Inflammatory and pain conditions of male urinary tract Flashcards

1
Q

NIH Classification of prostatis (4)

A

I. Acute bacterial prostatitis II. Chronic bacterial prostatitis IIIA. Chronic prostatitis/pelvic pain syndrome, inflammatory IIIB. Chronic prostatitis/pelvic pain syndrome, noninflammatory IV. Asymptomatic inflammatory prostatitis

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2
Q

Granulomatous prostatitis is diagnosed by the histologic finding of ____ with or without other inflammatory cells. It is commonly found on specimens from ___ and ____

A

Granulomatous prostatitis is diagnosed by the histologic finding of epithelioid granulomas with or without other inflammatory cells (Uzoh et al., 2007). It is commonly found on specimens from transurethral resections and prostate biopsies

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3
Q

IgG4-related disease is a fibroinflammatory condition characterized by several features: tendency to form __ at multiple sites, __ and ___, ___, and often, but not always, elevated levels of serum IgG4

A

IgG4-related disease is a fibroinflammatory condition characterized by several features: tendency to form tumorlike lesions at multiple sites, dense infiltrate of lymphocytes and IgG4 +plasma cells, characteristic pattern of fibrosis, and often, but not always, elevated levels of serum IgG4

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4
Q

Category I Prostatitis: Acute Bacterial Prostatitis

Risk factors for the development of acute prostatitis include: (7)

A

Risk factors for the development of acute prostatitis include
unprotected sexual intercourse, specifically insertive anal intercourse, phimosis, condom catheter use, indwelling urethral catheters, and urinary tract instrumentation, including endoscopic procedures and prostate biopsy

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5
Q

The presentation of category I prostatitis is acute symptoms of a urinary tract infection (UTI), characteristically including __ and ___. Some patients have symptoms suggestive of systemic infection, such as malaise, fever, and myalgias

A

The presentation of category I prostatitis is acute symptoms of a urinary tract infection (UTI), characteristically including urinary frequency and dysuria. Some patients have symptoms suggestive of systemic infection, such as malaise, fever, and myalgias

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6
Q

. Acute prostatitis should be considered in any man who presents with a febrile UTI. Febrile UTI in men can be from pyelonephritis, acute cystitis, or prostatitis

A

bacteria also have significantly higher rates of septicemia (Kim et al., 2015). Acute prostatitis should be considered in any man who presents with a febrile UTI. Febrile UTI in men can be from pyelonephritis, acute cystitis, or prostatitis

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7
Q

Acute prostatitis is the one situation in which one may palpate a truly ___ from __ and __. The prostate is tender and swollen in__of cases

A

Acute prostatitis is the one situation in which one may palpate a truly “boggy” prostate from edema from inflammation. The prostate is tender and swollen in 60% to 90% of cases

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8
Q

in acute bacterial prostatitis: Caution should be used to avoid __ that could lead to bacterial dissemination and sepsis.

A

Caution should be used to avoid aggressive palpation that could lead to bacterial dissemination and sepsis.

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9
Q

Antibiotics are the mainstay of therapy for acute bacterial prostatitis. The most recent European Association of Urology (EAU) guidelines on treating UTIs recommend the parenteral administration of high-dose bactericidal antibiotics such as a broad-spectrum ___, ___ cephalosporin, or a ____. In initial therapy, any of these can be combined with an aminoglycoside

A

Antibiotics are the mainstay of therapy for acute bacterial prostatitis. The most recent European Association of Urology (EAU) guidelines on treating UTIs recommend the parenteral administration of high-dose bactericidal antibiotics such as a broad-spectrum penicillin, third-generation cephalosporin, or a fluoroquinolone. In initial therapy, any of these can be combined with an aminoglycoside

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10
Q

___ should be suspected in men with high fever or a history of immunosuppression such as diabetes or HIV or who do not respond to initial therapy after 48 hours

A

Prostatic abscess should be suspected in men with high fever or a history of immunosuppression such as diabetes or HIV or who do not respond to initial therapy after 48 hours

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11
Q

__ should be used if long-term drainage is needed.

A

A suprapubic tube should be used if long-term drainage is needed.

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12
Q

Chlamydia spp. can cause prostatic infection by an a___ after urethral inoculation in animal models (Pal et al., 2004). The main argument is the difficulty of attributing the findings of Chlamydia spp. in the __ or ___ to prostate infection alone given the possibility of urethral contamination, as Chlamydia spp. are a common cause of urethritis

A

Chlamydia spp. can cause prostatic infection by an ascending route after urethral inoculation in animal models (Pal et al., 2004). The main argument is the difficulty of attributing the findings of Chlamydia spp. in the expressed prostatic secretions or semen to prostate infection alone given the possibility of urethral contamination, as Chlamydia spp. are a common cause of urethritis

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13
Q

prostatitis dx: The diagnosis is currently made by the ___ and ___ test also called the ____. The VB3 specimen gives information as to a persistent prostatic source of bacteria. The patient provides a midstream pre-massage urine specimen and a urine specimen (____) after prostatic massage to obtain ___

