| What is torsion of spermatic cord (intravaginal)? | This is the real emergency in urology because irreversible damage to the testis after 4-6 hours
- may result from lack of normal fixation of an appropriate portion of the testis and epididymis to the fascial and muscular of the scrotum (Bell-clapper deformity)
Usually testicular torsion occurs after puberty due to an increase in the volume of the testis
The cord may twist as far as 360 degree
Typical clinical presentation is an acute severe testicular pain
Prior history of mild testicular pain can be present
Physical examination is very helpful in differentiating torsion from other pathologies( high location , transverse position and absence of the cremasteric reflex |
| How is the management of spermatic cord torsion suspicion? | Manual detorsion may not totally correct the rotation that has occurred, and prompt exploration usually is still indicated. Usually done by untwisting the testis in the direction of the thigh ( outward ).
Color Doppler and radionuclide imaging are very accurate and used only to rule out other pathologies
When the diagnosis of torsion of the cord is suspected, prompt surgical exploration is warranted.
Intermittent Torsion of the Spermatic Cord
Present as intermittent acute testicular pain that resolves by itself
scrotal fixation of both testes should be performed when bell-clapper deformities are found |
| How is torsion of testicular/epididymal appendages? | The appendix testis, a müllerian duct remnant, and the appendix epididymis, a wolffian remnant, are prone to torsion in adolescence
Presentation is variable from mild to severe pain similar to a testicular torsion .
If the patient is seen early , the infarcted appendage is visible through the skin as a "blue dot sign“
Miscellaneous etiologies of scrotum swelling : idiopathic , Henoch-Schonlein purpura |
| What is a renal abscess? | Renal abscess is a collection of purulent material confined to the renal parenchyma caused by gram-negative organisms most of the time .
- due to ascending infection associated with tubular obstruction |
| How is dx of renal abscess? | Utrasound is the quickest and least expensive method to demonstrate a renal abscess. An echo-free or low–echo-density space-occupying lesion with increased transmission is found on the sonogram.
CT of a chronic abscess shows obliteration of adjacent tissue planes,thickening of Gerota's fascia, a round or oval parenchymal mass of low attenuation, and a surrounding inflammatory wall of slightly higher attenuation that forms a ring when the scan is enhanced with contrast material . The ring sign is caused by the increased vascularity of the abscess wall. |
| how is management of renal abscess? | Less than 3 cm , IV antibiotics
Less than 3 cm in immunocompromised host ----- percutaneous drainage
More than 3-4 cm , percutaneous drainage |
| What is acute urinary retention? | -Most of the time related to BPH
-The incidence of acute urinary retention was related to age, severity of symptoms, and size of the prostate gland.
-The incidence of urinary retention is around 1.2% -2.7% |
| How is presentation of acute urinary retention? | Most of the patients with acute urinary retention will present with severe suprapubic pain with inability to void
BUT dribbling can be the only presentation
Physical examination reveal suprapubic fullness
Imaging studies
These studies are used only in case of doubt – Ultrasound of pelvis and kidneys will reveal a large bladder full of urine with sometimes bilateral hydronephrosis |
| How is management of acute urinary retention? | Drainage of the bladder should be done in the emergency room
Alphablocker should be started
Voiding trial after 5 to 7 days
If successful voiding , we should keep the medications on daily basis
if the patient was unable to void , Foley catheter is reinserted and options of treatments are discussed with the patient . Most of the time , surgery ( Transurethral resection or open prostatectomy ) is the choice |
| What is Fornier's Gangrene? | Fournier gangrene is a potentially life-threatening form of necrotizing fasciitis involving the male genitalia( Fournier 1883) Infection most commonly arises from the skin, urethra, or rectal regions.
Predisposing factors include diabetes mellitus, local trauma, paraphimosis, periurethral extravasation of urine, perirectal or perianal infections, and surgery such as circumcision , herniorrhaphy or anal surgery |
| How are cultures of FG? How is presentation? | Mixed cultures containing facultative organisms (E. coli, Klebsiella, enterococci) along with anaerobes (Bacteroides, Fusobacterium, Clostridium, microaero- philic streptococci) have been obtained from the lesions.
