CRACKCast E231 - Genitourinary System

Alright everybody, welcome to Yeah, to all start referring here, of course. I am Dylan Rompsy and one of the PG. And the RCPSC Emergency Message Program here at the University of Saskatchewan. And I'm Owen Shire. I'm one of the R5s here in Saskatoon.

And uh we've got a special guest with us today. So why don't you go ahead and introduce yourself, Gwyn? Yeah, thanks for having me today. I'm Quentin Patterson. I'm an emerge doc royal college trained from uh last June and just started practice these last few months and working in Saskatoon, Saskatchewan. Nice, thanks for joining us Q. We got an all star cast and we thought what better chapter to review than chapter forty genital system?

A chapter ripe with the opportunity for dad jokes. Then to bring one of our colleagues on who is also a new dad. So we'll be looking at him for that. Owen, you wanna hit us off with the first key concept? Alright, so microscopic or gross immateria is suggestive of genital urinary trauma. However

The degree of hematuria does not correlate well with the severity of injury. Key concept number two, the kidney is the most frequently injured genital urinary organ, and imaging should be considered in patients with gross hematuria or microscopic hematuria with hemodynamic instability. Key concept number three Delayed CT images after IV contrast should be obtained in patients with mechanism or findings suggested of ureteral trauma. Blunt ureteral trauma is rare.

Next up, CT scan with IV contrast is not sensitive for diagnosing bladder injury. And retrograde cystography should be obtained if there's any concerns uh to allow for proper distention of the bladder, to allow for urinary uh extravization. Key cause number five, pelvic fractures associated with hematuria strongly suggest urethral injury. Key concept number six Retrograde urethography, or RUG, should be performed in patients with pelvic fractures and hematuria.

Perennial echymosis or swelling, or those with blood at the urethral miatus, because passage of a foli catheter blindly in these settings can worsen a pre existing urethral injury. And finally, key concept seven genital injury is rarely life threatening, but prompt diagnosis and evaluation is necessary to decrease the likelihood of future morbidity in these patients.

All right everybody for core questions, it's a little bit of a longer episode because we want to spend a little bit more time with you on our last. Uh we have ten core questions and five wisecracks. Owen, you want us uh do you want to start introducing the core questions? Uh sure. So core question one, outline the AAST's classification system for renal trauma. In core question number two, we ask you to list four complications of renal trauma.

Core question number three Outline the spectrum of testicular injury. Core question four compare and contrast true and false penile fractures. In core question number five, we ask you to list five indications for renal injury in the trauma patient. Core question number six.

List four indications for imaging in the patient suspected of having bladder injury. Core question seven, list four indications for ureteral imaging in the context of trauma. In core question number eight, we ask you to outline the indications. For and procedural specifics of a retroade urethogram or a rug. Core question number nine, outline the procedural steps required to perform superpubic catheterization. Nice. And core question ten. Outline an approach to the management of zipper injuries.

In Wisecracks, the first one we ask, what is the structurally weakest portion of the bladder? Wisecrack 2 lists four anatomic variations that increase the likelihood of renal injury in pediatric patients. Number three. What can be done if delayed CT imaging for ureteral injury is not performed initially? Yeah. Going from there Wisecrack five, how does one reduce uh testicle, dislocated testicle, presumed? It's uh definitely with uh the Cunningham technique.

Different ball, different socket. Exactly. Yes, that's a good one. All right everybody, Roses in perspective. Like we said, we did it. We have reached the end of Crackcast in today's episode Uh as you guys have heard, we're gonna review chapter 40 and roll this ninth edition, Janitor Urinary System. I can hear everybody wincing in pain as they listen, just as we have introducing the episode.

But try to pay attention because this episode is gonna cover some pretty valuable content. GU trauma is actually exceedingly common. About ten percent of all trauma cases in the US involve the GU track. While not life threatening, G U trauma can bring with it a whole host of lifelong complications like renal insufficiency, chronic hypertension, incontinence, sexual dysfunction.

and a whole bunch of other stuff can be consequences of missing these injuries in the ED. Thus, knowing this content cold is key to making sure your patients live happy and full lives after they leave the apartment door. If you're now reflecting on your last trauma case and and thinking about how a renal injury may have been missed, fear not. We got all the content to help quell those anxieties.

