Cimetidine in painful bladder syndrome: a histopathological study.

OBJECTIVE: To determine whether oral cimetidine, which reportedly improves symptoms in 60-70% of patients with painful bladder syndrome/interstitial cystitis has a similar mechanism of action on the human bladder and involving a similar peptidergic pathway as it has in human stomach, where it alters histamine-gastrin reactions mediated via H2 receptors and a proton pump. PATIENTS AND METHODS: Fourteen patients (13 women and one man, mean age 51 years) with refractory bladder pain and irritative urinary symptoms were treated with cimetidine. The response to cimetidine was assessed by outpatient follow-up and an analogue pain score. Bladder biopsies from eight patients were stained with haematoxylin and eosin, and a polyclonal antibody to gastrin, with counterstaining using toluidine blue, to detect mast cell granules containing histamine. Biopsies from normal areas of the bladder from an age-matched control group of patients with transitional cell carcinoma of the bladder were stained similarly. Human stomach and colon were used as positive controls for gastrin and toluidine blue, respectively. The clinical response to cimetidine was compared with the histology in a blinded fashion. RESULTS: Eight of the patients responded well to cimetidine; none of the biopsies showed evidence of carcinoma in situ. Although G cells in the stomach stained well for gastrin none of the bladder biopsies showed gastrin-like immunoreactivity, apart from some nonspecific urothelial staining. Numerous mast cells with crimson granules and pale nuclei were visible in three patients and fewer in three others; their presence or absence did not correlate with the symptomatic response. CONCLUSIONS: Cimetidine is a useful medical treatment for bladder pain but the presence or absence of gastrin or histamine-like immunoreactivity does not explain its therapeutic benefit.

Incidence of Helicobacter pylori in patients with interstitial cystitis.

OBJECTIVE: Chronic gastritis has compelling similarities to interstitial cystitis (IC). It is characterised by chronic pain in a tubular organ. Histologically, epithelial damage, inflammatory response in the lamina propria and epithelial ulcerations are seen. An infective cause was rarely considered until the emergence of Helicobacter pylori over the past 15 years. We have had experience of patients with bladder pain and irritability reporting improvement with antihistamines. It has also been reported that IC symptoms improved dramatically after treatment for H. pylori infection. Previous studies have determined the incidence of H. pylori antibodies in women with IC but we examined bladder material histologically and performed the Campylobacter-like organism (CLO) test on the biopsy specimens. MATERIALS AND METHODS: A prospective controlled study was performed. Patients with urinary symptoms fulfilling the National Institute of Diabetes and Digestive and Kidney Diseases criteria for IC underwent GA cystoscopy at which the macroscopic appearance of the bladder was noted and biopsies were taken. The biopsy material underwent histological examination and CLO test. Control patients who were undergoing cystoscopy for reasons other than investigation of IC also had biopsy taken and the CLO test was performed on these specimens. RESULTS: Five of 15 patients with symptoms and signs of IC had a positive CLO test. Three of 15 patients of the control group had a positive CLO test. With the 2-sided chi(2) test there was no statistical difference between the 2 groups. CONCLUSION: Our small prospective control study does not support the hypothesis that H. pylori is an important component in the pathogenesis of interstitial cystitis.

A randomized cross-over study comparing the use of a catheter valve and a leg-bag in urethrally catheterized male patients.

OBJECTIVES: To evaluate the use of a catheter valve (CV) and a leg-bag (LB) in men with urethral catheters and to determine the preferred modality. PATIENTS AND METHODS: Eighteen men (mean age 71.4 years, SD 3.4, range 63-76) presenting in acute retention and catheterized urethrally were enrolled in a 6-week randomized cross-over study comparing the CV with the LB (3 weeks with each modality). The outcome was assessed using a questionnaire which quantified the incidence of bladder spasms, nocturnal frequency, the extent of any by-passing episodes and the degree of discomfort. At the end of the study, the patients were asked to express a preference (using a subjective scoring scale) for either the CV or the LB and to give the reasons why. RESULTS: There was no difference in the reported incidence of bladder spasms or discomfort and no difference in positive urine cultures with each modality. However, with the CV, there was a slightly higher incidence in nocturnal frequency and by-passing episodes. Thirteen patients preferred the CV whilst five preferred the LB. With the subjective scoring scale (range 0-10), the CV scored significantly higher than the LB (7.2, SD 3.1 and 5.2, SD 2.8, P < 0.05: paired t-test). CONCLUSIONS: Most patients preferred to use the CV, reporting that it felt more comfortable and discreet, and many patients did not like the sensation of urine 'sloshing about' when using the leg-bag. Some patients using the CV were troubled by nocturnal frequency. In these patients we suggest that a combination of a valve during the day and an overnight bag may be the ideal solution.

