P53, UROLOGIC CONSIDERATIONS
DESCRIPTION The p53 gene produces a nuclear phosphorylation protein that has a tumor-suppression function. Loss of wild-type p53 is the most common genetic abnormality associated with TCC. Its presence is associated with high grade, late stage, and relapse. Potentially, it may be useful in grading tumors. In prostate cancer, p53 is associated with an increased probability of biochemical relapse and is found in a higher percentage of hormone-refractory cancers.
REFERENCE
Minimo C, Tawfiek ER, Bagley DH, et al. Grading of upper urinary tract transitional cell carcinoma by computed DNA content and p53 expression. Urology. 1997;50:869–874.
PAD TESTING
DESCRIPTION Used as a clinical tool to assess the severity of urinary incontinence, often in association with a micturition diary. The pad test provides a gross/semi-quantitative measurement of urine loss over a given period of time. Several types have been described, but none has met with widespread approval. 1 technique has a patient take Pyridium 200 mg TID and then change pads every 6 hr for a 24-hr period. The amount of staining is an estimate of incontinence. Another approach is to weigh the pads (1 g = 1-mL urine).
REFERENCE
Ryhammer AM, Djurhuus JC, Laurberg S. Pad testing in incontinent women: A review. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10(2):111–115.
PAGANO URETERAL ANASTOMOSIS
DESCRIPTION A 4–5-cm linear incision is made through the taenia of the colon, and the mucosa is dissected from the submucosa to the level of the mesentery. The ureters are pulled through the lateral muscular wall and implanted distally into the mucosa. The serosa is reapproximated while incorporating mucosa in the midline.
REFERENCE
Pagano F. Ureterocolonic anastomosis: Description of a technique. J Urol. 1980;123(3):355–356.
PAGE KIDNEY
DESCRIPTION This condition was 1st described in 1939, after hypertension was created by wrapping cellophane around a canine kidney. Applied clinically, this term was given to hypertension secondary to subcapsular or perirenal compression resulting in renal ischemia. Elevated renin secretion from the compromised kidney and decreased renin production from the contralateral renal unit result. Diagnosis can be made with US, CT, or MRI, demonstrating a surrounding hematoma or fibrous capsule. Clinical causes include blunt trauma, closed renal biopsy, anticoagulation, or tumor bleed. Treatment is directed at the primary cause. Further therapy may include ACE inhibitors, open or percutaneous drainage, or nephrectomy. Spontaneous resolution can occur secondary to reabsorption of the hematoma.
REFERENCE
Sterns RH, Rabinowitz R, Segal AJ, et al. “Page kidney.” Hypertension caused by chronic subcapsular hematoma. Arch Intern Med. 1985;145(1):169–171.
PAGET DISEASE, ANOGENITAL/EXTRAMAMMARY
DESCRIPTION Extramammary Paget disease is an adenocarcinoma of the epidermis that can exist in numerous areas, including the penis, scrotum, bladder, vulva, perianal area, umbilicus, axilla, and conjunctiva. An underlying adnexal neoplasm is associated 1/2 the time with an increased risk of other malignancies. Generally considered an adenocarcinoma that occurs in apocrine gland areas of the body, the mammary type originates from lactiferous ducts and extends into epidermis. The anogenital type is usually slow growing and resembles dermatitis clinically, rarely involving the penile or scrotal skin. Often associated with underlying carcinoma such as bladder, prostate, and urethral cancers. Typically presents in the 60s or 70s with lesions that appear as crusted, indurated, erythematous to whitish patches. Histologically, the intraepithelial neoplastic cells contain mucin and are PAS positive. Differential diagnosis includes SCC in situ or malignant melanoma. The lesions originate from pluripotent cells in epidermis that formed apocrine glands and may also result from extracutaneous adenocarcinoma that spread into the epidermis. Excision of skin lesion and evaluation for underlying malignancy should be performed.
REFERENCE
Balducci L, Crawford ED, Smith GF, et al. Extramammary Paget’s disease: An annotated review. Cancer Invest. 1988;6:293–303.
PAGET DISEASE, BONE
DESCRIPTION This condition affects up 10% of elderly individuals, with a 3:1 male-to-female ratio. Bone pain is the most common presenting symptom. Paget disease of the spine may also be a cause of low back pain. The disorder is due to increased bone remodeling, bone hypertrophy, and bone deformity of uncertain origin. Paget disease, also called osteitis deformans, is characterized by an initial phase of intense osteoclastic resorption, followed by an increase in bone formation, but the new skelet al tissues are deformed and prone to inducing pain and fracture. Approximately 1/3 of Paget disease cases have monostotic disease, with pelvic involvement in 72%. In these cases, the lumbar spine is involved in 58%, the thoracic spine in 45%, and the femur and skull in 55% and 42%, respectively. Patients’ elevated alkaline phosphatase or bone pain may be due to Paget disease or other diseases, such as liver disease, renal disease, or metastatic prostate cancer. Radiographically, the localized enlargement of bone is a characteristic feature. Areas of lysis due to osteoclastic reabsorption can also be present. It can be confused with metastatic prostate cancer to bone. Suspect Paget disease over metastatic prostate cancer when there is widening of the bone, thickening of the cortex, and a prominent trabecular pattern. MRI of the bone may help in differentiating the processes.
TREATMENT
• Pain reduction and decreasing long-term complications are the main goals.
• Inhibitors of osteoclastic bone resorption, such as bisphosphonates (zoledronic acid, risedronate, alendronate) are now the treatment of choice. (See Section II: “Osteoporosis and Osteopenia, Urologic Considerations.”) Calcitonin is reserved for those intolerant of bisphosphonates.
REFERENCE
Ralston SH, Langston AL, Reid IR. Pathogenesis and management of Paget’s disease of bone. Lancet. 2008;12;372(9633):155–163.
PAINFUL BLADDER SYNDROME (PBS)
DESCRIPTION The ICS defines PBS as suprapubic pain related to bladder filling, accompanied by other symptoms such as increased day- and night-time frequency, in the absence of proven urinary infection or other obvious pathology. According to the ICS, PBS differs from interstitial cystitis in that the latter has cystoscopic and histologic findings. Treatment begins with conservative measures including dietary modifications, behavioral changes, and nonprescription medications, followed by intravesical therapy and prescription medications. Patients who fail these therapies can move to more invasive therapies including hydrodistention, neuromodulation, and finally urinary diversion or augmentation.
REFERENCE
Chuang YC, Chancellor MB. Treatment of painful bladder syndrome and pelvic organ prolapse: Highlights of the 4th international consultation on incontinence, July 5–8, 2008, Paris, France. Rev Urol.2009;11(1):28–32.
PALLIATIVE RADIATION, UROLOGIC CONSIDERATIONS
DESCRIPTION The symptoms of advanced urologic malignancies are often treated with palliative radiation. Approximately 1/2 of prescribed radiotherapy is given for palliation of symptoms from incurable cancer. For example, 90% of patients with symptomatic bone metastases, commonly seen in metastatic prostate cancer, obtain some pain relief with a low-dose, brief course of palliative radiotherapy. Bone metastases can also result in erosion of cortical bone and tumor invasion into the extradural space, which elicits edema within the spinal cord and compression of the neurologic structures. The degree of edema within the cord is directly related to the neurologic impairment. Spinal cord compression from malignancy requires early diagnosis and treatment with emergency radiotherapy to prevent irreversible neurologic injury. Radiation therapy has also been shown to relieve clinical symptoms in 70–90% of patients with brain metastases, sometimes seen in patients with metastatic RCC.
REFERENCE
Hoegler D. Radiotherapy for palliation of symptoms in incurable cancer. Curr Probl Cancer. 1997;21(3):129–183.
PANCREATITIS, AUTOIMMUNE UROLOGIC CONSIDERATIONS
DESCRIPTION Autoimmune pancreatitis (AIP) has been referred to by a variety of names including sclerosing pancreatitis, tumefactive pancreatitis, and nonalcoholic destructive pancreatitis. It is recognized to be an immunoglobulin G4-related disease (IgG4-RD). IgG4-related kidney disease can include tubulointerstitial nephritis and membranous glomerulonephritis.
REFERENCE
Khosroshahi A, Stone JH. A clinical overview of IgG4-related systemic disease. Curr Opin Rheumatol. 2011;23(1):57–66.
PANETH CELL-LIKE CHANGE, PROSTATE
DESCRIPTION Describes the observation of prostatic glandular epithelium with distinct eosinophilic intracytoplasmic granules resembling Paneth cells, found in crypts of Lieberkühn in the small intestine. These cells are thought to represent a morphologic similarity to Paneth cells, rather than true Paneth cell metaplasia of the prostatic epithelium, due to the presence of PSA and PAP on immunohisto-chemistry. These changes have been described in normal, hyperplastic, dysplastic, and malignant prostate tissue, and must be differentiated from other prostatic intracytoplasmic inclusions including secretory vacuoles, melanin, CMV viral inclusions, or virus-like particles.
REFERENCE
Weaver MG, Abdul-Karim FW, Srigley J, et al. Paneth cell-like change of the prostate gland. Am J Surg Pathol. 1992;16(1):62–68.
PAPILLARY UROTHELIAL NEOPLASM OF LOW MALIGNANT POTENTIAL (PUNLMP)
DESCRIPTION The World Health Organization defines PUNLMP as a papillary urothelial tumor that resembles an exophytic urothelial papilloma, but shows increased cellular proliferation exceeding the thickness of normal urothelium. They are typically small (1–2 cm) and have little, if any, cytologic atypia. Treatment and follow-up are the same as for low-grade noninvasive urothelial carcinoma. (See also Section II: “WHO/ISUP Classification of Urothelial Neoplasms” [1998 and 2004].) (Image 
)
REFERENCE
Eble JN, et al. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. Lyon: IARC Press; 2004.
PAPILLOMA, BLADDER
DESCRIPTION A controversial diagnostic entity of the urinary bladder. The papillary lesion is small and unifocal, with a delicate fibrovascular stalk, and covered in cytologically and architecturally normal urothelium. Typically found in a younger age group than bladder cancer. Recurrences are common, and future development of invasive urothelial tumors of the urinary tract occurs in <10%. Many consider the lesion to be a very low-grade bladder cancer (grade I TCC) with limited potential to progress. Others propose that the terms low- and high-grade papillary urothelial carcinoma be replaced by low- and high-grade papillary intraurothelial neoplasia for all noninvasive urothelial cancers. (See also Section II: “WHO/ISUP Classification of Urothelial Neoplasms” [1998 and 2004].) (Image )
SYNONYMS
• WHO grade I papillary urothelial carcinoma
• Urothelial papilloma
TREATMENT
• Transurethral surgical resection is the main modality, with no defined role for intravesical therapy.
• These patients must be followed, due to the possible increased risk of having a urothelial malignancy.
REFERENCE
Van der Kwast TH, Zlotta AR, Fleshner N, et al. Thirty-five years of noninvasive bladder carcinoma: A plea for the use of papillary intraurothelial neoplasia as new terminology. Anal Quant Cytol Histol.2008;30(6):309–315.
PAPILLOMA, RENAL PELVIS
DESCRIPTION An extraordinarily rare urothelial lesion in the upper urinary tract. A papilloma is a small, delicate proliferation with a fibrovascular core lined by normal urothelium. By WHO criteria, this is considered a benign lesion.
REFERENCE
Eble JN, et al. World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. Lyon: IARC Press, 2004.
PAPILLORENAL SYNDROME
DESCRIPTION Also called renal coloboma, this is an autosomal dominant disorder characterized by bilateral congenital optic disc anomalies and hypoplastic kidneys. It is associated with mutations in the PAX2 gene. Many patients suffer from renal failure due to renal hypoplasia or chronic pyelonephritis from vesicoureteral reflux.
REFERENCE
Nguyen D, Riordan-Eva P. Abnormal optic discs and renal failure: Papillorenal syndrome. Acta Ophthalmol Scand. 2006;84:823–824.
PAQUIN URETERAL REIMPLANTATION
DESCRIPTION This repair is done using combined extravesical ureteral mobilization and intravesical implantation. A submucosal plane is developed toward the trigone with tenotomy scissors, and the freshly spatulated ureter is reimplanted.
REFERENCE
Atala A, Keating MA. Vesicoureteral reflux and megaureter. In: Walsh PC, Retik AB, Vaughan ED, et al., eds. Campbell’s Urology. 7th ed. Philadelphia, PA: Saunders, 1998:1882–1896.
PARAPHILIAS, UROLOGIC CONSIDERATIONS
DESCRIPTION Paraphilias are psychosocial conditions referring to abnormal sexual behavior. These may be encountered in daily urologic practice and are often referred for psychologic intervention. Different kinds of paraphilias, based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision (DSM-IV-TR) classification are noted in the accompanying table.
SYNONYM
Sexual Deviation
REFERENCE
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision (DSM-IV-TR) Arlington VA (2000).
PARASTOMAL HERNIA
DESCRIPTION A parastomal hernia is an incisional hernia related to an abdominal wall stoma. In urologic surgery, parastomal hernias occur infrequently (<5% of cases) and are more likely to arise in loop-type stomas than in end-type stomas. To prevent parastomal herniation, it is recommended that the stoma be placed through the rectus muscle and that the opening in the abdominal wall not be too large. In addition, some have placed mesh at the time of stoma creation to prevent hernia formation. Repair of a parastomal hernia follows the same principles as treating other types of incisional hernias and can be completed in an open or laparoscopic fashion, with or without mesh. (See also Section I: “Urostomy Problems.”)
REFERENCE
Israelsson LA. Parastomal hernias. Surg Clin N Am. 2008;88:113–125.
PARATESTICULAR RHABDOMYOSARCOMA
DESCRIPTION Rhabdomyosarcoma is the most common spermatic cord sarcoma, arising from the mesenchymal elements of the paratesticular tissues and representing 40% of all paratesticular malignancies and 5% of all testicular and paratesticular malignancies. There is a bimodal age distribution, with peaks at 3–4 mo and yr. Patients present with a painless firm mass which can be a wide range of sizes. Roughly 40% have metastases at presentation. Ultrasounds reveals a heterogeneous mass. CT scan of the abdomen and pelvis, liver function tests, bone scan, and chest x-ray are required for staging. Several histologic patterns are described, with almost all being embryonal. After treatment, cross-sectional imaging and liver function tests are needed every 2–3 mo. (See also Section I: “Tunica Albuginea/Paratesticular Tumors and Cysts.”)
TREATMENT
• Radical orchiectomy
• Boys 10 yr or older or those with evidence of retroperitoneal disease should undergo retroperitoneal lymph node dissection (RPLND)
• Those with evidence of lymphatic spread should undergo radiotherapy and multiagent chemotherapy
REFERENCE
Ahmed HU, Arya M, Muneer A, et al. Testicular and paratesticular tumours in the prepubertal population. Lancet Oncol. 2010;11(5):476–483.
PARAURETHRAL AND VAGINAL WALL MASSES
DESCRIPTION Paraurethral masses can be benign (urethral caruncles, Skene’s gland abscess/cysts, mucosal prolapsed, ectopic ureterocele, urethral diverticulum, vaginal wall cyst, Gartner’s duct cyst, leiomyoma, and hamartoma) or malignant (adenocarcinoma, SCC, TCC, histiocytoma, and sarcoma) and treatment varies upon the etiology of the lesion. The most common paraurethral mass is the urethral diverticulum, followed by the leiomyoma and the vaginal wall cyst. Masses may be asymptomatic or may cause pain and voiding dysfunction. VCUG, MRI, CT, and double-balloon retrograde urography all have a high detection rate for urethral diverticula. Videourodynamics and cystoscopy are useful tools, particularly for masses causing voiding dysfunction. Physical exam may help distinguish benign from malignant conditions. Urethral malignancies do not normally present as paraurethral masses, but more commonly with complaints of bleeding and discharge.
REFERENCE
Blaivas JG, Flisser AJ, Bleustein CB, et al. Periurethral masses: Etiology and diagnosis in a large series of women. Obstet Gynecol. 2004;103(5 Pt 1):842–847.
PARTIN TABLES
DESCRIPTION Nomograms for patients with biopsy-proven prostate cancer, developed by Dr. Partin and associates at Johns Hopkins University, these charts incorporate PSA, TNM stage, and Gleason score. They are used to predict rate of lymph node and distant spread or whether patients have organ-confined cancer, and to aid in making accurate treatment decisions. The tables have been updated several times, using larger patient cohorts. Information is available online: http://urology.jhu.edu/prostate/partintables.php, Accessed March 3, 2014.
REFERENCE
Eifler JB, Feng Z, Lin BM, et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int. 2013;111(1):22–29. Erratum in: BJU Int. 2013;111(3):524.
PATAU SYNDROME
DESCRIPTION This rare syndrome is associated with trisomy 13 and has a median survival of 3 mo. The incidence is 1 in 6,000 live births and is associated with multiple cardiac, neurologic, and renal abnormalities. Renal anomalies occur in about 80% of children. Unilateral renal agenesis, renal duplication, hydronephrosis, and polycystic kidneys have been associated with Patau syndrome.
REFERENCE
Martlew RA, Sharples A. Anesthesia in a child with Patau’s syndrome. Anesthesia. 1995;50:980.
PATIENT PERCEPTION OF BLADDER CONDITION (PPBC)
DESCRIPTION The Patient Perception of Bladder Condition (PPBC) is a questionnaire that attempts to obtain a global assessment of the patient’s bladder condition. It has been validated and shown to be responsive to changes. It has been translated into many languages and is widely available for use.
REFERENCE
Coyne KS, Matza LS, Kopp Z, et al. The validation of the patient perception of bladder condition (PPBC): A single-item global measure for patients with overactive bladder. Eur Urol. 2006;49:1079–1086.
PATIENT PERCEPTION OF INTENSITY OF URGENCY SCALE (PPIUS)
DESCRIPTION A single-question tool to assess the patient’s perception of the degree of urgency. PPIUS as a reliable measure of urgency in both clinical trials and real life settings. The question is as follows:
REFERENCE
Notte S, Marshall TS, Lee M, et al. Content validity and test-retest reliability of patient perception of intensity of urgency scale (PPIUS) for overactive bladder. BMC Urology. 2012;12:26.
PCA3 (PROSTATE CANCER GENE 3 URINE ASSAY)
DESCRIPTION Prostate cancer antigen 3 (PCA3) is a gene that expresses a noncoding RNA. PCA3 is over expressed in 95% of prostate cancers and is upregulated 66-fold in cancerous tissue as compared to normal tissue. No other human tissues have yet been shown to produce PCA3. While serum PSA levels are known to be influenced by volume of BPH tissue, age, inflammation, trauma, and use of 5α-reductase inhibitors (finasteride, dutasteride), preliminary data indicate that these factors do not appear to influence PCA3 scores. Urine samples are collected after an “attentive” digital rectal exam (3 sweeps on each side of the prostate). 1st voided urine is then collected and sent to labs for analysis. PCA3 and PSA can be detected in the urine utilizing reverse transcriptase PCR techniques on the collected cells. PCA3 expression is denoted against a background of prostate-specific genetic material, a PCA3 score (ie, a ratio of PCA3 to PSA mRNA). Studies have shown excellent specificity and sensitivity in men undergoing confirmatory prostate biopsy, and its role in the diagnosis of prostate cancer is currently evolving. A useful role of the new marker appears to be in men with persistently elevated serum PSA levels, but a negative initial biopsy.
The Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group in 2013 found insufficient evidence to recommend PCA3 testing to inform decisions for when to rebiopsy previously biopsy-negative patients for prostate cancer or to inform decisions to conduct initial biopsies for prostate cancer in at-risk men. (See Also Section II: “Attentive Digital Rectal Exam (DRE),” “TMPRSS2-ERG Gene Fusion, Prostate Cancer,” “Attentive Digital Rectal Exam Image.” )
REFERENCES
Groskopf J, Aubin SM, Deras IL, et al. APTIMA PCA3 molecular urine test: development of a method to aid in the diagnosis of prostate cancer. Clin Chem. 2006;52:1089–1095.
Parekh DJ, Ankerst DP, Troyer D, et al. Biomarkers for prostate cancer detection. J Urol. 2007;178:2252–2259.
Recommendations from the EGAPP Working Group: does PCA3 testing for the diagnosis and management of prostate cancer improve patient health outcomes? Genetics in Medicine (2013) doi:10.1038/gim.2013.141 Published online 26 September 2013.
PEARLY PAPULES OF PENIS
DESCRIPTION These are normal anatomic structures located on the proximal glans penis or corona. They appear as minute, dome-shaped, flesh-colored papules. The incidence is 19–30%. These lesions are asymptomatic and can be confused with genital warts. Histologically, these papules are angio-fibromas. No treatment is usually needed. Although these lesions represent a benign condition, psychological and cosmetic concerns often prompt patients to seek therapeutic removal. Multiple therapeutic modalities have been reported; however, use of CO2 laser has proven to be the most effective to date.
REFERENCE
Lane JE, Peterson CM, Ratz JL. Treatment of pearly penile papules with CO2 laser. Dermatol Surg. 2002;28(7):617–618.
PEDIATRIC-MODIFIED RISK INJURY FAILURE LOSS END-STAGE RENAL DISEASE (pRIFLE)
DESCRIPTION Acute kidney injury (AKI) is defined as a decrease in GFR, manifested by an elevated or rising creatinine. However, serum creatinine is often a delayed and imprecise test as it reflects GFR in individuals at steady state with stable kidney function, and may not estimate the GFR in a patient whose renal function is changing. Recognizing a need for a consensus definition of AKI called the RIFLE classification of AKI based on changes in creatinine and urine output were developed. The RIFLE criteria consists of 3 graded levels of injury (Risk, Injury, and Failure) based upon either the magnitude of elevation in serum creatinine or urine output, and 2 outcome measures (Loss and End-stage renal disease). This is a pediatric modification of the adult RIFLE classification (see table). The use of pRIFLE has been strongly advocated as a research and clinical tool. AKI defined by the pRIFLE criteria has been shown as an independent risk factor for mortality and morbidity. (See also Section I: “Acute Kidney Injury, Pediatric [Renal Failure, Acute].”)
REFERENCE
Akcan-Arikan A, Zappitelli M, Loftis LL, et al. Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int. 2007;71(10):1028–1035.
PEDICULOSIS PUBIS (CRAB LICE/PUBIC LICE)
DESCRIPTION Ectoparasitic infection (Phthirus pubis), marked by severe pruritus and tending to have an incubation period of ~4 wk. Signs include observation of the lice, 1–2 mm long gray-brown organisms, on the skin or on the hair shafts or the presence of “nits” (egg stage) on the hair shaft. The recommended regimens should not be applied to the eyes. Pediculosis of the eyelashes should be treated by applying occlusive ophthalmic ointment to the eyelid margins twice a day for 10 days. Bedding and clothing should be decontaminated (ie, either dry cleaned or machine-washed and dried using the heat cycle) or removed from body contact for at least 72 hr. Fumigation of living areas is not necessary. Nits need to be mechanically removed with a fine-toothed comb. Patients with pediculosis pubis should be evaluated for other STI/STDs. Patients should be evaluated after 1 wk if symptoms persist. Retreatment might be necessary if lice are found or if eggs are observed at the hair-skin junction. Patients who do not respond to 1 of the recommended regimens should be retreated with an alternative regimen. Sex partners that have had sexual contact with the patient within the previous month should be treated. (See also Section I: “Sexually Transmitted Infections [STI] (Sexually Transmitted Diseases [STD]), general.”)
TREATMENT
• CDC-recommended regimens: Permethrin 1% cream rinse applied to affected areas and washed off after 10 min OR Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 min
• CDC Alternative Regimens: Malathion 0.5% lotion applied for 8–12 hr and washed off OR Ivermectin 250 μg/kg orally, repeated in 2 wk
REFERENCE
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. 2010;59(No. RR-12).
PELIOSIS HEPATIS
DESCRIPTION Peliosis hepatis is a condition in which liver and splenic tissue is replaced with blood-filled cysts. This has been reported in patients receiving androgenic anabolic steroid therapy and other conditions. These cysts are sometimes present with hepatic dysfunction, or may be associated with liver failure. Can be easily confused with malignancy on imaging studies. Cysts are often not recognized until life-threatening liver failure or intra-abdominal hemorrhage develops. Withdrawal of drug usually results in complete disappearance of lesions.
REFERENCE
Neri M, Bello S, Bonsignore A, et al. Anabolic androgenic steroids abuse and liver toxicity. Mini Rev Med Chem. 2011;11(5):430–437. Review.
PELVIC FLOOR DYSFUNCTION
DESCRIPTION Pelvic floor dysfunction represents a constellation of symptoms that include lower urinary tract, bowel, sexual, and other local symptoms, including pelvic organ prolapse. These conditions are all associated with damage to the pelvic floor through disruption of the connective tissues or by primary or secondary neuropathy and myopathy. Many predisposing, inciting, and promoting factors can lead to pelvic floor dysfunction. Treatments range from conservative/behavioral therapies, to medications and surgical interventions.
REFERENCE
Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin. 1998;25:723–746.
PELVIC FRACTURE, UROLOGIC CONSIDERATIONS
DESCRIPTION Pelvic fractures can result in bladder and urethral injury. The length and tethered anatomy of the male urethra makes it more vulnerable to injury. Blood at the urethral meatus is the cardinal sign of urologic injury. For patients suspected of having a urethral injury, a retrograde urethrogram should be performed prior to insertion of a Foley catheter. This should be followed by a cystogram. Depending on the location and extent of trauma, several options exist for treatment including drainage of the bladder with a Foley catheter or suprapubic cystotomy, primary repair of the injury, or delayed repair after stabilization. (See also Section I: “Urethra, Trauma [Anterior AND Posterior].”)
REFERENCE
Cass AS. The multiple injured patient with bladder trauma. J Trauma. 1984;24:731.
