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Urology Primer TOPIC Page 1. Quick Referral Guide: Indications for Urology Referrals 2 2. Bladder Outlet Obstruction/Prostatism 4 3. Hematuria 6 4. Erectile Dysfunction 7 5. Urinary Incontinence 8 6. Prostate Cancer 9 7. Prostatitis 12 8. Renal Calculi 9. Urinary Tract Infection 13 14 10. Scrotal Masses 15 11. Circumcision 16 12. Testicular Torsion 17 13. Orchalgia 18 14. Appendix: AUA Scoring System 19 Urology primer - 1. Indications for Referral to Urology 1. Bladder Outlet Obstruction 1. Moderate to severe obstructive and/or irritative symptoms that interfere with the quality of life. Are the symptoms severe enough that the patient would want to take chronic medications or consider surgery on the prostate to relieve the symptoms? Is the AUA Symptom Score greater than 15? 2. Moderate to severe symptoms with post-void residual (PVR) 25% of bladder capacity or greater than 100cc – noted on imaging studies, when available. 3. Prostatism associated with a urinary tract infection 4. Hydronephrosis 5. Bladder calculi 6. Obstructive symptoms associated with urinary incontinence 7. Hematuria (see topic 2) 2. Hematuria Urological consultation should be obtained for a patient with hematuria once a UTI has been excluded or if the hematuria persists after as UTI has been appropriately treated. 3. Erectile Dysfunction This condition can be treated initially by the PCP and a referral to Urology clinic is not necessary. Please do not refer Erectile Dysfunction to Urology at ACMC. 4. Urinary Incontinence Overflow incontinence should be referred to urology. Stress and Urge incontinence should be managed in primary care. For women, the Gynecology service may be helpful. 5. Prostate Cancer Screening 1. Abnormal prostate exam in a male less than 75 years of age 2. PSA >10 in a male under the age of 75 6. Prostatitis Refer treatment failures to Urology. 7. Renal Calculi 1. 2. 3. 4. Recurrent calculi Obstructing/symptomatic stone that has not passed in 2-3 weeks Residual renal calculi or staghorn calculi Obstructing stone > 4mm in diameter 2 Urology primer - 3 5. Recurrent UTI 6. History of renal anomaly (solitary kidney, duplicated ureter, horsehoe kidney) or prior urological surgery. 8. Urinary Tract Infections 1. 2. 3. 4. History of urinary calculi Persistent hematuria (gross or microscopic) when uninfected Bacteria persistence in spite of adequate antibiotic therapy UTI symptoms in spite of negative cultures, and no other obvious cause 9. Scrotal Masses If uncertain about your clinical diagnosis, get a scrotal ultrasound. Refer solid masses to Urology. 10. Circumcision Adult Circumcision will not be preformed unless medically necessary (e.g. phimosis or recurrent balanitis) 11. Testicular Torsion Every torsion should be referred as a Urological Emergency, that is, send to an Emergency Department and call a Urologist. Urology primer - 4 2. Bladder Outlet Obstruction (BOO) Symptoms: 1. Frequency: (normally every 3-5 hours) may increase due to detrusor irritability or incomplete bladder emptying or both. 2. Nocturia: (awakening at night to urinate, normally once or twice during a night). Same etiology as for urinary frequency. 3. Nycturia: The passage of increased volumes of urine during the night resulting from the mobilization of dependent edema or from the use of diuretics. 4. Hesitancy: The interval of time before the urinary stream begins. 5. Intermittent Stream: Stopping and starting the urinary stream. 6. Difficulty stopping micturation/Terminal (post-void) dribbling 7. Decreased force (and caliber) or urinary stream 8. Feeling of incomplete bladder emptying 9. Urgency and urge incontinence 10. Overflow incontinence Quantifying the symptoms: see AUA Symptom Score Differential Diagnosis: 1. Benign prostatic hyperplasia-BPH/Prostatism 2. Prostate cancer-see discussion in this Primer (topic 5) 3. Urethreal obstruction-history of prior instrumentation, catheterization, trauma or STD 4. Inflammatory/Infectious conditions-cystitis, TB, prior pelvic radiation, bladder cancer 5. Impaired detrusor contractility- history of neurological disease, prescribed and OTC Rx most commonly the anti-histamines, decongestants, tricyclic antidepressants, ETOH). 