Genitourinary

							Genitourinary

     Debbie King FNP, PNP
         Spring 2009
             8800
Dysuria
   Is the subjective experience of pain or
    burning on urination
   Associated with a bladder problem and
    frequent voiding
   Common causes
       Inflammatory lesions
       Bladder/urethral infections
   Less common causes
       Tumors, renal failure, STD’s
Hematuria
   Defined as blood in the urine and can
    be gross or occult
   More than 3 RBC per high power field
   There is a direct relationship to quantity
    of blood and the probability of
    pathology
Hematuria
   Two types
       Transient
            Occurs on one occasion
       Persistent
            Occurs on two or more consecutive occasions
   Both can be a sign of serious disease
Hematuria
   Differentials
       Dietary substances
            Caffeine, spices, tomatoes, chocolate, alcohol citrus, soy
             sauce, some herbal meds
       Medications
            Beta-lactam antibiotics, sulfonamides, NSAIDS, Cipro,
             allopurinol, tagamet, dilantin
       Anticoagulation and papillary necrosis
            Warfarin, heparin, asa, NSAIDS
       Glomerulonephritis
            Hydrocarbons-(glue, paint), NSAIDS
       Urolithiasis
       Menses
Hematuria
   Patho- depends on the cause
   Diagnostic test and findings
       UA +blood
       Urine culture with ID and sensitivities
       Microscopic urine exam- more than 3 RBC per high power field
           If not more than 3- explore hemoglobinuria

           If more that 3 -test for cause

                ANA, immunoglobulins, CMP, CBC, ASO, Anti-DNASE B,

                 VDRL, PT, PTT, ESR
       PPD
       Intravenous pyelogram(IPV) to assess structure
       CT
       Cystoscopy to evaluate the Upper tract
Hematuria
   Causes grouped according to anatomic site of source and other findings
       Isolated with no other abnormal findings
           Anywhere in the renal pelvis to the urethra

       Along with cast in the urine
           Associated with kidney disease

       Along with bacteria in the urine
           Cystitis and urethritis

       Along with protein in the urine
           Nephritis

       Along with flank pain
           Kidney stone

       Along with HTN, sore throat
           Glomerulonephritis


        Gross hematuria is associated with malignancy
Proteinuria
   Indicative of renal pathology, most often glomerular
    in origin
   Can be functional and appears as intermittent
      Illness, stress, exercise, or benign

   Can develop from overproduction of filterable plasma
    proteins, may be associated with multiple myeloma
   Continuous is associated with renal pathology
       Best test for this is a 24 hour urine
            More than 165 mg of protein is abnormal
            More than 3.5 grams is indicative of nephrotic disease
Proteinuria
   Differentials
       Benign or functional causes
            Orthostatic proteinuria, exercise, environmental
             conditions, fever, illness, CHF, injury
       Bence Jones protein suggest multiple
        myeloma
       Nephrotic syndrome
Proteinuria
   Patho- depends on the cause
   Diagnostic tests for nonfunctional proteinuria
       24 hour urine
            Measure protein and creatinine
                 If excretion rate is above 3.0- 3.5 g/day the patient has
                  nephrotic syndrome
       Full chemistry panel- FBS
       Lipid profile
       UN/UC with ID and Sensitivity
Proteinuria
     CBC with diff
     Test for Bence Jones = is characterized as
      a free monoclonal light chain of protein, if
      this test is positive it suggests multiple
      myeloma
          Only used for low-risk patients- nondiabetic or
           nonpregnant
          If this test is positive do a serum protein
           electrophoresis
Proteinuria
   Management is complicated!
       With positive nephrotic syndrome per 24 hour
        urine
            REFER
       With 2grams of protein in 24 hour urine
            Test renal function
                  With normal renal function test urine on awakening before
                   upright for one minute and after standing for 2 hours
                      If first test is normal and second shows protein -refer

