Pediatric Urology Emergencies

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Pediatric Urology Emergencies

• Ahmed Al-Sayyad MD,FRCSC
• Assistant Professor-King Abdulaziz University

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Pediatric Urology Emergencies

• Acute scrotum
• GU Trauma
• Priapism
• Paraphimosis
• PUV
• Urosepsis in association of obstruction
• Urolithiasis

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Acute scrotum

• Torsion of the spermatic cordTorsion of the
  appendix testisTorsion of the appendix
  epididymisEpididymitisEpididymo-orchitisInguina
  l herniaCommunicating hydroceleHydroceleHydroce
  le of the cordTrauma/insect biteDermatologic
  lesionsInflammatory vasculitis (Henoch-Schönlein
  purpura)Idiopathic scrotal edemaTumorSpermatoce
  leVaricoceleNonurogenital pathology (e.g.,
  adductor tendinitis)

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Torsion of the Spermatic Cord (Intravaginal)

• Torsion of the spermatic cord is a true surgical
  emergency of the highest order
• Irreversible ischemic injury to the testicular
  parenchyma may begin as soon as 4 hours after
  occlusion of the cord
• Intravaginal torsion happens within the space of
  the tunica vaginalis this results from lack of
  normal fixation of the testis and epididymis to
  the fascial and muscular coverings that surround
  the cord within the scrotum

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Torsion of the Spermatic Cord (Intravaginal)

• Usually there is an acute onset of scrotal pain,
  but in some instances the onset appears to be
  more gradual
• A large number of boys give a history of
  previous episodes of severe, self-limited scrotal
  pain and swelling
• Nausea and vomiting may accompany acute torsion,
  and some boys have pain referred to the
  ipsilateral lower quadrant of the abdomen
• Dysuria and other bladder symptoms are usually
  absent

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Torsion of the Spermatic Cord (Intravaginal)

• Testis can be riding high in the scrotum or with
  transverse orientation
• The absence of a cremasteric reflex is a good
  indicator of torsion of the cord
• After several hours an acute hydrocele or
  massive scrotal edema obliterates all landmarks
• Color Doppler examination had a diagnostic
  sensitivity of 88.9 and a specificity of 98.8,
  with a 1 rate of false-positive results
• When the diagnosis of torsion of the cord is
  suspected, prompt surgical exploration is
  warranted
• When torsion of the spermatic cord is found,
  exploration of the contralateral hemiscrotum must
  be carried out

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Torsion of the Testicular and Epididymal
Appendages

• The appendix testis, a müllerian duct remnant,
  and the appendix epididymis, a wolffian remnant,
  are prone to torsion
• The symptoms associated with torsion of an
  appendage are extremely variable, from an
  insidious onset of scrotal discomfort to an acute
  condition identical to that seen with torsion of
  the cord

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Torsion of the Testicular and Epididymal
Appendages

• localized tenderness of the upper pole of the
  testis or epididymis
• Tender nodule may be palpated. In some
  instances, the infarcted appendage is visible
  through the skin as a blue dot sign
• The cremasteric reflex is usually present
• In cases in which the inflammatory changes are
  more significant, scrotal wall edema and erythema
  may be severe
• Color Doppler examination may show hyperemia at
  the upper pole of the testis or epididymis
• When the diagnosis of torsion of an appendage is
  confirmed clinically or by imaging, nonoperative
  management allows most cases to resolve
  spontaneously
• Limitation of activity and administration of
  nonsteroidal anti-inflammatory agents are only
  needed

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Perinatal Torsion of the Spermatic Cord

• Prenatal (in utero) torsion is typified by the
  finding at delivery of a hard, nontender testis
  fixed to the overlying scrotal skin
• The skin is commonly discolored by the underlying
  hemorrhagic necrosis
• Classic teaching has held that testes found to be
  hard, nontender, and fixed to the skin at birth
  do not merit surgical exploration
• However, controversy has arisen regarding the
  need for prompt exploration of the contralateral
  testis

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Perinatal Torsion of the Spermatic Cord

• Contralateral scrotal exploration traditionally
  has not been recommended in cases of prenatal
  torsion because extravaginal torsion is not
  associated with the testicular fixation defect
  (bell-clapper deformity) that is recognized as
  the cause of intravaginal torsion
• However, reports of asynchronous perinatal
  torsion have made the practice of avoiding prompt
  surgical exploration of the contralateral testis
  controversial

