testicular torsion and GU infections Flashcards
testicular torsion
- urologic emergency
- more common in neonates and postpubertal boys
- irreversible damage after 12 hours, may result in infertility of both testes
causes of testicular torsion
- can occur spontaneously or after inciting damage
- inadequate fixation of lower testes to tunica vaginalis
- bell clapper deformity- testes lay horizontally
clinical manifestations of testicular torsion
- mod- severe testicular pain
- swelling
- no cremasteric reflex
- n/v
diagnosis of testicular torsion
- H&P
- US with doppler flow- no arterial flow
management of testicular torsion
- manual detorsion- usu not successful
- detorsion surgery with gubernacular fixation to both sides
acute bacterial prostatitis
- make up very small % of prostatitis
- usu young an middle aged men
- route of infection- ascend up urethra
what are the most common pathogens in acute bacterial prostatitis
- e coli
- pseudomonas
risk factors for acute bacterial prostatitis
- urogenital tract infections
- prostate biopsy
- instrumentation
- structural abnormalities
clinical presentation of acute bacterial prostatitis
- pt will look very ill
- fever
- dysuria
- perineal, suprapubic and back pain
- may have obstructive sx
PE for acute bacterial prostatitis
- generalized pelvic tenderness
- DRE -> exquisite pain
- prostate is tender, edematous, warm
lab findings for acute bacterial prostatitis
- leukocytosis with L shift
- UA- pyuria, bacteriuria, hematuria
- UC
- elevated inflammatory markers
- elevated PSA
imaging for acute bacterial prostatitis
- usually none
- CT or MRI if no improvement in 48 hours- think prostatic abscess
indications for admission in acute bacterial prostatitis
- signs of sepsis
- cant tolerate PO abx
- multiple comorbodities
treatment for acute bacterial prostatitis
- empiric abx until culture results
- cipro, levo
- bactrim
- gentamycin
- abx X 4-6 weeks
chronic bacterial prostatitis
- chronic or recurrent urogenital sx with evidence of infection of prostate
- inadequate or too short tx for acute
- common in young and middle aged men
risk factors for chronic bacterial prostatitis
- acute episodes of bacterial prostatitis
- prostate stones
- same RF as acute
clinical presentation of chronic bacterial prostatitis
- can be very subtle
- irritative voiding sx that dont go away
- low grade fever
- dull pelvic or perineal pain
- testicular pain
- some asymptomatic
PE for chronic bacterial prostatitis
- often unremarkable
- prostate may feel boggy, normal or firm
- usu prostate is non-tender
lab findings for chronic bacterial prostatitis
- UA normal
- expressed prostate secretions tested by urology
- increased leukocytes and bacteria
- culture grows offending agent
imaging for chronic bacterial prostatitis
- usu not necessary
- may see prostate calculi on plain film
treatment of chronic bacterial prostatitis
- bactrim- assoc with best cure rate
- quinolones of cephalexin as alternative due to resistance
- tx for 6-12 weeks
inflammatory prostatitis
- most common of prostatitis
- unknown cause
- most common in young and middle aged men
clinical presentation of inflammatory prostatitis
- subtle sx
- pain in perineum, lower abd, testicles, penis
- voiding sx
- blood in semen
- ED, ejaculatory pain
- depression
labs for inflammatory prostatitis
- UA and UC normal
- expressed prostate secretions- done by urology
- prostate biopsy
- dx of exclusion
treatment for inflammatory prostatitis
- alpha blockers
- abx
- 5 alpha reductase inhibitors
- usu tamsulosin + cipro X 6 weeks
- dutasteride used in older men
epididymitis categories
- sexually vs non-sexually transmitted
sexually transmitted epididymitis
- most common in men < 35
- assoc with urethritis, gonorrhea, chlamydia
non-sexually transmitted epididymitis
- most common in older men
- assoc with UTI, prostatitis, e coli
what is the most common cause of acute onset scrotal pain in adults
- epididymitis
clinical presentation of epididymitis
- unilateral pain
- fever
- scrotal swelling
- pain radiates to flank
- urethral d/c
- dysuria
- normal cremasteric reflex
labs/imaging for epididymitis
- UA, UC
- urine for GC/ chlamydia
- scrotal US
treatment for epididymitis
- bed rest
- scrotal elevation
- ice
- if non-sexual- levoflox
- if GC/chlamydia- doxy, ceftriaxone, azithromycin
orchitis
- acute inflammatory reaction of testes d/t infection
- usu assoc with mumps
- 70% of time unilateral
- assoc with parotitis which presents 4-7 days prior
clinical presentation of orchitis
- fever
- malaise
- myalgias
- swollen red testicle
- rarely bilat
diagnosis of orchitis
- usually clinical
- may get scrotal US
treatment for orchitis
- supportive- mainly viral cause
- scrotal elevation
- NSAIDs
- ice
urethritis
- inflammation of urethra
- common manifestation of STI in men
