GU

Cases from the Community: Springing a Leak

Case

A 58 year-old male, with history of kidney stones and appendectomy, presents to the ED with complaint of left lower quadrant abdominal pain. The patient goes on to describe waxing and waning “deep” and moderately severe pain in the abdomen with radiation to the back for two days. He notes associated nausea and one episode of dark urine but denies any fevers, nausea, vomiting, diarrhea, or any other urinary symptoms. He reports the pain is similar to prior episode of kidney stones, but feels more anterior.

Vital Signs

BP 177/93 | Pulse 87  | Temp 98.1 °F (36.7 °C)  | Resp 20  | SpO2 97%

Exam
Constitutional: Well-developed, in no apparent distress.

Cardiovascular: Normal rate and regular rhythm.  

Pulmonary/Chest: Effort normal and breath sounds normal. He has no wheezes. He has no rales.

Abdominal: Soft. Focal left local quadrant tenderness, No rebound, rigidity or guarding.  

GU: Normal testicular lie, no tenderness or erythema of the testicles. Normal cremasteric reflex. No costovertebral angle  tenderness.

Workup

Labs performed including complete blood count and basic metabolic profile are within normal limits, with a creatinine of 0.74. Urinalysis demonstrates 10 red blood cells, 1 white bell cells, and is otherwise within normal limits.

Given the patient’s significant abdominal pain, Computed tomography (CT) abdomen/pelvis with contrast is performed:

Image 1.png
Figure 1: Axial and coronal views of the CT abdomen/pelvis.

Figure 1: Axial and coronal views of the CT abdomen/pelvis.

Diagnosis

Spontaneous calyceal rupture

Radiologic impression

Mild left hydronephrosis, with moderate to severe perinephric and lower left retroperitoneal fluid concerning for recent calyceal rupture. No discrete obstructing calculus currently visualized. Of note, there is a 1.1 cm calculus in the left renal pelvis. In addition, given, extensive fluid, superimposed infection cannot be excluded.

Discussion

The above case is a classic example of a not-too-common urologic finding in the ED: spontaneous calyceal rupture. This finding is thought to occur as a result of a sudden increase in pressure in the collecting system. Most commonly, this sudden increase pressure is due to an obstructing kidney stone (typically in the distal ureter), however, it has also been described in the setting of other pathologies that obstruct the urinary system, including cancer, prostatic hypertrophy, pregnancy, and abdominal aortic aneurysm, as well as iatrogenic causes. The collecting system, typically a low-pressure system, is poorly equipped to handle the sudden increase in pressure, and ruptures in the most susceptible part of the system — the calyx. More specifically, it is the fornix, the lateral aspect of the minor calyx, that is the most common culprit (Figure 1).

Figure 2: Anatomy of the kidney.

Figure 2: Anatomy of the kidney.

Most cases of calyceal rupture present with flank pain, nausea, and vomiting, although more severe symptoms, such as severe abdominal pain and systemic findings, can occur. Rupture results in extravasation of urine that can collect around kidney or even in the retroperitoneum. The feared complication of this process is infection of the urine collection, leading to perinephric abscess formation and sepsis. The diagnosis is made either via ultrasound or CT.

Management first involves relieving the cause of obstruction. In the ED, if the obstruction is secondary to prostatic hypertrophy a foley should be placed. The patient should receive hydration and analgesia. Urology should be consulted to understand which patients will need intervention such as stenting or lithotripsy. At this time there is no standard as to the appropriateness of antibiotic therapy. Of course, if a patient shows evidence of infection, antibiotics (and source control) are indicated. However, if a patient demonstrates no systemic signs of infection and has a negative urinalysis it is reasonable to consider deferring antibiotics at the index visit. This decision, as well as whether to admit or discharge the patient should be made in conjunction with our urology colleagues.

Case conclusion

The patient was managed conservatively with fluids and analgesia. Antibiotics were deferred in consultation with Urology. The patient was discharged to close urologic follow-up. At four month chart review the patient had suffered no further complications and no long term sequelae from his calyceal rupture.  

