- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
142 CHAPTER 5 Infections and inflammatory conditions
Recurrent urinary tract infection
Recurrent UTI is defined as >2 infections in 6 months, or 3 within 12 months. It may be due to reinfection (i.e., infection by different bacteria) or bacterial persistence (infection by the same organism originating from a focus within the urinary tract).
Bacterial persistence
This implies the presence of bacteria within a site in the urinary tract, the presence of which leads to repeat episodes of infection. Such sites include urolithiasis anywhere in the urinary tract, chronically infected pro-state (chronic bacterial prostatitis), bacteria within an obstructed or atrophic kidney, bacteria gaining access to the urinary tract via a fistula (bowel or vagina), and bacteria within a urethral diverticulum.
Thus, recurrent urinary infection due to bacterial persistence implies a functional or anatomical problem. The recurrent UTIs will not resolve until this underlying problem has been addressed.
Reinfections
Reinfections usually occur after a prolonged interval (months) from the previous infection and are often caused by a different organism than the previous infecting bacterium. Bacterial persistence often leads to frequent recurrence of infection (within days or weeks) and the infecting organism is usually the same organism as that causing the previous infection(s).
Women with reinfection do not usually have an underlying functional or anatomical abnormality. Reinfections in women are associated with increased vaginal mucosal receptivity for uropathogens and ascending colonization from the fecal flora. These women cannot be cured of their predisposition to recurrent UTIs, but they can be managed by a variety of techniques (see below).
Men with reinfection may have underlying BLADDER OUTLET OBSTRUCTION (due to prostate enlargement or urethral stricture), which makes them more likely to develop a repeat infection, but between infections their urine is sterile (i.e., they do not have bacterial persistence between symptomatic UTIs). A urethrogram, flexible cystoscopy, postvoid bladder ultrasound for residual urine volume, and, in some cases, urodynamics may be helpful in establishing the potential causes.
Both men and women with bacterial persistence usually have an underlying functional or anatomical abnormality and they can potentially be cured of their recurrent UTIs if this abnormality is identified and corrected.
Management of women with recurrent UTIs from reinfection
Most urologists will arrange a series of screening tests (KUB radiograph, renal ultrasound, CT scan, flexible cystoscopy) to evaluate for a potential source of bacterial persistence. In the absence of finding an underlying functional or anatomic abnormality, many of these patients cannot be cured of their tendency to recurrent UTI, but they can be managed in one of the following ways.
RECURRENT URINARY TRACT INFECTION 143
Avoidance of spermicides used with the diaphragm or on condoms
Spermicides containing nonoxynol-9 reduce vaginal colonization with lactobacilli and may enhance E. coli adherence to urothelial cells. Recommend an alternative form of contraception.
Estrogen replacement therapy
Lack of estrogen in postmenopausal women causes loss of vaginal lactobacilli and increased colonization by E. coli. In postmenopausal women, estrogen replacement, locally or systemically, has been shown to decrease the rate of recurrent UTI by recolonization of the vagina with lactobacilli and to eliminate colonization with bacterial uropathogens.1
Low-dose antibiotic prophylaxis
Oral antimicrobial therapy with full-dose oral tetracyclines, ampicillin, sulfonamides, amoxicillin, and cephalexin causes resistant strains in the fecal flora and subsequent resistant UTIs. However, trimethoprim, nitrofurantoin, low-dose cephalexin, and the fluoroquinolones appear to have minimal adverse effects on the fecal and vaginal flora.
Efficacy of prophylaxis
Recurrences of UTI may be reduced by as much as 90% when compared with placebo.2 Prophylactic therapy requires only a small dose of an antimicrobial agent, generally given at bedtime for 6 to 12 months.
Symptomatic reinfection during prophylactic therapy is managed with a full therapeutic dose with the same prophylactic antibiotic or another antibiotic. Prophylaxis can then be restarted.
Symptomatic reinfection immediately after cessation of prophylactic therapy is managed by restarting nightly prophylaxis.
Trimethoprim
The gut is a reservoir for organisms that colonize the periurethral area and that may subsequently cause episodes of acute cystitis in young women. Trimethoprim eradicates gram-negative aerobic flora from the gut and vaginal fluid (i.e., it eliminates the pathogens from the infective source). Trimethoprim is also concentrated in bactericidal concentrations in the urine following an oral dose.
Dosage for trimethoprim is 100 mg/day.
Adverse reactions include blood dyscrasias due to bone marrow depression; rarely, Stevens–Johnson syndrome; allergic reactions; and rarely, erythema multiforme, toxic epidermal necrolysis (photosensitivity).
