Male-female differences in the risk of tuberculosis in dialysis patients.

AIM: To define any gender-related differences in the prevalence and risk for tuberculosis (TB) in hemodialysis (HD) patients. METHODS: All active TB cases were recorded during a 36-month follow-up of 272 (193 male and 79 female) HD patients. Entering the study, HD patients were tested with tuberculin and 2,4-dinitrochlorobenzene, and a cell-mediated immunity (CMI) index was estimated. Relative risks (RR) for TB were calculated considering subjects from the background general population as a reference group. The independent effect of age, BMI and tuberculin sensitivity was determined using Cox's proportional hazard model. RESULTS: Female HD patients presented significantly lower CMI indices and rates of positive Mantoux tests, but higher rates of DM, as compared to males. The male:female ratio in TB for the general and HD patients population was 1.8 and 0.6, respectively. There was a significantly lower TB prevalence in male as compared to female HD patients (7.7% vs. 11.3%), and a subsequent female predominance in risk for TB in those HD patients aged <49 and 50-69 years (M:F adjusted relative risk 0.67 and 0.53) was recorded. CONCLUSIONS: In contrast to the general population, there is a female predominance among dialysis TB patients younger than 70 years associated with the coexistence of DM. Female gender should always be considered as a risk factor when evaluating diabetic HD patients for active TB.

Primary adrenal tuberculosis: role of computed tomography and CT-guided biopsy in diagnosis.

A case of isolated, bilateral, adrenal tuberculosis is presented. A 25-year-old male was admitted to the hospital due to lumbar pain, fever, weight loss and anorexia. Abdominal ultrasonography and computed tomography demonstrated bilateral adrenal enlargement. Laboratory investigations were remarkable for adrenal insufficiency. The Mantoux reaction was positive but there was no evidence of lung or urinary infection. CT-guided biopsy of the left adrenal gland was performed and established the diagnosis of adrenal tuberculosis.

Risk of tuberculosis in dialysis patients: association of tuberculin and 2,4-dinitrochlorobenzene reactivity with risk of tuberculosis.

BACKGROUND: Dialysis patients are at increased risk of tuberculosis (TB) and anergy due to attenuated cellular immunity. AIM: To define specific risks of TB in anergic and non-anergic dialysis patients. METHODS: A total of 272 dialysis patients were enrolled in this prospective study over a 36-month follow-up. Entering the study, participants had Mantoux and 2,4-dinitrochlorobenzene skin tests and their cell-mediated immunity (CMI)-index was estimated. Patients were classified as anergic (CMI-index

The relationship between the perineal length measurements and the urodynamic stress incontinence.

OBJECTIVE: The purpose of this study was to assess the relationship between the length of perineal body, the anal position index, the total fourchette-coccyx distance and the anal-coccyx length and female urodynamic stress urinary incontinence (USUI). PATIENTS AND METHODS: The study included 57 women with USUI (group A) and 45 women without USUI as control (group B). All patients underwent a urodynamic evaluation and measurement of the length of perineal body (PB) and the distance between the fourchette and the inferior margin of coccyx (FC). PB is the distance between the fourchette and the center of anal orifice. The ratio PB/FC is the anal position index. Subtracting the PB length from FC distance equals the anal-coccyx (AC) length. RESULTS: The student's t-test showed no significant statistical difference between any of the measured lengths in the two groups. Moreover, in the USUI group, ANOVA did not show any significant relationship between the urodynamic parameters and the measured lengths. Regarding to the investigated urodynamic parameters only the maximum urethral pressure (Pura max) presented a significant statistical difference between the two groups (P = 0.009). CONCLUSION: Theoretically, a differentiation of perineal distances probably brings to the surface a laxity of the pelvic floor, a factor predisposing to USUI. Furthermore, the anterior position of anus can be a cause of constipation which also contributes to USUI. However, our study did not reveal any relationship between the perineal length measurements and USUI. Further investigation with longer series of patients is needed to show if this simple, inexpensive and non-invasive test could be added in the armamentarium of the diagnostic and prognostic investigation of USUI. Regarding to the urodynamic parameters, our results emphasize the importance of the Pura max parameter in the urodynamic evaluation of USUI.

