Guidelines for the Treatment of Urinary Incontineence and Overactive Bladder

Urinary incontinence (UI) is the involuntary leakage of urine, while overactive bladder (OAB) is characterised by frequency, nocturia and urgency, with or without incontinence. This paper provides guidelines for the management of UI and OAB, focusing on primary health care. Although UI and OAB negatively impact on the patients quality of life more severely than diabetes mellitus or rheumatoid arthritis, surveys have shown that more than 60% of persons with UI never mention their problem to a doctor or nurse.Therefore, the primary care setting is ideal for screening, basic evaluation, and initial management of UI and OAB. A focused history and examination will usually enable the practitioner to distinguish between the different types of incontinence, such as stress, urge (overactive bladder), mixed, overflow and continuous incontinence. It should include a vaginal examination and cough test in women, rectal examination in men, dipsticks urinalysis, and assessment of the post-void residual urine.A bladder diary filled in by the patient can be very useful. There may be reversible conditions causing or contributing to the patients incontinence, such as urinary tract infection. In certain cases referral to a specialist is required, e.g. patients with incontinence after previous surgery, or associated with pain or hematuria. However, many patients with symptoms of OAB or UI can be eff ectively treated at the primary care level. Management options include lifestyle modification (e.g. smoking cessation and weight loss), pelvic floor exercises, and pharmacotherapy. Overactive bladder can be treated with muscarinic antogonists such as tolterodine and oxybutinin. Keywords: urinary incontinence, overactive bladder, treatment, Muscarinic antagonists SA Fam Prac Vol.25(2) 2002: 4-1

Comparison of men with acute versus chronic urinary retention: aetiology, clinical features and complications

Background: The objectives were to investigate the aetiology and clinical features of urinary retention and to analyse differences between acute urinary retention (AUR) and chronic urinary retention (CUR).Method: We analysed the clinical data of 558 men admitted to our institution with urinary retention between September 1998 and June 2007.Statistical analysis was performed with Student’s t-test, Mann-Whitney and Fisher’s exact tests, where appropriate.Results: The mean age of the men was 66.4 years (range 12.8–94.7). AUR was present in 90.7% and CUR in 9.3%. The most common causes were benign prostatic hyperplasia in 36.6%, adenocarcinoma of the prostate (ACP) in 36.0% and urethral stricture in 14.3%. Mean prostate volume was 56.6 cc (range 15–262). Comparing the groups with AUR versus CUR, a positive urine culture was significantly more common in the group with AUR (34.1% vs. 8%), whereas anaemia (15.9% vs. 34.1%), renal failure (9.1% vs. 46.2%) and hydronephrosis (23.9% vs. 53.9%) were significantly more common in the group with CUR. There was no significant difference in prostate volume or the proportion of men with histological prostatitis (29.5% vs. 23.1%).Conclusion: The prevalence of ACP and urethral stricture as aetiology of retention was higher than reported in the literature. The prevalence of anaemia, renal failure and hydronephrosis was significantly greater in patients with CUR compared to AUR. There was no significant difference in prostate volume or the prevalence of histological prostatitis, indicating that factors other than prostate size or histological prostatitis determine the development of AUR rather than CUR.Keywords: urine, retention, prostate, urethra, strictur

Prostate Cancer Screening, Detection and Treatment Practices, Among Sub-Saharan African Urologists

Introduction: Prostate cancer is reported to be the leading cancer in men in Sub-Saharan Africa (SSA) and the number of prostate cancer deaths is expected to double in the next 20 years. Despite the importance of this public health issue in SSA, there remains relatively limited information about practices related to prostate cancer treatment in this population. Objective: We conducted a survey of 28 urology practices in SSA to evaluate the scope of available screening, detection and treatment. Materials and Methods: Screening was more commonly reported as a part of general medical care in South Africa (SA) compared with East or West (EW) Africa. However, use of digital Rectal Examination (DRE) and Prostate Specific Antigen (PSA) were used at similar rates for screening in all locations. Screening is primarily focused in men over age 50 and those with symptoms. Routine screening was the primary reason for screening use in SA, while symptoms were the primary reason for screening use in EW. Financial and cultural barriers to screening were more commonly reported in EW than SA. Similar detection approaches were used in all regions, with free PSA and PSA velocity being more commonly used in SA than EW. Six core biopsies were more commonly used in EW and 12 core biopsies were more common in SA. Trans urethral ultrasounds and bone scans were more commonly used in SA than EW. Treatment options were similar in all regions, with brachytherapy less likely to be used in EW than SA. Results: The descriptive data suggest that differences in patterns of screening, detection and treatment exist across Africa. Differences by geography may also reflect differences in SES and racial composition of the populations in each region.Key Words: Prostate cancer, Screening and Detection, Practice guidelines, Sub-Saharan Afric

