Pφ

Urethritis can be infectious or noninfectious. In women, infectious urethritis can be secondary to typical urinary tract organisms such as Escherichia coli, Staphylococcus saprophyticus, Proteus mirabilis, Enterococcus spp., or Klebsiella spp. Additionally, infectious urethritis can be due to sexually transmitted organisms such as N. gonorrhoeae or C. trachomatis, or organisms associated with vaginitis, such as T. vaginalis, Candida spp., herpes simplex virus, and bacterial vaginosis.

In males, urethritis is most commonly secondary to sexually transmitted organisms including N. gonorrhoeae, C. trachomatis, Trichomonas, Candida, and herpes simplex virus. In both males and females, irritants, such as spermicides, lubricants, perfumes, and soaps, can cause a chemical urethritis.

TP

Painful urination, which is often associated with frequency and urgency, is the main presenting symptom of urethritis. Hematuria may be present when the cause is infection with typical urinary tract organisms but is often absent in urethritis due to C. trachomatis. Purulent discharge may be seen in urethritis secondary to N. gonorrhoeae. Patients with genital herpes may present with vesicular lesions.

Dx

Urinalysis reveals pyuria in urethritis secondary to typical urinary tract organisms and N. gonorrhoeae or C. trachomatis, but bacteriuria is often absent in N. gonorrhoeae or C. trachomatis urethritis. In urethritis secondary to typical urinary tract organisms, urine culture often reveals the causative organism. Urethritis secondary to N. gonorrhoeae or C. trachomatis is best diagnosed by DNA amplification of the urethral discharge. Urethritis caused by typical vaginal organisms is best diagnosed by examination of the discharge on smear and wet mount, assessment of the pH, and culture of the discharge. For patients who present with typical vesicular lesions, culture for herpesvirus can confirm the diagnosis. In patients with irritant urethritis, a temporal relationship between product use and symptoms suggests the diagnosis.

Pφ

Cystitis may be infectious or noninfectious. Infectious cystitis is caused by typical urinary tract organisms, such as E. coli, S. saprophyticus, P. mirabilis, Enterococcus spp., or Klebsiella spp. Unlike urethritis, sexually transmitted organisms and organisms associated with vaginitis do not typically cause infectious cystitis. In men, isolated infectious cystitis is quite uncommon. When it does occur, it is often seen in the setting of anatomic or functional urinary tract obstruction.

Interstitial cystitis is a cause of noninfectious cystitis. The pathogenesis is not clearly defined but may be due to an abnormality in the growth of cells that line the bladder. This disorder most commonly affects young women.

TP

Cystitis presents with painful urination, which is often associated with frequency and urgency. The location of the pain is typically suprapubic.

Dx

In infectious cystitis, urinalysis reveals pyuria and bacteriuria, and urine culture reveals a colony count >100,000 colony-forming units (CFU)/mL. Interstitial cystitis is diagnosed by typical symptoms and the absence of other etiologies. Pain and urgency symptoms elicited by filling of the bladder during cystoscopy may support the diagnosis.

Pφ

Acute pyelonephritis most commonly results from lower urinary tract organisms that ascend and invade the renal parenchyma. Anatomic abnormalities, such as vesicoureteral reflux, or obstruction at any level of the urinary tract, are risk factors for pyelonephritis. Additionally, host factors including the P1 blood group phenotype, which is associated with the presence of antigens that allow bacterial attachment to the urinary tract epithelium, are important to the development of pyelonephritis. Specific bacterial adhesion molecules, including the P-fimbriae family, are commonly found in pyelonephritis-producing E. coli.

TP

Patients with acute pyelonephritis present with lower urinary tract symptoms of dysuria and frequency as well as upper urinary tract symptoms of flank pain and costovertebral angle tenderness. Patients often have systemic symptoms including fever, chills, nausea, and vomiting.

