Male Genitalia Emergencies - Exam 3 Flashcards
What is testicular torsion? Who are the 2 MC pt populations?
Twisting of the spermatic cord leading to ischemia of the testicle and surrounding structures within the scrotum
neonates and puberty
sudden onset of severe, unilateral testicular, lower abdominal and/or inguinal pain
N/V may be present
What am I?
How is the pain defined?
testicular torsion
Pain is constant but may be intermittent
No change with position
aka CONSTANT pain regardless of position changes
When is the most frequent onset of testicular torsion?
most frequently after exertion!
but may occur during sleep due to contraction of the cremasteric muscle
How will the testicle present in testicular torsion? Will the affected testicle be larger or smaller?
Affected testical is firm, tender, elevated and lying transverse
affected testicle will appear LARGER and entire scrotol contents can be swollen and tender
What is a Bell clapper deformity? What PE finding is often absent?
Bell clapper deformity is a congenital (present at birth) anatomical abnormality of the scrotum where the testis is not properly anchored to the inner lining of the scrotum. This allows the testis to swing freely, like a bell clapper.
cremasteric reflex is often absent
What am I?
testicular torsion in a neonate
_____ is the imaging modality of choice for testicular torsion. What will it reveal? What might the UA show?
color-flow duplex US
diminished blood flow to the affected testis
may show pyuria
What is the management for testicular torsion? ** What is the associated timeframe?
URGENT urologic consultation!!
prep for sx: NPO, CBC, BMP, coags, pain meds and antiemetics
**6 hours after onset to detorsion
in testicular torsion, may attempt ______ if any delay in surgical detorsion or if close to 6 hour window. Describe the method
manual detorsion
open book method: detorsion is attempted by manually rotating testis in a medial to lateral direction usually 360 degrees
What will the pt report if manual detorsion is successful?
successful detorsion will result in pain relief
and need to hold manual detorsion until surgery detorsion can occur
______ is MORE common than testicular torsion. Is it an emergency?
Torsion of the Testicular Appendages
NOT a sx emergency
What are the 4 testicular appendages? Which one is MC torsed?
Paradidymis (organ of Giraldes)
appendix epididymis - MC torsed
Appendix testis
Vas aberrans of Haller: has both inferior and superior appendages
Sudden onset, severe pain, +/- N/V
Scrotal skin and testicle are usually normal appearing and minimally tender
may have isolated tender nodule
What am I?
**What is a common PE finding?
Torsion of the Testicular Appendages
**Blue dot sign
What am I?
What dx?
What should be in the dx eval? What will it show?
blue dot sign
torsion of the testicular appendages
doppler US: will show some blood flow to testis
What is the management of torsion of the testicular appendanges? When do symptoms resolve?
discharged home
Analgesics, bed rest, supportive underwear, and reassurance
s/s resolve in 3-5 days
in Torsion of the Testicular Appendages when will most appendages calcify and degenerate within? Need to follow-up with ______
10 to 14 days
need to schedule urology follow up
____ and _____ often occur simultaneously due to an underlying ______ etiology
Orchitis
epididymitis
bacterial infectious
isolated orchitis is often associated with _____ and rarely _____
viral or syphilitic disease
rarely occurs alone
Viral orchitis is most often due to _____ and will commonly present 5 days after _____
mumps
parotitis
What is the MC etiology of epididymitis? **Give the 2 options
Bacterial infection is most common
**Men < 35 who do not practice anal intercourse - Gonorrhea and Chlamydia are the most common etiology
** Men > 35 or those who do practice anal intercourse - Urinary pathogens (E.coli and Klebsiella) are usually the cause
**What is the MC etiology of epididymitis in men less < 35 who do NOT practice anal intercourse?
Gonorrhea and Chlamydia are the most common etiology
**What is the MC etiology of epididymitis in men Men > 35 or those who DO practice anal intercourse?
**Urinary pathogens (E.coli and Klebsiella) are usually the cause
Gradual onset of mild to severe unilateral testicular pain
+/- fever, recent hx of dysuria or urethral discharge
swollen, tender, warm testicle
What am I?
Where will the affected testis be hanging?
What PE finding?
Epididymitis and Orchitis
Affected testis will hang low in the scrotum
Cremasteric reflex is NORMAL
What is the Prehn sign? Will it be positive or negative in epididymitis and Orchitis?
Pain may be relieved with elevation of the scrotum
+ Prehn sign in E and O
What 3 things need to be included in the w/u of pt with Epididymitis and Orchitis?
UA with C&S
Urine PCR to check for gonorrhea and chlamydia
testicular US to confirm blood flow
**What is the tx for Epidid and Orchitis if suspected gonorrhea/chlamydia?
Ceftriaxone, 500 mg IM single dose
PLUS one of the following:
Doxycycline (preferred) or azithro
**What is the tx for Epidid and Orchitis if suspected urinary bacteria?
levo OR bactrim
What is the tx for Epidid and Orchitis if anal intercourse exposure?
ceftriaxone AND levo
What are the non-pharm tx adjunct for E and O? What is the recommended f/u?
