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Emergency Medicine Atlas > Part 1. Regional Anatomy > Chapter 8. Urologic Conditions >

Testicular Torsion

Associated Clinical Features

These patients are most often young men (average age 16 to 17.5 years) who present complaining of the sudden onset of pain in one testicle. The pain is then followed by swelling of the affected testicle, reddening of the overlying scrotal skin, lower abdominal pain, nausea, and vomiting. An examination reveals a swollen, tender, retracted testicle (Fig. 8.1) that often lies in the horizontal plane (bell-clapper deformity) (Figs. 8.2 and 8.3). The spermatic cord is frequently swollen on the affected side. In delayed presentations, the entire hemiscrotum may be swollen, tender, and firm (Fig. 8.4). The urine is usually clear with a normal urinalysis. In one-third of cases there is a peripheral leukocytosis.

Figure 8.1

Testicular Torsion Swollen, tender hemiscrotum, with erythema of scrotal skin and retracted testicle. (Courtesy of Stephen Corbett, MD.)

Figure 8.2

Bell-Clapper Deformity A bell-clapper deformity in testicular torsion results from the twisting of the spermatic cord and causes the testis to be elevated, with a horizontal lie. The lack of fixation of the tunica vaginalis to the posterior scrotum predisposes the freely movable testis to rotation and subsequent torsion. An elevated testis with a horizontal lie may be seen in asymptomatic patients at risk for torsion.

Figure 8.3

Testicular Torsion A retracted testicle consistent with early testicular torsion is seen. (Courtesy of David W. Munter, MD, MBA.)

Figure 8.4

Testicular Torsion Swollen, tender scrotal mass. (Courtesy of Patrick McKenna, MD.)

Differential Diagnosis

Alternative diagnoses that should be considered include acute epididymitis, torsion of the testicular appendix (Fig. 8.5), trauma, acute orchitis (mumps), hydrocele, spermatocele, varicocele, hernia, and tumor. A good history and physical examination helps narrow the diagnosis.

Emergency Department Treatment and Disposition

Urologic consultation should be obtained immediately and preparations made to go to the operating room without delay. Doppler ultrasound or technetium scanning may be helpful if these procedures will not delay surgery. In the interim, detorsion may be attempted if the patient is seen within a few hours of onset: the affected testicle should initially be opened like a book, that is, the right testicle turned counterclockwise when viewed from below and the left testicle turned clockwise when viewed from below. Pain relief should be immediate. Decreased pain should prompt additional turns (as many as three) to complete detorsion; increased pain should prompt detorsion in the opposite direction. Ancillary studies should not delay operative intervention, since testicular infarction will occur within 6 to 12 h after torsion.

Clinical Pearls

1. The cremasteric reflex is almost always absent in testicular torsion.

2. Patients may report similar, less severe episodes that spontaneously resolved in the recent past.

3. Half of all torsions occur during sleep.

4. Abdominal or inguinal pain is sometimes present without pain to the scrotum.

5. The age of presentation has a bimodal pattern, since torsion is also more prevalent during infancy and adolescence.

Torsion of a Testicular or Epididymal Appendix

Associated Clinical Features

Small vestigial remnants in the embryology of the scrotum are often found on the superior portions of the testicle or the epididymis. These appendages, which have no known function, are occasionally on a stalk that is subject to torsion. This most commonly occurs in boys up to 16 years of age but has been reported in adults. The patient will complain of sudden pain around the superior pole of the testicle or epididymis as the appendix undergoes necrosis and inflammation. Early in the course, palpation of a firm, tender nodule in this area will confirm the diagnosis.

Differential Diagnosis

Later in the course of appendiceal torsion, swelling and pain generalize to the rest of the scrotum. At this point the condition may be difficult to differentiate from testicular torsion, acute epididymitis, or acute orchitis. Hydrocele, spermatocele, varicocele, hernia, and tumor must also be considered.

Emergency Department Treatment and Disposition

Urologic consultation should be obtained immediately. Differentiating from the more emergent testicular torsion is the key responsibility. Ancillary studies are generally not helpful in making this diagnosis unless it presents very early in its course. A urinalysis is generally normal. The characteristic physical signs of a small, tender, upper-pole nodule along with a color Doppler ultrasound showing good flow to the testicle may mitigate the need for emergent surgery. With later presentations or an equivocal ultrasound, the diagnosis may not be made with confidence before surgery. Necrotic appendices are excised if found during an exploration to rule out testicular torsion. If surgery is not deemed necessary by the urologic consultant, analgesics and rest are all that is required. The appendix will involute and calcify in 1 to 2 weeks.

