CHAPTER 17 Genitourinary problems in males

Urinary tract problems in males represent a range of conditions from infections, inflammation, and urine outlet obstruction to congenital malformation, trauma, or neoplasm. Any part of the renal/urological/reproductive tract can be involved, and symptoms may often be localized to a single site. Symptoms may also be vague, reflect the involved area, or be referred from the actual site of involvement.

Dysuria in males is most commonly caused by urethritis, prostatitis, cystitis, or mechanical irritation of the urethra. Inflammation, although infrequent in young males, increases with age until elderly men are affected as frequently as elderly women.

Cystitis in men results from ascending infection of the urethra or prostate, or occurs secondary to urethral instrumentation. The most common cause of recurrent cystitis in men is chronic bacterial prostatitis. Escherichia coli is the usual gram-negative pathogen. Chlamydia trachomatis is the major cause of prostatitis and nongonococcal urethritis in men under age 40 and is sexually transmitted. Recurrent urinary tract infections (UTIs) may involve resistant gram-negative Klebsiella, Enterobacter, Pseudomonas, or Proteus mirabilis, or gram-positive Enterococcus and Staphylococcus aureus. Infection may involve the kidneys and cause pyelonephritis. Secondary infection can occur as the result of urinary stones.

The male patient with urinary problems may also present with symptoms involving urinary flow. Urine flow may be altered by compression of the urethra as it passes through an enlarged prostate, obstructing the flow of urine and producing hesitancy, slowing of the urinary stream, dribbling, and nocturia. Benign prostatic hyperplasia (BPH) is common in men older than 50 and progresses with age until 80% of men over 80 are affected. Patients with BPH are more prone to UTIs and incontinence. Urinary stones can occur anywhere in the urinary tract and are common causes of obstructive symptoms, bleeding, and pain.

Trauma to the urinary tract may be caused by penetrating, straddle, blunt, or crushing injuries or by surgery or instrumentation. Hematuria, oliguria, and pain are the most common symptoms.

Neoplasms occur more often in males than in females. Kidney, prostate, and bladder neoplasms are more common in elderly men. Kidney and bladder neoplasms often produce painless hematuria. Prostate cancer may produce symptoms of outlet obstruction.

Kidney problems can range from asymptomatic blood chemical changes to life-threatening abnormal renal function that could manifest in fluid-electrolyte and acid-base imbalances. Patients with renal insufficiency may present with nonspecific complaints such as fatigue, anorexia, or weakness. A discussion of renal insufficiency and renal failure is beyond the scope of this chapter.

Diagnostic reasoning: focused history

Are systemic or acute symptoms present?

Key questions

Have you had fever, chills, nausea, or vomiting?

Are you positive for HIV infection or receiving chemotherapy?

Are you having acute pain?

Have you been able to pass any urine?

Fever and chills

The presence of fever and/or chills suggests a systemic inflammatory response and indicates that the patient may be acutely ill and should be aggressively treated. Specifically, suspect pyelonephritis or lithiasis of the upper urinary tract or prostatitis, orchitis, or epididymitis of the lower urinary tract.

Immunocompromised patients

Immunocompromised patients are susceptible to overwhelming infections by both common and atypical organisms, and aggressive investigation is warranted.

Acute pain

Acute pain in the abdomen or flank is characteristic of bladder, ureter, and kidney involvement. Acute pain in the scrotum or testicles may indicate infection or pathology 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 inflammation of the testicles, epididymitis, or torsion of a testicle (see Chapter 24).

Anuria

A sudden decrease in urinary output may result from compromised renal blood supply (prerenal); damaged interstitia, glomeruli, or tubules (intrarenal); or obstructed urine flow (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 first, 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

Have you noticed blood in your urine?

Is there blood every time you urinate or just occasionally?

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?

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 and 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 include 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

Do you have trouble starting to urinate (e.g., slow/weakened urinary stream, dribbling of urine)?

Do you have low back, flank, or abdominal pain?

Do you have aching in the perineal area?

Do you have suprapubic discomfort?

Have you had urinary incontinence?

Do you have frequency, urgency, dysuria, or penile discharge?

Do you urinate at night?

Do you have an excessive volume of urine?

Hesitancy, slow urinary stream, and dribbling of urine

In men older than 50, the presence of hesitancy, slow urinary stream, 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 17-1). Using the index, classify symptoms as mild (0 to 7), moderate (8 to 19), or severe (20 to 35).

Table 17-1 The American Urological Association Symptom Index

Low back, flank, or abdominal pain

Patient reports of low back, flank, or abdominal pain are often indicative of ureteral and kidney involvement. 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 inflammation of the capsule.

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 inflammation. Bladder pain is most often caused by infection; however, it can also be produced by obstruction and bladder distention as the result of 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 24).

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 fluid ingestion.

Patients who report daytime frequency without nocturia are usually free of organic disease.

Polyuria

Polyuria is defined as a volume greater than 3 L of urine/day and depends on fluid 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 fluid intake is important to identify possible causes of polyuria. Pseudopolyuria results from increased fluid ingestion and may present with certain personality disorders. With the current emphasis on water ingestion, however, a large fluid intake can also produce pseudopolyuria. Alcohol ingestion inhibits antidiuretic hormone; glycosuria promotes excess solute excretion. Diabetes insipidus may also be implicated. Nocturia can occur with the mobilization of fluid during sleep, secondary to congestive heart failure.

Are there any specific risk factors to point me in the right direction?

Key questions

Have you had this or similar problems before?

Do you have a family history of renal or kidney problems, prostatitis, or prostate cancer?

How old are you? (What is the patient’s age?)

Have you been confined to bed (especially if elderly)?

Are you sexually active? How many partners do you have?

Do you ride an upright bicycle?

History of similar problems

Patients with previous urinary problems are at risk for chronic relapsing conditions, such as unresolved infections, 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 or kidney 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, collagen 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 and is usually painless. Patients have difficulty starting the urine stream; the urine stream has decreased force; and urine often continues 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 confined to bed are at an increased risk of infection. Likely mechanisms include urinary stasis and reflux.

Sexual activity

Sexually active males, especially those who engage in unprotected sex, are at risk for STIs, which can 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 fitted to the rider. Perineal and penile numbness, without pain, are symptoms frequently reported by long-distance cyclists.

What else could this be?

Key questions

Have you had recent instrumentation in the urethra or urinary tract?

Have you had recent treatment for an STI?

Have you been recently diagnosed with, but not treated for, an STI?

What drugs have you taken (prescription, over the counter, or illicit)?

What is your occupation?

What are your hobbies (toxic exposure)?

Recent instrumentation

Recent instrumentation in the urinary tract places the patient at risk for infections. Patients with indwelling catheters are also at risk for infection.

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