Boyd Burns
SCROTUM
Scrotal abscesses may be localized to the scrotal wall or may arise from extensions of infections of scrotal contents (ie, testis, epididymis, and bulbous urethra). A simple hair follicle scrotal wall abscess can be managed by incision and drainage; no antibiotics are required in immunocompetent patients unless signs of cellulitis or systemic involvement are present.
When a scrotal wall abscess is suspected of arising from an intrascrotal infection, ultrasound and retrograde urethrography may demonstrate pathology in the testis, epididymis, or urethra. Definitive care of any complex abscess calls for a urology consultation.
Fournier’s gangrene is a polymicrobial infection of the perineal subcutaneous tissues (see Fig. 57-1). Immunocompromised males, particularly diabetics, are at highest risk.
Prompt diagnosis is essential to prevent extensive tissue loss. Early surgical consultation is recommended for at-risk patients who present with scrotal, rectal, or genital pain.
Treatment for Fournier’s gangrene begins with aggressive fluid resuscitation (with normal saline). Broad-spectrum antibiotics should cover gram-positive, gram-negative, and anaerobic organisms, such as imipenem 1 gram IV every 24 hours, or meropenem 500 milligrams to 1 gram IV every 8 hours, with vancomycin if methicillin-resistant Staphylococcus aureus is suspected; surgical debridement is also necessary.
FIG. 57-1. A patient with Fournier’s gangrene of the scrotum. Note the sharp demarcation of gangrenous changes and the marked edema of the scrotum and the penis.
PENIS
Balanoposthitis is inflammation of the glans (balanitis) and foreskin (posthitis). Upon foreskin retraction, the glans and prepuce appear purulent, excoriated, malodorous, and tender.
Treatment of balanoposthitis consists of cleansing with mild soap, assuring adequate dryness, and application of antifungal creams (nystatin qid or clotrima-zole bid) and an oral azole (such as fluconazole), with urologic follow-up for possible circumcision. An oral cephalosporin (eg, cephalexin 500 milligrams qid) should be prescribed in cases of secondary bacterial infection. Recurrent balanoposthitis can be the sole presenting sign of diabetes.
Phimosis is the inability to retract the foreskin proximally (see Fig. 57-2). Hemostatic dilation of the preputial ostium relieves the urinary retention until definitive dorsal slit or circumcision can be performed.
Need for circumcision after phimoisis can often be averted by application of topical steroids (eg, triamcinolone 0.025% bid for 4–6 weeks).
Paraphimosis is the inability to reduce the proximal edematous foreskin distally over the glans (see Fig. 57-2). Paraphimosis is a true urologic emergency because resulting glans edema and venous engorgement can progress to arterial compromise and gangrene.
If surrounding tissue edema can be successfully compressed, as by wrapping the glans with 2 × 2-in. elastic bandages for 5 minutes, the foreskin may be reduced. Making several puncture wounds with a small (22- to 25-gauge) needle may help with expression of glans edema fluid.
Local anesthetic block of the penis is helpful for paraphimosis if patients cannot tolerate the discomfort associated with edema compression and removal. If arterial compromise is suspected, local lidocaine (1% without epinephrine) infiltration of the constricting band, followed by superficial vertical incision of the band, will decompress the glans and allow foreskin reduction.
Penile entrapment injuries occur when various objects are wrapped around the penis. Such objects should be removed, and imaging is often necessary to confirm urethral integrity (retrograde ure-throgram) and distal penile arterial blood supply (Doppler studies).
Penile fracture occurs when there is an acute tear of the penile tunica albuginea. The penis is acutely swollen, discolored, and tender in a patient with history of intercourse-related trauma accompanied by a snapping sound. Urologic consultation is indicated.
Peyronie’s disease presents with patients noting sudden or gradual onset of dorsal penile curvature with erections. Examination reveals a thickened plaque on the dorsal penile shaft. Assurance and urologic follow-up are indicated.
Priapism is a painful pathologic erection, which may be associated with urinary retention. Infection and impotence are other complications. In most cases, the initial therapy for priapism is terbutaline 0.25 to 0.5 milligram (repeated in 20 minutes if needed) injected subcutaneously in the deltoid area.
