Urological Investigation Research Articles

Increased Prevalence of Renal and Urinary Tract Anomalies in Children with Congenital Hypothyroidism

We investigated the prevalence of congenital renal and urologic anomalies in children with congenital hypothyroidism to determine whether further renal and urologic investigations would be of benefit. Prevalence of congenital hypothyroidism was obtained from the New York State Congenital Malformation Registry. The occurrence of urinary tract anomalies were calculated for children with congenital hypothyroidism and compared to children without congenital hypothyroidism. In addition we obtained congenital hypothyroidism data from New York State newborn screening, and the cases were matched to Congenital Malformation Registry. Analysis of Congenital Malformation Registry data showed 980 children with congenital hypothyroidism and 3 661 585 children without congenital hypothyroidism born in New York State (1992-2005). Children with congenital hypothyroidism have a significantly increased risk of congenital renal and urological anomalies with the odds ratio (OR) of 13.2 (10.6-16.5). The other significantly increased defects in congenital hypothyroidism were cardiac, gastrointestinal, and skeletal. Analysis of matched data confirmed an increase of congenital renal and urologic anomalies with OR of 4.8 (3.7-6.3). Children with congenital hypothyroidism have an increased prevalence of congenital renal and urologic anomalies. We suggest that these children should be evaluated for the presence of congenital renal and urologic anomalies with renal ultrasonography, and that further studies of common genes involved in thyroid and kidney development are warranted.

Patients' Acceptance of Repeated Invasive Urological Investigations

Patients' Acceptance of Repeated Invasive Urological Investigations

Enquête de la pratique de l’autosondage intermittent propre auprès des médecins généralistes

Introduction Clean intermittent self-catheterization is the recommended mode of bladder voiding in patients with urinary retention. Hence, this procedure should be well known and understood by the general practitioners (GP) who are responsible for monitoring such patients. Objective To assess GP’ state of knowledge regarding clean intermittent self-catheterization and to make recommendations for dealing with problems that occur during patient follow-up. Method A questionnaire focusing on the practice of clean intermittent catheterization was sent to 910 family GP in the Franche-Comté region of eastern France. Results Two hundred and fourty-six replies were analyzed. Sixty-four percent of GP believed that the appropriate number of bladder catheterizations per day was between two and four. Ninety percent of the GP prescribed perineal cleaning before catheterization and 29% prescribed the use of sterile gloves. Eighty-seven percent of general practitioners considered urinary tract infection to be the main complication of intermittent catheterization. Thirty percent always requested a urine culture in patients performing self-catheterization and 29% prescribed antibiotic therapy in cases of bladder colonization. Discussion General practitioners need to receive additional information on the role of clean intermittent catheterization in the prevention of urinary tract infection. In accordance with the French Urology Association guidelines, we produced a practical summary guide on preventing asymptomatic bacteriuria and urinary tract infections and/or preparing for urological investigations.

Important Military Role for Medical Expulsion Therapy of Urolithiasis

Kidney stones are a major problem affecting military personnel and may lead to decreases in individual and unit readiness. Various medications, including steroids, calcium channel blockers, and alpha-adrenergic antagonists have been shown to aid in the spontaneous passage of ureteral calculi. Several recent randomized clinical trials have shown that selective alpha blockers improve stone passage rates. Although medical expulsion therapy has been the subject of a number of urologic investigations, to date there has been very little written about the acute medical management of urinary stones in the emergency medicine and primary care literature. Medical management of ureteral stones may offer forward-deployed forces a useful adjunct for the management of ureterolithiasis thereby greatly reducing the need for potentially hazardous evacuations out of theater.

