111 Male Genitourinary Emergencies
Key Points• The five major male genitourinary emergencies are testicular torsion, Fournier gangrene (necrotizing fasciitis of the perineum), priapism, paraphimosis, and genitourinary tract trauma. An associated emergent condition is an incarcerated or strangulated inguinal hernia.
• Ultrasound examination is the primary diagnostic tool for differentiation of causes of acute scrotal pain.
• Urology services should be consulted immediately after initial patient evaluation when testicular torsion is suspected.
• Pain out of proportion to the findings on physical examination is the hallmark of early Fournier gangrene.
• In the setting of severe scrotal pain, a necrotic or ischemic cause should be suspected. Testicular torsion, Fournier gangrene, and an incarcerated or strangulated inguinal hernia are surgical emergencies.
• A trial of oral terbutaline, a β-adrenergic agonist, is the least invasive initial treatment of priapism. Corporal blood aspiration with or without irrigation or injection of an α-adrenergic receptor agonist (e.g., phenylephrine) may be necessary if the condition is not reversed rapidly.
• Successful reduction of paraphimosis can often be performed at the bedside without specialty consultation.
• A urologist should be engaged in the care of all but the most minor cases of genitourinary trauma.
Anatomy and Pathophysiology
The male genitalia is composed of the penis, with paired erectile bodies and the penile urethra, and the scrotum, which encases the testis, epididymis, and spermatic cord bilaterally. Beneath the scrotal skin is the superficial scrotal (dartos) fascia (which is contiguous with the fascia of the abdomen, known as the fascia of Scarpa), the perineal (Colles) fascia, and the penile (dartos) fascia. The spermatic fascia lies beneath the dartos fascia; it has three layers, with the middle layer forming the cremaster muscle. These anatomic layers may provide a conduit for the rapid spread of infection.
The fibrous capsule of the tunica albuginea surrounds each testis. A break in the integrity of the tunica albuginea represents a “ruptured” testicle, which can be caused by blunt trauma. External to the testicular parenchyma and tunica albuginea is the tunica vaginalis, which envelops each testicle and fastens it to the posterior scrotal wall.
The gubernaculum, or scrotal ligament, anchors each testis inferiorly and provides additional stability. The tunica vaginalis consists of both visceral (contiguous with the tunica albuginea) and parietal (contiguous with the deep spermatic fascia) layers, with an interposed potential space. A lack of firm attachment of the testicle to the posterior scrotal wall makes the testis prone to rotation in a horizontal plane about the spermatic cord, a condition termed testicular torsion.
The testicular artery originates from the aorta just below or directly from the renal artery. The spermatic cord contains both the blood supply to each testicle via the gonadal vessels and the vas deferens. Interruption of blood flow to the testis by twisting of the spermatic cord can lead to rapid ischemia and subsequent infarction of the affected testicle in cases of testicular torsion.
The appendix testes are embryologic remnants with no known physiologic function. These appendages are prone to torsion as well, which can lead to localized, self-limited necrosis. It results in clinical findings that may be confused with testicular torsion.
The epididymis adheres closely to the posterolateral aspect of each testis. It is involved in promoting sperm maturation and motility. The appendix epididymis is an embryologic remnant typically attached to each epididymis. These too are prone to torsion.
The vas deferens is a tubular structure involved in sperm transit; it extends from the epididymis distally to the prostatic portion of the urethra proximally.
The penis consists of the corpora cavernosa (erectile bodies) and the corpus spongiosum, which surrounds the urethra. In uncircumcised males, the retractile penile foreskin covers the glans. The potential constricting effect of proximally retracted foreskin may lead to paraphimosis. In paraphimosis, venous engorgement of the glans and edema resulting from constriction can potentially progress to arterial compromise and necrosis of the distal end of the penis. Each corpus cavernosum is surrounded by the tunica albuginea as well.
Priapism is a pathologic condition defined as the presence of a persistent erection lasting longer than 4 hours in the absence of sexual desire or stimulation. It most frequently results from engorgement of the corpora cavernosa with stagnant blood (termed low-flow priapism). Box 111.1 lists several causes of low-flow priapism.
High-flow priapism is rare and is caused by the development of traumatic arterial-cavernosal fistulas, which results in the accumulation of oxygen-rich blood in the corpora.
Presenting Signs and Symptoms
Genitourinary complaints are often influenced by patient embarrassment and apprehension, especially in children and adolescents. Complaints of abdominal pain, fever, or nausea may be offered by the patient, but information about scrotal or penile issues may be withheld. It is important to speak with the patient alone to maximize patient disclosure, privacy, and confidentiality.
