The urologist and the patient infected with human immunodeficiency virus or with acquired immunodeficiency syndrome

Acute and Chronic Infectious Prostatitis in Older Adults

Acute and chronic bacterial prostatitis are clinically significant entities that can be difficult to diagnose and appropriately treat. Herein, we review when to suspect these clinical conditions, how to diagnose them, and how to effectively treat them based on the extant literature. Our aim was to equip the practicing clinician with the ability to proficiently diagnose and manage acute and chronic bacterial prostatitis, particularly in older patients.

Renal Cell Carcinoma Associated With HIV/AIDS: A Review of the Epidemiology, Risk Factors, Diagnosis, and Treatment

Renal cell carcinoma (RCC), one of the most common genitourinary tumors, is induced by many factors, primarily smoking, obesity, and hypertension. As a non-acquired immunodeficiency syndrome (AIDS)-defining cancer, human immunodeficiency virus (HIV) may also play a critical role in the incidence and progression of RCC. It is evident that individuals who are infected with HIV are more likely than the general population to develop RCC. The age of RCC diagnosis among HIV-positive patients is younger than among HIV-negative individuals. However, many other characteristics remain unknown. With the increase in RCC incidence among HIV-infected patients, more research is being conducted to discover the relationship between RCC and HIV, especially with regard to HIV-induced immunodeficiency, diagnosis, and treatment. Unexpectedly, the majority of the literature suggests that there is no relationship between RCC and HIV-induced immunodeficiency. Nonetheless, differences in pathology, symptoms, or treatment in HIV-positive patients diagnosed with RCC are a focus. In this review, we summarize the association of RCC with HIV in terms of epidemiology, risk factors, diagnosis, and treatment.

Genitourinary Tract Infections

Similarly to the general population, genitourinary tract infections are common conditions in theimmunocompromised host. They can be furthermore divided into infections of the urinary tract and genital tract infections. Transplant recipients are more likely to have infections of the urinary tract infections while persons with human immunodeficiency virus (HIV) are at higher risk for the second group of infections, especially sexually transmitted infections (STIs). Manifestations of these diseases can be associated with more complications and can be more severe. We provide an overview of manifestations, diagnosis, and management of these disorders.

Prevalence of nephrolithiasis in human immunodeficiency virus infected patients on the highly active antiretroviral therapy

BACKGROUND AND PURPOSE

Protease inhibitors, specifically indinavir, have historically been implicated as a cause of nephrolithiasis in the human immunodeficiency virus (HIV) infected patients. There is a paucity of data, however, on stone disease with nonindinavir etiologies since the introduction of highly active antiretroviral therapy (HAART). We sought to describe the prevalence of nephrolithiasis in the HIV population since the use of HAART.

PATIENTS AND METHODS

We retrospectively reviewed HIV-positive patients currently receiving HAART treatment in whom image proven kidney and/or ureteral urolithiasis developed, between 1998 and 2010. A detailed analysis of patients' current treatment, surgical intervention, and metabolic studies was performed.

RESULTS

A total of 436 HIV-positive patients were included and 46 (11%) patients had nephrolithiasis. Each patient included in this study was receiving nonindinavir-based antiretroviral therapy. There were 41 men of whom 36 were Caucasian. Eleven (24%) patients underwent 24-hour urine collections with 11 metabolic abnormalities identified. Stone analysis was available for seven patients (four calcium oxalate monohydrate, one cystine, one uric acid, and one atazanavir).

CONCLUSIONS

We report the largest series of nephrolithiasis in an HIV population since the introduction of HAART and highlight not only the similar prevalence of nephrolithiasis to the non-HIV population but also the lack of consistent comprehensive metabolic evaluations in HIV patients with recurrent nephrolithiasis.

The evolution of lasers in urology

The world's first laser was developed by Theodore Maiman in 1960. Over the course of the past five decades, this technology has evolved into a highly specialized entity, also finding a niche market in the field of urology. Lasers obtained from various lasing mediums producing amplified light of different wavelengths have been tested for urological applications. Today, these lasers are most commonly used in the surgical management of benign prostatic hyperplasia and as intracorporeal lithotripters. Other uses include ablation of various urologic tumors and incising strictures of the upper- and lower urinary tract. A continuous process of evolution of this technology is taking place, resulting in surgical lasers becoming ever safer, more effective, and more affordable.

