Rosen & Barkin's 5-Minute Emergency Medicine Consult (577 page)

FOLLOW-UP

• Acute prostatitis:
  
  • Patients who appear ill or toxic
    
  • Hypotension
    
  • Urinary retention
    
• Chronic prostatitis:
  
  • Admission generally not warranted unless patient has signs or symptoms of acute prostatitis.
    

• Acute prostatitis:
  
  • Patient must be nontoxic.
    
  • Able to take fluids and oral medications (analgesia and antibiotics)
    
  • Urinate without difficulty
    
  • Immunocompetent
    
  • Relatively free of concurrent underlying disease
    
  • Have appropriate follow-up care
    
• Chronic prostatitis: Appropriate follow-up care should be available.
  

Patient with either acute or chronic prostatitis should be referred to an urologist.

• Obtain a good history to distinguish acute from chronic prostatitis, as longer antibiotic therapy may be warranted.
  
• Consider this diagnosis even in sexually active adolescent males.
  
• Acutely ill males with antibiotic treatment failure for prostatitis should be evaluated for abscess regardless of immunocompetence.
  

• Hedayati T, Keegan M. Prostatitis.
  eMedicine
  . Available at
  www.emedicine.medscape.com/article/785418
  . Updated July 29, 2009.
  
• Pontari MA. Chronic prostatitis/chronic pelvic pain syndrome.
  Urol Clin North Am
  . 2008;35(1):81–89, vi.
  
• Schaeffer AJ. Chronic prostatitis and the chronic pelvic painsyndrome.
  N Engl J Med
  .2006;355:1690–1698.
  
• Takhar S, Moran G. Diagnosis and management of urinary tract infection in the emergency department and outpatient settings.
  Inf Disease Clin of North America.
  2014;28(1):1--168.
  
• Touma NF, Nickel JC. Prostatitis and chronic pelvic pain syndrome in men.
  Med Clin North Am.
  2011;95(1):75–86.
  

CODES

• 601.0 Acute prostatitis
  
• 601.1 Chronic prostatitis
  
• 601.9 Prostatitis, unspecified
  

BASICS

• Unpleasant sensation that provokes a desire to scratch
  
• Mediated by unmyelinated C fibers in upper portion of dermis:
  
  • Transmitted to dorsal horn of spinal cord
    
  • Via spinothalamic tract to cerebral cortex
    
• Peripheral mediators (e.g., histamine and peptides such as substance P that release histamine) stimulate C fibers and induce itching
  
• Prostaglandins (PGE
  ₂
  , PGH
  ₂
  ) lower threshold to pruritus
  
• Opiates cause pruritus by acting on central receptors
  
• No single pharmacologic agent effectively treats all causes of pruritus
  
• “Itch–scratch–itch” cycle:
  
  • Itching triggers scratching
    
  • Scratching damages skin and stimulates nerve endings, thereby producing even greater itching
    

4 categories in proposed itch classification:

• Pruritoceptive: Generated in the skin from localized irritation or inflammation
  
• Neurogenic: Generated in the CNS due to circulating pruritogens
  
• Neuropathic: Due to CNS or PNS lesions
  
• Psychogenic
  

DIAGNOSIS

• Onset:
  
  • Shortly after freshwater bathing in swimmer’s itch
    
  • More intense at night with scabies
    
  • Paroxysmal with multiple sclerosis
    
  • With sudden changes in temperature in polycythemia vera
    
• Character: Paroxysmal, burning, pricking
  
• Time of occurrence, duration
  
• Severity; impact on quality of life
  
• With or without skin lesions
  
• Anatomic area (e.g., exposed skin only)
  
• Exacerbating or alleviating factors (e.g., water, heat, dryness, dampness, coolness)
  
• Medications
  
• New products (e.g., soap, cosmetics, laundry detergents, fabric softeners)
  
• Age
  
• Family history of atopic dermatitis or skin disease
  
• Personal history of allergies or asthma
  
• Pruritus in other family members
  
• Systemic or associated symptoms (e.g., night sweats, fever, tremors, weight loss, fatigue, jaundice, anemia, neurologic symptoms)
  
• Sexual history, history of HIV or AIDS
  
• Social: Occupation, hobbies, pets, travel
  

• Dermatologic:
  
  • Absence of rash
    
  • Diffuse or localized rash
    
  • Location: Genitals, interdigital webs, axilla, wrists, etc.
    
