Genetic investigations on causes of male infertility in Western Saudi Arabia.

In recent years, genetic studies have yielded great progress in elucidating causes of male infertility. This investigation aims to identify frequent genetic abnormalities, that is, sex chromosome aneuploidies and Y-chromosome microdeletions among infertile men in Western Saudi Arabia. From a population of infertile patients, 88 male patients with either azoospermia or severe oligozoospermia (sperm concentration <5 million/ml) were selected. In addition to a thorough clinical workup, karyotypes and Y-chromosomal microdeletions were investigated. Among those 88 infertile patients, we detected six patients with Klinefelter syndrome, two with 47 XYY syndrome and two with Y-chromosome microdeletions AZFb,c. While the prevalence of sex chromosome aneuploidies was in the range of globally investigated populations, the microdeletions appeared to be less frequent in Western Saudi Arabia compared to other regions of the world. All genetically abnormal cases showed sperm concentration <1 million/ml, and hence, this appears to be the threshold for warranting genetic investigations in Western Saudi Arabia. Since Klinefelter and 47 XYY syndromes were only discovered late in life, upon an infertility investigation, sex chromosome aneuploidies due to their many-fold comorbidities require earlier medical attention. A neonatal screening programme is suggested for detection of these aneuploidies in Saudi Arabia for the general health benefit of these patients.

Treatment of refractory category III nonbacterial chronic prostatitis/chronic pelvic pain syndrome with intraprostatic injection of onabotulinumtoxinA: a prospective controlled study.

INTRODUCTION: To evaluate the efficacy and safety of intraprostatic injections of onabotulinumtoxinA (onaBoNT-A) to treat refractory chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). MATERIALS AND METHODS: Prospective two-group controlled study. Treatment group included adult men with refractory category-III nonbacterial CP/CPPS who underwent transurethral intraprostatic injections of onaBoNT-A (200 U). Control group included comparable patients who underwent cystoscopy only. Primary outcome was the proportion of 6-point responders (≥ 6 points reduction of total score of National Institutes of Health-Chronic Prostatitis Symptom Index [NIH-CPSI]), at 3 months. Secondary outcomes included proportions of quality of life (QoL) responders (≤ 2 points in QoL domain), and global response assessment (GRA) responders (patients reporting moderately improved, or markedly improved), at 3 months. Other outcomes comprised changes from baseline NIH-CPSI scores, visual analog scale (VAS) sub-score of pain domain, PSA, prostate volume, post-void residual urine, and maximum flow rate. Significance was set at p < 0.05. RESULTS: Treatment group included 43 patients with mean age (SD) of 38.8 (7.3) years and mean duration of symptoms of 7.0 (2.9) years. At 3 months, the proportions of responders (NIH-CPSI 6-point, QoL, and GRA) were 72.1%, 69.8%, and 72.1%; which gradually declined to 37.2%, 25.7% and 27.9%, respectively, at 12 months. The baseline NIH-CPSI total score demonstrated -68.2% reduction at 3 months (-20.1 points; p < 0.0001); which gradually waned to -19% reduction (-5.6 points; p < 0.0001) at 12 months. Baseline VAS showed -79%, and -27.4% reductions at 3 and 12 months, respectively (p < 0.0001, each). None of control men has been 6-point, QoL nor GRA responder and none has demonstrated significant NIH-CPSI scores changes from baseline (p > 0.05, each). Compared to control, mean NIH-CPSI total scores of treated men at 1 and 3 months were significantly different (p < 0.001, each). CONCLUSION: OnaBoNT-A intraprostatic injections appeared to be effective and safe to ameliorate symptoms of refractory nonbacterial CP/CPPS; with pain most improved. The improvements gradually dwindled at 9-12 months.

Video Voiding Device for Diagnosing Lower Urinary Tract Dysfunction in Men.

