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Clinical Guidelines for Urology

Wednesday, August 23, 2017

Hospital news

Clinical Guidelines for Common Genitourinary Disorders

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, three 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. Alphabetized general topics are described first, followed by a brief list of urologic emergencies.

Kenneth Moore, M.D.

Robert Rosen, M.D.

Urology

Amistad Medical Professionals

Val Verde Regional Medical Center

February, 2017

Balanitis / Balanoposthitis

Definition: Balanitis is inflammation of the glans penis, while

balanoposthitis is inflammation of the foreskin and glans.

Both occur predominantly in uncircumcised individuals.

Pediatric patients tend to have bacterial invasion, while

adults suffer from a combination of intertrigo, irritant

dermatitis, maceration injury and bacterial or candida

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: 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)
  • Meatal dilatation if urine outflow obstructed by BXO

References: Campbell-Walsh pp. 451, 964

Gomella pp. 34-35, 674

Hanno p. 276

Bladder Calculi

Definition: Calculus material in the bladder that does not pass with normal voiding

Bladder outlet obstruction most common etiology in U.S.

  • Benign prostate hyperplasia (BPH) in men
  • Cystocele (bladder prolapse) in women

Work-up: UA and urine culture (treat any associated infection)

Pelvic US readily diagnoses most bladder calculi

CT stone search (non-contrast) has excellent sensitivity and

specificity for upper and lower tract calculi, if US inconclusive

CT/IVP or contrast CT needed only if hematuria present, to

rule out neoplasm, obstruction

KUB often fails to demonstrate radiolucent stones (uric acid,

ammonium acid urate)

Urology referral for: Definitive therapy as soon as imaging

study done and infection treated (if necessary)

References: Campbell-Walsh pp. 2521-2527

Gomella pp. 40-41, 512-513

Hanno p.489

Benign Prostatic Hyperplasia

Definition: The enlargement of the prostate gland during the later decades of life. It becomes clinically significant when the extrinsic obstruction caused by the gland obstructs the bladder outlet, including the bladder neck and prostatic portion of the proximal urethra.

Work- up: Digital Rectal Exam

Renal and Bladder US (Include Post-Void Residual)

UA C&S

BMP (Creatinine)

Urology Referral For: Gross Hematuria

Acute Urinary Retention

Upper Tract Obstruction (Hydronephrois on US)

Recurrent UTI

Progressive symptoms despite medical therapy

References: Campbell-Walsh pp. 2570-2694

Gomella pp. 294-295, 605

Hanno pp. 479-521

AUA Best Practice Guidelines

Condyloma Acuminata

Definition: 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: Check for associated STD’s

Careful inspection of anal region for warts also

Urology Referral For: urethroscopy if hematuria or

obstruction present (URETHRAL lesions)

Referral to General Surgery if anal lesions present

Topical therapy (imiquimod, trichloroacetic acid, podophyllin,

podofilox, 5-FU) often effective

Surgical therapy (excision, electrosurgery, CO2 laser,

cryotherapy) normally reserved for extensive or

refractory cases

References: Campbell-Walsh 411-413, 426-427

Gomella pp. 74-75, 410-411

Hanno pp. 592-593, 748-751

Epididymitis / Orchitis

Definition: Clinical syndrome characterized by inflammation of the epididymis and/or testicles (orchitis rarely exists in the absence of epididymitis).

Painful swelling in the scrotum, often severe and

developing rapidly over 24 to 48 hours (may be even

more acute)

Often associated with dysuria or irritative voiding

Symptoms (urgency, frequency)

Prehn’s sign: alleviation of pain with scrotal

elevation (present with epididymo-orchitis, not usually

with testicular torsion). Of note, cremasteric reflex

remains intact with orchitis (diminished or absent in

torsion).

Bacterial etiology most widely accepted:

  • coli (children)
  • 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: testicular torsion

hemorrhage into occult testicular tumor

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

erythema of overlying scrotal skin, urethral discharge or

voiding complaints as above; less commonly with

elevated WBC count

Digital rectal exam to check for prostatitis recommended

UA often unremarkable

Consider scrotal ultrasound with colorflow Doppler if

torsion, tumor, or trauma suspected

Antibiotics, rest, analgesics / anti-imflammatories 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 (place at bedrest with scrotal elevation)

Consider follow-up scrotal ultrasound if no resolution

with appropriate antibiotics (rule out abscess)

Urology Referral For: Abscess

References: Campbell-Walsh pp, 354-356, 3117-3118

Gomella pp. 112-113

Hanno pp. 186-188, 267

Edema – External Genitalia

Definition: Either generalized edema or confined to scrotum / penis

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

Scrotal US (with colorflow Doppler if available)

Retrograde urethrogram if urethral trauma suspected

Urology Referral For: Urinary Obstruction

Abscess

Suspected Fournier’s Gangrene (see below)

Reference: Campbell-Walsh pp. 463-465

Gomella p. 100-101

Epididymal Mass

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-Walsh pp. 359-3595, 1008-1009

Gomella pp. 110-111

Elevated Prostate Specific Antigen (PSA)

As prostate cancer screening and the use of PSA as a screening tool has become controversial recently with the recommendations of the United States Preventive Services Task Force, the American Urological Association (AUA) has developed Prostate Cancer Screening Guidelines as follows:

Under age 40: The panel recommends against PSA screening due to the low prevalence of clinically detectable prostate cancer and lack of evidence demonstrating the benefit of screening.

Ages 40 to 54: The panel does not recommend routine screening in men between ages 40 and 54 years at average risk and recommends that for men younger than age 55 years at higher risk – those with a positive family history or African American race – decisions regarding prostate cancer screen should be individualized.

Ages 55 to 69: the panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in one man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the panel strongly recommends shared decision-making for those who are considering PSA screening and proceeding based on a man’s values and preferences. The greatest benefit of screening appears to be in men ages 55 to 69 years.

Over age 70: The panel does not recommend routing PSA screening in men age 70+ or any man with less than a 10- to 15-year life expectancy; however, some men age 70 or older who are in excellent health may benefit from prostate cancer screening.

To reduce the harms of screening, the AUA suggests that a routine screening interval of two years or more may be preferred over annual screening in men who have participated in shared physician-patient decision-making and decided on screening. Intervals for rescreening can be individualized by a baseline PSA level.

Urology Referral For: PSA > 4.0 (men without risk factors above)

PSA > 2.5 (men with risk factors above)

References: Campbell-Walsh pp. 2560-2562

Gomella pp. 316-317

Hanno pp. 66-67, 531-533, 715

AUA Best Practice Guidelines

Erectile Dysfunction

Definition: Consistent inability to obtain or maintain an erection

sufficient for satisfactory sexual relations (90% primarily

organic)

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

CBC

BMP with random glucose level

TSH (other thyroid function tests only if TSH abnormal)

A.M. total serum testosterone level

(Serum free testosterone, LH and prolactin only if

initial testosterone abnormal)

Urology Referral For: Failure of medical therapy (PDE5 inhibitors)

References: Campbell-Walsh pp. 717-728

Gomella pp. 118-119, 694

Hanno pp. 675-681

AUA Best Practice Guidelines

Frequency and Urgency

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

day, >2 times per night).

Urgency is the sudden impulse to void, without leakage.

Work-up: Urinalysis

Urine culture and sensitivity (If indicated by UA)

BMP (BUN / creatinine)

Renal and Bladder US (if renal insufficiency or urinary

retention suspected)

Urology referral for: Hematuria

Pyuria

Persistent / worsening symptoms

Evidence of obstruction on US

Elevated creatinine

References: Campbell-Walsh pp. 75, 1872

Gomella pp. 185, 502-503, 584

Hanno 41-42

Hematuria - Adult

Definition: At least 3 RBC’s per high power field on microscopic exam

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

Work-up: Recommended for all patients (adult and pediatric) with gross

hematuria and all adult patients with microscopic hematuria

CBC, BMP

Urine for cytology

Urine for culture and sensitivity (if indicated by positive nitrite)

CT/IVP

(May substitute renal ultrasound for CT/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 CT/IVP whenever possible.)

Urology referral for: cystoscopy after other work-up complete

References: Campbell-Walsh pp 98-100

Gomella pp. 148-149

Hanno pp. 162, 260-261

AUA Best Practice Guidelines

Hematuria – Pediatric

Definition: At least 3 RBC’s per high power field on microscopic exam

of fresh urine (not dipstick), confirmed on at least 3

separate urinalyses

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

anti-streptolysin-O titer, calcium:creatinine ratio

Renal and bladder US

VCUG (May defer if US entirely normal)

Note: cystoscopy rarely indicated

Pediatric Nephrology referral if US, VCUG are normal

Urology Referral for: abnormal US, VCUG

References: Campbell-Walsh pp. 75-91, 1522-1523

Gomella pp. 150-151

Hanno pp. 162, 260-261

Hematospermia

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

Pathognomonic for chronic prostatitis

Work-up: UA and urine culture

Urine cytology

Urethral swab for GC, Chlamydia

Consider PSA (see PSA section above)

Consider course of lipophilic antibiotics for prostatitis

(quinolones, doxycycline, TMP/Sx)

Urology Referral For: Abnormal studies

Persistence of hematospermia despite abx

References: Campbell-Walsh p. 79

Gomella pp. 146-147, 648

Hydrocele (Adult and Pediatric)

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

persistent fluid present in the scrotum 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 painful)

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 diagnose testicular mass, if present

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 US 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 to Pediatric Surgery if a hernia is

suspected.

