Chapter 95: Complications of Urologic Procedures and Devices

Urinary catheters should be used sparingly. Indwelling urethral catheters are the most common; suprapubic catheters require a surgical procedure but have fewer infectious complications (see chapter 92, "Acute Urinary Retention"). Most catheters are made of latex; however, silicone catheters are available for patients with latex allergy.¹ Table 95-1 lists the complications of urinary catheters.

INFECTION

Catheter-associated urinary tract infections (UTIs) are one of the most common causes of nosocomial infections. The risk of infection is approximately 1% to 2% with a catheter in place for <24 hours, with the prevalence of bacteriuria reaching almost 100% for long-term catheterization (by 30 days).² Comorbidities that increase the risk of catheter-associated UTI include female sex, prostatic hypertrophy, creatinine >2 milligrams/dL, diabetes, advanced age, nonsurgical disease, and debilitation.³ Microbial factors associated with an incidence of catheter-associated UTI include the source of the organisms, the specific bacteria, the route of invasion, and the duration of catheterization.

Pathophysiology

In the noncatheterized urinary tract, bacteria are efficiently eliminated. In contrast, most bacterial strains that are introduced into the catheterized urinary tract are able to multiply to high concentrations in 24 hours. Bacteria may be able to gain access to the urinary tract through the catheter lumen (intraluminal) or along the catheter surface (extraluminal). The drainage tube of a urinary catheter must be opened periodically to drain the accumulated urine. If the drainage tube lumen is colonized, bacteria may ascend the collection bag and catheter, causing an infection. An infection from the catheter lumen route begins with the formation of a biofilm on the catheter's inner surface. This biofilm extends from the uroepithelium through catheters to the drainage bag and allows adherence of bacteria to a catheter or mucosal surface. Organisms become embedded within the biofilm and gain protection from the mechanical flow of urine, host defenses, and antibiotics.² The microbiology of catheter-associated UTI varies according to the duration of catheter placement. During short-term catheterization, infections are usually due to single organisms, most commonly Escherichia coli, followed by Klebsiella, Pseudomonas, Enterobacter, and gram-positive cocci such as staphylococci. With long-term catheterization (≤30 days), catheter-associated UTIs are usually polymicrobial from E. coli, Proteus mirabilis, Pseudomonas, Morganella morganii, and Candida species. These infections are usually difficult to treat due to antibiotic resistance by the infecting bacteria.²

Asymptomatic bacteriuria usually occurs with short-term catheterization, and removal of the catheter clears the bacteriuria. Antibiotic treatment of asymptomatic bacteriuria in a patient with a short-term indwelling urinary catheter is not recommended^2,3,4,5 (unless the patient is pregnant or immediately pending a urologic procedure). Guidelines and reviews recommend antibiotics for symptomatic catheter-associated UTI only.^2,3,4

Clinical Features

Signs and symptoms include fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort; and in those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness. In patients with spinal cord injury, increased spasticity, autonomic dysreflexia, and sense of unease are also compatible with catheter-associated UTI.⁴

Diagnosis

Diagnoses of catheter-associated UTI symptoms are listed in Table 95-2.⁴ Pyuria is universal for patients with long-term (>1 month) indwelling catheters; in the absence of clinical symptoms, pyuria should not be used in the diagnosis of symptomatic infection.^2,3,4 Hematuria is a better indicator of infection and also may suggest urinary obstruction. Bedside US can identify urinary obstruction.⁴

Pyelonephritis (complicated UTI; see chapter 91, "Urinary Tract Infections and Hematuria") is the most common complication of catheter-associated UTI with fever. Other related infections include prostatitis, epididymitis, and scrotal abscess. Obtain urine cultures prior to empiric antibiotic therapy, and obtain blood cultures if the patient is septic or immunocompromised.²

Treatment

Remove the catheter if clinically feasible, or replace the catheter if it has been in place for >7 days.^2,4 Empiric antibiotics should be instituted promptly in most cases⁴ unless the fever is low grade and the clinical condition allows for time to perform cultures and continued observation.² Assess local resistance patterns if available before instituting therapy. Treatment for complicated UTI is reviewed in Table 91-6. Outpatient treatment for patients without clinical toxicity is presented in Table 91-5 in chapter titled "Urinary Tract Infections and Hematuria". A total of 7 total days is the recommended duration of antimicrobial treatment for patients with catheter-associated UTI who have prompt resolution of symptoms, and a total of 10 to 14 days of treatment is recommended for those with a delayed response.⁴ Alter drug regimens for renal insufficiency. If candiduria exists, remove the catheter, and consider antifungal agents in symptomatic patients.^2,4