This episode will give you all the information you need for your next EDGU trauma patient. First we'll start off by reviewing the classification system used to describe and steward management of renal injuries. Then we'll dive into the hazy waters of diagnostic imaging in patients with GU injuries.

After that we'll crush on some high yield procedural content that you'll need to know to investigate and treat some of your uh tough GU trauma related pathology. And then last we'll end the episode as we always have with those high yield quick snappers to get you ready for exam time.

Clinton, mm-hmm. We always give the first core question to our guest. So I want you to answer for us the following. I want you to outline the AAST's classification system for renal trauma. Sounds good. You got it. Um, so the AAST classification for renal trauma, it gives you five different grades of injury.

Uh and within each of those grades it can break it down into uh different types. Um so for for grade one injuries, uh it can be a contusion or a hematoma. Uh the contusion is gonna have microscopic or gross hematuria, whereas hematoma Um is gonna have the same probably with some subcapsular, non expanding, uh perenchymal laceration.

Within grade two, this time a hematoma or a laceration. So the hematoma, it'll be non-expanding and it'll be perirenal and it'll be confined to the renal uh retroperitoneum. Whereas the laceration is going to be less than one centimeter uh in depth. And it will not have any urinary extravization. Grade three is gonna be a laceration of the kidney. It's usually gonna be greater than one centimeter in depth.

Uh and it's gonna be through the renal cortex, but no laceration into the collecting system and no urinary extravasation. Grade four, you can either have a laceration or a vascular injury. And in the laceration, you're gonna have perenchymal laceration extending through the renal cortex, medulla, and into the collecting system this time. Now a grade four vascular injury is gonna be the main artery or vein.

the hemorrhage is going to be contained. Now grade five is when you're really getting in s into trouble either with a laceration of the kidney or a vascular injury. In a laceration, this is a completely shattered kidney. And in a vascular injury, you're having an avulsion of the renal hilum, and this essentially devascularizes the kidney. Very serious. Mm-hmm. It's important to note that the high grade injuries are defined as three, four, and five.

and that the grade uh is made based on the highest grade assessment possible. Additionally, while multiple grades of injury can coexist, the injury is largely defined by the most significantly existing Tree there. So how does this affect management, you might be asking? Well, there's a decent amount of change in this field over the last several years. More and more surgeons are opting for more conservative management strategies for renal trauma.

Injuries graded one to three are often managed with serial imaging, typically ultrasound unless they're human dynamically unstable. Or if the hemoglobin's falling or if they have poor quality ultrasound images generated. Grade four segmental vascular or collecting system injuries are also managed in this way.

Grade five injuries are split into kind of two camps, those that are hemodynamically unstable and those who are not. Those who are unstable generally go for surgical exploration, while those who are stable are observed and have serial imaging. individuals who have microscopic hematuria and who are hemodynamically stable generally have a repeat urinalysis in six weeks time.

and are investigated as per those results. And so you'll oftentimes be ripping around on the trauma ward and you'll see that somebody's admission urine had some hematury on it. It was microscopic, it was never known to be macroscopic and they'd been hemodynamically stable throughout, say they have blunt abdominal trauma. Those people just need a year analysis at six weeks and then their family doctor can work'em up from there. All right one, so uh core question number two.

Uh can you outline for us four complications of renal trauma? Alright, so this is a hidden list in the book. Um so here's a couple complications listed in Rosins. First up, urinary tract infection. Next up is urinary leak and resultant urinoma. Next is loss of renal function. And there's a few percentages that might be good to know. So grade three injuries typically decrease renal function by fifteen percent.