Dx

The diagnosis of acute pyelonephritis is made by its typical clinical presentation, in conjunction with pyuria and isolation of a typical urinary tract pathogen. Other laboratory results, such as leukocytosis, may reveal signs of systemic infection. Urinalysis may reveal WBC casts. Imaging may not be necessary in otherwise healthy patients who respond to antibiotic therapy within 72 hours of treatment initiation. Pre- and post-contrast CT scan is the test of choice to reveal signs of complicated pyelonephritis, such as a perinephric abscess.

Pφ

The etiology of vulvovaginitis can be infectious or noninfectious. Infections with agents causing vulvovaginitis can be sexually transmitted, such as T. vaginalis or herpes simplex virus, due to Candida albicans, which may be exacerbated by antibiotic use, or a result of bacterial vaginosis, which is caused by an overgrowth of certain bacterial organisms. Noninfectious etiologies of vulvovaginitis include irritants, including soaps, sprays, and perfumes, and hypoestrogenemia in postmenopausal women.

TP

Patients with infectious vulvovaginitis typically present with external dysuria, vaginal discharge, odor, itch, irritation, and erythema. Hypoestrogenemia and atrophic vaginitis present with vaginal dryness, dyspareunia, and thinning of the vaginal mucosal lining.

Dx

The diagnosis of infectious vulvovaginitis is often made by vaginal culture and smear. On wet mount, the presence of branching hyphae and buds is typical of Candida, while mobile trichomonads are found in patients infected with T. vaginalis. Bacterial vaginosis is diagnosed by a positive whiff test and the presence of clue cells on wet mount. The diagnosis of noninfectious vulvovaginitis requires a careful history for use of irritants, sexual activity, and menopausal status in conjunction with a physical exam lacking vaginal discharge and perhaps significant for vaginal dryness and mucosal thinning.

Pφ

Acute prostatitis is usually infectious in origin and is caused by typical gram-negative urinary tract organisms as well as the agents of sexually transmitted infections. The infection is believed to result from reflux of infected urine into the prostatic ducts. Hematogenous, lymphatic, or contiguous spread from local infections can also occur. Acute prostatitis can occur after instrumentation of the urinary tract or prostate. It occurs most frequently in men with obstructive uropathy.

Chronic prostatitis is less well understood. Chronic prostatitis may be infectious or noninfectious. Infectious chronic prostatitis is caused by bacterial infections similar to those that cause acute prostatitis, but they recur or persist. Noninfectious chronic prostatitis is associated with a chronic pelvic pain syndrome in men that may not even involve infection or inflammation of the prostate gland.

TP

Acute prostatitis presents with symptoms of dysuria, as well as perineal, back, penile, and/or testicular pain. Patients often have associated urinary frequency, hesitancy, and incomplete bladder emptying. At times, systemic symptoms of fevers, myalgias, nausea, and vomiting are present.

Chronic bacterial prostatitis presents with recurrent symptoms similar to those of acute prostatitis. Chronic noninfectious prostatitis–chronic pelvic pain syndrome presents with symptoms of pain, including pain with ejaculation, urinary hesitancy, and frequency.

Dx

The diagnosis is made by a typical historical presentation in conjunction with a tender and swollen prostate on exam. Urinalysis and culture before and after prostatic massage can confirm the diagnosis and identify a causative organism. Prostatic massage is often deferred in the setting of acute prostatitis to avoid hematogenous spread of the infection.

Pφ

Epididymo-orchitis most often results from retrograde extension of bacteria from the vas deferens. Causative organisms include both typical urinary tract organisms and sexually transmitted infections. Rarely, epididymitis is caused by nonbacterial organisms, such as Candida, or chemical irritants, such as reflux of sterile urine.

TP

Patients with epididymo-orchitis present with dysuria, hesitancy, and frequency, as well as urethral discharge and a painful, edematous scrotum. Patients may also complain of abdominal pain and systemic symptoms.

