GU Emergencies Flashcards
twisting of spermatic cords
testicular torsion
testicular torsion
clinical features
young men (16-18)
sudden onset of UNILATERAL testicular pain
scrotal swelling/erythema
abdominal pain
bell clapper deformity
bell clapper deformity
affected testicle moves to horizontal plane
testicular torsion
immediate testicular torsion workup
Testicular U/S
urologic surgical consult
detorsion attempted
interim testicular torsion tx
de torsion maneuver (open book)
infarct occurs within 6 hrs
clinical pearls of testicular torsion
absent cremasteric reflex
history will have less severe episodes
50% occur during sleep
bimodal age presentation (infancy and adolescence)
twisting of appendix
Torsion of Testicular or Epididymal Appendix
clinical features of testicular torsion appendix
common among boys 10-16 (any age)
sudden onset of pain
inflammation and necrosis occurs
early- firm, tender
late- generalized edema and pain
appendix
embryological remnants
found on superior part of testicle or epididymis
no function
diagnosing appendix testicular torsion
Doppler U/S
treatment of testicular torsion appendix
immediate urological consult
necrotic appendages can be excised
analgesics and rest
calcifies in 1-2 weeks
pathognomonic testicular torsion appendix
Blue-Dot Sign
blue dot sign
stretching skin over necrotic nodule
during transillumination
clinical features of SUPERFICIAL scrotal abscess
indurated - can evolve
progressive pain and surrounding erythema
supercritical layer of scrotal wall
fever is usually absent (localized not systemic)
distinguishing between superficial abscess and Fournier’s gangrene
in gangrene - pt appears very ill
Treatment of superficial scrotal abscess
local anesthesia + incision and drainage
bactrim, clindamycin, doxycycline
sitz bath, wound care
Fournier’s gangrene
clinical features
ill out of proportion to exam
severe abdominal pain progressing to scrotum
fevers, tachycardia, hypotension
tense scrotal edema, blisters, bulla
those at risk for Fournier’s gangrene
middle aged, DM males
indwelling foley catheter
IV drug users
treatment of Fournier’s gangrene
aggressive fluid resuscitation
CBC, lactic acid, BMP, UA, C&S, CT scan
early surgical debridement and drainage
early broad spectrum ABx
hyperbaric O2 chamber
clinical features of orchitis
variable onset (mild- severe)
viruses - mumps (4-7 days after parotid)
scrotal pain/edema
unilateral
constitutional symptoms (malaise, HA, myalgia)
what should always be on your differential in orchitis?
testicular cancer (reactive hydrocele)
treatment of orchitis
supportive care
analgesics
cold pack
scrotal elevation
bacterial cause - epididymitis
testicular ultrasound orchitis
can distinguish viral or bacterial cause
viral: proceeding or concurrent parotid swelling supports mumps, orchitis
bacterial: large, boggy, tender epididymus
testicular tumor
clinical presentation
painless, firm testicular mass
complains of heaviness
distinctly palpable from testicle (early)
reactive hydrocele - late
treatment of testicular tumor
referral to urologist for surgical exploration
testicular tumor
acute hydroceles and hematocele should prompt consideration of a tumor
supraclavicular lymph node, abdominal mass, or chronic nonproductive cough
hydrocele
collection of peritoneal fluid b/t parietal and visceral layer of tunica vaginalis
communicating hydrocele
usually develops as a result of failure of processes vaginalis to close during develop
peritoneal fluid
common in newborns (congenital)
noncommunicating hydrocele
no connection to the peritoneum
fluid comes from mesothelial lining of tunica vaginalis
epididymitis, orchitis, testicular torsion, trauma, tumor
clinical features of hydrocele
asymptomatic
soft, fluid filled scrotum
transilluminated
hydrocele workup
directed toward discovering underlying cause
transilluminate, u/s
urology referral
hydrocele treatment
child under 1/neonate of age is usually supportive (typically resolve spontaneously)
surgical repair for communicating beyond 1 yr or idiopathic and symptomatic hydrocele
scrotal edema
scrotal skin becomes taunt with pitting edema
associated with CHF or nephrotic syndrome
clinical features of epididymitis
onset over hours
ipsilateral (pain on same side, inguinal canal, lower quadrant of abdomen)
tender, indurated, edematous epididymis
scrotal swelling, pain
UA = WBCs, pyuria, bacteriuria
fevers
differential diagnosis of epididymitis
testicular torsion - U/S to distinguish
testicular cancer
epididymitis treatment
<35 y/o = treat like STD
> 35 35 y/o = treat like UTI
febrile patients, consider IV abx and admission
epididymitis ABX used
<35 - STD (ceftriaxone, doxycycline)
> 35 (ciprofloxin/olfloxacin/Bactrim)
pathopneumonic epididymitis
Prehn sign
relief of pain with elevation of scrotum
bacterial inflammation of the prostate gland
acute prostatitis
acute prostatitis clinical features
low back pain
perineal pain
subrapubic pain
obstructive lower urinary tract
perineal pain with ejaculation
fever, chills
acute prostatitis risk factors
anatomic or neurophysiological lower UTI
acute epididymitis
anal intercourse
phimosis
intraprostatic ductal reflux
indwelling urethral catheter
causative organisms acute prostatitis
MC = E. Coli
