Male GU/Anorectal Emergencies Flashcards
1
Q
Acute scrotal pain
A
- Epididymitis
- The most common cause of scrotal pain
- Infectious vs. Noninfectious
- “Trauma”
- AutoImmune Dz, Vasculitis
- Epididymitis: epididymis lies posteriorly on the testis à MCC is STD
- Hx:
- Gradually increasing pain and swelling (over days)
- ?Dysuria/Fever
- PE:
- Ask the pt. to remove all clothes below the waist and lie down in order to examine
- Prehn’s Sign –
- Elevation of the scrotum relieves pain
- This is unreliable to differentiate Testicular Torsion
- Cremasteric Reflex –
- Stroking the thigh on the affected side causes the ipsilateral testis to pull upwards
- (Compare with the unaffected side)
- Useful and also Unreliable
- He says that these are test questions youll see over and over again. But he never does it because it will hurt the guy and its NOT A RELIABLE sign!
- Tx:
- UA, STD Testing, ?ULS (reactive Hydrocele Vs.)
- Possible Urine culture (E.coli, Pseudomonas,)
- Presumptive Therapy: Ceftriaxone 250 mg IM
- And Doxycycline 100mg PO BID X days
- If over age 35, consider Levofloxacin 500 mg qd X 10 days
- Analgesics, SITZ baths, Scrotal Support
- F/U instructions/expectations
2
Q
hydrocele
A
- Collection of fluid between the Parietal and Visceral layers of the Tunica Vaginalis.
- Arise over a longer period of time, Usually asymptomatic, but increasing pain with increasing size.
- Treatment rarely needed, Aspiration doesn’t work, Surgery will.
3
Q
Varicocele
A
- Dilatation of the Pampiniform plexus of spermatic veins. Left hemiscrotum.
- 20% of men
- Occas. Dull, achy pain.
- Tx: Scotal Support, NSAID, Surgery for infertility.
4
Q
epididymal cysts and spermatoceles
A
- Arise on the head of the epidymis, when larger than 2cm called Spermatoceles
- Generally asymptomatic, found on ULS.
- Testicular Cancer
- Usually painless, unless it causes hemorrhage or infarction
5
Q
orchitis
A
- Extension of epididymal infection into the testes, or complication of Mumps.
- More systemic symptoms:
- Fever, myalgias, malaise, parotid swelling
6
Q
inguinal hernia
A
- Failure of adequate embryonic closure of the
- Processus vaginalis in the inguinal canal, allowing intestines to force downwards into the scrotal sac.
- Sx:
- Uncomfortable but not acutely painful, usually reducible by a push or lying supine. Often gradually enlarge.
- PE:
- supine, and if not palpable, standing.
- If acutely painful, think:
- Obstructed vs. Incarcerated vs. Strangulated
- ULS/CT
- Let the surgeon decide to push
- Tx:
- Scrotal Support, Analgesics, Stool softeners, Surgical Referral.
7
Q
torsion of the appendix testis
A
- Caused by the infarction/necrosis of the appendix testis. Rare in adults.
- Most common scrotal pathology in children
- 7-14 y.o. Pain usually more gradual than testicular torsion. Tenderness localized to the anterosuperior testis and no swelling to the testis or epididymis.
- PE:
- Inspect the scrotal wall for the “Blue dot” sign… Testicular ULS.
- Tx: Pain Control
8
Q
testicular torsion
A
- The testis twists on the spermatic cord causing ischemia. Irreversible damage after 12-24 hours.
- Sx:
- Sudden severe pain, often a few hours after physical activity or trauma.
- PE:
- a ‘high riding’ testis on the affected side with with the long axis of the testis oriented ‘sideways’. A “Bell Clapper Deformity”.
- Testicular swelling early, leading to a reactive hydrocele, and lastly scrotal redness.
- The Cremasteric Reflex – absent in torsion
- Tx:
- “Time is Testicle”
- Analgesics, (UA, etc.)
- Immediate Urologic/Surgical consultation
- Manual Detorsion – ‘Opening a book’ until pain relieved. Supposedly dramatic relief. ?
- Color Doppler Ultrasound
- OR
9
Q
Fournier’s Gangrene
A
- Necrotizing Fasciitis. Mixed aerobic and anaerobic bacterial infection rapidly leading to systemic illness/Sepsis/death.
