Emerge in EM

E5: Urologic emergencies

• Mohamed Hagahmed

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Critical Urologic Emergencies Explained: Insights with Dr. Joseph Acquaye

In this insightful episode of EMERGE, I'm honored to host Dr. Joseph Acquaye as he delves into common urologic emergencies encountered in the emergency department and ICU. Dr. Acquaye shares his journey into urology, the significance of men's health, and the importance of addressing healthcare disparities. The discussion covers detailed protocols and techniques for managing acute urinary retention, kidney stones, penile emergencies, priapism, and testicular torsion. Tune in for actionable tips, clinical pearls, and practical advice to enhance patient care in urgent urologic scenarios.

Dr. Hagahmed:

Hey folks. Welcome back to Emerge and EM. And in today's episode, I am so honored to be joined by Dr. Acquaye to discuss some of the common urologic emergencies that we see in the ED or sometimes even in the ICU. Dr. Acquaye, thank you so much for joining us in discussing these topics and please tell us more about yourself and I'm actually curious about why you joined urology.

Dr. Acquaye:

First of all, thank you for having me. It's really an honor to be on this podcast. I'm looking forward to sharing some educational pearls with you all. My name is Dr. Joseph, Acquaye born and raised in Toronto, Ontario, Canada. My parents are from Ghana and I attended medical school Meharry before I finished my residency at the University of Minnesota. Currently practicing in Georgia. Now, in terms of why urology, it's always interesting when people ask me this question, because when I started med school, I had no idea what urology even was. I had experience working as a medical assistant for a couple of years and I was very convinced that I'd end up in primary care and you're very convinced you're going to end up in something until you do a rotation there and you're like, Hey, wait, this is not what I like. During my surgical rotation, you have to choose 3 electives. I really had no interest in surgery. In fact, I was very opposed to anything surgical. I couldn't see myself sitting or standing at an operating table for hours on end. Abdomen deep in somebody, but anyways, I chose a vascular surgery, I believe, ortho, and then I chose urology because that was all that was left. And funny enough, I did urology and I just loved the diversity of procedures. You're talking about outpatient procedures, like a vasectomy, robotic procedures, like a prostatectomy, endoscopic procedures, like a stone treatment. You're talking about office management and the, hospital management of complex issues. So I think that was the diversity of practice that really spoke to me and really interested me because you can essentially structure your practice however you want to. And then of course the men's health component, specifically serving black men because prostate cancer is twice as likely to kill a black. Individual compared to their white counterparts. So there is this disparity, which is both genetic, but also socioeconomical. And I think that. I am privileged to be able to work with patients who look like me, obviously working in Georgia, and being able to help build rapport and build their trust in the system, especially when it's very crucial for them to be on top of their screening for cancer, for example, and just navigating the normal things that occur with aging. I always laugh because I say, at one point in your life, your urologist is going to become your best friend, and it doesn't matter who you are, it's going to happen. It so I definitely like that. I tend to be the person who people interface with first. A lot of men have never seen a doctor till they see the urologist. And a lot of times my role is also to facilitate the rest of their care, get them set up with their primary care, get them into their colonoscopy, make sure they're on track with their vaccine schedule. So all of that is something I really enjoy. And it's like the passion that drives my interest in this field.

Dr. Hagahmed:

I'm happy you're here. Cause honestly, I need some help, man. I know you got to help me out.

Dr. Acquaye:

All right. That's what I'm here for

Dr. Hagahmed:

I would tell you like the last person that I had in the emergency department, it was one of the things that we see all of the time. And that was acute urinary retention and something that we deal with very frequently. We have an algorithm. Then we know what to do. But I was hoping you can give us more insight about how to deal or how to appropriately handle acute urinary retention. What is that and what's causing this?

Dr. Acquaye:

As the name implies, patient comes in suddenly unable to urinate. Alright, so it happens acutely. It happens in men, happens in women. and the etiologies are different in men versus women. Quick anatomy lesson, men have a prostate, and the prostate sits right below the bladder, and it surrounds the proximal part of the urethra, so basically the pro the top part of where they're gonna empty their bladder. As we know, enlargement of the prostate is a very common phenomenon that happens in men. And some men are lucky enough to have minimal symptoms. Some men might need medication here and there. But then there are some men whose prostate can enlarge to the point of completely obstructing the urethra. And if you get complete obstruction, you can't empty. There's nowhere for the urine to go. So you can imagine how you feel when you need a run and go use the restroom and you're able to get relief. These individuals don't get that relief. They show up to the emergency room. They've got these huge distended bellies. If you see a person in acute retention and it's been a while, it looks like they're pregnant. And I always say the first thing to do is address their attention. I always find it funny when they've gotten imaging, they've done labs, they've admitted to medicine. They've contacted me and I say, does the person have a catheter? And they say, what do you mean? I'm like, they need a catheter. That's the, first thing to do. So obviously it sounds like common sense, but get that catheter in. And sometimes that's easier said than done, especially in a person who already has a large prostate. So I always tell people when you're going for that catheter, you can start with a coude tip, 16 or 18 French, because a lot of people paradoxically seem to think if you. can't get it in, go smaller. But you gotta go larger because you're pushing past a pretty big prostate, so a bigger catheter will give you more leeway. And of course, if you're having issues. You're running into a lot of bleeding. You're not sure if the catheter is in the right place. That's when you got to let us know. There's no use continuing to poke the bear and cause a much bigger issue than you started with. So that's the classic man in retention. But of course you can also see retention after urologic procedures. If a person has had a resection of a bladder tumor or resection of a prostate and they start bleeding. They can bleed in the bladder, and then that blood can form clots, and then those clots can obstruct the urethra because some of them get so big you can't pee them out. And then you go into what we call clot retention. So that's a different presentation of urinary retention, and in that situation, it's a little bit different because you're not just trying to get a catheter in, you're trying to get a big catheter in that you can then use to irrigate the bladder. So, those are the people who may need a 22 or 24 French 3 way irrigate a bit, get them on CBI, or which is continuous bladder irrigation, and try to get them as clear as possible. Sometimes you're fortunate enough to do sometimes it's not gonna flow, it's super bloody, and again, that's when you get, let the urologist know and definitely keep those guys NPO as soon as they get there. In case we need to go back to the operating room. So that's the men's side of things. And then on the women's side, you can still get retention, but it's no prostate, so you're looking at different types of etiologies. So sometimes you can see it in diabetics, or people who have what we consider neurogenic bladders, spinal cord injuries. cauda acquina injuries things like that. Or a common scenario I can see in both men and women, chronic constipation, which leads to obstruction of the urethra, and again, ending up in retention. Same idea. Get your imaging, get your labs, admit if you need to, but get the catheter in and get a Foley catheter in. I've had patients try to, or providers try to put a condom catheter on the men, for example, and I'm like, that's not doing nothing. Same thing of trying to put like a pirouette. If you're getting any urine there, that's just overflowing consonants. They're really full and urine is just leaking out. Just a thing to keep in mind. Just don't be shy about it.

Dr. Hagahmed:

Thank you already for busting some of the myths, which is. Having a large bladder from acute urinary retention, people think that it's the most common reason is obstructive, right? So it can be non obstructive things. Like you said, neurologic things spinal things, cauda equina and also medications, right? Can you name some of the medications that can cause? urinary retention.

Dr. Acquaye:

Yeah I've seen it, some, let's say a person is taking Oxybutynin or Ditropan for the purpose of overactive bladder. That's meant to help relax your bladder, but of course if it works too potently, you're not going to be able to urinate. Or let's say a person is taking Sudafed, for example. I've seen that. It does the, it's an alpha agonist. So now you're looking at the exact opposite. Effect of things like Flomax. So of course, it can obstruct your prostate. I'm sure there's other examples not coming to me right now, but generally speaking, those are the ones I tend to see, or of course, a person has polypharmacy at play, and they're just overly sedated. You can definitely see some effects in terms of depression at the bladder level. So they tend to see those, or any medication that might constipate you. Because again, constipation can cause that obstruction.

Dr. Hagahmed:

A common one that I see, Dr. Kui, is People take it for a lot of things. And my favorite one is when all the people take Benadryl to fall asleep and then they end up getting really bad. I was like, I can't be doc. I cannot pee doc. And then this is what's happening.

Dr. Acquaye:

unfortunately you're not getting sleep in that situation.

Dr. Hagahmed:

not getting a situation either. Exactly. Now, when it comes to. Techniques or placement of the Foley catheter, I get this, common problem where the nurse tried with the 16 French initially didn't work. They might go less. Like you said, ideally go bigger than less. Any techniques wise, I know the process can be in a way, but do I have to do something anatomically to help facilitate the Foley? Yeah.

