13
Inflammatory and Pain Conditions of
the Male Genitourinary Tract
Prostatitis and Related Pain Conditions, Orchitis, and
Epididymitis
J. Curtis Nickel
Questions
1.The most likely candidate for cryptic infection in category III prostatitis is:
a.Chlamydia.
b.Ureaplasma.
c.nanobacteria.
d.Corynebacteria.
e.unknown.
2.The presence of white blood cells (WBCs) in the expressed prostatic secretion (EPS) of patients with category III chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS):
a.confirms significant prostatic inflammation.
b.correlates with severity of symptoms.
c.differentiates CP/CPPS patients from control patients.
d.differentiates CP/CPPS category IIIA patients from category IIIB patients.
e.differentiates CP category II patients from CP/CPPS category III patients.
3.The National Institutes of Health Chronic Prostatitis Symptom Index is:
a.a research tool that is useful only in clinical trials.
b.a research tool that is useful in clinical practice.
c.another invalidated and unreliable clinical symptom index.
d.an index that has been validated only in English.
e.a simple pain questionnaire that can be applied to prostatitis patients.
4.An obese 26-year-old man has an 8-hour history of severe dysuria, stranguria, and suprapubic and perineal pain with fever. On examination, he has suprapubic tenderness, and his prostate is enlarged, boggy, and exquisitely tender. Urinalysis shows pyuria. He continues to complain of symptoms despite insertion of a Foley catheter and has persistent fever following 30 hours of intravenous gentamicin and ampicillin. Culture grew Escherichia coli. What is the best next step?
a.Change antibiotic to a third-generation cephalosporin.
b.Perform a transrectal ultrasonographic examination.
c.Perform a cystoscopic examination.
d.Perform a bladder scan ultrasonographic examination.
e.Perform a computed tomography scan.
5.A 36-year-old man has a 4-month history of dull perineal and suprapubic discomfort, postejaculatory pain, and moderate obstructive voiding symptoms. A preprostatic massage urine sample was sterile, and microscopic evaluation of the sediment showed 2 white blood cells (WBCs) per high power field (HPF). No EPS was obtained during an uncomfortable digital rectal examination. A postprostatic massage urine sample grew 102 Staphylococcus epidermidis organisms per mL, and microscopy of the sediment showed 10 to 12 WBCs/HPF. What is the National Institutes of Health (NIH) chronic prostatitis classification?
a.Category I
b.Category II
c.Category IIIA
d.Category IIIB
e.Category IV
6.A 24-year-old man has an 8-month history of obstructive voiding symptoms and perineal and ejaculatory discomfort. A preprostatic massage urine sample was sterile, and microscopic evaluation of sediment showed 1 WBC/HPF. Microscopy of a minute amount of EPS showed 3 WBCs/HPF. A postprostatic massage urine sample was sterile, and microscopy of the sediment showed 2 WBCs/HPF. The CP/CPPS classification is:
a.Category I.
b.Category II.
c.Category IIIA.
d.Category IIIB.
e.Category IV.
7.A 42-year-old man was treated for cystitis but continued to have dysuria, ejaculatory pain, and perineal/testicular discomfort after 7 days of antibiotics. The prostate examination was unremarkable. A midstream urine sample was sterile, but culture of a drop of EPS produced moderate growth of Enterococcus faecalis. A postprostatic massage urine sample grew 102 E. faecalis organisms, and microscopic examination of the sediment showed 12 WBCs/HPF. What is the NIH classification?
a.Category I
b.Category II
c.Category IIIA
d.Category IIIB
e.Category IV
8.A 32-year-old man had been successfully treated for an E. coli cystitis with trimethoprim-sulfamethoxazole (7-day course) 4 months previously. A recurrence of similar symptoms was again successfully treated with ciprofloxacin (3 days), but no culture was done at this time. The patient presents 3 days after antibiotics were discontinued with continued perineal discomfort, ejaculatory pain, and mild dysuria. Pre-and postprostatic massage urine and EPS samples were sterile. Evaluation of the EPS showed 20 WBCs/HPF. The prostate felt normal. The best next step is:
a.treat with anti-inflammatory agents.
b.do a standard Meares-Stamey 4-glass test.
c.wait for 3 days and do standard Meares-Stamey 4-glass test.
d.restart trimethoprim-sulfamethoxazole.
e.restart fluoroquinolone antibiotics.
