Urological emergencies notes...

urology

causes of enterocutaneous fistula

FRIEND

Foreign body

Radiation

Infection/Inflammation

Epithelialization

Neoplasm

Distal obstruction

7 Urologic Emergencies (means take action now!)

1. Torsion - testicle twists- acute severe pain. 4-6 hour window before tissue death

diagnosis is US, tx can try and detorse (open book) turn each testicle laterally, will still need to operate orchiopexy

2. Priapism - either low flow or high flow. Low flow is emergency, drain it w/needle, tx w/phenylephrine,

low flow associated w/leukemias, multiple myeloma, sickle cell, can also try PDE5 inhibitors

high flow let go

3. Paraphimoses - 4-6 hour window before tissue death in glans, squeeze on glans and it goes back in (most times), still no? dorsal foreskin gets cut

4. Ureteral obstruction w/fever - no flow past stone soon to be urosepsis, patient w/diabetes even worse

5. Acute urinary retention - etiiology clot or bph, fix w/catheter

6. Ureteral damage - most often iatrogenic from not pushing the catheter all the way in, when balloon expands trauma to prostate PUSH THE CATHETER ALL THE WAY IN

7. Fornier's gangrene - infxn of perineum increased in diabetics, immunosuppression, chronic etoh, normal polymicrobial, requires empiric Abx and debridement bad news

bad news

ob/gyn clinical reflection

This rotation was my first experience with childbirth. It took just a few short weeks to gain some valuable insight into a really very truly dangerous right of passage. What a great privilege to be side by side with these mothers and witness for me this heretofore completely unknown event known as childbirth. First I should say that I was really surprised the first time I saw a mother's water break- water for me has always had a connotation of purity and cleansing and life (from baptism and all its religious symbolism to the water's obvious symbolism of life etc). The mother's water breaking and spilling all over the table and floor is a clarion call to the unstoppable force of life, the water breaks the baby is coming, the baby is pure and has not been in this world, it is clean, the baby waits for no one, not even tocolytics. It was really amazing. And then mix the water with blood. So much blood! For me blood has its own symbolism as well, blood is life and passion, in this context blood is the mother's life and it is literally spilling out onto the table with the newborn. The mother gives part of her life to the newborn and to the birth. These two fluids water and blood, have such gravity in the context of childbirth. It was apparent after seeing just one childbirth why for ages these two vital substances have held such great esteem throughout all of human culture. You can't name a culture that won't respect the sanctity of water and blood. What's more, during the OB portion of our rotation I really developed a sense for the cost of life, both in our more modern times and in the past. Even today it became clear that childbirth is an extremely dangerous event, even with packed red blood cells, and FFP and a team of skilled physicians standing by, how unpredictable and completely at the mercy of God, the universe, or who knows what else it is to be the mother bringing life into this world. I caught the spirit of the mystery of life, if only as a spectator. Can you imagine how dangerous it must have been to labor and deliver before such modern luxuries?? When faced with these mortal risks, to say nothing of the intense pain, the true cost of life becomes apparent to those women who choose to undertake its passing forward. The moment of delivery in its pain and suffering stands in stark contrast to the moment of pleasure and romance during conception, how diametrically opposed these two marvelous events are, both lived by the mother! I learned just how easy it is for mom to bleed uncontrollably, to give her life for another, half a liter of blood minute right out of the womb, life could be over in as short as 12 minutes. The gravity and sobriety of a delivery leaves its mark on the mother, especially the younger nulliparous. But despite these high costs, I saw that a mom can get what she paid for in the intense joy and mother's love toward the newborn, it seems that feeling is worth the risk, worth putting your up your life and limb to fortune. Now after this rotation, I can fully appreciate the cause for celebration when fortune smiles and a mother gives birth to a healthy baby with minimal complications. It really is a miracle.

ob/gyn abortion notes

6.3 million pregnancies a year US

50% of pregnancies unintended

1/2 of unintended from women who don't use contraceptive

low SES account for more unintended pregnancies

unintended pregnancies how they end up

40% abortion

40% birth

10% fetal loss

induced abortion

20-24 yrs 33% of abortion

25-29 yrs 23% of abortion

30-34 yrs 15% of abortion

86% of abortions unmarried

>60% of abortions are less than 9 weeks

80% done under 12 weeks

7/100,000 births are fatal for mom

safer to have abortion early than to carry pregnancy 2/100,000 if early abortion

medical abortion 5-9 weeks

surgical 5-14 weeks

medical

advantages

performed w/o delay

no anesthesia

psychological easier

misoprostol, mifepristone, methotrexate rarely used (used for ectopics)

complications of medical abortion

bleeding 9-16 days

failure

infection (rare)

surgical procedure

manual <10>10 weeks

2nd trimester - laminaria (cervical dilators, wrapped in sea weed), need anesthesia

complications of surgical

infection, incomplete, perf, bleeding, clots, asherman,

2nd tri medical induction

option for patient desiring to hold or view fetus, give misoprostol or pitocin every 4-6 hours

30% chance of retained placenta - would need d&c

ob/gyn clinical notes

2nd half of 2nd trimester is when estrogen upregs oxytocin receptors
hemabate

giving a uterotonic must ask two questions?
asthmatic or hypertensive?
postpartum hemorrhage? what do you do?
vaginal exam
1. where bleeding?
uterus, cervix (laceration), vagina
2. stop the bleeding

risk of cervical laceration - leep (changes nature of tissue), big baby, compound presentation (finger on head), sulcal tear vagina, tears can go all the way back.
drusian's incicsions cut cervix 12, 4, 8 oclock, don't cut 3&9 oclock where uterine arteries

risk factors for atony - multiple gestations, polyhydramnios, big baby, tocolytic (mag), prolonged labor, fibroids
blynch sutures - suspenders for the uterus to stop it from bleeding

then
uterine artery ligation
then
hysertectomy

hyaline casts in lungs - pathognomonic for amniotic fluid embolism

eclampsia - seizure and htn (don't need proteinuria)

code right after birth? think amniotic fluid embolism

boggy uterus - massage, not working give uterine tonics- stick w/one agent max it out
1mg cytotec (misoprostol),
methergine or hemabate, or pit wide open

flagyl - metronidazole - anearobes

subcutaneous emphesyma - used for laparoscope (rice krispies sign)

hpv vaccine - tetravalent insures against warts and cancers

endometritis = uterine tenderness postpartum + fever, physical diagnosis

gentamicin - covers aerobes, clinda- covers ug aneareaboes
ampicillin -