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Flashcards in Urologic Emergencies ER Med Deck (59)
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Acute scrotal pain
DDx? 4

1. Testicular torsion
2. Appendiceal torsion
3. Epididymitis
4. Testicular rupture


For Urologic emergencies what should our physical exam consist of? 6

1. Detailed exam of the abdomen
2. Exam of the testes, epididymis, cord and scrotal skin
3. Prehn’s sign? Lifting of testicle on affected side relieves pain? + more likely epididymitis
4. Exam of inguinal region
5. Cremasteric reflex
6. Possible digital rectal exam to check prostate


Work up: For UE? 2

1. UA and culture

2. Color Doppler ultrasound


Testicular torsion is a urologic emergency
1. History? 2
2. Pain where? 3
3. Symptoms? 4

1. History:
-sudden onset severe pain.
-Possible inciting event (trauma) or may occur spontaneously

- lower abdominal pain,
-inguinal canal or

3. Symptoms:
-Pain is not positional, can be constant or intermittent
-Pain is sudden in onset
-May awaken in the middle of the night with pain
-May have associated nausea and vomiting


Physical exam suggestive of testicular torsion

1. High-riding (elevated) testis on the affected side
2. Early on may have significant swelling
3. Epididymis may be displaced and not found in it’s normal posterolateral position
4. Testicle is firm
5. Exquisite tenderness
6. Cremasteric reflex is usually absent


Diagnostic evaluation for TT?

Color Doppler US of the testicle
-can determine if there is intratesticular flow but if sure of the diagnosis don’t wait to call urologist


Treatment of testicular torsion

1. Emergent urologic consultation and surgery

2. Potential for manual detorsion


TT: Potential for manual detorsion
1. Painful?
2. Twist laterally “like what?
3. May need to twist up to____ degrees
4. If successful, prognosis?
5. Still needs to have what? 2

1. yes!

2. opening a book”

3. 720

4. can give excellent relief of pain

-surgical exploration and


Epididymitis may be acute or chronic
1. Signs of acute? 5
2. Chronic? 4

1. 6 weeks
2. Subtle epididymal induration and tenderness
3. No irritative voiding symptoms
4. +/- inguinal lymphadenopathy


Epididymitis: Physical exam

1. Tenderness posterior and lateral to the testis
2. DRE to evaluate for prostatic involvement if history suggests
3. In acute cases may have swelling with a reactive hydrocele (epididymo-orchitis)
4. May have a positive Prehn’s sign


Epididymitis: Work Up

1. UA and urine culture,
2. test for GC and chlamydia if applicable
3. Urethral swab if discharge present
4. Rule out other causes of scrotal pain
5. Get an ultrasound to rule out torsion if acute in onset


Infectious Epididymitis: Treatment

Younger Men less than 35
1. Etiology?
2. Tx?
3. If septic needs what?

Older men or history of BPH, Urethral stricture, chronic UTI
1. Etiology?
2. Tx?
3. What kind of management?

1. Consider GC and Chlamydia
2. Ceftriaxone 250mg IM and Azithro 1000mg/Doxy 100mg BID x 10 days
3. Needs to be hospitalized for IV hydration and abs

1. Consider enteric gram - bacteria
2. Levaquin 500mg qday X10 days
3. OUtpatient


Epididymitis symptomatic treatment

2. Scrotal elevation
3. Ice


Inflammatory Epididymitis
1. Risk factors? 5
2. May be secondary to what?
3. Presentation?
4. Tx?

1. Risk factors:
-medication reaction,
-prolonged sitting,
-vigorous exercise,
-autoimmune disease

2. May be secondary to a reflux of urine within the ejaculatory ducts

3. Presentation: progressive, gradual onset of pain

4. Treatment:
Scrotal elevation, warm baths, NSAIDs


Appendiceal (appendix testis) torsion
What is this?

1. The appendix testis is a small appendage of normal tissue that is usually located on the upper portion of the testis.
2. Torsion of an appendage occurs when this tissue twists.


Torsion of the appendiceal testis
1. What ages commonly?
2. Symptoms? 4
3. Dx?

