Aqueous extract from Orthosiphon stamineus leaves prevents bladder and kidney infection in mice

BACKGROUND

Extracts from the leaves of Orthosiphon stamineus are used in phytotherapy for treatment of uncomplicated urinary tract infections.

PURPOSES

Evaluation of an aqueous extract against infection with uropathogenic Escherichia coli in vivo; investigation of underlying microbiological mechanisms.

STUDY DESIGN

In vivo studies in mice and in vitro investigations on cytotoxicity, antiadhesive potential, influence on bacterial gene expression and quorum sensing.

METHODS

Extract OWE was prepared by hot water extraction. For in vivo studies BALB/c mice were used in an UPEC infection model. The effect of OWE on bacterial load in bladder/kidney tissue was monitored in pre- and posttreatment. Cytotoxicity of OWE against different UPEC strains, T24 bladder/A498 kidney cells, gene expression analysis, monitoring of phenotypic motility and quorum sensing was investigated by standard methods of microbiology.

RESULTS

OWE was quantified (UHPLC) according to the content of rosmarinic acid, cichoric acid, caffeic acid. Three- and 5-day treatment of animals with OWE (750mg/kg) after transurethral infection with UPEC CFT073 reduced the bacterial load in bladder and kidney, similar to norfloxacin. Four- and 7-day pretreatment of mice prior to the infection with UPEC NU14 reduced bacterial bladder colonization. In vitro investigations indicated that OWE (≤2mg/ml) has no cytotoxic or proliferation-inhibiting activity against different UPEC strains as well as against T24 bladder and A498 kidney cells. OWE exerts a dose dependent antiadhesive activity against UPEC strains NU14 and UTI89. OWE reduced gene expression of fimH, but evoked increase of the expression of motility/fitness gene fliC. Increase of bacterial motility on gene level was confirmed by a changed bacterial phenotype by an increased bacterial motility in soft agar assay. OWE inhibited in a concentration-dependent manner bacterial quorum sensing.

CONCLUSION

OWE is assessed as a strong antiadhesive plant extract for which the traditional use in phytotherapy for UTI might be justified.

[A Case Diagnosed as Iatrogenic Vesical Tuberculosis 4 Years after Intravesical Immunotherapy Using Bacillus Calmette-Guérin (BCG) for the Treatment of Bladder Carcinoma]

We report a case of iatrogenic vesical tuberculosis diagnosed 4 years after intravesical immunotherapy using Bacillus Calmette- Guérin (BCG) for the treatment of bladder carcinoma. A 72-year-old man underwent a transurethral resection (TUR) of multiple noninvasive urothelial carcinomas and intravesical BCG infusion (40 mg/week) for 7 weeks to prevent the recurrence of bladder carcinoma. BCG infusion therapy was terminated because of the appearance of Reiter's syndrome, including arthritis of the left toe joint, conjunctivitis and non-gonococcal urethritis as complications. The patient suffered from repeated cystitis, bladder atrophy and urethral stenosis. The cystitis improved with the administration of antibiotics (Levofloxacin) but persisted without a complete cure. Four years later, a cystoscopy revealed mucosal erosion and a white coating. An acid-fast bacteria examination of a urine sample using bacteria incubation and DNA PCR revealed the presence of Mycobacterium bovis. Finally, anti-tuberculosis therapy (INH＋REP＋EB) was initiated after the patient was diagnosed as having iatrogenic bladder tuberculosis resulting from BCG immunotherapy. The tuberculosis bacteria subsequently disappeared from the urine samples, and the gross appearance of the bladder mucosa improved. Bladder carcinoma has not recurred to date. Intravesical BCG infusion therapy has a good anti-tumor effect and can help prevent tumor recurrence after TUR therapy in case of noninvasive bladder carcinoma. However, there is a risk of severe complications arising from the BCG infusion. In the present case, an adequate bacteria examination was not performed, even though antibiotics were repeatedly administered for cystitis. In particular, the patient was not tested for the presence of acid-fast bacteria for 4 years after the intravesical BCG infusion therapy. Furthermore, among patients who received anti-bacteria therapy for repeated cystitis after BCG infusion, a bacteria examination including bacteria incubation, was not ordered in 19 out of 30 cases treated at our hospital over the past 5 years. In conclusion, bacteria examination, including tests for acid-fast bacteria, should be immediately performed when repeated and/or persistent cystitis occurs after BCG infusion therapy.

Does the Urinary Microbiome Play a Role in Urgency Urinary Incontinence and Its Severity?

