[Can we prevent late complications of urinary tract infections?]

Urinary tract infections are one of the most common renal diseases sometimes leading to renal injury and in consequence to chronic renal failure. The most frequent causative pathogen responsible for this infection is Escherichia coli. There are several factors which increase the risk of infection including vesicoureteral reflux, cystic renal disease, urinary calculi, obstruction and other anatomical and functional abnormalities of urinary tract as well as neurological bladder dysfunction, long term indwelling catheters, mechanical vaginal diaphragms and intensive sexual intercourse. This paper will highlight general view on the treatment of different manifestations of urinary tract infections including asymptomatic bacteriuria, urethritis, cystitis, prostatitis as well as acute and chronic pyelonephritis. The details of those problems will be elucidated in another paper.

The effect of diet on lower urinary tract diseases in cats

Because dietary ingredients and feeding patterns influence the volume, pH and solute concentration of urine, diet can contribute to the etiology, management or prevention of recurrence of some causes of lower urinary tract disease. Most research assessing the effect of diet has focused on the latter two aspects, primarily because of interest in struvite urolithiasis. Manipulation of urine pH through dietary means has proven an effective tool for the management and prevention of struvite urolithiasis; acidification of urine, however, may be a risk factor for calcium oxalate urolithiasis, which now appears to occur with approximately equal frequency in cats. Prediction of urine pH from dietary analysis would thus be a valuable tool, but considerable further research is required before this can be achieved with commercial canned foods. With the growing importance of urolith types other than struvite, alternatives to the measurement of urine pH are required to assess critically the likely beneficial (or detrimental) effects of manipulation of nutrient profile. Measurement of urinary saturation may permit the development and fine tuning of nutrient profiles aimed at controlling lower urinary tract diseases in cats that are associated with a range of different mineral types. The majority of cats with signs of lower urinary tract disease do not, however, have urolithiasis; indeed, no specific cause can be established in most of these cats. Recent observations suggest that recurrence rates of signs in cats classified as having idiopathic lower urinary tract disease may be more than halved if affected animals are maintained on high, rather than low moisture content diets. J. Nutr. 2753S-2757S, 1998

Influence of urinary management on urologic complications in a cohort of spinal cord injury patients

OBJECTIVE

To study urologic complications in patients with spinal cord injury (SCI) in relation to their bladder management.

DESIGN AND SETTING

A cohort study of patients with SCI in a rehabilitation center.

PARTICIPANTS

One hundred eighty-two patients were studied; demographic data, disease characteristics, and urologic history were obtained for each.

INTERVENTION

Patients responding to a questionnaire were given a clinical exam. Their medical records were reviewed, with particular attention given to the following urologic complications: lithiasis, urinary infections, orchiepididymitis, urethral trauma, vesicorenal reflux, and renal failure.

RESULTS

Results are reported for 123 patients. Time since SCI was 8 years. Intermittent catheterization was the main method of bladder management. Only 32 patients had changed their method of vesical voiding. Urinary complications had developed in 75% of patients. The most common complication was urinary infection. Vesicoureteral reflux occurred in 26% of patients using percussion. Trauma related to catheterization was the main problem with intermittent catheterization, responsible for a high rate of orchiepididymitis.

CONCLUSION

Intermittent catheterization is the most-used method of bladder management, but with a nonnegligible rate of urethral trauma in men. Percussion and Credé maneuver appear to be acceptable techniques of bladder management if the patient is closely monitored.

An anatomical classification--a new paradigm for management of female lower urinary tract dysfunction

A new anatomical classification specifies anatomical defects in the anterior, middle and posterior zones of the vagina as the cause of female lower urinary tract dysfunction. An external musculoelastic mechanism stretches the vagina to open and close the outflow tract. The same pelvic floor muscles provide a peripheral control mechanism for micturition. The stretched vagina prevents the filling bladder from activating the stretch receptors in the bladder neck. Vaginal laxity may weaken transmission of muscle forces, interfering with urethral opening and closure, a mechanical process. Laxity may also destabilize the peripheral control mechanism, a neurological process, causing bladder control to swing between the open and closed modes urodynamically interpreted as bladder instability. Specific symptoms, signs, and urodynamic tests can be arranged into a pictorial algorithm. This acts as a practical guide for locating the three zones of anatomical defects. It has been possible to reinterpret almost all the definitions and descriptions of the International Continence Society (ICS) in terms of this classification, and to explain how vaginal laxity may cause premature activation of the micturition reflex (detrusor instability), stress incontinence and abnormal emptying (dribble, overflow). This convergence in anatomical and urodynamic (ICS) concepts explains many previously unexplained phenomena, and potentially opens up a new approach to management, nonsurgical strengthening of specific ligaments, or surgical reinforcement thereof with ambulatory "microinvasive" methods which do not require catheterization.

Role of laparoscopy in the management of chronic pelvic pain

Laparoscopy has rapidly become an important diagnostic and therapeutic tool in gynaecological surgery. The entity of chronic pelvic pain is best investigated laparoscopically before any treatment is planned. Often diagnosis and treatment can be a one-stage procedure.

