The infusion trial of micturition.

OBJECTIVE: To compare three methods for a trial of micturition (TOM) (the midnight removal of the catheter, dawn removal, and a new infusion method) in a randomized prospective study. PATIENTS AND METHODS: A total of 118 consecutive patients who had undergone transurethral resection of the prostate (TURP) or bladder neck incision (BNI) underwent TOM by one of the three methods. In the infusion method, the bladder was filled at a fast-drip rate via the catheter from a bag of normal saline connected by an intravenous supply set. The catheter was then removed, the patient voided and the volume was measured. From the volume of saline remaining, it was possible to calculate the residual volume in the patient. RESULTS: The infusion TOM took a mean 13 h less than the other two methods, which were statistically indistinguishable. CONCLUSION: The infusion TOM is safe and simple, is quick to carry out and can be performed at any time. It establishes the completeness of bladder emptying, which helps in the assessment of voiding.

Peri-urethral silicone microimplants (Macroplastique) for the treatment of genuine stress incontinence.

OBJECTIVE: To establish the safety and efficacy of the periurethral injection of silicone microimplants (Macroplastique) for the treatment of genuine stress incontinence in women. PATIENTS AND METHODS: Forty women (median age 50 years, range 27-74) with genuine stress incontinence confirmed on medium-fill video-cystometry were recruited to the study. Macroplastique (3-7 mL) was injected periurethrally 1 cm distal to the bladder neck at three or four points 'around the clock' under cystoscopic control. Where possible, the urodynamic study was repeated after 3 months. Results were graded as excellent (dry, no protection), good (better, but not totally dry) or poor (no improvement). RESULTS: Three months after a single injection, 16 (40%) were completely dry, 13 (33%) were improved and 11 (27%) were no better. Four patients who were improved were rendered dry by a second injection. After 3 years, 16 (40%) remained completely dry, seven (18%) were improved and 17 (42%) required alternative treatment with a Stamey bladder neck suspension. Dysuria for 48 h occurred in almost all patients; two were catheterized overnight and one required a catheter for 6 weeks. A comparison of maximum voiding pressures and flow rates before and 3 months after a single injection of Macroplastique revealed no urodynamic evidence of obstructed voiding (n = 25). CONCLUSION: Injectable silicone microimplants produced a good to excellent result in 73% of patients in the short-term and 58% of women maintained this response after 3 years. The injection is a day-case procedure which provides a satisfactory medium-term outcome in over half of patients with genuine stress incontinence. There are few side-effects and those patients with no improvement may go on to be treated by open surgery without complication.

A comparison of intramuscular ketorolac and pethidine in the alleviation of renal colic.

OBJECTIVE: To compare the analgesic efficacy of a single 30 mg intramuscular dose of ketorolac with that of intramuscular pethidine 100 mg, in a double-blind, parallel-group investigation of patients presenting with pain suggestive of renal colic. PATIENTS AND METHODS: Seventy-six patients (17 women, 15 men; mean age 45.2 years, range 20-80) were allocated by means of a pre-determined randomization schedule to receive ketorolac and 78 patients (20 women, 58 men; mean age 42.1, years range 18-70) to receive pethidine. Data from eight patients in the ketorolac group and six in the pethidine group were excluded from the efficacy analyses because of protocol violations. The severity of each patient's pain was assessed on a four-point verbal rating scale (VRS) and a 10 cm visual analogue scale at pre-dose and at 15 min intervals for the first hour post dosing. The time to first administration of rescue analgesic, up to 24 h following dosing with the study medication, was recorded. Adverse events were elicited by general questioning. RESULTS: Eighty-eight per cent of patients in each treatment group had improved according to the VRS of pain severity 1 h after dosing; the summed pain intensity differences up to 1 h were statistically significantly different in favour of ketorolac (P < 0.05). Fifty-six per cent of patients who were receiving ketorolac required rescue analgesia during the study period compared with 74% receiving pethidine. The incidences of adverse events were lower in the ketorolac group (28%) than the pethidine group (51%). CONCLUSION: Ketorolac can be considered a viable alternative to pethidine for the treatment of renal colic.

Agonist-induced contraction and accumulation of inositol phosphates in the guinea-pig detrusor: evidence that muscarinic and purinergic receptors raise intracellular calcium by different mechanisms.

In vitro contractile responses to electrical stimulation, ATP, histamine, and carbachol were measured in strips of guinea pig detrusor. The contractile responses were redetermined at intervals after replacement of the Krebs bicarbonate buffer with a nominally calcium-free medium. Agonist induced accumulation of [3H]-inositol phosphates was measured in a suspension of detrusor slices. Electrical stimulation (five second train; frequency 20 Hz; pulse width 100 microseconds) produced a contraction that was abolished by tetrodotoxin (10(-6) M) and reduced by approximately 50% in the presence of atropine (10(-8) M). This atropine resistant component was abolished by desensitization of the purine receptors with alpha, beta-methylene ATP, confirming that the response was mediated by nerves that released ATP and acetylcholine. Carbachol, ATP, and histamine produced concentration dependent contractions in guinea-pig detrusor strips. The response to ATP was much more dependent on extracellular calcium than the response to carbachol. Muscarinic, but not purine-receptor stimulation induced the accumulation of [3H]-inositol phosphates. These data suggest that ATP stimulates a purine receptor which opens a membrane ion channel and allows an influx of calcium while muscarinic receptor stimulation can mobilize intracellular calcium via hydrolysis of inositol phospholipid and production of the second messenger inositol triphosphate.

Indoramin--an effective new drug in the management of bladder outflow obstruction.

There is a need for symptomatic relief in some patients with bladder outflow obstruction. The alpha blocker indoramin was tested in a prospective, double-blind, placebo-controlled trial. Thirty men were given indoramin or placebo. Flow rates and cystometrograms were performed before inclusion and at the end of 8 weeks' treatment. Indoramin gave significant relief of symptoms and dramatically improved peak flow rates. There were three withdrawals because of adverse effects and two withdrawals in the placebo group because of retention. Other side effects were either minor or transient.

Cord compression and carcinoma of the prostate: is laminectomy justified?

Metastatic carcinoma of the prostate is a common cause of spinal cord compression. In this review of 37 men who underwent laminectomy for this condition this was the first presentation of previously undiagnosed cancer in 11 (29%). One year after decompression 17 (50%) were alive. Twenty patients (59%) could walk after laminectomy. All but 8 were relieved of pain and bladder function was improved in 13 (38%). Those ambulant before laminectomy (7) and those with occult prostate cancer did particularly well. Poor results were associated with a rapid onset of paraparesis and pre-operative progression to paraplegia. A delay in diagnosis was detrimental to outcome. A high index of suspicion in patients with carcinoma of the prostate is essential so that early diagnosis can be made before paraplegia is established. Carcinoma of the prostate must always be excluded in men with cord compression of unknown aetiology.