Eugene V. Cattolica

The effect of behavioral therapy on urinary incontinence: a randomized controlled trial

OBJECTIVE To evaluate the effect of a low‐intensity behavioral therapy program on urinary incontinence in older women. METHODS A randomized clinical trial for community‐dwelling women at least 55 years reporting at least one urinary incontinent episode per week was conducted. Women were randomly assigned to a behavioral therapy group (n = 77) or a control group (n = 75). The treatment group had six weekly instructional sessions on bladder training and followed individualized voiding schedules. The control group received no instruction but kept urinary diaries for 6 weeks. After this period, the control group underwent the behavioral therapy protocol. Using per‐protocol analyses, t and χ2 tests were used to compare the treatment and control groups, and paired t tests were used to evaluate the efficacy of behavioral therapy for all women (treatment and control groups before and after behavioral therapy). RESULTS Women in the treatment group experienced a 50% reduction in mean number of incontinent episodes recorded on a 7‐day urinary diary compared with a 15% reduction for controls (P = .001). After behavioral therapy, all women had a 40% decrease in mean weekly incontinent episodes (P = .001), which was maintained over 6 months (P < .004). Thirty (31%) women were 100% improved (dry), 40 (41%) were at least 75% improved, and 50 (52%) at least 50% improved. There were no differences in treatment efficacy by type of incontinence (stress, urge, mixed) or group assignment (treatment, control). CONCLUSION A low‐intensity behavioral therapy intervention for urinary incontinence was effective and should be considered as a first‐line treatment for urinary incontinence in older women.

Risk factors for surgically treatedbenign prostatic hyperplasia in a prepaid health care plan

The relationship of age, medical history, personal habits, and urologic symptoms to the incidence of surgically treated benign prostatic hyperplasia (BPH) was studied in a cohort of 16,219 men, aged forty years and over, who received multiphasic health checkups (MHCs) during 1971 and 1972 in Oakland or San Francisco while members of the Northern California Kaiser Permanente Medical Care Program, a large prepaid health care program. Follow-up was carried out for surgically treated BPH from the date of the MHC to the date of the earliest of the following: surgery for BPH (n = 1,027); incidence of prostate cancer (n = 329), bladder cancer (n = 119), or both (n = 10); other prostate surgery (n = 5); death (n = 2,525); membership termination (n = 4,235); or December 31, 1987 (n = 7,969). The mean length of follow-up was twelve years. In multivariate analysis utilizing the Cox proportional hazards model, the following characteristics were positively associated (p less than 0.05) with risk of surgically treated BPH: age, low body mass index, nonsmoking (vs. current smoking), urine pH greater than 5, history of kidney x-ray and of tuberculosis, and each of five urologic symptoms (dysuria, loss of bladder control, trouble starting urination, nocturia, slow urine stream). The risk of BPH associated with obstructive urologic symptoms decreased markedly with age. Some of these findings are consistent with those from other studies (age, nonsmoking), while others (high urine pH, history of tuberculosis) are new and should be examined in other study populations.

Vasectomy and the risk of prostate cancer in a cohort of multiphasic health-checkup examinees: second report.

The relationship of vasectomy to prostate cancer was studied in 5,119 men with a self-reported history of vasectomy, identified at multiphasic health checkups undergone during 1977–82 while members of the Northern California Kaiser Permanente Medical Care Program. Three unvasectomized comparison subjects were identified for each vasectomized man, matched for age, race, marital status, and date and location of the examination. Follow-up for incident prostate cancer was conducted for a mean length of 6.8 years. The relative risk of prostate cancer associated with vasectomy was 1.0 (95% confidence interval = 0.7–1.6); the relative risk was approximately one, regardless of length of interval (less than 10 years, 10–20 years, more than 20 years) between vasectomy and multiphasic health checkup or the age at vasectomy (less than 40 years vs more than 40 years). These data support earlier findings reported in this study group of the lack of an association of vasectomy with subsequent risk of prostate cancer.

High Testicular Salvage Rate in Torsion of the Spermatic Cord

Acute, nontraumatic scrotal emergency operations were done on 104 patients. The testes were saved in 79 per cent of 67 patients with torsion of the spermatic cord. When the patients who presented late are excluded, aggressive treatment allowed a 93 per cent testicular salvage rate. Spontaneous or manipulative detorsion preoperatively resulted in a 100 per cent testicular salvage rate. If the patient seeks medical advice early a high testicular salvage rate can be obtained by proper diagnosis and prompt, aggressive detorsion either by manipulation when examined initially or at operation. These maneuvers are combined with bilateral orchiopexy to ensure permanent cure.

