Emphysematous epididymo-orchitis: imaging plays a vital part in active management: case report and literature review.

We hereby present a rare cause of acute scrotum secondary to emphysematous epididymo-orchitis (EEO). It is often not diagnosed until crepitus is palpable in the scrotal wall with spreading cellulitis, at which point it has reached an advanced stage. This case report details a 55-year-old man with poorly controlled diabetes who presented with an acute scrotum that failed to resolve with oral antibiotics in primary care. Following rapid detection of EEO on an early scrotal ultrasound scan, the patient had surgical debridement and a near-total orchidectomy with only a small stump of testis and tunica albuginea left behind. This case highlights the importance of timely imaging, particularly in diabetic men with an acute scrotum with a high clinical suspicion of intratesticular abscess. An incidental but significant finding of EEO would warrant early surgical intervention to prevent a catastrophic sequelae i.e. Fournier's gangrene.

The clinical impact of British guidelines on post-vasectomy semen analysis.

INTRODUCTION: Following vasectomy, azoospermia may not be achieved and rare non-motile sperm (RNMS) may persist in the semen. International guidelines vary in management of this finding. Giving 'special clearance' enables vasectomy to be considered a success despite the presence of RNMS. The latest 2016 British guidelines require two centrifuged semen samples with RNMS in order to give special clearance. We investigate the impact of these latest recommendations. MATERIAL AND METHODS: Retrospectively, patients who underwent vasectomy between 2014 and 2018 were assessed. The patient sample was divided into two groups, pre- and post-implementation of the new guidelines. The primary outcome measures were (i) total number of post-operative semen samples submitted, (ii) post-vasectomy semen analysis (PVSA) outcomes, and (iii) the numbers issued special clearance. RESULTS: Implementation of the updated guidelines increased detection of RNMS from 18% to 27% (p <0.01) and increased use of repeat testing. In the two year period prior to implementation, no patients required special clearance, however, once implemented, it was offered to 10 patients. Furthermore, there was a 5-fold increase in PVSA processing costs. The first post-vasectomy semen sample demonstrated azoospermia or RNMS in 97.5% of patients. CONCLUSIONS: British guidelines are more resource intensive, result in prolonged follow-up with increasing rates of special clearance. The European Association of Urology permits clearance, not special clearance, after a single non-centrifuged sample demonstrating azoospermia or RNMS. Bringing British recommendations in-line with European guidance would enable clearance in up to 97.5% of patients following a single sample at 12 weeks.

Metachronous bilateral testicular cancer: Case reports and review of literature.

BACKGROUND: It is well recognised that men with unilateral testicular cancer may go on to develop metachronous cancer in the contralateral testis. Here, we present two cases of metachronous bilateral testicular cancer and a literature review. CLINICAL CASES: In both cases, the second testicular cancer occurred several years after the initial cancer, and both cases were not screened for presence of contralateral germ cell neoplasia in situ upon the first diagnosis. DISCUSSION: We also present a literature review on the need for screening biopsies of contralateral testis for germ cell neoplasia in situ and the risk factors which should encourage screening. Furthermore, we also explore the effect of chemotherapy on the incidence of contralateral testicular cancer and the effectiveness of radiotherapy in the treatment of germ cell neoplasia in situ. CONCLUSION: We believe that screening biopsies of the contralateral testis upon diagnosis of unilateral testicular cancer should be encouraged as it can lead to better management of the condition and a relatively favourable outcome on functional fronts.

Pyogenic Granuloma of the Penis: An Uncommon Lesion with Unusual Presentation.

We present the case of a 37-year-old man who presented with a penile lesion that engorged on erection. Ultrasound examination demonstrated vascularity of the lesion and the decision was made to perform a complete excision. Histological analysis confirmed the diagnosis of a pyogenic granuloma of the penis. Follow-up demonstrated no recurrence at 3 months.

Accidental, Non-masturbatory, Non-intercourse Related, Self-Inflicted Penile Fracture: Case Report and Review of Literature.

Penile fracture is a relatively rare condition arising from a rupture of the corpus cavernosum. In the western world, it is most commonly associated with sexual intercourse. We hereby, report a rare case of accidental, non-masturbatory, self-inflicted penile fracture. It was diagnosed promptly based on clinical assessment, confirmed radiologically and managed surgically, resulting in a good long-term clinical outcome. Our case highlights the importance of maintaining a high index of suspicion to diagnose this rare condition, even in the absence of a typical mechanism of injury, in order to ensure that such an injury is not missed.

Synchronous tumours of the breast and bladder.

