Urethral sensitivity in incontinent women.

OBJECTIVES: The aim of this study was to ascertain whether frequent voiding and urge incontinence are associated with supersensitivity to electrical stimulation in the posterior urethra. METHODS: Current perception thresholds (CPT) were tested at four stimulus frequencies (1, 3, 20, and 100 Hz; duration 0.5 ms) using a square-wave constant current electrical stimulator connected to ring electrodes on a urethral catheter. The strength of the current at the first tingling sensation was regarded as the CPT. CPT analysis and cystometry were performed on 61 women (ages 28-89 years). RESULTS: CPTs were significantly higher at lower than at elevated stimulus frequencies, and they were also generally higher in old than in younger patients. Seven women repeated the CPT test after two months, and the thresholds were unchanged. There were no significant differences in sensitivity between patient groups with stress incontinence, urge, or mixed symptoms. Moreover, CPT was not significantly related to bladder volume at first sensation of filling. CONCLUSION: Measuring CPT is an easy and reproducible method of testing urethral sensibility, but our results do not support the suspicion that urethral hypersensitivity is involved in increased voiding frequency and urge incontinence.

Acute erysipelatous oedema in the scrotum.

We present a case of penile and scrotal oedema in a young man. Although oestradiol treatment and compression bandaging provided some relief from the symptoms, neither therapy was ideal. Triangular resection of the foreskin was therefore performed, although the oedema persisted. The aetiology of the condition remains unknown.

Snoring as a cause of nocturia in men with lower urinary tract symptoms.

OBJECTIVES: Snoring increases with increasing age and body mass, and repeated periods of hypoxia cause nocturnal polyuria. Accordingly, we examined the occurrence of snoring problems in patients scheduled for transurethral prostatic resection. METHODS: Of 171 men scheduled for TUR-P, 41 were excluded due to cardiac disease, diabetes, or prostatic malignancy. Of the remaining 130 patients, 12% were troubled by snoring that disturbed their sleep. The severity of their snoring was evaluated by questionnaires, micturition charts, and determination of nocturnal capillary oxygen saturation (SaO(2)) and pulse rate. Plasma levels of cortisol, arginine vasopressin (AVP), and atrial natriuretic peptide (ANP) were measured in the morning and at 2 p.m. Fifteen non-snoring patients also scheduled for TUR-P served as controls. RESULTS: Compared to controls, the snoring patients had a significantly higher body mass index (BMI), voided more frequently, and produced more urine at night. They also had a significantly larger number of hypoxic episodes at night, which, along with low SaO(2) levels, correlated with the nocturnal diuresis. Snorers did not differ significantly from controls in regard to excretion of cortisol and AVP, but they did have higher plasma levels of ANP. CONCLUSIONS: We recommend that elderly obese men with urgency at night be questioned about snoring, and that micturition frequency and volume charts be completed before deciding to operate.

Impact on ureteral peristalsis in a stented ureter. An experimental study in the pig.

Peristalsis was examined in ten pigs with stented ureters. In five of the animals, the stents were inserted 6-8 weeks before examination, which was performed using a 3.5 Ch catheter equipped with thin copper wires in two sites 10 cm apart. This set-up enabled an analysis of the frequency, direction and velocity of the peristaltic waves to be made. When diuresis was gradually raised, the frequency and velocity of the contractions usually increased in normal ureters, whereas we observed a decline in both of these parameters. There was a statistically significant difference in the lower frequency in the long-term stented animals. Retrograde peristalsis, aberrant waves and incomplete contractions were common in the ureters after prolonged stenting, and urine flow was greater around than through the stent. Our results suggest that the flow of urine is obstructed by a ureteral stent, and they support clinical data showing that such devices prolong the time it takes for a stone to pass to the bladder.

Tension-free vaginal tape evaluated using patient self-reports and urodynamic testing--a two-year follow-up.

OBJECTIVE: Urinary incontinence entails both reduced quality of life for many women and considerable public expense. Compared with other methods aimed at alleviating incontinence, tension-free vaginal tape (TVT) is minimally invasive, can be performed under local anaesthesia and results in less morbidity and shorter hospitalization. The present study was carried out to evaluate early and late complications and as a 2-year follow-up after surgery. MATERIAL AND METHODS: In 1996-98, 75 women underwent TVT sling plasty; mean time for surgery was 39 min and for hospitalization 24 h. The procedure caused bladder perforation in 3 women, but this was detected by cystoscopy and immediately corrected. Postoperative retention occurred in 9 patients but was transient. RESULTS: After surgery 80% were cured, 9% showed improvement and 11% were failures. Two women exhibited vaginal erosion, and one of these had previously undergone radiation therapy. One sling caused obstruction and had to be cut. Improvements included less impact on social and physical activities and mental status and significant reduction of voiding frequency, leakage episodes and pad use. CONCLUSIONS: The TVT technique seems to provide results comparable with those obtained with Burch colposuspension, but it entails less risk of obstruction than previous slings techniques because it causes no compression of the urethra. TVT is effective in women with genuine stress incontinence due to urethral hypermobility and in elderly women with sphincter incompetence, although the outcome is better in the former.

