CAPD peritonitis
Renal colic
Scrotal pain
CAPD PERITONITIS
DIAGNOSIS
Clinical
Cloudy dialysate effluent + abdominal pain + fever
Microbiological
Send bag for:
urgent gram stain
WCC and differential
- WCC >100 x 106/L
+ > 50% PMN’s
fungal and bacterial culture and sensitivity
If WCC less than this discuss with Renal Medical staff
Differential Diagnosis
Other causes of peritonitis
TREATMENT
Contact the PDU or renal nurse on 8B to make up PD bag
Tell them:
Therapy required
Usual bag and dwell time
Therapy A
 No previous MRSA colonisation / infection
 No allergy to penicillin or cephalosporin
Cephazolin 1.5g intraperitoneal
+ Gentamicin 0.6mg/kg intraperitoneal (rounded to nearest 10mg and not
greater than 60mg)
Added to same bag to dwelled for a minimum of 6 hours
+ Cephradine 250mg PO QID (before each bag exchange)
If unable to tolerate oral cephradine will need to continue cephazolin 125mg/L in each bag
exchange and daily gentamicin
Therapy B
 Previous MRSA colonisation / infection
 Penicillin or cephalosporin allergy
Vancomycin 30mg/kg intraperitoneal rounded to nearest 500mg (not greater than 3g)
+ Gentamicin 0.6mg/kg intraperitoneal rounded to nearest 10mg (no
greater than 60mg)
Added to same bag to dwell for a minimum of 6 hours
Patients on intraperitoneal insulin should have their intraperitoneal doses changed to SC (usually half
the intraperitoneal dose) for the dose due with any antibiotics.
DISPOSITION
Admit if too unwell
Arrange review the following day – in PDU, Monday to Friday or Renal Ward on the weekend.
Further treatment will be per the Peritonitis Standing Order.
RENAL COLIC
DIFFERENTIAL DIAGNOSIS
Must be excluded in anyone with suspected renal colic, especially the elderly.
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Aortic and iliac aneurysms
Pyelonephritis
Peritonitis, including appendicitis and diverticulitis
Biliary colic
Renovascular compromise, including renal artery or vein thrombosis
Cancer esp renal
Endometriosis
Ovarian torsion
INVESTIGATIONS
MSU sent for microscopy and culture. Haematuria is present 85% of the time. !5 % of patients with
renal colic will not have haematuria. If there are white cells or bacteria in the urine, consider infected
stone.
FBC if there is a high fever T > 38 deg C with or without significant renal tenderness, infection maybe
present. The WCC is often raised even when there is no infection therefore is not indicated in
uncomplicated renal colic.
UREA / ELECTROLYTES & CREATININE is done in the elderly, impaired renal function,
diabetes, and in those who are hypovolaemic. The young and previously healthy do not need renal
function tests.
MANAGEMENT
Analgesia
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Morphine as per protocol for significant pain
Metoclopromide 10mg IV for nausea and vomiting.
Diclofenac sodium (voltaren) orally or rectally for moderate pain or with morphine for severe pain
Intravenous fluids. Hydrate intravenously with 0.9 % saline.
Antibiotics: Gentamicin 5 – 7mg/kg IV if co-existing urosepis is suspected.
FURTHER INVESTIGATION
In the young healthy patient in whom the diagnosis of renal colic is clinically not in question, and the
pain has completely settled and there is no suspicion of any complication there is no need to obtain an
immediate IVU.
If pain is severe and ongoing , if the diagnosis is in doubt, if another condition is suspected, or if the
patient is elderly, some diagnostic imaging is essential.
Noncontrast helical CT
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Becoming the first line of imaging.
Discuss with the radiologist on duty.
Advantages
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Sensitivity 95 -97 % in detection of renal stones
Specificity 96-98 % in detection of renal stones
Faster than IVU
Avoids intravenous contrast
Limitations : Will diagnose other conditions such as AAA and GIT disease but is not
as sensitive or as specific as CT with contrast
Intravenous Urogram
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Comparable to CT in sensitivity and specificity for stones, but also shows renal function.
Takes too long and exposes patient to contrast.
Contraindications
Serum creatinine > 0.2
History of adverse (allergic) reaction to contrast.
Contrast can be nephrotoxic in the following conditions
Preexisting renal insufficiency
Diabetics
Dehydrated patients
Hypotension
Age> 60
Multiple myeloma
Hypertension
Hyperuricemia
Use of diuretics for cardiovascular system
History of IV radiocontrast media within 72 hours
Ultrasound
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When IVU or CT is contraindicated, or when there is no haematuria.
Will detect larger > 5 mm stones , particularly in the proximal and distal ureter but only poorly
visualizes midureteric stones.
Very sensitive for hydronephrosis (98%) but 22 % of hydronephroses detected on ultrasound do
not represent obstruction.
Advantages: noninvasive, no contrast, no radiation, no side effects. Can give clues to other
pathology, such as AAA.
Obesity may reduce accuracy.
Plain X-ray KUB
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Limited use, but required by radiology prior to CT.
90 % of renal stones are radio-opaque but the sensitivity is only up to 22 to 58 % and the
specificity 69 to 74 %. Negative predictive value is only 23 %. In patients in whom the diagnosis
is already established, plain Xray is useful in following the passage of a radioopaque stone.
DISPOSITION OF PATIENT
Admit
1. Fever > 38 degrees, or septic as may require a nephrostomy.
2. Severe ongoing pain that does not settle with IV narcotic and NSAIDS.
3. Recurrent attacks of colic with repeated visits to the emergency department.
4.
5.
6.
Ureteric stone more than 6 mm in diameter. These are unlikely to pass.
Any stone in a solitary kidney.
Creatinine > 0.2
Discharge
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Everyone else.
