Intranasal steroids and septum perforation--an overlooked complication? A description of the course of events and a discussion of the causes

One of urodynamic diagnostic methods is visualisation of the bladder neck opening which enables seeing the difference between internal and external urethral sphincter disfunction. Micturition video cysto-urethrography with X-rays makes possible to carry on such examinations, but it requires catheterisation which makes the method invasive. My purpose is to replace this examination by dynamic functional evaluation of the internal urethral sphincter during transrectal ultrasonography. During 10 routine transrectal ultrasound examinations of the prostate, patients were asked to urinate. During examination changes in configuration of the bladder neck and prostatic urethra were observed. Two patients could not urinate in horizontal position. In the rest of the patients very clear pictures showing changes in the shape and dimensions of the urethra during urination, were achieved. They were much more clear in comparison with X-ray video cystourethrography. Transrectal sonography is a perfect technique of the visualisation of the bladder neck and prostatic urethra during urination. The suggested method should be included into the urodynamic examinations.     

Normal pelvic floor anatomy

The anatomy of the pelvic floor includes structures responsible for active and passive support of the urethrovesical junction, vagina, and anorectum. Intrinsic and extrinsic properties of the urethrovesical neck and anorectum allow maintenance of urinary and anal continence at rest and with activity. Damage to these structures may lead to loss of support and loss of normal function of the urethra, bladder, and anorectum. Over time, this damage can result in isolated or combined pelvic organ prolapse, urinary incontinence, and anal incontinence.     

The importance of sodium pyruvate in assessing damage produced by hydrogen peroxide

OBJECTIVES: The external striated urethral sphincter (rhabdosphincter) is a tubular muscle sleeve that extends from the prostato-membranous urethra and perineal membrane to the bladder neck. The male rhabdosphincter neuroanatomy remains unclear, and a better understanding of its innervation may provide insight into potential modifications of radical pelvic surgery to improve urinary continence. METHODS: Fresh cadaveric dissections of 12 male hemipelves were undertaken to investigate the neuroanatomy of the urinary rhabdosphincter. RESULTS: Neuroanatomic courses of the nerve supply to the rhabdosphincter revealed that, in the perineum, the perineal nerve (a terminal branch of the pudendal nerve) provided branches directly to the bulbospongiosus muscle and the urinary rhabdosphincter. In the pelvis, the course of the pelvic nerve was as follows: (1) arising from the inferior hypogastric plexus, it had a weblike course beneath the muscle fascia of the levator ani muscle; (2) traveling posterolateral to the rectum, it gave many branches that perforated into the lateral rectum; and (3) at the level of the prostatic apex, still beneath the levator ani muscle fascia (superior fascia), it sent multiple direct branches to the inferolateral aspect of urinary rhabdosphincter. The pudendal nerve traversed the pelvis in the pudendal canal, and, before leaving the pelvis to enter the perineum, it gave an intrapelvic branch that courses with the pelvic nerve to innervate the rhabdosphincter. CONCLUSIONS: Our understanding of the neuroanatomy of what may be the continence nerves has been improved by fresh cadaveric dissection. The rhabdosphincter receives nerve fibers from the pelvic nerve and dual innervation from an intrapelvic branch and a perineal branch of the pudendal nerve. Better understanding of these anatomic findings may have potential surgical significance with respect to improvement in postoperative urinary continence.     

Transrectal sonographic investigation of urethral and paraurethral structures in women with stress urinary incontinence

