9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions
Key Takeaways
- Prostate disorders, other urologic disorders including testicular torsion and scrotal masses, urinary incontinence and urologic cancer screening are separately enumerated blueprint subsections.
- Testicular torsion presents with acute severe pain, a high-riding transverse testis and an absent cremasteric reflex, and requires immediate surgical exploration.
- Alpha-blockers relieve benign prostatic hyperplasia symptoms within days, while 5-alpha-reductase inhibitors take months but reduce prostate volume and retention risk.
- Anticholinergic bladder agents are on the Beers list and should be used cautiously in older adults because of cognitive adverse effects.
- Overflow incontinence is identified by an elevated post-void residual and is worsened rather than helped by antimuscarinic therapy.
1. Benign Prostatic Hyperplasia
Progressive prostatic enlargement produces lower urinary tract symptoms, conventionally divided into:
- Storage (irritative): urgency, frequency, nocturia
- Voiding (obstructive): hesitancy, weak stream, straining, incomplete emptying, terminal dribbling
Initial evaluation: symptom score, digital rectal examination, urinalysis (to exclude infection, hematuria and glycosuria), and a medication review. Anticholinergics, opioids, decongestants (alpha-agonists) and antihistamines all worsen voiding and are a frequently overlooked reversible cause.
A post-void residual should be measured when retention is suspected. Routine PSA is a shared decision, not automatic.
Pharmacotherapy
| Class | Onset | Effect | Adverse effects |
|---|---|---|---|
| Alpha-1 blockers (tamsulosin, alfuzosin, doxazosin) | Days | Relax smooth muscle; symptom relief only | Orthostatic hypotension, dizziness, retrograde ejaculation, intraoperative floppy iris syndrome |
| 5-alpha-reductase inhibitors (finasteride, dutasteride) | 3 to 6 months | Shrink the gland; reduce retention and surgery | Decreased libido, erectile dysfunction, gynecomastia; lowers PSA by about 50% |
| Anticholinergics / beta-3 agonists | Weeks | For storage symptoms | Avoid anticholinergics with high residual volume |
| Phosphodiesterase-5 inhibitors (tadalafil) | Weeks | Symptoms plus erectile dysfunction | Contraindicated with nitrates |
Two examination points: finasteride halves the PSA, so a measured value must be doubled for interpretation, and a rising PSA on therapy is concerning regardless of the absolute number. Intraoperative floppy iris syndrome means an ophthalmologist must be told about tamsulosin exposure before cataract surgery — even remote exposure.
Indications for surgical referral: refractory retention, recurrent urinary infection, bladder stones, recurrent gross hematuria, renal insufficiency from obstruction, or failure of medical therapy.
2. Prostatitis
- Acute bacterial prostatitis: fever, dysuria, pelvic pain and an exquisitely tender prostate. Vigorous prostatic massage is avoided because it can precipitate bacteremia. Treated with a fluoroquinolone or trimethoprim-sulfamethoxazole for a prolonged course.
- Chronic bacterial prostatitis: recurrent urinary infections with the same organism; requires 4 to 6 weeks of therapy.
- Chronic prostatitis / chronic pelvic pain syndrome: by far the most common form, with no identifiable infection; managed multimodally with alpha-blockers, anti-inflammatories and pelvic floor physical therapy.
3. Acute Scrotum and Other Urologic Disorders
Testicular torsion is the emergency. Testicular viability falls sharply after roughly six hours.
| Torsion | Epididymitis | Torsion of appendix testis | |
|---|---|---|---|
| Onset | Sudden, severe | Gradual | Gradual |
| Position | High-riding, transverse | Normal | Normal |
| Cremasteric reflex | Absent | Present | Present |
| Prehn sign (elevation) | No relief | Relief | Variable |
| Fever, pyuria | Absent | Often present | Absent |
| Sign | — | — | Blue dot at upper pole |
If torsion is strongly suspected, go to the operating room — do not delay for imaging. Ultrasound is used when the diagnosis is genuinely uncertain.
Scrotal masses: a solid intratesticular mass is malignant until proven otherwise. A hydrocele transilluminates; a varicocele feels like a bag of worms, is usually left-sided and decompresses when supine — a right-sided varicocele, or one that does not decompress supine, suggests retroperitoneal or renal pathology and requires abdominal imaging.