Ureteropelvic junction obstruction: long-term followup of adults with and without surgical treatment.

PURPOSE: We compared the long-term outcome of hydronephrosis due to pyeloureteral obstruction based on excretory urography findings and renal function in patients who did and did not undergo pyeloplasty. MATERIALS AND METHODS: We followed 83 adults for a mean of 17 years after the diagnosis of hydronephrosis. The choice of conservative or surgical management was based on the results of excretory urography, pelvic manometry, fluoroscopy of pelvic and ureteral peristalsis, isotope renography and renal clearance studies but symptom severity was considered greatly important. Three patients not included in the study underwent primary nephrectomy due to poor ipsilateral function, while 47 underwent pyeloplasty and 36 no surgery. RESULTS: Nephrectomy was later performed in 2 patients each in the pyeloplasty and no surgery group, respectively, because of pyelonephritis and stone formation in 3 and persistent pain in 1. Hypertension developed in 2 cases in each group. Renal pelvic size was considerably decreased after pyeloplasty and dilatation increased in only a few kidneys in the nonsurgical group. Excluding the 4 patients treated with late nephrectomy serum creatinine pathologically increased in only 1 who was treated conservatively. Split function improved from 40.8% to 47.1% of total function after pyeloplasty but the total glomerular filtration rate did not improve significantly. CONCLUSIONS: In the absence of infection and stone formation hydronephrosis in adults seems to be a fairly benign condition and followup should be directed mainly toward detecting these complications. Recurrent flank pain still seems to be the best indication of the need for surgery.

Denervation of periurethral prostatic tissue by transurethral microwave thermotherapy.

PURPOSE: To determine whether transurethral microwave thermotherapy (TUMT) affects innervation of the urethra and periurethral prostate. MATERIAL AND METHODS: Ten patients with troublesome benign prostatic hyperplasia (BPH) were treated with TUMT 1 week prior to transurethral resection of the prostate (TURP). At surgery, a biopsy was taken for histological examination and for immunohistochemical staining of the non-specific neuromarker protein gene product (PGP) 9.5. Control material consisted of identical biopsies from 10 patients undergoing TURP because of BPH, but not subjected to TUMT prior to surgery. RESULTS: Histological examination revealed well-preserved, non-necrotic tissues in all biopsies. Nerve fibres were completely or almost absent in the smooth muscle layer in all but one of the TUMT cases, whereas all non-TUMT patients exhibited large numbers of nerve fibres in the smooth muscle layer. CONCLUSIONS: TUMT does affect innervation of the urethra and periurethral prostatic tissue.

[Tough working conditions for urologists]. / Hård arbetsmiljö för urologer.

A questionnaire sent by the Swedish Association of Urology to all active Swedish urologists (n = 249) was returned by 89%. Questions concerned actual urological work, emergency duties, education, development facilities and research access, but also job satisfaction, psychological fatigue and emotional stress, as well as each urologist's plans for the future. Answers indicate that Swedish urologists carry a heavy work load and experience considerable demands from patients, relatives and colleagues. Physical and psychological exhaustion are common, and many hope to find work outside hospitals or abroad. The tightening of health-care purses presumably augments the work load, but local factors are also involved. For the future, more and improved educational programs are planned, together with greater participation on the part of junior doctors in organizational and structural processes. Compared to other physicians, urologists show greater reserves of psychic energy, but also signs of increasing intellectual exhaustion.

Diclofenac treatment prolongs renal transit time in acute ureteral obstruction: a renographic study.

