Erectile Dysfunction and Urologic Emergencies PDF

**OUTLINE** I. **Erectile Dysfunction** II. **Urologic Emergencies** a. Acute Scrotum b. Torsion (Ischemia) c. Torsion of Testicular or Epididymal Appendages d. Fournier's Gangrene e. Epididymitis and Epididymo-orchitis f. Acute Urinary Retention g. Bladd...

**OUTLINE** I. **Erectile Dysfunction** II. **Urologic Emergencies** a. Acute Scrotum b. Torsion (Ischemia) c. Torsion of Testicular or Epididymal Appendages d. Fournier's Gangrene e. Epididymitis and Epididymo-orchitis f. Acute Urinary Retention g. Bladder Outlet Obstruction h. Bladder Dysfunction i. Priapism j. Paraphimosis k. Emphysematous Pyelonephritis III. **Review Questions** +-----------------------+-----------------------+-----------------------+ | **LEGEND** | | | +=======================+=======================+=======================+ | ⭐ | 🖊️ | 📖 | | | | | | Must | Lecture | Book | | | | | | Know | *\[lec\]* | *\[bk\]* | +-----------------------+-----------------------+-----------------------+ ERECTILE DYSFUNCTION {#erectile-dysfunction.TransOutline} ==================== - Erectile dysfunction is defined as the inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse. - Erection is a neurovascular event. - Most common cause of ED is psychogenic - Especially for patients who are relatively young - Erection is modulated by the parasympathetic NS. Stress and performance anxiety will make the ED worse. - Similar to ejaculation, which is modulated by the sympathetic NS, stress & anxiety will cause premature ejaculation. MECHANISM OF ERECTILE DYSFUNCTION {#mechanism-of-erectile-dysfunction.TransSubtopic1} --------------------------------- Mechanism of Erection and how PDE-5 Inhibitors work Step1: Sexual Stimulation Step2: Cavernous nerve releases Nitric oxide Step3: Nitric Oxide stimulates Guanylate cyclase Step4: Guanylate cyclase converts GTP to cGMP Step5: cGMP will activate cGMP-specific protein kinase decrease the Ca ion content in the smooth muscle Step6: cGMP-specific protein kinase will decrease the Ca ion content in the smooth muscle Step7: decreased Ca causes smooth-muscle relaxation(erection) Step8: Detumescence: PDE-5 will convert cGMP to 5'GMP, preventing the process that leads to erection. PDE-5 is the site of action for PDE5 inhibitor A diagram of a cell line Description automatically generated Figure 1. Mechanism of ED CAUSES OF ERECTILE DYSFUNTION {#causes-of-erectile-dysfuntion.TransSubtopic1} ----------------------------- +-----------------------+-----------------------+-----------------------+ | Table 1. Causes of Er | | | | ectile Dysfunction {# | | | | table-1.-causes-of-er | | | | ectile-dysfunction.T | | | | ransSub-subtopic2} | | | | --------------------- | | | | ------------------ | | | +=======================+=======================+=======================+ | Category | Disorder | Problem | +-----------------------+-----------------------+-----------------------+ | - Psychogenic | - Performance | - Loss of libido | | | Anxiety | | | | | - Over inhibition | | | - Depression | | | | | - Impaired nitric | | | | oxide release | +-----------------------+-----------------------+-----------------------+ | - Neurogenic | - Stroke | - Lack of nerve | | | | impulse or | | | - Spinal Cord | interrupted | | | Injury | transmission | | | | | | | - Diabetic | | | | Retinopathy | | +-----------------------+-----------------------+-----------------------+ | - Hormonal | - Hypogonadism | - Inadequate Nitric | | | | Oxide Release | | | - Hyperprolactinemi | | | | a | | +-----------------------+-----------------------+-----------------------+ | - Vasculogenic | - Atherosclerosis | - Impaired arterial | | (Arterial or | | or venous flow | | Venous) | - Hypertension | | +-----------------------+-----------------------+-----------------------+ | - Medication | - Antihypertensives | - Central | | induced | | Suppression | | | - Antidepressant | | | | | - Vascular | | | - Alcohol | insufficiency. | | | | | | | - Cigarette use | | +-----------------------+-----------------------+-----------------------+  Figure 2. Causes of ED SHIM QUESTIONNAIRE {#shim-questionnaire.TransSubtopic1} ------------------ A table with many squares Description automatically generated with medium confidence Figure 3. SHIM Questionnaire - Sexual Health Inventory for Men (SHIM) is used clinically to assess the degree of Erectile Dysfunction Table 2. SHIM questionnaire interpretation -------------------------------------------- --------------------- **SCORE** **INTERPRETATION** 1-7 Severe ED 8-11 Moderate ED 12-16 Mild to Moderate ED 17-21 Mild ED 22-25 No ED IMPLICATIONS OF ERECTILE DYSFUNCTION {#implications-of-erectile-dysfunction.TransSubtopic1} ------------------------------------ - The presence of ED in a known healthy man can signify the evolution of early systemic diseases that commonly affect the vascular system, such as: - Diabetes mellitus - Hypertension - Atherosclerosis - The penis has among the smallest arteries, & any vascular dysfunction will first affect erectile function being a purely neurovascular phenomenon. MANAGEMENT {#management.TransSubtopic1} ---------- GENERAL MANAGEMENT {#general-management.TransSub-subtopic2} ------------------ - "Clean living" - Quit smoking - Lose weight - More exercise - Complete sleep - Avoid alcohol PHARMACOLOGIC MANAGEMENT {#pharmacologic-management.TransSub-subtopic2} ------------------------ #### Phosphodiesterase-5 Inhibitors (PDE5I) {#phosphodiesterase-5-inhibitors-pde5i.TransSub-subtopic3} - Phosphodiesterase converts cGMP to 5' cGMP. - This enhances the effect of nitric oxide by inhibiting the breakdown of cGMP, which accumulates & in turn enhances & prolongs cavernous muscle relaxation. - - Improves the response, they do not trigger an automatic erection. - Usually taken at least an hour before sexual activity. - "On-demand" pill. - There is a need for the usual sexual stimulation & attraction. - Generally 70% success rate. - Common side effects include: - - - - - - **DRUG INTERACTIONS** - Nitrate-based drugs used in conjunction with PDE5Is are an absolute contraindication - Sublingual nitroglycerin, ISDN, ISMN, amyl nitrate o Can produce a potentially fatal sudden drop in blood pressure. - Alpha-adrenergic blockers o Terazosin & Doxazosin, especially. Alfuzosin & Tamsulosin have lesser interactions.  #### PROSTAGLANDIN E1 (Aprostadil) {#prostaglandin-e1-aprostadil.TransSub-subtopic3} - Intracavernous Injection - Patients are trained to give themselves a self-injection when they want an erection, and it takes approximately 5 to 15 minutes until they are fully rigid if they respond. - Greater concern for prolonged erection or priapism, so dose titration must be closely monitored. A diagram of a syringe being injected into a cavenosum Description automatically generated Figure 5. Aprostadil #### Intraurethral Suppository: Aprostadil {#intraurethral-suppository-aprostadil.TransSub-subtopic3} - Intraurethral suppositories are composed of alprostadil in the form of a pellet - Placed in the urethra and massaged for absorption. - With suppository use, there are concerns about efficacy (only 46--65%) and compliance due to a burning sensation that limits the interest of some users.  Figure 6. Intraurethral Suppository #### Vacuum Erection Device {#vacuum-erection-device.TransSub-subtopic3} - VED is a mechanical device composed of a cylinder placed around the penis which then uses a vacuum to create negative pressure and pull blood into the penis. - In order for blood to stay in the penis after the vacuum is released, a tight constriction band must be placed at the base of the penis. - poor compliance due to difficulty with use and the common reactions of petechia, temporary paresthesia, color changes, and the penis being cold to touch. A medical device with a tube attached to a tube Description automatically generated Figure 7. Vacuum Erection Device UROLOGIC EMERGENCIES {#urologic-emergencies.TransOutline} ==================== ACUTE SCROTUM {#acute-scrotum.TransSubtopic1} ------------- - "Acute Scrotum" is the Urologist's counterpart of the General Surgeon's "Acute Abdomen." - Both conditions are guided by similar management principles Management Principles {#management-principles.TransSub-subtopic2} --------------------- - The mainstay for Acute Scrotum is history and physical exam" - Imaging merely complements and will NOT replace good clinical judgement. - When in doubt, explore! Causes of Acute Scrotum {#causes-of-acute-scrotum.TransSub-subtopic2} ----------------------- - Ischemia - Trauma - Infectious - Inflammatory - Hernia - Acute on Chronic Events Other Causes of Acute Scrotum {#other-causes-of-acute-scrotum.TransSub-subtopic2} ----------------------------- - Inflammatory - Scrotal wall Heinrech-Scholein purpura (HSP), Fat necrosis. - Hernia - Incarcerated, strangulated; with or without testicular ischemia. - Acute