We introduce a novel diagnostic Visual Voiding Device (VVD), which has the ability to visually document urinary voiding events and calculate key voiding parameters such as instantaneous flow rate. The observation of the urinary voiding process along with the instantaneous flow rate can be used to diagnose symptoms of Lower Urinary Tract Dysfunction (LUTD) and improve evaluation of LUTD treatments by providing subsequent follow-up documentations of voiding events after treatments. The VVD enables a patient to have a urinary voiding event in privacy while a urologist monitors, processes, and documents the event from a distance. The VVD consists of two orthogonal cameras which are used to visualize urine leakage from the urethral meatus, urine stream trajectory, and its break-up into droplets. A third, lower back camera monitors a funnel topped cylinder where urine accumulates that contains a floater for accurate readings regardless of the urine color. Software then processes the change in level of accumulating urine in the cylinder and the visual flow properties to calculate urological parameters. Video playback allows for reexamination of the voiding process. The proposed device was tested by integrating a mass flowmeter into the setup and simultaneously measuring the instantaneous flow rate of a predetermined voided volume in order to verify the accuracy of VVD compared to the mass flowmeter. The VVD and mass flowmeter were found to have an accuracy of ±2 and ±3% relative to full scale, respectively. A VVD clinical trial was conducted on 16 healthy male volunteers ages 23-65.

Influence of Onabotulinumtoxin A on testes of the growing rat.

Onabotulinumtoxin A (onabotA) is gaining wide medical use in children. The present study was planned to investigate the influence of its injection on the maturing testicular structures in rats. Immature rats were injected in the bilateral cremaster muscles by onabotA with three doses of (10, 20, and 40 U/kg) three times in a 2-week interval. The effect of these injections on fertility indices was examined. Levels of antisperm antibodies and several apoptosis parameters were also investigated. DNA content in form of ploidy and histopathological alterations were assessed. OnabotA-injected groups showed decreased sperm count and semen quality, while sperm vitality, morphology, and testosterone levels were not significantly affected. Furthermore, DNA flow cytometric analysis confirmed delayed sperm maturation. Apoptosis markers were significantly increased by the injections. In conclusion, onabotA injection in growing rats adversely affected sperm count and maturation. OnabotA testicular effects are mediated, at least partly, by apoptosis.

Adverse testicular effects of Botox® in mature rats.

Botox® injections are taking a consistently increasing place in urology. Intracremasteric injections, particularly, have been applied for cryptorchidism and painful testicular spasms. Studies outlining their safety for this use are, however, scanty. Thus, the present study aimed at evaluating possible testicular toxicity of Botox® injections and their effect on male fertility. Mature rats were given intracremasteric Botox® injections (10, 20 and 40 U/kg) three times in a two-week interval. Changes in body and testes weights were examined and gonadosomatic index compared to control group. Semen quality, sperm parameters, fructose, protein, cholesterol and triglycerides contents were assessed. Effects on normal testicular function were investigated by measuring testosterone levels and changes in enzyme activities (lactate dehydrogenase-X and acid phosphatase). To draw a complete picture, changes in oxidative and inflammatory states were examined, in addition to the extent of connective tissue deposition between seminiferous tubules. In an attempt to have more accurate information about possible spermatotoxic effects of Botox®, flowcytometric analysis and histopathological examination were carried out. Botox®-injected rats showed altered testicular physiology and function. Seminiferous tubules were separated by dense fibers, especially with the highest dose. Flowcytometric analysis showed a decrease in mature sperms and histopathology confirmed the findings. The oxidative state was, however, comparable to control group. This study is the first to show that intracremasteric injections of Botox® induce adverse testicular effects evidenced by inhibited spermatogenesis and initiation of histopathological changes. In conclusion, decreased fertility may be a serious problem Botox® injections could cause.

Immunomodulatory effect of red onion (Allium cepa Linn) scale extract on experimentally induced atypical prostatic hyperplasia in Wistar rats.

Red onion scales (ROS) contain large amounts of flavonoids that are responsible for the reported antioxidant activity, immune enhancement, and anticancer property. Atypical prostatic hyperplasia (APH) was induced in adult castrated Wistar rats by both s.c. injection of testosterone (0.5 mg/rat/day) and by smearing citral on shaved skin once every 3 days for 30 days. Saw palmetto (100 mg/kg) as a positive control and ROS suspension at doses of 75, 150, and 300 mg/kg/day were given orally every day for 30 days. All medications were started 7 days after castration and along with testosterone and citral. The HPLC profile of ROS methanolic extract displayed two major peaks identified as quercetin and quercetin-4'-ß-O-D-glucoside. Histopathological examination of APH-induced prostatic rats revealed evidence of hyperplasia and inflammation with cellular proliferation and reduced apoptosis Immunohistochemistry showed increased tissue expressions of IL-6, IL-8, TNF-α, IGF-1, and clusterin, while TGF-ß1 was decreased, which correlates with the presence of inflammation. Both saw palmetto and RO scale treatment have ameliorated these changes. These ameliorative effects were more evident in RO scale groups and were dose dependent. In conclusion, methanolic extract of ROS showed a protective effect against APH induced rats that may be attributed to potential anti-inflammatory and immunomodulatory effects.

