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Bleeding angiokeratomas
this flood of new urologists recede? Surely they cannot all homestead in academia. No doubt reports, such as Dr. John K. Lattimer's in December, 1973, issue of Journal of Urology, will keep appearing giving the impression of a continuing drought in our specialty. This view is quite likely more palatable to those committed to education and, if followed, will do little for urologic contraception. Perhaps a grass-root study of the current urologic manpower situation, rather than periodic essays from academicians, would add some balance to the matter. UROLOGY is to be congratulated on having a format where discourse on matters such as these is possible. Edward A. Norcott, M.D. 4446 Rollingrock Carmichael, California 95608
A forty-six-year-old Caucasian man was having lu'nch and all of a sudden he felt that his underpants were wet. He thought he might have spilled some water. He went to the restroom and found that his pants were soaked with blood. He examined his sere. tum and groins but could not find the source of bleeding. He was brought to the office. Examination showed the patient's scrotum and groins were covered with blood clots. The blood was cleaned off the scrotum. There were multiple angiokeratomas present, and one of them was still oozing blood. Pressure was applied to the bleeding spot without any results. The area was cauterized using a silver nitrate stick with prompt stoppage of the bleeding. I had never seen such a small lesion bleed so profusely. Treatment is simple: cauterization of the bleeding angiokeratoma. Tara C. Sharma, Ivl.l). P.O. Box 2507 Huntington, West Virginia 25725
DELUSIONAL PRIAPISM
To the Editor: It was a pleasure to read the lucid, thorough, and well-documented review of "Priapism" by Jay J. Stein, M.D., and Donald C. Martin, M.D., in the January, 1974, issue of UROLOGY (page 8). Unfortunately, their list of 49 etiologic factors associated with priapism was incomplete. We recently saw a patient with a chief complaint of daily painful erections lasting two to three hours. Evaluation as an outpatient did not reveal a cause for his disease. Various medications were unsuccessful in resolving the problem. He, therefore, was admitted to the hospital with orders given to the urology resident to be paged "stat" when the patient had an erection. The "stat" page was heard on the hospital loudspeaker system on the second day. Residents, students, and nurses rushed to the bedside. The patient said he had a very painful erection. The resident examined him and found his penis was flaccid. The patient insisted that it was erect. The resident doubled it over on itself and showed it to the patient, who then allowed "it did not look very stiff." We would like to add "delusional priapism" to Stein and Martin's list. Stuart S. Howards, M.D. University of Virginia School of Medicine, Charlottesville, Virginia 22901
BLEEDING ANGIOKERATOMAS To the Editor: Angiokeratomas occur quite frequently on the male scrotum and are generally considered to be of no clinical significance. An interesting episode occurred in my office, and I think it is worth letting others know that such a benign, inconspicuous lesion can cause so much trouble.
528
ANGIOGRAPHY AND PENETRATING RENAL TRAUMA
To the Editor: We wish to compliment Dr. Leonard Marks and his associates for their most interesting article, "Angiography and Penetrating Renal Trauma," (UROLOGY, January, 1974, page 18). While the value of arteriography in traumatic renal injuries, both blunt and penetrating, is well known and capably described by Dr. Marks, several factors are worthy of debate. A substantial local exposure to renal injuries (more than 150 cases in the past six years) has led us to conclude that, contrary to Dr. Marks' experience, most often patients with renal injuries severe enough to warrant arteriography are not sufficiently elinica]ly stable to allow delay in intervention for associated injuries. Furthermore, although misleading informa" tion may attend excretory urography, such events are uncommon, and this study has proved rapid a;~d reliable, particularly when accompanied by high-dose or infusion volumes and tomography. Arteriography is resorted to in less urgent cases, intraoperatively, or at the time of persistent or delayed problems. A report, shortly forthcoming, will describe our success with conservative management of traumatic renal injuries, suggesting a heretofore underestinla' tion of the kidney's reparative power, as well as diminishing indications for surgery. Applying !hls experience to Dr. Marks' clinical examples, case~ e might well have healed spontaneously, since_..u'i superior pole cap was adequately vascularized. Cl~i t cal data favored conservatism with Case 2 wlu ..... arteriography, since uninfected extravasation within Gerota's fascia is no longer a rigid indicator for draitV age and repair, particularly in the presence of sariS" factory decompression down the ureter. Case 3 merely
