Introduction
Andrological emergencies include pathological conditions of the external male genitalia, which need prompt surgical and medical treatment, as priapism and traumas represent distinct situations and often need a surgical procedure. At the same time, other commodities, such as necrotic infections, have a lower incidence but worse outcomes. This article provides therapeutic and clinical aspects of major and rheological emergencies.
What Are the Most Common Andrological Emergencies?
1. Paraphimosis:
It is a common andrological emergency that occurs in uncircumcised men when the foreskin of the penis becomes trapped behind the corona of the glans penis, resulting in the impossibility of positioning it back by moving it distally to its anatomic position to cover the glans.
Complications and Clinical Features:
This condition results in inflammation and edema formation in the foreskin, which gradually impairs venous and arterial blood flow and lymphatic drainage that occurs within a few hours or days. If it is not treated on time, ischemia and glans necrosis are the serious consequences.
Management:
- Simple manual compression of the oedematous foreskin.
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Cut a thumb of a surgical glove, fill it with the local anesthetic cream, and place it over the penis for nearly 30 minutes to soften the oedematous skin and provide analgesia for pain relief.
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Apply granulated sugar or mannitol solution around the edematous skin that alleviates edema through osmosis.
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Injection of hyaluronidase directly into the edematous foreskin.
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If a manual reduction is not successful, a surgical procedure is advisable.
2. Penile Strangulation Injury:
It is a rare clinical entity in which the penis is circumferentially constricted and trapped in an object, resulting in venous and arterial blood flow impairment and subsequent vasculogenic damage to the corpus cavernous (tissue of the penis responsible for erection).
Complications and Clinical Features:Prolonged and unresolved entrapment may lead to edema, ischemia, urethral-cutaneous fistula, and tissue necrosis, which may lead to penile amputation.
Management:
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Local anesthesia with a standard penile block may be necessary.
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Prompt attempt to remove the constricting object with an appropriate method to preserve the integrity of the involved penile structures.
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To reduce excessive swelling of the glans, an incision or positioning of a needle into the glans to continuously draw blood and reduce engorgement while removing constricting objects is helpful.
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A surgical procedure such as penile reconstructive surgery is the last resort if all the attempts to remove a constrictive object are unsuccessful.
3. Penile Blunt Trauma:
It refers to penile trauma from an external force. Although rare, it can happen during sexual activity, work, traffic, and sports injury.
Complications and Clinical Features:
It may lead to penile fracture if trauma occurs on the erect penis. Local hematoma, swelling, tip deviation, and pain are common symptoms. Long-term complications include scars at the repair site, erectile dysfunction, penile deformity, and urethral stricture.
Management:
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Conservative management with compression bandages, ice pack application, antibiotic, anti-inflammatory, and analgesic therapy is only viable for contusions without penile fracture.
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In the case of penile fracture, surgery within a few hours after blunt trauma, especially in the presence of associated urethral injury.
4. Penile Open Trauma:
This is an occurrence of penetrating wounds to the male genitalia. It is very uncommon, and most open trauma to the penis is from wars, stabbing and bullet wounds, crime, traffic accidents, animal biting injuries, burn victims, and industrial machinery.
Complications and Clinical Features:
Severe to mild damage to the anatomic structure of the penis. Sequelae such as infection, erectile dysfunction, loss of penile sensation, skin necrosis, urethral stricture, and penile implant failure can occur.
Management: Treatment of open penile trauma is multifaceted and complex.
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Open wounds require immediate surgical exploration depending on and vary on a case.
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Reconstruction includes skin flaps, immediate or staged urethroplasty, and phalloplasty to treat affected anatomical structures of the genitals.
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In the case of penile amputation, the surgeon performs penile reimplantation surgery.
5. Testicular Trauma:
Trauma to the scrotum includes blunt and penetrating injuries associated with burns, bites, sports-associated trauma, traffic accidents (especially motorbikes), falls, and violent injury that can cause skin avulsions. Scrotal pain and swelling are the most common symptoms.
