Insulin and free oestradiol are independent risk factors for benign prostatic hyperplasia

The aetiology of benign prostatic hyperplasia (BPH) remains unclear. The objective of the present study was to test the insulin, oestradiol and metabolic syndrome hypotheses as promoters of BPH. The design was a risk factor analysis of BPH in which the total prostate gland volume was related to endocrine and anthropometric factors. The participants studied were 184 representative men, aged 72-76 years, residing in Göteborg, Sweden. Using a multivariate analysis, BPH as measured by the total prostate gland volume correlated statistically significantly with fasting serum insulin (beta=0.200, P=0.028), free oestradiol (beta=0.233, P=0.008) and lean body mass (beta=0.257, P=0.034). Insulin and free oestradiol appear to be independent risk factors for BPH, confirming both the insulin and the oestradiol hypotheses. Our findings also seem to confirm the metabolic syndrome hypothesis. The metabolic syndrome and its major endocrine aberration, hyperinsulinaemia, are possible primary events in BPH.

Sacral nerve stimulation for refractory urge symptoms in elderly patients

OBJECTIVE

The presence of an overactive detrusor (OD) is becoming more prevalent in the elderly and may severely influence the social life and activities of daily living in the senior, otherwise healthy, person. There is a marked age-dependent increase in OD above the age of 65 years, which is mainly attributed to dysfunction, with loss of voluntary control, of the micturition reflex and decreased perception of bladder fullness.

MATERIAL AND METHODS

Herein, we evaluate the outcome of sacral nerve stimulation in five patients aged >65 years derived from a large, multinational, randomized, prospective study.

RESULTS

The effect on symptoms was excellent in two subjects. There was a moderate improvement in another subject and a variable but eventually small effect in the remaining two patients. The results appeared to be more favourable in younger patients.

CONCLUSION

Our findings suggest that the outcome of sacral nerve stimulation is more unpredictable in the elderly, a fact that should be considered when counselling the patient. However, it should be remembered that, even for the older, active person, urge incontinence may have a severe impact on quality of life and that the majority of patients treated with an implant will benefit from this treatment.

The treatment of sphincter incontinence with periurethral silicone implants (macroplastique)

OBJECTIVE

Patients with genuine stress urinary incontinence (GSI) refractory to conservative measures often undergo a colposuspension when the reason for urine leakage is hypermobility of the bladder neck. Patients who suffer from an insufficiency of the intramural sphincter are instead often suitable for pubovaginal sling procedures, implantation of an artificial sphincter or peri/intraurethral injection of some expansion substance. Here, we present our experience of periurethral injection of silicone microimplants (Macroplastique).

METHOD

We studied 8 men and 22 women with urodynamically stable detrusor, and validated GSI on a standardized quantification test. Under direct endoscopic control Macroplastique was injected. Follow-up was performed by a questionnaire and a new standardized quantification test.

RESULTS

Nineteen of the 22 patients with follow-up in excess of 2 years reported a considerable amelioration and their subjective impressions were also validated by the postoperative standardized quantification test (preoperative 147 g, postoperative 9 g; p < 0.001). No side effects were reported except for mild dysuria for practically all the patients, in all cases transient. A few patients also reported a short initial sensation of incomplete bladder emptying.

CONCLUSION

Considering the difficulty in treating sphincter insufficiency, particularly iatrogenic, the results in this study appear to justify the attempt of injection therapy. It may very well be performed as an outpatient procedure and, moreover, side effects are rare. If silicone microimplants are used there is no obstacle to proceed with artificial sphincter implantation, should the patient's symptoms remain unaffected by the injection procedure.

Invasive urodynamic studies are well tolerated by the patients and associated with a low risk of urinary tract infection

OBJECTIVE

An essential part of investigation of the lower urinary tract is pressure/flow studies (pQS). In fact, pQS is the only way of diagnosing bladder outlet obstruction. There is controversy regarding whether or not prophylactic antibiotic treatment is necessary. This prospective study was carried out in order to determine the frequency of infections and/or distress after pQS performed without the use of antibiotic prophylaxis.

