Fractured penis: a review.

Fracture of the penis is a well-recognized clinical entity. The ideal management has evolved and repair remains largely surgical. We present the etiology and pathophysiology of this condition and outline the therapeutic options.

Dutasteride significantly improves quality of life measures in patients with enlarged prostate.

The purpose of this study was to determine the effect of dutasteride on quality of life of men with lower urinary tract symptoms associated with enlarged prostate or benign prostatic hyperplasia (BPH) as measured by symptom problem index (SPI), BPH-specific interference with activities (BSIA), BPH-specific psychological well-being (BPWB) and BPH-specific lifestyle adaptations (BSLA). Data were derived from three randomized, double-blind studies conducted in 4325 men treated with placebo or dutasteride (0.5 mg/day). Primary analyses included changes from baseline in mean SPI, BSIA, BPWB and BSLA scores. Men treated with dutasteride showed significant improvements in SPI, BSIA, BPWB and BSLA scores compared with placebo.

Responsiveness of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI).

OBJECTIVES: The NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) was developed to assess symptoms and quality of life in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). We assessed the responsiveness of the NIH-CPSI to change over time and defined thresholds for changes perceptible to patients. METHODS: We studied 174 men with CP/CPPS who participated in a placebo-controlled randomized clinical trial. Changes from baseline to six weeks in the NIH-CPSI total score and pain, urinary, and quality of life subscores were compared to a global response assessment (GRA). Effect sizes and Guyatt statistics were calculated to evaluate responsiveness; 95% confidence intervals were produced using bootstrapping. RESULTS: All scores decreased over time with the largest decrease in subjects who reported on the GRA that they were markedly improved. The NIH-CPSI total, pain, and quality of life scores were highly responsive in the improved groups; the urinary score showed minimal responsiveness. There was no evidence of responsiveness among those subjects who worsened on the trial. ROC curves identified a 6-point decline in the NIH-CPSI total score as the optimal threshold to predict treatment response. CONCLUSIONS: The NIH-CPSI total score and pain and quality of life subscores are responsive to change over time.

Distribution of the Brief Male Sexual Inventory in community men.

The objectives of the study were to characterize male sexual functioning as related to age in community-dwelling older men. In 1989, a random sample of men aged 40-79 y (n=2115) without prior prostate surgery, prostate cancer, or other conditions known to affect voiding function (except benign prostatic hyperplasia) was invited (55% agreed) to participate in the Olmsted County Study of Urinary Symptoms and Health Status Among Men. In 1996, a previously validated male sexual function questionnaire was administered to the cohort. The questionnaire has 11 questions measuring sexual drive (two questions); erectile function (three) and ejaculatory function (two), as well as assessing problems with sex drive, erections, or ejaculation (three); and overall satisfaction with sex life (one). Each question is scored on a scale of 0-4, with higher scores indicating better functioning. Cross-sectional age-specific means (+/-s.d.) for drive, erections, ejaculation, problems, and overall satisfaction declined from 5.2 (+/-1.5), 9.8 (+/-2.5), 7.4 (+/-1.4), 10.7 (+/-2.2), and 2.6 (+/-1.0), respectively, for men in their 40s to 2.4 (+/-1.6), 3.3 (+/-3.4), 3.6 (+/-3.2), 7.7 (+/-3.8), and 2.1 (+/-1.2) for men 70 y and older (all P<0.001). The cross-sectional decline in function with age was not constant, with age-related patterns differing by domain. The percentage of men reporting erections firm enough to have intercourse in the past 30 days declined from 97% (454/468) among those in their 40s to 51% (180/354) among those in their 80s (P&<0.001). In age-adjusted analyses, men reporting regular sexual partners had statistically significantly higher levels of sex drive, erectile function, ejaculatory function, and overall satisfaction than those who did not report regular sexual partners. Sexual drive, erectile functioning, ejaculatory functioning, and overall sexual satisfaction in men show somewhat differing cross-sectional patterns of decline with advancing age. Active sexual functioning is maintained well into the 80s in a substantial minority of community-dwelling men.

Improvements in benign prostatic hyperplasia-specific quality of life with dutasteride, the novel dual 5alpha-reductase inhibitor.

