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Emergency Medicine > Male Genitalia Emergencies > Flashcards

Male Genitalia Emergencies Flashcards

1
Q

Twisting of the spermatic cord leading to ischemia of the testicle and surrounding structures within the scrotum

A

Testicular Torsion

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2
Q

any male complaining of testicular, groin or lower abdominal pain, what should be top of ddx?

A

Testicular torsion

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3
Q

testicular torsion MC occurs in who?

A
  • neonates and during puberty
  • Can occur at any age
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4
Q

causes of testicular torsion

A
  • exercise, mild trauma or during sleep
  • MC no preceding event identified
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5
Q
  • Sudden onset of severe, unilateral testicular, lower abdominal and/or inguinal pain
  • N/V may be present
  • Infants/preverbal toddlers: inconsolable crying
  • constant/intermittent pain - No change with position
  • MC after exertion - May occur during sleep
  • h/o similar sx that resolved w/o intervention
A

Testicular Torsion

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6
Q

signs of testicular torsion

A
  1. firm, tender, elevated and lying transverse (Bell Clapper)
  2. may appear larger than unaffected testis
  3. Epididymis may be felt anteriorly
  4. (-) cremasteric reflex - most sensitive finding but nonspecific
  5. pain and tenderness spreads to other intrascrotal structures
  6. entire scrotal contents swollen and tender
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7
Q

w/u for testiular torsion

A
  1. Color-flow Duplex US scrotum/testicles: diminished blood flow to the affected testis; possibly normal despite torsion
  2. UA - may show pyuria - does not r/o
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8
Q

tx testicular torsion

A
  • Urgent urologic consult - if suspicion is high
  • detorsion 6 hours after onset
  • Prepare for surgery - NPO, CBC, BMP, coags
  • IV analgesic and antiemetic
  • Attempt manual detorsion if any delay in surgical detorsion or if close to 6 hour window - medial to lateral direction
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9
Q

most torsions occur in what direction

A

a lateral to midline

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10
Q
  • More common than testicular torsion
  • NOT a surgical emergency
A

Torsion of the Testicular Appendages

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11
Q

4 possible Torsion of the Testicular Appendages?
which is MC?

A
  1. Paradidymis (organ of Giraldes)
  2. appendix epididymis - MC torsed
  3. Appendix testis
  4. Vas aberrans of Haller - inferior and superior appendages
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12
Q
  1. Sudden onset, severe pain, +/- N/V
    - early: localized to upper pole of testis (in appendix epididymis)
  2. Scrotal skin and testicle are nml appearing and minimally tender
  3. isolated tender nodule
    - “Blue dot” - appearance of a cyanotic appendage
A

Torsion of the Testicular Appendages

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13
Q

w/u for Torsion of the Testicular Appendages

A
  • Doppler US - confirms blood flow to testis
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14
Q

tx Torsion of the Testicular Appendages

A
  1. Most DC home
  2. Analgesics, bed rest, supportive underwear, and reassurance
  3. resolution 3-5 d - Most calcify and degenerate 10-14 d
  4. Consult urology for surgical exploration if unable to r/o testicular torsion
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15
Q

two conditions that often occur simultaneously due to an underlying bacterial infectious etiology

A

Orchitis and epididymitis

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16
Q

cause of orchitis

A
  1. Isolated orchitis - viral or syphilitic dz (rarely occurs alone)
  2. Viral - mumps; orchitis commonly presents 5 days after parotitis
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17
Q

MCC Epididymitis

A

Bacterial infection

  • Men < 35 who do not practice anal intercourse - Gonorrhea & Chlamydia
  • Men > 35 or those who do practice anal intercourse - Urinary pathogens (E.coli and Klebsiella)
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18
Q
  1. Gradual onset of mild to severe unilateral testicular pain
    - lower abd, inguinal canal and/or scrotum
    - +/- F, recent h/o dysuria or urethral discharge
  2. Affected testis will hang low in scrotum
  3. swollen, tender, warm testicle/epididymis
    - Cremasteric reflex is normal
    - Pain relieved with elevation of scrotum (+ Prehn sign)
A

Epididymitis and Orchitis

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19
Q

w/u for Epididymitis and Orchitis

A
  1. UA with C&S in most patients
    - pyuria in 50% of patients
  2. Urine PCR or DNA probe (if discharge is present) for GC and Chlamydia
  3. Testicular US if needed to confirm blood flow
    - may show an increase in blood flow
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20
Q

tx for Suspected or confirmed GC/Chlamydia in Epididymitis and Orchitis

A

Ceftriaxone + Doxy (preferred)/Zithromax

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21
Q

tx for Suspected urinary/ bacteria in Epididymitis and Orchitis

A
  • levofloxacin
  • Bactrim
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22
Q

tx for Anal intercourse exposure in Epididymitis and Orchitis

A

ceftriaxone + levofloxacin

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23
Q

Nonpharmacologic therapies for Epididymitis and Orchitis

A
  1. Scrotal elevation, ice application, NSAIDs or opiates, stool softeners
  2. Avoid lifting heavy objects, avoid straining to have a BM
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24
Q

signs of toxicity or septicemia in Epididymitis and Orchitis that warrant admission?
w/u?
tx?

