醫學筆記匯整 ED Notes

 Five GU emergencies 
Testicular torsion, Fournier's gangrene,

Excellent salvage rates are expected with < 6 hours of symptoms,
but salvage declines rapidly thereafter.
 
常見 15-  25  y/o 
Sudden onset, cramping pain, testis axis 改變 ( Transverse lying )
Negative Prehn's sign ( No lifting sign ) : 睪丸上提無法緩解疼痛
 
可和  Epididymo - orchitis 做 D/D : Prehn's sign + (上提睪丸會緩解疼痛)
 
The presence of vomiting
makes the diagnosis of testicular torsion more likely.
 
Relief of pain with elevation of the affected testicle
(Prehn's sign–positive for epididymitis)
does not reliably distinguish torsion from epididymitis.
 
 
 
 
 
 
 
The most sensitive finding in excluding testicular torsion is the unilateral
presence of the cremasteric reflex, but the sensitivity ranges from 73% to 96%.
The absence of an ipsilateral cremasteric reflex is a nonspecific finding
and may be associated with scrotal inflammation from any cause
 
 
 
 
 
 
 
 
 
 
 
 
 Testicular appendages 
 
Appendix testis, appendix epididymis, paradidymis  (organ  of  Giraldes),  and  vas  aberrans
 
Prepubertal boys(9-11 y/o)
classically  lack  the  systemic  symptoms  of nausea and vomiting
Pain localized to the upper pole of the testis or epididymis
A blue spot may be observed through the scrotal skin—the blue dot  sign
 
If the diagnosis can be ensured and normal intratesticular blood flow to the involved testis
confirmed by color Doppler US, surgical exploration is not necessary.
Torsion of an appendage is usually self-limiting and best managed with analgesics, bed rest,
supportive underwear, and reassurance, with the expected symptom resolution within 3 to 5 days.
 
 
 

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The initial attempt should include one and
one-half rotations (540 degrees).
 
Any relief of pain is a positive end point,
and the success of the maneuver can be assessed with Doppler US,
worsening of the patient's pain
suggests that detorsion should then be done in the opposite direction (one third of cases)
 

- Obstruction : BPH, Cancer
- Medications : Anticholinergics
- Neurologic impairment : spinal cord injuries, stroke 
- Infection : Acute prostatitis, 
- Trauma 

<Left APN with focal abscess>
55y/o woman had fever for 3 days , left flank pain
1. 左右兩邊比較～
2. Left kidney: swelling/hyperechoic pattern in left cortex => pyelonephritis 
3. Upper part of left kidney with hypoechoic area (Triangle shape)=>Abscess 
4. 若有Doppler 可以協助分辨ischemia or inflammation
   (多半的機器沒有, 另外renal infarction->echo下，常不是出現hypoechoic pattern)
APN實際上還是以 臨床PE+Hx 就可以診斷
只是有時候在做Disposition時～
我們若知道有abscess formation, 有時候收治的科別會不一樣(Nephro-Uro)
當然跟病人解釋後續處置上也會不一樣～

- Nephrolithiasis : 腎結石
- Ureterolithiasis : 輸尿管結石
 
結石在 renal pelvis, bladder stone 通常無症狀, 或是只有 hematuria
一旦結石掉至輸尿管
就會引發 flank pain, renal colic, hematuria 
甚至 nausea, vomiting, fever 
根據結石卡住位置的不同
Pain radiation 會到不同位置
Flank pain, lower abdomen pain, groin pain

* PsA : Normal < 4 mg/dL 

 
0 - 4 : 2-5 % malignancy rate
4 -10 : 20- 30 % malignancy rate
> 10 : 50 % malignancy rate

1. PSA value > 4.0 ng/mL
2. Suspicious findings on DRE : the presence of nodules, induration, or asymmetry

好發 左側 ( 90 % )