Adenocarcinoma of the appendix with a fistula to the urinary bladder.

Adenocarcinoma of the vermiform appendix is a rare disease that constitutes less than 0.5% of all gastrointestinal malignancies. A patient was admitted with abdominal discomfort and urinary frequency but no symptoms suggestive of enterovesical fistula, e.g. pneumaturia or urinary tract infection. She was diagnosed with adenocarcinoma of the appendix with a fistula to the urinary bladder.

[Changes in treatment and cost of benign prostatic hyperplasia in Iceland.].

OBJECTIVE: During the last eight years there has been a dramatic change in the treatment of patients with benign prostatic hyperplasia (BPH) in Iceland. The number of transurethral resection of the prostate (TURP) has decreased while at the same time there has been a growing tendency to treat patients with a1-blockers and finasteride. The purpose of this study was to obtain statistical information regarding these changes and to estimate alterations in the cost of the BPH treatment. Possible changes in indications for TURP were also looked at. MATERIAL AND METHODS: Information on the number of patients who underwent surgery since 1984 was gathered from Icelandic hospitals. Information on the use and cost of medical treatment was obtained from the Icelandic Social Security. Medical records of 587 men who underwent surgery in the years 1988-1989 and 1998-1999 were reviewed. RESULTS: Since 1992 the number of TURP operations per year has dropped from its peak of about 560 to around 270 in 1999. This is more than a 50% reduction in eight years. The number of patients being treated for BPH has multiplied since the introduction of drugs and the total cost of BPH treatment has doubled since 1984. There was a trend but not a significant change in indications for TURP when the two periods were compared. CONCLUSIONS: Increasing number of Icelandic men with BPH are now recieving treatment although the number of TURP operations has decreased. The total cost of treatment has doubled since 1984, mainly attributed to the advent of medical treatment.

The ice-water test in the diagnosis of detrusor-external sphincter dyssynergia.

The ice-water test (IWT) implies rapid intravesical infusion of 100 ml of sterile ice-water during continuous pressure measurement and registration of fluid leakage. In a typical positive test, there is fluid leakage around the catheter(s) during the peak of detrusor contraction elicited by cold stimulation. Seventy-six patients, the majority with different forms of spinal disorders and a clinical and urodynamically suspected detrusor-external sphincter dyssynergia, were subjected to cystometry, needle electromyography (EMG) and an ice-water test. Detrusor-external sphincter dyssynergia was found in 44 (59%) patients and 41 of them had a positive IWT. A positive test with a high detrusor pressure indicates detrusor-external sphincter dyssynergia whereas the contrary applies to the negative test. Eighteen patients who responded to cold stimulation with detrusor contraction but without fluid leakage, called positive non-leakage IWT, all presented detrusor-external sphincter dyssynergia according to EMG. In this situation, the cheap, non-invasive and simple IWT can replace a needle EMG study.

Does anamnestic symptom evaluation or clinical examination give enough information to evaluate the severity of obstruction in benign prostatic hyperplasia?

In this study we have investigated 70 men fulfilling the usual criteria accepted for transurethral resection of the prostate (TURP). The anamnestic evaluation included the Madsen-Iversen symptom score and a quality of life questionnaire. The clinical examination included suprapubic pressure flow measurement, free urinary flow, the determination of residual urine and the ultrasound evaluation of the size of the prostate. The clinical data were correlated with the grade of obstruction according to Schäfer calculated from the pressure/flow studies. No correlation was found between the grade of obstruction and anamnestic symptom data, the size of the prostate or residual urine. A slight correlation was found between the Schäfer grade of obstruction and the flow curve pattern or peak flow.

Transurethral microwave thermotherapy versus transurethral resection for symptomatic benign prostatic obstruction: a prospective randomized study with a 2-year follow-up.

OBJECTIVE: To compare the outcome of transurethral resection of the prostate (TURP) and transurethral microwave thermotherapy (TUMT) on symptomatic benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Patients with symptomatic BPH were treated by either TURP (32 patients; mean age 70 +/- 6 years) or TUMT (37 patients; mean age 67 +/- 9 years) and assessed using the Madsen-Iversen symptom score, measurements of urinary free flow rate and post-void residual urine volume, digital rectal examination, transrectal ultrasonography, cystometry and pressure-flow measurement, ultrasonography or intravenous pyelography (IVP) of the upper urinary tract, urine analysis and routine blood chemistry including serum prostate-specific antigen (PSA) level. Examinations were repeated at fixed intervals for up to 24 months after treatment. RESULTS: After both TURP and TUMT there was an improvement in symptom score, residual urine volume, free flow rate and infravesical obstruction. The improvements of free flow rate and obstruction were more pronounced after TURP. Serious complications, such as bleeding requiring a re-operation, occurred only in patients who underwent TURP. CONCLUSION: Satisfactory results were obtained after both treatments and the improvements with either treatment lasted for at least 24 months.

Clinical and urodynamic effects of intravesical capsaicin treatment in patients with chronic traumatic spinal detrusor hyperreflexia.

