Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status.

PURPOSE: To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. METHODS: 658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann-Whitney U test were used. RESULTS: Patients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients' perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001). CONCLUSIONS: Patients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

[Lower urinary tract dysfunction in Guillain-Barre syndrome]. / Harntraktfunktionsstörungen bei Guillain-Barré-Syndrom.

BACKGROUND: Guillain-Barré syndrome (GBS) as acute inflammatory demyelinating polyradiculoneuropathy frequently leads to lower urinary tract dysfunction. The available knowledge in the medical literature is limited and good recommendations for diagnosis and therapy are rare. MATERIALS AND METHODS: In this study, 189 patients with GBS were screened for lower urinary tract dysfunction. In symptomatic patients, a urodynamic study was performed. Detrusor contractility, post-void residual, and changes of the symptoms over time were studied. Overall Barthel index and urinary control Barthel index as well as the relationship of time after onset of the disease and post-void residual were studied as possible screening criteria for urodynamic assessment. RESULTS: According to the urinary control Barthel index (BI), 115 of 189 patients (61%) presented lower urinary tract symptoms sometime during the course of disease. In 28 patients, these symptoms were temporary during the acute phase. At the time of urological assessment, 87 patients had lower urinary tract symptoms. At the end of rehabilitation, 37 had no symptoms anymore (BI 10), 20 were able to control micturition to a certain extent (BI 5), and 30 had no lower urinary tract control (BI 0). There was a significant negative correlation between post-void residual volume and overall BI (ρ -0.5823, p < 0.0001) and BI for urinary tract control (ρ -0.6430, p < 0.0001). CONCLUSIONS: Overall BI and BI for urinary tract control are suitable screening criteria for urodynamic assessment.

[How Does Lower Urinary Tract Dysfunction Affekt Female Sexuality?]. / Welchen Einfluss haben Symptome des unteren Harntraktes auf die weibliche Sexualität?

With increasing age many women suffer from lower urinary tract dysfunction (LUTD) and female sexual dysfunction. An increasing body of evidence supports an association between the 2 conditions. Especially women with urodynamically proved detrusor hyperactivity suffer from sexual dysfunction and there is some evidence that in patients with stress incontinence sexual health improves after successful surgery.

[Characteristic Features of Urinary Incontinence--Diagnostic Investigation in Geriatric Patients]. / Besonderheiten der Harninkontinenz--Diagnostik beim geriatrischen Patienten.

Urinary incontinence is a common medical and social problem in elderly people. It leads to a massive reduction in the quality of life of affected persons and their dependants and causes an enormous socio-economic burden, which will increase significantly within the next years and decades as the age structure of the German population changes. Successful treatment of urinary incontinence in the elderly requires a good pathophysiological understanding of the underlying problem as well as individually tailored diagnostic procedures, which must be oriented at the patient's wishes, the social environment and the resulting therapeutic consequences. This especially applies to persons with symptoms of dementia. Comorbidities such as diabetes mellitus, reduced mobility and a medication-induced decrease in cognitive function play a major role in the severity of urgency and urinary incontinence in the elderly. Also the frequently described concomitant diagnosis of urinary tract infection must be exactly evaluated. Before antibiotic treatment is given, it should be clarified if the patient suffers from "harmless" bacteriuria or a urinary tract infection requiring treatment. Patients with an age-associated decrease in brain power must be diagnosed quite carefully, because these patients may potentially be harmed by pharmacological treatment for overactive bladder syndrome.

[Imaging for urinary incontinence]. / Bildgebung bei Harninkontinenz.

BACKGROUND: Ultrasonography and functional cine magnetic resonance imaging (MRI) are noninvasive and x-ray free tools, which are currently widely used in clinical diagnostics and scientific research of male and female urinary incontinence. The increasing use and improving techniques of modern imaging tools are closely linked to rapid development of minimally invasive surgery in patients with urinary incontinence and insights gained in continence mechanisms. METHODS: Whereas ultrasonography is a cost-efficient and readily available diagnostic tool for a routine use, the more expensive functional MRI, as a tool with more precise visualization of functional interactions and spatial representation of anatomical structures of the pelvic floor, is suitable for complex diagnostic purposes and scientific research. Both tools are already well established for evaluations of the female pelvic floor. For evaluation of the male pelvic floor, and in particular postprostatectomy incontinence, perineal ultrasonography and functional cine MRI are becoming increasingly evident. CONCLUSION: Further development of both imaging tools will contribute to new insights into the continence mechanism and improve the techniques of radical prostatectomy and minimally invasive surgery of male and female urinary incontinence in the future.

