Viral lower urinary tract infections

Lower urinary tract infections (UTIs) are common among the general population and are most often caused by bacterial pathogens. Viruses are an uncommon cause of UTIs in an immunocompetent host; however, viruses are increasingly recognized as the cause of lower UTI, especially hemorrhagic cystitis, among immunocompromised patients. BK virus, adenovirus, and cytomegalovirus are predominant pathogens involved in hemorrhagic cystitis after stem cell and solid organ transplantation, and their early diagnosis and treatment may prevent significant morbidity of hemorrhagic cystitis. The diagnosis of viral lower UTI is based on molecular techniques, and real-time polymerase chain reaction is often the method of choice because it allows for quantification of viral load. Cidofovir is becoming a drug of choice in viral UTIs because it is active against the most common viral pathogens. This review discusses the epidemiology, pitfalls in diagnosis, and current treatment of viral UTIs.     

Laparoscopic lower urinary tract reconstruction

In the past decade laparoscopy has been successfully utilized for both the obliterative and reconstructive management of urologic disease. We have seen not only an advance in the technology available to perform these procedures, but also an effort on the part of laparoscopic urologists to refine their techniques to allow them to perform more complicated procedures. In the lower urinary tract, the development of reconstructive procedures has been slow. While early interest in laparoscopy prompted several pioneers to perform the initial reconstructive procedures, the difficulties associated with these procedures at that time largely precluded their widespread application or adoption. Recently, improvements in the skills of laparoscopic urologists and the advent of instruments to facilitate suturing (e.g. EndoStitch semi-automatic suturing device, Lapra-Ty clips to replace intracorporeal knotting, and advances in staple and clip technology) have facilitated a renewed interest in laparoscopic reconstructive surgery of the lower urinary tract. At present, almost all types of urologic open reconstructive procedures have been accomplished laparoscopically: urinary diversion (e.g. ureteroileal loop urinary diversion and continent diversion), bladder reconstruction (e.g. ureterovesicostomy, bladder augmentation, bladder diverticulectomy, partial cystectomy), ureteral reimplantation, and, most recently, urethrovesical anastomosis following radical prostatectomy. This article will review the development of these procedures.     

Endourology of lower urinary tract

Two methods for obtaining percutaneous access to the bladder are described. Depending on whether or not urethral access is available an endoscopic or fluoroscopic technique may be applied. We have successfully performed suprapubic percutaneous cystolitholapaxy, antegrade fulguration of posterior urethral valves, antegrade cystourethroscopy as an adjunct for urethroplasty, and internal drainage of a bulbar urethral abscess. Endourologic techniques may be readily applied to the lower urinary tract and may be specifically indicated in certain situations.     

Scleroderma of lower urinary tract

A case of scleroderma involving the lower urinary tract is reported. To our knowledge, this is the first instance of a living patient with this condition.     

Prostaglandins in lower urinary tract

The search for noncholinergic, nonadrenergic neurotransmitters in the lower urinary tract has recently focused on the prostaglandins (PG). Prostaglandin E₂ (PGE₂) and, to a lesser degree, prostaglandin F_Zα (PGF_zα), are produced by the bladder in response to mechanical and nerve stimulation. In vitro stimulation of detrusor smooth muscle, using the same two compounds, produces a slow, prolonged contraction which is independent of nervous activity. In contrast, in urethral smooth muscle PGF_2α causes contraction while PGE₂ causes relaxation. Clinically, intravesical or intravenous administration of PGE₂ or PGF_2α may produce improved bladder tone or uninhibited contraction. Similarly, inhibitors of PG synthesis may produce improvement of unstable bladder.     

alpha-Blockers improve chronic ischaemia of the lower urinary tract in patients with lower urinary tract symptoms

OBJECTIVE

To investigate whether a mechanism of action of α‐blockers on lower urinary tract symptoms (LUTS) involves improved perfusion of the LUT.

PATIENTS, SUBJECTS AND METHODS

The accuracy of perfusion measurements using transrectal colour Doppler ultrasound (TRCDUS) and colour pixel density (CPD) was initially confirmed in a porcine model. Following this confirmation, measurements were taken from four healthy male volunteers and 19 patients with LUTS. The urinary bladder was filled slowly (50 mL/min) with 0.2 m KCl, which resembles the osmolarity of concentrated urine, and evaluated by cystometry. In parallel, TRCDUS and measurement of the CPD of the LUT were performed. The patients with LUTS were then treated with daily α‐blocker (0.4 mg tamsulosin) for 5 weeks and urodynamic variables as well as perfusion were evaluated again.

