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Selective Urological Evaluation in Men With Febrile Urinary Tract Infection
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INFECTION AND INFLAMMATION OF GENITOURINARY TRACT
Editorial Comment: This article represents a meta-analysis of 70 studies determining the sensitivity, specificity and accuracy of dipstick urine tests in predicting urinary infection. Overall, the sensitivity of the urine dipstick test for nitrites was low (45% to 60% in most situations) with higher levels of specificity (85% to 98%). In general, sensitivity of the urine dipstick test for leukocyte esterase was slightly higher than the test for nitrites (48% to 86%), while the specificity was slightly lower (17% to 93%). The accuracy of dipstick test did not depend on the presence of symptoms. In the general population a negative test result for one or both tests has a sufficient predictive value for reasonable disease exclusion, and when both test results are positive there is sufficient evidence to rule in infection. Accuracy was highest in urology clinic patients and lower in children, surgical patients and family medicine patients. Richard E. Berger, M.D. Urologic Myofascial Pain Syndromes R. DOGGWEILER-WIYGUL, Department of Urology, University of Tennessee, Memphis, Tennessee Curr Pain Headache Rep, 8: 445– 451, 2004 Treatment of pain of urogenital origin, chronic pelvic pain syndrome, can be frustrating for patients and physicians. The usual approaches do not always produce the desired results. Visceral pain from pelvic organs and myofascial pain from muscle trigger points share common characteristics. Referred pain from myofascial trigger points can mimic visceral pain syndromes and visceral pain syndromes can induce trigger point development and myofascial pain and dysfunction. The referred pain syndrome can long outlast the initial event, making diagnosis difficult. Editorial Comment: One reason for lack of success in treating scrotal and “prostatitis pain” is making the wrong diagnosis. Examine your patients carefully for myofascial trigger points internally and externally. The abdominal muscles can be palpated during the general abdominal examination. I examine points over the pubic rami bilaterally, the crura and the bulbospongiosus in the perineum. The adductors tendons insertion at the pubis is also palpated. Internally, the levators laterally and their insertions into the pubis anteriorly and the sacrum posteriorly are palpated. I often find that the most tenderness is in the pelvic muscles and the prostate may not be tender at all. They are frequently present and the presence of these trigger points and/or myofascial tenderness may suggest the need for treatment by a myofascial therapist. Richard E. Berger, M.D. Selective Urological Evaluation in Men With Febrile Urinary Tract Infection P. ULLERYD, B. ZACKRISSON, G. AUS, S. BERGDAHL, J. HUGOSSON AND T. SANDBERG, Department of Infectious Diseases, Sahlgrenska University Hospital, Goteborg, Sweden BJU Int, 88: 15–20, 2001 OBJECTIVE: To investigate the prevalence and clinical importance of urological abnormalities in men with community-acquired febrile urinary tract infection (UTI). PATIENTS AND METHODS: In this prospective study, 85 men (median age 63 years, range 18 – 86) were followed for 1 year after an episode of febrile UTI. They were investigated by excretory urography, cysto-urethroscopy, uroflowmetry, digital rectal examination and measurement of postvoid residual urine volume by abdominal ultrasonography. RESULTS: The radiological examination of the upper urinary tract in 83 patients revealed 22 abnormal findings in 19 men. Relevant clinical abnormalities leading to surgical intervention were found in only one patient who had renal calyceal stones. The lower urinary tract investigation disclosed 46 findings in 35 men. In all, surgically correctable disorders were found in 20 patients, of whom 15 had previously unrecognized abnormalities. All patients who required surgery were identified either by a history of voiding difficulties, acute urinary retention at the time of infection, the presence of microscopic haematuria at follow-up after one month, or early recurrent symptomatic UTI. CONCLUSION: Routine imaging studies of the upper urinary tract seem dispensable in men with febrile UTI. To reveal abnormalities of clinical importance, any urological evaluation should primarily be focused on the lower urinary tract. Editorial Comment: Evaluation of upper and lower tracts of 23 men referred to infectious disease clinic with community aquired pyelonephritis revealed that 23% had abnormal findings. In all but 1 patient the abnormality was lower tract. Of these men with abnormalities 75% had not been previously diagnosed. Lower tract evaluation is recommended after pyelonephritis but upper tract evaluation may not be necessary in this population. However, until this study is repeated in a urological population I will continue to get upper tract studies. Richard E. Berger, M.D.
