Screening for Urogenital Disease

Chapter 10


Screening for Urogenital Disease


A 40-year-old athletic man comes to your clinic for an evaluation of back pain that he attributes to a very hard fall on his back while he was alpine skiing 3 days ago. His chief complaint is a dull, aching costovertebral pain on the left side, which is unrelieved by a change in position or by treatment with ice, heat, or aspirin. He stated that “even the skin on my back hurts.” He has no previous history of any medical problems.


After further questioning, the client reveals that inspiratory movements do not aggravate the pain, and he has not noticed any change in color, odor, or volume of urine output. However, percussion of the costovertebral angle (see Fig. 4-54) results in the reproduction of the symptoms. This type of symptom complex may suggest renal involvement even without obvious changes in urine.


Whether secondary to trauma or of insidious onset, a client’s complaints of flank pain, low back pain, or pelvic pain may be of renal or urologic origin and should be screened carefully through the subjective and objective examinations. Medical referral may be necessary.



Signs and Symptoms of Renal and Urologic Disorders


This chapter is intended to guide the physical therapist in understanding the origins and relationships of renal, ureteral, bladder, and urethral symptoms. The urinary tract, consisting of kidneys, ureters, bladder, and urethra (Fig. 10-1), is an integral component of human functioning that disposes of the body’s toxic waste products and unnecessary fluid and expertly regulates extremely complicated metabolic processes. The ureters, bladder, and urethra function primarily as transport vehicles for urine formed in the kidneys. The lower urinary tract is the last area through which urine is passed in its final form for excretion.



Formation and excretion of urine is the primary function of the renal nephron (the functional unit of the kidney) (Fig. 10-2). Through this process the kidney is able to maintain a homeostatic environment in the body. Besides the excretory function of the kidney, which includes the removal of wastes and excessive fluid, the kidney plays an integral role in the balance of various essential body functions, including the following:




The failure of the kidney to perform any of these functions results in severe alteration and disruption in homeostasis and signs and symptoms resulting from these dysfunctions (Box 10-1).1



Box 10-1   Signs and Symptoms of Genitourinary Disease









The Urinary Tract


The upper urinary tract consists of the kidneys and ureters. The kidneys are located in the posterior upper abdominal cavity in a space behind the peritoneum (retroperitoneal space) (see Fig. 4-50). Their anatomic position is in front of and on both sides of the vertebral column at the level of T11 to L3. The right kidney is usually lower than the left to accommodate the liver.2


The upper portion of the kidney is in contact with the diaphragm and moves with respiration. The kidneys are protected anteriorly by the ribcage and abdominal organs (see Fig. 4-49) and posteriorly by the large back muscles and ribs. The lower portions of the kidneys and the ureters extend below the ribs and are separated from the abdominal cavity by the peritoneal membrane.


The lower urinary tract consists of the bladder and urethra. From the renal pelvis, urine is moved by peristalsis to the ureters and into the bladder. The bladder, which is a muscular, membranous sac, is located directly behind the symphysis pubis and is used for storage and excretion of urine. The urethra is connected to the bladder and serves as a channel through which urine is passed from the bladder to the outside of the body.


Voluntary control of urinary excretion is based on learned inhibition of reflex pathways from the walls of the bladder. Release of urine from the bladder occurs under voluntary control of the urethral sphincter.


The male genital or reproductive system is made up of the testes, epididymis, vas deferens, seminal vesicles, prostate gland, and penis (Fig. 10-3). These structures are susceptible to inflammatory disorders, neoplasms, and structural defects.



image


Fig. 10-3 A, The prostate is located at the base of the bladder, surrounding a part of the urethra. It is innervated by T11-L1 and S2-S4 and can refer pain to the sacrum, low back, and testes (see Fig. 10-10). As the prostate enlarges, the urethra can become obstructed, interfering with the normal flow of urine. B, The prostate is composed of three zones. The transitional zone surrounds the urethra as it passes through the prostate. This is a common site for benign prostatic hyperplasia (BPH). The central zone is a cone-shaped section that sits behind the transitional zone. The peripheral zone is the largest portion of the gland and borders the other two zones. This is the most common site for cancer development. Most early tumors do not produce any symptoms because the urethra is not in the peripheral zone. It is not until the tumor grows large enough to obstruct the bladder outlet that symptoms develop. Tumors in the transitional zone, which houses the urethra, may cause symptoms sooner than tumors in other zones.


