Urinary Track Infections:◦ Cystitis

Is an infection of the bladder and most commonly cause by coliform bacteria (especially Escherichia coli) and occasionally Gram-positive bacteria (enterococci).

Route of infection: Ascending from the urethra. Clinical features:

Dysuria and suprapubic discomfort, and in women it may demonstrate with gross hematuria. In women these symptoms usually appear following intercourse.

Cystitis continue:◦ Laboratory studies:

Urinalysis may show pyuria, bacteriuria, and varying degrees of hematuria.

Urine culture is positive for offending organism. Imaging is only warranted if pyelonephritis, recurrent

infections, or anatomic abnormalities are suspected. Treatment:

Uncomplicated can be treated with short term antimicrobial therapy: Suggested regimen is fluoroquinolone for 3 days. Resistant E-Coli can be treated with Bactrin DS. Uncomplicated cystitis in male is uncommon Fluids should be encouraged Hot sitz baths or urinary analgesics like Pyridium can be

use.

Pyelonephitis:◦ Is an infection involving the kidney parenchyma

and renal pelvis.◦ Gram-negative bacteria are the most common to

include E-Coli, Proteus sp; Klesiella sp; Enterobacter and Pseudomonas.

◦ The infection usually ascends from the lower urinary tract.

◦ Chronic is usually cause by progressive inflammation of the renal intestitium either cause by bacteria infection or vesicoureteral reflux.

Clinical symptoms:◦ Fever◦ Flank pain◦ Shaking chills◦ Irritable voiding symptoms◦ Not uncommon◦ Nausea◦ Vomiting◦ Diarrhea

Laboratory:◦ CBC will shoe leukocytosis and left shift◦ Urinalysis shows pyuria, bacteriuria, and varying

degrees of hematuria◦ WBC casts may be also seen◦ Urine culture if obtained prior to antibiotics

demonstrates heavy growth of the offending agent.

Treatment:◦ In the outpatient setting, quinolones or Bactrin DS

for one to two weeks in immunocompetent patients is OK in patients immunocompromised should be treated for longer time.

◦ Hospital admission usually reserve for severe infections or older age, co morbid conditions, or signs of obstruction.

◦ IV quinolones or ampicillin and gentamicin should be initiated while waiting for labs and sensitive results. The IV antibiotics should be continued for 24-48 hours after the patient become afebrile then change to oral antibiotics for two weeks of therapy.

Pyelonephritis Treatment continued:◦ Failure to respond to treatment warrants

ultrasound to exclude complicating factors.◦ Follow-up urine culture are mandatory 1-2 weeks

following treatment.

Prostatitis:◦ Is cause by ascending infection of Gram-negative

rods into the prostatic ducts.◦ Chronic may be associated with evolution or

recurrence of an acute bacterial infection◦ Chronic nonbacterial prostatitis is the most

common of the prostatitis syndromes and its cause is unknown.

◦ Usually a diagnosis of exclusion, and often associated with the term chronic pelvic pain syndrome.

Clinical features:◦ Acute infection is characterized by sudden onset of

high fever, chills and low back and perineal pain.◦ Chronic infection has more variable symptoms.◦ All forms present with irritable bladder symptoms,

(frequency, urgency, and dysuria).◦ The prostate is swollen and tender on examination.◦ Labs:

Urinalysis reveals pyuria Prostatic fluid culture typically is positive for E-Coli in

acute infections. Chronic infection either E-Coli or enterococcus. In

none bacteria cultures are negative.

The four-glass localization test is the classic means of distinguishing a prostate infection from another urinary tract infection.◦ Urine sample are taken at initial void, midstream,

and after prostatic massage; prostatic secretions account for the fourth sample. Assessment of the samples helps to localize the nidus of infection.

Treatment:◦ For men younger that 35 years

Ofloxacin for 10 days or ceftiaxone, 250 mg IM, followed by 10 days of doxycycline is recommended.

In men older that 35 years a quinolone or Bactrin DS for 10-14 days may be use.

Some expects agreed on 3 weeks treatment as the best. In chronic prostatitis 4 weeks treatment with ciprofloxacin

or ofloxacin for 6 weeks or bactrin DS for 1-3 months. Nonsteroidal anti-inflammatory drugs are effective

analgesics. Chronic may need transurethral resection of the prostate

for ultimate resolution. Antibiotics are not effective in nonbacterial prostatitis.

Orchitis:◦ Normally caused by ascending bacterial infection

from the urinary tract.◦ It occurs in 25% of postpubertal males who have

mumps infection.

