorly around abdomen, and progresses toward the ipsilateral testicle of labia majora.  The discomfort can be extreme in intensity and may be associated with N/V, or diaphoresis.  Patients usually have a hard time finding a comfortable position.  Consequently, they are sometimes anxious, pacing, and reluctant to sit on an exam table.  The “writhing of renal colic” is helpful in the differential diagnosis.

Symptoms can be remarkably episodic due to intermittent relief of the obstructed ureter. If the stone passes or the obstruction is temporarily relieved then the patient will experience immediate relief of symptoms.

Anonymous Tintinalli p 641

A)  Typical Presentation- Urolithiasis may be asymptomatic until there is at least a partial obstruction of the urinary tract.  The usual episode occurs while the patient is sedentary or at rest.  Patients describe an acute onset of severe pain.  Typically the pain originates in either flank, radiates anterioinferiorly around the abdomen and progresses toward the ipsilateral testicle or labia majora.  The discomfort may be extreme in nature and may be associated with nausea, vomiting, or diaphoresis.  Patients will be unable to find a comfortable position consequently may be pacing, anxious, and reluctant to lie still on examination.

21.       Describe common finding on physical exam and what findings suggest concurrent pyelonephritis.

Zen Lite

• ↑BP

• ↑ pulse

• fever or hypotension = infection

• Mild tenderness over stone

concurrent pyelonephritis

• CVA tenderness c fever or other signs of UTI

Zen Seeker Tinitinalli EM Fifth Edition

PHYSICAL EXAMINATION

Special attention should be given to the abdominal and cardiovascular portions so that potential catastrophes mimicking acute renal colic are excluded. The vital signs should be carefully noted. There may be elevations of blood pressure and pulse secondary to extreme discomfort. The presence of fever or hypotension should suggest the possibility of concurrent infection or a diagnosis other than renal colic.

The abdominal examination is extremely important. It should specifically include a search for the presence of bruit or a pulsatile mass to ensure that a rupturing or dissecting aortic aneurysm is not missed. Likewise, the pulses in the distal extremities should be carefully examined. If they are diminished, absent, or asymmetric, this suggests a potential vascular catastrophe.

Mild tenderness may be noted over the site of an impacted stone. However, true peritoneal findings (e.g., guarding or rebound) are not a component of acute renal colic. If peritoneal signs are found, the differential diagnosis should be expanded to include those pathologic conditions known to result in discomfort at that anatomic region. Similarly, abdominal distention is not a feature of renal colic. If present, it suggests an alternative explanation of the patient´s presentation.

Of equal importance during the physical examination is the genitourinary examination. Costovertebral angle tenderness is not unusual, but, when present with fever or other signs of urinary tract infection, it may suggest pyelonephritis. Pyelonephritis can occur simultaneously with stone disease. In addition, since the radiating pattern of discomfort in renal colic includes the testicle or labia majora, these areas should be evaluated for a potential incarcerated hernia. In a male patient, the testicles should be inspected and palpated to exclude torsion or infection. A pelvic examination should be performed in females when the diagnosis is not clear to assess for ovarian cyst, torsion, infection, or, of importance in pregnant patients, ectopic pregnancy.

Other portions of the physical examination should address the cardiac, respiratory, musculoskeletal, and dermatologic systems. An abnormal cardiopulmonary examination may suggest an alternative diagnosis, such as lobar pneumonia or pulmonary embolus. Musculoskeletal complaints may result in flank pain similar to that caused by renal stones; however, comprehensive extremity and neurologic examinations are usually sufficient to exclude these conditions. Finally, the presence of a vesicular rash overlying a flank dermatome may suggest the onset of herpes zoster.

Jenn, Tintinalli pp641

PE (kidney stones):  The abdominal exam is extremely important.

•                    There may be elevations of BP and pulse secondary to extreme discomfort.

•                    The presence of fever or hypotension should suggest the possibility of concurrent infection or a diagnosis other than renal colic.

•                    Mild tenderness may be noted over the site of an impacted stone.  

•                    Symptoms include flank pain that radiates around the abdomen.  As the stone progresses to the mid-ureter, anterior abdominal pain may radiate back toward the flank.  With passage near the bladder, the patient may develop urinary frequency and urgency.  A history of fever is unusual.

Findings suggesting concurrent pyelonephritis:

Costovertebral angle tenderness is not unusual, but, when present w/fever or other signs of urinary tract infection, it may suggest pyelonephritis.

Symptoms of pyelonephritis:

•  Fever

•  Flank pain

•  Costovertebral angle tenderness following several days of dysuria and frequency.

Dustin, Tintinalli pg 641

• Elevated BP and pulse secondary to extreme discomfort.

• Presence of fever or hypotension should suggest the possibility of concurrent infection       or a diagnosis other than renal colic.

• Mild tenderness may be noted over the site of an impacted stone.

Findings that suggest concurrent pyelonephritis:  

• Costorvertebral angle tenderness

• Fever

• Signs of UTI

Anonymous

Common findings on PE:

Vital signs should be carefully noted. Elevations of BP and pulse secondary to extreme discomfort. Presence of fever or hypotension suggest the possibility of concurrent infection or other diagnosis. Abdominal exam is extremely important. Should specifically include search for presence of bruit or pulsatile mass to ensure that rupturing or dissecting aortic aneurysm is not missed. Pulses in extremities carefully examined for diminished, absent or asymmetry. Mild tenderness may be noted over site of impacted stone, but true peritoneal findings are not a component of renal colic. Abdominal distention is not a feature of renal colic. Eval testicle and labia majora areas for potential incarcerated hernia due to radiating pattern of discomfort. Testicles should be examined for torsion and females should get pelvic exam if diagnosis is not clear to asses for ovarian cyst, torsion, infection, or ectopic pregnancy. Address cardiac, respiratory, MS, and derm systems.

