Is urethral pressure profilometry useful in the preoperative assessment of benign prostatic hyperplasia?

The principal aim of this study was to provide an objective assessment of the potential role of urethral pressure profilometry as a technique for assessing prostatic size by direct comparison with endoscopic assessment of prostatic length and computed tomographic measurement of prostatic volume and length. There was a poor correlation between pre-operative prostatic length and amount resected in the operating theatre. The results obtained with urethral pressure profilometry correlated poorly with those obtained using the other techniques, and cannot therefore be relied upon in routine clinical practice. Although there was good correlation between the length of the prostate and prostatic size, assessed by pre-operative computed tomography, this correlated poorly with the amount of tissue resected at operation. Further studies need to be conducted to compare objectively the completeness of prostatic resection with the outcome following prostatectomy.

Subtrigonal phenol injection. How safe and effective is it?

A series of 24 patients underwent 27 transtrigonal phenol injections for the treatment of bladder instability. Only 2 of 18 patients with detrusor instability and 2 of 6 with detrusor hyperreflexia continued to derive benefit from the procedure 6 months after it was carried out. Serious complications attributable to phenol were seen in 2 patients in this series and in a further 4 patients referred for complications resulting from this therapy in other centres. These results and a review of the literature lead us to suggest that transvesical phenol injection should not be used except in the hyper-reflexic bladder when no alternative treatment is possible. Particular care should be exercised in patients who have undergone extensive prior surgery or radiotherapy.

Nerve fibre proliferation in interstitial cystitis.

The aetiology of pain in interstitial cystitis is not understood, although it has been reported to be due to release of mediators from mast cell granules. Cystolysis and intravesical instillation of dimethyl sulphoxide have been shown to relieve pain in this condition. We have studied the nerve population within the bladder wall using immunohistochemical stains for protein gene product 9.5. A group of 18 cases of chronic interstitial cystitis and 12 controls; neuropathic bladder (n = 1), chronic bacterial cystitis (n = 3), systemic lupus erythematosus cystitis (n = 2) and normals (n = 6), were investigated. There were significantly more nerve fibres within the sub-urothelial and detrusor muscle layers in chronic interstitial cystitis than there were in normals. Patients with chronic cystitis of other aetiology did not have a significant increase in nerve fibre density within the bladder wall suggesting a specific association between nerve fibre proliferation and interstitial cystitis. Cystolysis is shown to deplete selectively the submucosal nerve plexuses without altering the nerve density within detrusor muscle. This finding explains the desensitisation of the bladder without impairment of detrusor function after this procedure.

Autoradiographic analysis of alpha-adrenoceptors and muscarinic cholinergic receptors in the hyperplastic human prostate.

Radioligand receptor binding and autoradiography were used to characterize, localize and compare alpha-1 and alpha-2 adrenoceptors and muscarinic cholinergic receptor populations in human benign prostatic hyperplastic tissue. The binding of selective alpha-1 and alpha-2 ligands, [3H]-prazosin and [3H]-UK 14,304, to homogenates of human central and peripheral prostate was saturable and of high affinity. Scatchard analysis produced an equilibrium dissociation constant (KD) of 0.51 +/- 0.10 nM for alpha-1 adrenoceptors, and 2.34 +/- 0.40 nM for alpha-2 adrenoceptors. The mean densities, Bmax, of alpha-1 and alpha-2 adrenoceptors identified in the human adenomatous prostate were 65.9 +/- 12.9 and 36.1 +/- 7.0 fmoles/mg. protein respectively. Receptor autoradiography was used to examine the distribution of muscarinic cholinergic receptors [( 3H]-QNB), alpha-1 adrenoceptors [( 3H]-prazosin]), and alpha-2 adrenoceptors [( 3H]-rauwolscine) on consecutive sections of benign hyperplastic prostatic tissue. Although both subtypes of adrenoceptor were seen in the stromal component of the hyperplastic prostate, there was a substantial predominance of alpha-1 adrenoceptors. A densitometric computer-assisted analysis was performed on the autoradiographic slides to determine the mean ratio of specific alpha-1: alpha-2 adrenoceptors in the stromal compartment of the hyperplastic tissue. The ratio, expressed as % grain occupancy/unit area, was 3.9 +/- 0.75, which is in agreement with a functional alpha-1 adrenoceptor predominance shown in previous studies. Although sparsely distributed in the stroma, a dense alpha-2 adrenoceptor population was seen in association with blood vessels, and in close proximity to the base of some of the [3H]-QNB-labelled prostatic glandular epithelial cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterisation of human prostatic adrenoceptors using pharmacology receptor binding and localisation.

Benign prostatic enlargement is a common cause of bladder outlet obstruction. Recent work has demonstrated the important role played by the sympathetic nervous system in the control of prostatic muscle tone. Although isometric muscle strip studies and clinical trials have highlighted the influence of alpha-1 adrenoceptors, radioisotope ligand binding studies have demonstrated a relatively increased density of alpha-2 adrenoceptors in the muscle within prostatic tissue, the significance of which is as yet unexplained. Forty patients entered a study using pharmacological muscle strip experiments, radioligand binding assays and receptor autoradiography. Pharmacological data from these studies confirmed that contraction of prostatic muscle is mediated predominantly by alpha-1 adrenoceptor stimulation, with no evidence of significant alpha-2 adrenoceptor or cholinergic mediated effects. Radioligand binding studies confirmed that there is a higher concentration of alpha-1 binding sites as contrasted to alpha-2 within normal prostate, but that this relationship approaches equity in adenomatous prostate. Autoradiographic localisation demonstrated that alpha-1 adrenoceptor binding is predominant within prostatic stroma with only a small component of alpha-2 adrenoceptors in this compartment. This comprehensive study supports the suggestion that prostatic muscular contraction is controlled by the influence of the sympathetic nervous system acting via alpha-1 adrenoceptors. These findings support the therapeutic use of specific alpha-1 adrenoceptor blockade in the management of benign prostatic hyperplasia.

