Microbial diversity of genital ulcer disease in men enrolled in a randomized trial of male circumcision in Kisumu, Kenya

Background

Medical male circumcision (MMC) reduces the risk of genital ulcer disease (GUD) in men by 50%. In Ugandan and Kenyan trials, a sexually transmissible agent was not identified in 50–60% of GUD specimens by polymerase chain reaction (PCR) assay. We sought to better define the etiology of GUD in men participating in the Kenyan trial and examine how MMC affects GUD etiology.

Methods

We defined GUD of unknown etiology as negative for HSV (type 1 and type 2), T. pallidum, and H. ducreyi by PCR, and negative for HSV-2 and T. pallidum by serology. We identified bacterial microbiota in a subset of 59 GUD specimens using multitag pyrosequencing of the 16S rRNA gene, and compared results by unknown vs. STI-associated etiology. Statistical analysis employed Bray-Curtis similarity measure of bacterial community by etiology, hierarchical clustering and logistic regression.

Results

In 59 GUD specimens from 59 men, 23 (39%) had unknown etiology. Bacterial diversity was greater in GUD of unknown than STI etiology (p = 0.01). Fusobacteria (Fusobacterium spp. and Sneathia spp.) were more commonly detected in men with GUD of unknown etiology [adjusted OR = 5.67; 95% CI: 1.63–19.8] as were Oxobacter spp. and Anaerovorax spp. [adjusted OR = 3.12; 95% CI: 0.83–11.7]. Sequences from these four anaerobic bacterial taxa were more often detected in uncircumcised men than circumcised men (p<0.05).

Conclusions

Anaerobic bacteria are more common in genital ulcers of uncircumcised men. The specific anaerobic bacteria associated with GUD of unknown etiology have cytotoxic properties that can exacerbate epithelial disruptions leading to ulcer-like appearance. MMC may reduce GUD through a reduction in these anaerobic bacteria.

[A case report of Cowper's syringocele in an adult treated with transurethral unroofing]

We present an adult case of Cowper's syringocele. A 19-year-old male presented with the chief complaint of persistent post-voiding dribbling 5 months after onset. Urethroscopy demonstrated a thin membrane with a small orifice on the ventral aspect distal to the external sphincter. Magnetic resonance imaging showed a restiform shadow on the left side of the corpus spongiosum. Retrograde urethrogram showed filling of diverticulum-like structure in the region of urethral bulb terminating in the urogenital diaphragm. Considering the results mentioned above, we diagnosed the patient with Cowper's syringocele. Transurethral unroofing of the Cowper's syringocele was performed with a cold knife, and the excessive tissue on the edge of syringocele was electroresected to avoid recurrence. His post-voiding dribbling resolved completely after the procedure and has not recurred in 13 months postoperatively. Cowper's syringocele is typically diagnosed presenting with hematuria, urinary tract infection, and disuria in male infants and children. Adult cases of Cowper's syringocele are rare, and only 32 cases including the present case have been reported. Proper awareness of this entity and careful evaluation are important if patients present with persistent adult-onset voiding dysfunction.

Early aggressive treatment of lichen sclerosus may prevent disease progression

PURPOSE

When not recognized and treated aggressively, lichen sclerosus may progress and cause debilitating symptoms. It also may result in significant morbidity in patients undergoing treatment for urethral strictures because unrecognized, it may result in rapid and severe recurrence after surgical treatment. We present our experience treating patients with lichen sclerosus in an equal access health care system.

MATERIALS AND METHODS

We performed an institutional review board approved retrospective review of all adult men with lichen sclerosus treated at our institution during a 10-year period. We analyzed all patients diagnosed with lichen sclerosus, and recorded patient demographics and therapies. We recorded characteristics of the disease process including external and internal manifestations. We also recorded the various treatments, and whether the patients experienced recurrence.

RESULTS

A total of 43 patients were diagnosed with lichen sclerosus during the review period. Of those patients presenting with more severe (urethral) involvement and undergoing 1 or 2-stage urethroplasties, we noted 7 with recurrence. In the remainder of patients presenting with less severe disease who were treated aggressively with clobetasol and/or minor procedures, no recurrences were noted on followup examination, and all of these patients had documented normal flow patterns on noninvasive urodynamics.

CONCLUSIONS

Our data suggest that early aggressive topical therapy plus minimally invasive surgical therapy to relieve high pressure voiding may prevent the progression of lichen sclerosus in patients who present with limited disease involving the skin and meatus.

[Diagnosis and treatment of seminal vesicle cyst]

OBJECTIVE

To deepen the understanding of patients with seminal vesicle cyst to facilitate its correct diagnosis and treatment.

METHODS

Five patients with seminal vesicle cysts were treated during January 1996 to May 2010. Their symptoms, diagnostic results, treatments and outcomes were analyzed retrospectively. Their mean age at diagnosis was 35 years old (range: 20 - 45). The symptoms included hematospermia (n = 3), urinary frequency (n = 3), perineal malaise (n = 4), infertility (n = 3), post-ejaculation pain (n = 3), scrotal pain (n = 3) and dysuria (n = 1). Cyst was palpable on digital rectal examination in 4 patients. All underwent intravenous urography and cystoscopy. Others received the examinations of ultrasonography, computed tomography (CT) scanning, magnetic resonance imaging (MRI) and vaso-vesiculography. The size range of masses was from 3.8 cm × 3.0 cm × 2.6 cm-9.6 cm × 5.2 cm × 5.0 cm. Final open operations consisted of vesiculectomy (n = 2) and laparoscopic excision of seminal vesical cyst (n = 3).