Patients with priapism from sickle cell disease are usually treated with simple or exchange transfusion. Corporal aspiration and irrigation with either normal saline solution or an α-adrenergic agonist (ie, phenylephrine) is the next step and may need to be performed by the emergency physician. Even when emergency physicians provide stabilizing care, urologic consultation is indicated in all cases.
FIG. 57-2. Phimosis and paraphimosis.
TESTICULAR TORSION
CLINICAL FEATURES
Due to potential for infarction and infertility, testicu-lar torsion must be the primary consideration in any male complaining of testicular pain.
Though torsion is most common in the peripubertal period (when hormonal stimulation is maximal), this organ-threatening emergency may occur at any age.
Pain usually occurs suddenly, is severe, and is felt in either the lower abdominal quadrant, the inguinal canal, or the testis.
The finding with the highest sensitivity (99%) is unilateral absence of the cremasteric reflex.
Though pain may follow strenuous activity such as athletics, torsion also occurs during sleep (when unilateral cremasteric contraction is the cause). The pain may be constant or intermittent but is not positional, since torsion is primarily an ischemic event.
DIAGNOSIS AND DIFFERENTIAL
When the diagnosis is obvious, urologic consultation is indicated for exploration, since confirmatory imaging can be too time consuming. With acute torsion, testicular salvage is related to the duration of symptoms before surgical detorsion.
Excellent salvage rates are expected with detorsion within 6 hours of symptoms, but testicular preservation rates decline rapidly with longer delays to intervention. A rapid evaluation should be performed regardless of the duration of the symptoms. The emergency physician should move as expeditiously as possible in cases of suspected torsion.
In indeterminate cases, color-flow duplex ultrasound, and less commonly radionuclide imaging, may be helpful. Both techniques are subject to limitations associated with need for timely test availability and image interpretation.
Compared to radionuclide imaging, ultrasound offers the advantage of providing additional information about scrotal anatomy and differential diagnoses; however, ultrasound is more likely than radionuclide imaging to yield indeterminant results.
Torsion of the testicular appendage is more common than testicular torsion but is not dangerous, since the appendix testis and appendix epididymis have no known function. If the patient is seen early, diagnosis can be supported by the following: pain is most intense near the head of the testis or epididymis; there is an isolated tender nodule; or there is a (pathogno-monic) blue-dot appearance of a cyanotic appendage transilluminated through thin prepubertal scrotal skin.
The differential for testicular torsion also includes epididymitis, inguinal hernia, hydrocele, and scrotal hematoma.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
The emergency physician can attempt manual detorsion. Most testes twist in a lateral-to-medial direction, so detorsion is performed in a medial-to-lateral direction, similar to the opening of a book (see Fig. 57-3).
The endpoint for successful detorsion is pain relief; worsening of pain with detorsion may indicate the need for attempts at detorsion by lateral-to-medial rotation.
Regardless of whether detorsion appears successful, urologic referral is indicated.
If normal intratesticular blood flow can be demonstrated with color Doppler, immediate surgery is not necessary for torsion of the appendages, since most appendages calcify or degenerate over 10 to 14 days and cause no harm.
If the diagnosis cannot be ensured, urologic exploration is needed to rule out testicular torsion.
Consider testicular torsion in the differential of any male presenting with abdominal pain.
FIG. 57-3. Testicular detorsion. This procedure is best done standing at the foot of or on the right side of the patient’s bed. A. The torsed testis is detorsed in a fashion similar to opening a book. B. The patient’s right testis is rotated counterclockwise, and the left testis is rotated clockwise. (Reproduced with permission from Strange GR, Ahrens WR, Schafermeyer RW, et al: Pediatric Emergency Medicine, 3rd ed. © 2009, McGraw-Hill, Inc., New York, NY, p. 679.)
EPIDIDYMITIS AND ORCHITIS
CLINICAL FEATURES
Epididymitis, an inflammatory process, is characterized by gradual onset of pain.
Bacterial infection is the most common etiology, with infecting agent identity varying with patient age.
In patients younger than 40 years old, epididymitis is primarily due to sexually transmitted diseases (STDs); culture or DNA probe analysis for gonococci and Chlamydia is indicated in patients <40 years old, even in the absence of urethral discharge. In older men (>40 years), common urinary pathogens predominate.
