Management of bulbar urethral strictures: review of current practice

Male urethral stricture disease is one of the common conditions encountered in the day-to-day urological practice. It can present at any age and has a wide range of etiological factors including infection, trauma and instrumentation. It usually manifests itself as lower urinary tract symptoms or urinary tract infections with significant impairment in the quality of life. There are several treatment options for this condition and these mainly depend on the site, length, the underlying cause and previous treatment. The management of bulbar urethral strictures has greatly evolved over the last few decades with more patients being offered reconstructive surgical operations as a primary treatment option. This article provides an overview on the management of bulbar urethral strictures and the wide range of surgical procedures offered to the patients.     

The menopause and HRT. Urogenital effects of hormone therapy

The urogenital tract and lower urinary tract are sensitive to the effects 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 post-menopausal urinary incontinence remains controversial, its use in the management of women complaining of urogenital atrophy is now well established. This aim of this chapter is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of post-menopausal urinary incontinence, recurrent lower urinary tract infections and urogenital atrophy.     

Secondary urolithiasis

Urolithiasis may be associated with a wide range of unrelated conditions that in various ways predispose to the development of urinary tract calculi. The most common such conditions are urinary tract infection, structural abnormalities of the urinary tract, drugs, and foreign bodies. Evaluation of patients must rule out other underlying metabolic disorders. Treatment must address not only the calculi but also the correction or elimination of the predisposing factors.     

Kidney stones: pathophysiology and medical management

The formation of stones in the urinary tract stems from a wide range of underlying disorders. That clinicians look for the underlying causes for nephrolithiasis is imperative to direct management. There are many advances in genetics, pathophysiology, diagnostic imaging, medical treatment, medical prevention, and surgical intervention of nephrolithiasis. Here, I provide a brief general background and focus mainly on pathophysiology and medical treatment of kidney stones. Although important advances have been made in understanding nephrolithiasis from single gene defects, the understanding of polygenetic causes of kidney stones is still largely elusive. A substantial proportion of data that resulted in new methods of treatment and prevention, which can be empirical or definitive, has focused on urinary luminal chemical composition of the precipitating solutes. Manipulation of inhibitors and epithelial factors is important and needs further investigation. Advances in the management of nephrolithiasis depend on combined efforts of clinicians and scientists to understand the pathophysiology.     

Prospective multicenter surveillance study of funguria in hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses Study Group.

Although fungal urinary tract infections are an increasing nosocomial problem, the significance of funguria is still not clear. This multicenter prospective surveillance study of 861 patients was undertaken to define the epidemiology, management, and outcomes of funguria. Diabetes mellitus was present in 39% of patients, urinary tract abnormalities in 37.7%, and malignancy in 22.2%; only 10.9% had no underlying illnesses. Concomitant nonfungal infections were present in 85%, 90% had received antimicrobial agents, and 83.2% had urinary tract drainage devices. Candida albicans was found in 51.8% of patients and Candida glabrata in 15.6%. Microbiological and clinical outcomes were documented for 530 (61.6%) of the 861 patients. No specific therapy for funguria was given to 155 patients, and the yeast cleared from the urine of 117 (75.5%) of them. Of the 116 patients who had a catheter removed as the only treatment, the funguria cleared in 41 (35.3%). Antifungal therapy was given to 259 patients, eradicating funguria in 130 (50.2%). The rate of eradication with fluconazole was 45.5%, and with amphotericin B bladder irrigation it was 54.4%. Only 7 patients (1.3%) had documented candidemia. The mortality rate was 19.8%, reflecting the multiple serious underlying illnesses found in these patients with funguria.     

Recurrent urinary tract infections caused by Raoultella planticola after kidney transplant

Recurrent urinary tract infections are difficult to manage in patients with a history of kidney transplant and may contribute to graft loss. Few cases describe recurrent urinary tract infections due to Raoultella planticola in this population. We describe the management of recurrent urinary tract infections due to R planticola in a kidney transplant recipient and review other case reports of urinary tract infections due to this organism.     

