1. Genitourinary and Renal Emergencies
Chapter 21
Genitourinary and Renal Emergencies

2. National EMS Education Standard Competencies
Medicine
Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.

3. National EMS Education Standard Competencies
Genitourinary/Renal
Blood pressure assessment in hemodialysis patients
Anatomy, physiology, pathophysiology, assessment, and management of
Complications related to:
Renal dialysis
Urinary catheter management (not insertion)
Kidney stones

4. National EMS Education Standard Competencies
Genitourinary/Renal (cont’d)
Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of
Complications of:
Acute renal failure
Chronic renal failure
Dialysis

5. National EMS Education Standard Competencies
Genitourinary/Renal (cont’d)
Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of
Renal calculi
Acid/base disturbances
Fluid and electrolytes
Infection
Male genital tract conditions

6. Introduction The urinary system
Balances the levels of electrolytes, water, acids, and bases in the blood
Removes metabolic wastes, drug metabolites, and excess fluids from the blood

7. Introduction Types of renal disorder: Kidney disease Renal calculi
Urinary tract infection
Noncancerous enlargement of the prostate

8. Anatomy and Physiology

9. Kidneys Located in the retroperitoneal space Composed of: Hilus
Three outer layers
Three internal parts
Calyces
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10. Kidneys Ureters transport urine from the kidneys to the bladder.
One fourth of the body’s systemic cardiac output flows through the kidney each minute.

11. Kidneys Nephrons In the cortex
Structural and functional units that form urine

12. Kidneys

13. Kidneys Glomerular capsule Podocytes
Double-layered cup
Podocytes
Form filtration slits
Blood moves from the afferent arteriole into the capillaries of the glomerulus.
Pressure increases.

14. Kidneys
The filtrate initially contains everything that can pass through the filtration membrane.
As filtrate passes through the rest of the nephron, it is converted to urine.
Additional reabsorption of water and electrolytes occurs in the loop of Henle.

15. Kidneys After leaving the loop of Henle, the fluid enters the DCT.
The juxtaglomerular apparatus is formed where the efferent arteriole meets the DCT.
ADH and aldosterone control the final adjustments to the composition of urine.

16. Kidneys
Neurons in the hypothalamus monitor the solute concentration of the blood.
Aldosterone plays an active role in reabsorption.
Diuretics increase urinary output.
Work in a variety of ways

17. Ureters Urine: Enters the collecting ducts Passes through the calyces
Goes to the renal pelvis
Moves through the ureters

18. Urinary Bladder Collapses when empty Expands when full
The brain controls the urge to void.
External urinary sphincter remains contracted until conditions are favorable

19. Urethra Part of the lower urinary tract Expels urine
Male urethra is divided into three regions.

20. Scene Size-Up Take standard precautions to avoid contact with urine.
Renal problems may mimic other abdominal problems.
It may be difficult to identify the source of pain.

21. Primary Assessment Form a general impression Airway and breathing
Patient may exhibit extremes of activity
Airway and breathing
Circulation
Transport decision
Consider how the patient will be moved.

22. History Taking History and physical exam
Provide the necessary information for patient management
Eighty percent of all medical diagnoses are based on the patient's history.

23. Four quadrants (internal organs) Nine anatomic segments
Secondary Assessment
Four quadrants (internal organs)
Nine anatomic segments

24. Reassessment
Electrolyte imbalances can cause rapid deterioration in the functioning of organs.
Form a treatment plan.
Take serial vital signs at least every 5 minutes in patients with possible renal failure.

25. Pathophysiology, Assessment, and Management of Specific Emergencies
Range from mild to true emergencies
Prehospital care is usually supportive.
Recognizing the condition helps provide a positive outcome.
Many of these conditions cause urinary retention.

26. Pain Pathophysiology Assessment Pain may be:
Visceral
Referred
Assessment
Use OPQRST to evaluate type and severity

27. Pain
Management
After assessing ABCs, allow patient to assume a position of comfort.
Be prepared for potential nausea and vomiting.
Provide analgesia if necessary.
Establish an IV line.

28. Urinary Tract Infections (UTIs)
Definitive treatment requires antibiotics.
Pathophysiology
Usually develop in lower urinary tract
Spread if untreated

29. Urinary Tract Infections (UTIs)
Classic symptoms:
Painful urination
Frequent urges to urinate
Difficulty urinating
Pain
Patients appear restless and uncomfortable.
Vital signs vary based on degree of illness.

30. Urinary Tract Infections (UTIs)
Management
Mainly supportive care of ABCs
Transport in a position of comfort
Be prepared for nausea or vomiting.
Analgesics in severe cases only
Establish an IV line.

31. Urinary Catheters
Many patients hospitalized for a urinary problem or disease receive catheterization.
Urine backflow is a concern when transporting a catheterized patient.
Do not lift the drainage bag while handling the patient.