A

The diagnosis is currently made by the pre-massage and post-massage test (or two-glass test). The VB3 specimen gives information as to a persistent prostatic source of bacteria. The patient provides a midstream pre-massage urine specimen and a urine specimen (initial 10 mL) after prostatic massage to obtain expressed prostatic secretions (EPS)

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14
Q

prostatis : In men with human immunodeficiency virus (HIV), cultures should be sent not only for the usual bacteria but also for:

A

more atypical organisms, including anaerobes, anaerobes, fungi, and TB

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15
Q

chronic prostatis dx: Urine should be assessed for ___. If present in the setting of infection, it should be rechecked ___ after resolution of infection to look for resolution of the hematuria. Persistent hematuria should prompt an evaluation. Physical examination should evaluate for ___. Abdominal examination is necessary to rule out other causes of abdominal/suprapubic pain. Scrotal examination is needed to evaluate for any associated areas of inflammation and possible infection such as the___ and ___. A digital rectal examination is indicated to look for prostate size and any abnormalities to suggest prostate cancer. It is important to assess for bladder outlet obstruction and urinary retention. Retention of urine may predispose to recurrent urinary tract infection. A postvoid residual urine of more than ___ has been correlated with increased risk of infection

A

Urine should be assessed for hematuria. If present in the setting of infection, it should be rechecked 4 to 6 weeks after resolution of infection to look for resolution of the hematuria. Persistent hematuria should prompt an evaluation. Physical examination should evaluate for fever. Abdominal examination is necessary to rule out other causes of abdominal/suprapubic pain. Scrotal examination is needed to evaluate for any associated areas of inflammation and possible infection such as the epididymis and testis. A digital rectal examination is indicated to look for prostate size and any abnormalities to suggest prostate cancer. It is important to assess for bladder outlet obstruction and urinary retention. Retention of urine may predispose to recurrent urinary tract infection. A postvoid residual urine of more than 180 mL has been correlated with increased risk of infection

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16
Q

chronic prostatis: Imaging is not recommended/ recommended for men with a UTI and history of diabetes, chronic kidney disease, stones, voiding difficulties, neurologic disease, poor response to antibiotics, infection with urea-splitting bacteria, or hematuria more than 1 month after the infection

A

Imaging is recommended for men with a UTI and history of diabetes, chronic kidney disease, stones, voiding difficulties, neurologic disease, poor response to antibiotics, infection with urea-splitting bacteria, or hematuria more than 1 month after the infection

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17
Q

PRostatitis tx: Penetration into the prostate, therefore, is dependent on ___, and the factors that influence this transport are :(5)

preferred meds used: ___

A

The prostate capillary bed lacks active transport mechanisms for antibiotics. Penetration into the prostate, therefore, is dependent on passive transport (no capillary bed), and the factors that influence this transport are drug concentration, lipid solubility, degree of ionization or charge, degree of protein binding, and size and shape of the molecule

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18
Q

chronic prostatis tx: __ and ___ are the antibiotics of choice not only because of their tissue penetration but also because of their spectrum of coverage, which includes gram-negatives, including Pseudomonas, gram-positives, and atypical pathogens such as Chlamydia spp. and genital Mycoplasma spp. Duration of treatment is based on expert opinion; the recommendation is ___

A

Fluoroquinolones such as ciprofloxacin and levofloxacin are the antibiotics of choice not only because of their tissue penetration but also because of their spectrum of coverage, which includes gram-negatives, including Pseudomonas, gram-positives, and atypical pathogens such as Chlamydia spp. and genital Mycoplasma spp. Duration of treatment is based on expert opinion; the recommendation is 4 to 6 weeks.

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19
Q

chronic prostatis tx : Beyond Quinolones

give examples

A

cefoxitin

Piperacillintazobactam achieves prostatic levels that would be adequate to treat infections from E. coli, Klebsiella, and Proteus but not adequate levels to treat Pseudomonas

fosfomycin has in vitro activity against E. coli with antimicrobial resistance, includingChapter 56 Inflammatory and Pain Conditions of the Male Genitourinary Tract
ESBL strains

For patients whose symptoms are refractory to medical therapy, TURP has been used with results of 52% to 67% of patients responding to TURP down to the surgical capsule

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20
Q

Not all patients with chronic bacterial prostatitis need imaging.
In men younger than 45 years old with a first event of acute UTI, imaging showed no abnormalities. It is recommended, however, in this group to rule out ___. Men with a flow rate of more than ___ should be further evaluated

A

Not all patients with chronic bacterial prostatitis need imaging.
In men younger than 45 years old with a first event of acute UTI, imaging showed no abnormalities. It is recommended, however, in this group to rule out urethral stricture. Men with a flow rate of more than 15 mL/min should be further evaluated

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21
Q

The term prostatitis implies inflammation of the prostate gland. However only about __ of men with clinical CPPS have been found to have prostatic inflammation on biopsy

A

The term prostatitis implies inflammation of the prostate gland. However only about one-third of men with clinical CPPS have been found to have prostatic inflammation on biopsy