Caffeic acid phenethyl ester synergistically enhances docetaxel and paclitaxel cytotoxicity in prostate cancer cells.

Evidence is growing for the beneficial role of selective estrogen receptor modulators (SERM) in prostate diseases. Caffeic acid phenethyl ester (CAPE) is a promising component of propolis that possesses SERM activity. This study aimed at investigating the modulatory impact of CAPE on docetaxel (DOC) and paclitaxel (PTX) cytotoxicity in prostate cancer cells and exploring the possible underlying mechanisms for this chemomodulation. CAPE significantly increased DOC and PTX potency in PC-3, DU-145 and LNCaP prostate cancer cells. Combination index calculations showed synergistic interaction of CAPE/DOC and CAPE/PTX cotreatments in all the tested cell lines. Subsequent mechanistic studies in PC-3 cells indicated that cyclin D1 and c-myc were significantly reduced in the combined treatment groups with concurrent increase in p27kip. DNA-ploidy analysis indicated a significant increase in the percentage of cells in pre-G1 in CAPE/DOC and CAPE/PTX cotreatments. Decreased Bcl-2/Bax ratio together with increased caspase-3 activity and protein abundance were observed in the same groups. Estrogen receptor-ß (ER-ß) and its downstream tumor suppressor forkhead box O1 levels were significantly elevated in CAPE and combination groups compared to DOC or PTX-alone. ER-α and insulin-like growth factor-1 receptor protein abundance were reduced in the same groups. CAPE significantly reduced AKT, ERK and ER-α (Ser-167) phosphorylation in PC-3 cells. CAPE-induced inhibition of AKT phosphorylation was more prominent (1.7-folds higher) in cells expressing ER-α such as PC-3 compared to LNCaP. In conclusion, CAPE enhances the antiproliferative and cytotoxic effects of DOC and PTX in prostate cancer cells. This can be, at least partly, attributed to CAPE augmentation of DOC and PTX proapoptotic effects in addition to CAPE-induced alterations in ER-α and ER-ß abundance.

Local inflammation influences oestrogen metabolism in prostatic tissue.

UNLABELLED: What's known on the subject? and What does the study add? The role of oestrogen in prostatic inflammation has been extensively shown. The catechol oestrogens are known to be more potent oestrogenic moieties that not only aggravate the inflammatory response in situ, but are also believed to have oxidative stress and genotoxic effects. The present study highlights a significant role of inflammation in oestrogen metabolism and, particularly, in generating 'bad' oestrogen metabolites. This finding may pave the way for new therapeutic methods for the treatment and/or prevention of prostate diseases. OBJECTIVE: • To investigate the impact of experimentally induced inflammation on oestrogen metabolism in rat prostate. MATERIALS AND METHODS: • Prostatitis was induced in normal and oestrogen-treated male rats by injecting 2% carrageenan solution into the ventral prostate. After 48 h, the rats were killed and the ventral prostate was collected. • Prostatic inflammation and proliferation were confirmed by gross visual evidence, histology and elevated tumour necrosis factor-α, prostaglandin E(2) and cyclin-D(1) . • Expression of oestrogen-metabolizing enzymes was assessed using capillary electrophoresis, and oestrogen metabolites within prostate tissue were assayed using liquid chromatography mass spectrometry. RESULTS: • Animals exposed to carrageenan insult combined with oestrogen treatment showed the most prominent inflammatory and proliferative response. • Treatment of animals with oestrogen alone induced moderate inflammation and proliferation. • Oestrogen-metabolizing enzymes were overexpressed in animals with experimental prostatitis with sequential accumulation of catechol oestrogens within prostatic tissues. • Oestrogen receptor-α was underexpressed in the prostatitis with oestrogen group, while oestrogen receptor-ß was overexpressed. CONCLUSIONS: • The present work provides experimental evidence that local inflammation enhances oestrogen synthesis and directs oestrogen metabolism to generate catechol oestrogens within prostatic tissues. • This may contribute, at least partly, to enhanced prostatic cell proliferation.