Urinary Tract Infections in Renal Transplant Recipients

Infection of the urinary tract is the most common infectious complication of renal transplantation. The microbiology of post-transplant urinary tract infections is similar to what is seen in the general population, although transplant patients may develop infections due to unusual or opportunistic pathogens. The optimal management of urinary tract infections in renal transplant recipients is poorly studied, but recommendations for treatment are available. Antibiotic prophylaxis can reduce the risk of bacterial infection of the urinary tract post-transplant but is not used in all transplant centers. The influence of urinary tract infection on graft survival requires further study.     

Detrusor-Directed Therapy in Men With Benign Prostatic Hyperplasia

As men age, the incidence of benign prostatic hyperplasia and bothersome lower urinary tract symptoms increases. Until recently, treatment modalities focused on prostatic-directed management, but there has been a shift in focus as emerging research has implicated the bladder as a significant player in the development of lower urinary tract symptoms secondary to benign prostatic hyperplasia. Although initially avoided in this population, recent studies have demonstrated the safety and efficacy of antimuscarinics. Epidemiologic studies illustrating the link between erectile dysfunction and lower urinary tract symptoms then led to the investigation of phosphodiesterase-5 inhibitors for symptom management. Novel agents, including β₃ adrenoreceptor agonists, are now being introduced in trials. These agents may offer the efficacy of an anticholinergic without the associated side effects. As future research develops, we are sure to see the introduction of a host of novel agents in the management of lower urinary tract symptoms secondary to benign prostatic hyperplasia.     

Review of adolescent urinary tract infection

The diagnosis and management of adolescent urinary tract infection (UTI) shares some of the clinical features seen in infections of the young and old. Whereas most infections in the young patient demand an extensive radiologic work-up, the teenager with a UTI is not so straightforward. The clinical must balance being too aggressive with being too conservative in the diagnosis and management of these patients. UTIs occur most frequently among adolescent females and are usually uncomplicated and not associated with underlying anatomic abnormalities. Smaller numbers of adolescent males suffer from UTIs, and the need to search for underlying abnormalities is not clear. Adolescent UTI is associated with nascent sexual activity and is also more common in voiding/elimination syndromes. Future studies examining UTI, specifically in the adolescent age group, will help provide clinicians with a more focused algorithm in the diagnosis and management of adolescent UTIs.     

Urodynamics for Spinal Cord Injury – How,When, Why

Patients with spinal cord injury (SCI) often have lower urinary tract dysfunction. Their urological dysfunction should be managed as part of their overall holistic care in a specialist SCI unit. Whilst level of disease can cause broad categories of urological problems, lower urinary tract symptoms may be complex and difficult. Urodynamic studies investigate the urinary tract by measurement of flow and pressure. Urodynamic studies perform an important role in the urological management of patients with SCI. Invasive video urodynamic studies are the gold standard urodynamics of choice in these patients due to the extra information that can be gleaned from fluoroscopy. The major complication of neurogenic lower urinary tract dysfunction is of a risk to the upper tracts. Baseline urodynamic studies are performed in patients with SCI to assess symptoms and risk to the upper tracts, so that management can be planned accordingly. The optimum follow-up schedule for urodynamics remains controversial.     

Prevention of catheter-associated urinary tract infection

PURPOSE OF REVIEW: The underlying cause of catheter-associated urinary tract infection is biofilm formation by uropathogens on the urinary catheter. Biofilm is a relatively new concept in medicine, and current measures to prevent biofilm formation are inadequate. Considerable work is being done in this area, but little clinical progress has been made. The purpose of this review is to analyze recent publications concerning prevention of catheter-associated urinary tract infection. RECENT FINDINGS: Several recent studies have elucidated aspects of biofilm formation in catheter-associated urinary tract infection. Other researchers are working on methods to disrupt biofilm formation on catheter surfaces. At the same time, the magnitude of the problem of catheter-associated urinary tract infection has increased awareness of the effectiveness of basic infection control measures. A modern approach to infection control may include computerized ordering systems that minimize unnecessary days of catheterization. Finally, consumption of cranberry juice products and bacterial interference are two novel approaches to urinary tract infection prevention. SUMMARY: Biofilm-disrupting strategies offer promise for the future but have little immediate applicability. Implementation of infection control measures to improve catheter function and remove unnecessary catheters can be done at the present time. In general, prevention of catheter-associated urinary tract infection remains an elusive goal. More basic research at the level of pathogenesis is needed so that novel strategies can be designed.     

