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B.
Evaluate if the pain of bladder lling is partially or com-
12: GENITOURINARY GUIDELINES
pletely relieved by voiding.
C.
Does the client void frequently in order to maintain a low
bladder volume and avoid discomfort versus voiding frequently to avoid urge incontinence (OAB)?
D.
Are there any OAB triggers (e.g., citrus, beer, coffee) that
exacerbate symptoms?
E.
Are symptoms increased after stress, exercise, intercourse,
being seated for a long period, or during the menstrual cycle?
F.
How much do the symptoms affect the client’s quality of
life (e.g., sleep disturbance, loss of work, avoiding activities)?
G.
Does the client have any other chronic pain syndromes
such as IBS, chronic fatigue, dyspareunia, or bromyalgia?
H.
Review the client’s surgical history and history of genito-
urinary (GU) cancers.
I.
Is there any GU trauma or falls onto the coccyx?
J.
Review the client’s history of UTIs, urinary retention, and
urinary tract stones.
K.
Review all medications including over-the-counter and
herbal products.
L.
Administer a pain/symptom evaluation tool at each visit.
1.
The Pelvic Pain and Urgency/Frequency Patient
Symptom Scale (PUF) is available at www.ichelp.org/
wp-content/uploads/2015/06/PUF_Questionnaire.pdf.
2.
The Interstitial Cystitis Symptom Index (ICSI) is
available at https://www.goldjournal.net/article/
s0090-4295(99)80333-1/pdf.
PHYSICAL
A.
Check temperature (if indicated to rule out infection; fever
EXAMINATION
is not associated with IC) and blood pressure.
B.
Inspect:
1.
Note general appearance for signs of depression and
discomfort before and during examination.
2.
Inspect the male external genitalia for redness, edema,
lesions, and discharge.
3.
Inspect female genitalia for discharge, lesions, ssures;
inspect cervix for cervicitis.
4.
Perform pelvic exam to test pelvic oor muscles to
determine if any of the pain is related to spasms.
C.
Auscultate:
1.
Heart and lungs.
2.
Bowel sounds in all four quadrants.
D.
Palpate:
1.
Palpate back; note costovertebral angle (CVA) tenderness.
2.
Palpate the abdomen for suprapubic tenderness,
rebound masses, or pain.
3.
Perform bimanual examination to rule out other infec-
tions and pelvic inammatory disease (PID; tenderness of
the cervix, uterus, and adnexa should be absent). During
the pelvic examination, evaluate locations of tenderness
and trigger points.
4.
In males, complete palpation of external genitalia,
prostate, and rectal examination.
E.
Percuss:
1.
Bladder.
2.
Back for CVA tenderness.
F.
Perform neurologic exam:
1.
Perform a limited neurologic examination to rule out
an occult problem.
DIAGNOSTIC
A.
Urinalysis with microscopy to exclude hematuria.
B.
Urine culture and sensitivity may be ordered even with a
TESTS
negative urinalysis to evaluate low levels of bacteria.
C.
Postvoid residual volume by straight catheter or
ultrasound.
D.
Urodynamic testing is not currently considered to have a
role in the diagnosis of IC/PBS; however, urodynamic testing
should be used for complex presentations.
E.
Cystoscopy is usually reserved for gross or microscopic
hematuria.
F.
Hydrodistention is not required for diagnosis or treatment.
G.
Bladder biopsy is not required for diagnosis; however, it is
used for exclusion of other disorders.
H.
The potassium sensitivity test is not recommended for
routine use as results are nonspecic for IC/PBS.
DIFFERENTIAL
A.
UTI.
B.
IBS.
C.
Females:
1.
Endometriosis.
2.
Vulvodynia.
D.
Males:
1.
Chronic prostatitis.
2.
Benign prostatic hypertrophy.
DIAGNOSES
PLAN
A.
General interventions:
1.
Behavior modications are recommended. Restrict
uids to 64 oz/d, divided into 16 oz per meal and 8 oz
between meals.
2.
Progressively timed voiding on a 2- to 3-hour schedule.
If the client is unable to hold urine for this interval, progressively increase urine storage time between void by
15 minutes per week until the goal of a 2- to 3-hour interval is reached.
3.
Kegel exercises should be avoided with IC.
4.
Psychosocial support is an integral part of chronic pain
disorders.
5.
Pelvic oor therapy helps strengthen pelvic oor
muscles.
B.
Client teaching:
1.
Several foods have been identied as bladder irritants,
including foods rich in potassium. Clients may try to eliminate foods/drinks and reintroduce them one at a time
to identify any items that make their symptoms worse.
Examplesinclude:
a.
Alcohol.
b.
Tomatoes.
c.
Spices/spicy foods.
d.
Chocolate.
e.
Caffeinated beverages.
f.
Coffee.
g.
Articial sweeteners.
h.
Citrus: lemons, limes, and oranges (including
citrus-avored beverages).
i.
Cranberries/cranberry juice.
C.
Pharmaceutical therapies:
1.
Pentosan polysulfate sodium (Elmiron) is the only
oral medication approved by the Food and Drug
Administration (FDA) for treatment of IC.
a.
Dosage: 100mg orally TID.
2.
Amitriptyline (Elavil) is used in the treatment of other
pain syndromes, including IC. A self-titrated dose of
25mg orally every night may be used and increased in
increments of 25mg every week to a maximum dose of
100mg orally per day.
3.
Bladder instillation:
a.
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Intravesical dimethyl sulfoxide (DMSO; Rimso-50)
is the only drug approved by the FDA for bladder
instillation.
b.
Heparin instillation.
c.
Lidocaine instillation.
d.
“Bladder cocktail” combination of sodium bicar-
bonate, heparin, lidocaine, and/or triamcinolone; there
are various formulas/combinations.
4.
Medications may be instituted for treatment of any
comorbid depression.
