Varicocele in adolescents: a review and guideline for the daily practice.

OBJECTIVES: Varicocele in adolescent men is one of the most challenging topics in pediatric urology. What should be considered as a good indication for treatment and at what age? Does treatment improve fertility? Can we wait? What is the best surgical and minimal invasive treatment? To answer these questions we provide a guideline to use in daily practice. METHODS: We performed a search of the English literature of the last ten years through the Pub Med database using the following key words "varicocele", "diagnosis", "treatment", "fertility" and "adolescent". We then summated and compared the results of these studies. CONCLUSION: Adolescents with varicocele need regular follow-up including clinical examination and ultrasound measurements of the testis. Those with a persistent discrepancy between left and right testis size of more than 20% over a period of 12 months and those with pain need varicocelectomy independent of patient age, Tanner stage or varicocele size. The peak retrograde flow (PRF) seems to be a good diagnostic non-invasive tool in the follow-up and can be of help to select patients for surgery. PRF=38 cm/s in combination with testicular asymmetry =20% is a reason for surgery independent of age, Tanner stage or varicocele size. PRF<30 cm/s in combination with testicular asymmetry <20% should be followed annually. In case of worsening PRF or asymmetry surgery must be performed. Patients suitable for conservative management should be followed until semen analysis is possible. We present a flow-chart to use in the management of adolescent varicocele. The best results of varicocele treatment are obtained with microscopic subinguinal and laparoscopic lymphatic spearing techniques as shown in a meta-analysis performed in this review.

The association between Peyronie's and Dupuytren's disease.

Peyronie's disease (PD) is known to be associated with Dupuytren's disease (DD) since 1828. The aim of this study was to investigate the coexistence of DD in a consecutive series of patients with PD and their clinical characteristics. From January 1988 to December 2009 all patients, presenting at our outpatient urological clinic, with PD were also examined for DD. The sample consisted of 415 male subjects with PD, 89 (22.1%) also had DD. A total of 28 men (6.7%) reported to have one or more first or second degree relatives with DD.

18-year experience in the management of men with a complaint of a small penis.

In many cultures, the erect penis has been a symbol of masculine qualities. Because of this symbolism, a penis that is less than average size can cause insecurity or embarrassment. This series reports the authors' 18-year experience in the management of 60 men with a complaint of a small penis. For 44 of these 60 men, counseling was sufficient; the other 16 had surgery, and of these, 9 were satisfied with the result. Despite limitations, the authors conclude that those men who already achieve a penis length of no less than 7.5 cm (2.95 in) in erection, have only limited benefit from penis-enhancing surgery. This particular patient category should therefore be dissuaded from surgery.

Penile enlargement: from medication to surgery.

Penis lengthening pills, stretch apparatus, vacuum pumps, silicone injections, and lengthening and thickening operations are available for men who worry about their penis size. Surgery is thus far the only proven scientific method for penile enlargement. In this article, we consider patient selection, outcome evaluation, and techniques applied. In our view, sexological counseling and detailed explanation of risks and complications are mandatory before any operative intervention.

Intimate body piercings in women.

The popularity of (intimate) body piercing has increased as well as the chances of being confronted with (the complications) of it. This article provides information about the various types of intimate body piercings in women, the complications and concerns regarding the treatment of patients with intimate bodypiercings.

[Emphysematous cystitis: from bullae to pneumaturia]. / Emfysemateuze cystitis: van bullae tot pneumaturie.

A 91-year-old woman with type 2 diabetes presented at the emergency ward subconscious with lower abdominal swelling. Evaluation revealed dehydration and hyperglycaemia, and abdominal x-ray showed an air space surrounding a severely swollen bladder. After excluding enterovesical fistulae, the patient was diagnosed with emphysematous cystitis. Treatment for urinary retention, antibiotic treatment and control of the diabetes mellitus resulted in a rapid recovery. A second patient, a 65-year-old woman with a history of recurrent urinary tract infections and urolithiasis, presented with irritative urinary symptoms and pain in the lower abdomen. Explicit inquiry revealed that she also had intermittent pneumaturia. Urethrocystoscopy revealed submucosal bullae, which are a hallmark of emphysematous cystitis. The patient was given intravenous antibiotic therapy. Diabetes mellitus is a risk factor for emphysematous cystitis. The disorder is treated by draining the bladder with an indwelling catheter and intravenous antibiotic therapy, selected according to the urine culture results. In general, orally administered antibiotics are insufficient.

