Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 21: Genitourinary and Renal Emergencies
Chapter 21
Genitourinary and Renal Emergencies
Unit Summary
Upon completion of this chapter and related course assignments, students will be able to describe
the anatomy and physiology of the male and female urinary systems as well as the primary and
secondary assessments for patients with renal and genitourinary emergencies. Students will be
able to identify components of the physical exam of patients with genitourinary and renal
emergencies, questions to obtain a thorough history, and factors that may influence treatment
decisions enabling the construction of an effective treatment plan. Students will have an
understanding of the pathophysiology of common diseases and conditions of the renal and
genitourinary systems, including the male genital tract. Students will be able to discuss the
purpose and types of renal dialysis as well as potential complications and prehospital
interventions relevant to these emergencies.
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.
Genitourinary/Renal
• Blood pressure assessment in hemodialysis patients (pp 1174-1175)
Anatomy, physiology, pathophysiology, assessment, and management of
• Complications related to
–
Renal dialysis (pp 1174-1176)
–
Urinary catheter management (not insertion) (pp 1167, 1169)
• Kidney stones
Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations,
prognosis, and management of
• Complications of
–
Acute renal failure (pp 1170-1172)
–
Chronic renal failure (pp 1172-1173)
–
Dialysis (pp 1174-1176)
• Renal calculi (pp 1169-1170)
• Acid-base disturbances (p 1171)
• Fluid and electrolytes (pp 1163, 1174)
• Infection (p 1169)
• Male genital tract conditions (pp 1176-1177)
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Chapter 21: Genitourinary and Renal Emergencies
Knowledge Objectives
1. Describe the anatomy and physiology of the male and female urinary systems: kidneys,
ureters, urinary bladder, and urethra. (pp 1161-1164)
2. Describe the primary and secondary assessment processes for patients with renal and
genitourinary emergencies. (pp 1165-1166)
3. Specify factors that influence transport decisions for such patients. (pp 1166, 1167)
4. Discuss the questions that must be asked in order to obtain thorough historical
information from a patient. (p 1166)
5. Indicate the components of the physical examination for a patient with a renal or
genitourinary complaint. (p 1166)
6. Name the components of an effective treatment plan. (pp 1166-1167)
7. Specify best practices for documenting renal and genitourinary emergencies and
communicating with the receiving facility. (pp 1166-1167)
8. Compare visceral pain with referred pain, and explain how each contributes to the field
diagnosis. (p 1168)
9. Outline the pathophysiology, assessment, and management of common diseases and
conditions of the renal and genitourinary systems, including urinary tract infections,
kidney stones, acute renal failure, chronic renal failure, and end-stage renal disease. (pp
1169-1174)
10. Discuss the purpose and types of renal dialysis. (p 1174)
11. Identify the possible complications of dialysis and the prehospital interventions
associated with each. (pp 1174-1176)
12. Discuss the pathophysiology, assessment, and management of conditions related to the
male genital tract, including epididymitis, Fournier gangrene, phimosis, priapism, benign
prostate hypertrophy, testicular masses, and testicular torsion. (pp 1176-1177)
Skills Objectives
There are no skills objectives for this chapter.
Readings and Preparation
Review all instructional materials including Chapter 21 of Nancy Caroline’s Emergency Care in
the Streets, Seventh Edition, and all related presentation support materials.
• Direct students to the following web links:
o
“Renal Failure & Dialysis Patients: What the EMS Provider Should Know” by R. J.
Fairbanks, M. Goyal, & A. M. Marks: http://www.emsworld.com/article/10323936/renalfailure-and-dialysis-patients-what-the-ems-provider-should-know
o
“Patient Presents with Renal Condition” by D. Edgerly:
http://www.jems.com/article/patient-care/patient-presents-renal-failure
• Consider reading this article ahead of time and summarizing it for your students or using the
contents as a springboard for discussion about how dialysis patients may be affected during
disasters and the potential role of EMS to assist in managing these patients.
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Chapter 21: Genitourinary and Renal Emergencies
o “Medicare Announces Disaster Plan for People with Kidney Failure” by LexisNexis:
http://www.emsworld.com/news/10410722/medicare-announces-disaster-plan-forpeople-with-kidney-failure
Support Materials
• Lecture PowerPoint presentation
• Case Study PowerPoint presentation
• Obtain information related to Medicare coverage for patients with end-stage renal disease
(ESRD) at www.cms.org. Consider how this will affect students who may transport these patients
in a nonemergent capacity, including documentation needs for medical necessity. Refer to the
Documentation chapter for specific guidelines on documentation of medical necessity.
• Consider planning a field trip to a local dialysis center for students where students can see
various types of dialysis and devices used to perform dialysis.
• Contact local EMS organizations and obtain patient care protocols for treatment of patients with
ESRD. Prepare to share these with students.
• Prepare scenario cards for patients with these types of emergencies for use in group activities
during the lesson.
Enhancements
• Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the
Streets, Seventh Edition, at http://www.paramedic.emszone.com for online activities.
• Consider contacting a local dialysis center and inviting a dialysis nurse, nurse practitioner, or
physician’s assistant to speak with the class about patients who perform home dialysis, including
special needs for the peritoneal dialysis patient having an emergency.
• Consider inviting an expert on treatment of male genitourinary tract conditions to speak with the
class on recognition and management of this type of emergency.
• Content connections: Remind students that many genitourinary and renal emergencies may
present initially as abdominal complaints. Conducting a thorough patient assessment and
obtaining good patient histories will help reveal those patients with existing renal disease or those
who have chronic illnesses that may predispose them to development of acute renal failure.
Students should be reminded that the renal disease patient presents challenges when receiving
pharmacological treatment for other emergencies, and dosing guidelines should be recognized for
these patients.
Redirect students to review the challenges associated with vascular access of patients with
existing shunts and proper procedures for accessing shunts and the risk of bleeding in these
patients.
• Cultural considerations Male genitourinary emergencies may present as challenges for
cultural sensitivity. Male patients may be uncomfortable with female paramedics who will be
required to perform assessments.
Teaching Tips
Students may be not be familiar with various devices used by patients with renal and
genitourinary problems including catheters, shunts, and dialysis devices. Be prepared to provide
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Chapter 21: Genitourinary and Renal Emergencies
pictures and teaching aids including aiding students in becoming familiar with recognition and
access to these devices.
Students may be embarassed by the focus of discussion on male genitourinary structures.
Consider allowing students to work in smaller groups as they discuss issues related to these
emergencies.
Unit Activities
Writing activities: Ask students to research challenges associated with medical care, insurance,
disaster planning, and transportation for the ESRD patient. Assign them to prepare a paper that
summarizes these challenges and the availability of local resources for patients in managing them.
Student presentations: Have students, or small groups of students, research statistics on patients
dependent on dialysis in their areas. They can be encouraged to contact local dialysis centers to
determine how many patients are seen, numbers of patients on waiting lists for dialysis, numbers
of patients who receive dialysis at home, transportation challenges, numbers of patients awaiting
transplants, and outcomes for those who receive transplants. Students should prepare a
presentation outlining their findings.
Group activities: Using scenario cards prepared prior to the lesson, assign one scenario to each
group. Have them practice application of material learned in the Critical Thinking and Clinical
Decision Making chapter to apply those skills for this type of patient. Students should be able to
identify potential challenges to prehospital treatment for these patients.
Visual thinking: Create a poster of cardiac and respiratory emergency protocols. Divide the
class into two groups. Have students develop additional considerations that should be included in
these protocols for patients with acute renal failure or end-stage renal disease.
