Chap 22 & 23 quiz

Functions and Anatomy of the Urinary System

• The urinary system performs several critical metabolic and physiological functions:

  • Filters blood to remove metabolic waste products.

  • Manages the concentrations of various electrolytes.

  • Maintains the acid-base balance within the bloodstream.

  • Regulates fluid volume and blood pressure.

• Primary components of the urinary system include:

  • Kidneys: The primary filtering organs.

  • Ureters: Tubes that transport urine from the kidneys to the bladder.

  • Urinary bladder: Storage vessel for urine.

  • Urethra: The exit conduit for urine. It is notably shorter in females than in males.

• Internal Kidney Anatomy is divided into three distinct regions:

  • Cortex: The outer layer.

  • Medulla: The middle layer.

  • Pelvis: The central collecting region.

• Nephrons are the structural and functional units located in the cortex that form urine. Their composition includes:

  • Glomerulus

  • Glomerular (Bowman) capsule

  • Proximal convoluted tubule (PCT)

  • Loop of Henle

  • Distal convoluted tubule (DCT)

Anatomy of the Male Genital System

• The male genital system is closely related to the urinary system and shares the urethra as a common conduit for urine, semen, and other secretions.

• Key structures include:

  • Prostate gland: Surrounds the urethra and, along with seminal vesicles, secretes fluids into the urethra.

  • Testes: Located in the scrotum; responsible for the creation of spermatozoa.

• Mechanics of ejaculation:

  • Sperm travels from the epididymis into the vas deferens and through the ejaculatory ducts.

  • Semen is formed by mixing fluids from the seminal vesicles, bulbourethral glands, and the prostate.

  • Sperm enters the urethra to exit the body.

General Patient Assessment for Genitourinary and Renal Emergencies

• Scene Size-Up:

  • Take standard precautions to avoid contact with urine.

  • Recognize that renal and genital conditions may mimic other abdominal problems.

  • Causes of pain may include bacterial infection, extension of the ureter by a kidney stone, or prostate enlargement.

• Primary Survey:

  • Form a general impression.

  • Assess Airway, Breathing, and Circulation (ABCs).

  • Determine a transport decision.

• History Taking:

  • Use the SAMPLE mnemonic for patient history.

  • Evaluate pain using the OPQRST mnemonic.

  • Pain types include visceral and referred pain.

• Secondary Assessment:

  • Move from head to toe in a focused physical exam.

  • Abdominal division: Four quadrants overlying internal organs or nine anatomic segments.

  • Monitor vital signs every $5\,minutes$.

  • Assess for flank tenderness and visually inspect genitalia.

  • Utilize ECG monitoring for potential electrolyte-induced cardiac changes.

• Reassessment:

  • Monitor for rapid deterioration due to electrolyte imbalances which can impact organ function.

  • Document serial vital signs and update the treatment plan.

Emergency Medical Care and Pain Management

• Management strategies for renal/genitourinary patients:

  • Allow the patient to assume a position of comfort.

  • Be prepared for nausea and vomiting.

  • Establish an IV line and consider an antiemetic.

  • Do not withhold pain control; administer analgesia if local protocols allow.

Urinary Tract Infections (UTIs) and Catheterization

• UTIs:

  • Pathophysiology: Usually develop in the lower urinary tract and are more common in women. They can spread to the kidneys if untreated.

  • Classic Symptoms: Painful urination (dysuria), frequent urges to urinate, difficulty urinating, and general pain.

  • Management: Primarily supportive care; transport in a position of comfort and prepare for nausea. Pyelonephritis or sepsis requires aggressive treatment.

• Urinary Catheters (Foley Catheters):

  • These consist of a latex or plastic tube connected to a drainage bag for continuous outflow and measurement of urine.

  • Transport concerns: Avoid urine backflow by keeping the bag below the level of the patient. Do not pull or kink the tube. Ensure the internal balloon is deflated before removal.

Urinary Obstruction and Incontinence

• Urinary Retention: The incomplete emptying of the bladder or total inability to empty the bladder. Causes include:

  • Kidney stones (renal calculi).

  • Acute kidney injury (AKI).

  • Benign prostate hypertrophy (BPH).

  • Urethral obstructions, UTIs, and nerve damage.

• Urinary Incontinence: The loss of bladder control. Categorized into:

  • Urge incontinence: Sudden, intense urge with involuntary loss within seconds or minutes.

  • Overflow incontinence: Constant, continual slow flow of urine.

Kidney Stones (Renal Calculi)

• Pathophysiology: Originate in the renal pelvis when an excess of insoluble salts or uric acid crystallizes in the urine.

• Types of stones:

  • Calcium stones: Most common; often have a hereditary component.

  • Struvite stones: More common in women.

  • Uric acid stones.

