Genitourinary and Gynecologic Emergencies

Genitourinary and Gynecological Emergencies

Submitted by: 4Nu02-Group 7 Caparaz, David Capili, Kristian Dior  Cariño, Dennise Carvajal, Florence Salvador, Abigail

Submitted to: Mr.Vergel

EMERGENCY MANAGEMENT OF RENAL COLIC Initial

treatment of a renal colic patient in the ED starts with obtaining IV access to allow fluid, analgesic, and antiemetic medications to be administered. Many of these patients are dehydrated from poor oral intake and vomiting.  Although the role of supranormal hydration in the management of renal (ureteral) colic is controversial (see below), patients who are dehydrated or ill need adequate restoration of circulating volume.  After diagnosing renal (ureteral) colic, determine the presence or absence of obstruction or infection. Obstruction in the absence of infection can be initially managed with analgesics and with other medical measures to facilitate passage of the stone. Infection in the absence of obstruction can be initially managed with antimicrobial therapy. In either case, promptly refer the patient to a urologist. If

neither obstruction nor infection is present, analgesics and other medical measures to facilitate passage of the stone (see below) can be initiated with the expectation that the stone will likely pass from the upper urinary tract if its diameter is smaller than 5-6 mm (larger stones are more likely to require surgical measures).

If

both obstruction and infection are present, emergency decompression of the upper urinary collecting system is required (see Surgical Care). In addition, immediately consult with a urologist for patients whose pain fails to respond to ED management. Pain relief  The cornerstone of ureteral colic management is analgesia, which can be achieved most expediently with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSA IDs). If oral intake is tolerated, the combination of oral narcotics (eg, codeine, oxycodone, hydrocodone, usually in a combination form with acetaminophen), NSA IDs, and antiemetics, as needed, is a potent outpatient management approach for renal (ureteral) colic. Parenteral narcotics are the mainstay of analgesia for patients with acute renal colic. They work primarily on the central nervous system (CNS) to reduce the perception of pain. They are inexpensive and quite effective. When considering a medication and dosage range, remember that acute renal colic is probably the most painful malady to affect humans. Adverse effects of narcotic analgesics include respiratory depression, sedation, constipation, a potential for addiction, nausea, and vomiting. Morphine, meperidine, and butorphanol are the most commonly used. Morphine is a potent narcotic analgesic that controls severe pain primarily through a CNS mechanism via specific receptor site interactions. The usual dosage is 10 mg/70 kg body weight intramuscularly ( IM) or subcutaneously (SC) every 4 hours. The actual dosage required varies according to each individual patient¶s tolerance and severity of  discomfort. For more rapid results, morphine sulfate can be administered IV in doses of 4-10 mg, but this must be done slowly or in small increments to avoid excessive adverse effects.  Adverse effects of morphine include respiratory depression, drowsiness, mood changes, nausea, vomiting, increases in the cerebrospinal fluid pressure, and cough reflex depression. The most bothersome is respiratory depression caused by a direct effect on the brain stem respiratory center. This effect is most severe in patients who are elderly, debilitated, or both. Meperidine is a potent parenteral narcotic analgesic that is very similar in overall effect to morphine sulfate. A 60-80 mg dose of meperidine is roughly equivalent to 10 mg of morphine. Meperidine offers a slightly more rapid onset of  action and slightly shorter duration of analgesic activity than morphine sulfate. Some evidence suggests that meperidine may have slightly fewer adverse effects than morphine. The dosage range is usually 50-150 mg IM or SC every 3-4 hours; it is reduced by at least 50% with IV administration. The actual effective dosage varies according to the source of the pain and the individual¶s tolerance.  As with morphine sulfate, IV administration should be performed slowly. Meperidine is contraindicated in patients taking monoamine oxidase inhibitors. Butorphanol has some theoretical advantages based on studies that suggest it causes less smooth muscle spasm and respiratory depression than either morphine or meperidine. Butorphanol costs approximately $10/mg, compared with approximately $0.05/mg for meperidine. Because 1 mg of butorphanol is roughly equivalent in pain relieving efficacy to 20 mg of meperidine, butorphanol effectively is about 10 times as costly. Naloxone (0.4 mg or 1 mL) is a specific narcotic antagonist for both meperidine and morphine sulfate that can be administered to counteract inadvertent narcotic overdosage or unusual opioid sensitivity. Naloxone has no analgesic properties.

