3. Non-specific infections of the bladder and male genital organs; Urological emergency

Question 1

List the non-specific infections of the bladder and male genitals

Answer 1

Cystitis

Prostatitis and chronic pelvic pain syndrome

Urethritis

Epididymitis and orchitis

Balanitis
Balanoposthitis

Question 2

Cystitis causes and symptoms

Answer 2

From an organism ascending from the urethra.
E. Coli

Staph saprophyticus
Pseudomonas
Enterobacter
Ureaplasma uralyticum.

Symptoms

• Suprapubic tenderness
• Urinary urgency
• Hematuria
• Fever

Question 3

Cystitis diagnosis and treatment

Answer 3

Urinalysis
Trimethoprim-sulfamethoxazol or fluorquinolones for 3 days.

In 30% of the cases the cystitis is recurrent. Risk factors for recurrent infection:
• Gynecological infections (vaginitis, salpingitis)
• Frequent sexual intercourse
• Beta-lactam antibiotic usage
A recurrent infection can either be a relapse (within 2 weeks and same causative agent)
or a reinfection (later than 2 weeks and new causative agent).
Recurrent infection might be reduced with intravaginal estriol. Long-term, low dose
antibiotics might be required

In case of complicated cystitis we give immediate empiric treatment with ampicillin
and aminoglycosides.
Complicating factors:
• Old age
• Male sex
• Pregnancy
• DM
• Immunosuppression
• Nosocomial infection (Pseudomonas, Proteus, Klebsiella, enterococcus)
• Abnormality of the urinary tract
• Symptoms lasting over 7 days
- Indwelling catheter

Question 4

Prostatitis and chronic pelvic pain syndrome types and symptoms

Answer 4

Most common urological disease in men under 50.

Classification of prostatitis:
1. Acute bacterial prostatitis (ABP): Fever, chills and pain.
2. Chronic bacterial prostatitis
3. Chronic abacterial prostatitis/chronic pelvic pain syndrome: Infective agent
not found
4. Inflammatory chronic pelvic pain: Inflammatory cells in semen
5. Non-inflammatory chronic pelvic pain
6. Asymptomatic inflammatory prostatitis: inflammatory cells detected in semen.

The symptoms can be divided into 2 syndromes:
• (LUTS) Lower urinary tract symptoms in prostatitis: Weak stream, difficult
and frequent urination.
• Pain in prostatitis: Can be in the prostate/perineal region, scrotum, penis or
bladder.

Question 5

Causes of prostatitis and chronic pelvic pain syndrome types

Answer 5

Caused by:
• Infections from urethra (usually after intercourse or instrumentation)
• Prostate calculi
• Pelvic muscular spasms: High closure pressure of the external sphincter causing
high intraprostatic pressure. This allows for urine reflux in acinus and duct.
Most common pathogens:
• E.coli
• Pseudomonas
• Proteus
• Klebsiella
• Enterococcus

Question 6

Diagnosing prostatitis,

Treatment

Answer 6

1. Clinical evaluation
2. Exclusion of STDs
3. Urinanalysis and urine culture
4. Uroflowmetry and residual volume
5. Meares and Stamey localization technique 4-­‐glass test
6. Digital rectal exam - Acute bacterial prostatitis will be enlarged and tender.
7. Signs of inflammation: treatment with antibiotics

If bladder drainage is needed,
it must be done through a suprapubic cystostomy. Manipulations of acutely inflamed prostate via the urethra cause severe inflammation that is possibly fatal and are absolutely contraindicated.

Prostate abscesses can also be drained via perineal or transrectal US guided needles.

Broad spectrum Fluoroquinolones or 3rd gen cephalosporins. PLUS alpha-blockers.