  • Generalized morbilliform eruptions
    
  • Discrete weeping patches with vesicles
    
  • Dry skin
    
  • Jaundice
    
  • Follicular (around the hair)
    
  • Nonfollicular (e.g., insect bites, scabies)
    
  • Primary lesions:
    
    • Papular, pustular, urticarial, or polymorphic
      
  • Secondary lesions:
    
    • Excoriations
      
    • Lichenification
      
    • Hyperpigmentation
      
    • Prurigo papules: Thickened papular areas of skin from constant rubbing
      
• Psychogenic: Constant rubbing in areas patient can readily reach
  

• Detailed history is key in the ED workup
  
• Physical exam to characterize skin lesions
  
• Look for evidence of systemic disease
  

Indications for specific studies (e.g., CBC and differential, ESR, CRP, BUN/creatinine, glucose, LFTs, TSH, free T4, HIV, RPR, cancer screening, CXR, abdominal ultrasound, CT/MRI) vary based on the clinical presentation and should be guided by clinical judgment.

• Skin scrapings for scabies and dermatophytoses
  
• Skin biopsy performed by dermatologist at follow-up visit
  
• Skin culture for bacterial, viral, or fungal infection
  

• Xerosis (dry skin)
  
• Insect infestations:
  
  • Scabies: Vesicles and burrows on intertriginous areas
    
  • Pediculosis (lice)
    
• Insect bites: Localized clusters of papules
  
• Dermatitis:
  
  • Atopic dermatitis
    
  • Contact dermatitis (e.g., poison ivy contact)
    
  • Nummular dermatitis: Round eczematous or vesicular eruption
    
• Drug induced (suspect when no rash):
  
  • Opiates and derivatives
    
  • Aspirin/NSAIDs
    
  • Quinidine; amiodarone
    
  • Certain antibiotics, antifungals, antimalarials
    
  • Phenothiazines
    
  • Estrogens, progestins, testosterone
    
  • Statins
    
  • Others
    
• Lichen planus: Lichenification, hyperpigmentation, skin thickening
  
• Urticaria
  
• Bullous pemphigoid
  
• Eosinophilic folliculitis
  
• Psoriasis
  
• Dermatitis herpetiformis: Burning itch
  
• Sunburn
  
• Aquagenic pruritus
  
• Fiberglass dermatitis
  
• Seborrheic dermatitis: Scaly plaques on sebaceous gland-bearing areas
  
• Swimmer’s itch, schistosome cercarial dermatitis, or schistosomiasis:
  
  • Repeated freshwater exposure
    
  • Itching starts as water evaporates
    
  • Highly pruritic papules develop hours later
    
• Miliaria rubra (prickly heat)
  

• Polymorphic eruption of pregnancy
  
• Pemphigoid gestationis
  
• Intrahepatic cholestasis of pregnancy
  
• Atopic eruption of pregnancy
  

• HIV
  
• Parasites:
  
  • Ankylostomiasis/helminthiasis (hookworm)
    
  • Onchocerciasis/river blindness (nematode)
    
  • Ascariasis (roundworm)
    
  • Trichinosis (roundworm)
    

• Obstructive biliary disease
  
• Primary biliary cirrhosis
  
• Hepatic cholestasis secondary to drugs
  
• Intrahepatic cholestasis of pregnancy
  
• Extrahepatic biliary obstruction
  
• Chronic hepatitis, especially hepatitis C
  

• Polycythemia vera
  
• Iron-deficiency anemia
  
• Paraproteinemia
  
• Waldenström macroglobulinemia
  
• Mastocytosis