Chapter 33 Genitourinary Emergencies
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
Diagnostic Procedures
• 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
• 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.
Gross Hematuria
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.
Renal Calculi
• Presence of an ileal conduit or hypercalcemia
• Recent travel that may have contributed to dehydration or poor fluid intake
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
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
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
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
• A change in mental status may be the only indication of urinary tract infection in the elderly