Urinary incontinence. Screening and treatment of urinary dysfunction.

Most of the 13 million Americans who have urinary incontinence are adults, and a significant number are never treated. Undertreatment is due in part to reluctance by patients and physicians to discuss an uncomfortable topic. Unmanaged incontinence restricts normal daily activity and fundamental human interactions. Intervention is important not only to control symptoms, prevent infection, and impede incontinence progression, but also to restore quality of life. In most cases, the physical exam and patient history provide the necessary information for diagnosis. Behavioral treatments are easy to implement and inexpensive, although patient nonadherence can undermine effectiveness.

Efficacy and safety of oral sildenafil in men with erectile dysfunction and spinal cord injury.

OBJECTIVE: To assess the efficacy of sildenafil in men with spinal cord injury (SCI) and erectile dysfunction (ED). METHODS: Seventeen men with SCI were selected from February to September 1998 for sildenafil treatment of ED. The initial dose of 25 mg was increased by 25-mg increments as needed. Patients underwent baseline physical examination and answered questions from the abridged International Index of Erectile Function before and during therapy. RESULTS: Sixteen patients tolerated therapy; 1 developed hypotension and discontinued therapy. There was significant improvement in erectile function (P < .05) after 5.3 +/- 2.2 months when compared with baseline or previous therapies (P < .05). Of the 17 patients, 94% recommended sildenafil to others. Six of these 16 patients were available for long-term follow-up. There was further significant improvement in quality of erection (P < .05), but no change in satisfaction. CONCLUSION: Sildenafil is effective and well tolerated in men with SCI and ED.

Hemangioma of the testis: report of unusual occurrences of cavernous hemangioma in a fetus and capillary hemangioma in an older man.

We report two cases of hemangiomata of the testes which occurred in a 17-week-old fetus and a 73-year-old man. To our knowledge, these are the first reported cases of cavernous hemangioma of the testis in a fetus and capillary hemangioma of the testis in an older man. Although a hemangioma of the testis is rare, it should be considered in the differential diagnosis of a testicular tumor. Ann Diagn Pathol 5:80-83, 2001.

A simplified pharmacologic erection program for patients with spinal cord injury.

INTRODUCTION AND OBJECTIVES: Intracavernosal injection (ICI) of vasoactive agents has been successfully used in the treatment of erectile dysfunction (ED). The authors' pharmacologic erection program, using a fixed combination of prostaglandin E1 (PGE1) and papaverine, is notable for its simplicity and acceptance by patients who have suffered spinal cord injuries (SCIs). METHODS: Patients undergo baseline questionnaire, physical examination, and hormone profile followed by instruction and injection of a fixed combination of PGE1 and papaverine. On successive visits, the patient injects himself and the dosage is titrated until a satisfactory erection is obtained. Patients who do not respond to injection of 1.0 cc are considered treatment failures. Patients return periodically for routine follow-up. RESULTS: From May 1994 to March 1997, 37 patients with SCI underwent initial evaluation and 28 (76%) responded to injection therapy and were successfully using self-injection therapy at 3-month follow-up. Twenty-three patients are still on injection therapy. Five patients have dropped out for several reasons including a lack of a current sexual partner (60%) and pain with injection (40%). Patient age ranges from 24 to 72. The dosage range was 0.10 to 0.50 cc (mean = 0.29 cc). The average duration of erection was 43 minutes. At 3-month follow-up, 85% of the patients rated their erections as good or excellent. Forty-three percent of patients are using ICI 1 or more times per week. Seventy-seven percent of patients are moderately or extremely satisfied with their treatment and 89% said that they would recommend this program to a friend. CONCLUSIONS: This simplified pharmacologic erection program offers safe, well accepted, and effective therapy for ED to a SCI population with very high patient satisfaction.

Urodynamic findings in the tethered spinal cord syndrome: does surgical release improve bladder function?

