Two4 56 Prostatitis and related pain conditions Orchitis and Epididymitis

  1. National Institutes of Health (NIH) classification of Prostatitis?
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  2. Acute bacterial prostatitis?
    Peak age - 20-40 years, second peak at age >60 yrs 

    Etiology - ascending urethral infection, prostate biopsy, intraprostatic reflux of urine in prostate, hematogenous spread 

    Risk factors -   unprotected sexual intercourse, pimosis, condom catheter use, indwelling urethral catheters, and urinary tract  instrumentation, and prostate biopsy, urethral strictures, BPH 

    • Clinical features
    • - UTI, frequency, dysuria, fever, malaise 
    • - Urinary retention - because of swelling of prostate, pain or spasm of the bladder neck 
    • - Sepsis in severe case 

    • Microbiology 
    • - Most common causative organism - Escherichia coli, other organisms are pseudomonas, proteus

    • Evaluation 
    • - DM, HIV, neurological disese evaluation
    • - truly “boggy” prostate from edema from inflammation, prostate is tender and swollen Caution should be used to avoid aggressive palpation that could lead to bacterial dissemination and sepsis. Prostate massage should not be done in acute setting 
    • - CBC, culture (blood and urine) 
    • - PSA testing not recommended in acute setting 
    • - If abscess suspected - TRUS or CT 

    • Treatment 
    • - EAU - broad-spectrum penicillin, third-generation cephalosporin, or a fluoroquinolone. In initial therapy, any of these can be combined with an aminoglycoside
    • - After transrectal biopsy, resistance to quinolones and the incidence of ESBL bacteria  is high. Use a carbapenem antibiotic. AUA - patients who have a fever after prostate biopsy should: 
    • • Not be offered fluoroquinolones or TMP-SMX
    • • Be managed with aggressive resuscitation and broad- pectrum antibiotic coverage: carbapenems, amikacin, or second- and third generation cephalosporins (after urine and blood cultures)
    • Once fever has been subsided, fluroquinolones can be used on discharge, if bacteria is susceptible fluroroquinolone. 
    • Repeat culture after one week to make sure bacteria has been cleared.
    • 2 week antibiotic is enough to prevent chronic infection. 4 week is not required

    Adjunct therapy - NSAIDS, alpha blockers, SPC drainage may help
  3. Management of prostatic abscess?
    Risk factors - DM, HIV, immunosuppression, who do not respond to therapy in initial 48 hours 

    Imaging - USG, CT 

    • Treatment 
    • - 1-2 cm - antibiotics 
    • - Peripheral localized lesions that do not improve on medications - TRUS guided drainage 
    • - Those who do not respond on drainage, too large lesions - TURP and unroof of the abscess
  4. Chronic bacterial prostatitis?
    Chronic bacterial prostatitis is characterized by recurrent urinary tract infections with the same organism. 

    • Symptoms -
    • - dysuria, pain that generally respond on antibiotic treatment 
    • - Unlike men with CP/CPPS, they are relatively asymptomatic between episodes 

    Microbiology - E coli, pseudomonas, proteus, role of chlamydia is still controversial

    • Diagnosis 
    • - Perform the Meares and Stamey 2- or 4-glass test in patients with CBP. Strong EAU 2020 
    • - DRE, external genitalia examination 
    • - Rule out urethral stricture 
    • -  Do not routinely perform microbiological analysis of the ejaculate alone to diagnose CBP.Weak  EAU 2020

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    • Treatment 
    • - The treatment of category II prostatitis is limited to antibiotics that can penetrate  the prostate and achieve therapeutic levels
    • - Quinolones have excellent prostate penetration. Prescribe a fluoroquinolone (e.g. ciprofloxacin, levofloxacin) as first-line treatment for CBP for 4-6 weeks. Strong EAU 2020.
    • - Prescribe a macrolide (e.g. azithromycin) or a tetracycline (e.g. doxycycline) if intracellular bacteria have been identified as the causative agent of CBP. Strong EAU 2020.
    • - If resistant to fluoroquinolones, Piperacillin/Tazobactam, Fosfomycin are given.
    • - Prescribe metronidazole in patients with Trichomonas vaginalis CBP. Strong EAU 2020.
    • - For refractory cases, daily suppressive antibiotics dose or TURP can be used
  5. Describe chronic prostatitis and discuss its diagnosis and treatment. (TU 72-10)

    Aetiology of Chronic Prostatitis/Chronic Pelvic Pain Syndrome?
    • Infection 
    • Inflammation 
    • Neurologic Causes 
    • Pelvic Floor Dysfunction 
    • Psychosocial factors 
    • Endocrine abnormalities 
    • Genetics
  6. Diagnosis of CP/CPPS syndrome?
    • • CP/CPPS is a diagnosis of exclusion and should be made only after a thorough search for other causes of pelvic pain.
    • • CP/CPPS has potential issues outside of the pelvis (and usual scope of urology) such as psychological issues and neurologic problems.
    • • Patients with CP/CPPS must be assessed for other chronic pain syndrome such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome.
    • • Patients with tenderness on pelvis examination may benefit from pelvic floor physical therapy/myofascial release.
    • • Therapy for CPPS is best done in a multimodal fashion; the symptom classification UPOINT can be helpful in directing evaluation and subsequently therapy.
  7. Treatment of CP/CPPS?
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    • Antibiotics -
    • EAU: antimicrobial therapy (quinolones or tetracyclines) over a minimum of 6 weeks in treatment-naïve patients with a duration of CPPS less than 1 year. A repeated course of antibiotic therapy (4 to 6 weeks) should be offered if a bacterial source is confirmed or if there is a partial response to the first course.  Repeated courses of antibiotics in the absence of a positive urine culture is not accepted therapy.