RESULTS

The post-operative course was uneventful except in 1 patient with damaged ureters. All patients stayed symptom-free after open surgery.

CONCLUSION

Seminal vesicle cysts are rare but should be considered in males with hematospermia and otherwise inexplicable bladder irritation symptoms, perineal discomforts or other genitourinary complaints of unknown etiology. The diagnostic modalities consist of digital rectal examination, transrectal and abdominal ultrasonography, CT scan or MRI. Laparoscopic excision offers excellent outcomes.

Idiopathic scrotal calcinosis--a case report

Idiopathic scrotal calcinosis is a rare disorder characterised by multiple calcified nodules on the scrotal skin appearing in childhood or early adulthood. The exact aetiology is not known and calcium level in the blood remains normal in all individuals. Since only a few cases have been reported in the literature, a case is reported here with a review of literature. The present case is of a 40-year-old male presenting with dysuria and multiple painless nodules on the scrotum.

Amputation of the penis and bilateral orchiectomy due to extensive debridement for Fournier's gangrene: case report and review of the literature

Fournier's gangrene is a rare disease with rapidly progressive necrotising fasciitis of the genital, perineal and perianal regions and is known to have an impact in the morbidity and the mortality. Despite antibiotics and aggressive debridement, mortality rate is still high. We present a 79-year-old man who was admitted to School of Medicine, Harran University, Sanliurfa, Turkey, with painful swelling of penoscrotal region. Perineal examination revealed the entire perineal skin to be gangrenous, necrotic and foul smelling. Despite the aggressive drainage and broad-spectrum antibiotic therapy, the gangrene progressed rapidly in hours and the patient's general condition worsened. Secondary extensive debridement including bilateral orchiectomy and amputation of the penis was performed. This disease may result in loss of organ such as testes and penis even with sufficient therapy.

[Liposarcoma of the spermatic cord: a case report]

OBJECTIVE

The aim of the article is to summarize experience in the pathology, diagnosis and treatment of spermatic cord liposarcoma (SCL).

METHODS

The clinical data of a patient with liposarcoma of the spermatic cord was reviewed in combination with related literature.

RESULTS

A 24-year-old male presented with a 1-year history of a mass in the right hemiscrotum. The tumor was resected and right inguinal orchidectomy was performed. The tumor had not recurred after 6 months follow-up.

CONCLUSION

Spermatic cord liposarcoma (SCL) is a rare medical condition and it is therefore difficult to establish guidelines for treatment, diagnosis and prognosis. Radical orchidectomy with wide local excision of the mass is the recommended therapy, while adjuvant radiotherapy may be considered in intermediate or high-grade tumors and recurrent liposarcomas. The role of chemotherapy is not well-defined.

The effects of reduction operation with genital lymphedema on the frequency of erysipelas and the quality of life

Genital lymphedema represents a severe disability for patients particularly when complicated by erysipelas, the most frequent complication. The objectives of this study were: to investigate the frequency of erysipelas in patients with genital lymphedema and genital lymphatic cysts who underwent evaluation for surgical treatment, to observe the influence of resection operations on the frequency of erysipelas, and to measure changes in the quality of life due to the resection. A total of 93 patients with genital lymphedema were studied. All patients underwent integrated care treatment in the Földi Clinic, Hinterzarten and the Department of Plastic and Hand Surgery of the University Hospital Freiburg during the period between 1997 and 2007. 44 of these patients underwent surgical treatment of genital lymphedema. The results indicate that lymphatic cysts were the most important risk-aggravating factor for recurrent erysipelas with lymphorrhea in the genital region (p < 0.001). Following the resection operation, however, the number of erysipelas incidents significantly decreased (p < 0.001). In addition, the antibiotic dose could be reduced after surgery (p = 0.039) and an improved quality of life was achieved (p < 0.001).

Surgical treatment in a case of giant scrotal lymphedema

OBJECTIVE

Scrotal lymphedema (SL) is a rare clinical pathology with multiple etiologies. We report a case of idiopathic giant scrotal lymphedema and review the existing medical literature in Medline from the last ten years.

METHODS

We report the case of a male patient with a giant scrotal lymphedema (43×40 cm) of unknown etiology developed over four years.

RESULTS

The patient was treated by scrotal excision and reconstruction with skin graft plasty, with a successful result.

CONCLUSIONS

Scrotal Lymphedema is a rare entity, especially in industrialized countries. If the lymphedema is severe, surgery is the most appropriate therapeutic option, whatever the cause is. Complete resection up to healthy tissue and surgical reconstruction is the choice. Thin skin grafts are necessary for reconstruction when it affects the entire scrotum.

