- •Preface and Acknowledgments
- •Contents
- •Contributors
- •1: Embryology for Urologists
- •Introduction
- •Renal Development
- •Pronephros
- •Mesonephros
- •Metanephros
- •Development of the Collecting System
- •Critical Steps in Further Development
- •Anomalies of the Kidney
- •Renal Agenesis
- •Renal Aplasia
- •Renal Hypoplasia
- •Renal Ectopia
- •Renal Fusion
- •Ureteral Development
- •Anomalies of Origin
- •Anomalies of Number
- •Incomplete Ureteral Duplication
- •Complete Ureteral Duplication
- •Ureteral Ectopia
- •Embryology of Ectopia
- •Clinical Correlation
- •Location of Ectopic Ureteral Orifices – Male (in Descending Order According to Incidence)
- •Symptoms
- •Ureteroceles
- •Congenital Ureteral Obstruction
- •Pipestem Ureter
- •Megaureter-Megacystis Syndrome
- •Prune Belly Syndrome
- •Vascular Ureteral Obstructions
- •Division of the Urogenital Sinus
- •Bladder Development
- •Urachal Anomalies
- •Cloacal Duct Anomalies
- •Other Bladder Anomalies
- •Bladder Diverticula
- •Bladder Extrophy
- •Gonadal Development
- •Testicular Differentiation
- •Ovarian Differentiation
- •Gonadal Anomalies
- •Genital Duct System
- •Disorders of Testicular Function
- •Female Ductal Development
- •Prostatic Urethral Valves
- •Gonadal Duct Anomalies
- •External Genital Development
- •Male External Genital Development
- •Female External Genital Development
- •Anomalies of the External Genitalia
- •References
- •2: Gross and Laparoscopic Anatomy of the Upper Urinary Tract and Retroperitoneum
- •Overview
- •The Kidneys
- •The Renal Vasculature
- •The Renal Collecting System
- •The Ureters
- •Retroperitoneal Lymphatics
- •Retroperitoneal Nerves
- •The Adrenal Glands
- •References
- •3: Gross and Laparoscopic Anatomy of the Lower Urinary Tract and Pelvis
- •Introduction
- •Female Pelvis
- •Male Pelvis
- •Pelvic Floor
- •Urinary Bladder
- •Urethra
- •Male Urethra
- •Female Urethra
- •Sphincter Mechanisms
- •The Bladder Neck Component
- •The Urethral Wall Component
- •The External Urethral Sphincter
- •Summary
- •References
- •4: Anatomy of the Male Reproductive System
- •Testis and Scrotum
- •Spermatogenesis
- •Hormonal Regulation of Spermatogenesis
- •Genetic Regulation of Spermatogenesis
- •Epididymis and Ductus Deferens
- •Accessory Sex Glands
- •Prostate
- •Seminal Vesicles
- •Bulbourethral Glands
- •Penis
- •Erection and Ejaculation
- •References
- •5: Imaging of the Upper Tracts
- •Anatomy of the Upper Tracts and Introduction to Imaging Modalities
- •Introduction
- •Renal Upper Tract Basic Anatomy
- •Modalities Used for Imaging the Upper Tracts
- •Ultrasound
- •Radiation Issues
- •Contrast Issues
- •Renal and Upper Tract Tumors
- •Benign Renal Tumors
- •Transitional Cell Carcinoma
- •Renal Mass Biopsy
- •Renal Stone Disease
- •Ultrasound
- •Plain Radiographs and IVU
- •Renal Cystic Disease
- •Benign Renal Cysts
- •Hereditary Renal Cystic Disease
- •Complex Renal Cysts
- •Renal Trauma
- •References
- •Introduction
- •Pathophysiology
- •Susceptibility and Resistance
- •Epidemiological Breakpoints
- •Clinical Breakpoints
- •Pharmacodynamic Parameters
- •Pharmacokinetic Parameters
- •Fosfomycin
- •Nitrofurantoin
- •Pivmecillinam
- •b-Lactam-Antibiotics
- •Penicillins
- •Cephalosporins
- •Carbapenems
- •Aminoglycosides
- •Fluoroquinolones
- •Trimethoprim, Cotrimoxazole
- •Glycopeptides
- •Linezolid
- •Conclusion
- •References
- •7: An Overview of Renal Physiology
- •Introduction
- •Body Fluid Compartments
- •Regulation of Potassium Balance
- •Regulation of Acid–Base Balance
- •Diuretics
- •Suggested Reading
- •8: Ureteral Physiology and Pharmacology
- •Ureteral Anatomy
- •Modulation of Peristalsis
- •Ureteral Pharmacology
- •Conclusion
- •References
- •Introduction
- •Afferent Signaling Pathways
- •Efferent Signaling
- •Parasympathetic Nerves
- •Sympathetic Nerves
- •Vesico-Spinal-Vesical Micturition Reflex
- •Peripheral Targets
- •Afferent Signaling Mechanisms
- •Urothelium
- •Myocytes
- •Cholinergic Receptors
- •Muscarinic Receptors
- •Nicotinic Receptors
- •Adrenergic Receptors (ARs)
- •a-Adrenoceptors
- •b-Adrenoceptors
- •Transient Receptor Potential (TRP) Receptors
- •Phosphodiesterases (PDEs)
- •CNS Targets
- •Opioid Receptors
- •Serotonin (5-HT) Mechanisms
- •g-Amino Butyric Acid (GABA) Mechanisms
- •Gabapentin
- •Neurokinin and Neurokinin Receptors
- •Summary
- •References
- •10: Pharmacology of Sexual Function
- •Introduction
- •Sexual Desire/Arousal
- •Endocrinology
- •Steroids in the Male
- •Steroids in the Female
- •Neurohormones
- •Neurotransmitters
- •Dopamine
- •Serotonin
- •Pharmacological Strategies
- •CNS Drugs
- •Enzyme-inducing Antiepileptic Drugs
- •Erectile Function
- •Ejaculatory Function
- •Premature Ejaculation
- •Abnormal Ejaculation
- •Conclusions
- •References
- •Epidemiology
- •Calcium-Based Urolithiasis
- •Uric Acid Urolithiasis
- •Infectious Urolithiasis
- •Cystine-Based Urolithiasis
- •Aims
- •Who Deserves Metabolic Evaluation?