In males the posterior portion of the urethra is surrounded by the prostate gland, a gland approximately 3.5 cm long by 3 cm wide (about the size of two almonds). Located just below the bladder, this gland can cause severe urethral obstruction when enlarged from a growth or inflammation resulting in difficulty starting a flow of urine, continuing a flow of urine, frequency, and/or nocturia.


The prostate gland is commonly divided into five lobes and three zones. Prostate carcinoma usually affects the posterior lobe of the gland; the middle and lateral lobes typically are associated with the nonmalignant process called benign prostatic hyperplasia (BPH).



Renal and Urologic Pain



Upper Urinary Tract (Renal/Ureteral)


The kidneys and ureters are innervated by both sympathetic and parasympathetic fibers. The kidneys receive sympathetic innervation from the lesser splanchnic nerves through the renal plexus, which is located next to the renal arteries. Renal vasoconstriction and increased renin release are associated with sympathetic stimulation. Parasympathetic innervation is derived from the vagus nerve, and the function of this innervation is not known.


Renal sensory innervation is not completely understood, even though the capsule (covering of the kidney) and the lower portions of the collecting system seem to cause pain with stretching (distention) or puncture. Information transmitted by renal and ureteral pain receptors is relayed by sympathetic nerves that enter the spinal cord at T10 to L1 (see Fig. 3-3).


Because visceral and cutaneous sensory fibers enter the spinal cord in close proximity and actually converge on some of the same neurons, when visceral pain fibers are stimulated, concurrent stimulation of cutaneous fibers also occurs. The visceral pain is then felt as though it is skin pain (hyperesthesia), similar to the condition of the alpine skier who stated that “even the skin on my back hurts.” Renal and ureteral pain can be felt throughout the T10 to L1 dermatomes.


Renal pain (see Fig. 10-7) is typically felt in the posterior subcostal and costovertebral regions. To assess the kidney, the test for costovertebral angle tenderness can be included in the objective examination (see Fig. 4-54).


Ureteral pain is felt in the groin and genital area (see Fig. 10-8). With either renal pain or ureteral pain, radiation forward around the flank into the lower abdominal quadrant and abdominal muscle spasm with rebound tenderness can occur on the same side as the source of pain.


The pain can also be generalized throughout the abdomen. Nausea, vomiting, and impaired intestinal motility (progressing to intestinal paralysis) can occur with severe, acute pain. Nerve fibers from the renal plexus are also in direct communication with the spermatic plexus, and because of this close relationship, testicular pain may also accompany renal pain. Neither renal nor urethral pain is altered by a change in body position.


The typical renal pain sensation is aching and dull in nature but can occasionally be a severe, boring type of pain. The constant dull and aching pain usually accompanies distention or stretching of the renal capsule, pelvis, or collecting system. This stretching can result from intrarenal fluid accumulation such as inflammatory edema, inflamed or bleeding cysts, and bleeding or neoplastic growths. Whenever the renal capsule is punctured, a dull pain can also be felt by the client. Ischemia of renal tissue caused by blockage of blood flow to the kidneys results in a constant dull or a constant sharp pain.


Ureteral obstruction (e.g., from a urinary calculus or “stone” consisting of mineral salts) results in distention of the ureter and causes spasm that produces intermittent or constant severe colicky pain until the stone is passed. Pain of this origin usually starts in the costovertebral angle (CVA) and radiates to the ipsilateral lower abdomen, upper thigh, testis, or labium (see Fig. 10-8). Movement of a stone down a ureter can cause renal colic, an excruciating pain that radiates to the region just described and usually increases in intensity in waves of colic or spasm.


Chronic ureteral pain and renal pain tend to be vague, poorly localized, and easily confused with many other problems of abdominal or pelvic origin. There are also areas of referred pain related to renal or ureteral lesions. For example, if the diaphragm becomes irritated because of pressure from a renal lesion, shoulder pain may be felt (see Figs. 3-4 and 3-5). If a lesion of the ureter occurs outside the ureter, pain may occur on movement of the adjacent iliopsoas muscle (see Fig. 8-3).


