nancy (cervical, uterine or vaginal), infection (PID,

vaginal infections), trauma ( assault, sexual inter ­

course), foreign body (IUD, tampon, sexual devices),

and coagulopathies (genetic disorders, medical condi ­

tions, medications).

TREATMENT

When shock is present in a young woman with a positive

pregnancy test, ruptured ectopic pregnancy is presumed.

Initiate resuscitative measures immediately, including

oxygen administration, intravenous (IV) fluids, and/or

blood transfusion. Perform a bedside ultrasound and obtain

gynecology consultation for surgical intervention. A similar

work-up is pursued in women with a positive pregnancy

test and an acute abdomen (presumed ruptured ectopic

pregnancy), even when the initial vital signs are normal.

In pregnant patients with vaginal bleeding, always

obtain the Rh status. If the woman is Rh-negative (15% of

the white population), administer RhoGAM 50 meg intramuscularly (IM). Complete and threatened abortions

require no further treatment. In incomplete abortion,

bleeding will continue until all products of conception have

passed. Dilatation and curettage may be indicated if the

abortion does not complete on its own. Patients with a ruptured ectopic pregnancy require surgery. Some patients with

unruptured ectopic pregnancy are candidates for nonsurgical treatment by the gynecologist with use of methotrexate

and leucovorin (IV, orally [PO], or IM as a single dose).

In patients with vaginal bleeding unrelated to

pregnancy, consider blood transfusion in patients with

symptomatic anemia, especially when the hemoglobin is

<7 gm/dL. When bleeding is severe in patients with

chronic anovulatory bleeding, relief may be obtained with

hormonal therapy ( eg, medroxyprogesterone 10 mg PO for

10 days or Ortho-Novum 1/35 1 tablet QID for 5 days).

DISPOSITION

� Admission

Patients with hemodynamic instability, peritoneal findings, severe anemia (hemoglobin <7 grn!dL), or a con ­

firmed ectopic pregnancy on ultrasound should be

admitted. Pregnant patients with a closed cervical os, no

fetal tissue passed, no IUP visualized on ultrasound, and

�-hCG > 1,000 miU/mL are at high risk of ectopic preg ­

nancy; disposition should be made in consultation with a

gynecologist. Admission may be warranted.

� Discharge

Discharge patients with mild to moderate vaginal bleeding,

who are hemodynamically stable, and in whom ectopic

pregnancy has been excluded. Discharge with gynecology

follow-up, and a repeat �-hCG level in 48 hours is also

appropriate for reliable patients with no IUP seen on ultrasound when the �-hCG is < 1,000 miU/mL. This assumes

the patient is hemodynamically stable, has no significant

abdominal tenderness, and has no other ultrasound findings that suggest an ectopic pregnancy (moderate to large

amount of free fluid or a noncystic adnexal mass). In

patients with postmenopausal bleeding, refer to a gyne ­

cologist for endometrial biopsy.

CHAPTER 43

Complaint of vaginal bleeding

• Perform focused history and physical

• Assess risk factors for ectopic preg nancy

• Obta in urine pregna ncy test and hemoglobin

Os closed, no fetal tissue

rjo ectopic pregnancy, pelvic

us and serum �-hCG

Negative urine pregnancy test

Os open or feta l tissue present

Incomplete Abortion

Consider other etiologies

Figure 43-2. Vaginal bleeding diagnostic algorithm. ABCs, airway, breathing, and circu lation;

�-hCG, beta human chorionic gonadotropin; T&C, Type and Cross; US, ultrasound.

SUGGESTED READING

Clinical Policy: Critical Issues in the Initial Evaluation and

Management of Patients Presenting to the Emergency

Department in Early Pregnancy. Irving, TX: American

College of Emergency Physicians, April 1 0, 2012.

Krause RS, Janicke DM, Cydulka RK. Ectopic pregnancies and

emergencies in the first 20 weeks of pregnancy. 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. 676-684.

Morrison LJ, Spence JM. Vaginal bleeding in the nonpregnant

patient. 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: McGrawHill, 20 1 1, pp. 665-676.

Promes SB, Nobay F. Pitfalls in first-trimester bleeding. Emerg

Med Clin North Am. 2010;28:2 19-234.

Vaginal Discharge

joanna Wieczorek Davidson, MD

Key Points

• Vaginal discharge is a common presenting complaint in

reproductive-age women.

