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Chapter 16 • Fever 201

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the nail beds and petechiae of the conjunctivae indicate endocarditis.

The presence of a petechial skin rash indicates a serious infection that requires immediate referral and hospitalization.

Examine the Head and Neck

Percuss the sinuses and transilluminate for evidence of sinusitis (see Chapter 22). Examine and palpate the teeth for abscesses. Palpate the salivary glands for tenderness. Examine the throat and tonsils for signs of infection, specically enlarged or red tonsils, lymphadenopathy, or tonsillar or pharyngeal exudate. Examine the mouth for aphthous ulcers.

Inspect the ears and tympanic membrane (TM) for effusion, erythema, uid, or purulent secretion. Inspect the optic fundi for changes associated with infectious endocarditis (i.e., Roth spots—small, pale retinal lesions with areas of hemorrhage with white centers, usually located near the optic disc).

In the infant, feel for a tense or bulging anterior fontanel. This is best noted if the patient is in the sitting position. The normal fontanel may feel questionably tense if the infant is supine. Tenseness may be noted in the crying child but only during expiration; this physiological bulging disappears when the patient relaxes or inspires.

Palpate the Lymph Nodes

Palpate all lymph nodes for enlargement and tenderness.

n Anterior cervical—Suspect viral or bacterial phar-

yngitis.

n Preauricular or postauricular—Suspect ear infec-

tion.

n Posterior cervical—Suspect mononucleosis. n Supraclavicular—Suspect neoplasms. n Axillary—Suspect breast inammation, local infec-

tion, or neoplasm.

n Localized lymphadenopathy—Suspect local infec-

tious process.

n Generalized lymphadenopathy—Suspect immu-

nosuppression, such as being HIV positive, or

neoplasm.

Examine the Lungs and Chest

Percuss and auscultate the lungs (see Chapters 10 and 13). Adventitious sounds, decreased breath sounds, or areas of consolidation may indicate LRI or pneumonia.

Examine the sputum for color, consistency, and

presence of blood or odor.

n Yellow/green sputum—Suspect bacterial infection. n Brown sputum—Check smoking history. n Blood-streaked sputum—Suspect URI or bronchitis. n Hemoptysis—Suspect tumor, trauma, or pulmonary

embolism.

Palpate Breasts if Indicated

Inspect the breasts for signs of inammation (see Chapter 5). Palpate for masses, tenderness, and discharge. Palpate axillary lymph nodes for presence of tenderness.

Examine Genitourinary System if Indicated

Palpate for suprapubic tenderness, which may indicate PID or UTI, and for costovertebral angle (CVA) tenderness, which suggests pyelonephritis (see Chapters 24, 32, and 34). Perform a pelvic examination in women without another obvious source of fever. Cervical motion tenderness, discharge, or adnexal tenderness and lower abdominal tenderness may indicate PID. In men, examine for penile discharge, suggesting a sexually transmitted disease, UTI, or prostatitis.

Perform a rectal examination to evaluate for tenderness and discharge, which may indicate rectal abscess or infection, as well as retrocecal appendicitis.

Perform a prostate examination in men without another obvious source of fever because prostatitis may be the cause. If you suspect prostatitis, do not perform a vigorous examination or massage the prostate as this can release bacteria and produce septicemia.

Examine Musculoskeletal System if Indicated

Examination may suggest inammation or infection of bones or joints if there is swelling, increased warmth, or tenderness (see Chapters 20 and 21). Infants may present with poor feeding, irritability, fever, or vomiting. Examination should reveal decreased mobility of the affected bone or joint area, increased heat, tenderness, and swelling.

Examine the lower extremities for asymmetrical swelling, calf tenderness, or palpable vessels as an indicator of deep vein phlebitis.

Osteomyelitis may occur in young children, most commonly between 3 and 10 years of age. Septic arthritis

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can occur in children under the age of 3 and in young women who are sexually active.

