MALE GENITOURINARY EMERGENCIES

Transcription

1 MALE GENITOURINARY EMERGENCIES Objectives: 1. Distinguish between testicular torsion and epididymitis regarding the history and physical findings 2. Describe Prehn s sign and the cremasteric reflex and their utility in the diagnosis of testicular torsion 3. Discuss the meaning of the following: In the patient with suspected renal colic, the physical exam should be remarkably unremarkable 4. List the indications for hospitalization and/or urology consultation in a patient with renal colic Copyright UC Regents 1

2 MALE GENITOURINARY EMERGENCIES Anatomy a. penis 1. composed of three cylindrical bodies: two corpora cavernosa (erectile bodies) which are surrounded by tunica albuginea (connective tissue) and corpus spongiosum which surrounds the urethra. All three covered by Buck's fascia 2. blood supply is from internal pudendal artery 3. lymphatics drain into deep and superficial inguinal nodes b. scrotum & testis 1. testes lie vertically, are encased in tunica albuginea except posterolaterally where epididymis lies, average size 4X3 cm 2. tunica vaginalis anchors testis and epididymis to posterior scrotal wall 3. inferiorly testis anchored to scrotum by the scrotal ligament (gubernaculum) 4. posteriorly the tunica vaginalis and tunica albuginea are contiguous. 5. blood supply via the spermatic arteries in the spermatic cord 6. epididymis -a tubular structure that promotes sperm maturation and motility a. lies posterolaterally on the testis b. vestigial embryonic structures located here include the appendix epididymis and the appendix testis 7. vas deferens easily palpable within the adnexa of scrotal sac. It extends in the spermatic cord from the tail of the epididymis through the inguinal canal, behind the bladder, over the ureters, and joins the seminal vesicles to form the ejaculatory ducts in the prostatic urethra c. prostate 1. heart shaped structure 4x3x2 cm at base of bladder, surrounding urethra 2. two lateral lobes separated by median sulcus 3. when enlarges with age or with hyperplastic adenoma, may envelop the urethra between the bladder neck and the urogenital diaphragm causing bladder outlet obstruction PHYSICAL EXAMINATION a. **male abdominal exam not complete until GU exam done b. **male GU exam not complete until rectal done c. visual inspection, palpation d. includes exam of prostate, inguinal canals e. in trauma patient 1. inspect perineum for blood, echymosis, blood at urethral meatus 2. rectal exam for boggy, or high riding prostate, for sphincter tone, blood 3. inspect/palpate scrotum/testis for blood, testis disruption Copyright UC Regents 2

3 PENIS a. balanitis 1. inflammation of glans/foreskin 2. glans purulent, excoriated, tender, malodorous 3. often in children 2-5 yr. caused by irritant, infection, or poor hygiene 4. in adults may be presenting sign of diabetes 5. treatment, antibiotics for gram positive organisms, cleaning, drying, antifungal creams, sometimes circumcision b. phimosis- can t pull foreskin backwards 1. opening of foreskin so small that foreskin can't be retracted behind the glans 2. normal at birth, but 90% boys can retract foreskin by school age; don t forcibly retract 3. etiologies - poor hygiene, infection, scar tissue from prior injury 4. signs- redness, swelling of foreskin, purulent discharge, pain 5. treatment- 0.1% TAC, hot soaks, sitz baths, rarely may need dorsal incision or hemostat dilation of opening of foreskin 6. later, circumcision 7. Urology consultation if urinary retention or cellulites in diabetic 8. Don t blindly catheterize c. paraphimosis- can t bring foreskin forward 1. tight foreskin is retracted, becomes edematous, and can't be pulled back over the glans. Edema impedes circulation of the glans, and distal penis swells 2. causes- balanitis with contracture of foreskin, from hair wound around penis, cock ring 3. to prevent paraphimosis, after urinary catheterization, always pull the foreskin back over the glans, tape penis in upward position so catheter doesn t pull on urinary meatus and cause urethral injury 4. treatment- must reduce foreskin a. manual compression of glans for 5 minutes, or 2X2 gauze bandage wrapped around glans b. may need dorsal nerve block, or procedural sedation 1. circumcision to avoid recurrence d. Peyronie's Disease 1. patient complains of lump on dorsum of penis and painful penile curvature with erection 2. plaque involving the tunica albuginea of the corpora without urethra involvement 3. etiology unknown 4. on exam, palpate hard plaque, not movable, on dorsal surface of penis a. may be associated with Dupuytren's contracture of the hand b. non-emergent urology referral. Up to 50% regress spontaneously within 1 yr. Copyright UC Regents 3

