Bacteria-ball in the urinary tract: a rare entity.

A bacterial mass in the urinary tract is a very rare entity. We report the first case of a bacterial ball within the urinary tract of a patient with diabetic cystopathy on long term urinary indwelling catheter. She presented with fever and gross haematuria. CT scan of abdomen and pelvis revealed a gas containing hyperdense mass within the bladder suspicious of bladder stone. The lesion was resected, and histopathology revealed a matrix of acellular materials with bacteria colony.

The use of antimuscarinics, phosphodiesterase type V inhibitors and phytotherapy for lower urinary tract symptoms in men.

Besides the mainstay of α-blockers and 5α-reductase inhibitors, other forms of medical therapy complete the armamentarium in the treatment of lower urinary tract symptoms (LUTS) in men. These treatments can target specific symptoms as well as associated symptoms that would affect the quality of life of the patients. Many patients are bothered by storage symptoms, more so than the voiding symptoms. Antimuscarinics are efficacious and safe, provided the patients do not have high post void residual urine. Many patients with LUTS also have erectile dysfunction, and phosphodiesterase type V inhibitors are effective in relieving both LUTS as well as erectile dysfunction for such patients. Phytotherapy provides a popular and safe treatment for LUTS, however, the efficacy of the treatment has not been proven in well conducted prospective randomized controlled studies.

Ultrasound-guided percutaneous nephrolithotomy: Advantages and limitations.

PURPOSE: The use of ultrasound in percutaneous nephrolithotomy (PCNL) has not been shown to translate to better clinical and stone outcomes. To compare the operative outcomes, postoperative outcomes and complication rates of ultrasound-guided access PCNL (USGA-PCNL) versus fluoroscopy-guided access PCNL (FGA-PCNL). MATERIALS AND METHODS: A total of 184 consecutive patients who underwent PCNL from July 2008 to September 2014 were identified from our PCNL database. Seventy-two patients underwent USGA-PCNL and 112 FGA-PCNL. RESULTS: The patients were similar in age, sex, race, American Society of Anesthesiologists physical status classification, mean largest stone diameters, side of PCNL, number of stones and the degree of hydronephrosis between both groups. There were higher rates of upper pole (5.6% vs. 3.6%), mid pole (8.3% vs. 2.7%) and multiple pole punctures (4.2% vs. 0%) in USGA-PCNL compared to FGA-PCNL (p=0.027). There was no difference in the stone free rates of both groups in univariate analysis. Those who had FGA-PCNL were 2.26 (95% confidence interval, 1.09-4.75; p=0.029) times more likely to require a second-look procedure compared to USGA-PCNL on univariate analysis but not on multivariate analysis. There were no differences in Clavien-Dindo complications. No patient in the USGA-PCNL group experienced organ injuries during puncture compared to 1 patient in the FGA-PCNL group who had pneumothorax requiring urgent chest tube insertion. CONCLUSIONS: The use of ultrasonography to guide access puncture during PCNL eliminates the risk of inadvertent organ injuries. Similar operative and stone outcomes show that the learning curve for USGA is minimal compared to conventional FGA.

Outcomes of long-term follow-up of patients with conservative management of asymptomatic renal calculi.

OBJECTIVE: • To evaluate the long-term outcomes of patients undergoing observation of asymptomatic renal calculi. PATIENTS AND METHODS: • This is a retrospective review of 50 patients with 85 stones undergoing observation with annual imaging from January 2005 to December 2009. • The incidences of spontaneous stone passage, stone progression and intervention were evaluated and assessed for statistical difference according to initial size and location of stone. • Percutaneous nephrolithotomy, shock wave lithotripsy and ureteroscopy were performed when patients developed complications from the stones. RESULTS: • Patients were followed up for a mean of 46 months. Sixteen percent had bilateral stones and 38% had multiple stones. • The average stone size was 5.7 mm and 31%, 26% and 43% of the stones were located in the upper, middle and lower pole respectively. • Overall incidences of spontaneous passage, progression and intervention were 20%, 45.9% and 7.1% respectively. • Stones measuring 5 mm or less were significantly more likely to pass (P= 0.006). • There was no significant difference in the incidence of passage according to the initial location of the stone (P= 0.092). There was no significant difference in intervention or progression according to the initial size (P= 0.477 and 0.282 respectively) or location of stone (P= 0.068 and 0.787 respectively). CONCLUSIONS: • Patients with asymptomatic renal stones may be managed conservatively in view of low risk of intervention (7.1%). • Annual imaging should be performed as half of these stones will progress in size.