A
  • Fever, hypotension, tachycardia
  • CBC, CMP, lactic acid, blood cx
  • Suspected GC/Chlamydia - ceftriaxone + doxycycline
  • Suspected urinary pathogens - levofloxacin/ceftriaxone
  • Consult urology
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25
Q

2 presentations of scrotal abscess

A
  1. Localized to scrotal wall (superficial): hair follicle infections
  2. extension of intrascrotal infections (intrascrotal): extension of testis, epididymis or bulbous urethral infection
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26
Q
  1. Unilateral testicular/scrotal pain and swelling
  2. sx related to intrascrotal etiology: sx of a UTI/STD
  3. Erythema and edema of the scrotum
  4. Fluctuance may be palpable
  5. Tenderness of affected epididymis and/or testis may be present
A

Scrotal Abscess

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27
Q

w/u Scrotal Abscess

A

Scrotal ultrasound

  • differentiates intrascrotal abscess vs other causes of inflammatory mass
  • Localize involvement of abscess to the scrotal wall, epididymis, and/or testis
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27
Q

treatment of choice for scrotal abscess

A

Surgical drainage

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28
Q

specific mgmt for Localized scrotal abscess

A

I&D in the ED at bedside; DC; sitz baths

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29
Q

specific mgmt for Intrascrotal abscesses

A
  1. Immediate urology consultation for surgical intervention
  2. Broad-spectrum abx in immunocomp until cx are reviewed - pip/taz
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30
Q

A necrotizing fasciitis of the perineal, genital, or perianal anatomy

A

fournier’s gangrene

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31
Q

pathophys of fournier’s gangrene

A
  • polymicrobial infection
  • starts benign or simple abscess that quickly becomes virulent
  • Results in microthrombosis of small subcutaneous vessels = gangrene
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32
Q

RF for fournier’s gangrene

A
  • urethral strictures, perirectal abscesses, poor perineal hygiene, chronic alc use, DM, cancer, HIV and other immunocomp
  • MC in men but can occur in women
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33
Q
  1. Intense pain and tenderness in perineum
  2. Progressive clinical course
    - Prodromal fever and lethargy x 2-7 d
    - Pain in anterior abd wall, migrates to gluteal muscles, scrotum and penis
    - Intense genital edema, pain, tenderness of overlying skin
    - Dusky appearance, subcutaneous crepitation
    - gangrene of a portion of genitalia and purulent drainage from wounds
  3. Tense edema of the involved skin
  4. Blisters/bullae, crepitus/subcutaneous gas
  5. A feculent odor if infected with anaerobes bacteria
  6. +/- fever, tachycardia, hypotension
A

Fournier’s Gangrene

34
Q

w/u If clinical suspicion is less than high for Fournier’s Gangrene

A

CT w/ IV contrast: air along fascial planes or deeper tissue involvement

35
Q

mgmt If high clinical suspicion for Fournier’s Gangrene

A
  1. urgent urologic consultation before w/u
  2. fluids, NPO
  3. pip/taz
  4. Opiate analgesia, antiemetics
  5. Septic work up (after consult in preparation for surgery) - CBC, CMP, lactic acid, DIC panel, blood and urine cx, cx of any open wound or abscess
36
Q

inflammation of both the glans and foreskin

A

Balanoposthitis

37
Q

a condition that makes it difficult to retract the foreskin

A

Phimosis

38
Q

inflammation of the glans penis.

A

Balanitis

39
Q

causes of balanoposthitis

A
  • Inadequate hygiene
  • External irritation with subsequent microbial colonization: Candida, Staphylococcus, Streptococcus, Mycoplasma genialium
40
Q
  • foreskin retraction reveals the glans and prepuce appear purulent, excoriated, malodorous, and tender
  • complicated by bacterial infection: warmth, erythema, and edema of the glans, foreskin, and penile shaft
A

Balanoposthitis

41
Q

tx for Balanoposthitis

A
  • Frequent washing with saline and adequate drying; education on proper hygiene to prevent reoccurance
  • nystatin / clotrimazole topicals
  • fluconazole PO if severe
  • bacterial infection: Bacitracin / mupirocin (mild); clinda PO / flagyl PO
42
Q

tx for Persistent symptoms despite adequate treatment
in Balanoposthitis

A
  • Obtain fungal and bacterial specimen swabs: Rapid GAS test, KOH, Gram stain with bacterial cx
  • refer to urology/general surgery for circumcision
43
Q
  • The inability to reduce the proximal edematous foreskin distally over the glans penis into its natural position
  • A true urologic emergency - progression to arterial compromise and gangrene may occur
A

Paraphimosis

44
Q

mgmt options for paraphimosis

A
  1. Reduction of glans
    - local anesthetic block
    - compress glans x 5-10 m (hand or 2-in bandage)
    - attempt reduction
45
Q

next steps If initial reduction fails for Paraphimosis

A
  • release glans edematous fluid
  • make several small puncture wounds in the glans with a 22-25 gauge needle
46
Q

If reduction fails and there is arterial compromise in Paraphimosis:

A
  1. consult urology
  2. If urology unavailable - 1% lidocaine + dorsal incision of the foreskin
    - Incise constricting band of paraphimosis
    - Reduce foreskin, and suture
  3. F/u with urology in 3-5 d
47
Q

The inability to retract the foreskin proximally and posterior to the glans penis

A

Phimosis

48
Q

RF for Phimosis

A

infection, poor hygiene, and previous preputial injuries with scarring

49
Q

complication of phimosis?
mgmt?

A
  • urinary retention
  • hemostatic dilation (after topical anesthetic) of the preputial ostium temporarily relieves urinary retention
  • circumcision is curative
50
Q

mgmt for phimosis

A
  • refer to urology - consider circumcision or dorsal slit
  • topical steroid + daily manual preputial retraction may reduce need for circumcision - betamethasone, 0.05% - 0.10% BID apply from the tip of the foreskin to the glandis corona for 1 to 2 months
51
Q

A persistent (>4 hours), painful, pathologic erection unrelated to sexual stimulation and unrelieved by ejaculation

A

Priapism

52
Q
  • Priapism - Microscopic tissue damage begins after ?
  • Irreversible damage after ? - May result in urinary retention, infection, corporal fibrosis and permanent ED

hours

A
  • 4 hours
  • 24 hours
53
Q

2 types of priapism

A
  1. ischemic - low flow priapism
  2. Non-ischemic - high flow priapism
54
Q

causes of ischemic - low flow priapism

A
  1. Idiopathic (MC in adults)
  2. Sickle cell disease (MC in < 18 y/o), leukemia
  3. metastatic carcinoma
  4. ETOH, marijuana, cocaine, ecstasy
  5. PDE5 inhibitors, some antihypertensives and neuroleptics
55
Q
  1. Common, painful
  2. Blood gas on corporal aspirate shows hypoxemia (low O2, high CO2) - aspirated blood will appear black

which type of Priapism

A

ischemic - low flow priapism

56
Q
  1. rare, most often painless
  2. usually results from traumatic fistula between the cavernosal artery and the corpus cavernosum
  3. Blood gas on corporal aspirate is normal - aspirated blood is red
A

Non-ischemic - high flow priapism

57
Q

mgmt for priapism

A
  1. Urgent urology consult even if ED provider stabilizes patient
  2. Analgesics - opioid
  3. Corporal aspiration after dorsal block
    - +/- saline irrigation
    - instillation of phenylephrine
    - CI in high flow priapism
  4. Additional management (after corporal aspiration)
    - Sickle cell: hydration & O2
    - Leukemia and malignant priapism: consult hematology and admit
58
Q

priapism - If failure to respond to aspiration and phenylephrine injection consult urology for ?

A

shunting procedure

59
Q

how to prevent the formation of a hematoma when treating priapism?

A

compress puncture site for 30-60 seconds after removing the needle from the corpora cavernosa.

60
Q

Vascular occlusion injury that occurs when various objects are wrapped around the penis
Hair, string, metal rings, wire

A

Penile Entrapment

61
Q

techniques for object removal in Penile Entrapment

A
  1. compression/cooling of the penis followed by:
    - string technique
    - corporal aspiration: insert 18-gauge needle in one of corpora cavernosa to drain the edema and blood, then attempt removal
  2. cutting the object
  3. urologic surgical removal
62
Q

potential w/u used to look for injury in penile entrapment

A
  • Retrograde urethrogram to confirm urethral integrity
  • Doppler US evaluate penile arterial blood supply
63
Q
  • Occurs when the tunica albuginea of one or both corpus cavernosa ruptures due to direct trauma to the erect penis
  • May be associated with partial or complete urethral rupture or deep dorsal vein injury
A

Penile Fracture

64
Q

causes of Penile Fracture?
MC?