• Possible diagnoses include vaginitis, cervicitis, or pelvic

inflammatory disease (PI D).

INTRODUCTION

Many women come to the emergency department (ED)

with the chief complaint of vaginal discharge. It may be

accompanied by other symptoms such as fever, abdominal

or pelvic pain, malodor, itching, and dysuria. Vaginal discharge is usually due to vaginitis, cervicitis, or pelvic inflammatory disease (PID).

Vaginitis is a spectrum of diseases causing vulvovaginal

symptoms including burning, irritation, and itching, with

or without vaginal discharge. Normal vaginal flora maintains the vaginal pH at 3.8-4.5. Changes in the pH or disruption of the vaginal flora may result in the overgrowth of

pathogenic organisms, ultimately resulting in a change in

the appearance, consistency, or odor of vaginal secretions.

Noninfectious causes like atrophy and contact vaginitis are

fairly common-particularly in sexually inactive and postmenopausal women. The most common infectious causes

of vaginitis in descending order of frequency include hac ­

terial vaginosis (BV), vaginal candidiasis, and trichomonas

vaginitis. BV is caused by a pathologic overgrowth of nor ­

mal vaginal flora-Gardnerella vaginalis.

Infections of the upper reproductive tract (cervix, uterus,

fallopian tubes, adnexa) will also cause discharge. Cervicitis is

the term used when infection is present within the cervix

only. Pelvic inflammatory disease (PID) is a spectrum of

upper genital tract infections that includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually

transmitted organisms, especially Neisseria gonorrhoeae and

• Clinical eval uation for the diagnosis of PID is not

sensitive. Maintain a high suspicion and low threshold

to treat.

Chlamydia trachomatis, are implicated in the majority of

cases of both cervicitis and PID; however, other organisms

( Gardnerella vaginalis, Haemophilus influenza, anaerobic and

gram-negative bacteria, and Streptococcus agalactia) are also

causative. PID affects 1 1% of women of reproductive age and

requires hospital admission in 20%. Inflammation and infection can lead to scarring and adhesions within the fallopian

tubes, leading to major long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. The risk of

ectopic pregnancy is 12-15% higher in women who have had

PID.

 

 Urgent urologic consultation should be sought;

however, the emergency physician should also be prepared

to intervene when a urologist is not immediately available.

Uncomplicated phimosis and balanoposthitis are generally treated in the ED with prompt urologic follow-up

(Figure 42-2).

TREATMENT

Treatment of priapism begins with pain control. If lowflow priapism is suspected, treatment with subcutaneous

terbutaline in the deltoid region can be effective. If priapism persists, corporal injection with an alpha-adrenergic

agonist, such as phenylephrine, is performed.

If unsuccessful, corporal aspiration and irrigation can

be attempted. First, a penile nerve block is performed for

anesthesia. A 21-gauge or larger needle is inserted into the

cavernosum (lateral sides of the penis), proximal to the

PENILE DISORDERS

Attempt manual reduction of

foreskin; If unsuccessful,

perform dorsal slit procedure

in consu ltation with urologist

Disposition: Home with

urology follow-up if

reduction is successfu l.

Emergency urology consult

and admission if unable to

reduce

.A. Figure 42-2. Penile disorders diag nostic algorithm.

glans. Blood is then allowed to drain, or if needed, aspirated, typically until detumescence begins. If necessary,

aspiration is then followed by irrigation with 10-20 mL of

sterile normal saline, with or without an alpha-adrenergic

agent such as phenylephrine.

For priapism related to sickle cell disease, simple or

exchange transfusion may be necessary.

Treatment of paraphimosis involves reducing the

retracted foreskin. Ice packs or cold water immersion of

the penis may be helpful with edema and inflammation.

Compression wrapping with elastic bandage around the

glans for 5-10 minutes will also help with the swelling. The

glans may then be manually "pushed" back into the foreskin (Figure 42-3). Local injection with lidocaine may help

the patient tolerate the compression dressing better, but

will also contribute more fluid to the already swollen penis.