                  With abnormal renal function refer for biopsy
       Maybe managed with and ACE- by nephrology and
        primary care
            With coexisting HTN and hyperlipidemia aggressive
             treatment is warranted for all conditions to prevent renal
             failure
Urinary Incontinence
   Definition- is the involuntary loss of
    urine from the bladder.
       Is so common in women that many
        consider it normal
       Common in older men with enlarging
        prostate
   Can affect quality of life
Urinary Incontinence
   Patho- three major components are
    involved in urine storage and release;
    the central nervous system, the
    bladder, and the bladder outlet
    (urethral sphincters)
PATHO SUMMARY
   Bladder smooth muscle (the detrusor) contracts via
    parasympathetic nerves from spinal cord levels S2 to S4.
    Urethral sphincter mechanisms include proximal urethral
    smooth muscle (which contracts with sympathetic
    stimulation from spinal levels T11 to L2), distal urethral
    striated muscle (which contracts via cholinergic somatic
    stimulation from cord levels S2 to S4), and musculofascial
    urethral supports. In women, these supports form a two-
    layered "hammock" that supports and compresses the
    urethra when abdominal pressure increases.
PATHO- SUMMARY
   Micturition is coordinated by the central nervous
    system: Parietal lobes and thalamus receive and
    coordinate detrusor afferent stimuli; frontal lobes
    and basal ganglia provide signals to inhibit
    voiding; and the pontine micturition center
    integrates these inputs into socially appropriate
    voiding with coordinated urethral relaxation and
    detrusor contraction until the bladder is empty.
    Urine storage is under sympathetic control
    (inhibiting detrusor contraction and increasing
    sphincter tone), and voiding is parasympathetic
    (detrusor contractor and relaxation of sphincter
    tone
        Urinary Incontinence
   Subjective Presentation
       History
            Medical (DM, CA, illness)
                  Medications such as sedatives, hypnotics, diuretics, narcotics, alpha-
                   blockers, antispasmodics, antihistamines, calcium channel blockers,
                   decongestants, alcohol, anticholinergics
            Surgical
            Date of onset
            Number of voids day and night
            Fluid intake
            Types of fluid
            Characteristics of the incontinence
                  Sneezing, nocturina, urgency or dysuria
Urinary Incontinence
   Objective
       Physical exam
            ID underlying pathophysiologic causes
                 Maybe more than one
            Neuro assessment
                 CVA, Parkinson's
                 Cognitive ability and mobility
            Abdominal exam
                 Rule out constipation (common cause)
                 Masses
                 Distended bladder
Urinary Incontinence
   Physical continued
       Pelvic exam
            Check muscle strength
            Uterine prolapse
            Peineal structures
            Skin around this area
                 Atrophic vaginitis
                 Skin breakdowns-
                 In men check for foreskin, penis or perineum abnormalities
            Rectal
                 Check spincter tone
                 Prostate size in men
Urinary Incontinence
   Heart and Lungs
       Assess for CHF
   Cough stress test- observe for leaking
Urinary Incontinence
   Tests/Findings
       UI or pad test
            Patient takes pyridium wears a pad and checks
             for staining at determined intervals
       UA/UC
       Serum electrolytes
       Blood urea nitrogen (BUN), creatinine,
        calcium, glucose
       Post void catheterization
Urinary Incontinence
   Further testing depends on test results so far
    and if the onset is acute
   Urine shows no infection but is positive for
    sugar
   Urine shows infection may need further
    workup
   Urine shows increased RBC’s work up for
    tumor or infection
   Other test that may be indicated
       Cystometry, cystometrogram, video-urodynamics,
        ultrasound
Urinary Incontinence
   Differentials
       Four major types of incontinence
            Stress
            Urge
            Overflow
            Functional
       Other types
            Overactive bladder
                 A type of Overflow UI
            Compensated incontinence
                 Elderly
            Transient
                 Other major illness
Urinary Incontinence
Stress UI
Involuntary loss of urine caused by increased
  pressure- coughing, laughing, sneezing ect
  caused by hypermobility of the bladder neck,
  intrinsic shpincter deficiency, neurogenic
  sphincter deficiency, or medications.
Typically have a history of vaginal deliveries
Workup includes- history, pelvic exam, the pad
  test, cough stress test, ua, uc, video-
  urodynamics, and maybe a cystometrogram
Urinary Incontinence
   Stress UI continued
       Management includes- pelvic floor
        exercises, weight loss, electrical
        stimulation, HRT, medications such as a
        alpha-adrenergic agonist, surgical
        correction, periurethral bulking injections
       Feel free to refer these patients who are
        easily managed!
Urinary Incontinence
   Urge UI- also known as detrusor
    instability with leakage of urine
    resulting form the inability to delay
    voiding. It is the failure to store urine
    due to urinary tract infection, vaginitis,
    bladder stones and tumors. May also
    be caused by brain lesions, CVA,
    dementia, MS, or medications
    Urinary Incontinence
   Urge UI continued
       Workup includes- exam of perineal hygiene,
        pelvic exam , vaginal discharge smear, neurologic
        exam, assessment of mental status, UA, UC,
        Maybe a cystometrogram and video-urodynamics
       Treatment begins conservatively- pelvic floor
        exercises, scheduled voiding, management of
        fluid intake, medications as needed such as
        antibiotics if infection is present. Other
        medications may be used such as topical
        estrogen, anticholinergics, smooth muscle
