Critical urologic skills and procedures in the emergency department

The evaluation and management of genitourinary emergencies is a fundamental component of the training and practice of emergency physicians. Urologic procedures are common in the emergency room. Emergency physicians play a vital role in the initial evaluation and treatment because delays in management can lead to permanent damage. This article discusses the most common urologic procedures in which emergency physicians must be proficient for rapid intervention to preserve function and avoid complications. An overview of each procedure is discussed as well as indications, contraindications, equipment, technique, and potential complications.

Case series on testicular torsion: an educational emergency for sub-Saharan Africa

Testicular torsion remains a common surgical emergency of adolescent males presenting with sudden onset of intense scrotal pain in Africa. While the magnitude of testicular torsion is not known it has been identified as a cause of male infertility. Testicular loss in Africa is directly related to delay in surgery and the referral patterns at the point of first contact with health workers. This paper sets out to demonstrate the importance of the patient's age in the diagnosis of testicular torsion. A surgical audit was made of patients records collected over the last 30 years, for presentation of testicular related symptoms and analyzed to identify changes in the patterns of diagnosis over time and in different countries. There were 305 records found, for patients with an age range of 9-56 years. There were 195/305 (64%) with orchitis and 110/305 (36%) with testicular torsion. Testicular torsion is more common under the age of 18 years while orchitis was more common after 18 years of age (rho = -0.834, p value > 0.001 one tailed). This paper supports the development of educational interventions that promote the use of age in a simple diagnostic rule of the thumb for communities and lower cadre health workers in low resource settings.

[Acute scrotal pain]

The onset of the pain, tenderness and swelling in the scrotal content is a common complaint in the urological outpatient. A child with those symptoms should be looked on as an emergency sign requiring emergency surgical exploration as a testicular torsion. Testicular torsion represents a surgical emergency because the likelihood of testicular salvage diminishes with the duration of torsion. Therefore, we must act quickly to identify this condition in any patient who presents with an acute scrotum. The history, physical examination and patient age can provide important clues as to the exact cause of acute scrotal pain. Age is a key factor since many conditions responsible for acute scrotum commonly occur in certain age groups. Moreover, imaging is used more routinely to identify accurate diagnosis.

Testicular torsion: a 15-year single-centre clinical and histological analysis

AIM

This study reviewed the demographic, epidemiological and clinical factors of boys seen at a single centre who underwent surgical exploration for testicular torsion.

METHODS

Retrospective single-centre review of boys with testicular torsion between 1996 and 2011 was made.

RESULTS

Testicular torsion (right n = 43, left n = 60, bilateral n = 1) was identified in 104 boys between 0 and 18 years. Ten newborns presented with 11 intrauterine torsions. Nine torsions presented in undescended inguinal testes (one intrauterine). In 94 boys with descended testes, presentation included pain (76%), scrotal swelling (65%) and abdominal symptoms (22%). Ultrasonography was performed in 85 patients with false-negative results in 4 (4.7%). Orchiectomy was performed during initial exploration in 41, with significantly higher rates of orchiectomies in patients with late (>6 h) versus patients with early referrals (<6 h) (56% vs. 9.1%). Histological evaluation was carried out in 68 testes, with 43 resected testes demonstrating haemorrhagic necrosis. In 25 biopsied testes, histology revealed acute parenchymal bleeding (n = 14), onset of parenchymal infarction (n = 8), orchitis (n = 1) and normal tissue (n = 2). Eighty-two patients were followed up with pathological findings in four patients: testicular atrophies requiring orchiectomy (n = 2), testicular autolysis (n = 1) and small testicular vein thrombosis (n = 1).

CONCLUSION

Chances of testicular salvage after torsion are higher if patients present early. The majority of patients presenting late (>6 h) require orchiectomy owing to testicular necrosis.

[Testicular torsion: a tricky diagnosis]

In common urological practice, testicular torsion is one of the most serious emergencies. Consequences can be devastating for the patient, both physically and psychologically. The primary care physician should be able to quickly identify the pathology and refer immediately the patient to a center with surgical facilities. Rapid diagnosis provides the best chances to save the patient's testicle, which may suffer irreversible damage as soon as 6 hours after the onset of the symptoms. History and clinical examination remain the cornerstones of the diagnosis, and are often sufficient to select patients who need surgical exploration. If time allows it, Doppler Ultrasound can often help distinguish torsion from other scrotal conditions, but cannot be considered as a 100% diagnostic tool.

