Renal/Genitourinary

Rapid Review

• Background
  • Inflammation of the prostate due to ascending infection of gram-negative rods into the prostatic ducts.
  • Most commonly caused C. trachomatis and N. gonorrhoeae patients <35 years old; E. coli for patients >35 years old.
• Signs/Symptoms
  • Symptoms: Fever, chills, low back pain, irritative bladder symptoms (frequency, urgency, dysuria)
  • Signs: Tender, enlarged prostate
• Diagnosis
  • Clinical diagnosis
  • UA will show pyuria and hematuria
• Treatment
  • If < 35 years old, treat for chlamydia and gonorrhea (Ceftriaxone + Doxycycline)
  • If > 35 years old, treat for E. coli and pseudomonas (fluoroquinolones or TMP-SMZ)
• Disposition
  • Patients with non-complicated prostatitis can be discharged as long as they can tolerate PO antibiotics
  • Admit toxic-appearing patients or those with urinary retention.

Pearls

• For severe or persistent cases, consider ultrasound or CT to look for prostate abscess. If present, these patients will require urgent urologic consultation.
• Consider STIs in any sexual active male with prostatitis, regardless of their age.

Deep Dive

• Prostatitis (emDOCs)

Rapid Review

• Background
  • Acute reduction in renal function over hours to days. Previously referred to as “acute renal failure”.
  • Causes may be prerenal (CHF,  hemorrhage, hypovolemia), intrarenal (ATN, vasculitis, glomerulonephritis), or postrenal (nephrolithiasis, BPH)
• Signs/Symptoms
  • Usually asymptomatic; may have nausea/vomiting or skin changes (purpura)
  • May show signs of fluid overload. Seizures and coma may occur if untreated.
• Diagnosis
  • Laboratory diagnosis; defined as increase in serum creatinine 1.5x presumed baseline or an increase in serum creatinine by 0.3 mg/dL over 48 hours 
  • Imaging, biopsy, and other labs (FENa, urine osmolality, etc.) will help determine cause. 
• Treatment
  • Overall goal is to treat the underlying cause.
  • IV fluids, correct electrolyte deficiencies, dialysis if needed
• Disposition
  • Mild AKI with a clear cause and no electrolyte derangements can be discharged with follow-up as needed.
  • Admit any patients with significant metabolic derangements, AMS, or unclear etiology of the AKI.

Pearls

• NSAIDs should be avoided when possible  in any patient with an AKI, as these cause a decrease in glomerular blood flow.
• Although contrast as been associated with AKI, you should never withhold contrast from a patient who needs it to diagnose a life-threatening diagnosis, regardless of baseline renal function. 

Deep Dive

• Acute Kidney Injury – A Simple Emergency Approach to AKI (EM Cases)

Rapid Review

• Background
  • Infection of the kidney by a urinary tract infection ascending from the bladder. 
  • Most commonly caused by E. coli
• Signs/Symptoms
  • Symptoms: Flank pain, dysuria, nausea/vomiting
  • Signs: (+) CVA tenderness, (+) Fever
• Diagnosis
  • Urinalysis will likely show pyuria, hematuria, bacteriuria, and/or WBC casts
  • Diagnosis confirmed with urine culture
• Treatment
  • Antibiotics
    • Outpatient: Ciprofloxacin or bactrim
    • Inpatient: Gentamicin or 3rd/4th gen cephalosporin
• Disposition
  • Admit any complicated cases (sepsis, pregnancy, concomitant obstruction, failed outpatient therapy)
  • Uncomplicated cases who are tolerating PO and have close follow-up in 48-72 hours can be discharged.

Pearls

• CT imaging is not required to diagnose pyelonephritis, but can evaluate for obstructing stones or renal abscesses. 
• Always remember to get a urine culture. It may not change management in the ED initially, but will be very useful in the inpatient setting or those who bounceback after being discharged. 

Deep Dive

• Pyelonephritis: It’s not always so straightforward… (emDOCs)

Rapid Review

• Background
  • Urologic emergency involving rotation of the testicle around the spermatic cord, causing compromised blood flow and ischemia that can quickly lead to permanent effects on fertility within 4-6 hours.
• Signs/Symptoms
  • Symptoms: sudden, severe pain in testicle. May have nausea/vomiting
  • Signs: (-) Cremaster reflex, (-) Prehn’s sign. Very tender to palpation
• Diagnosis
  • Ultrasound w/ doppler
• Treatment
  • Manual detorsion (open-book method)
  • If unsuccessful, will require emergent surgery
• Disposition
  • All cases of confirmed testicular torsion will require admission for surgery. Consult urology early.

Pearls

• Remember time is testicle! The earlier the diagnosis can be made, the more likely the testicle can be salvaged. The risk of orchiectomy is 5% at 0-6 hours, 20% at 7-12 hours, and 80% at > 24 hours.
• Not every case of testicular torsion will present with testicular pain. Consider testicular torsion in any case of lower abdominal pain, especially in pediatrics.

Deep Dive

• Testicular Torsion (Core EM)