A. Mofferdin

Potential Effectiveness of Pelvic Floor Rehabilitation Treatment for Postradical Prostatectomy Incontinence, Climacturia, and Erectile Dysfunction: A Case Series

INTRODUCTION Radical prostatectomy is the treatment of choice for prostate cancer; although novel techniques have significantly reduced its side effects, the procedure can provoke urinary incontinence of various degrees and/or erectile dysfunction. AIM We evaluate the effect of a complete pelvic floor rehabilitation program on both incontinence and erectile dysfunction, including climacturia, in a preliminary case series. MAIN OUTCOMES MEASURES Pad usage and International Index of Erectile Function (IIEF-15) Questionnaire. METHODS Three male patients, previously submitted to nerve and bladder neck sparing radical prostatectomy, presented with urinary incontinence, climacturia and erectile dysfunction of new onset. We decided to manage those subjects with a pelvic-floor rehabilitation program consisting of active pelvic-floor muscle exercises, electromyography biofeedback for strength and endurance, electrical stimulation. The whole program lasted 4 months, with weekly sessions, including general advices on lifestyle changes. Pad usage for incontinence and IIEF-15 were used to assess symptoms before and after the procedure. RESULTS Before a complete rehabilitation program, pad usage was 1 per day in all the subjects, and the score for erectile function was set at 17 (range 15-20). After the procedure, all the patients experienced a satisfying urinary continence and an improvement in erectile function (mean IIEF score: 22, range 19-24). Similarly, climacturia seems to be subjectively reduced in all the subjects. CONCLUSION Pelvic floor muscles exercises seem to result in an improved urinary continence and erectile function after radical prostatectomy. Since this is the first clinical case series dealing with this topic, our outcomes are encouraging and suggest the potential usefulness of such noninvasive treatment modality.

ORIGINAL RESEARCH—WOMEN'S SEXUAL HEALTH: Biofeedback, Electrical Stimulation, Pelvic Floor Muscle Exercises, and Vaginal Cones: A Combined Rehabilitative Approach for Sexual Dysfunction Associated with Urinary Incontinence

INTRODUCTION Urinary incontinence (UI) is often associated with sexual dysfunction. We present our preliminary experience with a combined rehabilitative approach consisting of biofeedback, functional electrical stimulation, pelvic floor muscle exercises, and vaginal cones. AIM The potential impact of such practice on UI and sexual function was analyzed in our case series and discussed. MAIN OUTCOME MEASURES AND METHODS We evaluated three women affected by UI and sexual dysfunction. The patients underwent combined pelvic floor rehabilitation (PFR), kept voiding diaries, and filled out the Female Sexual Function Index (FSFI questionnaire) before and after the completion of PFR. We evaluated each domain score, including desire, arousal, lubrication, orgasm, satisfaction, and pain. RESULTS After the combined rehabilitation program, none of them had UI requiring pad use or referred urine leakage during sexual activity, including intercourse. Before PFR, FSFI score ranged from 16 to 21; after treatment, the FSFI score ranged from 22.1 to 29.3. There was an improvement in patients regarding desire, arousal, lubrication, orgasm, satisfaction, and pain. CONCLUSIONS A complete rehabilitation can provide a beneficial effect on sexual function. A larger trial, on a more extended female population, is currently in progress, in order to confirm our findings. The effectiveness of a complete PFR scheme, together with the lack of side effects, makes it a suitable approach to sexual dysfunction that is associated with UI.

Extracorporeal Shock Wave Lithotripsy in an Elderly Population : How to Prevent Complications and Make the Treatment Safe and Effective