OBJECTIVES

Traditionally, the urinary tract has been thought to be sterile in the absence of a clinically identifiable infection. However, recent evidence suggests that the urinary tract harbors a variety of bacterial species, known collectively as the urinary microbiome, even when clinical cultures are negative. Whether these bacteria promote urinary health or contribute to urinary tract disease remains unknown. Emerging evidence indicates that a shift in the urinary microbiome may play an important role in urgency urinary incontinence (UUI). The goal of this prospective pilot study was to determine how the urinary microbiome is different between women with and without UUI. We also sought to identify if characteristics of the urinary microbiome are associated with UUI severity.

METHODS

We collected urine from clinically well-characterized women with UUI (n = 10) and normal bladder function (n = 10) using a transurethral catheter to avoid bacterial contamination from external tissue. To characterize the resident microbial community, we amplified the bacterial 16S rRNA gene by PCR and performed sequencing using Illumina MiSeq. Sequences were processed using the workflow package QIIME. We identified bacteria that had differential relative abundance between UUI and controls using DESeq2 to fit generalized linear models based on the negative binomial distribution. We also identified relationships between the diversity of the urinary microbiome and severity of UUI symptoms with Pearson's correlation coefficient.

RESULTS

We successfully extracted and sequenced bacterial DNA from 95% of the urine samples and identified that there is a polymicrobial community in the female bladder in both healthy controls and women with UUI. We found the relative abundance of 14 bacteria significantly differed between control and UUI samples. Furthermore, we established that an increase in UUI symptom severity is associated with a decrease in microbial diversity in women with UUI.

CONCLUSIONS

Our study provides further characterization of the urinary microbiome in both healthy controls and extensively phenotyped women with UUI. Our results also suggest that the urinary microbiome may play an important role in the pathophysiology of UUI and that the loss of microbial diversity may be associated with clinical severity.

[REASONS OF DELAYED DIAGNOSIS OF BLADDER TUBERCULOSIS]

The fourth, terminal, stage of bladder tuberculosis (BT) manifests itself in irreversible changes and requires surgical treatment.

OBJECTIVE

To identify the reasons for delayed diagnosis of this urogenital tuberculosis complication. Medical history of 26 urogenital tuberculosis patients with a complicated form of stage 4 BT, referred to the Novosibirsk TB Research Institute for reconstructive surgery were analysed. In 22 patients, bladder volume ranged from 55 to 100 ml, 4 patients previously underwent cystostomy due to extremely small bladder volume. Average duration of BT hidden in the guise of "urogenital infection" was 6.2 years. Patients were treated with norfloxacin (a total of 104 courses), ciprofloxacin (86 courses), amikacin (43 courses), nitroxoline (27 courses), third generation cephalosporins (32 courses), lomefloxacin (17 courses), levofloxacin (11 courses), Amoxicillin clavulanate (4 courses), ampicillin (2 courses). It was demonstrated that all cases of BT stage 4 were iatrogenic. Irreversible debilitating complications occurred due to suboptimal therapy, primarily due to administration of amikacin and fluoroquinolones for urogenital infections, which was tuberculosis in disguise. Absence of M. tuberculosis growth does not exclude tuberculosis; pathological specimens must be further examined at least by PCR. Interventional material must be mandatory examined histologically and stained by Ziehl-Neelsen method to identify M. tuberculosis. Effective and not masking tuberculosis, optimal therapy for urogenital infections includes fosfomycin, furazidin (nitrofurantoin), gentamicin, III generation cephalosporins (in outpatient settings dispersible form of efixime should be preferable).

Reconstructive surgery for tuberculous contracted bladder: experience of a center in northern India

OBJECTIVE

To document the management of tuberculous cicatrized urinary bladder by incorporating bowel segment and the long-term follow-up after the reconstructive surgery.

MATERIALS AND METHODS

Twenty-three patients (out of 28) were managed by augmentation cystoplasty (AC) and 5 by orthotopic neobladder (OTN) reconstruction. Sigmoidocystoplasty was performed in 11 cases, ileocystoplasty in 10 patients and ileocecocystoplasty in 2 patients. Ileal neobladder reconstruction was done in 2 patients, ileocecal neobladder reconstruction in 1 patient and sigmoid neobladder reconstruction in 2 patients, respectively. The patients were followed according to standard follow-up protocols.

RESULT

The mean age of patients who underwent AC was 32.5 years and of those who underwent OTN reconstruction was 31 years. The mean pre-operative bladder capacity in patients with AC was 70 ml (range 40-100 ml) and of patients with OTN reconstruction was 14 ml (range 10-20 ml). The mean postoperative bladder capacity at 3 months following AC was 427 ml (range 450-500 ml) and following OTN reconstruction it was 430 ml (range 350-450 ml). The mean follow-up in patients who underwent AC was 43.3 months (range 12-90 months) and in those who underwent OTN reconstruction it was 35.6 months (16-60 months). None of the patients had upper urinary tract deterioration following the reconstructive surgery.

