Inflammatory and pain conditions of male urinary tract

Question 1

NIH Classification of prostatis (4)

Answer 1

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

Question 2

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

Answer 2

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

Question 3

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

Answer 3

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

Question 4

Category I Prostatitis: Acute Bacterial Prostatitis

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

Answer 4

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

Question 5

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

Answer 5

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

Question 6

. 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

Answer 6

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

Question 7

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

Answer 7

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

Question 8

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

Answer 8

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

Question 9

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

Answer 9

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

Question 10

___ 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

Answer 10

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

Question 11

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

Answer 11

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

Question 12

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

Answer 12

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

Question 13

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 ___

Answer 13

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)

Question 14

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

Answer 14

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

Question 15

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

Answer 15

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

Question 16

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

Answer 16

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

Question 17

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

preferred meds used: ___

Answer 17

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

Question 18

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 ___

Answer 18

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.

Question 19

chronic prostatis tx : Beyond Quinolones

give examples

Answer 19

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

Question 20

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

Answer 20

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

Question 21

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

Answer 21

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

Question 22

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

Answer 22

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

Question 23

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

Answer 23

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

Question 24

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

Answer 24

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

Question 25

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

Answer 25

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

Question 26

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

Answer 26

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

Question 27

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

Answer 27

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

Question 28

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

Answer 28

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

Question 29

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

Answer 29

Question 30

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

Answer 30

Question 31

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 \_\_\_

Answer 31

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**

Question 32

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

Answer 32

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).

Question 33

NIH Classification: (4)

Answer 33

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

Question 34

define (GUPI)

Answer 34

Genitourinary Problem Index : chronic prostatitis symptom index to assess genitourinary pain in men and women

Question 35

Sites of palpation for CPS

Answer 35

Question 36

Pharmacologic treatment for CPPS: (10) ## Footnote 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 9. Mepartricin - REDUCES/INCREASES serum estrogen levels and prostatic estrogen receptors in men 10. 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

Answer 36

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 9. Mepartricin - reduces serum estrogen levels and prostatic estrogen receptors 10. 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

Question 37

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

Answer 37

A subsequent systematic review of the literature concluded that evidence for a role of r**epetitive 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

Question 38

Prostate-Specific Treatments: 1. 2.

Answer 38

Local Hyperthermia and Needle Ablation Intraprostatic Injection of Onabotulinumtoxin A.

Question 39

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

Answer 39

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

Question 40

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

Answer 40

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

Question 41

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

Answer 41

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

Question 42

Acute orchitis can be divided into __ and \_\_\_\_

Answer 42

Acute orchitis can be divided into specific **orchitis** and **Viral orchitis**

Question 43

Viral orchitis is most commonly caused by the \_\_\_

Answer 43

Viral orchitis is most commonly caused by the **mumps virus**

Question 44

**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 \_\_\_**

Answer 44

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**

Answer 45

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

Question 46

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

Answer 46

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

Question 47

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

Answer 47

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

Question 48

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 \_\_\_

Answer 48

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

Question 49

Approximately 18% to 25% of chronic orchialgia is considered \_\_\_

Answer 49

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

Question 50

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

Answer 50

**_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

Question 51

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 \_\_.

Answer 51

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.

Question 52

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).

Answer 52

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).

Question 53

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. \_\_\_

Answer 53

**Doxycycline and quinolones** are recommended because of their penetration into the scrotal structures and because they can be used for up to **4 weeks** ## Footnote **2. spermatic cord block**

Question 54

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

Answer 54

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

Question 55

Treatment for epidydymitis . For symptom relief:

Answer 55

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

Question 56

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.

Answer 56

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

Question 57

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 \_\_

Answer 57

An indication for surgery is failure o**f 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**

Question 58

Nonmedical Therapy for Chronic Scrotal Pain: Chronic Orchitis (Orchalgia) and Chronic Epididymitis (Epididymalgia) (3)

Answer 58

Pelvic Floor Physical Therapy Pulsed Radiofrequency of the Spermatic Cord. Botox

Question 59

An option unique to patients with postvasectomy pain syndrome is to reverse the\_\_\_,

Answer 59

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

Question 60

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

Answer 60

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 t**rifecta nerve complex,** which is thought to form the anatomic basis for relief from the denervation procedure

Question 61

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 \_\_\_.

Answer 61

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.

Question 62

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

Answer 62

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

Question 63

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

Answer 63

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

Question 64

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

Answer 64

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

Question 65

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

Answer 65

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).

Question 66

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

Answer 66

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

Question 67

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 \_\_\_

Answer 67

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).**

Question 68

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 \_\_\_

Answer 68

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**

Question 69

T/F No correlation between WBCs and symptoms. =

Answer 69

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.

Question 70

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.

Answer 70

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

Question 71

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

Answer 71

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.

Question 72

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.

Answer 72

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

Question 73

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

Answer 73

true:

Question 74

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.

Answer 74

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.

Question 75

\_\_\_ 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\_\_\_

Answer 75

**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.**

Question 76

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

Answer 76

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

Question 77

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

Answer 77

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

Question 78

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

Answer 78

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**

Question 79

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

Answer 79

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