Hemospermia: review of the management with 5 years follow-up.

OBJECTIVE: To review our experience with hemospermia and a long term follow-up. MATERIAL AND METHOD: Medical records of patients with hemospermia treated at the Division of Urology, Ramathibodi Hospital between 1993 and 1995 were reviewed. Clinical presentation, investigation, diagnosis, treatment, outcomes and long term follow-up were noted. RESULTS: Sixty-eight patients were found and completed follow-up to 5 years. The mean age was 40 years (range 28-62). Physical examination including DRE and urine examinations were done in all of the cases. Special investigations such as PSA, TRUS, IVP and cystourethroscopy were performed in selected cases. Prostatitis was found in 27.9 per cent, tuberculosis in 4.4 per cent, sexually related causes in 5.8 per cent and idiopathic in 61 per cent No malignancy was found in this study. Hypertension was found in 7.3 per cent of the patients. Thirty-two per cent had recurrent episodes of hemospermia. Specific treatment was used only for prostatitis and tuberculosis. No specific treatment was used for the idiopathic group. CONCLUSIONS: Hemospermia is a benign condition. Most of the causes were from idiopathic and inflammation. Only simple investigation was needed and treatment was recommended depending on the diagnosis and no specific treatment was needed for idiopathic cause.

Pubovaginal sling for the treatment of female stress urinary incontinence: experience of 100 cases at Ramathibodi Hospital.

OBJECTIVE: To evaluate the outcome of pubovaginal sling procedure for treatment of female stress urinary incontinence. MATERIAL AND METHOD: From September 1997 to January 2000, one hundred consecutive patients with urodynamically proven stress incontinence had a pubovaginal sling procedure performed. Operative technique, intraoperative and post-operative complications, voiding patterns, residual urine as well as the follow-up course were reviewed. RESULTS: Of one hundred cases, the mean patient age was 52.6 years old (range 34-73). The etiologies of stress incontinence were 85 cases of urethral hypermobility and 15 cases of intrinsic sphincter deficiency (ISD). Eighteen cases were after failure of prior continence procedures. No intraoperative and post-operative complications were found except one case of wound infection. Minimal bleeding was noted. Marked post-operative residual urine (>100 ml) was found in 39 cases and clean intermittent catheterization was used. The mean time for catheterization was 8.9 weeks (range 2-12 weeks). The mean time to follow-up was 12.1 months (range 4-36 months). Ninety-four cases had been completely dried in the follow-up period since the last visit and 5 cases had much improvement of incontinence using only 1-2 pads/day. Only one case was found to have failed the procedure. De novo instability was found in 5 cases. CONCLUSION: On the basis of these results, we propose that pubovaginal sling is an effective treatment for female stress incontinence with very few complications.

Ejaculatory duct obstruction in the infertile male: experience of 7 cases at Ramathibodi Hospital.

OBJECTIVE: To study the clinical presentations, management, outcomes as well as pregnancy rate of ejaculatory duct obstruction treated at the Division of Urology, Ramathibodi Hospital. MATERIAL AND METHOD: This retrospective study was done from 1980 to 1999 and information from the medical records of the patients of ejaculatory duct obstruction was obtained. Phone and mail were used for long-term follow-up. RESULTS: Seven male patients with ejaculatory duct obstruction were identified. The age ranged from 32-45 years old (mean 34.5). All of the patients had azoospermia without other symptoms related to ejaculatory duct obstruction such as painful ejaculation, perineal or testicular pain. Normal testicles and secondary sex characteristics were noted in all. Seventy-one per cent had normal hormonal profiles and twenty-nine per cent had a slight increase of FSH, LH but not more than one fold of normal range. Vasography was used as the diagnosis tool in all of the cases and 71 per cent of seminal vesicles were >1.5 cm in diameter and all the rest were 1 cm in diameter. Transurethral resection of ejaculatory duct (TURED) was done in 6 cases and transurethral incision of ejaculatory duct (TUIED) was done in 1 case. Semen analysis was done in the third month after operation and 4 of 7 (57%) showed improvement of semen analysis but another 3 cases (43%) still had azoospermia. Six months after operation 6 of 7 (86%) showed improvement of semen analysis. Up to one year, 6 of 7 (86%) have normal semen analysis and another one still had azoospermia. In the long-term follow-up, 4 of 7 (57%) were able to impregnate their wives. CONCLUSIONS: Ejaculatory duct obstruction is a treatable cause of male infertility. In an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes and normal hormonal profiles, ejaculatory duct obstruction is suggested. Transrectal ultrasonography (TRUS) and/or vasography can be done to confirm the dilatation of seminal vesicles and obstruction of the ejaculatory duct. Transurethral resection of the ejaculatory duct (TURED) has resulted in marked improvement in semen parameters, and pregnancies have been achieved.

Risk factors for stress urinary incontinence in middle aged and elderly Thai women.