CATHETER OBSTRUCTION AND LEAKAGE

Urethral catheters can become obstructed for many reasons, most commonly from the formation of intraluminal encrustations during long-term placement. These concretions are composed of compounds, such as ammonium magnesium sulfate (struvite) and calcium phosphate (apatite), often with urease-splitting organisms, such as Protease and Morganella. Such encrustations can increase the risk of formation of infectious stones and cause bladder trauma, leading to blood clots. A catheter obstruction may lead to urinary leakage around the catheter and acute urinary retention. Management options include repeated bladder irrigations, methenamine treatment, and removal of the catheter if the other methods fail.

NONDEFLATION OF FOLEY RETENTION BALLOON

The Foley balloon is typically inflated with 10 mL of sterile water after successful insertion. Nondeflation of the retention balloon on the catheter can be caused by a faulty valve mechanism or crystallization of balloon fluid, yielding entrapment of the Foley catheter.⁶ One noninvasive method is introduction of a flexible guidewire into the balloon inflation channel after cutting off the plastic cylindrical valve from the catheter just below its head. The guidewire dilates the channel and may allow the balloon to deflate. If unsuccessful, try step 2; a 22-gauge central venous catheter can be passed over the guidewire. When the catheter tip is into the balloon, the wire can be removed, and the balloon may drain. If step 2 is unsuccessful, instill 10 mL of mineral oil and leave for 15 minutes in an attempt to dissolve the balloon. Repeat once (10 more mL of mineral oil) if unsuccessful. If simple methods do not work, urologic consultation for intervention and potential cystoscopy is recommended.⁷ Another alternative is US-guided percutaneous rupture of the balloon using a needle, typically done by the radiologist in the US suite with input from urology.

Percutaneous nephrostomy is a urinary drainage procedure used for supravesical or ureteral obstruction secondary to malignancy, pyonephrosis, GU stones, and ureteral strictures. It is also adjunctive to lithotripsy and ureteral stents. Nephrostomy tubes are also used for urinary diversion associated with vesical fistula, ureteral transection, and trauma. The percutaneous procedure to remove renal calculi is known as percutaneous nephrolithotomy. Nephrostomy tubes or stents are commonly left in place, but the tubeless percutaneous nephrolithotomy technique may have less risk of morbidity.⁸ Patients develop postoperative complications days or months after the percutaneous nephrostomy. In general, the risk of complications is low and includes bleeding, infection, mechanical complications related to the catheter (dislodgement or obstruction), and accidental punctures of adjacent organs.⁸

During insertion, injury can occur to the renal collecting system (subintimal dissection), lungs (pneumothorax), liver, spleen, and bowel (perforation).⁹ This complication usually is clinically apparent during or immediately after the procedure, but recognition may be delayed a few days.⁹

Bleeding and hemorrhage can occur, especially if the patient has a coagulopathy. Check hemoglobin, hematocrit, and renal function. Obtain coagulation studies (prothrombin time, partial thromboplastin time, and platelet count) and type and cross-match if bleeding is excessive or if coagulopathy is suspected. Most bleeding episodes are mild and can be managed with irrigation to clear nephrostomy tube blood clots. More severe bleeding can be handled by catheter tamponade, a procedure undertaken by the urologist and radiologist. Severe hemorrhage occurs from vascular injury, such as laceration of an artery, formation of an arteriovenous fistula, or bleeding from a pseudoaneurysm, and may occur in the retroperitoneal space or perirenal areas. In such cases, fluid resuscitation and blood transfusion, in addition to more definitive interventions, are required. Angiographic studies with possible embolization may be needed to ascertain the site of bleeding and effect treatment.⁹ Infectious complications from nephrostomy tubes include simple bacteriuria, pyelonephritis, renal abscess, bacteremia, and urosepsis. Signs and symptoms are fever, chills, rigors, pain, and purulent drainage at the site or from the tube. Obtain urine and wound drainage (if present) cultures, and give antibiotics after consultation with the urologist.

