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

• When using the hemostats to crush the foreskin, be sure that it is not inserted into the urethra. 
• Do not perform a dorasal slit until non-invasive techniques have been attempted.

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

• 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.

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

• 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)

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

• Aspiration for priapism is rarely beneficial if performed > 48 hrs from onset (permanent erectile dysfunction often occurs after 36 hours)
• Applying manual compression for 30-60 seconds over the puncture sites following injection/aspiration can help minimize hematoma formation. 

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

• When available, it is best to use ultrasound and observe the needle as it punctures the bladder.
• If initial insertion is unsuccessful, do not completely withdraw. Pull the needle back slightly and redirect 10 degrees in either direction. Maximum 3 attempts.

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

• Ultrasound should be used when possible to locate the bladder and ensure that bowel perforation does not occur.
• If a catheter is being placed for the first time, it should remain in place for at least 4 weeks to allow the catheter tract to become established.

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

• Sterile technique is essential for preventing urinary tract infections.
• If you meet resistance during insertion, do not use excessive force. This can causes urethral injury.

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

• 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.

Deep Dive

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