[Medical geography]

Hippocrates already noted that geographical factors such as climate, relief, geology but also settlement patterns had influenced the distribution of diseases. The task of medical geography is to investigate the associations between geographical factors and diseases. Thereby, geographic techniques and concepts are applied on health problems. Of particular importance is the mapping of diseases whose causes are environmental-related. In addition, epidemiological, ecological but also social scientific studies play an important part in the investigation of the associations between geographical factors and diseases. In order to understand the associations between the spatial distribution of diseases and environmental exposures, geographic information systems as well as statistical analyses have recently become more important. Some authors regard medical geography merely as supporting discipline of medicine. Nevertheless, as men and environment future and as they play an important part in the diffusion of diseases being regarded as defeated, medical geography will play an important part concerning medical questions. Especially travel medicine will rely on geographic knowledge, if a patient has to be consulted who plans to travel to an unknown country of which knowledge on the geographical distribution and ecology of diseases will be necessary.

Experience with 100 cases treated with botulinum-A toxin injections in the detrusor muscle for idiopathic overactive bladder syndrome refractory to anticholinergics

PURPOSE

In this prospective, nonrandomized, ongoing study we evaluated the efficacy and safety of botulinum-A toxin injections in the detrusor muscle to treat patients with idiopathic overactive bladder resistant to conventional treatment, such as anticholinergic drugs.

MATERIALS AND METHODS

A total of 23 men and 77 women with a mean age of 63 years (range 24 to 89) with nonneurogenic overactive bladder, including urgency-frequency syndrome, and incontinence despite the administration of maximal doses of anticholinergics were consecutively treated with injections of 100 U botulinum-A toxin in the detrusor muscle at 30 sites under cystoscopic guidance. Micturition diary, full urodynamics, neurological status and urine probes were performed in all participants before treatment. Bladder biopsies were done only in cases of suspected bladder fibrosis or unclear findings. Special attention was given to reflex volume, maximal bladder capacity, detrusor compliance, post-void residual urine, urgency and frequency/nocturia. Clinical, urodynamic and quality of life assessments were performed at baseline, and 4, 12 and 36 weeks after botulinum-A toxin treatment.

RESULTS

Overall after 4 and 12 weeks 88% of our patients showed significant improvement in bladder function in regard to subjective symptoms, quality of life and urodynamic parameters (p <0.001). Urgency disappeared in 82% of the patients and incontinence resolved in 86% within 1 to 2 weeks after botulinum-A toxin injections. Mean frequency decreased from 14 to 7 micturitions daily (-50%) and nocturia decreased from 4 to 1.5 micturitions. Mean maximal bladder capacity increased 56% from 246 to 381 ml, mean detrusor compliance increased from 24 to 41 ml/cm H(2)O and pretreatment detrusor instability (mean reflex volume 169 ml) resolved in 74% of patients. Mean volume at first desire to void increased from 126 to 212 ml and mean urge volume increased from 214 to 309 ml. There were no severe side effects except temporary urine retention in 4 cases. Only in 8 patients was the clinical benefit poor and analysis revealed preoperative low detrusor compliance. Mean efficacy duration +/- SD was at least approximately 6 +/- 2 months and then symptoms began to increase.

CONCLUSIONS

Our results show that intradetrusor botulinum-A toxin injections may be an efficient and safe treatment option in patients with severe overactive bladder resistant to all conventional treatments.

Retroperitoneoscopic nephropexy for symptomatic nephroptosis using a modified three-point fixation technique

INTRODUCTION

Laparoscopy has been reported as a minimally invasive approach for performing nephropexy in patients with nephroptosis. We evaluated our results after retroperitoneoscopic nephropexy using a modified three-point fixation technique.

TECHNICAL CONSIDERATIONS

Twelve women presenting with flank pain and radiologically documented nephroptosis underwent retroperitoneoscopic nephropexy. After complete dissection of the perirenal fat from the kidney, three nonabsorbable (Ethibond-0) sutures were placed on the posterior renal capsule between the upper pole, middle part, and lower pole of the kidney and the psoas muscle. The average operative time was 91 minutes (range 50 to 180), and the mean estimated blood loss was less than 50 mL in all patients. Postoperative urography revealed complete resolution of nephroptosis in all cases. On a comparative pain analog score patients had 84% improvement (range 0% to 100%). Nine patients had complete resolution of their pain, and two had improvement of 70% to 80%. One patient did not have any improvement. The mean follow-up time was 3.4 years (range 0.5 to 5.5).

