When patients request the impotence pill.

Erectile dysfunction is a common condition affecting men over age 50. With the recent increase in public awareness about available therapies, more and more men are seeking help. Primary care physicians usually can prescribe first-line treatments without acquiring additional equipment or staff. Patients who are not satisfied with oral medication, vacuum devices, injection therapy, or intraurethral suppositories may be referred to a urologist for further treatment. Development of new medical therapies is ongoing, and within the next few years, we expect to see the introduction of more medications for treatment of erectile dysfunction. Some agents act peripherally on the penile circulation and others centrally on the portion of the brain involved in producing erections.

Effects of doxazosin in patients with mild, intermediate, and severe benign prostatic hyperplasia.

Traditionally, drug therapy for benign prostatic hyperplasia (BPH) has been reserved for patients with mild or moderate symptoms. The objective of this analysis was to compare responses to an alpha 1-adrenergic receptor blocker, doxazosin, in patients with severe, intermediate, and mild disease. Data were analyzed from patients with symptomatic BPH who were enrolled in two 16-week, double-masked, placebo-controlled studies of doxazosin. In study 1, 163 hypertensive patients were stratified according to baseline maximum (Qmax) and mean (Qmean) urinary flow rate as having severe, intermediate, or mild disease. In study 2, 82 normotensive patients were stratified according to their baseline American Urological Association (AUA) BPH symptom severity score and modified Boyarsky symptom bothersomeness score. Overall, doxazosin was significantly more effective than placebo in improving Qmax and Qmean in study 1 and in improving the AUA-derived and modified Boyarsky scores in study 2. There were statistically significant differences in the response to treatment, as represented by Qmax' Qmean, and modified Boyarsky score, between patients with severe, intermediate, and mild disease. There were no significant differences in the AUA-derived scores of patients in the three severity groups. These results have important clinical implications, suggesting that the majority of BPH patients are candidates for a course of drug therapy, regardless of baseline disease status.

Effect of doxazosin on the symptoms of benign prostatic hyperplasia: results from three double-blind placebo-controlled studies.

The urinary symptoms characteristic of benign prostatic hyperplasia (BPH) can have a considerable impact on patients' quality of life. Symptom score assessment is now used in BPH, although a number of different instruments are available. Controlled clinical trials with selective alpha 1 adrenoceptor antagonists such as doxazosin, prazosin and terazosin have shown these agents to be effective in the treatment of BPH. The effects of doxazosin on the severity and bothersomeness of BPH symptoms were determined in three multicentre, double-blind, placebo-controlled clinical studies, involving a total of 609 normotensive and hypertensive patients. Doxazosin was initiated at a dosage of 0.5 or 1 mg once daily, with a final dose range of up to 12 mg once daily. The duration of active treatment was 12 to 14 weeks. Significant improvements were seen in symptom severity and bothersomeness with doxazosin compared with placebo, in both patient populations. The onset of symptomatic improvement was rapid, occurring within two weeks of treatment initiation, and efficacy was sustained throughout the treatment period. A long-term, open label extension of these studies has demonstrated sustained efficacy during 48 months of follow-up. Since symptom relief is the primary goal of therapy in BPH, and since doxazosin's effects are rapid in onset and sustained in duration, it appears that doxazosin is an effective agent for the treatment of symptomatic BPH in both normotensive and hypertensive men.

Doxazosin for benign prostatic hyperplasia: long-term efficacy and safety in hypertensive and normotensive patients. The Multicenter Study Group.