Mechanical complications, such as catheter dislodgement, tube blockage, and residual stone fragments, can occur with these devices. CT scan may be helpful for specific diagnosis. The risk of catheter dislodgement increases with increasing duration of the nephrostomy. Dislodgement occurring in the early postoperative period usually requires creation of a new tract at a different site. Dislodgement occurring after some period may be treated by recannulation under fluoroscopic guidance. Tube blockage can occur secondary to encrustations and kinking. The urologist has several techniques available to reestablish access to an obstructed nephrostomy tube.^8,9

The most common method of urinary diversion in the United States is the ileal conduit. With this procedure, a section of small bowel is isolated, and the free ends of the remaining small bowel are reunited, allowing for normal bowel function. The ureters are reimplanted to the isolated section of small bowel, most commonly at the base of the conduit. A stoma is created, typically on the anterior abdominal wall, where a collecting bag is attached. Postoperative complications include bowel obstruction, pyelonephritis, skin breakdown surrounding the stoma, stenosis of the stoma, and inflammatory changes of the upper tract due to reflux of urine back into the ureters. Complications occur in 66% of patients, including deterioration in kidney function (27%), stoma stenosis or infection (24%), bowel obstruction or symptoms (24%), symptomatic UTI/pyelonephritis (23%), conduit/ureteral anastomosis dysfunction (14%), and urolithiasis (9%).¹⁰

There are multiple newer methods of creating a neobladder for orthotopic bladder substitution. These methods all have a goal of creating a continent reservoir for urine without reflux of the urine into the reimplanted ureters, which predisposes the patient to pyelonephritis. Options include other means of isolating portions of the small bowel (Kock pouch, T pouch, "W" shape neobladder) or large bowel (ileocecal segment). An evidenced-based evaluation of multiple methods has failed to identify a superior procedure.¹¹ Bacteriuria is common after the procedure (85%) and mostly involves skin flora but may occasionally include uropathogenic strains (gram-negative Enterobacteriaceae species like E. coli, Proteus, Pseudomonas, and Enterococcus faecalis).^2,3,12 Clean intermittent catheterization, frequently required after procedure, is associated with increased bacteriuria and pyuria. Diagnosis of infection should be made on evidence of symptomatic infection based on fever, flank pain, a change in chronic symptoms, or culture of pathologic organisms. A threshold of at least 10⁴ colony-forming units/mL should be used as the criterion for a positive culture.¹³ Consultation with urology may be required for optimal management.

Extracorporeal shock wave lithotripsy is the application of repetitive high-intensity sound waves to fragment GU calculi so they can pass down the ureter more easily.¹⁴ Common complications include colicky pain in 15% to 40%, gross hematuria in 32%, skin bruising in up to 26%, and steinstrasse ("street of stone," aggregate of stone fragments lining and/or impacting the ureter) in up to 24%.^15,16,17 Uncommon complications include spleen rupture, kidney rupture, pyelonephritis/sepsis, bowel injury, ureteric perforations, psoas abscess, vascular injury, and pancreatitis (a small rise in lipase is common).^{15, 16, 17, 18} Postlithotripsy patients may present with abdominal and flank pain, nausea, vomiting (especially 48 hours after procedure), skin ecchymosis, gross hematuria, or fever in up to 30%. Uncommonly, patient may be unstable with hypotension or sepsis. Hematuria is generally self-limited (<24 hours); however, UTI may be coexistent. Diagnosis of minor complications usually requires blood counts, basic chemistries, urinalysis, and renal US if obstruction is suspected. CT scan or MRI (only if stable) is indicated if the serious complications are suspected (consider with flank hematoma, fall in hematocrit, hypotension, syncope, or significant pain). Acute management may include IV fluid hydration, antiemetics, analgesics, monitoring, fluid resuscitation, blood transfusions, and antibiotics. Most patients are managed conservatively with close monitoring of hemodynamic status, urine output, and laboratory studies to assess for decreasing hematocrit and renal function. Consult urology early on, because specific treatments, such as embolization and nephrectomy, may be required.¹⁴

Ureteral stents are used primarily in patients to relieve ureteral obstruction and maintain ureteral lumen patency. Obstruction to the ureter may result from causes such as stones, strictures, trauma, malignancies, or retroperitoneal fibrosis. Stents can be placed during ureteroscopy, by the percutaneous nephrostomy route, during surgery involving the GU tract to maintain urinary patency and drainage, and in very specific cases as an adjunct to lithotripsy in the management of nephrolithiasis. Table 95-3 lists the complications of ureteral stents.

Many factors contribute to stent-related UTIs. Stents induce a foreign body reaction, which increases the risk for infections. Encrustation of stents in the presence of infection with urea-splitting organisms also promotes infection. More serious infections, such as pyelonephritis and sepsis, can occur but are less common.

