Male Urology Flashcards
Causes of acute scrotum
- Testicular torsion
- Torsion of the Testicular appendage
- Epididymitis
- Orchitis
- Fournier’s Gangrene
- Priapism
- Penile Fracture
- Prostatis
- Phimosis
- Paraphimosis
- Entrapment
- Neoplasm
A 14 year old male presents with a one hour history of scrotal pain and vomiting. He denies fever or urinary symptoms but does report vomiting several times. On exam his cremasteric reflex is absent and the painful testicle has a horizontal lie.
testicular torsion
what is a bell clapper deformity
testicle lacks the normal attachment to the tunica vaginalis and rests within the scrotum, and has increased mobility as a result
when is the peak occurrence of testicular torsion
- Peak occurrences neonates and post pubertal
- average 16years old
Painful inguinal mass and empty scrotum =___
torsion
presentation of torsion
- severe pain w/ abrupt onset
- Usually starts in scrotum, but can be inguinal or abdominal
- pain can be constant or intermittent
- ~ 50% of patients have a hx of similar pain resolved* spontaneously
- Not positional (this is an ischemic event)
- Nausea, vomiting and anorexia is common
- May have a history of strenuous activity, may occur during sleep
- Can have unilateral cremasteric muscle contraction during sleep
PE of torsion
- inspect:
- Redness, swelling is inconsistent with torsion
- “High riding transverse testicle” - Loss of cremasteric reflex on the affected side is most sensitive (do this before palpating the testis)
- Palpate, evaluate penis for discharge
- Swollen, tender, firm hemiscrotum
how do you elicit the cremasteric reflex
- stroke ipsilateral inner thigh with a tongue depressor or gloved hand
- elevation of the testicle through contraction of cremasteric muscle
how do you dx torsion
- Doppler Ultrasound (sens 86-90%)**
- Test of choice in most places, looking for absent or decreased blood flow
- Non invasive, rapid
- Any procedure that delays the OR is unwise - Midstream urinalysis (consider infectious causes)
- Urethral swabs prior to urinating – or send urine for culture and GC/Cx – to evaluate for other causes
treatment of torsion
- Immediate Urologic consult
- Manual or Surgical detorsion and orchipexy (fixation of testicle of scrotal wall to prevent twisting)
- Almost 100% salvage rate if performed less than 6 hours, over 20% at 12 hours
- Manual detorsion
What way do testicles typically rotate and
how do you perform manual detorsion
- Teste usually twists lateral to medial – but 30% of cases torse laterally (so start with rotating outward–opening a book)
- Can torse 180-270 degrees
- Right testicle usually counterclockwise, left clockwise
- If pain becomes worse rotate the opposite direction
presentation of torsion of the testicular appendage
- Pain is usually more sub acute and of gradual onset
- Similar episodes not typical
- 3-5 mm nodule palpable between the epididymis and testicle
- “Blue –dot sign” visible through the skin early on
- Rarely any voiding symptoms or fever; may have a reactive hydrocoele
what is the blue dot sign
visible blue dot on the testicle
-sign of torsion of the testicular appendage
how do you dx and treat torsion of the testicular appendage
- Doppler US shows normal blood flow of the testicle
- Non surgical, appendages calcify or degenerate over 14 days
- Scrotal elevation
- Analgesics
- If pain is refractory, surgical excision may be needed
most common cause of acute scrotum
epididymitis
Key facts of epididymitis
- 75% of cases are post-pubertal
- More advanced cases present with testicular pain and swelling (epidimo-orchitis)
- Can be infectious or non infectious (often due to STDs)
untreated epididymitis may develop into a ___
scrotal abscess
presentation of epididymitis
- Usually gradual onset of pain
- Dysuria, urgency, frequency common
- Urethral discharge
- may be subtle in chlamydia - Nausea, vomiting anorexia are uncommon
- Fever, leukocytosis on 30-50%
- Can have lower abdominal, inguinal, scrotal or testicular pain
