Male Genitalia Emergencies Flashcards
Twisting of the spermatic cord leading to ischemia of the testicle and surrounding structures within the scrotum
Testicular Torsion
any male complaining of testicular, groin or lower abdominal pain, what should be top of ddx?
Testicular torsion
testicular torsion MC occurs in who?
- neonates and during puberty
- Can occur at any age
causes of testicular torsion
- exercise, mild trauma or during sleep
- MC no preceding event identified
- Sudden onset of severe, unilateral testicular, lower abdominal and/or inguinal pain
- N/V may be present
- Infants/preverbal toddlers: inconsolable crying
- constant/intermittent pain - No change with position
- MC after exertion - May occur during sleep
- h/o similar sx that resolved w/o intervention
Testicular Torsion
signs of testicular torsion
- firm, tender, elevated and lying transverse (Bell Clapper)
- may appear larger than unaffected testis
- Epididymis may be felt anteriorly
- (-) cremasteric reflex - most sensitive finding but nonspecific
- pain and tenderness spreads to other intrascrotal structures
- entire scrotal contents swollen and tender
w/u for testiular torsion
- Color-flow Duplex US scrotum/testicles: diminished blood flow to the affected testis; possibly normal despite torsion
- UA - may show pyuria - does not r/o
tx testicular torsion
- Urgent urologic consult - if suspicion is high
- detorsion 6 hours after onset
- Prepare for surgery - NPO, CBC, BMP, coags
- IV analgesic and antiemetic
- Attempt manual detorsion if any delay in surgical detorsion or if close to 6 hour window - medial to lateral direction
most torsions occur in what direction
a lateral to midline
- More common than testicular torsion
- NOT a surgical emergency
Torsion of the Testicular Appendages
4 possible Torsion of the Testicular Appendages?
which is MC?
- Paradidymis (organ of Giraldes)
- appendix epididymis - MC torsed
- Appendix testis
- Vas aberrans of Haller - inferior and superior appendages
- Sudden onset, severe pain, +/- N/V
- early: localized to upper pole of testis (in appendix epididymis) - Scrotal skin and testicle are nml appearing and minimally tender
- isolated tender nodule
- “Blue dot” - appearance of a cyanotic appendage
Torsion of the Testicular Appendages
w/u for Torsion of the Testicular Appendages
- Doppler US - confirms blood flow to testis
tx Torsion of the Testicular Appendages
- Most DC home
- Analgesics, bed rest, supportive underwear, and reassurance
- resolution 3-5 d - Most calcify and degenerate 10-14 d
- Consult urology for surgical exploration if unable to r/o testicular torsion
two conditions that often occur simultaneously due to an underlying bacterial infectious etiology
Orchitis and epididymitis
cause of orchitis
- Isolated orchitis - viral or syphilitic dz (rarely occurs alone)
- Viral - mumps; orchitis commonly presents 5 days after parotitis
MCC Epididymitis
Bacterial infection
- Men < 35 who do not practice anal intercourse - Gonorrhea & Chlamydia
- Men > 35 or those who do practice anal intercourse - Urinary pathogens (E.coli and Klebsiella)
-
Gradual onset of mild to severe unilateral testicular pain
- lower abd, inguinal canal and/or scrotum
- +/- F, recent h/o dysuria or urethral discharge - Affected testis will hang low in scrotum
-
swollen, tender, warm testicle/epididymis
- Cremasteric reflex is normal
- Pain relieved with elevation of scrotum (+ Prehn sign)
Epididymitis and Orchitis
w/u for Epididymitis and Orchitis
- UA with C&S in most patients
- pyuria in 50% of patients - Urine PCR or DNA probe (if discharge is present) for GC and Chlamydia
- Testicular US if needed to confirm blood flow
- may show an increase in blood flow
tx for Suspected or confirmed GC/Chlamydia in Epididymitis and Orchitis
Ceftriaxone + Doxy (preferred)/Zithromax
tx for Suspected urinary/ bacteria in Epididymitis and Orchitis
- levofloxacin
- Bactrim
tx for Anal intercourse exposure in Epididymitis and Orchitis
ceftriaxone + levofloxacin
Nonpharmacologic therapies for Epididymitis and Orchitis
- Scrotal elevation, ice application, NSAIDs or opiates, stool softeners
- Avoid lifting heavy objects, avoid straining to have a BM
signs of toxicity or septicemia in Epididymitis and Orchitis that warrant admission?
w/u?
tx?
