[Clinical Guidelines for Common Genitourinary Disorders:]{.underline}

Note: While this information packet is labeled "guidelines", it is
intended only to suggest the initial work-up and treatments for an
assortment of the most commonly encountered urology problems in an
effort to streamline the referral process. In many cases this may save
valuable time in telephone consultation (i.e. trying to determine what
labs to order prior to urology referral), and may even obviate referral
altogether if treatment is successful. The guidelines are not intended
to offer detailed or comprehensive treatises on genitourinary
conditions; there are many fine textbooks readily available for that
purpose, two of which are referenced with each entry. Nor are they meant
to deter appropriate referrals and questions. In short, this is our
department's attempt to make your decisions regarding the treatment of
urology patients easier and the referral system more user-friendly.
General topics are described first, followed by a list of urologic
emergencies.

Kenneth P. Moore, M.D.

Urology

Alaska Native Medical Center

7/24/2003

## [Balanitis / Balanoposthitis]{.underline}

[Definition:]{.underline} Balanitis is inflammation of the glans penis,
while

balanoposthitis is inflammation of the foreskin and glans.

Both occur predominantly in uncircumcised individuals.

Boys tend to have bacterial invasion, while men suffer from a

combination of intertrigo, irritant dermatitis, maceration injury

and bacterial or candidal overgrowth.

Poor hygiene, STD exposure, diabetes, and immune

compromise are known risk factors.

Balanitis xerotica obliterans (BXO) is characterized by white,

featureless, contracted skin around the urethral meatus,

causing meatal stricturing.

[Work-up:]{.underline} Diabetic screening (if adult male)

> Begin meticulous personal hygiene, keeping glans and foreskin clean
> and dry (soap and water daily, expose glans to air as often as
> possible)

Topical antibiotics, antifungals, or steroids as indicated

Biopsy of discrete lesion if topical therapy fails

Urology referral for:

-   Circumcision if recurrent or refractory

-   Biopsy of persistent lesion (may see Dermatology as alternative)

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-   Meatal dilatation if outflow obstructed by BXO

References: Campbell's p. 724

Gomella pp. 210-211

# 

#  [Bladder Calculi]{.underline}

> [Definition:]{.underline} Calculus material in the bladder that does
> not pass with normal micturition

Bladder outlet obstruction most common etiology in U.S.

-   Benign prostate hyperplasia (BPH) in men

-   Cystocele (bladder prolapse) in women

> [Work-up:]{.underline} UA and urine culture (treat any associated
> infection)
>
> Pelvic U/S readily diagnoses most bladder calculi
>
> CT stone search (non-contrast) has excellent sensitivity and
>
> specificity for upper and lower tract calculi
>
> KUB often [fails]{.underline} to demonstrate radiolucent stones (uric
> acid,
>
> ammonium acid urate)
>
> IVP or contrast CT needed only if cancer suspected
>
> Urology referral for: definitive therapy as soon as imaging
>
> study done and infection treated (if
>
> necessary)
>
> References: Campbell's pp. 3384-3386
>
> Gomella pp. 216-217

# 

# [Condyloma Acuminata]{.underline}

> [Definition:]{.underline} Soft, fleshy, vascular anogenital lesions,
> usually
>
> appearing on moist surfaces (diagnosis based on
>
> observation of characteristic lesions)
>
> Increased risk with number of sex partners, frequency of sexual
> activity, and presence of condyloma on
>
> partners
>
> Cigarette smoking may be associated with increased
>
> risk
>
> Possible association with cervical cancer
>
> [Work-up:]{.underline} Check for associated STD's
>
> Careful inspection of anal region for warts also
>
> Referral to Urology for urethroscopy if hematuria or
>
> obstruction present (URETHRAL lesions)
>
> Referral to General Surgery if anal lesions present
>
> Topical therapy (trichloroacetic acid, podophyllin,
>
> podofilox, 5-FU) often effective
>
> Surgical therapy (excision, electrosurgery, CO~2~ laser,
>
> cryotherapy) normally reserved for extensive or
>
> refractory cases
>
> References: Campbell's pp. 740, 2947-2948
>
> Gomella pp. 254-255

#  [Epididymitis / Orchitis]{.underline}

> [Definition:]{.underline} Clinical syndrome characterized by
> inflammation of the epididymis and/or testicles (orchitis rarely
> exists in the absence of epididymitis).
>
> Painful swelling in the scrotum, usually severe and
>
> develops rapidly over 24 to 48 hours (may be even
>
> more acute)
>
> Often associated with dysuria or irritative voiding
>
> symptoms
>
> Prehn's sign: alleviation of pain with scrotal elevation
>
> (present with epididymo-orchitis, not usually with
>
> testicular torsion). Of note, cremasteric reflex
>
> remains intact, in contrast to its decrease with
>
> torsion.
>
> Bacterial etiology most widely accepted:

-   E. coli (children)

-   E. coli (homosexual men)

-   Neisseria gonorrhoeae and Chlamydia

> trachomatis (heterosexual men less than 35 years old)

Mumps orchitis rare due to immunization for mumps,

occurring in post-pubertal boys older than 10 years,

begins 4 -- 6 days after onset of parotitis

Main differential includes testicular torsion and

hemorrhage into an occult testicular tumor

Work-up: Often associated with fever, reactive hydrocele,

erythema of overlying scrotal skin, urethral discharge or

voiding complaints as above, and elevated WBC count

Digital rectal exam to check for prostatitis recommended

Urinalysis often unremarkable

Consider scrotal ultrasound with colorflow Doppler if

torsion, tumor, or trauma suspected

Antibiotics, bed rest, analgesics and / or anti-

inflammatory agents and scrotal elevation are usually

effective

Extend antibiotic course as needed if prostatitis present

also (minimum 30 days therapy for prostatitis)

Always treat the sexual partner if suspected secondary

to an STD. Prostatitis and epididymo-orchitis are not

themselves considered STDs. National STD Hotline:

\(800\) 227-8922

Patients may require hospitalization for I.V. antibiotics if

systemically ill

Consider follow-up scrotal ultrasound if no resolution

with appropriate antibiotics (rule out abscess)

References: Campbell's pp. 678-680

Gomella pp. 280-281

[Edema -- External Genitalia]{.underline}

Definition: Either generalized edema or confined to scrotum and / or
penis

Work-up: Urinalysis and urine culture (look for proteinuria)

Chem 7

Scrotal ultrasound (with colorflow Doppler if available)

Retrograde urethrogram if urethral trauma suspected

Reference: Gomella p. 30-31

[Epididymal Mass]{.underline}

Definition: Solid paratesticular mass, with or without associated pain

Work-up: Urinalysis

Urine culture and sensitivity (if suggested by UA)

CBC with differential

Scrotal ultrasound (to determine testicular-vs-paratesticular,

cystic-vs-solid)

CXR, PPD (if tuberculosis suspected)

References: Campbell's p. 2362

Gomella pp. 38-39

[Elevated Prostate Specific Antigen (PSA)]{.underline}

Definition: Serum PSA drawn on routine screening for prostate cancer

Greater than 4.0 usually considered "elevated"

May represent any condition involving inflammation of the

prostate, including prostate cancer, acute or chronic

prostatitis, benign prostate hyperplasia (BPH), or recent

instrumentation

Work-up: Determine history suggestive of prostatitis or recent

instrumentation, or exam consistent with prostatitis. If

prostatitis present, treat for 30 -- 45 days with lipophilic

antibiotics (TMP-SX, Doxycycline, or quinolones) and repeat

PSA two weeks after antibiotics completed. If no prostatitis

present, or if PSA remains elevated (greater than 4.0) after

course of appropriate antibiotics, refer to Urology for

consideration of prostate biopsy.

[Erectile Dysfunction]{.underline}

Definition: Consistent inability to obtain and / or maintain an erection

sufficient for satisfactory sexual relations (90% primarily

organic)

Work-up (per 1993 NIH Consensus Conference Panel):

CBC

Chem 7 with random glucose level

TSH (other thyroid function tests only if TSH abnormal)

Early-morning total serum testosterone level

(Serum free testosterone, LH and prolactin only if

initial testosterone abnormal)

References: Campbell's pp. 1673-1705

Gomella pp. 40-41

[Frequency and Urgency]{.underline}

Definition: Frequency is voiding more often than normal (5-6 times per

day, 0-2 times per night).

Urgency is the sudden impulse to void, without leakage.

Work-up: Urinalysis

Urine culture and sensitivity (If indicated by UA)

Chem 7 (BUN / creatinine)

Renal ultrasound (if renal insufficiency or urinary retention)

Bladder ultrasound (if urinary retention suspected)

Urology referral for cystoscopy [if]{.underline}: Hematuria

Pyuria

Persistent / worsening

Symptoms

References: Campbell's p. 86

Gomella pp. 54-55

[Hematuria - Adult]{.underline}

Definition: More than 2 RBC's per high power field on microscopic exam

of fresh urine (not dipstick), confirmed on repeat urinalysis

Work-up: (Recommended for all patients with gross hematuria and all

adult patients with microscopic hematuria)

CBC, Chem 7

Urine for cytology

Urine for culture and sensitivity (if indicated by positive leukocyte

esterase and nitrite)

IVP [with tomograms and obliques]{.underline}

(May substitute renal ultrasound for IVP in contrast allergic

patients or those with elevated serum creatinine. This often

commits the patient to later retrograde pyelograms under

anesthesia, so get the IVP whenever possible.)

Urology referral for cystoscopy [after]{.underline} other work-up
complete

References: Campbell's p. 101

Gomella pp. 62-65

[Hematuria -- Pediatric]{.underline}

Definition: More than 2 RBC's per high power field on microscopic exam

of fresh urine (not dipstick), confirmed on at least three

separate urinalyses

Work-up: CBC, Chem 7, C3 / C4 levels, CH50, ANA, plasma IgA levels,

anti-streptolysin-O titer, calcium:creatinine ratio

Renal and bladder ultrasound

Voiding cystourethrogram (VCUG)

Note: cystoscopy rarely indicated

Pediatric Nephrology referral if U/S, VCUG are normal

References: Campbell's p. 1826-1827

Gomella pp. 66-67

[Hematospermia]{.underline}

Definition: Visible blood in the ejaculate (or "rust-colored" semen)

Work-up: Urinalysis and urine culture

Urine cytology

Urethral swab for GC, Chlamydia

PSA

Consider course of antibiotics for prostatitis, with repeat studies

and Urology referral if hematospermia persists or studies

abnormal

References: Campbell's p. 90

Gomella pp. 60-61

[Hydrocele (Adult and Pediatric)]{.underline}

Definition: Collection of serous fluid within the tunical vaginalis,
either

congenital or acquired

Congenital: Failure of the processus vaginalis to close

completely following testicular descent results in a

"communicating" hydrocele. Closure of the canal with fluid

present results in a "non-communicating" hydrocele.

Acquired: May be primary (idiopathic) or secondary to disease

of the testis (association with infection, torsion, or trauma

usually involves pain)

Work-up: Transillumination in the office favors simple hydrocele, but is

NOT diagnostic

Testes must be palpated bilaterally to rule-out undescended

testis and attempt to feel for testicular mass

Groin must be examined for evidence of inguinal hernia

Lab: UA / C&S if epididymitis suspected

Tumor markers (quantitative HCG, LDH, alphafetoprotein)

if tumor suspected

Scrotal ultrasound documents condition, location, and size of

testes as well as documenting nature of hydrocele fluid and

absence of tumor. Presence of testicular blood flow on

colorflow Doppler assures viability of testis.