MATERIAL AND METHODS

One hundred and twenty-three patients were included in the present study, all males. They were requested to answer a questionnaire I week after pQS. Questions were asked concerning symptoms of voiding disorders, dysuria, hematuria, incidence of fever and the patient's acceptance of the investigation after the pQS procedure. Urine was obtained for culture immediately before the investigation and 3 and 7 days after the pQS.

RESULTS

Forty-six per cent of the patients experienced some degree of transient dysuria after pQS. and 18.5% experienced voiding problems of varying nature. Five per cent of the patients had hematuria and 2.5% reported fever. Fifty per cent of the patients experienced some degree of discomfort during the pQS investigation, and 4.1% had positive culture and symptoms of UTI requiring antibiotic treatment.

CONCLUSIONS

PQS is well accepted by the patients and the regular use of propylactic antibiotics is not indicated. We recommend, though, that patients at risk for serious complications from infections (e.g. those with prosthetic heart valves) should receive prophylactic antibiotics.

Lidocaine cystometry in the diagnosis of bladder overactivity

The effect of intravesical lidocaine was studied in a group of patients with symptoms of urinary urgency with or without incontinence. Provocative water cystometry failed to demonstrate signs of unstable detrusor but all patients presented a continuous, steep rise of detrusor pressure at the end phase of filling. Repeat cystometry was performed after the bladder had been treated with 3 g lidocaine intravesically for 20 minutes. In the majority of patients, no change in configuration of the cystometrogram was noted. In a group of patients, a decrease of detrusor pressure occurred and there was also an influence on phasic bladder contractions. In three patients, phasic detrusor contractions developed after lidocaine. Thus, intravesical lidocaine seems to be a useful tool to increase the precision of the urodynamic diagnosis in bladder overactivity.

Clam ileocystoplasty: successful treatment of severe bladder overactivity

OBJECTIVE

When conservative treatment for bladder overactivity fails the "clam" ileocystoplasty has been proposed to restore continence and preserve urethral voiding. This study presents our experience with this technique.

MATERIALS AND METHODS

Thirty patients, 4 men and 26 women, with a mean age of 50.3 years (range 21-71 years) were operated upon. Five patients had an incomplete spinal lesion and detrusor hyperreflexia, 25 subjects had an idiopathic, unstable detrusor. The ileocystoplasty was combined with a colposuspension procedure in 8 patients. In one patient simultaneous repair of an urethro-vaginal fistula was performed using omentum flap interposition. The mean follow-up was 60 months (range 4-127).

RESULTS

To the surgeon, 27 patients (90%) reported satisfaction with bladder control and relief of symptoms at follow-up. When asked by a nurse in a written questionnaire, 18 out of 23 patients (78%) were quite happy with their bladder function postoperatively. No serious complications to surgery were noted. Postoperatively, 11 patients used self-intermittent catheterization and one, by choice, preferred an indwelling catheter. Due to failure, two patients later underwent reoperation with urinary diversion and one further patient required an additional artificial sphincter. Metabolic consequences owing to enteric malabsorption were infrequent and of a mild nature. No malignant change was identified.

CONCLUSION

In patients with refractory overactive bladder, we found the "clam" ileocystoplasty to be an effective technique for symptom reduction and increased quality of life.

Complete transurethral resection of ulcers in classic interstitial cystitis

Interstitial cystitis (IC) is a chronic disease of obscure etiology. It commonly affects females, who present with symptoms of pain on bladder filling and urinary frequency. There are two types of IC: classic and non-ulcer disease, which differ in many respects, including response to different therapies. In this retrospective study we evaluated the hitherto largest series of patients with classic IC treated by transurethral resection (TUR) of visible ulcers. Altogether 259 TURs of Hunner ulcers were performed on 103 patients: 92 experienced amelioration, and in 40% symptom relief lasted more than 3 years. In the remaining patients, although symptom recurrence was common, the majority responded well to subsequent TUR. In conclusion, TUR has a good outcome in patients with classic interstitial cystitis, and we suggest it as first-line treatment in this patient group.

