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Chapter 18 • Genitourinary Problems in Males
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209
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
l
Have you noticed blood or blood clots in your urine?
l
Is there blood every time you urinate or just occa-
sionally?
l
Does the blood start with the beginning of urination,
continue throughout urination, or occur only at the
end of urination? Is there blood without urinating?
l
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 urethritis, stricture, or meatal stenosis. Terminal hematuria
begins with clear urine, then becomes bloody, and is
suggestive of prostatic lesions or lesions in the prostatic 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 hematuria.
Gross hematuria is often transient but may continue
microscopically.
Pain
Hematuria with pain usually indicates the passage of a
stone or sloughed renal papilla, often with concurrent
infection. Painless gross hematuria is consistent with
upper or lower tract tumor, systemic coagulopathy, or
excessive anticoagulant effect. Less common causes in-
clude 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
l
Do you have trouble with your urine stream (e.g.,
slow/weakened urinary stream, trouble starting, intermittent stream, dribbling)?
l
Do you have low back, ank, or abdominal pain?
l
Do you have pain in the scrotum or testicles?
l
Do you have aching in the perineal area?
l
Do you have suprapubic discomfort?
l
Have you had urinary incontinence?
l
Do you have frequency, urgency, painful urination,
or penile discharge?
l
Do you urinate at night?
l
Do you have an excessive volume of urine?
Slow Urinary Stream, Hesitancy, Intermittency,
Dribbling of Urine
In men older than 50, the presence of slow urinary
stream, hesitancy, intermittency and dribbling of urine
with a gradual onset over time indicates obstructive
problems from benign prostatic hypertrophy. Have the
patient complete the American Urological Association
(AUA) Symptom Index (Table 18-1). Using the index,
classify symptoms as mild (0 to 7), moderate (8 to 19),
or severe (20 to 35).
Low Back, Flank, or Abdominal Pain
Patient reports of low back, ank, or abdominal pain
are often indicative of ureteral and kidney involve-
ment. Renal tract pain may present with a constant dull
ache in the costovertebral angle (CVA) area. Dislodged
kidney stones will produce an acute ureteral pain that
is colicky and cyclic in nature. Gross blood in the urine
and infection may accompany the ureteral pain. The
pain can radiate to the abdomen, testes, and penis.
However, renal disorders do not frequently cause pain.
True renal pain can originate from the calyces or renal
pelvis. Pain can result from stretching of the kidney
capsule, interstitial edema, or inammation of the
capsule.
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Chapter 18 • Genitourinary Problems in Males
Table 18-1
Patients rate their answers to each question on a scale of 0 to 5.
The American Urological Association Symptom Index
AUA SYMPTOM SCORE (CIRCLE ONE NUMBER ON EACH LINE)*
QUESTIONS
Over the past month, how often have you had a
sensation of not emptying your bladder completely
after you finished voiding?
Over the past month, how often have you had to
urinate again less than 2 hours after you finished
urinating?
Over the past month, how often have you found you
stopped and started again several times when you
urinated?
Over the past month, how often have you found it
difficult to postpone urination?
Over the past month, how often have you had a weak
urinary stream?
Over the past month, how often have you had to push
or strain to begin urination?
Over the past month, how many times did you typically
get up to urinate from the time you went to bed at
night until the time you got up in the morning?
From Barry MJ, Fowler FJ Jr, O’Leary MP, et al: The American Urological Association Symptom Index for benign prostatic hyperplasia: The Measurement Committee of the American Urological Association, J Urol 148:1549, 1992.
*AUA Symptom Score 5 sum of above circled numbers. Symptoms are classified as mild (0-7), moderate (8-19), or severe (20-35).
AT ALL
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
NOT
LESS THAN
ONE TIME IN FIVE
LESS THAN HALF
THE TIME
ABOUT HALF
THE TIME
MORE THAN
HALF THE TIME
ALMOST
ALWAYS
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211
Testicular/Scrotal Pain
Acute pain in the scrotum or testicles may indicate infection or a pathological condition 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 inammation of the testicles, epididymitis,
or torsion of a testicle (see Chapter 27).
Aching in the Perineal Area
Prostate pain is often interpreted by the patient as a
vague ache in the perineal area. The usual cause of
perineal aching is infection; another cause may be
prostatic stones with infection.
Suprapubic Discomfort and Urinary Incontinence
Discomfort in the suprapubic area is indicative of bladder involvement, whereas urinary incontinence is characteristic of bladder neck irritability caused by inammation. Bladder pain is most often caused by infection;
however, it can also be produced by obstruction and
bladder distention as the result of a tumor or stones.
