An Evidence-Based Approach To Male Urogenital Emergencies
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An Evidence-Based Approach To Male Urogenital Emergencies

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Abstract

Acute scrotal or penile pain can cause a high level of anxiety for the patient, parent, and even, at times, for the health care provider. Presentations are often delayed as a result of the patient's embarrassment, and the patient may not be initially forthright with the exact nature of the complaint. The care provider must be sensitive to both the emotional and physical needs of the patient.

The challenge in emergency practice is to differentiate conditions requiring prompt evaluation and action from urgent conditions that are amenable to outpatient management. Missed or delayed diagnosis of testicular torsion threatens testicular viability and future fertility. Similarly, early identification and aggressive management of necrotizing fasciitis of the perineum (Fournier's disease or Fournier's gangrene) is critical to maximizing outcomes. Emergent penile conditions include priapism and paraphimosis. Any form of GU trauma is presumed to be an emergency until proven otherwise.

The goal of this issue of Emergency Medicine Practice is to provide a risk management tool and to provide an evidence-based best practice approach to the male complaining of acute scrotal or penile pain.

Practice Recommendations (key points from the issue)

Click here to download a PDF of the Evidence-Based Practice Recommendations for this issue.

Case PresentationS

It's shortly after midnight, and a 12-year-old male is triaged with a chief complaint of severe testicular pain. His parents tell you that he just woke them up because of his inability to sleep; however, the onset of symptoms was several hours prior to ED arrival. You evaluate him without delay and discover that he has an acute, painful, swollen, tender hemiscrotum. You promptly phone the on call urologist, who asks you to "kindly order a sonogram" and says she will be in to see the patient first thing in the morning. Although you are uneasy with the proposed plan, you oblige. Your next call is to the on call radiologist, who informs you that he would be happy to coordinate the study, although it will be "several hours" until the tech arrives from home. Suddenly, you find yourself faced with several difficult decisions: How much pressure should you place on the urologist to see the patient more expeditiously? Is "several hours" waiting for the sonogram (not to mention the time to obtain the interpretation) too long? If your institution is unable to provide an emergent evaluation, should you transfer the patient to an institution that can? You realize you are in a tenuous position, yet in the end, the responsibility to make the right decisions is yours . . .

Critical Appraisal Of The Literature

One of the inherent difficulties in formulating an evidence-based approach to male GU emergencies is the paucity of available literature that is actually useful in "real-time" to the emergency clinician. For example, literature attempting to answer the age-old debate of "boxer briefs" versus "tighty-whities" is just not that helpful to the emergency practitioner at 3 o'clock in the morning!2 Therefore, it is necessary to rely on weak studies (retrospective studies, case series, case reports) to guide us in our clinical decision-making.

Etiology and Pathophysiology

The male genitalia is composed of the penis (paired erectile bodies and penile urethra) and the scrotum (encases the testis, epididymis and spermatic cord bilaterally). (See Figure 1.) The scrotal wall consists of several layers all deep to the epidermis, many of which are contiguous with the penis, perirectal region, and anterior abdominal wall. Each testis is encapsulated with a dense connective tissue layer termed the tunica albuginea. External to the tunica albuginea is the tunica vaginalis, which envelops each testicle and fastens it to the posterior scrotal wall. A lack of firm testicular attachment by the tunica vaginalis subjects it to potential horizontal or vertical rotation around or within the spermatic cord, resulting in testicular torsion. The appendix testes are embryologic remnants with no known physiologic function located at the uppermost pole of the testes. These appendages are prone to torsion as well, leading to localized, self-limited necrosis. The epididymis adheres closely to the posterolateral aspect of each testis, and it is responsible for promoting sperm maturation and motility. Similar to the appendix testis, the appendix epididymis is an embryologic remnant attached to the head of each epididymis and frequently is involved in self-limiting torsion that can simulate testicular torsion. The penis consists of the 2 corpora cavernosa (erectile bodies, each encapsulated by tunica albuginea) and the solitary corpus spongiosum, which surrounds the penile urethra. In uncircumcised males, the retractile penile foreskin (prepuce) is a sleeve that normally covers the head of the penis (glans). The potential constricting effect of a proximally retracted foreskin may lead to paraphimosis. Priapism is a pathologic condition defined by the presence of a persistent erection lasting longer than about 4 hours in the absence of any sexual desire or stimulation. It most frequently results from engorgement of the corpora cavernosa with stagnant blood (termed low-flow priapism). Although rare, high-flow priapism results from the development of a traumatic arterial-cavernosal fistulae, resulting in the accumulation of oxygen-rich blood in the corpora.

 

 

In the male presenting with GU pain, it is essential to delineate the precise anatomic regions where the pain is located. Pain may be due to structures within or adjoining a particular region or may be referred from adjacent areas. The majority of patients complaining of acute scrotal (or penile) pain will have a problem isolated to the genitalia. However, it is equally important to consider the etiologies of referred pain, including retroperitoneal processes such as renal colic, pyelonephritis, or abdominal aortic aneurysm.

Differential Diagnoses

GU complaints are broadly categorized into those involving the scrotum and the structures that it envelops (testicle, epididymis, and spermatic cord) or those involving the penis. Child abuse must be considered in the differential diagnosis for any pediatric patient presenting with GU complaints. The American Academy of Pediatrics (AAP) has published guidelines regarding the evaluation of sexual abuse in children.3

Acute Scrotal Pain

There are a wide variety of clinical conditions that present as an acute, painful, swollen, tender hemiscrotum, see Table 1.

