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EMERGENCY MEDICINE PRACTICE
A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E
Male Genitourinary
Emergencies: Preserving
Fertility And Providing Relief
“W
HAT was that again, sir? You’ll have to speak up—it’s awfully noisy
here in triage. You did what? You’re kidding, right?”
Problems that arise with the male genitourinary system range from benign
to life- and fertility-threatening. Whether the complaint represents a true
emergency or not, it is often of immense concern to the worried patient. This
issue of Emergency Medicine Practice discusses the diagnosis and treatment of
common penile complaints, the evaluation of the acute scrotum, as well as
addressing prostatitis and urinary retention.
“Tumescence is the period between pubescence and senescence.”—Robert Byrne
Priapism
Priapism is a prolonged, usually painful, penile erection not initiated by sexual
stimuli.1 It results from a disturbance in the normal regulatory mechanisms that
initiate and maintain an erection.1 Priapism results from either a low-flow or
high-flow etiology. This distinction is important because the associated treatment and prognosis differ.
Low-flow (ischemic) priapism occurs when decreased penile venous
outflow produces venous stasis. The subsequent penile ischemia results from
arterial compromise.2 Low-flow priapism is a time-sensitive emergency, as
irreversible cellular damage and fibrosis occur if treatment is not administered
within 24-48 hours.3 Complications include erectile dysfunction and recurrent
episodes of priapism.4
High-flow priapism is quite rare and is caused by increased arterial flow
into the corpus cavernosa.1 It usually results from direct trauma to the internal
pudendal artery producing an arterial to cavernosal shunt. High-flow priapism
is not considered as emergent because the penis does not become ischemic.5
Stephen A. Colucciello, MD, FACEP,
Assistant Chair, Director of
Clinical Services, Department of
Emergency Medicine, Carolinas
Medical Center, Charlotte, NC;
Associate Clinical Professor,
Department of Emergency
Medicine, University of North
Carolina at Chapel Hill, Chapel
Hill, NC.
Associate Editor
Andy Jagoda, MD, FACEP, Professor
of Emergency Medicine; Director,
International Studies Program,
Mount Sinai School of Medicine,
New York, NY.
Editorial Board
Judith C. Brillman, MD, Residency
Director, Associate Professor,
Department of Emergency
Volume 2, Number 11
Author
Lisa Freeman, MD, FACEP
Assistant Professor, Department of Emergency
Medicine, University of Texas Medical School at
Houston, Houston, TX.
Peer Reviewers
Atilla Üner, MD, FAAEM
Assistant Professor of Medicine/Emergency
Medicine, UCLA School of Medicine, Los Angeles, CA.
Robert E. Schneider, MD
Department of Emergency Medicine, Carolinas
Medical Center, Charlotte, NC.
CME Objectives
Overview
Editor-in-Chief
November 2000
Medicine, The University of
New Mexico Health Sciences
Center School of Medicine,
Albuquerque, NM.
W. Richard Bukata, MD, Assistant
Clinical Professor, Emergency
Medicine, Los Angeles County/
USC Medical Center, Los Angeles,
CA; Medical Director, Emergency
Department, San Gabriel Valley
Medical Center, San Gabriel, CA.
Francis M. Fesmire, MD, FACEP,
Director, Chest Pain—Stroke
Center, Erlanger Medical Center;
Assistant Professor of Medicine,
UT College of Medicine,
Chattanooga, TN.
Valerio Gai, MD, Professor and Chair,
Department of Emergency
Medicine, University of Turin,
Italy.
Michael J. Gerardi, MD, FACEP,
Clinical Assistant Professor,
Medicine, University of Medicine
and Dentistry of New Jersey;
Director, Pediatric Emergency
Medicine, Children’s Medical
Center, Atlantic Health System;
Chair, Pediatric Emergency
Medicine Committee, ACEP.
Michael A. Gibbs, MD, FACEP,
Residency Program Director;
Medical Director, MedCenter Air,
Department of Emergency
Medicine, Carolinas Medical
Center; Associate Professor of
Emergency Medicine, University
of North Carolina at Chapel Hill,
Charlotte, NC.
Gregory L. Henry, MD, FACEP,
CEO, Medical Practice Risk
Assessment, Inc., Ann Arbor,
MI; Clinical Professor, Department
of Emergency Medicine,
University of Michigan Medical
School, Ann Arbor, MI; President,
American Physicians Assurance
Society, Ltd., Bridgetown,
Barbados, West Indies; Past
President, ACEP.
Jerome R. Hoffman, MA, MD, FACEP,
Professor of Medicine/
Upon completing this article, you should be able to:
1. explain important aspects of the history and
physical exam in males with genitourinary
complaints (excluding problems associated with
urinary tract infections and kidney stones);
2. list the indications, advantages, and limitations of
imaging studies in patients with scrotal
complaints and know which patients need
immediate operation;
3. discuss evidence-based methods to evaluate the
acute scrotum; and
4. describe treatment regimens for common
genitourinary complaints, as well as management
of more obscure conditions.
Date of original release: November 1, 2000.
Date of most recent review: October 31, 2000.
See “Physician CME Information” on back page.
Emergency Medicine, UCLA
School of Medicine; Attending
Physician, UCLA Emergency
Medicine Center;
Co-Director, The Doctoring
Program, UCLA School of
Medicine, Los Angeles, CA.
John A. Marx, MD, Chair and Chief,
Department of Emergency
Medicine, Carolinas Medical
Center, Charlotte, NC; Clinical
Professor, Department of
Emergency Medicine, University
of North Carolina at Chapel Hill,
Chapel Hill, NC.
Michael S. Radeos, MD, FACEP,
Attending Physician in
Emergency Medicine, Lincoln
Hospital, Bronx, NY; Research
Fellow in Emergency Medicine,
Massachusetts General Hospital,
Boston, MA; Research Fellow in
Respiratory Epidemiology,
Channing Lab, Boston, MA.
Steven G. Rothrock, MD, FACEP,
FAAP, Associate Professor
of Emergency Medicine,
University of Florida; Orlando
Regional Medical Center; Medical
Director of Orange County
Emergency Medical Service,
Orlando, FL.
Alfred Sacchetti, MD, FACEP,
Research Director, Our Lady of
Lourdes Medical Center, Camden,
NJ; Assistant Clinical Professor
of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA.
Corey M. Slovis, MD, FACP, FACEP,
Department of Emergency
Medicine, Vanderbilt University
Hospital, Nashville, TN.
Mark Smith, MD, Chairman,
Department of Emergency
Medicine, Washington Hospital
Center, Washington, DC.
Thomas E. Terndrup, MD, Professor
and Chair, Department of
Emergency Medicine, University
of Alabama at Birmingham,
Birmingham, AL.
Epidemiology
ines, antihypertensives, anticoagulants, and sildenafil
(Viagra).8 Other drug-related causes include inter-cavernosal
injections for impotence (papaverine, phentolamine, or
prostaglandin E) and drugs of abuse such as alcohol,
cocaine, and marijuana.9 Determine whether there is a
personal or family history of sickle cell disease or thalassemia. (See Table 1.)
Priapism occurs in two age peaks. The first is between ages
5 and 10 years and the second between ages 20 and 50 years.
Priapism in children most often results from sickle cell
disease—a low-flow state.6 Other causes of priapism in
children include leukemias, lymphomas, pelvic tumors, and
trauma. In adults, most cases are caused by sickle cell
disease, drugs, or are idiopathic.6,7
Physical Examination
History
When examining the penis, palpate the glans to ascertain
whether it is hard or soft. Patients with low-flow priapism
usually have a rigid, painful penile shaft with a soft glans.
This is because the corpora cavernosa are erect but the
corpora spongiosum remains flaccid.10 In patients with highflow priapism, the entire penis is partially rigid and
painless; the glans is hard.1 If there is a history of trauma,
listen to the penis for a bruit. (Let the patient know this is an
accepted medical procedure.)
The remainder of the physical exam should focus on a
search for precipitating conditions.
The history should include the length of time the symptoms
have been present, any associated pain, any specific
symptoms related to malignancy or hemoglobinopathy, a
history of trauma, and any recent medication use. Specific
medications associated with priapism include phenothiaz-
Table 1. Common Etiologies Of Priapism.
Prescription Drugs
Psychotropics
Antihypertensives
Anticoagulants
Intra-cavernosal injections
Sildenafil (Viagra)
Laboratory Evaluation
The utility of laboratory studies in the evaluation of
priapism remains unknown. Some authorities recommend a
complete blood count, a coagulation profile, and possibly
Illicit Drugs
screening for sickle cell if the patient’s hemoglobinopathy
Ethanol
status is unknown. A toxicologic screen may be helpful if
Cocaine
Marijuana
the emergency physician suspects drug ingestion, especially
in a child. In some centers, gas analysis of aspirated
Hematologic
intracorporal blood is used to help differentiate low-flow
Sickle cell disease (most common etiology in most EDs)
from high-flow priapism. A urologist typically aspirates the
Leukemia
Thalassemia
corpus for blood, but the emergency physician can accomplish the procedure if no urologists are available. Prior to
Miscellaneous
performing corporal aspiration, a dorsal penile nerve block
Spinal cord injury
is helpful. A dorsal nerve block is easily accomplished by
Sources: Mulhall JP, Honig SC. Priapism: etiology and management.
injecting 1% lidocaine without epinephrine into the dorsal
Acad Emerg Med 1996;3:810; Sur RL, Kane CJ. Sildenafil citrateaspect of the penile base (See Figure 1). Five to 10 cc of the
associated priapism. Urology Online 2000;55(6):950.
lidocaine is deposited in a
subcutaneous ring taking care to
Figure 1. Penile Anatomy.
avoid intravascular injection.
After this is completed, the
physician stands to the right of
the patient and grasps the penis
with the left hand. Palpate the
engorged corpora cavernosum
bilaterally and, after preparing
the skin with Betadine, insert a
21- to 19-gauge butterfly needle
into either side at the 10 o’clock
or 2 o’clock position. The needle
may be placed anywhere from
the base of the penis to the distal
shaft, avoiding the glans. Avoid
deep penetration to minimize
risk of injury to the cavernosal
artery. Aspirate 20-30 mL of
blood while milking the corpus
with the other hand. Continue
Reproduced with permission: Snell R, Smith M. Emergency Medicine. St. Louis: Mosby; 1993:480. Figure 12-17.
aspiration until the egress of dark
Emergency Medicine Practice
2
November 2000
Physical Examination
blood ceases and bright-red arterial blood is obtained.11
Low-flow priapism is suggested by aspirated blood with a
pH of < 7.25, pO2 < 30 mmHg, and pCO2 > 60 mmHg.2
When the foreskin is retracted, the glans and prepuce
appear purulent, excoriated, and malodorous. These
structures will be tender to palpation. The most common
physical findings include redness, swelling, and discharge.16
Balanitis is commonly associated with a partially or
completely nonretractable foreskin, but true phimosis
(inability to retract the foreskin behind the glans) is usually
not present (unless the infection is recurrent).
