1.14.3 Male GU Emergencies

Question 1

Describe initial evaluation for the male GU complaint

Answer 1

• Gradual vs sudden onset
• Fever?
• Abd/flank pain?
• Vomiting?
• Traumatic injury?
• Age and comorbidities
• Ability to urinate and ejaculate
• Full medical history
• Supplements, drugs of abuse?
• Sexually active?

Question 2

Your patient presents with an acute scrotom. What are your DDx?

What will you include in your initial workup?

Answer 2

• Acute Scrotum DDx
  
  • Testicular torsion
  • Testicular infarction
  • Testicular rupture
  • Testicular hematoma
  • Epididymitis
  • Orchitis
  • Abscess
  • Fournier’s Gangrene
  • Incarcerated inguinal hernia
  • Ureteral stone
• Initial Workup
  
  • Hx and physical
  • UA
  • Urine culture
  • Clambidia/Ghonorrhea
    
    • Dont clean penis before urine sample
  • US scrotum with doppler
    
    • Dx of choice for emergency
    • Esp if c/f torsion
  • CBC, BMP
    
    • Infection, renal function

Question 3

Describe testicular torsion, including:

• Definition
• Risk factors
• Presentation
• Diagnostics
• Treatment

Answer 3

• Definition
  
  • Rotation of testicle around spermatic cord
  • Leading to testicular ischemia
• Risk factors
  
  • < 25 yo
  • Congenital bell-clapper deformity (teste up against scrotal wall)
  • Testicular tumor
  • Cryptochordism (undescended, can have torsion in the abdomen)
• Presentation
  
  • Sudden onset, severe UNILATERAL pain,
  • Swelling
  • N/V, abdominal pain
  • After activity
  • Wake from sleep
  • Elevated, enlarged testicle with horizontal lie
  • Exquisite tenderness
  • Absence of cremasteric reflex
• Diagnostics
  
  • CBC, UA (r/o infxn)
  • Scrotal US w Doppler
  • Surgical explortion
• Treatment
  
  • Analgesia
  • Manual detorsion
  • Orchiplexy
    
    • Definitive surgical anchoring

Question 4

Describe Epididymitis/Epididymo-orchitis

• Definition
• Risk factors
• Presentation
• Complications
• Diagnostics
• Treatment

Answer 4

• Definition
  
  • Bacterial infection of epididymis (and testicle)
• Risk factors
  
  • Men < 35: Chlamidia or Gonorrhea
  • BPH, UTI, Urethral stricture
  • Gram negative infxn: E Coli, PsA, Enterococcus
• Presentation
  
  • Gradual onset of scrotal pain, dysuria, and fever
  • Recent sexual activity
  • Incomplete bladder emptying
  • UTI
  • Tenderness to posterior-lateral testicle
  • Similar to testicular torsion, especially of orchitis is involved
• Complications
  
  • Scrotal abscess
  • Testicular infarct
  • Infertility
  • Recurrence/chronic epididymitis
• Diagnostics
  
  • CBC, UA
  • Scrotal US with Doppler
• Treatment
  
  • NSAIDs
  • Rest, scrotal elevation/support
  • STD?
    
    • Doxy 100mg BID x 10 days
    • and IM Ceftriaxone 250mg
  • Non-STD?
    
    • Levofloxacin 500mg daily x 10days
    • Augmentin BID x 10days

Question 5

Your patient has scrotal wall infection.

• 3 types/severities
• Risk factors
• Presentation
• Diagnostics
• Treatment

Answer 5

• 3 types/severities
  
  • Cellulitis
  • Abscess
  • Fournier’s gangrene (life threatening infection in the anorectum, urogenital tract, skin)
    
    • E. coli, bacteroides, proteus, staphylococcus, enterococcus, streptococcus, PsA, Klebsiella, Clostridium
• Risk factors
  
  • Morbid obesity
  • Diabetes
  • Immunocompromise
  • Older age
  • Male:Fm 10:1
• Presentation
  
  • Fever, gradual onset of pain
  • Erythema, tenderness, fluctuant abscess, crepitus, necrotic tissue
  • Examin perineum and perianal
    
    • R/o progressive necrotizing infection
• Diagnostics
  
  • CBC, CRP
  • C&S of any drainage
  • Scrotal US
  • CT pelvis with IV contrast
    
    • Deep space abscess?
• Treatment
  
  • I&D
  • Surgical debridement
  • Abx
    
    • Vanco and Zosyn
    • Clindamycin

Question 6

Priapism

• Definition
• Risk factors
• Presentation
• Treatment

Answer 6

• Definition
  
  • Persistent erection unrelated to sexual stimuli lasting >4h
  • Ischemic
    
    • Low in-flow, low out-flow
  • Non-Ischemic
    
    • High in-flow, high out-flow
• Risk factors
  
  • Adults 20-50 yo
  • Ischemic
    
    • Sickle cell
    • Malignant tumor
    • Drugs: PDE5i, a-blockers, hydralazine, CCBs, anticoags, trazodone, buproprion, cocaine, EtOH
  • Non-Ischemic
    
    • Needle injury
    • Trauma
    • Congenital AVM
    • Iatrogenic
• Presentation
  
  • Ischemic
    
    • Painful, fully hard penis
    • Tissue edema in 4h
    • Structural damage in 12h
    • Irreversible damage in 24h
  • Non-Ischemic
    
    • Persistent, partial, non-tender erection
    • 62% resolve spontaneously
• Treatment
  
  • Ischemic
    
    • IVF and analgesia
    • Urology consult
    • SQ terbutaline sulfate q30m PRN
    • Aspirate cavernosal blood to relieve pressure
    • Phenylephrine cavernosal injection
      
      • Need to do cardiac monitoring
    • Surgical mgmt