A comparison of hyaluronic acid and estradiol treatment in vulvovaginal atrophy.

OBJECTIVE: This study aims to compare the effects of vaginal estrogen and hyaluronic acid on vulvovaginal atrophy. PATIENTS AND METHODS: This randomized controlled study included a total of 300 patients, with 150 patients in each group (Group E and Group H). The VHI score was determined based on a pre-treatment evaluation conducted by a gynecologist. After one month of receiving vaginal estrogen in Group E and vaginal hyaluronic acid in Group H, the patients were re-evaluated by their physicians. RESULTS: A statistically significant difference was found between the pre- and post-treatment VHI scores in Group E and Group H (p = 0.000; p = 0.000). No statistical difference was found between Group E and Group H in terms of treatment efficacy (p = 0.712). The pre- and post-treatment complaints of dryness, itching, dyspareunia, burning, and dysuria were found to be statistically significant in Group E and Group H (p = 0.000; p = 0.000; p = 0.000; p = 0.000; p = 0.000 in Group E, respectively) (p = 0.000; p = 0.000; p = 0.000; p = 0.000; p = 0.000 in Group H, respectively). No statistical difference was observed regarding dyspareunia, dysuria, and burning complaints (p = 0.632; p = 0.106; p = 0.128, respectively). However, hyaluronic acid was found to be significantly more effective for itching complaints (p = 0.002), while estrogen was found to be significantly more effective for dryness complaints (p = 0.012). CONCLUSIONS: Hyaluronic acid and estrogen were equally effective in vaginal treatment. Hyaluronic acid may be preferred for patients in whom hormonal therapy is contraindicated or for those who prefer non-hormonal therapy.

Lower Urinary Tract Symptoms in Greek Women After Menopause: The LADY Study.

INTRODUCTION AND HYPOTHESIS: The genitourinary syndrome of menopause (GSM), apart from symptoms related to vulvovaginal atrophy (VVA), also consists of lower urinary tract symptoms (LUTS). Based on the common embryological origin of the genital and lower urinary system, the presence of estrogen receptors, and the high prevalence of VVA and LUTS in the menopausal population, the two conditions can coexist. This study is aimed at investigating the prevalence and risk factors of LUTS in a sample of Greek peri- and postmenopausal women. METHODS: Four hundred and fifty (450) women, aged 40-70 years, attending three outpatient gynecology clinics for routine examination, completed a structured interview and responded to a validated questionnaire (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms, ICIQ-FLUTS). RESULTS: Urinary urgency or frequency affected 51.6% and dysuria 43.6% of the participants. Mild urgency or frequency was described by 25.6%, moderate by 14.4%, and severe by 11.6% of the women. Mild dysuria was reported by 26.26%, moderate by 5.8%, and severe by 11.6%. Age, weight, BMI, and number of pregnancies and abortions correlated with a higher ICIQ-FLUTS score. Women with moderate/severe symptoms of VVA, such as irritation, a burning sensation, and pruritus of the vulva or vagina, had a higher ICIQ-FLUTS score than women without such symptoms (beta coefficient 2.42, CI 1.204, 3.635, p < 0.001). CONCLUSIONS: Lower urinary tract symptoms are very common among peri- and postmenopausal women and are linked to symptoms of VVA. Our data support the need for prompt evaluation of women transitioning to menopause, as these symptoms compromise the quality of life.

A rare case of IgG4-related disease masquerading as periurethral malignancy and review of the literature.

