Overview of Overactive Bladder, Prostatitis, and Lower Urinary Tract Symptoms for the Primary Care Physician

BLADDER DYSFUNCTION Overview of Overactive Bladder, Prostatitis, and Lower Urinary Tract Symptoms for the Primary Care Physician Richard S. Pelman, MD Department of Urology, University of Washington School of Medicine, Seattle, WA; Bellevue Urology Associates, Bellevue, WA As an increasing number of treatment options for urologic disorders become available, patients with these conditions are more often able to be managed in the primary care setting. Primary care physicians, therefore, must become more knowledgeable of the proper urologic terminology and the screening tools that have traditionally been used by urologists. To that end, this article reviews the terminology associated with lower urinary tract symptoms and describes the evaluation and treatment of patients presenting with these symptoms. The diagnoses of overactive bladder and prostatitis are discussed, as well as the therapeutic options available for these patients. [Rev Urol. 2004;6(suppl 1):S16-S23] © 2004 MedReviews, LLC Key words: Bladder dysfunction • Lower urinary tract symptoms • Overactive bladder • Prostatitis ver the past decade, an increasing number of pharmacologic options for the treatment of various urologic diseases have become available. As a result, certain urologic disorders may now be successfully treated in the primary care setting. Many patients appreciate this “one-stop shopping" and view the ability to receive treatment from their primary care physician as an invaluable benefit. Although patients realize the worth of referral when appropriate, they O S16 VOL. 6 SUPPL. 1 2004 REVIEWS IN UROLOGY OAB, Prostatitis, and LUTS also value the convenience of receiving treatment within the same visit to their primary care provider. At the current time, expectations are that primary care physicians utilize medications as first-line therapy for appropriate patients presenting with urologic disorders. Referral to a urologist should be made in the more difficult cases, such as patients whose symptoms span a constella- cians have a host of other disorders that need to be addressed during each patient encounter. To add the burden of urologic diseases to an already complex patient visit may cause the physician to simply refer the patient to a specialist. The question that then arises is how to promote the initial treatment of the various urologic disorders for which pharmacologic therapy is avail- The availability of new urologic medications requires primary care physicians to become more involved in the management of these disorders. tion of diagnostic considerations and diagnoses and those who have failed a trial of medication. The availability of new urologic medications requires primary care physicians to become more involved in the management of these disorders. For example, before the development of -blockers and 5--reductase inhibitors, the primary care physician had 2 management options for men presenting with benign prostatic enlargement: observe the patient or refer him to a urologist for surgery. However, the availability of pharmacologic therapy has made possible the successful management of these patients in the primary care setting, requiring primary care physicians to become increasingly knowledgeable and involved in the diagnosis and treatment of prostatic disorders. Likewise, the availability of pharmacologic agents for the treatment of prostatitis, overactive bladder, and erectile dysfunction has required the primary care physician to become facile in the diagnosis and management of these disorders. Through the experience of practice, many primary care providers have obtained the necessary knowledge base to manage these urologic disorders. However, primary care physi- able to the primary care physician, who has not had the advantage of years of residency in the specifics of urologic disease. In many instances, there are “tools of the trade," to which the primary care physician has not yet been introduced, which help urologists to decipher urologic symptoms and sort them into various disease categories. Many of these screening tools can be provided to primary care physicians, who can successfully utilize them to initiate the appropriate treatment for their patients. To this end, publications are available to provide primary care Terminology According to the current standardization of terminology of lower urinary tract function recommended by the International Continence Society, the term “lower urinary tract symptoms suggestive of bladder outlet obstruction" is used “when a man complains predominantly of voiding symptoms in