The measurement of psychological distress in men being investigated for the presence of prostate cancer.

High levels (>50%) of anxiety are reported in patients undergoing screening for prostate cancer, which may affect health-related quality of life. We aimed to determine the level and prevalence of anxiety and depression and to identify those aspects of the diagnostic pathway that induce the most stress in men being investigated for prostate cancer. A total of 159 prostate-specific antigen-unscreened men undergoing a transrectal ultrasound-guided biopsy of the prostate (TRUS-B) completed two questionnaires, prior to their biopsy and before receiving results, containing the Hospital Anxiety and Depression Scale (HADS) and a 10-point Visual Analogue Scale (VAS). Median scores and prevalence of anxiety (4-5, 4-7%) and depression (1-2, 1.4%) respectively were low for both questionnaires. Waiting for biopsy results received the highest median VAS score (6) and was the most stressful event in 65% of men. There is a low incidence of clinically significant anxiety and depression in men being investigated for prostate cancer but questionnaires such as HADS identify patients with psychological distress who may benefit from early counselling. Uncertainty about the future while awaiting biopsy results after TRUS-B seems to be the most stressful event in patients' lives and minimizing this wait should help optimize patient care.

Renal artery pseudoaneurysm following partial nephrectomy treated with stent-graft.

Haemorrhagic complications due to pseudoaneurysms of branch arteries can be treated by selective embolisation. Injuries to the main renal artery cannot be treated in this way without sacrificing the kidney. We report the successful percutaneous treatment of a main renal artery pseudoaneurysm with a stent-graft in a patient with a solitary kidney.

Sildenafil influences lower urinary tract symptoms.

OBJECTIVE: To assess the possible relationship between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) in men, and whether treatment of their ED with sildenafil influences their LUTS. PATIENTS AND METHODS: In all, 112 men with ED attending the andrology outpatient clinic were offered oral sildenafil and reviewed 1 and 3 months after treatment. They completed the International Index of Erectile Function and the International Prostate Symptom Score (IPSS) questionnaires at baseline and each review. Scores were designated to indicate the visit number and differences between the visits calculated. RESULTS: A third of the men had an initial IPSS of > 7; there was no relationship between baseline urinary and sexual function scores. After treatment with sildenafil, the urinary scores at 3 months correlated strongly with the sexual function scores. There was a significant inverse relationship between the baseline IPSS and sexual function scores after treatment. The overall trend in the IPSS was towards improvement after treatment with sildenafil. CONCLUSIONS: In men with ED there is no relationship between sexual function scores and urinary symptom scores before treating ED. Treatment with sildenafil appears to improve urinary symptom scores. A lower IPSS at baseline appears to predict a better response to ED therapy with sildenafil.

A study comparing various noninvasive methods of detecting bladder cancer in urine.

OBJECTIVES: To compare the nuclear matrix protein (NMP)-22 assay, bladder tumour specific antigen (BTAstat) test, telomerase activity (using the telomeric repeat amplification protocol assay, TRAP) and a haemoglobin dipstick test for their ability to replace voided urine cytology (VUC) for detecting bladder cancer. PATIENTS AND METHODS: The study included 120 urological patients prospectively recruited and assessed before surgery. A single freshly voided urine sample (approximate 100 mL) was collected from each patient and aliquoted for each test. All assays were conducted according to the manufactures' guidelines; 79 patients were tested for telomerase activity. The results were then compared with VUC and the diagnosis confirmed by cystoscopy and histology. RESULTS: Fifty-two patients had histologically confirmed transitional cell carcinoma. The overall sensitivity for BTAstat, NMP22, telomerase, VUC and dipstick testing was 63%, 81%, 84%, 48% and 50%, respectively. Combining the results for telomerase and NMP22 gave a sensitivity of 100%. For G1 tumours the respective sensitivities were 23%, 62%, 56%, 23% and 15%, for G2 tumours, 68%, 86%, 92%, 50% and 41% and for G3 tumours 88%, 88%, 100%, 71% and 82%. For pTa tumours the respective detection rates were 48%, 70%, 84%, 39% and 30%, for pT1 tumours 80%, 90%, 90%, 50% and 50%, for pT2/pTis tumours, 100/100%, 100/100%, 100/100%, 88/100% and 88/83%. The overall specificity for the respective tests was 82%, 87%, 93%, 87% and 54%; combining the results of NMP22 and telomerase activity increased the specificity to 96%. CONCLUSIONS: There was significantly better detection than VUC when using the NMP22 and TRAP assay, especially for well-differentiated (P < 0.001 and 0.0027, respectively) and superficial tumours (P < 0.001 and 0.034, respectively). Combining the results of NMP22 and telomerase activity yielded values comparable with cystoscopy.