        relaxers, tryicyclic antidepressants to improve the
        neuromuscular function. Surgical treatment as
        needed for stones or tumors.
Urinary Incontinence
   Urge incontinence subtype of UI
       Overactive Bladder or OAB- is a syndrome of
        symptoms that include urgency, frequency, and
        nocturia all of which are associated with
        involuntary contractions of the detrusor muscle.
        These patients may or may not be a feature of
        this syndrome
       1/3 have urge incontinence, such as stress
        incontinence
       This often mistaken for Urge UI
Urinary Incontinence
   Overactive Bladder continued
       The cause is multifactorial- it can include disorders
        of the lower urinary tact, alcohol and caffeine use,
        may be associated with certain medications, or
        with neurologic conditions
       Is most common in women
       Often results in anxiety and depression due to
        restriction of daily living
       Sexual dysfunction can occur due to fear of urine
        leakage
Urinary Incontinence
   OAB continued
       Work up the same as Urge UI
       Treatment begins with identifying women with the
        prblem
       6-27% seek treatmetn
       Nonpharmacologic methods as used for Urge UI
        are also tried here
       Medications such as antimscarinic agents are the
        most commonly used as the block the
        parasympathetic stimulation of the detrusor
        muscle by blocking acetylcholine
Urinary Incontinence
   Overflow incontinence is the involuntary
    leakage of small amounts of urine. It is
    caused by an over-distended bladder in a
    patient who does not feel the need to void
    due to an antonic detrusor muscle, outlet
    obstruction, BPH, or medications
   The history and PE may indicate hesitancy,
    dribbling, noctureia, decreased stream,
    feeling of not emptying the bladder, and/or
    constipation
   The PE should include a neurologic exam and
    prostate exam
Urinary Incontinence
   Overflow UI continued
       Testing should include UA, UC, serum
        creatinine, biding cystometrogram and
        maybe a video-urodynamics
       Treatment consists of treating the
        underlying disease-may include scheduled
        toileting, crede’s maneuver, medications
        such as alpha-blockers
Urinary Incontinence
   Functional urinary Incontinence- is the
    incontinence that occurs in a normal
    functioning urinary system. The leakage is
    caused by factors outside the lower urinary
    tract and can be transient in nature
   Causes vary and include delirium, impaction,
    immobility problems, medications such as
    diuretics, decongestants, alcohol.
Urinary Incontinence
   Functional UI continued
   History and PE should include
    assessment for fecal impaction, sleep
    pattern problems, mental status,
    hearing and vision, functional ability,
    fluid intake, accessibility, infection, and
    neuro deficits
Urinary Incontinence
   Functional UI
   Treatment consists of removing barriers,
    education regarding a scheduled bowel and
    bladder program, PT, OT, habit training.
    Patient may need caregiver assistance.
    Patients may need catheters. Medications
    should be used in conjunction with other
    treatments such as kegal exersices, vaginal
    rings, surgical interventions for prolapsed
    uterus, obstructions, enlarged prostate, or
    tumors may be indicated
Interstitial Cystitis
   Be careful using this diagnosis
       Insurance does not like it and may cause difficult
        with ins changes ect..
   Definition; chronic bladder inflammation
    syndrome characterized by pelvic pain and
    irritative voiding symptoms
   Unknown patho, related to autoimmune,
    allergic, infection etiologies
   Is a diagnosis of exclusion
Interstitial Cystitis
   Occurs mostly in women
   10% are men
   Onset between 30-70 years of age
   Does occur in children and is under
    diagnosed
Interstitial Cystitis
   Symptoms
       Pain, relived by voiding small amounts
       Uncomfortable constant urge to void
       May worsen the week before menstruation
   Differential Diagnosis
       UTI, prostatitis, cystitis
       GYN conditions such as vaginitis and
        endometriosis
       Neuropathic bladder dysfunction
       Neoplasm
       Overactive bladder
Interstitial Cystitis
   Diagnostic Test
       UA, UC, and maybe a potassium sensitivity test-
        slow instillation of 40ml of sterile water into the
        bladder, the patient grades the pain 0-5. This is
        the baseline, then empty bladder and repeat with
        potassium chloride solution. IC is suggested when
        there is a 2 point increase in pain or urgency
       Cystoscopy and hydro distention under anesthesia
        confirms diagnosis
Interstitial Cystitis
   Plan
       Education
            IC is not a malignancy, has an organic basis,
             no specific cure, is chronic, will treat
             symptoms, avoid acidic food, caffeine, alcohol
             artificial sweeteners, chocolate, cigarette
             smoking, drink plenty of water, bladder
             retraining may help
Interstitial Cystitis
   Medication treatments
       Tricyclic antidepressants
       Antihistamines
       Nonsteroidals
       Pyridium, ditropan, procardia may help ??
       May require long acting opioids
   Refer- for further treatments
Vulvovaginitis
   Definition; inflammation and infection of
    the vulva/vagina
   Etiology/Incidence
       Commonly caused by trichomonas
        vaginalis, bacterial vaginosis, or candida
        albicans
Vulvovaginitis
   Trichomonas-transmitted through intercourse
   Bacterial vaginosis- most frequently
    diagnosed symptomatic vaginitis, may not be
    STD, is associated with premature rupture of
    membranes..
   Candida vaginitis-occurs in close to 40-75%
    of women, not considered an STD,
    predisposed by pregnancy, diabetes,
    antibiotic, corticosteroids , heat, moisture,
    occlusive clothing
Vulvovaginitis
   Signs and Symptoms
       Bacterial vaginosis
       Trichomoniasis
          Malodorous yellow-green discharge with pruritus