Certain findings may suggest the causative organism.
Candidal balanitis will often follow intercourse with an
infected partner and manifests as a glazed discharge with
satellite pustules.14 Balanitis due to trichomonas may be
either superficial or erosive, and trichomonads are usually
visible on wet prep. The presence of a thin, purulent
discharge within the preputial-glandular sulcus without a
true urethral discharge may indicate a streptococcal
infection. Other signs of streptococcal disease include pain
and significant surrounding erythema.
Radiologic Evaluation
History and physical examination alone should distinguish
between high-flow and low-flow priapism in the vast
majority of cases. Occasionally, Doppler ultrasound can also
help differentiate between these states. Identification of an
arterial-to-cavernosal shunt or of high systolic flow into the
cavernosal artery is suggestive of high-flow priapism.1
Treatment
The management of priapism varies somewhat, depending on
the cause. However, all patients with priapism can be initially
treated with terbutaline 0.25-0.5 mg subcutaneously in the
deltoid muscle or terbutaline 5 mg PO.9,11 For patients with lowflow priapism likely due to sickle cell disease, several supportive measures are indicated. Analgesia, hydration, oxygen (and
occasionally erythrocyte exchange transfusion) are successful in
as many as 80% of patients.12 If simple interventions fail,
corporal aspiration and injection of a vasoconstrictor are
occasionally successful in sickle cell patients.1
The management of low-flow idiopathic priapism includes
corporal blood aspiration, as previously described, followed by
corporal injection of 200 mcg of phenylephrine (dilute 1 mg of
phenylephrine in 9 mL sterile water to achieve a concentration
of 1000
100 mcg/mL). If the history and clinical evaluation suggest
high-flow priapism, emergent treatment is unnecessary because
the risk of permanent sequelae is low.1 Injection of phenylephrine is contraindicated in high-flow priapism because the drug
will rapidly leak into the systemic circulation, causing severe
hypertension.13 If clinical suspicion is high that priapism is due
to malignancy, treatment is usually supportive, but corporal
aspiration and injection may be attempted.1 All cases of
priapism should be treated in consultation with a urologist, as
failure of conservative measures will require more invasive
procedures. It may be legally prudent to tell the patient (and
document this discussion in the chart) that permanent impotence is a possible consequence of priapism.
Diagnosis And Treatment
Balanitis or balanoposthitis that appears to have a nonspecific etiology is treated with mild soap, adequate drying,
and 0.5% hydrocortisone cream. Prescribe an antifungal
cream if candidal infection is suspected. As streptococcal
infections may be indistinguishable from nonspecific
balanitis, consider a rapid antigen detection test, culture, or
empiric therapy. If culturing is deemed necessary, use the
secretions or moist surface of the prepuce or glans. An oral
penicillin or first-generation cephalosporin is indicated for a
streptococcal or other bacterial superinfection. Anaerobic
bacteria may produce irritant enzymes that lead to recurrent
irritation balanoposthitis. In this case, a short course of a
macrolide or penicillin should kill the offending microbe.15
Penile Entrapment Injuries
Penile Zipper Entrapment
There are two types of zipper entrapment.17 The first is
when the zipper has moved past the site of entrapment,
catching the skin between the teeth. This is the least
common type and is most easily treated by cutting the
zipper below the point of entrapment. The second type—the
most common—is when the skin is caught in the moveable
zipper. This is where precise manipulation is most appreciated by the patient.
Tugging at the zipper will only result in tighter
entrapment, so choose another approach. One method
involves holding the zip teeth at the point of entrapment
and applying steady lateral, then inferior traction, in a
peeling motion. This will disarticulate the penile skin
as the zipper moves inferiorly. This maneuver is facilitated
with application of lubricant or mineral oil. While the
procedure is usually painless,15 a local anesthetic is a
reasonable precaution.
If traction fails, the zipper mechanism must be cut
apart. The most common way to accomplish this is by
cutting the median bar between the faceplates of the zipper
with bone cutters.18 An additional method was recently
Balanitis And Balanoposthitis
Balanitis is an inflammation of the glans, while posthitis is
an inflammation of the foreskin. Balanoposthitis refers to the
presence of both conditions.14
Etiology And Pathogenesis
The etiology of balanitis includes irritation by smegma,
urine, friction, trauma, or soaps/detergents. Poor foreskin
hygiene and exposure to sexually transmitted organisms are
also implicated. Responsible pathogens include various
bacteria, yeasts, and fuso-spiral organisms. These commensals become aggressive when there is lowered focal or
general host resistance. Chlamydia and mycoplasma can
also cause balanoposthitis.14 Recurrent balanitis can be the
sole presenting sign of diabetes.11 In children, most cases
are nonspecific, usually caused by inadequate hygiene of
the genitalia.15
November 2000
3
Emergency Medicine Practice
the edematous foreskin distally over the glans. Paraphimosis is a true urologic emergency, because edema and venous
engorgement can progress to arterial compromise and
gangrene of the glans.
The least invasive procedure for paraphimosis reduction does not involve surgical steel. First, snugly wrap the
distal penis with an elastic bandage for about 10 minutes to
reduce edema. Remove the bandage, and then apply a
topical anesthetic lubricant to the inner surface of the
foreskin. Grasp the penis with the right hand while using
the thumb of the other hand to push the glans through
the foreskin, using slow, steady pressure.9 Alternatively,
place both thumbs on the meatus and stuff the glans under
the foreskin.
If arterial compromise is suspected and manual
reduction isn’t successful, perform a dorsal slit procedure.11
The procedure begins by injecting plain 1% lidocaine into
the dorsal midline of the foreskin just beneath the superficial fascia. (See Figure 2 on page 5.) If adequate anesthesia is
not obtained, infiltrate subcutaneous lidocaine (without
epinephrine) circumferentially at the base of the penis
(“ring” block). This will provide profound distal anesthesia.9
Then use a hemostat to separate any adhesions between the
foreskin and the glans. While visualizing the urethral
meatus, use the hemostat to crush the anesthetized foreskin.
(See Figure 3 on page 5.) Leave the hemostat in place for
about five minutes. Remove the hemostat and cut the
crushed foreskin with a pair of straight scissors. When the
edges of the foreskin separate, each edge can be sutured
with absorbable running sutures to maintain hemostasis. Be
sure to replace the foreskin to its normal position after the
procedure to avoid iatrogenic paraphimosis.9 Once reduction is complete, ensure that the patient can urinate. If not,
place a Foley catheter and have the patient follow up with
a urologist.
described in a child whose foreskin had been caught in a
zipper for four days. The swelling was such that the median
bar was embedded deeper than the bone cutter could reach.
A hemostat was used to stabilize the zipper unit at the
handle base while a mini-hacksaw was used to saw through
the median bar between the inside and outside faceplates
and release the zipper.19 (Despite the ingenuity of this
method, consider blindfolding the patient before approaching his penis with a hacksaw.)
After removal of the zipper, ensure that the urethra has
not been injured and the patient can urinate without
difficulty. If so, local wound care is usually all that is
required. Follow-up with a urologist is recommended.
On occasion, patients presenting with a penile lesion
may state, “I think I might have caught my penis in my
zipper.” Rest assured that this history is unreliable and the
lesion represents a genital ulcer associated with an STD.
Catching one’s penis in a zipper is always a certainty—
never a hypothesis.
Other Entrapment Injuries
Other penile entrapment injuries besides zipper entrapment
occur when various objects are wrapped around the
penis, such as hairs in children. Hair removal creams
may be useful if the hair tourniquet is deeply embedded
in the penis due to surrounding edema. Urethral integrity
and distal arterial integrity should be evaluated when
indicated. As in the case of hematuria or persistent
cyanosis of the glans, evaluate the urethra with a retrograde
urethrogram. Either color-flow Doppler or arteriogram can
assess arterial flow.11
If a patient presents with a markedly ecchymotic penis
and no explanatory history, he may be too embarrassed to
admit to a vacuum-cleaner injury. These injuries are
relatively benign, unless the fan blades in the machine slice
the penis.
The Acute Scrotum:
Ruling Out Testicular Torsion
Urethral Stricture
If the patient’s bladder cannot be cannulated with a 14F or
16F Foley or Coudé catheter, consider urethral stricture,
external sphincter spasm, bladder neck contracture, or
benign prostatic hypertrophy. Voluntary external sphincter
spasm can be overcome by holding the patient’s penis
upright and encouraging him to relax his anus and breathe
slowly during catheter placement.11 Sometimes a larger,
rather than smaller, catheter will provide the added rigidity
needed for passage. Liberal use of xylocaine jelly instilled in
the urethra 15 minutes before attempting the procedure is
helpful. Care should be taken not to apply too much force
while placing the catheter, as this could create a false
passage. If multiple attempts at catheter placement are
unsuccessful, obtain a urology consultation.
“Time is testicle.”
Overview
When a male of any age presents with acute scrotal pain, the
first condition the clinician should rule out is testicular
torsion. Just as time is myocardium, time is also testicle.
Delays associated with diagnostic testing can lead to the
very condition you hope to prevent—loss of the testicle.
Anatomy
The testis normally descends through the inguinal ring and
into the scrotum between the 28th week of gestation and
birth. The testis drops within an outpouching of the
peritoneum, the processus vaginalis, and is suspended by
the spermatic cord, which supplies its blood. The processus
vaginalis covers the testis and epididymis and fixes them to
the posterior scrotal wall. The communication of the
processus vaginalis with the peritoneum usually obliterates
by the second year of life.20,21 Normally, there is a strong
attachment between the testis and epididymis, which is in
Phimosis And Paraphimosis
Phimosis is the inability to retract the foreskin proximally.
Phimosis typically isn’t an emergency unless urinary
retention is present. Paraphimosis is the inability to reduce
Emergency Medicine Practice
4
November 2000
pre-pubertal age group. Testicular torsion was the most
common diagnosis in the pubertal child and adult.28,29 (See
Table 2 on page 6.)
turn connected to the posterior scrotal wall. This prevents
the free rotation of the testis.22
In the so-called “bell-clapper” deformity, the epididymis and the testis become completely surrounded by the
processus vaginalis instead of being anchored to the scrotal
wall. This allows the testis and epididymis to hang freely
within the scrotum, allowing the spermatic cord to twist.23
Autopsy studies show that 10% of the population has an
abnormal testicular attachment, although the rate of
testicular torsion is much lower.24 The triggering event for
torsion is unclear. It is often thought to be due to a forceful
contraction of the cremasteric muscle secondary to trauma,
physical exertion, an erection, or exposure to an abrupt drop
in temperature.22 (See Figure 4 on page 6.)