pseudomonas, Klebsiella, enterobacter, serrate, staphylococcus
clinical findings of acute prostatitis
perineal tenderness
rectal sphincter spasm
prostatic tenderness and bogginess
diagnosis of acute prostatitis
digital rectal exam or prostatic massage is CI
urethral swab cultures, first void urine
acute prostatitis treatment
not STI cause
Cipro x 14 days
Bactrim DS x 14 days (alternative)
f/u w/PCP
treatment of acute prostatitis
STI cause
(age <35)
ceftriaxone (Rocephin) IM dose + doxycycline (Vibramycin)
acute prostatitis disposition
abnormal vital signs = admit + Zosyn
urethritis
STD
males = dysuria with discharge
females = vaginal discharge/irritation
urethritis chlamydia infection suspected when
vaginal discharge or irritation
history of partner with urethritis
cervicitis
pyruria
urethritis clinical features
dysuria
urethreal discharge
vaginal discharge
diagnosis of urethritis
clinical
UA
urethritis infectious pathogens
chalmydia trachmoatis
neisseria gonorrhoae
trichomonsa vaginalis
urethritis treatment
ceftriaxone (Rocephin)
azithromycin or doxycycline
entrapment of retracted forskin around penis
can’t be reduced, true emergency
paraphimosis
paraphimosis clinical features
pain, swelling, erythema
venous encouragement (which can lead to occlusion and tissue necrosis)
paraphimosis ER tx
analgesics/sedative
reduction technique (reduction firmly for 5 min to reduce swelling and foreskin)
local anesthesia and incision of constricting band + circumcision
inability to retract foreskin proximally and posterior to glans penis
phimosis
phimosis
normal in uncircumcised boys
caused by poor hygiene
can cause urinary retention
infection (ABX) + topical steroids, circumcision
infection and inflammation of glans penis
Balanitis
also involves overlaying foreskin
balanitis
pain, tenderness, pursuits lesions on glans (ulcerated or scaly)
may cause urinary retention
AA and hispanic males MC
etiologies of Balanitis
poor hygiene + uncircumcised
candidate infections
allergic/contact dermatitis
STDs
Balanitis diagnosis
avoid retraction, evaluate presence of urethral meatus and inspect for discharge
illicit history of immunosuppression and Reiter syndrome
treatment Balanitis
warm soaks 2x day
candidal infection clotrimazole and miconazole
treat STD accordingly
mini STRAIGHT cath
urology consult
hair tourniquet
hair or filament wraps around penis - surgical emergency
edema and arterial compromise and amputation
young children, penile rings
suspected in unconsolable crying infant
hair tourniquet ER tx
immediate release of constriction relieves pain and restores circulation
must be taken not to further injury
try cold packs to decrease swelling and visualize hair
penile zipper injuries
foreskin becomes entrapped in teeth of zipper as zipper is opened
tx = remove zipper and free foreskin
penile block at base of penis to ease removal
ensure intact urethra
penile fracture
trauma during intercourse
report sudden snapping sound
usually swollen and angulated at fracture, caused by tear of tunica albuginea
treatment of penile fracture
retrograde urethrogram
emergent surgical repair
urethral rupture
trauma
anterior: local infection/sepsis, straddle injury
posterior: pelvic fracture, blood from urethral meatus, can’t void, perineal bruising
ER tx of urethral rupture
urethrogram
evidence of urethral rupture = supra-pubic catheterization, no foley catheterization
clinical pearls of urethral rupture
foley catheter CI
consider in trauma patient: unable to void, blood at meatus, perineal trauma
cause scrotal swelling in males
straddle injuries
pain, swelling, ecchymosis, hematoma of perineum or scrotum
dysuria and urinary retention
caused blunt trauma
straddle injuries treatment
supportive - ice packs and elevation, mini cath
can obscure perineal laceration (swelling if careful exam not performed) and pelvic radiographs
priapism clinical features
persistant painful erection
presents within several hours to days
engorgement of corpora cavernosus (glans penis, corpus spongiosum(
arterial (trauma) and venous causes (ED, sickle cell, leukemia)
treatment of priapism
Ice packs
terbutaline
pseudoephedrine
aspiration of corpus cavernosusm
phenylephrine or epinephrine
urinary retention
painful urologic emergency - sudden inability to pass urine
mc in elderly men with benign prostate hypertrophy
can use a catheter to remove urine from the bladder
hematospermia
blood in sperm
benign condition (ass. with trauma)
CAN indicate infection or cancer
GU foreign bodies
tx, complications, clinical features
genital pricing, constrictive devices and uretheral foreign bodies
s/s: swelling, edema, pain, dysuria and urinary retention
comp: UTI, urethral rupture, contact dermatitis, vascular compromise (Constrictive)
hernia
protrusion of any viscous from it surrounding tissue walls
classified by anatomic location and status
direct hernia
inguinal
men >40
origin above inguinal ligament, rarely courses into scrotum
hernia badges anteriorly, not felt in inguinal canal
indirect hernia
mc of all hernias, all ages
origin above inguinal ligament, courses into scrotum
hernia bulges into canal and touches finger tips
femoral inguinal hernias
least common
women>men
below inguinal ligament, never scrotum