Nalbuphine is a potent parenteral analgesic that is partly antagonistic to narcotics. Its overall effectiveness in relieving pain is equivalent to the opioids. The usual starting dose is 0.5 mg IV or 1-1.5 mg IM every 4-6 hours as needed. Of the NSAIDs, the only one approved by the US Food and Drug Administration (FDA) for parenteral use is ketorolac. Ketorolac works at the peripheral site of pain production rather than on the CNS. It has been proven in multiple studies to be as effective as opioid analgesics, with fewer adverse effects. The dosage is 30-60 mg IM or 30 mg IV initially followed by 30 mg IV or IM every 6-8 hours. A dose of 15 mg is recommended in patients older than 65 years. In

more severe cases, ketorolac is particularly effective when used together with narcotic analgesics. Oral ketorolac is available in 10-mg pills, but the efficacy of this form in persons with acute renal colic is less clear. Some practitioners use parenteral ketorolac in the hospital but recommend either ibuprofen or oral cyclooxygenase-2 inhibitors (eg, celecoxib or meloxicam) for pain management in outpatients.

 An intranasal ketorolac preparation is now available for moderate-to-severe pain and may be particularly useful for  outpatient use in patients unable to take oral medication. A maximum of 5 days of ketorolac therapy is recommended. Chemically, ketorolac is similar to aspirin and may increase the prothrombin time when administered with anticoagulants. Ketorolac can increase methotrexate toxicity and phenytoin levels. It is potentiated by probenecid and should be avoided in patients with peptic ulcer disease, renal failure, or recent gastrointestinal (G I) bleeding. Antiemetic therapy Because nausea and vomiting frequently accompany acute renal colic, antiemetics often play a role in renal colic therapy. Several antiemetics have a sedating effect that is often helpful. Metoclopramide is the only antiemetic that has been specifically studied in the treatment of renal colic. In 2 doubleblinded studies, it apparently provided pain relief equivalent to narcotic analgesics in addition to relieving nausea. Its antiemetic effect stems from its dopaminergic receptor blockage in the CNS. It has no anxiolytic activity and is less sedating than other centrally acting dopamine antagonists. The effect of metoclopramide begins within 3 minutes of  an IV injection, but it may not take effect for as long as 15 minutes if administered IM. The usual dose in adults is 10 mg IV or IM every 4-6 hours as needed. Metoclopramide is not available as a suppository. Other medications commonly used as antiemetics include promethazine, prochlorperazine, and hydroxyzine. The author usually recommends antiemetics when patients with renal colic have been vomiting actively or report nausea sufficient to interfere with oral therapy. They also may be useful as anxiolytics in some cases. Whereas metoclopramide is the antiemetic of choice in the hospital or ED setting, a suppository formulation such as promethazine or prochlorperazine is recommended for outpatient use. Antidiuretic therapy Several studies have now demonstrated that desmopressin (DDAVP), a potent antidiuretic that is essentially an antidiuretic hormone, can dramatically reduce the pain of acute renal colic in many patients. It acts quickly, has no apparent adverse effects, reduces the need for supplemental analgesic medications, and may be the only immediate therapy necessary for some patients. It is available as a nasal spray (usual dose of 40 mcg, with 10 mcg per spray) and as an IV injection (4 mcg/mL, with 1 mL the usual dose). Generally, only 1 dose is administered.  Animal studies have demonstrated a significant reduction in mean intraureteral pressure after an acute obstruction in subjects administered desmopressin compared with controls. In human studies, approximately 50% of 126 patients tested had complete relief of their acute renal colic pain within 30 minutes after the administration of intranasal desmopressin without any analgesic medication. For patients in whom desmopressin therapy failed, suitable analgesics were administered. No adverse effects from the antidiuretic medication occurred.  Although desmopressin is thought to work by reducing the intraureteral pressure, it may also have some direct relaxing effect on the renal pelvic and ureteral musculature. A central analgesic effect through the release of  hypothalamic beta-endorphins has been proposed but remains unproved. Whether this therapy significantly affects eventual stone passage is unknown. While some of the human studies lack adequate controls and further studies must be conducted, desmopressin therapy currently appears to be a promising alternative or adjunct to analgesic medications in patients with acute renal colic, especially in patients in whom narcotics cannot be used or in whom the pain is unusually resistant to standard medical treatment. Antibiotic therapy