          Dyspareunia

          Dysuria, partner may also have this symptom

          Malodorous, white (fishy) discharge

          Spotting

          50% are asymptomatic

       Candida vaginitis
          Thick discharge with pruritus

            Erytherma of vagina and vulva
Vulvovaginitis
   Differential diagnosis
       Chlamydia
       Gonorrhea
       Herpes
       Condylomata acuminata
       Allergy, contact dermatitis
       Atrophic vaginitis
Vulvovaginitis
   Physical findings
       Trichomoniasis
            Diffuse erythema, inflamed lesions on cervix-
             strawberry patches (also on vaginal wall)
            Discharge- white /watery to thick and frothy
            Vaginal ph- higher that 4.5
Vulvovaginitis
   Physical findings
       Bacterial vaginosis
            Watery, grayish or white homogenous
             discharge, fish odor
            Discharge slightly adherent to vaginal walls
       Candida vaginitis
            White , cottage-cheese- discharge
            Marked vulvovaginal erythema/edema with
             intense pruritus
        Vulvovaginitis
   Tests/Findings
       Wet prep microscopic exam of vaginal
        secretions
            Trich-mixed with saline will show motile protozoan
            BV- mixed with saline will show clue cells, and
             amine-like odor when mixed with 10-20% potassium
             hydroxide (KOH) whiff test;
            Candida vaginitis mixed with 10% KOH will show
             pseudohyphae
Vulvovaginitis
   Further Testing
       Test for concomitant infection from other STD
            HIV, Syphilis, Warts, Gonorrhea, Chamydia
   Treatments
       Trich- Metronidazole 2 gram orally or 500 mg bid
        for 7 days. Treat partner
       BV- Clindamycin cream 2% intravaginally times 7
        nights or Metronidazole 500 bid x 7 day
       Candida –many different ways to treat, exp
        Miconazole, or po Diflucan
     Vulvovaginitis
   Education
       Discuss treatment plans
       Avoid intercourse until cured
       Education on prevention, transmission
       Emphasize importance of BV treatment for pregnant
        women
       Education regarding dangers of douching and
        incidence of infection
       Education regarding PID, association with BV
FYI
   All other female problems
        STDs, PID, dysmenorrhea, amenorrhea,
        PMS, ect… will be covered in the fall in
        women's health.
Urinary Tract Infection
   Definition: Inflammation and infection
    of the urinary bladder; urethra may be
    involved
   Etiology/Incidence
       Most common causative organisms
           E coli- women
           Proteus species- men
Urinary Tract Infection
   Etiology/Incidence- continued
       More common in women, urological evaluation
        required for men with UTI
       30-40% of women will experience at least one UTI
   Patho-lower UTI’s usually occur as a result of
    contamination from the patients own GI tract.
   Patho-Causes include poor hygiene,
    shortened urethera, intercourse,
    compromised pateints, catheters, DM with
    elevated pH, renal stones, vesicoureteral
    reflux
Urinary Tract Infection
   Contributing factors in women
       Sexual intercourse
       Pregnancy
       Diabetes
       Catheterization
       Instrumentation
       Retaining urine in bladder despite urge to go
       Constipation
       Diaphragm use
       Meatal stenosis
       Bowel incontinence
Urinary Tract Infection
FYI
   Oral antibiotic treatment cures 85% of
    uncomplicated urinary tract infections,
    although the rate of recurrence remains
    high. There is some debate over whether
    to treat young sexually active women with
    high bacterial counts but no symptoms
    (asymptomatic bacteriuria). Given growing
    bacterial resistance to antibiotics and the
    benign nature of this condition, many
    experts do not recommend routine
    treatment
Urinary Tract Infection
   Specific Antibiotics Used. The antibiotics
    used most often for uncomplicated UTIs
    are either trimethoprim-sulfamethoxazole
    (TMP-SMX) or an antibiotic known as a
    fluoroquinolone. Pregnant women should
    not take fluoroquinolones. For
    uncomplicated UTIs, better options during
    pregnancy may be sulfisoxazole or a
    cephalosporin. [See Box Specific
    Antibiotics Used for Most UTIs.]
        Urinary Tract Infection
        FYI
   Duration of Treatment. Studies are now reporting that uncomplicated
    female UTIs can often be successfully diagnosed over the phone. In such
    cases, a health professional provides the patient with a three-day
    antibiotic regimen without even requiring a urine test. A single oral dose
    of antibiotics, usually TMP-SMX (Bactrim, Cotrim, Septra) or a
    fluoroquinolone, is sometimes prescribed in mild cases, but cure rates
    are generally lower than with the three-day regimens. (Longer-term
    therapy, given for seven to 10 days, is now mostly limited to men,
    children, the elderly, people with diabetes with any UTI, and women with
    pyelonephritis or who are pregnant.) After a week of antibiotic treatment,
    most patients are free of infection. If the symptoms do not clear up within
    the first few days of therapy, physicians generally suggest that women
    submit a urine sample for culturing in order to identify the specific
    organism causing the condition.
        Urinary Tract Infection
   Treatment for Relapsing Infection
       A relapsing infection (caused by the same organism
        as the first episode) occurs within three weeks in
        about 10% of women. Relapse is treated similarly to
        a first infection but the antibiotics are continued for
        at least two weeks. (Relapsing infections may be
        due to structural abnormalities, abscesses, or other
        problems that may require surgery, and such
        conditions should be ruled out.)
Urinary Tract Infection
   Bacterial Resistance to Antibiotics
       Of major concern for physicians and the
        public is the emergence of strains of
        common bacteria, including E. coli, that
        are resistant to specific antibiotics. The
        prevalence of such bacteria has
        dramatically increased worldwide, in
        large part due to widespread use of
        antibiotics in people and animal feeds.
Urinary Tract Infection
   Preventive Antibiotics
    (Prophylaxis). Prophylaxis (preventive
    antibiotics) is an option for women who experience two or
    more symptomatic UTIs within six months or three or more
    over the course of a year. A woman's own perception of
    discomfort should guide her decisions on whether to use
    preventive antibiotics or not. The increasing use of
    antibiotics for many common infections is causing concern
    because of emerging strains of common bacteria that have
    become resistant to standard antibiotics.
         Urinary Tract Infection
   Antibiotics for Urethritis in Men
       Urethritis in men has typically been treated with a seven-day regimen of
        doxycycline. Some research is showing that a single dose of azithromycin may
        be just as effective while causing fewer side effects. One-dose treatment also
        improves compliance, so cure rates may even be better than with a long-term
        regimen. Of concern, however, is an infection that spreads to the prostate
        gland, which is harder to treat, so most physicians still prefer the longer
        regimen. It should be noted that azithromycin and similar antibiotics do not
        cure the infection and may mask the symptoms of an accompanying sexually
        transmitted disease, such as gonorrhea. Tests for such diseases should be
        conducted if urethritis is diagnosed