Clinical Pearls

1. Stretching of the scrotal skin across the necrotic nodule will occasionally reveal a bluish discoloration of the nodule, called the "blue-dot sign" (Fig. 8.5). This is pathognomonic for torsion of the appendix.

2. A reactive hydrocele may accompany appendiceal torsion. When the hydrocele is transilluminated, the blue-dot sign may be revealed.

Figure 8.5

Blue-Dot Sign A blue-dot sign is caused by torsion of the testicular appendix. It is best seen with the skin held taut over the testicular appendix. (Courtesy of Javier A. Gonzalez del Rey, MD.)

Hydrocele

Associated Clinical Features

Most hydroceles occur in older patients and develop gradually without any significant symptoms. A hydrocele generally presents as a soft, pear-shaped, fluid-filled cystic mass anterior to the testicle and epididymis that will transilluminate (Fig. 8.6). However, it can be tense and firm and will transilluminate poorly if the tunica vaginalis is thickened. Almost all hydroceles in children are communicating, resulting from the same mechanism that causes inguinal hernia. A persistent narrow processus vaginalis acts like a one-way valve, thus permitting the accumulation of dependent peritoneal fluid in the scrotum. Acute symptomatic hydroceles are more rare and can occur in association with epididymitis, trauma, or tumor.

Figure 8.6

Hydrocele Painless swelling in the scrotum of a young boy (top). Transillumination of the swelling (bottom) identifies the hydrocele. (Courtesy of Michael J. Nowicki, MD.)

Differential Diagnosis

Painless masses that must be differentiated from hydrocele include spermatocele, varicocele, inguinal hernia, and tumor. Painful masses to be differentiated include traumatic hematocele, epididymitis, orchitis, and torsion.

Emergency Department Treatment and Disposition

In an acute hydrocele, treatment must be directed at discovering a possible underlying cause. A positive urinalysis may point toward an infectious etiology. Transillumination helps demonstrate whether the mass is cystic or solid. Ultrasound can be very helpful in imaging the scrotal contents and delineating the composition of the mass. Acute hydroceles should not be considered benign and require referral to a urologist to rule out tumor or infection. Chronic accumulations are referred to a urologist on a more routine basis for elective drainage.

Clinical Pearls

1. Ten percent of testicular tumors have a reactive hydrocele as the presenting complaint.

2. An inguinal hernia with a loop of bowel in it may emit bowel sounds.

3. Hydroceles are almost never symptomatic.

4. Acute reactive hydroceles may be caused by infection, trauma, or torsion.

Testicular Tumor

Associated Clinical Features

In testicular tumor, a painless, firm testicular mass (Fig. 8.7) is palpated, with the patient often complaining of a "heaviness" of his testicle. If the patient presents early, the mass will be distinct from the testis, whereas later presentations will have generalized testicular or scrotal swelling. These lesions occasionally present with pain due to infarction of the tumor.

Figure 8.7

Testicular Tumor This painless left testicular mass is highly suspicious for tumor, as proved to be the case in this patient. (Courtesy of Patrick McKenna, MD.)

Differential Diagnosis

Epididymitis is the most frequent misdiagnosis, which unfortunately may delay surgical intervention. When the tumor presents with infarction pain, differentiation from epididymitis or torsion can be difficult. In some cases, ultrasound can help differentiate these entities.

Emergency Department Treatment and Disposition

Patients should be promptly referred to a urologist for surgical exploration.

Clinical Pearls

1. Acute hydroceles and hematoceles should prompt the physician to consider a tumor as the cause.

2. Pain from tumor infarction is usually not as severe as pain due to torsion or epididymitis.

3. Findings of an unexplained supraclavicular lymph node, abdominal mass, or chronic nonproductive cough resistant to conventional therapy should prompt a testicular examination for tumor.

Scrotal Abscess

Associated Clinical Features

A scrotal abscess is a suppurative mass with surrounding erythema involving the superficial layers of the scrotal wall (Fig. 8.8). The usual history is of progressive swelling of a small pustule or papule followed by increasing pain and induration or fluctuance. Constitutional symptoms and fever are generally absent.

Figure 8.8

Scrotal Abscess Suppurative mass on the scrotum. (Courtesy of David Effron, MD.)

