This article reviews common genitourinary surgical emergencies such as testicular torsion, priapism, phimosis, paraphimosis, meatal stenosis, urinary tract trauma, and zipper entrapment of the penile foreskin.
Torsion of the spermatic cord, or testicular torsion, is the most common surgical genitourinary emergency in the pediatrie age group.1'2 It occurs in one out of 160 men by the age of 25 years.2 Sixty-five percent of cases occur in children between 12 and 18 years of age, but this can happen any time from infancy to adolescence.2 Sheldon reported testicular torsion as the cause of scrotal pain in about 75% of children under 18 years of age.1·3
Testicular torsion results from abnormal attachments of the tunica vaginalis, which, in turn, lead to a high riding testis. If bilateral, this abnormality results in horizontal lie of the testes within the scrotal sac often referred to as the "bell clapper" deformity (Figure I).2·4 Undescended testes are 10 times more likely to torse than normally descended testes.2 Strong contraction of the cremasteric muscle from strenuous physical activity or trauma can result in additional rotation of the testis and adnexa with resultant torsion.1 These preceding events thus are frequent in the associated history. The conditions that cause sciotal pain and the differential diagnosis for testicular torsion are described in Tables 1 and 2. The presentation and clinical history of the patient often is confusing. Indeed, health-care professionals fail to diagnose testicular torsion on the first visit in nearly 50% of cases, often resulting in medicolegal action.2·5 Patients may present with acute pain for several hours or may have intermittent pain for months.2 15'6
The classic picture of acute onset of scrotal pain over several hours with subsequent swelling and edema of the testicle and scrotum occurs in nearly 75% of cases, but gradual onset of pain or intermit' tent pain may occur in 25%. Pediatrie patients are more likely to repon a gradual onset of pain compared with adult patients with testicular torsion.2 Associated symptoms may include nausea, vomiting, and abdominal or flank pain. Rarely, fever may be a part of the presentation. ''2^'7
Signs and Symptoms of Testlcular Torsion, Torsion of the Appendix Testls, and Epldldymltls
Physical findings suggestive of testicular torsion include horizontal tie of the testes, a high-riding testis, diffuse testicular tenderness and swelling, or absent cremasteric reflex on the symptomatic side.4 Prehn's sign, or relief of pain with elevation of the swollen scrotum, may be present in cases or" epididymitis, but often results in an increase in pain in cases of testicular torsion.1·8
There are many other causes of scrotal pain (Table 2), but none with the morbidity of testicular torsion.2·9'1' The practitioner should quickly determine if the scrotal swelling is associated with pain or not. Painful swelling may be caused by a number of conditions, with the most common being torsion of the spermatic cord and testis or its appendages.1·2·4·7·11
In the patient with a classic history and physical findings for torsion, preliminary laboratory, radionuclide scan, or Doppler flow studies should be avoided because they can delay surgical management. In these cases, urology should be consulted immediately. In equivocal cases of scrotal swelling, a urinalysis is obtained to look for obvious infection (epididymitis); however, a number of investigators have shown that 25% of cases of testicular torsion have pyuria on urinalysis. Conversely, pyuria may be absent in 20% of cases of epididymitis.2·4 Other laboratory studies complete Wood cell count and blood chemistries) typically are not helpful in establishing the diagnosis and could result in delay of definitive management.
Both radionuclide scanning with sodium pertechnetate Tc99m and color Doppler flow studies of the testes are highly accurate tests for diagnosing testicular torsion. U-1Z'14 In a review of more 400 cases in the published literature on radionuclide scanning and color Doppler studies for acute scrotal swelling, Haynes2 reports that the radionuclide scanning was 95% accurate with 4% false-positive or false-negative rates and that color Doppler flow studies were 88% accurate with 5% false-positive or false-negative rates and 7% indeterminate. One prospective study of the use of color Doppler ultrasonography and radionuclide scanning in 28 patients with acute scrotal swelling showed that color Doppler ultrasonography was able to identify all seven cases of testicular torsion, while radionuclide scanning identified six of the seven cases, with one false negative occurring in a patient with 180° torsion of the testis.12 A radionuclide scan indicates testicular torsion when a unilateral "cold spot" is detected on the affected side. Color Doppler ultrasonography indicates torsion when decreased or absent flow to one of the testes is demonstrated.12·14 A disadvantage of radionuclide scanning is the need for vascular access to provide a route for the injection of the radtoisotope. In addition, infants are technically more difficult to scan than older children or adolescents.1 On the other hand, color ultrasonography has a relatively high percentage of indeterminate studies because of normally reduced flow in the prepubescent testes.14 Overall, the utility of these studies for the diagnosis of testicular torsion will vary among institutions, depending on the availability of personnel and equipment, the wishes of the urology consultant, and the skill of the radiologist in reading the studies.
