Chapter 93: Male Genital Problems

This chapter reviews the common acute infectious and structural or anatomic GU disorders. There are five GU emergencies: testicular torsion, Fournier's gangrene, paraphimosis, priapism, and significant GU trauma (see chapter 265, "Genitourinary Trauma"). Related emergencies include strangulated inguinal hernia (see chapter 84, "Hernias") and ruptured abdominal aortic aneurysm (see chapter 60, "Aneurysmal Disease"), which may present with scrotal pain.

PENIS

Three cylindrical bodies—the corpus spongiosum, which surrounds the urethra, and the paired corpora cavernosa—form the shaft of the penis (Figure 93-1). The corpora cavernosa are the major erectile bodies, extending distally from the pubic rami and capped by the glans penis. These cylindrical structures are encased in a thick tunic of dense connective tissue, the tunica albuginea. External to the tunica albuginea is Buck's fascia, which fuses with Colles' fascia at the level of the urogenital diaphragm. The internal pudendal artery provides the blood supply, which branches to form the deep and superficial penile arteries. Lymphatics drain from the penis into the deep and superficial inguinal nodes.

SCROTUM

The prepubertal scrotal skin is thin and thickens with subsequent hormonal stimulation during puberty. Immediately beneath the skin are the smooth muscle and elastic tissue layers of Dartos' fascia, similar to the superficial fatty layer (Camper's fascia) of the abdominal wall. The deep membranous layer (Scarpa's fascia) of the abdominal wall extends into the perineum, where it is referred to as Colles' fascia, and forms part of the scrotal wall (Figure 93-2). The blood supply is derived primarily from branches of the femoral and internal pudendal arteries. Lymphatics from the scrotum drain into the inguinal and femoral nodes.

TESTES

The testes average in size between 4 and 5 cm in length and 3 cm in width and depth, and usually lie in an upright position, with the superior portion tipped slightly forward and outward. Each testis is encased in a thick fibrous tunica albuginea except posterolaterally, where it is in tight apposition with the epididymis. The enveloping tunica vaginalis covers the anterior and lateral aspects of the testes and attaches to the posterior scrotal wall. Superiorly, the testes are suspended from the spermatic cord; inferiorly, the testis is anchored to the scrotum by the scrotal ligament (gubernaculum). Maldevelopment with lack of firm posterior fixation of the tunica vaginalis leaves the testes and epididymis at risk for torsion about the spermatic cord. The posterior (visceral) leaf of the tunica vaginalis is adherent with the tunica albuginea of the anterior testicular surface. A potential space exists between this visceral leaf and the anterior (parietal) tunica vaginalis. Any traumatic or inflammatory event can impede the normal parietal tunica vaginalis from absorbing viscerally secreted fluid, resulting in hydrocele formation anterior to the testes (Figure 93-3). Hematocele results from accumulation of blood in the potential space.

The internal spermatic and external spermatic arteries provide the blood supply, traveling together in the spermatic cord. Venous return is primarily by the internal spermatic, epigastric, internal circumflex, and scrotal veins. The lymphatics drain toward the external, common iliac, and periaortic nodes.

EPIDIDYMIS AND VAS DEFERENS

The epididymis is a single, fine, tubular structure approximately 4 to 5 m long compressed into an area of about 5 cm. It serves to promote sperm maturation and motility. Vestigial embryonic structures, the appendix epididymis and the appendix testis, which have no known physiologic function, are often associated with the testes and epididymis. The appendix epididymis is found attached to the head of the epididymis, or globus major. The appendix testis, a pear-shaped structure, is usually situated on the uppermost portion of the testis at the junction of the testis and the globus major of the epididymis, although anatomic variation exists.

The vas deferens is a distinct muscular tube that is easily palpable within the scrotal sac. It extends cephalad in the spermatic cord from the tail of the epididymis (globus minor), traverses the inguinal canal, and crosses medially behind the bladder over the ureters to form the ampullae of the vas, where it joins with the seminal vesicles to form the paired ejaculatory ducts in the prostatic urethra.

PROSTATE

The prostate originates from the urogenital sinus at approximately the third month of embryonic life. It is continually enlarging and, in the young male, is often not definable on rectal examination. As a man matures, the prostate may enlarge dramatically, resulting in significant bladder outlet obstruction. The anterior, median, posterior, and lateral lobes define the divisions of the prostate.

The GU examination should be performed with the male patient in both the supine and upright positions in a well-illuminated, warm room if feasible. In uncircumcised males, fully retract the foreskin to inspect the glans, coronal sulcus, and preputial (foreskin) areas for ulceration or lesions. Note the location of the urethral meatus and presence of discharge. Replace the foreskin to its native position following examination to prevent iatrogenic paraphimosis. Carefully palpate the penile shaft for skin or subcutaneous lesions.