9.A 47-year-old man has a 5-year history of perineal and suprapubic pain/discomfort and obstructive voiding symptoms that has not responded to multiple courses of antibiotics, α-blockers, anti-inflammatory agents, repetitive prostatic massage, or phytotherapy. The prostate is tender, and the postprostatic massage urine sample was sterile and showed 20 WBCs/HPF. The PSA value was 1.2 mg/mL. What is the best next step?
a.Incision of bladder neck
b.Flow rate and bladder scan for residual urine
c.Video-urodynamics
d.CT scan of pelvis
e.Cystoscopy and transrectal ultrasound
.A 28-year-old man has been successfully treated for three episodes of cystitis (cultures not performed). He now presents with a 3-day history of frequency, urgency, dysuria, and suprapubic discomfort. The prostate feels normal and is nontender. An abdominal and pelvic ultrasonographic study had normal results. A midstream culture done 24 hours earlier by his family physician grew 105 E. coli organisms per mL. What is the best next step?
a.A lower urinary tract localization test (2-or 4-glass test)
b.Several days of nitrofurantoin therapy followed by lower urinary tract localization test
c.Four weeks of fluoroquinolone antibiotics therapy
d.Cystoscopy
e.Transrectal ultrasonography
.A 37-year-old man has a 3-month history of urinary frequency and urgency and discomfort localized to the perineum, suprapubic area, testicles, and penis. A sterile postprostatic massage urine sample showed 15 WBCs/HPF on microscopy. A year earlier, the patient had been successfully treated for moderately severe symptoms with an unspecified antibiotic. He is allergic to many medications, including ciprofloxacin. The symptoms are now a significant bother and affecting his quality of life. The best initial treatment is a trial of:
a.anti-inflammatory agents.
b.tetracycline.
c.trimethoprim-sulfamethoxazole.
d.trimethoprim.
e.carbenicillin.
.A 58-year-old man with a 2-year history of symptomatic recurrent urinary tract infections with Pseudomonas (6 to 8 per year) is asymptomatic between treated episodes. Pseudomonas aeruginosa is localized to the EPS and postprostatic massage (voided bladder 3, VB3) samples (but not the midstream urine sample, or VB2) during a period when he was asymptomatic. The EPS shows severe pyuria with WBC plugs or aggregates on microscopy. Transrectal ultrasonography shows extensive prostatic calcifications. Cystoscopy results are normal, residual urine is negligible, and the PSA value is 1.0 mg/mL. What is the best treatment?
a. Low-dose prophylactic antibiotics
b.Intraprostatic antibiotic injection
c.Radical TURP
d.Radical prostatectomy
e.Transurethral microwave thermotherapy
.A 24-year-old man with a 6-year history of severe perineal pain with irritative and obstructive voiding symptoms has no significant benefits with 4 weeks of therapy with trimethoprim-sulfamethoxazole, anti-inflammatory agents, α- blockers, or phytotherapy respectively. Prostate-specific specimens were sterile, and no WBCs were noted on microscopy. The physical examination had normal findings except for anal sphincter spasm and a tender but normalfeeling prostate gland. Video-urodynamics showed adequate funneling of the bladder neck with seemingly poor opening of the striated sphincter area and abnormal striated sphincter EMG activity during the emptying phase of micturition. What is the best next step?
a.Four weeks of fluoroquinolone therapy
b.Muscle relaxant therapy
c.Bladder neck incision
d.Biofeedback
e.Transurethral microwave thermotherapy
.A 52-year-old man continues to have high, spiking fever despite suprapubic catheterization and 36 hours of treatment with wide-spectrum intravenous antibiotics. Transrectal ultrasonography confirms a large prostatic abscess. What is the best next step?
a.Transperineal drainage
b.Transrectal aspiration
c.Transurethral drainage
d.Open drainage
e.Suprapubic aspiration
.Alpha blocker therapy for CP/CPPS:
a.is of proven value for Category I.
b.is of proven value for Category II.
c.is of proven value for Category III.
d.is of proven value for Category II and III.
e.May have value in some patients with Category III.