- Fever, hypotension, tachycardia
- CBC, CMP, lactic acid, blood cx
- Suspected GC/Chlamydia - ceftriaxone + doxycycline
- Suspected urinary pathogens - levofloxacin/ceftriaxone
- Consult urology
2 presentations of scrotal abscess
- Localized to scrotal wall (superficial): hair follicle infections
- extension of intrascrotal infections (intrascrotal): extension of testis, epididymis or bulbous urethral infection
- Unilateral testicular/scrotal pain and swelling
- sx related to intrascrotal etiology: sx of a UTI/STD
- Erythema and edema of the scrotum
- Fluctuance may be palpable
- Tenderness of affected epididymis and/or testis may be present
Scrotal Abscess
w/u Scrotal Abscess
Scrotal ultrasound
- differentiates intrascrotal abscess vs other causes of inflammatory mass
- Localize involvement of abscess to the scrotal wall, epididymis, and/or testis
treatment of choice for scrotal abscess
Surgical drainage
specific mgmt for Localized scrotal abscess
I&D in the ED at bedside; DC; sitz baths
specific mgmt for Intrascrotal abscesses
- Immediate urology consultation for surgical intervention
- Broad-spectrum abx in immunocomp until cx are reviewed - pip/taz
A necrotizing fasciitis of the perineal, genital, or perianal anatomy
fournier’s gangrene
pathophys of fournier’s gangrene
- polymicrobial infection
- starts benign or simple abscess that quickly becomes virulent
- Results in microthrombosis of small subcutaneous vessels = gangrene
RF for fournier’s gangrene
- urethral strictures, perirectal abscesses, poor perineal hygiene, chronic alc use, DM, cancer, HIV and other immunocomp
- MC in men but can occur in women
- Intense pain and tenderness in perineum
- Progressive clinical course
- Prodromal fever and lethargy x 2-7 d
- Pain in anterior abd wall, migrates to gluteal muscles, scrotum and penis
- Intense genital edema, pain, tenderness of overlying skin
- Dusky appearance, subcutaneous crepitation
- gangrene of a portion of genitalia and purulent drainage from wounds - Tense edema of the involved skin
- Blisters/bullae, crepitus/subcutaneous gas
- A feculent odor if infected with anaerobes bacteria
- +/- fever, tachycardia, hypotension
Fournier’s Gangrene
w/u If clinical suspicion is less than high for Fournier’s Gangrene
CT w/ IV contrast: air along fascial planes or deeper tissue involvement
mgmt If high clinical suspicion for Fournier’s Gangrene
- urgent urologic consultation before w/u
- fluids, NPO
- pip/taz
- Opiate analgesia, antiemetics
- Septic work up (after consult in preparation for surgery) - CBC, CMP, lactic acid, DIC panel, blood and urine cx, cx of any open wound or abscess
inflammation of both the glans and foreskin
Balanoposthitis
a condition that makes it difficult to retract the foreskin
Phimosis
inflammation of the glans penis.
