Martha Neighbor, MD
MALE GENITOURINARY EMERGENCIES
Objectives:
1. Distinguish between testicular torsion and epididymitis regarding the history
and physical findings
2. Describe Prehn’s sign and the cremasteric reflex and their utility in the
diagnosis of testicular torsion
3. Discuss the meaning of the following: “In the patient with suspected renal
colic, the physical exam should be remarkably unremarkable”
4. List the indications for hospitalization and/or urology consultation in a
patient with renal colic
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Martha Neighbor, MD
MALE GENITOURINARY EMERGENCIES
Anatomy
a. penis
1. composed of three cylindrical bodies: two corpora cavernosa (erectile
bodies) which are surrounded by tunica albuginea (connective tissue)
and corpus spongiosum which surrounds the urethra. All three
covered by Buck's fascia
2. blood supply is from internal pudendal artery
3. lymphatics drain into deep and superficial inguinal nodes
b. scrotum & testis
1. testes lie vertically, are encased in tunica albuginea except
posterolaterally where epididymis lies, average size 4X3 cm
2. tunica vaginalis anchors testis and epididymis to posterior scrotal wall
3. inferiorly testis anchored to scrotum by the scrotal ligament
(gubernaculum)
4. posteriorly the tunica vaginalis and tunica albuginea are contiguous.
5. blood supply via the spermatic arteries in the spermatic cord
6. epididymis -a tubular structure that promotes sperm maturation and
motility
a. lies posterolaterally on the testis
b. vestigial embryonic structures located here include the appendix
epididymis and the appendix testis
7. vas deferens easily palpable within the adnexa of scrotal sac. It
extends in the spermatic cord from the tail of the epididymis through
the inguinal canal, behind the bladder, over the ureters, and joins the
seminal vesicles to form the ejaculatory ducts in the prostatic urethra
c. prostate
1. heart shaped structure 4x3x2 cm at base of bladder, surrounding
urethra
2. two lateral lobes separated by median sulcus
3. when enlarges with age or with hyperplastic adenoma, may envelop
the urethra between the bladder neck and the urogenital diaphragm
causing bladder outlet obstruction
PHYSICAL EXAMINATION
a. **male abdominal exam not complete until GU exam done
b. **male GU exam not complete until rectal done
c. visual inspection, palpation
d. includes exam of prostate, inguinal canals
e. in trauma patient
1. inspect perineum for blood, echymosis, blood at urethral meatus
2. rectal exam for boggy, or high riding prostate, for sphincter tone, blood
3. inspect/palpate scrotum/testis for blood, testis disruption
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Martha Neighbor, MD
PENIS
a. balanitis
1. inflammation of glans/foreskin
2. glans purulent, excoriated, tender, malodorous
3. often in children 2-5 yr. caused by irritant, infection, or poor hygiene
4. in adults may be presenting sign of diabetes
5. treatment, antibiotics for gram positive organisms, cleaning, drying,
antifungal creams, sometimes circumcision
b. phimosis- can’t pull foreskin backwards
1. opening of foreskin so small that foreskin can't be retracted behind the
glans
2. normal at birth, but 90% boys can retract foreskin by school age; don’t
forcibly
retract
3. etiologies - poor hygiene, infection, scar tissue from prior injury
4. signs- redness, swelling of foreskin, purulent discharge, pain
5. treatment- 0.1% TAC, hot soaks, sitz baths, rarely may need dorsal
incision or hemostat dilation of opening of foreskin
6. later, circumcision
7. Urology consultation if urinary retention or cellulites in diabetic
8. Don’t blindly catheterize
c. paraphimosis- can’t bring foreskin forward
1. tight foreskin is retracted, becomes edematous, and can't be pulled
back over the glans. Edema impedes circulation of the glans, and
distal penis swells
2. causes- balanitis with contracture of foreskin, from hair wound around
penis, cock ring
3. to prevent paraphimosis, after urinary catheterization, always pull the
foreskin back over the glans, tape penis in upward position so catheter
doesn’t pull on urinary meatus and cause urethral injury
4. treatment- must reduce foreskin
a. manual compression of glans for 5 minutes, or 2X2 gauze bandage
wrapped around glans
b. may need dorsal nerve block, or procedural sedation
1. circumcision to avoid recurrence
d. Peyronie's Disease
1. patient complains of lump on dorsum of penis and painful penile
curvature with erection
2. plaque involving the tunica albuginea of the corpora without urethra
involvement
3. etiology unknown
4. on exam, palpate hard plaque, not movable, on dorsal surface of penis
a. may be associated with Dupuytren's contracture of the hand
b. non-emergent urology referral. Up to 50% regress spontaneously
within 1 yr.
