I. Schroeder-Printzen

Diagnosis and therapeutic management of 18 patients with prostatic abscess

OBJECTIVES Our retrospective study aimed to analyze the findings and therapeutic strategies in 18 men who were admitted to our department as outpatient emergency cases with prostatic abscess. METHODS During the period 1985 to 1997, prostatic abscess was diagnosed in 18 patients (mean age 48 years, range 20 to 68) on the basis of evidence of fluctuation at digital rectal examination and transrectal ultrasound (TRUS) findings. Diagnostic workup included analysis of midstream urine and abscess fluid for leukocytes and pathogens. Therapeutic options were conservative treatment and/or draining procedures. RESULTS Predisposing diseases were found in 13 men. Fluctuation at digitorectal palpation was present in 15 patients. In 3 patients, diagnosis was based on TRUS. All men demonstrated leukocytes in their midstream urine. Causative pathogens in midstream urine were found in 11 patients. In 3 men, additional microbiologic evaluation of abscess fluid revealed uncommon pathogens. All patients received antibiotic treatment. Nine men with monofocal abscess less than 1 cm in diameter were treated with antibiotic therapy and a suprapubic catheter. Surgical drainage (transperineal or transrectal puncture, partly guided by TRUS, or transurethral unroofing) was performed in 12 patients and included 3 patients in whom conservative treatment failed. CONCLUSIONS Our data confirm the importance of predisposing factors in the pathogenesis of prostatic abscess. Medical history and analysis of midstream urine indicated a diagnosis that was confirmed by digital palpation. In some cases, TRUS may improve diagnosis and treatment. Although both operative and conservative therapy strategies appear feasible, prostatic abscess chiefly requires individually selected drainage procedures.

Extracorporal Shock Wave Therapy in the Treatment of Peyronie’s Disease

Objective: To test whether extracorporal shock wave therapy (ESWT) has an effect in the treatment of Peyronie’s disease.Methods: 22 patients with Peyronie’s disease and previous unsuccessful oral drug therapy were treated with ESWT in a prospective design with a follow–up of at least 3 months; 23 age–matched patients without previous therapy received oral placebo drug for 6 months daily as control. The standard follow–up included palpation, ultrasound, autophotography and evaluation of symptomatology based on a symptom score. The shock waves were applied under ultrasound guidance using the ‘Storz Minilith SL1’ lithotripter.Results: The results show a significant decrease in penile curvature in the patients treated with ESWT. Concerning the decrease in pain, subjective improvement and improvement in the quality of sexual intercourse, there was no significant difference to the case–control group. The inhomogeneity of the 2 groups may influence these results due to the questionable varying natural history.Conclusions: A prospective, controlled multicenter study with standardized parameters (concerning technique and patients) is urgently required to test the effect of ESWT.

Evaluation of seminal plasma parameters in patients with chronic prostatitis or leukocytospermia

Summary. Though detailed cytological and microbiological diagnostic procedures are routinely carried out in male genital tract infection, the correct diagnosis and localization of inflammation or infection is often difficult. In this prospective study, the relevance of the seminal plasma markers PMN elastase, complement C3, CRP, fructose, PSP 94, PSA, and α‐glucosidase was investigated in 13 patients with chronic prostatitis, 31 patients with significant leukocytospermia, and 58 patients with non‐inflammatory diseases (controls). Statistically relevant results were obtained for PMN elastase when comparing chronic prostatitis with controls, leukocytospermia with controls (P<0.001) and chronic prostatitis with leukocytospermia (P<0.05); for complement C3 chronic prostatitis and leukocytospermia vs. controls (P<0.05) and for fructose/ejaculate leukocytospermia vs. controls (P<0.05). No statistically relevant differences were found for C‐reactive protein, α‐glucosidase, PSA and prostatic secretory protein (PSP 94). To delimit genital tract inflammation from non‐inflammatory patients, cutpoint levels for PMN elastase of 230 ng ml−1 and for C3c of 0.01 g l−1 were suggested. PMN elastase was shown to possess the strongest discriminating power. The assessment of a cutpoint for fructose to indicate seminal vesicle dysfunction is not possible as the significance level is weak (P<0.05).

