[Melanosis of the urinary bladder--a case report with 10 years of follow-up and review of literature]. / Melanose der Harnblase--Fallbericht mit Langzeitverlauf über 10 Jahre und Literaturübersicht.

INTRODUCTION: Extradermal melanotic lesions are found predominantly in the oral cavity, colon or conjunctiva, and by far less frequently in other organs. We report for the first time a case of solitary melanosis of the urinary bladder with a follow-up of more than 10 years. CASE REPORT: A 48-year old man presented with symptoms of frequency, urge incontinence, obstructive voiding symptoms and nocturia. On urethrocystoscopy under general anaesthesia, melanosis of the bladder with visibly reduced bladder capacity was diagnosed and confirmed on biopsy. The patient was treated for his micturation problems with alpha-blockers, intravesical electrostimulation and GAG-substitution therapy, without success. The chronic progression of bladder symptoms and shrinkage eventually led to cystoprostatectomy and bladder replacement by an orthotopic ileal neobladder, 10 years after primary diagnosis. CONCLUSION: The very low number of reported cases accounts for the lack of management guidelines for this disease. Symptomatic treatment as well as repeated cystoscopic monitoring are logical therapeutic recommendations. Since the development of malignant disease can only be ruled out microscopically, repeated biopsies or prophylactic cystectomy need to be considered.

Non-bacterial cystitis.

The concept of non-bacterial cystitis (NBC) combines sterile urine and cystitic symptoms as well as inflammatory changes, in particular in the mucosa and submucosa of the bladder. It includes a multiplicity of vicious circles along the entire continence reflex. An understanding of NBC presupposes knowledge of the origin of the normal urinary urge and its successful control. Against the background of the steadily increasing incidence of interstitial cystitis (often irreversible end-stage NBC), it is suggested here that in the face of a failure of first-line therapeutics (anticholinergics, cyclic antidepressants or oestrogens), one must consider without delay the possible presence of NBC.

Evidence for the autoregulation of vesical circulation by intravesical potassium chloride and distension in the normal human bladder.

OBJECTIVES: To determine the influence of distension and intravesical KCl on vesical blood flow in the normal human bladder. Subjects and methods Nine normal volunteers underwent comparative cystometry (NaCl vs 0.2 mol/L KCl; filling rate 50 mL/min). Peak systolic blood flow velocity (PSBFV) and end-diastolic blood flow velocity (EDBFV) were measured in several intramural arteries at a filling volume of 50 mL and at maximum cystometric capacity (Cmax). For these measurements a colour Doppler unit fitted with an endorectal probe was used. The resistance index (RI) was defined as (PSBFV-EDBFV)/PSBFV. RESULTS: In the presence of NaCl, the mean PSBFV increased significantly from 9 cm/s at 50 mL to 17 cm/s at Cmax (512 mL). Compared with NaCl, KCl induced a significantly higher mean PSBFV at 50 mL (15 cm/s). With increasing distension the rise in PSBFV with KCl filling (Cmax 478 mL) was nearly parallel to that obtained on NaCl filling (mean 22 cm/s); the RI did not change. CONCLUSIONS: Bladder distension and intravesical KCl significantly increased the PSBFV. The unchanged RI indicated a concomitant increase in perfusion rates. Hence, the composition of urine (high potassium concentrations and hyperosmolarity) and its storage govern the autoregulation (independent of cardiac output) of vesical circulation, probably by reflexive pathways. These findings provide further evidence for prevesical arteriovenous shunts.

Leaky urothelium and/or vesical ischemia enable urinary potassium to cause idiopathic urgency/frequency syndrome and urge incontinence.

Urine contains up to 10 times more potassium (K+) than blood plasma. Hence, extracellular K+ concentration of the bladder wall can increase secondary to a leaky urothelium (GAG layer deficiency) and/or vesical ischemia (reduced washout) at low filling volumes. Consequent sensory afferentiated excitation/depolarization of the detrusor leads to urgency/frequency and facilitates the onset of 'uninhibited' contractions. This feature, in association with a weak rhabdosphincter, causes urge incontinence. The non-neuromuscular (non-reflexive) origin explains refractoriness to any neurotransmitted inhibition. Even successful interference with contractility (Ca2+) leaves depolarization unaffected. Accordingly, comparative cystometry (saline versus 0.2 M KCl) is recommended in order to comprise better former falsely under-diagnosed 'normals' as well as former undiscovered urge incontinence, and thus indications for bladder neck surgery as well as neuromuscular drug treatment. Future first-line therapy in idiopathic storage disorders should be directed to the GAG layer, vesical blood flow (K+ washout) and the rhabdosphincter.

