Phimosis, torsion

Question 1

What is phimosis

Answer 1

When the prepuce fibroses distal to the glans of the penis making it difficult to urinate or causing balanitis
“Muzzle” in greek

Question 2

What causes phimosis and how do you treat it

Answer 2

Poor hygiene causes build up of endothelial cells/sebaceous secretions (smegma) under the foreskin so it gets stuck
Treat with circumcision

Question 3

What is paraphimosis

Answer 3

When the prepuce gets stuck proximal to the glans and can not be reduced 2/2 the glans becoming large and swollen (tons of arterial inflow, poor outflow form SF vein)

Question 4

If untreated, paraphimosis leads to

Answer 4

Penile necrosis!

Fournier’s gangrene if immunocompromised

Question 5

How do you treat paraphimosis

Answer 5

Reduction! give pain meds/sedate, or give penile block- wither squeeze the glans (literally) or- push glans down with thumbs while pulling prepuce up with index and middle fingers

Question 6

If reduction is not successful, how do you treat paraphimosis

Answer 6

Dorsal slit +/- circumcision

Question 7

What MUST you do after cathing an uncircumcised man

Answer 7

pull the prepuce back up! If you leave it down you could cause paraphimosis

Question 8

What are RF for testicular torsion

Answer 8

Undescended testes

Bell clapper deformity (epididymis is on top)

Question 9

How does testicular torsion usually present

Answer 9

In 12-18 y/o males
Acute, severe usually unilateral pain
NO swelling

Question 10

What will you see on PE for testicular torsion

Answer 10

Tender, firm, high, horizontal testis
ABSENT cremaster reflex
Thick sperm cord with epididymis on top (not behind) testis
Pain is NOT relieved with scrotal elevation

Question 11

How do you diagnose testicular torsion

Answer 11

*Clinically!
Doppler US shows decreased blood flow
Nuclear testicular scan is least helpful (takes long)

Question 12

How can you r/o acute epididymitis and orchitis when you suspect testicular torsion

Answer 12

Doppler and nuclear testicular scan for epididymitis will show INCREASED blood flow!

Question 13

How do you treat testicular torsion

Answer 13

Manually detorse (open the book) 
Surgical exploration ASAP, don't delay surgery for imaging! this is an EMERGENCY

Question 14

What do you do with the testis in surgery for torsion

Answer 14

If they are viable: Orchiopexy of both sides (permanently fix testicle to scrotum in correct position)
If they are not viable, orchiectomy of afcted side, and orciopexy of other side

Question 15

How can you tell if a testicle is viable (time wise)

Answer 15

If detorsed in <6 hours, most are viable

If >24 hours, likely not viable