Back Pain

pain relief with elevation of the affected testicle - what is this called and what does it mean?

+ Prehn sign indicates epidymitis and orchitis

testicular torsion prognosis

3 hours 100% salvage, 6 hours 50% •Studies have shown salvage up to 48 hours but extremely rare •6 hours is cut off •"open a book"

Epididymitis and Orchitis causal Bacterial agent most common, depending on age

< 35 yrs is usually STI derived (Should have GC and chlamydia test) > 35 yrs is other common urinary pathogens

Pyelonephritis disposition

Admission •Failed outpatient therapy - Recurrences < 1 month •Sepsis •Unilateral kidney •h/o renal failure •Intractable vomiting •Children •Pregnant Discharge •With follow up appointment set

Urolithiasis/Ureterolithiasis Treatment

Aggressive IV/PO hydration NSAIDs (ketorolac) Opioids Anti-emetics Alpha-blockers Urology Consultation •Large stones (>5mm) or complications •Lithotripsy

DIsposition in renal failure

All new onset renal failure should require admission •Likely ICU •Nephrologist

epidymitis and orchitis treatment

Antibiotics •Ceftriaxone, azithromycin, doxycycline •? Use of floroquinolones- for some patients NOT if primary concern is GC •Scrotal elevation

Symptoms of pyelonephritis

Back pain, flank pain, described as aching, dull, with urinary frequency and urgency and burning with urination as well as with fever, myalgias and arthralgias,chills, or n/v •Elderly present atypically!!

•Inflammation of glans and foreskin •Common in uncircumcised males

Balanoposthitis

Causes of renal failure

Cardiac vascular thrombotic glomerular disease diseases of renal tubules nephrotoxic drugs anatomic conditions (obstructions) •Volume overload, hypertension, pulmonary edema, mental status change or neurologic symptoms, nausea and vomiting, bone and joint problems, anemia, increased susceptibility to infection (leading cause of death)

Acute loss of function of lumbar plexus

Cauda Equina Syndrome

Urolithiasis/Ureterolithiasis Disposition

Discharge if pain controlled •Follow up with urology or PCP within a week •Strain all urine till passage Admission •Uncontrolled pain •Large stone (usually >5-6mm some sources say 8mm) •Concurrent infection with obstruction •Solitary kidney/ intrinsic renal disease •Urologic consultation

Gradual onset of pain, tenderness over epididymis

Epididymitis and Orchitis

the red flags of back pain

Fever Unexpected anal sphincter laxity Perianal/perineal sensory loss Major motor weakness Point tenderness to percussion Positive straight leg raise test result Loss of bowel/bladder function History of IV drug use Age >/= 50 Failure to improve after 1 month of therapy Previous history of cancer Unexplained weight loss (more than 4.5 kg in 6 months) No relief with bed rest or recumbency Pain worse at night Insidious onset Systemicaly unwell Constant, progressive, nonmechanical pain sensory level (altered sensation from trunk down) Anemia Fever Thoracic pain Elevated erythrocyte sedimentation rate (ESR), C-reactive protein level (CRP)

Take home notes for back pain

Fewer than 2% will have a disc herniation and even fewer have a life threatening illness Review and document +/- of RED FLAGS Start with a urine! Consider ob/gyn cases in the female patient Consider referred pain - Abdominal pathology -- Acute gallbladder, pancreatitis, mesenteric ischemia, diverticula, colitis, TOA, ectopic, appy, bowel obstruction, volvulus, constipation

Pyelonephritis treatment

Initial treatment - Oral antibiotics -- Cipro 500mg PO BID x 7d -- Levaquin 750mg PO QD x 5 d -- Bactrim DS 1 tab PO BID x 14 d -- Keflex 500mg PO QID x 10 - 14 d -- (consider first dose IV: ceftriaxone) Refractory - Ampicillin and gentamicin - Fluoroquinolones - Ceftriaxone

Extensive list of causes of rhabdomyolysis

Injuries that cause compartment syndrome, prolonged muscle compression, heat stroke, electrical injuries, prolonged immobilization, drug intoxication (amphetamines, PCP, cocaine, antihistamines) excessive muscular activity, seizures, DT's, medications (antipsychotics, cholesterol lowering, narcotics, colchicine)

Damage to nerve root L4 will result in... Pain where? Numbness where? Motor weakness where? Screening exam? Reflexes?

