69-Year-Old Male with Left Spermatic Cord Mass

CASE SCENARIO Case Scenario: 69-Year-Old Male with Left Spermatic Cord Mass Jeff Wieder, MD, Jim Hu, MD, Matt Bui, MD, Steve Freedland, MD, Arie S. Belldegrun, MD Department of Urology, University of California, Los Angeles School of Medicine, Los Angeles, CA [Rev Urol. 2002;4(3):153–156] © 2002 MedReviews, LLC CASE REPORT 69-year-old male presented to his local urologist complaining of a painless mass in the upper left scrotum that progressively enlarged over 3 months. He was otherwise asymptomatic. Examination of the external genitalia revealed a 3-cm, non-tender, mobile, firm, nodular mass in the left spermatic cord, several centimeters above the testicle. Overlying skin changes and inguinal hernia were absent. The rest of the physical examination (including testicles, scrotum, penis, and abdomen) was normal. Scrotal ultrasound revealed a 3-cm, solid, left A spermatic cord mass separate from the left testicle and normal testicles bilaterally. Abdominal/pelvic computerized tomography (CT) showed a solid enhancing mass in the left spermatic cord (consistent with the ultrasound findings), but no evidence of metastasis or lymphadenopathy. Chest x-ray, urinalysis, blood count, liver function tests, electrolytes, and creatinine were normal. Left radical inguinal orchiectomy revealed both high and low grade liposarcoma with cancer at the lateral and proximal surgical margin. The patient has been referred to you for further evaluation. MANAGEMENT OPTIONS Select one: ❑ 1. Surveillance ❑ 2. External beam radiation (XRT) to left groin ❑ 3. Wide excision of left groin (including excision of scar) ❑ 4. Wide excision of left groin (including excision of scar) and adjuvant XRT to left groin ❑ 5. Retroperitoneal lymph node dissection (RPLND) ❑ 6. RPLND and wide excision of left groin (including excision of scar) ❑ 7. RPLND, wide excision of left groin (including excision of scar), and adjuvant XRT ✁ Vote online at www.medreviews.com; fax your selection to MedReviews: (212) 971-4047; or send an e-mail message with your selection to dgern@medreviews.com. Selections will be tabulated and presented in the next issue of Reviews in Urology. VOL. 4 NO. 3 2002 REVIEWS IN UROLOGY 153 Case Scenario continued Responses to and Discussion of Last Issue’s Case Scenario: Prostatitis/Chronic Pelvic Pain Syndrome IN THE LAST ISSUE, DR. J. CURTIS NICKEL A 32-year-old, previously healthy man has a 9-month 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 PRESENTED THE FOLLOWING SCENARIO: symptoms 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 Readers were asked to respond to the following questionnaire in regard to the above case. Dr. Nickel’s discussion is based in part on the responses from the readers. 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 are new to my practice. 2. I believe that most cases of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) 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 154 VOL. 4 NO. 3 2002 REVIEWS IN UROLOGY 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 six white blood cells per high-power field. My first line medical therapy for this patient would be: a. Antibiotics d. Phytotherapy b. Alpha-blockers e. Other (please list) c. Anti-inflammatory agents 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 d. Phytotherapy b. Alpha-blockers e. Other (please list) c. Anti-inflammatory agents Case Scenario AUTHOR’S DISCUSSION Question 1: Epidemiology Readers see on average 17 prostatitis patients per month (range 6–40); on average, 22% (range 10%–40%) are new to their practice. North American Practice surveys have indicated that urologists see approximately 100–150 prostatitis patients per year, with about 30% being new to their practice. In fact, it is the most common urological outpatient diagnosis in men under 50 years of age (the third most common in men over 50). Question 2: Etiology Readers are split on the question of whether prostatitis is an inflammatory or neuromuscular problem, although psychological and infectious pathogenic mechanisms are also thought to be important. No reader thought that the process was immune mediated. The question was actually unfair, because we now believe that all these mechanisms may be implicated at various times as the syndrome or disease progresses along a cascade of events. The author believes that an initiator event, which could be an infectious, traumatic, noxious, or persistent stimuli such as would occur with an anatomic abnormality (eg, intraprostatic reflux, bladder neck obstruction) or high-pressure dysfunctional voiding (eg, with vesical–sphincter dyssynergia) causes either inflammation in the prostate or neurogenic injury in the prostate, periprostatic area, or perineum. The inflammation can be propagated via autoimmune mechanisms; the neurogenic problem can be compounded via neuropathic mechanisms (upregulation of local nerve fibers, “wind-up" in central nervous system). Inflammation can promote further neurogenic injury, and local perineal/pelvic neuropathy induces muscular problems and can even cause neurogenically mediated inflammation. The end result is pain (perineum, pelvis, referred to local area), voiding symptoms (irritative and obstructive), and sexual dysfunction (primarily related to ejaculatory pain). Question 3: Prostatitis Symptom Assessment A few readers have heard of