Urinary Retention in Women: Causes and Management

Objectives: Urinary retention in women is uncommon and there are numerous etiological factors. Most reported studies are from Europe and North America, with few studies from developing countries. The aim of this study was to review the etiology of urinary retention in women referredto our institution, a public sector hospital serving a largely indigent population.Patients and Methods: We reviewed the clinical records of all patients admitted with urinary retention to the Urology wards in our hospital during the period September 1998 to June 2007. In total there were 589 patients with urinary retention, 558 (94.7%) men and 31 (5.3%) women.Results: The average age of the 31 women was 51.9 years (range 20 to 88 years). The underlying pathology was cervical carcinoma (4 patients), urethral carcinoma (4), transitional cell carcinoma of the bladder (3), eosinophilic cystitis (3), hematuria due to miscellaneous causes (3), antiincontinence surgery (2), cerebral palsy (2), multiple sclerosis (1 patient), diabetes mellitus (1), hypotonic detrusor (1), bladder stone (1), vaginal leiomyoma (1), cyclophosphamide cystitis (1), constipation (1), postpartum (1), blocked indwelling catheter and idiopathic (1). Renal dysfunction was present in 17 (55%) of the patients.Conclusion: The most common causes of urinary retention in women in this study were malignancy in 11 patients (36%) and neuropathic bladder dysfunction in 5 (16%). Eosinophilic cystitis, normally a rare condition, was diagnosed in 3 women (10%). The high incidence of malignancy in this study differs from other reported series, in which neuropathic bladder dysfunction was the most common cause of urinary retention in women.Key Words : Urinary retention, women, etiolog

Vasectomy under local anaesthesia performed free of charge as a family planning service: Complications and results

Objective. To evaluate the safety and efficacy of vasectomy performed under local anaesthesia by junior doctors at a secondary level hospital as part of a free family planning service.Method. Men requesting vasectomy were counselled and given written instructions to use alternative contraception until two semen analyses 3 and 4 months after vasectomy had confirmed azoospermia. Bilateral vasectomy was performed as an outpatient procedure under local anaesthesia by junior urology registrars. Statistical analysis was performed using the Mann-Whitney, Kruskal-Wallis, Fisher’s exact orSpearman’s rank correlation tests as appropriate.Results. Between January 2004 and December 2005, 479 men underwent vasectomy at Karl Bremer Hospital, Western Cape, South Africa; their average age was 36.1 (range 21 - 66) years, they had a median of 2 (range 0 - 10) children, and only 19% had 4 or more children. The average operation time was 15.5 (range 5 - 53) minutes. Complications occurred in 12.9%; these were pain (7.3%), swelling (5.4%), haematoma (1.3%), sepsis (1%), difficulty locating the vas (1%), vasovagal episode (0.6%), bleeding (0.6%), wound rupture (0.4%) and dysuria (0.2%) (some men had more than one complication). Of the men 63.3% returned for one semen analysis and 17.5% for a second. The vasectomy failure rate ranged from 0.4%(sperm persisting >365 days after vasectomy) to 2.3% (sperm seen >180 days after vasectomy and/or in the second semen specimen). No pregnancies were reported. The complication (5.6%) and failure rates (0%) were lowest for the registrar who had performed the smallest number of vasectomies and whose average operation time was longest. Comparing the first one-third of procedures performed by each of the doctors with the last one-third, there was a significant decrease inaverage operating times but not in complication rates.Conclusions. Vasectomy can be performed safely and effectively by junior doctors as an outpatient procedure under local anaesthesia, and should be actively promoted in South Africa as a safe and effective form of male contraception

Genetic variations in androgen metabolism genes and associations with prostate cancer in South African men