Asymptomatic haematuria (author's transl)

Mesangioproliferative glomerulonephritis of varying severity was found by renal biopsy in 86.2% among 130 patients with asymptomatic haematuria. 3.2% had benign nephrosclerosis, 3.2% had benign nephrosclerosis, 1.6% had interstitial nephritis and one patient showed a previously undiagnosed perimembranous glomerulonephritis. Normal renal parenchyma was observed in only 6.9% of cases. Iummunohistological findings were positive in 25.7% of investigated cases. The majority were IgA deposits combined with IgG and C3 complement. The intensity of haematuria is not correlated with the type and severity of histological changes. "Physiological" haematuria (erythrocytes less than 7/ml) which is usually considered normal must be re-evaluated as a consequence of these histological findings. After exclusion of urological or extrarenal disease only histological investigation of the kidneys will bring the final diagnosis. Repeated radiographical or urological investigations can thus be avoided. The risks of percutaneous renal biopsy under fluoroscopic or sonographic control are decidedly less than the information gained from histological evaluation. The different histological findings indicate that isolated haematuria should be considered only as a symptom and not as a uniform disease indicating focal nephritis.

Vesico-sphincter dysfunctions in Pure Cerebellar Syndrome (PCS): a possible basis for the study of anatomo-functional correlations

The neurological polymorphism of Pure Cerebellar Syndromes (not including the heredodegenerative patterns) led the Authors to try to verify the possible correlations between neurological damages and urodynamic findings. Material and Methods. From 2001 to 2006 thirty patients affected by PCS were studied. They underwent several neurological and urological investigations, including videourodynamics. Results. Sixteen cases (76%) showed urinary incontinence due to non-inhibited detrusor contractions, with no evidence of vesico-sphincter dyssynergia; the remaining patients showed a moderate degree of incoordination. Conclusions. The authors highlight the basic role of cerebellum in modulating the motor activities and the coordination of the bladder-sphincter structures, also in the light of the outcomes gathered in these patients, who were not suffering from other superior structure deficiencies.

Diagnosis of Urologic Malignancies in Patients with Asymptomatic Dipstick Hematuria: Prospective Study with 13 Years’ Follow-up

To appraise the outcomes, determine the natural history, and instigate a rationale plan for follow-up of patients with asymptomatic dipstick hematuria. A total of 292 consecutive patients with asymptomatic dipstick hematuria referred between January 1992 and December 1994 were investigated and prospectively followed up. The initial investigations included urinalysis, urine culture and sensitivity, cytology, intravenous urography, with or without ultrasonography, and cystoscopy. Baseline data and follow-up events, particularly the development of urologic malignancy, were recorded for a 13-year period. Sixteen patients (5.4%) were found to have urologic malignancies on initial evaluation. Of these, 11 died. During a follow-up of 13 years, 21 patients (7%) were lost to follow-up and 42 died of various unrelated causes (other than urologic malignancies). Of the remaining 213 patients, 180 (84.5%) subsequently had negative urinalysis. None with negative urinalysis developed a urologic malignancy during follow-up. The presence of dipstick hematuria persisted in 33 patients. Of these 33 patients, 10 had nephrologic causes, 8 had urinary tract infection, and 15 underwent repeat investigation with no pathologic cause identified. One patient, discharged with negative findings after full initial investigations, presented 2 years later with frank hematuria and was found to have a new bladder tumor. Patients presenting with asymptomatic dipstick hematuria who have undergone thorough initial negative investigations can be discharged from tertiary urologic care services. Nephrologic referral is recommended if dipstick hematuria and proteinuria persist. The repetition of the urologic investigations is unwarranted, unless patients present with symptoms or develop frank hematuria.

