Search

INTRODUCTION AND OBJECTIVE:Interstitial cystitis/bladder pain syndrome (IC/BPS) is a devastating condition of chronic pelvic pain. We previously linked a locus encoding acyloxyacyl hydrolase (Aoah)...

INTRODUCTION AND OBJECTIVE:Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating condition of chronic pelvic pain often co-morbid with voiding dysfunction and depression. We have p...

We describe our experience with 2-stage proximal hypospadias repair. We report outcomes, and patient and procedure characteristics associated with surgical complications.We retrospectively studied patients with proximal hypospadias who underwent staged repair between January 1993 and December 2012. Demographics, preoperative management and operative technique were reviewed. Complications included glans dehiscence, fistula, meatal stenosis, nonmeatal stricture, urethrocele/diverticula and residual chordee. Cox proportional hazards model was used to evaluate the associations between time to surgery for complications and patient and procedure level factors.A total of 134 patients were included. Median patient age was 8.8 months at first stage surgery and 17.1 months at second stage surgery, and median time between surgeries was 8 months. Median followup was 3.8 years. Complications were seen in 71 patients (53%), with the most common being fistula (39 patients, 29.1%). Reoperation was performed in 66 patients (49%). Median time from urethroplasty to surgery for complication was 14.9 months. Use of preoperative testosterone decreased risk of undergoing surgery for complication by 27% (HR 0.73, 95% CI 0.55-0.98, p = 0.04). In addition, patients identified as Hispanic were at increased risk for undergoing surgery for complications (HR 2.40, 95% CI 1.28-4.53, p = 0.01).We review the largest cohort of patients undergoing 2-stage hypospadias repair at a single institution. Complications and reoperation rates were approximately 50% in the setting of complex genital reconstruction.

Purpose: We examine whether leukocytes and bacteria correlate with symptom severity in men with chronic prostatitis/chronic pelvic pain syndrome.Materials and Methods: All 488 men screened into the National Institutes of Health Chronic Prostatitis Cohort Study before close of recruitment on August 22, 2001 were selected for analysis. The National Institutes of Health Chronic Prostatitis Symptom Index, including subscores, were used to measure symptoms. Urethral inflammation was defined as white blood cell (WBC) counts of 1 or more (1+) in the first voided urine. Participants were classified as category IIIa based on WBC counts of 5 or more, or 10 or more (5+, 10+) in the expressed prostatic secretion, or 1+ or 5+ either in the post-expressed prostatic secretion urine (voided urine 3) or semen. Uropathogens were classified as localizing if the designated bacterial species were absent in voided urine 1 and voided urine 2 but present in expressed prostatic secretion, voided urine 3 or semen, or prese...

Purpose: We describe the study design of the National Institutes of Health Chronic Prostatitis Cohort (CPC) study characterizing men with chronic prostatitis/the chronic pelvic pain syndrome.Materials and Methods: All 488 men screened into the CPC study before close of recruitment on August 22, 2001 were selected for analysis. The National Institutes of Health Chronic Prostatitis Symptom Index, including subscores, was used to measure symptoms. A comprehensive history, physical examination and demographic profile were obtained from each participant. Generalized Mantel-Haenszel procedures were used to investigate baseline associations between selected factors and symptoms.Results: Chronic prostatitis/chronic pelvic pain syndrome is a chronic syndrome affecting men over a wide age range. The majority of CPC study participants are white, well educated and affluent. However, lower education, lower income and unemployment were associated with more severe symptoms. Patients most frequently reported pain in the ...

Purpose: We evaluated the efficacy of self-start therapy in women with recurrent urinary tract infections.Materials and Methods: Women with recurrent urinary tract infections received a dip slide urine culture kit and 6 tablets of norfloxacin (400 mg.). At each symptomatic urinary tract infection episode the patient performed a culture and initiated therapy. The culture was returned and the patient was resupplied with another kit and norfloxacin. Patients were seen 5 to 9 days and 4 to 6 weeks after therapy to assess treatment outcome.Results: A total of 34 women were enrolled in the study and were evaluable for treatment outcomes. Six women followed for 74 months were asymptomatic and 9 followed for 103 months had no infections. A total of 28 women followed for 355 months had 84 symptomatic episodes and 25 had 67 urinary tract infections. Patients had symptomatic episodes at a rate of 2.8 per patient-year (range 0 to 9) and infections at a rate of 2.3 per patient-year (range 0 to 9). The greatest...

