ECCHYMOSIS, FLANK
DESCRIPTION The presence of ecchymosis in the flank region (Grey–Turner sign) is a physical sign of retroperitoneal bleeding. Common associations may include renal trauma, ruptured abdominal aortic aneurysm, and acute pancreatitis.
REFERENCE
Bonani M, Franzen D, Anabitarte P, et al. Images in emergency medicine. Cullen’s sign and Grey–Turner’s sign. Ann Emerg Med. 2008;51(4):448–458.
ECHINOCOCCUS, RENAL
DESCRIPTION Renal hydatid disease is a parasitic tapeworm infestation that results in renal cysts that occupy space and cause local mass symptoms. This infection is caused by the larval stage of the cestode Echinococcus granulosus, whose definitive host is the dog and principal intermediate is the sheep. Common symptoms include flank pain, hematuria, and local pressure. The diagnosis of renal echinococcus requires a high index of suspicion and despite a complete clinical history, serologic, radiologic, and urine data, the yield is only 50%. Radiographic findings include a calcified, curvilinear cystic mass in the kidney. During cyst excision, great care must be taken to not spill or rupture the cyst, because the liberated parasites could be spread and cause anaphylaxis. (See also Section II: “Hydatid Cysts.”)
SYNONYMS
• Cystic hydatid disease
• Hydatid cysts
TREATMENT
• Surgical excision of intact cyst, with care not to spill or rupture cyst (praziquantel and albendazole may be given preoperatively 7–10 days before surgery)
• Medical treatment is reserved for nonsurgical candidates (albendazole 400 mg twice daily for 1–6 mo)
REFERENCE
Angulo J, Sanchez-Chapado M, Diego A, et al. Renal echinococcosis: Clinical study of 34 cases. J Urol. 1997;157(3):787–794.
EDEMA, LOWER EXTREMITY, UROLOGIC CONSIDERATIONS
DESCRIPTION Edema of the lower extremity can present bilaterally or unilaterally and can have multiple urologic implications, depending on the clinical presentation. Unilateral edema in the peri- or postoperative period may be a manifestation of deep venous thrombosis or an expected result after lymphadenectomy. Bilateral edema may be a result of underlying congestive heart failure or generalized anasarca. Postoperative fluid management should be closely monitored with this finding. In endemic regions, filariasis may present with significant bilateral lower extremity edema.
CAUSES
• Anasarca
• Congestive heart failure
• Deep venous thrombosis
• Filariasis
• IVC thrombosis/obstruction
• Lymphadenectomy (retroperitoneal, pelvic, inguinal)
• Superficial thrombophlebitis
• Urinary obstruction/retention
REFERENCE
Ely J, Osheroff JA, Chambliss ML, et al. Approach to leg edema of unclear etiology. J Am Board Fam Med. 2006;19(2):148–160.
EDWARD SYNDROME
DESCRIPTION Also known as trisomy 18, it is the 2nd most common autosomal trisomy after Down syndrome. Characterized by structural heart defects, kidney malformations, esophageal atresia, omphalocele, facial clefts, diaphragmatic hernias, and genital hypoplasia among other signs. High incidence of urologic abnormalities noted with Horseshoe kidney in about 20% of cases; hydronephrosis, hypospadias, and cryptorchidism are also common. Up to 90% of patients die within the 1st yr of life, usually secondary to cardiopulmonary problems. Uterine and vaginal abnormalities are common in females.
REFERENCE
Surányi A, Bitó T, Vajda G, et al. Unusual clinical history of a male infant with Edwards syndrome. Pathol Oncol Res. 2009;15(1):147–152.
EJACULATION, FEMALE
DESCRIPTION So called “female ejaculation" is the expulsion of fluid by females during or before sexual orgasm. The prevalence varies between 10–54%, whereas the amount of fluid ranges from 1–900 mL. These are natural sexual responses but may also represent symptoms of urinary incontinence. The term encompasses various phenomena with different underlying pathophysiologic mechanisms noted below:
• Vaginal lubrication: Vaginal fluid is forced out by the contractions of perivaginal muscles.
• Ejaculation orgasm: Either orgasmic expulsion of whitish secretion produced by the “female prostate” (known as Skene glands), or orgasmic expulsion of diluted urine (squirting/gushing), or the combination of both.