The treatment of sleep-related painful erections.

INTRODUCTION: As specialists in male genital problems, urologists and sexologists will most likely to be involved in the treatment of males presenting with sleep-related painful erections (SRPEs). This means that this phenomenon needs to be recognized by urologists and sexologists, and that they should have knowledge of the current diagnostic and therapeutic approaches. Aim. To review the literature on SRPE and to find the best pharmacological treatment. Methods. Four personal clinical observations from two clinics and 29 other cases with SRPE found in PubMed were analyzed, especially regarding the results of pharmacological treatment. MAIN OUTCOME MEASURES: The results of pharmacological treatment. RESULTS: Many of the various treatments proved to be ineffective and only a few showed efficacy for a few weeks or months. The only effective drugs in the long term were baclofen, clonazepam, and clozapine. CONCLUSIONS: Until now, the phenomenon of SRPE is not well understood. The rarity of the published cases undoubtedly does not reflect the actual occurrence of SRPE. Controlled double-blind pharmacological trials are needed, and long-term follow-up including polysomnography coupled with nocturnal penile tumescence and rigidity monitoring may provide further information about SRPE.

Torsion of the spermatic cord after orchiopexy.

The cases of spermatic cord torsion reported here show that this condition may occur even some time after fixation. Three men, aged 22, 30 and 35 years, visited the urologist with complaints of an acute scrotum following earlier orchiopexy for spermatic cord torsion. Different techniques are employed to fixate the testicles after spermatic cord torsion. These cases confirm that Jaboulay's bottleneck procedure is the method of choice for bilateral fixation in patients presenting with this condition.

The cryptorchidism prevalence among infants in the general population of Rotterdam, the Netherlands.

Published trends and geographical differences in cryptorchidism rates are almost exclusively derived from hospital-based birth defect registers, which are sensitive to selection bias and incomplete reporting. This study aimed to accurately assess the cryptorchidism prevalence in the general population of Rotterdam. Of 7652 consecutive male live births, 7292 (95%) were examined for cryptorchidism at Child Healthcare Centres around the age of 1 month. In a subgroup of cases, the persistence of cryptorchidism was re-assessed during a follow-up examination by expert specialists. The cryptorchidism rate at the median age of 35 days was 1.2% (89/7292). In the re-examined subgroup (median age 95 days) 69% of the boys (24/35) had persistent cryptorchidism, of which 20 were unilateral and four bilateral. The population rate of 1.2% falls within the range of 0.9-9% reported by others. Differences in case ascertainment and population characteristics probably explain part of the differences between studies. Our cross-sectional design does not allow for analysis of a temporal trend, but provides a baseline for future trend studies. To study cryptorchidism rates, trends, and risk factors, a systematic case ascertainment is warranted.

Myelomeningocele and female sexuality: an issue?

During the last 40 years more and more myelomeningocele (MMC) patients have survived to adulthood and since the 1980s there is growing interest in sexual functioning of these patients. However, most of what is known about the impact of MMC on sexual functioning pertains to males. We have reviewed the literature pertaining to female sexuality and MMC with regard to sexual development, activity, dysfunction, sexual knowledge and education, pregnancy and delivery, as well as future trends.

Expression and prognostic relevance of vascular endothelial growth factor (VEGF) and its receptor (FLT-1) in nephroblastoma.

