The four categories of prostatitis: a practical approach to treatment.

To diagnose prostatitis correctly and select appropriate therapy, one should use the Meares-Stamey technique for culturing urine and prostatic secretions and apply the classification system for prostatitis devised by the National Institutes of Health. The continuing search for an effective therapy for the most common type, chronic abacterial prostatitis, has led to adoption of treatments from other specialties and reevaluation of standard treatments.

Prospective identification of National Institutes of Health category IV prostatitis in men with elevated prostate specific antigen.

PURPOSE: Although prostatitis may cause elevated prostate specific antigen (PSA), asymptomatic patients are not routinely screened for this diagnosis before transrectal biopsy is performed to rule out cancer. Many negative biopsies reveal evidence of prostatitis classified as National Institutes of Health (NIH) category IV prostatitis or asymptomatic inflammation. To our knowledge this report represents the initial study of the incidence of NIH category IV prostatitis in men before biopsy and its clinical significance. MATERIALS AND METHODS: From 1996 to 1998 asymptomatic men with elevated PSA levels were evaluated for laboratory signs of prostatitis. Patients with expressed prostatic secretions or post-prostate massage urine (voiding bottle 3 [VB3]) positive for greater than 20 and greater than 10 white blood cells per high power field, respectively, received antibiotics for 4 weeks and were reevaluated after 6 to 8 weeks. Men without these clinical signs promptly underwent biopsy. Those with acute urinary tract infection and PSA greater than 30 ng./ml., without a rectum or who refused biopsy were excluded from study. RESULTS: Of the 187 study patients 122 were evaluable with a mean PSA of 9.35 ng./ml., including 51 (42%) with laboratory signs of prostatitis. After treatment PSA was normal in 22 cases and remained elevated in 29, including 9 in which biopsy revealed cancer. The change or improvement in PSA was significantly greater in men with benign results than in those with prostate cancer (-21.32 versus -1.33%, p = 0.001). In the cohort with negative expressed prostatic secretion and VB3 results transrectal ultrasound guided biopsy was done promptly. Screening decreased the number of biopsies by 18% (22 of 122 cases). The positive predictive value of PSA for detecting biopsy proved cancer improved with screening for prostatitis (45 of 122 cases or 37% versus 36 of 71 or 51%). Long-term followup revealed continued normal or stable PSA in the prostatitis cohort. CONCLUSIONS: Screening for NIH category IV prostatitis should be considered in men with elevated PSA. Although patients may be asymptomatic, anxiety caused by prostate cancer and diagnostic procedures contributes to the clinical significance of this disorder.

Association of chronic urinary symptoms in women and Ureaplasma urealyticum.

UNLABELLED: OBJECTIVES. To determine the incidence of Ureaplasma urealyticum in women experiencing chronic urinary symptoms and to determine whether antibiotic therapy targeting these organisms is effective. METHODS: Forty-eight consecutive women referred to our academic medical center for chronic voiding symptoms and possible interstitial cystitis underwent urologic evaluation, including culture screening for U. urealyticum and Mycoplasma hominis. Patients with positive cultures were treated with a 1-g dose of azithromycin; persistent infection was treated with 7 days of doxycycline, ofloxacin, or erythromycin. Patients reported symptom severity (0, mild; 3, severe) and voiding frequency before and 6 months after treatment. RESULTS: Positive cultures were obtained in 23 (48%) of 48 patients; 22 had U. urealyticum and 1 had M. hominis. All had negative cultures after treatment. The mean symptom severity score improved with treatment (2.2 to 0.7, P <0.001), and the mean urinary frequency decreased (9.2 daily to 6.8 daily, P <0.001). Two of the 23 patients experienced no improvement; one had detrusor instability and the other had medically related urinary frequency. Of the 25 patients with negative cultures, interstitial cystitis was established in only 9 (19% of the total sample). CONCLUSIONS: Although often overlooked or improperly treated, U. urealyticum and M. hominis infections may account for a large proportion of unexplained chronic voiding symptoms. Culture and treatment should be considered before pursuing more costly and invasive tests.

Pelvic floor physical therapy for patients with prostatitis.