L4 Pain: lateral thigh, lateral knee, anterior shin Numbness: medial knee Motor weakness: extension of quadriceps Screening exam: squat and rise Reflexes: knee jerk diminished

Damage to nerve root L5 will result in... Pain where? Numbness where? Motor weakness where? Screening exam? Reflexes?

L5 Pain: lateral butt cheek, lateral thigh, lateral shin Numbness: lateral shin Motor weakness: dorsiflexion of great toe and foot Screening exam: heel walking Reflexes: none reliable

"red flag" in the physical examination of patients with low back pain: a positive straight leg raise test result indicates....

L5 or S1 herniated disc

•Inability to reduce the proximal edematous foreskin distally over the glans •Consult urology, *true urologic emergency*

Paraphimosis

•Inability to retract foreskin proximally

Phimosis

Diagnosis of pyelonephritis

Pregnancy test! (age range?) Urine dipstick - Nitrites -- Gram-neg bacteria convert nitrate to nitrite -- E.coli, Klebsiella, Proteus - Leukocyte esterase -- Found on neutrophils Urinalysis - Bacteriuria -- Seen on gram stain -- E. coli most common -- Proteus, klebsiella, enterococcus, Staph saprophyticus -- Less common pseudomonas, mycobacterium, fungus WBC - 2-5/hpf (pyuria) Urine cultures - Expensive - Should be obtained in the hospitalized patient, those with chronic indwelling catheter, pregnant women, children and adult males

Constant erection of questionable etiology

Priapism

Back pain caused by... •Bones, ligaments, muscles and nerves •Trauma, sprain, strain •Local pathological process like a Tumor, infection, shingles

Primary back pain

diagnostic imaging for pyelonephritis

Rarely indicated Indications - Recurrent infection in young children - Elderly, diabetic or those unresponsive to therapy - Consider renal ultrasound or CT non contrast

Back pain caused by... •Abdominal aorta, pancreas, kidneys, ureter and GI tract •Extensive differential to consider

Referred back pain

Pre-renal failure treatment

Restore volume restore function

If ______________ was left untreated will develop renal failure, compartment syndrome and peripheral neuropathy

Rhabdomyolysis

Syndrome involves skeletal muscle injury, necrosis and release of intracellular contents

Rhabdomyolysis

Damage to nerve root S1 will result in... Pain where? Numbness where? Motor weakness where? Screening exam? Reflexes?

S1 Pain: butt cheek, posterior thigh, posterior calf, lateral foot (lil bit) Numbness: posterior calf and lateral foot Motor weakness: plantat flexion of great toe and foot Screening exam: walking on toes Reflexes: ankle jerk diminished

Diagnostic tests for disc herniation

Straight Leg Raise: sensitivity 91%, specificity 26% for disc herniation Crossed Straight Leg Raise: sensitivity 29%, specificity 88%

primary back pain imaging

Suspicious of tumor, fracture or infection •Plain films usually adequate Neurologic deficit •MRI CT may help identify bony abnormality

•Suspect with intense sudden onset of testicular pain •Common in young teen, pre teen males •Pain can sometimes only be lower abdomen •Torsion/detorsion symptoms •Most sensitive finding is unilateral absence of cremasteric reflex

Testicular torsion

lower UTI is called..?