Adults are referred to urology only if hydrocele causes

discomfort or cosmetic concerns, or if there is significant

underlying cause (i.e. tumor).

Children are referred to urology if hydrocele fails to resolve

by the age of two years, or if a hernia is felt to be present.

References: Campbell's pp. 2377-2379

Gomella pp. 308-309

[Male Infertility]{.underline}

Definition: Inability of couple to conceive within 1 year of unprotected

intercourse. (Note -- evaluation may begin upon

presentation, need not wait for 1 year of attempted

conception)

Work-up: Evaluation of partner by OB-GYN

Three separate semen analyses (SFA) for: volume, count,

motility, and fructose (following three days' abstinence from

intercourse)

Mycoplasma and Chlamydia urethral swabs if clinically indicated

(urethral discharge)

FSH, A.M. Testosterone if sperm count \<20 million / mL

LH, prolactin if A.M. Testosterone low

Scrotal ultrasound to confirm varicocele if found on exam

Referral to Urology [if]{.underline}: Persistent low volume (\< 1.5 mL)
+/- low

fructose

Varicocele

Associated hypospadius, penile chordee,

abnormal scrotal ultrasound

May [NOT]{.underline} need referral if: Bilateral testicular atrophy and

FSH \> 2x normal (primary testicular

failure)

References: Campbell's pp. 1480-1485

Gomella pp. 80-81

[Nephrocalcinosis]{.underline}

[Definition:]{.underline} Radiographically detectable diffuse renal
[parenchymal]{.underline}

calcifications, in contrast to nephrolithiasis in which

calcifications are located in the pyelocalyceal lumina

Associated with multiple renal diseases (not a single entity)

A specific disorder can be identified in many cases

(hyperparathyroidism, renal tubular acidosis, etc.)

Sex, familial and racial factors not found to be significant in

most series

Patients may develop nephrolithiasis, with stones causing the

typical flank pain / urinary obstruction symptoms

Work-up: Diagnosis is based on radiographs (KUB)

Radiographic extent or degree of renal calcium deposition is

not a reliable indication of the degree of impairment of renal

function

Lab (to determine specific etiology):

-   Serum BUN / creat, calcium, phosphorus, uric acid, electrolytes,
    alkaline phosphatase, albumin (PTH if serum calcium elevated)

-   24-hour urine for calcium, oxalate, uric acid, phosphate,
    creatinine, protein, citrate, magnesium and sodium

-   Urinary pH testing by patient with Nitrazine test paper over 48
    hours

-   UA C&S if UTI suspected

Treatment is that appropriate for the underlying cause of the

nephrocalcinosis, with urology evaluation reserved for those

patients with obstructing calculi requiring surgical

intervention. Stones may be treated conservatively as for

other patients, with infections treated aggressively with

antibiotics to prevent colonization.

References: Campbell's p. 1771

Gomella pp. 360-363

[Nephrolithiasis]{.underline}

Definition: Formation of crystalline stones within the urinary
collecting

system, with potential complications of urinary obstruction,

infection, and hematuria

After an initial episode, incidence of recurrence is 50% over

the next 10 years

Males affected more often than females (3:1)

Infected stones more common in females (3:2)

Prevalence highest in Europe, North America and Japan (high

intake of refined carbohydrate with low intake of crude fiber)

Pathophysiology remains poorly understood. Involves

supersaturated urine, lack of sufficient urinary inhibitors (i.e.

citrate), and / or presence of matrix (noncrystalline

mucoprotein) in the urinary system.

Most common types are calcium oxalate, calcium phosphate, or

a combination of the two (account for over 90% of all

stones), followed by uric acid, struvite (associated with

infection) and cystine (hereditary) which together account for

less than 10% of all stones.

Most common risk factor is low oral fluid intake. Medications

associated with urolithiasis include: acetazolamide,

antacids, protein supplements, triamterene, vitamins C and

D, indinavir.

Work-up: Detailed history, including number of prior stones,

urinary infections, calcium and fluid intake, occupation,

symptoms of hypercalcemia, hypertension, and renal failure.

Urinalysis, with attention to urine pH, hematuria, and evidence

of infection (nitrite, leukocyte esterase)

Serum calcium, phosphorus, electrolytes, uric acid, creatinine

(Parathyroid hormone) if calcium is high)

Spiral CT (usually ordered as "stone search CT") is excellent at

detecting both radio-opaque stones and radiolucent stones

(i.e. uric acid). Either spiral CT or IVP with tomograms should

be used to evaluate patients with acute renal colic.

IVP with tomograms allows qualitative evaluation of renal

function and excellent localization of ureteral calculi. Delayed

films must be carried out until ureter is visualized down to the

offending stone. Requires normal creatinine and involves

intravenous access and exposure to intravenous contrast.

KUB will miss radiolucent stones (uric acid, indinavir);

ultrasound can detect and localize stones but is often

inaccurate in determining stone size.

Greater than 90% of stones \<4 mm pass spontaneously,

50% of stones between 4 and 8 mm pass

spontaneously

10% - 50% of stones \>8 mm pass spontaneously

Referral to urology for: Intractable pain despite optimized

analgesic medication

Recurrent UTI's

Persistent bleeding

Stone in solitary kidney

Immune compromised patient

Chronic steroid use

Diabetic

Stone \> 6 mm in diameter

Intractable nausea and vomitting

Urosepsis

Elderly / debilitated patient

Clot or debris in renal pelvis, or

perinephric abscess on studies

References: Campbell's pp. 3365-3378

Gomella pp. 364-367

[Pneumaturia]{.underline}

Definition: Passage of gas through urethra

Work-up: Urinalysis

Urine culture and sensitivity (often multiple organisms -- E. coli,

Enterobacter spp.)