CONCLUSIONS

Retroperitoneosopic nephropexy with a modified three-point fixation technique of the upper posterior pole, middle part, and lower pole of the kidney to the psoas muscle is a rapid and effective minimally invasive procedure for treating symptomatic nephroptosis with excellent intermediate-term results.

Neurovascular bundle block as predictor of postoperative erectile function after radical prostatectomy

We assessed audiovisually induced erections after nerve block of the neurovascular bundle during prostate biopsy. We evaluated neurovascular bundle nerve block to mimic non-nerve-sparing radical prostatectomy in an experimental setup. Patients undergoing a transrectal ultrasound-guided prostate biopsy were randomized to bilateral injection of 5 ml ropivacaine hydrochloride 0.75% or NaCl 0.9% into the neurovascular bundle. The patients completed the International Index of Erectile Function 5-item questionnaire (IIEF-5) questionnaire, and a detailed patient history was obtained. A routine prostate biopsy was performed. Thereafter, patients were exposed to 60 min of audiovisual stimulation. Erections were recorded using a Rigiscan-Plus device. A total of 11 patients were randomized. Five patients received NaCl (group 1) and six patients ropivacaine (group 2). Patient characteristics were comparable in terms of age (group 1: 59.8 y; group 2: 61.8 y), mean PSA (4.1 vs 4.7 ng/ml), mean IIEF-5 score (20.5 vs 22) and risk factors for erectile dysfunction, respectively. Patients of group 1 showed significantly stronger and longer erections after audiovisual stimulation than patients in group 2. Patients with bilateral infiltration of saline solution to the neurovascular bundle showed significantly stronger erections than patients receiving local anesthesia of the neurovascular bundle. Thus, this experiment might serve as a model to assess postoperative erectile function after a unilateral nerve-sparing radical prostatectomy.

Sacral magnetic stimulation in non-inflammatory chronic pelvic pain syndrome

OBJECTIVES

To prospectively evaluate sacral magnetic high-frequency stimulation as a treatment option for patients with non-inflammatory chronic pelvic pain syndrome (CPPS, category IIIB).

PATIENTS AND METHODS

Fourteen men with CPPS IIIB were treated with high-frequency sacral magnetic stimulation, with 10 treatment sessions once a week for 30 min at a frequency of 50 Hz. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and quality-of-life index were determined before and after treatment.

RESULTS

All patients tolerated the stimulation well and 12 of 14 reported agreeable sensations during stimulation. There were no complications; only one patient did not complete the treatment course. The mean (range) total NIH-CPSI score did not change with treatment, at 27 (18-38) before and 27 (4-40) after treatment. Moreover, there was no sustained effect on the mean scores for pain, micturition complaints or quality of life.

CONCLUSIONS

High-frequency sacral magnetic stimulation in patients with CPPS IIIB only reduces pain during stimulation, with no sustained relief of symptoms. Therefore, intermittent sacral magnetic stimulation cannot be recommended as a treatment option for CPPS IIIB.

Ein Blick in die Blase—der Mensch dahinter

To study the inside of humans is an old wish of mankind. Cystoscopy and its development are known to-initiates. In the following we do not stress this examination, but focus on those people behind it who shared in paving the way for improvement with their fantasy and energy without neglecting to report on the human and very human aspects.

Extracorporeal shockwave therapy for Peyronie's disease does not correct penile deformity

To evaluate whether extracorporeal shockwave therapy (ESWT) offers an effective treatment for the main complications of Peyronie's disease (PD), that is, penile deformity and angulation, painful erection and most importantly unsatisfied sexual intercourse. From September 1999 to January 2001, 52 patients with PD were treated with ESWT. Pain during erection was assessed with a visual analogue scale. Penile deviation was determined by photographs with a goniometer. Five treatment sessions were performed at weekly intervals. Each consisted of 3000 shockwaves with an emission frequency of 120 shockwaves/min and a mean intensity of 0.17 mJ/mm(2). A Storz Minilith SL 1 with integrated inline ultrasound probe was used. In all, 52 patients were evaluated 6 weeks after ESWT for early follow-up. Before ESWT intercourse was difficult or impossible for 40 men; 29 patients suffered mainly from penile deformity, 14 from painful erection and eight mainly from loss of distal rigidity. A total of 30 patients mentioned painful erection before treatment. In 28 patients (93%) pain reduction was achieved. A total relief of pain was observed in 19 patients (63%). Mean pain score dropped from 4.2 to 1.3 in patients who suffered predominantly from painful erections. Intercourse satisfaction improved in 11 patients after therapy. Mean angulation before (40 degrees ) and after (37 degrees ) ESWT did not change significantly. Late follow-up after 11.1 months (4-17 months) could be completed in 36 patients. In total, 19 men reported that ESWT improved their PD. Of these, 16 noted no change. Only one of the patients noticed a worsening of his disease during or after treatment. Complication rate was low with only minor side effects such as minimal skin bruising; one urethral bleeding occurred. ESWT did reduce pain during erection in patients suffering mainly from painful erection due to PD. However, penile angulation did not improve significantly in our setup and thus intercourse difficulties did improve only in 28% of the patients. Therefore, we do not recommend ESWT as a primary treatment for PD.