PURPOSE: We administered capsaicin, a neurotoxic substance causing a reversible suppression of C fiber afferent neuronal activity, in an attempt to decrease bladder hyperreflexia. MATERIALS AND METHODS: Capsaicin solution (2 mM.) dissolved in 30% alcohol was instilled into the bladders of 10 men with traumatic chronic spinal lesions and left in place for 30 minutes. Effects on bladder function, including response to cold stimulation, were recorded during treatment, immediately after instillation and at followup. RESULTS: Bladder function improved in all but 1 patient, which was expressed as an increase in cystometric capacity and/or a decrease in maximal detrusor pressure. The effects lasted for 2 to 7 months. Immediately after capsaicin administration the ice water test was negative in half of the patients. CONCLUSIONS: The positive effects on bladder function of capsaicin treatment can be explained by the blocking of C fiber afferents. The optimum dose and treatment interval are presently not established. The ice water test might possibly be used as an instrument to monitor the ideal dosage.

Pressure, volume and infusion speed criteria for the ice-water test.

OBJECTIVE: To define pressure, volume and infusion speed criteria for the ice-water test (IWT). PATIENTS AND METHODS: In this prospective clinical study, cystometry and IWTs were performed in 115 patients. RESULTS: The critical response for a positive IWT was found to be a peak detrusor pressure above 30 cm H2O, with or without fluid leakage. Neither the infusion speed nor the infused volume was critical for the outcome of the test provided that the bladder wall was sufficiently cooled. CONCLUSION: The IWT is a rapid, simple and robust test, whose results are easy to interpret. The test increases the precision of urodynamic diagnosis, especially in patients with an overactive detrusor dysfunction, at a small cost.

The ice-water test--a simple and valuable supplement to routine cystometry.

The results of cystometrograms and ice-water tests (IWTs) were retrospectively evaluated in 557 patients with overactive bladders, lower motor neuron lesions or pure stress incontinence. The IWT was considered positive when, following ice-water instillation, the fluid was expelled from the bladder within 1 min. The test was considered false negative when no fluid escaped despite a sustained detrusor contraction of the same magnitude as the micturition contraction. Ninety-seven percent of patients with complete and 91% of those with incomplete upper motor neuron lesions had a positive or a false negative IWT. About 75% of the patients with multiple sclerosis, Parkinson's disease or previous cerebrovascular accident had a positive IWT. All patients with lower motor neuron lesions or pure stress incontinence had a negative IWT. There was a significant correlation between a positive IWT and an abnormal sensation of bladder filling and inability to inhibit micturition voluntarily, as well as between a negative IWT and the occurrence of phasic detrusor contractions during cystometry. The study shows that the IWT is a sensitive test for differentiating upper from lower motor neuron lesions. It is also a useful parameter for functional subdivision of overactive bladders. In patients with voiding dysfunction in the absence of lower urinary tract inflammation, a positive test is an indicator of a silent or overt neurological disorder.

Subtypes of overactive bladder in old age.

The prevalence of urinary incontinence increases dramatically with age and is mainly related to urge incontinence and bladder overactivity. It is a reasonable hypothesis that bladder overactivity primarily results from a disturbed central neuronal control of the lower urinary tract. Different sites and extents of neurogenic lesions or dysfunctions should result in different functional and urodynamic characteristics. We have recently identified three distinct urodynamic subtypes of bladder overactivity, and we report a retrospective study of the distribution of these subtypes in elderly patients. Eight hundred and fourteen patients aged 65 years or older with symptoms of urgency and/or urge incontinence underwent cystometry and the ice-water test. Two hundred and sixty-seven of them (33%) presented an overactive bladder. The prevalence of overactive bladder was constant up to the age of 65. A marked increase above this age was almost entirely ascribed to an increase of the so-called uninhibited overactive bladder subtype. This dysfunction occurred in 70% of the older patients. Patients with this condition have a coordinated reflex micturition at normal bladder volumes, but an abnormal perception of bladder fullness and lack of voluntary inhibitory control. This constellation of symptoms and signs indicates a suprapontine dysfunction.

Traditional acupuncture and electrical stimulation of the posterior tibial nerve. A trial in chronic interstitial cystitis.

A prospective study on the symptomatic effect of traditional Chinese acupuncture treatment and transcutaneous nerve stimulation (TENS) of the tibial nerve in patients with interstitial cystitis is presented. There was no difference in voiding frequency, mean voided volume, maximal voided volume or visual analogue scale symptom scores before or after treatment with either TENS or acupuncture. Only one patient became improved both subjectively and objectively after acupuncture for a short period of time. Even though the present material involves a small group of patients, it seems that the two methods, as applied in this study, have a very limited effect in patients with interstitial cystitis.

Transurethral microwave thermotherapy versus transurethral resection for benign prostatic hyperplasia: preliminary results of a randomized study.

The results of transurethral microwave thermotherapy (TUMT) were compared in a prospective randomized study with those of transurethral resection (TURP) in patients with benign prostatic obstruction. In this preliminary report, 39 and 40 patients treated with TUMT and TURP, respectively, were followed between 2 and 12 months. Statistically significant improvements in symptom score, maximum flow rate, residual urine and maximum bladder capacity at cystometry were observed in both groups. The improvements were more pronounced in the TURP group, but major complications were more frequent in this group. Results are compared to other published studies.

