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

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

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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% 6 hrs, 12 hrs, <10% after 24 hrs
Usually unprovoked- 4-8 % trauma

10. 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

11. Anatomy of the Penis
Foreskin
Image: aafp.org

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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)

19. 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

20. 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