PURPOSE: We retrospectively reviewed 39 patients with a tethered spinal cord to evaluate whether surgical release positively influenced urological symptoms or urodynamic findings. MATERIALS AND METHODS: The patients were divided into 2 groups: group 1-11 with occult spinal dysraphism and group 2-28 with secondary spinal cord tethering after previous closure of a myelomeningocele or resection of a lipomyelomeningocele. Diagnosis was confirmed in all cases by magnetic resonance imaging or spinal ultrasound. A comprehensive urodynamic evaluation was done immediately preoperatively and 2 to 21 months (mean 7) postoperatively. RESULTS: In group 1 the most common preoperative urodynamic finding was hyperreflexia, which improved or resolved after untethering in 62.5% of the patients. Four adults also reported improved bladder sensation or decreased urgency. In group 2 the most common urodynamic finding was impaired compliance, followed closely by detrusor hyperreflexia. Urodynamic patterns of detrusor hyperreflexia or compliance improved in only 30% of the patients, while 48% had worsened patterns. Only 14% of group 2 had improved symptoms of urinary control but 28% had improved lower extremity function. CONCLUSIONS: Urological symptoms and urodynamic patterns may be improved by early surgical intervention in patients with occult spinal dysraphism. However, untethering did not consistently benefit patients with secondary spinal cord tethering.

Proximal artificial sphincter cuff repositioning for urethral atrophy incontinence.

OBJECTIVES: Recurrent incontinence after implantation of an artificial urinary sphincter (AUS) may be due to urethral atrophy. Treatment options consist of decreasing the cuff size, increasing the balloon pressure, implanting a double-cuff system, or proximal cuff repositioning. The first three options may increase the risk of erosion. Increasing the balloon pressure does not effectively increase cuff pressure. This article demonstrates that proximal cuff repositioning is a safe, simple, and effective technique in the management of recurrent incontinence as a result of a loss of cuff compression due to urethral atrophy. METHODS: Six patients underwent proximal repositioning of the AUS (AS-800) cuff for recurrent post-prostatectomy incontinence. Urethral atrophy was determined by a thorough systematic evaluation. A detailed description of the surgical technique is provided. RESULTS: Five of 6 patients (83%) had significant improvement in incontinence with an average follow-up of greater than 1 year. In 1 patient with no improvement, preoperative urodynamics revealed poor detrusor compliance in addition to sphincter weakness due to loss of cuff compression. CONCLUSIONS: Proximal cuff repositioning on the bulbar urethra is an effective, safe, and simple technique in the management of recurrent incontinence due to urethral atrophy and may minimize the risk of erosion.

Is sphincterotomy the best management of the spinal cord injured bladder?

Transurethral incision of the external urinary sphincter with condom catheter drainage has long been used in the management of the male quadriplegic or high thoracic level paraplegic with neurogenic bladder. The decrease in outlet resistance is believed to lower the high intravesical pressures associated with detrusor-sphincter dyssynergia and obviate the need for an indwelling catheter, with its associated infectious complications. We reviewed 16 consecutive cases of sphincterotomy performed at our institution during the last 8 years to determine the long-term success rate and outcome of this mode of bladder management. Of the patients 13 are cervical level quadriplegics and 3 are thoracic level paraplegics who were unable to perform self-catheterization. Preoperative urodynamics most commonly demonstrated detrusor external sphincter dyssynergia, moderate to severe hyperreflexia and decreased compliance. Followup ranged from 3 months to 8 years (median 39 months). Only 8 of 16 patients still manage the bladder with a condom catheter, while 8 have an indwelling suprapubic cystostomy tube. Only 1 patient followed for more than 4 years postoperatively still uses condom catheter drainage. The most common reason for conversion to suprapubic drainage was difficulty with the external appliance but other reasons included desire for increased independence, high post-void residual volumes and renal deterioration. We conclude that sphincterotomy is generally effective in decreasing outlet resistance and improving voiding efficiency initially but that careful patient selection and close long-term followup are necessary to guarantee long-term success.

