Activation of bladder mast cells in interstitial cystitis: a light and electron microscopic study.

Interstitial cystitis, a sterile bladder condition, is characterized by urinary frequency, urgency, burning and suprapubic pain. Increasing evidence indicates that interstitial cystitis is a heterogeneous syndrome that reflects an immune response to a variety of triggers. More than 50% of the patients have allergies, 30% have the irritable bowel syndrome and almost 20% suffer from migraine headaches. Increased numbers of mast cells have been reported in interstitial cystitis. Mast cell activation, which is critical if these cells were to be implicated in this syndrome, has been investigated by electron microscopy, which definitively shows mast cell secretion. Recently, methylhistamine, the major metabolite of histamine, and the specific mast cell marker, tryptase, were shown to be significantly elevated in urine of interstitial cystitis patients. Bladder biopsies from 53 patients were analyzed blindly for the number and degree of activation of mast cells using 4 different stains for light microscopy, as well as electron microscopy. Controls included 16 patients with incontinence and chronic bacterial cystitis. Mast cells in controls were less than 10/mm.2 and were all nearly intact. Surprisingly, mast cells from 11 cancer patients averaged 50/mm.2 but almost all were intact. In contrast, mast cells from 26 interstitial cystitis patients averaged 40/mm.2 and more than 90% were activated to various degrees. Therefore, bladder mast cell activation is a characteristic pathological finding in at least a subset of patients with interstitial cystitis.

Prostatitis.

Several distinct types of prostatitis, or prostatitis syndromes, are now recognized. The most common forms include acute and chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia. Bacterial prostatitis, caused mainly by coliform bacteria, Pseudomonas, and Enterococcus faecalis, is often difficult to cure and usually requires extended therapy (4-16 weeks) with an appropriate antimicrobial agent that achieves therapeutic levels in the prostatic secretory system. About 90% of men with prostatitis have nonbacterial prostatitis or prostatodynia. Nonbacterial prostatitis is an inflammation of the prostate of unknown cause. Patients with prostatodynia typically have sterile cultures and normal prostatic secretions but demonstrate an acquired voiding dysfunction on videourodynamic testing. Because nonbacterial types of prostatitis have no recognized infectious cause, treatment using antimicrobial agents is ineffective and unwarranted.

Current patterns in nosocomial urinary tract infections.

Nosocomial infections develop in about 5 percent of patients admitted to acute care hospitals in the United States. The genitourinary tract is the primary site of infection in about 40 percent of cases, and urinary tract instrumentation and catheterization are implicated in about 80 percent of genitourinary tract nosocomial infections. Catheter-associated urinary tract infections are a frequent source of serious patient morbidity, urosepsis, and even death. The pathogenesis, risk factors, consequences, and preventive measures concerning nosocomial urinary tract infections are reviewed, and specific guidelines for catheter management are offered.

Spurious azotemia associated with 5-fluorocytosine therapy.

A patient with false elevation of serum creatinine level due to 5-fluorocytosine (5-FC) is reported. 5-FC interferes with the enzymatic method used for creatinine determination in the Kodak Ektachem analyzer. Clinicians should be aware of the potential for spurious azotemia in patients receiving 5-FC therapy for fungal urinary tract infections.

Acute and chronic prostatitis: diagnosis and treatment.

Several distinct types of prostatitis, or prostatitis syndromes, are now recognized. The most common types include acute and chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia. Bacterial prostatitis, caused mainly by enterobacteria, is often difficult to cure, and chronic bacterial prostatitis is a common cause of relapsing recurrent urinary tract infection in men. Nonbacterial prostatitis, the most common syndrome, is an inflammation of the prostate of unknown cause. Patients with prostatodynia typically have sterile cultures and normal prostatic secretions but demonstrate an acquired voiding dysfunction on video-urodynamic testing. Since nonbacterial types of prostatitis have no recognized infectious cause, treatment using antimicrobial agents is ineffective and unwarranted.

Multicentric angiomyolipoma: renal and lymph node involvement.

A retrospective review of 6 patients with renal angiomyolipoma treated surgically revealed regional lymph node involvement in 2--an incidence of 33 per cent. The clinical behavior in these patients suggests that nodal involvement is an expression of multicentricity rather than metastatic disease.

Urinary catheters and nosocomial infection.

Latex catheters appear to be associated with a higher incidence of complications than silicone or Silastic tubing. Patients with indwelling catheters in whom asymptomatic bacteriuria develop usually do not require treatment until the time of catheter removal. In symptomatic patients, however, samples of blood and urine should be obtained for culture and sensitivity testing. Empiric therapy with parenteral antibiotics--such as an aminoglycoside plus ampicillin or piperacillin--should then be initiated. To reduce infectious complications associated with the use of urinary catheters, clinicians should always carefully determine whether or not a true indication for catheterization exists. In addition, intermittent bladder catheterization and suprapubic drainage should be considered whenever appropriate. Specific guidelines for preventing infection or superinfection in patients with indwelling catheters are provided.

Nosocomial infection of urinary tract: changing pathogens, changing patterns.

