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HISTORY
FEMALE - feve r unc om mo n with unco mp licate d cys titis; hig h fev ers s ugg est p yelone phritis
- Hollow viscus:
- Ure tal obstruction
- Urin ary retention
- Capsule of an organ
- Acute prosta titis
- Acute pyelon ephritis
- Pain w malignancy is late manifestation - advanced
Ren al Pa in
Uretal Pain:
- Acute urinary retention -> severe supra pubic area (SPA ) pain
- Chronic -> painless despite large vesical distention
- Acute c ystitis: referred to distal urethra and associated with micturition
Prostatic Pain:
Penile Pain:
- Ere ct pe nis
- Peyronie's disease:
Fibro us pla que of tun ica alb ugine a -> p ainfu l curv ature of ere ct pe nis
- Priapism: prolonged painful erection necessitating immediate intervention
- Acute c onditions :
- Pain in scr otum with ra diatio n to ips ilatera l groin
- Trau ma, to rsion, ep ididym o-orch itis
- Chron ic pain:
- Epididymitis: if acute -> pain may persist for months following successful tx
- Varico cele or h ydroce le: dull heaviness w/o radiation
HEMATURIA
- Less frequent causes: staghorn calcu li, glomeruloneph ropathies, polycystic kidne ys
FREQUENCY:
Cloudy Urine:
- Urinary trac t infection (U TI)
- Alk aline p H co mm on in a bse nce of UT I - pre cipita tion o f pho sph ate c rystal
- Chyluria: lymph in urine (rare)
- Fistula UT - lymphatic systems
- Filariasis, TB, retroperitoneal tumors
PHYSICAL EXAM
GENERAL:
COMMON ABNORMALITIES
Hydro cele : collec tion o f fluid b etwe en 2 la yers o f tunic a vag inalis
- Dx via translumination
- 10% of tes ticula r tum ors h ave h ydroc ele
* Another analogy is to compare normal prostate to the tip of the nose (which also simulates the median
sulcus, the boggy prostate to the lips and the cancerous prostate to the forehead)
- Inspec t introits for atro phic cha nges, u lcers, d/c, w arts
- Ure thral m eatu s: ins pec t for c arun cles and p alpat ed fo r tum ors o r dive rticula
- Bimanual exam: bladder, uterus, adnexa
Specimen Collection
Dipstick of Urine
pH:
- No role in screen asymptomatic adults except for pregnant women
- Rang e 5.0-9.0
- Alkaline urine with UTI suggests urea-splitting organism
- P m irabilis is most common
- Klebsiella, pseudomonas, providencia species, staphylococcus
- Acid in pt with stones - calc uli: uric acid or cystine stones
- Failure to acidify below 5.5 with metabolic acidosis: suggests renal tubular acidosis.
PROTEIN
- Bromphenol blue detects concentration > 10 mg/dl
- Me asu res a lbum in
- Not sensitive for lt chain immunoglobulins (Bence Jones)
- Fals e pos itive if n um erou s leuk ocyte s and epith elial ce lls
UROBILINOGEN
-
Fro m c atab olism of co njug ated bilirub in in gu t by ba cteria
-
Most urobilinogen is cleared by liver
-
Increased with hemolytic processes or hepatocellular disease
-
Decreased
- Broad spectru m an tibiotics (alter flora of gut)
- Complete biliary obstruction
BILIRUBIN
KETONES
NITRITES
LEUKOCYTE ESTERASE:
- Enzym e produ ced by W BC; pos itive su gge sts b acte riuria
- False positive from specimen contamination
- False negative:
- High specific gravity (SG), glycosuria, urobilinogen
- Me dica tions : rifam pin, p hen azop yridine , asc orbic acid
BLOOD
- Me asu res in tact R BCs , free Hgb , myo globin
- False positive: menstrual blood
- False positive
- Concentrated urine as 1000 RBC/ml is normal excretion
- Vigorous exercise and vitamins or foods with high oxidant levels
LEUKOCYTES
- Greater than 5 per high power field (hpf) co nsidere d significan t pyuria
- Indicative o f injury to urinary tra ct which may or may not be due to infection
- Non -infe ctiou s ca use s of p yuria
Calculous disease, stricture disease, neoplasm,
glom erulo nep hrop athy, in terst itial cys titis
-Factors affecting count
- Method of collection
- State of hydration; degree of injury to urinary tract
ERYTHROCYTES
EPITHELIAL CELLS
Right: vaginal
squamous
Left: Transitional
Candida
CASTS
Upper: WBC cast
Lower: Hyaline cast
CRYSTALS
- Acid urine : uric acid , oxalate , cystine crystals
- Alkaline u rine: phospate crystals
- Seen in norm al pts as w ell as stone -form ers: uric acid, o xalate, ph ospha te
- Cystin e crys tals are p atho logic: seen only wit h cys tinuria
CRYSTALS
Right:Cystine
Left: Mg Ammonium
Phosphate
- Coliform usual etiologic agent for uncomplicated nosoc omial UTI - E coli most comm on
- Nosocomial often due to more resistant organisms - may require IV therapy
- Renal infections may result in loss of renal function if untreated
- Colony c ount
- Previously thought that 100,000 was required to treat for infection
- Studies have sh own tha t 50% s ymptom atic wom en have lower co unts
- Absen ce of pyur ia correlate s poorly w U TI
- U/A alone is not adequate for diagnosis - need culture
- Length of treatment: soft tissue vs mucosal
- Soft tissue - 3-4 weeks intensive therapy - pyelonephritis, parostitis
- Mucosal: 1-3 days therapy - cystitis
Pers isten t bac teriur ia: occurs when tra ct is sterilized bu t persistent source of infection remains
- Stones, chronic pyelonephritis, prostatitis, vesicoenteric or vesicovaginal fistulas
- Obstructive uropathy, foreign bodies, urethral diverticula.