◦ Clinical features: Testicular swelling and tenderness, usually unilateral Fever and Tachycardia are common

Laboratory studies:◦ Urinalysis reveals pyuria and bacteriuria with

bacterial infection◦ Cultures are positive for suspected organisms◦ Ultrasound is useful if abscess is suspected

◦ Treatment:◦ If mumps is the cause, relief may be obtained

with ice and analgesia.◦ If bacteria is the cause, it can be treated with

antibiotics◦ Carefully evaluate any scrotal masses.

Epididymitis:◦ It is an infection of the epididymis acquired by

retrograde spread of organisms through the vas deferens.

◦ In men younger that 35 years, Chlamydia and gonococci are the most common organisms

◦ In men older than 35 years E-Coli is the most common organism.

Clinical Presentation:◦ Presents with heaviness and dull, aching

discomfort in the affected hemicrotum, which can radiate up the ipsilateral flank.

◦ The epididymis will be markedly swollen and exquisitely tender to touch, also becoming warm and erythematous enlarged scrotal mass.

◦ Fever and chills are common

◦ The phehn’s sign (relief of pain with scrotal elevation) is a classic sign, but is not very reliable.

Laboratory studies:◦ Urinalysis reveals pyuria and bacteriuria◦ Cultures show positive results for suspected

organisms

◦ Treatment: In men younger than 35 years, ceftriaxone 250 mg

IM, plus doxycycline 100 mg BID for 10 days may be administered for gonococci or Chlamydia.

In men older than 35 ciprofloxin 250 mg BID for 10-14 days may be used.

Supportive care may include, bed rest, scrotal elevation and analgesics.

Benign Prostatic Hyperplasia:◦ Proliferation of the fibrostromal tissue of the prostate

can lead to compression of the prostatic urethra creating an obstruction of the urinary outlet.

◦ This is a disease of older men with the mean onset of age of 60-65 years.

◦ Clinical features: The symptom ( Prostatism) which includes symptoms of

obstruction and irritation. Obstructive symptoms which include decreased force of

urinary stream, hesitancy and straining, postvoid dribbling, and sensation of incomplete emptying.

Irritate symptoms include frequency, nocturia and urgency

Recurrent urinary tract infections and urinary retention also can occur

Digital rectal examination typically reveals and enlarged prostate

Laboratory findings:◦ PSA is slightly elevated◦ Other test done are to rule out renal damage or

bladder or prostate cancer.

Treatment:◦ Men with mild to moderate symptoms may

choose watchful waiting and frequent monitoring◦ Medicine options are Alpha adrenergic blockers

and 5/alpha reductase inhibitors◦ Procedures may include:

Ballroom dilatation Microwave irradiation Stent placements Surgical treatment is transurethral resection of

prostate or transurethral incision of the prostate.

Incontinence:◦ Means the unintentional leakage of urine at

inappropriate times.◦ Women are affected twice as often as men,

especially in older women.◦ Incontinence can be classified based on the

underlying pathophysiologic mechanism. Urge incontinence results from bladder contractions

that cannot be controlled by the brain. Stress occurs when urinary retention leads to

bladder distention and overflow of urine through the urethra follows.

Functional incontinence is untimely urination caused by physical or cognitive disability preventing a person from reaching a toilet

Mixed incontinence is a combination of elements of both stress and urge incontinence.◦ Clinical features;◦ Reversible causes such as medications side

effects, excess fluid intake, atrophic vaginitis, fecal impaction, urinary tract infections, impaired mobility and glycosuria

Urge incontinence is a strong desire to void, followed by loss of urine.

Overactive bladder disorder is a related symptom complex characterized by frequency urgency to urinate and nocturia.

Stress is leakage of urine with increased intra-abdominal pressure

Common with neurological disease (Stroke, Parkinson’s disease or dementia), metabolic disorders (hypoxemia, diabetic neuropathy, and pelvic disorders like uterine prolapsed).

Laboratory findings:◦ Urinalysis can identify diabetes glycosuria, or

urinary tract infections◦ Postvoid residual urine volume should be

measured to identify urinary retention◦ Simple cystometry (instillation of water into the

bladder) can identify bladder contractions.◦ Stress test, ultrasonography, cystocopy, and

urodynamics also may be used.

Treatment:◦ Pelvic floor muscle training (Kegel exercises) or

electrical muscle stimulation biofeedback and bladder training can improve the problem.

