Campbell-Walsh Urology, 11th Edition

PART III

Infections and Inflammation

13

Inflammatory and Pain Conditions of the Male Genitourinary Tract

Prostatitis and Related Pain Conditions, Orchitis, and Epididymitis

  1. Curtis Nickel

Questions

  1. The most likely candidate for cryptic infection in category III prostatitis is:
  2. Chlamydia.
  3. Ureaplasma.
  4. nanobacteria.
  5. Corynebacteria.
  6. unknown.
  7. The presence of white blood cells (WBCs) in the expressed prostatic secretion (EPS) of patients with category III chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS):
  8. confirms significant prostatic inflammation.
  9. correlates with severity of symptoms.
  10. differentiates CP/CPPS patients from control patients.
  11. differentiates CP/CPPS category IIIA patients from category IIIB patients.
  12. differentiates CP category II patients from CP/CPPS category III patients.
  13. The National Institutes of Health Chronic Prostatitis Symptom Index is:
  14. a research tool that is useful only in clinical trials.
  15. a research tool that is useful in clinical practice.
  16. another invalidated and unreliable clinical symptom index.
  17. an index that has been validated only in English.
  18. a simple pain questionnaire that can be applied to prostatitis patients.
  19. An obese 26-year-old man has an 8-hour history of severe dysuria, stranguria, and suprapubic and perineal pain with fever. On examination, he has suprapubic tenderness, and his prostate is enlarged, boggy, and exquisitely tender. Urinalysis shows pyuria. He continues to complain of symptoms despite insertion of a Foley catheter and has persistent fever following 30 hours of intravenous gentamicin and ampicillin. Culture grew Escherichia coli. What is the best next step?
  20. Change antibiotic to a third-generation cephalosporin.
  21. Perform a transrectal ultrasonographic examination.
  22. Perform a cystoscopic examination.
  23. Perform a bladder scan ultrasonographic examination.
  24. Perform a computed tomography scan.
  25. A 36-year-old man has a 4-month history of dull perineal and suprapubic discomfort, postejaculatory pain, and moderate obstructive voiding symptoms. A preprostatic massage urine sample was sterile, and microscopic evaluation of the sediment showed 2 white blood cells (WBCs) per high power field (HPF). No EPS was obtained during an uncomfortable digital rectal examination. A postprostatic massage urine sample grew 102Staphylococcus epidermidis organisms per mL, and microscopy of the sediment showed 10 to 12 WBCs/HPF. What is the National Institutes of Health (NIH) chronic prostatitis classification?
  26. Category I
  27. Category II
  28. Category IIIA
  29. Category IIIB
  30. Category IV
  31. A 24-year-old man has an 8-month history of obstructive voiding symptoms and perineal and ejaculatory discomfort. A preprostatic massage urine sample was sterile, and microscopic evaluation of sediment showed 1 WBC/HPF. Microscopy of a minute amount of EPS showed 3 WBCs/HPF. A post-prostatic massage urine sample was sterile, and microscopy of the sediment showed 2 WBCs/HPF. The CP/CPPS classification is:
  32. Category I.
  33. Category II.
  34. Category IIIA.
  35. Category IIIB.
  36. Category IV.
  37. A 42-year-old man was treated for cystitis but continued to have dysuria, ejaculatory pain, and perineal/testicular discomfort after 7 days of antibiotics. The prostate examination was unremarkable. A midstream urine sample was sterile, but culture of a drop of EPS produced moderate growth of Enterococcus faecalis. A post-prostatic massage urine sample grew 102E. faecalis organisms, and microscopic examination of the sediment showed 12 WBCs/HPF. What is the NIH classification?
  38. Category I
  39. Category II
  40. Category IIIA
  41. Category IIIB
  42. Category IV