References: Campbell-Walsh pp. 3583-3584

Gomella pp. 162-163, 396

Hanno pp. 57, 915

Male Infertility

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 female 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 (only if A.M. Testosterone low)

Scrotal US to confirm varicocele if found on exam

Urology Referral For: Persistent low semen volume (< 1.5 mL)

Low semen fructose

Persistent low sperm count

Varicocele or other anatomic abnormality

(hypospadius, penile chordee, abnormal US)

May NOT need referral if: Bilateral testicular atrophy and

FSH > 2x normal (primary testicular

failure)

References: Campbell-Walsh pp. 616-647

Gomella pp. 186-187

Hanno pp. 707-742

AUA Best Practices Guidelines

Nephrocalcinosis

Definition: Radiographically detectable diffuse renal parenchymal

calcifications, in contrast to nephrolithiasis in which

calcifications are located in the urinary collecting system

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

Nephrocalcinosis 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 / creatinine, 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 (if available)

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: Gomella pp. 218-219

Nephrolithiasis

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, and indinavir.

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

urinary infections, calcium and fluid intake, occupation,

symptoms of hypercalcemia, hypertension, and renal failure.

UA, 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 serum creatinine,

intravenous access and exposure to intravenous contrast.

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

US can detect and localize stones but is often

inaccurate in determining stone size (main use is in

pregnant patients).

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

Urology Referral 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 vomiting

Urosepsis

Elderly / debilitated patient

Clot or debris in renal pelvis, or

perinephric abscess on studies

References: Campbell-Walsh pp. 1287-1293

Gomella pp. 332-333

Hanno pp. 235-256

AUA Best Practice Guidelines

Pneumaturia

Definition: Passage of gas through urethra

Work-up: UA

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

Enterobacter spp.)

CBC with differential, BMP (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 or colovesical fistula.)

Urology and General Surgery Referral For: Findings in any of the

above studies that

suggest fistula

References: Campbell-Walsh pp. 79, 2253

Gomella pp. 262-263

Hanno p. 47

Premature Ejaculation

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)

Lidocaine 2.5% / prilocaine 2.5% (EMLA) cream

20 – 30 minutes pre-intercourse

Oral therapy:

Non-selective serotonin reuptake inhibitors (SRI’s)

Clomipramine (Anafranil)

Selective serotonin reuptake inhibitors (SSRI’s)

Fluoxetine (Prozac, Sarafem)

Paroxetine (Paxil)

Sertraline (Zoloft)

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

work-up) or exam abnormal. Consider referral to

psychotherapist / sex therapist also.

References: Campbell-Walsh pp. 770-779

Gomella pp. 102-103, 692

Hanno pp. 696-699

AUA Best Practice Guidelines

Prostatitis, Acute Bacterial

Definition: Generally associated with infection of both prostate and

Bladder (bacteriuria)

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 aggressive 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 (switch to oral antibiotics when afebrile for 48

hours)

Urine and blood cultures may guide therapy, but treatment

should not be delayed pending culture results

Avoid urethral instrumentation if possible (including urethral

catheters)

Check post-void urinary residual volume with bladder

  1. 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 antibiotics

Antibiotic course minimum of 30 – 45 days to prevent chronic

bacterial prostatitis

Urology Referral For: Suprapubic cystostomy tube placement

Single course of antibiotics fails to alleviate

symptoms (suspect prostate abscess)

References: Campbell-Walsh pp. 333-337

Gomella pp. 298-299

Hanno pp. 182-183

Prostatitis, Chronic Bacterial

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 WBC’s and

uropathogens in post-massage specimen compared with

pre-massage specimen

Imaging not usually helpful, unless bladder ultrasound needed

to rule out urinary retention

Antibiotics should continue for 4 – 6 weeks

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

sports and activities should be avoided

Warms baths, NSAIDS, frequent ejaculation often beneficial

Alpha blocker medication if obstructive voiding symptoms

References: Campbell-Walsh pp. 333-338

Gomella pp. 300-301

Hanno pp. 183-184

Prostate Nodule

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

involvement of entire gland

Work-up: UA

Urine cytology (if hematuria present)

Urine culture (if indicated by UA)

PSA (unless prostate exam suggests

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

urinary retention)

Urology Consult For: All prostate nodules

References: Campbell-Walsh pp. 2764-2767

Gomella pp. 290-291

Hanno pp. 60-61

Proteinuria

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

the urine

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 and Bladder US

Internal Medicine or Nephrology consult when work-up

completed

Urology Referral For: Focal lesion found on renal ultrasound

If renal biopsy required for specific diagnosis

References: Campbell-Walsh pp. 81-89, 3007-3009

Gomella pp. 310-311, 707

Pyelonephritis, Acute

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

  1. 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, BMP (Renal failure uncommon without sepsis)

UA, blood and urine cultures

No imaging necessary in uncomplicated cases

If no response to appropriate antibiotic therapy within 48 hours,

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

anatomic abnormality

Renal US may demonstrate calculi, perinephric abscess

(mild hydronephrosis common – does not necessarily indicate

obstruction – endotoxins impair ureteral peristalsis)

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

CT/IVP (study of choice) will 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 before switching to p.o.

Antibiotic course: 14 days required (6 weeks for renal abscess)

Urology Referral For: complications (calculi, obstruction,

perinephric or intrarenal abscess, etc.)

References: Campbell-Walsh pp. 266-267, 295-299

Gomella pp. 320-321, 500

Hanno pp. 173-174

Renal Mass

Most common lesion: simple renal cyst

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

Work-up: UA

Urine culture (if indicated by UA)

Urine cytology

CBC, CMP (BUN, creatinine, glucose, LFT’s,

calcium)

CXR (PA, lateral)

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

and without contrast (3-phase, includes delayed images)

Urology Referral For: All renal masses

References: Campbell-Walsh pp. 1418-1420, 1440-1443

Gomella pp. 366-367

Hanno pp. 114-116

Scrotal Mass

Definition: Painful or painless “lump” in the scrotal sac

Work-up: UA

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-Walsh pp. 63-67, 3586-3594

Gomella pp. 396-397

Hanno pp. 56-58

Undescended Testicle

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 US

Urology Referral For: US-confirmed absence of testis in scrotum

Note: If neither testis palpable, consider intersex disorder (female with

congenital adrenal hyperplasia / 21-hydroxylase deficiency

most likely); need karyotype, serum electrolytes, and referral

to Pediatric Urology

References: Campbell-Walsh pp. 3564-3565

Gomella pp. 464-465

Hanno pp. 112, 848-849, 911-915

AUA Best Practice Guidelines

Urethral Mass

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

the urethra

Work-up: UA

Urine gram stain and culture (include AFB)

Urethral swab for GC, chlamydia, TB

Urine cytology

BMP (for creatinine)

Urethral MRI

Urology Referral For: All urethral masses

References: Campbell-Walsh pp. 1798-1800

Gomella pp. 492-493

Urinary Incontinence, Adult

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 (US)

UA

Urine culture (treat UTI if present)

Urine cytology (if hematuria present)

BMP (BUN / creatinine, glucose)

CT/IVP for: Total incontinence in pediatric patient

Associated hematuria or recurrent UTI

Otherwise, Renal and bladder US (or 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 for: Patients with persistent leakage despite behavioral

therapy (Kegel exercises, timed voiding) or if anatomic

abnormality found on exam / imaging

Note: Patients should present to Urology clinic with a voiding

diary, to include time and amount of each void for a 48-

hour period

References: Campbell-Walsh pp. 1871-1873

Gomella pp. 178-181, 700

Hanno pp. 427-430

AUA Best Practice Guidelines

Urinary Incontinence, Pediatric

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)

UA

Urine culture (if indicated by UA)

KUB with lateral spine film

Renal and bladder US

VCUG (if associated UTI’s or hydronephrosis on US)

CT/IVP (if ureteral duplication suspected – i.e. continual

wetness in females)

Urology referral For: New onset of daytime wetting or encopresis

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-Walsh p. 3418

Gomella pp. 184-185

Urinary Tract Infection, Adult Female

Definition: >105 CFU bacteria / mL urine in an asymptomatic patient, or

>102 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 US: good initial study to R/O

hydronephrosis, abscess, bladder or renal stones

CT/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 and delayed images, “3-Phase CT”):

further evaluation of suspected renal abscess, renal

mass, or radiolucent renal calculus

VCUG: Hx of vesicoureteral reflux or neurogenic bladder.