[Urinary incontinence in men]. / Harninkontinenz des Mannes.

Stress urinary incontinence in men is predominantly iatrogenic whereby radical prostatectomy is the most common cause with persistent stress urinary incontinence rates varying between 10 % and 25 %. The first line therapy for postoperative male stress urinary incontinence is physiotherapy, especially pelvic floor muscle rehabilitation. If conservative treatment fails to show sufficient improvement, surgical therapy is recommended. Several treatment options are currently available for the surgical treatment of male stress urinary incontinence including artificial sphincters, adjustable and functional sling systems, bulking agents and implantable balloon systems.

[Magnetic urethral closure device. Negative outcome after implantation for the treatment of female urinary incontinence]. / Magnetisches Harnröhrenverschlusssystem. Desaströser Verlauf nach Implantation zur Behandlung der weiblichen Belastungsinkontinenz.

We report on a negative outcome after implantation of a magnetic urethral closure device, consisting of one part screwed into the pubic bone and one part as a vaginal cone, for the treatment of urinary stress incontinence grade III. Continence was never achieved for the patient. The urethra narrowed over time due to erosion and scarring and the patient started intermittent catheterization, because spontaneous micturition was not possible. The magnet was broken, the bladder neck was eroded, several fragments were found in the bladder, and numerous fragments were scattered throughout the small pelvis. Surgery consisted of removing most of the fragments, followed by bladder neck closure and suprapubic diversion.

[Characteristics of urinary incontinence in the elderly]. / Besonderheiten der Harninkontinenz im Alter.

Geriatric patients are defined as being over 70 years of age and are vulnerable due to multimedication and multimorbidity. The typical incontinence type in geriatric patients is the overactive bladder syndrome as a result of anatomical alterations and the influence of conditions which typically occur in the elderly, e.g. diabetes mellitus, vaginal atrophy, constipation, neurological affections and dementia. This multimorbidity leads to multimedication but many pharmaceutical compounds aimed at indications of diseases distant from the urinary tract can also influence the continence situation. This has been proven for cardiac medications, such as alpha-blockers and diuretics, neurological drug therapy and analgesics. Diagnostic investigations in geriatric patients are usually non-invasive and include geriatric assessment to quantify incontinence symptoms but invasive diagnostic tools are required if the primary therapy fails or an operative intervention is planned. Pharmacotherapy considers the special requirements of the very old patient with cognitive impairment and vulnerability due to falls or delirium. In the group of anticholinergic drugs, trospium chloride seems to be the favorite substance to treat this group of patients because this hydrophilic compound is considered to be unable to cross the blood-brain barrier and therefore minimizes the risk of side effects in the central nervous system (CNS).

[Conservative treatment in male urinary incontinence]. / Konservative Therapie der Harninkontinenz beim Mann.

Prevalence, pathophysiology, diagnostic and therapeutic approaches of urinary incontinence are well studied in women; however, studies on male urinary incontinence focus on incontinence following surgery of the bladder or prostate, predominantly incontinence after radical prostatectomy. Aging men suffer from incontinence, most frequently urge incontinence (overactive bladder, OAB), nearly as often as women do.The domain of conservative therapy of urinary stress incontinence in men is pelvic floor training. It remains unclear whether biofeedback procedures, electrostimulation therapy, or magnetic stimulation therapy can enhance pelvic floor training. There are data suggesting that an off-label therapy with Duloxetin®, a selective serotonin-noradrenaline reuptake inhibitor (SSNRI), improves urinary incontinence following radical prostatectomy. Antimuscarinic agents in combination with bladder training have been proven as safe and effective treatment in men with OAB. Data, however, suggest that men with OAB are far less frequently treated than women.

[Imaging diagnostics of the male pelvic floor]. / Bildgebende Diagnostik des männlichen Beckenbodens.