Urethritis- typically caused by STI, associated with discharge Cystitis- acute bacterial infection of the bladder

Urolithiasis/Ureterolithiasis Testing

Urinalysis usually shows hematuria - 10-20% clear urine - White cells from inflammation not infection Blood work - BMP - Acute renal insufficiency takes about 5 days CT non contrast- test of choice IVP - not utilized as often KUB- not utilized for ED diagnosis US- used in pregnant patients

The following red flags indicate...? Age>/=50 Failure to improve after 1 month of therapy Previous history of cacner Unexplained weight loss (more than 4.5 kg in 6 months)

cancer

"red flag" in the physical examination of patients with low back pain: a loss of bowel and or bladder function indicates....

cauda equina cord compression neurosurgical emergency

"red flag" in the physical examination of patients with low back pain: an unexpected anal sphincter laxity indicates....

cauda equina syndrome spinal cord compression

"red flag" in the physical examination of patients with low back pain: a perianal/perineal sensory loss indicates...

cauda equina syndrome spinal cord compression

Everyone not listed above (older non pregnant women with structurally and functionally normal urinary tracts, all men, women who are pregnant or have an underlying abnormality of the urinary tract get what kind of UTI's?

complicated

See slide 20

done

diagnosis of cauda equina syndrome

emergent MRI or CT scan

Isolated orchitis is uncommon in adults usually associated with ____________

epidiymitis

"red flag" in the physical examination of patients with low back pain: a point tenderness to percussion indicates....

fracture or infection

"red flag" in the physical examination of patients with low back pain: a fever indicates....

infection

"red flag" in the physical examination of patients with low back pain: a history of IC drug use indicates....

infection (osteomyelitis, discitis, spinal abscess)

signs of cauda equina syndrome

muscle weakness sphincter weakness saddle anesthesia

"red flag" in the physical examination of patients with low back pain: a major motor weakness indicates....

nerve root compression

If you have adequately rehydrated the patient and placed a foley catheter, you have essentially treated a possible ________ cause and eliminated a ________ cause. At this point, the investigation begins as to what may be causing an intrinsic renal issue.

pre-renal post-renal

part of the softer middle disc bulges through the fibrous outer ring and presses on the nerve as it leaves the spinal cord

prolapsed disc

upper UTI is called..?

pyelonephritis

Pain from _________ radiates from the buttock down the leg and can travel as far as the feet and toes

sciatica

treatment of cauda equina syndrome

surgical decompression

causes of Cauda Equina Syndrome

tumors trauma spinal stenosis

epidymitis and orchitis image of choice

ultrasound

Young, healthy, nonpregnant women with structurally and functionally normal urinary tracts get what kind of UTI's?

uncomplicated

Rhabdomyolysis treatment and disposition

•Aggressive IV rehydration therapy with crystalloid fluid •Urinalysis target of 200-300 cc/hour •Foley catheter in critically ill or those unable to void appropriately •Disposition - Critically ill, comorbidities, ARF = admit - Young, healthy, no comorbidities and cause is exertional = discharge

Post-renal failure treatment

•Appropriate urinary drainage

Urolithiasis/Ureterolithiasis Clinical features

•Asymptomatic until there is partial obstruction •Acute onset, severe, sharp, stabbing •Anxious, pacing, writhing •Diaphoretic, nauseated •Colicky pain, frequently in the flanks •Pain often in the genitalia

physical exam findings in pyelonephritis

•Hypotension uncommon except elderly consider urosepsis •Most will have CVA tenderness •Abdomen is usually nontender •GU exam performed with chaperone at bedside including DRE in men to rule out prostatitis

Pathophysiology of a UTI

•Incomplete bladder emptying due to structural or neurogenic bladder outflow abnormalities •Ureterovesicular reflux •Most common pathogen is E. coli (<80%), Staphylococcus saprophyticus, Chlamydia trachomatis •Present as acute cystitis or acute pyelonephritis

When is dialysis used in renal failure?