Most minor infections can be managed with outpatient antibiotics and do not require stent removal (see antibiotic recommendations for catheter-associated UTI in the "Infection" section above). If pyelonephritis or a systemic infection is suspected, IV antibiotics, radiologic studies to determine the position of the stent, and urologic consultation are required. Stents usually can be visualized by plain abdominal x-rays due to the presence of radiodense marking embedded within the catheters. US imaging can detect hydronephrosis, along with confirmatory CT studies if obstruction or pyelonephritis is present.^19,20

Symptoms, such as mild flank pain, and signs suggestive of an irritative bladder, such as dysuria, urgency, frequency, incontinence, and pain during voiding, occur commonly in patients with ureteral stents. Treatment options for these symptoms can include analgesics and anticholinergic medications and obtaining urine specimen to exclude UTI. New complaints and symptoms, such as severe flank pain, require evaluation for stent migration, infection, or obstruction. Asymptomatic microscopic hematuria is usually of no clinical significance, but gross hematuria may indicate stent migration or ureteral erosion. Imaging studies are needed to identify stent position.^19,20

Serious problems, such as stent migration and stent fragmentation—or even rarer, ureteral-arterial fistulization due to stent erosion into a nearby vessel—are usually late complications seen with long-term stent placements. Stent migration can occur upward above the ureteropelvic junction or downward below this junction. See Figure 95-1 for a radiographic demonstration of ureteral stent migration. Such migration can lead to obstruction and infections. Stent migration results in symptoms of new-onset abdominal pain, fever, and irritative bladder symptoms and hematuria.^19,20 For new anemia without hematuria, obtain a CT without contrast to rule out a stent-caused retroperitoneal hematoma.²¹ In the presence of severe gross hematuria and syncope or hypotension, assume vascular fistulization from an eroding stent exists until proven otherwise.²¹ Resuscitate with IV fluids, and conduct lab studies, bladder irrigation as indicated, and possible blood transfusion. Serious complications require immediate consultation with the urologist, and depending on the case, a surgeon and radiologist may need to be consulted.

Prostate surgery is commonly performed for symptomatic benign prostatic hyperplasia or prostate cancer. Surgical techniques include prostate needle biopsy, transurethral resection of the prostate, transurethral electrovaporization of the prostate, transurethral microwave thermotherapy of the prostate, transurethral needle ablation of the prostate, and visually assisted laser prostatectomy.^22,23 Complications include urinary retention (3%), clot retention (2%), UTI (1.7%), and bleeding requiring transfusion (0.4%). Less common complications include blood per rectum, urethral strictures, and urosepsis.^22,23 Patients may also experience obstructive or irritative voiding symptoms, including incontinence, dysuria, hesitancy, dribbling, urgency, and frequency.

Depending on severity of illness, appropriate laboratory studies may include urinalysis, CBC, blood type and screen, blood chemistries, and renal function. Assess for hemodynamic instability and treat with IV fluids or blood for life-threatening bleeding. Patients with outflow obstruction should be treated with a three-way Foley catheter. Start with manual irrigation to remove clots, and then initiate continuous irrigation with normal saline until clear or slight pink return.⁶ If bleeding does not clear, consult urology. Prolonged irrigation requires monitoring of serum electrolytes to assess for hyponatremia.⁶ If infection is suspected, obtain urine cultures, administer antibiotics, and consult with the urologist.

The artificial urinary sphincter is used for urinary incontinence secondary to sphincter disturbance, postsurgical incontinence, neurogenic bladder with incontinence, trauma to the urethra, and congenital conditions associated with bladder dysfunction, such as exstrophy and epispadias. There are many different models of sphincter devices. The basic principle of the artificial sphincter is to increase the resistance around the urethra and, thus, provide urinary continence.^24,25 Mechanical parts of the artificial sphincter include a pump, an inflatable cuff that encircles the urethra, and a pressure-regulating reservoir balloon (Figure 95-2). These are connected by a set of two tubes. Continence occurs when fluid is moved from the balloon to the cuff. To allow urination, the cuff is emptied, and fluid moves to the reservoir. Both activities are controlled by the pump, which is implanted in the scrotum of males or the pelvis of females.²⁵

Postoperative complications can include bleeding (including hematoma), infection, and malfunctions. Hematomas usually occur in the scrotum or the labia, and most resolve spontaneously. Larger hematomas may need to be drained to aid with the healing process (consult the surgeon).^24,25

