Genitourinary Patients Research Articles

Access to dental care for HIV patients: does it matter and does discrimination exist?

A number of surveys highlight a shortage of dentists in the UK. There is also evidence of discrimination against those with HIV reported within the dental profession and service users. We decided to assess the extent of this problem in our HIV outpatients by conducting a cross-sectional survey, asking them to complete a questionnaire exploring issues related to dental care access, and using clients attending the routine genitourinary (GU) medicine outpatient clinic as controls. A total of 241 outpatients completed the survey, of whom 51 (21%) were HIV patients. Significantly, more HIV patients reported difficulty registering with a dentist than GU patients (58.8% versus 18.2%, chi(2) with Yates correction = 8.76, P = 0.0031). They also report significantly more dental health problems compared with controls (54.9% versus 32.1%, chi(2) with Yates correction = 8.02, P = 0.0046). In total, 34.6% of HIV patients who had declared their status to a dentist thought that it had negatively impacted on their care, with 6.2% being refused treatment. Our small survey confirms that discrimination in relation to access and level of dental care exists, with black African women being at most risk. Efforts are needed to raise professional standards and HIV awareness to prevent continuing inequalities in dental care provision.

Is it time for the virtual chaperone in genitourinary medicine clinics?

The General Medical Council recommends that chaperones must be offered during intimate examinations. Implementation of these guidelines may serve to protect both patients and staff within the genitourinary (GU) medicine clinic, but is likely to have major ramifications from a practical, financial and staffing perspective. The Virtual Chaperone (VC) is an objective device making audio and visual recordings of patients' consultations and examinations. Information cannot be manipulated and is encrypted for security. It would not replace the human chaperone. This study investigated the attitudes of GU medicine staff and patients to the VC in an inner city sexual health clinic. Voluntary, anonymized questionnaires were distributed to all members of the multidisciplinary team and 200 patients. The patient response rate was 90% (n = 180). Only 40% of respondents felt the VC was acceptable in GU medicine clinics. Two-thirds felt unsure or were against the VC recording during consultations, and fewer wished the examination to be recorded. Most opted to switch off the video entirely. Almost 50% of respondents felt that the VC was designed to protect staff, whereas only 41% thought it would protect patients. The staff response rate was 69% (n = 35). Almost three-quarters of respondents were unsure or felt the device was unacceptable. Less than half would feel comfortable with the VC recording during consults. Overall, three-quarters of respondents were either unsure or did not support the introduction of the VC. There was a clear feeling (>80%) that the VC would protect staff and patients, 71% indicating that the trust would also benefit. Despite its success in other outpatient specialties, GU medicine staff and patients do not favour the introduction of the VC.

Recent advances in pediatric uroradiology

Pediatric Urology is a surgical subspecialty that is very dependent upon radiographic imaging as the majority of the genitourinary (GU) tract is internally located. Technological advances in various imaging modalities (e.g. ultrasonography, nuclear medicine, CT and MRI) have aided in our ability to visualize and evaluate the functionality of the GU tract, enabling the diagnosis of various disease processes that affect the genitourinary system. Collectively the advances in uro-radiology have improved our understanding of the natural history of many conditions that involve the GU tract. As a result of these newer imaging modalities, some of the more traditional techniques have assumed a limited role in the diagnostic evaluation of the pediatric GU patient (e.g. intravenous urography).The purpose of this article is to review the advances in radiographic imaging, in particular the cross-sectional imaging modalities and discuss their utility (appropriate indications and application) in Pediatric Urology, so that the reader can maximize the diagnostic yield of these studies. For a thorough review of any of the imaging modalities discussed in this article and their utility in the practice of pediatric urology, I would direct the readers to articles in the radiological literature that are specific to that technology. Besides the obvious technological advances in imaging modalities, this review also discusses the attention to radiation safety for the pediatric patient that every physician who orders a diagnostic imaging study in a child should be aware of.