AIMS: To investigate the prognostic relevance of vascular endothelial growth factor (VEGF) and its receptor Flt-1 in nephroblastoma and whether tumour microvessel density (MVD) immunoreactivity, determined by the CD31 antigen, is related to the expression of VEGF and Flt-1. METHODS: The expression of VEGF and Flt-1 and MVD were investigated by means of immunohistochemical analysis in 62 Wilms's tumours. Patients were treated preoperatively with chemotherapy and had a mean follow up of 5.7 years. RESULTS: In general, VEGF and Flt-1 were expressed in normal kidney parenchyma and to a variable extent in the three main components of Wilms's tumour, namely: the blastemal, epithelial, and stromal cells. In tumour tissue, 52% and 47% of blastemal cells were positive for VEGF and Flt-1, respectively. A non-significant correlation was found between the expression of VEGF and Flt-1 in blastemal and epithelial cells and the clinicopathological stage. MVD was significantly higher in VEGF and Flt-1 positive tumours than in VEGF and Flt-1 negative tumours. Univariate analysis showed that the expression of VEGF and Flt-1 in blastemal cells was indicative of clinical progression and tumour specific survival. In addition, MVD expression was indicative of clinical progression. Epithelial staining was of no prognostic value. In a multivariate analysis, VEGF protein expression by blastemal cells was an independent prognostic marker for clinical progression. CONCLUSIONS: These results indicate that VEGF and Flt-1 protein expression are closely related to MVD and seem to be an important predictor for poor prognosis in treated patients with Wilms's tumour. Therefore, the expression of these molecules in primary Wilms's tumour may be useful in identifying those patients at high risk of tumour recurrence and in guiding antiangiogenic treatment.

Identification of bladder wall layers by Raman spectroscopy.

PURPOSE: We explored the applicability of Raman spectroscopy to in situ investigation of bladder wall tissue. MATERIALS AND METHODS: Bladder wall tissue was obtained from a guinea pig model and frozen sections were used for Raman spectroscopic investigations. From each section 500 to 700 spectra were obtained in a 2-dimensional grid spanning the urothelium, lamina propria and muscle layer. The data set of spectra was subdivided into groups of similar spectra by a cluster analysis algorithm. With each group assigned a different color Raman maps of frozen sections were constructed based on group membership of measured spectra. These maps were then compared with histological and histochemical data obtained from hematoxylin and eosin and immunohistochemical staining for collagen I and III and for smooth muscle actin to correlate Raman spectral features with bladder wall structure and molecular composition. RESULTS: Urothelium, lamina propria and muscle layers could be clearly distinguished based on Raman spectra. Lamina propria spectra were dominated by signal contributions of collagen and the smooth muscle layer showed strong signal contributions of actin. The urothelium had a relatively strong lipid signal contribution. CONCLUSIONS: These results and the fact that Raman spectroscopy is rapidly evolving into a technology that can be applied in vivo by thin, flexible fiberoptic catheters indicate that prospects are good for in vivo analysis of the molecular composition of the normal and pathological bladder without biopsies.

A high hypospadias rate in The Netherlands.

BACKGROUND: Reports on increasing hypospadias trends are based on birth defect registries, which are prone to inaccuracy. We assessed the prevalence of hypospadias precisely, by prospective examination of all newborns in Rotterdam over a 2-year period. METHODS: A total of 7292 consecutive male births were examined for the presence of hypospadias, classified by severity. RESULTS: The frequency of hypospadias in newborn boys was 0.73% (53/7292). The rate among live births was 38 per 10 000, which is 6 times the previously reported rate for the Southwestern Netherlands (6.2) (P < 0.0001). This registry excludes glandular hypospadias. Without glandular cases, our rate is 26 per 10 000, which is still 4-fold higher (P < 0.0001). The ratio of minor to major hypospadias was 0.3. In 79% of cases, surgery was indicated. CONCLUSIONS: We found a 4-fold higher than expected hypospadias rate, which may be explained by case ascertainment differences. The proportion of major cases was higher than generally assumed. This study provides evidence for substantial geographical differences. Explanations for temporal and geographical differences need to be explored. To monitor hypospadias rates and trends accurately, complete case ascertainment, including standardized classification of severity, is warranted.

