Podcast #375: Retrograde Urethrogram

Author:  Jared Scott, MD

Educational Pearls:

  • Blood at urethral meatus in trauma can be a sign of bladder/urethral injury
  • Blind placement of a Foley catheter can make an undiagnosed urethral injury worse
  • Urethral injury is evaluated using a retrograde urethrogram (RUG)
  • If urethra is confirmed to be intact, Foley catheter can be placed to allow additional tests

 

References:

Avery, L. (2012). Imaging of male pelvic trauma. Radiologic Clinics of North America., 50(6), 1201-1217.

Podcast # 344: Foley troubleshooting

Author: Aaron Lessen, MD.

Educational Pearls:

  • When foley is stuck, balloon may not have deflated.
  • Make sure balloon is not in the urethra, which can block drainage.
  • Cut off the port as it may be obstructed.
  • If still not draining, pass guide wire through port to unclog catheter.
  • Other techniques have been described using mineral oil to dissolve, rupturing the balloon through over-inflation, and transcutaneous guided drainage.
  • Crystallization can be a cause of catheter obstruction – sterile water may be a better solution to inflate the ballon than saline when it is first placed.

 

References

Khan SA, Landes F, Paola AS, Ferrarotto L. Emergency management of the nondeflating Foley catheter balloon. Am J Emerg Med. 1991 May;9(3):260-3. PubMed PMID: 2018599.

Hollingsworth M, Quiroz F, Guralnick ML. The management of retained Foley catheters. Can J Urol. 2004 Feb;11(1):2163-6. PubMed PMID: 15003159.

Podcast #309: Return Visits to the ED for UTI

Author: Alicia Oberle, MD

Educational Pearls:

  • Recent study has shown risk factors for return included patients at high risk for resistance (nursing home, obstructive uropathy), patient where diagnogsis of pyelonephritis was missed, but the biggest risk factor was the existence of bug-drug mismatches.
  • Cephalexin (Keflex) was associated with highest rate of return, while nitrofurantoin (Macrobid) was associated with lowest return rate.
  • Recommendation is to continue to detect between pyelonephritis and cystitis, broaden coverage for patients with complications, and utilize your facilities antibiogram.

References:

Jorgensen S, et al. ( 2018). Risk factors for early return visits to the emergency department in patients with urinary tract infection. American Journal of Emergency Medicine. 36(1):12-17

Podcast #295: UTI

Author: Sam Killian, M.D.

Educational Pearls

  • Traditionally, UTI diagnosis has been dependent on urine culture, urinalysis and clinical symptoms. But a recent study casts some doubt on the utility of urine cultures.
  • A study in the Journal of Clinical Microbiology did urine cultures and E. coli PCR in 220 women with UTI symptoms and 86 women without UTI symptoms.
  • In the symptomatic women, 67% had positive E. Coli PCR and 98% had a pathogenic bacteria in their urine culture.
  • In the asymptomatic women, 10% had positive E. coli PCR and/or urine culture.
  • Therefore, this study suggests that urine culture may be of limited utility, since symptoms alone seemed to predict bacteriuria.

References: Burd EM, Kehl KS. A Critical Appraisal of the Role of the Clinical Microbiology Laboratory in the Diagnosis of Urinary Tract Infections. Journal of Clinical Microbiology. 2011;49(9 Supplement). doi:10.1128/jcm.00788-11.

Podcast #294: Rhabdomyolysis

Author: Michael Hunt, M.D.

Educational Pearls

  • Rhabdomyolysis is caused by the destruction of skeletal muscle that leads to the release of myoglobin, which causes renal failure. It presents with pain and weakness in the affected muscle, as well as dark urine.
  • Diagnosis is made with creatinine kinase levels
  • It can happen to extreme athletes after competition, but the most common presentation is in people who fall and are immobilized for long periods of time.
  • Other causes include burns, crush injuries, viral infections (influenza), bacterial infections (Legionella), and medications (statins in adults, propofol in kids)
  • Treatment is aggressive fluids

References: Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis ? an overview for clinicians. Critical Care. 2005;9(2):158-169. doi:10.1186/cc2978.

Deep Dive #6: Bacteriuria and the Elderly

Author: Heidi Wald, MD, MSPH 

Associate Professor of Medicine – University of Colorado School of Medicine, Physician Advisor – Colorado Hospital Association

Dr. Heidi Wald explains common misconceptions of UTI’s in elderly patients and provides tips on how to properly identify them.

References:

Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici  Antibiotics for asymptomatic bacteriuria  Cochrane Collaborative Online Publication Date: April 2015.

Trautner BW, Bhimani RD, Amspoker AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48.

Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015.

D’Agata ELoeb MB, and Mitchell.  Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc.2013 Jan;61(1):62-6. doi: 10.1111/jgs.12070.

Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-77.

Podcast #216: Roller Coasters and Kidney Stones

Author: Aaron Lessen, M.D.

Educational Pearls:

  • Anecdotal evidence suggests that roller coasters may help with kidney stones.
  • A recent study used a model of a kidney and ureter with different sized stones and put it on Thunder Mountain roller coaster in Disney World.
  • There was “dramatic passage” of the kidney stones at the rear of the roller coaster.

References: Marc A. Mitchell, DO; David D. Wartinger, DO, JD. Validation of a Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. The Journal of the American Osteopathic Association, October 2016, Vol. 116, 647-652. doi:10.7556/jaoa.2016.128. http://jaoa.org/article.aspx?articleid=2557373

 

Podcast #131: Antibiotics for a UTI

0242783e-863a-451d-a9e4-4455434c30daRun Time: 4 minutes

Author: Holly Anderson, PharmD PGY-1 Resident

Educational Pearls:

  • Patients with pyelonephritis typically show a leukocytosis, fever, nausea, HA, CVA tenderness. Patients with a lower tract UTI will have absence of systemic symptoms with predominantly voiding symptoms of frequency, urgency, dysuria, and hematuria. These 2 types of UTI require different antibiotics and treatment.
  • Based on IDSA guidelines, only patients with uncomplicated lower UTI should be receiving Macrobid.
  • For patients with uncomplicated pyelonephritis, fluoroquinolones and Bactrim are preferred.
  • Macrobid has good sensitivity for the classic bugs that cause UTI, while fluoroquinolones show increasing E. coli resistance and are not recommended for uncomplicated lower tract UTIs.
  • Macrobid should not be used for pyelonephritis because the medication penetrates to the bladder just fine, but not well enough to the kidneys.

Link to Podcast: http://medicalminute.madewithopinion.com/antibiotics-for-a-uti/ 

References: http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_by_Organ_System/Genitourinary/Uncomplicated_Cystitis_and_Pyelonephritis_(UTI)/

Podcast #116: Catch a UA in Infants

733e8ff1-5e09-4aff-ba9b-42d299223775Run Time: 2 minutes

Author: Dylan Luyten M.D.

Educational Pearls:

  • An upcoming study in the Journal of Pediatrics, to be published in July, looked at reducing unnecessary urinary catheterization rates in infants.
  • In the study they investigated bagged urines on infants and every infant got a catheter.
  • It was found that if you restricted true positive UA on the bagged kids to those with positive nitrites, and moderate to large leuk esterase; there were no missed UTIs if you only catheterized these kids.
  • This could potentially reduce the number of catheterizations necessary for infants coming to the Emergency Room.

Link to Podcast: http://medicalminute.madewithopinion.com/catch-a-ua-in-infants/

References: http://www.jpeds.com/article/S0022-3476(09)00010-9/fulltext