Author: Rob Greig / Editor: Ben Hughes, Charlotte Davies / Codes: / Published: 27/10/2020
Urology presentations are fairly common to the emergency department, and we hope this just in time reminder will emphasise some of the key management points. There are so many emergency problems that can occur with the male anatomy, that we’ve split this into two parts. Here’s part one…
Testicular Torsion “Castration by procrastination”
There is a current RCEM Learning piece on testicular torsion that I am not going to try replicate however the above quote comes from there, and I think it’s so true.
Too many testicles are confined to the pathology lab because of delays caused by clinicians sending cases for an ultrasound instead of exploratory surgery. It’s akin to a patient with chest pain and ST elevation on ECG: you send to the cath lab not the ECHO lab!
The age distribution of torsion is bimodal (Birth to 1 years of age and adolescence) although torsion occurs at any age. The classic presentation is the high riding testicle with loss of cremasteric reflex, difficulty walking, pale, nauseated, lower abdominal pain.
There are scoring systems e.g. Testicular Workup for Ischaemia (TWIST) but they are not recommended.
Stick to the SSSS2S acronym: Suddenly Sore Sac Send 2 Surgeon.
Testicular torsion is an easy surgical assumptive diagnosis: acute marked testicular pain – assume torsion and perform surgical exploration. End of discussion.
There is no need for ultrasound acutely unless the patient presents >24hrs after onset of pain because the USS could demonstrate a pathology that would prevent the urologist from operating. I have seen torsion in a post orchidopexy case. It’s very rare but it can happen. Below are images from a patient two years post orchidopexy who presented with a painful scrotum for 48hrs with a scrotal effusion:
Cut off for salvageability: 6 hours gets mooted as the cut off for salvageability – IGNORE. Torsions have been saved 12-24 hours after onset of symptoms as the course of torsion is often intermittent.
Beware male abdominal pain with “normal” abdomens: think testes! 20% of torsion presents as abdominal pain. But please give strong analgesia and antiemetics as these patients are often “heard before seen”: cannulate and give opiates as first line.
Open book detorsion technique: controversial and should not delay orchidopexy however I believe that all ED physicians should have “back pocket skills” for rare moments. You twist the testicle 1-2 turns medial to lateral, like opening a book. Success is if the pain subsides, it wont be instant because that testicle has been ischaemic so there will be a few minutes before relief, but it should now sit lower in the scrotum. Beware that this is not a remedy, it merely buys time, however it’s useful if youre working on a ship or at the Artic Station.
Priapism
A pathological disorder of penile erection that persists for >4hrs and is beyond or unrelated to sexual stimulation. Priapism can occur at all ages with sickle cell anaemia being the predominant causative pathology in the under 18s.
There are 3 types: Ischaemic, Arterial and Stuttering:
Ischaemic (low flow) is a persistent erection marked by rigidity of the corpora cavernosa and by little or no cavernous arterial inflow. Typically, it’s painful and examination reveals a rigid erection. This is the penile equivalent of compartment syndrome. It is a urological emergency.
Arterial (high flow) is less painful and a less large erection caused by unregulated cavernous arterial inflow. Often caused by a fistula between the cavernous artery and the venous drainage. This fistula can be caused by trauma, needle/injection or congenital. The penis will contain oxygenated blood and is more an issue that can be managed by the urology team.
Stuttering (recurrent or intermittent) Priapism is a distinct condition. Repetitive episodes of painful prolonged erections followed by flaccidity. The priapic episodes are ischaemic type (low flow) but generally reduced duration however a single episode can sometimes progress to a major ischaemic (low flow) episode.
Key points to ask in the history:
Duration of erection
Presence and degree of pain
Previous episodes of priapism and method of treatment
Current erectile function, especially the use of any erectogenic therapies
Prescription medications (and non prescription eg. viagra) and recreational drugs
Sickle cell disease, haemoglobinopathies, hypercoagulable states
Trauma to the pelvis, perineum, or penis
Spinal trauma can also cause priapism.
Causes
Haematological: Sickle Cell Anaemia, Leukaemia, Thalassaemia, Myeloma,
Trauma Spinal, Penile, Pelvic
Spider bites (watch out Spiderman!)
Medication: anticoagulants, antihypertensives, antidepressants, cocaine, intracavernosal injections
Clinical Management:
From the emergency clinicians’ point of view, it’s the ischaemic/low flow priapic cases that require acute management, but first one needs to aspirate some blood to confirm whether the priapism is ischaemic or arterial.
The below diagram should refresh your memory: the point for aspiration should be at 3 & 9 oclock to avoid critical structures.
Use either Entonox or Penthrox for analgesia/anxiolysis.
Divide the shaft up into thirds.
Insertion point is between the proximal 1/3 and mid 1/3.
Clean the skin.
Using a 30g needle (blue) raise a 2% Lidocaine bleb at the 3 and 9 o’clock positions of the shaft.