Cause of Painful Scrotal Swelling In Children
Figure 1. Left: Normal attachment of the tunica vaginalis to the testis. Middle: Abnormal attachment resulting in horizontal lie of the testis. Right: Torsion of the testes and spermatic cord. Reprinted with permission from Strange GR, Ahrens WR1 Lelyveld S, Schafermeyer RW, eds. Pediatrie Emergency Medicine: A Comprehensive Study Guide. Copyright ©1996, McGraw-Hill Co.)
Figure 2. Paraphimosis in a toddler.
Treatment of testicular torsion is immediate surgery with detorsión and bilateral orchiopexy.1'2·4 In equivocal cases, diagnostic studies may be obtained but should not delay consultation with the urologist. Any delay in management may result in further ischemia and loss of the testicle. Testicular salvage rates of 80% are found in patients presenting within 5 hours of the onset of pain but fall to zero after 24 hours.1'3 Manual detorsión of the testícíe may provide additional time before irreversible necrosis occurs, but surgery to relieve the torsion completely is still indicated.11 Manual detorsión is attempted only after an analgesic has been administered. This is performed by twisting the left testicle to the right (clockwise) or the right testicle to the left (counterclockwise) until the pain is relieved.11
TORSION OF THE APPENDIX TESTIS
Torsion of the appendix testis is a common cause of scrotal pain and swelling, and may be difficult to distinguish from testicular torsion (Table I).15 The clinical presentation of torsion of the appendix testes is often less dramatic than is testicular torsion.1'4 Classic physical findings for torsion of the appendix testis include testicular tenderness localized to the upper pole of the testis with a focal area of blue discoloration, of the scrotum ("blue dot" sign).4
No diagnostic studies are indicated in clear cases of torsion of the appendix testis. In equivocal cases, radionuclide scanning or color Doppler ultrasonography may be obtained to rule out testicular torsion. In torsion of the appendix testis, flow to the testicle will be normal or increased.
Most patients with torsion of the appendix testis can be managed conservatively with urologie followup.16 Surgical management is indicated for those patients in whom testicular torsion cannot be reliably excluded. Rarely, patients may require surgical intervention to relieve intense pain associated with ischemia of the torsed appendage.4
Priapism or sustained, painful erection without sexual stimulation is rare in children. It is caused by one of two mechanisms: 1) decrease in exit flow resulting in ischemia, such as in sickle cell disease or polycythemia of the newborn, or 2) increase in blood flow to the penis, as occurs in trauma.17 The first is by far the most common mechanism for priapism, and sickle cell anemia is the cause in two thirds of these cases.18 Other reported causes of priapism include polycythemia, thrombocytosis, medications or drugs (eg, phenothiazines, alcohol, or marijuana), leukemia, trauma, and idiopathic.4·17
Embarrassment may cause a delay in presentation.18 Physical examination reveals an erect, tender penis. The penis is firm on the dorsal surface secondary to the engorged corpora cavernosum and flaccid on the ventral surface (corpora spongiosum) and the glans.4 A distended bladder may be palpated secondary to urinary retention. Diagnostic evaluation should focus on determining the cause of the priapism. Ancillary studies should include a complete blood cell count to look for anemia (sickle cell disease or leukemia) or leukocytosis (leukemia), "sickle prep" or hemoglobin electrophoresis in patients in whom sickle cell disease is a possible cause, and renal function tests and electrolytes as indicated for prolonged urinary retention or signs of dehydration. Consider color Doppler ultrasonography to evaluate flow to the penis in traumatic priapism.17 Management of the pediatrie patient with priapism is conservative and centers on the treatment of the underlying condition. All patients are admitted to the hospital and urology consulted. A urinary catheter is placed to relieve uri' nary retention.
