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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.

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.

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.

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

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.

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.

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.

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.

The primary renal angiosarcoma is a rarely seen highly malignant tumor. Making a diagnosis based on histology may prove difficult. Because of hematogenous formation of metastases and bad prognosis in most cases we recommend that the surgical intervention be followed by the well tolerated systemic chemotherapy with Doxorubicin and Ifosfamid.

Sexual potency in its entire meaning implies: libido, erection, ejaculation which are discussed in view of its incidence or loss. Organic reasons for erectile dysfunction prevail at a high rate. These are listed regarding efficient diagnosis and the therapeutic measures.

A 34-year-old man was admitted because of headache with neck pain, hypertension and tachycardia. The symptoms started 10 days prior to presentation. In the past the patient was treated because of different vegetative symptoms, which were interpreted in relation to excessive private problems. Despite suggestive clinical presentation, the diagnosis phaeochromocytoma was confirmed late. Following removal of the tumor, blood pressure came into the normal range. The operation also abolished all vegetative symptoms and lead to stabilisation of the psychosocial situation.

Erectile dysfunction has taken on increasing importance in urologic practice. Still open is the question of which tests are mandatory for adequate clinical assessment of erectile dysfunction. One accepted standard modality is the intracavernous pharmacotest with vasoactive agents. In contrast, color duplex sonography is not considered mandatory although it reveals detailed information about penile vessels and functional implications. The question remains whether the information gained by color duplex sonography is relevant for therapy, making it an indispensable standard procedure. Patients with erectile dysfunction were evaluated, without preselection, by extensive history, clinical evaluation, laboratory tests, tumescence and rigidity measurements, intracavernous administration of vasoactive drugs and color duplex sonography. Seventy-nine patients were available for final analysis. Color duplex sonography revealed 39 normal tests, 16 arterial impairments. 19 venous leakages and 5 arteriovenous fistulae. Intracavernous vasoactive agents (pharmacotest) revealed 44 reactions sufficient for intercourse and 35 insufficient responses. In 89% of patients, the diagnoses on color duplex sonography and intracavernous pharmaco-testing were similar. The accuracy of the two methods in diagnosing erectile dysfunction was not statistically different (McNemar's test). In contrast to intracavernous pharmaco-testing, color duplex sonography permitted further etiologic subdivision into arterial disease, venous leakage, arteriovenous fistula and normal result. This was made possible by measuring significantly (P0.01) different arterial peak flow velocities, end-diastolic velocities and calculated resistance index. These data did not imply direct clinical consequences. Color duplex sonography and intracavernous pharmacotesting reveal comparable results concerning the diagnosis of an erectile dysfunction. In contrast to pharmacotesting, color duplex sonography reveals details of the nature of the erectile dysfunction. Because this information has no profound implications for the choice of therapeutic procedure, color duplex sonography can not be recommended as a standard procedure in the evaluation of erectile dysfunction.

The seminal vesicle cyst is a congenital malformation of the male urogenital tract, which seems to be more frequent than originally presumed. It is usually combined with an ipsilateral renal agenesis and an ectopic ureter. Two relevant cases are reported and embryology, major presenting symptoms, diagnostic procedures, differential diagnosis and therapy are extensively discussed.

Kaposi sarcoma was first described by Moritz Kaposi 1872. It is a disease of the reticuloendothelial system. Preferred manifestations are mainly skin, mucosa and gastrointestinal tract. Location of penile glans with meatal obstruction has been mentioned to date in 4 cases. We report a patient with acquired immune deficiency syndrome who presented a meatal obstruction caused by Kaposi-sarcoma. In this patient with a survival time of 8 months meatotomy and locoregional radiotherapy was an adequate therapy.

To avoid an operation, there are innumerable pharmaceutics on sale for the treatment of the benign prostatic hyperplasia. For this reason we have to distinguish between pharmaceutics without effect and those with proved action on the hyperplastic metaplasia. The symptoms can often be lessened at the initial stage by way of drugs with ineffective action (phytopharmaceutics); there could not yet be proved any effect on the biology of the prostatic hyperplasia. We make use of this therapeutic at the initial stage. Some of the substances with a real effect (alpha-receptor blockers, alpha-reductase inhibitors) do not necessarily provide an effective result in all cases. In addition to that, these therapeutics of partially serious side effects have to be taken for life. Here immediately arises the question of how it could be managed financially.