CBC with differential, Chem 7 (BUN, creatinine, glucose)

CT abdomen / pelvis, with and without contrast (I.V., oral, rectal)

(CT abdomen / pelvis looking specifically for air in the

bladder, performed prior to any urethral catheterization or

cystoscopy, is the most sensitive test available for

enterovesical fistula.)

Referral to General Surgery and Urology [if]{.underline} above studies

suggest enterovesical fistula

References: Campbell's pp. 90, 2075

Gomella pp. 102-103

[Premature Ejaculation]{.underline}

Definition: Recurrent or persistent ejaculation with minimal stimulation

before, during, and shortly after vaginal penetration

Work-up: Testosterone, FSH, prolactin

Pituitary MRI (if prolactin elevated)

Referral to Urology if erectile dysfunction present (see E.D.

work-up) or exam abnormal. Consider referral to

psychotherapist / sex therapist.

References: Campbell's p. 90

Gomella pp. 106-107

[Prostatitis, Acute Bacterial]{.underline}

Definition: Generally associated with infection of both prostate and

bladder

Serious illness, historically requiring treatment with parenteral

antibiotics (now often treated with oral fluorquinolones)

Usually involves an adult male with acute onset of lower back

pain, perineal pain, fever, chills, dysuria, hematuria, and

general malaise.

Elderly patients may already be hospitalized with other

diagnoses, often with a urethral catheter in place.

Risk factors include: Bladder outlet obstruction

Recent prostate biopsy

Cystoscopy

Catheterization

Anal Intercourse

Work-up: Digital rectal exam must be very gentle! Bacteremia,

hypotension, and sepsis can follow prostate massage with

acute prostatitis. Rectal exam should not be avoided, but

should be as gentle as possible.

Acutely ill patients require hospitalization for IV antibiotic

therapy (can switch to oral antibiotics when afebrile for 48

hours)

Urine and blood cultures may guide therapy, but don't wait for

culture results before starting treatment

Avoid urethral instrumentation if possible (including catheters)

Check post-void urinary residual volume with bladder

ultrasound. If urinary retention develops, consider

suprapubic cystostomy tube drainage rather than urethral

catheterization which may perpetuate the disease process.

Bedrest, analgesics, antipyretics and stool softeners are

recommended along with the antibiotics

Antibiotic course minimum of 30 -- 45 days to prevent chronic

bacterial prostatitis

Urology consult if: Suprapubic cystostomy tube placement

required

Single course of antibiotics fails to

alleviate symptoms

(suspect prostate abscess)

References: Campbell's pp. 603-625

Gomella pp. 424-425

[Prostatitis, Chronic Bacterial]{.underline}

Definition: Prostatitis associated with positive urine culture, but no
signs

of systemic infection.

Perineal, suprapubic, groin, penile, scrotal and / or rectal pain

Dysuria, poor stream, frequency, urgency, nocturia

Painful ejaculation, decreased libido

Risk factors include: Acute bacterial prostatitis

Obstructive, turbulent, or high-pressure

voiding

Urinary tract (bladder) infection

Urethritis

Urethral catheterization

Bladder neck hypertrophy

Detrusor / sphincter dyssynergia

Urethral stricture

Urethral meatal stenosis

Balanitis

Work-up: Not considered an STD, although the two may coexist

Culture of urine before and after prostate massage

Chronic bacterial prostatitis diagnosed if excessive leukocytosis

and uropathogens in post-massage specimen compared with

pre-massage specimen

Imaging not usually helpful, unless bladder ultrasound needed

to rule out urinary retention

Antiobiotics should continue for 4 -- 6 weeks

Alcohol, acidic drinks, caffeine, spicy foods, and high-impact

sports and activities should be avoided

Warms baths, NSAIDS often beneficial

Alpha blocker medication if obstructive voiding symptoms

References: Campbell's pp. 603-625

Gomella pp. 426-427

[Prostate Nodule]{.underline}

Definition: Firm portion of prostate on digital palpation, 1-mm to

involvement of entire gland

Work-up: Urine analysis

Urine cytology (if hematuria present)

Urine culture (if indicated by UA)

Prostate Specific Antigen (unless prostate exam suggests

acute prostatitis -- boggy, tender, patient febrile or in acute

urinary retention)

References: Campbell's pp. 3055-3056

Gomella pp. 110-111

[Proteinuria]{.underline}

Definition: 24-hour urine specimen confirming \>150mg protein per day in

the urine (MUST be confirmed by quantitative 24-hour

measurement)

Work-up: Quantitative 24-hour urine protein measurement as above

Protein electrophoresis for proteinuria of 300 -- 2,000 mg / 24 hr

Fasting glucose (rule out diabetes mellitus)

Renal ultrasound

Internal Medicine or Nephrology consult when work-up

completed

Urology consult [if]{.underline}: Focal lesion found on renal ultrasound

Renal biopsy required for specific diagnosis

References: Campbell's pp. 104-106

Gomella pp. 112-113

[Pyelonephritis, Acute]{.underline}

Definition: Inflammatory process involving renal parenchyma and renal

pelvis, most often result of bacterial infection but may involve

fungi, parasites, or viruses

Onset usually sudden, with: Fever and chills (80 -- 90%)

Flank pain (85 -- 100%)

CVA tenderness

Ileus with nausea and vomitting

Abdominal pain and tenderness

Frequency, urgency, dysuria

E. coli accounts for 80% of cases

Risk factors: Vesicoureteral reflux

Neurogenic bladder

Bladder outlet obstruction

Calculus disease

Indwelling catheters

Diabetes mellitus

Immunosuppression

Alcoholism

Female gender

Work-up: CBC, Chem 7 (Renal failure uncommon without sepsis)