VCUG study should be performed 6 weeks after acute

infection treated, to prevent false positives

Pelvic MRI with contrast: If urethral diverticulum suspected

(fluctuant urethral mass on exam, UTI’s with multiple

organisms, multiparity)

Urology referral For: Positive findings on imaging studies

Suspected urethral diverticulum

Failure to resolve with appropriate antibiotics

**Referral for recurrent uncomplicated UTI requires at least 3

documented infections (nitrite positive or organism identified)

within 12 months

References: Campbell-Walsh pp. 258, 290-294

Gomella pp. 506-507

Hanno pp. 155-164

Urinary Tract Infection, Adult Male

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 incidence

Complicated (Same as for complicated female UTI)

Urology Referral For: All complicated male UTI’s

References: Campbell-Walsh pp. 2602, 2620, 3092

Gomella pp. 508-509

Hanno pp. 177-181

Urinary Tract Infection, Pediatric

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

>105 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 and bladder US

Urology referral

Prophylactic antibiotics (Nitrofurantoin, TMP /

SMX, or cephalexin) should be given

until reflux and / or urinary obstruction are

excluded radiographically

Urology Referral For: First male UTI, first febrile or second afebrile UTI

in females

References: Campbell-Walsh pp. 089-3120

Gomella pp. 510-511, 717

Urologic Emergencies

Paraphimosis

Description – Painful swelling of the foreskin distal to a phimotic ring

after retraction of the foreskin for a prolonged period

Pathophysiology – 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 – 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 – 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 – 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: Campbell-Walsh pp. 964, 3539

Gomella pp. 100, 260-261

Hanno pp. 54, 276

Priapism

Description – 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

- 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 – 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

Ischemic “Low Flow”

  • 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

Arterial “High Flow”

-- Erection usually less than fully rigid and painless

-- Usually history of penile or perineal trauma

Laboratory

Corporal blood gas analysis

-- Oxygen content <40mmHg suggests ischemic etiology

-- Oxygen content >70mmHg suggests arterial form

Imaging

Ischemic – none

Arterial -- Penile and perineal ultrasonography confirms dx

-- Pudendal arteriography allows definitive

diagnosis and angioembolization treatment

Treatment

Ischemic

-- Intracavernosal injection with one ampule methylene blue

(preferred method in patient with HTN, cardiac history)

-- 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

Arterial

-- Not a true medical emergency

  • Expectant management is an option
  • Angioembolization may be attempted to close the fistula

Prevention

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

References – Campbell-Walsh pp. 749-769

Gomella pp. 276-277, 632

Hanno pp. 271-275, 699-703

AUA Best Practice Guidelines

Fournier’s Gangrene

Definition – Rare, progressive, necrotizing fasciitis of the genitalia and / or perineum

Pathophysiology

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

Local ischemia allows further proliferation of organisms

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

Risk Factors

Immunosuppressed conditions

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

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

History

Frequency, urgency, dysuria, cloudy urine, urethral discharge, decreased

force of stream or straining to void

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

Scrotal infections, genital drug injection

Diabetes, alcoholism, malignancy, or immune suppression

Recent surgery as above

Physical Exam

Genitalia and perineum

Assess for pain, inflammation, or crepitus

Presence / extent of erythema or eschar

Skin findings often underestimate the extent of involvement

Abdomen

Note extent of skin findings on abdomen also

Rectal exam

Assess for perirectal abscess or anal sphincter involvement

Lab Tests

CBC , BMP, UA, Cultures of blood, urine and any wounds

(Assess for leukocytosis, elevated BUN / Creatinine, hyperglycemia,

glucosuria or pyuria, and any positive cultures)

Imaging

Plain film KUB -- may show subcutaneous gas

Retrograde urethrogram -- reveals urethral stricture, disruption, urinary extravasation

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

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

Treatment -- Medical

Broad spectrum I.V. antibiotics

Unasyn and gentamicin, or

Zosyn and gentamicin, or

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

Tetanus toxoid

Treatment -- Surgical

Prompt, aggressive surgical debridement

Proctoscopy if perirectal disease suspected

May need to surgically divert both fecal and urinary streams if urethra or

rectum involved

Wound should be packed with Dakin’s solution (25%), Clorpactin, or

saline

Treatment -- Adjunctive

Hyperbaric oxygen

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

Follow-up

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 – Campbell-Walsh pp. 324-325

Gomella pp. 130-131

Hanno pp. 210-212, 277-278

Testicular Torsion

Definition -- Vascular event that involves cessation of blood flow to the

testes, ultimately leading to testicular loss unless blood flow is restored

Pathophysiology

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

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.

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

Risk Factors

Extravaginal -- incomplete testicular descent (antenatal / neonatal)

Intravaginal -- horizontal lie to testis, most common, early puberty

History

Acute onset of testicular pain, often with nausea and vomitting, may

awaken patient from sleep (suggests torsion)

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

UTI symptoms (suggests epididymo-orchitis)

History of trauma (cannot rule-out torsion)

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

Physical Exam

Look for pain on ambulation, scrotal asymmetry, elevated (“high-riding”)

testis

“Blue dot sign” over testis suggests torsed appendix testis

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

affected testis

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

testis

If spermatic cord is tender also, consider torsion

Presence of intact cremasteric reflex argues against torsion

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

Laboratory

UA / Culture and sensitivities if urinary complaints present. (Positive

results do not rule out torsion.)

Imaging

Color flow Doppler (Best)

Excellent for showing presence or absence of blood flow to testis,

ruling out testicular tumors

Operator dependent and may be difficult in small patients

Nuclear testis scan (Technetium-99m)

Documents presence or absence of perfusion

Expensive

Invasive

May be difficult to obtain after hours

Treatment -- Surgical

Prompt referral to urology (requires high index of suspicion)

Testis examined, detorsed and warmed, then secured with three-point

fixation orchidopexy if considered viable

Orchidopexy for contralateral testis as well

Prevention -- High index of suspicion

-- Strongly consider testicular ultrasound of any patient

with testicular complaint prior to sending them home

References – Campbell-Walsh pp. 74-75, 82-83, 3586-3594

Gomella pp. 142-143, 452-453

Hanno pp. 58, 266-267, 718

----------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------

References:

Campbell-Walsh Urology, 10th Edition. Alan J. Wein, Editor-in-Chief.

Saunders / Elsevier, 2012.

The 5-Minute Urology Consult, 2nd Edition. Leonard G. Gomella, Editor.

Lippincott, Williams & Wilkins, 2010.

The Clinical Manual of Urology. Philip M. Hanno, Editor-in-Chief.

Saunders / Elsevier, 2007.

American Urological Association (AUA) Best Practice Guidelines:

https://www.auanet.org/guidelines

Clinical Guidelines for Common Genitourinary Disorders

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, three 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. Alphabetized general topics are described first, followed by a brief list of urologic emergencies.

Kenneth Moore, M.D.

Robert Rosen, M.D.

Urology

Amistad Medical Professionals

Val Verde Regional Medical Center

February, 2017

Balanitis / Balanoposthitis

Definition: Balanitis is inflammation of the glans penis, while

balanoposthitis is inflammation of the foreskin and glans.

Both occur predominantly in uncircumcised individuals.

Pediatric patients tend to have bacterial invasion, while

adults suffer from a combination of intertrigo, irritant

dermatitis, maceration injury and bacterial or candida

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: 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)
  • Meatal dilatation if urine outflow obstructed by BXO

References: Campbell-Walsh pp. 451, 964

Gomella pp. 34-35, 674

Hanno p. 276

Bladder Calculi

Definition: Calculus material in the bladder that does not pass with normal voiding

Bladder outlet obstruction most common etiology in U.S.

  • Benign prostate hyperplasia (BPH) in men
  • Cystocele (bladder prolapse) in women

Work-up: UA and urine culture (treat any associated infection)

Pelvic US readily diagnoses most bladder calculi

CT stone search (non-contrast) has excellent sensitivity and

specificity for upper and lower tract calculi, if US inconclusive

CT/IVP or contrast CT needed only if hematuria present, to

rule out neoplasm, obstruction

KUB often fails to demonstrate radiolucent stones (uric acid,

ammonium acid urate)

Urology referral for: Definitive therapy as soon as imaging

study done and infection treated (if necessary)

References: Campbell-Walsh pp. 2521-2527

Gomella pp. 40-41, 512-513

Hanno p.489

Benign Prostatic Hyperplasia

Definition: The enlargement of the prostate gland during the later decades of life. It becomes clinically significant when the extrinsic obstruction caused by the gland obstructs the bladder outlet, including the bladder neck and prostatic portion of the proximal urethra.

Work- up: Digital Rectal Exam

Renal and Bladder US (Include Post-Void Residual)

UA C&S

BMP (Creatinine)

Urology Referral For: Gross Hematuria

Acute Urinary Retention

Upper Tract Obstruction (Hydronephrois on US)

Recurrent UTI

Progressive symptoms despite medical therapy

References: Campbell-Walsh pp. 2570-2694

Gomella pp. 294-295, 605

Hanno pp. 479-521

AUA Best Practice Guidelines

Condyloma Acuminata

Definition: 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: Check for associated STD’s

Careful inspection of anal region for warts also

Urology Referral For: urethroscopy if hematuria or

obstruction present (URETHRAL lesions)

Referral to General Surgery if anal lesions present

Topical therapy (imiquimod, trichloroacetic acid, podophyllin,

podofilox, 5-FU) often effective

Surgical therapy (excision, electrosurgery, CO2 laser,

cryotherapy) normally reserved for extensive or

refractory cases

References: Campbell-Walsh 411-413, 426-427

Gomella pp. 74-75, 410-411

Hanno pp. 592-593, 748-751

Epididymitis / Orchitis

Definition: Clinical syndrome characterized by inflammation of the epididymis and/or testicles (orchitis rarely exists in the absence of epididymitis).