the absence of infection or obvious pathology other than possible cause of outlet obstruction."2 How do urologists translate that information into initiating appropriate therapy? The symptoms carry with them specific meaning but do not attempt to classify a diagnosis. When the appropriate constellation of symptoms is present in the absence of conflicting pathology or metabolic disease, the symptoms may be categorized as a disease. Can we as urologists help primary care providers become familiar with our vocabulary of disease? To do so, it is helpful to review the terminology used to facilitate the diagnosis of various urologic conditions. As defined by the International Continence Society, symptoms are “the subjective indicator of a disease or change in condition as perceived by the patient, carer or partner and Bladder storage symptoms include increased daytime frequency, nocturia, urgency, and urinary incontinence. physicians with the information they need to appropriately treat urologic conditions or refer to a urologist when necessary. For example, the Urology for Primary Care manual reviews urologic disorders for which the primary care physician has pharmacologic treatment available and helps elucidate the various terminology and thought processes urologists have gained through years of clinical experience.1 may lead him/her to seek help from health care professionals."2 Lower urinary tract symptoms (LUTS) can be classified as bladder storage symptoms, sensation symptoms, or voiding symptoms (Table 1). Bladder storage symptoms include increased daytime frequency, nocturia, urgency, and urinary incontinence. Incontinence can further be classified into subcategories: stress incontinence, urge incontinence, mixed urinary incontinence, enuresis, VOL. 6 SUPPL. 1 2004 REVIEWS IN UROLOGY S17 OAB, Prostatitis, and LUTS continued Table 1 Lower Urinary Tract Symptoms Bladder storage symptoms • Increased daytime frequency • Nocturia • Urgency • Urinary incontinence – Stress urinary incontinence – Urge urinary incontinence – Mixed urinary incontinence – Enuresis – Continuous urinary incontinence Bladder sensation • Normal • Increased • Reduced • Absent Voiding symptoms • Slow urinary stream • Splitting or spraying of the urinary stream • Intermittent stream • Urinary hesitancy • Straining to void • Terminal dribbling Postmicturition symptoms • Feeling of incomplete emptying • Postmicturition dribbling Adapted from Abrams P et al. Neurourol Urodyn. 2002;21:167-178.2 or continuous urinary incontinence. LUTS can be classified into the following categories of bladder sensation2: • Normal awareness of bladder filling (ie, normal sensation) • Increased bladder sensation: the patient has an early and persistent desire to void • Reduced bladder sensation: the patient is aware of bladder filling but has a less-than-definitive need to void • Absent bladder sensation Voiding urinary symptoms include a slow urinary stream, splitting or spraying of the urinary stream, intermittent S18 VOL. 6 SUPPL. 1 2004 urinary stream, hesitancy, straining to void, and terminal dribbling. Terminal dribbling is distinguished from postmicturition dribbling in that it occurs as a prolonged and final part of micturition. Additional bladder storage symptoms occur as postmicturition symptoms, including a feeling of incomplete emptying and postmicturition dribbling. Utilizing LUTS to describe events associated with voiding and storage helps to separate symptoms from an initial diagnosis. In the past, many of these symptoms were categorized as either obstructive or irritative, implying that the predominant etiology in The International Prostate Symptom Score adds a quality-of-life question to the AUA Symptom Index to determine the extent to which patients are bothered by their symptoms. This tool categorizes symptoms as severe, moderate, or mild and allows the physician to understand the degree of inconvenience that patients perceive their symptoms to be causing. Some patients may have severe symptom scores but not be bothered by their symptoms. However, these patients deserve further evaluation as they may have significant obstruction causing chronic retention or be at risk for bladder dysfunction in the The AUA symptom score is useful in the initial evaluation of the patient and in following the adequacy of treatment. patients with obstructive symptoms was bladder outlet obstruction (BOO). It is now clear that many of the symptoms that were previously designated as irritative or obstructive in fact overlapped and that these designations served to restrict the physician’s thinking regarding the disease process. Using the new terminology described by the International