Penile Discharge With Frequency, Urgency,
and Dysuria
Penile discharge with frequency, urgency, and dysuria
is characteristic of anterior urethral irritation in males
and of exposure to a sexually transmitted infection
(STI) (see Chapter 27).
Nocturia
Primary bladder disease from infection, stones, or tumors can produce nocturia. Prostate enlargement characteristically produces nocturia. Most adults do not
need to void during the night but some may get up once
during the night, depending on the amount and timing
of uid ingestion.
Patients who report daytime frequency without noc-
turia are usually free of organic disease.
Polyuria
Polyuria is dened as a volume greater than 3 L of urine/
day and depends on uid intake and the patient’s state of
hydration. Polyuria may be an early indication of renal
disease progression because of the kidneys’ inability to
concentrate urine. Taking a history of uid intake is important to identify possible causes of polyuria. Pseudo
polyuria results from increased uid ingestion and may
present with certain personality disorders. With the current emphasis on water ingestion, however, a large uid
intake may also produce pseudo polyuria. Alcohol ingestion inhibits antidiuretic hormone; glycosuria promotes
excess solute excretion. Diabetes insipidus may also be
implicated. Nocturia can occur with the mobilization of
uid during sleep, secondary to congestive heart failure.
Are there any risk factors to point me in the right
direction?
Key Questions
l
Have you had this or similar problems before?
l
Do you have a family history of kidney problems,
prostatitis, prostate cancer, or diabetes?
l
How old are you? (What is the patient’s age?)
l
Have you been conned to bed (especially if elderly)?
l
Are you sexually active? How many partners do you
have?
l
Do you ride a bicycle?
History of Similar Problems
Patients with previous urinary problems are at risk for
chronic relapsing conditions such as unresolved infec-
tions, resistant strains of organisms, or reinfection.
Recurrent infections, pyelonephritis, or complications
warrant urological referral for workup and evaluation.
Family History of Urinary Problems
A family history of renal problems or prostatitis places
the patient at increased risk for urinary problems.
Familial disorders that may be implicated in kidney
disease include diabetes mellitus, hypertension, colla-
gen vascular disease, nephrolithiasis, and polycystic
kidney disease.
Age
The occurrence of UTIs in males increases with age.
Slow development of prostatic obstruction is common
in men older than 50 years and is usually painless.
Patients have difculty starting the urine stream; the
urine stream has decreased force; and urine often con-
tinues to dribble after voiding. Chlamydia is the major
cause of prostatitis, epididymitis, and nongonococcal
urethritis in males under 40 years of age. Adolescents
who are sexually active are at particular risk for STIs.
Confinement to Bed
Elderly patients conned to bed are at an increased risk
of infection. Likely mechanisms include urinary stasis
and reux.
Sexual Activity
Sexually active males, especially those who engage
in unprotected sex, are at risk for STIs, which can
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Chapter 18 • Genitourinary Problems in Males
produce urethritis. The risk increases with multiple
partners.
Bicycle Riding
On an upright bicycle, the design of the seat puts pressure on the ischial tuberosities and perineum of the
rider. The hip and pedaling motion of the rider contribute to neural symptoms by stretching the pudendal
nerve, especially if the seat is not correctly tted to
the rider. Perineal and penile numbness, without pain,
are symptoms frequently reported by long-distance
cyclists.
What else could this be?
Key Questions
l
Have you had a recent urological procedure or uri-
nary catheter?
l
Have you had recent treatment for an STI?
l
Have you been recently diagnosed with, but not
treated for, an STI?
l
What drugs have you taken (prescription, over-the-
counter, or recreational)?
l
What is your occupation?
l
What are your hobbies (toxic exposure)?
l
Has there been any scrotal swelling?
Recent Procedure or Catheter
Recent instrumentation in the urinary tract places the
patient at risk for infections. Patients with indwelling
catheters are also at risk for infection.
Recent Sexually Transmitted Infection
STIs can produce urethritis and urinary tract symptoms. Recent treatment for an STI may indicate treatment failure, a coinfection that was not covered by the
prescribed drug, or a reinfection.
Drugs
The most prevalent nephrotoxic drugs include aminoglycosides, nonsteroidal antiinammatory drugs, iodinated radiocontrast media, and angiotensin-converting
enzyme inhibitors. Less prevalent are antibiotics (such
as amphotericin B), chemotherapeutic agents, cocaine,
H2-receptor antagonists, phenytoin, sulfonamide diuretics, and volatile hydrocarbons.