Epididymitis causes lower abdominal, inguinal canal, scrotal, or testicular pain, alone or in combination. Urinalysis may show pyuria in about half of the patients.
Due to the inflammatory nature of the pain, patients with epididymitis may note transient pain relief when elevating the scrotal contents while recumbent (positive Prehn’s sign).
DIAGNOSIS AND DIFFERENTIAL
Initially, tenderness is well localized to the epididymis, but progression of inflammation and swelling-mediated obliteration of the sulcus between the epididymis and testis results in the physical examination finding of a single, large testicular mass (epididy-moorchitis).
Orchitis in isolation is rare; it usually occurs with viral or syphilitic disease and is treated with disease-specific therapy, symptomatic support, and urologic follow-up.
Testicular malignancy should be suspected in patients presenting with asymptomatic testicular mass, firmness, or induration. Ten percent of tumors present with pain due to hemorrhage within the tumor. Urgent urologic follow-up is indicated.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
If the patient appears toxic, admission for intravenous antibiotics is indicated (treatment is based on the presumed etiology).
Outpatient treatment is the norm in patients who do not appear toxic; urologic follow-up within a week is indicated.
In patients age <40, treatment is aimed toward gonorrhea and Chlamydia with doxycycline 100 milligrams twice daily for 10 days after IM ceftriaxone while in the ED. In patients age >40 treatment is directed toward gram-negative bacilli with ciprofloxacin 500 milligrams twice daily for 10 to 14 days or levofloxacin 250 milligrams daily for 10 to 14 days
Additionally, scrotal elevation, ice application, nons-teroidal anti-inflammatory drugs (NSAIDs), opioids for analgesia, and stool softeners are indicated.
Orchitis is treated with disease-specific therapy, symptomatic support, and urologic follow-up. Patients at risk for syphilitic disease should be treated as directed in Chapter 89, Sexually Transmitted Diseases.
ACUTE PROSTATIS
Patient complaints may include back pain, perineal, suprapubic, or genital discomfort, urinary obstruction, fever, or chills.
Diagnosis is clinical as the urinalysis and urine culture may both be negative.
Initial treatment is fluoroquinolone antimicrobial therapy for 30 days.
An alternative approach is trimethoprim-sulfameth-oxazole double strength (DS), one tablet PO twice daily for 30 days.
URETHRA
URETHRITIS
Characterized by purulent or mucopurulent urethral discharge. The diagnosis is clinical and most cases are due to Neisseria gonorrhea or Chlamydia trachomatis; see also Chapter 89.
Physical examination should exclude other disorders such as epididymitis, disseminated gonococccemia, or Reiter sydrome.
Treatment is ceftriazone 125 milligrams IM, administered with either azithromycin 1 gram PO × 1 or doxycycline 100 milligrams PO bid for 10 days.
URETHRAL STRICTURE
Urethral stricture is becoming more common due to the rising incidence of STDs. If a patient’s bladder cannot be cannulated with a 14F or 16F Foley or Coudé catheter, the differential diagnosis includes urethral stricture, voluntary external sphincter spasm, bladder neck contracture, or benign prostatic hypertrophy; see also Chapter 56, Acute Unrinary Retension.
Retrograde urethrography can be performed to delineate the location and extent of urethral stricture. Endoscopy is necessary to confirm bladder neck contracture or define the extent of an obstructing prostate gland.
Suspected voluntary external sphincter spasm can be overcome by holding the patient’s penis upright and encouraging him to relax his perineum and breathe slowly during the procedure.
After no more than three gentle attempts to pass a 12F Coudé catheter into a urethra prepared with anesthetic lubricant, urology consultation should be obtained.
In an emergency situation, suprapubic cystostomy can be performed; see Chapter 56.
Urologic follow-up should occur within 2 to 3 days.
URETHRAL FOREIGN BODIES
Urethral foreign bodies are associated with bloody urine and slow, painful urination.
Radiographs of the bladder and urethral areas may disclose a foreign body.
Removal of the foreign body may be achieved with a gentle milking action; retrograde urethrography or endoscopy is required in such cases to confirm an intact urethra.
Often, urologic consultation for endoscopy or open cystotomy is required for foreign-body removal.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 96, “Male Genital Problems,” by Bret A. Nicks and David E. Manthey.