 

 

Distinguishing exact causes can be particularly challenging in children, who are most likely to present with an undifferentiated "acute scrotum." Fortunately, in the vast majority of cases, the "acute scrotum" can be attributed to 1 of 3 diagnostic entities: testicular torsion, epididymitis, or appendage torsion. (See Table 2). This fact serves to better focus the ED evaluation. The frequency of each diagnosis varies significantly from study to study (depending on factors such as the age distribution of the population studied), making it difficult to draw firm conclusions from the data.5, 6 Having said this, each contributes to roughly one-third of pediatric "acute scrotum" cases.7 In a review of 238 consecutive cases presenting to a children's hospital ED, incidences of testicular torsion, appendage torsion, and epididymitis were 16%, 46%, and 35%, respectively.8 Similar to other studies, the predominant diagnosis varied by age group: testicular torsion in the first year of life, appendage torsion in the toddler to pre-pubertal (3-13 year old) range, and epididymitis after 13 years of age. Specifically, bimodal peaks in the incidence of testicular torsion were noted in newborns as well as peri-pubertal males, which is concordant with other investigations.9,10 In addition, up to 10% to 20% of cases may result from other causes entirely (such as incarcerated inguinal hernia or idiopathic scrotal edema,11 among others).

 

 

Fournier's disease should be considered in elderly, diabetic, or other immuno-compromised males complaining of perineal pain "out of proportion" to physical findings. Although Fournier's is typically thought of as an "elderly male" disease, it has also been reported in children (as well as females). 12 Interestingly, in contrast to adults, children with Fournier's disease may appear relatively non-toxic despite marked tissue inflammation and necrosis.13

Acute Penile Pain

Patients with penile complaints often present non-specifically, complaining of a "painful" or "swollen" penis. When penile swelling is the complaint, localized edema must be distinguished from that caused by a systemic derangement (ie, nephrotic syndrome or heart failure). Localized processes include constriction (ie, paraphimosis, entrapment injury), inflammation (ie, balanoposthitis), infection (ie, "bite" injury),14,15 or other trauma (ie, abrasion, contusion, burn).

Patients with problems localized to the penis are often readily distinguished from those presenting with an acute scrotum by history and findings on physical examination alone. Indeed, the etiology of acute penile pain, although not straightforward, is usually more apparent when compared with an "acute scrotum." (See Table 3.) Emergent penile conditions include priapism and paraphimosis (or entrapment injuries that mimic paraphimosis). Priapism is readily distinguishable by the presence of a persistent erection. Paraphimosis, on the other hand, must be differentiated from other conditions resulting in pain or edema of the distal penis. Balanitis and posthitis are defined as inflammation of the glans or prepuce, respectively, and typically result from inflammation (ie, local irritation) with or without coexisting bacterial (ie, Streptococcal or Staphylococcal species) or fungal (ie, Candida) infection. Phimosis is the inability to retract the penile foreskin proximally. This is typically a chronic condition, which may rarely present acutely to the ED as urinary retention when a patient is unable to void spontaneously as a result of distal foreskin obstruction caused by the chronic inflammatory process.16,17

 

 

Genitourinary Trauma

Traumatic injury must be included in the differential of any GU complaint, whether localized to the scrotum (and its contents), the penis, or to surrounding perineal structures. (See Table 4.) Importantly, trauma-induced testicular torsion has been reported.18 As such, consideration of testicular torsion in the differential of blunt scrotal trauma is prudent.19

 

 

Sexually Transmitted Disease

Genital infections that are likely to cause acute symptoms can be divided into diseases characterized by genital ulceration and diseases causing penile discharge (urethritis). (See Table 5.) Among the many infections that can cause genital ulceration, genital herpes, syphilis, and chancroid are most commonly seen in the United States, with genital herpes being most prevalent. Urethritis is typically characterized by discharge of mucopurulent or purulent material, with or without accompanying dysuria or urethral pruritis. The principal bacterial pathogens of proven clinical importance in men with urethritis are Neisseria gonorrhoeae and Chlamydia trachomatis. However, asymptomatic infections are common as well. In select populations, it is the author's experience that urethral trauma from compulsively stripping the urethra in search of purulent discharge is a potential cause of dysuria in sexually active men. The diagnosis is based soley on a thorough history by a suspicious physician.

 

 

Prehospital Care

Not surprisingly, there remains a paucity of data regarding the management of male GU conditions in the prehospital setting. With this in mind, it appears plausible to focus on symptom relief, typically with narcotic analgesics and antiemetic agents. In addition, administration of intravenous fluids (as well as maintenance of "NPO" status) is prudent for any conditions that may require procedural sedation or surgical intervention following ED arrival.

ED Evaluation

A diligent history and physical examination of the patient complaining of acute scrotal or penile symptoms is the cornerstone of formulating an appropriate plan of action. Such complaints will often be shadowed by a component of patient embarrassment and apprehension; this is especially true in adolescents. Care must be taken to respect and address privacy issues in the adolescent and prepubescent age groups. Similarly, parents may in some cases be uncomfortable discussing their child's problem. This may hold true for caretakers of adult patients as well. A useful approach to facilitating a more comprehensive history and examination is to offer to first interview, examine, and discuss with the patient alone and then speak with all parties in concert.

The Acute Scrotum: Important Historical Questions

Scrotal pain that begins abruptly and severely is testicular torsion until proven otherwise. The sudden twisting of the spermatic cord, characteristic of testicular torsion, leads to rapid diminution of blood supply to the affected testicle that causes "ischemic" pain. This is in contrast to the more indolent and smoldering pain of epididymitis, which is a gradually progressive inflammatory (rather than ischemic) process. Indeed, the pain of testicular torsion (or appendage torsion) often develops over seconds or minutes, whereas the pain associated with epididymitis frequently develops over the course of hours or days.

The distinction between constant/progressive and intermittent/colicky pain is very useful in the diagnosis of acute scrotal pain. Constant and progressive pain typically results from progressive inflammatory processes, such as epididymitis. Patients may exhibit pain with ambulation or movement resulting from the inflammation. Intermittent and colicky pain is more consistent with rapid "onset" and "offset" conditions, as occurs in testicular torsion. Pain may be intermittent, as the spermatic cord may torse and detorse spontaneously.

