Contents
Cover
Title Page
Copyright
Contributors
Preface to the First Edition
Section 1: Infections
Chapter 1: Infections of the urinary tract
Nomenclature
Epidemiology
Pathogenesis and basic science
Bladder infections
Kidney
Prostate
Testis and epididymis
Special infections
Multiple choice questions
References
Answers to multiple choice questions
Chapter 2: Antimicrobial prophylaxis for urologic procedures
Introduction
Risk factors for infection
Basic principles of antimicrobial prophylaxis
Procedure-specific recommendations
Special considerations
Multiple choice questions
References
Answers to multiple choice questions
Section 2: Urinary lithiasis
Chapter 3: Nephrolithiasis: etiology, stone composition, medical management, and prevention
Epidemiology
Stone formation
Stone composition
Medical evaluation
Medical management
Multiple choice questions
References
Answers to multiple choice questions
Chapter 4: Nephrolithiasis: evaluation and surgical treatment
Introduction
Evaluation
Surgical planning
Renal stone treatment
Ureteral stone treatment
Stone fragmentation techniques
Metabolic stone evaluation
Stones during pregnancy
Multiple choice questions
References
Answers to multiple choice questions
Section 3: Reproductive and sexual function
Chapter 5: Male infertility
Introduction
Physiology and pathophysiology of male reproduction
Seminal fluid, sperm characteristics
Etiology of male infertility
Management
Treatment
Conclusion
Multiple choice questions
References
Answers to multiple choice questions
Chapter 6: Erectile dysfunction and Peyronie’s disease
Erectile dysfunction
Peyronie's disease
Multiple choice questions
References
Answers to multiple choice questions
Section 4: Emergency urology
Chapter 7: Genitourinary trauma
Hematuria
Renal trauma
Ureteral trauma
Bladder injury
Urethral injury
Penile injury
Genital bites, burns, and skin loss
Multiple choice questions
References
Answers to multiple choice questions
Chapter 8: Testicular torsion and trauma
General evaluation
Epididymitis
Malignancy, erythema, and infectious orchitis
Testicular torsion: predisposing factors
Testicular torsion: types
Testicular torsion: presentation
Testicular torsion: surgical management
Torsion of the testicular appendices
Testicular trauma
Multiple choice questions
References
Answers to multiple choice questions
Chapter 9: Acute gross hematuria: etiology and management
Etiologies
Treatment of refractory hematuria
Multiple choice questions
References
Answers to multiple choice questions
Chapter 10: Priapism
Presentation and diagnosis
Treatment
Implantable penile prostheses
Multiple choice questions
References
Answers to multiple choice questions
Chapter 11: Urinary fistulae
Vesicovaginal fistulae
Ureterovaginal fistulae
Urethrovaginal fistulae
Uroenteric fistulae
Multiple choice questions
References
Answers to multiple choice questions
Chapter 12: Urethral stricture disease
Etiology and pathogenesis
Diagnosis
Conservative treatments and temporizing measures
Definitive management
Multiple choice questions
References
Answers to multiple choice questions
Section 5: Urine storage and emptying
Chapter 13: Neurourology
Normal micturition
Etiology of urinary incontinence
Neurologic conditions leading to lower urinary tract dysfunction
Management of neurogenic bladder disorders
Multiple choice questions
References
Answers to multiple choice questions
Chapter 14: Urogynecology
Classification of urinary incontinence
Pelvic floor anatomy and support
Pelvic organ prolapse
Urinary tract fistulae
Urethral diverticulum
Multiple choice questions
References
Answers to multiple choice questions
Chapter 15: Interstitial cystitis and chronic pelvic pain
Clinical presentation
Etiology
Diagnosis
Management
Multiple choice questions
References
Answers to multiple choice questions
Section 6: Oncology
Chapter 16: Prostate cancer screening and diagnosis
Introduction
Prostate-specific antigen
Multiple choice questions
References
Answers to multiple choice questions
Chapter 17: Prostate cancer: localized
Statistics and epidemiology
Prostate cancer screening
Other tools for screening
Prostate biopsy
Prostate cancer staging
Treatment for localized disease
Multiple choice questions
References
Answers to multiple choice questions
Chapter 18: Prostate cancer: treatment of metastatic disease
Introduction
Detection of metastatic disease
Hormone-naïve disease
Nonmetastatic castration-resistant disease
Chemotherapy for metastatic or hormone-refractory prostate cancer
Use of agents to decrease skeletal-related events
Palliative measures
Multiple choice questions
References
Answers to multiple choice questions
Chapter 19: Benign prostatic hyperplasia
Introduction
Etiology
Pathophysiology
Epidemiology
Diagnosis
Treatment
Multiple choice questions
References
Answers to multiple choice questions
Chapter 20: Bladder cancer: superficial
