- 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
- Be concerned about patients with painless, gross hematuria. Approximately 30% of these patients will have a malignancy.
- KUB (kidney/ureter/bladder) X-rays have very limited utility in the ED for the work-up of hematuria.
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
- Time is testicle! If you have a high clinical suspicion for testiciular torsion, you do not need to wait for ultrasound imaging. Consult surgery/urology immediately.
- The “TWIST” score can help determine the risk of testicular torsion and guide imaging/disposition decisions.
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
- Always consider neurological or spinal cord processes as the source of urinary retention (eg. cord compression, epidural abscess, guillane barre, multiple sclerosis)
- PSA levels are rarely useful in the ED, as they are usually elevated in the setting of acute urinary retention.
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
- Never take a patient’s word regarding their pregnancy status. Always confirm with laboratory testings. Surprises happen!
- Routine pelvic examination is controversial in these patients, however it can be useful for quantifying the amount of bleeding, identifying structural causes, and providing an opportunity for STI screening.
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
- Every pregnant woman who presents with vaginal bleeding should have RH status checked. If Rh-negative, Rhogam is indicated.
- Pelvic exam should NOT be performed in late pregnancy (> 20 weeks) unless placenta previa/vasa previa have been ruled out by ultrasound.
Emergency Medicine Physician Assistant. Duke University Graduate. Army National Guard PA/Combat Medic. Former Paramedic. Devoted to learning and sharing evidence-based medicine.