Priapism Persistent, painful erection

◦ Corporal bodies firm but glans not◦ Severe pain◦ Underlying disease state

Sickle Cell Pelvic malignancy Leukemia Blunt trauma Acute spinal cord injury

Question 7 Which of the following is the most

appropriate treatment of priapism in a patient with sickle cell anemia?◦ A Temporary surgical shunt◦ B Surgical Irrigation of corpora

cavernosa◦ C Exchange transfusion◦ D Observation in hospital

Priapism Treatment

◦ Surgical intervention Irrigate corpora cavernosa Shunt or vascular bypass

◦ Sickle Cell Exchange transfusion

Question 8 Choose the most accurate definition of

paraphimosis:◦ A Tight prepuce is retracted over glans

to level of corona, unable to easily reduce

◦ B Tight prepuce covers glans and is unable to be retracted

◦ C Inflammation/Infection of the most distal portion of the prepuce

◦ D Inflammation/Infection of glans◦ E One or more adhesion between

prepuce and glans

Paraphimosis

Phimosis: Inability to retract tight, scarred prepuce

Paraphimosis: tight prepuce is retracted at level of corona, unable to reduce◦ May cause ischemia

Treatment◦ Manual compression of glans to allow reduction◦ Surgical: dorsal slit◦ Circumcision may be indicated

Acute balanitis and posthitis Balanitis: inflammation of glans Posthitis: inflammation of prepuce Uncirmcumcised boys with entrapped

smegma beneath foreskin Treatment:

◦ Slight dilation of preputial opening◦ Warm baths◦ Broad spectrum antibiotics◦ Treat candida if present

Lesions of scrotum and scrotal contents

Median Raphe Cyst Epithelial inclusion cyst May have chain of cysts

◦ Midline of peritoneum and scrotum Usually asymptomatic Infection may occur Surgical excision of cysts and raphe

Question 9 Which of the following does NOT fit with the

diagnosis of “Torsion of spermatic cord?”◦ A Affected testis appears elevated◦ B Transverse orientation of contralateral

testis◦ C Cremasteric reflex absent◦ D Pain improves with elevation of testis◦ E Red, swollen scrotum

Acute scrotum Urologic surgical emergency Torsion of spermatic cord May occur at any age Acute, painful testicular swelling

Awakened by pain Or secondary to trauma Rarely insidious onset

Acute scrotum Abd pain, N/V Leukocytosis No dysuria Normal u/a

Acute Scrotum PE

◦ Scrotum red, swollen◦ Testis elevated◦ Transverse orientation of contralateral testis◦ Cremasteric reflex absent◦ Negative Prehn sign

Pain NOT improved with elevation of testis Color doppler Consult Urology as soon as suspected

Acute Scrotum Spermatogenesis may be lost in 4-6hrs May try manual detorsion

◦ Rotate testis outward Left testis clockwise

Surgical detorsion◦ If within 6hrs, 90% successful◦ Bilateral scrotal orchiopexy

Torsion of testicular appendages Appendix testis Appendix epididymis Small tender mass upper anterior

surface “blue dot” Nonoperative treatment if certain of dx

◦ Inflammation resolves 3-10 days

Epididymitis Bacterial or non-bacterial Non-bacterial:

◦ Reflux of urine into ejaculatory ducts◦ Ectopic insertion of ureter◦ Tx: NSAIDS, bedrest 48hrs

Bacterial:◦ Fever◦ Abnormal u/a◦ Tender swollen epididymis◦ Cremasteric reflex present◦ Positive Prehn sign

Improved pain on elevation of testis◦ Antibiotics◦ Urologic imaging

Chronic scrotal swelling

Varicocele Dilated veins of pampiniform

plexus Primarily Left side

◦ May be bilateral Should decompress when supine

◦ Otherwise think mass effect Pain absent Infertility in 1/3 of adults Ablation indicated if testicular

growth failure◦ Serial exams

Spermatocele Common in adolescents Painless cystic mass upper pole

of epididymis◦ Retention cyst (sperm)

Mobile, transilluminate, stable size

Excision only if painful or bothersome

Hydrocele Fluid within tunica or

processus vaginalis Large Transilluminate Painless In neonates

◦ Common and often resolve spontaneously

Testicular tumors Solid mass within substance of testis

◦ Malignant until proven otherwise May present at any age

Lesions of female genitalia

Labial hypertrophy Rule out by Physical exam

◦ r/o gonad (ovary/testis)◦ r/o hernia◦ Possible vascular or lymphatic malformation

Labial Adhesion (fusion) Prepubertal Labia minora If severe

◦ Dysuria◦ Postvoid dribbling◦ UTI

Manual separation

Urethral Prolapse Black girls (age 1-9 y/o) Bloody spotting, dysuria May be mistaken for abuse Tx, estrogen cream, sitz baths

◦ May require surgery

Ureterocele Prolapse• Ureterocele: cystic dilation

of distal ureter• Asymmetric protrusion

through urethra• Associated distended

bladder or hydronephrosis

Question 10 The clinical presentation that fits best with

the diagnosis of “ectopic ureter” is…◦ A Urinary hesitancy◦ B Urinary urgency◦ C Dribbling of urine between voids◦ D Prolapse of tissue at the introitus

Ectopic ureter Assoc w single collecting system OR

complete duplication Normal voiding but with continuous

dribbling incontinence

Paraurethral cyst Usually asymptomatic Rupture

spontaneously Aspiration or

marsupialization if symptomatic

Congenital obstruction of vagina Vaginal atresia or septa

◦ May have normal exam◦ Need imaging

Urogenital sinus Imperforate hymen

◦ Distended vagina (hydrometrocolpos)

◦ Bulging hymenal membrane

Genital trauma Penis or scrotum

◦ Think urethral injury◦ IV contrast through meatus◦ Then can perform catheterization safely

Scrotal trauma◦ U/S to r/o laceration or rupture of testicles

Breech delivery◦ Urologic evaluation if scrotal trauma

Low threshold for surgical exploration May need exam under anesthesia