- usu young sexually active men
- classified as gonococcal or non-gonococcal
- common coinfection with chlamydia
pathogens that cause urethritis
- n gonorrhea
- c trachomatis
- m genitalium
- trichomonas vaginalis
- treponema pallidum
clinical manifestations of urethritis
- dysuria
- pruritis and burning at urethral meatus
- discharge- if purulent likely gonorrhea, if watery likely chlamydia
- may be asymptomatic
PE for urethritis
- anxious
- inguinal LAD
- meatus may be red and tender
- prurulent brown/ greenish penile d/c
- white watery d/c
labs for urethritis
- UA
- first catch urine without cleansing
- pos for leukocytes
- > 10 WBCs
- can do genital swabs
treatment for urethritis
- usu treat sexually active men for gonorrhea and chlamydia
- chlamydia- azithromycin
- gonorrhea- ceftiraxone IM
- treat partners within last 60 days
cystitis
- infection of bladder
- lower UTI infection
- colonization of vaginal introitus or urethral meatus
- usu GN bacteria
common pathogens that cause cystitis
- e coli*
- enterobacteriaecea
- klebsiella pneumonia
- proteus
what bacteria can you assume are contaminants when testing for cystitis
- lactobacilli
- group B strep
- enterococci
- coag neg staph
clinical manifestations of cystitis
- dysuria, frequency, urgency
- suprapubic pain
- hematuria
- older women sx more subtle- falls, confusion, change in functional status
diagnosis of cystitis
- H&P
- UA
- +/- HCG
- urinalysis- look for leukocyte esterase and nitrites
- test for gonorrhea and chlamydia in men
management of cystitis
- macrobid
- bactrim
- cefpodoxime (vantin)
- cipro
- symptomatic tx with pyridium
risk factors for cystitis in women
- intercourse
- hx of UTI
- spermicide coated condoms
- diaphragms
- urinary tract abnormalities
risk factors for cystitis in men
- anal intercourse
- uncircumcised
pyelonephritis
- infection of kidney
- upper UTI, complicated
- less common than acute cystitis
- involves kidney parenchyma and renal pelvis
causes of pyelonephritis
- e coli*
- klebsiella pneumonia
- proteus
- pseudomonas if due to health care instrumentation
how does pyelonephritis occur
- ascend to kidneys via ureters
- seeding from bacteremia
clinical manifestations of pyelonephritis
- dysuria, frequency, urgency
- suprapubic pain
- hematuria
- fever, chills
- flank pain, CVA tenderness
- n/v
- more systemic sx than cystitis
diagnosis of pyelonephritis
- H&P
- UA, UC
- CBC- elevated with L shift
- blood cultures and lactate
- imaging not usu necessary but may use if suspicious of stone or unsure of dx
indications for hospitalization in pyelonephritis
- sepsis
- persistent fever
- pain control
- unable to maintain PO intake
- urinary tract obstruction
- pt adherence
inpatient management of pyelonephritis
- ceftriaxone
- zosyn
- cipro, levo
- vanco for MRSA
- imipenem- saved for critically ill pts
outpatient management of pyelonephritis
- cipro, levo
- ceftriaxone IV loading dose then PO bactrim, augmentin, or vantin
symptomatic treatment of pyelonephritis
- pyridium
- motrin, APAP
- anti-emetics
- IVF
UTI and pregnancy
- considered complicated
- commonly asymptomatic
- incidence same as nonpregnant females but more likely to be recurrent
- usu early in pregnancy
risk factors for UTI in pregnancy
- hx of prior UTI
- preexisting DM
- increased parity
- lower SES
diagnosis of UTI in pregnancy
- requires 2 positive UC
treatment for UTI in prengnacy
- macrobid
- augmentin
- cefpodoxime
- fosfomycin
- quinolones NOT recommended
follow up for UTI in pregnancy
- 30% fail to clear asymptomatic bacteriruria after short course tx
- f/u culture recommended
- repeat cultures monthly until end of pregnancy
pyelonephritis and pregnancy
- considered complicated
- usu d/t anatomic changes during pregnancy and immunosuppression
- most in 2nd and 3rd trimester
risks of pyelonephritis in pregnancy
- obstetric complications
- septic shock
- anemia
- bacteremia
clinical manifestations of pyelonephritis in pregnancy
- flank pain
- n/v
- fever
- CVA tenderness
- with or without typical sx
diagnosis of pyelonephritis in pregnancy
- H&P
- UA, UC
- +/- blood cultures and lactate
- renal US considered
management of pyelonephritis in pregnancy
- based on site of care and potential complications
- tx with beta lactams, penicillins, cephalosporins
- quinolones NOT recommended
asymptomatic bacteriuria
- isolation of bacteria without si/sx
- increased prevalence with age
- most common in pregnant women
diagnosis of asymptomatic bacteriuria
- in women need 2 consecutive clean catch voided urine samples
- in men nee one single clean catch voided urine sample
treatment for asymptomatic bacteriuria
- appropriate to treat and screen in pregnant women and pts undergoing procedures
- renal transplant
- use of abx same as cystitis
- older pts often colonized- do not treat
