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RLH Urology > 2 - scrotal trauma > Flashcards

2 - scrotal trauma Flashcards

1
Q

Define priapism

A

Prolonged penile erection (>4hrs) which is maintained without sexual simulation and persists despite ejaculation and orgasm

It is a urological emergency

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1
Q

What are the classifications of priapism?

A

1) Ischaemic priapism/low flow priapism
2) Non-ischaemic priapism/high flow priapism
3) Stuttering/recurrent priapism - frequent, self limitting priapism common in pt with sickle cell disease

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2
Q

Priapism: important Qs for history

A
  • Onset/Duration:
    • <48hrs, 48-72hrs, >72hrs
  • Pain? escalating pain = ischaemic, painless = non-ischaemic
  • Medication use
  • Illicit drug use
  • Symptoms suggesting underlying malignancy - FLAWS
  • Underlying haematological disorders - e.g. SCD
  • Previous episodes - suggestive of stuttering priapism
  • Recent perineal/penile trauma
  • Neurological symptoms
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3
Q

Priapism: important examination points

A
  • Pain = ischaemic, painless/uncomfortable with perineal/penile trauma = non-ischaemic
  • ?underlying malignancy - Abdo examination & DRE
  • Neurological examination
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4
Q

Priapism: investigations

A
  • Bloods:
    • FBC
    • blood film (haematological disorders)
    • autoimmune screen
    • Corporal blood - gas
  • Imaging:
    • penile doppler sudy (URGENT)- note paradoxical increased systolic velocities in proximal penile shaft if aspiration/shunt surgery has been attempted or fibrosis has started to develop in distal corpus cavernosum
    • Abdo & pelvic CT/MRI - exclude possible underlying pelvic/abdo malignancy
    • Penile MRI - assess viability of corpus cavernosum in refractory cases & aid decision re early penile prosthesis

Idiopathic priapism, search for malignancy:

  • CXR
  • CT Abdomen and pelvis
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5
Q

Management of ischaemic priapism

A
  • Penile block
  • Aspiration and istalation of phenylephrine
    • 19 guage needle/butterfly into corpus cavernosum - via lateral penile shaft/glans into tip - aspirate
      • send aspirate for gas: pO2/pH and glucose
        • Ischaemic = hypoxia, acidosis, glucopenia
        • Non-ischaemia = normoxia
    • Istillation of sympathomimetic/alpha adrenergic, phenylephrine (200-250 ug/1mL aliqots)
      • dilute into 50 or 20ml, ensure BP measurement during administation (systemic hypertension), avoid urethra and dorsal neurovascular bundle (deliver @3/9 O’clock), repeat up to a total of 1000ug
  • If <72 hrs and persists, Shunt surgery
    • LA/GA, winter or T shunt
      • Winter - Tru-cut biopsy needle through glans into tip of corpus cavernosum -> ‘fistula’
      • T shunt - 11 blade through mid glans into tip of corpora & rotated 90 with blade rotated away from urethra then withdrawn - repeated on contralateral corpus cavernosum if failure of detumescence. Penis compressed manually to ensure drainage of deox blood until ox blood appears, closure of glans wound with abdo sutures.
  • If <48hrs and persisting, Tunnelling procedure
  • If 48-72 hrs and persisting, TTT shunt
    • Metal dilator 8F through incision in glans through into corpus cavernosum
  • If >72hrs unlikely to have viable smooth muscle within corpus cavernosum, early penile prosthesis
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6
Q

Management of Non-ischaemic priapism

A
  • Conservative
  • If fistula present - duplex compression of fistula
  • Failure of resolution -> specialist referral:
    • arteriography & embolisation with absorbable material
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7
Q

Management of stuttering priapism

A
  • Combined management with haematologists
  • Post-pubertal patients -> hormone manipulation with anti-androgens
  • Etilefrine (named patient basis) - sympathomimetic
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8
Q

Priapism: follow up

A

long term follow up to assess the degree of late-onset erectile dysfunction:

  • Pharmacological: Trial of phosphodiesterase-5 inhibitors and intracavernosal prostaglandins
  • Surgical: penile prosthesis
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10
Q

Assessment of testicular trauma

A
  • Follow ATLS guidelines: check for other injuries, manage life threatening injuries first - resuscitated and stabilise patient
  • Ensure adequate analgesia pre-assessment
  • Examine - penis, scrotum, perineal
    • penetrating injuries
    • skin condition
    • degree of scrotal swelling or haematoma
  • If blood present at urethral meatus/rention - consider urethral injury
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11
Q

Testicular trauma: investigations

A
  • Imaging:
    • US
      • integrity of tunical albiguaena
    • Doppler
      • perfusion within testicle and integrity of vascular hilum
      • Impaired blood flow: haematoma/non-viable testicular tissue
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12
Q