 Antibiotic use in patients with kidney stones remains controversial. Overuse of the more effective agents leaves only highly resistant bacteria, but failure to adequately treat a UT I complicated by an obstructing calculus can result in potentially life-threatening urosepsis and pyonephrosis. Use antibiotics if a kidney stone or ureteral obstruction has been diagnosed and the patient has clinical evidence of a UTI. Evidence of a possible UT I includes an abnormal finding upon microscopic urinalysis, showing pyuria of 10 WBCs/hpf (or more WBCs than RBCs), bacteriuria, fever, or unexplained leukocytosis. Perform a urine culture in these cases because a culture cannot be performed reliably later should the infection prove resistant to the prescribed antibiotic. Active medical expulsive therapy The traditional outpatient treatment approach detailed above has recently been improved with the application of a more aggressive treatment approach known as active medical expulsive therapy (MET). Many randomized trials have confirmed the efficacy of MET in reducing the pain of stone passage, increasing the frequency of stone passage, and reducing the need for surgery. MET should be considered in any patient with a reasonable probability of stone passage. Given that stones smaller  than 3 mm are already associated with an 85% chance of spontaneous passage, MET is probably most useful for  stones 3-10 mm in size. Overall, MET is associated with a 65% greater likelihood of stone passage. The original rationale for MET was based on the possible causes of failure to spontaneously pass a stone, including ureteral stricture, muscle spasm, local edema, inflammation, and infection. Various common drugs were considered that would potentially benefit these problems, improve spontaneous stone passage, and alleviate renal colic discomfort.  Although NSAIDs have ureteral-relaxing effects and, as such, can be considered a form of MET, patient outcomes have been significantly improved only with the use of more potent (off-label) medications. The initially popularized regimens for MET included corticosteroids such as prednisone, as in the following example: y y y y y y y

Ketorolac at 10 mg orally every 6 hours for 5 days Nifedipine XL at 30 mg/d PO for 7 days Prednisone 20 mg PO twice a day for 5 days Trimethoprim/sulfamethoxazole DS once a day for 7 days Acetaminophen 2 tablets 4 times a day for 7 days An oral opioid pain medication (oxycodone-acetaminophen) as needed for breakthrough pain Prochlorperazine suppository as needed for control of nausea