If manual reduction fails, the dorsal slit procedure can

be attempted. A penile block or ring block is first performed

for anesthesia. Next, hemostats are placed at the 11 and

1 o'clock positions on the edematous foreskin and clamped

down for hemostasis. Scissors or scalpel are then used to

cut the paraphimotic ring at the 12 o'clock position,

Freely mobile foreskin

with associated erythema,

excoriation, and discharge

Instructions on cleansing,

antifungal cream, antibiotics,

and steroid cream when

indicated

Disposition: Home with

primary care follow-up.

Admission for diabetics

with systemic symptoms

indicating bacterial

infection

Non-retractable foreskin with

or without swelling or edema

No treatment or steroid

cream, if asymptomatic. If

co-existing urinary retention,

hemostat dilatation or dorsal

slit performed

Disposition: Home with

urology follow-up; 6-8 weeks

of steroid cream may

improve phimosis without

surgical i ntervention

Figure 42-3. Manual reduction of a paraphimosis.

Reproduced with permission from Reichman EF &

Simon RR: Emergency Medicine Procedures, 1 st edition. McGraw-Hill, New York, 2004.

CHAPTER 42

between the 2 clamped hemostats. Manual reduction of

the foreskin over the glans is then achieved. The reduced

foreskin is then repaired with sutures, or a circumcision

can then be performed by a urologist.

Phimosis requires far less emergent treatment because

no vascular risk exists. If manual retraction is unable to be

performed, topical steroid treatment applied under the

foreskin to the tip of the penis for 4-6 weeks can be effective. If urinary retention develops, a dorsal slit procedure

or full circumcision should be performed.

The treatment of balanoposthitis consists of regular

cleaning of the glans with soap and water, with the foreskin

retracted. Topical antifungal cream (nystatin, clotrimazole)

should also be used. If bacterial infection is suspected, an

oral antibiotic (ie, first-generation cephalosporin) should

be added to the above treatments.

DISPOSITION

Patients with persistent, ischemic priapism require emer ­

gent urologic consultation. If corporal injection, aspira ­

tion, and irrigation (performed by either the urologist or

ED physician) fail to achieve detumescence, surgery to

perform a cavernosal shunt will most often be necessary.

If the preceding treatment options are successful, the

patient should be watched in the ED for 4-6 hours to

ensure symptoms do not return. If an inciting cause was

identified, the patient should also be thoroughly educated

about future avoidance.

The disposition of paraphimosis is much like priapism.

Urgent urologic consultation is required for nonreducible

paraphimosis. Admission and surgery may be necessary if

manual reduction or dorsal slit are unsuccessful. Patients

with phimosis, as long as they can urinate, can generally be

treated as an outpatient with good patient instructions,

education, and urologic follow-up.

Most patients with balanoposthitis can also be safely

discharged home. Patients with signs of systemic illness or

severe comorbid disease may require admission and intravenous antibiotics. Patient education is also very important

as the best preventative medicine is good personal hygiene.

SUGGESTED READINGS

Dubin J, Davis JE. Penile emergencies. Emerg Med Clin North

Am. 201 1;29:485-499.

Nicks BA, Manthey DE. Male genital problems. In: Tintinalli's

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

New York, NY: McGraw-Hill, 20 1 1, pp. 645-65 1.

Vaginal B leeding

Steven H. Bowman, MD

Key Points

• Obta in a pregnancy test in any woman of childbearing

age who presents with vaginal bleeding or abdominal

pain.

• Risk factors are absent in more than 40% of women

who have an ectopic pregnancy.

INTRODUCTION

Menarche, the onset of menstruation, occurs in girls at

approximately age 12. Normal menstruation continues

until menopause, which occurs on average at age 51. The

adult menstrual cycle is 28 days ( ±7 days), with menstruation lasting 4-6 days. Normal menstrual blood flow is

approximately 30-60 mL; >80 mL of bleeding is consid ­

ered abnormal. Dysfunctional uterine bleeding (DUB) is

due to prolonged or excessive estrogen stimulation or ineffective progesterone production. Menorrhagia is an

increased volume or duration of bleeding that occurs at the

typical time of menstruation. Metrorrhagia is bleeding

that occurs at irregular intervals outside of the normal

menstrual cycle. Menometrorrhagia is irregular bleeding

that is also of increased duration or flow.

Pregnancy must be excluded in women of childbearing age who present with vaginal bleeding.

Vaginal bleeding complicates 20% of early pregnancies.

