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There are no prospective data describing the incidence and spectrum of long-term complications associated with traumatic urethral catheterisation (UC). We prospectively monitored the long-term clinical outcomes and complications of patients with traumatic UC injuries. A prospective study at two tertiary university hospitals was performed to record all referrals for iatrogenic urethral injuries caused by UC. Long-term follow-up was prospectively maintained by regular outpatient department visits and by monitoring all urological interventions and their outcomes from urinary catheter-related injuries. The incidence of traumatic UC was 13.4 per 1000 catheters inserted in male patients and 37 iatrogenic urethral injuries were recorded. The mean age was 74 ± 12 years and the mean length of follow-up was 37 ± 3.7 months. Urethral injuries were caused by inflating the catheter anchoring balloon in the urethra (n = 26) or by creating a false passage with the catheter tip (n = 11). In total, 29 patients (78%) developed urethral stricture disease during their follow-up; of which 11 have required at least one urethral dilation and two have required one urethrotomy. Three patients required long-term indwelling suprapubic catheter placement and seven patients opted for a long-term indwelling urethral catheter. There were eight patient mortalities; one of which was due to severe urosepsis resulting from catheter balloon inflation in the urethra. Catheter-related injuries are associated with significant long-term complications in this vulnerable patient cohort. In future, such injuries may be preventable if the safety profile of the urinary catheter is modified.

Botulinum toxin-A (BoNT-A) is a potent neurotoxin that is an effective treatment for patients with pharmacologically refractory detrusor overactivity (DO). Data assessing the effectiveness of trigonal BoNT-A are limited. This study evaluates adverse events (AEs) and short-term efficacy associated with trigonal and extratrigonal BoNT-A. Electronic databases (PubMed, EMBASE, and the Cochrane database) were searched for studies comparing trigonal and extratrigonal BoNT-A for DO. Meta-analyses were performed using the random effects model. Outcome measures included incidence of AEs and short-term efficacy. Six studies describing 258 patients met the inclusion criteria. The meta-analysis did not show significant differences between trigonal and extratrigonal BoNT-A for acute urinary retention (AUR; 4.2 vs 3.7 %; odds ratio [OR]: 1.068, 95 % confidence interval [CI]: 0.239–4.773; P = 0.931) or high post-void residual (PVR; 25.8 vs 22.2 %; OR: 0.979; 95 % CI: 0.459–2.088; P = 0.956). The incidence of urinary tract infection (UTI; 7.5 vs 21.0 %; OR: 0.670; 95 % CI: 0.312–1.439; P = 0.305), haematuria (15.8 vs 25.9 %; OR: 0.547; 95 % CI: 0.264–1.134; P = 0.105) and post-operative muscle weakness (9.2 vs 11.3 %; OR: 0.587; 95 % CI: 0.205–1.680, P = 0.320) was similar in both groups. Finally, differences in short-term cure rates between two study arms were not statistically significant (52.9 vs 56.9 %; OR: 1.438; 95 % CI: 0.448–4.610; P = 0.542). Although data are limited, no significant differences between trigonal and extratrigonal BoNT-A in terms of AEs and short-term efficacy were observed. Additional randomised controlled trials are required to define optimal injection techniques and sites for administering intra-vesical BoNT-A.

Acute cystitis is defined as a superficial infection of the bladder mucosa. Approximately 10% of females are diagnosed with cystitis on an annual basis and over 50% of females will have at least one episode of cystitis during their lifetime (Foxman 2002, Foxman et al. 2000). Typically, uncomplicated cystitis occurs in late adolescence and during the second and fourth decades in females with up to 30% of females 20 to 40 years of age having a history of cystitis (Hooton et al. 1996). Symptoms such as fever, chills and flank pain are absent as acute cystitis is not associated with involvement of the upper urinary tracts. Risk factors for acute cystitis include sexual intercourse, the use of spermicides and ascending bowel flora. Males with underlying structural and functional deficiencies of the genitourinary tract may also develop acute cystitis (Krieger et al. 1993). After the initial infection many patients tend to have recurrence with 25% to 50% of patients having another infection within 1 year. Recurrent episodes of cystitis are defined as symptomatic infections that follow the clinical resolution of a previous episode after treatment and their incidence is 3% to 5%. Although the vast majority of patients presenting with cystitis respond promptly to appropriate therapy, early identification and treatment of patients with complicated cystitis remains a significant clinical challenge to physicians and urologists. Herein, we discuss appropriate management strategies for patients presenting with symptoms consistent with both uncomplicated and complicated cystitis. We also place particular emphasis on appropriate antimicrobial treatment regimens for cystitis and discuss emerging patterns of resistance among different uropathogens.