Grade four injuries decrease renal function by thirty percent typically, and grade five injuries can decrease renal function by up to sixty-five percent. So fairly significant there. Um and the fourth and final complication is hypertension. So just to summarize those again

UTI, urinary leak and urinoma, loss of renal function, and hypertension. Those are the four that you should know. It's important to note that the risk of infection is fairly high in these folks, and as such, uh at least give consideration to antibiotics for patients with. significant renal trauma to avoid uh resultant uh UTI and perinephric abscess formation.

Alright. So next up, core question three. Excellent question. Uh outline the spectrum of testicular injury. This is another hidden list in Rosen's. There's a lot of hidden lists in this uh chapter for some reason. And just like I did when, you know, we talked about spectrum of cardiac injuries or blunt cardiac injuries. We'll talk about the spectrum of testicular injuries.

Um because the words have different meanings uh that identify different structures that have been um compromised. So um really uh broadstrokes overview, you have kind of six types uh of testicular injury. You have contusions, fractures, dislocation, rupture. uh traumatic torsion and then traumatic epididymitis. Um and so let's go through each one of those. So in terms of testicular contusions, this is defined as an introscotal blood vessel rupture and subsequent introscotal hematoma formation.

Bruise inside the testicle. Testicular fractures are defined as a linear avascular area within the testicle without rupture of the tunica albiginia. Whereas a testicular rupture is defined as uh a disruption of the testicular tunica albiginia. Okay. Then you have testicular dislocation. This is defined as a forced extra short migration of one or both testicles along the path of the spermatic cord, usually being found in the superficial inguinal area.

And then traumatic torsion, as you would think, uh it is defined as uh a rotation of the testicle about its axis, causing decreased blood flow to the testicular tissue in the setting of trauma.

And then traumatic epididomitis is epididymal inflammation secondary to trauma. And so you can think about it kind of as a stepwise approach. First you get a contusion or some blood within the testicle, then you get a fracture So there's an avascular line within the testicle but the tunica albaginia is still intact, and then you have a rupture where uh there's actually disruption of the outer layer of the tunica albaginia there.

All right, Q. I want you to take the daddiest of dad joke potential question. Okay. I want you to compare and contrast true and false penile fractures. Uh so I'll do my best to answer the question. No promises for dad jokes. If if if they come to me they come to me. If they don't, they don't. Um

Yeah, exactly. Exactly. If you force it then they become very cringy. Um just anyway. Just like female fractures. Just like penal fractures. Perfect. All right. We're well on our way here. So To answer their question, so a true pine penile fracture uh is gonna be a traumatic rupture of both the tunica albiginia as well as the corpus cavernosum.

Um and so this is largely gonna be based on history to differentiate the two. But in this in the setting of a true penile fracture, you're gonna have a swollen, echymotic, and deviated penis. And typically patients will present after vigorous sexual intercourse or masturbation and they will have heard a loud pop.

and subsequently have a rapid detumescence and discoloration. And so the real key there is that there's a rapid detumescence of the penis. In the setting of a false penile fracture, they usually don't rupture either of the structures less listed above, specifically the tunica aboginia or the corpus cavernosum.

Um, but they're more so penile vascular injuries and usually of the dorsal vein or artery. And so usually it's the same setting, sexual intercourse or masturbation, and they will not have heard a pop, they will not have had a rapid detumescence, but rather a gradual one.

And uh often they can have a new post injury erection that can occur. Um so again, you know, they might look very similar, so really have to nail down the history to differentiate between the two. Yeah, this is probably one of the most important historic features that you have to really pull out is Whether or not they heard a pop and whether or not they had a rapid D2 MC.

Because that's gonna help you differentiate between the two. Sometimes it's it's it's very difficult to differentiate between the two and you're gonna go about ultrasounding these anyways and so you'll be able to find out more definitively there. But generally you can make the diagnosis on the spot if you have a good history and physical exam.

All right, Owen. So uh core question number five. List five indications for renal imaging in the trauma patient. All right, excellent. So there's uh another hidden list in uh Rose's ninth edition. Um It's a source of my insanity this year. Uh is all these hidden lists. So anyways, indications for renal imaging in trauma. First up.