RESULTS

In the healthy men, perfusion of the LUT increased considerably (157%) during filling of the bladder to a mean (sd ) maximum cystometric capacity (C_max) of 481 (28.9) mL. All the patients with LUTS had a reduced mean C_max during filling with KCl at 322.4 (58.5) mL. The mean CPD in the urinary bladder and the prostate were only increased by 58.4% during filling with KCl. After α‐blocker therapy the mean C_max during filling with KCl rose to 382.5 (42.9) mL; furthermore, perfusion of the LUT measured by CPD was significantly increased (132.8%).

CONCLUSIONS

The present data strongly suggest that LUTS are associated with chronic ischaemia of the prostate and urinary bladder. α‐blockers increase perfusion in the LUT and C_max. These results might explain the therapeutic effects of α‐blockers on LUTS.     

Assessment of lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) encompass a range of symptoms commonly experienced by both men and women, and encountered by a wide range of healthcare practitioners (HCPs). This review summarizes the basic terminology and assessment that HCPs should be aware of, regardless of their professional discipline. Apart from emphasizing the need for standardization in terminology, there is a need to avoid misleading terms that suggest a causative mechanism until the mechanism has been identified by investigation. HCPs should also avoid arbitrary thresholds for judging severity of symptoms. The use of algorithms from evidence-based guidelines limits variation in management and avoids unnecessary investigations. However, a tailored approach is useful in understanding the underlying pathophysiology in individual patients. As symptoms are unreliable in predicting the underlying mechanism, a useful approach is to try and develop a urodynamic diagnosis mindful of the normal physiology of the lower urinary tract as the practitioner works through the symptoms, signs and appropriate urodynamic investigations, and use such investigations in a logical manner tailored to the individual to either support or refute assumptions and arrive at a working diagnosis.     

Physiology of lower urinary tract obstruction

One of the major dilemmas facing pediatric urologists today is discerning obstruction in the dilated urinary tract. Apparently similar anatomic obstructions can result in very dissimilar consequences. The authors focus on the physiologic response of the bladder and upper tracts to infravesical obstruction. They caution against treatment focused merely on the obstruction, noting that the entire urinary tract must be addressed.     

Neurotransmission and the lower urinary tract

The neurotransmitter activity in the lower urinary tract is very complex. This paper reviews the main substances, known today, their agonists, antagonists, metabolic pathways and their action and discusses the site of action of neuropharmacological substances. The existence of a non-adrenergic, non-cholinergic pathway, in parallel with the sympathetic adrenergic and the parasympathetic cholinergic pathways is thus clearly admitted.     

Assessment of lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) encompass a range of symptoms commonly experienced by both men and women, and encountered by a wide range of healthcare practitioners (HCPs). This review summarizes the basic terminology and assessment that HCPs should be aware of, regardless of their professional discipline. Apart from emphasizing the need for standardization in terminology, there is a need to avoid misleading terms that suggest a causative mechanism until the mechanism has been identified by investigation. HCPs should also avoid arbitrary thresholds for judging severity of symptoms. The use of algorithms from evidence-based guidelines limits variation in management and avoids unnecessary investigations. However, a tailored approach is useful in understanding the underlying pathophysiology in individual patients. As symptoms are unreliable in predicting the underlying mechanism, a useful approach is to try and develop a urodynamic diagnosis mindful of the normal physiology of the lower urinary tract as the practitioner works through the symptoms, signs and appropriate urodynamic investigations, and use such investigations in a logical manner tailored to the individual to either support or refute assumptions and arrive at a working diagnosis.     

Neuropeptides in lower urinary tract function

Summary The neuropeptides are a recently discovered group of chemical compounds that appear to play a major part in the control of visceral function. Some of them have been found in the lower urinary tract and in parts of the nervous system that are thought to control the lower urinary tract. The urological implications of these observations are discussed in the light of our current concepts of vesicourethral function and of neuropeptide pharmacology.     

Estrogens and the lower urinary tract

The urogenital tract is sensitive to the effect of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of postmenopausal urinary incontinence remains controversial its use in the management of women complaining of urogenital atrophy is now well established. This aim of this paper is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of postmenopausal urinary incontinence, overactive bladder, recurrent lower urinary tract infections and urogenital atrophy. In addition to a review of the available evidence suggestions are also made regarding priorities for further research in the field.     

Primary amyloidosis of lower urinary tract

Primary amyloidosis of the lower urinary tract is a rare condition with an excellent prognosis in most cases. Three patients with this condition are described. In the cases of localized amyloidosis of the urethra and urinary bladder, the clinical presentation mimicked cancer of the respective sites. This was also true in the case of primary systemic amyloidosis involving the bladder. If significant associated systemic or local disease can be excluded, management is symptomatic and expectant.     

Pathophysiology of lower urinary tract dysfunction

Lower urinary tract dysfunction can be considered in terms of two broad categories: problems caused by abnormalities of the filling and storage phase and problems related to the voiding phase. The author prefaces this discussion with a review of normal anatomy and physiology.