CONCLUSION

Urinary bladder rehabilitation either by AC or OTN reconstruction increases the bladder capacity and storage time and also preserves the upper tracts.

[Leucoplakia vesicae in females: diagnosis and treatment]

Sixty patients suffering from leucoplakia vesicae (LV) were examined using cystoscopy with biopsy of the urinary bladder wall, blood enzyme immunoassay for detection of antibodies to agents of sexually transmitted infections (STI), uroflowmetry, culture analysis of cervical canal and mucosa samples for STI. As shown by a pathomorphological examination of the vesical mucosa biopsy specimens, long-term persistence of pathogenic (chlamydia, trichomonades) and opportunistic (mycoplasma, ureaplasma, fungi) flora underlies development of LV. Morphogenesis of LV is characterized by hyperplastic reactions of urothelium and its metaplasy in laminated squamous keratosic epithelium, often with para- and dyskeratosis, developing in the presence of inflammatory reactions in the lamina in the presence of persisting infection. In LV, specific infection agents are often found in the urogenital tract. The spectrum of these agents is identical for samples from the cervical canal and vesical mucosa from leucoplakia foci. Vesical mucosa is most frequently contaminated with Mycoplasma hominis (57.2%), Candida albicans (51.4%), Ureaplasma urealiticum (37.1%) and Trichomonas vaginalis (22.9%). Associations of the infection agents are detected in 70% of LV patients. Persistent dysuria is a basic clinical symptom of leucoplakia. The following therapeutic measures should be taken: transurethral coagulation of the vesical mucosa, intravesical therapy, immunocorrection, antibacterial treatment by standard schemes or according to the isolated flora sensitivity.

FimH adhesin of type 1 fimbriae is a potent inducer of innate antimicrobial responses which requires TLR4 and type 1 interferon signalling

Components of bacteria have been shown to induce innate antiviral immunity via Toll-like receptors (TLRs). We have recently shown that FimH, the adhesin portion of type 1 fimbria, can induce the innate immune system via TLR4. Here we report that FimH induces potent in vitro and in vivo innate antimicrobial responses. FimH induced an innate antiviral state in murine macrophage and primary MEFs which was correlated with IFN-beta production. Moreover, FimH induced the innate antiviral responses in cells from wild type, but not from MyD88(-/-), Trif(-/-), IFN-alpha/betaR(-/-) or IRF3(-/-) mice. Vaginal delivery of FimH, but not LPS, completely protected wild type, but not MyD88(-/-), IFN-alpha/betaR(-/-), IRF3(-/-) or TLR4(-/-) mice from subsequent genital HSV-2 challenge. The FimH-induced innate antiviral immunity correlated with the production of IFN-beta, but not IFN-alpha or IFN-gamma. To examine whether FimH plays a role in innate immune induction in the context of a natural infection, the innate immune responses to wild type uropathogenic E. coli (UPEC) and a FimH null mutant were examined in the urinary tract of C57Bl/6 (B6) mice and TLR4-deficient mice. While UPEC expressing FimH induced a robust polymorphonuclear response in B6, but not TLR4(-/-) mice, mutant bacteria lacking FimH did not. In addition, the presence of TLR4 was essential for innate control of and protection against UPEC. Our results demonstrate that FimH is a potent inducer of innate antimicrobial responses and signals differently, from that of LPS, via TLR4 at mucosal surfaces. Our studies suggest that FimH can potentially be used as an innate microbicide against mucosal pathogens.

Mast cell-derived histamine mediates cystitis pain

Background

Mast cells trigger inflammation that is associated with local pain, but the mechanisms mediating pain are unclear. Interstitial cystitis (IC) is a bladder disease that causes debilitating pelvic pain of unknown origin and without consistent inflammation, but IC symptoms correlate with elevated bladder lamina propria mast cell counts. We hypothesized that mast cells mediate pelvic pain directly and examined pain behavior using a murine model that recapitulates key aspects of IC.

Methods and Findings

Infection of mice with pseudorabies virus (PRV) induces a neurogenic cystitis associated with lamina propria mast cell accumulation dependent upon tumor necrosis factor alpha (TNF), TNF-mediated bladder barrier dysfunction, and pelvic pain behavior, but the molecular basis for pelvic pain is unknown. In this study, both PRV-induced pelvic pain and bladder pathophysiology were abrogated in mast cell-deficient mice but were restored by reconstitution with wild type bone marrow. Pelvic pain developed normally in TNF- and TNF receptor-deficient mice, while bladder pathophysiology was abrogated. Conversely, genetic or pharmacologic disruption of histamine receptor H1R or H2R attenuated pelvic pain without altering pathophysiology.

Conclusions

These data demonstrate that mast cells promote cystitis pain and bladder pathophysiology through the separable actions of histamine and TNF, respectively. Therefore, pain is independent of pathology and inflammation, and histamine receptors represent direct therapeutic targets for pain in IC and other chronic pain conditions.

