Use of a solid-phase radioimmunoassay and formalin-fixed whole bacterial antigen in the detection of antigen-specific immunoglobulin in prostatic fluid.

The prostatic fluid of two patients with Escherichia coli bacterial prostatitis was analyzed for evidence of a local immune response to bacterial infection. A solid-phase radioimmunoassay was modified to measure the immunoglobulin (Ig)A and IgG antigen-specific antibody responses to infecting bacteria in serum and prostatic fluid from patient. Formalin-fixed whole E. coli were used as antigen. In one patient with acute E. coli prostatic infection, measurements of antigen-specific antibody confirm the presence of a systemic and local immune response. However, in another patient with a chronic E. coli prostatitis, a primarily local immune response was demonstrated. The response measured in the prostatic fluid appears to be locally stimulated and specific for the infecting bacteria. Furthermore, IgA was the predominant immunoglobulin involved in the local prostatic immune response to infection. Although elevations of serum IgA antigen-specific antibody levels were short-liver after treatment of prostatic infection, local IgA antigen-specific antibodies were detected for as long as 1 yr after the initial infection in both patients studied.

The characterization of bacterial and nonbacterial prostatitis by prostatic immunoglobulins.

Although inflammatory diseases of most human secretory surfaces are difficult to investigate clinically, the secretory immune system of the human prostate may be studied relatively easily because prostatic fluid may be obtained from the gland by digital massage. We studied inflammatory conditions of the prostate to establish whether we could use the humoral immune response to differentiate these conditions. Using a sensitive solid-phase radioimmunoassay, we measured total IgA and IgG, and IgA and IgG antibodies to Enterobacteriaceae in the serum and prostatic fluid of men with and without prostatic inflammation. These studies show that levels of IgA and IgG in the prostatic fluid of men with bacterial prostatitis are higher than those in men without histories of urinary or prostatic infections. In men with bacterial prostatitis, prostatic antibodies to Enterobacteriaceae were elevated 12 to 18 months after curative treatment and indefinitely after ineffective treatment; anti-Enterobacteriaceal IgG levels returned to normal after infection only with cure. Total IgA and IgG in the prostatic fluid of men with nonbacterial prostatitis--men who have signs of prostatic inflammation without evidence of old or ongoing bacterial infection--are also higher than levels found in uninfected individuals. Although this finding supports an inflammatory etiology for the symptoms seen in nonbacterial prostatitis, no significant IgA or IgG Enterobacteriaceal antibody titers were detected in these patients. This excludes a remote Enterobacteriaceal infection as a cause of nonbacterial prostatitis. These observations confirm that the prostate gland is a distinct part of the male secretory immune system.

Progressive renal shrinkage after simple pyelonephritis.

Nonobstructive, nonrefluxing pyelonephritis (or "simple" pyelonephritis) is not commonly associated with progressive renal scarring and global shrinkage. Although children are believed to be particularly susceptible to renal parenchymal scarring after simple pyelonephritis, progressive and global renal shrinkage remains an elusive clinical entity. We present such a case with close radiologic documentation.

Testicular torsion with contralateral vanishing testis.

An infant with a left hydrocele and nonpalpable right testis had an antenatal ultrasonogram showing a left hydrocele and normal right testis. When left inguinal hydrocelectomy was performed, extravaginal torsion of the spermatic cord and a normal testis was discovered. The right spermatic cord ended in a testicular remnant. We propose that this was a case of bilateral antenatal torsion that would have resulted in bilateral vanishing testis syndrome had the left hydrocele not prevented vascular compromise when antenatal testicular torsion occurred. This case gives visible support to the theory that testicular remnants are the result of antenatal torsion.

The management of urinary tract infections in children without urinary tract abnormalities.

Although most urinary tract infections in children with normal urinary tract anatomy pose little threat to renal function, pyelonephritis, particularly in infants, may cause renal scarring when not diagnosed and treated promptly. For most children, however, the problems of urinary tract infection may be related to a biologic predisposition to recurrent infections and the bothersome clinical symptoms associated with them. In these children, infections should be diagnosed carefully and then treated for 3 days with appropriate antimicrobial agents. In children with frequently recurrent infections (more than two in 6 months), a prophylactic antimicrobial agent in the proper low dosage may be useful. Children bothered by infection-associated symptoms of bladder dysfunction with persistent incontinence may improve with treatment with anticholinergic drugs and/or bladder rehabilitation. There may also be a decrease in the rate of urinary tract infections with this treatment. When covert bacteriuria is found and bothersome symptoms are associated with it, symptoms should be treated. If recurrent covert bacteriuria is truly asymptomatic, however, not treating the infection may be the best option.