•Initiated when other treatments fail, or major cardiac or electrolyte instability •BUN > 100 or Cr > 10 Very little improvement in mortality despite dialysis

Urolithiasis/Ureterolithiasis

•Kidney stone is misnomer •More common in males •Usually 3rd-5th decade of life •Genetic predisposition •Familial tendency - Prior h/o stones •Low fluid intake

treatment of primary back pain

•Most can be managed with NSAIDs •Consider muscle relaxant •Gradual return to routine activity as tolerated - bed rest for up to 48 hours appropriate in some cases •Short course of opioids as needed (morphine vs dilaudid) - If failed other conservative therapies Friendly reminder to instruct the patient to take any NSAID with food. Use with caution in the elderly, renal impairment, GI issues, etc. Instruct all patients that muscle relaxant may/will cause drowsiness.........no you can't drive home after receiving a muscle relaxant in the ED. Be sure they have a ride. Reserve narcotic pain medication for those failing more conservative therapy.

testicular torsion diagnosis

•Most sensitive finding is unilateral absence of cremasteric reflex •Ultrasound diagnostic TIME DEPENDANT SURGICAL EMERGENCY. If you are seeing a male with testicular pain, GET the ultrasound.

Rhabdomyolysis Symptomology

•Myalgias, muscle stiffness and fatigue, malaise, low grade fever •Dark colored urine •Nausea, vomiting, abdominal pain or palpitations •Signs and symptoms of renal failure •Can also present without usual signs or symptoms

signs and symptoms of penile fracture

•Penis acutely swollen, discolored and tender •Little to no pain better indicator of less damage

priapism treatment

•Phenylephrine 0.5mg to 1mg into penile cavern •Pseudoephedrine orally 60-120mgs •Penile (corporal) aspiration Consult urology

The big 6 for evaluating primary back pain

•Radiation ? •Loss of bowel/bladder function ? •Palpation (is there midline tenderness?) •Sensation •Motor Strength •Lower Extremity Reflexes

Intrinsic renal failure treatment

•Removed offending agents like digoxin, magnesium, sedatives, narcotics, IV contrast Use of low dose dopamine- support mean arterial pressure and renal perfusion

renal failure diagnostic studies

•Renal ultrasound image of choice to evaluate renal failure, when upper ureteral tract obstruction and hydronephrosis is suspected •Color flow doppler assess renal perfusion and the diagnosis of large vessel causes of failure

Physical examination of primary back pain

•Reproduction of the pain •Stiffness and decrease range of motion •Rashes or lesions •Crossed (contralateral) straight leg raise vs straight leg raise •Motor strength •Reflexes •Evaluate gait •Stand on heels and toes, deep knee bend and spinal flexion

penile fracture diagnosis and treatment

•Retrograde urethrogram should be done •Consult urology

Urolithiasis/Ureterolithiasis: Pathophysiology

•Seen in 2-10% of population •75% of stones are calcium based - Hypercalcemia, sarcoidosis, PUD •10% are magnesium-ammonium-phosphate (struvite) - Seen with recurrent UTI's with proteus & klebsiella •10% are uric acid •90% are radiopaque •*3 sites for impaction* KNOW - *Calyx, upj, uvj* •Recurrences - 1/3 in 1 year, ½ in 5 years

Diagnosis of Rhabdomyolysis

•Serum CK to be elevated 5 X greater than upper limit •CK starts to rise 2-12 hours and peaks 1-3 days •Value declines 39% a day •Urine dipstick •*Heme + but NO RBC's on microscopic exam* •Routine labs including CK, electrolytes, calcium and formal urinalysis The urine dipstick is unable to differentiate hemoglobin from myoglobin. So if the dipstick reads POSITIVE and there are no red blood cells seen under the microscope...........think myoglobin.

Balanoposthitis treatment

•Treat with oral and topical antifungals

renal failure laboratory studies

•Urinalysis, BMP, urine sodium and creatinine, urine osmolality •Pre renal azotemia >20:1 (BUN:Cr) •Renal azotemia 10:1 (15:1) •Post renal azotemia >10:1 (>15:1)