Atsunobu Esa

URINARY INCONTINENCE IN SENILE DEMENTIA OF THE ALZHEIMER TYPE (SDAT)

Twenty patients (1 male and 19 females) with senile dementia of the Alzheimer type were studied using cystometry in combination with sphincter electromyography, brain computed tomography (CT) and evaluating the activities of daily life (ADL), with special reference to urinary incontinence. Seven of the patients were continent and the remainder were incontinent. Cystometry revealed uninhibited detrusor contraction in 8 out of the 13 incontinent patients, while no uninhibited contraction was found in 7 continent patients. There was a significant correlation between uninhibited detrusor contraction and urinary incontinence (p 0.05). Brain CT showed that the degree of brain atrophy was more severe in those with uninhibited contraction than those without (p 0.05). There was no clear relationship between sphincter coordination and the occurrence of incontinence. The ADL score tended to be lower in incontinent patients, although no significant difference was apparent (0.05 p 0.1). Uninhibited detrusor contraction and poor ADL functioning caused by brain atrophy are thought to be major causes of urinary incontinence in patients with senile dementia of Alzheimer type.

Clinical Efficacy of Oxybutynin on Sensory Urgency as Compared with That on Motor Urgency

Objective: Anticholinergic drug is widely accepted as an effective medication for frequency, urgency and urge incontinence related to detrusor overactivity (motor urgency). In order to elucidate whether anticholinergic drug is also effective for these symptoms related to bladder hypersensitivity (sensory urgency), clinical efficacy of oxybutynin on sensory urgency was compared with that on motor urgency. Method: Twenty-four patients with sensory urgency, and 53 patients with motor urgency were treated with oxybutynin (6 mg/day) for 4 weeks and subjective and objective efficacies were evaluated. Subjective parameters were quantified with urge score (grade 0–3) and daily numbers of voiding and incontinence. Objective efficacies were evaluated with pre-/ postcomparison of cystometric parameters. Results: Excellent or good overall efficacy was obtained in 62.5% (15/24) of the sensory urgency group and 60.4% (32/53) of the motor urgency group. There was no statistical difference between these two groups. Objective cystometric parameters, bladder volume at first sensation and maximum cystometric capacity, statistically improved after the treatment in both groups. Conclucion: The results suggest that oxybutynin works as well on sensory urgency as it does on motor urgency.

Sympathetic Skin Response: A New Test to Diagnose Ejaculatory Dysfunction

Sympathetic skin responses were elicited from the palm and sole (plantar) with electrical stimulation on the dorsal nerve of the penis in 24 individuals. The palmar and plantar sympathetic skin responses were obtained in 12 subjects with normal ejaculatory function. On the other hand, the plantar sympathetic skin response was absent in 11 of 12 patients who lacked ejaculation. Since the plantar sympathetic skin response is correlated closely to the mechanism of ejaculation, this test is expected to be helpful to diagnose sexual dysfunction and to monitor the effects of treatment.

Glomus tumor of the kidney.

A 41‐year‐old man was diagnosed with a glomus tumor of the kidney, which was incidentally found by ultrasonography. Partial nephrectomy revealed a 10‐mm encapsulated mass. We diagnosed it as a glomus tumor using morphological and immunohistochemical stains.

Long-term results and curative mechanisms of vesicoureteral reflux by endoscopic injection of blood

We describe our new endoscopic procedure for correction of ureterovesical reflux by endoscopic injection of the patients own heparinized blood behind the ureteral orifice. Before drawing out the needle, small amounts of thrombin and protamine were injected to prevent the injected blood from leaking. Of the 16 ureters treated (13 patients) with international grade I-III reflux, 9 showed complete absence of reflux. The technique is advantageous because it is technically simple and injection can be repeated until the reflux had disappeared. Furthermore, no complications such as distant migration of injected material or escape from the bladder mucosa have been observed. However, the treatment is not consistently successful in cases of high-grade reflux. After the operation, mucosal swelling of ureteral orifice and narrowing of the intramuscular ureter were observed by ultrasonography. The mean pressure of the intramuscular ureter increased 10 cm H2O after the operation. These consequences of the operation may prevent vesicoureteral reflux.

Endoscopic correction of vesicoureteral reflux in patients with neurogenic bladder dysfunction

Transurethral injection of Teflon paste (TUI) was carried out in 24 ureters of 16 patients with vesicoureteral reflux (VUR) secondary to neurogenic bladder dysfunction at an age ranging from 4 to 77 years, and the results were compared with those of conventional open surgery. During the mean follow-up period of 20.1 months, reflux disappeared in 19 ureters (79%), so that the success rate of endoscopic operation was considered to be satisfactory as compared with that of conventional open surgery, in which reflux disappeared in 16 (80%) of 20 ureters in 16 patients with neurogenic bladder dysfunction at our department. No exacerbation of hydronephrosis was observed postoperatively, and no complication was noted. This procedure, which is minimally invasive and technically simple, may be regarded as the first choice for VUR secondary to neurogenic bladder dysfunction.

