Genitourinary Emergencies

Chapter 33 Genitourinary Emergencies



Susanne Quallich


This chapter discusses common genitourinary emergencies seen the emergency department. Problems of the urinary tract are covered, as well as problems unique to males and dialysis patients. See Chapter 47, Gynecologic Emergencies, for more information related to specific female genitourinary emergencies.



Problems of the Urinary Tract



Acute Uncomplicated Pyelonephritis


Pyelonephritis is an inflammation of the kidneys that involves the tubules, glomeruli, and renal pelvis. It is more commonly seen in women. The usual cause is a bacterial infection with gram-negative bacilli such as Escherichia coli. Risk factors for the development of pyelonephritis include anatomical or functional genitourinary abnormalities and a new sexual partner in women.



Signs and Symptoms




• Severe flank or back pain at the costovertebral angle


• Tenderness over the affected flank


• Fever, chills, and headache that can progress to rigors


• Nausea, vomiting, and diarrhea


• Lower urinary tract symptoms: frequency and urgency, dysuria, and nocturia


• Pyuria, hematuria, and bacteriuria



Diagnostic Procedures




• Urinalysis


• Blood urea nitrogen (BUN) and creatinine with history suggestive of decreased function


• Urine cultures and gram stain


• Blood cultures do not contribute to diagnosis or management


• A complete blood count will show leukocytosis but is otherwise noncontributory


• Renal ultrasound


• Computed tomography (CT) without contrast to rule out presence of renal calculi as a cause of symptoms



Therapeutic Interventions




• Encourage fluid intake to maintain brisk diuresis.


• Encourage bed rest as needed.


• Drainage via nephrostomy tube (if indicated).


• Administer broad-spectrum antibiotics.


• Patients with severe disease, immunosuppression, pregnancy, abscesses, gram-negative septicemia, age extremes, or significant comorbidities require hospital admission and parenterally administered antibiotics.

• Most other patients can take antibiotics orally on an outpatient basis.


Gross Hematuria


Hematuria is a symptom of nephrological and urological diseases; gross hematuria is enough blood present in the urine to cause a noticeable color change. Blood may appear in the urine as a result of the following:



• Trauma


• Renal calculi


• Excessive exercise


• Blood dyscrasias


• Urinary tract infections


• Renal, ureteral, or bladder tumors


• Recent urological manipulation


Bleeding at the start of urination suggests a problem in the region of the anterior urethra. If blood is visualized at the end of the urinary stream, suspect bleeding from the posterior urethra or prostate. If bleeding is noted throughout urination, the most likely cause is a bladder or upper urinary tract source.


Important considerations for the patient with gross hematuria include the following:



• Do not assume that all red-colored urine indicates hematuria. Urine may be tinted as a result of the ingestion of food colorings, certain medications, or beets.


• In females, determine whether the bleeding is actually vaginal or menstrual.


• Anticoagulation within the therapeutic range does not result in hematuria.


• It is very rare to lose enough blood via the genitourinary tract to alter hemoglobin and hematocrit (except in the case of trauma).


• Patient may have a history of radiation treatment to pelvic and rectal area, resulting in radiation cystitis that can be a cause of gross hematuria.



Signs and Symptoms




• Gross or microscopic blood in the urine


• May or may not have urinary symptoms



Diagnostic Procedures




• Carefully obtain a patient history.


• Collect a urine specimen for dipstick testing and urinalysis. In menstruating females it may be necessary to obtain the sample via a catheter.


• If signs of infection are present, check a complete blood count.



Therapeutic Interventions




• Maintain adequate hydration by encouraging oral intake or by intravenous fluid administration.


• Specific therapeutic interventions will depend on the cause. See “Renal Calculi” and “Acute Cystitis.”



