Pilot trial of bacterial interference for preventing urinary tract infection.

OBJECTIVES: To examine the safety and efficacy of bacterial interference in preventing symptomatic urinary tract infection (UTI). METHODS: A prospective, nonrandomized, pilot clinical trial was conducted in patients with spinal cord injury who had neurogenic bladder and had frequent episodes of symptomatic UTI. The bladder of patients was inoculated with a nonpathogenic prototype of Escherichia coli 83972. The rate of symptomatic UTI in successfully colonized patients while colonized with E. coli 83972 was compared with (a) their own baseline prestudy rate and (b) the rate of symptomatic UTI in patients who were not successfully colonized. RESULTS: Of 44 inoculated patients, 30 (68%) became colonized with E. coli 83972 for 1 month or longer. Only two episodes of symptomatic UTI occurred in the group of 30 patients while colonized with E. coli 83972 (a total of 34 patient-years), and none was attributed to E. coli 83972. The group of 30 patients experienced a 63-fold reduction in the rate of symptomatic UTI while colonized with E. coli 83972 versus their baseline prestudy period (mean 0.06 versus 3.77 episodes of symptomatic UTI/patient-year, P <0.001). The rate of symptomatic UTI was also 33-fold lower in this group of 30 patients while colonized with E. coli 83972 than in the well-matched group of 14 patients who were not successfully colonized (mean 0.06 versus 1.80 episodes of symptomatic UTI/patient-year, P <0.001). CONCLUSIONS: The results of this pilot study indicate that bacterial interference using E. coli 83972 may be safe and effective in preventing UTI.

Virulence properties of Escherichia coli 83972, a prototype strain associated with asymptomatic bacteriuria.

Little is known about bacteria associated with asymptomatic bacteriuria (ABU) with regard to urinary tract colonization mechanisms. In this study, virulence properties of Escherichia coli 83972, a strain that was isolated from a clinical ABU episode, were examined. The genetic potential for expression of P and type 1 pili was demonstrated, and DNA sequences related to type 1C and G (UCA) pilus genes were also detected. However, E. coli 83972 did not express D-mannose-resistant or D-mannose-sensitive hemagglutination after growth under standard conditions in vitro or upon isolation from the urine of colonized test subjects. Limited uroepithelial cell adherence was observed in vivo, and weak D-mannose-sensitive hemagglutination was detected after extended growth in urine in vitro.

Virulence factors of Escherichia coli isolates from patients with symptomatic and asymptomatic bacteriuria and neuropathic bladders due to spinal cord and brain injuries.

Chronic bacteriuria is a common occurrence among spinal-cord injury patients and others with neuropathic bladders. If bacteria are present in the urinary tract, the patient may develop symptoms of infection or remain asymptomatic. We have compared virulence properties of 28 Escherichia coli isolates from patients with symptomatic urinary tract infections (UTI) and 29 E. coli isolates from patients with asymptomatic bacteriuria (ABU). Bacteria from patients with symptomatic UTI were more likely to be hemolytic than isolates from patients with ABU (P = 0.05) or fecal isolates obtained from healthy volunteers (P < 0.001). Bacteria from patients with symptomatic UTI were also more likely than strains isolated from patients with ABU (P = 0.08) or fecal strains (P < 0.001) to exhibit D-mannose-resistant hemagglutination of human erythrocytes. The results suggest that E. coli isolates from nonimmunocompromised patients who require intermittent catheterization and who develop symptomatic UTI may be distinguished from bacteria recovered from patients who remain asymptomatic and possibly from normal fecal E. coli.

Decreased bladder compliance in patients with myelomeningocele treated with radiological observation.

PURPOSE: Recently others advocated frequent radiological surveillance to detect upper urinary tract deterioration in children with neurogenic bladder secondary to spina bifida. We reviewed the consequences of such expectant management on bladder compliance and urinary continence. MATERIALS AND METHODS: We retrospectively reviewed the records of 214 children presenting to our spina bifida clinic in a 13-year period. Follow-up is available for 95 girls and 86 boys. Imaging studies of the kidneys were repeated at 6 to 12-month intervals. Urodynamics were performed when upper urinary tracts deteriorated or in incontinent school age children. RESULTS: On radiographic study there was evidence of upper urinary tract deterioration in 79 children, including hydronephrosis in 34, hydronephrosis and vesicoureteral reflux in 19, and reflux only in 26. Follow up studies performed after clean intermittent catheterization and pharmacological therapy were instituted revealed resolution or improvement of upper tract deterioration in 52 patients (69%), while bladder compliance improved in only 42%. Surgical intervention was required in 34 children, despite improvement of upper tract changes in many of these patients on follow up radiographic studies. CONCLUSIONS: Although radiological surveillance of patients with myelomeningocele allows recognition of upper tract changes, the effects of elevated outlet resistance on bladder compliance are not as readily reversible as the initial radiographic findings. The incidence of enterocystoplasty exceeds that reported for patients treated prospectively based on urodynamic findings, which should be considered in the treatment of these children.