Staging accuracy of magnetic resonance imaging versus transrectal ultrasound in stages A and B prostatic cancer.

The present study was undertaken to compare the ability of magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) to identify the presence or absence of extracapsular tumor extension and seminal vesicle involvement in patients with clinically localized (stages A and B, T1-T2) prostatic cancer. Sixty-four patients (ages 44-77 years) underwent radical retropubic prostatectomy and pelvic lymphadenectomy after staging with both MRI and TRUS. Surgical specimens were step-sectioned and examined at multiple levels. Radiographic staging was correlated with pathological staging. Both MRI and TRUS demonstrated better staging accuracy than conventional digital rectal examination [42% for digital rectal examination (DRE), 63% by TRUS, and 67% by MRI], although they suffered from understaging (31% by TRUS and 22% by MRI). The positive predictive value (PPV) for stage B disease was disappointingly low (42% for DRE, 53% for TRUS and 59% for MRI). However, the PPV for stage C disease was higher (81% for TRUS and 77% for MRI). In the evaluation of extracapsular invasion, the PPV of TRUS (81%) was higher than that of MRI (77%). The negative predictive value (NPV), however, for both TRUS and MRI was low (58 and 56%, respectively). In the evaluation of seminal vesicle invasion, both TRUS and MRI demonstrated poor PPV (50 and 40%, respectively), but the NPV was excellent (90% for TRUS and 96% for MRI). MRI failed to detect metastatic lymph nodes in 4 of 6 patients while falsely predicting their presence in 4 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Fatal perforation of augmentation cystoplasty in an adult.

This is a case report of a fatal spontaneous perforation of an augmentation enterocystoplasty in a twenty-nine-year-old T12 paraplegic, thirteen months post augmentation and placement of artificial urinary sphincter. A review of the literature involving 41 episodes in 31 patients is provided with a discussion concerning presentation, etiology, and management.

Cell proliferation in prostatic adenocarcinoma: in vitro measurement by 5-bromodeoxyuridine incorporation and proliferating cell nuclear antigen expression.

We assessed cancer cell proliferation, a marker of the biologic activity of tumor cells, by evaluating bromodeoxyuridine (BrdUrd) incorporation and proliferating cell nuclear antigen (PCNA) expression. Prostatic carcinoma specimens (N = 48) were incubated in the presence of BrdUrd to label cells undergoing DNA synthesis, and immunocytochemical staining was performed with monoclonal antibodies to BrdUrd and PCNA and a standard indirect immunoperoxidase technique. The proportion of cells staining positively (labeling index or LI) for BrdUrd and PCNA was determined in 2 ways: by counting only high-power fields with the greatest concentration of stained cells (selected LI); or by counting cells in random fields (random LI). For BrdUrd the mean selected and random LIs were 3.08% and 1.62%, respectively; for PCNA they were 6.02% and 3.47%. Random and selected BrdUrd correlated well (r2 = 0.83), as did random and selected PCNA LIs (r2 = 0.86). However, a weaker correlation was noted when LIs of both techniques were compared, with the PCNA LI usually higher. The LIs of either technique correlated rather poorly with tumor grade and concentration of prostate-specific antigen, but correlated well with clinical stage as assessed by examination and imaging. In addition, either technique discriminated among tumors known to be pathologically confined (stages A and B) and those with extension to seminal vesicles (stage C) or metastatic to regional lymph nodes or bone (p < 0.019).

Recent advances in imaging studies for staging of penile and urethral carcinoma.