Motor evoked potentials (MEP) and evoked pressure curves (EPC) from the urethral compressive musculature (UCM) by functional magnetic stimulation in healthy volunteers and patients with neurogenic incontinence

AIMS

The aim of this study is to assess neurogenic lesions of the somatomotor efferent nervous pathway to the urethral compressive musculature (UCM) by means of motor evoked potentials (MEP) and simultaneously recorded evoked pressure curves (EPC).

METHODS

Nine healthy subjects and 33 patients (15 spinal cord injury, 14 cauda equina lesion, and 4 multiple sclerosis (MS)) with neurogenic urinary incontinence were prospectively examined by means of urodynamics and electrophysiology. MEP responses from the UCM were evoked after transcranial (tc) and lumbosacral (ls) single pulse magnetic stimulation. A ratio out of tx/ls latencies was calculated to distinguish between central (i.e., spinal) and peripheral lesions. The mechanical UCM pressure responses (=EPC) were recorded simultaneously with electromyographic (EMG) recordings using a microtip pressure transducer catheter with integrated bipolar surface electrodes.

RESULTS

In nine healthy subjects the central latency was 19.0 msec, the peripheral latency was 4.25 msec, and the ratio was 4.4. In patients with incomplete spinal cord lesion the central latency was significantly delayed (22.7 msec), whereas the peripheral responses were normal. The ratio (5.5) was increased. Thirteen of these 15 patients suffered from neurogenic incontinence. Patients with a complete spinal lesion showed no UCM reaction after tc stimulation, whereas peripheral responses were normal. Patients with MS showed significantly prolonged central latencies (25.5 msec). The increased ratio of 6.0 indicated a spinal lesion. Ten patients with incomplete cauda equina lesions and urinary incontinence had normal central latencies but prolonged peripheral latencies of 6.7 msec. The ratio of 3.4 indicated a lesion of the sacral caudal roots. In patients with complete cauda injury neither central nor peripheral responses could be evoked. Tc evoked mechanical pressure responses (i.e., contractions) from the UCM could only be recorded in intact or incompletely injured spinal and peripheral motor nervous pathways, whereas they could be evoked after ls stimulation only in cases with partially preserved sacral caudal roots independent of a spinal lesion.

CONCLUSIONS

MEP and EPC from the UCM proved to be a well tolerated disgnostic tool in patients with neurogenic incontinence that distinguished central and peripheral lesions of the motor efferent pathways to the UCM.

Metachronous bilateral leydig cell tumor in a male adult aged 20

We report a young male aged 20 who has suffered two episodes of Leydig cell tumor of the testis, the second occurring 5 years after the first in the contralateral testis. The case is outlined briefly, with references taken from the literature. This young man's history is exceptional as this type of tumor is infrequent, and metachronous bilateral presentation extremely rare.

Physiologie und Pathophysiologie der erektilen Dysfunktion

Notions and hypotheses of the pathophysiologic process in erectile dysfunction--its errors and embarrassment--are focused on beginning with Aristotle and continued in the Renaissance and the Enlightenment. Only in the middle of the nineteenth century was there recognition of the central role of relaxation of the trabecular muscles. It took another 100 years until we had a useful treatment option at hand.