6. Prostatitis/Prostatodynia-see discussion in this Primer (topic 6) Physical Examination: 1. Peripheral edema and signs of renal failure 2. Abdomen-distended bladder, sense of urgency during suprapubic palpation 3. Digital rectal examination (DRE) Estimating prostate size Normal 20 gm chestnut 1+ 25 gm plum 2+ 30-40 gm lemon 3+ 50-70 gm orange 4+ 70+ gm small grapefruit Urology primer - Texture Normal: Feels like the thenar eminence Abnormal (nodule): Feels like a knuckle Natural history of bladder neck obstruction secondary to BPH: 30-60%-spontaneous symptomatic improvement 20-50%-subjective worsening of symptoms 05-20%-risk of developing acute urinary retention Indications for Urological referral: 1. Moderate to severe obstructive and/or irratative symptoms that interfere with the quality of life. Are the symptoms severe enough that the patient would want to take chronic medications or consider surgery on the prostate to relieve the symptoms? Is the AUA Symptom Score greater than 15? 2. Moderate to severe symptoms with post-void residual (PVR) 25% of bladder capacity or greater than 100cc – noted on imaging studies, when available. 3. Prostatism associated with a urinary tract infection 4. Hydronephrosis due to BPH 5. Bladder calculi 6. Obstructive symptoms associated with urinary incontinence 7. Hematuria (see topic 3) Try alpha antagonists (Terazosin, Flomax, Cardura) prior to Urological consultation: Start with: Hytrin 1 mg qhs then after 3 days increase to 2 mg qhs Cardura 2 mg qhs then after 3 days increase to 4 g qhs Flomax 0.4 mg qam Obtain the following prior to Urological consultation: 1. UA/UC (per protocol) 2. Serum creatinine 3. AUA Symptoms Score 5 Urology primer - 3. Hematuria Definition: Blood in the urine Types of Hematuria: Microscopic (microhematuria – MH) - >5 RBC’ss per hpf, Gross Hematuria (GH) – blood you can see (tea to red colored) Heme + by dipstick is not enough. Obtain a microscopic analysis for RBCs Etiology: Stones Trauma/Sports Infection Inflammation Medications Hematologic disease Tumors of GU tract Renal (interstitial) disease Idiopathic Background: Microscopic hematuria is common (seen in approximately 15% of the general Population. Hematuria can be intermittent even if associated with significant urological disease. Smoking has an extremely strong association with bladder (transitional cell) cancer. Significant urological lesions (those needing treatment) are found in 5-10% of patients with microscopic hematuria and in 15-20% of patients with gross hematuria. Urological consultation should be obtained for a patient with hematuria once a UTI has been excluded or if the hematuria persists after as UTI has been appropriately treated. Obtain the following prior to Urological consultation: 1. At least 2 consecutive UA/Microscopic analysis performed 2 weeks apart in a lab to assess for microscopic hematuria. Dipstick UA is not sufficient. 2. Serum Creatinine 3. Imaging of the upper urinary tract: Contrast CT 4. Renal ultrasound and KUB if allergic to contrast or increased creatinine. 5. Please inform the patient that cystoscopy may be performed at the time of the Urological consultation. 6 Urology primer - 7 4. Impotence / Erectile Dysfunction This condition can be treated initially by the PCP and a referral to Urology clinic is not necessary. Definition: The inability to attain and/or sustain an erection adequate for sexual intercourse. TYPES Psychogenic impotence: Related to anxiety and/or stress preventing normal sexual function. A clue to this diagnosis is history of normal nocturnal or morning erections. Psychogenic impotence is likely in the absence of underlying medical conditions or drugs which can affect erections. Prior to trying empiric therapy, it is reasonable to try one of the following: o a book titled, Male Sexuality, by Bernie Zibergeld o Mental health referral Organic Impotence: May be subdivided into endocrine, vasculogenic, neurogenic, or drug related. Evaluation included urologic specific history and physical exam. A serum testosterone is indicated in only those who complain of decreased libido or who have bilateral or atrophic testicles. If serum testosterone is low, a pooled serum testosterone (PST) should be obtained. If PST is low, then consider Endocrinology consultation. Use of testosterone therapy can cause accelerated progression of both benign and neoplastic growth of the prostate. If it is used, a patient must be made aware of these risks. Treatment: Continue to treat underlying conditions such as diabetes, tobacco use and hypertension. Treatment is mainly empiric. We recommend Viagra with a starting dose of 50 mg taken an hour prior to intercourse. Patients must not be taking nitrates or alpha blockers. Patients also need to be told to review potential side effects with their pharmacist and that it is not a covered medication. The vacuum erection device costs approximately $160. The vacuum erection device is effective in treating ALL types of impotency and produces satisfactory erections in 80% of men. Problems with the device can be referred directly to the supplier’s 1-800 phone number. Other treatments are available to patients include MUSE (prostaglandin Urology primer - urethral suppositories), intracavernosal injection of prostaglandin and implants (surgery). Suggested treatment protocol for impotence: 1. 