Effects of Tadalafil Once-Daily or On-Demand vs Placebo on Return to Baseline Erectile Function After Bilateral Nerve-Sparing Radical Prostatectomy--Results from a Randomized Controlled Trial (REACTT).

INTRODUCTION AND AIM: The multicenter, randomized, double-blind, double-dummy, placebo-controlled REACTT trial suggested that treatment with tadalafil once daily (OaD) started early after bilateral nerve-sparing radical prostatectomy (nsRP) for prostate cancer may contribute to erectile function (EF)-recovery, which was predefined as achieving an International Index of Erectile Function (IIEF)-EF score ≥22. Here, we report descriptive post-hoc analyses, using the more strict definition for EF-recovery of returning back to the pre-surgery IIEF-EF-level ("back-to-baseline analysis"). METHODS: REACTT included 422 men <68 years with adenocarcinoma of the prostate and preoperative IIEF-EF ≥22 who underwent nsRP at 50 centers from 9 European countries and Canada. Patients were randomized post-nsRP 1:1:1 to 9-month double-blind treatment (DBT) with tadalafil 5 mg OaD (n = 139), tadalafil 20 mg on-demand (pro-re-nata, PRN; n = 142), or placebo (n = 141), followed by 6-week drug-free washout (DFW) and 3-month open-label tadalafil OaD treatment (OLT). MAIN OUTCOME MEASURES: Proportion of patients returning to their preoperative IIEF-EF category (22-25 or ≥26) at the end of DBT, DFW, and OLT. RESULTS: Overall, 92.4% of patients had pre-surgery (baseline) IIEF-EF scores ≥26 (tadalafil OaD 94.2%, PRN 91.6%, placebo 91.5%), 7.4% had IIEF-EF 22-25. At the end of DBT, 22.3% of patients on tadalafil OaD had achieved "back-to-baseline" IIEF-EF, compared with 11.3% on tadalafil PRN and 7.8% on placebo. Of all 58 patients "back-to-baseline" at the end of DBT, only 1 PRN-group patient had started from a baseline IIEF-EF <26. The treatment-group difference at the end of DBT was not maintained after DFW. After 3 months of OLT with tadalafil OaD, the proportion of patients with "back-to-baseline" IIEF-EF had almost doubled in all 3 groups. CONCLUSION: Changing the definition for EF-recovery from IIEF-EF ≥22 to the more strict definition of "returning back-to-baseline IIEF-EF" had no major impact. Tadalafil OaD started early after nsRP improved drug-assisted EF, but had no effect on unassisted EF following treatment cessation after 9 months.

Exploratory Decision-Tree Modeling of Data from the Randomized REACTT Trial of Tadalafil Versus Placebo to Predict Recovery of Erectile Function After Bilateral Nerve-Sparing Radical Prostatectomy.