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory disease that typically manifests as mass lesions affecting almost any organ including the pancreas, lacrimal and salivary glands, liver, lung and kidney. However, IgG4-RD with urethra involvement is scarce. We describe a rare case of IgG4-RD involving the urethra mimicking urethral carcinoma and review the published literature. A 64-years-old female presented with progressive dysuria for more than 2 months. Pelvic gadolinium-enhanced magnetic resonance imaging revealed a huge mass encasing the urethra which showed obvious enhancement in the arterial phase. And contrast-enhanced ultrasound showed that the entire mass was heterogeneously enhanced and displayed a fast-forward and fast-out pattern, which was highly suggestive of malignant tumor. The diagnosis of IgG4-RD was finally established by ultrasound-guided transvaginal mass needle biopsy. The patient was treated with methylprednisolone and cyclophosphamide and dysuria disappeared in the first week of therapy. She has been followed up in our clinic for 1 year without recurrence. The diagnosis of IgG4-RD should be considered in the differential diagnosis of a periurethral mass. Ultrasound-guided transvaginal mass needle biopsy is a safe and well-established tissue sampling method and should be performed in order to avoid unnecessary surgery.

Eosinophilia in the muscle layer of the esophagus and the urinary bladder in a Multiple System Atrophy patient with dysphagia and dysuria.

Multiple system atrophy (MSA) is a spinocerebellar degenerative disease characterized by cerebellar ataxia, parkinsonism, and autonomic failure. A 75-year-old woman who had suffered from dysphagia and dysuria under a diagnosis of probable MSA with predominant cerebellar ataxia underwent autopsy. Eosinophilia was seen extensively in the muscle layer of the esophagus and urinary bladder. Eosinophilic infiltration to the esophagus was localized in the smooth muscle layer and could be considered as "eosinophilic esophageal myositis" identified in patients with nutcracker esophagus and jackhammer esophagus. Dense eosinophilia was present within the smooth muscle layer of the urinary bladder along with muscle fiber degeneration. We suspected a neuropathic etiology associated with MSA as the cause of the histological changes in the esophagus and urinary bladder; however, the possibility that some other disease might also have been responsible for the eosinophilic infiltration of the muscle layer cannot be denied. To our knowledge, this is the first report showing localized eosinophilia in the muscle layers of the esophagus and urinary bladder in the same patient. Although localized eosinophilia in visceral muscle has not been understood well, our case suggests the possibility that it is a feature of functional motility disorders and may have a neuropathic etiology.

Clinical findings and diagnostic procedures in 270 small ruminants with obstructive urolithiasis.

BACKGROUND: Details of the clinical signs of obstructive urolithiasis in male small ruminants have not been documented in a large population. OBJECTIVE: To describe the clinical presentation and diagnostic procedures in a large group of small ruminants with urolithiasis. ANIMALS: Two hundred and seventy small ruminants (158 sheep and 112 goats). METHODS: Retrospective study of 270 cases identified based on clinical records. RESULTS: 81.2% affected goats were castrated and 91.7% sheep were intact males; 65.5% of the animals had been sick ≤2 days before referral. Common abnormalities included dysuria (93.6%), indigestion (84.4%), reduced general state of health (79.5%), signs of pain (73%), increased heart and respiratory rates (53.6% and 39.1%), and azotemia (89.4%). Blood urea nitrogen (BUN) and creatinine concentrations were strongly correlated (r2 = 0.81). Hypochloremia (52.2%), hyponatremia (43.3%), hypophosphatemia (52.4%), and abnormal potassium concentrations (26.2% hypokalemia and 24.5% hyperkalemia) were the most common serum electrolyte imbalances. Packed cell volume (PCV), plasma proteins, potassium, BUN, and creatinine concentrations were significantly increased in animals with uroperitoneum. Ultrasonography allowed for confirmation of diagnosis in 83.9% of the cases (135/161 with sufficient available information), uroliths were visible on 34 of 56 plain radiographs. CONCLUSIONS AND CLINICAL IMPORTANCE: Our study confirmed that clinical and ultrasonographic examinations are sufficient to diagnose urolithiasis. Clinical signs can be divided into an early stage with discrete unspecific clinical signs, a painful stage with frequent straining, expression of pain and moderately reduced general condition, and an advanced stage with a markedly reduced general condition and eventually recumbency.