Transrectal sonography of the urethra was used in 14 asymptomatic volunteers, 37 women with frequency-urgency syndrome, 42 patients with mild stress urinary incontinence, and 18 with severe stress urinary incontinence. Transverse scanning over the midurethra was performed and cross-sectional images of the urethral and paraurethral structures were compared among the four groups, with P < 0.05 being considered statistically significant. The total cross-sectional area of the midurethra was significantly smaller in patients with stress urinary incontinence than in those without this disorder (86.7+/-29.9 versus 104+/-35.6 mm2, P = 0.005); this difference resulted from a significantly smaller peripheral striated muscle component in patients with stress urinary incontinence (42.8+/-20.7 versus 58.3+/-27.3 mm2, P = 0.001). The thickness of the urethropelvic ligaments was significantly thinner in patients with stress urinary incontinence than in those without (5.9+/-1.7 versus 8.9+/-2.1 mm, P < 0.001). The distribution of the peripheral striated muscle around the urethra was variable: complete surrounding the urethra was noted in 35.7% of the control women and in 48.6% of frequency-urgency patients, but only in 16.7% of patients with mild stress urinary incontinence and 5.3% of patients with severe disease. Bladder neck incompetence was seen in 42 patients with stress urinary incontinence but in none of the control women. The length of the pubourethral ligaments was similar in the four groups. Our finding showed that stress urinary patients had a smaller striated muscle component in the midurethra and thinner urethropelvic ligaments. These defects in the continence mechanisms might have great implications in the pathophysiology of stress urinary incontinence. Transrectal sonography of the urethra is a valuable investigative tool in assessing urethral and paraurethral conditions in patients with stress urinary incontinence before deciding treatment modality.     

Neurotransmitters in the human urethral sphincter in the absence of voiding dysfunction

The purpose of this study was to elucidate the neuroregulation of sphincteric relaxation by investigating the density of nerves containing acetylcholine, noradrenaline, neuropeptide Y (NPY), galanin, vasoactive intestinal polypeptide (VIP) and calcitonin gene-related peptide (CGRP) in the urethral sphincter in patients without a voiding disorder. The complete urethral sphincter (from the bladder neck to beyond the striated external sphincter) was excised from four male and four female adult cadavers and one male and one female fetus. In transverse paraffin or cryostat sections, the above transmitters were identified by histochemical methods. The striated sphincter was densely innervated by cholinergic nerves. Adrenergic nerves next to striated fibers were rare, but were present in all patients. NPY was seen rarely along striated fibers. In the smooth sphincteric component, noradrenaline-, acetylcholine-, NPY- and galanin-reactive nerves were observed frequently. Only functional studies can clarify the clinical implications of these results. Judging from NPY's scarcity in the striated sphincter no efferent function is anticipated. In the smooth component the frequent appearance of NPY, galanin and noradrenaline suggests a regulatory role for these transmitters.     

Impact of the prostatic apex on continence and urinary flow in patients with intestinal neobladders

OBJECTIVE: To determine the impact of preserving the prostatic apex on continence and urinary flow in patients with post-cystectomy intestinal bladder substitutes. PATIENTS AND METHODS: A total of 38 male patients underwent radical cystectomy for bladder carcinoma and construction of a neobladder from ileum [9], sigmoid [9] or an ileocaecal segment [20]. The intestinal reservoir was anastomosed to the membranous urethra in 25 patients and to the apical prostatic capsule in 13. A subjective evaluation of urinary continence, uroflowmetry and urethral pressure profilometry were performed 1-3 years after surgery. RESULTS: The only variable which showed a significant difference between patients with and without preservation of the prostatic apex was the functional profile length (P < 0.05). Conversely, there was no statistically significant difference in the continence result, peak flow rate and maximum urethral pressure between these two groups. However, there was a significant difference (P < 0.05) in peak flow rate among the three versions of neobladder in patients with a preserved prostatic apex (9.4 mL/s in ileal vs 15.8 mL/s in sigmoid and ileocaecal segments). CONCLUSION: Preservation of the prostatic apex does not improve urinary continence in patients with intestinal neobladders and may present an element obstructing the evacuation of ileal bladders.     

Early detection of diabetic visceral neuropathy. An electrophysiologic study of bladder and urethral innervation

The segmental and supraspinal innervation of the detrusor muscle and periurethral striated musculature was studied in 27 patients with diabetes mellitus by gas cystometry, integrated sphincter electromyography, and spinal evoked-response latency measurements. Slowing of neural conduction velocities was a consistent finding in all the patients, even when cystometry did not show abnormalities. Thus, neuropathy in the segmental innervation of the bladder and urethra was documented.     