Unilateral multicystic dysplastic kidney: a combined pre- and postnatal assessment.

OBJECTIVE: To review the prenatal assessment of associated renal pathology, non-renal pathology and renal biometry, fetal outcome and postnatal urological management in the presence of unilateral fetal multicystic dysplastic kidney. METHODS: A total of 38 singleton pregnancies with fetal unilateral multicystic dysplastic kidney was studied over a 13-year period. Prenatally, fetal biometry, including head and abdominal circumferences and largest longitudinal diameter of the affected and contralateral kidneys, was performed. The amount of amniotic fluid was assessed. Fetal karyotyping was offered in cases of contralateral renal or non-renal pathology. A MAG 3 scan and voiding cystogram was performed approximately 4 weeks after delivery to establish renal function and to exclude urinary reflux. RESULTS: Unilateral fetal multicystic dysplastic kidney was left-sided in 53% and right-sided in 47% of cases. The fetus was male in 63% and female in 37% of cases. Associated renal and non-renal pathology existed in 21% and 5% of cases, respectively. The fetal karyotype in these subsets was always normal. The longitudinal diameter of the multicystic dysplastic kidney was above the 95th centile in 87%. There was polyhydramnios in three cases and oligohydramnios in two cases. The prematurity rate was 16%. Postnatal examination revealed a non-functional multicystic kidney in 87% (33/38) of cases. Following surgical removal of the affected kidney, these infants progressed normally. Of the remaining five infants, four died because of associated anomalies and one infant developed normally without surgery. CONCLUSIONS: Fetal outcome is determined by associated renal and/or non-renal structural pathology and not by the size/location of the unilateral multicystic dysplastic kidney or amniotic fluid volume.

Urodynamic follow-up of experimental urethral obstruction in individual guinea pigs.

It is unknown whether changes in bladder function due to urethral obstruction follow a specific sequence. To answer this, we adapted a small animal model to allow repeated complete pressure-flow studies, enabling individual follow-up of changes in bladder function on urethral obstruction. Obstruction was induced in guinea pigs by placing a silver ring around the urethra. Urodynamic studies were repeated under anesthesia with ketamine/xylazine. Bladders were filled and bladder pressure measured through a single suprapubic catheter. Urine flow rate was measured using an ultrasound probe around the penis. Accurate measurements of bladder pressure and urine flow rates were obtained at 1-week intervals for 11 weeks in individual guinea pigs. In the control animals, the urodynamic parameters did not show significant changes. In the obstructed group, urethral resistance (P(low,ave)) increased from 20 to 35 cm H(2)O after 4 weeks and remained at that level. The maximum flow rate (Q(max)) increased from 0.17 to 0.24 mL/s after 2 to 3 weeks. After this peak, it gradually decreased to lower than the starting value after 10 to 11 weeks. The pressure at maximum flow rate (p(Qmax)) increased from 24 to 47 cm H(2)O after 6 to 7 weeks and thereafter declined. During weeks 1 through 4 of obstruction, unstable contractions were seen. All animals followed a similar sequence of patterns but at variable rates. Our animal model allows complete urodynamic follow-up of individual animals with urethral obstruction. We observed a specific sequence of changes in urodynamic patterns and parameters of bladder function.

[Differential diagnosis and treatment of girls with 46XY-karyotype and androgen insensitivity syndrome]. / De differentiaaldiagnose en behandeling van meisjes met het 46XY-karyotype en ondervirilisatiesyndroom.

