Urology Flashcards
Hematuria definition
blood in urine where RBC count >3 per high power field (HPF) on urine microscopy
how much blood is usually required in the urine to be macroscopic hematuria
usually requiring minimum of 1mL of blood in 1L of urine
Differential diagnosis for post renal causes of hematuria
“TITS”: trauma, infection, tumor, stone
Mimics of hematuria
OB & GYN: menstruation, vaginal bleeding
medication: Pyridium, Phenytoin, Rifampin, Nitrofurantoin, Phenolphthalein
dyes: beets, rhodamine B
pigment: hemoglobinuria (hemolytic anemia), myoglobinuria (rhabdomyolysis), porphyria
macroscopic painless hematuria suggests what diagnosis
macroscopic painless hematuria is malignancy (bladder cancer) until proven otherwise
Urology approach to hematuria
1) Confirm hematuria
2) Differentiate Pre-Renal vs. Renal vs. Post-Renal
blood work (CBC, blood film, INR, aPTT) to rule in / out pre-renal hematologic causes
renal glomerular vs. post-renal hematuria differentiated based on history and urine analysis
1) Renal Glomerular History Color: tea/cola colored Clots: no clots Bloodwork: renal function high BUN/Cr Urinalysis Microscopy: dysmorphic RBC, RBC casts Dipstick: can have proteinuria
2) Post-Renal History Color: red Clots: may have clots Bloodwork: normal Urinalysis Microscopy: normal shaped RBC, no RBC casts Dipstick: otherwise normal
3) Work-up of Post-Renal
rule out causes of post-renal hematuria other than tumor (i.e. ITS of TITS) based on history, physical exam and investigations
diagnose urinary tract infection based on symptoms on history confirmed by positive urine culture and dipstick
diagnose trauma based on history of trauma or manipulation of urinary tract
diagnose stones based on symptoms on history confirmed by abdominal / pelvis CT
work-up for tumor = renal ultrasound, urine cytology
positive renal ultrasound or urine cytology concerning for malignancy -> referral to urology for cystoscopy
negative renal ultrasound and urine cytology with risk factors for malignancy -> referral to urology for cystoscopy
negative renal ultrasound and urine cytology without risk factors for malignancy -> urine analysis, urine cytology, blood pressure at 6 months, 1 year, 2 years, 3 years
Risk factors for bladder cancer
age >40 years
smoking history
occupational chemical exposure
gross hematuria
storage or voiding symptoms
recurrent urinary tract infections, recurrent urological disorder
pelvic radiation exposure
Renal cell carcinoma epidemiology
8th most common malignancy, 3% of all newly diagnosed cancer
3 male : 2 female ratio
peak incidence at age 50-60 years
Renal cell carcinoma risk factors
top 3 risk factors: smoking, hypertension, obesity
other: horseshoe kidney, acquired renal cystic disease
Renal cell carcinoma pathology
malignancy arising from proximal convoluted tubule epithelial cells
histological cell types: clear cell (80% cases) papillary (10-15%) chromophoric (5-10%) collecting duct
Renal cell carcinoma clinical presentation
most commonly asymptomatic and diagnosed incidentally by renal ultrasound or CT
classic triad of late symptoms in 10-15% cases: gross hematuria, flank pain, palpable mass
metastasis to brain, bone, lung and liver in 50% cases
para-neoplastic syndromes in 10-40% patients
Renal cell carcinoma para-neoplastic syndromes
hematologic: anemia, polycythemia, erythrocytosis, leukopenia, increased ESR
endocrine: hypercalcemia, increased hormones (prolactin, gonadotropin, TSH, insulin, cortisol)
liver: abnormal liver enzymes
hemodynamic: hypertension, peripheral edema
Renal cell carcinoma investigations
blood work: CBC, electrolytes, Ca, PO4, Mg, albumin, bilirubin, INR, AST, ALT, ALP, GGT, ESR
urine analysis
imaging: abdominal CT with contrast > renal ultrasound for visualization of mass; MRI for evaluation of vascular extension
biopsy: fine needle biopsy if considering observation or other non-surgical therapy
