Chapter 55. Male Genital Problems

Clinical Features

Testicular torsion must be the primary consideration in any male (in any age group) complaining of testicular pain. Pain usually occurs suddenly, is severe, and is felt in the lower abdominal quadrant, the inguinal canal, or the testis. The pain may be constant or intermittent but is not positional because torsion is primarily an ischemic event. Although symptom onset tends to occur after exertion, the testicle also may twist from unilateral cremasteric muscle contraction during sleep. Early in presentation, the affected testicle is firm, tender, elevated, and in a transverse lie compared to the contralateral testicle. The most sensitive finding (99% sensitive) in torsion is the unilateral absence of the cremasteric reflex.

Diagnosis and Differential

In indeterminate cases, color-flow duplex ultrasound and, less commonly, radionuclide imaging may be helpful. In addition, urinalysis is typically ordered, but pyuria does not rule out testicular torsion.

Torsion of the appendages is more common than testicular torsion but is not dangerous because the appendix testis and appendix epididymis have no known function. If the patient is seen early, diagnosis can be supported by the following: pain is most intense near the head of the epididymis or testis; there is an isolated tender nodule; or the pathognomonic blue dot appearance of a cyanotic appendage is illuminated through thin prepubertal scrotal skin. If normal intratesticular blood flow can be demonstrated with color Doppler, immediate surgery is not necessary because most appendages calcify or degenerate over 10 to 14 days and cause no harm. The differential for testicular torsion also includes epididymidis, inguinal hernia, hydrocele, and scrotal hematoma.

Emergency Department Care and Disposition

1. When the diagnosis is obvious, urologic consultation is indicated for exploration because imaging tests can be too time consuming. Testicular salvage is related to duration of symptoms with excellent salvage rates with < 6 hours of symptoms.

2. The emergency physician can attempt manual detorsion. Most testes twist in a lateral to medial direction, so detorsion is performed in a medial to lateral direction, similar to the opening of a book. The endpoint for successful detorsion is pain relief; urologic referral is still indicated.

3. Urology is consulted early in the patient's course even when confirmatory testing is planned. When the diagnosis of testicular torsion cannot be ruled out by diagnostic studies or examination, urologic consultation is indicated.

Clinical Features

Epididymitis is characterized by gradual onset of pain due to inflammatory causes. Bacterial infection is the most common, with infecting agents dependent on the patient's age. In patients younger than 40 years, epididymitis is due primarily to sexually transmitted diseases; culture or DNA probe for gonococcus and Chlamydia is indicated in males younger than 40 years even in the absence of urethral discharge. Common urinary pathogens predominate in older men. Epididymitis causes lower abdominal, inguinal canal, scrotal, or testicular pain alone or in combination. Due to the inflammatory nature of the pain, patients with epididymitis may note transient pain relief when elevating the scrotal contents while recumbent (positive Prehn sign).

Diagnosis and Differential

Initially, when tenderness is well localized to the epididymis, the clinical diagnosis is clear. However, progression of inflammation results in the physical examination finding of a single, large testicular mass (epididymoorchitis), which is difficult to differentiate from testicular torsion or carcinoma. Testicular malignancy should be suspected in patients presenting with asymptomatic testicular mass, firmness, or induration. Ten percent of tumors present with pain due to hemorrhage within the tumor. Orchitis in isolation is rare; it usually occurs with viral or syphilitic disease.

Emergency Department Care and Disposition

1. If the patient appears toxic, admission is indicated for intravenous antibiotics (eg, ceftriaxone 1 to 2 grams every 12 hours IV or trimethoprim/sulfamethoxazole 5 milligrams/kilogram IV of trimethoprim component every 6 hours).

2. Outpatient treatment is the norm in patients who do not appear toxic; urologic follow-up within 1 week is indicated. Age < 40: Treat gonorrhea and Chlamydia with ceftriaxone 250 milligrams IM single dose plus doxycycline 100 milligrams PO twice daily for 10 days. Age > 40: Treat gram-negative bacilli with levofloxacin 500 milligrams PO daily for 10 days or ofloxacin 300 milligrams PO twice daily for 10 days.

3. In addition, scrotal elevation, ice application, nonsteroidal anti-inflammatory drugs, opioids for analgesia, and stool softeners are indicated.

4. Orchitis is treated with disease-specific therapy, symptomatic support, and urologic follow-up. (Patients at risk for syphilitic disease should be treated as directed in Chapter 86.)

Patients present with varying complaints of suprapubic or genital pain, back pain, perineal pain, voiding difficulties, frequency, dysuria, pain with ejaculation, and fever and chills. Patients at risk include those with anatomic or neurophysiologic lower urinary tract obstruction, acute epididymitis or urethritis, unprotected rectal intercourse, phimosis, and indwelling urethral catheter. The causative organism is Escherichia coli in most cases, with Pseudomonas, Klebsiella, Enterobacter, Serratia, or Staphylococcus causing the remainder. Physical examination usually reveals perineal, rectal, and prostate tenderness. The diagnosis is clinical as urinalysis and culture are often negative even after prostate massage. Treatment is ciprofloxacin 500 milligrams twice daily, or levofloxacin 500 milligrams PO daily, or ofloxacin 300 milligrams PO twice daily. All treatments should be for a total of 30 days. Pain medicine may be required. Admission is not necessary unless the patient is septic, immunocompromised, has significant comorbidities, or has worsened on outpatient therapy.