PELVIC LIPOSARCOMA
DESCRIPTION Liposarcoma can present as a tumor of the spermatic cord or as a paratesticular tumor. Treatment includes inguinal orchiectomy with high ligation of the cord; adjuvant treatment is controversial but could include postoperative radiotherapy. Chemotherapy options are limited. (See also Section I: “Tunica Albuginea/Paratesticular Tumors and Cysts.”)
REFERENCE
Richie JP, Steele GS. Neoplasms of the testis. In: Wein AJ, Kavoussi LR, Novick AC, et al., eds. Campbell-Walsh Urology. 9th ed. Philadelphia, pa: Saunders Elsevier; 2007.
PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM (POP-Q)
DESCRIPTION A quantitative description of pelvic support using the hymenal ring as the reference point. Negative numbers are assigned to structures that have not prolapsed beyond the hymen, and positive numbers to those that are protruding. 3 reference points are defined anteriorly and 3 points posteriorly. Once the measurements are complete, the patient is assigned to 1 of 4 stages as noted below. (See also Section I: “Pelvic Organ Prolapse (Cystocele and Enterocele)” and Section II: “Cystocele Grading: Baden–Walker, Pelvic Organ Prolapse Quantification (POP-Q).”)
REFERENCE
Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–17.
PELVIC PAIN AND URGENCY/FREQUENCY (PUF) PATIENT SYMPTOM SCALE
DESCRIPTION Instrument for the evaluation and treatment of patients with Interstitial cystitis (IC)/Painful Bladder syndrome (PBS).
REFERENCE
Parsons CL, Dell J, Stanford EJ, et al. Increased prevalence of interstitial cystitis: previously unrecognized urologic and gynecologic cases identified using a new symptom questionnaire and intravesical potassium sensitivity. Urology. 2002;60(4):573–578.
PELVIC PAIN, MALE
See Section I: “Prostatitis, Chronic Nonbacterial, Noninflammatory (NIH CP/CPPS III A and B).”
PELVIS, BIFID, RENAL
DESCRIPTION A normal variant seen in ~10% of patients in which the renal pelvis is divided into 2 major calyces just inside the kidney. (See Pelvis, bifid, renal image )
REFERENCE
Dähnert W. Radiology Review Manual. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2007.
PELVIS, EXTRARENAL
DESCRIPTION Most often a normal anatomic variant and can be mistaken for a pathologic condition (hydronephrosis, parapelvic, or renal cyst, etc.). Calyces are normal appearing on imaging with an unobstructed extrarenal pelvis but will be dilated with hydronephrosis. The extrarenal pelvis can also be associated with conditions such as renal malrotation or ectopic kidney and rarely may cause urinary stasis and difficulties with infection and stones.
REFERENCE
Kidneys. In: Dalrymple NC, et al., eds. Problem Solving in Abdominal Imaging. Philadelphia, PA: Elsevier; 2009.
PEMPHIGUS FOLIACEUS AND VULGARIS
DESCRIPTION Pemphigus foliaceus and vulgaris refer to a group of rare autoimmune intraepidermal blistering diseases involving the skin and mucous membranes. The difference between pemphigus foliaceus and vulgaris involves the level of epidermis at which loss of cell–cell cohesion occurs. Almost all patients will have painful oral mucosal erosions and 50% may have cutaneous blisters involving the genitalia. The diagnosis is confirmed by light microscopy and immunofluorescence. Pemphigus carries a high mortality rate of 10% from sepsis as a result of skin breakdown and treatment-associated side effects.
TREATMENT
• Topical steroids (eg, clobetasol propionate 0.05% cream [mild cases])
• Glucocorticoids (prednisone) and immunosuppressants (cyclophosphamide, azathioprine, and IV immunoglobulin) for severe cases
REFERENCE
Habif TP. Vesicular and bullous diseases. In: Habif TP, ed. Clinical Dermatology. 4th ed. Philadelphia, PA: Mosby; 2004.
PENILE AND CORPORAL BODY MASS
DESCRIPTION Penile masses are relatively rare lesions. Benign solid tumors of the penis include angioma, fibroma, lipoma, and myoma, as well as other dermatologic lesions. Abscesses and granulomas should be included in the differential. Malignant tumors of the penis are more often seen in adults and include squamous cell carcinoma (SCC), melanoma, and soft tissue sarcoma. Cystic lesions are usually periurethral gland and retention cysts due to sebaceous glands in the skin. For malignant lesions, wide excision is recommended. (See also Section II: “Penis, Mass [Noncutaneous].”)
REFERENCE
Kocakoc E, Kazez A, Dagli AF, et al. Postcircumcision granuloma: A rare cause of a penile mass in a boy. J US Med. 2006;25(12):1611–1613.
PENILE BRACHIAL PRESSURE INDEX (PBI)
DESCRIPTION The PBI can be defined as the penile systolic BP divided by the brachial systolic BP. A penile brachial index of ≤0.7 has been suggested to indicate arteriogenic impotence. However, due to several limitations, this test is considered an unreliable tool to exclude arteriogenic impotence.
REFERENCE
Metz P, Bengtsson J. Penile blood pressure. Scand J Urol Nephrol. 1981;15:161.
PENILE DOPPLER ULTRASOUND INDICATIONS AND PARAMETERS
DESCRIPTION This type of minimally invasive vasculogenic imaging is used for men with ED who have a potentially surgically treatable cause (eg, younger men who may have suffered traumatic straddle injuries and do not respond to oral or intracavernosal therapy). Penile Doppler US is used for evaluation of penile blood flow and requires intracavernous injection of vasodilators. Peak systolic velocity (PSV) in healthy individuals varies from 35–47 cm/s. A PSV <25 cm/s has a sensitivity of 100% and specificity of 95% in patients with abnormal pudendal arteriography. Patients with severe ED will have a cavernous artery luminal diameter <0.7 mm and an increase of <75% in diameter post-injection. Patients with veno-occlusive dysfunction will exhibit good PSV (>25 cm/s) and have persistent end diastolic flow velocity of >5 cm/s with quick detumescence after stimulation. A resistive index calculation (RI = PSV – EDV/PSV) >0.9 (where EDV is end diastolic velocity) usually indicates no evidence of veno-occlusive dysfunction, whereas an RI of <0.75 was associated with venous leakage in 95% of cases.
REFERENCE
Wein AJ, Kavoussi LR, Novick AC, et al. Vascular surgery for erectile dysfunction. In: Wein AJ, et al., eds. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders Elsevier; 2007.
PENILE ENHANCEMENT AND LENGTHENING
DESCRIPTION Penile lengthening can be accomplished by release of the suspensory ligament of the penis and the use of penile weights. Increased girth can be obtained by the use of circumferential dermal fat grafts. There are reports of significant complications from lengthening and girth procedures including scarring, skin deformities, irregular fat nodules, scrotalization of the penis, and ED.
REFERENCE
Van Driel MF, Schultz WC, Van de Wiel HB, et al. Surgical lengthening of the penis. Br J Urol. 1998;82(1):81–85.
PENILE INTRAEPITHELIAL NEOPLASIA
DESCRIPTION Penile intraepithelial neoplasia is squamous cell carcinoma in situ and encompasses 3 clinical entities: Bowenoid papulosis (BP), erythroplasia of Queyrat (EQ), and Bowen Disease (BD), which vary in their epidemiology, clinical presentation, and malignant potential. BP is seen in young men and occurs on the penile shaft, but can also be seen on the glans or prepuce. Lesions are multiple, small, well-demarcated papules with a relatively benign course. EQ occurs in older uncircumcised men with plaques that are solitary, sharply defined, velvety, and red with malignant transformation in 10–33% of cases. While EQ refers to lesions of the mucocutaneous epithelium, BD refers to penile intraepithelial neoplasia on the follicle-bearing skin of the penis. BD is seen more commonly in elderly men and typically appears as a single, red, sharply defined plaque that can have areas of oozing or crusting and undergoes malignant transformation in approximately 5% of cases.
REFERENCE
Brady KL, Mercurio MG, Brown MD. Malignant tumors of the penis. Dermatol Surg. 2013;39(4):527–547.
PENILE NECROSIS (GANGRENE) NON-FOURNIER GANGRENE
DESCRIPTION Penile gangrene is a rare, but serious consequence following infection or ischemic injury. Vascular compromise may be caused by tourniquet syndrome, priapism, venous thrombosis, anticoagulants, and can be seen in diabetics with ESRD. Color Doppler ultrasonography can provide important information regarding thrombosis or rupture of cavernosal and dorsal penile vessels. Treatment involves correction of the underlying etiology and debridement of the nonviable tissue.
REFERENCE
Sabharwal S, Banerji JS, Kekre NS. Penile skin necrosis mimicking penile gangrene: an unusual case. Urol J. 2013; 10(1):755.
PENILE PAIN SYNDROME
DESCRIPTION In contrast to other chronic pain syndromes of reproductive organs, chronic penile pain seems to be extremely rare. Penile pain can be understood by etiology, which includes local conditions such as dermatitis, infection, and ischemia; referred pain from bladder, prostate, lower back, and hips; neuropathic pain resulting from injury to dorsal nerve, pudendal nerve, or cauda equina; and psychiatric conditions that may lead to extreme hypersensitivity and allodynia. Persistent pain can be treated by treating the underlying disease (paraphimosis, priapism, Peyronie disease, herpes). 1 case in the literature described a patient with episodic penile pain attacks and an inguinal hernia whose pain resolved after herniorrhaphy. His pain was likely due to the irritation of the ilioinguinal nerve in the inguinal canal, which also supplies the ventral base of the penis. In psychosomatic pain, analgesics may be helpful; however tricyclic antidepressants or anticonvulsants have also proven effective.
REFERENCE
Baranowski AP, Abrams P, Fall M. Urogenital Pain in Clinical Practice. Boca Raton, FL: CRC Press, 2007:248–252.
PENILE PROSTHESIS, MODELS AND DESCRIPTIONS
DESCRIPTION The earliest attempts of implantable devices began in the 1930s with the 1st viable and widespread adoption of the Carrian intracorporal silicone-based prosthesis in the 1970s. A variety of commercial implantable penile prosthesis are available with the majority used inflatable units. Self-contained inflatable units are no longer manufactured. They are in 3 categories: Semi-rigid, 2-piece, and 3-piece inflatable (see table) (Image ).
REFERENCE
Ellsworth PI. Penile Prosthesis http://emedicine.medscape.com/article/1987058-overview (Accessed April 17, 2014)
PENILE REHABILITATION
DESCRIPTION Erectile dysfunction (ED following radical prostatectomy (RP) is believed to include neuropraxia, which results in temporarily reduced oxygenation and subsequent structural changes in penile tissue. Penile rehabilitation management of this veno-occlusive dysfunction has focused on tissue oxygenation. Cavernosal hypoxia, resultant fibrosis, and venous leak are hypothesized as the predominant mechanisms for postprostatectomy ED. While animal studies support the use of phosphodiesterase type 5 inhibitors (PDE5Is) in the setting of cavernous nerve damage but results from human studies are contradictory. Penile rehabilitation has been classically defined as the use of a device or pharmacologic agent to aid erectile function recovery after RP. A scheduled regimen of early pharmacologic (PDE5 inhibitors, prostaglandins) therapy, nonpharmacologic (vacuum erection devices) therapy, or a combination thereof immediately following RP is thought to increase potency rates and help maintain penile length and girth. PDE5 inhibitors may help with maintaining penile length. (See Section II: “Penile Shortening.”) The largest study to date found no long-term effect of either daily or on-demand PDE5I use after RP compared with placebo and the utility of prostaglandin and vacuum erection devices are questionable and high-quality studies are lacking.
REFERENCES
Fode M, Ohl DA, Ralph D, et al. Penile rehabilitation after radical prostatectomy: what the evidence really says. BJU Int. 2013;112(7):998–1008.
Hakky TS, Baumgarten AS, Parker J, et al. Penile rehabilitation: the evolutionary concept in the management of erectile dysfunction. Curr Urol Rep. 2014;15(4):393. doi: 10.1111/bju.12228. Epub 2013 Jul 4.
PENILE SHORTENING
DESCRIPTION Penile shortening may occur congenitally in patients with bladder exstrophy and more commonly after radical prostatectomy (RP) and penile revascularization. Patients with bladder exstrophy have penile shortening because of diastasis of the pubic symphysis and short corporal lengths (<50% the size of controls). More commonly, patients may have shortening of the penis following RP because of unopposed sympathetic stimulation of the penis, fibrosis resulting from hypoxia (as a consequence of denervation), or possibly as a result of retraction of the penile structures into the pelvis. Treatment of Peyronie disease may result in minor penile shortening. Arterial revascularization surgery for vascular ED may result in penile shortening in 20% of patients as a result of scar formation.
In a prospective study of stretched flaccid penile length changes after RP, there was evidence of stretched flaccid penile length loss at 2 mo, but not at 6 mo after RP. PDE5 inhibitors use moderated stretched flaccid penile length loss, with patients who regularly used PDE5 inhibitors having no loss in stretched flaccid penile length.
REFERENCE
Berookhim BM, Nelson CJ, Kunzel B, et al. Prospective analysis of penile length changes after radical prostatectomy. BJU Int. 2013;113(5b):E131–e136. doi: 10.1111/bju.12443 [Epub ahead of print].
PENILE SKIN BRIDGES (PENILE BANDS)
DESCRIPTION Penile skin bridges are a rare complication of neonatal circumcision. They are caused by skin adhesions that occur during childhood. With aging, the adhesions separate partially at the corona to form skin bridges. Treatment involves surgical excision with attachment of the skin edges to the distal penile shaft proximally and the glans distally. Careful surgical technique and proper dressing at the time of initial circumcision are simple procedures that may help prevent adherence of the distal preputial skin flap to the glans penis.
REFERENCE
Kamal BA. Penile skin bridges: causes and prevention. Int Surg. 2009;94(1):35–37.
PENILE, MASS (NONCUTANEOUS)
DESCRIPTION Penile soft tissue tumors are rare and comprise approximately 5% of penile tumors and most have been reported as isolated case reports. These tumors can be classified as benign or malignant, superficial or deep, and in terms of age at presentation. The most common benign soft tissue tumors are vascular neoplasms, followed by tumors of neural, myoid, and fibrous origin. The most commonly reported malignant soft tissue tumors are Kaposi sarcoma and leiomyosarcoma. Correct diagnosis of these tumors, by considering clinical information, histopathologic findings, and immunohistochemical stains, is important because their behavior and clinical management vary considerably. (See also Section II: “Penile and Corporal Body Mass.”)
REFERENCE
Katona TM, Lopez-Beltran A, MacLennan GT, et al. Soft tissue tumors of the penis: a review. Anal Quant Cytol Histol. 2006;28(4):193–206.
PENIS, AGENESIS (APHALLIA)
DESCRIPTION Penile agenesis is a rare anomaly with an estimated incidence of about 1 in 10 million live births. Most cases have a 46, XY karyotype. The usual appearance is that of a well-developed scrotum with descended testes and an absent penile shaft. Associated anomalies are common. Associated urethral absence is usually accompanied by fatal anomalies. Immediate investigations for associated anomalies and karyotype are essential. Caused by failure of development of the genital tubercle, surgical reconstruction/gender reassignment is recommended in the newborn.
REFERENCE
Oesch IL, Pinter A, Ransley PG. Penile agenesis: A report of six cases. J Pediatr Surg. 1987;2:172–174.
PENIS, ANGIOSARCOMA
DESCRIPTION Approximately 32 cases of penile angiosarcoma have been reported. No site of predilection is demonstrated, and the tumor may be well circumscribed or diffuse. Death may occur 1 wk to 5 yr after presentation (mean: 13 mo). The application of immunoperoxidase staining for factor VIII, present in normal endothelial cells, aids in diagnosis.
TREATMENT
• Local excision with lymph node dissection
• Local radiotherapy
• Systemic chemotherapy with more widespread tumor
REFERENCE
Wu X, Chen Z, Ji H, et al. Angiosarcoma of the penis: a case report and literature review. Int Urol Nephrol. 2012;44(5):1341–1343.
PENIS, ARTIFICIAL NODULES (TANCHO NODULES, BULLETUS, FANG MUK, CHAGAN BALLS)
DESCRIPTION Tancho nodules are spherical foreign objects, in the form of beads, implanted in the subcutaneous tissue of the shaft of the penis proximal to the glans. They are placed to allegedly enhance the sexual pleasure of females during sexual intercourse. It is a practice common in southeast Asia, especially Thailand. However, non-Asian groups in Romania, Russia, and Middle East have adopted this practice as well. The incidence and severity of early or delayed complications are unknown but are probably underreported.
REFERENCES
Wilcher G. Artificial penile nodules: A forensic pathosociology perspective: Four case reports. Med Sci Law. 2006;46(4):349–356.
Fischer N, Hauser S, Brede O, et al. Implantation of artificial penile nodules–a review of literature. J Sex Med. 2010;7(11):3565–3567.
PENIS, BASAL CELL CARCINOMA
DESCRIPTION Basal cell carcinoma is a common cutaneous malignancy, but is very rare at the penis. Ultraviolet radiation is an important risk factor. Basal cell carcinoma of the penis most likely presents in the 5th–7th decades of life. The natural history is that of a slowly growing tumor with little propensity to metastasize. Lesions are successfully treated with simple local excision. (See also Section I: “Penis, Lesion, General.”)
REFERENCES
Bañón Pérez VJ, Martínez Barba E, Rigabert Montiel M, et al. Basal cell carcinoma of the penis. Arch Esp Urol. 2000;53(9):841–843.
Lidder S, Lang KJ, Nakhdjevani A. Basal cell carcinoma of the penis. Singapore Med J. 2011;52(10):e201–E202.
PENIS, BOWENOID PAPULOSIS
DESCRIPTION Bowenoid papulosis of the penis are benign lesions that appear as rounded, reddish, single, or multiple papules on the glans or shaft of penis, although they can occur anywhere on the external genitalia or perianal regions of both male and females. These papules typically occur in sexually active patients who are 20–35 yr of age. They are caused by HPV and maybe confused with carcinoma in situ (CIS) of the penis. Histologically, these lesions show parakeratosis and acanthosis in squamous epithelium with disorganization of the epithelial cells. They can be distinguished from CIS by possessing less mitotic figures and cellular dysplasia. Treatment is local destruction, including superficial excision, laser surgery, and use of topical retinoic acid, podophyllum resin, and topical 5-fluorouracil. The recurrence rate is 20%.
REFERENCE
Bhojwani A, Biyani CS, Nicol A, et al. Bowenoid papulosis of the penis. Br J Urol. 2003;80(3):508.
PENIS, BURIED (CONCEALED/HIDDEN/TRAPPED)
DESCRIPTION This condition must be differentiated from an abnormally small penis. A buried or concealed penis refers to a normal-sized penis that is hidden because of the prepubic fat pad. Congenital causes or obesity can hide the penile shaft. The penis can usually be exposed by retracting skin lateral to the penile shaft. The iatrogenic hidden penis after circumcision is more properly called a trapped penis. Children who undergo neonatal circumcision with testicular swelling or with a hernia or a webbed penis are at risk for excess penile shaft skin loss and a trapped penis. Congenital buried penis is a spectrum characterized by a longer inner prepuce and may include in addition; short penile shaft, abnormal attachment of fundiform, and suspensory ligaments and excess supra-pubic fat. Congenital mega prepuce (CMP) is a variant. Theoretically, obese adults who undergo circumcision are also at risk for removal of excess shaft skin. Symptoms can sometimes be associated (balanitis, UTI, painful voiding, ballooning of the foreskin, and urinary retention) with the condition.
SYNONYM
Inconspicuous penis (general term for buried, trapped, or webbed penis)
TREATMENT
• Surgical correction is optional and controversial.
• Liposuction has been used in cases of extreme obesity.
REFERENCES
Donatucci CF, Ritter EF. Management of the buried penis in adults. J Urol. 1998;159(2):420–424.
Hadidi AT. Buried penis: Classification surgical approach. J Pediatr Surg. 2014;49(2):374–379. doi: 10.1016/j.jpedsurg.2013.09.066. Epub 2013 Nov 7.
PENIS, CUTANEOUS HORN
DESCRIPTION Cutaneous horn is a clinical diagnosis referring to a conical projection above the skin that resembles a miniature horn. The lesions usually arise in sun-exposed skin and are benign. Penile cutaneous horn is rare and is characterized by overgrowth of epithelium above a lesion that may be a wart, nevus, or tumor. It is important to note that the incidence of SCC is 33% when penile horn is present. Treatment is surgical excision with a margin of tissue at base. Careful histologic evaluation of the base and close clinical follow-up of the excision site are highly recommended.
REFERENCE
Vera-Donoso CD, Lujan S, Gomez L, et al. Cutaneous horn in glans penis: A new clinical case. Scand J Urol Nephrol. 2009;43(1):92–93.
PENIS, CYSTS
DESCRIPTION Epidermal cysts found on the ventral surfaces of the penis have been attributed to defective embryologic closure of the median raphe, anomalous developmental rests of the periurethral glands of Littré, development of apocrine cystadenomas ectopically, and anomalous budding and separation of urethral columnar epithelium from the urethra. Penile cysts are commonly found lying just beneath the median raphe and are most likely derived from urethral columnar epithelium. Patients are most often asymptomatic.
TREATMENT
Surgical excision
REFERENCE
Paslin D. Urethroid cysts. Arch Dermatol. 1983;119(1): 89–90.
PENIS, DUPLICATION (DIPHALLUS)
DESCRIPTION This is an extremely rare anomaly, with an incidence of 1 in 5–6 million births. According to Aleem’s classification, the condition may be true diphallia (complete or partial), or bifid phallus (complete or partial bifid glans or bifid penis). Usually, the penises are unequal in size and lie side by side. Associated anomalies are frequent. Ultrasound may help in differentiating true complete diphallia (2 corpora cavernous in each penis) from complete bifid phallus (only 1 corpus cavernous in each penis). The condition is caused by a failure of fusion of paired mesodermal anlagen of the genital tubercle and treated by surgical reconstruction.
REFERENCE
Aleem AA. Diphallia: Report of a case. J Urol. 1972;108:357.
PENIS, FIXED DRUG ERUPTIONS
DESCRIPTION A fixed drug eruption is an allergy that produces a plaque or blister at the same cutaneous site each time the drug is ingested. The most common drugs with side effects afflicting the penis are tetracycline, phenolphthalein, sulfonamides, barbiturates, salicylates, penicillins, foscarnet, and Coumadin. Foscarnet can cause periurethral ulcerations and coumadin can cause a hemorrhagic necrosis of the penis.
REFERENCE
English JC 3rd, Laws RA, Keough GC, et al. Dermatoses of the glans penis and prepuce. J Am Acad Dermatol. 1997;37(1):1–24.
PENIS, HEMANGIOMA (CAVERNOUS HEMANGIOMA)
DESCRIPTION Penile hemangiomas are rare, occurring in 1% of all patients with hemangiomas. They should be differentiated from cutaneous hemangiomas, which are more common and tend to involute with time. By contrast, penile hemangiomas tend to become larger and may require surgical intervention. The physical exam often does not reveal the extent of the lesion, and ultrasound or angiography should be performed to delineate the anatomy. Treatment is surgical excision or laser ablation.
SYNONYMS
• Cavernous hemangiomas
• Subcutaneous hemangiomas
• Penile hemangiomas
TREATMENT
Surgical excision or laser ablation
REFERENCE
Alter GJ, Trengove-Jones G, Horton CE Jr. Hemangioma of penis and scrotum. Urology. 1993;42(2):205–208.
PENIS, HIRSUTE PAPILLOMA (PEARLY PENILE PAPULES, CORONAL PAPILLAE)
DESCRIPTION Hirsute papillomas of the penis, more commonly known as pearly penile papules, are asymptomatic acral angiofibromas, typically distributed circumferentially on the corona and sulcus of the glans penis. The lesion is often confused with STI/STD’s, and persists through life, gradually becoming less noticeable with increased age. Treatment is not required, but sometimes offered for cosmetic reasons. CO2 laser is effective.
REFERENCE
Bylaite M, Ruzicka T. Images in clinical medicine. Pearly penile papules. N Engl J Med. 2007;357(7):691.
PENIS, HYPOPLASIA
DESCRIPTION A small or hypoplastic penis may be the result of gonadotropin deficiency, hypospadias, or epispadias. (See Section I: “Micropenis [Microphallus].”)
REFERENCE
Schneck FX, Bellinger MF. Anomalies of the testes and scrotum and their surgical management. In: Wein AJ, et al., eds. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders Elsevier; 2007.
PENIS, KAPOSI SARCOMA
DESCRIPTION Kaposi sarcoma of the penis is rare, with only 37 cases reported in literature. Although most are associated with HIV, cases have been described in immunocompetent patients. It is clinically identified by painless, red-violaceous nodules, as well as papules, plaques, and wart-like pedunculated lesions. The lesions are most commonly found on the glans, although the foreskin, urethral meatus, and scrotum can also be affected. Treatments described include local surgery, radiotherapy, electrocoagulation, laser, and injection of interferon-α into the lesion. (See also Section I: “Penis, Lesion, General.”)
REFERENCE
Hernández-Bel P, López J, Sánchez JL, et al. Primary Kaposi sarcoma of the penis in an HIV-negative patient. Actas Dermosifiliogr. 2008;99(8):662–663.
PENIS, LEIOMYOMA
DESCRIPTION Penile leiomyoma is a rare benign tumor of smooth muscle that commonly involves the shaft, with glans penis involvement being next in frequency. These lesions tend to be small (1 cm in diameter), well-circumscribed, rubbery in consistency, with light yellow to white cut surfaces. Electron microscopy and immunohistochemistry should be used to confirm diagnosis. Multiple recurrences are rare. Primary excision of the tumor is the treatment of choice.
REFERENCE
Leoni S, Prandi S, Mora A. Leiomyoma of the prepuce. Eur Urol. 1980;6(3):188–189.