Bladder tuberculosis after BCG therapy

The initial treatment of bladder cancer is transurethral resection (TUR), but this cancer recurs at an important rate, and has 14% chance of progression after TUR alone. Intravesical chemotherapy with Bacillus Calmette-Guerin (BCG) is effective against recurrence and progression of bladder cancer. However, this therapeutic expose to many local and systemic side-effects. We report a case of 63-year-old man who presented bladder tuberculosis after a BCG therapy, which required 6 months of antitubercular therapy.

[Efficacy of instillagel against methicillin-resistant strains of Staphylococcus aureus in urinary bladder catheterization]

Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) present a global problem. Catheterization of the bladder is a risk factor of MRSA infection. Bacteriological tests showed that a lubricating agent for catheterization installagel has a special formulation killing MRSA for 5 minutes. Thereby, instillagel is recommended for catheterization in risk groups attending clinics and old people's homes.

Tumor necrosis factor alpha- and inducible nitric oxide synthase-producing dendritic cells are rapidly recruited to the bladder in urinary tract infection but are dispensable for bacterial clearance

The role of dendritic cells (DC) in urinary tract infections (UTI) is unknown. These cells contribute directly to the innate defense against various viral and bacterial infections. Here, we studied their role in UTI using an experimental model induced by transurethral instillation of the uropathogenic Escherichia coli (UPEC) strain 536 into C57BL/6 mice. While few DC were found in the uninfected bladder, many had been recruited after 24 h, mostly to the submucosa and uroepithelium. They expressed markers of activation and maturation and exhibited the CD11b+ F4/80+ CD8- Gr-1- myeloid subtype. Also, tumor necrosis factor alpha (TNF-alpha)- and inducible nitric oxide synthase (iNOS)-producing CD11bINT DC (Tip-DC) were detected, which recently were proposed to be critical in the defense against bacterial infections. However, Tip-DC-deficient CCR2-/- mice did not show reduced clearance of UPEC from the infected bladder. Moreover, clearance was also unimpaired in CD11c-DTR mice depleted of all DC by injection of diphtheria toxin. This may be explained by the abundance of granulocytes and of iNOS- and TNF-alpha-producing non-DC that were able to replace Tip-DC functionality. These findings demonstrate that some of the abundant DC recruited in UTI contributed innate immune effector functions, which were, however, dispensable in the microenvironment of the bladder.

Molecular epidemiologic identification of Escherichia coli genes that are potentially involved in movement of the organism from the intestinal tract to the vagina and bladder

A first step in urinary tract infection (UTI) pathogenesis in the otherwise healthy host is the movement of uropathogenic Escherichia coli from the intestinal tract to the urinary tract. We conducted a genomic subtraction to isolate genetic regions associated with this movement. A representative UTI isolate present in the rectum, vagina, and bladder of a woman with UTI was chosen as the tester; the driver was a phylogenetically distant rectal isolate (based on pulsed-field gel electrophoresis analysis) with a profile of uropathogenic virulence genes similar to that of the tester. Tester-specific regions identified by the subtraction were screened, using DNA dot blot hybridization, against a collection of 88 uropathogens isolated from the rectum, urine, and/or vagina of women with UTIs and 54 E. coli isolates from the same women that were found only in the rectum. Twelve genetic regions occurred more often in multisite isolates than in rectal site-only isolates. Eleven of these 12 genetic regions are homologous to regions in the sequenced uropathogenic E. coli CFT073 strain.

Virtual cystoscopy: reality in imaging of bladder tuberculosis

We present a case of urinary tuberculosis investigated initially by ultrasound and multidetector computed tomography (MDCT). The MDCT-derived volumetric data were used to generate virtual cystoscopy (VC) images, which revealed a bladder ulcer. The presence of this ulcer was confirmed by conventional cystoscopy-guided biopsy and there was good agreement regarding various features of the ulcer, such as the site, size and shape, as detected by virtual and conventional cystoscopies. VC, a result of simple postprocessing of preacquired MDCT data, proved valuable in the characterization of the bladder lesion in conjunction with CT and ultrasound images. Although a larger study is warranted, in our case these en face VC representations of the ulcer served as useful precursors to conventional cystoscopic biopsy.

Intramural bladder-wall abscess: a late complication arising after a urethrocystoscopy?

Intramural bladder-wall abscesses are serious but rather rare. In the few reported cases, their aetiology has not been explicitly explained. In our case, we found a traumatic outcome induced by a urethrocystoscopy that had taken place 4 years prior to the diagnosis of abscess. To date, there has not been much published on these bladder-wall abscesses or urinary tract infections from urethrocystoscopies and Burkholderia cepacia bacteria. As a result, their pathogenesis and aetiology have not been fully explained. In this paper we report on the clinical as well as the subjective well-being of a female child who was diagnosed with a massive full-blown intramural bladder-wall abscess that developed 4 years after she had undergone a urethrocystoscopy.