Introduction
Grade, stage, and tumor biology
Diagnosis
Surgical management
Immunotherapy
Intravesical chemotherapy
Cystectomy for aggressive superficial and refractory high-grade disease
Surveillance
Multiple choice questions
References
Answers to multiple choice questions
Chapter 21: Invasive bladder cancer and urinary diversion
Introduction
Staging and histology
Surgical therapy
Neoadjuvant and adjuvant systemic chemotherapy
Bladder preservation protocols
Recurrence
Multiple choice questions
References
Answers to multiple choice questions
Chapter 22: Penile and urethral cancer
Epidemiology
Clinical presentation
Investigations
Staging and grading
Primary lesion
Inguinal lymph nodes
Palpable inguinal nodes
Surgical technique of inguinal node dissection
Pelvic lymph node dissection
Complications of lymph node dissection
Summary
Urethral cancer
Anatomy and pathology
Clinical presentation
Initial evaluation
Treatment
Summary
Multiple choice questions
References
Answers to multiple choice questions
Chapter 23: Ureteral and renal pelvic tumors
Introduction
Pathology
Epidemiology
Pathophysiology
Diagnosis
Management
Prognosis
Surveillance
Multiple choice questions
References
Answers to multiple choice questions
Chapter 24: Angiomyolipoma, oncocytoma, and retroperitoneal fibrosis
General considerations in the diagnosis and evaluation of benign renal masses
Angiomyolipoma
Oncocytoma
Retroperitoneal fibrosis
Multiple choice questions
References
Answers to multiple choice questions
Chapter 25: Malignant Renal parenchymal tumors
Epidemiology
Risk factors
Diagnosis and evaluation
Histology and tumor grade
Staging and prognosis
Treatment
Multiple choice questions
References
Answers to multiple choice questions
Chapter 26: Adrenal disorders
Introduction
Anatomy and normal physiology
Cushing's syndrome
Primary hyperaldosteronism (Conn's syndrome)
Pheochromocytoma
Adrenal insufficiency (Addison's disease)
Adrenal cortical carcinoma
Adenoma and other benign lesions
Adrenal metastases
Summary: the incidentaloma
Multiple choice questions
References
Answers to multiple choice questions
Chapter 27: Testicular tumors
Epidemiology
Biology and pathological classification
Diagnosis and staging
Treatment and prognosis of germ cell testicular tumors
Non-germ-cell testicular tumors
Extratesticular tumors
Multiple choice questions
References
Answers to multiple choice questions
Section 7: Congenital and acquired disease
Chapter 28: Obstructing congenital anomalies of the urinary tract
Ureteropelvic junction obstruction
Ureterocele
Megaureter
Posterior urethral valves
Multiple choice questions
References
Answers to multiple choice questions
Chapter 29: Developmental abnormalities of the genitalia: disorders of sexual differentiation, hypospadias, and cryptorchidism
Disorders of sexual differentiation
Hypospadias
Cryptorchidism
Multiple choice questions
References
Answers to multiple choice questions
Chapter 30: Pediatric urinary infections, vesicoureteral reflux, and voiding dysfunction
Pediatric urinary tract infections
Vesicoureteral reflux
Voiding dysfunction
Multiple choice questions
References
Answers to multiple choice questions
Chapter 31: Pediatric genitourinary oncology
Wilms' tumor (Nephroblastoma)
Other renal tumors
Neuroblastoma
Testicular tumors
Rhabdomyosarcoma
Multiple choice questions
References
Answers to multiple choice questions
Chapter 32: The exstrophy–epispadias complex
Classic bladder exstrophy
Epispadias
Cloacal exstrophy
Multiple choice questions
References
Answers to multiple choice questions
Chapter 33: Bladder augmentation, bladder neck reconstruction, and continent diversions in children
Bladder neck reconstruction
Patient evaluation
Techniques
Augmentation cystoplasty
Techniques
Complications
Continent diversions
Techniques
Conclusion
Multiple choice questions
References
Answers to multiple choice questions
Chapter 34: End-stage renal disease and transplantation
End-stage renal disease
Transplantation
Donor evaluation and selection
Surgical technique
Immunology and immunosuppression
Types of immunosuppression
Rejection
Multiple choice questions
References
Answers to multiple choice questions
Addendum
Uropharmacology
α-adrenergic receptor blockers (α-blockers)
5α-reductase inhibitors
Anticholinergics (muscarinic receptor antagonists)
Benzodiazepines
Botulinum Toxin
Phenazopyridine (Pyridium)
Phosphodiesterase-5 inhibitors
Intracavernous injection
Testosterone
Index
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Library of Congress Cataloging-in-Publication Data
Handbook of urology /edited by J. Kellogg Parsons, John B. Eifler, Misop Han.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-470-67256-3 (softback : alk. paper) – ISBN 978-1-118-71373-0 (Pub) – ISBN 978-1-118-71374-7 (PDF) – ISBN 978-1-118-71375-4 (Mobi) – ISBN 978-1-118-71376-1