Functional electrical stimulation in the management of incontinence: Studies of urodynamics

Intermittent functional electrical stimulation (FES) was employed for the control of incontinence. One FES session lasted for 30 minutes. It was repeated at intervals of 3 days to 1 week via an anal plug electrode.The success rate was 64% in 41 patients with pollakiuria, urgency and/or urge incontinence, and 43% in 7 patients with stress incontinence. Detrusor activity measured by cystometry did not correlate significantly with the effect on subjective symptoms and the urethral pressure did not increase. The remarkable clinical effect was observed in patients with overactive detrusor function.It seems that FES indirectly inhibits detrusor contraction by suppressing the intrasacral pathway for detrusor activity.

Burst activities of cremasteric motor units

Electromyographic activities of the ipsilateral creamaster muscle evoked by electrical stimulation of either the thigh or the penis were analyzed for latencies and burst durations. Response latencies were 30 ms on thigh stimulation and 30–35 ms on penile stimulation. With the increase in stimulus intensity the latencies decreased to 30 ms in both cases. The changes were stepwise, indicating the switching between different reflex arcs. The burst duration on thigh stimulation was about 50 ms, and that for penile stimulation was 45 ms. Impulses producing the burst consisted of larger and smaller spikes, and this indicates the grouping of motor units for wing tonic and phasic units. The results suggest the existence of parallel neuronal circuitries for the spinal cremateric reflex, and it is expected to provide a clue for evaluating the clinical significance of the cremasteric reflex.

Procalcitonin as an indicator of urosepsis.

Background Procalcitonin has been advocated as a marker of bacterial infection, so this study was carried out to determine the usefulness of serum procalcitonin in the early diagnosis of urosepsis. Methods The subjects were 37 febrile patients with urinary tract infection in whom we examined the serum procalcitonin concentration at the start of treatment. Results Thirty patients had acute pyelonephritis (16 simple, 14 complex), one had emphysematous pyelonephritis, five had acute prostatitis, and one had acute epididymitis. The procalcitonin level was <0.5 ng/mL in 18 patients, ≥0.5 ng/mL in one patient, ≥2 ng/mL in seven patients, and ≥10 ng/mL in 11 patients. Five of the 11 patients with procalcitonin levels ≥ 10 ng/mL had disseminated intravascular coagulation. All patients with urinary tract obstruction and disseminated intravascular coagulation had procalcitonin levels ≥ 10 ng/mL. Conclusion Although this retrospective study comprised a small number of patients, we found that procalcitonin was a useful marker for urinary tract infection.

Plasmablastic lymphoma of the right testis

Plasmablastic lymphoma (PBL) is a very rare disease. In 1997 Delecluse et al. reported a series of aggressive nonHodgkin’s lymphomas arising in the oral cavity of HIVpositive patients. In terms of clinical behavior, PBL is highly aggressive with short survival. This is the first report of PBL of the testis in Japan. A 76-year-old man had notable right-side scrotal swelling in September 2009 and underwent a medical examination in our hospital in October of the same year. Ultrasonographic examination demonstrated an enlarged right testis with a heterogeneous echo pattern. Levels of serum testicular tumor markers, including b-human chorionic gonadotrophin, a-fetoprotein and lactate dehydrogenase were all normal. We suspected that it might be a testicular tumor, so right high orchiectomy was performed in October 2009. Macroscopically, the tumor was ash gray in color, and there was no presence of bleeding or necrotic tissue (Fig. 1a). It consisted of diffusely proliferative, relatively uniform large cells with abundant cytoplasm. In particular, the tumor cells were plasmablastic-like and there were almost no mature plasma cells (Fig. 1b). Immunohistochemistry revealed the tumor cells to be positive for CD138, CD56 and epithelial membrane antigen; and negative for CD20, CD79a, CD3, CD10, CD30, cytokeratin and S100 protein. The pathological diagnosis was PBL. There was no evidence of human herpes virus-8 infection (according to polymerase chain reaction analysis), Epstein–Barr virus (according to in situ hybridization) and HIV. Pathologically, PBL is characterized by an immunoblastic or plasmablastic morphology and a plasma cell immunophenotype, and thus, its differentiation from other large B cell lymphomas or plasmablastic plasma cell neoplasms is often problematic. The immunophenotype of PBL tumor cells is almost identical to that of plasma cells; in particular, the expression of leukocyte common antigen and CD20 is absent or weak, but that of plasmacytic markers, such as CD138, is strongly positive. PBL has a well-established association with immunosuppression, and most particularly with HIV infection: approximately 80% of PBL patients are HIV-infected. Cases of PBL have also been reported after solid organ transplantation and in association with steroid therapy for autoimmune disease. PBL typically occurs in the oral cavity. However, PBL of the testis is very rare. Schichman et al. reported the first case. This report documents the third case of PBL of the testis in the world. Although cases of PBL have been reported from countries across the world , there has been only one report from Japan in the English-language published work. This may be because HIV infection is less prevalent in Japan than in other countries. The number of PBL cases in Japan may increase in the future.