Urologic aspects of HIV infection

Although lifespan has dramatically improved in the human immunodeficiency virus-positive (HIV+) population, HIV and its treatment continue to be a source of substantial morbidity in many organ systems, including the genitourinary tract. As the number of long-term survivors increases with advances in antiretroviral therapy, age-associated urologic symptoms are also becoming increasingly relevant considerations for people living with HIV. Primary care physicians have a major role to play in maintaining the genitourinary health of their HIV+ patients. This role is of great importance not just for the well-being of the individual patient but for the public health, as the genitourinary tract is a common vector for HIV transmission. In this article the authors review the management of the genitourinary system in patients with HIV infection. Particular consideration is given to urinary tract infections, lower urinary tract symptoms, renal insufficiency, sexual and fertility problems, and cancers of the genitourinary tract. Management algorithms are outlined and indications for referral to a urologist are emphasized.

HIV-associated bladder cancer: a case series evaluating difficulties in diagnosis and management

BACKGROUND

Chronic human immunodeficiency virus (HIV) infection is associated with an increased incidence of Non-Acquired Immunodeficiency Syndrome (non-AIDS) defining cancers. To date, only a limited number of cases of bladder cancer have been linked with HIV infection. We sought to describe the clinical characteristics of HIV-associated bladder cancer.

METHODS

A retrospective study was performed involving HIV-positive patients with bladder cancer, combining cases from multiple institutions with published case reports. Data regarding patient demographics, HIV status, clinical presentation, pathology, cancer treatment, and outcome were analyzed using descriptive statistics.

RESULTS

Eleven patients were identified with a median age of 55 years (range, 33-67). The median CD4+ count at cancer diagnosis was 280 cells/mm3 (range, 106-572 cells/mm3). Six patients (55%) had a known risk factor for bladder cancer, and nine (82%) presented with hematuria. Ten patients had transitional cell carcinoma, and most had superficial disease at presentation. Treatment included mainly transurethral resection of bladder tumor followed by a combination of local and systemic therapies. One patient received intravesical bacillus Calmette-Guèrin (BCG) without complication. Several patients (55%) were alive following therapy, although many (64%) suffered from local relapse and metastatic disease.

CONCLUSION

Bladder cancer is part of the growing list of cancers that may be encountered in patients living longer with chronic HIV-infection. Our patients presented at a younger age and with only mild immunosuppression, however, they experienced an expected course for their bladder cancer. Hematuria in an HIV-infected patient warrants a complete evaluation.

Human immunodeficiency virus--associated renal cell carcinoma: a transatlantic case series

OBJECTIVE

The spectrum of diseases associated with human immunodeficiency virus (HIV) infection has changed dramatically following the introduction of highly active antiretroviral therapy (HAART). Non-AIDS-defining cancers, including renal cell carcinoma (RCC), are being recognized increasingly in this population. Our aim was to describe the risk factors, clinical findings, pathology, and response to therapy of RCC in patients infected with HIV.

PATIENTS AND METHODS

We identified 9 men with HIV infection who developed RCC. Data regarding their HIV status, RCC risk factors, clinical presentation, and pathology were collected. A detailed retrospective chart review focusing on the course of their malignancy, response to therapy, and outcome was performed.

RESULTS

Renal cell carcinoma was diagnosed in patients with a median age of 48 years, and most had a history of tobacco use. No association between HIV-related immunosuppression (mean CD4 count, 301 cells/mm3) and the development, clinical presentation, pathology, or behavior of RCC was identified. Long-term survival correlated with early nephrectomy, and the use of interleukin-2 therapy for advanced RCC was not additive. A total of 5 patients died, 1 from a pulmonary embolism and 4 from disseminated RCC.

CONCLUSION

Renal cell carcinoma should be included in the expanding array of non-AIDS-defining malignancies that develop during the course of HIV infection. Acknowledging the inherent limitations of our small study, these data show that the clinical presentation and behavior of RCC in patients with HIV appear similar to that of the HIV-negative population and that chronic immunosuppression plays a lesser role than age and exposure to risk factors in this setting.