History
No single element of the history can reliably distinguish testicular
torsion.30 Important historical points to obtain include
rapidity of onset and duration of pain, history of previous
similar episodes, presence of nausea and vomiting, anorexia, fever, association with erections, urethral discharge,
recent urethral instrumentation, voiding symptoms, and
recent trauma.30-33 The history should also focus on past
genitourinary problems and sexual activity. A prior history
of testicular torsion and subsequent orchiopexy doesn’t rule
out recurrent torsion, especially if absorbable sutures were
used.34,35 Both children and adults may complain only of
abdominal pain or minimize their symptoms out of fear
or embarrassment.
A recent study examined the incidence of various
symptoms in 543 patients with an acute scrotum, all of
whom had operative confirmation of their diagnosis.
Sudden onset of pain was seen in 90% of patients with
testicular torsion, in 69% of patients with appendix torsion,
in 58% of patients with epididymitis, and in 78% of patients
with normal scrotums. Fever was present in 10% of cases of
testicular torsion, in 4% of cases of appendix torsion, in 32%
of patients with epididymitis, and in 10% of normal
patients.36 Nausea, vomiting, and anorexia are fairly specific
for testicular torsion; up to 80% of patients with torsion
Appendix Testis
The testicular appendages are equivalent to the intestinal
appendix (and some say hospital administrators) in that
they serve no useful purpose and cause pain at random. The
appendix testis is a Mullerian duct remnant that is attached
to the superior pole of the testicle and rests in the groove
between the testis and epididymis. The appendix epididymis is a Wolffian duct remnant that is attached to the head
of the epididymis.25 (See Figure 5 on page 6.)
Epidemiology
The annual incidence of testicular torsion in males under
age 25 is estimated to be 1 in 4000. Torsion occurs in every
decade of life, from birth to 78 years.26,27 The reported peak
incidence is bimodal; the first peak is in the neonate within
the first few days of life, and the second peak is in puberty
between 12 and 18 years of age.22 Several recent studies
show that the incidence of torsion varies by age.28,29 In two
studies in which a total of 480 patients with an acute
scrotum were surgically evaluated, torsion of a testicular
appendage predominated as the cause of scrotal pain in the
Figure 3. Treatment Of Phimosis: Crushing the foreskin
in preparation for a dorsal slit procedure. Note: The
“inside” blade of the hemostat is between the foreskin
and the glans, not in the urethra.
Figure 2. Anesthesia For Dorsal Slit Procedure.
Foreskin “tented up”
at coronal sulcus
Reproduced with permission of The McGraw-Hill Companies from:
Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: A Comprehensive
Study Guide, 5th ed. New York: McGraw-Hill; 2000:881. Figure 73-16.
November 2000
Reproduced with permission of The McGraw-Hill Companies from:
Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: A Comprehensive
Study Guide, 5th ed. New York: McGraw-Hill; 2000:882. Figure 73-18.
5
Emergency Medicine Practice
Start with a visual inspection of the scrotum and penis. Note
any scrotal swelling or erythema. Inspect the penis for
urethral discharge or rash. The length of the penis may need
to be milked to express a discharge. Examine the femoral
area for lymphadenopathy.22 The physical exam should
include examination of the abdomen and, some believe,
the rectum.
Assess the cremasteric reflex on each side. The reflex is
elicited by gently stroking the inner thigh (a tongue blade is
useful) and observing for more than 0.5 cm elevation of the
ipsilateral testis.42 Of all physical exam findings, the
presence of the cremasteric reflex appears to be one of the
most helpful in ruling out torsion. A recent study of 543
patients with an acute scrotum found that the presence of
the reflex had a 96% negative predictive value for testicular
torsion. The false positives occurred in three infants in
report these symptoms. In fact, torsion is occasionally
misdiagnosed as gastroenteritis. On the other hand,
gastrointestinal complaints are uncommon in epididymitis
and appendix torsion.30,31,33
Be wary of a history of trauma or physical exertion
prior to the onset of symptoms, as this red herring is
present in 10%-20% of those with torsion.30,31,33,37-40 A prior
history of similar pain does not rule out torsion. Some
patients will spontaneously torse and detorse several times
in the weeks or months prior to an ED visit. Nearly half of
all adults with surgically proven torsion have had similar
episodes in the past.41
Physical Examination
The exam should proceed in a manner that respects the
patient’s privacy. This is especially important in children.
Figure 4. Bell-Clapper Deformity.
Figure 5. Torsion Of The Testis vs. Torsion Of The
Appendix Testis.
Reproduced with permission of The McGraw-Hill Companies from:
Knoop KJ, Stack LB, Storm AB, eds. Atlas of Emergency Medicine. New
York: McGraw-Hill; 1997:211. Figure 8.2.
Reproduced with permission of The McGraw-Hill Companies from:
Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: A Comprehensive Study Guide, 4th ed. New York: McGraw-Hill; 1996:536. Figure 92-7.
Table 2. Age Distribution Of Common Causes Of Acute Scrotum Found At Exploration.
Source: Watkin NA, Reiger NA, Moisey CU. Is the conservative management of the acute scrotum justified on clinical grounds?
Br J Urol 1996;78:623-627. (Retrospective; 209 patients)
Age 0-11 years
Age 12-16 years
Age 17-40 years
Testicular Torsion
6.6%
52%
48%
Appendix Torsion
62%
32%
5%
Epididymitis
6%
3%
27%
Source: Ben-Chaim J, Leibovitch I, Ramon J, et al. Etiology of acute scrotum at surgical exploration in children, adolescents and adults.
Eur Urol 1992;21:45-47. (Prospective; 171 patients)
Age 0-12 years
Age 13-21 years
Age 22-52 years
Testicular Torsion
34%
86%
88%
Emergency Medicine Practice
Appendix Torsion
47%
9%
6%
6
Normal
11%
5%
6%
Epididymitis
4%
0%
0%
November 2000
urine.30,33 If infection is suspected, obtain a urine culture. As
with most serious emergencies, a white blood cell count
is not helpful and is likely to confuse. Leukocytosis (WBC
> 10,000/HPF) is seen in torsion as well as epididymitis.29,36
whom the reflex was present, but who were found to have
torsion at time of operation, although the testis was not
ischemic.36 However, note that the presence of a cremasteric reflex
does not always exclude torsion.
Palpate the testicle and scrotal contents for localized
tenderness and masses. Have the patient stand to note how
the testicle lies in the scrotum. The normal testis rests in the
vertical axis with the superior pole tipped slightly forward.
The epididymis is located above the superior pole in the
posterolateral position. (See Table 3.)
Prehn reported that elevating the scrotum aggravated
torsion of the spermatic cord but relieved the pain of
epididymitis. However, “Prehn’s sign” (as this is known) has
been found to be extremely unreliable and should not be used—
even patients with torsion can feel some relief of pain with
this maneuver.27
Most patients with advanced torsion have a diffusely
tender and swollen testicle. In contrast, in epididymitis, the
tenderness is usually localized to the epididymis at the
lower pole of the testis. The operative words here are
“most” and “usually.” Up to 10% of patients with testicular
torsion have tenderness localized to the epididymis.30 This
probably represents inflammation of the twisted spermatic
cord. After several hours, torsion usually results in significant scrotal edema and makes palpation of the scrotal
contents and determination of how the testicles lie difficult
or impossible.
Torsion of a testicular appendage will often result in a
palpable tender nodule in the testicle near the epididymis.
The “blue-dot” sign, which represents an ischemic, torsed
testicular appendage, is sometimes visualized through the
scrotal skin.43 This finding is difficult to see even through the
translucent scrotum of the prepubescent boy, and it is nearly
impossible to visualize when the scrotum becomes dark and
thickened at puberty.
Radiologic Imaging:
“Castration Through Procrastination?”
Any patient who presents with a classic case of testicular
torsion should never see the inside of a radiologic suite.
Call the urologist and tell him he has a patient who needs
an operation.
Radiologic confirmation can be dangerous in a patient
with torsion. If a testis can survive for a maximum of 6-10
hours after becoming ischemic, why squander time on a test
that may ensure testicular death secondary to surgical
delay? How long does it take between the time you order a
testicular imaging study until the radiologist will call you
with the result? Could this interval damn the testis?
This danger associated with diagnostic imaging
has been termed “castration through procrastination.”44
Because of the false-negative rate associated with
imaging studies and the frequency of torsion in adolescents,
some children’s centers suggest immediate surgical
exploration for presumed testicular torsion. In one study,
radioisotope scanning and Doppler ultrasound were only
86% and 80% sensitive, respectively.32 Torsion is especially
likely if the child is 11 years or older, the duration of
symptoms is less than 12 hours, and the child has nausea
and vomiting.31
This said, some patients with a painful testis present
with equivocal history and physical findings. Such patients
may require an imaging study. The available tests include
nuclear scintigraphy and Doppler ultrasonography. The
available literature on this topic is crippled by a very
important bias in study design. No large, well-designed
study has prospectively performed diagnostic imaging
followed by surgical confirmation regardless of the
imaging result.
Nuclear scintigraphy assesses testicular blood flow by
detecting the accumulation of the intravenously administered technetium in the testis. In torsion, little or no isotope
collects in the testis. The sensitivity varies from 80%-100%,
with an overall accuracy of 95%. Nuclear scintigraphy is
rarely available on an immediate basis. The test is timeconsuming, as the radioisotope must be prepared, and the
study itself requires at least 20-30 minutes to perform.45-48
Because it provides no anatomic information, scintigraphy
cannot differentiate between epididymitis and appendiceal
torsion. It is also unable to detect cases in which intermittent
torsion or spontaneous detorsion has occurred.22 As a final
consideration, some men require convincing that radioactive testicles won’t prune the family tree.
Doppler ultrasound has replaced nuclear imaging in
many institutions. Color-flow Doppler can detect decreased
intratesticular blood flow. It is very sensitive for detecting
increased blood flow associated with scrotal inflammation
secondary to epididymitis or appendix torsion. However,
the sensitivity for torsion ranges from 83%-100%.47,49-51 It
appears to be accurate even in those patients who have
Laboratory Evaluation
Testicular torsion is a clinical, and occasionally radiographic,
diagnosis. Do not rely on laboratory tests to either confirm
or exclude the diagnosis. If urethral discharge is present, test
the patient for chlamydia and gonorrhea. Urinalysis is a
reasonable test as long as no decisions are made based on
the results. Patients with torsion may have pyuria, and half
of all patients with epididymitis have no leukocytes in their
Table 3. Physical Findings Strongly Suggestive
Of Testicular Torsion.
• Abnormal elevation of the affected testicle with shortening of the spermatic cord
• Abnormal axis of the affected testicle when the patient is
upright (i.e., horizontal lie)
• Abnormal position of the epididymis (i.e., anterior rather
than posterior)
• Abnormal axis of the contralateral testis
• Absence of cremasteric reflex (note that presence of
cremasteric reflex does not rule out torsion)
Adapted from: Knight PJ, Vassy LE. The diagnosis and treatment of
acute scrotum in children and adolescents. Ann Surg 1984;200:64.
