Gastrointestinal, Genitourinary, Gynecology, and Obstetrical Emergencies Study Guide for the CEN

Genitourinary

The genitourinary system encompasses the entire urinary system (kidneys, ureters, bladder, and urethra) and the patient’s genitals. Patients can experience a variety of infections and traumatic conditions that negatively impact the genitourinary system. Here’s a quick rundown of the most common ones that you may encounter in your nursing practice.

Genitourinary Infections

Urinary tract infections can occur among patients of all ages, but are most common in women and elderly patients. Prompt identification and treatment is key. If left untreated, the infection can progress to a kidney infection and eventually life-threatening urosepsis.

Assessment

Symptoms include urinary urgency, dysuria, cloudy urine, sudden incontinence, and foul-smelling urine. If the UTI progresses into a kidney infection, the patient will experience flank pain on the affected side and a possible fever. Severe kidney infections can lead to urosepsis, and the patient will display signs of septic shock. Elderly patients can suddenly experience altered mental status. A urinalysis and urine culture should be performed and antibiotics will be ordered based on the results of the culture. A kidney ultrasound or CT scan will also be obtained if the patient’s symptoms suggest a kidney infection.

Treatment

The primary treatment for a urinary tract infection or kidney infection is antibiotics. The specific antibiotic will be determined by the specific bacteria that grows in the urine culture, while the severity of the infection will determine whether the patient can take oral antibiotics or needs to be admitted to the hospital for intravenous antibiotics. Phenazopyridine can offer temporary relief of the urinary symptoms until the antibiotics take effect. Lifestyle changes such as increasing fluid intake and avoiding bladder irritants such as caffeine, alcohol, carbonated beverages, and spicy food can also help to decrease symptoms.

Priapism

Priapism is a prolonged penile erection that lasts more than four hours. The prolonged erection runs the risk of impeding blood flow to the penis and eventually causing tissue damage. It usually occurs without sexual arousal and can occur spontaneously or as a result of certain antidepressant or erectile dysfunction medication.

Assessment

The symptom of priapism is the prolonged erection and penile pain. Priapism can be either low-flow or high-flow. The condition is diagnosed through a physical exam of the genital region and a health history obtained from the patient. The provider should ask how long the condition has been present and under what circumstances it occurred.

Treatment

Fast treatment is key to preventing permanent erectile dysfunction. The key is to allow the erection to subside. Ice packs and pressure can be applied to the perineum in the short term. Vasoconstrictor medications such as phenylephrine can help blood to drain back out of the penis and stop the erection. If those measures fail, other options are to aspirate blood from the penis after numbing it, an intracavernous injection of an alpha-agonist, surgical ligation (for high-flow priapism) or a surgical shunt (low-flow priapism).

Renal Calculi

Renal calculi, also known as kidney stones, are stones that form in the kidneys. They can lodge in a ureter and result in fluid backing up into the kidney, or hydronephrosis. The obstruction of fluid can cause acute kidney injury and eventual permanent kidney damage. Obstructing kidney stones also increase the risk for kidney infection and possible urosepsis.

Assessment

Symptoms include sudden onset severe flank pain that can radiate to the lower abdomen and groin. The pain is usually very sharp and can come in waves. The patient can also experience pain while urinating and may see blood in their urine. Nausea and vomiting can also be present. If the patient has an infection, they may also have a fever and chills. Renal calculi are diagnosed using a CT scan. A CBC and BMP will also be ordered to evaluate kidney function and check for any signs of infection. A urinalysis will be obtained, and the provider may ask the patient to strain their urine to catch any stones that pass.

Treatment

Some patients are able to pass smaller stones without any intervention other than analgesics and anti-nausea medications. If they cannot pass stones, the provider may try extracorporeal shockwave therapy to break up the stones into a smaller size that the patient can pass. If they cannot, the next step is a surgical procedure called a ureteroscopy, Holmium laser lithotripsy to break up the stone internally, and stone basketing to retrieve the stone. A ureteral stent is commonly placed for several weeks to keep the ureter open and allow swelling/irritation to decrease. If the stone can’t pass, a percutaneous nephrolithotomy will be used to remove the stone through a small incision in the back, and a nephrostomy tube may be used to temporarily drain urine from the kidney. In some cases, stones will be analyzed to determine the composition. Patients with a history of kidney stones should drink lots of fluid to stay hydrated and, depending on the composition of their stone, make dietary changes such as avoiding foods that contain large amounts of calcium.

Testicular Torsion

Testicular torsion is an emergency situation in which the spermatic cord becomes twisted within or below the inguinal canal, constricting blood flow to the testicle. It occurs most commonly at puberty but can occur at any age. It is most commonly preceded by significant physical exertion, but can also happen during rest or sleep.

