Pediatric emergency medicine trisk 833

SCROTUM Goal of Treatment The goals of the acute management of children with scrotal injuries are to determine the extent of injury, evaluating for testicular injury and, in consultation with urology, ensuring adequate workup to determine definitive care FIGURE 108.5 Posterior urethral disruption and pelvic fracture Computed tomography of pelvis shows extravasation of contrast material from posterior urethra into the surrounding tissues CLINICAL PEARLS AND PITFALLS Scrotal trauma may occur as a result of straddle injuries or bicycle accidents, during sporting events or less commonly, from animal bites or machine injuries The patient may present with scrotal tenderness, edema, and ecchymosis Potential injuries include skin or dartos ecchymosis and lacerations, intrascrotal hematomas, testicular hematomas, testicular dislocation, and testicular rupture In addition, a testicle may torse after trauma Clinical Considerations Clinical Recognition When inspection of the scrotum and its contents is obscured by local swelling and pain, ultrasonography is helpful to define the extent of the injury An intratesticular hematoma may show as an echogenic or hypoechoic testicular mass A hematocele produces a complex extratesticular fluid collection Sonographic findings of rupture include the presence of hematocele, parenchymal heterogeneity, intraparenchymal hemorrhage, and disruption of the tunica albuginea or parenchyma If the ultrasound examination is inconclusive, radionuclide scanning may provide additional information Both ultrasonography and nuclear scintigraphy help in the diagnosis of testicular torsion (see Chapter 119 Genitourinary Emergencies ) Patients who sustain small intrascrotal hematomas, skin ecchymosis, or minor skin and dartos injury without evidence of injury to the testes can be managed conservatively Treatment consists of ice packs and scrotal support Minor testicular injuries such as contusions or hematomas can also be treated conservatively Large testicular hematomas (>3 to cm) or testicular disruption may require surgical management Delay in surgery may lead to ischemic necrosis, pain, secondary infections, and disruption of testicular function Initial Assessment, Management, and Diagnostic Testing Superficial lacerations of the scrotum can be repaired using absorbable sutures Local infiltration with lidocaine plus epinephrine provides adequate anesthesia Urologic consultation should be obtained if the laceration extends through the dartos Physical examination of the scrotal contents determines the need for debridement and primary closure All penetrating testicular injuries require surgical exploration Degloving injuries of the scrotum can be seen after motor vehicle (particularly motorcycle), industrial, or farm machinery accidents Scrotal injuries are associated with varying degrees of penile skin loss The underlying penile and scrotal structures are usually spared Management involves debridement with primarily closure or coverage of the defect by skin flaps or grafting if more than 50% to 70% of the scrotal skin is lost Testicular rupture is a surgical emergency It is characterized by a tear of the tunica albuginea and extravasation of testicular contents into the scrotal sac Such injuries require early surgical exploration and repair to avoid the potential complications of atrophy and persistent pain Ultrasonography has been demonstrated to be sensitive in the diagnosis of testicular rupture by informing the clinician of the integrity of the scrotal contents early The high specificity of the ultrasonography may also provide information to guide the clinician on the necessity of surgical exploration Testicular salvage is more likely when exploration is performed within 24 hours of the injury Ultrasonography has shown poor accuracy, however, for the evaluation of isolated epididymal lesions Other injuries requiring surgical management include tense hematoceles and torsion after trauma Testicular dislocation may occur either as a result of an upward blow to the scrotum or, rarely, as a result of compressive displacement following severe blunt abdominal trauma Dislocation has been described in the context of mild scrotal trauma as well Diagnosis of testicular dislocation can be made by thorough physical examination, including palpation of the testes Examination will reveal a well-developed, but empty, scrotal sac or palpation of an abnormally located testis Severe scrotal pain, obesity, ecchymosis, swelling, or associated pelvic injuries may make examination and diagnosis difficult In most cases, the dislocated testis lies in the inguinal canal Associated injuries, such as pelvic fracture, are common