Then through the bleb insert a 21-19g (green) needle, ideally connected to a standard ‘octopus’ extension piece. As you push in and you will feel a ‘give’ as you go through the fibrous Buck’s fascia stop once you get a flash back (to avoid causing damage to the central arteriole thus avoiding an iatrogenic vascular fistula).
You will need to put a needle on both sides.
Aspirate 20ml of corporal blood and analyse the blood gas sample. A blood gas with raised CO2 and reduced pH suggests ischaemic (low flow) priapism.
Then you need to inject an agent to create a detumescent state. Invariably its intracavernosal phenylephrine in 200mcg aliquots every 3-5mins per corpus cavernosum -Note this may cause hypertension and is contraindicated in patients with cardiovascular or cerebrovascular disease. Use a maximum of 1mg of Phenylephrine within 1 hour.
There are a variety of alternative medications and phenylephrine doses. The American Urological Association give a choice of drugs as Adrenaline, Noradrenaline, Metaraminol or Phenylephrine.
The European Association of Urologists recommend some safer medications for patients at high risk from cardiovascular or cerebrovascular disease.
Phenylephrine (as mentioned above) 200mcg every 3-5mins to a maximum of 1mg within 1hr
Etilephrine 2.5mg diluted in 1-2ml Normal Saline
Adrenaline 2ml of 1:100,000 given up to 5 times in a 20min period
Methylene Blue 50-100mg intracavernosal injection followed by aspiration and compression
If after instilling one of the above agents, you have been unable to achieve detumescence you need to speak to the urology team as the patient will require a trip to theatre for a wash out and further treatment.
Now, there’s a theoretical risk that aspiration may cause impotence so in some departments, urology will be asked to aspirate rather than ED. Find out what happens in your department – but, remember, high flow pripism is a urological emergency, so delays are unacceptable. Departments that see a lot of patients with sickle cell related priapism may try adjunctive measures first, like hydration, exercise and oral etilefrine – check your pathway.
Epididymo-orchitis
The ‘John Wayne (cowboy) walk’. These patients have very swollen epididymi and / or testicles (usually only one is affected) and it can be acute or chronic. This swelling is painful because of the tough fibrous capsule of the testicle being stretched. This is either a urinary tract infection or sexually transmitted infection (Chlamydia or Gonorrhoea) or mumps. TB can present this way whilst a rare side effect of amiodarone is epididymitis.
You don’t need me to tell you that of course the differential diagnosis here is testicular torsion.
The age range and the history will help differentiate but of course one must never make assumptions. Urinary tract infection with E. coli as the trigger is more likely with increased age, urinary catheter, recent urological surgery and benign prostatic hypertrophy.
Green purulent penile discharge, unprotected sexual intercourse and lower age range is more in keeping with Neisseria gonorrhoeae and Chlamydia trachomatis. Anal intercourse increases the risk of Enterobacteriaceae, usually E. coli.
University ‘Freshers’ tend to develop mumps, so check the history for abdominal pain (pancreatitis of mumps, amylase goes up) but freshers also fit in to the increased sexual activity group.
Clinically they have a unilateral grossly swollen testicle, occasionally both. The cremasteric reflex remains. The urinary dip is usually positive but its not categorical.
Ultrasound shows a hyperaemic testicle with preserved homogeneity, but this is a clinical diagnosis.
Urine should be sent for cultures and chlamydia and if any doubt for STI then a referral for GUM assessment. Don’t be tempted to start empirical therapy for STIs because of the great issue of antibiotic resistance with Gonorrhoea (worldwide). This is contrary to the guidance from the European Association of Urologists.
Antibiotics are the mainstay of treatment with a protracted course e.g. ciprofloxacin 500mg BD for 14 days (be mindful of the side effects and contraindications). Consider Doxycycline for the men under 35 when it’s more likely to be STI. That being said the author advises strongly that you consult local guidance for antibiotic stewardship.
Paraphimosis
A very common presentation in all age groups, especially in the elderly post catheterisation when the clinician forgets to pop the foreskin back.
There’s a knack to these and it’s very simple: squeeze and push. Everyone has a way or says they have a way. Over my career I have seen people use scalpels (!), some daft idea about osmosis with concentrated glucose and using penile blocks. Just don’t bother. Waste of time.
Firstly, the penis is a surprisingly robust organ and secondly as society regularly demonstrates men put their penis into anything. Thus, it’s designed towelltake a beating.
Firstly, get some analgesia to the patient. Oral will work later for after the reduction, you need something for immediate effect: either Entonox or Penthrox (but ideally consent the patient prior).
With a pair of gloved hands: take firm hold of the swollen part of the penis. Grab hard and squeeze. Mentally image that youre squeezing the oedema back into the base of the shaft from the glans through to the stricture. The penis is designed to swell and take sudden flow of interstitial fluid, youll need to do this for a few minutes.