[Urologic aspects of myelodysplasias in children]

At least 25% of the clinical problems seen in pediatric urology are the result of neurologic lesions that affect lower urinary tract function. The advent of clean intermittent catheterization and refinements in techniques of urodynamic studies in children dramatically changed the way this pediatric population was traditionally managed. Along with this change came a greater understanding of the pathophysiology of the many diseases that primarily affect children. The applicability of urodynamic testing has expanded to the point where most pediatric urologic centers now believe that functional assessment of the lower urinary tract is an essential element in the evaluation process and is as important as x-ray visualization in characterising and managing these abnormal conditions. The natural outcome of early functional investigation has been the advocacy of proactive or early aggressive management of children who are now considered at risk of urinary tract deterioration based on specific hostile urodynamic parameters. This paper first defines the testing process as it applies to children and second, conservative and surgery methods to prevent upper urinary tract deterioration and to correct continence.

Interventional uroradiology

The development of interventional uroradiologic techniques has had a major impact on the care of the urologic patient by allowing nonoperative treatment of many disease processes. This article will review percutaneous nephrostomy with emphasis on urologic calculi, interventional therapy for neoplasms and trauma of the urinary tract, diagnosis and treatment of renovascular hypertension, and the management of complications following renal transplantation.

Contemporary urologic management of patients with spinal cord injury

Urologic management strategies in patients with spinal cord injury are discussed herein, and the underlying pathophysiology and urodynamic principles are emphasized. Contemporary management of the spinal cord-injured bladder has allowed for near-elimination of renal failure as the primary cause of long-term morbidity in these patients; low urine storage, sterile urine, and effective emptying are imperative for good long-term results.

Risk factors for urinary tract symptoms in women: beliefs among general practitioners and women and the effect on patient management

BACKGROUND

Urinary tract symptoms are common in women. A variety of risk factors have been investigated in the past. One of the more likely risk factors for these symptoms is recent sexual intercourse; another is diaphragm use. Morbidity levels are increasing, although effective antibiotic treatment is available.

AIM

To study the beliefs of women and their general practitioners (GPs) about urinary tract symptoms and to determine how these may affect management.

METHOD

An interview survey with 113 women consulting with urinary tract symptoms and the 22 GPs they consulted.

RESULTS

Doctors and women have similar beliefs about the 'causes' of urinary tract symptoms, but the relative importance differs. Both acknowledge the association with sexual intercourse but fail to communicate about this during the consultation. Patients reported being embarrassed on their own and their GP's behalf if sensitive subjects were raised. Doctors failed to ask women what they thought had caused the symptoms and were also unlikely to suggest to them likely causes. They also reported reticence to do more than prescribe, at least in first consultations, and half of the doctors routinely prescribed antibiotics, regardless of a near patient diagnostic urinary stick test result. The advice given was not necessarily evidence based.

CONCLUSIONS

GPs need to be more aware of the risk factors associated with urinary tract symptoms in women and should formulate their advice accordingly. The reticence to discuss sensitive subjects by both GPs and patients has implications for the ability to broach sexual matters in any consultation in which they are not the reason or focus for that consultation.

[Rate of external consultation utilization. Organizational and managerial basis of a urology service]

INTRODUCTION

The frequency of visits to an outpatients office is indicative of the proportion of population to be served at that location.

MATERIAL AND METHOD

Analysis of the frequency of new cases to an outpatients office over one year and correlation with the conditions treated over the corresponding period.

OBJECTIVES

To know the overall frequency of new cases, by condition, affected organ and group of diseases. To know the percentage of surgical resolution of those conditions. To infer from these data the resources necessary in terms of offices, operating theatres and staff

RESULTS

The outpatients office shows an overall frequency of new cases of 124/10000 people/year. The highest frequencies by condition, affected organ and group of diseases correspond to BPH, inguinoscrotal area and andrology. 35% of all new cases are managed surgically. 17.5% BPHs and 16.4% prostate carcinomas undergo surgery. The necessary resource are inferred to be: 1.5 ambulatory operating theatres/week, 2-2.5 central operating theatres/week. 5-6 office visits/week and 3 urologists.

CONCLUSIONS

The study on the frequency of visits to the outpatients office is a useful tool for the organization and management of the Urology Service.

[Spontaneous rupture of the upper urinary tract in a pregnant woman. Value of ultrasonography and computed tomography in the diagnosis and treatment]

We report the eighteenth case of spontaneous rupture of the upper urinary tract in a pregnant woman (age = 24 years, term = 28 weeks). Sonography showed an anechogenic collection in the left perirenal area. Computed tomography confirmed the diagnosis of rupture. No cause could be determined due to the lack of an urography in post-partum. The first treatment was a double echo-guided percutaneous drainage. The pregnancy was completed to term with normal vaginal delivery of a live infant. Sonography showed complete cure.