We report our experience in evaluating PSA-follow-up of patients treated with radical prostatectomy. Also PSA is the most sensitive available screening test for relapse after radical prostatectomy, it is not 100% specific for cancer relapse while this serum marker is not specific for prostate cancer. In our opinion, patients with biochemical relapse (PSA0.5 ng/l) should undergo an early restaging including biopsy of the anastomosis. In 57% of our patients with PSA1.0 ng/l two months after surgery we found clinical recurrence 27 months later on.

The assessment of an erectile dysfunction (ED) includes the history, a clinical examination and blood tests. There is some confusion about which basic hormonal tests are needed at the beginning of clinical evaluation. We feel that with the results from our patients we could help to answer this question. From 1 January 1990 until the December 31 1993 we evaluated 1134 patients for ED. Those who favoured a surgical correction of their ED were fully evaluated by nocturnal penile tumescence testing, penile arteriography, intracavernosal injection of vasoactive agents and dynamic pharmaco-cavernosometry. The results from these tests were correlated with luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone and prolactin. 183 (16.1%) of our patients with a mean age of 45 +/- 14 were fully evaluated. From these patients 76 were excluded because their ED was posttraumatic, undoubtedly psychogenic or could not be proven by the tests mentioned above. From the 107 patients finally included in this study, 90 had normal endocrine parameters. 17 patients had low testosterone. 14 of these patients had otherwise completely normal hormonal tests without evidence of secondary hypogonadism. Three patients had their low testosterone levels confirmed by repeated measurements. In addition, prolactin was significantly increased, and FSH and LH were near or below the lower reference value. When evaluating patients for the first time because of an erectile dysfunction, the measurement of testosterone as a single endocrine test is adequate. If testosterone is low, repeated measurements, combined with LH, FSH and prolactin, will identify patients with an ED due to an endocrine disease.

Urolithiasis has always been a well known phenomenon to mankind. Whereas up to the beginning of the 19th century, open surgery for bladder stones was known to be a high risk operation due to its frequent complications, nowadays we are able to disintegrate renal and vesical calculi into spontaneously excretable fragments by means of shock waves generated extracorporeally (ESWL). The physical principles of shock waves and their impact on the stone are explained. By means of ESWL the time of hospitalisation as well as of recovery can be massively reduced saving billions to our economy.

Correct forecasting of prostatic carcinoma by means of serum PSA is limited. Prostatic carcinoma is said to increase PSA 10 times as much as prostatic adenoma. Therefore we evaluated whether PSA in the prostatic fluid is more specific for prostatic carcinoma than the level in the serum. In 31 consecutive patients with prostatic disease blood was taken for serum PSA first and then prostatic fluid (10 microliters) was expressed. The PSA was determined by the Pros-Check test in both the serum and in the prostatic fluid. The collection of the prostatic fluid failed in 7 (22.6%) patients. Of the remaining 24 patients, 5 had documented bacterial prostatitis, 4 had prostatic carcinoma and 15 had benign prostatic hyperplasia (BPH). The serum PSA was 5.6 +/- 5.0 micrograms/l in prostatitis, 148 +/- 208 micrograms/l in prostatic carcinoma and 6.9 +/- 6.8 micrograms/l in BPH. The serum PSA was significantly higher in prostatic cancer (Por = 0.01) than in prostatitis and BPH. The PSA levels in the prostatic fluid were 14.0 +/- 25.7 x 10(6) micrograms/l in prostatitis, 7.6 +/- 9.7 x 10(6) micrograms/l in carcinoma and 14.0 +/- 14.6 x 10(6) micrograms/l in BPH. There were no statistically significant differences. In the expressed prostatic fluid no significantly different PSA was found in carcinoma, bacterial prostatitis or BPH. In contrast to this, the serum PSA was significantly higher in cancer patients than in prostatitis or BPH. Therefore PSA in the expressed prostatic fluid is no more specific than that in the serum.(ABSTRACT TRUNCATED AT 250 WORDS)

The most important reasons for erectile dysfunction are summarized as well as its examination and the adequate treatment. In more than 80 percent erectile impotence is an organic disease. Therefore it is disgraceful for the patients concerned, if health insurance companies and the Federal Office for Social Insurances refuse to take on the liability to pay for the necessary examinations and forms of therapy.

