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History. 19-year-old male with acute right scrotal pain for the last 5 hours No fever, dysuria, nausea and vomiting No previous pain episodes No history of trauma Past history: Unremarkable. Physical exam. T = 37.2, P = 72, BP = 105/74 Chest, abdomen, and extremities are all normal

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History

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History l.jpg

History

  • 19-year-old male with acute right scrotal pain for the last 5 hours

  • No fever, dysuria, nausea and vomiting

  • No previous pain episodes

  • No history of trauma

  • Past history: Unremarkable


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Physical exam

  • T = 37.2, P = 72, BP = 105/74

  • Chest, abdomen, and extremities are all normal

  • Penis: Uncircumcised, no discharge or lesions

  • Left testis: Normal

  • Right scrotum: Swollen, erythematous and extremely tender


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Exam


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Laboratory

  • U/A: 5 WBC, 0 RBC, Mod. Bacteria

  • CBC: WBC 9.6, Hct 39


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Differential Diagnosis

  • Spermatic cord torsion

  • Torsion of testicular appendage

  • Epididymitis / orchitis

  • Trauma

  • Malignancy

  • Idiopathic


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Management

  • Epididymitis- Antibiotics

  • Torsion of appendage- Observation

  • Torsion of cord- Exploration

  • Trauma- Exploration

  • Malignancy- Exploration


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Imaging-Doppler Ultrasound


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Bell-clapper

Management – Exploration


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Management – Orchiopexy


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Epididymitis/Orchitis

  • Etiology

    • Sexually active

      • N. Gonorrhea

      • Chylamidia

      • Ureaplasma urealyticum

    • Prepubertal

      • E. Coli


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Infection: Management

  • STD

    • Azithromycin

    • Metronidazole

  • Prepubertal

    • Trim/sulfa

    • Cephalosporine


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Torsion of Appendage


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Torsion of Appendage

  • Observation (if you can be certain of the diagnosis)

  • Exploration if you can’t rule out spermatic cord torsion


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Acute Scrotum – Summary

  • Spermatic cord torsion most common cause

  • Doppler ultrasound most accurate noninvasive imaging study

    • 5% false negative

  • Suspect spermatic cord torsion

    • Immediate exploration


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History

  • 42-year-old white male w/ painful erection >6 hours

  • Past History: depression

  • Medications: trazadone


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Exam

  • T = 37, P = 78, BP = 126/82

  • Penis: erect with tumescence of corpora cavernosa, soft glans and ventrum


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Management

  • Aspiration / Irrigation

    • Blood gas on aspirate

    • pH = 7.4, pO2 = 38

  • Phenylephrine Irrigation

    • Monitor patient (BP, pulse)


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History

  • 26-year-old white male suffered “crossbar” injury

  • Erection >5 hours

  • Past History: Negative


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Exam

  • T = 37, P = 78, BP = 126/82

  • Penis: erect

  • Aspirate - Bright red blood

    • pH = 7.0, pO2 = 86


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High-flow Priapism

  • History of trauma

  • Diagnosis:

    • Duplex Doppler ultrasound

    • Arteriography

  • Management: Embolization


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