The natural history of condyloma in children

OBJECTIVES: To prospectively evaluate our previously established pathologic risk factors in women undergoing cystectomy for bladder cancer and to determine if these criteria identify appropriate female candidates for orthotopic diversion. METHODS: Prospective pathologic evaluation was performed on 71 consecutive female cystectomy specimens removed for primary transitional cell carcinoma of the bladder. The histologic grade, pathologic stage, presence of carcinoma in situ, number, and location of tumors were determined. In addition, final pathologic analysis of the bladder neck and proximal urethra was performed and compared with the intraoperative frozen-section analysis of the distal margin (proximal urethra). RESULTS: Tumor at the bladder neck and proximal urethra was seen in 14 (19%) and 5 (7%) cystectomy specimens, respectively. Bladder neck tumor involvement was found to be the most significant risk factor for tumor involving the urethra (P <0.001). All patients with urethral tumors demonstrated concomitant bladder neck tumors. However, more than 60% of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. Furthermore, no patient with a normal bladder neck demonstrated tumor involvement of the urethra. Intraoperative frozen-section analysis of the distal surgical margin was performed on 47 patients: 45 without evidence of tumor and 2 patients with urethral tumor involvement. In all cases, the intraoperative frozen-section analysis was correctly confirmed by final permanent section. CONCLUSIONS: We prospectively demonstrate that bladder neck tumor involvement is a significant risk factor for urethral tumor involvement in women. However, despite bladder neck tumor involvement, a number of women undergoing cystectomy for bladder cancer have a normal urethra and may be candidates for orthotopic diversion. Furthermore, our data demonstrate that intraoperative frozen-section analysis of the distal surgical margin accurately and reliably evaluates the proximal urethra and currently determines which patients undergo orthotopic diversion at our institution.     

A prospective study of alcohol, smoking, caffeine, and the risk of duodenal ulcer in men

OBJECTIVE: To examine whether transrectal voiding ultrasonography (TRVUS) can evaluate voiding movement in men with dysfunctional voiding. METHODS: Ninety-nine consecutive men complaining of voiding difficulties without benign prostatic hyperplasia, prostatic cancer, severe bladder neck contracture and urethral stricture received uroflowmetry and TRVUS. Those who had abnormal findings on both uroflowmetry and TRVUS underwent subsequent cystometry combined with electromyography (EMG) to confirm the presence of dysfunctional voiding. RESULTS: Uroflowmetry indicated abnormal findings in 31 of the 99 patients, and TRVUS demonstrated abnormal movements of the posterior urethra during voiding in all of these 31 patients and 11 of the other 68 patients whose uroflowmetry did not indicate abnormality. TRVUS findings of the former 31 were divided into type E (the external urethral sphincter closed or intermittently opened while the bladder neck manifested an opening movement of > 7 mm during voiding in 20) and type I (both the bladder neck and external urethral sphincter manifested an intermittent movement of < 7 mm in 11). Subsequent cystometry combined with EMG in the 31 patients who had abnormal findings on both uroflowmetry and TRVUS revealed overactivity of the external urethral sphincter (OS) and underactivity of the detrusor (UD) in 85 and 35% of type-E group and 55 and 73% of type-I group, respectively. Type E included significantly more OS without UD than type I (65 vs. 18%; p = 0.0233). All of type-E (20/20) and 91% of type-I (10/11) patients had voiding difficulty which resulted from either OS or UD, while a very limited number of patients (4/31) manifested neurological symptoms such as paraplegia except for voiding difficulties. CONCLUSIONS: Both uroflowmetry and TRVUS are easy and useful methods to evaluate dysfunctional voiding in men, especially when neural disorders or organic obstruction of the lower urinary tract are not apparent.     

Nitric oxide synthase in the heterogeneous population of intramural striated muscle fibres of the human membranous urethral sphincter