The most common form of prostatitis is National Institutes of Health category III, also known as chronic abacterial prostatitis/chronic pelvic pain syndrome. The search for effective and durable therapy for this condition remains frustrating for both patients and physicians. A new approach incorporating a neurobahavioral and musculoskeletal perspective is emerging as a means of diagnosing and treating affected patients. Adopting methods from gynecology, colorectal surgery, and physical therapy has had promising effects in men diagnosed with chronic prostatitis.

NMP22: a sensitive, cost-effective test in patients at risk for bladder cancer.

BACKGROUND: This study was designed to determine the clinical utility of NMP22 as a urinary marker for the early detection of transitional cell carcinoma (TCC) of the bladder in patients with hematuria or other indications for risk of malignancy. Its utility will be measured by sensitivity and specificity estimates as compared to cystoscopy. Since urine cytology is normally collected in this population of patients, it will also be analyzed and compared to cystoscopy. MATERIALS AND METHODS: Each patient submitted a single voided urine which was stabilized with the NMP22 urine collection kit or preserved in the appropriate cytology medium for cytopathologic testing. All patients provided the urine samples before cystoscopic exam. Of the 146 patients, there were 43 patients with microscopic hematuria and 13 with gross hematuria. Other indications for cystoscopy included unexplained or medically refractory voiding. There were 8 patients with biopsy confirmed bladder cancer and 138 patients with benign conditions of the bladder. RESULTS: The median NMP22 value for the bladder cancer malignancies was 27.8 U/mL (95% Confidence interval: 10.5-32.1 U/mL). The median NMP22 value for the benign conditions of the bladder was 3.25 U/mL (95% Confidence interval: 2.5-3.8 U/mL). The urinary NMP22 values from the bladder cancer group was statistically different (p < .000001 Mann-Whitney U test) than the NMP22 values in the benign conditions group. Using a reference value of 10.0 U/mL, the sensitivity of NMP22 was 100% with a specificity of 90%, while cytology had a sensitivity of 25% and a specificity of 100%. Due to its high negative predictive value, using NMP22 alone could have eliminated 124 cystoscopies with total savings ranging from $24,824 to $63,264 depending on the type of insurance carrier. CONCLUSIONS: This study indicates that urinary NMP22 is a useful, cost-effective marker for the early detection of bladder cancer.

Patient characteristics associated with vasectomy reversal.

PURPOSE: More than 30 million couples throughout the world are using vasectomy as a method of birth control. It is estimated that up to 6% of men who undergo voluntary sterilization will eventually request reversal, despite the high cost and relatively low success rate of the procedure. We identified characteristics that predict which vasectomy patients may request reversal. We also examined the cost and effectiveness of pre-vasectomy sperm cryopreservation followed by intrauterine insemination as an alternative method of achieving pregnancy. MATERIALS AND METHODS: We reviewed medical charts of 365 patients who underwent vasectomy and 290 who underwent vasectomy reversal between 1990 and 1997. Data were collected on patient age at the time of vasectomy, religion, occupation, wife employment status, number of marriages, number of children, reason for reversal, and number of years between vasectomy and reversal. Based on previously reported values, pregnancy rates and cost per successful pregnancy were estimated for vasectomy reversal surgery, and compared with a calculated cost per pregnancy for sperm cryopreservation and intrauterine insemination. RESULTS: Patient factors significantly associated with increased vasectomy reversal included younger age at time of vasectomy (p < 0.001) and a wife who worked outside the home (p < 0.001). Vasectomy reversal occurred 12.5 times more often (95% confidence interval [CI] 7.6 to 20.7) in men who underwent vasectomy in their 20s than in men who were older. Men whose wives were not employed requested reversal 0.48 times as often (95% CI 0.33 to 0.71) as those whose wives worked. Men who were younger at vasectomy tended to wait longer before reversal (median 10 years) than other patients (p < 0.001). At 10 years our calculated pregnancy rates and cost per pregnancy were 44% and $12,727 for vasectomy reversal, and 41% and $9,512 for intrauterine insemination with banked sperm (3 attempts). CONCLUSIONS: Patients who requested vasectomy reversal most often chose voluntary sterilization at a younger age. We believe that younger men should be given better pre-vasectomy counseling. However, the success rate and cost-effectiveness of sperm cryopreservation before vasectomy, with subsequent intrauterine insemination, may make this nonsurgical alternative desirable for younger couples who choose vasectomy even when properly informed about reversal rates.

Developing a patient self-medication program for the rehabilitation setting.