Dr. Acquaye:

So I always tell people, it's simple enough, but take the penis and put on some real stretch. Don't just try to be ginger about it. You got to really pull it tight to straighten out the urethra as much as you can. And I always actually start by, the lube they give you in the packs, put some aside for yourself, but inject the lube directly into the urethra, just like empty it in there. Not only will it provide you with lubrication, but it can also open things up a bit. Now, when you are putting that catheter, and especially like I said, for men, typically just go straight to coude. You don't have to play around with all that. Unless you think there's a stricture and your catheter is stopping really early, then you can try like maybe a silicone catheter because it's a little bit more rigid. But generally speaking, a coude catheter. And, making sure that the balloon port is on the bottom, the outflow port is on the top, because that means you have the right orientation of the coude facing upwards. So sometimes if you start, you may have to twist it, but you want to try to twist it so it can navigate up a large prostate, for example. So I always say those are some basic tips that can definitely make the catheter going a lot smoother. And then for women, the hardest part about putting a catheter in a woman is sometimes identifying the urethra, especially if you have a large woman. So I had a technique, which I came up with in conjunction with one of the nurses I used to work with in the ED a lot, where if you put a woman, especially a larger woman, into lateral decubitus, you would raise one hand, or say raise one leg, usually with the assistance of some other nurses. A lot of times your urethra will pop out at you and then you're able to find it because definitely it can be very difficult to find in the more morbidly obese patients, especially if they have limited mobility.

Dr. Hagahmed:

That is a tip. I actually never tried. I don't know if I want to be involved in that kind of conversation with the patient and this precarious position. And Suddenly someone walks into the room. So I have to give everybody a heads up and I'll definitely get a chaperone for

Dr. Acquaye:

Yes, you do not want to be caught doing that. It might not look, you might be like, no, Dr. Acquaye taught me this one and I'm going to have to be like, hey, I told me to get a chaperone

Dr. Hagahmed:

that is, that's good. That's good to know. Now let's say we get tried multiple times with the coude is not working. What do you do? Let's say, by the time we call you, we tell you, we tried everything. What is the one thing you do either surgically, non surgically, in the OR? What is the ultimate intervention? So

Dr. Acquaye:

honestly, I first will come, obviously, and tell, keep the patient MPO I'll come in and we have a bedside flexible cystoscopy. Obviously, that's not available at every institution, but it basically mimics what I would do in the operating room. What a cystoscopy is, for those who don't know, it's actually just a camera that looks directly into the urethra. So what I will do at that point, if you've tried multiple times, generally speaking, you guys know what you're doing. So I'm like, all right, there's no point in me going there. I might take one attempt, but I say, okay, we have what's called a urology card. So it's got the scope, it's got all these different catheters and all this stuff we need. And I will basically just prep them put the scope in. And what we're looking for is that sometimes when you're putting the catheter in, the catheter is going to want to take the path of least resistance. And it forms what's called a false passage. So if the urethra is going that way, then your catheter is actually going here. And every time you attempt, you push further and further and create this passage. And if the false passage is there, there's no way that camera, the catheter is going to go into the bladder. So what I do is I bring the camera right to that level where it is the false passage and the true passage. And I just navigate through into the, through the true passage. Pass the prostate into the bladder. Once we're in the bladder with the camera, I have a wire, call that a sensor wire, that I pass through the camera, and that wire goes all the way into the bladder. You get as much in the bladder as you can. So now you have a wire in the bladder. You can take your scope out. And then we have a special catheter called a council tip. The special thing about it is it has an opening at the top of it that you can feed over the wire. That way it can use the wire to guide it into the bladder. We call that the seldinger technique. So we do that. And then, yep. Once you get in there, everything else is standard, like normal catheter would be. And that's the exact same thing we would do in the operating room. Now, there are instances where I cannot make my way or find a true passage. Things are just so damaged. There may have been trauma. There may have been a, urethral disruption where they're not even connected anymore. So those guys are the guys who need the dreaded suprapubic. And a, suprapubic catheter, as the name implies, is the catheter that goes right through the suprapubic area. and into the bladder. So usually it's nothing crazy because their bladder is already really distended by that point. But I might use an ultrasound just to visualize the bladder. I get a needle, a spinal needle, just to get some urine return to make sure I'm in the right spot. And then we usually have these pre prepared suprapubic kits where you just basically stab right into the bladder. and then after you get urine drainage that way. And then we leave that in to let the urethral rest and eventually we'll talk about definitive options for them.