Infections are the most serious complication of the artificial sphincter. Periprosthetic infection can present early or late after surgical implantation. Infections occurring early after implantation are usually due to skin flora. Later infections are usually due to gram-negative organisms of the urinary tract. Symptoms and signs of infection can range from pain, swelling, and induration of the site to localized erythema of the pump or cuff site. More serious infections can present with fever, cellulitis, local abscess formation, drainage from incision sites, and erosion of the pump or the cuff. Infections can cause the components (e.g., cuff) to externalize out onto the skin or erode the urethra.²⁶ Treatment of periprosthetic infection requires antibiotics and removal of the sphincter. Patients with an artificial sphincter in place should receive antibiotic prophylaxis when undergoing procedures that may cause hematogenous seeding of the device, such as dental procedures.²⁶

Retained air bubbles, tube kinking, fluid leaks, and perforation of the cuff are some of the mechanical complications that can occur with the artificial sphincter. Air bubbles can cause blockage of the pump, leading to filling defects and, thus, incontinence. Ineffective device functioning secondary to fluid leakage also can lead to sudden onset of incontinence. Tube kinking, a rare complication, can result in fluid blockage, thereby leading to urinary retention. A careful history may provide clues to malfunction. A pump that is difficult to squeeze implies blockage due to any cause, whereas a pump that remains compressed after squeezing signifies pressure loss or fluid leakage. Incorrect urinary catheterization and damage to the device components during other nonurologic surgeries may account for iatrogenic malfunction of the artificial sphincter. Plain radiographs of the pelvis and other imaging studies are used to assess continuity of the mechanical components.^24,25

Urethral erosion secondary to infection or excessive cuff pressure around the urethra is another serious complication and one that is seen most commonly within several months after the implantation. Signs and symptoms include pain, swelling along the urethra and in the perineum, urinary incontinence, bloody urethral discharge, and infection. Cystourethroscopy and cuff removal are necessary for management of erosions.^24,25,26

Recurrent incontinence after artificial sphincter placement can have many causes—infection, cuff erosion, fistulas due to surgical injuries, or mechanical failure. Evaluation requires urodynamic studies to accurately define the cause. Acute urinary retention in a patient with an artificial sphincter implant may occur as a result of bladder neck contractures, urethral strictures, or cuff erosion. Evaluation usually requires cystourethrography or cystourethral endoscopy.

Evaluation in the ED of complications related to the artificial sphincter requires a thorough history noting the model type and make; symptom assessment; a detailed physical examination; urinalysis; appropriate labs, cultures, and imaging studies; and consideration for IV antibiotics as indicated. Never introduce a urethral urinary drainage catheter through an artificial urinary sphincter. Consult the urologist for further evaluation and management.

The most common causes of erectile dysfunction are diabetes, priapism, vascular disease, Peyronie's disease (deformity especially seen on erection due to nodules/fibrous plaques in penile tissue), pelvic trauma or surgery, spinal cord injury, and psychogenic reasons. Although oral medication and penile injectable device treatment currently exist for erectile dysfunction, some patients with erectile dysfunction fail pharmacologic therapy and are treated with nonpharmacologic interventions such as vacuum therapy, external splint devices, and the surgically implantable prostheses.²⁷ Two forms of injection therapy for erectile dysfunction are available: intracavernosal and intraurethral.

INTRACAVERNOSAL INJECTIONS

The intracavernosal injections are given along the lateral aspect of the penis, directly into the corpora cavernosa. The basic mechanism involves vasodilatation of arteries and veins leading to corporal smooth muscle relaxation and penile erection. Drugs used are papaverine, phentolamine, and alprostadil, a prostaglandin E₁ analog, singly or in combination. Side effects include penile pain, prolonged erections (4 to 6 hours), priapism (painful erection for longer than 6 hours), and localized hematoma. Of these, priapism is the most critical complication. Management of priapism includes emergent urology consultation for direct injection of terbutaline or α-adrenergic agonists, such as phenylephrine, and corporal aspiration of blood (see chapter 93).²⁸