[Laparoscopic excision of seminal vesicle cyst]

OBJECTIVE

To investigate the method and clinical efficacy of laparoscopic excision of seminal vesicle cyst.

METHODS

Laparoscopic excision of seminal vesicle cyst was performed under general anaesthesia in two patients with symptomatic seminal vesicle cyst confirmed by ultrasonography and CT scanning preoperatively. The sizes of the seminal vesicle cysts were 3.3 cm x 3.7 cm x 2.5 cm and 4.1 cm x 4.3 cm x 5.3 cm, respectively.

RESULTS

The operations were performed successfully in both the patients, with the operation time of 140 min and 100 min, blood loss of 50 ml and 20 ml, and postoperative stay of 6 days. The patients were followed up for 6 and 7 months, respectively. All the preoperative symptoms disappeared, and no complications and recurrence were found.

CONCLUSION

Laparoscopic excision of seminal vesicle cyst, with a good visual field, refined procedure, minimal invasiveness and rapid recovery, is a safe and effective surgical option for patients with seminal vesicle cyst.

Foreskin management: Survey of Canadian pediatric urologists

OBJECTIVE

To study the approaches to foreskin management of pediatric urologists in Canada.

DESIGN

An online questionnaire comprising several survey questions and clinical vignettes.

SETTING

Canada.

PARTICIPANTS

All members of the Pediatric Urologists of Canada.

MAIN OUTCOME MEASURES

Diagnoses and management strategies for common foreskin conditions seen in consultation, including how many pediatric urologists perform neonatal circumcisions, patient costs, and the reasons for performing the surgery.

RESULTS

Of the 32 members surveyed, 24 (75%) responded. By far most respondents do not perform neonatal circumcisions; however, many perform circumcisions under general anesthesia for religious and cultural purposes. Typically, patient costs for circumcision range from $500 to $1000. Management of asymptomatic physiologic phimosis is very conservative, with surgeons unlikely to intervene. Neither the presence of ballooning of the foreskin during voiding nor the child's age affects physicians' tendency toward conservative management. Balanitis xerotica obliterans was the only scenario in which most respondents believed there was a need to intervene with either topical steroids or circumcision.

CONCLUSION

Our data support the hypothesis that pediatric urologists across Canada are very similar in their conservative approach to the management of common foreskin issues. Our goal is to improve the knowledge base among primary care providers and subsequently decrease patient and family anxieties.

Idiopathic scrotal calcinosis: surgical treatment and histopathologic evaluation of etiology

Patients with idiopathic scrotal calcinosis present with multiple, asymptomatic calcified nodules on the scrotum that appear in childhood or early adulthood. The scrotal skin can be extensively affected, and scrotal reconstruction with complicated procedures usually seems to be needed after excision. However, primary closure is usually achievable. Two cases are presented with histopathologic findings of scrotal calcinosis. The possible etiologies are discussed, and the therapeutic alternatives are reviewed.

Novel application of da Vinci robotic system in patients of Zinners syndrome--case report and review of literature

Seminal vesicle cysts combined with ipsilateral renal agenesis, ectopic ureter and giant right ampullary cyst of vas deferens represent a rare urological anomaly, Zinners syndrome. In symptomatic patients' seminal vesiculectomy along with enbloc excision of the ipsilateral ampullary cyst, ectopic ureter and dysplastic, renal tissue is the preferred treatment option. We report robotic assisted removal of a large seminal vesicle cyst with ipsilateral renal agenesis, ectopic ureter and a giant right ampullary cyst of vas deferens in a 34-year-old male. We reviewed the literature about this rare urological anomaly and novel usage of da Vinci surgical robotic surgical system (DSRS) (Intuitive Surgical, Sunnyvale, California) in performing this procedure.

[A case of fibrous pseudotumor arising from the paratesticular area]

Intrascrotal fibrous pseudotumor is rarely observed, and only 40 cases have been reported in Japan. A 65-year-old male patient visited this hospital due to a painless right scrotal mass. Computed tomography demonstrated a solid mass with a cystic component ; however, the exact location of the mass in relation to other scrotal contents was not determined. Intraoperative findings revealed a solid mass, 2 cm in diameter, in the tunica vaginalis. The mass could not be dissected from the epididymis ; therefore, high orchiectomy was indicated. A histopathological diagnosis of fibrous pseudotumor was made. The patient's postoperative course was uneventful, and no recurrence has been found. It is difficult to make a diagnosis of paratesticuler tumor based on preoperative radiological results and even macroscopic observation during surgery. We strongly recommend that it is necessary to undergo high orchiectomy for a fibrous pseudotumor in which dissection from the peripheral tissue is very difficult since it may involve various types which may lead to a diagnosis of malignancy.

[Epididymal leiomyoma: a case report]

A 30-year-old male, who underwent orchiopexy of left undescending testis in his childhood, presented with right hemiscrotal swelling without pain. Ultrasonography revealed a paratesticular tumor which showed enhancement on magnetic resonance imaging (MRI). Diffusion-weighted MRI showed decreased diffusion in the tumor, and malignant tumor could not be ruled out. High inguinal orchiectomy was carried out and pathological diagnosis was benign leiomyoma of the epididymis.