• Coital incontinence: Leakage of urine that occurs during penetrations or orgasm. Usually associated with stress or urge urinary incontinence.
Penetration incontinence occurs more frequently and is usually caused by SUI. Urodynamic diagnoses of detrusor overactivity (DO) and SUI are observed in orgasmic incontinence. (See also Section I: “Incontinence, Urinary, Adult Female”; Section II; “Coital Incontinence [Coital Leakage/Intercourse Incontinence].”)
REFERENCE
Pastor Z. Female Ejaculation Orgasm vs. Coital Incontinence: A Systematic Review. J Sex Med. 2013;10(7):1682–1691.
EJACULATION, PAINFUL
DESCRIPTION The incidence of pain associated with or immediately after ejaculation is 1–9.7%. Can be iatrogenic, physiologic, or psychogenic in nature. Ejaculatory or postorgasmic pain is believed to arise from interference with the coordination of the muscles of the pelvic floor and male genitalia that are responsible for semen transport during ejaculation. (See also Section II: “Dysorgasmia.”)
CAUSES
• Prostatitis
• BPH
• Ejaculatory duct obstruction (EDO) by calculi
• Postoperative (prostatectomy)
• Antidepressants
• Pudendal neuropathy
TREATMENT
• α-Adrenoreceptor inhibitors
• Rule out and treat EDO
• Pudendal nerve injection with bupivacaine/triamcinolone
• Pudendal nerve release
REFERENCE
Ilie CP, Mischianu DL, Pemberton RJ. Painful ejaculation. BJU Intern. 2007;99(6):1335–1339.
EJACULATORY ANHEDONIA
DESCRIPTION A rare condition, affecting males predominantly, in which ejaculation occurs without an accompanying sense of orgasmic pleasure. Most common causes are psychogenic in origin or related to SSRI antidepressants usage.
REFERENCE
Lue TF, Giuliano F, Montorsi F, et al. Summary of the recommendations on sexual dysfunctions in men. J Sex Med. 2004;1(1),6–23.
EJACULATORY DUCT OBSTRUCTION (EDO)
DESCRIPTION EDO is found in 1–5% of infertile men, producing azoospermia with low-volume, acidic ejaculate that has no fructose. Obstruction of the ejaculatory ducts prevents the emission of sperm and seminal fluid into the posterior urethra during ejaculation. Congenital causes include utricular, müllerian and wolffian duct cysts; ejaculatory duct stenosis; or atresia. Acquired causes include infection, calculus, trauma, or prior instrumentation. Physical exam is usually normal, with the occasional palpable midline mass or dilated seminal vesicles. Semen analysis shows low-volume, acidic pH, absent fructose, and failure to coagulate. Transrectal ultrasonography (TRUS) demonstrates a cystic midline structure within the prostate, with dilated seminal vesicles. When TRUS is equivocal, additional tests include TRUS-guided seminal vesicle aspirate (demonstrates abundant spermatozoa) or vasography. (See also Section II: “Vasography, Technique and Indications.”)
TREATMENT
Through transurethral resection of ejaculatory duct, in which the ejaculatory duct cyst is unroofed by transurethral resection at the level of the verumontanum, until efflux from the ducts is seen.
REFERENCE
Fisch H, Lambert SM, Goluboff ET. Management of ejaculatory duct obstruction: Etiology, diagnosis, and treatment [review]. World J Urol. 2006;24(6):604–610.
ELECTROEJACULATION
DESCRIPTION Procedure for obtaining sperm for ARTs in patients who cannot ejaculate on their own, such as SCI patients, typically used after failure of vibratory penile stimulation. General anesthesia is used, except in cases of complete spinal cord compromise. A transrectal probe is positioned with electrodes against the anterior rectal wall. Electrical stimulation causes erection and ejaculation in >80% of patients. Rectosigmoidoscopy is performed before and after the procedure to rule out rectal injury. Blood pressure monitoring is essential during the procedure for patients who may have autonomic dysreflexia.
REFERENCE
Sønksen J, Ohl DA. Penile vibratory stimulation and electroejaculation in the treatment of ejaculatory dysfunction. Int J Androl. 2002;25(6):324–332.