Dx

The diagnosis is made by careful history and physical exam revealing a tender, erythematous, swollen scrotum. Early in the course of disease, before testicular involvement, tenderness may be localized to the epididymis. Gram stain and culture of the urethral discharge, and/or DNA amplification, can confirm the causative agent. The most important diagnosis to exclude when a patient presents with such symptoms is testicular torsion; imaging with Doppler ultrasound is often necessary to exclude this serious condition.

Pφ

BPH refers to the enlargement of the prostate gland, not from hypertrophy, but from hyperplasia of the stromal and epithelial cells of the prostate. This hyperplasia often occurs in the periurethral portion of the prostate. The pathogenesis is not completely understood, but it is clear that androgens, particularly dihydrotestosterone (DHT), are necessary but not sufficient to cause BPH. Further research shows that high estrogen levels accompanied by lower levels of free testosterone probably have a role in the development of BPH.

TP

Men with BPH present with obstructive and irritative urinary symptoms such as hesitancy, frequency, straining, and weakened stream. Men may be asymptomatic and be diagnosed by physical exam alone.

Dx

Diagnosis is made by finding an enlarged prostate on physical exam and possibly by a history of typical symptoms.

Pφ

Urethral strictures usually occur in patients with inflammation or scarring of the urethra resulting from recurrent urethritis or urethral instrumentation (most commonly by a urinary catheter or cystoscope). It is less common in women than men due to the short length of the female urethra. Rarely, external compression by a tumor can cause urethral stricture.

TP

Dysuria, difficulty urinating, spraying of urine, and slow urine stream are all symptoms of a stricture.

Dx

A suggestive history should prompt the clinician to obtain a retrograde urethrogram and/or a cystoscopy, which can definitively diagnose the disease.

Pφ

Urethral diverticulum is a condition seen in women who have an outpouching of a localized area of the urethra into the anterior vaginal wall. The etiology of the diverticulum is believed to be repeated infection of the periurethral glands, which leads to inflammation, fibrosis, and the formation of a cavity. This process ultimately leads to the development of a urethral diverticulum.

TP

The classic triad of symptoms includes post-void dribbling, dysuria, and dyspareunia. Frequency, urgency, incontinence, and recurrent infections are also common.

Dx

Typical symptoms, along with detection of an anterior vaginal wall mass that expresses urine when palpated, is highly suggestive of a urinary diverticulum. A voiding cystourethrography and MRI exam confirm the diagnosis and localize the pathologic area.

Pφ

Risk factors for kidney stones (i.e., nephrolithiasis) include Caucasian race, male gender, older age, obesity, a history of polycystic kidney disease, hyperparathyroidism, and RTA. Kidney stones arise when the urine becomes too concentrated and urinary minerals develop crystals that combine to form stones. The most common type of kidney stone is calcium stones, followed by struvite stones and uric acid stones. Cystine stones are rare. Calcium stones are more likely to form when there is excess calcium or oxalate in the urine or when there is a deficiency of citrate in the urine. Struvite stones almost always occur in the setting of chronic or recurrent UTIs. Uric acid stones occur in the setting of excess uric acid secondary to malignancies or disorders of uric acid metabolism.

TP

Kidney stones may be asymptomatic and found incidentally on abdominal imaging or in a workup for hematuria. Patients with large stones that cause obstruction or infection present with symptoms. The most common symptom is intense, colicky pain in the back, flank, lower abdomen, groin, and/or genitals. Other signs and symptoms may include hematuria, frequency, nausea, vomiting, fever, and chills.

Dx

When the history suggests kidney stones, the diagnosis is made through imaging tests. Potential tests including abdominal radiography, ultrasound, IVP, retrograde pyelogram, and noncontrast spiral CT scan. Currently noncontrast spiral CT scan is the test of choice. When a stone is obtained, its composition should be determined by stone analysis. Patients with recurrent stones should have a 24-hour urine stone risk profile performed. This evaluation can detect metabolic abnormalities of calcium, citrate, oxalate, and uric acid that make stone formation more likely.