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Perinatal Torsion of the Spermatic Cord

• Prompt exploration of suspected postnatal torsion
  of the spermatic cord is indicated (in
  conjunction with exploration of the contralateral
  testis) when the patient's general condition and
  anesthetic considerations allow for a safe
  procedure
• Exploration, when elected, should be carried out
  through an inguinal incision to allow for the
  most efficacious treatment of other potential or
  unexpected causes of scrotal swelling
• If torsion is confirmed, contralateral scrotal
  exploration with testicular fixation should be
  carried out
• The most effective and safest form of testicular
  fixation involves dartos pouch placement

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Priapism

• Priapism is a persistent penile erection of at
  least 4 hours in duration that continues beyond
  and is unrelated to sexual stimulation .There are
  three subtypes  
• Ischemic (veno-occlusive, low-flow) priapism is
  characterized by little or no cavernous blood
  flow, and cavernous blood gases are hypoxic,
  hypercapnic, and acidotic. The corpora are rigid
  and tender to palpation   
• Nonischemic (arterial, high-flow) priapism is
  caused by unregulated cavernous arterial inflow.
  Typically, the penis is neither fully rigid nor
  painful. There is often a history of antecedent
  trauma resulting in a cavernous arterycorpora
  cavernosa fistula   
• Stuttering (intermittent) priapism is a recurrent
  form of ischemic priapism with painful erections
  with intervening periods of detumescence

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Priapism

• The most common cause of priapism in children is
  sickle cell disease
• Priapism typically occurs during sleep, when mild
  hypoventilatory acidosis depresses oxygen tension
  and pH in the corpora. The pain experienced is a
  sign of ischemia
• On examination, there is typically significant
  corporal engorgement with sparing of the glans
  penis
• Medical therapy, including exchange transfusion,
  hydration, alkalinization, pain management with
  morphine, and oxygen should be started
• Intracavernous irrigation with a sympathomimetic
  agent, such as phenylephrine will be the next
  step. General anesthesia or intravenous sedation
  will be necessary.
• If irrigation and medical therapy are
  unsuccessful, a corporoglanular shunt should be
  considered

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Priapism

• For stuttering priapism, administration of an
  oral a-adrenergic agent (pseudoephedrine) once or
  twice daily is first-line therapy. If this
  treatment is unsuccessful, an oral ß agonist
  (terbutaline) is recommended a GnRH analog plus
  flutamide is recommended as third-line therapy
• Nonischemic (high-flow) priapism most commonly
  follows perineal trauma, such as a straddle
  injury, that results in laceration of the
  cavernous artery
• Spontaneous resolution may occur. If not,
  angiographic embolization is indicated

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Paraphimosis

• Paraphimosis develops when the tip of the
  foreskin retracts proximal to the coronal sulcus
  and becomes fixed in position
• Severe edema of the foreskin occurs within
  several hours, depending on the tightness of the
  tip of the foreskin
• In most cases, manual compression of the glans
  with placement of distal traction on the
  edematous foreskin allows reduction of the
  paraphimotic ring

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Renal Trauma

• The pediatric kidney is believed to be more
  susceptible to trauma because of a decrease in
  the physical renal protective mechanisms
• hematuria is very unreliable in determining who
  to screen for renal injuries
• Indeed, some studies have failed to find any
  evidence of either gross or microscopic hematuria
  in up to 70 of children sustaining grade 2 or
  higher renal injury

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Indications for Imaging

• A significant deceleration or high-velocity
  injury such as one sustained in a high-speed
  motor vehicle accident, a pedestrian/bicycle-motor
  vehicle accident, a fall from more than 15 feet,
  or a strike to the abdomen or flank with a
  foreign object (e.g., football helmet, baseball
  bat)
• Significant trauma that has resulted in fractures
  of thoracic rib cage, spine, pelvis, or femur, or
  bruising of the torso/perineum, or signs of
  peritonitis   
• Gross hematuria
• Microscopic hematuria (lt50 red blood cells per
  high-powered field) associated with shock
  (systolic blood pressure less than 90 mm Hg)
• penetrating injuries