INTRODUCTION The aim of our study is to consider the feasibility and the results of shock wave lithotripsy (SWL) in an elderly cohort of patients, considering different diseases and concomitant morbidity. MATERIALS AND METHODS From January 2003 up to July 2006, a total of 1100 SWL treatments were performed in our Stone Centre with Dornier Lithotripter S device. We retrospectively analyzed all the treatments carried out in patients older than 70 years of age, collecting a total of 130 patients. The average age was 75.1 years (range: 70-89). Stone location was renal in 95 and ureteral in 45 patients. Information about SWL outcomes and complications were collected as well as patients characteristics and treatment modalities. RESULTS Average stone size was 10.2+/-3.4 and 8.7+/-3.1 for the renal and ureteral location, respectively. 73 out of 140 patients (52.1%) were stone free after a single treatment; 49 patients (35%) required an adjunctive session, whereas SWL was unsuccessful in 18 (12.8%) patients. We observed 64, 24, 21, 10, 31 cases of concomitant arterial hypertension, diabetes mellitus, chronic renal failure, solitary kidney condition and previous neoplastic pathologies. A total of 8 and 6 subjects had previous cardiac surgery and atrial fibrillation respectively, thus requiring a warfarin scheduled conversion to low molecular weight heparin. Five patients had a pace maker implant and three patients an abdominal aortic aneurism. No SWL-related complications were found in this series considering both urological and systemic features. CONCLUSION SWL represents the treatment of choice for urolithiasis, and it has to be recommended especially to geriatric patients. In those subjects, SWL complications can be avoided with a proper and personalized preparation, together with an ECG and ultrasound continuously monitored procedure.

Experimental varicocele in the rat: early evaluation of the nitric oxide levels and histological alterations in the testicular tissue

The relationship between varicocele and male infertility remains to be explained. Oxidative damage because of the testicular venous backflow may represent one of the causes of gonad injury and seems to precede the histological alteration. Therefore measuring the values of spermatic or intratesticular nitric oxide (NO) could be useful in evaluating this oxidative distress. The aim of this study is to assess the role of testicular NO in early detection of the damages induced by an experimental varicocele in the Wistar rat. A left varicocele was induced in 10 animals (group A). A control group of 10 rats was performed (group B). Animals were killed 3 months after the operation. Both testicles were harvested, weighed and sectioned in two equal parts: one for the evaluation of the NO level and the other one for histological examination. All the rats in group A showed a conspicuous dilatation of the left spermatic vein. The histopathological analysis was normal in both the groups. Biochemistry showed a meaningful statistical difference (P < 0.001) in the concentrations of NO among the specimens of the left and right gonads in group A but no difference was found in group B. The increase in NO values and the presence of other oxidant agents represent the first sign of testicular distress and it seems to anticipate histopathological changes. As it is well known that a great difference exist between human and animal sperm, NO could therefore in the future be taken into consideration together with others parameters for the evaluation of patient who is affected by varicocele.

A knotted multi-length ureteral stent: a rare complication

Ureteral catheters represent essential devices in the management of upper urinary tract obstruction; complications are unusual. Knotting of the stent at its proximal coiled end is a very rare but potentially dangerous event that should be promptly recognized.

Bacille Calmette-Guérin intravesical instillation and erectile function: is there a concern?

The aim of our study was to evaluate the effect of bacille Calmette‐Guérin (BCG) therapy on erectile function in a cohort of male patients affected by non‐muscle invasive bladder cancer. Thirty male patients undergoing BCG treatment for non‐muscle invasive bladder cancer were enrolled in the study. Their mean age was 60.4 years. None of the patients had risk factors for erectile dysfunction (ED). All subjects underwent a BCG standard schedule therapy (once weekly instillation for 6 weeks). International Index of Erectile Function (IIEF‐5) and International Prostate Symptom score (I‐PSS) were addressed to the patients during the treatment schedule (at fourth or fifth instillation) and 1 month after the last instillation. The mean IIEF‐5 score was 17.6 ± 6.7 during therapy and 21.7 ± 2.92 a month after the last instillation (P = 0.008). Baseline ED and the association with lower urinary tract symptoms are variables significantly connected with post‐treatment results (P = 0.016 and 0.00 respectively) whereas the age seems not to be related to ED (P = 0.256). No major side effects were recorded. It is concluded that BCG treatment is effective for prophylaxis of non‐muscle invasive bladder cancer; however, it may induce a high incidence of ED. Although this effect is transient and reversible, erectile failure is another source of psychological distress that adversely affects the quality of life of men undergoing BCG treatment.