.Mandatory evaluation of a patient with CP/CPPS includes history, physical examination, and:
a. urine analysis, urine culture.
b.urine analysis, urine culture, Chronic Prostatitis Symptom Index (CPSI).
c.urine analysis, urine culture, CPSI, urine cytology.
d.urine analysis, urine culture, CPSI, urine cytology, postvoid residual.
e.urine analysis, urine culture, CPSI, urine cytology, postvoid residual, sexual function questionnaire.
.An asymptomatic 65-year-old man undergoes a prostate biopsy because of an indistinct prostate asymmetry on digital rectal examination. The PSA value is
2.2ng/mL. Pathology reveals extensive glandular and periglandular infiltration with acute and chronic inflammatory cells. What is the best next step?
a.Observation
b.Four weeks of antibiotics and then reassess
c.Four weeks of antibiotics and anti-inflammatories and then reassess
d.Repeat biopsy
e.Cystoscopy
.UPOINT is:
a.a painful urological trigger point.
b.an inflammatory biomarker.
c.a phenotype categorization.
d.a chronic prostatitis diagnosis.
e.a microscopic technique.
.Acupuncture as a treatment for CP/CPPS:
a.cannot be tested because of difficulty in developing a validated sham procedure.
b.is characterized by the increased effectiveness of electroacupuncture over traditional acupuncture.
c.has been proved ineffective in randomized controlled trials.
d.is a reasonable choice for selected patients.
e.has been shown to compare favorably to alpha blockers in comparative clinical trials.
.The following conservative therapy is associated with increased pain and disability in CP/CPPS patients:
a.rest.
b.diet modification.
c.exercise.
d.heat therapy.
e. physiotherapy.
.The following minimally invasive procedure does not provide any proven efficacy to ameliorate symptoms in men with CP/CPPS:
a.extracorporeal shock wave therapy.
b.electrical neuromodulation.
c.microwave thermotherapy.
d.botulinum toxin.
e.balloon dilation.
.Alpha blocker monotherapy for CP/CPPS category III is:
a.not recommended.
b.recommended for patients with obstructive voiding symptoms.
c.recommended for patients who are alpha blocker naïve.
e.recommended for patients who are alpha blocker naïve and have obstructive voiding symptoms.
f.recommended for patients who are newly diagnosed, alpha blocker naïve, and have obstructive voiding symptoms.
.Epididymectomy for chronic epididymalgia provides the best results when performed:
a.in recently diagnosed patients.
b.in postinfection cases.
c.when the etiology is traumatic.
d.postvasectomy.
e.when associated with Behçet disease.
Pathology
1.A 65-year-old man undergoes a transurethral resection of the prostate. The pathology is depicted in Figure 13-1, and the report states that there is amyloid that fills several benign prostatic acini. The next step in management is to:
FIGURE 13-1 (From Bostwick DG, Cheng L. Urologic surgical pathology. 2nd ed.
Edinburgh: Mosby; 2008.)
a.perform a transrectal biopsy.
b.refer to medicine for evaluation of systemic amyloidosis.
c.inquire as to whether the patient has been on estrogens.
d.ask the pathologist to perform immune stains for basal cells.
e.ask the pathologist if the diagnosis could be corpora amylacea.
2.A 70-year-old man had a transurethral resection of the prostate 10 years previously. A repeat procedure is performed, and the pathology depicted in Figure 13-2 is reported as showing granulomatous prostatitis. The next step in management is to:
FIGURE 13-2 (From Bostwick DG, Cheng L. Urologic surgical pathology. 2nd ed.
Edinburgh: Mosby; 2008.)
a.have the patient obtain a PPD.
b.refer to Infectious Disease for treatment.
c.inquire as to whether the patient received BCG.
d.observe the patient.
e.ask the pathologist to stain the slide for tuberculosis.
Imaging
1.A 40-year-old man with right scrotal pain is seen in the emergency department. Scrotal ultrasonography is performed (Figure 13-3). The most likely diagnosis is:
FIGURE 13-3
a.adenomatoid tumor of epididymis.
b.testicular torsion.
c.primary testicular neoplasm.
d.epididymo-orchitis.
e.orchitis.
2.A 60-year-old man presents with pelvic and perineal discomfort, fever, and chills. A CT image is shown in Figure 13-4. The next step in management is: