Testicular torsion and urological emergencies

• A urological emergency is one in which minutes to hours decide whether an organ, or the patient's life, is lost. The ones that matter most are testicular torsion, Fournier gangrene, acute (ischemic) priapism, paraphimosis, acute urinary retention, and an obstructed infected kidney stone. ^[2]
• Testicular torsion is the big one to never miss. It is a true vascular emergency: the testis is viable with surgery within about four to six hours of pain, and almost unsalvageable after a day.^[1]
• A man with an erection lasting more than four hours is an emergency. Acute ischemic priapism is a compartment syndrome of the penis.^[3]
• Fournier gangrene looks like cellulitis and kills like sepsis. Necrotizing fasciitis of the perineum; surgical debridement plus broad-spectrum intravenous antibiotics, never antibiotics alone.^[2]
• No voiding plus a swollen painful bladder is acute urinary retention. Catheterise first, diagnose second.^[2]
• Fever with a stone and a blocked kidney is obstructive pyelonephritis. It does not settle with antibiotics alone; the kidney must be drained urgently.^[5]
• "Acute scrotum" and these other emergencies share presentations; the skill is to separate the surgical emergency from its mimics and act on the one that cannot wait.

By the end of this page you should be able to:

1. Recognise testicular torsion clinically, state the time window for testicular salvage, and describe the surgical management.
2. Distinguish epididymitis and orchitis from torsion, and choose empirical antibiotic therapy by likely organism.
3. Recognise Fournier gangrene and state the emergency management.
4. Classify priapism, recognise acute ischemic priapism, and outline stepwise treatment.
5. Diagnose and reduce paraphimosis, and know when a dorsal slit is needed.
6. Manage acute urinary retention by catheterisation, cause and follow-up.
7. Recognise an obstructed infected stone and state the urgent drainage plan.
8. Know the common pitfalls that turn these emergencies into disasters.

A urological emergency is any condition of the urinary tract or male genitalia in which delay causes loss of organ function, sepsis, or death. The list is short but the cost of missing one is high, so the practical skill is pattern recognition plus a reflex for action.

Seven emergencies are covered here. They are grouped under one page because they share a way of working: suspect the worst, resuscitate, control the source, and never let imaging delay a needed operation.

• Testicular torsion and the acute scrotum.
• Epididymitis and orchitis, the common mimics.
• Fournier gangrene, necrotizing fasciitis of the perineum.
• Priapism, prolonged erection.
• Paraphimosis, a trapped foreskin.
• Acute urinary retention.
• Obstructed infected stone (obstructive pyelonephritis / pyonephrosis).

Testicular torsion is rotation of the testis and spermatic cord on its axis, twisting the testicular artery and producing ischemia. Three forms matter clinically: intravaginal torsion (the common adolescent form, usually with a "bell-clapper" deformity), extravaginal torsion (neonates, outside the tunica vaginalis), and torsion of the appendix testis (a vestigial remnant, benign and self-limiting).^[1]

Epididymitis is inflammation of the epididymis; orchitis is inflammation of the testis itself. When both coexist it is epididymo-orchitis. They are usually infectious: sexually transmitted organisms in younger sexually active men, and enteric Gram-negative organisms in older men or after instrumentation.^[4]

Fournier gangrene is necrotizing fasciitis of the perineum and genitalia, a polymicrobial (mixed aerobic and anaerobic) infection of fascia and subcutaneous tissue that spreads along fascial planes.^[2]

Priapism is a persistent erection lasting beyond sexual stimulation (conventionally beyond four hours). It is classified into three types: ischemic (low-flow, trapped deoxygenated blood), non-ischemic (high-flow, usually after trauma, uncontrolled arterial inflow), and stuttering (recurrent brief episodes). Only ischemic priapism is a true emergency.^[3]

Paraphimosis is the foreskin retracted behind the glans and unable to be reduced, constricting venous and lymphatic return. It is the urological equivalent of a tourniquet on the penis.^[2]

Acute urinary retention (AUR) is the sudden inability to void, usually painful, with a palpable bladder. It is the commonest urological emergency.^[2]

Obstructed infected stone occurs when a ureteric or pelvic stone blocks urine flow and the kidney becomes infected (obstructive pyelonephritis, pyonephrosis). It is a surgical emergency because it progresses to sepsis.^[5]