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Martha Neighbor, MD
e. priapism- Urologic Emergency
1. prolonged, involuntary erection, painful, not associated with sexual
arousal
2. thought to be due to imbalance between neural stimuli, and/or from
mechanical interference of venous outflow from penis
3. corpora cavernosa becomes engorged with stagnant blood, corpus
spongiosum is flaccid and patient can void
4. intracavernosal pressures may exceed arterial systolic pressures
resulting in ischemia, therefore is a urologic emergency requiring
consultation. Rapid treatment needed to prevent corporal fibrosis and
erectile dysfunction
5. morbidity is time dependent
a. 6 hr. may be OK
b. 24 hr. probably too late
6. types
a. low flow or ischemic (from decreased penile venous outflow,
sludging, blood stasis)
1. etiologies
a) sickle cell, thalassemia
b) leukemic infiltration causing sludging
c) drugs- trazadone, cocaine, alcohol, marijuana,
antihypertensives injections of papaverine, phentolamine, or
prostaglandin E1for
erectile dysfunction
2. on exam, corpus cavernosum is involved (penile shaft is hard)
and spongeosum is spared (glans is soft)
3. diagnosis of type is made with blood gas on blood from corpora
with low O2 and high CO2
4. treatment
a) emergent Urology consultation
b) pain relief
c) oxygen, hydration
d) if sickle cell- transfusion to hemoglobin>10g/d
e) corporal aspiration of blood
1) 21 gauge butterfly, aspirate 60 cc from corporus, close to
glans
2) irrigate with 10 cc normal saline to stir up sludge, then
withdraw and instill phenylephrine 100μg or epi
1:100,000 (1 mg in 10 cc NS), inject 2-3 cc to maximum
of 10 cc.
3) monitor, if no improvement need surgical shunt
5. complications- time dependent
a) resulting impotence not in future treatable with viagra, only
penile prosthesis
b) fibrosis, gangrene
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Martha Neighbor, MD
b. highflow (from increased arterial blood flow that overwhelms
venous system of penis)
1. from arterial-cavernosal shunt from groin/straddle injury
2. doesn’t cause ischemia, not true emergency
3. treatment is conservative vs embolization
4. priapism from spinal cord trauma has similar physiology
SCROTAL DISEASE
a. soft tissue
1. sebaceous cysts, superficial abscesses
2. look for deeper involvement of bulbous urethra, testis, epididymis
3. if deeper involvement, evaluate by ultrasound
b. scrotal (Fournier's) gangrene- necrotizing fasciitis of perineum
1. Urologic Emergency
2. life threatening
3. polymicrobial infection of subcutaneous tissues that originates from
perineal, perirectal site
4. surgical emergency requiring extensive debridement
5. peak incidence 50-70 years
6. rapidly progressive, in hours, preceded by genital discomfort, sweats,
fever, chills
7. may be toxic appearing
8. risk factors
a) 2/3 have diabetes
b) immunocompromised
c) alcoholic, wheelchair bound, poor hygeine
d) local trauma, surgery
e) think about entity in immunocompromised men with scrotal, rectal,
genital complaints out of proportion to physical findings
9. infection is foul smelling (anaerobes), may have evidence of gangrene,
gas in soft tissues. Early on may only be scrotal edema, blotchy
erythema
10. multiple organisms involved including gram negatives, bacteroides,
clostridia
11. treatment - antibiotic coverage for gram +, gram -, and anaerobes
(amp/genta/flagyl) AND wide, aggressive debridement, ICU care
12. mortality 13%
c. hydrocele
1. fluid collection within tunica vaginalis
2. if from infection (epididymitis/orchitis), develops over days
3. if from tumor, accumulates more slowly
4. if idiopathic, is chronic
5. transilluminate the scrotum. If it doesn't transilluminate or testicle can't
be palpated adequately, may need ultrasound and urologic referral to
establish if idiopathic etiology
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Martha Neighbor, MD
d. paratesticular masses- cancer
1. all testicular masses should be seen by Urology within 1 week
2. gradual, painless enlargement testicle
3. 10% acute testicular pain
4. 10% present with metastasis
a) back pain from retroperitoneal mets to nerve roots
b) cough, SOB from pulmonary mets
c) bone pain from skeletal mets
d) extremity swelling from vena caval obstruction
5. physical exam
a) firm, nontender mass separate from epididymis
b) initial misdiagnosis- epididymitis or hydrocele
e. orchitis (isolated), rare
1. usually mumps (in post pubertal boys) and preceded by parotiditis
2. may have severe pain and swelling, nausea, vomiting, fever, chills
3. unilateral in 70% cases
4. usually resolves in 5-10 days
5. treatment is supportive with bedrest, analgesics, scrotal support
6. seldom results in infertility
7. other viruses including dengue, influenza, mononucleosis, varicella,
echovirus, coxsackie
ACUTE SCROTAL PAIN
Differential diagnosis includes orchitis, trauma, hernia, renal colic, abscess,
varicocele, neoplasm, leukemia, Henoch-Schonlein purpura, hydrocele, torsion,
and epididymitis. Most important to differentiate are torsion and epididymitis.
