Chapter 35

Urology

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 Objectives
Label a diagram of the urinary system

Describe pathophysiology, signs and

symptoms, assessment, and management of:
Urinary retention Pyelonephritis
Urinary calculus Epididymitis
Testicular torsion

Outline examination of patients with

genitourinary disorders

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 Objectives
Discuss prehospital management for patients with
genitourinary disorders

Distinguish between acute and chronic renal

failure

Describe signs and symptoms of renal failure

Describe how to manage emergency conditions

associated with dialysis

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 Scenario
Your patient is 64 years old and complains of
weakness, dyspnea, and fatigue. She has a
history of renal failure but missed dialysis this
week. Her face, hands, and feet are swollen.
Her blood pressure is 190/110 mm Hg, pulse
is irregular; there are moist crackles in the
bases of the lungs; and her ECG shows
peaked T waves.

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 Discussion
What is the most likely explanation for this patients
symptoms?

Discuss whether furosemide would or would not be

appropriate to give her.

Which electrolyte imbalances do you anticipate in this

patient?

What should you consider if she experiences a

cardiac arrest?

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 Urinary System
Functions
Removes waste products
from blood
Helps to maintain constant
body fluid volume and
composition

Components
Kidneys
Ureters
Urinary bladder
Urethra

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 GU Disorders that Cause Pain
Urinary retention

UTI

Pyelonephritis

Urinary calculus

Epididymitis

Testicular torsion
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 Urinary Retention
Inability to urinate

Causes
Urethral stricture
Enlarged prostate
CNS dysfunction
Foreign body obstruction
Drugs

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 Urinary Retention
Signs and symptoms
Abdominal pain
Urge to urinate
Distended bladder

Management
Transport for urinary catheterization

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 Urinary Tract Infection (UTI)
Upper urinary tract infections
Pyelonephritis
Intrarenal and perinephric abscesses

Lower urinary tract infections

Bladder and urethra
Common among women
Short urethra

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 Urinary Tract Infection (UTI)
UTIs in men
Urethritis
Prostatitis
Cystitis

Also occur in children

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 Urinary Tract Infections
Signs and symptoms
Dysuria
Frequency
Hematuria
Abdominal pain
Fever, chills

Management
Hospital diagnosis, antibiotics

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 Pyelonephritis
Inflammation of kidney parenchyma

Bacterial infection reaches kidneys:

Blood or lymph
Through ureters from lower urinary tract

More common in women

May cause systemic infection

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 Pyelonephritis
Signs and symptoms
Fever
Chills
Flank pain
Nausea
Vomiting

Therapeutic intervention

Can progress to sepsis and result in renal failure

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Urinary Calculus (Kidney Stones)
Pathological concretions originate in renal
pelvis

Supersaturation of urine with insoluble salts:

Calcium oxalate and uric acid
Common in 20-40 y/o
Recurrent
More common in men

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 Urinary Calculus
Risk factors
Dehydration
CNS disorders
Drug use
Surgery

Signs and symptoms

Vary
Severe pain

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 Urinary CalculusS/S
Pain may radiate Low-grade fever

Restlessness Hematuria

Nausea and vomiting Dysuria

Urinary urgency/frequency Definitive care

Diaphoresis

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 Epididymitis
Bacterial infection

Sexually active men >20 y/o

Often related to venereal disease

Signs and symptoms

Gradual onset
Unilateral scrotal pain
Swollen scrotum and testicle

Management
Elevate scrotum

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 Testicular Torsion
True emergency

Testicle twists on spermatic

cord
Disrupts blood supply

Usually spontaneous
May result from blunt trauma

Two peaks
<1 y/o
Puberty
Range 5 mos to 41 yrs of
age

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 Testicular Torsion
Signs and symptoms
Tender epididymis
Painful swelling of the scrotal sac
Sudden
Often preceded by physical activity
Severe (sometimes radiates to left quadrant)
Unrelieved by position
Nausea and vomiting

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 Testicular Torsion
Must diagnose and treat <6 hrs
To prevent loss of testis from ischemic infarction

Therapeutic intervention
Ice packs
Pain management
Physician reduction
Surgery

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 History
Focused history

Identify location and type of pain and

associated signs and symptoms

OPQRST

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 History
Recent illness Weight loss

Past medical history Last oral intake

Medication use Last bowel movement

Change in bowel habits

Alcohol or drug use
Previous surgeries
Nausea or vomiting

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 History
Women
Menstrual activity
Possibility of pregnancy

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 Physical Examination
Protect privacy
If possible, same-gender paramedic should
examine patient
Chaperone

Examine with calm, caring, and competent

attitude

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 Physical Examination
Initial assessment
Physical examination
Appearance
Posture
Level of consciousness
Apparent state of health
Skin color
Vital signs
Abdominal examination
Genitalia examination (if indicated)

