Emphysematous Urinary Tract Infections

Brief HPI:

A 45 year-old female with a history of ureterolithiasis s/p bilateral percutaneous nephrostomies, hypertension and diabetes presents to the emergency department with flank pain and dysuria for two days. She noted that output from her right nephrostomy had diminished. On evaluation, her vital signs are notable for fever and tachycardia but are otherwise normal. Examination demonstrates right costovertebral angle tenderness to percussion. Drain sites appeared normal, without overlying erythema. Urinalyses from both nephrostomy collection bags were submitted. Computed tomography of the abdomen and pelvis was obtained to evaluate for nephrostomy malposition.

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CT Abdomen/Pelvis Interpretation

Complex perirenal fluid collection with gas suggestive of emphysematous pyelonephritis with abscess.

Hospital Course

The patient was treated with parenteral antibiotics based on prior culture data and was admitted to the intensive care unit with urology consultation and plan for interventional radiology percutaneous drainage. The patient underwent uncomplicated perinephric drain placement and nephrostomy exchange and was discharged on hospital day five to complete a course of oral antibiotics.

An Algorithm for the Evaluation and Management of Emphysematous Urinary Tract Infections

An Algorithm for the Evaluation and Management of Emphysematous Urinary Tract Infections

References

  1. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987;83(1):149-154.
  2. Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology. 1996;198(2):433-438. doi:10.1148/radiology.198.2.8596845.
  3. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997;49(3):343-346. doi:10.1016/S0090-4295(96)00501-8.
  4. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. JURO. 1997;157(5):1569-1573.
  5. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160(6):797-805.
  6. Roy C, Pfleger DD, Tuchmann CM, Lang HH, Saussine CC, Jacqmin D. Emphysematous pyelitis: findings in five patients. Radiology. 2001;218(3):647-650. doi:10.1148/radiology.218.3.r01fe14647.
  7. Park BS, Lee S-J, Kim YW, Huh JS, Kim JI, Chang S-G. Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis. Scand J Urol Nephrol. 2006;40(4):332-338. doi:10.1080/00365590600794902.
  8. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore). 2007;86(1):47-53. doi:10.1097/MD.0b013e3180307c3a.
  9. Mokabberi R, Ravakhah K. Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series). Am J Med Sci. 2007;333(2):111-116.
  10. Yao J, Gutierrez OM, Reiser J. Emphysematous pyelonephritis. Kidney Int. 2007;71(5):462-465. doi:10.1038/sj.ki.5002001.
  11. Thomas AA, Lane BR, Thomas AZ, Remer EM, Campbell SC, Shoskes DA. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007;100(1):17-20. doi:10.1111/j.1464-410X.2007.06930.x.
  12. Falagas ME, Alexiou VG, Giannopoulou KP, Siempos II. Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis. JURO. 2007;178(3 Pt 1):880–5–quiz1129. doi:10.1016/j.juro.2007.05.017.
  13. Somani BK, Nabi G, Thorpe P, et al. Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol. 2008;179(5):1844-1849. doi:10.1016/j.juro.2008.01.019.
  14. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: outcome of conservative management. Urology. 2008;71(6):1007-1009. doi:10.1016/j.urology.2007.12.095.
  15. Kapoor R, Muruganandham K, Gulia AK, et al. Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis. BJU Int. 2010;105(7):986-989. doi:10.1111/j.1464-410X.2009.08930.x.
  16. Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011;107(9):1474-1478. doi:10.1111/j.1464-410X.2010.09660.x.
  17. Lu Y-C, Chiang B-J, Pong Y-H, et al. Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis. BMC Infect Dis. 2014;14(1):418. doi:10.1186/1471-2334-14-418.

Acute Urinary Retention

Brief H&P:

A 62 year-old male with no significant medical history, presented to the emergency department with several days of vomiting. Examination showed suprapubic fullness with tenderness to palpation and a bedside ultrasound was performed:

RUQ
RUQ

RUQ

Right upper quadrant ultrasound with moderate hydronephrosis.

LUQ
LUQ

LUQ

Left upper quadrant ultrasound with moderate hydronephrosis.

Bladder
Bladder

Bladder

Relatively non-distended bladder.

Bladder Volume
Bladder Volume

Bladder Volume

Post-void bladder volume.