Toxic Exposures
Occupational hazards that may cause kidney problems
include exposure to volatile hydrocarbons, benzene,
aniline, xylene, heavy metals, and ionizing radiation.
Scrotal Swelling
Scrotal swelling may indicate a hernia or hydrocele. In
infants swelling increased with straining or crying may
indicate a communicating hydrocele.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Note General Appearance
A patient who appears ill or who is in pain is likely to
have an upper urinary tract problem such as pyelonephritis, urolithiasis, or acute prostatitis. Patients with
lower urinary tract problems usually do not present
with signs of systemic involvement, are free of fever,
and generally appear well.
Obtain Vital Signs
Obtain a resting blood pressure as hypertension is seen
in patients with nephritis. Fever may result in an increased heart rate.
Inspect Skin and Mucous Membranes
A pale skin color may suggest anemia caused by poor
nutrition or chronic renal failure. Yellow-colored to
brown-colored skin without scleral icterus may indicate severe chronic uremia. Other skin changes seen
with renal problems may range from rash to purpura.
Palpate and Percuss for Flank Pain at the
Costovertebral Angle
Pain that is reproducible is indicative of renal capsule
distention and characterizes acute pyelonephritis or
acute ureteral obstruction. Perinephric abscess may
cause ank swelling and redness.
Auscultate the Abdomen
If the patient is hypertensive, auscultate the abdominal
aorta and renal and iliac arteries for bruits, which could
indicate a renovascular cause of the hypertension.
Palpate and Percuss the Abdomen
Abdominal distention suggests ascites or uid collection
in the bowel. Pain in the lower quadrant indicates lower
ureter involvement. Perform deep palpation to identify
kidney or other abdominal masses. Normal kidneys are
usually not easily palpated. A distended bladder rises
above the symphysis pubis and is characteristic of
residual urine from incomplete bladder emptying. Palpation of an enlarged bladder may cause pain. Chronic
bladder distention is usually painless and cannot always
be determined by manual palpation alone.
Chapter 18 • Genitourinary Problems in Males
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213
Inspect and Palpate the External Genitalia
Inspect the skin and hair for inammation, lesions,
parasites, and dermatitis. Note hair pattern distribution
and level of development of structures for age. Palpate
the shaft of the penis for strictures. Observe for phimosis, if uncircumcised, and retract the foreskin. Note
inammation or presence of smegma. Inspect glans,
corona, and frenulum areas for lesions. Note personal
hygiene; phimosis or paraphimosis in uncircumcised
males; and presence of urine, discharge, and fecal
stains on undergarments. Check position of the urethral
meatus. Strip or milk the penis from the base toward
the glans or head of the penis. Note the color, consistency, and amount of any discharge.
Check scrotum skin surfaces and testicles for tenderness or masses, and also check for epididymis, spermatic cords, and inguinal canals. In infants palpate the
scrotum to assess for undescended testicles. Holding a
nger in the inguinal canal prevents the testicle from
slipping into the canal when palpating the scrotum. The
left scrotal sac usually hangs lower than the right. Elevation of an affected testicle may relieve discomfort
(positive Prehn sign) and is characteristic of epididymitis. In testicular torsion, elevation fails to relieve pain
(negative Prehn sign). A painful scrotal mass is usually
associated with inammation or testicular torsion.
Perform scrotal transillumination in a darkened
room. Do not use a halogen light source as it may burn
the patient. A solid mass prevents the passage of light
and requires further examination. A hydrocele is a nontender collection of uid in the scrotum. It will transilluminate but may make testicular palpation difcult. A
spermatocele (a cystic swelling on the epididymis) is
not as large as a hydrocele but does not transilluminate.
A varicocele occurs from dilated veins in the scrotal
sac and usually occurs on the left side. A varicocele is
often more prominent when the patient is standing and
regresses with the patient in the prone position. It is
classically described as a “bag of worms.”
Observe Voiding
Observing the patient urinating may be useful to check for
hesitancy in initiating the urine stream, force of stream,
and dribbling at end of micturition. Observe the abdominal force used during urination. Patients will use abdominal muscles to increase the intra-abdominal pressure to
force urine from the bladder while holding their breath.
Perform Digital Rectal Prostate Examination
Digital rectal examination of the prostate is performed to
identify irregularities of the prostate that are suggestive
of cancer and to note any tenderness or inammation.
The size and consistency should be noted. The median
sulcus and lateral margins should be palpated. Induration
or rmness is characteristic of early prostate disease; a
hard stony gland suggests advanced prostatic carcinoma.