OBJECTIVES: To examine the effect of the dual-action 5alpha-reductase inhibitor dutasteride on benign prostatic hyperplasia (BPH)-specific health status, as measured by the BPH Impact Index (BII), and to identify baseline and treatment risk factors for those most bothered by their BPH symptoms at the end of the protocol. PATIENTS AND METHODS: Data were derived from three randomized, double-blind, placebo-controlled, 2-year studies conducted in 4325 men with lower urinary tract symptoms caused by benign prostatic enlargement. Each study comprised a 1-month single-blind placebo run-in period, followed by randomization to oral dutasteride 0.5 mg once daily or placebo for 2 years. Patients eligible for inclusion were consenting men aged >/= 50 years with moderate to severe symptoms (American Urological Symptom Index, AUA-SI, score >/= 12), a prostate volume of >/= 30 mL, a serum prostate-specific antigen (PSA) level of >/= 1.5 or < 10 ng/mL, and a maximum urinary flow rate (Qmax) of /= 5 (greatest symptomatic burden) treatment with dutasteride improved the scores by 2.41, while the scores in placebo-treated patients only improved by 1.64. Dutasteride-treated patients with a baseline BII score of < 5 (least symptom burden) had a clinically significant improvement in health status, while placebo-treated patients deteriorated. Regression analysis showed that men with a combination of a baseline BII item-3 score of 3 (bothered a lot) and a high symptom score (AUA-SI >/= 20) were more likely to be bothered by their symptoms at the end of the study. Men receiving placebo were also more likely to be bothered at the end of the study than were those receiving dutasteride. CONCLUSIONS: Dutasteride treatment is associated with clinically significant improvements in BII score, reflecting improvements in the quality of life of men with BPH. Taken together with previously reported improvements in prostate volume, lower urinary tract symptoms and urinary flow, and diminution of the risk of acute urinary retention and the need for BPH-related surgery, dutasteride offers demonstrable efficacy in the management of BPH.

Tamsulosin: current clinical experience.

During the past decade, our understanding of the epidemiology and natural history of benign prostatic hyperplasia (BPH) has improved considerably. Population-based studies confirm that lower urinary tract symptoms (LUTS) are very common among aging men. These studies have confirmed that men with moderate-to-severe symptoms have 4 to 6 times more trouble and interference with activities of daily living and twice the level of worry as those with mild symptoms. The realization by patients and their physicians that most men >50 years of age will develop LUTS, has resulted in increased awareness of pharmacologic agents, principally alpha-adrenergic antagonists, as a first line of therapy for this condition. Alpha blockers were introduced >30 years ago to treat LUTS and today are the mainstay in pharmacologic therapy. Among the alpha blockers, tamsulosin more selectively targets the alpha(1A)-adrenergic receptor subtype and is as effective as conventional alpha(1) blockers in treating LUTS caused by BPH. Its subselectivity and pharmacodynamic properties may provide advantages in safety, tolerability, and administration compared with other alpha blockers, such as terazosin and doxazosin. Unlike other alpha blockers, tamsulosin does not require titration to be efficacious. Because of its rapid onset of action and lack of clinically significant effect on blood pressure in normotensive and hypertensive patients, a therapeutic dose is delivered at the onset of treatment. Studies have documented that tamsulosin produces rapid improvements in LUTS and peak urinary flow rates, and these responses have been found to be durable.

Endoscopic treatment of massive rectal bleeding following prostate needle biopsy.

We describe two cases of massive rectal bleeding following needle biopsy of the prostate. In each case, colonoscopic evaluation revealed bleeding from the biopsy site. Bleeding was controlled with the placement of a single band in one case, and with epinephrine injection in the other. Endoscopic evaluation of patients presenting with severe rectal bleeding following needle biopsy of the prostate may allow immediate therapy.

The Spanish National Institutes of Health-Chronic Prostatitis Symptom Index: translation and linguistic validation.

