Genitourinary Flashcards
Discuss priapism and its aetiology
Engorgement of the dorsal copora cavernosa resulting in penile erection lasting more than 4 hours
Can occur at any age including the neonate, sickle cell disease is responsible for most cases in children - with nearly 50% of all males with SSD have at least one episode of priapism
Other causes include
- malignancy
- immunosuppressive disorders
- medications
- drugs of abuse
- toxins
Contrast low flow and high flow priapism
Low flow is the most common form of priapism and occurs secondary to decreased venous out flow.
Stuttering priapism is recurrent episdoes of ischameic priapism most lasting less than 4 hours
High flow priprism is usually painless and is typically associated with trauma to the cavernosal artery, congential anomaly or fistula resulting in excessive inflow of arterial blood and corporal engorgment. - Oxygenation is maintained and emergent intervention is not typically necessary
Neurogenic priapism is not related to blood flow occlusion
Discuss management of priapisms
Low flow - is a compartment syndrome of the penis and requires emergent treatment. Management include
-hydration
-pain relief
-relief of urinary obstruction
-and treatment of underlying cause
Ring block of the penis should be performed prior to aspiration followed by intracavernous injection of sympathomimetic drugs. Pheylephrine is the preferred agent
Treatment of nonischaemic priapism is observation becuase over 2/3 of cases resolve spontaneously - refractory cases may require cavernosal artery embolization or arterial ligation
Discuss aspiration of the corpus cavernousum in priapism
Ring block
Place an 18 gauge angiocatheter - (smaller for younger children) percutaneously into the lateral aspect of the penile shaft entering the corpus cavernosum. Aspirate blood and evacuate from the cavernosa. Next irrigate with normal saline or in combination with dilute phenylephrine (100-500 mic of pheylephrine per mil of NS
Discuss complications of priapism
Penile firbosis
urinary retention
impotence
Discuss differentiating high flow and low flow priapism
Penile blood appearance
- low flow – venous looking
- high flow – arterial looking
Penile art gas
- Low flow, Pao2 <30mmhg, paco2 >60mmhg, ph <7.25
- high flowm pao2 >90mmhg , paco2 <40mmhg ph 7.4
Doppler
low flow - minimal or absent blood flow
high flow - blood flow normal to high velocity
Discuss phimosis
Constriction of the foreskin that prevents retraction of the prepuce from the glans. Most cases are physiological repreent normal development and do not require intervention.
Those with fully retractable foreskins 4% of newborns 25% of 6 month old 50% of 1 year old 80% of 2 year old 90% of 4 year old boys
Trauma, infection, chemical irritation, poor hygiene congenital abnormality or a complciation of cicumcision may contribute to the development of phimosis
Discuss management of phimosis
Gentle retraction and good hygiene are mainstays of management. Retraction of the prepuce should not be forced as this could lead to future adhesions and strictures.
A 6-8 weeks course of topical corticosteroids applied to the outlet twice daily may expedite the developemnt of retractable foreskin.
Disposition
-patient who are able to urinate and have no evidence of infection or ischaemia can be discharged with OPD urology follow-up
Discuss paraphimosis
Pathalogical condition in which the proximal foreskin is unable to be returned to its anatomic position covering the glans penis resulting in distal venous congestion
Can be caused infection, masturbation, trauma, hair or clothing tourniqutes or failure to reduce the foreskin
It is a urological emergency with potential for arterial compression, penile necrosis, gangrene and/or autoamputation
Discuss management of paraphimosis
Pain should be controlled parenterally and/or with a local dorsal penile nerve block or ring block
Oedema should be reduced –> sprinkle granulated sugar, apply pressure
May spont resolve as oedema resolves, If not manual reduction should be attempted with application of gentle steady pressure on the glans with both thumbs while the shaft is pulled straight
Discuss balanoposthitis
An inflammation that ivovles the glans foreskin, occurs in approximatly 5% of uncircumcised males.
Balanitis invovles the glans penis only.
usually secondary to poor hygeine, infection (bacterail or fungal) contact dermatitis, chemical irritation, or local trauma.
Less common causes include
- drug eruption
- scabies
- STI
- Nummular eczema
Discuss management of balnoposthitis
Emphasis on adequate hygiene with sitz baths to reduce inflammation. Painful micturation can be addressed by having a child urinate while in warm water baths.
Antibiotic ointments should be used for bacterial superinfection and topical corticosteroids may speed recovery.
If candida suspected antifungla should be used
Discuss complications and benifits of cicumcision
Prevents phimosis, paraphimosis, recurrent balanoposthitis and decreases UTIs STI and penile cancer.
most common complciation is minor bleeding
Discuss Entrapment and constrictive injury
Penile rigns, strings, wire and human hair tourniquets can result in penile venous and arterial occlusion. These should be removed and patient ensured that they can pass urine prior to discharge
Zipper entrapment of the foreskin typuically occurs in chidlren between 2 and 6 years of age. LA or sedation may facilitate removal. Cut the median bar of the zipper with mini-hacksaw or metal cutter
Discuss epididymitis
Is inflammation of the epididymis. Infectious causes vary by age. Young children commonly have viral infections. Bacterial epidiymitis in prepubertal boys is associated with structural anomalies of the urinary tract
Gonorrhoea and chlamydia are common causes in adolescents
Discuss clinical features of epididymitis
Presnets with a painful oedemaotus scrotum and tenderness at the epididymis. Urethral discharge may be present particularly when the condition is secondary to STI
Relief of pain with scrotal elevation (Prehns sign) is unreliable and should not be used to make a diagnosis
Discuss IX of epididymitis
Urine sample –>
Swab if puss
US to differentiate from torsion
Discuss management of epididymitis
Scrotal elevation and pain medications. If concerned for STI should be treated presumptively
Ceftriaxone IM and doxyxycline is the preferred treatment. Or azithromycin
In children with non STI epididymitis expectant management wihtout ABs can be undertaken
Discuss orchtiis
Result of bacterial or viral infection of the testes
Paramyxovirus is the most common associated with mumps. Other etiology include e.coli, klebsiella, pseudomonas, staph or strep. EBV, coxsackie, abrovirus, enterovirus, brucella, granulomatous, and filariae
Viral orchitis is mangemed with pain controle, if bacterial possible treat with orals covering gram -ve
Discuss testicular torsion
Most common cause of an acutely painful scrotum
Nearly 100% of testes can be salavaged if de-torted within 4 hours less than 10% if more than 24 hours
Bell clapper deformity(Tunica vaginalais completely covers the testis and attaches higher up on the spermatic cord) increases the risk of torsion
Discuss clinical features of torsion
ACute pain and swelling
elevated testicle
absence of the cremasteric reflex
abnormal (high riding and transverse) epididymal and testicular position may also be noted
Ultrasound is 85-98% sensitivty depending on operator and 100% specific
Both the appendix of the testis and the epididymis can torse but the former is more common
The pathognomic blue dot sign is present in less than 25% of cases
Discuss management of torsion
Should be operative
historically manual detorting has been attempted with analgesia and medial to lateral rotation
up to a 1/3 of patient have torted laterally and the above can worsen the torsion
even with successful detorision compartment syndrome may occyur