Assessment

The patient will have sudden onset severe testicular pain and edema. In children, the pain sometimes starts as diffuse abdominal discomfort initially. The diagnosis is made during a physical exam performed by a healthcare provider, which will reveal a firm scrotal mass. If the patient’s physical exam is unclear, a duplex Doppler ultrasound will be used to confirm the diagnosis.

Treatment

There are two treatment methods for testicular torsion: manual detorsion and emergency surgical repair. In manual detorsion, the left testicle will be rotated clockwise and the right will be rotated counterclockwise. If pain increases, the provider should try rotating the testicle the other way. If manual detorsion fails, the patient will need to have an emergency surgical repair called an orchiopexy to untwist the spermatic cord, and the patient’s testicle will be sutured to their scrotum to decrease the chances of a repeated torsion.

Genitourinary Trauma

Genitourinary trauma is any traumatic injury that affects the patient’s urinary tract or genitals. It is a rare injury that usually happens in conjunction with an injury to the pelvis. Approximately 65 percent of the trauma is blunt and 35 percent is penetrating. Young male patients most commonly experience this type of injury.

Assessment

The symptoms will vary depending on the specific type of trauma that the patient has experienced. They will have acute onset pain in their flanks, lower abdomen, or pelvic region. It is likely that they will experience hematuria. If the patient has experienced a bladder perforation, they will experience pain and swelling in their lower abdomen along with hematuria. Eventually they become febrile if they develop an infection. The best diagnostic tools will be a Focused Exam with Sonography for Trauma (FAST) and a CT scan if the patient is stable enough to determine the exact nature of the injury.

Treatment

The treatment varies depending on the specific type of injury. Some more minor injuries will heal with rest and time, but others will require surgical repair. If the patient has experienced an injury to the pelvis and/or bladder, they will likely have a Foley catheter inserted to temporarily drain their bladder and limit pelvic movement. Injuries to this region may require surgical collaboration between different specialities such as a urologist and an orthopedic surgeon.

Urinary Retention

Urinary retention is the inability to completely empty the bladder. The retained urine increases the risk of urinary tract infection and bladder distension that can cause permanent damage to bladder nerves. Common causes of urinary retention include medications, nerve damage such as a spinal cord injury, surgery, Foley catheter use, benign prostate hyperplasia, and spinal anesthesia.

Assessment

The patient will likely feel an urge to urinate, have a sensation that they are not emptying their bladder completely when they void, and may experience pressure and discomfort in their lower abdomen. Retaining urine makes them more prone to UTIs as well. The key diagnostic test is a voiding trial. The patient will urinate and then have a bladder scan/ultrasound performed immediately after the void to determine how much urine remains in their bladder. A CT scan will help to determine if there are any underlying structural abnormalities that are contributing to the urinary retention.

Treatment

In the short term, the most urgent treatment is to drain the bladder with a straight catheterization. There are several possible long-term interventions to treat urinary retention. Medications include oxybutynin, tolterodine, solifenacin, darifenacin, trospium, and fesoterodine. Tamsulosin and finasteride can treat an enlarged prostate, which can cause urinary retention in some older men. If medication is ineffective, the next steps would be intermittent catheterization performed by the patient when they need to urinate or placement of a suprapublic catheter. Pelvic floor therapy can also help to retrain the muscles in the pelvic floor and improve voiding dysfunction.

Gynecology

Gynecology concerns the female reproductive organs and several disorders can affect them. These disorders range from dysfunctional uterine bleeding to ovarian torsion to infections. Women of all ages can be affected.

Dysfunctional Uterine Bleeding

Dysfunctional uterine bleeding is vaginal bleeding that is heavier than usual, lasts an unusually long time, is unusually frequent, irregular or occurs outside of a patient’s regular menstrual cycle. It is particularly likely to occur during times of hormonal transition, such as perimenopause, the postpartum period, or at the beginning of menstruation.

Assessment

The primary symptom is vaginal bleeding. The provider should ask the patient about the bleeding that they’ve experienced: how heavy, how long, if they have recently given birth, whether they’ve been febrile, and whether they have seen any large clots. The patient should also have a CBC drawn. A vaginal ultrasound can determine whether the patient has any large uterine fibroids that are contributing to the bleeding.

Treatment

There are several methods of controlling vaginal bleeding. Hormonal birth control can help to regulate hormonal fluctuation. A uterine ablation is a minor surgical procedure that ablates the endometrium to reduce or stop bleeding. A myomectomy is a surgical procedure used to remove uterine fibroids but retains the integrity of the uterus. The treatment of last resort is a hysterectomy, particularly if the patient no longer desires to have children.

Gynecological Infections

The most common types of gynecological infections would be vaginal infections and uterine infections. These infections can be sexually transmitted diseases or can be viral, bacterial, fungal, or parasitical.