BACKGROUND: Understanding predictors for the recovery of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) might help clinicians and patients in preoperative counseling and expectation management of EF rehabilitation strategies. OBJECTIVE: To describe the effect of potential predictors on EF recovery after nsRP by post hoc decision-tree modeling of data from A Study of Tadalafil After Radical Prostatectomy (REACTT). DESIGN, SETTING, AND PARTICIPANTS: Randomized double-blind double-dummy placebo-controlled trial in 423 men aged <68 yr with adenocarcinoma of the prostate (Gleason ≤7, normal preoperative EF) who underwent nsRP at 50 centers from nine European countries and Canada. INTERVENTION: Postsurgery 1:1:1 randomization to 9-mo double-blind treatment with tadalafil 5mg once a day (OaD), tadalafil 20mg on demand, or placebo, followed by a 6-wk drug-free-washout, and a 3-mo open-label tadalafil OaD treatment. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Three decision-tree models, using the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score at the end of double-blind treatment, washout, and open-label treatment as response variable. Each model evaluated the association between potential predictors: presurgery IIEF domain and IIEF single-item scores, surgical approach, nerve-sparing score (NSS), and postsurgery randomized treatment group. RESULTS AND LIMITATIONS: The first decision-tree model (n=422, intention-to-treat population) identified high presurgery sexual desire (IIEF item 12: ≥3.5 and <3.5) as the key predictor for IIEF-EF at the end of double-blind treatment (mean IIEF-EF: 14.9 and 11.1), followed by high confidence to get and maintain an erection (IIEF item 15: ≥3.5 and <3.5; IIEF-EF: 15.4 and 7.1). For patients meeting these criteria, additional non-IIEF-related predictors included robot-assisted laparoscopic surgery (yes or no; IIEF-EF: 19.3 and 12.6), quality of nerve sparing (NSS: <2.5 and ≥2.5; IIEF-EF: 14.3 and 10.5), and treatment with tadalafil OaD (yes and no; IIEF-EF: 17.6 and 14.3). Additional analyses after washout and open-label treatment identified high presurgery intercourse satisfaction as the key predictor. CONCLUSIONS: Exploratory decision-tree analyses identified high presurgery sexual desire, confidence, and intercourse satisfaction as key predictors for EF recovery. Patients meeting these criteria might benefit the most from conserving surgery and early postsurgery EF rehabilitation. Strategies for improving EF after surgery should be discussed preoperatively with all patients; this information may support expectation management for functional recovery on an individual patient level. PATIENT SUMMARY: Understanding how patient characteristics and different treatment options affect the recovery of erectile function (EF) after radical surgery for prostate cancer might help physicians select the optimal treatment for their patients. This analysis of data from a clinical trial suggested that high presurgery sexual desire, sexual confidence, and intercourse satisfaction are key factors predicting EF recovery. Patients meeting these criteria might benefit the most from conserving surgery (robot-assisted surgery, perfect nerve sparing) and postsurgery medical rehabilitation of EF. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01026818.

Tadalafil 5 mg once daily for the treatment of erectile dysfunction during a 6-month observational study (EDATE): impact of patient characteristics and comorbidities.

BACKGROUND: To explore the impact of patient-characteristics and relevant comorbidities on treatment continuation rates, effectiveness, and satisfaction in patients with erectile dysfunction (ED) who started or switched to tadalafil 5 mg once daily (TAD-OaD) at baseline. METHODS: In the EDATE observational study, phosphodiesterase-type-5 (PDE5)-inhibitor pretreated or naïve ED patients who started or switched to TAD-OaD were prospectively followed for 6 months. Time to discontinuation of TAD-OaD was estimated using the Kaplan-Meier product-limit method at Months 2, 4, and 6 in subgroups stratified by age (18 - 65 years and >65 years), PDE5-inhibitor pretreatment, ED-severity (mild, moderate, severe), and presence or absence of relevant comorbidities (BPH, diabetes, CVD, hypertension, dyslipidemia). LSmean change from baseline in International Index of Erectile Function (IIEF) and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores and associated 95 % CIs were assessed using a mixed-model for repeated measures. Visit, ED etiology, and subgroups were included as fixed-effects. RESULTS: Overall, 778 patients received prescriptions for initiating or switching to TAD-OaD at baseline. At Month 2, >90 % of patients remained on TAD-OaD, except those aged >65 years (86.7 %) and patients with severe ED (89.0 %). More than 80 % of patients in all subgroups, except those aged >65 years (75.0 %), continued TAD-OaD at Month 6. There was a significant LSmean negative effect on IIEF- EF domain-score improvement for BPH (LSmean effect [95 % CI]: -2.77 [-4.98, -0.55], p = 0.014), previous PDE5-inhibitor treatment (-2.13 [-3.33,-0.94], p < 0.001), and mild vs moderate ED (-2.00 [-3.54,-0.46], p = 0.011); the latter possibly linked with a bigger treatment-effect in those with more severe ED at baseline. The LSmean effect on change in IIEF-EF was significantly positive for diabetes (2.28 [0.64,3.92], p = 0.007), most likely because those with diabetes had more severe ED at baseline. For all other parameters, no statistically significant LSmean effects in IIEF-EF changes were observed. No comorbidity or baseline-characteristic except age (18 - 65 years vs >65 years: 11.25 [2.96,19.54], p = 0.008) affected changes in EDITS. CONCLUSIONS: Under routine clinical conditions, treatment continuation rate or satisfaction does not seem to be significantly affected by the presence of comorbidities in men who choose ED-treatment with TAD-OaD. The magnitude of treatment effectiveness was affected by certain baseline characteristics and comorbid conditions. TRIAL REGISTRATION: The study (H6D-EW-LVIU) is registered in the German VfA Registry of Non-Interventional Studies (Verband Forschender Arzneimittelhersteller) since 06 December 2011; available at: http://www.vfa.de/de/arzneimittel-forschung/datenbanken-zu-arzneimitteln/nisdb/nis-details/_741 .