or use the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), but most are not aware of this very useful instrument. It was developed for use in clinical trials (to measure and compare responses to therapy), but it has turned out to be very useful in clinical practice as well. It consists of nine questions (taking 5 minutes to complete) that explore the three most important symptom domains in the life of a patient with chronic prostatitis: pain (location, frequency, severity), voiding dysfunction (irritative and obstructive), and impact on quality of life. It allows the patient to adequately express the degree of his symptomatology as well as the impact his symptoms have on his quality of life. It allows the physician to explore the most important symptoms of the syndrome, assess the degree of symptoms and their impact on the patient, and most importantly promotes the tracking of symptoms over time. In a medical syndrome in which amelioration of symptoms rather than cure is the therapeutic goal, the NIH-CPSI assists the physician and patient in determining outcomes over time. The NIH-CPSI can be found in any of the references noted at the end of this article. Question 4: Lower Urinary Tract Evaluation No reader admitted to performing the traditional MearesStamey four-glass test to evaluate the culture and inflammatory status of the lower urinary tract. This is consistent with urology practice surveys. Most readers indicated that they either do a single urinalysis and culture or the pre- and post-massage urinalysis/microscopy procedure. The fourglass test is cumbersome, expensive, difficult to interpret, and in most urologists’ opinions adds little to treatment decisions. A recent case-control study completed by the NIH Chronic Prostatitis Collaborative Research Network (presented at the American Urological Association meeting in Orlando in May 2002) was not able to validate the use of this traditional procedure to differentiate men with chronic prostatitis from men without prostatitis symptoms. The same number of cases compared to controls had uropathogenic bacteria cultured in prostate-specific specimens, and although white blood cell counts were higher in chronic prostatitis cases, there was a very high prevalence of elevated white blood cells in prostate-specific specimens of asymptomatic, control men. It seems reasonable to perform a simple urinalysis and culture (preferably post–prostatic massage) and reserve the more complex evaluation for patients suspected of having chronic bacterial prostatitis (by history—recurrent urinary tract infections—or from screening cultures). Question 5: Treatment of CP/CPPS There is no consensus among readers as to the most appropriate first-line therapy for patients presenting with symptoms of chronic prostatitis with negative bacterial cultures (definition of CP/CPPS). Antibiotics, anti-inflammatory agents, and -blockers are the most popular choices, not only among readers, but also of North American urologists. Most of the evidence for the efficacy of these agents is VOL. 4 NO. 3 2002 REVIEWS IN UROLOGY 155 Case Scenario continued based on anecdotal experience or small, uncontrolled studies. Within the next year, studies will be completed and published comparing antibiotics, -blockers, and anti-inflammatory agents to placebo. Urologists will then be able to pick their first-line therapy based on solid evidence. Question 6: Second-Line Therapy for CP/CPPS Unfortunately, it is the experience of most urologists that their primary choice of therapy does not always lead to significant amelioration of symptoms, and a second-line treatment is necessary. There is really very little clinical evidence on which to base a treatment decision. It appears that multimodal therapy rather than monotherapy will likely be the choice at this stage. Within the next year, the results of at least one study evaluating multimodal therapy (antibiotics plus -blockers) will be available to guide physicians. Conclusion Readers responding to this chronic prostatitis case scenario clearly outline the difficulties and challenges that lie ahead for researchers trying to understand the condition and urologists whose task is to treat chronic prostatitis patients. Most physicians reading the answers from other urologists will be reassured that they are probably employing the right approach at this time. However, the publication in the very near future of prospectively controlled natural history studies, case-controlled studies, and numerous randomized, placebo-controlled treatment trials will eventually allow us to manage this condition using an evidence-based approach. FURTHER READING Evidence and references for the statements and interpretations made by the author can be found in the following recent publications. Wein AJ, eds. Campbell’s Urology, 8th edition. Philadelphia: W.B. Saunders Company; 2002. Nickel JC. The Prostatitis Manual: A Practical Guide to the Management of Prostatitis/Chronic Pelvic Pain Syndrome. Oxford, UK: Bladen Press Ltd; 2002. Nickel JC. Prostatitis. In: Gillenwater JY, Greyhack JT, Howards SS, Mitchell ME, eds. Adult and Pediatric Urology. Philadelphia: W.B. Saunders Company; 2001:1655–1682. Nickel JC. Prostatitis and related conditions. In: Walsh PC, Retik AB, Vaughan Ed Jr, Nickel JC. The Textbook of Prostatitis. Oxford, UK: ISIS Ltd; 1999. 156 VOL. 4 NO. 3 2002 REVIEWS IN UROLOGY