Emphysematous Cystitis and Urinary Retention in a Male Patient With Diabetes Mellitus Type 2 Treated With Empagliflozin.

Objective: Emphysematous cystitis (EC) is a rare urinary tract infection (UTI) typically associated with severe diabetes in older women. We present a unique case of this gas-forming infection in a man with type 2 diabetes mellitus (T2DM) treated with empagliflozin. To the best of our knowledge, this is the first case report of EC associated with the use of a sodium-glucose cotransporter 2 inhibitor (SGLT2i). Case Report: A 62-year-old man with T2DM treated with an SGLT2i developed EC. His moderately controlled T2DM was treated for over 20 years with metformin, saxagliptin/metformin, and pioglitazone to which empagliflozin was added due to his consistently elevated hemoglobin A1c level, slightly reduced estimated glomerular filtration rate, and proteinuria. Four months after initiation of the SGLT2i, he reported lower urinary tract symptoms and was found to have EC radiographically. His urine cultures were positive for Klebsiella pneumonia and was found to have asymptomatic urinary retention. He was treated conservatively, and his outcome was favorable. Discussion: EC is commonly seen in patients with diabetes mellitus, and symptoms range from asymptomatic to severe sepsis. Most urine cultures grow Escherichia coli and K. pneumonia. The association of increased UTIs in susceptible patients with T2DM with the use of SGLT2i is yet to be determined. Most cases of EC are diagnosed radiographically and treated conservatively, although some cases require surgical intervention. Conclusion: Initially, our patient was considered a good candidate for treatment with an SGLT2i. The subsequent development of EC precluded its further use. The role of SGLT2i in patients with T2DM susceptible to UTI is controversial.

Mapping of spinal interneurons involved in regulation of the lower urinary tract in juvenile male rats.

Coordination between the urinary bladder (BL) and external urethral sphincter (EUS) is necessary for storage and elimination of urine. In rats interneuronal circuits at two levels of the spinal cord (i.e., L6-S1 and L3-L4) play an important role in this coordination. In the present experiments retrograde trans-synaptic transport of pseudorabies virus (PRV) encoding fluorescent markers (GFP and RFP) was used to trace these circuits. To examine the relative localization of EUS-related and BL-related interneuronal populations we injected PRV-GFP into the EUS and PRV-RFP into the BL wall. The PRV infected populations of spinal interneurons were localized primarily in the dorsal commissure (DCM) of L6/S1 and in a hypothesized lumbar spinal coordinating center (LSCC) in L3/L4 above and lateral to central canal (CC). At both sites colocalization of markers occurred in a substantial number of labeled interneurons indicating concomitant involvement of these double-labelled neurons in the EUS- and BL-circuits and suggesting their role in EUS-BL coordination. Intense GFP or RFP fluorescent was detected in a subpopulation of cells at both sites suggesting that they were infected earlier and therefore likely to represent first order, primary interneurons that directly synapse with output neurons. Larger numbers of weakly fluorescent neurons that likely represent second order interneurons were also identified. Within the population of EUS-related first order interneurons only 3-8 % exhibited positive immunoreaction for an early transcription factor Pax2 specific to GABAergic and glycinergic inhibitory neurons suggesting that the majority of interneurons in DCM and LSCC projecting directly to the EUS motoneurons are excitatory.

Is transurethral incision better than upper pole partial nephrectomy for management of duplex system ureterocoele diagnosed in the first year of life?

