Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction.

OBJECTIVES: Sildenafil has been demonstrated to be safe and effective in the treatment of men with erectile dysfunction. The role of sildenafil in treating women with sexual dysfunction has heretofore not been reported. The purpose of this preliminary study was to ascertain the response of postmenopausal women with self-described sexual dysfunction treated with sildenafil for 3 months. METHODS: Thirty-three consecutive postmenopausal women with sexual dysfunction based on history were entered in this open-label, nonrandomized study. All patients received 50 mg of sildenafil. Efficacy was assessed at weeks 4, 8, and 12 using a newly developed 9-item, self-administered Index of Female Sexual Function (IFSF) and a global efficacy question ([GEQ] Did treatment improve your sexual function?). The IFSF quantifies the domains of desire, quality of sexual intercourse, overall satisfaction with sexual function, orgasm, lubrication, and clitoral sensation. RESULTS: Of the group, 30 women (91 %) completed the study and were available for follow-up at 3 months. Mean baseline IFSF score before therapy was 24.8+/-9.8. Mean usage of sildenafil was 3.1+/-1.4 times per week for the duration of the study. The IFSF score improved to 29.5+/-7.6, 30.3+/-8.5, and 31.4+/-10.4 at 4, 8, and 12 weeks, respectively (P = 0.25). Mean scores for questions 2 (lubrication), 8 (orgasm), and 9 (clitoral sensation) improved by 23.2%, 7.4%, and 31.3%, respectively, at 12 weeks. Seven women (21%) noted improvement on the GEQ. Overall, only 6 (18.1%) of 33 patients had a significant (more than 60% improvement in IFSF score) therapeutic response. Clitoral discomfort and "hypersensitivity" occurred in 7 women (21%), 3 of whom withdrew from the study. Other side effects, which did not result in withdrawal from the study, included headache (n = 5), dizziness (n = 4) and dyspepsia (n = 3). CONCLUSIONS: The data suggest that sildenafil is well tolerated in postmenopausal women with sexual dysfunction. Overall sexual function did not improve significantly, although there were changes in vaginal lubrication and clitoral sensitivity. The role of sildenafil in treating sexual dysfunction in various cohorts of women remains to be determined.

Transurethral resection of the prostate versus transurethral electrovaporization of the prostate: a blinded, prospective comparative study with 1-year followup.

PURPOSE: Transurethral electrovaporization of the prostate has been increasingly used as a surgical adjunct in the management of men with lower urinary tract symptoms. In this prospective study we compare the safety and efficacy of transurethral resection of the prostate and electrovaporization. MATERIALS AND METHODS: We compared 32 consecutive men (mean age 68.9 years) with lower urinary tract symptoms treated by transurethral electrovaporization of the prostate to a cohort of 32 men (mean age 72.8 years) treated by transurethral resection of the prostate. Parameters of evaluation included American Urological Association symptom score, peak urinary flow rate, adverse events, including serial changes in serum hematocrit and sodium, operative time, postoperative catheterization time, hospitalization time and days lost from work. The data were analyzed by an investigator who was blinded to which procedure was performed. RESULTS: A total of 61 patients were evaluable for followup at 1 year. None required retreatment. At 1 year symptom score decreased 12.8 (66% of patients) and 12.2 (67%) and peak urinary flow increased 9.7 ml. per second (135%) and 11.3 ml. per second (136%) for electrovaporization and resection, respectively, (p <0.001). Operative time was significantly longer with electrovaporization than with resection (47.6 +/- 17.6 versus 34.6 +/- 11.2 minutes, p <0.003). Catheterization time (67.4 +/- 13.6 versus 12.9 +/- 4.6 hours), hospitalization time (2.6 +/- 0.9 versus 1.3 +/- 0.5 days) and days lost from work (18.4 +/- 7.6 versus 6.7 +/- 2.1) were significantly greater for resection than electrovaporization, respectively. There were no major complications in the electrovaporization group while in the resection group 1 patient required transfusion (5 units) and in 1 a clinical transurethral resection syndrome developed. Potency and retrograde ejaculation were normal in 18 of 18 patients (100%) and 13 of 17 (76%) after resection and 19 of 20 (95%) and 17 of 20 (85%) after electrovaporization. CONCLUSIONS: The results indicate that transurethral resection and transurethral electrovaporization of the prostate are effective in reducing lower urinary tract symptoms with similar preservation of sexual function. Both significantly improve peak urinary flow, although resection to a greater degree. Postoperative morbidity, catheterization time, hospitalization time and days lost from work were significantly less, and operative time was significantly longer with electrovaporization. Further studies are underway to determine the long-term durability of response of transurethral electrovaporization of the prostate relative to transurethral resection.