◦ Pessaries or implants can help to decrease stress incontinence

◦ Anticholinergic medications such as oxybutynin or tolterodine, are effective for urge incontinence. Alpha adrenergic or estrogen can be used for stress incontinence

◦ Tolterodine and oxybutynin can be used for overactive bladder

◦ Catheterization can be also use intermittent or indwelling for overflow Finally surgical intervention is very effective for stress incontinence.

Neoplasm's of the urinary tract:◦ Prostate Cancer

Prostate cancer is common, generally slow growing, malignant neoplasm of the adenomatous cells of the prostate gland and can lead to urinary tract obstruction and metastatic disease.

A disease of the aging, rarely seen in men younger than 40 years.

Cause is unknown, risk factors include genetic predisposition, hormonal influences, dietary and environmental factors and infectious agents.

Clinical features:◦ Many cases not clinically apparent◦ Symptoms of urinary obstruction occur.◦ In advance disease bone pain 2nd to metastases◦ The Prostate may be enlarged, nodular and asymmetric.

◦ Laboratory studies: PSA is usually elevated Pathologic examination of tissue removed for treatment

reveals malignancy Tranrectal ultrasound reveals hypoechoic lesions in prostate Biopsy confirms the diagnosis of adenocarcinoma, and

allows histological grading

Treatment:◦ Appropriate treatment depends on the staging which is

done with abdominal CT or MRI◦ The Gleason score is based on the architectural

pattern. Low grade tumors that are well differentiated may not required treatment.

◦ Stage A and B (Tumor confined to the prostate) may be treated with radical retropubic prostatectomy, brachytherapy or external-beam radiation therapy.

◦ Stage C treated the same way as A, and B but with reduced effectiveness.

◦ Stage D (distant metastases) is treated with hormonal manipulation using ochiectomy, antiandrogens, luteinizing hormone-releasing hormone agonist,

or estrogens. Chemotherapy has limited usefulness and palliative

treatment is given for advanced disease.

Bladder Cancer:◦ Causal factors include exposure to tobacco, occupational

carcinogens from rubber, dye, printing, and chemical industries; schistosomiasis, and chronic infections. Clinical features:

Hematuria is the most common Bladder irritability and infection are other presenting

symptoms Laboratory findings:

CBC and blood chemistry should be done to evaluate for infection and renal functions

Cystoscopy which has an accuracy rate of nearly 100% is the definitive diagnosis; with biopsy confirming the diagnosis.

Radiologic procedures which include IV urogram, pelvic abdominal CT, chest X-Ray, bone scan, and retrograde pyelography for renal pelvic tumors and staging.

Treatment:◦ Depends on the stage◦ Superficial lesions are treated with endoscopic

resection and fulguration, followed by cystoscopy every 3 months..

◦ Recurrent of multiple lesions can be treated with an intravesical instillation of thiotepa, mitomycin, or bacillus Calmette-Guerin.

◦ Radical cystectomy is used for recurrent cancer, diffuse transitional cell carcinoma in situ, or tumors that have invaded the muscle

◦ Combination chemotherapy has been used in bladder sparing trials with or without radiation therapy.

Renal Cell Carcinoma:◦ RCC is the most common type of renal

malignancy. It accounts for 3% of all adult cancers.

◦ RCC is more common in men, usually affecting those older that 55 years, and the incidence is equivalent in whites and blacks, but is about one-third higher in Hispanics.

◦ The cause is unknown, but cigarette smoking is a risk factor.

◦ There is an inherited form that is autosomal dominant.

Clinical features:◦ RCC is associated with a wide range of presenting

signs and symptoms and offer in called the (Internists Tumor).

◦ Classic triad is: Gross hematuria Flank pain Palpable mass (occurs in a small % of patients.) RCC is associated with paraneoplastic syndrome,

including erythrocytosis, hypercalcemia, hypertension, and hepatic dysfunction in the absence of hepatic metastases.

Laboratory findings:◦ Normochromic anemia occurs in nearly one third

of patients with RCC◦ An elevated erythrocyte sedimentation rate has

been reported in up to 75% of patients.◦ Patients presenting with hematuria should have

an IV urogram which usually identifies calcification overlying the renal shadow

◦ Patients presenting with an abdominal mass usually undergo CT studies

◦ Ultrasound can further identify lesions found on IV urogram

◦ MRI is equivalent to CT for staging of RCC

Treatment:◦ Depends on the stage of the tumor◦ Radical nephrectomy is the primary treatment for a

localized disease (Stage I, II, IIIA)Neoadjuvant or adjuvant radiation therapy has not been shown to prolong survival for early stage lesions.