ELECTROMYOGRAPHY, EXTERNAL SPHINCTER
DESCRIPTION Generally, electromyography is the measurement of bioelectric potentials generated by the depolarization of muscle. During urodynamics, the activity of the external sphincter can be monitored by transperineal needle electrodes or surface electrodes. During filling, there should be increase in activity, which will reach maximum near capacity. During voiding, there should be a persistent cessation of sphincter activity. At the end of the voiding phase, sphincter activity returns to baseline. To assess external sphincter activity, the patient may be asked to interrupt voiding in the middle of the stream, at which point there should be an abrupt increase in sphincter activity sufficient to stop the flow. Abnormal EMG patterns may be detected in detrusor sphincter dyssynergia and dysfunctional voiding. EMG monitoring may also be used during biofeedback therapy for dysfunctional voiding.
REFERENCE
Voiding disorders and bladder outlet obstruction. In: Chapple CR, MacDiarmid SA, Patel A, eds. Urodynamics Made Easy. 3rd ed. London, Elsevier, 2009:127–148.
ELEJALDE SYNDROME
DESCRIPTION Also known as acrocephalopolydactylous dysplasia, this exceedingly rare autosomal recessive syndrome is characterized by craniosynostosis and fibroblast hyperproliferation in organs such as skin, liver, kidney, and pancreas. High birth weight, craniofacial dysmorphism, polydactyly, hepatomegaly, splenic abnormalities, hypertrophic kidneys, and renal cysts are also common features.
REFERENCE
Silhánová E, Plevová P, Curík R, et al. 2006. Elejalde syndrome: A case report. Am J Med Genet Part A. 140A:2223–2226.
ELEPHANTIASIS, SCROTUM (ELEPHANTIASIS SCROTI)
DESCRIPTION Also called elephantiasis scroti, this is the end result of a progressive lymphatic obstruction in which the scrotum and penis can become massively enlarged. Usually associated with filariasis, which is uncommon in the United States. Differential includes filariasis and other infectious causes; malignancy obstructing lymphatics; surgical therapy that has altered lymphatic drainage; and idiopathic, such as Milroy disease. (See also Section I: “Edema, External Genitalia (Lymphedema, Peno-Scrotal Edema)”; Section II: “Filariasis, Urologic Considerations.” and (Image 
))
TREATMENT
• Drug therapy for any infectious etiology
• Surgery for resection of redundant scrotum with flap coverage of testes
REFERENCE
Zacharakis E, Dudderidge T, Zacharakis E, et al. Surgical repair of idiopathic scrotal elephantiasis. South Med J. 2008;101(2):208–210.
ENCOPRESIS, UROLOGIC CONSIDERATIONS
DESCRIPTION Children who are incontinent of stool, even with minor fecal soiling, usually have significant constipation. Occult pathology of the bowel or nervous system must be ruled out as a possible cause. Encopresis usually is helpful in identifying bowel problems when the parents of a child are not aware of the child’s stool habits. Children with encopresis and constipation have a higher risk of UTI and urinary incontinence. Successful treatment of functional constipation will usually resolve encopresis and associated urinary tract problems. The term “fecal incontinence” is sometime used as the preferred term over encopresis or soiling. (See also Section I: “Dysfunctional Elimination Syndrome.”)
TREATMENT
• Diet changes
• Laxatives, stool softeners
• Toilet schedules
REFERENCE
Combs AJ, Van Batavia JP, Chan J, et al. Dysfunctional elimination syndromes: how closely linked are constipation and encopresis with specific lower urinary tract conditions? J Urol. 2013;190(3):1015–1020.
ENCRUSTED CYSTITIS AND PYELITIS
DESCRIPTION Inflammatory ulcerating condition of the bladder and pelvicalyceal system characterized by encrustation with calcium deposits (struvite and apatite calculi). Commonly, the presence of alkaline urine, infection by urea-splitting Corynebacterium urealyticum (formerly called Corynebacterium group D2), a multiple antibiotic-resistant urea-splitting bacterium, is the most frequently incriminated agent, and recent history of a urologic procedure in a immunocompromised host (eg, renal transplant) is found. Clinical manifestations of encrusted cystitis are often fever, dysuria, and gross hematuria. Encrusted pyelitis may have lumbar pain in addition to symptoms of encrusted cystitis. Imaging on US and CT may reveal calcific encrustations with thick-walled edema of the bladder and/or pyelocaliceal system. Calcifications seldom appear on plain abdominal radiographs unless in association with staghorn calculi. The endoscopic appearance is of calcified white plaques adherent to a severely inflamed and ulcerated mucosa. Bacteriologic diagnosis of Corynebacterium group D2 requires culture for 48–72 hr at 37°C on media enriched with 5% carbon dioxide (CO2) or sheep blood agar.