Urodynamic observations and lower urinary tract symptoms associated with endometriosis: a prospective cross-sectional observational study assessing women with deep infiltrating disease.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the association between lower urinary tract disease (LUTD) and the presence of endometriosis at different anatomical sites. METHODS: Our prospective cross-sectional observational study evaluated 138 women with deep infiltrating endometriosis who had undergone preoperative evaluation of urodynamics and detailed assessment of lower urinary tract symptoms between August 2013 and May 2016. After laparoscopy, the anatomical sites of histologically confirmed endometriosis lesions were mapped. RESULTS: The presence of endometriosis in the bladder demonstrated significant negative angular coefficients for bladder compliance (mL/cmH2O) (P = 0.007; B = -54.65; 95%CI: -93.76 to -15.51) and for maximum cystometric capacity (mL; P = 0.001; B = -39.79; 95%CI: -62.51 to -17.06), whereas endometriosis in the parametrium showed significant positive coefficients for opening pressure (cmH2O) (P = 0.016; B = 5.89; 95%CI: 1.10-10.69) and post-void residual (mL) (P = 0.015; B = 31.34; 95%CI: 6.14-56.55). The presence of endometriosis in the bladder was a statistically significant independent predictor of low bladder compliance (P < 0.001; OR = 30.10; 95%CI: 9.48-95.55), whereas endometriosis in the parametrium was a statistically significant independent predictor of both abnormal residual urine (P = 0.019; OR = 5.21; 95%CI: 1.32-20.64) and bladder outlet obstruction (P = 0.011; OR = 7.91; 95%CI: 1.61-38.86). Correspondence analysis suggested two possible independent ways through which endometriosis acts on the genesis of urinary dysfunctions. CONCLUSIONS: Our findings strongly suggest that endometriosis involving the bladder might disturb storage function, whereas endometriosis in the parametrium disturbs the voiding phase.

The most bothersome symptom of vaginal atrophy: Evidence from the observational AGATA study.

OBJECTIVES: Vaginal atrophy (VA) is a chronic medical condition. It is managed unsatisfactorily, despite its high prevalence and negative impact on female quality of life. In order to meet their needs, it would be useful to know what women perceive to be the most bothersome symptom (MBS) of VA. STUDY DESIGN: Cross-sectional, multicenter study of 913 postmenopausal women consulting 22 gynecological outpatient services. MAIN OUTCOME MEASURES: Prevalence of the MBS perceived by postmenopausal women of different age and vaginal condition. RESULTS: Vaginal dryness was the most prevalent MBS (54.4%), followed by dyspareunia (17.6%), itching (7.8%), dysuria (5.9%) and burning (2.0%). The prevalence of vaginal dryness as the MBS increased with years since menopause, while that of itching, dysuria and burning remained approximately constant over time. The prevalence of dyspareunia as the MBS was 26.2% in the first 6 years after menopause and declined thereafter, to 8.8%. CONCLUSIONS: Among all postmenopausal women vaginal dryness per se, independent of dyspareunia, is the most commonly reported MBS. In each woman, the identification of the MBS may help to define more appropriate VA management.

Use of a novel fractional CO2 laser for the treatment of genitourinary syndrome of menopause: 1-year outcomes.