  43. A 32-year-old man had been successfully treated for an E. colicystitis with trimethoprim-sulfamethoxazole (7-day course) 4 months previously. A recurrence of similar symptoms was again successfully treated with ciprofloxacin (3 days), but no culture was done at this time. The patient presents 3 days after antibiotics were discontinued with continued perineal discomfort, ejaculatory pain, and mild dysuria. Pre- and post-prostatic massage urine and EPS samples were sterile. Evaluation of the EPS showed 20 WBCs/HPF. The prostate felt normal. The best next step is:
  44. treat with anti-inflammatory agents.
  45. do a standard Meares-Stamey 4-glass test.
  46. wait for 3 days and do standard Meares-Stamey 4-glass test.
  47. restart trimethoprim-sulfamethoxazole.
  48. restart fluoroquinolone antibiotics.
  49. A 47-year-old man has a 5-year history of perineal and suprapubic pain/discomfort and obstructive voiding symptoms that has not responded to multiple courses of antibiotics, α-blockers, anti-inflammatory agents, repetitive prostatic massage, or phytotherapy. The prostate is tender, and the post-prostatic massage urine sample was sterile and showed 20 WBCs/HPF. The PSA value was 1.2 mg/mL. What is the best next step?
  50. Incision of bladder neck
  51. Flow rate and bladder scan for residual urine
  52. Video-urodynamics
  53. CT scan of pelvis
  54. Cystoscopy and transrectal ultrasound
  55. A 28-year-old man has been successfully treated for three episodes of cystitis (cultures not performed). He now presents with a 3-day history of frequency, urgency, dysuria, and suprapubic discomfort. The prostate feels normal and is nontender. An abdominal and pelvic ultrasonographic study had normal results. A midstream culture done 24 hours earlier by his family physician grew 105E. coli organisms per mL. What is the best next step?
  56. A lower urinary tract localization test (2- or 4-glass test)
  57. Several days of nitrofurantoin therapy followed by lower urinary tract localization test
  58. Four weeks of fluoroquinolone antibiotics therapy
  59. Cystoscopy
  60. Transrectal ultrasonography
  61. A 37-year-old man has a 3-month history of urinary frequency and urgency and discomfort localized to the perineum, suprapubic area, testicles, and penis. A sterile post-prostatic massage urine sample showed 15 WBCs/HPF on microscopy. A year earlier, the patient had been successfully treated for moderately severe symptoms with an unspecified antibiotic. He is allergic to many medications, including ciprofloxacin. The symptoms are now a significant bother and affecting his quality of life. The best initial treatment is a trial of:
  62. anti-inflammatory agents.
  63. tetracycline.
  64. trimethoprim-sulfamethoxazole.
  65. trimethoprim.
  66. carbenicillin.
  67. A 58-year-old man with a 2-year history of symptomatic recurrent urinary tract infections with Pseudomonas(6 to 8 per year) is asymptomatic between treated episodes. Pseudomonas aeruginosa is localized to the EPS and postprostatic massage (voided bladder 3, VB3) samples (but not the midstream urine sample, or VB2) during a period when he was asymptomatic. The EPS shows severe pyuria with WBC plugs or aggregates on microscopy. Transrectal ultrasonography shows extensive prostatic calcifications. Cystoscopy results are normal, residual urine is negligible, and the PSA value is 1.0 mg/mL. What is the best treatment?
  68. Low-dose prophylactic antibiotics
  69. Intraprostatic antibiotic injection
  70. Radical TURP
  71. Radical prostatectomy
  72. Transurethral microwave thermotherapy
  73. A 24-year-old man with a 6-year history of severe perineal pain with irritative and obstructive voiding symptoms has no significant benefits with 4 weeks of therapy with trimethoprim-sulfamethoxazole, anti-inflammatory agents, α-blockers, or phytotherapy respectively. Prostate-specific specimens were sterile, and no WBCs were noted on microscopy. The physical examination had normal findings except for anal sphincter spasm and a tender but normal-feeling prostate gland. Video-urodynamics showed adequate funneling of the bladder neck with seemingly poor opening of the striated sphincter area and abnormal striated sphincter EMG activity during the emptying phase of micturition. What is the best next step?