The limited impact of involved surface area and surgical débridement on survival in Fournier's gangrene.

OBJECTIVE: To evaluate the influence of involved surface area (extent of disease) and the number and timing of surgical débridements on survival in patients with Fournier's gangrene. PATIENTS AND METHODS: The medical records of 30 patients with Fournier's gangrene treated over a 15-year period were reviewed. The extent of disease was quantified and expressed as a percentage of the body surface area by applying a modified diagram used to assess burn injuries. The number of surgical débridements and their timing with respect to initial presentation and to each other were also analysed. Patients were stratified by outcome (survival or death) and the data evaluated by Student's t-test, Fisher's exact test and regression analysis. RESULTS: Of 30 patients treated 13 died (43%) and 17 survived (57%). The mean surface area involved by disease among survivors was 4.3% (range 1-16.5%) and 7.2% (range 5-20.5%) for non-survivors (P = 0.10). Whilst no direct correlation between death rate and extent of disease existed, patients with < 5% surface area involvement were more likely to survive (P = 0.014). Every patient underwent surgical débridement of the involved area (mean 1.72 procedures per patient). Survivors underwent from one to four débridements (mean 1.79) and non-survivors one to three débridements (mean 1.63); the mean number of débridements did not influence outcome (P = 0.68). The performance of more than one débridement did not affect survival (P = 1.00). The initial débridement was performed within 24 h of presentation in 10 of 13 patients who died and 11 of 17 survivors and had no effect on outcome (P = 0.69). A second débridement was performed after a mean of 6.8 days (range 1-12) among the six survivors and 5.4 days (range 2-16) among the five non-survivors; this difference was not statistically significant (P = 0.65). Four survivors required a third débridement, one required a fourth and one patient who succumbed underwent a third débridement. CONCLUSION: The mortality rate from Fournier's gangrene continues to be substantial (43% in our series). Although no linear correlation existed, the quantified extent of disease may affect outcome as patients with > 5% of body surface area involved were more likely to succumb to the disease. Finally, the number of surgical débridements, even if first performed within 24 h of presentation, had no impact on outcome in patients with Fournier's gangrene.

Outcome prediction in patients with Fournier's gangrene.

We treated 30 patients with Fournier's gangrene during a 15-year period. Data were collected on demographics, medical history, admission signs and symptoms, physical examination, admission laboratory studies and bacteriology. The timing and degree of surgical débridement as well as antibiotic therapy were also reviewed. The extent of disease was calculated from body surface area nomograms. Data were stratified according to the outcomes of death (13 patients) or survival (17). Patients who survived were significantly younger (53 years old, range 23 to 90) than those who died (71 years old, range 53 to 83, p = 0.004). Admission laboratory parameters that were statistically related to outcome included hematocrit, blood urea nitrogen, calcium, albumin, alkaline phosphatase and cholesterol levels. White blood count, platelets, potassium, bicarbonate, blood urea nitrogen, total protein, albumin and lactic dehydrogenase levels 1 week following hospitalization were also associated with outcome. The greater mean extent of body surface area involved among patients who died was not statistically different from that of those who lived (7.16 and 4.32%, respectively, p = 0.1). The number of surgical débridements did not seem to influence outcome. To assess better the physiological profile of the patients in both outcome categories, the acute physiology and chronic health evaluation II severity score was modified to create a Fournier's gangrene severity index. The mean Fournier's gangrene severity index for survivors was 6.9 +/- 0.9 compared to 13.5 +/- 1.5 for nonsurvivors. Regression analysis demonstrated a strong correlation between Fournier's gangrene severity index and death rate (correlation coefficient = 0.934, p = 0.005). Using a Fournier's gangrene severity index threshold value of 9, there was a 75% probability of death with a score greater than 9, while a score of 9 or less was associated with a 78% probability of survival (p = 0.008). In conclusion, Fournier's gangrene is an infectious disease affecting an ever aging population of patients. Deviation from homeostasis is the most important parameter predictive of outcome and not the extent of disease or performance of surgical débridement. The Fournier's gangrene severity index is an objective and simple method to quantify the extent of metabolic aberration that may be used to predict outcome. We recommend the use of the Fournier's gangrene severity index when evaluating therapeutic options and reporting results.

