Urethral calculi: presentation and management.

OBJECTIVE: To determine the occurrence, symptoms, treatment and outcome in patients with urethral stones. PATIENTS AND METHODS: Fifty-one consecutive patients with urethral calculi were assessed prospectively; all were male and one was an infant. RESULTS: Acute retention of urine occurred in 78% of patients, urethral anatomical pathology in 6% and posterior urethral calculi in 88%. The urethral stones, solitary in each patient, consisted of calcium oxalate in 86%, struvite in 6%, mixed stones in 4%, calcium phosphate in 2% and uric acid in 2%. A methodical approach to therapy was used which aimed to clearly define the circumstances in which a given procedure was used, and the resulting success rate. CONCLUSION: The common belief that most urethral calculi in patients in developing countries originate from the bladder does not seem to be generally applicable. Urethral anatomical pathology does not seem to be a necessary condition for most of these calculi.

Anterior hypospadias. Is repair necessary with urination in a sitting or squatting position?

OBJECTIVE: To determine the chronic complication rate of anterior hypospadias repair and to explore whether the practice of placing the neomeatus at the tip of the penis should be applicable to all cases in our community where urination is in a sitting/squatting position. METHODS: Over a 10-year period commencing 1st September 1987, 312 patients had hypospadias repair of whom 72% had anterior hypospadias. The meatus was advanced to the tip of the penis in all repairs. The location of the meatus was also determined in 281 non-complaining men with a straight penis and normal sexual and reproductive functions. Following prior information that anterior hypospadias was not associated with sexual and reproductive dysfunction, 51 patients were given a choice between repair or no repair. RESULTS: Urethrocutaneous fistula occurred in 5% of patients, urethral stricture in 3% and meatal retraction in 3%, with 92% of patients having no complications. Forty six percent of non-complaining men had the meatus in locations other than the tip of the penis. Of 51 patients with the benefit of informed consent, 73% opted for no repair. CONCLUSION: Our results of anterior hypospadias repair compare favourably with those of other centers. Placement of the meatus at the tip of the penis for anterior hypospadias should not be applicable to all patients in this community where urination is in a sitting/squatting position. Before such repairs, an informed consent is warranted by making the patients and their parents aware of the non-association of sexual and reproductive disorders with these anomalies.

Unusual high presentation of torsion of testicular appendages.

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Prognosis of radiologically non-functioning obstructed kidneys.

Twenty patients found to have unilateral radiologically non-functioning obstructed kidneys on excretory urography (IVU), and who had normal contralateral kidneys, were further evaluated. Ultrasonography, radionuclide imaging and CT scan were carried out pre-operatively to try to predict which of the kidneys were potentially recoverable after relief of obstruction. Percutaneous nephrostomy was also performed on the last consecutive 7 patients 4 weeks before definitive treatment and the function of the kidneys determined daily. The patients were re-evaluated 2 months after the relief of obstruction. Ultrasonography, radionuclide imaging and CT scan were not found to be reliable in predicting whether these kidneys were potentially recoverable. We consider percutaneous nephrostomy a good procedure for obtaining prognostic information prior to definitive surgery.

Treatment of urethral strictures in University of Nigeria Teaching Hospital.

A review of 150 patients with urethral strictures treated over a period of seven years at the University of Nigeria Teaching Hospital, Enugu, showed that 83 per cent of the patients were treated with a form of bouginage. Recurrence rate among this group was 65 per cent as opposed to 44 per cent among the group treated with urethroplasty. About 40 per cent of the patients obtained good to excellent results, 26 per cent rather poor results, and the rest achieved fair results. Even though urethroplasty afforded the best results, bouginage, in spite of the high recurrence rate, should be encouraged in centers with limited facilities for urethroplasty.

Management of urethral injuries in University of Nigeria Teaching Hospital.

A plea is made for diversion of urine by suprapubic cystostomy as initial treatment in clinically established urethral injury. When early retrograde urethrography is not possible this study should be done between 3 and 6 weeks after injury, when infection or extravasation of urine at the injured site might have cleared. The quality of x-ray at this time is good and helps to determine the definitive treatment of the resultant stricture, if any. Good results were achieved in 32 patients treated along these guidelines. Poor results were achieved in 13 additional patients treated initially with interlocking sounds, even though the nature of the injury could have contributed partly to the bad result.