Predictors of Individual Response to Placebo or Tadalafil 5mg among Men with Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: An Integrated Clinical Data Mining Analysis.

BACKGROUND: A significant percentage of patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) achieve clinically meaningful improvement when receiving placebo or tadalafil 5mg once daily. However, individual patient characteristics associated with treatment response are unknown. METHODS: This integrated clinical data mining analysis was designed to identify factors associated with a clinically meaningful response to placebo or tadalafil 5mg once daily in an individual patient with LUTS-BPH. Analyses were performed on pooled data from four randomized, placebo-controlled, double-blind, clinical studies, including about 1,500 patients, from which 107 baseline characteristics were selected and 8 response criteria. The split set evaluation method (1,000 repeats) was used to estimate prediction accuracy, with the database randomly split into training and test subsets. Logistic Regression (LR), Decision Tree (DT), Support Vector Machine (SVM) and Random Forest (RF) models were then generated on the training subset and used to predict response in the test subset. Prediction models were generated for placebo and tadalafil 5mg once daily Receiver Operating Curve (ROC) analysis was used to select optimal prediction models lying on the ROC surface. FINDINGS: International Prostate Symptom Score (IPSS) baseline group (mild/moderate vs. severe) for active treatment and placebo achieved the highest combined sensitivity and specificity of 70% and ~50% for all analyses, respectively. This was below the sensitivity and specificity threshold of 80% that would enable reliable allocation of an individual patient to either the responder or non-responder group. CONCLUSIONS: This extensive clinical data mining study in LUTS-BPH did not identify baseline clinical or demographic characteristics that were sufficiently predictive of an individual patient response to placebo or once daily tadalafil 5mg. However, the study reaffirms the efficacy of tadalalfil 5mg once daily in the treatment of LUTS-BPH in the majority of patients and the importance of evaluating individual patient need in selecting the most appropriate treatment.

Erectile dysfunction in patients with chronic viral hepatitis: a systematic review of the literature.

INTRODUCTION: This article reviews the literature on epidemiology and pathogenetic factors of erectile dysfunction in patients with chronic viral hepatic (CVH) diseases in men and the potential implications for diagnosis and treatment. AREAS COVERED: A search to identify original articles, reviews and any other article suitable for the purposes of this review was conducted by combining the following terms: erectile dysfunction and/or sexual dysfunction, chronic viral hepatitis, hepatitis B virus infection and hepatitis C virus infection. EXPERT OPINION: The results of this review have led to the following main observations: i) there is scarce documentation on the association between CVH and sexual dysfunction; ii) hormonal impairment seems to be a major component in the development of erectile dysfunction in CVH; however, published evidence concerning the contribution of other pathogenetic factors is rare and inconclusive and iii) available treatment options for CVH potentially contribute to the development of sexual dysfunction in these patients. Due to the scarce body of evidence, more research is needed to better clarify the mechanisms underlying the association between CVH and sexual dysfunction, the impact of therapy and associated comorbidities on sexual dysfunction and the role of pharmacological treatments in the management of these patients.

