Urological Complaints Research Articles

Chronic pollakiuria: cystectomy or psychotherapy

Persistent unexplained urological complaints and diseases are a common problem in clinical practice. Psychological components can play an important role in urological complaints. Neglect of these facts can lead to an insufficient or incorrect treatment. Therefore, apart from the specific medical diagnostics, a complete examination of mental and psychological functions before an invasive intervention is also required. Illustrated by the case of a young woman with a request for a cystectomy while suffering from a chronic pollakiuria, this paper explains the importance of good interdisciplinary collaboration for evidence-based, guideline-oriented medical treatment. The patient's suffering and urge for removing the bladder was contrasted by a lack of medical indication for surgery and the principle of proportionality. The essay gives insight into the discipline of psychosomatic medicine, somotoform disorders found in urology and, especially, the symptoms of pollakiuria and overactive bladder. The case illustrates the importance of timely and simultaneous medical and psychosocial diagnostics for the treatment outcome in patients with unspecific physical complaints. Treatment recommendations for patients with somatoform complaints in clinical practice are provided.

Editorial Comment

The authors of this epidemiologic study performed a subanalysis of the 2012 Surgeons OverSeas Assessment of Surgical need survey. This robust study was developed to assess the prevalence of surgical conditions in Sierra Leone. The parent study revealed a large unmet need for the treatment of basic surgical conditions in this low-income country. In the present article, the authors study 1054 men older than 12 years and found that the period and point prevalence of gross hematuria and urinary retention indicate a large demand for urologic care in this developing country. The authors cite lack of urologic expertise, geographic limitations, financial limitations, and suboptimal surgical infrastructure as reasons for this burden. By virtue of this investigation, the authors of this study have successfully quantified a concerning disease burden in one country, which can likely be generalized to many developing countries. Gross Hematuria and Urinary Retention Among Men From a Nationally Representative Survey in Sierra LeoneUrologyVol. 83Issue 6PreviewTo estimate the prevalence of gross hematuria and urinary retention among men in Sierra Leone and report on barriers to care and associated disability. Gross hematuria and urinary retention are classic urologic complaints that require medical attention for significant underlying pathology, but their burden has not been quantified in a developing country. Full-Text PDF ReplyUrologyVol. 83Issue 6PreviewWe candidly agree with the sentiments of the authors. Measuring the burden of disease is just 1 step on the path toward taking action to address the needs identified. However, much urologic care is interventional in nature, and the thought of surgery as a public health intervention is a less commonly held notion compared with many medical treatments.1 What is needed is widespread recognition that surgical care can be cost-effective and should be included in the realm of basic health needs before action is possible. Full-Text PDF

Gross Hematuria and Urinary Retention Among Men From a Nationally Representative Survey in Sierra Leone

To estimate the prevalence of gross hematuria and urinary retention among men in Sierra Leone and report on barriers to care and associated disability. Gross hematuria and urinary retention are classic urologic complaints that require medical attention for significant underlying pathology, but their burden has not been quantified in a developing country. A cluster randomized, cross-sectional household survey was administered in Sierra Leone using the Surgeons OverSeas Assessment of Surgical need tool as a verbal head-to-toe examination. A total of 2 respondents in each of 25 households in 75 clusters were surveyed to assess surgical needs. Data on questions related to blood from the penis and the inability to urinate for men>12 years were included in the present analysis to determine the period and point prevalence of hematuria and urinary retention. From 3645 total respondents, 1054 (28.9%) were men>12 years included in the analysis. Period and point prevalence of gross hematuria were 21.8 per 1000 (95% confidence interval [CI] 13.0-30.7) and 12.3 per 1000 (95% CI 5.7-19.0), respectively, and for urinary retention, they were 19.9 per 1000 (95% CI 11.5-28.4) and 4.7 per 1000 (95% CI 0.5-8.9), respectively. Lack of financial resources was the major barrier to care. Disability assessment showed 19.1% were not able to work as a result of urinary retention, and 34.8% felt ashamed of their gross hematuria. The results provide a prevalence estimate of gross hematuria and urinary retention for men in Sierra Leone. Accessible medical and surgical care will be critical for early intervention and management.