Continence Society, the physician may be less inclined to focus on a specific disease entity until all components of the disorder—symptoms, signs, and examination—can unify the problem into a specific diagnosis. Diagnosis A patient may present with a mix of bladder storage and voiding symptoms. A useful tool that urologists have incorporated into their evaluation of LUTS suggestive of BOO is the American Urological Association (AUA) Symptom Index (Table 2).3 The AUA symptom score is useful in the initial evaluation of the patient and in following the adequacy of treatment. REVIEWS IN UROLOGY future. Patients may also have voiding or bladder storage symptoms that are not suggestive of BOO and need to be investigated for other potential etiologies. Assuming a working diagnosis of BOO, the physician should proceed with a physical examination of the patient. This should include an abdominal examination, palpating for distended bladder or abdominal mass; examination of the genitalia, inspecting the urinary meatus for evidence of stenosis or abnormality; and a digital rectal examination for evaluation of possible prostate induration, nodularity, or asymmetry or the presence of a rectal mass. A focused neurologic examination, including assessment of rectal sphincter tone, is also indicated. Laboratory evaluation should include measurement of serum creatinine, prostate-specific antigen (PSA), and postvoid residual urine volume (PVR), as well as urinalysis. If the prostate examination or PSA level is abnormal, further evaluation is necessary. OAB, Prostatitis, and LUTS Table 2 American Urological Association Symptom Index Not at All Less Than 1 Time in 5 Less Than Half the Time About Half the Time More Than Half the Time Almost Always 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 2. Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 3. Over the past month, how often have you found you stopped and started again several times when you urinated? ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 4. Over the past month, how often have you found it difficult to postpone urination? ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 5. Over the past month, how often have you had a weak urinary stream? ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 6. Over the past month, how often have you had to push or strain to begin urination? ❑0 ❑1 ❑2 ❑3 ❑4 ❑5 7. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? 0 none ❑ ❑ 1 1 time ❑ ❑ 2 2 times 3 3 times ❑ 4 4 times ❑ 5 5 or more times AUA symptom score = sum of questions 1 to 7. From Barry MJ et al. J Urol. 1992;148:1549-1557.3 Therapy After the initial evaluation has taken place, the decision can be made whether to manage the patient with expectant therapy or to initiate treatment. Patients eligible for expectant therapy may include those who have a moderate symptom score with a low bother score, negligible residual urine, normal urinalysis, and no history of incontinence or urinary tract infections. If the decision is made to initiate treatment, 2 pharmacologic therapies are available to the primary care physician: -blockers and 5-- reductase inhibitors. The utility of these medications in patients with BPH is discussed elsewhere in this supplement (see Lepor, p. S8). Patients who have an abnormal urinalysis, elevated PSA level, or significant overlap in symptoms leading to an increased complexity of diagnosis should be referred to a urologist for further evaluation. The patient who has a confounding number of symptoms may be further evaluated by a urologist using cystoscopy or urodynamics. Although these studies are not necessarily indicated in all patients, they help to differentiate patients with various pathologic entities from those who may have overlapping bladder storage and voiding symptoms. Patients with a high PVR, indicating chronic urinary retention, should be referred to a urologist, particularly if there has already been a failure of blocker therapy. It is important for the primary care physician to be aware that BOO may be caused by factors other than benign prostatic enlargement. Additional causes include meatal stenosis, cal- VOL. 6 SUPPL. 