November 2000
7
Emergency Medicine Practice
equivocal clinical findings.52 Color-flow Doppler is less
specific in small children and especially neonates as it
cannot detect blood flow in a testis smaller than 1 mL
volume. In neonates, up to 40% of normal testes will show
no blood flow.53-55
A recent study compared Doppler ultrasound with
scintigraphy in patients with an acute scrotum who
presented with equivocal findings. In boys, the two
modalities were equally sensitive for torsion but scintigraphy was more specific.52 However, ultrasound has the
advantages of being more readily available in most institutions, does not involve ionizing radiation, and, in addition,
Doppler can provide anatomic information.
The biggest pitfall of either study is the possible delay in
scrotal exploration associated with the diagnostic test. In
addition, the occasional false-negative study can ensure
testicular loss. Doppler ultrasound may demonstrate little or
no blood flow in an asymptomatic testis in young children
because of the normal “low-flow” state. Furthermore,
ultrasound has a higher rate of indeterminate studies when
compared to scintigraphy. Both modalities are limited in
their ability to detect spontaneous detorsion and intermittent torsion.56
To begin the detorsion attempt, explain to the
patient that while local anesthesia of the spermatic cord
can reduce the pain of detorsion, it also removes the allimportant endpoint of pain relief. Procedural sedation
using a narcotic (possibly combined with a benzodiazepine)
may be appropriate.
Detorsion is done in a manner similar to opening
a book. This means twisting the testicles outward, toward
the patient’s thighs. Stand facing the patient and rotate
the patient’s right testis in a counterclockwise fashion
(from a perspective of looking upward from below the
scrotum) or their left testis in a clockwise manner. Relief
of pain accompanies successful detorsion. The spermatic
cord should lengthen and the testis will develop a more
normal lie. Worsening of the pain (and shortening of the
cord) indicates that detorsion should be done in the
opposite direction. Successful manual detorsion does not
preclude an urgent scrotal exploration, as retorsion may
occur at any time.11
Most studies report a high viability of the testis—70%100%—if detorsion is achieved within 10 hours. Beyond 10
hours, the salvage rate drops to 20%.59,60 However, there have
been reports of testicular salvage after several days of
torsion, although the twisting was not as severe61-63 or may
have been intermittent.
Treatment And Prognosis Of Testicular Torsion
The Acute Scrotum: Differential Diagnosis
Pitfalls
Once torsion is strongly suspected, either clinically or
radiographically, call the urologist—quickly. While awaiting
his or her arrival, consider manual detorsion. There is no
large study that demonstrates which is the best way to
untwist the spermatic cord. Manual detorsion is successful
in approximately 25% of patients, and counterclockwise
twisting seems to be more common.23
Once the physician has ruled out testicular torsion as the
cause of acute scrotal pain, a variety of conditions may be
considered. (See Table 4.)
Epididymitis
Epididymitis is fully discussed in a subsequent section.
Table 4. Differential Diagnosis Of The Acute Scrotum.
Testicular Torsion
Epididymitis
Appendix Torsion
Age
>12 years
>18 years
0-11 years
Onset
Acute
Gradual more often than acute Acute or gradual
Previous similar pain
Common
Uncommon
Occasional
Nausea/vomiting
Common
Uncommon
Uncommon
Discharge or urinary symptoms
Rare
Common
Rare
Fever
Uncommon
Common
Rare
Testicular position
Abnormal axis
Normal
Abnormal elevation
Contralateral testis abnormal
Palpable nodule
Blue-dot sign in some patients
Tenderness
Diffuse
Local, then diffuse
Local, then diffuse
Cremasteric reflex
Usually absent
Usually present
Usually present
Pyuria
Uncommon
Common
Uncommon
Leukocytosis
Common
Common
Uncommon
Perfusion studies
Decreased flow
Normal or increased flow
Normal or increased flow
Adapted from: Haynes BE, Beesen HA, Haynes VE. The diagnosis and management of acute scrotal conditions in boys. JAMA 1983;249:2522; Burgher
SW. Acute scrotal pain. Emerg Med Clin North Am 1998;16(4):781-809.
Emergency Medicine Practice
8
November 2000
Appendix Torsion
on physical examination.
The appendix testis is the appendage most frequently
involved in torsion.27 Pain can begin either suddenly or
gradually and ranges from mild to severe. Nausea and
vomiting are seldom present. On exam, the “blue-dot” sign
is pathognomonic, but it is seen in only 26% of cases.26
Scrotal enlargement is often present due to edema and
inflammation. The diagnosis should be confirmed with an
imaging study, which should demonstrate normal or
increased testicular blood flow. The treatment is supportive;
the patient will require pain medications and scrotal
support.27 Most torsed appendages will calcify or degenerate in 10-14 days;11 however, some urologists believe that
surgery is indicated to resolve the pain.
Fournier’s Gangrene
A full discussion of this condition follows in a
subsequent section.
Orchitis
Isolated orchitis, or testicular inflammation, is vanishingly rare. It usually occurs in conjunction with other
systemic illnesses, such as mumps, various viral illnesses,
or syphilis. It is most often seen as an extension of
epididymitis (epididymo-orchitis). Orchitis usually
presents as bilateral testicular tenderness and swelling
of a few days’ duration. Treatment is symptomatic
and disease-specific.11
Hernia
Epididymitis
The presentation of a scrotal hernia will depend upon
whether the hernia is reducible, incarcerated, or strangulated. In a strangulated hernia, the patient will give a history
consistent with intestinal obstruction. The scrotal contents
may be tender, and in the case of advanced pathology,
peritoneal signs may be present. In scrotal hernias, there will
be inguinal as well as scrotal swelling. A normal testis can
usually be palpated below the hernia.
Epididymitis is an inflammation of the epididymis that is
usually due to infection (most often bacterial). It can also
result from sterile urine, which refluxes via the ejaculatory
ducts down the vas into the globus minor of the epididymis.64 It is predominately a disease of adult men and is rare
in boys and young adolescents. In prepubertal boys,
epididymitis is almost always associated with a urinary
tract anomaly.65
Idiopathic Scrotal Edema
This entity is usually seen in prepubertal males. It presents
as erythema and sudden onset of unilateral or bilateral
scrotal edema with little or no pain. The patient is afebrile
and non-toxic, and the testis and epididymis are non-tender
and of normal size. No blood or urine tests are necessary.
The condition usually resolves in 2-5 days without therapy,27
although some physicians prescribe H1 and/or H2 blockers
in hopes of accelerating resolution.
Pathophysiology
The etiologic agent responsible for epididymitis is related to
age and sexual activity/practices.66,67 In boys, homosexual
young men, and men over the age of 35 years, the most
common organisms are coliforms, Pseudomonas, and Grampositive cocci.27 The most common organisms in heterosexual young men include Chlamydia trachomatis and
Neisseria gonorrhoeae.27
The usual route of infection involves direct extension
to the epididymis via the vas deferens.68 Normally, a oneway valve protects the epididymis from urine reflux.
Many lower urinary tract anomalies predispose to
bacterial invasion of the vas deferens by urinary pathogens.
Conditions that lead to epididymitis include prostatic
hypertrophy, prostatectomy, urethral stricture, recent
urinary tract surgery, or instrumentation. Urinary tract
pathology or procedures do not seem to cause epididymitis
associated with sexually transmitted diseases.27 Congenital
bladder and urethral defects are important considerations
in children.65,66,69
Testicular Tumor
Acute pain involving a mass is thought to be due to
hemorrhage within the tumor. The testis is enlarged,
irregular, and tender. A reactive hydrocele is sometimes
present.27 Color-flow Doppler is the best means to diagnose
this condition.
Henoch-Schonlein Purpura
Henoch-Schonlein purpura (HSP) is an idiopathic
systemic vasculitis characterized by nonthrombocytopenic
purpura with skin, joint, and renal involvement. The
petechial rash is especially prominent over the buttocks
and lower extremities. This is a pediatric disease that
usually presents in patients 4-5 years of age. Genitourinary
findings include acutely painful scrotal swelling. The
scrotum is involved in 2%-38% of cases of HSP but is very
rarely the initial presentation.57,58
History
Pain usually develops over many hours to days but may be
sudden in onset. While the pain associated with epididymitis is usually unilateral, it may present on both sides. Fever
occurs in a substantial minority of patients.22 Irritative
voiding symptoms are frequent, but nausea, vomiting, and
anorexia are rare.
Peritonitis Or Intra-abdominal Hemorrhage
This is a very rare cause of scrotal pain, but it can be seen in
a patient with a patent processus vaginalis. It can occur with
appendicitis. Consider ruptured abdominal aortic aneurysm
in the differential diagnosis in the older patient. The
scrotum and scrotal contents appear normal and non-tender
November 2000
Physical Exam
Early in the course of the illness, tenderness is localized to
Continued on page 12
9
Emergency Medicine Practice
Clinical Pathway: Diagnosis And Treatment Of Priapism
→
History and
physical exam
Probable high-flow priapism? (Hard glans,
history of perineal trauma, penile bruit)
Yes
→
→
No
Urology consultation
(urologist may request
corporal blood aspiration
and/or penile Doppler)
(Class IIa)
Probable low-flow priapism
→
Idiopathic
or drug-related
→
→
Neoplastic
process


 →
• Corporal blood
aspiration after
urology consultation
(Class IIb)
→
→
Failure

Terbutaline 0.25 mg SC;
may repeat once (Class IIb)

→
→
• Urology consultation
(Class IIa)
• Consider terbutaline (see
terbutaline pathway)
→

Sickle cell disease
or thalassemia
Success
• Analgesia (Class IIa)
• Terbutaline (see
terbutaline pathway)
(Class IIb)
• Oxygen for sickle cell
(Class indeterminate)
• Hydration (Class IIb)
• Urology consultation
(Class IIa)
• Admission if persistent
priapism (Class IIa)
• Telephone urology
consultation (Class IIb)
• Probable discharge
(Class IIb)
→
• Finalize disposition with
urologist (Class IIa)
Failure
• Finalize disposition
with urologist (admit)
(Class IIa)
→
→
No
Intracorporal injection of phenylephrine 200 mcg; may
repeat twice (Class IIb)
→
Are the results as follows?
• pH < 7.25
Yes
• pO2 < 30 mmHg →
• pCO2 > 60 mmHg
Success
• Telephone urology
consultation (Class IIa)
• Probable discharge
(Class IIb)
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class IIa: Acceptable and useful. Very good evidence provides support. Class IIb: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright  2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriber limited
copying privileges for educational distribution within your facility or program. Commercial distribution to promote
any product or service is strictly prohibited.
Emergency Medicine Practice
10
November 2000
Clinical Pathway: Management Of The Acute Scrotum
Are there any of the following?
• Abnormal lie (Class IIa)
• Absent cremasteric reflex (Class IIa)
• Nausea or vomiting (Class IIb)
• Tender testicle (Class IIb)
Yes
→
→
No
Are there at least three of the following?
