A case-control study: are urological procedures risk factors for the development of infective endocarditis?

OBJECTIVE: To evaluate the association between urological procedures and the development of infective endocarditis (IE), as there are case-reports linking urological procedures to IE but evidence of a causal relationship is lacking and no major guidelines advise prophylaxis to prevent development of IE during transurethral urological procedures. No case-control study has been undertaken to examine the relationship between urological procedures and the development of IE. PATIENTS AND METHODS: Retrospective evaluation of the IE database at our institution. The population consisted of patients diagnosed with enterococcal, staphylococcal, Streptococcus bovis-group and oral streptococcal IE over a 10-year period. Possible risk factors for the development of IE, including urological procedures were collected. A case-control design was used and univariable and multivariable analyses were carried out. Missing data was accounted for using the multiple imputations method. RESULTS: We included 384 patients with IE. There was a statistical association between the development of enterococcal IE and preceding urological procedures (odds ratio 8.21, 95% confidence interval 3.54-19.05, P < 0.05). Increasing age and being an intravenous drug user were also associated with enterococcal IE. Haemodialysis and the presence of an intracardiac device were associated with the development of coagulase-negative staphyloccal IE. CONCLUSION: This is the first study to show a statistical association between urological procedures and the development of IE. The bacteraemia leading to IE may be a result of the urological procedures or a consequence of the underlying urological pathology causing recurrent subclinical bacteraemias.

Management of ED under the "severe distress" criteria in the NHS: a real-life study.

INTRODUCTION: The United Kingdom is unusual in that a significant proportion of patients with erectile dysfunction (ED) have their treatment fully reimbursed by the National Health Service (NHS). This may have consequences for the choice of treatment and for compliance with treatment. AIMS: The aim of this study was to evaluate the use and cost implications of phosphodiesterase type 5 inhibitor in an NHS setting. METHODS: Basic demographics and data on ED management for patients treated from January 2000 to April 2011 were obtained from a prospectively accrued database. We reviewed drug usage and costs as well as switching between drugs. Patients were given the choice of all available therapies and were followed up annually. MAIN OUTCOME MEASURES: Switching, compliance, and costs of treating ED under the "severe distress" criteria in the NHS were reviewed for this study. RESULTS: Two thousand one hundred fifty-nine patients qualified for reimbursed therapy. Two hundred twenty-six patients were excluded from further analysis owing to missing data. Patients were followed up on an annual basis. The mean patient age was 60.2 years (min 23, max 90), and the mean follow-up was 50.8 months (min 1, max 127). Six hundred ninety-six were started on sildenafil, 990 on tadalafil, 163 on vardenafil, and 84 on intracavernosal alprostadil. Eighteen percent of patients initially started on the scheme and stopped medication unilaterally. Of the patients, 12.3% changed their medication during follow-up. The cost of drugs increased year by year from £257,100 in 2007 to £352,519 in 2011. CONCLUSIONS: Our real-life observational study shows that in our institution, dropout of therapy is unusual. We hypothesize that this reflects, in part, the reimbursement issue. We also found that switching between drugs was unusual, although there are several possible explanations for that. Although this is a successful system for the patients, the hospital, which bears the costs of medication, is finding this an increasing economic drain.

Long-term outcome of the use of intravesical botulinum toxin for the treatment of overactive bladder (OAB).

OBJECTIVES: To assess the long-term compliance with repeated injections of intravesical botulinum toxin (BT) in a 'real-life' mixed population of patients with idiopathic detrusor overactivity and neurogenic detrusor overactivity. To identify the reasons why patients discontinued BT therapy and to explore the outcomes of those patients who did discontinue treatment. PATIENTS AND METHODS: Retrospective evaluation of the case notes of a series of patients who had received intravesical BT treatment at a large UK teaching hospital. No antibiotic prophylaxis was given for the procedure. RESULTS: Over a period of 7 years, 268 patients were initiated on intravesical BT treatment for overactive bladder (OAB) at our institution, with 137 followed up for ≥36 months, with 80 patients having ≥60 months follow-up after their first injection. Almost two-thirds of patients (61.3%) had discontinued intravesical BT therapy at 36 months, with a 63.8% discontinuation rate at 60 months. The main reasons for discontinuation were tolerability issues, mainly urinary tract infections and the need for clean intermittent self-catheterisation. Primary and secondary losses of efficacy were of secondary importance. Most of the patients that discontinued have remained under urology care and now receive alternative methods of treatment. CONCLUSIONS: Intravesical BT therapy is an effective short-term treatment for OAB. With time, two-thirds of patients discontinued treatment usually because of the tolerability issues associated with treatment.

Bacteraemia during Transurethral Resection of the Prostate: What Are the Risk Factors and Is It More Common than We Think?