Perform Neurological/Mental Status Examination

Evaluate for signs of meningeal irritation (see Chapters 12 and 18). Inammation of the meninges from infection or blood evokes reex spasm in the paravertebral muscles. In the cervical area, this manifests as neck stiffness. Normally the chin can be exed passively to touch the chest. If neck stiffness is present, this maneuver is not possible. With the patient supine, attempts to ex the neck cause the knees and hips to rise from the bed (Brudzinski sign) to reduce the pull on the meninges. In the lumbar region, meningeal irritation also causes spasm and can be demonstrated by passive movement of the lower limbs. Attempts to extend the knee joint when the hip joint is exed are resisted, and the other limb may ex at the hip (Kernig sign). Neck stiffness (nuchal rigidity) or resistance to neck exion or rotation is a late sign and not a true sign of meningitis in infants less than 3 months old, the very old, or the severely obtunded patient. Vomiting, headache, and photophobia may also be present.

Note the presence of focal decits, which suggests vascular occlusion or abscess formation. Assess for disturbances in mentation, irritability, lethargy, somnolence, or coma, which indicates increased intracranial pressure. Seizures occur in 20% to 30% of children with meningitis.

A seizure in a febrile infant less than 6 months old suggests meningitis rather than a simple febrile seizure. Benign febrile seizure is uncommon in very young infants.

LABORATORY AND DIAGNOSTIC STUDIES

Laboratory studies can be used selectively to conrm or negate the clinical diagnosis, especially if the history and physical examination ndings provide strong indication of a particular infectious process. In patients with obvious viral URI, no studies are necessary. Patients with a sore throat may require a throat culture, Monospot, or rapid strep test, depending on the clinical ndings. In patients with urinary symptoms, a urinalysis and culture may be sufcient unless clinical ndings indicate an upper UTI, which would warrant further diagnostic testing such as radiography, ultrasonography, or intravenous pyelography.

Also see appropriate chapters for specic present-

ing problems and discussion of diagnostic tests.

Complete Blood Count

Leukocytosis with a left shift suggests a bacterial infection. Atypical lymphocytes are characteristic of systemic viral infection. Immature neutrophils suggest leukemia.

Anemia may be seen in inammatory conditions, such as juvenile arthritis, malaria, and parvovirus B19 infections. Low platelet counts may be associated with Epstein-Barr virus infection, histoplasmosis, tuberculosis (TB), and spirochetal infections or may be drug induced. Thrombocytosis is common in Kawasaki disease (an acute febrile illness in children that resembles scarlet fever) and some viral infections.

Erythrocyte Sedimentation Rate

An elevated erythrocyte sedimentation rate (ESR) indicates an inammatory condition. However, the test is nonspecic and does not indicate the source or cause of inammation.

Antistreptolysin Titer

An increase in the antistreptolysin (ASO) titer is detectable by comparing two blood samples more than 2 weeks apart (see Chapter 29). An elevated titer indicates immunological response of the host after exposure to streptococcal antigen.

HIV Testing

There are two tests used to diagnose HIV infection. The enzyme-linked immunosorbent assay (ELISA) detects the presence of HIV-specic antibodies that the body produces in response to the virus. A positive test may be conrmed by a second test, the Western blot. Newer, more rapid tests are being developed.

Urinalysis

Use a dipstick urinalysis (U/A) to screen for upper or lower UTI, which would reveal the presence of nitrites and leukocyte esterase (see Chapter 32). Microscopic evaluation discloses the presence of cells (white and red blood cells) and blood casts.

Urine Culture and Sensitivity

Performed on a clean catch of urine, this test will conrm a diagnosis of UTI and isolate the organism(s) (see Chapter 32).

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Stool for Leukocytes

The presence of white blood cells (WBCs) may suggest invasive bacterial gastroenteritis (see Chapter 11).

Stool Culture and Sensitivity

Use stool culture and sensitivity to detect the presence of Salmonella or Shigella (see Chapter 11).

