Significance of hematuria in patients with interstitial cystitis: review of radiographic and endoscopic findings.

OBJECTIVES: Hematuria may be found in up to 30% of patients with interstitial cystitis (IC). However, few studies have described its etiology based on the findings of a complete evaluation. We reviewed the clinical significance of hematuria in the setting of IC. METHODS: We retrospectively reviewed the records of 148 patients fulfilling the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases inclusion criteria for IC. Patients with gross or microscopic hematuria were identified. Evaluation consisted of urine culture and cytology, cystoscopy, and intravenous urography (or retrograde pyelography plus renal ultrasound). Patients with urinary tract infections were excluded. RESULTS: Of 148 patients, 60 (41%) were found to have had at least one episode of hematuria during a mean follow-up of 18 months. Of 56 patients who agreed to be evaluated, 8 (14%) had positive urologic findings. Of these, none were highly significant; five were simple renal cysts (8.9%), one was a renal stone (1.8%), one was reflux nephropathy (1.8%), and one was medullary sponge kidney (1.8%). Cystoscopy, cytology, and bladder biopsy did not demonstrate malignancy in any patient. No statistically significant differences were found in age (49.9 versus 46.7 years), sex (90% versus 91% female), bladder capacity (792 versus 808 mL), and the presence of Hunner's ulcers (5% versus 2.4%), glomerulations (60% versus 59.9%), or detrusor mastocytosis (55% versus 47.6%) between patients with hematuria and those without (P >0.05). CONCLUSIONS: The incidence of hematuria in patients with IC may be higher than previously reported. Nevertheless, although many of these patients present with pelvic pain and irritative voiding symptoms, the hematuria evaluation is unlikely to reveal a life-threatening urologic condition.

Estrogen modulates the expression of myosin heavy chain in detrusor smooth muscle.

The effect of low serum estrogen levels on urinary bladder function remains poorly understood. Using a rabbit model, we analyzed the effects of estrogen on the expression of the isoforms of myosin, the molecular motor for muscle contraction, in detrusor smooth muscle. Expression of myosin heavy chain (MHC) isoforms, which differ in the COOH-terminal (SM1 and SM2) and the NH(2)-terminal (SM-A and SM-B) regions as a result of alternative splicing of the mRNA at either the 3'- or 5'-ends, was analyzed in age-matched female rabbits that were sham operated, ovariectomized (Ovx), and given estrogen after ovariectomy (4 rabbits/group). Ovx rabbits showed a significant decrease in the overall MHC content per gram of wet detrusor smooth muscle compared with controls (P < 0.04), which was reversed by estrogen replacement (P < 0.02). MHC content, as a proportion of total milligram of protein in the bladder tissue extracted, was also increased in estrogen-treated Ovx rabbits. Quantitative competitive RT-PCR revealed 1.72-, 2.63-, and 5.82 x 10(6) copies of MHC mRNA/100 ng total mRNA in Ovx, control, and estrogen-treated rabbits, respectively (P < 0.01). RT-PCR analysis using oligonucleotides specific for the region containing the SM1/SM2 MHC alternative splice sites indicated a lower SM2-to-SM1 ratio in estrogen-treated compared with control and Ovx rabbits (P < 0.05). Similarly, SDS-PAGE analysis of extracted myosin from estrogen-treated rabbits revealed a significantly lower SM2-to-SM1 isoform ratio compared with control and Ovx rabbits (P < 0.05). Expression of the SM-A and SM-B isoforms was not affected. These results indicate that myosin content is increased upon estrogen replacement in Ovx rabbits and that the abundance of SM1 relative to SM2 is greater in estrogen-treated rabbits compared with normal and Ovx rabbits. These data suggest that estrogen affects alternative splicing at the 3'-end of the MHC pre-mRNA to increase the proportion of SM1 vs. SM2.

Efficacy of sildenafil in erectile dysfunction after radical prostatectomy.