Pre-Lecture
You are the Medic
“You are the Medic” is a progressive case study that encourages critical-thinking skills.
Instructor Directions
Direct students to read the “You Are the Medic” scenario found throughout Chapter 21.
• You may wish to assign students to a partner or a group. Direct them to review the
discussion questions at the end of the scenario and prepare a response to each question.
Facilitate a class dialogue centered on the discussion questions and the Patient Care Report.
• You may also use this as an individual activity and ask students to turn in their comments
on a separate piece of paper.
Lecture
I. Introduction
A. The urinary system
1. Balances the levels of electrolytes, water, acids, and bases in the blood
2. Removes metabolic wastes, drug metabolites, and excess fluids from the blood
3. The kidneys perform these functions continuously.
a. They filter 200 L of blood every day.
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Chapter 21: Genitourinary and Renal Emergencies
4.
5.
6.
7.
b. They produce hormones that generate new red blood cells.
c. They help the liver convert glycogen to glucose.
Kidney disease is the most common renal disorder.
a. It affects more than 20 million Americans.
b. Approximately 50,000 Americans die of kidney disease each year.
c. More than 30,000 Americans require dialysis.
Renal calculi, also known as kidney stones, is the most common acute renal disease.
a. Two million cases are diagnosed each year.
Other common types of renal disease include:
a. Urinary tract infections
i. Affect more than 50% of all women
b. Noncancerous enlargement of the prostate
i. Will develop in 60% of all men by age 50
Most renal disorders can be prevented by practicing proper hygiene, following a healthy
diet, and staying hydrated.
II. Anatomy and Physiology
A. The urinary system consists of:
1.
2.
3.
4.
Kidneys: Filter blood and produce urine
Ureters: Transport urine from kidneys to the bladder
Urinary bladder: Stores the urine until it is released from the body
Urethra: Route by which urine exits the body
B. Kidneys
1. Bean-shaped
2. Located in the retroperitoneal space, with the right kidney slightly lower than the left
3. Hilus: Cleft located on the medial side of the kidney where the ureters, renal blood
vessels, lymphatic vessels, and nerves enter and leave the kidney
4. Fibrous capsule envelops the kidney and protects it against infection
5. Fatty mass of adipose tissue cushions the kidney and holds it in place
6. Renal fascia: Anchors the kidney to the abdominal wall
7. The internal anatomy of the kidney can be divided into three regions.
a. Cortex: Outer region closest to the capsule
b. Medulla: Middle layer; includes renal pyramids (urine-collecting tubules) and renal
columns (cotical tissue that surrounds the pyramids)
c. Renal pelvis: Flat, funnel-shaped tube that fills the sinus at the level of the hilus
8. Calyces: Major and minor; branch off the pelvis and connect with the renal pyramids
9. The ureters are a pair of thick-walled, hollow tubes that transport urine from the kidneys
to the bladder and receive urine that drains from the tubules.
10. Collected urine flows from the renal pelvis into the ureter on its way to the bladder.
11. One fourth of the body’s systemic cardiac output flows through the kidney each minute.
a. The renal artery takes blood from the heart to the abdominal aorta into the kidney.
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Chapter 21: Genitourinary and Renal Emergencies
12.
13.
14.
15.
16.
17.
b. After entering the kidney at the hilus, the artery branches to become the afferent
arteriole.
c. The afferent arteriole branches further into the glomerulus (a tuft of capillaries),
which serves as the kidney’s main filter.
d. Blood enters the efferent arteriole from the glomerulus into the peritubular
capillaries, where reabsorption occurs.
e. The kidney is the only organ in the body with two distinct capillary beds.
f. Cleansed blood is taken from the renal vein to the inferior vena cava.
Nephrons
a. Located in the cortex
b. Structural and functional units of the kidney that form urine
c. Composed of:
i. Glomerulus
ii. Glomerular (Bowman’s) capsule: Surrounds the glomerulus
iii. Proximal convoluted tubule (PCT)
iv. Loop of Henle
v. Distal convoluted tubule (DCT): Connects with the kidney’s collecting tubules
d. Each kidney has approximately 1.25 million nephrons.
Glomerular capsule: Double-layered cup with the inner layer infiltrating and surrounding
the capillaries of the glomerulus
Podocytes: Wrap around the capillaries in the glomerulus, forming filtration slits
a. Filtrate passes through the slits, across the filtration membrane, and into the capsule.
b. Prevents large molecules from entering the capsule
As blood moves from the afferent arteriole into the smaller capillaries of the glomerulus,
pressure increases.
a. Forces filtrate from the blood into the glomerular capsule
b. Glomerular filtration rate (GFR): Amount of filtrate produced
i. The GFR is maintained at a relatively constant rate of 125 mL/min in healthy
adults.
ii. Changes in the GFR cause many of the renal emergencies encountered in the
prehospital setting.
The filtrate initially contains everything that can pass through the filtration membrane
(salts, minerals, glucose, water, and metabolic wastes).
As the filtrate passes through the rest of the nephron, tubular reabsorption and tubular
secretion convert the filtrate into urine.
a. As the fluid passes through the PCT, cells lining the PCT remove all organic
nutrients and plasma proteins, as well as some ions.
b. Compounds are deposited in the interstitial fluid surrounding the PCT.
c. As these solutes accumulate, the concentration of the surrounding fluid becomes
higher than the filtrate.
d. Water will move from the filtrate by osmosis; fluid and nutrients in the interstitial
fluid move to peritubular capillaries around the PCT.
e. Homeostatic balance in the blood is reestablished.
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Chapter 21: Genitourinary and Renal Emergencies
18.
19.
20.
21.
22.
23.
f. Volume of the tubular filtrate is reduced.
Additional reabsorption of water and electrolytes occurs in the loop of Henle, which has
two sections.
a. The descending limb extends toward the medulla and its cells are permeable to water,
but impermeable to sodium and chloride ions.
b. The ascending limb moves toward the cortex and its cells are permeable to sodium
and chloride ions, but impermeable to water.
c. When the sodium chloride ions move out of the ascending limb, the solute
concentration of the fluid surrounding the descending limb increases.
d. Water moves into the vasa recta by osmosis.
i. Vasa recta: A series of peritubular capillaries that surround the loop of Henle
ii. Countercurrent multiplier: The process by which the body produces either
concentrated or diluted urine, depending on the body's needs.
After leaving the loop of Henle, the fluid enters the DCT.
a. About 80% of the water and 85% of the solutes originally forced out of the
glomerulus have been reabsorbed.
b. Ions are actively secreted or reabsorbed, and the body alters the permeability of the
DCT and collecting ducts to water as necessary, depending on the body's homeostatic
needs.
c. These adjustments to the final composition of the urine facilitate the removal of
metabolic wastes while maintaining the body's fluid-electrolyte balance.
The juxtaglomerular apparatus is formed where the efferent arteriole meets the DCT.
a. The cells in the efferent arteriole (juxtaglomerular cells) monitor blood pressure.
b. The cells in the DCT (macula densa cells) monitor the concentration of the filtrate in
the DCT and release renin when triggered by changes.
i. Renin initiates reactions in the body by converting the plasma protein
angiotensinogen into angiotensin.
ii. Other enzymes convert angiotensin I into angiotensin II.
iii. Angiotensin II is a potent blood vessel constrictor that promotes smooth muscle
contraction in the arterioles throughout the body.
iv. This constriction raises the blood pressure by increasing peripheral resistance.
v. Angiotensin II also increases the reabsorption of sodium from the PCT.
vi. An increase in sodium reabsorption increases water reabsorption and in turn
blood pressure.