Comparison of expressed prostatic secretions with urine after prostatic massage—a means to diagnose chronic prostatitis/inflammatory chronic pelvic pain syndrome

OBJECTIVES To compare the analysis of urine after prostatic massage (VB3) with expressed prostatic secretions (EPS) to assess the significance of leukocyte analysis in VB3 and to give a first hint of the diagnosis of inflammatory chronic pelvic pain syndrome (CPPS) when EPS cannot be obtained. METHODS Three hundred twenty-eight men (mean age 38 years, range 18 to 70) with expressible prostatic secretions were investigated. EPS were stained using the Papanicolaou stain and analyzed for leukocytes per high power field (HPF) (x1000). Additionally, identical aliquots of first voided urine (VB1), midstream urine (VB2), and VB3 were centrifuged, stained (Papanicolaou), and analyzed for leukocytes (x400). Patients with increased numbers of leukocytes in VB1 and VB2 (2 or more per x400) were excluded. For statistical analysis, Spearmans correlation coefficient for nonparametric tests was used. RESULTS Of 180 men with less than 10 leukocytes per HPF in EPS, 178 (98.9%) had less than 10 leukocytes per view field in VB3. In 148 men with 10 or more leukocytes per HPF in EPS, 136 (91.9%) also had elevated leukocyte counts in VB3. The presence of elevated leukocytes in VB3 predicted the presence of increased leukocytes in EPS with a high certainty: 91.9% sensitivity, 98.9% specificity, and 95.7% accuracy, with a positive and negative predictive value of 98.6% and 93.7%, respectively. CONCLUSIONS We conclude that the determination of leukocytes in VB3 is a feasible and reliable method compared with the analysis of EPS. However, although this association does not directly prove the significance of VB3 in those patients from whom no EPS can be obtained, we suggest this method be taken into account as an indirect indicator in the diagnosis of inflammation.

Serum levels of inhibin B and follicle-stimulating hormone may predict successful sperm retrieval in men with azoospermia who are undergoing testicular sperm extraction

To evaluate the predictive power for sperm retrieval in testicular sperm extraction of inhibin B and FSH levels in the peripheral blood in association with the testicular histology. Clinical study. Departments of andrology and urology at a university hospital.Fifty-two patients with azoospermia. Determination of serum levels of FSH and inhibin B in men with azoospermia. Testicular incision and histological investigation as well as testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection were performed. Comparison of hormone levels with different histological features of seminiferous tubules (normospermatogenesis, hypospermatogenesis, and Sertoli cell-only syndrome) and TESE outcome.With respect to the histological proof of spermatozoa, the sensitivity of the FSH levels >10 mU/mL was 82%, and of inhibin B levels, <79 pg/mL, 78%; the specificity was 80% for both hormone levels. With respect to the successful sperm extraction in the TESE procedure, the sensitivity of the FSH levels was 58% and the specificity was 50%; and the sensitivity of inhibin B levels was 52.5% and the specificity was 60%. Inhibin B and FSH levels are correlated with spermatogenetic activity. The combination of the two parameters is currently the best predictor for the presence of sperm, which may be found in TESE. However, the prediction is not absolutely reliable: TESE can be also successful when both hormone levels are outside the threshold levels.

