Patsy R. Rhodes

A prospective study of quantification of urinary incontinence and quality of life in patients undergoing radical retropubic prostatectomy

OBJECTIVES To prospectively evaluate the level of urinary incontinence and its impact on quality of life in patients undergoing radical retropubic prostatectomy. METHODS Patients completed a 24-hour pad test together with an incontinence and quality-of-life questionnaire before and after surgery. RESULTS Patients were followed up for an average of 7.6 months (range 4.7 to 12.5) after radical prostatectomy. The 24-hour pad test demonstrated that 87% of patients had some incontinence at 1 month and 63% at 6 months after surgery. The median volume of urine leakage was 34 mL at the last follow-up visit; 55% of patients indicated substantial bother from incontinence at the 1-month follow-up visit and 29% at the 6-month follow-up visit. For most patients, there was a substantial discrepancy between the reported and the measured level of incontinence. Patient-reported bother regarding incontinence correlated best to the actual amount of urine loss. CONCLUSIONS Patients become incontinent after surgery but improve over time. Seventeen percent of patients still experienced leakage of more than 150 mL daily at the last follow-up visit. The questionnaire utilized in this study identifies the presence of incontinence but was not accurate in estimating the amount of urine loss. Initially, quality of life was reduced by surgery but improved over time and nearly returned to the preoperative level.

Sequelae of definitive radiation therapy for prostate cancer localized to the pelvis

OBJECTIVES To evaluate sequelae and estimate quality of life utilizing a survey instrument in 133 consecutive patients who have undergone definitive radiation therapy for localized prostate cancer. METHODS All patients reported on have been followed for 14 to 60 months (median, 31 months) after radiation therapy and only patients with definitive prostate radiation therapy are included. Of the patients still alive at time of follow-up, 115 were mailed the questionnaire. Data regarding tumor grade and stage as well as treatment were extracted from patient files. RESULTS Of the 91% of patients who returned the questionnaire, 11% used a pad and 13% leaked more than a few drops of urine daily. Of all the respondents, 9% stated that incontinence was a problem, and 31% found urinary leaking significantly worsened after radiation therapy compared with before their diagnosis of prostate cancer. With respect to sexual function, 77% recalled being able to have full or partial erections prior to radiation therapy. At some time after radiation therapy, 22% of previously potent respondents were able to have a full erection and 41% were able to have a partial erection. Twenty-nine percent of all patients who were able to establish an erection prior to radiation therapy reported that impotence was a problem at the time of follow-up. Forty-nine percent of patients had abdominal pain, diarrhea, or abdominal cramping during or after radiation therapy and 31% of all patients still had some intestinal symptoms at the time of follow-up. Eighteen percent of all patients were significantly bothered by one or more of these bowel problems. Overall, 31% of all patients reported a persistent degree of physical discomfort that they believed was secondary to their prostate cancer or the effect of treatment. Eighty-one percent were satisfied with radiation therapy and 97% of the patients said they would have radiation therapy again if faced with the decision. CONCLUSIONS Utilizing a sensitive questionnaire on patients who had definitive radiation therapy for prostate cancer, we found the incidence of patients bothered by incontinence to be surprisingly frequent and higher than previously reported. The frequency of impotence is similar to previous studies. However, when our incontinence and impotence data were compared to Medicare patients who had undergone radical prostatectomy, the frequencies after radiation therapy were significantly lower. Despite the rates of sequelae, the patients were generally satisfied with the decision to undergo radiation therapy and with the medical treatment received.

Long-term experience with pentosanpolysulfate in interstitial cystitis

OBJECTIVES An oral preparation of pentosanpolysulfate sodium (PPS) was recently approved by the Food and Drug Administration for interstitial cystitis (IC). Previously published articles have documented improvement in symptoms in 28% to 63% of patients, but no long-term studies have been published. No unique characteristics except for Hunners ulcer have been found in patients experiencing relief from PPS. We report our experience with PPS following patients up to 116 months and analyze baseline parameters in an attempt to characterize long-term responders. METHODS Baseline and follow-up data from 97 patients with IC and enrolled in a compassionate use study with PPS at the University of Wisconsin from 1987 to 1995 are analyzed. Previous treatments had failed, and patients had to pay for PPS. Patients continuing treatment with PPS were monitored every 3 months with questionnaires and laboratory tests. In 1996 an update on medication and a questionnaire developed by the National Institutes of Health Interstitial Cystitis Database were sent to patients who had discontinued treatment. RESULTS By the end of the study period 11 (11.3%) of the patients were still taking PPS, with 6 (6.2%) doing so continuously for more than 18 months. Three (3%) patients who discontinued PPS were in long-term remission. An additional 15% had remission for a substantial period. Except for a weak correlation between less constant pain (P = 0.0439), no correlations were found between baseline parameters and duration of treatment with PPS. CONCLUSIONS On a long-term basis, between 6.2% and 18.7% of patients with IC benefit from PPS. The only baseline factor predicting response to PPS was less constant pain.

