Pelvic floor spasm as a cause of voiding dysfunction.

PURPOSE OF REVIEW: Pelvic floor disorders can present with lower urinary tract symptoms, bowel, sexual dysfunction, and/or pain. Symptoms of pelvic muscle spasm (nonrelaxing pelvic floor or hypertonicity) vary and can be difficult to recognize. This makes diagnosis and management of these disorders challenging. In this article, we review the current evidence on pelvic floor spasm and its association with voiding dysfunction. RECENT FINDINGS: To distinguish between the different causes of voiding dysfunction, a video urodynamics study and/or electromyography is often required. Conservative measures include patient education, behavioral modifications, lifestyle changes, and pelvic floor rehabilitation/physical therapy. Disease-specific pelvic pain and pain from pelvic floor spasm needs to be differentiated and treated specifically. Trigger point massage and injections relieves pain in some patients. Botulinum toxin A, sacral neuromodulation, and acupuncture has been reported in the management of patients with refractory symptoms. SUMMARY: Pelvic floor spasm and associated voiding problems are heterogeneous in their pathogenesis and are therefore often underrecognized and undertreated; it is therefore essential that a therapeutic strategy needs to be personalized to the individual patient's requirements. Therefore, careful evaluation and assessment of individuals using a multidisciplinary team approach including a trained physical therapist/nurse clinician is essential in the management of these patients.

A quantitative approach to histopathological dissection of elastin-related disorders using multiphoton microscopy.

BACKGROUND: Multiphoton microscopy (MPM) is a novel imaging technology that has recently become applicable for diagnostic purposes. The use of (near) infrared light in MPM allows for deep tissue imaging. In addition, this modality exploits the autofluorescent nature of extracellular matrix fibres within the skin. OBJECTIVES: To quantitate the structure and abundance of elastic fibres in human dermis in three dimensions utilizing autofluorescent signals generated by MPM for the objective examination of elastin-related skin disorders. METHODS: Cross-sections of skin samples from elastin-related disorders were analysed by MPM and correlated to histopathology. In situ visualization of elastic fibres by MPM was conducted by en face imaging of ex vivo skin samples through the intact epidermis. Image analysis software was used to quantify elastic fibres in three dimensions. RESULTS: Based on the MPM-detected elastin-specific autofluorescence, we developed the Dermal Elastin Morphology Index (DEMI), calculated as the ratio of elastic fibre surface area and volume. This enabled objective three-dimensional quantification of elastic fibres. Quantitative scoring of sun-damaged skin using DEMI correlated with qualitative histopathological grading of the severity of solar elastosis. Furthermore, this approach was applied to changes in elastic fibre architecture in other disorders, such as pseudoxanthoma elasticum (PXE), PXE-like syndrome, elastofibroma, focal dermal elastosis, anetoderma, mid-dermal elastolysis and striae distensae. We imaged elastic fibres in intact ex vivo skin imaged en face through the epidermis, indicating that this approach could be used in vivo. CONCLUSIONS: MPM has the potential for noninvasive in vivo visualization of elastic fibres in the dermis with near histological resolution. DEMI allows objective assessment of elastic fibres to support diagnosis and monitoring of disease progress or therapy of elastin-related skin disorders.

Understanding the murine cutaneous dendritic cell network to improve intradermal vaccination strategies.

Dendritic cells (DCs) form a heterogeneous group of antigen presenting cells that play different roles in tissue immunity. Recent studies have revealed the presence of distinct DC populations in murine skin, highlighting the complexity of the cutaneous DC network. In this review, we will define the major DC subsets that populate the different layers of the skin, focusing on their origin and the mechanisms controlling their homeostasis. We will also review recent evidence underlining the functional specialization of dermal DC subsets and its relevance in the design of novel vaccine approaches.

Improved detection rate of prostate cancer using the 10-core biopsy strategy in Singapore.

OBJECTIVES: To evaluate if changing the biopsy regime to 10 cores might improve the positive predictive value (PPV) of elevated prostate-specific antigen [PSA, elevated range, 4 to 20 ng per ml, normal range, < 4 ng per ml] for the diagnosis of prostate carcinoma. METHODS: From February 2000 to April 2001, 191 patients, mean age 64 years [range, 38 to 85 yr], underwent transrectal ultrasound [TRUS] for either elevated PSA [elevated range, 4 to 20 ng per ml] and/or abnormal digital rectal examination [DRE]. A 10-core TRUS-guided biopsy of the prostate was performed. This included the standard sextant biopsy and two additional cores for each far lateral zone. RESULTS: Using this technique, 47 out of 191 patients [24.6%] had prostate cancer. The PPV for PSA levels of 4.1 to 10.0 ng per ml and 10.1 to 20.0 ng per ml were 19.3% and 35.4%, respectively. The lateral cores contributed 21.3% of the cancer cases, which would have been missed if only sextant biopsies were performed. CONCLUSIONS: With the 10-core biopsy method, the PPV for prostate cancer for patients with a PSA in the range of 4 to 20 ng per ml was in the range of 25%. This is significantly different from previous reports. The reason for this may be due to the adoption of a better, more uniform and systematic biopsy strategy for patients with elevated PSA, or it may be a true reflection of the current population incidence. Hence, this biopsy strategy is highly recommended.