Spontaneous variation of leukocytospermia in asymptomatic infertile males

To investigate the spontaneous variation of leukocytospermia (>1 million/mL) in semen samples from infertile men. Prospective cohort study. Andrologic clinic at university hospital. Ninety-nine men evaluating for infertility causes. Two semen analyses according the World Health Organization criteria combined with urologic investigation without any treatment. Spontaneous (downward/upward) variation in leukocyte count, sperm concentration, total motility, and morphology between the two semen samples. In the first semen analysis, 21% of men had leukocytospermia. By the second analysis, leukocyte concentrations were within the normal range in 9 of these 21 men, corresponding to a downward variation of 43%. In contrast, 7 of 78 patients with normal leukocyte levels at the first analysis had leukocytospermia at the second analysis, corresponding to an upward variation of 9%. The upward variation rates for sperm concentration, total motility, and morphology were 4%, 17%, and 4%, respectively. Downward variation rates were considerably higher for total motility and morphology (30% and 28%, respectively). The rate for spontaneous downward variation of leukocytospermia in the absence of treatment was 43% in this study. This rate should be taken into consideration when treating infertile men with leukocytospermia, because effective medical therapy is still lacking.

Comparison of the long‐term effects of simple total abdominal hysterectomy with transcervical endometrial resection on urinary incontinence

To test the hypothesis that the hospital referral rate for urinary incontinence (UI) symptoms, within 10 years of a simple total abdominal hysterectomy (TAH) for dysfunctional uterine bleeding (DUB), would differ to that after a transcervical resection of the endometrium (TCRE). Retrospective case note review. Teaching hospital in north east Scotland. All women who had a TAH (316) or a TCRE (229) for DUB, during the period from 1 January 1990 to 31 December 1994, who had never been referred for symptoms of UI prior to their operation. Independent t tests, Mann-Whitney U tests and Chi-squared tests were used to compare the two study groups in terms of demographic details and outcome measures. Newcombe's method for the comparison of two unpaired proportions was used to calculate 95% CIs for the differences in outcome measures between the two operations. Logistic regression was conducted to investigate associations with hospital referral for UI. Hospital referral for UI at 10 years follow up. There were significantly more hospital referrals for UI in the TAH group compared with the TCRE group (46 [15%] versus 16 [7%]; OR 2.27, 95% CI 1.25-4.12). More women were referred for urological investigations after a TAH than after a TCRE (39 [12%] versus 13 [6%], 95% CI for the difference in proportions 2-11%). A higher, but statistically nonsignificant, proportion of women had objectively demonstrated UI after a TAH than after a TCRE (25 [8%] versus 10 [4%], 95% CI for the difference in proportions -1 to 8%). There were a greater number of hospital referrals for treatment of UI in the TAH group (36, 11%) than in the TCRE group (12, 5%), 95% CI for the difference in proportions (1-11%). After adjusting for age, weight, smoking status and mode of delivery, the increased rate of hospital referral for UI after TAH remained, with an odds ratio of 2.31, 95% CI 1.24-4.30. TAH is associated with a significantly increased incidence of hospital referral for UI, urological investigations and treatment for UI at 10 years of follow up compared with TCRE.

Editors’ Choice

Editors’ Choice

Retrograde Urethrocystography Impairs Computed Tomography Diagnosis of Pelvic Arterial Hemorrhage in the Presence of a Lower Urologic Tract Injury

There is controversy about the appropriate sequence of urologic investigation in patients with pelvic fracture. Use of retrograde urethrography or cystography may interfere with regular pelvic CT scanning for arterial extravasation. We performed a retrospective study at a regional trauma center in Toronto, Canada. Included were adult blunt trauma patients with pelvic fractures and concomitant bladder or urethral disruption who underwent initial pelvic CT before operation or hospital admission. Exposure of interest was whether retrograde urethrography (RUG) and cystography were performed before pelvic CT scanning. Main outcomes measures were indeterminate or false negative initial CT examinations for pelvic arterial extravasation. Sixty blunt trauma patients had a pelvic fracture and either a urethral or bladder rupture. Forty-nine of these patients underwent initial CT scanning. Of these 49 patients, 23 had RUG or conventional cystography performed before pelvic CT scanning; 26 had cystography after regular CT examination. Performing cystography before CT was associated with considerably more indeterminate scans (9 patients) and false negatives (2 patients) for pelvic arterial extravasation (11 of 23 versus 0 of 26, p < 0.001) compared with performing urologic investigation after CT. In the presence of pelvic arterial hemorrhage, indeterminate or false negative CT scans for arterial extravasation were associated with a trend toward longer mean times to embolization compared with positive scans (p=0.1). Extravasating contrast from lower urologic injuries can interfere with the CT assessment for pelvic arterial extravasation, delaying angiographic embolization.