PURPOSE: We evaluated the sustained efficacy and safety of doxazosin for long-term treatment (up to 48 months) of normotensive and hypertensive patients with benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A total of 272 normotensive and 178 mildly to moderately hypertensive men entered a long-term extension study of doxazosin therapy (1 to 8 and 1 to 12 mg. 1 time daily, respectively) for BPH following participation in double-blind, placebo controlled studies. The starting dose of doxazosin was 1 mg. with upward titrations at 2-week intervals to a stable, efficacious and well tolerated dose. At the time of data analysis patients had received between 1 and 48 months of stable dose doxazosin therapy (mean 668 days for normotensive and 807 for hypertensive patients). Mean daily doses were 4 and 6.4 mg. for normotensive and hypertensive men, respectively. RESULTS: At the end point analysis doxazosin treatment resulted in significant increases above baseline in maximum and average urinary flow rates (1.9 and 1.0 ml. per second, respectively). As assessed by the patient, total, obstructive and irritative BPH symptoms also improved significantly with doxazosin treatment. In the 28 patients who completed 45 to 48 months of treatment improvement in symptom bothersomeness (13.2%) was similar to that of the overall group at the end point (14.8%). Sustained blood pressure decreases (approximately 8/11 mm. Hg systolic/diastolic blood pressure) with doxazosin were statistically and clinically significant in hypertensive patients. Blood pressure decreases in normotensive patients were not clinically significant (approximately 4/2 mm. Hg) and few withdrew from study for reasons related directly to decreased blood pressure or hypotension. Changes in heart rate were not significant. Doxazosin was well tolerated with almost 90% of adverse experiences considered mild or moderate in severity. The most common adverse events were dizziness, headache and fatigue in normotensive and hypertensive patients. CONCLUSIONS: In this study long-term doxazosin treatment was significantly effective and well tolerated for treating BPH in normotensive and hypertensive patients.

Interstitial cystitis. When urgency and frequency mean more than routine inflammation.

Interstitial cystitis is fairly common in primary care practices and very common in urology practices. Still, it is probably underdiagnosed. Because symptoms can be confusing, patients are sometimes thought to have psychogenic problems or are treated repeatedly with antibiotics, despite the absence of evidence of bacterial infection. The key to correct diagnosis is awareness of the condition and its characteristics. In patients who have symptoms that resemble routine cystitis but normal results on urinalysis, interstitial cystitis should be considered as the working diagnosis. This is especially applicable in women, who are affected far wore often than men. Various therapies have been tried, but the cure, like the cause, remains unknown. Many patients respond to some form of therapy and may even have long-term remissions. However, arriving at the form of therapy that relieves symptoms in a given patient is often a trial-and-error process. A short-term trial of various methods is warranted initially. Ultimately, however, referral to a urologist may be necessary for definite diagnostic testing and additional therapy.

Renal vein thrombosis in renal cell carcinoma. Proteinuria as diagnostic sign.

In 4 patients with hypernephroma and extension of the tumor thrombus into the renal vein, there has been a significant degree of proteinuria. We believe that the proteinuria in association with a renal mass suggests a tumor thrombus in the renal vein and warrants the preoperative inferior venacavogram. After a larger number of patients have been studied, it may become clear that patients who do not have proteinuria do not have renal vein or vena caval involvement. If this proves to be the case, these patients may be selectively spared inferior venacavography. For the present time in patients with hypernephroma, we can only recommend that the index of suspicion for renal vein involvement with tumor thrombus should remain high if the patient has significant proteinuria.

Bacterial prostatitis: treatment with carbenicillin indanyl sodium.

The efficacy and safety of carbenicillin indanyl sodium were evaluated in 16 patients with acute or chronic bacterial prostatitis. Each patient received carbenicillin indanyl sodium (Geocillin) tablets, at a dosage of two 500 mg tablets (each tablet equivalent to 382 mg of carbenicillin) four times daily for either 14 days (acute patients) or 28 days (chronic patients). Clinical and bacteriologic success rates, based upon 4 week post therapy followup, were 93 per cent and 75 per cent respectively. There were no adverse reactions. Results with cephalexin in a concurrently treated alternative therapy group were generally unsatisfactory. Further evaluations of carbenicillin indanyl sodium in this treatment of resistant populations are clearly warranted.

Immunoglobulin A in split ejaculates of patients with prostatitis.

7S and 11S IgA (immunoglobulin A) levels in split ejaculates of 17 patients with chronic prostatis and 16 normal subjects were studied by the Hanson radial immunogel filtration method. The results suggest at least in certain cases of prostatitis increase of IgA level involves elevation of both types of IgA, and they are mainly of prostatic origin.