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Imaging

• Single-Shot Intravenous Pyelography Is useful in
  the unstable patient requiring emergent
  laparotomy
• Once the patient is stabilized in the operating
  room, single-shot intravenous pyelography (IVP)
  (2 mL/kg intravenous bolus of contrast agent)
  with the radiograph taken 10 to 15 minutes after
  injection may be of benefit
• Use of Arteriography is useful in patients with
  persistent or delayed hemorrhage which usually
  arises from the development of arteriovenous
  fistulas or pseudoaneurysm
• Approximately 25 of patients with grade 3 to
  grade 4 renal trauma, managed in a nonoperative
  fashion, will develop persistent or secondary
  (delayed) hemorrhage
• RGP \- DJ indications after renal trauma (1) to
  rule out the presence of a partial/total ureteral
  disruption and (2) to aid in the management of a
  symptomatic urinoma

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Renal pedicle injury
Involving artery and vein
With hematoma
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Delayed imaging
Injury to collecting system with extravasation
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Delayed imaging
Renal pelvis injury with leak of urine
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Management

• Majority of renal injuries can be managed
  conservatively
• Bed rest till urine is clear
• Frequent vitals and Hb checking
• Urine racking
• Follow up imaging after discharge

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Absolute indications for exploration

• Persistent renal bleeding
• Pulsatile, expanding or uncontained hematoma
• Avulsion of the main renal artery or vein

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Relative indications for exploration

• Significant (25-50) non-viable tissue
• Urinary extravasation
• Arterial thrombosis
• Penetrating trauma

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Surgical approach

• The goals of operative therapy are hemorrhage
  control and renal tissue preservation
• Midline incision, look for other injuries,
  central control of vessels
• Renal exploration, débridement of nonviable
  tissue, hemostasis by individual suture ligation
  of bleeding vessels, watertight closure of the
  collecting system, and coverage or approximation
  of the parenchymal defect

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URETEROPELVIC JUNCTION DISRUPTION

• Disruption of the UPJ is most commonly caused by
  acceleration-deceleration injuries
• The majority of patients sustaining a UPJ
  disruption will present with vascular
  instability, requiring emergent laparotomy with
  the patient unable to undergo preoperative
  imaging
• Emergent exploratory laparotomy for coexisting
  intra-abdominal injury is usually necessary and
  exploration fails to reveal the presence of a
  retroperitoneal hematoma
• Because of the frequent association of this
  injury with life-threatening trauma the diagnosis
  of a UPJ disruption is delayed for more than 36
  hours in more than 50 of patients
• Patients will eventually come to attention due to
  CT abnormalities found during the workup of
  persistent postoperative fever, chronic flank
  pain, continued ileus, or sepsis

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URETEROPELVIC JUNCTION DISRUPTION

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• Three classic findings on triphasic CT are
  associated with UPJ disruption (1) good renal
  contrast agent excretion with medial
  extravasation of contrast agent in the perirenal
  and upper ureteral area (2) absence of
  parenchymal lacerations and (3) no visualization
  of the ipsilateral distal ureter
• In the clinically stable patient in whom the
  diagnosis is made within 5 days after the
  traumatic insult it is preferred to proceed to
  immediate surgical repair with débridement of any
  devitalized tissue, spatulation and reanastomosis
  of the ureter over a stent
• In patients with a delayed diagnosis of 6 or more
  days it is preferred to place a nephrostomy tube
  and allow the patient and injury to stabilize for
  12 weeks
• The combination of remaining renal function and
  the length of the surgical defect allow the
  surgeon to make the proper surgical planning

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URETERAL TRAUMA

• Ureteral perforation after ureteroscopy can
  almost invariably be managed with stenting
• If recognized at the time of surgery, ureteral
  contusions secondary to a high-velocity gunshot
  wound or inadvertent ligation of the ureter
  should be treated by removal of any offending
  clip or ligature and placement of a ureteral
  stent for 6 to 8 weeks
• if the diagnosis of a traumatic ureteral injury
  is made within the first 5 days after the insult,
  we prefer to proceed with immediate surgical
  repair

