Flashcards in Urologic Emergencies Deck (64)
DDx for acute scrotal pain?
- testicular torsion**
- appendiceal torsion
- testicular rupture
Hx for acute scrotal pain?
- need to know exact time of onset of sxs in addition to usual pain questions
- assoc sxs: fever, chills, dysuria, hematuria, d/c
- H/O trauma?
PE of acute scrotal pain?
- detailed exam of abdomen
- exam of testes, epididymis, cord and scrotal skin:
prehns sign: lifting of testicle on affected side relieves pain + for epididymitis
- exam of inguinal region - hernia?
- cremasteric reflex - if absent could be torsion
- possible DRE to check prostate
W/U for acute scrotal pain?
- UA and culture
- color doppler US
Testicular torsion is a....
Hx and sxs of testicular torsion?
- hx: sudden onset of severe pain, possible inciting event (trauma) or may occur spontaneously
- sxs: lower abdominal pain, inguinal canal or testes:
pain isn't positional, can be constant or intermittent, pain is sudden in onset: may awaken in middle of night w/ pain, may have assoc N/V
PE findings suggestive of testicular torsion?
- high riding (elevated) testis on affected side
- early on may have significant swelling
- epidiymis may be displaced and not found in its normal posterolateral position
- testicle is firm
- exquisite tenderness
- cremasteric reflex is usually absent
Dx eval of poss. testicular torsion?
- color doppler US of testicle:
can determine if there is intratesticular flow but if sure of dx don't wait to call urologist
Tx of testicular torsion?
- emergent urologic consultation and surgery
- potential for manual detorsion:
twist laterally "like opening a book"
may need to twist up to 720 degrees, if successful can give excellent relief of pain.
Still needs to have surgical exploration and orchiopexy
- less than 6 wks
- swelling of epididymitis w. exquisite tenderness
- +/- inguinal lymphadenopathy
- may have systemic sxs of fever, chills, irritative voiding sxs
- may be seen in combo w/ acute prostatitis
- longer than 6 wks
- subtle epididymal induration and tenderness
- no irritative voiding sxs
- +/- inguinal lymphadenopathy
PE of epidiymitis?
- tenderness posterior and lateral to testis
- DRE to eval for prostatic involvement if hx suggests
- in acute cases may have swelling w/ reactive hydrocele (epididymo-orchitis)
- may have + Prehn's sign
W/U for epididymitis?
- UA and urine culture, test for GC and chlamydia if applicable
- urethral swab if d/c present
- r/o other causes of scrotal pain: get an US to r/o torsion if acute in onset
Tx of infectious epididymitis in men younger than 35?
- etiology: consider GC and chlamydia
- Ceftriaxone 250 mg IM + doxy 1000 mg BID x 10 days
- if septic needs to be hosp for IV hydration, and IV abx
Tx of infectious epididymitis in men older than 35, hx of BPH, urethral stricture or chronic UTI?
- etiology: consider enteric gram negative bacteria
- levaquin 500 mg qday x 10 days
- out pt management
or if septic needs to be hosp for IV abx
Sx tx for epididymitis?
- scrotal elevation
- RFs: med rxn, prolonged sitting, vigorous exercise, trauma, autoimmune disease
- may be secondary to reflux of urine w/in ejaculatory ducts
- presentation: progressive, gradual onset of pain
- tx: scrotal elevation, warm baths, NSAIDs, tx w/ abx if uncertain of etiology
What is the appendix testis? What is an appendiceal torsion?
- appendix testis is small appendage of normal tissue that is located on upper portion of testis
- torsion occurs when this tissue twists
Epidemiology, Sxs, dx of appendiceal torsion?
- epidemiology: most cases occur b/t age 7-14YO
gradual onset of pain
reactive hydrocele: which may transiluminate
exam of scrotal wall may reveal classic "blue dot" sign (tender blue or black spot beneath skin)
- dx: US shows torsed appendage as a lesion of low echogenicity w/ a central hypoechogenic area
Tx of appendiceal torsion?
rest, ice, NSAID. Recovery is slow and w/ discomfort, the infarcted tissue is usually reabsorbed
excision of appendix testis, while not necessary, is safe and quick, usually reserved for continued pain
- pts can usually resume normal activity w/o pain in few days
What is a testis rupture? Etiology? Main sxs?
- rip or tear of tunica albuginea resulting in extrusion of testicular contents
- seen in blunt or penetrating trauma
- rare in sports
- Main sxs:
Dx and tx of Testis rupture?
- dx: scrotal us
referral to Urologist for scrotal exploration, pain management, IV
What are other causes of scrotal pain?
- trauma: w/ possible testicular rupture
- strangulated hernia: usually abnormal abdominal exam
- post-vasectomy problems
- testicular cancer
- kidney stone
What is a priapism?
- erection unrelated to stimulation lasting typically longer than 4 hr
- occurs by trapping of blood in erectile bodies which can result in ischemia and infarction
Diff b/t ischemic and non-ischemic priapism?
- ischemic: MC, painful
- non-ischemic: rare, painful, usually from development of traumatic A/V fistula b/t cavernosal artery and corpus cavernosum
Etiology of priapism?
1 - primary (idiopathic)
2 - secondary:
heme, sickle cell anemia, leukemia, thalassemia, MM, TTP
Neuro (spinal shock)
perineal, penile trauma
Iatrogenic (injections - up to 25%, MC cause in adults)
drugs: antiHTN, antidepressants, anticoag, alpha blockers, cocaine)
Infection: malaria, spider toxins
metabolic disorders: gout, hemodialysis, high lipid content, TPN, diabetes, amyloidosis
Hx and PE findings of a priapism?
presence of pain, duration, role of antecedent factors, prior episodes. Existence of etiological conditions and erectile fxn status
-insepction and palpation of penis may indicate the extent and tumescence and presence and extent of tenderness
-abdominal, perineal, and rectal exams can reveal signs of trauma or malignancy
Dx of priapism?
- can use color duplex doppler US to dist. ischemic from nonischemic
- aspiration of blood from corpus cavernous can be eval:
if darkly colored (unoxygenated) - ischemic
if bright red (oxygenated) - nonischemic
-can do ABGs on aspirated blood
Tx of priapism?
- pain management, urgent urological consultation
evacuation of blood then intracavernous injection of alpha-adrenergic sympathomimetic agent- phenylephrine (penile shaft block can be done first)
-90% of men w/ ischemic priapism lasting more than 24 hrs don't regain ability to have sexual intercourse
initially - observe, 62% spontaneously resolve, urological consult for further management as other tx can cause ED