Use of point-of-care ultrasound (POCUS) by emergency physicians for general surgical patients in resuscitation room

Patients and methods Patients having general surgical presentation (i.e. excluding patients with neurosurgical, urological or cardiothoracic chief complaints) who attended Emergency Department of Prince of Wales Hospital, and triaged as category I or II (emergency or urgent) were included. The inclusion period was from Sep 2012 to Mar 2013. Patients’ clinical records were retrieved. Documented POCUS and scope of use by EP, yield to diagnosis, and eventual diagnoses after admission were studied.

Tethered Cord Syndrome in Adults: Experience of 56 Patients.

The aim of this study was to describe the results of surgery performed in a group of adult patients with tethered cord syndrome with their outcomes. This retrospective study included 56 patients. There were 38 females and 18 males. All patients were older than 18 years. The mean age at referral was 36 years and 1 month. The mean follow-up period was 10 months 27 days. 95% of all patients with back and leg pains improved and 5% remained the same. Three patients with motor deficits remained the same in the postoperative period. Of the 16 patients with urological complaints, 10 improved, 5 unchanged and 1 patient died in the postoperative first day due to pulmonary embolism. The syndrome of tethered cord may be a situation to be treated even in the elderly in case of normal level conus medullaris and filum terminale with a normal appearance as well as a low-lying conus and thick filum. To prevent overlooking the diagnosis of tethered cord and/or unnecessary spinal surgeries, the tethered cord syndrome should be remembered in the differential diagnosis list in the presence of back and leg pains, neurological deficits or urological complaints.

Thoraco-Lumbar Junction Disc Herniation and Tight Filum: A Unique Combination?

Purpose: The incidence of both symptomatic thoraco-lumbar junction disc herniation (TLJDH) and tight filum (TF) may be underestimated. Both conditions have a complex clinical presentation that may involve the distal spinal cord, conus medullaris, and/or cauda equina, including upper and/or lower motor neuron impairment, sensory impairment, urological and sexual dysfunction. The coexistence of both conditions has not been previously reported and may be a diagnostic and therapeutic challenge. Methods: We report three teenage girls, a 24-year-old woman, and two middle-aged women who were diagnosed with both conditions and treated at our institution. Results: Disc herniation level was T11-T12 in 2, T12-L1 in 3, and L1-L2 in one. All patients had a fatty filum (n = 5) and/or a low-lying CM (at or above L1-L2 in 2, at or below L2-L3 in 4), and were treated with filum sectioning first. All patients noted marked improvement of preoperative complaints including back pain (n = 5), leg pain and fatigue (n = 4), urological complaints (n = 4), and toe gait (n = 1). One 16-year-old girl successfully underwent a thoracoscopic microdiscectomy for persisting pain at the thoraco-lumbar junction two years after filum sectioning. Conclusions: Thoraco-lumbar junction disc herniation and tight filum both act on the distal spinal cord close to the transition to the cauda equina. Both conditions may coincide and may even act synergistically, the disc herniation acting as a fulcrum, aggravating the deleterious effect of the tethering force (and vice versa). This might explain why both conditions combined may present at a younger age. We suggest filum sectioning as the primary treatment option in all patients, however, more cases and a longer follow-up are needed to better understand their unique combination and interaction. Nevertheless, when confronted with a symptomatic TLJDH especially in young patients we advise to rule out a coinciding TF by careful consideration of all clinical, radiological, and urological data.

