T. Krarup

A Prospective Double-Blind Clinically Controlled Multicenter Trial of Sodium Pentosanpolysulfate in the Treatment of Interstitial Cystitis and Related Painful Bladder Disease

Painful bladder disease, sensory bladder disease, chronic abacterial cystitis and interstitial cystitis are ill-defined conditions of unknown etiology and pathogenesis, and, therefore, they are without any rational therapy. Pathogenetic theories concerning defects in the epithelium and/or mucous surface coat (including glycosaminoglycans) of the bladder, and theories concerning immunological disturbances predominate. Sodium pentosanpolysulfate (Elmiron) acts by substituting a defective glycosaminoglycan layer and inhibits complement reactions in inflammatory processes. We compared sodium pentosanpolysulfate versus placebo in a prospective double-blind, clinically controlled multicenter trial of 115 patients with painful bladder disease. Two protocols were used. Protocol A included 43 patients with clinically and pathologically anatomically verified interstitial cystitis (28 or more mast cells per mm.2), and protocol B included 72 patients with a painful bladder and unspecific histological findings. The patients were randomized to receive either sodium pentosanpolysulfate (200 mg. twice daily) or placebo capsules for 4 months. Before and after the trial the patients were evaluated with symptom grading, urodynamics and cystoscopy with distension and deep bladder biopsies. The results showed no difference between the pre-trial and post-trial values in the sodium pentosanpolysulfate and placebo groups in both protocols in regard to symptoms, urodynamic parameters, cystoscopic appearance and mast cell counts. A significant increase in the cystoscopically determined bladder capacity in the sodium pentosanpolysulfate group in protocol A was found. We conclude that no statistically or clinically significant effect of sodium pentosanpolysulfate was found compared to placebo in patients with painful bladder disease.

Painful Bladder Disease: Clinical and Pathoanatomical Differences in 115 Patients

The diagnostic criteria for interstitial cystitis considered as a subgroup of painful bladder disease (that is sensory bladder disease and chronic abacterial cystitis) are not well established. Some urologists rely on symptoms, while others rely on cystoscopic appearance or pathological findings. Among 115 patients with painful bladder disease we compared symptoms, and cystoscopic and urodynamic findings in those with and without detrusor mastocytosis (28 or more mast cells per mm.2) and attempted to elucidate possible differences between the groups. We chose the pathological anatomical criterion of detrusor mastocytosis to be diagnostic for interstitial cystitis. A total of 43 patients had detrusor mastocytosis and other pathological anatomical signs of interstitial cystitis, and 72 had no mastocytosis but the pathological diagnoses of chronic unspecific cystitis, fibrosis of the bladder, detrusor myopathy, intestinal metaplasia and normal findings. When the 2 groups of patients were compared we found no differences in regard to symptoms (pain, dysuria, frequency, nocturia and urgency), frequency of allergy and hysterectomy, duration of symptoms, petechial bleeding during cystoscopy with bladder distension and cystometric findings. The patients with mastocytosis differed from those without mastocytosis in that they were older, and had a higher frequency of hematuria, a higher frequency of a red, scarred and richly vascularized bladder at cystoscopy before distension, and a smaller cystoscopic bladder capacity. We conclude that by dividing patients with painful bladder into 2 groups according to the mast cell counts in the detrusor, certain differences in the clinical findings in the groups can be ruled out. However, in individual patients one cannot note with certainty to which pathological anatomical group the patient belongs, since great overlapping between the groups exists. Whether only patients with detrusor mastocytosis have interstitial cystitis depends on definitions and still remains an open question.

Transurethral Prostatectomy Compared with Incision of the Prostate in the Treatment of Prostatism Caused by Small Benign Prostate Glands

In a prospective, randomized study 60 patients with prostatism caused by small prostate glands (estimated weight < 20 g) had either transurethral prostatectomy (TURP, n = 31) or transurethral incision of the prostate (TUI, n = 29). Operating time and blood loss were significantly less in the group that underwent TUI. There were no differences between the groups in number of days with an indwelling catheter or days in hospital after operation. Eight patients in the TUI group required further operation, as did four in the TURP group, one of whom was discharged with a permanent indwelling catheter. In addition one patient developed a urethral stricture. Nine of the failures of treatment occurred within the first month. Fifty-one patients were followed up at 3 months and 47 were also seen at 12 months. Both operations significantly improved symptom scores and maximum flow rates compared with preoperatively, but the improvement in maximum flow rate was significantly better in the TURP group than in the TUI group. At 12 months TURP had also improved micturition time and voided volume, which TUI had not. Neither operation caused any significant change in sexual activity or erective potency postoperatively. Retrograde ejaculation was, however, seen in more than half of the patients in the TURP group, and only one in the TUI group. We recommend TUI for the treatment of prostatism caused by small prostate glands in patients who want to preserve normal ejaculation or are at poor surgical risk.

URINARY FLOW STUDIES IN NORMAL KINDERGARTEN- AND SCHOOLCHILDREN

The problems in the evaluation of children with suspected infravesical obstruction are shortly reviewed. Based upon literature studies it is concluded, that an isolated urinary flow measurement determining the Qmax is a suitable procedure of screening. Due to different shortcomings of earlier published normal materials, we investigated the spontaneous urination of 205 normal children aged 3 to 13 years in their normal environment. The mictiograph was installed in the toilet of two kindergartens and one school, enabling the children freely to void into the machine upon desire. From the flow curves the following parameters were calculated: Q1 sec, Qmax, Qmax time, and the micturition time, all of them being related to the square root of the voided volume. The data were non-parametrically statistically processed, and the limits of normal values (2 1/2% and 97 1/2% percentiles) are defined for different groups of age and sex. Furthermore, the different flow curve patterns are described, and it is found, that in 90% of the cases they are identical to the adult pattern.