2. 3. 4. 5. Rule out/treat diabetes Encourage cessation of smoking and reducing alcohol consumption Optimize anti-hypertension medications Offer vacuum erection or phosphodiesterase inhibitor Patients with premature ejaculation or anorgasmia should be treated by PCP. 8 Urology primer - 9 5. Urinary Incontinence Definition: Involuntary loss of urine Classification: Stress Urinary Incontinence (SUI): Incontinence associated with abdominal/pelvic stress, straining, or valsalva due to the loss of urethral and bladder support. SUI occurs most frequently in postmenopausal, multiparous women. Urge Incontinence: Incontinence due to the bladder contracting without the patients intention to void. It is commonly associated with neurological diseases such as multiple sclerosis, Parkinson’s disease, spinal cord injury, myelodysplasia, stroke, cerebral palsy, and CNS tumor, but most frequently occurs due to overactive bladder without an apparent cause. In men, the most common cause is bladder outlet obstruction. Urge incontinence can occur at any age and is often a self-limiting process in those patients with an obvious cause. Mixed Incontinence: Many women have both stress and urge incontinence. Usually one form of incontinence predominates in terms of causing the most distress and will dictate what form of treatment will be selected. Overflow Incontinence: Occurs when a patient’s bladder no longer contracts so urine simply “pours over the top of the dam”. It can occur secondary to other medical conditions such as diabetes, spinal cord injury and myelodysplasia but is very often acquired through infrequent/inadequate voiding leading to bladder decompensation. It can also be precipitated by medications with anticholinergic properties (antihistamines, tricyclic antidepressants, etc…) Treatment: Stress incontinence: 1. Kegel’s exercises to strengthen the pubococcygeus muscle. 2. Alpha agonists like Sudafed. 3. Referral for surgery if nonsurgical measures fail. Urge incontinence: Treatment is pharmacological with antimuscarinic agents like Ditropan, Detrol etc Overflow incontinence should be referred to urology. Urology primer - 10 6. Prostate Cancer Screening Recommendation: “Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen.” (American College of Physicians) Recommendations for specific modes of screening: For men over age 75, there is no need for routine prostate evaluation in absence of significant symptoms. 1. Digital Rectal Exam (DRE): A digital rectal examination can be used to assess the prostate gland in male patients over the age of 50. a. There is no need for routine prostate evaluation in asymptomatic men over age 75. b. For men below age 75 with abnormal prostate exams (nodules, induration, or asymmetry), refer to Urology. 2. PSA: If after individualized risk/benefit discussion, the patient and physician decide PSA is appropriate, the following guidelines should be followed a. There is no role for obtaining a free PSA in primary screening. The free PSA is helpful for patients who have had a negative biopsy, with a PSA in 4-10 range, to determine whether another biopsy would be appropriate. b. No PSA testing should occur within: i. 48 hrs of digital prostate exam, ii. 8 weeks after treatment of an episode of acute prostatitis or cystoscopy, etc. c. Men with mild-moderate obstructive symptoms and no mass or asymmetry, refer to 2a. d. For a normal exam and PSA results between 4-10, recheck after 8 weeks, before sending for consult. If the second recheck is below 4, do not refer. Recheck PSA in 12 months e. For men with obstructive symptoms and moderately enlarged prostate, but no palpable mass, and PSA between 4-10, see 2a. f. For a single result above 10 for men under the age of 75, referral to Urology is appropriate. Urology primer - 11 Discussion and Data for Use of PSA Other causes of elevated PSA: 1. Benign prostatic hyperplasia 2. Acute prostatitis (wait 8 weeks after treatment to draw PSA) 3. Prostate biopsy 4. Cystoscopy 5. TURP 6. Urinary retention 7. Ejaculation 8. Digital rectal examination 9. Perineal trauma 10. Prostatic infarction PSA measurements have considerable short-term variability Roughly 70% of patients with an elevated PSA level between 4 and 10 will have a negative prostate biopsy. (source: American Urological Association) “The use of PSA testing for the early detection of prostate cancer remains controversial, owing to its biological variability, high prevalence, and the strong evidence for over diagnosis and over treatment.” ( Prostate Specific Antigen Best Practice Statement: 2009 Update, American Urological Association) “ Major