- •Metabolic Workup for Stone Producers
- •Medical History and Physical Examination
- •Stone Analysis
- •Serum Chemistry
- •Urine Evaluation
- •Urine Cultures
- •Urinalysis
- •Twenty-Four Hour Urine Collections
- •Radiologic Imaging
- •Medical Management
- •Conservative Management
- •Increased Fluid Intake
- •Citrus Juices
- •Dietary Restrictions
- •Restricted Oxalate Diet
- •Conservative Measures
- •Selective Medical Therapy
- •Absorptive Hypercalciuria
- •Thiazide
- •Orthophosphate
- •Renal Hypercalciuria
- •Primary Hyperparathyroidism
- •Hyperuricosuric Calcium Oxalate Nephrolithiasis
- •Enteric Hyperoxaluria
- •Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Distal Renal Tubular Acidosis
- •Chronic Diarrheal States
- •Thiazide-Induced Hypocitraturia
- •Idiopathic Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Hypomagnesiuric Calcium Nephrolithiasis
- •Gouty Diathesis
- •Cystinuria
- •Infection Lithiasis
- •Summary
- •References
- •12: Molecular Biology for Urologists
- •Introduction
- •Inherited Changes in Cancer Cells
- •VEGR and Cell Signaling
- •Targeting mTOR
- •Conclusion
- •References
- •13: Chemotherapeutic Agents for Urologic Oncology
- •Introduction
- •Bladder Cancer
- •Muscle Invasive Bladder Cancer
- •Metastatic Bladder Cancer
- •Conclusion
- •Prostate Cancer
- •Other Chemotherapeutic Drugs or Combinations for Treating HRPC
- •Conclusion
- •Renal Cell Carcinoma
- •Chemotherapy
- •Immunotherapy
- •Angiogenesis Inhibitor Drugs
- •Conclusion
- •Testicular Cancer
- •Stage I Seminoma
- •Stage I non-seminomatous Germ Cell Tumours (NSGCT)
- •Metastatic Germ Cell Tumours
- •Low-Volume Metastatic Disease (Stage II A/B)
- •Advanced Metastatic Disease
- •Salvage Chemotherapy for Relapsed or Refractory Disease
- •Conclusion
- •Penile Cancer
- •Side Effects of Chemotherapy
- •Conclusion
- •References
- •14: Tumor and Transplant Immunology
- •Antibodies
- •Cytotoxic and T-helper Cells
- •Immunosuppression
- •Induction Therapy
- •Maintenance Therapy
- •Rejection
- •Posttransplant Lymphoproliferative Disease
- •Summary
- •References
- •15: Pathophysiology of Renal Obstruction
- •Causes of Renal Obstruction
- •Effects on Prenatal Development
- •Prenatal Hydronephrosis
- •Spectrum of Renal Abnormalities
- •Renal Functional Changes
- •Renal Growth/Counterbalance
- •Vascular Changes
- •Inflammatory Mediators
- •Glomerular Development Changes
- •Mechanical Stretch of Renal Tubules
- •Unilateral Versus Bilateral
- •Limitations of Animal Models
- •Future Research
- •Issues in Patient Management
- •Diagnostic Imaging
- •Ultrasound
- •Intravenous Urography
- •Antegrade Urography and the Whitaker Test
- •Nuclear Renography
- •Computed Tomography
- •Magnetic Resonance Urography
- •Hypertension
- •Postobstructive Diuresis
- •References
- •Introduction
- •The Normal Lower Urinary Tract
- •Anatomy
- •Storage Function
- •Voiding Function
- •Neural Control
- •Symptoms
- •Flow Rate and Post-void Residual
- •Voiding Cystometry
- •Male
- •Female
- •Neurourology
- •Conclusions
- •References
- •17: Urologic Endocrinology
- •The Testis
- •Normal Androgen Metabolism
- •Epidemiological Aspects
- •Prostate
- •Brain
- •Muscle Mass and Adipose Tissue
- •Bones
- •Ematopoiesis
- •Metabolism
- •Cardiovascular System
- •Clinical Assessment
- •Biochemical Assessment
- •Treatment Modalities
- •Oral Preparations
- •Parenteral Preparations
- •Transdermal Preparations
- •Side Effects and Treatment Monitoring
- •Body Composition
- •Cognitive Decline
- •Bone Metabolism
- •The Kidneys
- •Endocrine Functions of the Kidney
- •Erythropoietin
- •Calcitriol
- •Renin
- •Paraneoplastic Syndromes
- •Hypercalcemia
- •Hypertension
- •Polycythemia
- •Other Endocrine Abnormalities
- •References
- •General Physiology
- •Prostate Innervation
- •Summary
- •References
- •Wound Healing
- •Inflammation
- •Proliferation
- •Remodeling
- •Principles of Plastic Surgery
- •Tissue Characteristics
- •Grafts
- •Flap
- •References
- •Lower Urinary Tract Symptoms
- •Storage Phase
- •Voiding Phase
- •Return to Storage Phase
- •Urodynamic Parameters
- •Urodynamic Techniques
- •Volume Voided Charts
- •Pad Testing
- •Typical Test Schedule
- •Uroflowmetry
- •Post Voiding Residual
- •Further Diagnostic Evaluation of Patients
