Genitourinary


Dorsal Slit

Rapid Review

  • Background
    • Incision along the upper aspect of the foreskin to visualize the urethral meatus or relive strangulation of the glans from paraphimosis.
  • Indications
    • Paraphimosis (after non-invasive reduction techniques have failed)
    • Phimosis causing urinary retention (if catheter insertion not feasible)
  • Contraindications
    • No absolute contraindications. Use caution in patients with bleeding disorders or suspected infection of the foreskin. Consult urology if available.
  • Complications
    • Infection, bleeding, injury to glans/urethra

Pearls

Video Credit: Zaw Myint


Manual Testicular Detorsion

Rapid Review

  • Background
    • Manual rotation of the affected testis to restore perfusion. Should be performed within 6-8 hours. Successful in 30-70% of patients.
  • Indications
    • Testicular torsion (confirmed or clinically suspected)
  • Contraindications
    • Duration of torsion > 6 hours
  • Complications
    • Pain may prevent adequate detorsion

Pearls

Video Credit: Medgeeks


Paraphimosis Reduction

Rapid Review

  • Background
    • Paraphimosis is the inability to reduce a swollen, proximally positioned foreskin over the glans penis, causing vascular congestion and edema. Requires emergent reduction, which can be accomplished manually or with the use of non-invasive strategies (osmotic agents, ice water compression)
  • Indications
    • All patients with paraphimosis
  • Contraindications
    • Necrotic or ulcerated foreskin/penis
  • Complications
    • Penile/foreskin lacerations, swelling, pain, failure to achieve reduction (will then require dorsal slit)

Pearls

Video Credit: Dr. Dhanraj Chavan


Penile Injection/Aspiration

Rapid Review

  • Background
    • Procedure used in the management of ischemic priapism to preserve erectile tissue
  • Indications
    • Low-flow priapism not responding to conservative therapy
  • Contraindications
    • High-flow priapism, bleeding disorder, overlying skin infection
  • Complications
    • Recurrent priapism, fibrosis, urethral injury, infection

Pearls

Deep Dive

Video Credit: Larry Mellick


Suprapubic Bladder Aspiration

Rapid Review

  • Background
    • Insertion of a needle into the anterior abdominal wall (suprapubic region) to obtain an uncontaminated urine sample from the bladder. Performed when traditional urethral catheterization cannot be performed.
  • Indications
    • Urinary retention, urinalysis/culture in children less than 2 years of age or those with urethral stricture/trauma.
  • Contraindications
    • Unidentifiable bladder, known bladder tumor, overlying skin infection.
  • Complications
    • Infection, peritoneal/bowel perforation, hematuria

Pearls

Video Credit: umemergencymed


Suprapubic Catheterization

Rapid Review

  • Background
    • Placement of a drainage catheter into the urinary bladder above the pubic symphysis. Utilized when other methods (ex. Foley catheter) are not clinically feasible. 
  • Indications
    • Urethral obstruction (BPH, trauma, morbid obesity, urethral strictures, genital malignancy)
  • Contraindications
    • Inability to palpate or identify bladder on ultrasound
  • Complications
    • Bowel perforation, infection, hematuria

Pearls

Video Credit: Larry Mellick


Urethral Catheterization

Rapid Review

  • Background
    • Urinary catheterization is used to help facilitate drainage from the urinary bladder; may be used for diagnostic or therapeutic purposes.
  • Indications
    • Hygienic care of bedridden patients, acute urinary retention, monitoring of urine output, collection of uncontaminated urine specimen.
  • Contraindications
    • Traumatic injury to lower urinary tract
  • Complications
    • Bleeding, urethral strictures, infections, urethral perforation, paraphimosis (males)

Pearls

Video Credit: College of DuPage


Zipper Injury Management

Rapid Review

  • Background
    • Penile zipper injuries occur most frequently in young children and adolescents. Management involves analgesia, mineral oil, and cutting the median bar of the zipper, if needed. 
  • Indications
    • Penile zipper injury (may be caught in the teeth or in the sliding mechanism)
  • Contraindications
    • None
  • Complications
    • Additional trauma during extrication

Pearls

Video Credit: Larry Mellick
Brandon Simpson, PA-C
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