[Bilateral intrauterine testicular torsion in a newborn]

Bilateral intrauterine testicular torsion is a rare condition associated with a low salvage rate of the testes. Due to variable symptoms it is difficult to rapidly find the correct diagnosis. Here, we report on a newborn with bilateral livid swelling of the scrotum for which a bilateral orchiectomy was carried out. Histological investigation of the specimens confirmed bilateral hemorrhagic infarction. The management of bilateral intrauterine testicular torsion is still controversial. Immediate surgical intervention is still considered to be the treatment approach of choice to salvage the testes.

History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff

OBJECTIVE

To standardize the history and physical examination of boys who present with acute scrotum and identify parameters that best predict testicular torsion.

MATERIALS AND METHODS

Over a 5-month period, a standardized history and physical examination form with 22 items was used for all boys presenting with scrotal pain. Management decisions for radiological evaluation and surgical intervention were based on the results. Data were statistically analyzed in correlation with the eventual diagnosis.

RESULTS

Of the 79 boys evaluated, 8 (10.1%) had testicular torsion. On univariate analysis, age, worsening pain, nausea/vomiting, severe pain at rest, absence of ipsilateral cremaster reflex, abnormal testicular position and scrotal skin changes were statistically predictive of torsion. After multivariate analysis and adjusting for confounding effect of other co-existing variables, absence of ipsilateral cremaster reflex (P < 0.001), nausea/vomiting (P < 0.05) and scrotal skin changes (P < 0.001) were the only consistent predictive factors of testicular torsion.

CONCLUSION

An accurate history and physical examination of boys with acute scrotum should be primary in deciding upon further radiographic or surgical evaluation. While several forces have led to less consistent overnight resident staffing, consistent and reliable clinical evaluation of the acute scrotum using a standardized approach should reduce error, improve patient care and potentially reduce health care costs.

[Testicular torsion with atypical symptoms: seven cases report and review of the literature]

OBJECTIVE

To uplift the level in the early diagnosis and treatment of testicular torsion with atypical symptoms.

METHODS

Retrospective analysis of 7 cases testicular torsion with atypical symptoms and review of the related literature were performed.

RESULTS

Seven patients of testicular torsion came to the emergency department with back pain, among which 5 cases were received the detorsion successfully and 1 case underwent orchiectomy operation. The other patient given up surgery because of his family and himself refused to.

CONCLUSION

The attending doctor must firstly check the testicles when the patient complained of back pain as the first symptom, so as to avoid misdiagnosis. As soon as testicular torsion was suspected, urgent surgical exploration should be performed immediately.

[Surgical tactics in acute epididymitis in children]

Differentiated surgical policy was applied in the treatment of 147 children aged under 18 years with acute epididymitis. Basing on laboratory, clinical and ultrasound characteristics, three treatment methods were used: conservative treatment, puncture of the scrotum, revision of the scrotum. Puncture treatment of acute epididymitis appeared effective in accurate diagnosis of indications for this therapy and due performance. Ultrasound potential is shown in differential diagnosis in acute scrotum syndrome.

[Clinical characteristics of acute scrotum: analysis of 316 cases]

OBJECTIVE

To investigate the differential diagnosis and treatment of acute scrotum.

METHODS

We retrospectively analyzed the clinical characteristics of 316 cases of acute scrotum and reviewed the related literature.

RESULTS

Among the total number, there were 117 cases of acute epididymitis (37.0%), 76 acute orchitis (24.1%), 39 acute periorchitis (12.3%), 23 acute scrotal infection (7.3%), 21 testicular trauma (6.6%), 17 idiopathic scrotal edema (5.4%), 16 testicular torsion (5.1%), and 7 scrotal gangrene (2.2%). Eighty-one of them underwent surgery and 235 received conservative treatment, of whom 1 with scrotal gangrene died of toxic shock for refusing surgical drainage. Those with testicular torsion all showed positive results in Prehn's test and responded well to surgery.