The presentation of synchronous primary tumours is rare and presents a difficult diagnostic and therapeutic challenge to primary care clinicians and hospital specialists. Increased life expectancy, improved radiological and biochemical investigation and more rigorous pre- and postoperative evaluation will lead to an increasing clinical trend for both metachronous and synchronous primary neoplasms. We report on a case of synchronous bladder and breast cancer in an elderly woman. We detail our investigation and management of the patient, review the literature and suggest the possible causative factors for the association of these synchronous tumours. We also highlight the extent of multiple primary cancers and discuss the diagnostic, treatment and preventative strategies for metachronous and synchronous primary tumours.

A simple two-stage "bailout" technique for the removal of an unyielding ureteric stent.

OBJECTIVE: To describe a simple technique that can be used to manage an unexpected mildly to moderately (<10 mm) encrusted ureteric stent with consummate ease when time, equipment, or experience are unavailable. METHODS: We present a series of 5 patients with impacted ureteric stents that were difficult to remove owing to presumed encrustation of the upper end. The indwelling time for the stent ranged from 8 to 16 weeks. All 5 patients were managed by insertion of a second ureteric stent alongside the original one. RESULT: The encrusted stents were successfully retrieved in all 5 patients at a subsequent visit after the insertion of the second stent, without the need for further specialist equipment or expertise. CONCLUSION: Insertion of a second stent next to an unyielding, encrusted ureteric stent is a safe, simple, and effective technique to aid in its retrieval. We propose that it should be considered in select patients where encrustation is unexpected and an experienced endourologist is unavailable.

Multi-length or 24 cm ureteric stent? A multicentre randomised comparison of stent-related symptoms using a validated questionnaire.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: One of the suggested factors for stent-related symptoms is that excess distal intravesical stent mass may cause bladder irritation. There is a lack of studies investigating this in a randomised controlled fashion using a validated questionnaire. This study compared two of the most commonly used length of stents (a 30 cm multi-length vs a 24 cm long stent) and showed no significance difference in stent-related symptoms in patients with either of these stents. OBJECTIVE: To investigate whether excessive redundant intravesical stent component contributes to the severity of stent-related symptoms in patients with a ureteric stent. We compared stent-related symptoms in patients who had either a standard 24 cm or multi-length ureteric stent. PATIENTS AND METHODS: In all, 162 patients with upper urinary tract calculi requiring ureteric stent insertion were randomised to receive either a 6 F × 24 cm Contour(TM) or multi-length 6 F × 22-30 cm Contour VL(TM) stent. Patients were requested to complete the validated Bristol Ureteric Stent Symptom Questionnaire (USSQ) at 1 and 4 weeks after stent insertion and 4 weeks after removal. The mean scores for each domain of the USSQ for both groups were compared using the Student's t-test. Any adverse events, e.g. stent migration, early removal of stent due to stent-related symptoms and failure of stent insertion, were also recorded. RESULTS: In all, 153 patients who had successful stent insertion were requested to complete the USSQ and 74% of patients returned at least the week 1 questionnaire. At 1 and 4 weeks with the stent in situ, comparison of the mean scores showed no significant difference in urinary symptoms, pain, general health, work performance, sexual dysfunction and number of days patients stayed in bed or reduced their routine activities. Three (2%) patients had their stent removed early due to stent-related symptoms and five (3%) had failed stent insertion. CONCLUSIONS: This study did not find any difference in symptoms between the 24 cm or multi-length Contour stents. However, the study was not powered to detect small differences particularly for the pain symptom domain. Stents should only be used sparingly and the stent dwell-time should be minimised.

Limited shock wave therapy vs sham treatment in men with Peyronie's disease: results of a prospective randomized controlled double-blind trial.

OBJECTIVE: To assess the role of extracorporeal shock wave therapy (SWT), in a prospective randomized controlled trial, comparing limited SWT vs sham therapy in men with Peyronie's disease. PATIENTS AND METHODS: In all, 36 men were randomized to six sessions of SWT or sham treatment. Geometrical measurements of penile length and deformity, and the abridged International Index of Erectile Function (IIEF) score and visual analogue score (VAS) were recorded and re-evaluated at 6 months. The patient and assessor were unaware of the treatment type. Standard nonparametric tests were used for the statistical analysis. RESULTS: A full set of outcome data was obtained for 16 patients in the intervention group and 20 in the sham/control group (mean age 58 and 60 years, respectively, mean duration of symptoms 15 and 33 months). There was no significant difference in the mean change between the control and intervention groups on any outcome measure. There were improvements in the mean (sd) dorsal and lateral angle, of 5.3 (11.66)° and 3.5 (17.38)° in the control group, and a deterioration of 0.9 (16.01)° and 0.9 (15.56)° in SWT group. Mean improvements in curved and straight lengths were 0.2 (0.58) and 0.1 (0.8) cm in the control and mean reductions of 0.1 (0.9) and 0.1 (1.49) cm in the SWT group. The mean changes in the IIEF and VAS scores were 0.1 (3.32) and -0.8 (1.77) for control and 0.56 (2.6) and -1.05 (1.79) for SWT group. CONCLUSION: There were no significant differences in changes of variables in Peyronie's disease treated with short-term SWT.