The gland may feel soft because of inammation or infection. If hypertrophied, the prostate gland will extend
into the rectal canal, and the median sulcus may be obliterated. Do not massage the prostate if acute prostatitis is
suspected because of the possibility of spreading the infection. Document the amount of prostate extension into
the rectum using an acceptable clinical scale such as the
following:
l
Grade I: protrudes less than 1 cm into the rectum
l
Grade II: protrudes 1 to 2 cm into the rectum
l
Grade III: protrudes 2 to 3 cm into the rectum
l
Grade IV: protrudes more than 3 cm into the rectum
LABORATORY AND DIAGNOSTIC STUDIES
The history and the ndings of the physical examination determine the extent of diagnostic investigation.
The symptoms reported by the patient are taken into
account when ordering diagnostic tests to corroborate
or verify the diagnosis. General screening tests can be
used to provide additional data for patients with urinary tract problems.
Specic tests for kidney function include urinalysis, screening blood chemistry tests (such as urea,
nitrogen, and serum creatinine), and hematological
studies. Abnormal blood tests include elevated creatinine and blood urea nitrogen levels, hyperkalemia,
and hypocalcemia.
Urine collected for urinalysis should be freshly
voided and preferably midstream. If not examined immediately, the specimen should be refrigerated as cells
begin to hemolyze after 1 to 2 hours.
Urine Dipstick
Reagent strips can be used to screen urine in the clinical setting. A positive leukocyte esterase or nitrite test
result (a 1 on the reagent strip) is indicative of urethritis. Urine that tests positive for leukocyte esterase
should also be tested for bacteria. Proteinuria may
indicate kidney involvement. Suspect proximal renal
tubular damage if urine glucose is elevated while serum glucose levels are normal. Blood in the urine
could be caused by acute or chronic prostatitis, urethritis, hemorrhagic cystitis, renal stones, or tumors of
the kidney, renal pelvis, ureter, bladder, prostate, and
urethra. Hematuria with proteinuria usually suggests a
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Chapter 18 • Genitourinary Problems in Males
renal origin. Isolated hematuria is usually produced by
sites outside the kidneys.
Urinalysis With Microscopic Examination
Turbidity with a foul odor indicates infection. Color
changes of the urine may result from various sources:
hemoglobin from systemic red blood cell (RBC)
lysis; myoglobin from damaged muscle cells or rhabdomyolysis; vegetable pigments from food, such as
red beets; pigments from drugs, such as rifampin
and phenazopyridine; and porphyrins from porphyria.
RBCs indicate acute inammatory or vascular disorders of the glomerulus. Casts indicate hemorrhage or
conditions of the nephron. Red cell casts are characteristic of glomerular origin. The presence of abnormal
cells, protein, hemoglobin, myoglobin, or other debris
with a cast helps identify the type of renal disease.
Signicant proteinuria results from glomerulopathies,
whereas tubular disorders cause little proteinuria.
Therefore the sediment ndings are helpful to correlate with the degree of proteinuria. Urinalysis is indicated for all males presenting with lower urinary tract
symptoms.
Segmented Urine Collection (Meares-Stamey
4-Glass Test) for Gram Stain, Culture and
Sensitivity, and Leukocyte Count
Segmented urine collection is used to identify the site
along the urinary tract where the colonization of organisms is occurring. The standard method for specimen
collection and labeling is the following:
l
Voided bladder specimen 1 (VB 1): 5 to 10 mL of
rst-voided urine collected
l
Voided bladder specimen 2 (VB 2): sterile midstream
urine collected
l
Expressed prostatic secretion (EPS): prostatic mas-
sage performed and prostatic secretion collected
from meatal opening
l
Voided bladder specimen 3 (VB 3): complete empty-
ing of bladder; urine specimen collected
Box 18-1
I Acute bacterial prostatitis (acute symptoms)
II Chronic bacterial prostatitis (symptoms present
III Chronic prostatitis/chronic pelvic pain syndrome
IIIA Inflammatory CPPS (WBCs found in semen,
IIIB Noninflammatory CPPS (no WBCs in semen,
IV Asymptomatic inflammatory prostatitis (no
Reference: Krieger JN, Nyberg L Jr, Nickel JC: NIH consensus definition and classification of prostatitis. JAMA 282:236, 1999.