When bleeding occurs, 50% of patients will have a spontane ­

 

 Tubal factor infertility is increased 12-50% in women

with a past diagnosis of PID. Prevention of complications is

dependent on early recognition and effective treatment.

CLINICAL PRESENTATION

..... History

Any complaint of vaginal discharge or pelvic pain requires

a detailed gynecologic history. Inquire about history of

sexually transmitted infections (STis), intrauterine device

use, pregnancies, last menstrual period, and any previous

gynecologic procedure. History should include details of

vaginal discharge, odor, irritation, itching, burning, bleeding, dysuria, and dyspareunia. In addition, determine the

presence of abdominal pain, nausea, vomiting, fevers, rash,

or joint aches.

Patients with vaginitis lack significant abdominal pain

or fevers and do not appear systemically ill. BV typically

1 85

CHAPTER 44

presents with thin, whitish gray discharge that has a fishy

smell. In candidiasis, pruritus is the most common and

specific symptom; discharge tends to be white and occasionally thick and "cottage-cheese" like. It is important to

ask about risk factors for candida! colonization: uncontrolled diabetes mellitus, recent antibiotic use, immuno ­

suppression, and pregnancy. Patients with trichomonas

vaginitis (a sexually transmitted protozoan parasite) are

asymptomatic in 50% of cases, but the classic discharge is

described as yellow, frothy and malodorous.

Vaginal atrophy is present in 60% of women 4 years

after menopause. Symptoms of atrophic vaginitis include

vaginal dryness, soreness, itching and occasional thin,

scant, yellowish discharge.

Acute PID can be difficult to diagnose because of the

wide variation in symptoms and signs. The most common

presenting symptom is lower abdominal pain that tends to

be bilateral, dull or crampy. Approximately 75% of patients

with PID have abnormal vaginal discharge. Unilateral pain

should raise suspicion for a tuba-ovarian abscess or an

alternate diagnosis like appendicitis. Dyspareunia may be

present as well as urinary tract symptoms. Only one third

of patients with PID will have fever >100.4° F.

� Physical Examination

Obtain the patient's vital signs, particularly noting blood

pressure, pulse, and temperature. Before performing a pelvic exam, perform a focused general exam, including the

abdomen and flank. During the pelvic exam, inspect the

external genitalia. Make note of vulvar edema or erythema,

which can be a sign of vaginitis. On the speculum exam,

determine the presence of blood or discharge in the vaginal

vault. Visualize the cervix, looking for inflammation, foreign body, and discharge originating from the os.

Mucopurulent cervicitis is a common finding in both cer ­

vicitis and PID (Figure 44-l). On bimanual exam it is

important to note cervical motion tenderness (CMT) as

well as adnexal fullness or tenderness. CMT, also referred

to as the chandelier sign, is elicited by moving the cervix up

and down or laterally with the index and middle finger.

This causes movement of the uterus and tubes, which will

significantly reproduce pain in patients with PID. CMT is

sensitive but lacks specificity, as it can be positive in

patients with other sources of inflammation (appendicitis,

ruptured cysts, or ectopic pregnancy). Adnexal tenderness

appears to be the most sensitive finding (95%) for PID.

DIAGNOSTIC STUDIES

� Laboratory

Any evaluation of a woman of childbearing age in the ED

should including a pregnancy test, as the possibility of

ectopic pregnancy or septic abortion must be considered.

During the pelvic exam, vaginal secretions may be collected and tested. Microscopic examination of vaginal

secretions and evaluation of pH are useful diagnostic tools;

.A Figure 44-1. Discharge coming from the cervical os.

Reprinted with permission from Buckley RG, Knoop KJ.

Chapter 1 0. Gynecologic and Obstetric Conditions. In:

Knoop KJ, Stack LB, Storrow AB, Thurman RJ, eds. The

A tlas of Emergency Medicine. 3rd ed. New York:

McGraw-Hill, 201 0. Photo contributor: Sue Rist, FNP.

however, microscopes and reagents are not available in all

EDs.

 

The amount of testicular damage is related to the degree and

duration of venous and arterial obstruction. If pain has been

present for <6 hours, the testicular salvage rate is 80-100%.

• When considering testicular torsion as a diagnosis,

never al low an imaging study or laboratory test to delay

an emergent urologic consultation.

• When attempting manual detorsion, remember the

direction to turn the testicle is like opening a book.