Testicular nodularity or firmness should be considered carcinoma until proven otherwise. The epididymis usually lies on the posterolateral aspect of the testis and has a soft, fleshy feel similar to that of the earlobe. Many males experience pain and tenderness with palpation of a normal globus major (head), body, and globus minor (tail) of the epididymis. Males experience some discomfort during palpation of a normal prostate, and a lateral supine position helps prevent an infrequent vasovagal response. The prostate has a heart-shaped contour, with its apex located more distally, abutting the urogenital diaphragm. The consistency of the normal prostate has the same resiliency as the cartilaginous tip of the nose, whereas suspicious carcinogenic areas feel more like the bony prominence of the chin. The posterior lobe is small and thin, allowing palpation of the median raphe that distinguishes the two lateral lobes. A rectal prostate examination cannot assess the anterior or median lobes. The seminal vesicles, lying just superior to the prostate, cannot normally be distinguished unless there is inflammation, induration, or enlargement.

Examination of the inguinal canals for hernias and the scrotal spermatic cords for varicoceles is best done in the upright position, with the patient straining at the designated time. When the patient is upright, it should be determined whether the testes are aligned along a vertical or horizontal axis. Horizontally aligned testes are at greater risk for torsion. Likewise, an elevated, horizontally aligned testis may be the result of torsion.

An acute scrotum is defined as acute pain or painful swelling of the scrotum or its contents, accompanied by local signs or general symptoms. Testicular torsion and Fournier's gangrene are the most time-sensitive diagnoses of the acute scrotum; the first priority in the evaluation of patients with scrotal pain is differentiation these life- or testicular-threatening disorders from other entities.

SCROTAL EDEMA

Insect bites, human bites, and contact dermatitis may cause scrotal edema, or it may be idiopathic in young boys.¹ In the setting of hypoalbuminemia, or anasarca from any cause, contiguous scrotal and penile edema may occur. Idiopathic scrotal edema presents as unilateral or bilateral pain with scrotal, perineal, and inguinal swelling and erythema in boys between 3 and 9 years of age. US findings include an easily compressible thickened scrotal wall (mean 11.2 mm), increased peritesticular blood flow, and in some cases, a reactive hydrocele.^2,3 Episodes resolve in 1 to 4 days with scrotal elevation, rest, and nonsteroidal anti-inflammatory drugs, although recurrences occur.⁴ Antibiotics are sometimes used, but are not typically needed unless fever, increased warmth, or purulence is noted.

SCROTAL ABSCESS

Management of a scrotal abscess depends on its depth. In the case of a simple hair follicle abscess, the phlegmon is localized to the scrotal wall. A superficial abscess should be differentiated from a deeper abscess involving or originating from infection in one of the primary intrascrotal organs (i.e., testis, epididymis, or bulbous urethra). This distinction is difficult late in the course of the infection when a general scrotal mass may be the only physical finding. US can determine contiguous involvement of an inflammatory mass in the testis or epididymis with the scrotal skin. When in question, a retrograde urethrogram will delineate the integrity of the urethra.

A simple hair follicle scrotal wall abscess is managed by incision and drainage. Frequently, wound care can be simplified by circumferential excision of the entire roof of the abscess. This allows access for wound care and sitz baths and assures healing from the base outward.¹ Antibiotics are rarely needed in an immunocompetent male unless there are signs of cellulitis or systemic involvement. Definitive care of deep-seated or complex abscesses require consultation with urology.

FOURNIER'S GANGRENE

Fournier's gangrene is a polymicrobial, synergistic, infective necrotizing fasciitis of the perineal, genital, or perianal anatomy. This process typically begins as a benign infection or simple abscess that quickly becomes virulent, especially in an immunocompromised host, and results in microthrombosis of the small subcutaneous vessels, leading to the development of gangrene of the overlying skin. (Figure 93-4).⁵

Patients with diabetes and alcohol abuse are disproportionately affected with Fournier's gangrene.⁶ Mortality rates have varied from 3% to 67%,⁷ but contemporary estimates range from 20% to 40%.^{8,9,10,11,12,13} Age over 60 and complications during treatment are the most important predictors of death.^12,13