We determine the prevalence of ciprofloxacin resistant gram-negative bacilli in patients scheduled for transrectal ultrasound guided prostate biopsy, characterize the Escherichia coli strains recovered from this patient population, and characterize the mechanisms responsible for β-lactam and ciprofloxacin resistance.Rectal swabs from 991 patients were cultured for ciprofloxacin resistant gram-negative bacilli with a selective medium. Recovered E. coli isolates were further analyzed with susceptibility testing, pulsed field gel electrophoresis, plasmid isolation and sequencing.A total of 193 ciprofloxacin resistant gram-negative bacilli were recovered and of these isolates 167 (87%) were E. coli. The prevalence of ciprofloxacin resistant E. coli in the study population was 17%. Only 38 (26%) of the 149 E. coli isolates that received susceptibility testing were susceptible to ampicillin and ampicillin-sulbactam. In select isolates transferrable plasmids carrying β-lactamase were responsible for the resistance to the β-lactam agents and other nonβ-lactam antimicrobials. Diverse combinations of gyrA and parC mutations associated with fluoroquinolone resistance were identified. Strain typing and plasmid typing indicated that the E. coli isolates did not share a common origin.Of the patients in our study 17% carried ciprofloxacin resistant E. coli. Analysis of resistance mechanisms and plasmid analysis along with strain typing demonstrated that this patient population harbored organisms with heterogeneous phenotypic susceptibility, indicating that universal prophylaxis would not provide optimal coverage for patients undergoing transrectal ultrasound guided prostate biopsy.

We determined health related quality of life as reported by adolescents with bladder exstrophy or epispadias using a validated generic instrument.Adolescents age 11 to 18 years with bladder exstrophy or epispadias (57) completed a validated, generic, health related quality of life instrument, the CHQ-CF87 (Child Health Questionnaire-Child Form 87). Urinary incontinence, catheterization status, and medical and surgical history data were also obtained. Mean summary scores and 95% CIs for each subdomain of the CHQ-CF87 were calculated, and descriptively compared to 2 population based samples. In our sample health related quality of life outcomes by continence status were compared using univariate and multivariate analysis. However, this analysis was limited by a small sample size.Mean age of the 49 patients with bladder exstrophy and the 8 with epispadias was 14.3 years, 67% were male and 81% were Caucasian. There were 31 participants who reported incontinence and the median number of lifetime surgeries was 9. The exstrophy population scored well in all subdomains of the instrument when descriptively compared to 2 large samples of adolescent populations. In our sample incontinent patients had lower scores by multivariate analysis in 7 of 10 domains and better scores in 3 of 10 domains, although these differences were not statistically significant.Adolescents with bladder exstrophy and epispadias reported relatively good scores on the CHQ-CF87 when descriptively compared to other reference populations. This finding suggests that these children adapt well to the challenges of their condition. Analysis of the association of incontinence with health related quality of life was limited by the small sample size.

Chronic pelvic pain syndrome accounts for 90% of all chronic prostatitis but it has an unknown pathogenesis. We sought to understand the role of mast cells and nerve growth factor in chronic pelvic pain.Expressed prostatic secretions in men with chronic pelvic pain syndrome and controls were tested for mast cell tryptase and nerve growth factor. Mast cell number, activation status and nerve growth factor expression were examined in the NOD/ShiLtJ experimental autoimmune prostatitis model and in mast cell deficient KitW-sh/KitW-sh mice. Tactile allodynia was quantified using von Frey filaments as a measure of pelvic pain behavior. Inhibitors of mast cell degranulation, histamine receptor antagonists and anti-nerve growth factor neutralizing antibodies were tested to decrease pelvic pain behavior.Men with chronic pelvic pain syndrome showed increased mast cell tryptase and nerve growth factor in expressed prostatic secretions. In the experimental autoimmune prostatitis model increased total and activated mast cells were observed in the prostate. Mast cell deficient KitW-sh/KitW-sh mice showed attenuated pelvic pain behavior but no difference in inflammatory infiltrates in the prostate from controls. Mice with experimental autoimmune prostatitis also demonstrated increased intraprostatic nerve growth factor compared to that of KitW-sh/KitW-sh mice. Treatment of experimental autoimmune prostatitis with a mast cell stabilizer combined with a histamine 1 receptor antagonist resulted in a synergistic decrease in chronic pelvic pain. In contrast, neutralization of nerve growth factor in vivo did not result in pain relief.Results suggest that mast cells are important mediators of chronic pelvic pain in experimental autoimmune prostatitis cases. They may be potential targets for therapeutic intervention in men with chronic prostatitis/chronic pelvic pain syndrome.