The importance of the secretion and action of androgens during the critical period of male sexual development is exemplified in patients with androgen insensitivity syndrome. Their karyotype is always 46XY. In 2 sisters, aged 11 and 13 years, the androgen insensitivity syndrome was diagnosed based on an androgen receptor gene mutation. Ambiguous genital development of a new-born was shown to be due to a lack of testosterone production, based on a luteinizing hormone receptor gene mutation. Finally, in a phenotypically female new-born a gene mutation of 17-beta hydroxysteroid dehydrogenase type 3 was found to be responsible for insufficient testosterone synthesis during embryonic development. The presentation of a patient, and specifically a neonate, with abnormal genital development represents a difficult diagnostic and therapeutic challenge. Referral to a centre with experience in the diagnosis and management of disorders of sexual development is advised where the emphasis should be on psychological and genetic counselling.

Changes in bladder contractility and compliance due to urethral obstruction: a longitudinal followup of guinea pigs.

PURPOSE: We established the longitudinal changes in bladder contractility and compliance as a result of urethral obstruction using a guinea pig model. MATERIALS AND METHODS: Obstruction was induced in guinea pigs by a silver ring around the urethra. Urodynamic studies were performed longitudinally in individual animals. Bladder contractility and compliance were calculated from the measured bladder pressure and urine flow rate. RESULTS: Bladder contractility developed in distinct phases. It reached a maximum 200% increase after an average of 3.25 weeks concomitant with an almost 2-fold increase in urethral resistance, remained 150% to 200% increased during weeks 4 to 7 and then decreased to starting levels again, while urethral resistance remained almost 2-fold increased. Bladder compliance decreased by 80% during the first 3 weeks and continued to decrease to 5% of its original value after 10 to 11 weeks. CONCLUSIONS: Our data indicate that as a result of obstruction bladder function passes through a specific sequence of stages, including first a compensatory increase in contractility, then a stabilization phase and finally a decompensation state. In contrast bladder compliance shows a continuous decrease. The data suggest that for assessing how far a bladder has deteriorated due to obstruction a combination of functional and structural data may be warranted.

[Prenatal ultrasonic detection of asymptomatic urogenital abnormalities: advantages and disadvantages]. / Antenatale echografische ontdekking van asymptomatische urogenitale afwijkingen: voordelen én nadelen.

Prenatal ultrasound studies have significantly contributed to the understanding of congenital abnormalities of the urinary tract and the development of pediatric urology over the past decade. Besides providing more insight into pathophysiology of the developing urinary tract, it has promoted the possibilities of early postnatal intervention and of studying the natural history of developmental abnormalities such as pelviureteral junction obstruction and vesico-ureteric reflux. The downside of this development has been and probably still is a considerable amount of diagnostic and therapeutic interventions for so-called abnormalities which, left alone, will disappear with time and without significant sequelae. On the other hand, many children with severe obstructive uropathy are alive today because of early intervention. Longterm follow-up studies are needed to prove the efficacy of prenatal screening and to ascertain the contribution of these technical possibilities to quality of life.

Diagnosis and grading of detrusor instability using a computerized algorithm.

PURPOSE: Detrusor instability and hyperreflexia are characterized by involuntary detrusor contractions in the filling phase of the voiding cycle. The diagnosis is made when urodynamic evaluation reveals such contractions. To compare patients and evaluate treatment a method is needed to quantify the degree of instability. We developed an instability parameter based on the area under the curve of involuntary detrusor contractions on conventional filling cystometry. MATERIALS AND METHODS: We developed an automatic method to calculate the area under the curve of involuntary detrusor contractions in conventional filling cystometry. Logistic regression was used to construct decision rules to differentiate stable from unstable bladders. These rules, derived from a group of 100 children, were applied to a second group of 77 who were independently assessed by 3 urodynamics experts. RESULTS: Typically 88% of the second group were correctly classified as stable or unstable by the automatic procedure. In the unstable subgroup there was poor correlation between the calculated instability parameter and the instability score assigned by the experts. Most likely this difference occurred because the experts based their opinion mainly on the amplitude of the highest unstable contraction and the percentage of filling time that instability was found. CONCLUSIONS: The proposed method of automatically grading detrusor instability based on the area under detrusor contractions differs from the intuitive method used by experts. Since no standard is available, it cannot be concluded which method is better. Our proposed method is objective and it results in a single physical value.