PURPOSE: The prominence of health related quality of life end points in international clinical research underscores the importance of well validated and translated measures to enable cross-cultural comparison. The National Institutes of Health (NIH)-Chronic Prostatitis Symptom Index (CPSI) assesses symptoms and health related quality of life in men with chronic nonbacterial, NIH type III prostatitis. To expand its use to Spanish speaking patients we performed a translation and linguistic validation. MATERIALS AND METHODS: The 9-item NIH-CPSI was translated into Spanish according to a standard methodology of 2 forward translations, 1 reconciled version, back translation of the reconciled version and 3 independent reviews by bilingual experts. The purpose of this methodology was to create a single universal Spanish version that would be acceptable to native Spanish speakers inside and outside of the United States. After the translation process the Spanish version was pre-tested in Argentina, Mexico, Spain and the United States. Patient responses were analyzed to identify necessary modifications. The internal consistency of the CPSI was evaluated using Cronbach's alpha. Pearson's product moment correlations were used to evaluate construct validity. RESULTS: Data were collected from chronic prostatitis patients, including 15 in Argentina, 15 in Mexico, 4 in the United States and 3 in Spain. The translation had high reliability overall and in all subscales (Cronbach's coefficient alpha = 0.81 to 0.94), and the subscales correlated well with each other (r = 0.76 to 0.97). However, patients expressed difficulty in distinguishing the response categories "a menudo" ("often") from "normalmente" ("usually") in question 3. We revised "a menudo" to "muchas veces" ("much of the time") and "normalmente" to "casi siempre" ("almost always") to improve the distinctiveness of response categories. CONCLUSIONS: The Spanish NIH-CPSI has high reliability as well as face and construct validity in Spanish speaking men from various countries. The Spanish NIH-CPSI permits cross-cultural comparisons of men with chronic nonbacterial prostatitis.

Quality of life is impaired in men with chronic prostatitis: the Chronic Prostatitis Collaborative Research Network.

OBJECTIVE: Health-related quality of life (HRQOL) impairment may be a central component of chronic prostatitis for men afflicted with this condition. Our objective was to examine HRQOL, and factors associated with HRQOL, using both general and condition-specific instruments. DESIGN: Chronic Prostatitis Cohort (CPC) study. SETTING: Six clinical research centers across the United States and Canada. PARTICIPANTS: Two hundred seventy-eight men with chronic prostatitis. MEASUREMENTS AND MAIN RESULTS: The Short Form 12 (SF-12) Mental Component Summary (MCS) and Physical Component Summary (PCS), and the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) were measures used. CPC subjects' MCS scores (44.0 +/- 9.8) were lower than those observed in the most severe subgroups of patients with congestive heart failure and diabetes mellitus, and PCS scores (46.4+/-9.5) were worse than those among the general U.S. male population. Decreasing scores were seen in both domains with worsening symptom severity (P < .01). History of psychiatric disease and younger age were strongly associated with worse MCS scores, whereas history of rheumatologic disease was associated with worse PCS scores. Predictors of more severe NIH-CPSI scores included lower educational level and lower income; history of rheumatic disease was associated with higher scores. CONCLUSIONS: Men with chronic prostatitis experience impairment in the mental and physical domains of general HRQOL, as well as condition-specific HRQOL. To optimize the care of men with this condition, clinicians should consider administering HRQOL instruments to their patients to better understand the impact of the condition on patients' lives.

Quality of life and sexuality: methodological aspects.

Benign prostatic hyperplasia (BPH) can impact significantly on a patient's quality of life (QOL), including sexual functioning. With increased life expectancy, this aspect of the disease is becoming increasingly important. Symptom severity can be measured using a number of instruments, the most common one being the International Prostate Symptom Score (IPSS). A number of studies have shown that symptom severity is correlated with decreased QOL, i.e. the more severe the symptoms, the greater the impact on QOL. Specific questionnaires have been developed to address the issue of sexual function, including the Brief Sexual Function Inventory and the International Index of Erectile Function. Importantly, these instruments can usefully be applied to assess the effect of the various therapies for BPH on sexual function. In general, the alpha(1)-blockers have minimal impact on sexual function, compared with finasteride, which can affect libido, ejaculation and erectile function itself.

LUTS, ED, QOL: alphabet soup or real concerns to aging men?