staging requires abdominal / pelvis CT with IV contrast, blood work [liver enzymes (AST, ALT, ALP, GGT); liver function (albumin, bilirubin, INR)], bone scan
Renal cell carcinoma management
management based on staging
surgical options: partial nephrectomy, radical nephrectomy, surgical removal of solitary metastasis
partial nephrectomy = removal of part of kidney, sparing parenchyma
radical nephrectomy = en bloc removal of kidney, tumour, adrenal gland, Gerota’s capsule and para-aortic lympadenectomy
ablative techniques: cyoablation, radiofrequency ablation
radiotherapy
medication for advanced stage: anti-angiogenesis / anti-VEGF (Bevacizumab), mTOR inhibitor (Temsirolimus, Everolimus), IL-2, IFN-a, tyrosine kinase inhibitor (Sunitinib, Sorafenib)
Bladder cancer epidemiology
2nd most common urological malignancy
3 male : 1 female ratio
4 white : 1 black ratio
mean age at diagnosis = 65 years
Bladder cancer risk factors
smoking (implicated in 60% cases)
chemical exposure including aromatic amines
chemotherapy: cyclophosphamide
radiation to pelvis
chronic bladder irritation / inflammation: cystitis, chronic catheterization, bladder stones
Bladder cancer pathology
cell types: transitional cell carcinoma (TCC) in >90% cases; squamous cell carcinoma in 5-7% cases; adenocarcinoma in 1% cases; others in <1% cases
T staging:
superficial papillary in 75% cases with >80% survival
invasive in 25% cases with 50-60% survival
carcinoma in situ (flat non-papillary erythematous lesion) with poorer prognosis
Bladder cancer clinical presentation
asymptomatic in 20% cases
urinary symptoms: gross hematuria in 90% cases; pain in 50% cases; clot retention in 20% cases; failure to empty urinary symptoms
metastasis to lymph nodes (which may present with lower extremity lymphedema), bone, liver
bladder cancer have high recurrence rate within bladder due to urine stasis
Bladder cancer complications
obstruction of ureter -> hydronephrosis -> renal failure and uraemia (nausea, vomiting, diarrhea)
Bladder cancer investigations
blood work: bladder tumour markers (NMP-22, BTA, Immunocyt, FDP)
urine: R & M, C & S, urine cytology
imaging:
bladder ultrasound
CT scan with IV contrast or IVP for filling defect
cystoscopy with bladder washing (gold standard imaging for bladder cancer)
cystoscopy with bladder washing is initial procedure of choice for diagnosis and staging of bladder cancer
biopsy: resection is gold standard for pathological diagnosis (or cold punch biopsy transurethral)
Bladder cancer management
superficial (non-muscle invasive) disease: Tis, Ta, T1
- surgical: transurethral resection of bladder tumour (TURBT)
- surgical: consider cystectomy in select patients with high grade disease
- chemotherapy: once dose or 6 week course of intra-vesical chemotherapy or immune therapy (BCG, Mitomycin C) to decrease recurrence rate; maintenance with intravesical chemotherapy with BCG for 2-3 years
invasive disease: T2a, T2b, T3
- radical cystectomy surgical: radical cystectomy + pelvic lymphadenectomy with urinary diversion (ileoconduit, Indiana pouch, ileal neobladder)
- radiation: chemo-radiation for small tumours
- chemotherapy: neo-adjuvant chemotherapy prior to cystectomy
advanced / metastatic disease: T4a, T4b, N+, M+
1. systemic chemotherapy + radiotherapy + surgery
Definition lower urinary tract symptoms
any combination of urinary symptoms related to failure to store and / or failure to void
male with LUTS classically refer to symptoms due to bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH)
Clinical presentation failure to store
FUND = frequency, urgency / incontinence, nocturia, dysuria
Clinical presentation failure to void
SHEDS = stream changes (slow stream, intermittent stream), hesitancy, emptying incompletely, dribbling, straining to void
Definitions of
urinary incontinence
urgency incontinence
stress incontinence
mixed incontinence
overflow incontinence
overactive bladder
urinary incontinence = involuntary leakage of urine
