Evaluation of chronic urethritis. Defining the role for endoscopic procedures.

We determined the prevalence of structural and functional abnormalities of the lower urinary tract in a carefully defined population of 36 men with chronic urethritis who were attending a sexually transmitted disease clinic. They had experienced symptoms for an average of 12.1 months and had been treated with an average of 5.1 courses of antimicrobial drugs. All had objective evidence of urethral inflammation and negative cultures for both Neisseria gonorrhoeae and Chlamydia trachomatis. Structural abnormalities were documented in nine (25%) of 36 patients but were considered clinically significant in only four. Physical examination and uroflow testing led to clinical suspicion of anatomic abnormalities in all four patients with significant lesions, which included urethral strictures in three patients and benign prostatic hypertrophy in one patient. Additional abnormal findings included wide-bore strictures in three patients and developmental abnormalities of doubtful significance in two patients. Increased numbers of inflammatory cells in expressed prostatic secretions were associated with the presence of structural abnormalities. We conclude that among men with chronic urethritis, careful physical examination and uroflow studies can be used to screen for evidence of structural abnormalities that merit endoscopic evaluation.

Viral burden in genital secretions determines male-to-female sexual transmission of HIV-1: a probabilistic empiric model.

OBJECTIVE: To develop a model to predict transmission of HIV-1 from men to women. DESIGN: HIV-1 in seminal plasma, and endocervical CCR5 receptors were correlated with epidemiological studies of HIV-1 transmission to develop a probabilistic model. SETTINGS: Semen samples were collected from patient subjects in Seattle Washington, Chapel Hill, North Carolina, and St. Gallen, Switzerland. Endocervical biopsy specimens were obtained from women in Chicago, Illinois. PARTICIPANTS: Eighty-six men (not receiving antiretroviral therapy) in whom CD4 cell count and semen volume were available, and 24 women in whom the number of endocervical CCR5 receptors were determined. MAIN OUTCOME MEASURES: Prediction of transmission of HIV-1 from men to women per episode of vaginal intercourse based on the absolute burden of HIV (volume x HIV RNA copies/ml seminal plasma). RESULTS: The model suggests efficient heterosexual transmission of HIV-1 when semen viral burden is high. When semen contains 100 000 copies of non-syncytium-inducing (NSI) HIV RNA the probability of HIV-1 transmission is 1 per 100 episodes of intercourse; conversely, with 1000 copies NSI HIV RNA in semen, transmission probability is 3 per 10 000 episodes of intercourse. CONCLUSIONS: This model links biological and epidemiological data related to heterosexual HIV-1 transmission. The model can be used to estimate transmission of HIV from men with high semen viral burden from inflammation, or reduced burden after antiretroviral therapy. The results offer a biological explanation for the magnitude of the HIV epidemic in places where earlier studies have shown men have high semen viral burden, such as in sub-Saharan Africa. The model can be used to develop and test HIV-1 prevention strategies.

Trazodone and priapism.

Trazodone, an antidepressant with antianxiety effects, has been available in the United States since March 1982. Since then 11 cases of priapism, five requiring surgical procedures, have been reported. The authors present one of the latter cases.

Transient and chronic neurological complications of fast neutron radiation for adenocarcinoma of the prostate.

The records of 132 patients participating in clinical trials using fast neutron (n = 94), mixed neutron and photon (n = 16), or conventional photon (n = 22) irradiation for primary management of prostatic cancer were retrospectively reviewed to assess treatment-related neurological complications. With a median follow-up of 14 months (range 1 to 101 months), 31/132 patients (26 neutron, 3 mixed beam, 2 photon) have experienced either sciatica beginning during or shortly after treatment, or diminished bladder or bowel continence that developed at a median time of 6.5 months following treatment. Sciatica responded to oral steroids and was usually self-limited, whereas sphincter dysfunction appears to be permanent. Pre-treatment risk factors for complications included a history of hypertension, diabetes, cigarette smoking or peripheral vascular disease, with 81% of affected patients having one or more risk factors compared with 55% of unaffected patients (p = 0.01). Seven patients have moderate (5) or severe (2) residual problems, all in the cohorts receiving neutrons (6/7) or mixed beam therapy (1/7).