The understanding of the female pelvic floor during the last 20 years was very much influenced by the new techniques of sonographic and magnetic resonance imaging (MRI). Functional imaging of the male pelvic floor is, however, still in its infancy. In analogy to ultrasound examinations of the female pelvic floor, perineal ultrasound can be also be applied to men. The mobility of the proximal urethra, scarring of the bladder neck or implanted suburethral meshes can be easily visualized. Studies on healthy men provide information about different muscular structures during micturition. Morphology and function of the external sphincter can be visualized with transrectal or intraurethral ultrasound and also with a perineal approach. Using functional MRI the complex interactions of bladder, urethra, external sphincter and pelvic floor muscles can be evaluated. Functional MRI is so far not generally available but enables a better understanding of the function of the male pelvic floor. Imaging of the male pelvic floor makes a substantial contribution for improving surgical procedures for male incontinence in the future.

["Acute scrotum" in the neonate. Adrenal haemorrhage as cause]. / "Akutes Skrotum" beim Neugeborenen. Nebennierenblutung als Ursache.

The most common causes of an 'acute scrotum' in childhood are testicular torsion, torsion of an appendix testis, epididyoorchitis, idiopathic edema, and hematoma. In rare cases a scrotal hematoma can originate from an extra- or intraperitoneal adrenal bleeding. 12 such cases have been described in the literature, yet. We report on 3 further cases, that occurred in our institution between 1992 and 1997. In the first case we performed a scrotal exploration due to a suspected testicular torsion, but only a normal testicle and liquid hematoma were seen. Postoperatively we discovered an ipsilateral adrenal hemorrhage by sonography. In the latter two cases the adrenal bleeding was recognized primarily as causal for the scrotal mass and operation remained undone. In newborns adrenal hemorrhage is mostly due to birth-trauma, large birth-weight, hypoxia, and asphyxia. This was present as well with our 3 children. If the clinical situation of the child is stable, complete restitution under conservative therapy can be expected.

Numbers of IFN-gamma-producing cells against ESAT-6 increase in tuberculosis patients during chemotherapy.

ESAT-6 is a specific Mycobacterium tuberculosis complex antigen and strong inducer of interferon-gamma (IFN-gamma) production by T cells from tuberculosis patient T-cells. We studied the frequency of IFN-gamma producing cells reacting to ESAT-6 during anti-tuberculosis chemotherapy. The numbers of IFN-gamma producing cells in the peripheral blood were higher in tuberculosis patients after discharge from specific anti-tuberculosis chemotherapy, compared with untreated patients. These results indicate that monitoring specific M. tuberculosis antigen reactivity during anti-tuberculosis chemotherapy may avoid premature termination of treatment and resistant strains.

A pilot study to assess the use of megesterol acetate to promote weight gain in frail elderly persons residing in long-term care.

OBJECTIVE: The purpose of this pilot study was to determine the effectiveness of megesterol acetate (MA) for increasing body weight of frail older persons residing in long-term care settings. DESIGN: A retrospective study. SETTING: Two long-term care facilities in a large city in the southwestern US. PARTICIPANTS: Six white residents (five female, one male, mean age 87.8 years) of the facilities who had a sustained weight loss of 5% in 1 month or 10% in 6 months or longer. MEASUREMENTS: Weight gain or loss of participants receiving 480 milligrams of megesterol acetate for a minimum of 28 consecutive days. RESULTS: Five of the six subjects gained weight over a 2-month period after taking 480 milligrams of MA for 1 month or more. There was a delayed effect of non-fluid weight gain that was statistically significant 2 months after the end of treatment. One woman with diagnoses of stroke, arthritis, and hypertension lost weight despite taking MA continuously for 84 days. CONCLUSIONS: Results suggest that MA has been underutilized by geriatric health professionals as an intervention to ameliorate or reverse anorexia of aging after other nutritional efforts have failed. Using MA to prevent unintentional weight loss and malnutrition may significantly improve the health status of older patients. A prospective study using a larger sample and based on ideal weight should be carried out to evaluate the benefit of MA, with particular attention to weight gain that persists after 2 months. Future studies should also take into account the high dropout rate of participants and consider earlier intervention with MA.