PENIS, LEIOMYOSARCOMA
DESCRIPTION Penile leiomyosarcoma is a very rare malignant smooth muscle tumor that usually occurs on the 5th–7th decades. Superficial lesions commonly arise from the dermis of the shaft or the smooth muscle of the glans penis and usually form subcutaneous-nodules. Deep leiomyosarcoma is less common, arising from the smooth muscle of the corpora cavernosa, and tends to invade the urethra and metastasize early. These tumors are firm, gray-white, lobulated, and poorly circumscribed, and can range in size from 3–8 cm. Electron microscopy and immunohistochemistry should be used to confirm diagnosis.
TREATMENT
• Primary excision of the tumor is the treatment of choice in low-grade (superficial) tumors; however, the tumor tends to recur locally.
• In high-grade (deep) malignancies, the treatment depends on the age of the patient, size, location of the tumor, and the degree of invasiveness.
REFERENCE
Kathuria S, Jablokow VR, Molnar Z. Leiomyosarcoma of the penile prepuce with ultrastructural study. Urology. 1986;27(6):556–557.
PENIS, LENGTH, NORMAL
DESCRIPTION Data on pediatric penile length considerations are discussed in Section I: “Microphallus (Micropenis).” At birth, dimensions of the normal-term infant phallus are 3.5 ± 0.7 cm in stretched length and 1.1 ± 0.2 cm in diameter. In adults, concern over phallus size can direct some men to seek penile augmentation. There is no real delineation between normal and abnormal, since many variables (fat pad, erect vs. flaccid length) are present. For example, a large fat pad can cause a penis to become buried and give a shorter appearance. (See Section II: “Penis, Buried [Concealed, Trapped, or Hidden].”) 1 recent study provided the following data for mean measurements in adults (length from penopubic skin to the meatus):
• Flaccid length: 8.85 cm; stretched length: 12.45 cm
• Erect length: 12.89 cm; flaccid girth: 9.71 cm; erect girth: 12.3 cm
REFERENCE
Wessels H, McAninich JW. Penis size: What is normal? Contemp Urol. 1997;6671.
PENIS, LEUKOPLAKIA
DESCRIPTION These lesions present as solitary or multiple white plaques, usually involving the penile meatus. Histologically, parakeratosis, hyperkeratosis, and hypertrophy of the rete pegs are present, with dermal edema and lymphocytic infiltration. Leukoplakia is commonly associated with in situ SCC and verrucous carcinoma of the penis. Thus, close follow-up of the excision site with periodic biopsy of incompletely excised lesions is necessary to detect early malignant change.
TREATMENT
• Elimination of chronic irritation and circumcision may be indicated.
• Surgical excision and radiation have been used in the treatment of leukoplakia.
REFERENCE
Bain L, Geronemus R. The association of lichen planus of the penis with squamous cell carcinoma in situ and with verrucous squamous carcinoma. J Dermatol Surg Oncol. 1989;15(4):413–417.
PENIS, MALIGNANT FIBROUS HISTIOCYTOMA (MFH)
DESCRIPTION MFH is a rare sarcoma of the penis that may present as a subcutaneous penile mass in a patient with penile pain, priapism, or urinary retention.
TREATMENT
• Superficial tumors are treated with wide local excision vs. total amputation.
• Deep tumors arising from the corpora are treated with total penile amputation.
• Local recurrence is common, and complete amputation should be considered even for superficial tumors.
• Regional metastases are rare, and lymphadenectomy is unnecessary unless adenopathy is palpable.
REFERENCE
Katona TM, Shienbaum AJ, Wyatt LL, et al. Malignant fibrous histiocytoma of the glans penis: A case report. Anal Quant Cytol Histol. 2006;28(1):39–42.
PENIS, MELANOMA
DESCRIPTION Melanoma of the penis is extremely rare. It presents as a reddish brown or blue black pigmented papule, plaque, or ulceration on the glans penis and less commonly on the prepuce. The depth of skin invasion (Clark classification) and thickness of the tumor (Breslow classification) are of prognostic importance.
TREATMENT
• Surgery is the mainstay of therapy via partial or total penile amputation.
• Foreskin lesions may be treated with circumcision.
• Glanular lesions may be treated with partial penectomy.
• Lesions on the shaft often require total penile amputation.
REFERENCE
Te CC, Vemulapalli S, Confer SD, et al. Recurrent malignant melanoma of the penis. Urology. 2008;72(5):1185, e15–16.
PENIS, METASTASIS TO
DESCRIPTION Metastatic disease to the penis is rare, with roughly 200 cases reported during the past 100 yr. The bladder, prostate, rectum, and rectosigmoid are responsible for the greatest number of metastases. However, distal primaries (eg, lung) have been reported. Several mechanisms might lead to this condition: Direct extension, retrograde lymphatic spread, retrograde venous spread, direct arterial extension, secondary embolism, tertiary embolism, instrumental spread, and paradoxical spread. Patients may develop masses or malignant priapism. Most patients die within 6 mo of presentation. Penectomy may be indicated for pain or relief of urinary obstruction (Image ).
REFERENCE
Bachrach P, Dahlen CP. Metastatic tumors to the penis. Urology. 1973;1(4):359–362.
PENIS, NEURILEMOMA (SCHWANNOMA)
DESCRIPTION Penile neurilemmoma, also known as schwannoma, is a rare entity. It is an encapsulated tumor that arises from the sheaths of peripheral nerves. These are solitary, slow-growing, and often asymptomatic lesions. Most penile schwannomas are unifocal, benign, and tend to occur on the dorsal penile shaft, where the penile dorsal nerve is located, although cases on the glans penis have also been reported. A family history of neurofibromatosis is usually present. Malignant schwannomas are often associated with neurofibromatosis type I. Surgical excision is the treatment of choice, and regular follow-up is recommended because recurrence of benign schwannomas has been reported.
REFERENCE
Loeser A, Katzenberger T, Meuller JG, et al. Solitary schwannoma of the glans. Urology. 2007;70(5):1007.e5–e6.
PENIS, NEUROFIBROSARCOMA (MALIGNANT SCHWANNOMA)
DESCRIPTION A malignant nerve sheath tumor arising from Schwann cells that very rarely occurs on the penis. These lesions most commonly occur on the dorsal aspect of the penis, near the dorsal nerve. Nodules from Peyronie disease are uncommon in this location. Patients may have a history of von Recklinghausen disease or neurofibromatosis, and an exam for café au lait spots and other nodules should be undertaken.
TREATMENT
• Complete excision
• Careful follow-up for recurrence
• Recurrent schwannomas may require total penectomy
REFERENCE
Suzuki Y, Ishigooka M, Tomaru M, et al. Schwannoma of the penis: Report of a case and review of the literature. Int Urol Nephrol. 1998;30(2):197–202.
PENIS, SCLEROSING LIPOGRANULOMA (PARAFFINOMA)
DESCRIPTION This is a foreign-body reaction resulting from injection of paraffin, petroleum jelly, bear grease, or other materials into penile shaft, in an attempt to increase penile girth. Injections of oil-based substances may also be performed for therapeutic or cosmetic purposes, but these procedures are usually performed by the patient or an untrained person practicing medicine fraudulently. Complications usually occur, including penile deformity, skin necrosis, ED, and painful intercourse (Image ).
TREATMENT
• Complete excision of affected skin and subcutaneous tissue
• Skin graft coverage (full- or split-thickness skin graft)
• Flap coverage (usually scrotal) is required if skin graft does not take.
REFERENCE
Jeong JH, Shin HJ, Woo SH, et al. A new repair for penile paraffinoma: Bilateral scrotal flaps. Ann Plast Surg. 1996;37(4):386–393.
PENIS, SCLEROSING NONVENEREAL LYMPHANGITIS
DESCRIPTION Sometimes referred to as Mondor phlebitis of the penis, these are firm and often asymptomatic subcutaneous cordlike swellings along the dorsal shaft of the penis or around the coronal sulcus. They can be confused with lymphangioma circumscriptum, a uncommon tumor of the lymphatic channels. The lesion is caused by thickening or thrombosis of the superficial veins of the penis, probably secondary to trauma. Treatment is not usually necessary, and the condition usually resolves in several weeks. Avoid vigorous sexual activity. Failure to resolve in a timely manner may require biopsy.
REFERENCE
Kumar B, Narang T, Radotra BD, et al. Mondor’s disease of penis: A forgotten disease. Sex Transm Infect. 2005;81:480–482.
PENIS, STRANGULATION
DESCRIPTION Penile strangulation is caused by attachment of and encircling by a foreign object around the penis, which leads to entrapment and distal ischemia. These efforts are usually associated with an attempt to maintain a longer erection and sexual interest. Foreign objects used include iron rings, rubber bands, steel washers, and strings. Wearing constricting rings on the flaccid penis often result in the impossibility of their removal after erection, leading to vascular complications usually within a few hours. These injuries range from simple penile engorgement to ulceration, necrosis, urinary fistula, or even gangrene. The main objective in the treatment is acute decompression to avoid potential ischemic necrosis and autoamputation. Removing the constricting device is a challenge to the urologic surgeon, and each case requires an individual approach. Methods used include aspiration of the corpora, or the use of saws, grinders, and dental drills to remove object. The outcome is often good, but some can have serious complications such as penile amputation and urethrocutaneous fistula.
REFERENCE
Ivanovski O, Stankov O, Kuzmanoski M, et al. Penile strangulation: Two case reports and review of the literature. J Sex Med. 2007;4(6):1775–1780.
PENIS, SYRINGOMA
DESCRIPTION Syringomas are benign appendageal tumors that normally occur in adolescents on the face, neck, axillae, or abdomen. They are extremely rare on the penis; only 6 cases have been reported in the literature to date. On exam, 2–5-mm flesh-colored papules are seen. A punch biopsy can be obtained to relieve patient fears of STI/STD and cancer, and to rule out condyloma, lichen planus, and bowenoid papulosis, which may appear similarly. Because they are benign, treatment is usually considered cosmetic. CO2 laser has proved effective, as well as surgical excision and cryotherapy with liquid nitrogen.
REFERENCE
Olson JM, Robles DT, Argenyi ZB, et al. Multiple penile syringomas. J Am Acad Dermatol. 2008;59(2 Suppl 1):S46–S47.
PENIS, THROMBOSIS OF DORSAL VEIN
DESCRIPTION Thrombosis of the superficial dorsal vein of the penis, also known as Mondor disease, is a rare, poorly understood clinical entity. Some predisposing factors include vigorous sexual activity, trauma, and surgery to the pelvis or external genitalia. It can also be a manifestation of metastatic pancreatic cancer, or can be associated with bladder and prostate cancers. Clinically, the patient complains of swelling and pain on the dorsal aspect of the penis. On exam, a cordlike structure is palpated. Doppler US can demonstrate a noncompressible portion of the superficial dorsal vein, as well as a lack of venous flow signals. Treatment is conservative, as the disease is self-limited and often spontaneously resolves. Abstinence from sex and anticoagulation with heparin is sometimes recommended. NSAIDs may relieve pain and diminish inflammation. Thrombus excision may be the last resort in cases without resolution. Spontaneous thrombosis of the deep dorsal penile vein has also been described following trauma, or in a patient with thrombophilia. This condition improves with anticoagulation treatment.
REFERENCE
Kartsaklis P, Konstantinidis C, Thomas C, et al. Penile Mondor’s disease: A case report. Cases J. 2008;1(1):411.
PENIS, TORSION
DESCRIPTION Congenital rotation of the penile shaft such that the median raphe spirals obliquely around the penile shaft. The external genitalia are otherwise normal, but this condition may be associated with hypospadias or ventral hood penile deformity. The torsion tends to occur in a counterclockwise direction (ie, the twist is to the left). Mainly a cosmetic issue, repair is usually not necessary if the rotation is <60–90°.
TREATMENT
Mild cases require only simply freeing the penile shaft of its investing tissue.
REFERENCE
Pomerantz P, Hanna M, Levitt S, et al. Isolated torsion of penis. Report of six cases. Urology. 1978;11(1):37–39.
PENIS, VERRUCOUS CARCINOMA
DESCRIPTION Squamous cell carcinoma (SCC) of the penis represents about 1% of cancers in men in USA and 11–12% of all cancers in men in countries where circumcision is not routinely practiced. Verrucous carcinoma is an uncommon variant that accounts for only 5–16% of all penile SCCs. Diagnosis of verrucous carcinoma may be difficult because biopsies are usually performed on the superficial portion of the lesion. Therefore, it is crucial to perform a deep biopsy. Verrucous carcinoma exhibits an exophytic warty lesion of SCC and endophytic growth where cellular atypia is noted. (See also Section I: “Penis Cancer, General” and “Penis, Squamous Cell Carcinoma.”)
SYNONYMS
• Giant condyloma
• Buschke–Lowenstein tumor
CAUSES
• Lack of circumcision
• Prior trauma
• Previous disease
• Poor hygiene
• Phimosis
• Tight prepuce
TREATMENT
Partial penectomy
REFERENCE
Kanik AB, et al. Penile verrucous carcinoma in a 37-yr-old circumcised man. J Am Acad Dermatol. 1997;37(2):329–331.
PENIS, WEBBED
DESCRIPTION A congenital condition in which the scrotal skin extends onto the ventral aspect of the penile shaft. Although there are usually no associated abnormalities, there are a few reports of hypoplasia of the distal urethra. Occasionally, a webbed penis is the result of a circumcision in which there was excess removal of ventral penile shaft skin. Cosmetic repair is performed, as needed.
REFERENCE
Dilley AV, Currie BG. Webbed penis. Pediatr Surg Int. 1999;15(5–6):447–448.
PENN POUCH
DESCRIPTION A continent urinary reservoir is created based on the Mitrofanoff principle, which uses the appendix as the catheterizable continent apparatus. The pouch is made from joining a detubularized colon and ileum.
REFERENCE
Benson MC, Olsson CA. Continent urinary diversion. In: Walsh PC, Retik AB, Vaughan ED, et al., eds. Campbell’s Urology. 7th ed. Philadelphia, PA: Saunders, 1998:3190–3245.
PEREYRA URETHROPEXY
DESCRIPTION Pereyra, in 1959, was 1st to present a transvaginal approach to a urethropexy using a needle suture carrier, obviating the need for a transabdominal exposure. Through a T vaginal incision, the bladder neck and periurethral tissue are exposed. The suture carrier is passed through a suprapubic stab incision and, under digital guidance, delivered through the periurethral tissue. The bladder neck is then suspended with absorbable suture.
REFERENCE
Duggan ML. Another look at Pereyra’s Stint urethropexy. South Med J. 1975;68(11):1381–1384.
PERINEAL GROOVES
DESCRIPTION Perineal groove is a rare congenital malformation characterized by a wet sulcus lined by mucous membrane, extending from the posterior fourchette to the anterior edge of the anus. There are 2 reasons for surgical correction: Cosmetic reasons and the groove mucosa is often infected due to colonization by rectal germs. Patients present with inflammatory aspects of the groove mucosa, infection of the external genitalia, and urinary tract infection. Considering that infectious complications occur in about 50% of patients, surgical excision is often recommended. Generally, the tissue defect is closed by interrupted sutures and some advocate the use of surgical glue over the suture line to help prevent infection/movement of the skin edges and, therefore, the development of subsequent dehiscence.
REFERENCE
Esposito C, Giurin I, Savanelli A, et al. Current trends in the management of pediatric patients with perineal groove. J Pediatr Adolesc Gynecol. 2011; 24(5):263–265.
PERINEAL MASS
DESCRIPTION Perineal masses are classified as either benign or malignant and can arise from the perineum directly or from pelvic extension of gastrointestinal, genitourinary, or gynecologic structures. Benign conditions include soft tissue masses, traumatic saddle injury, infections leading to abscess formation, various fistulae, granulomatous disease, urethral foreign body, urolithiasis, Bartholin gland or prostatic cyst, and condyloma. Neoplasms that present as a perineal mass include sarcomas as well as malignancies of the prostate, urethra, anus, vagina, and metastases from other pelvic structures. Patients typically present with a palpable mass or with perineal, gluteal, or labial swelling. On occasion, clinical findings and symptoms suggest the underlying cause, such as inflammatory changes associated with infection. Cross-sectional imaging, with CT scan or MRI, is usually required to further define the anatomic origin, extent, and radiologic features of the lesion. Aggressive surgical treatment of mass lesions, in the form of wide local excision, is often the treatment of choice with the aim of negative resection margins without causing disturbances to urinary or anorectal function (Image ).
REFERENCE
Tappouni RF, Sarwani NI, Tice JG, et al. Imaging of unusual perineal masses. AJR Am J Roentgenol. 2011;196(4):W412–W420.
PERINEAL PAIN, DIFFERENTIAL DIAGNOSIS
DESCRIPTION According to the ICS, perineal pain syndrome is the occurrence of persistent or recurrent episodic perineal pain which is either related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction. Perineal pain is felt in the female, between the posterior fourchette (posterior lip of the introitus) and the anus, and in the male, between the scrotum and the anus. There is no proven infection or other obvious pathology. The ICS suggests that in men, the term prostatodynia (prostate-pain) should not be used as it leads to confusion between a single symptom and a syndrome. The differential diagnosis of perineal pain is long, with infectious, inflammatory, iatrogenic, anatomic, and other causes as listed below:
Infectious:
• Prostatitis
• Cystitis
• Epididymitis
• Orchitis
• Fournier gangrene
• Abscess
• Sexually transmitted infections (herpes, syphilis, chancroid)
Inflammatory:
• Interstitial cystitis (IC)/Painful bladder syndrome (PBS)
• Inflammatory dermatoses (lichen planus, lichen sclerosis, SLE, Behcet disease)
Iatrogenic:
• Sacral nerve stimulation
• Perineal sling
• Radiation therapy
• Cryotherapy
• Pelvic surgery
Prolapse:
• Bladder
• Urethra
• Vagina
• Uterus
• Rectum
Other:
• Ureteral stone
• Torsion (testicular, ovarian, appendix testis, appendix epididymis)
• Pudendal nerve entrapment
• Diabetic and HIV/AIDS neuropathy
REFERENCE
Warfield CA, Bajwa ZH. Perineal pain. In: Warfield CA, Bajwa ZH, eds. Principles and Practice of Pain Medicine. 2nd ed. New York, NY: McGraw-Hill; 2005.
PERINEAL TRAUMA (STRADDLE INJURY)
DESCRIPTION This refers to fracture of all 4 pubic rami or simply to blunt force trauma to the perineum causing urethral injury or high-flow priapism. Patients with blood at the urethral meatus, perineal hematoma, or urinary retention after blunt force trauma should be suspected of having a urethral injury. A retrograde urethrogram should be performed in males and urethroscopy in females. Patients with urethral injuries may have an attempt at primary realignment with a catheter but suprapubic cystotomy remains the standard of care. Anastomotic urethroplasty should be considered the gold standard, with endoscopic treatments reserved for posterior urethral strictures <1 cm or strictures following anastomotic repair. Straddle injury may also cause nonischemic high-flow priapism from a cavernosal artery–corpora cavernosa fistula. This may require angiographic embolization if it fails to resolve on its own. (See also Section I: “Urethra, Trauma [Anterior and Posterior].”) (Image )
REFERENCE
Park S, Mc Aninch JW. Straddle injuries to the bulbar urethra: Management and outcomes in 78 patients. J Urol. 2004;171(2 pt 1):722–725.
PERINEPHRIC MASS
DESCRIPTION Masses in the perinephric space may be due to tumor, fluid, inflammation, various proliferative disorders, or subcapsular renal diseases. Neoplasms include renal tumors, perinephric lymphoma, posttransplantation lymphoproliferative disorder, metastases, and various retroperitoneal tumors. Fluid may be present from hematoma, urinoma, abscess, or lymphangiomatosis. Inflammation is seen in conditions such as xanthogranulomatous pyelonephritis or pancreatitis. Proliferative diseases that appear as perinephric masses include extramedullary hematopoiesis, retroperitoneal fibrosis, sinus histiocytosis with massive lymphadenopathy (Rosai–Dorfman disease), and lipoid granulomatosis (Erdheim–Chester disease). In addition, subcapsular diseases, such as renal cortical necrosis or nephroblastomatosis, may also present as perinephric masses on cross-sectional imaging.
REFERENCE
Westphalen A, Yeh B, Qayyum A, et al. Differential diagnosis of perinephric masses on CT and MRI. AJR Am J Roentgenol. 2004;183(6):1697–1702.
PERINEPHRIC STRANDING
DESCRIPTION Fat stranding is seen on cross-sectional imaging as a linear or hazy increased attenuation within a region of fat, usually caused by fluid or inflammatory cells infiltrating the tissues and often accompanied by thickening of nearby fascial planes. Focal fat stranding can signal a focus of acute disease and should prompt inspection of adjacent structures. Perinephric stranding is commonly seen in healthy individuals, but when asymmetric, it may be secondary to an obstructive urinary calculus, pyelonephritis, inflammatory nephritis, renal infarction, neoplasm, or renal vein thrombosis.
REFERENCE
Leyendecker JR, Dalrynmple NC. Computed tomography incidentalomas. In: Dalrymple NC, et al., eds. Problem solving in abdominal imaging. Philadelphia, PA: Mosby Elsevier; 2009.
PERINEURAL INVASION, UROLOGIC CONSIDERATIONS
DESCRIPTION Perineural invasion most commonly refers to a pathologic finding on needle biopsy of prostate or radical prostatectomy specimens. Perineural invasion on needle biopsy specimens correlates with an increased risk of extraprostatic extension, lymph node metastases, and postoperative progression. Surprisingly, perineural invasion in RP specimens does not have any prognostic significance, perhaps because it represents spread of tumor along a plane of decreased resistance, as opposed to invasion into vascular or lymphatic structures, which portends a worse prognosis.
TREATMENT
Patients should be counseled on treatment options, nerve-sparing vs. non–nerve-sparing surgery, and prognosis based upon PSA, Gleason score, and TNM stage and possibly perineural invasion.
REFERENCES
Ng JC, Koch MO, Daggy JK, et al. Perineuralinvasion in radical prostatectomy specimens: Lack of prognostic significance. J Urol. 2004;172:2249–2251.
Stone NN, Stock RG, Parikh D, et al. Perineural invasion and seminal vesicle involvement predict lymph node metastasis in men with localized carcinoma of the prostate. J Urol. 1998;160:1722–1726.
PERIPHERAL NEUROPATHY, UROLOGIC CONSIDERATIONS
DESCRIPTION As it pertains to urology, peripheral neuropathy classically affects bladder and sexual function. The most common causes of peripheral neuropathy are diabetes, HIV/AIDS, alcoholism, side effects of chemotherapy, and B12 deficiency. The classic description of diabetic cystopathy is impaired bladder sensation, increased bladder capacity, decreased contractility, decreased flow rate, and increased residual volume. Patients may have involuntary bladder contractions and eventually develop areflexic bladders. Sexual function may be impaired, and patients may have ED or anorgasmia.
TREATMENT
• The underlying cause of neuropathy should be identified and treated, if possible.
• Careful evaluation for progression of disease should be sought, and patients may need to be on timed voiding or intermittent catheterization.
• Erectile dysfunction (ED) may require a vacuum erection device, medical therapy, or surgical intervention.
REFERENCE
Sasaki K, Yoshimura N, Chancellor MB. Implications of diabetes mellitus in urology. Urol Clin North Am. 2003;30(1):1–12.
PERIURETERITIS
DESCRIPTION Most cases of periureteritis, or inflammatory changes surrounding the ureter, are secondary to infection from microorganisms that cause infections elsewhere in the genitourinary tract. Any associated anatomic abnormality of the ureter, including stricture, megaloureter, and ureterocele, predisposes an individual to ureteritis. Urinary obstruction, trauma, and abdominopelvic radiation are other causes for periureteral inflammation. The 1st step in treatment of periureteritis is treating the underlying etiology, including the treatment of infection, stricture, stone, or tumor. This term is not used in current peer-reviewed literature.
REFERENCE
Giambroni L, Monticelli L, Simeone C, et al. Ureteritis. Arch Ital Urol Nefrol Androl. 1993;65(1):31–33.
PERIURETHRAL ABSCESS
DESCRIPTION A life-threatening infection of the urethra and periurethral tissues that can spread rapidly to the adjacent soft tissues. It most commonly presents with scrotal edema (94%), fever (70%), urinary retention (19%), a draining abscess (11%), dysuria, and urethral discharge. Periurethral abscesses have been associated with gonococcal urethritis infections, urethral strictures, periurethral bulking agent injections, and urethral diverticulum. Drainage and broad spectrum antibiotics are the mainstay of treatment.
REFERENCE
Kenfak-Foguena A, Zarkik Y, Wisard M, et al. Periurethral abscess complicating gonococcal urethritis: Case report and literature review. Infection. 2010;38:497–500.
PERLMAN SYNDROME
DESCRIPTION An overgrowth syndrome characterized by fet al gigantism, visceromegaly, distinct facial features, and nephroblastomatosis. Similar overgrowth syndromes include Beckwith–Weidemann, Sotos, and the Simpson–Golabi–Behemel syndromes. Neonatal mortality is extremely high. The kidneys are often dysplastic, with numerous cysts and nephrogenic rests. The cause is unknown, and the diagnosis is based entirely on the phenotypic description.
REFERENCE
Schilke K, Schaefer F, Waldherr R, et al. A case of Perlman syndrome: Fet al gigantism, renal dysplasia, and severe neurological deficits. Am J Med Genet. 2000;91(1):29–33.
PFANNENSTIEL INCISION
DESCRIPTION A transverse incision is centered ~2 fingerbreadths above the pubic symphysis. A transverse incision is made through the anterior rectus fascia, and entry into the retropubic space can be gained by separating the rectus muscle in the midline. Useful for bladder and other lower abdominal procedures.