Scrotal elevation, ice application, NSAIDs or opiates, stool softeners
Avoid lifting heavy objects, avoid straining to have a BM
Follow up with urology or PCP in 5-7 days for release to return to work
Most pts can be discharged for E and O, when do they need to be admited?
s/s of toxicity or septicemia
fever, hypotension, tachycardia
abx are the same, tx based on suspected pathogen source
What are the 2 presentations of a scrotal abscess?
Localized to the scrotal wall: hair follicle infection (superficial)
An extension of intrascrotal infections (intrascrotal): extension of testis, epididymis or bulbous urethral infection
Erythema and edema of the scrotum
Fluctuance may be palpable
Tenderness of the affected epididymis and/or testis may be present
What am I?
What diagnostic test should you order?
scrotal abscess
scrotal US: can localize the involvement of the abscess to the scrotal wall, epididymis, and/or testis and differentiate intrascrotal abscess from other causes of an inflammatory mass
What is the tx and disposition of a localized scrotal abscess?
I&D in the ED at bedside; discharge home; sitz baths
What is the tx for Intrascrotal abscesses?
Immediate urology consultation for surgical intervention
start pip/taz in IC pts until cultures are reviewed
What is fournier’s gangrene? What is the underlying cause?
A necrotizing fasciitis of the perineal, genital, or perianal anatomy
A polymicrobial infection
How does fournier’s gangrene begin? What does it result in?
Begins as a benign infection or simple abscess that quickly becomes virulent
Results in microthrombosis of the small subcutaneous vessels, resulting in gangrene of the overlying skin
Can Fournier’s Gangrene happen in women? What is super important to remember?
YES!! MC in men but can occur in women
Prompt recognition and diagnosis is vital to patient survival, mortality rate 20-40%
What are risk factors for fournier’s gangrene?
urethral strictures
perirectal abscesses
poor perineal hygiene
chronic alcohol use
diabetes
cancer
HIV
immunocompromised states
intense pain and tenderness in the perineum
Prodromal fever and lethargy for 2-7 days
Pain of the anterior abdominal wall
Intense genital edema, pain, tenderness of the overlying skin which is progressive in nature
Tense edema of the involved skin
Blisters/bullae, crepitus/subcutaneous gas
may have an odor
What am I?
What will the skin look like?
fournier’s gangrene
Dusky appearance of the overlying skin and subcutaneous crepitation may be noted, Obvious gangrene and purulent drainage from wounds
If clinical suspicion is less than high ____ should be ordered in fournier’s gangrene. What will it show?
CT scan with IV contrast
will show air along the fascial planes or deeper tissue involvement
If high clinical suspicion for fournier’s gangrene, ______ should be done first. What is the initial management?
consult urology!!!! before diagnostic eval
IV fluids
NPO
IV pip/taz
pain meds
septic work up (after consultation in preperation for sx)
_____ is inflammation of BOTH the glans and foreskin. What makes up this dx?
Balanoposthitis
Phimosis - a condition that makes it difficult to retract the foreskin
Balanitis - inflammation of the glans penis
What are the causes of balanoposthitis?
Inadequate hygiene
External irritation with subsequent microbial colonization
What organisms are commonly found in balanoposthitis?
Candida
Staphylococcus
Streptococcus
Mycoplasma genialium
foreskin retraction reveals the glans and prepuce appear purulent, excoriated, malodorous, and tender
What am I?
What makes it worse?
Balanoposthitis
complicated by bacterial infection
balanoposthitis
What is the treatment for balanopsothitis? give both fungal and bacterial infections
proper hygiene
topical/oral antifungals if fungal
mild bacterial infections in young children: Bacitracin or mupirocin topically
clinda OR metro
What should you do for balanoposthitis that is persistent despite adequate treatment?
culture fungal and bacterial
refer to urology for circumcision
what is paraphimosis? is it an emergency? why or why not?
the inability to reduce the proximal swollen foreskin distally over the glans penis into its natural position
true urologic emergency due to arterial compromise and gangreen
What am i?
paraphimosis
what is the management for paraphimosis?
Reduction of glans is the initial management
-local anesthetic block (at the base of the penis) to improve tolerability with reduction
-compress the glans for 5-10 minutes to reduce edema (hand compression or 2-inch elastic bandage )
-attempt reduction by moving the prepuce distally while the glans is pushed proximally
what is the treatment in paraphimosis if initial reduction fails?
if initial reduction fails may attempt to release glans edematous fluid
-make several small puncture wounds in the glans with a 22-25 gauge needle
what do you do if reduction fails in paraphimosis and there is arterial compromise?