 Faculty Reviewer: Dr. Kristy McAteer


References

  1. Al-Mujalhem AG, Aziz MS, Sultan MF, Al-Maghraby AM, Al-Shazly MA. Spontaneous forniceal rupture: Can it be treated conservatively? Urol Ann 2017:9(1);41-44 

  2. Doehn C, et al. Outcome analysis of fornix ruptures in 162 consecutive patients. J Endourol 2010;24(11):1869-73.

  3. Morgan TN, Bandari J, Shahait M, Averch T. Renal forniceal rupture: Is conservative management safe? Urology 2017;109:51-54.

  4. Tanwar S, Joshi A. A blow-out. Am J of Med 2011;124(1):37-39.

  5. https://opentextbc.ca/anatomyandphysiology/chapter/25-3-gross-anatomy-of-the-kidney/

A Tale of Two Bleeders

The following are two cases of vaginal bleeding seen in the a community Emergency Department during the same shift.

CASE 1:

HPI: 30 year old G3P1 female at 5 weeks pregnancy by LMP who presents to the ED with vaginal spotting. She states it started this morning while urinating. She reports about “a spoonful” of dark red blood with no clots. Associated symptoms include transient, lower abdominal cramping. Her pregnancy has had no complications so far, and she just established pre-natal care. Her second pregnancy was complicated by preterm delivery, for which she underwent C-section.

PE: Hemodynamically stable. No abdominal tenderness, guarding, rebound, or distention. On speculum exam, there is a mild amount of dark red blood and clot in the vaginal vault. No fetal tissue. The cervical os is closed. No CMT. No uterine or adnexal tenderness.

Bedside TVUS: No IUP

What now?

In any case of vaginal bleeding, the first step is determining if the patient is pregnant or not! In this case, we know our patient is pregnant. At this point, we develop our differential:

  1. Ectopic Pregnancy

  2. Abortion

  3. Gestational trophoblastic disease

  4. Implantation bleeding

Unlike our Miranda Rights, your patient is guilty of ectopic pregnancy until proven innocent! This is one of the “can’t-miss” diagnoses that we should all feel comfortable working up and managing.

Ectopic Pregnancy:

  • This occurs when there is conception outside of the uterine cavity. Risk factors include a history of STIs (especially PID), assisted reproductive techniques, history of pelvic surgery, advanced maternal age, previous ectopic pregnancy, and cigarette smoking.

  • The vast majority of ectopics take place in the fallopian tubes (ampullary portion), with about 1% taking place in the abdominal cavity, and <1% are cervical.

  • Most patient’s report a history of missed menses, although up to 15% of patients will report normal menses.

  • Abdominal pain is present in up to 90% of patients with ectopic pregnancies (secondary to tubal distention or rupture), although the absence of pain does not rule out ectopic pregnancy!

  • The physical examination in ectopic pregnancy is variable. In cases of ruptured ectopic pregnancy, the patients may be peritoneal with adnexal tenderness and possibly present in shock. Most patients, however, present with stable vital signs. An adnexal mass or tenderness could be an ectopic, although can also be a corpus luteum cyst in the setting of normal pregnancy and/or recent ovulation. Blood may be appreciated in the vaginal vault, although pelvic examination may be normal as well.

  • Definitive diagnosis of ectopic pregnancy is by ultrasound or direct visualization during laparoscopy or surgery.

  • But what about the beta-HCG level? Although absolute levels and “doubling times” are typically longer in ectopic pregnancy, it turns out that no level can reliably distinguish between a normal and pathological pregnancy.

  • The literature describes a discriminatory zone, or beta-HCG level at which you would expect to see an IUP at 1,500 mIU/mL for transvaginal scanning and 6,000 mIU/mL for transabdominal scanning. That being said, if ectopic is suspected, ultrasound should still be performed even with low beta-HCG levels.

  • The goal of ultrasound is to locate a viable IUP and exclude ectopic pregnancy. Visualizing an IUP is reassuring, although does not definitively exclude ectopic pregnancy if the patient is at high risk for a heterotopic pregnancy. Heterotopic pregnancy (both IUP and ectopic) has increased in the general population, largely in the setting of assisted reproduction technology (currently about 1:3,000 pregnancies).

