Acute Bacterial Prostatitis

Diagnosis

Mid-stream urine dipstick: 

To check nitrite and leukocytes 

Mid-stream urine culture

Blood culture 

Total blood count 

Imaging: 

If fevers persist for longer than 36 hours to rule out prostatic abscess.

Treatment

Resuscitation

Antibiotics:

For 2 weeks. Up to 4 weeks in some settings.

IV:

Initial route of treatment

Third-generation cephalosporin

Broad-spectrum penicillin

Carbapenems

Fluoroquinolone: should not be offered to patients who have a fever after prostate biopsy.

PO: 

Once fever has subsided. Patients who are not severely ill or vomiting may be treated initially with an oral fluoroquinolone.

Ciprofloxacin 500 mg bid, if bacteria is susceptible

Levofloxacin 500 mg daily, if bacteria is susceptible

NSAIDS

Alpha-blockers:

 If they have LUTS

Straight catheterization: 

For short period of time

Suprapubic catheter: for long-term bladder drainage

Drainage of prostate abscess:

Percutaneous drainage

Transurethral route:

 Lesions that do not respond to initial percutaneous drainage or are too large to adequately drain percutaneously

Chronic Bacterial Prostatitis

Diagnosis

2 glass test

NAAT

Chlamydia trachomatis or Mycoplasma

Treatment

Ciprofloxacin or levofloxacin: 4-6 weeks

Azithromycin or doxycycline: For intracellular bacteria 

Metronidazole: For Trichomonas vaginalis 

Alpha-blockers

Suppressive antimicrobials in HIV:

If patient is taking HAART and is still persistently immunocompromised, lifetime suppressive antimicrobials is recommended to lower the risk of progression to prostatic abscess.

HIV 

Diagnosis

Initial test

Antigen/antibody combination immunoassay (4th generation)

Detects HIV1 and HIV2 antibodies and p24 antigen.

If non-reactive, no further testing is needed.

Second test

HIV1/ HIV2 antibody differentiation immunoassay

Antibody immunoassay that differentiates HIV1 and HIV2 antibodies.

It is recommended in patients in whom the initial test was positive.

Third test:

HIV1 NAAT test

If first test is reactive and second test is non-reactive or indeterminant

Urethritis 

Diagnosis

NAATs:  on a first-void urine sample

Preferred method for detecting N.gonorrhoeae and C. trachomatis. 

May also be used for Trichomonas vaginalis in persistent cases.

Urethral swab culture:

Perform prior to initiation of treatment in patients with a positive NAAT for gonorrhoea to assess antimicrobial resistance profile. 

HIV and syphilis tests

Treatment

Treat gonorrhea or chlamydia. Treatment for coinfection with Chlamydia trachomatis with oral doxycycline should be administered when chlamydial infection has not been excluded.

Sexual partners should also be treated while  maintaining the patient' confidentiality.

Gonococcal infections: Ceftriaxone 500 mg IM, single dose

Chlamydia  Urethritis: Doxycycline 100 mg bid for 7 days.

Trichomonas vaginalis: Metronidazole,2 g, PO, single dose

Acute Infective Epididymitis 

Diagnosis

Exclude testicular torsion first.

NAAT- on a first-void urine sample

for N.gonorrhoeae and C. trachomatis. 

Mid-stream urine culture

Treatment

Acute epididymitis most likely caused by sexually transmitted chlamydia and gonorrhea:

Ceftriaxone 500 mg IM, single dose. Plus

Doxycycline 100 mg PO, bid, for 10 day.

Acute epididymitis most likely caused by sexually-transmitted chlamydia and gonorrhea and enteric organisms: 

Ceftriaxone 500  mg IM, single dose. Plus Levofloxacin 500 mg, PO, once a day for 10 days

Acute epididymitis most likely caused by enteric organisms:

Levofloxacin 500 mg, PO, once a day for 10 days

Follow-up

Signs and symptoms of epididymitis that do not subside within 3 days require re-evaluation of the diagnosis and therapy.

Children younger than 14 years and Men older than 50 years should be evaluated for anatomic problems.

Fournier’s gangrene

Treatment

Broad-spectrum antibiotics:

Piperacillin-tazobactam plus Vancomycin

Meropenem/ Ertapenem

Cefotaxime plus metronidazole or clindamycin

For dose, refer to common medications page.

Repeated surgical debridement

Limited debridement of non-viable tissues.

Tissues with marginal viability may survive due to collateral blood flow.

Multiple procedures in the operating room are needed.

Wound management options are: 

Gauze dressings

Silver sulfadiazine or topical antibiotic 

Wound Vac

Suprapubic diversion

If there is urethral trauma or extravasation

Colostomy

 If there is colonic or rectal perforation.

Genital Ulcer Disease (GUD)

Most genital ulcers in the United States are either herpes

(most common) or syphilis. Chancroid is seen in some parts of US, but granuloma inguinale usually is not. Lymphogranuloma venereum incidence is going up in male having sex with male.

Diagnosis

The minimum testing for all cases of GUD should include a viral identification test for HSV and a syphilis serology.

HSV tests:

Nucleic acid amplification tests (NAAT)- superior test

Viral culture

Antigen test: if above tests are not available.

Syphilis tests:

Swab from ulcer:

Dark-field examination 

or 

Direct/indirect fluorescent antibody (DFA/IFA) 

or 

NAAT

Screening serology:

Non-treponemal tests: RPR, or VDRL

or 

Treponemal-specific enzyme immunoassay (EIA)-more sensitive in primary syphilis 

Confirmatory serology:

TP-PA

MHA-TP

FTA-ABS

INNO-LIA™

Chancroid tests:

NAAT

Culture

Gram stain

Lymphogranuloma Venereum 

NAAT

Culture

Granuloma Inguinale

Biopsy- Identification of dark-staining Donovan bodies

Treatment

HSV: Refer to common medication section.

Primary, secondary, and early latent syphilis

Benzathine penicillin G 2.4 million units IM, single dose

In case of penicillin allergy: Doxycycline 100 mg PO bid for 14 days

HPV

Diagnosis

There is currently no approved test for HPV in men.

Treatment

Direct excision

Cryotherapy

CO2 laser

Patient-applied treatments

Vaccine

Preteens at age 11 or 12 years

vaccination of others not previously vaccinated aged 13-45 years

Molluscum Contagiosum

Diagnosis

Clinical

Treatment

No treatment is an option for immunocompetent patients.