Botulinum toxin for treating overactive bladder in men: A systematic review.

PURPOSE: We sought to systematically review the literature on the use of botulinum toxin (BTX-A) injections in the bladder to treat overactive bladder (OAB) in men. MATERIALS AND METHODS: A systematic review was performed to identify clinical trials on efficacy and safety of BTX-A injections in the detrusor for treatment of OAB in men published from inception to October 2020. Quality assessment was performed using the Cochrane Collaboration's tool for assessing risk of bias and study characteristics were extracted by two reviewers independently. RESULTS: After screening 75 abstracts, 12 trials were included in the qualitative synthesis, of which 6 were conducted exclusively in men (mean age: 66.7 years). Only two were randomized controlled studies and the remaining were observational studies, mostly case series. Total number of participants in each study ranged from 28 to 146. Therapeutic response to intravesical BTX-A injection was assessed differently across the studies, which used quality-of-life symptom questionnaires and voiding diary parameters. Urodynamics findings were reported separately for men before and after intravesical injection of BTX-A in two studies only. Pooling of outcome data was possible with adverse events reported after BTX-A by seven studies, which showed urinary tract infection, urinary retention, increased postvoid residual, de novo interstitial cystitis, and hematuria rates of 29.8%, 20.0%, 37.3%, 28.3%, and 12.4%, respectively. CONCLUSIONS: Limited information regarding the efficacy and safety of BTX-A bladder injections for male OAB from relatively low evidence is available. Further research is needed to better understand the risk-benefit profile of BTX-A in the male population.

Genital prevalence of HPV types and co-infection in men.

INTRODUCTION: HPV infection is a highly prevalent sexually transmitted disease and there is evidence of the relationship of HPV infection and the development of genital warts, penile intraepitelial neoplasia, invasive penile carcinoma and cervical cancer. However, there is sparse data regarding the prevalence of HPV types and co-infection of different HPV types among men. OBJECTIVES: To assess the prevalence of HPV subtypes infections and rates of co-infection among men. MATERIALS AND METHODS: 366 men were evaluated from March to October 2010. Men were referred to our institution for HPV diagnostic evaluation based on the following criteria: 1. presence of a genital wart; 2. presence of an atypical genital lesion; 3. absence of symptoms and a partner with a HPV diagnosis; 4. absence of symptoms and a desire to undergo a full STD diagnostic evaluation. Genital samples were collected from the urethra, penile shaft, scrotum and anus with Digene® collection and preservation kit and submitted to HPV genotype microarray detection (Papillocheck®). All men were tested for the low-risk HPV types 6-11-40-42-43-44 and for the high-risk HPV types 16-18-31-33-35-39-45-51-52-53-56-58-59-66-68-70-73-82. RESULTS: Of the 366 men, 11 were tested inconclusive and were excluded from the analysis. 256 men (72.1% of the men from the cohort referred to our institution) tested positive with genotype micro-array detection and 99 tested negative. The most preva¬lent HPV-subtypes in the studied population were 6, 42, 51 and 16. Co-infection was found in 153 men. Of those, 70 (19.7%) had a co-infection by 2 types, 37 (10.4%) by 3 types; 33 men (9.2%) by 4 types; 8 men (2.2%) by 5 types; 1 man (0.3%) by 6 types; 1 man (0.3%) by 7 types; 2 men (0.6%) by 8 types and 1 man (0.3%) by 9 types. CONCLUSION: The most frequent HPV types were 6, 16, 42 and 51. Co-infection was found in 59% of our patients. This information is vital to drive future public health policies including massive public vaccination campaign.

Urinary glycosaminoglycans excretion and the effect of dimethyl sulfoxide in an experimental model of non-bacterial cystitis.

