Urology

When What Goes Up Does Not Come Down ... Priapism Management in the ED

Priapus: son of Zeus & Amphrodite, rustic fertility god, protector of flocks, fruit plants, bees and gardens and star of the Priapeia.
Clinical Scenario: A 42 year old man with a history of hypertension presented with approximately 12 hours of priapism. He woke up and noticed his erection would not go away, even with ice, and is has been increasingly painful.  He denies any history of erectile dysfunction medication, sickle cell disease, malignancy or recreational drug use.  Urology was consulted, and after performing a penile ring block, two 18-gauge needles were inserted into the corpora cavernosa.  A few mL of blood were aspirated, and then approximately 100mcg of phenylephrine were injected bilaterally with resolution of the patient’s pain and erection.  Notably, he presented several days later with the same symptoms. 

Clinical question: What are the potential causes of priapism, and how should it be managed?


Review: Priapism is defined as an undesired erection lasting more than 4 hours, and can be divided into ischemic (low flow), non-ischemic (high flow) and stuttering (i.e. recurrent or intermittent) etiologies.  Prolonged ischemic priapism results in erectile dysfunction, corporeal fibrosis, and tissue necrosis.  Ischemic priapism results in a fully erect, painful penis; whereas non-ischemic priapism (which is less commonly seen) typically presents with a partially erect penis without persistent pain.   Sickle cell disease, thalassemia, leukemia, multiple myeloma, and medication side effects (intracorporeal injections, antidepressants, antihypertensives, and recreational drugs such as cocaine) are all potential risk factors for ischemic priapism; whereas non-ischemic priapism is usually attributable to congenital or traumatic arterio-venous malformations.  Stuttering priapism has been less studied but its etiology is thought to be related to ischemic priapism, and is seen more commonly in men with sickle cell disease, or more rarely with neurological disorders.  Overall incidence of priapism is low (1.5 per 100,000 person-years in all comers) but much higher in some populations (89% of males with sickle cell anemia will have an episode of priapism by age 20).

Diagnosis of priapism is clinical, but the differentiation between ischemic and non-ischemic can be confirmed with cavernosal blood gas analysis and Doppler ultrasonography.  Ischemic priapism will result in dark blood that is acidotic, hypoxic, and hypercarbic, and ultrasound will demonstrate minimal or absent flow.

Ischemic priapism is an urologic emergency, and along with analgesia, urologic consult should be obtained.  Oral systemic sympathomimetics such as terbutaline or pseudoephedrine can be initial
Image source: Reference 3
adjuncts, but clinical efficacy is estimated to be only 28-36% in one study, thus it is not standard of care.  Aspiration of the corpora, which is considered definitive care, involves inserting a 19 or 21 gauge butterfly needle into each corpora cavernosa.  Withdrawing about 5mL of blood should decompress the corpora.  100mcg of phenylephrine in 1mL of normal saline can then be injected into the corpora, and this can be repeated every 3-5 minutes until detumescence.  Vital signs should be measured continuously.   Should repeated aspiration and phenylephrine fail, shunt surgery can be performed, which involves creating a fistula between the corpus spongiosum and corpus cavernosum.

Non-ischemic priapism (because of maintenance of oxygenated blood) is non-emergent and can be followed up as an outpatient for arteriography with embolization of any offending fistulas.  Treatment of stuttering priapism focuses on prevention of future episodes through the use of hormonal therapies or PDE5 inhibitors, which paradoxically seem to aid in prevention in idiopathic and sickle-cell related cases.     

Submitted by Phil Chan, PGY-2
Edited by Maia Dorsett (@maiadorsett), PGY-3
Faculty reviewed by Joan Noelker, Clinical Instructor

Visual learner?  Here is great 5 min review of priapism by EM in 5 and a youtube video by Larry Mellick.

References:
1. Deveci S.  Priapism. UpToDate.  2014 Jan 22.  Accessed 2014 Oct 30.

2.Huang, Y. C., Harraz, A. M., Shindel, A. W., & Lue, T. F. (2009). Evaluation and management of priapism: 2009 update. Nature Reviews Urology, 6(5), 262-271.
3. Vilke, G. M., Harrigan, R. A., Ufberg, J. W., & Chan, T. C. (2004). Emergency evaluation and treatment of priapism. The Journal of emergency medicine, 26(3), 325-329.