1 2004 REVIEWS IN UROLOGY S19 OAB, Prostatitis, and LUTS continued culi, urethral carcinoma, urethral stricture disease, and BOO due to bladder neck hypertrophy. Meatal stenosis, calculi, carcinoma, and urethral stricture disease will not respond to therapy with -blockers or 5-reductase inhibitors. The Overactive Bladder Overactive bladder syndrome is currently described as urinary urgency with or without urge incontinence, usually with frequency and nocturia, in the absence of a pathologic or metabolic condition that might extrinsic to the bladder include urethral diverticulum, retroverted uterus, pelvic prolapse (including cystocele), endometriosis, gravid uterus, and loss or reduction of local vaginal estrogen. Disorders extrinsic to the bladder that are common in both men and women include pelvic mass, physiologic nocturnal diuresis, and polyuria due to factors such as excessive fluid intake, diuretic use, or diabetes. Symptoms of overactive bladder can also be caused by neurologic disorders, such as Parkinson disease, The syndrome of overactive bladder is exclusive of any underlying metabolic or pathologic condition. explain these symptoms.1 Thus, a patient who has an underlying pathologic or metabolic disorder may have symptoms of overactive bladder but does not have overactive bladder syndrome. The syndrome of overactive bladder is exclusive of any underlying metabolic or pathologic condition. Considerations of Differential Diagnosis The etiology of overactive bladder may be musculogenic or neurogenic in nature. It is incumbent upon the physician to rule out associated pathologic or metabolic diseases that may mimic the overactive bladder syndrome. These diseases can be categorized as disorders intrinsic or extrinsic to the bladder. In female patients, intrinsic disorders include urinary tract infection, bladder carcinoma, carcinoma in situ of the bladder, bladder calculi, and interstitial cystitis. In male patients, the most common extrinsic process responsible for the symptoms of overactive bladder is benign prostatic enlargement causing BOO. In female patients, diseases S20 VOL. 6 SUPPL. 1 2004 multiple sclerosis, cervical stenosis, spinal cord injury, diabetic neuropathy, and hydrocephalus. Bladder aging may also account for changes leading to bladder overactivity. In addition, a patient history of pelvic trauma; pelvic radiation; or bladder, prostate, or urethral surgery should be considered as possible causative factors. Transient causes of overactive bladder can be summarized using the DIAPPERS acronym described by Resnick and Yalla4: • • • • • • • • Delirium/dementia Infection Atrophic vaginitis/urethritis Pharmaceuticals Psychiatric causes Endocrine causes Restricted mobility Stool impaction Patient Evaluation When presented with a patient with symptoms of overactive bladder, the primary care physician should integrate the following into the patient evaluation to help determine the REVIEWS IN UROLOGY underlying cause of the symptoms: patient history; physical examination; laboratory data; use of tools such as voiding diaries and pad counts; and, in the case of male patients, measurement of PVR using ultrasound. When obtaining the patient history, the physician should focus on important risk factors, including a history of pelvic surgery or pelvic radiation, trauma, medical conditions, or neurologic problems. An up-to-date medical history and medication review should be obtained. A focused genitourinary history taking should be performed that takes into account the frequency of urination, urgency, amount of urine produced in response to the urge to void, and any sensation of incomplete emptying, as well as the time of day and duration of urge events. It is also helpful to review previous incontinent episodes, including information about the amount of urine lost and any association of urinary urgency with activities or events. Stress incontinence is typically associated with some type of activity, and urine loss can be quantified in these patients. Occasionally, patients have mixed urinary incontinence, in which they complain of urgency and the inability to control an unexpected loss of urine as well as stress incontinence. Voiding diaries and pad counts are useful in determining the severity of the disorder and monitoring outcomes after the initiation of treatment. When evaluating men with overactive bladder thought to be secondary to chronic BOO, the primary care physician should perform an appropriate examination of the prostate, PSA determination, urinalysis, and PVR measurement as determined by ultrasound. Overactive bladder symptoms due to chronic BOO can be treated with anticholinergic/antimuscarinic therapy, assuming residual OAB, Prostatitis, and LUTS Table 3 National Institutes of Health Classification of Prostatitis Category I Definition Acute bacterial prostatitis II Chronic bacterial prostatitis Recurrent infection of the prostate III Chronic nonbacterial prostatitis/chronic pelvic pain syndrome No demonstrable infection Inflammatory chronic pelvic pain syndrome White cells are found in the semen, EPS, or VB-3 IIIA IIIB IV Characteristics Acute infection of the prostate Noninflammatory chronic