Self-medication, the ability of the patient to administer his or her own medication, can be useful in the rehabilitation setting in reducing the incidence of polypharmacy, medication abuse, and inappropriate medication usage. However, a patient self-medication program also introduces a variety of issues, such as defining each team member's responsibilities and outlining the steps of the program. These issues may impede the development and implementation of the program. A review of the rehabilitation literature yields little information about program development in the rehabilitation setting or about dealing with such issues. The purpose of this article is to describe the need for a self-medication program in the rehabilitation setting, the development of one such program, and ways to overcome some of the problems that cause such programs to falter.

Pheochromocytoma in a pregnant patient.

Pheochromocytoma accounts for only 0.1% of hypertension found in adults between 40 and 70 years of age. Although it is extremely rare in pregnancy, if it occurs and is unrecognized in pregnant women, pheochromocytoma can have catastrophic effects. For instance, maternal fatal hypertension can be precipitated by anesthesia, vaginal delivery, uterine contractions, or even vigorous fetal movements. Fetal growth retardation is often seen secondary to decreases in uteroplacental perfusion. Fetal hypoxia or death can also occur with maternal episodes of headache, palpitations, and diaphoresis related to tumor secretions. Because many of the signs and symptoms of pheochromocytoma are similar to more frequently encountered hypertensive syndromes related to pregnancy, the diagnosis of pheochromocytoma can be easily overlooked. The case report presented here illustrates the difficulties associated with the diagnosis of pheochromocytoma in a pregnant patient, highlights problems encountered by patients with the tumor, and reviews diagnostic and treatment approaches.

Combined exercise radionuclide angiocardiography and single photon emission computed tomography perfusion studies for assessment of coronary artery disease.

Although there is widespread use of exercise thallium 201 scintigraphy and radionuclide angiocardiography in patients with coronary artery disease (CAD), little is known about the independence, concordance, or relative importance of these studies in the diagnosis, prognosis, and assessment of the outcome of therapy. The use of both tests in the same patient has been impractical because of the logistic considerations imposed by two exercise tests on separate days, and excessive radiation exposure. New technetium 99m-labeled radiopharmaceuticals with high myocardial extraction now permit the simultaneous assessment of myocardial perfusion (single photon emission computed tomography [SPECT]) and ventricular function (radionuclide angiocardiography [RNA]) during treadmill exercise (exercise tolerance test [ETT]). The ability to perform all three tests during a single exercise session offers a very attractive technique to evaluate patients with CAD. The investigators studied 86 patients with chronic CAD using the same-day perfusion and function protocol combined with treadmill exercise. The results demonstrate good concordance between myocardial perfusion and ventricular function as indicated by a significant correlation between tomographic perfusion defect size and ejection fraction (P less than .0001, R = 0.75 at rest and P less than .0001, R = 0.76 during exercise). Stepwise logistic regression was used to model ETT, RNA, and SPECT variables against the presence of one or more 60% stenoses by quantitative angiography, an end point present in 47 patients. Univariable analysis showed all three tests (ETT, RNA, and SPECT) to be significant predictors of the end points (lambda 2 = 5.1, P less than .05; lambda 2 = 12.5, P less than .001; and lambda 2 = 16.1, P less than .001, respectively). Multivariable analysis demonstrated that SPECT provided more diagnostic information than ETT and RNA (Lambda 2 = 16.1, P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Partial characterization of phosphoribosyl transferase, phosphoribosyl anthranilate isomerase, and indole glycerol phosphate synthase from Serratia marcescens.

The molecular organization of the enzymes phosphoribosyl (PR) transferase, phosphoribosyl anthranilate (PRA) isomerase, and indole glycerol phosphate (InGP) synthase of the tryptophan biosynthetic pathway of Serratia marcescens was investigated and compared with that reported in other enteric bacteria. PRA isomerase and InGP synthase activities were found to reside in a single polypeptide chain, a situation analogous to that in Escherichia coli, Salmonella typhimurium, and Aerobacter aerogenes. This bifunctional enzyme was purified to near homogeneity. Its molecular weight was estimated to be 48,000. PR transferase was found unassociated with PRA isomerase and InGP synthase after gel filtration and ion-exchange chromatography. Whereas in other enteric organisms PR transferase has been reported to form an aggregate with anthranilate synthase, it is a distinct entity in S. marcescens.