  • Cystine stones.

• Assessment findings:

  • Almost always involve pain, which may cause tachycardia and increased blood pressure.

  • Patients are often restless or guard the abdomen.

  • Hematuria (blood in urine) and flank tenderness occur if the stone obstructs the ureter.

• Management: Position of comfort, IV fluids, and analgesia. Some stones pass naturally; others require:

  • Extracorporeal lithotripsy.

  • Cystoscopy with stent placement.

  • Percutaneous nephrostomy (PCN) tube placement.

Acute Kidney Injury (AKI)

• Definition: A sudden decrease in filtration through the glomeruli leading to a buildup of toxins in the blood.

• Statistics: Up to $50\%$ of critically ill patients develop AKI, with a mortality rate as high as $70\%$ in critical cases.

• Diagnostic Thresholds:

  • Oliguria: Urine output of less than $500\,mL/day$ in an adult, or less than $0.5\,mL/kg/h$ in an adult or child.

  • Anuria: Complete cessation of urine production.

• Physiological Effects: Generalized edema, acid buildup, high levels of nitrogenous/metabolic wastes (uremia), hyperkalemia, and metabolic acidosis.

• Classification: Prerenal, intrarenal, or postrenal based on the location of the cause.

• Physical Findings:

  • Impaired mentation, fluid retention, tachycardia.

  • ECG changes: Increased PR and QT intervals.

  • Pale, cool, moist skin; flank pain; signs of heart failure in severe cases.

• Management: Support ABCs, administer IV boluses if shock is present, and monitor for comorbid diseases.

Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD)

• Chronic Kidney Disease (CKD):

  • Pathophysiology: Permanent loss of nephrons leading to scarring, uremia, and azotemia.

  • Assessment: Patients may show altered consciousness, lethargy, nausea, hypertension, pericarditis, and pulmonary edema.

• End-Stage Renal Disease (ESRD):

  • Occurs when kidneys lose all ability to function; fatal without treatment.

  • Signs and Symptoms: Uremic frost (powder on skin), muscle twitching, coagulopathy, chest pain, confusion, seizures, and coma.

  • Missed Dialysis: Leads to signs of volume overload.

  • Post-Dialysis Findings: Patients may feel weak or dehydrated.

Renal Dialysis

• Purpose: Filter toxic wastes, remove excess fluid, and restore electrolyte balance.

• Types:

  • Hemodialysis: Uses a vascular access point like a fistula or AV shunt.

  • Peritoneal Dialysis: Types include CAPD and APD.

• Dialysis Schedule: Typically performed every $2$ or $3$ days for $3$ to $5\,hours$.

• Complications:

  • Human error, cannulation issues, machine connection problems.

  • Muscle cramps, nausea, vomiting, infections at the access site.

  • Serious risks: Hypotension, shock, potassium imbalance, disequilibrium syndrome, and air embolism.

Male Genital Tract Conditions

• Infections:

  • Epididymitis: Inflammation of the epididymis on the posterior testis.

  • Orchitis: Infection of one or both testes.

• Fournier Gangrene: Necrosis of subcutaneous tissue and muscle in the scrotum; tissue appears gray-black, warm, and tender. Requires aggressive IV fluids.

• Priapism: Painful, persistent erection; maintain privacy and consider spinal cord injury immobilization.

• Phimosis and Paraphimosis:

  • Phimosis: Inability to retract distal foreskin; treat with cold compress.

  • Paraphimosis: Retracted foreskin becomes entrapped; true emergency that can cause glans necrosis.

• Benign Prostate Hypertrophy (BPH): Age-related enlargement; causes difficulty starting urine flow, incomplete emptying, and nocturia (increased night urination).

• Testicular Torsion: Twisting of the testicle on the spermatic cord reducing blood flow; medical emergency requiring prompt transport and analgesics.

• Testicular Masses: Most are benign (e.g., varicocele), but solid painless lumps can indicate cancer.

Anatomy of the Female Reproductive System

• Ovaries: Pair of organs releasing eggs (ova) and hormones.

• Uterus: Pear-shaped organ for embryo implantation. Parts include:

  • Fundus: Upper convex portion.

  • Myometrium and Endometrium: Layers of the uterine wall.

  • Cervix: The neck of the uterus inserting into the vagina.

• Vagina: Along with the lower uterus and cervix, it forms the birth canal.

• Perineum: Tissue between the vaginal opening and the anus.

• Hymen: Membrane protecting the vaginal orifice.

  • Imperforate hymen: Completely covers the orifice; can cause blockage of menses, endometriosis, or acute pain.

Menstruation and the Menstrual Cycle

• Definitions:

  • Menstruation: Normal discharge of blood, epithelial cells, mucus, and tissue.