- •Cystometry with or Without Video
- •Cystometry
- •Videocystometrography (Cystometry + Cystourethrography)
- •Cystometric Findings
- •Comment:
- •Measurements During the Storage Phase:
- •Measurements During the Voiding Phase:
- •Abnormal Function
- •Disorders of Sensation
- •Causes of Hypersensitive Bladder Sensation
- •Causes of Hyposensitive Bladder Sensation
- •Disorders of Detrusor Motor Function
- •Bladder Outflow Tract Dysfunction
- •Detrusor–Urethral Dyssynergia
- •Detrusor–Bladder Neck Dyssynergia
- •Detrusor–Sphincter Dyssynergia
- •Complex Urodynamic Investigation
- •Urethral Pressure Measurement
- •Technique
- •Neurophysiological Evaluation
- •Conclusion
- •References
- •Endoscopy
- •Cystourethroscopy
- •Ureteroscopy and Ureteropyeloscopy
- •Nephroscopy
- •Virtual Reality Simulators
- •Lasers
- •Clinical Application of Lasers
- •Condylomata Acuminata
- •Urolithiasis
- •Benign Prostatic Hyperplasia
- •Ureteral and Urethral Strictures
- •Conclusion
- •References
- •Introduction
- •The Prostatitis Syndromes
- •The Scope of the Problem
- •Category III CP/CPPS
- •The Goal of Treatment
- •Conservative Management
- •Drug Therapy
- •Antibiotics
- •Anti-inflammatories
- •Alpha blockers
- •Hormone Therapies
- •Phytotherapies
- •Analgesics, muscle relaxants and neuromodulators
- •Surgery
- •A Practical Management Plan
- •References
- •Orchitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment of Infectious Orchitis
- •Epididymitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation of Epididymitis
- •Treatment of Acute Epididymitis
- •Treatment of Chronic Epididymitis
- •Treatment of Spermatic Cord Torsion
- •Fournier’s Gangrene
- •Definition and Etiology
- •Risk Factors
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment
- •References
- •Fungal Infections
- •Candidiasis
- •Aspergillosis
- •Cryptococcosis
- •Blastomycosis
- •Coccidioidomycosis
- •Histoplasmosis
- •Radiographic Findings
- •Treatment
- •Tuberculosis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Schistosomiasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Filariasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Onchocerciasis
- •References
- •25: Sexually Transmitted Infections
- •Introduction
- •STIs Associated with Genital Ulcers
- •Herpes Simplex Virus
- •Diagnosis
- •Treatment
- •Chancroid
- •Diagnosis
- •Treatment
- •Syphilis
- •Diagnosis
- •Treatment
- •Lymphogranuloma Venereum
- •Diagnosis
- •Treatment
- •Chlamydia
- •Diagnosis
- •Treatment
- •Gonorrhea
- •Diagnosis
- •Treatment
- •Trichomoniasis
- •Diagnosis
- •Treatment
- •Human Papilloma Virus
- •Diagnosis
- •Treatment
- •Scabies
- •Diagnosis
- •Treatment
- •References
- •26: Hematuria: Evaluation and Management
- •Introduction
- •Classification of Hematuria
- •Macroscopic Hematuria
- •Microscopic Hematuria
- •Dipstick Hematuria
- •Pseudohematuria
- •Factitious Hematuria
- •Menstruation
- •Aetiology
- •Malignancy
- •Urinary Calculi
- •Infection and Inflammation
- •Benign Prostatic Hyperplasia
- •Trauma
- •Drugs
- •Nephrological Causes
- •Assessment
- •History
- •Examination
- •Investigations
- •Dipstick Urinalysis
- •Cytology
- •Molecular Tests
- •Blood Tests
- •Flexible Cystoscopy
- •Upper Urinary Tract Evaluation
- •Renal USS
- •KUB Abdominal X-Ray
- •Intravenous Urography (IVU)
- •Computed Tomography (CT)
- •Retrograde Urogram Studies
- •Magnetic Resonance Imaging (MRI)
- •Additional Tests and Renal Biopsy
- •Intractable Hematuria
- •Loin Pain Hematuria Syndrome
- •References
- •27: Benign Prostatic Hyperplasia (BPH)
- •Historical Background
- •Pathophysiology
- •Patient Assessment
- •Treatment of BPH
- •Watchful Waiting
- •Drug Therapy
- •Interventional Therapies
- •Conclusions
- •References
- •28: Practical Guidelines for the Treatment of Erectile Dysfunction and Peyronie´s Disease
- •Erectile Dysfunction
- •Introduction
- •Diagnosis
- •Basic Evaluation
- •Cardiovascular System and Sexual Activity
- •Optional Tests
- •Treatment
- •Medical Treatment
- •Oral Agents
- •Phosphodiesterase Type 5 (PDE 5) Inhibitors
- •Nonresponders to PDE5 Inhibitors
- •Apomorphine SL
- •Yohimbine
- •Intracavernosal and Intraurethral Therapy
- •Intracavernosal Injection (ICI) Therapy
- •Intraurethral Therapy