INTRAURETHRAL INJECTION

Intraurethral injections of alprostadil are successful in producing penile engorgement. One marketed product, the MUSE^® (medicated transurethral system for erection), uses a medicated pellet via an applicator that allows insertion of the drug into the urethra. The basic mechanism of intraurethral administration is similar to intracavernosal injections. The drug is absorbed from the urethra and through the local communicating vessels and exerts its actions on the corpora. Side effects are few and can include penile pain, urethral bleeding, laceration of the cavernosal artery, and dizziness. Very rarely, priapism can occur. Intraurethral administration is usually free of any major systemic side effects, but syncope secondary to a vasovagal reaction due to the anxiety of the injection and the vasodilatory effects of the drug can occur.²⁹

VACUUM DEVICES AND PENILE SPLINTS

Vacuum devices work by use of negative pressure and the use of a constriction ring to cause venous and arterial congestion, thus causing penile engorgement. The most common complaint reported is pain during application of the device and during ejaculation secondary to inappropriate pressure rise. Both symptoms can be resolved with proper education on use of the device. Local skin cyanosis secondary to a drop in penile blood flow from the negative pressure may also be seen. Serious complications from the use of a vacuum device include penile skin necrosis, urethral bleeding, ischemia, and subcutaneous hemorrhage with ecchymosis. Peyronie's disease and Fournier's gangrene have also been reported.³⁰

The external penile splint consists of two steel support rods in a silicone cover that have a support loop at the distal end, to loop around the subcoronal sulcus, and support rings at the proximal end, to position around the base of the penis. Aside from occasional dislodgement during sexual intercourse, these splints are relatively free of side effects.²⁷

PENILE PROSTHESES

Surgical implantation of a penile prosthesis is reserved for men who fail pharmacologic treatment. Several different kinds of implantable penile prostheses are used: the malleable or semirigid devices, and inflatable types that contain fluid to give a more natural erection. The malleable or semirigid device consists of implanted semirigid rods and is always somewhat firm. The penis may be positioned away from the body to achieve penetration. There are self-contained and three-piece inflatable devices. The self-contained device consists of a pair of inflatable cylinders inserted in the cavernosa and a scrotal pump. The three-piece device is composed of a pair of inflatable cylinders, a scrotal pump, and an abdominal fluid reservoir. Postoperative urinary retention, penoscrotal hematoma formation, and superficial wound infections have been reported. Infection is the most devastating of all penile prosthesis complications and usually occurs soon after the primary surgery for implantation. Late infections can occur years after the procedure secondary to seeding through the bloodstream. Organisms causing penile prosthesis infection are typically Staphylococcus epidermidis, Staphylococcus aureus, and gram-negative bacilli. Infections present as pain along the device (e.g., in the scrotum or along the penis), erosion, and purulent urethral discharge. Treatment requires antibiotics and removal of the entire device by the urologist.^29,30

Erosion of the prosthesis can occur into penile tissue and often is accompanied by an infection in the same area. Migration of the device may occur proximally or distally, presenting as extrusion through the urethral meatus. Erosion problems and device migration require consultation with the urologist for removal of the prosthesis. Penile ischemia and necrosis are rare but serious complications occurring mainly in patients with predisposing factors such as diabetes and vascular disease. Mechanical failures may occur, such as pump autoinflation or fluid leakage from tubing, cylinder, or reservoir. Evaluation of mechanical problems requires an assessment of the device by a urologist.^27,29

With few exceptions, vasectomies are completed in the urologist's office. Complications of infection, symptomatic hematoma, and chronic scrotal pain occur in 1% to 3%.³¹ Less common complications include bleeding and scrotal hematoma, local wound infections (cellulitis and abscess), epididymitis, and painful sperm granulomas. Patients may develop persistent testicular pain or congestive epididymitis (pain and testicular tenderness on the affected side) months to years later.³¹

Evaluate for infection especially if the patient is immunosuppressed, and treat accordingly; consider scrotal US and consult urology for deep abcess (see chapter 93). When there is no evidence of bleeding or wound infection, treat postvasectomy epididymitis with ice packs, scrotal support, and analgesia with nonsteroidal anti-inflammatory drugs or opiates.

Circumcision, or foreskin resection, is usually performed on infant males. However, the procedure is also performed in adolescents and adults.³² Complications after circumcision include bleeding and infection (most common), pain, hematomas, swelling, suture tears, and wound dehiscence due to premature erection before completion of healing. Treat minor bleeding with direct pressure, or a topical thrombostatic agent as needed. Administer oral antibiotics (trimethoprim-sulfamethoxazole or ciprofloxacin) with local wound care for minor infections. Give analgesia as indicated. Consult urology for significant bleeding or infection.