Learning to Manage Common Urological Problems; a case-based approach

INTRODUCTION

2006-12-07T16:59:00.000-08:00

Some common problems encountered in a urological practice are discussed using case-based presentations. The material is arranged in a manner to make it more accessible to medical students and educators. Each of the conditions discussed is introduced by a letter from the referring physician outlining the issues of concern followed by my response.

Many diagnostic and therapeutic measures have attendant risks which may actually be more damaging than the underlying medical problem itself. Indeed, not all problems require active therapy. The risk/benefit ratio of any proposed study or therapy must be weighed against the natural course of the disease and the patient must be actively involved in any planning process.

The material presented herein is not intended to provide a thorough analysis of the issues since details of diagnostic and therapeutic modalities can be found in other medical publications. It is important, however, that the medical student be very aware that all options must be made available to the patient and be sensitive to the patient’s responses. Close observance of the patient’s verbal and body language is critical. There should be an interactive discourse between the patient and physician, conducted in a relaxed environment as free from time constraints as possible.

PSYCHOSOMATIC ILLNESS:

2006-12-07T16:58:00.000-08:00

PSYCHOSOMATIC ILLNESS:

Dear Sumner,

I am sending you Jocelyn Brent, a 42 year old woman with complaints of lower abdominal pains for the past 5 years. She has been a vice president of an advertising firm for about 10 years and is under constant pressure in her job. While she recognizes that her symptoms are more severe while at work, she, nonetheless, is certain that there is something seriously wrong with her kidneys. She has already been evaluated by a gynecologist, gastroenterologist, endocrinologist, general surgeon as well as an urologist, and no obvious cause for her symptoms has been found thus far. I have advised a psychological evaluation but she resents any suggestion that her problems are based in her head. Quite frankly, I am at my wit’s end in dealing with her. I would be most grateful if you would see her, and, hopefully, if not render a cure, at least calm her down.

Dear Brenda,

As I know you are well aware, Jocelyn is convinced that she has a real problem. The bulk of my time with her (about an hour) involved a rather extended discussion re the anatomy, physiology and psychology of the genitourinary tract. We went over in some detail the “negative” results from her previous evaluations, as well as those from my exam. We spoke quite openly about the fact that the body can definitely be influenced by emotional factors and even if her symptoms are caused, or exacerbated, by her mental state, the symptoms themselves are still very real for her. I mentioned to her that although we (the physicians) did not come up with a diagnosis, in the process of the evaluation, no serious underlying problem was revealed. (REASSURANCE IS A POWERFUL THERAPEUTIC MODALITY.) I felt that, apropos of your last request in your referral letter, Jocelyn left my office in a much calmer state than when she arrived!

HYDROCELE

2006-12-07T16:57:00.000-08:00

HYDROCELE

Dear Sumner:

A very tense young man just left my office, convinced that he has a testicular cancer. Bob is 26 years of age and has been aware of a scrotal swelling since “as long as he can remember.” He states the mass causes him no pain, although it seems to be getting progressively tenderer to touch (his girlfriend expresses her concern every time they are having sex). It was interesting that Bob commented that the swelling sometimes gets larger after he exercises, but soon reverts to its previous size. I believe we are dealing with a hydrocele given the history and the consistency of the mass. And assuming that the underlying diagnosis is, indeed, a hydrocele, is interventional therapy indicated? If it gets larger, can’t you just remove the fluid with a syringe or inject a chemical to destroy the sac?

Dear Craig:

I had a good talk with Bob and his girlfriend re his situation. Most likely we are, indeed, dealing with a hydrocele, since the mass did transilluminate on my physical examination. The cystic nature of the lesion was confirmed on ultrasound study. I believe that the progressive tenderness of the testis is likely secondary to the multiple self-examinations along with a bit of Bob’s “fixation” on this part of his anatomy. Ordinarily unless a hydrocele is sufficiently large as to cause local distress (either physically or psychologically), surgical intervention is not necessary. To answer your question about possible therapy, a hydrocele can be aspirated, but since the lining of the hydrocele sac secretes the fluid, the sac will likely refill within a few weeks, and, therefore, if surgery were to be done, it is best to remove the entire sac. Besides which, sticking a needle into the closed space of the hydrocele runs a risk of secondary infection.

However, in Bob’s case, these points are probably moot. Since the swelling has apparently been present since early childhood and is variable in size, there is very likely a persistent connection between the scrotal and peritoneal cavities: a patent processus vaginalis. (Ordinarily the processus vaginalis, which is the channel through which the testis descends from the abdominal cavity through the inguinal canal into the scrotum, closes spontaneously prior to birth). For practical purposes, I would treat this as a hernia (congenital) and I would advise its repair along with removal of the hydrocele sac (as an encore).

SPERMATOCELE (AKA EPIDIDYMAL CYST):

2006-12-07T16:56:00.000-08:00

SPERMATOCELE (AKA EPIDIDYMAL CYST):

Dear Sumner:

George, a 23 year old man, called me last week in a panic that he had found an extra testicle in his scrotum. When I examined him, I found a mass above and separate from his left testicle which seemed to be softer than the testis. I think that the mass represents a spermatocele although George would like to be certain that he doesn’t have a tumor. Assuming that it is, indeed, a spermatocele, can the fluid within it be aspirated and its lining destroyed with some type of chemical solution, or must the entire mass be removed. If nothing is done, might it affect his fertility? He will be calling you for an appointment in the near future.

Dear Felicia:

George was still quite anxious about the mass in his scrotum when I saw him in the office today. The fact that the mass transilluminated and was separate from the testis itself is consistent with the diagnosis of a spermatocele. A spermatocele is usually thought to arise from obstruction of an epididymal duct, with the secondary dilatation forming a cystic structure. Smaller spermatoceles are sometimes referred to as epididymal cysts. However, we did discuss what procedures might be considered if there was associated discomfort due to a significant increase in its size, as well as the potential risks of invasive therapy. In the case of a spermatocele, my own feeling is that active treatment may cause more problems than surveillance only. For example, not only might reaccumulation of the fluid occur after needle aspiration of a spermatocele, but the procedure itself runs a risk of infection. Even more importantly, epididymal obstruction can result from both the surgery as well as from the chemical destruction of its lining (sclerotherapy)--which obviously could adversely affect his fertility.

At this time, being reasonably certain of the diagnosis and being assured that there is no life threatening process present and that it should not interfere with his fertility or sexual function, George expressed his desire to avoid any invasive procedures. In fact, said he (with a sheepish grin), he really enjoys the comments he receives about his “profile” in his tight Speedo bathing suit!

VARICOCELE:

2006-12-07T16:55:00.000-08:00

VARICOCELE:

Dear Sumner:

I’d like your opinion on Ralph, a 16 year old, who came to my office today complaining of a large cluster of wormy- like structures in his scrotum. From my examination, I believe this is a varicocele. It was on the left side, and I thought that the left testicle was slightly smaller than its mate. Does this need any medical attention? It does not seem to bother Ralph.

Dear Marv:

I had a good discussion with Ralph and his Dad about varicoceles and their possible significance. They were surprised to learn that about 15% of all men have varicoceles. As is the case with Ralph, most occur on the left side. This is influenced by hydraulics. The vein from the left testicle drains into the left renal vein at a right angle, whereas the vein from the right testicle has a more gradual insertion, draining directly into the vena cava. This may result in reversed flow of blood in the left testicular vein stretching and enlarging the tiny veins above the testicle. This is referred to as a varicocele.

The question you pose is, of course, the critical one: “Does Ralph’s varicocele need any medical attention?”

Ralph’s varicocele is, indeed, quite prominent, especially when he is in the standing position. As expected, when he lay down on the examining table, the varicocele was barely detectable. (This demonstration was most reassuring to Ralph.) Ralph’s left testicle is somewhat smaller than its mate. It is certainly possible that this is secondary to the varicocele, or perhaps just a variation of his anatomy. I explained that the function of the scrotum is to regulate the temperature of the testes; added heat from the varicocele can impair sperm production. (This is one of the reasons for bringing an undescended testicle into the scrotum at an early age: the other main reason being its increased potential for malignant changes. Marv, you may have noticed that the testes of many mammals are usually up in their abdomen most of the year, descending into the scrotum during mating season in the spring. Now won’t that little tid-bit of information make for good conversation at your next cocktail party?)

The main purpose of surgical intervention is to interrupt or remove the varicose veins in the scrotum in order to detour the flow of blood into normal veins. Surgery would be advisable only if there were evidence that the varicocele is causing a problem with Ralph’s fertility and the most direct way to check his fertility status is to check a semen analysis. However, since Ralph has no immediate plans for fatherhood, both he and his Dad preferred to hold off on a sperm count for now.

It is difficult to know whether early surgery will reverse the effect of the varicocele on spermatogenic activity. In a significant number of men who have undergone varicocele surgery, there has been improvement of sperm count and motility. Unfortunately it has not been definitely established whether early interruption of the varicocele is indicated.