4 e. priapism- Urologic Emergency 1. prolonged, involuntary erection, painful, not associated with sexual arousal 2. thought to be due to imbalance between neural stimuli, and/or from mechanical interference of venous outflow from penis 3. corpora cavernosa becomes engorged with stagnant blood, corpus spongiosum is flaccid and patient can void 4. intracavernosal pressures may exceed arterial systolic pressures resulting in ischemia, therefore is a urologic emergency requiring consultation. Rapid treatment needed to prevent corporal fibrosis and erectile dysfunction 5. morbidity is time dependent a. 6 hr. may be OK b. 24 hr. probably too late 6. types a. low flow or ischemic (from decreased penile venous outflow, sludging, blood stasis) 1. etiologies a) sickle cell, thalassemia b) leukemic infiltration causing sludging c) drugs- trazadone, cocaine, alcohol, marijuana, antihypertensives injections of papaverine, phentolamine, or prostaglandin E1for erectile dysfunction 2. on exam, corpus cavernosum is involved (penile shaft is hard) and spongeosum is spared (glans is soft) 3. diagnosis of type is made with blood gas on blood from corpora with low O 2 and high CO 2 4. treatment a) emergent Urology consultation b) pain relief c) oxygen, hydration d) if sickle cell- transfusion to hemoglobin>10g/d e) corporal aspiration of blood 1) 21 gauge butterfly, aspirate 60 cc from corporus, close to glans 2) irrigate with 10 cc normal saline to stir up sludge, then withdraw and instill phenylephrine 100μg or epi 1:100,000 (1 mg in 10 cc NS), inject 2-3 cc to maximum of 10 cc. 3) monitor, if no improvement need surgical shunt 5. complications- time dependent a) resulting impotence not in future treatable with viagra, only penile prosthesis b) fibrosis, gangrene Copyright UC Regents 4

5 b. highflow (from increased arterial blood flow that overwhelms venous system of penis) 1. from arterial-cavernosal shunt from groin/straddle injury 2. doesn t cause ischemia, not true emergency 3. treatment is conservative vs embolization 4. priapism from spinal cord trauma has similar physiology SCROTAL DISEASE a. soft tissue 1. sebaceous cysts, superficial abscesses 2. look for deeper involvement of bulbous urethra, testis, epididymis 3. if deeper involvement, evaluate by ultrasound b. scrotal (Fournier's) gangrene- necrotizing fasciitis of perineum 1. Urologic Emergency 2. life threatening 3. polymicrobial infection of subcutaneous tissues that originates from perineal, perirectal site 4. surgical emergency requiring extensive debridement 5. peak incidence years 6. rapidly progressive, in hours, preceded by genital discomfort, sweats, fever, chills 7. may be toxic appearing 8. risk factors a) 2/3 have diabetes b) immunocompromised c) alcoholic, wheelchair bound, poor hygeine d) local trauma, surgery e) think about entity in immunocompromised men with scrotal, rectal, genital complaints out of proportion to physical findings 9. infection is foul smelling (anaerobes), may have evidence of gangrene, gas in soft tissues. Early on may only be scrotal edema, blotchy erythema 10. multiple organisms involved including gram negatives, bacteroides, clostridia 11. treatment - antibiotic coverage for gram +, gram -, and anaerobes (amp/genta/flagyl) AND wide, aggressive debridement, ICU care 12. mortality 13% c. hydrocele 1. fluid collection within tunica vaginalis 2. if from infection (epididymitis/orchitis), develops over days 3. if from tumor, accumulates more slowly 4. if idiopathic, is chronic 5. transilluminate the scrotum. If it doesn't transilluminate or testicle can't be palpated adequately, may need ultrasound and urologic referral to establish if idiopathic etiology Copyright UC Regents 5