 Although corticosteroids are effective, concerns about their side effects (admittedly not supported by randomized data) limited the acceptance of MET. More recently, randomized studies have demonstrated great efficacy of the following individual agents, sparing the corticosteroid component. The calcium channel blocker nifedipine is indicated for angina, migraine headaches, Raynaud disease, and hypertension, but it can also reduce muscle spasms in the ureter, which helps reduce pain and facilitate stone passage. Ureteral smooth muscle uses an active calcium pump to produce contractions, so a calcium channel blocker such as nifedipine would be expected to relax ureteral muscle spasms. The alpha-blockers, such as terazosin, and the alpha-1 selective blockers, such as tamsulosin, also relax the musculature of the ureter and lower urinary tract, markedly facilitating passage of ureteral stones. Some literature suggests that the alpha-blockers are more effective in this setting than the calcium channel blockers, and most practitioners currently use alpha-blockers preferentially over calcium channel blockers. Multiple prospective randomized controlled studies in the urology literature have demonstrated that patients treated with oral alpha-blockers have an increased rate of spontaneous stone passage and a decreased time to stone passage. The best studied of these is tamsulosin, 0.4 mg administered daily.  A systematic review by Singh et al found that MET using either alpha antagonists or calcium channel blockers augmented the stone expulsion rate for moderately sized distal ureteral stones. Adverse effects were noted in 4% of  those taking alpha antagonists and in 15.2% of those taking calcium channel blockers.  A systematic review by Beach et al found that MET with alpha antagonists for 28 days increased the rate of stone passage, decreased the time to stone passage, and decreased the rates of hospitalization and ureteroscopy, with minimal adverse effects.

Not all data support MET. A randomized study of 77 ED patients with ureterolithiasis found no benefit to a 14-day course of tamsulosin, though the study group was small and the average stone size was 3.6 mm, making spontaneous passage without MET highly likely. MET with calcium channel blockers and alpha-blockers also appears to improve the results of ESWL (see Surgical Care) inasmuch as the stone fragments resulting from treatment appear to clear the system more effectively.  Analgesic therapy combined with MET dramatically improves the passage of stones, addresses pain, and reduces the need for surgical treatment. Ibuprofen can be substituted for the ketorolac tablets recommended in the original studies. Fewer complications with ibuprofen occur while maintaining efficacy for pain relief. An oral narcotic (eg, oxycodone/acetaminophen) is used as needed to control breakthrough pain. A typical regimen for this aggressive therapy is as follows: 1-2 oral narcotic/acetaminophen tablets every 4 hours as needed for pain 600-800 mg ibuprofen every 8 hours MET with 30 mg nifedipine extended-release tablet once daily, 0.4 mg tamsulosin once daily, or 4 mg of terazosin once daily y y y

Limit MET to a 10- to 14-day course, as most stones that pass during this regimen do so in that time frame. outpatient treatment fails, promptly consult a urologist.

If 

Future studies may identify a subgroup of patients such as those with larger stones or history of inability to pass stones that would benefit from MET. Intravenous hydration IV

hydration in the setting of acute renal colic is controversial. Whereas some authorities believe that IV fluids hasten passage of the stone through the urogenital system, others express concern that additional hydrostatic pressure exacerbates the pain of renal colic. One small study of 43 ED patients found no difference in pain score or rate of  stone passage in patients who received 2 L of saline over 2 hours versus those who received 20 mL of saline per  hour. IV

hydration should be given to patients with clinical signs of dehydration or to those with a borderline serum creatinine level who must undergo intravenous pyelography ( IVP). Straining urine for stones

Collecting any passed kidney stones is extremely important in the evaluation of a patient with nephrolithiasis for  stone-preventive therapy. Yet, in a busy ED, the simple instruction to strain all the urine for stones can be easily overlooked. Knowing when a stone is going to pass is impossible regardless of its size or location. Even after a stone has passed, residual swelling and spasms can cause continuing discomfort for some time. Be certain that all urine is actually strained for any possible stones. An aquarium net makes an excellent urinary stone strainer for home use because of  its tight nylon weave, convenient handle, and collapsible nature, making it very portable; it easily fits into a pocket or  purse.

*J Stuart Wolf Jr, MD, FACS The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical  Association, Endourological Society,Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

EMERGENCY MANAGEMENT OF PYELONEPHRITIS Pyelonephritis is a serious bacterial kidney infection of the kidney that can be acute or chronic. y

y

Acute pyelonephritis is a sudden inflammation caused by bacteria. It primarily affects the interstitial area and the renal pelvis or, less often, the renal tubules. Chronic pyelonephritis is persistent kidney inflammation that can scar the kidneys and may lead to chronic renal failure. This disease is most common in patients who are predisposed to recurrent acute pyelonephritis, such as those with urinary obstructions or vesicoureteral reflux.