Intravenous urography for diagnosing synchronous upper-tract tumours in patients with newly diagnosed bladder carcinoma can be restricted to patients with high-risk superficial disease

To determine the incidence of synchronous upper-tract transitional cell carcinomas (TCCs) in patients with newly diagnosed bladder cancer and to evaluate the need for performing intravenous urography (IVU) in these patients. Imaging data on 330 consecutive patients who were diagnosed with TCC of the bladder over a 2-year period were retrospectively reviewed. Only 233 out of the 330 patients had IVU at presentation. The IVU results were recorded as normal, abnormal, or equivocal. The follow-up radiological or urological investigations in the patients who had an equivocal IVU were reviewed. Clinical follow-up data on all 330 patients were also recorded. Only 233 out of the 330 patients had an IVU at presentation. Four of these (1.7%) patients were found to have synchronous upper-tract tumours. Twenty-two patients were reported to have equivocal findings on IVU. Nine of these patients had follow-up imaging [computed tomography (CT)=5, IVU=4], which were reported as normal. Retrograde urography was performed in two patients, which was normal. The remaining 11 patients did not have any evaluation of the upper tracts despite the equivocal findings on IVU, but routine clinical follow-up did not reveal any significant disease. Three patients with high-risk superficial disease developed upper-tract tumours that were detected on follow-up. IVU for diagnosing synchronous upper-tract tumours in patients with newly diagnosed bladder carcinoma can be restricted to patients with high-risk superficial disease.

Disparities in the management of multiple sclerosis–related bladder symptoms

Participants enrolled in the North American Research Committee on Multiple Sclerosis (NARCOMS) registry report disability status using Performance Scales (PS), a self-report measure. The bladder/bowel subscale (PSB) of PS has not been validated. It is also unknown whether ethnic or socioeconomic disparities exist in bladder care. We aimed to validate the bladder/bowel subscale used by the NARCOMS registry and to describe urologic symptoms, investigations, and treatments received by registry participants. In the Fall 2005 update questionnaire, we collected the Bowel Control Scale (BWCS) and Urogenital Distress Inventory-6 (UDI-6) as criterion measures and urologic investigations and treatments. We measured associations between investigations, treatments, and symptoms with clinical and sociodemographic variables using chi(2) tests for categorical variables and Kruskal-Wallis tests for continuous variables, followed by multivariable logistic regression. Nine thousand six hundred eighty-eight participants completed the survey. For the UDI-6, the median (interquartile range) score was 33.3 (16.7 to 50.0), for the BWCS 3 (1 to 6), and for the PSB 1 (1 to 3). The correlation between the PSB and the UDI-6 was r = 0.67 and between the PSB and the BWCS r = 0.53 (both p < 0.0001). Participants had increased odds of receiving medication for bladder symptoms if they had health insurance (odds ratio [OR] 1.90; 1.07 to 3.35). Participants who were white (OR 1.5; 1.16 to 1.94) and had health insurance (OR 2.0; 1.3 to 3.07) had increased odds of undergoing urologic investigations. The Performance Scales bladder question has adequate criterion and construct validity in multiple sclerosis (MS). There are ethnic and socioeconomic disparities in bladder management in MS.