OBJECTIVE: Prostaglandin inhibitors, mostly diclofenac, are currently first-choice therapy for ureteral colic, their main action being reduction of intrapelvic pressure and diuresis. We hypothesized that diclofenac, by increasing tubular reabsorption, can delay excretion of contrast medium and give a false impression of severe obstruction. METHODS: Gamma camera renography was performed with 50 MBq (99)Tc(m)-MAG3 before and with 150 MBq 30 min after intramuscular injection of 75 mg diclofenac in 10 patients with acute ureteral colic. The time to maximum isotope activity in each kidney, T(max), was compared with T(max) in 10 control patients, who did not receive diclofenac but underwent two identical renographies. RESULTS: T(max) was significantly delayed after diclofenac, from 353 s at baseline to >1,200 s on the stone side, and from 225 to 465 s on the healthy side. Without diclofenac there was no T(max) retardation between the two renographies. CONCLUSION: Diclofenac treatment can lead to overestimation in ureteral stone disease, by delaying renal excretion bilaterally, but predominantly on the side of calculus.

The impact of the geometry of the lithotriptor aperture on fragmentation effect at extracorporeal shock wave lithotripsy treatment.

The aim of this study was to determine the impact of the aperture size of an electro-hydraulic lithotriptor on the fragmentation effect. We also wanted to investigate whether a potential change in the capacitance of the pulse forming network (PFN), at a certain energy level, might have an impact on fragmentation rate. Two different apertures with a diameter of 23 and 17 cm respectively were compared using two different values of total PFN capacitance: 50 nF and 80 nF. Model stones of similar size and weight were fragmented. The number of shots for complete fragmentation or the grade of fragmentation after a certain number of shots was measured. This study shows that for the shock wave system used, the 23-cm aperture seems to provide more effective fragmentation as function of the number of shots compared with the 17-cm aperture at the same energy level. Furthermore, a minor change in the PFN capacitance between reasonable limits does not affect the fragmentation efficiency. This article also highlights the fact that it is not relevant simply to compare the voltage level given in the shots in extracorporeal shock wave lithotripsy treatment between different lithotriptors.

Quality of life and urinary incontinence pad use in women.

Women utilizing the free provision and home delivery of urinary incontinence pads by the Swedish health services were sent a questionnaire concerning their quality of life and pad use. Evaluable and complete replies were received from 460 of 521 women. The incontinence was chronic and moderate to severe, considerably restricting general and professional activities. Feelings of anxiety, isolation and depression were common, their prevalence rising with incontinence grade. Satisfaction with the supplied pads was generally good, with absorptive and antiodor properties most appreciated. The threatened introduction of charges for the pads was reported as a dominant anxiety. A drawback of free supply may be that, as in 24% of the present series, women primarily use the pads as a solution to the problem of incontinence, without a doctor's intervention and before a trial of continence-promoting or curative measures.

Sexual function one year after transurethral prostatic resection. Patients' own assessments.

One year after transurethral resection of the prostate for benign hyperplasia, 127 men received a questionnaire requesting personal evaluation of sexual function, including erection, ejaculation, libido and satisfaction. Significant postoperative dysfunction was reported in all these respects: 54% of the responders claimed deterioration and half of them blamed the operation. Decline in sexual function had a multifactorial background, including advancing age, morbidity, and changed marital and social conditions. Although other examinations with preoperative and postoperative evaluation report a lower incidence of impotence development, which may be more reliable, it is psychologically interresting that the patients themselves suspect the transurethral resection as the cause of impaired sexuality.

Effect of sucralfate on induced chemical cystitis in rabbits.

OBJECTIVE: To study the histological effect of locally applied sucralfate on the urinary bladder in rabbits with chemically induced cystitis. MATERIALS AND METHODS: Sucralfate (1 g dissolved in 10 mL saline) was instilled into the bladders of six rabbits, while four controls had no instillation. The procedure was repeated 4 days later and followed immediately by 10 mL of 2% formaldehyde infused into the bladder and retained for 10 min in all 10 rabbits. After careful flushing with saline, 10 mL sucralfate solution was again instilled in the study group and 10 mL of saline only in the control group. On day 6, the sucralfate instillation was repeated in the six treated animals. All the rabbits were then killed on day 8-9, their bladders removed and examined macroscopically and histologically. RESULTS: Formaldehyde instillation was quickly followed by gross haematuria in all animals. It subsided in the group treated with sucralfate, but not in the controls. Examination revealed only slight changes in the former group, but severe inflammatory lesions in the latter. CONCLUSIONS: Intravesically instilled sucralfate protected rabbit bladder urothelium against chemically induced cystitis. Clinical trials of intravesical sucralfate seem warranted in patients irradiated for pelvic cancer or with severe cystitis caused by cytotoxic drugs.

The International Continence Society "Benign Prostatic Hyperplasia" Study: international differences in lower urinary tract symptoms and related bother.