Percutaneous nephrostomy tube with perirenal balloon fixation.

Despite a variety of available systems the fixation of nephrostomy catheters has not been solved satisfactorily so far. Secure and comfortable fixation of the presented nephrostomy tube is provided by its inflatable balloon which is placed in the perinephric space so that the abdominal wall will retain it.

Changes of hypo- and hypertonic sodium chloride induced by the rat urinary bladder at various filling stages. Evidence for an increased transurothelial access of urine to detrusor nerve and muscle cells with distension.

By means of a transaortal injection of a gelatine ink mixture, a manifold mucosa to muscularis blood flow ratio was proved. In addition, the treatment of hypo- and hypertonic NaCl by the rat urinary bladder has been studied at 0.3-, 0.6- and 0.9-ml filling levels in conjunction with continuous bladder pressure recording. With distension an increased permeability to NaCl (efflux) and/or water (influx) was found in hypertonic conditions. In order to demonstrate this, the decreasing surface to volume ratio with distension has to be considered. Final urea concentrations in hypertonic media significantly exceeded those in hypotonic probes. The phenomenon has been hypothetically attributed to the existence of an arteriovenous counter current exchange within mucosal vessels. In comparison to hypotonic bladder contents, hypertonic media increased basic bladder pressures and phasic pressure amplitudes preferably at the 0.9-ml level. Hence, in context with an increased permeability, distension favors access of the bladder content to detrusor nerve and muscle cells thereby facilitating their excitability.

Permeability characteristics of the rat urinary bladder in experimental cystitis and after overdistension.

The permeability characteristics of the rat urinary bladder were investigated in experimental cystitis achieved by xylene/Escherichia coli, after dimethylsulfoxide (DMSO) exposure and 3 and/or 10 days after overdistension. The changes were found to be comparable between experimental cystitis and DMSO treatment, whereas those after overdistension were specifically different in nature. Passive increases in NaCl permeability were shown to be accompanied by functional, metabolic impairment of the urothelium. It has been suggested that the concept of an almost impermeable 'blood-urine barrier' is completely misleading under these circumstances. This should be taken into account in future clinical considerations.

Intravesical ions, osmolality and pH influence the volume pressure response in the normal rat bladder, and this is more pronounced after DMSO exposure.

The influence of intravesical ions, osmolality, pH value, and active transurothelial NaCl-transport inhibition (furosemide) on the rat bladder volume-pressure response was studied according to the concept of a permeable urothelium and according to direct effects of osmolality and K+ on in vitro muscle preparations. It was found that the bladder capacity was decreased by K+, hyperosmolality and pH5, whereas it was increased by hypoosmolality, electrolyte-free media, furosemide and pH 8. The effects were found to be pronounced after dimethyl sulfoxide (DMSO) exposure. In this condition, furosemide showed less effect. It has been suggested that, especially in diseased bladders with increased permeability, frequent voiding and painful urge sensations are due to an enhanced urine access to nerve and muscle cells of the detrusor. On the other hand, frequent voiding reduces the urinary contact time within the bladder, thereby protecting from urine recirculation and thus from renal insufficiency. It has been further suggested that the bladder is not exclusively under central nervous control. As far as the present study is concerned, CO2, water, and normal saline do not seem to be appropriate urodynamic test media for providing the standard situation of bladder filling.

Angiotensin I converting enzyme in the ejaculate of fertile and infertile men.

ACE has been measured in the seminal plasma of fertile and infertile men according to the method of Cushman and Cheung. High enzyme activity was found in fertile subjects which did not significantly differ from those with oligozoospermia and those with the Sertoli cell-only syndrome. Enzyme activity was significantly lower after vasectomy. The data suggest a higher enzyme/sperm cell ratio in oligozoospermia. Considerable enzyme activity in obstructive azoospermia can be attributed to enzyme formation within either the prostate or the seminal vesicles.

Post-vasectomy impairment of transepithelial water reabsorption in the initial segment of the epididymis.

Using a modified split-droplet micropuncture technique there was an impairment of water reabsorption in the initial segment of the epididymis 2 weeks post vasectomy. This was supported by light-microscopy. The cause and a possible reversal of this impairment are not apparent. However, in men, low sperm counts post vasectomy reversal and eventually otherwise could be attributed not only to suppression of spermatogenesis in the testis but also to impairment of sperm concentration in the epididymis.