Wound infections in renal transplant recipients--a complication of urinary tract infections during allograft malfunction.

Both wound and urinary tract infections are common in renal transplant recipients. Certain recipients, however, develop detrimental complications following such infections, and our aim was to analyze factors that predisposed recipients to such complications. Analysis of 174 consecutive transplants performed over a 7-year period ending December 1980 demonstrated that a urinary infection developing during acute tubular malfunction (ATM) led to serious septic complications. The complication rate was 70% in the 30 recipients in whom urinary tract infection occurred during ATM but only 10% in the 20 recipients with infection in the absence of ATM (P less than 0.001). Similarly, analysis of 14 deep wound infections showed that the source of the organisms was the urinary tract (12 cases), especially when the urinary tract infection occurred in the setting of ATM. Deep injections led to high rates of morbidity and mortality. Conversely, superficial wound infections (10 cases) contained staphylococci and healed without complications. We suggest that urinary tract organisms, which are difficult to eradicate with antibiotics because of low urinary concentration of antibiotics during ATM, lead to infection of the perirenal tissues.

Amniotic fluid interleukin-6 and preterm delivery: a review.

OBJECTIVE: To evaluate the potential role of amniotic fluid (AF) interleukin (IL)-6 as a predictor of preterm delivery and to consider possible explanations for the proportion of women with elevated AF IL-6 who deliver preterm yet lack microbiologically detectable intra-amniotic infection. DATA SOURCES: We searched the English language human literature in MEDLINE, 1966 through September 1999, using the keywords "labor/infant," "premature," "cytokines/interleukin-6," and "AF." We also examined abstracts from the 1999 meetings of the Society for Maternal-Fetal Medicine and the Society for Epidemiologic Research. We identified other studies by reviewing the reference lists of published articles. METHODS OF STUDY SELECTION: The MEDLINE search yielded 55 citations. We focused on studies that reported on the association between AF IL-6 and preterm delivery. TABULATION, INTEGRATION, AND RESULTS: There is consensus in the literature that elevated AF IL-6 is a stronger predictor of preterm delivery than intra-amniotic infection detected by either microbiologic culture or polymerase chain reaction (PCR). Among women with elevated AF IL-6, PCR could detect a higher proportion of intra-amniotic infection than culture. A number of women with elevated AF IL-6 (33-70%) deliver preterm and do not have evidence of intra-amniotic infection by either culture or PCR. Possible explanations for this observation are considered. CONCLUSION: Elevated AF IL-6 is strongly associated with preterm delivery and merits future consideration in clinical settings to predict preterm delivery and guide patient care. Development of improved polymerase chain reaction-based clinical methods to detect intra-amniotic infection is necessary to better understand the relationship between elevated AF IL-6, intra-amniotic infection, and preterm delivery.

Comparison of assays to detect cytomegalovirus shedding in the semen of HIV-infected men.

We sought to determine the optimal assays for cytomegalovirus (CMV) shedding in semen. Over a 2-month period, 149 HIV-1-infected men who have sex with men each provided up to three semen specimens. Specimens were tested for CMV by culture, rapid assay (shell vial) and polymerase chain reaction (PCR). By culture, 30% of seminal plasma and 28% of seminal cell specimens grew CMV. By rapid assay, results were 38 and 33%, respectively. By PCR, 56% of seminal cell specimens demonstrated CMV: 20% in a single semen specimen; 33% in two specimens; and 34% in all three specimens. Overall, 69% of men had CMV detected by PCR in at least one seminal cell specimen. By quantitative PCR, 14% had ten, 14% had 100, 16% had 1000, and 12% had 10000 copies in 6.25 microl of semen analyzed. Adjusting for initial CD4+ cell count, men with CMV shedding demonstrated by PCR at the first visit were approximately four times as likely to shed CMV at a subsequent visit (RR 4.28, CI: 2.30-7.95). CMV shedding was associated with decreased CD4+ cell counts in peripheral blood (P=0.05). It is concluded that the PCR assay provided the greatest sensitivity among the three detection methods.

