The use of amitriptyline in patients with urinary frequency and pain.

OBJECTIVE: To evaluate the usefulness of amitriptyline (AMI) in the treatment of patients with urinary frequency or genital, pelvic, or suprapubic pain syndromes. METHODS: Charts of 22 patients (12 male and 10 female) without interstitial cystitis and having vague nonspecific urinary and pelvic or genital complaints were reviewed. All were treated with AMI in doses ranging from 25 to 100 mg. RESULTS: Eleven patients became symptom-free, six showed significant improvement and five did not respond. Four of the five could not tolerate the medication. Fifteen patients attempted tapering off the medication after 6 months, and 11 experienced an early return of symptoms. A therapeutic response was again seen with retreatment. CONCLUSIONS: AMI is therapeutically useful in vague voiding dysfunctions, especially in the presence of urinary frequency or genital, pelvic, or suprapubic pain. It is effective for the treatment of both men and women. The response is durable, but the dose of the medication must be maintained.

Urologic care in long-term facilities.

The urologic care of the institutionalized elderly is confounded by the high prevalence of comorbid conditions. There is also a challenge to provide cost effective care to this group that requires a disproportionate share of health care resources. Bacteriuria, hematuria, and problems of urine control and drainage provide unique clinical conditions that must be dealt with.

Indications for urethroscopy in male patients with penile condylomata.

Benson et al recommended that to detect condylomata, urethroscopy should be performed on the male partners of women with cervical dysplasia. Considering this, in April 1990 we began to perform urethroscopy on all of our patients who presented with genital condylomata. Between April 1990 and January 1993, 84 patients were referred for initial evaluation of condylomata. The penis, scrotum, perineum and perianal areas were inspected, and the penis was reinspected after staining with 5% acetic acid. Intraurethral condylomata were detected in 13 patients (15%), 11 of whom had visible lesions on physical examination with spreading of the meatus. Urethroscopy confirmed these lesions to be limited to the fossa navicularis. Two patients had lesions of the fossa not visible at the meatus. No patient in this series had lesions of the more proximal urethra. All patients eventually determined to have intraurethral lesions had external condylomata on the distal penis (glans, corona or frenulum). Using the presence of distal penile lesions as the criterion for urethroscopy, 30 patients (36%) would have undergone urethroscopy, including all 13 eventually diagnosed to have intraurethral condylomata, for a yield of 43%. A total of 54 patients (64%) who failed to meet this criterion would have been spared the procedure. Consideration of dysuria or urinalysis did not improve the yield. When evaluating male patients with genital condylomata, we recommend spreading the urethral meatus during the examination. Urethroscopy is indicated only for those with distal penile or meatal lesions.

Long-term follow-up of sphincterotomy in the treatment of autonomic dysreflexia.

Autonomic dysreflexia (AD) is a syndrome affecting a majority of patients with high spinal cord lesions. An association between AD and detrusor-sphincter dyssynergia (DSD) is often seen. Between 1980 and 1988 we performed 51 transurethral sphincterotomies in 38 patients. Twelve of these patients underwent procedures primarily for the prevention of AD related to bladder distension. This study presents their long-term follow-up. One patient was lost to follow-up secondary to unrelated death; the remaining 11 patients were followed on average 117.5 months (94-154) after the initial operative procedure. Repeat sphincterotomy was required in 9 of 11 patients (82%). Six (66%) of these were performed within 24 months. One patient (11%) required delayed sphincterotomy greater than 100 months from the initial procedure. Overall, sphincterotomy was successful in controlling symptoms of AD in 10 of 11 (91%) patients. No major complications were recorded. Sphincterotomy is a safe and effective treatment for AD associated with DSD, however long-term urologic follow-up and management are necessary.

A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older community-dwelling women.

BACKGROUND: Research using biofeedback as a treatment for sphincteric incontinence began with Kegel's early studies using a perineometer and pelvic muscle exercises demonstrating a 90% improvement in urine loss symptoms. More recent studies using varying combinations of biofeedback and pelvic muscle exercises found symptom reduction rates of 78% to 90%, but these studies lacked the rigor of a "phase three," or randomized controlled clinical trial. METHODS: A randomized controlled trial assessed the efficacy of biofeedback for older women for treatment of sphincteric incompetence. One hundred thirty-five community-dwelling women were randomized in a single-blind trial to three groups: biofeedback, pelvic muscle exercise, or control. Incontinent episodes were monitored over 8 weeks of treatment and at 3 and 6 months thereafter. RESULTS: The number of incontinent episodes decreased significantly in the biofeedback and pelvic muscle exercise subjects but not in the control subjects for all severity of incontinence frequency subgroups. Improvement was maintained within the moderate and severe symptom subgroups for both treatments for at least 6 months but declined in subjects with mild incontinence frequency. Pelvic muscle activity (EMG) was significantly correlated with decreases in incontinent episodes, and only the biofeedback subjects showed significant improvement in EMGs. CONCLUSIONS: Biofeedback and pelvic muscle exercises are efficacious for sphincteric incompetence in older women. Benefits are maintained and improvement continues for at least 6 months postintervention. These therapies may be useful before considering invasive treatment.