Radical retropubic prostatectomy (RRP) is an important cause of iatrogenic erectile dysfunction (ED). While sildenafil has been widely used since its introduction as a new treatment option for ED, its efficacy in post-RRP patients has not been extensively studied. We retrospectively compared the efficacy of sildenafil in post-RRP and non-surgical patients with ED (NSED) using a subset of questions from the International Index of Erectile Function (IIEF) and correlated results with their specific etiology of ED based on penile blood flow study (PBFS). A brief questionnaire regarding satisfaction with sildenafil was administered to 72 consecutive post-RRP patients (nerve sparing status unknown) and 32 consecutive NSED patients who had previously undergone PBFS with pharmacotesting as part of their evaluation for ED. PBFS diagnoses were arterial insufficiency (AI) for peak systolic velocity (PSV) < 25 cm/sec; venogenic (CVOD) for PSV > or = 35 cm/sec, mixed vascular for PV > 25 but < 35 cm/sec and resistive index (RI) < 0.9; a vascular normal diagnosis (neurogenic impotence) required excellent rigidity sustained for 20 min. Differences in the IIEF subscores for the different groups of patients were assessed. Success with sildenafil was defined as moderate or excellent improvement (3/4 or 4/4) with ability for penetration. No differences were found among the different subgroups of RRP patients with respect to IIEF scores or success rates with sildenafil. NSED patients had both significantly higher post-treatment IIEF scores (3.6/3.4 vs 2.5/2.2; t=4.50, P<0.0001) and success rates (63% vs 31%; t=3.11, P < 0.01) with sildenafil treatment than RRP patients. We found that sildenafil is significantly less effective in impotent RRP patients than in age-matched patients with ED (31% vs 63%). We had postulated that sildenafil would be least effective among RRP patients with excellent sustained rigidity to PGE1, as this subgroup is likely to have neurogenic impotence. We found that sildenafil response rates among subgroups of RRP patients were statistically similar regardless of PBFS diagnosis. IIEF scores for the RRP subgroups were similar but statistically lower than in men with ED and no history of RRP. While individuals with normal vascular responses to PGE1 have an increased likelihood of having neurogenic impotence, in RRP patients, we were unable to demonstrate any difference in efficacy of sildenafil, regardless of the PBFS diagnosis.

Erectile function and quality of life after interstitial radiation therapy for prostate cancer.

Few studies have evaluated erectile function after interstitial radiation therapy for localized prostate cancer. Using a validated quality of life questionnaire, we assessed post-treatment erectile function and its relationship to treatment satisfaction and quality of life. We retrospectively reviewed the records of 171 consecutive patients who underwent Pd-103 or I-125 brachytherapy for prostate cancer between December 1992 and June 1998. Seventy percent of patients received neoadjuvant androgen deprivation therapy. All patients were mailed a validated questionnaire assessing sexual function and overall quality of life (UCLA Prostate Cancer Index and SF-36). Sixty-seven percent of all questionnaires were available for evaluation (114/171). The mean age was 69.1 y with a mean follow-up of 23 months (range 4-72, median 24). Seventy-one percent of patients (81/114) had pre-treatment erections sufficient for sustained vaginal penetration. Of these patients, potency was maintained in 49% of men (40/81). An additional 26% had erections firm enough for foreplay but not penetration (21/81). Erectile dysfunction rates were significantly lower in younger patients (48%) vs older patients (55%). There was no difference in post-treatment potency between men who received neoadjuvant hormonal therapy and those who did not (P>0.05). In addition, there were no differences in physical function (86, scale 0-100), general health perception (78), emotional well-being (83), energy/fatigue (74), and overall satisfaction (84) between men with erectile dysfunction and those without. In summary, two years following brachytherapy 25% of patients complained of complete (20/81) or partial (26%, 21/81) erectile dysfunction, for an overall rate of 51% (41/81). Short-term neoadjuvant hormonal therapy (<3-6 months) did not increase the likelihood of post-treatment erectile dysfunction. Interestingly, overall satisfaction rates among brachytherapy patients were high (84/100) and surprisingly did not correlate with post-treatment sexual function.

Artificial urinary sphincter for post-prostatectomy incontinence: impact of prior collagen injection on cost and clinical outcome.

PURPOSE: We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment. MATERIALS AND METHODS: The records and preoperative urodynamic studies of 30 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had undergone prior collagen injection (collagen group) and 7 had not (noncollagen group). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of less than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen injection and chosen artificial urinary sphincter primarily. RESULTS: Of the 30 patients 24 (80%) were incontinent following radical retropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients alternated the use of pads with the use of clamps or a condom catheter to aid in controlling leakage. Mean number of collagen treatment sessions for the injection group was 2.9 (range 1 to 7). There was a significant difference in mean time from prostatectomy to artificial urinary sphincter between the noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the groups, including mean age (66.2 years, range 45 to 83), mean followup (26.2 months), mean preoperative pads daily (5.8+/-3.4), median preoperative quality of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsalva leak point pressure (42.7+/-21.4 cm. water). For all patients in the study the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically significant differences between the collagen and noncollagen groups in any of these parameters. Among the collagen group 17 patients (73.9%) had a Valsalva leak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary sphincter) to be 12.9 months and the additional treatment costs (including pads daily and mean number of collagen syringes per patient), the direct costs of treatment for the collagen group were 85.6% higher than those for patients who chose artificial urinary sphincter primarily. CONCLUSIONS: Prior collagen therapy did not adversely influence the surgical complication rate or compromise effectiveness of the artificial urinary sphincter. However, patients with Valsalva leak point pressure less than 60 cm. water have lower rates of success with collagen injection therapy and could benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary therapy.

Sex inventories: can questionnaires replace erectile dysfunction testing?