TESTICULAR TORSION Urologic Emergency where Time is of the Essence
a. introduction
1. annual incidence 1/4000 males under age of 25; about 3-4 patients/yr.
in large hospital
2. age
a) can occur at any age, reported in utero to 90 years
b) neonatal- from twisting before complete testicular descent and
fusion toscrotal wall
c) most common at puberty, but 28-45 % occur after adolescence
b. pathophysiology
1. predisposed in testes with an abnormally high attachment of the tunica
vaginalis. If the tunica attaches not on the posterolateral surface, but
above the epididymis, the testes can rotate within the tunica, testis
and spermatic cord twists, occluding venous return, leads to edema,
and decreased arterial flow, infarction, necrosis
2. spermatogenesis on unaffected side may decrease
3. salvageability is time dependent and dependent on # of rotations of
cord
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Martha Neighbor, MD
c.
d.
e.
f.
g.
h.
a) 100% @ 3 hr., 90% @ 5 hr., 75% @ 8 hr.
b) 50-70% @ 10 hr., 10-20% @ 24hr.
c) testicles can torse and detorse, so diagnose even if many hours
have passed
symptoms
1. sudden onset pain in scrotum, but may complain of groin, abdomen,
flank pain
2. 50% occur in sleep
3. 42% have nausea, vomiting
4. urinary voiding symptoms are rare
5. because may only have abdominal pain, all males with abdominal pain
should have a careful genital exam
physical findings
1. rare to have significant fever
2. extreme pain and swelling typically results in sub-optimal exam and
difficulty differentiating scrotal contents
3. twists in the cord my lead testicle to have "horizontal lie", or be "highriding" because of spermatic cord shortening
4. epididymis may be rotated anteriorally
5. testicle may be larger secondary to venous congestion
6. elevation of the testicle (Prehn's sign) does not give relief, but is a very
unreliable diagnostic maneuver
7. cremasteric reflex usually is absent in torsion (stroking inner thigh
normally elicits retraction of the ipsilateral testicle moving upward at
least .5cm)
history of spontaneous resolution, and previous episodes in only 11-50%
laboratory findings
1. urinalysis is normal in 90%
2. 1/3 patients may have leukocytosis
3. ancillary studies looking for decreased blood flow (shouldn’t delay
surgery)
a) ultrasonography may be helpful, but is operator dependent
1) if pulses are not preset, is very predictive of torsion
2) if pulse is found, may be false negative, doesn't rule out torsion
b) technetium-99m pertechnetate scans show "cold", hypoperfused
area with torsion, not always available, may be time delay
c) "ultimate" ancillary study is surgical exploration
treatment
1. surgery
2. temporizing measure is to detorse testicle manually. Testes twist
medially, treat by “opening the book”, hard to do because very painful
a) should give relief of pain (over hours)
b) but maneuver may only detorse partially, if testicle is twisted many
times
torsed testicular appendages (appendix testis, or appendix epididymis)
1. are vestigial tissues with no known function
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Martha Neighbor, MD
2. less marked pain than testicular torsion
3. see pathognomonic "blue dot" through scrotal skin, or palpable tender
nodule at superior aspect of testicle next to epididymis
4. consult Urology, but can treat this conservatively if can exclude
testicular torsion by ultrasound
EPIDIDYMITIS
a. introduction
1. most common cause of acute scrotal pain/mass
2. incidence is 1/1000 men/year
3. disease of adult men, rarely occurs at puberty, and even more rarely in
prepubertal boys
4. rarely is there isolated epdidymitis, usually epididymo-orchitis
5. complications are abscess, chronic pain
b. etiology
1. from retrograde spread of organism from vas deferens from infected
urine in bladder, urethra, prostate. 10% time is bilateral
2. organisms in younger (<40 yr) men- chlamydia , gonorrhea
3. in "older" men- coliforms as E.Coli, Pseudomonas, Proteus more
common
4. in immunocompromised- TB, cryptococcus, fungal
c. symptoms
1. pain begins gradually, peaking over many hours, sometimes described
as "sudden onset"
2. pain may be sharp and radiate to groin, or dull, aching, scrotal
discomfort
3. 10-20% have urinary frequency, urgency, dysuria
4. may begin after straining, GU surgery, instrumentation, sexual contact
d. physical findings
1. may have low grade fever, sepsis is rare
2. early on is localized, indurated, tender epididymis
3. scrotum may be erythematous, edematous
4. scrotal elevation/support may give relief (positive Prehn's sign)
e. laboratory findings
1. urinalysis- 90% have pyruia/bacteruria (>10 WBC/hpf)
2. WBC may be 10-30,000
f. treatment
1. strict bed rest with scrotal elevation
2. analgesics, ice pack or heat
3. antibiotics
a) <35 yr- ceftriaxone 125 mg IM and doxycycline 100mg bid for 7
days
b) in older men, consider treatment for gram negatives, i.e.