Ultrasound revealed moderate bilateral hydronephrosis with a relatively non-distended bladder. Labs were notable for new renal failure and the patient was admitted for continued evaluation. He was ultimately diagnosed with idiopathic retroperitoneal fibrosis with bilateral distal ureteral obstruction requiring stenting.

Anatomy of Acute Urinary Retention:

Differential Diagnosis of Acute Urinary Retention:1,2,3

Algorithm for the Evaluation of Acute Urinary Retention

Macroscopic Hematuria

CC:

Macroscopic hematuria

HPI:

85yo male with a history of prostate cancer s/p radiation and androgen deprivation therapy four years ago complicated by urethral strictures requiring chronic indwelling catheter who presented to the ED yesterday with 3 days of red urine followed by no output from catheter and abdominal pain. In the ED, the patient was found to have stable hemoglobin and creatinine and was discharged with urology follow-up after symptom resolution with catheter irrigation.

Today, the patient reports no new issues, denies abdominal/flank pain, further catheter obstruction, fevers/chills. He states that his urine has been light pink in color, without clots, and significantly more clear than the prior 3 days. He has had intermittent episodes of blood in his urine in the past, but never causing obstruction. His catheter is managed at home with regular (q3wk) changes and no recent traumatic catheterizations.

He denies any new back/bone pain or unintentional weight loss.

PMH:

  • Prostate CA
  • HTN
  • DM
  • CKD
  • CAD

PSH:

  • None

FH:

  • Non-contributory

SHx:

  • No current or previous t/e/d use
  • Lives with wife

Meds:

  • lisinopril 20mg p.o. daily
  • glyburide/metformin 1.25/250mg p.o. b.i.d.
  • atorvastatin 20mg p.o. daily
  • ASA 81mg p.o. daily

Allergies:

  • NKDA

Physical Exam:

VS: T 98.4 HR 64 RR 13 BP 136/94 O2 99% RA
Gen: Well-appearing, pleasant man in no acute distress.
Abd: +BS, soft, NT/ND, no suprapubic tenderness, no CVAT
GU: Foley catheter in place draining clear-pink fluid to leg bag, no clots. No evidence of trauma to urethra, no visible skin lesions. Testes descended bilaterally, no inguinal lymphadenopathy.

Assessment/Plan:

85M hx CaP (2009) s/p radiation and androgen deprivation therapy with urethral strictures requiring chronic indwelling catheter presenting with macroscopic hematuria. Given patient’s history, radiation cystitis is a likely cause of his symptoms. However, given the long-standing catheter, other considerations include trauma and infection. Also, recurrence or new malignancy must be considered. Will obtain UA, UCx, and schedule patient for cystoscopy with bilateral retrograde pyelogram. Also, educated patient on how to irrigate catheter if needed and provided ED precautions should obstruction persist despite irrigation attempts. Patient’s last surveillance PSA undetectable, continue routine follow-up.

Differential Diagnosis of Macroscopic Hematuria

Differential Diagnosis of Macroscopic Hematuria

Important Historical Elements:

  • Painless: suggests malignancy
  • Painful: suggests calculi/infection
  • Urinalysis: presence of dysmorphic RBC’s, RBC/WBC casts, proteinuria suggest intrinsic renal disease
  • Timing: early (distal urethra), throughout (upper urinary tract), terminal (bladder neck, prostatic)

Guided Lecture

EM Ed
Watch “Gross Hematuria: Just a Bit of Kool-Aid” from EM Ed. In this lecture Dr. Basrai reviews the differential diagnosis and management of macroscopic hematuria in the emergency department.

References:

  1. Hicks, D., & Li, C.-Y. (2007). Management of macroscopic haematuria in the emergency department. Emergency medicine journal : EMJ, 24(6), 385–390. doi:10.1136/emj.2006.042457
  2. Mazhari, R., & Kimmel, P. L. (2002). Hematuria: an algorithmic approach to finding the cause. Cleveland Clinic journal of medicine, 69(11), 870–872–4– 876.
  3. Howes DS, Bogner MP. Chapter 94. Urinary Tract Infections and Hematuria. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6362340. Accessed June 14, 2013.
  4. Sutton, J. M. (1990). Evaluation of hematuria in adults. JAMA : the journal of the American Medical Association, 263(18), 2475–2480.