We determined whether data mining derived algorithms from electronic databases can improve empirical antimicrobial therapy in outpatients with a urinary tract infection.The electronic medical records from 3,308 visits associated with a positive urine culture at Northwestern's outpatient Urology and Internal Medicine clinics and Emergency Department from 2005 to 2009 were interrogated. Bacterial species and susceptibility rates for trimethoprim-sulfamethoxazole, ciprofloxacin and nitrofurantoin were compared. Using data mining techniques we created algorithms for empirical therapy of urinary tract infections and compared the theoretical outcomes from data mining derived therapy to those from conventional therapy.Patients were significantly older in the Department of Urology vs Internal Medicine vs Emergency Department, and more patients in the Department of Urology were male. During the 5-year period the susceptibility rates for ciprofloxacin in the Department of Urology and trimethoprim-sulfamethoxazole in Internal Medicine decreased significantly. In the Department of Urology the susceptibility rate for nitrofurantoin was greater than for ciprofloxacin, which was greater than for trimethoprim-sulfamethoxazole. In all departments, bacteria were more resistant to trimethoprim-sulfamethoxazole than to ciprofloxacin or nitrofurantoin. All drugs were more effective in the Emergency Department and Internal Medicine than the Department of Urology. Prior resistance patterns were the strongest predictor of current susceptibility profiles. In the Department of Urology the algorithms for patients with or without prior cultures theoretically outperformed conventional therapy in men (13.2%) and women (10.1%).Antimicrobial resistance patterns in outpatient urinary tract infections are time dependent, and drug and site specific. Data mining directed therapy significantly improved theoretical outcomes compared to conventional therapy for Department of Urology outpatients and for female patients in the Emergency Department.

We report on our first 4 years of experience with a pilot urology residency curriculum. This novel program was approved by the Urology Residency Review Committee and involves a flexible educational program for residents, incorporating elective time (4 months each in postgraduate years 2 and 4 of training) into the residency rotation schedule.We performed a prospective assessment of the urology residency program overall, the electives chosen by the residents, and the impact on resident operative logs and in-service scores compared to residents completing residency before the implementation of the elective curriculum. Overall faculty and resident evaluation of the residency program and elective curriculum was collected, and categorized as positive, negative or neutral.When comparing the first 3 years of the pilot program to the 5 years before implementation of the program, the average final graduated resident case total increased by 232 (2,390 vs 2,158). Resident in-service scores (postgraduate years 3 to 5) trended higher since the elective program was instituted with a 5% increase in percentile scores compared to their peers (75% vs 72%). Subjective evaluations of the new residency program by residents and faculty were overwhelmingly positive.The pilot urology residency curriculum including elective time had a positive impact on the program based on resident and faculty feedback without a deleterious effect on urology index case logs or in-service scores.

We report the urological, orthopedic and neurological complications of primary closure of classic bladder exstrophy using modern staged repair of exstrophy.An approved database identified 137 males and 57 females with classic bladder exstrophy who underwent primary repair by 1 of 2 surgeons in 23 years. A total of 185 patients underwent primary closure using modern staged repair of exstrophy with or without osteotomies, whereas 9 underwent delayed primary closure with epispadias repair at age 12 months. Of the patients 63 received osteotomies. Mean age at closure was 60 days and mean followup was 9 years.There were 14 major complications (11%) and 27 minor complications (14%). Major urological complications included bladder prolapse or dehiscence in 6 male patients (3%), which was successfully reclosed. Major orthopedic complications, including osteotomy nonunion in 2 cases, leg length inequality in 1 and persistent joint pain in 1, developed in 4 of the 63 patients (6%) who underwent osteotomy. Major neurological complications included femoral nerve palsy in 4 patients (2%). There were 21 minor urological complications (11%), including posterior bladder outlet obstruction in 4 cases, urethrocutaneous fistula in 2, suprapubic tube removal in 2, intrapubic stitch erosion in 4, febrile urinary tract infection in 6 and surgical site infection in 3. Six patients (3%) had minor orthopedic complications, including pelvic osteomyelitis in 1, pin site infection in 3 and a pressure sore from immobilization in 1.Closure of bladder exstrophy is a safe surgery with an acceptable risk of complications. A critical review of outcomes provides insight to further refine the technique and manage complications when they develop.