Bonney's blue cystitis: a warning.

The instillation of diluted Bonney's blue into the bladder during gynaecological operations has been quite common practice over the last 50 years. Bonney's blue is composed of a 1:1 mixture of brilliant green and crystal violet dissolved in ethanol (90%) or industrial methylated spirit. Before insertion into the bladder this solution must be diluted with water to a 0.5% solution. Failure to do this will result in a severe inflammatory reaction within the bladder. The degree of resultant damage depends upon the duration of exposure. Persistent pain is a feature of this condition, although the other symptoms (frequency and urgency) may settle in time. Two cases of chemical cystitis resulting from the use of undiluted Bonney's blue are described to illustrate the possible consequences. Both patients were awarded 6-figure sums as compensation.

Quantitative study of phenol as a neurolytic agent in the urinary bladder.

The endoscopic subtrigonal injection of a 6% aqueous phenol solution is an effective technique for denervating the bladder but its clinical usefulness is limited by unpredictable side effects. This study explored the possibility of making this procedure safer by comparing the neurolytic effects of different concentrations and carriers of phenol. Phenol in 2.5 and 5% solutions in three different carriers (water, glycerine and oil) was injected into the rectovesical pouch in 35 rats. After 3 weeks the bladders were excised and the effects on the density of acetylcholinesterase-positive nerves were assessed in each animal using morphometric techniques. The density of enzyme-containing nerves was reduced by 20% in the phenolised animals when compared with controls. This reduction was maximum when water was used as the carrier for either 2.5 or 5% phenol solutions.

Bladder muscle biopsy and urethral sphincter EMG in patients with bladder dysfunction after pelvic surgery.

Eleven patients who suffered persistent bladder dysfunction after pelvic surgery have been investigated by needle urethral sphincter electromyography (EMG) and bladder muscle biopsy, and the results compared with those obtained in a series of controls. Individual motor units recorded from the urethral sphincter in patients who had undergone pelvic surgery were strikingly abnormal, suggesting the presence of reinnervation, and the density of detrusor innervation was significantly reduced. However, since reduction in the density of detrusor innervation may occur in circumstances other than peripheral nerve injury, we conclude that urethral sphincter EMG provides the most effective means of assessing damage to vesico-urethral innervation as a result of previous pelvic surgery.

Radiological trabeculation for the male bladder--a clinical and urodynamic assessment.

Two hundred and fifty patients have been studied by synchronous cine/pressure/flow cystometry to assess the relationship between radiological trabeculation and the urodynamic findings. There is a strong association between detrusor instability and trabeculation. Trabeculation, however, may also occur in the presence of high pressure outflow obstruction, usually at prostate level, in the absence of instability. It is suggested that frequent uninitiated detrusor contraction against a voluntarily closed sphincter is a likely cause of the more prominent varieties of trabeculation. However, the presence of minor degrees of trabeculation noted at cystoscopic examination in the absence of detrusor instability is not disputed.

A long-term study of the persistence of the urodynamic characteristics of the unstable bladder.

Sixty-four patients with normal bladder function, stress incontinence, idiopathic instability or instability associated with enuresis underwent pressure/flow videocystography. This was repeated from one month to 8 years later (average 19.4 months). Filling cystometry remained qualitatively unchanged in 95% of cases overall, whilst the actual pressure recordings during cystometry in the 37 patients with instability remained identical or very similar in 73%. The results demonstrated the accuracy of cystometry and the consistency of bladder dynamics over the longest period so far reported in these apparently non-progressive disorders.

The results of prostatectomy: a symptomatic and urodynamic analysis of 152 patients.

There were 152 patients with prostatism investigated by inflow cystometry and pressure flow analysis of micturition before and after elective prostatectomy. Many symptoms attributed to obstruction were found to be owing to bladder instability, which was demonstrated in 60 per cent of the patients. The symptomatic improvement postoperatively was accompanied by a decrease in the incidence of instability to 25 per cent. The repeat urodynamic studies and symptom analysis demonstrated a surgical success rate of 88 per cent.

Nocturnal enuresis.

Primary enuresis is essentially of two main types - the common diurnal-nocturnal type with associated bladder instability and the less common nocturnal type which shows normal cystometry. The importance of depth of sleep in both types is stressed, particularly the former. A rationale of treatment, self-monitored, voluntary, escalating cystometry, is described.

A urodynamic analysis of micturition symptoms in the female.

The presenting symptoms of 570 females with micturition disorders have been studied with particular reference to the urodynamic state of the detrusor in an attempt to define those symptoms and symptom complexes which are associated with the presence of absence of detrusor instability. The results show that patients who complain of recurrent urinary tract infection or stress incontinence in the absence of any other micturition symptoms usually have stable bladders and do not require cystometric confirmation of this fact. When the symptom of urge incontinence is associated with persistent frequency and nocturia, there is a high correlation with detrusor instability, although hypersensitive urethral states which may present with identical symptoms and are usually associated with stable bladders are difficult to differentiate clinically. Groups of patients in whom it was difficult to predict the detrusor state from the symptoms were studied, and the results of a prospective analysis, predicting the detrusor state from the micturition history of 230 incontinent females, have been presented.