Ultrasonography and abdominal radiography versus intravenous urography in investigation of urinary tract infection in men: prospective incident cohort study.

OBJECTIVES: To compare ultrasonography and abdominal radiography with intravenous urography in the investigation of urinary tract infection in men. DESIGN: Prospective study in two hospital departments. Radiological procedures and urological assessments performed on different days by different clinicians SETTING: District general hospital. PARTICIPANTS: Consecutive series of men (n=114) referred to the department of urology for investigation of proved urinary tract infection. INTERVENTIONS: Ultrasonography and intravenous urography of renal tract and assessment of urinary flow rate. Clinical assessment, cystoscopy, urodynamic studies, and transrectal ultrasonography with biopsy. MAIN OUTCOME MEASURES: Sensitivity and specificity of ultrasonography and abdominal radiography compared with intravenous urography. RESULTS: Important abnormalities were seen in 53 of 100 fully evaluated patients, the most common being a poorly emptying bladder (34). The combination of plain radiographs of kidneys, ureter, and bladder and ultrasonography detected more abnormalities than intravenous urography alone. No important abnormality was missed by this combination (sensitivity 100% and specificity 93%). CONCLUSIONS: Ultrasonography with abdominal radiography is as accurate as intravenous urography in detecting important urological abnormalities in men presenting with urinary tract infection. This combination is safer than intravenous urography and should be the initial investigation for such patients. Additional determination of urinary flow rate is useful for the assessment of an incompletely emptying bladder.

Prevalence of undiagnosed prostate cancer in men with erectile dysfunction.

OBJECTIVE: To explore the prevalence of prostate cancer in men presenting with erectile dysfunction (ED). PATIENTS AND METHODS: In a prospective study, 127 men with ED of at least 6 months duration underwent screening for prostate cancer using prostate specific antigen (PSA) and a digital rectal examination (DRE). Men with a high PSA level (> 4 ng/mL) had sextant biopsies taken under sedoanalgesia. The serum testosterone level was measured in all the men. RESULTS: Twenty-six men were aged < 50 years and all had a normal PSA level; of 101 men aged > 50 years, 20 had an abnormal PSA. The detection rate for prostate cancer using PSA and DRE was 5%, which was not significantly higher than in the general population. All the detected cancers were clinically significant (> T2a, Gleason grade > 4). Two of the five men diagnosed with prostate cancer were Afro-Caribbean. Of the 127 men, 31% had a low serum testosterone level, but there was no association between testosterone and PSA levels. CONCLUSIONS: Prostate cancer is no more common in men with ED than in the normal male population. Therefore, routine screening for prostate cancer in men with ED is not indicated.

Acute periprostatic haematoma following a transrectal ultrasound-guided needle biopsy of the prostate.

Transrectal ultrasound (TRUS)-guided needle biopsy is routinely performed to diagnose and stage prostate carcinoma in an outpatient setting. Although serious adverse effects are rare, minor complications are common. We report the occurrence of an acute periprostatic haematoma as an unusual complication of TRUS-guided needle-biopsy of the prostate, resulting in the patient requiring prompt resuscitation and hospital admission.

Prevalence of undiagnosed diabetes mellitus in male erectile dysfunction.

OBJECTIVE: To determine the prevalence of previously undiagnosed diabetes mellitus (DM) in men presenting with erectile dysfunction (ED), using fasting blood glucose (FBG) compared with urinary dipstick testing for glycosuria. PATIENTS AND METHODS: A prospective prevalence study was carried out in an andrology outpatient clinic of a urology department in a district general hospital serving a mixed urban and rural population. In all, 129 consecutive men presenting with ED underwent FBG and urinary dipstick testing to detect undiagnosed DM in those presenting with ED. RESULTS: The prevalence of known DM was 17% and the that of undiagnosed DM 4.7% of the 107 remaining men; an abnormal fasting glucose level was found in a further 12%. The sensitivity of urine dipstick test for diagnosing DM was 20%. CONCLUSIONS: The prevalence of undiagnosed DM is higher in men with ED than in the general population. ED is a marker symptom for DM and DM should be actively sought in men presenting with ED. Urinary dipstick testing for glycosuria, if used as a screening test, will miss the diagnosis in 80% of these men. FBG testing should be undertaken to reliably diagnose DM in men presenting with ED.

The early detection and diagnosis of bladder cancer: a critical review of the options.