• Gradual onset of symptoms
• Dysuria, discharge, or instrumentation
• History of genitourinary problems
• Fever
• Isolated tenderness of epididymis
• Pyuria
(See Table 5 on page 12)
Yes
→
1.Call the urologist and advise him or her that there is a
patient who may need to go to the OR (see individual
findings for Class of evidence)
2.Manual detorsion (Class indeterminate if the duration of
symptoms is short and there will be no delay to surgery;
Class IIa if symptoms have lasted for more than six hours
or there will be a delay in scrotal exploration)
1.If urethral discharge, test for gonorrhea and chlamydia
(Class IIb)
2.If prepubertal, consult urology (Class IIa)
3.If postpubertal, treat for epididymitis (a new-generation
quinolone, such as ofloxacin or levofloxacin, for 10-14
days will cover nearly every clinical scenario regarding
age and sexual practices) (Class IIa)
→
No
Imaging study (If duration of symptoms plus anticipated time to test results is greater than 8-10 hours and torsion is a likely
possibility, consult urology before obtaining study) (Class IIa)
Equivocal study
• Urology consultation (Class IIa)
→
→
→
Normal study
• Treat for epididymitis or evaluate
for other condition (Class IIa)
• Urology follow-up (Class IIb)
Decreased flow
• Emergent urology consultation
(Class I)
• Consider manual detorsion
(Class indeterminate if the
duration of symptoms is short
and there will be no delay to
surgery; Class IIa if symptoms
have lasted for more than six
hours or there will be a delay in
scrotal exploration)
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class IIa: Acceptable and useful. Very good evidence provides support. Class IIb: Acceptable and useful.
Fair-to-good evidence provides support. Class III: Not acceptable, not useful, may be harmful. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute, professional judgment and may be changed depending upon a
patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright  2000 Pinnacle Publishing, Inc. Pinnacle Publishing (1-800-788-1900) grants each subscriber limited
copying privileges for educational distribution within your facility or program. Commercial distribution to promote
any product or service is strictly prohibited.
November 2000
11
Emergency Medicine Practice
Continued from page 9
group is characterized by pyuria, bacteriuria, and a positive
culture. These patients should follow up with a urologist.
Among the vast majority of males with epididymitis,
infection is due to one of two main types of organisms—the
coliforms and sexually transmitted diseases. Always suspect
chlamydia in sexually active males, as up to one-third of
patients will not have a urethral discharge.70
the epididymis. As the infection progresses, a reactive
hydrocele may develop and the infection may spread to the
testis, resulting in an epididymo-orchitis and generalized
testicular tenderness.27 The cremasteric reflex is typically
present. Most importantly, the testicular lie should be
normal. While urethral discharge is common, it is not
necessary to make the diagnosis.
No single clinical finding will diagnose epididymitis
to the exclusion of torsion, as many signs and
symptoms overlap.
Homosexual Or Sexually Inactive Males
Both homosexuals and sexually inactive males should be
presumed to have coliform epididymitis (assuming no
urethral discharge is present). In the adult, or teenagers
older 17 years, current recommendations include a
fluoroquinolone such as ciprofloxacin 500 mg PO BID or
ofloxacin 200 mg PO BID for 10-14 days.71 Children or teens
younger than 17 years with presumed bacterial disease
(secondary to infected urine) may benefit from
sulfamethoxazole/trimethoprim or amoxicillin clavulanate,
as quinolones are contraindicated in this age group.
Laboratory Evaluation
If patients have a urethral discharge, test for chlamydia and
gonorrhea. If the patient does not report or have a discharge,
milk the length of the urethra to express the thin discharge
of a chlamydia infection. For patients without a discharge,
collect a midstream urine sample and evaluate it for pyuria
(≥10 WBC/HPF) and bacteriuria (≥1 Gram-negative rods
[GNR]/HPF). These findings, in the appropriate clinical
setting, provide evidence for coliform epididymitis.27
Because children have less of an inflammatory response,
pyuria in this age group is defined as 3 WBC/HPF
or greater.22
Knight and Vassy reviewed the charts of 395 boys 30
days to 17 years old to identify findings suggestive of acute
epididymitis. (See Table 5.) In their study, the presence of
any three out of six findings was specific for epididymitis.
However, a few cases of testicular torsion presented with
two findings. While it may help exclude torsion, requiring
three findings to make the diagnosis of epididymitis
significantly reduces sensitivity. Only about one-third of the
patients with this final diagnosis presented with at least
three criteria.27,30
Heterosexual Males Younger Than 35
Sexually active males who have epididymitis and present
with a urethral discharge should be treated for a sexually
transmitted disease regardless of age. There are several
accepted strategies, all of which address the likelihood of
concomitant chlamydial and gonorrheal infections. Recommended regimens include single-dose ceftriaxone 250 mg
IM plus doxycycline 100 mg PO BID for 10 days, or
ofloxacin 300 mg PO BID alone for 10 days.71 Single-dose
therapy with azithromycin and ofloxacin, while appropriate for
simple urethritis, is inadequate in the treatment of epididymitis.
Heterosexual Males 35 Or Older, Or Bisexual Males
If a sexually active male engages in anal intercourse or is
older than 35 years, he may have coliforms, chlamydia,
gonorrhea, or some combination. In such cases, a 10-day
course of a quinolone such as ofloxacin or levofloxacin will
cover “all players.” Ciprofloxacin should not be used in such
patients, as it has no activity against chlamydia.71
Treatment
Since epididymitis is almost always infectious, antibiotics are
generally indicated. One exception includes prepubertal
boys, who for the most part have “sterile” epididymitis and
do not require antibiotics.67,69 A minority of prepubertal boys
will have bacterial epididymitis, usually associated with a
urinary tract abnormality. Bacterial epididymitis in this age
Supportive Measures
Additional supportive measures are important and include
oral analgesics, bedrest with scrotal elevation to aid in
lymphatic drainage of the epididymis, and scrotal support
when ambulatory. A combination of both nonsteroidals and
narcotic analgesics may be necessary in those with significant pain. Scrotal elevation is best achieved with the use of a
“scrotal bridge.” Instruct the patient to take a folded towel
and place it across his upper thighs when he is lying flat. He
can then place his aching testes on this bridge to find some
relief. Indications for admission include toxic appearance,
presence of immunosuppression, or, on occasion, severe
bilateral epididymitis.
Table 5. Knight-Vassy Criteria For The Diagnosis Of
Acute Epididymitis In Children And Adolescents.
Three of the following should be present:
1. Gradual onset of pain
2. Dysuria, urethral discharge, recent diagnostic
cystoscopy, or indwelling Foley catheter
3. History of urinary tract infection, imperforate
anus, an abnormality of bladder emptying, or a
hypospadias repair
4. An admission temperature exceeding 101˚F (may
indicate epididymo-orchitis or intratesticular abscess)
5. Tenderness and induration localized to the epididymis
6. ≥10 WBC/HPF or ≥10 RBC/HPF in the urinary sediment
Fournier’s Gangrene
Overview
In 1883, Jean Alfred Fournier first described the condition
that would later bear his name. Fournier’s gangrene (FG) is
Source: Knight PJ, Vassy LE. The diagnosis and treatment of the acute
scrotum in children and adolescents. Ann Surg 1984;200:664.
Emergency Medicine Practice
12
November 2000
Diagnosis
a rapidly progressing necrotizing fasciitis of the perineal,
genital, or perianal regions.72 It was originally defined as
idiopathic, but it is now known that gastrointestinal or
genitourinary lesions play an important role in its development. While Fournier found the disease in young men, FG is
not limited to particular age groups, or the male sex.73
An ill-appearing patient with a fever, scrotal pain, and gas
in the perineum provides no diagnostic dilemma. The
challenge is detecting an early case of FG in hopes of
promoting a better outcome. Plain x-rays may or may not
reveal soft-tissue air.
The modality of choice for early diagnosis is either
surgical consultation or, in unclear cases, scrotal ultrasound.
Scrotal ultrasound usually reveals diffuse swelling and
thickening of the scrotum. It may also detect gas within
the scrotal wall.86,87 Computed tomography of the area is
only useful to reveal the extent of the infection. Key
differential considerations include scrotal cellulitis, scrotal
abscess, and hernia.
Epidemiology
FG is an uncommon, but aggressive, disease. There have
been approximately 400 cases reported in the literature
in the post-antibiotic era,74,75 but there are no doubt many
unreported cases as well. Two recent studies describe the
demographics of FG patients. The average age was 54
(range, 20-82).74 Cases even occur in children younger than 3
months.76-78 The most frequent disorders associated with FG
include diabetes (40%-60% of patients) and chronic alcoholism (25%-50% of patients).74,79-81
Treatment
Once the diagnosis of FG becomes a realistic concern, call a
surgeon. Begin aggressive resuscitation with IV fluids (and
pressors) if necessary. Parenteral broad-spectrum antibiotics
such as a third-generation cepalosporin (or extendedspectrum penicillin/beta-lactamase inhibitor) and an
aminoglycoside will cover Gram-positive, Gram-negative,
and anaerobic agents. Clindamycin may be useful, as it is
effective against anaerobes and can inhibit toxin production.88 Antibiotics are only an adjunct to surgical debridement.
After surgery, the patient may benefit from hyperbaric
oxygen therapy.
Etiology And Pathogenesis
FG results when normal flora with low to moderate
virulence gain entry into the skin. Colorectal or urogenital
diseases provide the portal for most cases. (See Table 6.) The
combination of immune suppression and synergistic
organisms sparks an infectious conflagration.73 The infection
begins near the portal of entry and progresses rapidly
through the deep fascial planes. An obliterative endarteritis
causes vascular thrombosis and tissue necrosis. This allows
the commensal flora to enter previously sterile areas,
progressively destroying tissue.73
FG is typically polymicrobial.79,82 Both aerobes and
anaerobes are usually present, but the anaerobes are less
frequently isolated, probably due to technical difficulties in
culturing those organisms.83 The most commonly isolated
species include the enterobacteria, especially E. coli,
Bacteroides, and streptococcal species. Clostridium is the
anaerobe most often identified.84
Prognosis
Mortality in FG ranges widely, from 0%-80%.89 Factors that
increase mortality include comorbid disease, extremes of
age,83,90 primary anorectal infections,91,92 and delay in
Table 6. Etiologies Of Fournier’s Gangrene.
Colorectal sources
Perirectal abscess
Incarcerated inguinal hernia
Hemorrhoid banding
Rectal biopsy
Clinical Presentation
The most common presenting symptoms are scrotal pain,
perineal erythema, and swelling, often associated with
fever.84 The patient develops induration, cyanosis, and
blistering of the skin as the infection deepens.85 Soft-tissue
crepitus may be present.
Patients are often critically ill at initial presentation.