It is critical to ask about "systemic" findings in the patient presenting with an acute scrotum. As a general rule, patients with testicular torsion are more ill-appearing (with associated systemic symptoms such as nausea and vomiting) than patients with the other common etiologies of acute scrotal pain (epididymitis or appendage torsion).20,21 While patients with epididymitis may present with nausea, malaise, or low grade fever, it is typically those with more advanced degrees of infection (epididymo orchitis) whom exhibit more "systemic" involvement. It is common for patients with acute scrotal pain to complain of low abdominal, proximal lower extremity (ie, inner thigh, groin, inguinal), or back/flank pain. Likewise, it is important to consider acute GU pathology in any male patient presenting with seemingly isolated pain to the aforementioned anatomic regions. For instance, always consider GU conditions in the differential for any male with a presenting complaint of abdominal, inguinal, or flank pain.

Always inquire about changes in urination, including urgency, frequency, dysuria, hesitancy, and hematuria. Urinary symptoms may accompany many causes of acute scrotal pain. Classically, epididymitis may be accompanied by urinary complaints such as dysuria and urgency.

The Acute Scrotum: Important Physical Findings

When examining a patient with acute scrotal complaints, their general appearance provides important diagnostic clues. Patients with "intermittent and colicky" pain (ie, testicular torsion or renal colic) tend to writhe on the gurney or pace about the examination room as they cannot find a position of comfort. In contrast, patients with progressive inflammatory conditions (such as epididymitis or epididymo-orchitis) tend to minimize activity, as the slightest degree of movement may exacerbate their pain, while rest and elevation bring relief.

A complete abdominal examination is crucial in any patient presenting with an acute scrotum, as many intra-abdominal conditions may present with a component of GU pain. It is important to examine the male genitalia both while the patient is standing and lying supine. Exercise caution when examining a standing patient as some males may experience a strong vagal response to scrotal (or prostate) stimulation, leading to pre-syncope or syncope. Also, examination of the testicle and epididymis may cause significant discomfort even in the absence of pathology. Always examine the unaffected side first since many patients will have unilateral localization of pain. This serves as a control and will help in gaining patient confidence and trust (which may rapidly wane after examination of a swollen and painful scrotum). Key visual features of testicular torsion include a high riding testicle with a transverse lie, both resulting from twisting of the spermatic cord. (See Figure 2.) Unfortunately, such "textbook" presentations rarely, if ever, occur in clinical practice. More commonly, patients with acute scrotal pain, regardless of the underlying etiology, present identically: with a diffusely painful, swollen, tender hemiscrotum.

 

 

As mentioned, differentiating among the etiologies of acute scrotal pain is challenging. Often confounding the problem is the exquisite pain and discomfort elicited by examination itself. However, there are some findings which, if present, may facilitate a more accurate diagnosis.22

If isolated swelling and tenderness of the epididymis is present, epididymitis is the likely diagnosis. The natural progression is to initially affect only the epididymis and then progress to the ipsilateral testicle as well (epididymo-orchitis).

The presence of an intact ipsilateral cremasteric reflex is reportedly highly sensitive for excluding the diagnosis of testicular torsion.23,24 The reflex is elicited by stroking the ipsilateral inner thigh with a tongue depressor or gloved hand (see Figure 3), resulting in elevation of the testicle through contraction of the cremasteric muscle. Although the presence of an intact cremasteric reflex is useful in ruling-out torsion, it is a soft finding as the absence of this reflex is non-specific, and some healthy individuals lack the reflex altogether (particularly males in their first few years of life).25 Importantly, there have been several published reports of testicular torsion presenting with an intact cremasteric reflex.26,27,28

 

 

Prehn's sign, or relief of pain with scrotal elevation, was previously thought to help in differentiating epididymitis (inflammatory pain relief with scrotal elevation) from testicular torsion (no change in ischemic pain with elevation).29 However, this sign is generally considered unreliable in distinguishing these 2 disorders (although a specific reference to its sensitivity and specificity remains elusive after much searching).30 Therefore, its use for this purpose is additive but not diagnostic.

Isolated nodularity at the superior pole of either the testicle or epididymis is often the result of appendage torsion, given the anatomic location of these vestigial structures. The blue dot sign is pathognomonic for appendage torsion.31 As appendage torsion is most common in the prepubescent age group, visualization of the infarcted appendage (the "blue dot") may be seen through thin, non-hormonally stimulated prepubertal skin. This finding is very specific, yet insensitive.

Scrotal transillumination may be helpful in cases of suspected hydrocele. The scrotal fluid will supposedly transilluminate when a light is shined against the posterior scrotal wall. However, practitioners whom seldom utilize this technique tend to "overcall" positive test results (ie, every scrotum transilluminates), so results should be cautiously interpreted in the context of the overall clinical picture.32

Priapism

Patients with low-flow priapism often complain of a prolonged and exquisitely painful erection. Stagnant, oxygen-poor, acidic blood accumulates in the corpora, resulting in "ischemic" pain. Ischemia resulting from prolonged erection may lead to irreversible cellular damage, permanent fibrosis, and impotence. Several common etiologies of low-flow priapism are listed in Table 6. Of important note, use of oral erectile dysfunction treatments such as sildenafil has only rarely been associated with priapism. 33 Patients with high-flow priapism often complain of a persistent, yet painless, erection. In this condition, there is continuous inflow of oxygen-rich blood through traumatic arterial-cavernosal fistulae.