5.
Medications may be instituted for treatment of any
comorbid infections (e.g., UTIsand sexually transmitted
infections), inammatory bowel disease, or endometriosis.
6.
Other medications that have been used for symptom-
atic reliefinclude:
a.
Hydroxyzine hydrochloride (Vistaril, Atarax) 25 to
75mg orally at bedtime.
b.
Gabapentin 300mg up to 2,400mg in divided doses;
requires careful dose titration due to sedation.
c.
Uro-Blue medications for short-term bladder
spasms.
d.
Nonsteroidal anti-inammatory drugs.
7.
Cyclosporine A has been used when other treatments
have not provided relief or control of symptoms.
D.
Intradetrusor botulinum toxin A (BTX-A) therapy may
require posttreatment intermittent self-catheterization.
E.
Laser or electrocautery may be doneif Hunner ulcers are
present.
F.
Surgical options are available if all other therapies have
failed.
G.
Therapies that are not recommended/should not be
offered include:
1.
Long-term antibiotics.
2.
High-pressure, long-duration hydrodistention.
3.
Systemic steroids.
4.
Intravesical resiniferatoxin (ultrapotent capsaicin
analog).
5.
Intravesical Bacillus Calmette-Guérin (BCG).
6.
Potassium sensitivity testisnot recommended for rou-
tine use. It is nonspecic and is a painful test.
FOLLOW-UP
A.
Allodynia, the perception of nonnoxious stimuli, such as
touch being noxious or painful, may be present; therefore, an
adequate pelvic examination may not be possible. Consider
empiric treatment and have the client return for a pelvic
examination to nish evaluation.
B.
Have the client keep a 1-day bladder diary before visits to
evaluate a pattern of low urine volume frequency characteristic of IC/PBS.
C.
As with all medications, start at the lowest dose and titrate/
increase doses if there is an improvement in symptoms.
CONSULTATION/REFERRAL
A.
Refer to a urologist for more thorough workup and testing.
B.
Refer to a pain management specialist if indicated.
C.
Electrical stimulation therapy may be considered. The
implanted sacral neuromodulation device is FDA-approved
for treatment of urinary urgency and frequency but not specically for treatment of IC/PBS.
INDIVIDUAL
A.
Pediatrics:
1.
CONSIDERATIONS
The evaluation for IC is essentially the same in children
as it is for adults.
PROSTATITIS
2.
Treatment options are similar to those discussed,
459
including dietary modications and self-help strategies.
RESOURCES
Adult
Pediatric Urology & Urogynecology: www.adultpe-diatricuro.com
American
International
Interstitial
Interstitial
Pelvic
Urological Association (AUA): www.auanet.org
Painful Bladder Foundation: www.painful-bladder.org
Cystitis Association (ICA): www.ichelp.org
Cystitis Network: www.ic-network.com
Pain and Urgency/Frequency Patient Symptom Scale: https://www.
ichelp.org/wp-content/uploads/2015/06/PUF_Questionnaire.pdf
Society
of Urodynamics, Female Pelvic Medicine & Urogenital
Reconstruction: www.sufuorg.com
BIBLIOGRAPHY
American Urological Association. (2014). Diagnosis and treatment of inter-
stitial cystitis/bladder pain syndrome. https://www.auanet.org/educati
on/guidelines/ic-bladder-pain-syndrome.cfm
Cepeda, M. S., Reps, J., Sena, A. G., & Ochs-Ross, R. (2019). Risk factors for
interstitial cystitis in the general population and in individuals with
depression. International Neurourology Journal, 23(1), 40–45. https://
doi.org/10.5213/inj.1836182.091
Chen, W.-C., Lee, M.-H., & Wu, H.-C. (2017). Relationship among symp-
toms, mood, and personality traits in patients with interstitial cystitis/
bladder pain syndrome. Urological Science, 28(3), 147–151. https://doi
.org/10.1016/j.urols.2016.05.003
Clemens, J. Q. (2017, October 17). Pathogenesis, clinical features, and diag-
nosis of interstitial cystitis/bladder pain syndrome. UpToDate. https://
www.uptodate.com/contents/pathogenesis-clinical-features-anddiagnosis-of-interstitial-cystitis-bladder-pain-syndrome
Diagnosis of Interstitial Cystitis | NIDDK. (2017, July). National insti-
tute of diabetes and digestive and kidney diseases. https://www.niddk.
nih.gov/health-information/urologic-diseases/interstitial-cystitispainful-bladder-syndrome/diagnosis
PROSTATITIS
DEFINITION
A.
Prostatitis is acute or chronic infection of the prostate
gland. Prostatitis is the most important cause of urinary infection in males. Prostatitis constitutes about 2 million outpatient visits a year to urologists and primary care providers.
There are four types of prostatitis according to the National
Institutes of Health (NIH):
1.
Acute bacterial prostatitis (least common).
2.
Chronic bacterial prostatitis.
3.
Chronic prostatitis/chronic pelvic pain syndrome
(CP/CPPS; common in males of any age):
a.
Inammatory (presence of white blood cells [WBCs]
in the semen, expressed prostatic secretions [EPS], or
voided bladder urine postprostatic massage).
b.
Noninammatory (absence of white cells).
4.
Asymptomatic inammatory prostatitis.
INCIDENCE
A.
About 50% of adult males in the United States will be
treated for prostate conditions during their lifetime.
B.
Acute and chronic bacterial prostatitis occurs in about 1 in
10 males. About 5% of acute prostatitis cases progress to CP.
C.
Nonbacterial prostatitis occurs in about 6 in 10 males.
D.
Prostatodynia occurs in about 3 in 10 males.
PATHOGENESIS
A.
Nonbacterial prostatitis is an inammatory condition with an
unknown etiology. Infection results in prostatitis in four ways:
1.
Ascending infection of urethra.
2.