Even in the early stages, they may display systemic signs of
sepsis, disproportionate to the appearance of the scrotal
skin.73 The erythema, which is a notable early sign, may be
difficult to appreciate in dark-skinned individuals. Many
patients are symptomatic for 4-8 days before presentation77,78
and may have already consulted a physician (who might
possibly have prescribed an antifungal cream).
Patients who are likely to develop FG include
chronically ill nursing home patients with decubiti,
Foley catheters, diapers, and feeding tubes. Unfortunately,
poor hygiene or contractures may discourage completely
exposing the perineum. Thus, it is tempting to
automatically ascribe fever and “dirty urine” in an elderly
male to urosepsis. Such a patient requires a careful examination of the perineal and rectal areas.
November 2000
Genitourinary sources
Urethral stricture
Scrotal carbuncle
Scrotal scratches
Indwelling catheter
Traumatic catheterization
Vasectomy
Prostate biopsy
Sources: Olsofka JN, Carrillo EH, Spain DA, et al. The continuing challenge
of Fournier’s gangrene in the 1990s. Am Surg 1999;65:1156-1159;
Basoglu M, Gui O, Yildirgan I, et al. Fournier’s gangrene: A review of
fifteen cases. Am Surg 1997;1019-1021; Smith GL, Bunker CB, Dinnen MD.
Fournier’s gangrene. Br J Urol 1998;81:347-355; Baskin LS, Carroll PR,
Caltolica EV, et al. Necrotizing soft tissue infections of the perineum and
genitalia: Bacteriology, treatment and risk assessment. Br J Urol
1990;65:524-529; Stephens BJ, Lathrop JC, Rice WT, et al. Fournier’s
gangrene: Historic (1764-1978) versus contemporary (1979-1988)
differences in etiology and clinical importance. Ann Surg 1993;59:149162; Enriquez JM, Moreno S, Devesa M, et al. Fournier’s syndrome of
urogenital and anorectal origin: A retrospective, comparison study. Dis
Col Rect 1987;30:33-37; Karim MS. Fournier’s gangrene following urethral
necrosis by indwelling Foley catheter. Urology 1984;23:173-175.
13
Emergency Medicine Practice
treatment.92 Surprisingly, there has been only minimal
improvement in survival rates over the past decades. The
mortality before 1945 (before antibiotics) and from 1945 to
1988 remained the same—20%-22%.89 Surgical debridement
is key; the latest “gorillacillin” is only an accessory.
are susceptible to UTIs and therefore to prostatitis.96
The causative organisms in bacterial prostatitis are
similar to those responsible for UTIs—E. coli is the most
common, followed by other Enterobacteriaceae species and
possibly Gram-positive organisms.98 In some men with CBP,
the pathogenic organisms in their prostatic fluid are the
same as those found in the vaginal cultures of their female
sexual partners. This suggests a possible role for ascending
sexually transmitted infection.93,96
The cause and pathogenesis of NBP remain unclear.
Possibilities include an unidentified pathogenic organism(s),
a non-infectious disease, or a “chemical” prostatitis caused
by urine reflux.96
Prostate Problems
Anatomy
The prostate gland in the normal adult male weighs
approximately 20 grams. The prostatic glands produce a
complex fluid that constitutes approximately 15%-30% of
the typical ejaculate. During ejaculation, the fluid is released
through multiple ducts into the prostatic urethra and mixes
with the seminal fluid, providing a suitable transport
medium for sperm.93
Physical Examination
In ABP, the prostate is typically tender, swollen, firm, and
warm. The patient may or may not have a urethral exudate.
Aggressive palpation of an acutely infected gland may
precipitate bacteremia, so palpation should be gentle. The
physical findings in a patient with CBP or NBP/prostodynia
are often indistinguishable from ABP, although symptoms
are typically milder and fever is uncommon.96 The gland is
usually tender. During the evaluation of possible prostatitis,
the emergency physician should carefully examine the
genitalia and abdomen.
Incidence
Little information concerning the true incidence of
prostatitis is available, but it is commonly diagnosed
(perhaps overdiagnosed) in adult men while rarely affecting
prepubertal boys. Some estimate that half of all men will
suffer from symptoms of prostatitis at some point during
their lives.94
Types Of Prostatitis
Prostatitis is divided into acute bacterial prostatitis (ABP),
chronic bacterial prostatitis (CBP), and non-bacterial
prostatitis (NBP)/prostodynia.
ABP is a febrile illness with an acute onset. Genitourinary signs and symptoms predominate, such as low back
pain, perineal pain, urinary frequency, urgency, and dysuria.
Acute prostatitis has been likened to sitting on a flaming
golf ball. Urinary retention may be present in addition to the
constitutional symptoms.95 ABP is relatively rare—a typical
urologist may see only two or three cases a year, if that.93
CBP is a more subtle illness, marked by recurrent urinary
tract infections (UTIs) with the same pathogen. It may be
caused by persistence of the pathogen in the prostatic secretory
system despite repeated courses of therapy.95 The organism
persists due to poor accumulation of antibiotics within the
prostate.96 Most patients complain of irritative voiding symptoms and pain in various sites of the pelvis and genitalia. No
physical exam findings are characteristic of CBP.96
Patients with NBP have inflammatory cells in the
prostatic secretions but negative cultures. In patients with
prostodynia, the patient has a painful prostate but normal
prostatic secretions and no history of UTI. In general,
treatment of NBP and prostodynia is the same, so they are
usually considered together.96
Laboratory Evaluation
The most important laboratory test in a patient with
suspected ABP is the examination of a clean catch, midstream urine specimen. This will demonstrate pyuria and/
or bacteriuria. Urine culture will identify the pathogenic
organism. Although prostatic massage usually produces
purulent secretions, bacteremia may result from manipulation of an inflamed gland. Contrary to older recommendations,
prostatic massage is unnecessary and should be avoided.96,99
Quantitative bacteriologic culture confirms the
diagnosis of bacterial prostatitis. The classic “three-glass”
method for localizing infection to the prostate involved
prostatic massage and is rarely used in modern practice.
Some urologists have the patient with suspected bacterial
prostatitis masturbate into a specimen cup and then culture
the ejaculate.100 (Like auscultation of the penis, this suggestion may raise a few eyebrows in the ED.) If a urethral
discharge is present, test it for chlamydia and gonorrhea.
Treatment
In the normal host, antibiotics diffuse poorly into the
prostate. However, during ABP, the intense inflammatory
reaction appears to enhance drug passage from plasma into
the prostatic secretory system.96 Antibiotics effective against
urinary pathogens also treat ABP, as the organisms are the
same. Fluoroquinolones are among the drugs of choice.
ABP requires prolonged therapy. Oral doses of
ciprofloxacin, norfloxacin, ofloxacin, or enoxacin are
generally prescribed for 30 days. If the patient is ill
enough to require parenteral medication, consider gentamicin plus ampicillin. An intravenous fluoroquinolone is
another good alternative.96
Oral treatment is indicated for CBP, using the same
Etiology And Pathogenesis
Bacterial prostatitis results from an ascending urethral
infection or reflux of infected urine into prostatic ducts. The
intraprostatic reflux of urine may play a crucial role in the
pathogenesis of bacterial prostatitis.97 Other possible routes
of infection include local invasion by rectal bacteria or by
lymphatic or hematogenous spread.96 Patients with indwelling urinary catheters and condom catheter drainage systems
Emergency Medicine Practice
14
November 2000
Disposition
agents as for ABP. Intravenous therapy is rarely, if ever,
indicated. For patients with ABP who are younger than
35 years of age, treatment should be directed toward
gonorrhea and chlamydia. Remember that ciprofloxacin is
not active against chlamydia.
For patients over the age of 35 or who have a history of
anal intercourse, a fluoroquinolone regimen is necessary.71
As in epididymitis, the newer-generation quinolones such
as ofloxacin or levofloxacin will treat gonorrhea, chlamydia,
and the urinary pathogens.71
There are multiple therapeutic approaches to NBP and
prostodynia, usually directed by a urologist. The emergency
physician should make the appropriate referral and control
pain with a short course of anti-inflammatory medications
or narcotics. When narcotics are given for prostatitis, a stool
softener is a useful adjunct to prevent a downward spiral of
constipation and tenesmus.
Most patients with bacterial prostatitis can be managed on
an outpatient basis with urologic referral. Indications for
admission include intractable nausea and vomiting, toxic
appearance, or the existence of significant comorbidities.
Diabetes or other immunosuppressive conditions may
predispose to complications.
Acute Urinary Retention
Acute urinary retention (AUR) manifests as a sudden
inability to pass urine. Urinary retention syndromes can
range from overt retention to insidious overflow incontinence. The condition is far more common in men than
women.13 In one study, benign prostatic hypertrophy was
the most common etiology (53%). Other causes include
constipation, prostate cancer, urethral stricture, clot reten-
Ten Excuses That Don’t Work In Court
1.“I was sure I felt a torsed appendix testis. Besides, the
scrotum looked a little blue, so I sent him for follow-up in
two days.”
The testis was removed several days later; it was the testicle
that was blue. To make the diagnosis of torsed appendix testis,
have a urologist operate on the scrotum or obtain a timely
imaging study.
6.“It was a simple case of urinary retention. He got a Foley and
went home!”
Actually, it was a simple case of spinal cord compression. The
patient had back pain and acute urinary retention. The
plaintiff’s attorney made quite a point regarding the lack of a
neurologic examination (and no documentation of rectal
tone) and the fact that the patient left in a wheelchair as
opposed to walking.
2.“I knew it was a torsion, but I had to get an ultrasound to
be sure.”
You were right about the torsion, but wrong about the
imaging study. If it’s any consolation, the pathology report did
show a recently deceased testicle. This patient presented at 2
a.m. after seven hours of pain. The ultrasound tech had a flat
tire, the Doppler was on the fritz, and the radiologist didn’t
realize the study was completed until 8 a.m.
Some proponents of mandatory exploration for the acute
scrotum suggest imaging studies only if the following caveat
is observed: Male emergency physicians must forcefully
squeeze their own testicles (and those of the radiologist) every
15 minutes until the test results are back. Female emergency
physicians should just be conscientious.
7.“There was nothing wrong with his scrotum. Even though
he complained of testicular pain, the testes weren’t tender.”
True enough. The testicles are rarely tender in appendicitis,
although they may suffer from referred pain. A number of
abdominal conditions—most notably, appendicitis,
diverticulitis, and abdominal aortic aneurysm—may present
with scrotal pain.107 If the testes are non-tender, document a
detailed examination of the abdomen.
8.“Little Joey didn’t tell me he had pain in his scrotum. He said
his stomach hurt.”
This is the converse of excuse #7. Some patients with scrotal
pathology may complain only of abdominal pain. This is
especially true in children. They may also minimize their
symptoms out of fear or embarrassment. Patients with
abdominal complaints need a genital exam in most cases (and
vice versa).
3.“But I thought his UTI was the source of his fever. The
nursing home didn’t mention any scrotal pain.”