32. Urinary Incontinence Loss of bladder control
Medical problem if in one of two categories:
Urge incontinence
Overflow incontinence

33. Renal Calculi (Kidney Stones)
Pathophysiology
Originate in renal pelvis
Form when an excess of insoluble salts or uric acid crystallizes in the urine
© Jones & Bartlett Learning. Photographed by Kimberly Potvin.

34. Renal Calculi (Kidney Stones)
Pathophysiology (cont’d)
Calcium stones
Most common
May have a hereditary component
Struvite stones
More common in women
Uric acid and cystine stones
Least common

35. Renal Calculi (Kidney Stones)
Assessment findings
Patients almost always experience pain.
Patient may be restless or guard abdomen
Palpation may be difficult.
Vital signs vary.

36. Renal Calculi (Kidney Stones)
Management
Ensure ABCs.
Position of comfort
Administer analgesia if local protocols allow.
Establish an IV line and administer fluids.

37. Acute Renal Failure (ARF)
Sudden decrease in filtration through the glomeruli
Causes toxins to accumulate in the blood
Two to seven percent of hospitalizations in the United States
Mortality rate of 50–80% in critical cases

38. Acute Renal Failure (ARF)
Oliguria
Urine output of less than 500 mL/day
Anuria
Complete cessation of urine production
Patient may experience:
Generalized edema
Acid buildup
High levels of nitrogenous
High levels of metabolic wastes in the blood

39. Acute Renal Failure (ARF)
If untreated, can lead to:
Heart failure
Hypertension
Metabolic acidosis
Classified into three types
Based on where it occurs

40. Acute Renal Failure (ARF)
Pathophysiology
Toxic buildup of nitrogenous wastes/salts in the blood causes problems including:
Impaired mentation
Hypotension
Fluid retention
Tachycardia

41. Acute Renal Failure (ARF)
Pathophysiology (cont’d)
Prerenal ARF
Caused by hypoperfusion of the kidneys
Intrarenal acute renal failure (IARF)
Involves damage to 1 of 3 areas of the kidney
Postrenal ARF
Caused by blockage of urine flow from kidneys

42. Acute Renal Failure (ARF)
Findings may include:
Tinnitus
Anorexia
Hypertension
Altered mental status
Prolonged bleeding
Flank pain
Look for any scars, ecchymosis, or distention on the abdomen.
Palpate for pulsing masses.
If available, a hematocrit and urinalysis may be helpful.

43. Acute Renal Failure (ARF)
Management
Metabolic changes caused by ARF are life threatening.
Support the ABCs.
Place in shock position.
Many ARF patients have comorbid diseases.

44. Chronic Renal Failure (CRF)
Pathophysiology
Inadequate kidney function caused by the permanent loss of nephrons
Scarring occurs as the damaged nephrons cease to function.
Uremia and azotemia develop.
Systematic complications develop.

45. Chronic Renal Failure (CRF)
Assessment findings
Patients present with:
An altered level of consciousness
Hypotension
Tachycardia
Other signs and symptoms vary.
Pericarditis and pulmonary edema are common.

46. Chronic Renal Failure (CRF)
Management
Similar to patients with ARF
Patients will ultimately require renal dialysis.
Due to electrolyte imbalances, be conservative with treatment plans.
Transport in a calm manner.

47. End-Stage Renal Disease (ESRD)
Pathophysiology
Result of untreated acute or chronic renal failure
Kidneys have lost all ability to function
Fatal unless treated by dialysis or renal transplant

48. End-Stage Renal Disease (ESRD)
Initial signs and symptoms:
Confusion
Shortness of breath
Peripheral edema
Bruising
Chest pain
Bone pain
Signs and symptoms of advanced ESRD include:
Pruritus
Muscle twitching
Hallucinations
Hypotension
In the late stages, seizures/coma are possible.

49. End-Stage Renal Disease (ESRD)
Management
Treatment is limited to renal dialysis or kidney transplant.
Provide supportive care.
Place the patient in the shock position.

50. Renal Dialysis Technique for: Two types:
Filtering the blood of its toxic wastes
Removing excess fluid
Restoring the normal balance of electrolytes
Two types:
Peritoneal dialysis
Hemodialysis
© Chris Priest/Photo Researchers, Inc.

51. Renal Dialysis
Most patients undergoing chronic hemodialysis have some sort of shunt.

52. Renal Dialysis
You will usually only encounter dialysis machines when transporting patients to and from dialysis centers.
Patients requiring dialysis usually undergo the process every 2 or 3 days for 3 to 5 hours.