Pseudospirochaetosis of the urinary bladder

This report describes an elderly patient with urinary symptoms who showed surface colonisation of the transitional mucosa of the bladder by an unusual haematoxophilic microorganism superficially resembling the "blue fuzz" seen in colonic biopsies showing intestinal spirochaetosis. Special stains showed that the organisms were Gram and Giemsa positive, weakly argyrophilic, and Ziehl-Nielsen negative. Immunostains were negative for Helicobacter pylori and electron microscopy revealed curious curved bodies, which were difficult to classify. Therefore, this condition was described as pseudospirochaetosis of the urinary bladder. The urinary symptoms regressed on treatment with ciprofloxacin. The clinicopathological relevance of these findings is discussed in the report.

Spontaneous bladder wall abscess in a child

Spontaneous bladder wall abscess in the pediatric population is a rare event. We present a unique case of spontaneous Staphylococcus aureus bladder wall abscess in a 2-year-old boy who had no underlying risk factors. The abscess was successfully managed with intravenous antibiotics followed by complete surgical excision.

[Bladder mucormycosis. Report of one case]

OBJECTIVES

To report one case of an opportunistic bladder infection by fungus of the Mucorales order.

METHODS

An old patient with permanent bladder catheter due to cerebral vascular accident presented with hematuria associated with change in his general health status, and a bladder mass on ultrasound Cystoscopy and cold biopsy were performed

RESULTS

Pathology reported bladder mucormycosis.

CONCLUSIONS

Mucormycosis is an opportunistic infection by fungus of the Mucorales order, which disseminate hematogenously from an entrance. Diagnosis is usually histological, seeing characteristic hyphae and ischemic or hemorrhagic necrosis. Bladder involvement is very uncommon. Treatment is based on the combination of debridement of the necrotic areas and intravenous antifungal drugs (amphotericin B).

Intracellular bacterial biofilm-like pods in urinary tract infections

Escherichia coli entry into the bladder is met with potent innate defenses, including neutrophil influx and epithelial exfoliation. Bacterial subversion of innate responses involves invasion into bladder superficial cells. We discovered that the intracellular bacteria matured into biofilms, creating pod-like bulges on the bladder surface. Pods contained bacteria encased in a polysaccharide-rich matrix surrounded by a protective shell of uroplakin. Within the biofilm, bacterial structures interacted extensively with the surrounding matrix, and biofilm associated factors had regional variation in expression. The discovery of intracellular biofilm-like pods explains how bladder infections can persist in the face of robust host defenses.

Spontaneous expulsion of a screw during urination: an unusual complication 9 years after internal fixation of pubic symphysis diastasis

Nine years after treatment of symphysiolysis and dislocation of the left sacroiliac joint, a screw was spontaneously voided during urination. Unstable plate fixation of the symphysis pubis probably caused screw migration into the bladder, creating a fistula with abscess formation and septic complications.

Unusual bladder masses in children

Benign and malignant bladder masses in children are extremely rare pathologic lesions. The presentation can include gross hematuria, irritable or obstructive voiding symptoms, and urinary infection. We present 2 cases in which large bladder masses suspicious for malignancy were diagnosed as benign lesions. One patient presented with abdominal pain and frequency 2 weeks after a minor bicycle accident and had a bladder wall abscess with sterile urine. Another child presented with gross hematuria and was found to have a giant cystitis glandularis lesion with no precipitating event or infection. The evaluation and differential diagnosis are discussed, and a review of the literature is presented.

Isolation of Buttiauxella gaviniae from a spinal cord patient with urinary bladder pathology

A gram-negative Buttiauxella gaviniae-like organism (LBV449) was isolated from a urine sample of a patient suffering from urine bladder pathology and neurological problems. The isolate was positive for adonitol fermentation and L-arginine dihydrolase and negative for melibiose and L-ornithine decarboxylase. The API 20E code was 3004113. Retrospectively, another isolate (ENT107), from a leg wound, was recovered from our collections and was shown to have similar biochemical characteristics. DNA-DNA hybridization showed 77% similarity between both strains, and strain LBV449 revealed 74% DNA-DNA similarity to the type strain of B. gaviniae. Neither 16S rRNA gene sequencing nor fatty acid analysis were useful for identification. The characteristic tRNA-PCR patterns obtained for these two clinical isolates consisted of fragments with lengths of 102.2, 105.4, 116.6, and 136.9 bp and most resembled the tRNA-PCR pattern obtained for B. gaviniae, but they lacked the B. gaviniae fragments of 88.2 and 239.5 bp. To our knowledge, no clinical cases with Buttiauxella strains have been described thus far.