Acute Scrotal Pain
One of the most challenging aspects of male genitourinary complaints is that a wide variety of clinical conditions may all be manifested as acute, unilateral (or bilateral) pain and swelling of the scrotum. Although the differential diagnosis for such symptoms is extensive, threats to life and fertility need to be excluded. Testicular torsion, Fournier gangrene, and an incarcerated or strangulated inguinal hernia are surgical emergencies. The vast majority of acute testicular pain, however, can be attributed to one of three diagnostic entities: testicular torsion, epididymitis, or appendage torsion (Table 111.1).1
History
Pain may be due to structures within or adjoining a particular region or may be referred from other areas. Delineation of the source of the pathology is essential. For example, pain from abdominal aortic aneurysms, renal colic, and pyelonephritis can radiate to the testicles.
Onset of Symptoms
Pain that begins abruptly and is severe suggests testicular torsion.2 Intermittent severe pain can signal intermittent torsion. Twisting of the spermatic cord leads to rapid diminution of blood supply to the affected testicle and resultant ischemic pain. This is in contrast to the more indolent pain of epididymitis, a gradually progressive inflammatory process. Patients with long-standing inguinal hernias often complain of isolated genital pain of prolonged duration. However, patients with an incarcerated (cannot be reduced) or strangulated hernia (with ischemic or infarcted, herniated bowel) may experience more acute pain.
Testicular torsion may accompany a report of minor scrotal trauma.3 Testicular torsion can also take place in the absence of such events and may even occur during sleep.
Character of Symptoms
The distinction between constant progressive and intermittent colicky pain is potentially useful in the diagnosis of acute scrotal pain. Constant and progressive pain typically results from progressive inflammatory processes such as epididymitis. Patients may exhibit pain with ambulation and other movements as a result of the inflammation. Intermittent and colicky pain is more consistent with rapid onset and offset conditions, as occurs with twisting of the spermatic cord, either suddenly or intermittently.
Patients with testicular torsion often complain of severe pain as a consequence of ongoing testicular ischemia. Pain resulting from inflammatory processes (epididymitis) may be relieved temporarily by rest and scrotal elevation with a supportive undergarment such as a jockstrap. Similarly, the inflammatory pain is often exacerbated by movement, thus leading a patient to remain still. Alternatively, patients exhibiting the colicky symptoms of testicular torsion may writhe in pain as they try (and often fail) to find a position of comfort. These symptoms are generalizations and, when considered alone, lack high sensitivity or specificity.
Associated Symptoms
Patients with nausea or emesis are less likely to have torsion of an appendage or simple, uncomplicated epididymitis. It is more likely that substantial pathology is present. Patients with abdominal pain, nausea, or constitutional symptoms may have testicular torsion, an incarcerated hernia, or another process.2,4,5 Patients with epididymitis may have a low-grade fever, nausea, and malaise; those with advanced infection (e.g., epididymoorchitis) may demonstrate more pronounced constitutional symptoms.6
Physical Examination
Abdominal Examination
Because many intraabdominal conditions may be associated with genitourinary pain, abdominal, flank, and back evaluation is useful. It is important to assess for lower abdominal tenderness or a mass, which potentially signals acute appendicitis, inguinal hernia, genitourinary malignancy, abdominal trauma, or an advanced perineal infection such as Fournier gangrene. Tenderness at the costovertebral angle may be present with retroperitoneal processes such as pyelonephritis, renal colic, and an expanding or ruptured abdominal aortic aneurysm.
Genital Examination
The genitalia should be examined while the patient is both standing and lying supine. Caution should be used when examining a standing patient because some males experience a strong vagal response to scrotal (or prostate) stimulation that can lead to presyncope or syncope. In addition, examination of the testicles and epididymis may cause significant discomfort, even in the absence of pathology. Because many patients have unilateral pain, the unaffected side should be examined first. This serves as a control and helps gain the trust of the patient.
Visual examination of the genitals may reveal cutaneous rashes or lesions, abnormal testicular symmetry or position, edema evident by loss of the scrotal skin folds, and masses. Key visual features of testicular torsion include a high-riding and transverse lie of the affected testicle.2,4,7
A digital rectal examination provides information regarding the prostate and the prostatic portion of the urethra. Exquisite prostate tenderness may indicate acute prostatitis. Firmness and enlargement of the prostate are typically signs of benign prostatic hypertrophy; nodularity is concerning for prostatic carcinoma. These conditions may be accompanied by variable genitourinary symptoms.
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