CLINICAL PRESENTATION

..... History

Abnormal development of the fixation of the tunica vaginalis to the posterior scrotal wall can cause the t esticle to

hang freely in the scrotum like the clapper of a bell, aligned

in a horizontal rather than vertical axis (Figure 41-1). This

predisposes the testicle to torse, frequently in the context of

strenuous physical activity or scrotal t rauma. Torsion can

also occur during sleep, when the cremaster muscle con ­

tracts. Other risk factors for testicular torsion include

incomplete descent of the testes and testicular atrophy.

Patients will present with acute onset of unilateral scro ­

tal pain. The pain is usually severe and noted in the lower

abdomen, the inguinal canal, or the testis. Nausea and

vomiting are often associated. Because it is an ischemic

vascular event, the pain is not positional initially. Later,

with significant testicular and scrotal edema, the pain may

become more positional.

..... Physical Examination

Examination of the opposite testis may be helpful because

anatomic abnormalities are often bilateral. Examine the

patient in both the supine and standing positions. When

the patient is standing, look for the affected testicle to be

aligned in a horizontal (bell-clapper deformity) rather

1 74

TESTICULAR TORSION

Twisted spermatic -....lUi"-'"'""

cord

Testicle in

horizontal -�t'hl�,:.;...­

plane

Figure 41-1 . Bel l-clapper deformity. Reprinted with

permission from Bondesson J D. Chapter 8. Urologic

Conditions. In: Knoop KJ, Stack LB, Storrow AB, Thurman

RJ, eds. The Atlas of Emergency Medicine. 3 rd ed. New

York: McGraw-Hill, 201 0.

than vertical axis (normal). The involved testicle will often

lie higher in the scrotum than the opposite side.

The involved testicle will be firm, swollen, tender, and the

scrotmn will usually be edematous. The size of the scrotal

mass is an unreliable indicator of the underlying etiology,

and the examination may occasionally be unremarkable.

Prehn sign (relief of pain with elevation and support of

the scrotmn) is more indicative of epididymo-orchitis than

testicular torsion; however, this distinction is unreliable.

The cremasteric reflex is tested by lightly scratching the

inner aspect of the thigh. A positive reflex is elicited when

the ipsilateral testicle retracts upward. This reflex may be

normally absent in infants and toddlers, however, absence

of this reflex is relatively specific for torsion.

DIAGNOSTIC STUDIES

.... Laboratory

Urinalysis will usually be normal. Complete blood count

most often reveals an absence of a leukocytosis.

.... Imaging

Color Doppler ultrasound is the preferred diagnostic study

and has a sensitivity of 85-100% and a specificity of 100%.

Ultrasound is also helpful for diagnosing other conditions

that are part of the differential diagnosis of t orsion, such as

epididymitis, torsion of a testicular appendage, testicular

rupture, hydrocele, hematocele, or hernia.

Nuclear radioisotope scanning has similar sensitivity to

ultrasound; however, the specificity of nuclear scans is

much lower. In addition, nuclear scans are more tirneconsmning than ultrasound.

MEDICAL DECISION MAKING

Testicular torsion is a time-sensitive condition that can

result in loss of the testicle with associated loss of fertility.

Therefore, assmne acute testicular pain is torsion until

proven otherwise.

Perform a focused history and physical examination as

soon as possible. If your clinical suspicion for torsion is

high, obtain an immediate urology consult and attempt

manual detorsion.

Factors associated with testicular torsion include abrupt

onset of pain, pain for less than 24 hours at the time of

presentation, nausea and vomiting, high position of the

testis, and abnormal cremasteric reflex. Torsion of a testicular appendage typically presents as pain that is more

localized to one point on the testicle, more gradual in

onset, and without nausea and vomiting. These small

developmental remnants may be located at various positions on the testicle and on exam may be palpable as a hard

tender nodule, most often at the upper pole of the testicle.

 

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.

 

Upper vs lower tract infection?

Flank pain & tenderness, fever, vomiting, dehydration, sepsis

Lower - Only mild suprapubic tenderness, burni ng, frequency, urgency

+

H&P: Alternate diagnosis?

Pelvic - Cervicitis, PID, pregnancy

GU - urethritis, prostatitis, epididymitis, orchitis

Abdomen - Appendicitis, diverticul itis, cholecystitis

�

H&P and labs: Complicated infection?

