Varicocele in adolescents: a review and guideline for the daily practice.

OBJECTIVES: Varicocele in adolescent men is one of the most challenging topics in pediatric urology. What should be considered as a good indication for treatment and at what age? Does treatment improve fertility? Can we wait? What is the best surgical and minimal invasive treatment? To answer these questions we provide a guideline to use in daily practice. METHODS: We performed a search of the English literature of the last ten years through the Pub Med database using the following key words "varicocele", "diagnosis", "treatment", "fertility" and "adolescent". We then summated and compared the results of these studies. CONCLUSION: Adolescents with varicocele need regular follow-up including clinical examination and ultrasound measurements of the testis. Those with a persistent discrepancy between left and right testis size of more than 20% over a period of 12 months and those with pain need varicocelectomy independent of patient age, Tanner stage or varicocele size. The peak retrograde flow (PRF) seems to be a good diagnostic non-invasive tool in the follow-up and can be of help to select patients for surgery. PRF=38 cm/s in combination with testicular asymmetry =20% is a reason for surgery independent of age, Tanner stage or varicocele size. PRF<30 cm/s in combination with testicular asymmetry <20% should be followed annually. In case of worsening PRF or asymmetry surgery must be performed. Patients suitable for conservative management should be followed until semen analysis is possible. We present a flow-chart to use in the management of adolescent varicocele. The best results of varicocele treatment are obtained with microscopic subinguinal and laparoscopic lymphatic spearing techniques as shown in a meta-analysis performed in this review.

18-year experience in the management of men with a complaint of a small penis.

In many cultures, the erect penis has been a symbol of masculine qualities. Because of this symbolism, a penis that is less than average size can cause insecurity or embarrassment. This series reports the authors' 18-year experience in the management of 60 men with a complaint of a small penis. For 44 of these 60 men, counseling was sufficient; the other 16 had surgery, and of these, 9 were satisfied with the result. Despite limitations, the authors conclude that those men who already achieve a penis length of no less than 7.5 cm (2.95 in) in erection, have only limited benefit from penis-enhancing surgery. This particular patient category should therefore be dissuaded from surgery.

Penile enlargement: from medication to surgery.

Penis lengthening pills, stretch apparatus, vacuum pumps, silicone injections, and lengthening and thickening operations are available for men who worry about their penis size. Surgery is thus far the only proven scientific method for penile enlargement. In this article, we consider patient selection, outcome evaluation, and techniques applied. In our view, sexological counseling and detailed explanation of risks and complications are mandatory before any operative intervention.

The treatment of sleep-related painful erections.

INTRODUCTION: As specialists in male genital problems, urologists and sexologists will most likely to be involved in the treatment of males presenting with sleep-related painful erections (SRPEs). This means that this phenomenon needs to be recognized by urologists and sexologists, and that they should have knowledge of the current diagnostic and therapeutic approaches. Aim. To review the literature on SRPE and to find the best pharmacological treatment. Methods. Four personal clinical observations from two clinics and 29 other cases with SRPE found in PubMed were analyzed, especially regarding the results of pharmacological treatment. MAIN OUTCOME MEASURES: The results of pharmacological treatment. RESULTS: Many of the various treatments proved to be ineffective and only a few showed efficacy for a few weeks or months. The only effective drugs in the long term were baclofen, clonazepam, and clozapine. CONCLUSIONS: Until now, the phenomenon of SRPE is not well understood. The rarity of the published cases undoubtedly does not reflect the actual occurrence of SRPE. Controlled double-blind pharmacological trials are needed, and long-term follow-up including polysomnography coupled with nocturnal penile tumescence and rigidity monitoring may provide further information about SRPE.

Intimate body piercings in women.

The popularity of (intimate) body piercing has increased as well as the chances of being confronted with (the complications) of it. This article provides information about the various types of intimate body piercings in women, the complications and concerns regarding the treatment of patients with intimate bodypiercings.

[Emphysematous cystitis: from bullae to pneumaturia]. / Emfysemateuze cystitis: van bullae tot pneumaturie.