Reux of infected urine into the prostate through ejac-
ulatory and prostatic ducts that empty into the prostatic
urethra.
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3.
4.
12: GENITOURINARY GUIDELINES
Hematogenous spread, causing bacterial prostatitis.
Invasion by rectal bacteria by direct extension or lymph
system spread.
B.
Causative organisms: Escherichia coli, Klebsiella,
Pseudomonas, Enterococcus, Ureaplasma, Gardnerella vaginalis, Trichomonas vaginalis, Chlamydia trachomatis, Chlamydia,
Mycoplasma, or Neisseria gonorrhoeae; cytomegalovirus (CMV),
Mycobacterium tuberculosis, and fungi have all been associated
with prostatitis in HIV-infected clients.
C.
Incubation period depends on pathogen.
PREDISPOSING
A.
More common in younger and middle-aged males.
B.
Sexual transmission of bacteria.
C.
Neuromuscular dysfunction.
D.
Structural voiding dysfunction.
E.
Benign prostatic hypertrophy (BPH).
F.
History of allergies and asthma (increase in nonbacterial
FACTORS
prostatitis).
G.
Genetics.
H.
Ethnicity; more common in African Americans.
I.
Socioeconomic conditions.
E.
Prostatodynia (cause is unknown):
1.
Prostate irritation.
2.
Pain and discomfort in the prostate, testicles, penis,
and urethra.
3.
Difculty urinating.
SUBJECTIVE
A.
Ask the client to complete the National Institutes of
DATA
Health Chronic Prostatitis Symptom Index (NIH-CPSI)
self-evaluation form (Table 12.3). The assessment tool evaluates pain, urinary symptoms, and the impact on quality of life.
B.
Review the onset, duration, and course of symptoms.
C.
Are there any other symptoms, such as discharge, pain,
hematuria, hesitancy, back pain, or weight loss?
D.
Has the client ever had the same symptoms? If so, how
were they treated?
E.
Does any sexual partner(s) have any symptoms, lesions, or
known sexually transmitted infections (STIs)?
F.
Does the client engage in anal intercourse?
G.
Has the client noted any impaired urinary ow?
H.
Has the client required any recent urethral catheterization
or instrumentation?
COMMON
A.
B.
COMPLAINTS
Dysuria.
Perineal, rectal, or suprapubic pain (chronic pain
syndrome).
C.
Less urine ow.
D.
Spiking fever.
E.
Back pain.
F.
Sexual dysfunction.
OTHER
SIGNS AND SYMPTOMS
A.
Acute bacterial prostatitis:
1.
Fever and chills, malaise.
2.
Acute onset of dysuria.
3.
Hesitancy.
4.
Urinary frequency and low back pain.
5.
Pain with intercourse and with defecation.
6.
Initial or terminal hematuria and edema with acute
urinary retention.
7.
Arthralgia or myalgia.
8.
Nocturia.
B.
Chronic bacterial prostatitis:
1.
Usually presents with recurrent urinary tract infections
(UTI).
2.
May be asymptomatic between acute episodes; some
males have large uctuation in symptom severity.
3.
Perineal, inguinal, or suprapubic pain, or irritative
symptoms on voiding, such as frequency and urgency.
4.
Hematuria, hematospermia, or painful ejaculations.
5.
Prostatic calculi.
C.
Nonbacterial prostatitis (most common):
1.
Vague discomfort or increasing pain: prostatic, lower
back, perineum, groin, scrotum, or suprapubic pain; ejaculatory pain.
2.
Dysuria, urinary frequency, urgency, hesitancy, and
decreased urine ow.
3.
Penile discharge, especially noted during the rst
bowel movement of the day.
4.
Sexual difculty.
5.
Low sperm count.
6.
Blood or urine in ejaculate.
D.
Asymptomatic inammatory prostatitis is found when
looking for causes of infertility and testing for prostate cancer.
PHYSICAL
A.
Check temperature and blood pressure.
B.
Inspect:
EXAMINATION
1.
Examine the client generally for discomfort before and
during examination.
2.
Check the urethral meatus for discharge.
3.
Retract foreskin (if present) and assess for hygiene and
smegma.
4.
Check the shaft of the penis, glans, and prepuce for
lesions.
C.
Palpate:
1.
Palpate testes and epididymides for inammation,
tenderness, and masses; palpate scrotum for hydrocele or
varicocele.
2.
Check back for costovertebral angle tenderness.
3.
Evaluate for an enlarged tender bladder due to urinary
retention.
4.
Palpate the abdomen for masses, urinary distension,
suprapubic tenderness, and organomegaly.
5.
Palpate inguinal lymph nodes; check the inguinal and
femoral areas for bulges and hernias; have the client bear
down and cough and reexamine them.
6.
Rectal examination:
a.
Before the rectal examination, have the client obtain
a clean-catch urine specimen for culture. Check for
symmetry, swelling, tenderness, and enlarged prostate.
b.
In acute prostatitis, rectal examination reveals the
prostate gland to be exquisitely tender and boggy.
c.
A uctuant prostatic mass suggests an abscess that
may require surgical intervention.
d.
Perform prostate massage for postmassage urine
sample (see Section II: Procedures, “Prostatic Massage
Technique: Two-Glass Test”).
DIAGNOSTIC
A.
Acute infection:
1.
2.
3.
4.
TESTS
Complete blood count (CBC) with differential.
Urinalysis and urine culture.
Culture for STIs.
Gram stain, culture of EPS:
a.
Avoid vigorous massage when obtaining specimen
due to the risk of inducing bacteremia.