fluroquinolone
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Martha Neighbor, MD
4. **urology follow-up, testicular cancer may initially be misdiagnosed as
epdidymitis, pain is due to acute hemorrhage in the tumor
5. indications for hospitalization/Urology consultation
a) intractable pain, nausea, vomiting
b) sepsis with high fever, rigors
c) all pediatric cases (rare, diagnosis more likely torsion)
PROSTATITIS
a. most misdiagnosed disorder in male urology
b. acute bacterial prostatitis
1. significant dysuria, frequency, urgency, back or perineal pain, fever,
chills, dehydration
2. prostatic tenderness, swelling, hard or boggy
3. organisms include coliforms, gc, chlamydia
4. hospitalize and treat with quinolone for 4-6 weeks
5. avoid foley catheterization which can obstruct prostatic drainage, may
need suprapubic catheter if can’t void
6. don’t massage the prostate
7. bed rest, analgesics, stool softeners, antipyretics
c. chronic bacterial prostatitis
1. variable symptoms of dysuria, urgency, frequency, nocturia, pain;
rectal exam not helpful
2. diagnosis based on recurrent positive cultures after prostate massage
3. usually gram negatives, treat with antibiotics for 4-6 weeks
d. nonbacterial prostatitis
1. like chronic prostatitis, but cultures negative
2. treat like chronic prostatitis plus NSAIDs, sitz bath
ACUTE URINARY RETENTION & OVERFLOW INCONTINENCE
a. etiologies (really two types: detrusor failure, e.g. “pump” failure, and
outflow obstruction)
1. neurogenic (spinal cord compression below L4/5)
2. trauma- urethral disruption, penile strangulation
3. obstructive most common etiology (BPH, prostate or bladder cancer,
urethral stricture)
4. degenerative (diabetes, multiple sclerosis, Parkinson's)
5. pharmacologic- anticholinergics, sympathomimetics acting that inhibit
bladder emptying
b. history
1. obtain history of medications
2. obtain history for obstruction, i.e. nocturia, hesitancy, diminished force
of voiding, poor urinary stream, urethritis, stricture history, low
abdominal pain inability to void, urgency
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c. exam
1. perform good neuro exam, especially of lower extremities because of
similar neurovascular innervation
2. good GU/rectal exam for meatus stenosis, masses, abscesses,
prostate size
3. percuss/palpate for bladder distention
d. treatment- catheterization
1. lubrication of catheter (lidocaine jelly into the urethra first), 16F-18F
foley or Coude catheter which has a firm, angulated tip
2. hold penis straight up when passing catheter
3. don't inflate balloon until catheter fully inserted
4. if no urine, before inflate balloon, irrigate the foley with 60 cc NS, then
will typically get drainage
5. don't have to drain bladder in stages
6. occasionally if chronic distention, may have bladder mucosal edema
and rapid decompression will result in transient gross hematuria (216%) not clinically significant
7. treat with antibiotics if urine is infected or catheter will be in place for
more than 5 days
8. watch for post obstructive diuresis. If urinary retention has been
chronic, should observe for several hours to assess for this. More
likely if patient has an elevated BUN/creatinine > 4.0 or if urine
output>200cc/hr for more than 4 hr. Therefore should observe for
several hours
9. Urology follow-up
GU EVALUATION IN MULTIPLE TRAUMA
a. life threatening injuries take precedence over diagnostic evaluation of GU
tract
b. GU evaluation during secondary survey
c. Suspect GU injury if:
1. blood at meatus
2. gross hematuria or microscopic hematuria in setting of hypotension
3. abnormal prostate exam
a) high riding, boggy
b) prostate sheared from pelvis and migrates up, and hematoma fills
normal position of prostate
4. flank, abdominal, perineal hematoma/eccymosis
5. fractures of the pelvis, lower ribs, lumbar spine
d. penile injuries
1. penile“fracture”
a) from sudden flexion of erect penis (i.e. penis slips out of vagina and
thrust against perineum)
b) from linear tear in tunica albuginea with injury to corporal body due
to trauma to erect penis
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c) complain of sudden, severe pain, snapping sound, loss of erection