Urinalysis, blood and urine cultures

No imaging necessary in uncomplicated cases

If no response to appropriate antibiotic therapy within 72 hours,

consider imaging to rule-out obstruction, abscess, or other

anatomic abnormality

Renal ultrasound may demonstrate calculi, perinephric abscess

(mild hydronephrosis common -- does not necessarily indicate

obstruction -- endotoxins impair ureteral peristalsis)

IVP may demonstrate stones, obstruction (normal in 75%)

CT abdomen with and without contrast may demonstrate renal

and perinephric abscesses, stones, obstruction, renal

parenchymal gas (emphysematous pyelonephritis), and gives

a qualitatitive measure of renal function.

Any pediatric patient requires work-up with renal ultrasound,

VCUG and nuclear renal scan (do not perform VCUG until 4-

6 weeks after UTI resolved to prevent false positive "reflux"

call)

If I.V. antibiotics required, continue until patient is afebrile for 48

hours

Antibiotic course: full 14 days required

\*\*Urology referral for complications (calculi, obstruction,

perinephric or intrarenal abscess, etc.)

References: Campbell's pp. 516, 543-544

Gomella pp. 438-439

[Renal Mass]{.underline}

Most common: simple renal cyst

Most common solid tumor (85%): Renal cell carcinoma

Work-up: Urinalysis

Urine culture (if indicated by UA)

Urine cytology

CBC, Chem 20 (BUN, creatinine, glucose, liver function tests,

calcium)

CXR (PA, lateral)

CT abdomen / pelvis, with 5-7mm cuts through kidneys, with

and without contrast

\*\*Referral to Urology when above studies complete

Reference: Comella pp. 122-125

[Scrotal Mass]{.underline}

Definition: Painful or painless "lump" in the scrotal sac

Work-up: Urinalysis

Urine culture and sensitivity (if UA, clinical evaluation suggests)

Urethral swab for GC, Chlamydia (if urethral discharge)

CBC

Tumor markers (AFP, LDH, quantitative HCG if testicular mass

on ultrasound)

Scrotal ultrasound

\*\*Note: Do not delay surgical evaluation to obtain ultrasound

if testicular torsion is strongly suspected.\*\*

Urgent / Emergent Urology referral for suspected testis cancer

References: Campbell's pp. 95-96

Gomella pp. 134-135

[Undescended Testicle]{.underline}

Definition: Testicle not present in scrotum on exam

Work-up: Rule out "retractile" testis -- examiner with warm hands

> \-- patient supine (consider frog-leg)

Scrotal and Inguinal Ultrasound

If neither testis palpable, consider [intersex]{.underline} disorder
(female with

congenital adrenal hyperplasia most likely)

\*\*Referral to Urology with ultrasound if indicated

References: Campbell's pp. 2356-2377

Gomella pp. 152-153

[Urethral Mass]{.underline}

Definition: Mass visible at urethral meatus or palpable along the course
of

the urethra

Work-up: Urinalysis

Urine gram stain and culture (include AFB)

Urethral swab for GC, chlamydia, TB

Urine cytology

Chem 7 (for creatinine)

IVP with tomograms (or renal and bladder ultrasound, if

creatinine elevated)

References: Campbell's p. 2442

Gomella pp. 162-163

[Urinary Incontinence, Adult]{.underline}

Definitions: Stress incontinence -- leakage with coughing, sneezing,
lifting

Urge incontinence -- leakage with sudden uncontrollable

urgency

Overflow incontinence -- leakage from distended bladder

Total incontinence -- continual drainage or urine regardless of

position, due to anatomic abnormality

(fistula, ectopic ureter, etc.)

Work-up: Post-void residual urine volume

Urinalysis

Urine culture (treat UTI if present)

Urine cytology (if hematuria present)

Chem 7 (BUN / creatinine, glucose)

IVP for: Total incontinence in pediatric patient

Associated hematuria or recurrent UTI

Renal and bladder ultrasound (if BUN / creatinine elevated)

Complex urodynamic study for: Female with prior anti-

incontinence surgery or

pelvic radiation tx

Male with prior prostate

surgery or pelvic radiation tx

Suspected neurologic etiology

Urology referral if behavioral therapy (timed voiding with

increasing intervals) and Kegel excercises fail or if evidence

of obstruction or anatomic abnormality found

\*\*Note: Patients must present to Urology clinic with a voiding

diary, to include time and amount of each void, of three

days' duration

References: Campbell's pp. 87-89, 1043-1047, 1148

Gomella pp. 164-169

[Urinary Incontinence, Pediatric]{.underline}

Definitions: Incontinence -- involuntary loss of urine due to an
underlying

anomaly requiring evaluation and treatment

Enuresis -- involuntary wetting when no underlying anatomic

or functional abnormality of the urinary tract

is detected

Primary enuresis -- child has never been dry

Secondary enuresis -- child was dry at least 6 months

before wetting again

Work-up: Voiding diary (3-7 days)

Urinalysis

Urine culture (if indicated by UA)

KUB with lateral spine film

Renal and bladder ultrasound

VCUG (if associated UTI's or hydronephrosis)

IVP (if ureteral duplication suspected -- i.e. constant wetness in

females)

Urology referral if: new onset of daytime wetting, or

anatomic abnormality found on work-up, or

primary nocturnal enuresis refractory to

conservative measures (fluid restriction at

bedtime, waking once at night to void)

