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Emergency Medicine > Male Urology > Flashcards

Male Urology Flashcards

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1
Q

Causes of acute scrotum

A
  1. Testicular torsion
  2. Torsion of the Testicular appendage
  3. Epididymitis
  4. Orchitis
  5. Fournier’s Gangrene
  6. Priapism
  7. Penile Fracture
  8. Prostatis
  9. Phimosis
  10. Paraphimosis
  11. Entrapment
  12. Neoplasm
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2
Q

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.

A

testicular torsion

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3
Q

what is a bell clapper deformity

A

testicle lacks the normal attachment to the tunica vaginalis and rests within the scrotum, and has increased mobility as a result

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4
Q

when is the peak occurrence of testicular torsion

A
  • Peak occurrences neonates and post pubertal

- average 16years old

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5
Q

Painful inguinal mass and empty scrotum =___

A

torsion

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6
Q

presentation of torsion

A
  1. severe pain w/ abrupt onset
  2. Usually starts in scrotum, but can be inguinal or abdominal
  3. pain can be constant or intermittent
  4. ~ 50% of patients have a hx of similar pain resolved* spontaneously
  5. Not positional (this is an ischemic event)
  6. Nausea, vomiting and anorexia is common
  7. May have a history of strenuous activity, may occur during sleep
  8. Can have unilateral cremasteric muscle contraction during sleep
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7
Q

PE of torsion

A
  1. inspect:
    - Redness, swelling is inconsistent with torsion
    - “High riding transverse testicle”
  2. Loss of cremasteric reflex on the affected side is most sensitive (do this before palpating the testis)
  3. Palpate, evaluate penis for discharge
    - Swollen, tender, firm hemiscrotum
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8
Q

how do you elicit the cremasteric reflex

A
  1. stroke ipsilateral inner thigh with a tongue depressor or gloved hand
  2. elevation of the testicle through contraction of cremasteric muscle
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9
Q

how do you dx torsion

A
  1. 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
  2. Midstream urinalysis (consider infectious causes)
  3. Urethral swabs prior to urinating – or send urine for culture and GC/Cx – to evaluate for other causes
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10
Q

treatment of torsion

A
  1. Immediate Urologic consult
  2. Manual or Surgical detorsion and orchipexy (fixation of testicle of scrotal wall to prevent twisting)
  3. Almost 100% salvage rate if performed less than 6 hours, over 20% at 12 hours
  4. Manual detorsion
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11
Q

What way do testicles typically rotate and

how do you perform manual detorsion

A
  1. Teste usually twists lateral to medial – but 30% of cases torse laterally (so start with rotating outward–opening a book)
  2. Can torse 180-270 degrees
  3. Right testicle usually counterclockwise, left clockwise
  4. If pain becomes worse rotate the opposite direction
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12
Q

presentation of torsion of the testicular appendage

A
  1. Pain is usually more sub acute and of gradual onset
  2. Similar episodes not typical
  3. 3-5 mm nodule palpable between the epididymis and testicle
  4. “Blue –dot sign” visible through the skin early on
  5. Rarely any voiding symptoms or fever; may have a reactive hydrocoele
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13
Q

what is the blue dot sign

A

visible blue dot on the testicle

-sign of torsion of the testicular appendage

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14
Q

how do you dx and treat torsion of the testicular appendage

A
  1. Doppler US shows normal blood flow of the testicle
  2. Non surgical, appendages calcify or degenerate over 14 days
  3. Scrotal elevation
  4. Analgesics
  5. If pain is refractory, surgical excision may be needed
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15
Q

most common cause of acute scrotum

A

epididymitis

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16
Q

Key facts of epididymitis

A
  1. 75% of cases are post-pubertal
  2. More advanced cases present with testicular pain and swelling (epidimo-orchitis)
  3. Can be infectious or non infectious (often due to STDs)
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17
Q

untreated epididymitis may develop into a ___

A

scrotal abscess

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18
Q

presentation of epididymitis

A
  1. Usually gradual onset of pain
  2. Dysuria, urgency, frequency common
  3. Urethral discharge
    - may be subtle in chlamydia
  4. Nausea, vomiting anorexia are uncommon
  5. Fever, leukocytosis on 30-50%
  6. Can have lower abdominal, inguinal, scrotal or testicular pain
  7. Positive Prehn Sign- feels better when testicle is lifted up
  8. unilateral enlarged/angry looking testicle
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19
Q

most common misdiagnosis for torsion

A

epididymitis

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20
Q

how do you evaluate epididymitis

A
  1. first r/o torsion
  2. urinalysis (+/- GC/ chlamydia)

*Non infectious epididymitis usually has less aggressive or concerning clinical presentation, and a cause is not often identified