Detrusor pressure in bladder outlet obstruction.

Synchronous urinary flow and pressure studies were done on 51 male adults consiting of 12 normal subjects and 39 patients with varying degrees of bladder outlet obstruction due to benign prostatic hypertrophy. Mean maximum detrusor pressure levels of 50 mm. Hg and above were found to be indicative of bladder outlet obstruction. Elevated mean maximum detrusor pressure fell preoperatively within normal limits after prostatecomy. Chronic retention of urine was not associated with poor contraction of the detrusor muscle. Clinical findings of obstruction were shown to be inadequate for estimation of maximum detrusor pressure. Recording the detrusor pressure was found to be a better urodynamic test for bladder outlet obstruction than recording the urinary flow rate. Recording urinary flow is, however, a simple test and should remain a screening test for impaired drainage of the bladder outlet.

Direct recording of urethral resistance using the "urethroresistance".

Observations on urethral resistance during micturition in non-obstructed men and in patients with bladder outlet obstruction owing to benign prostatic hypertrophy are presented. The "Urethroresistance", a new instrument, was used for the direct recording of urethral resistance. The upper limit for the minimum urethral resistance during micturition for normal non-obstructed men was 0.5 units. Two patterns of urethral resistance were observed solely in non-obstructed subjects and 3 other patterns, which were found solely in patients with a moderate or severe degree of bladder outlet obstruction, were shown to be characteristic of bladder outlet obstruction. While direct recording of urethral resistance is a better test for bladder outlet obstruction than the recording of urinary flow rate the recording of urinary flow is a simple urodynamic test, which remains a useful screening test for bladder outlet obstruction. With the exception of severe obstructive symptoms none of the other clinical methods for the assessment of bladder outlet obstruction--the size of the prostate gland, the volume of post-micturition residual urine and the degree of bladder trabeculation--is reliable to determine the degree of bladder outlet obstruction.

Urodynamics in benign prostatic hypertrophy.

Synchronous urinary flow and pressure studies were carried out on 51 male subjects of whom 12 were normal subjects and 39 had benign prostatic hypertrophy with varying degrees of bladder outlet obstruction. A urodynamic scoring system was evolved for accurate and objective diagnosis of bladder outlet obstruction. The minimum urethral resistance was found to be the most valuable single urodynamic parameter for the diagnosis of bladder outlet obstruction. Hitherto this urodynamic parameter was determined through tedious calculations. In the course of the present study a new instrument, the Urethroresistance, was devised for the direct recording of urethral resistance during micturition.

Intravesical pressure in benign prostatic hypertrophy.

Synchronous pressure and flow studies were carried out on 51 men over 50 years of age. The subjects were divided into groups based on degree of bladder outlet obstruction. Eight patients were also examined six to ten weeks after prostatectomy. Following multiple pressure and flow recordings, the mean premicturition resting intravesical pressure, the mean intravesical pressure at the commencement of voiding (the commencing intravesical pressure), the mean maximum intravesical pressure and the mean intravesical pressure at the end of voiding (mean cessation intravesical pressure) were determined for each subject. The maximum intravesical pressure varies in the same individual. A mean maximum intravesical pressure of 75 mm Hg and above indicates moderate or severe bladder outlet obstruction. However, this pressure is not of value in the determination of clinically doubtful or mild obstruction. None of the other intra-vesical pressures is of value in the diagnosis of bladder outlet obstruction. Six to ten weeks following successful prostatectomy the mean maximum intravesical pressure fell to normal limits.

Effect of estrogen therapy on metastatic carcinoma of the prostate.

Forty-one patients with metastatic carcinoma of the prostate (stage IV) were treated with diethylstilbestrol or bilateral orchidectomy or both and followed for a period of two years. The effect of treatment was determined every six months and was based on the size and consistency of the primary lesions on rectal palpation, the effects on pain, obstructive symptoms, osseous metastases, level of serum prostatic acid phosphatase and on the overall clinical evaluation of the patient. Bilateral orchidectomy was as effective as a combination of bilateral orchidectomy and diethylstilbestrol therapy. Diethylstilbestrol given alone was less effective. The poorer results obtained were attributed to the failure of many patients to adhere strictly to their estrogen regimen. Rectal digital palpation of the prostate as well as an estimation of the level of serum prostatic acid phosphatase is recommended in developing countries for all male patients over 50 years of age seen at the hospital.

