Acute Bacterial Prostatitis
- 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.
- Symptoms: Fever, chills, low back pain, irritative bladder symptoms (frequency, urgency, dysuria)
- Signs: Tender, enlarged prostate
- Clinical diagnosis
- UA will show pyuria and hematuria
- 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)
- 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.
- 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.
Acute Kidney Injury
- 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)
- Usually asymptomatic; may have nausea/vomiting or skin changes (purpura)
- May show signs of fluid overload. Seizures and coma may occur if untreated.
- 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.
- Overall goal is to treat the underlying cause.
- IV fluids, correct electrolyte deficiencies, dialysis if needed
- 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.
- 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.
- Infection of the kidney by a urinary tract infection ascending from the bladder.
- Most commonly caused by E. coli
- Symptoms: Flank pain, dysuria, nausea/vomiting
- Signs: (+) CVA tenderness, (+) Fever
- Urinalysis will likely show pyuria, hematuria, bacteriuria, and/or WBC casts
- Diagnosis confirmed with urine culture
- Outpatient: Ciprofloxacin or bactrim
- Inpatient: Gentamicin or 3rd/4th gen cephalosporin
- 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.
- 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.
- 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.
- Symptoms: sudden, severe pain in testicle. May have nausea/vomiting
- Signs: (-) Cremaster reflex, (-) Prehn’s sign. Very tender to palpation
- Manual detorsion (open-book method)
- If unsuccessful, will require emergent surgery
- All cases of confirmed testicular torsion will require admission for surgery. Consult urology early.
- 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.
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