The final adjustments to the composition of urine at the DCT and collecting duct are
controlled primarily by the antidiuretic hormone (ADH) and aldosterone.
a. ADH: Produced by the hypothalamus and stored in the posterior lobe of the pituitary
b. Aldosterone: Produced in the adrenal glands
Neurons in the hypothalamus monitor the solute concentration of the blood.
a. When solute concentration increases, ADH is released into the bloodstream and
travels to the DCT and collecting ducts, increasing permeability to water.
b. Secretion of ADH stops as the solute concentration returns to normal
Aldosterone increases the rate of active reabsorption of sodium and chloride ions with a
corresponding increase in water reabsorption.
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a. Aldosterone also decreases the reabsorption of potassium ions, resulting in potassium
being secreted in the urine.
24. Diuretics: Chemicals that increase urinary output; work in a variety of ways
a. Alcohol encourages diuresis by inhibiting the production of ADH.
b. Other diuretics, including caffeine, inhibit the sodium importers in the DCT and
collecting ducts.
C.
Ureters
1. Urine enters the collecting ducts, passes through the minor calyx into the major calyx,
and then into the renal pelvis.
2. From there, urine moves through the ureters and is stored in the urinary bladder.
3. One ureter descends from each kidney, making up the upper urinary tract.
D.
Urinary bladder
1. Most of the urinary bladder rests in the anterior abdominal cavity, but some of it also sits
in the retroperitoneum, where the ureters and kidneys reside.
2. When the bladder is empty, it collapses.
3. When the bladder is full, it expands, becomes pear-shaped, and the micturition reflex is
produced.
a. Micturition reflex: Spinal reflex that causes contraction of the bladder's smooth
muscle, producing the urge to void as pressure is exerted on the internal urinary
sphincter
4. The brain controls the urge to void by keeping the external urinary sphincter contracted
until conditions are favorable.
a. When inhibition of the external urinary sphincter is reduced urine passes from the
urinary bladder into the urethra.
E. Urethra
1. The lower urinary tract is made up of the urinary bladder and the urethra.
2. Urine is expelled at the beginning of the urethra, which sits at the inferior aspect of the
bladder.
3. The female urethra exits at the site of the external genitalia and is shorter than the male
urethra.
4. The male urethra is divided into three regions:
a. Prostatic urethra: Begins at the bladder and extends through the prostate gland
b. Membranous urethra: Extends from the prostate gland through the abdominal wall
and into the penis
c. Spongy, or penile, urethra: Passes through the penis to the external urethral opening
III. Patient Assessment
A. Assessment of a patient with a renal and genitourinary emergency is the same as
for any other medical patient.
1. Scene size-up
2. Primary assessment
3. Patient history
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4.
5.
6.
7.
Secondary assessment, including physical exam
Field impression
Treatment decision
Continuously reassess en route.
IV. Scene Size-Up
A. Ensure the scene is safe, consider the MOI, assess for hazards and the need for
additional help, and determine the number of patients.
B. Take standard precautions to avoid contact with urine.
C. Patients with renal problems may exhibit many of the same symptoms as a
patient with other abdominal problems.
1.
2.
3.
4.
5.
6.
Nausea and vomiting
Constipation or diarrhea
Weight loss
Loss of appetite
Chest pain
Abdominal pain
D. It is often difficult to determine the source of abdominal pain.
1. Urologic pain can have many origins.
2. Assessment is designed to detect and prevent life threats and provide supportive care.
3. Do not waste time trying to determine the exact cause of the pain in the prehospital
setting.
V. Primary Assessment
A. Form a general impression
1. Check for life-threatening conditions.
2. A patient with genitourinary or renal problems may exhibit extremes of activity.
a. Observe the patient's body movements, posture, skin color, breathing pattern, mental
acuity, and other factors to determine the severity of the patient's condition.
B. Airway and breathing
1. Check for life threats by assess the patient's mental status and airway, breathing, and
circulation.
2. Look for signs of respiratory distress or failure.
3. Ensure that the airway is patent.
a. Depending on the patient’s respiratory status, clear the airway and provide
suctioning, bag-mask ventilation, or high-flow supplemental oxygen if necessary.
C. Circulation
1. Assess the patient's skin color, heart rate, and blood pressure.
2. Look for signs of profuse bleeding or circulatory compromise.
3. Check the patient's abdomen.
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Chapter 21: Genitourinary and Renal Emergencies
4. Check for signs of shock.
5. Correct any life-threatening conditions, and transport the victim to an appropriately
equipped facility.
a. Contact the facility en route so they can mobilize resources and staff.
D. Transport decision
1.
2.
3.
4.
5.
6.
Use the information from the primary assessment when making a transport decision.
Determine if urgent transport for life threats is warranted as quickly as possible.
Consider how the patient will be moved.
Consider any special equipment needed.
Consider the diagnostic and treatment equipment at the receiving facility.
The transport ride should be as smooth and gentle as possible.
VI. History Taking
A. In genitourinary patients, the history and physical examination will provide the
information you need to successfully manage the patient.
1. Eighty percent of all medical diagnoses are based on the patient's history, so ask the right
questions.
a. Knowing that a patient’s pain started in one location and moved to another, for
example, can affect the field diagnosis.
2. Use the mnemonic SAMPLE as a guide in obtaining historical information.
VII. Secondary Assessment
A. The physical examination can be focused or may be more head to toe, depending
on the signs and symptoms.
1. The abdomen can be divided into four quadrants overlying the internal organs.
2. The abdomen can be divided into nine anatomic segments.
3. If it cannot be performed at the scene, do more a detailed physical exam en route to the
hospital.
4. Monitor the patient's vital signs as part of the physical exam.
a. Obtain serial vital signs at least every 5 minutes if renal failure is suspected.
b. Take prompt action if any deterioration is noted.
c. Consider the link between abnormal vital signs and the patient's history.
5. ECG monitoring is very important in any patient with a suspected urologic emergency.
VIII. Reassessment
A. Patients with urologic emergencies, especially those with signs and symptoms of
renal failure, require reassessment.
1. Electrolyte imbalances that result from toxin buildup can cause rapid deterioration in the
functioning of the body's organs, especially the heart.
2. Use the information obtained from the history and physical examination to form a field
impression and select a treatment plan.
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Chapter 21: Genitourinary and Renal Emergencies
a. The treatment plan includes the transport decision, which may be made at any time
during the assessment.
b. If medical procedures beyond the scope of the prehospital setting are necessary,
perform the primary assessment and transport, reassessing en route to the hospital.
3. Take serial vital signs at least every 5 minutes in patients with possible renal failure.
a. Note any trends in the vital signs and level of consciousness, as they may indicate
disease progression.
b. Do not give patients with possible urologic disease anything by mouth.
c. Document vital signs, and report apparent trends to the receiving facility.
IX. Pathophysiology, Assessment, and Management of
Specific Emergencies
A. Diseases and problems of the renal and urologic systems can range from mild to
true emergencies.
1. Prehospital care for many urologic diseases is supportive, but your ability to recognize
these conditions is critical to providing the best chance of a positive outcome.