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22
Q

CPPS: On awakening, serum cortisol levels rise; there is a significantly ____ in men with CPPS compared with controls. Men with CPPS also have a lower/higher ___ level and blunted ACTH rise in response to stress than men without symptoms

A

On awakening, serum cortisol levels rise; there is a significantly greater cortisol rise in men with CPPS compared with controls. Men with CPPS also have a lower baseline adrenocorticotropic hormone (ACTH) level and blunted ACTH rise in response to stress than men without symptoms

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23
Q

There have been few biomarkers that correlate with symptoms in CP/CPPS. One of these markers is ___), a neuropeptide that plays a role in nociception

A

There have been few biomarkers that correlate with symptoms in CP/CPPS. One of these markers is nerve growth factor (NGF), a neuropeptide that plays a role in nociception

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24
Q

CPPS symptoms: severe symptom was ___, followed by urinary frequency and obstructive voiding symptoms. The most frequent site of pain was the __

A

severe symptom was pain in the pelvic region, followed by urinary frequency and obstructive voiding symptoms. The most frequent site of pain was the perineum

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25
Q

The prevalence of ED in men with CP/CPPS is reported at ___

A

The prevalence of ED in men with CP/CPPS is reported at 15% to 40%

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26
Q

men with CP/CPPS were ___ more likely to self-report a history of cardiovascular disease, most commonly hypertension. A follow-up study by Shoskes et al. found ___ in men with CPPS compared with controls

A

men with CP/CPPS were six times more likely to self-report a history of cardiovascular disease, most commonly hypertension. A follow-up study by Shoskes et al. found greater arterial stiffness in men with CPPS compared with controls

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27
Q

Men with CP/CPPS were__ more likely to self-report a history of nervous system disease compared with asymptomatic age-matched controls

A

Men with CP/CPPS were 5 more likely to self-report a history of nervous system disease compared with asymptomatic age-matched controls

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28
Q

UPOINT: THE “SNOWFLAKE HYPOTHESIS”: the largest domain has been __ and ___, and the smallest domain has been the __ category. Men with CP/CPPS generally are characterized by multiple domains. In an early description, only one in five men were positive for only one domain, one-third of men were characterized by two domains, and the rest by three or more domains

A

UPONT snowflake theory: the largest domain has been organ-specific and urinary, and the smallest domain infectious category. Men with CP/CPPS generally are characterized by multiple domains. In an early description, only one in five men were positive for only one domain, one-third of men were characterized by two domains, and the rest by three or more domains

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29
Q

Evaluation for Men With Chronic Pain and Chronic Pelvic Pain Syndrome: enumerate

Mandatory

A
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30
Q

Evaluation for Men With Chronic Pain and Chronic Pelvic Pain Syndrome:

recommended

Optional

A
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31
Q

Role of anti-inflamattory on CPS:

Results from meta-analyses indicate that anti-inflammatory medications are considered to have ____ for some patients. They are likely INEFFECTIVE/EFFECTIVE if used alone but useful in combination therapy with an __ and a muscle relaxant that also has ___

A

Results from meta-analyses indicate that anti-inflammatory medications are considered to have beneficial effects for some patients (Thakkinstian et al., 2012). They are likely ineffective if used alone but useful in combination therapy with an alpha-blocker and a muscle relaxant that also has anti-inflammatory properties

In conclusion, anti-inflammatory monotherapy is not recommended but can be used as part of multimodal therapy

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32
Q

Dutasteride at 0.5 mg was studied in the ___, a 4-year, randomized, double-blind, placebo-controlled study of prostate cancer risk reduction. The NIH-CPSI survey was used to measure baseline and change in symptom severity. The dutasteride group noted a ______ CPSI total score compared with placebo

Overall, 5α-reductase inhibitor (5ARI) medications appear to be
effective in some patients.

The decision in whom to use 5ARI medications must also be made in the context of side effects, including: ___

This indicates that they may be best used in ___ with CP/CPPS who also have voiding symptoms from BPH

A

Dutasteride at 0.5 mg was studied in the REDUCE trial, a 4-year, randomized, double-blind, placebo-controlled study of prostate cancer risk reduction. The NIH-CPSI survey was used to measure baseline and change in symptom severity. After 48 months, the dutasteride group noted a significant decrease of 6 points or greater in CPSI total score compared with placebo (49% vs. 37%, P = 0.0033) (Nickel et al., 2011). Overall, 5α-reductase inhibitor (5ARI) medications appear to be
effective in some patients. This is demonstrated when the previous trials are subjected to a meta-analysis, with significant reduction in
NIH-CPSI scores compared with placebo (−4.6, 95% CI −8.7 to −0.5) (Anothaisintawee et al., 2011). The decision in whom to use 5ARI medications must also be made in the context of side effects, including reduced volume of ejaculate, erectile dysfunction, and decrease in libido (Thompson et al., 2003). This indicates that they may be best used in older patients with CP/CPPS who also have voiding symptoms from BPH (Rees et al., 2015a).