A Novel Snorkel Approach for Management of Horseshoe Kidney During EVAR

Horseshoe kidneys are associated with a high incidence of aberrant renal vasculature and pose a unique challenge to repairing an abdominal aortic aneurysm (AAA). Traditional approaches can be associated with disruption of either the collecting system or even to the blood supply itself. Here, we present a novel snorkel technique for managing this condition. During imaging for a urologic complaint, a 61-year-old male was found to have a 5.8 × 6.3 cm AAA as well as a horseshoe kidney. He underwent an angiogram to further delineate the blood supply to the renal isthmus, which revealed a single right renal artery, two main renal arteries on the left, and a very large inferior mesenteric artery (IMA). The patient was felt to be at intermediate risk for an open AAA repair so the decision was made to proceed with an endovascular aneurysm repair (EVAR). We also performed a snorkel technique to preserve the IMA due to the concern that this vessel was supplying a significant portion of the renal parenchyma. Completion angiography demonstrated a well-positioned endograft without evidence of endoleak. The patient recovered uneventfully and had preserved renal function. AAA associated with horseshoe kidneys present a challenge to repair while also preserving renal parenchyma and arterial supply. A growing experience with snorkel techniques allows for a minimally invasive approach to this complex problem.

Paucity of evidence for urinary tract outcomes in closed spinal dysraphism: a systematic review

To describe the long-term upper (UUT) and lower urinary tract (LUT) outcomes in patients with closed spinal dysraphism (CSD). CSD differs from open spinal dysraphism (OSD) by its long asymptomatic course and consequent later diagnosis. The outcome of UUT and LUT function in adults with CSD is relatively unknown. A systematic review was performed following the standards of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An extensive search was made of PubMed and EMBASE. Included were papers on adults with any form of primary CSD that described bladder and/or kidney function. Only English and Dutch language papers were included. Excluded were papers on patients aged <18 years and patients with secondary tethered cord following childhood OSD repair. International Continence Society terminology was used to describe LUT outcomes. Eventually, only seven studies (90 patients) were included and none of these described renal outcomes. Five of the seven papers were on outcomes after untethering surgery during adulthood. Urological complaints were present in 54/79 (68.4%) patients. Urodynamic studies (48 patients available) revealed detrusor underactivity in 46.5% of the evaluated cases, detrusor overactivity in 32.6% and normal findings in 16.3% of the studied patients. Symptomatic improvement after surgery for tethered cord occurred in 33.3-90.0%, depending on the subgroup studied. Urodynamic improvement rates ranged from 11.1% to 54.5% (but based on three studies with only 24 patients). Success of surgery depended on the time between onset of symptoms and operation, and (sometimes) type of lesion. Few data are available on long-term urological outcomes in adult patients with CSD. More extensive research on follow-up, including the functional status of the UUT, is recommended. Based upon the little evidence available, we think life-long follow-up (from birth into adulthood) of those with CSD and neurogenic bladder is advisable.

Tongue mass in post nephrectomy patient

Metastatic lesions of the oral cavity are extremely rare, accounting for approximately 1% of all malignant oral tumors. Renal cell carcinoma (RCC) is the third most frequent neoplasm to metastasize to the head and neck region preceded only by breast and lung cancer. The nose and paranasal sinuses are most commonly affected followed by the oral cavity. Within the oral cavity, the tongue is a frequent target for RCC metastasis.We report the case of a 66-year-old Malay man presenting with a lesion in oral cavity which has grown substantially over several months without any urological complaint except a history of left nephrectomy for unsure pathology about 17years ago.

Urological Complaints and Sexual Abuse: A Case Control Study Identifying Multiple Urological Complaints in Relation to Sexual Abuse History