I. Parsons, J. Kellogg. II. Eifler, John B. III. Han, Misop.
[DNLM: 1. Urologic Diseases–Handbooks. 2. Female Urogenital Diseases–Handbooks. 3. Male Urogenital Diseases–Handbooks. WJ 39]
RC871
616.6–dc23
2013013055
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © James Benet istockphoto.com
Cover design by Andrew Magee Design Ltd
Contributors
Ifeanyichukwu Anusionwu, MD
Resident, Urological Surgery
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Mark W. Ball, MD
Resident, Urological Surgery
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Trinity J. Bivalacqua MD, PhD
Associate Professor of Urology and Oncology
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Arthur L. Burnett, MD, MBA
Patrick C. Walsh Professor of Urology
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
John B Eifler, MD
Resident, Urological Surgery
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Nicholas C. Field, MD, MBA
Southern Alberta Institute of Urology
University of Calgary
Calgary, AB, Canada
Bishoy A. Gayed, MD
Chief Resident
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Angela D. Gupta, MD
Resident, Urological Surgery
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Elias Hyams, MD
Instructor and Fellow
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Matthew Eric Hyndman MD, PhD
Attending Physician
Rockyview General Hospital
Calgary, AB, Canada
Adam Kern, MD
Resident, Urological Surgery
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Stacy Loeb, MD
Assistant Professor of Urology and Population Health
Department of Urology
New York University School of Medicine and Manhattan Veterans Affairs Medical Center
New York, NY, USA
Ahmed Magheli, MD, PhD
Attending Physician and Assistant Professor
Department of Urology
Charité Universitätsmedizin Berlin
Berlin, Germany
Markus Margreiter, MD, FEBU
Assistant Professor of Urology
Department of Urology
Medical University Vienna
Vienna, Austria
Eric Z Massanyi, MD
Pediatric Urology
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Brian Matlaga, MD MPH
Associate Professor
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Jeffrey K. Mullins, MD
Resident, Urological Surgery
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Phillip M. Pierorazio, MD
Chief Resident, Urological Surgery
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Ashley E Ross, MD, PhD
Assistant Professor Urology, Oncology and Pathology
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Michelle Jo Semins, MD
Assistant Professor in Urology
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Varun Sharma MS, MCh (Urology)
Assistant Professor
Institute of Kidney Diseases and Research Centre
Institute of Transplantation Sciences (IKDRC - ITS)
Ahmedabad, Gujarat, India
Debasish Sundi MD
Resident
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Kristina D. Suson, MD
Attending Physician, Pediatric Urology
Children's Hospital of Michigan
Detroit, MI, USA
Kenneth S Tseng, MD, MPH
Resident
The James Buchanan Brady Urological Institute and Department of Urology
The Johns Hopkins School of Medicine
Baltimore, MD, USA
Robert M. Turner II, MD
Resident
Department of Urology
University of Pittsburgh
Pittsburgh, PA, USA
Preface to the First Edition
Urology residency is challenging, both for the prodigious knowledge required to be a competent urologist and for the paucity of time available to acquire it. Our intention in writing the Handbook of Urology is to distill pertinent topics to the bare essentials that can be easily digested in one night of reading. Urology trainees selected the content of each chapter, drawing upon their experiences during training.