CVA tenderness is not uncommon, but when present with fever or other signs of UTI, it may suggest polynephritis. Polynephritis may occur simultaneously with stone disease.

Anonymous  

Writhing or guarding, stillness if peritoneal involvement (think pyelonephritis), tachycardia and increased B/P secondary to pain, afebrile (x concurrent UTI), nausea/vomiting, diaphoretic, CV tenderness (think pyelonephritis) or abdominal tenderness over site of impacted stone.

Anonymous Tintinalli p 641

A)  Common Physical Exam Findings Include:

             1.  Elevation in blood pressure and pulse due to extreme discomfort

             2.  Presence of fever or hypotension should suggest possible concurrent infection

             3.  Possible local tenderness above the stone upon palpation

             4.  Costovertebral tenderness is not unusual, but if present with concurrent fever or other signs of a urinary

                  tract infection suggests pyelonephritis

22.       Discuss the importance of urinalysis in diagnosing kidney stones, including the importance of collecting any passed stones.

Zen Lite

• bld in urine supports dx renal colic

• UA help exclude other DDx

• Urinary crystals (oxalate or rarely urate), may indicate etiology of attack

• ↑ urine pH (>7.6) associated c infection may indicate the presence of a urea-splitting organism (magnesium- ammonium-phosphate (struvite))

• collected stones should be retained for pathologic analysis

Zen Seeker Tinitinalli EM Fifth Edition

LABORATORY TESTS

All patients with suspected renal colic require a urinalysis. The presence of blood in the urine supports the diagnosis of renal colic. However, there is no correlation between the amount of hematuria and the degree of urinary tract obstruction.7 Some patients demonstrate gross hematuria, but in up to 15 percent microscopic hematuria is absent.8 A urine dipstick is an expedient method to aid in the initial diagnosis. The dipstick has excellent sensitivity for detecting red blood cells; however, hemoglobin and myoglobin will also test positively for blood. Therefore, a microscopic analysis should be performed on all dipstick-positive urines. A urinalysis may also help in excluding other alternative or associated conditions, such as infection. Patients with fever, pyuria, or a history of fever and chills should also have a urine culture obtained. Blood cultures, although not routinely required in uncomplicated pyelonephritis,9,10 should be considered with concurrent obstruction, underlying comorbidity, or systemic toxicity. Urinary crystals, usually oxalate or rarely urate, may indicate the etiology of the present attack and the composition of the stone. However, because such crystals may be seen without association with renal stones, their presence is not diagnostic and should be interpreted cautiously. An elevated urine pH (>7.6) associated with infection may indicate the presence of a urea-splitting organism. An alkaline urine is also seen in renal tubular acidosis or following ingestion of large amounts of alkali. Urine should be collected and strained for the identification of any passed stones. All collected stones should be retained for pathologic analysis.

A pregnancy test specific for the β-HCG subunit should be performed on women of childbearing age. A positive β-HCG test result may indicate an important alternative cause of the patient´s complaints, such as ectopic pregnancy. In addition, a positive test result will affect the choice of imaging study to confirm the diagnosis of renal colic.

A complete blood count is indicated if the history or physical examination suggests the possibility of anemia or infection. In straightforward cases of renal colic, a complete blood count is not indicated. If obtained, a complete blood count may demonstrate mild leukocytosis. This indicates white blood cell demargination from stress. A very high white blood cell count may represent infection.

Other laboratory evaluations can be individualized. Serologic testing of renal function (e.g., determination of blood urea nitrogen and creatinine levels) may be required in patients at risk for nephrotoxicity (elderly patients, those with renal insufficiency, diabetic patients, and hypovolemic patients) if a radiocontrast dye study is planned. In addition, diabetic patients should have a glucose level determination to ensure the stress of renal colic has not caused significant hyperglycemia. Diabetics with significant nausea and vomiting may be at risk for hypoglycemia.

Jenn, Tintinalli pp641-42

All patients w/suspected renal colic require a urinalysis.  

•                    The presence of blood in the urine supports the diagnosis of renal colic.  However, there is no correlation between the amount of hematuria and the degree of urinary tract obstruction.  

•                    A urine dipstick is an expedient method to aid in the initial diagnosis.  The dipstick has an excellent sensitivity for detecting RBCs; however, hemoglobin and myoglobin will also test positively for bld.  Therefore, a microscopic analysis should be performed on all dipstick-positive urines.  

•                    Urine crystals, usually oxalate or rarely urate, may indicate the etiology of the present attack and the composition of the stone.  However, because such crystals may be seen w/out association w/.renal stones, their presence is not diagnostic and should be interpreted cautiously.  

•                    Urine should be collected and strained for the identification of any passed stone.  All collected stone should be retained for pathologic analysis.

Dustin, Tintinalli pg. 641-2

All patients with suspected renal colic require a urinalysis.  The presence of blood in the urine supports the diagnosis of renal colic.  However, there is no correlation between the amount of hematuria and the degree of urinary tract obstruction.  A urine dipstick is an expedient method to aid in the initial diagnosis.  The dipstick has an excellent sensitivity for detecting rbc’s; however, hemoglobin and myoglobin will also test positively for blood.  Therefore, a microscopic analysis should be performed on all dipstick-positive urines.  A urinalysis may also help in excluding other alternative or associated conditions, such as infection.  