scientific or medical organizations, including the American Cancer Society (ACS), US Preventive Services Task Force (USPSTF), American College of Physicians (ACP), National Cancer Institute (NCI), American Academy of Family Physicians (AAFP), and American College of Preventive Medicine (ACPM) do not support routine testing for prostate cancer at this time. These organizations (the ACS, AUA, ACP, NCI, AAFP, ACPM, and the USPSTF) recommend that health care professionals discuss the possible benefits, side effects, and questions about early prostate cancer detection and treatment so that men can make informed decisions taking into account their own situation and risk.” (source: American Cancer Society) How useful is a PSA for prostate cancer screening? Sensitivity: 70-80% Specificity: 60-70% Urology primer - 12 If you chose to order a PSA for prostate cancer screening: The American College of Physicians in addition to several other professional societies and task forces emphasize the need for shared decision making. “Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen.” (American College of Physicians) Risks of prostate biopsy 1. 2. 3. 4. 5. Physical discomfort Urinary tract infection, urosepsis Hematuria, hemospermia Urinary retention 1% of men have risks which require hospitalization 6. High anxiety level because of high false negative rate Risks of radical prostatectomy 1. 2. 3. 4. Operative mortality rate is 0 .5% urinary incontinence, (15-50%) sexual dysfunction (20%-70% of patients) bowel problems. Risks of external beam radiation 5. 6. 7. 8. Erectile dysfunction in 20 to 45 percent of men with previously normal erectile function, Urinary incontinence in 2 to 16 percent of previously continent men, Bowel dysfunction in 6 to 25 percent of men with previously normal bowel function Prostatorectal fistula. More detail as of July 2009 Recommendation The United States Preventive Services Task Force Guidelines Age <75 years, the benefits of screening for prostate cancer are uncertain and the balance of benefits and harms cannot be determined. www.ahrq.gov/clinic/uspstfix.htm. Age >75, there is moderate certainty that the harms of screening for prostate cancer outweigh the benefits. Found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated may never have developed symptoms related to cancer Urology primer - 13 during their lifetime. There is also adequate evidence that the screening process produces at least small harms, including infection, pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results Canadian Task Force on the Periodic Health Examination Recommends against screening for prostate cancer with PSA American Urologic Association Prostate cancer screening leads to over detection and overtreatment of some patients. Therefore, the AUA supports that men be informed of the risks and benefits of prostate cancer screening before biopsy www.auanet.org American Cancer Society www.cancer.org American College of Physicians At this time, routine screening should not be recommended for all men. Rather, these early findings support the recommendation that men should make informed decisions based on available information, discussion with their doctor, and their personal perspectives on the benefits and side effects of screening and treatment Rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen Urology primer - 14 7. Prostatitis Acute Bacterial: Symptoms of chills, perineal and low back pain, dysuria, and occasionally bladder outlet obstruction. Tender and swollen prostate on digital rectal exam. Chronic bacterial: The most common cause of relapsing UTI in men. Irritative voiding symptoms, pelvic pain, bilateral testicular pain. Prostate may be tender or normal on DRE. IVP and cystoscopy usually not indicated. Results in a relapsing UTI from the same organism. Makes up only 10% of the prostatitises. Non-bacterial: The most common form of prostatitis. The symptoms are the same as for bacterial prostatitis through the urine and expressed prostatic secretion (EPS) cultures are negative. The EPS will show WBC’s This condition is intermittent and will likely recur. Therefore, patient education is very important. Helpful remedies include: 1. Increased water consumption 2. Avoid straining when voiding 3. Stress reduction techniques 4. Warm sitz baths 5. NSAIDs 6. Decrease alcohol 7. Decrease coffee 8. Reassurance Prostatodynia: The findings and treatment are the same as for non-bacterial prostatitis though the EPS will show no WBC’s. Antibiotics are not indicated! Use alpha blockers (Terazosin, Doxazosin, Tamsulosin) Urology primer - 15 The treatment of bacteria prostatitis: 1. Treat with either Septra DS (BID), or Doxycycline (100mg BID), or Quinolones (Cipro, Levaquin) for 2 weeks for acture prostatitis and 8 weks for chronic prostatitis. Relapses are common. Sometimes the therapy needs to be extended to 12 weeks. 