Each chapter is preceded by an abstract, a bulleted summary of key points, multiple choice questions and detailed answers, as well as key pitfalls and clinical vignettes. Important results from seminal clinical studies are included and should guide a more thorough review of the topic. As a result, I feel this book is an ideal reference for residents in urology and will also augment the in-service study material currently available.
I am indebted to the exceptional residents and fellows of the The James Buchanan Brady Urological Institute and Department of Urology of the The Johns Hopkins School of Medicine, whose insightfulness and industry were critical to the preparation of this resource.
Finally, I am grateful for the mentorship and expertise of my co-editors, J. Kellogg Parsons, MD, and Misop Han, MD, without whom this book would not be possible.
John B. Eifler, M.D.
Department of Urologic Surgery
Vanderbilt University Medical Center
Nashville, TN
USA
Section 1 Infections
1
Infections of the urinary tract
Nomenclature
Urinary tract infection (UTI) refers to bacterial invasion of the urothelium causing an inflammatory response. When the site of infection is known, it is more informative to name the site of infection; in other words, cystitis should be used for bladder infection and pyelonephritis for kidney injection, rather than using the generic UTI. Bacteriuria, on the other hand, refers to the presence of bacteria in the urine, which may be either asymptomatic or associated with infection. Pyuria refers to the presence of white blood cells (WBCs) in the urine, which can occur in the setting of either infection or other inflammatory states (nephrolithiasis, malignancy, or foreign body).
Epidemiology
UTI is the most common bacterial infection, responsible for at least 7 million office visits and 100,000 hospitalizations per year. Most infections are diagnosed based on clinical symptoms and a suggestive urinalysis (UA). This algorithm, however, misses 20% of patients who will have positive urine cultures and causes unnecessary treatment of 50% of patients who will not go on to have a positive urine culture. The bacteria that most often cause UTIs are enteric in origin, with Escherichia coli being the most common [1].
Pathogenesis and basic science
Infection of the urinary tract occurs as a complex interaction of both bacterial virulence factors and impaired host defense. Routes of entry into the genitourinary (GU) tract are (in order of frequency) ascending infection via the urethra, direct hematogenous spread, and lymphatic spread.
Bacterial virulence factors increase the infectivity of a bacterial inoculum. The ability of bacteria to adhere to vaginal and urothelial epithelial cells is necessary for an infection to develop. Type 1 pili are expressed by E. coli and adhere to uroplakins on umbrella cells of the bladder epithelium. Studies have shown that inoculation of the urinary tract with type 1 piliated organisms results in increased colonization with those organisms. P pili are bacterial adhesins that bind glycolipid receptors in the kidney. The P stands for pyelonephritis, designated because of the high percentage of pyelonephrogenic E. coli that express these pili. Bacteria may downregulate the expression of pili once infection is established since pili increase phagocytosis of the organisms. The ability of bacteria to regulate the expression of their pili is known as phase variation.
Host defense factors decrease the likelihood of infection. Colonization of the vaginal introitus, urethra, and periurethral skin by non-uropathogenic bacteria provide a mechanical barrier to colonization. Normal voiding also washes away colonizing uropathogenic bacteria. There is genetic variation in the receptivity of epithelial cells to bacterial adhesion. There may be an association between adherence and a protective effect of the HLA-A3 allele. Complicating factors that increase infection risk are due to obstruction, anatomic abnormality, and epithelial cell receptivity. Obstruction or urinary stasis can increase host susceptibility to UTIs. Calculus disease, vesicoureteral reflux, benign prostatic hypertrophy, and neurogenic bladder all increase the susceptibility of the host to UTIs [1].
Interpreting the urinalysis
While urine culture is the gold standard for diagnosing UTIs, it is a test that takes 1–2 days to provide results and potentially longer for antibacterial sensitivity analysis. UA is more expeditious and can support the diagnosis made by history and physical. A UA often consists of two parts: a dipped UA and a microscopic UA. The dipped component tests for pH and the presence of leukocyte esterase (LE), nitrates, and blood. The microscopic component identifies red and white blood cells, red and white blood cells casts, granular casts, bacteria, and yeast.