NIH Classication of Prostatitis
for 3 months)
(CPPS) (no bacterial cause)
expressed prostatic secretions, or final voided
specimen)
expressed prostatic secretions, or final voided
specimen)
subjective symptoms; incidental detection of
WBCs in expressed prostatic secretions or
prostate tissue)
Another option is the premassage and postmassage
urine test (PPMT) (see Evidence-Based Practice box:
4 Glasses or 2?). The following two urine samples are
collected:
l
A midstream urine specimen before prostatic massage
l
A rst-voided urine specimen immediately after
prostatic massage
Label each of the specimens and perform culture
and sensitivity or Gram staining. The presence of bacteria in VB 1 suggests urethritis. The presence of bacteria in VB 2 suggests cystitis. Bacteria present in EPS
or VB 3 in the absence of bacteria in VB 1 and VB 2
specimens or a bacterial culture at least 10 times higher
in VB 3 samples than in VB 1 and VB 2 samples, is
suggestive of bacterial prostatitis.
On microscopic analysis, increased numbers of leu-
kocytes in the EPS and VB 3 are indicative of inammation. The presence of white blood cells (WBCs) helps
diagnose prostatitis and chronic pelvic pain syndrome
(Box 18-1).
EVIDENCE-BASED PRACTICE
The Meares-Stamey 4-glass test is the standard method
of assessing in flammation and the presence of bacteria in
the lower urinary tract in men presenting with chronic
prostatitis. However, evidence suggests that the simpler
2-glass premassage and postmassage urine test (PPMT)
may be sufficient to detect infl ammation and bacteria. In a
Data from Nickel J, Shoskes D, Wang Y, et al: How does the premassage and postmassage 2-glass test compare to the Meares-Stamey 4-glass test
in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol 17:119, 2006.
4 Glasses or 2?
study of 353 men, the 2-glass PPMT was compared to the
Meares-Stamey 4-glass test in detecting inflammation
and bacteria in men with chronic prostatitis syndro me. The
PPMT had strong concordance with the 4-glass test
and predicted a correct diagnosis in more than 96% of
subjects.
Chapter 18 • Genitourinary Problems in Males
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215
Urodynamic Testing
Urodynamic studies can be used to determine diminished force of urination and obstruction. Flow rate is
dened as the volume of uid expelled from the urethra per unit of time and is expressed in milliliters per
second. The patient must have a full bladder because
urine ow rate depends on voided volume. The patient
urinates into an insert in the toilet, which measures the
ow rate of the urine. The normal ow pattern exhibits
a rapid increase to maximal ow rate, within one third
of the ultimate voiding time. After achieving maximal
rate, the ow decreases more slowly; average ow rate
should be approximately 50% of the maximal urine
ow rate.
Gram Stain
Gram stain of urethral exudate or spun urine should be
performed to determine inammation (WBCs) and the
presence of either gram-negative or gram-positive bacteria. Gram-negative bacteria stain pink-red; grampositive bacteria stain dark blue to purple. The nuclei
of polymorphonuclear neutrophils (PMNs) (leukocytes) stain pink-red. A Gram stain with more than 4
PMNs/high-power eld (HPF) is indicative of urethritis (dened by the presence of 5 to 10 PMNs/HPF).
However, any number of WBCs is suggestive of urethritis. A symptomatic patient with risk factors but no
abnormal laboratory results should be retested using
the rst voided urine of the day.
If the stain is positive for PMNs, examine the smear
for gram-negative intracellular diplococci (GNICDCs).
If GNICDCs are found, the smear is considered positive for gonococcal urethritis. A smear that is equivocal
or atypical indicates a mixed gonococcal and nongonococcal urethritis. If there are no GNICDCs, nongonococcal urethritis is indicated. The Gram stain has 95%
specicity in gonococcal urethritis, with nearly 100%
sensitivity in urethritis.
(PCR) tests. Tests are available for Chlamydia tracho-
matis and Neisseria gonorrhoeae as well as other
organisms.
Creatinine and Blood Urea Nitrogen
Serum creatinine and blood urea nitrogen levels are
used to indicate kidney function.
Prostate-Specific Antigen
Tumor markers, such as prostate-specic antigen
(PSA), may be used to detect or monitor prostate
cancer. PSA results should be correlated with the
digital rectal examination (DRE). For average-risk
males, levels of 1 to 4 ng/mL are considered within
reference range, whereas 4 to 10 ng/mL are elevated
levels that fall into a gray zone and may require other
tests such as transrectal ultrasound (TRUS) and prostate biopsy. PSA levels of 10 ng/mL or above are abnormal and are suggestive of malignant activity of the
prostate. The threshold level for African American
males who are at risk may be lower than for other
groups. The higher the PSA level, the more likely the
presence of prostate cancer; however, men with prostate cancer may have a normal or borderline PSA
level. In men taking nasteride, normal PSA is less
than 2 ng/mL because nasteride halves the PSA
level. A normal PSA level and a normal DRE make
the presence of cancer unlikely.