Acute urinary obstruction is a painful occurrence well known to every physician. It is a matter of a reflexogenic closure of the bladder neck. As the nerves, regulating the neck as well as the motoricity of the bladder, extend directly over the capsule of the prostate, functional disorders during growth of the prostate are possible at any time, independent of the prostatic volume. Since in case of prostatic hyperplasia the smooth muscles of the bladder neck are partly transformed into fibrous tissue, drug treatment in case of acute urinary obstruction is impossible. Therefore catheterisation is applied now as before.

Among the therapeutical options surgical revascularisation represents the most physiological treatment of the wide-spread vascular impotence. In contrast isolated surgery on the penile venous system is rarely efficient. So far the most impressive results have been achieved by intracavernous injection of vasoactive drugs. External penile devices, such as the vacuum-constrictor-apparatus, were not successful just as the implantation of penile prostheses.

During the past decade innovative research in physiology of erection and pathophysiology of impotence has brought a better understanding of the differential diagnosis and a new consideration of therapy in erectile dysfunction (ED). The basic anatomical structures and physiological mechanisms are described followed by a critical illustration of the various functional diagnostic tests. Intracavernosal injection with vasoactive agents proved to be the best functional screening test. The nocturnal continuous monitoring of penile tumescence and rigidity still appears to be of great value in the differential diagnosis of psychogenic impotence but is not frequently used as a routine investigation. Apart from the invasive methods as cavernosography, cavernosometry and selective penile arteriography the ultrasound examination using duplex scan or, in particular, the colored duplex scan (Angiodynography) turned out to be excellent tests to answer the vascular questions. For lack of an evident neurological test the diagnosis of neurogenic impotence is made by exclusion.

According to our opinion, so-called venous leakage is not a venous disease but a result of impaired cavernous tissue. Since in over 90% of all patients with venous leakage arterial disease has also been discovered, and since in addition ultrastructural degenerative processes have also been detected in the cavernous bodies, we consider the traditional treatment in the form of venous surgery unphysiological and illogical. We suggests arterial revascularization combined with mechanical penis banding as a new therapeutic concept.

Urinary continence is guaranteed by many factors. The most important are an intact bladderneck and a normally operating proximal urethra. Predominantly the smooth muscular system is involved. The striated external sphincter is primarily not responsible for continence. At prostatectomy the bladderneck and a great part of the smooth muscles of the proximal urethra inevitably are removed. Postoperatively only a small distal segment of the posterior urethra continues to guarantee continence. This segment may be changed by the growth of the prostate and can be destroyed by an untrained operator. Then, urinary incontinence is the result.

A retrospective study was conducted in 13 patients with phlebographically diagnosed tumor-induced renal vein occlusion to evaluate the incidence and extent of proteinuria and/or nephrotic syndrome. In 5 patients minimal proteinuria was found, but in none of the patients were the criteria of nephrotic syndrome fulfilled. These data can be used as additional evidence that renal vein occlusion is not the cause of nephrotic syndrome. They underline the hypothesis that, in cases of nephrotic syndrome associated with renal vein occlusion, the thrombic occlusion of the renal vein is a complication of the excessive renal protein loss and developing hypercoagulability.

Ten patients with common bile duct stones not removable by endoscopic measures after sphincterotomy were treated by extracorporeally generated shock waves. In 9 patients stones up to 30 mm in diameter were disintegrated. Two patients became free of stone fragments spontaneously within one day and in 7 patients the stone fragments were extracted endoscopically. No complications occurred. Extracorporal shock wave treatment represents a promising alternative to surgery in cases where common bile duct stones cannot be extracted endoscopically.

We report our experience with the directly to the urethra anastomosed continent ileal reservoir. Our results suggest that the S-Pouch is superior to the proceeding suggested by Kock both from clinical and urodynamic view. Continence is to be expected at an anastomosis of this pouch with the bladder neck, whereas at an anastomosis with the posterior urethra occasional cases of nightly incontinence were registered. This always happened when the neurovascular bundle had not been preserved intraoperatively. If an ileal reservoir is installed metabolic acidosis has to be carefully avoided.