Comparison of the efficacy of tolterodine and oxybutynin in different urodynamic severity grades of idiopathic detrusor overactivity.

OBJECTIVE: To compare the efficacy of tolterodine and oxybutynin in the treatment of specific, according to their urodynamic grade of severity, populations with overactive detrusor. METHODS: In this open, randomized, two-way crossover study 128 women with urodynamically confirmed, idiopathic detrusor overactivity were recruited. Patients were categorized in 4 grades of severity groups, according to the characteristics of the first overactive detrusor contraction during filling cystometrogram: high volume-low pressure (grade-group I), high volume-high pressure (grade-group II), low volume-low pressure (grade-group III) and low volume-high pressure (grade-group IV). The primary outcome measure was average volume of voided urine per micturition. RESULTS: 107 patients successfully completed the study protocol and were included in the analyses: 40 in group IV, 36 in III, 25 in II and 6 in group I. In groups IV and III both oxybutynin and tolterodine significantly increased the average volume of voided urine per micturition but the differences between the drugs were not significant (p > 0.05). In group II neither of the drugs achieved significant changes in the outcome measure (p > 0.05). CONCLUSIONS: Tolterodine and oxybutynin are clinically equipotent in treating detrusor overactivity in specific severity groups of patients, although urodynamic effects are somewhat different.

Assessment of encrustations on polyurethane ureteral stents.

PURPOSE: To determine the composition and the extent of crystalline (and other) encrustation on ureteral catheters inserted under sterile conditions in stone formers, in comparison with catheters of the same type inserted in nonstone formers for the same time but for different clinical reasons. MATERIALS AND METHODS: Forty consecutive self-retained polyurethane pigtail ureteral catheters removed by cystoscopy between November 2000 and February 2002 were studied, 30 from stone formers and 10 from patients without stone histories. The mean dwelling time was 55 days for the stone formers and 79 days for the other patients. The encrustations were collected and analyzed with Fourier-transform infrared spectroscopy, powder X-ray diffraction, or both. The stones from nine of the patients were also subjected to the same spectroscopic analysis. Representative sections of the catheters were investigated by scanning electron microscopy and energy-dispersive X-ray analysis. RESULTS: The most common encrustation in stone formers was calcium oxalate monohydrate. In patients without stones, deposits of organic compounds were found consistently. The mean mass of encrustation of stone formers was larger (71.05 mg) than that of patients without stones (1 mg). CONCLUSIONS: Calcium oxalate is the predominant type of encrustation on ureteral catheters in stone formers. Prevention of heavy encrustation should be directed to therapeutic measures concerning calcium oxalate lithiasis and development of new materials by the medical industry that are less prone to encrustation.

Paranephric abscess during pregnancy: a case for a low-dose interventional CT.

A young pregnant woman hospitalized in our department with sepsis due to a paranephric abscess, and treated successfully with a nephrostomy under the guidance of low-dose CT, is presented. Based on this successful and safe treatment for the fetus, it is proposed that low-dose CT can be applied without any risk to pregnant women with special urological problems such as paranephric and splenic abscesses, dysmorphic and ectopic or horseshoe kidneys.

Vardenafil (Levitra) for erectile dysfunction: a systematic review and meta-analysis of clinical trial reports.