Operative repair is required if closed reduction fails PENIS Clinical Recognition The most common cause of penile trauma in infants is iatrogenic, especially at the time of circumcision Complications include transection of the glans, urethrocutaneous fistula, deskinning of the penile shaft, and coagulation necrosis of the entire penis from electrocautery These injuries usually require extensive surgical repair Penile gunshot wounds are uncommon because of the position and mobility of the penis but have the potential to significantly affect quality of life Signs that may indicate corpora cavernosa injury include uncontrolled bleeding, expanding hematoma, blood at the meatus, or a palpable corporeal defect Urethral injury should be ruled out by retrograde urethrography if these signs are present These injuries require urologic evaluation to determine the need and timing of surgical management Blunt penile trauma from toilet seats falling on the glans or distal shaft can occur in toddlers Significant injury to the corporal bodies or the urethra is fortunately rare and patients can generally be managed expectantly with warm soaks Although the child does not commonly experience urinary retention, he may be more comfortable voiding in a tub of warm water Tourniquet injuries to the penis may result from bands, rings, or human hair In the infant, strangulation with a fine hair may be difficult to recognize because of local edema The initial diagnosis may be balanitis or paraphimosis Local or general anesthesia may be required to expose and remove the hair A high degree of suspicion should be maintained as complications include urethrocutaneous fistula or loss of the penis Fracture of the penis is produced by traumatic rupture of the corpus cavernosum This injury usually occurs when the erect penis is forced against a hard surface, most commonly during sexual activity The patient may hear a cracking sound and develop pain, edema, and deformity of the penis shaft with abrupt loss of erection An “eggplant deformity” of the penis is often present The urethra may be involved in 3% to 32% of injuries, especially in those with more extensive or bilateral corporal injuries Penile fractures require surgical treatment with evacuation of the penile hematoma, repair of the torn tunica albuginea, urethral repair if necessary and a pressure dressing Superficial lacerations of the penile shaft can be repaired with absorbable sutures under local anesthesia or penile block Lacerations extending to the corporal bodies or the urethra require urologic consultation due to the depth of injury and significant bleeding Injuries to the corporal bodies should be repaired primarily to prevent fibrosis and impotence If concomitant urethral injury is suspected, diagnostic evaluation includes a RUG to define the extent of the injury Injuries to the urethra may require primary repair and/or temporary urinary diversion Zipper entrapment of the penis or foreskin is a common complaint that can be managed in the ED Methods of emergent release have been described in relation to the zipper parts and depending on the type of zipper The median bar of the zipper may be cut with wire cutters and thus disassembling the zipper mechanism ( Fig 108.6 ) This technique may sometimes prove difficult when the metal bar is sturdy and there is edema of the entrapped penile tissue within the zipper fastener, limiting access to the metal bar Such may be the case with heavy metal zippers such as those found on jeans and dungarees, and success may depend on the strength of the operator and the availability of bone or wire cutters Therefore, this technique may work best with plastic or lightweight zippers Cutting the dentition of the zipper at any position, permitting unzipping of the zipper from the rear may work best for heavy-duty metal zippers Disengagement of the fastener by inserting a flathead screwdriver between the inner and outer faceplates and applying torque toward the median bar ( Fig 108.7 ) may prove helpful when it is difficult to grasp the tiny median bar with bulky cutting pliers Elliptical incision of the entrapped foreskin or emergency circumcision can be of value when less invasive methods have failed Regardless of technique, procedural sedation may facilitate the procedure Edema can be treated with warm soaks  ... or grafting if more than 50% to 70% of the scrotal skin is lost Testicular rupture is a surgical emergency It is characterized by a tear of the tunica albuginea and extravasation of testicular... the tiny median bar with bulky cutting pliers Elliptical incision of the entrapped foreskin or emergency circumcision can be of value when less invasive methods have failed Regardless of technique,