In advanced Fournier's gangrene, the local signs and symptoms are usually dramatic, with marked pain and swelling. Crepitus and ecchymosis of the inflamed tissues are common features. Prompt recognition of Fournier's gangrene in its early stages may prevent extensive tissue loss that accompanies delayed diagnosis or treatment. Treat with aggressive fluid resuscitation, gram-positive, gram-negative, and anaerobic antibiotic coverage (see also chapter 151, "Sepsis"). Recommended agents include piperacillin-tazobactam, 3.375 to 4.5 grams IV every 6 hours, or imipenem, 1 gram IV every 24 hours, or meropenem, 500 milligrams to 1 gram IV every 8 hours, plus vancomycin.^7,8,9 Urgent urologic consultation is required for wide surgical debridement.⁷ The addition of clindamycin, 600 to 900 milligrams IV every 8 hours, or metronidazole, 1 gram IV, then 500 milligrams IV every 8 hours, to the antimicrobial regimen may be of benefit.⁷ Hyperbaric oxygen therapy in the pre- and postoperative setting is a treatment option but does not improve mortality.¹⁴ Admission to the intensive care unit postoperatively is typically required.⁷

Ischemic priapism, paraphimosis, and entrapment injuries are priority diagnoses that, if left untreated, can result in necrosis of the penis.

BALANOPOSTHITIS

Balanitis (inflammation of the glans penis), posthitis (inflammation of the foreskin), and balanoposthitis (inflammation of the glans and the foreskin) are primarily caused by inadequate hygiene or external irritation with subsequent colonization with Candida species, Staphylococcus species, Streptococcus species,¹⁵ and less commonly, Mycoplasma genialium.¹⁶ Infections are frequently mixed flora.¹⁵ On examination, when foreskin retraction is attempted, the glans and apposing prepuce appear purulent, excoriated, malodorous, and tender. Balanoposthitis can be the sole presenting sign of diabetes.¹⁷ Consider Candida, Gardnerella, and anaerobes as potential causes.¹⁵ Treatment consists of cleansing the area with saline, ensuring adequate dryness after cleaning, application of antifungal creams (nystatin or clotrimazole), treatment with an oral azole in severe cases (fluconazole 150 milligrams orally), and circumcision for recurrent cases.¹⁵ Soap may increase inflammation during the acute phase, but routine hygiene is essential to prevent reoccurrence. Bacterial infection is suggested by warmth, erythema, and edema of the glans, foreskin, and penile shaft; anaerobic organism is suggested by foul smell.¹⁵ If these signs are present, oral clindamycin, 300 milligrams three times per day for 7 days, or metronidazole, 500 milligrams two time per day for 7 days, is recommended.^15,18 Cases that persist warrant culture for potential infective causes or biopsy and follow-up with urology.

PHIMOSIS

Phimosis is the inability to retract the foreskin proximally and posterior to the glans penis (Figure 93-5). Physiologic phimosis occurs naturally in uncircumcised newborns. By 3 years of age, fewer than 10% of foreskins remain nonretractile, with nearly all becoming retractile by late adolescence. Infection, poor hygiene, and previous preputial injuries with scarring are common causes of pathologic phimosis. Scarring at the tip of the foreskin can occlude the preputial meatus, infrequently causing urinary retention. Hemostatic dilation of the preputial ostium will temporarily relieve the urinary retention. Circumcision is curative. Alternatively, topical steroid treatment (such as betamethasone, 0.05% to 0.10% twice daily) applied from the tip of the foreskin to the glandis corona for 1 to 2 months, along with daily manual preputial retraction, has been shown to be an effective nonsurgical management option for phimosis.¹⁹

PARAPHIMOSIS

Paraphimosis, a true urologic emergency, is the inability to reduce the proximal edematous foreskin distally over the glans penis into its natural position (Figure 93-5). The resulting glans edema and venous engorgement can progress to arterial compromise and gangrene.

Paraphimosis can often be reduced by compression of the glans for several minutes to reduce edema and allow for successful reduction of the now smaller glans through the foreskin. Tightly wrapping the glans with a 2-inch elastic bandage for 5 minutes will reduce edema. A local anesthetic block of the penis can help the patient tolerate the pain of compression but also adds fluid to an already swollen penis. The patient may require an anxiolytic before the injection of a "ring" of local anesthetic at the base of the penis. If these methods are unsuccessful, local infiltration of the constricting band with 1% lidocaine without epinephrine followed by superficial dorsal incision of the band will allow foreskin reduction.²⁰ Use of an iris scissor may help prevent damage to underlying tissue. The examining provider should perform this procedure in cases of impaired perfusion to the glans, unless a urologist is immediately available.