REFERENCE
Montague DK. Surgical incisions. In: Novick AC, Streem SB, Pontes JE, eds. Stewarts Operative Urology. Baltimore, MD: Williams & Wilkins; 1989:15–40.
PHI (PROSTATE HEALTH INDEX) (SEE SECTION II: “PROSTATE HEALTH INDEX (PHI) AND [-2] PROPSA”)
PHIMOSIS, CLITORAL
DESCRIPTION Phimosis should be suspected in women with clitoral pain, itching, or burning. A physical exam may reveal a mild, moderate, or severe degree of an inability to visualize the entire clitoris. Initial conservative treatment involves testosterone and estrogen creams to improve the elasticity of the prepuce and potentially antifungal agents such as nystatin or fluconazole. Rarely, lichen planus may result in a white scarring of the clitoris, prepuce, and perineum. Treatment with clobetasol cream may improve symptoms. Women with refractory symptoms may require a dorsal slit.
REFERENCE
Munarriz R, Talakoub L, Kuohung W, et al. The prevalence of phimosis of the clitoris in women presenting to the sexual dysfunction clinic: Lack of correlation to disorders of desire, arousal and orgasm. J Sex Marital Ther.2002;28(1):181–185.
PHOSPHATE NEPHROPATHY, ACUTE
DESCRIPTION Acute phosphate nephropathy is characterized by acute and subsequent chronic renal failure following exposure to oral sodium phosphate (OSP) bowel purgatives. Renal biopsy demonstrates acute and chronic tubular injury with prominent tubular and interstitial calcium phosphate deposits. Risk factors include older age, female gender, hypertension (HTN), chronic kidney disease (CKD) and treatment with angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers, and diuretics. The pathologic mechanism of action involves hypovolemia-induced proximal salt and water reabsorption, delivery of a large phosphate load to the distal nephron, and precipitation of calcium phosphate in the distal tubule and collecting duct. Prevention of acute phosphate nephropathy is best achieved by avoiding sodium phosphate purgatives in high-risk patients, aggressive hydration, minimizing the dose, and maintaining a minimum of 12 hr between administrations.
REFERENCE
Markowitz GS, Perazella MA. Acute phosphate nephropathy. Kidney Int. 2009; 76(10):1027–1034.
PINWORMS, UROLOGIC CONSIDERATIONS
DESCRIPTION Approximately 209 million people are infected with intestinal pinworms (Enterobius vermicularis) worldwide. They most commonly reside in the large intestine, and females lay ~15,000 eggs nightly on the perineum, causing intense perineal itching and sleep disturbances. Occasionally, worms may ascend the vagina and uterus and enter the peritoneal cavity through the fallopian tubes, where they may lay eggs causing an intense inflammatory response resulting in fever, abdominal pain, adhesions, and granulomas. Involvement of the urinary tract is rare, and only 1 report exists of Enterobius in the bladder.
TREATMENT
• Mebendazole 100 mg PO once (1st-line) or pyrantel pamoate 11 mg/kg up to 1 g PO once (2nd-line)
• Treat household contacts
• Clean bedrooms and bedding
REFERENCES
Ben Musa NA. Intestinal parasites in school aged children and the 1st case report on amoebiasis in urinary bladder in Tripoli, Libya. J Egypt Soc Parasitol. 2007;37(3):775–784.
Kucik CJ, Martin GL, Sortor BV. Common intestinal parasites. Am Fam Physician. 2004;69(5): 1161–1168.
PIPE STEM URETHRA
DESCRIPTION A form of intrinsic sphincter deficiency (ISD) caused by a fixed, open, and nonfunctioning urethra. This is usually the result of prior pelvic surgery, irradiation, or long-standing indwelling catheter drainage. Patients typically have a high bladder neck on cystoscopic exam and severe urinary incontinence.
TREATMENT
• Mid-urethral sling
• Urethrolysis
• Artificial urinary sphincter
REFERENCE
Ghoniem GM, Shaaban A. Sub-urethral slings for treatment of stress urinary incontinence. Int Urogynecol J. 1994;5(4):228–239.
PI-RADS PROSTATE MRI SCORING SYSTEM
DESCRIPTION The European Society of Urogenital Radiology (ESUR) developed a scoring system to present multi-parametric prostate MRI data in a simple but meaningful way in the diagnosis of prostate cancer. The system is similar to that used by breast radiologist (BI-RADS for x-ray mammography, breast ultrasound, and MRI). Multiple parameters for each lesion are scored on a 5-point scale and the overall score predicts the chance of the lesion being a clinically significant cancer.
• Score 1 = Clinically significant disease is highly unlikely to be present.
• Score 2 = Clinically significant cancer is unlikely to be present.
• Score 3 = Clinically significant cancer is equivocal.
• Score 4 = Clinically significant cancer is likely to be present.
• Score 5 = Clinically significant cancer is highly likely to be present.
REFERENCE
Barentsz JO, Richenberg J, Clements R, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012;22(4):746–757.
PLAP (PLACENTAL ALKALINE PHOSPHATASE)
DESCRIPTION PLAP is a fet al isoenzyme that has a different structure than the adult alkaline phosphatase. It is 1 of many tumor markers used for the diagnosis, staging, and monitoring of treatment response in patients with GCT, and it may be useful as a prognostic index. Although the individual sensitivity of PLAP is low, when combined with gamma-glutamyl transpeptidase, simultaneous determinations have shown elevations of 1 or both in 80% of patients with active disease.
REFERENCE
Javadpour N. Multiple biochemical tumor markers in testicular cancer. Cancer. 1983;52:887.
PLASMACYTOID UROTHELIAL CARCINOMA
DESCRIPTION Plasmacytoid urothelial carcinoma (PUC) is a rare and recently described histologic variant of urothelial carcinoma (TCC). Tumor tissue is predominantly manifested by infiltrating tumor cells with characteristics of plasmacytoid morphology. Cells appear medium-sized and dyscohesive with abundant eosinophilic cytoplasm, small hyperchromatic nuclei, and frequent mitotic features. In addition, immunohistochemical staining plays an important role in the diagnosis of PUC. The most common presenting symptom is hematuria, generally accompanied by irritative lower urinary tract symptoms. However, early diagnosis cannot be made due to the absence of hematuria until the later stages of disease. Due to the highly metastatic potential and poor prognosis of this variant of TCC, treatment options include deep TURBT for initial diagnosis, followed by radical cystectomy with adjuvant therapy.
REFERENCE
Wang Z, Lu T, Du L, et al. Plasmacytoid urothelial carcinoma of the urinary bladder: A clinical pathological study and literature review. Int J Clin Exp Pathol. 2012;5(6):601–608
PLASMACYTOMA, BLADDER
DESCRIPTION This tumor is characterized by a monotonous proliferation of plasma cells at variable stages of differentiation, with predominance of the immature variety. 5 cases have been reported in the literature, with a mean age of 54 yr, none of which had multiple myeloma at the time of diagnosis. Local suprapubic recurrences and regional lymph node metastasis may occur. Survival up to 12 yr after diagnosis has been reported.
TREATMENT
• Subtotal cystectomy
• Radiation and chemotherapy
REFERENCE
Yang C, Motteram R, Sandeman TF. Extramedullary plasmacytoma of the bladder: A case report and review of literature. Cancer. 1982;50:146–149.
PLASMACYTOMA, TESTICULAR
DESCRIPTION Neoplastic collections of plasma cells occurring in the testicles. Plasmacytomas are most commonly found in the head and neck region. These are very rare tumors, with an incidence of ~1 in 1,000 testicular tumors. They are most commonly associated with a previous or concurrent diagnosis of multiple myeloma and are generally not believed to occur as primary tumors. Presentation is a painless testicular mass. Treatment is radical orchiectomy and monitoring or management of multiple myeloma.
REFERENCE
Berrondo C, Gorman TE, Yap RL. Primary plasmacytoma of the testicle: a case report. J Med Case Rep. 2011;5:494.
PLOIDY ANALYSIS, BLADDER CANCER
DESCRIPTION Ploidy is the chromosomal content of cells, which can be measured using flow cytometry. Ploidy analysis, when considered as an independent variable, is a fair predictor of clinical outcome. Tumor stage and grade are considered to be the most important predictors of survival. Although ploidy may be more significant in predicting survival than grade, the addition of ploidy to the known stage and grade of a bladder tumor usually does not drastically alter the clinical management of a patient.
REFERENCE
Bittard H, Lamy B, Billery C. Clinical evaluation of cell deoxyribonucleic acid content measured by flow cyto-metry in bladder cancer. J Urol. 1996 ;(155):1887–1891.
PLOIDY ANALYSIS, PROSTATE CANCER
DESCRIPTION Ploidy is a variation in the number of chromosomes in a cell. Aneuploidy is a variation in the number of chromosomes in a cell that is other than a simple multiple of the number of chromosomes. In a prostate specimen, flow cytometry is used to measure the DNA content of the cells. DNA ploidy in addition to the histologic grading may improve the ability to predict the pathologic state and ultimately the prognosis of any given lesion. The frequency of aneuploidy increases with advancing tumor stage. Inherent problems with ploidy analysis include heterogeneity of DNA cell sampling, as well as whether it will change clinical management.
REFERENCE
Dejter SW, Cunningham RE, Noguchi PD, et al. Prognostic significance of DNA ploidy in carcinoma of prostate. Urology. 1989;33:361–366.
PNEUMORETROPERITONEUM
DESCRIPTION Pneumoretroperitoneum, the presence of air in the retroperitoneal space, unless immediately postoperatively, is always considered an abnormal finding. It can be due to a perforated retroperitoneal viscus or from residual air following a retroperitoneal surgical procedure. Duodenal, colonic, or rectal perforation can result from peptic ulcer disease, abdominal trauma, endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), colonoscopy, colorectal carcinoma, diverticulitis, ischemic colitis, or foreign-body insertion. Often accompanied by pneumoperitoneum, pneumomediastinum, or subcutaneous emphysema. Early diagnosis and treatment are important, as certain unrecognized conditions may become life-threatening (viscous perforation with sepsis). Treatment of the underlying etiology may be conservative or surgical, and allows for the pneumoretroperitoneum to resolve.
REFERENCE
Pretre R, Robert J, Mirescu D, et al. Pathophysiology, recognition and management of pneumoretroperitoneum. Br J Surg. 1993;80(9):1138–1140.
PNEUMOSCROTUM
DESCRIPTION Pneumoscrotum, the presence of air within the scrotum, can result from both pathologic and iatrogenic etiologies. This term includes both scrotal emphysema, which is subcutaneous air palpated as crepitus, and pneumatocele, where air is present within the tunica vaginalis and not directly palpable. Air may come from extraperitoneal (thoracic [pneumothorax], retroperitoneal), intraperitoneal (perforated viscus), or local (air-producing microorganisms) sources. The underlying cause must be recognized early, as certain conditions may be life-threatening (pneumothorax, Fournier gangrene, intestinal perforation) and treatment of the underlying cause allows the pneumoscrotum to resolve. Today, pneumoscrotum is sometimes seen after laparoscopic or robotic transperitoneal or extraperitoneal procedures and resolves spontaneously.
REFERENCES
Watson HS, Klugo RC, Coffield KS. Pneumoscrotum: review of two cases and review of mechanisms of its development. Urology. 1992;40(6):517–521.
Wilson C, Green A, Bader S, et al. Pneumoscrotum as the presenting symptom of pneumothorax and pneumoperitoneum after jet ventilation. Anesthesiology. 2012;117(2):408.
POLYARTERITIS NODOSA (PAN), UROLOGIC CONSIDERATIONS
DESCRIPTION PAN can affect many organ systems but usually presents with a systemic illness characterized by malaise, weight loss, myalgia, arthralgia and signs of end-organ damage. PAN is not well understood, but is believed to be caused by the deposition of immune complexes on the walls of primarily medium-sized arteries, causing deformative changes in those walls. This may lead to thickening and aneurysmal changes, causing acute renal hemorrhage and often leading to chronic renal failure. When left untreated, the 5-yr survival rate of PAN is 13% with some renal features being associated with poor prognosis: Renal insufficiency (serum creatinine >1.58 mg/dL) and proteinuria (>1 g/d). Corticosteroids and azathioprine are used in the treatment of PAN. The majority of patients with PAN have renal involvement. Flank pain is sometimes present and glomerular ischemic changes and renal artery vasculitis can cause renal failure (a small percentage of patients may require dialysis), hypertension, or both. Infrequently patients may develop pain over the testicular or ovarian area with testicular infarction reported. Spontaneous renal hemorrhage is also reported. Steroids with or without cyclophosphamide is the standard treatment.
REFERENCE
Pettigrew HD, Teuber SS, Gershwin ME. Polyarteritis nodosa. Compr Ther. 2007 Fall;33(3):144–149.
POLYEMBRYOMA
DESCRIPTION A mixed germ cell tumor (GCT) of the testis, containing embryonal carcinoma and yolk sac tumor. Histologic analysis reveals a distinctive, well-organized pattern of embryoid bodies in a myxoid stroma, which resembles extraembryonic mesenchyme. Due to the yolk sac component there may be substantial alpha fetoprotein (AFP) elevation. Treatment mirrors that for GCT.
REFERENCE
Ulbright TM. Germ cell neoplasms of the testis. Am J Surg Pathol. 1993;17(11):1075–1091.
POLYOMA VIRUS (BK, JC), UROLOGIC CONSIDERATIONS
DESCRIPTION The polyoma viruses may cause transplant renal nephropathy, ureteral obstruction or stricture, and hemorrhagic cystitis. BK virus may cause transplant renal nephropathy in up to 6% of transplant recipients, and may cause ureteral obstruction secondary to fibrosis. It is also thought to be the causative agent in the majority of patients with hemorrhagic cystitis following immunosuppression for bone marrow or solid organ transplantation. BK virus causes clinical disease of the genitourinary tract, due in part to its tropism for genitourinary epithelium. The JC virus causes a similar disease pattern but is less common. BK nephropathy occurs in up to 10% of kidney transplant recipients and causes graft failure in as many as 50% of individuals affected. BK and JC viruses can be diagnosed with PCR of the urine or blood. Urine cytology may demonstrate the so-called “decoy cells.’ Most renal transplant programs employ posttransplant screening programs. Decreasing immunosuppressive medications is essential. Additional therapies include agents such as ciprofloxin and IVIG. (See also Section I: “Immunocompromised Patients, Urologic Considerations” and Section II: “BK Virus, Urologic Considerations.”)
REFERENCE
Hirsch HH, Brennan DC, Drachenberg CB, et al. Polyomavirus-associated nephropathy in renal transplantation: Interdisciplinary analyses and recommendations. Transplantation. 2005;79:1277–1286.
POLYORCHIDISM
DESCRIPTION This is a very rare condition characterized by multiple (>2) testicles. It may be the result of transverse division of the urogenital ridge. The majority of cases are asymptomatic and associated with inguinal hernia, torsion, or cryptorchidism. It is most often discovered as an asymptomatic swelling in the scrotum; the supernumerary testis usually occurs with its own separate epididymis and vas deferens. If a testicular tumor can be ruled out using US or MRI, and if surveillance indicates no other associated disorders, surgical exploration is not necessary.
TREATMENT
Surveillance, exploration, and biopsy, if indicated
REFERENCE
Arlen AM, Holzman SA, Weiss AD, et al. Functional supernumerary testis in a child with testicular torsion and review of polyorchidism. Pediatr Surg Int. 2014;30(5):565–568. [Epub ahead of print]
POLYTHELIA, UROLOGIC CONSIDERATIONS
Polythelia (the presence of extra nipples) is linked with abnormalities of the urinary tract and is usually found within the milk line extending from the axilla to pubic region. Urologic abnormalities include supernumerary kidneys, failure of renal formation, and carcinoma of the kidney. The association of polythelia and renal anomalies is not uniform but is supported by some studies. 1 group reported 40% of children with polythelia had obstructive renal anomalies or duplications of the excretory system. The presence of extra nipples in children should heighten the clinician’s suspicion of possible renal anomalies.
REFERENCE
Grossl NA. Supernumerary breast tissue: Historical perspectives and clinical features. South Med J. 2000;93(1):29–32.
POLYURIA
DESCRIPTION Generally defined as >3 L of urine output from a person without excessive fluid intake (2 L/m2 in children). It is necessary to differentiate it from nocturnal polyuria (NP) (the production of >1/3 of total 24-hr urine output between midnight and 8 AM). Normally, a person’s urine output is decreased overnight, when compared to daytime urine output. It is useful to measure the urine osmolality to determine whether the polyuria is due to a water diuresis (urine osmolality <250 mOsmol/kg) or a solute diuresis (urine osmolality >300 mOsmol/kg). Polyuria has numerous causes. A solute diuresis may be caused by excessive hypertonic saline infusion, high-protein feedings, uncontrolled diabetes, or postobstructive diuresis. A water diuresis can be caused by multiple conditions, including polydipsia, loop diuretics, diabetes insipidus, and infusion of hypotonic solutions. Correct the underlying cause. (See also Section II: “Nocturnal Polyuria.”)
REFERENCE
Kujubu DA, Aboseif SR. An overview of nocturia and the syndrome of nocturnal polyuria in the elderly. Nat Clin Pract Nephrol. 2008;4(8):426–435.
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING, CHOLINE C 11
DESCRIPTION Choline C 11 injection is a radiotracer where choline is labeled with carbon C 11, a positron-emitting isotope. An active, carrier-mediated transport mechanism for choline allows for uptake into tumor cells where it is phosphorylated by choline kinase, an enzyme that is often upregulated in cancer. Therefore, these lesions can be differentiated from normal tissue on PET imaging. C-Choline PET/CT has been FDA approved in the detection of distant relapses in prostate cancer patients with a biochemical recurrence. In addition, accurate imaging of cancers within the prostate is important for patients with a high clinical suspicion for prostate cancer, but previous negative core biopsies. For these patients, targeted biopsy may improve detection rates of prostate cancer. This imaging study has been shown to accurately detect and locate major areas of prostate cancer and differentiate segments with prostate cancer from those with benign hyperplasia, chronic prostatitis, or normal prostatic tissue.
REFERENCE
Kitajima K, Murphy RC, Nathan MA. Choline PET/CT for imaging prostate cancer: an update. Ann Nucl Med. 2013;27(7):581–589.
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING, UROLOGIC CONSIDERATIONS
DESCRIPTION The most common urologic applications for the PET scan are in seminoma, kidney cancer, and prostate cancer. Patients who are treated for seminoma and have a residual retroperitoneal mass >3 cm should have a PET scan performed. A positive scan implies viable tumor, whereas a negative scan implies freedom from disease. Emerging data from combination PET/CT scans show potential in identifying small renal masses with reported 94% sensitivity and 100% specificity rates for clear cell RCC, but is still considered experimental. PET scans may also be useful in prostate cancer for distinguishing local vs. distant failure, determining progression of disease, and assessing the degree of androgen receptor expression but are not yet standard of care studies.
REFERENCE
Larson SM, Schöder H. Advances in positron emission tomography applications for urologic cancers. Curr Opin Urol. 2008;18(1):65–70.
POST MICTURITION SYMPTOMS
DESCRIPTION LUTS are conventionally classified into symptoms of storage, voiding, and postmicturition symptoms. Postmicturition symptoms include the sensation of incomplete bladder emptying and postmicturition dribble. These symptoms have an overall prevalence of ~10% of the population, are most often present in the setting of other storage or voiding symptoms, and are noted to increase with age in men. Incomplete bladder emptying is seen more commonly in women whereas men more often experience postmicturition dribbling. Despite the fact that the importance of these symptoms is not always highlighted, studies have shown that their presence can have a significant adverse effect on patient health-related quality of life.
REFERENCE
Maserejian NN, Kupelian V, McVary KT, et al. Prevalence of postmicturition symptoms in association with lower urinary tract symptoms and health-related quality of life in men and women. BJU Int. 2011;108(9):1452–1458.
POSTORGASMIC ILLNESS SYNDROME (POIS)
DESCRIPTION Post orgasmic illness syndrome (POIS) is characterized by debilitating mental and physical symptoms following orgasm that may last from a few hours to several days. Mental symptoms include cognitive dysfunction, irritability, discomfort, anxiety, and depression. Physical symptoms include fatigue, headache, and allergic or flu-like symptoms. Patients typically avoid sexual activity altogether or plan to engage in intercourse when they have adequate time to recover. Some hypothesize that allergy to one’s own semen may contribute to the illness. Others believe that a lack of the neurosteroid progesterone, or defect in neurosteroid precursor synthesis, leads to the observed pathophysiology.
REFERENCE
Waldinger MD, Meinardi MM, Zwinderman AH, et al. Postorgasmic illness syndrome (POIS) in 45 Dutch Caucasian males: Clinical characteristics and evidence for an immunogenic pathogenesis (Part 1). J Sex Med. 2011;8(4):1164–1170.
POSTATROPHIC HYPERPLASIA OF THE PROSTATE
DESCRIPTION Postatrophic hyperplasia is a histologic pattern showing atrophic and hyperplastic glands, sometimes with a small acinar configuration. Atrophy followed by hyperplasia results in acini with nuclear enlargement. Nucleoli are enlarged as well. The basal cell layer may be difficult to see, but its presence rules out prostate cancer. Immunohisto-chemistry with 34βE12 stain, which stains for basal cell CK, may be helpful. This entity can be confused with prostate cancer on needle biopsy, but is a benign condition. (See also Section III: “Atypical Small Acinar Proliferation, Prostate [ASAP]”; “Atypical Adenomatous Hyperplasia of the Prostate.”)
REFERENCE
Amin MB, Tamboli P, Varma M, et al. Postatrophic hyperplasia of the prostate gland: A detailed analysis of its morphology in needle biopsy specimens. Am J Surg Pathol. 1999;23(8):925–931.
POSTCOITAL PROPHYLACTIC ANTIBIOTICS
DESCRIPTION Women who suffer recurrent UTIs (≥2 infections in 6 mo or ≥3 infections in 1 yr) may have an association of their UTIs with sexual activity. Gram-negative organisms colonizing the vagina are often the cause. The problem is typically seen in premenopausal women. (See also Section I: “Urinary Tract Infection [UTI], Adult Female.”)
TREATMENT
• Hydrate well and empty bladder immediately after intercourse (have not been proven to be uniformly effective in clinical trials).
• Cranberry juice/supplements have not been proven beneficial in trials
• Suppressive antibiotic therapy immediately after intercourse; single dose of the following has been reported: Trimethoprim-sulfamethoxazole, nitrofurantoin, cephalexin, and the fluoroquinolones; if pregnant: Cephalexin (250 mg) or nitrofurantoin (50 mg).
REFERENCE
Fiore DC, Fox CL. Urology and nephrology update: recurrent urinary tract infection. FP Essent. 2014;416:30–37.
POSTCOITAL TEST
DESCRIPTION A test that evaluates the interaction between sperm and cervical mucus. It determines the adequacy of sperm and the receptivity of cervical mucus. Testing consists of retrieving specimens from the posterior vaginal fornix, exocervix, and endocervical canal ~6–8 hr after intercourse. The test should be performed close to the time of ovulation, and couples are asked to abstain from sex for 48 hr prior to the test. These specimens are examined to determine the number of motile sperm, with 10 sperm/hpf considered adequate and excluding the cervical mucosa as cause of infertility. When these test results are poor, the specimens may be repeated on another occasion, 1–3 hr after coitus.
SYNONYM
Sims–Huhner Test
REFERENCE
Leushuis E, van der Steeg JW, Steures P, et al.; CECERM study group. Prognostic value of the postcoital test for spontaneous pregnancy. Fertil Steril. 2011;95(6):2050–2055.
POSTERIOR TIBIAL NERVE STIMULATION (PTNS)
DESCRIPTION PTNS provides retrograde stimulation to the sacral plexus through stimulation of the posterior tibial nerve. The currently available United States system is the Urgent PC (Uroplasty, Minnetonka, MN). It is FDA approved for the treatment of urinary urgency, urinary frequency, and urge incontinence (overactive bladder). Other uses described include nonobstructive urinary retention, neurogenic bladder, pediatric voiding dysfunction and chronic pelvic pain syndrome (CPP)/Painful bladder syndrome (PBS). The PTNS mechanism of action is unclear, and may be due to effects on different areas of the CNS or a peripheral effect on the target organ. The -gauge disposable needle insertion point is 4–5 cm cephalad to the medial malleolus. The current is a continuous, square wave (duration of 200 μs, frequency of 20 Hz). The current is determined by the highest level that is tolerated by the patient. The stimulations sessions last for 30 min and are performed once a week for 10–12 wk PTNS was found to be effective in 37–100% of patients with OAB, in 41–100% of patients with nonobstructive urinary retention and in up to 100% of patients with CPP/PBS. (See also Section I: “Overactive Bladder (OAB)” and Section II: “Sacral Neuromodulation.”) (Image )
REFERENCE
Gaziev G, Topazio L, Iacovelli V, et al. Percutaneous tibial nerve stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BMC Urol. 2013;13:61.
POSTOPERATIVE SPINDLE CELL NODULE, BLADDER
DESCRIPTION These benign lesions appear 5 wk to 3 mo after surgical procedures in the lower urogenital tract. They grossly resemble a sarcoma and develop after damage to the bladder wall. Microscopically, they appear as intersecting spindle cells intermingled with inflammatory infiltrates. The main differential diagnosis is leiomyosarcoma. They have been reported most commonly in the bladder and prostate.
SYNONYMS
• Postoperative spindle cell nodule of Proppe
• Pseudosarcoma
TREATMENT
Transurethral resection
REFERENCE
Young, RH. Non-neoplastic disorders of the urinary bladder (Chapter 5). In: Bostwick DG, ed. Urologic Surgical Pathology. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2008:238.