PROSTATITIS
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TABLE
12.3 NATIONAL INSTITUTES OF HEALTH CHRONIC PROSTATITIS SYMPTOMS INDEX (NIH-CPSI)
Pain or Discomfort
1. In the past week, have you experienced any pain or discomfort in the following areas?
Yes No
a. Area between rectum and testicles (perineum) □1 □0
b Testicles □1 □0
c Tip of the penis (not related to urination) □1 □0
d Below your waist, in your pubic or bladder area □1 □0
2. In the past week, have you experienced:
Yes No
a. Pain or burning during urination? □1 □0
b Pain or discomfort during or after sexual climax (ejaculation)? □1 □0
3. How often have you had pain or discomfort in any of these areas over the past week?
□ 0 Never
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□ 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 past week?
□ □ □ □ □ □ □ □ □ □
1 2 3 4 5 6 7 8 9 10
No pain Pain
as 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 past week?
□ 0 Not at all
□ 1 Less than one time in five
□ 2 Less than half the time
□ 3 About half the time
□ 4 More than half the time
□ 5 Almost always
6. How often have you had to urinate again less than 2 hours after you finished urinating, over the past week?
□ 0 Not at all
□ 1 Less than one time in five
(continued)
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12: GENITOURINARY GUIDELINES
TABLE 12.3 NATIONAL INSTITUTES OF HEALTH CHRONIC PROSTATITIS SYMPTOMS INDEX (NIH-CPSI)
(CONTINUED)
Pain or Discomfort
□ 2 Less than half the time
□ 3 About half the time
□ 4 More than half the time
□ 5 Almost always
Impact of Symptoms
7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the past
week?
□ 0 None
□ 1 Only a little
□ 2 Some
□ 3 A lot
8. How much did you think about your symptoms, over the past week?
□ 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 past 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-CPSI 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 = ________
Calculate and report three separate scores (pain, urinary symptoms, and quality of life).
Calculate and report a pain and urinary score (range 0–31), referred to as the “symptom scale score”: mild = 0–9; moderate = 10–18; severe =
19–31.
Calculate and report total score (range 0–43).
Notes:
1.
Mild = 0 to 14 total score.
2.
Moderate = 15 to 29 total score.
3.
Severe = 30 to 43 total score.
An
online National Institutes of Health symptom index that self-scores is available at www.prostatitis.org/symptomindex.html.
Source:
Adapted from NIDDK-funded Chronic Prostatitis Research Network. National Institutes of Health. Available at www.prostatitis.org/symptomindex.html.
PROSTATITIS
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b.
Gram stain of EPS demonstrates infectious organ-
isms or WBCs typical of an immune response (>10
WBC/high-power microscope eld is abnormal).
Clients with abnormal WBC but no bacterial growth
may have chlamydial or Ureaplasma infection and need
to be tested or treated empirically.
B.
Chronic infection:
1.
Blood urea nitrogen.
2.
CBC with differential.
3.
Creatinine.
C.
Chronic bacterial prostatitis:
1.
If recurrent infections are conrmed, evaluate for struc-
tural or functional abnormality with CT scan.
2.
Measure residual urine after voiding.
3.
If no urologic abnormalities are found and repeated
cultures indicate the same bacterial strain, chronic bacterial prostatitis is likely.
D.
Other tests such as ultrasound, MRI, and biopsies are used
as required to rule out other pathology.
DIFFERENTIAL
A.
Prostatitis:
1.
Acute: readily evident by clinical presentation and
DIAGNOSES
examination.
2.
Chronic: more difcult to diagnose; the hallmark
symptom is recurrent UTI, and often resembles prostatic
hypertrophy, strictures, and prostatic carcinoma.
3.
CPPS.
B.
Pyelonephritis.
C.
Epididymitis.
D.
Anal stulas and ssures.
E.
BPH causes urinary retention due to obstruction.
F.
Urethral stricture or stone.
G.
Chronic pain syndromes/back pain.
PLAN
A.
General interventions:
1.
Treatment should be directed toward symptom sup-
port and culture ndings.
2.
Clients with acute prostatitis may need hospitalization
and intravenous therapy for severe infection (high fever,
increased WBC, dehydration). Less toxic clients may be
treated on an outpatient basis.
3.
Older males without evidence of infection with lower
tract symptoms should have urine cytology to rule out
malignancy.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Prostatitis.”
1.
Having the client self-massage to reduce symptoms is
questionable; the massage of an acutely infected gland is
contraindicated due to the risk of bacteremia.
2.
Recommend sitz baths two to three times daily.
C.
Dietary management:
1.
Increase uid intake.
2.
Reduce caffeine and alcohol, which can irritate the urethra.
D.
Pharmaceutical therapy: Full treatment guideline for
the “Diagnosis and treatment of chronic bacterial prostatitis
(CBP) and chronic prostatitis/chronic pelvic pain syndrome:
A consensus guideline” is available with open access through
the Wiley Online Library at onlinelibrary.wiley.com/doi/
abs/10.1111/bju.13101.
1.
Pain relief:
a.
Analgesics:
i.
Nonsteroidal anti-inammatory drugs (NSAIDs)
should be offered only for short-term treatment
of pain to clients with early-stage CBP or CP/CPPS
whose symptoms are suspected to be caused by
an inammatory process/are. NSAIDs should be
stopped within 4 to 6 weeks of treatment if they do
not reduce symptoms.
ii.
Opioids should not be used in clients with
early-stage CBP or CP/CPPS due to the risk of
dependency.
iii.
If pain is considered neuropathic in origin,
treatment may include a gabapentinoid (e.g., pregabalin or gabapentin), a tricyclic antidepressant (e.g.,
amitriptyline, nortriptyline, or trimipramine), or a
selective serotonin and norepinephrine reuptake
inhibitor (SNRI; e.g., duloxetine).
iv.
When pain is severe and refractory to the treat-
ments or is signicantly impairing the client’s
quality of life in daily activities, referral to a pain
specialist should be considered.
2.
Alpha-adrenergic antagonists:
a.