PURPOSE: Nitric oxide (NO) is known to relax urethral smooth muscle. The role of NO in the control of urethral striated muscle remains unknown. We have investigated the distribution of nitric oxide synthase (NOS) immunoreactivity and its possible relationship with subtypes of intramural striated muscle fibers in the human male membranous urethra. MATERIALS AND METHODS: Whole transverse cryostat sections from seven membranous urethrae were studied using NOS immunohistochemistry and NADPH diaphorase histochemistry. Striated fiber subtypes were demonstrated using immunohistochemistry for troponin T and histochemistry for myofibrillary adenosine triphosphatase (ATPase). Consecutive sections were used to assess the correlation between the distribution of NOS immunoreactivity and the type of striated fibers. RESULTS: NOS immunoreactivity and NADPH diaphorase activity were detected in the sarcolemma of 48.5% of the intramural striated muscle fibers. NOS immunoreactive nerve trunks and fine nerve fibers, a few of which appeared to end on muscle fibers, were present in the striated sphincter. Fast twitch fibers were detected by ATPase staining, and also exhibited positive immunoreactivity for troponin T, constituting 34.6% of the total number of striated fibers. Two populations of slow twitch fibers were identified; one with small diameter (mean: 15.7 microns) and another of larger diameter (mean: 21.7 microns) comparable to that of fast twitch fibers. 86% of the fast twitch fibers and 29% of slow twitch fibers (most of which had larger diameters) exhibited NOS immunoreactivity and NADPH diaphorase activity in the sarcolemma. CONCLUSIONS: The presence of nitrergic nerve fibers in the striated urethral sphincter suggests an involvement in the innervation of urethral striated muscle. Furthermore, the presence of NOS immunoreactivity in the sarcolemma may indicate a role for NO in the regulation of urethral striated muscle metabolism and contraction.     

Muscular urinary sphincter: electrically stimulated myoplasty for functional sphincter reconstruction

PURPOSE: To reconstruct an electrically stimulated muscular urinary sphincter (MUS) using a tailored gracilis muscle free flap with intact nerve. MATERIALS AND METHODS: Unilateral surgically tailored gracilis muscle free flaps were transferred into the pelvis in eight dogs, leaving the obturator nerve intact. The muscle's pedicle vessels were anastomosed to the inferior epigastric artery and vein in the pelvis and the muscle was wrapped around the bladder neck. Electrodes were inserted into the MUS and connected to a programmable pulse generator. After 8 weeks of training the MUS, the pulse generator was programmed to be "on" for 4 hours and "off' for 15 minutes in a continuous cycle. Urodynamic studies were performed periodically, and at the end of the experiment the MUS and proximal urethra were harvested for histology. Three control dogs had sham operations. RESULTS: All MUS's functioned well following the procedure. Histology of the MUS/urethra complex showed no evidence of stricture. Except for one dog, all urethras were easily catheterized. CONCLUSIONS: This electrically stimulated innervated free-flap MUS technique effectively increases bladder outlet resistance without producing urethral obstruction.     

Anatomy of radical prostatectomy as defined by magnetic resonance imaging

PURPOSE: We examined and defined anatomical structures relevant to radical prostatectomy using magnetic resonance imaging. MATERIALS AND METHODS: Before radical prostatectomy, 15 men underwent high-resolution magnetic resonance imaging studies of their pelvic floors (fast spin echo, T2 weighting of 3- to 4-mm. contiguous or overlapping slices) in axial, coronal, and sagittal planes. RESULTS: Pubovesical ligaments, rather than the commonly reported puboprostatic ligaments, were observed attaching the bladder-prostate unit to the pubis. We suggest that the part of the urethra that extends from the apex of the prostate to the bulb of the penis, which is surrounded by the striated sphincter, should be termed the sphincteric urethra rather than the membranous urethra. Further, we found no evidence that supports the traditional concept of a urogenital diaphragm. The lower part of the striated urethral sphincter was flanked on its sides by the anterior recesses of the ischioanal fossae. The portion of the levator ani, which we have termed the puboanalis sling, flanked the apex of the prostate. The most anteromedial portion of this sling inserts into the perineal body and should be termed the puboperinealis. The terminal part of the gastrointestinal tract (the part continued beyond the levator ani) should be termed the anal canal, not the rectum, as used frequently in the urologic literature. Therefore, the initial plane of dissection in radical perineal prostatectomy passes along the anterior portion of the anal canal, not the rectum. CONCLUSION: We used magnetic resonance imaging to study male pelvic floor and perineal anatomy without the artifact of dissection. This study allowed us to devise a more precise nomenclature with respect to radical prostatectomy and, in so doing, to provide a better understanding of both the retropubic and the perineal operations.     

Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study

PURPOSE: The impact was determined on post-prostatectomy urinary incontinence of a technique preserving the anterior attachments of the proximal urethra to the posterior pubis by comparison to the results of other surgical methods. MATERIALS AND METHODS: Urinary continence in 51 patients undergoing preservation of the anterior urethral attachments was compared to that of 70 patients undergoing an anatomical prostatectomy with resection of the bladder neck, 55 patients with preservation of the bladder neck and 14 patients undergoing a dorsal vein gathering procedure. Comparisons were made for rate of total continence, time to return of continence, incidence of extra organ disease and operative blood loss. RESULTS: Total continence at 1 year was 84.3%, 89.1%, 85.7% and 100% respectively. Immediate total continence after catheter removal was seen in 25.5% after preservation of the anterior urethral attachments, 80.4% at 3 months compared to 41.4%, 50.9% and 50% at 3 months for anatomical prostatectomy with bladder neck resection, preservation and dorsal vein gathering. Clinical staging with the incidence of specimen confined disease was similar in all groups. Mean operative blood loss was 1,031 ml. for those patients undergoing anatomical prostatectomy compared to 681 ml. for those with preservation of the anterior urethral attachments. CONCLUSIONS: Preservation of the anterior urethral attachments results in improved urinary continence and lower operative blood loss without an increase in positive surgical margins.     

Value of transrectal ultrasonography in the assessment of failures of stress urinary incontinence surgery in women

OBJECTIVES: To describe the role of transrectal ultrasonography as an alternative imaging technique in the evaluation of women who continue to be incontinent following surgical management of female stress urinary incontinence. METHODS: The means of independent samples of transrectal ultrasound parameters of two groups of patients (group I, patients who were continent after surgery; group II, patients who remained incontinent after surgery) were compared. RESULTS: Patients who were continent after surgery showed scanty caudal and dorsal mobility of the bladder neck and proximal urethra during the periods of increased intraabdominal pressure. The US finding in this group of patients is characterized by a funnel surrounding the bladder neck and the proximal urethra. The existence of an intrinsically incompetent sphincter can also be determined with this technique. CONCLUSIONS: Transrectal ultrasonography constitutes an alternative imaging technique in the evaluation of women who continue to be incontinent following surgical management of female stress urinary incontinence. It permitis determining whether incontinence is due to a failed procedure, the existence of an intrinsically incompetent sphincter, or whether other causes of incontinence should be investigated.     

Trace elements in egg contents and egg shells of slider turtles (Trachemys scripta) from the Savannah River Site

OBJECTIVES: Stricture of the vesico-urethral anastomosis is a well-known complication after radical prostatectomy. Dilatation, stricture incision or resection have been proposed for endoscopic treatment. METHODS: In a retrospective study of 340 patients with prostatic cancer who underwent a radical retropubic prostatectomy from 1988 until 1996, we looked at the incidence of anastomotic strictures. RESULTS: An anastomotic stricture was found in 24 cases (7%) requiring endoscopic treatment. Based on prospective X-ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. No continence problems were encountered following structure resection in a follow-up of 12-72 months determined by a questionnaire and pad test. CONCLUSION: The transurethral resection of anastomotic stricture allows for a rather generous tissue resection, which is preferable to incision or dilatation in our hands.     

Decreased sensitivity in the membranous urethra after orthotopic ileal bladder substitute

PURPOSE: The effect of cystoprostatectomy with orthotopic substitution on membranous urethral sensation and subsequent urinary continence is unknown. We determined the sensory threshold for electrical stimulation of the membranous urethra and correlated it with continence, nerve sparing surgical technique and potency. MATERIALS AND METHODS: The sensory threshold was measured in a control group of 35 men before radical prostatectomy or cystoprostatectomy and in 47 men after cystoprostatectomy and ileal bladder substitution. RESULTS: The sensory threshold of the membranous urethra was 9+/-2 in the control group compared to 27+/-11 mA. in the postoperative group (p<0.001). Patients with daytime continence had a threshold of 24+/-9 compared to 39+/-10 mA. in incontinent patients (p<0.001). We were unable to show any correlation between the sensory threshold in patients with (25+/-10 mA.) and without (31+/-11 mA.) attempted nerve sparing surgery (p = 0.1) nor between potent (25+/-12 mA.) and impotent (27+/-11 mA.) patients (p = 0.4). CONCLUSIONS: Sensitivity in the membranous urethra decreased in patients after cystoprostatectomy and ileal bladder substitution. Urethral sensitivity in the sphincter area was better in continent than incontinent patients. Since we were unable to find any correlation between the sensory threshold and nerve sparing surgery or potency, it may be assumed that at least part of the sensory fibers to the membranous urethra pass through the pudendal nerve and/or the intrapelvic extrapudendal nerve fibers.     