Dr. Hagahmed:

Wow. That's like a nice review too. I feel like I've been seeing a lot of suprapubic catheters. Especially in post cancer patients, radiation therapy, those kind of things. But they tend to have more complications with infection. Is that something you agree?

Dr. Acquaye:

Between a suprapubic and a urethral catheter, it's actually pretty similar in terms of infection rate. But that being said, you'll definitely see I tend to see more skin infection that can become UTIs with the suprapubic just because, a lot of times the site is not really kept or it gets dirty. So it serves as. Fertile breeding ground for some of those pathogens.

Dr. Hagahmed:

Nice. So let's talk about a different, now switching topics a little bit to another common ED presentation. Kidney stones or nephrolithiasis, right? Something that we see commonly every day. I saw a few days ago. What do you think in this country, the most common reason why people experience kidney stones?

Dr. Acquaye:

People don't like to drink water. That's it. If I were to go, I always give people the same spiel. There's four things that are contributing to 90 percent of kidney stones. Number one, water intake. Less than 2 liters is not where you want to be. You want to be above 2, 2. 5 liters. Number two, red meat intake, because of the nitrite content, which can predispose you to certain stones. Number three salt intake, because salt increases the absorption of calcium in the collecting system. And number four, fruit and veggie intake, more so for the benefits of the citrus and helping to get a more alkaline urine because urine tends to be acidic. So those are your four things, but number one by far is still water intake, and I'd say that's the most common reason. And then after everything else falls into diet.

Dr. Hagahmed:

How about if I tell you I drink too much milk, Dr. Kwe, I'm, I work out every single day. I got to drink my milk. Is this myth still exists with calcium and too much

Dr. Acquaye:

It's a myth. I always tell people too little calcium is going to give you stones. Too much calcium is going to give you stones. So as long as you're drinking in moderation, it's fine. The only time I've seen calcium from stone or stones from calcium excess are people taking Tums. You're taking a bunch of calcium carbonate. It's just overloading your system and then you can definitely form stones that way. But Drinking too much milk, that's definitely a myth and you have to drink quite a bit of milk.

Dr. Hagahmed:

So a gallon, maybe less than a gallon. I'm going to slow down. I promise. I'm not going to be your customer in the near future. But so when do we worry though? Like when do we actually pursue a workup just to investigate why this patient keeps getting these kidney stones?

Dr. Acquaye:

So usually I tell people, honestly, if you want to get a workup after the first kidney stone by the guidelines, that's fine. Most people don't, but I always say if you're a current stone former, so even if it's been like a year or two before between one stone and the next, that's still considered recurring stone forming versus the person who had a stone 20 years ago and has another one now. All right. So I always say, Hey, if you want to do a workup, you're welcome to do it at any point in time. The workup essentially is some blood testing and a 24 hour urine collection. Plus, if we have the stone, we do a stone analysis and all that together gives us a good metabolic picture of what you look like and what may be predisposing you to stone formation.

Dr. Hagahmed:

Okay. So I'll make this really easy for you. Okay. It's 2 a. m. in the morning. Getting this young guy was celebrating Thanksgiving, sudden flank pain out of control. I find either with ultrasound or CT, a four millimeter stone that is right by the UV junction. So just about to pop, so to say. And I gave him some pain medication. I'm like, you know what, you're feeling much better. I'll send you home. When do you want me to call you at 2am? Or when do you rather tell me like, you know what, don't call me, just send him home. Like exactly what I was going to do with this patient.

Dr. Acquaye:

scenario you described is perfect, right? Because you don't need to call me for a stone like that. So think about stones on a bit of a scale. If a stone is five millimeters, You have about a 50 percent chance of passing it. It's four millimeters, 60%, three millimeters, 70%, so on and so forth. So the patient you described has a 60 percent chance of passing that stone alone. There is no evidence of infection. His symptoms are well controlled. So you don't need to call me because what am I going to tell you? I want to say, Yeah. send them home. So you had the right thought there. Now, if you've got a patient with uncontrolled pain, That's one indication of uncontrolled nausea. You've given them IV morphine, IV Dilaudid, you've given them Zofran, they can't keep anything down, they're dehydrated, they got an AKI going. Yeah, you could say, okay, listen, this person probably needs to be admitted. I can let urology know just so they have the patient on their radar, so that would be a scenario where we should know. And you don't necessarily have to let us know emergently. Sometimes, depending on your hospital system, they'll let us know through a page or something. Or. The more pertinent scenario, the person with an infection. Of course, if you've got a stone in place, that's fine. Your symptoms are controlled, nothing else going on, go home. But if you've got a stone in place, even if you're not having much symptoms, if you've got obstruction plus an infection, Based on your urinalysis, based on your white count, your lactate it just, the urine just looks bad. That person is somebody urology needs to know about, because that constitutes a urologic emergency, and you want to get decompression as soon as possible. Now, I've been some scenarios where it's like a two millimeter UVJ stone. They've got infection. It's minimally obstructing that person. You could probably still let us know, but I might be more inclined to say, Hey, as long as you're doing well, they can closely follow up with me on an outpatient basis. So there's a little bit of. of finesse in that diagnosis, but generally speaking, uncontrolled symptoms and concern for concurrence infection are the two situations with stones that you should let us know. Now, sometimes you may also want to let us know if the stone is just huge. They got a big stag horn calculus, but otherwise they're doing well. Again, that's probably still going to be an outpatient follow up unless obviously there's those criteria we discussed earlier. But we do like to know about them just in case we might have a different thought.

Dr. Hagahmed:

So to summarize, toxic appearing objective data, like of sepsis, leukocytosis, lactate, maybe kidney injury hemodynamic, obviously instability that needs to go to the ICU or needing pressers. So we call you as soon as possible. The thing is also that I'm experiencing is that those folks that look otherwise well. But yeah, they have an eight millimeter stone, like they come in, they have this kind of vague complaint. They look completely fine. They tell you I had a kidney stone before. This might be it. Urine is clean, labs good, eight millimeter stone. So what would you do with

Dr. Acquaye:

Yeah. Still go home, I always tell them, hey, give them return precautions, give them all the pain meds and the nausea stuff and the Flomax and the strainer and, the instructions to drink a lot, give them all that, let them go home. I know we use 20 percent as okay, they have an 8 millimeter stone, you have a 20 percent chance of passing it, but everybody is different. Recurrent stoneformers can, past stones that you wouldn't believe. I had a guy pass a three centimeter stone and it got stuck in his urethra and I was skeptical and I went in there and I was like, that is the biggest stone I've ever seen somebody pass. It was so big that it couldn't get to the urethra, but somehow it made it down from the kidney. So again, as long as you're doing well, we're not gonna force a person to the operating room or something for asymptomatic stone. They may still pass it.

Dr. Hagahmed:

And any specific medication besides the NSAIDs

Dr. Acquaye:

Yeah. I really Toradol for stone pain specifically, and it's non drowsy, so patients who want to get to work, it definitely helps. I like the lotted or, the narcotic of choice as a backup, that's like the pain is really bad, not controlled, but generally speaking, I'm a Toradol person. And then pyridium, for some of the dysuria they're going to get and then of course your Flomax and then give them a urine strainer. I think that's usually a good enough strategy. You can have to make the judgment call based on, how they Look in the ed. Some patients, you just look at them. This person's going to have difficulty with pain control if it comes on.

Dr. Hagahmed:

Is there a strong evidence with Tamsolusin or Flomax or no?

Dr. Acquaye:

Yeah, definitely. Medical expulsive therapy has a lot of research and it's definitely useful more so for the larger stones. Once you get over five, six millimeters, that's where the true efficacy of the flow max comes into play. The smaller stones actually not so much, even then we still give them flow max. It's got a minimal side effect profile. You get them some. And we just keep it on board until they pass the stone, potentially.

Dr. Hagahmed:

Moving along to another not so frequent emergency for me, but something that you prefer to see all the time, which are penile emergencies. I know I've seen a few cases when I was in a trauma ICU not as much lately, but what is the most common penile emergency that you deal with?

Dr. Acquaye:

Yeah. I would say that the most common I tend to see is paraphimosis So for people who don't know what that is in uncircumcised men If you retract the foreskin and don't return it to its normal position The foreskin can actually get trapped behind the glans because the glans will swell and then the foreskin is stuck there And then that causes the blood flow to the glans to become compromised. You can get things like pain, worst case scenario necrosis. So that's definitely the most common thing I would see because, you have a lot of uncircumcised patients and sometimes somebody might forget to put it back.

