Daniel Morrissy DO

ADVENTURES IN EMERGENCY MEDICINE UROLOGY

TODAY’S TOPICS

• Infection

• Renal/ureteral Calculi

• Urinary Retention

URINARY TRACT INFECTIONS

• Diagnosis and treatment is dependent on the age, sex and commorbities of the patient

SIGNS AND SYMPTOMS OF UTI

• Dysuria

• Urgency

• Frequency

• Polyuria

• Suprapubic tenderness

• Flank Pain

• Fever

DIAGNOSTIC TESTS

• Urine Culture = Gold standard

• Urine Dipstick

• Nitrite –High Specificity, moderate sensitivity (gram negatives)

• Leukesterase – less specific, moderate sensitivity

• Hematuria – very sensitive, Low specificity

• Urine Microscopy

• Gram stain sensitive above <105 cfu/mL

SUSPECTED LOWER UTI IN NONPREGNANT FEMALE

• Absence of vaginal itch or discharge

• Multiple symptoms present = treat (nitrofurantoin or TMP-SMX)

• Few symptoms + Dipstick positive = Treat

• Symptoms + negative or equivocal dipstick = Offer empiric therapy and investigate further if still symptomatic

SUSPECTED UPPER UTI – NONPREGNANT FEMALE

• Signs of UTI with fever, flank pain, systemic inflammatory response

• Urine culture recommended

• Quinolones recommended

• Admission for systemic disease/ unwell

PREGNANT WOMEN

• Symptomatic Bacturia

• Treat with appropriate antibiotic

• Urine culture should be sent

• Follow up culture in 7 days after completion should be done

• Asymptomatic Bacturia

• Urine culture to determine treatment – NOT dipstick

• If culture positive confirm with second and treat

CATHETER ASSOCIATED UTI

• Signs of UTI without other identifiable source

• <103 cfu/mL of 1 or more bacterial species in urine specimen where catheter has been changed in last 48 hrs

• Replace catheter if in place >2 weeks to onset of symptoms

• Obtain culture prior to antibiotics from new catheter or midstream urine

• Pyuria alone cannot differentiate colonization vs infection

• Absence of pyuria suggests alternative diagnosis

• Empiric use of quinalones then guided by culture

CHILDREN• Age - Dramatic decrease in prevalence after 1 year

• 0-2 months

• 2 month – 2 years

• 2-6 years

• >6 years

• Females greater than males

• Uncircumcised greater than circumcised

• Specimens should be straight cath or suprapubic aspiration if unable to control urine or significant external irritation (urine bags are not recommended, only helpful if cx neg)

• Culture is gold standard

• Urinalysis can guide initiation of antibiotics (50,000 CFU/ml)

MALE UTI• Differentiate Sexually transmitted disease from UTI

• Prostatitis

• Epididimitis

• Epiditimo-orchitis

• Orchitis

RENAL CALCULI

RENAL CALCULI

ETIOLOGY OF STONE FORMATION• Dependant on type of Stone

• Calcium 75% (oxalate > phosphate)

• Struvite 15% (Urease-producing bacteria – proteus, klebsiella, Pseudomonas, staph)

• Uric Acid 6% (Low urine pH, Low output, high uric acid level)

• Combination of high concentrations of stone-forming salts and insufficient inhibitory proteins

DIFFERENTIAL DIAGNOSIS

DIAGNOSITIC STUDIES

• Urinalysis (check for blood, rule out infection)

• Labs – CBC?, Urea??, Cr???

• Radiographic studies – KUB (60% of stones visible), Intravenous pyelogram

• Ultrasound - Pregnacy/children

• Non-Enhanced CT Abd/Pelvis

• MRI

TREATMENT

• Pain Control – NSAIDS, Narcotics

• Anti-emetics as needed

• IV Fluids???

• Medical Expulsive Therapy – Calcium Channel Blockers, Steroids, Alpha-adrenergic Blockers

• Tamsulosin 0.4mg daily x 4 weeks (44% more likely to pass)

HEY DOC?

