Urology

Question 1

Urinary Retention Management

Answer 1

• If bladder severely distended (>700 mL), leave catheter in for at least 5-7 days to allow time for bladder muscles to heal
• In males consider starting Flomax a day or two before trial of void
• Constipation is a commonly overlooked precipitant of retention, make sure to ask and start laxatives
• Some pyuria can be expected from bladder distension alone, but consider treating for UTI if the urinalysis is grossly positive (nitrites, bacteria)
• In chronic/severe obstruction, watch for post-obstructive diuresis
  
  • u/o > 200 mL/h for 2h (not counting initial decompression)
  • Leads to dehydration, especially in patients with poor PO intake
  • Admit for IVF to medicine or urology

Question 2

Microhematuria management

Answer 2

• <40/HPF = GP within 2 weeks
• >40/HPF = uro within 2 weeks
• Travel to Middle-East, Africa, think schistosomiasis

Question 3

Gross Hematuria Management

Answer 3

• All new gross hematuria patients will need imaging, though not necessarily in ED
  
  • Consider triphasic CT (CT IVP) or US to expedite outpatient work-up
• If not in retention, no clots, and blood is dark, may DC home if stable with urgent cysto
• If bright red, need closer monitoring/serial Hb
• If clots/retention, need to manually declot + CBI
  
  • 22 Fr three-way catheter or larger
  • Using large slip-tip syringe, enter main (drainage) port of catheter and sequentially flush and aspirate 20-30 mL aliquots of saline
  • Continue until no further clots
  • CBI
    
    • May try adding CBI irrigation solution from freezer for hemostasis
    • In males, may add some traction on inflated balloon by taping the catheter under tension to the leg to help tamponade prostatic bleeding
    • When the irrigation solution can be clamped for 30 min and fluid remains light pink with no blockage 30 min later, can DC home
    • If not resolving, consider CT to look for large clot in bladder (may need cystoscopy)
    • If no significant retention component (just clots) then DC catheter before sending home (otherwise may cause continued irritation and bleeding)
    • If retention was a component of patient presentation then send home with 3-way catheter with irrigation port plugged (no need to change to Foley), for 5-7 days before trial of void
  • Dr. Golda reverses warfarin if supratherapeutic or if bleeding is bright red
  • Dr. Golda likes to hold all anticoagulants/antiplatelets until urine is clear for 2 days (unless recent stent/active thrombus)
  • Most gross hematuria in men is from BPH and in women is from UTI
  • Some pyuria can be expected from bladder wall distension/irritation but consider antibiotics if nitrites/ bacteria on urinalysis, at least until culture resulted

Question 4

Phimosis

Answer 4

see evernote GU EM

Question 5

Paraphimosis

Answer 5

See evernote GU EM

Question 6

Balanoposthitis tx

Answer 6

• keflex +- clotrimazole/cortisone 1%/1% cream, saline soaks

Question 7

Priapism

Answer 7

see evernote GU EM

Question 8

Suprapubic catheter

Answer 8

• POCUS to ensure no interposed bowel
• Complication rate increases with previous abdominal surgery, Dr. Golda would not attempt without US guidance or IR
• Place in Trendelenburg to offload bowel
• Enter with 18G spinal needle no higher than 2 cm above pubic symphysis
• Insert 0.035-inch guide wire through needle
• Remove needle
• Insert dilator + sheath assembly over guidewire
• Remove dilator
• Insert Foley (min 16 Fr, better 20 Fr)
• Inflate balloon with 5-10 mL (not 30 mL) water/saline
• Peel away sheath
• Tape in place