TESTICULAR TUMOR:

2006-12-07T16:54:00.000-08:00

TESTICULAR TUMOR:

Dear Sumner:

I need your help with Joe, a 32 year old man, whose wife noticed a firm area on the bottom of his right testicle about one week ago. The mass appears to be localized and. palpation of the testis does not elicit pain. I found no other abnormalities on physical examination. The family’s anxiety level is increased by the fact that one of Joe’s cousins was recently diagnosed with testicular cancer. (I have known his family for many years and they have been “surfing the net” for any information about testicular tumors). What diagnostic and therapeutic steps should be taken at this time? What about doing a biopsy of the testicle to see if we are, indeed, dealing with a cancer and if no cancer were found, the testis could be saved? It does not seem right to remove the testis on the basis of suspicion alone.

Dear Harry:

Except for the finding of the distinct area of firmness at the base of Joe’s right testicle, I found nothing unusual on exam. For “starters,” I am obtaining a testicular ultrasound study to ascertain if the firm area that we feel is within the testis itself and if it is solid or cystic. I feel that any solid mass within the testis itself is highly suspicious for malignancy. However, since testicular tumors usually spread via the retroperitoneal lymph nodes, I will be ordering staging procedures to include abdominal/pelvic and chest CT scans.

One of the most challenging of your inquiries was about doing a biopsy on the testis prior to possible removal. This point is controversial. The standard approach for the surgery is via an inguinal approach, exposing the spermatic cord and putting some type of tourniquet around the entire cord prior to delivering the testis into view. If the mass in question is confirmed to be within the testis itself, given the high probability that there is a cancer within, along with the chance of causing spread of the tumor by cutting into it, most urologists (including myself) would be to proceed with its removal, with analysis of the tissue being done in the laboratory. However, in the event we were dealing with a solitary testicle and/or the patient stated that even though he realized the risk of possible spread if there was a cancer present, he wanted that testis saved if at all possible, then I would go ahead with a biopsy, obtain a frozen section, but leave the tourniquet in place until I got the results of the biopsy and proceed with removal of the testis only if the pathologist finds a definite cancer therein.

I will be proceeding with a radical orchiectomy (via an inguinal approach) in the near future. Statistically the tumor, if present, is most likely to be a seminoma, in which case the cure rate is very high. Since an elevation of the tumor markers, beta sub-unit human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP), could occur from other testicular tumors such as embryonal cell carcinoma or choriocarcinoma, I will be getting these studies prior to any surgery. It is interesting that his cousin also had a testicular carcinoma, suggesting the possibility of a genetic (or maybe even an infectious or immunological) component with this tumor; studies are currently going on re these possibilities

I will let you know the findings and further plans. Hopefully, this will turn out to be a pure seminoma, and all of the staging studies will reveal no evidence of spread. However, if there were evidence of current metastases or if there were subsequent recurrence, for most testicular tumors, adjunctive therapy is quite effective. Needless to say, we will follow Joe closely over the years to come. I appreciate your permitting me to be involved in Joe’s care.

TENDER TESTICLE:

2006-12-07T16:53:00.001-08:00

TENDER TESTICLE:

Dear Sumner:

I am sending you a 45 year old Silicone Valley executive for a second opinion. He has been bothered by a painful right testicle for about 4 months. Craig did see another urologist a few weeks ago, who reputedly rushed him through an abbreviated exam and failed to address all of his concerns. No obvious abnormalities were found on either physical exam or urinalysis. However, he is still worried that he has a serious underlying condition. I would be most grateful if you would see him.

Dear Ken:

You were certainly correct in your appraisal of Craig’s degree of anxiety. I spent the bulk of our time together trying to address his concerns. Craig admitted he was worried about an unrecognized infection--or even a tumor! We discussed the differential diagnosis of tender scrotal contents, namely inflammatory or infectious processes of the testis, epididymis or spermatic cord structures, as well as testicular torsion. Other entities, which could, though do not ordinarily, produce discomfort include inguinal hernia, hydrocele, varicocele, spermatocele (AKA epididymal cyst) or a testicular tumor. Primary disorders of the back, or pressure secondary to a ureteral stone, can also cause radiating pain to the testicle.

I went ahead with Doppler testicular ultrasonography which showed good blood flow to the testes and no testicular masses. An abdominal ultrasound revealed no gross obstruction of the renal collecting system. Given these findings, I was able to assure Craig that we had ruled out any obvious condition that required interventional therapy. We discussed the fact that the genital structures have more nerves than many other parts of the body, and may, therefore, be more sensitive to any underlying irritative or inflammatory processes (which can cause secondary spasm of the perineal muscles, with resultant pressure on the surrounding nerves, causing more muscle spasms, etc., etc.) I am hoping (and I’m actually optimistic) that a trial of anti-inflammatory meds (e.g. ibuprofen) along with relaxing in warm tub baths (possibly with a friend), combined with a good dose of reassurance, will result in a cure!

UNDESCENDED versus HYPERMOBILE TESTIS:

2006-12-07T16:52:00.001-08:00

UNDESCENDED versus HYPERMOBILE TESTIS:

Dear Sumner:

I am sending you Josh, a boy who I have followed since his birth 3 years ago. I thought I could feel both testes in the scrotum at birth as well as at 3 and 6 months of age. However, since then his scrotal sac has been quite tight, and I’ve uncertain as to the location of the testes, particularly the left one. Although his mother says she has felt both testes when Josh is having a bath, I would feel more comfortable having your opinion.

Dear Bert:

When I first examined Josh, I was unable to feel either testis in the scrotum. In fact, he was not at all happy about lying on the examining table. Both Mom and I decided that Josh and his testes might be more relaxed on Mom’s lap. Indeed, in the comfortable and secure environs of Mom’s lap, Josh’s testes were able to be found within the confines of the scrotal cavity.

It is often very difficult to feel testes in the scrotum in little guys, particularly with their small and tight scrotal sacs along with the usual active cremasteric reflexes present at this age. The fact that Mom was able to feel his testes in the warm tub was reassuring. If I get the history that a parent has been able to feel both testes in the scrotum, and I have confidence in the parent’s observational skills, I feel comfortable avoiding surgical intervention. However, as I did with Josh’s family, I always mention the possibility, albeit slight, that with the hyperactive cremasteric reflexes in young boys, a testis may move upward into the inguinal canal and “get stuck” there, necessitating eventual surgery. More likely, however, the hypermobile testis spends most of its time residing happily in the scrotum.

UNDESCENDED TESTIS:

2006-12-07T16:50:00.000-08:00

UNDESCENDED TESTIS:

Dear Sumner:

At what age should I start to worry if a testis has not descended? I have read various reports giving conflicting ages, going from 6 months to 13 years. Henry is now one year of age and his parents have requested that you examine him and give your opinion. They would also like to know if hormone shots can bring the testes down without surgery.

Dear Gail:

I had a good discussion with Henry’s parents (with Henry listening attentively) re the various aspects of undescended testes. There is, indeed, conflicting advice in the literature. Many years ago it was advised that if a testis had not descended by the time of puberty, surgery to bring the testis into the scrotum (orchiopexy) should be done then. However, by that time, not only is the testis often atrophic, lacking spermatogenic activity, but there is also an increased risk of subsequent testicular tumor. An undescended testis is histologically normal at birth. However, by one year of age failure of development and atrophy may be detected and by the 2nd year of life the number of germ cells is significantly reduced. Therefore, I recommend that orchiopexy be performed around one year of age. Since almost all undescended testes have an associated hernia, a hernia repair would be done as well at that time.

Re hormone shots, I routinely advise a trial of injections of human chorionic gonadotropin (HCG) in cases of bilateral undescended testes. The chances that a unilaterally undescended testis will come down with HCG are very slim.

BUBBBLE BATH URETHRITIS:

2006-12-07T16:49:00.000-08:00

BUBBBLE BATH URETHRITIS:

Dear Sumner:

I have a challenge for you (as she has been for me since the time I first saw her about one year ago). Gwen is a 55 year old single woman who has already consulted 2 other urologists because of persistent irritative symptoms of the lower urinary tract. Although no infection had ever been documented, she had been treated empirically with various antibiotics, without relief of her symptoms. She underwent both radiological studies and cystoscopy and even had a psychiatric evaluation, none of which revealed any obvious abnormalities. She pleads for help. Can you work any of your magic on her?

Dear Carol:

I appreciate your confidence in my ability to come up with a magical cure. I must confess that I felt a bit uncomfortable as Gwen, during the initial consultation, berated the other physicians that she had seen. Nevertheless, she was receptive to my comments that her irritative symptoms could be caused by something other than infection. She accepted the premise that while urinary tract infections almost always set off a secondary inflammatory reaction, an inflammatory reaction can occur without the presence of infection. We went over some possible causes for her symptoms such as a reaction to perfumed soaps, vaginal creams or bubble bath products, as well as local inflammation of the urethral-vaginal area resulting from atrophic urethrovaginitis or vaginal infection. Gwen volunteered that her symptoms were minimal during the day. However, every evening, despite relaxing in a nice warm sudsy bubble bath, her symptoms of irritation flared up. All of a sudden a wide grin appeared on her face. “Could this pleasurable (albeit transient) activity of the bubble bath be the source of her problem?” she asked. “Yes, indeed!” replied I. She agreed, albeit reluctantly, to give up the bubble baths. She called me last week and reported that her irritative symptoms had completely cleared and that she was overjoyed with her new lease on life.