   -SO, men always need to be cultured and treated
    for all STD on the day of service as well as for
    urethritis.
Urinary Tract Infection
back to the basics
   Contributing factors in men
       Residual urine (prostatic enlargement)
       Naturopathic bladder
       Calculi
       Prostatitis
       Catheterization
       Instrumentation
       Meatal stenosis
Urinary Tract Infection
   Signs and Symptoms
       Dysuria, frequency, urgency
       Suprapubic discomfort
       Foul smelling urine
Urinary Tract Infection
   Differential Diagnosis
       Vaginitis- females
       Prostatitis-males
       Gonorrhea
       Chlamydia infection
       Renal calculi
       Pyelonephritits
       epididymitis
Urinary Tract Infection
   Physical Findings
       Urinary meatus may be
        erythematous/edematous
       Negative costovertebral angle tenderness
       Negative pelvic or prostate examination
       May have suprapubic tenderness on
        palpation
        Urinary Tract Infection
   Diagnostic tests/findings
       Pyuria--- 10 WBC/HPF
       Complete urinalysis (clean catch) with culture
        and sensitivity testing
            Bacteria count over 100,000 organisms per ml in
             fresh “clean catch” midstream specimen is reliable
             indicator of active urinary tract infection; women
             with acute cystitis may have more than 10 to the 3rd
             but less that 10 to the 5th per mL in mid stream
             urine cultures
        Urinary Tract Infection
   Urinalysis- continued
   Dipstick results
       Leukocyte esterase dipstick test-positive; means there
        are WBCs in the urine
            False positive from;
                  Kidney stones, tumors, urethritis, contamination
       Nitrite positive test=gram negative infections
            False negative from diuretics, inadequate dietary nitrate, or
             gram positive bacteria
       Urine dipstick positive for protein, blood, nitrites
        suggestive of UTI
        Urinary Tract Infection
   Other tests may be required for very ill
    patient or any male with true UTI
       CBC with diff, BC, ESR STD screen for all
        males and for females when indicated
       Male with UTI- VCUG or IVP, renal ultrasound
        Treatments for UTI
   Management/Treatment/Uncomplicated/ female
       Single dose regimens-Septra DS-2 tabs, Amoxicillin
        500mg-6 tabs
       Three day regimens –Septra DS 1 tab bid for 3 days is
        standard of care for women
       Fluoroquinolones-
            used in area with high resistant rates to sulfa drugs
            Used when a sulfa has been used in the last 6 months
            Used for women who were recently in the hospital
       Nitrofurantoin and Monurol
            Useful if resistance to others increases
         Treatments for UTI
   Treatment Complicated/Female
       Based on Culture Results
       Gram negative organism
            Septra DS- 10-14 days
            Fluoroquinolone- 14 days
       Gram positive organism
            Amoxil 875 bid for 10-14 days
            Augmentin 875 bid for 10-14 days