OBJECTIVE: To determine risk factors of stress urinary incontinence in middle aged and elderly Thai women. MATERIAL AND METHOD: Between March 1999 and January 2000, 46 women with stress urinary incontinence (SUI) with the mean age of 49.05 years old and 168 continent women with the mean age of 49.05 years old were interviewed. The risk factors (e.g. cigarette smoking, childbirth, menopausal status, family history, previous abdominal hysterectomy, transvaginal surgery and body mass index) were studied. The Chi Square or Fisher exact test were used for statistical analysis and p<0.05 was considered as a level of statistical significance. Odds Ratio (O.R.) and its 95 per cent confidence of interval was calculated. RESULTS: The study suggested that menopausal status, childbirth, previous abdominal hysterectomy, transvaginal surgery and family history had no correlation with SUI. The risk factor of body mass index (BMI) > or = Kg/m2 had statistical correlation with SUI. (p=0.000, O.R.=3.570, 95% C.I. of O.R.=1.779 to 7.163). No smokers were found among the studied group so this factor could not be evaluated. CONCLUSIONS: Body mass index was the only identified risk factor of SUI in middle aged and elderly Thai women.

Stricture of the male urethra: 29 years experience of 323 cases.

The authors reported 323 cases of male urethral stricture managed at Ramathibodi Hospital from 1969 to 1998 (29 years period). Etiology included traumatic causes 237 (73%) and post infection 54 cases (16%). The managements were urethroplasties 281 cases (87%), urethrotomy 21 cases (6%) and dilatation 21 cases (6%). The over all successful rate of urethroplasty was 89 per cent. The mean follow-up time was 2.5 years (0.5-15 years).

Urethral diverticulum in females: 25 years experience at Ramathibodi Hospital.

We retrospectively reviewed the urethral diverticulum in females from 1972 to 1997. Sixty seven patients were found in this study. Nine per cent were nulliparous and the rest were multiparous with the mean of 2.2 births (range 1-6). Voiding cystourethrography and intravenous pyelography were the main diagnostic investigations (92.4%). Stones in the diverticulum were found in 4.4 per cent. The treatment included marsupialization for the diverticulum at distal urethra in 14 per cent and diverticulectomy for the diverticulum at middle and proximal urethra in 86 per cent. The complications included 1.4 per cent of stress incontinence and 4.4 per cent of recurrent infection.

Vesico-vaginal fistula: experience of 230 cases.

We reviewed 230 cases of vesico-vaginal fistula in Ramathibodi Hospital from 1969 to 1997. The cases of fistula included 164 cases after transabdominal hysterectomies, 5 cases after anterior colporrhaphies, 8 cases after radical hysterectomy, 23 cases after vaginal hysterectomy, 10 cases after prolonged or traumatic birth, 9 cases after radiation for cervical carcinoma, 7 cases of cervical cancer invasion, 2 cases after suprapubic cystolithotomy and 2 cases after pelvic fracture. Most of them were referred from other hospitals. In 7 cases, the fistula closed spontaneously after indwelling urethral catheters for 4-6 weeks. Five cases were cured after transurethral fulgurations. The rest were treated with different surgical procedures i.e. transvaginal, transvesical and retrovesical repairs. Ten cases were treated by urinary diversions, usually after failure using other surgical procedures.

The usage of Andrographis paniculata following Extracorporeal Shock Wave Lithotripsy (ESWL).

One hundred consecutive cases with renal stones less than 3 cm in size and normal renal function underwent ESWL from January to March 1994. Out of these, 50 were given Andrographis paniculata tablets (250 mg), 4 tablests tid, 25 were given cotrimoxazole 2 tablets bid and 25 received norfloxacin 200 mg bid, started immediately after ESWL and continued for 5 days. All tolerated the treatment well and none had complications. At one month follow-up, pre- and post-ESWL pyuria, hematuria and proteinuria among the Andrographis paniculata group were 84, 58, 72, 40, 52, 22 per cent; the cotrimoxazole group 88, 64, 84, 64, 56, 44 per cent and the norfloxacin group 92, 56, 72, 40 per cent and 56, 28 per cent respectively. The results showed that post ESWL pyuria and hematuria in patients receiving Andrographis peniculata were reduced to 0.69 and 0.55 time of pre ESWL value. We think that this herbal medicine is beneficial in the treatment of post ESWL urinary tract infection. Besides the herbal drug given to eighteen previously sulfa sensitized patients resulted in no allergic reaction.

Urinoma, a case report with unusual presentation.

A case of urinoma in a 28-year-old man who had received blunt abdominal injury was reported. This urinoma developed from the detached but still functioned upper pole of the right kidney. The misdiagnosis from the previous surgical exploration and subsequent investigations thus delayed the proper management.

Promotion of vasectomy in Thailand.

Though vasectomy plays an important great role in the national family planning program, its popularity has been very low in the past requiring a lot of promotion. During the promotion phase of 1972 to 1984, various methods were used with the stress on mobile vasectomy campaign. However, after 1984, there was evidence of deceleration of vasectomy rate. In this phase, non-scalpel vasectomy has been promoted including the training courses for physicians in provincial hospitals and local health centers. It is expected that vasectomy will gain better acceptance in the future.