on Chronic Events - Rupture/Hemorrhage/Infection of Spermatocele, Hydrocoele, Testicular Tumor - Markedly symptomatic Varicocele TORSION (ISCHEMIA) {#torsion-ischemia.TransSubtopic1} ------------------ - When the testicle spontaneously twists thus obstructing the blood supply, causing necrosis and pain - The testicle is normally adherent to the tunica vaginalis on the postero-medial aspect thus limiting the twisting movement - Torsion patients usually have a congenitally high attachment of tunica vaginalis, such that the testicle can rotate freely on the spermatic cord. Known as a "**Bell-Clap Deformity**"  Figure 9. Bell-Clap Deformity - The testicle lies transverse as opposed to a longitudinal lie of the affected testes. - This congenital abnormality is present in approximately 12% of males. A close-up of a human body Description automatically generated Figure 10. Torsion TYPES OF TORSION {#types-of-torsion.TransSub-subtopic2} ---------------- #### Intravaginal {#intravaginal.TransSub-subtopic3} 🖊️*Is the more common one, torsion of testicle inside tunica vaginalis* Twists spontaneously on the spermatic cord, causing venous occlusion and engorgement, with subsequent arterial ischemia and infarction Experimental evidence indicates that 720 degrees twist is required #### Extravaginal {#extravaginal.TransSub-subtopic3} 🖊️Torsion is the tunica vaginalis itself, not common and usually seen antenatally during the latter part of the pregnancy In neonates, the testicle frequently has not yet descended into the scrotum, after which it becomes attached within the tunica vaginalis This is increased mobility of the testicle predisposes it to torsion (extravaginal testicular torsion) #### Torsion due to long mesorchium {#torsion-due-to-long-mesorchium.TransSub-subtopic3} 🖊️*Not common and usually seen antenatally during the latter part of the pregnancy*  Figure 11. Types of Torsion CLINICAL PRESENTATION {#clinical-presentation.TransSub-subtopic2} --------------------- - ⭐**[Left testicle more commonly affected]** - 🖊️*When you have problems in the testis and its congenital or hereditary in origin, usually the left side is commonly involved. Same with problems such as varicocele and with kidneys.* - Among neonatal testicular torsion cases, 70% occur prenatally and 30% occur postnatally. - The testis salvage rate approaches 100% in patients who undergo detorsion ⭐**[within 6 hours of the start of pain]** - 🖊️*Important to ask what time it started then count 6 hours. Kasi if lumampas na ng 6 hours, the chances are you cannot salvage the testes. More likely you will do orchiectomy na lang. In older children, it usually happens at 2-3 am or in the middle of the night.* - However, there is only a **20% viability rate** if detorsion occurs **\>12 hours**. - Virtually **no viability** if detorsion is delayed **\>24 hours**. - Rapid or sudden of onset of severe testicular pain & swelling. - The onset of pain can be preceded by trauma, physical activity, or more commonly, by no activity (e.g., during sleep). - It most often occurs in children or adolescents but may occur at any age. - Torsion should be in the differential for any sudden acute scrotal pain or swelling. - Exquisitely tender testicle with a high, horizontal lie. A close-up of a person\'s buttocks Description automatically generated  Figure 12. Torsion (1^st^), Prehn Sign (2^nd^) - ⭐**[Prehn sign]** -- gently elevate the testis with your hand. If the pain is relieved upon lifting over the symphysis pubis, this is recorded as a (+) Prehn Sign, which is indicative more for [epididymoorchitis]. - 🖊️*Kung di nawala sakit, or lalong sumakit, could be a [torsion].* - The mainstay of diagnosis is an ⭐**[Emergency Color- Doppler Ultrasound]** - Color-Doppler will show decreased perfusion for torsion & increased for epididymitis. - Ultrasound will also diagnose other possible causes of acute scrotum such as hernia and trauma (e.g., hematoma, incarcerated/strangulated hernia). A close-up of a ultrasound Description automatically generated  A close-up of an ultrasound Description automatically generated Figure 13. Torsin of the R testis (1^st^), Longitudinal View (2^nd^), Whirlpool Sign (3^rd^) - ⭐**[Whirlpool Sign]** due to twisted spermatic cord. - 🖊️*Note that testicular torsion is a surgical emergency that **requires intervention within 6 hours**, you have **acute pain and swelling, twisting of the testis and spermatic cord** resulting in ischemia and doppler ultrasound shows **decreased blood flow.