 

 

Paraphimosis

Paraphimosis classically develops in uncircumcised males when the proximally retracted tight foreskin acts as a constricting band on the distal portion of the penile shaft. Initial disruption of venous drainage by the constricting foreskin leads to a cycle of progressive glans edema followed by arterial compromise with subsequent glans necrosis and gangrene. The penile foreskin should always be replaced (reduced) after retraction for examination or urethral catheter placement to prevent iatrogenic paraphimosis. Glans edema mimicking paraphimosis can occur in circumcised or uncircumcised males in the case of penile entrapment injury. External objects may constrict the mid to distal shaft leading to the same pathophysiologic derangements as seen with paraphimosis. These objects may be placed intentionally for sexual stimulation (ie, string, metal rings, or rubber rings) or may occur accidentally, as in the case of a hair tourniquet in male infants.34 Hair tourniquets may be particularly difficult to diagnose, as the offending hair may be nearly invisible within a ring of edema fluid or edematous coronal sulcus of the glans penis. An occult hair tourniquet should be considered (along with testicular torsion) in the infant with inconsolable crying.

Genitourinary Trauma

Trauma to the GU system may be either blunt or penetrating in nature. Although a detailed discussion is beyond the scope of this article, several pertinent points deserve mention.

Scrotum Trauma

Significant trauma to the scrotum and its associated structures (testicle, epididymis, and spermatic cord) occurs infrequently with minor blunt force mechanisms owing to both testicular mobility (ie, testes can "roll with the punches") and the protective cremasteric reflex. In addition, each testicle is encapsulated by its fibrous tunica albuginea, which may protect the testicular parenchyma from injury. Blunt force injury may cause a testicular contusion or, less frequently, rupture of the tunica albuginea (testicular rupture). Also, traumatic dislocation of the testicle to an aberrant location outside of the scrotal confines is possible with significant blunt force trauma. All but the most superficial penetrating scrotal injuries will require specialty consultation for possible exploration.35 Patients with either blunt or penetrating GU trauma may present with a hematocele, which is a painful, tender, ecchymotic scrotal mass resulting from the accumulation of blood within the tunica vaginalis.

Penis Trauma

Trauma to the penis often presents with a distressing component of pain. A penile fracture results from an acute tear or rupture of the tunica albuginea of the corpus cavernosum. Patients often relate a history of a sudden "snapping" sound during intercourse or other sexual activity or as a result of blunt trauma in the setting of an erect penis. Physical examination reveals a swollen, ecchymotic, detumescent (limp) penis that is tender to palpation.36 A penile contusion results from less severe direct blunt force trauma to a typically detumescent penis. In a penile contusion, the tunica albuginea remains intact, and the patient presents with localized ecchymoses and tenderness at the site of trauma. This may result from a toilet seat injury sustained while toilet training in the toddler/pre-school age groups or as a result of a "straddle" injury in any age group. Penetrating penile injuries necessitate specialty consultation in all cases.

Sexually Transmitted Disease

Genital Ulceration

Genital herpes (either primary or recurrent) may present with severe pain, pruritis, or burning localized to the penis, scrotum, rectum, or elsewhere in the perineum. However, the typical pattern of multiple grouped vesicular (or ulcerative) lesions may be absent entirely in many acutely infected persons, rendering the diagnosis elusive. Definitive diagnosis of any ulcerative condition based on history and physical examination alone is frequently inaccurate.37

Urethritis

Any patient presenting to the ED with a complaint of penile discharge should be assumed to have urethritis. However, the distinction between urethritis with or without accompanying epididymitis is critical in the male presenting with penile discharge, as it has important management implications. When accompanying epididymal pain or tenderness is present, both the dosage and duration of antimicrobial treatment increase, as epididymitis represents a more advanced infection.

Although testing to determine the specific etiology in cases of STD (whether ulcerative or urethritis) is recommended, this is often impractical in the busy ED setting, given the difficulties in ensuring timely follow-up counseling and treatment for abnormal test results. Therefore, empiric antimicrobial treatment for likely pathogens should be initiated, and counseling regarding notification of sexual contacts should be underscored.

Diagnostic Studies

The key to managing acute GU problems is the timely recognition of fertility and testicular viability threatening conditions. Most routine diagnostic aids (such as blood work and urinalysis) add little to distinguish among the common etiologies of acute scrotal pain. Instead, they detract from patient outcome by causing delays in diagnosis, referred to by some as "castration through procrastination." If the history and examination suggests the diagnosis of testicular torsion, urology (or pediatric surgery) consultation and plans for immediate surgical exploration should be initiated without delay. A patient of appropriate age (neonate, adolescent) with classic findings of testicular torsion does not require any diagnostic tests. Indeed, testicular salvage rates are time sensitive. A meta-analysis of 1140 patients in 22 series demonstrated a greater than 90% salvage rate with surgery within 6 hours of pain onset. Likewise, the risk of subsequent testicular atrophy increased (despite surgical detorsion) beyond this 6 hour window. (See Figure 4).38 However, with less distinct ("indeterminate") circumstances, a confirmatory diagnostic study (typically color Doppler ultrasound) is indicated.39 In fact, although surgical exploration is the initial treatment of choice with a strong clinical suspicion for testicular torsion, guidelines published by the American College of Radiology state that confirmatory imaging can be performed if readily available and performed within 30 to 60 minutes of the request to simultaneously prepare the operating room.40

 

 

The diagnosis of priapism and paraphimosis are made solely on clinical grounds. In cases of GU trauma, a sonogram can be very useful in delineating the extent of injury and for assessing distal penile vascular integrity. STD's may require additional confirmatory microbiologic laboratory testing, including direct culture or other automated techniques such as polymerase chain reaction testing, none of which are practical in the ED setting because of the difficulties with ensuring follow-up on abnormal test results.