pelvic pain syndrome White cells are not found in the semen, EPS, or VB-3 Asymptomatic inflammatory prostatitis No subjective symptoms, but white blood cells are found in prostate secretions or in prostate tissue during evaluation for other disorders EPS, expressed prostatic secretions; VB-3, voided bladder urine-3. From Executive Summary: Chronic Prostatitis Workshop. National Institute of Diabetes and Digestive and Kidney Diseases; 1995.7 urine is negligible. The physician can initiate treatment at the level of the bladder outlet, with -blockers or 5--reductase inhibitors, or at the bladder level. The decision as to which strategy to employ should include multiple factors and take into account which symptoms are most bothersome to the patient. A trialand-error of different medications or combination therapy may be required. When evaluating women with overactive bladder symptoms, the primary care physician should examine the following: the genitalia; the pelvic vault with regard to the urethral position; hypermobility during coughing or straining; evidence or absence of urethral diverticulum; level of local estrogen or atrophy; and the potential for loss of pelvic support, such as cystocele, enterocele, rectocele, or pelvic prolapse. Antimuscarinic/anticholinergic therapy can be prescribed by the primary care physician. After the initiation of therapy, patients should continue to record a voiding diary to monitor treatment response. Antimuscarinic/ anticholinergic therapy has been shown to be more effective when used in combination with behavioral modification techniques.5 Behavioral modification, utilizing biofeedback, deferred voiding, or timed voiding, is an important component of therapy for overactive bladder.6 Feedback through use of a personal bladder scanner may be beneficial for patients employing behavioral modification techniques. The physician can provide these patients with a preset target volume of urine. The patients can then use the bladder scanner at home to determine whether they have reached their target goal and, if not, defer voiding appropriate diagnosis. Incontinence not responding to medication and voiding dysfunction that does not fit the criteria for overactive bladder present additional diagnostic dilemmas. These patients require referral to a urologist for evaluation with urodynamics, cystoscopy, and possibly voiding studies. Prostatitis The NIH classification system describes 4 categories of prostatitis, each of which has various presenting Feedback through use of a personal bladder scanner may be beneficial for patients employing behavioral modification techniques. until the goal is met. As the practitioner monitors the success of the patient in achieving the preset volume, the amount of target urine can be increased. The theory that this methodology will enhance treatment outcomes is currently being studied, and data is anticipated to be available early next year. A female patient with overactive bladder who has an abnormal urinalysis with hematuria or sterile pyuria should raise concern regarding the symptoms, diagnostic parameters, and therapeutic options (Table 3).7 Not all cases of prostatitis are believed to be infection-related. In fact, cases of acute and chronic bacterial prostatitis account for only 5% of patients presenting with prostatitis.8 Category I: Acute Bacterial Prostatitis Patients with acute bacterial prostatitis present with fever, a toxic appearance, complaints of difficulty voiding, slowing of the urinary VOL. 6 SUPPL. 1 2004 REVIEWS IN UROLOGY S21 OAB, Prostatitis, and LUTS continued stream, dysuria, urgency, and frequency. The urine appears infected on urinalysis. Urine culture usually reveals the presence of Escherichia coli. These patients will demonstrate an elevated white blood cell count. Physical examination reveals a febrile, ill patient. The genitalia are benign on examination and should be checked for the possibility of acute epididymitis as the cause of therapy can be continued or a secondline antibiotic, such as trimethoprimsulfamethoxazole, can be utilized. If a quinolone is used, therapy should continue for at least 2 more weeks; if a second-line antibiotic is used, duration of treatment should be longer. The risk of failure to sterilize the prostate is to invite a chronic bacterial prostatitis. Use of an -blocker to relieve The risk of failure to sterilize the prostate is to invite a chronic bacterial prostatitis. infection. The prostate examination will reveal a firm and indurated prostate. A gentle examination should be performed so as not to cause further bacteremia. The PSA value should not be obtained during this time, as it will be elevated and