BPH/LUTS and ED: common pharmacological pathways for a common treatment.

INTRODUCTION AND AIM: This article reviews the current literature on common physiopathogenetic factors and pharmacological pathways of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) in men and their implications for diagnosis and treatment. MAIN OUTCOME MEASURES AND METHODS: A literature search was conducted to identify original articles, reviews, editorials, and international scientific congress abstracts by combining the following terms: lower urinary tract symptoms, erectile dysfunction and phosphodiesterase type 5 inhibitors (and their abbreviations LUTS, ED and PDE5-Is). RESULTS: We identified manuscripts presenting: (i) The existence of several newly discovered common pathophysiological mechanisms of LUTS and ED indicating that PDE5-Is might represent an alternative to current treatments of men with LUTS (e.g., α1-adrenergic blockers and 5α-reductase inhibitors); (ii) Randomized controlled clinical trials have shown that treatment with PDE5-Is is associated with improvements in both LUTS and ED in men with significant problems in both areas. CONCLUSION: The presence of common pathophysiological mechanisms between LUTS and ED seems well recognized and needs further exploration. Further comparisons between different PDE5-Is would be useful to determine the most appropriate regimen and their efficacy to safety ratio.

Erectile rehabilitation with intracavernous alprostadil after radical prostatectomy: refusal and dropout rates.

UNLABELLED: Study Type--Therapy (outcomes) Level of Evidence 2a. What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a well known implication of radical prostatectomy (RP). Despite the search for technical improvement in the surgical procedure (e.g. nerve-sparing surgery, robot-assisted RP), many patients still suffer from an inability to achieve a satisfactory erection after surgery. In the last 20 years a great effort has been made to re-establish good sexual function in these patients. Many different approaches have been used, such as intracavernous prostaglandin E1 (PGE1), phosphodiesterase-5 inhibitors, vacuum devices and penile prostheses. Although many studies have addressed the main questions about efficacy of different approaches to ED, there is a lack of data about adherence to therapy and the main reasons why patients drop out of these treatment programmes. In the present study, a cohort of men treated with RP underwent a postoperative rehabilitation protocol with PGE1 intracavernous injections. During the follow-up period, we were able to assess a real-life practice pattern of adherence and dropout, evaluating the main causes of therapy discontinuation. This could be of help in the counselling of these patients during the path towards erection recovery. OBJECTIVES: • To assess the rate of compliance in the first 6 months of a rehabilitation protocol that includes intracavernous alprostadil administration in patients undergoing radical retropubic prostatectomy. • To determine the reasons for and timings of dropout from the protocol by the patients and their subsequent outcomes. PATIENTS AND METHODS: • All patients undergoing radical prostatectomy (RP) at our institution between 1 January 2007 and 31 December 2009 were considered for a protocol of postoperative intracavernous sexual rehabilitation and were administered entry questionnaires to evaluate their preoperative sexual activity. • Four weeks after surgery, the patients were invited to return for a first visit, where the aim of the protocol and possible risks and benefits were explained. For those who agreed to attend, subsequent visits to include assisted self-administration of increasing doses of intracavernous alprostadil and a period of autonomous homely self-administration were planned. • Patients were followed up at 3-month intervals, where data on functional outcomes, patient satisfaction, and the number of patients who dropped out and their reasons, were recorded by means of appropriate questionnaires. • Statistical analysis was performed using Student's t-test or a chi-squared test, where appropriate. RESULTS: • Of 430 patients, 157 (36.5%) refused to undergo the protocol of rehabilitation and 18.6% of the patients who began the protocol dropped out over the first 6 months. • Reasons for refusal were: patient's lack of sexual interest (51.6%); lack of interest by the partner (30.2%); and presence of transitory incontinence (26.7%). • Reasons for dropout were: disappointment with treatment efficacy (64.7%); injection pain (45%); and difficulties with or fear of performing the injection by themselves or by the partner (35.2%). No patient claimed the cost of the drug to be a cause for dropout. CONCLUSIONS: • The protocol we used, involving intracavernous alprostadil injection, proved to be a safe and efficient way of achieving sexual rehabilitation in patients who have undergone RP. Nevertheless, high patient motivation and adherence to the protocol were required. • Factors influencing patients refusal and early-to-medium time dropout were both patient- and partner-related. Appropriate information, counselling and support of the couple before the beginning and at all stages of the rehabilitation play a fundamental role in reducing the dropout rate. • The situation regarding those patients who still need adjuvant therapy after surgery is less clear and further research on this is required.

