{"id":5125,"date":"2011-07-14T20:23:41","date_gmt":"2011-07-14T20:23:41","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5125.htm\/"},"modified":"2015-05-27T23:10:40","modified_gmt":"2015-05-28T03:10:40","slug":"genitourinary-urologic-disorders","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/medical-surgical\/renal\/genitourinary-urologic-disorders.htm\/","title":{"rendered":"Genitourinary and Urologic Disorders (GU)"},"content":{"rendered":"

<\/span>Urinary Tract Infections<\/span><\/h2>\n

Diagnosis<\/h4>\n

Dipstick 78-92% sensitive and 65-96% specific<\/p>\n

Metaanalysis showed Sensitivity of 75% for the dipstick (Emerg Med J 20:362, 2003)<\/p>\n

 <\/p>\n

1. Escherichia coli<\/em><\/p>\n

2. Staphylococcus aureus<\/em>*<\/p>\n

3. Klebsiella pneumoniae<\/em><\/p>\n

4. Proteus mirabilis<\/em><\/p>\n

5. Enterococcus<\/em>* faecalis<\/em><\/p>\n

6. Pseudomonas aeruginosa<\/em><\/p>\n

7. Enterobacter cloacae<\/em><\/p>\n

8. Citrobacter<\/em><\/p>\n

\u00a7 = Listed in order of decreasing frequency * = Gram-positive organisms<\/p>\n

Corynebacterium, Lactobacillus, <\/em>and Streptococcus <\/em>species are identified only rarely; when they are present, they nearly always represent contamination of the specimen rather than a true pathogen. In complicated UTI, in addition to E. coli, <\/em>there is a higher prevalence of Pseudomonas<\/em>, Enterobacter <\/em>species, Serratia, Acinetobacter, Klebsiella, <\/em>and enterococci.<\/p>\n

 <\/p>\n

Rx<\/p>\n

Uncomplicated UTI:\u00a0 <\/strong>\u00bd Dose Fluoroquinolone for 3 days or consider 1st gen. cephalosporin, nitrofurantoin for a week.\u00a0 Agent of choice at this point should be Cipro XR 500 mg OD or Cipro 250 BID.\u00a0 3 days in uncomplicated UTI is sufficient.<\/p>\n

Give phenazopyridine 100-200 mg TID for no more than 48 hours.<\/p>\n

 <\/p>\n

Complicated UTIs:<\/strong><\/p>\n

Underlying abnormality<\/p>\n

Immunocomprimised Host<\/p>\n

Urinary Tract Obstruction<\/p>\n

Failed Out-Pt management<\/p>\n

Progression of uncomplicated UTI<\/p>\n

Persistent Vomiting<\/p>\n

Renal Failure<\/p>\n

Urosepsis<\/p>\n

Age>60<\/p>\n

No follow-up or poor social situation.<\/p>\n

 <\/p>\n

Treat for 10-14 days<\/p>\n

 <\/p>\n

Pyelo (Outpt):\u00a0 <\/strong>Full Dose Fluro for 1 week or 1st Gen Ceph for 1 week<\/p>\n

fosfomycin tromethamine \u00a03 g, single oral dose.\u00a0 The single dose is well-absorbed, produces therapeutic concentrations in urine for 2-4 days, \u00a0\u00a0The suprapubic discomfort or dysuria common with UTI can be treated with phenazopyridine (adults, 100 mg 2 tablets tid or 200 mg 1 tablet tid not to exceed two days of therapy; children ages 6-12, 12 mg\/kg\/d divided into tid dosing not to exceed two days of therapy).11 Elderly females with lower tract UTI symptoms and no systemic complications may be treated for three days with regimens similar to those prescribed for younger women<\/p>\n