A 91-year-old woman with type 2 diabetes presented at the emergency ward subconscious with lower abdominal swelling. Evaluation revealed dehydration and hyperglycaemia, and abdominal x-ray showed an air space surrounding a severely swollen bladder. After excluding enterovesical fistulae, the patient was diagnosed with emphysematous cystitis. Treatment for urinary retention, antibiotic treatment and control of the diabetes mellitus resulted in a rapid recovery. A second patient, a 65-year-old woman with a history of recurrent urinary tract infections and urolithiasis, presented with irritative urinary symptoms and pain in the lower abdomen. Explicit inquiry revealed that she also had intermittent pneumaturia. Urethrocystoscopy revealed submucosal bullae, which are a hallmark of emphysematous cystitis. The patient was given intravenous antibiotic therapy. Diabetes mellitus is a risk factor for emphysematous cystitis. The disorder is treated by draining the bladder with an indwelling catheter and intravenous antibiotic therapy, selected according to the urine culture results. In general, orally administered antibiotics are insufficient.

Gonadal function after surgery and chemotherapy in men with stage II and III nonseminomatous testicular tumors.

The gonadal functions were studied in 54 patients with disseminated nonseminomatous testicular tumors who had been subjected to combination chemotherapy (cisplatin, vinblastine, and bleomycin [PVB]) and surgery (hemiorchiectomy, retroperitoneal lymph node dissection or removal of retroperitoneal residual tumor after chemotherapy) and in 17 patients with a stage I tumor subjected to hemiorchiectomy exclusively. In the patients treated with chemotherapy, the plasma testosterone levels remained at the lower limit of normal and the luteinizing hormone (LH) levels remained elevated for 2 years after completion of treatment. The follicle-stimulating hormone (FSH) levels also remained significantly elevated, but showed a tendency to decrease after 2 years. Semen analysis was performed in 25 patients; of the other patients, 18 had no antegrade ejaculation, eight had undergone a vasectomy and three patients did not cooperate. Before treatment, 72% of the patients showed azoo- or oligozoospermia; 2 years after discontinuation of the chemotherapy, 48% had azoo- or oligozoospermia while 28% had more than 60 X 10(6) spermatozoa/mL. However, interestingly the proportion of patients with azoospermia had increased from 4% to 28%. In the course of this study, eight pregnancies occurred; one ended in an early spontaneous abortion; the other seven pregnancies ran an uncomplicated course. Seven healthy children were born. In 17 patients with a stage I tumor treated by hemiorchiectomy only, the testosterone, LH and FSH levels were also observed for 2 years; until 2 years after treatment, the testosterone levels remained lower and the FSH levels remained higher than normal. Insufficiency of the Leydig's cells in the unaffected gonad appeared to be responsible for the altered hormone concentrations in the blood.

Developmental pattern and regulation by androgens of androgen receptor expression in the urogenital tract of the rat.

Distribution and regulation of androgen receptor expression during fetal and neonatal virilization of the rat fetus was assessed by immunohistochemistry. In mesonephric duct derivatives the androgen receptor expression became evident first in the efferent ductules and epididymis (on fetal day 14), subsequently in the vas deferens and finally in the seminal vesicle. Mesenchymal cells of the urogenital tubercle were positive for androgen receptors from fetal day 14 onwards. In the mesenchymal cells of the prostate anlagen, androgen receptor positive cells were found first on fetal day 16. Administration of 5alpha-dihydrotestosterone to pregnant rats from day 11 to day 20 of gestation caused a stabilization of the wolffian duct in female fetuses. The androgen receptor expression pattern became similar as found in mail fetuses, and showed an increase in density and in frequency of androgen receptor positive cells. Administration of the androgen antagonist flutamide during the same interval caused a reduction in density and frequency of androgen receptor positive cells in male fetuses. These findings indicate that androgens enhance the expression of androgen receptors in the developing rat genital tract by induction of androgen receptor positive cells, and by increasing the frequency. The developmental pattern of androgen receptor expression in the rat mesonephric duct system reflects the androgen-responsiveness of the ducts, and is consistent with induction of the androgen receptor along the ducts by testosterone reaching these structures in an exocrine fashion.

Expression and prognostic relevance of vascular endothelial growth factor (VEGF) and its receptor (FLT-1) in nephroblastoma.

