Advances in the antibiotic management of epididymitis

INTRODUCTION

Acute epididymitis is commonly encountered and typically presents acutely within a wide clinical spectrum. Most cases of acute epididymitis are caused by bacterial infection, most often by sexually transmitted organisms and urinary pathogens. Current treatment regimens remain empirical, although recent advances using modern diagnostic techniques support a change in the management paradigm.

AREAS COVERED

The choice of the initial antibiotic regimen is empirical and based on the most likely causative pathogen, whether sexually transmitted, enteric or other. Adherence of clinical practice remains short of available guidance, which may be improved by thorough clinical and microbiologic assessment, supported by a knowledge of the commonly associated pathogenic organisms, and the appropriate choice of tests required for their identification. Use of advanced microbiology techniques and studies of current practice provide new insights that have challenged traditional management paradigms. The authors discuss these points in and provide their expert perspectives on its treatment and future developments.

EXPERT OPINION

Relatively sparse direct trial data exists on antimicrobial treatments for acute epididymitis. Much of the presently available guidance is derived from previous guidance recommendations, knowledge of antimicrobial activities of specific agents, and treatment outcomes in uncomplicated infections. Identification of specific pathogens and prescribing accuracy is dependent on the extent to which cases are investigated and is therefore variable.

Antimuscarinic drug therapy for overactive bladder syndrome in the elderly - are the concerns justified?

INTRODUCTION

The use of antimuscarinic drugs is common in the management of the overactive bladder (OAB). Concerns have been raised over their use in the elderly population in whom the use of these drugs is highly prevalent, consequent to the reported link between these drugs and cognitive impairment and dementia. Areas covered: Recent publications have heightened concerns regarding antimuscarinic drug use in the elderly. In this review, the author discusses the available evidence upon which conclusions have been based and has presented the need for cortical review and need for caution in interpreting the data. The available evidence is inconsistent, differences in pharmacokinetics have not been widely recognized in clinical trials, clinical estimation of antimuscarinic activity has not been standardized, and serum antimuscarinic activity has not been found to correlate with cognitive impairment. Furthermore, the significant heterogeneity within cognitive aging processes raises questions regarding the extent to which various factors, including medication, influences this process. Expert opinion: Whilst caution should indeed be exercised in the use of antimuscarinic medication in the elderly, advocacy of discontinuation of their use may deprive patients of the benefits of improved quality of life from treatment where currently alternative management remain limited or invasive.

Acute urinary retention: medical management and the identification of risk factors for prevention

Male lower urinary tract symptoms associated with benign prostatic hyperplasia can be progressive in some patients and lead to adverse consequences such as acute urinary retention (AUR), which might require prostate surgery. This Review identifies baseline and dynamic variables that have been recognized as risk factors that might predispose men to AUR. Evidence for the use of medical therapy to reduce the risk of benign prostatic hyperplasia progression, which might prevent AUR, has been critically evaluated. The literature describing the pharmacological management of men with AUR, and in those who have successfully voided after removal of a catheter, has been critically appraised in this article.

Recognition and effective management of autonomic dysreflexia in spinal cord injuries

Autonomic dysreflexia is a potentially life-threatening hypertensive medical emergency that occurs most often in spinal cord-injured individuals with spinal lesions at or above the mid-thoracic spinal cord level. It is a condition that remains poorly recognised outside of spinal cord injury centres, which may result in adverse outcomes including mortality from potentially delayed diagnosis and treatment. Acute autonomic dysreflexia is characterised by severe paroxysmal hypertension associated with throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, bradycardia, apprehension and anxiety, which is sometimes accompanied by cognitive impairment. The key to effective management is prevention of the condition, by recognition and avoidance of factors that initiate the condition. When it occurs, immediate recognition and reversal of trigger factors along with prompt administration of pharmacological treatment is of paramount importance in order to prevent complications, which include intracranial and retinal haemorrhage, convulsions, cardiac irregularities and death. Promising data from recent animal studies may hold the key to future treatment options.

Where do we stand with chronic prostatitis? An update

Chronic prostatitis remains a difficult management problem, which reflects the fact that its aetiology remains incompletely understood. It is a common condition that is characterized by protracted symptoms and high morbidity. Although lacking a reliable diagnostic test, antibiotic therapy remains the mainstay of treatment in the majority of cases.

The treatment of male stress urinary incontinence with polydimethylsiloxane in compliant bladders following spinal cord injury

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

To evaluate the safety and efficacy of polydimethylsiloxane (PDS, Macroplastique) submucosal injections, in the treatment of male genuine stress urinary incontinence secondary to spinal cord injury (SCI).

SETTING

London Spinal Injuries Unit, Stanmore, UK and Institute of Urology and Nephrology, London, UK.

PATIENTS AND METHODS

A retrospective analysis identified 14 patients treated with PDS for stress urinary incontinence secondary to SCI between 1997 and 2001. A single surgeon at a specialist spinal injuries unit managed all patients. A total of 13 patients had suffered a traumatic SCI (T11:n=2; T12:n=5; L1:n=5; L2:n=1), while one developed stress incontinence after spinal surgery. The mean age was 41 years (range 26-69 years) and the mean duration of injury was 9.6 years (range 1.5-48 years). The preoperative investigations included video cystometrogram (VCMG) confirming the presence of urodynamically proven stress incontinence without evidence of urge incontinence. Complete cure was defined as a cessation of pad usage with no evidence of leakage on VCMG. Incomplete cure with improvement was defined as a >50% reduction in the number of pads used, with incontinence present on VCMG.