Comprehensive evaluation and treatment of 75 men referred to chronic prostatitis clinic.

We investigated the role of genitourinary tract infections, structural and psychologic abnormalities in 75 men referred to a "chronic prostatitis" clinic. Patients had had symptoms for an average of eighty-three months and had received an average of ten weeks of antimicrobial treatment during the three months prior to evaluation. Specific infectious diseases, structural or functional causes were identified in 34 (45%) of the 75 patients. Genitourinary tract pathogens were isolated from 26 patients and inflammation was documented in urethral or prostatic secretions of 24 patients. Structural or functional abnormalities that merited treatment were identified in 8 cases. In addition, major criteria for depression were documented in 9 of 17 patients who agreed to this evaluation. Overall, a comprehensive approach to diagnosis led to specific treatment for 37 (49%) of the 75 men with chronic prostatitis, despite longstanding symptoms and failure of multiple prior courses of therapy.

DNA and RNA amplification in urology: the polymerase chain reaction.

Polymerase chain reaction (PCR) technology is a promising molecular approach for diagnosis of genitourinary tract infections, inherited disorders, tumor-associated genetic alterations and tumor markers. Because it is based on exponential amplification, the technology is capable of ultimate theoretical sensitivity. Although not entirely free of technical limitations, PCR holds advantages over other diagnostic tests, including exquisite sensitivity, specificity, interchangeability and speed.

Role of human papillomavirus typing in diagnosis and clinical decision making for a giant verrucous genital lesion.

A 60-year-old man presented with a 12.0 x 10.0-cm exophytic, verrucous genital plaque. Multiple biopsy specimens were evaluated by standard histologic analysis and polymerase chain reaction assays for human papillomavirus (HPV) deoxyribonucleic acid. All biopsy specimens showed histopathologic changes consistent with giant condyloma of Buschke-Lowenstein (GCBL), were uniformly positive for HPV 6/11, and showed a weaker signal for HPV 16. Published reports suggest that the presence of HPV may be useful in differentiating GCBL from verrucous carcinoma (VC), but absence of "high-risk" HPV types in GCBL cannot exclude focally invasive squamous cell carcinoma. Screening for HPV may be a helpful adjunct in differentiating GCBL from VC, but histopathologic criteria for malignancy should take precedence over HPV typing when determining management.

Adenocarcinoma of rete testis. Role of inguinal orchiectomy plus retroperitoneal lymph node dissection.

Adenocarcinoma of the rete testis is diagnosed rarely. We describe the clinical and pathologic findings in a forty-seven-year-old man with this unusual tumor. Treatment modalities are reviewed emphasizing the role of radical orchiectomy and retroperitoneal lymph node dissection.

Urinary tract infection in pediatric renal transplantation.

Urinary tract infection is a frequent complication following renal transplantation and represents a potential focus for systemic infection in the immunosuppressed transplant recipient. The incidence, etiologic factors, temporal pattern, bacteriology, and prognostic significance of urinary tract infection were determined by analysis of 85 renal allografts in 69 patients. Significant bacteriuria occurred after 49 of 85 transplants (58 per cent). The incidence of infection was not related to success or source of the allograft, but was related to patient gender. Urinary tract infections developed in 68 per cent of females, while only 43 per cent of males became infected (p less than 0.05). Escherichia coli caused most first infections (30 per cent), while Pseudomonas aeruginosa and E. coli were equally responsible for recurrent infections (25 per cent each). Children with previous reconstructive urologic surgery had similar allograft success (63 per cent) and infection rates (53 per cent) as our other children (61 per cent and 58 per cent, respectively). No apparent correlation was noted between episodes of infection and graft rejection. Thorough preoperative assessment and preparation and prompt, specific treatment minimize the adverse influences of urinary tract infection.