The infection commonly starts as cellulitis adjacent to the portal of entry. Early on, the involved area is swollen, erythematous, and tender
the swelling and crepitus of the involved area quickly increase, and dark purple areas develop and progress to extensive gangrene. the process can spread very rapidly in few hours , Alterations in mental status, tachypnea, tachycardia, and temperature greater than 38.3°C (101°F) or less than 35.6°C (96°F) suggest gram-negative sepsis |
| What are Labs and Radio findings in FG? | Because crepitus is often an early finding, a plain film of the abdomen may be helpful in identifying air.
Scrotal ultrasonography is also useful in this regard.
Ctscan can confirm if we are in doubt |
| How is management of FG? | Prompt diagnosis is critical because of the rapidity with which the process can progress.
The presence of marked systemic toxicity out of proportion to the local finding should alert the clinician.
Immediate debridement is essential. ++++
Usually testes are not involved
Antimicrobial regimens include broad-spectrum antibiotics especially if Pseudomonas is suspected, ampicillin plus sulbactam, or vancomycin or carbapenems plus clindamycin or metronidazol |
| How is outcome of FG? | Mortality ranges from 7% to 70 %
Dependent on early diagnosis and immediate debridement |
| What is priapism? | Priapism is a persistent, usually painful, erection that lasts for more than four hours and occurs without sexual stimulation
Classified into: 1/Ischemic Priapism (Veno-Occlusive, Low-Flow)
2/Stuttering Priapism (Intermittent)
3/Nonischemic Priapism (Arterial, High-Flow) |
| What is ischemic priapism? | a persistent erection marked by rigidity of the corpora cavernosa (CC) and little or no cavernous arterial inflow resulting in progressive hypoxia and acidosis
The patient typically reports penile pain after 6 to 8 hours, and the examination reveals a rigid erection.
Interventions beyond 48 to 72 hours of onset may help relieve erection and pain but have little benefit in preserving potency
After 48 hours thrombus can be found in the sinusoidal spaces, and smooth muscle necrosis –
Ischemic priapism is an emergency. |
| What is sluttering priapism? and non ischemic priapism? | is characterized by a pattern of recurrence. The term has historically described recurrent unwanted and painful erections
Nonischemic priapism is much rarer than ischemic priapism, and the cause is largely attributed to trauma resulting in laceration of the cavernous artery or one of its branches within the corpora |
| What are etiologies of ischemic priapism? | 1/Hematologic dyscrasias are a major risk factor for ischemic priapism( Sickle Cell Disease , thalassemia, granulocytic leukemia, myeloid leukemia, lymphocytic leukemia,Hemodialysis
2/Iatrogenic :complication of the intracavernous vasoactive medications ( 0.5% to 35%)
Oral PDE5 ( sildenafil ,…) Rare case report |
| What are etiologies of stuttering priapism and non-ischemic? | Pattern of recurrent priapism that resolved after 4 hours by itself mainly due to Sickle Cell Disease (stuttering)
The cause most commonly reported is a straddle injury to the crura. (non-ischemic) |
| How is dx and evaluation of priapism? | History : ( drug use , trauma , hematologic disease …)
Physical examination :In ischemic priapism the corporal bodies will be completely rigid and painful ; the glans penis and corpus spongiosum are not
In nonischemic priapism the corpora will be tumescent but not completely rigid and not painful |
| What are labs for priapism? | CBCD
Hemoglobin electrophoresis
corporal blood gas by aspiration (priapism in case PO2<30, P CO2 >60, pH <7.25)
Color Doppler Ultrasound
Penile arteriography : reserved for the management of HFP, when embolization is planned |
| What are key findings differentiating ischemic and non-ischemic priapism? | . |
| How is tx of ischemic priapism? | 1/Ischemic Priapism
a/ Aspiration of the corpora cavernosa: success in 36%
b/Phenylephrine (alpha 1 adrenergic receptor medication ) is the agent of choice recommended
surgical: 1/ Distal percutaneous shunting
2/Open distal shunting
3/Proximal shunting |
| How is tx of high-flow priapism? | Arterial priapism is not an emergency and may be managed expectantly.
• Diagnosis of HFP is best made by penile or perineal Color Doppler Ultrasound
• Penile aspiration and injection of α-adrenergic agents is not recommended for HFP.
•• Overall success rates with embolization are high, although a single treatment carries a recurrence rate of 30% to 40%.
• When angioembolization fails or is contraindicated, surgical
ligation is reasonable. |