Abdominal rebound tenderness results when the adjacent peritoneum becomes inflamed. Active trigger points along the upper rim of the pubis and the lateral half of the inguinal ligament may lie in the lower internal oblique muscle and possibly in the lower rectus abdominis. These trigger points can cause increased irritation and spasm of the detrusor and urinary sphincter muscles, producing urinary frequency, retention of urine, and groin pain.3



Pseudorenal Pain


Pseudorenal pain may occur secondary to radiculitis or irritation of the costal nerves caused by mechanical derangements of the costovertebral or costotransverse joints. Disorders of this sort are common in the cervical and thoracic areas, but the most common sites are T10 and T12.4 Irritation of these nerves causes costovertebral pain that can radiate into the ipsilateral lower abdominal quadrant.


The onset is usually acute with some type of traumatic history such as lifting a heavy object, sustaining a blow to the costovertebral area, or falling from a height onto the buttocks. The pain is affected by body position, and although the client may be awakened at night when assuming a certain position (e.g., sidelying on the affected side), the pain is usually absent on awakening and increases gradually during the day. It is also aggravated by prolonged periods of sitting, especially when driving on rough roads in the car. It may be relieved by changing to another position (Table 10-1).



Radiculitis may mimic ureteral colic or renal pain, but true renal pain is seldom affected by movements of the shoulder or spine. Exerting pressure over the CVA with the thumb may elicit local tenderness of the involved peripheral nerve at its point of emergence, whereas gentle percussion over the angle may be necessary to elicit renal pain, indicating a deeper, more visceral sensation usually associated with an infectious or inflammatory process such as pyelonephritis, perinephric abscess, or other kidney problems.


Fig. 4-54 illustrates percussion over the CVA (Murphy’s percussion or punch test). Although this test is commonly performed, its diagnostic value has never been validated. Results of at least one Finnish study5 suggested that in acute renal colic loin tenderness and hematuria (blood in the urine) are more significant signs than renal tenderness.6


A diagnostic score incorporating independent variables, including results of urinalysis; presence of CVA and renal tenderness; and duration of pain, appetite level, and sex (male versus female), reached a sensitivity of 0.89 in detecting acute renal colic, with a specificity of 0.99 and an efficiency of 0.99.5



Lower Urinary Tract (Bladder/Urethra)


Bladder innervation occurs through sympathetic, parasympathetic, and sensory nerve pathways. Sympathetic bladder innervation assists in the closure of the bladder neck during seminal emission. Afferent sympathetic fibers also assist in providing awareness of bladder distention, pain, and abdominal distention caused by bladder distention. This input reaches the spinal cord at T9 or higher. Parasympathetic bladder innervation is at S2, S3, and S4 and provides motor coordination for the act of voiding. Afferent parasympathetic fibers assist in sensation of the desire to void, proprioception (position sensation), and perception of pain.


Sensory receptors are present in the mucosa of the bladder and in the muscular bladder walls. These fibers are more plentiful near the bladder neck and the junctional area between the ureters and bladder.


Urethral innervation, also at the S2, S3, and S4 level, occurs through the pudendal nerve. This is a mixed innervation of both sensory and motor nerve fibers. This innervation controls the opening of the external urethral sphincter (motor) and an awareness of the imminence of voiding and heat (thermal) sensation in the urethra.


Bladder or urethral pain is felt above the pubis (suprapubic) or low in the abdomen (see Fig. 10-9). The sensation is usually characterized as one of urinary urgency, a sensation to void, and dysuria (painful urination). Irritation of the neck of the bladder or the urethra can result in a burning sensation localized to these areas, probably caused by the urethral thermal receptors. See Box 10-2 for causes of pain outside the urogenital system that present like upper or lower urinary tract pain of either an acute or chronic nature.



Box 10-2   Extraurologic Conditions Causing Urinary Tract Symptoms


Acute or chronic conditions affecting other viscera outside the urologic system can refer pain and symptoms to the upper or lower urinary tract. These can include




Renal and Urinary Tract Problems


Pathologic conditions of the upper and lower urinary tracts can be categorized according to primary causative factors. Inflammatory/infectious and obstructive disorders are presented in this section along with renal failure and cancers of the urinary tract.


