Urologic Emergencies

Maude LatulippeCCFP-EM

FGH, October 15th 2009

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

Renal Colic

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

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.

Indications for Admission

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

NOT indications

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

Conservative Management

Rosen’s textbook of EM0-5mm→90%5-8mm→15%>8→unlikely… but…New research on medical

expulsive therapy can facilitate spontaneous passage for stones up to 10mm.

Let’s talk about treatment

• Fluid – controversialClearly indicated if:

Dehydration, DM, RF

• Pain controlNarcoticsNSAIDs

• Antiemetics

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

Antibiotics

Controversial↑ resistance rate vs potential life

threateningIf unsure = treat• Urinalysis USELESS – will always

show WBC, RBC• Send culture if you’re worried about

infection

• Calcium channel blocker

• alpha blockers (tamsulosin)

• Prednisone

• Anticholinergic (oxybutinin)

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/acetaminophen) as needed for breakthrough pain

• Prochlorperazine suppository as needed for control of nausea

HEMATURIA

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

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

Priapism

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.

Priapism

• Primary (Idiopathic): 30-50%• Common causes:

– Injectable (and oral) erectile medications

– Trazodone– Cocaine– Sickle cell anemia– (trauma, neuro, tumor…)

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

Treatment of Venous Priapism

• Aspiration– 21 butterfly– Withdraw 50 cc of blood

• Irrigation– Irrigate with 20 - 50 cc of NS– Repeat

• Vasoconstrictors– Phenylephrine– Epinephrine

Vasoconstrictors

• 1 amp phenylephrine 1% (ie 10 mg/mL)

• Mix with 1 L normal saline• Inject 10 cc (100 mcg phenylephrine)

at a time

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

• Circumferentially infiltrate lidocaine 1% around the base of the penis

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

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

Phenylephrine:

• Inject 10 cc (100 mcg phenylephrine) at a time

• Continue until detumescence

• If fails, consult urology for shunting

• Apply pressure to prevent hematoma

Urinary Retention

Think about the pattern…

• Acute vs chronic• Outflow obstructionBPH (53%), Constipation (7.5%), Prostate cancer

(7%), Urethral stricture (3.5%),• Neurologic impairmentSpinal cord injury, DM, CVA, epidural meta, abscess• Overdistension• MedicationAnticholinergic, sympathomimetic

Others: UTI, post-op

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

Indications for Operative Intervention

• Renal Failure• Bladder Stones• Sepsis• Intractable Hematuria

Catheter Issues

Helpful Hints:

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

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)

NEVER TRY TO CATHETERIZE SOMEONE POST RADICAL

PROSTATECTOMY!!!

Bard suprapubic catheter set

Rutner suprapubic catheter set

1. Equipement

Ultrasound image of distended urinary

bladder

Skin preparation

Local anesthesia

Local anesthesia - urine return into

syringe

Suprapubic tube

insertion

Unlocking the needle obturator from the

catheter

Advancing the catheter over the needle

Connection of the extension tubing.

Connection to a urinometer

Repositionning, tape, dressing

Thank you