- •Vacuum Constriction Devices
- •Surgical Therapy
- •Conclusion
- •Peyronie´s Disease (PD)
- •Introduction
- •Oral Drug Therapy
- •Intralesional Drug Therapy
- •Iontophoresis
- •Radiation Therapy
- •Surgical Therapy
- •References
- •29: Premature Ejaculation
- •Introduction
- •Epidemiology
- •Defining Premature Ejaculation
- •Voluntary Control
- •Sexual Satisfaction
- •Distress
- •Psychosexual Counseling
- •Pharmacological Treatment
- •On-Demand Treatment with Tramadol
- •Topical Anesthetics
- •Phosphodiesterase Inhibitors
- •Surgery
- •Conclusion
- •References
- •30: The Role of Interventional Management for Urinary Tract Calculi
- •Contraindications to ESWL
- •Complications of ESWL
- •PCNL Access
- •Instrumentation for PCNL
- •Nephrostomy Drains Post PCNL
- •Contraindications to PCNL
- •Complications of PCNL
- •Semirigid Ureteroscopy
- •Flexible Ureteroscopy
- •Electrohydraulic Lithotripsy (EHL)
- •Ultrasound
- •Ballistic Lithotripsy
- •Laser Lithotripsy
- •Ureteric Stents
- •Staghorn Calculi
- •Lower Pole Stones
- •Horseshoe Kidneys and Stones
- •Calyceal Diverticula Stones
- •Stones and PUJ Obstruction
- •Treatment of Ureteric Colic
- •Medical Expulsive Therapy (MET)
- •Intervention for Ureteric Stones
- •Stones in Pregnancy
- •Morbid Obesity
- •References
- •Anatomy and Function
- •Pathophysiology
- •Management
- •Optical Urethrotomy/Dilatation
- •Urethral Stents
- •Preoperative Assessment
- •Urethroplasty
- •Anastomotic Urethroplasty
- •Substitution Urethroplasty
- •Grafts Versus Flaps
- •Oral Mucosal Grafts
- •Tissue Engineering
- •Graft Position
- •Conclusion
- •References
- •32: Urinary Incontinence
- •Epidemiology and Risk Factors
- •Pathophysiology
- •Urge Incontinence
- •Conservative Treatments
- •Pharmacotherapy
- •Invasive/ Surgical Therapies
- •Stress Urinary Incontinence
- •Male SUI Therapies
- •Female SUI Therapies
- •Mixed Urinary Incontinence
- •Conclusions
- •References
- •33: Neurogenic Bladder
- •Introduction
- •Examination and Diagnostic Tests
- •History and Physical Examination
- •Imaging
- •Urodynamics (UDS)
- •Evoked Potentials
- •Classifications
- •Somatic Pathways
- •Brain Lesions
- •Cerebrovascular Accident (CVA)
- •Parkinson’s Disease (PD)
- •Multiple Sclerosis
- •Huntington’s Disease
- •Dementias
- •Normal Pressure Hydrocephalus (NPH)
- •Tumors
- •Psychiatric Disorders
- •Spinal Lesions and Pathology
- •Intervertebral Disk Prolapse
- •Spinal Cord Injury (SCI)
- •Transverse Myelitis
- •Peripheral Neuropathies
- •Metabolic Neuropathies
- •Pelvic Surgery
- •Treatment
- •Summary
- •References
- •34: Pelvic Prolapse
- •Introduction
- •Epidemiology
- •Anatomy and Pathophysiology
- •Evaluation and Diagnosis
- •Outcome Measures
- •Imaging
- •Urodynamics
- •Indications for Management
- •Biosynthetics
- •Surgical Management
- •Anterior Compartment Repair
- •Uterine/Apical Prolapse
- •Enterocele Repair
- •Conclusion
- •References
- •35: Urinary Tract Fistula
- •Introduction
- •Urogynecologic Fistula
- •Vesicovaginal Fistula
- •Etiology and Risk Factors
- •Clinical Factors
- •Evaluation and Diagnosis
- •Pelvic Examination
- •Cystoscopy
- •Imaging
- •Treatment
- •Conservative Management
- •Surgical Management
- •Urethrovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Ureterovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Vesicouterine Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Uro-Enteric Fistula
- •Vesicoenteric Fistula
- •Pyeloenteric Fistula
- •Urethrorectal Fistula
- •References
- •36: Urologic Trauma
- •Introduction
- •Kidney
- •Expectant Management
- •Endovascular Therapy
- •Operative Intervention
- •Operative Management: Follow-up
- •Reno-Vascular Injuries
- •Pediatric Renal Injuries
- •Adrenal
- •Ureter
- •Diagnosis
- •Treatment
- •Delayed Diagnosis
- •Bladder and Posterior Urethra
- •Bladder Injuries: Initial Management
- •Bladder Injuries: Formal Repair
- •Anterior Urethral Trauma
- •Fractured Penis
- •Penile Amputation
- •Scrotal and Testicular Trauma
- •Imaging
- •CT-IVP (CT with Delayed Images)
- •Technique
- •Cystogram
- •Technique
- •Retrograde Urethrogram (RUG)
- •Technique
- •Retrograde Pyelogram (RPG)
- •Technique
- •One-Shot IVP
- •Technique
- •References
- •37: Bladder Cancer
- •Who Should Be Investigated?