Voiding and erectile function after delayed one-stage repair of posterior urethral disruptions in 50 men with a fractured pelvis.

We evaluated 50 men who suffered a total disruption of the posterior urethra in conjunction with a fractured pelvis. The urethral disruption was treated with immediate placement of a suprapubic cystostomy and delayed one-stage urethroplasty. Subsequently, 15 required at least one visual urethrotomy and three underwent one urethral dilatation. All 50 now have a patent urethra and 38 (76%) void normally and are continent. Five have an areflexic bladder secondary to the injury and intermittently catheterize themselves but are continent. Three patients have mild urge incontinence and three mild stress incontinence, not requiring treatment or protection. One patient with an open bladder neck has moderate stress incontinence which has responded to imipramine therapy. Impotence was present both preoperatively and postoperatively in 24 (48%) of the patients but by one year only 16 (32%) of them were still not having erections. Eighteen patients (36%) claim to have erections equal to their pre-injury quality. However, 16 (32%) of the patients, although potent and able to have intercourse, have less than optimal erections.

alpha-Chloralose alters autonomic reflex function of the lower urinary tract.

The effects of alpha-chloralose on the micturition reflex were evaluated using an efficiently voiding decerebrate cat model. At laparotomy cannulas were introduced into the urethra and/or bladder for measurement of urethral perfusion pressure and/or bladder pressure during bladder filling and voiding. After establishment of efficient voiding in the anesthetic-free decerebrate cat, chloralose, 50 mg/kg iv, was administered. Parameters assessed before and after anesthetic included bladder pressure at peak of contraction (voiding pressure), intravesical pressure at onset of bladder contraction (threshold pressure), contraction amplitude, duration of bladder contraction, bladder volume at onset of bladder contraction (volume threshold), and residual bladder volume after voiding (postvoid residual). In addition to these parameters, preparations with intact bladder-urethra and with divided bladder-urethra were used to assess effects of chloralose on voiding efficiency and coordination between bladder and urethra, respectively. Chloralose significantly reduced voiding pressure, contraction amplitude, and voiding efficiency. Neither vehicle for the chloralose nor sympathetic denervation of the lower urinary tract affected these reductions. Chloralose had no effect on direct contraction of the bladder and urethra produced by intra-arterial acetylcholine (25-100 micrograms). Chloralose converted the synergic bladder and urethral responses during voiding to dyssynergic responses. Neuromuscular blockade with gallamine, 10 mg/kg iv, improved voiding efficiency.(ABSTRACT TRUNCATED AT 250 WORDS)

The incontinent myelodysplastic patient.

Urinary incontinence is a socially devastating aspect of the lives of many myelodysplastic children. Incontinence results from abnormal bladder storage function, urethral sphincteric incompetence, or both. Unfortunately, the vesicourethral dysfunction in an individual patient cannot be discerned from the level of the vertebral defect or the coexisting neurologic deficits. Therefore, thorough urodynamic assessment is required to identify altered physiology precisely and to guide rational treatment. Our therapeutic armamentarium includes external devices, intermittent self-catheterization, pharmacologic therapy, prosthetics, electrical stimulation, biofeedback, and innovative surgical procedures. Comprehensive evaluation, thoughtful tailoring of therapy to the individual patient, and a commitment by the urologist to indefinite follow-up will enable most patients to attain social continence while preserving renal function.

Bladder contracture following intravesical doxorubicin therapy: case report and a review of the literature.

Intravesical doxorubicin rarely has been implicated as a cause of bladder contracture. We present a case of severe bladder contracture, documented radiographically and urodynamically after 8 weekly intravesical instillations of doxorubicin. The patient subsequently underwent cystectomy because of voiding dysfunction and the specimen demonstrated marked fibrosis in the bladder wall. We postulate that a benign, recurrent bladder ulceration during doxorubicin therapy may have potentiated the fibrotic response in the bladder to the doxorubicin. Objective monitoring of bladder capacity should be considered in patients treated with intravesical chemotherapy.

Simple cyst of the testis.

We report 5 cases of simple cyst of the testis, the largest series to date, and review the literature. Included are 2 autopsy cases, a case of a multilocular simple cyst and 1 case treated nonoperatively. Based on our experience, simple cyst of the testis should be suspected particularly in an enlarged but otherwise palpably normal testis. High resolution real-time scrotal sonography revealing an anechoic mass in the testis with well defined walls, and enhanced posterior through transmission and edge shadowing is diagnostic for a simple cyst. An asymptomatic simple cyst of the testis may be treated with observation alone. The symptomatic simple cyst should be treated ideally with local parenchyma-sparing excision.