Radiologic Testing

When utilized in the appropriate clinical setting, sonography remains the most useful diagnostic modality in the evaluation of GU complaints. A color flow duplex Doppler ultrasound may be very helpful in indeterminate cases of acute scrotal pain. The classic sonographic finding suggestive of testicular torsion is diminished intratesticular blood flow. In addition, examination of the spermatic cord itself with high-resolution gray-scale sonography may reveal "coiling" or "kinking" of the cord at the site of torsion (see ‘Controversies/Cutting Edge’ section).41 Sonography is used not only to exclude testicular torsion but also to search for alternative causes of acute scrotal pain.42 In epididymitis, perfusion will be normal (or increased) due to the effects of inflammatory mediators on local vascular beds.43 An infarcted appendage (resulting from appendage torsion) may be visualized on ultrasound as well.44 Ultrasonography may also identify hydroceles, hematoceles, varicoceles, hernias, tumors, abscesses or gonadal vasculitis. Finally, ultrasound is an invaluable tool in the evaluation of GU trauma.45,46 At least one recent study suggests that emergency physicians may be able to accurately diagnose patients presenting with acute scrotal pain using bedside sonography.47

Radionuclide scintigraphy and color Doppler sonography show similar sensitivity as well as false negative rates for the diagnosis of testicular torsion. 48 However, given the widespread availability and expertise with ultrasound technology and the inherent risks associated with radiation exposure, radionuclide procedures have fallen out of favor at many centers. Magnetic resonance imaging (MRI) has been explored as well.49,50 However, major limitations include availability and the amount of time required for adequate imaging. Computed tomography (CT) may be helpful in assessing the degree of extension in cases of GU infection (abscess, Fournier's disease), or in the search for coexisting injuries in the evaluation of GU trauma.51 In cases of Fournier's disease, delays in recognition and definitive surgical debridement can be life threatening, so imaging should not delay surgical consultation.

Treatment

The primary goals of treatment in the ED setting are physiologic stabilization, symptom relief, administration of antibiotics when indicated, and, in some cases, preparation for surgical intervention.

Pain Relief

Acute scrotal and penile problems encountered in the ED commonly present with a significant (and often distressing) component of pain. The greatest priority is identifying GU pathology that necessitates rapid surgical intervention. Therefore, initial pain relief should in many cases be administered parenterally. Under no circumstance should analgesia be withheld pending consultation. If the likelihood of surgical intervention is low or if the pain is mild on presentation, a trial of oral medications can be offered. Agents used most frequently are narcotic analgesics, non-steroidal anti-inflammatories (NSAIDs), or acetaminophen.

The pain of testicular torsion may be relieved following a trial of manual detorsion of the affected testicle.52 As the testes most frequently torse in a lateral to medial fashion, detorsion is often accomplished by rotation of the affected testicle from medial to lateral (frequently described as "opening a book"). The end-point of the detorsion procedure is relief of pain or sonographic evidence of improved intratesticular blood flow. A case series and meta-analysis of previously reported series demonstrated an overall success rate of greater than 95% (100 out of 105 cases) following manual detorsion.53

Scrotal elevation may be beneficial in patients with inflammatory conditions such as epididymitis. This is easily accomplished by use of a towel roll or supportive undergarments (such as a "jock strap"). In addition, ice may reduce edema and provide a mild degree of analgesia.

Antimicrobials

Antimicrobial agents are indicated in cases of suspected or proven infection. Early intravenous broad-spectrum antibiotic therapy (covering Gram positive, Gram negative, and anaerobic species) is imperative in any case of suspected Fournier's disease. Suggested regimens include extended-spectrum penicillin/beta-lactamase inhibitors (such as ampicillin/sulbactam or piperacillin/tazobactam), a third generation cephalosporin plus clindamycin, or vancomycin plus metronidazole. In addition, there is some emerging literature to suggest a potent synergistic role of clindamycin along with beta-lactam antimicrobials (ie, clindamycin plus piperacillin/tazobactam) in combating necrotizing soft tissue infections, particularly when Streptococcal species are involved.54,55 The role of hyperbaric oxygen therapy in the management of Fournier's disease has been suggested, although its utility is still the subject of much debate in the medical literature.56,57 Although early consultation and administration of broad-spectrum antibiotics is indicated in all suspected cases of Fournier's disease, surgical debridement is imperative and remains the definitive treatment.58,59,60

Antibiotics are the cornerstone of therapy for epididymitis. Antimicrobial selection is guided by patient demographics: younger (less than 35 years old) sexually active males are treated with agents to cover Neisseria gonorrhoeae and Chlamydia trachomatis, such as ceftriaxone (250 mg IM single dose) with oral doxycycline (10 day course). It is important to note that both the dosage and duration of antimicrobial treatment differ for epididymitis when compared with urethritis. For instance, a typical treatment regimen for isolated urethritis is a single dose of ceftriaxone 125 mg (IM) plus azithromycin 1 g (PO), whereas typical treatment for epididymitis is ceftriaxone 250 mg (IM) plus doxycycline 100 mg (PO) twice daily for 10 days. Importantly, fluoroquinolones (such as ciprofloxacin) are no longer recommended for the treatment of gonococcal infections owing to increased resistance patterns in the United States and abroad.61

Epididymitis may also occur in prepubescent males.62 This is thought by some to be caused by reflux of sterile urine into the epididymis, which may result from congenital GU anomalies, although the precise mechanisms remain unclear.63,64 Recommendations regarding treatment of the resulting inflammation vary from treating all boys with antibiotics65 to limiting their use to patients with documented urinary findings (pyuria, positive urine culture).63 If utilized, prophylactic antibiotics should cover the common urinary pathogens. Treatment for other STDs is covered in Table 7.