Therapie und Prophylaxe rezidivierender Harnwegsinfekte

Recurrent urinary tract infections are typical diseases of sexually active young women. Only elder women show significant rates of underlying, mostly urological diseases. Besides behavioral changes long-term antimicrobial therapy is still the mainstay of both prophylaxis and therapy. This report provides information on the etiology for recurrent urinary tract infections. Strategies for prevention are illustrated. The actual significances of organic remedies and antibiotics respectively are discussed; ineffective therapies are identified. Furthermore an outlook is given on promising novel therapeutics, i.e. vaccines which are already tested in clinical trials.     

Hyperammonemic encephalopathy in urinary diversion with urea-splitting urinary tract infection

We present two cases of hyperammonemic encephalopathy secondary to urea-splitting urinary tract infection with urinary diversion. One patient had a ureterosigmoidostomy, the other an ileal loop diversion. Neither patient had significant underlying liver disease, but both had considerable muscle atrophy that may have predisposed them to develop hyperammonemia. Medical therapy did not provide long-term control of symptoms. In both cases, hyperammonemic encephalopathy resolved after revision of their urinary diversions. The probable mechanism of the metabolic derangements produced by urea-splitting urinary tract infections is reviewed. We suggest that patients with urinary diversion who develop hyperammonemic encephalopathy secondary to a urea-splitting urinary tract infection be treated with surgical revision of the urinary system to improve drainage and decrease bowel contact time.     

Group B Streptococcus: a cause of urinary tract infection in nonpregnant adults.

Group B Streptococcus (GBS) is a well-known cause of infection in the perinatal and puerperal periods, but its role as a urinary tract pathogen of adults in nonobstetric situations has not yet been defined. We carried out a prospective 19-month study of all nonpregnant adult patients with significant GBS bacteriuria. This microorganism accounted for 2% of positive urine cultures. Our series included 60 patients, 85% of whom were women and 95% of whom had at least one underlying condition. Urinary tract abnormalities (60%) and chronic renal failure (27%) were among the most frequent underlying problems. The infection was community acquired in 65% of cases. Clinical manifestations were related equally to the upper and the lower urinary tract (37% and 38% of cases, respectively). The clinical outcome was poor in 18% of episodes despite treatment. All isolates were sensitive to all antibiotics tested except gentamicin. We conclude that GBS is a significant urinary pathogen in nonpregnant adults and that its presence signals a need for screening for urinary tract abnormalities.     

Fetal and neonatal kidney function. Implications for fetal urinary tract abnormalities

High-resolution sonography provides the opportunity for prenatal detection of fetal anomalies of the urinary tract. In view of various options of prenatal urinary diversion to alleviate obstruction, it has become a scientific goal to measure fetal renal function and to determine the prognosis of urinary tract malformations. The article outlines the accumulated knowledge of the development of fetal renal function and the diagnostic possibilities offered by sonography and by laboratory test with focus on the chemistry of the amniotic fluid. Taking into consideration the high risks of prenatal intervention, these findings are discussed as to their relevance for the clinical management of pregnancies complicated by fetal urinary tract abnormalities. Lastly, criteria are proposed for the decision making in clinical practice.     