A guinea pig model for study of bladder mast cell function : histamine release and smooth muscle contraction

To study the function of mast cells in bladder tissue, guinea pigs were sensitized with ovalbumin by intraperitoneal injections, bladder tissue strips were superfused, and tissue contractile force and histamine release were studied. Upon challenge with ovalbumin, bladder tissue contracted 64 +/- 4% (mean +/- S.E.M.) of the maximum carbachol contraction and released 14.1 +/- 1.6% of the total tissue histamine content. Incubation of sensitized bladder tissue with indomethacin led to an increased force and duration of the contraction while incubation with nordihydroguaiaretic acid combined with pyrilamine reduced histamine release and abolished the contraction. Tissue histamine content was significantly higher in the bladder neck than in the dome, and significantly elevated following sensitization. Histochemical studies of bladder tissue demonstrated mast cell degranulation in antigen challenge experiments. In addition, a group of guinea pigs were sensitized to ovalbumin through bladder instillations. With this model, study of the functional characteristics of bladder mast cells and the acute actions of mast cell products on the bladder microenvironment, should now be feasible.

Reproducibility of pressure-flow variables in patients with symptomatic benign prostatic hyperplasia.

OBJECTIVES To study the reproducibility of pressure-flow studies in patients with symptomatic benign prostatic hyperplasia and to investigate if the reproducibility is influenced by the method of intravesical pressure measurement, that is, transurethral catheterization versus suprapubic puncture. METHODS The within-patient variation of maximum urinary flow rates and detrusor pressure at maximum flow was investigated in 25 patients in whom 2 (transurethral group) or 3 (suprapubic group) sequential voidings during urodynamic investigation were analyzed. RESULTS The within-patient variation of pressure-flow values was evaluated by the intraclass correlation coefficient, which was 0.71 for maximum urinary flow rate and 0.84 for detrusor pressure, suggesting a relatively high degree of reproducibility. However in 26% of the patients, the maximum flow rates changed by more than 3 mL/s or the detrusor pressure by more than 20 cm H2O during the repeated tests. There was no significant difference in the within-patient variation of pressure-flow values between the suprapubic group and the transurethral group. CONCLUSIONS In larger clinical trials where the assessment of treatment effects between groups is desired, a single pressure-flow test is sufficient. In the individual patient, a single pressure-flow curve is of limited value due to a considerable within-patient variation of the test and, for these patients, multiple consecutive tests are recommended for diagnosis of intravesical obstruction and assessment of individual patients response to treatment.

In vitro effects of bladder mucosa and an enkephalinase inhibitor on tachykinin induced contractility of the dog bladder

Tachykinin-induced contractility of smooth muscle strips from dog bladders was studied in vitro, and the presence of substance P-like immunoreactivity and neurokinin A and neurokinin B-like immunoreactivity was examined in bladder sections. Nerve fibers with substance P-like immunoreactivity were present in the mucosa, submucosa and smooth muscle. Fibers were also found in nerves, intramural ganglia, and around blood vessels. Neurokinin A-like immunoreactivity had similar distribution, and no neurokinin B-like immunoreactivity was observed. Removal of the mucosa significantly enhanced the sensitivity and the maximum responses to the tachykinins. After removing the mucosa, the sensitivity to these tachykinins increased 0.4 to 0.5 log units (p less than 0.02). The responses to carbachol were not altered by mucosa removal. The leftward shifts of the concentration-response curves for neurokinin A were of similar magnitude after removal of the mucosa, and after pretreatment with phosphoramidon (10 microM), an enkephalinase inhibitor, in the presence of mucosa. However, phosphoramidon did not alter the sensitivity of the bladder strips to neurokinin B, and slightly changed the sensitivity to substance P (0.2 log units). Additional shifts of the substance P and neurokinin A curves to the left were observed in the presence of phosphoramidon when the mucosa was removed (0.6 and 0.5 log units, p less than 0.005). The order of potency for the tachykinins (neurokinin A greater than substance P) was not altered by mucosa removal, addition of phosphoramidon, or both. Neurokinin A was degraded by enkephalinase located in the bladder mucosa and addition of phosphoramidon or mucosa removal resulted in an inhibition or loss of enkephalinase activity. It is concluded that the responses to neurokinin A, which acts on NK-2 type of receptors, prevail on the dog bladder.