ENTRAPMENT INJURIES

Circumferential objects surrounding the penis can occlude the veins and, subsequently, the arterial blood supply. Hair, string, metal rings, and wire have been wrapped around the penis for accidental, experimental, or sexual reasons. Removing the offending object requires care and ingenuity.²¹ Removal techniques include compression and cooling the penis, cutting the object, and urologic surgical removal.²¹ Lubrication with petroleum jelly may assist. Ice packs can help decrease inflammation and edema, but take care to avoid cooling injury. The compression technique uses the same modified string method recommended for removing finger rings, with the addition of inserting an 18-gauge needle into the end of one of the two corpora cavernosa through the glans to allow edema and blood to be pushed out by the proximal to distal compression of the penis. Start by inserting the short end of the tape under the constriction device to be left proximally, while the long end is used to compress the penis winding in a proximal to distal direction.²¹ Cutting devices can remove penile rings. Protect underlying skin with a hard object, preferably metal. Also avoid overheating the surrounding tissues. Urologic consultation may be required depending on the entrapment complexity and physiologic concerns.²¹

The penile hair-tourniquet syndrome (Figure 93-6) seen in young males presents with swelling of the glans. The offending hair may be invisible within the edematous coronal sulcus. Several common techniques for removal consist of unwinding the hair, lancing the hair when easily accessible, or surgical removal when circumferential edema prevents access to the constricting source.²²

Another common entrapment injury is penile or scrotal entrapment in a zipper. The reported interventions include dismantling the zipper with wire cutters or trauma shears and surgical interventions like circumcision. First, cleanse the affected area with povidone-iodine and provide local anesthesia with 1% to 2% lidocaine. Next, try coating the zipper and affected area with mineral oil or other nontoxic lubricant. If this does not free the zipper, cut the zipper away from clothing to make the zipper easier to handle. Next, try cutting the sliding bar of the zipper and the zipper teeth.²³ The bottom bar of the zipper apparatus can also be cut and then unzipped from below.

FRACTURE OF THE PENIS

A penile fracture occurs when the tunica albuginea of one or both corpus cavernosa ruptures due to direct trauma to the erect penis.²⁴ It can be associated with partial or complete urethral rupture (18%) or deep dorsal vein injury.²⁴ The most common cause is sexual intercourse, but other causes include animal bites, stabbing, bullet wounds, and self-mutilation.^24,25 On examination, the penis is acutely swollen but flaccid, discolored, and tender. A retrograde urethrogram may be necessary to assure urethral integrity, but radiologic evaluation rarely influences surgical managment.²⁵ Surgical treatment consists of hematoma evacuation and suture apposition of the disrupted tunica albuginea.

PEYRONIE'S DISEASE

Peyronie's disease produces progressive penile deformity, typically curvature with erections, that is painful and may result in erectile dysfunction or preclude successful vaginal penetration during intercourse.²⁶ Examination of the penile shaft will disclose a thickened plaque, typically on the dorsum, involving the tunica albuginea of the corpora bodies. Urologic referral is warranted. Peyronie's disease of the penis has been noted in association with Dupuytren's contractures of the hand.

PRIAPISM

Priapism is a urologic emergency that is characterized by persistent, usually painful, pathologic erection in which both corpora cavernosa are engorged with stagnant blood.²⁷ Even though the glans penis and the corpus spongiosum are characteristically soft and uninvolved, urinary retention may develop. Impotence can result in 35% of cases with sustained erections for prolonged periods, so emergency urologic consultation is needed.

Many cases of priapism in adults are pharmacologically related to intracavernosal injection of vasoactive substances for impotence (papaverine, prostaglandin E₁), use of oral agents for hypertension (hydralazine, prazosin, calcium channel blockers), neuroleptic medications (chlorpromazine, trazodone, thioridazine), or oral agents related to erectile dysfunction.²⁷ Most cases of priapism in children are due to hematologic disorders, usually sickle cell disease.

Priapism is classified into high-flow (nonischemic) priapism and low-flow (ischemic) priapism. High-flow (nonischemic) priapism is rare, most often painless, and usually results from traumatic fistulae between the cavernosal artery and the corpus cavernosum. Blood gas analysis of the first corporal aspirate is recommended to differentiate arterial (high-flow) from ischemic priapism.²⁷ High-flow priapism may be further delineated by color Doppler US and is treated by embolization. Low-flow (ischemic) priapism is more common, is usually quite painful, and is diagnosed by the aspiration of dark acidic intracavernosal blood from the corpus cavernosum.

Provide adequate narcotic analgesia. Corporal aspiration followed by irrigation (with plain saline or α-adrenergic agonists [i.e., phenylephrine]) is the primary treatment method for persistent priapism. The urologic consultant usually performs this procedure, but if one is not readily available, the examining provider may need to intervene. On each lateral side of the proximal penis, raise a wheal with 1% lidocaine using a 27-gauge needle. After local anesthesia, insert a 19-gauge butterfly needle into the corpora cavernosa on each side, approximately 0.5 cm deep. The needle must penetrate the skin, subcutaneous tissue, and the tunica albuginea in order to enter the corpus cavernosum. The needles can be supported in place by using a combination of small gauze pads on either side of the "butterfly wings" and roller gauze around the penis to secure its position. Aspirate blood from each side.²⁷ If medical treatment or phenylephrine irrigation fails to produce detumescence, surgery may be required.²⁷ If priapism due to sickle cell crisis fails to respond to adequate analgesia and hydration, consult both urology and hematology. The role of exchange transfusion has been reexamined; penile aspiration and irrigation, with or without instillation of α- or β-adrenergic agonists, is recommended for acute ischemic episodes in sickle cell patients.²⁸

PENILE CARCINOMA

Carcinoma of the penis is rare, usually appearing in the fifth or sixth decade in an uncircumcised male. Carcinoma may appear as a nontender ulcer or warty growth beneath the foreskin in the area of the coronal sulcus or glans penis and is often hidden by an inflamed phimotic foreskin.