Since I could have such a happy ending to that adventure, I thought you might enjoy hearing of another case which involved a physician whose twin sons had received a bottle of bubble bath for Christmas. The young lads really enjoyed their nightly bubble baths. However, after just a few days, one of the boys starting wetting his bed and complained of pain during urination. (His twin brother had no such problem). Their father, a physician, immediately became concerned that he was possibly dealing with a very serious underlying condition. He became very distraught, even imagining that his son might end up with a kidney transplant (a good example why physicians should not treat close family members!) Fortunately his wife, the mother of the children , analyzed the situation , and suggested in a very calm voice ( in no way did she wish to embarrass or seem to question the accuracy of the diagnostic acumen of her husband, the physician) that, just perhaps, the bed wetting and the painful urination might be a result of the bubble bath acting as a local irritant. The bubble baths were stopped and the boy’s symptoms cleared completely. However, the physician, the true scientist, wanted to check out the accuracy of the etiology of the symptoms. Accordingly, he added some bubble bath to the tub water of his sons once again. Within twelve hours, the symptoms returned. Yes, the bubble bath was then duly discarded. Ever since that fateful day the family has lived in joyous harmony, although without the pleasures (and trauma) of the bubble bath. (And, Carol, the time for confession has arrived: Since then, my son has had no further such problems.)

Postscript: I subsequently became aware of many such patients who had experienced these adverse effects from bubble bath/liquid detergents and wrote an article for a medical journal titling it “A Soap Opera.” Shortly after publication of the article, I began receiving samples of bubble bath products from companies throughout the world , requesting that I try their product on my patient and write an appropriate testimonial as to its safety and, of course, to its pleasurable qualities. Needless to say, neither my wife nor my son would agree to such.

NON-SPECIFIC URETHRITIS:

2006-12-07T16:48:00.000-08:00

NON-SPECIFIC URETHRITIS:

Dear Sumner:

Harry, a 43 year old married man, is sure he has contracted a venereal disease. He told me he woke up to find some sticky, mucous-like material on his pajamas and experiences slight discomfort while urinating. The discharge from his penis has become more marked each time he checks to see if it is still present. On further questioning he admitted to having had a recent sexual contact with an old friend about one week previously. We are probably dealing with non-specific urethritis, but I will order the standard venereal disease tests. While waiting for you to see him, I will start him on tetracycline. But given the extent of his distress, both he and I would feel much more comfortable if you would advise any further evaluation or therapy.

Dear Scott:

As you know non-specific urethritis (NSU), also referred to as Non-gonococcal-urethritis, is usually caused by chlamydia or mycoplasma organism. Occasionally the symptoms are caused by an inflammatory process without an offending organism. While waiting for the results of the culture (which, in the case of chlamydia, may take a week or so for the final word, you very wisely started him on tetracycline. The fact that the cultures came back negative means either that the offending organism was not picked up on the culture ort that there was no infection present. The symptoms could have been caused by a reaction to a local irritant such as soap, vaginal creams or spermicides used by his partner, or even from excessive irritation from sexual activity. As you stated in your letter, Harry has been squeezing his penis fairly often to see if the discharge is still present. In the process, it is possible that these maneuvers themselves are perpetuating the inflammatory process causing the persistent urethral discharge By the time that Harry arrived in my office I received the results of cultures and blood studies. As you probably know, both urethral discharge and urine cultures were negative for mycoplasma and chlamydia organisms. If Harry was having repeated sex with this woman, and if chlamydia were the culprit, consideration would be given to giving her a course of the tetracycline (or some other appropriate medication, realizing the potential of causing a Vaginitis in the process of trying to eradicate the chlamydia). Rechecking Harry’s urethral washings (1^st part of the urine) would be advisable after a few weeks would be appropriate. Also it would be wise if Harry used his penis only for urinating for a couple of weeks.

RECURRENT URINARY TRACT INFECTIONS:

2006-12-07T16:47:00.000-08:00

RECURRENT URINARY TRACT INFECTIONS:

Dear Sumner:

I would appreciate if you would evaluate a 22 year old woman for me. Since her marriage last April, Sue has had one bladder infection after another. Her husband feels like it’s his entire fault (which, indirectly, it probably is!), and is ready to move into another room! I have treated each infection with 7 day courses of antibiotics, but the infections keep recurring. I realize that these infections are related to sexual activity, but my dilemma is coming up with a simple way of “breaking the cycle” of the recurrent infections. Sue (and her husband!) will be eternally grateful for your help!

Dear Mary:

You are absolutely correct that most urinary tract infections (UTI’s) in women follow sexual activity, usually occurring about 24 to 48 hours thereafter. The organisms, which are normally present in the urethral-vaginal area, get massaged up into the bladder during intercourse. I suggested to Sue that she void right after sexual activity, in hopes of “flushing out” the organisms before they multiply and cause the local tissue reaction with its associated irritative symptoms. We talked about the fact that the normal, non-inflamed urethral-vaginal tissue has a “built-in local defense mechanism.” With the recurring infections, this tissue becomes inflamed, rendering it more susceptible to the offending organisms. I am hoping that if Sue remains infection free for a prolonged period, there will be re-establishment of healthy tissue, making it more difficult for these organisms to colonize. If the simple post-coital flushing technique fails to achieve this goal, then Sue will take post-coital medication: e.g. one tablet of nitrofurantoin or trimethoprim sulfa, for a few months (along with post-coital voiding).

It is obviously very important to obtain an accurate sexual history. During my early years of training, I saw a teenager of 15 with a problem of recurrent urinary tract infections. Haltingly I inquired... ”Do you…you know…ever have sex with anyone?” Her reply was a combination of denial by both verbal and body language. I very rapidly learned that unambiguous questions are more likely to result in direct answers. For example, when I recently asked a coed at a local University who was having recurrent UTI’s: “Do these infections occur 24 to 48 hours after sex?” she replied: “Dr. Marshall, that’s hard to say since it’s unusual that 24 hours goes by without my having sex.”

URINARY TRACT INFECTIONS (DRUG-RESISTANT):

2006-12-07T16:46:00.000-08:00

URINARY TRACT INFECTIONS (DRUG-RESISTANT):

Dear Sumner:

I’d like your help. It involves a 26 year old sexually active woman, Anne Smith, who has had many recurrent urinary tract infections. She has been treated with various medications and, unfortunately, has had allergic reactions from both trimethoprim-sulfa and nitrofurantoin. Culture and sensitivity studies of the current infection reveal an organism which is sensitive only to injectable antibiotics. I’m reluctant to give these meds because of their toxicity potential. Anne’s only symptom now is mild discomfort during urination. I do not know how aggressively I should try to sterilize her urine. Anne will be making an appointment to see you shortly.

Dear Glenda:

It was a pleasure seeing your patient, Anne Smith, although disconcerting that it has been so difficult to clear her infections. There was nothing unusual in her sexual history: She is currently monogamous. Her partner is circumcised and he has not had any symptoms suggestive of infections. They engage in vaginal intercourse about 4 times per week. No abnormalities were noted on physical exam. Culture and sensitivities of a catheterized urine specimen confirmed your findings of an organism resistant to all of the oral medications tested. Given this situation of the many recurrent infections, particularly when dealing with the accompanying resistant organisms, I obtained a renal ultrasound. Happily no obvious anatomical abnormalities of the urinary tract were found.

I discussed with Anne the pros and cons of trying to render her infection free with the use of injectable antibiotics (as per the results of the sensitivity studies). Since she has not been unduly distressed by the infectious process, and the infection seems to be limited to the lower urinary tract (no fevers, back pain and grossly normal renal ultrasound--as per her request, we did not do a voiding cystourethrogram), we opted, for the time being, to delay active treatment of the infection and treat the symptoms of discomfort only.

This plan is particularly expedient when dealing with a resistant organism and a strong allergic history. I have found that, with the passage of time, possibly a few weeks or longer, there is often a shift in the sensitivity pattern, with the emergence of an organism which can be eradicated with less toxic medications. (Sometimes the “flushing” effect of a high fluid intake alone can actually clear up the infection without the use of antibiotics!) Assuming we can, indeed, clear the current infection, post-coital voiding and appropriate post coital meds for a few months may help prevent recurrent infections by reestablishment of a more healthy urethral-vaginal area, providing a less susceptible environment for the offending organisms. There is, of course, the possibility that we are still unable to clear the infection without treating her with injectable medications. We would the have to decide whether her clinical situation warranted such an approach. (The body can live in a symbiotic relationship with many organisms: The cure must never be worse than the disease!)

URINARY TRACT INFECTIONS WITH INDWELLING CATHETERS:

2006-12-07T16:45:00.000-08:00

URINARY TRACT INFECTIONS WITH INDWELLING CATHETERS:

Dear Sumner:

I would like your opinion about a 45 year old paraplegic male who has worn an indwelling catheter for the past 12 years (since his initial injury). He prefers to change his catheter monthly, rather than to do intermittent catheterization. He complains that his urine has a foul odor and suspects there is an infection. Should I treat him with antibiotics?