53. Renal Dialysis
Patients who miss dialysis treatments often present with signs of electrolyte imbalance.
Other complications of dialysis include:
Muscle cramps
Nausea and vomiting
Infections at the IV site

54. Renal Dialysis

55. Male Genital Tract Conditions
Epididymitis
Infection that causes inflammation of epididymis along the posterior border of testis
Orchitis
When one or both testes become infected
Prehospital management is supportive.

56. Male Genital Tract Conditions
Fournier gangrene
Causes infection and necrosis of the subcutaneal tissue and muscle in the scrotum
The scrotum will be spongy.
Tissues will be gray-black.
Prompt transport is required.
Assess and treat for shock.

57. Male Genital Tract Conditions
Priapism
A painful, tender, persistent erection
Maintain the patient’s privacy.
Do not make assumptions about the cause.
Treat the patient with respect.
Ensure immobilization if you suspect spinal cord injury.

58. Male Genital Tract Conditions
Phimosis
Inability to retract the distal foreskin over the glans penis
Apply cold compress.
Transport.
Paraphimosis
Foreskin is retracted over the glans penis, is entrapped
True emergency
Can result in necrosis of the glans

59. Male Genital Tract Conditions
Benign prostate hypertrophy (BPH)
Age-related nonmalignant enlargement of the prostate gland
May be asymptomatic, or may lead to:
Difficulty starting urine flow
Incomplete emptying of the bladder
Increased urination at night

60. Male Genital Tract Conditions
Testicular masses
Rarely require prehospital treatment
May present with or without pain
Most are benign cystic masses or a varicocele.
Testicular cancer usually presents as a painless solid lump.

61. Male Genital Tract Conditions
Testicular torsion
Twisting of the testicle on the spermatic cord
Medical emergency if twisting reduces blood flow to testis
Usually unilateral
Transport carefully and promptly.

62. Summary Chronic kidney disease is the most common renal disorder.
The genitourinary system includes kidneys, its structures, urinary bladder, ureters, urethra, and reproductive organs.
Blood flows through the kidney into the afferent arteriole, then through the glomerulus, then the efferent arteriole, and finally the peritubular capillaries where it is reabsorbed.

63. Summary Urine forms in the nephrons.
In the glomerular capsule, filtrate from the blood is converted into urine and is further concentrated.
In the distal convoluted tubule, the composition of urine is further refined based on the body’s needs. Antidiuretic hormone and aldosterone are involved in adjusting the urine.

64. Summary The juxtaglomerular apparatus releases renin.
Diuretics are chemicals that increase urinary output.
As urine collects in the bladder, the micturition reflex causes the bladder to contract, stimulating the urge to void.
The female urethra is shorter than the male urethra and more prone to UTIs.

65. Summary
During the physical exam, use the four-quadrant system and abdominal region mapping, perform cardiac monitoring, and do not give anything orally.
Visceral pain and referred pain are two types of pain.
Use OPQRST during assessments.
Manage pain with positioning, analgesics and fluids as indicated, and supportive care.

66. Summary
Symptoms of a UTI include painful urination, frequent urination, difficulty urinating, and foul-smelling, cloudy urine. Management is mainly supportive care of the ABCs, keeping the patient in a position of comfort, administering IV fluid, and possibly administering analgesics.
Catheterization of the bladder allows continuous outflow of urine and is a means to measure urine output. Avoid backflow.

67. Summary
Kidney stones result when an excess of insoluble salts or uric acid has crystallized in the urine. Symptoms include severe flank pain that may migrate to the groin.
ARF results in a release of toxins into the blood. The three types are prerenal, intrarenal, and postrenal. Signs and symptoms range from hypotension and tachycardia to hematuria and peripheral edema.

68. Summary
CRF is progressive and irreversible inadequate kidney function that leads to a buildup of wastes and fluid in the blood.
Patients with ARF or CRF require support of the ABCs, administration of medications, calm transport, and psychological support.
Acute or chronic renal failure can progress to end-stage renal disease.

69. Summary
Renal dialysis removes toxic wastes and excess fluids from the blood, usually through a shunt, which connects the patient to the dialysis machine.
Dialysis patients must be monitored.
Leaking shunts should be tightened. If it has become disconnected at the vein, clamp the cannula and disconnect the patient from the machine.

70. Summary
Epididymitis, Fournier gangrene, priapism, phimosis, benign prostate hypertrophy, testicular masses, and testicular torsion are specific conditions to the male genital tract. Prehospital management for most of these conditions is supportive. Consider administering analgesics; transport gently.

71. Credits Chapter opener: © Life in View/Photo Researchers, Inc.
Backgrounds: Orange—© Keith Brofsky/ Photodisc/Getty Images; Blue—Jones & Bartlett Learning. Courtesy of MIEMSS; Green—Jones & Bartlett Learning; Purple—Jones & Bartlett Learning. Courtesy of MIEMSS; Blue—Courtesy of Rhonda Beck.
Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.