OBJECTIVES: To assess safety and efficacy of a fractional CO2 laser therapy for the treatment of genitourinary syndrome of menopause (GSM) with follow-up to 1 year posttreatment. METHODS: Women presenting with GSM and meeting inclusion criterion were enrolled. Visual Analog Scales were used to grade vaginal pain, burning, itching, dryness, dyspareunia, and dysuria. Dilators were used to rate vaginal elasticity at baseline and at each follow-up visit. Before each treatment and at follow-up, Vaginal Health Index scoring and Female Sexual Function Index questionnaires were completed. Women received three vaginal laser treatments spaced 6 weeks apart. Participant satisfaction was measured on 5-point Likert scales (1 = very dissatisfied, 5 = very satisfied). RESULTS: Of 30 women (mean age 58.6 ±â€Š8.8 years), three were lost to follow-up at 3 months and six at 1 year. None were discontinued or withdrew due to an adverse event. Average improvement in Visual Analog Scale scores for all symptom categories was statistically significant at 3 months and remained so through 1 year, except dysuria. Differences between data at 3 months and 1 year were not statistically significant, indicating persistence of positive outcomes. Average overall improvement in pain was 1.9 (±3.4), burning 1.9 (±3.1), itching 1.4 (±1.9), dryness 5.9 (±2.8), dyspareunia 4.9 (±3.3), and dysuria 0.9 (±3.1). Improvement in average Vaginal Health Index and Female Sexual Function Index scores was also statistically significant (P < 0.0001). Of 19 women undergoing dilator examination at 1 year, 18 (94.8%) were comfortable with the same or larger dilator size. Twenty-two of 24 women (92%) were satisfied or extremely satisfied with the treatment at 1 year. CONCLUSIONS: Based on study data up to 1 year, the fractional CO2 laser may be an effective and safe treatment for women suffering from symptoms of GSM, although additional studies with larger populations and placebo control is needed to confirm these results.

Pathogenic Features of Dysuria in Young Women with Secondary Amenorrhea Caused by Body Weight Loss.

We examined 11 women aged 19-26 years (mean age 22.5±3.5 years) with secondary amenorrhea complaining frequent urination over 1.5 years and repeatedly, but unsuccessful treated for overactive bladder and chronic cystitis. The rare cause of sustained urination disorders in young female patients of reproductive age was established: development of secondary amenorrhea caused by weight loss ("cosmetic" amenorrhea) with subsequent estrogene deficit and urogenital atrophy. Morphological examination of the bladder mucosa, an important clue to the diagnosis, helps to identify the true cause of dysuria, urogenital atrophy of the bladder mucosa, in secondary ("cosmetic") amenorrhea, and determine future course of etiopathogenic treatment of sustained dysuria in young women. The treatment is often effective in case of proper and timely diagnosis and the absence of irreversible changes.

Bladder symptoms and urodynamic observations of patients with endometriosis confirmed by laparoscopy.

INTRODUCTION AND HYPOTHESIS: Patients with deep infiltrating pelvic endometriosis (DIE) often describe having lower urinary tract symptoms (LUTS). Bladder pain syndrome in women is also often associated with endometriosis. In this study, we aimed to describe the characteristics of LUTS and urodynamic observations in patients with posterior endometriosis versus those with posterior and anterior endometriosis. METHODS: This was a prospective observational study of 30 patients from two gynecologic surgical settings with experience in DIE surgery. All patients underwent preoperative standardized investigation including detailed evaluation of LUTS and urodynamic studies. During surgery, endometriosis locations were recorded and correlated to symptoms and urodynamic observations. RESULTS: Twenty-three patients (76.7 %) had one or more LUTS symptoms and 29 (96.7 %) had one or more abnormalities at urodynamic examination. At surgery, all patients had posterior endometriosis and ten of them also had anterior endometriosis. Patients with anterior endometriosis had increased bladder sensation (90.0 % versus 45.0 %, p = 0.024) and painful bladder filling (70.0 % versus 30.0, p = 0.04) compared with patients with posterior endometriosis only. Voiding symptoms (60.0 %), impairment of flowmetry (30.0 %), and increased maximum urethral closure pressure (90.0 %) were frequent and not correlated with any specific location. CONCLUSIONS: Endometriosis infiltrating the bladder wall is associated with painful bladder symptoms. Dysfunctional voiding suggests an impairment of the inferior hypogastric plexus by posterior DIE. Clinical preoperative evaluation of bladder function should be systematic; urodynamic tests could be of interest in selected patients with DIE. Endometriosis may be a major cause of bladder pain syndrome.

[VIRAL INFECTIONS: HUMAN PAPILLOMAVIRUS AND GENITAL HERPES TYPE 1 AND TYPE 2 AS A CAUSE OF CHRONIC RECURRENT CYSTITIS WITH SEVERE DYSURIA IN WOMEN WITH URETHRAL HYPERMOBILITY AND HYPOSPADIAS].