    • Conservative therapy 
    • - Lifestyle changes and diet and exercise 
    • - stress management 
    • - acupuncture 

    • Minimally Invasive Therapy 
    • - Pelvic floow physiotherapy and skeletal muscle relaxants 
    • - Botulinum toxins 
    • - Prostate massage 

    • Prostate specific treatments 
    • - Local hyperthermia and needle ablation 
    • - Intraprostatic injection of botulinum toxins 

    • Surgical therapy
    • - Bladder neck incision if bladder neck hypertrophy 
    • - Cystosocopy and fulguration of hunner ulcers 
    • - Neurostimulation
  8. Clinical features of acute epididymitis?
    Acute epididymitis represents sudden occurrence of pain and swelling of the epididymis associated with acute inflammation of the epididymis.

    • Organism  
    • - E. coli - age >35 years, children 
    • - Chlamydia trachomatis and Neisseria gonorrhoeae - In sexually active men with age < 35 years

    • Clinical features 
    • - Pain and swelling. Swelling usually starts at the cauda of the epididymis and then ascends to reach the rest of the epididymis and then to the testis.
    • - Presentation is usually unilateral 
    • - Fever
    • - Epididymal abscess
    • - Dysuria
  9. Treatment of acute epididymitis?
    The management goal is to relieve inflammation and any associated infection.

    • To relieve inflammation
    • - use of ice packs, NSAIDS, scrotal elevation, and rest to avoid traumatic exacerbation.
    • - In the absence of UTI, symptoms improve spontaneously without antibiotics.
    • - In the presence of pyuria, broad-spectrum antibiotics

    Treatment: CDC guidelines divide this into three groups

    a) likely caused by STD - ceftriaxone 250 mg in single IM dose plus doxycycline 100 mg orally twice per day for 10 days

    b) likely caused by STD and enteric organism (men who practice insertive anal sex) - ceftriaxone 250mg IM single dose plus levofloxacin 500 mg PO daily for 10 days is substituted for doxycycline

    c) likely only caused by enteric organisms - levofloxacin (or ofloxacin) alone is recommended

    If gonorrhoeal infection is likely give single dose ceftriaxone 500 mg intramuscularly in addition to a course of an antibiotic active against C. trachomatis.Strong EAU 2020

    • [@ STD - Ceftriaxone 250 IM single+Doxy10
    • STD/Enteric - Ceftriaxone + Levo 10
    • Enteric - Levo]

    Men with confirmed chlamydia or gonorrhea should also be tested for other STDs including HIV, and their sex partners should also be referred for evaluation and presumptive  treatment

    Follow up - Men whose symptoms do not resolve within 72 hours be re-evaluated. Follow-up ultrasound may be needed in patients who are not clinically responding to rule out  progression of an infection to an abscess or testicular infarction, which would require surgical treatment.
  10. Treatment of Chronic epididymitis?
    Chronic epididymitis refers to inflammation and pain in the epididymis, usually without swelling (but with induration in long-standing cases), persisting for over 6 weeks. C11-331

    • Classification - 
    • a) Inflammatory - infective from chlamydia, postinfective after acute bacterialepididymitis, granulomatous from tuberculosis, drug-induced from amiodarone 
    • b) Postobstructive - congenital, acquired, or iatrogenic obstruction, such as postinfective or postsurgical, including postvasectomy
    • c) Chronic epididymyalgia

    • Treatment - 
    • - Conservative measures
    • - Rule out a malignancy
    • - Scrotal support and warm compresses may be beneficial.
    • - Antibiotics, anti-inflammatories, phytotherapy, and anxiolytics.
  11. What is Chronic orchalgia?
    • Chronic orchalgia or chronic scrotal content pain or chronic post -vasectomy pain is
    • - >3 months of pain
    • - no definable pathology on examination or scrotal ultrasound
    • - refractory to conservative treatment options
    • CSP is seen in about 2.5-4.8% of all urology visits
  12. Treatment of Chronic Scrotal Pain?
    • Minimally Invasive Treatments
    • 1. Pelvic Floor Physical Therapy - pelvic floor PT should be considered in men with orchlgia and abnormal tone on digital rectal examination.
    • 2. Botox. Local cord denervation with onabotulinumtoxin A (Botox) has been used for chronic scrotal pain.
    • 3. Pulsed Radiofrequency of the Spermatic Cord. Pulsed radiofrequency has been performed for chronic back pain and sciatica, as well as for chronic visceral pelvic pain

    • Surgical Therapy
    • 1. Surgical Therapy for Orchalgia in Patients With Identifiable Intrascrotal Lesions - Patients can present with pain that appears to be localized to specific lesions (i.e., a varicocele or spermatocele). Patients can also have surgery for intermittent torsion.
    • 2. Vasovasostomy or Vasoepididymostomy for Treatment of Postvasectomy Pain
    • 3. Microsurgical Denervation of the Spermatic Cord - transecting the nerves in the spermatic cord, while preserving the blood supply and lymphatics to prevent formation of a hydrocele
    • 4. Epididymectomy for Chronic Pain - Better rates are reported in cases with incorporation of the distal portion of the vasectomy site with the epididymectomy specimen
    • 5. Orchiectomy for Chronic Scrotal Pain
    • 6. Persistent testicular pain after inguinal hernia repair - genital branch of the genitofemoral nerve at the external ring is identified and neuroma is resected, and the proximal end of the nerve is placed in the pelvis

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Two4 56 Prostatitis and related pain conditions Orchitis and Epididymitis