urgency incontinence = incontinence accompanied by urgency (sudden and compelling desire to past urine that is difficult to defer)
stress incontinence = involuntary leakage with increased intra-abdominal pressure (e.g. exertion, sneezing and / or coughing)
mixed incontinence = combination of urgency and stress incontinence
overflow incontinence = incontinence due to failure to void (bladder full of urine where intra-vesical pressure exceed urethral pressure)
overactive bladder = syndrome of urgency, frequency, nocturia, urinary incontinence
Etiology of urgency incontinence
Urgency incontinence due to bladder (detrusor overactivity or decreased compliance)
A) detrusor overactivity
neurologic: CNS lesion such as spinal cord injury
inflammation: cystitis, stone, tumour
structural: bladder neck obstruction (tumour, stone), BPH
idiopathic
B) decreased bladder compliance
fibrosis of bladder
non-functioning bladder neck or proximal urethra: neurological disease, trauma, surgery, aging
Etiology of stress incontinence
stress incontinence due to sphincter / urethra (urethral hyper mobility and / or intrinsic sphincter deficiency)
A) urethral hyper mobility = weakened pelvic floor allowing bladder neck and urethra to descend with increased intra-abdominal pressure (multiple) childbirth pelvic surgery aging levator muscle weakness
B) intrinsic sphincter deficiency = weakness or failure of urethral sphincter or urethra aging hypo-estrogen state pelvic surgery neurologic problem
Mixed incontinence etiology
combination of causes of urgency and stress incontinence
Overflow incontinence etiology
causes of failure to void
What medications can contribute to urinary incontinence
anti-histamine
anticholinergics
ACE inhibitor, diuretics
anti-depressants, antipsychotics
alpha agonists, alpha 1 blockers
narcotics
ephedrine/pseudoephedrine
Neurological levels that control genitoanal region sensation, anal tone and bulbocavernosal reflex
sensation: penis S2, peri-anal S2-3
anal tone: S2
bulbocavernosal reflex (S2-4)
Failure to store (urinary incontinence) investigations
urine: urine analysis R & M, C & S
if suspected overflow incontinence, post-voidal residual bladder ultrasound
if severe voiding symptoms, then urine flow rate and possibly urodynamic testing
Diagnosis of urgency, stress and overflow incontinence
urgency incontinence: diagnosed based on urgency incontinence on history and urodynamics study
stress incontinence: diagnosed based on stress incontinence on history and positive stress test on physical exam
overflow incontinence: bladder ultrasound showing post-voidal (PVR) residual >200cc
Urgency incontinence management
1st line = lifestyle modification, bladder habit training
2nd line = medication:
anti-cholinergics (Tolterodine, Oxybutynin, Trospium, Solifenacin, Darifenacin, TCA)
last line = Botulinum toxin, sacral neuromodulation
Stress incontinence management
1st line = lifestyle modification, weight loss, Kegel exercises, bulking agents
2nd line = pessary for female (medical device to provide structural support of vagina)
last line = surgery: slings, tension-free vaginal tape, transobturator tape, artificial sphincter
Overflow incontinence management
lifestyle changes
catheterization
treat underlying cause
Mixed incontinence management
combination of management for urgency and stress incontinence
Failure to void (urinary retention) etiology
1) Outflow obstruction
urethra: stricture, phimosis, traumatic disruption
bladder neck & urethra: stone, clot, foreign body, neoplasm
prostate: BPH, prostate cancer
external obstruction: constipation, pelvic mass
2) Neurogenic bladder
CNS: stroke, tumour, Parkinson’s disease, cerebral palsy
spinal cord: spinal cord injury, disc herniation, multiple sclerosis
autonomic neuropathy: diabetic neuropathy
peripheral: post-pelvic surgery, trauma
3) Urinary tract irritation
inflammation: urinary tract infection, prostatitis, abscess, genital herpes, varicella zoster
traumatic: infected foreign body
