Urologic Emergencies

Denise Watt

Feb 7, 2002

Outline

• Cases• Renal calculi

– Epidemiology / pathophysiology– Clinical presentation– DI– Management

• Hematuria• Urinary retention

Case 1

62 yo male, sudden onset Rt flank/back pain.

Constant, can’t get comfortable, N&V.

PMHx: HTN

O/E: pale, bp 100/75, HR 105, T37

Urine dip: + hematuria

DDx: ?

Case 2

02:00

45 yo male, sudden onset lt flank pain to

groin, hematuria, prior renal calculi x 2

To image or not to image?

Case 3

30 yo female, RLQ/pelvic pain x 12 hr.

Fever, chills, N&V.

O/E: 140/90, 110, T 38.5

DDx: ?

Imaging modality?

Rx?

Case 4

Renal CalculiEpidemiology

• Present since antiquity• 3-5% of population, 12% white males• 50% recurrence in 10 yrs• whites, rare in Africans & Natives• peak incidence b/w 20-50• M:F = 3:1• familial• ‘stone belt’: SE US• peak months July-September: heat + sunlight?

Epidemiology

• types: Ca oxalate, struvite, uric acid, cystine, misc

• 80% Calcium– most Ca oxalate, some Ca phosphate

– most hypercalciuric (absorptive, resorptive, ideopathic)

• hypercalcemic: hyperparathyroid, hyperthyroid, sarcoidosis

• hereditary causes: PCKD, RTA, PTH, cystinuria

Pathophysiology: Ca oxalate

• urine supersaturated Ca & oxalate crystals• lack of inhibitors: pyrophosphate, citrate• crystals usually washed away into bladder• crystals stick in tubules/ducts, grow, obstruct

– medullary sponge kidney, intramed stasis, abn tubular epithelium

• diet: protein? Ca? oxalate? Na?• low urine volume: water intake, bowel disease

Pathophysiology: Struvite

• 10-20%• staghorn calculi: Mg, NH4, PO4• requires pH>7.2 & NH4 in urine • caused by urease-producing UTIs

– Proteus, Klebsiella, Staph, Providencia, Corynebacterium

• atypical presentation in subset: malaise, weakness

Pathophysiology: Others

• Uric acid– 6-10%, most common radiolucent stones secretion uric acid, acidic urine, urine vol– 1%/yr after 1st gouty attack

• Cystine– 1%, insoluable in low pH– cystinuria: autosomal recessive

• Drugs– triamterene, indinavir, sulfonamides, CA inh.

History

• Renal colic: worse than labour???– Severe, sudden, paroxysmal pain, flankgroin,

referred to testicle, writhe– urinary sx (UVJ/bladder)– N/V (celiac plexus)

• Risk factors: prior episode, FH• Complications: UTIs, solitary kidney, renal

transplant, anat abn, immunocompromised• r/o DDx

Physical Exam

• VS: adrenergic, no fever– Hypotension rare (vasovagal): r/o AAA, sepsis

• Flank pain (r/o pyelo), no peritoneal signs

• CV exam: r/o embolic ds

• r/o bladder retention

• pv exam (PID, preg)

Differential Diagnosis

• HUGE!• AAA

– commonly misdiagnosed as renal colic

– suspect > 50, hypotension

– can have hydronephrosis, hematuria

• renal artery thrombosis/dissection– diff dx, contrast CT

• appendicitis: can have hematuria, CT• pyelo/cystitis: mimic or mask; infected obstruction is

emergency

Lab

• U/A– 90% hematuria– sens with acute flank pain 89%; spec 29%– pyuria common w/o infection– pH: high struvite, RTA; low uric acid– crystals

• Lytes AG met acidosis + Ca oxalate = ?– NonAG met acidosis + hypokalemia = ?

Lab

Urea/Cr– not caused by stone– affects Rx, diagnostic tests

• CBC: non-specific, pain/stress

• Ca, Mg,PO4, uric acid: don’t change mgt

• Pt passes stone: send for analysis

Diagnostic Imaging

• Role– Confirm dx– R/o other serious dx– Detect complications of stone– Define site/size of stone

• Who needs emergent imaging?– No consensus: 1st stone, suspect other dx

Diagnostic Imaging

• How good are we clinically?– High PTP: 70% had stones on IVP (Twinem,

Wrenn)– Are we missing serious other disease if we

don’t image?

• Bottom line: we must decide how confident we are with our dx, r/o serious DDx (esp. in elderly), close F/U to confirm dx

Diagnostic Imaging Modalities

Study Sens. Spec. Advantages Limitations

Plain film

45-59% 71-77% Cheap, accessible Only radiolucent calculi, no info on other causes, function

U/S 19%

97% Accessible, no radiation, good for renal calculi/ hydronephrosis/ gyne dx

poor for ureteral stones, no function, operator dependent

IVP 64-87% 92-94% Assess function & anatomy both kidneys, stone size & location, degree of obst

Contrast, bowel prep, time consuming, no non-urinary info

Non-contrast CT

95-100%

94-96% Most sens & spec, indirect signs of degree of obst (kidney size, inflam, stranding, distention), non-urinary info

More $ (slight), no functional info

Ultrasound

IVP

CT

Diagnostic Imaging

• IVP– (Relative) contraindications:

• Cr >130, allergy, DM, multiple myeloma, dehydration, pregnancy

– obstruction: delayed nephrogram or hydro– delayed films until comlunization in 2 – extravasation: renal calyx or ureteral rupture– no infection extravasation not treated– no kidney uptake: think renal infarction