To report the medium term effects of the pubovaginal sling (PVS) on patient quality of life (QOL). Patients and Methods Over a two year period, 72 females aged between 17 and 63 years (mean 46.1 years) underwent PVS for urodynamic stress incontinence (USI). All data were accrued prospectively. Preoperative assessment consisted of a full history (including King's Health and SF-36 questionnaires), physical examination, urinalysis and urodynamics. Postoperatively all patients were assessed at 6 weeks and 6 months. At these intervals each patient was questioned regarding persistence or recurrence of USI, presence of urge/urge incontinence (UI) and QOL. Preoperatively, 60 patients (83.3%) demonstrated type II USI and 12 (16.7%) had type III USI. Detrusor overactivity (DO) was also present in 3 patients. At 6 weeks 100% of patients remained completely dry, 8 (11%) patients complained of urgency but none complained of UI. At 6 months 95% of the subjects remained dry, 3 complained of recurrent USI, 7 complained of urgency and 1 of UI. The incidence of de novo urgency was 5.5%. There were significant improvements in 4 of the 8 domains of the SF-36, and in 8 of the 9 domains of the King's Health questionnaire, at both 6 weeks and 6 months follow-up. PVS is effective in the treatment of all types of USI, with early success rates of up to 95%. The procedure is associated with minimal morbidity and has a positive impact on patient QOL.

Endometriosis is a common disease, but ureteral involvement is rare. Nonspecific clinical presentations of ureteral endometriosis may result in diagnostic difficulty.To discuss the diagnosis and management of such a case.To report a case of ureteral involvement with endometriosis and review the literature.The case presented with right lower quadrant pain giving rise to initial diagnostic possibility of acute appendicitis. Subsequent evaluation revealed the diagnosis of right pyonephrosis due to midureteral endometriosis with right ovarian mucinous cystadenoma.The diagnosis of ureteral endometriosis requires a high index of clinical suspicion. The importance of ultrasound in the evaluation of acute abdomen in women can not be overemphasised.

The pubovaginal sling has been criticized as having a higher incidence of postoperative voiding dysfunction than other surgical approaches for the management of stress urinary incontinence. In 2 similar patient groups we prospectively compared the rates of early postoperative voiding dysfunction after the pubovaginal sling or Stamey procedure.Between June 1995 and January 1997, 50 consecutive patients underwent the pubovaginal sling or Stamey procedure. Emptying efficiency was measured 48 hours postoperatively by suprapubic catheter in the Stamey group and intermittent catheterization in the pubovaginal sling group. When emptying efficiency was greater than 75%, intermittent catheterization was stopped or the suprapubic catheter was removed.There was no statistically significant difference in emptying efficiency for the first 3 voids using the Dunn multiple comparison method. Median voiding efficiencies were 37%, 43% and 61% with the Stamey procedure in group 1 (mean 43%, 45% and 54%), and 60%, 75% and 75% with the pubovaginal sling in group 2 (mean 49%, 68% and 69%), respectively. The mean number of intermittent catheterizations performed in patients with the pubovaginal sling was 5.7 in less than 1 day. In the Stamey group the suprapubic catheter was removed an average of 6 days postoperatively. The mean duration of hospital stay was similar for the sling and Stamey groups (5.4 versus 6 days, respectively). There were 2 patients in each group who were voiding inefficiently after day 7. Voiding efficiency was restored at 53 and 86 days in the 2 patients with slings and at 18 days in 1 of the 2 who underwent the Stamey procedure, respectively. The second patient who underwent the Stamey procedure was able to void without using the catheter at all, and it was removed 30 days postoperatively when emptying efficiency was confirmed greater than 75%.These data show that early postoperative voiding dysfunction, measured using bladder emptying efficiency, after the pubovaginal sling is no more common than after the Stamey procedure and help justify the broadened indications for pubovaginal sling for treatment of stress urinary incontinence.