Infection stones. Evaluation and management.

Infection stones may be the cause of persistent or recurrent bacterial urinary infection. Evaluation of the infection and the character of the stones often aids in the selection of management and treatment options. The ultimate success of the treatment of infection stones should be measured, however, by control or removal of both the stone and the urinary infection.

Evaluation and management of pediatric urinary tract infections.

Urinary tract infections (UTIs) are relatively common in children. We describe the evaluation and management of children with UTIs, as well as the risks and consequences related to the UTI. This article describes a rational approach to the evaluation and management of childhood UTIs with the relation to the natural history and risk factors.

Pediatric urinary tract infections.

Urinary tract infection in the pediatric population can lead to significant morbidity if not treated promptly and appropriately. All first infections may signify possible underlying anatomic or functional abnormality and require imaging of the lower and upper tracts. Accurate diagnosis of UTIs requires a properly collected quantitative urine culture. Treatment should be tailored to the pathogen as dictated by the urine culture sensitivities to minimize the development of multidrug-resistant organisms. Prophylactic agents should differ from the antibiotic used in the acute setting and preferably concentrated in the urinary tract, with minimal effects on the normal fecal flora. In the long term, patients with documented evidence of renal scarring should be followed up for signs of renal deterioration and hypertension.

Prostatitis.

Classification of patients with prostatic complaints into one of the categories of bacterial or nonbacterial prostatitis or prostatodynia (see Table 3) enables a physician to give rational advice to men with confusing symptoms. By examining the prostatic fluid of patients with prostatic symptoms, a physician may easily identify those men with prostatodynia who will never respond to antimicrobial or anti-inflammatory agents. Carefully obtained fractionated cultures of the urine will usually distinguish patients with bacterial and nonbacterial prostatitis, so that only those men who have bacterial prostatitis are treated with long courses of antimicrobial agents. Although recent measurements documenting elevated IgA and IgG in the EPS of men with nonbacterial prostatitis support theories of an antigenic cause for the prostatic inflammation and symptoms, the causes for this inflammation must still be identified. In addition, the etiology of prostatodynia is also unclear. As a result, the optimal treatment for most patients with nonbacterial prostatitis and prostatodynia remains unknown.

The role of an indium leukocyte scan in the diagnosis of a pyeloduodenal fistula associated with spontaneous disappearance of a staghorn calculus.

The use of a 111indium oxine-leukocyte scan (white cell scan) to establish the diagnosis of a pyeloduodenal fistula is described. The patient had a fistula that was associated with spontaneous disappearance of a large staghorn calculus in the involved kidney. The disappearance of the calculus and the presence of a pyeloduodenal fistula were confirmed at surgical exploration. Although neither an excretory urogram nor a retrograde pyelogram was useful to diagnose the fistula preoperatively a 111indium oxine-leukocyte scan revealed the renal abscess and pyeloduodenal fistula.

Pediatric genitourinary tumors.

During the past two decades, highly effective multimodality therapy involving surgery, chemotherapy, and radiation has been developed through consecutive national and international study protocols for childhood genitourinary cancers with the model being Wilms' tumor. These studies represent a landmark achievement in the history of pediatric oncology and mark the success of multi-institutional studies. With the excellent survival rates that have been established, current interest is now directed toward examining survivors for long-term treatment complications and minimizing the side effects while preserving treatment efficacy. In addition, new developments in the molecular biology of Wilms' tumor have made this neoplasm a model for understanding the molecular and genetic aspects of tumorigenesis. This article reviews some of the publications from 1992 on pediatric genitourinary tumors.

The effect of pregnancy on rat urinary tract dynamics.