PURPOSE: We reproduced a non-bacterial experimental model to assess bladder inflammation and urinary glycosaminoglycans (GAG) excretion and examined the effect of dimethyl sulfoxide (DMSO). MATERIALS AND METHODS: Female rats were instilled with either protamine sulfate (PS groups) or sterile saline (control groups). At different days after the procedure, 24 h urine and bladder samples were obtained. Urinary levels of hyaluronic acid (HA) and sulfated glycosaminoglycans (S-GAG) were determined. Also to evaluate the effect of DMSO animals were instilled with either 50% DMSO or saline 6 hours after PS instillation. To evaluate the effect of DMSO in healthy bladders, rats were instilled with 50% DMSO and controls with saline. RESULTS: In the PS groups, bladder inflammation was observed, with polymorphonuclear cells during the first days and lymphomononuclear in the last days. HA and S-GAG had 2 peaks of urinary excretion, at the 1st and 7th day after PS injection. DMSO significantly reduced bladder inflammation. In contrast, in healthy bladders, DMSO produced mild inflammation and an increase in urinary HA levels after 1 and 7 days and an increase of S-GAG level in 7 days. Animals instilled with PS and treated with DMSO had significantly reduced levels of urinary HA only at the 1st day. Urinary S-GAG/Cr levels were similar in all groups. CONCLUSIONS: Increased urinary levels of GAG were associated with bladder inflammation in a PS-induced cystitis model. DMSO significantly reduced the inflammatory process after urothelial injury. Conversely, this drug provoked mild inflammation in normal mucosa. DMSO treatment was shown to influence urinary HA excretion.

Genital prevalence of HPV types and co-infection in men

Introduction: HPV infection is a highly prevalent sexually transmitted disease and there is evidence of the relationship of HPV infection and the development of genital warts, penile intraepitelial neoplasia, invasive penile carcinoma and cervical cancer. However, there is sparse data regarding the prevalence of HPV types and co-infection of different HPV types among men. Objectives: To assess the prevalence of HPV subtypes infections and rates of co-infection among men. Materials and Methods: 366 men were evaluated from March to October 2010. Men were referred to our institution for HPV diagnostic evaluation based on the following criteria: 1. presence of a genital wart; 2. presence of an atypical genital lesion; 3. absence of symptoms and a partner with a HPV diagnosis; 4. absence of symptoms and a desire to undergo a full STD diagnostic evaluation. Genital samples were collected from the urethra, penile shaft, scrotum and anus with Digene® collection and preservation kit and submitted to HPV genotype microarray detection (Papillocheck®). All men were tested for the low-risk HPV types 6-11-40-42-43-44 and for the high-risk HPV types 16-18-31-33-35-39-45-51-52-53-56-58-59-66-68-70-73-82. Results: Of the 366 men, 11 were tested inconclusive and were excluded from the analysis. 256 men (72.1% of the men from the cohort referred to our institution) tested positive with genotype micro-array detection and 99 tested negative. The most prevalent HPV-subtypes in the studied population were 6, 42, 51 and 16. Co-infection was found in 153 men. Of those, 70 (19.7%) had a co-infection by 2 types, 37 (10.4%) by 3 types; 33 men (9.2%) by 4 types; 8 men (2.2%) by 5 types; 1 man (0.3%) by 6 types; 1 man (0.3%) by 7 types; 2 men (0.6%) by 8 types and 1 man (0.3%) by 9 types. Conclusion: The most frequent HPV types were 6, 16, 42 and 51. Co-infection was found in 59% of our patients. This information is vital to drive future public health ...

Urinary glycosaminoglycans as biomarker for urothelial injury: is it possible to discriminate damage from recovery?

OBJECTIVES: The glycosaminoglycan (GAG) layer is referred to as a bladder protective factor. We reproduced an experimental model of urothelial damage to assess GAG metabolism in the process of injury and recovery of the urothelium. METHODS: Wistar female rats were bladder catheterized and instilled with either protamine sulfate (PS groups) or sterile saline (control groups). At different days after the procedure, 24-hour urine samples were obtained. The urinary levels of hyaluronic acid (HA) and sulfated glycosaminoglycan were determined in all groups and in nonmanipulated rats (day 0). Additionally, sulfated-GAG synthesis was assessed by the incorporation of [(35)S]-inorganic sulfate. The bladders were analyzed by histochemical staining for HA and immunofluorescence for heparin sulfate and syndecan-4. RESULTS: Urinary HA and sulfated-GAG were elevated after PS injection (P <0.05). A greater concentration of [(35)S]-labeled GAG in the PS group animals on the fifth day and, especially, on the seventh day represented increased GAG synthesis at these periods (P <0.05). Bladder sections from the PS group animals on day 1 showed a greater amount of HA in the urothelium. PS instillation damaged the urothelium layer of heparin sulfate and syndecan-4 seen in the control animals. On day 5, patchy areas of a restored layer were seen, and, on day 7, this layer had completely regenerated. CONCLUSIONS: Urinary GAG cannot differentiate urothelial damage from recovery. Elevated levels of urinary GAG can result from either desquamation of the surface cell GAG layer or increased GAG synthesis to regenerate the damaged urothelium.