- consult urology
- dorsal incision of the foreskin
- reduce the foreskin
- suture the incision
- follow up with urology in 3-5 days
what is phimosis? what are the risk factors?
the inability to retract the foreskin proximally and posterior to the glans penis
risk factors: infection, poor hygiene, previous preputial injuries with scarring
what are the complications of phimosis? what is the treatment of the complication? give both temporary and definitive treatments
urinary retention
hemostatic dilation and circumcision is curative
what is the management of phimosis?
- refer to urology
- topical steroid therapy with manual retraction (betamethasone)
- circumcision is curative
what is priapism? when does tissue damage begin to occur? when does irreversible damage begin?
a persistent (>4 hours), painful, pathologic erection unrelated to sexual stimulation and unrelieved by ejaculation
microscopic tissue damage begins after 4 hours
irreversible damage after 24 hours
what are the 2 types of priapism? which one is MC?
ischemic - low flow
non-ischemic - high flow
ischemic is MC
compare and contrast low flow and high flow priapism
ischemic is MC in painful, caused by blood going in but not out, PDE5 inhibitors and sickle cell disease
non-ischemic is rare and PAINLESS, results from tramautic fistula between the cavernosal artery and the corpus cavernosum
what is the difference in the blood gas between low and high flow priapism?
low flow - Blood gas on corporal aspirate shows hypoxemia (low O2, high CO2), blood will be black
high flow - normal, blood will be red
what is the management for priapism? what additional steps are needed in sickle cell? leukemia?
- refer to urology
- pain meds
- dorsal block then aspirate
- instillation of phenylephrine
aggressive hydration and oxygen
consult hematology and admit
when is corporal aspiration CI in priapism?
high flow priapism
in a corporal irrigation, where do you insert the needles? how long do you aspirate for? what is the final step?
insert needles at the 9 and 3 o’clock positions close to the base
aspirate until the blood turns red
compress the puncture site for 30-60 seconds to prevent a hematoma
what is the technique to remove an object causing penile entrapment?
what two diagnostic imagining should you consider following the removal of an object causing penile entrapment?
retrograde urethrogram to confirm urethral integrity
doppler US to evaluate penile arterial blood supply
when does a penile fracture occur? give the tissue layers
occurs when the tunica albuginea of one or both corpus cavernosa ruptures due to direct trauma to the erect penis
what is the MC etiology of a penile fracture? what will the patient report? how will the penis present?
sexual intercourse
an audible “snap”
acutely swollen, flaccid, discolored, and tender
what is the treatment for a penile fracture?
- refer to urology (URGENT, PENIS IS BROKEN)
- prepare man for a empty life of no sexual intercourse
- prepare for surgery; preoperative retrograde urethogram
who is at the highest risk of urethral foreign bodies? what is the management?
children and mentally unstable patients
pelvic x-ray; consult urology
what are two causes of urethal strictures?
- hx of urethral instrumentation, injury or infection
- cause unknown
decreased strength of urinary stream
incomplete bladder emptying
recurrent UTIs
urinary spraying
decreased force of ejaculate during orgasm
what am I? what is the management?
urethral stricture
straight fully cath into the bladder; if unsuccessful, try with a coude cath
leave foley in place and refer to urology for appointment within 1 wk
johannah has stinky feet from her stinky shoes
what should you do if you are unsuccessful in passing a foley cath after 3 attempts in a patient with a urethral structure?
refer to urology; if unavailable, perform an emergent suprapubic cystostomy with catheter placement
follow-up with urology within 48 hrs.
in what patient population is urinary retention seen most frequently? name some additional causes
elderly men with BPH
medication SE, neurologic dysfunction, urinary tract bleeding/calculi/infection, urethral stricture, GU trauma, organic mass
rapid onset of lower abdominal pain/distention with the inability to pass urine
what am I? what 2 exams do you need to do in males and females? what needs to be done in both sexes?
urinary retention
male - urethral exam and prostate exam
female - external GU and pelvic exam
neurologic exam to assess perineal sensation and anal sphincter tone
how do you diagnose urinary retention? what will it show?
post void residual ultrasound
residual volume of greater than 50-150 cc
what is the treatment for urinary retention if hematuria is present?
insert a 3-point foley and profusely irrigate the bladder until it is no longer bloody
attempt a foley cath; if unsuccessful, attempt with coude tip
urgent urology consult if unable to place a cath
what is the management in urinary retention if urology consult is unavailable?
emergent suprapubic cath
send UA for analysis and culture
BMP to check for electrolytes
control bladder spasms with oxybutynin
what is the disposition for urinary retention?
can send pt home with cath in place, follow-up with urology in 3-7 days
admit patients who have signs of post-obstructive renal failure or post-obstructive diuresis
what is considered post-obstructive diuresis? how long do you need to monitor for?
> 200 ml/hr of urine output for at least 2 consecutive hours is indicative of post-obstructive diuresis requiring admission for fluid replacement and electrolyte monitoring
monitor urine output in ED for 4-6 hours