A UA suggestive of infection typically has positive LE, pyuria, microscopic hematuria, and bacteria. Nitrite is present with gram-negative infection. The presence of epithelial cells can indicate contamination with vaginal flora and should prompt repeat midstream collected urine after adequate cleaning [1].
Bladder infections
Cystitis
Cystitis, or infection of the bladder, may be classified as uncomplicated or complicated. Factors that make cystitis complicated are infections in a male, the elderly, children, diabetics, the immunosuppressed, in the presence of anatomic abnormality, during pregnancy, after recent instrumentation, in the presence of a urinary catheter, and after recent antimicrobials or hospitalization. The typical presentation of cystitis includes symptoms of dysuria, frequency, urgency, ±suprapubic pain, and ±hematuria. Notably, constitutional symptoms including fever and chills are usually absent. This history is crucial in making diagnosis since as many as 50–90% of patients presenting with these symptoms will have cystitis. The diagnosis is supported by urinalysis findings of pyuria, bacteriuria, and the presence of nitrite and LE [1].
Treatment of uncomplicated UTI is dependent on availability, allergy, and local resistance patterns. The Infectious Diseases Society of America (IDSA) guidelines recommend the following agents as first line: Nitrofurantoin macrocrystals 100 mg bid × 5 days, trimethoprim–sulfamethoxazole 160/800 mg bid × 3 days, or fosfomycin 3 g single dose. Second-line agents include fluoroquinolones or beta-lactams. Knowledge of institutional and community antibiograms should influence prescriber patterns [2].
Cystitis is considered complicated when it occurs in a compromised urinary tract. Treatment regimens are generally the same as for complicated UTI, but the duration is 7–14 days. Nitrofurantoin should not be used in complicated UTI as it has poor tissue penetration. Additionally, modifiable factors such as removal of foreign bodies including stones and indwelling urinary catheters should be considered if clinically indicated. Indwelling catheters in place for over 2 weeks associated with UTI should be changed [3, 4].
Asymptomatic bacteriuria
Asymptomatic bacteriuria is defined as bacteria in the urine in the absence of clinical signs of infection. It is more common in women than men, but increases in prevalence in both sexes with age. Patients with indwelling catheters, bladder reconstruction using bowel, and patients with neurogenic bladders almost always have bacteriuria. Asymptomatic bacteriuria should not be screened for nor treated with a few important exceptions. Pregnant women and patients undergoing urologic procedures should be screened and treated [5].
Recurrent UTI
Unresolved UTI refers to an infection that has not responded to antimicrobial therapy. This commonly occurs because of resistant bacteria or can occur in the case of other unrealized complicating factors (see section Cystitis).
Recurrent UTI is an infection that occurs after resolution of a previous infection. These infections may represent either reinfection or bacterial persistence. Reinfection designates a new event in which the same or different organism enters the urinary tract, or bacterial persistence. Persistence, on the other hand, is when the same bacteria reappear from a nidus such as infected stone or hardware. Reinfection is responsible for 80% of recurrent UTIs [1].
Pyocystis
Pyocystis is a condition in which purulent material is retained in the bladder. Typically, the bladder is defunctionalized as a result of urinary diversion or hemodialysis. Presenting symptoms include purulent discharge, fever, or suprapubic pain. Treatment begins with placing a catheter to drain the purulent material and antibiotics. Oral antibiotics may be used in nonseptic patients, while intravenous (IV) antibiotics should be chosen in ill patients. Additionally, intravesical instillation of an antibiotic or antiseptic may be considered as well as periodic self-catheterization and saline irrigation. Refractory cases warrant more aggressive management—including cystectomy, bladder sclerosis, or surgically created fistula (vaginal or perineal vesicostomy) [1].
Emphysematous cystitis
Emphysematous cystitis is a rare type of cystitis in which gas is found within the wall of the urinary bladder. It is caused by infection with gas-forming bacteria and most often presents in diabetics and elderly patients. Symptoms are essentially the same as in typical cystitis, and treatment consists of culture-specific antibiotics. This condition must be distinguished from air within the lumen of bladder, which is much more common, and often caused by urinary tract instrumentation, indwelling Foley catheter, or by colovesical or enterovesical fistula [1].