Dear John:

It is near impossible to sterilize the urine in the presence of long term catheter drainage. It is important to distinguish between bacilluria and a clinical urinary tract infection. (Bacilluria refers to the presence of the organisms in the urine. A clinical infection is when these organisms cause manifestations of a disease process) If the only problem is an odor of the urine, there are medications on the market which can control that problem. If your patient is not having any undue distress, then antibacterial medication is not only unnecessary its use may be contraindicated because of the likely emergence of resistant organisms, which could impede the treatment of subsequent clinical infections. However, since there can be silent damage to the urinary tract organs and/or the formation of stones, it might be wise at some point to get some radiological evaluation of the urinary tract: e.g. renal ultrasound or intravenous pyelogram; if there is evidence of renal damage, a voiding cystourethrogram should be obtained as well. Assuming no obvious problem is revealed on these studies, active urological intervention is not necessary at this time.

URINARY FREQUENCY:

2006-12-07T16:44:00.000-08:00

URINARY FREQUENCY:

Dear Sumner:

Bill Jones will be calling your office for an appointment. He is 75 years of age and is a bit of a hypochondriac. He has been my patient for the past 25 years and claims to be very aware of the way his body “works.” He becomes fixated on particular bodily functions and is currently loosing sleep worrying about his current “fixation,” that of urinary frequency. Save for mild problems with his prostate (he claims his stream is “not what it used to be”) he is amazingly good condition. He complains that he has to urinate every hour, day and night. I would be most grateful if you could help Bill (and me!)

Dear John:

I, too, found no gross abnormalities on Bill. His prostate was palpably benign, his urine was free of infection, and his post-void residual was negligible. We had a rather extensive discussion re the machinations of the urinary tract. I must admit I had quite a time getting him to accept the simple concept of intake and output; i.e. what goes in must come out. He enjoys his cups of coffee with each meal and his eight glasses of water during the day. One very revealing additional bit of information was that, in order to help him go back to sleep each time he gets up, he drinks a large glass of warm milk. It was very exciting (and most gratifying) to note Bill’s expression on his face when he realized that merely modifying his fluid intake could take care of his problem (It will be interesting to see what his new “fixations” will be!)

By the way, John, I see so many patients with similar stories. One of my favorites involved a patient I saw during my Urology Residency. This man was referred to me because of nocturia times five. Upon further questioning, I learned that he voided at most once during the day. The doctors in the Medical Clinic had run multiple diagnostic studies to rule out any serious medical conditions. Happily, none were found. John, what do you think I discovered? He was a night watchman!

LARGE POST-VOID RESIDUAL:

2006-12-07T16:43:00.000-08:00

LARGE POST-VOID RESIDUAL:

Dear Sumner:

During an evaluation of a 73 year old man for excessive flatulence, I found on an ultrasound study that he had a post-void residual of 400ccs. of urine. Indeed, until this was pointed out to him, he was not even aware that he had a “problem.” He says that he is voiding without difficulty, and although he gets up once during the night and his urinary stream is not as fast as that of his grandson (they sometimes see who can finish first: his grandson almost always wins the race), he is not distressed with the situation. Should further diagnostic studies be done? Does the presence of a large post-void residual of itself dictate the necessity for some form of intervention therapy? I’d appreciate having your opinion on this matter.

Dear Don:

Thanks for the opportunity of seeing your patient for evaluation of his post-voiding residual urine (which you picked up during an abdominal ultrasound study, the study having been done for his problem with excess flatulence). The question always arises as to “how aggressive must we get?” Basic urological tenets teach us that a large post-void residual can lead to “back pressure” and resultant impaired drainage of the kidneys, with the potential for renal failure. Many urologists would advise drainage of the bladder with a catheter. However, your patient has no associated distention of his renal collecting systems or ureters, his renal function studies are completely within normal range, and there have been no associated infections of the urinary tract. As you know, he is not at all distressed with his voiding pattern, and I feel quite comfortable in holding off on further urological workup at this time. If, however, there is evidence of developing problems, then consideration would be given to establishing more satisfactory drainage of the urine (e.g. via a catheter initially). I think it wise that you obtain another renal ultrasound study, to include a post-voiding film, in about 6 months, earlier if symptoms referable to the urinary tract occur before then. Please keep me informed re these follow-up studies and feel free to call me at any time.

HEMATOSPERMIA:

2006-12-07T16:42:00.000-08:00

HEMATOSPERMIA:

Dear Sumner:

Robert, who is a 44 year old man, will be seeing you in the near future. He recently discovered blood on the sheets after having had intercourse with his wife. She was not having her period at the time. He did not see any blood in his urine, and there was no associated discomfort with either urination or ejaculation. Needless to say, he has since been VERY upset, and is convinced that there is something seriously wrong. He denies any new sex contacts, although he is now wondering if this is from some pre-marital “exposure.” I tried to reassure him that the underlying condition is most likely not serious, but I think he needs your special touch. I await hearing your words of wisdom.

Dear Martha:

I can certainly understand Robert’s distress. The presence of blood in the ejaculate is very frightening to a man. He verbalized to me that he was afraid he had a malignancy, a venereal disease, or that this might portend the loss of his ability to have erections! He seemed a bit more relaxed when I explained that bloody ejaculates (aka hematospermia), fortunately, is almost always benign in nature caused by an underlying inflammatory process. The bloody ejaculates are usually of brief duration, although in some cases they may persist for years. A urine specimen sent for cytological examination, as expected, showed no malignant cells. I told him that if the bloody ejaculates did persist, I would get x-rays of the area and possibly look up into his urethra and bladder. When he asked what he should do if all of the studies showed no serious underlying problem and yet the bleeding recurred. I advised him to have sex in the dark.

GENITAL WARTS:

2006-12-07T16:40:00.000-08:00

GENITAL WARTS:

Dear Sumner:

Frank is a 43 year old man who will be calling for an appointment to see you shortly. His problem is that of recurrent warts on the shaft of his penis and under his foreskin. He has been treated with various methods including topical lotions, liquid nitrogen as well as fulguration, but the warts keep returning. He is married and claims to have a monogamous relationship. He is uncircumcised. What would you suggest as the next steps, both diagnostically and therapeutically? Assuming you rid Frank of his warts, what can he do to prevent their recurrence?

Dear Percy:

As you probably know, genital/venereal warts, (also called condylomata acuminata) are caused by the human papillomavirus. They are very contagious and are spread during oral, genital or anal sex with an affected partner, usually appearing within three months after contact. The lesions in Frank were quite apparent on both the shaft of his penis and under his foreskin. I applied some acetic acid (vinegar), which revealed a few other small areas on his penis to whiten, suggesting that these areas were also infected (I routinely apply acetic acid to any male patient when there is a suspicion of genital warts, since this method may reveal otherwise undetected lesions). However, it is often difficult to find the lesions in the woman, since they can occur not only externally, but also deep in the vagina. It is, therefore important that Frank’s wife be examined by her gynecologist who will likely do a Pap smear and maybe even a biopsy.

Now for the important questions: how do we get rid of the warts, and perhaps even more critical, how can we prevent their recurrence? There is a myriad of caustic agents which can be applied locally. If any of the lesions appear atypical, I do a biopsy prior to their destruction. I personally prefer to destroy the lesions with electrocautery, but cryosurgery or laser therapy is similarly effective.

The only way to prevent a recurrence is to avoid direct contact with the virus. This means, of course, that the virus must be completely eradicated in both Frank and his wife (assuming there are no other partners involved), since the virus is transmitted by skin-to-skin contact. Unfortunately, there is still a possibility that the virus may remain in the body even though the external lesions have been eradicated. But, as Frank says, he and his wife enjoy the skin-to-skin contact and have decided to use condoms only if either of them becomes suspicious of a recurrence. I should mention that Frank wishes to keep his foreskin despite the realization that it might harbor the virus, leading to a greater chance of recurrence.

Dear Sumner:

Dear Percy:

GENITAL HERPES:

2006-12-07T16:39:00.000-08:00

GENITAL HERPES:

Dear Sumner:

How would you handle Peter, a 38 year old man, with periodic flare-ups of herpes? He is not married, but he tells me that he has been in a monogamous relationship for the past year. I have checked him out for the “standard” sexually transmitted diseases (gonorrhea, syphilis, non-specific urethritis and HIV) all of which were negative. His fiancée, Melissa, thus far, has shown no signs of herpetic lesions. However, she is quite concerned that it is only a matter of time before she becomes infected. First of all, how can we be sure she is currently free of the disease, and what is the best way available currently to protect her? How can she tell if/when she gets the disease? Are there tests available to monitor her status? Can Peter take some medication which will prevent his being infectious?