 <\/p>\n

 <\/p>\n

Pyelo (Inpt):\u00a0 <\/strong><\/p>\n

Ciprofloxacin 400 mg IV bid<\/p>\n

Alternative:<\/em><\/strong><\/p>\n

Gatifloxacin 400 mg IV qd<\/p>\n

Levofloxacin 250 mg IV qd<\/p>\n

Ofloxacin 400 mg IV bid<\/p>\n

Ampicillin 150-200 mg\/kg\/day divided q 3-4 h (gentamicin 5-7 mg\/kg qd)<\/p>\n

Cefotaxime 1-2 g q 4-12 h<\/p>\n

Ceftriaxone 1-2 g IV qd<\/p>\n

 <\/p>\n

Complicated Pyelo (Inpt):\u00a0 <\/strong><\/p>\n

Ciprofloxacin 400 mg IV q 8 hr + (tobramycin 5-7 mg\/kg\/day)<\/p>\n

Ampicillin 150-200 mg\/kg\/day IV divided q 4 h\u00a0 (tobramycin)<\/p>\n

Pipercillin\/tazobactam 3.4 g IV q 6 or 4.5 g q 8<\/p>\n

Ticarcillin\/clavulinic acid\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 3.1 g IV q 6<\/p>\n

Imipenim 0.5 g IV q 6<\/p>\n

 <\/p>\n

Blood cultures in immunocompetent patients appear to have little value (Annals Emerg Med 2005;46(3):285)<\/p>\n

<\/span>UTI in Women<\/span><\/h3>\n

obstruction, instrumentation.\u00a0 E Coli and Staph<\/p>\n

Upper Vs. Lower Tract<\/p>\n

1 day, 3 day, 7-10 day of Bactrim<\/p>\n

Cipro 250 bid or keflex (can also be used for mild pyelo) Upper tract gets 2 weeks<\/p>\n

Always Rx pregnant women: nitrofurantoin or keflex<\/p>\n

for sx relief-pyridium 200 mg pot id (max 2 days)<\/p>\n

Suprapubic Puncture for kids <1 yr<\/p>\n

Hemorrhagic cystitis<\/p>\n

If recurrent uti, consider paraurethral gland infection from chlamydia, give doxy for 2-4 weeks<\/p>\n

Clean catch is fairly useless (Arch Intern Med 160, 200)<\/p>\n

 <\/p>\n

 <\/p>\n

<\/span>UTI in men<\/span><\/h3>\n

Urethritis-Gonococcal and non.\u00a0 Ceftriaxone 250 mg IM and Doxy 100 BID x 1 week<\/p>\n

Prostatitis-1 month of Rx<\/p>\n

Epididymitis (usually chlamydia)-treat as for STD<\/p>\n

Orchitis-can be viral (mumps) or bacterial<\/p>\n

 <\/p>\n

antibiotics (trimeth) reduces duration of sx even if dip negative (BMJ 2005;331;143) Dee Richards, Les Toop, Stephen Chambers and Lynn Fletcher blind randomised controlled trial negative dipstick urine test results: double symptoms of urinary tract infection but Response<\/p>\n

 <\/p>\n

UA Stuff<\/p>\n

Specific Gravity<\/p>\n

SG 1.002 correlates with osmal of 50-100<\/p>\n

SG 1.030-1.040 correlates with osmal 1000-1200<\/p>\n

1.010 is is isosthenia; correlates with osmal (300). Indicative of renal tubule damage<\/p>\n

Glucose makes urine look more concentrated than it is; IV contrast does the same<\/p>\n

 <\/p>\n

Urine pH<\/p>\n

normally acidic (4.5-6.5)<\/p>\n

if urine pH is high, suspect a UTI: proteus cleaves urea into NH4<\/p>\n

 <\/p>\n

Glucose<\/p>\n

 <\/p>\n

Ketones<\/p>\n

Urine dipstick measures acetone and acetoacetate<\/p>\n

 <\/p>\n

Billirubin<\/p>\n

conjugated billi is water soluble and excreted in urine when elevated<\/p>\n

 <\/p>\n

Nitrites<\/p>\n

nitrates are normally present in the urine. Gram negatives reduce nitrates to trites.<\/p>\n

 <\/p>\n

Leuk Esterase<\/p>\n

neutrophil specific esterase; indicates presence of WBCs. Any inflammatory cause<\/p>\n

 <\/p>\n

Protein<\/p>\n

 <\/p>\n

 <\/p>\n

Specificity of the urine nitrite test for urinary tract infection decreases as a function of increasing serum bilirubin. Most patients with hyperbilirubinemia and a positive nitrite test in our sample did not have an associated urinary tract infection. (The American Journal of Emergency Medicine Volume 25, Issue 1 , January 2007, Pages 10-14)<\/p>\n