*** MANAGEMENT {#management-1.TransSub-subtopic2} ---------- - It is better to explore a testis unnecessarily than to neglect to do so when needed. - Best results are obtained when exploration is done within 4 to 6 hours of incident. - 🖊️*When in doubt, explore!* - \>12 hours, testicular atrophy is significant - If exploration is delayed from 12 to 24 hours, testicular preservation is done only if the testicular appearance improves following detorsion - If \>24 hours or with no improvement after detorsion, orchiectomy or orchidectomy is done. - An **orchidopexy or orchiopexy** is always performed on the **contralateral** as the **"Bell-Clapper Deformity"** is usually **bilateral**.  Close-up of a person\'s stomach Description automatically generated Figure 14. You open up the scrotum, you can see the torsia (1^st^), Itim na so an orchiectomy is an order for this kind of torsion (2^nd^) - 🖊️*When you do detorsion on one side, you do an orchidopexy to fix the testis, but you also have to do orchidopexy on the other side to prevent torsion in the future.* - If the testis is to be preserved, an orchidopexy is also performed. - Orchidopexy is done by anchoring the tunica albuginea of the testis to the overlying parietal tunica vaginalis and scrotal dartos muscle. - **Patient with "intermittent torsion"**, a bilateral prophylactic orchidopexy can be done. - 🖊️*Patient that has torsion then the next 6 hours mawawala na lang mag-isa. It happens frequently.* TORSION OF TESTICULAR OR EPIDIDYMAL APPENDAGES {#torsion-of-testicular-or-epididymal-appendages.TransSubtopic1} ---------------------------------------------- - Small polypoid appendages are often found attached to the testis or epididymis and are either Mullerian or Wolffian duct remnants. - Can also present with the acute onset of scrotal pain and mass. - Testis is usually palpable and has a **normal lie.** - When examined early, the edematous, torsed appendage can often be palpated at the **upper pole of the testis.** - *Torsion of the testicular or epididymal appendage is **often self- limited**, with the infarcted appendage undergoing atrophy with time* - *If exploration is pursued, the appendage is simply excised and **no orchidopexy is needed.***  Figure 15. Left -- Normal groin, Right -- Torsion of the Appendix Testis ***\ *** An ultrasound of a fetus Description automatically generated Figure 16. Ultrasound with color doppler 🖊️ *You can see this mass (arrows) at the area of epididymis with some reactive hydrocele (H). This is the left testis (LT).*  Figure 17. Ultrasound with color doppler A close-up of a person\'s tongue Description automatically generated Figure 18. Appendix testis  Figure 19. Large appendix testis FOURNIER'S GANGRENE {#fourniers-gangrene.TransSubtopic1} ------------------- - Scrotal wall infections may result from infected sebaceous cysts, folliculitis, or other dermatologic conditions. - **Fasciitis of scrotum and groin**, termed Fournier's gangrene - **Aggressive treatment** is mandatory even for superficial conditions since these can easily progress - 🖊️*We treat this by doing incision and drainage with gauze packing and broad-spectrum antibiotics are prescribed for these superficial conditions* - Associated with predisposing issues including urethral perforation and periurethral abscess and is most often seen in the **immunocompromised or diabetic patient** - Diffuse enlargement, thickening and erythema of the scrotal wall, groin and perineum - There may be necrotic black or ecchymotic patches of genital skin present - The most diagnostic is the finding of **crepitus**, a spongy, cracking feeling within the skin that indicates gas-producing microorganisms underneath that can be felt in the scrotum or perineum - 🖊️***Crepitus** - literally when you palpate the skin, it's like a cellophane, yung ingay na parang umaapoy. This crepitation is very pathognomonic in this kind of conditon* - When left untreated, can progress over mere hours and result in overwhelming bacterial sepsis with an associated high mortality rate. - **Broad spectrum antibiotics** that cover aerobic and anaerobic organisms, **and urgent and repeated surgical drainage and debridemen**t are required to control the infection A diagram of a person\'s body Description automatically generated Figure 20. 