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URETERAL TRAUMA

• If the patient is hemodynamically unstable and
  unable to tolerate the additional operative time
  required for ureteral repair or if the ureteral
  injury is too extensive to allow for a direct
  anastomosis, tie off the damaged ureter, place a
  large clip at the proximal end and insert PCN
• The type of delayed ureteral repair to be used is
  based on the location and the extent of ureteral
  damage
• Options include ureteral anastomosis to the
  renal pelvis, primary ureteroureterostomy,
  transureteroureterostomy, ureteral reimplantation
  with or without a psoas hitch, ileal ureter,
  autotransplantation and nephrectomy

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BLADDER INJURIES

• The urinary bladder is well protected from
  external trauma by the bony confines of the
  pelvis
• The majority results from blunt trauma which
  include motor vehicle accidents,falls and
  assaults
• They are frequently associated with multiple
  organ trauma, with an average of three coexisting
  organ injuries and a mortality rate of 20
• Absolute indications for bladder imaging after
  blunt abdominal trauma are currently limited to
  two indications (1) the presence of gross
  hematuria coexisting with a pelvic fracture and
  (2) inability to void

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Classification

• Bladder contusion
• Extraperitoneal bladder rupture
• Intraperitoneal bladder rupture
• Combination of intraperitoneal and
  extraperitoneal ruptures

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BLADDER INJURIES

• Traumatic bladder lacerations in children are
  approximately two times more likely to extend
  through the bladder neck compared with adults
• The diagnosis of a traumatic bladder injury
  should be assessed by either standard or CT
  cystography
• The amount instilled within the bladder should,
  at a minimum, be equal to one half of the
  estimated bladder capacity for age
• All patients with traumatic bladder lacerations,
  either extraperitoneal or intraperitoneal, should
  initially be treated with intravenous antibiotics
  with oral antibiotic therapy continued for 48
  hours after removal of bladder catheters

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Intra and extra peritoneal bladder rupture
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BLADDER INJURIES

• In extraperitoneal bladder injury, consideration
  for open surgical intervention should be given if
  a bony spicule is found to protrude into the
  bladder on CT evaluation or if concern for a
  bladder neck laceration is present
• If these two complications are not present,
  management by an indwelling urethral catheter can
  be considered
• Urinary drainage via the bladder catheter is
  maintained for 7 to 10 days, and a cystogram
  should be obtained to verify healing of the
  injury before catheter removal
• In intraperitoneal bladder injuries, open
  surgical repair of the laceration is the
  recommended treatment modality

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URETHRAL INJURIES

• Classified into 2 broad categories based on the
  anatomical site of the trauma
• Mechanism of injury include blunt trauma such as
  MVA or falls, penetrating injuries, straddle
  injuries and Iatrogenic injury like traumatic
  catheter placement
• Posterior urethral injuries commonly associated
  with pelvic fractures
• Anterior urethral injuries come from blunt trauma
  to the perineum (straddle injuries)

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URETHRAL INJURIES

• children with a posterior urethral injury will
  differ from adults with this injury in four ways
• First, a pelvic fracture is more likely to be
  unstable and associated with a severely and
  permanently displaced prostatic urethra.
• Second, the severe displacement of the prostate
  off the pelvic floor makes a complete posterior
  urethral disruption more common in boys than men
• Third, in children, concurrent bladder and
  urethral injuries may occur in up to 20 of the
  patients
• Fourth, in prepubertal girls, pelvic fractures
  are four times more likely to be associated with
  a urethral injury than in adult women

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URETHRAL INJURIES

• Radiographic or cystoscopic evaluations to rule
  out this injury are mandatory in the following
  circumstances
• (1) when the patient presents with the classic
  triad of findings of a perineal/penile hematoma,
  blood at the meatus/vaginal introitus, and
  inability to void
• 2) when one or more pubic rami are fractured or
  symphyseal diastases are present
• (3) when radiographic findings suggest a bladder
  neck injury

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Diagnosis

• Symptoms include hematuria or inability to void
• Physical examination may reveal blood at the
  meatus or a high-riding prostate gland upon
  rectal examination. Extravasation of blood along
  the fascial planes of the perineum is another
  indication of injury to the urethra
• The diagnosis is made by performance of a
  retrograde urethrogram
• "Pie in the sky" findings revealed by cystogram
  usually indicate urethral disruption