Currently the use of PSA testing to screen men for
prostate cancer is variable (see Evidence-Based Practice
box: Prostate Cancer Screening).
Radiography
If microscopic hematuria is present and the patient is
under 50 years of age, obtain a at plate of the abdomen to identify structures of the kidney, ureters, and
bladder (KUB). Urinary calculi are usually visible on
radiographs (see Chapter 40).
Culture and Sensitivity
Culture and sensitivity should be performed on specimens to identify the causative organism and its sensitivity to antibiotics. This is especially important in
populations at increased risk for resistant organisms.
DNA Testing for Infectious Organisms
DNA testing using a sample taken from the urethra
or rst-voided urine provides rapid, sensitive, and specic results.
DNA tests include DNA probes, nucleic acid ampli-
cation tests (NAATs), and polymerase chain reaction
Ultrasound
Ultrasonography is noninvasive and provides information on the kidneys, ureters, bladder, vascular
structures, prostate, and testicles. Renal ultrasound is
a good rst test to determine kidney size and contour
and the presence of calculi. A urinary bladder sonogram is used to identify tumors of the bladder, thickening of the bladder wall, posterior masses behind
the bladder, and obstruction of the lower urinary tract
evidenced by residual urine. A scrotal sonogram
is used to evaluate chronic scrotal swelling; it can
be used to identify abscess, infected testes, tumor,
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Chapter 18 • Genitourinary Problems in Males
EVIDENCE-BASED PRACTICE
Evidence about mortality outcomes from prostate cancer
screening varies. Results from a large scale randomized
clinical trial on prostate-cancer mortality showed no difference in mortality rates from prostate cancer between the
screening group and the usual care group (Andiole et al,
2009). Mortality from prostate cancer was low in both
groups. Screening provided no reduction in death rates at
7 years and no indication of a benefit appeared with 67% of
the subjects having completed 10 years of follow-up.
However, a European study (Schröder et al, 2009) reports contrary evidence. The study is a combination of seven
European trials with different screening protocols and different ages of entry. The study demonstrated that the relative risk of death from pros tate cance r was reduced by 20%
in men aged 55 to 69 years who underwent serial PSA
screening. The absolute risk difference was 0.71 deaths per
Data from Andriole G, Crawford E, Grubb R III, et al: Mortality results from a randomized prostate-cancer screening trial, N Engl J Med 360:1310,
2009; Schröder F, Hugosson J, Roobol M, et al: Screening and prostate-cancer mortality in a randomized European study, N Engl J Med
360:1320, 2009.
hydrocele, spermatocele, adherent scrotal hernia, and
Prostate Cancer Screening
1000 men. This means that 1410 men would need to be
screened and 48 additional cases of prostate cancer would
need to be treated to prevent one death from prostate
cancer.
Conclusion: The decision to engage in prostate cancer
screening is complex. Based on the evidence of the benefits
and harms of the service and an assessment of the balance,
the U.S. Preventive Services Task Force recommends against
(D grade) routine PSA-based screening. Authorities agree that
a PSA test for screening should not be done unless the individual being screened understands the uncertainties, risks,
and potential benefits of prostate cancer screening and
makes a personal decision that even a small possibility of
benefit outweighs the known risk of harms. Most authorities
agree that prostate cancer screening should include prostate
examination and PSA testing.
DIFFERENTIAL DIAGNOSIS
chronic epididymitis. However, because it does not
assess perfusion, it is less helpful in the initial examination of an acute condition of the scrotum. A Doppler
blood ow imaging examination is more appropriate.
Transrectal prostate ultrasound imaging can be used to
evaluate the prostate for tumors or nodules and to determine the volume of the prostate. It is also useful in
diagnosing prostatitis, benign prostatic hyperplasia,
and cancer of the prostate.
Cystitis/Urethritis
Males may have inammation limited to the penile segment of the urethra. The history would include meatal
burning and discharge. Classic symptoms are frequency,
urgency, and dysuria. Nocturia with suprapubic or low
back pain is common.
Screening can be done in most settings with urine
dip strips. A positive leukocyte esterase and nitrate test
indicates infection. Urine culture and sensitivity con-
Computed Tomography
Noncontrast helical (spiral) computed tomography
(CT) is the gold standard for evaluating kidney stones.
It has 95% sensitivity and 98% specicity.
rms diagnosis and identies the causative organism(s).