Hemodynamic instability with evidence of intraperitoneal injury on abdominal examination. So next up is uh presence of a pelvic fracture. Then we've got penetrating traumatic mechanism. Fourth is presence of lower rib fractures, and fifth is post traumatic gross hematuria. So Just to take those again, hemodynamic instability plus intraperitoneal injury, presence of a pelvic fracture, penetrating uh abdominal trauma.

uh lower rib fractures, and post-traumatic gross hematuria. So it's important to note the first four indications, if present, should prompt imaging, regardless of whether the patient has hematuria or not. And additionally, it's important to note that uh CT scan is your imaging modality of choice with

delayed phase uh scanning, which is a scan that's done ten minutes after the administration of contrast, basically to allow that contrast to make its way down to the kidneys and neurons. And basically that's how we uh perform CT to look for evidence of renal injury or collecting system injury. Yeah, that delayed pays is really important for the collecting system just because you have to let it filter out.

um into the kidney so you can begin to see the pacification of, you know, the renal hilum and then subsequently the ureters and such. But that's a good little tight list. Remember if they're sick. you're getting a scan. If they're stabbed, you're getting a scan. If there's some pretty significant trauma with lower rib fractures or pelvic fracture, getting a scan. Or if they have gross hematuria, get the scan, man.

Yeah, I feel like, you know, in in eMERGE sometimes we have the reputation for just shooting from the hip with with ordering CTs, but this is one of those situations in trauma where there's a bit of nuance, so um just keep

keep uh renal injury on your radar and just realize that there's some specific studies you have to order if you are suspecting this. And regarding the delayed phase, make sure you chat with your radiologists or radtex. Um because it you know this may be site specific, but countless times I've written it on the rec.

It's not actually done and I don't know if it's just'cause they're less familiar with it or not expecting it, but make sure that it gets done because if it if it doesn't, then you have to pursue different imaging down the road. All right, so next up, uh Dylan, let's do core question six. List four indications for imaging in the patient suspected of having a bladder injury. So indications for bladder injury. There are

four of them. Okay. You have gross hematuria and a pelvic fracture, or you have microscopic hematuria and one of the following, a pelvic ring fracture or an obturator fracture. And then uh you also would get bladder imaging if you have penetrating trauma to the pelvis. It's important to remember here guys that CTU with uh IV contrast alone is insufficient for these injuries.

Um, because the contrast doesn't actually sufficiently distend the bladder to look for small perforations. Uh you'll need a retrograde stress cystography performed by diluting 30cc of water soluble contrast in 500cc of warm saline. You instill about three to four hundred C Cs via a fully catheter.

This helps to displace those clots that have formed and allow for extravasation. This helps to differentiate extraperitoneal bladder rupture from intraperineal bladder rupture. You can look for a molar tooth appearance on cystography. um to help differentiate between the two. That would be more in keeping with an extraparentineal bladder rupture.

Intraperitoneal bladder rupture, cystocopy typically shows um intraperitoneal structures like the colon being outlined. Also an important thing to remember that differentiating between intra and extraperitoneal bladder rupture Changes management pretty significantly. Most EVRs are managed conservatives, while all IBRs will require surgical exploration and further intervention.

Uh alright Q you're up next. Core question seven. List four indications for ureteryl imaging in the context of trial. A couple of indications are as follows. So any unexplained or persistent hematuria needs to be uh considered uh to be f coming from the ureter and therefore needs some imaging.

The other thing that you're going to look for is evidence of injury adjacent to the ureter. So this could be a retroperitoneal vascular injury, it could be a vertebral fracture, and usually a transverse process fracture and penetrating injuries to the flank. Um so if if you find any of these you need to go looking for any uh injury to the ureters.