2. Many of these conditions can cause urinary retention.
a. Urinary retention: Incomplete emptying of the bladder, or a complete lack of ability
to empty the bladder
3. Conditions that may cause urinary retention include:
a. Renal calculi
b. Acute renal failure
c. Benign prostate hypertrophy
d. Urethral obstructions
e. Urinary tract infections
f. Nerve damage
B. Pain
1. Pathophysiology
a. Pain is often a cardinal sign of an emergency.
b. Determining the origin of referred pain can be an important diagnostic tool in some
urologic and renal diseases.
c. When receptors at the affected organs are stimulated, they send impulses along the
nerves to the brain, which are evaluated and interpreted as pain.
d. Visceral pain
i. Most commonly associated with urologic problems
ii. Usually occurs when receptors in the hollow structures are stimulated
iii. Pinpointing the source of such pain is challenging
e. Referred pain
i. Pain that originates in one area of the body but is perceived as coming from a
different area of the body
2. Assessment findings
a. Use the OPQRST mnemonic to evaluate the type and severity of pain.
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i.
ii.
iii.
iv.
v.
O = Onset, when the pain started and what the patient was doing at the time
P = Provocation, determine what, if anything, provokes the pain
Q = Quality
R = Region, radiation, or referral
S = Severity, rate the pain on a scale from 1 to 10, keeping in mind that the
severity of the pain might not be consistent with the severity of the problem;
repeat this assessment
vi. T = Timing, sudden or gradual, constant or intermittent
3. Management
a. After checking the ABCs, allow the patient to assume a position of comfort.
b. Nausea and vomiting are possible, so be prepared to suction; aspiration may be
possible.
c. Provide analgesia if necessary.
i. Masking abdominal pain is not a goal of prehospital care.
ii. Contact medical control before administering pain medication.
d. Establish an IV line.
i. Administer a bolus of fluid to the patient with a UTI or kidney stone if kidney
function is present.
C. Urinary tract infections
1. Urinary tract infection (UTI) is most common in females after infancy, but increase in
men after age 50.
2. Definite treatment requires antibiotics.
3. Pathophysiology
a. UTIs usually develop in the lower urinary tract when normal flora enter the urethra
and grow.
b. More common in women because of the relatively short urethra and its close
proximity to the vagina and rectum.
c. UTIs in the upper urinary tract occur most often when lower UTIs go untreated.
d. Upper UTIs can lead to pyelonephritis and abscesses and ultimately reduce kidney
function.
e. In severe cases, untreated UTIs can lead to sepsis.
4. Assessment findings
a. Classic UTI symptoms:
i. Painful urination
ii. Frequent urges to urinate
iii. Difficulty urinating
b. Pain
i. Begins as a visceral discomfort
ii. Becomes extreme and burning, especially during urination
iii. Remains localized in the pelvis
iv. Often perceived as bladder pain in women/prostate pain in men
v. Sometimes referred to the shoulder or neck
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c. Urine will have a foul odor and may appear cloudy.
d. Patients appear restless and uncomfortable.
e. Skin
i. Lower UTI: Pale, cool, and moist
ii. Upper UTI: Warm and dry
f. Vital signs vary based on the degree of illness.
g. Depending on the area of infection, palpation of the abdomen usually reveals
tenderness over the pubis or pain in the flank.
5. Management
a. Mainly of supportive care of the ABCs
b. Patients should be allowed to ride in a position of comfort.
c. Be prepared for nausea or vomiting.
d. Analgesics will probably be needed in severe cases of pyelonephritis only.
i. Nonpharmacologic pain management with breathing and relaxation techniques is
sufficient for most patients.
e. Establish an IV line.
f. Administer a fluid bolus.
g. Transport the patient to the nearest appropriate facility for evaluation.
D. Urinary catheters
1. Many patients who are hospitalized for a urinary problem or other medical disease
receive catheterization.
a. Bladder catheterization introduces a latex or plastic tube through the urethra into the
bladder.
b. The tube is connected to a drainage bag, which is hung below the level of the
bladder.
2. Urine backflow is a concern when transporting a catheterized patient.
a. Do not lift the drainage bag while handling the patient.
E. Urinary incontinence
1. Loss of bladder control— the inability to control the release of urine from the bladder
2. Can occur in anyone, but may be a medical problem if it falls in one of two categories:
a. Urge incontinence
i. Sudden, intense urge to urinate with involuntary urine loss occurring within
seconds or minutes
ii. Urination is frequent.
iii. Many potential medical causes, including:
(a) Urinary tract infection
(b) Bladder irritants
(c) Bowel problems
(d) Parkinson disease
(e) Alzheimer disease
(f) Stroke
(g) Injury
(h) Nervous system damage associated with multiple sclerosis
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3. Overflow incontinence
a. Constant, continual slow flow of urine
i. May have medical causes, including:
(a) Damaged bladder
(b) Blocked urethra
(c) Nerve damage from diabetes
(d) Men with prostate gland problem
F. Renal calculi (kidney stones)
1. Pathophysiology
a. Extremely common
b. Originate in the renal pelvis
c. Form when an excess of insoluble salts or uric acid crystallizes in the urine
i. Typically the result of water intake that is insufficient to dissolve the salts
d. Stone consist of different chemicals, depending on the imbalance
e. Calcium stones
i. Most common
ii. More frequent in men than women
iii. May have a hereditary component
iv. Form in patients with hormonal or metabolic disorders
f. Struvite stones
i. More common in women than men
ii. May be associated with chronic UTI or frequent catheterization
g. Uric acid and cystine stones
i. Least common
ii. Uric acid stones tend to run in families, especially those with a history of gout.
iii. Cystine stones are associated with a condition that causes large amounts of amino
acids and proteins to be excreted in the urine.
2. Assessment findings
a. Patients who have kidney stones almost always experience pain.
i. Usually starts in the flank, but it may migrate forward toward the groin as the
stone passes.
ii. Vague discomfort that progress to intense pain within 30 to 60 minutes
iii. Many patients rate pain as an 11 on a scale of 1 to 10.
b. Patients may appear agitated and restless; others may guard the abdomen.
i. In either case, palpation of the abdomen is difficult.
c. Vital signs vary based on pain severity.
i. The greater the pain, the higher the BP and pulse.
d. Most kidney stones can be treated without surgery.
i. Usual protocol is to consume plenty of water (2 to 3 quarts per day) to help move
the stone
ii. Signs and symptoms of a UTI (including hematuria) without fever may indicate
that a kidney stone has become lodged in the lower ureter.
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iii. Extracorporeal lithotripsy uses shockwaves to pulverize stones into passable
fragments.
e. Direct endoscopy may also be used to remove stones.
f. If you suspect a kidney stone, obtain a patient and family history.
3. Management
a. Prehospital management centers on pain relief.
b. Ensure the ABCs.
c. Allow the patient to assume a position of comfort.
d. Administer analgesia if local protocols allow.
i. If analgesia is not allowed, contact medical control for pain relief options.
e. Pain relief is critical, but here are some instances where narcotics should not be
given.
i. Example: Possible GI condition
ii. Nitrous oxide is a viable alternative.
iii. Pain management may be accomplished by using breathing techniques similar to
those used by women during labor.
f. Establish an IV line, and administer fluids to accelerate the stone’s movement.
g. Transport the patient to an appropriate facility, with a lithotripsy unit if possible.
h. Provide supportive care en route.