Kidney
Acute pyelonephritis
Diagnosis and workup
Acute pyelonephritis is a renal parenchymal infection that is usually caused by ascending infection from the bladder. Escherichia coli is the most common organism. The classic presentation is acute onset of fever, chills, and flank pain; however, presentation is variable and there is no sine qua non to make the diagnosis. Abdominal pain, nausea or vomiting often accompanies the condition. Physical examination often reveals costovertebral angle tenderness. Laboratory tests often reveal an elevated serum WBC count, while UA findings are similar to those found in acute cystitis. Figure 1.1 shows classic radiographic signs of acute pyelonephritis, including enlarged kidney, wedge-shaped areas of low attenuation giving a “moth-bitten appearance,” and asymmetrical nephrogram [1].
Figure 1.1 CT of pyelonephritis. Contrast CT of the abdomen and pelvis demonstrating enlarged right kidney with wedge-shaped areas of low attenuation, giving a “moth-bitten appearance” consistent with pyelonephritis. Right ureteral stent in place.
Treatment
Treatment is dependent upon the severity of illness and comorbidities. Patients who are nonseptic and can tolerate oral antibiotics may be treated empirically with a fluoroquinolone as an outpatient after urine culture is obtained. Most patients will improve within 72 hours of antimicrobial initiation. Failure to improve warrants more aggressive therapy with hospitalization and broad spectrum antibiotics initiated if culture data are not available. Additionally, radiologic investigation is indicated to rule out obstruction or development of an abscess. Abscesses may require drainage, and obstruction should be relieved with a ureteral stent or percutaneous nephrostomy tube.
In septic patients, blood and urine cultures should be obtained and intravenous antibiotics should be initiated. Common regimens include third-generation cephalosporins (e.g., ceftriaxone), fluoroquinolones (e.g., levofloxacin or ciprofloxacin), or ampicillin plus gentamicin. Early radiologic investigation is warranted in these patients as well [1, 2].
Chronic pyelonephritis
Chronic pyelonephritis is an often asymptomatic condition caused by multiple bouts of acute pyelonephritis. It can result in renal insufficiency. The diagnosis is made with imaging, which demonstrates atrophic, scarred, and pitted kidneys. Management is to treat active infection and prevent future infections. The condition is rare in patients without underlying urinary tract disease but may occur in vesicoureteral reflux and other abnormalities [1].
Emphysematous pyelonephritis
Emphysematous pyelonephritis is an acute, necrotizing infection of the renal parenchyma resulting from infection with gas-producing organisms. It is more common in diabetic patients and in the presence of obstruction. Diagnosis is made by cross-sectional imaging, demonstrating air in the renal parenchyma. Treatment consists of IV antibiotics, relief of any obstruction, supportive care, and often nephrectomy. Despite aggressive treatment, the mortality rate is over 50% [1].
Renal abscess
Renal abscess (or renal carbuncle) is a collection of purulent material within and confined to the parenchyma. Gram-negative organisms from ascending infection are the most common causative organisms. Hematogenous spread can also occur and gram-positive organisms are often isolated in this mechanism. Risk factors include diabetes mellitus and recurrent UTIs. Presentation begins identical to pyelonephritis, but it does not respond to typical antimicrobial therapy. Failure to respond after 72 hours of therapy warrants imaging to rule out an abscess [1].
Treatment is directed by abscess size. Lesions of any size require parenteral antibiotics. Abscesses less than 3 cm may be observed in the patients that are not immunocompromised or severely ill. Abscesses, 3–5 cm, along with small abscesses that fail conservative therapy necessitate percutaneous drainage. Abscess greater than 5 cm and others failing percutaneous drainage may require surgical drainage [6].
Perinephric abscess
Perinephric abscess is a collection of purulence outside the kidney parenchyma but inside Gerota's fascia. Gram-negative organisms are usually causative, with E. coli being the most common. Clinical presentation, diagnosis, and treatment are similar to parenchymal infection. Up to 50% of blood cultures will be positive.
Treatment of perinephric abscess almost always requires drainage. Percutaneous drainage should be considered first line for smaller lesions. Larger abscess or those associated with a nonfunctioning kidney may require nephrectomy [1].
Infected hydronephrosis
Infected hydronephrosis is an infection in an obstructed, hydronephrotic kidney. It is a urologic emergency. Patients are typically very ill, often in urosepsis, with flank pain. It can lead to pyonephrosis or suppurative damage to renal parenchyma. Treatment consists of broad spectrum antibiotics and emergent drainage with either retrograde ureteral stent or percutaneous nephrostomy tube. In decompensating patients, percutaneous nephrostomy is preferred given that it may be performed under less sedation, and to avoid high pressure from irrigation on the collecting system. Drainage should be followed by 10–14 day course of culture-specific antibiotics [1, 7].
