8CHAPTER 1 Preliminary investigation

Hematospermia

Sometimes spelled “hemospermia,” hematospermia is the presence of blood in the semen. It can be bright red, coffee-colored, rusty, or darkened in appearance and may change as blood ages. Usually hematospermia is intermittent, benign, or self-limiting and has no cause identified.

Causes

•Iatrogenic: following prostate biopsy, cystoscopy or prostate intervention (resection, hyperthermia), prostate brachytherapy or radiation; usually clears in weeks to months

•Age <40 years: usually inflammatory (e.g., prostatitis, epididymoorchitis, urethritis, urethral condylomata) or idiopathic (this cause likely reflects the limited investigation usually carried out in this age group). Rarely there is testicular tumor, or perineal or testicular trauma.

•Age >40 years: as for men aged <40, prostate cancer; bladder cancer; BPH with dilated veins in the prostatic urethra; prostatic or seminal vesicle (SV) calculi; hypertension; carcinoma of the seminal vesicles

•Rare causes at any age: bleeding diathesis; utricular cysts; Müllerian cysts; TB; schistosomiasis; amyloid of prostate or seminal vesicles; following therapeutic injection of hemorrhoids

Examination

Examine the testes, epididymis, prostate, and seminal vesicles. On digital rectal exam (DRE) evaluate for nodularity, tenderness, masses, midline and cystic structures. SV fullness can be associated with schistosomiasis (egg burden). Measure blood pressure.

Investigation

Send urine for culture. If the hematospermia resolves, an argument can be made for doing nothing else. If it recurs or persists, arrange a transrectal ultrasound (TRUS), flexible cystoscopy, and renal ultrasound. If hematuria coexists, investigate with an upper tract imaging study and cystoscopy (as described in Chapter 2). In general, evaluation in men >40 years of age should be more extensive.

Treatment

•Directed at the underlying abnormality, if found

•Watchful waiting in most men if no cause identified

•Empiric antibiotics (doxycycline or flouroqinolones) sometimes considered

Further reading

Ahmad I, Krishna NS (2007). Hemospermia. J Urol 177:1613–1618.

Kumar P, Kapoor S, Nargund V (2006). Haematospermia—a systemic review. Ann R Coll Surg Engl 88:339–342.

Leocadio DE, Stein BS (2009). Hematospermia: etiological and management considerations. Int Urol Nephrol 41(1):77–83.

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10 CHAPTER 1 Preliminary investigation

Lower urinary tract symptoms (LUTS)

Many terms have been coined to describe the symptom complex traditionally associated with prostatic obstruction due to BPH. The classic prostatic symptoms of hesitancy, poor flow, frequency, urgency, nocturia, and terminal dribbling have in the past been termed prostatism or simply BPH symptoms. One sometimes hears these symptoms being described as due to BPO (benign prostatic obstruction) or BPE (benign prostatic enlargement) or, more recently, LUTS/BPH.

However, these “classic” symptoms of prostatic disease bear little relationship to prostate size, urinary flow rate, residual urine volume, or urodynamic evidence of bladder outlet obstruction (BOO).1 Furthermore, age-matched men and women have similar “prostate” symptom scores;2 women obviously have no prostate.

Therefore, these terms are no longer used to describe the symptom complex of hesitancy, poor flow, etc. Instead, the preferred term today is lower urinary tract symptoms (LUTS), which is purely a descriptive term avoiding any implication about the possible underlying cause of these symptoms.3

The new terminology of LUTS is useful because it reminds the urologist to consider possible alternative causes of symptoms, which may have absolutely nothing to do with prostatic obstruction. It also reminds us to avoid operating on an organ, such as the prostate, when the cause of the symptoms may lie elsewhere.

Overactive bladder is a newly defined symptom complex during which patients experience urgency with or without urge incontinence, usually accompanied by frequency and/or nocturia.4

Baseline symptoms can be measured using a validated symptom index. The most widely used in men is the International Prostate Symptom Score (IPSS), a modified version of the AUA Symptom Index5 (Fig. 1.1). It is useful for the initial evaluation and for determining the effectiveness of therapeutic intervention.

Other causes of LUTS

In broad terms, LUTS can be due to pathology in the prostate, the bladder, the urethra, or other pelvic organs (uterus, rectum) or to neurological disease affecting the nerves that innervate the bladder. These pathologic processes can include benign enlargement of the prostate causing bladder outflow obstruction (BPE causing BOO) and infective, inflammatory, and

1 Reynard JM, Yang Q, Donovan JL, et al. (1998) The ICS-‘BPH’ study: uroflowmetry, lower urinary tract symptoms and bladder outlet obstruction. Br J Urol 82:619–623.

2 Lepor H, Machi G (1993) Comparison of AUA symptom index in unselected males and females between fifty-five and seventy-nine years of age. Urology 42:36–41.

3 Abrams P (1994). New words for old—lower urinary tracy symptoms for ‘prostatism’. Br Med J 308:929–930.

4 Voelzke BB (2007). Overactive bladder; prevalence, pathophysiology, and pharmacotherapy. Urol Rep 1:16–22.

5 Barry MJ, Fowler FJ Jr, O’Leary MP, et al. (1992) The American Urological Association Symptom Index for benign prostatic hyperplasia. J Urol 148:1549–1557.

Figure 1.1 The International Prostate Symptom Score (IPSS). This figure was published in Barry MJ, Fowler FJ Jr, O’Leary MP, et al. (1992). The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 148(5):1549–1557. Copyright Elsevier 1992.

12 CHAPTER 1 Preliminary investigation

neoplastic conditions of the bladder, prostate, or urethra. While LUTS are, in general, relatively nonspecific for a particular disease, the associated symptoms can indicate their cause.

For example, LUTS in association with hematuria suggests a possibility of bladder cancer. This is more likely if irritative symptoms (urinary frequency, urgency), and bladder (suprapubic) pain are prominent. Carcinoma in situ of the bladder, a superficial, noninvasive, and potentially very aggressive form of bladder cancer, which very often progresses to muscle invasive or metastatic cancer, classically presents in this way.

Recent onset of bed wetting in an elderly man is often due to highpressure chronic retention. Visual inspection of the abdomen may show marked distension due to a grossly enlarged bladder. The diagnosis of chronic retention is confirmed by palpating the enlarged, tense bladder, which is dull to percussion; ultrasound measurement; and drainage of a large volume following catheterization.

Rarely, LUTS can be due to neurological disease.

Multiple sclerosis can cause urgency and urge incontinence.

Parkinson disease is associated with urinary symptoms and incontinence. Many patients also have detrusor overactivity and impaired contractility.

Spinal cord or cauda equina compression due to pelvic or sacral tumors can cause urinary symptoms. Associated symptoms include back pain, sciatica, ejaculatory disturbances, and sensory disturbances in the legs, feet, and perineum. In these rare cases, loss of pericoccygeal or perineal sensation (sacral nerve roots 2–4) indicates an interruption to the sensory innervation of the bladder, and an MRI scan often confirms the clinical suspicion that there is a neurological problem.

Further reading

Abrams P, et al. (2002). Lower urinary tract function. Neurourol Urodyn 21:167–178.

Gravas S, Melekos MD (2009). Male lower urinary tract symptoms: how do symptoms guide our choice of treatment? Curr Opin Urol. 19(1):49–54.

Vishwajit S, Anderson KE (2009). Terminology of lower urinary tract symptoms. Helpful or confusing? Sci World J 18;9:17–22.

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