Urinalysis with microscopic examination can determine if 20 or more organisms/HPF are present, which
is indicative of UTI. Less than 20 organisms/HPF merits further study, such as culture and sensitivity. Colo-
Doppler Flow Studies
Doppler blood ow studies are used to measure blood
nization has taken place if 103 or more organisms/mL
are present in the culture.
ow to the scrotal structures. Color Doppler provides a
color image depicting the direction of the ow and the
velocity in shades of blue and red. It is useful in the
differential diagnosis of testicular torsion and epididymitis. A Doppler of testicular torsion demonstrates reduced or absent blood ow, and epididymitis will show
blood ow.
Pyelonephritis
The patient with pyelonephritis has fever and chills,
appears toxic, and reports back pain. Nausea and vomiting may be present. Some patients also report lower
urinary tract symptoms including frequency and dysuria. The patient feels and looks ill. On physical
examination, CVA tenderness is usually present. The
Biopsy
Biopsy of the prostate is necessary for denitive diagnosis of cancer. Guided biopsy is performed using
transrectal ultrasound.
abdomen may also be tender. On microscopic examination, WBCs are usually present. White cell casts
suggest pyelonephritis. Bacterial casts, although rare,
are pathognomonic of pyelonephritis. Urine culture
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and sensitivity conrm the diagnosis and identify the
pathogen, which is usually E. coli, Klebsiella, Proteus
mirabilis, or Enterobacter.
Urolithiasis
Urinary stones can occur anywhere in the urinary tract
and may produce symptoms of pain, hematuria, and
secondary infection. Many calculi are “silent” and may
only cause hematuria, either microscopic or gross. Renal calculi may occur when a stone obstructs the urinary tract. Typical symptoms of renal colic include
severe ank pain that radiates along the pathway of the
ureter to the scrotum or inner thigh. Chills, fever, and
urinary frequency are common. The patient may have
nausea, vomiting, and abdominal distention. There
may be a history of hematuria. Painful hematuria is
characteristic of a stone, and the pain is described as
colicky. Evaluate if the hematuria occurs at the time
of urine initiation, at termination of micturition, or
throughout micturition. This may be helpful in localizing the stone.
The clinical diagnosis is supported by urinalysis and
imaging ndings. The urine test results may be normal;
gross or microscopic hematuria is common. Pyuria
(WBCs) with or without bacteria may be present. Crystalline structures might be present. Noncontrast helical
(spiral) CT is the gold standard for evaluating kidney
stones.
Acute Bacterial Prostatitis
The patient with acute prostatitis is obviously ill and
presents with chills, high fever, urinary frequency and
urgency, perineal pain, and low back pain. The patient
may exhibit varying degrees of obstructive symptoms,
dysuria or burning, nocturia, hematuria, arthralgia,
and myalgia. On examination, the prostate gland is
tender, swollen, indurated, and warm. Do not massage
the gland because bacteremia can result from the
expression of microorganisms. Urine or prostate secretion culture can conrm the diagnosis. The most
common causative organism is E. coli. Other common
organisms include species of Klebsiella, Enterobacter,
and Proteus. (See Box 18-1 for the classication of
prostatitis.)
Chronic Bacterial Prostatitis
Chronic prostatitis is a common cause of recurrent
cystitis in men. The patient may present with recurrent
urinary tract infections. Chronic bacterial prostatitis is
caused by the same pathogens seen in acute prostatitis.
Patients may be asymptomatic. Common symptoms, if
evident, include low back pain and perineal discomfort, urinary frequency, and painful urination. Traditionally, symptoms are present for at least 3 months for
a diagnosis of chronic prostatitis. Infection can involve
the scrotal contents, producing epididymitis. Palpation
of the prostate may reveal no specic ndings. It may
be moderately tender and irregularly indurated or
boggy. Copious secretion may be present. Diagnosis is
made on the basis of clinical symptoms and by culture
of prostatic secretion or positive bacteria culture from
postmassage urine. WBCs will be present in EPSs
and VB 3.
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
The diagnostic criterion for chronic prostatitis/chronic
pelvic pain syndrome (CPPS) is pelvic pain that has
been present for at least 3 of the preceding 6 months,
with no bacterial cause. The pain may be accompanied
by additional symptoms such as dysuria, urgency,
frequency, and backache. Patients may or may not
have had obstructive voiding symptoms. Inammatory CPPS is characterized by the absence of bacteria
and the presence of WBCs in the semen, EPS, or VB 3.
This category was previously called nonbacterial prostatitis. Noninammatory CPPS is characterized by
the absence of both bacteria and WBCs in the semen,
EPS, or VB 3. This condition was formerly called
prostadynia. The prostate may feel normal on clinical
examination.