Actinomycosis of the urinary bladder

The case of a 49 year-old female patient, with frequency of urination for 2 years, having a mass at the anterior bladder wall and at the anterior abdominal wall is reported. Cystoscopy found an impression of the anterior bladder wall and hyperremic edematous bladder mucosa. Pre-operative computerized tomography suspected bladder tumor. Laparotomy revealed an inflammatory firm mass at the anterior bladder wall and another mass at the anterior abdominal wall. Partial cystectomy and excision of the mass at the anterior abdominal wall were performed. After the pathological examination confirmed actinomycosis, the patient was treated post operatively with penicillin. She recovered well.

Primary actinomycosis of the urinary bladder

Actinomycosis is caused by bacilli of the Actinomyces sp. They are Gram-positive, anaerobic or microaerophilic non-spore-forming bacilli. Actinomyces israelii is the most common aetiological agent. A case is reported of primary actinomycosis in the urinary bladder successfully treated with ceftriaxone.

[Bladder candidosis after renal transplantation: contribution of ultrasonography]

Candidosis of the ureter and the bladder is an infrequent complication after renal transplantation. A case occurring early after kidney transplantation is reported in a patient presenting with candiduria. Ultrasound examination detected several fungal bezoars, presenting as a proliferating, avascular lesions, located within the ureter and the bladder. It allowed to demonstrate the rapid extension of lesions, in spite of a medical treatment, leading to a successful endoscopic removal of fungus balls.

Bladder infection in the menopausal monkey

PURPOSE

The highest incidence of urinary tract infection in females occurs in elderly women. This study was done to determine whether this is due to the declining immune response that occurs during advancing age, or the menopausal state in the aged.

MATERIALS AND METHODS

Adult female monkeys (average age 19 years) were studied, half being subjected to bilateral oophorectomy to produce the menopause. In addition, old females (average age 29 years) already at menopause were studied before and after hormonal replacement with estradiol and progesterone. Bacterial adherence to vaginal cells was studied prior to and after urethral infection with E. coli. Plasma estradiol and progesterone levels were done, as well as white blood counts, plasma cytokine assays and serum antibody titers.

RESULTS

Bacteriuria was not prolonged, nor was there a significant difference in bacterial adherence to vaginal cells due to menopause. Interleukin-1 levels were depressed after surgical menopause but not as much as found in the old menopausal females and this low level was not corrected by hormonal replacement. The initial interleukin-2 levels were higher after spontaneous menopause, but the increasing plasma levels seen in cycling animals after infection did not occur in the aged menopausal females following infection even after hormone replacement. The antibody titers to the E. coli infection showed a trend to a lessened response to infection after menopause but were not significantly decreased.

CONCLUSIONS

The deficient Il-1, Il-2 and antibody response following infection was not corrected by hormone replacement and thus appears to be due to aging rather than lack of female hormones. These facts may be explained by the T cell senescence known to occur in aged individuals.

Urinary tract infection after urodynamic studies in women: incidence and natural history

OBJECTIVE

To study the incidence, natural history and symptomatic effects of bacteriuria after urodynamic studies in women.

PATIENTS AND METHODS

In a prospective study in the urogynaecology clinic of a large District General Hospital, 214 women (mean age 52.3 years, range 23-81) underwent urodynamic studies. Bacteriuria was detected by semiquantitative culture at 2 and 7 days after the test. Women completed a 7-day diary of symptoms and events.

RESULTS

The incidence of bacteriuria after urodynamic studies was 7.9%. Bacteriuria was transient in four of 17 women but persisted in nine and developed late in four; only one of 17 infections gave rise to symptoms. Irritative bladder symptoms after the test occurred in 34% of women, but only three went to their doctors because of concern about a possible urinary tract infection. Advancing age was the only variable associated with bacteriuria after urodynamic studies (P= 0.05). Menopausal status, past history of urinary tract infection, number of urethral instrumentations required, order number in a session, peak urinary flow rate and urodynamic diagnosis were not associated variables.

CONCLUSIONS

In a large series of women presenting to a urogynaecology clinic, urodynamic investigations were associated with a high incidence of transient irritative symptoms but a low incidence of bacteriuria (8%). Infection was asymptomatic in most patients, but its natural history was unpredictable. Transient, persistent and late cases of bacteriuria all occurred. In this population, urodynamic studies are associated with a low level of morbidity.