Don’t miss an early Fournier’s gangrene for lack of a complete
examination. Be sure to examine the perineum when looking
for the source of a fever—especially in the elderly.
4.“But his Prehn’s sign was positive. That means epididymitis.”
Never use this sign to make a diagnostic decision. It is no
better than a coin toss. Patients with torsion may develop relief
with this maneuver.
9.“He had a penile discharge, so he got single-dose therapy. It
always works!”
Not if the patient has epididymitis. This patient’s chief
complaint was scrotal pain, not dysuria. Patients with
epididymitis (even if sexually transmitted) need at least 10-14
days of antibiotic therapy.
5.“But I got the diagnosis right. I knew it was Fournier’s
gangrene, so I gave quadruple antibiotics and admitted him
to medicine.”
Correct diagnosis—wrong disposition. Fournier’s gangrene is a
surgical emergency. Antibiotics are a “nice touch,” but the
patient needs to go straight to the operating room.
10.“How could it have been torsion? He had white cells in
his urine.”
Pyuria does not exclude torsion. Age (either very young or
very old) does not exclude torsion. Even a normal cremasteric
reflex does not exclude torsion. (Hopefully, following the
Clinical Pathway on page 11 may exclude torsion.) ▲
November 2000
15
Emergency Medicine Practice
able to be discharged without a catheter, compared to only
8% of those with larger residual volumes.106
In patients with chronic retention, post-obstructive
diuresis may occur, so the patient should be monitored for a
few hours after catheterization.11 Most patients may be
discharged with the catheter in place, connected to a leg
bag. Instruct the patient and/or his family in how to care for
the bag.
An indwelling catheter causes bladder spasm with
resultant constant urge to void. This can be treated with
belladonna and opium (B&O) suppositories. Antibiotics are
indicated if a concomitant urinary tract infection is present
or for prophylaxis if the catheter is to be left in place for
more than a few days.11 However, the evidence behind
using prophylactic antibiotics for this indication is admittedly weak (none).
The patient should follow up with a urologist in 2-4
days. If an acute neurologic etiology is suspected, obtain
urgent consultation in the ED.
tion, neurologic disorders, postoperative complications,
drugs, and infection.101 In paraplegics, acute overdistention
of the bladder can produce autonomic dystonia, characterized by diaphoresis and marked hypertension.102 Among
children, cystitis, operations, and voluntary overdistention
may all lead to AUR.103
A detailed history, including prescription and over-thecounter medications, may reveal the cause of the urinary
retention. Anticholinergics and sympathomimetics are the
most common offenders. These agents are often found in
over-the-counter medications and in a variety of herbals and
health supplements.
Physical examination should include a search for
meatal stenosis, penile masses, phimosis, and paraphimosis.
Examine the abdomen for suprapubic masses. A rectal exam
is essential to determine the prostate’s size and consistency.
Evaluate anal sphincter tone to help exclude a neurologic
problem. The neurologic exam should focus on the sensory
and motor exam and the bulbocavernosus reflex to identify
neurogenic bladder or spinal cord compression.11 The
bulbocavernosus reflex can be elicited by placing a finger in
the patient’s rectum. Pinching their glans (gently), or
tugging on an inserted Foley catheter, will cause the
sphincter to spontaneously contract around the finger in the
rectum. Absence of this reflex suggests a neurologic disorder
involving the sacral plexus.
Treatment of acute urinary retention consists of
inserting a straight urinary catheter to decompress the
bladder. If the straight catheter will not pass, a Coudé
catheter may be used. If resistance is met, take care not to
use excessive force, as this could create a false passage. The
use of a Coudé catheter or a larger size Foley (which is more
rigid) may ensure success. If the catheter cannot be passed,
obtain urologic consultation, as filiformes and followers or a
suprapubic tube may be required.
In the past, there was some concern that rapid decompression of the bladder could lead to complications—most
notably, significant hematuria. This led to the practice of
clamping the Foley after several hundred ccs of urine were
released, waiting some unspecified period of time, and then
releasing another aliquot. This practice appears to have no
basis in fact. One paper analyzed five studies for complications associated with rapid and complete bladder emptying
in patients with acute urinary retention. Hematuria
occurred in 2%-16% and was never severe.104 In fact, no
patient had significant complications. The authors believe
that “quick, complete emptying of the obstructed bladder is
safe, simple, and effective and is recommended as the
optimal method for decompressing the obstructed urinary
bladder.” A prospective study of 300 cases of urinary
retention also supports this conclusion.105
Once a patient with acute urinary retention has been
treated with a catheter, most emergency physicians send the
patient home with the catheter in place. However, this may
not be necessary in all cases. In one randomized, controlled
trial of 60 males catheterized for AUR, the volume of
residual urine correlated with the ability to urinate without
a catheter after bladder decompression. Forty-four percent
of patients with residual volumes of less than 900 cc were
Emergency Medicine Practice
Summary
Some male genitourinary complaints represent true
emergencies. Testicular torsion, Fournier’s gangrene,
paraphimosis, and penile entrapment injuries require
prompt diagnosis and treatment to save life, penis, or
testicle. If testicular torsion is likely, call a urologist. Manual
detorsion is another important consideration.
In the case of possible torsion, paraphimosis with
distal cyanosis, or Fournier’s gangrene, the alacrity of
consultation and intervention may prevent a catastrophic
outcome. Diagnostic testing may adversely delay necessary
treatment. For these reasons, document the time of calls to
consultants such as urology and radiology, and chart that
you discussed the diagnostic possibilities and proposed
management with them. ▲
References
Evidence-based medicine requires a critical appraisal of the
literature based upon study methodology and number of
subjects. Not all references are equally robust. The findings
of a large, prospective, randomized, and blinded trial
should carry more weight than a case report.
To help the reader judge the strength of each reference,
pertinent information about the study, such as the type of
study and the number of patients in the study, will be
included in bold type following the reference, where
available. In addition, the most informative references cited
in the paper, as determined by the authors, will be noted by
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67.* Lau P, Anderson PA, Giacomantonio JM, et al. Acute
epididymitis in boys: Are antibiotics indicated? Br J Urol
1997;79:797. (Prospective; 48 boys: no if UA is negative)
68. Rinker JR, Hanock CV, Henderson WD. A statistical study of
unilateral prophylactic vasectomy in the prevention of
epididymitis: 1029 cases. J Urol 1970;104:303. (Prospective)
69. Anderson PA, Giacomantonio JM, Schwartz RD. Acute scrotal
pain in children: Prospective study of diagnosis and management. Can J Surg 1989;32:29. (Prospective; 48 patients)
70. Watson RA. Gonorrhea and acute epididymitis. Milit Med
1979;144:785-787. (Review)
71. Gilbert DN, Moellering RC, Sande MA, eds. The Sanford Guide
to Antimicrobial Therapy, 13th ed. Portland, OR: Oregon Health
Science University; 2000.
72. Fournier JA. Gangrene foudroyante de la verge. Medecin
Pratique 1883;4:589-597.
73.* Smith GL, Bunker CB, Dinnen MD. Fournier’s gangrene. Br J
Urol 1998;81:347-355. (Review)
74. Spirnak JP, Resnik MI, Hampel N, et al. Fournier’s gangrene:
report of 20 patients. J Urol 1984;131:289-291. (Case series)
75. Fahal AH, Hassan MA. Fournier’s gangrene in Khartoum. Br J
Urol 1988;61:451-454. (9 cases)
76. Samm BJ, Dmochowski BR. Urologic emergencies. Postgrad
Med 1996;100(4):187-194. (Review)
77. Olsofka JN, Carrillo EH, Spain DA, et al. The continuing
challenge of Fournier’s gangrene in the 1990s. Am Surg
1999;65:1156-1159. (Retrospective; 14 patients)
78. Basoglu M, Gui O, Yildirgan I, et al. Fournier’s gangrene: A
review of fifteen cases. Am Surg 1997;1019-1021. (Retrospective; 15 patients)
79. Baskin LS, Carroll PR, Caltolica EV, et al. Necrotizing soft
tissue infections of the perineum and genitalia: Bacteriology,
treatment and risk assessment. Br J Urol 1990;65:524-529.
(Retrospective; 29 patients)
80. Lamb R, Juler G. Fournier’s gangrene of the scrotum: A poorly
defined condition or misnomer? Arch Surg 1983;118:38.
(Retrospective; 12 patients)
81. Clayton MD, Fowler JE Jr, Sharifi R. Causes, presentation and
survival of 57 patients with necrotizing fasciitis of the male
genitalia. Surg Gynaecol Obstet 1990;170:49-55. (Retrospective;
57 patients)
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18
Bahlmann JC, Fourie IJ, Arndt TC. Fournier’s gangrene and
necrotizing fasciitis of the male genitalia. Br J Urol 1983;55:8588. (Prospective; 9 patients)
Laucks SS. Fournier’s gangrene. Surg Clin North Am
1994;74:1339-1359. (Review)
Paty R, Smith AD. Gangrene and Fournier’s gangrene. Urol
Clin North Am 1992;19:149-162. (Review)
Sutherland ME, Meyer AA. Necrotizing soft-tissue infections.
Surg Clin North Am 1994;74:591-607. (Review)
Biyani CS, Mayor PE, Powell CS. Case report: Fournier’s
gangrene—roentgenographic and sonographic findings. Clin
Radiol 1995;50:728-729. (Case)
Dogra VS, Smeltzer JS, Poblette J. Sonographic diagnosis of
Fournier’s gangrene. J Clin Ultrasound 1994;22:571-572. (Case)
Stevens DL, Bryant AE, Hackett SP. Antibiotic effects on
bacterial viability, toxin production, and host response. Clin
Infect Dis 1995;20 Suppl 2:S154-S157.
Stephens BJ, Lathrop JC, Rice WT, et al. Fournier’s gangrene:
Historic (1764-1978) versus contemporary (1979-1988)
differences in etiology and clinical importance. Ann Surg
1993;59:149-162. (Observational)
Laor E, Palmer LS, Bhupendra MT, et al. Outcome prediction
in patients with Fournier’s gangrene. J Urol 1995;154:89-92.
(Retrospective; 30 patients)
Enriquez JM, Moreno S, Devesa M, et al. Fournier’s
syndrome of urogenital and anorectal origin: A retrospective,
comparison study. Dis Col Rect 1987;30:33-37. (Retrospective;
28 patients)
Oh C, Lee C, Jacobson J. Neccrotizing fasciitis of perineum.
Surgery 1982;91:49-51. (Case)
Cooner WH, Roberts RG. Prostate disease. Am Fam Phys
1994;monograph:1-8 (Review)
Stamey T. Pathogenesis and Treatment of Urinary Tract Infections.
Baltimore: 1980:342-429. (Textbook)
Rosen P, Barkin R, eds. Emergency Medicine: Concepts and Clinical
Practice, 4th ed. St. Louis, MO: Mosby; 1998. (Textbook)
Mears EM: Prostatitis and related disorders. In: Walsh PC,
Retik AB, Vaughn ED, et al, eds. Campbell’s Urology, 7th ed.