POSTTRANSPLANT LYMPHOPROLIFERATIVE DISORDER
DESCRIPTION Posttransplant lymphoproliferative disorder (PTLD) is a heterogeneous disease that may occur in recipients of solid organ transplants and hematopoietic stem cell transplants. The risk of lymphoma is increased 20–120% compared with the general population. Epstein–Barr virus infection at the time of transplantation appears to be a significant risk factor. Based on morphologic, immunophenotypic, and molecular criteria, PLTD are classified into 4 pathologic categories: Early lesions, polymorphic, monomorphic, and classical Hodgkin lymphoma. A mainstay of therapy is reduction of immune suppression but often single-agent rituximab or even combination chemotherapy is needed.
REFERENCE
Jagadeesh D, Woda BA, Draper J, et al. Post transplant lymphoproliferative disorders: Risk, classification, and therapeutic recommendations. Curr Treat Options Oncol. 2012;13(1):122–136.
POSTVOID DRIBBLING
DESCRIPTION Urine that leaks out or the urethra at the end of micturition. It may be caused by bladder outlet obstruction, a urethral diverticulum, or vesicovaginal reflux of urine. Recent data suggests it may be a surrogate for median lobe hypertrophy.
REFERENCE
Hassler E, Krakau I, Häggarth L, et al. Questioning questions about symptoms of benign prostatic hyperplasia. Fam Pract. 2001;(3):328–332.
POTASSIUM SENSITIVITY TESTING
DESCRIPTION A diagnostic test proposed for Interstitial cystitis (IC)/Painful Bladder syndrome (PBS). The pathogenic mechanism of PBS/IC may involve increased epithelial permeability or loss of tight junctions between epithelial cells. Patients with a normal urothelium and sensory nerves will have no pain associated with the instillation of 400 mM (0.4 M) of potassium chloride solution into the bladder, whereas those with PBS/IC may have pain. Patients may be asked to rank their degree of pain on a visual analog scale. More recently, potassium chloride has been used to predict the responsiveness of patients to intravesical hyaluronic acid therapy.
REFERENCE
Parsons CL, Greenberger M, Gabal L, et al. The role of urinary potassium in the pathogenesis and diagnosis of interstitial cystitis. J Urol. 1998;159(6):1862–1866.
POTTER SYNDROME/POTTER SEQUENCE
DESCRIPTION A fetus with Potter syndrome (oligohydramnios sequence) a rare fatal disorder that occurs in sporadic and autosomal recessive forms with an incidence of 1 in 4,000 births may show signs of Potter facies (a flat nose, recessed chin, epicanthal folds, low-set ears) and limb abnormalities. These deformities are believed to be secondary to compression of the fetus due to severe oligohydramnios resulting from bilateral renal agenesis. Skelet al malformations may include hemivertebrae, sacral agenesis, and limb anomalies. Babies are often stillborn or die early in the neonatal period. Death usually results from respiratory insufficiency from lack of development of the alveolar sacs. (See also Section II: “Renal Agenesis [Bilateral and Unilateral].”)
REFERENCES
Potter EL. Bilateral renal agenesis. J Pediatr. 1946;29:68–76.
Shastry SM, Kolte SS, Sanagapati PR. Potters Sequence. J Clin Neonatol. 2012;1(3):157–159.
POUCHITIS
DESCRIPTION Pouchitis is the most common long-term complication in patients with restorative proctocolectomy and ileal pouch-anal anastomosis and is more completely described in the literature for this population. In patients undergoing continent catheterizable stoma, pain in the region of the stoma, along with an increase in pouch contractility is also referred to as pouchitis. The increased intestinal segment contractility can cause temporary loss of the continence mechanism. The patient may complain of sudden, explosive loss of urine through the catheterizable stoma. Anecdotal reports of continent orthotopic neobladder also exist. Most cases involving urinary diversion are caused by a bacterial infection that responds to a 10-day course of antibiotics based on sensitivity testing.
REFERENCE
Colwell JC, et al. eds. Fecal & Urinary Diversions: Management Principles. Philadelphia, PA: Mosby Elsevier; 2012.
PRADER–WILLI SYNDROME
DESCRIPTION This is secondary to a chromosomal abnormality consisting of partial deletion of the long arm of chromosome 15 (q11–13). Children often present as obese, hypotonic, and retarded, with hypogonadism, and cryptorchidism. Obesity and behavioral problems are the major cause of morbidity and mortality in affected individuals.
REFERENCE
Cassidy SB. Prader-Willi syndrome. J Med Genet. 1997;34(11):917–923.
PRECOCIOUS PUBERTY
DESCRIPTION Precocious puberty is sexual development at an earlier age than expected. In general, signs of secondary sexual development in boys <9 and breast or pubic hair development in white girls <7 or in black girls <6 is precocious. Common causes include medications (exogenous estrogen or testosterone), idiopathic causes, pituitary and CNS tumors (hamartomas, others), CAH, adrenal tumor, ovarian cysts and tumors, McCune–Albright syndrome, Leydig cell tumors, hCG-secreting GCT, testotoxicosis, or pseudoprecocious puberty.
REFERENCE
Carel JC, Leger J. Clinical practice. Precocious puberty. N Engl J Med. 2008;358(22):2366–2377.
PREGNANCY, BACTERIURIA, PYURIA, AND URINARY TRACT INFECTION
DESCRIPTION Pregnant women with asymptomatic bacteriuria have a higher likelihood of developing a UTI and should be treated to reduce the incidence of pyelonephritis, sepsis, and fet al complications (low birth weight, prematurity, death). Pyuria in the presence of bacteriuria indicates UTI. Pyuria in the absence of bacteriuria should raise suspicion for nephrolithiasis, TB, or less commonly, malignancy of the urinary tract. Penicillins and cephalosporins (FDA category B) are generally agreed to be safe in pregnancy. Drugs with very high protein binding (eg, Ceftriaxone), may be inappropriate the day before parturition because of the possibility of bilirubin displacement and kernicterus risk. Fluoroquinolones should be AVOIDED in pregnancy. (See also Section I: “Bacteruria and Pyuria” and “Pregnancy, Urolithiasis.”)
TREATMENT
The following regimens have been reported in eradicating asymptomatic bacteriuria in pregnancy:
• Nitrofurantoin 100 mg BID × 5 days
• Amoxicillin 500 mg PO BID 3–7 days
• Amoxicillin-clavulanate 500 mg PO BID 3–7 days
• Cephalexin 500 mg 500 mg PO BID 3–7 days
• Fosfomycin 3 g orally as a single dose
The following regimens have been reported in treating cystitis in pregnancy modified based on urine culture results:
• Nitrofurantoin 100 mg orally every 12 hr for 5 days
• Cefpodoxime: 100 mg twice daily for 3–7 days
• Amoxicillin-clavulanate: 500 mg orally every 12 hr for 3–7 days
• Fosfomycin: 3 g orally as a single dose
The following regimens are reported for mild to moderate pyelonephritis in pregnancy:
• Ceftriaxone: 1 g every 24 hr
• Cefepime: 1 g every 12 hr
• Aztreonam: 1 g every 8 to 12 hr
The following regimens are reported for severe pyelonephritis with immunocompromise and/or incomplete urinary drainage.
• Ticarcillin-clavulanate: 3.1 g every 6 hr
• Piperacillin-tazobactam: 3.375 g every 6 hr
• Meropenem: 500 mg every 8 hr
• Ertapenem: 1 g every 24 hr
• Doripenem: 500 mg every 8 hr
REFERENCES
Hooton TM, Gupta K. Urinary tract infections and asymptomatic bacteriuria in pregnancy in UpToDate.com. Accessed March 5, 2015.
Macejko AM, Schaeffer AJ. Asymptomatic bacteriuria and symptomatic urinary tract infections during pregnancy. Urol Clin North Am. 2007;(341):35–42.
PREGNANCY, HEMATURIA
DESCRIPTION Microscopic hematuria is a common finding during pregnancy, however it rarely impacts the outcome of the pregnancy. However, these patients should be assessed postpartum for continued microscopic hematuria to assess for further urologic or kidney disease.
REFERENCE
Brown MA, Holt JL, Mangos GJ, et al. Microscopic hematuria in pregnancy: Relevance to pregnancy outcome. Am J Kid Dis. 2005;45:667–673.
PREGNANCY, RADIOLOGIC CONSIDERATIONS
DESCRIPTION Urologists are commonly confronted with pregnant patients with hydronephrosis, renal colic, and stone disease. Imaging is difficult to interpret due to anatomic and physiologic changes in the gravid patient, as well as because of the concern of exposing a fetus to ionizing radiation. The maximum safe dose of radiation allowable to the fetus in the 1st trimester is thought to be 20,000 mrads, and 50,000 mrads in the 2nd and 3rd trimesters. The initial imaging modality of choice should be abdominal ± transvaginal color Doppler ultrasound (US) to evaluate renal resistive indices, ureteral dilation distal to the iliac vessels, and ureteral jets in the bladder. If further evaluation is needed, a diuretic magnetic resonance urogram (MRU) or low-dose CT reported average exposure 705 mrads) can be performed. In the OR, stent placement can be done with intraoperative US and, if absolutely necessary, fluoroscopy with shielding of the fetus by placement of lead below the patient’s lower abdomen and pelvis. Iodinated contrast materials may be used in pregnancy, when indicated. Gadolinium is not recommended for use in the pregnant patient unless benefit justifies the potential fet al risk.
REFERENCES
Goldstone K, Yates SJ. Radiation issues governing radiation protection and patient doses in diagnostic imaging. In: Grainger RG, Allison DJ, et al. Diagnostic Radiology. 5th ed. Philadelphia, PA: Elsevier; 2008.
White WM, Zite NB, Gash J, et al. Low-dose computed tomography for the evaluation of flank pain in the pregnant population. J Endourol. 2007;21(11):1255–1260.
PREGNANCY, RENAL TRANSPLANTATION
DESCRIPTION Successful renal transplantation restores normal ovulatory function and the potential for successful conception. Pregnancy does not appear to affect long-term graft survival. However, pregnancies after renal transplant are at significant risk for maternal and fet al complications including hypertension, preeclampsia, and infection, as well as preterm delivery and fet al growth restriction. Renal transplantation is not a contraindication to vaginal delivery and care should be taken during cesarean section not to injure the renal unit. General safe guidelines for pregnancy after renal transplantation are good health and functioning renal unit 2 yr after transplantation without any evidence of infection or obstruction and on low doses of immunosuppression.
REFERENCE
Fuchs KM, Wu D, Ebcioglu Z. Pregnancy in renal transplant recipients. Semin Perinatol. 2007;31:339–347.
PREGNANCY, URINARY DIVERSION
DESCRIPTION Pregnancy after urinary diversion has not been well studied, and only 250 cases have been reported in the literature thus far. Patients have more difficulty getting pregnant because of their inherent underlying disease process, metabolic changes from urinary diversion, and because of the fixed position of the uterus from prior surgery. These patients have special antepartum considerations from decreased perfusion of the bowel segment from compression of the conduit or neobladder by the uterus, malabsorption of food due to use of the terminal ileum, stomal prolapse from increased intra-abdominal pressure, stomal stenosis from impaired blood flow, difficulty catheterizing continent pouches from stretching of the efferent limb, and an increased risk of UTI from the presence of bacteriuria. Unique postpartum issues include adhesions of the small intestine that may complicate cesarean section, increased residual urine volumes from stretching of conduits or neobladders, and an increased risk of pelvic organ prolapse.
REFERENCE
Hautmann RE, Volkmer BG. Pregnancy and urinary diversion. Urol Clin North Am. 2007;31:71–88.
PREGNANCY, URINARY TRACT OBSTRUCTION
DESCRIPTION Urinary tract obstruction during pregnancy most commonly occurs from a ureteral stone or extrinsic compression from the gravid uterus. Patients will commonly present with flank pain. US, magnetic resonance urography, or low-dose CT may be used to evaluate for a ureteral stone and evidence of obstruction. Hydronephrosis is a common finding in pregnancy and may be found in 15%, 20%, and 50% of patients in their 1st, 2nd, and 3rd trimesters, respectively. It is more common on the right side, and is commonly thought to occur from progesterone-mediated ureteral dilation and extrinsic compression. (see also Section I: “Pregnancy, Urolithiasis” and Section II: “Pregnancy, Radiologic Considerations.”)
TREATMENT
• Initially, conservative with IV hydration and analgesic therapy.
• Patients who fail may require stent or nephrostomy tube placement. Stents can rapidly encrust due to increased urinary calcium excretion and should be changed in a timely fashion.
• Ureteroscopy and laser lithotripsy.
REFERENCE
McAleer SJ, Loughlin KR. Nephrolithiasis and pregnancy. Curr Opin Urol. 2004;14(2):123–127.
PREGNANCY, UROLOGIC MALIGNANCY
DESCRIPTION Urologic malignancies are rare in pregnancy but often misdiagnosed due to overlapping signs and symptoms with preeclampsia and eclampsia. The most common tumor is RCC, which may present as flank pain, hematuria, and a palpable mass. It is often identified incidentally on imaging. Pheochromo-cytomas have been reported to occur in 1 of 50,000 term pregnancies. They present with severe hypertension, headaches, palpitations, vomiting, visual changes, and without proteinuria unlike preeclampsia. Adrenal adenomas may present with Cushing syndrome. Renal angiomyolipoma may present with flank pain, hematuria, and retroperitoneal hemorrhage, although it is sometimes incidentally diagnosed on imaging. Urothelial carcinoma of the upper or lower tracts is rare and presents with hematuria. If urine analysis reveals hematuria and the culture is negative, cytology, cystoscopy, and upper tract imaging are warranted.
TREATMENT
• Removal of pheochromocytomas is controversial, but medical therapy may be used until the 3rd trimester or delivery of the fetus.
• The size and type of tumor should dictate management for RCC, and laparoscopic nephrectomy has been shown to be safe in pregnant women.
• Angiomyolipoma (AML) with hemorrhage may be managed with embolization or partial or total nephrectomy.
• Urothelial cancer should be managed endoscopically given its propensity for aggressive growth and lymphatic invasion. Mitomycin should be avoided, and only 1 case report exists of using BCG.
REFERENCE
Martin FM, Rowland RG. Urologic malignancies in pregnancy. Urol Clin North Am. 2007;341):53–59.
PREGNANCY, UROLOGIC MEDICATIONS
DESCRIPTION Medications in pregnancy have not been well studied or documented. Urologic issues include antibiotics for UTIs and anesthesia for surgical procedures. Macrobid is a safe, well-tolerated antibiotic classified as a category B (no evidence of harm to human fetus) drug by the FDA. There is a recommendation against using this in the 3rd trimester because of the risk of hemolytic anemia in patients with G6PD deficiency. Fluoroquinolones are considered category C medications, but multiple studies have failed to demonstrate any evidence of harm. Penicillins are category B drugs, and often the medication of choice in pregnancy. General anesthesia may carry a slightly higher risk of fet al malformations and premature labor; this effect is directly related to the complexity and length of the procedure but the overall increased risk is thought to be minimal. (See also Section II: “Pregnancy, Bacteruria, Pyuria, and UTI.”)
REFERENCE
Shrim A, Garcia-Bournissen F, Koren G. Pharmaceutical agents and pregnancy in urology practice. Urol Clin North Am. 2007;34(1):27–33.
PREHN SIGN
DESCRIPTION Prehn sign is a clinical test used to aid in distinguishing epididymitis from testicular torsion although it is not always reliable. The physical lifting of the testicles is said to relieve the pain of epididymitis (positive Prehn sign), but does not relieve the pain of testicular torsion (negative Prehn sign). It is important to note that Prehn sign is not always reliable and Doppler ultrasound is a valuable tool in confirming the diagnosis.
REFERENCE
Lavallee ME, Cash J. Testicular torsion: Evaluation and management. Curr Sports Med Rep. 2005; 4(2):102–104.
PRENTISS MANEUVER
DESCRIPTION Additional cord length in an orchiopexy operation can be gained by incising the inguinal floor and ligating the inferior epigastric vessels. The internal ring and transversalis fascia are then closed lateral to the cord.
REFERENCE
Kelly CE. The relationship between pressure flow studies and ultrasound-estimated bladder wall mass. Rev Urol. 2005;Suppl 6:S29–S34.
PREPUTIAL STONES
DESCRIPTION Preputial stones (preputial calculi) are rare occurrences, generally found in adults and associated with poor genital hygiene, low socioeconomic status, and phimosis. Factors in preputial stone formation include obstruction, stasis, foreign body, nidus formation, and infection. Removal of stone and elimination of the predisposing condition is the treatment.
REFERENCE
Ellis DJ, Siegel AL, Elder JS, et al. Preputial calculus: A case report. J Urol. 1986;1362:464–465.
PRESSURE–FLOW STUDIES
DESCRIPTION The simultaneous measurement of bladder pressure and uroflow throughout the entire voiding cycle. Performed as part of urodynamic study, these studies improve on some of the imitations of uroflowmetry alone. Measurements for this study can include the variables that affect the study: Intravesical pressure, rectal pressure, intraurethral pressure, sphincter electromyogram, and urine flow rate. A small catheter is placed to fill the bladder and measure the flow. All variables are plotted and recorded simultaneously to compare the various readings during various points in the micturition study.
REFERENCE
Nitti VW. Pressure Flow urodynamic studies: the gold standard for diagnosing bladder outlet obstruction. Rev Urol. 2005;7(Suppl 6): S14–S21.
PRIAPISM, STUTTERING (INTERMITTENT PRIAPISM)
DESCRIPTION Priapism that is recurrent in nature should be treated initially as for ischemic priapism. Emphasis should be placed on long-term prevention using medical or self-injection therapy. (See also Section I: “Priapism.”)
SYNONYMS
• Recurrent priapism
• Intermittent priapism
TREATMENT
• Hormonal therapy (leuprolide, flutamide, bicalutamide)
• Self-injection therapy with phenylephrine
REFERENCE
Burnett AL, Bivalacqua TJ. Priapism: Current principles and practice. Urol Clin North Am. 2007;344:61–62.
PRIMITIVE NEUROECTODERMAL TUMORS (PNET) (EXTRASKELET AL EWING SARCOMA)
DESCRIPTION Primitive neuroectodermal tumors are part of the Ewing family of tumors (EFT) that include Ewing’s sarcoma of the bone. Peripheral PNET is a very aggressive neoplasm that predominantly affects children and adolescents. Renal PNET is the most reported PNET of the genitourinary tract, however bladder, prostate, ureter, and seminal cord PNETs have also been reported. PNETs are often diagnosed as metastatic disease (25–50%) and the outcome is often poor; with a 5-yr survival rate (45–55%).
TREATMENT
Multimodal therapy including surgical resection, chemotherapy, and radiation.
REFERENCE
Ellinger J, Bastian PJ, Hauser S, et al. Primitive neuroectodermal tumor: Rare, highly aggressive differential diagnosis in urologic malignancies. Urology. 2006;68:257–262.
PRINCETON III CONSENSUS RECOMMENDATIONS: ERECTILE DYSFUNCTION (ED) AND CARDIOVASCULAR DISEASE
DESCRIPTION The recommendations of the 3rd Princeton Consensus Conference focus on (1) evaluation and management of cardiovascular risk in men with ED and no known CVD, (2) reevaluation and modification of the 2nd conference recommendation for evaluation of cardiac risk associated with sexual activity in men with known CVD, and (3) the role of testosterone replacement therapy (TRT) in ED and CVD management (Image ).
REFERENCE
Nehra A, Nehra A1, Jackson G, Miner M, et al. The princeton III consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012;87(8):766–778.
PROLACTIN, SERUM LEVEL
DESCRIPTION Elevated prolactin levels are associated with infertility and ED. Hyperprolactinemia may be caused by a pituitary tumor, stress, medications, hypothyroidism, or idiopathic causes. A pituitary tumor will result in low serum gonadotropin and testosterone levels and elevated prolactin levels. The mainstay of therapy for prolactinomas is medical management.
Elevated prolactin levels >50 ng/mL suggest a prolactinomas. Renal failure, stress, medications, and hypothyroidism have serum prolactin value <50 ng/mL.
TREATMENT
• Cabergoline
• Bromocriptine
• Surgical excision
REFERENCE
Verhelst J, Abs R. Hyperprolactinemia: Pathophysiology and management. Treat Endocrinol. 2003;2(1):23–32.
PROLAPSE, STAGING SYSTEMS
DESCRIPTION Since the early 1960s multiple practitioners including Porges, Baden, Walker, and Beecham have attempted to classify pelvic organ prolapse. Then in 1996 the American Urogynecologic Society, the Society of Gynecologic Surgeons, and the ICS adopted the Pelvic Organ Prolapse Quantitation (POP-Q) exam. The POP-Q exam, in which 9 specific points of measurement are obtained in relation to the hymenal ring, has been demonstrated to be learned easily and performed quickly with highly reproducible exam findings. The most widely used classification systems used today are the Baden–Walker and POPQ systems. (See also Section II: “Cystocele Grading: Baden–Walker, Pelvic Organ Prolapse Quantification [POP-Q].”)
REFERENCE
Theofrastous JP, Swift SE: The clinical evaluation of pelvic floor dysfunction. Obstet Gynecol Clin North Am. 1998;25:783–804.
PROPANTHELINE STIMULATION TEST
DESCRIPTION This test is used when involuntary detrusor contractions are demonstrated during cystometry to predict the outcome of pharmacologic treatment with anticholinergics. Propantheline bromide is an anticholinergic with side effects that include dry mouth and blurred vision. Once involuntary detrusor contractions have been confirmed, 15 mg of propantheline bromide are administered parenterally. Once effects of the drug are noticed, cystometry is repeated. A positive response is defined as the complete abolition of involuntary detrusor contractions, or a 200% increase in the bladder volume at which they occur. If the parenteral dosage is effective, a favorable clinical response to the orally administered dose can be expected in most patients.
REFERENCE
Blaivis JG, Scott RM, Labib KB. Urodynamic evaluation as a test of sacral cord function. Urology. 1979;13:682–687.
PROPHYLACTIC ANTIBIOTICS, AUA GUIDELINES
DESCRIPTION Recommendations include limiting antibiotic prophylaxis to a maximum of 24 hr, no prophylaxis solely to prevent infectious endocarditis, and defining characteristics for patients at higher risk. These characteristics include advanced age, anatomic anomalies of the urinary tract, poor nutritional status, smoking, chronic corticosteroid use, immunodeficiency, externalized catheters, colonized endogenous/exogenous material, distant coexistent infection, and prolonged hospitalization.
Recommendations for specific procedures and agents are found in Section VII: “Reference Tables: Antibiotic Prophylaxis: AUA guidelines.”
REFERENCE
Wolf JS Jr., Bennett CJ, Dmochowski RR, et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008;179(4):1379–1390.
PROSTASCINT SCAN
DESCRIPTION A nuclear medicine imaging study designed to localize prostate cancer cells using a radiolabeled monoclonal antibody to PSMA (prostate-specific membrane antigen) called indium-111 capromab pendetide. Patients are injected, and single photon emission computed tomography is performed immediately after scan and 4–5 days later. This allows for washout of antibody from the blood and bowel. The test was initially designed to identify extraprostatic disease, and current applications include identifying the location of cancer recurrence following definitive therapy for prostate cancer. It has traditionally suffered from poor specificity and interobserver reliability and issues concerning uptake of mid abdominal lymph nodes. Recent data suggest that there may be renewed interest in integrating the ProstaScint scan in clinical decision making for deciding between local vs. systemic salvage therapy for PSA recurrence following definitive management of prostate cancer (Image ).
REFERENCE
Taneja S. ProstaScint Scan: Contemporary use in clinical practice. Rev Urol. 2004;S10:19–28.
PROSTATE CANCER SCREENING GUIDELINES
DESCRIPTION Screening asymptomatic men for prostate cancer is controversial. Concerns about over diagnosis and overtreatment of clinically important cancers are part of this reason. Many professional organizations have developed guidelines concerning prostate cancer screening that are summarized in the table. (See also Section II: “PSA, General Considerations” and Section VII: Reference Tables: Prostate Cancer Screening Guidelines.)
REFERENCES
Gomella LG, Liu XS, Trabulsi EJ, et al. Screening for prostate cancer: the current evidence and guidelines controversy. Can J Urol. 2011;18(5):5875–5883. Review
ACP 2013 Prostate Cancer Screening Guidelines (www.acponline.org); NCCN 2014 Prostate Cancer Early Detection Guidelines Version 1.2014 (www.nccn.org) Accessed March 30, 2014.
PROSTATE CANCER, ACTIVE SURVEILLANCE AND WATCHFUL WAITING
DESCRIPTION Screening for prostate cancer can result in the diagnosis of prostate cancer in many men who are not likely to suffer any consequences or die from the disease. This often results in overtreatment of many men with prostate cancer. Deferred therapy for prostate cancer generally involves 2 different approaches although the terms are often used interchangeably, they are not completely identical:
• Active surveillance is a strategy aiming to individualize the management of early prostate cancer by selecting only those men with significant cancers for curative therapy. This involves actively monitoring the course of prostate cancer with the intent of intervention with definitive local therapy (eg, radiation therapy, RP) if cancer progression is documented.
• Watchful waiting uses less aggressive follow-up until the patient develops symptomatic disease progression, at which time he is often placed on hormonal treatment. (See also Section I: “Prostate Cancer, General” and “Prostate Cancer, Very Low Risk and Active Surveillance”; Section II: “Life Expectancy, Urologic Considerations.”)
REFERENCE
NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer V.1.2014. Available at www.nccn.org. Accessed March 4, 2014)
PROSTATE CANCER, BASAL CELL CARCINOMA
DESCRIPTION A very rare variant of prostate cancer comprising <0.01% of malignant tumors. Lesions exist in 2 distinct forms, adenoid cystic carcinoma (ACC), and basaloid carcinoma (BC), that may occur clinically separate or as mixed tumors with 1 dominant pattern. Immunohistochemical analysis reveals strongly positive results for both 34βE12 and p63. Once thought to be a more indolent form of prostate cancer, current evidence supports the potential for local recurrence and metastasis and therefore suggests radical surgery with life-long follow-up as 1st-line management.
