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Priapism pathologic condition prolonged erection (>4 hours) unrelated to sexual stimulation unrelieved by ejaculation painful and tender penis peak 5-10 and 20-50 y.o.

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Priapism Evaluation

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Priapism 1. Aspiration 2. Intracavernosal Injection: Phenylephrine Epinephrine 3. Shunting Procedures:

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Acute Scrotum New onset of pain, swelling and or tenderness of intrascrotal contents spermatic cord torsion requires immediate scrotal exploration

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Spermatic Cord Torsion reduction of blood supply to the testis due to the partial or complete failure of fusion of the tunica vaginalis along the epididymis peak: 12-16 y.o. and post-pubertal

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Spermatic Cord Torsion

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Spermatic Cord Torsion sudden, severe scrotal pain nausea and vomiting generalized testicular tenderness absent cremasteric reflex scrotal ultrasound with doppler: reduced arterial flow (63-90%)

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Emergent scrotal exploration is indicated after detorsion, determine if orchiectomy is indicated fixation performed on both testes Spermatic Cord Torsion

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Case # 1

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M.C. 7/M Data DOI: 2-13-12 TOI: 3pm POI: Cavite MOI: pedestrian vs. jeepney came in 36 hrs (1 ½ days post-injury) (+) loss of consciousness (+) bloody urine (+) left lower quadrant pain

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Abdomen: Sl globular abdomen, soft, sl. direct tenderness, left lower quadrant

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Lab Results Urinalysis RBC 20-25 WBC 1-2 CBC: Hgb= 78, Hct=.23 Crea 65 Pelvic X-ray: no fractures CXR: no fractures, no pneumo/hemothorax Cranial CT scan No fractures No intracranial abnormalities

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1. What diagnostic test would you request? Whole abdominal ultrasound CT Stonogram Whole abdominal CT with contrast Serial urinalysis

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2. What would you do next? send the patient home repeat abdominal CT scan admit for observation exploratory laparotomy

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Hemoglobin/Hematocrit Course in the Wards: GCS 15, follows commands tolerating feeding afebrile for > 48 hrs pink conjunctivae BP 100/60 (no hypotensive episodes since admission) HR 90 RR 20 Soft, nontender abdomen, no CVA tenderness UO: 20-30 cc/hr, clear

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3rd hospital day: recurrence of gross hematuria Hgb/ hct persistently dropped tolerating feeding, stable abdominal findings

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What would you do? transfuse to correct anemia continue conservative management strict bed rest exploratory laparotomy

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Final Diagnosis Multiple injuries secondary to vehicular crash (pedestrian vs. tricycle) Grade V Renal Injury (Shattered kidney) Left Multiple abrasions Operation EL, nephrectomy left (2-17-12 Plaza/Lascano) Operative Findings Shattered left kidney; (+) retroperitoneal hematoma left

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Case # 2

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Data DOI: 3-13-12 TOI: 2 am POI: Taguig MOI: motorcycle vs. tricycle came in 4 hrs post-injury (+) drowsy (+) alcoholic breath (+) gross hematuria; feeling of incomplete voiding

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Physical Exam: BP= 110/70 HR=86 RR=18 Abd: Flat, soft, (+) abrasions, hematoma, suprapubic area, (+) direct tenderness, suprapubic area, (+) distended bladder Genitalia: (+) blood, urethral meatus

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What would you do next? await spontaneous void and submit urine sample for urinalysis insert Foley catheter Fr. 16 to drain bladder and to get a urine sample perform a retrograde urethrogram perform a cystogram

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What is the next step? indwelling foley catheter suprapubic tube cystostomy stress cystogram observation

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What is your plan of management? indwelling catheter for 2 weeks repair the bladder injury suprapubic tube cystostomy no intervention is indicated

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Thank you.