4) Medications anticholinergics narcotics including opioids anti-hypertensives: ganglionic blocker, methyldopa anti-histamines ephedrine, pseudoephedrine psychosomatic substance
Urinary retention clinical presentation
LUTS: SHEDS symptoms, may present with overflow incontinence
physical exam: palpable / percussible (dull) bladder
acute vs. chronic urinary retention:
acute retention is a medical emergency characterized by pain, anuria, normal bladder volume and architecture, which have risk of bladder rupture
chronic urinary retention is usually asymptomatic characterized by increased bladder volume, detrusor hypertrophy, detrusor atony
Urinary retention investigations
blood work: CBC, electrolytes, creatinine, BUN, PSA
urine: urine R & M, C & S
foley catheter
imaging: bladder ultrasound and post void residual (PVR) renal ultrasound CT scan cystoscopy urodynamic studies
Diagnosis of urinary retention
urinary retention confirmed with any of the following
PVR >200cc on ultrasound
large drainage from initial Foley catheterization followed by post-obstructive diuresis (>200cc/hr x 2 hrs after initial foley output)
hydronephrosis on renal ultrasound or CT
hydronephrosis may not develop if acute urinary retention or presence of peri-nephric fibrosis
Urinary retention management
1) Treat underlying cause of urinary retention
2) Drainage of bladder
1st line = catheterization
acute retention: immediate catheterization to relieve retention, leave Foley catheter to drain bladder while closely monitor fluid status and electrolytes
chronic retention: intermittent catheterization
2nd line = supra-pubic tube placement
Contraindication to foley catheterization
signs of urinary tract injury in setting of trauma including blood at urethral meatus
scrotal hematoma
high riding prostate
obvious disruption of anatomy
indications for supra-pubic tube placement
Foley catheter contraindicated
Foley catheter insertion failure (prostates, urethral stricture, severe BPH, other anatomic abnormalities)
Urinary tract obstruction classification
upper urinary tract obstruction = above bladder (supra-vesical)
lower urinary tract obstruction = bladder and below (infra-vesical)
acute vs. chronic
unilateral vs. bilateral
anatomical site: intra-renal, ureter, bladder, prostate, urethra
extraluminal vs. intra-luminal vs. intra-mural
Etiology of urinary tract obstruction
Extraluminal: lymphadenopathy, mass (tumor, abscess, cyst), BPH, prostate cancer
Intra-luminal: stone, blood clot
Intra-mural: stricture, tumor, polyps
Urinary tract obstruction clinical presentation
can be asymptomatic
urinary symptoms: urinary retention, overflow incontinence, SHEDS LUTS, oliguria / anuria
history: recurrent urinary tract infections
other symptoms associated with different causes: renal colic in stones
Urinary tract obstruction investigations
Same as failure to void
Urinary tract obstruction complications
hydronephrosis -> acute renal failure: uraemia
recurrent urinary tract infection -> urosepsis
stones in kidney, ureter or bladder
Urinary tract obstruction management
1) Drain urine to decompress urinary tract
for upper urinary tract obstruction, percutaneous nephrostomy tube to drain kidney or JJ tube to drain ureter
for lower urinary tract obstruction, catheterization or supra-pubic tube to drain and decompress bladder
2) Remove cause of obstruction
if stone, then extraction of stone
if tumor, then resection of tumor
if BPH, then consider medication and / or surgical options
Prostate anatomical lobes and their divisions
1 anterior lobe (isthmus) anterior to urethra
2 lateral lobes that are posterior to urethra and adjacent to rectum
lateral lobes are separated from one another and from isthmus by median sulcus
3 clinically described prostate zones in adults, their relative volume, location and pathologies that arise there
peripheral zone ~70% of volume and typical site of cancer
central zone ~25% of volume and surround the ejaculatory ducts
