CC: “It hurts down there” Male Genitourinary Emergencies Emily Willner, MD Pediatric Emergency Medicine Children’s National

Learning Objectives Recognize common male genitourinary complaints and their treatments Identify male genitourinary conditions requiring urgent and emergent care

Question 1: The Painful Scrotum A 6 year old boy presents w CC scrotal pain and swelling. Symptoms began yesterday, but worsened today. He denies vomiting, fever or dysuria. He appears comfortable. GU exam is as shown below. Which physical exam finding would reassure you most? Horizontal orientation of the affected testis Bilateral cremasteric reflexes are present Tenderness of the entire hemi-scrotum Elevating the affected side worsens the pain

Anatomy of the Scrotum Posterior Anterior Spermatic cord Image: aafp.org Spermatic cord Vas deferens Venous plexus Epididymis Testis Tunica vaginalis Appendix of epididymis Cremaster muscle Appendix of testis Posterior Anterior

Acute Unilateral Scrotal Pain: Differential Referred pain (stone) Hernia (in- carcerated) Extra-scrotal Intra-scrotal Hydro-cele Varico-cele Tumor Testicular torsion Epididymitis Orchitis Torsion appendix testis

Acute Unilateral Scrotal Pain: Distinguishing Features Epididymitis/Orchitis Any age group Association with UTI, STI, viral Vertical testicular lie Relief of pain with scrotal elevation Symmetric cremasteric reflexes Testicular torsion More common in teens Severe, acute pain* Horizontal, high, swollen testicle Often with abd pain/vomiting Absent cremasteric reflex* Torsion of appendix testis Tenderness is posterior and high “Blue dot” sign early Torsion appendix testis is embryonic remnant. Under 15 is a very common cause of testicular pain Difficult to differentiate based on symptoms alone- one study of 240 boys found no difference in presenting sx except time of sx prior to seeking care! High riding= very specific No cremasteric- most sensitive

Question 2: The Painful Scrotum You are working in a community ED when a 13 year old boy is triaged with CC: testicular pain. Pain started yesterday, resolved, and then re-started 2 hours ago and has been severe and persistent. +nausea. Exam: L testis swollen and tender, with a horizontal testicular lie and absent cremasteric reflex. What do you want to do first? Urology consult Stat testicular ultrasound with Doppler Stat urinalysis Obtain sexual history

Spermatic cord twists on itself Compression of venous, then arterial flow leads to testicle infarct Image: Mayo Foundation

Congenital abnormality: testis can rotate within tunic vaginalis Testicular torsion Congenital abnormality: testis can rotate within tunic vaginalis “Bell clapper deformity” 1:4000 males under 25 Definitive treatment is detorsion and orchiopexy 90% viable @ 6 hrs, 50% @ 12 hrs, <10% after 24 hrs Usually unprovoked- 4-8 % trauma

Testicular torsion is a surgical emergency: “Time is testicle” Pearls Testicular torsion is a surgical emergency: “Time is testicle” Doppler ultrasound helpful but not 100% sensitive Expedite surgical care if dx strongly suspected If epididymitis is in differential, check a UA to r/o UTI In sexually active teens with epididymitis, test for STIs and treat empirically

Anatomy of the Penis Foreskin Image: aafp.org

Question 3: Acute Penile Pain A 3 year old uncircumcised male is brought in for dysuria and penile pain since yesterday. His mother states his penis is “swollen”. He is afebrile, has normal VS, and a normal testicular exam. What is it?  Paraphimosis Sexual abuse Balanoposthitis UTI

Balanoposthitis Infection of the foreskin (posthitis), glans penis (balanitis), or both (balanoposthitis) Common complaint in uncircumcised males, especially those with phimosis Treated with improved hygiene (frequent warm soaks, very mild soap) +/- topical antifungal More severe cases  treat with PO antibiotics

Question 4: Acute Penile Pain A 4 year old complains of acute penile pain after a bath. There is no reported history of trauma. Exam is shown. What is the abnormality? Insect bite Allergic reaction to bath product Edematous retracted foreskin Inflicted injury

Paraphimosis Phimotic “tight” foreskin is retracted forcibly Foreskin swells, can compress shaft of penis and restrict blood flow to glans Both glans and foreskin are swollen and painful Requires manual reduction

Paraphimosis Reduction Local analgesia and/or sedation Firm steady pressure on swollen glans to reduce edema Push on glans with thumbs while pulling trapped foreskin back into position

Question 5: Acute Penile Pain 3 yo M w genital area pain x 6 hours. Brought to ED by a family friend caring for child while parent is away, who thinks he has some medical problems but not sure what. On exam he is crying and has a tender, erect penis. What underlying condition are you most concerned about? Undisclosed trauma Sickle cell anemia Drug ingestion Precocious puberty

Priapism in Pediatrics Most commonly associated with sickle cell disease May be seen with other causes of hyperviscosity causing intravascular sludging Severe polycythemia Hyperleukocytosis in leukemia If unexpected, check a CBC! May be seen in adolescents using erectile dysfunction drugs or other drugs illicitly Rarely seen after GU trauma (straddle injury)

Priapism in Sickle Cell Disease Sickled RBCs block normal venous outflow of corpora cavernosa Stagnant venous blood becomes acidotic and hypoxic/ischemic  pain and permanent damage A form of compartment syndrome Treat as a sickle cell crisis O2, IVF, analgesia, trial PO pseudoephedrine Transfusion: simple vs exchange Consult Urology early: may need corpora irrigation/injection

Summary Testicular torsion is a surgical emergency important to differentiate from other causes of scrotal pain Acute penile pain complaints can frequently be managed by the emergency provider Urgent Urology evaluation for pediatric priapism, concern for testicular torsion, or paraphimosis unable to be reduced in ED