Intravesical bacillus Calmette-Guerin and dimethyl sulfoxide for treatment of classic and nonulcer interstitial cystitis: a prospective, randomized double-blind study

PURPOSE

We conducted a prospective, double-blind study with a crossover design of intravesical bacillus Calmette-Guerin (BCG) and dimethyl sulfoxide to determine whether patients with classic and nonulcer interstitial cystitis, respectively, might benefit from either regimen.

MATERIALS AND METHODS

A total of 21 patients, including 11 with classic and 10 with nonulcer interstitial cystitis, randomly underwent treatments with intravesical BCG or dimethyl sulfoxide and, if not improved, were treated with the other substance after a washout period. All 21 patients were evaluated with symptom questionnaires, including a visual analog pain scale and voiding diaries.

RESULTS

Regardless of regimen, there was no improvement in maximal functional capacity. There was a reduction in urinary frequency following dimethyl sulfoxide treatment but only in the classic subtype (p <0.05), whereas no reduction was seen following BCG in either subtype. A substantial pain decrease was noted in classic (p <0.05) as well as nonulcer (p <0.05) interstitial cystitis following dimethyl sulfoxide.

CONCLUSIONS

Intravesical BCG has been presented as a promising new option for treatment of interstitial cystitis. We failed to demonstrate benefit from this treatment. Dimethyl sulfoxide had no positive effect on maximal functional capacity but resulted in a significant reduction in pain and urinary frequency, although only in patients with classic interstitial cystitis.

First Scandinavian experience of electrical sacral nerve stimulation in the treatment of the overactive bladder

OBJECTIVE

This study aimed to evaluate the efficacy of electrical sacral nerve stimulation (SNS) in the treatment of urinary incontinence and urinary retention refractory to conservative treatment, and to assess the impact of urodynamic abnormalities and electrode position.

MATERIAL AND METHODS

Thirty patients (10 men, 20 women) with a mean age of 59 years (range 21-79 years), all of whom had longstanding symptoms ranging from 2 to 46 years (mean 12.4 years), were subjected to a percutaneous test stimulation. Ten patients responded well, resulting in a permanent implant in nine patients. Electrode positions were determined by plain X-ray and computed tomography.

RESULTS

Radiologically, a variety of positions of the temporary electrodes was seen. In the implanted patients, long-term symptom reduction varied over time, ranging from total relief to partial or total recurrence of symptoms.

CONCLUSIONS

SNS is a new promising option for the treatment of urge incontinence. Refined instruments for proper patient selection and the optimal way to position the electrode remain to be developed.

Impaired renal arterial blood flow velocity in nephroptosis

The diagnosis nephroptosis, as well as surgical treatment of the condition, has been profoundly questioned in recent decades. Here, we report on a case of nephropexy in a young woman with nephroptosis with complete resolution of symptoms and with correction of preoperatively abnormal 99mTc-DMSA scan and renal arterial Doppler examination.

Treatment guidelines for classic and non-ulcer interstitial cystitis

Interstitial cystitis (IC) is a chronic disease of as yet unknown etiology. It commonly affects females, presenting with symptoms of pain on bladder filling, and urinary frequency. Accumulated evidence indicates that IC is a heterogeneous syndrome. Compared to classic IC, the non-ulcer type appears different concerning symptomatic, endoscopic and histological findings, as well as the response to various forms of treatment. This review gives an introduction to the syndrome of IC, concerning epidemiology, clinical characteristics, diagnostic criteria and etiological considerations. A variety of treatment modalities have been suggested and are assessed and reviewed, such as hydrodistension of the bladder, intravesical instillation therapy, oral medication, transcutaneous electrical nerve stimulation, transurethral resection of diseased bladder tissue, and supratrigonal cystectomy followed by enterocystoplasty and urinary diversion. Our algorithm on non-surgical and surgical treatment for classic and non-ulcer IC is presented.

Increased tyrosine hydroxylase immunoreactivity in bladder tissue from patients with classic and nonulcer interstitial cystitis

PURPOSE

Interstitial cystitis is a chronic debilitating condition which mainly affects women. Accumulated evidence indicates that interstitial cystitis is a heterogeneous syndrome. The nonulcer subtype appears different than classic interstitial cystitis in regard to symptoms, and endoscopic and histological findings as well as response to various treatments. We further explore the neurogenic nature of this disease using indirect immunofluorescence to evaluate the presence and density of various autonomic and sensory nerve fibers.