Painful swelling in the scrotum, often severe and

developing rapidly over 24 to 48 hours (may be even

more acute)

Often associated with dysuria or irritative voiding

Symptoms (urgency, frequency)

Prehn’s sign: alleviation of pain with scrotal

elevation (present with epididymo-orchitis, not usually

with testicular torsion). Of note, cremasteric reflex

remains intact with orchitis (diminished or absent in

torsion).

Bacterial etiology most widely accepted:

  • coli (children)
  • 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: testicular torsion

hemorrhage into occult testicular tumor

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

erythema of overlying scrotal skin, urethral discharge or

voiding complaints as above; less commonly with

elevated WBC count

Digital rectal exam to check for prostatitis recommended

UA often unremarkable

Consider scrotal ultrasound with colorflow Doppler if

torsion, tumor, or trauma suspected

Antibiotics, rest, analgesics / anti-imflammatories 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 (place at bedrest with scrotal elevation)

Consider follow-up scrotal ultrasound if no resolution

with appropriate antibiotics (rule out abscess)

Urology Referral For: Abscess

References: Campbell-Walsh pp, 354-356, 3117-3118

Gomella pp. 112-113

Hanno pp. 186-188, 267

Edema – External Genitalia

Definition: Either generalized edema or confined to scrotum / penis

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

Scrotal US (with colorflow Doppler if available)

Retrograde urethrogram if urethral trauma suspected

Urology Referral For: Urinary Obstruction

Abscess

Suspected Fournier’s Gangrene (see below)

Reference: Campbell-Walsh pp. 463-465

Gomella p. 100-101

Epididymal Mass

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-Walsh pp. 359-3595, 1008-1009

Gomella pp. 110-111

Elevated Prostate Specific Antigen (PSA)

As prostate cancer screening and the use of PSA as a screening tool has become controversial recently with the recommendations of the United States Preventive Services Task Force, the American Urological Association (AUA) has developed Prostate Cancer Screening Guidelines as follows:

Under age 40: The panel recommends against PSA screening due to the low prevalence of clinically detectable prostate cancer and lack of evidence demonstrating the benefit of screening.

Ages 40 to 54: The panel does not recommend routine screening in men between ages 40 and 54 years at average risk and recommends that for men younger than age 55 years at higher risk – those with a positive family history or African American race – decisions regarding prostate cancer screen should be individualized.

Ages 55 to 69: the panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in one man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the panel strongly recommends shared decision-making for those who are considering PSA screening and proceeding based on a man’s values and preferences. The greatest benefit of screening appears to be in men ages 55 to 69 years.

Over age 70: The panel does not recommend routing PSA screening in men age 70+ or any man with less than a 10- to 15-year life expectancy; however, some men age 70 or older who are in excellent health may benefit from prostate cancer screening.

To reduce the harms of screening, the AUA suggests that a routine screening interval of two years or more may be preferred over annual screening in men who have participated in shared physician-patient decision-making and decided on screening. Intervals for rescreening can be individualized by a baseline PSA level.

Urology Referral For: PSA > 4.0 (men without risk factors above)

PSA > 2.5 (men with risk factors above)

References: Campbell-Walsh pp. 2560-2562

Gomella pp. 316-317

Hanno pp. 66-67, 531-533, 715

AUA Best Practice Guidelines

Erectile Dysfunction

Definition: Consistent inability to obtain or maintain an erection

sufficient for satisfactory sexual relations (90% primarily

organic)

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

CBC

BMP with random glucose level

TSH (other thyroid function tests only if TSH abnormal)

A.M. total serum testosterone level

(Serum free testosterone, LH and prolactin only if

initial testosterone abnormal)

Urology Referral For: Failure of medical therapy (PDE5 inhibitors)

References: Campbell-Walsh pp. 717-728

Gomella pp. 118-119, 694

Hanno pp. 675-681

AUA Best Practice Guidelines

Frequency and Urgency

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

day, >2 times per night).

Urgency is the sudden impulse to void, without leakage.

Work-up: Urinalysis

Urine culture and sensitivity (If indicated by UA)

BMP (BUN / creatinine)

Renal and Bladder US (if renal insufficiency or urinary

retention suspected)

Urology referral for: Hematuria

Pyuria

Persistent / worsening symptoms

Evidence of obstruction on US

Elevated creatinine

References: Campbell-Walsh pp. 75, 1872

Gomella pp. 185, 502-503, 584

Hanno 41-42

Hematuria - Adult

Definition: At least 3 RBC’s per high power field on microscopic exam

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

Work-up: Recommended for all patients (adult and pediatric) with gross

hematuria and all adult patients with microscopic hematuria

CBC, BMP

Urine for cytology

Urine for culture and sensitivity (if indicated by positive nitrite)

CT/IVP

(May substitute renal ultrasound for CT/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 CT/IVP whenever possible.)

Urology referral for: cystoscopy after other work-up complete

References: Campbell-Walsh pp 98-100

Gomella pp. 148-149

Hanno pp. 162, 260-261

AUA Best Practice Guidelines

Hematuria – Pediatric

Definition: At least 3 RBC’s per high power field on microscopic exam

of fresh urine (not dipstick), confirmed on at least 3

separate urinalyses

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

anti-streptolysin-O titer, calcium:creatinine ratio

Renal and bladder US

VCUG (May defer if US entirely normal)

Note: cystoscopy rarely indicated

Pediatric Nephrology referral if US, VCUG are normal

Urology Referral for: abnormal US, VCUG

References: Campbell-Walsh pp. 75-91, 1522-1523

Gomella pp. 150-151

Hanno pp. 162, 260-261

Hematospermia

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

Pathognomonic for chronic prostatitis

Work-up: UA and urine culture

Urine cytology

Urethral swab for GC, Chlamydia

Consider PSA (see PSA section above)

Consider course of lipophilic antibiotics for prostatitis

(quinolones, doxycycline, TMP/Sx)

Urology Referral For: Abnormal studies

Persistence of hematospermia despite abx

References: Campbell-Walsh p. 79

Gomella pp. 146-147, 648

Hydrocele (Adult and Pediatric)

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

persistent fluid present in the scrotum 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 painful)

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 diagnose testicular mass, if present

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 US 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 to Pediatric Surgery if a hernia is

suspected.

References: Campbell-Walsh pp. 3583-3584

Gomella pp. 162-163, 396

Hanno pp. 57, 915

Male Infertility

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 female 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 (only if A.M. Testosterone low)

Scrotal US to confirm varicocele if found on exam

Urology Referral For: Persistent low semen volume (< 1.5 mL)

Low semen fructose

Persistent low sperm count

Varicocele or other anatomic abnormality

(hypospadius, penile chordee, abnormal US)

May NOT need referral if: Bilateral testicular atrophy and

FSH > 2x normal (primary testicular

failure)

References: Campbell-Walsh pp. 616-647

Gomella pp. 186-187

Hanno pp. 707-742

AUA Best Practices Guidelines

Nephrocalcinosis

Definition: Radiographically detectable diffuse renal parenchymal

calcifications, in contrast to nephrolithiasis in which

calcifications are located in the urinary collecting system

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

Nephrocalcinosis 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 / creatinine, 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 (if available)

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: Gomella pp. 218-219

Nephrolithiasis

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, and indinavir.

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

urinary infections, calcium and fluid intake, occupation,

symptoms of hypercalcemia, hypertension, and renal failure.

UA, 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 serum creatinine,

intravenous access and exposure to intravenous contrast.

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

US can detect and localize stones but is often

inaccurate in determining stone size (main use is in

pregnant patients).

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

Urology Referral 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 vomiting

Urosepsis

Elderly / debilitated patient

Clot or debris in renal pelvis, or

perinephric abscess on studies

References: Campbell-Walsh pp. 1287-1293

Gomella pp. 332-333

Hanno pp. 235-256

AUA Best Practice Guidelines

Pneumaturia

Definition: Passage of gas through urethra

Work-up: UA

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

Enterobacter spp.)

CBC with differential, BMP (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 or colovesical fistula.)

Urology and General Surgery Referral For: Findings in any of the

above studies that

suggest fistula

References: Campbell-Walsh pp. 79, 2253

Gomella pp. 262-263

Hanno p. 47

Premature Ejaculation

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)

Lidocaine 2.5% / prilocaine 2.5% (EMLA) cream

20 – 30 minutes pre-intercourse

Oral therapy:

Non-selective serotonin reuptake inhibitors (SRI’s)

Clomipramine (Anafranil)

Selective serotonin reuptake inhibitors (SSRI’s)

Fluoxetine (Prozac, Sarafem)

Paroxetine (Paxil)

Sertraline (Zoloft)

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

work-up) or exam abnormal. Consider referral to

psychotherapist / sex therapist also.