• How Long does it take for stones to pass?

• What size stone requires Urology consultation?

• What can the patient do to prevent future stone formation?

INDICATIONS OF ADMISSION/ INTERVENTION

• Obstruction with infection

• Intractable pain with refractory vomiting

• Impending renal failure

• Severe dehydration

• Single kidney or transplant

• Bilateral obstruction

• Urinary Extravasation

ACUTE URINARY RETENTION

ACUTE URINARY RETENTION

• Inability to pass urine voluntarily

• Distending bladder causing extreme discomfort

ETIOLOGY

• Pharmacological

• Neurological

• Infectious/Inflammatory

• Obstruction

What is the most common presentation in the emergency department?

PHARMACOLOGICAL CAUSES• Increased sphincter tone or prolonged bladder immotillity

• Antiarrhythmics

• Anticholinergics

• Antidepressants

• Antihistamines

• Antihypertensives

• Antiparkinsonians

• Antipsychotics

• Muscle Relaxants

• Sympathomimetics

• Etc…….

NEUROLOGIC CAUSES• Diabetic Cystopathy

• Upper Motor Neuron Lesions – Multiple Sclerosis, Parkinson’s disease, Trauma, Stroke, neoplasms

• Lower motor Neuron Lesions – Spinal cord tumors, epidural abcesses, trauma

INFECTIOUS CAUSES• Urethritis, Prostatitis, Severe Vulvovaginitis

• Genital Herpes – involving the Sacral nerves

OBSTRUCTIVE CAUSES• Intrinsic – BPH, bladder stones, blood clots

• Extrinsic – Masses, cystocele, rectocele

Women Men

Obstructive – Cystocele, tumor Obstructive – BPH, Meatal stenosis, Phimosis/paraphimosis, tumor

Infectious Infectious

Operative Operative

LABORATORY TESTING• Urinalysis – MOST IMPORTANT

• Hematuria

• Infection

• Electrolytes, Urea, Creatinine – Evaluate renal function in setting of prolonged obstruction

• CBC – Select patients with serious infection, hematologic disorders or hypovolemia

IMAGING STUDIES• Bladderscan – bladder volume

• Renal Ultrasound – Hydronephrosis, stone, obstruction

• Bladder ultrasound – Bladder masses,stone, free fluid, volume

Does the degree of hydronephrosis correlate with serum creatinine?

TREATMENT

• Immediate and complete decompression of the bladder through urinary catheterization

• Complications – Hematuria, hypotension, post-obstructive diuresis(Which patients are at risk?), infection.

What is the proper technique?

TYPES OF CATHETERS

Foley Cathetyer Coude Catheter Triple lumen catheter

When do you use each catheter?

BLADDER IRRIGATION

• What fluid do you use?

RELATIVE CONTRAINDICATIONS TO CATHETER PLACEMENT

• Pelvic trauma with blood at meatus

• Penile deformity

• Perineal hematoma

• Known impassible catheterization

• History of known recent prostate or bladder neck surgery

When do you call the Urologist?

SUPRAPUBIC CATHETERS INDICATIONS

• Failure of Urethral catheter in Acute Urinary Retention

• Contraindication to urethral catheterization

• Major Urethral Trauma and no Urologist Available

Use ultrasound to help ensure proper placement.

DISPOSITION

• DISCHARGE if Successful catheterization

• Leave catheter in for BPH (70% recurrence rate)

• Place a leg bag

• Prescribe Alpha Blocker (Tamulosin)

• ADMIT - If any of the following present:

• Severe infection

• Significant comorbidity

• Impaired Renal function

• Neurological deficits

• Catheter complications

SPECIAL CONSIDERATIONS

• Antibiotics – Only if treating infection

• How long should the catheter stay in? BPH vs precipitated?

• Should you test the foley balloon prior to insertion?

• What should the balloon be filled with? Why?

QUESTIONS?