Clincial Male Gential Emergencies Flashcards
Phimosis
Constriction oft he foreskin preventing retraction of the foreskin
- causes inability to void urine, scarring of the penis and sometimes ischemia if not fixed
Two subtypes
- physiological = young boys and is normal and will resolve by school age
- pathological = due to scarring fo the foreskin
Treatment = dorsal slit procedure is definitive treatment
- will require circumcision in the future
Paraphimosis
Inability to completely reduce the foreskin dismally to its natural position
- results in complete inability to void urine and also ischemia of the head if not fixed
- only really occurs in really young or really old people
In elderly = almost always caused by retraction of the foreskin during catherter insertion and forgetting to fix it
often is confused with edema
Treatment = decrease edema around the glans of the penis with compression, ice or sugar and then reduce the foreskin down
Balanoposthitis
Inflammation of both the glans penis and the foreskin
- most commonly is caused by Candida albicans
- can also be caused by bacteria and STI infections or soap and irritants to the skin
Risk factors
- uncircumcised
- phimosis past or present
- poor hygiene
- diabetes mellitus
Always check glucose in these patients to make sure if there is new onset diabetes or not underlying
Treat with antibiotics for organism and if recurrent = circumcision
Fournier gangrene
Necrotzing fasciitis of the perineum and scrotum and vagina (can infect women also)
- can spread to anterior abdominal wall and gluteal muscles also
Is NOT superficial but is difficult to differentiate from cellulitis
- POOP suggests necrotizing fasciitis over cellulitis
- also look for systemic symptoms (tachycardia, tachypnea, hypotension, fever)
Risk factors:
- diabetes
- indwelling urethral catheters
- immunocompromised states
Are almost always polymicrobial so need to treat with vancomycin, ceftriaxone and Clindamycin treatments
- gram positive = vancomycin
- gram negative = piperacillin or 3rd gen cephalosporin
- anaerobic = clindamycin
Also do surgical debridement and imaging (CT/MRI) to check for free air in tissues
DONT WAIT FOR IMAGING THOUGH
What is the most severe complication from necrotizing fasciitis fasciitis
Gangrene of a limb
- requires surgical amputation and often hip replacements also if in groin or leg
Testicular torsion
Most common in neonates and teenagers
Results in the spermatic cord to twist around the testicle and lay superior and sometimes horizontal
- often shows abdominal pain, nausea and vomiting
- often shows no creamaster reflex (although if its positve cant 100% rule out)
- *NEEDS to be corrected surgically within 6hrs or will lose testicle likely (24hrs = 100%)
- often requires orchioplexy of both testicles to prevent recurrence since for unknown reasosns chances of it occurring on the contralateral side goes up
Manual detorsion of scrotum
Can be used while waiting for surgery (SHOULD STILL REQUEST SURGERY)
Usually need a cord block or serious sedation
Rotate limbs inward and then rotate them out slowly
- often times is excruciatingly painful and is very unlikely to work if scrotal swelling is present
- however within the first 3 hrs is possible to work
Urethritis
Inflammation and infection of the urethra
- in males = almost always chlamydia or gonorrhea
- in females = can be a STI but also need to rule out E. Coli and staph saprophyticus
Tests = nucleic acid amplification tests
Treatment = ceftriaxone and azithromycin + doxycycline (Zithromax)
Epididymitis and orchitis
Infections that start at the urethra and anterograde down into the testicles and epididymis
- most common = chlamydia and gonorrhea
- enteric organisms are also possible if anal sex occurs
Presents with unilateral tenderness and edema of the epididymis
- often shows Prehn (+) sign (pain relieved with testicular elevation) however this is NOT diagnostic
Treatment
1) if acute with no anal sex = ceftriaxone 250 IM+ doxycycline
2) if acute with anal sex history = ceftriaxone 250 IM + levofloxacin 500 mg oral
3) if you know 100% this caused by enteric organism = levofloxacin 500mg oral
Priapism
Prolonged erection > 4hrs in the absence of sexual stimulation
- compression of the emissary veins caused by increased arterial blood flow
Almost always involves the corpora cavernous only (but can also affects corpus spongiosum and glans (however these are usually flaccid))
Will cause ischemia if not fixed
Causes:
- sickle cell disease (most common cause)
- hematologic malignancies (especially leukemia)
- brain injuries and strokes
- spinal cord injuries
- medications (alpha blockers, PDE5, prostaglandin injectable, phenothizines are most common)
Treatment =
1st line = intracorpal injection of phenylephrine (alpha agonist) or terbutaline
2nd line = add corporal aspiration and irrigation
- last resort = spongiosum-cavernous also shunts
Penile fractures
Common occurs during intercourse when the penis slips out and hits the pelvis
- is a fracture of the tunica albuginea
Casues intense ecchymosis and angular ion of the shaft of the
Always requires surgery and complications are deformity and erectile dysfunction
What can a straddle injury or direct trauma cause?
Testicular rupture (tunica albuginea of the testicle)
Corpora cavernosa injury
Tunica aluginea injury to the penis
Urethral injuries
Testicular rupture
Characteristzed by a tear of the tunica albuginea
Will show ecchymosis of the scrotum and blood in the hemi-scrotum
Need to get a scrotal ultrasound to confirm and surgery is the only way to treat successfully
