Genitourinary

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

Deep Dive

• Dorsal Slit of the Foreskin (Medscape)

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

Deep Dive

• Ultrasound-Guided Manual Testicular Detorsion in the Emergency Department (Science Direct)

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

Deep Dive

• How To Do Paraphimosis Reduction Without Dorsal Slit (Merck Manuals)

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

• Priapism (Core EM)

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

Deep Dive

• Suprapubic Bladder Aspiration (NEJM)

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

Deep Dive

• Suprapubic Bladder Catheterization (StatPearls)

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

Deep Dive

• How To Do Urethral Catherization in a Female (Merck Manuals)
• How To Do Urethral Catheterization in a Male (Merck Manuals)

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

Deep Dive

• Unlocking Common ED Procedures: Penile Zipper Injuries and Entrapment (emDocs)