Urine crystals, usually oxalate or rarely urate, may indicate the etiology of the present attack and the composition of the stone.  However, because such crystals may be seen without association with renal stones, their presence is not diagnostic and should be interpreted cautiously.  

Stones are to be retained for pathologic analysis.

Anonymous

• All patients with suspected renal colic require a UA. Presence of blood in urine supports the diagnosis of renal colic. There is no correlation between the amount of hematuria and degree of urinary tract obstruction.

• Dipstick has excellent sensitivity for RBC’s, however hemoglobin and myoglobin may also test positive.  Microscopic analysis should be performed on all dipstick-positive urines.

• Patients with fever, pyuria, or history of fever and chills should also have urine culture obtained.

• Blood cultures should be considered with concurrent obstruction, underlying comorbidity, or systemic toxicity. Urinary crystals, usually oxalate or rarely urate, may indicate etiology of the present attack and composition of stone.

• An elevated pH >7.6 associated with infection may indicate the presence of a urea-splitting organism.

• Alkaline urine is also seen in renal tubular acidosis or following ingestion of large amounts of alkali.

• Urine should be collected and strained for the identification of any passed stones. All collected stones should be retained for pathologic analysis.

Anonymous  

UA is important to check for hematuria, crystalluria, pH, leukocytosis, hyperchloremia, hyperclacemia.  Stones must be checked for pathology incase further treatment or evaluation is necessary (antibiotics, thyroid involvement, other renal pathology)

Anonymous Tintinalli p 641

A)  Urine Analysis- all patients with suspected renal colic require a urinanalysis.  The presence of blood in the urine supports the diagnosis of renal colic.  Urine dipstick may speed the detection of hematuria and exclude other possible causes such as infection.  The presence of crystals usually oxalate or rarely urate may indicate the type of the stone.

B)  The urine should be strained for any passed stones and all collected stones should be retained for pathologic analysis

23.       Identify the advantages and disadvantages of noncontrast helical CT in the detection of renal stones.

Zen Lite

• sensitive (95-97%) and specific (96-98%)

• comparable or superior to IVP

• unilateral ureteral dilatation and perinephric stranding PPV 96% stone Dx

• both absent NPV93-97%

Advantages

• avoidance of exposure radiocontrast agent

• > potential for identifying causes other than stone disease

• superior speed

Disadvantages

• Ø evaluate renal function

• Ø provide physiologic info ° obstruction

• need special skilled radiologist

• possible >cost

Zen Seeker Tinitinalli EM Fifth Edition

COMPUTED TOMOGRAPHY

The noncontrast helical CT scan has been shown to be both sensitive (95 to 97 percent) and specific (96 to 98 percent) in the detection of renal stones.12,13 Its accuracy is comparable or superior to that of the IVP.14 Images are obtained from the top of the kidney to the base of the bladder. Refocused images can be obtained in smaller increments through levels of suspicious calcifications and areas of ureteral caliber change. Secondary signs of ureteral obstruction, such as ureteral dilatation, stranding of perinephric fat, dilation of the collecting system, and renal enlargement, can also be helpful in making the diagnosis. In combination, unilateral ureteral dilatation and perinephric stranding have a positive predictive value of 96 percent for stone disease.13,15 When both are absent, the negative predictive value is 93 to 97 percent.13,15

Noncontrast helical CT has several advantages over other imaging modalities, including the avoidance of exposure to radiocontrast agent, greater potential for identifying causes other than stone disease, and superior speed. However, because oral and intravenous radiocontrast agents are not used, the specificity and sensitivity for other diseases, such as AAA or gastrointestinal disorders, are not as great as with imaging protocols employing contrast. Interpretation of a “negative” noncontrast CT scan, when obtained to evaluate the possibility of urologic stone disease, should be done cautiously and with consideration of the limitations of the study. Most newer-generation CT scanners can complete the study within 5 min.13

Several disadvantages exist in the use of CT. Helical CT does not evaluate renal function or provide physiologic information about the degree of obstruction. Furthermore, its diagnostic ability relies on a newer-generation CT scanner with a radiologist skilled in using this modality to evaluate stone disease. At some institutions the cost of CT may be greater than that of other imaging modalities.

Abdominal CT scanning is the modality of choice if suspicion of a perinephric abscess exists. However, the use of radiocontrast agents may be required for adequate detection of a potential abscess.

Jenn, Tintinalli pp 642

• Has been shown to be both sensitive (95-97%) and specific (96-98%) in the detection of renal stones.

• Accuracy is comparable or superior to that of the IVP.

• Images are obtained from the top of the kidney to the base of the bladder.

• Refocused images can be obtained in smaller increments through levels of suspicious calcifications and areas of ureteral caliber change.

• Secondary signs of ureteral obstruction, such as ureteral dilatation, stranding of perinephric fat, dilation of the collecting system, and renal enlargement, can also be helpful in making the diagnosis.  In combination, unilateral ureteral dilatation and perinephric stranding have a positive predictive value of 96% for stone disease.

Advantages over other imaging modalities:

•        Avoidance of exposure to radiocontrast agt

•        Greater potential for identifying causes other than stone disease

•        Superior speed

Disadvantages:

•        Helical CT does not evaluate renal function

•        Can not provide physiologic information about the degree of obstruction

•        Diagnostic ability relies on a newer-generation CT scanner w/a radiologist skilled in using this modality to evaluate stone disease.