Prostate cancer screening using fine-needle aspiration cytology prior to open prostatectomy.

We performed a prospective study to evaluate fine-needle aspiration (FNA) cytology as a screening tool of carcinoma of the prostate in 159 men with normal digital rectal examinations and acid phosphatase prior to open prostatectomy for voiding symptoms. The incidence of carcinoma of the prostate was 5.6%. 4 patients had A1 lesions and 5 had A2 lesions. Only one A2 lesion was malignant cytologically. The sensitivity was 56%, specificity 69%, positive predictive value 24% and negative predictive value 90%. Sufficient cytologic specimens were provided in 66% of cases. While FNA is at least equal to core biopsy as a diagnostic modality of palpable prostatic abnormalities, it does not prove to be an adequate screening modality for occult carcinoma of the prostate in the prostatectomy candidate.

Distribution and variability of resistive index values in undilated kidneys in children.

OBJECTIVES: To assess better the utility of duplex Doppler sonography in the diagnosis of obstructive hydronephrosis in children, we specifically studied undilated urinary tracts with the intention of establishing a nomogram of resistive index (RI) values and determining if the RI value of 0.7 reliably precludes an undilated collecting system. METHODS: Renal duplex Doppler ultrasound was performed in a standard fashion on 47 children more than 12 months of age (93 renal units) where there was no suspicion of upper urinary tract dilation. RI and RI ratio (RIR) were calculated and statistical analysis performed. RESULTS: There were 27 males and 20 females 12 to 180 months old (mean, 63.9 months). Kidney size ranged from 5.0 to 9.8 cm (mean, 7.28 cm), RI ranged from 0.34 to 0.94 (mean, 0.65), and RIR ranged from 1.00 to 1.76 (mean, 1.14). There was no statistically significant relationship between the RI and renal size or laterality, gender, or age (p > 0.05). However, between the ages of 24 and 108 months, the RI was significantly higher in females compared with males (p = 0.002). If one were to use 0.7 and 1.10 as discriminatory values for RI, 37% of renal units had values above 0.7, and 41% of RIR values were above 1.10. CONCLUSIONS: We believe that RI values in undilated kidneys of children vary significantly and its routine use and reliability need to be evaluated further in the pediatric population.

Unusual case of renal Candida fungus balls.

Renal fungus balls are rare in the adult population. A case of asymptomatic renal pelvic fungus balls is presented, and several approaches to treatment are discussed.

Simplified gonadotropin-releasing hormone (GnRH) stimulation test.

Provocative gonadotropin-releasing hormone (GnRH) stimulation testing indirectly assesses testicular function with more sensitivity than determination of basal gonadotropin levels alone. Unfortunately, the drawbacks of multiple blood sampling and high cost have limited the clinical usefulness of this test. We herein present a simplified, two-point, thirty-minute GnRH stimulation test. Statistical analysis of data from 55 men with normal baseline gonadotropin levels, reveal that this simplified test is just as accurate as the traditional test (p less than 0.0001) without the latter's attendant difficulties. In addition, we found that normal basal gonadotropin levels had little correlation to the actual responses obtained from GnRH stimulation testing (r = 0.20 and r = 0.39 for luteinizing hormone and follicle-stimulating hormone, respectively).