[Urogenital tuberculosis. Apropos of 40 cases]

The authors report a series of 40 cases of genitourinary tuberculosis diagnosed and treated in the department of urology "B" of Avicenne hospital over a 7-year period. The objective of this study is to define the various diagnostic and therapeutic aspects of this disease. The patients were predominantly males (62.5%) with a mean age of 40 years. 25% of cases reported a history of extra-urinary tuberculosis. The very polymorphous clinical presentation is dominated by signs of cystitis (45%). Intravenous urography is frequently suggestive of the diagnosis based on the appearance and multiplicity of the lesions. The radiological lesions most frequently encountered were silent kidney (19 cases) and small tuberculous bladder (11 cases). The definitive diagnosis was established by pathological examination in 38 cases (biopsies, operative specimens, prostatic resection chips) and/or by demonstration of AFB in 2 cases (urine, pus). Tuberculostatic treatment was administered to all patients, either alone (5 cases) or, more usually, in combination with surgical and/or endo-urological treatment (35 cases), reflecting the magnitude and severity of the destructive and scar lesions.

[A severe form of urinary tuberculosis in children]

Urinary tuberculosis is a rare disease in children. It poses major diagnostic problems because of clinical symptoms, which are often atypical and misleading. It causes serious lesions which are often multifocal and extensive, requiring complex surgical excision and urinary tract reconstruction. Prevention of this disease is based on generalized vaccination with BCG and adequate treatment of pulmonary tuberculosis. The authors report a case of urinary tuberculosis in a fourteen-year-old child who presented episodes of cystitis and hematuria refractory to treatment. The diagnosis, confirmed by the positive test for AFB in the urine was established late, at the stage of silent kidney and scleroatrophic bladder. The patient was treated with antituberculous chemotherapy (Isoniazid; Rifampicin, PZA) and nephro-ureterectomy with augmentation enterocystoplasty.

Helicobacter pylori infection in a child with gastric augmentation

The existence of Helicobacter pylori (HP) infection in those children who had previous bladder augmentation with gastric patch has not been described before. In this report, a girl with bladder exstrophy, who previously underwent gastric augmentation is presented. She had multiple admissions to our unit with persisting urinary symptoms (perineal pain, dysuria, hematuria) and gastric symptoms as well. Enzyme-linked immunosorbent assay (ELISA) test results for HP infection were positive, and plasma gastrin level was high. The histopathologic examination of the biopsy specimen showed HP infection in the gastric part of the reconstructed neobladder. This report indicates that the pediatric surgeon should think about HP infection in gastrocystoplasty patients to eliminate the potential risks of HP colonization.

Renal malakoplakia: report of a case with multifocal involvement

The authors report the light microscopic and ultrastructural features in one case of malakoplakia involving the kidney, the urinary bladder, and the skin. The kidney was excised. Lesions of the urinary bladder and the skin regressed after topical treatment with cholinergic agonists and antimicrobial drugs. This case illustrates the pathogenesis of malakoplakia and the possibility that early lesions can be cured with medical therapy before extensive tissue destruction has taken place.

[Spontaneous bladder perforation secondary to bladder candidiasis]

Presentation of an spontaneous vesical perforation secondary to vesical candidiasis in a patient with in-dwelling catheter due to BPH. Analysis of etiological factors, clinical signs and symptoms, diagnosis and management of both entities.

Spontaneous loss of antibiotic-resistant plasmids transferred to Escherichia coli in experimental chronic bladder infection

BACKGROUND

We investigated whether Escherichia coli that has been transformed with antibiotic-resistant plasmids spontaneously loses the plasmids while infecting the rat bladder.

METHODS

A nontransmissible antibiotic-resistant plasmid was transferred to a clinically isolated strain of E. coli. A knotted thread holding the strain was implanted into the bladder of male Wistar rats. One or 4 weeks later, the total number of bacteria and that of plasmid-carrying bacteria were measured in the bladder.

RESULTS

When plasmid-carrying E. coli alone was inoculated, most of the plasmid-carrying E. coli were replaced with plasmid-free E. coli. When plasmid-carrying and plasmid-free E. coli were simultaneously inoculated, this replacement was accelerated.

CONCLUSION

These results suggest that E. coli carrying antibiotic-resistant plasmids spontaneously lose the plasmids as time passes, and thus become sensitive to antibiotics.

Primary actinomycosis of the urinary bladder. Case report and review of the literature

The case of a female patient, aged 37, with signs of partial intestinal obstruction, repeated cystitis and a tumoral mass in the hypogastrium is reported. Preoperative examinations could not establish the nature of the tumour. Colonoscopy as well as barium enema stopped at a sharp angulation of the sigmoid. Laparotomy evidenced an inflammatory tumour, with departure point in the urinary bladder, which involved the sigmoid and the uterus. After adhesiotomy a partial cystectomy was performed. The macroscopic aspect of the bladder was pseudopolypoid, while the microscopic one was typical for actinomycosis. The patient was discharged cured and was prescribed a penicillin course for 4 weeks.