Balanitis
causes of balanoposthitis
- Inadequate hygiene
- External irritation with subsequent microbial colonization: Candida, Staphylococcus, Streptococcus, Mycoplasma genialium
- foreskin retraction reveals the glans and prepuce appear purulent, excoriated, malodorous, and tender
- complicated by bacterial infection: warmth, erythema, and edema of the glans, foreskin, and penile shaft
Balanoposthitis
tx for Balanoposthitis
- Frequent washing with saline and adequate drying; education on proper hygiene to prevent reoccurance
- nystatin / clotrimazole topicals
- fluconazole PO if severe
- bacterial infection: Bacitracin / mupirocin (mild); clinda PO / flagyl PO
tx for Persistent symptoms despite adequate treatment
in Balanoposthitis
- Obtain fungal and bacterial specimen swabs: Rapid GAS test, KOH, Gram stain with bacterial cx
- refer to urology/general surgery for circumcision
- The inability to reduce the proximal edematous foreskin distally over the glans penis into its natural position
- A true urologic emergency - progression to arterial compromise and gangrene may occur
Paraphimosis
mgmt options for paraphimosis
- Reduction of glans
- local anesthetic block
- compress glans x 5-10 m (hand or 2-in bandage)
- attempt reduction
next steps If initial reduction fails for Paraphimosis
- release glans edematous fluid
- make several small puncture wounds in the glans with a 22-25 gauge needle
If reduction fails and there is arterial compromise in Paraphimosis:
- consult urology
- If urology unavailable - 1% lidocaine + dorsal incision of the foreskin
- Incise constricting band of paraphimosis
- Reduce foreskin, and suture - F/u with urology in 3-5 d
The inability to retract the foreskin proximally and posterior to the glans penis
Phimosis
RF for Phimosis
infection, poor hygiene, and previous preputial injuries with scarring
complication of phimosis?
mgmt?
- urinary retention
- hemostatic dilation (after topical anesthetic) of the preputial ostium temporarily relieves urinary retention
- circumcision is curative
mgmt for phimosis
- refer to urology - consider circumcision or dorsal slit
- topical steroid + daily manual preputial retraction may reduce need for circumcision - betamethasone, 0.05% - 0.10% BID apply from the tip of the foreskin to the glandis corona for 1 to 2 months
A persistent (>4 hours), painful, pathologic erection unrelated to sexual stimulation and unrelieved by ejaculation
Priapism
- Priapism - Microscopic tissue damage begins after ?
- Irreversible damage after ? - May result in urinary retention, infection, corporal fibrosis and permanent ED
hours
- 4 hours
- 24 hours
2 types of priapism
- ischemic - low flow priapism
- Non-ischemic - high flow priapism
causes of ischemic - low flow priapism
- Idiopathic (MC in adults)
- Sickle cell disease (MC in < 18 y/o), leukemia
- metastatic carcinoma
- ETOH, marijuana, cocaine, ecstasy
- PDE5 inhibitors, some antihypertensives and neuroleptics
- Common, painful
- Blood gas on corporal aspirate shows hypoxemia (low O2, high CO2) - aspirated blood will appear black
which type of Priapism
ischemic - low flow priapism
- rare, most often painless
- usually results from traumatic fistula between the cavernosal artery and the corpus cavernosum
- Blood gas on corporal aspirate is normal - aspirated blood is red
Non-ischemic - high flow priapism
mgmt for priapism
- Urgent urology consult even if ED provider stabilizes patient
- Analgesics - opioid
-
Corporal aspiration after dorsal block
- +/- saline irrigation
- instillation of phenylephrine
- CI in high flow priapism - Additional management (after corporal aspiration)
- Sickle cell: hydration & O2
- Leukemia and malignant priapism: consult hematology and admit
priapism - If failure to respond to aspiration and phenylephrine injection consult urology for ?
shunting procedure
how to prevent the formation of a hematoma when treating priapism?
compress puncture site for 30-60 seconds after removing the needle from the corpora cavernosa.
Vascular occlusion injury that occurs when various objects are wrapped around the penis
Hair, string, metal rings, wire
Penile Entrapment
techniques for object removal in Penile Entrapment
- compression/cooling of the penis followed by:
- string technique
- corporal aspiration: insert 18-gauge needle in one of corpora cavernosa to drain the edema and blood, then attempt removal - cutting the object
- urologic surgical removal
potential w/u used to look for injury in penile entrapment
- Retrograde urethrogram to confirm urethral integrity
- Doppler US evaluate penile arterial blood supply
- Occurs when the tunica albuginea of one or both corpus cavernosa ruptures due to direct trauma to the erect penis
- May be associated with partial or complete urethral rupture or deep dorsal vein injury
Penile Fracture
causes of Penile Fracture?