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Management

• The traditional intervention for patients with
  posterior urethral injury secondary to pelvic
  fracture is placement of a suprapubic catheter
  for bladder drainage and subsequent delayed
  repair
• The suprapubic catheter can be safely placed
  either percutaneously or via an open approach
  with a small incision
• Ultimate repair can be performed 6-12 weeks after
  the event, after the pelvic hematoma has resolved
  and the patient's orthopedic injuries have
  stabilized

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Management

• An attempt at primary realignment of the
  distraction with a urethral catheter is
  reasonable in stable patients either acutely or
  within several days of injury (ie, 5-7 d post
  injury)
• When the urethral catheter is removed after 4 to
  6 weeks, it is imperative to retain a suprapubic
  catheter because most patients will, despite
  realignment, develop posterior urethral stenosis

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Management

• Placement of a catheter across a urethral
  disruption injury may rarely allow healing
  without stricture but in most patients, mild
  stenosis 1 to 2 cm in length develops
• Incomplete urethral tears are best treated by
  stenting with a urethral catheter
• There is no evidence that a gentle attempt to
  place a urethral catheter can convert an
  incomplete into a complete transection

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Management

• In cases of female urethral disruption related to
  pelvic fracture, most authorities suggest
  immediate primary repair, or at least urethral
  realignment over a catheter, to avoid subsequent
  urethrovaginal fistulas or urethral obliteration
• Concomitant vaginal lacerations must also be
  closed acutely to prevent vaginal stenosis.
  Delayed reconstruction is problematic because the
  female urethra is too short (about 4 cm) to be
  amenable to anastomotic repair when it becomes
  embedded in scar

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Management

• Penetrating anterior urethral injuries should be
  explored
• The area of injury should be examined, and
  devitalized tissue should be debrided carefully
  to minimize tissue loss
• Defects of up to 2 cm in the bulbar urethra and
  up to 1.5 cm in the penile urethra can be
  repaired primarily via a direct anastomosis over
  a catheter with fine absorbable suture.
• Longer defects should never be repaired
  emergently Urinary diversion with a suprapubic
  catheter is performed till time of delayed
  reconstruction

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Testicular Trauma

• Testicular injuries can be divided into 3 broad
  categories based on the mechanism of injury
• (1) blunt trauma
• (2) penetrating trauma
• (3) degloving trauma

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Testicular Trauma

• Testicular rupture or fractured testis refers to
  a rip or tear in the tunica albuginea resulting
  in extrusion of the testicular contents
• Blunt trauma accounts for approximately 85 of
  cases, and penetrating trauma accounts for 15
• As many as 80 of hematoceles (blood in the
  tunica vaginalis) are associated with testicular
  rupture

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Clinical diagnosis

• Patients typically present to ER with a
  straightforward history of injury
• Symptoms include extreme scrotal pain, frequently
  associated with nausea and vomiting
• Physical examination often reveals a swollen,
  severely tender testicle with a visible hematoma
• Scrotal or perineal ecchymosis may be present
• When evaluating a patient with a clinical
  history of only minor trauma, do not overlook the
  possibility of testicular torsion or epididymitis

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Clinical diagnosis

• For penetrating injuries, determine the entrance
  and exit sites of the wound.
• Screening urinalysis is important to rule out
  urinary tract infection or epididymo-orchitis
• Scrotal ultrasound imaging with Doppler studies
  is valuable for diagnosing and staging testicular
  injuries
• The presence of a disrupted tunica albuginea is
  pathognomonic for testicular rupture

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Management

• Institute conservative treatment for patients
  with minor trauma in which the testes are spared
  and the scrotum has not been violated
• The usual treatment consists of scrotal support,
  nonsteroidal anti-inflammatory medications, ice
  packs, and bed rest for 24-48 hours

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Indications for scrotal exploration

• Uncertainty in diagnosis after appropriate
  clinical and radiographic evaluations
• Disruption of the tunica albuginea
• Large hematocele
• Absence of blood flow on scrotal ultrasound
  images with Doppler studies

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scrotal exploration

• Clinical hematoceles that are expanding or of
  considerable size (eg, 5 cm or larger) should be
  explored
• Collections of smaller size are also often
  explored, because it has been shown that such
  practice allows for more optimal pain control and
  shorter hospital stays
• If the testis is fractured, testicular
  debridement and surgical closure of the tunica
  albuginea are necessary

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Thank You