- •Epidemiology
- •Risk Factors
- •Role of Screening
- •Signs and Symptoms
- •Imaging
- •Cystoscopy
- •Urine Tests
- •PDD-Assisted TUR
- •Pathology
- •NMIBC and Risk Groups
- •Intravesical Chemotherapy
- •Intravesical Immunotherapy
- •Immediate Cystectomy and CIS
- •Radical Cystectomy with Pelvic Lymph Node Dissection
- •sexual function-preserving techniques
- •Bladder-Preservation Treatments
- •Neoadjuvant Chemotherapy
- •Adjuvant Chemotherapy
- •Preoperative Radiotherapy
- •Follow-up After TUR in NMIBC
- •References
- •38: Prostate Cancer
- •Introduction
- •Epidemiology
- •Race
- •Geographic Variation
- •Risk Factors and Prevention
- •Family History
- •Diet and Lifestyle
- •Prevention
- •Screening and Diagnosis
- •Current Screening Recommendations
- •Biopsy
- •Pathology
- •Prognosis
- •Treatment of Prostate Cancer
- •Treatment for Localized Prostate Cancer (T1, T2)
- •Radical Prostatectomy
- •EBRT
- •IMRT
- •Brachytherapy
- •Treatment for Locally Advanced Prostate Cancer (T3, T4)
- •EBRT with ADT
- •Radical Prostatectomy
- •Androgen-Deprivation Therapy
- •Summary
- •References
- •39: The Management of Testis Cancer
- •Presentation and Diagnosis
- •Serum Tumor Markers
- •Primary Surgery
- •Testis Preserving Surgery
- •Risk Stratification
- •Surveillance Versus Primary RPLND
- •Primary RPLND
- •Adjuvant Treatment for High Risk
- •Clinical Stage 1 Seminoma
- •Risk-Stratified Adjuvant Treatment
- •Adjuvant Radiotherapy
- •Adjuvant Low Dose Chemotherapy
- •Primary Combination Chemotherapy
- •Late Toxicity
- •Salvage Strategies
- •Conclusion
- •References
- •Index
22
Prostatitis and Male Chronic Pelvic
Pain Syndrome
J. Curtis Nickel
Introduction
Our management of the clinical prostatitis syndromes has evolved significantly from the days of organ centric therapy for prostate infe ction and inflammation. It was only a decade or so ago when prostatitis seemed easy to under stand and for the most part simple to manage. Traditionally, prostatitis involved acute or chronic inflammation of the prostate gland, either bacterial or nonspecific. Our treatment lay then, in eradicating offending organisms and reducing inflammation. Despite new and improved antimicrobials and antiinflammato ries, we realize that the prevalence and burden of prostatitis is as bad today as it was before these pharmacological agents were even dis covered.1 Physicians have become discouraged and patients frustrated by our lack of clinical success. The good news is that our improved understanding of the etiology, pathogenesis, and epidemiology of the prostatitis syndromes has given us the tools to help the majority of patients who have failed our traditional approach of antibiotics and antiinflammato ries.2,3 This chapter will present important epidemiological data, explain our new under standing of the etiological processes involved, help classify and diagnose patients, outline the new evidence from clinical treatment trials and finally give the reader a blueprint for a therapeutic algorithm that works in clinical practice.
The Prostatitis Syndromes
In the past, most discussion of the prostatitis syndromes centered on acute and chronic bac terial prostatitis, welldefined diseases that could be objectively evaluated with laboratory cultures of urine and prostatic secretions and treated with antibiotics. Very little was dis cussed, written, or researched about abacterial prostatitis or prostatodynia, nebulous clinical entities that were referred to by many as the “waste basket of urological diagnoses.” These traditional diagnostic terms should now be abandoned in favor of the more accepted con temporary diagnostic terminology. The NIH classification of the prostatitis syndromes has been available now for over a decade and is the foundation of our clinical evaluation and treat ment.4 Table 22.1 describes the details of this classification system. In summary, Category I refers to patients with an acute bacterial infec tion of the prostate, Category II to patients with a chronic infection of the prostate while Category III refers to the vast majority of pros tatitis patients in whom a bacterial infection cannot be documented. Category III has been further subdivided into an inflammatory sub category (IIIA) and a noninflammatory subcat egory (IIIB). Category IV, or asymptomatic inflammatory prostatitis, is not a symptomatic clinical syndrome (diagnosis based on the find ing of asymptomatic inflammation localized to the prostate) and will not be addressed in this
C.R. Chapple and W.D. Steers (eds.), Practical Urology: Essential Principles and Practice, |
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DOI: 10.1007/978-1-84882-034-0_22, © Springer-Verlag London Limited 2011 |
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Table 22.1. national institutes of Health classification system for the prostatitis syndromes
Category |
Description |
Presentation |
category i |
acute infection of the prostate gland |
acute febrile illness associated |
acute bacterial |
|
with perineal and suprapubic pain, |
prostatitis |
|
dysuria and obstructive voiding |
|
|
symptoms |
category ii |
chronic infection of the prostate |
recurrent urinary tract infections |
chronic bacterial |
|
(usually with the same organism) |
prostatitis |
|
associated frequently with voiding |
|
|
disturbancesa |
category iii |
chronic genital urinary pain in the |
chronic prostatitis/ |
absence of uropathogenic bacteria |
chronic pelvic pain |
localized to the prostate gland |
syndrome (cP/cPPs) |
employing standard methodologya |
category iiia |
significantb number of white blood cells in |
inflammatory cP/cPPs |
expressed prostatic secretions, post prostatic |
|
massage urine sediment (VB3) or semen |
category iiiB |
insignificantb number of white blood cells in |
non-inflammatory |
expressed prostatic secretions, post prostatic |
cP/cPPs |
massage urine sediment (VB3) or semen |
chronic perineal, suprapubic, groin, testicular, penile, ejaculatory pain associated with variable dysuria and obstructive and irritative voiding symptoms
athere is still discussion and controversy on how to classify men with chronic symptoms,no history of Uti,but uropathogenic bacterial localization to prostate specific specimens.
bthere is no consensus on what constitutes significant (or conversely insignificant) number of white blood cells.
chapter (although Category IV is an extremely interesting condition).