Introduction: The relationship between sexual abuse and urinary tract symptoms has been described for urgency, frequency and nocturia. Aims: To investigate if other urological complaints in females, like urinary tract infections, incontinence, voiding complaints and lower abdominal pain are also correlated with a history of sexual abuse (SA) and to measure the prevalence of sexual abuse in our urological patient population, using a clinical case control study. Methods: 1383 female patients of 18-year-old or older visiting our outpatient urological university clinic were asked to fill out a questionnaire evaluating referral indications and urological complaints. The questionnaire consisted out of two parts. The first part was designed characteristics and medical history. The second part included referral indications, the urological complaints and a possible history of SA. The sample was divided into two groups: those with and those without a history of SA. The Outcome Measures: 1) The comparison of the frequency of voiding complaints, urinary tract infections (UTI’s), lower abdominal pain, hematuria and incontinence in respondents with and without SA; 2) The prevalence of SA in female patients presenting at our university urological outpatient clinic; 3) The number of urological symptoms presented at the time of referral by respondents with a history of SA compared the non-abused. Results: 436/1383 (32%) patients were willing to participate. 304 (70%) questionnaires were properly filled in. The reported prevalence of sexual abuse was 17% (51/304). More than half of the females with a history SA presented with voiding complaints (32/51 p = 0.18), incontinence (31/51 p = 0.10) and urinary tract infections (27/51 p = 0.22). However, comparing the data of respondents without SA we found no significant differences with regards specific complaints. Patients with SA report more symptoms than those without (Armitage’s trend test 0.14 (p = 0.004) for 4 complaints or more). Conclusions: No significant correlation between SA and voiding complaints, incontinence nor lower abdominal pain was found. The prevalence rate of SA in female patients visiting our university urological outpatient clinic was 17%. These abused females mentioned more synchronous complaints as reason for referral at their first visit than the non-abused.

Asymptomatic hypospadias with tight meatal stricture in the father of twelve children.

Hypospadias is a highly prevalent congenital anomaly. English articles, indexed in PubMed, published the long-term sexual and reproductive outcome following hypospadias repair. Almost all repairable cases of hypospadias are operated in childhood. Although distal hypospadias does not interfere with fertility, it is worthy reporting a case of an elderly man, who fathers 12 children and has no urologic complaint, presented with unrepaired coronal hypospadias and severely tight external urethral meatus.

Crohn Disease and the Gynecologic Patient

Although Crohn disease (CD) is considered an inflammatory bowel disease, extraintestinal gynecologic manifestations are varied, frequent, and oftentimes difficult to manage. Its predilection for young and reproductive-age women makes it an important disease process for the gynecologist to understand, as its complications can have long-term repercussions on the developmental, sexual, reproductive, and psychological health of affected women. Patients may present with a variety of vulvovaginal, perineal, perianal, and urologic complaints. Perianal involvement from an intestinal fistula is the most common skin manifestation seen in CD. Other gynecologic manifestations include metastatic CD and rectovaginal and urovaginal fistulas. Recognition and accurate diagnosis of extraintestinal gynecologic manifestations, as well as a good understanding of the gynecologic effects of chronic disease, are necessary for optimal management. The article provides an overview of CD and highlights the gynecologic considerations in caring for women affected by this disease.

Nonleukemic Ureteral Granulocytic Sarcoma Presenting with Unilateral Urinary Obstruction and Hematuria

Granulocytic sarcoma is an extramedullary tumor which is composed of myeloblasts and immature myeloid cells. It usually occurs in association with acute myeloid leukemia and most commonly involves skin, soft tissue, lymph nodes, bone, and periosteum. We report a case of isolated ureteral granulocytic sarcoma without hematologic manifestations. Our patient presented with bloody urine and left-sided lumbar pain. Preoperative clinical and radiologic features raised the suspicion of an upper urinary tract transitional cell carcinoma, and he was scheduled for nephroureterectomy. However, perioperative pathologic feedback and the unusual endoscopic appearance of the tumor altered our surgical strategy towards segmental ureterectomy and ureteroneocystostomy. Eventual pathologic diagnosis was granulocytic sarcoma of the ureter. Postoperative workup failed to demonstrate any sign of an accompanying hematologic disorder. He started receiving the chemotherapy protocol of acute myeloblastic leukemia. To our knowledge, this is the first documented case of nonleukemic ureteral granulocytic sarcoma which came to attention due to urologic complaints.

Are GPs ready to talk about death and dying?

Are GPs ready to talk about death and dying?