A rare association of crossed fused renal ectopia

BackgroundThrombocytopenia and absent radius syndrome (TAR) is a rare genetic disorder. It is an autosomal recessive disorder characterised by radial aplasia and thrombocytopenia that may have additional anomalies. We report a case of TAR syndrome with crossed fused renal ectopia. This anomaly has not been previously reported in association with TAR syndrome.Case presentationA 24 years old female with Thrombocytopenia and absent radius syndrome admitted with pelvic fracture was investigated for recurrent urinary tract infections. Abdominal ultrasonography could not visualise the kidney on right side. Further extensive investigations in the form of intravenous urography (IVU), Magnetic resonance imaging (MRI) and renal isotope scans revealed a crossed fused renal ectopia.ConclusionThis report describes the new finding of a crossed fused renal ectopia associated with TAR syndrome that has not been reported before in the literature. Ectopic kidneys have increased susceptibility to develop complications like urinary infections, urolithiasis, and abdominal mass. There is a reported case of TAR syndrome with renal anomaly that developed Wilm's tumor. Finding of crossed fused renal ectopia warrants complete urologic investigation to rule out surgically correctable pathology in the urinary tract.

Urinary calculi following traumatic spinal cord injury

To investigate the time aspect of the development of renal and bladder calculi in individuals with traumatic spinal cord injury (SCI) and a possible relation between the development of calculi and the bladder-emptying method. The study comprised a retrospective data collection from medical records and a questionnaire follow-up at least 10 years after the SCI. A total of 236 individuals with SCI (82% male, 18% female; 47% tetraplegic, 53% paraplegic) who were injured between 1956 and 1990 participated in the study and the response rate was 84.6%. The mean age at the time of follow-up was 50.5 years (range 28-84 years). The mean duration from the time of SCI was 24.1 years (range 10-45 years). During follow-up 47 participants (20%) had at least one episode of renal calculi and 32 (14%) had at least one episode of bladder calculi. The risk of first renal and bladder calculus was highest within the first 6 months post-injury. The cumulative proportion of calculi-free participants 45 years post-injury was 62% for renal calculi and 85% for bladder calculi. For participants who did not develop renal calculi within the first 2 years post-injury, the risk of having a renal calculus within the next 43 years was 34%. For bladder calculi the corresponding risk of having a bladder calculus within the next 43 years was 5%. No significant differences were found regarding the bladder-emptying method and either renal or bladder calculi, only a non-significant trend that more participants with bladder calculi used indwelling catheters. Participants with renal or bladder calculi were not statistically significantly different from the remainder of the study group regarding gender, para- or tetraplegia or Frankel classification. The risk of developing renal and bladder calculi was higher in the SCI population compared to the normal population. Bladder calculi primarily occur early post-injury and renal calculi appear both early post-injury and years later. Therefore, it is important to follow individuals with SCI regularly by means of urological investigations from the time of the injury until death.

Condylomata acuminata

HPV infection is one of the most common sexually transmitted infections worldwide. Although most infections are transient, persistent ones can lead to condylomata acuminata, genital intraepithelial neoplasia and genital cancer. The recent approval of vaccines against HPV has raised great hopes. Since 1990, 5,392 urological investigations for HPV were carried out in 1,792 men in special HPV centres. We report on the epidemiology and natural course of condylomata, techniques for HPV detection, treatment surveillance and long-term sequelae. Condylomata acuminata proved to be pathognomonic; partner infections were diagnosed in 50% and more. Systematic HPV DNA analyses in partner investigations or as screening investigations cannot be recommended. Ultimately, within the spectrum of therapeutic options for condylomata, no method is really superior to others; recurrences occurred in 30-70% of cases. We definitely need the HPV vaccination programme to get rid of one of the oldest and up to now unsolved problems of mankind.