References: Campbell-Walsh pp. 770-779

Gomella pp. 102-103, 692

Hanno pp. 696-699

AUA Best Practice Guidelines

Prostatitis, Acute Bacterial

Definition: Generally associated with infection of both prostate and

Bladder (bacteriuria)

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 aggressive 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 (switch to oral antibiotics when afebrile for 48

hours)

Urine and blood cultures may guide therapy, but treatment

should not be delayed pending culture results

Avoid urethral instrumentation if possible (including urethral

catheters)

Check post-void urinary residual volume with bladder

  1. 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 antibiotics

Antibiotic course minimum of 30 – 45 days to prevent chronic

bacterial prostatitis

Urology Referral For: Suprapubic cystostomy tube placement

Single course of antibiotics fails to alleviate

symptoms (suspect prostate abscess)

References: Campbell-Walsh pp. 333-337

Gomella pp. 298-299

Hanno pp. 182-183

Prostatitis, Chronic Bacterial

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 WBC’s and

uropathogens in post-massage specimen compared with

pre-massage specimen

Imaging not usually helpful, unless bladder ultrasound needed

to rule out urinary retention

Antibiotics should continue for 4 – 6 weeks

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

sports and activities should be avoided

Warms baths, NSAIDS, frequent ejaculation often beneficial

Alpha blocker medication if obstructive voiding symptoms

References: Campbell-Walsh pp. 333-338

Gomella pp. 300-301

Hanno pp. 183-184

Prostate Nodule

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

involvement of entire gland

Work-up: UA

Urine cytology (if hematuria present)

Urine culture (if indicated by UA)

PSA (unless prostate exam suggests

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

urinary retention)

Urology Consult For: All prostate nodules

References: Campbell-Walsh pp. 2764-2767

Gomella pp. 290-291

Hanno pp. 60-61

Proteinuria

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

the urine

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 and Bladder US

Internal Medicine or Nephrology consult when work-up

completed

Urology Referral For: Focal lesion found on renal ultrasound

If renal biopsy required for specific diagnosis

References: Campbell-Walsh pp. 81-89, 3007-3009

Gomella pp. 310-311, 707

Pyelonephritis, Acute

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

  1. 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, BMP (Renal failure uncommon without sepsis)

UA, blood and urine cultures

No imaging necessary in uncomplicated cases

If no response to appropriate antibiotic therapy within 48 hours,

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

anatomic abnormality

Renal US may demonstrate calculi, perinephric abscess

(mild hydronephrosis common – does not necessarily indicate

obstruction – endotoxins impair ureteral peristalsis)

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

CT/IVP (study of choice) will 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 before switching to p.o.

Antibiotic course: 14 days required (6 weeks for renal abscess)

Urology Referral For: complications (calculi, obstruction,

perinephric or intrarenal abscess, etc.)

References: Campbell-Walsh pp. 266-267, 295-299

Gomella pp. 320-321, 500

Hanno pp. 173-174

Renal Mass

Most common lesion: simple renal cyst

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

Work-up: UA

Urine culture (if indicated by UA)

Urine cytology

CBC, CMP (BUN, creatinine, glucose, LFT’s,

calcium)

CXR (PA, lateral)

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

and without contrast (3-phase, includes delayed images)

Urology Referral For: All renal masses

References: Campbell-Walsh pp. 1418-1420, 1440-1443

Gomella pp. 366-367

Hanno pp. 114-116

Scrotal Mass

Definition: Painful or painless “lump” in the scrotal sac

Work-up: UA

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-Walsh pp. 63-67, 3586-3594

Gomella pp. 396-397

Hanno pp. 56-58

Undescended Testicle

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 US

Urology Referral For: US-confirmed absence of testis in scrotum

Note: If neither testis palpable, consider intersex disorder (female with

congenital adrenal hyperplasia / 21-hydroxylase deficiency

most likely); need karyotype, serum electrolytes, and referral

to Pediatric Urology

References: Campbell-Walsh pp. 3564-3565

Gomella pp. 464-465

Hanno pp. 112, 848-849, 911-915

AUA Best Practice Guidelines

Urethral Mass

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

the urethra

Work-up: UA

Urine gram stain and culture (include AFB)

Urethral swab for GC, chlamydia, TB

Urine cytology

BMP (for creatinine)

Urethral MRI

Urology Referral For: All urethral masses

References: Campbell-Walsh pp. 1798-1800

Gomella pp. 492-493

Urinary Incontinence, Adult

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 (US)

UA

Urine culture (treat UTI if present)

Urine cytology (if hematuria present)

BMP (BUN / creatinine, glucose)

CT/IVP for: Total incontinence in pediatric patient

Associated hematuria or recurrent UTI

Otherwise, Renal and bladder US (or 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 for: Patients with persistent leakage despite behavioral

therapy (Kegel exercises, timed voiding) or if anatomic

abnormality found on exam / imaging

Note: Patients should present to Urology clinic with a voiding

diary, to include time and amount of each void for a 48-

hour period

References: Campbell-Walsh pp. 1871-1873

Gomella pp. 178-181, 700

Hanno pp. 427-430

AUA Best Practice Guidelines

Urinary Incontinence, Pediatric

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)

UA

Urine culture (if indicated by UA)

KUB with lateral spine film

Renal and bladder US

VCUG (if associated UTI’s or hydronephrosis on US)

CT/IVP (if ureteral duplication suspected – i.e. continual

wetness in females)

Urology referral For: New onset of daytime wetting or encopresis

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-Walsh p. 3418

Gomella pp. 184-185

Urinary Tract Infection, Adult Female

Definition: >105 CFU bacteria / mL urine in an asymptomatic patient, or

>102 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 US: good initial study to R/O

hydronephrosis, abscess, bladder or renal stones

CT/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 and delayed images, “3-Phase CT”):

further evaluation of suspected renal abscess, renal

mass, or radiolucent renal calculus

VCUG: Hx of vesicoureteral reflux or neurogenic bladder.

VCUG study should be performed 6 weeks after acute

infection treated, to prevent false positives

Pelvic MRI with contrast: If urethral diverticulum suspected

(fluctuant urethral mass on exam, UTI’s with multiple

organisms, multiparity)

Urology referral For: Positive findings on imaging studies

Suspected urethral diverticulum

Failure to resolve with appropriate antibiotics

**Referral for recurrent uncomplicated UTI requires at least 3

documented infections (nitrite positive or organism identified)

within 12 months

References: Campbell-Walsh pp. 258, 290-294

Gomella pp. 506-507

Hanno pp. 155-164

Urinary Tract Infection, Adult Male

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 incidence

Complicated (Same as for complicated female UTI)

Urology Referral For: All complicated male UTI’s

References: Campbell-Walsh pp. 2602, 2620, 3092

Gomella pp. 508-509

Hanno pp. 177-181

Urinary Tract Infection, Pediatric

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

>105 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 and bladder US

Urology referral

Prophylactic antibiotics (Nitrofurantoin, TMP /

SMX, or cephalexin) should be given

until reflux and / or urinary obstruction are

excluded radiographically

Urology Referral For: First male UTI, first febrile or second afebrile UTI

in females

References: Campbell-Walsh pp. 089-3120

Gomella pp. 510-511, 717

Urologic Emergencies

Paraphimosis

Description – Painful swelling of the foreskin distal to a phimotic ring

after retraction of the foreskin for a prolonged period

Pathophysiology – 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 – 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 – 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 – 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: Campbell-Walsh pp. 964, 3539

Gomella pp. 100, 260-261

Hanno pp. 54, 276

Priapism

Description – 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

- 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 – 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

Ischemic “Low Flow”

  • 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

Arterial “High Flow”

-- Erection usually less than fully rigid and painless

-- Usually history of penile or perineal trauma

Laboratory

Corporal blood gas analysis

-- Oxygen content <40mmHg suggests ischemic etiology

-- Oxygen content >70mmHg suggests arterial form

Imaging

Ischemic – none

Arterial -- Penile and perineal ultrasonography confirms dx

-- Pudendal arteriography allows definitive

diagnosis and angioembolization treatment

Treatment

Ischemic

-- Intracavernosal injection with one ampule methylene blue

(preferred method in patient with HTN, cardiac history)

-- 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

Arterial

-- Not a true medical emergency

  • Expectant management is an option
  • Angioembolization may be attempted to close the fistula

Prevention

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

References – Campbell-Walsh pp. 749-769

Gomella pp. 276-277, 632

Hanno pp. 271-275, 699-703

AUA Best Practice Guidelines

Fournier’s Gangrene

Definition – Rare, progressive, necrotizing fasciitis of the genitalia and / or perineum

Pathophysiology

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

Local ischemia allows further proliferation of organisms

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

Risk Factors

Immunosuppressed conditions

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

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

History

Frequency, urgency, dysuria, cloudy urine, urethral discharge, decreased

force of stream or straining to void

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

Scrotal infections, genital drug injection

Diabetes, alcoholism, malignancy, or immune suppression

Recent surgery as above

Physical Exam

Genitalia and perineum

Assess for pain, inflammation, or crepitus

Presence / extent of erythema or eschar

Skin findings often underestimate the extent of involvement

Abdomen

Note extent of skin findings on abdomen also

Rectal exam

Assess for perirectal abscess or anal sphincter involvement

Lab Tests

CBC , BMP, UA, Cultures of blood, urine and any wounds

(Assess for leukocytosis, elevated BUN / Creatinine, hyperglycemia,

glucosuria or pyuria, and any positive cultures)

Imaging

Plain film KUB -- may show subcutaneous gas

Retrograde urethrogram -- reveals urethral stricture, disruption, urinary extravasation

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

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

Treatment -- Medical

Broad spectrum I.V. antibiotics

Unasyn and gentamicin, or

Zosyn and gentamicin, or

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

Tetanus toxoid

Treatment -- Surgical

Prompt, aggressive surgical debridement

Proctoscopy if perirectal disease suspected

May need to surgically divert both fecal and urinary streams if urethra or

rectum involved

Wound should be packed with Dakin’s solution (25%), Clorpactin, or

saline

Treatment -- Adjunctive

Hyperbaric oxygen

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

Follow-up

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 – Campbell-Walsh pp. 324-325

Gomella pp. 130-131

Hanno pp. 210-212, 277-278

Testicular Torsion

Definition -- Vascular event that involves cessation of blood flow to the

testes, ultimately leading to testicular loss unless blood flow is restored

Pathophysiology

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

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.