Self-referred older Asian males in a men's health clinic: the inter-relationships between androgens, metabolic parameters and quality of life measures.

BACKGROUND: Current data on late-onset hypogonadism, derived from healthy males in epidemiological studies, may not reflect the profile of men seen in actual clinical practice. OBJECTIVE: To examine androgen levels in relation to metabolic status and quality of life (QOL) measures in self-referred men at a hospital-based Men's Health clinic. METHODS: Cross-sectional study of 238 consecutive Asian males. Fasting total testosterone (TT), sex-hormone binding globulin (SHBG), luteinising (LH) and follicle stimulating (FSH) hormones, glucose (FPG) and lipid profile were measured. Bioavailable (cBT) and free testosterone (cFT) were calculated. Waist circumference (WC) and body mass index (BMI) were collected. Subjects also answered the modified International Index of Erectile Dysfunction (IIEF-5) and Ageing Male Symptom (AMS) questionnaires. RESULTS: Among non-diabetic males (N = 201), no change was noted for TT, although SHBG and gonadotrophins rose, while cBT and cFT declined, significantly with age. Sex hormones were negatively related with WC, BMI and FPG. SHBG displayed a stronger association with metabolic components than testosterone. Testosterone was not related to lipids, IIEF-5 or AMS scores. WC, not BMI, was a key determinant of TT, cBT and cFT in younger subjects, while FSH seemed a more sensitive indicator of primary hypogonadism than LH in older males. CONCLUSION: The preferred measures of serum testosterone in older men are cBT and cFT. Visceral adiposity and SHBG, rather than testosterone, appeared to be the link between androgen deficiency and poorer metabolic status. QOL scores correlate poorly with androgen concentrations.

Presentation and progression of benign prostatic hyperplasia: a Singapore experience profiling ethnic differences in a multiracial study cohort.

INTRODUCTION: While benign prostatic hyperplasia (BPH) incidence has been shown to vary by race and ethnicity, data is lacking among Asians. This study aimed to describe the baseline symptom profile and response to medical therapy in a multiracial Singaporean cohort with BPH. MATERIALS AND METHODS: International Prostate Symptom Score (IPSS), uroflowmetry and prostate specific antigen (PSA) levels were retrospectively analysed for 887 men at presentation and on follow-up 1 year later. Following diagnosis, 150 men were managed conservatively and 586 men with drugs; 151 received surgery. RESULTS: Overall median IPSS scores were 9.0 at baseline. Malay men most often had severe symptoms (17.3%), compared to other groups (Chinese 11.7%, Others 11.1%, Indians 10.7%). Indians most frequently showed improvement in the Quality of Life (QOL) score following intervention (64.3%). Malays had the poorest initial mean peak-flow rates (9.6 mL/s) and Chinese, the highest (12.0 mL/s). Initial post-void residual urine volume was highest in Malays (100.1 mL) but showed greatest reduction with medical treatment. Median IPSS scores decreased from 10.5 below 50 years old to 7.0 above 80 years old. Peak-flow rates were 12.6 to 7.2 mL/s respectively, with a corresponding upward trend in RU. Treatment with a combination of 5-alpha-reductase inhibitor and alpha-blocker yielded the greatest improvement in IPSS and QOL scores, and residual urine volume (71.4%, 60% and 68.8%, respectively). Indians had the lowest initial and follow-up PSA (1.5 and 1.2, P = 0.8 and 0.6, respectively). CONCLUSIONS: Inter-ethnic differences in symptom perception and quantitative assessment of BPH were evident among our multiracial urban study cohort, as well as varied degrees of response to the medical treatments instituted.

Traumatic epidural emphysema.

STUDY DESIGN: This is a case report. OBJECTIVE: A rare case of epidural emphysema secondary to traumatic pneumomediastinum in the absence of pneumothorax is reported. SUMMARY OF BACKGROUND DATA: Epidural air secondary to traumatic pneumomediastinum in the absence of pneumothorax has only been reported previously by Willing. Other causes of traumatic epidural emphysema include pneumothorax, pelvic fracture, dural enteric fistula, and herniation of a spinal disc. METHODS: A young man who sustained blunt cervical and chest trauma after a basketball game accident was found to have pneumomediastinum and surgical emphysema on a chest radiograph and underwent computed tomography (CT). RESULTS: The CT scan demonstrated surgical emphysema, pneumomediastinum, and epidural emphysema with no pneumothorax. The patient was managed conservatively, and the epidural emphysema and pneumomediastinum resolved spontaneously. CONCLUSION: Epidural emphysema secondary to traumatic pneumomediastinum is benign and self-limiting. However, the life-threatening causes should be considered and ruled out.