  74. Four weeks of fluoroquinolone therapy
  75. Muscle relaxant therapy
  76. Bladder neck incision
  77. Biofeedback
  78. Transurethral microwave thermotherapy
  79. A 52-year-old man continues to have high, spiking fever despite suprapubic catheterization and 36 hours of treatment with wide-spectrum intravenous antibiotics. Transrectal ultrasonography confirms a large prostatic abscess. What is the best next step?
  80. Transperineal drainage
  81. Transrectal aspiration
  82. Transurethral drainage
  83. Open drainage
  84. Suprapubic aspiration
  85. Alpha blocker therapy for CP/CPPS:
  86. is of proven value for Category I.
  87. is of proven value for Category II.
  88. is of proven value for Category III.
  89. is of proven value for Category II and III.
  90. May have value in some patients with Category III.
  91. Mandatory evaluation of a patient with CP/CPPS includes history, physical examination, and:
  92. urine analysis, urine culture.
  93. urine analysis, urine culture, Chronic Prostatitis Symptom Index (CPSI).
  94. urine analysis, urine culture, CPSI, urine cytology.
  95. urine analysis, urine culture, CPSI, urine cytology, postvoid residual.
  96. urine analysis, urine culture, CPSI, urine cytology, postvoid residual, sexual function questionnaire.
  97. An asymptomatic 65-year-old man undergoes a prostate biopsy because of an indistinct prostate asymmetry on digital rectal examination. The PSA value is 2.2 ng/mL. Pathology reveals extensive glandular and periglandular infiltration with acute and chronic inflammatory cells. What is the best next step?
  98. Observation
  99. Four weeks of antibiotics and then reassess
  100. Four weeks of antibiotics and anti-inflammatories and then reassess
  101. Repeat biopsy
  102. Cystoscopy
  103. UPOINT is:
  104. a painful urological trigger point.
  105. an inflammatory biomarker.
  106. a phenotype categorization.
  107. a chronic prostatitis diagnosis.
  108. a microscopic technique.
  109. Acupuncture as a treatment for CP/CPPS:
  110. cannot be tested because of difficulty in developing a validated sham procedure.
  111. is characterized by the increased effectiveness of electro-acupuncture over traditional acupuncture.
  112. has been proved ineffective in randomized controlled trials.
  113. is a reasonable choice for selected patients.
  114. has been shown to compare favorably to alpha blockers in comparative clinical trials.
  115. The following conservative therapy is associated with increased pain and disability in CP/CPPS patients:
  116. rest.
  117. diet modification.
  118. exercise.
  119. heat therapy.
  120. physiotherapy.
  121. The following minimally invasive procedure does not provide any proven efficacy to ameliorate symptoms in men with CP/CPPS:
  122. extracorporeal shock wave therapy.
  123. electrical neuromodulation.
  124. microwave thermotherapy.
  125. botulinum toxin.
  126. balloon dilation.
  127. Alpha blocker monotherapy for CP/CPPS category III is:
  128. not recommended.
  129. recommended for patients with obstructive voiding symptoms.
  130. recommended for patients who are alpha blocker naïve.
  131. recommended for patients who are alpha blocker naïve and have obstructive voiding symptoms.
  132. recommended for patients who are newly diagnosed, alpha blocker naïve, and have obstructive voiding symptoms.
  133. Epididymectomy for chronic epididymalgia provides the best results when performed:
  134. in recently diagnosed patients.
  135. in postinfection cases.
  136. when the etiology is traumatic.
  137. postvasectomy.
  138. when associated with Behçet disease.