OBJECTIVE: To compare the outcomes of transurethral incision (TUI) and upper pole partial nephrectomy (PN) in patients with duplex system ureterocoele (DSU). PATIENTS AND METHODS: We retrospectively reviewed the medical charts of patients who presented with DSU in the first-year of life and were managed with either TUI or PN. Patients' demographics, ultrasonography examinations, voiding cystourethrogram studies, and dimercaptosuccinic acid scans were reviewed. Also, the postoperative vesico-ureteric reflux status and febrile urinary tract infection occurrences, and subsequent surgical interventions were identified. The outcomes for the DSU location (intravesical vs extravesical) were compared. RESULTS: Between January 1995 and September 2015, 44 patients underwent TUI (31 patients) or PN (13). The TUI patients presented at a median age of 1.1 months and were followed-up for a median of 47.4 months, whilst those who underwent PN presented at a median age of 1.06 months and were followed-up for a median of 44.23 months. Postoperatively, in the TUI group, four of 15 units had improved renal function and 11 units had stable function. In the PN group, five of nine units had stable renal function and the remaining four had worsened function (P = 0.019). Furthermore, 15 of the 31 patients (48%) in the TUI group required second interventions compared with one of 13 patients in the PN group (P = 0.01). There was no significant difference between the outcomes of intravesical and extravesical DSUs after TUI and PN. CONCLUSION: This study shows significant renal function preservation with TUI compared to PN. However, secondary surgical interventions were higher with TUI.

A new tool for self-evaluation of adherence to antimuscarinic drugs treatment in patients with urinary incontinence.

ABSTRACT OBJECTIVE: To evaluate the validity of the Medication Adherence Self-Report Inventory (MASRI) questionnaire in determining antimuscarinic drugs adherence in patients with urinary incontinence (UI). PATIENTS AND METHODS: In all, 629 patients [355 (56.4%) women and 274 (43.6%) men], aged 18-65 years, were included. All patients were prescribed antimuscarinic drugs and treatment adherence was tested at the start, and after 4, 8 and 12 weeks using the MASRI. The standard of external monitoring was the Brief Medication Questionnaire (BMQ) and visual count of the remaining pills. The functional status of the lower urinary tract was tested using voiding diaries and uroflowmetry. RESULTS: The correlation between indicators of adherence according to the MASRI and screen mode of the BMQ was r = 0.84 (P ≤ 0.01), r = 0.72 (P ≤ 0.01), r = 0.7 (P ≤ 0.05) at 4, 8 and 12 weeks of follow-up, respectively, which indicated a satisfactory competitive validity. In the study of the discriminant validity, we found that non-adherent patients were correctly identified according to the MASRI in 96.2%, 96.9% and 96.2% of cases at 4, 8 and 12 weeks of follow-up, respectively. The values of the positive likelihood ratio (7.92, 10.81, and 12.8 at 4, 8 and 12 weeks of follow-up, respectively) were quite acceptable for the adherence forecast. The receiver operating characteristic analysis revealed a failure of the null hypothesis of the excess/insufficient discrimination power of the MASRI. The correlation between the percentage of non-adherent patients and the percentage of patients with impaired lower urinary tract function according to uroflowmetry data was r = 0.55 (P ≤ 0.05) at 4 weeks; r = 0.59 (P ≤ 0.05) at 8 weeks; and r = 0.62 (P ≤ 0.01) at 12 weeks. CONCLUSION: The MASRI questionnaire is highly constructive, competitive, has discriminant validity, and is suitable for self-assessment of treatment adherence in patients with UI taking antimuscarinics. Using the MASRI is less costly and faster compared with other assessment tools.

The efficacy of different doses of solifenacin in elderly patients after treating a urinary tract infection.