References: Campbell's pp. 1029-1031

Gomella pp. 170-173

[Urinary Tract Infection, Adult Female]{.underline}

Definition: \>10^5^ CFU bacteria / mL urine in an asymptomatic patient,
or

\>10^2^ CFU bacteria / mL urine in a symptomatic patient

Work-up: For "complicated" UTI

-   Persistent fevers after 72 hours of treatment

-   *Proteus* in urine culture with pH \> 8.0

-   Bacterial persistence

-   Unexplained hematuria

-   Suspected upper tract obstruction

-   History of calculi

-   Neurogenic bladder dysfunction

-   Diabetes

> Renal and Bladder U/S: good initial study to R/O
>
> hydronephrosis, abscess, bladder or renal stones
>
> IVP: appropriate initial study if hematuria, flank pain, or
>
> analgesic abuse present, or to further evaluate
>
> hydronephrosis on U/S
>
> Noncontrast spiral CT: when contrast contraindicated
>
> CT Abd / Pelvis )with and without contrast, with 5mm cuts
>
> through kidneys): further evaluation of suspected renal
>
> abscess, renal mass, or radiolucent renal calculus
>
> VCUG: Hx of vesicoureteral reflux or neurogenic bladder, or if
>
> urethral diverticulum suspected. (VCUG to be performed 6
>
> weeks after acute infection treated.)
>
> Urology referral for: positive findings on imaging studies, for
>
> suspected urethral diverticulum, or failure to resolve with
>
> appropriate antibiotics. Referral for recurrent uncomplicated
>
> UTI requires at least 3 documented infections (nitrite
>
> positive or organism identified)

References: Campbell's pp. 515-592

Gomella pp. 176-177

[Urinary Tract Infection, Adult Male]{.underline}

Definition: Midstream clean-catch urine specimen with retracted
foreskin,

following prostate massage if prostatitis suspected

-   Positive nitrites (lots of false negatives)

-   PH\> 8 (consider urea-splitting organisms)

-   Glucose (? New diabetic)

-   Leukocyte esterase (71% sens, 83% specif for UTI)

-   \>10 WBCs / HPF (unspun)

-   \>10,000 CFU bacteria / mL (clean catch) or

> \>100 CFU bacteria / mL (catheterized)

Work-up: Uncomplicated (uncommon)

-   Urethral swab for GC, Chlamydia if urethral

> discharge present

-   7 -- 14 days ABX (many treat for 30 days for

> presumed associated prostatitis)

-   If infection persists or recurs, treat for 4-6 weeks

> (to clear prostatitis) and repeat UA

-   TMP / SMX, Doxycycline, and quinolones all work

> Well for prostatitis

-   Nitrofurantoin has poor tissue levels, Amp/Amox

> have high resistance factor

Complicated (Same as for complicated female UTI)

-All complicated male UTI requires referral to Urology

References: Campbell's pp. 515-592

Gomella pp. 178-179

[Urinary Tract Infection, Pediatric]{.underline}

Definition: In children \< 1 year old, 4 times more common in boys

In children \> 1 year old, 3 times more common in girls

Most common organism is E. coli

May see increased incidence during toilet training in young

Girls

First morning void is most accurate for evaluation of nitrite,

leukocyte esterase

Nitrite positive / Leukocyte esterase positive with bacteria on

micro positively identifies UTI

Nitrite negative / Leukocyte esterase negative correctly

identifies lack of UTI

Urine culture: Suprapubic aspirate most accurate

Cath specimen needed in uncircumcised males

and younger girls

Midstream-voided samples reasonable in

circumcised boys and older girls

\>10^5^ CFU bacteria / mL indicates UTI

\>50,000 CFU / mL indicates UTI in febrile

children \<2 years old

Work-up: For first UTI in boys, and first febrile or second afebrile UTI
in

Girls

-   VCUG

-   Renal U/S

-   Urology referral

-   Prophylactic antibiotics (Nitrofurantoin, TMP /

> SMX, or cephalexin) should be given
>
> until reflux and / or urinary obstruction are
>
> excluded radiographically

References: Campbell's pp. 2054-2060

Gomella pp. 180-181

[Urologic Emergencies]{.underline}

# [Paraphimosis]{.underline}

> [Description]{.underline} -- Painful swelling of the foreskin distal
> to a phimotic ring
>
> after retraction of the foreskin for a prolonged period
>
> [Pathophysiology]{.underline} -- In children, caused by a congenitally
> narrowed

preputial opening, with the foreskin retracted behind the glans penis

and not promptly reduced. This leads to venous congestion, edema,

and enlargement of the glans, followed by arterial occlusion and

necrosis of the glans. In adults, usually occurs in elderly men and

may be associated with poor hygiene and balanoposthitis. Chronic

inflammation leads to formation of a fibrotic ring of tissue at the

opening of the prepuce, resulting in constriction when the foreskin is

retracted behind the glans, venous congestion and edema, and

necrosis of the glans penis if not promptly reduced.

> [Risk Factors]{.underline} -- Chronic balanoposthitis
>
> \-- Chronic indwelling catheter
>
> \-- Phimosis
>
> \-- Diabetes mellitus

### History and Physical Exam

> \-- (See above)

-   \-- Edema and swelling of penile shaft proximal to

-   glans and corona

> \--Tight phimotic ring proximal to corona

-   \-- Late -- swelling of the glans, venous congestion,

-   necrosis of the glans

> [Treatment]{.underline} -- Penile block (12cc or dosage appropriate
> for pediatric
>
> patients) 1% lidocaine without epinephrine,
>
> followed by wrap of edematous tissue with cool, moistened Kerlex

and Ace wrap for 15 minutes

-   Steady pressure against glans with both thumbs, pulling the foreskin
    forward over the glans with the fingers

-   Use gauze to facilitate traction on the foreskin

-   May require multiple stab wounds in the edematous foreskin with
    25-gauge needle to help remove edema fluid