We investigated the urodynamics of the renal pelvis and bladder during spontaneous bladder filling and emptying in 13 pregnant and 19 nonpregnant Sprague-Dawley rats to examine the characteristics of the dilated urinary tract in pregnancy. For each group renal pelvic and bladder pressures were measured continuously and simultaneously during various urinary flows, while the bladder was filled and emptied. In pregnant rats the ureter was wider and the renal pelvis was longer and wider than in nonpregnant rats. At urinary flows of 10 to 30 ml/kg. per hour pregnant rats had significantly lower renal pelvic pressures than nonpregnant rats during bladder filling. In addition, pregnant rats had higher bladder compliance and capacity than nonpregnant rats (compliance 0.09 +/- 0.12 ml./cm. water versus 0.05 +/- 0.05 ml./cm. water, p < 0.01 and bladder capacity 0.669 +/- 0.61 ml. versus 0.490 +/- 0.38 ml., p < 0.05). These findings imply that much of the hydroureteronephrosis during pregnancy may relate to increased urinary tract compliance rather than obstruction.

Pediatric genitourinary tumors.

Although genitourinary tumors make up only 10% of childhood cancers, with Wilms' tumor accounting for most, the study of these tumors has yielded a model of cancer development. Tremendous interinstitutional and international cooperation has improved the survival and lowered the morbidity of treatment. Advances in molecular biology and improvement in experimental techniques make this a tremendously exciting field, with discoveries being made almost routinely. Most importantly, however, the study of this group of tumors and the ensuing application of multi-modality therapy has saved the lives of thousands of children.

Oxybutynin decreases renal pelvic pressures in normal and infected rat urinary tract.

Since abnormally elevated renal pelvic pressures may contribute to renal damage, we examined whether an anticholinergic agent could decrease elevated renal pelvic pressures. We have previously demonstrated in a rat model that renal pelvic pressures rise physiologically during normal bladder filling and high urinary flows; these pressures rise to abnormal levels during acute urinary tract infection (UTI). In these studies we investigated the effects of oxybutynin on the in vivo rat urinary tract. Simultaneous bladder and renal pelvic pressures were measured with and without oxybutynin at low (<2 ml./kg./hr.), moderate (2-10), high (10-20), and very high (>20) urinary flows while the rat bladder filled and emptied spontaneously. Although minimal differences were found between bladder filling pressures with and without oxybutynin, at higher urinary flows the renal pelvic pressure in oxybutynin treated rats was significantly lower than in nontreated animals. Indeed, when rats with urinary tract infection were treated with oxybutynin, their renal pelvic pressures were lower than those in uninfected rats. We conclude that oxybutynin affects rat upper urinary collecting system pressures, and is capable of decreasing abnormally elevated renal pelvic pressures due to urinary tract infection to normal or subnormal levels.

Pediatric genitourinary tumors.

Childhood genitourinary tumors are rare and continue to demand collaborative protocols to accumulate adequate numbers of patients for studies, and a multidisciplinary approach for treatment. This paper reviews all the 1990 literature on the most common of these tumors--Wilms' and testicular tumors and rhabdomyosarcoma. The molecular and cellular biology and pathology of Wilms' tumor, as well as treatment advances, are discussed, emphasizing attempts to minimize treatment morbidity and mortality while maintaining optimal quality and quantity of life.

Biology and treatment of pediatric genitourinary tumors.

Treatment of childhood genitourinary tumors continues to advance through the use of collaborative protocols and a multidisciplinary approach. This paper reviews the 1993 literature, with an emphasis on Wilms' tumor, rhabdomyosarcoma, and testicular intraepithelial neoplasia and its relationship to testicular maldescent.

The effect of urinary flow and bladder fullness on renal pelvic pressure in a rat model.

We describe an in vivo animal model used to study the interactions of urinary flow, and bladder pressure and fullness on renal pelvic pressure. These parameters were examined in 17 nonrefluxing Sprague-Dawley rats. At urinary flow rates less than 14 cc/kg. per hour and bladders less than 60% full, renal pelvic pressures were below 9 cm. water but at urinary flow rates more than 30 cc/kg. per hour renal pelvic pressure increased above 10 cm. water when the bladder was only 20% full. At all urinary flow rates examined renal pelvic pressure increased to more than 20 cm. water as the bladder approached 100% fullness. To quantitate the combined effects of these changes in renal pelvic pressure and urinary flow on the renal pelvis a renal pelvic work index (renal pelvic pressure times urinary flow rate) was defined. Using this index the magnitude of the change between low urinary flows with an empty bladder and high urinary flows with a full bladder can be observed. The results of these studies in this model might be applicable to high urinary flow states or bladders that fail to empty completely.