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10 Common Genitourinary Emergencies in Men
The authors review key clinical considerations for emergent penile conditions, scrotal injuries, epididymitis, Fournier’s gangrene, testicular torsion, urethral injuries, urinary retention, urinary tract infections, hematuria, and nephrolithiasis.
By Alicia S. Devine, MD, and Francis L. Counselman, MD
Male genitourinary emergencies encompass a full spectrum of disease, from symptomatically irritating conditions (such as urethritis) to a testicle-threatening problem (torsion, for example) to a truly life-threatening disorder (Fournier’s gangrene). In this article, we will review 10 common male genitourinary emergencies, including those secondary to trauma and infection, with an emphasis on patient presentation, timely diagnosis, and initial management. Treatment options are outlined in the box below.
PENILE EMERGENCIES
Emergent conditions involving the penis include trauma, phimosis, paraphimosis, and priapism.
Trauma. Blunt trauma to the penis results in penile fracture when the tunica albuginea of the corpus cavernosum is ruptured. This occurs most often with the penis erect, since the tunica albuginea is thinnest during erection. Common mechanisms of injury include vigorous sexual activity or masturbation or falls out of bed.
Patients, who are usually aged 30 to 40 years, will often report hearing a crack or tear followed by the abrupt onset of pain, swelling, and detumescence. Physical exam findings, in addition to swelling, include ecchymosis and deviation of the penis away from the fracture site. Occasionally, a tender immobile swelling is palpable over the fracture site.
Diagnosis of penile fracture is often made on the basis of the patient’s history and the physical examination. Imaging studies include ultrasound, cavernosography, and magnetic resonance imaging; however, some authors question their significance. An emergent urology consult is appropriate for surgical exploration in cases of suspected penile rupture. A retrograde urethrogram is indicated in cases of suspected associated urethral injury. Immediate surgical repair yields the best long-term results. Conservative management can result in plaque formation at the site of the rupture of the corpus cavernosum, necessitating surgical correction and possibly causing erectile dysfunction.
Phimosis. Phimosis occurs when the distal aspect of the foreskin (prepuce) of the penis becomes stenosed and cannot be retracted over the glans. In uncircumcised babies, this condition is caused by adhesions; in adolescents and adults, adhesions, balanitis (inflammation of the glans), or dermatitis can cause phimosis. Complications can include urinary retention, and treatment in the emergency department is dilation of the orifice with hemostats. Definitive therapy is circumcision by a urologist.
Paraphimosis. In paraphimosis, the retracted foreskin cannot be pulled back over the glans behind the coronal sulcus. This is an emergent condition because the retracted foreskin can act as a tourniquet and become swollen as venous and lymph drainage is impaired, resulting in possible ischemia and necrosis of the glans. The foreskin should be reduced immediately. This can be attempted after patient sedation and analgesia by compression of the glans and manual reduction of the foreskin. Inability to reduce the foreskin in this manner requires local anesthesia with 1% plain lidocaine and a superficial dorsal incision through the stenotic ring of tissue, usually by a urologist. If these methods are unsuccessful, emergent circumcision is required.
Priapism. Priapism is a prolonged, usually painful erection that can be classified as high-flow or low-flow. In high-flow priapism, arterial blood from a cavernous artery is shunted into the corpus spongiosum and corpora cavernosa. Typical causes of high-flow priapism are trauma or straddle injuries such as those seen in motorcycle or bicycle accidents. This condition is minimally painful and initial treatment is conservative. Definitive treatment is embolization of the injured artery.
Low-flow priapism, a true emergency, occurs when venous drainage of the corpus spongiosum and corpora cavernosa is impaired. This condition is very painful, and complications include ischemia and fibrosis. Priapism is often associated with sickle cell disease, but it can also be caused by drugs used to treat erectile dysfunction, hypertension, and depression, as well as anticoagulants. Examples include hydralazine, bupropion, trazodone, fluoxetine, heparin, and coumadin. Alcohol, cocaine, and even scorpion stings have been cited as causes of priapism.