Dog bites to the male genitalia: Characteristics, management and comparison with human bites

Dog bites to the external male genitalia occur infrequently. We present 4 new cases and review 4 others described previously. Victims tend to seek medical care quickly. Thus, morbidity is directly related to the severity of the initial wound and delayed infectious complications appear to be minimal. Guidelines for management include irrigation, debridement as necessary, empiric antibiotics, consideration of tetanus and rabies immunization, and primary wound closure or surgical reconstruction. The differences between dog bites and human bites to the genitalia--primarily interval to presentation and subsequent likelihood of infection--are summarized. Measures to prevent dog bites are discussed.

Massive Hemospermia: A New Etiology and Simplified Treatment

Hemospermia is a common urologic symptom that is usually benign and self-limited, and required no clinical investigation. Massive hemospermia causing hematuria, with clot formation and occasional urinary retention, occurs in a subset of patients. Three patients are reported in whom cystourethroscopy demonstrated nonvaricose abnormal posterior urethral vessels. Treatment consisted of fulguration of the vessels. One patient was cured, 1 had no symptoms for 3 years and 1 improved slightly. Endoscopically, this is a safe simple outpatient surgical procedure that is recommended for massive hemospermia due to abnormal posterior urethral vessels.

REOPERATION AND MORTALITY AFTER SURGICAL TREATMENT OF BENIGN PROSTATIC HYPERTROPHY IN A LARGE PREPAID MEDICAL CARE PROGRAM

The incidence of reoperation and mortality after prostatectomy was studied in 8,219 men who underwent surgical treatment for benign prostatic hypertrophy between 1976 and 1987 while they were members of the Kaiser Permanente Medical Care Program, Northern California Region. The vast majority (94.5%) received transurethral prostatectomy (TURP). The cumulative 8-year probability of a second prostatectomy was 7.6% after TURP and 2.1% after open prostatectomy. The risk of mortality associated with transurethral prostatectomy relative to open prostatectomy was 1.6 (95% confidence interval 1.2, 2.1) 8 years postsurgery. The increased risk of mortality associated with transurethral prostatectomy was most prominent during the first 5 years postsurgery (relative risk 1.8, 95% confidence interval 1.3, 2.5) and declined to 1.1 (95% confidence interval 0.8, 1.6) for deaths occurring after the first 5 years. The finding of an increased risk of mortality associated with transurethral prostatectomy is consistent with other studies and is unexplained.

Comparison of laparoscopic and minilaparotomy pelvic lymphadenectomy for prostate cancer staging in a community practice.

OBJECTIVES To compare the cost-effectiveness and morbidity of minilaparotomy (MINILAP) and laparoscopic pelvic lymphadenectomy (LAP) in a community practice setting. METHODS We reviewed our experience with 44 consecutive patients with prostate cancer who had staging pelvic lymphadenectomy from January 1992 through April 1995 in a general health maintenance organization urology practice. Of this group, 22 men had LAP and 22 men had MINILAP. RESULTS MINILAP and LAP groups were similar in age (mean 67 years). Gleason score (mean 7.2 and 6.8), prostate-specific antigen level (mean 46 and 49 ng/mL), and clinical stage (T1 to T3). Operative time was statistically significantly shorter for MINILAP (mean 1.2 hours) than for LAP (mean 2.9 hours). Complication rate was 9.1% for MINILAP and 31.8% for LAP. Lymph node metastasis was found in 45% of MINILAP patients and in 27% of LAP patients. Mean initial hospital stay was 1.0 day for MINILAP and 1.6 days for LAP. Total hospital stay including hospital readmission for complications was 1.5 days for MINILAP and 2.6 days for LAP. Cost of MINILAP was at least

The safety of transurethral prostatectomy: a cohort study of mortality in 9,416 men.

1900 less than that of LAP because of shorter total hospital stay, shorter operation time, and lower equipment cost. CONCLUSIONS Compared with LAP, MINILAP was more cost-effective and produced less morbidity. Patient satisfaction with the procedures was similar. MINILAP is an excellent alternative to LAP for prostate cancer staging in general urology practice.

Preoperative Manual Detorsion of the Torsed Spermatic Cord

PURPOSE We assessed the mortality rate from transurethral resection of the prostate. MATERIALS AND METHODS From 1976 to 1984, 4,708 patients undergoing transurethral resection of the prostate for benign prostatic hypertrophy (BPH) were compared retrospectively to an age-matched group of 4,708 randomly selected Kaiser Permanente Medical Care Program members not undergoing surgery. The risk of mortality associated with transurethral resection of the prostate relative to no surgery was determined using proportional hazards models. RESULTS The relative risk for surgery versus no surgery for the total group was 0.88 (95% confidence interval 0.82 to 0.95). Similarly, the results for each 5-year age group demonstrated a relative risk of 0.77 to 0.95. CONCLUSIONS This cohort study showed no excess mortality for patients undergoing transurethral resection of the prostate compared to age-matched comparison subjects randomly selected from health plan members who did not undergo surgery. Information from this study about the safety of transurethral resection of the prostate can be shared with patients when discussing treatment options.