Nocturnal penile tumescence and rigidity (NPTR) findings in spinal cord injured men with erectile dysfunction

This prospective study aimed at determining whether nocturnal penile tumescence and rigidity (NPTR) findings correlate to the neurologic disorders in spinal cord injured (SCI) patients suffering from erectile dysfunction (ED). A total of 25 acute SCI male patients with post-traumatic ED underwent neurological, electrophysiological and urodynamic examinations, respectively, as well as NPTR recordings. The mean value for rigidity (R), tumescence (T) and duration (D) during NTPR tests were 83.3%, 3.3 cm, 6.4 min in patients with a complete lesion above the sacral (S2-S4) spinal cord (n=10), 46.1%, 1.6 cm, 5.5 min in patients with a complete lesion involving the sacral metameres (n=5) and 89.8%, 3.8 cm, 29 min in patients with an incomplete suprasacral lesion (n=7). The differences among these groups were statistically significant (P<0.05). Patients with lesions involving both sacral and thoracolumbar spinal cord showed no erections (n=3). We found four NTPR patterns: (1) normal R and T, short D; (2) weak R and T, short D; (3) normal R, T and D; and (4) no erections, which can be assigned to different levels and completeness of spinal cord lesions. Nocturnal erections of normal quality need preservation of thoracolumbar and sacral neuronal control as well as partially intact connections of the spinal erection centres with brain areas responsible for sexual arousal.

Second Transurethral Resection of Superficial Transitional Cell Carcinoma of the Bladder: A Must Even for Experienced Urologists

INTRODUCTION

As even experienced urologists have a high percentage of persisting carcinoma after transurethral bladder tumour resection (TUR-B) the importance of a routine second resection in the management of transitional cell carcinoma (TCC) of the bladder is defined.

PATIENTS AND METHODS

The medical records of all patients treated with TUR-B at our institution between January 1989 and September 2000 were reviewed. 214 patients with pTa and pT1 carcinoma undergoing a second resection 4-6 weeks later were included in the analysis. The rate of persisting carcinoma in the second resection was compared to the actual tumour stage and grade, the patient's age, sex and the experience of the urologist performing the resection.

RESULTS

Of the 214 patients 99 had pTa and 115 pT1 carcinoma. The rate of persisting tumour in the second resection was 27% in pTa and 37% in pT1 carcinoma. This rate was independent of the patient's age and sex. Urologists in training had an equally low rate of persisting carcinoma in the second resection compared to senior urologists (p = 0.08).

CONCLUSIONS

Routine second resection of superficial transitional cell carcinoma of the bladder should be part of the treatment even in larger operative experience.

Apomorphine sublingual as primary or secondary treatment for erectile dysfunction in patients with spinal cord injury

OBJECTIVES

To evaluate the effectiveness of apomorphine sublingual (SL) 3 mg, as a primary or secondary treatment for erectile dysfunction (ED) in patients with spinal cord injury (SCI), and to determine possible differences in efficacy considering clinical, urodynamic and neurophysiological findings.

PATIENTS AND METHODS

The study included 22 patients with chronic SCI and neurogenic ED who were examined physically and by a video-urodynamic evaluation. A neurophysiological evaluation included somatosensory evoked potentials of the pudendal nerve, palmar and plantar sympathetic skin responses and bulbocavernous reflex recordings. Thereafter the patients received 8 tablets of apomorphine SL 3 mg and were asked to complete the International Index of Erectile Function questionnaire before and after treatment. Side-effects, subjective efficacy compared with other treatments and satisfaction with the SL administration were recorded.

RESULTS

Of the 22 men, 11 had upper motor neurone lesions (six complete, five incomplete), eight lower motor neurone lesions (seven complete, one incomplete) and three had mixed lesions. In all, 12 patients took sildenafil citrate and five alprostadil intracavernosally beforehand, and five had used nothing to treat their ED. Seven patients had some response and reported that the drug helped them to obtain an erection, but only two reported erections sufficient for intercourse and would agree to continue apomorphine SL as their standard treatment; all the others reported being disappointed. Nine patients reported side-effects. There were no significant correlations for electrophysiological or urodynamic findings and treatment success. Of the 22 patients 20 preferred SL rather than the normal administration.

CONCLUSIONS

Apomorphine SL, a D1/D2 dopamine agonist, facilitates erectile function in a heterogeneous group of patients with no significant relationship with any of the assessed urodynamic or electrophysiological variables. The overall low rates of response either for primary or secondary treatment suggests that apomorphine will have limited applicability in patients with SCI.

The effect of seminal vesicle-sparing radical prostatectomy on serum prostate-specific antigen level

OBJECTIVE

To investigate if the remaining seminal vesicle tips can affect serum levels of prostate-specific antigen (PSA) in patients after seminal vesicle-sparing radical prostatectomy (SVRP).