- Sx:
- Scrotal pain, tense edema, blisters, hemorrhagic bullae, fever, tachycardia, hypotension.
- Tx:
- IV/Labs/broad spectrum antibiotics/CT. Immediate Surgical consult
- OR – early and aggressive surgical debridement
- Being a diabetic is a huge risk factor
- You get high white counts and low sodium
10
Q
Balanitis
A
- “Balanos” is Greek for “Acorn” –Inflammation of the Glans.
- Balanoposthitis is when the foreskin is involved.
- Most common etiology is Candida albicans
- Sx:
- Increasing tenderness, pain, swelling, and discharge over days.
- Tx:
- Fingerstick glucose, STD labs
- 1-3 weeks of antifungal.
- Clotrimazole/Miconazole BID, Hydrocortisone 1% cream.
- Single dose of Fluconazole PO ?
- Better Hygeine
11
Q
Phimosis and paraphimosis
A
- “Phimoun” from the Greek, “to muzzle”.
- When the foreskin tightens over the glans and cannot be retracted it is Phimosis.
- If the foreskin is retracted and becomes so swollen that it constricts like a tourniquet around the glans it is Paraphimosis.
- Sx:
- Balanitis gone bad.
- Foreskin adheses, glans swells
- Tx:
- Phimosis doesn’t usually need treatment different from balanitis.
- Paraphimosis requires manual decompression or surgical circumcision
12
Q
Penile entrapment injury
A
- Hair Tourniquet in Infants
- Adult Sexual Midadventures
- Penile Fracture
13
Q
priapsim
A
- A painful erection lasting more than 4 hours (without sexual excitation)
- Priapus was the Greek God of Fertility
- The bastard son of Zeus and Venus, born with too generous an endowment, cast off to live with shepherds, who noticed that flowers would bloom and animals would copulate whenever he walked by.
- The blood in the corpora cavernosa becomes entrapped and ‘stagnates’due to impaired relaxation of the smooth muscle.
- Uncommon.
- Hx should include duration of erection, prior episodes, history of Sickle Cell, Leukemia, medications(antidepressants, antipsychotics, antihypertensives, impotence injectables, Atarax, Reglan, and Prilosec), recreational drugs… Spinal cord injuries,Black Widow and Scorpion envenomations, Malaria, etc.
- Tx:
- Doppler ULS or Cavernosal blood gas if nonischemic priapism suspected (aspirated blood is red instead of black).
- CBC, HgB electrophoresis, Utox
- Surgical/Urologic Consult
- Intracorporeal Aspiration /Irrigation and Phenylephrine 100-500 mcg per ml, injected into the corpus cavernosum every 3-5 minutes for an hour (or until 1 mg total reached)
- OR, surgical shunt cut between corpus cavernosum and corpus spongiosum.
14
Q
Hemorrhoids
A
- Hemorrhoids
- Dilated AV channels and connective tissue with veins arising from the superior and inferior hemorrhoidal veins in the submucosal layer of the inferior rectum.
- Internal hemorrhoids above the dentate line and External hemorrhoids below.
- All are graded on the degree that they prolapse
- Sx:
- Painless bleeding, Prolapse, Pain, Pruritus
- Hx/PE:
- Risk assessment for GI bleeding (PUD, IBD)
- Position the pt. so that you can see. Light!
- If painful look for fissures, abscess, or thrombosed hemorrhoid.
- If nothing external then anoscopy.
- in general, hemorrhoids don’t hurt, they just bleed which is what scares people
- Tx:
- Sitz baths. Increase Fiber, decrease Straining.
- Fiber supplementation (Methylcellulose/Psyllium, 20-30 G/d)
- Analgesic/Hydrocortisone Creams or Suppsitories
- Stool Softeners
- Surgery Referral:
- Rubber Band Ligation, Infared Coagulation, Sclerotherapy, Cryosurgery, Surgical Hemmorhoidectomy
15
Q
PeriAnal/Rectal Abscess
A
- Infected Anal Crypt gland.
- 50% become fistulas!
- Sx: Pain,Swelling, Mass, Pus, Fever
- PE: Positioning, Light!
- Digital Exam. If palpable induration or significantly increased pain, consider CdT with
- Contrast. Surgery Consult. Labs.
- Tx: I&D with local anesthesia. Elliptical skin excision because of no packing, or use rubber drains… SITZ baths.Analgesics. Stool Softeners.
- Antibiotics depending on size and comorbidities
