Urethritis, Epididymitis, Prostatitis

Question 1

What is urethritis

Answer 1

inflammation of the urethra

Question 2

What are non-infectious causes of urethritis

Answer 2

Trauma
Reiter’s
Urethral stricture, stone, or lesions

Question 3

What are infectious causes of urethritis

Answer 3

Gonorrhea (gram neg intracellular diplococci**)

chlamydia, Mycoplasma genitalium, trich, adenovirus

Question 4

What are Sx of urethritis

Answer 4

Dysuria 
urethral discharge 
urethral pruritis 
Gonorrhea: produse purulent discharge 
Chlamydia: clear, purulent, or absent discharge

Question 5

What will you find on urethritis labs

Answer 5

First void UA: Leukocyte esterase, >10 WBC

Gram stain of urethral dx: >5 WBC

Question 6

How can you test for gonorrhea

Answer 6

Urethral swab >1hr after void (collect from meatus, or insert swab 2-4cm, rotate, withdraw)- shows sensitivity
NAAT first 10-30mL >1hr after last void- no sensitivities

Question 7

How can you test for chlamydia

Answer 7

Urethral swab for culture >1 hr after last void

NAAT

Question 8

How do you treat Gonorrhea

Answer 8

Rocephin (Ceftriaxone) 250mg IM x 1 dose
alternative: Cefixime 400mg PO x 1 dose
No sex for 7 days after first dose

Question 9

How do you treat Chlamydia

Answer 9

Azithromycin 1g po x 1 dose
Doxycycline 100mg PO BID x 7 days
No sex for 7 days after first dose

Question 10

How do you follow up on gonorrhea s/p Tx

Answer 10

Test for cure 3 months s/p Tx

Must test 1 week and 3 months s/p Tx if Cefixime given

Question 11

How do you follow up on chlamydia s/p Tx

Answer 11

If uncomplicated urethritis is responsive, no need to f/u

If pregnant, need test of cure 3-4 weeks s/p Tx completion

Question 12

General urethritis follow up includes

Answer 12

Referring sex partners and treating all those in sexual contact with patient in past 60 days

Question 13

What is epididymitis

Answer 13

Inflammation of epididymis

orchitis is inflammation of testicle- many have epididymo-orchitis

Question 14

What can cause epididymitis

Answer 14

Behcet’s disease (oral and genital ulcers, uveitis, skin lesions)
Amiodarone
Tumor of testis or epididymis
Acute bacterial (M <35, gonorrhea/chlamydia) (M>35, E. coli)
Viral
Granulomatous
fungus, ureaplasma, trichomonas

Question 15

How does epididymitis present

Answer 15

Testicular pain

Urethral discharge and urethritis if STD

Question 16

What will you see on epididymitis PE

Answer 16

Swollen, tender testicle, epididymis, or spermatic cord

+/- fever, hydrocele

Question 17

What evaluation is done for epididymitis

Answer 17

Urine culture
Test for STD if suspected
+/- Scrotal US w/ doppler (will show increased blood flow)

Question 18

How do you treat epididymitis

Answer 18

Scrotal support (provides relief) 
Analgesics, cold
Abx- STD susp. give rocephin and doxy
non-STD susp. give Levofloxacin (or doxy) 
May need IV abx if severe 
Anti-tuberculars if TB

Question 19

What is chronic epididymitis

Answer 19

Epididymitis lasting longer than 3 months

Question 20

What referred pain can look like epididymitis

Answer 20

Stone
Hernia repair
Indirect inguinal hernia

Question 21

How do you evaluate chronic epididymitis

Answer 21

UA
Urine C&S
Scrotal US with doppler
CT for stones

Question 22

Conservative Tx for chronic epididymitis includes

Answer 22

analgesics 
scrotal support 
modify ALD 
moist heat 
spermatic cord block 
Abx

Question 23

Surgical Tx for chronic epididymitis includes

Answer 23

Testicular denervaiton
removal of sperm granuloma
orchiopexy if torsion
inguinal orchectomy

Question 24

What is the hallmark of prostatitis

Answer 24

Prostatic pain

Question 25

What are the types of prostatitis

Answer 25

Acute bacterial Chronic bacterial Inflammatory, non bacterial Prostadynia (non bacterial and non inflammatory)

Question 26

How does Acute bacterial prostatitis present

Answer 26

Fever Irritative Warm, boggy, tender prostate +/- obstructive voiding

Question 27

What causes acute bacterial prostatitis

Answer 27

MC E. Coli | young men

Question 28

What should you do to evaluate acute bacterial prostatitis

Answer 28

H&P (NO vigorous prostate exam) Urine culture (no prostate massage, dont want to spread bacteria) CBC, blood cultures

Question 29

How do you treat acute bacterial prostatitis

Answer 29

Significant fever, high WBC, sepsis: ADMIT after dc, 4-6 weeks abx If fever persists, get a pelvic CT to r/o abscess

Question 30

How does Chronic bacterial prostatitis present

Answer 30

Pain: genitals, perineum, low back Irritative urinary Sx: dysuria, urgency, frequency Pain with ejaculation

Question 31

What causes chronic bacterial prostatitis

Answer 31

E. Coli | OLDer men

Question 32

How do you evaluate chronic prostatitis

Answer 32

Pt will have a Hx of recurrent UTI | PE shows: tender boggy prostate

Question 33

What labs should you get to eval chronic prostatitis

Answer 33

Expressed prostatic secretion | Post prostate massage urine culture

Question 34

How do you treat chronic prostatitis

Answer 34

1. Empiric Bactrim x 8-16 wks #2. Empiric Fluoroquinolones (tendinitis) x 8-16 wks adjust based on culture results -NSAID, Alpha blockers, Anticholinergics

Question 35

Other chronic prostatitis Tx includes

Answer 35

Phytotheraoy, zinc, diet, stress management, prostate massage, ejaculation, sitz bath (soak in warm water for 30 min

Question 36

How does Inflammatory chronic pelvic pain syndrome (NONbacterial prostatitis)present

Answer 36

Similar to chronic prostatitis; pain in genitals, perineum, low back dysuria, urgency, frequency, pain with ejaculation

Question 37

What will you classically fine on evaluation of nonbacterial prostatitis

Answer 37

History of UTI Prostate tenderness Prostatic fluid with leukocytes (WBC) but cultures are negative!

Question 38

How do you treat Nonbacterial prostatitis

Answer 38

Empiric Bactrim x 6-8 weeks | If unresponsive, Doxy x 4-6 weeks (ureaplasma, chlamydia, mycoplasma)

Question 39

How do you treat Nonbacterial prostatitis

Answer 39

palliative measures; NSAID, anticholinergics, alpha blockers, sitz bath, stress reduction, zinc, nickel, saw palmetto, prostate massage, caffeine, alcohol, spicy food, Benzos, TCA, analgesics

Question 40

How does Prostadynia present

Answer 40

Like chronic prostatitis Pain in genitals, perineum, low back pain with ejaculation dysuria, urgency, frequency

Question 41

What will evaluation for Prostadynia show

Answer 41

No bacteria on culture No leukocytes in prostatic fluid (not inflammatory) hard to Dx!

Question 42

How do you treat Prostadynia

Answer 42

Same palliative measures as nonbacterial prostatitis