Regarding the management of priapism in the ED, which ONE of the following statements is most CORRECT?
Answer: B: If a patient has low-flow priapism due to thrombosis from sickle cell crisis then he should be treated with intravenous rehydration, oxygen, analgesia, and exchange transfusion as required.
Otherwise, low-flow priapism is typically managed with aspiration of blood from the corpus cavernosum +/− injection of diluted phentolamine or adrenaline into the corpus cavernosum. If the patient is in urinary retention a urethral catheter should be inserted. A urologist should always be consulted. Treatment should be commenced rapidly, preferably within 4 hours of onset to reduce the incidence of long-term sequelae.
High-flow priapism is a very rare presentation. It is not a urological emergency and patients typically have an erection that is not fully rigid; however, the fully flaccid state is not reached either. The diagnosis can be confirmed by penile Doppler ultrasound. Angiography is typically required as arteriovenous fistula formation is the usual aetiology.
References:
Regarding urogenital trauma, which ONE of the following statements is TRUE?
Answer: A: About 80% of ureteral injuries are iatrogenic, mostly related to intraabdominal or pelvic surgery. The ureter is well protected during its course to the bladder so ureteral trauma is rare accounting for ~1% of genitourinary injuries. Injury to the ureter is more likely to be due to penetrating trauma (usually from gunshot injuries) than blunt trauma because a significant amount of force is required to injure the ureter.
The majority of cases of urogenital injury including ureteral injury secondary to blunt trauma have other major organ involvement, about one-third of which can be life threatening. Ureteral injury from blunt trauma occurs as a result of rapid deceleration. Significant deceleration forces can cause avulsion of the ureter from its fixed points, namely the pelvoureteric junction (PUJ) or less frequently the vesicoureteric junction (VUJ). Approximately 10% of trauma involves the genitourinary tract, with the kidney being the most frequently injured genitourinary organ.
In blunt trauma, the degree of haematuria and the severity of the genitourinary injury do not always correlate well.
Gross haematuria can occur as a result of minor injury such as minor renal contusions; microscopic haematuria (or no haematuria) may be seen in renovascular injuries. However, gross haematuria should be investigated. Microscopic haematuria (≤50 RBCs/hpf) doesn’t require further investigation unless there are signs of unexplained haemodynamic compromise.
Table below shows the American Association for the Surgery of Trauma (AAST) grading system for renal trauma. A grade III renal injury does not have urinary extravasation or rupture of the collecting system.
GRADING OF RENAL TRAUMA:
Regarding testicular torsion, which ONE of the following statements is TRUE?
Answer: D: In the majority of cases, testicular torsion is a result of medial rotation of the spermatic cord. Lateral rotation occurs in about one-third of cases.
The peak age of occurrence is puberty – ages 12–16 years old. A typical presentation of an abrupt onset of pain in the affected testis, groin or lower abdomen may follow sudden movement, sporting or strenuous physical activity or trauma. Many occur spontaneously, particularly at night (where contraction of the cremasteric muscle results in torsion). Other common associated features of presentation include nausea, vomiting and fever (20% of cases).
The examination findings include swelling and tenderness in the affected side of the scrotum; the affected testis may have a high riding position and a horizontal lie. The cremasteric reflex may be absent. The more delayed the presentation the more swollen the scrotum is likely to be and assessment of the cremasteric reflex and scrotal structures may be difficult.
Scrotal ultrasound scan (USS) is useful when investigating testicular torsion. It also can identify testicular and extratesticular masses, epididymitis, orchitis, hydroceles, hernias and varicoceles. However, the time delay to get a USS can be detrimental to the patient because testicular torsion is a time-critical diagnosis. The testis can usually be salvaged up to 12 hours after onset; the chances of testis survival at 24 hours is near zero. Ideally, the patient should undergo surgery within 6 hours of symptom onset.
Doppler USS can produce both false positives and negatives. Even the torted testis can demonstrate intra-testicular blood flow on Doppler USS, which can be misleading and lead to an incorrect diagnosis. It has only 80% sensitivity for diagnosis of testicular torsion.
All of the following conditions cause scrotal pain EXCEPT:
Answer: D: Abdominal aortic aneurysm and renal colic can cause referred pain to the scrotum.
Viral infections such as mumps can cause orchitis. Orchitis develops in approximately 20% of prepubertal boys with mumps but in almost no postpubertal males with mumps. It tends to arise several days after the onset of parotitis. Owing to the testes’ relatively high threshold of resistance to infection, bacterial orchitis more commonly results from local bacterial spread from epididymis. The most frequent bacterial pathogens are Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli, Klebsiella, and Pseudomonas aeruginosa. These organisms tend to infect postpubertal males and men older than 50 years of age with benign prostatic hypertrophy (BPH).
Which ONE of the following statements regarding urinary retention is TRUE?
Answer: C: Urinary retention is the inability to void; however, the patient may pass small volumes of urine frequently. This suggests retention with overflow. Most cases of urinary retention presenting to the ED are due to an obstructive cause such as:
Approximately 25% of men who present to the ED with acute urinary retention have a diagnosis of prostate cancer (the majority of which was not diagnosed previously).
Medications that can cause urinary retention include anticholinergics (e.g. antispasmodics and tricyclic antidepressants), analgesics such as opiates and NSAIDs, antihistamines and beta-blockers.
Most presentations of acute urinary retention can be classified as ‘low-pressure’ retention. In these cases the detrusor pressure remains low while storing urine and there is no associated hydronephrosis or renal impairment. Less commonly, men present with ‘high-pressure’ urinary retention that is associated with high bladder storage pressures, bilateral hydronephrosis and renal impairment. Men with high-pressure retention frequently describe nocturnal enuresis.
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