Position-related changes in voiding dynamics in men.

OBJECTIVES To investigate by urodynamic study position-related changes in uroflowmetry and postvoid residual urine volume (PVR) in men because altered bladder function in the supine position may be a predisposing factor for urinary tract infections in the institutionalized elderly. METHODS Two healthy men, 34 and 59 years of age and living at home, and 53 nursing home residents (mean age 71.8 years, range 46 to 92) were evaluated with uroflowmetry in the standing and recumbent positions (lying on the left or right side); corresponding PVRs were measured by transabdominal ultrasonic bladder scanning. The two healthy men were monitored longitudinally with multiple recordings in both voiding positions, and the nursing home residents were subjected to two observations: one measurement of the variable parameters in either position. Differences were considered to be significant at P < 0.05. RESULTS The 34-year-old man performed 51 3 flows (368 standing and 145 recumbent). The mean of all the peak flow rates in the upright (28.2 +/- 4.2 mL/s) versus the recumbent (16.8 +/- 4.1 mL/s) position revealed a highly significant difference (P = 0.0001). Sixteen urinary flows and corresponding PVRs were completed by this subject in either voiding position. The difference between PVRs in the standing (13.1 +/- 14.7 mL) versus recumbent (15.3 +/- 17.5 mL) position was not statistically significant. The 59-year-old man completed 156 flows (128 standing and 28 recumbent). A highly significant difference was noted between the mean of all peak flows in the upright (18.9 +/- 4.1 mL/s) versus recumbent (12.6 +/- 2.0 mL/s) position (P = 0.0001). Thirty-seven urinary flows and corresponding PVRs were completed by this individual (10 PVRs were determined after voiding in the standing and 27 after voiding in the recumbent position). No significant difference was noted between PVRs in the standing (24.6 +/- 34.4 mL) versus recumbent (16.5 +/- 60.0 mL) position. In the nursing home residents, the difference between the mean peak flow rates in the standing (14.5 +/- 8.6 mL/s) versus recumbent (12.4 +/- 6.7 mL/s) position also reached statistical significance (P = 0.0084). The difference between PVRs in the standing (60.5 +/- 125.6 mL) versus recumbent (84.8 +/- 186.2 mL) position barely reached statistical significance (P = 0.0497). CONCLUSIONS The urinary flow rate decreases in the recumbent position. Bedridden residents may be predisposed to urinary tract infections because of alterations in voiding dynamics in the supine position. This area needs further study.

Pelvic pain following radical retropubic prostatectomy: a prospective study.

OBJECTIVES To evaluate subacute and chronic pelvic pain after radical retropubic prostatectomy (RRP) performed for clinically localized prostate cancer. METHODS Twenty-four consecutive patients undergoing RRP completed pain, quality-of-life, and incontinence questionnaires. They also wore pads for 24 hours to measure urine loss objectively before and after surgery. RESULTS Three patients had pelvic pain preoperatively. Thirteen, 7, and 5 patients had pelvic pain at 1, 3, and 6 months, respectively, after RRP. At 6 months, none of the 5 patients with pelvic pain required analgesic medication. There was a strong relationship between pain and cancer worry, as well as between pain and incontinence. CONCLUSIONS Many patients have subacute pelvic pain after RRP but improve over time. Severe chronic pain is unlikely after RRP.

The Ampicillin Concentration in Prostatic Tissue and Prostatic Fluid

The concentration of ampicillin in prostatic fluid, prostatic tissue, blood and urine was determined in different groups of patients and dogs using bioassays. The concentration found in prostatic fluid was as high as that of blood and in patients with chronic prostatitis slightly higher. It is shown that this is probably due to contamination of prostatic fluid with urine, even if care had been taken to minimize this possibility. The importance of considering this factor in similar experiments is stressed. Only insignificant amounts of ampicillin were found in prostatic tissue removed at open prostatic surgery. Ampicillin was not found in therapeutic concentration in prostatic fluid of a patient with ureterosigmoidostomy and of dogs in which a prostatic fistula previously had been made. It is concluded that ampicillin is not found in prostatic tissue and prostatic fluid in therapeutic concentrations and therefore doubtful whether ampicillin will benefit patients with chronic prostatitis.