Patients with sickle cell disease are given oxygen, hydration, and analgesics. If the priapism is not relieved within 24 hours, a partial red cell exchange transfusion with 30 mL/kg of packed red blood cells is recommended.4'17'18 The goal is to increase the patient's hemoglobin concentration to at least 10 g/dL4·18 Rarely, the exchange transfusion will not result in detumescence after 24 hours; in these cases, surgical management with a cavernous-glans shunt may be indicated.14'18 Intracavernous injection of epinephrine, ephedrine, or phenylephrine may be attempted prior to surgical management.19 Intravenous ketamine hydrochloride has been used to successfully treat priapism in the newborn.20 Patients with leukemia often will respond with detumescence after chemotherapy has begun.4'18
Phimosis accounts for about 3% of all complications involving the foreskin of uncircumcised males.21 In a study of 545 male children, Herzog and Alvarez21 found that the incidence of phimosis decreased with age and was more common (2.6% versus 0-4%) in the uncircumcised male. Phimosis occurs when the distal prepuce is contracted and cannot be retracted over the glans penis.4·22 Normally, at birth, 95% of boys have adhesions that prevent the foreskin from being retracted over the glans; this percentage decreases with increasing age to less than 10% by the time the child enters school.4'23
Patients often present to a pediatrician or emergency physician because a parent notes that their son's foreskin cannot be retracted over the glands. Most frequently, these children are asymptomatic, but occasionally they have infection of the prepuce (balanitis) or of the glans and prepuce (balanoposthitis).22 Parents may offer a history that the urinary stream is decreased or diverted. In asymptomatic patients, parents can be reassured that the prepuce will be retractable over the glans with time. Patients with recurrent balanitis, balanoposthitis, urinary tract infection, or obstruction should be referred to a urologist for elective circumcision.4·23
Paraphimosis is rare compared with phimosis and is a condition in which the prepuce is retracted over the glans penis and then cannot be moved back into normal position over the glans. Once this occurs, the glans may become edematous secondary to venous engorgement, which further inhibits the retraction. Patients with paraphimosis are anxious and in pain. Physical examination of the penis reveals a swollen glans and distal prepuce (Figure 2). Verify by history that indeed the patient is uncircumcised as a paraphimosis-like condition may occur in the circumcised male from a constricting band of hair (hair tourniquet) just proximal to the glans.23 Management strategies to reduce swelling of the glans, such as ice packs to the groin, are not well tolerated by young children, but may be attempted in the cooperative patient to facilitate manual retraction of the prepuce. Often, conscious sedation is needed for manual retraction. Manual retraction can be achieved by placing both index fingers on the dorsal border of the penis behind the retracted prepuce and both thumbs on the end of the glans (Figure 3).4 Thumb pressure is used to push the glans back through the prepuce while the index fingers nudge the prepuce over the glans. Rarely, when the prepuce cannot be retracted into normal position, urologìe consultation is obtained and a circumcision performed.
Figure 3. Manual reduction of the prepuce over the glans. (Reprinted with permission from Strange GR, Ahrens WR, Lelyveld S, Schafermeyer RW, eds. Pediatrie Emergency Medicine: A Comprehensive Study Guide. Copyright ©1996, McGraw Hill.)
Meatal stenosis occurs in circumcised boys from trauma, inflammation, or infection of the urethral meatus. The diagnosis is not made by the visual appearance of the urethral meatus but by observing the urinary stream for decreased caliber or deflection and by noting if the child strains or takes a long time to void.24 Indications for dilatation of the meatus include a pinpoint caliber to the urinary stream, marked deflection of the stream, straining with voiding, and difficulty in emptying the bladder.24 Dilatation of the meatus can be accomplished simply in the pediatrician's office or in the emergency department by using a small amount of viscous lidocaine at the meatus followed by the gentle insertion of the tip of a either small mosquito hemostat or a 1/8 ounce tube of ophthalmic ointment into the meatus to gently dilate it,24 Those boys with marked meatal scarring should be referred to a urologist for dilatation of the meatus under local or general anesthesia.
Figure 4. Algorithm for evaluating the pediatrìe trauma patient tor genitourinary injury. (Reprinted with permission from Barkin RM1 Asch S, Caputo G, Jaffa D, Knapp J, Schafermeyer R1 Seidel JS, eds. Pediatrìe Emergency Medicine: Concepts and Clinical Practice. Copyright ©1996, Mosby-Year Book (nc.)