-   Dorsal slit -- after penile block

-   Consider antibiotics for several days if dorsal slit necessary

-   Completion circumcision should be performed when inflammation and
    edema resolve

> [Prevention]{.underline} -- When inserting or changing Foley
> catheters, or
>
> perfoming clean intermittent catheterization, foreskin must be
>
> completely reduced following the procedure
>
> \*\*Without definitive treatment (i.e. dorsal slit or circumcision),
> paraphimosis tends to recur\*\*

#  [References]{.underline} -- Campbell's pp. 94, 3904

**Gomella pp. 376-377**

# 

# [Priapism]{.underline}

> [Description]{.underline} -- Prolonged erection developing in the
> absence of
>
> sexual stimulation and unrelieved by ejaculation lasting \>6 hours.
>
> Categorized as either veno-occlusive (ischemic, low-flow) or
>
> arterial (non-ischemic, high-flow).
>
> [Pathophysiology]{.underline}
>
> -- Ischemic form results from persistent relaxation
>
> of the erectile smooth muscle (pharmacologic) or from
>
> sludging of blood (hematologic) with subsequent prevention
>
> of venous outflow, resulting in failure of blood to drain from
>
> the erectile chamber.
>
> \-- Arterial form results from blunt or penetrating trauma, with

unregulated inflow of arterial blood into the corpora

cavernosa secondary to a fistula between the cavernous

artery and the corpus cavernosum.

> [Risk Factors]{.underline} -- Erectile dysfunction (on injectable
> medication)
>
> \-- Sickle cell (40% have at least one episode)
>
> \-- Perineal trauma
>
> \-- Psychiatric patients (psychotropic medications)
>
> \-- Recreational drugs
>
> \-- Toxins (spider venom, rabies)
>
> [History and Physical Exam]{.underline}

a.  Ischemic form

-   Painful erection, typically fully rigid (often turgid corpora with
    flaccid glans)

-   Careful questioning regarding above etiologies

\-- Time elapsed from onset (longer ischemic time =

> higher risk for permanent tissue damage \-- priapism of 24 hours
> duration associated with 50% incidence of permanent erectile
> dysfunction

b.  Arterial form

> \-- Erection usually less than fully rigid and painless

\-- Usually history of penile or perineal trauma

> [Laboratory]{.underline}

a.  Corporal blood gas analysis

> \-- Oxygen content \<40mmHg suggests ischemic etiology
>
> \-- Oxygen content \>70mmHg suggests arterial form
>
> [Imaging]{.underline}

a.  Ischemic -- none

b.  Arterial \-- Penile and perineal ultrasonography confirms dx

-   \-- Pudendal arteriography allows definitive

-   diagnosis and angioembolization treatment

> [Treatment]{.underline}

a.  Ischemic

> \-- Intracavernosal injection with alpha-adrenergic agonist (Neo-
>
> Synephrine)

-   Requires strict blood pressure and pulse monitoring (occasional
    hypertension and bradycardia)

-   No safe maximum dose defined

-   Consult cardiologist if significant cardiac history

-   Use 10 mg (10,000 microgm) / mL stock solution, diluted 9:1 (9mL
    normal saline : 1mL Neo) for 1,000 microgm / mL solution

-   Inject 500 microgm (0.5cc) intracavernosally, over 1 minute

-   Repeat at 5 to 10 minute intervals; for erection duration \<8 hours,
    2 to 4 injections usually successful

\-- If injection does not produce detumescence, corporal

aspiration necessary

-   Place 19-gauge butterfly needle into corporal body and aspirate all
    possible blood

-   Irrigate with normal saline and repeat Neo-Synephrine injection

\-- Failure to achieve detumescence requires surgical creation of

shunt between corpus cavernosum and corpus spongiosum

\-- In Sickle Cell patients, must correct underlying abnormality

-   Oxygenation, I.V. hydration, and alkalinization mandatory (consider
    hyperbaric oxygen if refractory)

-   Plasmaphoresis may be required

-   Intracorporal Neo-Synephrine injection still useful

-   All efforts intended to reverse corporal smooth muscle paralysis
    resulting from intracorporal acidosis

b.  Arterial

> \-- Not a true medical emergency

-   Expectant management is an option

-   Angioembolization may be attempted to close the fistula

> [Prevention]{.underline}

-   Careful, precise instruction to patients beginning intracorporal
    injection therapy for erectile dysfunction (with first injection in
    the clinic to document correct dose)

**[References]{.underline} -- Campbell's pp. 94-95, 1610-1613**

**Gomella pp. 108-109**

## [Fournier's Gangrene]{.underline}

> [Definition]{.underline} -- Rare, progressive, necrotizing fasciitis
> of the genitalia and / or perineum
>
> [Pathophysiology]{.underline}

a.  Aerobic and anaerobic organisms synergistically produce a
    progressive endarteritis leading to vascular thrombosis and gangrene

b.  Local ischemia allows further proliferation of organisms

c.  Most common organisms: E. coli, Bacteroides, streptococci, and
    staphylococci

> [Risk Factors]{.underline}

a.  Immunosuppressed conditions

b.  Recent procedures (groin, perineal, rectal, or genital)

c.  Children: trauma, insect bites, circumcision, burns, and perineal
    skin infections

> [History]{.underline}

a.  Urinary frequency, urgency, dysuria, cloudy urine, urethral
    discharge, decreased force of stream or straining to void

b.  Rectal pain or bleeding, history of anal fissures, fistulae, or
    hemorrhoids

c.  Scrotal infections, genital drug injection

d.  Diabetes, alcoholism, malignancy, or immune suppression

e.  Recent surgery as above

> [Physical Exam]{.underline}

a.  Genitalia and perineum

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1.  Assess for pain, inflammation, or crepitus