Diagnostic Value of Magnetic Resonance Imaging in Peyronie’s Disease—A Comparison Both with Palpation and Ultrasound in the Evaluation of Plaque Formation ☆

OBJECTIVE To compare the value of magnetic resonance imaging (MRI) with palpation and ultrasound in the evaluation of plaque formation in Peyronies disease. METHODS 57 patients underwent a standardized diagnostic procedure to evaluate plaque formation consisting of palpation and ultrasonography (7.5 MHz). MRI was performed during flaccidity and during erection induced by Prostaglandin E(1) including intravenous application of Gadolinium-diethylenetriaminepentaacetic acid (Gd-DPTA). RESULTS With all methods, 93 plaques have been detected in 57 patients. 85 plaques (91.4%) have been evaluated by palpation alone. Using ultrasound, 52 of these 93 plaques (55.9%) were detectable. This is equivalent to 61.1% of the palpable plaques. MRI confirmed 58 of the palpated plaques (68.2%) and exposed 8 primarily not palpable plaques at the penile basis. MRI revealed more palpable plaques than ultrasound, but this finding was not significant (p = 0.083). By means of sonography, calcification was evident in 14 plaques. MRI failed in revealing any calcification. After application of Gd-DPTA, 5 of 57 patients (9%) demonstrated contrast enhancement indicating local inflammation. None of these patients reported on penile pain. CONCLUSIONS Penile palpation in combination with ultrasound represents the method of choice to diagnose plaque formation in Peyronies disease. MRI provides better information on plaque formation at the penile basis. Calcification can only be proven by ultrasound, not by MRI. There may be additional information by MRI about local inflammation. A prospective study comparing the histological and MRI findings should be performed to answer the question, if pain is really associated with inflammation.

Influence of autogenous leucocytes and Escherichia coli on sperm motility parameters in vitro

Urogenital infections are considered important factors in male infertility. In this in vitro study we have evaluated the impact of leucocytes in association with an artificial infection with Escherichia coli on the motility of human spermatozoa. Ejaculates and blood samples were obtained from healthy donors with normal semen parameters. Ejaculates were prepared by swim‐up technique and five fractions were isolated for incubation. Leucocyte subtypes were separated from blood samples by gradient centrifugation. Purified sperm suspensions were adjusted to a concentration of 20 × 106 ml−1 and incubated with lymphocytes/ monocytes, polymorphonuclear granulocytes (PMN), and E. coli. Samples were incubated for up to 6 h at 37 °C. Motility analysis was performed using a computer‐assisted sperm analyzer (CASA). Spermatozoa incubated with 3 × 106 PMN ml−1 revealed a significant (P=0.003) decrease in progressive motility after 2 h. This decrease remained weakly significant (P=0.024) after 4 and 6 h. Lymphocytes and monocytes had no effect on sperm motility. Spermatozoa incubated with granulocytes and E. coli demonstrated highly significant alterations in motility after 4 and 6 h of incubation (P < 0.001). The PMN indicate an effect on motility of spermatozoa under experimental conditions. However, the results suggest that bacteria are the primary agents that interfere with sperm motility.

Long-Term Results of Plaque Thinning with Carbide Burs, Small Incisions and Venous Grafting for Correcting Complex Penile Curvature in Peyronie’s Disease: Poor Results of an “Ideal” Approach

PURPOSE We evaluated the long-term results of plaque thinning by carbide burs, small transverse incisions and venous grafting for correcting complex penile curvature in patients with Peyronies disease. MATERIALS AND METHODS A total of 13 patients with Peyronies disease and complex penile curvature received plaque thinning by carbide burs equipped with a fraise, small plaque incision and venous grafting. All patients were available for long-term followup at a mean of 29 months. Preoperatively the mean dorsal curvature angle was 73 degrees with an additional malrotation in 4 patients. Followup consisted of a standardized interview and 3-dimensional photo documentation during erection. RESULTS Although penile straightening was achieved intraoperatively, dorsal curvature (mean 35 degrees) recurred in 8 men, of whom 3 noticed this deterioration after a longer period. Penile shortening (mean 3.3 cm.) occurred in 7 patients, and decreased rigidity during intercourse occurred in 4. CONCLUSIONS Hypothetically, a combined technique of thinning, incision and grafting seems to be an ideal surgical approach for correction of complex penile curvatures in Peyronies disease without plaque excision. Although the penis had been completely straightened intraoperatively, severe dorsal curvatures recurred and significant penile shortening became obvious in more than half of the patients. Manipulation of the plaque may be associated with activation of the disease, with all of the risks of recurrence and deterioration. Due to the poor results of the thinning procedures, we stopped using this surgical approach and now prefer a combination of small incisions and grafting only.