Dimensions of urine loss among older women with genuine stress incontinence.

The specific maneuvers that cause women to be incontinent can become important diagnostic aids and major factors in differentiating the effectiveness of the current pharmacological, surgical, and behavioral treatments for urinary incontinence. The purpose of this study was to evaluate whether meaningful dimensions could be identified within the multiple movements that produce urine loss in stress-incontinent women. The Stress Incontinence Questionnaire (SIQ) was constructed from items derived from a compilation of studies and reports of urinary incontinence experts. An exploratory factor analysis using maximum likelihood method of extraction and a varimax rotation procedure identified four dimensions: active maneuvers, passive maneuvers, planned maneuvers, and unplanned maneuvers. The alpha coefficients for the four identified factors were acceptable and ranged from .71 to .79, with 8-week test-retest correlations for the active (r = .87), passive (r = .87), planned (r = .85), and the unplanned maneuvers (r = .60) all highly significant. The four factors also showed differential patterns of relationships with various gynecologic and urologic measures. These latter findings suggest that the factors identified in this study may be acknowledging different types or components of stress incontinence. In either case, the findings may have implications for treatment approaches to stress incontinence. Further research is needed to substantiate the various components of stress incontinence found in this study and the implications these findings may have for treatment of incontinence.

Factors discriminating between genuine stress and mixed incontinence.

Nurse practitioners (NP) are often confronted with female clients who describe various types of urine loss symptoms. To establish an accurate diagnosis and therapeutic intervention, it is important for the NP to identify the etiology of the urine loss complaint. The purpose of the study is to compare symptoms and physical findings that differentiate between the urodynamic diagnoses of genuine stress incontinence (GSI) and mixed incontinence (MI) in 135 clinical trial subjects: 123 diagnosed as GSI and 12 as MI. These subjects participated in a randomized controlled clinical trial to investigate the efficacy of biofeedback and pelvic floor exercises for incontinence treatment. Data were analyzed for significant differences between these two groups on urologic and gynecologic symptoms, pelvic muscle relaxation, vaginal mucosa, vaginal electromyograph readings, urodynamic parameters, and quantified measure of urine loss. One-way analysis of variance (ANOVA) showed significant difference in nocturnal and diurnal voidings and urine loss immediately after sensing the urge to void in the MI and GSI subjects. Chi-square analyses found a significantly decreased incidence of poor vaginal tone and atrophic vaginal mucosa in the MI group as compared to the GSI group. The MI group also lost significantly more urine than did the GSI group on the hand wash maneuver of the perineal pad test. Although the sample size of MI subjects was small, these results show that a noninvasive history and physical examination can differentiate between urologic diagnoses. This approach provides a cost-effective expedient protocol to aid the NP in establishing a differential diagnosis between genuine stress and mixed incontinence.

Traumatic torsion of the testis.

Torsion of the testis is a common urological emergency. Blunt scrotal trauma also may precipitate an emergency. We recently treated 2 adolescent boys in whom blunt scrotal trauma induced testicular torsion. A retrospective review of the charts of 138 patients explored for acute scrotal pain at our hospital revealed a history of scrotal trauma in 3 of 57 patients (5 per cent) with testicular torsion and 7 of 73 (10 per cent) with torsion of the testicular appendages. The possibility of torsion must be considered in cases of scrotal trauma.

Peyronie's disease: an unusual location.

An unusual case of a Peyronie's plaque presenting only as a septal mass without penile deformity is presented.

Traumatic dislocation of testis.

Traumatic dislocation of the testis is a rare disorder with only 46 cases having been reported. We herein add 3 cases. Its association with motorcycle accidents and early adulthood are noted. Its mechanism, classification, diagnosis and pathology are discussed. Early closed reduction or surgical orchiopexy is recommended.

Hypertension secondary to massive upper pole hydronephrosis.

Hypertension secondary to hydronephrosis is uncommon, and when a duplex system is involved it is rare. A patient presenting with hypertension and an abdominal mass on the left side was found to have a non-functioning, massively dilated upper pole of a duplex system causing hyperreninemic hypertension. Treatment consisted of an upper pole partial nephrectomy. This unique case is discussed and the literature regarding hypertension secondary to hydronephrosis is reviewed.

Alteration of semen quality in dogs after creation of varicocele.

A left vein varicocele was created in male dogs by partially obstructing the left renal vein medial to the entrance of the left internal spermatic vein. Eight dogs had semen parameters determined preoperatively (2 times/week for five weeks) and postoperatively (2 times/week for twelve weeks). Semen quality was altered by the experimental varicocele. A significant decrease in sperm count, motility, per cent viable, and per cent oval sperm were noted. Semen volume was not affected. The possible chemical influence of serotonin is mentioned. Testosterone levels were unchanged by the varicocele. Histologic findings in the left and right testicles are mentioned before and after creation of the varicocele.

Topical levarterenol in control of bladder hemorrhage.

Topical levarterenol was evaluated for the control of bladder hemorrhage. Its possible toxic effects were investigated in the intact dog bladder, and its use was compared with saline irrigations in experimental massive bladder hemorrhage. Eight mg.% levarterenol was found to be safe and effective in our model.