When screening for any conditions affecting the kidney and urinary tract system, keep in mind factors that put people at increased risk for these problems (Case Example 10-1). Early screening and detection is recommended based on the presence of these risk factors.7



Case Example 10-1   Screening in the Presence of Risk Factors for Kidney Disease


A 66-year-old African-American woman with a personal history of systemic lupus erythematosus (SLE) lost her balance and fell off the deck at her home. She sustained vertebral and rib fractures at T10 and T11. She is a retired paint factory worker. She reported daily exposure to paint and paint solvents during her 15 years of employment.


She was seen as a walk-in at the local medical clinic where she is a regular patient. She did not see the rheumatologist who was managing her SLE. The attending physician told her the injuries were “probably from the long-term use of prednisone for her lupus.” She was referred to physical therapy by the attending physician for postural exercises.


During the interview, when asked, “Are you having any symptoms of any kind anywhere else in your body?” the client admitted to a pink color to her urine and some burning on urination. These symptoms have been present since the day after the fall 3 weeks ago.


There were no other signs or symptoms reported. Blood pressure measured 175/95 on three separate occasions. The client reported her blood pressure was elevated at the time of her visit to the doctor, but she thought it was caused by the stress of the fall.


Question: As you step back and conduct a Review of Systems, what are the red flags to suggest medical referral is needed? To whom do you refer this client?


Red flags:



The therapist may not recognize specific factors present that put the client at increased risk for kidney disease, but the obvious changes in urine color and pattern along with changes in blood pressure require medical referral.


Without the medical records, it is impossible to know what (if any) testing was done related to kidney function (e.g., urinalysis, blood test) at the time of the initial injury. A phone call to the referring physician is probably the best place to start. Documentation of the recent events and current red flag symptoms should be sent to the referring physician, the primary care physician, and the rheumatologist (if different from the primary care doctor).


Physical therapy intervention is still appropriate given her musculoskeletal injuries. Further medical assessment is warranted based on the development of symptoms unknown to the referring physician.




Inflammatory/Infectious Disorders


Inflammatory disorders of the kidney and urinary tract can be caused by bacterial infection, by changes in immune response, and by toxic agents such as drugs and radiation. Common infections of the urinary tract develop in either the upper or lower urinary tract (Table 10-2).



Upper urinary tract infections (UTIs) include kidney or ureteral infections. Lower UTIs include cystitis (bladder infection) or urethritis (urethral infection). Symptoms of UTI depend on the location of the infection in either the upper or lower urinary tract (although, rarely, infection could occur in both simultaneously).



Inflammatory/Infectious Disorders of the Upper Urinary Tract


Inflammations or infections of the upper urinary tract (kidney and ureters) are considered to be more serious because these lesions can be a direct threat to renal tissue itself.


The more common conditions include pyelonephritis (inflammation of the renal parenchyma) and acute and chronic glomerulonephritis (inflammation of the glomeruli of both kidneys). Less common conditions include renal papillary necrosis and renal tuberculosis.


Symptoms of upper urinary tract inflammations and infections are shown in Table 10-3. If the diaphragm is irritated, ipsilateral shoulder pain may occur. Signs and symptoms of renal impairment are also shown in Table 10-4 and if present, are significant symptoms of impending kidney failure.





Inflammatory/Infectious Disorders of the Lower Urinary Tract


Both the bladder and urine have a number of defenses against bacterial invasion. These defenses are mechanisms such as voiding, urine acidity, osmolality, and the bladder mucosa itself, which is thought to have antibacterial properties.


Urine in the bladder and kidney is normally sterile, but urine itself is a good medium for bacterial growth. Interferences in the defense mechanisms of the bladder such as the presence of residual or stagnant urine, changes in urinary pH or concentration, or obstruction of urinary excretion can promote bacterial growth.


Routes of entry of bacteria into the urinary tract can be ascending (most commonly up the urethra into the bladder and then into the ureters and kidney), bloodborne (bacterial invasion through the bloodstream), or lymphatic (bacterial invasion through the lymph system, the least common route).