Uroflowmetry in Neurologically Normal Children with Voiding Disorders

A prospective study was undertaken to delineate the role of spontaneous uroflowmetry as screening procedure for functional infravesical obstruction (detrusor/sphincter dyssynergia). More than 70% of thirty-nine children referred for urinary tract infections and/or enuresis in the absence of neurological deficits underwent a complete diagnostic program including intravenous urography, voiding cystography and cystoscopy as well as spontaneous uroflowmetry, cystometry-emg and pressure-flow-emg study. The incidence of dyssynergia was 22%. However, neither the flow curve pattern nor single flow variables were able to identify children with dyssynergia. Consequently uroflowmetry seems inefficient in the screening for dyssynergia in neurological normal children with voiding disorders in the absence of anatomical bladder outlet obstruction.

Herald Lesion of the Urinary Bladder

The herald lesion of the urinary bladder is defined as an unspecific localized cystitis, eventually polypoid, in patients with symptoms from the lower urinary tract. The herald lesion is visualized by cystoscopy. Biopsies from the lesion show unspecific acute and/or chronic inflammation often accompanied by hyperplasia of the transitional cell epithelium. The herald lesion portends a neoplastic or inflammatory process in neighbouring organs. At our Institute of Pathology fourteen cases of the herald lesion were diagnosed during one and a half years. In 113 consecutive patients with ulcerative colitis and Crohns disease no case of the herald lesion was found.

Contamination of Urological Wounds by Aerobic Bacteria: Transvesical Prostatectomy Used as a Model

The density of aerobic bacteria in the subcutaneous wound was quantified by the velvet pad rinse technique before (first stage) and after (second stage) opening of the bladder in 13 patients undergoing transvesical prostatectomy. Six patients had bacteria in the urine preoperatively (group A) and the same bacteria were isolated from bladder puncture during the operation and during second stage. Seven patients (group B) had sterile urine preoperatively and the bacteria isolated during first and second stage were commensals of the skin and the upper-respiratory tract. The bacterial density in group B was median 3.1 viable counts (v.c.) x 10(-1)/cm2 during first stage rising to median 4.7 v.c. x 10-1/cm2 during second stage, while group A showed an increase from median 4.3 v.c. x 10(-1)/cm2 during first stage to median 169,5 v.c. x 10(-1)/cm2 during second stage. The results of the study indicate the possibility of using selective antibiotic prophylaxis, with the relevant antibiotic for the bacteria isolated in the urine preoperatively, to reduce postoperative wound infection in urological surgery with opening of the urinary bladder.

LONG-TERM REMISSION OF TRANSITIONAL CELL CARCINOMA AFTER BACILLUS CALMETTE-GUERIN INSTILLATION IN THE RENAL PELVIS

Intravesical therapy with bacillus Calmette-Guerin (BCG) after transurethral resection of the bladder is known to reduce superficial transitional cell carcinoma recurrences. We report 2 cases of previous rapid recurrences of transitional cell carcinoma in the renal pelvis of a solitary kidney with long-term remission after BCG instillation through a nephrostomy tube. CASE REPORTS

Transurethral Prostatectomy or Incision of tie Prostate in the Treatment of Prostatism Caused by Small Benign Prostates

In a prospective, randomized study 21 patients with prostatism caused by small prostates (estimated weight less than 20 gram) had a transurethral prostatectomy (TURP), and 17 patients a transurethral incision of the prostate (TUI). In the TUI group operation time and blood loss was significantly less than in the TURP group, while there was no intergroup difference in postoperative fever greater than 38 degrees C, antibiotic treatment, number of days with indwelling catheter or days of hospitalization after surgery. Three patients in the TUI group had repeated surgery. In the TURP group one patient underwent reoperation and one was discharged with a permanent indwelling catheter. Thirty-three patients had a follow-up of 3 months. Both surgical procedures significantly improved symptoms and maximum flow rates, and there was no intergroup difference of the surgical outcome. Forty-five per cent in the TURP group developed retrograde ejaculation versus none in the TUI group. In this preliminary report TUI was as effective as TURP in relieving bladder outlet obstruction caused by small prostates.

Is there need for both intravenous urography and voiding cystography in the evaluation of children with recurrent urinary tract infections

SummaryIn a prospective study 33 children (aged 6–14 years) consecutively referred for recurrent urinary tract infections (RUTI), underwent intravenous urography (IVU) as well as voiding cystography (VC). Seven children had unilateral and two children had bilateral renal scarring, while ten children had unilateral and six children had bilateral vesico-ureteral reflux (VUR). Following normal IVU VUR was demonstrated in 22% of the ureters, but in all cases of low grade. In abnormal IVU, i.e. renal scarring or dilatation of the ureters, VC showed high grade VUR in 54% of the ureters. Based on these results and the current theories on the significance of patient age and the grade of VUR, we conclude that in case of a normal IVU in children with RUTI and age of at least 6 years, there is no reason to supplement the pre-treatment evaluation with VC.