Complications and Clinical Features:
Trauma to the scrotum may result in testicular contusion, hematoma, testicular dislocation, hematocele, and testicular rupture. Long-term sequelae such as impaired fertility, hypogonadism, and chronic pain can occur in untreated or delayed treated cases.
Management:
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Conservative management in mild injury includes ice pack application, anti-inflammatory drugs, painkillers, and scrotal elevation support.
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Surgical management in major trauma, such as testicular rupture, large hematoma, hematocele, and penetrating injuries, mandates prompt surgical intervention.
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Penetrating trauma needs the removal of non-viable tissue and reconstruction. Surgical drainage is required in case of larger hematocele and hematoma.
6. Testicular Torsion:
This is a serious and true andrology emergency that occurs due to twisting of the spermatic cord leading to venous congestion, impaired arterial blood flow, and consequent ischemia of the testis. The onset may be spontaneous, due to physical activity, or associated with scrotal trauma. It is a very commonly occurring emergency.
Complications and Clinical Features:
It can cause scrotal enlargement, redness, retraction of the scrotum's skin, testicular pain on palpation, proximal dislocation of the testes with or without aberrant positioning, nausea, and vomiting. Untreated or delayed treatment leads to infertility.
Management:
- The surgeon attempts Manual detorsion, not intended to avoid surgical exploration but to limit the effects of prolonged ischemia while preparations for surgical intervention are underway.
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Surgical intervention under anesthesia is a gold standard for confirming or ruling out a diagnosis of testicular torsion and comprises the treatment of choice.
7. Priapism:
Priapism is a penile erection lasting longer than four hours without sexual stimulation. Most commonly, it is due to minimal or no arterial inflow along with complete closure of venous outflow of the corpora cavernosa.
Complications and Clinical Features:
This phenomenon leads to edema, inflammation, and progressive necrotic degeneration of the muscle of the penis. It can happen in someone with sickle cell disease or other hematologic diseases. The most frequent cause includes the recreational use of erectile agents, antipsychotic drugs, and trazodone. Rarely it can be caused by amyloidosis, pelvic tumors, spinal cord, or peripheral nerve injuries. It is characterized by a rigid erection often associated with penile pain.
Management:
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It includes the patient’s medical history, physical examination, and penile blood gas analysis. History focuses on the onset and duration of the erection, the presence of concomitant diseases, the use of recreational drug medications, history of traumas, and previous experience of priapism. The physical examination must also include the evaluation of the abdomen.
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Penile blood aspiration is done after local anesthesia to achieve a flaccid state.
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Supportive therapy for underlying hematological conditions, including hydration, oxygen administration, and blood transfusions, as well as long-term therapy to prevent future episodes, is helpful.
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In case of failure of the above steps, surgical management is considered. Surgical procedures are divided into shunting procedures and penile prosthesis implantation.
8. Fournier’s Gangrene:
This is a form of necrotizing fasciitis of the genital and perineal parts with concurrent thrombosis of local arteries. It leads to skin and subcutaneous tissue gangrene, sepsis, and multiple organ failure. It is often associated with morbid obesity, poor hygiene, impaired self-care ability, and low socioeconomic status.
Complications and Clinical Features:
Local signs and symptoms can be discoloration and ulceration of genital and perianal skin, full-on tissue necrosis with swelling, palpable crepitus, and purulent discharge, usually appearing and worsening within three to four days. There can be concurrent voiding symptoms and micturition impairment. General signs and symptoms of sepsis, such as fever, can be present.
Management:
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Broad-spectrum antibiotics reduce systemic toxicity and limit the circulation of the causative microorganism.
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Surgical debridement with the removal of necrotic and infected tissue is vital to halt the progression of the disease.
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In the case of larger defects, plastic reconstruction techniques are mandatory to regain some of the functions of the genitals.
Conclusion
True andrological emergencies include a wide range of acute genital injuries requiring immediate specialist care. Delaying or missing treatment often leads to permanent loss of function or, in some cases, losing the affected organ. Thus, these emergencies demand prompt management to recover and regain the normal sexual function of the affected individuals, as sexual functions are the key factor influencing interpersonal relationships and a person's overall health.