105: A Comprehensive Toxicity Analysis of 1232 Prostate Cancer Patients Treated With Pelvic External Beam Radiotherapy (EBRT) With High Dose Rate (HDR) Brachytherapy Boost, Adaptive EBRT (ART), or Brachytherapy Alone (BT)

We analyzed the acute and chronic genitourinary (GU) and gastrointestinal (GI) toxicity of prostate cancer patients treated with 3 different high-dose RT techniques at a single institution. From 1992-2003, 1232 patients with clinically localized prostate cancer were treated with ART (n=512), EBRT+HDR (n=421), or BT alone (n=299, 204 Pd103 implants, 95 HDR alone). Median delivered dose with ART was 75.6 Gy (minimal peripheral dose) to the prostate gland +/- seminal vesicles. For EBRT+HDR, the whole pelvis was treated to 46 Gy + a median of 9.5 Gy via 2 HDR prostate implants. The dose delivered with Pd103 was 120 Gy and with HDR, 38 Gy in 4 fractions and a single implant. Neoadjuvant androgen deprivation was used in 52% for EBRT+HDR, 37% for BT, and 32% for ART. NCI-CTC version 2 was used for toxicity scoring. Median age was 73, 68 and 66 years for ART, EBRT+HDR and BT patients (p<0.01). Median follow-up was 4.6 years (EBRT+HDR and BT) and 3.4 for ART with 31% of patients having a follow-up over 5 years. Grade ≥ 2 acute GU toxicity was greater for EBRT+HDR (52%) vs. BT (39%) vs. ART (40%, p<0.01) mainly due to more dysuria (26% vs 11% vs 2%, respectively). Grade ≥ 2 acute GI toxicity was greater for patients receiving EBRT (34% for EBRT+HDR and 28% for ART vs 4% for BT, p<0.01) primarily due to more diarrhea and tenesmus. Grade ≥ 2 chronic GU toxicity was greater in brachytherapy patients (29% for EBRT+HDR and 24% for BT vs 17% for ART, p<0.01) mainly due to more urinary retention (12% for EBRT+HDR and 10% for BT vs 3% for ART, p<0.01). Grade ≥ 2 chronic GI toxicity was higher for ART (19%) vs EBRT+HDR (10%) and BT (only 1%, p<0.01), mainly due to more rectal bleeding with EBRT (13% for ART vs 7% for EBRT+HDR vs 1% for BT, p<0.01). Grade ≥ 3 acute GU toxicity was higher with the use of brachytherapy (see table). Grade ≥ 3 chronic GU toxicity was also greater with brachytherapy primarily due to a higher rate of urethral dilatations in these patients (10% for EBRT+HDR). Grade ≥ 3 chronic GI toxicity was higher for ART due to more rectal bleeding.Tabled 1Toxicity gr≥3ARTBT AloneEBRT + HDRp-Valueany acute gr≥3 GU2%10%7%<0.01any acute gr≥3 GI0.3%0.3%2%<0.01Any Acute gr≥3 Toxicity3%10%10%<0.01Chronic gr≥3 GUretention2%3%5%0.02urethral dilatation1%3%10%<0.01any gr≥3 GU3%6%11%<0.01Chronic gr≥3 GIrectal bleeding3%0.4%0.3%<0.01any gr≥3 GI4%0.4%1%0.01Any Chronic Toxicity gr≥37%7%12%0.03 Open table in a new tab In hormone-naïve patients and no pre-RT erectile dysfunction (ED), EBRT+HDR had higher rate of ED (57%) than ART (38%) and BT (22%, p<0.01). Chronic grade ≥ 3 toxicity rates were low for all treatment modalities. Brachytherapy patients experienced more GU toxicity (more urethral strictures with EBRT+HDR) and patients receiving EBRT had more GI toxicity with a higher rate of rectal bleeding with ART. Patients treated with BT alone had the best GI toxicity profile and the lowest rate of ED compared with ART and EBRT+HDR.