1. Epidemiology: Most cases occur between age 7-14YO

2. Symptoms:
-Gradual onset of pain
-Reactive hydrocele—which may transilluminate
-Localized tenderness
-Examination of scrotal wall may reveal classic “blue dot” sign (a tender blue or black spot beneath the skin)

3. Dx: US shows torsed appendage as a lesion of low echogoenicity with a central hypoechogenic area


Torsion of the appendiceal testis
1. Conservative tx? 3
2. Surgical
-When do pts usually resume normal activity?

-Rest, ice and NSAIDs
-Recovery is slow and with discomfort
-The infarcted tissue is usually reabsorbed

2. Surgical:
-Excision of the appendix testis, while not necessary, is safe and quick, usually reserved for continued pain
-Patients can usually resume normal activity without pain in a few days


Testis Rupture
1. What is it?
2. When is it seen?
3. Main symptoms? 3

1. Rip or tear in the tunica albuginea resulting in extrusion of testicular contents
2. Seen in blunt or penetrating trauma- Rare in sports

3. Main symptoms
-Scrotal swelling
-Severe pain


Testis Rupture
1. Dx?
2. Tx? 3

1. Diagnostics
Scrotal ultrasound

2. Treatment
-Referral to Urologist for scrotal exploration
-Pain management


Other causes of scrotal pain

1. Trauma—with possible testicular rupture
2. Strangulated hernia—usually abnormal abdominal exam
3. Post-vasectomy problems
4. Mumps
5. Testicular cancer
6. Kidney stone


1. What is it?
2. Occurs how?

1. Definition: erection unrelated to stimulation lasting typically longer then 4 h

2. Occurs by trapping of blood in the erectile bodies which can result in ischemia and infarction


Priapism can be ischemic or non-ischemic

1. What makes them different?

2. Nonischemic is from what?

-Most common, painful
-Rare, painful,

-usually from development of a traumatic A/V fistula between cavernosal artery and corpus cavernosum


What are two common causes to remember with priapism?

1. Sickle cell dz
2. Iatrogenic (injections often)


1. Hx? 3
2. PE? 2

1. Presence of pain
2. Duration, role of antecedent factors, prior episodes
3. Existence of etiological conditions and erectile function status

1. Inspection and palpation of the penis may indicate the extent of tumescence and the presence and extent of tenderness
2. Abdominal, perineal and rectal exams can reveal signs of trauma or malignancy


Dx? 3

1. CBC

2. Can use color duplex doppler ultrasound to distinguish ischemic vs. nonischemic

3. Aspiration of blood from corpus cavernosum can be evaluated


Priapism: Aspiration of blood from corpus cavernosum can be evaluated
1. If darkly colored?
2. If bright red?
3. Can do what on aspirated blood?

1. If darkly colored (unoxygenated)—ischemic
2. If bright red (oxygenated)—nonischemic
3. Can do ABGs on aspirated blood


1. Tx? 2
2. Ischemic?

3. 90% of men with ischemic priapism > what time period do not regain the ability to have sexual intercourse?

1. Treatment:
-pain management,
-urgent urological consultation

2. Ischemic:
-Evacuation of blood then intracavernous injection of alpha-adrenergic sympathomimetic agent—phenylephrine (penile shaft block can be done first)‏
3. 24 h


Priapism: Non ischemic?
1. Initial management?
2. Prognosis?
3. Further management?

1. Initial management is observation
2. 62% spontaneously resolve
3. Urological consult for further management as other treatments can cause erectile dysfunction


1. Penile Fracture is what?

2. Cause? 3

1. Rupture of one or both of the tunica albuginea that covers the corpora cavernosa

2. Cause
-Rapid blunt force to an erect penis
-Vaginal intercourse
-Aggressive masturbation


Penile Fracture
1. Signs and symptoms? 3
2. Dx? 1

1. Signs & Symptoms
-Popping or cracking sound
-Severe pain
-Immediate loss of erection

2. Diagnostics
-RUG (retrograde urethrogram) if suspect urethral injury