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Management and Treatment Plan
Airway, ventilatory, and circulatory support

Oxygen if indicated

ECG and vital sign monitoring

Pain management

Transport
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Management and Treatment Plan
Do not permit patient to eat or drink

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 Renal Failure
Kidneys maintain homeostasis by:
Controlling extracellular fluid volume
Maintaining proper electrolyte composition
Regulating blood pH
Eliminating wastes

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 Renal Failure
Uremia
Encephalopathy
Pericarditis

Hyperkalemia

Acidosis

Hypertension

Volume overload
CHF

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 Acute Renal Failure
Sudden decrease in glomerular filtration

Leads to accumulation of:

Salt
Water
Nitrogenous wastes
Azotemia

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 Acute Renal Failure
Onset may be within hours

Oliguric
<500 mL/day urine

Nonoliguric
>500 mL/day urine

Anuria
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 Acute Renal Failure
Edema

Acidosis

Uremia

Can lead to:

Heart failure
Fluid overload
Hyperkalemia
Acidosis

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 Prerenal ARF
Inadequate kidney perfusion

Cant clear urea and creatinine

Causes
Hypovolemia
Decreased cardiac output
Renal artery obstruction

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 Prerenal ARF
Signs and symptoms
Dry mouth, thirst
Hypotension
Tachycardia

Management
Treat underlying condition
IV fluids

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 Intrarenal ARF
Damage to both kidneys

Glomerular, tubular diseases

Interstitial diseases

90% by ischemia or toxins

Drugs
NSAIDs, antibiotics, anticancer drugs, dyes, alcohol, cocaine

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 Intrarenal ARFS/S
Fever Hypertension

Flank pain Confusion

Joint pain Seizure

Headache Oliguria

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 Intrarenal ARF
Treat underlying cause

Restore adequate renal blood flow

Renal dialysis

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 Postrenal ARF
Obstruction of urine flow in both kidneys
Bilateral calculi
Prostatic enlargement
Urethral strictures

Severity related to degree of obstruction

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 Postrenal ARF
Urine retention
Distended bladder
Hematuria
Low back pain
Pain in groin, genitalia
Edema
Treat obstruction to reverse

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 Chronic Renal Failure
Develops over months to years
Congenital disorders
Prolonged pyelonephritis
Diabetes
Hypertension
Autoimmune disorders
Causes scarring of kidneys

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 Chronic Renal Failure
Progressive abnormality in blood counts and
blood chemistry levels

In final stages, requires dialysis or renal

transplantation

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 Chronic Renal Failure
Gastrointestinal
Anorexia
Nausea
Vomiting

Cardiopulmonary
Hypertension
Pericarditis
Pulmonary edema
Peripheral, sacral, and periorbital edema

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 Chronic Renal Failure
Nervous system
Anxiety
Delirium
Progressive obtundation
Hallucinations
Muscle twitching
Seizures

Metabolic or endocrine
Glucose intolerance
Electrolyte disturbances
Anemia

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 Chronic Renal Failure
Personality changes
Fatigue
Mental dullness

Uremia
Yellow skin
Thin extremities
Uremic frost

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 Renal Dialysis
Technique to normalize blood chemistry

Acute or chronic renal failure

Hemodialysis and peritoneal dialysis
Bring blood in contact with a semipermeable
membrane
Water-soluble substances diffuse into a dialyzing
fluid (dialysate)

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 Renal Dialysis
Amount that transfers during dialysis depends
on:
Concentration difference
Molecular size of substance
Time

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 Hemodialysis
Heparinized blood is pumped through:
Arteriovenous fistula
OR
Arteriovenous graft

Internal shunts usually on inner aspect of

forearm

Medial aspect of lower extremity

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 Arteriovenous Fistula

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 Peritoneal Dialysis
Dialysis membrane is peritoneum

Slower than hemodialysis

Over time just as effective
Does not require chronic blood access

Peritonitis is a major complication

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 Dialysis Emergencies
Vascular access problems

Hemorrhage

Hypotension

Chest pain

Severe hyperkalemia
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 Dialysis Emergencies
Disequilibrium syndrome
Group of neurological findings
Occurs during or immediately after dialysis
Symptoms are usually mild but may be severe
If seizures, diazepam may be indicated

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 Air Embolism
Negative pressure on venous side of dialysis tubing
Malfunction in dialysis machine
Air embolism enters patient's bloodstream
Oxygen
Rapid transport
Position on left side
Modified Trendelenburg position

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Dialysis EmergenciesManagement
Support airway and ventilation

Oxygen administration

Vascular access if needed

Aseptic technique

ECG

Vital sign monitoring

Rapid transport to appropriate facility

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 Conclusion
Management of patients with genitourinary
disorders often begins in the prehospital
setting. Successful outcomes may be
determined, in part, by paramedic
assessment and care.

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 Questions?

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