Medications for pyelonephritis: Intravenous ( IV)

antibiotics may be used initially to control the bacterial infection if your infection is severe or you cannot take antibiotics by mouth. In acute cases of pyelonephritis, you may receive a 10- to 14-day course of  antibiotics. Chronic pyelonephritis may require long-term antibiotic therapy. It is imperative that you finish taking the entire course of prescribed antibiotics. Commonly used antibiotics include the following: y y y y

Sulfa drugs such as sulfisoxazole/trimethoprim Amoxicillin Cephalosporins Levofloxacin and ciprofloxacin

Permanent kidney damage can rarely result from these infections when they are chronic, when they occur in a transplanted kidney, or when multiple infections occur during infancy or childhood. Acute kidney injury (acute renal failure) may occur when an infection is severe enough to result in shock (low blood pressure). Severe episodes of  acute kidney injury may result in permanent kidney damage and lead to chronic kidney disease. The elderly, infants, and people with a compromised immune system are at increased risk for developing sepsis (a severe blood infection) and shock. Often, these people will be admitted to the hospital to receive frequent monitoring for potential problem and to receive IV antibiotics, additional IV fluids, and other medications as necessary. Nursing intervention: y

y

y

y

y

y

Assess the patient's temperature every 4 hours and report if the temperature is above 38.50 C Rational: Vital signs indicate a change in the body Record the characteristics of urine Rational: To find out / identify indications of progress or deviations from expected results. Instruct the patient to drink 2-3 liters if no contraindications Rational: To prevent urine stasis Monitor re-examination of the urine culture and sensitivity to determine response to therapy. Rational: Knowing how far the effect of treatment on patient circumstances. Instruct the patient to empty the bladder completely each time the bladder. Rational: To prevent bladder distension Give perineal care, maintain to keep them clean and dry. Rational: To maintain cleanliness and avoid bacterial infection of the urethra making.

y

y

y

y

Assess the intensity, location, and factors that aggravate or relieve pain. Rational: Extreme pain indicates an infection. Provide adequate rest periods and activity levels that can be tolerant. Rational: Clients can rest in peace and to relax the muscles. Encourage drinking plenty of 2-3 liters if no contraindications Rational: To assist clients in micturition. Give appropriate analgesic drugs with therapy programs. Rational:  Analgesic block the path of pain.

Possible Complications y y y y

Recurrence of pyelonephritis Perinephric abscess (infection around the kidney) Sepsis Acute renal failure

EMERGENCY MANAGEMENT OF CHLAMYDIA INFECTION / VAGINAL INFECTION CHLAMYDIAL INFECTION       

The most commonly reported bacterial sexually transmitted disease and the leading cause of infertility in women in the US. Chlamydia trachomatis is the causative agent which is an obligate intracellular bacterium. It usually appears asymptomatic for both males and females but may muco-purulent cervicitis for  women and urethritis for men Females may manifest inter-menstrual and post-coital bleeding, adnexal tenderness, lower abdominal pain, fever, and 80% are asymptomatic In males, unilateral pain and swelling of the scrotum, muco-purulent rectal discharge, fever and 50% are asymptomatic It is usually caused by sexual contact through oral, anal and vaginal course Risk factors are multiple sexual partners, unprotected sex, and co-infection with another STD

Medical Management:

1.

2.

Azithromycin (Zithromax) -inj: 500 mg, tab: 250, 500, 600 mg -Drug of choice -treat mild to moderately severe microbial infections -for single dose treatment Doxycycline (Bio-Tab, Vibramycin) -inhibits bacterial growth -cap: 40, 50, 75, 100, 150 mg, inj: 100, 200 mg

Nursing Management:

1. 2. 3. 4. 5.