Dear Mark:

I had quite a discussion with Peter and Melissa re the various aspects of genital herpes. I tried to address their many questions. Herein is a brief summary of our discussion:

First of all, the incidence of genital herpes is quite high; 25% of women and 20% of men are infected with the virus. Unfortunately once the genital herpes virus (HSV type 2) gets into the body, it remains in certain nerve cells for life and may be reactivated at any time. However, after the first episode, subsequent outbreaks are almost always of shorter duration, less severe, and occur less frequently. I commented that it is not known what factors cause the virus to become active, although flare-ups seem more common during times of either emotional or physical stress, , possibly resulting from an added strain on the immune system. They were quite aware that the infection is most commonly spread during the time when there is a lesion/sore, which can shed viruses, but were taken aback when I mentioned that Peter could be infectious without any obvious sores being apparent. We discussed how, with the first episode of infection, there may be associated flu-like symptoms of fever, muscle aches and malaise and that the initial small red bumps evolve into blisters and subsequently become painful open sores which become crusty. These lesions usually heal without leaving a scar. . Since they engage in oral as well as vaginal sex, I mentioned that HSV type 1, the virus causing blisters on the lips (commonly referred to as “fever blisters”) can also be spread to the genital area with oral sex.

Melissa was concerned about her current status. Although she has not seen any herpetic lesions on herself, she inquired about tests which could tell if the virus had gotten into her body, as yet in an undetected state. We will be obtaining a blood test a blood test which, by checking the antibody titer, will indicate if Melissa has ever been infected with either HSV 1 and/or 2. Unfortunately, this test is unable to determine if that person is currently infectious. Indeed, a person could have genital herpes with a “negative” titer for HSV. The only sure way of confirming the diagnosis is by culturing out the virus from a herpetic lesion. Should she become pregnant while infected with the virus, she asked about the chances of infecting her fetus. I replied that this would be likely to occur only if she had an active vaginal lesion at the time of the birth and if so, the delivery would be done via caesarian section.

The “bottom line” is that Peter and Melissa must come to a mutual understanding, realizing the potential hazards of the disease while realizing that they can “live with herpes” as long as they take reasonable precautions. These precautions include avoiding sexual contact during any obvious outbreaks, and anytime there is any suspicion or concern, they would use condoms. I informed them that although there is no medication currently on the market which has been proven to prevent transmission of genital herpes, certain medications can “inactivate” the virus. Indeed, some studies have shown that these medications can prevent outbreaks for a year or longer. Peter has opted to take famciclover, one of the antiviral medications.

PEYRONNIE’S DISEASE:

2006-12-07T16:38:00.000-08:00

PEYRONNIE’S DISEASE:

Dear Sumner:

I have a very upset man with a bent penis. Jack, who is 48 years old, has noted over the past couple of months that when he has an erection, there is some associated discomfort and his penis bends upward at an angle of about 30 degrees but he is still able to have intercourse without difficulty. I am not sure how much of his discomfort is emotional rather than physical. He is worried about the possibility of the deformity getting worse, I have told him that I believe he has Peyronie’s Disease, and I tried to assure him that this was not a life-threatening situation. He responded that I seemed to be downplaying the seriousness of his problem. How can I reassure him more effectively? Or perhaps even more importantly, what measures are available for treating this disease?

Dear Gwen:

I had the opportunity to talk with both Jack and his wife about this problem. I was able to assure them that we are dealing with a benign (non-cancerous) process that is usually self-limited. However, I did explain that Peyronie’s Disease can produce variable sizes of plaques from very small to fairly large with accordingly variable degrees of bend to the penis (during erection). In Jack the plaque has developed on the upper side of the penis, causing it to bend upward. The etiology for the plaques’ development is not known although it is likely some type of inflammatory process. As you pointed out in your letter, Jack is able to engage in intercourse although he experiences some discomfort with the erection. I explained to Jack that the inflammatory process generally reaches a plateau after about one year with no further plaque formation along with resolution of the discomfort and since a certain percentage of the lesions may actually regress spontaneously, I generally do not institute active therapy during that first year.

Therapy is a “mixed bag.” Since the etiology of the lesion is, thus far, not known, a variety of non-surgical therapeutic approaches have been tried, ranging from topical and injectable steroidal and non-steroidal anti-inflammatory preparations to radiation and ultrasound treatments. The results of these approaches have been sub-optimal. I have become a bit of a skeptic since, if there is improvement, it is difficult to know if the improvement is from the treatment employed or from the natural course of the disease process. If the penile bend prevents satisfactory intercourse, then surgical intervention is offered. Since Jack‘s erections are quite rigid, if surgical straightening of the penis were to be done, it would not be necessary to insert a penile prosthesis.

CIRCUMCISION (NEWBORN):

2006-12-07T16:35:00.000-08:00

CIRCUMCISION (NEWBORN):

Dear Sumner:

I have spent an inordinate amount of time with one of my families, Mary and Bob Stevens, discussing with them whether or not they should have their soon to be born son circumcised. This is not a religious issue. Dad is circumcised, as are their other 2 sons, but Mom has been reading a lot recently about the “brutality” of cutting on a defenseless newborn, who has no say in the matter. I realize that this is a very controversial topic, which is fraught with much emotional overtones (as has definitely been the case in this family!) What is your personal opinion (based on scientific facts, of course) re circumcision of the newborn? The family has requested a consultation with you. I think it would be wise to allot sufficient time in your schedule to go over the subject with them.

Dear Myron:

I really appreciated your alerting me to the possible time which I should allow to talk with the Stevens family about having their newborn son undergo a circumcision. As you mentioned, they have literally agonized over this subject for the entire time of Mary’s pregnancy. The Stevens’ dilemma is made more acute by the fact that all males in that family are circumcised. They had obviously read extensively about the pros and cons of circumcision, including the possible complications of the procedure itself. I tried to act as a sounding board, while interjecting my own interpretation of the available material on the subject. While it is a fact that over 80% of males in this country are circumcised, in the world at large, this figure is probably well under 5%.

We reviewed the evidence, both pro and con re circumcision. On the negative side, we considered the risks of the procedure itself, including reactions to anesthesia (if anesthesia were to be used), bleeding, infection, secondary scarring, fistula formation, incomplete or excessive skin removal necessitating surgical revision, and inclusion cyst formation. On the positive side, circumcision reputedly decreases the chance of urinary tract infections, HIV infections, penile carcinoma, and carcinoma of the cervix in women whose partners are circumcised. After spending close to an hour with the Stevens, I still felt that although they seemed to be leaning toward arranging for the circumcision, they still seemed a bit ambivalent. I suggested that they postpone the decision for a bit longer. I also emphasized to them that, if they opted to defer or not circumcise their son, they should avoid the temptation to try to retract the foreskin themselves at this time, since it is “normal” that the foreskin is non-retractable in most boys until they are about 2 years of age. I remain ever available.

CIRCUMCISION: USE OF LOCAL ANESTHESIA

2006-12-07T16:33:00.001-08:00

CIRCUMCISION: USE OF LOCAL ANESTHESIA

Dear Sumner:

I have a family from Berkeley that I’d like you to see. They wish to have their son circumcised, but they want to be sure he will not experience any pain during the procedure. They have searched the internet for information about the risks of local anesthesia in a newborn as well as the possible physical and psychological trauma which might result if no anesthetic is used. His father wishes to watch the procedure being done. Will this be OK with you? They will be calling your office for an appointment.

Dear Bob:

There is little argument that the use of some form of local anesthesia in the newborn helps decrease the pain level during circumcision. I addressed this issue with the family as well as the possibility, albeit very rare, of an allergic reaction to the anesthetic. With their own religious backgrounds, they were already well aware of the use of wine to sedate the child (the mainstay for religious circumcisions for centuries!). We also talked about the use of topical anesthetic cream. (To be effective, it should be applied at least one hour before the procedure is started.) After much discussion, weighing the pros and cons (including potential risks) of local anesthesia, all parties involved (parents and doctor--infant Josh didn’t offer his opinion), decided that local anesthesia would provide the most effective method off minimizing the discomfort of the circumcision.

Re their desire to be present during the procedure, I pointed out very clearly that I wanted to give my full attention to their child. I.e. I do not want to have to divert any of my attention to either of them, should they become distressed during the procedure. They both expressed VERY strong feelings about being in the room, and promised to be “good.” Using a very tiny needle, I injected less than 1cc. of 0.5% lidocaine circumferentially in the area just proximal to the foreskin. Josh was quiet and his parents breathed a big sigh of relief. (As did I!)

Bob, I’d like to share another story of an older boy, just to point out that anesthesia is not always necessary. Mark, age 4, came to me for the release of adhesions of the foreskin to the glans (head of the penis). Given his age and level of concern of his father (although the boy himself was pretty relaxed about the whole thing), I planned on using a local anesthetic to try to minimize the trauma (mainly for the parents). When the time came to proceed, since Mark was not very enthusiastic about having a needle stuck in his penis, I thought I’d give a quick try to see if I could release the adhesions without the use of an anesthetic. “OK, Mark” said I, “This may hurt for just a few seconds.” A quick maneuver and the adhesions were released. Mark looked down, looked up, and with wide-eyed wonderment exclaimed to his father: “Wow, Dad, Dr. Marshall did it with his bare hands! “

CIRCUMCISION: USE OF LOCAL ANESTHESIA

2006-12-07T16:33:00.000-08:00

CIRCUMCISION: USE OF LOCAL ANESTHESIA

Dear Sumner:

Dear Bob:

CIRCUMCISION (ADULT):

2006-12-07T16:31:00.000-08:00

CIRCUMCISION (ADULT):

Dear Sumner:

Al is a 62 year old man who has noticed that his foreskin has been progressively tighter over the past few months and in the last two weeks he has been unable to retract it at all. Isn’t it unusual that a previously retractable foreskin should become totally non-retractable? Any idea as to why this should occur at this time in his life? He (as well as I) would like your opinion about possible measures that can be taken to achieve a retractable structure, short of circumcision. If the foreskin does not loosen despite conservative measures, does this mean he should be circumcised? Al would like to keep his foreskin if at all possible. Are there procedures which can achieve this goal yet still spare the foreskin? Could you take a look at Al (and his foreskin) and let me know your thoughts and recommendations.