Scrotal abscesses may be localized to the scrotal wall or may arise from extensions of infections of intrascrotal contents (ie, testis, epididymis, and bulbous urethra). A simple hair follicle scrotal wall abscess can be managed by incision and drainage; no antibiotics are required in immunocompetent patients. When a scrotal wall abscess is suspected of coming from an intrascrotal infection, ultrasound and retrograde urethrography may demonstrate pathology in the testis, and/or epididymis, and in the urethra, respectively. Definitive care of any complex abscess calls for a urology consultation.

Fournier gangrene is a polymicrobial infection of the perineal subcutaneous tissues. Diabetic males are at highest risk, but any immunocompromise can be associated with the disease. Prompt diagnosis is essential to prevent extensive tissue loss. Early surgical consultation is recommended for at-risk patients who present with scrotal, rectal, or genital pain. Treatment mainstays include aggressive fluid resuscitation with normal saline solution and broad-spectrum antibiotics to cover gram-positive, gram-negative, and anaerobic organisms: imipenem 1 gram IV every 8 hours or meropenem 500 milligrams to 1 gram IV every 8 hours plus vancomycin 1 gram IV every 12 hours if methicillin-resistant Staphylococcus aureus is suspected. Care usually includes hyperbaric oxygen therapy (if readily available) and surgical debridement.

Balanoposthitis is inflammation of the glans (balanitis) and foreskin (posthitis). Upon foreskin retraction, the glans and prepuce appear purulent, excoriated, malodorous, and tender. Treatment consists of cleaning with mild soap, ensuring adequate dryness, applying antifungal creams (nystatin 100,000 units/g, 4 times daily or clotrimazole 1% cream bid) and using an oral azole (fluconazole 150 milligrams single dose, reevaluate at 7 days for repeat dosing). Urologic referral is needed for reassessment and possible circumcision. An oral cephalosporin (eg, cephalexin 500 milligrams 4 times daily) should be prescribed in cases of secondary bacterial infection.

Phimosis is the inability to retract the foreskin proximally (Fig. 55-1). Hemostatic dilation of the preputial ostium relieves the urinary retention until definitive dorsal slit or circumcision can be performed. Topical steroid therapy, such as hydrocortisone 1% cream for 4 to 6 weeks, reduces the rate of required circumcision.

Paraphimosis is the inability to reduce the proximal edematous foreskin distally over the glans (see Fig. 55-1). Paraphimosis is a true urologic emergency because resulting glans edema and venous engorgement can progress to arterial compromise and gangrene. If surrounding tissue edema can be successfully compressed, as by wrapping the glans with 2 × 2-in elastic bandages for 5 min, the foreskin may be reduced. Making several puncture wounds with a small (22- to 25-gauge) needle may help with expression of glans edema fluid. Local anesthetic block of the penis is helpful if patients cannot tolerate the discomfort associated with edema compression and removal. If arterial compromise is suspected or has occurred, local infiltration of the constricting band with 1% plain lidocaine followed by superficial vertical incision of the band will decompress the glans and allow foreskin reduction.

Penile entrapment injuries occur when various objects are wrapped around the penis. Such objects should be removed, and urethral integrity (retrograde urethrogram) and distal penile arterial blood supply (Doppler studies) should be confirmed when indicated.

Penile fracture occurs when there is an acute tear of the penile tunica albuginea. The penis is acutely swollen, discolored, and tender in a patient with history of intercourse-associated trauma accompanied by a snapping sound. Retrograde urethrography may be indicated for assurance of urethral integrity. Urologic consultation is indicated.

Peyronie disease presents with patients noting sudden or gradual onset of dorsal penile curvature with erections. Examination shows a thickened plaque on the dorsal penile shaft. Assurance and urologic follow-up are indicated.

Priapism is a painful pathologic erection that may be associated with urinary retention. Infection and impotence are other complications. In most cases, the initial therapy for priapism is terbutaline 0.25 to 0.5 milligrams (repeated in 20 min, if needed) subcutaneously in the deltoid area. If patients present early (within 4 hours), oral pseudoephedrine (60 to 120 milligrams) may be effective. Patients with priapism from sickle cell disease are usually treated with simple or exchange transfusion. Corporal aspiration and irrigation with normal saline solution or an α-adrenergic antagonist is the next step and may need to be performed by the emergency physician when urologic consultation is not available. Even when emergency physicians provide stabilizing care, urologic consultation is indicated in all cases.

Urethral stricture is becoming more common due to the high incidence of sexually transmitted diseases. If a patient's bladder cannot be cannulated with a 14- or 16-French Foley or Coudé catheter, the differential diagnosis includes urethral stricture, voluntary external sphincter spasm, bladder-neck contracture, or benign prostatic hypertrophy. Retrograde urethrography can be performed to delineate the location and extent of urethral stricture. Endoscopy is necessary to confirm bladder neck contracture or define the extent of an obstructing prostate gland. Suspected voluntary external sphincter spasm can be overcome by holding the patient's penis upright and encouraging him to relax his perineum and breathe slowly during the procedure. After no more than 3 gentle attempts to pass a 12-French Coudé catheter into a urethra prepared with anesthetic lubricant, urologic consultation should be obtained. In an emergency situation, suprapubic cystotomy can be performed. The infraumbilical and suprapubic areas are prepped with povidone-iodine solution. A 25- to 27-gauge spinal needle is used to locate the bladder (emergency department ultrasound can facilitate this), followed by placement of the cystotomy with the Seldinger technique. Urologic follow-up should occur within 48 hours.

Urethral foreign bodies are associated with bloody urine and slow, painful urination. Radiography of the bladder and urethral areas may disclose a foreign body. Removal of the foreign body may be achieved with a gentle milking action; retrograde urethrography or endoscopy is required in such cases to confirm an intact urethra. Often, urologic consultation for endoscopy or open cystotomy is required for foreign body removal.