Category: Renal and Urogenital

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Kidney Stones are a Diagnosis of Exclusion!!!

Introduction

• Testicular torsion is a time sensitive diagnosis (risk of infertility, etc)
• Commonly mimics kidney stones

History

• Sudden onset pain
  • Epididymitis tends to be slower in onset
• Flank/lower abdomen/scrotal pain
• Frequently causes vomiting
• Uncommon in geriatric patients

Exam

• Perform a GU exam and look for
  • Unequal/horizontal “lie”
  • Testicular tenderness
  • Swelling
  • Absent cremasteric reflex

Testing Plan

• Testicular/Scrotal Ultrasound
• Urinalysis

Treatment Plan

• Consult urology when suspected (even if ultrasound hasn’t returned yet)
• Manual detorsion
  • “Open the Book”
  • Twist medial to lateral
    • Switch directions if no pain relief

Additional Reading

• Flank Pain Practice Case (EM Clerkship)
• Pediatric Abdominal Pain (EM Clerkship)

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Kidney Stones are a Diagnosis of Exclusion!!!

Step 1: Consider the Differential Diagnosis for Flank Pain

• Appendicitis
• Abdominal Aortic Aneurysm
• Ectopic Pregnancy
• Testicular/Ovarian Torsion
• Kidney Stone

Step 2: Diagnose the Kidney Stone

• Option 1- Renal Ultrasound
  • Findings consistent with kidney stone diagnosis
    • Hydronephrosis
    • Lack of ureteral jets (in bladder)
    • Kidney stones (poor sensitivity for this)
  • Benefits
    • Can be performed at bedside
    • No radiation
• Option 2- Non-contrast CT scan
  • Great for identifying alternative diagnoses

Step 3: Rule Out Infection

• Fevers
• Urinalysis with nitrites or bacteria
  • If present, patient needs antibiotics

Step 4: Control Symptoms

• Analgesics
  • NSAIDS (such as ketorolac)
  • Opiates
• Antiemetics
  • Zofran

Step 5: Rule Out Kidney Injury

• Elevated creatinine
• Solitary kidney

Admission Criteria for Kidney Stones

• Coexisting Urinary Tract Infection
• Unable to Control Symptoms
• Renal Injury/Solitary Kidney

Additional Reading

• How to Interpret a Urinalysis (EM Clerkship)

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The nerve, artery, and vein are at 12 o’clock. The urethra is at 6 o’clock.

Two Types of Priapism

• High flow (non-ischemic)
  • Common causes
    • Trauma
    • AV malformations
    • Tumors
  • Priapism from too much blood coming IN
  • Not painful
  • Consult urology
• Low flow (ischemic)
  • Common causes
    • Sickle cell disease
    • Drug side-effects
  • Priapism from blood being unable to flow OUT
  • Patient requires emergent detumescence
    • 50% chance of erectile dysfunction

Step 1: Prepare (4c approach)

• Collect
  • 19G needle
  • 21G needle
  • Variety of syringes
  • Gauze
  • Sterile drape
  • Betadine
  • Normal saline
• Consent
  • 50% chance of erectile dysfunction even with successful procedure
• Clean
  • Set up supplies and sterile field
• Control pain
  • Penile nerve block (YouTube)

Step 2: Drain

• Nerve/Artery/Vein on top (12 o’clock)
• Urethra on bottom (6 o’clock)
• Insert 19G needle at either 3 or 9 o’clock and aspirate
  • UPDATE: Recommended insertion at either 2 or 10 o’clock
• 30% chance of detumescence at this step alone

Step 3: Send Venous Blood Gas

• Confirms high-flow (non-ischemic) from low-flow (ischemic) priapism

Step 4: Irrigate

• Inject normal saline through the needle and then aspirate

Step 5: Phenylepherine

• Dilute 1ml (10 mg/ml) in 9 ml NS (results in 1mg/ml solution)
  • Inject 0.25 ml of 1 mg/ml solution and repeat q10 minutes
  • Alpha agonist effect constricts smooth muscle and facilitates venous outflow

Additional Reading

• Dorsal Penile Nerve Block (YouTube)
• Drainage of Ischemic Priapism (SinaiEM)