Assessment of urodynamic bladder behavior on filling with solutions representing physiological extremes of urinary osmolarity.

OBJECTIVE: Verify if there is any difference in sensitive and motor bladder response in the presence of solutions with different osmolarities, simulating physiological extremes of urinary osmolarity. MATERIALS AND METHODS: Thirty-three patients (24 men and 9 women) with mean age of 46.4 years (8 to 87 years) took part in this study. They were all subjected to 2 consecutive urodynamic examinations. In each exam, the vesical filling was accomplished by using a hyperosmolar (1000 mOsm/L) or hypo-osmolar (100 mOsm/L) sodium chloride solution in similar speed. The sequence in which each solution was instilled was determined by a double blind draw. The urodynamic results obtained from the infusion of both solutions were compared, regardless the sequence of administration. RESULTS: Fifteen patients (45.4%) showed detrusor hyperactivity, 12 of whom with neurological antecedents. The mean age of those with detrusor hyperactivity was 45.8 years, against 46.9 for those without hyperactivity. The infusion of the hyperosmolar/hypo-osmolar solution generated the following results, when comparing patients without vs. with detrusor hyperactivity: initial sensation of vesical filling (mL): 167.5/159.2 vs. 134.9/157.3 (p > 0.05); volume of occurrence of the first involuntary bladder contraction (mL): 163.9/151.9 (p > 0.05); detrusor micturition pressure (cm H2O): 24.0/24.4 vs. 13.8/27.5 (p > 0.05). CONCLUSION: The vesical filling with solutions simulating extreme urinary osmolarities, accomplished with similar speed and without previous identification, did not likewise alter the sensitive and motor urodynamic behavior in the current study.

Male infertility in spinal cord trauma.

Every year there are 10 thousand new cases of patients victimized by spinal cord trauma (SCT) in the United States and it is estimated that there are 7 thousand new cases in Brazil. Eighty percent of patients are fertile males. Infertility in this patient group is due to 3 main factors resulting from spinal cord lesions: erectile dysfunction, ejaculatory disorder and low sperm counts. Erectile dysfunction has been successfully treated with oral and injectable medications, use of vacuum devices and penile prosthesis implants. The technological improvement in penile vibratory stimulation devices (PVS) and rectal probe electro-ejaculation (RPE) has made such procedures safer and accessible to patients with ejaculatory dysfunction. Despite the normal number of spermatozoa found in semen of spinal cord-injured patients, their motility is abnormal. This change does not seem to be related to changes in scrotal thermal regulation, frequency of ejaculation or duration of spinal cord damage but to factors related to the seminal plasma. Despite the poor seminal quality, increasingly more men with SCT have become fathers through techniques ranging from simple homologous insemination to sophisticated assisted reproduction techniques such as intracytoplasmic sperm injection (ICSI).

Combined vaginoscopy-cystoscopy: a novel simultaneous approach improving vesicovaginal fistula evaluation.

PURPOSE: Using a device that permits simultaneous viewing on the same display (picture in picture) of 2 images we performed combined vaginoscopy-cystoscopy (CVC) during evaluation for vesicovaginal fistula as a means of better visualization, allowing more precise identification and better preoperative planning. MATERIALS AND METHODS: A regular cystoscope and a 10 mm 0-degree laparoscope were used. Each was attached to a different microcamera and light source. The cameras were hooked to the back of a Twinvideo (Karl Storz Endoscopy, Tuttlingen, Germany), allowing a wide variety of views combining the 2 images. Cystoscopy was performed as usual and the laparoscope was used for vaginoscopy with a transparent vaginal speculum to maintain the vagina open, while allowing visualization of the vaginal wall. The 2 images were combined in picture in picture, providing confidence during the fistula identification process. Urinary leakage was viewed simultaneously with guide wire passage through the cystoscope and vaginal wall, showing the exactly fistula position. RESULTS: The CVC procedure using 2 images in picture in picture allows precise identification during evaluation for vesicovaginal fistula. CONCLUSIONS: CVC has become a routine procedure in suspicious cases or in those of a confirmed diagnosis of vesicovaginal fistula at our institution. It increases the likelihood of fistula diagnosis and identification, allowing better surgical planning.