Send a referral to the urology outpatients clinic. The patient will be seen in 4 weeks with an
updated KUB film unless the stone is radiolucent when a limited IVU will be done.
Advice patient to strain urine.
Give the patient a script for voltaren unless there is a contraindication to the drug.
The patient should return promptly if they develop a fever.
BEWARE DRUG SEEKERS
SCROTAL PAIN
COMMONEST CAUSES
1. Torsion of testicular appendage
2. Epididymitis
3. Testicular torsion
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Testicular torsion occurs in less than 1/3 of the cases but is the presumptive diagnosis until
proven otherwise.
Testicular function unlikely to be recoverable after 12 hours.
HISTORY
Take a good history. There are no pathognomonic distinguishing features and presentations may be
misleading.
Testicular Torsion
Testicular
Appendage
Torsion
Epididymitis
Age
First few days, 13 – 15
Previous similar episodes
with pain free episodes
Strongly suggestive or
intermittent or recurrent
torsion
Usually severe
30 – 80%
Sudden onset
Usually within 6 hours
Often nocturnal
10 – 20%
No
Younger – STD
Older – UTI
organisms
Not self resolving
Rare
Often a few
days
Rare
Often later >24 hours
Insidious onset
No
No
50%
Pain
Nausea, vomiting, anorexia
Time of presentation
History of trauma or
physical exertion
Dysuria, frequency or
urethral discharge
THOROUGH PHYSICAL EXAMINATION
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Generally the patient with torsion of the testis will appear uncomfortable whereas the patient with
appendicular torsion and epididymitis will appear relatively comfortable.
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Examine the parotids for mumps.
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Local inspection should rule out a hernia.
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The penis is inspected for discharge.
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Inspect the scrotum for swelling, redness and tenderness. Swelling to the entire scrotum is
common to all three conditions. With torsion swelling comes on typically later, usually after 12
hours.
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Try and elicit the cremasteric reflex. If present testicular torsion is very unlikely.
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Examine the testis for abnormal elevation and lie.
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Palpate the testis for tenderness
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Transilluminate for hydrocoele
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Abdomen for pathology causing referred pain
Testicular torsion is suggested by
1.
2.
3.
4.
An abnormal elevation (high-riding testis) with a palpable twist in the spermatic cord.
Abnormal axis with the patient standing up.
Abnormal position of the epididymis within the scrotum.
An abnormal axis in the contralateral testis. Horizontal lie -- bell clapper deformity. Or
the epididymis is palpated at the inferior pole.
Torsion of a testicular appendage
1.
2.
Palpable 3 to 5 mm tender nodule or mass in the groove between the testis and the
epididymis.
The blue dot sign - where a blue dot is present in the superior portion of the scrotum
through stretched scrotal skin, is not as common.
Epididymitis
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Superior pole is tender. 10 % of cases of torsion will initially present with tenderness in a similar
position. Scrotal elevation to relieve pain is unreliable as a differentiating feature from torsion of
the testis.
DIFFERENTIAL DIAGNOSIS
Emergencies
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Torsion of the testis
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Traumatic testicular rupture
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Fournier's gangrene
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Peritonitis with patent processus vaginalis
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Abdominal aortic aneurysm
Non-emergencies
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Torsion of appendix testis or epididymis Acute
epididymo-orchitis
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Idiopathic scrotal oedema
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Traumatic haematoma
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Scrotal abscess
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Acute haemorrhage into testicular neoplasm
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Renal colic
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Hydrocoele
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Varicocoele
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Henoch-Schonlein Purpura
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Insect bite
INVESTIGATIONS
Urinalysis:
Pyuria is defined as greater than or equal to 10 WBC/HPF
About 50 % of patients with epididymitis will have pyuria but its
absence does not confirm epididymitis or nor does its presence rule
out torsion.
Urethral swab: Gram stain, chlamydia immunofluorescence, N gonorrhoea
culture.
Serum WBC count is not useful on its own, as it is raised in 30 to 50 % of
patients with either condition, epididymitis or testicular torsion.
Colour Doppler Ultrasonography:
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Can differentiate between epididymitis and torsion by patterns of blood flow.
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Can detect and differentiate between testicular haematoma and rupture.
Indications
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Unclear clinical picture.
But do not wait for ultrasound if this is going to be delayed; obtain an urgent urological
consultation while waiting.
MANAGEMENT
1.
Suspected torsion of testis
Analgesia
Refer to the urology registrar. Obtain an urgent ultrasound.
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2. Epididymo-orchitis
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The aetiology depends on age.
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In the young male it is most commonly an STD, the organisms being Chlamydia, Neisseria
gonorrhoea and Ureaplasma urealyticum.
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In the older male it is most commonly a gram negative rod, such as E.coli and Klebsiella and
rarely Pseudomonas.
Patient febrile and toxic: admit for IV antibiotics and studies to rule out abscess.
Patient non toxic: Discharge on antibiotics, bed rest, scrotal elevation with folded towel, ice for 10
minutes 3 to 4 times a day and advise to ambulate when pain free. Prescribe NSAID and paracetamol
Antibiotics
Suspected STD: Appropriate swabs
Ciprofloxacin 500 mg po stat only (alternatively ceftriaxone 250 mg im stat
only),
followed by
Doxycycline 100mg bd for 10 days (alternatively
erythromycin )
STD not suspected:
IV gentamycin 5 7mg/kg daily
or Trimethoprim 300mg daily 10 days
or Nitrofurantoin 50mg QD for 10 days
At discharge refer all patients to their general practitioner for follow up. If concerned refer to urology
clinic
3. Torsion of testicular appendage
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Bed rest, NSAIDS, analgesia, and ice.
The affected appendage will necrose in 14 days and become asymptomatic.
Refer to urology clinic.