Prognostic value of CD44 expression in penile squamous cell carcinoma: a pilot study.

BACKGROUND: Several studies have reported on the prognostic value of molecular markers for metastasis risk and survival in penile squamous cell carcinoma (SCC) patients. The usefulness of CD44 expression as such a marker has been studied in different tumors, but not in penile SCC. Our aim was to determine whether CD44 expression may serve as a prognostic marker for lymph node metastasis and survival in penile SCC patients. METHODS: CD44 immunoistochemical expression was investigated in tissue specimens from 39 patients with penile SCC. CD44 cell positivity, staining intensity and distribution were analyzed and correlated with tumor stage, grade, lymph node status and disease-specific survival. RESULTS: CD44 expression was detected in epithelial cells of both intratumoral and normal tissues with different intensities and staining distributions. In normal tissues CD44 protein was mainly detected in cell membranes, whereas in the tumor compartments it was found in both the cell membranes and the cytoplasm. The intensities and percentages of CD44 expressing cells did not correlate with tumor stage and/or grade. Seventy-three percent of the patients with lymph node metastasis showed high intensities of CD44 staining, as compared to 44% of the patients without lymph node metastasis (P = 0.03). Lymph node-positive patients showed both cytoplasmic and membranous CD44 expression. High CD44 expression was found to be significantly correlated with a decreased 5 year overall survival (P = 0.01). CONCLUSIONS: CD44 levels and patterns of expression can be considered as markers for penile SCC aggressiveness and, in addition, may serve as predictive markers for lymph node metastasis, also in patients with clinically negative lymph nodes. CD44 expression may provide prognostic information for penile SCC patients, next to classical clinical-pathological factors.

Efficacy of tigecycline and rifampin alone and in combination against Enterococcus faecalis biofilm infection in a rat model of ureteral stent.

BACKGROUND: We investigated the efficacy of tigecycline and rifampin alone or combined in preventing ureteral stent infection due to Enterococcus faecalis. MATERIALS AND METHODS: The activities of the two antibiotics were previously studied in vitro in absence or in presence of biofilm. For in vivo research, the study included a control group without bacterial challenge to evaluate the sterility of surgical procedure, a challenged control group that did not receive any antibiotic prophylaxis and, for each bacterial strain, three challenged groups that received: (1) 2 mg/kg intraperitoneal tigecycline, immediately after stent implantation; (2) rifampin-coated ureteral stents where 0.2 cm(2) sterile ureteral stents were incubated in 10 mg/L rifampin solution for 30 min immediately before implantation; and (3) intraperitoneal tigecycline plus rifampin-coated ureteral stent at the above concentrations. Ureteral stents were explanted at d 5 following implantation and biofilm bacteria enumerated. RESULTS: The in vitro studies showed that the biofilm was strongly affected by the presence of rifampin and, in its presence, tigecycline had MICs and MBCs lower than those obtained in the absence of rifampin. Intraperitoneal tigecycline exerted stronger effect than rifampin on bacterial numbers. The combination rifampin plus tigecycline showed efficacies higher than that of each single compound. CONCLUSION: These results highlight the potential usefulness of tigecycline in preventing enterococcal ureteral stent infections and the role of rifampin as an interesting antibiotic enhancer.