Plausible mechanism of small bowel injury during trocar cystostomy.

An 86-year-old man presented with urinary retention secondary to detrusor failure and bulbar urethral stricture. He had a non-tender, palpable, grossly distended bladder and a very poor tone in the muscles of the abdominal wall. He did not allow urethral or suprapubic catheterisation under local anaesthesia; hence, a trocar cystostomy was performed under a short general anaesthesia, which led to injury to the small bowel when least expected. We discuss its subsequent management and plausible mechanism underlying this unexpected complication in the given circumstances.

Phyllodes tumour of the prostate posing diagnostic and therapeutic dilemmas.

A rare case of phyllodes tumour of the prostate of which less than 100 cases have been reported in the literature. It has an unclear clinical course and uncertain management options. In an inoperable case such as this, the authors discuss the difficulties faced with its management and the limited, possibly palliative role, of hormonal treatment using luteinising hormone-releasing hormone analogue in managing it over a medium term.

One-stage tubeless antegrade ureteric stenting: a safe and cost-effective option?

INTRODUCTION: Antegrade insertion of ureteric stent has become an established mode of management of upper tract obstruction secondary to ureteric pathology. It is conventionally performed as a two-stage procedure for various reasons but, more recently, a one-stage approach has been adopted. PATIENTS AND METHODS: We discuss our experience of primary one-stage insertion of antegrade ureteric stent as a safe and cost-effective option for the management of these difficult cases in this retrospective observational case cohort study of patients referred to a radiology department for decompression of obstructed upper tracts. Data were retrieved from case notes and a radiology database for patients undergoing one-stage and two-stage antegrade stenting. It was followed by telephone survey of regional centres about the prevalent local practice for antegrade stenting. Outcome measures like hospital stay, procedural costs, requirement of analgesia/antimicrobials and complication rates were compared for the two approaches. RESULTS: a one-stage approach was found to be suitable in most cases with many advantages over the two-stage approach with comparable or better outcomes at lower costs. Some of the limitations of the study were retrospective data collection, more than one radiologist performing stenting procedures and non-availability of interventional radiologist falsely raising the incidence of two-stage procedures. CONCLUSIONS: In the absence of any clinical contra-indications and subject to availability of an interventional radiologist's support, one-stage antegrade stenting could easily be adopted as a routine approach for the management of benign or malignant ureteric obstruction.

Urological pathology causing free air under the diaphragm?

We report a case of long-standing, keratinising, squamous metaplasia of the bladder with undiagnosed malignant transformation to squamous cell carcinoma presenting as acute peritonitis secondary to spontaneous perforation of the bladder tumour. This presentation as an acute abdomen mimicking a perforated peptic or duodenal ulcer is the most unusual aspect of the case.

Nephroureterectomy for transitional cell carcinoma - the value of pre-operative histology.

INTRODUCTION: Nephroureterectomy with excision of a cuff of bladder remains the standard for managing upper tract transitional cell carcinoma (TCC). Increasing use of diagnostic upper tract endoscopy has underlined the importance of obtaining a pre-operative histological diagnosis in order to avoid under-treating high-grade or multifocal disease and over-treating low-grade disease, which could, in selected cases, be managed conservatively. We review nephroureterectomy at our institution over a 10-year period with particular reference to a pre-operative histological diagnosis. PATIENTS AND METHODS: Nephroureterectomy was performed in 113 patients from February 1994 to February 2004. Of these cases, 58 were for upper tract TCC and 50 of these 58 had intravenous urography (IVU): 9 had only IVU, 28 had an additional CT scan, 5 had an additional ultrasonography and 8 had additional CT + ultrasonography for pre-operative work-up. Thirty-four of the 58 cases had retrograde pyelography. Nineteen (32.7%) of the 58 cases had a pre-operative ureteroscopy (URS) and biopsy; 14 of these had rigid URS for tumours in the lower (11) and middle (3) thirds of the ureter and 5 had flexible URS for pelvicalyceal tumours by an experienced endourologist. Thirty-one (53%) of the 58 tumours were within the pelvicalyceal system and 27 within the ureter (upper, 5; middle, 3; lower, 19). Forty-eight patients underwent a total nephroureterectomy: 40 had a two incision approach and 8 had an endoscopic resection of the lower ureter. Five of the 58 cases had a sub-total nephroureterectomy and 5 a laparoscopic nephroureterectomy with open excision of lower ureter. RESULTS: Nineteen (32.7%) of the 58 patients had a pre-operative histological diagnosis - 17 G2pTa, 1 G1pTa, and 1 G2pT1. Fourteen (74%) biopsies matched the final postoperative histology, but 1 was down-staged, 3 up-staged and 1 up-graded compared to the original histology. Five (12.8%) of 39 patients without pre-operative histology had no TCC in the final surgical specimen: 4 (10.25%) had benign pathology such as capillary haemangioma, urothelial cysts and reactive urothelial changes while one had renal cell carcinoma (RCC). CONCLUSIONS: This study underlines the importance of obtaining a pre-operative histological diagnosis in cases with presumed upper tract TCC. Failure to do so can result in unnecessary ablative surgery for benign disease. Such an approach can also help identify multifocality and grade of disease so that treatment of upper tract TCC can be tailored more appropriately with ablative surgery for high-grade or multifocal disease and conservative (endoscopic) therapy for low-grade disease in selected cases. Patients with suspected TCC of the upper tract should be managed at centres where facilities for the comprehensive evaluation of such tumours exist.