6 d. paratesticular masses- cancer 1. all testicular masses should be seen by Urology within 1 week 2. gradual, painless enlargement testicle 3. 10% acute testicular pain 4. 10% present with metastasis a) back pain from retroperitoneal mets to nerve roots b) cough, SOB from pulmonary mets c) bone pain from skeletal mets d) extremity swelling from vena caval obstruction 5. physical exam a) firm, nontender mass separate from epididymis b) initial misdiagnosis- epididymitis or hydrocele e. orchitis (isolated), rare 1. usually mumps (in post pubertal boys) and preceded by parotiditis 2. may have severe pain and swelling, nausea, vomiting, fever, chills 3. unilateral in 70% cases 4. usually resolves in 5-10 days 5. treatment is supportive with bedrest, analgesics, scrotal support 6. seldom results in infertility 7. other viruses including dengue, influenza, mononucleosis, varicella, echovirus, coxsackie ACUTE SCROTAL PAIN Differential diagnosis includes orchitis, trauma, hernia, renal colic, abscess, varicocele, neoplasm, leukemia, Henoch-Schonlein purpura, hydrocele, torsion, and epididymitis. Most important to differentiate are torsion and epididymitis. TESTICULAR TORSION Urologic Emergency where Time is of the Essence a. introduction 1. annual incidence 1/4000 males under age of 25; about 3-4 patients/yr. in large hospital 2. age a) can occur at any age, reported in utero to 90 years b) neonatal- from twisting before complete testicular descent and fusion toscrotal wall c) most common at puberty, but % occur after adolescence b. pathophysiology 1. predisposed in testes with an abnormally high attachment of the tunica vaginalis. If the tunica attaches not on the posterolateral surface, but above the epididymis, the testes can rotate within the tunica, testis and spermatic cord twists, occluding venous return, leads to edema, and decreased arterial flow, infarction, necrosis 2. spermatogenesis on unaffected side may decrease 3. salvageability is time dependent and dependent on # of rotations of cord Copyright UC Regents 6

7 a) 3 hr., 5 hr., 8 hr. b) 10 hr., 24hr. c) testicles can torse and detorse, so diagnose even if many hours have passed c. symptoms 1. sudden onset pain in scrotum, but may complain of groin, abdomen, flank pain 2. 50% occur in sleep 3. 42% have nausea, vomiting 4. urinary voiding symptoms are rare 5. because may only have abdominal pain, all males with abdominal pain should have a careful genital exam d. physical findings 1. rare to have significant fever 2. extreme pain and swelling typically results in sub-optimal exam and difficulty differentiating scrotal contents 3. twists in the cord my lead testicle to have "horizontal lie", or be "highriding" because of spermatic cord shortening 4. epididymis may be rotated anteriorally 5. testicle may be larger secondary to venous congestion 6. elevation of the testicle (Prehn's sign) does not give relief, but is a very unreliable diagnostic maneuver 7. cremasteric reflex usually is absent in torsion (stroking inner thigh normally elicits retraction of the ipsilateral testicle moving upward at least.5cm) e. history of spontaneous resolution, and previous episodes in only 11-50% f. laboratory findings 1. urinalysis is normal in 90% 2. 1/3 patients may have leukocytosis 3. ancillary studies looking for decreased blood flow (shouldn t delay surgery) a) ultrasonography may be helpful, but is operator dependent 1) if pulses are not preset, is very predictive of torsion 2) if pulse is found, may be false negative, doesn't rule out torsion b) technetium-99m pertechnetate scans show "cold", hypoperfused area with torsion, not always available, may be time delay c) "ultimate" ancillary study is surgical exploration g. treatment 1. surgery 2. temporizing measure is to detorse testicle manually. Testes twist medially, treat by opening the book, hard to do because very painful a) should give relief of pain (over hours) b) but maneuver may only detorse partially, if testicle is twisted many times h. torsed testicular appendages (appendix testis, or appendix epididymis) 1. are vestigial tissues with no known function Copyright UC Regents 7

