Urologic Emergencies

Leah Harrington

Introduction

Phimosis

Inability to retract neonatal/infantile foreskin is a normal condition secondary to congenital adhesions between the glans and foreskin
Congenital phimosis rates: 1-3 months: 91%; 3 years: 35%; 8-13 years: 3-6%; 17 years: 1%
Numbers quoted in the literature vary widely
Phimosis should be treated if accompanied by symptoms of urinary obstruction or infection/balanitis or balanoposthitis
Foreskin ballooning during voiding is a benign occurrence and does not require treatment
Controversy in the literature as to definition of true phimosis requiring treatment
Some authors consider nonretractable foreskin with a whitish ring of hardened sclerotic skin at the tip of the prepuce to be a true phimosis (balanitis xerotica obliterans): extremely rare in pre-school boys
Normal developmental foreskin tightness is commonly misdiagnosed as phimosis requiring treatment
Medical management: 65-90% of cases can be treated with topical steroids (i.e., betamethasone 0.05% cream or triamcinolone 0.1% applied to tip of foreskin 2-3 times daily, 85-90% response)
Surgical management includes dorsal or ventral slit, circumcision

Paraphimosis

Fixation of foreskin behind glans
Occurs when foreskin is retracted and not replaced immediately
Fibrous ring of foreskin causes venous congestion; results in extreme pain and swelling of glans
If untreated may lead to ischemia, necrosis; can present as a surgical emergency

Treatment

No prospective, randomized, controlled studies comparing efficacy of treatment options
Preparation: sedation, analgesia, and/or penile block may facilitate reduction process
Topical anesthetic 2% lidocaine gel, 2.5% lidocaine (EMLA cream) applied to skin for 45-60 minutes prior to reduction may be effective
Ice application or manual compression of the foreskin glans and penis helps decrease edema
Coban tape may be used to apply pressure to glans and prepuce to reduce edema: apply from distal tip of glans to proximal shaft of penis. Manual pressure may also be used following application of tape
Manual reduction: “inverting the sock”: place both index fingers on dorsal aspect of penis proximal to retracted prepuce. Place both thumbs on tip of glans. Apply pressure to tip of glans while using index fingers to pull prepuce back into position over glans
Puncture technique requires a 21G needle to puncture one or more openings into edematous foreskin: release of edema facilitates manual reduction of foreskin
Dorsal slit procedure: vertical incision along dorsal aspect of preputial ring will loosen constricting ring of tissue and facilitate reduction of foreskin

Balanitis

Inflammation of glans; may be associated with inflammation of inner surface of foreskin (balanoposthitis)
3% of male children
Etiology: infectious origin (case reports of group A beta hemolytic streptococcus), contact irritation, trauma, and allergy

Treatment

Treat underlying cause
Gentle cleaning, antibiotic ointment, oral antibiotics (i.e., cephalosporin providing staphylococcal coverage) if more extensive involvement of foreskin
Consider circumcision in recurrent cases

Priapism

Painful erection unaccompanied by sexual excitation
> 60% pediatric patients also have sickle cell disease, more typical in older adolescents
Two types:
- Low-flow, ischemic: painful, although pain may disappear with prolonged priapism. Associated with thromboembolic/hypercoagulable states, sickle cell disease, polycythemia, thalassemia, vasculitis
- High-flow, nonischemic: generally painless, may be episodic. Associated with blunt, penetrating injury to the perineum, straddle injury

Treatment

Sickle-cell-related priapism: oxygenation, IV morphine, hydration, alkalinization, exchange transfusion to maintain hematocrit value > 30%, hemoglobin-S < 30%
Surgical decompression if conservative management fails; consider early urological consultation
Complications: fibrosis and impotence result from prolonged persistent erection; urinary retention

Table 31.1 Scrotal Swelling: Approach

CONDITION	ONSET OF SYMPTOMS	AGE	TENDERNESS	URINALYSIS	CREMASTERIC REFLEX	TREATMENT
Testicular torsion	Acute	Early puberty	Diffuse	Negative	Negative	Surgical exploration
Appendiceal torsion	Subacute	Prepubertal	Localized to upper pole	Negative	Positive	Bed rest and scrotal elevation
Epididymitis	Insidious	Adolescence	Epididymal	Positive or negative	Positive	Antibiotics
Source: Adapted from: Galejs LE, Kass EJ. Diagnosis and treatment of the acute scrotum. Am Fam Physician. 1999;59:817-824.