Predisposing factors of systemic fungal infections of the genitourinary tract

We reviewed 50 patients with genitourinary fungal infections between 1982 and 1992. Infections were classified as simple--localized to the bladder and complex--demonstrated evidence of upper tract and/or systemic infection. Predisposing factors of fungal infections, including diabetes mellitus, prolonged Foley catheter drainage and corticosteroid use, were not significantly different. The incidence of obstructive uropathy (88% versus 20%), malnutrition (88% versus 48%), neoplasia (56% versus 16%), renal failure (24% versus 8%) and prolonged antibiotic use (60% versus 32%) were significantly greater in patients with complex infections. The incidence of fungemia in patients with complex infections was 81% with an associated mortality rate of 36%. Of the patients with complex infections 56% required urological intervention. Given the high incidence of obstructive uropathy with complex fungal infections, upper tract imaging is essential.

Fungal infections of the perivesical space

We describe 3 patients with fungal infection in the perivesical space who manifested lower abdominal pain and urinary tract symptomatology. Imaging studies demonstrated perivesical abnormalities. Urine culture was positive for fungus in only 1 patients. Management required surgical exploration, drainage, débridement of necrotic tissue and in 1 patient partial bladder resection. Systemic antifungal therapy was administered postoperatively. All patients had a successful outcome.

Moderate stress protects female mice against bacterial infection of the bladder by eliciting uroepithelial shedding

We have previously shown (M. Aronson, O. Medalia, D. Amichay, and O. Nativ, Infect. Immun. 56:1615-1617, 1988) that shedding of viable uroepithelial cells (elicited by invading microorganisms) constitutes an antimicrobial defense mechanism. The present study deals with two different stress-involving procedures, in which increased uroepithelial shedding rendered female mice resistant to vesical infection. Moderate stress was induced in female mice by exposing the animals either to constant illumination for 96 h or to 37 degrees C heat for 24 h. In both cases, the rate of infection was considerably reduced as a result of increased epithelial shedding (P < 0.0001). Stress was manifested by both reduced thymic weight and increased blood corticosterone levels. Shedding was also elicited by intraperitoneal injection of norepinephrine together with hydrocortisone or by intravesical injection of corticosterone. Constant illumination as well as heat enormously facilitated the migration of polymorphonuclear cells into the bladder following the action of chemotactic stimuli. Male mice subjected to identical stress-generating conditions did not display considerable epithelial shedding or increased migration of polymorphonuclear cells, and they were not protected from intravesical infection.

[Inhibition of biofilm formation by clarithromycin (CAM) in an experimental model of complicated bladder infection--in vitro study using automated simulation of urinary antimicrobial concentration]

The role of clarithromycin (CAM) in biofilm formation has recently been reported. Inhibition of the production or promotion of the dissolution of the glycocalyx, a major component of biofilm, has been implicated in its mechanism of action. However, the details remain unclear. We used an experimental model of complicated urinary bladder infection and automated simulation of the variations in urinary antimicrobial concentration to study the efficacy of CMA in inhibiting biofilm formation and obtained the following results. 1) Prior to biofilm formation, Pseudomonas aeruginosa (P. aeruginosa) was exposed to ciprofloxacin (CPFX, MIC: 8 micrograms/ml), which was active against the organism, at a dose of 200 mg t.i.d. for 7 days. The bacteria were apparently eradicated from the culture medium in the experimental model of bladder infection (model bladder) after 32 hours. However, when the medium was changed to eliminate the antimicrobial agent on Day 7, bacterial regrowth was initiated after 4 hours. Scanning electron microscopy demonstrated sequential biofilm formation on the surface of glass beads in the model bladder diverticulumn, suggesting inside the biofilm were a source of regrowth. 2) Prior to biofilm formation, P. aeruginosa was also exposed to CAM alone, which has no antimicrobial activity against the organism (MIC: > 128 micrograms/ml) at a dose of 200 mg t.i.d. for 7 days. In this situation, CAM was not active against P. aeruginosa and the bactericidal concentration in the model bladder did not decrease markedly, reaching the initial level (10(7) CFU/ml) within 48 hours. However, although numerous bacteria were attached to the glass beads in the diverticulum, no biofilm was formed. 3) Exposure to a combination of CPFX and CAM (each at 200 mg t.i.d. for 7 days) resulted in the eradication of bacteria from the model bladder at 32 hours, and no bacterial regrowth was demonstrated after the medium was exchanged on Day 7. In addition, no biofilm was formed and the bacteria did not become attached to the glass beads. 4) The content of alginate, a major component of P. aeruginosa biofilm, was measured per 5 glass beads on Day 3, 5, and 7 after starting drug administration. The alginate content increased with time when CPFX was given alone at a dose of 200 mg t.i.d..(ABSTRACT TRUNCATED AT 400 WORDS)