Unless specific contraindications exist, terbutaline 0.25 mg administered subcutaneously in the arm and repeated in 20 to 30 minutes, if needed, is effective in a significant number of cases of low-flow priapism. Other treatment options involve a urology consult with irrigation of the corporal bodies, followed by injection of phenylephrine into the corpora cavernosa if irrigation is not successful. Conservative treatments such as ice packs or ejaculation can be tried, but these are usually not successful.
SCROTAL INJURIES
Blunt trauma to the scrotum can cause several types of injuries to the testicles, scrotum, epididymis, and urethra, resulting in significant morbidity and, in some cases, loss of a testicle. Testicular injuries following blunt trauma include rupture, hematoma, contusion, torsion, dislocation, hematocele (blood in the tunica vaginalis), hydrocele (fluid in the tunica vaginalis), and pyocele (pus in the scrotum). Blunt trauma to the scrotum can also lead to scrotal lacerations or hematoma.
Testicular hematomas and contusions result from injury to the testes with preservation of the tunica albuginea, whereas testicular fracture or rupture is a consequence of rupture of the tunica albuginea. Hematomas and fractures are typically caused by physical assault, athletic injuries, or motor vehicle collisions. The mechanism is usually a direct blow to the testicle against a hard surface, usually the pubic bone or thigh. The right testicle is injured more often than the left due to its higher position. A testicular mass or tumor can also constitute a hard surface, and testicular rupture or hematoma can result in the presence of a mass with considerably less force.
Patients with blunt trauma to the scrotum present with complaints of pain, swelling, and bruising; the injury itself is often not discernible based on presentation. Patients with testicular rupture complain of pain and occasionally urinary retention, nausea, and vomiting. On examination, a ruptured testicle will appear edematous and tense and will not transilluminate. Often, it is difficult to distinguish a testicular hematoma from a testicular fracture, in which case a prompt urology consult is appropriate, as surgical exploration provides definitive diagnosis and management.
Ultrasound of the scrotum in equivocal situations can be helpful. Findings consistent with rupture are a breach in the tunica albuginea, loss of homogeneous parenchyma, and the presence of a hematocele. The presence of a disrupted tunica albuginea is pathognomic for testicular rupture. Rupture of a testicle can lead to infertility as a result of exposure of testicular contents to the patient’s immune system.
Testicular rupture is managed surgically. Testicular hematoma and contusions are managed conservatively, with bed rest, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs). Patients diagnosed with a hematoma or any documented testicular injury require immediate urology follow-up.
Testicular torsion can result from blunt trauma to the scrotum and presents with pain, nausea, vomiting, and abdominal pain. On examination, the testicle will appear swollen and ecchymotic and may be positioned horizontally. It is important to diagnose testicular torsion following blunt scrotal trauma early, because the salvage rate is low after six hours.
Blunt abdominal trauma as well as blunt scrotal trauma can cause testicular dislocation, typically as a result of high-speed motorcycle accidents. Incidence is rare, however, and therefore often missed initially. Physical exam findings include an empty scrotum or abnormally located testis. In a 15-year period in one hospital in Taiwan, there were only nine cases of testicular dislocation. A few were diagnosed on an initial computed tomography (CT) scan, but most were discovered only after the patient noticed an empty scrotum. Early detection of testicular dislocation may allow manual closed reduction; adhesions can form in as little as four days. Late detection of dislocation requires surgical reduction.
Pyoceles, hydroceles, and epididymitis can result from blunt trauma to the scrotum. Typically, they present days to weeks following the trauma with pain, swelling, and fever. Ultrasound is helpful in diagnosing these entities, although they are usually diagnosed by the history and physical exam.
Presence of a pyocele, hydrocele, or epididymitis resulting from trauma requires referral to urology. Pyoceles are typically treated surgically, whereas hydroceles and epididymitis may be managed conservatively with symptomatic treatment and observation initially.
EPIDIDYMITIS AND FOURNIER’S GANGRENE
Epididymitis presents as gradual onset of scrotal pain, often associated with urinary symptoms. Fever and leukocytosis are frequently present, and pyuria or bacteriuria is found in up to 50% of patients. Ultrasound is a valuable tool in cases of suspected epididymitis and can be used to differentiate the source of acute scrotal pain. Findings suggesting epididymitis include increased blood flow (as opposed to decreased blood flow with testicular torsion), decreased echogenicity on the affected side, and enlargement of the epididymis.