MATERIALS AND METHODS

Specimens from the bladder wall of 6 patients with classic interstitial cystitis, 7 with nonulcer interstitial cystitis and 6 controls were evaluated to determine the presence and density of nerve fibers containing tyrosine hydroxylase, calcitonin gene-related peptide, neuropeptide Y and substance P using specific antibodies, and the general presence of nerve fibers using a mixture of antibodies against nerve filament, neuron specific enolase and S-100 protein.

RESULTS

Increased density and number of nerve fibers immunoreactive for tyrosine hydroxylase were noted in interstitial cystitis cases compared to controls. Furthermore, there was a difference between classic and nonulcer disease in the overall density of nerves using the antibody mixture.

CONCLUSIONS

Our findings indicate an altered peripheral sympathetic innervation in interstitial cystitis cases, which may be an indication of primary neurogenic etiology. The difference in nerve density observed after incubation with the antibody mixture between classic and nonulcer interstitial cystitis supports the hypothesis that the 2 forms represent separate entities.

Recruitment, distribution and phenotypes of mast cells in interstitial cystitis

PURPOSE

Interstitial cystitis (IC) is a chronic disabling condition of unknown etiology. One of its major characteristics is an increase in mast cells (MC) showing signs of activation. It has been suggested that the proteinase content defines two MC types: MC(TC), containing chymase and tryptase, and MC(T), which contains tryptase but lacks chymase. Here, we investigated the MC distribution and the MC proteinase expression in IC together with the tissue expression of the major MC growth factors, stem cell factor (SCF) and interleukin-6 (IL-6).

MATERIALS AND METHODS

MC were enumerated in bladder specimens from patients with classic IC, nonulcer IC and controls. MC were visualized in terms of metachromasia, reflecting glycosaminoglycan content, and immunohistochemically, visualizing tryptase, chymase and IL-6 as well as the surface markers CD117 and SCF.

RESULTS

Classic IC displayed a 6 to 10-fold increase of MC identified by proteinase content while in nonulcer IC there were twice as many MC as in controls. In contrast to nonulcer IC and controls, classic IC displayed an abundance of epithelial MC. Fewer CD117+ than proteinase+ MC were detected in IC but not in controls. Classic IC coexpressed SCF and IL-6 in the epithelium and displayed numerous SCF and IL-6+ cells in the mucosa and detrusor muscle, many of which were MC.

CONCLUSIONS

Redistribution of MC into the epithelium and a high bladder wall MC density distinguish classic IC from nonulcer IC. Our findings suggest an SCF/IL-6-driven MC response in IC. They also indicate a downregulation of the SCF receptor in IC.

Decreased levels of S-100 protein in non-ulcer interstitial cystitis

Interstitial cystitis (IC) is a chronic debilitating condition which mainly affects women. Accumulated evidence indicates that IC is a heterogeneous syndrome. As compared to classic IC, the non-ulcer type of IC appears to be different concerning symptomatic, endoscopical and histological findings, as well as in response to various forms of treatment. S-100 is a neural protein considered to be located primarily in the axons. To explore further the neurogenic nature of the disease, we compared bladder wall S-100 content in controls and in patients with classic and non-ulcer IC. We noticed a decrease in S-100 content in non-ulcer IC as compared to controls. This may be an expression of altered peripheral innervation in non-ulcer IC, which, in turn, may be an indication of primary neurogenic etiology. The difference in S-100 content between classic and non-ulcer IC supports the hypothesis that they represent separate entities, which may explain differences in response to various treatments.

