persistent, painful erection ◦ corporal bodies firm but glans not ◦ severe pain ◦ underlying...
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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