We determined the effect of a urethral catheter on abdominal leak point pressure in men and women with intrinsic sphincter deficiency.A total of 21 consecutive men treated with prostatectomy and 19 women with intrinsic sphincter deficiency underwent abdominal leak point pressure measurements with a rectal catheter before and after removal of a 10F urethral catheter.Of the 19 women 2 had leakage only when the urethral catheter was removed, while 17 had excellent correlation between abdominal leak point pressures before and after catheter removal (r = 0.83). In contrast, 10 of 21 men had leakage only when the urethral catheter was removed and 11 had weak correlation between abdominal leak point pressures before and after catheter removal (r = 0.46).An indwelling 10F urethral catheter is much more likely to invalidate abdominal leak point pressure measurement in men than in women with intrinsic sphincter deficiency.

The present study investigated the role of nitric oxide (NO) in the reflex changes in urethral outlet activity during micturition. Isovolumetric bladder contractions, urethral pressure and external urethral sphincter electromyogram (EUS EMG) activity were recorded independently in urethane-anesthetized rats. During reflex bladder contractions, the urethra exhibited reflex responses characterized by an initial decrease in urethral pressure in conjunction with a rise in bladder pressure. This was followed by a period of high frequency oscillations (HFOs) associated with maximal urethral relaxation and burst type EUS EMG activity. Administration of N-nitro-L-arginine (L-NOARG) 10 mg./kg. intravenously, a nitric oxide synthase inhibitor, reversibly decreased the magnitude (62%, p0.05) and duration (40%, p0.05) of reflex urethral relaxation (N = 7). In 4 additional experiments, L-NOARG (10 to 15 mg./kg. intravenously) completely eliminated reflex urethral relaxation during micturition, and this effect was reversed in all animals by the administration of L-arginine (100 to 150 mg./kg. intravenously). Administration of N-nitro-D-arginine (D-NOARG) (10 to 30 mg./kg. intravenously) had no effect on reflex urethral relaxation. Neuromuscular blockade (vecuronium bromide 5 mg./kg. intravenously) reversibly decreased resting urethral pressure and eliminated the HFOs. The urethral smooth muscle relaxation that remained after neuromuscular blockade was eliminated following administration of L-NOARG (10 mg./kg. intravenously) in 2 of 3 animals. These results suggest that reflex urethral responses during micturition involve changes in both smooth and striated muscle activity, and that the predominant neurotransmitter mechanisms that mediate reflex urethral smooth muscle relaxation involve NO.

SummaryFollowing a cluster of patients with acute appendicitis in pregnancy in our unit, appendicitis in pregnancy over 6 1/2 years was reviewed. of 11 patients who underwent appendicectomy 8 had the diagnosis of appendicitis confirmed. The incidence of appendicitis in the pregnant population was 1:1642. The clustering of cases in late 1985 and early 1986 is unexplained. Pain was the only reliable symptom and tenderness and muscle guarding the only reliable signs. There was no mortality and no significant maternal or fetal morbidity.Early surgical intervention is mandatory and does not lead to an increased fetal loss.

ALL sports injuries seen in our casualty department over a one year period were reviewed. We emphasise the importance of head and facial injuries in hurling and hand injuries in Gaelic football and suggest that adequate protection would reduce their incidence. We have also drawn attention to the over-use of x-rays and suggest that the general practitioner may have an even greater role to play in the management of sports injuries.

Summary Isolated renal mucormycosis is very rare and we describe such a case masquerading as a hypernephroma in a poorly-controlled diabetic.