• Testicular torsion occurs most often in the neonatal period and around puberty; torsion of the appendix testis occurs across a wider age range. Bilateral perinatal torsion occurs in 11 to 21 percent of perinatal cases.^[1]
• Acute scrotal pain in children is far more likely to be torsion (of the cord or appendix) than epididymitis, whereas men over 25 are more likely to have epididymitis.^[1]
• Epididymitis in children has a predicted incidence of roughly 1.2 per 1000 children per year, and prepubertal boys with acute epididymitis have an underlying urogenital anomaly in about 29.1 percent.^[1]
• Fournier gangrene has a prevalence of about 1.6 cases per 100000 men per year; it is less common in women (about 23 percent of patients in one series), usually in adults 50 and older. Diabetes, obesity, immunosuppression, malignancy, alcohol, smoking, and renal failure are all risk factors.^[2]
• Priapism is uncommon. All forms are time-dependent, which is why every prolonged erection is treated as an emergency until proven otherwise.^[3]
• AUR affects men far more than women (about 13 times more often). Roughly 10 percent of men aged 70 to 79 and 30 percent aged 80 to 89 will have at least one episode.^[2]
• Stone disease carries an about 11 percent lifetime risk of nephrolithiasis, so the obstructed infected stone is a common emergency everywhere.^[2]

Testicular torsion is usually spontaneous. The bell-clapper deformity (incomplete fixation of the testis within the tunica vaginalis) is present on both sides in most cases, which is why the contralateral testis is always fixed at surgery. Undescended testes can torsion, trauma can precipitate it, and neonatal (extravaginal) torsion is a distinct group.^[1]

Epididymitis is usually infectious. Sexually transmitted organisms (Chlamydia trachomatis, less often Neisseria gonorrhoeae) dominate in sexually active men under about 35 years; enteric organisms such as Escherichia coli dominate in older men, in men who practice insertive anal intercourse, and after prostate biopsy or instrumentation. Non-infectious causes include post-vasectomy congestion, drugs, and autoimmune disease.^[4]

Fournier gangrene starts with a mucosal breach (urethral, anorectal, or cutaneous). Sources include a urinary tract infection, a perianal abscess, recent genital or perineal surgery, trauma, or even a trivial skin lesion. The infection is synergistic: mixed facultative and anaerobic organisms including E. coli, Klebsiella, enterococci, Bacteroides, Fusobacterium, Clostridium, and occasionally fungi.^[2]

Priapism is caused by impaired venous outflow (ischemic), uncontrolled arterial inflow (non-ischemic, often post-traumatic fistula), or sickle cell disease and haematological disorders. Drugs, intracavernosal vasoactive injections, and spinal pathology are other triggers.^[3]

Paraphimosis is almost always iatrogenic or after poor hygiene: the foreskin is retracted and not returned to its covering position after cleaning, voiding, catheterisation, cystoscopy, or penile examination. Phimosis and abnormal skin (inflammation, decreased elasticity) predispose.^[2]

AUR results from obstruction plus failure of compensation: bladder outflow obstruction (most often benign prostatic hyperplasia in older men), urethral stricture, prostate or bladder cancer, clots, stones, phimosis or paraphimosis, constipation, drugs (anticholinergics, sympathomimetics, opioids, anaesthesia), and neurogenic bladder. In men with BPH, severity of symptoms, large prostate volume, low flow rate, and a PSA above 2.5 are risk factors.^[2]

Obstructed infected stone occurs when a calculus (ureteric or pelvic) obstructs flow and bacteria proliferate upstream. Any urinary obstruction plus infection can produce it.^[5]

Torsion. The spermatic cord twists and the testicular artery (and venous drainage) is compressed. Ischemia begins within minutes; the risk of necrosis rises steeply with time and with the degree of twist (greater than 360 degrees is worse). Reperfusion after detorsion generates oxygen free radicals, which can injure the testis even after rescue, and contralateral testicular function can be affected.

Epididymitis and orchitis. Infection ascends from the urethra and bladder, or spreads by blood. The epididymis swells, becomes tender, and inflammation may extend into the testis. The end artery supply of the testis means that severe epididymitis can compromise testicular perfusion, and abscess or necrosis can follow.