 <\/p>\n

URINE DIPSTICKS<\/h4>\n

A report in Evidence Based Medicine summarises research into the value of dipstick results in women suspected of having urinary tract infection. Urine dipstick testing was found to be of relatively limited value, with negative test results failing to satisfactorily rule out infection. (Evid Based Med<\/em> 2009; 14:<\/strong> 155)<\/p>\n

 <\/p>\n

 <\/p>\n

<\/span>Nephrolithiasis<\/span><\/h2>\n

In pts with CT Scan + for stone<\/p>\n

Dipstick:<\/strong><\/p>\n

sensitivity, specificity and diagnostic accuracy were 80%, 35% and 57%, respectively.<\/p>\n

UA c 1 RBC considered Positive <\/strong>89%, 29% and 58%<\/p>\n

UA c >1 RBC Considered Positive \u00a0<\/strong>81%, 49% and 65%<\/p>\n

UA c >5 RBC Considered Positive <\/strong>67%, 66% and 67%<\/p>\n

(J Urol 162:685, September 1999)<\/p>\n

 <\/p>\n

UA was at least trace positive for blood in 84% of the patients with ureterolithiasis and in 52% of patients with completely negative CT scans or scans demonstrating alternate diagnoses. At this RBC threshold hematuria on microscopic urinalysis had a sensitivity and specificity for ureterolithiasis of 84% and 48%, respectively, and positive and negative predictive values of 72% and 65 respectively. If a cut-off of 10 RBC\/ml or higher is used as an indicator of hematuria, the sensitivity and specificity of hematuria as a marker of renal colic were 81% and 51 respectively, and the positive and negative predictive values were 73% and 62%, respectively. The urinalysis was falsely negative in 17% of patients with ureteral stones measuring 5mm or less, and 11 of those with larger stones. (Urology 59(6):839, June 2002)<\/p>\n

 <\/p>\n

The American Journal of Emergency Medicine Volume 21, Issue 6 , October 2003, Pages 492-493<\/p>\n

The purpose of this study was to determine whether the presence of hematuria or its absence can predict the presence or absence of urinary calculi as determined by computed tomography (CT) scan in patients presenting to the ED with acute abdominal colic. We reviewed the urine analysis and CT scans of all patients presenting to the ED over a 12-month period with acute colic and a clinical suspicion of urinary calculi. Urine samples were drawn on arrival in the ED before CT scanning. Two hundred seventy-seven patients were included in the study. The prevalence of urinary stones as detected by CT was 57.4%. The positive predictive value, negative predictive value, and accuracy for hematuria as a marker for stone disease was 60.9%, 72.4%, and 62.1%, respectively. A total of 3.24% of patients had some degree of obstruction, all of whom had hematuria. The absence of hematuria is not a reliable exclusion criterion for urinary calculi. The detection of urinary stones without hematuria does not imply obstruction.<\/p>\n

 <\/p>\n

The authors suggest that about 95% of ureteral stones measuring 4mm or less will pass spontaneously, but passage may require up to 40 days, and that about half of patients with larger stones may require a stone recovery intervention (J Urol 162:688, September 1999)<\/p>\n

 <\/p>\n

Crohn’s patients are prone to stones secondary to hyperoxaluria, Elevated pH points to stuvite stone.<\/p>\n

<\/span>Infected Stones<\/span><\/h3>\n

UTI with obstructing stone is an emergency. UTI coincident with stone is not<\/p>\n

“Association of Pyuria and Clinical Characteristics With the Presence of Urinary Tract Infection Among Patients With Acute Nephrolithiasis”
\nhttp:\/\/www.ncbi.nlm.nih.gov\/pubmed\/23850311
\nfever & >5 wbc on 86% sensitive and 79% specific for UTI<\/p>\n