REFERENCE
Montironi R, Mazzucchelli R, Stramazzotti D, et al. Basal cell hyperplasia and basal cell carcinoma of the prostate: A comprehensive review and discussion of a case with c-erbB-2 expression. J Clin Pathol. 2005;58:290–296.
PROSTATE CANCER, CIRCULATING TUMOR CELLS (CTC’s)
DESCRIPTION Circulating tumor cells (CTC) can be detected using molecular techniques such as RT-PCR. An identification assay for actual circulating cells (CellSearch) is commercially available for use in patients with hormone-refractory prostate cancer. In patients with advanced prostate cancer, men with ≥5 CTCs per 7.5 mL blood prior to chemotherapy had a significantly shorter median survival (10 vs. 21 mo in those with <5 CTCs). The role of the CTC assay continues to evolve in the management of prostate cancer; it appears to be only valid at present for men with advanced, castrate resistant prostate cancer disease and is not as useful for earlier stages of disease. (See also Section II: “PSA, RT-PCR.”)
REFERENCE
de Bono JS, Scher HI, Montgomery RB, et al. Circulating tumor cells predict survival benefit from treatment in metastatic castration-resistant prostate cancer. Clin Cancer Res. 2008;14(19):6302–6309.
PROSTATE CANCER, DUCTAL ADENOCARCINOMA
DESCRIPTION These terms have been replaced by ductal adenocarcinoma of the prostate. It accounts for 0.2–0.8% of prostate adenocarcinoma. Due to its appearance, ductal adenocarcinoma was previously thought to arise from müllerian remnants and possess unique clinical features related to its origin. While further analyses have shown that these tumors do in fact arise from prostatic tissue. The lesion originates from periurethral prostatic ducts and may grow into an exophytic urethral lesion around the verumontanum. A mixture of cribriform and papillary structures is seen on microscopy, resembling endometrial adenocarcinoma of the uterus and hence the earlier descriptive terms. Histologically, these tumors are composed of tall columnar cells with clear to eosinophilic cytoplasm and large nucleoli. The cells form glands with scant intervening stroma. Prostatic ductal carcinoma cells express PSA. Prostate adenocarcinoma is also present in 77% of cases.
Early presentation is hematuria, irritative and obstructive symptoms and it tends to occur in older men (60–80 yr). Serum PSA levels and DRE at the time of diagnosis tend to underestimate disease. Cystoscopically it may appear multiple polypoid friable protruding from near the mouth of the prostatic utricle but often there are no defining endoscopic findings. Sources are conflicting concerning the clinical presentation with some stating due to the early symptom presentation most are organ confined and others more likely to present with advanced stage cancer. The behavior has been compared to behaved similar to Gleason’s 8 (4 + 4) acinar prostate adenocarcinoma.
SYNONYMS
• Ductal carcinoma of the prostate
• Endometrioid carcinoma, prostate
• Endometrial carcinoma of the prostate
• Papillary adenocarcinoma of the prostatic utricle
TREATMENT
Similar to high-grade acinar adenocarcinoma of prostate. Most in the literature have been managed by radical prostatectomy. Ductal carcinoma of the prostate tends to be hormone sensitive and advanced disease is initially responsive to androgen deprivation. The overall mortality was significantly worse in men with ductal prostate adenocarcinoma, almost 3-fold higher rate of death, as compared to acinar prostate adenocarcinoma.
REFERENCES
Bostwick DG, Meiers I. Neoplasms of the prostate. Chapter 9 in Bostwick DG, ed. Urologic Surgical Pathology. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2008:493–495.
Morgan TM, Welty CJ, Vakar-Lopez F, et al. Ductal adenocarcinoma of the prostate: Increased mortality risk and decreased PSA secretion J Urol. 2010;184(6):2303–2307.
PROSTATE CANCER, FAMILIAL
DESCRIPTION The risk of prostate cancer is directly dependent upon the number of affected 1st-degree relatives, the age of the relative when diagnosed, and whether the relative is a father or brother. Risk is also associated with a family history of breast cancer.
REFERENCE
Bruner DW, Moore D, Parlanti A, et al. Relative risk of prostate cancer for men with affected relatives: Systematic review and meta-analysis. Int J Cancer. 2003;107:797–803.
PROSTATE CANCER, LEIOMYOSARCOMA, AND OTHER UNCOMMON SARCOMAS
DESCRIPTION Leiomyosarcoma of the prostate is extremely rare and a highly aggressive neoplasm, accounting for <0.1% of primary prostate malignancies. It is the most common primary prostatic sarcoma of the prostate in adults and comprises 38–52% of adult prostatic sarcomas. Rhabdomyosarcoma most common in pediatric patients and can be seen in adults. Other less common prostate sarcomas include MFH and prostatic stromal sarcoma. Presentation can include urinary obstruction frequency, urgency, hematuria, perineal and/or rectal, pain, constipation, burning on ejaculation, and constitutional symptoms. The diagnosis of prostate sarcoma was usually established with ultrasound-guided biopsy or transurethral resection, and PSA is usually normal. Multimodality therapy using surgery RP, radical cystectomy, pelvic exenteration with pre- or postoperative radiation and pre- or postoperative chemotherapy have been used with no standard of care. Doxorubicin-based combinations with agents such as cyclophosphamide, ifosfamide, vinblastine, or vincristine have been reported with mixed results.
REFERENCES
Pace G, Pomante R, Vicentini C. Sarcoma of prostate: Case report and review of the literature. Arch Ital Urol Androl. 2010;82(2):105–108.
Sexton WJ, Lance RE, Reyes AO, et al. Adult prostate sarcoma: The MD Anderson cancer center experience. J Urol. 2001;166(2):521–525.
PROSTATE CANCER, MUCINOUS ADENOCARCINOMA
DESCRIPTION These very rare tumors are histopathologically defined as having lakes of extracellular mucin comprising at least 25% of the primary prostate tumor. They generally are considered to have a slightly worse prognosis than typical adenocarcinoma of the prostate but other literature states the behavior is similar to adenocarcinoma of the prostate with no statistically significant difference in biochemical failure or survival. They can be hormonally refractory, and bone metastasis are common. Radiation and/or surgery can be considered.
REFERENCES
Ro JY, Grignon DJ, Ayala AG, et al. Mucinous adenocarcinoma of the prostate: Histochemical and immunohistochemical studies. Hum Pathol. 1990;21:593–600.
Lane BR, Magi-Galluzzi C, Reuther AM, et al. Mucinous adenocarcinoma of the prostate does not confer poor prognosis. Urology. 2006;68(4):825–830.
PROSTATE CANCER, PREVENTION (CHEMOPREVENTION)
DESCRIPTION Numerous medications and nutraceuticals, including selenium, statins, and green teas, have been evaluated for the prevention of prostate cancer, but the most notable remain the 5α-reductase inhibitors (5 ARIs) finasteride and dutasteride. The Prostate Cancer Prevention Trial (PCPT) using finasteride demonstrated an almost 25% reduction in the incidence of prostate cancer but a slightly increased incidence of higher Gleason score cancers. Some have hypothesized that this may be due to selective inhibition of low-grade cancers along with a smaller prostate size resulting in less sampling error and better detection of higher-grade cancers already present. This is supported by whole-mount correlation from RP specimens. The REduction DUtasteride of prostate Cancer (REDUCE) trial using dutasteride (a dual 5α-reductase inhibitor) reported a 23% reduction in prostate cancer in high-risk men with a slight increase in high-grade cancers. The large SELECT trial using selenium and vitamin E was stopped prematurely because it did not appear that either agent alone or in combination reduced the risk of prostate cancer. In 2011, updated trial data showed that the men taking vitamin E had a 17% increased risk of prostate cancer compared to men taking the placebo. In 2014, an analysis showed that men who started the trial with high levels of selenium, as assessed by measures of selenium in their toenail clippings, doubled their risk of developing a high-grade prostate cancer by taking selenium supplements and men who had low levels of selenium at the start of the trial doubled their risk of high-grade prostate cancer by taking vitamin E. Trial sponsors recommended that men avoid supplementation with these agents.
In 2008, ASCO and the AUA 2008 issued the following Clinical Practice Guidelines:
• Asymptomatic men, PSA <3.0 ng/mL who are regularly screened or anticipate undergoing annual PSA screening may benefit from a discussion of risks and benefits of 5-ARIs for 7 yr for the prevention of prostate cancer.
• Men taking 5-ARIs for LUTS should also discuss risks and benefits.
• A reduction of PSA by 50% at 12 mo is expected in men on 5-ARIs; the panel did not recommend a specific cut-point to trigger a biopsy for men taking a 5-ARI.
However at the present time there is no approved agent to prevent the development of prostate cancer.
REFERENCES
Kramer BS, Hagerty KL, Justman S, et al. Use of 5α-reductase inhibitors for prostate cancer chemoprevention: American Society of Clinical Oncology/American Urological Association 2008 Clinical Practice Guideline. J Urol. 2009;181:1642–1657.
Parnes HL, Brawley OW, Minasian LM, et al. Phase III prostate cancer chemoprevention trials. Recent Results Cancer Res. 2014;202:73–77.
Selenium And Vitamin E Cancer Prevention Trial (SELECT) http://www.cancer.gov/newscenter/qa/2008/selectqa, Accessed March 6, 2014.
PROSTATE CANCER RISK CALCULATORS
DESCRIPTION Usually in the form of tables or nomograms, these are predictive instruments developed to aid clinicians and patients alike in objectively assessing different aspects of prostate disease throughout its various stages of diagnosis and treatment. Most calculators are available online, with interactive modules that facilitate their incorporation into clinical practice (see below).
REFERENCES
Caras RJ, Sterbis JR. Prostate cancer nomograms: a review of their use in cancer detection and treatment. Curr Urol Rep. 2014;15(3):391.
Eifler JB, Feng Z, Lin BM, et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int. 2013;111(1):22–29.
PROSTATE CANCER, RISK STRATIFICATION (D’AMICO CLASSIFICATION)
DESCRIPTION One challenge presented by prostate cancer is choosing the appropriate therapy based on the risk of disease progression. It is often useful to assign a relative risk to an individual. These risk groups were established from literature and based on known prognostic factors: PSA level, biopsy Gleason score, and 1992 AJCC T staging. 1 typical system, commonly referred to as the D’Amico classification, is described here. Note that this is risk of PSA progression posttherapy and not overall or disease-specific survival:
• Low risk: Stages T1c and T2a, PSA level of ≤10 ng/mL, and biopsy Gleason score of ≤6 (<25% PSA progression at 5 yr post therapy)
• Intermediate risk: PSA levels ≤10–20 ng/mL, biopsy Gleason score of 7, or AJCC clinical stage T2b (25–50% PSA progression at 5 yr post therapy)
• High risk: T2c disease or a PSA level >20 ng/mL or a biopsy Gleason score of ≥8 (>50% PSA progression at 5-yr post therapy)
REFERENCE
D’Amico AV, Whittington R, Malkowicz SB, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998;280(11):969–974.
PROSTATE CANCER, SECONDARY HORMONAL THERAPY
DESCRIPTION In the setting of primary ADT failure (rising PSA with castrate level of testosterone considered to be a serum testosterone of <50 ng/dL), is called castrate refractory prostate cancer (CRPC). A variety of strategies involving so-called “secondary hormonal therapy” can be applied. It should be noted that in all cases, castrate levels of testosterone should be maintained through the use of agents such as LHRH analogs while these additional therapies are applied. Common secondary hormonal therapies include:
• Antiandrogen withdrawal (See Section II: “Antiandrogen Withdrawal Syndrome [Flutamide Withdrawal Syndrome].”)
• Administration of antiandrogens (eg, bicalutamide, nilutamide, flutamide)
• Administration of ketoconazole (ketoconazole has a weak and nonspecific inhibitory affect on several enzymes involved in androgen synthesis and has been widely used in combination with hydrocortisone for the treatment of CRPC)
• Estrogens, such as DES
To date, none of these agents have demonstrated a prolongation in overall survival in the prechemotherapy setting. The use of secondary hormonal manipulation is decreasing with the approval of multiple newer medications for CRPC. In the presence of metastasis (mCRPC) abiraterone acetate with low-dose prednisone and enzalutamide prolong overall survival among men with metastatic CRPC who have been previously treated with docetaxel. Abiraterone acetate can be considered for men with metastatic CRPC the predocetaxel metastatic CRPC setting. Other new agents for mCRPC include sipuleucel-T, cabazitaxel and radium 223. (See also Section I: “Prostate Cancer, Rising PSA Following Androgen Ablation [Castrate Refractory Prostate Cancer, CRPC, mCRPC]”.)
REFERENCES
Al-Asaaed S, Winquist E. Secondary hormonal manipulation in castration resistant prostate cancer. Can J Urol. 2014;21(Suppl 1):37–41.
NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer V.1.2014. Available at www.nccn.org, Acessed March 25, 2014.
PROSTATE CANCER, SMALL CELL (NEUROENDOCRINE)
DESCRIPTION A rare subtype of prostate malignancy that has a rapidly fatal course. Considered to be a variant of Gleason 5 adenocarcinoma of the prostate, it is identical to small cell carcinomas of the lung and has neuroendocrine (small cell, oat cell) differentiation. In 50% of the cases, the tumors are mixed small cell carcinoma with adenocarcinoma. Histologically, prostatic SCCs of the prostate are part of a spectrum of anaplastic tumors of the prostate and are similar to SCCs of the lungs. Neuroendocrine cells are identified by special staining (ie, neuron-specific enolase [NSE] or other markers). It should be noted that the normal prostate does have some neuroendocrine positivity, but it is limited and can only be detected by staining. About 10% of acinar adenocarcinomas of the prostate can have Paneth-like cells (large eosinophilic cells) that are neuroendocrine, and it is recognized that adenocarcinoma of the prostate that is not classified as neuroendocrine can have some patchy cells that stain as neuroendocrine cells. Large numbers of Gleason 5 cells in a prostate sample should prompt a neuroendocrine staining workup of the sample. Tumors can exhibit a spectrum of differentiation, with a carcinoid-like pattern (low-grade neuroendocrine carcinoma) to the small cell undifferentiated type (oat cell), the highest grade of neuroendocrine tumor. Immunohistochemically, these cells can stain for serotonin, calcitonin, ACTH, hCG, and other markers. Most of these small cell tumors do not produce detectable levels of hormones but sometimes can produce detectable levels in the serum. They may also express and stain for PSA and acid phosphatase, but pure small cell carcinoma usually does not stain for PSA. The clinical behavior of small cell prostate carcinomas is characterized by extensive local disease, visceral disease, and low PSA levels despite large metastatic burden. At diagnosis, 70% of patients have metastatic disease, and visceral metastases are common (ie, liver). The average survival is <1 yr. Androgen receptor–positive tumors have a worse prognosis than do tumors that do not express the receptor median survival (10 mo vs. 30 mo). Diagnosis is made by TRUS biopsy, symptoms associated with metastasis, and elevated LFTs and CEA.
SYNONYMS
• Small cell anaplastic carcinoma of the prostate (SCCP)
• Oat cell carcinoma of the prostate
• Neuroendocrine prostate cancer
• Carcinoid of the prostate
TREATMENT
• These tumors respond poorly to androgen ablation, but this should be attempted.
• Surgery and/or radiation therapy may provide local control.
• Chemotherapy with agents such as VP-16 and cisplatinum have some activity.
REFERENCE
Nadal R, Schweizer M1, Kryvenko ON, et al. Small cell carcinoma of the prostate. Nat Rev Urol. 2014;11(4):213–219.
PROSTATE CANCER, SQUAMOUS AND ADENOSQUAMOUS
DESCRIPTION A rare lesion that can arise in patients infected with Schistosoma haematobium. It can be confused with more common conditions, such as squamous metaplasia of the prostate due to infarction, radiation, and hormonal therapy. Pure primary SCC of the prostate does not respond to estrogen therapy, and it does not develop elevated serum PSA or PAP levels with metastatic disease. Bone metastases are osteolytic instead of osteoblastic. Median survival is about 14 mo.
REFERENCE
Bostwick DG, Meiers I. Neoplasms of the prostate (Chapter 9). In: Bostwick DG, ed. Urologic Surgical Pathology. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2008:512.
PROSTATE HEALTH INDEX (PHI) AND [–2] proPSA
DESCRIPTION The Beckman Coulter Prostate Health Index (phi) is a mathematical combination of total PSA (tPSA), free PSA (fPSA) and [–2] proPSA (an isoform of PSA). The mathematical equation is: ([–2] proPSA/fPSA) × (√tPSA). The phi has been shown to have a higher PCa predictive value than both total PSA and free PSA. The measurement of %[–2] proPSA improves the accuracy of prostate cancer detection in comparison with PSA or % of PSA, particularly in the group of patients with PSA between 2 μg/L and 10 μg/L. The phi may be able to reduce the number of unnecessary biopsies, maintaining a high cancer detection rate. Published results also showed that %[–2] proPSA and phi are related to the aggressiveness of the tumor.
REFERENCES
Lazzeri M, Haese A, de la Taille A, et al. Serum isoform [-2]proPSA derivatives significantly improve prediction of prostate cancer at initial biopsy in a total PSA range of 2–10 ng/ml: A multicentric European study. Eur Urol. 2013;63(6):986–994.
Filella X, Giménez N. Evaluation of [-2] proPSA and Prostate Health Index (phi) for the detection of prostate cancer: A systematic review and meta-analysis. Clin Chem Lab Med. 2013;51(4):729–739.
PROSTATE URETHRAL ANGLE
DESCRIPTION The prostatic urethra runs through the prostate from the base to the apex, making an anterior angle of ~35° at the proximal verumontanum. In men with prostate hyperplasia this angle tends to be >35°. However, men without hyperplasia can also have an increased prostatic urethral angle. On cystoscopic exam, an increased prostatic urethral angle (PUA) is often noted as a high bladder neck in men without prostatic enlargement. In preliminary clinical studies, the PUA was inversely associated with the urinary flow rate.
REFERENCE
Cho KS, Kim JH, Kim DJ, et al. Relationship between prostatic urethral angle and urinary flow rate: Its implication in benign prostatic hyperplasia pathogenesis. Urology. 2008;71:858–862.
PROSTATE, BASAL CELL HYPERPLASIA
DESCRIPTION Basal cell hyperplasia is important in that it is commonly associated with BPH and may sometimes be mistaken for prostate cancer. The prostatic epithelium consists of 3 major cell types: Epithelial, basal, and neuroendocrine cells. The basal cells are small and round with a scant cytoplasm and dark nuclei. These cells are less differentiated and almost devoid of secretory products; they are located between the secretory cells and rest on the basement membrane. Basal cells are negative for PSA and PAP. Typical basal cell hyperplasia consists of a proliferation of basal cells ≥2 cell layers thick at the periphery of prostate glands and acini. Basal cell proliferation in the prostate gland exhibits a spectrum from focal basal cell hyperplasia in the setting of nodular hyperplasia to a florid adenoid basal cell tumor. Many confusing names have been used in the literature fet alization of prostate, embryonal hyperplasia, basal cell tumor, basal cell adenoma, BC, adenoid cystic carcinoma. The differential diagnosis includes transitional cell hyperplasia, squamous metaplasia, urothelial carcinoma (TCC) of the prostate, and adenocarcinoma of prostate.
REFERENCE
Bhat S, Thomas A, Nazar M, et al. Basal cell hyperplasia of prostate-an entity a urologist must know. Indian J Urol. 2000;17:61–62.
PROSTATE, BENIGN ENLARGEMENT (BENIGN PROSTATE ENLARGEMENT [BPE])
DESCRIPTION Benign prostatic enlargement (BPE) is used when there is gland enlargement and is usually a presumptive diagnosis based on the size of the prostate. This term differs from BPH which is reserved for the histologic pattern it describes. A patient may have LUTS with or without BPE. (See also Section I: “Bladder Outlet Obstruction [BOO],” “Prostate, Benign Hyperplasia/ Hypertrophy [BPH]” and Section II: “Prostate, Benign Obstruction (Benign Prostatic Obstruction [BPO]).”)
REFERENCE
Abrams P, Chapple C, Khoury S, et al. Evaluation and treatment of lower urinary tract symptoms in older men. J Urol. 2009;181:1779–1778.
PROSTATE, BENIGN OBSTRUCTION (BENIGN PROSTATIC OBSTRUCTION [BPO])
DESCRIPTION BPO is used when obstruction has been proven by pressure–flow studies, or is highly suspected from flow rates and if the gland is enlarged. This is different from bladder outlet obstruction, the generic term for all forms of obstruction to the bladder outlet (eg, urethral stricture) including BPO. (See also Section I: “Bladder Outlet Obstruction [BOO]”, “Prostate, Benign Hyperplasia/Hypertrophy [BPH]” and Section II: “Prostate, Benign Enlargement (Benign Prostate Enlargement [BPE]).”)
REFERENCE
Abrams P, Chapple C, Khoury S, et al. Evaluation and treatment of lower urinary tract symptoms in older men. J Urol. 2009;181:1779–1787.
PROSTATE CALCULI
DESCRIPTION Calculi are more common in older males and are rarely found in children. They usually occur in clusters and are associated with other disease processes. Often found in a dilated prostatic utricle. They are generally asymptomatic but may cause symptoms such as decreased urinary stream, prostatism, and lower back pain; they are a rare source of chronic bacterial prostatitis. Calculi may form secondary to calcification of the corpora amylacea and simple precipitation of prostatic secretions.
TREATMENT
• Generally none
• Transurethral resection with laser lithotripsy as needed if markedly symptomatic
REFERENCE
Klimas R, Bennett B, Gardner WA Jr. Prostatic calculi: A review. Prostate. 1985;7(1):91–96.
PROSTATE, FEMALE
DESCRIPTION A coined radiologic expression that refers to an impression at the base of the female bladder seen on excretory urography or cystogram. The impression resembles an enlarged prostate in the male and can be caused by urethral diverticulum, benign and malignant tumors of the anterior vaginal wall, urethral neoplasm, and repair of SUI. Anatomically Skene paraurethral glands and ducts are considered homologous to the male prostate and immunohistochemical studies demonstrate expression of PSA and prostate-specific acid phosphatase (PSAP) in these paraurethral glands and ducts.
REFERENCES
Amis ES, Newhouse JH, eds. Essentials of Uroradiology. 1st ed. Boston: Little, Brown; 1991:289.
Zaviaĉiĉ M, Ablin R. The female prostate. J Natl Cancer Inst. 1998;90(9):713.
PROSTATE, HEMATURIA
DESCRIPTION Hematuria attributed to bleeding from the prostate is a diagnosis of exclusion. Patients should have an appropriate workup according to the guidelines provided by the AUA. Older patients with larger, more vascular prostates are more susceptible and can be managed with 5α-reductase inhibitors or transurethral resection if bleeding is refractory to medical therapy. Most often idiopathic, bleeding can also be iatrogenic after prostate biopsy and endoscopic urologic procedures or due to locally advanced prostate cancer late manifestation.
TREATMENT
• 5α-reductase inhibitors (1st-line therapy for troublesome benign prostatic hypertrophy bleeding)
• Intravesical alum, silver nitrate, and formalin (2nd-line therapy)
• Transurethral resection or vaporization of the prostate
REFERENCE
Rastinehad AR, Ost MC, VanderBrink BA, et al. Persistent prostatic hematuria. Nat Clin Pract Urol. 2008;5(3):159–165.
PROSTATE, INFARCTION
DESCRIPTION The etiology of prostatic infarction is still unclear, although it has been linked to prostate hyperplasia. Histologic findings include infraction of prostatic epithelium, with hemorrhage and neutrophils in the intervening stroma. Recent infarcts generally do not have squamous metaplasia, whereas older ones do. Typically, the infarctions are multiple and located in the central and middle concentric zones of the middle 3rd of the prostate. Prostatic infarction may elevate PSA levels.
REFERENCE
Brawn PN, Foster DM, Jay DW, et al. Characteristics of prostatic infarcts and their effect on serum prostate-specific antigen and prostatic acid phosphatase. Urology. 1994;44(1):71–74.
PROSTATE, MASSAGE
DESCRIPTION Repetitive prostatic massage is not a new tool in the urologists’ armamentarium. It can be used to localize lower UTIs or as a therapeutic modality. Once the most popular therapeutic maneuver used to treat prostatitis, it was abandoned as primary therapy almost 30 yr ago. Based on experience reported outside North America and anecdotal experiences of some patients and their physicians, some believe it has a role in certain forms of prostatitis, such as chronic non-bacterial prostatitis or chronic pelvic pain syndrome (CPPS). The prostate is massaged from the lateral border to the medial aspect on each side, from base to apex. Firm pressure is necessary to express prostatic fluid into the urethra. A sterile container should be held by the patient at the meatus to capture the expressed prostatic fluids. The test is contraindicated in acute bacterial prostatitis. (See also Section II: “Attentive Digital Rectal Exam [DRE]” “Expressed Prostatic Secretions [EPS]” and “Stamey Test [Three-glass test, Four-glass tests, Meares-Stamey Test].”)
REFERENCE
Nickel JC, Alexander R, Anderson R, et al. Prostatitis unplugged? Prostatic massage revisited. Techniques Urol. 1999;5(1):1–7.