TREATMENT
• Treat Corynebacterium infection according to sensitivity; most are susceptible to vancomycin and teicoplanin (not available in the United States)
• Acidify urine through irrigation (eg, Suby’s solution G, Thomas C24) or PO acetohydroxamic acid
• Remove calcified plaques where bacteria harbor: TUR, endoscopic
REFERENCE
López-Medrano F, García-Bravo M, Morales JM, et al. Urinary tract Infection due to Corynebacterium urealyticum in kidney transplant recipients: An underdiagnosed etiology for obstructive uropathy and graft dysfunction—Results of a prospective cohort study. Clin Infect Dis. 2008;46(6):825–830.
ENCRUSTED URETERAL STENT
DESCRIPTION Indwelling ureteral stents are routinely employed for the prevention and treatment of ureteral obstruction secondary to intrinsic, extrinsic, and iatrogenic causes such as urolithiasis, strictures, and/or malignancy. Indwelling time seems to affect rate of encrustation: Consensus is that stents should not remain in place longer than 3–6 mo (high degree of variation according to different series). Reported risk factors include urinary tract infections (urease-producing microorganisms) and pregnancy. Site and degree of encrustation will guide the appropriate approach (single or multimodal). For this purpose several grading systems and management algorithms have been proposed. Good communication between physician and patient is imperative in preventing this challenging complication.
REFERENCE
Acosta-Miranda AM, Milner J, Turk TM. The FECal Double J: A simplified approach in the management of encrusted and retained ureteral stents. J Endourol. 2009;23(3):409–415.
ENDOCARDITIS (SBE) PROPHYLAXIS, UROLOGIC CONSIDERATIONS
DESCRIPTION Antimicrobial prophylaxis for genitourinary procedures solely to prevent infectious endocarditis is no longer recommended by the American Heart Association; the risk of adverse events exceeds the benefit. The AHA guidelines concluded that bacteremia resulting from random daily activities are much more likely to cause infectious endocarditis than bacteremia associated with GU procedures.
REFERENCE
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council. Circulation. 2007;116(15):1736–1754.
ENDOCERVICOSIS, BLADDER
DESCRIPTION This rare mucinous analog of endometriosis histologically demonstrates glandular lesions characterized by a prominent endocervical-type epithelium that may involve the urinary bladder in women of reproductive age. Typically are observed in the posterior wall of the bladder or the dome. Lack of awareness may lead to confusion with an adenocarcinoma, particularly of urachal origin given its location. Because of this, patients are presumed to have an underlying malignancy and are treated surgically. Patients usually present with irritative voiding symptoms and pelvic pain. Transurethral resection or partial cystectomy is curative, and close follow-up is recommended.
REFERENCE
Young RH. Tumor-like lesions of the urinary bladder. Modern Pathology. 2009;22:s37–s52.
ENDOMETRIOSIS, GENITOURINARY
DESCRIPTION Endometriosis is a condition in which endometrial tissue is found outside the uterus. Most common sites in the GU system are the bladder and distal 3rd of ureter. Symptoms are variable and may include dysmenorrhea and pelvic pain with or without urinary symptoms of gross hematuria, flank pain, frequency, or urgency. Urinary symptoms may or may not be exacerbated with menstruation, and the classic symptom of “cyclical hematuria” is uncommon. Diagnosis is through IVP/CT urography and urine analysis, laparoscopy to inspect the pelvis and obtain tissue biopsy, or cystoscopy or ureteroscopy to evaluate hematuria and obtain biopsy.
TREATMENT
• Hormonal therapy with oral contraceptives, danocrine, or GNRH agonists
• Surgery when medical treatment fails
• Partial cystectomy, ureterolysis, ureteric reimplantation, or ureteral stenting may be performed
REFERENCE
Umar SA, MacLennan GT, Cheng L. Endometriosis of the ureter. J Urol. 2008;179(6):2412.