Dr. Hagahmed:

Now we have that patient now in the ED and I'm going to try to maybe not call you. So what's some techniques do you recommend? And please tell me that sugar is included in that technique. Oh, no,

Dr. Acquaye:

that reduction yourself. So you gotta buckle up and squeeze that thing and squeeze it very hard and the patient's not going to like you and it's going to be very uncomfortable but what you're doing is trying to squeeze the edema out of the glans before you even attempt any reduction maneuvers. So it becomes a very kind of awkward situation because it's basically you and the patient and you're just squeezing their glans and you're trying to make conversation as they're in pain. But once you feel like the edema is down, then, they talk about the It's take the glans, get your two thumbs, and push the glans in as much as you can until it pops through. And then that way you can pull the foreskin back. It may not go completely back, but as long as the glans has reduced back into more of a native position, you should be all right. Okay. But definitely the first thing you gotta do is just squeeze the edema out that glans and that might take five minutes of just squeezing before you can push it in.

Dr. Hagahmed:

I'm just thinking of that awkward silence, I don't even know what to say, or do you even have a playlist?

Dr. Acquaye:

Yeah, I'm happy. I'm like, listen, this is going to be a very forthcoming. I'm like, this is gonna be very awkward. I don't know if you got a Spotify playlist or anything. I don't know if you prepared one for this particular scenario. But just pretend I'm not here as I squeeze your glans.

Dr. Hagahmed:

now what is the likelihood this is going to, this is going to work.

Dr. Acquaye:

So it works at a pretty high rate, I would say 70 to 80 percent of the time I've been calling for paraphimosis, even if it's been a while, the issue is that the person just didn't want to squeeze because they're being too gingerly about it. You got to be pretty aggressive and it's going to hurt. You can try and pre medicate them, but it's a sensitive area. So I feel like most of the time it's been successful only on a few occasions. Have I had to say, okay, it's not going to work, get the patients medicated. I'm going to go come in and do what's called a dorsal slit. So a dorsal slit is basically when. You make an incision in the top part of the foreskin that's stuck to open it up and then you can push the, glans in. So it's a bit of a bedside procedure. Sometimes, oftentimes it may just take him to the operating room, especially if they're not tolerating things that bedside. But you basically just cut into the foreskin and push the glans back in.

Dr. Hagahmed:

And then you also proceeded with a circumcision as well?

Dr. Acquaye:

Not really. you don't want to do it at that moment in time. And a lot of patients are actually very resistant to the idea of getting the circumcision. So I say, okay, we'll do this dorsal slit, but ultimately a lot of them eventually say, yeah, let's just do it. You're just trying to mitigate the immediate issue, which is that compromised glans.

Dr. Hagahmed:

See. Got it. So it's a true emergency. You have to be aggressive and you have to be very firm pun intended. Okay. So when it comes to penile fractures and I struggle with this because sometimes I see some swelling and I'm like maybe it's fractured. Maybe it's not. What do you think the best way for me to find that out

Dr. Acquaye:

So honestly, in most situations, penile fracture is a clinical diagnosis. There's not like a spec, a consistent imaging modality that will always give you a diagnosis. So you could do an ultrasound, a penile ultrasound, look for compromised blood flow, or look to see if there's any evidence of a destruction in the ra. You could do an MRI, which looks for the same thing, but much more sensitively, but obviously it might take a little bit longer to get that done. But ultimately the patient tells you, yeah, I was having intercourse. I heard a big pop. I have this swelling. That's really as much as you need. I don't think you have to really waste time with additional modalities if you're pretty convinced based on their history, because what we're going to do is explore. Worst case scenario, it's a bunch of bleeding, we don't find a fracture, it's fine. Or sorry, best case scenario. But worst case scenario, we go in there, there's a big disruption in the corpora, and then the urethra is damaged. So you want to have a high index of suspicion that something is going on, even if It's not super obvious based on imaging or something. It's a pretty consistent clinical picture.

Dr. Hagahmed:

So penile fractures, easy clinical diagnosis, call you, that's an easy disposition for us. What about priapism? What is that? And what are some of the things that we can do in the ED to intervene immediately? We'll

Dr. Acquaye:

Priapism is an erection that won't go down. I generally use the. Framework, if you have an erection that lasts longer than three hours, come into the emergency room. Alright, with priapism, there's two general categories, ischemic, which means a lack of blood flow, and non Ischemic which is an excess of blood flow. Ischemic is much more common in the scenario that you're more likely to see. With non ischemic, you tend to see that in patients with blood dyscrasia, like sickle cell and They tend to present in a much milder way, and it may be something they've had many times before. And in that situation, especially if it's a sickle cell patient, just give them fluids, give them oxygen, the usual way you would address like a sickle cell crisis, because you can think about that as a sickle cell crisis of the penis. The ischemic priapism, on the other hand You want to look at their presentation. Usually I took a medication that I wasn't supposed to take. I took a medication, a psych medication, like trazodone I taking a trimix injection for erectile dysfunction and the erection didn't go down. So the clinical picture will give you a lot of information. But that being said, you still want to get some objective data. And how you can do that is through a penile blood gas. So that's basically getting a sample of the blood from the corpora. So you put a needle in the penile shaft. Don't go to the top. That's where all the nerves and vessels are. Don't go to the bottom. That's where the urethra is. But anywhere else is fair game. Just get a sample, send it to the lab, send it on ice. That way you can see. Where you're at and where you're starting because after you've done your interventions and you think that the erection is down You want to be able to send another blood gas as a means of comparison?

Dr. Hagahmed:

how about

Dr. Acquaye:

So what do you do once you sent that blood gas? Obviously, you get the patient as comfortable as possible and you want to start with what's called aspiration and irrigation, as well as getting phenylephrine from the pharmacy because you're going to be injecting that as well, making sure the patient is set up to a monitor because if you're going to be injecting phenylephrine, you want to be watching their vitals. But yes, with aspiration, that means you're putting a needle into the penile shaft. Could be like a big, but a large gauge butterfly needle getting the blood out and you're going to initially be getting all this.

Dr. Hagahmed:

your

Dr. Acquaye:

Dark blood out because it's gonna be a lot of old blood that has collected in there and then at the same time, you want to see if you can get a potentially another needle and irrigate, just putting in some, maybe a little bit of a saline flush in there because you're trying to break apart some of that old clot as you're sucking it out. And then concurrently, You might inject some phenylephrine, so you do both, you just throw everything at it, and you do a couple of rounds, you want, you don't want to exceed the maximum dosage of phenylephrine, but you want to, get to there, you want to try aspirating and irrigating, and of course, if you're not having any luck, notify urology, keep the patient NPO, because we might need to take them to the operative room for a more aggressive intervention, otherwise known as a shunt. Where we basically would make an incision in the glans and drain out the blood that way.

Dr. Hagahmed:

You talked to a lot about intervention, which is something that we definitely have to be mindful of, because this is a true emergency. We have to intervene. Otherwise, the most common complication these patients will suffer from is erectile dysfunction, right? What is the rate of erectile dysfunction relating to the duration of priapism?

Dr. Acquaye:

Once you're above 3 hours, you're starting to see a drop in likelihood of regaining your natural reptile function. It's still possible, I've had patients come 4, 5, 6 hours, but then I've had the patient come in 2, 3 days later, which is always mind boggling to me because I don't know how you hide that for 2, 3 days. But generally speaking, I would say percentage wise, if it's after three hours, now you're looking at 50 to 60 percent chance of regaining erectile function. And then once you're out of the 10 hour window, that number drops quite significantly. And then when these come, people come in after a few days, I always, I usually know that they're not really going to get their function back, partially because they're going to need some very aggressive interventions. I remind people that Priapism is essentially a heart attack for the penis. So how long do you think you would last if you had no blood flow to an organ for so so and so number of hours?

Dr. Hagahmed:

I like the analogy. And by the way, also, my analogy is like telling patients, Priapism is like having a stroke, if you have a clot in your brain, your brain cells would die quickly. So the same thing with,

Dr. Acquaye:

Yeah, what happens is if the erectile tissue gets no blood, it just scars down and then you end up with scar tissue which cannot facilitate an erection.

Dr. Hagahmed:

For sure. Now moving to a last topic that I think is very relatable to emergency medicine, of course, urology. is testicular torsion. It's one of the scrotal emergencies. I feel like testicular torsion is very tricky to diagnose. Why do you think that is? And what is the gold standard to diagnose them? Do

Dr. Acquaye:

says possible torsion events, maybe intermittent torsion, something like that, where they get very vague about it. So I tell people at that point, There is no immediate concern that the organ is going to be lost. Yes, you can notify urology, but don't get too concerned when you have at least some blood flow, even if they mention intermittent torsion. Intermittent torsion is not an emergency, per se, because there's blood flow to the organ. It's fine. The patient's doing fine. We usually will see them on an outpatient basis. And in rare cases, I'll do a elective fixation of the testicle bilaterally. Now, the easy type to diagnose is, of course, you take an ultrasound and there's no blood flow, and they're in very, or they present to you very acutely, some swelling, you can barely touch it. So I always say, some of it is just clinical. If you see them and they look like it looks like pretty bad, just let your urology know, because again, this is a emergency. And if there's any concern that the organ is at risk because of a lack of blood flow, even if the ultrasound is not, is equivocal, and still let us know because we may still want to just do a testicular exploration.