URINARY HYALURONIC ACID AND HYALURONIDASE: MARKERS FOR BLADDER CANCER DETECTION AND EVALUATION OF GRADE

Specific patterns of progression and frequent recurrence of bladder tumors determine the choice of treatment, frequency of surveillance, quality of life, and ultimately, patient prognosis. The prognosis would be improved if an accurate noninvasive test was available for diagnosis. Identification of markers that function in bladder cancer progression would be helpful in designing such diagnostic tests. The glycosaminoglycan, hyaluronic acid (HA), promotes tumor metastasis. Hyaluronidase (HAase), an endoglycosidase, degrades HA into small fragments that promote angiogenesis. We have previously shown that both HA and HAase are associated with bladder cancer and may function in bladder tumor angiogenesis. In this study we examined whether urinary HA and HAase levels serve as bladder cancer markers. Among the 513 urine specimens analyzed, 261 were from transitional cell carcinoma (TCC) patients, 9 from patients with non-TCC tumors, and 243 from controls (normals, patients with other genitourinary (GU) conditions or a history of bladder cancer (HxBCa)). The urinary HA and HAase levels were measured by two ELISA-like assays that utilize a biotinylated HA binding protein for detection. These levels were normalized to total urinary protein and were expressed as ng./mg. (HA test) and mU/mg. (HAase test), respectively. The urinary HA levels were elevated (2.5 to 6.5 fold) in bladder cancer patients (1173.7+/-173.4; n = 261) as compared with normals (246.1+/-38.5; n = 41); GU patients (306.6+/-32.2; n = 133), and patients with a HxBCa (351.1+/-49.1; n = 69) (p <0.001). The urinary HAase levels were elevated (3 to 7 fold) in G2/G3 bladder cancer patients (26.2+/-3.2) as compared with normals (4.5+/-0.9) and patients with either GU conditions (5.8+/-1.3), HxBCa (8.2+/-2.6) or G1 tumors (9.7+/-2.5) (p <0.001). The HA test showed 83.1% sensitivity, 90.1% specificity and 86.5% accuracy in detecting bladder cancer, regardless of the tumor grade. The HAase test showed 81.5% sensitivity, 83.8% specificity and 82.9% accuracy to detect G2/G3 patients. Combining the inferences of the HA and HAase tests (HA-HAase test) resulted in detection of bladder cancer, regardless of tumor grade and stage, with higher sensitivity (91.2%) and accuracy (88.3%), and comparable specificity (84.4%). Our results show that the HA-HAase urine test is a noninvasive, highly sensitive and specific method for detecting bladder cancer and evaluating its grade.

Current Issues in the Management of Genital Herpes

Genital infection by herpes simplex virus (HSV) produces a variety of clinical manifestations, patient presentations and management problems which differ in their severity and complexity. In the UK the currently available data for the incidence of genital HSV have been provided predominantly by the KC60 returns from diagnoses made in genitourinary (GU) medicine clinics. The increasing availability and recent publication of the first results, using HSV type-specific antibody tests within GU and non-GU patient populations, provide a tool to monitor trends in the epidemiology of HSV. It is, however, important to understand that the sexual behaviour which leads to this infection is variable and not necessarily general. The clinical availability of type-specific HSV antibody tests also gives rise to the possibility of screening individuals and informing those who test positive of their, previously undiagnosed, condition. The practicalities and problems of this approach need to be fully assessed. The possibility of uncovering previously undiagnosed cases through general practitioners is being considered, first, in terms of surveys of the general practitioners' management of genital HSV and, secondly, because the funding of health care in the UK has put the cost-effectiveness in GU medicine clinics under the spotlight. This paper will explore the new developments in the management of genital HSV and suggests adherence to the clear principles of diagnosis and treatment that is in the patient's best interest. This has the clear aim of improving the patient's quality of life, a factor which must remain paramount as new technologies, healthcare strategies and therapies become available.