  • An empty uterus with an embryo visualized outside the uterus is diagnostic, however this is only seen in up to 10% of transabdominal scans, and up to 25% of transvaginal scans. A pelvic mass (especially adnexal) in the setting of free fluid (evaluated in the cul de sac, posterior to the uterus) is highly suggestive of ectopic pregnancy.

  • If an ultrasound is indeterminate and the patient is hemodynamically stable, the patient should have close OB/GYN follow up in two days for a repeat beta-HCG level and be given strict return precautions. However, if the patient’s beta-HCG was above the discriminatory zone, it is advisable to seek consultation in the ED prior to disposition.

  • For ruptured ectopic pregnancies, surgical treatment is the preferred treatment modality.

  • For unruptured ectopic pregnancies, in the absence of contraindications, patients who are hemodynamically stable with minimal symptoms and who have appropriate OB follow up, medical treatment with methotrexate can be considered. This is typically given as a single IM dose, although the success rate of a multiple dose regimen was shown to be higher (92.7% vs 88.1%, p<0.05).

  • Treatment failure overall occurs in about 1/3 of cases. There is about a 5% chance of ectopic rupture and patients should avoid sexual intercourse for 2-3 weeks given the risk for this.

  • Abdominal pain 3-7 days after treatment with methotrexate is a common side effect, often attributed to tubal abortion/distention, although is difficult to differentiate from treatment failure and ectopic rupture. It is suggested that these patients undergo repeat laboratory testing (CBC) and pelvic ultrasound.

Figure 1: Ectopic pregnancy within the left adnexae. Source: Radiopaedia.org

Figure 1: Ectopic pregnancy within the left adnexae. Source: Radiopaedia.org

Figure 2: Fluid appreciated in the cul-de-sac posterior to the uterus. Source: Radiopaedia.org

Figure 2: Fluid appreciated in the cul-de-sac posterior to the uterus. Source: Radiopaedia.org

CASE 2:

History: 36 year old female G3P2 s/p D&C for a missed abortion at 7 weeks who presents to the ED with three days of worsening vaginal bleeding. Today, she reports “a large amount” of dark, red blood with clots. She reports using a pad every 10-15 minutes. Associated symptoms include intermittent, lower abdominal cramping and fatigue. No other associated symptoms. No pregnancy complications in the past.

Pertinent PE: No abdominal tenderness, guarding, rebound, or distention. On speculum examination, there is a moderate amount of blood in the vaginal vault with clots. No fetal tissue. The cervical os is closed. No CMT. No adnexal or uterine tenderness.

Bedside TVUS: No IUP. Heterogenous material appreciated within the uterine cavity.

What now?

This is a case of a patient with retained products of conception (RPOC) following an abortion.

  • Patient’s will often present with vaginal bleeding and pelvic pain, which are expected symptoms typically associated with low morbidity.

  • In patients with heavy vaginal bleeding, prolonged bleeding greater than three weeks, fever, uterine tenderness, and/or pain not controlled by over the counter medications, further evaluation is indicated to rule out other potential etiologies (or rule in RPOC).

  • Ultrasound is the best imaging modality to assess for RPOC

  • In patients with RPOC and bleeding greater than three weeks, hemodynamic instability, or sepsis, surgical treatment is preferred.

  • Patients can otherwise opt for expectant management or medical management, which typically consists of a dose of misoprostol (intravaginally or oral), especially given its low cost, low side effect profile, and easy availability. Notably, after consultation with the patient’s OB/GYN, our patient went home on methergine (an ergot alkaloid and uterotonic medication).

And for both cases, don’t forget the rhogam for your Rh negative patients! The dose is generally 300 micrograms given IM.

Faculty Reviewer: Dr. Kristy McAteer

REFERENCES:

  1. Carusi, Daniella et al. Retained Products of Conception. UptoDate. <www.uptodate.com>. 2018.

  2. Ibrahim, Dalia, Gaillard, Frank, et al. Ectopic Pregnancy. Radiopaedia. <https://radiopaedia.org/articles/ectopic-pregnancy>. 2018.