•        Some institutions the cost of CT may be greater than that of other imaging modalities.

Dustin, Tintinalli pg. 642

The noncontrast helical CT scan has been shown to be both sensitive (95 to 97 percent) and specific (96 to 98 percent) in the detection of renal stones.  Its accuracy is comparable or superior to that of the IVP.  Images are obtained from the top of the kidney to the base of the bladder.  Refocused images can be obtained in smaller increments through levels of suspicious calcifications and areas of ureteral caliber change.  

Advantages:

¨ Avoidance of exposure to radiocontrast agent,

¨ Greater potential for identifying causes other than stone disease

¨Superior speed.

Disadvantages:

¨ Does not evaluate renal function or provide physiologic information about the degree of obstruction.

¨Its diagnostic ability relies on a newer-generation CT scanner with a radiologist skilled in using this modality to evaluate stone disease.  

¨ At some institutions the cost of CT may be greater than that of other imaging modalities.

Anonymous

Advantages:

• Avoidance of exposure to radiocontrast agent, greater potential for identifying causes other than stone disease, and superior speed.

• Specificity and sensitivity for other diseases such as AAA and GI disorders are not as great as with imaging employing contrast. Interpretation of a “negative” CT when ontained to evaluate possible stone disease should be done cautiously and with consideration of the limitations of the study.

Disadvantages:

• Does not evaluate renal function or provide physiologic information about the degree of obstruction. Diagnostic ability relies on a newer-generation CT with radiologist skilled in using this modality to evaluate stone disease. Cost may be higher at some institutions to use the CT.

Anonymous  

Advantages include: fast results and avoidance of exposure to contrast agents.  Disadvantages include: no evaluation of renal function, need newer-generation CT scanner and operator dependent.

Anonymous Tintinalli p 642

A)  Advantages to noncontrast helical CT include:

             1.  Highly sensitive and specific for detection of renal stones.  

             2.  Avoidance of exposure to radiocontrast media

             3.  Greater potential for identifying causes other than stone disease

             4.  Superior speed.

B)  Disadvantages to noncontrast helical CT include:

             1.  Does not evaluate renal function

             2.  Relies on a newer generation of CT scanner with a radiologist skilled in using this modality

             3.  Cost is greater

24.       Identify the advantages and disadvantages of intravenous pyelogram (IVP).

Zen Lite

sensitivity of 64-90% and specificity of 94-100%

Advantages

• both renal function and anatomic morphology

• more widely available than CT

• valuable as an adjunct to CT

Disadvantages

• risk of renal injury from radiocontrast dye (anaphylaxis)

• Radiocontrast-agent nephrotoxicity > preexisting renal insufficiency or DM

• predisposing factors

  • dehydration

  • hypovolemia

  • hypotension

  • >70 yrs

  • multiple myeloma

  • hyperuricemia, hypertension

  • hx IV radiocontrast media within 72h

  • use of diuretics to Tx CV Dx

• detect renal calculi < CT

• used c caution if taking metformin (severe lactic acidosis and nephropathy)

• time to complete study (up to several h)

• possible obstipation or ileus (s bowel prep in ED)

Zen Seeker Tinitinalli EM Fifth Edition

INTRAVENOUS PYELOGRAM

The IVP yields information regarding both renal function and anatomic morphology. Its ability to detect renal calculi has been found to be less than that of CT, with a sensitivity of 64 to 90 percent and specificity of 94 to 100 percent.16,17

When performing the IVP, intravenous fluid is administered to ensure that the patient is hydrated and will sustain adequate urinary flow throughout the procedure. Maintaining adequate urine output by the administration of intravenous fluids prior to radiocontrast media may decrease the risk of renal injury from radiocontrast dye. After radiocontrast media is administered, an initial scout radiograph is obtained, followed by repeat films at 5, 10, and 20 min. The first and most reliable indication of the presence of obstruction is a delay in the appearance of the nephrogram. Since the ureter is a peristaltic structure, it is usually not completely seen on any one radiograph. Visualization of the entire ureter is suggestive of obstruction. 

The location of a radiolucent obstructing stone can often be determined by a ureteral dye-column cutoff. Adjuncts to the diagnosis of renal colic include the presence of a prolonged nephrogram, renal enlargement, dilatation of the collecting system or ureter, and dye extravasation.18 If extravasation of dye is noted, it should be considered evidence of an obstruction that has decompressed into the perinephric tissue. Extraurinary collections of urine (urinoma) have the potential for infection and abscess formation.

A postvoid film is useful for identifying stones at the UVJ or distal ureter that are otherwise obscured by a full bladder. Multiple delayed films may be required to precisely determine the level of obstruction.

The main advantage of the IVP over other imaging modalities is its ability to give information on both renal function and anatomy. In addition, IVP may be more widely available than CT, depending on the institution. It may also be valuable as an adjunct to CT when functional information and knowledge of the degree of obstruction are required.

The most important potential disadvantage of the IVP is use of radiocontrast dye. Side effects of radiocontrast dye, allergic reaction and nephrotoxicity, must always be considered when ordering an IVP. Prior to obtaining an IVP, the patient should be closely questioned regarding the presence of allergy to radiocontrast media. Appropriate material for managing acute anaphylaxis should be immediately available for unexpected allergic reactions. A history of dye allergy should prompt the selection of an alternative diagnostic modality.