 

 

Priapism

The treatment of priapism will most frequently be managed by a urologist. However, in certain circumstances, it may be necessary for the emergency physician to initiate treatment for low-flow priapism in the ED. The classic teaching is that the initial treatment (oral or subcutaneous terbutaline) for low-flow priapism is the same regardless of inciting etiology.66 It is thought that terbutaline, a beta-2 adrenergic agonist, may increase venous outflow from the engorged corpora by way of relaxation of venous sinusoidal smooth muscle, although the precise mechanisms are poorly understood. However, additional evidence, as well as consensus expert opinion, question the utility of this intervention. 67,68 Overall, terbutaline is of unproven benefit. However, given its fairly "low risk" profile for untoward events, its use may still be warranted.69 Other treatments include corporal blood aspiration, saline irrigation, and injection of an alpha-adrenergic receptor agonist (such as phenylephrine, epinephrine, or pseudoephedrine). The goal of treatment in the sickle cell disease patient with priapism is reduction of red cell sickling thereby reducing vascular sludging and vaso-occlusion. Preferred treatments in this setting include oxygen, intravenous hydration, and possibly simple or exchange transfusions,70 although evidence-based guidelines are lacking.71 Regardless of precipitating etiology, surgical shunt procedures are used as a last resort in patients with low-flow priapism unresponsive to the aforementioned treatments.

Paraphimosis

Paraphimosis is relatively unique among the GU emergencies, as it may be managed by the emergency practitioner without the need for emergent specialty consultation. The most commonly employed maneuvers involve initial alleviation of distal penis and prepuce edema, followed by reduction of the glans penis back through the constricting band of foreskin. (See Figure 5.) Paraphimosis Reduction.) 72 Various techniques to assist in alleviation of glans and prepuce edema have been reported in the medical literature. These include non-pharmacologic methods (ice water filled glove,73,74 circumferential pressure with a gloved hand,75 circumferential compressive elastic dressing,76) pharmacologic treatments (application of granulated sugar to the surface of the glans and prepuce,77 injection of hyaluronidase into the edematous prepuce,78) and minimally invasive techniques (placement of multiple puncture wounds in the swollen glans or prepuce with a goal of expressing edema fluid.79-81) An evidence-based review in 2004 concluded that given the lack of comparative or randomized trials, current treatment recommendations are based solely on local practice preference.82 However, these treatment recommendations are to be discouraged as there is no firm evidence that they work. The only definitive treatment here is reduction of the foreskin with the thumb and index fingers or incision of the phimotic ring by a practitioner experienced in this procedure.

 

 

Special Circumstances

In terms of diagnosis, vigilance is essential in order to arrive at the possibility of a GU source for a vague or non-specific complaint in the first place. As such, in males of any age, it is important to always consider GU pathology in your differential and take the time to look "down there." This is particularly important in males at the extremes of age or otherwise non-communicative patients. Parents or caretakers may be entirely unaware of the possibility of a GU etiology of a patient's symptoms.

Immuno-compromised patients may exhibit an atypical (or "blunted") response (ie, blunted fever, pain, or peritoneal signs) to medical or surgical disease. Always be weary of pain that appears to be "out of proportion" to what you see on examination. This is the hallmark of necrotizing fasciitis (Fournier's).

Finally, although essential in any patient, it is particularly important to address privacy and confidentiality issues in the peripubescent age group. Otherwise, you may find yourself forced to make decisions with limited information from the history or examination.

Controversies/Cutting Edge

High Resolution Ultrasound In The Evaluation Of The "Acute Scrotum"

Color flow Doppler ultrasonography (CDUS) has long been regarded as the diagnostic modality of choice in indeterminate presentations of the acute scrotum. However, sporadic reports began to emerge in the early 1990's regarding the limitations (ie, false negatives) of sonography in the diagnosis of testicular torsion.83-89 Many of these studies are limited by small numbers and retrospective design (case reports or small case series). Despite this, the most concerning data comes from Baud90 and Kalfa,41 where 6 of 23 cases (26%) and 50 of 208 cases (24%) of testicular torsion, respectively, had demonstrated flow on CDUS. CDUS assessment may reveal the presence of seemingly adequate intratesticular arterial flow with partial torsion, which can be very misleading to the practitioner. Similar limitations of CDUS resulting from partial torsion have been documented in animal models.91

Given the potential limitations of CDUS, investigations began to focus on alternative techniques to improve the diagnostic accuracy of sonography in the evaluation of the "acute scrotum." Recent reports have suggested that the addition of high-resolution ultrasound (HRUS) imaging of the spermatic cord to standard CDUS imaging of the testicle may improve diagnostic accuracy.92,93 However, Karmazyn94 noted some important limitations of HRUS imaging. Importantly, the spermatic cord may appear entirely normal during the "detorsed" interval with intermittent torsion-detorsion. In addition, a "tortuous" spermatic cord (resulting from inflammation and edema in epididymitis) may be very difficult to differentiate from a "coiled" or "kinked" spermatic cord as seen with testicular torsion.

The latest (and greatest) evidence for HRUS comes from Kalfa et al,41 who conducted a multicenter investigation of 919 patients (208 patients with proven testicular torsion). They found that HRUS was highly sensitive for ruling-in as well as highly specific for ruling-out spermatic cord torsion (HRUS detected a "twist" of the cord in 96% (199/208) of patients with testicular torsion; HRUS= revealed a normal "linear" cord in 99% (705/711) of patients without testicular torsion). The authors concluded that given its high sensitivity and specificity, HRUS can significantly improve the management of children presenting with an acute scrotum. However, they were careful to point out that spermatic cord HRUS requires extensive practice and experience, is highly operator-dependent, and therefore should be performed by a radiologist experienced in the procedure (and not by an emergency physician with limited experience.)

So, what's the bottom line regarding sonography for the diagnosis of testicular torsion? While excellent overall, important limitations of CDUS exist (false negatives). The addition of HRUS imaging of the spermatic cord appears to significantly improve the overall diagnostic accuracy of sonography. HRUS may be a very useful adjunct; however, it may not yet be ready for "prime time" at many centers. The real bottom line is if the HRUS is not definitively diagnostic, the scrotum needs to be explored as soon as possible.