Based on the findings upon arteriography, cavernosography and clinical features two different kinds of priapism are differentiated: Type I ("low flow priapism") is characterized by severe blood stasis within the corpora cavernosa and reduction of arterial perfusion through compression of the deep arteries of the penis. The penis is very hard and painful upon palpation. A delay of treatment over 48 hours will result in a damage of the corpora cavernosa and impotence. Type II ("high flow priapism") is characterized by arterial hyperperfusion. Outflow obstruction is absent. The penis is erected but of an elastic consistence, pain is absent. Even with a delay of treatment of up to 6 months the corpora cavernosa remain intact, normal erectile function is preserved.

Urinary continence is guaranteed by the system of smooth urethral musculature, the so-called sphincter internus. The striated sphincter externus has primarily no responsibility for continence. One of its most important functions is the initiation of a voluntary micturition. Further functions are: the voluntary interruption of the urinary stream, the reflectory occlusion by elevated intraabdominal pressure (coughing, sneezing, laughing, heavy physical work), expression of the rest of urine in the urethra after micturition, stabilization of the proximal urethra in the urogenital diaphragm. To get an optimal function after prostatectomy an intact sphincter externus becomes important for the smooth urethral muscular system which is further responsible for the continence. About 90% of all patients with a postprostatectomy incontinence have an intact sphincter externus. In these cases we have a high incidence of incontinence cure. Only in 10% of incontinence after prostatectomy the sphincter externus is damaged. In those cases the incontinence operation is inadequate.

Results after internal urethrotomy under direct vision are comparable to the results after open plastic procedures for strictures of the urethra. Internal urethrotomy at present is preferred to plastic procedures because of its simplicity. But plastic procedures maintain their indication for some special types of strictures. Postoperative treatment after internal urethrotomy under direct vision varies with the etiology of the stricture. In iatrogenic strictures results are better using an indwelling catheter for a period up to 6 weeks after internal urethrotomy under direct vision.

The prognosis of testicular tumors is largely depending on an early as possible tinning of the diagnosis. The present tumormakers do not bring a diagnostic security. However they are important for the continuing observation of the patients, especially of those with cytostatic chemotherapy. Today's acknowledged treatment of malignant testicular tumors is the high semicastratio, for Seninoms the additional highvoltage radiotherapy, for the Teratocarcinomas the additional retroperitoneal lymphnode extirpation and for the cases with retroperitoneal metastases the subsequent high-voltage radiotherapy and the adjuvant cytostatic chemitherapy. Between the alternative of the transperitoneal and the thoracoretroperitoneal lymphadenextomy we prefer the latter. The operation is radical, the thoracic complication are minimal and this technic besides advantages because the postoperative number of patients with a loss of ejaculation is much lower.

We present 2 cases from our clinic with complications due to unilateral multicystic dysplastic kidneys: 1 case with arterial hypertension, another case with a renal carcinoma in a multicystic dysplastic kidney. Compared with the 62 cases already published, these are the 2nd case of hypertension and the 3rd case of carcinoma in multicystic dysplastic kidneys. Because of such complications nephrectomy of multicystic dysplastic kidneys is indicated.

We are of the opinion that in most cases of erectile dysfunction morphological factors are involved. These have to be defined by means of adequate diagnostic procedures. When vascular disease is responsible it is necessary to distinguish between arterial, venous and arteriovenous conditions. Whereas arterial failure can often be corrected, the treatment of venous leakage is problematic, as the primary disease seems to affect the cavernous bodies directly.

Cryosurgical technique as therapy of infravesical obstruction is of palliative character. Experience and results with patients from the years 1973-1978 are reported. The incidence and the rate of complications influence our technique and the precise indication for cryosurgery of the prostate to avoid failures in the future.

Priapism is a pathological and mostly painful permanent penile erection. Typically only both corpora cavernosa and not the corpus spongiosum urethrae and the glans penis are involved. The vascular and nervous preconditions for a normal erection are discussed and a new concept presented. On this basis the conditions for a priapism are enumerated and the principles of therapy are discussed.