Epididymitis may be associated with dysuria, urgency,

and pyuria. Ultrasound will show preserved or increased

blood flow. A positive Prehn sign is helpful but is not always

present. Epididymitis can extend to become epididymoorchitis, which is more likely to be associated with signs of

systemic illness such as fever, nausea, and vomiting. Isolated

orchitis is rare and usually viral in origin. These infectious

processes are all more likely to be gradual in onset.

An incarcerated inguinal hernia is another diagnostic

consideration. However, the patient is likely to have a history of hernia or scrotal swelling before the episode of

incarceration. Similarly, a tumor is usually gradual in onset

and is often painless.

Direct testicular tramna can precipitate torsion or cause

testicular contusion or rupture. Ultrasound will demonstrate rupture and possibly a hematocele. Consider torsion

in any patient with testicular tramna who still has pain

1-2 hours after what seems like a relatively minor injury.

There is no single feature of the history, physical examination, or diagnostic studies that is completely reliable in

diagnosing or excluding testicular torsion. Because this is a

fertility-threatening diagnosis, high clinical suspicion mandates immediate urologic consultation (Figure 41-2). If

ultrasound is rapidly available, it may be helpful in confirming a diagnosis, but should not delay urologic consult.

TREATMENT

Most testicular torsions occur in the lateral to medial

direction. Manual detorsion should be performed by rotating the affected testis in the lateral direction 1.5 rotations

Acute scrotal pain

• I mmediate GU consult

Risk factors for

testicular

torsion

Focused GU

and abdominal

exam

• Attempt manual detorsion

• Diagnostic ultrasound

Definitive

surgical care

CHAPTER 41

Figure 41-2. Testicular torsion diagnostic algorithm.

(540 degrees). To remember the direction to detorse, think

of opening a book (Figure 41-3). The end point of the

maneuver is relief of pain. If pain becomes more severe,

attempt detorsion in the opposite direction. If manual

detorsion is successful (ie, relief of pain), emergent consultation with a urologist is still required.

Manual detorsion is a painful procedure. You should

warn your patient and consider administering intravenous

(IV) narcotics before the procedure. A single dose of IV

narcotics is not likely to ameliorate the pain of testicular

torsion or remove the clinical end point (ie, relief of pain)

of the detorsion maneuver.

When manual detorsion is unsuccessful, emergent s urgical exploration and detorsion is indicated. Patients usu ­

ally require surgical fixation of both the affected and the

unaffected testes to avoid future torsion.

A

B

.A. Figure 41-3. Manual detorsion of the testicle. Reprinted

with permission from Gausche-Hill M, Williams JW. Chapter 82.

Male Genitourinary Problems. In: Strange GR, Ahrens WR,

Schafermeyer RW, Wiebe RA, eds. Pediatric Emergency

Medicine. 3rd ed. New York: McGraw-Hill, 2009.

DISPOSITION

� Admission

Admission for operative urologic intervention is indicated

in testicular torsion or suspected torsion with an equivocal

ultrasound.

� Discharge

If no torsion is noted on ultrasound and an alternative

diagnosis is established, the patient may be discharged with

treatment as indicated (antibiotics for epididymitis, pain

medications for torsion of a testicular appendage) and

return precautions.

SUGGESTED READING

Cokkinos, DD, Antypa E, Tserotas P, et al. Emergency ultrasound

of the scrotum: A review of the commonest pathologic conditions. Curr Prob Diagnost Radial. 201 1 ;40: 1-14.

Davis JE, Silverman M. Scrotal emergencies. Emerg Med Clin

North Am. 20 1 1;29:469-484.

Sdmeider RE. Male genital problems. In: Tintinalli JE, Stapczynski JS,

Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1, pp. 613--620.

Schmitz D, Safranek S. How useful is a physical exam in diagnosing testicular torsion? J Pam Pract. 2009;58:433-434.

Penile Disorders

S. Spencer Topp, MD

Key Points

• Priapism and paraphimosis are urologic emergencies.

• Prolonged priapism (>6 hours) may result in impotence.

• Paraphimosis may lead to glans ischemia and necrosis.

INTRODUCTION

Penile disorders are a relatively uncommon presentation to

the emergency department (ED); however, a few of these

conditions are truly emergent. The penis is composed of

3 external anatomic parts-the shaft, glans, and foreskin.

Penile disorders can be classified according to how these

anatomic areas are affected. This chapter focuses on priapism, phimosis and paraphimosis, and balanoposthitis.

..... Priapism

Priapism is a persistent, often times painful, erection in

which both sides of the corpus cavernosa are engorged with

blood.