Unilateral testicular torsion: abnormal histological findings in the contralateral testis--cause or effect?

A histological review of testicular biopsies of the contralateral testis, obtained at the time of surgical intervention for testicular torsion, was performed in 20 post-pubertal men. Contralateral histological abnormalities were found in 12 specimens. The duration of torsion correlated well with the viability of the involved testis but not with the presence of contralateral abnormalities. The high incidence of contralateral histological abnormalities and their nature suggest that they existed prior to the torsion since they would be unlikely to appear at such an early stage. We believe that some patients who suffer testicular torsion probably have congenital anomalies of both testes. These abnormalities involve testicular parenchyma as well as the suspension system.

Paravesical granulomas masquerading as bladder neoplasms: late complications of inguinal hernia repair.

Paravesical granuloma formation after inguinal herniorrhaphy is a rare complication due to infected suture material. We present 8 cases of large paravesical granulomas masquerading as bladder tumors. Irritable symptoms predominate the symptom complex and accurate diagnosis can be obtained with multiple, sonographically guided, needle biopsies of the mass. An operation results in complete resolution of the symptoms, while nonoperative management may help to improve but not resolve the symptoms.

Detection of testicular endocrine abnormalities and their correlation with serum antisperm antibodies in men following vasectomy.

We measured the serum gonadotropin response to gonadotropin-releasing hormone in 25 men who underwent vasectomy 2 to 64 months before the study. Ten age-matched fertile men were used as controls. Baseline serum follicle-stimulating hormone, luteinizing hormone and testosterone levels were not significantly different between vasectomized men and controls. However, mean serum follicle-stimulating and luteinizing hormone responses to an intravenous bolus injection of 100 mcg. gonadotropin-releasing hormone were significantly greater in the vasectomy group (p equals 0.008 and 0.003, respectively). There was no correlation between these responses and the interval after vasectomy. Serum antisperm antibodies were present in 13 vasectomized men (52 per cent) using enzyme-linked immunosorbent assay and microagglutination techniques. A significant correlation (p equals 0.003) was found between the presence of serum antisperm antibodies and a normal follicle-stimulating hormone response to gonadotropin-releasing hormone stimulation. Of 13 patients with demonstrable antisperm antibody titers 9 (69 per cent) had normal follicle-stimulating hormone responses, compared to only 1 of 12 (8 per cent) without identifiable antisperm antibody titers. Our data suggest that certain men following vasectomy have abnormalities in seminiferous tubule and Leydig cell functions of the testes. These abnormalities are unrelated to the interval after vasectomy and are not identifiable with routine static hormonal measurements. In addition, serum antisperm antibodies are most likely to be present in men who demonstrate normal seminiferous tubular activity after vasectomy.

Gonadal dysfunction after testicular torsion: luteinizing hormone and follicle-stimulating hormone response to gonadotropin releasing hormone.

We studied 14 postpubertal patients at an average of 33 months after treatment for testicular torsion. Of these patients 11 had been treated by detorsion and 3 by orchiectomy. Five normal male volunteers of the approximate age of the study group served as controls. The patients treated by detorsion were subdivided into 3 groups based on the degree of atrophy of the detorsed testicle: group 1--no testicular atrophy (5), group 2--25 per cent testicular atrophy (2) and group 3--greater than 90 per cent testicular atrophy (4). Mean duration of torsion was greatest in the orchiectomy group (161 hours) compared to 6, 16 and 29 hours for groups 1, 2 and 3, respectively. The serum luteinizing hormone and follicle-stimulating hormone response to an intravenous bolus of 100 mcg. synthetic gonadotropin releasing hormone was measured in all patients. All groups had a greater mean follicle-stimulating hormone response to gonadotropin releasing hormone stimulation than controls (p less than 0.05). Patients who underwent orchiectomy had the greatest follicle-stimulating hormone response to gonadotropin releasing hormone stimulation. Mean luteinizing hormone response to gonadotropin releasing hormone stimulation was normal in patients without atrophy (group 1) but it was greater than controls in patients who had atrophy (groups 2 and 3) or who underwent orchiectomy (p less than 0.05). Several conclusions could be made from our study. All patient groups treated for torsion had evidence of testicular dysfunction. Patients who underwent orchiectomy displayed more testicular dysfunction than patients who had atrophy after detorsion. Testicular dysfunction after torsion is more likely to involve spermatogenic before Leydig cell function.