Due to adverse side effect proles, consider offering
uroselective alpha-adrenergic antagonists (e.g., tamsulosin, alfuzosin, and silodosin) as rst-line treatment in
clients with CBP and CP/CPPS who present with voiding lower urinary tract symptoms.
3.
Antibiotics: Antimicrobial therapy should be guided
by bacterial cultures and sensitivities, taking into consideration drug interactions and/or contraindications. Dose
and duration should be sufcient to eradicate the infection. Treatment typically consists of 4 to 8 weeks of antibiotic therapy but may need to be extended to 12 weeks.
a.
First-line therapy for early-stage CBP and CP/CPPS
is a quinolone:
i.
Ciprooxacin 500mg BID × 4 weeks.
ii.
Ooxacin 400mg BID × 4 to 6 weeks.
iii.
Levooxacin 500 to 750mg daily × 4 weeks.
b.
Second-line therapy:
i.
Trimethoprim-sulfamethoxazole (TMP-SMX): 1
double strength (DS) BID × 14 days or 2 to 3 months
if chronic infection.
ii.
Tetracyclines: doxycycline 100 mg BID × 4 weeks.
c.
Macrolides are reserved for special indications,
based on advice from microbiologic ndings.
4.
There is insufcient evidence to warrant recommend-
ing 5-alpha-reductase inhibitors as monotherapy in CP/
CPPS, unless coexisting BPH is present.
FOLLOW-UP
A.
See the client in 2 to 10 days depending on their symptoms
and course.
B.
Culture urine at completion of drug therapy. Test of cure
for antibiotics requires elimination of bacteria from prostatic
uid to prevent chronic ares. Some clients may not achieve
cure even after 6 to 12 weeks of therapy.
C.
Clients who achieve a partial response may be given a
second course of antibiotics. Those failing to demonstrate an
organism may benet from a course of doxycycline or erythromycin for Chlamydia and/or Ureaplasma coverage.
D.
Notify the health department for reportable STIs.
CONSULTATION/REFERRAL
A.
Obtain a referral to a urologist for recurrent acute bacterial
prostatic infections or infections that persist.
B.
Cystoscopy may be required to rule out interstitial cystitis.
C.
Urinary retention concomitant with acute prostatitis may
require hospitalization.
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12: GENITOURINARY GUIDELINES
INDIVIDUAL
A.
Adults:
1.
CONSIDERATIONS
Prostatitis is the most common prostate infection in
males younger than 50 years.
RESOURCES
American
National
The
Urological Association (AUA): www.auanet.org
Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK): www.niddk.nih.gov
Prostatitis Foundation: www.prostatitis.org
BIBLIOGRAPHY
American Urological Association. (2013, revised 2018). Early detection of
prostate cancer: AUA guideline. https://www.auanet.org/guidelines/
prostate-cancer-early-detection-guideline
Associates in Urology. (n.d.[c]). Quality of life questionnaire. http://www.
njurology.com/_forms/qualityoife.php
Deem, S. (2017, September 7). Acute bacterial prostatitis. Medscape. emedici
ne.medscape.com/article/2002872-overview
Kreamer, S. (2019, January 15). Chronic Bacterial Prostatitis. Medscape.
https://emedicine.medscape.com/article/458391-overview
U.S. Preventive Services Task Force. (2019). Final update summary: Prostate
cancer screening. https://www.uspreventiveservicestask-force.org/Pa
ge/Document/UpdateSummaryFinal/prostate-cancer-screening1?ds
=1&s=prostate
Watson, R. (2017, May 22). Chronic pelvic pain in men. Medscape.
https://emedicine.medscape.com/article/437745-overview
Zhang, J., Liang, C., Shang, X., & Li, H. (2020). Chronic Prostatitis/
Chronic Pelvic Pain Syndrome: A disease or symptom? Current perspectives on diagnosis, treatment, and prognosis. American Journal of
Men’s Health, 14(1), 155798832090320. https://doi.org/10.1177/15579
88320903200
PROTEINURIA
DEFINITION
A.
Proteinuria is excess protein (albumin) in the urine.
Proteinuria may be an incidental nding and have no symptoms. Use of a urine dipstick for screening is acceptable for
rst detecting proteinuria (Table 12.4); however, the dipstick
should not be used to quantify the amount of urinary protein.
Protein concentration is a function of urine volume as well as
the quantity of protein present.
B.
The measurement of protein excretion is used to establish
the diagnosis and to follow the course of glomerular disease.
The normal rate of albumin excretion is less than 20mg/d;
the rate is about 4 to 7 mg/d in healthy young adults and
increases with age and increase in body weight. Persistent
albumin excretion between 30 and 300mg/d is called microalbuminuria. Values of 300mg/d or higher of protein are considered overt proteinuria or macroalbuminuria. Levels over
300mg/d which persist for 3 months are considered chronic
kidney disease (CKD).
C.
When proteinuria coexists with hematuria, the likeli-
hood of clinically signicant renal disease is high. In clients
with diabetes, microalbuminuria usually indicates incipient
diabetic nephropathy. In nondiabetics, the presence of microalbuminuria is associated with cardiovasculardisease. Protein
is also the cardinal sign of pregnancy-induced hypertension
(PIH).
D.
Functional/transient proteinuria is associated with fever,
exercise, dehydration, cold exposure, and stress, and is not
associated with underlying renal disease. Orthostatic proteinuria, a transient proteinuria condition, is related to postural
changes that affect the glomerular hemodynamics. Orthostatic
proteinuria rarely exceeds 1 g/d. Signicant renal disease is
not usually found on further testing and workup.
E.
Persistent proteinuria is dened as greater than 4 mg/m
2
/
hr of protein in a 24-hour urine collection or greater than 0.02
mg/mg of polymerase chain reaction (PCR) on a spot urine.
Persistent proteinuria requires further evaluation to rule out
underlying renal pathology.
1.
