- Dysuria
- Hematuria
- Testicular/Scrotal Pain
- Urinary Retention
- Vaginal Bleeding (Non-Pregnant)
- Vaginal Bleeding (Pregnant)

Dysuria
Rapid Review
Pearls
Deep Dive

Hematuria
Rapid Review
- Differentials
- Urinary tract infection
- Nephrolithiasis
- Bladder/Kidney cancer
- Nephropathy
- Foreign Body
- BPH
- History
- Ingestion of new foods or medications
- Consider pseudohematuria
- Clots
- Consider nonglomerular etiology (bladder)
- Beginning, middle, or end of stream
- Helps identify source of bleeding
- Recent procedures or trauma
- Consider urethral injuries
- Ingestion of new foods or medications
- Physical Exam
- CVA tenderness
- Suggests pyelonephritis or nephrolithiasis
- Suprapubic tenderness
- Suggests cystitis
- External lesions/lacerations
- Evidence of urethral injury
- CVA tenderness
- Work-Up
- Labs
- CBC, BMP, Coags, CK
- Urinalysis
- Urine culture
- Imaging
- CT (may be useful for identifying pyelonephritis vs nephrolithiasis)
- Labs
Pearls

Testicular/Scrotal Pain
Rapid Review
- Differentials
- Testicular
- Testicular torsion
- Orchitis
- Epididymitis
- Neoplasm
- Testicular rupture
- Scrotal
- Hydrocele
- Fournier gangrene
- Scrotal abscess
- Abdominal/Renal
- Abdominal aortic aneurysm
- Nephrolithiasis
- Inguinal hernia
- Testicular
- History
- Onset of pain
- Surgery typically required within 12 hours of testicular torsion
- Fever
- Consider infectious causes
- Recent strain or exercise
- Consider hernia or testicular torsion
- New sexual partners
- Consider epididymitis
- History of renal colic
- Pain may be referred to testicular region
- Onset of pain
- Physical Exam
- Absent cremasteric reflex or horizontal lie of testicle
- Suggests testicular torsion
- CVA tenderness
- Consider renal colic
- Urethral discharge
- Consider gonorrhea/chlamydia
- Scrotal mass
- Consider hernia
- Transilluminated mass
- Consider hydrocele
- Absent cremasteric reflex or horizontal lie of testicle
- Work-up
- Labs
- Urinalysis, STI testing
- Imaging
- Testicular ultrasound
- Evaluate for torsion
- CT abdomen/pelvis
- If concern for nephrolithiasis
- Testicular ultrasound
- Labs
Pearls

Urinary Retention
Rapid Review
- Differentials
- Urethral obstruction
- Pelvic organ prolapse
- Foreign body
- Stricture
- Prostatic obstruction
- Benign prostatic hypertrophy (BPH)
- Prostate cancer
- Prostatitis
- Prostate avulsion
- Bladder obstruction
- Calculi
- Clots
- Cancer
- Neurogenic
- Multiple sclerosis
- Cauda equina syndrome
- Diabetic neurogenic bladder
- Spinal cord compression
- Medications
- Anticholinergics
- Antihistamines
- Nifedipine
- Sympathomimetics
- Urethral obstruction
- History
- Time since last urination
- Evaluate severity
- Fever/chills
- Consider infection
- Family Hx of cancer
- Consider prostate or bladder cancer
- Neurologic symptoms
- Consider cauda equina, MS, cord compression
- Medication list
- Several medications may cause retention
- Time since last urination
- Physical Exam
- Abdominal exam
- Palpate for masses
- Pelvic exam
- Evaluate for organ prolapse
- Neurologic exam
- Decreased strength/sensation in lower extremities or saddle region suggests cauda equina
- Abdominal exam
- Work-up
- Labs
- CBC (if suspect infection/hematuria), BMP
- Urinalysis and urine cultures
- Imaging
- Bedside ultrasound
- Confirm urinary retention
- CT abdomen/pelvis
- If concerned for malignancy, bladder calculi, mass
- MRI/spinal imaging
- If concern for cauda equina
- Bedside ultrasound
- Labs
Pearls

Vaginal Bleeding (Non-Pregnant)
Rapid Review
- Differentials
- Menstruation w/ coagulopathy
- Uterine fibroids
- Polyps
- Breakthrough bleeding w/ OCPs
- Atrophic vaginitis
- Foreign Body
- Endometrial/Cervical cancer
- History
- Amount of blood (in pads or tampons)
- Helps quantify severity of bleeding
- Recently started contraceptives
- Consider breakthrough bleeding
- Family history of malignancy
- Consider endometrial or cervical cancer
- Abdominal/Pelvic pain
- Consider ectopic pregnancy
- Amount of blood (in pads or tampons)
- Physical Exam
- Signs of trauma
- Consider vaginal or uterine injury
- Abdominal/Pelvic tenderness
- Consider ectopic pregnancy or ovarian cyst
- Signs of trauma
- Work-Up
- Labs
- CBC, CMP, Type and Cross
- Beta-hCG
- DIC panel (fibrinogen, coags, reticulocyte count, d dimer)
- Imaging
- Transvaginal ultrasound
- Labs
Pearls

Vaginal Bleeding (Pregnant)
Rapid Review
- Differentials
- Early pregnancy (<20 weeks)
- Ectopic pregnancy
- Abortion (threatened, complete, incomplete)
- Trauma
- Post-Couital bleeding
- Later pregnancy (>20 weeks)
- Placental abruption
- Placenta previa
- Cervical/vaginal trauma
- Bloody show (cervical insufficiency or labor)
- Vasa previa
- Early pregnancy (<20 weeks)
- History
- Amount of bleeding
- > 1 pad/hour is severe
- Painful vs painless bleeding
- Ectopic pregnancy and placental abruption are classically painful
- Fever/chills
- Consider cervicitis, septic abortion
- Passage of tissue
- Consider miscarriage
- Recent sexual intercourse in past 24 hours
- Consider post-coital bleeding
- Amount of bleeding
- Physical Exam
- Abnormal vitals (hypotension, tachycardia)
- Consider ectopic pregnancy, placental abruption
- Abdominal exam
- Estimate gestation (20 weeks at umbilicus)
- Tenderness suggests abruption
- Pelvic exam
- Evaluate source of bleeding
- Determine if os is open or closed
- Abnormal vitals (hypotension, tachycardia)
- Work-up
- Labs
- CBC, type and screen, coagulation studies, quantitative hCG, urinalysis
- Procedures
- Fetal heart tones
- Present > 10 weeks
- Normal fetal HR is 120-160
- Fetal heart tones
- Imaging
- Transvaginal/Transabdominal
- Confirm intrauterine pregnancy
- “Snowstorm” appearance in gestational trophoblastic disease
- Transvaginal/Transabdominal
- Labs
Pearls