0071643192.pdf

RENAL AND GENITOURINARY

EMERGENCIES

Phimosis Treatment

Daily cleaning of foreskin

Topical steroids

Immediate intervention if

outlet obstruction or vascular

compromise develops

Paraphimosis is a true

urologic emergency!

Manual reduction with firm

pressure for 5—10 minutes is

the initial treatment.

TREATMENT

■ Gentle, but not forceful, retraction of the foreskin

■ Improved hygiene

■ Topical steroids for 4 to 6 weeks (very effective)

■ Dilation of the meatus with forceps if signs of urinary outlet obstruction

■ Dorsal split procedure or circumcision in cases of vascular compromise

■ Admission for patients with urinary obstruction, evidence of systemic

infection, or vascular compromise

PARAPHIMOSIS

Paraphimosis occurs when the proximal foreskin cannot be reduced distally over

the glans penis, resulting in distal vascular congestion. This is a true urologic

emergency.

SYMPTOMS/EXAM

■ Patient often reports inability to replace foreskin back over glans (see

Figure 18.6).

■ Exam reveals a flaccid proximal penis with erythema and engorgement

distal to the obstruction.

DIAGNOSIS

Diagnosis is largely based on clinical examination.

TREATMENT

■ Supportive care with analgesia

■ Dorsal penile nerve block as needed

■ Manual reduction with firm pressure to the glans for 5–10 minutes to reduce

edema and slide foreskin distally

■ Dorsal slit procedure if manual reduction is unsuccessful

■ Circumcision

■ Admission for patients unable to void spontaneously

A 25-year-old male with history of schizophrenia presents to the ED with

priapism. He was recently started on risperdal and has a history of cocaine

use. On examination, the corpora cavernosa are rigid and tender with palpa-

tion. What is the most appropriate initial therapy?

This patient is presenting with low-flow (ischemic) priapism, likely related to

risperdal and cocaine use. This is a true urologic emergency. Immediate intervention

includes terbutaline (SQ or PO) and pseudoephedrine (PO) and immediate urologic

consultation for corpus cavernosum aspiration and diluted phenylephrine injection.

PRIAPISM

The penis is composed of two corpora cavernosa and the corpus spongiosa

surrounding the urethra. With normal erection the corpora cavernosa fill

with well-oxygenated blood (which on blood gas analysis has the appearance

of arterial blood).