Epididymitis is caused by infection and inflammation that arise from the urinary tract. Neisseria gonorrhoeae and Chlamydia trachomatis are the usual causative organisms in men under age 35; Escherichia coli is typically the cause in older men. Treatment is ceftriaxone administered intramuscularly and a 10-day course of oral doxycycline for men under age 35, or a fluoroquinolone for 10 to 14 days for older men. Patients benefit from scrotal support while recovering. Laboratory testing should include urinalysis and culture; the clinician may also consider obtaining urethral cultures for gonorrhea and chlamydia testing.
Complications of epididymitis include involvement of the testis (orchitis) and scrotum, as well as abscess formation. An abscess can present with testicular pain and swelling with a palpable mass; occasionally, it will present as a painless testicular mass, similar to a neoplasm. An abscess should be suspected when the patient presents with fever or a toxic appearance, or both, or when there is no improvement of a scrotal infection with antibiotic therapy. The finding on ultrasound of increased vascularity around the mass, consistent with inflammatory changes, is suggestive of an abscess as opposed to neoplasm. Treatment is admission with incision and drainage in the operating room. Pathogens are the same as those that cause epididymitis. If left untreated, a scrotal abscess can rupture or lead to the formation of sinus tracts or granulomas.
A true emergency, Fournier’s gangrene is a necrotizing fasciitis of the scrotum and perineum. Causative bacteria include E. coli, Bacteroides, Streptococcus, Pseudomonas, Proteus, Clostridium, Salmonella, Klebsiella, and Corynebacterium. (Usually, more than one species is involved.) An impaired immune system, as in diabetes mellitus or alcoholism, as well as obesity, are predisposing conditions. Patients may appear toxic, with a necrotic scrotum and perineum; however, some patients may present with perineal, rectal, or scrotal pain out of proportion to their physical exam findings. Morbidity and mortality with Fournier’s gangrene are extremely high, making early diagnosis and treatment critical.
In its early stages, Fournier’s gangrene can be mistaken for other causes of scrotal pain, such as cellulitis. Indeed, early presentation of Fournier’s gangrene includes lower abdominal pain and scrotal swelling or pain without erythema or fever. Patients with Fournier’s gangrene frequently present with pain or pruritus, which can progress rapidly to fever, chills, and perineal swelling. Crepitus is often present on palpation. Eventually the tissue in the involved area sloughs and becomes malodorous.
Scrotal ultrasound can be very helpful in diagnosing Fournier’s gangrene by demonstrating soft tissue gas and thickening of the scrotal skin. Pathognomic findings on ultrasound for Fournier’s gangrene are soft tissue gas and skin thickening. As with testicular torsion, early diagnosis is important in minimizing morbidity, which includes the loss of the testicles, prolonged hospitalization, and colostomy or cystostomy, or both.
Treatment for Fournier’s gangrene includes intravenous (IV) fluid resuscitation, broad-spectrum antibiotics, and an immediate urology consult for surgical debridement. Due to the polymicrobial etiology of this disease, a multidrug regimen of IV penicillin plus gentamicin or a third-generation cephalosporin, plus metronidazole, is often used. A single-drug regimen includes meropenem or imipenem.
TESTICULAR TORSION
Patients with testicular torsion will often give a history of trauma or strenuous physical activity. They usually report the sudden onset of unilateral testicular pain. Nausea and vomiting are frequently present. Torsed testicles are usually, but not always, high in the scrotum, swollen, and diffusely tender. Physical examination may reveal a transverse rotation of the testicle, with the epididymis in an anterior position. A thickened spermatic cord is also suggestive of torsion. Absence of a cremasteric reflex is very sensitive for torsion, while the absence of Prehn’s sign is not. A cremasteric reflex is present if the scrotum and testicle retract with scratching of the ipsilateral inner proximal thigh. Prehn’s sign is the relief of testicular pain with scrotal elevation, often observed in epididymitis and absent in torsion.
