Cecoureterocele Presenting as a Urethral Mass in an Infant Female: A Rare Case Report

PREVALENCE AND BOTHERSOMENESS OF LOWER URINARY TRACT SYMPTOMS IN BENIGN PROSTATIC HYPERPLASIA AND THEIR IMPACT ON WELL-BEING

To assess the significance and current status of the benign prostatic hyperplasia (BPH) impact index (BII) in the evaluation of subjective symptoms of impaired urination in so-called QOL disease, BPH. Over the past 2 year-period, in 159 patients with the diagnosis of BPH were asked to reply to each of the international prostate symptom score (I-PSS), QOL index and BII questionnaires. The subjective symptom scores (a total of 246 points) were evaluated from the viewpoint of clinical statistics in the search for any these and to find which questions cover the BII, most. 1) Statistically significant but moderate correlations were observed among I-PSS total score, QOL index and BII. The correlations among Qmax, BII and QOL were very weak. 2) Out of the 11 domains in both IPSS and BII, 2 questions of BII ("bothersomeness caused by urinary problems" and "degree of worry about well-being") and 4 questions of IPSS ("residual sense," " pollakisuria," "weak urinary stream" and "nocturia") were shared as QOL indices. Patient satisfaction was affected also by the questions in the BII. 3) Of the 7 BPH symptoms assessed in IPSS, 4 symptoms ("residual sense," "pollakisuria," "weak urinary stream" and "nocturia") affected the QOL index, and 4 symptoms ("urgency on micturition," "residual sense," "nocturia" and "strain at urination") affected BII. 4) Of the 7 symptoms assessed by IPSS, different symptoms affected each of the 4 BII questions. It is needed to assess BPH symptoms not only by the IPSS and QOL index but also based on BII to provide the detailed therapeutic instructions and thorough patients consultation.

Inguinal bladder herniation is a rare condition and is frequently underdiagnosed because of its nonspecific presentation. We report the case of a 68-year-old man who presented with progressively worsening lower urinary tract symptoms, including frequency, nocturia, weak urinary stream, elevated post-void residual volume, and a slowly enlarging right inguinoscrotal swelling. The coexistence of severe voiding symptoms and obstructive urinary parameters initially suggested benign prostatic obstruction. However, the presence of two-stage micturition requiring manual compression of the scrotal mass to complete bladder emptying (Mery's sign) raised suspicion of bladder involvement. Contrast-enhanced computed tomography with delayed excretory-phase acquisition revealed a giant right inguinoscrotal bladder hernia with marked distortion of the bladder contour, while three-dimensional reconstruction provided precise anatomical characterization and facilitated surgical planning. The patient underwent successful surgical repair with complete resolution of urinary symptoms. This case highlights the diagnostic challenge posed by giant inguinoscrotal bladder hernias, particularly when they mimic common causes of bladder outlet obstruction, and emphasizes the importance of recognizing Mery's sign and performing preoperative cross-sectional imaging to establish the diagnosis, prevent iatrogenic bladder injury, and optimize surgical management.