8 2. less marked pain than testicular torsion 3. see pathognomonic "blue dot" through scrotal skin, or palpable tender nodule at superior aspect of testicle next to epididymis 4. consult Urology, but can treat this conservatively if can exclude testicular torsion by ultrasound EPIDIDYMITIS a. introduction 1. most common cause of acute scrotal pain/mass 2. incidence is 1/1000 men/year 3. disease of adult men, rarely occurs at puberty, and even more rarely in prepubertal boys 4. rarely is there isolated epdidymitis, usually epididymo-orchitis 5. complications are abscess, chronic pain b. etiology 1. from retrograde spread of organism from vas deferens from infected urine in bladder, urethra, prostate. 10% time is bilateral 2. organisms in younger (<40 yr) men- chlamydia, gonorrhea 3. in "older" men- coliforms as E.Coli, Pseudomonas, Proteus more common 4. in immunocompromised- TB, cryptococcus, fungal c. symptoms 1. pain begins gradually, peaking over many hours, sometimes described as "sudden onset" 2. pain may be sharp and radiate to groin, or dull, aching, scrotal discomfort % have urinary frequency, urgency, dysuria 4. may begin after straining, GU surgery, instrumentation, sexual contact d. physical findings 1. may have low grade fever, sepsis is rare 2. early on is localized, indurated, tender epididymis 3. scrotum may be erythematous, edematous 4. scrotal elevation/support may give relief (positive Prehn's sign) e. laboratory findings 1. urinalysis- 90% have pyruia/bacteruria (>10 WBC/hpf) 2. WBC may be 10-30,000 f. treatment 1. strict bed rest with scrotal elevation 2. analgesics, ice pack or heat 3. antibiotics a) <35 yr- ceftriaxone 125 mg IM and doxycycline 100mg bid for 7 days b) in older men, consider treatment for gram negatives, i.e. fluroquinolone Copyright UC Regents 8

9 4. **urology follow-up, testicular cancer may initially be misdiagnosed as epdidymitis, pain is due to acute hemorrhage in the tumor 5. indications for hospitalization/urology consultation a) intractable pain, nausea, vomiting b) sepsis with high fever, rigors c) all pediatric cases (rare, diagnosis more likely torsion) PROSTATITIS a. most misdiagnosed disorder in male urology b. acute bacterial prostatitis 1. significant dysuria, frequency, urgency, back or perineal pain, fever, chills, dehydration 2. prostatic tenderness, swelling, hard or boggy 3. organisms include coliforms, gc, chlamydia 4. hospitalize and treat with quinolone for 4-6 weeks 5. avoid foley catheterization which can obstruct prostatic drainage, may need suprapubic catheter if can t void 6. don t massage the prostate 7. bed rest, analgesics, stool softeners, antipyretics c. chronic bacterial prostatitis 1. variable symptoms of dysuria, urgency, frequency, nocturia, pain; rectal exam not helpful 2. diagnosis based on recurrent positive cultures after prostate massage 3. usually gram negatives, treat with antibiotics for 4-6 weeks d. nonbacterial prostatitis 1. like chronic prostatitis, but cultures negative 2. treat like chronic prostatitis plus NSAIDs, sitz bath ACUTE URINARY RETENTION & OVERFLOW INCONTINENCE a. etiologies (really two types: detrusor failure, e.g. pump failure, and outflow obstruction) 1. neurogenic (spinal cord compression below L4/5) 2. trauma- urethral disruption, penile strangulation 3. obstructive most common etiology (BPH, prostate or bladder cancer, urethral stricture) 4. degenerative (diabetes, multiple sclerosis, Parkinson's) 5. pharmacologic- anticholinergics, sympathomimetics acting that inhibit bladder emptying b. history 1. obtain history of medications 2. obtain history for obstruction, i.e. nocturia, hesitancy, diminished force of voiding, poor urinary stream, urethritis, stricture history, low abdominal pain inability to void, urgency Copyright UC Regents 9

10 c. exam 1. perform good neuro exam, especially of lower extremities because of similar neurovascular innervation 2. good GU/rectal exam for meatus stenosis, masses, abscesses, prostate size 3. percuss/palpate for bladder distention d. treatment- catheterization 1. lubrication of catheter (lidocaine jelly into the urethra first), 16F-18F foley or Coude catheter which has a firm, angulated tip 2. hold penis straight up when passing catheter 3. don't inflate balloon until catheter fully inserted 4. if no urine, before inflate balloon, irrigate the foley with 60 cc NS, then will typically get drainage 5. don't have to drain bladder in stages 6. occasionally if chronic distention, may have bladder mucosal edema and rapid decompression will result in transient gross hematuria (2-16%) not clinically significant 7. treat with antibiotics if urine is infected or catheter will be in place for more than 5 days 8. watch for post obstructive diuresis. If urinary retention has been chronic, should observe for several hours to assess for this. More likely if patient has an elevated BUN/creatinine > 4.0 or if urine output>200cc/hr for more than 4 hr. Therefore should observe for several hours 9. Urology follow-up GU EVALUATION IN MULTIPLE TRAUMA a. life threatening injuries take precedence over diagnostic evaluation of GU tract b. GU evaluation during secondary survey c. Suspect GU injury if: 1. blood at meatus 2. gross hematuria or microscopic hematuria in setting of hypotension 3. abnormal prostate exam a) high riding, boggy b) prostate sheared from pelvis and migrates up, and hematoma fills normal position of prostate 4. flank, abdominal, perineal hematoma/eccymosis 5. fractures of the pelvis, lower ribs, lumbar spine d. penile injuries 1. penile fracture a) from sudden flexion of erect penis (i.e. penis slips out of vagina and thrust against perineum) b) from linear tear in tunica albuginea with injury to corporal body due to trauma to erect penis Copyright UC Regents 10