🖊️ This is a typical progression of Fournier's gangrene.. It will start with a simple furuncle (or tigyawat) then a large area of the scrotum becomes infected showing some infected vesicles, then all of this erythema will progress and become black or gangrenous and eventually will slough off. Patients rarely reach this stage on their own unless they really neglected it. At this stage, pwedeng patay na yung pasyente because before you reach this, the patients are usually very septic and can go into septic shock. So that's why Fournier's gangrene is considered a true urologic emergency  Figure 21. Fournier's Gangrene A person\'s hand holding a tube Description automatically generated Figure 22. Fournier's Gangrene with Typical Blackened Patches  Figure 23. 🖊️As you can see, parang mas maraming tinapyas kaysa don sa nakita mo superficially. You can see virtually all of the skin was taken out. Take note the testes cannot be seen here because the testes were swung superiorly. So you pick up the testis and put it in another location. Testes are usually not involved. You can have all of this necrotic tissue but after scraping them off, you'll see the testes and see that they are quite intact. Blood supply of the scrotum is completely different from the blood supply of the testes. A close-up of a person\'s buttocks Description automatically generated Figure 24. 🖊️ Another example of a patient with Fournier's gangrene which shows the blackened patches  A close-up of a ct scan Description automatically generated Figure 25. 🖊️ Axial CT scan. A plain CT scan done in a patient with Fournier's gangrene.  Figure 26. **Post-debridement of the patient in the previous CT scan** 🖊️ You can see up to the thigh nadebride. This is actually around the third or fourth day after initial debridement. Now you can see all of the tissues are alive, you don't see any pus and if you smell this, mabango na siya. Yung Fournier's gangrene, apakabaho nyan because of a lot of anaerobic infection. So now you could also see a lot of healthy granulation tissue and healing that's happening here. You can see the borders of the wound have started to contract. After a few days na nililinis mo lang, you could take culture studies of this wound, and if they turned out to be negative, perhaps they can be prepared for a reconstruction. This would require the services of the reconstructive surgeons such as plastic surgeons, or even specialized genito-urinary reconstructive surgeons EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS {#epididymitis-and-epididymo-orchitis.TransSubtopic1} ----------------------------------- - *Epididymitis and epididymo-orchitis are not identical,* *epididymo-orchitis would be the later stage of epididymitis.* - May be difficult to distinguish from torsion or blunt trauma. - 🖊️*The problem with epididymitis, especially with epididymo orchitis, this may be difficult to distinguish from torsion or blunt trauma and that's the mainstay of your diagnostics*. - 🖊️*You must distinguish it because the treatments for these three conditions are completely different, and the repercussions are bad if you misdiagnose them.* - *Treatment is medical with epididymitis and epididymo orchitis. But with torsion or blunt trauma, you must explore.* - Affects males of virtually all ages. - Usually results from the spread of infection from the bladder, urethra, or prostate via the ejaculatory ducts and vas deferens into the epididymis. - 🖊️*They usually spread via retrograde. If you have a problem in the urethra, and you have retrograde passage of urine, sometimes infected urine, into the vas deferens, it can crawl up to the epididymis and cause epididymitis which can eventually progress to epididymo-orchitis*. ETIOLOGY {#etiology.TransSub-subtopic2} -------- - Infectious - STD, UTI, BOO, BPH - Non-infectious - ADR, urinary reflux in ejaculatory ducts, sperm fluid extravasation from vasectomy or blunt trauma - 🖊️*With blunt trauma, pwede mag-extravasate yung contents sa vas deferens and that can cause non-infectious epididymo-orchitis*. - In boys, related to a UTI and/or an underlying GU congenital anomaly. - 🖊️*If you have a pediatric male with epididymo-orchitis, it's a good idea to work them up for a possible GU congenital anomaly*. - In elderly men, BPH and associated stasis, UTI, and catheterization are the most common cause of epididymitis - Bacterial prostatitis and/or seminal vesiculitis are associated with epididymal infection in post pubertal males of all ages - STDs for younger men \