Philadelphia: W.B. Saunders; 1998:604-613. (Review)
Kirby RS, Lowe D, Bultitude MI, et al. Intra-prostetic urinary
reflux: an aetiological factor in abacteral prostatitis. Br J Urol
1982;54:729-731. (Prospective; 10 cadavers)
Domingue GJ, Hellstrom WJ. Prostatitis. Clin Micro Rev
1998;11(4):604-613. (Review)
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Principles of Internal Medicine, 12th ed. New York: McGrawHill; 1991. (Textbook)
Riedasch G, Mohring K, Ritz E. Do antibody-coated bacteria
prove bacterial prostatitis? Infection 1991;19 Suppl 3:S141-S143.
Murray K, Massey A, Feneley RC. Acute urinary retention: A
urodynamic assessment. Br J Urol 1984;56:468-473. (Prospective; 30 patients)
Hart RG, Kanter MC. Acute autonomic neuropathy. Two
cases and a clinical review. Arch Intern Med 1990;150(11):23732376. (Review)
Choung S, Emberton M. Acute urinary retention. Br J Urol
2000;85:186-201. (Review)
Nyman MA, Schwenk NM, Silverstein MD. Management
of urinary retention: rapid versus gradual decompression
and risk of complications. Mayo Clin Proc 1997;72(10):
951-956. (Review)
Glahn BE, Plucnar BJ. Quick complete emptying of the
bladder in 300 cases of urinary retention. The occurrence of
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controlled; 60 patients)
McGee SR. Referred scrotal pain: case reports and review. J
Gen Intern Med 1993;8(12):694-701.
November 2000
Physician CME Questions
72. Which statement regarding priapism is false?
a. Low-flow or ischemic priapism that is not treated
within 24-48 hours can result in erectile dysfunction and recurrent priapism.
b. Priapism in children is commonly due to
sickle cell disease.
c. Dark corporal blood suggests low-flow priapism.
d. High-flow priapism is a urologic emergency that
requires prompt treatment in the ED.
65. Which statement regarding testicular torsion
is correct?
a. The bell-clapper deformity is found in less than
5% of the population.
b. Testicular torsion does not result from direct
scrotal trauma.
c. The annual incidence of testicular torsion in
males under age 25 is estimated to be 1 in 4000.
d. The blue-dot sign is suggestive of
testicular torsion.
73. Which of the following signs or symptoms should not
be used in the decision-making process when
evaluating an acute scrotum?
a. Age
b. Length of symptoms
c. Prehn’s sign
d. Testicular lie
66. Which symptom is not commonly seen
in epididymitis?
a. Scrotal pain
b. Nausea and vomiting
c. Dysuria
d. Gradual onset of pain
74. Which statement about prostatitis is correct?
a. Prostatic massage is necessary to produce a
diagnostic urinary specimen.
b. Fluoroquinolones will treat the majority of
organisms responsible for bacterial prostatitis.
c. Prostatitis is always infectious.
d. It is not necessary to treat for sexually transmitted
diseases in patients with prostatitis because
gonorrhea and chlamydia do not cause prostatitis.
67. Which physical exam finding is most suspicious for
testicular torsion in a patient with scrotal pain?
a. Diffuse scrotal tenderness
b. Absence of urethral discharge
c. Abnormal testicular lie
d. Scrotal edema
68. Which of the following statements is true regarding
Fournier’s gangrene?
a. There is no imaging modality useful in making an
early diagnosis.
b. It occurs in men only.
c. Infection is typically polymicrobial.
d. Genitourinary sources carry the highest mortality.
75. A 14-year-old male presents with a one-hour history
of scrotal pain and vomiting. There is no fever or
urinary symptoms. On exam, his cremasteric reflex is
absent and the painful testicle has a horizontal lie.
Which of the following is the most appropriate
management strategy?
a. Immediate urologic consultation for
scrotal exploration.
b. Order a scrotal ultrasound.
c. Order a nuclear perfusion study of the scrotum.
d. Order a urinalysis.
69. Which age group is at highest risk for testicular
torsion as a cause of acute scrotal pain?
a. Newborn and post-pubertal
b. Age 35-50 years
c. Over age 50
d. Age 5-10 years
76. Which of the following is not a Knight-Vassy
criterion for diagnosing acute epididymitis?
a. History of sexual activity
b. Dysuria or recent urinary tract instrumentation
c. An admission temperature exceeding 101˚F
d. Tenderness and induration localized to
the epididymis
70. Which of the following statements is not characteristic of low-flow priapism?
a. The most common causes in adults are
related to sickle cell disease, idiopathic causes,
and drugs.
b. Physical exam reveals a rigid, painful penile shaft
with a soft glans.
c. It can be treated with intra-cavernosal injections
of phenylephrine.
d. It often results from trauma.
77. What is the most likely etiology in a patient with
balanitis who presents with a thin, purulent discharge that is seen with foreskin retraction, penile
pain, and erythema?
a. Candida
b. Trichomonas
c. Irritation
d. Streptococcus
71. Which patient is at highest risk for developing
Fournier’s gangrene?
a. A healthy young male with traumatic brain injury
who has a Foley catheter placed in the ED
b. An elderly diabetic male with a sacral decubitus
ulcer and an indwelling Foley catheter
c. An immunocompetent 40-year-old male with a
recent vasectomy
d. A 3-month-old infant with a history of constipation
who had a recent rectal biopsy
November 2000
78. Which of the following conditions is considered a
urologic emergency?
a. Phimosis with no urinary retention
b. Paraphimosis
c. Urethral stricture without urinary retention
d. Balanoposthitis
19
Emergency Medicine Practice
Physician CME Information
79. Which of the following is not a common cause of
balanitis or balanoposthitis?
a. HIV
b. Irritation
c. Candida
d. Trichomonas
e. Streptococcus
This CME enduring material is sponsored by Mount Sinai School of
Medicine and has been planned and implemented in accordance with
the Essentials and Standards of the Accreditation Council for Continuing
Medical Education. Credit may be obtained by reading each issue and
completing the post-tests administered in December and June.
Target Audience: This enduring material is designed for emergency
medicine physicians.
Needs Assessment: The need for this educational activity was
determined by a survey of medical staff, including the editorial board
of this publication; review of morbidity and mortality data from the
CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for
emergency physicians.
Date of Original Release: This issue of Emergency Medicine Practice
was published November 1, 2000. This activity is eligible for CME
credit through November 1, 2003. The latest review of this material
was October 31, 2000.
Discussion of Investigational Information: As part of the
newsletter, faculty may be presenting investigational information
about pharmaceutical products that is outside Food and Drug
Administration approved labeling. Information presented as part of
this activity is intended solely as continuing medical education and is
not intended to promote off-label use of any pharmaceutical product.
Disclosure of Off-Label Usage: This issue of Emergency Medicine Practice
discusses no off-label use of any pharmaceutical product.
Faculty Disclosure: In compliance with all ACCME Essentials,
Standards, and Guidelines, all faculty for this CME activity were asked
to complete a full disclosure statement. The information received is as
follows: Dr. Freeman, Dr. Üner, and Dr. Schneider report no significant
financial interest or other relationship with the manufacturer(s) of any
commercial product(s) discussed in this educational presentation.
Accreditation: Mount Sinai School of Medicine is accredited by the
Accreditation Council for Continuing Medical Education to sponsor
continuing medical education for physicians.
Credit Designation: Mount Sinai School of Medicine designates this
educational activity for up to 4 hours of Category 1 credit toward the
AMA Physician’s Recognition Award. Each physician should claim only
those hours of credit actually spent in the educational activity.
Emergency Medicine Practice is approved by the American College of
Emergency Physicians for 48 hours of ACEP Category 1 credit (per
annual subscription).
Earning Credit: Physicians with current and valid licenses in the United
States, who read all CME articles during each Emergency Medicine
Practice six-month testing period, complete the CME Evaluation Form
distributed with the December and June issues, and return it
according to the published instructions are eligible for up to 4 hours
of Category 1 credit toward the AMA Physician’s Recognition Award
(PRA) for each issue. You must complete both the post-test and CME
Evaluation Form to receive credit. Results will be kept confidential.
CME certificates will be mailed to each participant scoring higher than
70% at the end of the calendar year.
80. Which statement regarding prostatitis is true?
a. Acute bacterial prostatitis and chronic
bacterial prostatitis are easy to distinguish
on physical exam.
b. Prostatitis is always infectious.
c. Organisms responsible for bacterial prostatitis
include those that cause urinary tract infections.
d. Intraprostatic reflux of urine is not known to be an
important cause of prostatitis.
Class Of Evidence Definitions
Each action in the clinical pathways section of Emergency
Medicine Practice receives an alpha-numerical score based on
the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy
and effectiveness
• Must be used in the
intended manner for
proper clinical indications
Level of Evidence:
• One or more large
prospective studies
are present (with
rare exceptions)
• Study results consistently
positive and compelling
Class IIa
• Safe, acceptable
• Clinically useful
• Considered treatments
of choice
Level of Evidence:
• Generally higher levels
of evidence
• Results are consistently
positive
Class IIb
• Safe, acceptable
• Clinically useful
• Considered optional or
alternative treatments
Level of Evidence:
• Generally lower or
intermediate levels
of evidence
• Generally, but not
consistently, positive results
Class III:
• Unacceptable
• Not useful clinically
• May be harmful
Level of Evidence:
• No positive high-level data
• Some studies suggest or
confirm harm
Indeterminate
• Continuing area of research
• No recommendations until
further research
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent,
contradictory
• Results not compelling
Adapted from: The Emergency
Cardiovascular Care Committees
of the American Heart Association
and representatives from the
resuscitation councils of ILCOR:
How to Develop Evidence-Based
Guidelines for Emergency Cardiac
Care: Quality of Evidence and
Classes of Recommendations; also:
Anonymous. Guidelines for
cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee and
Subcommittees, American Heart
Association. Part IX. Ensuring
effectiveness of community-wide
emergency cardiac care. JAMA
1992;268(16):2289-2295.
Publisher: Robert Williford. Vice President/General Manager: Connie Austin.
Executive Editor: Heidi Frost.
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Emergency Medicine Practice (ISSN 1524-1971) is published monthly (12 times per year)
by Pinnacle Publishing, Inc., 1000 Holcomb Woods Parkway, Building 200, Suite 280,
Roswell, GA 30076-2587. Opinions expressed are not necessarily those of this
publication. Mention of products or services does not constitute endorsement. This
publication is intended as a general guide and is intended to supplement, rather than
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should not be used for making specific medical decisions. The materials contained
herein are not intended to establish policy, procedure, or standard of care. Emergency
Medicine Practice is a trademark of Pinnacle Publishing, Inc. Copyright 2000 Pinnacle
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Emergency Medicine Practice
20
November 2000