Risk factors for the development of nosocomial infection, i.e., diabetes, immunosuppressive therapy, etc., are reviewed. In most cases, the patient's own fecal flora is the primary reservoir for potentially infecting pathogens, such as Escherichia coli, Pseudomonas, Klebsiella, Enterobacter, Proteus, Serratia, and enterococcus. Hospitalized patients are likely to have antibiotic-related changes in fecal flora. Abnormal urethral flora in men, as well as high rates of vaginal and urethral colonization in women, increase the risk of infection associated with urinary catheterization or instrumentation. The costs of nosocomial urinary tract infections, both in economic and health terms, are briefly discussed. After a review of the causes and consequences of bacterial resistance to antibiotics, the issue of perioperative prophylaxis is addressed. It is concluded that the most important aspects of effective perioperative prophylaxis are achievement of suitable drug-tissue levels at the time of surgery and a limited period of postoperative antibiotic administration. The problem and probable causes of cross contamination are described. Recommendations for reducing nosocomial infections are offered.

Computed tomographic findings in renal angiomyolipoma: an histologic correlation.

Accurate preoperative diagnosis of renal angiomyolipomas is essential if conservative resection or angiographic embolization is to be used. Computed tomographic (CT) scanning failed to diagnose angiomyolipoma preoperatively in 2 patients, and this led to a retrospective review of 6 patients to define the limits of CT scanning in preoperative diagnosis. The CT findings were correlated with the histology of the tumors. Two tumors with positive attenuation coefficients suggestive of renal adenocarcinoma had significant amounts of immature "fetal" fat, and one of these had a virtual absence of mature fat. The relative inability of CT scanning to identify immature "fetal" fat, especially in the presence of abundant vessel and muscle elements, is a limitation to its use in the preoperative diagnosis of angiomyolipoma. A negative attenuation coefficient is highly characteristic of renal angiomyolipoma with mature fat elements. A positive attenuation coefficient, although suggestive of renal cell carcinoma, may be found in angiomyolipomas with paucity of mature fat or high proportions of immature fat.

Female urethral syndrome: clinical and urodynamic perspectives.

Eighteen women with the urethral syndrome were studied urodynamically with synchronous video-pressure flow studies and electromyography of the external urethral sphincter (EUS). When compared with an age and sex matched control group, the most striking finding was a significantly higher than normal maximum urethral closure pressure. Abnormal and low urinary flow rates, instability of the intraurethral pressure at rest, incomplete funnelling of the bladder neck, and distal urethral narrowing during voiding constitute other typical urodynamic findings in the female urethral syndrome. Detrusor-striated sphincter dyssynergia or primary striated sphincter spasm was not observed. Even though striated EUS spasticity cannot be excluded as a cause of this syndrome in some patients, an autonomically mediated spasm of the smooth muscle sphincter seems plausible to explain both our urodynamic findings and a favorable response of 4 patients treated with alpha-blocking agents.

Hemiacidrin irrigation in the management of struvite calculi: long-term results.

Renacidin (10 per cent hemiacidrin) irrigation has been used in the management of renal struvite calculi in 25 patients. Of these patients 22 were free of stone after irrigation: 16 after dissolution of residual stone fragments postoperatively, 4 after prophylactic postoperative irrigation and 2 after primary, nonsurgical percutaneous dissolution. Recurrent urinary tract infections owing to the original urease-producing bacteria occurred in 14 per cent of these patients and recurrent nephrolithiasis occurred in 9 per cent during an average followup period of 66 months.

Dissolution of struvite calculi by hemiacidrin solution.

Struvite calculi result from urinary tract infections secondary to urease-producing bacteria. To prevent recurrent infection and stone formation complete removal of struvite calculi is recommended. Two illustrative reports of patients with renal struvite calculi are presented in which 10% hemiacidrin (Renacidin) irrigation was instituted for stone dissolution. After surgical removal of the calculi a nephrostomy tube was placed in the renal pelvis. With confirmation of residual struvite calculi, 10% hemiacidrin irrigation was initiated. Urine cultures, electrolytes and nephrotomograms were performed and adverse effects monitored. Using strict aseptic technique and appropriate precautions, hemiacidrin irrigation safely dissolves struvite calculi.

Prostatodynia: clinical and urodynamic characteristics.

Twenty patients with prostatodynia were studied urodynamically with synchronous video-pressure-flow studies and electromyography of the external urethral sphincter. The most striking finding was a significant increase in maximum urethral closure pressure compared to an age and sex-matched control group. Typically, peak and average urinary flow rates were decreased. Another prominent feature was incomplete funneling of the bladder neck during voiding with an accompanying urethral narrowing at the level of the external urethral sphincter. These findings are not consistent with a diagnosis of tension myalgia of the pelvic floor or detrusor-striated sphincter dyssynergia but suggest a primary abnormality involving the pelvic sympathetic nervous system. We believe that more advanced methods than those available currently are needed to elucidate fully the role of the autonomic nervous system, especially its sympathetic component, in the etiology of prostatodynia.

Renal immunoblastic sarcoma complicating immunosuppressive therapy for Wegener granulomatosis.

A renal tumor developing in a patient receiving cyclophosphamide (Cytoxan) therapy for Wegener granulomatosis is reported. The tumor was similar histologically to the "immunoblastic" sarcoma that develops in renal allograft recipients as a complication of immunosuppressive therapy. This case report strengthens the cause and effect relationship between immunosuppressive drug usage and the subsequent development of neoplasia.