(191) COMPLEX FEMALE URETHRAL DIVERTICULUM WITH STAGED URETHRALRECONSTRUCTION

Introduction: Cowper’s glands, also known as bulbourethral glands, were first described by French surgeon Jean Mery in 1684 and later detailed by William Cowper in 1699. Cowper’s duct syringocele, a rare condition involving cystic dilatation of Cowper’s gland, can mimic symptoms of prostatic obstruction, posing diagnostic challenges. Common presentations include lower urinary tract symptoms (LUTS) such as urgency, weak stream, and incomplete emptying, often leading to misdiagnosis as benign prostatic hyperplasia (BPH). Accurate diagnosis involves imaging studies like transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI), along with retrograde urethrography and cystourethroscopy. Management varies from conservative measures to surgical intervention, depending on symptom severity. Case Presentation: A 36-year-old male presented with urinary obstruction symptoms, reporting a poor stream and straining to urinate over three months, with exacerbation characterized by incomplete voiding. No hematuria, UTIs, or urolithiasis history was noted. Examination was largely unremarkable, except for a flat prostate on per rectal examination. Uroflowmetry indicated a maximum flow rate (Qmax) of 15 ml/sec with an interrupted pattern. MRI revealed a cystic lesion in the posterior urethra, raising suspicion for Cowper’s duct syringocele. Diagnostic cystoscopy confirmed the cystic dilatation, which was deroofed using monopolar energy. The patient’s recovery was uneventful, with follow-up uroflowmetry showing significant improvement, with a Qmax of 27 ml/sec. Discussion: This case underscores the importance of considering Cowper’s duct syringocele in the differential diagnosis of LUTS, especially in patients with atypical presentations. The diagnostic approach included uroflowmetry, MRI, and cystoscopy, which confirmed the cystic lesion. Management involved transurethral deroofing, leading to symptom resolution and improved urinary flow. Early recognition and intervention are crucial for favorable outcomes. Literature highlights the role of imaging and endoscopic techniques in diagnosing and managing this rare condition, emphasizing the need for interdisciplinary collaboration in complex urological cases. Conclusion: This case emphasizes the need for considering Cowper’s duct syringocele in patients with LUTS to avoid misdiagnosis and inappropriate management. Accurate diagnosis through a combination of uroflowmetry, imaging, and cystoscopy, followed by appropriate surgical intervention, can significantly improve patient outcomes. The case underscores the efficacy of endoscopic techniques and the importance of interdisciplinary collaboration in optimizing care for patients with rare urological conditions.

ImportanceUp to 40% of men older than 50 years have lower urinary tract symptoms, including urinary urgency, nocturia, and weak urinary stream, due to disorders of the bladder and prostate. These symptoms negatively affect quality of life and may be associated with urinary retention, which can cause kidney insufficiency, bladder calculi, hematuria, and urinary tract infections.ObservationsIn men, lower urinary tract symptoms can be caused by bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), an overactive bladder detrusor (a syndrome of urinary urgency and frequency), or both. Behavioral therapy, including pelvic floor physical therapy, timed voiding (voiding at specific intervals), and fluid restriction, can improve symptoms. Medications including α-blockers (such as tamsulosin), 5α-reductase inhibitors (such as finasteride), and phosphodiesterase 5 inhibitors (such as tadalafil) improve lower urinary tract symptoms (mean improvement, 3-10 points on the International Prostate Symptom Score [IPSS], which ranges from 0-35, with higher scores indicating greater severity) and can prevent symptom worsening measured by increased IPSS greater than or equal to 4 points or development of secondary sequelae, such as urinary retention. Combination therapies are more effective than monotherapy. For example, α-blockade (eg, tamsulosin) combined with 5α-reductase inhibition (eg, finasteride) lowers progression risk to less than 10% compared with 10% to 15% with monotherapy. Treatment for overactive bladder detrusor muscle, including anticholinergics (eg, trospium) and β3 agonists (eg, mirabegron), reduces voiding frequency by 2 to 4 times per day and reduces episodes of urinary incontinence by 10 to 20 times per week. Surgery (eg, transurethral resection of the prostate, holmium laser enucleation of the prostate) and minimally invasive surgery are highly effective for refractory or complicated cases of BPH, defined as persistent symptoms despite behavioral and pharmacologic therapy, and these therapies can improve IPSS by 10 to 15 points. Minimally invasive procedures, such as water vapor therapy (endoscopic injection of steam into BPH tissue) and prostatic urethral lift (endoscopic insertion of nonabsorbable suture implants that mechanically open the urethra), have lower complication rates of incontinence (0%-8%), erectile dysfunction (0%-3%), and retrograde ejaculation (0%-3%) but are associated with increased need for surgical retreatment (3.4%-21%) compared with transurethral resection of the prostate (5%) and holmium laser enucleation of the prostate (3.3%).Conclusions and RelevanceLower urinary tract symptoms, defined as urinary urgency, nocturia, or weak stream, are common among men and are usually caused by BPH, overactive bladder detrusor, or both. First-line therapy consists of behavioral interventions, such as pelvic floor physical therapy and timed voiding, as well as pharmacologic therapy, including α-adrenergic blockers (tamsulosin), 5α-reductase inhibitors (finasteride), phosphodiesterase inhibitors (tadalafil), anticholinergics (trospium), and β3 agonists (mirabegron).