◦ Radiation therapy is an important method of palliation in patients with disseminated disease to the brain, bone, and lungs.

◦ Hormonal therapy and chemotherapy have shown little effect.

◦ Medications such as Alpha interferon and interluking have been successful in reducing the growth some RCC, including some with metastasis

Wilms’ Tumor:◦ Also known as nephroblastoma most common renal

tumor in childhood.◦ Yearly almost 500 cases in familial and nonfamilial

forms.◦ Mostly occurring in healthy children 10% in unhealthy

children's.◦ Most cases are curable 10% associated with anaplasia

and poor prognosis.◦ Clinical Features:

Abdominal Mass Anorexia, nausea, vomiting, fever, abdominal pain and

hematuria. Hypertension cause by elevated levels of renin.

Laboratory Studies:◦ Urinalysis show hematuria, and anemia may be

present.◦ Ultrasound is the study of choice.◦ CT or MRI is done to evaluate tumor extension.◦ Chest X-Ray to evaluate metastases in the lungs.◦ Treatment:

The most effective therapy includes: Surgery Chemotherapy Radiation Therapy

Medications:◦ Dactinomycin

◦ Vincristine

◦ Doxorubicin

◦ Radiation therapy is added for stage III and IV tumors.

Testicular cancer:◦ Is the most common malignant tumor in young

man and the average age is 32 years.◦ Risk factor include history of cryptorchidism, or

previous history. Of testicular cancer.◦ Clinical features:

90% present with painless solid testicular swelling. Para-aortic lymph node involment can present as

urethral obstruction. Also painful abdominal and possible mass.

Laboratory Studies:◦ Scrotal ultrasound.◦ Chest X-ray◦ CT◦ MRI, Elevated blood levels of alpha fetoprotein or

B-human chorionic gonadotropin are diagnostic for nonseminomatous germ cell tumors.

◦ Tumors are classified as seminomatous or nonseminomatous. (Subtypes are embryonic carcinoma, teratoma, yolk sac carcinoma, and choriocarcinoma).

Treatment:◦ Orchiectomy ◦ Seminomatous tumors are radiosensitive.◦ Nonseminomatous tumors are radioresistant.◦ Surgery:

Non seminomatous tumors Stage I disease limited to the testis can be treated with nerve sparing retroperitoneal lymph node dissection or rigorous surveillance without surgery or chemotherapy.

Stage II tumors can be treated with surgery or chemotherapy

Stage III always treated with both

Seminomatous tumors:◦ The mainstay of therapy for stage I disease

isolated to the testis is radiation therapy to the Para-aortic and ipsilateral iliac nodal areas.

◦ Therapy for stage IIa and IIb increased radiation to the affected nodes.

◦ Therapy for stage IIc and III is chemotherapy.

Phimosis:◦ Is characterized by inability to retract the foreskin

over the penis.◦ It can be congenital or acquired.◦ Congenital phimosis is common in children and

adolescents and usually is physiologic.◦ Acquired phimosis is more typical in adults and

usually caused by poor hygiene and chronic balanitis.

Clinical features:◦ History of recent catheterization or forcible

retraction of the foreskin.◦ Foreskin cannot be retracted over the glans penis.◦ Obstructed urinary stream, hematuria, or pain of

the prepuce can indicate more severe constriction.◦ Laboratory studies: NONE◦ Treatment:

If it is asymptomatic, a congenital phimosis should be left alone.

If symptomatic refer for circumcision. Steroidal creams or nonsteroidal ointments may be of

benefit.

Paraphimosis:◦ Is defined as entrapment of the foreskin behind

the glans penis.◦ Frequent catheterizations without reducing the

foreskin can lead to paraphimosis.◦ Forcibly retracting a constricted foreskin

(phimosis) for cleaning can lead to paraphimosis.◦ Vigorous sexual activity can predispose men to

paraphimosis.◦ Clinical features:

Pain, Edema, tenderness, and erythema of the glans and the foreskin are present.

Identification of any foreign body is important.

Laboratory findings: NONE Treatment:

◦ Paraphimosis should be reduced emergently◦ Manual reduction should be tried initially.◦ Surgical reduction may have to be done.◦ After reduction referral for circumcision should be

done.