The Scope of the Problem
No matter how you look at the epidemiology of prostatitis, there is no getting away from the fact that it is very prevalent and results in a signifi cant impact on patients’ quality of life and costs to society as a whole. The prevalence and inci dence issue can be examined from a number of view points: we can look at the number of patients diagnosed with prostatitis based on outpatient visit diagnoses or billing data, sur veys based on patient’s recollections of a diag nosis of prostatitis or determine the prevalence of patients suffering from symptoms that sound like prostatitis (but not necessarily diagnosed). Amongst North American adult males, 4–16% have either a physician or patient selfreported diagnoses of prostatitis, being one of the most common outpatient diagnoses in urology.57 In fact it is the most common outpatient diagnosis in men under 50 years of age in urologic prac tice.8 The prevalence for men in the community
experiencing chronicprostatitislike symptoms ranges from 6.5% to 12%, with moderate symp toms ranging from 2% to 6%.7,912 The impact of these diagnoses and/or these prostatitis symp toms is usually underestimated. In fact, the qual ity of life of a patient with a chronic prostatitis syndrome rivals that of a patient with active Crohn’s disease, severe diabetes and/or conges tive heart failure.13,14 Biopsychosocial parame ters such as depression, stress, anxiety, social maladjustment and poor coping behaviors not only exacerbate symptoms but are also associ ated with poorer quality of life.1517 The direct costs to society, in terms of medical care, is also enormous, more than that required for patients with rheumatoid arthritis, amounting to mil lions of dollars a year in North America alone.18 The indirect costs (in terms of work and pro ductivity loss) may be incalculable.
The Etiology of the Prostatitis
Syndromes
Category I and II: These categories are associated with acute (Category I) infection and chronic
297
Prostatitis and MalE cHronic PElVic Pain syndroME
infection (Category II) of the prostate with |
lar dysfunction or immunologic reaction can |
|
uropathogenic organisms, usally Enterobacteria |
progress because of persisting initiating factors |
|
ceae sp. (particularly E. coli but also Klebsiella sp., |
(persistence of bacteria, dysfunctional voiding, |
|
Pseudomonas sp.and other Enterobacteriaceae sp.) |
anatomic variance of prostate ducts or perineal |
|
and occasionally gram positive Enterococci sp.19 |
trauma) or the pathology could persist even with |
|
Category II is associated with similar organisms |
eradication or amelioration of these factors |
|
but there is some evidence that other organisms |
through self perpetuating stimulatory loops |
|
such as Chlamydia sp., Mycoplasma sp. and per |
(inflammation by autoimmune mechanism while |
|
haps even anaerobic bacteria, Corynebacterium sp. |
peripheral neuropathy can progress because of up |
|
and in some specific cases (such as immunocom |
regulation of the local pelvic neuroloop and“wind |
|
promised patients) fungi, viruses, etc. may also be |
up” of the spinal cord). The patients who suffer |
|
involved.20 In both categories, lower urinary tract |
from chronic prostatitis for many months or |
|
infection is associated with the acute exacerbation |
many years eventually develop a typical neuro |
|
of symptoms (and in the case of Category I, per |
pathicpainpattern,associatedwithlocalmuscular |
|
haps even urosepsis). Effective treatment usually |
dysfunction. This process is further influenced by |
|
eradicates the offending organism in Category I, |
supratentorial CNS mechanisms such as depres |
|
but in Category II,the patient may continue to have |
sion and maladaptive coping behaviors.23 |
|
a prostate nidus of infection resulting in the typical |
|
|
clinical picture of recurrent lower urinary tract |
The Diagnosis of the Prostatitis |
|
infections with the same organism. Some patients |
||
|
||
suffering from these recurrent episodes of infec |
Syndrome |
|
tion may develop symptoms between acute epi |
||
sodes or may progress to Category III with chronic |
Category I: Acute bacterial prostatitis patients |
|
symptoms, negative cultures and no improvement |
||
with antibiotics. |
present with lower urinary tract infection symp |
|
Category III: By definition, these patients do |
toms (dysuria, urgency, frequency, suprapubic |
|
not have urinary tract infections.There is still dis |
pain/discomfort, hematuria), varying degrees of |
|
agreement among experts on how to classify |
urinary obstructive voiding symptoms (includ |
|
patients who do not have infection (or recurrent |
ing acute urinary retention) and generalized |
|
urinary tract infections), but uropathogenic bac |
symptoms such as fever.19 On physical examina |
|
teria are localized to the prostate during evalua |
tion the patient is usually uncomfortable, may |
|
tion.2,20 The reason for this controversy is the fact |
be feverish, a tender bladder may be palpable, |
|
that normal asymptomatic control men localize |
the prostate is usually soft (often referred to as |
|
such bacteria to the prostate gland in similar |
“boggy”) and usually exquisitely tender. The |
|
prevalence as patients clinically categorized as |
white count may be elevated and white cells will |
|
Category III CP/CPPS.21 Similarly, CP/CPPS does |
be present in the urine (or evidence of infection |
|
not necessarily imply inflammation in the pros |
on dipstick examination). Urine culture and in |
|
tate (histological prostatitis). In fact, there is little |
cases where the patient is clinically septic, blood |
|
correlation between prostate inflammation and |
culture are procured, but therapy is initiated |
|
symptoms in this condition and it is now recog |
immediately. An ultrasound or bladder scan |
|
nized that patients without symptoms may have |
may be indicated to determine if the patient is in |
|
prostate inflammation (Category IV).21 It is |
acute urinary retention.23 |
|
becoming quite evident that the symptom com |
Category II: Chronic Bacterial Prostatitis is |
