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U16 Urology
Infectious and Inflammatory Diseases Toronto Notes 2019
Investigations
• U/A,urineC&S
• CBCanddifferential:leukocytosis,leftshift
• imagingifcomplicatedpyelonephritisorsymptomsdonotimprovewith48-72hoftreatment
■ abdominal/pelvic U/S
■ CT
• nuclearmedicine:DMSAscancanbeusedtohelpsecurethediagnosis
■ a photopenic defect indicates active infection or scar; if normal alternative diagnoses should be considered
Treatment
• hemodynamicallystable
■ outpatient oral ABx treatment ± single initial IV dose (see Table 8, U13)
• severeornon-resolving
■ admit, hydrate, and treat with IV ABx (see Table 8, U13)
• emphysematouspyelonephritis
■ most patients receive nephrectomy after IV ABx started and patient stabilized ■ consider temporization with nephrostomy tubes
• renalobstruction
■ admit for emergent stenting or percutaneous nephrostomy tube
Prostatitis/Prostatodynia
Epidemiology
• prevalence:9%ofmen/year,6%withbothersomesymptoms
• mostcommonurologicdiagnosisinmen<50,3rdmostcommoninmen>50
Classification
Table 9. Comparison of the Four Types of Prostatitis
Etiology
Clinical Features
Investigations
Treatment
Acute Bacterial Prostatitis (Category I)
Acute infection
SEEK PP (80% E. coli)
LUTS, pelvic pain Systemic signs: fever, chills, malaise Leukocytosis in prostatic fluid
Positive bacterial cultures
Hx, P/E (abdo, external genitalia, perineum, prostate)
U/A, urine C&S
TRUS if suspect abscess
ABx (see Table 8, U13) Catheterization if severe obstructive
Drainage if abcess is present
Chronic Bacterial Prostatitis (Category II)
Chronic infection ± prostatitis symptoms
LUTS, pelvic pain
No systemic signs Recurrent UTIs Leukocytosis in prostatic fluid
Positive bacterial cultures
Hx, P/E (same as Category I + pelvic floor)
4 glass test for culture: VB1 (urethra)
VB2 (bladder)
EPS (post- massage) VB3 (post-massage)
ABx (see Table 8, U13) α-blocker if obstruction
Chronic Pelvic Pain Syndrome (Category III)
Symptoms without evidence of infection
IIIA: inflammatory
IIIB: non-inflammatory
LUTS, pelvic pain
IIIA: leukocytosis in prostatic fluid
IIIB: no leukocytosis in prostatic fluid
Hx, P/E (same as
Category II)
Symptom score (NIH-CPSI*) 4-glass test
Consider psychological assessment
Supportive measures ABx if ABx naïve Multimodal therapy (UPOINT), including: Alpha-blockers Anti-inflammatories Phytotherapy (quercetin, cernilton)
Asymptomatic Prostatitis (Category IV)
Incidental inflammation
No symptoms Leukocytosis in prostatic fluid
No investigations unless considering ABx for elevated PSA or infertility
ABx if elevated PSA, infertility, or planned prostate biopsy
*NIH-CPSI: National Institute of Health Chronic Prostatitis Symptom Index