Female hypospadias presenting as a misplaced urethral opening is a common cause of chronic recurrent cystitis. Cystitis occurs when urogenital infection and anaerobic bacteria enter the urethra and bladder from the vagina. The authors argue that chronic infections of the lower urinary tract in women with hypospadias should be treated surgically by meatal transposition. They present a study confirming the role of the antiviral drug Panavir in prevention of inflammatory complications in the postoperative period in patients with a history of viral infection (human papillomavirus and herpes).

Childhood lichen sclerosus--a challenge for clinicians.

Childhood lichen sclerosus (LS) is a rare and often misdiagnosed inflammatory dermatitis with an unpredictable course. The complications of LS are architectural changes of the vulva; malignant transformation is possible. The objective of our study was to define the background and the long-term course of childhood LS. A registery study identified 44 children with LS treated at Tampere University Hospital, Tampere, Finland, from 1982 to 2010. A questionnaire was sent to the identified patients and 15 responded. The clinical depiction of LS varied significantly. LS was diagnosed in only 16% of the patients at the referring unit. Autoimmune disorders were observed in 6 of the 44 patients. High prevalences of Turner's syndrome (2/44) and kidney disease (2/44) were noted. The majority of the patients were treated with topical corticosteroids. Eight developed architectural changes of the vulva. The questionnaire revealed that three of six patients who were asymptomatic at the end of the registery study follow-up experienced a recurrence of symptoms. None of them were undergoing follow-up. Nine of the 15 patients reported reduced quality of life. Childhood LS is a heterogeneous disease with a remarkable effect on quality of life. The misdiagnosis of childhood LS is common. The association between LS and autoimmune diseases should be noted. The high prevalence of Turner's syndrome raises questions regarding the influence of low estrogen levels on the development of LS. The prognosis cannot be predicted, so long-term follow-up is recommended. New tools for diagnosis and surveillance are needed.

Rare cause of dysuria: eosinophilic cystitis.

Eosinophilic cystitis is an inflammatory condition characterized by eosinophilic infiltration of whole layers of the bladder wall. The condition occurs more commonly in adults. We report a case of eosinophilic cystitis mimicking a bladder tumor in a 5-year-old boy with symptoms of dysuria and urinary incontinence. The diagnosis was confirmed by histopathology and he underwent clinical treatment with trimethoprim-sulfamethoxazole and antihistamine (cetirizine). The symptoms fully resolved in follow up, which is continuing. Although very rare, eosinophilic cystitis should be considered in cases of dysuria and increased bladder wall thickness but no identified urinary tract infection.

Histological changes due to intravesical instillation of mitomycin C.

OBJECTIVE: Transurethral resection (TUR) is highly effective in the local control of superficial bladder cancer. However, the recurrence rate can reach 80% of the cases. Adjuvant intravesical chemotherapy may decrease significantly tumor recurrence. We describe a bladder adverse reaction to mitomycin C as adjuvant therapy for non-invasive bladder cancer METHODS: Three patients with diagnosis of pTa G1 urothelial carcinoma were treated by TUR plus an instillation of 40 mg. of mitomicin C. A month later, the patients were attended for dysuria and hematuria. Cystoscopy and bladder biopsy were performed in all cases. RESULTS: Multiple sessile lesions suspicious of tumor recurrence were found on cystoscopy. The histopathological diagnosis disclosed the existence of severe atypia of the urothelium and stromal changes similar to those observed after radiotherapy CONCLUSIONS: Adjuvant intravesical chemotherapy with mitomycin C may cause local reactions with macroscopic patterns similar to tumoral recurrences.