4. Salonia A, et. al. European Association of Urology Guidelines on Priapism.  Eur Urol. 2014 Feb; 65(2): 480-9. 

Submitted by Phil Chan, PGY-2
Edited by Maia Dorsett (@maiadorsett), PGY-3
Faculty Reviewed by Joan Noelker, Clinical Instructor
 

Let it Flow: Tamsulosin For Kidney Stone Expulsion

Clinical Scenario:
A middle- aged man with no significant past medical history presents with acute onset right flank pain.  A CT renal stone protocol scan finds a 4 mm kidney stone.  You provide hydration and pain control, and soon the patient starts to feel better.  As you are preparing to discharge the person, what is the evidence that tamsulosin helps with stone expulsion?


Image source: modified from gopixpic.com
Literature review:
A 2014 meta-analysis published in the Canadian Journal of Emergency Medicine [Ref 1] selected 22 studies which were all randomized, had radiologic confirmation of renal stone, and compared tamsulosin (mostly 0.4mg daily) against placebo with standard therapy given to all patients (NSAIDs, hydration, and/or opioids).  The primary outcome was percent of spontaneous passage of distal ureterolithiasis of less than or equal to 10mm, while secondary outcomes evaluated mean time to expulsion, complications/side effects, and impact of varying stone size on expulsion.  Many of the studies had a high risk of bias secondary to poor descriptions of the randomization process.  Of the 22 studies, there was an overall suggested benefit for stones less than or equal to 5mm (RR 1.50 95% CI 1.31-1.71) and among the studies that were double-blind and randomized there was a suggested benefit (1.22 95% CI 1.06-1.41).  However, of the studies that were considered to have low risk of bias, there was no statistically significant relation between tamsulosin and expulsion (RR 1.15 95% CI 0.92-1.47). Thirteen studies analyzed mean time to expulsion of distal stones, and it was found that tamsulosin decreased expulsion time by 3.33 days.  There did not seem to be a significant association for the number of hospitalizations, urology consults, or average number of pain episodes with the use of tamsulosin.  Again, when limited to studies with low risk of bias, there was no significant gain in mean time to expulsion with tamsulosin.  The most common side effects were orthostatic hypotension and retrograde ejaculations.

A 2014 meta-analysis published by the Cochrane Database [Ref 2] presented data more in favor of the use of tamsulosin.  Tamsulosin had better rate of expulsion (RR 1.48, 95% CI 1.32 to 1.67, P < 0.00001) as well as time to expulsion with 2.91 days shorter when compared to control (95% CI -4.00 to -1.81, P < 0.00001).  It did not significantly affect pain scoring, but slightly reduced the number of pain episodes.  Patients using tamsulosin were more likely to experience side effects compared to standard therapy and placebo including dizziness, palpitations, headache, retrograde ejaculations, fatigue, and postural hypotension.

Take Home:
-Tamsulosin seems to shorten time to expulsion of kidney stones
-Tamsulosin does not reduce pain from kidney stones
-Most common side effects are orthostatic hypotension and retrograde ejaculations

References:
1. Malo C, Audette-Côté JS, Emond M, Turgeon AF. Tamsulosin for treatment of unilateral distal ureterolithiasis: a systematic review and meta-analysis. CJEM. 2014 May 1;16(3):229-42.
2. Campschroer T, Zhu Y, Duijvesz D, Grobbee DE, Lock MT. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Database Syst Rev. 2014 Apr 2;4:CD008509.
Submitted by Lydia Luangruangrong, PGY-3.
Edited by  Steven Hung (@DocHungER), PGY-2
Faculty reviewed by Joan Noelker

A Happy Ending?

Your patient is a young adult male with no significant past medical history presenting with a chief complaint of testicular pain and heaviness. He reports that the pain occurred 2 hours prior to presentation. It was gradual in onset, progressively worsened, and is now plateaued. The pain is constant, dull, and achy. It is not localized to a single side. The patient feels like his scrotum is heavy, like someone is weighing it down. It is worse with movement, better when still. The patient could not recall any inciting trauma. 

Prior to onset of symptoms, the patient reports “getting my swerve on” with a new female partner, which he insisted did not consist of penetrating vaginal or anal intercourse would not further elaborate. He denies ejaculation prior to pain onset. He denies a history of penetrating intercourse altogether, but does endorses receptive oral sex activity. He denies a history of STI. Further ROS is negative. 

The physical exam is notable for bilaterally descended testes, and normal-appearing Tanner stage 4 genitalia. There is generalized bilateral testicle tenderness to palpation, without scrotal discoloration, testicular deformation, or penile discharge. There is no transverse lie, nor change in symptoms with elevation. The cremasteric reflex is intact.

You’re pretty sure you are least colloquially familiar with this patient’s current affliction, but have no idea if there’s any evidence-based interventions to lessen his discomfort.

Clinical Question:

What are suggested treatments for male pelvic congestion?