OBJECTIVES: "Paper and pencil" sexual inventories are widely used by the pharmaceutical industry for categorizing the severity of erectile dysfunction (ED) and for efficacy end points of drug therapy. The International Index of Erectile Function (IIEF) evaluates several domains of male sexual behavior: erection, orgasm, desire, and satisfaction. We compared the subjective IIEF score for erectile function with the severity and etiology of ED as determined by pharmacologic testing with prostaglandin E1 (PGE1) and color duplex Doppler ultrasound testing (penile blood flow study [PBFS]). METHODS: Five questions from the IIEF that require the patient to quantify his erectile performance were compared with PBFS data. Examiners were unaware of IIEF scores during testing. PBFSs were performed after PGE1 injection, privacy, and self-stimulation; dosing was 6 microg (50 to 59 years) or 10 microg (60 years or older). PBFS diagnoses were arterial insufficiency (AI) for peak systolic velocity (PSV) less than 25 cm/s; cavernous venous occlusive disease (CVOD) for PSV greater than 35 cm/s and resistive index (RI) less than 0.9; and mixed vascular erectile dysfunction for a PSV from 25 to 35 cm/s and RI less than 0.9. A normal vascular diagnosis required a PSV greater than 35 cm/s and an RI of 0.9 or greater. Visual ratings of the erectile responses without Doppler assessment (inadequate, adequate, or excellent) were also compared with the IIEF and Viagra Study Group criteria (Q3+4). RESULTS: Eighty-nine patients underwent the complete evaluation. Eight patients (9%) were found to be normal vascularly (mean PSV 40.9 cm/s, mean RI 0.99). Thirty-four patients (38%) had AI (mean PSV 17.5, mean RI 0.74), 33 patients (37%) had mixed vascular ED (mean PSV 29.1, mean RI 0.80), and 14 patients (16%) had CVOD (mean PSV 45.9, mean RI 0.73). The mean IIEF score for the normal responders was 13.3; patients with AI, mixed vascular ED, and CVOD had mean IIEF scores of 6.9, 8.5, and 8.1, respectively. IIEF and Q3+4 values differed significantly between the normal and abnormal groups (P<0.05 and P<0.025, respectively), but no statistically significant differences in IIEF or Q3+4 scores were noted among the subgroups of abnormal responders. Analysis of the visual ratings of erections demonstrated that IIEF scores were significantly different between inadequate and excellent responders (P<0.05). CONCLUSIONS: IIEF scores did not statistically differentiate among the specific etiologies of ED as determined by evidence-based testing with PBFS. Furthermore, patients with normal results after testing with PGE1 (10 microg or less) had surprisingly low self-ratings of erectile performance (13 of 25 points). For the primary caregiver, the IIEF may help in the taking of the male sexual history, but for the specialist, sexual inventory scores will not distinguish among the various etiologies of vascular ED and do not predict the results of pharmacologic testing.

Collagen injection therapy for post-radical retropubic prostatectomy incontinence: role of Valsalva leak point pressure.

PURPOSE: We retrospectively evaluated the role of Valsalva leak point pressure as a predictor of successful management of post-radical retropubic prostatectomy incontinence with collagen injection. MATERIALS AND METHODS: Urodynamic studies and Valsalva leak point pressures of 31 men who received retrograde collagen injection for post-radical retropubic prostatectomy incontinence were reviewed. Patients were interviewed before and after treatment to assess pad use and the American Urological Association quality of life index (scale 0 to 6). Parameters for success were postoperative quality of life score 3 or less or 50% or greater decrease in pad use and that the patient would recommend collagen therapy to someone else. RESULTS: Of 31 patients 11 (35%) met the criteria for success, 2 (6%) were completely dry and 9 (29%) were improved. Successfully treated patients had a mean Valsalva leak point pressure of 64.0 cm. water compared to 42.2 cm. water in the failure group (p <0.01). Of patients with Valsalva leak point pressure of 60 cm. water or greater, 70% responded favorably to collagen injection (positive predictive value), while 81% with Valsalva leak point pressure less than 60 cm. water had treatment failure (negative predictive value) (p <0.02). There were no other statistically significant differences between those successfully treated with collagen injection and those in whom treatment failed, including mean age (62.7 to 68.1 years), mean volume of collagen (26.1 to 28.9 ml.), mean number of treatment sessions (2.45 to 2.65), mean followup (14.9 to 15.1 months), preoperative quality of life score (5.1 to 4.9), and preoperative pads per day (4.0 to 3.37). CONCLUSIONS: Our data suggest that collagen injection improves 35% but cures a minority of patients (less than 10%) with post-radical retropubic prostatectomy incontinence. A pretreatment Valsalva leak point pressure of 60 cm. water or greater has high predictive value for a beneficial outcome after collagen injection. We propose a role for Valsalva leak point pressure to select men cost-effectively with post-radical retropubic prostatectomy incontinence for therapy with collagen injection.