If torsion is suspected, time is of the essence; the salvage rate decreases rapidly with treatment delay. Complications from a missed diagnosis include loss of the testicle and infertility. An urgent urology consult is appropriate; a color Doppler scrotal ultrasound can be obtained while waiting for urology. Reduction of testicular torsion can be attempted manually in the emergency department, but this should in no way delay surgical consult. Reduction of a torsed testicle involves rotation of the anterior portion of the testicle laterally, often described as the motion used to open a book. Pain relief indicates some reduction of the torsion. If the procedure worsens the torsion and increases the pain, rotation should be attempted in the opposite direction. Regardless of whether this procedure is successful, surgical evaluation is mandatory. Ultrasound is the imaging study of choice in evaluating for testicular torsion.
Distinguishing between torsion and epididymitis as the cause of acute scrotal pain is often challenging. As in torsion, patients with epididymitis may give a history of acute onset. In torsion, however, urinalysis may be significant for infection, while patients with epididymitis can have normal urinalysis results in up to 50% of cases. Epididymitis can, in severe cases, cause testicular torsion. The use of ultrasound, therefore, is a key tool in the evaluation of the acute scrotum. However, for patients with a presentation highly suggestive of torsion, a urology consult should not be delayed while waiting for ultrasound confirmation.
Torsion of a testicular appendage, an embryologic remnant, is not uncommon. There are four possible remnants susceptible to torsion, but the appendix testis and the appendix epididymis are the most commonly involved.
Patients typically present with localized scrotal pain. The “blue dot sign,” which can be observed through the scrotal skin, is the actual necrotic testicular appendage. The blue dot sign may not be visible with darker skin or with increased edema. Unlike testicular torsion, there will be normal testicular blood flow on ultrasound, with the torsed portion appearing hyperechoic. Management is nonsurgical, with scrotal support and analgesia as the mainstays of treatment.
URETHRAL INJURIES AND URINARY RETENTION
Blunt trauma to the scrotum can lead to urethral injuries, which should be suspected when a patient presents with a history of trauma followed by pain, urinary retention, or hematuria. Physical exam findings include blood at the meatus, a high-riding prostate, and ecchymosis around the perineum or scrotum. A retrograde urethrogram is the study of choice for suspected urethral injuries. A urology consult is appropriate for surgical correction of urethral injuries.
Urinary retention can be caused by obstruction, infection, medications, or neurogenic etiologies. Benign prostatic hyperplasia (BPH) is the most common obstructive cause of acute urinary retention in older men. Patients with BPH can present in distress due to a distended bladder and occasionally overflow incontinence. A rectal exam will find the prostate enlarged. Treatment involves insertion of a urinary catheter, discharge with the catheter and leg bag, and referral to urology for follow-up.
Other obstructive causes of acute urinary retention include prostate cancer, urethral strictures, and bladder stones and tumors. Patients with prostate cancer will often have a nodular prostate on rectal examination; treatment includes insertion of a urinary catheter and referral to urology. Urethral strictures can be caused by prior instrumentation, infection, or trauma and can develop anywhere from the meatus to the neck of the bladder. Treatment involves insertion of a urinary catheter; if a small catheter cannot be advanced past the stricture, a urology consult is appropriate for urethral dilation or suprapubic catheter placement. Bladder stones can act as a ball-valve mechanism and cause intermittent urinary retention; treatment again is insertion of a urinary catheter with urologic follow-up for definitive treatment. A bladder tumor should be suspected in patients with acute urinary retention who give a history of hematuria and passage of clots. Hemoglobin and hematocrit levels should be ordered for these patients and a large three-way urinary catheter inserted. Urologic follow-up is required.
Infectious causes of acute urinary retention include prostatitis, herpes, abscess, and tuberculous cystitis. Underlying disease processes should be treated and admission considered in appropriate cases. A urinary catheter should be inserted.
