BASICS
A rapid increase in blood urea nitrogen (BUN) and creatinine
ETIOLOGY
Prerenal
• Volume depletion, heart failure, liver failure, sepsis, burns, bilateral renal artery stenosis, drugs (nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitor)
Postrenal
• Obstruction (benign prostatic hyperplasia, calculi, tumors)
Intrinsic
• Renal ischemia
• Nephrotoxin exposures
• Acute tubular necrosis
Most common
Caused by renal ischemia secondary to trauma, sepsis, rhabdomyolysis (Table 14.1)
SIGNS AND SYMPTOMS
Nausea, vomiting, oliguria
Hyperkalemia
Metabolic acidosis
DIAGNOSTICS
Laboratory testing, including basic metabolic panel, urine electrolytes
TREATMENT
IVFs
Diuresis to prevent volume overload
Monitor electrolytes
Dialysis if:
• Critical electrolyte abnormalities
• Unresponsive metabolic acidosis
• Uremia
• Toxic ingestion
BASICS
A stone formed in the kidneys from dietary minerals
ETIOLOGY
Eighty percent Ca (others:uric acid, struvite)
Risk factors:
• Previous stones
• Male gender
• Family history
• History of gastric bypass
• Medications (hydrochlorothiazide, allopurinol)
• Diabetes
• Gout
• Dehydration
SIGNS AND SYMPTOMS
Flank pain, can radiate to the groin
Colicky, waxing, and waning pain
Restless
Hematuria (70% to 90%)
Nausea, vomiting, urinary urgency, dysuria
DIAGNOSTICS
Lab tests, including urinalysis, basic metabolic panel
Imaging:
• Noncontrast CT scan is test of choice
Ureterovesicular junction is most common site to see stones as it is the most narrow
• Kidney, ureter, and bladder x-ray (can miss stones and does not show hydronephrosis)
• Ultrasound
TREATMENT
IV fluids, pain medication (nonsteroidal anti-inflammatory drugs and opiates)
Urology consult for acute renal failure, urosepsis, unrelenting pain, stone >10 mm
Stone passage: smaller, more distal stones more likely to pass (most <5 mm pass spontaneously, then the percentage drops proportionally to the increasing size of the stone)
α-Blockers help facilitate the passage of the stone
BASICS
Inability to retract foreskin over glans (distally)
ETIOLOGY
Uncircumcised males
Failure to return foreskin after exam, cleaning, catheter
SIGNS AND SYMPTOMS
Pain, edema with constricting skin around glans
DIAGNOSTICS
Clinical exam findings
TREATMENT
Manual reduction of the prepuce
• Thumbs are placed on the glans, and the skin is rolled over the glans
If unsuccessful, obtain urology consult for a dorsal slit
Preventative interval circumcision
BASICS
Inability to retract foreskin over glans (proximally)
ETIOLOGY
Abnormal stricture of distal foreskin secondary to infections or inflammation
SIGNS AND SYMPTOMS
Pain and inability to retract foreskin
DIAGNOSTICS
Clinical exam findings
TREATMENT
Manual retraction, then thorough cleaning and proper hygiene
If unsuccessful, obtain urology consult
BASICS
Pathologic erection lasting >4 hours
ETIOLOGY
Idiopathic, sickle cell disease, drugs (Viagra, hypertensives cocaine), spinal cord injury
SIGNS AND SYMPTOMS
Erection can be painful
End result can cause ischemia, necrosis, urinary retention, impotence
DIAGNOSTICS
Clinical exam findings
TREATMENT
Phenylephrine and terbutaline injections
Needle aspiration of corpora cavernosa
Ice packs, pressure dressing
Recurrent episodes may require surgery
PYELONEPHRITIS, URINARY TRACT INFECTION, UROSEPSIS, PERINEPHRIC ABSCESS
BASICS
An inflammation and infection of the kidney
Women more common than men
ETIOLOGY
Most commonly caused by E. coli, followed by Proteus, Klebsiella
The bacterial infection spreads up the urinary tract to the kidneys
SIGNS AND SYMPTOMS
Dysuria, frequency, urgency, hematuria, fever, flank pain, vomiting
Costovertebral angle (CVA) tenderness
DIAGNOSTICS
Physical exam findings consisting of CVA tenderness, fever
Urinalysis, urine culture
Image if:
• Persistent symptoms after 48 to 72 hours
• Kidney stones or abscess suspected
• Immunosuppression
CT is the choice to assess for stone, gas-forming infections, hemorrhage, renal abscess
TREATMENT
Based on prior culture data
Cephalosporins or fluoroquinolones for 10 to 14 days
Admit if:
• Complicated/comorbidities
• Patient not tolerating orals
• Pregnant
• Renal transplant, single kidney
• Abscess
BASICS
Infection in any part of urinary system, most commonly bladder or urethra
Affects women more than men
ETIOLOGY
Common microbes: E. coli, Proteus, Klebsiella, Enterobacter
SIGNS AND SYMPTOMS
Lower abdominal pain, dysuria, urinary frequency
Foul-smelling urine
DIAGNOSTICS
Urinalysis
TREATMENT
Tailor to presumed microbes
Antibiogram dependent, but often Bactrim and Keflex are first line
Macrobid 100 mg bid for 5 days for pregnant patients
Men must be treated for 14 days
BASICS
Severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream
Can be life-threatening if it is not treated immediately
ETIOLOGY
Caused by bacteria from urinary tract infections (UTIs) and pyelonephritis
Risk factors: elderly patients, HIV, transplant recipients, diabetics, and immunosuppressed patients