UROLOGY / APBILI974 / VOLUMEIII, NUMBI~II4
A forty-six-year-old Caucasian man was having lu'nch and all of a sudden he felt that his underpants were wet. He thought he might have spilled some water. He went to the restroom and found that his pants were soaked with blood. He examined his sere. tum and groins but could not find the source of bleeding. He was brought to the office. Examination showed the patient's scrotum and groins were covered with blood clots. The blood was cleaned off the scrotum. There were multiple angiokeratomas present, and one of them was still oozing blood. Pressure was applied to the bleeding spot without any results. The area was cauterized using a silver nitrate stick with prompt stoppage of the bleeding. I had never seen such a small lesion bleed so profusely. Treatment is simple: cauterization of the bleeding angiokeratoma. Tara C. Sharma, Ivl.l). P.O. Box 2507 Huntington, West Virginia 25725
DELUSIONAL PRIAPISM
To the Editor: It was a pleasure to read the lucid, thorough, and well-documented review of "Priapism" by Jay J. Stein, M.D., and Donald C. Martin, M.D., in the January, 1974, issue of UROLOGY (page 8). Unfortunately, their list of 49 etiologic factors associated with priapism was incomplete. We recently saw a patient with a chief complaint of daily painful erections lasting two to three hours. Evaluation as an outpatient did not reveal a cause for his disease. Various medications were unsuccessful in resolving the problem. He, therefore, was admitted to the hospital with orders given to the urology resident to be paged "stat" when the patient had an erection. The "stat" page was heard on the hospital loudspeaker system on the second day. Residents, students, and nurses rushed to the bedside. The patient said he had a very painful erection. The resident examined him and found his penis was flaccid. The patient insisted that it was erect. The resident doubled it over on itself and showed it to the patient, who then allowed "it did not look very stiff." We would like to add "delusional priapism" to Stein and Martin's list. Stuart S. Howards, M.D. University of Virginia School of Medicine, Charlottesville, Virginia 22901
BLEEDING ANGIOKERATOMAS To the Editor: Angiokeratomas occur quite frequently on the male scrotum and are generally considered to be of no clinical significance. An interesting episode occurred in my office, and I think it is worth letting others know that such a benign, inconspicuous lesion can cause so much trouble.
528
ANGIOGRAPHY AND PENETRATING RENAL TRAUMA
To the Editor: We wish to compliment Dr. Leonard Marks and his associates for their most interesting article, "Angiography and Penetrating Renal Trauma," (UROLOGY, January, 1974, page 18). While the value of arteriography in traumatic renal injuries, both blunt and penetrating, is well known and capably described by Dr. Marks, several factors are worthy of debate. A substantial local exposure to renal injuries (more than 150 cases in the past six years) has led us to conclude that, contrary to Dr. Marks' experience, most often patients with renal injuries severe enough to warrant arteriography are not sufficiently elinica]ly stable to allow delay in intervention for associated injuries. Furthermore, although misleading informa" tion may attend excretory urography, such events are uncommon, and this study has proved rapid a;~d reliable, particularly when accompanied by high-dose or infusion volumes and tomography. Arteriography is resorted to in less urgent cases, intraoperatively, or at the time of persistent or delayed problems. A report, shortly forthcoming, will describe our success with conservative management of traumatic renal injuries, suggesting a heretofore underestinla' tion of the kidney's reparative power, as well as diminishing indications for surgery. Applying !hls experience to Dr. Marks' clinical examples, case~ e might well have healed spontaneously, since_..u'i superior pole cap was adequately vascularized. Cl~i t cal data favored conservatism with Case 2 wlu ..... arteriography, since uninfected extravasation within Gerota's fascia is no longer a rigid indicator for draitV age and repair, particularly in the presence of sariS" factory decompression down the ureter. Case 3 merely
UROLOGY / APBILI974 / VOLUMEIII, NUMBI~II4