UNDESCENDED versus HYPERMOBILE TESTIS:

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:

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:

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:

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:

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):

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:

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.