While these conditions are unrelated and
have different symptoms, they all require urgent care.
Delaying treatment in some cases can result in surgical
removal of testicles (orchiectomy), permanent inability to
achieve an erection (impotence), or death.
Acute Urinary Retention
Acute urinary retention is the sudden inability to urinate and
is usually symptomatic of another condition that needs
treatment.
Incidence and Prevalence
Anyone can experience acute urinary retention. The causes and
rate of occurrence varies greatly between genders until about
age 60, when men are more often affected as a result of benign
prostatic hyperplasia (BPH).
Risk Factors
Kidney stones, prostate cancer, prostatitis, and BPH are risk
factors in men. Women with a history of kidney stones or
urinary tract infections (UTIs), pregnant women, and those who
have had recent gynecological surgery are at higher risk.
Causes
Acute urinary retention is caused by obstruction in the
bladder or the tube that carries urine from the bladder
outside the body (urethra), a disruption of sensory
information in the nervous system (e.g., spinal cord or nerve
damage), or a situation or event that causes the bladder to
become distended.
Factors associated with acute urinary retention include the
following:
Alcohol consumption
Allergy or
cold medications containing decongestants or
antihistamines
Certain
prescription drugs (e.g., ipratropium bromide, albuterol,
epinephrine) that cause the urethra to become narrow
Delaying
urination for a long time
Long period
of inactivity or bed rest
Prolonged
exposure to cold temperatures
Spinal cord
injury/nerve damage
Surgery
(e.g., complication of anesthesia)
Urinary
system obstruction (e.g., benign prostatic hyperplasia (BPH),
kidney stones)
urinary tract
infection
Signs and Symptoms
Acute urinary retention produces severe lower abdominal pain,
a distended abdomen, and/or the sudden inability to pass
urine.
Complications that may develop with untreated urinary
retention include bladder damage and chronic kidney failure.
Diagnosis
Diagnosis is based on a sudden lack of urinary output and
bladder swelling (distention) observed during a physical
examination.
Treatment
Treatment should be obtained within 5 hours of the onset of
symptoms to avoid the development of complications. The
underlying cause of urinary retention (e.g., kidney stones)
must be diagnosed and treated as well.
A small tube (catheter) is inserted into the bladder through
the urethra to drain the urine. Catheterization relieves pain
and distention.
Prognosis
Depending on the underlying cause, the recurrence rate can be
up to 70% within a week after initial treatment. BPH is
responsible for most recurrences.
Testicular Torsion
Testicular torsion is a disorder in which the testicles rotate
(twist) and strangle the spermatic cord, which consists of
blood vessels, lymphatic vessels, nerves, and the duct that
carries sperm from the body (vas deferens), cutting off the
blood supply to the testicles. Torsion can cause shrinkage
(atrophy) and tissue death (necrosis), and may require
surgical removal of the testicles (orchiectomy) if not treated
promptly. Torsion often occurs during sleep.
Incidence and Prevalence
Testicular torsion primarily affects infants in the first year
of life and adolescent boys age 12-18, although it can occur
at any age. Males with one or both testicles not descended
into scrotum (cryptorchidism) develop testicular torsion more
often than the general population.
Risk Factors
Injury to the scrotum or groin and vigorous physical activity
are risk factors.
Causes
Injury to the scrotum can initiate a muscle spasm that cause
the testicles to twist. Some cases result from inadequate
connective tissue that "anchors" the testicle within the
scrotum. Many cases are idiopathic (i.e., have no known
cause).
Signs and Symptoms
Symptoms include the following:
Blood in
semen
Lower
abdominal pain
Lump in
testicle
Nausea and
vomiting
Sudden,
severe testicular pain, followed by diminishing pain after
several hours (after necrosis begins to set in)
Redness of
scrotum
Swelling of
one testicle
Diagnosis
A patient history and physical examination is usually
sufficient to diagnose testicular torsion. Testicular torsion
may cause symptoms (e.g., testicular pain and swelling)
similar to epididymitis (i.e., inflammation of the tubule
where sperm is stored) and diagnostic tests may be necessary.
Color Doppler sonography (color printout of an
ultrasound echo test) is used to identify the absence of blood
flow typically found in a twisted testicle, which
distinguishes the condition from epididymitis.
Urinalysis (analyzing chemical composition of urine)
can be used to rule out bacterial infections.
Surgical exploration may be necessary if diagnosis
cannot be made using other methods.
Treatment
Treatment involves untwisting (detorsion), manually if
possible and surgically if necessary. Surgical detorsion
requires anesthesia followed by an incision in the scrotum.
The testicles are untwisted and evaluated for necrosis. Dead
tissue is removed; removal of one or both testicles may be
necessary. If necrosis has not occurred, the healthy
testicle(s) are then sutured (stitched) to the scrotal wall to
avoid recurrence.
Prognosis
If torsion is diagnosed and treated within 5-6 hours, the
prognosis is good. The more time that elapses before
resolution worsens the prognosis. After 18-24 hours, necrosis
usually develops and indicates removal of the affected
testicle (orchiectomy).