A lower UTI occurs most commonly in women because of the short female urethra and the proximity of the urethra to the vagina and rectum. The rate of occurrence increases with age and sexual activity since intercourse can spread bacteria from the genital area to the urethra. Chronic health problems, such as diabetes mellitus, gout, hypertension, obstructive urinary tract problems, and medical procedures requiring urinary catheterization, are also predisposing risk factors for the development of these infections.8


Individuals with diabetes are prone to complications associated with UTIs. Staphylococcus infection of the urinary tract may be a source of osteomyelitis, an infection of a vertebral body resulting from hematogenous spread or local spread from an abscess into the vertebra. The infected vertebral body may gradually undergo degeneration and destruction, with collapse and formation of a segmental scoliosis.9


This condition is suspected from the onset of nonspecific low back pain, unrelated to any specific motion. Local tenderness can be elicited, but the initial x-ray finding is negative. Usually, a low-grade fever is present but undetected, or it develops as the infection progresses. This is why anyone with low back pain of unknown origin should have his or her temperature taken, even in a physical therapy setting.


Older adults (both men and women) are at increased risk for UTI. They may present with nonspecific symptoms, such as loss of appetite, nausea, and vomiting; abdominal pain; or change in mental status (e.g., onset of confusion, increased confusion). Watch for predisposing conditions that can put the older client at risk for UTI. These may include diabetes mellitus or other chronic diseases (e.g., Alzheimer’s disease, Parkinson’s disease), immobility, reduced fluid intake, use of incontinence management products (e.g., pads, briefs, external catheters), indwelling catheterization, and previous history of UTI or kidney stones.



Cystitis


Cystitis (inflammation with infection of the bladder), interstitial cystitis (inflammation without infection), and urethritis (inflammation and infection of the urethra) appear with a similar symptom progression (Case Example 10-2).



Case Example 10-2   Bladder Infection


A 55-year-old woman came to the clinic with back pain associated with paraspinal muscle spasms. Pain was of unknown cause (insidious onset), and the client reported that she was “just getting out of bed” when the pain started. The pain was described as a dull aching that was aggravated by movement and relieved by rest (musculoskeletal pattern).


No numbness, tingling, or saddle anesthesia was reported, and the neurologic screening examination was negative. Sacroiliac (SI) testing was negative. Spinal movements were slow and guarded, with muscle spasms noted throughout movement and at rest. Because of her age and the insidious onset of symptoms, further questions were initiated to screen for medical disease.


This client was midmenopausal and was not taking any hormone replacement therapy (HRT). She had a bladder infection a month ago that was treated with antibiotics; tests for this were negative when she was evaluated and referred by her physician for back pain. Two weeks ago she had an upper respiratory infection (a “cold”) and had been “coughing a lot.” There was no previous history of cancer.


Local treatment to reduce paraspinal muscle spasms was initiated, but the client did not respond as expected over the course of five treatment sessions. Because of her recent history of upper respiratory and bladder infections, questions were repeated related to the presence of constitutional symptoms and changes in bladder function/urine color, force of stream, burning on urination, and so on. Occasional “sweats” (present sometimes during the day, sometimes at night) was the only red flag present. The combination of recent infection, failure to respond to treatment, and the presence of sweats suggested referral to the physician for early reevaluation.


The client did not return to the clinic for further treatment, and a follow-up telephone call indicated that she did indeed have a recurrent bladder infection that was treated successfully with a different antibiotic. Her back pain and muscle spasm were eliminated after only 24 hours of taking this new antibiotic.


According to the Interstitial Cystitis Association (ICA), interstitial cystitis (IC), also known as painful bladder syndrome, is a condition that consists of recurring pelvic pain, pressure, or discomfort in the bladder and pelvic region and affects more than 4 million people in the United States.10 IC is often associated with urinary frequency and urgency. Men can be affected by this condition, but the majority of people living with IC are women. Several other disorders are associated with IC including allergies, inflammatory bowel syndrome, fibromyalgia, and vulvitis.11


Bladder pain associated with IC can vary from person to person and even within the same individual and may be dull, achy, or acute and stabbing. Discomfort while urinating also varies from mild stinging to intense burning. Sexual intercourse may ignite pain that lasts for days.11


Clients with any of the symptoms listed for the lower urinary tract in Table 10-3 at presentation should be referred promptly to a physician for further diagnostic workup and possible treatment. Infections of the lower urinary tract are potentially very dangerous because of the possibility of upward spread and resultant damage to renal tissue. Some individuals, however, are asymptomatic, and routine urine culture and microscopic examination are the most reliable methods of detection and diagnosis.