Trials of the efficacy and safety of vardenafil in the treatment of male erectile dysfunction (ED) were meta-analysed. All available databases were searched (January 1, 2001-November 30, 2003). Trials were eligible if they included men with ED, compared vardenafil with placebo, were randomized, were at least of 12 weeks duration, and assessed clinically relevant outcomes. Two reviewers independently evaluated study quality and extracted data in a standardized fashion. Nine trials (6809 men) met the inclusion criteria. In results pooled from seven fixed-dose trials, vardenafil increases the Erectile Function domain of the International Index of Erectile Function questionnaire by 6.18 units (weighted mean difference (WMD)). Vardenafil also increases the percentage of erections firm enough to allow vaginal penetration (WMD: 26) and the percentage of sexual attempts that were successful per participant (WMD: 29.8). The percentage of men agreeing with the statement that 'the treatment they have been taking over the past 4 weeks improved their erections', is also in favour of vardenafil (relative risk (RR): 3). These efficacy variables appeared greater at higher doses, although there are no significant differences between 10 and 20 mg dose. The same results were extracted for the two flexible 'as needed' dosing trials. Discontinuations are greater at the vardenafil groups compared to placebo (RR: 2.25). Specific adverse events with vardenafil included flushing, dyspepsia, headache, and rhinitis. Vardenafil was not significantly associated with serious cardiovascular events or death. Vardenafil, in all treatment regimens, shows to possess superior efficacy to placebo in the treatment of patients with erectile dysfunction. More data is needed on patients' subgroups.

Efficacy of apomorphine and sildenafil in men with nonarteriogenic erectile dysfunction. A comparative crossover study.

To compare the efficacy of apomorphine and sildenafil in men with nonarteriogenic erectile dysfunction (ED), 40 men were studied. Post-injection penile peak systolic velocity was greater than 25 cm s(-1). Twenty men started on apomorphine 2 mg and 20 on sildenafil 50 mg, the doses titrated up to 3 and 100 mg, respectively, if necessary. After a 1-week washout period each group switched to the other treatment mode. Efficacy was the percentage of attempts resulting in erections firm enough for intercourse, based on an event log data. The majority (85%) of the men had concomitant diseases, risk factors for ED and 95% were heavy smokers. The overall success rate of apomorphine was 62.7%, compared with 73.1% of sildenafil (Yates-corrected chi-square, P < 0.0004). The response to apomorphine 2 mg and sildenafil 50 mg was age related. Sildenafil was statistically more effective than apomorphine in impotent men with normal penile Doppler. Given the contraindication of sildenafil in men taking nitrates and the quick time of action of apomorphine, the two drugs are satisfactory first line therapeutic tools in such individuals and the choice should be based on patient's needs and preferences.

Erectile dysfunction in men with obstructive sleep apnea syndrome: a randomized study of the efficacy of sildenafil and continuous positive airway pressure.

The aim of this study was to compare the efficacy of sildenafil and continuous positive airway pressure (CPAP) in men with erectile dysfunction (ED) and obstructive sleep apnea syndrome (OSAS). In all, 30 men were randomly treated for 12 weeks either with sildenafil 100 mg before intercourse (15 men) or CPAP during night time sleep (15 men). Under sildenafil, 97/180 (53.9%) of attempted intercourses were successful compared to 33/138 (23.9%) under CPAP. The mean IIEF (erectile function domain score) was 12.9 and 9.3 after sildenafil and CPAP treatment, respectively (P=0.007), compared to 7.9 and 7 at baseline. In all, 53.3% of patients were satisfied with sildenafil and 20% with CPAP for ED treatment (P=0.058). Although sildenafil was superior to CPAP, comorbidities and OSAS per se possibly resulted in a lower effectiveness of sildenafil compared to that in the general population of ED men. While about half of the patients were not satisfied even with the more effective treatment, we conclude that a combination of the two therapeutic tools or a different therapeutic mode should be studied further.

A comparative, crossover study of the efficacy and safety of sildenafil and apomorphine in men with evidence of arteriogenic erectile dysfunction.