Xanthogranulomatous pyelonephritis
Xanthogranulomatous pyelonephritis (XGP) is a chronic, destructive renal infection. It is often associated with unilateral obstructing calculi. The end result is an enlarged, nonfunctioning kidney. The differential diagnosis includes renal cell carcinoma; consequently, this entity must be ruled out. The pathognomonic feature at the cellular level is the presence of lipid-laden macrophages. Treatment often requires nephrectomy [1].
Prostate
Prostatitis
The most common urologic diagnosis in men younger than 50 years is prostatitis and is most prevalent in men between aged 20 and 49 years. Enterobacteriaceae and Enterococci are the two most common pathogens. The NIH classifies prostatitis into four categories.
Category I: Acute bacterial prostatitis
Patients with acute bacterial prostatitis present with lower urinary tract symptoms, including dysuria, frequency and urgency, and often obstruction. It typically is associated with a profound systemic inflammatory response, including fever, chills, and malaise. Systemic symptoms include fever, chills, or perineal pain. Digital rectal examination demonstrates a swollen, exquisitely tender prostate.
Treatment should be tailored to cultures. Fluoroquinolones may be empirically started with duration of 4–6 weeks. Bladder obstruction has classically been treated with a suprapubic cystostomy tube, since indwelling Foley catheters are through to cause further obstruction of urethral ducts. However, straight catheterization to relive the initial obstruction is an appropriate first step [8].
Category II: Chronic bacterial prostatitis
The hallmark of chronic bacterial prostatitis is a history of recurrent UTIs. The traditional classification of chronic prostatitis relied on the Meares–Stamey four-glass test. This technique consists of collecting four samples of urine to distinguish urethral, bladder, and prostate infection. The voided bladder 1 (VB1) specimen is the first 10 mL of urine, representing the ureteral specimen. Voided bladder 2 (VB2) is a midstream specimen, representing the bladder specimen. Next, the prostate is massage, and the expressed prostatic secretions (EPSs) are collected. Finally, voided bladder 3 (VB3) is the first 10 mL of urine after massage. Each specimen is analyzed for leukocytes and microbes, as well as sent for culture. Alternatively, a two-cup test has been proposed that consists of collecting urine before and after massage. Chronic bacterial prostatitis will have both WBCs and positive cultures in both the EPS and VB3 specimens [8].
Category III: Chronic pelvic pain syndrome
Patients with chronic pelvic pain syndrome (CPPS) present with pain lasting greater than 3 months. The pain is most often in the perineum. Men often complain of pain associated with ejaculation. This category is subdivided into inflammatory (IIIa) and noninflammatory (IIIB) CPPS. This is distinguished by the four-glass test that demonstrates WBCs in the EPS and VB3 in category IIIA, and no WBC in IIIB. Cultures are negative for both. More information about chronic pelvic pain can be found in Chapter 15 [8].
Category IV: Asymptomatic inflammatory prostatitis
This classification is reserved for asymptomatic patients who are found to have inflammation incidentally during prostate biopsy or fertility workup. Treatment is not warranted unless treating an elevated prostate-specific antigen (PSA) with a trial of antimicrobials [8].
Prostate abscess
Prostate abscesses typically evolve from cases of acute bacterial prostatitis. An abscess should be suspected when a patient with acute prostatitis fails to respond to antimicrobial therapy. The diagnosis is confirmed with transrectal ultrasound or computed tomography (CT). Treatment involves drainage of the abscess by one of several methods. Classically, transurethral incision has been used for most prostatic abscess, though transperineal incision and drainage may be required for abscesses that extend beyond the prostatic capsule. Percutaneous drainage may also be employed to drain a prostatic abscess and may offer a less morbid approach [8].