- Positive Prehn Sign- feels better when testicle is lifted up
- unilateral enlarged/angry looking testicle
most common misdiagnosis for torsion
epididymitis
how do you evaluate epididymitis
- first r/o torsion
- urinalysis (+/- GC/ chlamydia)
*Non infectious epididymitis usually has less aggressive or concerning clinical presentation, and a cause is not often identified
treatment for epididymitis for pre-pubertal
-consider underlying GU abnormality
treatment for epididymitis for sexually active males any age
ceftriaxone 250 mg IOM
AND
Doxycycline 100mg BIDx10d OR Azithromycin (1 gram for the clam)
treatment for epididymitis for MSM
ofloxacin or levofloxacin to cover enteric organisms
treatment for epididymitis for non-infectious
symptoms management: Scrotal elevation, NSAIDs, decreased activity
other considerations for treatment for epididymitis
- Abstinence from sex/safe sex/STD counseling
- Consider testing for HIV/syphilis
- Consider treatment of sexual partners
__ usually occurs as extension of epididimytis
orchitis
___ decreased the incidence of orchitis
-May occur with __ or ___
mumps vaccine
syphilis or other viral
*Should be considered in non immune adult
orchitis can cause
- testicular atrophy
2. impaired fertility
presentation of orchitis
- Testicle itself is large and tender
- Follows or is concurrent with parotitis*
- Usually presents as bilateral tenderness
differentiation of acute epididymitis and testicular torsion
testicular torsion:
- 14y/o and neonate
- sudden onset, not affected by position
- worse w/ exercise/sleep
- peaks in hours
- 20% fever
- vomiting from pain
- testicular swelling only after 12 hrs
- rare voiding compliants
- non-tender prostate
- decreased doppler blood flow
- previous episodes in past 2 weeks
- UA: 30% have WBCs/baceria
Epididymitis:
- 25y/o
- gradual onset, worse w/ standing
- rarely after sleeping
- peaks in days
- fever* (95%)
- common testicular swelling
- common dysuria/discharge
- prostate tender
- increased doppler blood flow
- UA: 50% may be normal
**imaging studies are always indicated in differentiating btwn these two
___ are always indicated in differentiating btwn testicular torsion or epididymitis
imaging studies
Unexplained testicular mass should be approaches as a ___
possible neoplasm
___ may present similar to torsion with acute pain
Hemorrhage into a neoplasm
Epididymitis or hydrocele not resolved in 2 weeks should be evaluated with __
a doppler US
presentation of testicular neoplasm
- lump/mass
2. heaviness to testicle
dx of testicular neoplasm
- US*
- AFP
- HCG
- LDH
*Very high cure rate if contained to testicle (5 yr survival is 95% with early detection)
what is Fournier’s Gangrene
- Necrotizing fasciitis of the perineum
- Mortality rate approximately 25%
- Surgical emergency
Organisms that cause of Fournier’s Gangrene
Polymicrobial (average 3.4 organisms)
anaerobic Streptococcus, B. fragilis, E. coli
who is at risk for Fournier’s Gangrene
- immunocompromised
- diabetes
- alcoholics
- IV drug use
presentation of Fournier’s Gangrene
- ALWAYS UNDRESS YOUR PATIENT
- Pain or itching in the genitals followed by
- fever, chills and sometime
- massive perineal swelling
- Swelling may involve abdomen, back and thighs with crepitance
- Consider in any patient with scrotal, rectal or genital pain and tachycardia out of proportion to exam.
*can rapidly progress in 4-6 hrs
PE of Fournier’s Gangrene
- Genital exam shows edema, erythema, and foul smelling discharge, or frank necrotic tissue
- Consider in any patient with scrotal, rectal or genital pain and tachycardia out of proportion to exam.
cause of Fournier’s Gangrene
- Perineal infection
- Trauma, including anal intercourse
- Scratches
- Chemical or thermal injury/burns
Pathophysiology of Fournier’s Gangrene
- bacterial invasion causes leading to dermal gangrene
2. erythema, edema, inflammation infection in closed space
how do you dx and tx Fournier’s Gangrene
- Surgery Consult STAT.