TESTICULAR TORSION

The differential diagnosis of acute scrotal pain includes testicular torsion, torsion of the testicular appendages, epididymitis, incarcerated hernia, and trauma, among others. Frequent causes of acute scrotal pain include testicular torsion or epididymitis in adults, with the added possibility of appendage torsion in children (Table 93-1). Because of the potential for infarction and infertility, testicular torsion must be the primary consideration in acute scrotal pain. The annual incidence of testicular torsion is 3.8 in 100,00 males under the age of 18.²⁹ Testicular torsion presents in a bimodal age distribution, with extravaginal torsion occurring in the perinatal period and intravaginal torsion peaking during puberty,²⁹ although this may occur at any age.

Torsion of the testis or spermatic cord results from abnormal fixation of the testis within the tunica vaginalis. This allows the testis to twist, especially after episodes of minor trauma and during periods of testicular growth such as puberty. Torsion usually occurs in the absence of a preceding event; only a small percentage occurs due to associated trauma. Torsion may occur during sleep, when unilateral cremasteric muscle contraction results in twisting of the testis. Inadequate fixation of the tunica vaginalis to the posterior scrotal wall (bell-clapper deformity) places the testis at risk for torsion. A testis aligned along a horizontal rather than a vertical axis is at particular risk.

Patients usually complain of acute severe pain, usually felt in the lower abdominal quadrant, the inguinal canal, or the testis. Although the pain may be constant or intermittent, it is not positional in nature, because testicular torsion is primarily an ischemic event that becomes inflammatory only after the testis has infarcted. The presence of vomiting makes the diagnosis of testicular torsion more likely.³⁰

When examined early, the involved testis is firm, tender, and often higher than the contralateral testis and frequently with a transverse lie.³¹ The epididymis may be displaced and not found in its normal posterolateral position. The most sensitive finding in excluding testicular torsion is the unilateral presence of the cremasteric reflex. Testicular torsion has, however, been reported in the setting of an intact cremasteric reflex. Although commonly associated with testicular torsion, the absence of an ipsilateral cremasteric reflex is a nonspecific finding and may be associated with scrotal inflammation from any cause. In addition, some healthy young males may have an underdeveloped reflex, particularly in the first few years of life. Relief of pain with elevation of the affected testicle (Prehn sign–positive for epididymitis) does not reliably distinguish torsion from epididymitis.

In obvious cases of testicular torsion, emergent urologic consultation and surgical exploration are essential. With acute torsion, testicular salvage is related to the duration of symptoms before surgical detorsion. Excellent salvage rates are expected with <6 hours of symptoms, but salvage declines rapidly thereafter. There are no readily available clinical or laboratory parameters to judge the degree or duration of testicular ischemia. Therefore, no matter how long the patient has been symptomatic, a rapid evaluation, including emergency scrotal exploration if necessary, should be performed. Doppler US and radionuclide scintigraphy are two imaging modalities used to evaluate patients with equivocal clinical presentations. Both may be useful, but their routine clinical use is limited by timely availability and operator experience in interpreting the images, particularly for radionuclide scintigraphy. These studies are considered "positive" for testicular torsion when they demonstrate absent or clearly reduced ipsilateral intratesticular blood flow, and "negative" when flow is normal or increased. Older duplex US studies report sensitivities ranging from 69% to 90% and specificities ranging from 98% to 99% for testicular torsion¹; however, a 2013 prospective study found a sensitively of only 83%.³² Importantly, partial torsion may reveal falsely reassuring blood flow in an ischemic testicle. Likewise, normal or increased flow may be seen in a high-risk testicle following spontaneous detorsion. Gray-scale US imaging of the spermatic cord itself assessing for coils or kinks may aid in diagnosis. US findings need to be interpreted with caution in the context of the overall clinical picture. US has the advantage of demonstrating scrotal anatomy, which may indicate an alternative diagnosis. Within these limitations, testicular imaging modalities, when used in equivocal cases, can be very helpful tools.¹

