Download - Emergency Medicine Board Review 2014 GU
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Derek Orchard
PGY 4
EMERGENCY MEDICINE
PENIS AND
RENAL STUFFBOARD REVIEW
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GAME PLAN
• Male GU Diseases
• Polycystic Kidney Disease
• Kidney Stones
This is going to be concise and to the point board review.
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ANATOMY
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BALANITIS/BALANOPOSTHITIS• Balanitis = Glans
• Posthitis = Foreskin
• Think: Uncircumcised, DM, Poor Hygiene, Obesity (picture Rundio)
• Clinical: itching, discharge, redness, pain
• Treatment
• Hygiene
• Topical Antifungal
• +/- antibacterial
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PHIMOSIS VS PARAPHIMOSIS• Phimosis
• 2/2 recurrent balanitis, inadequate circumcision
• Tx
• Nonobstructive: Urology Follow-up
• Obstructive: place urinary catheter (may have to place suprapubic), consult Urology, Circumcision
• Paraphimosis
• PARAmedics
• Tx
• Reduce it manually
• Circumcision
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EPIDIDYMITIS & ORCHITIS• Ascending infection
• Most are STD related
• Chemical epididymitis is due to reflux
• Older men with BPH, Stricture or CA
• Clinical: progressive pain, swelling, erythema, dysuria, fever, discharge
• Phren’s sign
• Clinical Dx with US and UA
• TX: Think 35!!!
• <35 Chlamydia/Gonorrhea – Doxy 14 days + Ceftriaxone
• >35 E. coli – Cipro, Bactrim
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PRIAPISM• Low Flow (more common) vs High Flow (rare)
• High Flow – Trauma (rupture of cavernous artery), AV fistula
• Low Flow
• Medications – Viagra, Trazadon
• Sickle Cell Disease
• Malignancy
• Cord Injury
• DX: Clinical, Blood Gas
• TX
• Terbutaline, Pseudoephedrine, Ice, Phenylephrine, Aspiration
• Sickle Cell: Exchange transfusion
• Urology Consultation
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PENILE FRACTURE• Not Ortho
• Urologic Emergency
• Traumatic tear of tunica albuginea
• Exclude urethral injury with retrograde urethrogram
• Management
• Immediate Surgical Repair
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TORSION• Bimodal
• Highest Risk @ 1yr (undescended testicle, Bell clapper deformity)
• During puberty
• Child with abdominal pain/nausea --- Examine the testicles!
• Time is Testicle
• 6 hours!!!• Ultrasound – GO with the EXAM, not the US!!!
• Manual de-torsion
• Immediate Urology
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FOURNIER’S GANGRENE
• Necrotizing infection of the scrotum and perineum
• Rapidly Progressive
• DM, Immunocompromised, Recent trauma
• Dx: Clinical, XR, CT
• Management
• Surgical Emergency
• Abx, Hyperbaric oxygen
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POLYCYSTIC KIDNEY DISEASE
• Autosomal Dominant, multiple kidney cysts
• Cysts can become infected and bleed
• Associated with Liver Cysts and Cerebral Aneurysm
• Clinical: Flank Pain, Hematuria, Hypertension
• DX
• Renal Insuffciency
• CT scan, Ultrasound
• Tx: Blood Pressure Control and Nephrology Referral
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NEPHROLITHIASIS• Age 20-50
• Recurrence is common
• < 5mm 90% pass rate
• Stone Type
• Calcium Oxalate – MC 80%
• Struvite – 2nd most common
• Majority of staghorn calculi, Proteus
• Uric Acid
• Radiolucent
• Gout, Leukemia, Tumor Lysis
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NEPHROLITHIASIS• Diagnosis
• R/O AAA
• US – Hydro
• UA – Hematuria
• CT
• Most Common Sites of Impaction
• Ureterovesical Junction
• Ureteropelvic Junction
• Pelvic Brim
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MANAGEMENT
• No obstruction or infection
• IVF, Analgesia, +/- alpha blockers, CCB
• Obstruction
• May require surgical measures and lithotripsy
• Obstruction + Infection
• Emergent Decompression
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ACUTE RENAL FAILURE
• Rapid Decline in GFR
• 50% increase in Cr from baseline
• 3 Types
• PRErenal
• INTRINSIC
• POSTrenal
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PRERENAL
• Think >>>>>> SHOCK• Decreased effective blood volume• Sepsis, burns, anaphylaxis, low albumin states,
decreased cardiac output,…..
• Kidney
• Reabsorbs water and salt
• Concentrated Urine and Low urine Na
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INTRINSIC RENAL FAILURE• Intrinsic damage to the kidney/renal tubule:
• Can’t Concentrate pee and Reabsorb Na
• Acute Tubular Necrosis (ATN)• 90%
• Prolonged prerenal injury, Nephrotoxins, Others
• Rhabdomyolysis• Myoglobin injures renal tubules, especially in an acidic environment
• Bicarb (for exam)
• Aggressive Hydration
• Hypo K+ can cause and lead to Hyper K+
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POST-RENAL FAILURE
• Obstruction to urine flow
VS
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WORKUP
• Cr, Lytes, CK
• Check the pee
• UA, Urine Lytes, Osmolality
• Foley
• +/- Ultrasound/CT/Finger
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PRE VS POST VS INTRINSICTest PRErenal POSTrenal Intrinsic
Ur Osmolality >500 <400 <300
Ur Na <20 >40 >40
FENa (%) <1 >2 >2
• BUN:Cr >20 • High CK, Blood in UA, No RBC• Renal Tubular/Muddy Brown casts• Eosinophilia, White cell casts• RBC casts, Proteinuria
• PRErenal• Rhabdo• ATN• AIN• Acute Glomerulonephritis
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REVIEW• Balanitis – Glans
• Paraphimosis – PARAmedics
• Epididymitis/Orchitis – Think 35
• Priapism – Low Flow, Drugs or Sickle Cell
• Torsion – 6 hours
• Fournier’s Gangrene – Surgery
• Polycystic Kidney Disease – Cerebral Aneurysms
• Kidney Stones - < 5mm, r/o AAA