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33
Q

NIH Classification:

(4)

A

I. Acute bacterial prostatitis II. Chronic bacterial prostatitis IIIA. Chronic prostatitis/pelvic pain syndrome, inflammatory IIIB. Chronic prostatitis/pelvic pain syndrome, noninflammatory IV. Asymptomatic inflammatory prostatitis

34
Q

define (GUPI)

A

Genitourinary Problem Index :

chronic prostatitis symptom index to assess genitourinary pain in men and women

35
Q

Sites of palpation for CPS

A
36
Q

Pharmacologic treatment for CPPS: (10)

  1. Antibiotic- ___ have been the most widely studies antibiotics
    for this condition. The rationale for their use is originally based on their spectrum of activity as well as their pharmacokinetic properties allowing for high prostatic concentration In patients with fluoroquinolone-resistant bacteria, ___ can be used. Other second-line agents include: (3)
  2. alpha-blocker(alfuzosin,tamsulosin)-The rationale includes the idea that some cases of CP/CPPS come from ____voiding. The ____ have also been shown to be active in long-term pain syndromes. The ICUD study recommends alpha-blockers for newly diagnosed, alpha-blocker–naive patients who have voiding symptoms .The EAU guidelines recommend use of alpha-blockers for patients with a duration of PPS ___ year
  3. anti-inflammatory- A study of another ___, in a study of men with IIIA prostatitis showed significant reduction in total NIH-CPSI score, pain, and quality-of-life subscores, but not the urinary subscore
  4. reductase inhibtors - A significant improvement with ____ compared with placebo in the Prostatitis Symptom Severity Scale, a precursor to the NIH-CPSI,
  5. neuropathic pain - A trial of an inhibitor of ____, a synaptic membrane enzyme responsible for the breakdown of endogenous cannabinoids (eCBs), showed no improvement in pain reduction compared with placebo. However, there was greater improvement in voiding frequency compared with placebo in all groups tested
  6. Phototherapy- pollen extract Cernilton for ___ to placebo and found significant improvement in total NIH-CPSI scores, as well as pain and qualityof-life domains
  7. bladder Specific: ___ - augmenting the bladder’s layer of glycosaminoglycans, which acts as a protective barrier.

8, Allopurinol - lower levels of serum urate, urine urate, and EPS urate and xanthine

  1. Mepartricin - REDUCES/INCREASES serum estrogen levels and prostatic estrogen receptors in men
  2. PDE5 Inhibitors - PDE5 inhibitors are useful to treat erectile dysfunction in men with CPPS at any age. Tadalafil can treat lower urinary tract symptoms, erectile dysfunction, and possibly the symptoms of CP/CPPS
A
  1. Antibiotic- Fluoroquinolones have been the most widely studies antibiotics
    for this condition. The rationale for their use is originally based on their spectrum of activity as well as their pharmacokinetic properties allowing for high prostatic concentration In patients with fluoroquinolone-resistant bacteria, trimethoprim alone (TMP), or in combination with sulfamethoxazole can be used. Other second-line agents include tetracycline, doxycycline, and macrolides
  2. alpha-blocker(alfuzosin,tamsulosin)-The rationale includes the idea that some cases of CP/CPPS come from dysfunctional voiding The α receptors in the central nervous system have also been shown to be active in long-term pain syndromes. The ICUD study recommends alpha-blockers for newly diagnosed, alpha-blocker–naive patients who have voiding symptoms (Nickel et al., 2013).The EAU guidelines recommend use of alpha-blockers for patients with a duration of PPS less than 1 year
  3. anti-inflammatory- A study of another COX-2 inhibitor, celecoxib, in a study of men with IIIA prostatitis showed significant reduction in total NIH-CPSI score, pain, and quality-of-life subscores, but not the urinary subscore
  4. reductase inhibtors - A significant improvement with finasteride compared with placebo in the Prostatitis Symptom Severity Scale, a precursor to the NIH-CPSI,
  5. neuropathic pain - A trial of an inhibitor of fatty acid amide hydrolase (FAAH), a synaptic membrane enzyme responsible for the breakdown of endogenous cannabinoids (eCBs), showed no improvement in pain reduction compared with placebo. However, there was greater improvement in voiding frequency compared with placebo in all groups tested
  6. Phototherapy- pollen extract Cernilton for 12 weeks to placebo and found significant improvement in total NIH-CPSI scores, as well as pain and qualityof-life domains
  7. bladder Specific: Pentosan Polysulfate- augmenting the bladder’s layer of glycosaminoglycans, which acts as a protective barrier.

8, Allopurinol - lower levels of serum urate, urine urate, and EPS urate and xanthine

  1. Mepartricin - reduces serum estrogen levels and prostatic estrogen receptors
  2. PDE5 Inhibitors- DE5 inhibitors are useful to treat erectile dysfunction in men with CPPS at any age. Tadalafil can treat lower urinary tract symptoms, erectile dysfunction, and possibly the symptoms of CP/CPPS
37
Q

A subsequent systematic review of the literature concluded that evidence for a role of ____ as an adjunct in the management of CP is, at most, “soft” but that the practice could be considered as part of multimodal therapy in selected patients

A

A subsequent systematic review of the literature concluded that evidence for a role of repetitive prostatic massage as an adjunct in the management of CP is, at most, “soft” but that the practice could be considered as part of multimodal therapy in selected patients

38
Q

Prostate-Specific Treatments:

1.