Dear Miriam:

In the world at large, circumcised men are in the minority (so obviously not every male needs a circumcision). When a previously retractable foreskin becomes non-retractable, one should always think about the possibility of underlying diabetes. And, indeed, Al did have sugar in his urine and he will be seeing you shortly for a diabetes evaluation. In the interim, I will see if oral and local anti-inflammatory preparations (e.g. steroid creams) may decrease the inflammatory process and permit foreskin retraction once again. Al will try to “stretch” the skin himself by trying to pull it back at least a few times per day. I mentioned to Al that he always bring the foreskin back over the head of the penis, since, with the tight foreskin there is a high possibility that the foreskin could not be brought forward, referred to as “paraphimosis” which might require emergency intervention to release it.

Personally I feel very strongly that, given the possibility of undetected lesions or infections occurring beneath this structure, it is wise that the entire penile shaft be able to be inspected. Therefore, if our conservative measures are not successful, once the diabetes has been brought under good control, then either a dorsal slit (an incision in the foreskin) or removal of a portion, or all of the foreskin (i.e. partial or total circumcision) would be recommended. Since Al has become attached to his foreskin over these many years, if surgery is necessary, then we will likely do just the dorsal slit.

TRAUMA (KIDNEY):

2006-12-07T16:29:00.000-08:00

TRAUMA (KIDNEY):

Dear Sumner:

Sorry to bother you with what may be an insignificant problem, but I’m uncertain as to what steps should be taken at this time. Daniel, a 20 year old man, was hit rather vigorously in his right flank while playing basketball. Shortly thereafter he noticed some blood in his urine, but this was just once. Since then the urine has been totally clear. However, when I saw him in the office today, I found a few red blood cells in both the first and second glasses, which, according to your teaching, indicates that the source of the blood is above the bladder neck, and, given the history of the flank pain, probably from the kidney. (You see, Sumner, I did stay awake during your lecture!)Daniel is no longer experiencing any pain. Should I suggest that Daniel hold off on contact sports for awhile? Do I need to get X-rays of his kidneys and, if so, what kind? What sort of follow-up is advisable?

Dear Craig:

First of all, my thanks for staying awake during my lecture and, even more so, for remembering (and using!) the information of the “3-glass urine.” I agree with you completely that the blood is most likely of renal origin, and since the urine was grossly red on only one occasion he probably experienced only a renal contusion rather than any disruption of the renal collecting system (assuming the bleeding was secondary to the trauma and not from other causes).

There are a variety of approaches for the problem of renal trauma. If Daniel’s urine was microscopically free of red blood cells on follow-up urines, I think it reasonable to obtain just a renal ultrasound study to rule out any obvious perirenal hematoma or space-occupying lesions in the urinary tract. However, if there is persistence of the hematuria and/or Daniel has any return of his back or abdominal pain, I would recommend obtaining a CT scan (with dye) which will give us a more accurate picture of the integrity of the renal collecting system (as well as possibly reveal any problems of other adjacent organs or structures). Happily most of the renal injuries caused by blunt trauma can be treated conservatively. (On the other hand penetrating injuries have a much greater chance for more serious injuries usually requiring surgical intervention).

Feel free to contact me if you have any further questions or concerns.

TRAUMA (PENIS):

2006-12-07T16:28:00.000-08:00

TRAUMA (PENIS):

Dear Sumner:

This letter follows my call to you re John, who is a very embarrassed and frightened 24 year old man who was having a rather vigorous sexual experience with his girlfriend (she was in the dominant position), when heard an actual snapping sound and felt a sharp pain in his penis. He has been unable to urinate since then. As you have probably observed yourself by this time, his penis is very tender, swollen and discolored. He is sure that this is the end of his sex life! How can you find out what is going on here and, more importantly, what can you do to “make it all better?” Both John and his girlfriend would be extremely grateful for your help.

Dear Elsie:

This was surely one very distressed young man. My diagnosis was that of a penile fracture…i.e. disruption of one or both of the compartments which fill with blood during erection (the corpora cavernosa). Generally, imaging studies are not necessary since, in such cases, you can usually feel a distinct firm mass on the penis, which represents the hematoma at the site of disruption. However, it is important to be certain there is no associated injury of the urethra. Especially since John was unable to urinate since his injury, I obtained a urethrogram. His channel appeared intact.

Penile fracture is obviously not a very common occurrence and some physicians treat this problem conservatively, hoping for spontaneous healing to take place. However, because of the high incidence of complications with that approach, such as penile curvature and erectile dysfunction, early surgical intervention may be preferable. Accordingly, after a rather detailed discussion with John and his girlfriend weighing the pros and cons of surgery, we did proceed with the repair. The surgery went smoothly and I am optimistic that John and his girlfriend will have a happy future together (though perhaps a bit less vigorous than in the past).

POST-VASECTOMY PREGNANCY:

2006-12-07T16:27:00.000-08:00

POST-VASECTOMY PREGNANCY:

Dear Sumner:

John is a 43 year old patient of mine who had a vasectomy about 9 months ago (not by you). He had his semen checked at about 4 months after the procedure, and no sperm was found. Contraception was then discontinued. It came as quite a surprise to John and his wife when she missed her period last month, particularly when a pregnancy test done a few days ago was positive. I immediately ordered another semen check, with no sperm being found once again. This couple has been married for 25 years and has 3 children, ranging in ages from 10 to 18. They are currently trying to decide whether to have an abortion. Needless to say, this pregnancy has caused considerable strain in their marriage. His wife categorically denies any extramarital activity. They have always seemed like an exemplary couple and have done a wonderful job raising their kids. I would be very distressed if this marriage broke up because of this pregnancy. I would appreciate if you would see John and try to help sort things out.

Dear Mel:

Post vasectomy pregnancies are very rare and usually occur within the first few weeks of vasectomy because the couple has incorrectly assumed that there is no need for contraception once the vasectomy has taken place. However, there may still be residual sperm present within the ductal system at that time. In 1972, I reported on a more uncommon phenomenon: the transient reappearance of sperm after vasectomy (JAMA: 219:1753, 1972). I had a good talk with both John and his wife re this study. They both seemed VERY relieved after our visit together and decided not to interrupt the pregnancy.

Mel, I feel that it is important that the involved physicians be aware of the possible transient reappearance of sperm after vasectomy and convey this information to the marital partners. I think you will agree with me that it is better to err on the side of incorrect paternity and let the couple work out the situation themselves than to destroy a marriage by denying the possibility of the husband’s transient fertility.

ERECTILE DYSFUNCTION:

2006-12-07T16:26:00.000-08:00

ERECTILE DYSFUNCTION:

Dear Sumner:

I have asked George, a 62 year old man, to call you for an appointment, since, unfortunately, I have been unable to provide him with satisfactory solutions for his problem with maintaining erections. He states he is able to gain a fairly firm erection, but as soon as he attempts insertion, the penis becomes flaccid. He has tried oral and intraurethral medications, penile injections as well as a vacuum pump, all with variable degrees of success. I found no obvious causes for his difficulties. It’s your turn now! Thanks in advance for your help.

Dear Craig:

Most of my time with George involved listening: having him tell me when and under what conditions he had difficulties (or no difficulties) achieving and/or maintaining erections. I questioned him about his occupation, interpersonal relationships, the time and situation of onset of his erectile dysfunction and how he performs sexually under varying circumstances, including self stimulation or with a partner-- or partners. (I had a patient consult me because he was having problems maintaining an erection when with his wife. He had no such problems when with his mistress.) When I learned that George was able to have firm erections during vacation without the use of medications or devices I felt confident that he had no physiological disturbance of his erectile “mechanism.”

My main approach was one of counseling--and reassurance. I pointed out to him that while a teenager may be able to attain an erection “at will”, this ability lessens with age (and George realizes that he is no longer a teenager). Our discussion included the fact that most men over the age of 50, and often younger men as well, experience intermittent difficulty with erectile function.

But perhaps the most meaningful point of discussion for George was his realization that he often tried to gain an erection even when there was no sexual stimulation. Almost every time he was unsuccessful. This series of failures eventually turned into a self-fulfilling prophecy of erectile dysfunction—at least when he was not on vacation.