Asymptomatic Inflammatory Prostatitis
This condition is diagnosed in patients during the
evaluation of another genitourinary (GU) problem,
such as benign prostatic hypertrophy. These patients do
not experience genitourinary pain. WBCs are found in
the expressed prostatic secretions.
Epididymitis/Orchitis
The patient with epididymitis/orchitis is usually a
sexually active young male, and pain is the likely presenting symptom. The patient may be febrile. The history usually indicates a slow onset of discomfort over
hours or days as compared with testicular torsion,
which has a rapid onset of symptoms. Elevation of the
affected testicle may reduce the discomfort. Swelling
of the scrotum and testicle may be present. Palpable
swelling of the epididymis is usually present. Doppler
ow studies with color can locate hot spots and identify intact blood ow. Urethral discharge or an intraurethral swab specimen should be Gram stained for
a diagnosis of urethritis. DNA testing using either a
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Chapter 18 • Genitourinary Problems in Males
urethral specimen or rst-void urine should be performed to test for N. gonorrhoeae and C. trachomatis.
Testicular Torsion
The patient with testicular torsion is usually a pubescent male with previous episodes of testicular pain.
The history indicates a rapid onset of acute pain. Nausea and vomiting may have occurred or be present.
Doppler blood ow studies may support the diagnosis
by identifying lack of blood ow to the affected testicle. This is an emergent condition, and intervention
must take place within the rst 4 to 6 hours to salvage
the testicle from infarction.
Hydrocele, Spermatocele, and Varicocele
A hydrocele is a nontender rm mass in the scrotum
that results from uid accumulation. It will transilluminate but may make testicular palpation difcult. A
spermatocele (a cystic swelling on the epididymis) is
not as large as a hydrocele but does not transilluminate.
A varicocele occurs from dilated veins in the scrotal
sac and usually occurs on the left side. A varicocele is
often more prominent when the patient is standing and
regresses with the patient in the prone position. It is
classically described as a “bag of worms.”
Benign Prostatic Hyperplasia
Prostatic hypertrophy is common in men older than 50.
Presenting symptoms include hesitancy, slow urine
stream, and dribbling. Digital rectal examination reveals an enlarged prostate with a reduced or obliterated
median sulcus. Induration or rmness is characteristic
of early prostate disease, and a hard stony gland sug-
gests advanced prostatic carcinoma. The gland may
feel soft because of inammation or infection. The
American Urological Association Symptom Index (see
Table 18-1) is useful in determining treatment options
based on the severity of symptoms, ranging from mild
to severe. Digital rectal examinations combined with
PSA tests are done annually by many clinicians for
men older than 50 and for men at risk, including
African American males starting at age 40, to differentiate between BPH and prostate cancer.
Prostate Cancer
Patients with prostate cancer often present with the same
obstructive symptoms as BPH, but they may also be
asymptomatic. Males who report lower abdominal pain
may have an extension of the cancer with metastasis. On
examination, the prostate is stony hard and protrudes into
the colon. PSA levels may be elevated, and TRUS indicates enlargement or nodules. An abnormal digital rectal
examination or an elevated PSA level necessitates further
evaluation to determine or rule out prostate cancer (see
Evidence Based Practice box: Prostate Cancer Screening).
Bladder or Kidney Tumor
Silent hematuria in elderly patients is often a latepresenting indication of cancer. It is more common in
men than women. Patients often have a history of
smoking or alcohol abuse.
Perineal Compression Syndrome
Compression of the pudendal nerve in long-distance
cyclists can result in genital numbness without pain. An
ill-tting bicycle seat may contribute to the problem.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Cystitis/
urethritis
Pyelonephritis Fever, chills, back pain, nausea
Urolithiasis Pain, hematuria; may have
Common Causes of Genitourinary Problems in Males
Frequency, urgency, dysuria;
nocturia with low back
pain
and vomiting, toxic appearance; some patients also
have frequency and dysuria
symptoms of secondary
infection; renal colic; pain
that radiates to inner
thigh; nausea, vomiting
Discharge may be present;
may have suprapubic
tenderness
Feels and looks ill; tempera-
ture .101º F; CVA
tenderness; abdomen may
be tender
May have CVA tenderness;
looks ill during periods of
acute pain; may have
abdominal distention
Urine dipstick: positive leukocyte
esterase; hematuria; urinalysis
with microscopic examination;
segmented urine collection; Gram
stain; C&S; urine DNA test
Microscopic examination: WBCs
may have white cell casts or
bacterial casts; urine C&S;
blood cultures
Urinalysis: gross or microscopic
hematuria; WBCs with or
without bacteria; crystalline
structures may be present;
radiograph or ultrasound
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