Erectile Dysfunction:◦ Is defined as the inability to maintain an erect penis

with sufficient rigidity to allow sexual intercourse.◦ Normal erection requires intact parasympathetic and

somatic nerve supply, and unobstructive blood flow.◦ Most have a primary organic and a psychogenic cause,

and nearly all cases have a secondary psychogenic component.

◦ This condition affects millions of American men and its incidence is age related.

◦ Erectile dysfunction in men with type 2 diabetes can be an indicator of early silent cardiovascular disease.

Clinical features:◦ Medical history must be adequately evaluated.◦ A completed sexual history should be taken

including amount of partners and timing of intercourse.

◦ Past medical history should document Hypertension, diabetes, endocrine disorders, medications, and pelvic surgery or trauma.

◦ Physical examinations should look for penile deformities, testicular atrophy, vascular or neurological abnormalities.

Laboratory findings:◦ CBC◦ Urinalysis◦ Lipid Profile◦ Thyroid function◦ Serun testosterone◦ Glucose◦ Prolatin◦ Measuring of follicle-stimulating hormone and

luteinizing hormone may be required for patients with abnormalities of testosterone or prolactin.

Nocturnal penile tumescence testing can be done to differentiate between organic and psychogenic impotence.

Direct injection of vasoactive substances into the penis induces erections in men with intact vascular systems.

Patients who do not need to undergo vascular studies such as ultrasound of the cavernous arteries, pelvic arteriography, and cavernosonography.

Treatment:◦ True psychogenic causes can be treated with

behavioral oriented sex therapy.◦ Patient with organic causes may also benefit from

this form of therapy.◦ Phosphodiesterase-5 (PDE-5) inhibitor therapy is

now the standard treatment.◦ For those that cannot use this medication there

are also form of treatment to included vacuum constriction devices, use of injected vasoactive substances, and penile prostheses. Patients with arterial system disorders are candidates for arterial reconstruction.

Scrotal Mass:◦ Hydrocele:

Is a mass if the fluid filled congenital remnants of the tunica vaginalis, usually resulting from a patent processus vaginalis.

Clinical features: A soft nontender fullness of the hemiscrotum that

transluminates. The mass may wax and wane in size, also an indirect hernia

may be concurrently present. Laboratory: FEW Urinalysis Ultrasonography rarely is indicated but can be

use to distinguish between hydrocele, spermatocele, and testicular tumors.

Treatment: Elective repair as clinically indicated.

Spermatocele:◦ A spermatocele typically is a painless cystic mass

containing sperms.◦ Most are less than 1 cm in size.◦ They lie superior and posterior and are distinct

from the testes.◦ Some may stimulate a solid tumor.◦ Clinical features:

Palpable, round, firm cystic mass with distinct borders, free floating above the testicles, which translluminate, and at time tender.

Laboratory studies:◦ Needle aspiration should not be preformed.◦ Ultrasound provides a very accurate diagnosis.◦ Treatment:

No treatment required. Large ones can be surgically removed or scleroses.

Testicular torsion:◦ The abnormal twisting of the testicles on its

spermatic cord, compromising arterial supply and venous draining of the testis, leading to ischemia.

◦ Most common in young men between the ages of 12-18 years of age.

◦ Specifically with history of cryptorchidism.◦ Clinical features:

Sudden onset of severe unilateral pain and scrotal swelling.

Testis is painful to palpation and scrotum is edematous, and no relief with elevation of the testicle. (Prehn”s sign)

Laboratory findings:◦ This is a clinical diagnosis.◦ Doppler ultrasound demonstrates decreased blood

flow to the affected spermatic cord and testis.◦ Radioisotope scan demonstrates decreased uptake

in the affected testes.◦ Treatment:

Mild analgesics may be given. Surgical emergency. (surgical detorsion and

orchipexy are the definitive therapy). This surgery must be follow by elective surgery on the

contralateral testis, which also is at risk or torsion.

Varicocele:◦ Is the formation of a venous varicosity in the

spermatic vein.◦ The left testicle has an increased incidence

because of anatomical factors.◦ Clinical features:

A CHRONIC NON-TENDER MASS THAT DOES NOT TRANSILLUMINATE USUALLY ON THE LEFT SIDE.

It feels like a bag of worms, and increases in size with valsalva , and decrease in size with elevation of the scrotum or supine position.

Laboratory studies:◦ NONE◦ Doppler sonography is the diagnostic method of

choice.◦ Treatment:

Surgical repair can be performed if the varicocele is painful or if it appears to be a cause of infertility.

END