The severity of symptoms and the degree to which they negatively impact on quality of life (QOL) are the major factors prompting patients with benign prostatic hyperplasia (BPH) to seek treatment. Several tools have been developed to assess symptom severity in patients with BPH, including the International Prostate Symptom Score (IPSS), the Danish Prostate Symptom Score (DAN-PSS), and the International Continence Society (ICS) questionnaire. Data from the Veterans Affairs Cooperative Study show that reductions in IPSS scores predict global ratings of improvement with treatment. Instruments have also been developed to measure the impact of urinary symptoms on QOL and have shown that as symptom severity increases, the impact on QOL also increases. Data from studies conducted in the United States, France, Scotland, and Japan reveal a similar pattern regarding the impact of symptom severity on QOL. Studies have also demonstrated that medical treatment with alpha-blockers, for example, is associated with a reduction in symptoms and a corresponding improvement in QOL. Patients with BPH frequently also have coexisting erectile dysfunction, which significantly affects QOL. Thus, in addition to assessment of symptoms and QOL in patients with BPH, sexual function should also be assessed in these patients.

1999 American Urological Association Gallup Survey: changes in physician practice patterns, treatment of incontinence and bladder cancer, and impact of managed care.

PURPOSE: The Health Policy Survey and Research Committee of the American Urological Association and the Gallup Organization have performed a yearly survey of American urologists since 1992 to assess practice patterns. The results of the 1999 survey are presented. MATERIALS AND METHODS: A random sample of 503 urologists was interviewed in February and March 1999. Major content areas were physician practice patterns, the impact of managed care, and the treatment of pediatric patients, prostate cancer and benign prostatic hyperplasia, female incontinence and bladder cancer. RESULTS: The average urologist is 46.8 years old, certified by the American Board of Urology, sees 78 patients and performs 3.1 major surgical procedures weekly, refers moderate and complex pediatric procedures to specialists, and receives 40.6% of practice income from managed care. CONCLUSIONS: In an era when large group practices seem to be the norm remarkably 32% of urologists remain in solo practice. There has been a shift in where urologists spend their time, that is more in the office and less in the operating room. Minor and major open surgical procedures increased from 12.4 weekly to 16.4 and 2.9 to 3.1 in 1995 and 1999, respectively. Most urologists are comfortable treating straightforward pediatric problems such as cryptorchidism but refer more complex problems to pediatric urologists. Managed care represents an ever increasing proportion of urologist practice income, while office expenses continue to increase.

A comparison of patient and partner responses to a brief sexual function questionnaire.

PURPOSE: Patient self-administered questionnaires have recently been developed to assess sexual function in men with erectile dysfunction. However, it may also be important to assess satisfaction with and any improvements in sexual function from the perspective of the female partner. We report the results of a brief 3-item questionnaire developed for the female partner and its association with an 11-item questionnaire developed for men with erectile dysfunction. MATERIALS AND METHODS: Men and their female partners each self-administered a brief sexual function questionnaire several times during a clinical trial of an experimental treatment for erectile dysfunction. Items addressed the frequency and firmness of erection, and satisfaction with sex life on a 5-point Likert scale with responses ranging from 0 to 4. We compared mean values of the 3 items common to each questionnaire by respondent, and also analyzed item and scale correlations using weighted kappa statistics and/or the Pearson correlation coefficient. RESULTS: Data from 389 pairs were available. Generally patient results were fairly consistent with those of partners. Men reported slightly more frequent erection (1.6 versus 1.5), identical firmness of erection (1.2) and less satisfaction (1.2 versus 1.4) than partners. Weighted kappas of the 3 items ranged from 0.47 to 0.61, representing good agreement. The Pearson correlations were slightly higher. Internal consistency reliability using Cronbach's alpha of the 3-item scale was 0.69 (0.77 for patient and 0.81 for partner). CONCLUSIONS: These data support the use of patient and partner assessments of sexual function in clinical trials of erectile dysfunction.

1998 American Urological Association Gallup Survey: changes in physician practice patterns, treatment of ureteral stones and impact of managed care.

PURPOSE: The American Urological Association first commissioned the Gallup Organization to conduct a study to assess urologist practice patterns in 1992. We present the results of the seventh consecutive Gallup Survey performed for the Association. MATERIALS AND METHODS: A random sample of 537 American urologists who completed urological residency and practiced at least 20 hours weekly in 1997 were interviewed by telephone in March 1998. Major topic areas included general demographics, practice patterns, treatment of ureteral stones and experience with managed care. RESULTS: Demographic trends indicated a significant decrease in average urologist age from 49.4 years in 1992 to 46.8 in 1998. Of the urologists 99% reported that they treat ureteral stones. Managed care had an increasingly larger role in most practices, particularly in the western United States, where 73% of urologists reported that they contract with a Medicare health maintenance organization. CONCLUSIONS: The average age of practicing urologists significantly decreased, which may be due to an increasing number of urologists retiring at an earlier age, although this finding is not clear. Nearly all urologists treated ureteral stones with considerable consistency. Finally, managed care appeared to have a major impact on most urologists throughout the United States.