Differential Diagnosis

An apparently superficial scrotal abscess must be distinguished from a deep scrotal abscess or early Fournier's gangrene. In the latter two cases, patients tend to appear quite ill. The erythema of the skin overlying an abscess should not be mistaken for an urticarial reaction, erythema multiforme, or drug eruption.

Emergency Department Treatment and Disposition

Using local anesthesia, simply make a stab incision and drain the abscess. The patient is then instructed to use a sitz bath and to change the dressing frequently. An alternative method of treatment is to unroof the abscess by circumferential excision. This ensures that there is adequate wound drainage. Immunocompromised patients may require intravenous antibiotics and admission.

Clinical Pearl

1. If the patient appears ill out of proportion to the superficial appearance, suspect that this mass is the point of a deep scrotal abscess.

Fournier's Gangrene

Associated Clinical Features

Fournier's gangrene most frequently occurs in a middle-aged diabetic male who presents with swelling, erythema, and severe pain of the entire scrotum (Fig. 8.9), but it is also known to occur in females (Fig. 8.10). In males, the scrotal contents often cannot be palpated because of the marked inflammation. The patient has constitutional symptoms with fever and frequently is in shock. There is often a history of recent urethral instrumentation, an indwelling Foley catheter, or perirectal disease. A localized area of fluctuance cannot be appreciated.

Figure 8.9

Fournier's Gangrene Markedly swollen, necrotic, tender scrotum, perineum, and adjacent thighs are seen. (Courtesy of David Effron, MD.)

Figure 8.10

Fournier's Gangrene Swollen, tender, erythematous labia, perineum, and inner thighs in a female patient with Fournier's gangrene. (Courtesy of Daniel L. Savitt, MD.)

Differential Diagnosis

The differential diagnosis includes cellulitis, superficial scrotal abscess, edema due to heart failure or lymphatic obstruction, allergic reaction, and epididymoorchitis with skin fixation.

Emergency Department Treatment and Disposition

These patients require aggressive fluid resuscitation and early surgical consultation for immediate debridement and surgical drainage. Broad-spectrum antibiotics effective against gram-positive, gram-negative, and anaerobic organisms should be given as soon as possible in the ED. There is anecdotal experience that treatment is enhanced by hyperbaric oxygen.

Clinical Pearls

1. Pain out of proportion to the clinical findings may represent an early presentation of Fournier's gangrene.

2. A plain pelvic radiograph may reveal subcutaneous air.

3. Fournier's gangrene is usually quite painful but has been known to present with only a mildly uncomfortable necrosis of the scrotal wall and exposed testis.

Paraphimosis

Associated Clinical Features

Paraphimosis is the entrapment of a retracted foreskin that cannot be reduced behind the coronal sulcus (Fig. 8.11). Pain, swelling, and erythema are common. If severe, the constriction causes edema and venous engorgement of the glans, which can lead to arterial compromise with subsequent tissue necrosis.

Figure 8.11

Paraphimosis Moderate edema of retracted foreskin, which is entrapped behind the coronal sulcus. (Courtesy of Alan C. Heffner, MD.)

Differential Diagnosis

In contrast to paraphimosis, phimosis is the inability to retract the foreskin (Fig. 8.12), usually a chronic condition. Other diagnoses to consider include superficial balanitis, hair tourniquet, contact dermatitis, and urticaria.

Figure 8.12

Phimosis In phimosis, the foreskin cannot be retracted, often due to meatal stenosis and scarring.

Emergency Department Treatment and Disposition

Squeezing the glans firmly for 5 min to reduce the swelling can lead to successful reduction of the foreskin. Local infiltration of anesthesia with vertical incision of the constricting band should be performed by a urologist if manual reduction fails.

Clinical Pearls

1. In the presence of arterial compromise, if a urologist is not immediately available, the emergency physician should incise the constricting band.

2. The patient should be referred to a urologist for circumcision if successfully reduced.

3. Phimosis is "physiologic" in young males (generally less than 5 to 6 years old).

4. Phimosis, if "reduced" (retracted proximally over the glans), can cause a paraphimosis—a true emergency.

Priapism

Associated Clinical Features

These patients present with persistent, usually painful erection due to pathologic engorgement of the corpora cavernosa (Fig. 8.13). Patients may present within several hours or several days of their first symptoms. The glans penis and corpus spongiosum are generally not engorged and remain flaccid. The physiology is either arterial, which is generally traumatic, or venoocclusive. Reversible causes of venoocclusive disease include sickle cell disease, direct injection of erectile agents, and leukemic infiltration. Nonreversible causes include idiopathic ones—the most common, spinal cord lesions, and a variety of medications.