Metaplastic transformation of urinary bladder epithelium: effect on mast cell recruitment, distribution, and phenotype expression

Mucosal mast cells (MCs) are normally found in the connective tissue stroma but are redistributed into the epithelium in conditions associated with immunoglobulin E responses, such as allergic inflammation and nematode infections, as well as in interstitial cystitis, a condition of unknown etiology. The potential role of epithelium-derived factors in this response prompted this inquiry into growth and differentiation signaling in normal tissue as well as in tissues from five different metaplastic conditions of the urothelium (cystitic cystica, cystitis glandularis, colonic metaplasia, squamous cell metaplasia, and nephrogenic metaplasia). Expression of the two major human MC growth factors, stem cell factor (or kit ligand) and interleukin 6, was detected using immunohistochemistry. In the case of interleukin 6, its mRNA expression was also detected using in situ reverse transcription-polymerase chain reaction. Among the different metaplastic lesions, nephrogenic metaplasia was the only one associated with an abundance of MCs, which were distributed within or in close relationship to the epithelium. Unlike in the other types of metaplasia, the epithelium strongly co-expressed interleukin 6 and stem cell factor. The MCs expressed the stem cell factor receptor CD117 and exhibited a variable tryptase immunoreactivity, but lacked chymase. They also displayed a relative deficiency of granular glycosaminoglycan, as indicated by a lack of metachromasia, and were sensitive to strong aldehyde fixation. The findings suggest that the MC response in nephrogenic metaplasia may be the result of local epithelial stem cell factor/interleukin 6 expression.

The treatment of interstitial cystitis with supratrigonal cystectomy and ileocystoplasty: difference in outcome between classic and nonulcer disease

PURPOSE

Interstitial cystitis is a chronic debilitating condition that mainly affects women. Accumulated evidence indicates that interstitial cystitis is a heterogeneous syndrome. The nonulcer type seems to respond less favorably to various conservative treatments than the classic type. Supratrigonal cystectomy with ileocystoplasty is established treatment for interstitial cystitis refractory to conservative treatment. We evaluate whether classic interstitial cystitis responds differently than nonulcer disease to subtotal bladder resection and ileocystoplasty.

MATERIALS AND METHODS

We evaluated 13 patients 27 to 79 years old with interstitial cystitis who underwent supratrigonal cystectomy and ileocystoplasty due to failure to respond to conservative treatment.

RESULTS

In all 10 patients with classic interstitial cystitis symptoms were relieved after ileocystoplasty. In the 3 patients with nonulcer interstitial cystitis pain remained, while the frequency of voiding somewhat decreased. In these patients trigonal resection and urinary diversion with a Kock pouch resolved the symptoms.

CONCLUSIONS

Our study confirms that supratrigonal cystectomy with ileocystoplasty results in a good outcome in classic interstitial cystitis. However, this method seems to be unsuitable for nonulcer disease. Identification of the relevant subtype of interstitial cystitis is of crucial importance for selecting the appropriate method of lower urinary tract reconstruction.

Superoxide dismutase isoenzymes in human seminal plasma and spermatozoa

Superoxide radicals may exert both toxic and physiological regulating actions on spermatozoa. The objective of the present study was to examine the occurrence and distribution of the three superoxide dismutase (SOD) isoenzymes in human seminal plasma and spermatozoa. Human seminal plasma has previously been reported to possess high SOD activity. Here we show that the normally cytosolic CuZn-SOD remarkably accounts for 75% of the activity while the secretory extracellular SOD (EC-SOD) accounts for 25%. Studies of split ejaculates suggest that both these SOD isoenzymes are of primarily prostatic origin. The Mn-SOD activity was negligible. The total SOD activity of seminal plasma was 20 times higher than that of human blood plasma. While native EC-SOD shows high affinity for heparin and heparan sulphate, 90% of the EC-SOD in seminal plasma lacks the high affinity at ejaculation. Thus only a minor part of the seminal plasma EC-SOD has the potential to bind to cell surfaces. Human spermatozoa were found to contain exceptionally large amounts of CuZn-SOD. There was little Mn-SOD activity and the amount of EC-SOD was negligible. We conclude that spermatozoa in semen are exceptionally well protected against superoxide radicals both internally and externally. This should be of importance for both their survival and the integrity of DNA, and may also have physiological effects such as influencing capacitation.

Nephrogenic adenoma--a study with special reference to clinical presentation

OBJECTIVE

To obtain information on the presenting symptoms, location, sex distribution, age, endoscopic appearance, histopathology, suitable treatment and recurrence of nephrogenic adenoma, a rare, benign lesion of the urinary tract mucosa.