peri-urethral transitional zone ~5% of gland and surrounds the urethra, which is typical site of benign prostate hyperplasia
Physiology of the prostate gland (what does it contribute, purpose of this, components of this)
seminal vesicles, prostate gland and bulbourethral glands all contribute to semen
prostate gland secrete a thin, milky fluid, which make up 20% of semen volume
prostate secretion is important for sperm viability and motility
prostatic secretion contains citric acid, zinc, acid phosphatase, clotting enzyme and fibrinolysin
fibrinolysin to help break clotted ejaculate, so that sperm can swim away
epithelial cells of prostate gland secrete prostate-specific antigen (PSA), which liquefies semen in seminal coagulum and allow sperm to swim freely
PSA is elevated in setting of prostate cancer, benign prostate hyperplasia, prostatitis, trauma from DRE / catheterization, ejaculation
What stimulates the growth of prostate cancer cells
prostate cancer cells growth is stimulated by androgens (mainly testosterone and dihydrotestosterone (DHT) secreted by testicles)
Prostate histology
prostate formed by tubuloalveolar glands surrounded by fibromuscular stroma
epithelium of the glands is lined by simple columnar or pseudostratified columnar epithelium
in lumen of protatic gland, there can be corpora amylacea, which are hyaline solid prostatic concretion, which is normal and increase with age
Prostate cancer epidemiology
most prevalent cancer in males
2nd leading cause of male cancer deaths; lifetime risk of 1/6
on autopsy, patients age >50 have 10-30% rate of histologic prostate cancer; patients at age 80 have 50% rate of histologic prostate cancer
mean age of diagnosis is 72 (75% cases diagnosed between age 60 and 85)
at age 50, lifetime risk for prostate cancer is 50% and risk of death from prostate cancer is 3%
Prostate cancer risk factors
African descent
family history of prostate cancer
high dietary fat
cigarette smoking
Prostate cancer pathology (cell types and location)
cell types:
>95% of prostate cancer is adenocarcinoma, often multifocal
5% of prostate cancer is urethelial carcinoma associated with transitional cell carcinoma of bladder, which is not hormone responsive
<1% of prostate cancer is endometrial cancer of the utricle
cancer location
60-70% of prostate cancer arise in peripheral zone
10-20% of prostate cancer arise in transition zone
5-10% of prostate cancer arise in central zone
Prostate cancer clinical presentation
early stages: usually asymptomatic, so commonly detected by DRE, elevated PSA or incidental finding on TURP
late stage: LUTS, erectile dysfunction, incontinence, hematuria, hematospermia (blood in semen), lower urinary tract obstruction causing renal failure
metastases:
bony metastasis (osteoblastic, sclerotic) to axial skeletal
less commonly to liver, lung and adrenal
groin lymphadenopathy (obturator > iliac > pre-sacral / para-aortic) can cause leg pain and edema
DRE: hard irregular nodule or diffuse dense induration involving one or both lobes
differential diagnosis of prostate nodule on DRE
prostate cancer in 30% cases
BPH prostatitis
prostatic infarct
prostatic calculus
tuberculous prostatitis
Prostate cancer investigations
blood work: PSA
differential diagnosis of elevated PSA: prostate cancer, benign prostate hyperplasia, prostatitis, trauma from DRE / catheterization, ejaculation
if (abnormal DRE or abnormal PSA) and >10 years life expectancy, trans-rectal ultraounsd (TRUS) for tumor size / local staging and TRUS guided needle biopsy antibiotic prophylaxis (Fluoroquinolone and Septra) to prevent risk of infection
CT abdominal scan for metastases
Risk of tans-rectal ultrasound guided needle biopsy for prostate
Infection (prostatitis)
Bleeding
Pain
Urinary retention
False negative result in 30% cases
Prostate cancer treatment
T1, T2 (localized, low mortality risk based on PSA, Gleason score, staging)
if adequate life expectancy and no other comorbidity, active surveillance or definitive local treatment