Late Diagnosis of Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency

Congenital adrenal hyperplasia results from 21-hydroxylase deficiency in more than ninety percent of cases. The classical form of 21-hydroxylase deficiency presents in the neonatal period with virilization or adrenal insufficiency, with or without concurrent salt wasting. We report on a rare case of classic 21-hydroxylase deficiency diagnosed in late adulthood. A 39-year-old male patient presented for workup of infertility. Urologic investigation revealed small testes, bilateral testicular masses, and asthenozoospermia. The patient's steroid metabolism showed markedly increased levels of adrenal androgens, in particular of 17-hydroxyprogesterone amd 21-deoxycortisol. The gas chromatographic-mass spectrometric (GC-MS) urinary steroid profile was dominated by metabolites of 17-hydroxyprogesterone, while the endogenous glucocorticoid production was subnormally low. ACTH levels in plasma were elevated. These hormonal findings were consistent with 21-hydroxylase deficiency. Therapy with dexamethasone was initiated. The CTP21A2 gene analysis revealed the mutation I172N (ATC --> AAC) in exon 4 of allele 1 and a large gene deletion in allele 2. Cases of 21-hydroxylase deficiency diagnosed in late adulthood are rare; however, clinicians should be alert of this possibility.

Diagnostic approach in patients with asymptomatic haematuria: efficient or not?

Many patients with asymptomatic haematuria are primarily referred to urological examination. To analyse the efficiency of this strategy, we investigated the diagnostic process in 134 patients with asymptomatic haematuria (91 macroscopic and 43 microscopic) who were referred to our urology department. The frequency of diagnostic procedures was urine culture: 91%, cystoscopy: 87%, intravenous urography: 86%, ultrasound: 73%, examination of urinary sediment: 20%. In 70 patients (52%), a urological diagnosis was made. In the remaining 64 patients, the urinary sediment was examined for the presence of dysmorphic erythrocytes and erythrocyte casts in 17 patients (27%). Signs of glomerular haematuria were found in nine of them (53%). The diagnostic strategy in these patients with asymptomatic haematuria was not discordant from several published algorithms but appeared neither efficacious nor efficient. We estimate that when examination of the urinary sediment would have been performed at the start of work-up, 25% of patients could have spared from extensive urological investigation.

Serum lipid levels in benign prostatic hyperplasia

The relationship between serum lipid levels and measures of benign prostatic hyperplasia was investigated. The study was community based. All the participants had undergone a urological investigation which included International Prostate Symptom Score (I-PSS) and Quality of Life Score (QoL), serum lipid concentrations and determination of prostate volume with transrectal ultrasonography. Body mass index was calculated with the formula of weight (kg)/surface area (m(2)) respectively. Men were considered obese if their body mass index was over 25 kg/m(2). BPH was defined by prostate volume greater than 20 ml and I-PSS greater than seven. Comparisons of serum lipid levels between men with BPH and without BPH were done. There was no correlation for serum lipid levels with either mean I-PSS and QoL scores. However, triglyceride and cholesterol levels were the lowest in severe symptomatic men than men with low symptoms. Using clinical definition of BPH that prostate volume was greater than 20 ml and I-PSS was greater than seven, men with BPH had not significantly different serum lipid levels from men without BPH. Our population-based data reflect that there was no relationship between serum lipid levels and certain physiological measures of lower urinary tract symptoms and clinical benign prostatic hyperplasia.

Haematuria

Haematuria is the presence of red blood cells in the urine and is a common problem in urological practice in the UK. All patients with an episode of haematuria must undergo investigation because it may be associated with malignancy. Haematuria can be classified as dipstick, microscopic or macroscopic. Dipstick testing has poor specificity, so microscope confirmation of haematuria is advised. Macroscopic haematuria is much more likely to have a serious underlying cause than haematuria of a lesser degree, but malignancy can still present with microscopic haematuria, so full evaluation is warranted in both patient groups. A ‘one-stop’ haematuria clinic is the ‘gold standard’ for the diagnosis of haematuria in the UK. In such clinics, synchronous urological and radiological investigations will be performed to determine the cause of haematuria. The specific format of radiological assessment remains controversial because there is no single imaging modality with the desired diagnostic sensitivity and specificity. The evaluation of haematuria accounts for a considerable amount of new urological consultations, so it is important to be aware of the common causes and how to investigate appropriately.