Urologic Emergencies

Question 1

Acute Scrotal Pain DDx

Answer 1

Testicular torsion

Appendiceal torsion

Epididymitis

Testicular rupture

Question 2

Prehn’s Sign

Answer 2

Lifting of testicle on affected side relieving pain

Positive sign: epididymitis

Negative sign: testicular torsion

Question 3

Testicular Torsion

Answer 3

Sudden onset severe pain - spontaneous or w/ inciting event (trauma)

Pain in lower abdomen, inguinal canal, or testes

-not positional pain, may have N/V

Absent cremasteric reflex, testicle is firm and tender

Question 4

Testicular Torsion Treatment

Answer 4

Manual detorsion - lateral twisting - open a book; up to 730 degrees

Still need surgical exploration and orchiopexy

Question 5

Acute Epididymitis

Answer 5

< 6 weeks; swelling of epididymis w/ exquisite tenderness

May have systemic symptoms of fever, chills, irritative voiding

May be in combination with acute prostatitis

Question 6

Chronic Epididymitis

Answer 6

>6 weeks

Subtle epididymal induration and tenderness

No irritative voiding symptoms

Question 7

Infectious Epididymitis Treatment - Younger and older than 35

Answer 7

<35 years: consider GC and chlamydia - Rocephin and Azithromycin; hospitalize w/ sepsis

>35 years: consider enteric gram-negative bacteria - Levaquin 500 qday for 10 days w/ outpatient management

Question 8

Inflammatory Epididymitis

Answer 8

Risk factors: medication reaction, prolonged sitting, vigorous exercise, trauma, AI disease

Possibly secondary to urine reflux within the ejaculatory ducts

Progressive, gradual onset of pain

Treatment: scrotal elevation, warm bath, NSAIDs

Question 9

Appendiceal Torsion - Appendix testis

Answer 9

Small appendage of normal tissue located on the upper portion of the testis twists

Most occur between 7-14 yo

Sx: gradual onset of pain, reactive hydrocele, localized tenderness, blue dot sign

Dx: US shows torsed appendage with central hypoechogenic area

Question 10

Appendiceal Torsion Treatment

Answer 10

Conservative: rest, ice, NSAIDs; slow and uncomfortable recovery while infarcted tissue is reabsorbed

Surgical: excision of appendix testis - safe and quick; reserved for continued pain

Question 11

Testis Rupture

Answer 11

Rip or tear in tunica albuginea causing testicular content extrusion

Blunt or penetrating trauma, rare in sports

Scrotal swelling, severe pain, ecchymosis

Dx w/ US

Treat with referral to urologist, pain management, and IV fluids

Question 12

Cremasteric Reflex Distinction

Answer 12

Positive with Epididymitis, Fournier’s Gangrene, and appendiceal torsion

Negative with testicular torsion

Question 13

Priapism

Answer 13

Erection unrelated to stimulation lasting longer than 4 hours

Blood gets trapped in erectile bodies causing ischemia and infarction

Can be ischemic (MC - dark, unoxygenated blood) or not (traumatic A/V fistula involvement between cavernosal artery and corpus cavernosum)

Secondary cause is MC sickle cell anemia

Question 14

Priapism Treatment - Ischemic and Non-ischemic

Answer 14

Ischemic: evacuate blood and inject phenylephrine (alpha-adrenergic agent)

• 90% with ischemic priapism >24 hours do not retain sexual ability

Non-Ischemic: Observe, may spontaneously resolve

-Urology consult if remains

Question 15

Penile Fracture

Answer 15

Rupture of one or both tunica albuginea covering the corpora cavernosa

Rapid blunt force to erect penis; popping/cracking sound with severe pain and immediate loss of erection

Dx: retrograde urethrogram (RUG)

Treatment: surgical correction

Erectile dysfunction, penile curvature, pain are complications

Question 16

Paraphimosis

Answer 16

Foreskin of uncircumcised/partially circumcised male retracts behind glans penis and causes venous/lymphatic congestion

r/o angioedema or constricting band and remove if there

Treatment: Ice, compression bandages, osmotic agents, traction

Question 17

Pyelonephritis

Answer 17

CVA tenderness

Fever, nausea/vomiting

UA shows white cell casts

Mild/Moderate illness: IV ceftriaxone for 8-12 hours, DV on fluoroquinolone x 7days

Severe illness: hospitalize with high fever, marked debility or pregnancy

Question 18

Prostate Position with GU Trauma

Answer 18

Prostate “riding high” or boggy - may indicate disruption of membranous urethra

Question 19

Most Common Site Urethral Injury

Answer 19

Avulsion of puboprostatic ligament causes stretching of the membranous urethra

This can result in a partial or complete disruption of the urethra

Disruption commonly occurs at weakest point - bulbomembranous junction right at pubic bone

Question 20

Signs of Urethral Injury

Answer 20

Blood at the urethral meatus

Gross hematuria

Inability to void

Absent/abnormally positioned prostate

Ecchymosis/hematoma of penis, scrotum, or perineum

Pelvic fracture on plain films

Question 21

Bladder Injuries

Answer 21

Contusions: partial thickness injury to bladder wall without rupture

Intraperitoneal rupture: blunt for to low abdomen w/ full bladder - rupture of bladder dome and urine in peritoneal cavity

Extraperitoneal rupture: pelvic fractures - rupture of anterior or anterior-lateral wall; bony fragments may impale the bladder

Question 22

Cystogram

Answer 22

All patient w/ pelvic fracture or gross hematuria should have a cystogram to r/o bladder rupture

Question 23

Renal Injuries Suspicion

Answer 23

Bruising, pain, or tenderness to flank/abdomen

Posterior rib or spine fracture

Hematuria - gross or microscopic

Shock

Fever, flank mass (urinoma)