The Literature:

There is a paucity of academic information regarding this phenomenon:  scrotal pain following sustained sexual arousal unrelieved due to lack of orgasm and ejaculation. In the limited literature available, it is known as male pelvic congestion or epididymal hypertension. In lay terms, it has been referred to as “blue balls,” “lover’s nuts,” or “deadly sperm build-up” (DSB). Most of the available information is from anecdotal reports – “common knowledge and experience,” as one (unreferenced) article from a human sexuality journal described in 1989. Prior to the publication of a case report, with responding letters to the editor/author, published in Pediatrics in 2000, there was no information on the subject to be found in textbooks or online searchable databases (as concluded by medical librarians in three different institutions queried by the authors of this case report).

The included signs and symptoms are similar to the patient’s presentation above. In most cases the tenderness appears to be localized to the epididymis. The remainder of the GU exam and urinalysis should be normal. The pain usually resolves spontaneously within three hours of onset.

Proposed pathophysiology involves sexual arousal that produces increased blood flow to the penis and testes leading to pelvic venous dilatation. If this persists over time, testicular venous drainage slows, pressure builds, and this causes pain. 

Anecdotal treatments include sexual release via ejaculation, Valsalva maneuver, or lifting a heavy object. The case report included an anecdote about a physician in Los Angeles in the 1940s who, while teaching a course on human sexuality, gave a lecture on “lover’s nuts” in which he advised that masturbation was an appropriate medical treatment. This view is shared by most sexual health "experts" in the lay press.

Take home:

Male pelvic congestion is a real phenomenon, but is rarely discussed in medical literature.

It is a self-limiting and non-morbid process, but anecdotal evidence suggests that Valsalva, weight-lifting, or ejaculation via masturbation may expedite relief of discomfort.  

References:
1) Pediatrics. 2000;106;843-843.
2) Pediatrics 2001;108;1233

Contributed by Daniel Kolinsky, PGY-2.

Imaging in Renal Colic

You are working in the Emergency Department when a 30ish year-old female is wheeled by, clasping on to her right flank and clearly in pain.  You head into the room and find out that she had the acute onset of right flank pain that has been coming and going for the last hour.   She is otherwise healthy and denies any prior history of renal stones.  Thinking that this is probably a kidney stone, you order some pain medication, a UA, and a urine pregnancy test.  She is (thankfully) not pregnant and has 2+ blood in her UA.

You log back in to order your next diagnostic test of choice.  You start to click on “renal stone protocol CT” but pause…  and think to yourself: “Do I need to irradiate this woman to make the diagnosis?  Will the results of the CT scan change my management in some way?  What are the alternatives?”

Clinical Question #1:

Does a CT scan change management in cases of suspected uncomplicated renal colic?
                
The Literature:

There are several smaller studies that addressed whether a CT scan changes the clinical management in a patient where there is a high suspicion for renal stone.
                
Zwank et. al. [1] published a prospective observational study addressing this question.  The study enrolled providers caring for 93 “clinically stable” patients  > 18 yo with abdominal or flank pain, > 18 years of age and the  “most likely diagnosis” of renal colic.   Patients at higher risk of complication, i.e. those with a history of chronic kidney disease, nephrectomy, renal transplant, UTI, prior renal stones, were excluded from the study.  Prior to the CT, providers were surveyed as to what their top 3 differential diagnoses were and whether they thought that the CT scan might change management.    In the end, 62/93 patients who were scanned were diagnosed with renal colic (as a side note only 84% of these had hematuria on UA).   Five (5.3%) patients received an alternative diagnosis after CT scan – two ovarian cysts, one ovarian tumor, diverticulitis, and mesenteric edema.  Of the 16 patients where CT scan was obtained even though the provider thought it was very unlikely to change management, 10 had symptomatic renal stones and reportedly none had a change in management (unclear why the disparity if a diagnosis was not reach in 6/16 cases).    On this small pool of data, the authors conclude that “This result indicates that providers who are confident with the diagnosis of renal colic and who do not anticipate benefit from a CT scan can trust their low pre-test probability or ‘gestalt’ of low likelihood of benefit and should strongly consider not ordering a CT scan.” 
                
Another way of framing the question about whether CT scans change management in patients thought to have renal colic is to examine the incidence of alternative diagnoses that are found on CT in these patients.   In their prospective study, Pernet et. al. [2] examined this question by following the CT diagnosis of 155 patients with suspected uncomplicated renal colic (i.e. exclusion of patients with compromised renal function, UTI, fever, suspected bilateral renal stones).  118/155 (77%) were found to have uncomplicated stones, while 10 (6%) of these patients were found to have alternative diagnoses after CT.  These diagnoses included large calculi needing urology intervention, pyelonephritis, biliary colic, appendicitis, ileitis, small bowel obstruction and intra-renal hemorrhage.  Though a similar proportion of alternative diagnoses were found in this study when compared with Zwank et. al. above, these authors argue that CT(low-dose radiation) should be performed in cases of predicted uncomplicated renal colic because of the proportion of alternative diagnoses that mandated other intervention or hospitalization.  They further argue, that the population of patients which people would least want to irradiate (young women) are also the most likely to have some alternative diagnoses.   