Few patients with "chronic prostatitis" have significant bladder outlet obstruction.

OBJECTIVES: A high prevalence of significant bladder outlet obstruction has been reported among men diagnosed as having "chronic prostatitis." To evaluate the possibility that case selection may determine this high prevalence, we compared findings in patients referred directly to our Urodynamic Unit with that of patients evaluated in our Prostatitis Clinic. METHODS: The videourodynamics records of 201 men aged 18 to 50 years who presented to the Urodynamic Unit with any lower tract symptoms (irritative and/or obstructive with or without pain) were compared with the findings in 123 Prostatitis Clinic patients. The latter were evaluated for obstruction with flow rates and, if abnormal, by retrograde urethrograms and videourodynamics. RESULTS: Only 37 (18%) of 201 patients referred to the Urodynamic Unit had pain as a significant symptom and might have been diagnosed as having chronic prostatitis. Of these 37 patients, 4 (11%) had definite obstruction, 6 (16%) were equivocal, 6 (16%) were hypocontractile, 1 (3%) had pseudodyssynergia, and 7 (19%) had normal findings. The remainder had abnormalities of bladder filling (hypersensitivity in 11 [30%] and detrusor instability in 2 [5%]). Fewer of the 123 patients with prostatitis had obstruction (definite in 2 [1.6%] and equivocal in 1 [0.8%]) (P = 0.03), 2 (1.6%) had hypocontractile detrusors, and 2 had urethral strictures. CONCLUSIONS: Patients referred to the Urodynamic Unit with lower urinary tract symptoms and pain rarely have bladder outlet obstruction. However, they are significantly more likely to have bladder outlet obstruction than patients referred to the Prostatitis Clinic who can be screened for obstruction by history, flow rate, postvoid residual, and retrograde urethrogram.

Urinary calculous disease in Southeast Asian immigrants.

Recent immigrants from Southeast Asia accounted for 39 of 149 hospital admissions for treatment of urinary tract stones. Presumptive diagnosis of a urinary calculus was possible in only 19 per cent of the refugees compared with 60 per cent of other patients treated at the same hospital (p less than 0.005). Calculi in Southeast Asian immigrants were larger (p less than 0.001), and surgical procedures were required more often (p less than 0.05) than for other patients with calculi. Urinary stones should be considered a likely cause of abdominal or urinary tract complaints in recent immigrants from Southeast Asia.

Chronic pelvic pains represent the most prominent urogenital symptoms of "chronic prostatitis".

OBJECTIVES: To refine and standardize evaluation of current symptoms in men with "chronic prostatitis." METHODS: We reviewed the literature, developed a symptom index, and evaluated the clinical utility of this tool in 50 patients with chronic prostatitis and 75 control patients (25 with benign prostatic hyperplasia [BPH] and 50 with sexual dysfunction). RESULTS: Patients with prostatitis reported more perineal, lower abdominal, testicular, penile, and ejaculatory pain than patients with BPH (P < 0.05 for each symptom) or sexual dysfunction (P < 0.01 for each symptom). Ejaculatory pain was also more common among men with prostatitis than among men with BPH (P = 0.07) or among men with sexual dysfunction (P < 0.01). Although described as characteristic of prostatitis in the literature, low back or rectal pain did not distinguish patients with prostatitis from those with BPH. Patients with prostatitis were intermediate between patients with BPH and sexual dysfunction on the voiding scale and similar to the BPH group on the sexual dysfunction scale. CONCLUSIONS: Pain symptoms were the predominant urologic manifestations of chronic prostatitis. The symptom index may prove valuable for evaluating patients and describing clinical results.

Urinary infection in kidney transplantation.