Radiocontrast-agent nephrotoxicity is most likely to occur in patients with preexisting renal insufficiency or diabetes mellitus.18 These patients have a 9 percent risk of nephrotoxicity attributable to radiocontrast dye.18 Other predisposing factors include dehydration, hypovolemia, hypotension, advanced age (over 70 years), multiple myeloma, hyperuricemia, hypertension, a history of intravenous radiocontrast media within 72 h, and the use of diuretics to treat cardiovascular disease. In patients at risk for nephrotoxicity when the administration of a radiocontrast agent is not otherwise contraindicated, the dye administration should be deferred until normal blood urea nitrogen and creatinine levels are documented. Although they are also nephrotoxic, nonionic contrast agents may result in a lower frequency of kidney damage. Finally, radiocontrast media should be used with caution in patients taking metformin, which has been associated with severe lactic acidosis and nephropathy in combination with radiocontrast material. Other imaging modalities, such as noncontrast CT or ultrasound, may be preferred for these patients.

Another disadvantage of the IVP is the potential time required to complete the study. If evidence of obstruction exists, serial delayed films are often obtained to delineate the level of obstruction. This may require several hours and multiple repeat radiographs and may delay the final diagnosis. Also affecting the quality of the IVP is the state of the bowel. Since emergency department practice does not allow for a bowel preparation, the IVP can be adversely affected by obstipation or ileus.

A false-negative IVP infrequently occurs when there is a small or radiolucent, partially obstructing stone. The IVP will also be “negative” if the ureteral stone passes into the bladder before radiocontrast dye is excreted by the kidneys. If this happens, the patient usually experiences nearly complete relief of pain. The IVP may also show evidence of ureteral spasm after passage of a stone.

Jenn, Tintinalli pp 642

The IVP yields information regarding both renal function and anatomic morphology.

Advantage of the IVP over other imaginig modalities:

• Its ability to give information on both renal function and anatomy.

• IVP may be more widely available than CT, depending on the institution

• May also be valuable as an adjunct to CT when functional information and knowledge of the degree of obstruction are required.

Disadvantages:

• Use of the radiocontrast dye.  Side effects of radiocontrast dye, allergic reaction and nephrotoxicity, must always be considered when ordering an IVP.

• Radiocontrast-agt nephrotoxicity is most likely to occur in patients w/preexisting renal insufficiency or DM.  Other predisposing factors include dehydration, hypovolemia, hypotension, advanced age (>70yo), multiple myeloma, hyperuricemia, hypertension, a history of intravenous radiocontrast w/in 72h and the use of diuretics to treat cardiovascular disease.

• Potential time required to complete the study, If evidence of obstruction exists, serial delayed films are often obtained to delineate the level of obstruction.  This may require several h and multiple repeat radiographs and may delay the final diagnosis.

• State of the bowel affects the quality of the IVP

• False-negative IVP infrequently occurs when there is a small or radiolucent, partially obstructing stone.

• The IVP may be negative if the ureteral stone passes into the bladder before radiocontrast dye is excreted by the kidneys.

Dustin, Tintinalli pg. 642-3

Advantages:

¨ Ability to give information on both renal function and anatomy.

¨ IVP may be more widely available than CT, depending on the institution.

¨ May also be valuable as an adjunct to CT when functional information and knowledge of the degree of obstruction are required.

Disadvantages:

¨ It uses radiocontrast dye.  Side effects of radiocontrast dye, allergic reaction and nephrotoxicity, must always be considered when ordering an IVP.

¨ Radiocontrast-agent nephrotoxicity is most likely to occur in patients with preexisting renal insufficiency or diabetes mellitus.  These patients have a 9 percent risk of nephrotoxicity attributable to radiocontrast dye.  Other predisposing factors include dehydration, hypovolemia, hypotension, advanced age (over 70 years), multiple myeloma, hyperuricemia, hypertension, a hx of intravenous radiocontrast media within 72 h, and the use of diuretics to treat cardiovascular disease.

¨ Radiocontrast media should be used with caution in patients taking metformin, which has been associated with severe lactic acidosis and nephropathy in combination with radiocontrast material.

¨ Another disadvantage of the IVP is the potential time required to complete the study.  If evidence of obstruction exists, serial delayed films are often obtained to delineate the level of obstruction.  This may require several hours and multiple repeat radiographs and may delay the final diagnosis.

¨The state of the bowel also affects the quality of the IVP.

¨ False-negative IVP infrequently occurs when there is a small or radiolucent, partially obstructing stone.

¨ The IVP will also be “negative” if the ureteral stone passes into the bladder before radiocontrast dye is excreted by the kidneys.

Anonymous

Advantages:

• Ability to give information on both renal function and anatomy. IVP may be more widely used than CT depending on the institution. May be valuable as an adjunct to CT when functional information and knowledge of degree of obstruction is required.

Disadvantages:

• Use of radiocontrast dye, side effects of dye, allergic reactions, and nephrotoxicity must be considered. Potential time required to complete study if obstruction exists. May take several hours and multiple repeat films to delineate level of obstruction. IVP can be affected by state of bowel since there is no bowel preparation. Can be affected by obstipation or ileus. A false-negative IVP infrequently occurs when there is a small or radiolucent, partially obstructing stone. May also be “negative” if stone passes into bladder before dye is excreted by kidneys. IVP may also show ureteral spasm after passage of stone.