Stool Sample for Ova and Parasites

Have the patient collect three stool samples over a 5-day period (see Chapter 11). The rst morning stool is preferred and must be delivered to the laboratory in 30 minutes or less after defecation.

Sputum for Acid-Fast Bacilli

A sputum sample to test for acid-fast bacilli (AFB) is used to diagnose respiratory TB (see Chapter 10). A smear is prepared from a series of three rstmorning specimens collected on three separate days to catch the sporadic discharge of the bacilli from the tubercle.

Sputum for Gram Staining

A smear is prepared from a sputum sample and stained with Gram stain. Gram-positive organisms stain purple; gram-negative organisms stain red.

n Gram-positive cocci or diplococci indicate

pneumococcal, staphylococcal, or streptococcal infections.

n Gram-negative cocci indicate meningococcal or

gonococcal infections.

n Enteric gram-negative bacilli indicate Escherichia

coli, Proteus, Bacteroides, Klebsiella, typhoid, Salmonella, or Shigella.

n Other gram-negative bacilli indicate Haemophi-

lus, pertussis, chancroid, brucellosis, tularemia, or

plague.

Sputum for Culture and Sensitivity

Use a sputum culture to isolate a specic organism (see Chapter 10). Have the patient rinse the mouth well with water without swallowing before coughing to produce a specimen; this decreases the amount of saliva present. Do not use mouthwash because this can kill the bacteria. An early morning sample is best. The sample must contain mucoid or mucopurulent material.

Cultures of Discharge

Cultures can be prepared from any source with a dis-

charge (e.g., vaginal, urethral, wound). Place the cul-

ture in the transport medium indicated. Culture is used

to isolate causative organisms.

Collect a specimen of vaginal or penile discharge on a sterile swab and place in the medium provided. For penile discharge, use a sterile urethral swab to collect a specimen from the anterior urethra by gentle insertion and scraping of the mucosa. For wound culture, use a sterile swab or aspirate with a sterile needle and syringe from the moist area. Bacteria from the center of a wound may be nonviable; culture near the periphery.

Molecular Testing for Infectious Organisms

Molecular testing using a sample taken from the vagina provides rapid, sensitive, and specic results. A number of products are available. Follow manufacturer directions to collect and transport the sample. Polymerase chain reaction (PCR) is a very specic test for detecting the presence of Borrelia DNA in Lyme disease and dengue fever. A positive PCR suggests presence of the specic organism.

DNA probes and nucleic acid amplication tests (NAATs) are available to test for Chlamydia trachoma- tis and Neisseria gonorrhoeae. Single or dual organism tests are available.

Blood Cultures

Two culture specimens are obtained at two different venipuncture sites. If one culture produces bacteria and the other does not, the positive culture is likely from a contaminant and not the infecting agent. Culture specimens drawn through an intravenous catheter are frequently contaminated. All cultures should be drawn before initiation of antibiotics if possible. Most organisms require approximately 24 hours for growth in the laboratory, and a preliminary report can be given at that time. Often 48 to 72 hours are required for growth and identication of organisms. Blood cultures may be positive in bacteremia.

Lumbar Puncture

A lumbar puncture is indicated if you suspect meningitis (see Chapter 18). Laboratory data on cerebrospinal uid (CSF) always include leukocytes, protein, glucose,

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Gram stain, cell count, and culture and sensitivity. In meningitis, expect cloudy CSF uid with many polymorphonuclear cells containing bacteria. Glucose level in CSF is decreased compared with blood glucose level, protein is increased, and the culture will be positive.

Radiographic Imaging

Chest radiographs may detect inltrates, effusions, masses, or nodes. Kidney, ureter, and bladder (KUB) and upright abdominal lms can reveal air-uid levels in the bowel. Computed tomography (CT) scan may be used to detect abscess or tumor. Radiographs are useful for detecting bone and joint involvement in osteomyelitis. Radionuclide scanning is also benecial in detecting osteomyelitis.