2.

A

Local Hyperthermia and Needle Ablation

Intraprostatic Injection of Onabotulinumtoxin A.

39
Q

Surgical Therapy for Chronic Prostatitis and Chronic Pelvic Pain Syndrome:

Surgical Therapy for Bladder Neck Hypertrophy - There are no pathognomonic diagnostic criteria. This should be suspected in men with chronic pelvic pain who also have significant ____ symptoms. Pressure flow urodynamics are expected to show decreased/increased voiding pressure and increased/decreased flow, with a relative narrowing of the bladder neck,significant improvement in 31 of 32 men with bladder neck hypertrophy and symptoms of chronic prostatitis treated with bladder neck incision

Neurostimulation - __ and __ percutaneous tibial nerve stimulation (PTNS) are FDA approved for urinary symptoms but not specifically for pelvic pain

____.- Mean total and pain subscales were significantly improved at 24 weeks compared with baseline. International Prostate Symptom Score (IPSS) scores were also significantly improved compared with baseline

Cystoscopy and Fulguration of ____- Men with pain thought to be of bladder origin (i.e., pain with bladder filling and/ or relieved by bladder emptying) should have a cystoscopy to look for a Hunner ulcer. Although not commonly found, fulguration of these areas can provide symptom relief

A

Surgical Therapy for Bladder Neck Hypertrophy - There are no pathognomonic diagnostic criteria. This should be suspected in men with chronic pelvic pain who also have significant obstructive voiding symptoms. Pressure flow urodynamics are expected to show increased voiding pressure and decreased flow, with a relative narrowing of the bladder neck,significant improvement in 31 of 32 men with bladder neck hypertrophy and symptoms of chronic prostatitis treated with bladder neck incision

Neurostimulation - Sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) are FDA approved for urinary symptoms but not specifically for pelvic pain

Electromagnetic Stimulation.- Mean total and pain subscales were significantly improved at 24 weeks compared with baseline. International Prostate Symptom Score (IPSS) scores were also significantly improved compared with baseline

Cystoscopy and Fulguration of Hunner’s Ulcer- Men with pain thought to be of bladder origin (i.e., pain with bladder filling and/ or relieved by bladder emptying) should have a cystoscopy to look for a Hunner ulcer. Although not commonly found, fulguration of these areas can provide symptom relief

40
Q

radical prostatectomy is not recommended/recommended in the absence of treatment for prostate carcinoma

A

Not recommended is surgical removal of painful structures in the setting of pain elsewhere in the pelvis. Certainly radical prostatectomy is not recommended in the absence of treatment for prostate carcinoma

41
Q

___ can be used in men with pain who also have frequency and urgency.

A

Sacral neuromodulation can be used in men with pain who also have frequency and urgency.

42
Q

Acute orchitis can be divided into __ and ____

A

Acute orchitis can be divided into specific orchitis and Viral orchitis

43
Q

Viral orchitis is most commonly caused by the ___

A

Viral orchitis is most commonly caused by the mumps virus

44
Q

Orchitis is usually associated with ___ and ____, resolving within ___ week. ___ of the testis occurs in half the cases and can be associated with oligospermia and decreased fertility but usually not ___

A

Orchitis is usually associated with epididymitis and fever, resolving within 1 week. Atrophy of the testis occurs in half the cases and can be associated with oligospermia and decreased fertility but usually not complete infertility

45
Q
A

Urine culture should be obtained in all patients. Urine culture has been reported to be positive in 38.5% of patients diagnosed with isolated orchitis and 37.5% of those diagnosed with orchidoepididymitis. In sexually active patients, especially with epididymal involvement, testing for STD should be performed. Imaging with scrotal US can help to distinguish testicular torsion from orchitis and identify testicular tumors and abscess

46
Q

Secondary autoimmune orchitis may be treated with systemic medications:(3)

A
  1. corticosteroids
  2. immunosuppressive medications such as azathioprine, or IV cyclophosphamide
  3. intravenous immunoglobulin
47
Q

acute orchitis: Patients should also be counseled that, although the acute pain can resolve in___, the ensuing inflammation can last ___ before completely resolving

A

Patients should also be counseled that, although the acute pain can resolve in 1 to 3 days, the ensuing inflammation can last 2 to 4 weeks before completely resolving

48
Q

Orchialgia is defined as scrotal pain, intermittent or constant, lasting at least ___, and can be unilateral or bilateral One of the first considerations in assessing orchialgia is to determine if the pain is limited to the ___ or if ___

A

Orchialgia is defined as scrotal pain, intermittent or constant, lasting at least 3 months, and can be unilateral or bilateral One of the first considerations in assessing orchialgia is to determine if the pain is limited to the testis/ scrotum or if it is part of a larger pelvic pain problem including other pain sites consistent with CP/CPPS