Urachal remnants in adults.

Urachal disorders are uncommon and present with varied appearances. Three cases of urachal disease, one congenital and two acquired, are reported. Each case is representative of the symptoms and findings of its respective category. A review of the literature is presented. A basic understanding of urachal development is necessary to suspect a diagnosis of urachal disease.

Continence mechanisms following transphincteric urethroplasty.

Urinary continence mechanisms were studied in 6 patients, 5 of whom had undergone end-to-end urethroplasty for membranous urethral strictures. All patients were able to interrupt the urinary stream on command by contracting the distal intrinsic sphincteric mechanism, despite an absent extrinsic sphincter. In 2 patients with prostatectomy and transphincteric urethroplasty, the intrinsic sphincteric mechanism was the sole remaining sphincter. These observations suggest that the intrinsic sphincteric mechanism is intramurally located, is also under somatic innervation and alone is capable of performing all of the sphincteric function required in the male.

Unstable bladder: urodynamic diagnosis and observations in evaluating urinary incontinence in the female.

Unstable bladder in the female has been the subject of controversy with regard to its etiology, identification, and treatment. One hundred thirty consecutive female patients referred with incontinence were evaluated as to their symptoms and urodynamic findings. A stress cystometrogram, systematically done, was introduced and observations were made regarding certain findings on the urodynamic examination. These criteria were used subsequently for making a diagnosis of unstable bladder. Forty per cent of these patients were found to have an unstable bladder. History of frequency and urgency correlated best with a diagnosis in 70 to 80 per cent of our cases, and the new stress cystometrogram proved to be the most sensitive urodynamic test (78%) for detecting this condition. A systematic approach such as we describe is advocated as a first step toward gaining a better understanding of this puzzling entity.

Role of urodynamics in management of urethral diverticulum in females.

This report deals with 10 female patients with urethral diverticula, 8 of whom were also found to have findings of stress incontinence. This association was proved by urodynamic studies. Three patients were seen with incontinence postdiverticulectomy. Seven patients were evaluated prior to diverticulectomy, and of these 5 had anatomic changes of stress urinary incontinence. Those patients in whom the preoperative evaluation considered them to be at risk for development of stress incontinence postdiverticulectomy were treated with a prophylactic urethropexy. Patients so treated were continent and voided well and were probably spared having a postoperative problem with incontinence. The role of urodynamic techniques in the detection of any association between the diverticulum and a possible risk of postdiverticulectomy incontinence, and how to recognize the problem and its correction before it becomes clinically manifest are the stated purposes of this report.

On percutaneous drainage of retroperitoneal collections: when is primary surgical drainage preferable?

Percutaneous drainage of retroperitoneal collections is a method employed with an ever-increasing frequency. The indication for primary surgical drainage of these collections is rapidly decreasing. Herein we describe what we consider to be the indications for primary surgical drainage of retroperitoneal collections illustrated by the recurrence of the abscess in 3 of our patients following adequate primary percutaneous drainage.

Influence of indwelling urinary tract stones on twenty-four-hour urine chemistries.

Twenty-two patients with ureteral stones underwent twenty-four-hour urinary excretion studies of calcium, phosphorus, and uric acid before and after stone elimination from the urinary tract. Comparison of pre- and post-stone elimination studies showed no significant differences suggesting that the presence of stones in the urinary tract has little influence on the twenty-four-hour urinary excretion of calcium, phosphorus, and uric acid.