Next take the thumb of your non-squeezing hand and push the glans of the penis through the stricture band, imagining that youre pushing the glans all the way into the pelvis down through the penile shaft. Alternatively, one can use two hands, with index and middle fingers on restricting band and thumbs to push glans down the shaft.
As you get through the skin band stricture, youll feel a click of the stricture skin popping over the terminal end of the glans and it will grasp around your thumb. You can stop at this point, but I tend to keep my thumb in place and pull the foreskin distally (i.e. away from the pelvis) to ensure that it has completely resolved.
You can pop some soft paraffin cream under the foreskin because invariably the glans will be a touch dry and damaged after this episode.
Incidentally having had paraphimosis doesn’t mean that the patient needs a circumcision.
However good your anatomical knowledge is, sometimes that is not really necessary:
Scrotal wall damage is treated by debridement and primary closure after contents are checked for viability however sometimes more than that is required, hence any through and through scrotal wall injuries should be referred to your friendly neighbourhood urologist.
Blunt scrotal/testicular trauma rarely results in testicular damage but may cause rupture to the vascular bundle of the spermatic cord. The tunica albuginea is a very tough structure, it envelops each testicle. Rupture of a testicle suggests high force mechanism. Blunt scrotal/testicular trauma may also cause testicular torsion, epididymal rupture or avulsion.
Penetrating trauma warrants surgical exploration and the clinician needs to be mindful as to where the penetrating injury finishes: could it be perineal, pelvic or abdominal? It’s advisable to give prophylactic antibiotics for cases of penetrating genital injury: think Fournier’s Gangrene cocktail Clindamycin, Flucloxacillin and Benzylpenicillin.
If animal bites are the source of the penetrating injury swap out the Benzylpenicillin for Co-Amoxiclav.
Of course, cover for Tetanus or check Tetanus immunisation status, and if in doubt (unconscious patient) give Tetanus and Tetanus Immunoglobulin combined.
Penile Shaft Fracture
Apparently according to one paper from the Canadian Urology association, 77% of penile fractures occur during consensual sexual intercourse, often drunk, with the rear entry or ‘Doggy’ position, to use a colloquialism, being the highest risk. The failure to penetrate causes a buckling of the erect penis. Patients report a sudden pop or snap noise, similar to Achilles tendon rupture and immediate detumescence (loss of erection).
The penis presents heavily bruised (“aubergine deformity”) and this bruising can track round to the scrotum, as explained previously. 21% of patients also have a urethral injury which will be highly suggested if they have Visible Haematuria (coming later).
The penis will be very sore, so please give analgesia earlier rather than later, and inquire as to whether the patient is on anticoagulants.
These all require referral to the on call Urological team.
It’s probably one of the few fractures that doesn’t go to orthopaedics.
This was the start of my datix:
Adrian S. (@DrAdrianSputnik) September 4, 2020
Ortho SHO(me): *answers bleep* ‘Hello orthopaedic on call’
AE SHO: ‘Hello, I was hoping you could see a fractured penis’
Me: ‘Actually, urology usually..
It got heated
I closed by saying ‘Order an X-ray – if you find a bone I’ll take it’
=Datix https://t.co/YKE8YuCglG
Foreskin “minor” injuries
Zip meets Foreskin Very common. Apply a single piece of gauze soaked with a topical ophthalmic local anaesthetic for 5 mins. The skin will go numb. Then inject in 2% Lidocaine with 1:200,000 Adrenaline (yes Adrenaline into the foreskin), wait one minute and then open the zip. Alternatively, just use Entonox but these cases tend to bleed afterwards, and the LA with adrenaline takes away the discomfort and bleeding.
Foreskin frenulum bleeds: commonly caused by sexual intercourse or masturbation. The replacement of the foreskin often allows for a thick haematoma to form under the foreskin. However, if it doesn’t abate, insert some LA with 1:200,000 adrenaline and insert a tie suture to close the offending damaged blood vessel. This generally stops the bleeding – let the patient go home, then wash under the foreskin gently with a shower head, or sit in a salty bath.
Penile/ Scrotal/ Testicular Trauma
This is a topic that makes most XY based doctors take a full tidal volume. It’s oddly rare given nature’s position of said organs but with scrotal trauma the clinician must think about pelvic and femoral fractures.
Bruising of the genitals also suggests damage in the abdomen or pelvis with blood tracking along Scarpas fascia. We know with Fournier’s Gangrene the infection spreads rapidly along fascial planes: Scarpa’s fascia totally envelops the scrotum and perineum then merges into Colle’s fascia of the anterior abdominal wall. So, trauma to the anterior abdominal wall can cause a bruised scrotum, even though no scrotal injury has occurred.
Also, trauma to the external urethra (classically the Foley Catheter Balloon inflated in the wrong position) can present as a bruised penis but normal scrotum due to Buck’s fascia demarcation.
Watch out for part two coming to an RCEMLearning blogsite near you! If you can’t wait… have a look at the RCEM testicular pain moduleand reference, and then try these SAQs here and here.