d) physical- tender, swelling, eccymosis of penile shaft
e) treatment- may have associated urethral disruption (consider if
blood at meatus or hematuria), need retrograde urethrogram to
evaluate
f) consult Urology, surgery usually necessary to correct or prevent
sequelae
2. entrapment
a) from objects around penis (string, metal rings, wire, etc.) occluding
venous, then arterial blood supply may result in severe edema,
urinary retention, gangrene of skin, fistulas
b) in young boys, entrapped hair is often cause of glans swelling after
careful removal, need to ensure urethra and blood supply are intact
c) zipper entrapment- cut median bar of zipper or cut across zipper
transversely below entrapment and zipper pulls apart
3. penile amputation
a) high success rate of reimplantation, with good urinary and erectile
function
b) penis should be placed in bag, and bag on ice in a cooler
e. urethral injury
1. may manifest as blood at urethral meatus, inability to void, difficulty in
catheter insertion, perineal ecchymosis, high riding prostate on exam
2. if is blood at meatus, etc. need retrograde urethrogram before
instrumentation to prevent partial urethral laceration from becoming
complete, or false passage
3. alternative is suprapubic cystostomy
4. anterior urethral injury (distal to urogenital diaphragm)
a) straddle injuries, fractured pelvis, foreign body
b) signs- hematuria, pain, butterfly hematoma of perineum (blood
through Buck’s fascia to Colles fascia), abdominal wall
c) rarely an isolated injury, complications of stricture, fistula,
incontinence, impotence
d) evaluation is retrograde urethrogram (RUG)
1) Foley cath tip into urethra, occlude urethra gently with pressure
around glans
2) gently insert 20-40 cc water soluble contrast (renografin) with
Toomey syringe
3) get oblique x-ray to visualize best urethral disruption
5. posterior urethral injury (membranous/prostatic urethra)
a) most associated with pelvic fracture; 35% have associated bladder
injury
b) signs include distended bladder, can't urinate, blood at meatus,
gross hematuria, low abdominal pain
c) high riding or boggy prostate
d) diagnosis with retrograde urethrogram
e) treatment is suprapubic drainage, delayed repair
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Martha Neighbor, MD
f.
g.
h.
i.
f) complications are stricture, incontinence, impotence
bladder injury
1. associated with other injuries, 2/3 with pelvic fractures, or with steering
wheel injury
2. severe abdominal pain, tender abdomen, shock, can't urinate, no urine
with Foley, blood at meatus
3. gross hematuria (10% have no hematuria)
4. diagnosis by CT cystogram
5. treatment is foley catheter if rupture is extraperitoneal, surgery if
intraperitoneal
ureter injury
1. 90% are from penetrating or iatrogenic (post hystererctomy)
2. asymptomatic and often missed and found during surgery
3. U/A doesn’t predict/exclude injury
4. IVP sensitive, CT is poor at diagnosing
5. complications include abscess, urinoma, hydronephrosis
6. repair surgically
renal injury- Grades 1-5
1. 90% from blunt trauma
2. usually associated with injury to other organs
3. suspect if gross hematuria, or microscopic with hypotension
4. diagnosis by CT scan
5. treatment
a) increasingly conservative, non-operative for Grades 1-3
b) Grade 3- through medulla, not into collecting system
c) Grade 4- through collecting system
d) Grade 5- shattered kidney, avulsed from pedicle treat with
nephrectomy
renal vascular injury
1. think about with lower rib fracture, transverse process fracture of L1-2
2. in children think when is mechcanism of deceleration (injury typically of
left kidney)
3. think if have previously abnormal kidney
4. 30% have no hematuria
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Martha Neighbor, MD
MALE GENITOURINARY EMERGENCIES
Case 1
A 16 year old adolescent male comes to the ED complaining of severe right flank
and scrotal pain beginning several hours ago, awakening him from sleep. He
denies GU trauma, fever, chills, sexual activity, dysuria, hematuria, urinary
discharge, frequency, nocturia. On physical examination he appears in moderate
pain. His BP =130/88, P=100 R=20, T=37 °C.