Obstructive Disorders


Urinary tract obstruction can occur at any point in the urinary tract and can be the result of primary urinary tract obstructions (obstructions occurring within the urinary tract) or secondary urinary tract obstructions (obstructions resulting from disease processes outside the urinary tract).


A primary obstruction might include problems such as acquired or congenital malformations, strictures, renal or ureteral calculi (stones), polycystic kidney disease, or neoplasms of the urinary tract (e.g., bladder, kidney).


Secondary obstructions produce pressure on the urinary tract from outside and might be related to conditions such as prostatic enlargement (benign or malignant); abdominal aortic aneurysm; gynecologic conditions such as pregnancy, pelvic inflammatory disease, and endometriosis; or neoplasms of the pelvic or abdominal structures.


Obstruction of any portion of the urinary tract results in a backup or collection of urine behind the obstruction. The result is dilation or stretching of the urinary tract structures that are positioned behind the point of blockage.


Muscles near the affected area contract in an attempt to push urine around the obstruction. Pressure accumulates above the point of obstruction and can eventually result in severe dilation of the renal collecting system (hydronephrosis) and renal failure. The greater the intensity and duration of the pressure, the greater is the destruction of renal tissue.


Because urine flow is decreased with obstruction, urinary stagnation and infection or stone formation can result. Stones are formed because urine stasis permits clumping or precipitation of organic matter and minerals.


Lower urinary tract obstruction can also result in constant bladder distention, hypertrophy of bladder muscle fibers, and formation of herniated sacs of bladder mucosa. These herniated sacs result in a large, flaccid bladder that cannot empty completely. In addition, these sacs retain stagnant urine, which causes infection and stone formation.



Obstructive Disorders of the Upper Urinary Tract


Obstruction of the upper urinary tract may be sudden (acute) or slow in development. Tumors of the kidney or ureters may develop slowly enough that symptoms are totally absent or very mild initially, with eventual progression to pain and signs of impairment. Acute ureteral or renal blockage by a stone (calculus consisting of mineral salts), for example, may result in excruciating, spasmodic, and radiating pain accompanied by severe nausea and vomiting.


Calculi form primarily in the kidney. This process is called nephrolithiasis. The stones can remain in the kidney (renal pelvis) or travel down the urinary tract and lodge at any point in the tract. Strictly speaking, the term kidney stone refers to stones that are in the kidney. Once they move into the ureter, they become ureteral stones.


Ureteral stones are the ones that cause the most pain. If a stone becomes wedged in the ureter, urine backs up, distending the ureter and causing severe pain. If a stone blocks the flow of urine, urine pressure may build up in the ureter and kidney, causing the kidney to swell (hydronephrosis). Unrecognized hydronephrosis can sometimes cause permanent kidney damage.12


The most characteristic symptom of renal or ureteral stones is sudden, sharp, severe pain. If the pain originates deep in the lumbar area and radiates around the side and down toward the testicle in the male and the bladder in the female, it is termed renal colic. Ureteral colic occurs if the stone becomes trapped in the ureter. Ureteral colic is characterized by radiation of painful symptoms toward the genitalia and thighs (see Fig. 10-8).


Since the testicles and ovaries form in utero in the location of the kidneys and then migrate at full term following the pathways of the ureters, kidney stones moving down the pathway of the ureters cause pain in the flank. This pain radiates to the scrotum in males and the labia in females. For the same reason, ovarian or testicular cancer can refer pain to the back at the level of the kidneys.


Renal tumors may also be detected as a flank mass combined with unexplained weight loss, fever, pain, and hematuria. The presence of any amount of blood in the urine always requires referral to a physician for further diagnostic evaluation because this is a primary symptom of urinary tract neoplasm.



Clinical Signs and Symptoms


Obstruction of the Upper Urinary Tract





Obstructive Disorders of the Lower Urinary Tract


Common conditions of (mechanical) obstruction of the lower urinary tract are bladder tumors (bladder cancer is the most common site of urinary tract cancer) and prostatic enlargement, either benign (BPH) or malignant (cancer of the prostate). An enlarged prostate gland can occlude the urethra partially or completely.


Mechanical problems of the urinary tract result in difficulty emptying urine from the bladder. Improper emptying of the bladder results in urinary retention and impairment of voluntary bladder control (incontinence). Several possible causes of mechanical bladder dysfunction include pelvic floor dysfunction, UTIs, partial urethral obstruction, trauma, and removal of the prostate gland.