HIV-AIDS: urologic considerations

The prevalence of HIV continues to grow in the United States and worldwide. HIV-positive patients experience many genitourinary disease processes. With improvements in HIV therapy, patients have questions and concerns pertaining to their quality of life. This article reviews conditions such as HIV-related urinary tract infections, urolithiasis, voiding dysfunction, fertility, sexual dysfunction, HIV-related nephropathy, malignancies, and occupational exposure and prophylaxis. Knowledge of the various HIV manifestations of genitourinary conditions and their treatment options benefits clinicians and improves patient outcomes.

Bladder carcinoma and HIV infection during the highly active antiretroviral therapy era: A rare, but intriguing association. Two case reports and literature review

Two very rare case reports of bladder transitional cell carcinoma associated with HIV infection in patients treated with combined antiretroviral therapy are described, and discussed on the ground of the most relevant and updated literature resources. Only 13 cases of vesical carcinoma have been reported to date in the setting of HIV infection, but only 3 anecdotal single reports (the last in the y 2001) described clinical, therapeutic, and outcome issues of this rare disease association in some detail. In our patients, micro- or macro-haematuria was the clue for in-depth diagnosis and prompt treatment, which was limited to multiple local interventions in 1 case, but finally required a radical cystectomy in the second patient. No relationship was found with the very favourable underlying HIV-related virological and immunological status, and the present 8-12-month follow-up did not show disease relapses.

The management of chronic prostatitis in men with HIV

Prostatitis is a common urologic diagnosis. Although treatment algorithms are available for this poorly understood entity, several adaptations must be made in order to accommodate the therapeutic needs of HIV-positive patients. The most important consideration when treating HIV-infected patients for prostatitis is their current immune status, whether they are immunocompromised or not (non-progressive disease or reconstituted with highly active antiretroviral therapy). A treatment algorithm for those with chronic bacterial prostatitis (Category II), chronic nonbacterial prostatitis (Category IIIA), and prostatodynia (Category IIIB) is presented in this article. In the HIV-positive patient population, there is a greater likelihood for atypical pathogens including fungi, tuberculosis, anaerobes, and viruses. Because the HIV-infected patient is at increased risk for the development of prostatic abscess and urosepsis than the general population, increased monitoring and evaluation and longer-term appropriately directed antimicrobial therapy are required.

Disseminated, lethal prostate cancer during human immunodeficiency virus infection presenting with non-specific features

INTRODUCTION

Prostate cancer is a very infrequent occurrence in persons aged 55 years or less, and it has been rarely reported in HIV-infected patients (10 overall cases so far); therefore, an increased incidence compared with the general population has not been established, although a younger age seems more frequent among population with HIV disease.

CASE REPORT

We report a case of metastatic prostate cancer occurred in a 53-year-old HIV-infected man, admitted due to non-specific signs, and symptoms: impaired general conditions, fever, weight loss, fatigue, and exertional dyspnea. A remarkable anemia and an aortic systolic murmur were the prominent initial findings, while AIDS-related conditions were not suspected due to a sustained CD4+ count and a contained viremia, which never required antiretroviral therapy. Repeated red blood cell transfusions and an empiric, combined antimicrobial therapy were promptly carried out, under the suspicion of infectious endocarditis, but no appreciable improvement of clinical conditions was achieved. Subsequently, our patient complained not only of an increasingly severe pain at the root of his left thigh, together with overcoming dysuria and urgency, but also urinary tract infection that was rapidly ruled out. During the diagnostic workup for an HIV-associated fever of undetermined origin, a bone marrow biopsy disclosed a metastatic prostatic cancer, with elevated prostate specific antigen (PSA) and acid phosphate levels. An abdominal-pelvic ultrasonography and computerized tomographic scan allowed to detect a dyshomogeneous endopelvic expansive mass with extrinsic compression of the urinary bladder, and involvement of the last lumbar vertebra, large portions of pelvis, and the proximal epiphysis of the right femur. A skeleton scintigraphy pointed out multiple hypercaptation (areas of concentrated traces of radioactivity) areas with involvement of cranial, cervical, dorsal, lumbar, and sacral vertebrae, as well as the pelvis and upper portions of both femurs. Despite therapeutic attempts, our patient deceased after seven weeks due to an overwhelming disseminated intravascular coagulation (DIC).