Shock wave lithotripsy in patients with renal calculi.

OBJECTIVE: To demonstrate the efficacy of shock wave lithotripsy (SWL) in the primary treatment of 1647 patients with renal calculi using a Dornier Doli U/50 lithotripter. METHODS: One thousand and six hundred forty-seven patients underwent SWL as day-cases at King Abdulaziz University Hospital in Jeddah, Saudi Arabia between October 2001 and July 2007, using intravenous sedation (Pethidine 1mg/kg and Midazolam 5-10mg) for analgesia in 85.5% of the patients. The treatment outcome of 2241 renal calculi was analyzed and stratified according to the size and the site of the stones. Recorded data included shock waves intensity, number of shocks, treatment time, analgesia, stone related factors such as size, site, number, nature, composition, and any related complications. The stones were grouped into 5 groups according to the largest stone size in the kidney. Patients were followed up for 6-18 months, mean of 13 months. RESULTS: Complete clearance of the stones occurred in 2154 kidneys (89.5%). At 3-months follow up. The overall re-treatment rate was 57.2% and for each group it was 132 (23.5%) for Group I, 254 (36.1%) for Gourp II, 473 (85.5%) for Group III, 278 (100%) for Group IV and 147 100% for Group V. Treatment failed in 87 patients with stone size of 20-29mm in 57 patients, and in 30 patients with stone size of 30-39mm. Fifty-six were solitary pelvic stones treated with ureteroscopy, while 31 were calyceal stones treated by other modalities such as percutaneousnephro-lithotomy. The most common complication was pyelonephritis with or without obstruction. CONCLUSION: Shock wave lithotripsy treatment was a successful primary management of renal stones of variable sizes in 89.5% of the treated kidneys.

Fingolimod interrupts the cross talk between estrogen metabolism and sphingolipid metabolism within prostate cancer cells.

Sphingolipids are critical regulators of tumor microenvironments and play an important role in estrogen-dependent cancers. Estrogen and estrogen metabolites were found to be involved in prostate cancer. Fingolimod (FTY720) is a sphingokinase-1 (SphK1) inhibitor with anticancer properties against various tumor cell types. Herein, we investigated the interference of FTY720 with the cross talk between sphingolipid metabolism and estrogen metabolism within prostate cancer cells. FTY720 showed cytotoxic antiproliferative effects against androgen-dependent and -independent prostate cancer cells with IC50 ranging from 3.0 ±â€¯0.3 to 6.8 ±â€¯1.7 µM. Exposure of prostate cancer cells to FTY720 resulted in a dramatic decrease in the concentration of estradiol, estrone, 4-hydroxyestradiol and 16α-hydroxyestrone compared to control cells. However, FTY720 significantly increased the concentration of 2-methoxyestrone and 2-methoxyestradiol within prostate cancer cells. This was mirrored by significant downregulating of the expression of estrogen and catechol estrogen-synthesizing enzymes (CYP19, CYP1A1 and CYP1B1) within prostate cancer cells. On the other hand, FTY720 significantly upregulated the expression of catechol estrogen-detoxifying enzyme (COMT). Additionally, FTY720 abolished estrogen-stimulated expression of ERα and basal expression of ERß within prostate cancer cells. Furthermore, FTY720 suppressed the expression of the ER-downstream regulated genes, CXCR4 and cyclin D1. Reciprocally, it was found that estradiol and catechol estrogens significantly induced the expression of SphK1 while methoxylated catechol estrogen suppressed its expression within prostate cancer cells in a dose-dependent manner. Current research has highlighted the hazardous influence of the estrogenic component to prostate cancer. We found that fingolimod (FTY720) could modulate the estrogenic micromilieu and interrupt its cross talk with sphingolipid metabolism.

Metformin Attenuates Testosterone-Induced Prostatic Hyperplasia in Rats: A Pharmacological Perspective.