Anticholinergics, alpha-agonists, and some antipsychotic and antidepressant medications can cause urinary retention due to their effects on the detrusor muscle or bladder neck smooth muscle. Examples include atropine, oxybutynine, tolterodine, ephedrine, phenothiazine antipsychotics, and monoamine oxidase inhibitors. Treatment includes stopping the medication and insertion of a urinary catheter if retention is present.
Neurologic conditions, such as spinal epidural metastasis or hematoma, must be excluded as the cause of urinary retention. A thorough neurologic exam will usually identify such a cause.
URINARY TRACT INFECTIONS
All urinary tract infections (UTIs) in men are considered complicated. Such infections in young healthy men are typically caused by E. coli, but, as is the case with women, other organisms can be involved, including Proteus mirabilis or the Enterococcus or Klebsiella species. Patients typically present with dysuria, frequency, and urgency, and the diagnosis is based on urinalysis results.
Treatment in men should extend for seven days to cover occult prostatic infection. Fluoroquinolones are the best option for empiric treatment of UTIs, given their excellent prostate penetration, although trimethoprimsulfamethoxazole DS is another option. Unlike with women, urine cultures should be obtained in all men diagnosed with a UTI. Urologic referral is not necessary for the first uncomplicated UTI in an otherwise healthy male patient; however, adolescents and men with UTI complications or a recurrent infection need to be evaluated by a urologist in the outpatient setting.
Pyelonephritis is diagnosed by the presence of pyuria along with signs and symptoms of an upper tract infection, such as fever and flank pain. Outpatient therapy is acceptable for uncomplicated pyelonephritis in immunocompetent patients, but hospital admission is required if there is intractable vomiting or sepsis, the patient is very young or very old, previous outpatient treatment has failed, or there are risk factors for complicated pyelonephritis.
Fluoroquinolones are the first-line treatment for pyelonephritis. Equivalent outcomes are obtained with oral and IV ciprofloxacin. Length of treatment for men with pyelonephritis varies: 14 days for men younger than 60 years old without prostatitis or anatomic or renal abnormalities and six weeks for men with recurrent UTIs. Pyelonephritis complicated by the presence of prostatitis can be treated with a fluoroquinolone, doxycycline, or trimethoprim-sulfamethoxazole. Four weeks of therapy are required for acute prostatitis; 6 to 12 weeks for chronic prostatitis.
The available evidence does not support obtaining blood cultures in nonpregnant patients with acute pyelonephritis, because they have not been shown to significantly change management or therapy. Exceptions would be cases in which the diagnosis is unclear, a hematogenous source for the infection is suspected, or the patient appears toxic or is immunocompromised.
Urethritis is typically classified as gonococcal or nongonococcal. Gonococcal urethritis is caused by N. gonorrhoeae; the typical presentation includes dysuria and purulent discharge. Testing of a urethral swabbed specimen can be by culture on Thayer Martin media or by nonculture methods such as ELISA. Emergency medicine physicians should have a low threshold for empiric treatment based on symptoms and should treat for coinfection with chlamydia. Patients should be counseled to have all partners tested and treated and to refrain from unprotected sex until all therapies have been completed. Sexual preferences are an important part of the history, because gonorrhea can also infect the oropharynx and rectum.
The most common cause of nongonococcal urethritis is C. trachomatis, which can present as urethral discharge or be asymptomatic. Diagnosis is typically by nonculture analysis of a urethral specimen; treatment is with single-dose azithromycin or a seven-day course of doxycycline.
Men who are infected with the herpes simplex virus types 1 and 2 typically develop lesions on the penis. Primary infection begins with a prodrome of fever, malaise, and lymphadenopathy, followed by the development of vesicles on an erythematous base. The vesicles then burst, leaving ulcers that are painful or pruritic. After the primary infection, subsequent reactivations can occur in response to a variety of stimuli but are usually less severe than the primary infection. Definitive diagnosis is by viral culture, although physical findings and the presence of multinucleated giant cells on a Tzanck test are highly suggestive. Treatment is with acyclovir, famciclovir, or valacyclovir, with dosing determined by whether the infection is primary or recurrent.