11 c) complain of sudden, severe pain, snapping sound, loss of erection d) physical- tender, swelling, eccymosis of penile shaft e) treatment- may have associated urethral disruption (consider if blood at meatus or hematuria), need retrograde urethrogram to evaluate f) consult Urology, surgery usually necessary to correct or prevent sequelae 2. entrapment a) from objects around penis (string, metal rings, wire, etc.) occluding venous, then arterial blood supply may result in severe edema, urinary retention, gangrene of skin, fistulas b) in young boys, entrapped hair is often cause of glans swelling after careful removal, need to ensure urethra and blood supply are intact c) zipper entrapment- cut median bar of zipper or cut across zipper transversely below entrapment and zipper pulls apart 3. penile amputation a) high success rate of reimplantation, with good urinary and erectile function b) penis should be placed in bag, and bag on ice in a cooler e. urethral injury 1. may manifest as blood at urethral meatus, inability to void, difficulty in catheter insertion, perineal ecchymosis, high riding prostate on exam 2. if is blood at meatus, etc. need retrograde urethrogram before instrumentation to prevent partial urethral laceration from becoming complete, or false passage 3. alternative is suprapubic cystostomy 4. anterior urethral injury (distal to urogenital diaphragm) a) straddle injuries, fractured pelvis, foreign body b) signs- hematuria, pain, butterfly hematoma of perineum (blood through Buck s fascia to Colles fascia), abdominal wall c) rarely an isolated injury, complications of stricture, fistula, incontinence, impotence d) evaluation is retrograde urethrogram (RUG) 1) Foley cath tip into urethra, occlude urethra gently with pressure around glans 2) gently insert cc water soluble contrast (renografin) with Toomey syringe 3) get oblique x-ray to visualize best urethral disruption 5. posterior urethral injury (membranous/prostatic urethra) a) most associated with pelvic fracture; 35% have associated bladder injury b) signs include distended bladder, can't urinate, blood at meatus, gross hematuria, low abdominal pain c) high riding or boggy prostate d) diagnosis with retrograde urethrogram e) treatment is suprapubic drainage, delayed repair Copyright UC Regents 11

12 f) complications are stricture, incontinence, impotence f. bladder injury 1. associated with other injuries, 2/3 with pelvic fractures, or with steering wheel injury 2. severe abdominal pain, tender abdomen, shock, can't urinate, no urine with Foley, blood at meatus 3. gross hematuria (10% have no hematuria) 4. diagnosis by CT cystogram 5. treatment is foley catheter if rupture is extraperitoneal, surgery if intraperitoneal g. ureter injury 1. 90% are from penetrating or iatrogenic (post hystererctomy) 2. asymptomatic and often missed and found during surgery 3. U/A doesn t predict/exclude injury 4. IVP sensitive, CT is poor at diagnosing 5. complications include abscess, urinoma, hydronephrosis 6. repair surgically h. renal injury- Grades % from blunt trauma 2. usually associated with injury to other organs 3. suspect if gross hematuria, or microscopic with hypotension 4. diagnosis by CT scan 5. treatment a) increasingly conservative, non-operative for Grades 1-3 b) Grade 3- through medulla, not into collecting system c) Grade 4- through collecting system d) Grade 5- shattered kidney, avulsed from pedicle treat with nephrectomy i. renal vascular injury 1. think about with lower rib fracture, transverse process fracture of L in children think when is mechcanism of deceleration (injury typically of left kidney) 3. think if have previously abnormal kidney 4. 30% have no hematuria Copyright UC Regents 12