49
Q

Approximately 18% to 25% of chronic orchialgia is considered ___

A

Approximately 18% to 25% of chronic orchialgia is considered idiopathic

50
Q

___ is marked by the presence of granulomatous inflammation in the testis and has multiple causes, including tuberculosis, brucellosis, actinomycosis, syphilis, leprosy, and sarcoidosis

A

Granulomatous orchitis is marked by the presence of granulomatous inflammation in the testis and has multiple causes, including tuberculosis, brucellosis, actinomycosis, syphilis, leprosy, and sarcoidosis

51
Q

The diagnosis is directed at ruling out the other causes of chronic orchalgia. Rule out__ and __

On review of systems, the presence of symptoms of ___ with constipation or diarrhea that may be indicative of ___ should be asked

Also important are symptoms of ___ and vertebral disk disease, because orchalgia can be referred pain from back problems

LUTS could indicate a history of voiding dysfunction, which could lead to __.

A

The diagnosis is directed at ruling out the other causes of chronic orchalgia. Rule out torsion and infectious causes (testicular or epidydmal infection).

On review of systems, the presence of symptoms of bowel dysfunction with constipation or diarrhea that may be indicative of IBS should be asked

Also important are symptoms of lower back pain and vertebral disk disease, because orchalgia can be referred pain from back problems

LUTS could indicate a history of voiding dysfunction, which could lead to UTI.

52
Q

Cui and Terlecki reported that on screening for__ and ___ in men with chronic orchialgia, 125 of 154 were found to be deficient in either or both compounds (Cui and Terlecki, 2016).

A

Cui and Terlecki reported that on screening for__ and ___ in men with chronic orchialgia, 125 of 154 were found to be deficient in either or both compounds (Cui and Terlecki, 2016).

53
Q

Therapy for Idiopathic Orchialgia and Chronic Scrotal Pain Syndrome

  1. __ and ___ are recommended because of their penetration into the scrotal structures and because they can be used for up to___
  2. ___
A

Doxycycline and quinolones are recommended because of their penetration into the scrotal structures and because they can be used for up to 4 weeks

2. spermatic cord block

54
Q

Acute epididymitis is defined as pain, swelling, and inflammation of the epididymis that lasts more than ___

The widely accepted route of infection is the a___ from the urethra, as reported by Campbell in 1927 in cases of __ and ___

The causative organisms depend on the age of the patient. The classic teaching has been that men over the age of 35, as well as in children, the organisms are similar to those causing a ___. In men under 35 who are ___, Chlamydia trachomatis and Neisseria gonorrhoeae are more common

A

Acute epididymitis is defined as pain, swelling, and inflammation of the epididymis that lasts more than 6 weeks

The widely accepted route of infection is the ascent of microorganisms from the urethra, as reported by Campbell in 1927 in cases of gonococcal urethritis and subsequent epididymitis

The causative organisms depend on the age of the patient. The classic teaching has been that men over the age of 35, as well as in children, the organisms are similar to those causing a urinary tract infection, such as E. coli. In men under 35 who are sexually active, Chlamydia trachomatis and Neisseria gonorrhoeae are more common

55
Q

Treatment for epidydymitis . For symptom relief:

A

Treatment. For symptom relief, the traditional recommendations are bed rest, elevation of the scrotum, and local cooling.

56
Q

The CDC guidelines divide this into three groups: acute epididymitis likely caused by STD, likely caused by STD and enteric organism (men who practice insertive anal sex), and likely only caused by enteric organisms.

For the first group, the recommendation is ___ dose plus ___ orally twice per day for 10 days;

for the second group ___ (or ___ 300 mg PO twice per day) for 10 days is substituted for ___, and

third group ___ alone is recommended.

A

For the first group, the recommendation is ceftriaxone 250 mg in single IM dose plus doxycycline 100 mg orally twice per day for 10 days; for the second group levofloxacin 500 mg PO daily (or ofloxacin 300 mg PO twice per day) for 10 days is substituted for doxycycline, and for the third group levofloxacin (or ofloxacin) alone is recommended. Men with confirmed chlamydia or gonorrhea should also be tested for other STDs including HIV, and their sex partners should also be referred for evaluation and presumptive treatment

57
Q

Tubercular epdydymitis: An indication for surgery is failure of a scrotal mass to ___ of antitubercular chemotherapy; the mass should be explored by an inguinal incision to rule out __ or __

A

An indication for surgery is failure of a scrotal mass to respond or increases in size after 3 weeks of antitubercular chemotherapy; the mass should be explored by an inguinal incision to rule out testicular or epididymal malignancy

58
Q

Nonmedical Therapy for Chronic Scrotal Pain: Chronic Orchitis (Orchalgia) and Chronic Epididymitis (Epididymalgia)

(3)

A

Pelvic Floor Physical Therapy

Pulsed Radiofrequency of the Spermatic Cord.

Botox

59
Q

An option unique to patients with postvasectomy pain syndrome is to reverse the___,

A

An option unique to patients with postvasectomy pain syndrome is to reverse the vasectomy and restore patency of the vas.