       Is best to culture urine before and after treatments
Treatments for UTI
   Recurrent/Female
       Culture before and after treatment
       Consider treating longer- up to 8 weeks
       Tests BUN/ Creatinine, IVP or VCUG, LYTES,
       Explore causes- diaphragm, voiding timely
       Advise to increase H2O and decrease carbonated
        drinks
       Refer to specialist!
Treatments for UTI
   UTIs related to intercourse
       May prescribe
            Septra DS 2 tabs after coitus
            Macrodantin 200 mg tab after coitus
Acute Pyelonephritis
   Definition; an acute bacterial infection of the
    upper urinary tract (kidney and renal pelvis)
    usually result of ascending infection
   Etiology/incidence
       E. coli (gram negative) –80%
       Staphylococcus saprophyticus and Streptococcus
        faecalis (gram positive)-5-10%
       Majority are young women/ rare in men under 50
       Most common patients- pregnant, disruptive
        urinary flow, neurogenic bladder, or vesicoureteral
        reflux
Acute Pyelonephritis
   Signs and Symptoms
       Shaking chills
       Malaise, generalized muscle tenderness
       Nausea, vomiting, and diarrhea
       Flank pain- can be either bilateral or unilateral
       Abdominal
       Dysuria, frequency or urgency- may or may not be
        present
Acute Pyelonephritis
   Differential Diagnosis
       Cystitis
       Prostatitis
       Musculoskeletal back pain
       Appendicitis
       Diverticulitis
       Pelvic inflammatory disease
       Ectopic pregnancy
Acute Pyelonephritis
   Physical findings
       Fever, tachycardia
       CVA tenderness
       Peritoneal signs-usually absent
       Ill appearing
Acute Pyelonephritis
   Diagnostic Tests/Findings
       Microscopic urinalysis
            5-10 WBC/HPF
            Occasional erythrocytes
            White cell casts-!!
            Mild proteinuria
       Urine culture
            100,000 bacteria per ml of urine, ID and
             sensitivity testing must be done
Acute Pyelonephritis
   Tests/findings- con’t
       CBC – will see left shift
       Increase in ESR
       BUN and creatinine are usually normal
       Electrolytes- may be abnormal, esp if
        dehydrated
Acute Pyelonephritis
   Management/treatment
       MD- specialist consult
       Inpatient treatment
            If pregnant, have underlying illness, have underlying
             illness, have decreased renal reserve, very toxic, unable
             to tolerate po therapy, most all men
       Out patient treatment
            Antibiotics- based on culture and WBC results (I give
             rocephin pending results, but have a BC pending first)
            Follow up in office in 24 hours- resting until recheck
            Repeat UC in two weeks
            Instruct no intercourse
            Educate for emergency signs and symptoms
            Second episode is referral for sure
Acute Pyelonephritis
   Females-diagnostics and management
   Males the same as females- plus
       Consult with a specialist
       Suggests a structural problem
       Indication for hospitalization
       IV meds- only(almost always)
       IVP, US- workup
Acute Pyelonephritis
   Follow up
       Based on situation, severity of illness,
        number of past episodes, results of
        workup- esp men
       After first two outpatient visits if stable
        may switch to po meds and follow up in 2
        weeks and repeat uc
       Recheck uc again in 3 months
Acute Bacterial Prostatitis
   Definition; inflammation/infection of the
    prostate gland
   Etiology/Incidence
       E.coli or other gram-negative bacteria-common
       Occasionally acute urinary retention develops-requires
        suprapubic drainage ,NO CATHS
       Absence of zinc in prostatic fluid can predispose
       Young men more prone to nonbacterial
          WBC are present in expressed prostatic secretions, but

           no organisms culture out
          Causative agents include mycoplasma, gonorrhea, and

           chlamydia
Acute Bacterial Prostatitis
     Physical findings
          Fever
          Bladder distention may be present
          Prostate- edematous, firm or boggy, warm and
           tender
          Avoid vigorous massage, it may lead to
           bacteremia
Chronic Bacterial Prostatitis
   Uncommon type
   Men 50-80
   Symptoms are slow in onset-varying degrees
    of bladder obstruction-dribbling, hesitancy,
    loss of stream force
   Hematuria, hematospermia, or painful
    ejaculation
   Hallmark feature is recurrent UTI,
    asymptomatic between episodes
Chronic Nonbacterial
prostatitis/Chronic Pelvic Pain
Syndrome (CPPS)
   Most common type
   Men 30-50
   Symptoms are indistinguishable from
    bacterial Type II
   In men with Type IIIB pelvic pain is the
    predominant complaint
Asymptomic inflammatory
prostatitis
   Diagnosed incidentally with eval of other
    disorders
   Limited research on natural history, clinical
    presentation