SIGNS AND SYMPTOMS
Fever, weakness, hypotension, flank pain
DIAGNOSTICS
Urinalysis, urine culture
Lab testing, including complete blood count, lactate, blood cultures
Consider imaging, including ultrasound, chest x-ray
TREATMENT
ABCs, supportive
IV fluids, antibiotics
Consider ICU admission if patient persistently hypotensive, hypoxic, on pressors
BASICS
Abscess in perinephric space
ETIOLOGY
Usually from obstructed pyelonephritis
Risk factors: stones, diabetes mellitus, bacteremia
SIGNS AND SYMPTOMS
Symptoms similar to severe pyelonephritis
Few symptoms in the elderly, neuropathy, diabetes mellitus, alcoholics
DIAGNOSTICS
Must have high clinical suspicion
Urinalysis may be normal if no communication with the collecting system
Ultrasound or CT scan
TREATMENT
IV antibiotics for 2 to 3 weeks, drainage, and relief of any urologic obstruction
Renal abscess >5 cm = percutaneous drainage and antibiotics
Renal abscess <5 cm = antibiotics initially and if no response can consider drainage
Perinephric abscess should be drained for diagnostic and therapeutic options
SEXUALLY TRANSMITTED INFECTIONS
ETIOLOGY
Transmitted from sexual intercourse, usually herpes simplex virus type 2
SIGNS AND SYMPTOMS
Prodrome of hyperesthesia, parasthesia, or itching in area of peritoneum or genitals prior to outbreak
Occasional flu-like symptoms, inguinal lymphadenopathy, and fever
Exquisitely tender vesicles on erythematous base
DIAGNOSTICS
Clinical exam findings
Tzanck smear
TREATMENT
Vesicles are self-limiting and last 1 to 2 weeks
Oral antiviral therapy (acyclovir, or valacyclovir) can shorten the outbreak
Advise patient that the virus can be transmitted even when there are no symptoms
ETIOLOGY
Treponema pallidum
SIGNS AND SYMPTOMS
Primary syphilis:
• Usually with a chancre, a painless ulcer
Secondary syphilis:
• Various cutaneous lesions which are usually pink papules or macules often seen on palms and soles
• Sore throat and fever
Tertiary syphilis:
• Neurology manifestations
DIAGNOSTICS
Clinical exam findings
Polymerase chain reaction
TREATMENT
Primary and secondary should be treated with benzathine penicillin G 2.4 million units by intramuscular (IM) injection
ETIOLOGY
Chlamydia trachomatis
Neisseria gonorrhoeae
SIGNS AND SYMPTOMS
Men: asymptomatic or present with dysuria
Females: dysuria, vaginal discharge, pelvic pain, cervicitis
DIAGNOSTICS
Direct swab or collect urine/urethral swab
TREATMENT
Chlamydia:
• Azithromycin 1,000 mg po or doxycycline 100 mg po bid for 7 days
Gonorrhea
• Ceftriaxone 250 mg IM
• If penicillin or cephalosporin allergy, may give double dose of azithromycin
ETIOLOGY
Human papillomavirus
SIGNS AND SYMPTOMS
Fleshy warts appearing like cauliflower on the external genitalia
TREATMENT
Freeze or remove the warts
Immunization for preexposure prophylaxis
BASICS
A surgical emergency that may result in the loss of the affected testicle if not treated promptly
ETIOLOGY
Twisting of the spermatic cord constricts blood supply, which if left untreated can cause testicle necrosis
More common in children and young adults
SIGNS AND SYMPTOMS
Acute onset of pain and scrotal swelling
Occasional nausea and vomiting
The involved testis may be swollen or have a palpable torsed section
DIAGNOSTICS
Ultrasound to evaluate blood flow
TREATMENT
Occasional attempt at emergent manual reduction and emergent urologic consultation for surgical intervention
BASICS
Inflammation of the testicles
ETIOLOGY
Usually secondary to viral illness, mumps, or sexually transmitted infection
SIGNS AND SYMPTOMS
Pain and swelling of the testicle
DIAGNOSTICS
Ultrasound helpful to distinguish it from other pathology
TREATMENT
Symptomatic treatment
Treat the underlying etiology if suspected infectious cause
BASICS
Inflammation of the epididymis
ETIOLOGY
Epididymal swelling caused by infection, trauma, or idiopathic
Common causes: C. trachomatis and gonorrhea in young men who are sexually active; E. coli, Pseudomonas, and Enterobacter species in older men
SIGNS AND SYMPTOMS
Gradual onset of unilateral pain and swelling over a few hours
Epididymis and scrotum can be swollen and tender
May also have signs of UTI, but not consistent
DIAGNOSTICS
Urinalysis
Ultrasound
TREATMENT
If age <35:
• Treat for both C. trachomatis and gonorrhea with ceftriaxone 250 mg IM and doxycycline 100 mg bid
If age >35:
• Assume enteric pathogen and treat with Cipro for 10 days
Pain control and close urology follow-up
BASICS
Necrotizing fasciitis of perineal, genital, or perianal regions
ETIOLOGY
Polymicrobial
High rate of mortality
Most patients have diabetes
SIGNS AND SYMPTOMS
Edema, erythema tenderness in groin and genitals
Necrosis, crepitus of skin and subcutaneous tissue
DIAGNOSTICS
Clinical exam findings
Labs for leukocytosis
X-ray or CT scan may show subcutaneous gas
TREATMENT
ABCs, supportive, IV fluid, antibiotics
Surgery and/or urology consult for consideration of surgical debridement