Question 7

Urethritis classification and causes

Answer 7

Inflammation of the urethra, which can be either:
• Primary: STD
• Secondary: Infection occur after urological intervention (cystoscopy)
Most common causative agents:
• Neisseria gonorrhea (gonococcal urethritis)
• Chlamydia (non-gonococcal urethritis)
Less common pathogens: Ureoplasma, trichomonas and candida.
After cystoscopy the most common pathogens are E.coli and Pseudomonas

Question 8

Urethritis diagnosis

Answer 8

Urethritis may be aymptomatic or can present with burning and pus discharge. Can be diagnosed with a swab that is smeared onto a glass slide (5 or more pathogens per high power field resolution).

PCR test for chlamydia or intracellular inclusions on smear.

Treatment :
• Gonorrhea: Ceftriaxone or ciprofloxacin
• Chlamydia: Azithromycin and doxycycline for 7 days

Question 9

Epididymitis and orchitis, symptoms

chronic symptoms

treatment

Answer 9

There is local pain and tenderness with swelling and redness. Also nausea and vomiting.

Fever and urethral discharge can occur. Most often caused by retrograde flow of pathogens from the vas deferens.
Orchitis can occur following a mumps infection.

15% of the cases can become chronic, resulting in induration of the epididymis and spermatic cord.

Treatment: Ofloxacin or levofloxacin for 10 days.

Question 10

Inflammation of the penis

Answer 10

• Balanitis: Inflammation of the glans penis
• Balanoposthitis: Inflammation of glans and foreskin

• Acute balanoposthitis: Hyperemia and pus discharge. Retraction of the foreskin
is painfull. Can cause ulcers and fever. Can cause phimosis due to edema.
• Chronic balanoposthitis: Hyperemic patches and yellow scars. Can cause
phimosis due to scars.

Treatment: Clean the preputium sack with antiseptics and give antibiotics if the patient has fever or gangrene. Circumcision can be a permanent solution.

Question 11

the Urological emergencies are:

8

Answer 11

Acute renal failure
Acute urinary retention
Hematuria
Kidney colic
Testicular torsion
Paraphimosis
Priapism
Fournier's Gangrene

Question 12

Acute renal failure, definition and types

Answer 12

Sudden drop in renal function,
decreased GFR, oliguria/anuria, and azotemia.

Anuria = less than 100ml urine in 24 hours.

Prerenal - decreased blood flow.
BUN:Cr ratio is above 15
FeNa is < 1%
urine osmolarity > 500mOsm

Intrarenal: Glomerulonephritis, interstitial nephritis, HUS, ATN
BUN:Cr < 15
FeNa > 2%
Osmolarity < 500

Postrenal - Must be a bilateral obstruction, or an obstruction in patients with only one kidney.
BUN:Cr < 15
FeNa > 2%
Osmolarity < 500
Ultrasound will show an empty bladder and pyelon dilation (if there is no pyelon
dilation postrenal origin can be excluded)

Question 13

Acute renal failure treatment

Answer 13

Treatment: Serum electrolytes must be assessed to help determine degree of kidney failure and in case of potassium >7mmol/l, hemodialysis must be performed. Insert a urethral catheter (double J/pigtail stent) and do an ultrasound guided puncture of the dilated renal collecting system and insert a nephrostomy set.
In case of pyonephros, give broad spectrum antibiotics

Question 14

Acute urinary retention

Causes and Treatment

Answer 14

Most commonly caused by bladder outlet obstruction (BPH, urethral stricture, bladder neck necrosis, prostate tumor, urethral valve or stone in urethra).

Can also be caused decreased detrusor function (drugs, peripheral nerve denervation)

Other causes; pregnancy, prolonged bed rest or neurological.
Symptoms:
• Unable to urinate, even with full bladder
• Pain
• Distended belly

Treatment:
• Empty bladder. This can be done with a transurethral catheter (foley) or a
suprapubic catheter.

Question 15

Hematuria causes

Answer 15

Severe urological disorders can present with hematuria. E.g. bladder tumor, cystitis, prostate tumor, BPH, kidney tumor, ureteral tumor and stone.
NB: clotting of blood can cause urinary retention.