Urinary tract endometriosis: report of 2 cases and a review of the literature

Endometriosis of the urinary tract is a relatively rare condition. Since clinical signs are not specific the diagnosis is difficult and the therapy is not well defined. Two cases and a review of the literature are presented.

Overview: role of stents in urology

Catheterization of the urinary tract for drainage is the mainstay of urologic manipulations. Although the material of which the catheters are made changed during the years, they all remained external communicating devices, causing ascending infections and discomfort. A concept of completely internal catheters for use in urology developed during the last few decades. Although the first self-retaining internal ureteral catheters (stents) were developed for use in open surgical procedures or on malignant obstructions, later, they caused a considerable leap in the development of minimally invasive endourologic procedures. The development of intraurethral stents also started to change some of the approaches to the management of bladder outlet obstruction. This paper summarizes the subject of urologic stents, which is presented in detail in this special issue of the Journal of Endourology.

Effect of radionuclide renograms on treatment of patients with spinal cord injuries

OBJECTIVE

Urinary tract problems stemming from neurologic dysfunction are a major cause of morbidity in patients with spinal cord injury. Radionuclide renograms have been used to monitor renal function in these patients. However, the effect of renographic results on the treatment of patients has not been studied. A retrospective study was done to determine the effect of radionuclide renography on the diagnostic evaluation and therapeutic treatment of patients with spinal cord injury.

MATERIALS AND METHODS

The records of 199 patients with spinal cord injuries were reviewed. A decline in effective renal plasma flow of 20% or more, a low effective renal plasma flow for age, and abnormal tracer time-activity curves were correlated with diagnostic procedures and therapeutic interventions. Diagnostic procedures included renal sonography, CT, excretory urography, and urodynamics. Therapeutic interventions included changes in medication, changes in bladder management, and surgery.

RESULTS

Patients with abnormal findings on renograms underwent more diagnostic procedures and therapeutic interventions. A significant correlation was found between abnormal tracer time-activity curves and use of excretory urography. A decline in effective renal plasma flow was the best predictor of therapeutic intervention.

CONCLUSION

Radionuclide renograms influence the diagnostic evaluation and therapeutic treatment of patients with spinal cord injury.

Common office problems in pediatric urology and gynecology

The number of genital problems that pediatricians encounter is substantial. The most common ones have been reviewed in this article. Perhaps the most important point to reinforce is the appropriateness of nonintervention in uncircumcised boys whose foreskins have not become retractile during early school years. Without infections or pathologic phimosis, these boys do well, and most foreskins become retractile as they approach puberty. Abnormalities beyond those discussed or those not fitting the anticipated pattern probably warrant specialty referral.

Common medical problems in sports

This article reviews the most common medical problems encountered in the day-to-day care of athletes at all levels of competition. Common medical conditions affecting the pulmonary, gastrointestinal, urological, and endocrine systems are reviewed, as well as common infectious diseases. Review of environmental factors affecting athletes, including sleep disorders, travel, and exposure to the environment during athletic competition, are discussed.

The urological manifestations of hollow visceral myopathy in children

PURPOSE

Hollow visceral myopathy is a rare clinical entity characterized by impaired intestinal function in the absence of mechanical occlusion. It can affect the smooth muscle of the whole or segments of the gastrointestinal tract and occasionally the urinary tract. We examined the urological manifestations of hollow visceral myopathy and management in the pediatric population.

MATERIALS AND METHODS

We reviewed the records of 14 male patients 1 day to 2 years old (mean age 4.6 months) and 10 female patients 1 day to 5 years old (mean age 9.4 months) at presentation to our institution with hollow visceral myopathy. In all patients genitourinary tract ultrasound, voiding cystourethrography and serum creatinine measurement were done at presentation.

RESULTS

All patients had gastrointestinal obstructive symptoms at presentation and 11 (46%) had urological symptoms, including urinary retention in 2, urinary tract infection in 3, and a prenatal diagnosis of megacystis and hydroureteronephrosis in 6. Overall 22 patients (92%) had urological abnormalities, all had poor bladder emptying and recurrent urinary tract infections, and 13 had megacystis associated with bilateral hydroureteronephrosis in 9 and unilateral hydroureteronephrosis in 2. There were 9 deaths from extensive gastrointestinal involvement and sepsis. Of the surviving 15 patients 13 have urological abnormalities, including 8 who perform and tolerate clean intermittent catheterization via the urethra and are well. Of the 4 male infants who did not tolerate clean intermittent catheterization appendicovesicostomy was done in 1, a Casale tube was placed in 1 and vesicostomy was performed in 2. The remaining female patient has day and night wetting.

CONCLUSIONS

Urological abnormalities are common in hollow visceral myopathy and they can contribute to presenting symptoms. Clean intermittent catheterization via the urethra to aid in bladder emptying and decrease the frequency of urinary tract infections is the mainstay of treatment but surgery to construct an alternative catheterizable channel or vesicostomy may be required in intolerant patients.