1960 LOWER URINARY TRACT DYSFUNCTION AMONG ADULT WOMEN WITH DIABETIC MELLITUS

Unsuccessful Outcomes After Posterior Urethroplasty: Definition, Diagnosis, and Treatment

To measure the prevalence of pelvic floor symptoms in noncare-seeking older women and the association between symptoms and lifestyle factors. Women enrolled at one site of the Women's Health Initiative Hormone Therapy clinical trial completed a questionnaire, modified from the Pelvic Floor Distress Inventory, on bladder, bowel, and prolapse symptoms. Individual symptoms and symptom groups were examined in a cross-sectional analysis. In the 297 women who participated, mean age was 68.2 years, mean body mass index (BMI) was 30.2 kg/m(2), and median vaginal parity was 3. The median number of symptoms endorsed was 3 (range 0-18). The most prevalent symptoms were stress urinary incontinence (51.2%), urge urinary incontinence (49.2%), urinary frequency (29.0%), straining for bowel movements (25.0%), a sense of incomplete bowel movements (34.8%), and involuntary loss of gas (33.0%). The symptom groups most frequently endorsed were stress urinary incontinence, overactive bladder, obstructive voiding, and obstructive colorectal groups (>/=1 symptom per group in 51.2%, 61.3%, 40.8%, and 48.3%, respectively). In analyses adjusted for age, BMI, caffeine ingesting, smoking, and exercise, older women more frequently reported incomplete bladder emptying (adjusted OR 3.4, 95% CI 1.3, 9.2), weak urinary stream (adjusted OR 6.4, 95% CI 2.0, 20.0), intermittent urinary stream (adjusted OR 4.0, 95% CI 1.6, 10.4), and a feeling of incomplete bowel movements (adjusted OR 2.7, 95% CI 1.2, 5.9). Women who exercised weekly had less fecal urgency (adjusted OR 0.3, 95% CI 0.2, 0.8). Coffee drinking was associated with difficulty emptying the bladder (adjusted OR 8.6, 95% CI 1.4, 55.0) and weak stream (adjusted OR 5.3, 95% CI 1.5, 19.0). Pelvic floor symptoms, especially urinary incontinence and irritative and obstructive urinary and bowel symptoms, are common in older women. Some symptoms are associated with potentially modifiable lifestyle factors.

BackgroundObstructive voiding symptoms (OVS) are common following prostate cancer treatment with radiation therapy. The risk of urinary retention (UR) following hypofractionated radiotherapy has yet to be fully elucidated. This study sought to evaluate OVS and UR requiring catheterization following SBRT for prostate cancer.MethodsPatients treated with SBRT for localized prostate cancer from February 2008 to July 2011 at Georgetown University were included in this study. Treatment was delivered using the CyberKnife® with doses of 35 Gy-36.25 Gy in 5 fractions. UR was prospectively scored using the CTCAE v.3. Patient-reported OVS were assessed using the IPSS-obstructive subdomain at baseline and at 1, 3, 6, 9, 12, 18 and 24 months. Associated bother was evaluated via the EPIC-26.Results269 patients at a median age of 69 years received SBRT with a median follow-up of 3 years. The mean prostate volume was 39 cc. Prior to treatment, 50.6% of patients reported moderate to severe lower urinary track symptoms per the IPSS and 6.7% felt that weak urine stream and/or incomplete emptying were a moderate to big problem. The 2-year actuarial incidence rates of acute and late UR ≥ grade 2 were 39.5% and 41.4%. Alpha-antagonist utilization rose at one month (58%) and 18 months (48%) post-treatment. However, Grade 3 UR was low with only 4 men (1.5%) requiring catheterization and/or TURP. A mean baseline IPSS-obstructive score of 3.6 significantly increased to 5.0 at 1 month (p < 0.0001); however, it returned to baseline in 92.6% within a median time of 3 months. Late increases in OVS were common, but transient. Only 7.1% of patients felt that weak urine stream and/or incomplete emptying was a moderate to big problem at two years post-SBRT (p = 0.6854).ConclusionsSBRT treatment caused an acute increase in OVS which peaked within the first month post-treatment, though acute UR requiring catheterization was rare. OVS returned to baseline in > 90% of patients within a median time of three months. Transient Late increases in OVS were common. However, less than 10% of patients felt that OVS were a moderate to big problem at two years post-SBRT.