take weeks to decline to normal levels. The patient should be evaluated for urinary retention using a portable bladder ultrasound device. Treatment of acute bacterial prostatitis should be initiated with high-dose quinolone therapy for a minimum of 2 weeks. At that time, quinolone voiding difficulties may be considered. Urinary catheterization should be performed in patients with urinary retention. After the acute infection has been treated, the patient should be followed for sterility of urine and prostate secretions. The physician should also confirm that the patient is voiding without restriction or significant retention of urine. Category II: Chronic Bacterial Prostatitis Patients with chronic bacterial prostatitis often present with symptoms that mirror those of patients with type I prostatitis. However, because these patients are typically men who suffered an episode of acute bacterial prostatitis but received insufficient treatment, they are usually less ill in that they present at initial onset of symptoms. The urine culture, prostatic secretions, or ejaculate of patients will be positive for gram-negative bacteria or other uropathic organisms. Expressed prostatic secretions (EPS) will yield abundant inflammatory cells. Patients with category II prostatitis require aggressive and prolonged antibiotic therapy. Adequacy and efficiency of voiding mechanics should be assessed. Ultrasound should be performed to rule out urinary retention. Category IIIA: Chronic Prostatic Pelvic Pain Syndrome of the Inflammatory Type Although they are afebrile, patients with chronic prostatic pelvic pain syndrome of the inflammatory type may have symptoms similar to those of patients with chronic bacterial prostatitis. Patients with type IIIA prostatitis will have excessive leukocytes in EPS. However, they differ Main Points • The availability of new urologic medications has made possible the successful management of a variety of urologic disorders in the primary care setting. As a result, primary care physicians must become familiar with the terminology and screening instruments used by urologists to decipher and categorize urologic symptoms. • Lower urinary tract symptoms can be classified as bladder sensation symptoms, storage symptoms, or voiding symptoms. Bladder storage symptoms include increased daytime frequency, nocturia, urgency, and urinary incontinence. Voiding symptoms include a slow urinary stream, splitting or spraying of the urinary stream, intermittent urinary stream, hesitancy, straining to void, and terminal dribbling. • Overactive bladder is defined as urinary urgency with or without urge incontinence, usually with frequency and nocturia, in the absence of a pathologic or metabolic condition that might explain these symptoms. The diagnosis of overactive bladder should be made after a careful history taking; physical examination; laboratory testing; use of tools such as voiding diaries and pad counts; and, in the case of male patients, measurement of postvoid residual urine volume using ultrasound. • The NIH classification system describes 4 categories of prostatitis, each of which has various presenting symptoms, diagnostic parameters, and therapeutic options: acute bacterial prostatitis (category I); chronic bacterial prostatitis (category II); chronic nonbacterial prostatitis/chronic pelvic pain syndrome (category III), which is further described as inflammatory (IIIA) or noninflammatory (IIIB); and asymptomatic inflammatory prostatitis (category IV). Cases of acute and chronic bacterial prostatitis account for only 5% of patients presenting with prostatitis. S22 VOL. 6 SUPPL. 1 2004 REVIEWS IN UROLOGY OAB, Prostatitis, and LUTS from patients with category I or II prostatitis in that the urine culture, ejaculate, and EPS are sterile. It is possible that these patients may be infected by microorganisms not identified with current culture methods, as they seem to benefit from long-term antibiotic therapy. The addition of antibiotics effective against Chlamydia and Ureaplasma organisms has been suggested for patients who do not respond to initial therapy.9 The physician should evaluate for mechanical voiding dysfunction and perform ultrasound for detection of possible residual urine. Other therapies that may benefit patients with type IIIA prostatitis include anti-inflammatory agents,10 -blockers,11 and possibly phytogens such as saw palmetto, although this has yet to be proved in clinical trials.12 Category IIIB: Chronic Prostatic Pelvic Pain Syndrome of the Noninflammatory Type Patients with chronic prostatic pelvic pain syndrome of the noninflammatory type are distinguished from those with category IIIA prostatitis