If his problem continues, I suggested he utilize variations of the techniques of Masters and Johnson, sometimes referred to as “sensate exercises”. This involves stimulating and subsequently bringing his partner to orgasm without his inserting, the purpose being to avoid any pressure on him to “perform. “ (Usually, during the time of his partner’s being stimulated, he himself becomes aroused--and erect). Hopefully, after awhile, George will be more relaxed when with his partner and the “problem” will straighten itself out spontaneously. I am optimistic that the self realization that his reactions are not abnormal will itself be therapeutic. He was somewhat concerned about his wife’s reaction to his perceived failure of performance. If his problem does not resolve, he agreed to make another appointment for both him and his wife . Craig, I’d like to share a story with you how one’s attitude can influence his reaction to his erectile function. One of my patients told me that on his 85^th birthday he wrote in his diary: “Last night I had an erection. I was unable to bend it with both hands.” On his 86^th birthday he entered in his diary: “Last night I had an erection. I was able to bend it with both hands. I must be getting stronger.”

URINARY STRESS INCONTINENCE:

2006-12-07T16:25:00.000-08:00

URINARY STRESS INCONTINENCE:

Dear Sumner:

I have a delightful 92 year old woman as my patient who has had progressive bouts of urinary incontinence over the past 20 or so years. The problem occurs only when she does any physical activities; there is no leakage when she is in bed. This is particularly distressing since one of her great pleasures in life had been attending church, but the embarrassment of wet panties has curtailed this activity. She is very reluctant to undergo any surgical procedures and has asked me whether there is some “non-invasive” procedure which will help her. Let me know what you and she decide is best for her. By the way, Myrtle is one of my favorite patients, and I am sure she will soon be one of yours as well.

Dear Kim:

After meeting and talking with Myrtle, I can certainly understand why she is one of your favorites. Not only is she delightful, she is also very bright and seemed to grasp the entire subject of the various approaches to urinary incontinence. For example, she explained to me that urinary stress incontinence is usually secondary to decreased local support of the urethra and bladder most often occurring in women after multiple vaginal deliveries. We talked about the options for restoring the supporting mechanism. As you know, she wanted a non-surgical approach. We decided to try the “old fashioned” vaginal pesssary, (which is particularly useful for high risk women with medical diseases or for women who just want to avoid any surgical procedures). I told her that sometimes local inflammation can occur with the use of a pessary, and occasionally it can become displaced or even fall out. I asked her what she would do if the pessary popped out when she was walking down the aisle in church. Without a moment’s hesitation she looked at me with a twinkle in her eye and said: “Why, Dr. Marshall, I’d just pick it up off the floor, and hold it up in the air and ask: Did anyone here loose this?”

Happily, the insertion of the vaginal pessary did provide satisfactory local support for her cystourethrocele, resulting in marked improvement of her urinary control (and it stayed in place both during, as well as after, church services!)

By the way, Kim, a vaginal tampon can provide local support for a woman with mild stress incontinence during such activities of tennis or square dancing.

POST-VOID DRIBBLING:

2006-12-07T16:23:00.000-08:00

POST-VOID DRIBBLING:

Dear Sumner:

What can you do with a man who claims he always has a few drops of urine wetting his underpants when he finishes urinating? This is complaint of my 48 year old patient Roger, who has never had any documented urinary tract infections or venereal diseases and is otherwise totally asymptomatic. I have been unable to find any cause for his problem. I would appreciate your input.

Dear Gretchen:

I am optimistic that we have helped Roger solve his problem. I think the underlying basis for the leakage is a disturbance of the coordination of the voluntary and involuntary muscular components of his urethral sphincter, sometimes referred to as “dyssynergia”. Ordinarily these two components contract synchronously. Roger, in a conscious effort to stop the urinary flow, would initiate the voluntary muscle component of the urethral sphincter, perceiving that he had completed the act of voiding. However, before the involuntary muscle component contracted, the small amount of urine “trapped” in the posterior urethra would dribble out spontaneously and soil his pants. (How’s that for an esoteric explanation for a rather common phenomenon?) By relaxing his perineal muscles at the time of perceived completion of urination--possibly allowing time for contraction of the involuntary component--and by applying direct pressure with his finger on the area of his penoscrotal junction, Roger was able to eject those last few drops from the urethra and thereby avoid the embarrassing wet spots on his pants.

BED WETTING (ENURESIS):

2006-12-07T16:21:00.002-08:00

BED WETTING (ENURESIS):

Dear Sumner:

I need your advice on how to handle Beverly, a four year old girl, who wets her bed nightly. I realize that this situation of itself is not unusual, but her parents are very distraught, and are not willing to accept the fact that she will likely “outgrow it.” Her mother has told me--numerous times--how bright and well-adjusted she is and how she gets along so well with her pre-school classmates. However, as soon as Beverly walks through the door of my office, she becomes very emotional and immediately starts crying and clinging to her mother. Her urine is free of infection and no gross abnormalities are noted on physical exam. When I suggested a trial of medication, her parents refused this approach. When I suggested some “counseling” they became very angry. However, they did agree, and in fact, were most pleased, when I suggested that they have you see her. Are you willing? I hope so since they’ve already made an appointment.

Dear Phil:

I appreciated very much your introductory note on Beverly, particularly with the warning of her seeming emotional lability. As my office manager always tells me: “Forewarned is forearmed!” For that reason, when Beverly first walked into my office (clinging to her mother), I informed her that I’m a cookie doctor, not a “shot” doctor. (I always have a supply of chocolate chip cookies in my office). I chose to examine her in my office (consultation room), rather than in a separate examining room. Sitting on her mother’s lap during the exam seemed to add to her feeling of security. Before embarking on my examination of Beverly, she and I examined her doll. No abnormalities were found on either Beverly or her doll.

My approach with Beverly was an attempt to involve her in solving the problem. Assuming that Beverly really wanted to stop wetting the bed, I asked her to make a calendar and, if she woke up dry, to affix a star of her favorite color to that day (for daytime wetting one can modify the calendar accordingly). If she wet, she will record possible causes—with the help of her parents. (Phil, I want you to know that some of the things the kids write down are quite original: e.g. “the dog peed on my leg “or “my pajamas fell into the toilet.”) In addition, I asked her to postpone voiding as long as possible, noting the maximum volume of urine she could produce at any one time. Obviously one of her parents will have to help her collect and measure the urine. (Whether this actually increases her bladder capacity is not as important as making her aware of the sensation of bladder fullness, and then recognize that the time has come to deposit the urine in a proper receptacle.) I further suggested that she stop and start the stream during voiding to try to reinforce her awareness that she can control her voiding pattern. I am well aware that these steps may not result in totally dry beds, but if we can get any dry nights, this will be a positive start.

I then asked the family to make an appointment for 3-4 weeks hence in order for me to go over the record with the child. (Her parents’ eyebrows rose at the thought of paying for another office visit, but quickly relaxed when they are told there will be no charge for that subsequent visit.) Phil, it is very gratifying when a child appears with a big smile, so pleased that there are some stars on the calendar to show me (besides which, she also gets a chocolate chip cookie along with my encouraging words). The main point is that she must answer to a person other than a parent.

As a reward for sending me this “challenge,” I’d like to share with you a couple of experiences I had with some other families involving bed wetters. As you know it is critical to observe the interchange between the child and family members. For example, I had one 5 year old boy who sat quietly in the room sucking his thumb as his mother pointed an accusing finger at him, telling me how “this little brat can never stay dry and always embarrasses us with his constant wetting.” This is certainly not a very healthy family constellation! Another example involved a 6 year old youngster who came to office with his mother. Unlike with the other case, this mother looked lovingly at her son, smiling at his every word and action. “Dear Johnny,” said she, “tries so hard to stay dry and whenever he does, we give him a reward. Why last week alone he got a new tricycle, a special puzzle and a Mickey Mouse watch.” When I talked to Johnny separately, I asked him how he felt about being dry. He acknowledged that, while it did make him happy to wake up dry. he didn’t want to wake up dry every day, at least not right away. His reason: “Doc, I got it made! Do you see the way I got my Mom twisted around my little finger?”

However, not all parents will accept my approach. I had one mother who wore a very satisfied look on her face when she brought her son back for a follow-up visit. “Doctor” she said, “you may have all your fancy calendars and chocolate chip cookies, but I discovered a quicker way to stop my son from wetting. I got him an electric blanket and told him that if he wet the bed, he’d electrocute himself. (I personally do not recommend this approach for the treatment of enuresis!)

Medications or alarm systems remain other options.

HEMATURIA:

2006-12-07T16:21:00.001-08:00

HEMATURIA:

Dear Sumner:

How do you handle a 62 year old man with red urine? Harry, who I has been my patient for 22 years, told me during his yearly routine checkup that for the past 6 months or so he has noted a reddish discoloration of his urine. Since this was intermittent, lasting only for one or two urinations and he had no associated discomfort, he figured that there was nothing seriously wrong and saw no need to call me earlier. I didn’t want to alarm him, but, quite frankly, I am, indeed, worried about a possible serious problem. (I seem to remember from my medical school days that with gross blood in the urine a tumor somewhere within the urinary tract must be ruled out. Am I correct in this assumption? I suggested he call your office for an appointment for the very near future.