[Differentiated metastasis of mature testicular teratoma as differential kidney and adrenal tumor diagnosis]. / Differenzierte Metastase eines reifen Hodenteratoms als Differentialdiagnose eines Nieren-bzw. Nebennierentumors.

We report on the eighth known case of a mature metastasis of a mature teratoma of the testis. In a 19-year-old patient who had undergone a pyeloplasty of the left renal pelvis 6 years before, a mature metastasis of an occult mature teratoma of the testis was found at the former operation site. This case--in addition to those published previously--emphasizes the fact that a mature teratoma of the testis has to be regarded as a malignant tumor in adults. It is supposed that the mature teratoma originates, as other testicular tumors, from carcinoma-in-situ-cells, which are responsible for metastasize and are not detected after lysis.

Nutrition support for the critically ill older patient.

Changing demographics will increase the geriatric population in the intensive care unit. Geriatric clients are more likely to be malnourished than their younger counterparts, making the early initiation of appropriate nutritional support vital. The nutrition support process adapted for critical care nurses is outlined. Strategies for identification and management of common complications are presented.

Promoting weight loss in type II diabetes.

OBJECTIVE: To examine strategies-behavioral therapies, exercise, diet, anorectic drugs, surgery, or a combination of strategies-used for promoting weight loss in people with type II diabetes. RESEARCH DESIGN AND METHODS: Meta-analysis was used to synthesize research of promoting weight loss in the population. Literature search strategies involved reviewing bibliographies, conducting computer searches and surveys of relevant master's degree programs, and contacting representatives of the Centers for Disease Control. The final sample consisted of 89 studies involving 1,800 subjects. Data were extracted on 80 variables characterizing the sample of studies/subjects and on 23 outcome variables, including weight, metabolic control, lipids, and other physiological parameters. RESULTS: Diet alone had the largest statistically significant impact on weight loss (-20 lb) and metabolic control (-2.7% in glycosylated hemoglobin). All diets significantly improved fasting blood sugar. Behavioral programs alone had a statistically significant impact on weight loss (-6.4 lb) and metabolic control (-1.5%) but effects were less than for diet alone. Data from the few exercise studies indicated that weighted average effects for exercise on weight loss (-3.4 lb) and metabolic control (-0.8%) were less than diet alone. Behavioral therapy plus diet plus exercise was associated with statistically significant effect size estimates for weight loss (-8.5 lb) and metabolic control (-1.6%). Diet alone achieved better results. Effects of weight promotion strategies, in general, were smaller in experimental studies and for individuals over age 55. CONCLUSIONS: Dietary strategies are most effective for promoting short-term weight loss in type II diabetes. A number of gaps exist in the extant literature- descriptions of subjects, interventions, or longitudinal outcomes beyond 12 months after intervention.

Effects of dietary linolenate on the fatty acid composition of brain lipids in rats.

Weanling male rats were fed hydrogenated coconut oil to induce essential fatty acid (EFA) deficiency. After 15 weeks, the rats were divided into six groups. Five groups were fed graded amounts of purified linolenate (18:3 omega 3) with a constant amount of linoleate (18:2 omega 6) for six weeks. Fatty acid composition was determined in brain lipids. Increasing dietary 18:3 omega 3 resulted in a decrease in arachidonic acid (20:4 omega 6), docosatetraenoic acid (22:4 omega 6) and docosapentaenoic acid (22:5 omega 6), whereas 18:2 omega 6 and eicosatrienoic acid (20:3 omega 6) were increased both in total lipids and phospholipids. These results suggest that dietary 18:3 omega 3 exerts its inhibitory effect mainly on the desaturation of 20:3 omega 6 to 20:4 omega 6 in brain lipids. Linolenate was undetectable in brain lipids from any dietary treatments. The levels of eicosapentaenoic acid (20:5 omega 3) in groups receiving dietary 18:3 omega 3 were not different from that of the group receiving no 18:3 omega 3. These results indicate that, in the brain, 18:3 omega 3 is rapidly converted mainly to 22:6 omega 3 without being accumulated and imply that dietary 18:3 omega 3 can modulate the level of precursor of diene prostaglandins (PG) but not that of triene PG in the rat brain.