   FYI all types can have dangerous sequelae
    and lead to urinary retention, renal
    parenchymal infection, or bacteremia, chronic
    infection and may produce prostatic stones
         Prostatitis
   Classifications
       Type I- acute infection
       Type II- chronic or recurrent
       Type III- chronic genitourinary pain in absence of
        infection and uropathogenic bacteria in gland
       Type IIIA- inflammatory- WBCs in semen, expressed
        secretions, or post prostate massage urine
       Type IIIB-noninfammatory- No WBCs in any secretions
       Type IV- asymptomatic inflammatory- No subjective
        symptoms- diagnosis by biopsy, or WBCs in secretions
          Classifications- update
   While the original 1995 classification system was not officially revised,
    consensus participants felt that there was little evidence to show that
    chronic bacterial and nonbacterial (category II and category III) patients
    responded differently to antibiotic treatment. Therefore, the guideline
    advocating clinical use of localization studies to differentiate category II and
    III prostatitis was downgraded from "mandatory" to "recommended." The
    panel members also concluded that classifying CP/ CPPS into inflammatory
    and noninflammatory (category IIIA and IIIB) based on leukocyte counts
    "appears to offer little clinically useful information." Thus, the labor-
    intensive 4-glass localization test was downgraded to "optional." The more
    convenient "2-glass test," in which the postprostatic massage fluid is
    cultured and compared with pre-massage urethral cultures, was suggested
    as a replacement by some members of the panel. Any pathogens present in
    the massage fluids and absent in the urethral swab are considered to
    localize to the prostate and deserve antimicrobial treatment.
Prostatitis
   Signs and symptoms
       Men 40-60 years
       May have painful intercourse
       Fever/chills, malaise, myalgias
       Low back pain
       Dysuria, urgency, nocturia, frequency
       Perineal pain increased with defecation
            Abscess is complication, consider if not
             responding to treatment
Prostatitis
   Differential Diagnosis
       Acute/chronic bacterial cystitis
       Chronic prostatitis
       Nonbacterial prostatitis
       Prostatic seminal vesicle abscesses
       BPH
       Prostatic cancer
       Epididymitis
       Acute diverticulitis
       Nongonococcal urethritis
Prostatitis
   Diagnostic Tests/findings
       Urine culture-is positive
       Prostatic secretions-expressed prostitic secretions-
        WBC greater than 20 cells/HPF is abnormal
       Diagnosis is best make by performing
        simultaneous quantitative bacterial cultures
       Of urethral urine, bladder urine, and expressed
        secretions- the glass test
       Patient often treated based only on physical exam
        and urine culture
Prostatitis
   Management/treatment
       Acute bacterial
            With severe symptoms- hospitalization with IV
             antibiotics, aggressive with abscess
       Chronic bacterial
            3-4 month Bactrim DS bid
            Consider prophylactics
            Evaluate prn for stones with xray
            Cultures every 4-6 weeks
            Prostatic massage once or twice a week for 4 weeks may
             be helpful
Prostatitis
   Chronic nonbacterial-
       No effective treatments available
            Can try meds such as doxycycline,
             erythromycin or bactrim
            Reassure
            Counseling
            Nonsteroidals
            Ditropan
            alpha-adrenergic blocking drugs
Prostatitis
   Asymptomatic inflammatory prostatitis
       Limited research to guide treatments
       With elevated PS may try antibiotics
       Education
            Avoid alcohol, coffee, or tea
            Discontinue and avoid otc drugs with
             anticholinergic properties such cold meds
            Recheck is four to six weeks
Epididymitis
   Definition; Inflammation of the epididymis,
    with an acute intrascrotal infection
   Etiology/Incidence
       Caused by infection from the bladder, the
        prostate, or ascending urethral infection
       Common affliction of men 35 and younger;
        chlamydia usual cause, gonorrhea far less
        common, E coli is some situations
       May be caused by cath or surgery
       “Sterile” may be caused by vigorous activity,
        caused by vasal reflux of sterile urine which leads
        to chemical inflammation of the epididymis
Epididymitis
   Etiology con’t
       In boys may indicate underlying congenital
        anatomic abnormalities
       Is usually unilateral
       May be complicated by development of
        testicular necrosis, atrophy or infertility
Epididymitis
   Signs and Symptoms
       Painful, scrotal swelling- pain may radiate up into
        lower abdomen
       Sensation of scrotal heaviness
       Symptoms of prostatitis or UTI may be present
       Systemic symptoms may develop-fever/chills
       Nausea/vomiting rare
       May have hydrocele and palpable swelling
Epididymitis
   Differential Diagnosis
       Mumps
       Testicular torsion
       Testicular abscess
       Tumor of testicle with or with out hemorrhage
       Hydrocele
       Trauma
       Infarction
Epididymitis
   Diagnostic Tests/Findings
       Men
            STD testing
            Urinalysis
            Culture of urine
            Scrotal ultrasonography
            CBC- may show increased WBC and left shift
       Older man
            Search for obstruction at the bladder outlet, IVP