For emergency or preoperative treatment, consider manual detorsion of the affected testis. Explain to the patient that detorsion is a painful procedure but successful detorsion will help to relieve the presenting pain. Most testes twist in a lateral to medial fashion (two thirds of cases); therefore, detorsion initially should be done in a medial to lateral motion.³³ Detorsion is typically done in a manner similar to opening a book (Figure 93-7A). If one were to stand at the patient's feet, the patient's right testis would be rotated in a counterclockwise fashion and the patient's left testis in a clockwise fashion (Figure 93-7B). The initial attempt should include one and one-half rotations (540 degrees). Any relief of pain is a positive end point, and the success of the maneuver can be assessed with Doppler US, demonstrating restoration of blood flow. An occasional patient will require manipulation beyond the initial one and one-half rotations. A worsening of the patient's pain suggests that detorsion should then be done in the opposite direction (one third of cases). Successful detorsion converts an emergent procedure to an elective one. The timing of the elective surgical correction should depend on the patient's compliance and responsibility.

Young boys may present to the ED with nonspecific abdominal pain suggestive of gastroenteritis only to return 1 to 2 days later with a diagnosis of testicular torsion. Whether these patients had undisclosed testicular torsion at their initial evaluation is not known, but consider testicular torsion in the differential diagnosis of any male presenting with abdominal pain or vomiting.

APPENDAGEAL TORSION

The four testicular appendages—appendix testis, appendix epididymis, paradidymis (organ of Giraldes), and vas aberrans—have no known physiologic function. These pedunculated structures are capable of torsion and, in prepubertal boys, probably twist more often than the testes, with the appendix epididymis and appendix testes accounting for approximately 8% and 90% of appendage torsion, respectively. Presenting symptoms, although similar to testicular torsion, classically lack the systemic symptoms of nausea and vomiting. If the patient is seen early, with the pain localized to the upper pole of the testis or epididymis, a blue spot may be observed through the scrotal skin—the "blue dot sign." This "sign" is pathognomonic for torsion of the appendix testis or epididymis. If the diagnosis can be assured and normal intratesticular blood flow to the involved testis is confirmed by color Doppler US, surgical exploration is not necessary. Torsion of an appendage is usually self-limiting and best managed with analgesics, bed rest, supportive underwear, and reassurance, with the expected symptom resolution within 3 to 5 days. If late in the process and testicular swelling is present, or if the color Doppler US is equivocal, then urologic consultation and surgical exploration are needed to exclude testicular torsion.¹

EPIDIDYMITIS

The onset of pain in epididymitis or epididymo-orchitis is usually gradual. Bacterial infection is the most common cause, and the type of infection tends to depend on age. In young boys, epididymitis or epididymo-orchitis is commonly associated with sterile reflux of urine, but may be due to coliform bacteria, often associated with congenital anomalies of the lower urinary tract. Other considerations include increases in abdominal pressure from lifting or straining, which promote urinary reflux into the tail of the epididymis and subsequent inflammation. In young men <35 years old, epididymitis is due primarily to sexually transmitted diseases or associated complications (i.e., urethral stricture). Consider fungal or coliform infection of the lower urinary tract in addition to the more common sexually transmitted disease organisms in the setting of anal insertive intercourse. In men >35 years old, epididymitis is more commonly caused by common urinary pathogens, such as Escherichia coli and Klebsiella, or sexually transmitted diseases. In elderly men with epididymitis and urinary tract infection, consider associated benign prostatic hypertrophy or urethral stricture. Large residual urine volume (>50 to 100 mL urine) suggests outlet obstruction as the cause of the patient's infection (see chapter 92, "Acute Urinary Retention"). Chemical epididymitis can occur due to reflux of sterile urine and should be considered as a cause of prolonged symptoms despite appropriate antibiotic treatment.

CLINICAL FEATURES

Epididymitis may cause lower abdominal, inguinal canal, scrotal, or testicular pain alone or in combination. The retrograde progression of infection from the prostatic urethra to the epididymis explains the location and progression of pain. Epididymitis represents a more advanced GU tract infection when compared with urethritis. Patients with epididymitis are more prone to lower urinary tract voiding discomfort and may note transient pain relief in the recumbent position with scrotal elevation. Initially, isolated firmness and nodularity of the affected globus minor are noted on examination. As the disease progresses, the sulcus between the epididymis and testis becomes obliterated, and the inflammatory epididymal mass may become contiguous with the testis, producing a large, tender scrotal mass (epididymo-orchitis) that may be difficult to differentiate from testicular torsion or abscess.

Urinalysis may show pyuria in about half of patients. Obtain a specimen for gonorrhea and Chlamydia if urethral discharge is present, or in patients <35 years old. Obtain urine culture in children and elderly men. Adjunctive diagnostic modalities, such as color flow duplex Doppler sonography or radionuclide scintigraphy, will demonstrate increased or preserved blood flow to the testes. A reactive hydrocele may be seen on US.