Anonymous  Tintinalli, pgs. 642-3

The main advantage of the IVP over other imaging modalities is its ability to give information on both renal function and anatomy.  Although its ability to detect renal calculi has been found to be less than that of CT, IVP may be more widely available than CT.  It may also be valuable as an adjunct to CT when functional information and knowledge of the degree of obstruction are required.

The most important potential disadvantage of the IVP is use of radiocontrast dye.  Side effects of radiocontrast dye, allergic reaction and nephrotoxicity, must always be considered when ordering an IVP.

Radiocontrast-agent nephrotoxicity is most likely to occur in patients with preexisting renal insufficiency or DM.  Other predisposing factors include dehydration, hypovolemia, hypotension, a history of IV radiocontrast media within 72 h, and the use of diuretics to treat CV disease.  Another disadvantage of the IVP is the potential time required to complete the study.

Anonymous Tintinalli p 642

A)  Advantages to IVP- this yields information regarding both renal function and anatomic morphology.  

B)  Disadvantages to IVP- potential adverse reactions to necessary radiocontrast dye

25.       Explain why getting plain abdominal films is important even though they have a low sensitivity for detecting stones.

Zen Lite

• 90% urinary calculi radiopaque

• a low sensitivity (29-58%) and specificity (69-74%)

• low NPV (23%)

• exclusion of other pathologic conditions

• helpful c dye allergy

• other imaging unavailable

• F/U known radiopaque stones

• localizing established migrating stone

Zen Seeker Tinitinalli EM Fifth Edition

PLAIN ABDOMINAL RADIOGRAPHS

The composition of most urinary calculi makes them sufficiently dense that the majority (90 percent) are radiopaque.2 Calcium phosphate and calcium oxalate stones have a density similar to that of bone. Magnesium-ammonium-phosphate (struvite) calculi are slightly less radiodense, followed by cystine, which is only partially radiodense. Uric acid and matrix stones are essentially radiolucent. Most stones associated with medications are radiolucent as well, including those associated with the protease inhibitor indinavir.21 However, because of their small size and the overlapping soft-tissue and bone shadows seen on abdominal radiographs, urinary stones are visible much less frequently on plain films. Plain abdominal radiographs alone have a low sensitivity (29 to 58 percent) and specificity (69 to 74 percent) compared to other imaging modalities.17,22,23 In addition, a low negative predictive value (23 percent) makes a “negative” radiograph of little value in ruling out stone disease.22 While a plain abdominal radiograph can assist in localizing some large radiopaque stones, its greatest utility is in the exclusion of other pathologic conditions. However, a plain abdominal radiograph may be helpful in patients with dye allergy, when other imaging modalities are unavailable, or in follow-up of known radiopaque stones. In patients for whom the diagnosis is already established (recent IVP, CT, or ESWL), a plain abdominal radiograph may suffice in localizing a migrating stone.

Jenn, Tintinalli pp 643

While a plain abdominal radiograph can assist in localizing some large radiopaque stones, its greatest utility is in the exclusion of other pathologic conditions.

Dustin, Tintinalli, pg. 643

While a plain abdominal radiograph can assist in localizing some large radiopaque stones, its greatest utility is in the exclusion of other pathologic conditions.  However, a plain abdominal radiograph may be helpful in patients with dye allergy, when other imaging modalities are unavailable, or in follow-up of known radiopaque stones.  In patients for whom the diagnosis is already established (recent IVP, CT, or ESWL), a plain abdominal radiograph may suffice in localizing a migrating stone.

Anonymous

• Plain abdominal films alone have a low sensitivity (29-58%) and specificity (69-74%) compared to other imaging modalities. A low negative predictive (23%) makes a “negative” radiograph of little value in ruling out stone disease.

• It’s greatest utility is the exclusion of other pathologic conditions. May be helpful in patients with dye allergy, when other imaging modalities unavailable, or in followup of known radiopaque stones. In patients whom diagnosis already established (recent IVP, CT, or ESWL) a plain film may suffice in localizing a migrating stone.

Anonymous   Tintinalli, pg. 643

The composition of most urinary calculi makes them sufficiently dense that the majority (90%) are radiopaque.  However, because of their small size and the overlapping soft-tissue and bone shadows seen on abdominal radiographs, urinary stones are visible much less frequently on plain films.  While a plain abdominal radiograph can assist in localizing some large radiopaque stones, its greatest utility is in the exclusion of other pathologic conditions.

Anonymous Tintinalli p 643

A)  A plain radiograph can assist in localizing some radio opaque stones, its greatest utility is in the exclusion of other pathological conditions.

26.        Describe the typical treatment of kidney stones in the ED.

Zen Lite

• pain control

  • multiple doses IV narcotics, titrated

  • c or s NSAIDs

  • NSAIDs used c caution (compromised renal function)

• antiemetic prn

• IV fluids

• antibiotics prn

• urologic consultation

Zen Seeker Tinitinalli EM Fifth Edition

Treatment

The mainstay of emergency department treatment is pain control. Because in most cases the diagnosis is clinical, a rapid urine dipstick test for heme may provide sufficient information, coupled with clinical findings, to initiate analgesic therapy. Pain medication should not be delayed pending test results. Adequate analgesia frequently requires multiple doses of intravenous narcotics, titrated to the patient´s level of discomfort. Narcotics may be accompanied by nonsteroidal anti- inflammatory drugs (NSAIDs) but NSAIDs should not be used in place of narcotics. The time of onset of NSAIDs is slower than that of intravenous narcotics. NSAIDs should be used with caution in patients with suspected compromise in overall renal function (elderly patients, diabetics, those with known renal insufficiency, and hypovolemic patients) so as not to precipitate or accelerate a decline in renal function. An antiemetic is an appropriate adjunct when emesis accompanies the symptoms or when nausea accompanies narcotic use. Intravenous fluids, usually normal saline solution, should be administered. For patients with evidence of associated infection, parenteral antibiotics should be administered promptly in the emergency department, and emergency urologic consultation should be obtained.