Screening as a prognostic factor in cervical cancer: analysis of survival and prognostic factors based on Icelandic population data, 1964-1988.

Survival rates were computed for 376 women diagnosed with carcinoma of the uterine cervix between 1964 and 1988. The 5-year survival rate for the entire group was 63%. The effect of age at diagnosis, clinical stage, histopathology, year of diagnosis, and screening program attendance was studied by univariate analysis and simultaneously with a multivariate analysis, the Cox proportional hazards model. All these parameters had a significant effect on survival, with clinical stage as the strongest parameter followed by histology, year of diagnosis, age at diagnosis, and attendance at screening. Women who had attended the cervical screening program fared significantly better than those who had never attended. Patients treated in the late years of the study period had a significantly better survival rate, possibly indicating improved treatment. Young women had a significantly better prognosis than older women. Women with adenocarcinoma and anaplastic tumors had a significantly worse prognosis than women with squamous and adenosquamous carcinoma. The prognostic effect of screening was mainly attributed to the more favorable distribution of early stages and younger age at diagnosis among the screened women. After all the analyzed parameters had been adjusted for the nonattenders still had poorer prognosis.

Painful autoimmune thyroiditis occurring on amiodarone therapy.

A 51-year-old housewife, who had been on treatment with amiodarone for ten months, developed a painful enlargement of the thyroid gland. Thyroid antibody titers were highly elevated and a fine needle aspirate of the gland showed infiltration of lymphocytes and plasma cells. Initially the patient was hyperthyroid, later she developed hyperthyroidism which required thyroid substitution. The possibility of amiodarone provoking autoimmune thyroiditis is discussed.

Organization of screening in technically advanced countries: Iceland.

Mass screening for cervical carcinoma in Iceland over the past 20 years (1964-1983) has resulted in a 60% drop in the incidence of and mortality from the disease in the country. A study of the screening histories of the 77 incident cases of grossly invasive cervical cancer diagnosed in Iceland in the past nine years showed that 70% of the tumours occurred in women who had failed to attend screening or had done so very irregularly. Approximately 20% of the cervical cancers were either diagnostic or therapeutic failures, in that the women had been diagnosed with cytological changes but this did not result in the prevention of the tumour. The remaining 10% of the incident cervical carcinomas seemed to have escaped cytological detection and proved to be unusual types of cancer. Prevention of the last cases of cervical cancer is becoming increasingly laborious because of difficulties in maintaining interest among the public to attend regular screening. Women may escape surveillance of a cytological abnormality unless they are constantly reminded about follow-up visits. A small, but significant number of the tumours may continue to escape detection because of their unusual nature, but alterations in sampling techniques and increased awareness of the rarer forms of the disease could alter this.

Familial breast cancer in Iceland.

Women who have relatives known to have had breast cancer are at an increased risk of getting the disease compared with the general population. On the basis of an extensive collection of family trees of women with breast cancer, the magnitude of this increase in risk is computed. Previously published results on other breast cancer risk factors are drawn upon and it has been possible to take account of some of these e.g., age, decade of birth, age at first childbirth and parity in the risk estimates. The relative risk with such adjustment is found to be 2.59 for mothers and 2.56 for sisters.

Tumours in Iceland. 5. Malignant tumours of the cervix uteri. Histological types, clinical stages and the effect of mass screening.

The histological material from patients with invasive cervical carcinoma diagnosed in Iceland during the period 1955-1974 was reviewed and retyped in accordance with the WHO classification of tumours. Out of 314 malignant epithelial tumours 86.0 per cent were squamous carcinomas (subtypes: 6% microcarcinomas, 30% keratinizing, 45% non keratinizing and 5% small cell carcinomas), 9.0 per cent adenosquamous carcinoma, 3.5% adenocarcinoma and 1.5 per cent undifferentiated carcinoma. A mass screening for uterine cancer in the population, ages 25-59, led to an increased incidence of cervical carcinoma, due to the finding of early tumours (clinical stages IA and IB). The increase was most marked in the first five years of screening (1965-69). The screening did not increase the incidence of the more advanced stages and a longer observation will be needed to determine whether a decline will occur in such tumours. All the major histological types of cervical carcinoma appear to progress at the same rate through the clinical stages, from the early to the far advanced.

Screening for cancer of the uterine cervix in Iceland 1965--1978.

The trends in the mortality and morbidity from cervical cancer in Iceland for the period 1965--1978 are examined in relation to the screening programme that began in 1964. By 1970 over 80% of the female population under the age of 65 had been screened at least once, and by 1977 over 65% of women under the age of 75 had been screened at least twice. Mortality fell by 60% between 1959--1970 and 1975--1978, with a corresponding fall in the incidence of advanced tumors. The mortality rates among the unscreened population are more than ten-fold greater than among the screened. The greater part of the fall in mortality is attributed to the mass screening programme.