 <\/p>\n

NHCT is more accurate than IVP (Annals EM 40, 2002; p. 280)<\/p>\n

 <\/p>\n

The flat plate radiograph uses the same orientation and anatomical presentation that is observed on fluoroscopy, retrograde pyelograms, or during endoscopic ureteral surgery, such as ureteroscopy or intracorporeal lithotripsy. Even if a stone is not visible on a flat plate radiograph, the calculus could be a radiolucent uric acid stone that can be dissolved with alkalinizing medication. Such a stone is more likely if the urine pH indicates very acidic urine. In practice, any patient with symptoms of acute renal colic who demonstrates a urine pH lower than 6.0 should be considered at risk for a possible uric acid stone and should have a KUB radiograph performed to help determine radiolucency. The flat plate radiograph is inexpensive, quick, and usually helpful even if no specific stone is observed. It is extremely useful in following the progress of previously documented radiopaque calculi and checking the position of any indwelling double-J stents. The KUB radiograph can suggest the fluoroscopic appearance of a stone, which determines whether it can be targeted with extracorporeal shock-wave lithotripsy (ESWL). The KUB radiograph is also quite accurate in determining the exact size and shape of a visible radiopaque stone, which can only be estimated using a CT scan alone because the x-ray beam of the CT scan does not always cross the stone at its widest point. Differentiation between a phlebolith and an obstructing calcific stone becomes easier when the KUB radiograph demonstrates a lucent center, identifying the calcification as a phlebolith. This central lucency is not observed as often on CT scanning. Many urologists recommend the flat plate radiograph in addition to CT scan for any renal colic\u0096type scenario for these reasons. A number of studies have suggested that the flat plate has a relatively low sensitivity and specificity for renal and ureteral calculi. Many patients have numerous pelvic calcifications that make pinpointing specific stones difficult. Any calcific density observed on KUB radiograph that happens to overlie the course of the ureter is not guaranteed to be a stone. A number of emergency physicians argue that the flat plate radiograph adds little to the identification and treatment of a stone in the ED. Furthermore, obtaining a flat plate radiograph may cause delays, may unnecessarily increase the cost of the workup, and produces additional patient radiation exposure; consequently, flat plate radiograph is no longer required in the modern era when unenhanced CT scans are now the criterion standard for diagnosis of acute renal colic. A large clinical study from Johns Hopkins by Jackman and associates (2000) concluded that “plain abdominal x-ray is more sensitive than scout CT for detecting radiopaque nephrolithiasis. Of the stones visible on plain abdominal x-ray, 51% were not seen on CT. To facilitate outpatient clinic follow-up of patients with calculi, plain abdominal x-rays should be performed.” Many urologists, including this author, recommend that a KUB radiograph, in addition to other studies such as noncontrast helical or spiral CT scans, be obtained in patients with a clinical presentation of acute flank pain suggestive of renal colic. Knowing the exact size and shape of a stone, its position, fluoroscopic appearance, surgical orientation, and relative radiolucency is an advantage. Also, the progress of the stone can easily be monitored with follow-up flat plate radiograph. These advantages far outweigh the few disadvantages of performing the examination. The digital CT scout radiograph can be used as a reasonable substitute for the KUB radiograph if cost factors, excessive delays, or logistical problems make obtaining a formal abdominal flat plate study difficult.\u00a0 (Emedicine)<\/p>\n

 <\/p>\n

<\/span>Pain Meds<\/span><\/h3>\n

Morphine plus ketorolac is better than either of them alone (Ann Emerg Med 2006;48:173)<\/p>\n

 <\/p>\n

<\/span>Alpha Blockers<\/span><\/h3>\n

Use flomax o.4 mg po qd until uro f\/u<\/p>\n

 <\/p>\n

The comparison and efficacy of 3 different alpha1-adrenergic blockers for distal ureteral stones. (J Urol. 2005 Jun;173(6):2010-2) Randomized trial of the efficacy of tamsulosin (flomax), nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi. (J Urol. 2005 Jul;174(1):167-72)<\/p>\n

 <\/p>\n

Lancet. 2006 Sep 30;368(9542):1171-9. Although a high-quality randomised trial is necessary to confirm its efficacy, our findings suggest that medical therapy is an option for facilitation of urinary-stone passage for patients amenable to conservative management, potentially obviating the need for surgery. SR (Ann emerg med 2007;50:552)<\/p>\n