Reinfection: new infe ction with ne w patho gens o ccur fo llowing suc cessf ul treatm ent
Susceptibility Factors:
Bacterial Virulence Factors - E coli accounts for over 90% of first infections
- Greater than 150 strains - most by 5 serogroups (01, 04, 06, 018, 075)
- Implicated strains: have greater bacterial adherence
- Bac terial f imb riae o r pili
- Strains with pili-fimbriae associated with pyelon ephritis
- Strains without w/o pili-fimbriae cause pyelonephritis only with reflux
Susceptibility Factors
Male-specific factors:
ACUTE CYSTITIS
- Irritative voiding
- Patie nt us ually af ebrile
- Positive urine culture
General Considerations
Clinical Findings
Laboratory Findings
- UA : pyuria , bac teriur ia and varyin g hem aturia
- Severity may not correlate w degree pyuria and bacteriuria
- Positive urine culture but count need not be > 100,0000 (as was previous thinking)
Imaging
-
Vulvovaginitis, PID (distinguished via pelvic exam and U/A)
-
Prostatitis and urethritis men (distinguished via urethral d/c - prostatic tenderness)
-
Cystitis in men is rare (suggests infected stones, prostatitis, chronic urinary retention)
-
Non-infectious cystitis-like syndrome
- Pelvic irradiation and chemotherapy (cyclophosphamide)
- Bladder carcinoma
- Interstitial cystitis, voiding dysfunction disorders, psychosomatic disorders
Treatment
Prognosis:
TREATMENT GUIDELINES
Amoxicillin 250 mg q8h x 7d
No quinolones in pregnancy; use as first
Cefpodoxime (Vantin) 100 mg q 12h x 7d
line agents may promote resistence
Ciprofloxacin (Cipro) 250 mg q 12h x 3 d
3 day regimen appropriate for 250 mg q 12h x 7d
uncomplicate d UTI
Lomefloxacin (Maxaquin) 400 mg qd x 3d
Patients may remain symptomatic x 2d 400 mg qd x 7d
Pregnant w simple UTI - 7d
Nitrofurantoin (Macrodantin) 100 mg qid x 7d
Complicated UTI 10-14 days; Nitrofurantoin (Macrobid) 100 mg bid x 7d
occasionally 4-6 weeks
Ofloxacin (Floxin) 200 mg q 12h x 3h
Fluoroquinolones drug of choice for 200 mg q 1 2h x 7d
complicated U TIs
Trimethoprim/ 160/800 q 12h x 3d
Phenazopyridine (Pyridium) - azo dye- Sulfamethoxazole 160/800 q12h x 7d
serves as topical anesthetic 200 mg tid (Bactrim DS, Septra DS)
- Fever
- Flan k pa in
- Irritative voiding symptoms
- Positive urine culture
General Considerations:
Clinical Findings
Laboratory Findings:
- CBC with leuko cytosis an d left shift
- U/A: (pyuria, bacteriuria, hematuria (variable),
white cell ca sts possible)
- Culture: heavy growth of offending organism
Treatm ent:
Prognosis:
Essentials of Diagnosis:
- Obstructive symptoms
- Decreased force and caliber of stream
- Intermittent stream
- Urinary hesitancy
- Irritative (may be function bladder dysfunction)
- Frequency
- Noc turia
- Urgency
Laboratory Findings:
- BUN and creatinine may be elevated (high post-void volumes, impaired renal function)
- U/A to ex clud e ass ocia ted in fectio n or h em aturia
- PSA: to increase sensitivity of CA detection (elevated in BPH as well as CA)
Diagnostics
- Intravenous urography
- May aid in detection of the following
- Elevation bladder base; trabeculation and thickening of bladder
- Diverticular formation, elevation of distal ureters
- Poor emptying, Hydronephrosis (less commonly seen)
- Norm al in ma jority of pts
- Once routinely ordered for all pts with s/s BPH
- Currently ordered only with hematuria or suspicion of upper UT disease
Routine imaging not necessary with mild to moderate signs and symptoms and normal U/A, creatinine, P/E
Urodynamic Evaluation:
- Guidelines
- Cover s mo st patients
- Does not cover patients with medical problems resulting in an increased surgical risk
- PSA is optional
- Increase detection of prostate CA
- Overlap between BPH and prostate CA
- Rarely indicated
- Imaging upper UT
- Cystometry
- Cystourethroscopy
TREATMENT OPTIONS
Medical Treatment
- Alternatives to TURP
INVESTIGATIONAL TREATMENTS
General Considerations
- Most common Ca in American men
- 300,000 new cases per year (1996) -> 41,000 deaths
- Incidence of disease not equal prevalence on autopsy
- 40% men >50 have prostatic CA
- Most a re sm all and con tained wi pr ostate
- Few associated w regional or distant disease
