Urogenital Emergencies

Question 1

Acute Scrotal Pain:

-PE should include?

Answer 1

PE:

• exam of abdomen
• exam of testes, epidiymis, cord, and scrotal skin
• prehns sign (lifting of testicle on affected side relieves pain? + = more likely epididymitis
• cremasteric reflex
• inguinal exam
• possible DRE

Question 2

Acute Scrotal Pain: TESTICULAR TORSION

• sx
• PE findings
• Dx
• Tx

Answer 2

Sx:

• suden onset of severe pain
• lower abd pain, inguinal canal or testes
• pain is not positional, constant or intermittent
• N/V

PE:

• high riding testis on the affected side
• swelling
• firm testicle
• exquisite tenderness
• cremasteric reflex usually ABSENT

Dx:
-Color Doppler US of testicle.

Tx:

• emergent urologic consultation and surgery
• manual detorsion “like opening a book”

Question 3

Acute Scrotal Pain: EPIDIDYMITIS

• acute and chronic sx
• PE findings
• dx
• Tx

Answer 3

Acute Sx:

• less than 6wks
• swelling of epididymis with exquisite tenderness
• +/- inguinal lymphadenopathy
• may have systemic sx; fever chills, irritative voiding

Chronic Sx:

• greater than 6wks
• subtle epididymal induration and tenderness
• no irritative voiding sx
• +/- inguinal lymphadenopathy

PE:

• tenderness is in the epididymis (posterior and lateral to testis)
• DRE for prostatic involvement
• reactive hydrocele possible
• • prenhs sign

Dx:

• UA and UC for chlamydia and gonorrhea
• urethral swab
• US to r/o torsion

Tx:

• men less than 35YO consider GC and chlamydia = Rocephin and doxy
• older men or hx of BPH, urethral stricture, chronic UTI = Levaquin
• sx management with NSAIDS, ICE, scrotal elevation

Question 4

Acute Scrotal Pain: INFLAMMATORY EPIDIDYMITIS

• risk factors
• presentation
• tx

Answer 4

Risk factors

• medication rxn
• prolonged sitting
• vigorous exercise
• trauma
• autoimmune

Presentation:
-progressive gradual onset of pain

Tx:
-scrotal elevation warm baths,and NSAIDS

Question 5

Acute Scrotal Pain: APPENDICEAL TORSION

• what is this?
• MC ages
• sx
• dx
• tx

Answer 5

What: appendix testis si a small appendage of normal tissue that is usually located on the upper portion of the testis.

MC: in 7-14YO

Sx:

• gradual onset of pain
• reactive hydrocele
• tenderness
• blue dot sign**

Dx:
-US, shows torsed appendage as a lesion of low echogoenicity w/ central hypoechogenic area

Tx:

• Rest, ICE, NSAIDS
• surgery; excision of the appendix testis

Question 6

Acute Scrotal Pain: 
TESTIS RUPTURE 
-what is this? 
-cause
-sx
-dx 
-tx

Answer 6

What: rip or tear in the tunica albuginea resulting in extrusion of testicular contents

Cause: MC seen in blunt or penetrating trauma

Sx:

• scrotal swelling
• severe pain
• ecchymosis

Dx:
-scrotal US

Tx:

• referral to urologist for scrotal exploration
• pain management
• IV

Question 7

Priapism:

• definition
• types
• causes
• sx
• PE exam
• dx
• tx

Answer 7

definition: erection unrelated to stimulation lasting typically longer than 4hrs

Types:

• ischemic = MC and painful
• non-ischemic = rare and painful

Causes:

• primary = idiopathic
• 2ndry = iatrogenic (intracavernous injections)

Sx:

• pain
• erection longer than 4hrs…?

PE findings:
-inspection and palpation of the penis may indicate the extent of tumescence (refers to the normal engorgement w/ blood of the erectile tissues)

Dx:

• CBC
• US to distinguish ischemic vs non-ischemic
• aspiration from corpus cavernosum ( if blood dark =unoxygenated/ ischemic. if bright = oxygenated/ nonischemic.

Tx:

• pain management, urgent urological consultation
• Ischemic: evacuation of blood then intracavernous injection of alpha-adrenergic sympathomimetic agent such as phenylephrine (sudafed; vasocontriction)
• *Men with ischemic priapism greater than 24hrs do not regain the ability to have sexual intercourse.

-non-ischemic: observation, most resolve on own. urologic consult for further management.

Question 8

Penile Fracture

• definition
• cause
• signs and sx
• dx
• tx
• complications

Answer 8

Definition
-rupture of one or both of the tunica albuginea that covers the corpora cavernosa

Cause
-rapid blunt force to an erect penis (intercourse)

Signs and sx

• popping or cracking sound
• severe pain
• immmediate loss of erection

Dx
-RUG if suspect urethral injury

Tx
-surgical correction

Complications

• ED
• Penile curvature
• pain

Question 9

Paraphimosis:

• what is this?
• sx
• PE findings
• tx

Answer 9

What:
-occurs when the foreskin in the uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion and cannot be returned to its normal position.

Sx:

• swelling of the penis and penile pains
• irritability in preverbal infant

PE findings:

• ensure no constricting FB
• edema and tenderness of the glans
• painful swollen, painful retracted foreskin
• penile shaft is unaffected
• with ischemia glans will change from normal pink to blue/back and will be firm rather than soft.

Tx:

• ICE
• Compression bandages
• osmotic agents
• manual compression (w/ your hand!!!) and reduction
• traction with forceps
• puncture technique (aspiration w/ small gauge needle)