Questions of the Week for 8/22/2023

Authors: Christian Gerhart and Aaron Lacy

You have a 14-year-old boy who had sudden onset, acute, testicular pain 10 hours prior to presentation with diagnosed testicular torsion on doppler ultrasound. The family is concerned about his testicular viability after they read online that detorsion should occurs within 6 hours. What can you advise the family about possible testicular viability rates in patients who present with torsion that has been ongoing >6 hours, and what is your next step? 

  • You can inform the family there can be testicular viability in patients who present with decreased testicular flow >6 hours. Specifically, a meta-analysis of over 2000 patients showed that testicular survival is: 97% at 0-6h; 79% at 7-12h; 61% 13-18h; 43% 19-24h; 24% 24-48h; and 7% if >48 hours (PMID: 28953100). Given that there is likely still a high chance of testicular viability aggressive management, starting with rapid urologic consultation, should be pursued. If there will be delay in urologic evaluation (transfer, etc) you can consider manual detorsion. 

     

15-year-old boy presented to the emergency department after developing severe lower abdominal pain after soccer practice. He was diagnosed with stomach cramps and discharged home after a CT abdomen pelvis was done and negative for appendicitis. He represented to a different emergency department the next day and was found to have testicular torsion, and during scrotal exploration the testicle was non-viable, and orchiectomy was performed. How common is it for patients with testicular torsion to present without testicular pain, and is it possible that the first emergency physician can be found liable for missing the initial torsion presentation?  

  • Abdominal or flank pain is the only presenting symptom in up to 20% of testicular torsion cases. The testicles originate in the abdomen during embryogenesis and testicular torsion can present with abdominal pain. Because the first physician did not document a testicular exam (even if one was performed) they can be found viable for missing testicular torsion. There is legal precedent for this, and over 1/3 of testicular medical malpractice cases ruled against EM physicians the only presenting symptom was abdominal pain. The number one cause of missing testicular torsion is due to not doing a testicular exam, so a low threshold exists for doing a GU exam.  

A patient with known, severe aortic stenosis presents with generalized weakness and dyspnea. On exam they are ill appearing with cool extremities. Lungs are clear. Vitals are BP 85/60, HR 123 (irregular), T: 37, RR 28, O2 sat 94% on RA. EKG shows atrial fibrillation with rapid ventricular response. Describe your initial approach and stabilization package.  

  • Patients with AS are very preload dependent. Consider small fluid boluses 250-500cc. It is crucial to maintain their MAP in a normal range to maintain coronary perfusion (perfused in diastole). Patients with severe AS tolerate atrial fibrillation (especially with RVR) very poorly. Consider rhythm control with electrical or chemical cardioversion if ill appearing or especially if unstable. Phenylephrine can be considered as a vasopressor since it does not have any beta-adrenergic activity and sometimes leads to reflex bradycardia, which can be helpful in atrial fibrillation with RVR.

List 4 chronic conditions in which atrial fibrillation with rapid ventricular response is especially poorly tolerated.  

  • Severe aortic stenosis, mitral stenosis, pulmonary hypertension and diastolic dysfunction are notorious for poor tolerance of AF w/ RVR. These patients are especially dependent on their atrial kick for preload and cardiac output and the combined decreased in cardiac output from loss of atrial kick and decreased filling from tachycardia can cause instability. In most patients, the heart rate in atrial fibrillation needs to approach and often exceed 150 in order to cause hemodynamic instability. However, in patients with the above conditions, hemodynamic instability or acute heart failure can occur with rates much lower than this. Again, a rhythm control strategy should be seriously considered early for any of these patients.

You have a 68 yo male who presents with right flank pain. The patient has a history of prior renal stones, which have all passed spontaneously without intervention. He has normal vital signs and no fevers. He reports this feels exactly like his previous stones. What, if any, imaging would you order?

  • Given the patient’s age, this patient should probably undergo a CT scan to assess for other sinister causes of flank pain such as a vascular emergency, infection or perforation. The exact CT protocol is debatable and would depend heavily on each clinical scenario. Generally, a contrasted CT a/p can assess for most causes of flank pain, as well as rule out obstructive uropathy, and will only limit assessment of stones if they are very small (<1-2mm)2,3 . The paper that Dr. Schnieder referenced in his lecture (ref. #4) is an excellent resource for guiding these decisions.