Clinical use of immunoelectrophoresis of split ejaculates. I. Variation of patterns due to antisera.

As a preliminary investigation for the clinical application of immunoelectrophoresis of ejaculate in the diagnosis of male reproductive organ diseases, variations of immunoelectrophoretic patterns in normal subjects due to the difference of antigenicity between split ejaculates were demonstrated with rabbit antisera. Fresh samples and antisera against them gave larger numbers of and more intense precipitin lines than in stored samples. The precipitin lines developed by acid phosphatase were most remarkable between first portion of ejaculate (F1) and anti-F1, whereas the line caused by protein from the seminal vesicle was most prominent between the remainder of the ejaculate following F1 (F2) and anti-F2.

Studies in ureteral regeneration: replacement of a large segment of ureter with an in situ pedicle graft of proximal ureter.

The phenomenon of ureteral regeneration has been of interest to clinicians, anatomists, and physiologists for many years. The object of this investigation was to study the regeneration of a long pedicle graft of ureter. Regeneration of the pedicle graft over a stent took place in 4 to 5 weeks. At sacrifice 8 to 10 months postoperatively, 7 of 10 operations were completely successful with no evidence of hydronephrosis, obstruction, or pyelonephritis. Two animals exhibited slight dilation of the upper tracts, and one operation was a failure. It is evident from this study that a strip of ureter removed from the ureteral artery will regenerate over a stent in 4 to 5 weeks if the blood supply from the adjacent adventitia is left intact.

Phenoxybenzamine in the management of neurogenic vesical dysfunction.

The clinical effect of phenoxybenzamine, an alpha blocking agent, was studied in a series of 37 patients with varying degrees of neurogenic vesical dysfunction. An over-all 78 per cent success rate was achieved, with an 86 per cent success rate in patients with reflex neurogenic bladder. Phenoxybenzamine demonstrates excellent results in patients with neurovesical dysnfunction who are unable to empty their bladders by other means. The drug demonstrated effectiveness regardless of the level of the lesion, cystometric findings or duration of neurogenic vesical disease.

Renal cell carcinoma metastatic to urinary bladder.

A case is presented of renal cell carcinoma metastatic to the urinary bladder. The rarity of this lesion makes it worthy of report.

Semen cultures in the diagnosis of bacterial prostatitis.

The bacterial flora of semen from normal men has been studied. Positive cultures were obtained in 45 per cent of these individuals but only in smally colony counts of non-pathogenic bacteria. The seminal flora of patients with bacterial prostatitis was then studied. Excellent correlations have been noted between cultures of prostatic secretions and semen. Semen cultures will almost invariably be diagnostic in patients with bacterial prostatis. This technique has definite usefulness in selected patients in whom it is otherwise difficult to establish a diagnosis of bacterial prostatis.

Metastatic carcinoma of prostate masquerading as abdominal aortic aneurysm.

A case is reported in which the patient had classic findings of an abdominal aortic aneurysm, including a pulsatile abdominal mass, curvilinear aortic calcification, and anterolateral deviation of the left ureter. These findings were subsequently demonstrated at surgery to be due to metastatic nodes from prostatic carcinoma. Data presented indicate that further diagnostic studies may be in order in unusual cases in which patients are suspected of having abdominal aortic aneurysm. This is especially true if the patient is known to have another condition such as carcinoma which may mimic aneurysm with metastatic periaortic lymph nodes. Aortography and/or lymphangiography occasionally have their place in selected patients, and this is discussed.

Ureteral replacements.

The clinical necessities of replacing all or part of the diseased or destroyed ureter have plagued surgeons for many years. In the past seventy years more than 100 surgical techniques have been described for ureteral replacement. Methods of replacement have fallen into four categories; nonbiologic substitutes, pedicle grafts, free grafts, and implantation and diversion. This review discusses the history and present status, and presents a look to the future in the surgery of ureteral replacement.