EPCA-2 (EARLY PROSTATE CANCER ANTIGEN)
DESCRIPTION A nuclear matrix protein (NMP) that showed promise as a new serum-based biomarker of prostate cancer, which was postulated to have better sensitivity and specificity than PSA. However, at the request of the authors (Leman et al., Urology. 2012;79(2):490), the original article was retracted as there were inconsistencies in validating their data collection.
REFERENCE
Leman ES, Cannon GW, Trock BJ, et al. EPCA-2: A highly specific serum marker for prostate cancer. Urology. 2007;69:714–720.
EPIDIDYMAL CYST
DESCRIPTION Epididymal cysts tend to occur in the head of the epididymis and may be mistaken for a testicular mass. They are increased in male offspring of mothers who used DES during pregnancy. They are often asymptomatic. The distinction between a spermatocele and an epididymal cyst is based on size; epididymal cystic masses > 2 cm are called spermatoceles. Spermatoceles are always located superior to the testis and are palpated as distinct from the testis, which differentiates them from hydroceles. Transscrotal ultrasound is diagnostic and no treatment is necessary. (See also Section I: “Scrotum and Testicle, Mass” and “Spermatocele”; Section II: “Epididymal Cystadenoma/Papillary Cystadenoma.”)
REFERENCE
Eyre RC. Evaluation of nonacute scrotal pathology in adult men. www.UpToDate.com. Wolters Kluwer, Accessed April 1, 2014.
EPIDERMOID CYST, TESTICLE
DESCRIPTION Epidermoid cysts account for ∼1% of testicular tumors. Producing keratinizing, stratified, squamous cell–lined cysts supported by fibrous tissue, these cysts are considered special cases of teratoma, but are not truly considered a teratoma since only a single germinal layer and not the required 2 layers is represented. Benign in behavior; scrotal US is suggestive of the diagnosis but not usually definitive. (See also Section I: “Scrotum and Testicle, Mass.”)
TREATMENT
• Inguinal orchiectomy
• Some advocate organ-sparing surgery if the diagnosis is definitively proven by frozen section
REFERENCE
Heidenreich A, Engelmann UH, Vietsch HV, et al. Organ preserving surgery in testicular epidermoid cysts. J Urol. 1995;153(4):1147–1150.
EPIDIDYMAL CYSTADENOMA/PAPILLARY CYSTADENOMA
DESCRIPTION This is a benign tumor that accounts for 1/3 of all primary epididymal tumors. Epididymal cystadenomas are seen in up to 2/3 of patients with von Hippel–Lindau disease and are often bilateral with this syndrome. They have a cystic appearance on ultrasound and can be up to 6 cm. Cut surface is gray-brown and contain fluid. The histologic appearance is that of dilated tubules with a single or double layer of cuboidal or low columnar epithelium. Rarely can be mistaken for metastatic RCC. Papillary cystadenomas are benign and generally asymptomatic and no treatment is required. (See also Section I: “Scrotum and Testicle, Mass,” “Spermatocele,” and “Von Hippel–Lindau Disease/Syndrome” and Section II: “Epididymal Cysts.”)
REFERENCES
Bostwick DG. Chapter 14. Spermatic cord and testicular adnexae. In: Bostwick DG, Cheng L, eds. Urologic Surgical Pathology. 2nd ed. Philadelphia, PA: Mosby Elsevier: 2008.
Eyre RC. Evaluation of nonacute scrotal pathology in adult men. www.UpToDate.com. Wolters Kluwer. Accessed April 1, 2014.
EPIDIDYMIS, METASTASIS TO
DESCRIPTION Extremely rare, with primary sites reported to include colon, stomach, kidney, prostate, carcinoid, and pancreatic tumors. Prognosis is related to that of the primary disease. Patients can present with pain and swelling or as an incidental finding on orchiectomy for prostate cancer. 4 mechanisms for spread have been proposed, including direct extension, retrograde venous extension, retrograde lymphatic extension, and arterial embolism.
REFERENCE
Powell BL, Craig JB, Muss HB. Secondary malignancies of the penis and epididymis: A case report and review of the literature. J Clin Oncol. 1985;3:110–116.