Priapism
Priapism is a prolonged, painful penile erection that occurs
when blood in the penis is "trapped," or unable to drain. The
stagnant blood causes an erection that can last from hours to
days. A painful erection lasting for more than 4 hours
indicates priapism. If not treated promptly, scarring and
permanent inability to achieve an erection (impotence) can
result.
Types
Veno-occlusive (low flow)
Veno-occlusive (blocked vein) priapism develops when
circulation in the penis becomes sluggish due to obstructed
veins. This type usually occurs without a known cause in men
who are otherwise healthy.
Arterial (high flow)
This rare, less painful type of priapism results from an
injury to the penis or area between scrotum and anus
(perineum) that prevents blood in the penis from circulating
normally. It indicates a ruptured artery in the penis. There
may be a lapse between the time of injury and onset of
priapism.
Incidence and
Prevalence
Priapism can affect men of any age. Most veno-occlusive
priapism in men with sickle cell disease occurs between ages
19-21. The rate of veno-occlusive priapism is higher in men
who have malaria, leukemia, and Fabry disease.
Risk Factors
Diseases that affect blood circulation may predispose men to
developing the condition. Forty-two percent of men with sickle
cell disease develop veno-occlusive priapism at least once.
Recreational or "party" drug use (e.g., cocaine, ecstasy,
marijuana) is a risk factor. An overdose of injectable
medication such as papaverine and phentolamine (Regitine®) for
erectile dysfunction is also a risk factor. Men with sickle
cell disease, leukemia, malaria, and Fabry disease are
predisposed to priapism.
Alcohol consumption, androgenic steroids (used to increase
muscle size), anticoagulants (Coumadin®, Warfilone®), and
antihypertensives (Prazosin®) increase risk. Prolonged sexual
activity is also a risk factor.
Causes
Priapism may develop as a result of prolonged sexual activity.
Other causes include the following:
Penile or
perineal injury (e.g., perineal trauma against the top
tube of a bicycle)
Prescription antidepressive drugs trazodone (Desyrel®) and
chlorpromazine (Compazine® , Serentil®)
Spinal
cord trauma
Tumor
Signs and Symptoms
A painful penile erection that lasts 4 hours or more, and a
soft head (glans) with a hard shaft are signs of priapism.
Diagnosis
Diagnosis includes a patient history and a physical
examination to detect an injury or underlying problem.
In veno-occlusive priapism, angiography may be used to help
locate blocked veins. Angiography uses a special dye injected
into the bloodstream to enable the physician to see blockages
on x-ray.
Doppler sonogram (i.e., digital images of ultrasound echos
that detect poor blood flow) may be used to diagnose high- or
low-flow priapism.
Treatment
There are several forms of treatment. Ice packs are applied to
the penis and perineum to reduce swelling. Walking up a flight
of stairs is sometimes effective, because mild exercise may
divert blood flow to other areas of the body. The underlying
injury (i.e., ruptured artery) causing arterial priapism is
treated by tying off the artery (surgical ligation) to restore
normal blood flow.
Intracavernous injection
Low-flow priapism is treated with vasoconstrictive medications
injected into the chambers in the penis that fill with blood
to create an erection (corpora cavernosa) to narrow the veins
and cause swelling to subside. Alpha agonists terbutaline
(Adrenalin®, Alupent®) and phenylephrine (Neo-Synephrine®) are
commonly used.
Puncture
After numbing the area, a needle is used to drain the blood
from the corpora cavernosa to allow the swelling to subside.
Surgical shunt
For veno-occlusive priapism, a passageway (shunt) may be
surgically inserted to divert blood flow and reestablish
circulation.
The underlying cause is treated when disease is present (e.g.,
leukemia, sickle cell disease).
Prognosis
The prognosis is good for both types of priapism when the
condition is resolved quickly. When treatment is delayed,
penile scarring and permanent impotence can result.
Fournier’s Gangrene
Fournier’s gangrene, sometimes called Fournier’s disease, is a
bacterial infection of the skin that affects the genitals and
perineum (i.e., area between the scrotum and anus in men and
in women between the vulva and anus). The disease develops
after a wound or abrasion becomes infected. A combination of
anaerobic (living without oxygen) microorganisms (e.g.,
staphylococcal) and fungi (e.g., yeast) causes an infection
that spreads quickly and causes destruction (necrosis) of
skin, tissue under the skin (subcutaneous tissue), and muscle.
Staphylococcal bacteria clot the blood, depriving surrounding
tissue of oxygen. The anaerobic bacteria thrive in this
oxygen-depleted environment and produce molecules that
instigate chemical reactions (enzymes) that further the spread
of the infection. Fournier’s gangrene can be fatal if the
infection enters the bloodstream.
Incidence and Prevalence
Men are ten times more likely than women to develop Fournier’s
gangrene. Men aged 60-80 with a predisposing condition are
most susceptible.
Women who have had a pus-producing bacterial infection
(abscess) in the vaginal area, a surgical incision in the
vagina and perineum to prevent tearing of skin during delivery
of a child (episiotomy), an abortion resulting in fever and an
infection of the lining of the uterus (septic abortion), or
surgical removal of the uterus (hysterectomy) are susceptible.
