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Urologic Emergencies

Urologic Emergencies. Denise Watt Feb 7, 2002. Outline. Cases Renal calculi Epidemiology / pathophysiology Clinical presentation DI Management Hematuria Urinary retention. Case 1. 62 yo male, sudden onset Rt flank/back pain. Constant, can’t get comfortable, N&V. PMHx: HTN

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Urologic Emergencies

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  1. Urologic Emergencies Denise Watt Feb 7, 2002

  2. Outline • Cases • Renal calculi • Epidemiology / pathophysiology • Clinical presentation • DI • Management • Hematuria • Urinary retention

  3. Case 1 62 yo male, sudden onset Rt flank/back pain. Constant, can’t get comfortable, N&V. PMHx: HTN O/E: pale, bp 100/75, HR 105, T37 Urine dip: + hematuria DDx: ?

  4. Case 2 02:00 45 yo male, sudden onset lt flank pain to groin, hematuria, prior renal calculi x 2 To image or not to image?

  5. Case 3 30 yo female, RLQ/pelvic pain x 12 hr. Fever, chills, N&V. O/E: 140/90, 110, T 38.5 DDx: ? Imaging modality? Rx?

  6. Case 4

  7. Renal CalculiEpidemiology • Present since antiquity • 3-5% of population, 12% white males • 50% recurrence in 10 yrs • whites, rare in Africans & Natives • peak incidence b/w 20-50 • M:F = 3:1 • familial • ‘stone belt’: SE US • peak months July-September: heat + sunlight?

  8. Epidemiology • types: Ca oxalate, struvite, uric acid, cystine, misc • 80% Calcium • most Ca oxalate, some Ca phosphate • most hypercalciuric (absorptive, resorptive, ideopathic) • hypercalcemic: hyperparathyroid, hyperthyroid, sarcoidosis • hereditary causes: PCKD, RTA, PTH, cystinuria

  9. Pathophysiology: Ca oxalate • urine supersaturated Ca & oxalate  crystals • lack of inhibitors: pyrophosphate, citrate • crystals usually washed away into bladder • crystals stick in tubules/ducts, grow, obstruct • medullary sponge kidney, intramed stasis, abn tubular epithelium • diet: protein? Ca? oxalate? Na? • low urine volume: water intake, bowel disease

  10. Pathophysiology: Struvite • 10-20% • staghorn calculi: Mg, NH4, PO4 • requires pH>7.2 & NH4 in urine • caused by urease-producing UTIs • Proteus, Klebsiella, Staph, Providencia, Corynebacterium • atypical presentation in subset: malaise, weakness

  11. Pathophysiology: Others • Uric acid • 6-10%, most common radiolucent stones •  secretion uric acid, acidic urine,  urine vol • 1%/yr after 1st gouty attack • Cystine • 1%, insoluable in low pH • cystinuria: autosomal recessive • Drugs • triamterene, indinavir, sulfonamides, CA inh.

  12. History • Renal colic: worse than labour??? • Severe, sudden, paroxysmal pain, flankgroin, referred to testicle, writhe • urinary sx (UVJ/bladder) • N/V (celiac plexus) • Risk factors: prior episode, FH • Complications: UTIs, solitary kidney, renal transplant, anat abn, immunocompromised • r/o DDx

  13. Physical Exam • VS: adrenergic, no fever • Hypotension rare (vasovagal): r/o AAA, sepsis • Flank pain (r/o pyelo), no peritoneal signs • CV exam: r/o embolic ds • r/o bladder retention • pv exam (PID, preg)

  14. Differential Diagnosis • HUGE! • AAA • commonly misdiagnosed as renal colic • suspect > 50, hypotension • can have hydronephrosis, hematuria • renal artery thrombosis/dissection • diff dx, contrast CT • appendicitis: can have hematuria, CT • pyelo/cystitis: mimic or mask; infected obstruction is emergency

  15. Lab • U/A • 90% hematuria • sens with acute flank pain 89%; spec 29% • pyuria common w/o infection • pH: high struvite, RTA; low uric acid • crystals • Lytes •  AG met acidosis + Ca oxalate = ? • NonAG met acidosis + hypokalemia = ?

  16. Lab • Urea/Cr • not caused by stone • affects Rx, diagnostic tests • CBC: non-specific, pain/stress • Ca, Mg,PO4, uric acid: don’t change mgt • Pt passes stone: send for analysis

  17. Diagnostic Imaging • Role • Confirm dx • R/o other serious dx • Detect complications of stone • Define site/size of stone • Who needs emergent imaging? • No consensus: 1st stone, suspect other dx

  18. Diagnostic Imaging • How good are we clinically? • High PTP: 70% had stones on IVP (Twinem, Wrenn) • Are we missing serious other disease if we don’t image? • Bottom line: we must decide how confident we are with our dx, r/o serious DDx (esp. in elderly), close F/U to confirm dx

  19. Diagnostic Imaging Modalities

  20. Ultrasound

  21. IVP

  22. CT

  23. Diagnostic Imaging • IVP • (Relative) contraindications: • Cr >130, allergy, DM, multiple myeloma, dehydration, pregnancy • obstruction: delayed nephrogram or hydro • delayed films until comlunization in 2 • extravasation: renal calyx or ureteral rupture • no infection  extravasation not treated • no kidney uptake: think renal infarction