EPIDIDYMIS, OBSTRUCTION
DESCRIPTION A cause of obstructive azoospermia. Most common cause is vasectomy, which results in a fixed obstruction and elevated vessel pressures resulting, in the blowout of the epididymal tubules. Other causes include trauma, congenital malunion of the vas and epididymis, infection, inflammatory damage to the epididymis, and idiopathic. Epididymovasostomy is the treatment of choice. (See also Section I: “Infertility, Urologic Considerations” and “Vas Deferens, Congenital Absence”; Section II: “Azoospermia.”)
REFERENCE
Kim ED, Winkel E, Orejuela F, et al. Pathological epididymal obstruction unrelated to vasectomy: Results with microsurgical reconstruction. J Urol. 1998;160(6, Part 1):2078–2080.
EPITHELOID HEMANGIOMA, PENIS AND SCROTUM
DESCRIPTION Rare vascular lesion, typically arising on the head and distal extremities, whose pathogenesis is not fully understood. Genital involvement has rarely been reported. These lesions do not recur following excision and no metastasis has been reported. Macroscopically, the lesions are described as an inflammatory red to brown nodule. Microscopically, the lesions are characterized by endothelial cells arranged in nests surrounded by immature vessels and eosinophilic cell infiltrate. Differential diagnosis includes epithelioid hemangio-endothelioma, epithelioid hemangiosarcoma, Kimura’s disease, and bacillary angiomatosis. Treatment is local excision.
REFERENCE
Ismail M, Damato S, Freeman A, et al. Epithelioid hemangioma of the penis: case report and review of literature. J Med Case Rep. 2011;5:260.
ERECTILE DYSFUNCTION INVENTORY OF TREATMENT SURVEY (EDITS)
DESCRIPTION A validated satisfaction questionnaire for both patient (11 items) and partner (5 items) based on their subjective evaluation of the treatment for ED. Few of the disease-specific instruments used to assess ED address sexual dysfunction related quality of life, psychosocial impact, and satisfaction. EDITS attempts to address both patient and partner satisfaction with ED treatment, in addition to sexual functioning.
REFERENCE
Althof SE, Corty EW, Levine SB, et al. EDITS: Development of questionnaires for evaluating satisfaction with treatments for erectile dysfunction. Urology. 1999;53(4):793–799.
ERECTION HARDNESS SCORE (EHS) FOR ED
DESCRIPTION The EHS was developed as a single-item, patient-reported outcome to quantify erection hardness data. It is easy to use and highly responsive to treatment. Psychometric analysis supports its use as a simple, valid, reliable, and responsive tool for the assessment of erection hardness in clinical research.
REFERENCE
Mulhall JP, Goldstein I, Bushmakin AG, et al. Validation of the erection hardness score. J Sex Med. 2007;4(6):1626–1634.
ERYSIPELAS, EXTERNAL GENITALIA
DESCRIPTION Superficial bacterial infection of the dermis with marked dermal lymphatic involvement. The irritation afflicts extremes of ages, and the most common site of involvement is the face. Typically heralded by pain, superficial erythema, and plaque-like edema with a sharply defined margin to normal skin, it may often be described as a peau d’orange appearance. The clinician must differentiate erysipelas from cellulitis and Fournier gangrene (exclusion of this diagnosis is a priority in all cutaneous infections of the external genitalia). It is usually caused by Group A hemolytic streptococcus (eg, S. pyogenes), or rarely S. aureus.
TREATMENT
• Mild infection: PO penicillin, macrolides, or clindamycin
• Severe infection: Parenteral penicillin or vancomycin
REFERENCE
Link RE. Cutaneous disease of the external genitalia. In: Wein AJ, et al., eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders; 2012:416–467.
ERYTHEMA MULTIFORME (EM), EXTERNAL GENITALIA
DESCRIPTION EM is a common acquired blistering skin condition that affects all age groups, ethnicities, and sex. EM minor is a mild subtype that usually is confined to skin and oral involvement. EM major (Stevens–Johnson syndrome) affects skin and often other mucoepithelial-lined surfaces including the eyes, oral cavity, and external genitalia. The hallmark of EM is a target lesion, a circular erythematous macular lesion resembling a bulls-eye, commonly occurring on the hands. Painful rash is characteristic, and macules, papules, urticaria, vesicles, bullae, purpura, or petechiae are pleomorphic. In EM major, large tracts of skin and oral mucosa may be denuded, along with conjunctivitis, and GU and upper GI involvement. HSV is the most common cause but virtually any infectious agent or drug can cause EM. Main differential is toxic epidermal necrolysis.