It's important to note that blunt injury uh to the ureter is quite rare, but if it is missed, uh there are significant implications. Um they'll often present later uh after their injuries with sepsis, hydronephrosis from obstruction, or a urinary fistula. And so to investigate for these injuries, you're gonna want to use an imaging strategy where you're using s uh CT with IV contrast. And this has uh essentially replaced uh pylography or urugraphy.

uh as well as retrograde pylography. So also remember that these patients need a delayed phase. So again, you're going to be chatting with your radiology colleagues, getting a CT scan with IV contrast. And then you're going to ten minutes later get the CT scan um to allow time for the the kidneys to essentially put that contrast down into the ureters. All right, Owen. Core question number eight.

Outline the indications for and procedural specifics of a retrograde urethrogram. All right. So uh not quite that like thoracotomy or lateral cantholomy, but still in the category of things that I've never seen. Uh never done, but still will need to know how to do for shot the rug, dude? I haven't. Amateur at the Apollo read. Doctor Riley Hartman's done it. Yeah. I bet Riley did it. Yeah.

Nice. Um so yeah, we'll take you through the uh technique for performing a rug. This is based on a box in the text uh forty point one in the ninth edition. So first step uh you're going to flush a sixteen to eighteen French Foley catheter. Uh or Hysterocell pingogram catheter with radiopaid contrast to avoid air bubbles.

Step two, you're gonna prep for the procedure. So uh the glands and miatus, uh you're going to clean those with antiseptic. Um then the catheter is inserted into the penis. Um And the balloon is partially inflated with one to two C C just right in the fossa navicularis, so this is just um kind of at the distal uh aspect of the urethra. Uh the penis is then pulled laterally uh to straighten the urethra under moderate traction.

Next up, you're going to get a pre-contrast scout view just to get a sense of any baseline prostatic calcifications that might be confused for extra visated contrast. After that, you're going to uh under fluoroscopic visualization, inject twenty to thirty C Cs into the um catheter with the goal of filling the entire urethra.

If spasm of the external sphincter prevents posterior urethral filling, slow and gentle pressure may allow out pacification. So um just go go slow, gentle pressure, don't try and force your force your way in there with contrast and then finally uh obtain your images so you're gonna get some static images to demonstrate whether extravization is present or not.

All right, nice. So next up, Dylan, core question nine. Outline the procedural steps required to perform superpubic catheterization. So let's say that we've shot a rug, feeling good about ourselves. And you see a urethral injury, what are we gonna do? Answer uh instead of trying to ram a fully catheter up there anyways and worsening the injury, you're just gonna do SUPP catheterization.

It's important, uh, like I said, uh not to catheterize these patients um transurethrally, as you're likely going to worsen the injury uh and potentially complete it. um increasing their risk for uh downstream urinary strictures and stuff like that. And so um if you're wondering how to do a superpupa catheterization, uh there is a good post from WikiM. We linked it in the show notes, so check that out.

Um but we'll rip through it as the Royal College likes us to do by talking about indications, contraindications, and then the steps. Okay. So the indications for a superpubic catheterization is they have a traumatic urethral disruption, exactly what we're talking about today. or they have a severe stricture or prostatic disease.

Contraindications, if they have an empty or unidentifiable bladder on ultrasound or they have bowel anterior to the uh bladder on ultrasound, probably don't want to be hocking a huge catheter through there and poking bowel. In terms of the steps, step one, you're gonna use the bedside ultrasound to locate um uh and mark the bladder.

Um, you know, there's the some techniques out there that talk about the use of real-time ultrasound guidance. There are others that, you know, advocate for a Seldinger technique. Use whichever one you're most comfortable with. Uh the next thing you're gonna do is you're gonna sterilize the field with antiseptic. Third step. Fill a syringe with local anesthetic and attach a spinal needle. Uh then you're going to in step four raise a wheel at the mark site and infiltrate the tissues in

Down to and including the rectus muscle fascia. Step five, you're going to advance a spinal needle into the bladder while constantly aspirating. Step six, once you get flashback uh of urine, remove the syringe. Uh, and then step seven, you're gonna advance the guide wire through the needle into the bladder. Uh in step eight, then you would remove the needle and leave the guide wire inside you.