Testis and epididymis
Orchitis often presents with associated epididymitis, or epididymo-orchitis. The presence of orchitis alone suggests viral infection, such as mumps orchitis. More commonly, the combined epididymo-orchitis usually occurs via retrograde spread of bacteria through the ejaculatory ducts and vas deferens into the epididymis. The original source is often the bladder, urethra, or prostate. In prepubescent patients, a chemical etiology is more common than an infectious etiology and is related to the reflux of urine up the genital tract in dysfunctional voiders. In adults younger than 35 years, the most common cause of epididymitis is sexually transmitted infection, most common Neisseria gonorrhoeae and Chlamydia trachomatis. In men older than 35 years, the source is often coliform bacteria that have colonized the bladder or prostate, with E. coli being the most common.
Clinical presentation reveals tender epididymis and testis. The spermatic cord is often tender as well. Radiographic presentation with ultrasound demonstrates increased vascularity in the epididymis, testis, or both. Ultrasound should be obtained when the diagnosis is unclear to rule out torsion, which has decreased or no flow, as well as malignancy. Untreated epididymitis sometimes progresses to a paratesticular abscess or pyocele. Figure 1.2 demonstrates the appearance of pyocele on ultrasound. This requires open incision and drainage [8].
Figure 1.2 Ultrasound of pyocele. Scrotal ultrasound demonstrating heterogenous collection adjacent to testis found to be pus upon scrotal exploration.
Treatment
Treatment of isolated orchitis is mainly supportive—scrotal support, bed rest, antipyretics. Antimicrobials may be used when a bacterial origin is presumed with fluoroquinolones being the agent of choice. There is no antiviral regimen for mumps orchitis. Treatment of epididymitis is dependent on age. The Center for Disease Control and Preventions guidelines recommend ceftriaxone and doxycycline for men younger than 35 years and levofloxacin or ofloxacin for men older than 35 years. The antibiotic course is typically 10 days but may be longer if concomitant prostatitis is suspected [8].
Special infections
Genitourinary tuberculosis
While tuberculosis (TB) is most commonly a pulmonary process, 10% of cases occur in extrapulmonary sites. Of these, 30–40% of extrapulmonary TB occurs in the GU tract. Seeding of the GU tract occurs via hematogenous spread from the alveoli to hilar lymph nodes to the blood stream. The primary landing site is the kidney due to its high vascularity. Downstream infection of the bladder and urethra can occur. The epididymis may also be seeded due to hematogenous spread [9].
Fournier gangrene
Fournier Gangrene is necrotizing fasciitis of the perineum. It is a rapidly progressive, potentially life-threatening infection that is usually polymicrobial, consisting of gram-positive, gram-negative, and anaerobic bacteria. Because of the high morbidity and mortality (16–40%) associated with the infection, it must be ruled out in every case of soft tissue infection of the genitalia. Diabetes mellitus, peripheral vascular disease, alcoholism, and malnutrition are risk factors. Examination may demonstrate cellulitis, blisters, or frankly necrotic areas. Pain out of proportions to visible infection may indicate more extensive underlying infection. Treatment includes broad-spectrum parenteral antibiotics and extensive surgical debridement [1, 9].
Antimicrobial therapy
The goal of antimicrobial therapy is to eliminate microbial growth in the urinary tract. Table 1.1 lists the most common antibiotics used to treat infections of the urinary tract, along with the mechanism of action, spectrum, and common adverse reactions of each drug. Institutional antibiograms and regional resistance patterns should guide antimicrobial therapy [1].
Table 1.1 Common antimicrobials
Multiple choice questions
References
1 Schaeffer AJ, Schaeffer EM. Infections of the urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders; 2011.
2 Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103–e120.
3 Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50(5):625–663.
4 Johns Hopkins Antibiotic Handbook, 2012–2013. Johns Hopkins Hospital Antimicrobial Stewardship Program.
5 Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40(5):643–654.
6 Lee SH, Jung HJ, Mah SY, Chung BH. Renal abscesses measuring 5 cm or less: outcome of medical treatment without therapeutic drainage. Yonsei Med J 2010;51(4):569–573.
7 Mokhmalji H, Braun PM, Martinez Portillo FJ, Siegsmund M, Alken P, Köhrmann KU. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. J Urol 2001;165(4):1088–1092.
8 Nickel J. Prostatitis and related conditions, orchitis, and epididymitis. In: Wein AJ, editor. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders; 2011.
9 Ghoneim I, Rabets J, Mawhorter S. Tuberculosis and other opportunistic infections of the genitourinary system. In: Wein A, Kavoussi L, Novick A, Partin A, Peters C, editors. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders; 2011.
Answers to multiple choice questions