  24. Diagnostic Imaging • Non-contrast CT • Chen, J Emerg Med 1999;17:299-303 • 100 pt: sens 98%, spec 100% • alternate dx in 50% pt w/o stone • cost $600 vs. IVP $400 • study of choice? • same as IVP for hydronephrosis/ hydroureter; better at ID stone

  25. Management:r/o Emergency • Urosepsis + obstructing stone • Need drainage (nephrostomy, stent) + IV Abx • Acute renal failure/ anuria • bilat obst/ solitary kidney

  26. Absolute intractable vomiting/pain solitary kidney or transplant with obstruction UTI with obstruction hypercalcemic crisis Relative stone > 6 mm high grade obstruction solitary kidney/ transplant w/o obstruction intrinsic renal disease extravasation social issues Management:Criteria for Admission

  27. Management:Analgesia • Narcotics • Still the best analgesics • Problems: SE, don’t address pathophysiology • NSAIDS •  RBF, ureteral Sm contraction, inflammation • Ketorolac as good as merperidine • Cordell. Annals Emerg Med 1996;28:151-8; Larkin. Am J Emerg Med 1999;17:6-10 • higher incidence GI bleed?, worsens RF, CHF, HTN • contraindicated 3 days prior to ESWL

  28. Probability of Stone Passage

  29. Disposition: Stones < 5mm • Analgesia • strain urine until stone passes • send for analysis • return to ED if worsens, fever

  30. Disposition:Urology Referral • Emergencies • stones >= 5 mm • renal stones, incl. staghorn • not passed after 2-4 weeks observation • complication rate triples (29%)

  31. Complications • renal failure • rare if no infection, other kidney works • need obstruction x 4 weeks? (Campbell’s) • ureteral stricture • infection, sepsis • urine extravasation • perinephric abscess

  32. Special concerns • Pregnancy • U/S to minimize radiation • Children • Rare: look for metabolic cause • Elderly • Rare first-time stones; look for other causes • CT (consider contrast) • beware NSAIDS/ narcotics

  33. Surgical Management • ESWL • Ureteral stones < 1cm • Renal stones < 2 cm • Uretoscopy • Ureteral stones • Ureterorenoscopy • Renal stones < 2 cm • Percutaneous nephrolithotomy • Renal stones > 2 cm • Proximal ureteral stones > 1cm

  34. Doc - I never want to go through this again! • increase fluid intake • diet • low Calcium:  stones secondary to  oxalate • Borghi et al, NEJM 2002;346:77-84 • low protein:  acid-induced Ca excr. & urate • low Sodium: urinary Na Ca No clinical excr. • Low oxalate: nuts, chocolate, rhubarb, beets, dark green veggies

  35. Prevention • thiazides, amiloride (hypercalciuria) • allopurinal, alkalinize urine if pH low (uric acid) • potassium citrate (hypocitraturia)

  36. Summary • stones are common • clinical dx + hematuria isn’t reliable • CT probably the best DI • analgesia: NSAID + opiod • watch out for emergencies • when to consult • prevention

  37. Hematuria: the quick and dirty • DDx huge: look it up • infection 25% • stones 20% • NYD 10% • others: trauma, glomerular, renal, extrarenal, coagulopathy, factitious, pigmenturia • most common worldwide: schistosomiasis

  38. Hematuria • Gross • r/o bladder/kidney CA • Micro • >3 RBC/hpf

  39. History • Quantity • Timing • initial hematuria: anterior urethral lesion • urethritis, stricture, meatal stenosis • terminal:post. urethra, bladder, neck, trigone • post urethritis, polyps, tumours • total: source above bladder • stone, tumour, infection

  40. Hematuria is an Emergency! (sometimes) • trauma • gross hematuria causing hypovolemic shock • urosepsis • obstructing stones + infection or RF • glomerulonephropathies + CHF, HTN emergencies, RF, infection • coagulopathy, bleeding from multiple sites

  41. Diagnosis • Dipstick • 90% sensitive • FP: Mb, menses • U/A • RBC casts + proteinuria = GMN • DI • stones • trauma

  42. Management • Glomerulonephropathies • supportive • lower BP if HTN urgency/emergency • judicious diuresis if CHF • dialysis prn • Abx prn • steroids if nephrotic syndrome • d/c + F/U if mild protein/hematuria, stable VS, no infection, other B/W normal

  43. Management:Microscopic hematuria • F/U U/A • Fam MD or urologist • Urology W/U if: • >3 RBC/hpf on at least 2 U/A or one episode >100 RBC/hpf or gross hematuria

  44. Management:Gross hematuria • Admit • severe, unstable, worsening RF, anemia, coagulopathy, pain-control • significant, not severe (?) • 3-way foley irrigation • d/c with foley + leg bag + F/U urology

  45. Hematuria Trivia 1. Micro hematuria in 6 yr old 2 weeks after URI + sore throat. > Post-Strep GMN 2. Known narcotic abuser + gross hematuria > Papillary necrosis 3.Micro hematuria in pt with RA on Indocid > Interstitial nephritis

  46. Hematuria Trivia 4. Gross hematuria in 5 yr old, FH of RF > Medullary sponge kidney 5.Recent travel to Africa, gross hematuria > Schistosomiasis 6. Hemopytsis + chronic micro hematuria > Goodpasture’s

  47. Hematuria Trivia 7. Micro hematuria in9 yo with FH deafness > Alport’s 8. African-Canadian 11 yo, abd pain, dehydrated, gross hematuria > sickle cell crisis 9. URI 2 days ago, micro hematuria + protein > IgA nephropathy

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