GENITAL

INFECTION

dr. Pande Made Wisnu Tirtayasa, SpU(K),

PhD, FICS

Department of Urology
Faculty of Medicine Universitas Udayana
Today’s lecture will cover
1. Prostatitis
2. Epididymitis
3. Urethritis
4. Balanoposthitis
5. Fournier’s Gangrene
Anatomy and physiology of prostate
• Male genitalia organ located
inferior to bladder, anterior to
rectum and cover the prostatic
urethra
• Candlenut-shaped size 4x3x2.5cm
~ 15-20 gr
• Producing prostatic secrete 🡪
25% of total ejaculate volume
Definition of prostatitis
• Inflammation of prostate due to both
bacterial or non-bacterial
• Could be related to infection or sterile
inflammation
• Pathological finding 🡪 increased
number of inflammatory cells in
prostate 🡪 most of them were
lymphocytes
• 4 types of prostatitis

Normal prostate Prostatitis

Epidemiology
• Prostatitis is the most common urologic diagnosis in males < 50 years
• Prevalence 🡪 2% to 13% around the world
• Men diagnosed with prostatitis 🡪 5% had bacterial origin prostatitis,
64% had non-bacterial prostatitis, and 31% had pelvic-perineal pain
syndrome
Type 1: acute bacterial prostatitis
• Acute inflammation of the prostate gland 🡪 presence of pelvic pain
and urinary tract symptoms, may be accompanied by fever
• Prevalence is up to 10% of all prostatitis diagnosis
• Age range between 20 and 40 years
Type 1: acute bacterial prostatitis
• Risk factors
• Sexually active
• Immunocompromised patients
• Transurethral manipulation
• Etiologies
• Major cause 🡪 Escherichia coli
• Neisseria gonorrhea & Chlamydia trachomatis 🡪 sexually active person
• Cryptococcus, Salmonella, and Candida sp 🡪 immunocompromised pts
• Pseudomonas 🡪 after transurethral manipulation
Type 1: acute bacterial prostatitis
• Diagnosis
• Physical examination 🡪 NOT RECOMMENDED to perform a prostate massage
• Urine analysis and culture 🡪 midstream urine culture 🡪 presence of WBC
• Imaging 🡪 may be helpful but unnecessary 🡪 USG exam (first choice)
• Serum PSA is not recommended
• Treatment
• Antibiotic 🡪 empirical therapy (fluoroquinolone, cephalosporin)
• Urinary drainage
• Hospitalization 🡪 high risk patients, urosepsis
• Drainage of prostate abscess
• Additional treatment 🡪 alpha blocker
Diagnosis and treatment algorithm for acute bacterial prostatitis
Type 2: chronic bacterial prostatitis
• Second type of prostate inflammation caused by infection of the
bacteria
• Differs from acute type 🡪 type 2 persists for three months or longer
and its development is slow
• The prevalence is less than 5%
• The diagnosis can be challenging 🡪 symptoms can arise and vanish
over a period of weeks and months
Type 2: chronic bacterial prostatitis
• Pathogenesis
• Prevalence is very low (5-10%)
• Often accompanied by urogenital infection
• Pathogens 🡪 gram-positive and gram-negative bacteria
• Chronic infection 🡪 formation of biofilm 🡪 growth condition favorable for the
pathogens 🡪 formation of pathogenic colonies and assisting this pathogenic
condition
• Main cause:
• Any bacteria causing UTI
• STD, such as gonorrhea and chlamydia
• E. Coli after having urethritis, urogenital infection or orchitis
Type 2: chronic bacterial prostatitis
• Diagnosis
• Physical exam 🡪 external genitalia, pelvic floor, prostate, abdomen and
perineum
• 4-glass Meares-Stamey 🡪 “gold standard” for localizing infection of the
prostate gland 🡪 presence of bacteria in prostatic secretions and in the VB3
>> VB1 and VB2
• Semen analysis 🡪 optional
• Transrectal ultrasound 🡪 not mandatory
• Urodynamics 🡪 optional
The Meares-Stamey 4-glass test
Type 2: chronic bacterial prostatitis
• Treatment
• Antibiotics 🡪 fluoroquinolones (recommended),
trimethoprim-sulfamethoxazole (2nd line), cephalosporins, erythromycin,
imipenem
• Alpha-blockers 🡪 combination therapy may reduce the high recurrence rate
• Treatment for refractory cases
• Sporadic antibiotic intervention of symptomatic episodes
• Low-dose antibacterial suppression
• Open prostatectomy or TURP
Type 3: chronic prostatitis
• Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
• Non-bacterial prostatitis
• Male patients characterized by genital or pelvic discomfort, voiding
symptoms and sexual dysfunction
• Poorly understood. However most common GU problem in males <50
years
• Prevalence 🡪 90-95% of all prostatitis
• Affect considerably on quality of life and daily routine functions
Type 3: chronic prostatitis
• Etiology and pathogenesis
• The etiology is uncertain and the cause of the syndrome is controversial, considered
as mysterious disease
• Might be due to infections, uric acid level, inflammation, auto-immunity or
neuro-muscular mechanism
• Psychological factors??
• Intraprostatic urine reflux 🡪 chemical damage to the prostatic epithelium 🡪 triggers
immune response 🡪 initiating chronic inflammation
• Diagnosis
• No gold standard test remains
• Questionnaire 🡪 NIH chronic prostatitis symptom index
• 4 glass test may help
• Transrectal USG 🡪 increased blood flow to the prostate
Type 3: chronic prostatitis
• Treatment
• Antibiotics 🡪 fluoroquinolones
• Alpha blockers
• NSAIDs 🡪 reduce the synthesis of prostaglandin by constraining the enzyme
cyclooxygenase
• Phytotherapy
• Other medical therapies
Type 4: asymptomatic inflammatory
prostatitis
• Painless prostate inflammation 🡪 characterized by the presence of
WBC in the prostate fluids and having no symptoms nor signs of
infection
• May have bacteria in their semen
• Diagnose accidentally when patients undergo a prostate biopsy or
sperm test
• Does not require any treatment
Classification of prostatitis
Epididymitis
• Inflammation of the epididymis
• Can affect children and adults
• Often occurs with orchitis (inflammation
of the testis) 🡪 epididymo-orchitis
• Acute epididymitis 🡪 pain and scrotal
swelling are present less than 6 weeks
• Chronic epididymitis 🡪 lasts longer than 3
months and is usually characterized by
pain in the absence of scrotal swelling
Etiology and pathophysiology of epididymitis
• Risk factors 🡪 history of UTI or STI, anatomic abnormalities, urinary
tract surgeries, prolonged sitting, cycling or trauma
• Etiology 🡪 highly dependent on age
• Younger than 14 yrs 🡪 Mycoplasma pneumoniae, enteroviruses, adenoviruses
• Sexually active males 🡪 Chlamydia trachomatis, Neisseria gonnorrhoeae
• > 35yrs 🡪 retrograde flow of infected urine
Epididymitis
• Presentation & findings
• Severe scrotal pain that
may radiate to the groin or
lower abdomen
• Scrotal enlargement
Epididymitis
• Physical exam
• Edematous tender epididymis
• Erythematous edematous scrotum
• Prehn’s sign positive 🡪 distinguish
epididymitis from testicular torsion
• Urethral discharge (10%)
• Fever or other constitutional symptoms
Diagnosis of epididymitis
• History and physical examination
• Gradual onset of posterior scrotal pain and swelling over 1-2 days
• Concurrent symptoms (fever, hematuria, dysuria, urinary frequency, radiating
pain to lower abdomen)
• Tenderness of the epididymis and swelling of the scrotum
• Elevating the scrotum may alleviate the pain (positive Prehn sign)
• Diagnostic testing
• Urinalysis 🡪 evaluate infectious cause
• Color Doppler USG
• Acute phase reactants (C-reactive protein)
Differential diagnosis of acute scrotal pain
Treatment of epididymitis
• Antibiotics
• Empiric
• Based on case
• Definitive
• Supportive therapy
• Analgesics
• Anti-inflammatories
• Scrotal elevation
• Hospitalization in selected cases
Empiric antibiotic therapy for acute
epididymitis
Urethritis
• Inflammation of the urethra
• Discharge +/-
• Dysuria
• Asymptomatic
Causes of urethritis
• Infectious disease • Non Infectious disease
• Gonococcal (Neisseria Go ~ • Trauma
50-90%) • Urethral stricture
• Non gonococcal • Catheterization
• Chlamydia trachomatis (20-50%) • Chemical irritants
• Ureaplasma urealyticum (20-80%)
• Dehydration
• Mycoplasma genitalium (10-30%)
• Trichomonas vaginalis (1-70%)
• Yeast
• HSV
Symptoms of urethritis
• Burning on urination
• Urinary frequency
• Urinary urgency
• Bloody discharge from the penis
• Blood in the urine
• Yellowish discharge from the urethra
• Itching or irritation around the opening of
the penis
• Lower abdominal pain
• Painful sexual intercourse
Diagnosis of urethritis
Most patients do not appear ill 🡪 primary focus on exam is on the
genitalia:
• Inspect the underwear for secretions
• Penis 🡪 examine lesions that may indicate other STDs
• Urethra 🡪 inspect and exam thoroughly
• Testes
• Lymphatics
• Prostate during DRE
Diagnosis of urethritis
• Urethritis can be diagnosed based on the presence of one or more of
the following:
• A mucopurulent urethral discharge
• Urethral smear 🡪 5 leukocytes/field on microscopy
• First voided urine specimen 🡪 leukocyte esterase on dipstick test or at least
10 WBCs/field on microscopy
• All patients with urethritis should be tested for Neisseria gonorrhoeae
and Chlamydia trachomatis
Imaging studies for urethritis
• Unnecessary except in cases of
trauma or possible foreign body
insertion
• In cases of urethral trauma 🡪
perform catheterization to avoid
urinary retention and tamponade
urethral bleeding
• In cases when catheterization is
not possible 🡪 perform
cystoscopy
• Placement of suprapubic tube
Management of urethritis
• Symptoms of urethritis spontaneously resolve over time, regardless of
treatment. Regardless of symptoms, one should be administered
antibiotics on:
• Patients with positive Gram stain or culture results
• All sexual partners of the above patients
• Patient with negative Gram stain results who are not likely to return for follow
up and are likely to continue transmitting infection
• Antibiotics (Azythromicin, Ceftriaxone, Cefixime, Ciprofloxacin,
Doxycycline)
Prognosis, complications and prevention
• Uncomplicated urethritis spontaneously recover with or without
treatment
• Complications 🡪 stricture, stenosis, abscess might occur though quite
rare. PID and tubo-ovarian abscess 🡪 may predispose to infertility in
females
• Prevention
• Educate at-risk patients on how to prevent disease recurrence
• Educate patients on risks of other STI, including HIV
• Evaluate and treat sexual partners
Balanoposthitis
• Balanos 🡪 head of penis (glans)
• Posthe 🡪 foreskin (prepuce)
• + itis 🡪 inflammation

• Defined as the inflammation of the glans penis and mucosal surface

of the prepuce, COMMONLY IN UNCIRCUMCISED males, accompanied
with sub-preputial discharge and phimosis
• Incidence 2%
Etiology
• Infections
• Fungal (eg. Candida)
• Anaerobic (eg. Corynebacterium)
• Spirochaetal (eg. Treponema)
• Viral ( eg. HSV)
• Mycobacteral (eg. Tuberculosis)
• Aerobic (eg. Streptococcus,
Pseudomonas)
• Protozoal (eg. Trichomonas)
• Parasitic (eg. Scabies)
• Uncontrolled diabetes
• Irritants / allergens
• Smegma, soaps, urine
• Traumatic
• Post coital/ post masturbation
• Zip laceration
• Teeth bites, etc
• Drug eruptions
• Premalignant conditions
• Malignant disease
Clinical signs
• Prepucial edema, phimosis
• Pain, burning micturition
• Papules, pustules or vesicles
• Ulceration
• Erosions
Clinical features of balanoposthitis
• Smooth erythematous papules with peeling of skin, plaque + erosions
(candida albicans)
Clinical features of balanoposthitis
• Gray-whitish vesicles on erythematous base with/without ulceration,
with urethritis (Trichomonas)
Clinical features of balanoposthitis
• Superficial erosions with purulent urethral discharge (Neisseria
Gonorrhoeae)
Clinical features of balanoposthitis
• Erosive indurated painless with phimosis (Syphilis)
Clinical features of balanoposthitis
• Painful shallow non-indurated ulcers with/without phimosis
(Chancroid)
Clinical features of balanoposthitis
• Bright red annular plaques (penile psoriasis)
Clinical features of balanoposthitis
• Chronic inflammation followed by anthropic sclerosis,
depigmentation, induration, phimosis and urethral stricture (Lichen
Sclerosus et Athropicus/Balanitis Xerotica Obliterans)
Diagnosis of balanoposthitis
• Thorough history taking
• Proper clinical examination
• Confirm diagnosis
• KOH (candida)
• Subpreputial swab (Trichomonas)
• Tzanck smear (HSV)
• Urethral swab (Gonorrhoeae)
• Skin biopsy (susp. Malignancy)
Treatment for balanoposthitis
• General measures
• Circumcision (PHIMOSIS/Intractable balanoposthitis)
• Treatment of sexual partners
• Management of systemic disease
• Personal hygiene
• Specific measures
• Oral and/or topical antibiotics, antifungals (based on cases)
• Mohs microsurgery
• Surgical management
Complications of balanoposthitis
• Scarring of the penis
• Prepucial fibrotic and phimosis
• Paraphimosis
• Glans necrosis
Fournier’s Gangrene
• Synergistic polymicrobial
necrotizing fasciitis of the
perineum and genitalia
• Predisposing factors
• DM, alcoholism, malnutrition,
obesity, poor hygiene,
immunosuppression
• Risk factors
• Circumcision, episiotomy,
urethral stricture
• Clinical presentation
• Prodromal symptoms (fever and
lethargy) 🡪 for 2-7 days
• Intense genital pain and
tenderness associated with
edema of the skin
• Increasing genital pain 🡪
progressive erythema
• Dusky appearance 🡪
subcutaneous crepitation
• Obvious gangrene of the
genitalia 🡪 purulent fluid from
the wounds
Fournier’s Gangrene
Summary
• We have discussed about several genital infection
• Definitions
• Etiologies
• Clinical features, signs, symptoms
• How to diagnose
• Differential diagnosis
• Management
• Each case is unique, no cases are the same
• General practitioner 🡪 Detailed history taking and thorough physical
exam are the KEY
Further reading

https://play.google.com/store/books/details/Gede_Wirya_Kusuma_Duarsa_LUTS_PROSTATITIS_BPH_dan?id=9lTwDwAAQBAJ

https://play.google.com/store/books/details/Gede_Wirya_Kusuma_Duarsa_Buku_Ajar_INFEKSI_GENITAL?id=PmT9DwAAQBAJ
THANK
YOU