Benign prostatic hyperplasia (BPH) is uncontrolled proliferation of prostate tissue. Metformin, a widely prescribed anti-diabetic agent, possesses anticancer activity through induction of apoptotic signaling and cell cycle arrest. This study aimed to investigate the protective effect of metformin against experimentally-induced BPH in rats. Treatment with 500 and 1000 mg/kg metformin orally for 14 days significantly inhibited testosterone-mediated increase in the prostate weight &prostate index (prostate weight/body weight [mg/g]) and attenuated the pathological alterations induced by testosterone. Mechanistically, metformin significantly protected against testosterone-induced elevation of estrogen receptor-α (ER-α) and decrease of estrogen receptor-ß (ER-ß) expression, with no significant effect of androgen receptor (AR) and 5α-reductase expression. It decreased mRNA expression of IGF-1 and IGF-1R and protein expression ratio of pAkt/total Akt induced by testosterone. Furthermore, it significantly ameliorated testosterone-induced reduction of mRNA expression Bax/Bcl-2 ratio, P21 and phosphatase and tensin homolog (PTEN) and AMPK [PT-172] activity. In conclusion, these findings elucidate the effectiveness of metformin in preventing testosterone-induced BPH in rats. These results could be attributed, at least partly, to its ability to enhance expression ratio of ER-ß/ER-α, decrease IGF-1, IGF-1R and pAkt expressions, increase P21, PTEN, Bax/Bcl-2 expressions and activate AMPK with a subsequent inhibition of prostate proliferation.

Leptin influences estrogen metabolism and accelerates prostate cell proliferation.

AIM: The present study was designed to investigate the effect of leptin on estrogen metabolism in prostatic cells. MAIN METHODS: Malignant (PC-3) and benign (BPH-1) human prostate cells were treated with 17-ß-hydroxyestradiol (1 µM) alone or in combination with leptin (0.4, 4, 40 ng/ml) for 72 h. Cell proliferation assay, immunocytochemical staining of estrogen receptor (ER), liquid chromatography-tandem mass spectrometry method (LC-MS) and semi-quantitative reverse transcriptase polymerase chain reaction (RT-PCR) were used. KEY FINDINGS: Cell proliferation assay demonstrated that leptin caused significant growth potentiation in both cells. Immunocytochemical staining showed that leptin significantly increased the expression of ER-α and decreased that of ER-ß in PC-3 cells. LC-MS method revealed that leptin increased the concentration 4-hydroxyestrone and/or decreased that of 2-methoxyestradiol, 4-methoxyestradiol and 2-methoxyestrone. Interestingly, RT-PCR showed that leptin significantly up-regulated the expression of aromatase and cytochrome P450 1B1 (CYP1B1) enzymes; however down-regulated the expression of catechol-o-methyltransferase (COMT) enzyme. SIGNIFICANCE: These data indicate that leptin-induced proliferative effect in prostate cells might be partly attributed to estrogen metabolism. Thus, leptin might be a novel target for therapeutic intervention in prostatic disorders.

Prostate cancer in Saudi Arabia in 2002.

Epidemiologic studies revealed that there are variations in the geographic and ethnic distribution of cancer of the prostate (CaP) gland. This cancer varies dramatically between being very common in black American men, to rare in Asian and Chinese men. Genetic, familial predisposition and environmental factors in addition to methods of cancer detection and reporting contribute to these variations. Prostate cancer is the ninth most commonly diagnosed cancer in the world yet it ranks first in the United States of America (USA) where resources allow large epidemiological studies. The health policy makers take major decisions such as mass population screening according to data derived from such studies that include information on disease specific mortality rates and incidence rates for each of the ethnic sub-populations living in the USA. Until now, we do not have similar information in the Kingdom of Saudi Arabia (KSA); therefore, policy decisions should consider the possibility of the difference in situations since genetic, familial and environmental conditions are different. Our current local data, although little, indicates that prostate cancer occurs at a lower incidence rate than western countries. The objective of this article is to provide all the available information on the different aspects of CaP gland in KSA. A second more important objective is to attract the attention of the future expectations that need preparation since the possibility of disease prevention does exist.

Results of prostate biopsies in a teaching hospital in Western Saudi Arabia.

