Franklin C. Lowe

The evaluation and treatment of nocturia: a consensus statement

What’s known on the subject? and What does the study add?

Cranberry juice and urinary tract infections: What is the evidence?

I is well “known” by the general lay public that cranberry juice is helpful in treating and preventing urinary tract infections (UTIs). However, the evidence for this assumption has never been critically reviewed in urologic reports or elsewhere. The evidence for the two proposed mechanisms of action of cranberry juice, urinary acidification and inhibition of bacterial adherence, are critically analyzed. Blatherwick1 in 1914 reported that cranberries are rich in benzoic acid and that benzoic acid is excreted as hippuric acid in the urine. For years, it was reported that the beneficial effect of cranberry juice was through the acidification of urine.2–4 We review the more current studies on the mechanism of action of cranberry juice on UTIs and its possible utility in the treatment of UTIs. Cranberries are one of three major native North American fruits, the others being concord grapes and blueberries. Native American Indians used the berries as a food source. In addition, they believed cranberries had medicinal properties. From the 1600s to the 1800s, cranberries were reportedly used for a variety of complaints, including blood disorders, stomach ailments, liver problems, and fevers. In the 1800s, cranberries were used by seamen to prevent scurvy at sea. Cranberries or Vaccinium macrocarpon are mainly grown in Massachusetts, Wisconsin, New Jersey, Oregon, Washington, and Canada. Cranberries can be processed into fresh fruit, concentrate, sauce products, and juice drinks. The single strength juice is very acidic (pH 5 2.5 or less) and is unpalatable. In the early 1950s, the cranberry juice cocktail was developed. Cranberry juice cocktail is a mixture of single strength cranberry juice (at least 25% by volume), sweetener, water, and vitamin C. Table I shows the composition of raw cranberries and cranberry juice per 100 g.5

Tamoxifen for flutamide/finasteride-induced gynecomastia.

OBJECTIVES Current therapies for advanced prostate carcinoma lead to a marked decrease in serum testosterone levels, which renders patients impotent. In preliminary studies, combination therapy with flutamide and finasteride has been used as an alternative therapy for the treatment of prostate carcinoma because potency can be preserved. Both of these agents can cause gynecomastia and breast/nipple tenderness. METHODS Six men being treated for advanced prostate carcinoma with flutamide/finasteride combination therapy developed painful gynecomastia, which was treated with tamoxifen 10 to 30 mg/day for 1 month. Clinical follow-up included breast measurements and determination of prostate-specific antigen (PSA), testosterone, and estradiol levels. RESULTS While on this combination therapy for prostate carcinoma, 4 of 6 patients experienced a decrease in PSA level to less than 0.5 ng/mL. All patients remained potent. Serum testosterone increased in each patient who had a baseline level drawn. Estradiol levels were noted to be elevated in 4 of 6 patients at the time of evaluation for gynecomastia. After treatment with tamoxifen, circulating estradiol levels increased in 3 patients from 1.3 to 2.2 times the baseline level. Five patients experienced complete resolution of breast and nipple pain on tamoxifen 10 mg/day within the first month. The other patient had to be treated with 30 mg/day for 1 additional month, which subsequently resulted in pain resolution. CONCLUSIONS These preliminary results suggest that low-dose tamoxifen is useful in treating painful gynecomastia for those patients on flutamide/finasteride combination therapy for advanced prostate carcinoma.

Placebo-controlled study of oral terbutaline and pseudoephedrine in management of prostaglandin E1-induced prolonged erections

Prolonged erections, priapism, secondary to pharmacologic stimulation are usually treated by drainage of the corporeal bodies and irrigation with a sympathomimetic. To study the efficacy of oral medical therapy in the treatment of priapism, 75 patients with pharmacologically induced (prostaglandin E1) prolonged erections were randomized to receive terbutaline, pseudoephedrine, or placebo. Detumescence occurred in 36 percent, 28 percent, and 12 percent, respectively. Terbutaline was significantly better than placebo (p < 0.05) in achieving detumescence. The results of this study suggest that oral terbutaline should be considered in the initial management of pharmacologically induced prolonged erections.

THE EFFECTS OF PROSTATIC MANIPULATION ON PROSTATE-SPECIFIC ANTIGEN LEVELS

Serum PSA determinations are an important part of the urologic evaluation for prostate cancer. DRE, TRUS, cystoscopy, and ejaculation have minimal effects on serum PSA levels. Prostatic massage, needle biopsy, TURP, and prostatitis can cause significant elevations of serum PSA (Table 1). These factors should be kept in mind for interpretation of PSA values.