AIMS: To investigate the prognostic relevance of vascular endothelial growth factor (VEGF) and its receptor Flt-1 in nephroblastoma and whether tumour microvessel density (MVD) immunoreactivity, determined by the CD31 antigen, is related to the expression of VEGF and Flt-1. METHODS: The expression of VEGF and Flt-1 and MVD were investigated by means of immunohistochemical analysis in 62 Wilms's tumours. Patients were treated preoperatively with chemotherapy and had a mean follow up of 5.7 years. RESULTS: In general, VEGF and Flt-1 were expressed in normal kidney parenchyma and to a variable extent in the three main components of Wilms's tumour, namely: the blastemal, epithelial, and stromal cells. In tumour tissue, 52% and 47% of blastemal cells were positive for VEGF and Flt-1, respectively. A non-significant correlation was found between the expression of VEGF and Flt-1 in blastemal and epithelial cells and the clinicopathological stage. MVD was significantly higher in VEGF and Flt-1 positive tumours than in VEGF and Flt-1 negative tumours. Univariate analysis showed that the expression of VEGF and Flt-1 in blastemal cells was indicative of clinical progression and tumour specific survival. In addition, MVD expression was indicative of clinical progression. Epithelial staining was of no prognostic value. In a multivariate analysis, VEGF protein expression by blastemal cells was an independent prognostic marker for clinical progression. CONCLUSIONS: These results indicate that VEGF and Flt-1 protein expression are closely related to MVD and seem to be an important predictor for poor prognosis in treated patients with Wilms's tumour. Therefore, the expression of these molecules in primary Wilms's tumour may be useful in identifying those patients at high risk of tumour recurrence and in guiding antiangiogenic treatment.

Prenatal diagnosis, management and outcome of fetal uretero-pelvic junction obstruction.

Prenatal diagnosis, management and outcome were studied retrospectively in 24 cases of unilateral and bilateral uretero-pelvic junction obstruction (UPJO). Moderate-to-marked pelvic dilatation was documented in 19 out of 24 cases. The low morbidity and mortality observed in this study are probably determined by the late (third trimester) detection of UPJO, resulting in an underestimation of the prevalence of more severe renal pathology. Amniotic fluid was increased in 4 out of 14 cases of unilateral UPJO and in 5 out of 10 cases of bilateral UPJO, the underlying mechanism of which is still unclear. There was no oligohydramnios. The incidence of extrarenal structural pathology was low, i.e., 3 out of 24 cases. A close agreement could be demonstrated between pre- and postnatal sonographic grading of pelvic dilatation. However, postnatal ultrasonic grading of pelvic dilatation correlated poorly with the degree of functional obstruction as determined by IVP and lasix renography. Despite the severity of pelvic dilatation in the majority of cases, enlarged kidneys were revealed by postnatal clinical examination in only three instances, underlining the importance of prenatal sonographic detection of UPJO.

[Prenatal ultrasonic detection of asymptomatic urogenital abnormalities: advantages and disadvantages]. / Antenatale echografische ontdekking van asymptomatische urogenitale afwijkingen: voordelen én nadelen.

Prenatal ultrasound studies have significantly contributed to the understanding of congenital abnormalities of the urinary tract and the development of pediatric urology over the past decade. Besides providing more insight into pathophysiology of the developing urinary tract, it has promoted the possibilities of early postnatal intervention and of studying the natural history of developmental abnormalities such as pelviureteral junction obstruction and vesico-ureteric reflux. The downside of this development has been and probably still is a considerable amount of diagnostic and therapeutic interventions for so-called abnormalities which, left alone, will disappear with time and without significant sequelae. On the other hand, many children with severe obstructive uropathy are alive today because of early intervention. Longterm follow-up studies are needed to prove the efficacy of prenatal screening and to ascertain the contribution of these technical possibilities to quality of life.

[Routine urodynamic studies is not indicated in children with enuresis]. / Routinematig urodynamisch onderzoek bij kinderen met enuresis niet geïndiceerd.

From January 1980 to January 1992, urodynamic examinations were performed in 339 enuretic children without constipation or anatomical or neurogenic causes of incontinence. Nocturnal enuresis was seen in 178 patients, 130 children suffered from nocturnal and diurnal enuresis, and 31 had only diurnal enuresis. M. detrusor instability was found in 44% of the children and 73% showed more than 15% reduction in functional bladder capacity. In 5% an infravesical obstruction was suspected on pressure-flowmetry and in 12% dysfunctional voiding was seen. Routine urodynamic studies are not indicated in children with enuresis.