Bladder cancer has a high worldwide incidence matched by a tendency to recur, necessitating close and regular follow-up. Current methods of investigation of bladder cancer involve cystoscopy, ultrasound scanning and contrast urography, with additional information provided by cytology. These methods, although having a high detection rate, are expensive, time-consuming, invasive and uncomfortable. There is, therefore, a need for an inexpensive, noninvasive, quick and simple investigation with a high sensitivity and specificity for the detection of bladder cancer. There are an increasing number of molecular assays available for the detection of bladder cancer. From bladder tumour antigens to nuclear matrix proteins to adhesion molecules, cytoskeletal proteins and growth factors, urology has looked at them all to support the early detection and diagnosis of bladder cancer. This review critically discusses both the commercial as well as the research-based diagnostic assays available (their mode of action, overall accuracy - both by stage and grade, and their uses and limitations from both a clinical as well as a practical point of view). Aiming to give an insight into the options currently available for noninvasive bladder cancer diagnosis, it also provides prospective comment on what new methods/technologies may be useful in the medium term.

Increased patient satisfaction from transrectal ultrasonography and biopsy under sedation.

OBJECTIVE: To determine the acceptability and patient satisfaction of transrectal biopsy undertaken with the patient under sedation. Patients and methods A retrospective questionnaire was sent to 100 patients who had undergone transrectal biopsy between January and August 1998. Levels of patient acceptability and satisfaction were assessed using visual analogue scales (VAS, with a maximum score of 10 being the least satisfactory or acceptable) and direct questions about the side-effects of the procedure. A subsequent prospective study was undertaken on 130 patients undergoing transrectal biopsy with sedation between January 1999 and January 2000. RESULTS: The mean score for patient discomfort with sedation was 1.5, compared with 3.5 with no sedation. The overall satisfaction score improved from 3.1 to 0.9 with sedation. Complication rates were comparable, although slightly higher overall in the prospective group. Conclusion Sedation can significantly reduce patient discomfort and make the transrectal biopsy a more satisfactory experience for the patient. This is particularly important in the proportion of men who need to be considered for repeat biopsies.

Is follow-up necessary after transurethral resection of the prostate?

OBJECTIVE: To assess the necessity for routine out-patient review following transurethral resection of the prostate (TURP) for benign prostatic hypertrophy. PATIENTS AND METHODS: One-hundred and two patients with histologically proven benign prostatic hypertrophy were prospectively reviewed as out-patients. The views of their general practitioners were established by postal questionnaire. RESULTS: At their first out-patient review 94 of 102 (92%) patients were discharged and only 2% (2/102) patients remained under review after 1 year. Apart from routine urine analysis, only four additional investigations were initiated at the routine clinical assessment. One patient was listed to undergo prostatic surgery again following the post-operative out-patient review. Over the next 16 months only three patients (3%) were re-referred with further urological problems. Confidence in a system without routine hospital out-patient review was expressed by 90% of general practitioners and 78% of patients. CONCLUSION: Follow-up after TURP cannot be justified in terms of the perceived therapeutic benefit to patients. Patients should be discharged to the community and be assessed rapidly in out-patients if and when problems arise.

Erectile function following transurethral prostatectomy.

OBJECTIVE: To determine the true incidence and possible aetiology of impotence following transurethral prostatectomy. PATIENTS AND METHODS: Over a 9-month-period 268 patients who were about to undergo transurethral prostatectomy were interviewed about their sexual function. Full details of each operation were recorded including size of prostate, operative time, grade of surgeon and the occurrence of capsular perforation. The interviews were repeated by letter or telephone 3 months after operation. RESULTS: Of the 268 men interviewed, 246 (91.8%) were suitable for inclusion in the study. Pre-operatively, 137 (55.7%) were fully potent, 43 (17.5%) could achieve a partial erection and 66 (26.8%) were impotent. Of the fully potent patients, 20 (14.6%) became partially potent and four (2.9%) became impotent post-operatively. Of those who were partially potent before operation, 16 (37.2%) became impotent post-operatively. Overall, the risk of impotence was 28.1% if the prostate capsule was breached at operation but only 10.0% if it was not (P < 0.01). CONCLUSION: In fully potent men the risk of impotence after transurethral prostatectomy is fairly low, but it is higher in men who already have a degree of erectile failure. The risk of impotence is related to the incidence of capsular perforation at the time of surgery.

Proteinuria and enzymuria in vesicoureteric reflux.

Vesicoureteric reflux is a common abnormality of the urinary tract leading to significant renal morbidity and premature mortality. No reliable non-invasive method exists for its diagnosis. This study investigated the presence of urinary proteins and enzymes in healthy children and those with reflux. A log normal distribution was found for all analyte/creatinine ratios. Significantly higher tubular protein/creatinine ratios were found in patients with reflux nephropathy. Three enzyme/creatinine ratios (n-acetyl-B-D-glucosaminidase, gamma-glutamyl transferase and lactate dehydrogenase) were higher in children with reflux who had no renal scarring, but the degree of overlap with the normal range was such that it is doubtful whether any will be of use as a urinary marker.