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

Risk Factors

Extravaginal -- incomplete testicular descent (antenatal / neonatal)

Intravaginal -- horizontal lie to testis, most common, early puberty

History

Acute onset of testicular pain, often with nausea and vomitting, may

awaken patient from sleep (suggests torsion)

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

UTI symptoms (suggests epididymo-orchitis)

History of trauma (cannot rule-out torsion)

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

Physical Exam

Look for pain on ambulation, scrotal asymmetry, elevated (“high-riding”)

testis

“Blue dot sign” over testis suggests torsed appendix testis

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

affected testis

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

testis

If spermatic cord is tender also, consider torsion

Presence of intact cremasteric reflex argues against torsion

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

Laboratory

UA / Culture and sensitivities if urinary complaints present. (Positive

results do not rule out torsion.)

Imaging

Color flow Doppler (Best)

Excellent for showing presence or absence of blood flow to testis,

ruling out testicular tumors

Operator dependent and may be difficult in small patients

Nuclear testis scan (Technetium-99m)

Documents presence or absence of perfusion

Expensive

Invasive

May be difficult to obtain after hours

Treatment -- Surgical

Prompt referral to urology (requires high index of suspicion)

Testis examined, detorsed and warmed, then secured with three-point

fixation orchidopexy if considered viable

Orchidopexy for contralateral testis as well

Prevention -- High index of suspicion

-- Strongly consider testicular ultrasound of any patient

with testicular complaint prior to sending them home

References – Campbell-Walsh pp. 74-75, 82-83, 3586-3594

Gomella pp. 142-143, 452-453

Hanno pp. 58, 266-267, 718

----------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------

References:

Campbell-Walsh Urology, 10th Edition. Alan J. Wein, Editor-in-Chief.

Saunders / Elsevier, 2012.

The 5-Minute Urology Consult, 2nd Edition. Leonard G. Gomella, Editor.

Lippincott, Williams & Wilkins, 2010.

The Clinical Manual of Urology. Philip M. Hanno, Editor-in-Chief.

Saunders / Elsevier, 2007.

American Urological Association (AUA) Best Practice Guidelines:

https://www.auanet.org/guidelines

Clinical Guidelines for Common Genitourinary Disorders

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, three 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. Alphabetized general topics are described first, followed by a brief list of urologic emergencies.

Kenneth Moore, M.D.

Robert Rosen, M.D.

Urology

Amistad Medical Professionals

Val Verde Regional Medical Center

February, 2017

Balanitis / Balanoposthitis

Definition: Balanitis is inflammation of the glans penis, while

balanoposthitis is inflammation of the foreskin and glans.

Both occur predominantly in uncircumcised individuals.

Pediatric patients tend to have bacterial invasion, while

adults suffer from a combination of intertrigo, irritant

dermatitis, maceration injury and bacterial or candida

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: 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)
  • Meatal dilatation if urine outflow obstructed by BXO

References: Campbell-Walsh pp. 451, 964

Gomella pp. 34-35, 674

Hanno p. 276

Bladder Calculi

Definition: Calculus material in the bladder that does not pass with normal voiding

Bladder outlet obstruction most common etiology in U.S.

  • Benign prostate hyperplasia (BPH) in men
  • Cystocele (bladder prolapse) in women

Work-up: UA and urine culture (treat any associated infection)

Pelvic US readily diagnoses most bladder calculi

CT stone search (non-contrast) has excellent sensitivity and

specificity for upper and lower tract calculi, if US inconclusive

CT/IVP or contrast CT needed only if hematuria present, to

rule out neoplasm, obstruction

KUB often fails to demonstrate radiolucent stones (uric acid,

ammonium acid urate)

Urology referral for: Definitive therapy as soon as imaging

study done and infection treated (if necessary)

References: Campbell-Walsh pp. 2521-2527

Gomella pp. 40-41, 512-513

Hanno p.489

Benign Prostatic Hyperplasia

Definition: The enlargement of the prostate gland during the later decades of life. It becomes clinically significant when the extrinsic obstruction caused by the gland obstructs the bladder outlet, including the bladder neck and prostatic portion of the proximal urethra.

Work- up: Digital Rectal Exam

Renal and Bladder US (Include Post-Void Residual)

UA C&S

BMP (Creatinine)

Urology Referral For: Gross Hematuria

Acute Urinary Retention

Upper Tract Obstruction (Hydronephrois on US)

Recurrent UTI

Progressive symptoms despite medical therapy

References: Campbell-Walsh pp. 2570-2694

Gomella pp. 294-295, 605

Hanno pp. 479-521

AUA Best Practice Guidelines

Condyloma Acuminata

Definition: 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: Check for associated STD’s

Careful inspection of anal region for warts also

Urology Referral For: urethroscopy if hematuria or

obstruction present (URETHRAL lesions)

Referral to General Surgery if anal lesions present

Topical therapy (imiquimod, trichloroacetic acid, podophyllin,

podofilox, 5-FU) often effective

Surgical therapy (excision, electrosurgery, CO2 laser,

cryotherapy) normally reserved for extensive or

refractory cases

References: Campbell-Walsh 411-413, 426-427

Gomella pp. 74-75, 410-411

Hanno pp. 592-593, 748-751

Epididymitis / Orchitis

Definition: Clinical syndrome characterized by inflammation of the epididymis and/or testicles (orchitis rarely exists in the absence of epididymitis).

Painful swelling in the scrotum, often severe and

developing rapidly over 24 to 48 hours (may be even

more acute)

Often associated with dysuria or irritative voiding

Symptoms (urgency, frequency)

Prehn’s sign: alleviation of pain with scrotal

elevation (present with epididymo-orchitis, not usually

with testicular torsion). Of note, cremasteric reflex

remains intact with orchitis (diminished or absent in

torsion).

Bacterial etiology most widely accepted:

  • coli (children)
  • 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: testicular torsion

hemorrhage into occult testicular tumor

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

erythema of overlying scrotal skin, urethral discharge or

voiding complaints as above; less commonly with

elevated WBC count

Digital rectal exam to check for prostatitis recommended

UA often unremarkable

Consider scrotal ultrasound with colorflow Doppler if

torsion, tumor, or trauma suspected

Antibiotics, rest, analgesics / anti-imflammatories 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 (place at bedrest with scrotal elevation)

Consider follow-up scrotal ultrasound if no resolution

with appropriate antibiotics (rule out abscess)

Urology Referral For: Abscess

References: Campbell-Walsh pp, 354-356, 3117-3118

Gomella pp. 112-113

Hanno pp. 186-188, 267

Edema – External Genitalia

Definition: Either generalized edema or confined to scrotum / penis

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

Scrotal US (with colorflow Doppler if available)

Retrograde urethrogram if urethral trauma suspected

Urology Referral For: Urinary Obstruction

Abscess

Suspected Fournier’s Gangrene (see below)

Reference: Campbell-Walsh pp. 463-465

Gomella p. 100-101

Epididymal Mass

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-Walsh pp. 359-3595, 1008-1009

Gomella pp. 110-111

Elevated Prostate Specific Antigen (PSA)

As prostate cancer screening and the use of PSA as a screening tool has become controversial recently with the recommendations of the United States Preventive Services Task Force, the American Urological Association (AUA) has developed Prostate Cancer Screening Guidelines as follows:

Under age 40: The panel recommends against PSA screening due to the low prevalence of clinically detectable prostate cancer and lack of evidence demonstrating the benefit of screening.

Ages 40 to 54: The panel does not recommend routine screening in men between ages 40 and 54 years at average risk and recommends that for men younger than age 55 years at higher risk – those with a positive family history or African American race – decisions regarding prostate cancer screen should be individualized.

Ages 55 to 69: the panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in one man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the panel strongly recommends shared decision-making for those who are considering PSA screening and proceeding based on a man’s values and preferences. The greatest benefit of screening appears to be in men ages 55 to 69 years.

Over age 70: The panel does not recommend routing PSA screening in men age 70+ or any man with less than a 10- to 15-year life expectancy; however, some men age 70 or older who are in excellent health may benefit from prostate cancer screening.

To reduce the harms of screening, the AUA suggests that a routine screening interval of two years or more may be preferred over annual screening in men who have participated in shared physician-patient decision-making and decided on screening. Intervals for rescreening can be individualized by a baseline PSA level.