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21
Q

treatment for epididymitis for pre-pubertal

A

-consider underlying GU abnormality

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22
Q

treatment for epididymitis for sexually active males any age

A

ceftriaxone 250 mg IOM
AND
Doxycycline 100mg BIDx10d OR Azithromycin (1 gram for the clam)

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23
Q

treatment for epididymitis for MSM

A

ofloxacin or levofloxacin to cover enteric organisms

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24
Q

treatment for epididymitis for non-infectious

A

symptoms management: Scrotal elevation, NSAIDs, decreased activity

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25
Q

other considerations for treatment for epididymitis

A
  1. Abstinence from sex/safe sex/STD counseling
  2. Consider testing for HIV/syphilis
  3. Consider treatment of sexual partners
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26
Q

__ usually occurs as extension of epididimytis

A

orchitis

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27
Q

___ decreased the incidence of orchitis

-May occur with __ or ___

A

mumps vaccine

syphilis or other viral

*Should be considered in non immune adult

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28
Q

orchitis can cause

A
  1. testicular atrophy

2. impaired fertility

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29
Q

presentation of orchitis

A
  1. Testicle itself is large and tender
  2. Follows or is concurrent with parotitis*
  3. Usually presents as bilateral tenderness
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30
Q

differentiation of acute epididymitis and testicular torsion

A

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

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31
Q

___ are always indicated in differentiating btwn testicular torsion or epididymitis

A

imaging studies

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32
Q

Unexplained testicular mass should be approaches as a ___

A

possible neoplasm

33
Q

___ may present similar to torsion with acute pain

A

Hemorrhage into a neoplasm

34
Q

Epididymitis or hydrocele not resolved in 2 weeks should be evaluated with __

A

a doppler US

35
Q

presentation of testicular neoplasm

A
  1. lump/mass

2. heaviness to testicle

36
Q

dx of testicular neoplasm

A
  1. US*
  2. AFP
  3. HCG
  4. LDH

*Very high cure rate if contained to testicle (5 yr survival is 95% with early detection)

37
Q

what is Fournier’s Gangrene

A
  1. Necrotizing fasciitis of the perineum
  2. Mortality rate approximately 25%
  3. Surgical emergency
38
Q

Organisms that cause of Fournier’s Gangrene

A

Polymicrobial (average 3.4 organisms)

anaerobic Streptococcus, B. fragilis, E. coli

39
Q

who is at risk for Fournier’s Gangrene

A
  1. immunocompromised
  2. diabetes
  3. alcoholics
  4. IV drug use
40
Q

presentation of Fournier’s Gangrene

A
  1. ALWAYS UNDRESS YOUR PATIENT
  2. Pain or itching in the genitals followed by
  3. fever, chills and sometime
  4. massive perineal swelling
  5. Swelling may involve abdomen, back and thighs with crepitance
  6. Consider in any patient with scrotal, rectal or genital pain and tachycardia out of proportion to exam.

*can rapidly progress in 4-6 hrs

41
Q

PE of Fournier’s Gangrene

A
  1. Genital exam shows edema, erythema, and foul smelling discharge, or frank necrotic tissue
  2. Consider in any patient with scrotal, rectal or genital pain and tachycardia out of proportion to exam.
42
Q

cause of Fournier’s Gangrene

A
  1. Perineal infection
  2. Trauma, including anal intercourse
  3. Scratches
  4. Chemical or thermal injury/burns
43
Q

Pathophysiology of Fournier’s Gangrene

A
  1. bacterial invasion causes leading to dermal gangrene

2. erythema, edema, inflammation infection in closed space

44
Q

how do you dx and tx Fournier’s Gangrene

A
  1. Surgery Consult STAT.

2. Plain film of CT may show free air in soft tissue

45
Q

tx of Fournier’s Gangrene

A

Treatment includes

  1. Aggressive IV fluid resuscitation
  2. Broad spectrum IV antibiotics to cover gram (+), gram (-) , anaerobic organism
  3. Emergent surgical debridement
    - Often a colostomy and suprapubic drainage system are created; Testis and spermatic cord are usually preserved ( thigh pouch)
46
Q

what is priapism

A

-Prolonged painful erection, NOT associated with sexual stimulation
+/- urinary retention

47
Q

who gets priapism and their most common causes

A
  1. Bimodal: 5-10 years, and 20-50 years old
  2. Children:
    - sickle cell disease (66%), leukemia, lymphoma or pelvic tumors
  3. Adults:
    - sickle cell disease, drugs, idiopathic, neurogenic causes like spinal cord trauma
48
Q

2 types of priapism

A
  1. low flow (ischemic)– most common 80-90%

2. high flow

49
Q

describe low flow priapism

A

Low flow (ischemic)