Dr. Hagahmed:

Have you seen a strange cause for testicular torsion? What are some of the causes for testicular torsion in your experience?

Dr. Acquaye:

in, in kids, cause I see, I still see teenagers. So of course, you talk about things like the bell clapper deformity and this congenital anomalies that predispose the testicle to twisting, for example, if it lies horizontally, which is that deformity I was talking about. Much easier to twist that way. On the same token for older patients, the old guys who come with torsion I'm usually thinking either really bad epididymitis or testicular cancer. All right. So again, that is one of the reasons why sometimes You know, we do want to explore. So those are what you can tend to see in rare cases. It might be like actual genital injury that might have caused that, but that's pretty rare, but those are the causes in terms of the age distribution. that I do tend to see.

Dr. Hagahmed:

And we always talk about, documentation and, legal consideration when it comes to making sure not to miss that diagnosis. What do you think about the cremasteric reflex and how reliable that is in ruling in or ruling out a testicular torsion?

Dr. Acquaye:

I've, I think it's a useful tool, but it's just one piece of the puzzle. And you still want to just look at the patient, you still want to get the imaging and the cremasteric reflex is almost just a confirmatory thing. If it's absent, then of course that's a kind of a strong rule in, but if it's present, Doesn't mean they don't have a torsion. So again, I don't really rely on that too much, between their presentation and the imaging. If there's any question I'll just do a testicular exploration because the risk of missing is always, the inconvenience of having to go to the operating room.

Dr. Hagahmed:

And what do you do for them surgically to fix that problem?

Dr. Acquaye:

So of course we'll go in and we have to deliver the involved testicle. We untwist it. You hear a lot about the open book technique that some people will say you can do as a bedside maneuver to try and reduce torture. I don't think I've ever seen that actually work, maybe once, but generally speaking, we do that same. Open book techniques in terms of untwisting the testicle. And then what you have to do is determine if that testicle is viable. So I'll untwist that one, put it to the side, wrap it up in warm saline. I go work on the other side. The reason we work on the other side is even if that side is fine. Because one side torse, the other side is likely to be able to do that too. So what we'll do is we'll open the other side, fixate that testicle, do what we need to do, and then return to the other side. If after all that, it hasn't pinked up, still looks dead, then we'll do an orchiectomy and just remove it. But if it's starting to get some life, and there's even some chance, we'll put that testicle back in. Worst case scenario, hey, it doesn't, you'd gain its initial functionality. but it's not going to cause any issues. All right. But if it's completely dead, you don't want to obviously put it back in.

Dr. Hagahmed:

Nice. I'm telling you, man, this has been an incredible deep dive into the world of urologic emergencies. I want to make sure there are no final words or anything that you want our listeners to know. If you have any questions to learn more about, or maybe any tips on your end for our acute care physicians or clinicians.

Dr. Acquaye:

I think we definitely were able to cover a lot of topics in good detail, but bringing it back to the basics, one of the things is a pet peeve of mine is a patient coming in for a UTI or pyelonephritis and they get empiric antibiotics and nobody sends a culture. All right. Because That happens more often than you think. And I'm just like because we want to know what we're treating. The patient's gonna come to me after, and if their patient, their symptoms are refractory, my hands are tied because they're already on some empiric antibiotic that's skewing the results of the culture, but they may be on the wrong one, so then you're delaying their treatment weeks, potentially, all because a culture wasn't sent as a reflex. I always thought it was automatic, but it's not. So that's the only little caveat I want to put in there. But again bigger picture, don't be worried or scared about urologic issues and emergencies really just be able to identify. Hey, this needs urgent intervention. Like I said, infected stones, any situation where there's potential for organ loss. I think if you look at it through that framework, it's pretty easy in terms of being able to treat out of these patients. But yeah, thank you for having me. It's been fun. It's been great discussion and I hope that listeners get a lot from this.

Dr. Hagahmed:

Wise words, man. I'm so happy that I finally got you out of your busy clinical and surgical schedule. And thank you for sharing your expertise. I hope all of you listeners can get something to use at bedside and help your patients and please stay sharp, stay prepared, stay compassionate, and thank you for tuning in.