OBJECTIVE: To evaluate the prostate cancer detection rate in 45 patients who underwent transrectal ultrasound scan (TRUS) guided biopsies at King Abdul-Aziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia (KSA) and compare it with the previously reported national and international rates. METHODS: Forty-five charts reviewed for patients underwent TRUS guided biopsies in the period between July 1997 through to November 2002 at KAUH. Patients were entered in the study either as of high serum prostatic specific antigen (PSA) or abnormal digital rectal examination (DRE), or both. Cases with large prostate size or suspected elevation of PSA due to causes other than prostatic cancer was excluded from the study. RESULTS: Out of the 45 patients who underwent TRUS guided biopsy; cancer of the prostate was detected in 13 (28.8%). The cancer detection rate in patients presented with abnormal DRE alone was 7.6%, and was 15.3% in the group with elevated PSA but normal DRE (stage T1c). When PSA was elevated to 4-10 ng/ml TRUS guided biopsy detected cancer in 21.4%, elevation of PSA to10-20 ng/ml lead to cancer detection in 40% of the patients, and when PSA was above 20 ng/ml all cases were positive for cancer. CONCLUSION: Cancer prostate is common in Western countries; national studies reported a low incidence of prostate cancer in KSA. Yet in our local patients using this precise method of investigation, our study confirms that the detection rate of prostate cancer through TRUS guided biopsies match the results of previously reported national studies and still lower than the international rates. Although the number of cases are small to draw solid and final conclusions; this study should stimulate further research and more reports on this important subject.

Urethral polyp verumontanum.

Congenital posterior urethral polyps are rare benign lesions that can cause a variety of symptoms in young boys, the diagnosis is usually made by cystourethrogram and ultrasonography where the polyp appears as a soft tissue mass arising at the base of the urinary bladder. We present a case of verumontanum polyp in a 7-year-old boy who presented to us in October 2001 with terminal hematuria, dysuria, interrupted stream and suprapubic pain. The polyp was diagnosed by ultrasonography and cystourethrogram. Transurethral resection of the polyp was performed and pathological assessment revealed a fibroepithelial lesion which is consistent with congenital posterior urethral polyp. After 18 months follow up, the patient was free of symptoms. We reviewed the literature to identify the presentation, diagnosis, treatment options and prognosis of these polyps. In the past 20 years the posterior urethral polyp has become more common than before, and it should be considered in boys with lower urinary tract dysfunction and hematuria.

Salt losing nephropathy simulating congenital adrenal hyperplasia in an infant.

Pseudo-hypoaldosteronism occurring predominately in male infants has been reported in association with a spectrum of urologic diseases including obstructive uropathy. This is thought to reflect tubule unresponsiveness to aldosterone. We report a case, which was misdiagnosed as a case of congenital adrenal hyperplasia and treated inappropriately with hydrocortisone and fludrocortisone for 12-months before he had a urinary tract infection and was discovered to have obstructive uropathy on ultrasound. He presented with vomiting, dehydration, hyperkalemia, hyponatremia and metabolic acidosis. His initial 17 hydroxyprogestrone was high. His electrolytes improved to normal after relieving the obstruction by vesicostomy and his treatment weaned slowly without complications. This case demonstrates the importance of urine culture and ultrasound examination in suspected cases of pseudo-hypoaldosteronism.

Fournier's gangrene in diabetic and renal failure patients.

OBJECTIVE: To report our experience in the management of 9 patients with Fournier's gangrene seen in our institute, to identify the most common prognostic variables in our patients, and to evaluate the outcome of aggressive management in patients with Fournier's gangrene. METHODS: We reviewed the medical records of 9 patients admitted to King Abdul-Aziz University Hospital (KAUH) in Jeddah, Kingdom of Saudi Arabia from November 1999 until November 2002. Their age, sex, clinical presentation, predisposing factors, microbiology testing, management and prognosis were studied. RESULTS: Nine male patients were diagnosed and treated. The mean age was 68 years, 6 patients (66.6%) were diabetics and one of them had renal insufficiency not requiring dialysis, while 3 patients were on regular hemodialysis. Bacterial culture results revealed a single organism in 44.4%, and more than one organism in 55.6% of the cases. No anaerobes could be cultured, and one patient had Candida albicans. All patients had temporary suprapubic catheter diversion while stool diversion by colostomy was required in only one patient. In 7 patients, aggressive debridement and parental antimicrobial were successful to eradicate the infection, whereas 2 patients (22.2% of the cases) died of uncontrolled sepsis. CONCLUSION: Fournier's gangrene is a very serious disease, understanding the criteria of early recognition of the disease, referral to the specialist, and aggressive debridement with the use of appropriate antimicrobial therapy will improve the outcome of the patients and decrease the mortality rate.