Diagnostic Imaging

• Non-contrast CT– Chen, J Emerg Med 1999;17:299-303– 100 pt: sens 98%, spec 100%– alternate dx in 50% pt w/o stone– cost $600 vs. IVP $400– study of choice? – same as IVP for hydronephrosis/ hydroureter;

better at ID stone

Management:r/o Emergency

• Urosepsis + obstructing stone– Need drainage (nephrostomy, stent) + IV Abx

• Acute renal failure/ anuria– bilat obst/ solitary kidney

Management:Criteria for Admission

• Absolute– intractable

vomiting/pain

– solitary kidney or transplant with obstruction

– UTI with obstruction

– hypercalcemic crisis

• Relative– stone > 6 mm

– high grade obstruction

– solitary kidney/ transplant w/o obstruction

– intrinsic renal disease

– extravasation

– social issues

Management:Analgesia

• Narcotics– Still the best analgesics– Problems: SE, don’t address pathophysiology

• NSAIDS RBF, ureteral Sm contraction, inflammation– Ketorolac as good as merperidine

• Cordell. Annals Emerg Med 1996;28:151-8; Larkin. Am J Emerg Med 1999;17:6-10

• higher incidence GI bleed?, worsens RF, CHF, HTN• contraindicated 3 days prior to ESWL

Probability of Stone Passage

Stone location and size

Probability of passage (%)

Proximal ureter >5 mm 0 5 mm 57 <5 mm 53 Middle section of ureter

>5 mm 0 5 mm 20 <5 mm 38 Distal ureter >5 mm 25 5 mm 45 <5 mm 74

Disposition: Stones < 5mm

• Analgesia

• strain urine until stone passes

• send for analysis

• return to ED if worsens, fever

Disposition:Urology Referral

• Emergencies

• stones >= 5 mm

• renal stones, incl. staghorn

• not passed after 2-4 weeks observation– complication rate triples (29%)

Complications

• renal failure – rare if no infection, other kidney works– need obstruction x 4 weeks? (Campbell’s)

• ureteral stricture

• infection, sepsis

• urine extravasation

• perinephric abscess

Special concerns

• Pregnancy– U/S to minimize radiation

• Children– Rare: look for metabolic cause

• Elderly– Rare first-time stones; look for other causes– CT (consider contrast)– beware NSAIDS/ narcotics

Surgical Management

• ESWL– Ureteral stones < 1cm

– Renal stones < 2 cm

• Uretoscopy– Ureteral stones

• Ureterorenoscopy– Renal stones < 2 cm

• Percutaneous nephrolithotomy– Renal stones > 2 cm

– Proximal ureteral stones > 1cm

Doc - I never want to go through this again!

• increase fluid intake

• diet– low Calcium: stones secondary to oxalate

• Borghi et al, NEJM 2002;346:77-84

– low protein: acid-induced Ca excr. & urate– low Sodium: urinary Na Ca No clinical excr.– Low oxalate: nuts, chocolate, rhubarb, beets,

dark green veggies

Prevention

• thiazides, amiloride (hypercalciuria)

• allopurinal, alkalinize urine if pH low (uric acid)

• potassium citrate (hypocitraturia)

Summary

• stones are common

• clinical dx + hematuria isn’t reliable

• CT probably the best DI

• analgesia: NSAID + opiod

• watch out for emergencies

• when to consult

• prevention

Hematuria: the quick and dirty

• DDx huge: look it up– infection 25%– stones 20%– NYD 10%– others: trauma, glomerular, renal, extrarenal,

coagulopathy, factitious, pigmenturia– most common worldwide: schistosomiasis

Hematuria

• Gross– r/o bladder/kidney CA

• Micro– >3 RBC/hpf

History

• Quantity

• Timing– initial hematuria: anterior urethral lesion

• urethritis, stricture, meatal stenosis

– terminal:post. urethra, bladder, neck, trigone• post urethritis, polyps, tumours

– total: source above bladder• stone, tumour, infection

Hematuria is an Emergency! (sometimes)

• trauma

• gross hematuria causing hypovolemic shock

• urosepsis

• obstructing stones + infection or RF

• glomerulonephropathies + CHF, HTN emergencies, RF, infection

• coagulopathy, bleeding from multiple sites

Diagnosis

• Dipstick– 90% sensitive– FP: Mb, menses

• U/A– RBC casts + proteinuria = GMN

• DI– stones– trauma

Management

• Glomerulonephropathies– supportive– lower BP if HTN urgency/emergency– judicious diuresis if CHF– dialysis prn– Abx prn– steroids if nephrotic syndrome– d/c + F/U if mild protein/hematuria, stable VS, no

infection, other B/W normal

Management:Microscopic hematuria

• F/U U/A – Fam MD or urologist

• Urology W/U if:– >3 RBC/hpf on at least 2 U/A or one episode

>100 RBC/hpf or gross hematuria

Management:Gross hematuria

• Admit– severe, unstable, worsening RF, anemia,

coagulopathy, pain-control

• significant, not severe (?)– 3-way foley irrigation– d/c with foley + leg bag + F/U urology

Hematuria Trivia

1. Micro hematuria in 6 yr old 2 weeks after URI + sore throat.

> Post-Strep GMN

2. Known narcotic abuser + gross hematuria

> Papillary necrosis

3.Micro hematuria in pt with RA on Indocid

> Interstitial nephritis

Hematuria Trivia

4. Gross hematuria in 5 yr old, FH of RF

> Medullary sponge kidney

5.Recent travel to Africa, gross hematuria

> Schistosomiasis

6. Hemopytsis + chronic micro hematuria

> Goodpasture’s

Hematuria Trivia

7. Micro hematuria in9 yo with FH deafness

> Alport’s

8. African-Canadian 11 yo, abd pain, dehydrated, gross hematuria

> sickle cell crisis

9. URI 2 days ago, micro hematuria + protein

> IgA nephropathy