PATIENTS AND METHODS

Thirty-six patients were treated by either radical retropubic prostatovesiculectomy (23) or SVRP (13). Serum PSA was monitored in all patients before surgery, and at 6 weeks and 30 months afterward. Samples of normal seminal vesicles from radical cystectomies (six) were also snap-frozen and either processed for semiquantitative reverse transcriptase-polymerase chain reaction (RT-PCR) using primers against PSA and alpha-actin (for normalization) or for PSA immunohistochemistry.

RESULTS

RT-PCR and sequencing showed that the seminal vesicles synthesise PSA mRNA. Furthermore, PSA peptide was detectable in the glandular epithelium of the seminal vesicle using immunohistochemical methods. There was no significant difference in serum PSA levels after standard or SVRP, with median (range) values (ng/mL) at 6 weeks of 0.04 (0.04-0.9) and 0.04 (0.04-0.66) and at 30 months of 0.17 (0.04-3.8) and 0.22 (0.04-58.2), respectively.

CONCLUSION

Although the seminal vesicles produce PSA, the PSA derived from the remaining seminal vesicle tips after SVRP has no effect on the oncological follow-up of these patients.

Immunological alterations in the ejaculate of chronic prostatitis patients: clues for autoimmunity

The aim of this prospective study was to observe immunophenotypic patterns in the ejaculate of patients with noninflammatory chronic pelvic pain syndrome (Cat IIIB CPPS) and to test for a possible autoimmune aetiology. Thirty-five patients of a total of 88 patients with chronic prostatitis Cat IIIB were consecutively selected. Monthly ejaculate testing was carried out for IgG, IgA, IgM, IL-1alpha, sIL-2R and IL-6. The control group for ejaculate analysis was composed of 96 normal ejaculates (according to the WHO criteria). Immunohistochemical detection of CD3 cells (T lymphocytes) and CD20 cells (B lymphocytes) was performed in 71 biopsy cylinders of Cat IIIB CPPS patients and in 25 prostate biopsy cylinders of subjects without symptoms or obstruction. Intra-acinar T-lymphocytic infiltrates were dominated by T-cytotoxic cells (P = 0.05). Ejaculate IL-6 and ejaculate IgA increased significantly and dropped again, correlating with a release of clinical symptoms. Inflammatory ejaculate interleukin concentrations correlated with the immunohistochemical findings with presence of large numbers of T cells (all P-values < or = 0.01). Immunomodulation was performed in a pilot series of three patients by five monthly cycles of IgG (Sandoglobulin), 1 g kg-1 body weight. Immunomodulation with IgG decreased pain moderately and did not change ejaculate interleukin and immunoglobulin concentrations. In summary, interleukin and immunoglobulin determinations in the ejaculate revealed an inflammatory process even in Cat IIIB CPPS. The findings of intra-acinar T-cell rich infiltrates and the associated inflammatory reaction may indicate a possible autoimmune component in the aetiology of CPPS. Exact origin and role of interleukin changes in the ejaculate of CPPS patients need to be further evaluated. Unfortunately, pilot series with immunomodulation with IgG do not seem to provide clear clinical benefit.

[Gap junctions in the human urinary bladder]

PURPOSE

Gap junctions are intercellular contacts important for the synchronization of muscle cell activity through electrical coupling. Since the role of gap junctions for the function of smooth bladder muscle is still a matter of debate, we investigated the occurrence of gap junctions and the gap junctional protein connexin (Cx) 45 in the detrusor of the nonobstructed stable human bladder.

MATERIALS AND METHODS

Detrusor biopsies from 6 patients aged 64 (55-72) years with stable nonobstructed bladders were investigated for the occurrence of gap junctions by electron microscopy, molecular biological techniques and immunohistochemistry.

RESULTS

Transmission electron microscopy and freeze fracture showed the presence of gap junction at plasma membranes of detrusor smooth muscle cells. By reverse transcriptase (RT) polymerase chain reaction (PCR) and in situ hybridization, we found an expression of Cx45 in the detrusor. These data were confirmed by immunolocalization of Cx45 on smooth muscle cells.

CONCLUSIONS

This study provides morphological as well as molecular biological and immunohistochemical evidence that bladder smooth muscle cells are electrically coupled.

Clinical value of combined electrophysiological and urodynamic recordings to assess sexual disorders in spinal cord injured men

AIMS

To assess the significance of combined neurophysiological and neurourological examinations for diagnosis of neurogenic male sexual dysfunction.

