Prostatitis/Chronic Pelvic Pain Syndrome

CASE SCENARIO We are pleased to introduce a new feature to Reviews in Urology: the “Case Scenario" section. In each issue, a brief case report will be presented, followed by multiple management options. After reviewing the case, readers will make their selection regarding case management by faxing, e-mailing, or voting online at www.medreviews.com. The distribution of responses will be summarized in the next issue of the journal, along with a discussion by one of our editors of the various management options and the editor's choice as to the best of these. Prostatitis/Chronic Pelvic Pain Syndrome J. Curtis Nickel, MD, FRCSC Department of Urology, Queen’s University, Kingston, Ontario, Canada [Rev Urol. 2002;4(2):95–96] © 2002 MedReviews, LLC CASE SCENARIO 32-year-old, previously healthy man has a 9month history of perineal, suprapubic, and penile pain. The pain waxes and wanes but is always present during waking hours. He also complains of pain during and for 2 hours after ejaculation as well as mild irritative and obstructive voiding symptoms. The symp- A toms are severely impacting on his quality of life. Although he has never had a urinary tract infection, he was treated by his family physician 5 months earlier with 2 weeks of amoxicillin with no significant amelioration of symptoms. He is currently taking zinc and saw palmetto extract. READER QUESTIONNAIRE The author will prepare a follow-up article on the above case management scenario based on reader response to the following questionnaire. Please read the questions below and choose the answer that is most true for you and your practice: 1. I see the following number of prostatitis patients in an average month in my clinical practice: a. ___ patients in an average month b. ___ percentage of these patients is new to my practice. 2. I believe that most cases of chronic prostatitis/chronic pelvic pain syndrome are: a. Psychological b. Infectious c. Inflammatory d. Immune mediated e. Neuromuscular 3. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was developed to provide a validated symptom assessment tool for baseline evaluation and clinical follow up of chronic prostatitis patients. In regard to the NIH–CPSI: a. Never heard of it b. Sounds interesting and perhaps useful c. Would use it if it were generally available d. Use it in my clinical practice e. Will unlikely use it in my clinical practice 4. Following history and physical examination, I usually perform the following tests on chronic prostatitis patients prior to initiating treatment: a. No further specific tests b. Urine culture c. Microscopic urinalysis and standard urine culture d. Meares-Stamey 4-glass test (microscopic and culture evaluation of VB1, VB2, EPS, and VB3). e. Pre- and post-massage 2-glass test (microscopy and culture evaluation of urine specimens before and after prostate massage). 5. The patient had negative urine cultures, expressed prostatic secretions were unobtainable, and VB3 (post-massage urine specimen) showed 6 white blood cells per high-power field. My first line medical therapy for this patient would be: a. Antibiotics b. Alpha-blockers d. Phytotherapy c. Anti-inflammatory agents e. Other (please list) 6. My second line of medical therapy for prostatitis patients who did not respond to the first line therapy noted in question #5 is: a. Antibiotics b. Alpha-blockers d. Phytotherapy c. Anti-inflammatory agents e. Other (please list) ✁ Answer this questionnaire online at www.medreviews.com, or fax your completed questionnaire to MedReviews: (212) 971-4047, or send an e-mail message with your answers to dgern@medreviews.com. Responses will be tabulated and presented in the next issue of Reviews in Urology. VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY 95 Case Scenario continued Responses to and Discussion of Last Issue’s Case Scenario IN THE LAST ISSUE, DR. JACOB RAJFER AND COLLEAGUES PRESENTED THIS CASE REPORT: A 26-year-old male presented to the emergency room with acute onset of right-sided scrotal pain. The pain awoke him from sleep approximately 2 hours prior to presentation and began in the right lower quadrant, then quickly localized to the scrotum. With the onset of pain he noted swelling of the right testicle. There was no fever, chills, nausea, or vomiting. Upon examination, the abdomen was benign. THESE The right scrotum appeared mildly enlarged. Palpation revealed a thickened spermatic cord and a mildly enlarged but tender testicle. The epididymis was palpated in the anterolateral part of the scrotum. The cremasteric reflex could not be demonstrated on either side. Initial laboratory tests including urinalysis were normal except for mild leukocytosis. WERE THE MANAGEMENT OPTIONS OFFERED: ❑ 1. Obtain scrotal ultrasound ❑ 2. Go directly to operating room for scrotal exploration ❑ 3. Urine culture and antibiotics and re-evaluation in 3 days ❑ 4. Testis tumor markers and CT scan of abdomen READER’S CHOICES Readers’ choices as to the best management option were as follows: Of the responses received, 70% chose option 1; 30% option 2; No respondents chose options 3 or 4. AUTHOR’S DISCUSSION The differential diagnosis of this case includes testicular torsion, epididymo-orchitis, ruptured testicular neoplasm, and incarcerated hernia. Although the age of the patient is not typical for torsion, the history of acute onset and finding of abnormal epididymal lie on examination is presumptively diagnostic of testicular torsion. Scrotal ultrasound/Doppler is often used in the work-up of scrotal pain. In the case of torsion, an inhomogeneous testicle with varying echogenicity and decreased or absent intratesticular blood flow compared to the unaffected testicle is the most common finding. However, there are a significant number of false negatives with Doppler ultrasound, especially in early torsion, because the cessation of blood flow is generally gradual and the ultrasonographer may mistakenly image flow on the surface of the testis rather than intratesticular flow.1 As a result, it is always prudent to compare the echotexture and intratesticular blood flow of the uninvolved testis to identify any differences between the two that may be suggestive of an unrecognized torsion of the testis. Therefore, the history and physical examination should be the key factor in determining the diagnosis of torsion, so that operative exploration can be expedited. In this case, the authors chose to proceed directly to the operating room without obtaining a preoperative Doppler ultrasound primarily because the operating room became available before the ultrasound could be performed. Had the 96 VOL. 4 NO. 2 2001 REVIEWS IN UROLOGY ultrasound been performed first and had it demonstrated normal testicular flow and echotexture, surgery would not have commenced. In this instance, a median raphe incision was made, and the right scrotum was opened. A 720-degree intravaginal torsion of the testicle was observed. The testicle appeared dusky blue, but not necrotic. It was quickly detorsed and then placed in warm saline-soaked sponges while orchiopexy of the contralateral testicle was performed.2 Within several minutes, the testicle appeared pink, and a strong Doppler signal was elicited, indicating restoration of blood flow. A small stab incision was made through the tunica albuginea, and bright red blood was observed. At this point, we were confident that the affected testicle was viable and an orchiopexy was also performed on this side, and the wound was closed. The time from urology consultation to operating room was approximately 1 hour. Necrosis of the testicle secondary to torsion may occur within 6 hours.3 Therefore, prompt surgical exploration, if possible, in the setting of a high clinical suspicion for torsion is clearly the key to preventing testicular loss. References 1. 2. 3. Sidhu PS. Clinical and imaging features of testicular torsion: role of ultrasound. Clin Radiol. 1999;54:343–352. Mishriki SF, Winkle DC, Frank JD. Fixation of a single testis: always, sometimes or never. Br J Urol. 1992;69:311–313. Lee LM, Wright JE, McLoughlin MG. Testicular torsion in the adult. J Urol. 1983;130: 93–94.