2.  Presence / extent of erythema or eschar

3.  Skin findings often underestimate the extent of involvement

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b.  Abdomen

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1.  Note extent of skin findings on abdomen also

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c.  Rectal exam

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1.  Assess for perirectal abscess or anal sphincter involvement

> [Lab Tests]{.underline}

a.  CBC , Chem 7, UA, Cultures of blood, urine and any wounds

> (Assess for leukocytosis, elevated BUN / Creatinine, hyperglycemia,
> glucosuria or pyuria, and any positive cultures)
>
> [Imaging]{.underline}

a.  Plain film KUB \-- may show subcutaneous gas

b.  Retrograde urethrogram \-- reveals urethral stricture, disruption,
    urinary extravasation

c.  Ultrasound \-- sensitive for soft-tissue gas and allows examination
    of scrotal contents, perineum and abdomen

d.  CT abdomen, pelvis, perineum \-- helpful for intraabdominal and
    retroperitoneal processes, demonstrates extent of subcutaneous
    emphysema

> [Treatment \-- Medical]{.underline}

a.  Broad spectrum I.V. antibiotics

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1.  Unasyn and gentamicin, or

2.  Zosyn and gentamicin, or

3.  Third-generation cephalosporin and gentamicin (not as good against
    gram (+) organisms

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b.  Tetanus toxoid

> [Treatment \-- Surgical]{.underline}

a.  Prompt, aggressive surgical debridement

b.  Proctoscopy if perirectal disease suspected

c.  May need to surgically divert both fecal and urinary streams if
    urethra or rectum involved

d.  Wound should be packed with Dakin's solution (25%), Clorpactin, or
    saline

> [Treatment \-- Adjunctive]{.underline}

a.  Hyperbaric oxygen

-   increased oxygen tension is bacteriocidal and promotes
    epithelialization, wound healing

> [Follow-up]{.underline}

a.  Monitoring

-   Allow culture results to guide antibiotic regimen

-   Wet-to-dry dressing changes 3 times per day (may add Silvadene cream
    to dressings once granulation begins)

-   Daily whirlpool

-   Frequently requires return trips to the operating room for further
    debridement

-   Nutritional support vital; most patients are in a catabolic state
    and require early enteral feeding or TPN

-   Must correct underlying cause (urethral stricture, uncontrolled DM,
    etc.)

> **[References]{.underline} -- Campbell's pp. 590-591**

####  **Gomella pp. 288-289**

## 

## [Testicular Torsion]{.underline}

> [Definition]{.underline} \-- Vascular event that involves cessation of
> blood flow to the
>
> testes, ultimately leading to testicular loss unless blood flow is
> restored
>
> [Pathophysiology]{.underline}

a.  Extravaginal torsion \-- Testis, spermatic cord, and tunica
    vaginalis all twist together, due to lack of fixation in the scrotum
    (prenatal and neonatal)

b.  Intravaginal torsion \-- Spermatic cord twists inside the tunica
    vaginalis due to its high insertion on the cord, allowing the testis
    to turn freely within the scrotum. Often occurs around puberty due
    to increase in testicular size.

c.  Vascular compromise results in rapid onset of swelling, with tissue
    necrosis after 6 to 8 hours

> [Risk Factors]{.underline}

a.  Extravaginal \-- incomplete testicular descent (antenatal /
    neonatal)

b.  Intravaginal \-- horizontal lie to testis, most common, early
    puberty

> [History]{.underline}

a.  Acute onset of testicular pain, often with nausea and vomitting, may
    awaken patient from sleep (suggests torsion)

b.  Mild onset over a few days (suggests torsion of testicular
    appendage)

c.  UTI symptoms (suggests epididymo-orchitis)

d.  History of trauma (cannot rule-out torsion)

e.  Prior inguinal / scrotal surgery (cannot rule-out torsion)

> [Physical Exam]{.underline}

a.  Look for pain on ambulation, scrotal asymmetry, elevated
    ("high-riding") testis

b.  "Blue dot sign" over testis suggests torsed appendix testis

c.  Palpate normal testis first, looking for horizontal position in
    relation to affected testis

d.  If only upper aspect of involved testis is tender, suspect torsed
    appendix testis

e.  If spermatic cord is tender also, consider torsion

f.  Presence of intact cremasteric reflex argues against torsion

g.  Co-existing reactive hydrocele is a common (and non-specific)
    finding

[Laboratory]{.underline}

a.  UA / Culture and sensitivities if urinary complaints present.
    (Positive results do not rule out torsion.)

##### Imaging

a.  Color flow Doppler

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1.  Excellent for showing presence or absence of blood flow to testis,
    ruling out testicular tumors

2.  Operator dependent and may be difficult in small patients

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```
b.  Nuclear testis scan (Technetium-99m)

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```
1.  Documents presence or absence of perfusion

2.  Expensive

3.  Invasive

4.  May be difficult to obtain after hours

##### Treatment \-- Surgical

a.  Prompt referral to urology (requires high index of suspicion)

b.  Testis examined, detorsed and warmed, then secured with three-point
    fixation orchiopexy if considered viable

c.  Orchidopexy for contralateral testis as well

> **[Prevention]{.underline} \-- High index of suspicion**
>
> \-- **Strongly consider testicular ultrasound of any patient**
>
> **with testicular complaint prior to sending them home**
>
> **[References]{.underline} -- Campbell's pp. 96, 1506, 1801**
>
> **Gomella pp. 538-539**
>
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
> \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

References:

Campbell's Urology, 8^th^ Edition. Patrick C. Walsh, Editor-in-Chief.

Saunders, 2002.

The 5-Minute Urology Consult. Leonard G. Gomella, Editor. Lippincott,

Williams & Wilkins, 2000.