Prostaglandin E1 long-term self-injection programme for treatment of erectile dysfunction--a follow-up of at least 5 years.

Summary. Prostaglandin EI (PGE1) is currently the vasoactive drug of choice for intracavernous self‐injection therapy in the treatment of erectile dysfunction. PGE1 is often said to have a low incidence of side‐effects. However, real long‐term follow‐up reports are rare. Here, a report is presented on 32 patients who joined a long‐term self‐injection programme in which they used PGE1 for a minimum of 5 years under standardized protocol conditions. All these patients had an organic aetiology of erectile dysfunction, and their mean age was 58.7 ± 8.6 years. The period of observation was on average 75.4 ± 16.9 months, and the PGE1 dosage 13.5 ± 5.9μg. A total of 6799 injections were registered. The average number of injections was 213 ± 127 per patient, which is 2.8 injections per month and patient. As regards side‐effects, haematomas were registered in 1.9% of the patients and five cases of prolonged erection (0.07%) caused by unauthorized redosing were noted. Three patients developed reversible penile nodules. In 10 patients, the initial dosage had to be increased. Five patients dropped out after 5 years, none of them due to treatment complications. It is concluded that PGE1 self‐injection therapy is a simple and reliable method for long‐term use with hardly any side‐effects. The patients do not stop treatment because of complications.

Rational diagnosis of erectile dysfunction

SummaryIn diagnostics of erectile dysfunction there are different simple or large-scale procedures available. Refering to a three-step-scheme that makes difference in the diagnostics in I. non-invasive, II. semi-invasive and III. invasive procedures the current diagnostic measures will be explained. To the non-invasive measures do account the extensive patients history taking including the sexual history and the psychological diagnostics, the physical examination and laboratory screenings. The semi-invasive procedures include the intracavernous injection test with vasoactice substances, the doppler sonography and duplex or color duplex sonography, the corpus-cavernosum-electromyogram (CC-EMG) and other neurophysiological examinations. The third invasive step contains the dynamic infusion pharmacological cavernosography and cavernosometry (DICC) and the selective pharmacological phallo-arteriography. The procedures of this step are essentially limited to patients with erectile dysfunction who are planned for surgical interventions.ZusammenfassungZur Diagnostik der erektilen Dysfunktion (ED) stehen verschiedene einfache und aufwendige Verfahren zur Verfügung. Ausgehend von einem 3-Stufen-Schema, das die Diagnostik in I. nicht invasive, II. semiinvasive und III. invasive Maßnahmen unterteilt, werden die einzelnen, momentan aktuellen Verfahren erläutert. Zu den nichtinvasiven Maßnahmen zählen die ausführliche Anamnese einschließlich der Sexualanamnese und der psychologischen Diagnostik, die körperliche Untersuchung und Laboruntersuchungen. Die semiinvasiven Verfahren umfassen die Schwellkörperinjektionstestung (SKAT-Test) mit vasoaktiven Substanzen, die Doppler- bzw. Duplex- und farbkodierte Duplexsonographie, das Corpus-cavernosum-Elektromyogramm (CC-EMG) und die übrige neurophysiologische Diagnostik. Die 3. invasive Stufe umfaßt die dynamische Infusionspharmakokavernosographie und -metrie (DICC) sowie die selektive Pharmakophalloarteriographie. Die Maßnahmen dieser Stufe beschränken sich im wesentlichen auf die Abklärung von Patienten, bei denen operative Eingriffe geplant und möglich sind.