Over the past decade, the principal advances in the imaging of genitourinary cancer have come in the fields of ultrasound, CT, and MR imaging. As applied to carcinomas of the urethra and penis, these techniques show promise. The local staging of the lesion may be done with either ultrasound or MR imaging. Ultrasound has correctly staged two penile cancers and predicted the presence or absence of lymph node metastasis. Sonourethrography has been successful in the evaluation of urethral stricture disease and should now be studied for imaging carcinomas of the urethra. Magnetic resonance imaging allows direct tumor visualization. This and its large field of view make it more accurate than clinical staging by palpation. In addition, MR imaging can identify destruction of both the tunica albuginea and the septum between the corpora by metastases to the penis or contiguous involvement by other neoplasms. It also offers the advantage of imaging in three orthogonal planes, giving more anatomic detail of the primary tumor. Tissue contrast is superb, and the study can simultaneously evaluate the pelvic nodes. After careful palpation of the primary tumor and examination of the regional and distant lymph nodes, we perform physical examination under anesthesia and obtain histologic confirmation of the cancer. We then base our decision to obtain further imaging studies on the grade and invasiveness of the tumor along with the findings on physical examination. In patients with tumors that appear to be superficial and are of low grade who have no evidence of regional or distant nodal disease on physical examination, further imaging is not carried out.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary malignant lymphoma of the female urethra: report of a case and review of the literature.

Primary extranodal lymphoma of the female urethra is rare. We present case 10 and review the literature. Management in the past has varied markedly. Strategies have included simple excision, external beam and intracavitary radiation therapy, and multiple agent chemotherapy. The majority of patients have done well: 7 of 10 are alive with no evidence of disease. Newly diagnosed patients should undergo complete staging with the Ann Arbor staging system and the tumors should be classified histologically according to the Working Formulation for Clinical Usage. Therapy must be individualized but in most cases we recommend that patients be treated as if they have systemic illness, with multimodality therapy.

Acquired immunodeficiency syndrome-related Kaposi's sarcoma of the male genitalia: management with radiation therapy.

Kaposi's sarcoma of the genitalia is an infrequent complication of the acquired immunodeficiency syndrome but it often is difficult to manage. A total of 19 men (mean age 39 years) with penile and/or scrotal lesions underwent radiotherapy at dosages of 600 to 3,000 cGy. in fractions of 150 to 800 cGy. Of the patients 6 achieved a complete and 10 a partial response, while 2 had no response and 1 died too soon after treatment to be evaluated. Recurrences were noted in 8 patients, 7 of whom received additional radiation (1 patient had 2 recurrences and both responded). Of the retreatments 3 effected complete and 4 partial responses. Over-all, of 25 evaluable treatment courses 9 complete (36%) and 14 partial (56%) responses yielded a total response rate of 92%. There was 1 complication, a skin ulceration. Radiation therapy is well tolerated and will result in effective palliation in the majority of patients with Kaposi's sarcoma of the genitalia.

Thromboendarterectomy for chronic, major-vessel thromboembolic pulmonary hypertension. Immediate and long-term results in 42 patients.

Since 1970, forty-two patients with pulmonary hypertension due to chronic, thromboembolic obstruction of the major pulmonary arteries have had pulmonary thromboendarterectomy at the University of California, San Diego, and the San Diego Veterans Medical Centers. Duration of symptoms before admission averaged 4.4 years, with many alternative diagnoses having been made. At admission, 29 patients had class IV disease by New York Heart Association criteria, and 12, class III. Immediately after surgery, pulmonary vascular resistance declined significantly (p less than 0.001) from 897 +/- 352 dynes/s.cm-5 to 278 +/- 135 dynes/s.cm-5. Seven patients with class IV disease died in the postoperative period. Of the 35 survivors (mean follow-up, 28 months), 16 had class I disease; 18, class II; and 1, class III. Of the 17 patients who have returned for cardiac catheterization at 4 to 12 months after surgery, a further decline (p less than 0.05) in pulmonary vascular resistance has occurred. This experience indicates that the disorder is commoner than we previously suspected and that thromboendarterectomy is feasible, even in patients with severe and protracted hemodynamic compromise.