Urinary tract infections in women: etiology and treatment options.

Urinary tract infections (UTI) are common among the female population. It has been calculated that about one-third of adult women have experienced an episode of symptomatic cystitis at least once. It is also common for these episodes to recur. If predisposing factors are not identified and removed, UTI can lead to more serious consequences, in particular kidney damage and renal failure. The aim of this review was to analyze the factors more commonly correlated with UTI in women, and to see what possible solutions are currently used in general practice and specialized areas, as well as those still under investigation. A good understanding of the possible pathogenic factors contributing to the development of UTI and its recurrence will help the general practitioner to interview the patient, search for causes that would otherwise remain undiscovered, and to identify the correct therapeutic strategy.

D2-40 immunoreactivity in penile squamous cell carcinoma: a marker of aggressiveness.

D2-40 immunohistochemical expression was investigated in tissue specimens from 39 patients with squamous cell carcinoma of the penis who underwent partial or total penectomy between 1987 and 2008. Patient age, tumor size, and grade; D2-40-positive lymphatic vessel density in intratumoral, peritumoral, and normal tissue; cell positivity for D2-40 in intratumoral and normal tissue; and D2-40 staining intensity and distribution were analyzed and correlated with disease-specific survival. Analysis of D2-40-positive lymphatics disclosed that mean lymphatic vessel density was greater in peritumoral tissue than in intratumoral and normal tissue and lower in patients with lymph node metastasis than in those without lymph node metastasis. The receiver operating characteristic curve showed that an intratumoral lymphatic vessel density greater than 2.0 had 83.3% sensitivity and 78% specificity in predicting lymph node metastasis. Analysis of cell immunoreactivity showed cytoplasmic D2-40 positivity in intratumoral and normal tissue in 89.7% and 65.5% of patients, respectively. A strong correlation emerged between grade of cell differentiation and D2-40 immunoreactivity in intratumoral tissue; in particular, 88.9% of tumors with weak podoplanin expression were G1, whereas strong cellular immunoreactivity was detected in 83.3% of G3 patients (P = .003; χ(2) test). A significant correlation was also noted between pattern of reactivity and tumor grade because the basal layer was positive in patients with undifferentiated tumors (100% of G3) and in 72.2% of G1 tumors (P = .021; χ(2) test). D2-40 seems to be a useful marker for the development of node metastasis in squamous cell carcinoma of the penis, although validation in larger series is required to confirm its predictive value.

The role of uroflowmetry biofeedback and biofeedback training of the pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a randomized controlled prospective study.

OBJECTIVES: To evaluate the efficacy of a training program with uroflowmetry biofeedback and pelvic floor relaxation biofeedback on urodynamic and voiding parameters in women with dysfunctional voiding. METHODS: Eighty-six women with recurrent urinary tract infections (UTIs) and dysfunctional voiding were randomly assigned to receive a treatment schedule as follows: uroflowmetry biofeedback (group 1), biofeedback training of the pelvic floor muscles (group 2), uroflowmetry biofeedback combined to biofeedback training of the pelvic floor muscles (group 3), no treatment (group 4). Patients were regularly evaluated by American Urological Association Symptom Index and urodynamics during the study period. All the patients were followed up for 1 year with monthly urine cultures. A further evaluation was done at month 24 by American Urological Association Symptom Index and free uroflowmetry with measurement of residual urine. RESULTS: The prevalence of storage and emptying symptoms decreased significantly at 3, 6, and 12 months in the groups 1, 2, and 3, and remained stable during the study period. Mean flow rate, flow time, voiding volume increased significantly, whereas postvoid residual urine decreased. The prevalence of UTI decreased significantly in groups 1, 2, and 3. At month 24, storage and emptying symptoms and voiding patterns were similar to the baseline values in all the patients. The incidence of UTIs was similar to baseline values in groups 1, 2, and 3. CONCLUSIONS: Training the voluntary control of the pelvic floor seems essential in obtaining control over the bladder function. These results reinforce the importance of pelvic floor therapy in the resolution of UTIs.

