# Clinical Cases: Genitourinary Emergencies

## Case 1: Testicular Torsion in an Adolescent Male

### Patient Demographics
- **Age:** 16 years
- **Sex:** Male
- **Occupation:** High school student

### Chief Complaint
"My left testicle hurts really bad and I feel like I'm going to throw up."

### History of Present Illness
The patient presents to the emergency department with sudden onset of severe left scrotal pain that began approximately 3 hours ago while he was playing basketball. The pain started abruptly without any direct trauma to the groin. He describes the pain as constant and severe, rated 9/10, with radiation to the left lower abdomen. He has vomited twice since the pain began. He denies dysuria, urinary frequency, fever, or penile discharge. He has no prior history of similar episodes. The patient's mother notes that he has been otherwise healthy with no significant medical history.

### Vital Signs
- Temperature: 98.8 degrees F (37.1 degrees C)
- Blood pressure: 138/82 mmHg
- Heart rate: 98 bpm
- Respiratory rate: 18/min
- Oxygen saturation: 99% on room air

### Physical Examination
**General:** Adolescent male in obvious distress, lying still on the stretcher, appears nauseated
**Abdomen:** Soft, mild tenderness in left lower quadrant, no peritoneal signs
**Genitourinary:**
- Left testicle: High-riding within the scrotum with horizontal (transverse) lie
- Significant swelling and erythema of the left hemiscrotum
- Exquisite tenderness to palpation of the left testicle
- Cremasteric reflex: Absent on the left, present on the right
- No relief of pain with testicular elevation (negative Prehn sign)
- Right testicle: Normal position, non-tender, normal lie
- No penile discharge or lesions
- No inguinal lymphadenopathy

### Diagnostic Studies
**Urinalysis:** Clear, no blood, no WBCs, no bacteria
**Scrotal Doppler Ultrasound:**
- Left testicle: Absent intratesticular blood flow on color Doppler
- Right testicle: Normal blood flow
- No hydrocele or varicocele identified
- Findings consistent with left testicular torsion

### Diagnosis
**Left testicular torsion** - urologic emergency requiring immediate surgical intervention

### Management
**Immediate Actions:**
1. NPO status established
2. IV access obtained, normal saline bolus initiated
3. Pain management with morphine 4 mg IV
4. Antiemetic ondansetron 4 mg IV
5. Emergent urology consultation placed

**Manual Detorsion Attempted:**
- "Open the book" maneuver attempted (lateral rotation of the left testicle)
- Patient reported partial pain relief after external rotation
- Repeat Doppler showed improved but not normal blood flow
- Decision made to proceed directly to surgical exploration

**Surgical Management:**
- Emergent scrotal exploration within 4 hours of symptom onset
- Intraoperative findings: 540-degree torsion of the left spermatic cord
- Detorsion performed with return of normal color to the testicle
- Bilateral orchiopexy performed (both testicles fixed to the scrotal wall)
- Testicle viable, no orchiectomy required

**Post-Operative Course:**
- Uncomplicated recovery
- Discharged on post-operative day 1
- Follow-up in urology clinic in 2 weeks

### Clinical Pearl
The classic presentation of testicular torsion includes sudden onset of severe unilateral scrotal pain, nausea/vomiting, a high-riding testicle with horizontal lie, and an absent cremasteric reflex. The salvage rate is nearly 100% when detorsion occurs within 6 hours, drops to approximately 20% at 12 hours, and approaches 0% after 24 hours. Imaging should never delay surgical exploration when clinical suspicion is high. Bilateral orchiopexy is performed because the contralateral testicle has the same anatomic predisposition (bell-clapper deformity) in approximately 80% of cases.

### Clinical Image
![Testicular Torsion Ultrasound](case_01_image.jpg)

**Image Description:** Scrotal Doppler ultrasound demonstrating absent blood flow to the affected testicle on the left compared with normal blood flow to the contralateral testicle on the right, consistent with testicular torsion.