Urinary glycosaminoglycans excretion and the effect of dimethyl sulfoxide in an experimental model of non-bacterial cystitis

PURPOSE: We reproduced a non-bacterial experimental model to assess bladder inflammation and urinary glycosaminoglycans (GAG) excretion and examined the effect of dimethyl sulfoxide (DMSO). MATERIALS AND METHODS: Female rats were instilled with either protamine sulfate (PS groups) or sterile saline (control groups). At different days after the procedure, 24 h urine and bladder samples were obtained. Urinary levels of hyaluronic acid (HA) and sulfated glycosaminoglycans (S-GAG) were determined. Also to evaluate the effect of DMSO animals were instilled with either 50 percent DMSO or saline 6 hours after PS instillation. To evaluate the effect of DMSO in healthy bladders, rats were instilled with 50 percent DMSO and controls with saline. RESULTS: In the PS groups, bladder inflammation was observed, with polymorphonuclear cells during the first days and lymphomononuclear in the last days. HA and S-GAG had 2 peaks of urinary excretion, at the 1st and 7th day after PS injection. DMSO significantly reduced bladder inflammation. In contrast, in healthy bladders, DMSO produced mild inflammation and an increase in urinary HA levels after 1 and 7 days and an increase of S-GAG level in 7 days. Animals instilled with PS and treated with DMSO had significantly reduced levels of urinary HA only at the 1st day. Urinary S-GAG/Cr levels were similar in all groups. CONCLUSIONS: Increased urinary levels of GAG were associated with bladder inflammation in a PS-induced cystitis model. DMSO significantly reduced the inflammatory process after urothelial injury. Conversely, this drug provoked mild inflammation in normal mucosa. DMSO treatment was shown to influence urinary HA excretion.

Assessment of urodynamic bladder behavior on filling with solutions representing physiological extremes of urinary osmolarity

OBJECTIVE: Verify if there is any difference in sensitive and motor bladder response in the presence of solutions with different osmolarities, simulating physiological extremes of urinary osmolarity. MATERIALS AND METHODS: Thirty-three patients (24 men and 9 women) with mean age of 46.4 years (8 to 87 years) took part in this study. They were all subjected to 2 consecutive urodynamic examinations. In each exam, the vesical filling was accomplished by using a hyperosmolar (1000 mOsm/L) or hypo-osmolar (100 mOsm/L) sodium chloride solution in similar speed. The sequence in which each solution was instilled was determined by a double blind draw. The urodynamic results obtained from the infusion of both solutions were compared, regardless the sequence of administration. RESULTS: Fifteen patients (45.4 percent) showed detrusor hyperactivity, 12 of whom with neurological antecedents. The mean age of those with detrusor hyperactivity was 45.8 years, against 46.9 for those without hyperactivity. The infusion of the hyperosmolar/hypo-osmolar solution generated the following results, when comparing patients without vs. with detrusor hyperactivity: initial sensation of vesical filling (mL): 167.5 / 159.2 vs. 134.9 / 157.3 (p > 0.05); volume of occurrence of the first involuntary bladder contraction (mL): 163.9 / 151.9 (p > 0.05); detrusor micturition pressure (cm H2O): 24.0 / 24.4 vs. 13.8 / 27.5 (p > 0.05). CONCLUSION: The vesical filling with solutions simulating extreme urinary osmolarities, accomplished with similar speed and without previous identification, did not likewise alter the sensitive and motor urodynamic behavior in the current study.

Male infertility in spinal cord trauma

Every year there are 10 thousand new cases of patients victimized by spinal cord trauma (SCT) in the United States and it is estimated that there are 7 thousand new cases in Brazil. Eighty percent of patients are fertile males. Infertility in this patient group is due to 3 main factors resulting from spinal cord lesions: erectile dysfunction, ejaculatory disorder and low sperm counts. Erectile dysfunction has been successfully treated with oral and injectable medications, use of vacuum devices and penile prosthesis implants. The technological improvement in penile vibratory stimulation devices (PVS) and rectal probe electro-ejaculation (RPE) has made such procedures safer and accessible to patients with ejaculatory dysfunction. Despite the normal number of spermatozoa found in semen of spinal cord-injured patients, their motility is abnormal. This change does not seem to be related to changes in scrotal thermal regulation, frequency of ejaculation or duration of spinal cord damage but to factors related to the seminal plasma. Despite the poor seminal quality, increasingly more men with SCT have become fathers through techniques ranging from simple homologous insemination to sophisticated assisted reproduction techniques such as intracytoplasmic sperm injection (ICSI).