INFECTION AND INFLAMMATION OF GENITOURINARY TRACT
Editorial Comment: This article represents a meta-analysis of 70 studies determining the sensitivity, specificity and accuracy of dipstick urine tests in predicting urinary infection. Overall, the sensitivity of the urine dipstick test for nitrites was low (45% to 60% in most situations) with higher levels of specificity (85% to 98%). In general, sensitivity of the urine dipstick test for leukocyte esterase was slightly higher than the test for nitrites (48% to 86%), while the specificity was slightly lower (17% to 93%). The accuracy of dipstick test did not depend on the presence of symptoms. In the general population a negative test result for one or both tests has a sufficient predictive value for reasonable disease exclusion, and when both test results are positive there is sufficient evidence to rule in infection. Accuracy was highest in urology clinic patients and lower in children, surgical patients and family medicine patients. Richard E. Berger, M.D. Urologic Myofascial Pain Syndromes R. DOGGWEILER-WIYGUL, Department of Urology, University of Tennessee, Memphis, Tennessee Curr Pain Headache Rep, 8: 445– 451, 2004 Treatment of pain of urogenital origin, chronic pelvic pain syndrome, can be frustrating for patients and physicians. The usual approaches do not always produce the desired results. Visceral pain from pelvic organs and myofascial pain from muscle trigger points share common characteristics. Referred pain from myofascial trigger points can mimic visceral pain syndromes and visceral pain syndromes can induce trigger point development and myofascial pain and dysfunction. The referred pain syndrome can long outlast the initial event, making diagnosis difficult. Editorial Comment: One reason for lack of success in treating scrotal and “prostatitis pain” is making the wrong diagnosis. Examine your patients carefully for myofascial trigger points internally and externally. The abdominal muscles can be palpated during the general abdominal examination. I examine points over the pubic rami bilaterally, the crura and the bulbospongiosus in the perineum. The adductors tendons insertion at the pubis is also palpated. Internally, the levators laterally and their insertions into the pubis anteriorly and the sacrum posteriorly are palpated. I often find that the most tenderness is in the pelvic muscles and the prostate may not be tender at all. They are frequently present and the presence of these trigger points and/or myofascial tenderness may suggest the need for treatment by a myofascial therapist. Richard E. Berger, M.D. Selective Urological Evaluation in Men With Febrile Urinary Tract Infection P. ULLERYD, B. ZACKRISSON, G. AUS, S. BERGDAHL, J. HUGOSSON AND T. SANDBERG, Department of Infectious Diseases, Sahlgrenska University Hospital, Goteborg, Sweden BJU Int, 88: 15–20, 2001 OBJECTIVE: To investigate the prevalence and clinical importance of urological abnormalities in men with community-acquired febrile urinary tract infection (UTI). PATIENTS AND METHODS: In this prospective study, 85 men (median age 63 years, range 18 – 86) were followed for 1 year after an episode of febrile UTI. They were investigated by excretory urography, cysto-urethroscopy, uroflowmetry, digital rectal examination and measurement of postvoid residual urine volume by abdominal ultrasonography. RESULTS: The radiological examination of the upper urinary tract in 83 patients revealed 22 abnormal findings in 19 men. Relevant clinical abnormalities leading to surgical intervention were found in only one patient who had renal calyceal stones. The lower urinary tract investigation disclosed 46 findings in 35 men. In all, surgically correctable disorders were found in 20 patients, of whom 15 had previously unrecognized abnormalities. All patients who required surgery were identified either by a history of voiding difficulties, acute urinary retention at the time of infection, the presence of microscopic haematuria at follow-up after one month, or early recurrent symptomatic UTI. CONCLUSION: Routine imaging studies of the upper urinary tract seem dispensable in men with febrile UTI. To reveal abnormalities of clinical importance, any urological evaluation should primarily be focused on the lower urinary tract. Editorial Comment: Evaluation of upper and lower tracts of 23 men referred to infectious disease clinic with community aquired pyelonephritis revealed that 23% had abnormal findings. In all but 1 patient the abnormality was lower tract. Of these men with abnormalities 75% had not been previously diagnosed. Lower tract evaluation is recommended after pyelonephritis but upper tract evaluation may not be necessary in this population. However, until this study is repeated in a urological population I will continue to get upper tract studies. Richard E. Berger, M.D.