[Experiences with extracorporeal shockwave lithotripsy in 61 children]. / Ervaringen met extracorporele schokgolfithotripsie bij 61 kinderen.

Between March 1985 and January 1987 2547 ESWL treatments were performed on 2064 patients, including 33 boys and 28 girls younger than 18 years. Almost identical results were obtained in children as in adults. All stones desintegrated and success was achieved in 97%; 79% was considered stone-free after 6 months and 18% had passable asymptomatic residual fragments (biggest fragments less than 3 mm) which did not grow larger during a mean follow-up of 17.8 months. One patient had a recurrent stone, after having been stone-free for 13 months. Post-ESWL complications and morbidity were minimal. Auxiliary measures were necessary in 5 patients before ESWL and in 6 patients after ESWL. Failure to render the kidney free of stones occurred in 2 patients with complex urolithiasis. Because of these results ESWL should be considered the treatment of choice in the paediatric age group for urolithiasis.

[Differential diagnosis and treatment of girls with 46XY-karyotype and androgen insensitivity syndrome]. / De differentiaaldiagnose en behandeling van meisjes met het 46XY-karyotype en ondervirilisatiesyndroom.

The importance of the secretion and action of androgens during the critical period of male sexual development is exemplified in patients with androgen insensitivity syndrome. Their karyotype is always 46XY. In 2 sisters, aged 11 and 13 years, the androgen insensitivity syndrome was diagnosed based on an androgen receptor gene mutation. Ambiguous genital development of a new-born was shown to be due to a lack of testosterone production, based on a luteinizing hormone receptor gene mutation. Finally, in a phenotypically female new-born a gene mutation of 17-beta hydroxysteroid dehydrogenase type 3 was found to be responsible for insufficient testosterone synthesis during embryonic development. The presentation of a patient, and specifically a neonate, with abnormal genital development represents a difficult diagnostic and therapeutic challenge. Referral to a centre with experience in the diagnosis and management of disorders of sexual development is advised where the emphasis should be on psychological and genetic counselling.

The association between Peyronie's and Dupuytren's disease.

Peyronie's disease (PD) is known to be associated with Dupuytren's disease (DD) since 1828. The aim of this study was to investigate the coexistence of DD in a consecutive series of patients with PD and their clinical characteristics. From January 1988 to December 2009 all patients, presenting at our outpatient urological clinic, with PD were also examined for DD. The sample consisted of 415 male subjects with PD, 89 (22.1%) also had DD. A total of 28 men (6.7%) reported to have one or more first or second degree relatives with DD.

Torsion of the spermatic cord after orchiopexy.

The cases of spermatic cord torsion reported here show that this condition may occur even some time after fixation. Three men, aged 22, 30 and 35 years, visited the urologist with complaints of an acute scrotum following earlier orchiopexy for spermatic cord torsion. Different techniques are employed to fixate the testicles after spermatic cord torsion. These cases confirm that Jaboulay's bottleneck procedure is the method of choice for bilateral fixation in patients presenting with this condition.

The cryptorchidism prevalence among infants in the general population of Rotterdam, the Netherlands.

Published trends and geographical differences in cryptorchidism rates are almost exclusively derived from hospital-based birth defect registers, which are sensitive to selection bias and incomplete reporting. This study aimed to accurately assess the cryptorchidism prevalence in the general population of Rotterdam. Of 7652 consecutive male live births, 7292 (95%) were examined for cryptorchidism at Child Healthcare Centres around the age of 1 month. In a subgroup of cases, the persistence of cryptorchidism was re-assessed during a follow-up examination by expert specialists. The cryptorchidism rate at the median age of 35 days was 1.2% (89/7292). In the re-examined subgroup (median age 95 days) 69% of the boys (24/35) had persistent cryptorchidism, of which 20 were unilateral and four bilateral. The population rate of 1.2% falls within the range of 0.9-9% reported by others. Differences in case ascertainment and population characteristics probably explain part of the differences between studies. Our cross-sectional design does not allow for analysis of a temporal trend, but provides a baseline for future trend studies. To study cryptorchidism rates, trends, and risk factors, a systematic case ascertainment is warranted.