TREATMENT

Most cases of epididymitis can be managed with oral antibiotics (Table 93-2).³⁴ Admission criteria for epididymitis include fever and clinical toxicity, which can be indicative of epididymal or testicular abscess formation. The ambulatory patient should wear a scrotal supporter, being careful not to lift heavy objects or strain when having a bowel movement, both of which will increase intra-abdominal pressure and exacerbate the inflammatory cycle. A urologist will need to reevaluate the patient in 5 to 7 days and then ultimately decide when the patient may return to work based on his job description (i.e., a sedentary worker would be able to return sooner than a laborer).

ORCHITIS

Isolated orchitis, or inflammation of the testicle, is quite rare and usually occurs in conjunction with other systemic infections, such as mumps or other viral illnesses (coxsackie virus, Epstein-Barr virus, varicella, or echovirus). Mumps orchitis presents with unilateral involvement in 70% of cases, followed by contralateral involvement in 1 to 9 days. Bacterial orchitis is almost always associated with epididymitis. Orchitis in immunocompromised patients can be due to mycobacteriosis, cryptococcosis, toxoplasmosis, or candidiasis. Patients with orchitis usually present with testicular tenderness and swelling over a few days in duration. The diagnosis is primarily clinical using history and physical examination, but US can exclude testicular torsion or abscess. Treatment for acute episodes starts with antibiotic coverage as listed above for epididymitis; IV antibiotics should be considered for patients with abnormal vital signs.³⁴ Immunocompromised patients or patients with risks for tuberculosis (exposure, uncontrolled human immunodeficiency virus, or diabetes) require admission if they have abnormal vital signs or, if not, referral to urology and/or infectious disease for further management.

TESTICULAR MALIGNANCY

The hallmark of testicular carcinoma is an asymptomatic testicular mass with firmness or induration. Ten percent of tumors will present with pain secondary to acute hemorrhage within the tumor. Metastatic testicular tumors can be insidious and must be suspected in any male with unexplained supraclavicular lymphadenopathy, abdominal mass, or chronic nonproductive cough from a lung metastasis. Testicular examination may disclose a primary tumor. Any unexplained testicular mass must be approached as a possible tumor with urgent urologic referral.

Acute prostatitis is bacterial inflammation of the prostate gland. Patient complaints can include low back pain; perineal, suprapubic, or genital discomfort; obstructive lower urinary tract voiding symptoms; frequency or dysuria; perineal pain with ejaculation; and fever or chills. Risk factors include anatomic or neurophysiologic lower urinary tract obstruction, acute epididymitis or urethritis, anal receptive intercourse, phimosis, intraprostatic ductal reflux, and indwelling urethral catheter or condom drainage. The causative organism is E. coli in most cases, with other uropathogens such as Pseudomonas, Klebsiella, Enterobacter, Serratia, or Staphylococcus causing the remainder. In contrast to acute prostatitis, chronic bacterial prostatitis is characterized by prolonged or recurrent symptoms and relapsing bacteriuria.

Clinical findings include perineal tenderness, rectal sphincter spasm, and prostatic tenderness or bogginess. The diagnosis is clinical, because urinalysis and urine culture may both be negative. Prostatic massage is not necessary to make the diagnosis. Obtain urethral cultures or first-void urine for gonorrhea and chlamydia testing.

Initial treatment is fluoroquinolone antimicrobial therapy for 2 to 4 weeks,³⁵ such as ciprofloxacin, 500 milligrams orally for 14 days, with plan for primary care revelation at 2 weeks for possible continued therapy as needed. If drug cost is an issue, trimethoprim-sulfamethoxazole double-strength, one tablet PO twice a day, is an alternative, although cure rates are lower than for the fluoroquinolones. Consider treating for sexually transmitted disease organisms in younger patients or older patients with sexually transmitted disease risk factors; give ceftriaxone, 250 milligrams IM as a single dose, plus doxycycline, 100 milligrams PO twice a day for 14 days. Provide adequate narcotic analgesia.

Most patients can be treated as outpatients. Patients with abnormal vital signs should be admitted and given a broad-spectrum antibiotic such as piperacillin-tazobactam, 3.375 to 4.5 grams IV, or cefotaxime combined with an aminoglycoside.³⁵ If associated with urinary retention, urology consultation is needed. Urologic follow-up should be provided for discharged patients to ensure eradication of infection and to provide continuity of care in case of relapse. Chronic prostatitis is managed with urine cultures after prostatic massage, long-term antibiotics based on culture for chronic bacterial infections, anti-inflammatory medicines plus α-blockers for nonbacterial chronic prostatitis, and urology follow-up.