G. Acute renal failure
1. Acute renal failure (ARF) is a sudden decrease in filtration through the glomeruli,
causing toxins to accumulate in the blood.
a. Loss of function may occur over several days
2. Accounts for between 2% and 7% of all hospitalizations in the United States
3. Critically ill patients with ARF have an overall mortality rate of 50% to 80%.
a. Disease is reversible if diagnosed and treated early
4. Oliguria is urine output of less than 500 mL/day.
5. Anuria is a complete cessation of urine production.
6. Patient may experience:
a. Generalized edema
b. Acid buildup
c. High levels of nitrogenous and metabolic wastes in the blood
7. ARF can lead to heart failure, hypertension, and metabolic acidosis if left untreated.
8. ARF is classified into three types, based on where it occurs:
a. Prerenal
b. Intrarenal
c. Postrenal
9. Pathophysiology
a. The toxic buildup of nitrogenous wastes and salts in the blood associated with ARF
causes:
i. Impaired mentation
ii. Hypotension
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iii. Fluid retention
iv. Tachycardia
v. Acid/base imbalances
vi. Increased PR and QT intervals associated with hyperkalemia
b. Prerenal ARF
i. Caused by hypoperfusion of the kidneys (not enough blood passing into the
glomeruli for the production of filtrate)
ii. Most common causes:
(a) Hypovolemia (low blood volume caused by hemorrhage or dehydration)
(b) Trauma
(c) Shock
(d) Sepsis
(e) Heart failure
iii. Often reversible if the underlying condition can be treated and perfusion restored
to the kidney
c. Intrarenal acute renal failure (IARF)
i. Involves damage to one of three areas of the kidney:
(a) Glomeruli capillaries and small blood vessels
(b) Cells of the kidney tubules
(c) Renal parenchyma (interstitial cells around the nephrons)
ii. Damage to the small vessels and glomeruli hinders blood flow to vital parts of
the nephrons.
(a) Damage is often caused by immune-mediated diseases.
iii. Tubule damage can be caused by prerenal ARF or toxins.
iv. Chronic inflammation of the interstitial cells surrounding the nephrons
(interstitial nephritis ) can also produce IARF.
(a) May be caused by medications, alcohol, or drugs of abuse
d. Postrenal ARF
i. Caused by obstruction of urine flow from the kidneys
ii. Source of obstruction is often a blockage of the urethra by an enlarged prostate
gland, renal calculi, or strictures
iii. Blockage raises pressure in the nephrons, eventually shutting them down
iv. Kidneys can no longer carry out their cleaning functions, and hyperkalemia
and/or metabolic acidosis develops
(a) Both conditions are life-threatening and can lead to fatal cardiac
dysrhythmias
10. Assessment findings
a. Findings may include:
i. Pale, cool, moist skin
ii. Edema of the extremities and face
iii. Tinnitus
iv. Excessive urinary output at night
v. Metallic taste in the mouth
vi. Decreased urinary output
vii. Neuropathies of the hands and feet
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viii. Anorexia
ix. Hypertension
x. Altered mental status
xi. Prolonged bleeding
xii. Flank pain
b. Look for any scars, ecchymosis, or distention while inspecting the abdomen.
i. If abdomen is distended, note if swelling is symmetric.
c. Palpate abdomen for pulsing masses
i. Could indicate an aortic aneurysm
d. If available, a hematocrit and urinalysis may be helpful in identifying the cause.
11. Management
a. Because metabolic changes caused by ARF can be life-threatening, the treatment
plan must support the ABCs.
b. Administer high-flow supplemental oxygen.
c. If necessary, provide ventilatory support with bag-mask ventilation.
d. Place the patient in the position dedicated for shock.
e. Consult medical control if you suspect ARF and are transporting a patient with
antibiotic or analgesic drips.
i. If medical control is unavailable, discontinue the medication and transport the
patient to the nearest appropriate facility.
f. Many patients with ARF have other comorbid diseases.
i. ARF patients need psychological support.
ii. Talk with your patient and inform him or her of what you are doing and what is
occurring.
iii. Be confident and calm in your responses to questions.
H. Chronic renal failure
1. Over 300,000 people in the United States are on long-term dialysis.
a. 11.5% of Americans age 20 and older have signs and symptoms of chronic kidney
disease.
2. Pathophysiology
a. Chronic renal failure (CRF) is the progressive and irreversible inadequate kidney
function caused by the permanent loss of nephrons.
i. Develops over months or years
ii. More than half of all cases are a consequence of systemic disease, but can also be
caused by congenital disorders or prolonged pyelonephritis.
b. Scarring occurs as the damaged nephrons cease to function.
i. As scarring progresses, tissue shrinks and wastes away, leading to a loss of
nephrons and renal mass.
ii. As waste products and fluid build up in the blood, kidney function diminishes.
c. Uremia and azotemia develop.
i. Uremia: An increased concentration of urea and other waste products in the
blood
ii. Azotemia: An increased level of nitrogenous wastes in the blood
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d. Systematic complications develop:
i. Hypertension
ii. Congestive heart failure
iii. Anemia
iv. Electrolyte imbalances
3. Assessment findings
a. Patients with CRF have an altered level of consciousness and may also present with:
i. Lethargy
ii. Nausea
iii. Headaches
iv. Cramps
v. Signs of anemia
vi. Weakness
vii. Vomiting
viii. Anorexia
ix. Increased thirst
x. Pruritus
xi. Hypertension
xii. Rusty-brown urine
xiii. In late stages, seizures and coma are possible.
xiv. Pale, cool, moist skin that may appear jaundiced
xv. Uremic frost, especially on the face
xvi. Skin that appears bruised
xvii. Muscle twitching
xviii. Edema in the extremities and face
b. Patients with CRF are hypotensive and tachycardic.
c. As hyperkalemia develops, the heart’s electrical conduction will decrease.
i. The ECG monitor will show lengthened PR and QT intervals.
ii. As the hyperkalemia progresses, these may evolve into an idioventricular rhythm.
d. Pericarditis and pulmonary edema are also common.
i. Should be evaluated in auscultation of the chest
4. Management
a. Similar to patients with ARF
i. Support the ABCs.
ii. Administer high-flow supplemental oxygen.
iii. If necessary, provide ventilator support with bag-mask ventilation.
iv. Place the patient in the position dictated for shock.
v. Administer an IV bolus if the patient shows signs of shock, if there are no signs
of pulmonary edema.
vi. Focus on regulating fluid imbalances and cardiovascular functions.
b. Patients with CRF will ultimately require renal dialysis.
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i.
After life threats have been addressed, transport the patient to the appropriate
facility for treatment.
c. Due to electrolyte imbalances associated with CRF, be conservative with treatment
plans.
d. Transport the patient in a calm manner to a medical facility.
i. Talk quietly and calmly with the patient.
ii. Monitor orientation frequently and record any changes in patients with altered
mental status.
I. End-stage renal disease
1. Pathophysiology
a. Acute or chronic renal failure will progress to end-stage renal disease (ESRD) if left
untreated.
b. Kidneys have lost all ability to function, and toxic waste materials build up in the
patient's blood
c. Fatal unless treated by dialysis or renal transplant
2. Assessment findings
a. Initial signs include:
i. Confusion
ii. Shortness of breath
iii. Peripheral edema
iv. Bruising
v. Chest pain
vi. Bone pain
b. As toxins accumulate, the following may occur:
i. Pruritus
ii. Nausea and vomiting
iii. Muscle twitching and tremors
iv. Hallucinations
v. Lethargy
vi. Headaches
vii. Cramps
viii. Signs of anemia
ix. Pale, cool, and moist skin that may appear jaundiced or bruised
x. Uremic frost around the face
xi. Edema of the extremities and face
xii. Hypotension
xiii. Tachycardia
xiv. Lengthening PR and QT intervals on the ECG monitor
c. As hyperkalemia increases, dysrhythmias may become an idioventricular rhythm.
d. Pericarditis and pulmonary edema are also common.
i. Should be evaluated during auscultation of the chest.
e. In the late stages, seizures and coma are possible and the patient may ultimately die.