2. Warm sitz baths prns. 3. NSAIDs prn 4. Inform the patient that the resolution of symptoms will be gradual, relapses are common 5. Treat urinary retention as discussed in Bladder Outlet Obstruction. 6. Refer treatment failures to Urology. Urology primer - 16 8. Renal Calculi Background: Up to 12% of the American population will develop renal calculi, causing considerable morbidity and cost approximately $100,000,000 per year in lost wages and in medical expenses.. 50% of all patients will have recurrence of renal calculi within 5 years if no preventative measures are undertaken Types of calculi (and frequency of occurrence): Calcium oxalate (75%) Uric Acid (6%) Calcium phosphate (9%) Cystine (2%) Struvite (8%) 1. 2. 3. 4. Of the store forming salts in urine, Uric Acid crystallizes the easiest. Uric Acid crystals often form the nidus around with a a CaOx stone may form. Only the calcium containing stones are readily seen on plain X-rays. Struvite stones are formed by urea-splitting bacteria which include Proteus, Kleb, Pseudomonas, and Staph. Epidermidis but not E. coli. 5. For small stones (<4 mm) and those in the ureter, start an alpha blocker. Indications for Urological referral: 1. 2. 3. 4. 5. 6. Recurrent calculi Obstructing/symptomatic stone that has not passed in 2-3 weeks Residual renal calculi or staghorn calculi Obstructing stone > 4mm in diameter Recurrent UTI History of renal anomaly (solitary kidney, duplicated ureter, horsehoe kidney) or prior urological surgery. Obtain the following prior to Urological consultation: 1. UA. If positive, obtain a culture. 2. Creatinine 3. Current GU imaging (non contrast) Urology primer - 17 9. Urinary Tract Infections Urinary tract infections in adult women: Background: 80-90% of women with dysuria and occasional bacterial reinfections do not require radiologic evaluation or Urologic referral. Most commonly, these lower urinary tract, nonfebrile, infections reflect a defect in local host defenses. The aim of therapy is to help the immune system until the defense barriers can be repaired. Suggestions toward this goal include: 1. Increase fluid consumption 2. Void frequently (ex. every 2-3 hours) 3. Be sure to void after sexual intercourse 4. Consider suppressive antibiotic therapy 5. Consider Estrogen replacement therapy in post-menopausal women Suppressive antibiotic therapy: Trimethoprim/sulfamethoxazole If sulfa allergic then try: Trimethoprim or Macrodantin 1 tab (SS) QD for 6 to 12 months 50mg 1 tab QD for 6 to 12 months 50mg 1 cap QD for 6 to 12 months If the infections are temporally related to intercourse, then the above medications can be taken post-coitus only. Urinary tract infections in adult men: Cystitis: Evaluation and treatment is as for Prostatitis Urethritis: Treat men <35 years of age for Chlamydia STD (ex. Doxycycline 100mg po bid x 7 days) Treat men >35 years of age for Postatitis (e. Septra) Consider treating the partner to avoid re-infection Indications for Urological referral: 1. 2. 3. 4. 5. History of urinary calculi Persistent hematuria (gross or microscopic) when uninfected Bacteria persistence in spite of adequate antibiotic therapy UTI symptoms in spite of negative cultures, and no other obvious cause Children/Infants Urology primer - 18 10. Scrotal Masses Background: The key to evaluating patients with a scrotal mass is to first determine if the mass is fluid filled versus solid and secondly to decide whether or not emergent Urological consultation is needed. The history and physical examination plays an important role in helping make this decision. Transillumination of the scrotum performed in a dark room will detect most hydroceles and spermatoceles. Urological non-emergencies: 1. Hydrocele 2. Spermatocele 3. Varicocele 4. Epididymitis/Orchitis 5. Sperm Granuloma 6. Inguinal Hernia Seen in 6% of full term boys. Don’t refer if the mass is less than the size of an orange. Usually located adjacent to superior pole of the testicle. Do not refer if the mass is less than the size of an orange. Seen in 9.5% of adult males and 90% occur on the left side. Frequently refractory to surgery. Treat only if indicated for infertility. 