Priapism lasting more than four hours is a compartment emergency; ischemic (low-flow) priapism requires aspiration and phenylephrine injection. Sickle cell disease and intracavernosal or oral erectile agents are common precipitants.
4. Urinary Incontinence
The blueprint lists urinary incontinence in women and in men separately. Classification by mechanism determines treatment, and misclassification leads to therapy that worsens the problem.
| Type | Mechanism | Trigger | First-line therapy |
|---|---|---|---|
| Stress | Urethral sphincter or pelvic support failure | Cough, sneeze, laugh, lift | Pelvic floor muscle training; pessary; sling surgery |
| Urgency (overactive bladder) | Detrusor overactivity | Sudden urge, running water, key in door | Bladder training, fluid and caffeine modification; beta-3 agonist or antimuscarinic |
| Overflow | Impaired detrusor contractility or outlet obstruction | Continuous dribbling; elevated post-void residual | Relieve obstruction; catheterization; avoid antimuscarinics |
| Functional | Cognitive or mobility limitation with an intact urinary tract | Cannot reach the toilet in time | Scheduled toileting, environmental modification |
| Mixed | Stress plus urgency | Both patterns | Treat the more bothersome component first |
Every evaluation begins with reversible causes, captured by the mnemonic DIAPPERS: Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological, Excess urine output, Restricted mobility, Stool impaction.
Post-void residual measurement is the pivotal test. A high residual identifies overflow incontinence, in which an antimuscarinic — the reflexive treatment for urgency — precipitates frank retention. Getting this backwards is a classic exam trap.
In older adults, prefer a beta-3 agonist (mirabegron) over an antimuscarinic. Antimuscarinics such as oxybutynin appear on the AGS Beers Criteria because of anticholinergic cognitive burden, dry mouth, constipation and falls. Behavioral therapy has the best benefit-to-harm ratio and should be first-line at any age.
In men, new incontinence with an enlarged prostate is often overflow rather than urgency, which again makes post-void residual essential before prescribing.
5. Urologic Cancer Screening
A separately enumerated blueprint subsection, and the correct answers are mostly negative.
| Cancer | Screening |
|---|---|
| Prostate | Shared decision-making for PSA roughly ages 55 to 69; not recommended at 70 and above |
| Bladder | Not recommended — evaluate hematuria instead |
| Renal | Not recommended in the general population |
| Testicular | Not recommended; USPSTF gives a D recommendation to screening in asymptomatic adolescents and adults |
PSA counseling should cover the possibility of detecting a cancer that would never have caused harm, the biopsy and treatment cascade that follows an abnormal result, and the risks of incontinence and erectile dysfunction — set against a modest reduction in prostate cancer mortality.
Causes of an elevated PSA other than cancer: benign prostatic hyperplasia, prostatitis, urinary retention, recent ejaculation, prostate biopsy or instrumentation, and vigorous cycling. A single elevated value should be repeated after several weeks before proceeding.
6. Erectile Dysfunction
Enumerated under both other urologic disorders and testes and male reproductive health. The internist-relevant framing: erectile dysfunction is frequently an early marker of endothelial dysfunction and may precede a cardiovascular event by years, so a new diagnosis warrants cardiovascular risk assessment.
Review medications — thiazides, beta-blockers, selective serotonin reuptake inhibitors, finasteride, antiandrogens — and screen for diabetes, hypogonadism, depression and obstructive sleep apnea.
Phosphodiesterase-5 inhibitors are first-line but are absolutely contraindicated with nitrates in any form, including as-needed sublingual nitroglycerin, because of profound hypotension. Caution is also required with alpha-blockers, where staggered dosing reduces symptomatic hypotension.
An 81-year-old man with benign prostatic hyperplasia reports new urinary leakage described as continuous dribbling, along with nocturia. His daughter asks about starting oxybutynin, which helped a friend with similar symptoms. Post-void residual by bladder scan is 340 mL. What is the most appropriate management?
A 19-year-old man presents with two hours of severe left testicular pain and vomiting. The left testis is high-riding and lies transversely, and the cremasteric reflex is absent on that side. He is afebrile and urinalysis is normal. What is the most appropriate next step?