Complicated - Pregnancy, immunosuppression, obstructed

urinary flow (stones, prostate, strictures, compressed

ureters)

I maging if obstruction, extensive or suppurative infection

or differential includes additional abdominal infection

Send urine cultures (when ind icated), consult local

antibiogram for susceptibilities in your area

i

upper tract or

Complicated

lower tract

Alternate diagnosis

IV antibiotic dose, IVF

Consider admission1 Q-1 4 days of antibiotics

Manage as

appropriate

• Figure 40-1. Urinary tract infections diag nostic algorithm. GU, gen itourinary; H&P, history and

physical exam; PID, pelvic inflammatory disease.

DISPOSITION

..... Admission

Admission is advised for patients with UTI compli ­

cated by urinary obstruction, immunosuppression,

urosepsis, or associated unremitting vomiting, severe

dehydration, renal insufficiency, or electrolyte derangements. Pregnant patients with any upper tract disease

should be admitted for observation with an obstetrics

consultation .

..... Discharge

Patients with uncomplicated lower tract infection or

uncomplicated upper tract infection may be discharged

home with follow-up instructions to return to the ED for

any complicating factors.

URINARY TRACT I NFECTIONS

Table 40-2. Treatment of UTI.

Type of Infection Pathogens

Acute cystitis E. coli, 5. saprophyticus,

P. mirabilis

Asymptomatic bacteriuria and E. coli, 5. saprophyticus,

cystitis of pregnancy P. mirabilis

Pyelonephritis E. coli, 5. saprophyticus,

(outpatient) P. mirabilis

Pyelonephritis E. coli, 5. saprophyticus,

(Inpatient) P. mirabilis

Urosepsis E. coli, Proteus, Klebsiella,

Pseudomonas

SUGGESTED READINGS

Gupta K, Hooton TM, Naber KG, et al. International Clinical

Practice Guidelines for the Treatment of Acute Uncomplicated

Cystitis and Pyelonephritis in Women: A 2010 update by the

Infectious Disease Society of America and the European

Society for Microbiology and Infectious Disease. Clin Infect

Dis. 20 1 1;52:e103-3 120.

Howes DS, Bogner MP. Urinary tract infections and hematuria.

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.

Antibiotic Regimen

Trimethoprim/sulfamethoxazole

OR ciprofloxacin

Nitrofurantoin

OR amoxicillin- clavulanate

Ciprofloxacin

First dose IV in ED

Ciprofloxacin

OR ceftriaxone

Ampicillin and gentamicin

OR ceftriaxone

Dose and Duration of Treatment

1 DS tab BID for 3 days

500 mg BID for 3 days

1 00 mg BID for 5 days

500mg BID for 7 days

500 mg BID for HH 4 days

500 mg IV BID

1g IV QD

Continue IV until improved

1 g and 5 mg/kg/day IV

1 g IV QD

Testicu lar Torsion

Lynne M. Ya ncey, MD

Key Points

• Consider the diagnosis of testicu lar torsion in any male

with abdominal pain.

• Perform a genitourinary (GU) examination on males

complaining of abdominal pain, even if they have no GU

complaints. This is especially important in adolescent males.

INTRODUCTION

Testicular torsion is a primary concern in a male with acute

scrotal pain and should be considered in all males with

abdominal pain. Torsion is due to twisting of the testicle

around the spermatic cord. It initially compromises venous

outflow, and later arterial blood flow to the testicle, resulting

in ischemia and infarction. The longer the torsion persists, the

less chance of testicular survival. Hence, time is of the essence

in the diagnosis and management of suspected torsion.

Peak incidence of testicular torsion occurs in the first

year of life, before the testes descend into the scrotum, with

a second peak at puberty, when the volume of the testes

rapidly increases. It occurs in about 1 in 4,000 males a year.

Testicular torsion is 10 times more likely to occur in a male

with an undescended testis.

The initial effect of torsion is obstruction of venous

return. If torsion persists, venous obstruction leads to worsening edema and ultimately to arterial obstruction and

ischemia. The amount of venous obstruction is related to

the degree of rotation of the testis on the spermatic cord and

vascular supply. Incomplete rotation causes a lesser degree

of edema and vascular congestion, whereas complete rotation leads to immediate complete obstruction and ischemia.