1. What is your differential diagnosis for acute scrotal pain, and what is this
patient’s “worst possible” diagnosis?
2. What should you look for in the GU exam?
3. What laboratory studies should be sent? Why? Any ancillary studies?
Case 2
A 35 year old man presents to the ED with the sudden onset of severe LLQ
abdominal pain radiating to his left groin. He notes urinary urgency, and
frequency, but denies fever, chills, hematuria. He states he had a kidney stone 5
years ago and his current symptoms are identical.
1.
Is the physical examination helpful in diagnosing kidney stones?
2.
What laboratory or ancillary tests should be ordered in patients suspected of
having renal colic? What is the best way to diagnose a kidney stone?
3.
How is renal colic treated in the ED?
4.
What are the indications for admitting a patient with renal colic to the
hospital?
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ANSWERS
Case 1
1) The major entities to be distinguished in acute non-traumatic scrotal pain are
testicular torsion and epididymitis. Of these two, torsion is the “worst”, as
untreated torsion will result within hours in testicular ischemia, possible
necrosis, and possible resulting infertility.
2) The GU exam in patients with acute scrotal pain can be difficult. Patients with
epididymitis typically have associated orchitis and severe tenderness. It is
frequently very difficult to delineate the epididymitis. Patients with torsion
may have a “horizontal” orientation of the torsed testicle. They may have
increased pain on elevation of the scrotum (i.e. Prehn’s sign, a test which is
insensitive and nonspecific for torsion). The presence of a cremasteric reflex
makes torsion unlikely, but if missing does not rule out (or in) torsion.
3) A urinalysis (looking for pyruia0 is the best “quick” ED test for epididymitis,
although up to 15% of patients with epididymitis may not have pyuria. A CBC
is unhelpful as patients with both epididymitis and torsion may have elevated
white blood cell counts (why?). The best ancillary test to diagnose torsion is a
testicular ultrasound, although surgery is the “gold standard”.
Case 2
1) The physical examination in a patient with kidney stones should be
“remarkably unremarkable”. This means that any significant findings suggest
that the patient does NOT have renal colic. Peritoneal findings on the
abdominal exam are NOT found in renal colic, and other diagnoses must be
entertained. Similarly, women with an abnormal pelvic exam, and men with
abnormal GU/rectal exams, probably do not have renal colic.
2) Urinalysis (looking for microscopic hematuria) should be obtained.
Electrolytes and renal function tests are also appropriate. CBC should be
sent if other abdominal/GU pathology or infection is being considered. Other
tests such as calcium and uric acid will not typically change ED management
of renal colic, but may be helpful to the physician providing follow-up.
3) Pain management is of foremost importance in patients with renal colic.
Ketorolac (30 mg IV) may be tried. If this does not relieve their pain within 20
minutes, morphine, the “gold standard”, should be titrated to effect. Patients
should be given enough IV fluids to make them euvolemic, but should not be
“flooded” with fluids, as there is no evidence large amounts of fluid facilitates
passage of the stone, and may cause increased pain.
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4) Indications for hospitalization or Urology consultation for patients with kidney
stones include:
a. fever
b. intractable pain
c. intractable nausea and vomiting
d. renal insufficiency, one kidney
e. kidney stones >5mm size
f. ?immunocompromise
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MALE GENITOURINARY EMERGENCIES
Bibliography
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Dec;16(4):905-27.
2. Rosenstein D, McAninch JW. Urologic emergencies. Med Clin North Am.
2004 Mar;88(2):495-518
3. Marcozzi D, Suner S. The nontraumatic, acute scrotum. Emerg Med Clin
North Am. 2001 Aug;19(3):547-68.
4. Galejs LE. Diagnosis and treatment of the acute scrotum. Am Fam
Physician. 1999 Feb 15;59(4):817-24.
5. Hanno PM, Wein AJ. UrologicTrauma. Emerg Med Clin North Am. 1984
Nov;2(4):823-41.
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