Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

Wilderness and Rescue Medicine 220

Signs and symptoms indicating that infection has progressed beyond the superficial lining of the urethra and bladder indicate a more serious condition. These include fever, back pain, and an ill-appearing patient. The possibility of sexually transmitted disease should also be considered an indication for early medical evaluation. Antibiotic therapy and urgent evacuation are indicated.

agitation. In an unresponsive patient, failure of the bladder to empty may go unnoticed if you are not paying attention. In either case, a urinary tract that is not urinating regularly indicates an emergency. Bladder Outlet Obstruction This usually affects men, and is usually due to an enlarged or infected prostate. A chronically con- stricted urethra can become an acutely obstructed one with just a little inflammation. Some drugs can contribute as well (eg: diphenhydramine). The initial complaint of “I can’t pee” will become seri- ous abdominal pain as the bladder distends. The usual treatment is to pass a catheter through the penis into the bladder. The sooner that you recognize the problem and catheterize the patient, the better. In extreme cases, a suprapubic tap can be accomplished by inserting a long hypodermic needle through the abdominal wall into the blad- der just above the pubic bone. If you have neither the equipment nor the training to perform these procedures, emergency evacuation is indicated. Kidney Stone Urine is normally a solution with various com- pounds (the solute) dissolved in water (the sol- vent). Under certain conditions some of the solute can precipitate as crystals, some of which can become large enough to obstruct the transport of urine. These “stones” usually lodge in the ureter below the kidney. Testicular Pain Like any other organ, testicles can become obstructed, infected, or ischemic. A rare but dangerous cause of sudden onset pain is testicu- lar torsion, where the testicle twists inside the scrotum, impinging its blood supply. Ischemia causes pain and will result in infarction of the testicle if not corrected. Testicular torsion can sometimes be relieved by gently elevating the scrotum and allowing the testicle to unwind spon- taneously. Even if this maneuver is successful and pain is relieved, nonemergent medical follow-up

Urinary Tract Infection

General Principles

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Serious: • Male • Back pain (kidney involvement) • Fever (systemic infection) • Serious abdominal pain • Bloody urine • Known sexually transmitted infection

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“Antibiotic therapy and urgent evacuation are indicated .”

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Urinary Tract Obstruction The kidneys filter blood and produce the filtrate (urine) at a rate of about one milliliter a minute in a healthy and normally hydrated person. Urine is then transported through the ureters to the blad- der. This transport is both passive due to gravity and active by peristaltic action of smooth muscle in the wall of the ureter. The bladder stores urine until you are ready to urinate. Sphincters at the bladder outlet allow you some degree of control over when and where you do so. Loss of bladder control with involuntary uri- nation can be a symptom of a serious problem like spinal cord injury or brain failure, or a less serious issue like uncomplicated urinary tract infection. While it is inconvenient or embar- rassing, unplanned urination is rarely due to a serious problem within the urinary tract itself. Obstruction of urinary drainage, on the other hand, is serious. Anything that blocks the normal flow of urine from the kidney to the outside can cause kidney failure, infection, or rupture of the bladder or ureters. In an awake and responsive patient the problem usually presents as increasing pain and