DIFFERENTIAL DIAGNOSIS

Upper Respiratory Infection

Viral infections can occur in any age-group and are more prevalent during winter months (see Chapter 10). The temperature is usually less than 38.7° C (101.5° F). Systemic symptoms are common. Known contact with others who have had similar symptoms or illness is typical but not necessary. The patient usually has a cough; any sputum is nonpurulent. Pharyngitis may be present with erythema of the oral pharynx.

Prostatitis

In men without another obvious source of fever, suspect prostatitis (see Chapter 24). The prostate will be exquisitely tender to gentle palpation. Other system examinations will be normal.

Pharyngitis

The patient reports a sore throat. In children, fever may precede throat complaints by 1 or 2 days. The pharynx is red, and the tonsils may be enlarged or have exudate. For differential diagnosis of bacterial and viral pharyngitis, see Chapter 29. Mononucleosis occurs most often in young adults and may present with palatine petechiae, tonsillar exudate, and posterior cervical lymphadenopathy.

Sinusitis

Sinuses that are tender to percussion or do not transilluminate may indicate sinusitis, especially in the presence of purulent nasal discharge. Patients often report a frontal headache, which worsens as the patient leans forward (see Chapter 22). Patients sometimes experience a sore throat and cough from postnasal discharge, which may be apparent in the posterior pharynx.

Gastroenteritis

Nausea, vomiting, and diarrhea are the hallmarks of a GI infection (see Chapter 11). Fever is usually mild. Abdominal cramping may be present.

Urinary Tract Infection

UTIs are more common in females (see Chapter 32). Localized urinary tract symptoms are common in adults; systemic symptoms are more common in children. CVA tenderness indicates upper UTI. The temperature associated with an upper UTI is likely to be a high fever, and the patient feels systemically ill. Urinalysis can support a clinical diagnosis of UTI. Urine for culture and sensitivity usually conrms the diagnosis.

Pelvic Inﬂammatory Disease

Suspect PID in women with a fever for which there is no other explanation (see Chapter 34). There may be vague reports of lower abdominal pain; suprapubic tenderness may be present on abdominal examination. Pelvic examination reveals cervical motion tenderness, discharge, and/or adnexal tenderness.

Ear Infections

Otitis media is more common in children (see Chapter 14). The tympanic membrane will appear red and may bulge. The light reex will be absent or diminished. Tympanic membrane mobility will be limited. The child may tug at the ear and act restless or irritable. The young child or infant may feed poorly. The temperature may be a high- or low-grade fever. Respiratory symptoms occur if the patient has a concomitant respiratory tract infection. Ear infections are commonly associated with other upper respiratory tract symptoms.

Meningitis

The signs and symptoms of meningitis are related to nonspecic ndings associated with bacteremia or a systemic infection or to specic manifestation of meningeal irritation with central nervous system inammation (see Chapter 18). Inspect the skin for petechiae, cyanosis, and state of hydration and peripheral perfusion. Nuchal rigidity, back pain, Kernig sign, Brudzinski sign, nausea, vomiting, and bulging fontanel (in infants) may

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be seen. Papilledema is rarely seen. If it is present, look for other processes, such as brain abscess or subdural empyema. Ataxia may be a presenting sign. Lumbar puncture conrms the diagnosis.

Osteomyelitis

Bone infection is usually caused by bacteria and may arise from a clinically evident infection or from general bacteremia (see Chapter 20). Patients report pain in the affected bone or joint and may exhibit soft tissue tenderness and swelling. Children demonstrate localized tenderness near the epiphysis. Diagnosis requires isolation of the responsible organism via blood cultures, pus from tissue abscesses, synovial uid aspirate, or material from needle aspiration or bone biopsy. Radionuclide scanning, CT, or magnetic resonance imaging (MRI) may be helpful in determining the extent of infection and destruction.