Figure 8.13

Priapism A painful persistent erection due to pathologic engorgement of the corpora cavernosa is seen in this patient with sickle cell disease. The glans penis and corpus spongiosum are not engorged (Courtesy of Kevin J. Knoop, MD, MS.)

Differential Diagnosis

Priapism is confirmed when there is a prolonged erection with a flaccid glans and corpus spongiosum. The history and physical examination should be directed toward signs of trauma, infection, medications, drug use, and the diseases that predispose to priapism. Traumatic priapism is more flaccid and generally less painful than the venoocclusive form.

Emergency Department Treatment and Disposition

The diseases that are associated with reversible priapism should be treated. Ice packs to the perineum have traditionally been recommended but are frequently unsuccessful. Terbutaline given orally or subcutaneously occasionally reverses priapism. Aspiration of blood from the corpus cavernosum can lead to detumescence and should be followed by a compressive dressing. Injectable erectile agents can be reversed by aspiration followed by intracavernous injection of alpha-adrenergic agents such as phenylephrine. Urologic consultation should be obtained immediately for traumatic or persistent priapism despite initial treatment, with close urologic follow-up for those that are successfully reversed in the ED. Patients with persistent priapism despite treatment must frequently undergo surgery.

Clinical Pearls

1. Patients should be advised that impotence is a frequent complication of priapism, regardless of the length of the symptoms or the success of any treatment.

2. Although the glans penis and corpus spongiosum are generally not affected, urinary retention often accompanies priapism.

Urethral Rupture

Associated Clinical Features

Urethral injury is rarely an isolated event; it is often associated with multiple trauma. Anterior urethral injuries are most often the result of a straddle injury and may present late (many patients are still able to void), with a local infection or sepsis from extravasated urine. Posterior urethral injuries occur in motor vehicle and motorcycle accidents and are usually the result of pelvic fractures. Patients have blood at the urethral meatus (Fig. 8.14), cannot void, and have perineal bruising. In males, the prostate is often boggy or free-floating or may not be palpable at all if there is a retroperitoneal hematoma between the prostate and the rectum.

Figure 8.14

Urethral Rupture Blood at the urethral meatus in a patient with urethral rupture secondary to trauma. (Courtesy of David Effron, MD.)

Differential Diagnosis

Bladder rupture, higher urinary tract injuries, urethritis, and penile fracture may all present with blood at the meatus.

Emergency Department Treatment and Disposition

Urethral instrumentation such as Foley catheterization should not occur prior to a retrograde urethrogram with highly concentrated water-soluble contrast. If there is only a partial anterior tear, a gentle attempt at catheterization can be made if it is abandoned at the first sign of resistance. If catheterization is unsuccessful and whenever there is a posterior tear, a suprapubic catheter should be placed in the ED with a trocar if relief of bladder distention is required prior to operative repair.

Clinical Pearls

1. Foley catheter insertion is contraindicated in patients with a suspected urethral injury prior to a retrograde urethrogram.

2. Urethral injury should be suspected in the multiple trauma patient who is unable to void or has blood at the meatus, a high-riding prostate, or perineal trauma.

3. Vaginal lacerations due to trauma in females should prompt consideration of a urethral tear.

4. Occasionally urine from an anterior urethral tear will extravasate into the scrotum, causing marked swelling.

5. Posterior injuries are frequently associated with other intraabdominal injury.

Fracture of the Penis

Associated Clinical Features

Patients usually present complaining of trauma during sexual arousal and often relate experiencing a sudden "snapping" sound or sensation, pain, and deformity, which is caused by a tearing of the tunica albuginea. The shaft of the penis is swollen and often angulated at the fracture site (Fig. 8.15).

Figure 8.15

Fractured Penis A swollen, ecchymotic penis is shown. Note the angulation at the midshaft of the penis, indicating the "fracture" site. Blood at the meatus, as shown here, is further evidence of a urethral injury. (Courtesy of Kevin J. Knoop, MD, MS.)

Differential Diagnosis

Penile fracture can be confused with penile trauma without tear of the tunica albuginea, urethral injury, Peyronie's disease (dorsal contracture), priapism, or foreign bodies.

Emergency Department Treatment and Disposition

If the patient cannot urinate, a retrograde urethrogram may be required to rule out urethral injury (Fig. 8.16). These patients require admission and referral to a urologist, who frequently takes them immediately to the operating room for repair.