Dry gangrene of the foreskin after second attempt at prepuce-sparing surgery for congenital penile curvature: case report and literature review.

INTRODUCTION: Dry gangrene of the foreskin following corrective surgery for congenital penile curvature (CPC) or Peyronie's disease is extremely rare. It is noted as a consequence of intraoperative penile degloving. AIM: We report one such case with its natural history presented by serial clinical pictures, discuss the management dilemmas, and review a rather scant relevant literature. METHODS: A 32-year-old man with CPC underwent prepuce-sparing corrective surgery for penile curvature on two occasions resulting in dry gangrene of the foreskin following the second attempt. RESULTS: It was managed conservatively with a satisfactory result. CONCLUSION: Gangrene of the foreskin is most likely to occur as a complication after a second attempt at prepuce-sparing surgery. It can be managed nonsurgically with a satisfactory outcome.

Multifocal symptomatic intracerebral metastases as the first manifestation of prostatic carcinoma: a report and literature review.

We report an unusual case of prostatic carcinoma in a middle-aged man with symptomatic multifocal intracerebral metastases as its initial manifestation to highlight the importance of its accurate diagnosis and implications on its management and review relevant literature.

Prospective randomized crossover trial of lubricant gel against an anaesthetic gel for outpatient cystoscopy.

OBJECTIVE: Flexible cystoscopy is routinely performed under local anaesthetic. The aim of this study was to compare the outcomes of using an anaesthetic gel and a non-anaesthetic gel in the same patient. MATERIAL AND METHODS: Men undergoing 3-monthly check cystoscopies were recruited to this prospective, randomized, double-blind, crossover trial. Primary outcome measures were visual analogue scale scores for pain and the incidence of infection. A total of 51 men were randomized to receive 11 ml of either a non-anaesthetic gel or Instillagel as a lubricant on their first visit; they then crossed over to the other agent on their next visit. A nurse who was blinded to the type of lubricant used recorded post-procedural visual analogue scale scores for pain and contacted the patients 48 h postoperatively to check the incidence of infection. RESULTS: The median difference in pain score (non-anaesthetic minus anaesthetic) was 0 (range -5.3 to 7.5) and the mean difference 0.24 (SD 2.3), with no evidence of a 'time period effect' between instillations, i.e. the sequence of instillation with Instillagel followed by aqueous gel or aqueous gel followed by Instillagel in an individual did not have a significant effect. One patient had a urinary tract infection after using each type of gel. A non-inferiority test gave strong evidence that the mean difference in pain score was < 1 (p = 0.011). CONCLUSIONS: Our study suggests that the pain experienced with the non-anaesthetic gel is no greater than that experienced with the anaesthetic gel. The non-anaesthetic gel is as effective as the anaesthetic gel and its regular use should be advocated in routine practice.

Is the current practice providing an integrated approach to the management of LUTS and ED in primary care? An audit and literature review.

INTRODUCTION: Lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are highly prevalent in aging men. A common pathophysiology is hypothesized to explain causal link. However, prevalence of ED in patients with LUTS remains underdiagnosed, as we believe general practitioners (GPs) do not inquire about ED in men presenting with LUTS. AIM: Our goal to find out if LUTS and ED were dealt with in an integrated fashion in primary care. METHODS: One hundred consecutive patients with LUTS attending the prostate assessment clinic anonymously completed a locally developed, qualitatively validated questionnaire and sexual health inventory for men. MAIN OUTCOME MEASURES: (i) Prevalence of concomitant ED in men presenting with LUTS; (ii) proportion of GPs enquiring about ED; (iii) patients with LUTS + ED who were offered treatment in primary care; and (iv) patients who sought treatment on review in secondary care. RESULTS: The age of patients was 39-86 years. Fifty-four percent admitted to ED: 66% >/=60 years, and 28%