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3. Management
a. Treatment for patient with ESRD is limited to renal dialysis or kidney transplant.
b. Provide supportive care.
c. Administer high-flow supplemental oxygen, and be ready to provide ventilator
support with bag-mask ventilation if the patient shows signs of respiratory distress.
d. Place the patient in the shock position.
e. Regulate fluid imbalances, electrolyte abnormalities, and cardiovascular function
under the direction of medical control.
J. Renal dialysis
1. Renal dialysis and problems associated with it may require prehospital care.
2. Renal dialysis: Technique for filtering the blood of its toxic wastes, removing excess
fluid, and restoring the normal balance of electrolytes
3. There are two types of dialysis:
a. Peritoneal dialysis: Large amounts of specially formulated dialysis fluid are infused
into, and then drained from, the abdominal cavity.
i. Fluid remains in the cavity for 1 to 2 hours.
ii. Effective, but carries a high risk of peritonitis.
(a) Aseptic technique is essential.
iii. Can be performed in the home
b. Hemodialysis: The patient's blood circulates through a dialysis machine that
functions much like normal kidneys.
i. Most patients undergoing chronic hemodialysis have some type of shunt.
(a) Patient is connected to machine through a shunt.
(b) Blood flows from the body into the dialysis machine and back to the body
c. Types of shunts/devices
i. Scribner shunt: Two tubes, one fastened in the radial artery, the other in the
cephalic vein, that are joined near the wrist by a Teflon connector
ii. Thomas shunt: Similar to Scribner shunt, but usually placed on the groin
iii. HemaSite: Small, button-shaped device that has a rubber septum that can be
punctured with dialysis needles during treatment; usually placed in the upper arm
or proximal anterior thigh
iv. Internal shunt (arteriovenous [AV] fistula): An artificial connection between a
vein and an artery, usually in the forearm or upper arm
d. The internal shunt may be used for IV access only in a life-threatening emergency.
i. They should not be used in routine blood draws.
e. You will mostly likely only encounter dialysis machines if your service transports
patients to and from dialysis centers.
f. Patients requiring dialysis usually undergo the process every 2 or 3 days for 3 to 5
hours.
i. Dialysis is done in the hospital, community dialysis facility, or at home.
ii. Patients who have home dialysis units have extensive training; if a problem with
the machine occurs, ask what the patient has done prior to your arrival—he or
she may know a lot more about the machine than you do.
g. Problems related to dialysis may result from:
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i. Accidental disconnection from the machine
ii. Malfunction of the machine
iii. Rapid shifts in fluids and electrolytes that produce hypotension
iv. Potassium imbalances
v. Disequilibrium syndrome
h. Patients who miss dialysis treatments often present with signs of electrolyte
imbalance.
i. Weakness of muscles
ii. Cramping
iii. Pulmonary edema
iv. Uremic frost
i. Other general complications of dialysis include:
i. Muscle cramps
ii. Nausea and vomiting
iii. Infections at the IV site
4. Hypotension and shock
a. A sudden drop in blood pressure is not uncommon during or immediately following a
dialysis treatment.
i. Can lead to cardiac arrest if not properly detected and treated
b. Patient may feel light-headed or become confused.
i. Often yawns more than usual
c. Dialysis alters the blood's chemistry.
i. May experience electrolyte imbalance
ii. Monitor the patient for cardiac dysrhythmias.
d. Shock secondary to bleeding is also possible from a number of causes.
i. Attempt to tighten any leaking shunts.
ii. For any disconnected shunts, clamp the cannula and disconnect the patient from
the machine.
e. In a suicide attempt, the patient may open up the cannula.
i. These patients have often endured numerous medical interventions to simply
survive.
ii. Immediately clamp off the cannula, and apply direct pressure.
5. Potassium imbalance
a. One consequence of renal impairment is the inability to excrete ingested potassium
causing a potassium imbalance.
b. CRF patients are prone to hyperkalemia, especially with increased potassium intake
or catabolic stress.
c. Patient may present with:
i. Profound muscular weakness
ii. Peaked T waves on the ECG
iii. A prolonged QRS complex on the ECG
iv. Sometimes the P waves may disappear on the ECG
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v. Complete heart block and asystole may occur.
d. If the signs of hyperkalemia are present, treatment is urgently required.
i. Must be undertaken in the field if you are any distance from the hospital
e. Hyperkalemia may occur from overaggressive dialysis.
i. Potassium level is most likely to fall during or immediately after a dialysis cycle.
ii. Patient may be hypotensive.
iii. Cardiac dysrhythmia (usually bradycardia) is almost always present.
iv. Treat the dysrhythmia if it is hemodynamically significant.
6. Disequilibrium syndrome
a. As a consequence of dialysis, water initially shifts from the bloodstream into the
CSF, which mildly increases intracranial pressure.
i. As a result, the patient experiences disequilibrium syndrome.
b. Characterized by nausea, vomiting, headache, and confusion
c. Symptoms resolve on their own after a few hours, when the fluid will reequilibrate
between the blood and CSF.
7. Air embolism
a. Results when air enters the system (in this case, due to loose fittings and connections
in the dialysis system)
b. Symptoms include:
i. Sudden dyspnea
ii. Hypotension
iii. Cyanosis
c. If you suspect an air embolism:
i. Disconnect the patient from the dialysis machine.
ii. Place him or her in the left lateral recumbent position with about 10° of headdown tilt.
iii. Transport immediately.
K. Male genital tract conditions
1. Epididymitis and orchitis
a. Epididymitis
i. Complication of male UTI
ii. Infection that causes inflammation of the epididymis along the posterior border
of the testis
b. Orchitis
i. When one or both testes become infected
ii. Infection causes one or both testes to become enlarged and tender.
iii. Results in pain and swelling in the scrotum
iv. Swelling may occur in the groin on the affected side.
v. Pain may increase during bowel movements.
vi. Patient will have a fever and urine with a foul odor.
c. Prehospital management is supportive.
i. Consider administering analgesics.
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2. Fournier gangrene
a. Results from bacteria entering a laceration to the scrotum or perineum
b. Causes infection and subsequent necrosis of the subcutaneal tissue and muscle in the
scrotum
c. The scrotum will be spongy to the touch.
d. The scrotal tissues will become gray-black.
e. Drainage will occur from the wound site.
f. Fever and scrotal pain will be present.
g. A true emergency—prompt transport to the hospital is required.
h. If left untreated, the infection can enter the bloodstream, causing sepsis.
i. Assess and treat patients for shock.
3. Priapism
a. A painful, tender, persistent erection
b. Can result from:
i. Diseases such as leukemia and tumors
ii. Blunt perineal trauma
iii. Spinal cord injury
iv. Abuse of cocaine
c. Maintain the patient’s privacy.
d. Do not make assumptions about the condition’s cause.
e. Treat the patient with respect.
f. Administer analgesics for pain.
g. Ensure proper immobilization if spinal cord injury is suspected.