The aim of the study was to establish and compare the efficacy and safety of sildenafil and apomorphine in men with arteriogenic erectile dysfunction (ED). In all, 43 men with ED and postinjection max penile systolic velocity <25 cm/s in repeated Doppler ultrasonography were included. Of these, 24 men started on apomorphine 2 mg and 19 on sildenafil 50 mg, the doses titrated up to 3 and 100 mg according to effectiveness and tolerability. Safety was evaluated according to adverse events (AEs) and patient withdrawal. Efficacy was the percentage of attempts resulting in erections firm enough for intercourse, based on event log data. The incidence of AEs with apomorphine 3 mg was higher than with sildenafil 100 mg. Two men on apomorphine 3 mg discontinued treatment due to AEs. The overall success rate of sildenafil was 63.7% compared to 32.1% of apomorphine (Pearson chi(2), P<0.01). Of all men, 25 (58.1%) responded to sildenafil 50 mg without the need for dose increase, while only one responded to apomorphine 2 mg. The response to sildenafil 50 mg was age related (analysis of variance, p=0.04). Satisfaction was reported by 76.75 and 13.95% of patients for sildenafil and apomorphine, respectively, but 20.9% were not satisfied with any of the two drugs. In conclusion, this study provides clear evidence that sildenafil, even at 50 mg dose, is more effective than apomorphine 3 mg in men with arteriogenic ED. The fact that one out of five patients is not satisfied with the above-studied drugs shows that new oral agents need to be evaluated for the treatment of this disorder.

Gabapentin in the management of the recurrent, refractory, idiopathic priapism.

Recurrent idiopathic priapism is a difficult problem to treat and a true emergency for the physicians, and often even invasive therapeutic interventions fail. We recently managed three men with refractory idiopathic priapism with oral gabapentin. They responded to treatment within 48 h. Two men continue not to experience prolonged erections while treated with lower doses of gabapentin for 16 and 24 months, respectively. The third, after a successful treatment for 6 months, stopped gabapentin and priapism recurred. He responded to treatment again and continues to be free of episodes for 9 months. Gabapentin may be a safe alternative for the management of refractory idiopathic priapism.

Long-term results of transvaginal colposuspension for the treatment of genuine stress incontinence combined with vaginal hysterectomy.

We assessed the long-term efficacy of a modified transvaginal needle bladder neck suspension, combined with vaginal hysterectomy, for the treatment of female stress incontinence. Thirty-two women who underwent this procedure were followed up clinically and urodynamically 1 and 5 years postoperatively. A total of 27 women (84.4%) were cured 1 year postoperatively. Of the 29 women who were followed up 5 years postoperatively, 21 (72.4%) had a satisfactory result (p = 0.157). No significant differences were observed in maximum urine flow rate, residual volume of urine, and functional length of the urethra. On the contrary, the maximum urethral closure pressure was significantly decreased (p = 0.004). Although the results of our study show a decline in success rate by time, the overall long-term efficacy of this technique is undoubtedly satisfactory. This technique is promising as an easy and minimally invasive surgical procedure for bladder neck suspension.

Combination treatment with an alpha-blocker plus an anticholinergic for bladder outlet obstruction: a prospective, randomized, controlled study.

PURPOSE: We evaluate the effect of tolterodine combined with tamsulosin on quality of life in patients with bladder outlet obstruction and concomitant detrusor instability. MATERIALS AND METHODS: The study included 50 consecutive patients with urodynamically proven mild or moderate bladder outlet obstruction and concomitant detrusor instability. All patients were initially treated with 0.4 mg. tamsulosin orally once a day. A week later the patients were randomly allocated into group 1-25 who continued treatment with tamsulosin only and, group 2-25 who also received 2 mg. tolterodine orally twice daily. Reevaluation with a quality of life questionnaire and urodynamic study was performed after 3 months. RESULTS: Two patients from group 2 stopped tolterodine while 1 patient from each group stopped tamsulosin because of hypotension. Analysis revealed statistically significant improvement in quality of life scores only in group 2 patients (mean score 525.0 and 628.4 before and after treatment, respectively, 2-sided t test p = 0.0003). A significant difference was noted in both groups after treatment for maximum flow rate and volume at first contraction. Additionally, in group 2, a statistically significant difference was observed for maximum detrusor pressure and maximum unstable contraction pressure after treatment. CONCLUSIONS: Combination treatment with an alpha-blocker (tamsulosin) plus an anticholinergic (tolterodine) improves quality of life in patients with bladder outlet obstruction and concomitant detrusor instability. Interestingly, no acute urinary retention was observed and tolterodine did not affect the quality of urine flow or residual urine volume. The proposed combination appears to be an effective and relatively safe treatment option in patients with bladder outlet obstruction and detrusor instability.