Epididymitis in Boys
   Requires more extensive work up
   Refer for consult
   IVP, VCUG, Scrotal US,
   Surgical exploration may be required
Epididymitis
   Physical exam
       Inspect for edema and erythema
       Palpate scrotum
       Will appear normal, with palpable swelling
        if epididymis is usually present
       Passive elevation of testis may relieve pain-
        Prehn’s sign
       Rectal exam, may elicit prostatic
        tenderness and lead to urethral discharge
Epididymitis
   Treatment
       Referral or consult if
            Patient is a child
            Systemic symptoms of infection- should be
             hospitalized
            Possible torsion of testes
Epididymitis
   Treatment con’t
       Men less than 35 year, with probable STD
            Cefriaxone 250mg IM plus doxycycline
       Men less than 35 years, with enteric organisms or
        allergic to tetracyclines and or cephalosporins
            Floxin 200-400mg bid for 10 days (17years and older)
            Or Levofloxacin 500 QD times 10 days
       Treat sexual partners- PRN
       Instruct to avoid intercourse until all treatments
        completed
Epididymitis
   Men over 35 years, men allergic to
    cephalosporins and/or tetracyclines, and for
    cases most likely caused by enteric organisms
       Floxin 300 bid for 10 days
       Levaquin 500 bid for 10 days
   All cases- treatment
       Bed rest, scrotal elevation, analgesic, ice, heat,sitz
        baths
   Follow up
       Recheck in three days, reevaluate
       For older men reculture after treatment
Testicular torsion
   Definition; twisting of spermatic cord
    which results in compromised blood
    flow
   Patho; occurs when free floating testis
    rotates on the spermatic cord and
    occludes its blood supply, may occur in
    sleep or after activity or trauma
    (masturbation)
Testicular Torsion
   Seen in boys 6-12 and teens and in men over
    21
   If not surgically treated there will be ischemic
    injury and necrosis of the testis
   May also have lower abdominal pain with
    leads to misdiagnosis
   Nausea and vomiting in about half the
    patients
   MUST INTERVENE IN 4-8 HOURS
Benign Prostatic Hyperplasia
   Definition; progressive, benign hyperplasia of
    prostate gland tissue
   Etiology/Incidence
       Cause is uncertain
       About 50% of men have BPH by age 60
       By age 85 is 90%
       Most common cause of bladder outlet obstruction
        in men over 50
       Symptoms are attributed to mechanical
        obstruction of the urethra by the enlarged
        prostate gland
Benign Prostatic Hyperplasia
   Signs and symptoms
       Gradual worsening of the following
       Frequency, urgency, urge incontinence
       Nocturia, dysuria
       Weak urinary stream, dribbling, hesitancy
       Sensation of full bladder even after voiding
       retention
Benign Prostatic Hyperplasia
   Differential Diagnosis
       Urethral stricture
       Prostate or bladder cancer
       Neurogenic bladder
       Bladder calculus
       Acute or chronic prostatitis
       Bladder neck contractor
       Medications that affect micturition
Benign Prostatic Hyperplasia
   Physical findings
   Abdomen- may have distended bladder
    secondary to retention
   Prostate- nontender with asymmetrical or
    symmetrical enlargement, gross enlargement
    atypical
   Consistency is smooth and rubbery (eraser)
   Nodules may be present- differentiation from
    BHP and CA needs biopsy
        Benign Prostatic Hyperplasia
   Tests/ Findings
       UA- NO hematureia or UTI
       Urinary flow rate- voided volume and peak urinary flow
        rate (Uroflowmetry) may show detect obstruction of
        flow
       Abdominal US- rules out upper tract pathology
       PSA levels should be normal
       Consider postvoid residual urine volume
       Creatinine to assess renal function, elevated levels
        suggest urinary retention or underlying renal disease-
        refer this patient
Benign Prostatic Hyperplasia
   Treatment/ Management
       Refer men who have the following
            Refractory urinary retention who have failed
             one attempt at cath removal
            Recurrent infection, recurrent retention,
             refractory hematuria, bladder stone, large
             bladder diverticula's, or renal insufficiency
             related to BPH
            Consider referral if complications exist or if
             patients have severe symptoms
Benign Prostatic Hyperplasia
   Management
       For men who have no indications for
        surgery
            Discuss risks and benefits of all options
            Watchful waiting (observation)
            Behavioral techniques to reduce symptoms
                 Limit fluid after dinner
                 Avoid medications such as. Antidepressant,
                  antiparkinson agents, antipsychotic, antispasmodics,
                  cold meds, and diuretics
Benign Prostatic Hyperplasia
   Medication treatments
       Alpha adrenergic blocker- for smaller prostates
       5alpha adrenergic blocker for larger prostates
       Combo therapy is an a-adrenergic blocker and
        finasteride is used now for men with large
        prostates
   Surgery has the best chance for relief of
    symptoms,but has the greatest risks
Benign Prostatic Hyperplasia
   Follow up
       Teach signs of retention and obstruction
       If observing for now, recheck every 6-12
        months
       If on meds recheck in 4-6 weeks
       If post surgery- follow up is at the
        discretion of the urologist