TREATMENT
• EM minor: Wet compress with topical astringent, topical acyclovir (for HSV-related EM)
• EM major (Stevens–Johnson syndrome): Hospitalization required, nutrition, hydration, aggressive topical nursing care equivalent to burn protocols
REFERENCE
Fine JD. Blistering diseases. In: Kerdel FA, FJimenez-Acosta, eds. Dermatology: Just the Facts. New York, NY: McGraw-Hill; 2003:143–145.
ERYTHRASMA
DESCRIPTION Superficial, asymptomatic cutaneous infection by the diphtheroid Corynebacterium minutissimum. Physical exam reveals sharply delineated, round to oval patches with scales in the intertriginous or interdigital regions. Wood’s lamp exam reveals coral-red fluorescence. Histologically, only the stratum corneum is affected, with all other layers normal. More common in tropical climates. Despite there being no consensus on the ideal treatment for the condition, usually it consists of topical or oral antibiotic therapy for 14 days (erythromycin or tetracycline). Recent evidence suggests single-dose clarithromycin may be an alternative regimen.
REFERENCE
Blaise G, Nikkels AF, Hermanns-Lê T, et al. Corynebacterium-associated skin infections. Int J Dermatol. 2008;47(9):884–890.
EXCRETORY UROGRAM, INTRAOPERATIVE (“ON TABLE IVP”/“SINGLE-SHOT IVP”)
DESCRIPTION The preferred imaging study for renal trauma is contrast-enhanced CT, and the indications for intraoperative excretory urography is uncommon. However, a “single-shot” IVP may be performed in a setting in which renal trauma is suspected during abdominal exploration for a trauma patient too unstable for CT. A single film is shot on the operative table at 10 min after administration of 2 mL/kg of IV contrast. An abnormal or inconclusive study should prompt renal exploration to complete staging of the renal injury and perform appropriate repairs; a properly performed study can potentially reduce the need for renal exploration by 32%. The study is also valuable in confirming the presence of a normal contralateral renal unit before renal exploration.
REFERENCES
Jankowski JT, Spirnak JP. Current recommendations for imaging in the management of urologic traumas. Urol Clin N Am. 2006;33(3):365–376.
Morey AF, McAninch JW, Tiller BK, et al. Single shot intraoperative excretory urography for the immediate evaluation of renal trauma. J Urol. 1999;161(4):1088–1092.
EXPRESSED PROSTATIC SECRETIONS (EPS)
DESCRIPTION EPS represents prostatic fluid expressed after vigorous prostatic massage. Evaluation of this fluid is part of the Stamey test used in the evaluation of prostatitis. Note that prostate massage is contraindicated in the setting of acute bacterial prostatitis. The WBC count in an EPS for a diagnosis of chronic bacterial prostatitis (NIH category II) is >10 WBCs/hpf (40× objective) or clumping of WBCs with the presence of oval fat bodies and a positive EPS bacterial culture. NIH category III prostatitis is divided into IIIa and IIIb, based on whether greater or fewer than 10 WBCs are seen on microscopic exam of the EPS, respectively. The pH of prostatic fluid increases with infection (6.5–>8.0).
REFERENCE
Nickel JC, Shoskes D, Wang Y, et al. How does the premassage and postmassage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol. 2006;176(1):119–124.
EXSTROPHY–EPISPADIAS COMPLEX (EEC)
DESCRIPTION EEC is a rare congenital urogenital anomaly with a spectrum of complexity ranging from epispadias and bladder exstrophy to cloacal exstrophy. Incidence of bladder exstrophy is between 1 in 10,000 and 1 in 50,000 live births, with a male preponderance. The risk of recurrence in a family is 1 in 100. The condition is believed to be due to failure of the cloacal membrane to be reinforced by in growth of mesoderm, therefore preventing the medial migration of mesenchymal tissues and lower abdominal wall development. The defective cloacal membrane ruptures prematurely and, depending on the stage of development during which the rupture occurs, a variant of the complex will result. Most anomalies relate to defects of the abdominal wall, bladder, genitalia, pelvic bones, rectum, and anus. (See also Section I: “Epispadias” and “Exstrophy, Bladder [Classic Exstrophy].”)
