Week 48: Renal + Genitourinary Pathology

When a child presents with abdominal pain, nausea and vomiting, one must perform a testicular/scrotal exam to rule out acute scrotal or testicular pathologies. In this case, the presence of a swollen right testicle and scrotal pain but negative ultrasound findings is concerning for intermittent testicular torsion. It is important to remember that testicular torsion is a clinical diagnosis, requiring a high index of suspicion, even in the face of early, unremarkable ultrasound findings. Blue-dot sign is typically seen in torsion of the appendix testis. Pain alleviation with testicular elevation is seen in epididymitis. The treatment of testicular torsion starts with manual detorsion, followed by timely surgical detorsion and fixation.

Infected obstructing urolithiasis is a urologic emergency. A critical aspect of treatment is prompt decompression of the renal collecting system by percutaneous nephrostomy catheter or retrograde ureteral stent placement. While adjunctive therapy with broad-spectrum intravenous antimicrobials is important, decompression remains the critical intervention. Foley catheter placement and monitoring of urinary output are important adjunctive interventions in patients with a variety of conditions such as sepsis.

Epididymitis occurs most commonly in men between the ages of 14 and 35 years. However, it can occur in any age group. It occurs from an ascending infection from the urethra, prostate, or bladder, and occasionally by hematogenous spread. Epididymitis is characterized by gradually increasing dull, unilateral scrotal pain, fever, and dysuria.Examination usually reveals localized epididymal edema and tenderness (posterior aspect of scrotum), possible testicular tenderness, and a normal cremasteric reflex. Pain may be relieved with testicular elevation (positive Prehn sign). Scrotal pain should be initially evaluated with a color Doppler ultrasound test, and in the case of epididymitis, the typical findings are an enlarged, thickened epididymis with increased blood flow. The most common organism responsible for epididymitis in those 14 to 35 years-of-age are Neisseria gonorrhoeae and Chlamydia trachomatis. In older individuals (traditionally >35 years of age) and nonsexually active individuals, the Gram-negative rod bacteria (Escherichia, Klebsiella, Enterobacter and Citrobacter species) are most common. Trimethoprim-sulfamethoxazole or a fluoroquinolone such as levofloxacin or ciprofloxacin is the recommended treatment in this age group.

The patient in this case has priapism. Given the history of sickle cell disease, and no preceding trauma, this is likely the ischemic, or low-flow type of priapism. All of the above treatment options are appropriate for low-flow priapism, with the exception of angiography with embolization, which is used for high-flow priapism. Other treatment options for low-flow priapism include intracavernosal aspiration and surgical shunt placement. Urology consultation should be obtained for low-flow priapism.

Amiodarone can cause a chemical epididymitis, which is characterized by testicular pain and swelling. This effect is more common with chronic (greater than 4 months) and high dose (more than 400 milligrams per day) amiodarone use. Amiodarone concentrates in the testicle where is causes lymphocytic infiltration and fibrosis. Unlike patients with infectious epididymitis, patients do not experience fever, pyuria, or leukocytosis.

Phimosis is the inability to retract foreskin over the glans penis. It is a complication seen in uncircumcised men. About 50% of boys typically are able to retract their foreskin by 1 year of age and 80% by age 3. Topical estrogen therapy has been reported as successful, but no randomized trials support its use. However, low-potency topical corticosteroid therapy combined with daily prepuce retraction appears effective for phimosis. If retraction of foreskin is unsuccessful, the patient will require circumcision.

Uric Acid stones are usually radiolucent and will not show on plain films. The order of decreasing radiopacity is Calcium Phospate, Calcium Oxalate, Struvite, Cysteine, then Uric Acid.

The patient presents with priapism , a urologic emergency that should be relieved emergently with corporeal aspiration. Priapism describes engorgement of the corpora cavernosa due to either low-flow (more common) or high-flow states. Low-flow priapism is due to decreased venous outflow and is commonly seen in sickle cell diseaseand leukemia. A number of medications can also cause this disorder. High-flow priapism is generally painless and results from excessive inflow of arterial blood or spinal trauma. Management should be expeditious as prolonged priapism can result in fibrosis and erectile dysfunction. Cavernosal aspiration and irrigation with phenylephrine is the most effective treatment modality. A dorsal nerve block should first be performed followed by aspiration from the corpora cavernosa until the penis detumesces. This can be followed by phenylephrine irrigation into the corpora. Patients with persistent priapism or underlying sickle cell disease or leukemia should be considered for admission.

This patient’s presentation is highly suspicious for a traumatic dislocation of the testicle. Physical exam findings consistent with this diagnosis include a swollen and ecchymotic scrotum with an absent testis. Emergent operative intervention is required by a urologist to relocate the displaced testicle (usually from the abdominal wall).

Doppler ultrasound (A) would be a reasonable test to order if there were uncertainty about the diagnosis or if alternative testicular injuries such as torsion or fracture were suspected. However, in this case, traumatic dislocation is highly likely and, to optimize outcomes, immediate evaluation by a urologist is needed. NSAIDs (B) and outpatient urology follow-up is the treatment of choice for testicular contusions without laceration or dislocation. Retrograde urethrogram (C) is useful in the workup of distal urethral injuries, not testicular injuries.

This patient is presenting in severe sepsis and Fournier’s gangrene. Empiric antibiotics and medical resuscitation should be administered, but this patient requires emergent surgical debridement for definitive treatment. While hyperbaric oxygen has been used in the treatment of necrotizing fasciitis, it is an adjunctive therapy.