Roy L. Alson
LITHOTRIPSY
Hematuria is common complication of extracor-poreal shockwave lithotripsy, usually self-limiting and resolves in 1 to 2 days.
Other post-procedure complications include nausea, vomiting, flank pain and bruising, fever, and renal calculi. All managed with supportive therapy. Monitor creatinine and urine output. Appropriate antibiotics for UTI and fever.
Steinstrasse (street of stone) is a result of dis-perals of multiple fragments posttreatment that can obstruct ureters. Symptoms include ureterolithiasis: flank pain and hematuria. Stones may be seen on plain films. Treat like ureterolithiasis. If fully obstructed, repeat lithotripsy or percutaneous nephrostomy.
Rare injury to viscus or abdominal organs by lithotripsy. Pain with or without signs of peritonitis. CT or US to rule out and surgical or urological consult.
COMPLICATIONS OF URINARY CATHETERS
Infection is the most common complication of urinary catheters (3%-10% incidence of bacteria per day with 100% by day 30), with females, diabetics, elderly, debility, and BPH increasing risk.
Presence of catheter interferes wth uriniary clearance of bacteria allowing colonization and/or infection. Longer term catheters are more likely to have pol-ymicrobial infections.
Antibiotic treatment of asymptomatic bacteriuria in a patient with a short-term catheter is not recommended.
Pyuria is universal for patients with long-term (1 month) indwelling catheters; pyuria should not be used in the diagnosis of asymptomatic infection. Hematuria is a better indicator of infection.
Catheter-related UTI in patients with indwelling urethral, indwelling suprapubic, or intermittent cath-eterization is defined by the presence of symptoms or signs compatible with UTI with no other identified source of infection along with ≥103 colony-forming units/mL of ≥1 bacterial species in a single catheter urine specimen.
Signs and symptoms compatible with catheter-related UTI include new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort; and in those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness.
In those patients with mild symptoms, treatment is ciprofloxacin 500 milligrams twice a day, or levo-floxacin 500 milligrams once a day, or cefpodoxime 200 milligrams twice a day.
Seven days is the recommended duration of antimicrobial treatment for patients with catheter-related UTI who have prompt resolution of symptoms (A-III), and 10 to 14 days of treatment is recommended for those with a delayed response.
Pyelonephritis is the most common complication of catheter-related UTI with fever. Admission is frequently required (see Chapter 55, Urinary Tract Infections and Hematuria, for further antibiotic recommendations). Check urine cultures and blood cultures if septic (see Chapter 91 for septic shock). Replace the catheter if it has been in place >7 days.
Other infectious complications in males include prostatits, urethritis, epididymits, and absecess. See Chapter 57, Male Genital Problems, for diagnosis and treatment.
Damage to urethra from improper insertion can casue bleeding or creation of false passage. Urethral stricture or prostatic hypertrophy increases risk of injury. Consider use of coude tip catheter.
Cessation of urine output suggests uretheral disruption or obstruction by clots. Inflation of retention balloon with catheter in urethra may also cause injury.
Minor traumatic complications of urinary catheters may require no therapy, while major complications (such as bladder perforation or urethral disruption) require consultation with a urologist.
NONDRAINING CATHETER
Obstruction is suggested if the catheter does not flush easily or if there is no return of the irrigant. Obstruction of the catheter by blood clots often creates a situation in which the catheter is easily flushed, but little or no irrigant is returned.
If obstruction occurs, the catheter can be replaced with a triple-lumen catheter so that the bladder can be easily irrigated. If after clearing the bladder of all clots evidence of continued bleeding is present, urologic consultation is recommended for possible cystoscopy.
Some physicians advocate the use of single-lumen catheters to lavage the bladder, as its larger lumen may aid in the evacuation of larger clots.
Pericatheter leakage may be a result of catheter obstruction by clot or concretions (see bullets immediately above). If not due to obstruction, treat spasm with anti-spasmodics such as oxybutynin or dicyclomine.
Make sure after placing catheter that foreskin is returned to normal position to prevent paraphimosis.