4. Phimosis and paraphimosis
a. Phimosis
i. Inability to retract the distal foreskin over the glans penis
ii. Usually associated with poor hygiene and scarring of the foreskin by bacterial
infection
iii. Apply cold compress, and transport to a medical facility.
b. Paraphimosis
i. Results when the foreskin is retracted over the glans penis and becomes
entrapped
ii. Usually occurs in elderly men
iii. Can occur after piercing of the glans penis
iv. True emergency—failure to relieve the paraphimosis can result in necrosis of the
glans
5. Benign prostate hypertrophy (BPH)
a. Age-related nonmalignant (noncancerous) enlargement of the prostate gland
b. Occurs in about 50% of men older than 60
c. May be asymptomatic, or may lead to:
i. Difficulty starting urine flow
ii. A slow, weak urine flow once started
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iii. Incomplete emptying of the bladder
iv. Increased urination at night
v. Urinary retention
6. Testicular masses
a. Rarely require prehospital treatment
b. May be painful or painless
i. If painful, may radiate up the spermatic cord or be localized to a specific scrotal
point
c. Most are benign cystic masses or a varicocele (a mass of dilated veins posterior to the
testicle).
d. Testicular cancer usually presents as a painless solid lump on the testicle.
i. Reported cases of testicular cancer in the United States have doubled since 1975.
7. Testicular torsion
a. Twisting of the testicle on the spermatic cord from which it is suspended
b. Associated with sudden-onset scrotal pain and swelling
c. Medical emergency if the twisting of the vessels reduces blood flow to the testis
d. Usually unilateral, occurring in only one testis at a time
e. May occur with or without blunt trauma, a testicular lump, or blood in the semen
f. Patients should be carefully and promptly transported to a medical facility.
g. Allow patient to assume a position of comfort.
h. Provide analgesics for pain control if necessary.
X. Summary
A. Chronic kidney disease is the most common renal disorder. Kidney stones and
urinary tract infections also affect many people.
B. The genitourinary system includes the kidneys, urinary bladder, ureters,
urethra, male and female reproductive organs, and specific structures within the
kidneys.
C. 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.
D. Urine forms in the nephrons. Nephrons are composed of the glomerulus, the
glomerular capsule, the proximal convoluted tubule, the loop of Henle, and the
distal convoluted tubule.
E. In the glomerular capsule, filtrate from the blood passes through a membrane. It
then passes through the rest of the nephron converted into urine then passes
through the proximal convoluted tubule and the loop of Henle to be further
concentrated.
F. 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 composition.
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G. The juxtaglomerular apparatus in the kidneys releases renin.
H. Diuretics are chemicals that increase urinary output.
I. As urine collects in the bladder, the micturition reflex causes the bladder to
contract, stimulating the urge to void.
J. The female urethra is shorter than the male urethra and more prone to urinary
tract infections.
K. During the physical examination, the four-quadrant system and abdominal
region mapping should be used, cardiac monitoring should be performed, and
urologic patients should not be given anything orally.
L. Visceral pain and referred pain are two types of pain. Visceral pain is the type
most often associated with genitourinary problems.
M. The OPQRST mnemonic is used during the primary and secondary assessments.
N. Pain is managed with patient positioning, analgesics and fluids as indicated, and
supportive care.
O. Symptoms of a urinary tract infection include painful urination, frequent urges
to urinate, difficulty urinating, possibly referred pain in the shoulder or neck,
and foul-smelling, cloudy urine. Management of patients with UTIs consists
mainly of supportive care of the ABCs, allowing the patient to remain in a
position of comfort, administering IV fluid, and possibly administering
analgesics.
P. Catheterization of the bladder allows a continuous outflow of urine and provides
a means of measuring urine output in hemodynamically unstable patients. To
avoid backflow of urine, the drainage bag should not be lifted above the level of
the patient’s bladder.
Q. Kidney stones result when an excess of insoluble salts or uric acid crystallizes in
the urine. Symptoms include severe flank pain that may migrate to the groin.
R. Acute renal failure is a sudden decrease in filtration through the glomeruli,
resulting in a release of toxins into the blood. The three types of acute renal
failure are prerenal, intrarenal, and postrenal. Signs and symptoms range from
hypotension, tachycardia, dizziness, and thirst, to pain, oliguria, distended
bladder, hematuria, and peripheral edema.
S. Chronic renal failure is progressive and irreversible inadequate kidney function,
which causes damage to the nephrons, causing them to lose their functionality,
leading to a buildup of wastes and fluid in the blood. Symptoms can include an
altered level of consciousness, lethargy, nausea, headaches, cramps, anemia,
bruised skin, edema in the extremities and face, hypotension, tachycardia, and
possibly seizures or coma.
T. Patients with acute or chronic renal failure require support of the ABCs,
administration of medications, and calm transport with psychological support.
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U. If left untreated, acute or chronic renal failure will progress to end-stage renal
disease. Prehospital care is supportive, including treating for shock and, under
medical direction, regulating fluid imbalances, electrolyte abnormalities, and
cardiovascular function.
V. Renal dialysis is a procedure for removing toxic wastes and excess fluids from
the blood, usually through a shunt, which connects the patient to the dialysis
machine. Such patients are vulnerable to problems such as hypotension,
potassium imbalance, disequilibrium syndrome, and air embolism.
W. Dialysis patients should be monitored for signs of hyperkalemia, including
cardiac dysrhythmias, shock secondary to bleeding, and peaked T waves on the
ECG.
X. Leaking shunts should be tightened. If it has become disconnected at the vein,
clamp the cannula and disconnect the patient from the machine.
Y. 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.
Post-Lecture
This section contains various student-centered end-of-chapter activities designed as
enhancements to the instructor’s presentation. As time permits, these activities may be presented
in class. They are also designed to be used as homework activities.
Assessment in Action
This activity is designed to assist the student in gaining a further understanding of issues
surrounding the provision of prehospital care. The activity incorporates both critical thinking and
application of paramedic knowledge.
Instructor Directions
1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the
end of Chapter 21.
2. Direct students to read and individually answer the quiz questions at the end of the
scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class
review and dialogue of the answers, allowing students to correct responses as may be
needed. Use the quiz question answers noted below to assist in building this review.
Allow approximately 10 minutes for this part of the activity.
3. You may wish to ask students to complete the activity on their own and turn in their
answers on a separate piece of paper.
Answers to Assessment in Action Questions
1. Answer: D.
Scene safety
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Rationale: When friends and family are hurt or sick, it is easy to get caught up in the
moment. However, you need to remember safety first and treat this scene as you would
any other.
2. Answer: A.
Sudden, severe pain
Rationale: When torsion occurs, patients experience a sudden, severe onset of pain in
one or both testicles that can also be accompanied by swelling, testicular deformity,
nausea and vomiting, and lightheadedness.
3. Answer: B.
Testicular torsion
Rationale: Whereas all of these injuries are serious, testicular torsion involves disruption
of the blood supply to the testes, which requires urgent transport because it may require
immediate surgery.
4. Answer: B.
Surgical intervention
Rationale: If a physician is unable manually correct or detorse the testicle, this condition
will require immediate surgery to restore blood flow to the testicle.
5. Answer: D.
Winter
Rationale: Testicular torsion oftentimes occurs in winter, and is sometimes referred to as
“winter syndrome.” When the scrotum is warm and then suddenly exposed to cold
temperatures, the scrotum will contract. If the spermatic cord was twisted while warm,
the sudden scrotal contraction can result in testicular torsion.
Additional Questions
6. Rationale: Beyond the obvious concern about the busy street, you may have additional
issues that can accompany this type of scene. Although you were not drinking, your
friends may have been. Because of the competitive nature of the game, there may be
heated emotions that can be exacerbated from drinking.