2. Plain film of CT may show free air in soft tissue
tx of Fournier’s Gangrene
Treatment includes
- Aggressive IV fluid resuscitation
- Broad spectrum IV antibiotics to cover gram (+), gram (-) , anaerobic organism
- Emergent surgical debridement
- Often a colostomy and suprapubic drainage system are created; Testis and spermatic cord are usually preserved ( thigh pouch)
what is priapism
-Prolonged painful erection, NOT associated with sexual stimulation
+/- urinary retention
who gets priapism and their most common causes
- Bimodal: 5-10 years, and 20-50 years old
- Children:
- sickle cell disease (66%), leukemia, lymphoma or pelvic tumors - Adults:
- sickle cell disease, drugs, idiopathic, neurogenic causes like spinal cord trauma
2 types of priapism
- low flow (ischemic)– most common 80-90%
2. high flow
describe low flow priapism
Low flow (ischemic)
- most common (80-90%)
- Decrease venous outflow produces venous stasis
- Ischemia from arterial compromise, VERY PAINFUL
describe high flow priapism
High Flow
- Increased arterial flow into corpus cavernosum
- Usually from direct trauma (saddle or perineal) to internal pudendal artery
- Not as emergent, penis does not become ischemic, MINIMAL PAIN
Presentation of low flow priapism
PEX:
- PAINFUL
- glans is soft
- rigid shaft
- Corpus spongiosum is flaccid**
presentation of high flow priaprism
PEX:
- PAINLESS
- hard glans
- entire penis is rigid
taking a hx regarding priapism
- Duration of erection
- Tissue damage after 4-6hr; irreversible damage after 24-48 hours - Associated symptoms
- Prior episodes
- Symptoms of malignancy or hematologic disease, especially Sickle Cell Disease
- Hx of trauma
- ***Medication and recreational drug use
-Tissue damage after ___; irreversible damage after ___
4-6hr
24-48 hours
common causes of priapism
- prescription drugs (Invega, viagra, psychotropics**, antihypertensives)
- illicit drugs (ethanol, cocaine, THC**)
- hematologic dz (sickle cell*, leukemia, thalassemia)
- spinal cord injury
tx of priapism
- Terbutaline .25-.5mg q 20 min IM deltoid
- Oral Sudafed (60-120 mg)
- Corporal cavernosum irrigation with a butterfly needle (2 or 10 o’clock)
- 19/21g gauge; aspirate 3-5 mL
* *Do not inject near urethra or deep and superficial dorsal veins - Urology consult
- surgical shunt may need to be placed - Sickle cell: detumesce with O2, hydration, analgesia, and alkalization
what is a penis fracture
Disruption of the tunica albuginea surrounding the corpora cavernosa
presentation of penis fracture
- Usually occurs during vigorous intercourse or bending the penis during masturbation
- Classic history involves a popping sound,
- pain,
- swelling and
- rapid detumescence
PE of penis fracture
- There may be a palpable hematoma or defect.
- If buck’s fascia is intact only the shaft will be ecchymotic; otherwise bruising will travel to the scrotum
- Many patients will have gross blood at the meatus and an inability to void
___ is the deep fascia covering the three erectile bodies of the penis
Bucks fascia
urology consult for penis fracture is important for:
Retrograde urethrography to evaluate for damage to the urethra
presentation of prostatitis
- Suprapubic, back, perineal pain
- Dysuria/frequency/urgency;
- painful ejaculation, F/C
risk factors for prostatitis
- Anatomic variants
- STDs
- Acute epididimytis/urethritis
- Urinary catheter
how do dx prostatitis
- clinical
2. UA- culture often neg
tx of prostatitis
- Cipro/ Levo for 30d
- Pain meds
- Admit if immunocompromised/septic
Presentation of phimosis
- Inability to retract the foreskin proximally
- painful to pull back
- tight, clingy foreskin
- Usually no difficulty voiding
tx of phimosis
- Topical hydrocortisone for 1 moth
2. Circumcision is definitive treatment
complication of paraphimosis
- can lead to arterial compromise and gangrene
* surgical emergency
what is paraphimosis
Inability to REDUCE the edematous proximal foreskin over the glans
treatment ofparaphimosis
- Try wrapping the gland
- Puncture wounds to express edema fluid
- Provide local or regional anesthesia
- Superficial vertical incision until f/u w urology
dx/ tx of penile entrapment
- objects are wrapped around penis
- Urology consult
- Remove object
- Imaging: retrograde urethrogram or ultrasound
high riding testicle usually means
torison
risk factors for epididymitis for those under 35y/o
- Usually STD - Chlamydia or GC
- Co-infection in ~30% of cases
- Can be several months post exposure
consider ___ for epididymitis in MSM
consider enteric organism, HSV
risk factors for prepuberal epididymitis
- anatomic abnormality,
- foley,
- inappropriate contact
common cause of epididymitiis in someone over 35 y/o
E. coli or klebsiella
Consider in any patient with scrotal, rectal or genital pain and tachycardia out of proportion to exam.
Fournier’s Gangrene
Cavernosal blood gas analysis to help determine cause if history does not elicit for priapism
- ischemic: dark blood with hypoxemia, hypercarbia and acidemia
- Nonischemic: red blood with normal levels of oxygen, CO, and pH