Abdominopelvic Ultrasound: A Cost-Effective Way to Diagnose Solitary Kidney

Solitary kidneys are detected on approximately 1 of 1,500 prenatal ultrasounds and during evaluation for other urological complaints. Although renal scintigraphy is currently the gold standard for confirming the diagnosis and ruling out renal ectopia, scintigraphy is associated with radiation exposure, placement of an intravenous line and sedation. We hypothesize that ultrasonography alone is sufficient to detect solitary kidneys and that confirmatory renal scintigraphy is unnecessary. We reviewed the records of children with a solitary kidney who underwent ultrasound and nuclear scintigraphy at our institution from 2001 to 2010. Radiological findings were compared to assess the accuracy of ultrasound in diagnosing solitary kidneys. Costs were calculated based on 2011 Medicare global reimbursement. A total of 25 children met the inclusion criteria of undergoing ultrasound and renal scintigraphy (dimercapto-succinic acid or mercaptoacetyltriglycine scan). The majority of cases were male (16, 64%) and left sided (17, 68%). Median age was 9 days (range 1 day to 11.6 years) at first ultrasound and 4.4 months (3 weeks to 12 years) at first renal scintigraphy. In 24 patients ultrasound correctly diagnosed a solitary kidney as confirmed by nuclear scan. In 1 patient ultrasound suggested a pelvic kidney but repeat ultrasound was negative, as was dimercapto-succinic acid scan. The diagnostic accuracy of ultrasound was 96%. Medicare reimbursement for dimercapto-succinic acid scan (CPT 78700) is $460 to $720 ($222 plus $240 for radiotracer plus $260 for anesthesia, if used). Our findings suggest that ultrasonography alone is sufficient to make the diagnosis of solitary kidney. Omitting routine renal scintigraphy saves approximately $460 to $720 per case, and avoids radiation and discomfort without sacrificing diagnostic accuracy.

The fate of small renal masses, less then 1 cm size: outcome study

We evaluated the outcome and etiologies of small renal masses (less than 1 cm in size) discovered incidentally on 2 consecutive CTs that investigated nonurologic abdominal complaints. A retrospective search for incidentally discovered small renal masses, less then 1 cm in size, was carried out in the files of 6 major US medical centers. 4822 such lesions had been reported over a 12 year period. A search of these patients' records revealed 1082 subsequent new CTs for non urologic complaints, allowing the assessment of the fate of the masses. Lesions enlarging, of ambivalent contour or enhancement were examined by a third multiphasic MDCT. The findings were interpreted by 2 blinded radiologists. Six hundred and four masses could no longer be identified, 231 were significantly smaller, 113 unchanged in size and 134 larger. Of the disappearing lesions 448 were located in the medulla, 94 both in medulla and cortex and 62 in cortex. Multiphasic MDCTs obtained in 308 masses enlarging, unchanged in size or of ambivalent appearance, revealed 7 neoplasms, 45 inflammatory lesions, 8 abscesses and 62 renal medullary necrosis. Concurrent antibiotic therapy of GI conditions may have caused some of the 496 lesions to disappear. It is questionable whether the small number of malignant neoplasms (0.4%), inflammatory lesions (5%) and renal medullary necrosis (6%) justify routine follow-up CTs and exposure to radiation. The delay in intervention in neoplastic lesions probably didn't influence tumor-free survival potential and clinical symptoms would soon have revealed inflammatory conditions. With exception of ambivalent lesions, clinical surveillance appears adequate.

Advance Provision of Emergency Contraception in an Urban Pediatric Emergency Department

Study Objective To assess whether a policy and educational intervention in an urban, pediatric emergency department (ED) increases advance provision of emergency contraception (EC) to patients. Design/Setting/Participants A pre- and post-intervention, retrospective chart review was conducted in an urban, pediatric ED assessing provider care of sexually active female adolescents and young adults. Intervention/Main Outcome Measures A policy was instituted recommending that ED providers prescribe EC and provide an educational handout to all sexually active female adolescents and young adults. ED providers were educated about EC and this policy. Charts, subsequently reviewed, included sexually active female patients, age 13–21 years, presenting to the ED status post sexual assault, seeking EC, or with an abdominal, gynecologic, or urologic complaint. Student’s t-tests, Pearson’s chi-square and Fisher’s Exact tests compared pre- and post-intervention provider and patient characteristics and outcomes. Results The mean age of the patient sample was 18.8 years (SD=1.7), 83% were Black or Hispanic, 43% were previously pregnant, 25% reported not using birth control. Last unprotected sexual intercourse was not documented for 87% of patients presenting with medical complaints. There was no difference in the advance prescribing of EC or the provision of the educational handout to patients pre- (3.3%) or post- (5.6%) intervention ( P = 0.73). Conclusions Despite a policy and an educational intervention for providers, little change occurred in advance EC prescribing in an urban, pediatric ED. Additionally, many providers were not documenting last unprotected sexual intercourse, potentially missing an opportunity to treat patients with EC at the time of their visit.