The use of the tissue adhesive enbucrilate (histoacryl) in the treatment of symptomatic nephroptosis.

PURPOSE: To evaluate the use of the tissue adhesive enbucrilate in the treatment of symptomatic nephroptosis. MATERIALS AND METHODS: We performed adhesive nephropexy in 9 patients who presented with well-documented symptomatic nephroptosis that was demonstrated with intravenous pyelography and/or radionuclide renogram studies. The ptotic kidney was fixed on the psoas muscle using 0.5 ml of enbucrilate (Histoacryl). RESULTS: Adhesive nephropexy was successful in all 9 patients. Average operative time was 37 min. Postoperative opioid analgesia duration and hospital stay were limited (mean 2 and 4.4 days, respectively). Most patients returned to normal activity within 2 weeks (mean 14.2 days). Mean follow-up was 25 months and showed postoperatively a good anatomical result in radiographic studies as well as significant pain alleviation (mean 1 vs. 7 preoperatively, on a 10-point scale, p < 0.005 Wilcoxon rank test). CONCLUSIONS: The tissue adhesive enbucrilate seems to be a safe, efficient agent to obtain good results in a simple, quick approach in the surgical treatment of symptomatic nephroptosis.

Switching from long-term treatment with self-injections to oral sildenafil in diabetic patients with severe erectile dysfunction.

OBJECTIVE: To assess the efficacy of oral sildenafil in diabetic men with severe erectile dysfunction (ED), who are successfully treated with intracavernous injections of vasoactive drugs. METHODS: 81 impotent diabetic men (29 with type 1 and 52 with type 2) were treated for 1-7 years with self-injections. 13 men were treated with 10 microg and 15 with 20 microg of prostaglandin E1 (PGE1), and 53 with a mixture of PGE1 20 microg and papaverine 7.5-40 mg (MIX). After a 1-week washout period, they changed to oral sildenafil in titrating doses up to 100mg. The change was successful if the man achieved an erection and penetration even once. RESULTS: Sildenafil was discontinued in 23 men because of insufficiency. Eleven men (13.6%), all with type 2 diabetes, responded to sildenafil (10 previously treated with 10 microg and 1 with 20 microg of PGE1, none treated with MIX). Thus, 39.2% of the treated with PGE1 responded to oral sildenafil. The response was influenced by the age, the type of diabetes (type 2) and the kind of the previously injected drug (PGE1 10 microg); it was not influenced by the duration of diabetes, ED and treatment with self-injections. CONCLUSIONS: Despite the well documented efficacy of sildenafil, self-injections continue to be the solely effective therapeutic modality in many diabetic men afflicted by severe ED. Only the younger men with non-insulin-dependent diabetes, treated with low doses of PGE1 are more likely to respond to oral sildenafil and change treatment. Men with insulin-dependent diabetes or treated with mixtures of vasoactive drugs are not likely to respond to oral sildenafil.

Penile lipomas, cause of sexual dysfunction.

We report 2 cases of penile lipomas. Although the simultaneous sexual dysfunction proved to be phsychogenic their surgical excision improved their sexual life.

Coated v noncoated ureteral metal stents: an experimental model.