Surgical management of ischemic penile gangrene in diabetics with end stage atherosclerosis.

PURPOSE We determined whether early surgical intervention for ischemic penile gangrene in diabetics can be successful and limit morbidity. MATERIALS AND METHODS A retrospective review was done of 7 diabetic patients with ischemic penile gangrene. RESULTS Three patients underwent early distal penectomy without complications. All 4 patients initially observed suffered liquefaction and progression from dry to wet gangrene, and 2 underwent surgery (subtotal penectomy in 1 and distal penectomy in 1 who required reoperations for wound complications). CONCLUSIONS With appropriate patient selection, surgical intervention can be successful and provide a better quality of life for those without terminal disease. Delaying intervention will usually require more extensive surgery and increase the risk of wound complications. However, observation is indicated for moribund hospitalized patients.

Kaposi’s Sarcoma of the Penis in Patients with Acquired Immunodeficiency Syndrome

With the growing number of patients with the acquired immunodeficiency syndrome there has been a marked increase in the incidence of Kaposis sarcoma. Kaposis sarcoma of the penis was the initial presenting manifestation of acquired immunodeficiency syndrome in 4 patients. Overall, less than 3% of all acquired immunodeficiency syndrome patients with Kaposis sarcoma have the initial lesion on the penis. However, eventually almost 20% of those with Kaposis sarcoma will have lesions on the genitalia. Therefore, urologists must have an understanding of the entity and its management. A conservative approach to treatment of these lesions is recommended.

PC-SPES: herbal formulation for prostate cancer∗ ☆

PC-SPES is a potent eight-herb formulation sold directly to consumers; it has promising efficacy in the treatment of prostate cancer (CaP). The product induces a castrate status in most, if not all, men, resulting in a 50% or greater prostate-specific antigen reduction in the great majority of men with androgen-dependent CaP and in more than one half of the men with androgen-independent CaP. The duration of response is not yet clear. The efficacy of PC-SPES appears to exceed that of androgen ablation alone, but is not necessarily separate from an estrogenic effect. Common side effects include gynecomastia, nipple tenderness, loss of libido, and impotency; uncommon side effects include a 4% incidence of thromboembolic phenomena, but also two reports of bleeding diatheses. The mechanisms of action may involve downregulation of the androgen receptor, induction of apoptosis by way of inhibition of the bcl-2 gene, and increased expression of p53. Two marker compounds in PC-SPES are baicalin and oridonin, both of which exhibit antiproliferative effects in CaP cell lines. Thousands of men are currently obtaining this nonprescription medicine, and physicians should ask patients specifically about its use. PC-SPES is of great interest in men with androgen-independent CaP, an area in which future research should be primarily directed.

Herbal medications in the treatment of benign prostatic hyperplasia (BPH)

Herbal medications are used widely in the treatment of BPH. Recent studies suggest a benefit for some of these products with few side effects. The results of these studies are summarized and the possible mechanism of action of these medications are reviewed.

Use of magnetic resonance urography

OBJECTIVES Magnetic resonance urography (MRU) is a new technique that uses heavily weighted T2 coronal images with fat suppression pulse. Urine appears white on MRU, resembling an intravenous urogram (IVU). Contrast agents are not necessary. This study describes the use of MRU in the diagnosis and treatment of patients with hematuria. METHODS One hundred six patients with microscopic or gross hematuria and 6 normal volunteers underwent MRU between 1992 and 1995. A modified, heavily weighted T2 technique with intravenous administration of furosemide and ureteral compression was used. Thirty-two patients had other imaging techniques as well for comparison. RESULTS MRU provided high-resolution images in almost all cases; 73 (69%) had a normal MRU. Significant findings in the 33 patients with abnormalities included renal cysts in 17 (51%), renal cell carcinoma in 6 (18%), transitional cell carcinoma in 5 (15%), ureteropelvic junction obstruction in 3 (9%), and stones causing obstruction in 6 (18%). Five patients with renal failure also had good visualization of the entire urinary tract. MRU was comparable to other imaging modalities except in identifying nonobstructing calculi. CONCLUSIONS MRU provides an alternative to conventional imaging of the urinary tract, especially in those patients who have contraindications to ionizing radiation and contrast agents. Improvements in resolution, technique, and cost have to be addressed before it can be used regularly in urologic practice.