  3. Tintinalli, et. al. Ectopic Pregnancies and Emergencies in the First 20 Weeks of Pregnancy. Emergency Medicine. 8th Edition. 2016. 628-633.HHHf

FURTHER READING:

  1. 1st Trimester Pregnancy Ultrasound Podcast Part I: http://www.ultrasoundpodcast.com/2014/10/pregnancy-ultrasound-part-1-foamed-back-back-basics-cabo-update/

  2. 1st Trimester Pregnancy  Ultrasound Podcast Part II: http://www.ultrasoundpodcast.com/2014/10/1st-trimester-pregnancy-ultrasound-part-2-ectopic-topics-foamed/

  3. EM in 5: First Trimester Bleeding https://emin5.com/2015/11/09/vaginal-bleeding-in-1st-tm-pregnancy/

  4. EM Updates: Ruling out Ectopic Pregnancy http://emupdates.com/2013/06/03/rule-out-ectopic-in-the-emergency-department/

Brown Sound: Firecracker vs Testicle

Ultrasound Case of the MontH

A 20-something year old male with PMH of anxiety, depression, and ADHD presents to the Emergency Department after an accidental firecracker injury. Patient denies LOC and respiratory distress, but has a degloving injury to left anterior thigh and a macerated laceration to left wrist. Additionally, he has first degree burns to the ventral aspect of the penile shaft, partial thickness burn and stellate laceration with associated swelling of the left hemiscrotum, and diffuse tenderness of the left testicle. Denies pain to right testicle.

A scrotal ultrasound was obtained demonstrating left-sided hematocele and testicular rupture. Video with audio discussion below.

Testicular injury ultrasound

Discussion

The above images demonstrate heterogeneous echotexture within the testis as compared to the normal testicle, which has a relatively homogenous echogenicity. There appears to be an area representing herniation of the left testicular parenchyma through a defect in the tunica albuginea with associated hematocele. There is Doppler flow present in relatively equal amounts to that of the normal testicle.

The patient was taken to the OR with urology for emergency surgical exploration. Intraoperatively, patient had 200cc of hematocele evacuated. Ultimately, patient had preservation of approximately 25% of left testicular parenchyma after resection of non-viable testicular parenchyma. General surgery was able to address his other injuries in the OR as well.

Testicular rupture is most commonly the result of blunt sports-related injuries, with 12-15% involving bicyclists/motorcyclists. (1) Ultrasound for testicular rupture has a sensitivity and specificity ranging from 56 to 95%. (2) Irregular contour of the testicle is the most significant predictor of testicular rupture. A study found that the delay of performing testicular ultrasound does not lead to negative outcomes due to delayed surgical intervention. (2)

Step-wise testicular exam. Using a high-frequency linear probe, a “buddy view” should be first obtained in transverse, showing the medial aspects of both left and right testicles in order to compare relative echogenicity and size. Just as you would when you ultrasound for testicular torsion, it is important to obtain images of the normal testicle before the abnormal one. The normal (in this case, right-sided testicle) was interrogated, paying special attention to homogeneity of the testes and circumscribed contour. Then finally, the testicle of concern was ultrasounded, first in transverse and then sagittal views.

Don’t forget your setup! Optimize your exam to minimize patient discomfort. Patient was pre-medicated for with IV pain medications. Lay one towel across the patient’s thighs and suspend the scrotum over the towel. With a second towel, cover the penile shaft so only the scrotum is exposed. Use liberal amounts of gel in order to minimize contact of the probe with the painful area.

Faculty Reviewer: Kristin Dwyer

Additional Resources

https://radiopaedia.org/articles/testicular-and-scrotal-ultrasound

References

Bauer NJG. Case report: Traumatic unilateral testicular rupture. International Journal of Surgery Case Reports. 2016;25:89-90. doi:10.1016/j.ijscr.2016.05.059.

Wang A, Stormont I, Siddiqui MM. A Review of Imaging Modalities Used in the Diagnosis and Management of Scrotal Trauma. Curr Urol Rep. 2017;28(12):98. doi: 10.1007/s11934-017-0744-1.