Manual rotation of the affected testis to restore perfusion. Should be performed within 6-8 hours. Successful in 30-70% of patients.
Testicular torsion (confirmed or clinically suspected)
Duration of torsion > 6 hours
Pain may prevent adequate detorsion
The “Open Book” method has the potential to worsen torsion if the testicle is twisted laterally. If the patient is not feeling any relief in pain or the anatomy is not improving with attempts, try twisting in the other direction. Ultrasound can be used to guide detorsion.
The “Traction Technique” can also be attempted, which involves pulling inferior traction briefly and allowing the testicle to detorse itself in the direction of least resistance.
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)
All patients with paraphimosis
Necrotic or ulcerated foreskin/penis
Penile/foreskin lacerations, swelling, pain, failure to achieve reduction (will then require dorsal slit)
The use of hypertonic agents (sugar and salt) can take hours to draw out edema Do not use this for acute paraphimosis when time is of the essence.
If using a clamp technique, it is essential to use babcock clamps (these are non-crushing)
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.
Urinary retention, urinalysis/culture in children less than 2 years of age or those with urethral stricture/trauma.
Unidentifiable bladder, known bladder tumor, overlying skin infection.
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.
Penile zipper injury (may be caught in the teeth or in the sliding mechanism)
Additional trauma during extrication
Patient may require analgesics or sedation to facilitate cooperation
If conservative measures fail, the penis can be anesthetized and the zipper can be pulled back through the direction it came. However, this will likely worsen trauma and should only be used as a last resort.