METHODS

This is a prospective study of 32 spinal cord injured men. Each underwent clinical and neurophysiological examinations (sympathetic skin responses (SSR), pudendal somato-sensory evoked potentials (P-SSEP), bulbocavernosus reflex (BCR)) and neuro-urological measurements (urodynamic examination (UE), reflex erections (RE), psychogenic erections (PE) and nocturnal penile tumescence recordings (NPTR)).

RESULTS

Erectile dysfunction due to impairment of RE was associated with loss of BCR and detrusor areflexia (P > 0.001), whereas that due to impairment of PE was associated with loss of perineal SSR (P < 0.001). P-SSEP corresponded in 94% with impairment of penile sensibility and duration of erections in NPTR. The NPTRs were less related to functional sexual impairment. NPTRs in complete and incomplete suprasacral (level > T10) spinal lesion showed sufficient erections despite strongly disturbed PE. NPTRs in lumbosacral lesion revealed significant reduction in or absent erections and underestimated the presence of well excitable PE.

CONCLUSIONS

Combined neurophysiologic and neurourologic testing provides highly relevant diagnostic informations about sexual dysfunction in men with spinal cord injury. Loss of the BCR and detrusor areflexia imply loss of somatic and parasympathetic reflex activity and correlate with loss of RE. Loss of PE correlates with loss of perineal SSR (sympathetic denervation).

Demonstration of acid secretion in the gastric pouch through the pentagastrin stimulation test

INTRODUCTION

The aim of this study is to determine the relationship of hydrochloric acid secretion in gastric pouch (GP), an orthotopic neobladder using a stomach segment, to gastrin.

MATERIAL AND METHOD

Pentagastrin (PG) stimulation test (PGST) was applied in 10 patients who had had GP surgery 5-70 months ago, and their urinary pH changes in the next 2 h were observed.

RESULTS

Significant pH decreases (from 6.6 +/- 0.6 to 2.9 +/- 1.0 in the mean) 30-75 min after injection of PG, demonstrating gastrin-triggered acid secretion in GP were observed in all patients. The pH values were normalized in 2 h (6.6 +/- 1.0 in the mean).

CONCLUSION

In PGST, urinary pH decreases, demonstrating the close relationship between gastrin release and acid secretion in the GP. Inhibition of gastrin by any means may be useful in keeping the urinary pH on physiological levels.

Penile revascularization surgery in erectile dysfunction

Anastomoses between the dorsal artery of penis and the deep penile artery are necessary for revascularization of penile arteries. Radiologic and anatomic proof is provided. Arterio-arterial anastomosis represents a risk factor for thrombosis. For its exclusion the necessary operative course of action is showed. By building an additional arteriovenous shunt close to the arterio-arterial anastomosis the risk of thrombosis is markedly decreased. Our technique produces good results in patients with diagnosed erectile dysfunction of vascular origin with a spontaneous erection when the occasion arises.

[Diagnosis of chronic prostatitis: 4 or 2 glass sample?]

Chronic pelvic pain syndrome is still an important clinical problem. The NIH-prostatitis classification introduced 1998 for diagnosis and treatment measures is based on extended microbiological analysis of urine, expressed prostate secretion (4-glass test), and ejaculate. We investigated if a simple urine analysis of an urine sample before and after prostatic massage (2-glass test) could replace the 4-glass test. 143 patients with the diagnosis chronic prostatitis were included in this prospective study. The results showed that the expensive and time consuming 4-glass test can be replaced by a simple 2-glass test. Extended examinations should only be performed in special cases.

[Four-glass or two glass test for chronic prostatitis]

Chronic pelvic pain syndrome is still an important clinical problem. The NIH prostatitis classification introduced in 1998 for diagnosis and treatment measures is based on extended microbiological analysis of urine and expressed prostate secretion (4-glass test). In 1997 J.C. Nickel proved that the culture and microscopic examination of urine before and after prostatic massage leads to the same results as the 4-glass test. In our prospective study on 143 patients with a diagnosis of chronic prostatitis, we analyzed this statement and came to the same results. We therefore recommend replacing the expensive and time-consuming 4-glass test by a simple preprostatic and postprostatic massage urine culture. Further examinations should only be performed in special cases.

[Erectile dysfunction: reasonable diagnostics and treatment in general practice]

The availability of efficacious oral drugs has radically changed the diagnostic and therapeutic approach to erectile dysfunction. Complicated examinations as well as invasive treatment options have been widely abandoned. Instead the management of impotent men has become much more pragmatic and focused on the symptom. Consequently only a minority of impotent men needs to be referred to an urologist, which makes the therapy of erectile dysfunction increasingly attractive for general practitioners. However, successful treatment first of all still needs time and a genuine interest in the field of erectile dysfunction. In this article a reasonable diagnostic evaluation of impotent patients in general practice is described. Furthermore indication and use of little or non-invasive therapies are discussed.

