Acute Urinary Retention

This is defined as the sudden (acute) inability to urinate. It is a relatively common problem that causes agonizing suprapubic pain and demands urgent relief. Causes include benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland; urethral stricture, a narrowing of the tube that carries urine from the bladder out of the body; blood clots; prostate cancer; bladder neck contracture; myopathic bladder; neurogenic bladder, a loss of bladder control caused by damage to the nerves controlling the bladder; reactions to medications, such as allergy or cold medications containing decongestants or antihistamines, which may produce a side effect that prevents the bladder opening from relaxing; and psychogenic problems, nonorganic problems originating in the mind. Initial management involves draining the bladder by the least invasive method possible, usually some form of catheterization. Once this is accomplished, the underlying cause of the acute episode of retention should be determined and treated.

Testicular Torsion

Testicular torsion is a surgical emergency characterized by a sudden onset of pain in the scrotum; the pain may alternately be located to the lower abdomen or inguinal region. Although torsion can occur at any age, the peak incidence is in adolescence, with a smaller peak in pediatric patients between 0 and 3 years.

The condition usually manifests itself as a painful testicular mass. It occurs when one or more of the blood vessels that supply the testicle twists back on itself, cutting off blood supply to the testicle. Unless detorsion (untwisting) of the blood vessel(s) can be accomplished and blood flow restored promptly, necrosis (death of the tissue) will occur and the testicle will die. In most cases, if this can be accomplished within 6 hours of the onset of pain, the testicle will survive and remain normal. After 12 hours or more the rate of testicular salvage drops precipitously to about 20%. After detorsion the testicle usually is "tacked" in place so that repeat torsion does not occur. This is done via a procedure known as an orchiopexy. Because there is a high incidence of torsion occurring on the side opposite the initial problem, an orchiopexy usually is performed on the other testicle as well.

Priapism

This condition is a prolonged, painful erection of the penis that can persist for anywhere up to a few days. Such erections are not associated with sexual arousal or activity, but are caused by a failure of blood flowing into the penis to drain back as it would normally. Because there is little room for blood to circulate in the penis, it quickly becomes stagnant, acidifies and loses oxygen. Without oxygen, the red blood cells become stiff and even less able to drain out of the penis.

In most cases, priapism results either from the use of certain medications or medical conditions. Penile injections used to treat some forms of impotence can cause priapism, although this usually occurs only if a man inadvisably increases his dosage. In some cases, psychiatric medications, such as antidepressants, seem to cause priapism, although precisely how this occurs is uncertain. Certain medical conditions and diseases also can cause priapism. Such conditions typically thicken the blood or cause red blood cells to lose their flexibility and mobility; sickle-cell anemia and leukemia are the most common causes.

If not treated early enough, priapism can scar the penis and lead to impotence. Fortunately, the pain and discomfort of priapism induces most men experiencing the condition to seek treatment within four to six hours. Treatment typically involves draining the stagnant blood with a needle inserted into the side of the penis. Medications that act on the blood vessels also can be injected to help shrink blood vessels and decrease blood flow into the penis.

Fournier's Gangrene

This is a massive, rapidly progressive gangrenous infection of the genitalia. It begins as an extension of an infection from urinary, perianal, abdominal or retroperitoneal sites, or as a secondary result of local trauma. It can be caused by a wide range of aerobic and anaerobic organisms. It can occur in any age group, but most often occurs in persons 50 or older. Most patients have an underlying systemic disease, of which diabetes is the most common. Immunosupression, alcohol abuse, steroid use and other infections also are associated with Fournier's gangrene. It often presents rapidly with severe pain of the penis, scrotum or perineum, with rapid progression from erythrema (redness) to necrosis (death of the tissue) sometimes within hours. Other cases have a slower, more insidious, onset, with generalized symptoms of malaise, fever, chills or sweats and genital discomfort.

This is a serious condition, with mortality rates up to 50% being reported. The mainstay of treatment is aggressive surgical debridement (cutting away of infected or necrotic tissue) and triple drug antibiotic therapy. Flagyl, ampicillin and gentamicin are the usual first choices. An exploration of the abdomen and diverting colostomy occasionally are necessary as well.

Paraphimosis

This is a condition particular to uncircumcised males and those who may not have been appropriately or completely circumcised. It is characterized by an inflammation of the foreskin of the penis, causing the foreskin to become inflamed and swollen. The inflammation may be caused by infection or may be associated with poor personal hygiene; it occasionally develops after direct trauma to the area, which results in swelling. When this occurs, the foreskin becomes retracted behind the head (glans) of the penis and cannot be returned to its normal position covering the head. In effect, it becomes stuck behind glans, where it acts like a tourniquet, trapping the return flow of blood from the penis within the glans and producing even greater swelling.

If the condition persists, the inflow of blood to the head of the penis also will be cut off, causing ischemia (lack of oxygen) and possible necrosis (death) to that part of the penis. If the condition is not relieved rapidly, gangrene may develop. The probable outcome is excellent if the condition is diagnosed and treated rapidly.

Autonomic Dysreflexia

This is a syndrome characteristic of persons who have suffered a spinal cord injury. It is characterized by a major sympathetic nervous response to visceral stimulation. It usually occurs three to six months after the initial injury. Symptoms include sweating, piloerection (hairs standing on end), a pounding headache, bradycardia (slow heartbeat), and a sense of "impending doom" on the patient's part. Autonomic dysreflexia can occur in response to stimulation of the bladder, urethra or rectum in patients with a spinal cord lesion at T5 or higher. Treatment is to drain the bladder with the placement of a catheter.

Lower Extremity Weakness in Advanced Prostate Cancer

Occasionally patients present with untreated metastatic prostate cancer and signs that spinal cord compression is causing lower extremity weakness and lax anal sphincter tone. These patients need emergency treatment (i.e., neurosurgery or radiation therapy) to decrease their tumor mass and relieve the spinal cord compression.