Pediatric Urologic Emergencies

Non-traumatic

Testicular Torsion

  • 4-6 hour window before irreversible ischemic injury
  • Hx: acute onset of scrotal pain, unilateral scrotal swelling and tenderness (bilateral possible), more common in the left testes, nausea/vomiting, no UTI symptoms
  • Risk factor: Bell-clapper deformity, i.e. high attachment of tunica vaginalis on spermatic cord --> intravaginal torsion
  • Physical exam: high riding, horizontal testes, no cremaster reflex, hydrocele, check inguinal region
  • Prehn sign negative (pain relief upon elevation of testes, occurs in epididymitis)
  • Management: UA, Color Doppler US, Emergent Urologic consult
  • Surgical Management: surgical exploration, orchiopexy if nonviable testicle
  • Manual detorsion is possible if within 6 hours

Extravaginal vs Intravaginal

  • Intravaginal is most common in peripubertal 12-18 years old

Torsion of Appendage

  • Blue dot sign
  • Acute to insidious onset
  • Present cremaster reflex
  • Management: NSAIDs for pain, rest

Paraphimosis

  • foreskin retracted into fixed position behind glans that acts as tourniquet leading to edema of the glans
  • Management: manual reduction, consult Urology so they are aware, assisted manual, phimotic ring incision, emergent circumcision
  • Manual reduction: patient supine with legs abducted, analgesia, apply pressure to reduce edema for several minutes, then use index fingers to pull foreskin forward

Traumatic

Renal

  • Blunt trauma

Bladder

Classic Triad

  • Suprapubic pain
  • Difficulty voiding
  • Hematuria

Urethral Injury

Anterior

  • "Falling on the seasaw"

Posterior

  • Associated with pelvic fractures