PURPOSE: We investigated the international differences in the reporting of lower urinary tract symptoms and related bother in patients with symptoms suggestive of bladder outlet obstruction. MATERIALS AND METHODS: Multiple logistic regression analysis was used to evaluate international differences in the reporting of lower urinary tract symptoms and related bother in 1,271 patients from 12 countries who participated in the International Continence Society "benign prostatic hyperplasia" study. RESULTS: Country of origin was significantly associated with the prevalence of a large number of lower urinary tract symptoms (10 of 20), even after adjusting for potentially confounding variables, including physical and socio-demographic factors. Country of origin was also significantly associated with the reporting of bother but for a much smaller number of symptoms (2). CONCLUSIONS: In different countries lower urinary tract symptoms may be reported to different extents. Therefore, the results of studies in particular countries may not be generally applicable to other countries. It is likely that symptom scores will conceal this variation, necessitating consideration of individual symptoms (as in the International Continence Society "benign prostatic hyperplasia" study) or the development of country specific scoring systems. An alternative would be to focus on bother, which appeared to be much less sensitive to international differences.

Transurethral microwave thermotherapy for benign prostatic hyperplasia. Subjective response and urodynamic changes.

Results of transurethral microwave thermotherapy for benign prostatic hyperplasia were good after 1 year in 68% of 66 cases. Despite good correlation between subjective assessment of results and improvement in urodynamic parameters, no predictive factors for probably successful outcome could be identified. Diminution in frequency of micturition (diurnal from 8.8 to 6.8 times, nocturnal from 3.0 to 1.6 times), increased flow rates (Q max from 8.8 to 14.2 ml/s) and reduction of detrusor pressures during voiding (Pdet max from 86.9 to 75.0 cm H2O) were significant, but the change in residual volume (from 52 to 37 ml) was of lesser degree (all mean values). Transurethral microwave thermotherapy can be tried for relief of moderate obstruction when transurethral prostatic resection involves risk, or the patient himself requests noninvasive treatment.

Progress in urodynamic research on the upper urinary tract: implications for practical urology.

The development of new surgical techniques for bladder substitution and continent urinary diversion has extended interest in urodynamics of the upper urinary tract. From a subdiscipline attracting mainly scientists and bioengineers, renal pelvic kinetics and ureteral peristalsis have evolved as important factors in routine clinical urology. The observed changes in peristaltic pattern during high diuresis, obstruction and urinary reflux have influenced management of stone disease and neurogenic bladder. The demonstration that high intravesical pressure is reflected to the kidney not only when the ureteric orifice is incompetent, but also during high diuresis, established the necessity for low pressures in neobladders. Much further clarification of urinary transport from the renal tubules to the bladder should be achievable by refined techniques of fluoroscopy, isotopic renography and manometry.

Burch colposuspension for stress urinary incontinence. 5-year results in 153 women.

The long-term results of Burch colposuspension for stress urinary incontinence were evaluated in 153 women operated on in 1984-1990. At follow-up 2 months postoperatively, 88% of the women reported continence, 5% were almost continent and the failure rate was 7%. At 24 months the corresponding figures were 86.7 and 7% and 39-102 months (mean 5 years) postoperatively they were 78, 11 and 11%. There were few complications. Follow-up urodynamic investigations showed significant rise of the pressure transmission from bladder to urethra in the cured patients. Reasons for failure are discussed. For patients with low urethral closure pressure, a vaginal sling procedure is preferable to Burch operation. Burch colposuspension is safe and advisable for patients with genuine stress incontinence. Urodynamic evaluation thus should be made preoperatively, but need not to be repeated if the clinical result is good.

Implications of cavitation phenomena for shot intervals in extracorporeal shock wave lithotripsy.

OBJECTIVE: To study the influence of shot intervals and the quality of the coupling medium (degassed water) in extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS: Acoustic scattering and damping (and thereby also the focal size) were modelled with respect to the conditions of the coupling medium, using continuous wave high intensity ultrasound. The influence of the shot interval on rise time and attained shock wave pressure were quantified with a modified ESWL apparatus and a specially designed hydrophone. RESULTS: In tap water, which has a high content of dissolved gases, the focus produced was bulb-shaped, with a diameter of approximately 4 cm, whereas degassed water gave a small focus that produced a water jet only a few millimetres in diameter. The efficacy of the acoustic energy decreased with shot intervals shorter than 1.2s. Longer pauses resulted only in prolonged treatment times. CONCLUSION: ESWL becomes inefficient if the intervals between pulses are too short, particularly when ECG R-wave triggered pulses are used on patients with tachycardia. The gas content of the coupling medium is also important for successful ESWL. The efficacy of the system used for degassing the water should be checked at regular intervals.