CONCLUSION

Acute scrotum is detrimental to male health, for which early diagnosis and prompt treatment are essential.

Timing and surgical management of neonatal testicular torsions

BACKGROUND

The timing and surgical management of neonatal testicular torsions (NTTs) remain controversial, varying from immediate orchiectomy with empirical contralateral orchiopexy to expectant management with resulting atrophy of the affected testicle. The goal of the present study is to review the management of this entity at our institution.

MATERIALS AND METHODS

A retrospective study of all patients with NTT from 1989 to 2007 was undertaken. The age, clinical presentation, investigation, management, and short- and long-term outcomes were noted.

RESULTS

Forty-four patients were included. Most presented with a firm testicular mass, scrotal discoloration, and hydrocele (42), whereas a few presented with testicular atrophy (2). The median age at presentation was 1 day of age (range, 0-84 days), with NTT occurring on the right side in 22 patients and the left side in 20. Two patients (5%) had bilateral torsion at presentation. In 33 patients, the diagnosis was confirmed by Doppler ultrasonography, whereas 11 patients did not undergo any additional investigation. Surgical management included ipsilateral orchiectomy and contralateral orchiopexy (IOCO) (27), orchiopexy of the contralateral testis (CO) (7), bilateral orchiopexy (4), orchiectomy of the ipsilateral testis (1), orchiopexy of the ipsilateral testis (2), and observation (1). The 2 bilateral torsions underwent bilateral orchiectomy (2). The median age at surgery was 25 days (range, 1-912 days). Postoperative complications occurred in 8 patients (18%), mainly in those with IOCO (4) and CO (4) operated before 12 days of age, and included recurrent hydrocele (3), wound infection (2), urinary tract infection (1), and others (2). Upon follow-up, patients who underwent CO developed ipsilateral testicular atrophy (6). No patients were readmitted for recurrence of torsion or other complications.

CONCLUSION

At our institution, the most frequent management of unilateral neonatal testicular torsions is IOCO or CO, but this carries an 18% complication rate, particularly if surgery is performed early. There seems to be no advantage to early intervention, and the need for orchiectomy is debatable because torsion leads to ipsilateral testicular atrophy. Contralateral orchiopexy done to decrease the incidence of bilateral asynchronous torsion should, at the very least, be deferred until the risks of anesthesia and surgery are improved, given its rarity. Given the fact that most patients underwent IOCO or CO, we cannot conclude which strategy is the best for neonatal testicular torsions. A prospective study is welcomed.

Filariasis: an emergent cause of acute scrotal pain

A 25-year-old man from Bangla Desh with acute right scrotal pain was subjected to scrotal surgical exploration because of the suspicion of testicular torsion. The testicle appeared normally positioned; an epididymal nodule was removed, and pathology showed the presence of the filaria worm. Filariasis is a tropical disease which has been estimated to affect 120 millions people throughout the world. Lymphadenitis and lymphangitis are the more common clinical settings; in men, there is a frequent scrotal involvement. In some cases, acute scrotal pain may lead to the suspicion of testicular torsion. The observation of patients with genital filariasis is likely to become more frequent in an era of massive immigration from different countries; nowadays, the disease should always be taken into consideration in the differential diagnosis in patients with acute scrotal pain coming from tropical areas.

Is procalcitonin valuable in the differential diagnosis of testicular torsion and epididymo-orchitis

OBJECTIVE

To evaluate the efficacy of procalcitonin (PCT) in the differential diagnosis of testicular torsion and epididymo-orchitis.

METHODS

This experimental study was performed in the research laboratory of Dicle University, School of Medicine, Diyarbakir, Turkey between March and June 2008. The study included 24 male rats randomized equally in 3 groups: sham, epididymo-orchitis, and torsion groups. Blood samples were obtained from all rats at the beginning of the study. After torsion and infection occurred in the testes, new blood samples were obtained for PCT measurement. Then, all the right testes of the rats were excised for histopathological evaluation. The Wilcoxon signed test was used for statistical evaluation.

RESULTS

Pre- and post PCT levels were statically compared, and PCT levels were significantly higher in the epididymo-orchitis group.

CONCLUSION

Procalcitonin could be an easy, fast, and safe marker for use in the differential diagnosis of testicular torsion and epididymo-orchitis.