RESULTS

The follow-up ranged from 12 to 58 months (mean 34.7 months). Five patients (36%) reported complete success, confirmed by VCMG. Three patients (21%) reported improvement with >50% reduction in the use of pads. The procedure failed completely in six patients (43%). No immediate or late complications were noted with the procedure.

CONCLUSIONS

The use of PDS is a safe and minimally invasive treatment for genuine stress urinary incontinence in males following SCI with a stable compliant bladder. We achieved complete cure in 36% of our patients with confirmation on VCMG. A further 21% reported greater than 50% reduction in usage of pads; however, on VCMG stress incontinence was demonstrated in these patients. We suggest that PDS can be used as the first line of treatment in this difficult group of patients with complex problems.

Surgical and patient reported outcomes of 'clam' augmentation ileocystoplasty in spinal cord injured patients

OBJECTIVE

To study the outcomes and effectiveness of 'clam' augmentation ileocystoplasty in the treatment of suprasacral spinal cord injured patients with detrusor hyperreflexia refractory to pharmacological and other conservative therapy.

METHODS

A retrospective review of spinal injured patients who had undergone 'clam' augmentation ileocystoplasty was performed, followed by a specifically designed questionnaire/telephone interview to assess patient satisfaction and other issues from this specific group of patients with suprasacral spinal cord lesions. 32 patients were followed up for a mean of 6.0 +/- 3.6 years.

RESULTS

Complete continence was found in all patients. There was a significant improvement in bladder capacity from a mean 143 +/- 81 ml pre-operatively to 589 +/- 188 ml post-operatively, and the maximum detrusor pressure fell from a mean of 108 +/- 43 cm H(2)O to 19 +/- 15 cm H(2)O. Pre-operative vesico-ureteric reflux resolved completely in 4 out of 5 patients and improved from grade IV to grade II in one, illustrating the need for achieving low bladder pressures rather than the performance of an anti-reflux procedure at the time of cystoplasty. The use of the questionnaire, designed to evaluate this subset of patients after augmentation cystoplasty, highlighted the high levels of satisfaction with the operation in this group of patients with 96.2% of patients reporting an improvement in quality of life parameters.

CONCLUSION

Using an appropriate questionnaire we have found high satisfaction rates, in addition to successful surgical outcomes, in spinal cord injured patients following augmentation cystoplasty. We recommend using this questionnaire as part of the work-up and ongoing assessment of spinal injured patients undergoing 'clam' augmentation ileocystoplasty.

Experience of tension-free vaginal tape for the treatment of stress incontinence in females with neuropathic bladders

STUDY DESIGN

Retrospective.

OBJECTIVE

To evaluate the safety and efficacy of the tension-free vaginal tape (TVT) for the treatment of stress incontinence in females with neuropathic bladders.

SETTING

London Spinal Injuries Unit, Stanmore & Institute of Urology, London, UK.

METHODS

Twelve women (mean age 53.3 years; range 41-80 years) with neuropathic bladder dysfunction and stress urinary incontinence were treated with tension-free vaginal tape (TVT) between November 1997 and December 2000. The group consisted of women with: (i) traumatic spinal cord injuries (n=3); (ii) post lumbar spinal surgery (n=6); (iii) spinal stenosis (n=3). Four of the 12 patients had previously failed surgery for stress incontinence. All patients underwent pre- and post-TVT evaluation with video-urodynamic studies.

RESULTS

Mean follow-up was 27.1 months (range 17-54 months). Three patients were voiding spontaneously (stress voiding) before surgery and continued to do so post-operatively. The remaining 9 were performing clean intermittent self-catheterisation before the insertion of TVT and continued to do so after the surgery. At follow up 10 patients (83.3%) were dry. The procedure failed in one patient and the other complained of mild leakage, but she reported a decrease in the number of pads used. One patient developed detrusor hyperreflexia on post-operative video-urodynamics but there was no evidence of stress incontinence. One patient had a bladder perforation on insertion of TVT, managed successfully with extended use of a urethral catheter post-operatively. Three patients developed post-operative urinary tract infection successfully treated with oral antibiotics.

CONCLUSIONS

Tension-free vaginal tape insertion is minimally invasive, safe and effective for the treatment of stress incontinence in females with bladder neuropathy with intrinsic sphincter deficiency. Previous surgery for incontinence did not affect post-operative complications or outcome.

Current concepts in the pharmacotherapy of benign prostatic hyperplasia

Benign prostatic hyperplasia is a major men's health issue, with approximately 80% of all men developing this condition within their lifetime. A variety of oral treatments is available, including alpha-adrenoceptor antagonists (alpha-blockers), 5alpha reductase inhibitors, aromatase inhibitors and phytotherapy. A large number of alpha-blockers can be administered, but no single agent has demonstrated a clear superiority over the other drugs. 5alpha Reductase inhibitors have demonstrated similar efficacy in larger volume prostates but most evidence suggests that there is no benefit in combining them with alpha-blockers. The use of phytotherapy is not entirely novel but requires further long-term evaluation before it can be endorsed for clinical use in benign prostatic hyperplasia.