  • most common (80-90%)
  • Decrease venous outflow produces venous stasis
  • Ischemia from arterial compromise, VERY PAINFUL
50
Q

describe high flow priapism

A

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
51
Q

Presentation of low flow priapism

A

PEX:

  1. PAINFUL
  2. glans is soft
  3. rigid shaft
  4. Corpus spongiosum is flaccid**
52
Q

presentation of high flow priaprism

A

PEX:

  1. PAINLESS
  2. hard glans
  3. entire penis is rigid
53
Q

taking a hx regarding priapism

A
  1. Duration of erection
    - Tissue damage after 4-6hr; irreversible damage after 24-48 hours
  2. Associated symptoms
  3. Prior episodes
  4. Symptoms of malignancy or hematologic disease, especially Sickle Cell Disease
  5. Hx of trauma
  6. ***Medication and recreational drug use
54
Q

-Tissue damage after ___; irreversible damage after ___

A

4-6hr

24-48 hours

55
Q

common causes of priapism

A
  1. prescription drugs (Invega, viagra, psychotropics**, antihypertensives)
  2. illicit drugs (ethanol, cocaine, THC**)
  3. hematologic dz (sickle cell*, leukemia, thalassemia)
  4. spinal cord injury
56
Q

tx of priapism

A
  1. Terbutaline .25-.5mg q 20 min IM deltoid
  2. Oral Sudafed (60-120 mg)
  3. 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
  4. Urology consult
    - surgical shunt may need to be placed
  5. Sickle cell: detumesce with O2, hydration, analgesia, and alkalization
57
Q

what is a penis fracture

A

Disruption of the tunica albuginea surrounding the corpora cavernosa

58
Q

presentation of penis fracture

A
  1. Usually occurs during vigorous intercourse or bending the penis during masturbation
  2. Classic history involves a popping sound,
  3. pain,
  4. swelling and
  5. rapid detumescence
59
Q

PE of penis fracture

A
  1. There may be a palpable hematoma or defect.
  2. If buck’s fascia is intact only the shaft will be ecchymotic; otherwise bruising will travel to the scrotum
  3. Many patients will have gross blood at the meatus and an inability to void
60
Q

___ is the deep fascia covering the three erectile bodies of the penis

A

Bucks fascia

61
Q

urology consult for penis fracture is important for:

A

Retrograde urethrography to evaluate for damage to the urethra

62
Q

presentation of prostatitis

A
  1. Suprapubic, back, perineal pain
  2. Dysuria/frequency/urgency;
  3. painful ejaculation, F/C
63
Q

risk factors for prostatitis

A
  1. Anatomic variants
  2. STDs
  3. Acute epididimytis/urethritis
  4. Urinary catheter
64
Q

how do dx prostatitis

A
  1. clinical

2. UA- culture often neg

65
Q

tx of prostatitis

A
  1. Cipro/ Levo for 30d
  2. Pain meds
  3. Admit if immunocompromised/septic
66
Q

Presentation of phimosis

A
  1. Inability to retract the foreskin proximally
  2. painful to pull back
  3. tight, clingy foreskin
  4. Usually no difficulty voiding
67
Q

tx of phimosis

A
  1. Topical hydrocortisone for 1 moth

2. Circumcision is definitive treatment

68
Q

complication of paraphimosis

A
  • can lead to arterial compromise and gangrene

* surgical emergency

69
Q

what is paraphimosis

A

Inability to REDUCE the edematous proximal foreskin over the glans

70
Q

treatment ofparaphimosis

A
  1. Try wrapping the gland
  2. Puncture wounds to express edema fluid
  3. Provide local or regional anesthesia
  4. Superficial vertical incision until f/u w urology
71
Q

dx/ tx of penile entrapment

A
  1. objects are wrapped around penis
  2. Urology consult
  3. Remove object
  4. Imaging: retrograde urethrogram or ultrasound
72
Q

high riding testicle usually means

A

torison

73
Q

risk factors for epididymitis for those under 35y/o

A
  1. Usually STD - Chlamydia or GC
  2. Co-infection in ~30% of cases
  3. Can be several months post exposure
74
Q

consider ___ for epididymitis in MSM

A

consider enteric organism, HSV

75
Q

risk factors for prepuberal epididymitis

A
  1. anatomic abnormality,
  2. foley,
  3. inappropriate contact
76
Q

common cause of epididymitiis in someone over 35 y/o

A

E. coli or klebsiella

77
Q

Consider in any patient with scrotal, rectal or genital pain and tachycardia out of proportion to exam.

A

Fournier’s Gangrene

78
Q

Cavernosal blood gas analysis to help determine cause if history does not elicit for priapism

A
  • ischemic: dark blood with hypoxemia, hypercarbia and acidemia
  • Nonischemic: red blood with normal levels of oxygen, CO, and pH

Emergency Medicine (22 decks)

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