External sphincter dyssynergia: an abnormal continence reflex.

Some of the characteristics of detrusor-external sphincter dyssynergia were examined in 14 patients with traumatic upper motor neuron lesions within 44 weeks of injury. The sacral evoked response latencies of the male patients were shortened at any time after injury. A continence reflex could be demonstrated in most patients at any time after injury. Comparing averaged values for the group at 4-week intervals, resting pressure at the external urethral sphincter and post-void residual volumes reached nadirs at 12 weeks while voiding efficiency peaked at this time. Thus, voiding function appears to be optimal 12 weeks after injury. During reflex detrusor activity, increases in external urethral sphincter electromyographic activity and external urethral sphincter pressure were associated clearly with a positive slope of the intravesical pressure trace, whereas decreases in both parameters were associated with a negative slope. Voiding occurred only during a negative slope. Although propantheline induced detrusor areflexia, episodic peaks in external urethral sphincter pressure and electromyographic activity continued to occur. We propose that external sphincter dyssynergia, which is independent of detrusor contraction, is the continence reflex exaggerated owing to the loss of supraspinal influences. We believe that the multiple patterns of dyssynergia described previously by others are variations, largely owing to technique, of the single pattern we have observed. The observation of synergic-like urethral responses in some patients during a negative slope of the intravesical pressure, even with complete suprasacral spinal lesions, implies existence of a pathway for synergic-like voiding in the spinal cord.

Urodynamic evaluation of incontinence in patients undergoing modified Campbell radical retropubic prostatectomy: a prospective study.

A prospective urodynamic study was performed on 17 consecutive patients undergoing a modified Campbell radical retropubic prostatectomy for prostatic carcinoma. There was 1 postoperative death, leaving 16 evaluable patients. Patients were evaluated preoperatively and at 6 weeks, 3 months and 6 months postoperatively. The only urodynamic parameter 6 months postoperatively that differed significantly from the preoperative value was the functional urethral length, 1.6 and 4.3 cm., respectively. The incidence of clinical and/or urodynamic urinary incontinence preoperatively was 19 per cent and 6 months after the procedure it was 87 per cent. The incontinence rate did not correlate with the pathological stage or histological grade of the tumor. There was a strong trend toward improvement of continence with time but all patients who were incontinent 6 months postoperatively and followed for more than 1 year remained incontinent. While this incontinence rate is the highest reported, we believe that it reflects detailed patient interviews and objective fluoroscopic evidence of urethral urinary loss. These results and those of others suggest that modification of the technique of radical prostatectomy to produce a functional urethral length of at least 2.8 cm. may be desirable.

Adult respiratory distress syndrome complicating percutaneous nephrolithotripsy.

In an otherwise healthy thirty-six-year-old man adult respiratory distress syndrome developed following percutaneous nephrolithotripsy. Absorption of a large volume of irrigating solution occurred during the procedure and resulted in respiratory compromise, neither of which was appreciated intraoperatively. Close intraoperative monitoring of irrigation fluid input and output is necessary, and if a significant discrepancy develops, we believe the procedure should be terminated and diuresis instituted. In a difficult procedure, consideration should be given to establishing a maximum operating time and shortened if patient risk factors so warrant.

Familial juvenile type III spinal cord arteriovenous malformation: urodynamic findings.

Two sisters with juvenile type III spinal cord arteriovenous malformations were studied urodynamically. Micturitional dysfunction was prominent in the clinical presentation of both cases. Although both patients had similar lesions 1 demonstrated detrusor-sphincter dyssynergia and detrusor hyperreflexia, while the other showed only detrusor hyperreflexia. This is the first report of a familial occurrence of juvenile type III arteriovenous malformation and of the associated urodynamic findings.

Segmental renal artery emboli treated with low-dose intra-arterial streptokinase.

Herein we describe a sixty-one-year-old man with unilateral segmental renal artery emboli treated with renal intra-arterial streptokinase infusion. The initial infusion rate was 9,000 units/hr. which was decreased to 5,000 units/hr. over the next six hours. Periodic arteriography demonstrated progressive lysis and virtual complete resolution after fifty-two hours of infusion. Intravenous pyelogram (IVP) six weeks later showed almost complete return of functional compared with IVP obtained six years earlier. We have demonstrated successful clot lysis at an infusion rate of 5,000 units/hr., compared with reported rates of 25,000 units/hr. and without the frequently utilized initial large intravenous bolus. Such low-dose streptokinase infusion should, theoretically, limit the incidence of recognized dose-related complications and permit its use in clinical settings where higher dosages are contraindicated. Intra-arterial streptokinase therapy seems particularly suitable for the high surgical risk patient and in arterial lesions not amenable to surgery. The availability of this potentially efficacious therapy suggests that aggressive diagnostic studies be pursued early in patients suspected of having an acute renal arterial embolus.