INJURY TO THE URINARY TRACT
Injury to the urinary tract is not uncommon in children, occurring in 10% of trauma patients presenting to the emergency department.25 The kidney is the most common urinary organ injured, followed by the bladder and rarely the ureter and the urethra.26
Physical findings of urinary injury may be absent or subtle.
Signs of urinary injury are listed in Table 3.25>26 Associated neurologic and intra-abdominal injury occur in approximately 80% of cases.26·27 Urinary tract injury also may occur from nonaccidental trauma or child abuse.24 Rarely are these injuries treated surgically. The most important aspects of the management of nonaccidental genitourinary tract trauma in children is the recognition and subsequent reporting of the injury.25 Toddlers who are being toilet trained are at particular risk to be physically abused by a frustrated caretaker.28 Injuries may occur to the glans when it is forcibly pinched after "an accident" while toilet training. Nonaccidental trauma should be considered in any child with perineal burns, ecchymoses, or lacerations25 and a report to child protective services and law enforcement.25,18
Evaluation of the trauma patient for urinary tract injury is dependent on associated injury, the area of suspected injury in the urinary tract, presence and degree of hematuria, and the mechanism of injury (blunt versus penetrating). Figure 4 outlines the diagnostic evaluation of the pediatrie trauma patient for genitourinary injury.25 Overall, the order of the radiographie evaluation of the trauma patient begins with the urethra and ends with the kidney.29 An exception to this rule occurs when the patient is multiply injured and requires emergent computerized tomography (CT) for evaluation of intra-abdominal injury. In these cases, if indicated, a cystourethrogram is delayed until after the CT of the abdomen.
Signs and Symptoms of Genitourinary Tract Injury
Figure 5. Bone cutter used to release the foreskin entrapped in a zipper. (Reprinted with permission from Barkin RM1 Asch S, Caputo G, Jaffe D, Knapp J, Schafermeyer R1 Seidel JS1 eds. Pediatrie Emergency Medicine: Concepts and Clinical Practice. Copyright ©1996, Mosby-Year Book Inc.)
Management of more than 90% of patients with renal injury will be conservative.25·29 Indications for surgical intervention for renal injury include renal pedicle injury, presence of an expanding or pulsatile hematoma, and extensive laceration of the kidney with extravasation of urine (fractured kidney).30'32 Contusion is the most common injury to the bladder, occurring in 67% of cases and is managed conservatively with urinary catheter drainage. Other injuries to the bladder include extraperitoneal bladder rupture (18%), intraperitoneal bladder rupture (13%), and combined intraperitoneal and extraperitoneal bladder rupture (2%).25'33 Extraperitoneal bladder rupture is managed conservatively with urinary catheter drainage. Intraperitoneal bladder rupture is managed intraoperatively with repair and suprapubic catheter drainage.
Diagnosis of injury to the ureter often is made at the time of exploratory laparotomy for the management of intra-abdominal injury. Primary reanastamosis of the ureter, if possible, and reconstitution of urinary flow are the goals of surgical management. Definitive management of urethral transection is controversial. Many urologists opt to place a suprapubic catheter for drainage of the urinary bladder and then delay repair of the urethra for several months until the patient is stable.25 Complications of urinary injury include shock, peritonitis, hypertension, chronic abdominal pain, and impotence.
ZIPPER ENTRAPMENT OF THE PENILE FORESKIN
Zipper injury to the foreskin occurs when the uncircumcised male zips up his pants quickly, entrapping the foreskin in the zipper mechanism. The patient is often a young male between 3 and 6 years of age. Often, the family has tried to remove the zipper and may actually cut the zipper from the pants prior to bringing the child in for evaluation. Physical examination reveals an anxious male with the zipper fixed to the foreskin. Removal of the zipper can be accomplished by one of two mechanisms: 1 ) soaking the zipper and attached foreskin in mineral oil for 10 minutes and then easing the foreskin from underneath the zipper mechanism or 2) using bone cutters to split the median bar causing the zipper mechanism to fall apart and releasing the entrapped foreskin (Figure 5).34-36
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Signs and Symptoms of Testlcular Torsion, Torsion of the Appendix Testls, and Epldldymltls
Cause of Painful Scrotal Swelling In Children
Signs and Symptoms of Genitourinary Tract Injury