Figure 8.16

Fractured Penis Retrograde urethrogram showing urethral injury from the fractured penis in Fig. 8.15. (Courtesy of David W. Munter, MD.)

Clinical Pearls

1. Patients sometimes concoct elaborate, non-sexually-related stories surrounding the circumstances of injury, but penile fracture most commonly occurs during sexual arousal.

2. Penile implants are also subject to injury in a similar fashion.

Straddle Injury

Associated Clinical Features

In straddle injury, the patient has pain, swelling, contusion, and hematoma of the perineum or scrotum following direct blunt trauma (Figs. 8.17 and 8.18). This injury is commonly caused by a fall onto a bicycle frame cross-tube, playground equipment, or a toilet seat. Swelling can be severe enough to interfere with urination. Scrotal contents can also be contused or crushed with this injury.

Figure 8.17

Straddle Injury Ecchymosis, swelling, and contusion of the perineum in a 3-year-old female who tripped and fell on a large plastic toy. (Courtesy of James Mensching, MD.)

Figure 8.18

Straddle Injury Contusion of the scrotum and lower abdomen in a young boy consistent with a straddle injury. (Courtesy of David W. Munter, MD.)

Differential Diagnosis

Fournier's gangrene, cellulitis, and urticaria are similar in appearance but without the history of trauma. Sexual or physical abuse should be considered.

Emergency Department Treatment and Disposition

Treatment is supportive and includes cold packs, elevation, rest, and analgesics. If unable to void, the patient may require catheterization.

Clinical Pearls

1. Laceration of the perineum can be obscured by swelling if a careful examination is not performed.

2. Pelvic radiographs should be obtained in all perineal injuries.

3. Males and females are at high risk for urethral injuries with this type of injury.

4. Straddle injury is differentiated from abuse with a good history from a reliable caregiver that matches the injury.

Balanoposthitis

Associated Clinical Features

Balanoposthitis is an infection and inflammation of the glans penis that also involves the overlying foreskin (prepuce) (Fig. 8.19). Balanitis is isolated to the glans, whereas posthitis involves only the prepuce. Pain, erythema, and edema of the affected parts of the penis are typically present. Patients may refrain from urination secondary to dysuria, or the edema may induce meatal occlusion, leading to urinary retention or obstruction. Common etiologies include overgrowth of normal bacterial flora secondary to poor hygiene (pediatric patients), sexually transmitted diseases (adolescents and adults), and candidal infections (the elderly or immunocompromised) (Fig. 8.20).

Figure 8.19

Balanoposthitis Note the erythema, localized edema, and significantly constricted preputial orifice of the distal penis. (Courtesy of Lawrence B. Stack, MD.)

Figure 8.20

Balanitis Candidal balanitis in an elderly patient with no other complaints. New-onset diabetes was diagnosed. (Courtesy of Kevin J. Knoop, MD, MS.)

Differential Diagnosis

The diagnosis is usually straightforward; however, the underlying etiology often must also be addressed. Examples are sexually transmitted diseases in healthy adults and diseases associated with immunocompromise (e.g. diabetes mellitus, AIDS, alcoholism). Phimosis occurs when chronic infection due to poor hygiene causes fibrosis and contracture of the preputial opening. Other diagnoses to consider include contact dermatitis, fixed drug eruptions, lichen sclerosus et atrophicus, and squamous cell carcinoma.

Emergency Department Treatment and Disposition

Treatment is directed at the suspected etiology. Warm soaks and topical antibiotics (bacitracin) are the mainstay of therapy for infectious etiologies owing to poor hygiene. Parents should be counseled about proper cleansing and handling of the prepuce. Oral or intravenous antibiotics may be indicated if there is an accompanying cellulitis. If urinary obstruction is present, catheterization may be attempted using a small catheter. If catheterization is unsuccessful, urologic consultation for emergent surgical correction of the prepuce is required. Candidal infections are treated with meticulous hygiene and topical antifungal agents. Routine urologic referral is indicated for suspected lichen sclerosus et atrophicus and squamous cell carcinoma.

Clinical Pearls

1. The inability to retract the foreskin completely is normal in young males up to age 4 or 5. Attempting to do so could cause a paraphimosis, a true emergency.

2. Placing the child in a bathtub with warm water will help alleviate difficulty with micturition assuming that no obstruction is present.

3. Candidal balanitis or balanoposthitis may be associated with an undiagnosed immunocompromised state.

4. Suspected sexually transmitted diseases require treatment for the partners as well.