Kawasaki Disease

Kawasaki disease is an acute mucocutaneous lymph node syndrome that is classied as a vasculitic syndrome (of which fever is only one sign) affecting infants and young children under age 9 (see Chapter 25). It is more common in males and often occurs in fall and spring. The etiology is unknown. Fevers are of a highspiking remittent pattern in the range of 38° C to 40° C (100.4° F to 104° F, respectively, with some to 107° F) and persist despite the use of empiric antibiotics and antipyretics. Seizures may be present, and other neurological causes must be ruled out. The febrile phase lasts from 5 to 25 days with a mean of 10 days. Because of the rash associated with the fever, Kawasaki disease resembles scarlet fever.

To make the initial diagnosis of Kawasaki disease, fever lasting at least 5 days with at least four of the following signs, in the absence of a known diagnosis or infection, must be present:

n Bilateral conjunctival hyperemia n Mouth lesions—dry ssured lips and injected phar-

ynx or strawberry tongue

n Change in peripheral extremities, edema, erythema,

desquamation of skin at 10 to 14 days

n Nonvesicular erythematous rash n Cervical lymphadenopathy

Factitious Fever

Suspect factitious fever when there is a discrepancy between oral or rectal temperature and urine temperature. The pulse rate will be inconsistent with elevated

temperature. The patient has no weight loss. Repeated monitored temperature-taking does not support previous readings.

Roseola Infantum

Roseola infantum is the most common exanthema of children younger than 3 years of age. Symptoms include an irritable child who has high fever, with rapid defervescence when the rash appears on day 3 or 4. The rash is maculopapular and lasts 1 to 2 days.

Fevers Without Localizing Signs

Often examination fails to disclose any specic signs or symptoms other than the fever itself. Most children who have a fever without localizing signs have neither an unusual nor a serious disease. In many cases, the fever will clear within a few days without a specic diagnosis. However, the longer the child has a fever without localizing signs, the less likely the fever is the result of infectious disease. Viral illness or malignancy must be considered.

Always investigate in the history and physical examination any abnormal growth suggesting any possibility of preexisting chronic disease. Morning stiffness suggests rheumatoid arthritis, weight loss or abdominal pain suggests inammatory bowel disease, and frequent respiratory tract infection suggests cystic brosis or immunodeciency.

Enterovirus

All enteroviruses may cause a mild, nonspecic, febrile illness that lasts 2 to 5 days. Most are seasonal, occurring in late summer and early fall. Herpangina, nonexudative pharyngitis with or without lymphadenopathy, generally occurs.

Occult Bacteremia

Occult bacteremia is diagnosed in children older than 3 months who have positive blood cultures but do not have the usual clinical manifestation of sepsis or septic shock. Occult means hidden from view; the child looks well. The majority of children who look well and are playful are at low risk for bacteremia despite fever. Those who look ill or toxic are at signicant risk. The primary concern is the small but important percentage of those children who develop secondary complications from invasive bacterial disease (i.e., meningitis, bacterial sepsis, septic arthritis, or pneumonia). Peak ages for bacteremia are between 6 and 24 months, with

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Streptococcus pneumoniae being the organism most commonly responsible.

lasts an average of 4 days. Besides the fever, the child has malaise, sore throat, cervical adenopathy, and aphthous stomatitis. The white blood cell count may be

Periodic Fever in Children

This condition is characterized by an abrupt fever that occurs in children 2 to 5 years of age on a regularly recurring basis, generally every 6 weeks. The fever

elevated (13,000/mm3), as is the sedimentation rate. There are no associated diseases or other physical examination and laboratory ndings. The child has normal growth and development.