Disposition

There are several GU emergencies which require immediate evaluation by an appropriate specialist (ie, urologist or surgeon) in the ED. Emergent "scrotal" conditions include suspected (or indeterminate) cases of testicular torsion and Fournier's disease. Emergent penile conditions include persistent priapism and non-reduced paraphimosis. In addition, maintain a very low threshold for specialty consultation in cases of GU trauma, whether blunt or penetrating.

On the other hand, many GU "emergencies" may be suitable for close specialty follow-up following telephone consultation (ie, priapism that has resolved, paraphimosis that has been successfully reduced, minor GU trauma). However, err on the side of caution, and obtain appropriate consultation while the patient is in the ED. When evaluating pediatric GU complaints, always remain vigilant to the possibility of child abuse; obtain additional history, diagnostic testing, or social services consultation if specific concerns arise.

Always provide prescription analgesics or recommendations for over-the-counter analgesics. Also, provide prescriptions for outpatient antimicrobials, when indicated.

Patients with unclear diagnoses, intractable pain or vomiting, unreliable follow-up, or an unstable social situation may require inpatient management by an appropriate specialist (urologist, pediatric surgeon, general surgeon) or a primary care provider (internist, pediatrician, family practitioner).

Documentation Keys And Patient Teaching Tips

Documentation keys are presented in Table 8. Documentation of the time and nature of any discussions with specialty consultants (ie, urology, radiology, general surgery, pediatric surgery) is crucial. In addition, always document the results of the GU examination in the evaluation of any non-verbal patient. This is particularly important in the elderly population, as well as in infants with inconsolable crying.

 

 

Summary

Male GU problems are anxiety provoking for all parties involved. Precise diagnosis of GU problems is not always feasible in the ED setting. However, differentiating GU emergencies from GU urgencies takes precedence over definitive diagnosis. Identification of testicular torsion is of paramount importance, given its implications for future fertility. The 2 other most common causes of the "acute scrotum" are epididymitis and appendage torsion, both of which can typically be managed in the outpatient setting once testicular torsion has been excluded. Other GU emergencies include Fournier's disease, priapism, paraphimosis, and any form of GU trauma. With a careful history and thorough examination, as well as ultrasound assistance when needed, the initial phase of these "high-risk" conditions can be skillfully and effectively managed by the emergency practitioner.

Key Points

  1. There are five GU emergencies: testicular torsion, Fournier's disease (necrotizing fasciitis of the perineum), priapism, paraphimosis, and any form of GU trauma unless proven otherwise.
  2. Differentiating true GU emergencies (requiring prompt action) from urgent conditions (safe for outpatient management) takes precedence over definitive diagnosis in the majority of cases.
  3. Ultrasound examination is widely available and extremely useful at differentiating among the etiologies of acute scrotal pain, including indeterminate presentations; it is also an invaluable tool in assessing distal penile vascular integrity.
  4. In cases of suspected testicular torsion, emergent specialist consultation is imperative: remember that "time is testicle," so be careful to avoid" castration by procrastination."
  5. The appearance of overt physical findings in Fournier's disease may indicate that it's too late to mitigate patient morbidity and mortality. The hallmark of this disease is pain out of proportion to physical findings in any high-risk (ie, diabetic or other immune compromised) patient.
  6. Although largely of unproven benefit, the initial treatment for priapism is the same regardless of precipitating cause- a trial of oral or subcutaneous terbutaline (a bete-adrenergic agonist) remains the first-line ED treatment.
  7. Paraphimosis is relatively unique among the GU emergencies, as successful reduction can often be performed solely by the emergency physician, without the need for speicalty consultation.
  8. Consider consulting urology (telephone conversation at a minimum) in all but the most minor cases of GU trauma to help guide clinical decision making and patient disposition.

Pitfalls To Avoid

1. "They were new parents; their newborn was afebrile and looked fine overall, just a bit fussy. I figured it was most likely colic and sent them home to follow-up with their pediatrician the following morning."

In the male infant with inconsolable crying, always perform a GU examination to exclude conditions such as testicular torsion, paraphimosis, or penile entrapment injury (ie, hair tourniquet).

2. "Sure, he was a bashful teenager, but I asked if there were any other symptoms, and the answer

was a definitive ‘no.’ How was I supposed to know that he had testicular pain?"

In any male patient with abdominal pain, always ask about GU symptoms and maintain a low threshold for performing a thorough GU examination. This is particularly important in the prepubescent and adolescent age groups, who may try to hide such "sensitive" complaints.

3. "He was sent from the nursing home for fever. There was no mention of scrotal signs or symptoms anywhere in the nursing home documentation."

In the non-communicative male patient (ie, dementia, mental retardation, other), always perform a comprehensive GU examination as a potential cause of illness in the work-up of fever, vomiting, crying, or any other change in the patient's baseline health status. In some cases, caretakers may be entirely unaware of acute GU problems.

4. "I figured he was just another drug seeker. He was complaining of severe perineal pain, but the skin examination would barely qualify as a ‘faint’ cellulitis!"

When faced with a patient complaining of pain out of proportion to physical findings (particularly in patients who are elderly, diabetic, or immuno-compromised) consider early Fournier's disease and initiate surgical consultation and broad-spectrum antimicrobial treatment without delay.

5. "We placed the urinary catheter, but when it became clear that he would be safe for ED discharge, we decided to remove it. We didn't even think to check his foreskin prior to sending

him home."

In uncircumcised males, always replace penile foreskin following examination or urethral catheter placement (or removal) to avoid an iatrogenic paraphimosis.

6. "There was a malodorous stench in the room, but the pain was present for several days and he reported a yellow-green discharge. I just empirically treated him for urethritis without even looking down there!"

Turns out that it wasn't urethritis at all, but, it was a vacuum cleaner-induced penile injury! In patients with an inconsistent history, difficult examination, or when things just don't make sense, question the possibility of GU trauma (self-induced or other mechanism).

