Category: Renal and Urogenital

Testicular Torsion

Kidney Stones are a Diagnosis of Exclusion!!!

Introduction
  • Testicular torsion is a time sensitive diagnosis (risk of infertility, etc)
  • Commonly mimics kidney stones
History
  • Sudden onset pain
    • Epididymitis tends to be slower in onset
  • Flank/lower abdomen/scrotal pain
  • Frequently causes vomiting
  • Uncommon in geriatric patients
Exam
  • Perform a GU exam and look for
    • Unequal/horizontal “lie”
    • Testicular tenderness
    • Swelling
    • Absent cremasteric reflex
Testing Plan
  • Testicular/Scrotal Ultrasound
  • Urinalysis
Treatment Plan
  • Consult urology when suspected (even if ultrasound hasn’t returned yet)
  • Manual detorsion
    • “Open the Book”
    • Twist medial to lateral
      • Switch directions if no pain relief
Additional Reading

Flank Pain and Kidney Stones

Kidney Stones are a Diagnosis of Exclusion!!!

Step 1: Consider the Differential Diagnosis for Flank Pain
  • Appendicitis
  • Abdominal Aortic Aneurysm
  • Ectopic Pregnancy
  • Testicular/Ovarian Torsion
  • Kidney Stone
Step 2: Diagnose the Kidney Stone
  • Option 1- Renal Ultrasound
    • Findings consistent with kidney stone diagnosis
      • Hydronephrosis
      • Lack of ureteral jets (in bladder)
      • Kidney stones (poor sensitivity for this)
    • Benefits
      • Can be performed at bedside
      • No radiation
  • Option 2- Non-contrast CT scan
    • Great for identifying alternative diagnoses
Step 3: Rule Out Infection
  • Fevers
  • Urinalysis with nitrites or bacteria
    • If present, patient needs antibiotics
Step 4: Control Symptoms
  • Analgesics
    • NSAIDS (such as ketorolac)
    • Opiates
  • Antiemetics
    • Zofran
Step 5: Rule Out Kidney Injury
  • Elevated creatinine
  • Solitary kidney
Admission Criteria for Kidney Stones
  • Coexisting Urinary Tract Infection
  • Unable to Control Symptoms
  • Renal Injury/Solitary Kidney
Additional Reading

Priapism

The nerve, artery, and vein are at 12 o’clock. The urethra is at 6 o’clock.

Two Types of Priapism

  • High flow (non-ischemic)
    • Common causes
      • Trauma
      • AV malformations
      • Tumors
    • Priapism from too much blood coming IN
    • Not painful
    • Consult urology
  • Low flow (ischemic)
    • Common causes
      • Sickle cell disease
      • Drug side-effects
    • Priapism from blood being unable to flow OUT
    • Patient requires emergent detumescence
      • 50% chance of erectile dysfunction

Step 1: Prepare (4c approach)

  • Collect
    • 19G needle
    • 21G needle
    • Variety of syringes
    • Gauze
    • Sterile drape
    • Betadine
    • Normal saline
  • Consent
    • 50% chance of erectile dysfunction even with successful procedure
  • Clean
    • Set up supplies and sterile field
  • Control pain

Step 2: Drain

  • Nerve/Artery/Vein on top (12 o’clock)
  • Urethra on bottom (6 o’clock)
  • Insert 19G needle at either 3 or 9 o’clock and aspirate
    • UPDATE: Recommended insertion at either 2 or 10 o’clock
  • 30% chance of detumescence at this step alone

Step 3: Send Venous Blood Gas

  • Confirms high-flow (non-ischemic) from low-flow (ischemic) priapism

Step 4: Irrigate

  • Inject normal saline through the needle and then aspirate

Step 5: Phenylepherine

  • Dilute 1ml (10 mg/ml) in 9 ml NS (results in 1mg/ml solution)
    • Inject 0.25 ml of 1 mg/ml solution and repeat q10 minutes
    • Alpha agonist effect constricts smooth muscle and facilitates venous outflow

Additional Reading

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