Dear Ben:

First of all, thanks for encouraging Harry to see me so promptly. Statistically speaking, hematuria is more likely to be secondary to a benign process such as from an inflammatory/infectious process or a stone, although I always worry about the possibility of a tumor within the urinary tract. Of course, it is possible that the reddish discoloration of his urine was secondary to dye or some breakdown products in medication or foods rather than from blood. When I checked Harry’s urine today, I did not find any red blood cells in either the urethral washings or mid-stream urine samples. However, that does not mean he didn’t have them before, and with the history as presented, I feel that Harry’s urinary tract should be visualized via some radiological study and urine examined for abnormal cells (cytology). (I have a general rule that every patient with hematuria be it gross or microscopic only, gets a minimum of a renal/bladder ultrasound and urine for cytology; with gross hematuria, I will add cystoscopy to the workup).

If there is anything suspicious noted on the renal ultrasound, or if the urine is subsequently found to contain red blood cells, or if the urine cytology shows any abnormal cells, then I will follow with an intravenous pyelogram (IVP). A CT scan or MRI study as well as cystoscopy may also be done. I will let you know my findings and further thoughts.

Dear Ben:

The renal/abdominal ultrasound study showed no gross abnormalities and the urine cytology, no abnormal cells. However, I subsequently found red blood cells in both the 1^st and 2^nd glass urines, suggesting their source to be proximal to the bladder neck, i.e. from the bladder, ureters or kidneys. I did obtain a CT scan which, happily, revealed no obvious tumors or enlarged lymph nodes. On cystoscopy, however, I found a sessile lesion which had the gross appearance of a low grade tumor and, indeed, on histological examination that diagnosis was confirmed. (By the way, Ben, a negative cytology does not rule out the presence of a tumor, only that, if a tumor is present, it is likely low grade and probably not invading the deeper layers of the bladder wall). I will be looking in Harry’s bladder at three month intervals for one year and then at increasing intervals thereafter. Should there be multiple recurrences, and then consideration would be given to the use of intravesical therapy, such as chemotherapeutic or immune boosting agent. Hopefully, the use of such will not be necessary. Generally in cases of superficial tumors of the bladder, the overall prognosis is quite good

PROSTATIC CANCER TREATMENT (WITHOUT BIOPSY):

2006-12-07T16:18:00.000-08:00

PROSTATIC CANCER TREATMENT (WITHOUT BIOPSY):

Dear Sumner:

Mr. Y., an 86 year old man, came to my office last week complaining of progressive slowing of his urinary stream along with rather severe lower back pains. The back pains lessened with the use of Tylenol, local heat and bed rest. He is a bit “fragile,” having had a heart attack about 3 years previously and is generally quite weak. He is currently on prophylactic low dose aspirin. On rectal examination I found his prostate to be hard and bumpy. I obtained a PSA level, which the lab reported as 32 (normal level for that lab is <4). style=""> Where should we go from here? Do we need a tissue diagnosis prior to starting hormonal therapy?

Dear Bob:

I certainly agree with you about the high probability of your patient having prostate cancer. The question arises as to the best way of handling the current situation. I had a long discussion with both Mr. Y and his family about the “statistics” of prostatic cancer with increasing age: i.e. after the age of 70, there is approximately a 70% chance of there being a focus of cancer in the prostate, over the age of 80, an 80% incidence, and after 90, almost all men will have a focus of cancer in the prostate. The message is: if you live long enough, you will die with, but not from, prostate cancer. (Of course, in this case, he could, indeed, die from metastatic disease.).

Re the question you brought up about the necessity of obtaining a tissue diagnosis prior to initiating treatment, under the best of circumstances, prostatic biopsies run the risk, albeit very low, of possible complications such as bleeding or infection, not to mention the discomfort. And taking into account your patient’s age, his past medical history, the fact that he is on prophylactic aspirin, and the clinical picture of probable prostatic cancer (PSA of 32 with an underlying firm and irregular prostate), I would opt for starting him on anti-androgen therapy without having a tissue diagnosis.

TERMINALLY ILL PATIENT:

2006-12-07T16:10:00.000-08:00

TERMINALLY ILL PATIENT:

Dear Sumner:

I would like you to see Harry, a 68 year old patient of mine who was diagnosed with renal cancer about 5 years ago. He underwent a radical nephrectomy shortly after the lesion was discovered. He has had no recent weight loss and currently has no symptoms suggestive of recurrent tumor. However, a routine chest X-ray done a few days ago revealed obvious metastatic lesions. Blood chemistries are consistent with spread of the tumor into the liver. These came as quite a shock to both him and his family, since they had been reassured by his previous urologist that the tumor had been completely removed. Needless to say, some active steps should be taken to handle this very distressing situation. Although Harry, himself, is currently in no dire distress, given the radiological and serological findings, we are likely dealing with a non-curable process that will likely manifest itself clinically in the very near future. I and the family will be most grateful for your input.

Dear Bill:

I had a very frank discussion with Harry and his family about the various aspects of kidney tumors. It was interesting to note Harry’s attitude shift from one of anger and total dismay to one of relative calm as he gradually came to grips with his own disease process. (Of course, it would have been a better situation if Harry as well as his family would have already anticipated the possible happenstance of metastatic/terminal disease before this state actually occurred, but unfortunately, this was not the case here.) Harry asked some very thoughtful and practical questions about possible scenarios involving metastatic disease. We spoke quite openly about the potential conflicts involving the issues of quality versus quantity of life and the fact that medical technology today has awesome capabilities of prolonging life. Harry expressed his preferences regarding the future management of his care, stating quite emphatically that he wanted neither to have his life prolonged by artificial means, nor to suffer with severe pains. I think it was also very helpful for Harry to have his family in on the discussion as he came to grips with his current condition.( This can really help avoid future feelings of guilt if family members feel that insufficient steps are being taken to prolong the patient’s life.) Harry and his family agreed that as his physical condition deteriorated, Hospice care would be initiated.

TERMINALLY ILL PATIENT (FAMILY DEMANDS):

2006-12-07T16:07:00.000-08:00

TERMINALLY ILL PATIENT (FAMILY DEMANDS):

Dear Sumner:

I am faced with a very difficult situation. It involves a 79 year old man who was diagnosed with bladder cancer about 4 years ago. He has since had a stroke, which has left him with left sided weakness as well as aphasia. He has had many episodes of hematuria, necessitating readmission to the hospital for multiple blood transfusions and local cauterization to try to control the bleeding. Earlier in his care, he had expressed the desire that, should the situation arise when he would be considered “incurable”, he did not wish to have his life prolonged by artificial measures. (He had expressed these wishes in a living will.) Because of the aphasia, he is currently unable to communicate with either me or his family, He continues to have bleeding, and since his family has been unable to handle the problems at home , I have had to admit him to the hospital many times in the past few months for both catheter irrigations as well as for blood transfusions. While I personally think that it is futile to continue to give him blood transfusions since the underlying tumor remains his son demands that we continue with active treatment. Would you be willing to see this patient (and his son)?

Dear Percy:

I certainly share your, and the family’s distress. This is, indeed, a very difficult situation. My first effort was directed to his son. I listened as he explained that even though his father had previously signed a living will requesting that no undue measures be taken to prolong his life, there was no way of knowing if, indeed, his father had since changed his mind. (Of course, given his father’s current aphasic state, this presumption is only conjectural). I discussed the very practical considerations involving the utilization of limited resources, e.g. blood, nursing time, time taken up by the surgical and nursing staff and the expense of the supplies as well as the repeated catheter irrigations and bladder cauterizations causing trauma to his father. His son counter-argued that he has paid into the insurance company for many years, and his father is entitled to this care. Quite frankly, Percy, I believe that the son has strong feelings of guilt that he, the son, is not fulfilling his filial duties if he permits the cessation of active therapy on his father. After a lengthy with the son, I suggested that his father’s case be presented to the Ethics Committee of our local hospital, which is made up of medical staff as well as clergy and lawyers. When all members of the committee agreed that cessation of active therapy would be the wisest course here, the son accepted this suggestion with apparent relief, since it seemed to take the burden of this decision off of him personally.

Learning to Manage Some Urological Probems: a Case-Based Approach

2006-12-07T15:56:00.000-08:00

EPILOGUE I feel very privileged to have practiced medicine for so many years. Gratifying, satisfying, rewarding are words which describe my experience. I have found over the years that injecting some humor into my letters was much appreciated by the physicians and perhaps even more so by their office staff. Indeed, very often I received referrals directly from the staff, who confessed to me later that their primary motivation for the referral (with tongue in cheek?) was to get my referral letter. Involving the students in the physician-patient relationship is a critical part of the learning process. Having the students play the role of patients can be a very effective teaching tool. The students must be able to empathize with the patients and must recognize the inherent risks of any diagnostic or therapeutic measures. These must be weighed against the natural course of the disease. Medical Students must remain open to the individual needs of the patients as they guide them in their medical dilemmas. I have attempted to present this material in an instructive yet informal style often using storytelling as a device to engage the readers’ attention. I hope that the above material will serve as a productive resource for medical students and educators.