DIFFERENTIAL DIAGNOSIS OF Common Causes of Fever

CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES

URI Any age-group; systemic

symptoms; often known contact with ill others

Gastroenteritis Nausea, vomiting, diarrhea;

abdominal cramping

UTI Females more than males;

burning urgency; frequency in adults; systemic symptoms/ bedwetting in children

PID May have pelvic or lower

abdominal pain

Pharyngitis Sore throat; may or may

not have other upper respiratory tract symptoms

Prostatitis Perineal discomfort,

frequent urination, chills

Sinusitis Facial or sinus pressure or

Ear infections Earache, pain; may have

Meningitis Nonspeciﬁc symptoms;

Osteomyelitis Pain in affected bone or

Kawasaki

disease

and malaise

pain; headache

upper respiratory tract symptoms; child tugs at ear

nausea, vomiting, irritability

joint

Under 5 yr of age; males

more than females; fall and spring

Fever ,38.7° C (101.5° F); cough;

nonpurulent sputum; erythema of pharynx; viral exanthema

Mild fever; abdomen may be

diffusely tender

CVA tenderness with upper UTI;

fever with upper UTI

May have suprapubic tenderness;

cervical discharge; CMT, adnexal tenderness

Erythematous pharynx; may have

pharyngeal or tonsillar exudates or ulcers; may have palatine petechiae in mononucleosis; lymphadenopathy

Prostate tender to palpation; fever Segmental urine specimen;

Purulent nasal discharge; sinuses

tender to percussion; headache or pressure worsens on bending forward

High- or low-grade fever; TM red,

may bulge, landmarks absent; TM mobility impaired; child irritable/ restless

Petechiae, nuchal rigidity, positive

Kernig’s and Brudzinski’s signs, petechiae; bulging fontanel in infant

Swelling or tenderness over affected

area of joint

High fever, spikes; persists despite

antibiotic therapy; may have seizures; fever for 5 days with at least 4 of the following: bilateral conjunctival hyperemia, mouth lesions, edema, erythema, desquamation of skin, nonvesicular erythematous rash, cervical lymphadenopathy

None

U/A; urine C & S; CBC

if suspect upper UTI

CBC; molecular testing

CBC; culture; rapid strep

test if suspect strep; Monospot if suspect mononucleosis

C & S of urine; C & S of prostate discharge

Radiographs or CT scan of

limited value

Pneumatic otoscopy

Lumbar puncture

Culture; CBC; radionuclide

scan, CT, MRI

WBC increased, shift to left;

slight anemia; thrombocytosis; positive C-reactive protein; ESR increased; serum IgM, IgE increased

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DIFFERENTIAL DIAGNOSIS OF Common Causes of Fever—cont’d

CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES

Factitious

fever

Roseola

infantum

Fevers without

localizing signs

Enterovirus Mild, nonspeciﬁc febrile

Occult

bacteremia

Periodic fever

in children

CBC, complete blood count; CVA, costovertebral angle; C & S, culture and sensitivity; CT, computed tomography; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; PID, pelvic inﬂammatory disease; TM, tympanic membrane; U/A, urinalysis; URI, upper respiratory infection; UTI, urinary tract infection; WBC, white blood cell.

Vague or no symptoms Normal physical examination; no

weight loss; pulse rate normal (not consistent with temperature elevation)

Irritable child with fever for

4-5 days

No other speciﬁc

symptoms

illness lasting 2-5 days; summer and early fall peaks

Fever in children older than

3 mo

Abrupt fever on periodic

basis (about every 6 wk); lasts about 4 days; child aged 2-5 yr; malaise

Normal physical examination; when

fever breaks, rash appears

Physical examination usually normal

initially; repeat examination in 24 hr and as needed

Nonexudative pharyngitis with or

without lymphadenopathy frequently observed

No localizing signs; child appears

well

Cervical adenopathy, aphthous

stomatitis

Discrepancy between

oral/rectal temperature and urine temperature; repeated monitored temperature-taking does not support previous readings

None

U/A; urine C & S; chest

x-ray; WBC; rule out systemic disease, malignancy

None

Blood culture; WBC

WBC and ESR elevated

REFERENCES AND READINGS

Baraff LJ: Management of fever without source in infants and children,

Ann Emerg Med 36:602, 2000.

Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa

TT: Practice guideline for evaluation of fever and infection in long-term care facilities, J Am Geriatr Soc 49:210, 2001.