The current case history is a good example of the challenge that the critically ill infant may represent. Information regarding weak urine stream must trigger further diagnostic imaging. Ultrasound examination of the urinary tract will be able to indicate hydronephrosis and thickening of the bladder wall, if posterior urethral valves are present. However, ultrasound is a method which is dependent on the experience and skill of the person conducting the examination, and an indication of possible hydronephrosis requires that the patient be adequately hydrated. The diagnosis itself must be verified using voiding cystourethrogram (MCUG), one reason being that both a neurogenic and nonneurogenic bladder may give the same ultrasound findings (4). The infant’s poor weight gain and general failure to thrive alone imply a need for thorough investigation. This symptom complex may be caused by an upper urinary tract infection, even though the young infant has no fever. The importance of urinalysis in all infants with unclear symptoms or findings cannot be stressed enough. This applies not only where a bacterial urinary tract infection is suspected, but also in conditions which directly or indirectly afflict the renal tubules and/or renal interstitium. Knowledge not only about electrolytes, but also pH, amino acids (metabolic screening) and glucose can be crucial for further diagnosis. To sum up, the case report underlines that information on weak urine stream must be acted upon using imaging, that general failure to thrive must always be investigated and that urinalysis is of great importance when conditions in infants are unclear.

This study was done to identify frequency, intensity of urinary dysfunction and daily life distress in women after a radical hysterectomy for cervical cancer. One hundred and fifty seven women who had undergone a radical hysterectomy and one hundred and sixty five women as healthy controls completed questionnaires on intensity of urinary dysfunction and daily life distress caused by urinary dysfunction. Women with cervical cancer showed higher frequency of urinary dysfunction than healthy controls. Major urinary dysfunction for women with cervical cancer in order of frequency were night-time incontinence (odds ratio=10.39, p<.001), difficulty in starting urination, weak urine stream and sense of incomplete emptying of bladder. The highest score on intensity was difficulty in starting urination, followed by urgency, weak urine stream, daytime frequency and sense of incomplete emptying. Night-time incontinence was the urinary symptom causing the most daily life distress for cervical cancer women followed by difficulty in starting urination, urgency, sense of incomplete emptying, and night-time frequency. Results suggest that nurses should address the potential postoperative urinary complications and develop long term interventions to decrease urinary dysfunction and daily life distress for women who have had a radical hysterectomy for cervical cancer.

Postmenopausal labial adhesion: A 5-stage classification system and clinical outcomes in a 14-patient series.

Rationale:Herpes zoster (HZ) involving sacral dermatome is very rare, which can sometimes cause voiding dysfunction.Patient concerns:A 52-year-old man presented with acute pain and voiding dysfunction, following HZ in his right sacral dermatomes.Diagnoses:Twenty two days before presentation HZ occurred and 9 days after the onset of the HZ, he had trouble with starting urination and weak urine stream which was managed with tamsulosin 0.4 mg orally once a day and intermittent urinary catheterization. He was treated with 150 mg of pregabalin 2 times a day, tramadol 50 mg 2 times, and acetaminophen 600 mg 2 times a day. However, his pain intensity was 5 on the numerical analogue scale (NRS) from 0 (no pain) to 10 (worst pain imaginable).Interventions:Fluoroscopy guided caudal block was performed with a mixture of 0.5% lidocaine 10 mL and triamcinolone 40 mg.Outcomes:One day after the procedure, the pain decreased to 1 on the NRS score. In addition, voiding difficulty greatly improved. Three days after the intervention, the patient reported complete resolution of pain and voiding dysfunction. He currently remains symptom free at a 3-month follow-up.Lessons:A caudal block with steroid can be an effective option for treatment of acute voiding dysfunction and pain following sacral HZ.

SCROTAL HERNIATION OF THE BLADDER SECONDARY TO PROSTATE ENLARGEMENT