OBJECTIVE: To determine the efficacy and safety of solifenacin for correcting the residual symptoms of an overactive bladder (OAB) in patients who were treated for a urinary tract infection (UTI). PATIENTS AND METHODS: Using random sampling, 524 patients aged >60 years were selected (347 women, 66.2%, and 177 men, 33.8%). They denied the presence of any symptoms of detrusor overactivity in their medical history, but had a diagnosis of a UTI. At least 1 month after the end of treatment and a laboratory confirmation of the absence of infection, each patient completed an OAB-Awareness Tool questionnaire (OAB signs, total score 8 points), and a noninvasive examination of urinary function (uroflowmetry). Each day patients in group A took solifenacin 10 mg and those in group B took 5 mg, with patients in group C being given a placebo. RESULTS: During the study 58.8% of patients had symptoms of an OAB at 1 month after the end of the treatment for a UTI, and normal laboratory markers. During treatment with the standard and higher dose of solifenacin, within 8 weeks most variables of the condition of the lower urinary tract reached a normal state or improved. CONCLUSION: Patients aged >60 years who had been treated for a UTI have a high risk of developing symptoms of an OAB. Solifenacin in standard doses is an efficient and safe means of managing overactive detrusor symptoms after a UTI.

A quantitative comparison between free uroflow variables and urodynamic data, and the effect of the size of urodynamic catheters on its interpretation.

OBJECTIVE: To assess the effect of the urodynamic catheter on the urinary flow rate and residual volume in various urodynamic diagnoses, and compare the outcome when using a smaller catheter, as the effect of this catheter on free uroflow variables is mostly studied in patients with bladder outlet obstruction (BOO) and little is known about its effect in other urodynamic diagnoses. PATIENTS AND METHODS: In all, 319 men undergoing a pressure-flow study (PFS) with a 5 F filling and 5 F measuring bladder catheter were subdivided into three groups based on a urodynamic diagnosis, i.e. normal PFS (group 1), BOO (group 2) and detrusor underactivity (DU, group 3). Another group (4) comprised 61 patients who had a PFS with the filling catheter removed before the voiding phase. The effect of the catheters on the maximum urinary flow rate (Qmax) and the postvoid residual volume (PVR) was analysed statistically and compared among the groups. We also compared the free-flow variables with the clinical and urodynamic variables. RESULTS: Groups 1-3 (with two catheters) had a significantly lower Qmax and higher PVR than those voiding with one catheter (group 4). The reduction in Qmax was highest in group 3 (41.9%) and least in group 2 (21%). Group 4 showed no significant change in Qmax in cases with BOO and a normal PFS but a significant decline in those with DU (19.6%). The PVR was positively associated with the bladder capacity and negatively with detrusor contractility, but no association with a urodynamic diagnosis of BOO or any specific symptom. CONCLUSION: Detrusor contractility was the strongest predictor of the obstructive effect caused by the catheter. This study justifies the use of a single 5 F catheter at the time of voiding, although that can also cause a reduction in flow in patients with DU.

Metaphylaxis, diet and lifestyle in stone disease.

OBJECTIVE: The most common urinary stones (calcium salts, uric acid) form due to genetic factors and lifestyle. This review describes why, if and how medication and lifestyle changes can reduce the risk of formation. METHODS: Previous reports were reviewed to obtain information on three aspects of urolithiasis, i.e. epidemiology, mechanisms linking lifestyle and urolithiasis and lifestyle intervention for preventing urolithiasis. RESULTS: Epidemiological evidence links the prevalence of urinary stone formation to general lifestyle factors. Detailed analysis has identified individual lifestyle elements that affect the risk of urinary stone formation. Currently there are several concepts that explain the mechanism of stone formation. Urinary markers like calcium, oxalate, phosphate, uric acid and urinary pH are involved in all these concepts. Many studies show that changing (combinations of) specific lifestyle elements has a favourable effect on these urinary markers. Based on this evidence, protocols have been developed that use a combination of these lifestyle changes and medication to prevent stone formation. In well-controlled studies where patients are optimally informed and continuously motivated, these protocols clearly reduce the stone formation rate. In general practice the result is less clear, because the time and tools are insufficient to maintain long-term patient compliance in the use of medication and lifestyle advice. CONCLUSION: The risk of stone formation can be reduced in general practice when the patient's compliance is optimised by providing individualised advice, continuous information, and feedback and incorporation of the advice into a regular lifestyle. The use of 'e-tools' might enable this without increasing the time required from the physician.