- Auto psy inc idenc e sam e - clin ical inc idenc e var ies ge ogra phic ally
- Suggests environm ental or dietary factors
- High: N America and Europe
- Intermediate: S. America
- Low in Far East
Clinical Findings
- PSA produced only in cytoplasm of benign and malignant prostate cells (glycoprotein)
- Level correlates w volume of benign and malignant prostatic tissue
- Us eful
- To detect and stage CA
- Monitor respon se tx
- Detecting recurrence
- In untreated pts: level of PSA correlates with level and stage of disease
- 98% metastatic disease have elevated PSA
- Most o rgan co nfined C A: PSA < 10 ng/m l
- Advan ced C a > 40 ng /ml
- Occasional localized Ca has substantial elevation -
- Can't make tx decisions based on PSA alone
- Rising PSA consistent with progressive disease
Imaging
- Transrectal U/S: high definition images
- Transrectal U/S-guided bx (vs digital Bx)
- MRI: pr ostate plu s regiona l node eva luation - pos itive predictive v alue sim ilar to U/S
- CT scanning plays little or no role - can't ID or stage
- Serial PSA may increase specificity - rate change > 0.75 ng/ml per year increase detection
- Fever
- Irritative voiding symptoms
- Perineal or SP pain - exquisite tenderness on DRE
- Positive urine culture
General Considerations:
Laboratory Findings
- Leukocytosis and shift left
- U/A: pyuria, bacteriuria, hematuria - positive urine cultures
Differential Diagnosis:
- Acute p yeloneph ritis and epid idymitis - disting uishable via location o f pain and P/E
- Acute d iverticulitis (occ asionally con fused) - distinguish history and U /A
- Urinary retention: BPH or prostatic CA - distinguish by initial or f/u DRE
Treatm ent:
General considerations
- Chronic may evolve from acute but many have no acute infection
- Gram negative rods most common
- Enterococcus is only gram positive organism with chronic disease
Clinical Findings:
Differential Diagnosis:
Treatm ent:
- Few antim icrob ial age nts a chie ve intr apro static levels in absence of acute inflammation
- TMP does diffuse into prostate thus has best cure rates
- Other e ffective ag ents: carbenicillin, erythromycin, cephalexin, quinolones
- Optimum duration of therapy is controversial: ranges from 6-12 wks
- NSAIDs and sitz: provide symptomatic relief
Prognosis:
ACUTE EPIDIDYMITIS
- Fever
- Irritative Voiding
- Pain ful en large me nt of e pididym is
General Considerations:
- Non-STD
- Typically in older men
- Ass ocia ted w ith UT I and pros tatitis
- Etiology: gram negative rods
- Rou te of In fectio n: ure thra - > eja cula tory du ct -> v as de fere ns -> epidid ymis
- Am iodar one : ass ocia ted w ith se lf-lim iting e pididym itis
Clinical Findings
Laboratory Findings:
- CBC: leukocytosis and left shift
- Intracellular gram-negative diplococci if gonorrhea (GC)
- WBC without organisms on urethral smear for nongonococcal urethritis (NGU)
- Chla myd ia trac hom atis most likely organism for NGU
- Non-s exually trans mitted v ariety:
- Pyur ia on U /A, ba cteriu ria, va rying d egre es of hem aturia
- Urine culture reveals causative organism
Ima ging: Scro tal U/S ma y aid if P /E diff icult (h ydroc ele) o r with q ues tiona ble dia gno sis
- Tumors
- Caus e painles s enlarge men t of testis with n orm al epididym is on P/E
- U/A negative; scrotal ultrasound (U/S) useful
- Prehn's sign
- Help ful bu t not c om plete ly reliab le
- Elev ation of sc rotum abov e sym phys is pub is im prov es pa in with epidid ymitis
Treatment
Prognosis:
General Considerations
- T: Primary tumor
- N: Regional lymph nodes
- D: Distant metastasis
Clinical Findings:
- Advanced disease
- Supraclavicular adenopathy
- Abdominal retroperitoneal mass on palpation
- Gynecomastia: 5%
Laboratory Diagnosis:
Imaging:
Treatm ent:
- Inguinal exploration w early vascular control of spermatic cord structures is initial intervention
- If CA cannot be excluded by exam of testes -> radical orchiectomy
- Scrotal approaches and open biopsy to be avoided
- Chemotherapy for high stage seminomas - 95% complete response w chemo and orchiectomy
- Surgical resection of residual retroperitoneal masses warranted under some circumstances
- Pts with bu lky retrope ritoneal dise ase - 55 -80% disease free 5 yr su rvival rate