PROSTATE STENTS (UROLUME AND SPANNER)
DESCRIPTION The UroLume stent is a woven tubular mesh designed to treat obstructions secondary to BPH, recurrent bulbar urethral strictures (RBUS), or detrusor external sphincter dyssynergia (DSD or DESD) long-term. The cylinder is made of high strength, impact grade, super alloy wire. It has the potential to expand to a diameter of 14 mm (42F) and is available in lengths of 1.5, 2.0, 2.5, and 3.0 cm. UroLume is provided preloaded in a sterile, disposable delivery instrument. The outer diameter of the tool is 22F along the shaft and 24F at the tapered tip. Numerous problems have plagued the stent, including short-term problems with irritative voiding symptoms, painful ejaculation, and stent migration. Long-term problems include stent encrustation and ingrowth of epithelial tissue causing restenosis. It may have a role in patients who present with urinary retention and are considered at high risk for surgical intervention, but it should otherwise not be used for patients who can tolerate a surgical procedure.
The Spanner stent is similar to a Foley catheter in that it has a proximal port to drain urine, a balloon that resides at the bladder neck to prevent migration, and a stent that spans the prostatic urethra. Considered a temporary device, it may have a role in temporary management of bladder outlet obstruction following procedures such as brachytherapy or TUMT. Other stents such as the Memotherm (Angiomed Gmbh & Co.) are available outside the United States. EAU considers prostate stents are an alternative to catheterization for men unfit for surgery (Image ).
REFERENCES
Vanderbrink BA, Rastinehad AR, Badlani GH. Prostatic stents for the treatment of benign prostatic hyperplasia. Curr Opin Urol. 2007;17(1):1–6.
Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2013;64(1):118–140.
Goh MH, Kastner C, Khan S, et al. First experiences with the SpannerTM temporary prostatic stent for prostatic urethral obstruction. Urol Int. 2013;91(4):384–390.
PROSTATIC ACID PHOSPHATASE (PAP)
DESCRIPTION Human PAP is a glycoprotein dimer of 102,000 MW. Its activity is much greater in the prostate than in any other tissue. PAP is not prostate-specific, and can be found in other tissues. Historically, PAP was used as a serum marker for the staging and detection of prostate cancer before the discovery of prostate-specific antigen (PSA). Although enzymatic elevation of PAP is associated with advanced prostate cancer, other causes of an elevated PAP are possible, including liver, skelet al, and renal disease. PAP is the primary target for the prostate cancer immunotherapy sipuleucel-t.
REFERENCES
Romas M, Kwan DJ. Prostatic acid phosphatase. Urol Clin N Am. 1993;20:581–588.
Gomella LG, Gelpi-Hammerschmidt F, Kundavram C. Practical guide to immunotherapy in castration resistant prostate cancer: the use of sipuleucel-T immunotherapy. Can J Urol. 2014;21(Suppl 1):48–56.
PROSTATIC URETHRAL POLYPS
DESCRIPTION Urethral polyps are rare abnormalities in male children who present with hematuria or obstructive symptoms. Strangury (slow and painful urination) may be seen, with large lesions on a long stalk. The diagnosis is best confirmed by voiding cystourethrography. These polyps are nearly always in the prostatic fossa, although anterior urethral polyps have been reported. These are benign lesions and are not related to the polypoid masses of sarcoma botryoides.
TREATMENT
Transurethral excision of the polyps
REFERENCE
Raviv G, Leibovitch I, Hanani J, et al. Hematuria and voiding disorders in children caused by congenital urethral polyps. Principles of diagnosis and management. Eur Urol. 1993;23:382–385.
PROSTATIC UTRICLE ANOMALIES
DESCRIPTION The prostatic utricle is a small slitlike orifice found at the apex of the verumontanum. The utricle has been considered by most to be a remnant of the fused caudal ends of the müllerian ducts while others propose the origin is from the urogenital sinus. The most common anomaly associated with the prostatic utricle is a prostatic utricle cyst. Can be associated with unilateral renal agenesis, hypospadias, and cryptorchidism. Prostatic utricle cysts always arise from the level of the verumontanum and are always in the midline. Prostatic utricle cysts have been associated with LUTS, infertility, infection, stone formation, hypospadias, recurrent epididymitis, and neoplastic degeneration. However, prostatic utricle cysts are often asymptomatic (found in up to 4% of newborns and 1% of adults). The incidence of prostatic utricle cyst is 11–14% in association with hypospadias or intersex anomalies and up to 50% of perineal hypospadias. Rarely these may contain cancer (clear cell or squamous cell carcinoma). Differential diagnoses include müllerian duct cysts, bladder diverticulum, teratoma, seminal vesicle cyst, epididymal cyst, and wolffian duct cyst. Prostatic utricle cysts can be diagnosed on VCUG or trans rectal ultrasound.
Stones may also be found in the dilated prostatic utricle. These are considered to belong to the category of prostatic pseudocalculi (not caused by abnormal urine composition, but from deciduous epithelial cells of enlarged prostatic utricle). (See also Section II: “Müllerian Duct Remnants and Persistent Müllerian Duct Syndrome [PMDS] and Prostatic Utricle Calcification.”)
SYNONYMS
• Müllerian duct cyst (however müllerian duct cysts can be found anywhere along the path of müllerian duct regression, from the prostatic utricle into the scrotum whereas prostatic utricle cysts are always midline)
• Utricular cysts
• Utriculoceles
• Mega-utricles
TREATMENT
• Transurethral unroofing, endoscopic incision
• Surgical excision (suprapubic, transvesical, perineal, or laparoscopic)
REFERENCES
Priyadarshi V, Singh JP, Mishra S, et al. Prostatic utricle cyst: A clinical dilemma. APSP J Case Rep. 2013; 4(2):16.
Song NH, Wu HF, Xu NC, et al. The composition and structure of stones in enlarged prostatic utricles (EPU). J Androl. 2012;33(1):45–49.
PROSTATIC UTRICLE CALCIFICATION
DESCRIPTION The prostatic utricle is a remnant of the müllerian ducts. It is a small indentation located at the apex of the verumontanum. Enlargement of the prostatic utricle (EPU) is a rare abnormality which is associated with hypospadias and is the result of insufficient androgenic stimulation. The incidence of stones in EPU is unknown. 1 study found stones in 8 patients out of 44 (18.2%). Their size ranged from 3–18 mm and they were all composed of hydroxyapatite (HAP) crystal. Treatment includes transurethral utricle fenestration and stone removal. (See also Section II: “Prostatic Utricle Anomalies” and “Calcification, Prostate" (Image ).)
REFERENCE
Song NH, Wu HF, Xu NC, et al. The composition and structure of stones in enlarged prostatic utricles (EPU). J Androl. 2012;33(1):45–49.
PROSTATITIS, ASYMPTOMATIC INFLAMMATORY (NIH IV)
DESCRIPTION A type of nonbacterial prostatitis that is not associated with any specific symptom but is seen as inflammation on prostate biopsy. No specific treatment is necessary. (See Section II: “Prostatitis, NIH Classification.”)
REFERENCE
Habermacher GM, Chason JT, Schaeffer AJ. Prostatitis/chronic pelvic pain syndrome. Annu Rev Med. 2006;57:195–206.
PROSTATITIS, MYCOTIC (FUNGAL PROSTATITIS)
DESCRIPTION A type of granulomatous prostatitis caused by fungi and typically associated with systemic mycosis or immunocompromised hosts. Fungal infections can include blastomycosis, coccidiomycosis, cryptococcosis, histoplasmosis, and Candida. Diagnosis is based on prostatic histology and culture results. For systemic therapy, see the specific causative agent. (See Section I: “Fungal Infections, Genitourinary” and “Prostatitis, Granulomatous.”)
SYNONYM
Fungal prostatitis
REFERENCE
Schwartz J. Mycotic prostatitis. Urology. 1982;19:1–5.
PROSTATITIS, NIH CLASSIFICATION SYSTEM
DESCRIPTION A classification proposed by an NIH working group that clearly defines the different types of prostatitis in order to improve the diagnosis and management of the disease. (See Section I: “Prostatitis, Acute, Bacterial [NIH I],” “Prostatitis, Chronic, Bacterial [NIH II],”, “Prostatitis, Chronic Nonbacterial, Inflammatory & Noninflammatory [NIH CP/CPPS III A and B]” and Section II: “Prostatitis, Asymptomatic Inflammatory [NIH IV].”) For an explanation of EPS (expressed prostatoc secretions) and VB3 (voided bladder urine 3) see Section II: Stamey Test (Three-glass Test, Four-glass Tests, Meares-Stamey Test)
• Category I: Acute bacterial prostatitis; acute infection of the prostate gland
• Category II: Chronic bacterial prostatitis; recurrent infection of the prostate
• Category III: Chronic non-bacterial prostatitis/CPPS; no demonstrable infection
– Category IIIA: Inflammatory CPPS; WBCs in semen/EPS VB3
– Category IIIB: Noninflammatory CPPS; no WBCs in semen/EPS VB3
• Category IV: Asymptomatic inflammatory prostatitis; no symptoms
REFERENCE
Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236–237.
PROSTATITIS, STRESS
DESCRIPTION Classically defined as a subset of chronic abacterial noninflammatory prostatitis/prostatodynia in which a pattern of excessive tension could be identified as a trigger of the syndrome. Symptoms usually responded to anxiolytic agents or behavioral modifications. No longer considered an appropriate term in the NIH Prostatitis classification system.
REFERENCE
Miller HC. Stress prostatitis. Urology 1988;32:507.
PROSTATITIS, TUBERCULOUS
DESCRIPTION TB of the prostate is rare, and in many cases, it is diagnosed incidentally after a transurethral resection in the prostate chips. Tuberculous prostatitis results from hematogenous dissemination, with an incidence of 10% with men in TB. Symptoms are nonspecific. Irritative voiding may be the only complaints; other complaints include perineal pain and infertility. On exam, the prostate may be hard, irregular, and nodular. On labs, urine analysis can demonstrate microscopic hematuria or sterile pyuria. Acid-fast bacilli staining of urine and semen has a sensitivity of only 52%; however, culture can take up to 8 wk. A transrectal ultrasound can demonstrate collections or abscess, and an intravenous urogram (IVU) or CT Urogram (CTU) should be done because 72% of patients with prostatic TB have renal TB.
TREATMENT
• Hospitalization is usually unnecessary.
• Transurethral resection of the prostate in patients with obstructive symptomatology is reasonable.
• Medication includes a 3-drug regimen of isoniazid, pyrazinamide, and either ethambutol or streptomycin.
• In complicated cases, 9–12 mo therapy may be required. A negative prostatic biopsy to document successful treatment is recommended.
REFERENCE
Cek M, Lenk S, Naber KG, et al. EAU guidelines for the management of genitourinary TB. Eur Urol. 2005;48(3):353–362.
PROSTATODYNIA
DESCRIPTION Classically described as a symptom complex of multiple complaints including pain in the perineum, lower back, or upon ejaculation; slow stream; and hesitancy. Patients exhibit no evidence of prostatic inflammation. Dysuria, frequency, and systemic signs are usually absent. This term is not currently considered to be appropriate and has been replaced by the designation chronic pelvic pain syndrome or CPPS NIH Category III Chronic Abacterial Prostatitis. (See also Section I: “Prostatitis, Chronic Nonbacterial, Inflammatory & Noninflammatory [NIH CP/CPPS III A and B].”)
REFERENCE
Orland SM, Hanno PM, Wein AJ. Prostatitis, prostatosis, and prostatodynia. Urology. 1985;25(5):439–459.
PROSTHESIS, INFECTED PENILE
DESCRIPTION A dreaded complication of penile prosthesis implantation. Rates of infection range from 1–8%; risk factors include spinal cord injury (SCI), diabetes mellitus especially (if poorly controlled with HgbA1C >11.5%), history of UTI, and multiple prosthesis operations. Infection usually occurs within 6 mo after implantation, but delayed infection is also reported. The most common symptom is persistent pain; patients also present with erythema, drainage, or fever. Causes of infection are Staphylococcus epidermidis (most common); gram-negative rods and yeast are also common. In the presence of an infection the implant and all foreign material should be removed. A salvage procedure, during which the wound is thoroughly washed with antiseptic solutions after device removal and placement of a new implant during the same procedure, has a high success rate and is becoming a popular approach. The alternative is device removal with return at a later date for placing a new implant, which entails a more difficult corporal dilation, and the resulting erection is noticeably shorter. (See also Section I: “Penile Prosthesis Problems [Infection/Extrusion/Malfunction] and Section II: “Mulcahy Protocol.”)
TREATMENT
• Surgical removal
• Irrigation and antibiotic treatment
• Immediate salvage procedures with surgical removal
• Washout and immediate replacement have reported with good results: Vigorous intraoperative irrigation with 4 different solutions, including vancomycin; immediate reimplantation of a new inflatable penile prosthesis; and postoperative outpatient antibiotics, with oral ciprofloxacin or IV vancomycin or cefazolin.
REFERENCE
Mulcahy JJ. Current approach to the treatment of penile implant infections. Ther Adv Urol. 2010; 2(2): 69–75.
PRURITUS, EXTERNAL GENITALIA, MALE
DESCRIPTION The anogenital area is a common location for pruritic complaints in men and women. Itching can precede the appearance of a rash or other lesion. When the itching results in red, weeping skin with crusts, it is often called eczematous dermatitis. Pruritus scroti is a historic term for scrotal itching. The differential diagnosis of itching of the male external genitalia includes:
• Allergic reactions (allergic dermatitis)
• Cancer: Penile, scrotal, extra-mammary Paget disease (intraepidermal adenocarcinoma, found in areas with apocrine sweat glands).
• Candidal infection
• Chemical irritants: Detergents, fabric softeners, soaps, creams, ointments and sexual lubricants
• Dermatologic conditions: Seborrheic dermatitis, psoriasis, eczema (atopic dermatitis), lichen simplex chronicus (LSC)
• Fixed drug reaction
• HIV: Pruritus is 1 of the most frequent symptoms encountered in HIV infection and can even be the 1st clinical symptom
• Infestations: Pubic lice (“crabs”), scabies
• Nutritional deficiencies: Riboflavin, nicotinic acid
• Red scrotum syndrome possibly due to steroid abuse
• Sexually transmitted infections: Genital herpes
• Sunitinib toxicity
• Systemic illnesses: Diabetes mellitus, renal failure
• Tinea cruris: Also known as ringworm of the groin
Some patients manifest itching with or without a demonstrable local factor. The skin may appear normal or demonstrate excoriation (lichenification skin thickening) from rubbing, or both. These patients tend to have chronic illness (eg, diabetes) or depression with no pathogen identified. When treating anogenital pruritus, topic irritants and potential sensitizers must be eliminated and cleansing and toilet habits should be addressed. Treatment of the specific pathogen is essential. A short course of a high-potency topical steroid usually brings relief. Sedating antihistamines may limit nighttime symptoms. Some patients may require psychotropic agents for adequate sedation. Antidepressants may be required in patients refractory to standard treatment or those with underlying psychiatric disorders. (See also Section II: “Scabies, Urologic Considerations.”)
REFERENCES
Johnston G, Sladden M. Scabies: diagnosis and treatment. BMJ. 2005;331(7517):619–622.
Krishnan A, Kar S. Scrotal Dermatitis - Can we consider it as a Separate Entity? Oman Med J. 2013;28(5):302–305.
PSA, AGE-ADJUSTED (SEE SECTION II “PSA, GENERAL CONSIDERATIONS”)
PSA BOUNCE (SEE SECTION II “PSA, GENERAL CONSIDERATIONS”)
PSA COMPLEXED (SEE SECTION II “PSA, GENERAL CONSIDERATIONS”)
PSA DENSITY (PSAD) (SEE SECTION II “PSA, GENERAL CONSIDERATIONS”)
PSA FAILURE, ASTRO AND PHOENIX DEFINITIONS (SEE SECTION II “PSA, GENERAL CONSIDERATIONS”)
PSA, FREE AND TOTAL (SEE SECTION II “PSA, GENERAL CONSIDERATIONS”)
PSA, GENERAL CONSIDERATIONS AND PSA DERIVATIVES
DESCRIPTION
• PSA Background:
– PSA was initially approved by the FDA as prostate cancer monitoring test in 1986 and as an aid for prostate cancer detection in 1994 in combination with DRE. PSA is a glycoprotein secreted by both malignant and benign prostate cells. PSA functions as a serine protease with the primary function to split the seminal vesicle proteins to liquefy the seminal coagulum. PSA is expressed in nearly all prostate cancers, although its level of expression on a per cell basis, especially in poorly differentiated prostate cancers, is actually lower than in normal prostate epithelium. The disruption of the basement membrane of prostate cancer allows more PSA to “leak” into the circulation.
• PSA Physiology:
– PSA is a kallikrein that is also known as human glandular kallikrein 3 (hK3). The kallikreins are a type of enzymes (serine proteases), that cleave protein peptide bonds.
– PSA is produced as a proenzyme (proPSA) by the secretory cells of the prostate acini and secreted into the lumen, where the proPSA is cleaved to enzymatically active PSA.
– PSA circulates in serum in complexed forms (bound to protease inhibitors) or in un-complexed (free or unbound) forms
– Active PSA undergoes proteolysis to form inactive PSA, of which a small portion enters the bloodstream in an unbound state (free PSA).
10–30% of PSA is free in the serum and composed of various PSA isoforms. It is composed of 3 distinct isoforms: ProPSA, BPSA and iPSA (for “intact PSA” which decreases with cancer).
The precursor form of PSA (pro-PSA), especially its truncated (-2) form is significantly increased in PCa patients.
– Active PSA can also enter the bloodstream where it is rapidly bound and inactivated (complexed) by protease inhibitors (alpha-1-antichymotrypsin [ACT] and alpha-2-macroglobulin). Most of the PSA in serum exists as a complex with ACT.
– With prostate cancer the disrupted basal membrane allows proPSA and several truncated PSA isoforms direct access to the circulation. This PSA
“leaking” into the blood has a larger fraction of the PSA produced by malignant tissue escaping proteolytic processing (ie, activation of proPSA to active PSA and degradation of active PSA to inactive PSA).
– In men with a normal prostate (no cancer or infection), the majority of free PSA in the serum reflects protein inactivated by internal proteolytic cleavage. In contrast, the cleaved fraction is relatively decreased in prostate cancer. Thus, the percentage of free or unbound PSA is lower in the serum of men with prostate cancer (and conversely, the amount of complexed PSA is higher) compared with those without cancer.
– These observations have resulted in the use of the ratio of free to total PSA and complexed PSA (cPSA) as a means of distinguishing prostate cancer and BPH.
• PSA Collection: The PSA blood sample should be centrifuged, and the serum separated in 2–3 hr. If the assay is not performed within the next 2–3 hr, the serum should be frozen.
• PSA Basic Clinical Considerations: There is a vast amount of clinical data available to guide the clinicians in the use of PSA in patient care. This section highlights some of the published PSA clinical data in a highly annotated form.
– Routine PSA blood testing refers to Total PSA and is reported in ng/mL; SI units mcg/L are identical.
– Half-life: of PSA is 2.2 days.
– PSA measured repeatedly can vary due to intrinsic biologic and assay variability (6–14%).
– For serial PSA measurements using the same lab with the same analytic method is recommended.
– No diurnal variation in PSA levels exists.
– Increased BMI is associated with lower PSA.
– Lower limits of PSA detection: 1st-generation assays 0.2 ng/mL; 2nd-generation assays <0.1 ng/mL; 3rd-generation “ultrasensitive assays” as low as 0.003 ng/mL. (Note: The utility of “ultrasensitive” PSA testing has not been clearly established in the post radical prostatectomy setting).
• Normal PSA: The exact definition of an “abnormal” PSA is subject to controversy. The historically defined level of 4.0 ng/mL was considered to be normal. PSA 4.0–10 ng/mL were considered to be mostly due to BPH.
– Age-specific PSA reference ranges: Accounts for increases in prostate volume with age.
40–49 yr: 0 to 2.5 ng/mL
50–59 yr: 0 to 3.5 ng/mL
60–69 yr: 0 to 4.5 ng/mL
70–79 yr: 0 to 6.5 ng/mL
– Race-specific PSA normal ranges: Different ethnic and racial groups are reported to have different average PSA.
– Common causes of elevated PSA:
– BPH, prostate cancer, acute prostatitis, prostate trauma (prostate biopsy, TURP, instrumentation, cystoscopy, perineal trauma), urinary retention, prostatic infarction
– Wait at least 6 wk after biopsy or TURP before measuring PSA to avoid false elevation; less time after cystoscopy.
– Following relief of urinary retention PSA levels decrease by 50% in 24–48 hr
– A routine DRE will not clinically significantly increase PSA whereas formal prostate massage may elevate PSA.
– In a small subset of men, sexual activity (ejaculation) and vigorous bicycle riding may elevate PSA. It is prudent to refrain from ejaculation and aggressive bicycle riding for 48 hr before PSA testing.
– PSA levels tend to increase with age (related to prostate volume). Most PSA is made in the transition zone of the prostate, the region of the prostate that increases in volume in men with BPH.
– Medication effects on PSA:
– 5-ARI (finasteride/dutasteride) regardless of dose will reduce PSA by 50% at 6 mo; “correct” PSA by doubling value.
– Any increase in PSA from baseline in men on 5-ARI should raise the concern for the development of prostate cancer.
– Statins, thiazides, NSAID’s and acetaminophen all appear to lower PSA. Whether the relatively small changes in PSA with these drugs has clinical relevance is unknown.
– Lowering serum testosterone to castrate levels (<50 ng/dL using androgen deprivation using LHRH analogs/antagonists) will significantly decrease PSA initially. However, if the prostate cancer develops castration resistant features, the PSA usually rises.
– Increasing testosterone levels through supplementation can sometimes increase PSA.
– α1-adrenergic antagonists for BPH (tamsulosin, others) and herbals such as saw palmetto do not impact PSA.
• PSA and Prostate Cancer Treatment:
– Due to the half-life, wait a minimum 3 wk following RP for PSA nadir.
– A widely accepted definition of cancer recurrence following RP: A PSA >0.2 ng/mL that has risen on at least 2 separate occasions at least 2 wk apart and measured by the same lab.
– Persistently detectable PSA immediately following RP suggests systemic disease.
– A slowly rising PSA after being undetectable for >2 yr is most likely to be a prostate bed recurrence following RP.
– PSA >20 ng/mL with a diagnosis of prostate cancer is associated with extraprostatic disease and/or metastasis.
AUA guidelines suggest that bone scans and CT/MRI imaging is unnecessary with a PSA <20 ng/mL and no symptoms suggestive of advanced disease.
– Positive bone scan and PSA: 2.3% PSA <10.0 ng/mL; 5.3% PSA 10.1–19.9 ng/mL; 16.2% PSA >20.0 ng/mL
– PSA nadir of <1.0 ng/mL is associated with best long-term outcome following radiation therapy.
– If measured during external beam radiation therapy for prostate cancer, PSA shows a progressive decline.
– Since prostatic glandular tissue remains after radiation, PSA levels are unlikely to fall to undetectable following radiation therapy unless androgen ablation is also used.
– Optimum outcome for interstitial prostate brachytherapy is a PSA <0.7 ng/mL at 5 yr.
– Recurrence after radiation therapy for prostate cancer:
3 consecutive rises in PSA (1996 ASTRO definition)
2 point rise in PSA above posttreatment nadir (2005 Phoenix definition).
– PSA bounce: An initial decline in PSA followed by a transient rise (the so-called “bounce”) 12–18 mo following radiation therapy (brachytherapy up to 40% of cases, also described for external beam radiation).This transient rise may not be a recurrence and should be followed. The PSA increases are generally small (<0.8 ng/mL) but can sometimes reach 10 ng/mL and may last 6–18 mo. Ironically bounces may predict a good outcome.
– PSA should fall to a low level after high intensity focused ultrasound (HIFU) and cryotherapy and should not rise on successive occasions. Data is limited using other.
– Salvage radiation following RP; especially those with positive surgical margins receiving treatment when the PSA is low (ie, 0.5–1.5 ng/mL) and slowly rising; appear to have best outcomes.
– With metastatic disease on androgen deprivation, failure to nadir PSA <4.0 ng/mL 7 mo after initiation of therapy is associated with a poor prognosis (median survival: 1 yr). With PSA nadir of <0.2 ng/mL median survival is 6 yr.
– PSA increase after RP or radiation with no radiologic evidence of metastases, a PSA nadir of >0.2 ng/mL within 8 mo of androgen suppression is associated with a 20-fold greater risk of prostate cancer-specific mortality vs. a nadir of <0.2 ng/mL.
• PSA Derivatives: There is recent conflict in the literature if PSA-V or PSADT add value to the screening and detection of prostate cancer. The following information is based on published data that provide support for these derivatives.
– PSA density (PSAD): PSAD is a ratio of PSA to prostate size, as measured by transrectal ultrasound. (PSAD = PSA divided by prostate volume). Proposed as a method to differentiate benign vs. malignant with an elevated PSA of 4–10 ng/mL without evidence of prostate cancer on digital rectal exam. May also prevent unnecessary prostate biopsies.
Higher PSA density values (>0.15 ng/mL/cc) are more suggestive of prostate cancer; lower values suggest BPH.
Potential role as predictor for Gleason score upgrade after RP in patients with clinically low-risk disease.
PSA transition zone density (PSAD-TZ) is a similar concept but not commonly used.
– PSA velocity (PSA-V): Rate of PSA change over time; the utility of PSA velocity is in part limited by intra-patient variability; at least 3 consecutive measurements should be performed.
PSA-V >0.75 ng/mL/yr distinguished patients with prostate cancer from BPH or no prostate disease in 1 study. Other studies suggest >0.4 ng/mL/yr is better for cancer detection.
PSA-V <0.35 ng/mL/yr is often associated with the development of BPH
PSA-V >0.35 ng/mL/yr and PSA <4.0 ng/mL associated with prostate cancer death at 15 yrs.
PSA-V >2 ng/mL/yr in the year prior to diagnosis: Associated with an increased risk of prostate cancer death after RP or radiation.
