- •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
168 CHAPTER 5 Infections and inflammatory conditions
Prostatitis: presentation, evaluation, and treatment
Evaluation
•History of previous urological disease and conditions
•NIH-CPSI questionnaire (National Institute of Health Chronic Prostatitis Symptom Index). This scores three main symptom areas: pain (location, frequency, severity), voiding (obstructive and irritative symptoms), and impact on quality of life. It can be useful in guiding response to therapy.
•Segmented urine cultures and EPS. When cultures are negative, increased leukocytes per high-powered field (>10) favor a diagnosis of inflammatory chronic pelvic pain syndrome.
Acute bacterial prostatitis
Acute bacterial prostatitis (NIH I) is infection of the prostate associated with lower urinary tract infection and generalized sepsis. E. coli is the most common cause; Pseudomonas, Serratia, Klebsiella, and enterococci are less common causes.
Acute onset of fevers, chills, nausea and vomiting; perineal and suprapubic pain; irritative urinary symptoms (urinary frequency, urgency, and dysuria); and obstructive urinary symptoms (hesitancy, strangury, intermittent stream or urinary retention) are the hallmarks. Signs of systemic toxicity (fever, tachycardia, hypotension) may be present.
Suprapubic tenderness and a palpable bladder will be present if there is urinary retention. On digital rectal examination, the prostate is extremely tender and aggressive manipulation of the prostate is to be discouraged.
Treatment
If the patient is not systemically ill, use an oral quinolone such as ciprofloxacin 500 mg bid for at least 3 weeks.
For a patient who is ill, use IV gentamicin with a third-generation cephalosporin or ampicillin, pain relief, anti-inflammatory medications, and relief of retention if present. Traditional teaching was that a suprapubic (rather than urethral) catheter should be inserted to avoid the potential obstruction of prostatic urethral ducts by a urethral catheter. However, in-and- out catheterization or a short period with an indwelling catheter probably does no harm and is certainly an easier way of relieving retention than suprapubic catheterization.
A total course of 3 weeks of antibiotics is essential to minimize the chance for the development of chronic bacterial prostatitis. A negative culture should be confirmed after treatment.
Chronic bacterial prostatitis
NIH II classification of chronic bacterial prostatitis typically presents with history of documented recurrent UTI. E coli is responsible for 75–80% of cases, with enterococci and other gram-negative aerobes responsible.
Chronic episodes of genitourinary pain and voiding dysfunction may be a feature. DRE may show a tender, enlarged, and boggy prostate, or it may be entirely normal.
PROSTATITIS: PRESENTATION, EVALUATION, AND TREATMENT 169
This condition is characterized by bacterial growth in culture of the expressed prostatic fluid, semen, or post-massage urine specimen. The EPS usually contains >10 WBCs/HPF and macrophages. The recurrent organism is usually the same each time.
Treatment
An empiric trial of antibiotics is used if the evaluation suggests chronic bacterial prostatitis and is administered long term (4–6 weeks).
•Trimethoprim-sulfamethoxazole (TMP-SMZ) 80/400 mg PO bid given twice a day
•Fluoroquinolone (e.g., ciprofloxacin 500 mg or ofloxacin 400 mg) PO bid. Ofloxin may be the best choice in men <35 years because of increased activity against Chlamydia.
Chronic pelvic pain syndrome (CPPS)
Both inflammatory (IIIA) and noninflammatory (IIIB) types present with >3-month history of localized pain (perineal, suprapubic, penile, groin, or external genitalia); pain with ejaculation; LUTS (frequency, urgency, poor flow); and erectile dysfunction. Prostadynia is an older term that should no longer be used.
Etiology is not clear. Symptoms can recur over time and severely affect the patient’s quality of life.
There is no evidence of pyuria and bacteriuria, but excess WBCs in EPS may be found in IIIA but are absent in IIIB.
Treatment
•While there is not a defined role for antibiotics, an empiric trial of a quinolone or TMP-SMX is often tried with variable results.
•A-Blockers (doxazosin, terazosin, tamsulosin) have become the mainstay of therapy. These act on prostate and bladder neck A-receptors, causing smooth muscle relaxation, improved urinary flow, and reduced intraprostatic ductal reflux.1
•Anti-inflammatory drugs
•Sitz baths, more frequent ejaculation, dietary modifications (avoid caffeine, tobacco, spicy foods), biofeedback, and significant psychological support all may have potential benefits in this group of patients.
•Microwave thermotherapy is considered when severe symptoms are refractory to all treatments.
Asymptomatic inflammatory prostatitis
There is incidental histological diagnosis of prostatic inflammation from prostate tissue taken for other indications (i.e., biopsy for raised PSA). No specific therapy is usually indicated for this incidental finding.
Further reading
Habermacher GM, Chason JT, Schaeffer AJ (2006). Prostatitis/chronic pelvic pain syndrome. Annu Rev Med 57:195–206.
1 Nickel JC (2005). Alpha-blockers for treatment of the prostatitis syndromes. Rev Urol. 7(Suppl 8):S18–25.
170 CHAPTER 5 Infections and inflammatory conditions
Other prostate infections
Prostatic abscess
Failure of acute bacterial prostatitis to respond to an appropriate antibiotic treatment regimen (i.e., persistent symptoms and fever while on antibiotic therapy) suggests the development of a prostatic abscess.
A transrectal ultrasound or CT scan (if the former proves too painful) is the best way of diagnosing a prostatic abscess. This may be drained by a transurethral incision.
Granulomatous prostatitis
This is a very uncommon form of prostatitis and can result from bacterial, viral, or fungal infection, systemic granulomatous diseases, and the use of BCG to treat bladder cancer. Most often it is idiopathic.
Patients can present as with bacterial prostatitis. Rectal examination is similar to prostate cancer (hard, indurated, nodular). The diagnosis is usually made after prostate biopsy to rule out cancer.
Some patients respond to antibiotic therapy and temporary bladder drainage. With histological evidence of eosinophilic granulomatous prostatitis, steroids may be useful.
TURP may be necessary if there is no response to treatment and the patient has bladder outlet obstruction.
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