Abstract
Common urogenital complaints are discussed with clinical presentation, diagnostic features, and treatment recommendations offered.
Keywords
epididymitis, genital herpes simplex, prostatitis, kidney stones, urethritis, urinary tract infection (UTI)
1
What organisms commonly cause epididymitis?
Sexually transmitted infections ( Neisseria gonorrhoeae and Chlamydia trachomatis ) are the most common in 16- to 30-year-old men, but Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa are a prevalent cause in the 51- to 70-year-old age group. Noninfectious inflammation of the epididymis is far less common, occurring mostly in prepubertal boys.
2
How does acute epididymitis typically present?
Several days to weeks of progressive dull aching pain of the epididymis and testes, often with swelling. Associated abdominal pain and fever are common, and urinary tract infection symptoms, such as dysuria, frequency, and hematuria, may also be present.
4
What other urologic conditions can mimic epididymitis?
Scrotal pain and swelling can be caused by trauma, inguinal hernia, testicular torsion, torsion of the appendix epididymis (most common in prepubertal boys), Fournier gangrene, and testicular cancer may all cause genital pain and swelling of the scrotal contents.
5
What is the best exam approach to assess for scrotal pain?
A standing exam is helpful to differentiate epididymitis. Pain relief by elevation of the scrotum (Prehn sign) correlates highly with epididymitis, and presence of ipsilateral cremasteric reflex is reassuring that testicular torsion is not as likely. Tenderness and swelling of the epididymis, and often the adjacent testes, is palpable. A mass within the testes is not consistent with epididymitis and warrants further investigation. Supine abdominal examination is also integral to assess for an intraabdominal process radiating pain to the external genitalia.
6
What testing is indicated in the evaluation of suspected epididymitis?
Testing for sexually transmitted infections (STIs), especially gonorrhea and chlamydia, should be done for sexually active men, at least those under 35 years of age. A urine analysis with culture is indicated, particularly for older men and younger adolescents, as coliform bacteria are more likely causative in these age groups.
8
With such variable bacterial causes, what treatment should be started for presumed epididymitis?
Treatment should be tailored to likely pathogens. Because sexually transmitted infection is the most common cause of epididymitis in younger men, standard treatment for N. gonorrhoeae and C. trachomatis should be given while studies are pending. For older men the same treatment may be appropriate given the clinical presentation, but coverage for typical urinary pathogens may be more appropriate. See Table 7.1 for drug and dosage details.
| Epididymitis most likely STI with C or GC | Ceftriaxone 250 mg IM x 1 dose Doxycycline 100 mg bid x 10 days | |
| Epididymitis in MSM with enteric organism coverage | Ceftriaxone 250 mg IM x 1 dose Doxycycline 100 mg bid x 10 days OR ceftriaxone 250 mg IM x 1 dose + ofloxacin 300 mg bid x 10 days | |
| Epididymitis most likely enteric organism | Levofloxacin 500 mg/d x 10 days OR ofloxacin 300 mg/d x 10 days | |
| Urethritis, likely GU or NGU | Ceftriaxone 250 mg IM x 1 dose + azithromycin 1 g po x 1 dose | If ceftriaxone not available, cefixime 400 mg po x 1 dose + azithromycin 1 g po x 1 dose If cephalosporin allergy, gemifloxacin 320 mg po x 1 dose + azithromycin 1 g po x 1 dose OR gentamycin 250 mg IM x 1 dose + azithromycin 1 g po x 1 dose |
| NGU, confirmed chlamydia | Azithromycin 1 g po x 1 dose OR doxycycline 100 mg bid x 7 days | Erythromycin base 500 mg qid x 7 days Erythromycin ethyl succinate 800 mg qid x 7 days Levofloxacin 500 mg/d x 7 days Ofloxacin 300 mg bid x 7 days |
| NGU persistent/recurrent | Use the other treatment as above OR If T. vaginalis is highly prevalent, metronidazole 2 g po 1 dose | If failed on azithromycin, use moxifloxacin 400 mg/d x 7 days (active against Mycoplasma genitalium ) |
| Trichomonas vaginalis | Metronidazole 2 g po 1 dose OR tinidazole 2 g po 1 dose | Metronidazole 500 mg bid x 7 days Consider sensitivities if treatment failure |
| Herpes simplex—genital first episode Episodic treatment | Acyclovir 400 mg tid x 7 days Valaciclovir 1 g bid x 7 days Famciclovir 250 mg tid x 7 days Acyclovir 400 mg tid x 5 days Valaciclovir 500 mg bid x 3 days Famciclovir 125 mg bid x 5 days | Acyclovir 200 mg 5 times a day x 7 days or 800 mg tid x 7 days Acyclovir 800 mg bid x 5 days or 800 mg tid x 2 days Valaciclovir 1 g/d x 5 days Famciclovir 1 g/bid x 1 day or 500 mg once + 250 mg bid x 2 days |
10
What tests should be considered for patients presenting with genital vesicles and/or ulcers?
