Edwin M. Meares

Activation of Bladder Mast Cells in Interstitial Cystitis: A Light and Electron Microscopic Study

Interstitial cystitis, a sterile bladder condition, is characterized by urinary frequency, urgency, burning and suprapubic pain. Increasing evidence indicates that interstitial cystitis is a heterogeneous syndrome that reflects an immune response to a variety of triggers. More than 50% of the patients have allergies, 30% have the irritable bowel syndrome and almost 20% suffer from migraine headaches. Increased numbers of mast cells have been reported in interstitial cystitis. Mast cell activation, which is critical if these cells were to be implicated in this syndrome, has been investigated by electron microscopy, which definitively shows mast cell secretion. Recently, methylhistamine, the major metabolite of histamine, and the specific mast cell marker, tryptase, were shown to be significantly elevated in urine of interstitial cystitis patients. Bladder biopsies from 53 patients were analyzed blindly for the number and degree of activation of mast cells using 4 different stains for light microscopy, as well as electron microscopy. Controls included 16 patients with incontinence and chronic bacterial cystitis. Mast cells in controls were less than 10/mm.2 and were all nearly intact. Surprisingly, mast cells from 11 cancer patients averaged 50/mm.2 but almost all were intact. In contrast, mast cells from 26 interstitial cystitis patients averaged 40/mm.2 and more than 90% were activated to various degrees. Therefore, bladder mast cell activation is a characteristic pathological finding in at least a subset of patients with interstitial cystitis.

Prostatodynia: Clinical and Urodynamic Characteristics

Twenty patients with prostatodynia were studied urodynamically with synchronous video-pressure-flow studies and electromyography of the external urethral sphincter. The most striking finding was a significant increase in maximum urethral closure pressure compared to an age and sex-matched control group. Typically, peak and average urinary flow rates were decreased. Another prominent feature was incomplete funneling of the bladder neck during voiding with an accompanying urethral narrowing at the level of the external urethral sphincter. These findings are not consistent with a diagnosis of tension myalgia of the pelvic floor or detrusor-striated sphincter dyssynergia but suggest a primary abnormality involving the pelvic sympathetic nervous system. We believe that more advanced methods than those available currently are needed to elucidate fully the role of the autonomic nervous system, especially its sympathetic component, in the etiology of prostatodynia.

Current patterns in nosocomial urinary tract infections

Nosocomial infections develop in about 5 percent of patients admitted to acute care hospitals in the United States. The genitourinary tract is the primary site of infection in about 40 percent of cases, and urinary tract instrumentation and catheterization are implicated in about 80 percent of genitourinary tract nosocomial infections. Catheter-associated urinary tract infections are a frequent source of serious patient morbidity, urosepsis, and even death. The pathogenesis, risk factors, consequences, and preventive measures concerning nosocomial urinary tract infections are reviewed, and specific guidelines for catheter management are offered.

Computed tomographic findings in renal angiomyolipoma: An histologic correlation

Accurate preoperative diagnosis of renal angiomyolipomas is essential if conservative resection or angiographic embolization is to be used. Computed tomographic (CT) scanning failed to diagnose angiomyolipoma preoperatively in 2 patients, and this led to a retrospective review of 6 patients to define the limits of CT scanning in preoperative diagnosis. The CT findings were correlated with the histology of the tumors. Two tumors with positive attenuation coefficients suggestive of renal adenocarcinoma had significant amounts of immature fetal fat, and one of these had a virtual absence of mature fat. The relative inability of CT scanning to identify immature fetal fat, especially in the presence of abundant vessel and muscle elements, is a limitation to its use in the preoperative diagnosis of angiomyolipoma. A negative attenuation coefficient is highly characteristic of renal angiomyolipoma with mature fat elements. A positive attenuation coefficient, although suggestive of renal cell carcinoma, may be found in angiomyolipomas with paucity of mature fat or high proportions of immature fat.

Hemiacidrin Irrigation in the Management of Struvite Calculi: Long-Term Results

Renacidin (10 per cent hemiacidrin) irrigation has been used in the management of renal struvite calculi in 25 patients. Of these patients 22 were free of stone after irrigation: 16 after dissolution of residual stone fragments postoperatively, 4 after prophylactic postoperative irrigation and 2 after primary, nonsurgical percutaneous dissolution. Recurrent urinary tract infections owing to the original urease-producing bacteria occurred in 14 per cent of these patients and recurrent nephrolithiasis occurred in 9 per cent during an average followup period of 66 months.

Multicentric angiomyolipoma: renal and lymph node involvement.

A retrospective review of 6 patients with renal angiomyolipoma treated surgically revealed regional lymph node involvement in 2--an incidence of 33 per cent. The clinical behavior in these patients suggests that nodal involvement is an expression of multicentricity rather than metastatic disease.

Female urethral syndrome: Clinical and urodynamic perspectives

Eighteen women with the urethral syndrome were studied urodynamically with synchronous video-pressure flow studies and electromyography of the external urethral sphincter (EUS). When compared with an age and sex matched control group, the most striking finding was a significantly higher than normal maximum urethral closure pressure. Abnormal and low urinary flow rates, instability of the intraurethral pressure at rest, incomplete funnelling of the bladder neck, and distal urethral narrowing during voiding constitute other typical urodynamic findings in the female urethral syndrome. Detrusor-striated sphincter dyssynergia or primary striated sphincter spasm was not observed. Even though striated EUS spasticity cannot be excluded as a cause of this syndrome in some patients, an autonomically mediated spasm of the smooth muscle sphincter seems plausible to explain both our urodynamic findings and a favorable response of 4 patients treated with alpha-blocking agents.

Dissolution of struvite calculi by hemiacidrin solution.

Struvite calculi result from urinary tract infections secondary to urease‐producing bacteria. To prevent recurrent infection and stone formation complete removal of struvite calculi is recommended. Two illustrative reports of patients with renal struvite calculi are presented in which 10% hemiacidrin (Renacidin) irrigation was instituted for stone dissolution. After surgical removal of the calculi a nephrostomy tube was placed in the renal pelvis. With confirmation of residual struvite calculi, 10% hemiacidrin irrigation was initiated. Urine cultures, electrolytes and nephrotomograms were performed and adverse effects monitored. Using strict aseptic technique and appropriate precautions, hemiacidrin irrigation safely dissolves struvite calculi.

Primary carcinoma of fossa navicularis

A case of primary carcinoma of the fossa navicularis of the male urethra is discussed. The lesion presented as an ulcerative process that circumferentially involved the external urinary meatus in a sixty-three-year-old man. Initially, the lesion was confused with a superficial carcinoma of the penis, since results of urethroscopic examination were normal. Following midshaft penectomy, despite normal gross appearance of the distal urethra, histologic examination indicated poorly differentiated epidermoid carcinoma along the mucosa of the distal urethra up to the line of surgical resection. Subsequent total penectomy showed only a small area of residual tumor at the line of previous resection. Lymphadenectomy was not performed. The patient remains alive without evidence of residual disease five years later.

SPURIOUS AZOTEMIA ASSOCIATED WITH 5-FLUOROCYTOSINE THERAPY

A patient with false elevation of serum creatinine level due to 5-fluorocytosine (5-FC) is reported. 5-FC interferes with the enzymatic method used for creatinine determination in the Kodak Ektachem analyzer. Clinicians should be aware of the potential for spurious azotemia in patients receiving 5-FC therapy for fungal urinary tract infections.