Urologic Emergencies Flashcards
Acute Scrotal Pain DDx
Testicular torsion
Appendiceal torsion
Epididymitis
Testicular rupture
Prehn’s Sign
Lifting of testicle on affected side relieving pain
Positive sign: epididymitis
Negative sign: testicular torsion
Testicular Torsion
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
Testicular Torsion Treatment
Manual detorsion - lateral twisting - open a book; up to 730 degrees
Still need surgical exploration and orchiopexy
Acute Epididymitis
< 6 weeks; swelling of epididymis w/ exquisite tenderness
May have systemic symptoms of fever, chills, irritative voiding
May be in combination with acute prostatitis
Chronic Epididymitis
>6 weeks
Subtle epididymal induration and tenderness
No irritative voiding symptoms
Infectious Epididymitis Treatment - Younger and older than 35
<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
Inflammatory Epididymitis
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
Appendiceal Torsion - Appendix testis
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
Appendiceal Torsion Treatment
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
Testis Rupture
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
Cremasteric Reflex Distinction
Positive with Epididymitis, Fournier’s Gangrene, and appendiceal torsion
Negative with testicular torsion
Priapism
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
Priapism Treatment - Ischemic and Non-ischemic
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
Penile Fracture
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
Paraphimosis
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
Pyelonephritis
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
Prostate Position with GU Trauma
Prostate “riding high” or boggy - may indicate disruption of membranous urethra
Most Common Site Urethral Injury
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
Signs of Urethral Injury
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
Bladder Injuries
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
Cystogram
All patient w/ pelvic fracture or gross hematuria should have a cystogram to r/o bladder rupture
Renal Injuries Suspicion
Bruising, pain, or tenderness to flank/abdomen
Posterior rib or spine fracture
Hematuria - gross or microscopic
Shock
Fever, flank mass (urinoma)