NONDEFLATING RETENTION BALLOON
If the obstruction is distal, the result of a crush or defective valve, the catheter can be cut proximal to the defect. If this does not deflate the balloon, a lubricated guidewire can be introduced into the cut inflation channel in an attempt to clear the obstruction.
The balloon can be ruptured within the bladder. However, consider urologic consultation prior to rupturing the balloon, as overinflation (using sterile water) often requires 10 to 20 times the normal balloon volume.
Urologic consultation may be required if simple measures are not successful.
COMPLICATIONS OF PERCUTANEOUS NEPHROSTOMY TUBES
Percutaneous nephrostomy is a urinary drainage procedure used for supravesical or ureteral obstruction secondary to malignancy, pyonephrosis, genitourinary stones, or ureteral strictures.
Bleeding may occur, and most episodes can be managed with irrigation to clear the nephrostomy tube of clots. In resistant cases check complete blood count (CBC), renal function, and coagulation studies (as indicated by comorbidities).
Treat the patient for hemodynamic instability and consult urology.
Infectious complications of nephrostomy tubes range from simple bacteriuria and pyelonephritis to renal abscess, bacteremia, and urosepsis. Culture any wound drainage, start an antibiotic such as ciprofloxacin 400 milligrams IV, and consult urology.
Mechanical complications, such as catheter dislodge -ment and tube blockage, can occur with these devices. The urologist has several techniques available to reestablish access to an obstructed nephrostomy tube.
COMPLICATIONS OF ARTIFICAL URINARY SPHINCTERS
Artifical sphincter is a device that increases resistance around urethra and provides continence. Several types exist. Basic design is a cuff around urethera with tubing to a pump that moves fluid to cuff, constricting urethra.
Postoperative complications include hematomas at implantation site. Infections are serious as they are periprosthetic. Appropriate antibiotics need to cover gram negatives and also skin flora. Removal of device is necessary.
Patients with device in place should receive prophylactic antibiotics when undergoing procedures that may cause hematogenous seeding, such as dental procedures.
Air in the fluid path of the sphincter may compromise function and pumps or tubes may fail. Urologic evaluation is warranted.
Never introduce urinary catheter through an artificial sphincter.
COMPLICATIONS OF URETERAL STENTS
Dysuria, urinary urgency, and frequency, as well as abdominal and flank discomfort, are common complaints in patients with ureteral stents. The baseline discomfort in a functioning, well-positioned stent can range anywhere from minimal to debilitating. However, an abrupt change in the character, location, or intensity of the pain requires further evaluation for stent malposition or malfunction.
Ureteral stents may remain in place for weeks to months and often function with no complications during the entire period. However, stents can often become encrusted with mineral deposits and may obstruct.
Complete obstruction of urine flow is possible, although this tends to occur more often in patients with stents in place for long-term use. These patients may require urologic consultation, and in some cases may require stent replacement.
URINARY TRACT INFECTION VERSUS STENT MIGRATION OR MALFUNCTION
Changing abdominal or flank pain or bladder discomfort may be indicative of stent migration. Radiographic examination is indicated with comparison to a previous film to evaluate stent position, and urologic consultation with further studies to evaluate stent position may eventually be necessary.
When a urinary tract infection occurs in the presence of a stent, stent removal is not mandatory, because most infections can be managed with outpatient antibiotics. However, if pyelonephritis or systemic infection is evident, then further evaluation and emergent intervention are indicated.
Plain radiograph examination to check for stent migration, and urologic consultation for evaluation of stent migration and malfunction are indicated, as well as initiation of antibiotic therapy.
URINARY DIVERSION AND ORTHOTOPIC BLADDER SUSBSITUTION
Ileal conduit most common urinary bladder diversion. Postoperative complications include bowel obstruction, pyelonephritis, renal insufficiency, and stoma breakdown or stenosis. Reflux of urine into implanted ureters is a major cause of these complications.
Other newer techniques for neobladder construction now exist, with less urine reflux into ureters. Bacturia is common postprocedure.
Diagnosis of infection should be made based on clinical findings including fever and flank pain or urine culture (>104 CFU/ML). Consult with urology for treatment recommendations if UTI is found.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 98, “Complications of Urologic Procedures and Devices,” by Elaine B. Josephson and Moira McCarty.