active surveillance = serial PSA, DRE and biopsies
definitive local therapy = radical prostatectomy or brachytherapy or external beam radiotherapy
no difference in cure rate between definitive treatment modalities
in older population: watchful waiting + palliative treatment for symptomatic progression (cancer death rate >10%)
T1, T2 (localized intermediate or high mortality risk based on PSA, Gleason score, staging)
definitive local treatment preferred over active surveillance
T3, T4
external beam radiotherapy +/- androgen deprivation therapy; or radical prostatectomy +/- adjuvant external beam radiotherapy +/- androgen deprivation therapy
androgen deprivation hormonal therapy can be any of the following:
GnRH agonist: Leuprolide (Lupron, Eligard), Goserelin (Zoladex)
anti-androgen: Bicalutamide (Casodex)
past androgen deprivation therapies: bilateral orchiectomy (for removal of 90% testosterone), estrogen (Diethylstilbestrol DES)
N>0 or M>0
hormonal therapy and / or palliative radiotherapy for metastases
palliative radiotherapy includes
local irradiation of painful secondary tumors (e.g. bone metastases)
half-body irradiation
if hormone refractory metastatic prostate cancer, then chemotherapy (Docetazel, Cabazitaxel, Sipuleucel-T)
What does PSA screening measure
measured total serum PSA is combination of free (unbound) PSA (15%) and complexed PSA (85%)
PSA and correlation with prostate cancer
normal measured total serum PSA at <4ug/L, but may vary with age (higher PSA with increasing age) and ethnicity (Asian < Caucasian < African)
6 ways of making PSA more accurately predict risk of prostate cancer: age, race, PSA level, PSA velocity, free to complex PSA level, PSA density
level of PSA correlate with risk of prostate cancer in a continuous fashion, where higher level of PSA increases risk of prostate cancer, so there is no single justifiable cutoff
PSA >10ng/mL have very high risk of prostate cancer
however, 75% of patients with prostate cancer may have normal PSA
free to total PSA ratio: <10% free PSA level suggestive of cancer; >20% free PSA level suggests benign cause used in PSA 4-10
PSA velocity: increase of >0.75ng/mL/year associated with increased risk of cancer
PSA density (PSA / prostate volume on trans-rectal ultrasound): >0.15ng/mL/g of prostate associated with increased risk of cancer
PSA screening Canadian Guidelines
population based routine PSA screening not recommended for men of any ages (Canadian Task Force on Preventive Health Care)
baseline PSA at age 40 (before increased levels confounded by BPH)
based on discussion between patient and physician on risk factors, test charcteristics, risk of over-detection & over treatment, treatment, active surveillance options, men can elect to undergo both PSA and DRE, typically screening at age 50 Q1-2 years until age 75
Use of PSA in prostate cancer patients
work up:
prostate cancer with PSA <20.0ng/mL without bony involvement on history or clinical exam have low risk of bone metastasis, so may not require bone scan
disease monitoring: serum PSA falling to low level following radiation therapy is a good prognostic factor
undetectable PSA following radical prostatectomy = good prognostic factor
outcome prediction: metastatic prostate cancer receiving androgen suppression with failure to reach PSA nadir of <4.0ng/mL have very poor prognosis (survival ~1 year)
BPH definition
hyperplasia of stroma and epithelium in peri-urethral area of prostate (transition zone)
BPH epidemiology
more commonly in older aged men (50% at 50 years old; 80% at 80 years old)
BPH clinical presentation
LUTS: both failure to void and failure to store symptoms FUNWISE
FUNWISE = Prostate Symptom Score each symptom have score of 5 where 0-7 = mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic
DRE: symmetrically enlarged smooth rubbery prostate
BPH complications
urinary retention -> overflow incontinence
obstruction causing hydronephrosis & renal failure
increased risk of urinary tract infection