Renal Calculi


The pain of renal colic typically radiates from the flank to the ipsilateral lower quadrant, the groin, and (occasionally) the leg. Men may also describe pain that radiates to the testicle on the affected side, while women may report pain in the labia on the affected side. This pain results from ureteral distension caused by the passage of renal calculi. The size of the stone or clot does not necessarily relate to pain severity. Important patient historical information includes the following:



• Previous stones


• Presence of an ileal conduit or hypercalcemia


• Recent travel that may have contributed to dehydration or poor fluid intake



Calcium stones account for 80% of all renal calculi.8



Signs and Symptoms




• Sudden onset of severe, colicky, radiating flank pain on affected side


• Restlessness; the patient is unable to find a position of comfort and often cannot remain on the stretcher


• Tenderness to the costovertebral angle on affected side


• Urinary urgency, frequency, and dysuria


• Nausea, vomiting, diaphoresis, and low-grade fever



Aortic and iliac aneurysms can mimic renal colic. Assess for abdominal bruits and pulsatile masses.



Diagnostic Procedures




• Gross or microscopic hematuria, with patient noting small clots in urine and possible stones.


• BUN and creatinine levels if compromise to kidney function is suspected.


• Abdominal radiographs and ultrasound may reveal calculi but are not sensitive.


• Helical CT has replaced intravenous pyelogram as the diagnostic procedure of choice.



Therapeutic Interventions




• Strain the urine for calculi.


• Initiate an isotonic, intravenous crystalloid infusion.


• Provide analgesics; narcotic analgesics are commonly prescribed.


• Administer an antiemetic such as ondansetron (Zofran) or promethazine (Phenergan) if the patient is nauseated or vomiting.


• If kidney function is determined to be adequate, consider administering non-steroidal anti-inflammatory drugs (NSAIDs) such as ketalorac (Toradol).


• For ongoing care, including pain management, patients may require hospital admission, pharmacological stone dissolution, extracorporeal shock wave lithotripsy, laser lithotripsy, or surgical intervention.1



Urinary Retention


Urinary retention is the inability to completely empty the bladder of urine; the problem may be acute or chronic. Urinary retention may be caused by a variety of conditions, including the following:



• Urethral strictures


• An enlarged prostate or acute prostatis


• Blood clots


• Renal calculi


• Neurogenic bladder


• Pelvic organ prolapse


• Multiple sclerosis or other neurologic compromise


• Bladder calculi


Urinary retention is also a side effect of parasympatholytic agents and certain other drugs such as over-the-counter cold medicines, especially in men. Risk factors include recent genitourinary instrumentation and back injury that may have compromised the lumbosacral spine.



Signs and Symptoms




• Lower abdominal discomfort


• Bladder distension (a mass may be palpable just above symphysis pubis)



Diagnostic Procedures




• An ultrasonic bladder scan can quickly confirm urine retention.



Therapeutic Interventions




• Insert an indwelling urinary catheter for immediate relief.


• In men with urinary retention secondary to benign prostatic hypertrophy, the insertion of a curved-tipped Coude catheter may be easier and cause less patient discomfort.


• In rare instances, a suprapubic catheter may be necessary.


• Determine the cause and treat as indicated.


• Consider urological consultation to investigate functional status of the bladder.



Urinary Tract Infection (Acute Cystitis)1,2


Acute cystitis is an infection of the lower urinary tract, primarily the bladder, that results from bacterial migration from the urethra. The most common organism is E. coli. Females are more likely to have this condition because of their shorter urethras. Acute cystitis may also be precipitated by women having a new sexual partner. Males may contract acute cystitis as a result of the incomplete bladder emptying secondary to an enlarged prostate or following acute prostatitis.



Signs and Symptoms




• Patient reports difficulty starting urinary stream, accompanied by pain and burning


• Other irritative voiding symptoms such as dysuria, urgency, frequency, and nocturia may be present


• The patient may void only small amounts of cloudy urine at a time


• Patients often report foul-smelling urine


• Normal temperature or low-grade fever


• Suprapubic pressure or pain or low back pain


• Prostate tenderness possible


• Urinary retention in males


• A change in mental status may be the only indication of urinary tract infection in the elderly

Related posts:

Default ThumbnailWorkplace Violence and Disruptive Behavior Alcohol Abuse Stroke Mental Health Emergencies Burns Spinal Cord and Neck Trauma

Stay updated, free articles. Join our Telegram channel
Tags:
Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Genitourinary Emergencies

Full access? Get Clinical Tree
Get Clinical Tree app for offline access