PURPOSE: The purpose of the present study was to compare the standard metal stents with internally and externally coated metal stents in the pig model. MATERIALS AND METHODS: In nine female pigs weighing between 25 and 30 kg, the metal stents were randomly placed in either the right or left ureter, for a total of 18 stented ureters. Six ureters were stented with a Wallstent (Schneider, Zurich, Switzerland), six with a Passager stent (Boston Scientific, Natick, MA, USA), and six with a Corvita endoluminal graft (CEG) (Boston Scientific, Natick, MA, USA). Patency was examined by nephrostotomography 24 hours and 21 days after the initial procedure. RESULTS: Free flow of urine through the stents into the bladder was revealed in all ureters with the exemption of four cases where a Passager stent migrated into the bladder, jeopardizing ureteral patency. The Wallstent generated mild inflammation with metaplasia of the urothelium; the CEG a more pronounced inflammatory response in the adjacent ureter; and the Passager stent severe inflammatory reaction with necrosis of the urothelium. The sections of the Wallstents revealed the presence of a mild polypoid reaction adherent to the internal surface of the devices. The coated stents showed no tissue ingrowth through the lining material into the ureteral lumen, and thus, the urothelium was compressed beneath the prostheses. CONCLUSIONS: Our experimental results suggest that the standard Wallstent generates less inflammation of the surrounding tissues than coated stents. The coated stents have the advantage of minimal tissue ingrowth but have a tendency to migrate toward the bladder.

Diabetic impotence treated by intracavernosal injections: high treatment compliance and increasing dosage of vaso-active drugs.

AIMS: To compare patient compliance with treatment and the dosages of vaso-active drugs used, for the management of impotence in diabetic and non-diabetic patients. METHODS: Eighteen diabetic and a control group of 22 non-diabetic men were followed up regularly for 7 years after they had begun self-injections for severe erectile dysfunction. Rigiscan was used for the objective determination of the initial dosage and then doses were regulated in order to introduce an erection suitable for penetration and maintenance of erection for 30 min. RESULTS: Sixteen of 18 diabetic men are still using self-injections successfully after 7 years while of the 22 non-diabetic men, only 7 still continue injections. Compliance of diabetic men with treatment is significantly higher compared to the control group (p = 0.001). Doses of prostaglandin E(1) (PGE(1)) or mixtures of PGE(1) and papaverine (PAP) had to be increased over time. Although self-injections were a safe kind of treatment and no major complications were observed in both groups, a decrease in the frequency of injections was observed, particularly in the diabetic group, but this was not statistically significant (p = 0.15). CONCLUSIONS: Diabetic patients with severe erectile dysfunction have much higher compliance with self-injections than the non-diabetic patients. They respond initially to reasonable doses of PGE(1) but over time need increasing doses of PGE(1) or mixtures of PGE(1) and PAP. Frequent follow-up visits and the adjustment of dosage to continue the success of therapy may prevent patient dissatisfaction and drop-out from treatment. Patients treated with self-injections decrease the frequency of injections over time. They are satisfied with less frequent but successful intercourse and have a low risk of side-effects.

Urologic manifestations of multiple sclerosis: proposed treatment algorithms.

PURPOSE: A detailed clinical management of the urological manifestations of multiple sclerosis (MS) is presented as it is practiced in our department, and therapeutic algorithms are constructed. MATERIALS AND METHODS: One hundred and ten patients were consecutively and prospectively studied with a clinical syndrome of MS. ranging in age from 32 to 65 years of age. Clinical diagnosis of the voiding dysfunction associated with MS was classified as a malfunction causing either problems of bladder evacuation, or storage, or a combination of both. RESULTS: All patients were initially managed in a conservative way avoiding surgical procedures and following primarily pharmacologic treatment, because of the quite common reversibility of MS. The detailed management of the related voiding dysfunction is given by the proposed algorithms. CONCLUSIONS: Our purpose was to present the algorithms that can help the practicing physician to come to reasonable conclusions as to therapeutical choices directed to specific pathophysiologic characteristics of voiding dysfunction related to MS.