Dr. Mohammed Bassil
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Testicular torsion is a twist of the spermatic
cord, resulting in strangulation of the blood
supply to the testis.
most frequently between the ages of 10 and
30 (peak incidence 13–15years of age), but
any age group may be affected.
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There is a sudden onset of severe pain in the
hemiscrotum.
and is often associated with nausea.
There is sometimes a history of minor trauma
to the testis.
Some patients report previous episodes with
spontaneous resolution of the pain.
The torted testis is usually moderately
swollen and very tender to the touch.
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It may be high riding compared to the
contralateral testis and may lie in a horizontal
position due to twisting of the cord.
Thecremasteric reflex is nearly always absent.
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Epididymoorchitis.
torsion of a testicular appendage.
Color Doppler ultrasound .
radionuclide scanning .
In many hospitals these tests are not readily
available and the diagnosis is based on
symptoms and signs.
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Scrotal exploration should be undertaken as a
matter of urgency since delay in relieving the
twisted testis results in permanent ischemic
damage to the testis, causing atrophy, loss of
hormone and sperm production, and, as the
testis undergoes necrosis and the blood–
testis barrier breaks down, an autoimmune
reaction against the contralateral testis
(sympathetic orchidopathy).
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Bilateral testicular fixation should always be
performed since the bellclapper abnormality
that predisposes to torsion often occurs
bilaterally.
Manual detorsion may be attempted in the
emergency room while awaiting surgery.
Occasionally, the induction of anesthesia will
reduce spasm and promote spontaneous
detorsion—in both of these instances,
bilateral orchiopexy should still be performed
to prevent recurrence.
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The appendix testis
and the appendix
epididymis can undergo infarction, causing
pain that mimics a testicular torsion.
The “blue dot” sign is the typical physical
finding for appendix testis infarction. At
scrotal exploration they are easily removed
with scissors or electrocautery.
If
these
diagnoses
are
confirmed
radiographically , analgesics may be given
and surgical exploration is unnecessary.
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is when the uncircumcised foreskin is retracted
under the glans penis and the foreskin becomes
edematous, and cannot be pulled back over the
glans into its normal anatomical position.
Paraphimosis is usually painful. The foreskin is
edematous and a small area of ulceration of the
foreskin may have developed.
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The best initial maneuver for manually
reducing paraphimosis is to forcefully
squeeze the edematous prepuce for several
minutes. Then the skin may be manipulated
distally with the fingers of both hands as the
glans is pressed down with the thumbs.
If this fails, the traditional surgical treatment
is a dorsal slit under general anesthetic or
ring block. A longitudinal incision is made in
the tight band of constricting tissue and the
foreskin pulled back over the glans.
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Fournier gangrene is a necrotizing fasciitis of
the genitalia and perineum primarily affecting
males and causing necrosis and subsequent
gangrene of infected tissues.
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Culture of infected tissue reveals a mixed
polymicrobial infection with aerobic (E. coli,
enterococcus, Klebsiella) and anaerobic
organisms
(Bacteroides,
Clostridium,
microaerophilic streptococci).
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Conditions predisposing to the development
of Fournier gangrene include diabetes, local
trauma to the genitalia and perineum (e.g.,
zipper injuries to the foreskin, periurethral
extravasation of urine following traumatic
catheterization or instrumentation of the
urethra), and surgical procedures such as
circumcision.
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A fever is usually present, the patient looks
very ill, with marked pain in the affected
tissues, and the developing sepsis may alter
the patient’s mental state. The genitalia and
perineum are edematous.
and on palpation of the affected area,
tenderness and crepitus may be present,
indicating presence of subcutaneous gas
produced by gas-forming organisms.
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As the infection advances, blisters (bullae)
appear in the skin and, within a matter of
hours, areas of necrosis may develop on the
genitalia and perineum that spread to involve
adjacent tissues (e.g., the lower abdominal
wall).
The condition advances rapidly—hence its
alternative name of spontaneous fulminant
gangrene of the genitalia.
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The diagnosis is a clinical one and is based
on awareness of the condition and a high
index of suspicion. CT will demonstrate areas
of subcutaneous areas of necrosis and gas.
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Do not delay. While IV access is obtained, blood
taken for culture, IV fluids started, and oxygen
administered, broad-spectrum antibiotics are
given to cover both gram-positive and gramnegative aerobes and anaerobes.
debridement
of
necrotic
tissue
(skin,
subcutaneous fat) can be carried out. Extensive
areas of tissue may have to be removed.
but it isunusual for the testes or deeper penile
tissues to be involved.
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Priapism is prolonged and often painful
erection in the absence of a sexual stimulus,
lasting >4–6 hours, which predominantly
affects the corpus cavernosa.
Low-flow (ischemic) priapism
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It manifests as a painful, rigid erection, with
absent or low cavernosal blood flow. Ischemic
priapism beyond 4 hours requires emergency
intervention.
Blood gas analysis shows hypoxia and
acidosis
High-fl ow (nonischemic) priapism
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This is usually post-traumatic in nature and
does not require emergent intervention. It is
due to unregulated arterial blood flow.
presenting with a semi-rigid, painless
erection.
Blood gas analysis shows similar results to
arterial blood.
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Ischemic priapism of >4 hours implies a
compartment syndrome and requires decompression
of the corpora cavernosa. Aspiration of blood from
corpora ± intracavernosal injection of A1-adrenergic
selective agonist are performed every 5–10 minutes
until detumescence occurs.
High-fl ow priapism
Early stages may respond to a cool bath or icepack.
Delayed presentations require arteriography and
selective embolization of the internal pudendal
artery.
Complications
These include fibrosis and impotence.