Massive intraperitoneal hemorrhage associated with renal pathology.

We report on 2 patients who presented with massive intraperitoneal hemorrhage. In spontaneous renal hemorrhage there is often an underlying pathological condition, usually renal carcinoma. The investigation of choice is computerized tomography, while arteriography is reserved for cases in which no renal mass is found. Nephrectomy may be life-saving but conservative treatment is an acceptable alternative when the underlying pathological condition is benign and the patient is in stable condition.

Renal function following surgical correction of vesico-ureteric reflux in childhood.

To assess the effectiveness of the surgical correction of vesico-ureteric reflux, current renal function was determined in 56 children with scarred kidneys who had undergone ureteric reimplantation between 1978 and 1983. The children were aged between 2 and 15 years, had no coexisting urological disease and a glomerular filtration rate (GFR) of less than 90 ml/min/1.73 m2. In the 32 patients who had bilateral reimplantation of ureters draining bilaterally scarred kidneys the improvement in GFR following surgery was highly significant (P less than 0.001), with improvement occurring in 75%. The greatest improvement was in patients where the GFR was less than 50 ml/min/1.73 m2 (29%). Individual kidney GFR was estimated in 42 kidneys and 81% improved after surgery. This improvement was highly significant (P less than 0.001).

Transvesical phenolisation of the pelvic plexuses: a simple technique for the treatment of refractory detrusor instability and hyperreflexia.

A simple endoscopic technique for the infiltration of pelvic plexuses with phenol is described. The results suggest that this is a useful technique in the management of detrusor hyperreflexia and for the older patient with detrusor instability when standard conservative measures have failed. It is contraindicated in male patients because of the risk of impotence.

The effect of hemodilution upon patients with intermittent claudication.

Seventeen patients with stable intermittent claudication and a PCV of more than 0.45 were venesected until a PCV of 0.35 was achieved. Only patients that were not considered candidates for surgical treatment were entered into the study. Each patient acted as their own control and was studied twice before the venesection at a mean PCV of 0.49 then after achieving a PCV of 0.35 or less (mean PCV of 0.33), and finally one month after the last venesection (mean PCV of 0.37). Angina developed in one patient after the third venesection and was withdrawn from the study. In the remaining sixteen patients, blood flow of the calf muscle during exercise increased significantly after venesection from 5.90 to 8.84 milliliters per 100 grams per minute (p = 0.02). This was measured by xenon 133 clearance and a cadmium telluride detector. There was also a substantial decrease (p less than 0.001) in whole blood viscosity at both low and high shear stresses, but there was no change in plasma viscosity or plasma fibrinogen. Treadmill claudication distance improved in only two patients. Ten patients were tired when the PCV decreased to 0.35 and subjective claudication distance deteriorated in four of these patients. Subsequent isovolemic venesection with dextran 70 volume replacement to a PCV of 0.35 did not improve the response in the six patients restudied. We conclude that venesection did not benefit these patients with intermittent claudication and there was an unacceptable incidence of side effects. Therefore, we suggest that reducing the PCV to 0.35 should be avoided in patients with intermittent claudication who have been refused surgical treatment.

Percutaneous pyelolysis: indications, complications and results.

The results of percutaneous pyelolysis in 28 patients are presented. There were 18 successful and 10 unsuccessful cases. The indications for the procedure are defined in the light of this analysis.

Results of transvesical infiltration of the pelvic plexuses with phenol in 116 patients.

One hundred and sixteen patients with detrusor instability, detrusor hyper-reflexia or bladder hypersensitivity who had failed to respond to standard conservative methods of management were treated by transvesical infiltration of the pelvic plexuses with phenol. A satisfactory response was obtained in detrusor hyper-reflexia (82%), in detrusor instability in patients over 55 years of age (69%) and in idiopathic bladder hypersensitivity (68%). The response rate was much less satisfactory in detrusor instability in patients less than 55 years of age (14%) and when there was a definable cause for bladder hypersensitivity (0%).