The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network.

PURPOSE: Chronic abacterial prostatitis is a syndrome characterized by pelvic pain and voiding symptoms, which is poorly defined, poorly understood, poorly treated and bothersome. Research and clinical efforts to help men with this syndrome have been hampered by the absence of a widely accepted, reliable and valid instrument to measure symptoms and quality of life impact. We developed a psychometrically valid index of symptoms and quality of life impact for men with chronic prostatitis. MATERIALS AND METHODS: We conducted a structured literature review of previous work to provide a foundation for the new instrument. We then conducted a series of focus groups comprising chronic prostatitis patients at 4 centers in North America, in which we identified the most important symptoms and effects of the condition. The results were used to create an initial draft of 55 questions that were used for formal cognitive testing on chronic prostatitis patients at the same centers. After expert panel review formal validation testing of a revised 21-item draft was performed in a diverse group of chronic prostatitis patients and 2 control groups of benign prostatic hyperplasia patients and healthy men. Based on this validation study, the index was finalized. RESULTS: Analysis yielded an index of 9 items that address 3 different aspects of the chronic prostatitis experience. The primary component was pain, which we captured in 4 items focused on location, severity and frequency. Urinary function, another important component of symptoms, was captured in 2 items (1 irritative and 1 obstructive). Quality of life impact was captured with 3 items about the effect of symptoms on daily activities. The 9 items had high test-retest reliability (r = 0.83 to 0.93) and internal consistency (alpha = 0.86 to 0.91). All but the urinary items discriminated well between men with and without chronic prostatitis. CONCLUSIONS: The National Institutes of Health chronic prostatitis symptom index provides a valid outcome measure for men with chronic prostatitis. The index is psychometrically robust, easily self-administered and highly discriminative. It was formally developed and psychometrically validated, and may be useful in clinical practice as well as research protocols.

Distinguishing chronic prostatitis and benign prostatic hyperplasia symptoms: results of a national survey of physician visits.

OBJECTIVES: The morbidity of chronic prostatitis results from a constellation of genitourinary symptoms. A recent study classified 21 of these symptoms into three categories: pain, voiding complaints, and sexual dysfunction. Pain symptoms predominated among patients with prostatitis. Using data from a nationwide survey of physician visits, we examined the most common symptoms reported by men at chronic prostatitis visits and contrasted the results with visits for benign prostatic hyperplasia (BPH). METHODS: We analyzed 81,034 visits by men (18 years and older) to office-based physicians of all specialties in the National Ambulatory Medical Care Surveys of 1990 to 1996, using sampling weights to make national estimates. U.S. physicians selected by random stratified sampling completed visit forms that included patients' reasons for visits and physicians' diagnoses. RESULTS: In 1990 to 1996, there were 765 visits (national estimate 1.5 million visits/yr; 95% confidence interval = 0.9 to 2.1) with a diagnosis of chronic prostatitis. Among chronic prostatitis visits, 20% were for pain, 19% for urinary symptoms, and 1% for sexual dysfunction. Among 2271 BPH visits, 2% were for pain, 33% for voiding complaints, and 1% for sexual dysfunction. The most common reason coded for chronic prostatitis visits was painful urination (14% of chronic prostatitis visits, but only 1.7% of BPH visits). CONCLUSIONS: Pain was slightly more common than voiding complaints, but much more common than sexual dysfunction among chronic prostatitis visits. The most common reason for chronic prostatitis visits was painful urination, which was uncommon among patients with BPH. Pain distinguished chronic prostatitis from BPH better than any other urinary symptom.

Sexual dysfunction in patients with benign prostatic hyperplasia.

Two of the most common problems presenting to urologists are benign prostatic hyperplasia and sexual dysfunction, with an increasing number of patients presenting for treatment as a result of the proliferation of less invasive therapies. How such therapies for lower urinary tract symptoms affect sexual function in men is important to both urologists and their patients, and is the focus of this review.