Prenatal ultrasonographic findings of intra-abdominal cystic lymphangioma: a case report

The integrity and functional capacity of the urethral sphincter is one of the important prerequisites of urinary incontinence in women. Urodynamic investigations revealed repeatedly that the maximum closure pressure in the median portion of the urethra corresponds to the maximal thickness of the external urethral sphinctor (rhabdosphincter urethrae). This striated muscle is adapted to maintain a relatively steady tonus which assists the closure mechanism of the urethra [4]. In the submitted study the authors focused attention on the ultrasonic visualization of the internal urethral sphincter in order to assess the relationship between the size of this sphincter and the stress type of incontinence (genuine stress incontinence-GSI). The investigation comprised thirty women with confirmed GSI and a control group of thirty asymptomatic volunteers. During perineal ultrasonic examination of women in a supine position by means of an ACUSON 128 XP 10 apparatus using a convex probe with a frequency of 5 MHz the authors recorded statistically significant differences in the areas and maximal thickness of the urethral sphincter in women with stress incontinence and symptom-free women. From the results ensues that the size of this muscle is much smaller in women suffering from GSI.     

The longitudinal muscle of the anal canal

The longitudinal muscle (LM) represents a strong muscular structure of the anal canal situated between the internal (IAS) and the external anal sphincter (EAS). Terminal fibres of this muscle insert at the submucosa of the anal canal, representing the m. canalis ani. Others cross the subcutaneous part of the EAS to become the m. corrugator ani. Thus, the LM connects the visceral and somatic parts of the anal sphincter complex. Histologically ganglionic cells and as Vater-Pacinian corpuscles can be identified inside the LM. Morphology, topography and histology of the LM suggest that this muscle participates in maintaining anorectal continence. It is mandatory that the exact functions of this muscular structure be to elaborated upon, if we are to understand the mechanism of anorectal continence.     

Innervation of the striated muscle of the membranous urethra of the male dog

PURPOSE: To identify the functional innervation of the striated muscle layer of the post-prostatic urethra of male dogs. MATERIALS AND METHODS: Detailed anatomic dissection of the pelvic and pudendal nerves was carried out. The pressure and contractile responses to stimulation of these nerves were recorded in vivo and in vitro. RESULTS: Small branches of the pelvic nerve entered the membranous urethra but passed through the striated muscle to the inner smooth muscle layer. Stimulation of the nerve with 1 msec pulses at 10 Hz produced a slow contraction of the urethra which was unaffected by d-tubocurarine. Pudendal nerve branches entered the striated layer from the caudal end. Stimulation produced a rapid, visible contraction that was abolished by d-tubocurarine. Field stimulation of isolated strips of striated muscle resulted only in rapid, d-tubocurarine sensitive contractions. CONCLUSIONS: The striated muscle of the membranous urethra is innervated exclusively by the pudendal nerve.     

Brain iron and neurological disorders

The use of metal stents for the relief of prostate obstruction in the elderly has increased in popularity since 1980. The finding that fine metal wire stents become covered with prostatic epithelium led to the recent use of stents that can be left in place permanently. Because the prostatic urethra does not always conform to the cylindrical shape of these stents, and because the bladder neck/urethral angle is not a right angle and may not be circular in outline, problems may occur with positioning and subsequent inadequate epithelial covering. Three-dimensional imaging of the prostatic urethra using transrectal ultrasound scanning during voiding may give additional help in defining the variety of possible shapes of this area, but more work on the compliance of prostate tissue and the shape of the prostatic urethral lumen is essential in order to improve stent design and reduce the risks and complications of these useful devices.