[Partial androgen deficiency in the aging male: diagnosis and therapy]

After the fourth decade, androgen serum level fall while the binding capacity for testosterone, the sex hormone binding globulin, raises. Clinical symptoms and hypogonadism define the syndrome of the partial androgen deficiency of the aging male (PADAM). Testosterone substitution may be performed by intramuscular injections, oral or transdermal testosterone application. Each patient should undergo urological evaluation before starting a testosterone replacement therapy. Life style drugs should not be used according the currently rational data. Well balanced nutrition, physical training and an active social and sexual life are important factors to achieve a healthy aging.

Treatment of varicocele: a prospective randomized comparison of laparoscopy versus antegrade sclerotherapy

OBJECTIVES

To compare the therapeutic success, the morbidity and the costs of antegrade sclerotherapy versus laparoscopic varicocelectomy.

METHODS

Seventy-six consecutive varicocele patients were randomly assigned to two treatment arms. Preoperative and 3 month postoperative sperm density, motility and morphology were analysed. The diagnosis of the varicocele was established clinically and with Doppler ultrasonography.

RESULTS

Fifty-eight patients treated by either of the two methods were followed up. The recurrence rate increased progressively with the size of the varicocele in both groups. The postoperative incidence of complications particularly hydrocele formation was significantly higher in the laparoscopic group. The costs of the disposable material for laparoscopic varicocelectomy was twice as high as for sclerotherapy.

CONCLUSIONS

Antegrade sclerotherapy is the less invasive treatment method of male varicocele with lower costs and better outcome and should therefore be the preferred treatment method for male varicocele.

Ultrastructure of the trigone and its functional implications

OBJECTIVE

To investigate the ultrastructure of the trigonal muscle (= superficial trigone), relate it to normal function, and identify any changes it may undergo in voiding dysfunction.

MATERIALS AND METHODS

20 men (median age 67 years) with low-stage prostatic carcinoma, 10 with and 10 without bladder outlet obstruction, were selected by urodynamic evaluation. Trigonal biopsy was performed at radical prostatectomy, and processed for electron-microscopic study by standard procedures. Biopsies were evaluated independently by 2 examiners without prior knowledge of urodynamic data.

RESULTS

Three obstructed and 1 unobstructed bladder had impaired detrusor contractility, and 1 obstructed bladder had detrusor overactivity. Compared to the previously investigated detrusor, the trigonal muscle had smaller compact bundles and fascicles with less collagen and more elastic tissue. Muscle cells had no or rare intermediate junctions that mediate mechanical coupling in normal detrusor, but predominant close cell appositions that mediate electrical coupling. Smooth muscle in most biopsies had widespread or focal features characteristic of the aged detrusor. None, however, had the features previously associated with obstructed detrusor, or detrusor with impaired contractility.

CONCLUSIONS

The trigonal muscle does not undergo structural changes as previously described in the detrusor in association with voiding dysfunction. Its contraction depends on electrical coupling of its muscle cells, and has a supportive role in normal micturition, mooring the terminal ureters to the bladder base, to allow efflux and guard against reflux of urine. Activation of volume and tension sensory neuroterminals may contribute to some storage and voiding micturition reflexes, and may be related to normal and abnormal perception of urge.

Transient paralysis of the bladder due to wound botulism

In the last 10 years, wound botulism has increasingly been reported and nearly all of these new cases have occurred in injecting-drug abusers. After absorption into the bloodstream, botulinum toxin binds irreversibly to the presynaptic nerve endings, where it inhibits the release of acetylcholine. Diplopia, blurred vision, dysarthria, dysphagia, respiratory failure and paresis of the limbs are common symptoms of this intoxication. Surprisingly and despite the well-known blocking action of the botulinum toxin on the autonomic nerve system, little attention has been paid to changes in the lower urinary tract following acute botulinum toxin poisoning. Here we report a case of bladder paralysis following wound botulism. Early diagnosis and adequate management of bladder paralysis following botulism is mandatory to avoid urologic complications. Accordingly, the prognosis is usually favorable and the bladder recovery complete.