**Attribution:** Image from Wikimedia Commons, Category: Ultrasound images of testicular torsion. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/Category:Ultrasound_images_of_testicular_torsion

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## Case 2: Obstructed Infected Kidney (Pyonephrosis)

### Patient Demographics
- **Age:** 54 years
- **Sex:** Female
- **Occupation:** Office manager

### Chief Complaint
"I have terrible pain in my right side and I've been shaking with chills."

### History of Present Illness
The patient presents with 2 days of progressively worsening right flank pain, now severe and constant, rated 10/10. She initially thought she had another kidney stone, as she has a history of calcium oxalate nephrolithiasis with two prior episodes. The pain was initially colicky but has become constant over the past 24 hours. She developed fever and rigors last night and has been unable to keep any food or fluids down due to nausea and vomiting. She reports dysuria and urinary frequency over the past several days. Her last kidney stone was 2 years ago and passed spontaneously after several days. She has no history of diabetes or immunocompromise.

### Vital Signs
- Temperature: 103.4 degrees F (39.7 degrees C)
- Blood pressure: 92/58 mmHg
- Heart rate: 118 bpm
- Respiratory rate: 22/min
- Oxygen saturation: 94% on room air

### Physical Examination
**General:** Ill-appearing woman, diaphoretic, rigors observed during examination
**Cardiovascular:** Tachycardic, regular rhythm, no murmurs
**Pulmonary:** Clear to auscultation bilaterally, tachypneic
**Abdomen:** Soft, mild right lower quadrant tenderness, no peritoneal signs
**Back:** Severe right costovertebral angle tenderness
**Skin:** Warm, flushed, no rashes

### Laboratory Findings
- WBC: 24,500/microL with 88% neutrophils and 8% bands (left shift)
- Hemoglobin: 13.2 g/dL
- Platelets: 168,000/microL
- Sodium: 136 mEq/L
- Potassium: 4.1 mEq/L
- BUN: 32 mg/dL
- Creatinine: 1.8 mg/dL (baseline 0.9)
- Lactate: 4.2 mmol/L
- Urinalysis: Cloudy, large leukocyte esterase, positive nitrites, >100 WBCs/HPF, many bacteria

### Imaging
**Non-Contrast CT Abdomen/Pelvis:**
- 9 mm obstructing stone at the right ureterovesical junction
- Moderate right-sided hydronephrosis with perinephric fat stranding
- Urothelial thickening suggesting pyelonephritis
- No evidence of abscess formation

### Diagnosis
**Obstructed infected kidney (pyonephrosis)** - urologic emergency requiring emergent decompression
- Urosepsis with septic shock
- Obstructing right ureteral stone

### Management
**Sepsis Resuscitation:**
1. Large-bore IV access x2, aggressive crystalloid resuscitation (30 mL/kg bolus)
2. Blood cultures x2 obtained
3. Urine culture obtained
4. Broad-spectrum IV antibiotics: Piperacillin-tazobactam 4.5 g IV
5. Foley catheter placed for urine output monitoring
6. Arterial line placed for continuous blood pressure monitoring
7. Norepinephrine initiated for persistent hypotension after 2L fluid resuscitation

**Emergent Urologic Intervention:**
8. Emergent urology consultation
9. Decision for emergent ureteral stent placement versus percutaneous nephrostomy
10. Patient taken to cystoscopy suite for retrograde ureteral stent placement
11. Grossly purulent urine drained upon stent placement
12. Successful decompression achieved

**Post-Procedure Management:**
- Admitted to ICU
- Vasopressors weaned off within 24 hours
- Blood cultures grew Escherichia coli
- Urine culture grew E. coli >100,000 CFU/mL
- Antibiotics narrowed to ceftriaxone based on sensitivities
- Creatinine improved to 1.1 by day 3
- Stone management deferred until infection resolved

### Clinical Pearl
The combination of urinary obstruction and infection creates a closed-space infection that can rapidly progress to septic shock and death. This is one of the few urologic emergencies where emergent intervention (ureteral stent or percutaneous nephrostomy) is required regardless of time of day. Neither antibiotics nor fluid resuscitation alone will adequately treat this condition without decompression. The stone itself is addressed electively after the infection has resolved, typically 4-6 weeks later.

### Clinical Image
![Hydronephrosis CT](case_01_image.jpg)

**Image Description:** Non-contrast CT scan of the abdomen demonstrating moderate hydronephrosis with an obstructing ureteral stone at the ureterovesical junction and perinephric fat stranding indicating inflammation.

**Attribution:** Image from Wikimedia Commons, Category: CT images of hydronephrosis. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/Category:CT_images_of_hydronephrosis