The aim of this work was to investigate the microbial causes, incidence, duration, risk factors and clinical implications of bacteraemia occurring during transurethral resection of the prostate (TURP) surgery to better inform prophylaxis strategies. An ethically approved, prospective, cohort study of patients undergoing TURP was conducted. Clinical information and follow-up details were collected using standardized data collection sheets. Blood was obtained for culture at 6 different time points peri-procedure. Standard of care antibiotic prophylaxis was given prior to surgery. Bacteriuria was assessed in a pre-procedure urine sample. Histopathology from all prostate chips was assessed for inflammation and malignancy. 73 patients were consented and 276 blood samples obtained. No patients developed symptomatic bacteraemia during the procedure, 17 patients developed asymptomatic bacteraemia (23.2%). Enterococcus faecalis and Pseudomonas aeruginosa were the most common organisms cultured. 10 minutes after the start of the TURP, the odds ratio (OR) of developing bacteraemia was 5.38 (CI 0.97-29.87 p = 0.05), and 20 minutes after the start of the procedure, the OR was 6.46 (CI 1.12-37.24, p = 0.03), compared to before the procedure. We also found an association between the development of intra-operative bacteraemia and recent antibiotic use (OR 4.34, CI 1.14-16.62, p = 0.032), the presence of a urinary catheter (OR 4.92, CI 1.13-21.51, p = 0.034) and a malignant histology (OR 4.90, CI 1.30-18.46, p = 0.019). There was no statistical relationship between pre-operative urine culture results and blood culture results. This study shows that asymptomatic bacteraemia is commonly caused by TURP and occurs in spite of antibiotic prophylaxis. Our findings challenge the commonly held view that urine is the primary source of bacteraemia in TURP-associated sepsis and raise the possibility of occult prostatic infection as a cause of bacteraemia. More work will be needed to determine the significance of transient bacteraemia in relation to more serious complications like infective endocarditis and malignancy.

The evaluation of apomorphine for the treatment of erectile dysfunction.

INTRODUCTION: Erectile dysfunction (ED) is a common condition affecting men. Apomorphine is one of the oral medications that has been used in the management of ED, though over recent years, its use in the management of ED has dwindled. AREAS COVERED: The authors review the evidence available for the use of apomorphine in the management of ED. A Medline search was performed searching for the articles related to the use of apomorphine in the treatment of ED from 2000 to present. The article reviews the erectogenic properties of apomorphine and evaluates its efficacy, suitability and tolerability in management of patients with ED. EXPERT OPINION: Apomorphine SL is more effective than placebos in treating ED and is generally well tolerated in the sublingual formulation, causing tolerable side effects. Newer nasal-spray formulations provide faster efficacy. Its efficacy in patients with multiple co-morbidities is more limited. However, it is not as effective as PDE5-I in the treatment of ED. Its most significant strength is its safety profile. It may have a niche in the treatment ED in patients who have failed treatment with, or are intolerant to other well-established pharmacological treatment for ED (e.g., PDE5-Is). Apomorphine is not a first-line treatment option for patients with ED, especially as it is no more widely available in the western world.

Medical therapy for premature ejaculation.

Premature ejaculation (PE) is a common male sexual dysfunction. Advances in PE research have been hampered owing to a nonstandardized definition of PE, until the definition by the International Society of Sexual Medicine (ISSM) in 2009. Once the diagnosis of PE is established through a thorough history, a variety of medical therapies is available, including tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), centrally acting opiates, phosphodiesterase 5 inhibitors and topical desensitizing creams. Most of these treatments increase the intravaginal ejaculation latency time (IELT) and patient satisfaction scores, with the most convincing evidence for SSRIs and topical creams. Daily SSRIs such as paroxetine, although efficacious, do have a substantial and prolonged side effect profile. Dapoxetine, which is a on-demand SSRI, is the only licensed drug for the treatment of PE, increasing IELT by a factor of 2.5 to 3 with limited and tolerable side effects. In the near future, the topical aerosol PSD502 is due to be licensed for the treatment of PE, increasing IELT by up to a factor of 6 but having minimal local and negligible systemic side effects.

The impact of Down's syndrome on the immediate and long-term outcomes of children with Hirschsprung's disease.

Hirschsprung's disease (HD) in Down's syndrome (DS) patients is stated to have a worse outcome than HD alone. In our study we reviewed the immediate and long-term outcomes of these children and questioned whether DS should influence the operative management. Data were collected on all children with HD (including total colonic aganglionosis), between January 1990 and December 2000. They were divided into two groups based on the presence or absence of Trisomy 21 and compared retrospectively. In this time period we treated 173 children with HD; 17 of these had DS. Both the groups were comparable in their mean gestational age, birth weight and presentation except that the DS group had a significantly higher overall incidence of pre and/or postoperative enterocolitis. A tota1 of 164 children underwent a Swenson pull-through and 9 had a Soave's procedure. Follow-up ranged from 1 to 10 years. Continence assessed using the Wingspread scoring system in children over the age of 4 years showed no significant difference. Although children with both HD and DS are predisposed to complications and required a more cautious management, long-term outcome in terms of continence was not significantly worse than in HD alone. Thus the co-existence of DS should not influence the decision to offer these children and their parents the choice of definitive repair.