Noninflammatory chronic pelvic pain syndrome: immunological study in blood, ejaculate and prostate tissue

OBJECTIVES

The aim of this prospective study was to observe immunophenotypic patterns in patients with noninflammatory chronic pelvic pain syndrome (Cat IIIB CPPS) for further description and as possible surrogate markers for diagnosis and treatment.

METHODS

Eighty-eight patients with a referral diagnosis of chronic prostatitis underwent fractionated urinary cultures including expressed prostate secretion (EPS) and ejaculate analysis twice on two occasions. Monthly serum analyses included C3c, C4, IL-1alpha, sIL-2R, and IL-6. One hundred samples from healthy individuals were used as the control group for serum analysis. Monthly ejaculate testing was done for IgG, IgA, IgM, IL-1alpha, sIL-2R, and IL-6. The control group for ejaculate analysis was composed of 96 normal ejaculates (according to the WHO criteria). Immunohistochemical detection of CD3 cells (T lymphocytes) and CD20 cells (B lymphocytes) was performed in 71 biopsy cylinders of Cat IIIB CPPS patients and in 25 prostate biopsy cylinders of men without symptoms or obstruction.

RESULTS

Complete sampling of urinary, serum and ejaculate specimens was achieved in 50/88 (57%) patients. Cat IIIB CPPS was observed in 44/50 (88%) patients. Intra-acinar T-lymphocytic infiltrates were dominated by T cytotoxic cells (p = 0.05). Immunohistochemical studies showed inflammatory expression in serum complement, serum interleukin, and ejaculate interleukin concentrations in relation to the presence of large numbers of T cells (all p values < or =0.01). No difference was found in the proportion of B lymphocytes in patients with Cat IIIB CPPS compared to the control group. Serum and ejaculate IL-6 and ejaculate IgA increased significantly and dropped again, correlating with a release of clinical symptoms.

CONCLUSIONS

Interleukin, complement and immunoglobulin determinations in serum and ejaculate reveal an inflammatory process even in Cat IIIB CPPS. The findings of intra-acinar T-cell-rich infiltrates and the associated inflammatory reaction may be a significant advance in defining Cat IIIB CPPS caused by a possible autoimmune component. Serum and ejaculate IL-6 and ejaculate IgA are possible surrogate markers for the diagnosis and treatment of Cat IIIB CPPS.

Evidence of trigonal denervation and reinnervation after radical retropubic prostatectomy

PURPOSE

Urinary incontinence continues to be a major consequence of radical prostatectomy. To understand the pathophysiology of this dysfunction we studied the impact of autonomic innervation of the superficial trigone on postoperative urinary continence.

MATERIALS AND METHODS

To investigate nerve fiber density biopsies of the superficial trigone were obtained in 34 patients preoperatively as well as 6 weeks and 6 months postoperatively in 15 and 19, respectively. Specimens were Bouin fixed, paraffin embedded and processed for light microscopic immunohistochemical evaluation using an antibody against protein gene product 9.5, a general neuronal marker protein. In parallel we performed a comprehensive urodynamic evaluation, including determination of maximal urethral closure pressure and posterior urethral sensory threshold.

RESULTS

Postoperatively protein gene product 9.5 immunoreactive nerve fiber density was generally decreased. However, nerve fiber density after 6 weeks of incontinence in 12 of 15 patients was only 7%, while 3 of 15 who were continent preserved 36% of initial nerve fiber density. After 6 months nerve fiber density in 19 patients increased in 3 with incontinence to 20% and in 16 with continence to 44% of intraoperative density. Urinary incontinence was associated with decreased trigonal innervation, a high sensory threshold and low maximal urethral closure pressure.

CONCLUSIONS

Protein gene product 9.5 immunoreactive nerve fiber density corresponds with posterior urethral sensory threshold and urinary continence. Thus, preserving trigonal innervation and postoperative reinnervation may be important factors for achieving early postoperative urinary continence after radical prostatectomy.

Primary erectile dysfunction in combination with congenital malformation of the cavernous bodies

Primary erectile dysfunction in combination with congenital malformation of the cavernous bodies has only rarely been reported. We report on 2 young patients with different congenital malformations. To our knowledge this is the first time partial aplasia of the distal part of the cavernous bodies is described, whilst complete isolation of the cavernous bodies in combination with veno-occlusive dysfunction has yet been described in 3 cases. After complete examination, including penile angiography and cavernosometry, a surgical correction with a fully satisfying result was achieved in the patient with distal aplasia. In case of isolated cavernous bodies with severe veno-occlusive dysfunction, the implantation of a penile prosthesis remains the treatment of choice.