In step nine, just as you do with central venous catheters, you can use a scalpel to make a stab incision at the site of the guide wire two. In step ten, pass a peel away sheath and indwelling dilator over the guide wire into the bladder. In step eleven of this process you'd be would be to remove the guide wire and fascial dilator, leaving the peel away sheath.

And then you're going to in step 12, insert a foley catheter through the sheath into the bladder. At step 13, you're going to confirm your placement by aspirating urine through the foley. Once you've done this, you move on to step 14, inflating the foley balloon. Step fifteen you're going to remove the peel away sheath and then step sixteen duress the site.

Generally a fairly well tolerated procedure. Um, there's some good videos online uh of urologists doing them in their merch in the state and with adequate local Patients have absolutely zero problem with it. It's probably gonna be a lot more comfortable for them to have one poke to relieve their hugely distended bladder or pee through a partially torn urethra than it is to you know, uh get jabbed once. So

Uh do it if you need to do it. And we can't talk about this without me telling a story about a colleague who'll remain nameless, but uh they uh they went for uh a femoral central line and inadvertently did uh bladder aspiration. So that's That's the second less preferred way to get uh an urine out of the bladder. Oh dang. Um but it but it happens and it worked. And it worked. I've got flash. Yeah, I got flash.

This man is suffering from a very serious illness. He has a urine for blood. Yes, he's very anemic. There is no red color in the plastic. It's all plasma. Yeah. It's pure plasma. Oh man.

All right. Uh core question number 10. Peter Patterson. Let's get Atterson. Alrighty. Outline an approach to matchment as a bigger. All right. Uh so for those of you out there in the podcast land thinking that this is something really only seen in movies like There's Something About Mary, think again.

Uh, zipper injuries are common, so common in fact, that the US military actually has a how to guide for managing these. That's concerning, uh what kind of, you know, zippers do they have in the military that, you know Yeah, I didn't know that. Evidently it's happened enough for them to like protocolise something. It was a small piece of trivia that I had uh found many years ago. And so I knew when I read the chapter how to do it. I was like oh

I've read the US Naval Guide zipper interest. Yeah. Titanium zippers or something. Terrifying. Anyway, uh so here's how we're gonna treat the next Ben Stiller that walks through your emergency department doors. Um so if the zipper is stuck, uh pinching the penis or scrotum and there's some cloth material, try cutting the cloth between the interlocking dentition of the zipper.

and this may actually free the patient's tissue without having to go much further. If the penis is caught in the buckle of the fastener, unzipping can be attempted using mineral oil to help with removal. Thirdly, if the above two tricks don't work, the medial bar of the zipper can be cut with a set of bone cutters or wire cutters to separate the two plates of the zipper.

And lastly, if all else fails, a circumcision or elliptical incision of the penis skin can be performed to release the trapped tissue. Zipper should be bad. Yeah, almost convinced of it. Ro Roberts and Hedges actually has a decent section on various ways to dismantle the zipper. So like in addition to cutting the median bar you can um

potentially get a flathead screwdriver to actually pry apart the two plates of the zipper as well. So yeah, before you go to like, you know, making uh giving giving reverse circumcision circumcision, there's probably a few a few uh things that can be tried to troubleshoot.

Alright, I went to glass cruck number one. What's the structurally weakest for? Alright, so this is the dome of the bladder where it sits against the peritoneum. This is the weakest portion of the bladder. This weakness is highlighted in patients with rupture after blunt trauma. uh which is directed against a distended bladder. Uh this is typically where they they will rupture. Mm-hmm.

All right, uh Dylan, let's do wisecrack number two. List four anatomic variations that increase the likelihood of renal injury in pediatrics. Tell you to list four things. Just remember, kids are weak, not obese, and that's about it. So uh kids have weaker abdominal walls, kids have less perinephric fat, kids have relatively larger kidneys, and they also have a soft elastic chest wall.

All of those things increase your likelihood for renal injuries. Of course, if you have less protection intra abdominally from perinephic fat, externally from chest wall and abdominal walls, and if your kidneys are kind of bulbous or large in comparison to your body. Qui scrack number three.