Urinary tract infection is the most frequent complication following renal transplantation and is important in the etiology of post-transplantation sepsis. The 87 renal homografts done in 1974 at The New York Hospital-Cornell Medical Center were reviewed retrospectively, with at least one year follow-up, in all cases, with particular attention to factors relating urinary tract infection to ultimate success or failure of the renal graft. The over-all incidence of urinary tract infection was 61%. Early infection was associated with a particularly poor prognosis for graft survival. Most patients with urinary infections after successful transplantation experience a combination of both early and late infections. Anatomic factors constitute a remediable cause of urinary infections after transplantation and should be searched for in cases of multiple, recurrent infections, de novo hypertension, or deterioration of previously stable graft function. There were significant differences in the bacteriologic spectrum of urinary tract infections associated with successful transplants as opposed to unsuccessful transplants.

Anaerobic bacteriuria in renal transplantation.

Renal allograft recipients were studied prospectively utilizing improved culture techniques to investigate anaerobic bacteriuria. The study population was compared with a population of patients with chronic renal insufficiency and end stage renal disease. The over-all incidence of anaerobic urinary tract infection was 7.5 per cent while the over-all incidence of aerobic urinary tract infection was 23.5 per cent. Patients with cadaver renal transplants during the early postoperative period had the highest incidnece of both anaerobic (42.9 per cent) and aerobic (71.4 per cent) urinary tract infection of all groups. The potential association between significant anaerobic bacteriuria during the first postoperative month and poor prognosis for cadaver renal allografts merits further investigation.

Differential diagnosis of genitourinary tumors using monoclonal antibodies to intermediate filament proteins.

Definitive diagnosis of poorly differentiated and metastatic neoplasms may be impossible using conventional histologic criteria. Recent developments in cell biology and immunology now enable us to answer such difficult diagnostic problems. Several varieties of structural proteins can be identified in malignant cells using monoclonal antibodies. The composition of these proteins can yield information regarding the origin of a neoplasm. Intermediate filaments are one such family of structural proteins. By characterization of these proteins, using a panel of monoclonal antibodies, poorly differentiated tumors may be definitively classified as carcinomas, sarcomas, lymphomas, or neural tumors. This approach to tumor diagnosis is now applicable to difficult problems in clinical urology.

Fast neutron radiotherapy for locally advanced prostate cancer. Update of a past trial and future research directions.

Between June, 1977, and April, 1983, the Radiation Therapy Oncology Group (RTOG) sponsored a phase III study comparing fast neutron radiotherapy as part of a mixed beam (neutron/photon) regimen with conventional photon (x-ray) radiotherapy for patients with locally advanced (Stages C and D1) adenocarcinoma of the prostate. A total of 91 analyzable patients were entered into the study with the two treatment groups balanced in regard to all major prognostic variables. The current analysis is for a median follow-up of 6.7 years (range 3.4-9.0 yrs.). The results are statistically significant in favor of the mixed-beam group of all parameters mentioned. At five years the freedom from local/regional relapse rate is 81 percent on the mixed-beam arm compared with 60 percent on the photon arm. The actuarial overall survival rate at five years is 70 percent on the mixed beam compared with 56 percent on the conventional photon arm. The determinantal survival at five years (which excluded death due to intercurrent disease in patients clinically free of cancer) was 82 percent on the mixed-beam arm compared with 61 percent on the photon arm. The type of therapy appeared to be the most important predictor of both local tumor control and patient survival in a step-wise Cox analysis. There was no difference in the treatment-related morbidity for the two patient groups. Mixed-beam therapy may be superior to standard photon radiotherapy for treatment of locally advanced prostate cancer.

Kinetics of killing or growth of Trichomonas vaginalis in the presence of aminoglycosides, neomycin and geneticin (G418).

Few therapeutic drugs, other than metronidazole and close derivatives, are currently available to treat trichomoniasis. Trichomonas vaginalis is known to have a primitive ribosome based on small subunit ribosomal DNA sequence comparisons. Targeting ribosomal subunits, the aminoglycosides neomycin and geneticin (G418, distinct from gentamycin) were tested for activity against T. vaginalis. While neomycin had no effect, G418 was effective in killing cultured T. vaginalis cells at doses intermediate between those previously effective against prokaryotes and eukaryotes. G418 cytotoxicity requires further study before recommending this agent as topically applied therapy in refractory patients.