Very high PSA-V (>3.0 ng/mL/year) is often associated with prostatic inflammation as the cause of the elevated PSA
– PSA doubling time (PSA-DT): Another reported measure of PSA change over time. PSADT is defined as the time it takes for a patient’s PSA value to double based on an exponential growth pattern. Pretreatment PSA-DT has little diagnostic value but it can predict tumor progression, therapeutic outcome, and tumor-specific mortality.
PSA-DT <3 mo, prostate cancer-specific mortality rates 5 yr. After biochemical failure were 35% (Gleason scores ≤7) and 75% (Gleason Score ≥8).
PSA-DT ≥3 mo, the 5-yr prostate cancer-specific mortality rates for 4% (Gleason scores ≤7) and 15% (Gleason score ≥8).
• Other PSA Based Tests
– Free vs. total f/t) PSA:
Prostate cancer has a lower percent of free PSA in the serum relative to benign prostate conditions.
In the PSA range of 2–10 ng/mL the lower the ratio of free/total(f/t) PSA, the increased likelihood of prostate cancer. The probability of cancer f/t PSA <10% is 56%; f/t value >25%, 8% have cancer.
– Complexed PSA:
Complexed PSA (cPSA) relies on the level of anti-chymotrypsin (ACT) bound PSA. This should provide similar enhanced specificity as the f/t PSA but requires only the measurement of a single analyte.
Compared to a PSA cutoff ≥4.0 ng/mL, cPSA cutoff of 3.75 ng/mL provides higher specificity (48% vs. 33%) for cancer diagnosis with a small decrease in sensitivity.
Complexed PSA is approved for monitoring men with prostate cancer.
– [-2]proPSA Percent:
[-2]proPSA is 1 of the PSA isoforms that can leak into the circulation that is unbound. The ratio of [-2]proPSA to free PSA (expressed as percent [-2]proPSA or %[-2]proPSA) is under study for prostate cancer screening and is approved in the EU.
– Prostate Health Index (phi): The phi is a composite test which incorporates: PSA, free PSA, and [–2]pro-PSA.
The calculation involves a formula: phi = ([-2] proPSA/fPSA × √PSA)
Use of phi level of >27 for prostate biopsy (with total PSA 2–10 ng/mL), may decrease unnecessary biopsies and reduce over-detection of indolent prostate cancer.
Prostate cancer risk increases with increasing phi values.
The probability of finding cancer on biopsy: phi 0–24.9 = 11%; phi 25.0–34.9 = 28.25; phi 35.0–54.9; 32.7%; phi >55 = 52.1%.
Correlation of phi and high-grade prostate cancer (Gleason score of >7): phi 0–24.9 = 26.1%; phi 25.0–34.9 = 28.2%; 35.0–54.9 = 30.1% phi; phi >55 = 42.1%.
• 4K score (4-kallikrein panel): Consists of these 4 kallikreins: PSA, freePSA, intactPSA, and human kallikrein 2 (hK2) are combined with a patient’s age and digital rectal exam using a proprietary algorithm to calculate the probability of a finding of aggressive prostate cancer. Ordered after an elevated PSA to determine the need for biopsy if an aggressive cancer is suspected. hK2 is a prostate-specific kallikrein produced by the prostatic epithelium with approximately 80% DNA sequence homology with PSA and >20,000 times the activity of the relatively weak protease PSA.
• PSA Screening. The use of PSA as a screening test is controversial but remains in place using PSA and DRE in appropriate patients based on various organizations guidelines. (See Section II: “Prostate Cancer Screening Guidelines.”)
– Challenges related to PSA based screening for prostate cancer:
About 15% of men with a “normal” PSA level (<4 ng/mL) may have prostate cancer.
The Prostate Cancer Prevention Trial: With a PSA cutoff of 1.1 ng/mL 17% of cancers would be missed, including 5% poorly differentiated cancers.
2 out of 3 men with an elevated PSA level don’t have prostate cancer.
1 out of 3 men with an elevated PSA level will have cancer.
2 out of 3 men who have a biopsy do not have cancer.
Biopsies in 1 in 5 men can miss prostate cancer.
– There is no clear cutpoint between “normal” and “abnormal” PSA levels.
– Historically PSA >4.0 ng/mL has been most accepted as abnormal. It is a balance between missing important cancers at a curable stage and avoiding detection and treatment of insignificant disease and avoiding unnecessary prostate biopsies
• “Normal” PSA levels must be interpreted on an individual basis.
– Population-based PSA levels in a random sample of men without regard to any specific prostate condition or race.
• 13% of men >55 yr have a PSA level of ≥ 4 ng/mL
• Positive predictive value of PSA in detecting prostate cancer (US Studies):
– PSA > 4.0 ng/mL: 30%
– PSA 4–10 ng/mL: 25%
– PSA >10 ng/mL: 42–64%
• Negative predictive value for PSA <4.0 ng/mL: 85%
• Based on biopsies from European Randomized Study of Screening for Prostate Cancer (ERSPC) the risk of finding prostate cancer based on PSA:
• Based on the following data there is some support for 1.5 ng/mL being the new “normal” PSA in mid-life.
– In one longitudinal PSA biopsy study baseline PSA level >1.50 ng/mL, the risk of prostate cancer increased from 12.3–76.8% at 7.6 yr.
– PSA >1.5 ng/mL between the ages of 45 and 49 yr account for nearly 1/2 of the prostate cancer deaths over the next 30 yr.
– PSA level at age 44–50 was very strongly associated with the likelihood of developing prostate cancer up to 25 yr later. The odds ratio for a PCA diagnosis:
PSA ≤0.50 ng/mL; (population average = Odds Ratio 1.0).
PSA 0.51–1.0 ng/mL: Odds ratio 2.51
PSA 1.0–1.5 ng/mL: Odds ratio 7.02
PSA 2.01–3.0 ng/mL:Odds ratio 9.01
REFERENCES
PSA Testing for the Pretreatment staging and Post Treatment management of Prostate Cancer. http://www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Specific-Antigen.pdf, Accessed April 4, 2013.
Catalona WJ, Partin AW, Sanda MG, et al. A multicenter study of [-2] Pro-PSA combined with PSA and free PSA for prostate cancer detection in the 2.0 to 10.0 ng/mL PSA range. J Urol. 2011;185:1650.
Gann PH, Hennekens CH, Stampfer MJ A prospective evaluation of plasma prostate-specific antigen for detection of prostatic cancer. JAMA. 1995;273: 289–94.
Freedland, S. Measurement of prostate specific antigen. www.UpToDate.com, Accessed April 4, 2013.
Lughezzani G, Lazzeri M, Larcher A, et al. Development and internal validation of a prostate health index based nomogram for predicting prostate cancer at extended biopsy. J Urol. 2012;188:1144–1150.
Moul JW, Lee RW. Rising serum PSA following local therapy for prostate cancer: Definition, natural history, and risk stratification. www.UpToDate.com, Accessed April 4, 2013.
Shahrokh F. Shariat, Tumor markers in prostate cancer I: blood-based markers Acta Oncol. 2011;50(Suppl 1): 61–75.
Vickers AJ, Gupta A, Savage CJ, et al. A panel of kallikrein marker predicts prostate cancer in a large, population-based cohort followed for 15 years without screening. Cancer Epidemiol Biomarkers Prev. 2011;20(2):255–261.
Vickers AJ, Thompson IM, Klein E, et al. Commentary on PSA velocity and doubling time for clinical decisions in prostate cancer. Urology. 2014;83(3):592–598.
PSA, RACE-ADJUSTED (SEE SECTION II “PSA, GENERAL CONSIDERATIONS AND PSA DERIVATIVES”)
PSA, RT-PCR
DESCRIPTION First clinically reported in 1992, RT-PCR is used to amplify mRNA transcripts of PSA. These PSA mRNA species should theoretically only be present in prostate tissues. Extraprostatic tissue of patients with biopsy-proven prostate cancer is tested, including peripheral blood, lymph nodes, and bone marrow, to detect PSA mRNA transcripts and presumably prostate cells in extraprostatic sites. It is being investigated as an assay to detect micrometa-stasis of prostate cancer before clinical presentation or evidence of disease spread (molecular staging). Its clinical utility as a diagnostic assay remains uncertain and is generally replaced by CTC assays.
REFERENCE
Gomella LG, Raj GV, Moreno JG. Reverse transcriptase polymerase chain reaction for prostate specific antigen in the management of prostate cancer. J Urol. 1997;158:326–337.
PSA VELOCITY (PSAV) AND PSA DOUBLING TIME (PSADT) (SEE SECTION II “PSA, GENERAL CONSIDERATIONS AND PSA DERIVATIVES”)
PSEUDODYSSYNERGIA (HINMAN SYNDROME)
DESCRIPTION A form of detrusor-external sphincter dyssynergia in which voluntary contraction of external sphincter occurs during detrusor contraction. It produces the functional voiding dysfunction seen in children with intractable voiding symptoms, men with chronic prostatitis or prostatodynia, and women with urethral syndrome. It may sometimes be a cause of urinary incontinence. This condition is thought to be a learned behavioral abnormality, possibly an overcompensation of the continence mechanism. Diagnosis is based on urodynamic evidence of increased or vacillating external sphincter activity during detrusor contraction, usually with simultaneous elevation of intra-abdominal pressure indicating voluntary nature of contraction, without clinical evidence of neurologic deficit. (See also Section II: “Hinman Syndrome [Hinman–Allen Syndrome, Nonneurogenic Neurogenic Bladder, Occult Neuropathic Bladder].”)
SYNONYMS
• Nonneurogenic neurogenic bladder
• Hinman syndrome/Hinman–Allen syndrome in children
• Dysfunctional voiding syndrome
• Occult Neuropathic Bladder
TREATMENT
• Children must be motivated to participate in the therapy.
• Teach how to void and defecate properly.
• Timed voiding, voiding diary, double voiding, psychotherapy, and biofeedback may all be appropriate in select children.
• Anticholinergics may control instability; α-adrenergics may improve outlet resistance.
• Psychotherapy, with a change in parental attitude, can greatly improve the situation.
• Intermittent catheterization may be necessary in more difficult cases (eg, with upper tract changes, failure to respond to less invasive measures).
• Biofeedback
REFERENCE
Kaplan SA, Santarosa RP, D’Alisera PM, et al. Pseudodyssynergia (contraction of the external sphincter during voiding) misdiagnosed as chronic nonbacterial prostatitis and the role of biofeedback as a therapeutic option. J Urol. 1997;157(6):2234–2237.
PSEUDOMYXOMA OVARII-LIKE POSTTHERAPEUTIC ALTERATION IN PROSTATE ADENOCARCINOMA
DESCRIPTION Pseudomyxoma ovarii-like posttherapeutic alteration in prostate adenocarcinoma refers to histologic alterations observed in prostate cancer foci after exposure to total androgen blockade. Changes in nontumoral glands exposed to total androgen blockade characteristically display acinar atrophy, basal cell hyperplasia, squamous or transitional cell metaplasia, and stromal hypercellularity. Conversely, tumor glands may shrink in size and extravasate mucin. This extravasated mucin resembles pseudomyxoma ovarii. This is an important distinction, as this appearance can be easily confused with mucinous carcinoma. It is important to recognize these posttreatment effects, as it may be the sole histologic evidence of therapeutic response and may guide definitive treatment after neoadjuvant hormone deprivation.
REFERENCE
Tran TA, Jennings TA, Ross JS, et al. Pseudomyxoma ovarii-like post therapeutic alteration in prostatic adenocarcinoma: A distinctive pattern in patients receiving neoadjuvant androgen ablation therapy. Am J Surg Pathol.1998;22:347–354.
PSMA (PROSTATE-SPECIFIC MEMBRANE ANTIGEN)
DESCRIPTION A protein with intracellular, transmemberane, and extracellular components of prostatic epithelial cells. PSMA levels are reported to be elevated in hormone-refractory prostate cancer and with metastatic disease. Its use as a tumor marker is not as useful in screening as PSA. PSMA is a highly sensitive and specific immunomarker for the detection of metastatic prostate carcinoma, however cells of the small intestine, proximal renal tubules, and salivary glands also can also express PSMA. PSMA is an in vivo target for imaging utilizing radiolabeled mAb 7E11 (CYT-356, capromab), the ProstaScint Scan. PSMA is currently being targeted as a therapeutic intervention for advanced prostate cancer including monoclonal Ab-directed therapy (PSMA Specific Membrane Antigen Antibody Drug Conjugate [PSMA ADC]), radionuclides and anti-PSMA vaccines and other immunotherapies.
REFERENCE
Eder M, Eisenhut M, Babich J, et al. PSMA as a target for radiolabelled small molecules. Eur J Nucl Med Mol Imaging. 2013;40(6):819–823.
PSOAS ABSCESS, UROLOGIC CONSIDERATIONS
DESCRIPTION A psoas abscess is a discrete abscess or phlegmon in the retroperitoneum, adjacent to the psoas muscle. Usually the consequence of direct spread of infection from an adjacent structure; primary psoas abscesses are rare and are a result of hematogenous spread. A wide variety of etiologies are reported in the literature, including perinephric abscess; pyelonephritis; postoperative infection following renal, ureteral, or bladder surgery; complications from ESWL; and urothelial carcinoma metastasis. Clinical presentation includes fever, lower abdominal or back pain, referred lower extremity pain, limp, flexion deformity of the hip from a reflex spasm, flank mass, and a psoas sign. Rarely, a psoas abscess can directly obstruct the ipsilateral ureter or cause a retroperitoneal inflammatory response. Treatment can initially be medical using antibiotic therapy; however, failure to resolve requires drainage. (See also Section I: “Retroperitoneal Abscess; Retroperitoneal Masses and Cysts.” (Image ))
REFERENCE
Hamano S, Kiyoshima K, Nakatsu H, et al. Pyogenic psoas abscess: Difficulty in early diagnosis. Urol Int. 2003;71:178–183.
PSOAS HITCH PROCEDURE
DESCRIPTION A surgical procedure used to replace short segments of distal ureteral loss or in combination with a ureteral reimplantation to provide a fixed posterior bladder wall. The bladder is mobilized and stretched superiorly along the axis of the ureteral deficit. The stretched bladder is then sutured to the fascia of the ilio-psoas muscle (Image ).
REFERENCE
Amis ES, Newhouse JH, eds. Essentials of Uroradiology. 1st ed. Boston: Little, Brown; 1991:370.
PSORIASIS, EXTERNAL GENITALIA
DESCRIPTION A chronic papulosquamous skin disease frequently affecting external genitalia, more commonly in males. Genital involvement is reported in 25–40% of patients with psoriasis. The lesions characteristically are sharply demarcated plaques with silvery, scaly patches. Psoriasis most frequently involves the penis in males and the mons pubis, labia majora, and inguinal crease in females. It is reported to increase the risk of squamous cell carcinoma (SCC) genitalia. Treatment includes topical steroids, tar preparations and maintaining good hygiene. (See Also Section II: “Pruritus, External Genitalia, Male.”)
REFERENCES
Farber EM, Nall L. Genital psoriasis. Cutis. 1992;50(4):263–266.
Loughlin KR. Psoriasis: Association with two rare cutaneous urological malignancies. J Urol. 1997; 157(2):622–623.
PSYCHOGENIC POLYDIPSIA
DESCRIPTION Psychogenic polydipsia (PPD) is a clinical disorder characterized by polyuria and polydipsia, and is a common occurrence in inpatients with psychiatric disorders. The underlying pathophysiology of the syndrome is unclear, but multiple factors have been implicated, including a hypothalamic defect and adverse medication effects. Workup for PPD includes a comprehensive evaluation for other medical causes of polydipsia, polyuria, hyponatremia, and the syndrome of inappropriate secretion of antidiuretic hormone. Workup should include plasma and urine osmolality and plasma and urine sodium. Other tests may include a complete metabolic panel, urinalysis, urea, chest x-ray, and CT scan of the head.
TREATMENT
• Treatment for hyponatremia: Fluid restriction, furosemide (if hypervolemic), intravenous normal saline, or hypertonic saline
• Behavioral treatments: Fluid restriction, therapy including cognitive techniques
• Drug treatments: Atypical antipsychotics, clozapine, risperidone, olanzapine, β-blockers, demeclocycline, clonidine, ACE inhibitors, conivaptan
REFERENCE
Dundas B, Harris M, Narasimhan M. Psychogenic polydipsia review: Etiology, differential, and treatment. Curr Psychiatry Rep. 2007;9:236.
PUDENDAL NERVE ENTRAPMENT/PUDENDAL NEUROPATHY
DESCRIPTION Compression of the pudendal nerve or its branches causing chronic perineal numbness or pain. The pudendal nerve carries sensations from the external genitalia, distal rectum, and the perineum. Symptoms can be seen if these nerve branches are compressed during pelvic surgery, a finding commonly seen in male and female pelvic sling operations (tension-free vaginal tape or transobturator tape) for incontinence, or it can occur spontaneously. A validated set of simple diagnostic criteria (Nantes criteria) include: (1) Pain occurs in the anatomic territory of the pudendal nerve, (2) is worsened by sitting, (3) the patient is not awakened at night by the pain, (4) no objective sensory loss is found on clinical exam, and (5) a positive response is seen to anesthetic pudendal nerve block. Exclusion criteria include purely coccygeal, gluteal, or hypogastric pain; exclusively paroxysmal pain; exclusive pruritus; or the presence of imaging abnormalities able to explain the symptoms. The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results for this disease. However, a combination of criteria can be suggestive of the diagnosis. Initial symptoms should be managed conservatively with anti-inflammatory medications and analgesics. Physical therapy, infiltration with steroids, or surgical decompression are treatment options. If applicable, sling removal should be considered if symptoms persist >6 wk.
REFERENCE
Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306–310.
PULMONARY METASTASIS, UROLOGIC CONSIDERATIONS
DESCRIPTION The lungs are the site of potential metastasis in all GU cancers. It is the most common site of metastasis in RCC and a common metastatic site in prostate, urothelial carcinoma, and testicular tumors. Chest CT is more sensitive at detecting pulmonary nodules as it can detect lesions <1 cm, the typical minimal size for plain film detection. Since a direct correlation exists between the likelihood of malignancy and size of pulmonary nodule, lesions <1 cm in size are usually nonclinical. Therefore, plain chest x-ray is the screening test of choice. Malignant nodules usually appear as noncalcified soft tissue densities. Suspicious nodules on chest x-ray warrant a chest CT. Tissue diagnosis of suspicious lesions should be performed if doing so will alter the intervention. Although metastatic disease requires systemic therapy, resection of pulmonary RCC metastases have been shown to improve survival when compared to immunotherapy alone.
REFERENCE
Hofmann HS, Neef H, Krohe K, et al. Prognostic factors and survival after pulmonary resection of metastatic renal cell carcinoma. Eur Urol. 2005;48:77–81.
PURPLE URINE BAG SYNDROME
DESCRIPTION Purple urine bag syndrome (PUBS) is an uncommon disorder in which the urine bags of catheterized patients turn purple or blue. Most patients are bedridden, cognitively impaired, and constipated. The discoloration is attributed to indigo and indirubin pigments, which appear purple when combined. The pigments are created when ingested tryptophan is exposed to intestinal flora in patients with altered gut motility. PUBS is usually associated with organisms that have indoxyl phosphatase/sulfatase activity (Klebsiella pneumonia, Providencia stuartii, Enterobacter, Proteus mirabilis, Morganella morganii, and Escherichia coli).
TREATMENT
• Antibiotics to treat urinary tract infection
• Catheter change
REFERENCE
Keenan CR, Thompson GR: Purple Urine Bag Syndrome. J Gen Internal Medicine. 2011;26:1506.
PYELITIS CYSTICA
DESCRIPTION Ingrowth of urothelial cells into the lamina propria with subsequent liquefaction, giving a cystlike appearance. Identical to cystitis cystica, this lesion occurs in the renal pelvis and calyces. It is a rare condition, usually associated with chronic infection, and is more common in females, usually >50 yr of age. Presenting symptoms are related to chronic infections, including fever, dysuria, hematuria, and flank pain. Identified on radiographic studies as multiple small cysts up to 10 mm in diameter in the renal pelvis and calyces, and confirmed by endoscopic biopsy. Not thought to be a premalignant condition, but urine cytology and biopsy are recommended to rule out other neoplastic conditions. (See also Section I: “Filling Defect, Upper Urinary Tract [Renal Pelvis and Ureter].”)
REFERENCE
Gronlund A, Glenthøj A, Kvist E. Pyelitis cystica. Scand J Urol Nephrol. 1997;31(5):509–511.
PYELITIS GLANDULARIS
DESCRIPTION In this condition, combined urothelial hyperplastic and metaplastic changes of the renal pelvis occur and characteristic glandular structures are seen haphazardly arranged within the lamina propria. These glands are lined by mucin-secreting columnar epithelial cells, which differentiate them from other forms of urothelial hyperplasia such as Vonbrunn nests and pyelitis cystica. It is not uncommon to see later hyperplastic changes and pyelitis glandularis in a single specimen. Intracellular and luminal mucin can be demonstrated by mucicarmine stain. Most commonly, the overlying surface epithelium remains of the transitional cell type, although metaplastic squamous epithelium or mucous-secreting columnar cells may be seen. Pyelitis glandularis is commonly focal. Extensive lesions with columnar cell metaplasia of the surface urothelium bear a high resemblance to colonic mucosa. However, the absence of muscularis mucosa helps distinguish these 2 entities. (See also Section I: “Filling Defect, Upper Urinary Tract [Renal Pelvis and Ureter].”)
REFERENCE
Dabbs DJ. Cytology of pyelitis glandularis cystica. A case report. Acta Cytol. 1992;36(6):943–945.
PYELOGENIC CYST
DESCRIPTION A pyelogenic cyst is a smooth intrarenal diverticulum that communicates directly with the renal pelvis. Conversely, a calyceal diverticulum communicates indirectly to the renal pelvis through a calyx or infundibulum. Pyelogenic cysts are lined with transitional cell epithelium. Diagnosis is best made by CT urogram or delayed-phase or retrograde pyelography showing contrast pooling in the cyst. Asymptomatic pyelogenic cysts do not require treatment. Pain, persistent or recurrent infections, stones, and milk of calcium warrant surgical intervention through ureteroscopic, percutaneous, laparoscopic, or open surgical techniques.
REFERENCE
Canales B, Monga M. Surgical management of the calyceal diverticulum. Curr Opin Urol. 2003; 13(3):255–260.
PYOCYSTIS
DESCRIPTION Pyocystis is a severe UTI of the bladder associated with a nonfunctioning bladder or in patients with chronic oligo-/anuria. Also called vesical empyema. Commonly seen (20–30%) in patients with a neurogenic bladder treated with urinary diversion. Pyocystis should be suspected in patients with a nonfunctioning bladder or in those who are oligo/anuric presenting with systemic signs of infection. Bladder catheterization should be performed and the pus cultured. A positive culture is diagnostic; however, imaging studies such as CT may reveal diagnostic signs such as bladder wall thickening. Conservative medical therapy is often adequate, comprised of culture-specific antibiotics and bladder drainage. Some advocate periodic bladder irrigations and instillations with antibiotic solutions therapy are directed by the specific organisms isolated. Bladder irrigation with either saline or an antibiotic solution benefit is not clear. Cystectomy is reserved for refractory pyocystis.
REFERENCE
Bibb JL, Servilla KS, Gibel LJ, et al. Pyocystis in patients on chronic dialysis. A potentially misdiagnosed syndrome. Int Urol Nephrol. 2002;34(3):415–418.
PYONEPHROSIS
DESCRIPTION Infected, obstructed collecting system with grossly purulent drainage and suppurative necrosis of renal parenchyma. This can be a chronic, indolent infection, but it usually presents acutely with sepsis, flank pain, and ipsilateral loss of renal function. Immediate aspiration with retrograde or percutaneous catheter drainage is essential.
REFERENCE
Baumgarten DA, Baumgartner BR. Imaging and radiologic management of upper urinary tract infections. Urol Clin N Am. 1997;24(3):545–569.
PYOSPERMIA
DESCRIPTION The World Health Organization defines pyospermia as >1×106 WBCs/mL semen (either peroxidase or by immunohistologic methods). Pyospermia (also referred to as leukocytospermia) has multifactorial causes, including infection, inflammation, and autoimmunity, and is considered to be 1 of the causes of male infertility. The short half-life of polymorphonuclear neutrophils (PMNs) in semen makes them a major source for factors that can be harmful to sperm. The differential diagnosis of symptomatic pyospermia includes infection, autoimmune disease, and inflammation of the accessory sex glands and lower male urogenital tract. Urogenital infections include acute and chronic prostatitis, seminal vesiculitis, epididymo-orchitis, cystitis, urethritis, urethral stricture, stone disease, foreign bodies, upper UTI, retrograde ejaculation, localized sepsis of the adjacent lower GI tract, and asymptomatic bacteriuria. The chronic infections that may result in pyospermia include fungal, mycobacterial, and congenital lesions causing infection of the urogenital tract. Autoimmune diseases that afflict the urogenital tract include Behçet syndrome and Reiter syndrome (Reactive arthritis/reactive arthritis triad). There is no defined medical management of pyospermia since the specific cause cannot be reliably identified. Options include antibiotic treatment (doxycycline, trimethoprim-sulfamethoxazole, ofloxacin) and other medications such as calcium dobesilate, propofol, rebamipide, N-acetyl-L-cysteine, glutathione, and vitamins C and E. Removal of cause and primary predisposing factors include the correction of any congenital or acquired defect in the GU tract harboring infection and inflammation, vesicourethral reflux, prostatic obstruction and infection, retrograde ejaculation, and urethral valves. Although antibiotics are a commonly used empiric therapy, studies have not confirmed their benefit, and a high rate of spontaneous resolution occurs without specific therapy. (See also Section II: “Semen Analysis, Abnormal Findings and Terminology”; “Semen Leukocytes.”)
REFERENCE
Pentyala S, Lee J, Annam S, et al. Current perspectives on pyospermia: A review. Asian J Androl. 2007;9(5):593–600.