PATIENTS AND METHODS

The records of 31 patients with nephrogenic adenoma diagnosed at the Sahlgrenska University Hospital between 1980 and 1996 were reviewed to determine the symptomatology, imaging investigations, endoscopic presentation, clinical outcome after resection and the frequency of recurrence.

RESULTS

The lesions were found in the urinary bladder, bulbar urethra, urethral diverticula and the prostatic urethra. Eight patients presented with haematuria, 13 complained of urinary frequency and bladder pain and in 12 patients without subjective symptoms from the urinary tract, the lesion was found accidentally. Twenty-seven of the patients had a history of previous urothelial trauma, either by instrumentation or inflammation. Seventeen of the lesions were polypoid at endoscopy, the remainder being flat except for two cases, in which they were not noted because they were concealed in another lesion to be resected. Seven patients had one or more recurrences. All patients with symptoms responded well to transurethral resection.

CONCLUSION

Nephrogenic adenoma mimics tumour or chronic cystitis and it is rarely suspected on clinical grounds; instead, the diagnosis is almost always histological. This study supports the view that nephrogenic adenoma may represent a metaplastic response to trauma of the urothelium and that transurethral resection provides a good method of relieving the symptoms in symptomatic nephrogenic adenoma.

The urological fate of young adults with myelomeningocele: a three decade follow-up study

OBJECTIVE

Virtually all patients with myelomeningocele suffer from neurogenic disorder of the bladder. Problems with incontinence are common and there is also a risk of deterioration of renal function. The aim of the present study was to determine the long-term urological fate of this patient group.

PATIENTS AND METHODS

Twelve young adults with myelomeningocele were interviewed and their records reviewed.

RESULTS

The patients started clean intermittent catheterization (CIC) at the age of 10-21 years. Three patients underwent urological surgery prior to the start of CIC. This was also the case for 3 patients after having started CIC. Only 1 patient is completely continent. In the rest, the degree of incontinence varies. With few exceptions, the glomerular filtration rate was well preserved. Six of the incontinent patients had, on at least one occasion, denied incontinence to his doctor.

CONCLUSION

It seems that the prognosis is good as far as renal function is concerned. However, continence is a prerequisite for good social adjustment. An obstacle for a rational treatment of incontinence, in the adolescent patient group, is the patient's strong tendency to underreport the actual incontinence situation. Thus, every effort must be made in order to obtain a correct history. In patients with validated incontinence, an aggressive treatment policy, including surgical intervention, is justified.

Does transurethral resection of a clinically benign prostate gland increase the risk of developing clinical prostate cancer? A 10-year follow-up study

BACKGROUND

Theoretical considerations have raised the suspicion that transurethral resection of the prostate (TURP) may increase the risk of developing prostate cancer in clinically benign prostate glands. Previous studies have not shown an increased risk among men who had undergone TURP for benign prostatic hyperplasia compared with the risk in age-matched control subjects. However, in all of these studies, all men with stage T1 prostate cancer in the TURP-group were excluded, possibly creating a bias, because no similar exclusion could be made for the controls.

METHODS

The incidence and mortality of clinical prostate cancer were studied in 198 patients who had TURP and in 203 age-matched male control subjects. In both groups, all patients with known prostate cancer and patients with suspected cancer by digital rectal examination were excluded from the study. However, patients with stage T1 cancer found by the TURP were included in the comparison between the groups.

RESULTS

The mean age in the two groups was 67 +/- 6 years. The patients were followed for an average of 10.2 +/- 1.2 years and 10.4 +/- 1.8 years in the TURP group and the control group, respectively. Clinical prostate cancer developed in six patients who had TURP and subsequently in five control (odds ratio, 0.8 [0.2-3.1]; P < 0.97). Before follow-up, three men in each group died because of prostate cancer (odds ratio, 1.3 (0.24-7.45); P < 0.97).

CONCLUSIONS

The results of this study suggest that neither benign prostatic hyperplasia nor TURP increased the risk of developing clinical prostate cancer over the next 10 years in patients with a benign prostate gland determined by rectal examination before TURP.