|
plex associated with Category III CP/CPPS is not |
traditionally associated with recurring or relaps |
|
secondary to a single defined etiologic agent but |
ing lower urinary tract infection, usually with |
|
is rather a syndrome consisting of a continuous |
the same organism and usually without clinical |
|
spectrum, initiated and propagated by multiple, |
sepsis.2,20,23 The patient may or may not be symp |
|
and likely interrelated factors.22,23 The initiators |
tomatic between episodes of treated infection. If |
|
could be infection, high pressure dysfunctional |
symptomatic, the symptoms may be indistin |
|
voiding, trauma or some unknown toxin in a |
guishable from those of patients with Category |
|
genetically or anatomically susceptible man. This |
III. This category is suspected in men with |
|
initiating event results in either injury and/or |
relapsing symptoms associated with bacteriuria |
|
inflammation. The initial neuropathy, muscu |
who experience improvement in symptoms with |
|
|
298 |
|
|
|
|
|
Practical Urology: EssEntial PrinciPlEs and PracticE |
antibiotic therapy. The optimal time to make the |
clinical trials in CP/CPPS.28 Nine separate |
|
diagnosis is between episodes of acute exacerba |
items that could be answered by most patients |
|
tions employing some form of lower urinary |
in about 5 min addressed all these important |
|
tract localization study. The traditional tech |
issues. The 6 major locations or type of pain or |
|
nique to localize infection to the prostate gland |
discomfort, the frequency of pain or discom |
|
was the MearesStamey 4glass test24 which |
fort and the severity of pain or discomfort are |
|
included culture of the first initial voided urine |
rated on a scale of 0–21. The irritative and |
|
(voided bladder 1 or VB1), the midstream urine |
obstructive voiding symptoms are rated on a |
|
(voided bladder 2 or VB2), expressed prostatic |
score of 0–10 while the impact on quality of life |
|
secretion (EPS) obtained following prostate |
is rated on a score of 0–12. Each of these |
|
examination and the initial stream urine speci |
domains can be assessed independently or the |
|
men collected after prostate massage (voided |
3 can be added together for a total NIHCPSI |
|
bladder 3 or VB3). If the colony count of uro |
score of 0–43. The CPSI is a valuable tool for |
|
pathogenic bacteria were significantly higher in |
the practicing physician to evaluate a patient at |
|
EPS and/or VB3 compared to VB1 and VB2, then |
initial presentation and to follow him over time |
|
a diagnosis of chronic prostate infection can be |
to assess treatment outcomes.29,30 The NIH |
|
made and patient classified as Category II. |
CPSI is presented in Fig. 22.1. |
|
However the 4glass test is cumbersome, expen |
A rather comprehensive evaluation routine |
|
sive, and most physicians, including urologists |
should be followed when assessing CP/CPPS |
|
have abandoned it.25 A simpler 2glass test |
patients, particularly during the initial visit.31 |
|
compares the bacterial culture results of the |
Physical examination may detect suprapubic, |
|
premassage urine (PreM or VB2) to the post |
perineal, prostate, pelvic floor or external geni |
|
massage urine specimen (postM or VB3).26 A |
talia discomfort or pain or it may be completely |
|
higher bacterial count in the PostM specimen |
noncontributory. The lower abdominal, genital, |
|
compared to the PreM specimen is indicative of |
perineal, rectal and focused neurogenic exami |
|
chronic prostate infection. This Pre and Post |
nations are primarily necessary to rule out other |
|
Massage test (PPMT) provides almost as accu |
causes for the patients’ symptoms. Urinalysis |
|
rate localization data as the more difficult 4glass |
and urine cytology (particularly important if |
|
test and can be easily employed in any clinical |
the patient has hematuria or irritative obstruc |
|
practice situation.27 |
tive voiding symptoms) are collected along with |
|
Category III: By definition chronic prostati |
the preM urine specimen. Following pelvic and |
|
tis/chronic pelvic pain syndrome (CP/CPPS) is |
prostate examination, prostate massage is |
|
associated with genitourinary and/or pelvic |
undertaken to produce either EPs or more easily |
|
pain with no evidence of infection.2,4 Patients |
a postM specimen of urine for culture. |
|
have one or more of perineal, ejaculatory, |
Microscopy of the EPS and/or PostM (VB3) |
|
penile, testicular, suprapubic and penile pain/ |
specimen can determine if the patient should be |
|
discomfort with variable irritative and/or |
classified as Category IIIA or IIIB, but at the |
|
obstructive voiding symptoms and perhaps |
present there is no clinical indication to actually |
|
some degree of associated sexual dysfunction. |
do this step since no clinical trial to date has |
|
Patients experience waxing and waning symp |
determined a differential treatment effect |
|
toms that are extremely bothersome and |
between these two categories.21,32 That may |
|
impact on activities. Since this category is a |
change in the future. If the patient is at an age |
|
syndrome defined by a symptom complex it is |
that prostate cancer is a possibility, a serum |
|
imperative that a comprehensive symptom |
prostate specific antigen (PSA) can be collected. |
|
inventory documenting the location, severity, |
Other urologic tests such as cystoscopy, urody |
|
frequency of the pain, any urinary symptoms |
namics and imaging (transrectal ultrasound, |
|
and impact on activities and quality of life is |
CAT scan, etc.) are optional and indications are |
|
undertaken. This can now be accomplished by |
based on specific findings from history, urinaly |
|
administering the NIH Chronic Prostatitis |
sis, cytology and physical examination. |
|
Symptom Index (CPSI), a validated and sensi |
Table 22.2 represents a suggested diagnostic |
|
tive symptom assessment tool developed for |
plan for the prostatitis syndromes. |
299
Prostatitis and MalE cHronic PElVic Pain syndroME
NIH-Chronic Prostatitis Symptom Index (NIH-CPSI)