  • Menarche: Onset of the first menses.

  • Menopause: Cessation of ovarian function and the menstrual cycle.

• Cycle Phases:

  • Ovarian Cycle: Follicular phase (days $1$ to $13$) and Luteal phase (days $14$ to $28$).

  • Uterine Cycle: Proliferative phase (days $5$ to $14$) and Secretory phase (days $14$ to $28$).

• Ovulation: Release of an ovum, usually $14\,days$ after the start of the last period. Menstruation lasts $4$ to $6\,days$ with a blood loss of $25$ to $65\,mL$.

• Mittelschmerz: Sharp, cramping, localized midcycle lower abdominal pain.

• Amenorrhea: Absence of menses. Causes include pregnancy (most common), exercise, low body fat, stress, or anorexia nervosa.

Assessment of Gynecologic Emergencies

• Common Signs: Vaginal bleeding, abdominal pain, vomiting, fever, tachycardia, hypotension, syncope, and dyspareunia (pain during intercourse).

• Assessment Protocols:

  • Scene Size-Up: Prepare for blood/fluids and potential legal testimony.

  • Primary Survey: Assess ABCDEs; provide fluid resuscitation if needed. Do not pack dressings inside the vagina.

  • History: Quantify bleeding by "pads per hour." Ask for the Date of Last Normal Menstrual Period (LNMP), pregnancy history (miscarriages/abortions), and STI history.

  • Secondary Assessment: Use same-gender paramedics when possible. Check for bruising (abuse), needle tracks, or Cullen/Grey-Turner signs (internal bleeding symbols). Palpate the abdomen starting away from the pain to check for rebound tenderness or masses.

Specific Gynecologic Emergencies

• Pelvic Inflammatory Disease (PID):

  • Pathophysiology: Infection of reproductive organs; organisms migrate from vagina to uterus and tubes, potentially causing peritonitis or abscesses.

  • Symptoms: Pain during/after menses, discharge, fever, and dysuria. Risk factors include multiple partners, douching, and IUD use.

• Bartholin Abscess:

  • Blocked Bartholin glands/ducts lead to cysts. Infection results in a painful vulvar lump and painful intercourse requiring surgical incision.

• Vaginitis and Vulvovaginitis:

  • Inflammation caused by infection (often Candida albicans yeast). Symptoms include itching, discharge, and odor. If untreated, can lead to infertility or PID.

• Cystitis: Bladder infection; signs include suprapubic pain, cloudy urine, and hematuria. Untreated cystitis can lead to pyelonephritis (kidney infection).

• Ovarian Cyst and Torsion:

  • Cysts: Usually asymptomatic but can rupture, causing radiating back pain.

  • Ovarian Torsion: Twisting that interrupts blood supply; surgical emergency presenting with acute unilateral lower abdominal pain and a palpable mass.

• Endometritis and Endometriosis:

  • Endometritis: Inflammation of the endometrium, often after childbirth ($36\,hours$ post-partum). Symptoms: fever, foul-smelling discharge, and pelvic pain.

  • Endometriosis: Endometrial tissue outside the uterus. Causes heavy flow, painful cramping, and rectal pressure.

• Uterine Prolapse: Uterus protrudes outside the vagina due to weakened pelvic support. Management: Do not replace tissue; cover with warm, moist dressings.

Vaginal Bleeding and Ectopic Pregnancy

• Dysfunctional Uterine Bleeding (DUB): Abnormal amount/frequency (more than every $21\,days$). Risks include stress, polycystic ovary disease, or obesity.

• Traumatic Vaginal Bleeding: Caused by intercourse, straddle-type injuries, pelvic fractures, or foreign bodies. Treat for hypovolemic shock.

• Ectopic Pregnancy:

  • Definition: Fertilized oocyte implants outside the uterus, usually in fallopian tubes.

  • Classic Triad: Abdominal pain, delayed menses, and abnormal vaginal bleeding (spotting) $6$ to $8\,weeks$ after LNMP.

  • Management: Life-threatening emergency. High-flow oxygen, left lateral recumbent position, $18-gauge$ IV line, cardiac monitor, and rapid transport.

Sexual Assault and Foreign Bodies

• Sexual Assault and Rape:

  • Use professional, sensitive care. Preserve evidence (discourage patient from washing/voiding). Record emotional state, clothing condition, and injuries.

  • Be aware of "date rape" drugs: symptoms include hypotension, bradycardia, and coma.

• Intimate Partner Violence: Prioritize safety of the crew and the patient.

• Vaginal/Anal Foreign Bodies:

  • Can involve "fisting" (fist/wrist insertion) or live animals; organ rupture is likely.

  • Management: Do not remove the object. Transport with knees flexed and legs together. Maintain nonjudgmental professionalism and patient dignity.