Management of blunt testicular trauma

A
  • Often unilateral and managed conservatively
  • absence of scrotal swelling/haematoma does not exclude testicular injury
  • Scrotal US to assess testicle and scotal content
    • If tunica intact and small haematoma -> conservative management
      • Scrotal support, analgesia, anti-inflammatory meds
      • repeat US@48hrs - assess progression
    • Disruption of tinuca albuginae = testicular rupture
      • exploration and surgical repair
    • large/expanding hamatoma/haematocoele indicates sig injury to testicle/paratesticular structures
      • exploration req to salvage testicle
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13
Q

Management of penetrating scrotal injuries

A
  • Follow ATLS guidelines: check for other injuries, manage life threatening injuries first - resuscitated and stabilise patient
  • Tetanus booster & broad spec ABx
  • Determine entry and exit sites of penetrating wound
  • Urgent scrota US to assess testicles and scrotal contents
  • Scrotal exploration:
    • Determine severity of injury
    • Wound washout
    • Control intra-scrotal haemorrhage
    • Breached tunica albuginae -> debridement of non-viable seminiferous tubules, primary closure of TA
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14
Q

Degloving injury and blast injuries to scrotum

A
  • Testicular injuries associated with loss of scrotal skin
  • Scrotal US - ensure no underlying testicular injury
  • Necrotic tissue debrided and vigorous saline washout prior to primary closure
  • Closure:
    • Pimary closure
    • Skin graft - if extensive scrotal skin loss
      • testicles can be left exposed with daily moist saline dressing until granulation tissue forms and meshed split-thickness skin graft can be applied
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15
Q

Genital mutilation

A
  • most commonly self mutilation - ‘self castration’
    • asociated psych history & will require psych input
  • If <12hrs - consider replantation req microvascular skills
  • If >12hrs - cryopreservation from testicle/ejactulated sample
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16
Q

Testicular dislocation

A
  • testicle removed from its orthotopic position
  • 2ndary to blunt trauma - displaced to superficial ring/SUPERFICIALpouch
  • Predisposing factors:
    • inguinal hernia, atropic testicle
  • Management:
    • Early manual closed reduction
    • If unsuccessful, Surgical exploration and fixation
17
Q

Wrong testicl ampuration

A
  • Rare but potentially catastrophic - wrong testicle at orchidectomy, re-do inguinoscrotal surgery
  • Issues:
    • medicolegal, fertility, endocrine (if contralateral testicle non-functioning)
  • Liaise with fertility units:
    • Cryopreservation
  • Microvascular replantation <4hrs
    • reanastomose vascular structures then vas deferens
    • DO NOT place testicular prosthesis in acute setting
    • Continue broach spec Abx post op
    • Warn of testicular atrophy
      *
18
Q

Technicalities of scrotal exploration after trauma

A
  • Indications:
    • uncertain diagnosis
    • clinicial findings consistent with testicular injuries
    • disruption of tunica albuginea
    • expanding or large hamatocele
    • abscence of blood flow on US with doppler
  • Operative management:
    • debride necrotic/devitalised tissue
    • Copious saline irrigation if wound is contaminated
    • meticulous haemostasis
    • Closure of TA with absorbable sutures - 4/0 polyglactin (vicryl)
    • If uncertain testicular viability - wrap with warm saline soacked gauze for 5min to improve blood flow
    • Sharply incise TA - brisk red bleeding signifies adequate blood flow
      • dark fluid - suggestive of testicular infarction ?req orchidectomy
    • If testicular rupture - debride non-viable/extruded seminiferous tubules
    • Cover large defect with patch of Tunica vaginalis if primary closure not possible
    • Place corrugated drain at end of procedure
    • Close dartos layer and scrotal skin using absorbable suture - 3/0 polyglactin for dartos, 4/0 polyglactin for skin
  • Post op:
    • Commence boad spec ABx until discharge and after discharge if contaminated wounds
    • Discharge with PO ABx, analgesics, scrotal support
    • Avise ice packs to groin area and bed rest
19
Q

Conservative management of testicular trauma

A
  • Scrotal support
  • Analgesic including NSAIDs
  • Ice packs
  • Bed rest 24-48hrs
  • If epididymitits or UTI -> ABx
  • Failute of medical Mx @48hrs of observation -> re-image with US and doppler
  • Re-review @1-2wks
  • Expect scrotal swelling to settle @4wks
  • ?Repeat US to assess resolution
20
Q

Testicular trauma: indications for referral to specialist units

A
  • Associated complex urological injuries
  • Salvageable testicular amputation req micro-vasc support
  • maj inj requiring reconstruction
  • patients requiring sperm cryo

RLH Urology (2 decks)

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