Genitourinary Disorders: BPH, Urinary Incontinence, UTIs & Prostatitis

Genitourinary Disorders: BPH, Urinary Incontinence, UTIs & Prostatitis

Genitourinary (GU) disorders are common in adult and geriatric primary care, spanning obstructive uropathies, functional bladder dysfunction, and urogenital infections.

Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia is a non-malignant proliferation of prostatic stromal and epithelial cells in the transition zone surrounding the urethra. Dihydrotestosterone (DHT), converted from testosterone by 5-alpha reductase, is the primary androgen mediator of prostate growth.

Clinical Presentation & Diagnostic Evaluation

Symptoms are categorized into lower urinary tract symptoms (LUTS):

• Storage Symptoms (Irritative): Frequency, urgency, nocturia, and urge incontinence.
• Voiding Symptoms (Obstructive): Hesitancy, weak stream, intermittency, straining, incomplete emptying.
• Evaluation Tools: International Prostate Symptom Score (IPSS) questionnaire. Digital Rectal Examination (DRE) reveals a symmetrically enlarged, smooth, firm/rubbery, non-tender prostate with a preserved median sulcus.
• Diagnostic Testing: Urinalysis (rule out UTI) and serum Prostate-Specific Antigen (PSA).

Pharmacological Management Algorithm

1. Alpha-1 Adrenergic Antagonists (Selective: Tamsulosin, Silodosin; Non-Selective: Doxazosin, Terazosin):

   • Block alpha-1a receptors in prostate stroma and bladder neck, causing smooth muscle relaxation.
   • Provide rapid relief of voiding symptoms (within 1 to 2 weeks). They do not reduce prostate size.
   • Adverse Effects & Warnings: Orthostatic hypotension, dizziness, retrograde ejaculation. Intraoperative Floppy Iris Syndrome (IFIS) warning before cataract surgery.

2. 5-Alpha Reductase Inhibitors (Finasteride, Dutasteride):

   • Inhibit 5-alpha reductase, blocking conversion of testosterone to DHT.
   • Reduce prostate volume by 20–25%, halt BPH progression, and decrease acute urinary retention risk.
   • Onset & PSA Pearl: Requires 3 to 6 months for symptom relief. Finasteride reduces serum PSA levels by ~50%. Clinicians must double measured serum PSA in patients on 5-ARIs for >= 6 months when screening for prostate cancer.

3. Combination & PDE5 Inhibitors: Combination therapy (Alpha-blocker + 5-ARI) is superior for large prostates. Tadalafil 5 mg daily is indicated for coexisting BPH and Erectile Dysfunction.

Urinary Incontinence Subtypes & Diagnostic Evaluation

Screen for reversible causes using the DIAPPERS mnemonic: Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological, Excess output, Restricted mobility, Stool impaction.

Diagnostic Diagnostics & Post-Void Residual (PVR)

Diagnostic evaluation of chronic urinary incontinence includes a detailed 3-day voiding diary, urinalysis to exclude UTI or hematuria, and measurement of Post-Void Residual (PVR) volume via bladder ultrasound:

• PVR < 50 mL: Normal bladder emptying.
• PVR 50–200 mL: Borderline; monitor clinically.
• PVR > 200 mL: Incomplete bladder emptying / urinary retention; suggestive of overflow incontinence or severe bladder outlet obstruction.

Overactive Bladder Pharmacotherapy & Beers Criteria Safety

• Anticholinergic Agents (Oxybutynin, Tolterodine, Solifenacin): Block M2/M3 receptors to relax detrusor muscle. Beers Criteria Risk: High risk of dry mouth, constipation, urinary retention, blurred vision, and cognitive decline/dementia in older adults. Avoid in older adults.
• Beta-3 Agonists (Mirabegron, Vibegron): Stimulate detrusor relaxation during storage without anticholinergic side effects. Preferred in older adults. Monitor baseline and ongoing blood pressure.

Urinary Tract Infections (UTIs) Across the Lifespan

Over 80% of uncomplicated UTIs are caused by uropathogenic Escherichia coli.

Acute Uncomplicated Cystitis

Uncomplicated cystitis presents with dysuria, frequency, urgency, and suprapubic pain without systemic symptoms.

• First-Line Antibiotics:
  1. Nitrofurantoin (Macrobid): 100 mg PO BID for 5 days (avoid if eGFR < 30 mL/min/1.73m² or pyelonephritis).
  2. Trimethoprim-Sulfamethoxazole (Bactrim DS): 160/800 mg PO BID for 3 days (if local resistance < 20%).
  3. Fosfomycin: 3 grams PO single dose.
• Fluoroquinolones (Ciprofloxacin): Do NOT use for uncomplicated cystitis due to severe black box warnings (tendon rupture, aortic dissection, QT prolongation).

Recurrent UTIs & Prophylaxis Strategies

Recurrent UTI is defined as 2 or more infections in 6 months or 3 or more in 12 months. Prophylactic strategies include:

• Non-pharmacologic: Hydration, post-coital voiding, cranberry supplements (mixed evidence).
• Postmenopausal Women: Topical vaginal estrogen cream reverses urogenital atrophy and restores lactobacilli protective flora.
• Post-coital or daily low-dose antimicrobial prophylaxis (Nitrofurantoin 50 mg daily or TMP-SMX 40/200 mg daily) for refractory cases.

Complicated UTIs & Asymptomatic Bacteriuria

Complicated UTIs (males, pregnancy, catheters, pyelonephritis) require urine culture prior to treatment. Pyelonephritis is treated with oral Ciprofloxacin 500 mg BID for 7 days or Levofloxacin 750 mg daily for 5 days. Asymptomatic Bacteriuria (ASB) (>= 10^5 CFU/mL without symptoms) should NOT be treated in older adults or catheterized patients. Screen and treat ASB ONLY in pregnant women and before endourologic procedures with mucosal bleeding.

Bacterial Prostatitis: Acute vs. Chronic

• Acute Bacterial Prostatitis: Abrupt onset of high fever, chills, perineal pain, dysuria, and urinary retention. Etiology: E. coli in men > 35; N. gonorrhoeae / C. trachomatis in men < 35. On DRE, the prostate is exquisitely tender, warm, and boggy. Vigorous prostatic massage is strictly contraindicated (risk of bacteremia/sepsis). Treatment requires extended therapy: Ciprofloxacin 500 mg BID or TMP-SMX DS BID for 4 to 6 weeks.
• Chronic Bacterial Prostatitis: Recurrent UTIs with the same pathogen and chronic relapsing pelvic discomfort. Diagnostic confirmation utilizes post-prostatic massage urine culture (Meares-Stamey 4-glass test). Requires 4 to 6 weeks of fluoroquinolones or TMP-SMX.
• Chronic Pelvic Pain Syndrome (CPPS / Non-Bacterial Prostatitis): Chronic pelvic pain with negative urine cultures. Treated with alpha-blockers, anti-inflammatories, and physical therapy.