What is Happening Down There? Urological Emergencies Faculty Jonathan Snashall, M.D. Emergency Medicine Physician Shady Grove Adventist Hospital Medical Emergency Professionals Rockville, MD Faculty Disclosures No Disclosures Learning Objectives At the conclusion of this session the participant will be able to 1. Recognize Urological emergencies and when to call a specialist 2. Know the Management of Fournier’s gangrene 3. Understand phimosis and paraphimosis 4. Understand the treatment for pathological erections 5. Know how to quickly evaluate for testicular torsions 6. Understand the management of urologic infections 7. Know kidney stone diagnosis and treatment 8. Have a basic understanding of renal transplant patients *This lecture is supported by Medical Emergency Professionals.* Professionals.* 8/20/2013 Urological Emergencies Jonathan Snashall, MD Trends in Patient Management Conference Maryland Academy of Physician Assistants Medical Emergency Professionals Ocean City, Maryland September 12th, 2013 Fournier’s Gangrene • Surgical Emergency – Polymicrobial – Immunocompromised – Begins as benign infection (cellulitis, abscess) – Consider in any patient with scrotal, rectal or genital pain out of proportion to clinical findings Fournier’s Gangrene • Surgical Emergency – Polymicrobial – Immunocompromised – Begins as benign infection (cellulitis, abscess) – Consider in any patient with scrotal, rectal or genital pain out of proportion to clinical findings 1 8/20/2013 Necrotizing Soft Tissue Infection • • • • • • • • • Pain out of proportion (POOP) or Indifference Vital signs derangements (especially tachycardia) Extremely elevated WBC count Low serum sodium Blisters Odor Rapid change Skin appearance will be variable Subcutaneous air (Crepitus) Necrotizing Soft Tissue Infection • • • • • • • • • Pain out of proportion (POOP) or Indifference Vital signs derangements (especially tachycardia) Extremely elevated WBC count Low serum sodium Blisters Odor Rapid change Skin appearance will be variable Subcutaneous air (Crepitus) “Did you look at his nuts?” Phimosis • Characteristics – Definition: Unable to retract foreskin • Rarely emergent – Complication: Urinary retention (rare) • Treatment – Dilation of preputial ostium • Only if retention present 2 8/20/2013 Phimosis • Characteristics – Definition: Unable to retract foreskin • Rarely emergent – Complication: Urinary retention (rare) • Treatment – Dilation of preputial ostium • Only if retention present Paraphimosis • Characteristics – Definition: Retracted foreskin (Emergency) – Complication: Necrosis of glans 3 8/20/2013 Phimosis vs Paraphimosis Phimosis vs Paraphimosis Phimosis vs Paraphimosis 4 8/20/2013 Paraphimosis • Treatment: – – – – Compression (Manual Reduction) Elastic Bandage Non-crushing Clamps Osmotic Method: • Granulated Sugar • Swab in 50 mL of 50% Dextrose – – – – – Puncture Method Hyaluronidase Method Aspiration Vertical (Dorsal) Incision Emergent Circumcision Manual Reduction of Paraphimosis 5 8/20/2013 Paraphimosis – Clamp Method Paraphimosis – Puncture Method Paraphimosis – Dorsal Slit 6 8/20/2013 Fractured Penis • Occurs during intercourse – Reverse Cowgirl • Rupture of tunica albuginea / corpus cavernosum • Hematoma formation, may involve urethra Fractured Penis • Diagnosis: – Diagnosed based on H&P – Equivocal Cavernosonography or MRI. – Urethral injury must be considered – Preoperative retrograde urethrographic Fractured Penis • Surgical management – Goals of Surgery: • Preservation of penile length • Preservation of erectile function • Maintenance of the ability to void while standing 7 8/20/2013 Priapism • Definition: – Pathologic erection – Involves both corpora cavernosa but NOT the glans or corpus spongiosum • Shaft but no glans = Pathology • Complications: – Urinary retention – Impotence Priapism Etiology • Two Forms / Causes – Low-Flow Priapism (Ischemic) • • • • Sickle cell or other hematologic diseases Intracavernosal injections Drugs (Phenothiazines, SSRIs, Viagra, Neuroleptics) Spinal cord injuries – High-Flow Priapism (Arterial Injury) • Trauma (straddle mechanism) • Fistula Priapism Treatment • Treatment Low Flow: – – – – – – Terbutaline Pseudophedrine Corporal aspiration and irrigation Phenylephrine injection into corpora If Sickle Cell consider transfusion Surgery: Shunt placement • Treatment High Flow: – Observation – Embolization – Surgery: Ligation of offending vessel 8 8/20/2013 Priapism Treatment Priapism and Sickle Cell • • • • • • • Treat the underlying etiology Hydration Alkalization Analgesia Oxygenation Blood Transfusion Exchange Transfusions Testicular Torsion • Peak incidence in puberty • Bell Clapper Deformity: – Testis is free to swing and rotate inside the tunica vaginalis, failure of posterior anchoring by the gubernaculum. 9 8/20/2013 Testicular Torsion Presentation • • • • • • Sudden onset of testicular pain Testicle is elevated Horizontal lie Cremasteric reflex, usually absent Bedside Sono – no color vs color Prehn’s sign usually absent – Relief of pain by scrotal elevation – Sign of epididymitis • Consider torsion in any young male with abdominal pain Testicular Torsion Presentation Testicular Torsion Presentation 10 8/20/2013 Testicular Torsion Presentation Testicular Torsion Presentation Testicular Torsion Presentation 11 8/20/2013 Testicular Torsion Diagnosis Testicular Torsion Treatment Manual Detorsion THEN Emergency Surgery • Manual Detorsion: – Detorse medial-to-lateral • Open the book when looking from the feet – – – – Relief of pain, normal lie indicates success If unsuccessful, try opposite direction High salvage rate if detorsed within 6 hours High loss rate if detorsed after 8 hours • Emergency Surgery: – Call the urologist STAT – THEN do the formal U/S or nuclear scan – Bilateral Orchidopexy Testicular Torsion Treatment 12 8/20/2013 Prostatitis • Causes: – Same etiologies and age related factors as epididymitis • Young Boys: structural abnormality – E. Coli • Sexually Active (< 35): STD related (Chlamydia, GC) • Older Patients: Obstruction, Enlarged Prostate – E. Coli • Presentation – Perineal pain, frequency, dysuria – Fevers, chills, urinary retention – Boggy, enlarged, tender prostate Prostatitis Treatment • Acute Outpatient Treatment: – STD Suspected < 35: Ceftriaxone 250 mg IM Once + Doxycycline 100 mg PO BID x 14 days – STD Not Suspected > 35: Ciprofloxacin 500 mg PO BID x 28 days • Acute Inpatient Treatment – IV Antibiotics – Suprapubic draining PRN – Do NOT massage prostate or place foley catheter • Chronic Treatment – Long term outpatient antibiotics Urinary Tract Infection • Complicated UTI – – – – – – – • Simple UTI – 13 8/20/2013 Urinary Tract Infection • Complicated UTI (Send Cx) – Children – Pregnancy (asymptomatic) – Male – Structural Abnormalities – Instrumentation – Recurrent UTI – Immunocompromised • Simple UTI (No Cx) – Urinary Tract Infection • Complicated UTI (Send Cx) – Children – Pregnancy (asymptomatic) – Male – Structural Abnormalities – Instrumentation – Recurrent UTI – Immunocompromised • Simple UTI (No Cx) – 21 y/o college girl, burns when she pees, reading Cosmo, just got back from weekend get away with boyfriend, afebrile Pediatric UTI Treatment • Treat 3-5 Days if > 2 years old and 1st UTI – Treat 7-10 Days