Urology Referral For: PSA > 4.0 (men without risk factors above)

PSA > 2.5 (men with risk factors above)

References: Campbell-Walsh pp. 2560-2562

Gomella pp. 316-317

Hanno pp. 66-67, 531-533, 715

AUA Best Practice Guidelines

Erectile Dysfunction

Definition: Consistent inability to obtain or maintain an erection

sufficient for satisfactory sexual relations (90% primarily

organic)

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

CBC

BMP with random glucose level

TSH (other thyroid function tests only if TSH abnormal)

A.M. total serum testosterone level

(Serum free testosterone, LH and prolactin only if

initial testosterone abnormal)

Urology Referral For: Failure of medical therapy (PDE5 inhibitors)

References: Campbell-Walsh pp. 717-728

Gomella pp. 118-119, 694

Hanno pp. 675-681

AUA Best Practice Guidelines

Frequency and Urgency

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

day, >2 times per night).

Urgency is the sudden impulse to void, without leakage.

Work-up: Urinalysis

Urine culture and sensitivity (If indicated by UA)

BMP (BUN / creatinine)

Renal and Bladder US (if renal insufficiency or urinary

retention suspected)

Urology referral for: Hematuria

Pyuria

Persistent / worsening symptoms

Evidence of obstruction on US

Elevated creatinine

References: Campbell-Walsh pp. 75, 1872

Gomella pp. 185, 502-503, 584

Hanno 41-42

Hematuria - Adult

Definition: At least 3 RBC’s per high power field on microscopic exam

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

Work-up: Recommended for all patients (adult and pediatric) with gross

hematuria and all adult patients with microscopic hematuria

CBC, BMP

Urine for cytology

Urine for culture and sensitivity (if indicated by positive nitrite)

CT/IVP

(May substitute renal ultrasound for CT/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 CT/IVP whenever possible.)

Urology referral for: cystoscopy after other work-up complete

References: Campbell-Walsh pp 98-100

Gomella pp. 148-149

Hanno pp. 162, 260-261

AUA Best Practice Guidelines

Hematuria – Pediatric

Definition: At least 3 RBC’s per high power field on microscopic exam

of fresh urine (not dipstick), confirmed on at least 3

separate urinalyses

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

anti-streptolysin-O titer, calcium:creatinine ratio

Renal and bladder US

VCUG (May defer if US entirely normal)

Note: cystoscopy rarely indicated

Pediatric Nephrology referral if US, VCUG are normal

Urology Referral for: abnormal US, VCUG

References: Campbell-Walsh pp. 75-91, 1522-1523

Gomella pp. 150-151

Hanno pp. 162, 260-261

Hematospermia

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

Pathognomonic for chronic prostatitis

Work-up: UA and urine culture

Urine cytology

Urethral swab for GC, Chlamydia

Consider PSA (see PSA section above)

Consider course of lipophilic antibiotics for prostatitis

(quinolones, doxycycline, TMP/Sx)

Urology Referral For: Abnormal studies

Persistence of hematospermia despite abx

References: Campbell-Walsh p. 79

Gomella pp. 146-147, 648

Hydrocele (Adult and Pediatric)

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

persistent fluid present in the scrotum 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 painful)

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 diagnose testicular mass, if present

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 US 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 to Pediatric Surgery if a hernia is

suspected.

References: Campbell-Walsh pp. 3583-3584

Gomella pp. 162-163, 396

Hanno pp. 57, 915

Male Infertility

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 female 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 (only if A.M. Testosterone low)

Scrotal US to confirm varicocele if found on exam

Urology Referral For: Persistent low semen volume (< 1.5 mL)

Low semen fructose

Persistent low sperm count

Varicocele or other anatomic abnormality

(hypospadius, penile chordee, abnormal US)

May NOT need referral if: Bilateral testicular atrophy and

FSH > 2x normal (primary testicular

failure)

References: Campbell-Walsh pp. 616-647

Gomella pp. 186-187

Hanno pp. 707-742

AUA Best Practices Guidelines

Nephrocalcinosis

Definition: Radiographically detectable diffuse renal parenchymal

calcifications, in contrast to nephrolithiasis in which

calcifications are located in the urinary collecting system

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

Nephrocalcinosis 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 / creatinine, 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 (if available)

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: Gomella pp. 218-219

Nephrolithiasis

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, and indinavir.

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

urinary infections, calcium and fluid intake, occupation,

symptoms of hypercalcemia, hypertension, and renal failure.

UA, 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 serum creatinine,

intravenous access and exposure to intravenous contrast.

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

US can detect and localize stones but is often

inaccurate in determining stone size (main use is in

pregnant patients).

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

Urology Referral 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 vomiting

Urosepsis

Elderly / debilitated patient

Clot or debris in renal pelvis, or

perinephric abscess on studies

References: Campbell-Walsh pp. 1287-1293

Gomella pp. 332-333

Hanno pp. 235-256

AUA Best Practice Guidelines

Pneumaturia

Definition: Passage of gas through urethra

Work-up: UA

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

Enterobacter spp.)

CBC with differential, BMP (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 or colovesical fistula.)

Urology and General Surgery Referral For: Findings in any of the

above studies that

suggest fistula

References: Campbell-Walsh pp. 79, 2253

Gomella pp. 262-263

Hanno p. 47

Premature Ejaculation

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)

Lidocaine 2.5% / prilocaine 2.5% (EMLA) cream

20 – 30 minutes pre-intercourse

Oral therapy:

Non-selective serotonin reuptake inhibitors (SRI’s)

Clomipramine (Anafranil)

Selective serotonin reuptake inhibitors (SSRI’s)

Fluoxetine (Prozac, Sarafem)

Paroxetine (Paxil)

Sertraline (Zoloft)

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

work-up) or exam abnormal. Consider referral to

psychotherapist / sex therapist also.

References: Campbell-Walsh pp. 770-779

Gomella pp. 102-103, 692

Hanno pp. 696-699

AUA Best Practice Guidelines

Prostatitis, Acute Bacterial

Definition: Generally associated with infection of both prostate and

Bladder (bacteriuria)

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 aggressive 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 (switch to oral antibiotics when afebrile for 48

hours)

Urine and blood cultures may guide therapy, but treatment

should not be delayed pending culture results

Avoid urethral instrumentation if possible (including urethral

catheters)

Check post-void urinary residual volume with bladder

  1. 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 antibiotics

Antibiotic course minimum of 30 – 45 days to prevent chronic

bacterial prostatitis

Urology Referral For: Suprapubic cystostomy tube placement

Single course of antibiotics fails to alleviate

symptoms (suspect prostate abscess)

References: Campbell-Walsh pp. 333-337

Gomella pp. 298-299

Hanno pp. 182-183

Prostatitis, Chronic Bacterial

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 WBC’s and

uropathogens in post-massage specimen compared with

pre-massage specimen

Imaging not usually helpful, unless bladder ultrasound needed

to rule out urinary retention

Antibiotics should continue for 4 – 6 weeks

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

sports and activities should be avoided

Warms baths, NSAIDS, frequent ejaculation often beneficial

Alpha blocker medication if obstructive voiding symptoms

References: Campbell-Walsh pp. 333-338

Gomella pp. 300-301

Hanno pp. 183-184

Prostate Nodule

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

involvement of entire gland

Work-up: UA

Urine cytology (if hematuria present)

Urine culture (if indicated by UA)

PSA (unless prostate exam suggests

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

urinary retention)

Urology Consult For: All prostate nodules

References: Campbell-Walsh pp. 2764-2767

Gomella pp. 290-291

Hanno pp. 60-61

Proteinuria

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

the urine

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 and Bladder US

Internal Medicine or Nephrology consult when work-up

completed

Urology Referral For: Focal lesion found on renal ultrasound

If renal biopsy required for specific diagnosis

References: Campbell-Walsh pp. 81-89, 3007-3009

Gomella pp. 310-311, 707

Pyelonephritis, Acute

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

  1. 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, BMP (Renal failure uncommon without sepsis)

UA, blood and urine cultures

No imaging necessary in uncomplicated cases

If no response to appropriate antibiotic therapy within 48 hours,

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

anatomic abnormality

Renal US may demonstrate calculi, perinephric abscess

(mild hydronephrosis common – does not necessarily indicate

obstruction – endotoxins impair ureteral peristalsis)

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

CT/IVP (study of choice) will 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 before switching to p.o.

Antibiotic course: 14 days required (6 weeks for renal abscess)

Urology Referral For: complications (calculi, obstruction,

perinephric or intrarenal abscess, etc.)