Pathology

  1. A 65-year-old man undergoes a transurethral resection of the prostate. The pathology is depicted in Figure 13-1, and the report states that there is amyloid that fills several benign prostatic acini. The next step in management is to:

FIGURE 13-1 (From Bostwick DG, Cheng L. Urologic surgical pathology. 2nd ed. Edinburgh: Mosby; 2008.)

  1. perform a transrectal biopsy.
  2. refer to medicine for evaluation of systemic amyloidosis.
  3. inquire as to whether the patient has been on estrogens.
  4. ask the pathologist to perform immune stains for basal cells.
  5. ask the pathologist if the diagnosis could be corpora amylacea.
  6. A 70-year-old man had a transurethral resection of the prostate 10 years previously. A repeat procedure is performed, and the pathology depicted in Figure 13-2is reported as showing granulomatous prostatitis. The next step in management is to:

FIGURE 13-2 (From Bostwick DG, Cheng L. Urologic surgical pathology. 2nd ed. Edinburgh: Mosby; 2008.)

  1. have the patient obtain a PPD.
  2. refer to Infectious Disease for treatment.
  3. inquire as to whether the patient received BCG.
  4. observe the patient.
  5. ask the pathologist to stain the slide for tuberculosis.

Imaging

  1. A 40-year-old man with right scrotal pain is seen in the emergency department. Scrotal ultrasonography is performed (Figure 13-3). The most likely diagnosis is:

FIGURE 13-3

  1. adenomatoid tumor of epididymis.
  2. testicular torsion.
  3. primary testicular neoplasm.
  4. epididymo-orchitis.
  5. orchitis.
  6. A 60-year-old man presents with pelvic and perineal discomfort, fever, and chills. A CT image is shown in Figure 13-4. The next step in management is:

FIGURE 13-4

  1. magnetic resonance imagine (MRI) for staging.
  2. antimicrobial therapy.
  3. drainage.
  4. retrograde urethrography.
  5. transrectal prostate biopsy.