Chemical and Mineralogical Analysis of Ureteral Stent Encrustation and Associated Risk Factors.

OBJECTIVE To assess the burden and chemical and mineralogical composition of stent coating at both stent ends, with evaluation of associated risk factors. MATERIALS AND METHODS A total of 40 consecutive patients submitted to ureteral-stent removal were considered. Stents were previously positioned for both urolithiasis and during the management of other urologic diseases and/or procedures. Mean indwelling time was 59.2 ± 7.5 days. ANALYTICAL PROCEDURES Encrustations were submitted to chemical-mineralogical analysis as well as to their quantification. Quantification was achieved by measuring the weight of stent fragments before and after oxidative acid treatment to dissolve the deposited (both organic and inorganic) material. The analytical solution obtained by acid attack was used to acquire information on calcium and magnesium content with atomic-absorption spectroscopy. X-ray diffraction was used to determine the mineralogy of encrustations for a group of stent samples characterized by relatively high amounts of deposited material. RESULTS The composition of encrustations at the proximal coil reflected the composition of stones in patients with urolithiasis. Whewellite was the more common encrustant. In a regression model, the variable mostly related to the burden of proximal encrustation was urolithiasis (P = .04), especially in frequent stone formers. At the distal coil, higher degrees of encrustation were related to urinary tract infection (P = .012) and patients aging (P = .05), thus suggesting a possible association with a bladder outlet dysfunction. CONCLUSION The present study highlighted some variables related to stent encrustation and seems to be the first one analyzing separately the two coils. Our outcomes suggest that the so-obtained risk factors have to be considered when positioning a ureteral stent.

Changes in peak systolic velocity induced by chronic therapy with phosphodiesterase type‐5 inhibitor

The aim of this study was to assess the influence of chronic therapy with phosphodiesterase type‐5 inhibitor on penile haemodynamics at colour Doppler ultrasound. Thirty patients affected by erectile dysfunction (ED) of different aetiology tested with the International Index of Erectile Function (IIEF‐5) were evaluated with penile colour Doppler ultrasound during basic and dynamic phases (10 μg PGE1) before and after chronic self‐administration of sildenafil citrate (dosage: 100 mg as required, two to three times a week) for a period of 5–20 months (mean: 12.3). Treatment was interrupted 14–21 days before the second ultrasound evaluation. Peak systolic velocity (PSV) and end‐diastolic velocity (EDV) were recorded by means of colour Doppler; cut off values were 25 and 5 cm s−1 respectively. Data were compared by nonparametric tests. Twenty‐two of the 30 patients showed normal pre‐treatment PSV, while eight of 30 had an insufficient arterial flow. Mean pre‐treatment EDV was 4.7 ± 0.5. After chronic therapy with sildenafil, a global improvement of 10.5% on PSV was seen (P < 0.001), without any statistical difference between patients with normal pre‐treatment peak and those with a borderline one. No statistically significant changes were found for EDV (P = 0.98). It is concluded that chronic therapy with phosphodiesterase‐5 inhibitor results in a significant improvement in PSV values, probably due to a penile chronic vasoactive enhancement.

Knotted urethral catheter in an 80-year-old woman: Prevention and management of this unusual complication

Intravesical catheter knotting represents a rare event, especially described in paediatric literature. We report a case of a catheter knot, occurring in an 80-year-old woman, managed by means of sustained traction.

Urological concerns: Should trans-urethral catheter be located over or under the thigh?

INTRODUCTION Bladder catheterization is a common practice after several surgical procedures; a wrong trans-urethral catheter position can affect the outcomes of some urological maneuvers. We assess with a physical model the variation of intra-vesical pressures due to different locations of the catheter. MATERIALS AND METHODS Using a plastic bag fulfilled with 5l of normal saline, we try to reproduce bladder condition assessing pressures in case of catheter located over or under the thigh. RESULTS In case of catheter over the thigh, the flow of liquid is not allowed, and only a pressure of 23 cm of water induces the passage of fluid. CONCLUSION A wrong catheter position may adversely affect intravesical pressures; this finding has to be taken into consideration, especially when dealing with post-urological surgery catheterization.