Epidemiology of intensive care unit-acquired urinary tract infections

PURPOSE OF REVIEW: The development of urinary tract infections in critically ill adult patients is associated with considerable morbidity, prolonged hospitalization, and greater healthcare expenditures. We review the occurrence, microbiology, risk factors for acquisition, and outcomes associated with intensive care unit-acquired urinary tract infections. RECENT FINDINGS: Reports from several countries indicate that nosocomial urinary tract infections frequently complicate the course of patients admitted to intensive care units. Virtually all patients who develop an intensive care unit-acquired urinary tract infection have indwelling urinary catheters; other factors associated with the development of these infections include increased duration of urinary catheterization, female sex, intensive care unit length of stay, and preceding systemic antimicrobial therapy. The most frequent pathogens include Escherichia coli, Pseudomonas aeruginosa, enterococci, and Candida albicans; both the species distribution and rates of resistance vary considerably among institutions and regions. Secondary bloodstream infections are uncommon. Although acquisition of an intensive care unit-acquired urinary tract infection has been associated with a prolongation of intensive care unit length of stay, higher cost, and a higher crude case fatality rate, they do not appear to independently increase the risk for death. SUMMARY: Urinary tract infection is a common complication of critical illness that is associated with increased patient morbidity but not mortality. There is a relative paucity of research on nosocomial urinary tract infection specifically acquired in the intensive care unit and further studies are needed to better define the epidemiology and management of these infections.     

Evaluation and Management of Urinary Retention Following Colorectal and Gynecologic Oncologic Surgery

Urinary retention after radical pelvic surgery is a relatively common, well-recognized complication. The primary problem is neural disruption to or from the bladder during curative surgery. Resulting symptoms may include urinary retention presenting post operatively early or late. Other symptoms include overflow incontinence, to controlled stress incontinence, or urinary tract infections. Management is predicated on the clinical history, examination, physical findings and urodynamic evaluations. The principles of neurogenic bladder management are based on management of urinary incontinence or retention, prevention of urinary tract infections, prevention of stone disease and preservation of renal function. While not all patients who undergo radical pelvic surgery for oncological disease, develop neurogenic bladder, it must be considered in patient??s with urinary retention. In men, retention after pelvic surgery may not be caused by BPH, but neurogenic bladder, thus a transurethral resection of prostate may not be the appropriate management. Management of urological complications of pelvic surgery depends on a full neurourological assessment of the patient, and a treatment plan based on objective findings of the complete examination.     

Infection in the elderly

Many functional, demographic, and immunologic changes associated with aging are responsible for increasing the incidence and severity of infectious diseases in the elderly. Management is complicated by age-related organ system changes. Because many of the elderly are on multiple medications for underlying illnesses, antimicrobial therapy needs to be chosen keeping drug interactions and adverse events in mind. Common infections seen in the elderly are infections of skin and soft tissue, urinary tract, respiratory tract, and gastrointestinal tract. Organized and well-funded programs to address infectious disease issues in the elderly are the only way to improve care.     

Putative therapeutic targets in the treatment of visceral hyperalgesia

The management of abdominal pain remains a major challenge for clinicians despite an explosion of knowledge regarding the physiology and pathophysiology of sensory neural circuits. Initial progress was made in the field of somatic pain and this provided broad hypotheses that could be tested in the field of visceral pain. The major advances in our understanding of basic mechanisms underlying visceral pain originated in the urinary tract and have been applied to the gut. As yet, this increased understanding of enteric sensory physiology has yet to generate new effective treatments for abdominal pain. This review addresses novel insights into peripheral mechanisms underlying visceral hyperalgesia and their applicability to the development of novel therapeutic approaches to the treatment of chronic abdominal pain.     

Role of Bladder Dysfunction in Vesicoureteral Reflux

Lower urinary tract dysfunction (LUTD) is associated with vesicoureteral reflux (VUR) as well as urinary tract infections (UTIs), particularly when micturition abnormalities occur in the voiding phase. The most common presenting symptoms are urinary urgency and frequency, UTI, incontinence, holding behaviors, and dysuria; many children will also have concurrent constipation. Since LUTD is associated with lower VUR resolution rates, increased rates of breakthrough UTI, and increased rates of surgical treatment failure, successful management of VUR in the setting of LUTD requires therapy for the VUR as well as concomitant management of the LUTD to maximize treatment success. LUTD treatment should be applied sequentially, beginning with behavioral modification and progressing to pharmacologic agents, biofeedback, and neuromodulation in refractory patients.