Answers

  1. e. unknown.A careful review of the evidence for and against the role of microorganisms—culturable, fastidious, or nonculturable—leaves the reviewer undecided, and etiologic mechanisms other than microorganisms must be considered.
  2. d. differentiates CP/CPPS category IIIA patients from category IIIB patients.The differentiation of the two subtypes of category III CPPS is dependent on cytologic examination of the urine and/or EPS.
  3. b. a research tool that is useful in clinical practice.The National Institutes of Health Chronic Prostatitis Collaborative Research Network developed a reproducible and valid instrument to measure the symptoms and quality of life/impact of chronic prostatitis for use in research protocols as well as in clinical practice. The symptom index has also proved its usefulness in the evaluation and follow-up of patients in general clinical urologic practice.
  4. b. Perform a transrectal ultrasonographic examination. Development of a prostate abscess is best detected with transrectal ultrasonography.Patients with acute bacterial prostatitis are easily diagnosed and successfully treated with appropriate antibiotic therapy, as long as the clinician keeps a high index of suspicion for prostate abscess in patients who fail to respond quickly to the antibiotics.
  5. c. Category IIIA.Diagnosis of category IIIA CP/CPPS, or inflammatory CPPS, is based on the presence of excessive leukocytes in EPS, a postprostatic massage urine sample, or semen.
  6. d. Category IIIB.Diagnosis of category IIIB CP/CPPS, or noninflammatory CPPS, rests on no significant leukocytes being found in similar specimens.
  7. b. Category II.Category I is identical to the acute bacterial prostatitis category of the traditional classification system. Category II is identical to the traditional chronic bacterial prostatitis classification.
  8. e. restart fluoroquinolone antibiotics.The most important clue in the diagnosis of category II, chronic bacterial prostatitis is a history of documented recurrent urinary tract infections. The fluoroquinolone should be continued for a minimum of 4 weeks.
  9. c. Video-urodynamics.A wide constellation of irritative and obstructive voiding symptoms is associated with CP/CPPS. Proposed etiologies to account for the persistent irritative and obstructive voiding symptoms include detrusor vesical neck or external sphincter dyssynergia, proximal or distal urethral obstruction, and fibrosis or hypertrophy of the vesical neck. Although flow rate and bladder scan can be done to further delineate these conditions, these abnormalities can be clarified and diagnosed best by urodynamics, particularly video-urodynamics.
  10. b. Several days of nitrofurantoin therapy followed by a lower urinary tract localization test.In a patient who has acute cystitis, the localization of bacteria in the EPS or VB3 specimen (postprostatic massage sample) is impossible, and, in this case, the patient can be treated with a short course (1 to 3 days) of antibiotics such as nitrofurantoin, which penetrates the prostate poorly but eradicates the bladder bacteriuria. Subsequent localization of bacteria in the postprostatic massage urine sample or EPS sample is then diagnostic of category II prostatitis.
  11. d. trimethoprim. Studies of animals with and without infection showed that trimethoprim concentrated in prostatic secretion and prostatic interstitial fluid (exceeding plasma levels), whereas sulfamethoxazole and ampicillin did not. It would be appropriate therefore to not prescribe the combination trimethoprim-sulfamethoxazole in a patient with multiple allergies.
  12. a. Low-dose prophylactic antibiotics.Prolonged therapy with low-dose prophylactic or suppressive antimicrobials can be considered for recurrent or refractory prostatitis, respectively.
  13. d. Biofeedback.On the basis of the possibility that the voiding and pain symptoms associated with CPPS may be secondary to some form of pseudodyssynergia during voiding or repetitive perineal muscle spasm, biofeedback has the potential to improve this process. Bladder neck incision in a young man should be avoided until after he has his family because of the possibility of retrograde ejaculation.
  14. c. Transurethral drainage. In patients who fail to respond quickly to antibiotics, a prostatic abscess is optimally drained by the transurethral incision route, although ultrasound-guided percutaneous aspiration (via any route) could be attempted first.
  15. e. May have value in some patients with Category III.Six randomized placebo-controlled trials have shown efficacy for terazosin, alfuzosin, and tamsulosin in patients with CPPS. However, two recent NIH-sponsored large randomized placebo controlled trials have not confirmed its efficacy in heavily pretreated chronic patients, or in recently diagnosed α-blocker naive patients. A number of meta-analyses have confirmed a modest treatment effect, but it appears that the best results are obtained when α-blockers are used as part of a multimodal treatment strategy.
  16. a. urine analysis, urine culture.Mandatory evaluation of a typical man presenting with CP/CPPS includes history-taking, physical examination, urinalysis, and urine culture.
  17. a. Observation.Asymptomatic inflammatory prostatitis (Category IV) by definition does not require symptomatic therapy.
  18. c. a phenotype categorization.UPOINT is a classification system that categorizes CP/CPPS patients into one or more of six distinct clinical phenotypes.
  19. d. is a reasonable choice for selected patients.In a number of sham-controlled trials, acupuncture was shown to be effective in some patients.
  20. a. rest.Studies show that the maladaptive pain coping technique of using "pain contingent resting" (the use of rest rather than more active behaviors to control pain) is not beneficial.
  21. e. balloon dilation. Some minimally invasive surgical procedures (electrical neuromodulation, extracorporeal shock wave therapy, electroacupuncture, and perhaps transurethral microwave therapy and botulinum toxin injection) may be beneficial for treatment for CP/CPPS in selected patients, however, large, well designed sham controlled trials are required before they can be considered recommended therapy.Balloon dilation is ineffective.
  22. a. not recommended. Alpha-blocker monotherapy is not recommended. Alpha-blocker therapy may be considered as part of multimodal treatment strategy for newly diagnosed, alpha-blocker naïve patients who have voiding symptoms (Table 13-1).

Table 13–1

Suggested Therapies for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (NIH Category III)

Modified from evidence based consensus, International Consultation of Urologic Disease, Fukuoko, Japan, 2012. (Nickel JC, Shoskes DA, Wagenlehner FM. Management of chronic prostatitis/chronic pelvic pain syndrome [CP/CPPS]: the studies, the evidence and the impact. World J Urol 2013;31:747–53.)

  1. d. postvasectomy.Better surgical results (up to 70%) have been reported for epididymectomy for postvasectomy pain.

Pathology

  1. e. Ask the pathologist if the diagnosis could be corpora amylacea.Corpora amylacea are most often associated with BPH. Amyloid of the prostate does not look like this; moreover, if there is concern for amyloid, a Congo Red stain should be obtained. Asking the pathologist to clarify the diagnosis, which would be unusual given the circumstances, is most appropriate.
  2. d. observe the patient.The pathology shows multinucleated giant cells, which are not uncommonly seen after chronic irritation. There is no evidence of caseating necrosis and, in this patient with a cause for the giant cells, observation is the correct course.