URETHRITIS

Urethritis is characterized by purulent or mucopurulent urethral discharge. Diagnosis is clinical, although it can be confirmed by evidence of pyuria or bacteriuria in a first-void urine specimen. Most cases are due to Neisseria gonorrhoeae or Chlamydia trachomatis. Herpes simplex virus, Ureaplasma urealyticum, or Trichomonas vaginalis are less frequent causes. Physical examination should exclude other disorders such as epididymitis, disseminated gonococcemia, or Reiter's syndrome. Treatment for urethritis is ceftriaxone, 250 milligrams IM, and azithromycin, 1 gram PO, or doxycycline, 100 milligrams PO twice a day, for 7 days. Failure to respond suggests reinfection or reexposure or infection with T. vaginalis or doxycycline-resistant U. urealyticum. Treatment with metronidazole or azithromycin should be considered depending on the infectious etiology. See chapter 149, "Sexually Transmitted Infections" for further discussion of sexually transmitted diseases.

URETHRAL STRICTURES

In decades past, sexually transmitted diseases caused the largest percentage of urethral strictures; however, trauma (such as pelvic fractures) and urinary instrumentation have been shown to cause the majority of strictures in recent assessment (Figure 93-8).³⁶

If a patient requires measurement of his residual urine volume, simple bedside US can be performed. Most urologists agree that postvoid volumes of 50 to 100 mL may signify an abnormal residual urine volume. If the patient has difficulty voiding or is in urinary retention and a 14- or 16-F Foley or Coudé catheter cannot be easily placed into the bladder, the differential diagnostic possibilities include urethral stricture, voluntary external sphincter spasm, bladder neck contracture, or benign prostatic hypertrophy. If time permits, retrograde urethrography can be done, which will define the location and extent of a urethral stricture. Only cystoscopy can confirm a bladder neck contracture or the extent of an obstructing prostate gland. Suspected voluntary external sphincter spasm can be overcome by holding the penis upright and encouraging the patient to relax his perineum and breathe slowly during urinary catheter insertion. Liberal preapplication of intraurethral anesthetic lubricant jelly for male urinary catheterization is prudent.

When a urethral stricture is encountered, copious anesthetic lubrication is placed intraurethrally after the foreskin has been controlled with folded 4 × 4 gauze. This latter maneuver is especially important in uncircumcised patients. A 12- or 14-F Coudé catheter may negotiate the strictured area, because this catheter has an angled bend near its tip. If there are previous false passages from attempts at dilation or unsuccessful instrumentation, passage of the Coudé catheter may be difficult. Further urethral manipulation may create new false passages, leading to unnecessary hemorrhage and possible gram-negative bacteremia. If two or three gentle attempts to pass the catheter fail, urologic consultation is indicated. A catheter guide or urethral sound should be used only by a urologist.

For emergency bladder decompression, consider a suprapubic cystostomy using the Seldinger technique (see chapter 92, "Acute Urinary Retention").

URETHRAL FOREIGN BODIES

Patients of all ages, but especially young children, may be victims of innocent urethral exploration or attempts to heighten sexual experiences by using a variety of foreign bodies such as bobby pins; long, thin paint brushes; or ball point pens.³⁷ Bloody urine combined with infection and slow, painful urination should suggest a possible foreign body in the lower urinary tract. An x-ray of the bladder and urethral areas may disclose the presence of a radiopaque foreign body.

Foreign bodies often require cystoscopic removal or even open cystotomy. Occasionally a gentle milking action of the proximal end of the urethral foreign body by an experienced examiner will allow its retrieval from the distal urethral meatus. Even then, retrograde urethrography or endoscopic confirmation of an intact urethra is indicated.

Hemospermia, or hematospermia, is a disturbing symptom that produces extreme anxiety in sexually active males. The incidence and prevalence of this condition are not known. For all practical purposes, hematospermia can be regarded as gross hematospermia—that is, visually apparent to the patient—as microscopic analysis of semen is rarely performed. Most symptomatic men seek medical attention after one or two occurrences. Any process that results in trauma or other injury (e.g., tumor with erosion), inflammation, or infection of the male ejaculatory system may result in bloody semen.³⁸ It is not uncommon after vigorous sexual activity. Unless the cause can be determined on physical exam, the diagnosis cannot be completed in the ED. Seventy percent of cases are diagnosed as idiopathic hematospermia after a complete outpatient urologic workup. Hematospermia should be differentiated from hematuria based on a clean catch urinalysis (see chapter 91, "Urinary Tract Infections and Hematuria"). Infection, including sexually transmitted disease, should be considered, and if suspected based on history and physical, the patient should be cultured and treated appropriately. Although all patients with hematospermia should be referred to a urologist, those >40 years are at higher risk for cancer and should be strongly advised to seek further evaluation by a urologist even when there is spontaneous resolution of hematospermia.