Pain or Discomfort |
|
|
|
6. How often have you had to urinate again less than two |
|
1. In the last week, have you experienced any pain or |
|
|
hours after you finished urinating, over the last week? |
||
|
|
|
Not at all |
||
discomfort in the following areas? |
|
|
|
0 |
|
|
Yes |
No |
|
1 |
Less than 1 time in 5 |
a. Area between rectum and |
1 |
|
0 |
2 |
Less than half the time |
testicles (perineum) |
|
|
|
3 |
About half the time |
b. Testicles |
1 |
|
0 |
4 |
More than half the time |
c. Tip of the penis (not related to |
1 |
|
0 |
5 |
Almost always |
urination) |
|
|
|
Impact of Symptoms |
|
d. Below your waist, in your |
1 |
|
0 |
||
pubic or bladder area |
|
|
|
7. How much have your symptoms kept you from doing |
|
|
|
|
|
||
2. In the last week, have you experienced: |
|
|
|
the kinds of things you would usually do, over the |
|
a. Pain or burning during |
Yes |
No |
|
last week? |
|
1 |
|
0 |
0 |
None |
|
urination? |
|
|
|
||
b. Pain or discomfort during or |
1 |
|
0 |
1 |
Only a little |
after sexual climax (ejaculation)? |
|
|
|
2 |
Some |
|
|
|
|
3 |
A lot |
3. How often have you had pain or discomfort in any of these areas over the last week?
8. How much did you think about your symptoms, over the last week?
0 Never
1 Rarely
2 Sometimes
3 Often
4 Usually
5 Always
4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week?
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
NO |
|
|
|
|
|
|
|
|
PAIN AS |
|
PAIN |
|
|
|
|
|
|
|
BAD AS |
||
|
|
|
|
|
|
|
|
|
YOU CAN |
|
|
|
|
|
|
|
|
|
|
IMAGINE |
Urination
5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?
0 Not at all
1 Less than 1 time in 5
2 Less than half the time
3 About half the time
4 More than half the time
5 Almost always
0 None
1 Only a little
2 Some
3 A lot
Quality of Life
9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?
0 Delighted
1 Pleased
2 Mostly satisfied
3 Mixed (about equally satisfied and dissatisfied)
4 Mostly dissatisfied
5 Unhappy
6 Terrible
_____________________________________________________
Scoring the NIH-Chronic Prostatitis Symptom Index
Domains
Pain: Total of items 1a, 1b, 1c, 1d, 2a, 2b, 3, and 4 = ____
Urinary Symptoms: Total of items 5 and 6 |
= ____ |
Quality of Life Impact:Total of items 7, 8, and 9 |
= ____ |
Figure 22.1. the national institutes of Health chronic Prostatitis symptom index (niH-cPsi) captures the three most important domains of the prostatitis experience: pain (location, frequency
and severity), voiding (irritative and obstructive symptoms) and quality of life (including impact).this index is useful in research studies and clinical practice28 (reprinted with permission).
300
Practical Urology: EssEntial PrinciPlEs and PracticE
Table 22.2. Evaluation of a man presenting with a Prostatitis or cPPs syndrome |
|
|
||
Recommendation |
Evaluation |
Cat I |
Cat II |
Cat III |
Mandatory (all patients) |
History |
+ |
+ |
+ |
|
Physicala |
+ |
+ |
+ |
|
Urinalysis |
+ |
+ |
+ |
|
Urine culture |
+ |
+ |
+ |
|
Blood culture |
+/−b |
− |
− |
recommended (most patients) |
localization culture c |
− |
+ |
+ |
|
cPsi |
− |
+/−c |
+ |
|
Flow rate |
− |
+/−c |
+ |
|
residual urine |
+ |
+/−c |
+ |
|
Urine cytology |
− |
− |
+ |
optional (selected patients) |
Pressure/flow |
− |
−/+ c |
+ |
|
Videourodynamics |
− |
− |
−/+ |
|
Urethral culture |
− |
− |
+ |
|
semen culture |
− |
+ |
+ |
|
cystoscsopy |
− |
+/−c |
+ |
|
imagingd |
+ |
+ |
+ |
|
Psa |
− |
− |
+ |
aincludes digital rectal Examination. bif patient has urosepsis.
cshould be considered in patients with chronic symptoms between Utis, exacerbations or failure to respond to antibiotic therapy. dtransrectal ultrasound, abdominal and/or pelvic ultrasound, cat scan, Mri.
Treatment of the Prostatitis
Syndromes
The Bacterial Prostatitis Categories
(Categories I and II)
The treatment of the two bacterial categories (I and II) are easier to formulate and results more predictable and therefore these two syndromes will be discussed separately from the much more difficult to manage Category III CP/CPPS. Both categories I and II are associated with bacterial infection in the prostate with uropathogenic bac teria. The role of therapy is to eradicate the bac teria, ameliorate the symptoms and prevent recurrence (not always possible for Category II).
For Category I acute bacterial prostatitis, wide spectrum antibiotics (if septic, parenteral is the
preferred route) are indicated. The best drugs are either a combination of penicillin (e.g. ampi cillin) and an aminoglycoside (e.g. gentamicin), second or third generation cephalosporins or one of the fluoroquinolones.19,23,33 If the patient is in urinary retention, then insertion of a small caliber foley catheter will be required and depending on the situation can be left indwell ing until the acute infection has resolved. If the foley catheter is too uncomfortable and the patient requires continued bladder drainage, then a small suprapubic catheter can be inserted. Once the patient’s condition improves, treat ment can be switched to oral antibiotics (prefer ably based on culture and sensitivity results). The most effective are the fluoroquinolones (with ciprofloxacin and levofloxacin being more effective than ofloxacin and all being more effec tive than norfloxacin) with second line being trimethoprim (with or without sulfamethox