The Meares-Stamey 4-glass test is the standard method of assessing inflammation and the presence of bacteria in the lower urinary tract in men presenting with the chronic prostatitis syndrome. However, most urologists do not use it in daily practice because of the time and difficulty in performing it, as well as the additional expense. We evaluated a simpler test, the 2-glass pre-massage and post-massage test, and compared it with the Meares-Stamey 4-glass test to detect inflammation and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome.The study population included 353 men enrolled in the National Institutes of Health Chronic Prostatitis Cohort study with baseline leukocyte counts and 2-day bacterial cultures on specimens obtained from a standard 4-glass test (VB1, VB2, expressed prostatic secretions, VB3). The chi-square test was performed to assess associations of white blood cell counts in expressed prostatic secretions and VB3. A receiver operating characteristic curve was constructed to determine the optimal cut point of white blood cells in VB3 in predicting white blood cells in expressed prostatic secretions. Sensitivity and specificity of VB3 cultures predicting expressed prostatic secretions and positive Meares-Stamey results were calculated from 2 x 2 contingency tables.Analysis of binary leukocyte outcomes (no white blood cells vs any white blood cells) suggests that white blood cells tend to be present in expressed prostatic secretions when there are any white blood cells in VB3, p0.0001, the optimal cut point being white blood cell counts of 3 in VB3 (best predictive ability with area under ROC 0.771) to predict 5+ in expressed prostatic secretions with a sensitivity of 76% and specificity of 70%. The optimal cut point of white blood cells in VB3 to predict 10 white blood cells in expressed prostatic secretions was 4 (62% sensitivity and 75% specificity). Uropathogens localizing to expressed prostatic secretions or VB3 confirms a positive 4-glass Meares-Stamey localization test. The sensitivity and specificity of a VB3 localizing culture only in predicting a positive Meares-Stamey 4-glass test result for any uropathogen were 44% to 54% (depending on definition) and 100%, respectively. The pre-massage and post-massage test predicted a correct diagnosis in more than 96% of subjects.The value of localizing leukocytes and uropathogens to prostate specific specimens remains controversial in chronic heavily pretreated patients, but these data may help direct therapy (anti-inflammatory or antimicrobial) when obtained at first presentation. The pre-massage and post-massage test has strong concordance with the 4-glass test and is a reasonable alternative when expressed prostatic secretions are not obtained.

Purpose: We compared baseline and post-therapy prostate specific antigen (PSA) in patients with chronic bacterial prostatitis who were treated with levofloxacin or ciprofloxacin. Materials and Methods: Subset analysis was done using a randomized, multicenter, doubleblind, active control trial of 500 mg levofloxacin daily for 28 days vs 500 mg ciprofloxacin twice daily in 28 days in men with chronic bacterial prostatitis. Results: Of the 377 men in the intent to treat population, including 197 treated with levofloxacin and 180 treated with ciprofloxacin, 35 on levofloxacin and 37 on ciprofloxacin with baseline PSA greater than 4 ng/ml were included in this analysis. Excluded from analysis were 2 levofloxacin treated patients with extremely high PSA at baseline (62 and 103 ng/ml, respectively). Mean baseline PSA SD in the patients analyzed was 8.33 4.46 ng/ml, which decreased to 5.36 3.82 ng/ml after therapy. There was no significant difference in the mean change in PSA between the levofloxacin and ciprofloxacin groups. Approximately 42% of patients with increased baseline PSA had a post-therapy PSA of 4 ng/ml or less. Of patients who were microbiologically evaluable and had normalized PSA after therapy levofloxacin eradicated the pathogen in 90.9% (10 of 11). However, of patients in whom post-therapy PSA remained increased the microbiological eradication rate was 69.2% (9 of 13). Similarly 93.3% of the ciprofloxacin group (14 of 15 patients) with normalized post-therapy PSA experienced microbiological eradication compared with 61.5% (8 of 13) with continued increased PSA after therapy. Conclusions: Approximately 20% of patients diagnosed with chronic bacterial prostatitis had increased PSA. A significant decrease in PSA was observed in these patients after treatment with levofloxacin or ciprofloxacin. An association was observed between bacterial persistence and the likelihood that PSA would return to normal.