Rarely, children may develop Fournier’s gangrene as a
complication in wounds that result from a burn, circumcision,
or insect bite.
Risk Factors
Men with alcoholism, diabetes mellitus, leukemia, morbid
obesity, and immune system disorders (e.g., HIV, Crohn’s
disease), and intravenous drug users are at increased risk for
developing Fournier’s gangrene. Surgery is also a risk factor.
Causes
Fournier’s gangrene develops when multiple bacteria infect the
body through a wound, usually in the perineum, tube that
carries urine outside the body from the bladder (urethra), or
colorectal area. Existing immune system deficiencies help
infection to spread quickly, producing a disease that destroys
the skin and superficial and deep fascia (membranes that
separate muscles and protect nerves and vessels) of the
genital area. The chambers in the penis that fill with blood
to create an erection (corpora cavernosa), testicles, and
urethra are not usually affected.
Signs and Symptoms
The early physical symptoms of Fournier’s gangrene do not
always indicate the severity of the condition. Pain sometimes
diminishes as the disease progresses. Symptoms are progressive
and include the following:
Crepitant
("spongy" to the touch) skin
Dead and
discolored (gray-black) tissue; pus weeping from injury
Fever and
drowsiness (lethargy)
Increasing
genital pain and redness (erythema)
Odor
Severe
genital pain accompanied by tenderness and swelling of the
penis and scrotum
Diagnosis
Physical examination and blood tests are necessary. A
diagnosis is made on finding gangrenous (i.e., spongy,
weeping, discolored) skin. Microscopic examination of a tissue
specimen (biopsy) may be taken if visible symptoms are
insufficient to distinguish between Fournier’s and other
bacterial infections.
Treatment
Antibiotics (often double or triple drug therapy) along with
aggressive surgical removal of all of the diseased tissue is
required immediately for an optimal outcome.
Without early treatment, bacterial infection enters the
bloodstream and can cause delirium, heart attack, respiratory
failure, and death.
Complications
Incomplete debridement (surgical removal of dead tissue)
allows wound infection to continue to spread. In this event,
follow-up surgery is performed.
Paraphimosis
Paraphimosis occurs when the fold of
skin that covers the head (glans) of an uncircumcised penis
(i.e., the foreskin) has been retracted and narrows below the
glans, constricting the lymphatic drainage and causing the
glans to swell. If not corrected, blood flow in the penis
becomes impeded by the increasingly constricting band of
foreskin, which causes further swelling of the glans. Because
lack of oxygen from the reduced blood flow can cause tissue
death (necrosis), paraphimosis is considered a medical
emergency and requires immediate treatment.
Incidence and Prevalence
In the United States, paraphimosis occurs in about 1% of males
over age 16. It can occur at any age but is most common during
adolescence. Paraphimosis occurs in the elderly who need
frequent catheterizations and those who have a history of poor
hygiene or bacterial infections.
Risk Factors
Uncircumcised males are at risk. Piercing the penis increases
the risk if the penile ring interferes with foreskin
retraction or replacement over the glans, and if infection
results from the piercing.
Causes Causes include the following:
Bacterial
infection (e.g., balanoposthitis)
Catheterization (i.e., if the foreskin is not returned to
its original position after a urethral catheter is
inserted, the glans may become swollen, which can initiate
paraphimosis)
Poor hygiene
Swelling-producing injury
Vigorous
sexual intercourse
Signs and
Symptoms
Symptoms
include the following:
Band of
retracted foreskin tissue beneath the glans
Black tissue
on the glans (indicates necrosis)
Inability to
urinate (urinary retention)
Penile pain
Redness (erythema)
Swollen glans
(the shaft of the penis is not swollen)
Tenderness
Complications Tissue death caused by loss of blood
supply (gangrene) and spontaneous detachment of diseased
tissue (autoamputation) of the glans are possible
complications of paraphimosis.
Diagnosis
Paraphimosis is diagnosed during a physical examination.
Treatment
Because paraphimosis can be severely painful, a pain reliever
is administered before treatment. The first method of
treatment after diagnosis involves manual manipulation of the
penis to reduce swelling and to replace the foreskin over the
glans. An ice pack may be applied to the penis (after the
penis has been wrapped in plastic) to help reduce swelling.
If manual treatment is unsuccessful, the puncture technique
uses a needle to drain excess watery fluid in the swollen
tissue (edematous fluid) from the glans to reduce swelling.
A third option is to make a small incision in the foreskin to
alleviate constriction and allow the swelling to subside. With
this procedure, local anesthesia is administered to minimize
discomfort.
After reduction of swelling is achieved, antibiotics are
prescribed for any underlying infection.
Prognosis
Full recovery from paraphimosis is expected with prompt
treatment.
Prevention
Circumcision is recommended after treatment to prevent a
recurring episode.
The Austin Diagnostic Clinic, A
Multi-Specialty Medical Clinic
12221 MoPac Expressway North |
Austin, TX 78758 | 512.901.1111
Serving the communities of Austin, Round Rock, Pflugerville, San
Marcos and
Central Texas since 1952
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