Upper vs lower tract infection?

Flank pain & tenderness, fever, vomiting, dehydration, sepsis

Lower - Only mild suprapubic tenderness, burni ng, frequency, urgency

+

H&P: Alternate diagnosis?

Pelvic - Cervicitis, PID, pregnancy

GU - urethritis, prostatitis, epididymitis, orchitis

Abdomen - Appendicitis, diverticul itis, cholecystitis

�

H&P and labs: Complicated infection?

Complicated - Pregnancy, immunosuppression, obstructed

urinary flow (stones, prostate, strictures, compressed

ureters)

I maging if obstruction, extensive or suppurative infection

or differential includes additional abdominal infection

Send urine cultures (when ind icated), consult local

antibiogram for susceptibilities in your area

i

upper tract or

Complicated

lower tract

Alternate diagnosis

IV antibiotic dose, IVF

Consider admission1 Q-1 4 days of antibiotics

Manage as

appropriate

• Figure 40-1. Urinary tract infections diag nostic algorithm. GU, gen itourinary; H&P, history and

physical exam; PID, pelvic inflammatory disease.

DISPOSITION

..... Admission

Admission is advised for patients with UTI compli ­

cated by urinary obstruction, immunosuppression,

urosepsis, or associated unremitting vomiting, severe

dehydration, renal insufficiency, or electrolyte derangements. Pregnant patients with any upper tract disease

should be admitted for observation with an obstetrics

consultation .

..... Discharge

Patients with uncomplicated lower tract infection or

uncomplicated upper tract infection may be discharged

home with follow-up instructions to return to the ED for

any complicating factors.

URINARY TRACT I NFECTIONS

Table 40-2. Treatment of UTI.

Type of Infection Pathogens

Acute cystitis E. coli, 5. saprophyticus,

P. mirabilis

Asymptomatic bacteriuria and E. coli, 5. saprophyticus,

cystitis of pregnancy P. mirabilis

Pyelonephritis E. coli, 5. saprophyticus,

(outpatient) P. mirabilis

Pyelonephritis E. coli, 5. saprophyticus,

(Inpatient) P. mirabilis

Urosepsis E. coli, Proteus, Klebsiella,

Pseudomonas

SUGGESTED READINGS

Gupta K, Hooton TM, Naber KG, et al. International Clinical

Practice Guidelines for the Treatment of Acute Uncomplicated

Cystitis and Pyelonephritis in Women: A 2010 update by the

Infectious Disease Society of America and the European

Society for Microbiology and Infectious Disease. Clin Infect

Dis. 20 1 1;52:e103-3 120.

Howes DS, Bogner MP. Urinary tract infections and hematuria.

In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 201 1.

Antibiotic Regimen

Trimethoprim/sulfamethoxazole

OR ciprofloxacin

Nitrofurantoin

OR amoxicillin- clavulanate

Ciprofloxacin

First dose IV in ED

Ciprofloxacin

OR ceftriaxone

Ampicillin and gentamicin

OR ceftriaxone

Dose and Duration of Treatment

1 DS tab BID for 3 days

500 mg BID for 3 days

1 00 mg BID for 5 days

500mg BID for 7 days

500 mg BID for HH 4 days

500 mg IV BID

1g IV QD

Continue IV until improved

1 g and 5 mg/kg/day IV

1 g IV QD

Testicu lar Torsion

Lynne M. Ya ncey, MD

Key Points

• Consider the diagnosis of testicu lar torsion in any male

with abdominal pain.

• Perform a genitourinary (GU) examination on males

complaining of abdominal pain, even if they have no GU

complaints. This is especially important in adolescent males.

INTRODUCTION

Testicular torsion is a primary concern in a male with acute

scrotal pain and should be considered in all males with

abdominal pain. Torsion is due to twisting of the testicle

around the spermatic cord. It initially compromises venous

outflow, and later arterial blood flow to the testicle, resulting

in ischemia and infarction. The longer the torsion persists, the

less chance of testicular survival. Hence, time is of the essence

in the diagnosis and management of suspected torsion.

Peak incidence of testicular torsion occurs in the first

year of life, before the testes descend into the scrotum, with

a second peak at puberty, when the volume of the testes

rapidly increases. It occurs in about 1 in 4,000 males a year.

Testicular torsion is 10 times more likely to occur in a male

with an undescended testis.

The initial effect of torsion is obstruction of venous

return. If torsion persists, venous obstruction leads to worsening edema and ultimately to arterial obstruction and

ischemia. The amount of venous obstruction is related to

the degree of rotation of the testis on the spermatic cord and

vascular supply. Incomplete rotation causes a lesser degree

of edema and vascular congestion, whereas complete rotation leads to immediate complete obstruction and ischemia.