Centers for Disease Control and Prevention: Locally acquired

dengue—Key West Florida, 2009-2010, MMWR 59:577, 2010.

Claudius I, Baraff L: Pediatric emergencies associated with fever,

Emerg Med Clin North Am 28:67, 2010.

High KP, Bradley SF, Gravenstein DR, Quagliarello VJ, Richards C,

Yoshikawa TT: Clinical practice guideline for the evaluation of

fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America, J Am Geriatr Soc 57:375, 2009.

Long S: Distinguishing among prolonged, recurrent, and periodic fever

syndromes: approach of a pediatric infectious diseases subspecialist, Pediatr Clin North Am 52:811, 2005.

McPhee SJ, Papdakis MA: Current medical diagnosis and treatment,

ed 49, New York, McGraw Hill, 2010.

Norman DC: Fever in the elderly, Clin Infect Dis 31:148, 2000.

C H A P T E R

https://t.me/med1917

Genitourinary Problems in Males

rinary tract problems in males represent a range of conditions from infections, inammation,

formation, trauma, or neoplasm. Any part of the renal/ urological/reproductive tract can be involved, and symptoms may often be localized to a single site. Symptoms may also be vague, reect the involved area, or be referred from the actual site of involvement.

urethritis, prostatitis, cystitis, or mechanical irritation of the urethra. Inammation, although infrequent in young males, increases with age until elderly men are affected as frequently as elderly women.

urethra or prostate, or occurs secondary to urethral instrumentation. The most common cause of recurrent cystitis in men is chronic bacterial prostatitis. Escherichia coli is the usual gram-negative pathogen. Chlamydia tracho- matis is the major cause of pro statitis and nongonococcal urethritis in men under age 40 and is sexually transmitted. Recurrent urinary tract infections (UTIs) may involve resistant gram-negative Klebsiella, Enterobacter,

Pseudomonas, or Proteus mirabilis, or gram-positive Enterococcus and Staphylococcus aureus. Infection may

involve the kidneys and cause pyelonephritis. Secondary infection can occur as the result of urinary stones.

present with symptoms involving urinary ow. Urine ow may be altered by compression of the urethra as it passes through an enlarged prostate, obstructing the ow of urine and producing hesitancy, slowing of the urinary stream, dribbling, and nocturia. Benign prostatic hyperplasia (BPH) is common in men older than 50 and progresses with age until 80% of men over 80 are affected. Patients with BPH are more prone to UTIs and incontinence. Urinary stones can occur anywhere in the urinary tract and are common causes of obstructive symptoms, bleeding, and pain.

trating, straddle, blunt, or crushing injuries or by surgery

and urine outlet obstruction to congenital mal-

Dysuria in males is most commonly caused by

Cystitis in men results from ascending infection of the

The male patient with urinary problems may also

Trauma to the urinary tract may be caused by pene-

or instrumentation. Hematuria, oliguria, and pain are the most common symptoms.

Neoplasms occur more often in males than in females. Kidney, prostate, and bladder neoplasms are more common in elderly men. Kidney and bladder neoplasms often produce painless hematuria. Prostate cancer may produce symptoms of outlet obstruction.

Kidney problems can range from asymptomatic blood chemical changes to life-threatening abnormal renal function that could manifest in uid-electrolyte and acid-base imbalances. Patients with renal insufciency may present with nonspecic complaints such as fatigue, anorexia, or weakness. A discussion of renal insufciency and renal failure is beyond the scope of this chapter.

DIAGNOSTIC REASONING: FOCUSED HISTORY

Are systemic or acute symptoms present?

Key Questions

n Have you had fever, chills, nausea, or vomiting? n Are you positive for HIV infection or receiving

chemotherapy?

n Are you having acute pain? n Have you been able to pass any urine?

Fever and Chills

The presence of fever and/or chills suggests a systemic inammatory response and indicates that the patient may be acutely ill and should be aggressively treated. Specically, suspect pyelonephritis or lithiasis of the upper urinary tract or prostatitis, orchitis, or epididymitis of the lower urinary tract.