Fournier gangrene. Mixed bacteria (aerobes plus anaerobes) produce toxins and cause thrombosis of small vessels, producing skin necrosis and rapid spread along fascial planes. The systemic inflammatory response drives sepsis and multi-organ failure; the skin may look unimpressive early on.

Priapism (ischemic). The corpora cavernosa become a closed compartment with no venous outflow. Hypoxia, hypercapnia and acidosis develop, smooth muscle dies, and fibrosis replaces erectile tissue if drainage is not restored within about four hours.

Paraphimosis. The trapped foreskin acts as a tourniquet: venous and lymphatic congestion produce oedema, which tightens the band, and if it persists arterial inflow falls and the glans becomes ischemic.

AUR. The bladder cannot empty. Pressure rises, the detrusor fatigues, and with ongoing obstruction the patient develops overflow, hydroureter, hydronephrosis and eventually renal injury. Decompression is therefore required before the cause is fully worked out.

Obstructed infected stone. Obstruction raises intrapelvic pressure, impairs renal perfusion, and lets bacteria multiply in the stagnant urine. Unrelieved, this becomes urosepsis and septic shock.

Testicular torsion. Abrupt, severe unilateral scrotal pain, often with nausea or vomiting ("vagal" symptoms). Many present within 12 hours (69 percent, versus 31 percent for epididymitis); prepubertal boys often have atypical and delayed presentations.^[1] There may be a history of similar transient episodes (intermittent torsion) or minor trauma. Ask about undescended testis and previous episodes.

Epididymitis. Gradual onset over hours to days of unilateral scrotal pain and swelling, often with dysuria, urethral discharge, fever (11 to 19 percent), and frequency. Pain may be relieved by scrotal elevation (Prehn's sign), but this sign is unreliable and must not be relied on; the "blue dot" sign of a torsed appendix is seen in only 10 to 23 percent.^[1]

Appendix torsion. Sharp pain localised to the upper pole of the testis, often with the classic "blue dot" on the scrotal skin; usually in boys.

Fournier gangrene. Pain out of proportion in the perineum or genitals, often with swelling, redness, crepitus, fever, chills, nausea, vomiting, malaise, urinary retention, and a toxic appearance. It can follow a trivial skin lesion; there may be no obvious portal of entry.

Priapism. A persistent, often painful erection. The patient can rarely void; urinary retention may occur because the rigid penis prevents normal micturition.

Paraphimosis. Pain, swelling of the glans and foreskin, and a visible constricting band. The patient may be unable to void if the urethra is compressed. In patients unable to give a history, look for physical findings and ask whether they are circumcised.

AUR. Sudden lower abdominal pain, an inability to void, lower abdominal or suprapubic distension, urgency, and overflow dribbling. The bladder is palpable and dull to percussion. Chronic retention, by contrast, may be painless.

Obstructed infected stone. Renal colic plus fever, rigors, dysuria, and costovertebral tenderness; some patients present early with subtle symptoms only, and some are frankly septic with hypotension and tachycardia.^[5]

Testicular torsion. The testis is tender, high-riding and horizontal; the cremasteric reflex is absent (100 percent sensitivity, 66 percent specificity).^[1] The epididymis may be felt anteriorly. Elevation of the scrotum does not relieve pain. Remember that a normal urinalysis does not exclude torsion.

Epididymitis. A tender, swollen epididymis (often posterior/superior), epididymal induration, scrotal warmth and erythema, and, in epididymo-orchitis, testicular enlargement. The cremasteric reflex is preserved. Fever (11 to 19 percent) is more common than in torsion.^[1]

Fournier gangrene. Cellulitis of the perineum/scrotum with crepitus (gas in tissues), skin discoloration, bullae, necrosis, foul odour, tachycardia, hypotension, and pyrexia. The extent of disease is often greater than the skin suggests.

Priapism. A rigid, tender penis in ischemic priapism; corpora cavernosa are engorged while the glans and corpus spongiosum remain soft. Non-ischemic priapism is typically painless with partial tumescence after perineal trauma.

Paraphimosis. A swollen, dusky glans with a proximal constricting band of foreskin; distal oedema. A pink glans suggests reasonably good perfusion; a dark or black glans suggests ischemia or necrosis.

