Urologic Emergencies

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Urologic Emergencies

• Maude Latulippe
• CCFP-EM
• FGH, October 15th 2009

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What to expect in the next hour

• Urolithiasis
• Which modality?
• When to admit
• How to manage
• Macro/microscopic hematuria (in a non-trauma
  setting)
• Who needs to be investigated and how
• Priapism
• What is this?
• How to manage
• Urinary retention
• DDx
• Crash cart

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Renal Colic
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Investigations

• MUST HAVE RADIOLOGIC PROOF OF STONE ?!?
• CT KUB is gold standard, sens 94-100, spec
  93-98
• Urinalysis?
• usually not helpful
• 10-15 of patients with colic will NOT have
  hematuria
• KUB sens 69 spec 82
• USS sens 30
• USS KUB sens 95 spec 67
• IVP old gold standard

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Radiation effective dose exposure estimate
Value (mSv)
Abdo or pelvic CT 10
Abdo and pelvic 20
2-film KUB 0.7-1.7
IVU 2.5-7

• Reported effective radiation doses vary
• Average for Americans 3.6mSv per year
• NRC limits occupational radiation exposure to
  adults working with radioactive material to 5,000
  mrem (50 mSv) per year.

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Indications for Admission

• Intractable pain
• Renal failure
• Sepsis (fever)
• Intractable vomiting/dehydration
• Solitary or transplanted kidney

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NOT indications

• High grade obstruction
• Size of stone
• Repeat presentation
• Time

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Conservative Management

• Rosens textbook of EM
• 0-5mm?90
• 5-8mm?15
• gt8?unlikely but
• New research on medical expulsive therapy can
  facilitate spontaneous passage for stones up to
  10mm.

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Lets talk about treatment

• Fluid controversial
• Clearly indicated if
• Dehydration,
• DM,
• RF
• Pain control
• Narcotics
• NSAIDs
• Antiemetics

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Antidiuretics

• DDAVP
• Would work by ? intraureteral pressure
• ? need for other analgesic medications
• Usual dose 40mcg (4 nasal spray) or 4 mcg (1mL)
  IV. Only one dose administred

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Antibiotics

• Controversial
• ? resistance rate vs potential life threatening
• If unsure treat
• Urinalysis USELESS will always show WBC, RBC
• Send culture if youre worried about infection

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• Calcium channel blocker
• alpha blockers (tamsulosin)
• Prednisone
• Anticholinergic (oxybutinin)

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Aggressive medical therapy

• Ketorolac at 10 mg orally every 6 hours for 5
  days
• Tamsulosin at 0.4 mg/d PO for 7 days
• Prednisone 20 mg PO twice a day for 5 days
• Trimethoprim/sulfamethoxazole DS once a day for 7
  days
• Acetaminophen (Tylenol) 2 tablets 4 times a day
  for 7 days
• An oral opioid pain medication (oxycodone/acetamin
  ophen) as needed for breakthrough pain
• Prochlorperazine suppository as needed for
  control of nausea

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HEMATURIA
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• DDX
• Infection
• urolithiasis
• Trauma
• Cancer bladder, renal, prostate
• Benign e.g. BPH
• (Anticoagulation)

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Hematuria Admission

• Gross hematuria with clots /- retention
• Esp post op TURP, TURBT
• 22 F 3 way Foley catheter
• Bladder irrigation
• Debate for empiric Abx
• Consult urology

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Priapism
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Priapism

• 2 Types
• ischaemic (veno-occlusive, low flow (most common)
• Due to haematological disease, malignant
  infiltration of the corpora cavernosa with
  malignant disease, or drugs.
• Painful.
• nonischaemic (arterial, high flow).
• Due to perineal trauma, which creates an
  arteriovenous fistula.
• Painless
• Age
• Any age
• two main age groups affected are 5-10 years old
  boys and 20-50 years old men.

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Priapism

• Primary (Idiopathic) 30-50
• Common causes
• Injectable (and oral) erectile medications
• Trazodone
• Cocaine
• Sickle cell anemia
• (trauma, neuro, tumor)

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Diagnosis

• Arterial vs. Venous
• ABG of corporal blood
• If arterial need further imaging
• Usually hx of trauma (perineal/saddle)
• Usually painless
• If venous, start treatment algorithm
• Imaging
• Angiography to find AV fistula to corporeal blood
  supply

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Treatment of Venous Priapism

• Aspiration
• 21 butterfly
• Withdraw 50 cc of blood
• Irrigation
• Irrigate with 20 - 50 cc of NS
• Repeat
• Vasoconstrictors
• Phenylephrine
• Epinephrine

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Vasoconstrictors

• 1 amp phenylephrine 1 (ie 10 mg/mL)
• Mix with 1 L normal saline
• Inject 10 cc (100 mcg phenylephrine) at a time

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• Circumferentially infiltrate lidocaine 1 around
  the base of the penis

• Insertion sites at the 10- and 2-o'clock
  positions.

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• Proximal and distal positions for irrigation
  (thin arrows) and aspiration (thick arrows)
  needles

• Straight needle inserted in the 9-o'clock
  position with active aspiration of blood

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• Phenylephrine
• Inject 10 cc (100 mcg phenylephrine) at a time
• Continue until detumescence
• If fails, consult urology for shunting
• Apply pressure to prevent hematoma

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Urinary Retention
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Think about the pattern

• Acute vs chronic
• Outflow obstruction
• BPH (53), Constipation (7.5), Prostate cancer
  (7), Urethral stricture (3.5),
• Neurologic impairment
• Spinal cord injury, DM, CVA, epidural meta,
  abscess
• Overdistension
• Medication
• Anticholinergic, sympathomimetic
• Others UTI, post-op

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Acute urinary retention

• Initial Management
• Urethral catheterisation
• Suprapubic catheter ( SPC)
• Do not worry about decompression
• Start Flomax CR 0.8 mg /- Avodart 0.5 mg
• Leave catheter in for 7 days
• Follow-up with GP or Uro (if previously seen)
• Late Management
• Treating the underlying cause

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Indications for Operative Intervention

• Renal Failure
• Bladder Stones
• Sepsis
• Intractable Hematuria

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Catheter Issues
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Helpful Hints

• Think about portable cysto cart!!
• Catheter size
• Catheter type
• Lubrication/local
• Filiform catheter Spiral tip
• Phillips catheter follower
• Suprapubic catheter

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Unable to Cath where is the level of
obstruction?

• Tip
• Meatal stenosis
• Require dilation with sounds or Kelly
• Mid
• Urethral stricture (esp if they have a previous
  history)
• Requires dilation with cysto
• Deep
• Most common BPH
• Try Coude catheter
• Other bladder neck stenosis (if hx of TURP)

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NEVER TRY TO CATHETERIZE SOMEONE POST RADICAL
PROSTATECTOMY!!!
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• Bard suprapubic catheter set

• Rutner suprapubic catheter set

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1. Equipement
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Ultrasound image of distended urinary bladder
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Skin preparation
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Local anesthesia
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Local anesthesia - urine return into syringe
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Suprapubic tube insertion
Unlocking the needle obturator from the catheter
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Advancing the catheter over the needle
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Connection of the extension tubing. Connection to
a urinometer
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Repositionning, tape, dressing
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Thank you