Effects of varicocele on serum testosterone and changes of testosterone after varicocelectomy: a prospective controlled study.

OBJECTIVE: To examine the hypotheses that clinical varicoceles affect baseline serum total testosterone levels (T) and varicocelectomy improves T. MATERIALS AND METHODS: This prospective, nonrandomized, controlled study involved 4 groups of adult men. Varicocele-infertile treatment group (VIT) included 66 men who underwent varicocelectomy. Thirty-three varicocele-infertile control men (VIC) and 33 varicocele-fertile control men (VFC) were only observed. Normal-control (NC) group included 33 fertile men without varicocele. Varicocele groups were stratified into baseline hypogonadal (T <300 ng/dL) or eugonadal (T ≥300 ng/dL) subgroups. Main outcome measurements were between-group baseline T differences; and within-group T changes at 6- and 12-month follow-ups of men with varicocele. P <.05 was considered significant. RESULTS: Means (standard deviations) of baseline T in VIT, VIC, VFC, and NC were 347.4 (132.1), 339.7 (125.8), 396.6 (164.9), and 504.8 (149.7) ng/dL, respectively. The baseline T levels of varicocele groups were comparable, whereas they were significantly low compared with NC group. At 6-month follow-up, VIT demonstrated significant T improvements (mean change = 44.7 ng/dL; 12.9%; P <.0001). T changes were more remarkable among baseline hypogonadals (mean change = 93.7 ng/dL; 40.1%; P <.0001) compared with eugonadals (mean change = 8.6 ng/dL; 2.01%; P = .1223). These improvements were persistent at 12-month follow-up. Contrariwise, VIC and VFC exhibited nonsignificant T changes. Postvaricocelectomy T changes correlated significantly and inversely with baseline T (r = -0.689; P <.0001). This correlation was stronger and more significant among hypogonadals (r = -0.528; P = .004) than eugonadals (r = -0.400; P = .013). T improvements also exhibited significant positive correlations with preoperative and postoperative sperm concentrations. CONCLUSION: Baseline T was significantly low in men with varicocele compared with normal men. Varicocelectomy yielded significant T improvements among hypogonadal men but insignificant changes in eugonadals. T changes correlated strongly and significantly with baseline T and sperm concentrations.

Botulinum Toxin A Intradetrusor Injection for Treating Neurogenic Detrusor Overactivity, A Single Centre Experience.

OBJECTIVES: To evaluate the efficacy and safety of Botulinum Toxin A (BoNTA) intradetrusor injections in patients with neurogenic detrusor overactivity. METHODS: All patients provided clinical history and voiding diary, submitted to clinical examination, urine culture; serum creatinine; imaging, including plain abdominal X-rays, abdomino-pelvic ultrasonography and voiding cystourethrogram; and urodynamic tests (CMG) . They were managed by intradetrusor injections of BoNTA. For the typical patient, 300 units of BoNTA were injected through 30 injections of 10 u/mL intradetrusally into equally spaced sites of the bladder wall, excluding the trigone, under cystoscopic guidance. Patients were commenced clean intermittent catheterizations (CICs) every 4-6 h post-injection. Follow up included voiding diaries, abdomino-pelvic ultrasonography, serum creatinine and CMG, were completed for all patients at 6 and 12 weeks. This study used IBM SPSS Version 20.0 for statistical analysis. RESULTS: Forty-five patients (28 males and 17 females) with a mean age of 19.6 years were subjected to BoNTA intradetrusor injections. A good clinical response (dry patient either completely or more than 50% of the period between CICs) was observed in 68.9 and 66.7% of the patients after 6 and 12 weeks of follow up, respectively. In the group that responded well, the mean bladder volume increased post-injection by 48.2% and the mean maximum intravesical pressure decreased to 35.3 cm H2 O, a 33.4% improvement. No patients had side-effects related to BoNTA or to the procedure, and no patients experienced a deterioration of their renal functions. CONCLUSIONS: Intradetrusor BoNTA injections provide a good clinical response. The urodynamic parameters significantly improved in patients with neurogenic detrusor overactivity.