7. Rationale: Depending on your locale, there may or may not be a legal duty to act. In
addition to the duty to act, it is extremely important to know what you are allowed to do
when you are off-duty. Some states only allow providers, including paramedics, to only
perform first aid skills when off-duty. Always follow your local and state, district, or
commonwealth rules and regulations.
8. Rationale: In addition to extreme pain, genital injuries can create extreme anxiety for
your patient. Keep this in mind when caring for your patient.
Assignments
A. Review all materials from this lesson and be prepared for a lesson quiz to be
administered (date to be determined by instructor).
B. Read Chapter 22, Gynecologic Emergencies, for the next class session.
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Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 21: Genitourinary and Renal Emergencies
Unit Assessment Keyed for Instructors
1. What are the two main functions of the urinary system? Identify at least one task the
kidneys perform to support these functions.
Answer: The urinary system acts as the body’s “accounting firm” (balances the levels of
electrolytes, water, acids, and bases in the blood) and serves as the blood’s “sewage
treatment plant” (removes metabolic wastes, drug metabolites, and excess fluids).
The kidneys filter approximatly 200 L of bloody daily, produce hormones that generate
new red blood cells, and help the liver convert glycogen to glucose.
p 1161
2. List the structural and functional units of the kidney responsible for urine formation.
Answer: Glomerulus; glomerular (Bowman’s) capsule; proximal convoluted tubule
(PCT); loop of Henle; and distal convoluted tubule (DCT)
p 1162
3. What is the micturition reflex?
Answer: The micturition reflex is a spinal reflex that causes the bladder’s smooth muscle
to contract and exert pressure on the internal urinary sphincter producing an urge to void.
p 1164
4. Why is it important to reassess patients with a renal or urologic emergency?
Answer: Patients with urologic emergencies, especially those with signs and symptoms
of renal failure, can experience electrolyte imbalances caused by a buildup of toxins. This
can result in rapid deterioration in the functioning of the body’s organs, particularly the
heart. Trends in vital signs and level of consciousness can be indicators of disease
progression.
pp 1166-1167
5. Identify six conditions that may cause urinary retention.
Answer: Renal calculi; acute renal failure (ARF); benign prostate hypertrophy (BPH);
urethral obstructions, urinary tract infections (UTIs); and nerve damage
p 1167
6. Discuss the pathophysiology of urinary tract infections (UTIs). Include how they occur,
the patient populaton that is most commonly infected, the relationship between upper and
lower UTIs, and complications they may result from a UTI.
Answer: Urinary tract infections usually begin in the lower urinary tract (urethra and
bladder) when normal flora (bacteria that naturally populate the skin) enter the urethra
and grow. They are more common in women due to the relatively short urethra and its
close proximity to the vagina and rectum. UTIs may advance to the upper urinary tract
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Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 21: Genitourinary and Renal Emergencies
when lower UTIs go untreated. Upper UTIs can progress to pyelonephritis (inflammation
of the kidney linings) and abscesses. These conditions can reduce kidney function and,
without intervention, UTIs may lead to sepsis.
p 1169
7. Identify signs and symptoms associated with toxic build-up of nitrogenous wastes and
salts in the acute renal failure patient.
Answer: Impaired mentation; hypotension; fluid retention/edema; tachycardia; acid-base
imbalance; and increased PR and QT intervals associated with hyperkalemia
p 1170
8. Identify four systematic complications of chronic renal failure.
Answer: Hypertension; congestive heart failure; anemia; and electrolyte imbalances
p 1172
9. Describe the two types of renal dialysis.
Answer: In peritoneal dialysis, large amounts of specially formulated dialysis fluid are
infused into (and then drained from) the abdominal cavity. This fluid remains in the
cavity for 1 to 2 hours, allowing equilibrium to occur as waste diffuses across the
peritoneal membrane and into the fluid.
In hemodialysis, the patient’s blood circulates through a dialysis machine that functions
in much the same way as the normal kidneys. Patients are connected to the dialysis
machine through a shunt, which allows blood to flow from the body into the dialysis
machine and back to the body.
p 1174
10. Identify at least four male genital tract conditions that may be encountered in the
prehospital setting. Define each disorder, including either its signs and symptoms (at least
two per condition) or an explination of why it occurs.
Answer: Any four of the following:
Epididymitis: Infection that causes inflammation of the epididymis along the posterior
border of the testis; possible complication of UTI. Signs/sumptoms: Enlarged and tender
testes; pain and swelling in the scrotum; fever; foul-smelling urine; swelling may also
occur in the groin on the affected side; pain may increase during bowel movements
Orchitis: One or both testes become infected. Signs/symptoms: Same as epididymitis
Fournier gangrene: Bacteria enter the scrotum or perineum because of a laceration;
infection causes necrosis of the subcutaneal tissue and muscle in the scrotum.
Signs/symptoms: Scrotum is spongy to the touch; gray-black scrotal tissues; drainage
from wound site; fever; scrotal pain; sepsis may occur in untreated cases
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Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 21: Genitourinary and Renal Emergencies
Priapism: Painful, tender, persistent erection, can result from diseases such as leukemia
and tumors, from blunt perineal trauma, spinal cord injury, abuse of cocaine, or erectile
dysfunction drugs
Phimosis: Inability to retract the distal foreskin over the glans penis; usually associated
with poor hygiene and scarring of the foreskin by bacterial infection
Paraphimosis: Results when the foreskin is retracted over the glans penis and becomes
entrapped; the glans swells even further, making it even harder to slide the foreskin back
into the normal position; usually occurs in elderly men, but can occur after piercings of
the glans penis
Benign prostate hypertrophy (BPH): Age-related nonmalignant (noncancerous)
enlargement of the prostate gland; occurs in about half of men over age 60.
Signs/symptoms: Difficulty starting urine flow, a slow weak urine flow once started,
incomplete emptying of the bladder, increased urination at night, and urinary retention;
some patients are asymptomatic
Testicular masses: May be benign or cancerous; most are benign cystic masses or a
varicocele (painless mass of dilated veins posterior to the testicle); testicular cancer
usually presents as a painless solid lump on the testicle, incidence is on the rise.
Signs/symptoms: May be painful or painless, and if painful, the pain may radiate up the
spermatic cord or be localized to a specific scrotal point
Testicular torsion: Twisting of the testicle on the spermatic cord, from which it is
suspended; usually unilateral, occuring in one testis at a time; may occur with or without
blunt trauma. Signs/symptoms: Sudden onset scrotal pain and swelling; a testicular lump
and/or blood in the semen may or may not be present.
pp 1176–1177
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Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 21: Genitourinary and Renal Emergencies
Unit Assessment
1. What are the two main functions of the urinary system? Identify at least one task the
kidneys perform to support these functions.
2. List the structural and functional units of the kidney responsible for urine formation.
3. What is the micturition reflex?
4. Why is it important to reassess patients with a renal or urologic emergency?
5. Identify six conditions that may cause urinary retention.
6. Discuss the pathophysiology of urinary tract infections (UTIs). Include how they occur,
the patient populaton that is most commonly infected, the relationship between upper and
lower UTIs, and complications they may result from a UTI.
7. Identify signs and symptoms associated with toxic build-up of nitrogenous wastes and
salts in the acute renal failure patient.
8. Identify four systematic complications of chronic renal failure.
9. Describe the two types of renal dialysis.
10. Identify at least four male genital tract conditions that may be encountered in the
prehospital setting. Define each disorder, including either its signs and symptoms (at least
two per condition) or an explination of why it occurs.
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