References: Campbell-Walsh pp. 266-267, 295-299

Gomella pp. 320-321, 500

Hanno pp. 173-174

Renal Mass

Most common lesion: simple renal cyst

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

Work-up: UA

Urine culture (if indicated by UA)

Urine cytology

CBC, CMP (BUN, creatinine, glucose, LFT’s,

calcium)

CXR (PA, lateral)

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

and without contrast (3-phase, includes delayed images)

Urology Referral For: All renal masses

References: Campbell-Walsh pp. 1418-1420, 1440-1443

Gomella pp. 366-367

Hanno pp. 114-116

Scrotal Mass

Definition: Painful or painless “lump” in the scrotal sac

Work-up: UA

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-Walsh pp. 63-67, 3586-3594

Gomella pp. 396-397

Hanno pp. 56-58

Undescended Testicle

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 US

Urology Referral For: US-confirmed absence of testis in scrotum

Note: If neither testis palpable, consider intersex disorder (female with

congenital adrenal hyperplasia / 21-hydroxylase deficiency

most likely); need karyotype, serum electrolytes, and referral

to Pediatric Urology

References: Campbell-Walsh pp. 3564-3565

Gomella pp. 464-465

Hanno pp. 112, 848-849, 911-915

AUA Best Practice Guidelines

Urethral Mass

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

the urethra

Work-up: UA

Urine gram stain and culture (include AFB)

Urethral swab for GC, chlamydia, TB

Urine cytology

BMP (for creatinine)

Urethral MRI

Urology Referral For: All urethral masses

References: Campbell-Walsh pp. 1798-1800

Gomella pp. 492-493

Urinary Incontinence, Adult

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 (US)

UA

Urine culture (treat UTI if present)

Urine cytology (if hematuria present)

BMP (BUN / creatinine, glucose)

CT/IVP for: Total incontinence in pediatric patient

Associated hematuria or recurrent UTI

Otherwise, Renal and bladder US (or 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 for: Patients with persistent leakage despite behavioral

therapy (Kegel exercises, timed voiding) or if anatomic

abnormality found on exam / imaging

Note: Patients should present to Urology clinic with a voiding

diary, to include time and amount of each void for a 48-

hour period

References: Campbell-Walsh pp. 1871-1873

Gomella pp. 178-181, 700

Hanno pp. 427-430

AUA Best Practice Guidelines

Urinary Incontinence, Pediatric

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)

UA

Urine culture (if indicated by UA)

KUB with lateral spine film

Renal and bladder US

VCUG (if associated UTI’s or hydronephrosis on US)

CT/IVP (if ureteral duplication suspected – i.e. continual

wetness in females)

Urology referral For: New onset of daytime wetting or encopresis

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-Walsh p. 3418

Gomella pp. 184-185

Urinary Tract Infection, Adult Female

Definition: >105 CFU bacteria / mL urine in an asymptomatic patient, or

>102 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 US: good initial study to R/O

hydronephrosis, abscess, bladder or renal stones

CT/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 and delayed images, “3-Phase CT”):

further evaluation of suspected renal abscess, renal

mass, or radiolucent renal calculus

VCUG: Hx of vesicoureteral reflux or neurogenic bladder.

VCUG study should be performed 6 weeks after acute

infection treated, to prevent false positives

Pelvic MRI with contrast: If urethral diverticulum suspected

(fluctuant urethral mass on exam, UTI’s with multiple

organisms, multiparity)

Urology referral For: Positive findings on imaging studies

Suspected urethral diverticulum

Failure to resolve with appropriate antibiotics

**Referral for recurrent uncomplicated UTI requires at least 3

documented infections (nitrite positive or organism identified)

within 12 months

References: Campbell-Walsh pp. 258, 290-294

Gomella pp. 506-507

Hanno pp. 155-164

Urinary Tract Infection, Adult Male

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 incidence

Complicated (Same as for complicated female UTI)

Urology Referral For: All complicated male UTI’s

References: Campbell-Walsh pp. 2602, 2620, 3092

Gomella pp. 508-509

Hanno pp. 177-181

Urinary Tract Infection, Pediatric

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

>105 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 and bladder US

Urology referral

Prophylactic antibiotics (Nitrofurantoin, TMP /

SMX, or cephalexin) should be given

until reflux and / or urinary obstruction are

excluded radiographically

Urology Referral For: First male UTI, first febrile or second afebrile UTI

in females

References: Campbell-Walsh pp. 089-3120

Gomella pp. 510-511, 717

Urologic Emergencies

Paraphimosis

Description – Painful swelling of the foreskin distal to a phimotic ring

after retraction of the foreskin for a prolonged period

Pathophysiology – 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 – 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 – 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 – 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: Campbell-Walsh pp. 964, 3539

Gomella pp. 100, 260-261

Hanno pp. 54, 276

Priapism

Description – 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

- 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 – 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

Ischemic “Low Flow”

  • 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

Arterial “High Flow”

-- Erection usually less than fully rigid and painless

-- Usually history of penile or perineal trauma

Laboratory

Corporal blood gas analysis

-- Oxygen content <40mmHg suggests ischemic etiology

-- Oxygen content >70mmHg suggests arterial form

Imaging

Ischemic – none

Arterial -- Penile and perineal ultrasonography confirms dx

-- Pudendal arteriography allows definitive

diagnosis and angioembolization treatment

Treatment

Ischemic

-- Intracavernosal injection with one ampule methylene blue

(preferred method in patient with HTN, cardiac history)

-- 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

Arterial

-- Not a true medical emergency

  • Expectant management is an option
  • Angioembolization may be attempted to close the fistula

Prevention

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

References – Campbell-Walsh pp. 749-769

Gomella pp. 276-277, 632

Hanno pp. 271-275, 699-703

AUA Best Practice Guidelines

Fournier’s Gangrene

Definition – Rare, progressive, necrotizing fasciitis of the genitalia and / or perineum

Pathophysiology

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

Local ischemia allows further proliferation of organisms

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

Risk Factors

Immunosuppressed conditions

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

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

History

Frequency, urgency, dysuria, cloudy urine, urethral discharge, decreased

force of stream or straining to void

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

Scrotal infections, genital drug injection

Diabetes, alcoholism, malignancy, or immune suppression

Recent surgery as above

Physical Exam

Genitalia and perineum

Assess for pain, inflammation, or crepitus

Presence / extent of erythema or eschar

Skin findings often underestimate the extent of involvement

Abdomen

Note extent of skin findings on abdomen also

Rectal exam

Assess for perirectal abscess or anal sphincter involvement

Lab Tests

CBC , BMP, UA, Cultures of blood, urine and any wounds

(Assess for leukocytosis, elevated BUN / Creatinine, hyperglycemia,

glucosuria or pyuria, and any positive cultures)

Imaging

Plain film KUB -- may show subcutaneous gas

Retrograde urethrogram -- reveals urethral stricture, disruption, urinary extravasation

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

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

Treatment -- Medical

Broad spectrum I.V. antibiotics

Unasyn and gentamicin, or

Zosyn and gentamicin, or

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

Tetanus toxoid

Treatment -- Surgical

Prompt, aggressive surgical debridement

Proctoscopy if perirectal disease suspected

May need to surgically divert both fecal and urinary streams if urethra or

rectum involved

Wound should be packed with Dakin’s solution (25%), Clorpactin, or

saline

Treatment -- Adjunctive

Hyperbaric oxygen

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

Follow-up

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 – Campbell-Walsh pp. 324-325

Gomella pp. 130-131

Hanno pp. 210-212, 277-278

Testicular Torsion

Definition -- Vascular event that involves cessation of blood flow to the

testes, ultimately leading to testicular loss unless blood flow is restored

Pathophysiology

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

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.

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

Risk Factors

Extravaginal -- incomplete testicular descent (antenatal / neonatal)

Intravaginal -- horizontal lie to testis, most common, early puberty

History

Acute onset of testicular pain, often with nausea and vomitting, may

awaken patient from sleep (suggests torsion)

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

UTI symptoms (suggests epididymo-orchitis)

History of trauma (cannot rule-out torsion)

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

Physical Exam

Look for pain on ambulation, scrotal asymmetry, elevated (“high-riding”)

testis

“Blue dot sign” over testis suggests torsed appendix testis

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

affected testis

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

testis

If spermatic cord is tender also, consider torsion

Presence of intact cremasteric reflex argues against torsion

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

Laboratory

UA / Culture and sensitivities if urinary complaints present. (Positive

results do not rule out torsion.)

Imaging

Color flow Doppler (Best)

Excellent for showing presence or absence of blood flow to testis,

ruling out testicular tumors

Operator dependent and may be difficult in small patients

Nuclear testis scan (Technetium-99m)

Documents presence or absence of perfusion

Expensive

Invasive

May be difficult to obtain after hours

Treatment -- Surgical

Prompt referral to urology (requires high index of suspicion)

Testis examined, detorsed and warmed, then secured with three-point

fixation orchidopexy if considered viable

Orchidopexy for contralateral testis as well

Prevention -- High index of suspicion

-- Strongly consider testicular ultrasound of any patient

with testicular complaint prior to sending them home

References – Campbell-Walsh pp. 74-75, 82-83, 3586-3594

Gomella pp. 142-143, 452-453

Hanno pp. 58, 266-267, 718

----------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------

References:

Campbell-Walsh Urology, 10th Edition. Alan J. Wein, Editor-in-Chief.

Saunders / Elsevier, 2012.

The 5-Minute Urology Consult, 2nd Edition. Leonard G. Gomella, Editor.

Lippincott, Williams & Wilkins, 2010.

The Clinical Manual of Urology. Philip M. Hanno, Editor-in-Chief.

Saunders / Elsevier, 2007.

American Urological Association (AUA) Best Practice Guidelines:

https://www.auanet.org/guidelines