CONCLUSIONS

The non-specific clinical presentation of our case (mimicking other generalized or focal illnesses), and the final, lethal complication (DIC) pose striking problems related to the differential diagnosis during HIV disease, while the rapid evolution into an advanced, complicated, and widely metastatic disease with extensive bone marrow invasion which preceded the appearance of local signs-symptoms, and the lethal overwhelming DIC, deserves attention by specialists who care for HIV-infected subjects.

Objective measurement of bladder sensation: use of a new patient-activated device and response to neuromodulation

Detrusor overactivity is the primary objective focus of most investigations into the diagnosis and management of patients with urgency incontinence. Patients with an overactive bladder are characteristically troubled by subjective sensations of bladder fullness and urinary urgency, and frequently void at low bladder volumes attained before noticeable detrusor overactivity occurs. Bladder sensations are therefore crucial to understanding voiding patterns and symptoms, but little progress has been made in objectively describing the range of these sensations, and adequate information is lacking about their response to neuromodulation. Towards this end, a keypad 'urge score' device was designed to measure sensations during bladder filling. This patient-activated device gathers information about patient perceptions of bladder filling and the successive stages of increasing bladder sensation, without prompting or intervention by the investigator. The accuracy of the 'urge keypad' during filling cystometrography was validated in patients with urgency incontinence, and compared with data abstracted from patient voiding diaries. The device provides reliable and repeatable measures of different bladder sensations, with excellent, statistically significant consistency between bladder volumes and corresponding levels of sensation. Subsequently, it was shown that the sensation of urgency can be suppressed by neuromodulation in most patients tested; this suppression occurs with improvements in bladder capacity and voided volumes. It is therefore suggested that urodynamics with concurrent sensory evaluation may offer a more useful assessment tool for selecting those patients for therapies such as neuromodulation who present predominantly with the symptom of urgency.

The urological management of the patient with acquired immunodeficiency syndrome

In people infected with the human immunodeficiency virus (HIV) both the CD4 T-cell count and the viral load are used to monitor disease progression to acquired immunodeficiency syndrome (AIDS). CD4 counts of <500/mm(3) are associated with opportunistic infections and certain malignancies, so-called 'AIDS-defining' conditions. Highly active antiretroviral therapy, using combinations of reverse transcriptase inhibitors and/or protease inhibitors, can improve considerably the prognosis of people who are HIV-positive, but such therapy is not yet widely available in many developing countries. People with AIDS are predisposed to urinary tract infection (UTI) by uncommon bacteria and pathogens, e.g. fungi, parasites and viruses, which may affect any urogenital organ; treatment should be culture-specific and long-term, because there is a tendency to recurrence, infection with multiple organisms and resistant isolates. Voiding dysfunction in patients with AIDS is usually a result of neurological complications caused by opportunistic infections, and has a poor prognosis. Of patients with AIDS, 30-50% develop a cancer, especially Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma (NHL). KS may involve any urogenital organ, but is usually part of systemic disease. Small lesions on the external genitalia can be treated with laser, cryotherapy or surgical excision, larger lesions with radiotherapy, and disseminated or visceral KS with multidrug chemotherapy. NHL may involve the kidneys, testes and retroperitoneal lymph nodes, thus obstructing the ureters, which may require ureteric stenting or percutaneous nephrostomy. NHL can be treated with radiotherapy and combination chemotherapy. Urolithiasis in patients with AIDS may be caused by indinavir, a protease inhibitor, but the more common types of stones may also occur. Fluid-electrolyte and acid-base disturbances are common in patients with advanced AIDS, secondary to vomiting, diarrhoea, malnutrition or septicaemia. HIV-associated nephropathy occurs in 10-30% of patients, and often leads to renal failure. Testicular atrophy is common, leading to infertility, erectile dysfunction (ED) and decreased libido. Treatment for ED must include counselling about strategies to reduce the transmission of HIV. The risk of HIV transmission after parenteral exposure to blood from an HIV-positive patient is relatively low (0.2-0.4%); the urologist can reduce the risk of transmission during surgery by adopting certain precautions. After occupational exposure to HIV, chemoprophylaxis with antiretroviral medication can significantly reduce the probability of HIV transmission.

AIDS and the urologist

The management of HIV infection has dramatically altered the natural history of the disease. Prevention of opportunistic infections and the development of HAART regimens altered the manifestations and conditions that urologists are being asked to evaluate and manage in this patient population.