35-40% of infertile men have varicoceles Treat as for UTI (topic #8) and with reassurance, scrotal elevation, warm compresses and NSAIDs. Severe cases may be Urological emergencies occur in <1% of vasectomy patients. These are usually palpated as tender pea- to marble- sized nodules on the vas deferens. Treat conservatively with reassurance, elevation, warm compresses and NSAIDs refer to General Surgery if symptomatic and/or large Urological emergencies: 1. Testicular cancero: 2. Testicular torsion: peak incidences - <10 y/o, 20/40 y/o, >60 y/o Risk – White: 1/500, Black: 1/2000 History of cryptorchidism – found in 7-10% of patients with cancer see topic 12 in this Primer If uncertain about your clinical diagnosis, get a scrotal ultrasound. Refer solid masses to Urology. Urology primer - 19 11. Circumcision Background: 1. Management of the foreskin: a. The foreskin should never be forcibly retracted from the glans. It will naturally peel away from the glans as the child grows – usually after 3-4 years. b. 10% of boys will still have an adherent foreskin at age 3, so be patient. 2. If previous foreskin trauma has resulted in a tight circular scar (phimosis), then circumcision is indicated. 3. Circumcision done after the newborn period requires general anesthesia. 4. Circumcision is not routinely recommended in adults without medical reasons. 5. Circumcision is sometimes done in men who have recurrent balanitis (often associated with diabetes mellitus) or phimosis. Urology primer - 20 12. Testicular Torsion Types of Torsion: 1. Extravaginal 2. Intravaginal 3. Torsion of the peritesticular appendages Extravaginal Torsion: 1. 2. 3. 4. Torsion of all spermatic cord structures at the external ring Occurs in utero or in the neonatal period Infants are noted to have a hard but nontender lump and are usually free of distress Testicular salvage is unlikely so surgery is probably not indicated, but the Urology service should be consulted. Intravaginal Torsion: Every torsion should be referred as a Urologic Emergency 1. 2. 3. 4. 5. 6. 7. 8. Torsion of the testicle and epididymis occurs within the tunica vaginalis. Usually occurs in adolescents and young adults. Can occur after sports, after trauma, during sleep, or, in other words, at any time. Patients often give a past history suggestive of episodes of torsion and spontaneous detorsion. On exam, the testicle is usually swollen and very tender. It is often, but not always, fixed and high riding. The contra-lateral testicle often has the “bell clapper” of horizontal orientation. The cremasteric reflex is usually lost in the present of testicular torsion. The rotation of the testicle during torsion will alter the normal posterio-lateral orientation of the epididyis relative to the testicle. Surgical exploration needs to be done expeditiously to preserve testis viability: Torsion corrected in <6 hours: Almost 100% testicular survival Torsion corrected in 6-12 hours: 70% testicular survival Torsion corrected in >12 hours: <20% testicular survival Torsion of peritesticular appendages: 1. The peak incidence is prior to puberty. 2. The patient presents with moderately severe pain which early in is confined to the upper pole of the testicle but later on can involve the entire scrotum. 3. Swelling is present but ht testicle hangs normally in the scrotum. 4. One may the “Blue Dot” sign – a blue subdermal spot adjacent to the upper pole of the testicle. Urology primer - 21 5. Testicular torsion is unlikely if a normal Cremasteric Reflex can be elicited. 6. If the diagnosis is made with certainly, the patient many be managed with pain medications, ice pack and NSAIDs. The pain and swelling can be bothersome for a week or more. 7. If the diagnosis is in doubt, emergent Urological consultation is needed. Urology primer - 22 13. Indiopathic Orchalgia Background: Often adults present with long standing history of intermittent pain in testes with no fever, no pyuria, no bacteriuria. Scrotal ultrasound – normal: 1. Treatment is reassurance that there are no significant abnormalities in the form of infection or neoplasm. 2. Prescribe NSAID as needed 3. Do not refer to urology. Urology primer - 23 Appendix American Urological Association BPH Symptom Index Questionnaire Never Less than 1 time in 5 Less About than half half the the time time More than half the time Almost always 0 pts 1 point 2 points 3 points 4 points 5 points never 1 time 2 times 3 times 4 times 5 times or more 1. Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 2. Over the past month or so, how often have you had to urinate again less than two hours after you finished urinating? 3. Over the past month or so, how often have you found you stopped and started again several times when you urinated? 4. Over the past month or so, how often have you found it difficult to postpone urination? 5. Over the past month or so, how often have you had a weak urinary stream? 6. Over the past month or so, how often have you had to push or strain to begin urination? 7. Over the last month, how many times did you usually get up to urinate from the time you went to bed at night until the time you got up in the morning?