Bladder wall tension in benign prostatic hypertrophy.

Two hundred forty-three synchronous urinary flow and intravesical pressure recordings were carried out on 51 men all of whom were over 50 years of age. They consisted of 12 normal subjects and 39 patients with benign prostatic hypertrophy in various stages of bladder outlet obstruction. Bladder wall tension was determined from each pressure and flow recording. Bladder wall tension at the commencement of micturition was found to be of value for the diagnosis of bladder outlet obstruction attributable to benign prostatic hypertrophy. A technique for direct recording of bladder wall tension is desirable.

Correlations between clinical findings and urinary flow rate in benign prostatic hypertrophy.

Measurement of urinary flow rate was carried out on 39 male patients with bladder outlet obstruction due to benign prostatic hypertrophy. All patients were over 50 years of age. Ten subjects, by clinical evaluation, had doubtful bladder outlet obstruction, nine had mild obstruction and 20 patients had moderate or severe obstruction. Four criteria were used for clinical diagnosis: obstructive symptoms, size of prostate by rectal digital exploration, volume of postmicturition residual urine and degree of bladder trabeculation seen on cystourethroscopy. Considerable inaccuracy results from basing the degree of impairment of urinary flow on the patient's obstructive symptoms, degree of prostatic enlargement, postmicturition residual urine or degree of bladder trabeculation. Severe obstruction symptoms generally indicate impaired urinary flow but the absence of obstructive symptoms does not exclude impaired flow.

The effect of a 6FG urethral catheter on urinary flow in benign prostatic hypertrophy.

Free voiding and micturition alongside a fine indwelling urethral catheter of similar voided volumes of urine were recorded for 43 men over 50 years of age. All had benign prostatic hypertrophy. Ten men had no bladder outlet obstruction, seven had clinically questionable obstruction, nine had slight obstruction and 17 had moderate or severe bladder outlet obstruction. I found no statistically significant lowering of peak flow rate when voiding was carried out alongside an indwelling 6FG catheter in subjects with no obstruction and with various degrees of bladder outlet obstruction due to benign prostatic hypertrophy. My findings demonstrate that the lower urinary tract is not a simple hydrodynamic system but a biologically functioning organ. The bladder outflow tract possesses considerable elasticity and accommodation. The present findings justify the use of the fine perurethral catheter technic for urodynamic studies, particularly in subjects with clinically questionable bladder outlet obstruction due to benign prostatic hypertrophy.

Patterns of urinary flow in benign prostatic hypertrophy.

Multiple urinary flow recordings were carried out on 51 men and without bladder outlet obstruction due to benign prostatic hypertrophy. All patients were over 50 years of age. Six urinary flow patterns (types 0-5) were defined. Types 0-3 were found in patients without obstruction, while all six patients were observed in those with clinical obstruction. Following prostatic surgery, only types 1, 2 and 3 were found. Only type 5 flow pattern can be determined by flow rate alone because it is by definition on the curve obtained when peak flow rate is below 4 ml per second. In this study, no type of flow pattern was characteristic of bladder outlet obstruction due to benign prostatic hypertrophy. The supposedly characteristic type of flow pattern in this clinical condition reported by earlier workers is mainly a result of a difference in the age distribution between their control and test groups.

Urinary flow rate in benign prostatic hypertrophy.

Multiple urinary flow measurements were recorded on 12 men without bladder outlet obstruction, ten men with a clinically doubtful diagnosis of bladder outlet obstruction due to benign prostatic hypertrophy, 29 men with a proven clinical diagnosis of bladder outlet obstruction due to benign prostatic hypertrophy and eight men before and after prostatic surgery. All were over 50 years of age. Mean peak flow rates for non-obstructed men varied from 11.8 to 35.0 ml per second and the minimum threshold for mean peak flow rate in these subjects was 15.0 ml per second for voided volumes of 200 ml and above. The vast majority of subjects with obstruction had mean peak flow rates below 15 ml per second. Mean peak flow rates reverted to normal after prostatic surgery. Our findings justify the use of multiple determinations of peak flow rate as a routine screening examination in subjects who may have bladder outlet obstruction due to benign prostatic hypertrophy.