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Priapism is a semi-rare time sensitive emergent disease, and this article is a summary of guidelines for diagnosis and management.
Source
Diagnosis and Management of Priapism. JAMA vol. 330,6 (2023): 559-560. doi:10.1001/jama.2023.13377
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Pulling traction on a testicle with torsion is proposed by these authors to help relieve pressure, identify direction of torsion, and to make manual detorsion easier to perform. See figure below for technique.
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Diagnostic characteristics that help differentiate testicular torsion from other causes of acute scrotal pain include vomiting, age > 13, scrotal edema, and palpation of a hard testis. Use caution with normal ultrasound results in those with high pretest probability.
Source
Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience. Emerg Med J. 2022 Dec 16;emermed-2021-211946. doi: 10.1136/emermed-2021-211946. Online ahead of print.
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Fluoroquinolone-resistant (FQR) E. coli was present in 22.1% of UTI pathogens studied at 15 geographically diverse EDs. IDSA guidelines recommend changing empiric treatment if local resistance is >10% and adding a dose of parenteral antibiotic, such as ceftriaxone, prior to discharge home.
Source
High prevalence of fluoroquinolone-resistant UTI among US emergency department patients diagnosed with urinary tract infection, 2018-2020. Acad Emerg Med. 2022 Sep;29(9):1096-1105. doi: 10.1111/acem.14545. Epub 2022 Aug 5.
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Antibiotics have a good and bad side for women with uncomplicated cystitis. Use of trimethoprim-sulfamethoxazole (TMP-SMX) and other antibiotics, when compared to nitrofurantoin, had higher risk of adverse events.
Source
Association of Adverse Events With Antibiotic Treatment for Urinary Tract Infection. Clin Infect Dis. 2022 Apr 28;74(8):1408-1418. doi: 10.1093/cid/ciab637.
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Children <24 months may still have a UTI even with as few as 3 WBCs/hpf on urine microscopy if the urine is very dilute. Small leukocyte esterase on urinalysis was a powerful positive discriminator at all urine concentrations.
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Contrast-enhanced CT has a very high negative predictive value (100%) for obstructive urolithiasis and appears to accurately and safely exclude obstructing ureteral calculi for patients with acute flank pain. In addition, IV contrast improves the diagnostic yield for other acute abdominopelvic pathology and perhaps should be the test of choice for patients presenting with acute flank pain.
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Consider the erector spinae plane block to reduce NSAID and opioid use in patients with renal colic.
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Appropriate diagnosis of urinary tract infection (UTI) in children is important, as missed UTI can lead to renal scarring and other complications while over-diagnosis promotes antibiotic resistance.
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For acute pain from renal colic in the ED, a dose of ketoroloc as low as 10mg IV was as effective as a 30mg dose.