if < 2 years old or h/o UTI – Inpatient Antibiotics: • Ceftriaxone 50 mg/kg IV daily • Cefotaxime 50 mg/kg IV q 8 • Ampicillin 50 mg/kg IV q 6 + Gentamicin 2.5 mg/kg IV q 8 – Home Antibiotics: • • • • Cefixime 8 mg/kg PO once daily TMP/SMP 5 mg/kg PO BID Amoxicillin/Clavulanic Acid 25 mg/kg PO BID Nitrofurantoin 1.5 mg/kg PO q 6 hours 14 8/20/2013 Adult UTI Treatment • Uncomplicated – – – – – – • TMP/SMX (DS) 1 tablet PO BID x 3 days Ciprofloxacin 250 mg PO BID x 3 days Levofloxacine 250 mg PO daily x 3 days Macrobid 100 mg PO BID x 7 days (pregnant) Cephalexin 500 mg PO q 8 x 7 days (pregnant) Amoxcillin 500 mg PO q 8 x 7 days (pregnant and E. Coli susceptible) Complicated – – – – – – Ciprofloxacin 500 mg PO BID (400 mg IV BID) Levfloxacin 750 mg IV/PO daily Ampicillin 500 mg IV q 6 + Gentamicin 2 mg/kg IV q 8 Cefepime 1 g IV BID Imipenem / Cilastin 500 mg IV q 6 Meropenem 1 g IV q 8 Kidney Stones • Calcium Stones (75%) – – – – Related to diet IBD (Crohn’s & UC) Hyperparathyroidism Male Predominance • Struvite Stones (15%) – Chronic infection (Proteus, pseudomonas) – Staghorn formation – High pH (>7) • Cysteine Stones (1%) - In-born error of metabolism - Staghorn formation - Renal failure • Indinivir Stones (<1%) - HIV treatment • Uric Acid Stones (10%) – – – – Gout Congenital errors of metabolism Radiolucent Low pH (<6) Kidney Stone • Hematuria Absent (10 - 20%) • Common Areas of Impaction – – – – Renal Calyx Ureteropelvic Junction (UPJ) Pelvic Brim Ureterovesical Junction (UVJ) • Most common site 15 8/20/2013 Kidney Stone Mimics • • • • • • AAA: Most Common Testicular Torsion Ectopic Pregnancy Appendicitis Incarcerated Hernia Biliary Colic Kidney Stone Mimics • • • • • • AAA: Most Common Testicular Torsion Ectopic Pregnancy Appendicitis Incarcerated Hernia Biliary Colic Imaging Kidney Stones • Plain Film: KUB – Not sensitive or specific • Ultrasound: – NOT sensitive but more specific – Good for pregnant patients • Non-Contrast CT: – Sensitive – Most Specific – gold standard – No information on function • IV Pyelogram or CT Urogram: – Evaluates kidney function 16 8/20/2013 Kidney Stone Treatment • NSAIDS: – Avoid in congenital stones – Avoid with renal failure • Opioids • Hydration – Fluid boluses increase pain • • • • • Flomax Lithotripsy Percutaneous Lithotomy Retrograde Lithotomy Open Surgery Kidney Stone Admission • • • • • • Concurrent infection Concurrent renal insufficiency Solitary kidney Uncontrolled pain / vomiting Ruptured renal capsule Severe hydronephrosis Pass Rate of Kidney Stones • < 5 mm pass 50% of time • > 6 mm pass 10% of time • 1 cm stones do NOT pass 17 8/20/2013 Renal Transplant Pearls • Most Common solid organ transplant • Tranplant Location: Retroperitoneal in pelvis • Hepatitis C and CMV very common • Patient receives azathioprine, cyclosporine and prednisone • Cyclosporine is nephrotoxic – Check levels • Infection and Rejection: – Any rise in Creatinine is cause for alarm – Consult transplant team References • Brown, Wyatt, Illingworth, et al. Oxford American Handbook of Emergency Medicine. New York; Oxford University Press, 2008. Print. • Rosen, Marx, Hockberger, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice, Sixth Edition. Philadelphia; Mosby Elsevier, 2006. Print. • Fleisher and Ludwigs. 5-Minute Pediatric Emergency Medicine Consult. Philadelphia; Lippincott Williams & Wilkins, 2012. Print. • Bukata, Klauer, Mallon, Mattu, Sokolove, Swadron, Birnbaumer. 16th Annual National Emergency Medicine Board Review. Arlington, Virginia, August 2nd – 5th, 2012. Centers for Emergency Medical Education. • www.emedicine.com • www.google.com/images 18