Derek Orchard

PGY 4

EMERGENCY MEDICINE

PENIS AND

RENAL STUFFBOARD REVIEW

GAME PLAN

• Male GU Diseases

• Polycystic Kidney Disease

• Kidney Stones

This is going to be concise and to the point board review.

ANATOMY

BALANITIS/BALANOPOSTHITIS• Balanitis = Glans

• Posthitis = Foreskin

• Think: Uncircumcised, DM, Poor Hygiene, Obesity (picture Rundio)

• Clinical: itching, discharge, redness, pain

• Treatment

• Hygiene

• Topical Antifungal

• +/- antibacterial

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

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

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

PENILE FRACTURE• Not Ortho

• Urologic Emergency

• Traumatic tear of tunica albuginea

• Exclude urethral injury with retrograde urethrogram

• Management

• Immediate Surgical Repair

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

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

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

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

NEPHROLITHIASIS• Diagnosis

• R/O AAA

• US – Hydro

• UA – Hematuria

• CT

• Most Common Sites of Impaction

• Ureterovesical Junction

• Ureteropelvic Junction

• Pelvic Brim

MANAGEMENT

• No obstruction or infection

• IVF, Analgesia, +/- alpha blockers, CCB

• Obstruction

• May require surgical measures and lithotripsy

• Obstruction + Infection

• Emergent Decompression

ACUTE RENAL FAILURE

• Rapid Decline in GFR

• 50% increase in Cr from baseline

• 3 Types

• PRErenal

• INTRINSIC

• POSTrenal

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

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+

POST-RENAL FAILURE

• Obstruction to urine flow

VS

WORKUP

• Cr, Lytes, CK

• Check the pee

• UA, Urine Lytes, Osmolality

• Foley

• +/- Ultrasound/CT/Finger

PRE VS POST VS INTRINSICTest 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

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