The nerves that carry pain sensation from the prostate do not localize the source of pain very precisely, and therefore it may be difficult for the man to describe exactly where the pain is coming from. Discomfort can be localized in the suprapubic region or in the penis and testicles, or it can be centered in the perineum or rectum (see Fig. 10-10).



Prostatitis: Prostatitis is a relatively common inflammation of the prostate causing prostate enlargement. This condition affects up to 10% of the adult male population, accounting for the 2 million or more men who seek treatment annually in the United States.13,14 It is often disabling, affecting men at any age, but typically found in men ages 40 to 70 years. Acute bacterial prostatitis occurs most often in men under age 35.


The National Institutes of Health (NIH) Consensus Classification of Prostatitis15,16 includes four distinct categories:
















Type I Acute bacterial prostatitis
Type II Chronic bacterial prostatitis
Type III Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
A. Inflammatory
B. Noninflammatory
Type IV Asymptomatic inflammatory prostatitis

Type I is an acute prostatic infection with a uropathogen, often with systemic symptoms of fever, chills, and hypotension. The prostate is inflamed and may block urinary flow without treatment. Type II is characterized by recurrent episodes of documented UTIs with the same uropathogen repeatedly and causes pelvic pain, urinary symptoms, and ejaculatory pain. The source of recurrent infections in the lower urinary tract must be identified and treated.


Chronic (type III, nonbacterial) prostatitis is characterized by pelvic pain for more than 3 of the previous 6 months, urinary symptoms, and painful ejaculation without documented urinary tract infections from uropathogens.


The symptoms of CP/CPPS appear to occur as a result of interplay between psychologic factors and dysfunction in the immune, neurologic, and endocrine systems.17 Studies show a major impact on quality of life, urinary function, and sexual function along with chronic pain and discomfort (Fig. 10-4).18,19



The pain of prostatitis can be exacerbated by sexual activity, and some men describe pain upon ejaculation. A digital rectal examination by the physician will reproduce painful symptoms when the prostate is inflamed or infected (Fig. 10-5).



In men with chronic prostatitis, voiding complaints similar to those caused by BPH are the predominant symptoms. These complaints include urgency, frequency, and nocturia (getting up at nighttime more than once); less frequently, men may complain of difficulty starting the urinary stream or a slow stream.


These symptoms typically differ from symptoms of BPH in that they are associated with some degree of discomfort before, during, or after voiding. Physical or emotional stress and/or irritative components of the diet (e.g., caffeine in coffee, soft drinks) commonly exacerbate chronic prostatitis symptoms.


The causes of prostatitis are unclear. Although it can be the result of a bacterial infection, many men have nonbacterial prostatitis of unknown cause. Risk factors for bacterial prostatitis include some sexually transmitted diseases (e.g., gonorrhea) from unprotected anal and vaginal intercourse, which can allow bacteria to enter the urethra and travel to the prostate.


Other risk factors include bladder outlet obstruction (e.g., stone, tumor, BPH), diabetes mellitus, immunosuppression, and urethral catheterization. Neither prostatitis nor prostate enlargement is known to cause cancer, but men with prostatitis or BPH can develop prostate cancer as well.


The NIH Chronic Prostatitis Symptom Index (NIH-CPSI) provides a valid outcome measure for men with chronic (nonbacterial) prostatitis. The index may be useful in clinical practice, as well as research protocols.20


Anyone with significant symptoms assessed by the NIH-CPSI associated with constitutional symptoms should be rechecked by a physician. Individuals with significant symptoms but no constitutional symptoms and individuals nonresponsive to antibiotics should be assessed by a pelvic floor specialist. The index is available for clinical practice and may be useful for research protocols. It is available online at www.prostatitis.org/symptomindex.html.


A less complete list of questions for screening purposes are most appropriate for men with low back pain and any of the risk factors or symptoms listed for prostatitis and may include the following.



image Follow-Up Questions



Related posts:

Interviewing as a Screening Tool Pain Types and Viscerogenic Pain Patterns Screening the Shoulder and Upper Extremity Screening the Sacrum, Sacroiliac, and Pelvis Physical Assessment as a Screening Tool Screening for Gastrointestinal Disease

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Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Screening for Urogenital Disease

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