Emergency Medicine Board Review 2014 GU

1. PENIS
AND
RENAL STUFF
BOARD REVIEW
Derek Orchard
PGY 4
EMERGENCY MEDICINE

2. GAME PLAN
• Male GU Diseases
• Polycystic Kidney Disease
• Kidney Stones
This is going to be concise and to the point board review.

3. ANATOMY

5. BALANITIS/BALANOPOSTHITIS
•
Balanitis = Glans
•
Posthitis = Foreskin
•
Think: Uncircumcised, DM, Poor Hygiene, Obesity (picture Rundio)
•
Clinical: itching, discharge, redness, pain
•
Treatment
• Hygiene
• Topical Antifungal
• +/- antibacterial

7. 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

8. 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

9. 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

10. PENILE FRACTURE
•
Not Ortho
• Urologic Emergency
•
Traumatic tear of tunica albuginea
•
Exclude urethral injury with retrograde urethrogram
•
Management
• Immediate Surgical Repair

11. 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

13. 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

14. 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

15. 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

16. NEPHROLITHIASIS
• Diagnosis
• R/O AAA
• US – Hydro
• UA – Hematuria
• CT
• Most Common Sites of Impaction
• Ureterovesical Junction
• Ureteropelvic Junction
• Pelvic Brim

18. MANAGEMENT
• No obstruction or infection
• IVF, Analgesia, +/- alpha blockers, CCB
• Obstruction
• May require surgical measures and lithotripsy
• Obstruction + Infection
• Emergent Decompression

19. ACUTE RENAL FAILURE
• Rapid Decline in GFR
• 50% increase in Cr from baseline
• 3 Types
• PRErenal
• INTRINSIC
• POSTrenal

20. 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

21. 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+

22. POST-RENAL FAILURE
• Obstruction to urine flow
VS

23. WORKUP
• Cr, Lytes, CK
• Check the pee
• UA, Urine Lytes, Osmolality
• Foley
• +/- Ultrasound/CT/Finger

24. PRE VS POST VS INTRINSIC
Test
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

25. 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