The role of the prostatic stroma in chronic prostatitis/chronic pelvic pain syndrome.

OBJECTIVE: To confirm the hypothesis of prostatic stromal involvement in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). MATERIALS AND METHODS: A literature review to analyze mechanisms commonly indicated as a cause of CP/CPPS that can interfere with the processes of cell growth of smooth muscle fibrocells and may cause smooth muscle cell hypertrophy, periurethral edema, and inflammation. RESULTS: Our review strongly suggests a prevalent stromal involvement, specifically of the smooth muscle cells, in CP/CPPS physiopathology. The involvement of the endocrine system, in particular the role of estrogens, the neurological pathway mediated by noradrenalin, and the presence of inflammation, support the hypothesis that CP/CPPS could be a disease with a prevalent role of smooth muscle stromal cells rather than glandular structures. Neurogenous inflammation, oxidative stress and psychological factors may be involved in the chronic nature of the disease. CONCLUSIONS: We believe that new studies regarding chronic prostatitis should also be focused on prostatic stromal involvement in the inflammatory pathway.

Perineal ultrasound evaluation of dysfunctional voiding in women with recurrent urinary tract infections.

PURPOSE: We used urodynamics and perineal ultrasound to assess the function and morphology of the urethral sphincter and detrusor muscle in the evaluation of dysfunctional voiding in female patients with recurrent urinary tract infections. MATERIALS AND METHODS: Patients selected for study purposes completed the American Urological Association Symptom Index and underwent multichannel video urodynamics and perineal ultrasound to evaluate urethral sphincter volume and detrusor thickness. RESULTS: Of the 337 patients referred to our institution for recurrent urinary tract infections 166 were finally evaluated, including group 1-65 women with recurrent urinary tract infections and dysfunctional voiding, group 2-77 with recurrent urinary tract infections without dysfunctional voiding and group 3-24 healthy controls. Storage and emptying symptoms were recorded in 87.6% and 84.6% of group 1 patients, respectively. Opening and maximum flow detrusor pressure significantly correlated with urethral sphincter volume, and mean and maximum urethral closure pressure and detrusor thickness correlated with urethral sphincter volume. Dysfunctional voiding could be diagnosed by ultrasound when an increase in detrusor thickness and striated sphincter volume were observed. A threshold sphincter volume of 1.96 cm3 had 100% sensitivity and 63.2% specificity, and a threshold detrusor thickness of 4.95 mm had 100% sensitivity and 85.4% specificity for identifying patients with dysfunctional voiding. CONCLUSIONS: We think that perineal ultrasound is useful in the evaluation of dysfunctional voiding in women with recurrent urinary tract infections.

Hematospermia: diagnosis and treatment.

The presence of blood in ejaculate represents 1% of all andrologic and urologic symptoms. In most cases it has a benign character and tends to regress spontaneously after the first episode. But in the same case it can be caused by bladder-prostate or systemic malignant patology, so it is necessary to subject the patient to laboratory and instrumental tests in order to find the best treatment that, as for hematospermia, is an etiological one. Most important for correct diagnosis are patient history, physical examination, laboratory tests, transrectal ultrasound examination of the prostate, MRI, CT, cistoscopy. Hematospermia is rarely associated with significant pathology, especially in younger men. The 3 factors that dictate the extent of the evaluation and treatment are patients age, the duration and recurrence of the hematospermia, and the presence of any associated hematuria. So it is possible to distinguish idiopathic from secondary hematospermia, because secondary hematospermia, i.e. the one in which the bleeding cause is known or suspected, requires an etiologic treatment. Urologists must make rational decisions based on evidence rather than practice defensive medicine. Understanding the pathophysiology and prevalence in populations of different ages helps minimize the likelihood of problems. When in doubt, performing a TRUS, cystoscopy, and basic laboratory analyses limits exposure.