Glomerular proteinuria (albuminuria): Associated
with pathologic damage to the glomerulus and increased
ltration of macromolecules across the glomerular capillary wall. The standard urine dipstick is able to detect
glomerular proteinuria. Some causes of glomerular proteinuria include diabetes, hypertension (HTN), nephrotic
syndrome, infections including hepatitis, HIV, cytomegalovirus, malaria, syphilis, and streptococcal infections,
chemotherapeutic agents, Alport syndrome, and hemolytic uremic syndrome.
2.
Tubular proteinuria: This is related to interference with
proximal tubular reabsorption. A urinary dipstick is often
unable to detect tubular proteinuria. Some causes of tubular proteinuria include toxins, pyelonephritis, nonsteroidal
anti-inammatory drugs (NSAIDs), antibiotics, and inherited causes such as Lowe syndrome and Wilson disease.
3.
Secretory (overow) proteinuria: This refers to
increased excretion from the tubules secondary to an overproduction of a particular protein (light chains in multiple
myeloma, myoglobin in rhabdomyolysis) or commonly
noted in interstitial nephritis. A urinary dipstick is unable
to detect overow protein.
4.
Postrenal proteinuria: Inammation of the urinary tract,
often caused by urinary tract infection (UTI), increases
urinary protein excretion. Clients with nephrolithiasis or
tumors of the urinary tract may also have proteinuria.
TABLE
12.4 DIPSTICK ANALYSIS:DETECTING AND QUANTIFYING PROTEINURIA
Dipstick Grade Quantity of Protein (mg/dL)
Negative <10
Trace 10–20
1+ 30
2+ 100
3+ 300
4+ 1,000
5.
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It is currently recommended that a diagnosis of kidney
damage can only be made if at least two separate measurements are elevated.
INCIDENCE
A.
Approximately 6% of males and 9.7% of females have pro-
teinuria detected by a single routine dipstick test.
B.
The incidence of proteinuria found on a urine dipstick in
school-age children is approximately 10%. When repeat testing is done, the incidence decreases to 0.1% of school-age
children.
C.
The prevalence of orthostatic proteinuria is 2% to 5% and
is noted more commonly in older children and adolescents.
D.
The prevalence of proteinuria is higher in the elderly and
in clients with comorbidities.
PATHOGENESIS
A.
Pathogenesis depends on the underlying etiology. An
alteration in glomerular ltration that increases excretion (ltration) of plasma proteins occurs. Increased glomerular permeability, increased production of abnormal proteins (Bence
Jones protein), decreased tubular reabsorption, surgical traumas, and infections may increase urinary protein. Urinary
protein may also be affected by dietary protein intake.
PREDISPOSING
A.
Fever.
B.
Increased exercise.
C.
UTI/pyelonephritis.
D.
Medications:
1.
Penicillamine.
2.
NSAIDs.
3.
Angiotensin-converting enzyme (ACE) inhibitors.
4.
Aminoglycosides.
5.
Cisplatin.
6.
Amphotericin B.
7.
Quinolones.
8.
Sulfonamides.
9.
Cimetidine (Tagamet).
10.
Allopurinol (Zyloprim).
11.
Antiretroviral drugs can be nephrotoxic.
E.
Heavy metal exposure:
1.
Gold.
2.
Cadmium.
3.
Mercury.
4.
Lead.
5.
Copper.
F.
Collagen vascular disease or vasculitis.
G.
Family history of proteinuria or pyelonephritis.
H.
HTN.
I.
Renal disease.
J.
Congestive heart failure (CHF) or endocarditis.
K.
Diabetes.
L.
Lupus.
M.
Infections:
1.
HIV.
2.
Syphilis.
3.
Hepatitis B and C.
4.
Group A beta-hemolytic Streptococcus.
5.
Viral infection (e.g., mononucleosis).
6.
Malaria.
N.
Malignancy:
1.
Lymphoma.
2.
Hodgkin disease.
FACTORS
PROTEINURIA
3.
Breast tumor.
4.
Lung tumor.
5.
Colon tumor.
O.
Heroin use.
P.
PIH.
Q.
Radiocontrast media.
R.
Elderly.
COMMON
A.
B.
C.
D.
OTHER
A.
B.
COMPLAINTS
Asymptomatic.
Increased weight.
Decreased urine output.
Pediatrics:
1.
Growth failure.
2.
Deafness or visual impairment suggests hereditary
SIGNS AND SYMPTOMS
Edema: periorbital, presacral, genital, or ankle.
Nephrotic syndrome: hypercholesterolemia and
465
hyper triglyceridemia.
C.
Protein malnutrition: anorexia and vomiting.
D.
“Frothy” urine.
SUBJECTIVE
A.
Review the onset, course, and duration of presenting
DATA
complaints.
B.
Question the client concerning urinary output, thirst or
uid intake, edema, andincrease in weight. Establish usual
weight history.
C.
Establish the rst day of the female client’s last period.
Are they pregnant? If so, what is the fetus’s gestational age?
Is there edema, HTN, headache, visual changes (scotoma),
hyperreexia, and/or right upper quadrant pain?
D.
Review the client’s medical history for renal disease, dia-
betes, CHF, systemic disorders such as lupus, and substance
abuse.
E.
Does the client have signs or symptoms of a UTI or
pyelonephritis?
F.
Review the client’s recent history for exertion, emotional
stress, surgical trauma, fever, and any acute illness.
G.
When was the client’s last evaluation for cholesterol? Are
they on any special diet?
H.
Review medication list, including prescribed and over-the-
countermedications and herbal products.
I.
Review the client’s occupational exposure, smoking his-
tory, and risk factors for infectious diseases.
PHYSICAL
A.
The client’s physical examination may have few abnor-
EXAMINATION
malities unless there are features of multisystem disease.
B.
Check temperature (if indicated), blood pressure (BP),
pulse, respiration, and weight.