HEMATURIA
There are many possible causes of hematuria, and the source of the blood can be anywhere along the genitourinary tract. Hematuria can be noticed by the patient or discovered incidentally on urinalysis. The causes of gross hematuria and microscopic hematuria are the same. The history, physical exam, and the patient’s age and sex can be helpful in determining the cause. A history of cigarette smoking, exposure to benzene or aromatic amines,
strenuous exercise, recent travel or infection, flank pain, medications, or urinary frequency, urgency, or dysuria can be important factors in determining the diagnosis. The physical examination should include a cardiac exam to detect murmurs or atrial fibrillation, an abdominal exam to determine if flank tenderness is present or if the kidneys are enlarged, and a prostate and genital exam. Elevated blood pressure is important to note, as well as the presence of extremity edema.
Laboratory studies that should be ordered include urinalysis, blood urea nitrogen, creatinine, and complete blood count. Prothrombin time and an INR are appropriate tests for patients on anticoagulation therapy.
Urine dipstick testing is 91% to 100% sensitive and 65% to 99% specific for the presence of more than three red blood cells (RBCs) per high-powered field. Povidone-iodine, myoglobin, and free hemoglobin have been known to cause false positive results. Consumption of beets, red food coloring, berries, and certain medications can cause red urine that is negative for RBCs on urinalysis. Patients with lipid, protein, or RBC casts on urinalysis should be advised to follow up as an outpatient for evaluation of renal disease. Patients with white blood cells or bacteria found on urinalysis should be treated for infection, with repeat urinalysis in six weeks.
Imaging studies typically ordered in the emergency department include ultrasound and a noncontrast spiral CT scan of the abdomen and pelvis. Ultrasound of the kidneys can provide information about their size and the presence of any masses. Spiral CT without contrast is the study of choice for suspected nephrolithiasis.
While the patient who presents in the emergency department with hematuria usually can be followed up as an outpatient, it is important to remember that patients older than 40 with painless hematuria need a urology referral for evaluation for malignancy.
NEPHROLITHIASIS
The presence of renal calculi in the genitourinary tract can cause considerable pain, which often brings patients to the emergency department for relief. The pain is usually severe and colicky in nature, originating in the flank and possibly radiating to the abdomen or groin. Nausea and vomiting are common. Patients may report dark urine.
Most renal stones are composed of calcium, with a smaller percentage made of uric acid, cystine, and struvite. Uric acid stones are radiolucent; the other varieties are radiopaque and can be observed on a plain x-ray. The majority of kidney stones that are 5 mm or smaller in diameter typically pass through the genitourinary system on their own within four weeks. Only 15% of stones between 5 and 8 mm will pass on their own within four weeks. These larger stones often require lithotripsy or surgical removal. Complications of an obstructing stone include impairment of renal function and infection secondary to stasis. The infection can also contribute to a decrease in renal function.
Urinalysis should be obtained to evaluate for infection, and urine cultures should be ordered. The urine pH can provide clues about the type of stone: urine with an elevated (alkaline) pH is commonly associated with struvite stones, while a low (acidic) pH is suggestive of uric acid stones. The presence of RBCs is associated with renal stones, but it is important to remember that stones can be present without hematuria in approximately 10% to 15% of cases. Blood urea nitrogen and creatinine levels should be checked to evaluate kidney function.
Patients with no history of kidney stones who present with suspected renal colic should have imaging studies done while in the emergency department. Recurrence of renal colic is common, but repeat imaging is not necessary on subsequent visits unless there is a concern for a complication such as infection. Appropriate imaging studies include a KUB, IV pyelogram, and spiral CT scan of the abdomen and pelvis without contrast. Noncontrast spiral CT is now considered the study of choice in evaluating patients with suspected kidney stones. It is very accurate, has the advantage of identifying other potential intra-abdominal sources of pain, and does not require the use of contrast. In addition, it can be performed more quickly than an IV pyelogram.
Treatment in the emergency department includes hydration, pain control with an NSAID or narcotic analgesic, and an antiemetic. Patients can be discharged with a urology follow-up once their pain is under control, with instructions to drink plenty of fluids and to strain their urine. Uncontrolled pain or vomiting, infection in the presence of obstruction or dehydration, and having only one kidney are all indications for admission.
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