RCT which was underpowered and had no real size stones showed no benefit (Ann Emerg Med 2009;54:432) \u00a0 pH>7.6 consider proteus or morganella morganii no damage to kidney with obstruction for 2-4 weeks \u00a0 Urolithiasis was present (as defined by low-dose unenhanced MDCT) in 507\/638 patients (79%); 341\/638 (53%) were true positive for urolithiasis, 76 (12%) were true negative, 55 (9%) were false positive and 166 (26%) were false negative. Microhaematuria as a test for urolithiasis in patients presenting to the emergency department therefore has a sensitivity, specificity, positive predictive value and negative predictive value of 67%, 58%, 86% and 31%, respectively. 58% of the urinalysis results were negative for haematuria in the subset of patients with significant alternative diagnoses. (Emergency Medicine Journal 2008;25:625-630)<\/p>\n

<\/span>Urinary Retention<\/span><\/h2>\n

Etiologies include:\u00a0 bph, prostate ca, urethral strictures, nephrolithiasis, bladder neoplasm, phimosis, meatal stenosis, post urethral valves (peds), ureterocele (women), prostatitis, cystitis, anticholinergic and sympathomimetic drugs, neurogenic lesions, post-operative,<\/p>\n

There is no utility to gradual bladder drainage.\u00a0 Hematuria will happen anyway, decreased blood pressure is probably just BP returning to pre retention levels and risk of renal damage is higher with continued obstruction.<\/p>\n

 <\/p>\n

Men presenting with AUR caused by BPH were randomized to immediate removal, or removal at 3 or 7 days. Sixty-two percent of the men randomized to the 7-day catheter group were able to void successfully after removal of the catheter. Rates for men in whom the catheter was removed immediately or after 3 days were 44% and 51%, respectively. The authors of this study conclude that men with AUR who are found to retain volumes in excess of 1300 ml should have longer periods of catheter placement to increase their chances of subsequent successful voiding<\/p>\n

(Emergency Medicine Clinics 19:3, August 2001 & Mayo Clin Proc 72:951, October 1997)<\/p>\n

 <\/p>\n

<\/span>Fournier\u0092s Gangrene<\/span><\/h2>\n

Necrotizing fasciitis, from skin, urethra, or rectum<\/p>\n

Associated c instrumentation, strictures, obstruction of urethra<\/p>\n

Predisposing factors are dm, trauma, paraphimosis, uti<\/p>\n

G<\/a>et blood and wound cultures<\/p>\n

Rx mixed flora and anaerobes<\/p>\n

Crepitus, fever, swelling, tachy, temp<\/p>\n

G<\/a>et KUB and\/or scrotal uts to look for free air<\/p>\n

IVF, Unasyn or Ceft, Gent, Clinda<\/p>\n

High Mortality<\/p>\n

<\/span>Foley Issues<\/span><\/h2>\n

Catheter removal can sometimes be difficult.<\/p>\n

three possibilities:<\/p>\n

(1) the valve where water is injected into the catheter may be blocked;<\/p>\n

(2) external clamping or kinking may have damaged the tube; and<\/p>\n

(3) crystallization of the fluid used to inflate the balloon may be preventing the balloon from deflating.<\/p>\n

The first step is to cut the balloon port proximal to the inflation valve. If this does not result in a release of water, and ability to remove the catheter, then a wire is passed through the inflation channel. The wire from a central venous cannula set is appropriate for this task. The wire may be passed into the balloon and used to perforate it. However, sometimes a firmer structure is needed and, in this case, the venous catheter itself is used. It is passed over the guidewire into the balloon.<\/p>\n

If the venous catheter does not rupture the balloon, leave the catheter in place and use it to introduce chemicals into the balloon. These chemicals will sufficiently degrade the balloon so that it ruptures but does not disintegrate. Chemicals such as ether, chloroform, acetone or mineral oil are used. Of these, mineral oil is recommended. Ten ml of mineral oil are drawn up into a syringe and introduced into the catheter balloon. After waiting for about 15 minutes, an attempt is made to remove the urinary catheter. If unsuccessful, an additional 10 ml is instilled.<\/p>\n

If the balloon ruptures, inspect it carefully and ensure no bits have been left behind. They can\u00a0 act as a nidus for Infection, or calculus formation, and can produce significant irritation when voiding.<\/p>\n

 <\/p>\n

<\/span>Macroscopic Hematuria<\/span><\/h2>\n

 <\/p>\n

Box 1: Differential diagnoses in macroscopic haematuria<\/strong><\/p>\n

 <\/p>\n