Urgent urologic consultation should be sought;

however, the emergency physician should also be prepared

to intervene when a urologist is not immediately available.

Uncomplicated phimosis and balanoposthitis are generally treated in the ED with prompt urologic follow-up

(Figure 42-2).

TREATMENT

Treatment of priapism begins with pain control. If lowflow priapism is suspected, treatment with subcutaneous

terbutaline in the deltoid region can be effective. If priapism persists, corporal injection with an alpha-adrenergic

agonist, such as phenylephrine, is performed.

If unsuccessful, corporal aspiration and irrigation can

be attempted. First, a penile nerve block is performed for

anesthesia. A 21-gauge or larger needle is inserted into the

cavernosum (lateral sides of the penis), proximal to the

PENILE DISORDERS

Attempt manual reduction of

foreskin; If unsuccessful,

perform dorsal slit procedure

in consu ltation with urologist

Disposition: Home with

urology follow-up if

reduction is successfu l.

Emergency urology consult

and admission if unable to

reduce

.A. Figure 42-2. Penile disorders diag nostic algorithm.

glans. Blood is then allowed to drain, or if needed, aspirated, typically until detumescence begins. If necessary,

aspiration is then followed by irrigation with 10-20 mL of

sterile normal saline, with or without an alpha-adrenergic

agent such as phenylephrine.

For priapism related to sickle cell disease, simple or

exchange transfusion may be necessary.

Treatment of paraphimosis involves reducing the

retracted foreskin. Ice packs or cold water immersion of

the penis may be helpful with edema and inflammation.

Compression wrapping with elastic bandage around the

glans for 5-10 minutes will also help with the swelling. The

glans may then be manually "pushed" back into the foreskin (Figure 42-3). Local injection with lidocaine may help

the patient tolerate the compression dressing better, but

will also contribute more fluid to the already swollen penis.

If manual reduction fails, the dorsal slit procedure can

be attempted. A penile block or ring block is first performed

for anesthesia. Next, hemostats are placed at the 11 and

1 o'clock positions on the edematous foreskin and clamped

down for hemostasis. Scissors or scalpel are then used to

cut the paraphimotic ring at the 12 o'clock position,

Freely mobile foreskin

with associated erythema,

excoriation, and discharge

Instructions on cleansing,

antifungal cream, antibiotics,

and steroid cream when

indicated

Disposition: Home with

primary care follow-up.

Admission for diabetics

with systemic symptoms

indicating bacterial

infection

Non-retractable foreskin with

or without swelling or edema

No treatment or steroid

cream, if asymptomatic. If

co-existing urinary retention,

hemostat dilatation or dorsal

slit performed

Disposition: Home with

urology follow-up; 6-8 weeks

of steroid cream may

improve phimosis without

surgical i ntervention

Figure 42-3. Manual reduction of a paraphimosis.

Reproduced with permission from Reichman EF &

Simon RR: Emergency Medicine Procedures, 1 st edition. McGraw-Hill, New York, 2004.

CHAPTER 42

between the 2 clamped hemostats. Manual reduction of

the foreskin over the glans is then achieved. The reduced

foreskin is then repaired with sutures, or a circumcision

can then be performed by a urologist.

Phimosis requires far less emergent treatment because

no vascular risk exists. If manual retraction is unable to be

performed, topical steroid treatment applied under the

foreskin to the tip of the penis for 4-6 weeks can be effective. If urinary retention develops, a dorsal slit procedure

or full circumcision should be performed.

The treatment of balanoposthitis consists of regular

cleaning of the glans with soap and water, with the foreskin

retracted. Topical antifungal cream (nystatin, clotrimazole)

should also be used. If bacterial infection is suspected, an

oral antibiotic (ie, first-generation cephalosporin) should

be added to the above treatments.

DISPOSITION

Patients with persistent, ischemic priapism require emer ­

gent urologic consultation. If corporal injection, aspira ­

tion, and irrigation (performed by either the urologist or

ED physician) fail to achieve detumescence, surgery to

perform a cavernosal shunt will most often be necessary.

If the preceding treatment options are successful, the

patient should be watched in the ED for 4-6 hours to

ensure symptoms do not return. If an inciting cause was

identified, the patient should also be thoroughly educated

about future avoidance.

The disposition of paraphimosis is much like priapism.

Urgent urologic consultation is required for nonreducible

paraphimosis. Admission and surgery may be necessary if

manual reduction or dorsal slit are unsuccessful. Patients

with phimosis, as long as they can urinate, can generally be

treated as an outpatient with good patient instructions,

education, and urologic follow-up.

Most patients with balanoposthitis can also be safely

discharged home. Patients with signs of systemic illness or

severe comorbid disease may require admission and intravenous antibiotics. Patient education is also very important

as the best preventative medicine is good personal hygiene.

SUGGESTED READINGS

Dubin J, Davis JE. Penile emergencies. Emerg Med Clin North

Am. 201 1;29:485-499.

Nicks BA, Manthey DE. Male genital problems. In: Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 20 1 1, pp. 645-65 1.

Vaginal B leeding

Steven H. Bowman, MD

Key Points

• Obta in a pregnancy test in any woman of childbearing

age who presents with vaginal bleeding or abdominal

pain.

• Risk factors are absent in more than 40% of women

who have an ectopic pregnancy.

INTRODUCTION

Menarche, the onset of menstruation, occurs in girls at

approximately age 12. Normal menstruation continues

until menopause, which occurs on average at age 51. The

adult menstrual cycle is 28 days ( ±7 days), with menstruation lasting 4-6 days. Normal menstrual blood flow is

approximately 30-60 mL; >80 mL of bleeding is consid ­

ered abnormal. Dysfunctional uterine bleeding (DUB) is

due to prolonged or excessive estrogen stimulation or ineffective progesterone production. Menorrhagia is an

increased volume or duration of bleeding that occurs at the

typical time of menstruation. Metrorrhagia is bleeding

that occurs at irregular intervals outside of the normal

menstrual cycle. Menometrorrhagia is irregular bleeding

that is also of increased duration or flow.

Pregnancy must be excluded in women of childbearing age who present with vaginal bleeding.

Vaginal bleeding complicates 20% of early pregnancies.

When bleeding occurs, 50% of patients will have a spontane ­