60
Q

Three areas identified that had the highest areas of WD were the __, ___ and ___ ; these areas were called the ___, which is thought to form the anatomic basis for relief from the denervation procedure

A

Three areas identified by Parekatil et al. that had the highest areas of WD were the cremasteric muscle fibers, the perivasal sheath, and the posterior lipomatous tissue; these areas were called the trifecta nerve complex, which is thought to form the anatomic basis for relief from the denervation procedure

61
Q

Although orchiectomy may be considered the last resort for treatment of scrotal pain, pain may persist, called a___ ‘

Treatment of pain that persists after orchiectomy is handled in a manner similar to that described for treating persistent testicular pain after inguinal hernia repair. The genital branch of the genitofemoral nerve at the external ring is ___, and the proximal end of the nerve is placed in the ___.

A

phantom pain,

Treatment of pain that persists after orchiectomy is handled in a manner similar to that described for treating persistent testicular pain after inguinal hernia repair. The genital branch of the genitofemoral nerve at the external ring is identified and neuroma is resected, and the proximal end of the nerve is placed in the pelvis.

62
Q
  1. A man with chronic pelvic pain has a negative urine culture and no evidence of inflammation on expressed prostatic secretions (EPS) or VB3 or in his seminal plasma. What is his category of prostatitis in the NIH classification? a. Category I b. Category II c. Category IIIA d. Category IIIB e. Category IV
A

d. Category IIIB. TheNIH classification is IIIB, chronic prostatitis chronic pelvic pain syndrome. He has no infection to suggest acute or chronic bacterial prostatitis, and he is symptomatic and therefore not category IV. The absence of inflammatory cells separates the subclasses of IIA and IIIB. He has no inflammation on EPS, VB3, or seminal plasma and therefore is category IIIB

63
Q

A 65-year-old male undergoes a transrectal ultrasound-guided biopsy for an elevated PSA. He has no pelvic pain. Biopsy shows no cancer, but he does have many areas of prostate inflammation. What is his NIH prostatitis category? a. Category I b. Category II c. Category IIIA d. Category IIIB e. Category IV

A

Category IV. Category IV is asymptomatic inflammatory prostatitis. Asymptomatic means no symptoms of pelvic pain. This usually diagnosed on specimens taken for treatment of other problems such as BPH, prostate cancer, or infertility

64
Q

A 58-year-old male with a history of autoimmune pancreatitis presents urinary retention. He is refractory to medical therapy for benign prostatic hyperplasia (BPH), and a transurethral resection of the prostate (TURP) is planned. What type of histology may be expected from the prostate resection? a. No inflammation b. Granulomatous prostatitis c. Scant periglandular mononuclear infiltrate d. Heavy intraductal lymphocytic infiltrate e. Immunoglobulin G4 (IgG4)-positive plasma cells and fibrosis

A

e. Immunoglobulin G4 (IgG4)-positive plasma cells and fibrosis. IgG4-positive plasma cells and a characteristic pattern of fibrosis are seen in IgG4 disease. First described in autoimmune pancreatitis, multiple previously described disorders including Ormond disease (retroperitoneal fibrosis) are currently considered to fall within this category. One of the characterist

65
Q

A man presents after transrectal prostate biopsy with a fever of 102°F, rigors, and many white blood cells and bacteria in the urine. Which antibiotic is the best choice for initial therapy until urine and blood culture results are available? a. Ciprofloxacin b. Levofloxacin c. Trimethoprim-sulfamethoxazole d. Cefpodoxime e. Meropenem

A

e. Meropenem. The Update of the American Urological Association White Paper on the prevention and treatment of complications after prostate biopsy recommends that patients who present with a fever after prostate biopsy should not be offered fluoroquinolones or trimethoprim-sulfamethoxazole. Management should consist of aggressive resuscitation and broad-spectrum antibiotic coverage—carbapenems, amikacin, or second- and thirdgeneration cephalosporin (after urine and blood cultures).

66
Q

A 41-year-old male presents with his second urinary tract infection in the past 4 months. He is growing the same E. coli as his previous culture. Evaluation should include: a. computed tomography (CT) urogram b. uroflow and postvoid residual urine to rule out retention c. cystoscopy d. four-glass urine test e. nuclear amplification test for gonorrhea and chlamydia

A

d. No correlation between WBCs and symptoms. No correlation between WBCs and symptoms. In the Chronic Prostatitis Collaborative Research Network (CPCRN) study, men with no symptoms had equal amounts of inflammation in EPS as those with pelvic pain

67
Q

The Update of the American Urological Association White Paper on the prevention and treatment of complications after prostate biopsy recommends that patients who present with a fever after prostate biopsy should not be offered fluoroquinolones or trimethoprim-sulfamethoxazole. Management should consist of aggressive resuscitation and ___

A

The Update of the American Urological Association White Paper on the prevention and treatment of complications after prostate biopsy recommends that patients who present with a fever after prostate biopsy should not be offered fluoroquinolones or trimethoprim-sulfamethoxazole. Management should consist of aggressive resuscitation and broad-spectrum antibiotic coverage—carbapenems, amikacin, or second- and thirdgeneration cephalosporin (after urine and blood cultures).

68
Q

In a man younger than 45 years, imaging is not usually helpful. A cystoscopy could be done if he has an __ to rule out ___ if he has a ___ and elevated ___. The four-glass test is __ routinely used for cases of suspected chronic bacterial prostatitis. The nuclear amplification test would be indicated if he had a ___

A

In a man younger than 45 years, imaging is not usually helpful. A cystoscopy could be done if he has an elevated residual to rule out stricture. if he has a decreased uroflow and elevated postvoid residual urine. The four-glass test is no longer routinely used for cases of suspected chronic bacterial prostatitis. The nuclear amplification test would be indicated if he had a urethral discharge

69
Q

T/F

No correlation between WBCs and symptoms. =

A

T. No correlation between WBCs and symptoms. In the Chronic Prostatitis Collaborative Research Network (CPCRN) study, men with no symptoms had equal amounts of inflammation in EPS as those with pelvic pain.

70
Q

what psychological factor is correlated with overall pain along with urinary symptoms and depression in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS):

___ predict overall pain along with urinary symptoms and depression in men with CP/CPPS.

A

Helplessness and catastrophizing predict overall pain along with urinary symptoms and depression in men with CP/CPPS.

71
Q

What is the most common overlapping pain condition (COPC) in men with CP/CPPS?

A

c. Irritable bowel syndrome (IBS). The most COPC is IBS. Men should be queried about signs and symptoms of bowel dysfunction such as constipation, diarrhea, and the relationship to pelvic pain to bowel movements. Referral to a gastroenterologist should be made if indicated.

72
Q

In a case-crossover study in the NIH Multidisciplinary Approach to Pelvic Pain (MAPP) study, Only __ and ___ symptoms were predictive of flare. Items that did not predict a flare included diet, physical activity or sedentary behavior, stress, and constipation.

A

Only recent sexual activity and urinary tract infection (UTI)-like symptoms were predictive of flare. Items that did not predict a flare included diet, physical activity or sedentary behavior, stress, and constipation.

73
Q

t/F

Men with CP/CPPS are more likely to have ejaculatory pain and premature ejaculation

A

true:

74
Q

t/f : The GUPI is a modified version that contains questions about bladder pain. These symptoms were found in approximately 40% of men in the NIH-sponsored MAPP study.

A

true: The GUPI is a modified version that contains questions about bladder pain. These symptoms were found in approximately 40% of men in the NIH-sponsored MAPP study.

75
Q

___ is retained electrical activity of the external sphincter during voiding in the absence of abdominal straining, and/or brief and intermittent closing of the membranous urethra during voiding detected by electromyography, or fluoroscopy in videourodynamics. These men are considered to have___

A

c. Pseudodyssynergy. Pseudodyssynergy is retained electrical activity of the external sphincter during voiding in the absence of abdominal straining, and/or brief and intermittent closing of the membranous urethra during voiding detected by electromyography, or fluoroscopy in videourodynamics. These men are considered to have pelvic floor dysfunction.

76
Q

T/F No treatment for asymptomatic prostate inflammation (category IV) is necessary. Treatment with antibiotics is not indicated and should not be used to “treat” his elevated PSA to try to get it back to normal levels. He should be followed for his PSA elevation and have periodic repeat PSA and digital rectal

A

True No treatment for asymptomatic prostate inflammation (category IV) is necessary. Treatment with antibiotics is not indicated and should not be used to “treat” his elevated PSA to try to get it back to normal levels. He should be followed for his PSA elevation and have periodic repeat PSA and digital rectal

77
Q

Autoimmune orchitis is defined as an autoimmune aggression of the testes characterized by the presence of ____ . Primary autoimmune orchitis is primarily a problem in the evaluation of male infertility. The main causes of secondary autoimmune orchitis are usually associated with a primary vasculitis, particularly Behçet disease, polyarteritis nodosa, and Henoch-Schönlein purpura

A

Autoimmune orchitis is defined as an autoimmune aggression of the testes characterized by the presence of antisperm bodies (ASAs). Primary autoimmune orchitis is primarily a problem in the evaluation of male infertility. The main causes of secondary autoimmune orchitis are usually associated with a primary vasculitis, particularly Behçet disease, polyarteritis nodosa, and Henoch-Schönlein purpura

78
Q

t/f Sexually transmitted diseases and particularly chlamydia are the most common cause of chronic epididymitis. Patient should not be suspected of chlamydia even if deny recent intercourse, because the infection does always correlate with the reported sexual history

A

false. Sexually transmitted diseases and particularly chlamydia are the most common cause of acute epididymitis. Patient should be suspected of chlamydia even if they deny recent intercourse, because the infection does not always correlate with the reported sexual history

79
Q

T.F CP/CPPS is a diagnosis of exclusion and should be made only after a thorough search for other causes of pelvic pain

A

True CP/CPPS is a diagnosis of exclusion and should be made only after a thorough search for other causes of pelvic pain

80
Q
A