Suzy Tint 644

Pain control.  IV narcotics, titrated to patient's level of discomfort. NSAIDS accompanied but used with caution in pts. suspected compromise in overall renal function (elderly, diabetics, those with known renal insufficiency, and hypovolemic pts).

Antiemetic if appropriate. IV fluids, and if evidence of associated infection parenteral antibiotics.

Urology consultation for infection.

Shauna Tintintalli pg 644

The mainstay of ED treatment is pain control. Pain medication should not be delayed pending test results. Adequate analgesia frequently requires multiple doses of intravenous narcotic, titrated to the patient’s level of discomfort. NSAIDs may accompany narcotics, but should not be used alone. An antiemitic is an appropriate adjunct when emesis accompanies the symptoms or when nausea accompanies narcotic use. IV fluids should be administered. For patients with evidence of associated infection, parenteral antibiotics should be administered promptly in the ED, and emergency urologic consultation should be obtained.

Anonymous

Mainstay of treatment is pain control. Because most cases the diagnosis is clinical, a rapid urine dipstick test foe heme may provide sufficient information, coupled with clinical findings, to initiate analgesic therapy. Pain meds should not be delayed pending test results. Adequate analgesia frequently requires multiple doses of IV narcotics titrated to patient level of discomfort. Narcotics my be accompanied by NSAIDS but used cautiously in those with suspected compromise in overall renal function. Antiemetic when emesis accompanies symptoms or when nausea from narcotic use. IV fluids, usually normal saline, is administered. For patients with evidence of associated infection, parenteral antibiotics administered promptly in ER and emergency urology consult obtained.

Anonymous   Tintinalli, pg.

The mainstay of ED treatment is pain control.  Because in most cases the diagnosis is clinical, a rapid urine dipstick test for heme may provide sufficient information, coupled with clinical findings, to initiate analgesic therapy.  Pain medication should not be delayed pending test results.  Adequate analgesia frequently requires multiple doses of IV narcotics and NSAIDs.  An antiemetic is an appropriate adjunct when emesis accompanies the symptoms or when nausea accompanies narcotic use.  IV fluids, usually normal saline solution, should be administered.  For patients with evidence of associated infection, parenteral antibiotics should be administered promptly in the ED, and emergency urologic consultation should be obtained.

Anonymous Tintinalli p 644

A)  The mainstay of emergency department treatment is pain control.  Other treatments may include:

             1.  A urine analysis may aid in diagnosis but not should delay pain control.  

             2.  Antiemetic may be necessary in addition to curb nausea in some patients.  

             3.  Intravenous fluids namely normal saline should be administered

             4.  For patients with evidence of infection parenternal antibiotics should be administered promptly.  

             5.  Urologic consultations should be arranged if not performed directly in the ED.

27.       Identify which patients should be admitted.

Zen Lite

1. infection c concurrent obstruction

2. solitary kidney and complete obstruction

3. uncontrolled pn

4. intractable emesis

Zen Seeker Tinitinalli EM Fifth Edition

Disposition

Admission to the hospital is indicated if there is (1) infection with concurrent obstruction, (2) a solitary kidney and complete obstruction, (3) uncontrolled pain, or (4) intractable emesis.2 Patients with an infection and concurrent obstruction have the potential for severe systemic toxicity and represent a urologic emergency. Patients with renal impairment are candidates for consideration of a drainage procedure, since they have little functional renal reserve. Because of lower rates of spontaneous passage, patients with large (>5 mm), irregular, or proximal stones should be considered for admission. If there is severe concurrent underlying disease (e.g., angina or chronic obstructive pulmonary disease) or in the fragile elderly, when the patient may be unable to tolerate the stress of renal colic, a lower admission threshold is indicated. When the IVP or CT scan demonstrates complete obstruction, or dye extravasation, the admission decision requires individualization and discussion with a urologist. Patients who have previously been diagnosed and managed as outpatients are more likely to require admission if they return with continued pain. A careful history and physical examination are indicated to ensure that the diagnosis is correct, but repeat imaging is probably unnecessary.

Suzy Tint 644

1-infection with concurrent obstruction - potential for severe systemic toxicity

2-a solitary kidney and complete obstruction - consider a drainage procedure

3- uncontrolled pain - There maybe an underlying disease (angina or COPD) or fragile elderly

4-intractable emesis

Shauna Tintinalli pg 644

Admission to the hospital is indicated if there is:

-infection with concurrent obstruction,

-a solitary kidney and complete obstruction,

-uncontrolled pain,

-intractable emesis.

Anonymous

• Admission indicated IF:

  • infection with concurrent obstruction

  • a solitary kidney and complete obstruction

  • uncontrolled pain

  • intractable emesis.

• Patients with an infection and concurrent obstruction have potential for severe systemic toxicity and represent urologic emergency.

• Patients with renal impairment are candidates for consideration of a drainage procedure since they have little functional renal reserve.