Imaging

  1. d. epididymo-orchitis.The image demonstrates skin thickening in the scrotum, hydrocele, and a complex hypoechoic mass in the enlarged epididymis that has no flow; color flow Doppler images demonstrate increased flow in the testis and in the remainder of the epididymis, consistent with epididymo-orchitis complicated by an epididymal abscess. These composite findings make the other listed possibilities less likely.
  2. c. drainage.The CT image demonstrates low-attenuation areas in the prostate, primarily the left posterolateral aspect, with extension into the left periprostatic region. The appearance is most compatible with an abscess. This could be confirmed with transrectal ultrasonography. These findings on CT along with the clinical history and a rectal examination, which would reveal extreme tenderness, are sufficient to suggest a prostate abscess. Urgent drainage is prudent in such patients. Although urethral strictures and upper tract abnormalities may be the cause of recurrent urinary tract infections in a male, neither study is required urgently in a patient with a prostatic abscess. Antimicrobial therapy alone is not sufficient treatment at this stage of the infection. MRI may help in delineating the extent of involvement in equivocal cases but is unlikely to add more useful information when the results of CT and the physical examination are flagrantly abnormal. The appearance of the prostate on the CT image is not consistent with prostate cancer.

Chapter review

  1. Granulomatous prostatic inflammation is a common occurrence following surgery or BCG treatment.
  2. The most common cause of acute bacterial prostatitis is the Enterobacteriaceae family of gram-negative bacteria.
  3. Bacteria reside deep in the ducts of the prostate gland and form aggregates called biofilms that allow the bacteria to persist in the presence of antibiotics.
  4. Factors that increase the risk of bacterial colonization of the prostate include (1) intraprostatic ductal reflux, (2) phimosis, (3) specific blood groups, (4) unprotected anal intercourse, (5) urinary tract infections, (6) acute epididymitis, (7) indwelling urethral catheters, (8) condom catheter drainage, and (9) transurethral surgery.
  5. Prostate-specific antigen levels can be markedly elevated during an episode of prostatitis.
  6. Cytokines appear to play an important role in the development of prostatitis.
  7. There is no validated level of WBCs in prostatic fluid that differentiates noninflammatory from inflammatory conditions; however, a finding of 5 to 10 WBCs/HPF is considered by many to be the upper limit of normal for prostatic fluid.
  8. Patients with prostatitis-like symptoms who have no evidence of infection and complain of irritative voiding symptoms should have urine cytology performed.
  9. It may not be the specific type of bacteria that causes CPPS but rather the individual's response to the infection being greater in those prone to get CPPS. The symptoms may continue chronically because of persistent immunologic mechanisms long after the bacterial infection has been eradicated.
  10. Dysfunctional voiding may be a cause of CPPS.
  11. Altered autonomic function may be responsible for the pain.
  12. The NIH Chronic Prostatitis Symptom Index has three domains: pain, urinary function, and quality of life.
  13. UPOINT is a 6-point clinical classification that includes the following categories: urinary, psychosocial, organ specific, infection, neurologic/systemic, and tenderness.
  14. Orchitis is rare and usually viral in origin; most cases of bacterial orchitis are secondary to local spread from the epididymis.
  15. Epididymitis usually results from spread of infection from bladder, urethra, or prostate via the vas deferens.
  16. Development of a prostate abscess is best detected with transrectal ultrasonography. A prostatic abscess is optimally drained by the transurethral incision route,
  17. The classification of prostatitis is as follows: Category I is identical to the acute bacterial prostatitis category of the traditional classification system. Category II is identical to the traditional chronic bacterial prostatitis classification. Category IIIA CP/CPPS, or inflammatory CPPS, is based on the presence of excessive leukocytes in EPS, a postprostatic massage urine sample, or semen. Category IIIB CP/CPPS, or noninflammatory CPPS, rests on no significant leukocytes being found in similar specimens.