A
  • sex (MC)
  • other causes: masturbation, animal bites, stabbing, bullet wounds, self-mutilation
65
Q
  • Patient will report trauma during intercourse (or other etiology) with an audible “snap”
  • Penis becomes acutely swollen, flaccid, discolored and tender
A

Penile Fracture

66
Q

mgmt for Penile Fracture

A
  1. Urgent urologic consultation to determine need for surgical repair
  2. Prepare for surgery - reop retrograde urethrogram
  3. Analgesics
  4. Anxiolytics
67
Q

A localized fibrotic disorder of the tunica albuginea which causes progressive penile deformity typically resulting in curvature with erections

A

Peyronie’s Disease

68
Q

Hx of sexual dysfunction, penile pain, indentation, curvature, shortening deformity during erection
thickened plaque, involving the tunica albuginea of the corpora bodies

dx?
mgmt?

A

Peyronie’s Disease
refer

69
Q

w/u and mgmt for urethral FB?

A
  • Clinical presentation of bloody urine and/or slow, painful urination
  • Highest risk: children and mentally unstable patients
  • Pelvic x-ray
  • Consult urology
70
Q

A narrowing of the urethra leading to chronic obstructive voiding symptoms and occasionally complete obstruction

A

Urethral Stricture

71
Q

causes of Urethral Stricture

A
  • hx of urethral instrumentation, injury or infection
  • often times etiology remains unknown
72
Q

presentation of urethral stricture

A
  1. decreased strength of urinary stream
  2. incomplete bladder emptying
  3. recurrent UTIs
  4. urinary spraying
  5. decreased force of ejaculate during orgasm
73
Q

tx for urethral stricture

A
  1. 14- or 16- Fr Foley straight tip catheter
    - If unable to pass, use 12- Fr Coude catheter with anesthetic lubricant
  2. If successful, leave foley in place and refer to urology for appt within 1 week
  3. If failure to pass cath after 3 attempts, consult urology
  4. If urology is unavailable - emergent suprapubic cystostomy w/ catheter placement - f/u with urology within 48 hours
74
Q

An emergent condition characterized by the inability to pass urine

A

Urinary Retention

75
Q

Urinary Retention is MC in who? other causes?

A
  • elderly men with BPH
  • medication SE, neurologic dysfunction, urinary tract bleeding/calculi/infection, urethral stricture, GU trauma, organic mass
76
Q

presentation of urinary retention

A
  1. Rapid onset of lower abd pain/distention with the inability to pass urine
  2. Male: Urethral exam - look for signs of stricture; Prostate exam - assess for enlargement
  3. Female: External GU exam - assess for prolapsed bladder, urethral stricture; Pelvic exam
  4. Neuro exam: complete exam + assessing perineal sensation and anal sphincter tone
77
Q

w/u for urinary retention

A

Post void residual US - residual volume of > 50-150 cc is indicative of retention

78
Q

mgmt for urinary retention

A
  • If hematuria is present: 3-port Foley
  • Attempt a 12- or 14- Fr Foley catheter with anesthetic lubrication - If failed, insert Coude tip catheter
  • Leave Foley in place unless underlying cause for retention is thought to be post-anesthesia related
  • Emergent suprapubic catheter if immediate urologic consult not available
  • send urine for analysis and cx, BMP, analgesics
  • tx underlying
79
Q

Urgent urology consult for urinary retentation if:

A

failure to pass Foley or Coude catheter, recent instrumentation, obstruction due to stricture, prostatitis or trauma

80
Q

tx for bladder spasms in urinary retention

A

oxybutynin 5 mg - watch for medication induce obstruction

81
Q

disposition for urinary retention MC?

A
  • sent home with catheter in place
  • follow up with urology in 3-7 days - catheter will be removed at that time
82
Q

Admit urinary retention who meet any of the following criteria

A
  1. signs of post-obstructive renal failure
  2. signs of post-obstructive diuresis
    - monitor urine output in ED for 4-6 hours
    - >200 ml/hr UO for 2 consecutive hours = post-obstructive diuresis - admit for fluid replacement and electrolyte monitoring

Emergency Medicine (20 decks)

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