Purpose: We evaluated the long-term efficacy of the male bulbourethral sling procedure in the treatment of post-radical prostatectomy urinary incontinence. Materials and Methods: Between October 1994 and June 2000, 95 patients with post-radical prostatectomy incontinence underwent bulbourethral sling placement with tetrafluoroethylene bolsters at our hospital. Ultimately 71 of these patients responded to our questionnaire and they were classified into 2 groups. Group 1 consisted of 62 patients who had not undergone prior radiation therapy and group 2 consisted of 9 who had undergone radiation therapy before the sling procedure. Patients were asked to respond to questions regarding continence status as well as the validated Incontinence Quality of Life and International Prostate Symptom Score questionnaires. Results: Mean followup from the most recent sling procedure was 4 years (range 0.27 to 6.55). Average patient age at questionnaire response was 74 years. A total of 86 procedures were performed on 71 patients. Of the 71 patients 7 underwent either sling removal or artificial urinary sphincter placement and were excluded from questionnaire analysis. Including retightening procedures 68% of the patients (72% of group 1, 43% of group 2) required 2 or less pads daily. Of the patients 36% (42% of group 1 and 14% of group 2) required 0 pads. Conclusions: The male bulbourethral sling procedure remains an effective treatment for post-prostatectomy incontinence at 4-year followup.

While the distribution of post-void residual urine volume (PVR) has been well studied in men, scant literature is available concerning PVR in women. We characterized any relationship between PVR and urinary tract infection (UTI). We also characterized other factors that could impact bladder emptying, including oral estrogen replacement therapy.Inclusion criteria were at least 2 clinic visits and no antimicrobial prophylaxis in the last year. Women with a history of diabetes or cystocele were excluded. In a 17-month period 204 women met inclusion criteria. PVR was measured by catheterized specimen. Patients were categorized into groups by UTI history, namely 94 of those with no UTIs in the last year (group 1) and 110 with 1 or more documented UTIs in the last year (group 2). Factors that could affect bladder emptying were tested for the impact on PVR.Mean PVR in the study group was 53.13 ml. The mean PVR in groups 1 and 2 was 33 and 70.25 ml, respectively. The difference between these 2 groups was significant (p0.0001). Estrogen status data were available on 186 patients. The 62 patients on estrogen replacement therapy had a mean PVR of 39.33 ml. The 124 patients not on estrogen replacement therapy had a mean PVR of 66.67 ml. The difference between these 2 groups was significant (p = 0.002) and independent of UTI history.Of elderly women those with high PVR were more likely to have recurrent UTIs. Improved bladder function was documented in women receiving oral estrogen replacement therapy.

Lymphoma of the prostate is uncommon, and synchronous bladder involvement is even rarer. We report a case of bladder outlet obstruction due to prostate and bladder involvement by lymphoma, and briefly review the literature. CASE REPORT A 70-year-old white male presented with gross hematuria and acute onset of severe obstructive voiding symptoms. Physical examination was significant for a nontender 6 8 5 cm. prostate with obliteration of the median furrow, distinct lateral sulci and lack of nodularity. A Foley catheter was placed and cystoscopy with clot evacuation was performed. Basic laboratory values were normal except for an increased calcium level of 13.9 mg./dl. (normal 8.4 to 10.2). Prostate specific antigen was 2.0 ng./ml. Urine cytology revealed no atypical cells. Computerized tomography of the chest, abdomen and pelvis showed a 1.5 cm. right axillary lymph node, irregular thickening of the bladder wall and diffuse prostate enlargement. Calcitonin, furosemide and intravenous hydration controlled the hypercalcemia. After the hematuria abated, cystoscopy demonstrated trilobar hyperplasia of the prostate and 2, 1.0 cm. irregular tan areas in the bladder. Bladder and transperineal prostate biopsies were obtained. Pathological evaluation of the left prostate cores revealed diffuse large B-cell lymphoma (figs. 1 and 2). Bladder biopsies exhibited an atypical lymphoid infiltrate consistent with lymphoma (figs. 3 and 4). The axillary lymph node was excised and confirmed diffuse large B-cell lymphoma. The patient responded well to a combined regimen of cyclophosphamide, doxorubicin, vincristine and prednisolone and was without evidence of disease 10 months after diagnosis, with resolution of the bladder outlet obstruction.