111 - Male Genitourinary Emergencies

The fibrous capsule of the tunica albuginea surrounds each testis. A break in the integrity of the tunica albuginea represents a “ruptured” testicle, which can be caused by blunt trauma. External to the testicular parenchyma and tunica albuginea is the tunica vaginalis, which envelops each testicle and fastens it to the posterior scrotal wall. The gubernaculum, or scrotal ligament, anchors each testis inferiorly and provides additional stability. The tunica vaginalis consists of both visceral (contiguous with the tunica albuginea) and parietal (contiguous with the deep spermatic fascia) layers, with an interposed potential space. A lack of firm attachment of the testicle to the posterior scrotal wall makes the testis prone to rotation in a horizontal plane about the spermatic cord, a condition termed testicular torsion. The testicular artery originates from the aorta just below or directly from the renal artery. The spermatic cord contains both the blood supply to each testicle via the gonadal vessels and the vas deferens. Interruption of blood flow to the testis by twisting of the spermatic cord can lead to rapid ischemia and subsequent infarction of the affected testicle in cases of testicular torsion. The appendix testes are embryologic remnants with no known physiologic function. These appendages are prone to torsion as well, which can lead to localized, self-limited necrosis. It results in clinical findings that may be confused with testicular torsion. The epididymis adheres closely to the posterolateral aspect of each testis. It is involved in promoting sperm maturation and motility. The appendix epididymis is an embryologic remnant typically attached to each epididymis. These too are prone to torsion. The vas deferens is a tubular structure involved in sperm transit; it extends from the epididymis distally to the prostatic portion of the urethra proximally. The penis consists of the corpora cavernosa (erectile bodies) and the corpus spongiosum, which surrounds the urethra. In uncircumcised males, the retractile penile foreskin covers the glans. The potential constricting effect of proximally retracted foreskin may lead to paraphimosis. In paraphimosis, venous engorgement of the glans and edema resulting from constriction can potentially progress to arterial compromise and necrosis of the distal end of the penis. Each corpus cavernosum is surrounded by the tunica albuginea as well. Priapism is a pathologic condition defined as the presence of a persistent erection lasting longer than 4 hours in the • The five major male genitourinary emergencies are testicular torsion, Fournier gangrene (necrotizing fasciitis of the perineum), priapism, paraphimosis, and genitourinary tract trauma. An associated emergent condition is an incarcerated or strangulated inguinal hernia. • Ultrasound examination is the primary diagnostic tool for differentiation of causes of acute scrotal pain. • Urology services should be consulted immediately after initial patient evaluation when testicular torsion is suspected. • Pain out of proportion to the findings on physical examination is the hallmark of early Fournier gangrene. • In the setting of severe scrotal pain, a necrotic or ischemic cause should be suspected. Testicular torsion, Fournier gangrene, and an incarcerated or strangulated inguinal hernia are surgical emergencies. • A trial of oral terbutaline, a β-adrenergic agonist, is the least invasive initial treatment of priapism. Corporal blood aspiration with or without irrigation or injection of an α-adrenergic receptor agonist (e.g., phenylephrine) may be necessary if the condition is not reversed rapidly. • Successful reduction of paraphimosis can often be performed at the bedside without specialty consultation. • A urologist should be engaged in the care of all but the most minor cases of genitourinary trauma. KEY POINTS