PIP: A study was undertaken to determine whether vasectomy affects water reabsorption at the site of its greatest capacity. To supply the data, additional histology slides were provided. 10 male Sprague Dawley rats weighing between 300-350 gcm were anesthetized by intraperitoneal injection of sodium pentobarbital (Nembutal), 100 mg/kg body weight. Bilateral vasectomy was performed through a midline laparatomy incision. The vas deferens was dissected free from the major deferential blood vessels prior to removal of a 5 mm section of the vas between 3-0 vicryl ligatures. At the end of the operation the abdominal muscle and skin layers were closed separately with interrupted 3-0 vicryl sutures. A 2nd group (n = 5) was sham operated. The vasa were only manipulated without interrupting their continuity. In both groups after surgery the testes were repeatedly palpated to ensure scrotal location. Sham operated and treatment animals were anesthetized with an intraperitoneal injection of Inactin, 120 mg/kg body weight. The trachea was cannulated and the right external jugular vein was catheterized for steady infusion of Ringer's solution for continued proper fluid balance. The gonads were approached through an inguinal incision and the epididymides prepared for micropuncture. For assessment of fluid reabsorption a modified split droplet micropuncture tecnique was applied. After injecting a Sudan black stained castor oil bolus into a selected tubulus segment free flow of the bolus was blocked by squeezing the tubulus distalwards. After removing the oil capillary tube, 3 nl of NaCl, 145 mmol/l was injected into the middle of the oil bolus, thereby dividing it into 2 columns. As a result of reabsorption of the test fluid, the 2 separated oil columns moved towards each other and came into contact after a period of time. Specimens obtained from the initial segment of the epididymis were fixed with Bouin solution, dehydrated in increasing concentrations of propanol, and embedded in Paraplast. All treated animals developed typical sperm granulomas close to the site of the ligature and a distended and stuffy packed cauda epididymides. The more proximal parts of the epididymides and testes appeared to be normal. All sham operated animals failed to show any alteration. 2 weeks after sham operation the mean time required for reabsorption of 3 nl NaCl, 145 mmol/l was 11.1 + or - 3.6 minutes, which is in the range of untreated animals of the same age. 1 week postvasectomy this time was 26.6 + or - 4.8 minutes, which differed significantly from the former value. 2 weeks thereafter 32.6 + or - 3.5 minutes were evaluated. If fluid reabsorption failed to become visible within 30 minutes, the experiment was discontinued. According to light microscopy no apparent difference concerning tubulus diameter, epithelium cell height, and sperm density between sham operated and treatment animals was found.

The effect of age, mating and vasoligature on angiotensin I converting enzyme in rat testis and epididymis.

Angiotensin I converting enzyme was measured in testis, different sections of epididymis and vas deferens of rats with the analytical method of Piquilloud et al. In tissue specimens without a prior washout of seminal fluid the highest enzyme activity was found in the testis. The enzyme activity fell significantly towards the end of the excurrent ducts, suggesting that the enzyme is synthesized in the Sertoli cells of the testis, undergoes exocrine secretion and is partially inhibited during passage through the epididymis. This was supported by additional analyses of seminal fluid from rete testis and vas deferens. According to data obtained from various age groups, sexual stimulation due to mating and bilateral vasoligature, enzyme synthesis in the testis and enzyme inhibition in the epididymis seem to be under simultaneous (androgenic) control. Though the highest specific enzyme activity in the rat is located in the gonads, CE's enzyme substrate and the anatomical structures on which its reaction product is effective are not yet apparent.

[Bladder injuries--diagnosis, acute care and late results]. / Blasenverletzungen--Diagnose, Akutversorgung und Spätergebnisse.

From 1962 up to 1980 82 bladder injuries have been diagnosed and treated at the University Hospital Innsbruck, Department of Urology. Excluding the iatrogenic bladder trauma, we report on the extraperitoneal and intraperitoneal rupture as well as the contusion. Diagnosis and acute management are emphasized. The effectiveness of the diagnostic and therapeutic regimen is supported by the lack of major complications and by the encouraging late results.

Angiotensin I converting enzyme in rat testis, epididymis and vas deferens under different conditions.

Angiotensin I converting enzyme (ACE) was found in the testis, epididymis and vas deferens of rats. In tissue specimens without a prior washout of seminal fluid the highest specific ACE activity was measured in the testis. The enzyme activity was significantly lower towards the end of the excurrent ducts, suggesting that the enzyme is synthesized in the testis and secreted into the seminal fluid there. An ACE inhibiting substance may be secreted by the epididymal epithelium. Enzyme synthesis and enzyme inhibition are probably under simultaneous endocrine control. In-vitro inhibition, pH- and temperature-dependence of gonadal ACE correspond with that of lung and blood plasma. However, the physiological function of the enzyme on sperm motility and fertility remains unsolved.