You have a 35 yo male with a past medical history of urolithiasis who presents with left flank pain and nausea. He has hematuria on his UA without any WBCs. He has not had any fevers and says this feels similar to his prior stones, none of which have required intervention in the past. He is well appearing, nontoxic, with a benign abdomen and his pain is improving after IV ketorolac. What, if any, imaging would you pursue?

  • This patient can probably be evaluated either with point of care US or no imaging4 as the diagnosis of urolithiasis is likely and he is less likely to have a dangerous alternative diagnosis such as a vascular emergency, appendicitis or perforation.

A 35 yo male with no past medical history presents with acute onset left flank pain and nausea. He has hematuria but no WBCs on his UA. His exam is notable for LLQ abdominal tenderness. He feels better after IV analgesia. What, if any, imaging would you obtain for this patient?

  • Most experts recommend this patient be evaluated with a CT as the patient does not have a history of renal stones and his exam findings of abdominal tenderness raises concern for an alternative diagnosis that may require intervention4. Always at least consider CT imaging when making the diagnosis of a first-time renal stone.

A 45-year female with a history of renal stones presents with acute onset right flank pain, vomiting, and chills. Her vitals are HR: 110, BP: 110/70, RR: 22, O2 sat: 98% RA, T: 38C. Her hCG is negative. Her UA micro shows 50+ WBCs and 20-50 RBCs. What, if any, imaging would you obtain for this patient?

  • Given this patient’s presentation with a chief complaint of abrupt onset of flank pain, fever and a history of renal stones, a CT should be seriously considered to assess for an infected, obstructing stone. The patient has clear evidence of a UTI on her UA and if there is a urinary obstruction present with infection, this is a urologic emergency as she would likely need to undergo stenting or percutaneous nephrostomy to relieve the obstruction. Antibiotics should be started immediately as well. For patients who are septic from a urinary source, always consider abdominal imaging to assess for urinary obstruction or a stone as this can dramatically change management.

You have a 38 yo male patient with no past medical history who you just diagnosed with a 11 mm ureteropelvic junction ureteral stone on CT with moderate hydronephrosis. The patient has normal vital signs, no WBCs on their UA and feels better after IV analgesia. Their creatinine is normal and they are able to tolerate PO intake in the ED. How would you manage this patient? 

  • A urology consult (or at least a phone call to urology from the ED if working in the community) is beneficial in a case like this since a stone this large is very unlikely to pass spontaneously and will probably require an intervention. Depending on the clinical scenario, the patient may benefit from admission for intervention if they have significant comorbidities, any concerning vital signs or lab findings, poor pain control, or this is a repeat ED visit. Given this patient’s reassuring exam, labs and symptomatic improvement they may be a candidate for outpatient management. However, given the size and proximal location of their stone, they will require close urologic follow if they are discharged.

References: 

 

1) Augustin, K. (2022, July 1). CV-EMCRIT 327 - acute valve disasters part 2 - management of critical aortic stenosis. EMCrit Project. https://emcrit.org/emcrit/critical-aortic-stenosis/ 

2) Lei B, Harfouch N, Scheiner J, Demissie S, Hayim M. Can obstructive urolithiasis be safely excluded on contrast CT? A retrospective analysis of contrast-enhanced and noncontrast CT. Am J Emerg Med. 2021 Sep;47:70-73. doi: 10.1016/j.ajem.2021.03.059. Epub 2021 Mar 22. PMID: 33774453. 

3) Dym RJ, Duncan DR, Spektor M, Cohen HW, Scheinfeld MH. Renal stones on portal venous phase contrast-enhanced CT: does intravenous contrast interfere with detection? Abdom Imaging. 2014 Jun;39(3):526-32. doi: 10.1007/s00261-014-0082-4. PMID: 24504541; PMCID: PMC4295488. 

4) Moore CL, Carpenter CR, Heilbrun ME, et al. Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. J Am Coll Radiol. 2019;16(9 Pt A):1132-1143. doi:10.1016/j.jacr.2019.04.004 

5) Jendeberg J, Geijer H, Alshamari M, Cierzniak B, Lidén M. Size matters: The width and location of a ureteral stone accurately predict the chance of spontaneous passage. Eur Radiol. 2017;27(11):4775-4785. doi:10.1007/s00330-017-4852-6 

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