Semiología renal y genitourinaria en pediatría: primera parte / Nephrologoy and urology semiology in children: first part

A pesar de los avances tecnológicos, la historia clínica y el examen físico continúan y continuarán siendo la base de un buen enfoque y aproximación diagnóstica correcta, por ésto, la semiología sigue siendo un área muy importante en la medicina. En ésta revisión se plantea una guía sistemática e integral para la evaluación del sistema nefro-urológico en el niño desde las herramienta básicas y fundamentales como la historia clínica, el examen físico con sus componentessemiológicos en lo normal y lo patológico, integrando además los métodos diagnósticos de laboratorio e imagen disponibles en la actualidad, para lograr un buen enfoque y aproximación diagnóstica en niños con enfermedad renal.

Despite technological advances, medical history and physical examination remain the foundation of a good approach and correct diagnosis; semiology remains a very important area in medicine. In this review a systematic and comprehensive guide for the evaluation of nephron urological system in children is presented, with emphasis in medical history, physical examination and semiotic aspects, in normal and pathological conditions; additionally laboratory and imaging studies available to achieve a good diagnostic approach in children with renal disease are presented.

A pilot study to evaluate the clinical relevance of endometriosis-associated nerve fibers in peritoneal endometriotic lesions.

OBJECTIVE: To investigate the clinical relevance of endometriosis-associated nerve fibers in the development of endometriosis-associated symptoms. DESIGN: Prospective nonrandomized study. SETTING: University hospital endometriosis center. PATIENT(S): Fifty-one premenopausal patients underwent surgical laparoscopy because of chronic pelvic pain, dysmenorrhea, or for ovarian cysts. Endometriosis was diagnosed in 44 patients. INTERVENTION(S): The preoperative and postoperative pain scores were determined using a standardized questionnaire with a visual analogue scale from 1-10. Patients with peritoneal endometriosis were divided into two groups depending on their preoperative pain score: group A with a pain score of at least 3 or more and group B with a pain score of 2 or less. Patients without peritoneal endometriosis were classified as group C and patients without endometriosis were classified as group D. Immunohistochemical analysis of neurofilament and protein gene product 9.5 were used for nerve fiber detection. Occurrence of endometriosis-associated nerve fibers was correlated with the severity of pelvic pain and/or dysmenorrhea. RESULT(S): Peritoneal endometriosis-associated nerve fibers were found significantly more frequently in group A than in group B (82.6% vs. 33.3%). CONCLUSION(S): The present study suggests that the presence of endometriosis-associated nerve fibers in the peritoneum is important for the development of endometriosis-associated pelvic pain and dysmenorrhea.

Alfuzosin-induced acute liver injury.

We describe a 56-year-old man who developed an acute liver injury after taking alfuzosin for 1 month to control his newly diagnosed benign prostatic hypertrophy (BPH). There was no history of alcohol consumption or the taking herbal or traditional remedies. Viral causes, autoimmune hepatitis, and biliary tree obstruction were excluded. Other rare causes of hepatitis such as hemochromatosis, primary biliary cirrhosis and Wilson's disease were also absent in this patient. His liver test results began to improve after discontinuing the alfuzosin. Two weeks later, alfuzosin was administered again because the patient complained of dysuria. After 10 days of alfuzosin reuse, his liver test results worsened. Five months later after the complete discontinuation of the drug, his liver test results had returned to normal. This clinical sequence suggests that alfuzosin caused his acute liver injury.

Alfuzosin-induced Acute Liver Injury / 대한간학회지

We describe a 56-year-old man who developed an acute liver injury after taking alfuzosin for 1 month to control his newly diagnosed benign prostatic hypertrophy (BPH). There was no history of alcohol consumption or the taking herbal or traditional remedies. Viral causes, autoimmune hepatitis, and biliary tree obstruction were excluded. Other rare causes of hepatitis such as hemochromatosis, primary biliary cirrhosis and Wilson's disease were also absent in this patient. His liver test results began to improve after discontinuing the alfuzosin. Two weeks later, alfuzosin was administered again because the patient complained of dysuria. After 10 days of alfuzosin reuse, his liver test results worsened. Five months later after the complete discontinuation of the drug, his liver test results had returned to normal. This clinical sequence suggests that alfuzosin caused his acute liver injury.