Extramammary Paget's disease of scrotum.

We describe 4 cases of extramammary Paget's disease of the scrotum with underlying invasive carcinoma from 1997 to 1999. Three patients had metastatic inguinal lymphadenopathy. The delay in diagnosis was significant (mean 1 year). The diagnosis was made by skin biopsy in all patients. Histologically, intraepidermal cells with enlarged vesicular nuclei and vacuolated cytoplasm, which was mucin positive, were found. The mainstay of treatment is wide surgical excision, but positive margins remain a major problem. Other modes of treatment have been advocated but the efficacy for invasive disease is low. The key to successful control of the disease is therefore a high index of suspicion and early diagnosis.

Acute renal colic: value of unenhanced spiral computed tomography compared with intravenous urography.

OBJECTIVE: The objective of this study was to compare the efficacy of plain spiral computed tomographic (CT) scan with intravenous urography (IVU) in the evaluation of patients with suspected urinary calculi/obstruction. MATERIALS AND METHODS: Twenty consecutive patients with acute signs of renal colic were prospectively examined with unenhanced spiral CT followed by an IVU within the same day. The CT scans were reviewed jointly by 2 radiologists blinded to the IVU and a consensus was reached for each finding. The IVU was similarly reviewed by another 2 separate radiologists. RESULTS: Eleven of the 20 patients had signs of urinary obstruction on CT and IVU. Of these 11 patients, 7 had a ureteric calculus that was demonstrated on CT and IVU and 4 had a calculus that was demonstrated on CT only. Two patients had a urinary calculus seen on CT and IVU with no signs of urinary obstruction. One patient had a calculus seen on CT alone with no urinary obstruction. Two patients only had signs of urinary obstruction on CT. The remaining 4 cases had normal findings on CT and IVU. CONCLUSION: Unenhanced CT is more effective than IVU in identifying ureteric calculi and is equally effective in detecting urinary obstruction. CT is also useful in detecting secondary signs of obstruction even in the absence of any calculus.

Bilateral synchronous renal oncocytoma: a case report and review.

INTRODUCTION: Renal oncocytoma is a rare benign tumour. CLINICAL PICTURE: A 73-year-old man presented with bilateral renal tumours, suggestive of renal cell carcinoma (RCC). Nephron-sparing surgery (NSS) and radical nephrectomy were performed. Both specimens revealed renal oncocytoma on final histology. A review of nephrectomy specimens showed 4 other solitary oncocytomas out of 250 RCCs over the period 1991 to 2000. Diagnosis of oncocytoma could only be firmly established by careful histological evaluation to exclude RCC. TREATMENT: Renal oncocytoma carries a good prognosis. The use of NSS for synchronous bilateral renal masses is highlighted. CONCLUSION: NSS is recommended for renal oncocytoma wherever possible.

Clinics in diagnostic imaging (67). Hydronephrotic horseshoe kidneys with multiple calculi.

Horseshoe kidney is the commonest congenital renal anomaly. Its inherently-poor drainage system renders the patient prone to stone formation. A 56-year-old man with bilateral renal stones in a horseshoe system associated with hydronephrosis is presented. He was treated successfully with bilateral CT-guided percutaneous nephrostomy and percutaneous nephrolithotripsy. Various treatment options, including ESWL, PCNL and open surgery, are discussed.

Renal cell carcinoma: incidental detection and pathological staging.

In developed countries, there has been increased incidental detection of renal cell carcinoma (RCC). The incidence, pathological stage and survival of incidentally detected carcinoma in a developing country in Asia where, from 1990 to 1998, 165 renal cell carcinomas were identified. The clinical presentation, diagnostic-imaging modality employed, pathological staging and patient survival was reviewed. Incidental renal cancers included those that were diagnosed through health screening or detected incidentally through imaging studies for other conditions. The survival between these incidentally detected lesions and their symptomatic counterparts (suspected group) was compared. Sixty-four patients (39%) had their tumours detected incidentally, including 39 who were entirely asymptomatic and 25 who presented with non-specific symptoms, not initially suggestive of RCC. For the entire group, computed tomography provided the definitive diagnosis in 81% of cases. The incidental detection group had significantly smaller size of tumour (5.9 cm c.f. 7.6 cm), lower stage and lower histological grading. In particular, 78% of patients with incidental RCC had stage I or II diseases (TNM stage classification), compared with 57% of patients with suspected tumour (p < 0.05; Chi-square test). The disease free survival was significantly better for those with incidental detection (86% c.f. 66% at last follow up; p < 0.05; log-rank test) over a mean follow up period of 33 months (range 1-91). Regression analysis showed that stage of disease was the only independent variable predictive of clinical outcome. In conclusion, that significant numbers of RCC were detected incidentally. These tumours were of a lower clinical pathological stage and had a better prognosis.