C.
Inspect:
1.
Inspect overall general appearance for edema (pedal,
hand, facial, or periorbital edema), buttery rash (lupus),
or ascites.
2.
Evaluate for protein wasting.
3.
Evaluate for jugular vein distension.
4.
Funduscopic examination: Evaluate for retinopathy.
5.
Inspect for pharyngitis.
D.
Auscultate:
1.
Heart.
2.
Lungs.
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E.
Palpate:
1.
12: GENITOURINARY GUIDELINES
Examine the abdomen; evaluate bladder distension,
suprapubic tenderness, masses or ascites, abdominal
tenderness.
2.
Palpate for costovertebral angle tenderness.
3.
Check deep tendon reexes, especially in pregnant
individuals.
DIAGNOSTIC
A.
Urine dipstick is a good screening tool in the outpatient
TESTS
setting.
1.
The dipstick result may be difcult to read if the urine
is abnormally colored due to nitrofurantoin, riboavin,
azo-containing sulfonamide antimicrobials, or blood.
B.
Single-void “spot” urine testing:
1.
The rst urine specimen of the morning is optimal and
is guideline-recommended. Evaluation of the rst morning specimen excludes any postural effect on the protein
component.
2.
The gold standard for measurement of protein excre-
tion is a 24-hour urine collection but is now being replaced
by the easier-to-obtain and less-complicated spot test. The
24-hour urine is considered impractical for generalized
testing, especially in the pediatric population. The normal
amount of protein in the urine is <150mg/d.
C.
Polymerase chain reaction (PCR) test or albumin-to-cre-
atinine ratio (ACR) test on a rst-morning or a random spot
specimen. The PCR or ACR is useful in following trends in the
client’s proteinuria.
D.
Complete blood count and serum electrolytes.
E.
Serum creatinine (if renal disease is suspected).
F.
Lipid prole.
G.
Blood urea nitrogen(BUN) serves as an index of renal
excretory capacity. Urea is the nitrogenous end product of
protein metabolism.
H.
Urinalysis, urine culture, and sensitivity (if indicated).
I.
Ultrasound of the full urinary tract.
J.
Screen for diabetes and other testing related to physical
ndings.
K.
Renal biopsy is required to establish the diagnosis in most
cases.
DIFFERENTIAL
A.
See the“Predisposing Factors” section.
DIAGNOSES
PLAN
A.
General interventions:
1.
Current guidelines for screening for evaluation of
albuminuria/proteinuria vary by country, but recommendations include at-risk individuals with diabetes, HTN,
obesity, smokers, indigenous populations, family history
of CKD, age greater than 50 years, structural renal tract
disease, renal calculi, prostatic hypertrophy, vascular disease, and autoimmune disease.
2.
Management for nephrotic syndrome includes
diet with sodium and protein restriction, loop
and distal-acting diuretics, control of cholesterol
(low-saturated-fat, low-cholesterol diet), lipid-lowering
agents, pneumococcal and inuenza vaccines to prevent
infections, and use of steroids and immunosuppressive
agents as necessary.
3.
Clients with hematuria and proteinuria need a 24-hour
urine collection for protein and creatinine clearance.
B.
Client teaching:
1.
Encourage low-fat/low-cholesterol diet if hyperlipid-
emia is present.
2.
Encourage sodium- and protein-restricted diet for
nephrotic syndrome.
C.
Pharmaceutical therapy:
1.
There is no specic drug therapy for excess protein.
2.
Use drug therapy appropriate to the underlying medi-
cal disease-causing proteinuria.
3.
In clients with CKD, the administration of ACE inhib-
itors and/or angiotensin receptor blockers is aimed at
reducing the degree of proteinuria.
4.
The Advisory Committee on Immunization Practices
recommends immunization with 13-valent pneumococcal
conjugate vaccine, followed by a dose of 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later, in
clients with nephrotic syndrome.
FOLLOW-UP
A.
If proteinuria is found on a dipstick and the rst-morning
test results are trace or negative for protein, repeat a
rst-morning test in 1 year.
B.
There is no consensus on how often to screen for protein-
uria. Guidelines include annual screening (especially for diabetics), every 5 years for clients older than 50 years or smokers,
and every 3 years for clients who have HTN, obesity, family history of kidney disease, or are indigenous. Monitoring
should always include BP, quantitative testing by PCR or
ACR, and a serum creatinine.
C.
Client should be assessed at routine examination appoint-
ments for vasculitic skin changes, rashes, retinopathy,
lymphadenopathy, signs of heart failure, abdominal masses,
organomegaly, guaiac stools, prostatic enlargement, and joint
inammation.
CONSULTATION/REFERRAL
A.
Consider client referral to a nephrologist if kidney damage
is progressing from medical disease (systemic lupus erythematosus, HTN, diabetes).
B.
Refer the client as necessary; HTN is a poor prognostic
sign of signicant renal impairment.
C.
Consultation for diagnostic tests to be considered: kidney,
ureter, and bladder; intravenous pyelogram; renal ultrasonography; renal biopsy.
D.
Referral to a pediatric nephrologist should be consid-
ered if a denitive diagnosis is required or a renal biopsy is
considered.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Protein excretion is considered abnormal in pregnancy
when it exceeds 300mgper 24 hours or greater than 0.3 g
of protein per gram of creatinine in a random urine specimen. A urine specimen with 1+ protein is considered the
cutoff for proteinuria.
2.
The gestational age at which proteinuria is rst docu-
mented is important in establishing the likelihood of PIH
versus other renal diseases. Proteinuria before or early in
pregnancy suggests preexisting renal disease.
3.
Monitor urine protein and BP at each prenatal visit and
refer the client if urinary protein remains elevated.
4.
Monitor for intrauterine growth restriction.
5.
Proteinuria (or HTN) that persists longer than 3 months
after delivery should be followed closely.