Assessment

The patient may experience increased or foul-smelling vaginal discharge, itching/vaginal discomfort, pain during sex, lesions on the vulva, and painful urination. The provider will perform a pelvic examination and take swabs to determine what type of infection the patient is experiencing.

Treatment

The treatment depends on the specific type of infection that the patient is experiencing. For instance, a patient with a yeast infection will likely take fluconazole or terconazole, which is available in a cream, ointment, tablet, or vaginal suppository, for 3-7 days. Bacterial infections will call for antibiotics, as do most sexually transmitted infections.

Ovarian Disorders

There are several disorders that can affect the ovaries, including ovarian cysts and ovarian torsion. Cysts are a benign mass that grows in the ovary and increases the risk for ovarian torsion (twisting of the ovary on the fallopian tube) because it unbalances the entire structure. If the problems are not identified and treated promptly, they can be life-threatening due to possible hemorrhage.

Assessment

Symptoms include sudden onset severe abdominal pain, usually localized to the side of the ovary that is experiencing the problem. Abdominal swelling may be present as well. If the patient has an ovarian cyst, a pelvic examination will reveal a cystic mass. The cyst usually remains asymptomatic unless it ruptures. The patient will also experience nausea and vomiting. The most common diagnostic tests will be an abdominal or vaginal ultrasound. A CT scan will also be ordered if the results of the ultrasound are inconclusive.

Treatment

The intervention depends on the specific disorder that the patient is experiencing. If the cyst is smaller, the patient may require only analgesics and pain medications. A larger cyst can cause internal hemorrhage that requires intravenous fluid replacement or even a blood transfusion. Cysts are sometimes removed in a procedure called a cystectomy. Ovarian torsion requires immediate surgery to prevent permanent damage to the ovary. Cystectomies are often performed at the same time if a cyst is present. Ovarian damage can result in decreased fertility and even necessitate an oophorectomy (surgical removal of an ovary).

Sexual Assault and Battery

Sexual assault and battery encompasses any forcible sexual encounter that the patient has experienced. Remember that penetration doesn’t have to have occurred for the patient to have experienced sexual assault. Patients of all genders can experience sexual assault, not just women. Their psychological state matters just as much as their physical state.

Assessment

The patient may have rectal or vaginal pain or abrasions/ecchymosis/lacerations anywhere on their body, as well as psychological trauma. They may be withdrawn, tearful, or stoic. After obtaining the patient’s permission, conduct a head-to-toe physical exam. A specific process (such as having the patient undress and stand on paper) will need to be used to ensure that any physical evidence isn’t lost. The patient may be more comfortable with a nurse of the same gender; many emergency departments will have a nurse who is certified as a Sexual Assault Nurse Examiner and specially trained to care for patients who have experienced a sexual assault.

Treatment

The treatment completely depends on the physical injuries the patient has sustained. Surgical repair is rarely required, although suturing in the ER may be required to close any lacerations. The patient should receive prophylactic medication to prevent the transmission of sexually transmitted infections such as chlamydia and gonorrhea. The CDC currently recommends ceftriaxone in a 500 mg dosage administered intramuscularly. The patient should receive a referral to a counselor experienced in caring for victims of sexual assault and ideally speak to a social worker while still in the emergency department. Remember that nurses are mandated reporters and are required to report any instances of suspected abuse or assault. A police officer may come and interview the victim in the ER as well if they are willing to speak to the police.

Gynecological Trauma

Gynecological trauma describes any injury to the female genital region. It can be accidental or a result of abuse. Common causes include blunt force trauma, child birth, shaving, sexual assault, or penetrating injuries. The injury can be minor or severe.

Assessment

Symptoms vary depending on where the injury occurred and the severity of the trauma. The patient may experience pelvic pain, vaginal bleeding or discharge, stinging, itching, or pain while urinating. The patient’s healthcare provider will perform a pelvic exam to assess the degree of damage. Vaginal tears sustained during childbirth are graded at a first degree (skin tear only), second degree (skin and muscle tear), third degree (skin and muscle tear extending to the anus), and fourth degree (skin and muscle tear extending through the anus. A transvaginal ultrasound or CT scan may be required to assess more severe internal injuries if present.

Treatment

Most types of gynecological trauma will resolve with rest. The patient may be advised to abstain from sexual activity or heavy lifting until she is healed. Sitting on a donut pillow and applying ice packs will also help to relieve discomfort. The patient may be prescribed analgesics to manage pain until the healing process progresses. More extensive injuries, such as second and third degree tears in childbirth, will require suturing for closure. A fourth degree tear or similar severe internal injury will require an extensive surgical repair under general anesthesia and will have a far more extensive healing process.