Background. In South Africa white men have the highest incidence of prostate cancer (PCa), coloured (mixed ancestry) men have an intermediate incidence, and low incidences are reported for black and Asian men. It has been suggested that ethnic differences in incidence and mortality of PCa are related to genetic variations in genes that regulate androgen metabolism. We investigated the role of genetic variants in the androgen metabolism genes and the probability of developing PCa in South African coloured and white men. Methods. Genotype and allele counts and frequencies of single nucleotide polymorphisms (SNPs) in CYP3A5, CYP3A4 and CYP3A43 were assessed in coloured men (160 case individuals, 146 control individuals) and white men (121 case individuals, 141 control individuals). Results. A genetic association indicating an increased probability of developing PCa was observed with the G allele of the SNP rs2740574 in CYP3A4 in coloured men, the A allele of rs776746 (CYP3A5) and the G allele of rs2740574 (CYP3A4) in white men, and the G allele of rs2740574 and the C allele of rs501275 (CYP3A43) in the combined ethnic groups analysis. In addition, we identified allele combinations (termed haplotypes) with significantly higher frequencies in the PCa case individuals than in the control individuals. Conclusions. The findings support the role of variants in genes that regulate androgen metabolism and the probability of developing PCa. The study paves the way to identify other genetic associations in South African men, and to establish genetic profiles that could be used to determine disease progression and prognosis

Schistosomiasis and Urinary Bladder Cancer in North Western Tanzania: A Retrospective Review of 185 Patients.

Worldwide, cancers of the urinary bladder are well known to be associated with environmental chemical carcinogens such as smoking and occupational exposure to polycyclic aromatic hydrocarbons. These cancers are typically transitional cell carcinoma (urothelial carcinoma). In areas where schistosomiasis is endemic there is a high incidence of squamous cell carcinoma of the urinary bladder. Schistosomiasis causes chronic granulomatous cystitis leading to squamous metaplasia of transitional epithelium, and subsequently development of squamous cell carcinoma. The western part of Tanzania on the shores of Lake Victoria is such an endemic area. This study was done to document the burden of urinary bladder cancer associated with schistosomiasis in this region. This was a descriptive retrospective study of histologically confirmed cases of urinary bladder cancer seen at the Department of Pathology Bugando Medical Centre (BMC) over a period of 10 years. Data were retrieved from the records of the Departments of Pathology, Medical Records and Surgery. Data were analyzed by the use of contingency tables. A total of 185 patients were diagnosed with cancer of the urinary bladder during the study period, where as 90 (48.6%) were males and 95 (51.4) were females. The mean age at diagnosis was 54.3 years. Squamous cell carcinoma was the most frequent histological type (55.1%), followed by conventional transitional cell carcinoma (40.5%). Eighty three of all cancer cases (44.9%) were found to have schistosomal eggs. Schistosomiasis was commonly associated with squamous cancers compared to non squamous cancers. Most of the cancers associated with schistosomiasis had invaded the muscularis propria of the urinary bladder at the time of diagnosis (p<0.001) and such cancers were frequent below 50 years of age with a significant statistical difference (p<0.001). Poorly differentiated tumors were more frequent in females than males with a significant statistical difference (p=0.006). The majority of urinary bladder cancers seen in the Lake Region were squamous cell carcinoma associated with schistosomiasis. These cancers showed an aggressive behavior and were commonly seen in the younger age groups. Effective control of schistosomiasis in this region should significantly reduce the burden of urinary bladder cancer

The morbidity of urethral stricture disease among male Medicare beneficiaries

<p>Abstract</p> <p>Background</p> <p>To date, the morbidity of urethral stricture disease among American men has not been analyzed using national datasets. We sought to analyze the morbidity of urethral stricture disease by measuring the rates of urinary tract infections and urinary incontinence among men with a diagnosis of urethral stricture.</p> <p>Methods</p> <p>We analyzed Medicare claims data for 1992, 1995, 1998, and 2001 to estimate the rate of dual diagnoses of urethral stricture with urinary tract infection and with urinary incontinence occurring in the same year among a 5% sample of beneficiaries. Male Medicare beneficiaries receiving co-incident ICD-9 codes indicating diagnoses of urethral stricture and either urinary tract infection or urinary incontinence within the same year were counted.</p> <p>Results</p> <p>The percentage of male patients with a diagnosis of urethral stricture who also were diagnosed with a urinary tract infection was 42% in 2001, an increase from 35% in 1992. Eleven percent of male Medicare beneficiaries with urethral stricture disease in 2001 were diagnosed with urinary incontinence in the same year. This represents an increase from 8% in 1992.</p> <p>Conclusions</p> <p>Among male Medicare beneficiaries diagnosed with urethral stricture disease in 2001, 42% were also diagnosed with a urinary tract infection, and 11% with incontinence. Although the overall incidence of stricture disease decreased over this time period, these rates of dual diagnoses increased from 1992 to 2001. Our findings shed light into the health burden of stricture disease on American men. In order to decrease the morbidity of stricture disease, early definitive management of strictures is warranted.</p