B.
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https://t.me/med1917
Pediatrics:
1.
The American Academy of Pediatrics recommends that
children be screened on two occasions during childhood:
a.
Before entrance into school.
b.
During adolescence.
2.
Although there are no set guidelines for children,
a child with persistent proteinuria should be initially
worked up with a physical examination, BP, urinalysis,
serum creatinine, and BUN every 6 to 12 months.
3.
When the child is stable, the follow-up should be done
annually.
4.
There are no dietary or physical activity limitations.
C.
Geriatrics:
1.
Renal function deteriorates in the elderly who may also
have coexisting medical conditions (HTN, diabetes) that
may cause nephropathy.
BIBLIOGRAPHY
American College of Obstetricians and Gynecologists. (2019).
Hypertension in pregnancy. https://www.acog.org/Clinical-Guidance
-and-Publications/Practice-Guidelines-and-Reports-Search?Keyword
=hypertension%20in%20pregnancy
Ekiz, A., Kaya, B., & Polat, I. (2016). The outcome of pregnancy with new
onset proteinuria without hypertension: Retrospective observational
study. Journal of Maternal-Fetal & Neonatal Medicine, 29(11), 1765–1769.
Gagnadoux, M. (2016, May 31). Evaluation of proteinuria in children. UpToDate.
www.uptodate.com/contents/evaluation-of-proteinuria-in-children
Jhawar, M. (2017). Burden of proteinuria and risk factors of chronic kid-
ney disease among adult population in Urban Puducherry, India.
Journal of Clinical and Diagnostic Research. https://doi.org/10.7860/jc
dr/2017/24492.10430
Kallen, R. (2021). Pediatric Proteinuria: Overview, Detection of Proteinuria,
Orthostatic Proteinuria. EMedicine. https://emedicine.medscape.com/
article/984289-overview#a2
Thadhani, R. (2019, February 11). Proteinuria in pregnancy: Evaluation and
management. UpToDate. . www.uptodate.com/contents/proteinuria-in
-pregnancy-evaluation-and-management
PYELONEPHRITIS
DEFINITION
A.
Pyelonephritis is an acute infection and inammatory
disease of the upper urinary tract (renal pelvis, tubules, and
interstitial tissue) of one or both kidneys. Acute pyelonephritis is an ascending urinary tract infection (UTI) that has progressed from the lower urinary tract.
B.
Fever has been strongly correlated with the diagnosis of
acute pyelonephritis; therefore, clients with clinical symptoms
of pyelonephritis in the absence of fever should be evaluated
for alternative diagnoses.
C.
Acute pyelonephritis characteristically causes some
scarring to the kidney and may lead to significant damage, kidney failure, abscess formation, and sepsis.
Antibiotic therapy is essential to prevent the progression
of pyelonephritis.
INCIDENCE
A.
Thirty percent of the female population have at least one
UTI in their lifetime.
B.
Annual rates of pyelonephritis in females are 15 to 17 cases
per 10,000 and 3 to 4 cases per 10,000 for males.
C.
Acute pyelonephritis develops in 20% to 30% of pregnant
clients who have untreated asymptomatic bacteriuria (2%–
9.5%). This infection occurs most often during the late second
and early third trimesters.
PYELONEPHRITIS
D.
Upper UTIs are less common and more serious than lower
467
UTIs. After puberty, the prevalence of UTI increases slightly in
females, but remains low in males.
E.
After the age of 65 years, UTIs are more common with an
equal incidence in both sexes.
F.
Approximately 7% of pyelonephritis cases require
hospitalization.
PATHOGENESIS
A.
Pyelonephritis is caused by ascending infection from the
bladder, usually caused by Escherichia coli (75%–90%) and
other gram-negative bacteria including Proteus mirabilis (5%),
Klebsiella pneumoniae (5%), Enterobacter (3%), and group B
Streptococcus (GBS; 1%). Gram-positive causative agents are
less common; 10% to 15% of cases are caused by Staphylococcus
saprophyticus.
B.
Bacteria can also reach the kidneys through the blood-
stream from intravenous (IV) drug abuse and endocarditis.
C.
In females, the short urethra in close proximity to the peri-
rectal area makes colonization possible. In pregnancy, the
increased glycosuria, increase in urinary amino acids, urinary
stasis, and the presence of vesicoureteral reux facilitate bacterial growth.
D.
In children, vesicoureteric reux is the most common
pathology.
E.
In males, benign prostatic hypertrophy (BPH) causing
bladder obstruction is a common pathology.
F.
Indwelling catheters increase ascending infections and
pyelonephritis.
PREDISPOSING
A.
Previous UTI, cystitis, and pyelonephritis.
B.
Sickle cell disease.
C.
Diabetes.
D.
Urinary catheterization.
E.
Obstruction: calculi, tumors, and urethral strictures.
F.
Neurogenic bladder disease: strokes, multiple sclerosis,
FACTORS
and spinal cord injuries.
G.
Urinary reux.
H.
HIV.
I.
Trauma.
J.
Chronic constipation (children).
K.
Incomplete bladder emptying related to medications (e.g.,
anticholinergics).
L.
Sex:
1.
Females:
a.
Increased sexual activity, failure to void after inter-
course, diaphragms, and spermicides.
b.
Pregnancy.
c.
Atrophic vaginal mucosa predisposes to the coloni-
zation of pathogens and UTIs.
2.
Males:
a.
Homosexuality.
b.
Sexual partner with colonization.
c.
Obstruction: prostatic hypertrophy.
d.
Age 50 years or older.
e.
Acute or chronic bacterial prostatitis.
COMMON
A.
B.
C.
D.
E.
COMPLAINTS
Shaking, chills, and fever.
Flank pain or tenderness.
Urinary frequency or urgency.
Costovertebral angle (CVA) tenderness.
Guarding.
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