180 CHAPTER 5 Infections and inflammatory conditions

HIV in urological surgery

Human immunodeficiency virus (HIV)

HIV disease results from the acquired deficiency of cellular immunity caused by the human immunodeficiency virus (HIV). The signature hallmark of the disease is the reduction of the helper T-lymphocytes in the blood and the lymph nodes, the development of opportunistic infections (Pneumocystis carinii pneumonia, cytomegalovirus (CMV) infections, tuberculosis, candida infections, cryptococcosis, others), and the development of malignancy such as lymphoma and Kaposi sarcoma.

The spectrum HIV infections range from asymptomatic seropositivity, thru AIDS-related complex (ARC), to acquired immunodeficiency syndrome (AIDS). HIV-1 is pandemic and accounts for significant mortality in developing countries.

HIV-2 has less pathogenicity and is predominant in West Africa. Transmission is via sexual intercourse, contaminated needles, mother-to- fetus transmission, and infected blood and blood products (blood transfusion risks are now minimal).

Urological manifestations of HIV/AIDS include bacterial and nonbacterial infections, urolithiasis, increased risk of malignancy, renal impairment, and voiding dysfunction.

Pathogenesis

HIV is a retrovirus. It possesses the enzyme reverse transcriptase that enables viral RNA to be transcribed into DNA, which is then incorporated into the host cell genome. HIV binds to CD4 receptors on helper T-lymphocytes (CD4 cells), monocytes, and neural cells. After an extended latent period (8–10 years), CD4 counts decline.

AIDS is defined as HIV positivity and CD4 lymphocyte counts <200 x 106/L. The associated immunosuppression increases the risk of opportunistic infections and tumors.

Diagnosis

Screening HIV-1 antibody titer, if positive, is confirmed by Western blot or immunofluorescence. Separate consent for HIV testing is required. Informed consent is required for the test.

Urological sequelae

•Urinary tract infections: Common bacterial pathogens are most common in HIV: E. coli, Enterobacter (enterococci), Pseudomonas aeruginosa, Proteus spp, Klebsiella, Acinetobacter, Staphylococcus aureus, group D streptococcus, Serratia, and Salmonella spp. If UTI is suspected and C&S are negative, consider atypical organisms such as fungi, parasites, or viruses

•Kidneys: cytomegalovirus, Aspergillus, Toxoplasma gondii infections, which can cause acute tubular necrosis and abscess formation; renal failure; HIV-associated nephropathy (HIVAN): nephrotic disease with proteinuria >3.5 g/day and edema, hypertension. Progresses to dialysis in <10 months; renal stones (secondary to indinavir treatment). Up to 8-fold risk of renal cell carcinoma.

•Ureters: calculi associated with indinavir therapy

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•Bladder: voiding dysfunction and retention (hypoand hyperreflexia, acontractile hypoactive bladder, and detrusor-sphincter dyssynergia); UTI (opportunistic organisms); squamous cell carcinoma

•Urethra: Reiter syndrome (urethritis, conjunctivitis, arthritis); bacterial urethritis

•Prostate: bacterial prostatitis and abscesses (opportunistic organisms)

•External genitalia: chronic or recurrent genital herpes; atypical syphilis; opportunistic infections of testicle and epididymis (Salmonella epididymitis); scrotal and penile Kaposi sarcoma; Fournier gangrene. Testicular tumors are up to 50 times more common, usually seminoma.

Needle stick injury

The risk of seroconversion following needle stick injury from a seropositive patient is ~0.3%. Risks are increased if the patient has terminal ARC illness and if the needle is hollow bore with visible blood contamination, inserted deeply or directly into a vein.

The seroconversion rate after cutaneous exposure to HIV-infected blood is 0.09%. Immediately wash the area well, report to occupational health, and where appropriate, commence antiviral prophylaxis as soon as possible.

Health care workers exposed to infected blood from non-AIDS or acute HIV should be given zidovudine plus lamivudine.

For increased-risk exposure use a three-drug regimen including a protease inhibitor (lopinavir and ritonavir).

Further reading

Cohen MS, Hellmann N, Levy JA, DeCock K, Lange J (2008). The spread, treatment and prevention of HIV-1: evolution of a global pandemic. J Clin Invest 118:1244–1254.

Lebovitch S, Mydlo JH (2008). HIV-AIDS: urologic considerations. Urol Clin North Am 35(1):59–68.

182 CHAPTER 5 Infections and inflammatory conditions

Inflammatory and other disorders of the penis

See Table 5.6 for dermatologic descriptors. Most penile ulcers and vesicobullous lesions are associated with a sexually transmitted disease.

Premalignant lesions associated with penile cancer are discussed in Chapter 6.

Balanitis

This is a condition seen most commonly in uncircumcised men with poor hygiene. Balanitis is the inflammation of the glans penis. When the foreskin and prepuce are involved it is termed balanoposthitis. The most common complication of balanitis is phimosis.

Daily hygiene is most critical in treatment, with careful cleaning after retraction of the foreskin. Clotrimazole can be used in adults with probable candidal balanitis. Betamethasone 0.05% applied bid is useful, with some reports of success with topical 1% pimecrolimus cream.

Circumcision may sometimes be necessary.

Paraphimosis

This is a true urological emergency where in an uncircumcised male the foreskin is pulled behind the glans and cannot be brought back to the normal position. If not immediately reduced, swelling ensues and the tight band of tissue can compromise lymphatic and vascular flow to the distal, resulting in pain, edema, and possible tissue loss.

Manual reduction is preferred using ice packs, elastic compression, and topical anesthetic such as 2% lidocaine gel. Operative dorsal slit may be required in refractory cases.

Phimosis

Phimosis is when the foreskin cannot be retracted behind the glans. A physiological phimosis is present at birth due to adhesions between the foreskin and glans. As the penis develops, epithelial debris (smegma) accumulates under the foreskin, causing gradual separation.

Ninety percent of foreskins are retractile at age 3; few persist into adulthood (<1% phimosis at age 17). Recurrent balanitis in uncircumcised males can cause new phimosis.

Treatment

Older children with phimosis, suffering recurrent infection (balanitis), can be treated with a 6-week course of topical 0.1% dexamethasone cream, which acts to soften the phimosis and allow foreskin retraction (avoid circumcision where possible).

Adults may require a dorsal slit or circumcision for recurrent balanitis, voiding obstruction, or difficulties with sexual intercourse.

Complications

These include recurrent balanitis; balanoposthitis (severe balanitis where inflammatory secretions and pus are trapped in the foreskin by the phimotic band); paraphimosis; chronic inflammation; and squamous cell carcinoma of the penis.

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