in that, although they may present with similar symptoms, their EPS are normal; that is, they do not have a pathologic increase in inflammatory cells. The urine culture, as well as cultures of EPS and ejaculate, lacks any identifiable pathogen. These patients should be evaluated for mechanical problems associated with emptying of the lower urinary tract. Evaluation of the bladder with ultrasound should be performed to check for residual urine. Urodynamics evaluation should be contemplated. Some patients with type IIIB prostatitis may suffer from pelvic floor syndromes and benefit from antiinflammatory agents10 or -blocker therapy.11 Other patients may benefit from biofeedback training to relax the pelvic floor.13 Whether antibiotic therapy has a place in the treatment of type IIIB prostatitis remains to be seen. Recent investigations have demonstrated the presence of inflammatory cells in the prostatic secretions of healthy male “control" patients,14 further blurring the line between type IIIA and type IIIB prostatitis. Therefore, it may prove worthwhile to administer an initial trial of antibiotic therapy for both groups of patients. A failure to respond to an initial trial of quinolone therapy should lead to further evaluation for an alternative etiology of the patient’s symptoms. No patient—including those with severe infection—should require longer than 6 weeks of therapy to resolve the condition. The possibility of referred pain should be considered for patients who are refractory to therapy. Patient education and reassurance are helpful to relieve patient anxiety. Category IV: Asymptomatic Inflammatory Prostatitis Patients with category IV prostatitis have inflammation of the prostate found upon prostate biopsy, surgical specimen (transurethral resection of the prostate chips), or investigation of EPS. However, these patients are asymptomatic. In general, category IV prostatitis does not require therapy or evaluation. tis rather than acute prostatitis will result in inadequate treatment. Whereas acute pyelonephritis will usually respond to 2 weeks of quinolone therapy, acute prostatitis requires a longer course of antibiotics in order to sterilize the prostate gland. Thus, having the correct presumptive diagnosis will help prevent the emergence of recurrent infection secondary to partial or incomplete treatment. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Conclusion All febrile urinary tract infections should be considered complicated. In women, the kidney should be considered as the source of infection; in men, the kidney, prostate, testis, and epididymis should be considered. Incorrectly diagnosing the etiology of infection in men as acute pyelonephri- 12. 13. 14. Pelman R, ed. Urology for Primary Care. Bothell, Wash: Diagnostic Ultrasound; 2001. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21:167-178. Barry MJ, Fowler FJ Jr, O’Leary MP, for the Measurement Committee of the American Urological Association. The American Urological Association symptom index for benign prostatic hyperplasia. J Urol. 1992;148:1549-1557. Resnick NM, Yalla SV. Management of urinary incontinence in the elderly. N Engl J Med. 1985;313:800-805. Burgio KL, Locher JL, Goode PS. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc. 2000;48:370-374. Clinical Practice Guideline Number 2 (1996 Update): Urinary Incontinence in Adults: Acute and Chronic Management. Rockville, Md: Agency for Health Care Policy and Research, US Dept of Health and Human Services; 1996. AHCPR publication 96-0682. Executive Summary: Chronic Prostatitis Workshop. Bethesda, Md: National Institute of Diabetes and Digestive and Kidney Diseases; 1995. Schaeffer AJ. Epidemiology and demographics of prostatitis. Andrologia. 2003;35:252-257. Stevermer JJ, Easley SK. Treatment of prostatitis. Am Fam Physician. 2000;61:3015-3022, 3025-3026. Nickel JC, Pontari M, Moon T, et al, for the Rofecoxib Prostatitis Investigator Team. A randomized, placebo controlled, multicenter study to evaluate the safety and efficacy of rofecoxib in the treatment of chronic nonbacterial prostatitis. J Urol. 2003;169:1401-1405. Cheah PY, Liong ML, Yuen KH, et al. Terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome: a randomized, placebo controlled trial. J Urol. 2003;169:592-596. Shoskes DA. Phytotherapy in chronic prostatitis. Urology. 2002;60:35-37. Nadler RB. Bladder training biofeedback and pelvic floor myalgia. Urology. 2002;60:42-44. Nickel JC, Alexander RB, Schaeffer AF, et al, for the Chronic Prostatitis Collaborative Research Network Study Group. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol. 2003;170:818-822. VOL. 6 SUPPL. 1 2004 REVIEWS IN UROLOGY S23