What can be done if delayed C T imaging for ureteral injury is not performed initially? Something that you wanted to talk about. Yeah, so we were talking about this before, you know, if if for whatever reason the the imaging isn't done and now you're in this position where they may have a ureteric injury and you're not quite certain.

Um what you can do is wait 30 minutes from the contrast injection. So find out when radiology actually injected the contrast, and then shoot a plain radiograph of the abdomen. Um this can reliably identify large scale extravization into the pelvis from the ureter. And alternatively you can order a retrograde pylogram, those studies that have largely been replaced by that 10-minute delayed CT uh phase. But this is kind of your backup if

If things went awry for some reason. Yeah. And again, like uh Q is saying, it's actually pretty common. Even if you do call them, sometimes it gets it gets uh missed in the shuffle. So stuff to consider. So oh, and number four here. How much force is required to fracture a testicle? Sounds like a like the lead up to a joke.

Yeah. So you can either give us an answer or uh you know a good j uh punchline. Uh punch line. Yeah. Um I'm just line. So the the answer uh is approximately fifty kilos, which uh that's That's uh the uh average amount of uh fifty kilos of force? What? Um, so that's to rupture the Tunica Albignea and cause a rupture. So I mean like I feel I'm just trying to conceptualize what that would be. That would be like a a kind of uh adolescent or small adult weight uh weighted person like

standing on it or like other uh I would I would I I would guess so. Oh my god dude. I I guess you know oh god the other the other part of of force obviously is velocity so if you got uh yeah. But that's yeah it seems fairly significant. Swift kick. Yeah. Well e even then, like I don't know if a a a swift kick would necessarily uh fifty kilos of of of like kicking force is pretty substantial.

I wonder I'm gonna look up this after. I'm gonna look up who like the average force of like a my tie kicker, like how much you're actually getting contacted with and then we'll figure it out from there. But that's incredible. Resilience structures those testicles. Yeah, yeah, yes there. Um all right. So uh Wisecrack 5. How does one reduce a testicle? This is unfortunately the last question we have. Is this the last question of the podcast, Dylan? It's it's a good one. Things are changing.

That's okay. All right. How do you reduce a testicle? We made a joke saying that uh it was probably the Cunningham technique. We were wrong. Uh so ways to reduce a testicle. Okay, you are going to uh gently apply caudad pressure along the path of the dramatic cord. So you're essentially going to pull down along the path of the somatic cord gently.

You're gonna give the patient good analgesia and per s a potential sedation because as you can imagine, this is gonna be very painful for them. Once you do pull down, you may feel um a slight give way or or a pop down. Um you can use an ultrasound uh to perform whether or not the procedure was successful or unsuccessful um and uh whether or not uh there is vascular compromise of the testicle for most practitioners, uh at least in our site.

knowing the specifics of testicular vascular imaging probably isn't within our wheelhouse and so I would send them away for a formal one after just to make sure. Um but you should always be getting that ultrasound thereafter. Um if you successfully reduce the testicle that's dislocated, these people are gonna likely need operative intervention for orchopexy in the future. And so um go ahead and give uh your friendly neighborhood urologist a call and you're done. That's it, boys.

Yeah, different ball, different socket. That's good to find you now. That was the perfect addro. Yep. Love it. That's good. Well, I'm glad you guys got to to join in on the last episode and for everybody else in Podcast Land, thanks for supporting us over the years. We've had a hell of a time doing this. Um we uh will be back after the crushing exam year is finished.

Um uh with the danger zone we're gonna record probably more episodes of that. Uh but I think going through Rosen so one and a half times is probably sufficient, so we think we'll end it there. But thanks for listening. Thanks for the support. We'll catch you on the flip side. Alright, see ya everyone.

And uh Quinn, thank you for coming on. Definitely appreciate your uh wisdom and dad jokes and uh really appreciate that you're able to join us. Yeah, thanks for having me. And I I don't want the last thanks to go to me. Um I think I can speak for all of your listeners out there that they appreciate everything you definitely helped uh disseminate knowledge that's helpful to improving patient care.