Lower pole ratio: a new and accurate predictor of lower pole stone clearance after shockwave lithotripsy?

BACKGROUND: Lower pole spatial anatomy is an important determinant of success after extracorporeal shockwave lithotripsy. In the present study, we determine whether there is a significant relationship between lower pole ratio (infundibular length : infundibular width) on preoperative intravenous urograms and stone fragment clearances after shockwave lithotripsy. METHODS: A total of 42 patients with isolated lower pole stones were retrospectively reviewed. Anatomical factors, such as infundibular length, width and infundibulopelvic angle were measured and the lower pole ratio was calculated on pretreatment intravenous urogram. Stone fragment clearance was assessed at three months with a plain abdominal X-ray. RESULTS: The overall three-month stone-free rate was 62%. Mean stone size +/- SD was 10 +/- 4.8 mm, mean infundibular length was 21.7 +/- 6.9 mm, mean infundibular width was 6.1 +/- 2.3 mm, mean infundibulopelvic angle was 62.1 +/- 30.1 degrees and mean lower pole ratio was 4.3 +/- 2.8. Stone-free status after shockwave lithotripsy was significantly related to infundibular length and width as well as to lower pole ratio, but not to infundibulo-pelvic angle. Infundibular length less than 30 mm, width greater than 5 mm and lower pole ratio less than 3.5 were noted to have an improved three-month stone-free rate (P = 0.049, 0.01 and <0.01, respectively). CONCLUSION: Caliceal anatomy is an important consideration for lower pole stone clearance after shockwave lithotripsy. The present study suggests that a lower pole ratio of less than 3.5, which considers both infundibular length and width, is a promising predictor for stone-free status.

Clinical efficacy and safety of sildenafil citrate (Viagra) in a multi-racial population in Singapore: A retrospective study of 1520 patients.

BACKGROUND: Sildenafil citrate (Viagra), a selective inhibitor of cGMP-specific phosphodiesterase type-5, has been used as an oral therapeutic drug for erectile dysfunction. The present paper is a clinical study of the success rate and side-effects of the use of sildenafil in a multi-racial population in Singapore. METHODS: From April 1999 to May 2000, 1520 patients were given sildenafil citrate. Of these, 912 patients (mean age, 54.6 years; age range, 22-99 years) were followed up and evaluated for clinical efficacy and safety of the drug. The mean duration of erectile dysfunction (ED) and follow-up periods were 31.5 and 3.0 months, respectively. RESULTS: Satisfactory erections assessed by single global efficacy question (GEQ) occurred in 83% of patients, major side-effects in the form of flushing (3.48%), headache (1.97%), blurred vision (1.25%), giddiness (1.18%), warmth (1.11%) and others (4.92%) were recorded in 127 patients (13.9%). Racially, Chinese men with ED had higher efficacy (85.7%), compared to Indian men (74.2%) and Malay men (72.8%). With respect to comorbid profiles, an efficacy of 77.8% (n = 271), 83.9% (n = 292), 86.4% (n = 44) and 83.3% (n = 199) was recorded in diabetic, hypertensive, ischemic heart disease patients and in benign prostatic hyperplasia patients, respectively. Patients who smoked (n = 135) and drank alcohol (n = 118) showed an efficacy of 80%. Baseline hormonal profiles of luteinizing hormone, follicle stimulating hormone, testosterone and prolactin did not affect the success rates of sildenafil citrate. Many patients had earlier received other forms of treatment (medicated urethral suppository for erection (MUSE; 84.9%); vacuum devices (86.8%), traditional medicines (100%) and other oral medications (89.2%)), but this did not influence the success rate of sildenafil citrate. But patients previously treated with prostaglandin-E intracavernosal injections were less successful on sildenafil citrate (77.3%). In the total cohort, 50 mg sildenafil citrate was an effective dose in 49% of patients and 46.5% patients needed 100 mg sildenafil citrate, while 4.1% of the total cohort needed only 25 mg sildenafil citrate. CONCLUSION: Oral sildenafil citrate has been shown to be an effective, safe and well tolerated drug in Singaporean men with ED, as in men from other parts of the world.