Question 16

Investigations that must be done if there is hematuria

Answer 16

US to look for tumors, prostate, stone and blood clot.
Cystoscopy to check potential intravesicle causes.
Intravenous pyelography and CT to look for upper urinary tract bleeding. Can also
do an ureterorenoscopy.

Question 17

Treating severe hematuria

Answer 17

Treatment: A large caliber catheter is used to remove blood clots. In active bleeding a 3-way catheter must be placed to perform rinsing.
Bleeding from prostate can be treated with a balloon catheter.
If the bleeding cant be stopped by conservative measures, a transurethral
electrocoagulation is needed.

Question 18

Kidney colic

Answer 18

Usually caused by ureteral stones. Can also be caused by ureteral strictures or tumors or
extraureteral compression.
There is strong pain in the kidney area that radiates to the testicular area and labia
minora.
Urgency can be felt if the stone is close to the bladder. Vomiting may occur.
Do an US to demonstrate dilation of the collecting system above the stone.
Treatment: Larger stones may require nephrolithotomy.
• No fever: Analgesics, spasmolytics and alcohol
• Fever: Draining and catheterization and antibiotics.

Treatment: Larger stones may require nephrolithotomy.
• No fever: Analgesics, spasmolytics and alcohol
• Fever: Draining and catheterization and antibiotics.

Question 19

Testicular torsion

Answer 19

There is torsion of the spermatic cord that causes strangulation of the blood supply to
the testes.
Severe pain develops suddenly (50% at night) without any extrinsic factor. Fever is
usually absent. Pain may be increased by lifting the testis over the symphysis. Absent
creamsteric reflex.
Diagnosis: Doppler ultrasound show decreased arterial blood flow. Testicular
scintigraphy is the most definite test.
Treatment: Prior to surgery manual detortion may be attempted. Surgical fixation
during the next few days.

Question 20

Paraphimosis

Answer 20

The foreskin is retracted over the glans and cannot be put back in its normal position.
The phimotic ring causes venous congestion leading to edema and enlargement of the
glans. It will progress to arterial occlusion and necrosis.

Manual reposition may be attempted by squeezing with a wet towel.. If not, surgical incision with local anesthesia.

Question 21

Priapism

Answer 21

Persistent erection (>4hours) unrelated to stimulation. Causes:
• 60% idiopathic
• Intracavernous injection (therapy for impotence)
• Leukemia
• Sickle cell syndrome
• Trauma
• Antidepressants (trazodone)
• CO poisoning

1. High flow: Non-ischemic/arterial priapism caused perineal trauma, causing loss
   of regulation of arterial blood flow. No pain and no emergency.
2. Low flow: Physiological obstruction of venous drainage causing clotting of blood
   in corpora cavernosa. Glans and corpora spongiosum are typically not tense.
   Painful and medical emergency. Attempt to cool the penis. Make a puncture.

Stuttering priapism is a variant of the ischemic type that is characterized by repetitive, transient, painful, self-limiting episodes of priapism. It is associated with various hematological disorders, including sickle cell disease and pharmacological treatments.
Malignant priaprism from metastases. very rare.

Question 22

Fournier’s gangrene

Answer 22

A rapid, fulminant gangrenous infection of the genitalia. Begins as an extension of an infection from urinary, perianal, abdominal or retroperitoneal tissues, a form of necrotizing fasciitis.

Contains anaerobic and aerobic bacteria.
Mainly seen in DM and older patients.
Starts with abruptly severe pain of penis, scrotum or perineum with rapid progression
from erythema to necrosis. Mortality rate is 40%.
Treatment: Start triple-drug antibiotic therapy: Metronidazole, ampicillin and gentamicin.
Start aggressive surgical debriment

Question 23

What is the four glass test

Answer 23

1st glass : 10 mL urine

patient urinates 200ml into the toilet

2nd glass: 10 ml urine

then a prostate masage via DRE for 1 minute.

3rd glass: expressed prostate secretion EPS

4th glass: patient urinates into glass after prostate massage.