increased risk of bladder stone
gross hematuria
BPH investigations
urine: urine analysis R&M C&S to exclude urinary tract infection (UTI symptoms can mimic BPH such as frequency, urgency)
blood work:
creatinine & BUN for renal function
PSA to rule out prostate cancer
renal ultrasound to assess for hydronephrosis
consider uroflowmetry to measure flow rate
bladder ultrasound with post-void residual (PVR) for urinary retention
BPH management
a) Conservative management
indication: mild symptoms
watchful waiting (50% patients improve spontaneously)
lifestyle changes (evening fluid restriction, planned voiding)
b) Medication
alpha-adrenergic antagonist that reduce stromal smooth muscle tone: Terazosin (Hytrin), Doxazosin (Cardura), Tamsulosin (Flomax), Alfuzosin (Xatral)
5-alpha reductase inhibitor that inhibit conversion of testosterone to DHT to reduce prostate size: Finasteride (Proscar), Dutasteride (Avodart)
c) Surgery
surgical options include
trans-urethral resection of prostate (TURP)
open prostatectomy for large prostate, which can have supra-pubic or retro-pubic approach
minimally invasive therapy: prostatic stents, microwave therapy, laser ablation, water induced thermotherapy, cryotherapy, high intensity focused ultrasound (HIFU),
transurethral needle ablation (TUNA)
BPH surgery absolute and relative indications
absolute indication:
renal failure due to obstructive uropathy
relative indication: refractory urinary retention recurrent UTI recurrent hematuria bladder stones
Indication to refer BPH to urology
hematuria
urinary retention with hydronephrosis
recurrent urinary tract infections
abnormal DRE
elevated PSA
Prostatitis epidemiology
most common urologic diagnosis in men <50 eyars
incidence of 10-30%
Prostatitis risk factors
BPH
recent instrumentation of urinary tract: cystoscopy, prostatic biopsy
Prostatitis etiology
bacterial infection of prostate (usually peripheral zone): KEEPS organisms (Klebsiella, E. coli, Enterococcus, Proteus, Staphylococcus saprophyticus)
ascending urethral infection and reflux into prostatic ducts
may have abacterial prostatitis with inflammatory and non-inflammatory subtypes due to intra-prostatic reflux of urine and urethral hypertonia
Prostatitis clinical presentation
urinary symptoms: LUTS, hematuria
systemic symptoms: fever, chills, malaise
rectal, lower back and perineal pain
DRE: may have enlarged, tender and warm prostate
Prostatitis investigations
urine: urine analysis C&S from 4 specimens VB1 = voided bladder urine initial from urethra VB2 = midstream from bladder EPS = expressed prostatic secretion VB3 = postmassage/DRE from prostate) R & M colony counts in EPS and VB3 may exceed VB1 and VB2 by 10 times, which suggest prostate source
bloodwork: CBC
consider blood culture if systemically unwell
Prostatitis management
antibiotics:
Ciprofloxacin or Septra PO for 4-6 weeks
consider IV Ampicillin + Gentamicin if systemically unwell
mid-stream urine C&S at 1 and 3 months post antibiotic therapy to ensure eradication
symptomatic management: anti-pyretics, analgesics, sto ol softeners
admission if sepsis, urinary retention, immune deficiency
small drainage catheter if obstruction suspected
catheterization contraindicated due to risk of bacteremia and systemic infection
Differential diagnosis of groin lumps
GI: inguinal hernia, femoral hernia
GU: undescended testis
infection / inflammatory: lymphadenopathy, psoas abscess
vascular: femoral artery aneurysm, saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
neoplasm: soft tissue tumour (muscle, fat e.g. sarcoma, lipoma), lymphoma
Physical exam hernia
hernia: usually soft, compressible and may gurgle, usually are reducible
Physical exam groin hernia
groin hernia: indirect and direct hernia have bulge that originate from above the inguinal ligament descending into testes, which have cough impulse (descends with cough)
Physical exam femoral hernia
femoral hernia: bulge at below inguinal ligament