7. "Urology said to get the sonogram, and they would be in to see the patient first thing in the morning. I didn't realize that testicular salvage rates decreased so precipitously with time!"

Testicular torsion is a true GU emergency. As such, ‘time is testicle’ and we need to be careful to avoid ‘castration by procrastination!’ If you are having difficulty convincing a consultant to see a high-probability patient based on history and examination alone, offer to activate the internal machinery to have a sonogram performed simultaneously as the urologist (or pediatric surgeon) makes their way into the ED.

8. "It was a busy shift, and I only had a few minutes with the patient. He was complaining of left testicular pain, so I decided to save a step by examining the left side first."

When examining the testes, always examine the unaffected side first. This serves as a control and will help in gaining patient confidence and developing trust (which may rapidly wane after examination of a swollen and painful scrotum!).

9. "He's now getting a head CT after ‘hitting the deck’ during my GU examination!"

Always examine the GU system with the patient in both supine and standing positions; however, exercise caution when examining a standing patient, since some males may experience a particularly strong vagal response to scrotal (or prostate) stimulation, which leads to pre-syncope or syncope.

10. "They talk about Prehn's sign in every textbook… I always thought that it was one of those key exam features that truly stood the test of time!"

Although Prehn's sign (elevation of the scrotum relieves the pain of epididymitis, while increasing the pain of testicular torsion) is frequently referenced as a historical method of differentiating testicular torsion from epididymitis, the information provided is additive but by no means diagnostic.

Cost-Effective Strategies

  • For males presenting with GU complaints, standard laboratory testing is useless in the vast majority of cases. Routine investigations (CBC and chemistry panel) add little to distinguish among the causes of acute scrotal or penile pain. Caveats: A urinalysis ( and urine culture may be helpful in assessing for uninary tract infection. In addition, it may provide valuable information in the diagnosis of epididymitis. Also, in the case of Fournier's disease, comprehensive laboratory testing should be undertaken to assess for the many physiologic derangements that may be present in association with this potentially devastating disease.
  • It is prudent to invest in an ultrasound examination in "indeterminate presentation," as the acute scrotum is a very high-risk complaint from a medicolegal perspective. Caveat: 'time is testicle,' so be careful to avoid' castration through procrastination!' In a patient of appropriate age, with suggestive findings by history and on examiantion, specialty consultation takes precedence over confirmatory radiographic testing. Precious time may be wasted in the radiology suite. As an alternative, focus on activating the pathways necessary in order to get the patient to the operating room for surgical exploration as rapidly as possible.
  • You may not need the urology (or pediatric surgery) consultant to come in from home after-all. Paraphimosis is relatively unique among the GU emergencies, as it can frequently be managed solely by the emergency physician. Although numerous techniques to assist in paraphimosis reduction have been reported in the medical literature, the time-tested method of manual reducton using your thumb/ index digits is all that is typically required. Caveat: of your initial trials of reduction are met without success, it is prudent to summon the assistance of your more experienced colleagues!.
  • No need to look beyond...the medicine chest? Removal of the offending hair from the coronal sulcus in an infant presenting with a hair tourniquet entrapment injury can be challenging. It has been reported that over-the-counter chemical depilatories have been used successfully in the removal of digital (finger, toe) hair tourniquents suggesting their utility for genital hair tourniquets as well.95 Caveat: although it has been reported in the medical literature, this recommendation is extrapolated from comparatively weak (case series) and limited date regarding the treatment of digital (finget, toe) hair tourniquets.

Case Conclusion

With that lingering uneasy feeling that remains after speaking with the on call urologist and radiologist regarding your 12-year-old patient with an acute scrotum, you decide to place more pressure on both consultants. First, remembering that "time is testicle," you urge the urologist to come to the ED right away to evaluate the patient for possible exploratory surgery. The urologist balks at first but then reconsiders the high-risk nature of the complaint and informs you that they will be in as soon as possible. In the meantime, you broker a deal with your consultant, simultaneously activating the internal hospital machinery needed to make the sonogram happen as rapidly as possible…whoever gets to the patient first is fine, but at least both wheels are in motion. Given the patients presentation (appropriate age, sudden onset of symptoms, high-riding testicle with transverse lie, absent cremasteric reflex), you perform manual detorsion that unfortunately, is unsuccessful. Urology arrives shortly thereafter, just as ultrasound images are filtering-in. The sonogram reveals significantly diminished intratesticular blood flow and a "kinked" spermatic cord. The patient is whisked to the operating room for surgical detorsion and bilateral orchiopexy. Fortunately, his testicle is salvaged. However, the long-term fertility consequences will take time to uncover. By acting swiftly and aggressively, you feel confident that you did everything to ensure that your patient has the best possible chance for favorable short and long-term outcomes.

Clinical Pathway For The Treatment Of "Acute Scrotum"

 

 

Clinical Pathway For The Treatment Of Penile Pain And Swelling

 

 

Tables and Figures

 

Differential Diagnosis Of Acute Scrotal Pain

 

 

Differentiationg Testicular Torsion Versus Epididymitis Versus Appendage Torsion

 

 

Differential Diagnosis Of Acute Penile Pain

 

 

Genitourinary Trauma

 

 

Common STD's Presenting With GU Symptoms

 

 

Etiologies Of Low Flow Priapism

 

 

Medication Dosages For STDs

 

 

Documentation Keys

 

 

Anatomy Of The Scrotum by Emegency Medicine Practice

 

 

Testicular Torsion Versus Appendage Torsion

 

 

Cremasteric Reflex

 

 

Testicular Salvage And Atrophy Rates Over Time In Testicular Torsion

 

 

Paraphimosis Reduction

 

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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology

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Publication Information
Authors

Jonathan E. Davis; Robert E. Schneider

Publication Date

February 1, 2009

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