By far, the most common cause of such genital lesions is herpes simplex virus (HSV), with or without systemic prodromal symptoms. Other ulcer-causing infectious agents include chancroid, granuloma inguinale, lymphogranuloma venereum, and syphilis. There are less common noninfectious etiologies, including Behçet syndrome and trauma.
11
Is viral culture better than polymerase chain reaction (PCR) testing, and better than serologic testing for genital herpes simplex?
Viral culture is the diagnostic standard of care for genital infection. PCR testing currently has a higher rate of detection and may replace culture at some time. Serologic testing (antigen detection) by enzyme-linked immunosorbent assay (ELISA) and Western blot assay have high sensitivity and specificity for herpes simplex—that is, 96% to 100% and 97% to 100%, respectively.
12
Should the diagnosis be confirmed before initiating treatment?
No. Treat presumptively while cultures are pending. In addition to antiviral medication, pain management is important. Burrow solution or baking soda compresses (1 tsp to 1 quart of cool water) applied locally may provide significant relief.
13
How long is genital herpes contagious?
There is no clear-cut answer as asymptomatic viral shedding is quite common and the patient should be appropriately counseled. Abstinence from sexual contact during any prodromal symptoms or while there are active lesions should be maintained until there is complete healing. A barrier contraceptive method may be appropriate even when asymptomatic.
14
What are the antiviral treatment options for genital herpes?
See Table 7.1 .
15
How is acute urethritis in men diagnosed?
History of penile discharge (with or without dysuria), urgency, or other typical urinary tract infection (UTI) symptoms with examination findings of urethral discharge, positive leukocyte esterase, or greater than 10 white blood cells (WBCs) per high-power field on urine analysis are diagnostic of acute urethritis.
16
Is acute urethritis in men always due to STIs?
Essentially yes. The incidence of reactive arthritis with urethritis subsequent to chlamydial nongonococcal urethritis (CNGU) is estimated to be 1% of presenting urethritis. For clinical purposes, urethritis can be categorized as gonococcal (GU) and nongonococcal (NGU). Gonorrhea and chlamydia are the most prevalent STIs. Trichomonas and Ureaplasma urealyticum are also common. Mycoplasma genitalium is a potential cause of NGU; however, specific testing for this is not currently available. Other less common causes include Haemophilus influenzae, adenovirus, and herpes simplex.
17
Do all patients with urethritis require diagnostic tests?
Remember that STIs are frequently coincident. In addition to symptom relief, preventing complications in the patient and sexual partner, and identifying and limiting transmission of additional STIs, testing should be done uniformly. For men who have sex with men, IV drug use, and other high-risk sexual behavior, hepatitis B, hepatitis C, human immunodeficiency virus (HIV), herpes (HSV), and syphilis should also be assessed.
18
What treatment is appropriate for urethritis?
Treatment should be given at the point of access to care (see Table 7.1 ). Expedited partner treatment, as advocated by the Centers for Disease Control and Prevention (CDC) and approved in many U.S. states, may be considered. Guidelines and legal status are available online through the CDC.
19
What populations get urinary tract infections?
UTIs are most common in women of childbearing age, but they are not uncommon in children with various urologic anatomic and functional problems. UTIs are less common in men, but with the onset of prostatic enlargement around age 50, they increase in frequency to equal the incidence in postmenopausal women.
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