Metabolic Syndrome in Female Patients With Overactive Bladder

To investigate the relevance of metabolic syndrome in the etiopathogenesis of overactive bladder in female patients. It has been shown that obesity has been associated with overactive bladder (OAB), and the metabolic syndrome and insulin resistance have been related to the annual growth rates of prostate and lower urinary tract symptoms. Female patients applying to our policlinics with OAB symptoms or other urologic complaints were enrolled in the study. The International Diabetes Federation criteria were used for the definition of the metabolic syndrome. The chi-square, Student t, and Mann-Whitney U tests and logistic regression analyses were used to compare differences in the variables. The metabolic syndrome was diagnosed in 201 (64%) of 313 patients with OAB and 73 (35%) of 208 patients without OAB. The difference was statistically significant (P=.002). A larger waist circumference, greater body mass index, low high-density lipoprotein level, and incidence of hypertension were significantly greater statistically in the OAB group than in the controls. The metabolic syndrome correlates highly with OAB in female patients. The metabolic syndrome can be an etiologic pathway for the onset of symptoms.

Case Studies

The following vignette clinical cases are inspired by the large patients' libraries of the authors of this special issue in order to complement their respective articles and highlight the need for a holistic approach to the management of premature ejaculation (PE). This condition has been considered in the recent past a “simple” symptom of a psychological derangement. On the contrary, we now have plenty of evidence of several factors, co-etiologies, and risk factors that, at several levels, may provoke the loss of ejaculatory control. The following real-life scenarios from different countries show the various aspects and mosaics of PE, regarding its manifestation and existence with other concomitant sexual or urological complaints. They also demonstrate how the experts have managed these challenges to improve the daily sexual experience of the man and couple as a whole. Moreover, these cases provide convincing evidence that, in PE, the partner should be considered and involved, in terms of their own sexual life and satisfaction, to yield the best outcome for the couple.

Quantitative methods in ethnobotany and ethnopharmacology: Considering the overall flora—Hypothesis testing for over- and underused plant families with the Bayesian approach

Ethnopharmacological relevanceWe introduce and explain the advantages of the Bayesian approach and exemplify the method with an analysis of the medicinal flora of Campania, Italy. The Bayesian approach is a new method, which allows to compare medicinal floras with the overall flora of a given area and to investigate over- and underused plant families. In contrast to previously used methods (regression analysis and binomial method) it considers the inherent uncertainty around the analyzed data. Materials and methodsThe medicinal flora with 423 species was compiled based on nine studies on local medicinal plant use in Campania. The total flora comprises 2237 species belonging to 128 families. Statistical analysis was performed with the Bayesian method and the binomial method. An approximated χ2-test was used to analyze the relationship between use categories and higher taxonomic groups. ResultsAmong the larger plant families we find the Lamiaceae, Rosaceae, and Malvaceae, to be overused in the local medicine of Campania and the Orchidaceae, Caryophyllaceae, Poaceae, and Fabaceae to be underused compared to the overall flora. Furthermore, do specific medicinal uses tend to be correlated with taxonomic plant groups. For example, are the Monocots heavily used for urological complaints. ConclusionsTesting for over- and underused taxonomic groups of a flora with the Bayesian method is easy to adopt and can readily be calculated in excel spreadsheets using the excel function Inverse beta (INV.BETA). In contrast to the binomial method the presented method is also suitable for small datasets. With larger datasets the two methods tend to converge. However, results are generally more conservative with the Bayesian method pointing out fewer families as over- or underused.