Immunocompromised Patients

Immunocompromised patients are susceptible to overwhelming infections by both common and aty pical organisms, and aggressive investigation is warranted.

208

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Acute Pain

Acute pain in the abdomen or ank is characteristic of bladder, ureter, and kidney involvement. Acute pain in the scrotum or testicles may indicate infection or pathology of the scrotal contents or it may be referred pain from other sites in the urinary tract. Pain in the scrotum or testicles is characteristic of inammation of the testicles, epididymitis, or torsion of a testicle (see Chapter 24).

Anuria

A sudden decrease in urinary output may result from compromised renal blood supply (prerenal); damaged interstitia, glomeruli, or tubules (intrarenal); or obstructed urine ow (postrenal). Patients with prerenal failure usually have a history of volume depletion or a reduction in arterial blood volume, such as in low cardiac output states. Patients with intrarenal failure may present with history of renal damage from nephrotoxic agents. Postrenal failure is the least likely cause of anuria, but it should be ruled out rst, because when failure results from obstructive causes, mechanical intervention may reestablish kidney function before permanent nephron damage occurs. Patients at greatest risk for acute renal failure are the elderly, diabetic patients, and those with a history of renal, heart, or liver disease.

Anuria may represent obstruction or renal failure.

Is there hematuria?

Key Questions

n Have you noticed blood in your urine? n Is there blood every time you urinate or just

occasionally?

n Does the blood start with the beginning of urina-

tion, continue throughout urination, or occur only at the end of urination? Is there blood without urinating?

n Do you have pain with the blood?

Hematuria

Blood can enter the urinary tract at any site. The most common source of isolated hematuria is extrarenal. A lesion of the bladder or lower urinary tract is demonstrated in more than 60% of patients. The most common causes of gross hematuria from the kidney are nephropathy and polycystic kidney disease. No

cause for hematuria can be found in 10% to 15% of

patients.

Timing

Initial hematuria becomes clear during voiding and is

indicative of anterior urethral lesions, such as urethri-

tis, stricture, or meatal stenosis. Terminal hematuria

begins with clear urine and then becomes bloody and

is suggestive of prostatic lesions or lesions in the pros-

tatic urethra. Total hematuria is usually characteristic

of lesions in the kidneys and ureters. Bladder lesions

may produce bleeding independent of micturition.

Recent trauma to the kidneys can also produce hema-

turia. Gross hem aturia is often transient but may con-

tinue microscopically.

Pain

Hematuria with pain usually indicates the passage of a

stone or sloughed renal papilla, often with concurrent in-

fection. Painless gross hematuria is consistent with upper

or lower tract tumor, systemic coagulopathy, or excessive

anticoagulant effect. Less common causes include acute

necrosis or sloughing of a papilla. In elderly men, painless

hematuria may be a late presenting sign of renal cancer.

Can the symptoms be localized within the urinary tract?

Key Questions

n Do you have trouble starting to urinate (e.g., slow/

weakened urinary stream, dribbling of urine)?

n Do you have low back, ank, or abdominal pain?

n Do you have aching in the perineal area?

n Do you have suprapubic discomfort?

n Have you had urinary incontinence?

n Do you have frequency, urgency, dysuria, or penile

discharge?

n Do you urinate at night?

n Do you have an excessive volume of urine?

Hesitancy, Slow Urinary Stream,

and Dribbling of Urine

In men older than 50, the presence of hesitancy, slow

urinary stream, and dribbling of urine with a gradual

onset over time indicates obstructive problems from be-

nign prostatic hypertrophy. Have the patient complete

the American Urological Association (AUA) Symptom

Index (Table 17-1). Using the index, classify symptoms

as mild (0 to 7), moderate (8 to 19), or severe (20 to 35).

210 Chapter 17 • Genitourinary Problems in Males

https://t.me/med1917

Table 17-1

Patients rate their answers to each question on a scale of 0 to 5.

QUESTIONS