Urological infections and inflammatory disease: classify, image, drain
What the exam tests
Classification and empirical treatment of urinary infection, the inflammatory mimics, and the urological emergencies of infection.
Core rules
- Separate uncomplicated from complicated infection. Complicated infection implies structural or functional abnormality, instrumentation, pregnancy, diabetes or immune suppression, and needs broader cover plus imaging.
- Acute pyelonephritis: admit if septic, vomiting, pregnant, or unable to take oral therapy. Image the tract if there is no improvement within 48 to 72 hours, or earlier if there is obstruction, to exclude an abscess or obstructing stone.
- Acute bacterial prostatitis presents with fever, perineal pain and dysuria; do not perform prostatic massage. Treat with a quinolone or third-generation cephalosporin for 14 days.
- Epididymo-orchitis: under 35 years think Chlamydia and gonorrhoea; older men think coliforms. Always exclude torsion.
- Fournier gangrene is polymicrobial necrotising fasciitis of the perineum, commoner in diabetes; it needs immediate broad-spectrum antibiotics and urgent surgical debridement with planned re-look.
- Chronic pelvic pain syndrome is a diagnosis of exclusion; avoid repeated antibiotic courses.
Worked example
A 68-year-old with poorly controlled diabetes has scrotal pain, fever and crepitus on examination. Reasoning: crepitus means gas in soft tissue and necrotising infection until disproved. He needs resuscitation, urgent surgical debridement and empirical cover of mixed aerobes and anaerobes; imaging must not delay theatre.
Traps
Treating non-resolving pyelonephritis with a second antibiotic instead of imaging; missing torsion in a young man with epididymitis-like symptoms; relying on antibiotics alone in Fournier gangrene; forgetting tuberculosis and schistosomiasis as causes of urological inflammatory disease.