Ensure client¶s compliance to antibiotic therapy by mentioning the consequences and effectiveness effect iveness of  the therapy Administer pain relievers Send specimens from sites of infection and discharges for test Pregnancy tests may be performed to alter alter antibiotic antibiotic treatment Provide counselling and information to prevent future STDs and consider referral for H IV testing

6. 7.

Encourage the client to abstain from intercourse intercourse until after treatment and testing of all partners is completed. Consider possible Gonorrhoeal infection

Complications:

1. 2. 3. 4. 5. 6.

Infertility

Urethral screening PID Chronic pelvic pain Pelvic inflammatory Disease Cervical Cancer 

Other vaginal infection: CANDIDIASIS y y y y

Is

a fungal infection or yeast caused by Candida albicans It is the fourth most common vaginal infection in the world It is common with pregnancy or with a systemic condition that causes immunosuppression In candidiasis, there is inflammation of vaginal epithelium causing itching, reddish irritation, white, cheeselike discharge clinging into epithelium

Medical Management

1.

Miconazole (Monistat) Vaginal Suppository 200mg Nystatin (Mycostatin) Cream 1000u/gm Clotrimazole (Gyne-Lotrimin) Vaginal suppository 100mg Terconazole (Terazole) Cream 0.4% -

2.

-

3.

-

4.

-

Complications    

Meningitis Endocarditis Arthritis Endophtlmitis

Nursing management   

Relieve discomfort by recommending sitz bath to alleviate irritation Reduce the anxiety by explaining the therapeutic effects of compliance and let her verbalize her  feelings Prevent the spreading of the disease by keeping the area clean and dry

TRICOMONIASIS    

Is

richomonasvaginalis, caused by T richomonasvaginalis, 7.4 cases is reported each year  There is a yellow to yellow-green, malodourous and very irritating Is present on a vaginal pH greater than 4.5

Medical Management 

Metronidazole ER: IV

Complications 

Infertility



Pelvic inflammatory disease Cervical neoplasma Preterm birth

 

Nursing management   

Relieve discomfort by recommending sitz bath to alleviate irritation Reduce the anxiety by explaining the therapeutic effects of compliance and let her verbalize her  feelings Prevent the spreading of the disease by keeping the area clean and dry

Gonorrhea    

Has the same causative agent of chlamydia, Chlamydia trachomatis 50% of women with gonorrhea have no symptom, but without treatment, 40% may develop to P ID Has burning sensation when voiding 700,000 new cases a year 

Medical Management  

Deoxycycline (vibramycin) Azithromycin (Zithromax)

Complications   

Pelvic inflammatory disease Perihepatitis In pregnancy: stillbirth o neonatal death o premature labor  o infertility o

Nursing Management  

Explain the therapeutic effects of compliance Let her verbalize her feelings.

Acute Tubular Necrosis

Definition This is a term for common renal injuries that are results of nephrotoxic and ischemic renal injuries. It is a severe ofrm of acute renal failure. The pathologic conditions that occur with ATN are (1) necrosis of the tubular  epithelium and leaving the basement membrane intact after an acute ischemic event, (2) necrosis of both tubular epithelium and basement membrane. It is classified as : prerenal, intrarenal, postrenal.  ATN occurs usually after acute ischemic or toxi event such as nephrotoxic medications. The onset is characterized by decrease in glomerular filtration rate (normal is 125 ml/min). Symptoms y

Urine output, decreased or none

y y y y

y y y y y y y y y y y y

Urination, excessive volume, Urination, excessive at night Generalized swelling, fluid retention Nausea, vomiting Decreased consciousness Drowsy, lethargic, hard to arouse o Delirium or confusion o Coma o Seizures Easy bruising or bleeding Vomiting blood Bloody stools Decrease in sensation , especially the hands or feet Chills, shaking  Abnormal urine color  Blood in the urine Joint pain Flank pain Urinalysis may show casts, renal tubular cells, and red blood cells. Urine sodium may be high.

Stages of ATN INIT I y y y

y

Initial y y y y y y y y

AL  Acute ischemic toxic  Acute decreased GFR Urine production