• Patients with >5mm, irregular, or proximal stones should be considered for dmission because of lower spontaneous passage rates.

• If severe underlying disease, fragile elderly, or when the patient may be unable to tolerate the stress of renal colic have a lower admission threshold.

• When IVP or CT demonstrates complete obstruction or dye extravasation, admission decision requires individualization and discussion with urologist.

• Patients previously diagnosed and managed as outpatients are more likely to be admitted if they return with continued pain.

Anonymous  

Admit if: infection with concurrent obstruction, a solitary kidney and complete obstruction, uncontrolled pain, or intractable emesis. (Tintinalli, p. 644)

Anonymous Tintinalli p 644

A)  Admission to the hospital is indicated if there is:

             1.  Infection with concurrent obstruction

             2.  Solitary kidney and complete obstruction

             3.  Uncontrolled pain

             4.  Intractable emesis

28.       Identify which patients are safe to be discharged home and how outpatient management differs according to whether the stone passed in the ED or not.

Zen Lite

Discharge appropriate (all)

• smaller

• rounded stones

• Ø infection,

• pn controlled by PO analgesics

passed stone in ED Ø need further Tx

Zen Seeker Tinitinalli EM Fifth Edition

In most situations, unilateral renal obstruction has minimal acute or permanent effects. Discharge is appropriate in patients with smaller, rounded stones, in the absence of infection, and when pain is controlled by oral analgesics. Patients should be given a urinary strainer with instructions to save any stones that are passed for pathologic evaluation. Patients should be counseled to return promptly for fever, vomiting, or uncontrolled pain, and they require a prescription for an oral narcotic. Follow-up with a urologist should be arranged within 7 days.24 Patients whose stone passes in the emergency department require no further treatment. Elective urologic consultation should be arranged so that the etiology of the stone can be determined and a prophylactic strategy arranged. Patients with hematuria, negative imaging study findings, and no other attributable source require urologic follow-up to determine the etiology of their hematuria.

The management of patients with protease-inhibitor-induced urolithiasis is similar to the management of other causes of stone disease; however, adequate hydration is particularly important.21 In addition, discontinuation of the offending agent for a short period of time may be necessary. Such a decision should be made in consultation with a urologist and an infectious disease specialist. Disposition should be discussed with a urologist if there is (1) renal insufficiency, (2) severe underlying disease, (3) an IVP showing extravasation or complete obstruction, (4) multiple visits, (5) a large stone, or (6) sloughed renal papillae.2

Suzy Tint 644

Patients who have previously been diagnosed and managed as outpatients are more likely to require admission if they return with continued pain.

Discharge is appropriate in patients with smaller, rounded stones, in the absence of infection, and when pain is controlled by oral analgesics. Pts should be given a urinary strainer with instructions to save any stones for pathologic evaluation. Pts should be counseled to return promptly for fever, vomiting, or uncontrolled pain, and they require a prescription for an oral narcotic. Follow-up with an urologist within 7 days.

Stone passes in the ED require no further treatment. Elective urology consultation should be arrange so that the etiology of the stone can be determined and a prophylactic strategy arranged. Pts with hematuria, negative imaging study findings, and no other attributable source require urology follow-up to determine the etiology of their hematuria.

Protease-inhibitor-induced urolithiasis is similar to the management of other causes of stone disease however, adequate hydration is particularly important.

Shauna Tintinalli pg 644

Discharge is appropriate in patients with smaller, rounded stones, in the absence of infection, and when pain is controlled by oral analgesics. Patients should be given a urinary strainer with instructions to save any stones that are passed for pathologic evaluation. Patients should be counseled to return promptly for fever, vomiting, or uncontrolled pain, and they require a prescription for an oral narcotic. Follow-up with a urologist should be arranged within 7 days.  Patients whose stone passes in the ED require no further treatment

Anonymous

Patients with smaller, rounded stones, in the absence of infection, and when pain is controlled by oral analgesics. Patients given oral strainer to collect passed stones for pathologic analysis. Counseled to return promptly for fever, vomiting, and uncontrolled pain. Given prescription for oral analgesic and follow-up with urologist within 7 days.

Patient whose stone passes in ER does not require further treatment. Elective urologic consultation should be arranged to determine stone etiology and prophylactic strategy arranged. Patients with hematuria, negative imaging, and no other attributable source require urologic follow-up to determine etiology of hematuria.

Anonymous  Tintinalli, p. 664

Discharge appropriate if: pt has smaller, rounded stones, absence of infection, or when pain is controlled by oral analgesics. If stone is not passed in ED, give strainer (with instructions to save any passed stones for pathology evaluation), counsel to return promptly for fever, vomiting or uncontrolled pain, give Rx for oral narcotic. Arrange follow-up with urologist within 7 days. Pt. who passes stone in ED requires no further treatment. Refer for elective urology consult to determine etiology of stone and develop prophylactic strategy.

Anonymous Tintinalli p 644

A)  Discharge is appropriate in patients:

             1.  Patients with smaller rounded stones

             2.  Patients with absence of infection

             3.  Patients who have achieved pain control

B)  Outpatient management- Patients are given a urine strainer with instructions to save any stones that are passed for pathologic evaluation.  Patients should be counseled to return promptly if fever, vomiting, or uncontrolled pain.  Follow up with a urologist should be scheduled within 7 days.  

C)  Patients with hematuria, negative imaging study findings, and no other attributable source require urologic follow up to determine the etiology of their hematuria.