Clinical Question #2:

Given that stones requiring urologic intervention and alternative diagnoses are found on CT imaging, how does ultrasound measure up as an imaging modality?

The Literature:

An older article in the British Journal of Radiology published in 2001  [3] [around the advent of use of CT and Ultrasound for diagnosis of renal calculi as opposed to intravenous urography (IVU)] prospectively evaluated the sensitivity and specificity of non-contrast CT and ultrasound for renal calculi.  They prospectively enrolled 62 patients with suspected uncomplicated renal colic.  These patients underwent both renal ultrasound and CT scan.  The gold standard was stone recovery or urological intervention.  43 (69%) of patients with suspected renal colic were confirmed by the “gold standard”.  Ultrasound showed 93% sensitivity and 95% specificity in the diagnosis of ureterolithiasis, while CT showed 91% and 95%.    Alternative pathology was found in six patients (~ 10%).  These alternative pathologies were cholelithiasis, cholecystitis, ovarian torsion, adnexal masses and appendicitis.  Both CT and ultrasound detected these, with the exception of the case of appendicitis, which was detected by CT scan alone.  Given advances in imaging technology, it is likely the sensitivity of CT has increased with time, but this is an impressive comparison.

Another study compared KUB + ultrasound versus CT scan for detection of clinically significant renal stones [4].   This was a retrospective study of 300 patients evaluated with KUB, US, non-contrast CT or some combination of the above for renal colic.  The study is overall very confusing because of the number of combinations of imaging modalities that patients had.  Despite this, one interesting observation was that among 147 patients who underwent KUB and/or US and CT scan, 22 had a normal KUB or US (unclear what proportion had what) and a CT scan positive for stone.  Of these, mean stone size was < 5 mm suggesting that this was a population of patients who was unlikely to need any type of urologic intervention.

Along the same lines of sensitivity of ultrasound for renal stones requiring urologic intervention, two separate studies examined the incidence of urologic intervention needed in patients with “normal” renal ultrasounds [5, 6].  In one of these studies (Yan et. al.) ,  they prospectively followed 341 patients with renal colic who were evaluated with ultrasound.   Of the 105 (30.8%) patients were classified as “normal”, none had urologic intervention in the following 90 days.  Alternative pelvic pathologies were identified on ultrasound (such as ovarian cysts and pregnancy) but there was no avenue for direct comparison with CT in this study.  A similar study from Edmonds et. al. retrospectively reviewed the records of all patients undergoing renal ultrasound for suspected nephrolithiasis over the course of a year.  Of a 352/817 (43%) that were classified as “normal”, only 2 patients (0.6%) required urologic intervention in the following 90 days.  They did not comment on alternative diagnoses.

Take home:

Renal ultrasound is a reasonable initially imaging modality for patients with suspected uncomplicated renal colic.  While we are overall pretty good an predicting who has renal colic based on history and exam (~ 60- 70% of all patients with this as a suspected diagnosis had imaging confirming it in the above studies), we should keep in mind that anywhere between 5 – 10% of these patients will have an alternative diagnosis requiring alternative management.   Ultrasound is good at picking up these alternative diagnoses as well.

References:

1. Zwank et. al. “Does computed tomographic scan affect diagnosis and management of patients with suspected renal colic?” American Journal of Emergency Medicine 32 (2014) 367–370
2. Pernet et. al. “Prevalence of alternative diagnoses in patients with suspected uncomplicated renal colic undergoing computed tomography: a prospective study.” CJEM. 2014 Feb 1;16(0):8-14.
3. Patlas et. al. “Ultrasound vs CT for the detection of ureteric stones in
patients with renal colic”. The British Journal of Radiology, 74 (2001), 901–904
4. Ekici and Sinanoglu. “Comparison of conventional radiography combined
with ultrasonography versus nonenhanced helical computed
tomography in evaluation of patients.” Urol Res (2012) 40:543–547
5. Yan et. al. “Normal renal sonogram identifies renal colic patients at low risk for urologic intervention: a prospective cohort study” CJEM 2014:1-8.


6. Edmonds et. al.  “The utility of renal ultrasonography in the diagnosis of renal colic in emergency department patients” CJEM 2010;12(3):201-6.

Kindly submitted by Maia Dorsett, PGY-3.