Urologic Emergencies

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, cant get comfortable, NV.
• PMHx HTN
• O/E pale, bp 100/75, HR 105, T37
• Urine dip hematuria
• DDx ?

4
Case 2

• 0200
• 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, NV.
• 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
• MF 31
• 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 pHgt7.2 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 gt 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 dont 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 dont
  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 gt130, 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 199917299-303
• 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
Managementr/o Emergency

• Urosepsis obstructing stone
• Need drainage (nephrostomy, stent) IV Abx
• Acute renal failure/ anuria
• bilat obst/ solitary kidney

26
ManagementCriteria for Admission

• Absolute
• intractable vomiting/pain
• solitary kidney or transplant with obstruction
• UTI with obstruction
• hypercalcemic crisis

• Relative
• stone gt 6 mm
• high grade obstruction
• solitary kidney/ transplant w/o obstruction
• intrinsic renal disease
• extravasation
• social issues

27
ManagementAnalgesia

• Narcotics
• Still the best analgesics
• Problems SE, dont address pathophysiology
• NSAIDS
• ? RBF, ureteral Sm contraction, inflammation
• Ketorolac as good as merperidine
• Cordell. Annals Emerg Med 199628151-8 Larkin.
  Am J Emerg Med 1999176-10
• higher incidence GI bleed?, worsens RF, CHF, HTN
• contraindicated 3 days prior to ESWL

28
Probability of Stone Passage
29
Disposition Stones lt 5mm

• Analgesia
• strain urine until stone passes
• send for analysis
• return to ED if worsens, fever

30
DispositionUrology Referral

• Emergencies
• stones gt 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? (Campbells)
• 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 lt 1cm
• Renal stones lt 2 cm
• Uretoscopy
• Ureteral stones
• Ureterorenoscopy
• Renal stones lt 2 cm
• Percutaneous nephrolithotomy
• Renal stones gt 2 cm
• Proximal ureteral stones gt 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 200234677-84
• 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 isnt 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
• gt3 RBC/hpf

39
History

• Quantity
• Timing
• initial hematuria anterior urethral lesion
• urethritis, stricture, meatal stenosis
• terminalpost. 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
ManagementMicroscopic hematuria

• F/U U/A
• Fam MD or urologist
• Urology W/U if
• gt3 RBC/hpf on at least 2 U/A or one episode gt100
  RBC/hpf or gross hematuria

44
ManagementGross 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.
• gt Post-Strep GMN
• 2. Known narcotic abuser gross hematuria
• gt Papillary necrosis
• 3.Micro hematuria in pt with RA on Indocid
• gt Interstitial nephritis

46
Hematuria Trivia

• 4. Gross hematuria in 5 yr old, FH of RF
• gt Medullary sponge kidney
• 5.Recent travel to Africa, gross hematuria
• gt Schistosomiasis
• 6. Hemopytsis chronic micro hematuria
• gt Goodpastures

47
Hematuria Trivia

• 7. Micro hematuria in9 yo with FH deafness
• gt Alports
• 8. African-Canadian 11 yo, abd pain, dehydrated,
  gross hematuria
• gt sickle cell crisis
• 9. URI 2 days ago, micro hematuria protein
• gt IgA nephropathy