Nitrofurantoin
Nitrofurantoin is completely absorbed and/or degraded or inactivated in the upper intestinal tract and therefore has no effect on gut flora. It is present for brief periods at high concentrations in the urine and leads to repeated elimination of bacteria from the urine. Nitrofurantoin prophylaxis therefore does not lead to a change in vaginal or introital colonization with Enterobacteria.
1 Perrotta C, Aznar M, Mejia R, Albert X, Ng CW (2008). Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 16;(2):CD005131. 2 Kaur H, Arunkalaivanan AS (2007). Urethral pain syndrome and its management. Obstet Gynecol Surv. 62(5):348–351
144 CHAPTER 5 Infections and inflammatory conditions
The bacteria colonizing the vagina remain susceptible to nitrofurantoin because of the lack of bacterial resistance in the fecal flora.
Dosage of nitrofurantoin is 50 mg/day or nitrofurantoin macrocrystals 100 mg/day.
Adverse reactions include acute pulmonary reactions (pulmonary fibrosis has been reported), allergic reactions (angioedema, anaphylaxis, urticaria, rash and pruritus), peripheral neuropathy, blood dyscrasias (agranulocytosis, thrombocytopenia, aplastic anemia), liver damage, lupus erythemato- sus–like syndrome, and chronic pulmonary reactions.
The risk of an adverse reaction increases with age, with the greatest number occurring in patients older than 50 years.
Cephalexin
Cephalexin at low dose is an excellent prophylactic agent because fecal resistance does not develop at this low dosage.
Dosage of cephalexin is 125–250 mg/day. Adverse reactions include allergic reactions.
Fluoroquinolones (e.g., Ciprofloxacin)
Short courses can eradicate Enterobacteria from fecal and vaginal flora. Dosage of ciprofloxacin is 125 mg/day.
Adverse reactions to quinolones include tendon damage (including rupture), which may occur within 48 hours of starting treatment (quinolones are contraindicated in patients with a history of tendon disorders related to quinolone use; elderly patients are more prone, and risk is increased by concomitant use of corticosteroids).
Other adverse reactions are arthropathy in children, Stevens–Johnson syndrome, allergic reactions, and pseudomembranous colitis.
Alternative therapies
Natural yogurt
Yogurt applied to the vulva and vagina can help restore normal vaginal flora, and some believe that this improves the natural resistance to recurrent infections. Immunoactive prophylaxis using various products such a vaginal vaccines are under study, and the use of probiotic such as lactobacillus remains unproven.3
There is some evidence from four randomized controlled trails (RCTs) that cranberry juice may decrease the number of symptomatic UTIs over a 12-month period in women with recurrent UTI.
Post-intercourse antibiotic prophylaxis
Sexual intercourse has been established as an important risk factor for acute cystitis in women, and women who use the diaphragm have a significantly greater risk of UTI than women who use other contraceptive methods. Post-intercourse therapy with antimicrobials such as nitrofurantoin, cephalexin, or trimethoprim, taken as a single dose, effectively reduces the incidence of reinfection.
3 Naber KG, Cho YH, Matsumoto T, Schaeffer AJ (2009). Immunoactive prophylaxis of recurrent urinary tract infections: a meta-analysis. Int J Antimicrob Agents 33(2):111–119.
RECURRENT URINARY TRACT INFECTION 145
“Self-start therapy”
Women keep a home supply of an antibiotic (e.g., trimethoprim, nitrofurantoin, a fluoroquinolone) and start treatment when they develop symptoms suggestive of UTI. This program should be limited to those who have been completely evaluated and are knowledgeable in the appropriate use of self-directed therapy.
Management of men and women with recurrent UTIs due to bacterial persistence
Investigations
These are directed at identifying the potential causes of bacterial persistence, outlined above.
•KUB radiograph to detect radio-opaque renal calculi.
•Renal ultrasound to detect hydronephrosis and renal calculi. If hydro-nephrosis is present, but the ureter is not dilated, consider the possibility of a radio-opaque stone obstructing the PUJ (this will
usually be seen as an acoustic shadow on the ultrasound; arrange a CT urogram if no stone is seen) or a PUJO (arrange a MAG3 renogram to
determine the presence or absence of PUJO).
•Determination of post-void residual urine volume by bladder ultrasound
•IVP or CT urogram where a stone is suspected but not identified on plain X-ray or ultrasound
•Flexible cystoscopy to identify possible causes of recurrent UTIs such as bladder stones, an underlying bladder cancer (rare), urethral or bladder neck stricture, or fistula
Treatment
Treatment depends on the functional or anatomical abnormality identified as the cause of the bacterial persistence. If a stone or multiple stones are identified, they should be removed. If there is obstruction (e.g., BPO, PUJO, DSD in spinal injured patients), this should be corrected.
Further reading
Schooff M, Hill K (2005). Antibiotics for recurrent urinary tract infections [review]. Am Fam Physician 1;71(7):1301–1302.