AUR. Suprapubic fullness and tenderness, a bladder palpable up to or above the umbilicus in massive retention, and dull percussion.

Obstructed infected stone. Costovertebral tenderness, flank pain, fever, signs of sepsis. The person may not look as sick early on; maintain a high index of suspicion.

The acute scrotum is the classic differential problem. The key is not to be clever but to exclude the one diagnosis that costs a testis or a life.

The diagnosis is clinical. History and examination come first; imaging never delays surgery. Colour Doppler ultrasound is a useful adjunct: sensitivity 63.6 to 100 percent and specificity 97 to 100 percent, positive predictive value 100 percent and negative predictive value 97.5 percent, but it is operator-dependent and can mislead in early, partial or intermittent torsion (24 percent of torsed testes show normal or increased flow). Comparison with the contralateral side is mandatory. A twisted cord ("whirlpool sign") on high-resolution ultrasound is highly specific.^[1]

Urinalysis is part of the work-up, but a normal result does not exclude epididymitis and an abnormal one does not exclude torsion. In infants, 40 percent of testes may have no flow even when normal, so clinical suspicion drives management in neonates.

NAATs for C. trachomatis and N. gonorrhoeae on first-void urine; urine bacterial culture for older men. Point-of-care tests (urethral Gram stain, leukocyte esterase, microscopy of spun urine) document inflammation. Ultrasound may be needed to exclude torsion or abscess. Blood tests only if the person is systemically unwell.

Clinical diagnosis. Imaging (plain film, ultrasound, or CT) may show subcutaneous gas but must not delay debridement. Labs (full blood count, renal function, glucose, lactate, coagulation) assess severity and comorbidity. Blood and wound cultures, taken before antibiotics if possible.

Corporal blood gas is the key test: ischemic blood is hypoxic, hypercarbic and acidotic; non-ischemic blood is bright red and oxygenated. Penile duplex Doppler ultrasound helps when the distinction is unclear. Tests for cause (sickle cell screen, full blood count, drug history) are done in parallel with treatment.

Clinical diagnosis. Look for an external constricting material (hair tourniquet, ring) that can mimic it.

Clinical diagnosis with a palpable bladder. Bladder scan (post-void residual) helps; a PVR above about 200 mL is abnormal and above 400 mL usually indicates retention. (Normal bladder capacity is about 500 mL.) Chemistries, full blood count, urinalysis and culture; renal ultrasound if the residual exceeds 1500 mL, renal function is abnormal, or there is azotemia. CT if another pathology is suspected. Imaging must not delay catheterisation in obvious cases. ^[2]

Non-contrast CT (stone protocol) is the study of choice to confirm stone, level of obstruction, and size. Ultrasound can show hydronephrosis and is first-line in pregnancy. Ultrasound may miss small ureteric stones, so CT follows when the diagnosis is unclear or the patient is very unwell. Blood and urine cultures before antibiotics where possible.

TWIST score (Testicular Workup for Ischemia and Suspected Torsion) is a clinical risk score for acute scrotum in boys: testicular swelling, hard testis, absent cremasteric reflex, nausea or vomiting, and high-riding testis. It stratifies risk and can streamline care, but it does not prove or exclude torsion and should not be used alone. In settings with limited testing, lowering the threshold for intervention is prudent.^[1]

Salvage windows (testicular torsion). Early surgical intervention (mean torsion time under 13 hours) preserves fertility and avoids testicular loss in many; semen analysis may be normal in only 5 to 50 percent in long-term follow-up. Subfertility occurs in 36 to 39 percent after torsion. Urgent exploration is mandatory for all torsions within 24 hours; beyond 24 hours, semielective exploration. Severe atrophy can occur with as little as four hours of torsion if the twist exceeds 360 degrees; incomplete torsion (180 to 360 degrees) up to 12 hours may leave no atrophy; torsion greater than 360 degrees beyond 24 hours leaves an absent or severely atrophied testis.^[1]

Corporal blood gas (priapism). Ischemic priapism: pO2 low, pCO2 high, pH acidic. Non-ischemic: well oxygenated.

Fournier Severity Index exists in the surgical literature but is not needed for first-line action: recognise, debride, resuscitate.

Principle: it is a surgical emergency; do not wait for a scan if the diagnosis is likely. Notify a senior urologist, keep the patient nil by mouth, give analgesia, and do not delay surgery for imaging when suspicion is high. At the bedside, manual detorsion can be attempted while awaiting theatre: rotate outward (lateral) first, using the "opening the book" manoeuvre (counter-clockwise on the right, clockwise on the left); success is immediate pain relief and normal findings. It is an adjunct, not a substitute, for surgery, and it is contraindicated if symptoms have lasted more than 6 hours. Residual torsion at exploration occurs in 17 of 53 patients, even in 11 who had reported pain relief after manual detorsion, so surgical exploration is always required.^[1]

At surgery: scrotal exploration, delivery of the testis, opening of the tunica vaginalis, manual detorsion, wrapping in warm moist gauze, and inspection for "pinking up". Contralateral orchiopexy is performed in the same sitting, because the bell-clapper deformity is assumed bilateral. If the testis is viable, orchiopexy is done (anchoring tunica albuginea to parietal tunica vaginalis and dartos). If it is clearly non-viable, orchiectomy. The tunica may be incised to prevent compartment syndrome. Recurrence after orchiopexy is rare (4.5 percent) and may present years later. Follow-up addresses fertility and hormonal function; up to half of patients may develop testicular atrophy despite timely surgery, so counsel accordingly. ^[1]

Rule out torsion first. Empirical therapy by likely organism (CDC, 2021 STI guidelines):

• Likely chlamydia or gonorrhoea (sexually active men): ceftriaxone 500 mg IM single dose plus doxycycline 100 mg orally twice daily for 10 days.^[4]
• Insertive anal intercourse (chlamydia, gonorrhoea or enteric organisms): ceftriaxone 500 mg IM single dose plus levofloxacin 500 mg orally once daily for 10 days.^[4]
• Enteric organisms only (older men, post-instrumentation): levofloxacin 500 mg orally once daily for 10 days (monotherapy if gonorrhoea excluded).^[4]

Dosing: persons weighing 150 kg or more receive 1 g ceftriaxone. Add bed rest, scrotal elevation, and NSAIDs. Treat sex partners for gonorrhoea/chlamydia; advise abstinence until treated. Test for HIV and syphilis. Reassess if there is no improvement within 3 days. In children (EAU), epididymitis is often self-limiting and antibiotics are indicated only if infection is proven. Mumps orchitis is viral: no antibiotics; supportive care; possible fertility impact. ^[4]

Treat as necrotizing fasciitis until proven otherwise. Resuscitate (fluids, oxygen, analgesia), start broad-spectrum intravenous antibiotics immediately, and take the patient to theatre for aggressive debridement without waiting. Common antimicrobial choices cover Gram-positives, Gram-negatives and anaerobes (for example piperacillin-tazobactam or a carbapenem plus clindamycin, with MRSA cover where indicated; local guidelines govern). Because tissue involvement is often greater than first appears, plan "second-look" debridement within 24 hours. Excision of affected tissue is mandatory; antibiotics alone carry roughly 100 percent mortality. Coordinate with general and plastic surgery, urology and critical care. Colostomy may be needed for perianal involvement; urinary drainage by catheter or cystostomy if there is urethral swelling. Hyperbaric oxygen may reduce debridement but is adjunctive. Hospitalise anyone with severe pain, fever, diabetes or high CRP.

Acute ischemic priapism (emergency).

1. Take a history and examine; obtain a corporal blood gas.
2. Conservative measures (exercise, ice, ejaculation) are unlikely to work and must not delay definitive treatment. ^[3]
3. First-line: intracavernosal phenylephrine with corporal aspiration, with or without irrigation, before any operative intervention; monitor blood pressure and heart rate during injections.
4. If phenylephrine and aspiration fail, perform a distal corporoglanular shunt (with or without tunnelling); consider corporal tunnelling thereafter. There is inadequate evidence to support routine proximal shunting after distal shunting.
5. If erection persists after shunting, obtain a corporal blood gas or colour duplex Doppler before repeat surgery to assess cavernous oxygenation and arterial inflow.
6. Penile prosthesis may be considered for acute ischemic priapism untreated beyond 36 hours or refractory to shunting.
7. Counsel all patients that erectile dysfunction is likely after prolonged events; recovery of function is unlikely after more than 36 hours. ^[3]
8. In sickle cell and other haematological disorders: do not delay standard urological management; exchange transfusion is not the primary treatment. Intracavernosal phenylephrine and aspiration remain first-line.
9. Prolonged erection of 4 hours or less after intracavernosal vasoactive injection is treated with intracavernosal phenylephrine; instruct patients to return for any erection over 4 hours.
10. In stuttering priapism (recurrent ischemic episodes), hormonal regulators may impair fertility and function; optimal prevention is unknown.

Non-ischemic priapism. Not an emergency. Observe initially (some resolve). If persistent and the patient wishes treatment, penile duplex ultrasound localises the fistula and embolisation is first-line, with repeat embolisation preferred over surgical ligation if needed. Counsel about risks of erectile dysfunction, recurrence, and failure.

Reduce promptly. After a penile block, decompress the oedema with firm gentle compression using gauze for several minutes, apply water-based lubricant, then pull (not push) the foreskin over the glans. If reduction fails, perform an emergency dorsal slit (incision of the dorsal foreskin) and then reduce. Counsel patients with prior episodes about circumcision or formal dorsal slit to prevent recurrence. Topical steroids help when phimosis precipitated the event. Rule out a hair tourniquet or other external constrictor.

Decompress first. Insert a urethral catheter (16 Fr, 5 to 10 mL balloon) immediately; use a suprapubic tube if the urethra is impassable or transurethral catheterisation is contraindicated (recent radical prostatectomy, urethral reconstruction). Record the volume drained; a volume above 400 mL supports retention and the catheter should stay in place; 200 to 400 mL depends on the clinical picture; under 200 mL argues against AUR. Clamping the catheter and partial drainage do not prevent complications and cause discomfort and infection risk. For residuals under 1000 mL, clean intermittent self-catheterisation is an alternative. ^[2]

Then diagnose and treat the cause. Start or increase alpha-blocker therapy for BPH; allow time for the drug to take effect before a voiding trial. Obtain urine for analysis and culture, chemistries, full blood count; CT or bladder scan as indicated. Perform a renal ultrasound for large residuals (over 1500 mL), new renal failure, or azotemia. For refractory BPH, surgery. Post-anesthetic or drug-induced retention may resolve once the trigger is removed. ^[2]

This is a urological emergency. Confirm the obstruction on imaging (non-contrast CT or ultrasound), but resuscitate and drain without waiting for a full work-up in the septic patient. Urgently decompress the obstructed collecting system by ureteral stenting or percutaneous nephrostomy: the two are equally effective in terms of success, complications, and time to defervescence. Start antibiotics immediately, send blood and urine (and repeat urine after decompression) for culture and sensitivity, and re-evaluate the regimen once results return. Definitive stone treatment waits until the infection has cleared. Intensive care may be needed. Acute pyelonephritis that does not respond to antibiotics, and all septic patients with pyelonephritis, require imaging to exclude obstruction. ^[5]

• Testicular torsion: testicular necrosis and loss, atrophy even after rescue (up to half), subfertility (36 to 39 percent), impaired semen quality (normal in only 5 to 50 percent long term), contralateral effects, recurrent torsion (4.5 percent after orchiopexy), metachronous contralateral torsion in neonates.
• Epididymitis: abscess, necrotic testis, sepsis, chronic pain, infertility, recurrence.
• Fournier gangrene: sepsis, multi-organ failure, death (high mortality despite treatment), anal sphincter involvement with incontinence and colostomy, urethral swelling needing urinary diversion, need for repeated reconstruction.
• Priapism: permanent erectile dysfunction, cavernosal fibrosis, penile curvature, urethral injury from instrumentation.
• Paraphimosis: glans ischemia, necrosis, urethral compression with urinary retention.
• AUR: renal injury, hydroureter, hydronephrosis, overflow incontinence, post-obstructive diuresis, delirium in older adults.
• Obstructed infected stone: urosepsis, septic shock, acute kidney injury, renal abscess, need for nephrectomy in extreme cases.

• Torsion: excellent if operated within the window; salvage falls sharply after 12 hours and beyond 24 hours the testis is usually lost.^[1]
• Epididymitis: most resolve; complete resolution may take weeks.^[4]
• Fournier: mortality remains high even with optimal care; early debridement is the main modifiable factor.
• Priapism: function preserved if treated within about 4 hours; poor after 36 hours.
• Paraphimosis: excellent if reduced before ischemia.
• AUR: usually reversible once decompressed.
• Obstructed infected stone: good with prompt drainage; poor if drainage is delayed.

Little is acutely preventable, but clinicians can:

• counsel boys and parents about sudden scrotal pain and the need for rapid assessment;
• replace the foreskin after every retraction (the single most effective prevention of paraphimosis);
• manage BPH and review anticholinergic/alpha-agonist drugs in older men;
• ensure patients with intracavernosal injection therapy know the 4-hour rule;
• manage stone disease and urinary infections early.

Children. Testicular torsion and appendix torsion dominate acute scrotal pain; epididymitis is less common and may signal an underlying urogenital anomaly (about 29.1 percent). Manage neonatal (extravaginal) torsion with early bilateral exploration and fixation. In children, antibiotics for epididymitis only if infection is proven (EAU).

Older adults. AUR and BPH dominate; post-operative retention is common. Polypharmacy (anticholinergics, narcotics, decongestants) and constipation are frequent, reversible contributors.

Sickle cell disease. Priapism is common; standard urological management should not be delayed for exchange transfusion.

Pregnancy. Stone disease and urinary infection are common; hydronephrosis of pregnancy complicates diagnosis. Ultrasound is first-line imaging; low-dose CT is a last resort. AUR is rare but can occur with a gravid uterus.

Immunocompromised patients. Fournier gangrene and atypical infections (CMV, fungal, mycobacterial epididymitis) occur; these patients need specialist input.

• Recognise torsion clinically; do not wait for Doppler if a scanner is unavailable or would delay surgery. A mobile surgeon who can explore is worth more than an ultrasound.
• Bedside manual detorsion is free and can save a testis while arranging transfer.
• Fournier debridement with basic instruments and broad-spectrum antibiotics (where available) is life-saving; transfer early to a centre with surgical capability.
• A urethral catheter is the treatment for AUR in any setting; if none is available, suprapubic drainage with a large needle or improvised set is better than waiting.
• For the obstructed infected stone, a percutaneous nephrostomy can be placed under ultrasound; transfer for definitive care.
• Counselling about the 4-hour erection rule and foreskin replacement costs nothing.

• A normal urinalysis does not exclude testicular torsion; an abnormal one does not exclude it either.
• Prehn's sign is unreliable; do not reassure yourself with it.
• Doppler ultrasound can show normal or increased flow in up to 24 percent of torsed testes early on; persistent arterial flow does not exclude torsion.
• A boy with fever and scrotal pain is more likely to have epididymitis, but torsion still must be excluded first.
• Non-ischemic (high-flow) priapism is usually painless and is not an emergency; do not subject it to ischemic protocols.
• All septic patients with pyelonephritis need imaging: acute (uncomplicated) pyelonephritis is medical, but obstructive pyelonephritis needs drainage.
• AUR is not "just" prostate trouble: stones, strictures, drugs, clots and neurogenic causes all count.

• Urological emergencies are time-critical; the default is to suspect the worst and act.
• Testicular torsion: suspect in sudden severe scrotal pain, with or without a "vagal" episode; salvage is best within about four to six hours and surgery is mandatory.
• Epididymitis/orchitis: mimic; select antibiotics by age and risk (STI versus enteric organism), always exclude torsion first.
• Fournier gangrene: necrotizing fasciitis of the perineum; debride plus IV antibiotics; antibiotics alone carry ~100 percent mortality. ^[2]
• Priapism: an erection over four hours is ischemic (low-flow) until proven otherwise; phenylephrine plus aspiration first-line; shunt if it fails; poor recovery after 36 hours. ^[3]
• Paraphimosis: a tourniquet on the glans; reduce early, dorsal slit if needed; always replace the foreskin.
• AUR: catheterise first, investigate after; 13 times more common in men. ^[2]
• Obstructed infected stone: renal colic plus fever; equal success with stent or nephrostomy, plus antibiotics, then delayed stone treatment.

• Urological infection and sexually transmitted infection management
• Male reproductive system examination
• Prostatic disease and benign prostatic hyperplasia
• Renal and ureteric stone disease
• Scrotal and testicular masses
• Sepsis recognition and resuscitation