TREATMENT
• Immediate at birth: Prevent irritation/trauma to exposed mucosal surfaces (eg, Saran wrap)
• Surgical reconstruction must consider appearance of lower abdomen and genitalia, pelvic bone reconstruction, continence, and subsequent sexual function
• Staged reconstruction: Early bladder, abdominal wall, and posterior urethral closure, with osteotomy. Epispadias repair between 6 and 12 mo. Reconstruction of continent bladder neck and ureteric reimplantation, usually at age 4–5 yr.
• Single-stage reconstruction
REFERENCE
Eeg K, Khoury A. The exstrophy-epispadias complex. Curr Urol Rep. 2008 9;9(2):158–164.
EXTRAGONADAL GERM CELL TUMORS (EGCT)
DESCRIPTION Rare entity representing 3–5% of all GCT. There is a clinical association with Klinefelter syndrome, and testicular ultrasound is necessary to exclude primary tumor. Extragonadal GCT must show no evidence of a primary tumor in the testes (or ovaries in females). Primary EGCT are usually midline in decreasing frequency: Mediastinum, retroperitoneum, pineal/suprasellar region, and the sacrococcygeal region. All tumor types are reported, with nonseminomatous being most common. They can present with wide local invasion and advanced metastasis with few symptoms. Transformation to sarcoma or carcinomas has been reported with chemotherapy resistance common in these cases. 1 or both testicular tumor markers (β-HCG or AFP) are elevated in 85% of cases of EGCT. Management of EGCT parallels that of metastatic testicular GCT, however EGCT have a worse prognosis.
TREATMENT
• Surgical excision, if feasible
• Chemotherapy, irradiation, or combination based on histology and in general follows testicular cancer regimens.
REFERENCE
Bokemeyer C, Nichols CR, Droz JP, et al. Extragonadal germ cell tumors of the mediastinum and retroperitoneum: Results from an international analysis. J Clin Oncol. 2002;20(7):1864–1873.
EXTRAMAMMARY PAGET DISEASE, UROLOGIC CONSIDERATIONS
DESCRIPTION A rare cutaneous malignancy arising from ducts of apocrine-gland bearing skin, most often involving the anogenital region, more commonly seen in the elderly and women. The condition presents with a well-circumscribed erythematous scaly patch, similar in appearance to mammary Paget disease. There is a 10% association with underlying metachronous GU (most commonly bladder) or GI (most commonly colon) malignancy. Differential diagnoses include SCC in situ or malignant melanoma.
TREATMENT
• Surgical excision with wide margin, Moh’s microsurgical excision, or radiation
• Screen for occult GU and GI malignancy
REFERENCE
Smoller BR. Paget’s disease. In: Morgan MB, et al. eds. Deadly Dermatologic Diseases: Clinicopathologic Atlas and Text. New York, NY: Springer; 2007:43–50.
EXTRAMEDULLARY HEMATOPOESIS, RENAL
DESCRIPTION This is a reactive process in response to the failure of hematopoiesis in the bone marrow. It commonly occurs in organs such as the liver, spleen, and kidney. It commonly occurs in the presence of myelofibrosis (most common), chronic myeloproliferative disorder, polycythemia vera, and essential thrombocytosis. Considered a cause of renal pseudotumor, a renal mass in association with any of these disorders should raise the possibility of an extramedullary hematopoiesis. Biopsy confirmation is usually required.
REFERENCE
Bhatt S, MacLennan G, Dogra V. Renal pseudotumors. AJR Am J Roentgenol. 2007;188:1380–1387.
EXTRAVASATION DURING UROLOGIC SURGERY
DESCRIPTION Perforation of the urinary tract can lead to extravasation of irrigation fluid, contrast, urine, and/or blood. This can lead to flank pain, fever, and ileus, depending on the site of perforation. Potential complications include formation of an infected urinoma or hematoma. The extent of fluid collection can be documented by imaging studies in the form of CT scan or ultrasound. Fluid collections due to extravasation can be managed with either observation, when appropriate, or drainage.
REFERENCE
Lytton B, Weiss RM, Green DF, et al. Complications of ureteral endoscopy. J Urol. 1987;137:649–653.