13 MALE GENITOURINARY EMERGENCIES Case 1 A 16 year old adolescent male comes to the ED complaining of severe right flank and scrotal pain beginning several hours ago, awakening him from sleep. He denies GU trauma, fever, chills, sexual activity, dysuria, hematuria, urinary discharge, frequency, nocturia. On physical examination he appears in moderate pain. His BP =130/88, P=100 R=20, T=37 C. 1. What is your differential diagnosis for acute scrotal pain, and what is this patient s worst possible diagnosis? 2. What should you look for in the GU exam? 3. What laboratory studies should be sent? Why? Any ancillary studies? Case 2 A 35 year old man presents to the ED with the sudden onset of severe LLQ abdominal pain radiating to his left groin. He notes urinary urgency, and frequency, but denies fever, chills, hematuria. He states he had a kidney stone 5 years ago and his current symptoms are identical. 1. Is the physical examination helpful in diagnosing kidney stones? 2. What laboratory or ancillary tests should be ordered in patients suspected of having renal colic? What is the best way to diagnose a kidney stone? 3. How is renal colic treated in the ED? 4. What are the indications for admitting a patient with renal colic to the hospital? Copyright UC Regents 13

14 ANSWERS Case 1 1) The major entities to be distinguished in acute non-traumatic scrotal pain are testicular torsion and epididymitis. Of these two, torsion is the worst, as untreated torsion will result within hours in testicular ischemia, possible necrosis, and possible resulting infertility. 2) The GU exam in patients with acute scrotal pain can be difficult. Patients with epididymitis typically have associated orchitis and severe tenderness. It is frequently very difficult to delineate the epididymitis. Patients with torsion may have a horizontal orientation of the torsed testicle. They may have increased pain on elevation of the scrotum (i.e. Prehn s sign, a test which is insensitive and nonspecific for torsion). The presence of a cremasteric reflex makes torsion unlikely, but if missing does not rule out (or in) torsion. 3) A urinalysis (looking for pyruia0 is the best quick ED test for epididymitis, although up to 15% of patients with epididymitis may not have pyuria. A CBC is unhelpful as patients with both epididymitis and torsion may have elevated white blood cell counts (why?). The best ancillary test to diagnose torsion is a testicular ultrasound, although surgery is the gold standard. Case 2 1) The physical examination in a patient with kidney stones should be remarkably unremarkable. This means that any significant findings suggest that the patient does NOT have renal colic. Peritoneal findings on the abdominal exam are NOT found in renal colic, and other diagnoses must be entertained. Similarly, women with an abnormal pelvic exam, and men with abnormal GU/rectal exams, probably do not have renal colic. 2) Urinalysis (looking for microscopic hematuria) should be obtained. Electrolytes and renal function tests are also appropriate. CBC should be sent if other abdominal/gu pathology or infection is being considered. Other tests such as calcium and uric acid will not typically change ED management of renal colic, but may be helpful to the physician providing follow-up. 3) Pain management is of foremost importance in patients with renal colic. Ketorolac (30 mg IV) may be tried. If this does not relieve their pain within 20 minutes, morphine, the gold standard, should be titrated to effect. Patients should be given enough IV fluids to make them euvolemic, but should not be flooded with fluids, as there is no evidence large amounts of fluid facilitates passage of the stone, and may cause increased pain. Copyright UC Regents 14

15 4) Indications for hospitalization or Urology consultation for patients with kidney stones include: a. fever b. intractable pain c. intractable nausea and vomiting d. renal insufficiency, one kidney e. kidney stones >5mm size f.?immunocompromise Copyright UC Regents 15

16 MALE GENITOURINARY EMERGENCIES Bibliography 1. Bakht FR, Guerriero WG. Genitourinary emergencies. Prim Care Dec;16(4): Rosenstein D, McAninch JW. Urologic emergencies. Med Clin North Am Mar;88(2): Marcozzi D, Suner S. The nontraumatic, acute scrotum. Emerg Med Clin North Am Aug;19(3): Galejs LE. Diagnosis and treatment of the acute scrotum. Am Fam Physician Feb 15;59(4): Hanno PM, Wein AJ. UrologicTrauma. Emerg Med Clin North Am Nov;2(4): Copyright UC Regents 16