MC?
- sex (MC)
- other causes: masturbation, animal bites, stabbing, bullet wounds, self-mutilation
- Patient will report trauma during intercourse (or other etiology) with an audible “snap”
- Penis becomes acutely swollen, flaccid, discolored and tender
Penile Fracture
mgmt for Penile Fracture
- Urgent urologic consultation to determine need for surgical repair
- Prepare for surgery - reop retrograde urethrogram
- Analgesics
- Anxiolytics
A localized fibrotic disorder of the tunica albuginea which causes progressive penile deformity typically resulting in curvature with erections
Peyronie’s Disease
Hx of sexual dysfunction, penile pain, indentation, curvature, shortening deformity during erection
thickened plaque, involving the tunica albuginea of the corpora bodies
dx?
mgmt?
Peyronie’s Disease
refer
w/u and mgmt for urethral FB?
- Clinical presentation of bloody urine and/or slow, painful urination
- Highest risk: children and mentally unstable patients
- Pelvic x-ray
- Consult urology
A narrowing of the urethra leading to chronic obstructive voiding symptoms and occasionally complete obstruction
Urethral Stricture
causes of Urethral Stricture
- hx of urethral instrumentation, injury or infection
- often times etiology remains unknown
presentation of urethral stricture
- decreased strength of urinary stream
- incomplete bladder emptying
- recurrent UTIs
- urinary spraying
- decreased force of ejaculate during orgasm
tx for urethral stricture
- 14- or 16- Fr Foley straight tip catheter
- If unable to pass, use 12- Fr Coude catheter with anesthetic lubricant - If successful, leave foley in place and refer to urology for appt within 1 week
- If failure to pass cath after 3 attempts, consult urology
- If urology is unavailable - emergent suprapubic cystostomy w/ catheter placement - f/u with urology within 48 hours
An emergent condition characterized by the inability to pass urine
Urinary Retention
Urinary Retention is MC in who? other causes?
- elderly men with BPH
- medication SE, neurologic dysfunction, urinary tract bleeding/calculi/infection, urethral stricture, GU trauma, organic mass
presentation of urinary retention
- Rapid onset of lower abd pain/distention with the inability to pass urine
- Male: Urethral exam - look for signs of stricture; Prostate exam - assess for enlargement
- Female: External GU exam - assess for prolapsed bladder, urethral stricture; Pelvic exam
- Neuro exam: complete exam + assessing perineal sensation and anal sphincter tone
w/u for urinary retention
Post void residual US - residual volume of > 50-150 cc is indicative of retention
mgmt for urinary retention
- If hematuria is present: 3-port Foley
- Attempt a 12- or 14- Fr Foley catheter with anesthetic lubrication - If failed, insert Coude tip catheter
- Leave Foley in place unless underlying cause for retention is thought to be post-anesthesia related
- Emergent suprapubic catheter if immediate urologic consult not available
- send urine for analysis and cx, BMP, analgesics
- tx underlying
Urgent urology consult for urinary retentation if:
failure to pass Foley or Coude catheter, recent instrumentation, obstruction due to stricture, prostatitis or trauma
tx for bladder spasms in urinary retention
oxybutynin 5 mg - watch for medication induce obstruction
disposition for urinary retention MC?
- sent home with catheter in place
- follow up with urology in 3-7 days - catheter will be removed at that time
Admit urinary retention who meet any of the following criteria
- signs of post-obstructive renal failure
- signs of post-obstructive diuresis
- monitor urine output in ED for 4-6 hours
- >200 ml/hr UO for 2 consecutive hours = post-obstructive diuresis - admit for fluid replacement and electrolyte monitoring
