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Angiography and penetrating renal trauma
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 loan was having lunch 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 scro . turn 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 pros fusely. Treatment is simple : cauterization of the bleeding angiokeratoma . Tara C . Sharma, MA), 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 .
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 clinically stable to allow delay in intervention for associated injuries . Furthermore, although misleading infomta • don may attend excretory urography, such events are uncommon, and this study has proved rapid and reliable, particularly when accompanied by high-dose or infusion volumes and tomography . Arteriogralhy 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 underestima tion of the kidney's reparative power, as well as hi diminishing indications for surgery . Applying experience to Dr. Marks' clinical examples, Case h might well have healed spontaneously, since the superior pole cap was adequately vascularized . Cliu" cal data favored conservatism with Case 2 WItl out arteriography, since uninfected extravasation within r Gerota's fascia is no longer a rigid indicator fordrm " , age and repair, particularly in the presence of sails . Case 3 m factory decompression down the ureter NUMRt at
528
UROLOGY
1
APRIL 1974 / VOLUME III .
indicatesth ure in the potential hazard extensive hemorrhage s uture (,, x panding hematoma), as well as the fact that parenchymal suture or drainage is seldom adequate in severe cases, or necessary in the nonsevere injuries ; a final lesson is the need for arteriography in the presence of severe, unrelenting, or delayed renal hemorrhage . Case 4 would probably have fooled afYone. pr. Marks and his associates are to be commended for their ambitious attempt to underscore the imporlance and reliability of arteriography in the evaluation
of the traumatized kidney ; our attempt to define its indications and encourage perspective in no way detracts from their good work . Norman E . Peterson, M .D ., Chief, Division of Urology, Denver General Hospital ; Derek P . Stables, FCP(SA), DMRD Associate Professor Radiology Colorado General Hospital 4200 East Ninth Avenue Denver, Colorado 80220
SPERMATORRHEA
RING
Nocturnal spermatorrhea or nocturnal emis-
sions was the term often used to circumvent the admission of male masturbation . In the 1800s and into the early 1900s masturbation in the male was considered very bad for the individual and was blamed on many things including politics . In 1827 a German, Heinrich Robbi, is quoted as having said,
"Masturbation comes from French influences and German nationalism was a likely antidote .", Masturbation's consequences were said to include insanity, paresis, impotence, epilepsy, death, and malformed children. Gross' stated, "I endeavored to show that confirmed mastur-
bation is just as sure to result in urethritis and the formation of a stricture as is gleet (gonorrhea). . . . ofone hundred and seventy-three (masturbators) in all, only twenty-two were free from stricture . . . . my notes show that thirteen out of every one hundred cases of stricture are due to onanism ." Victorianism contributed much to embellish the dangers of masturbation, and many and varied mechanical belts, corsets, girdles, and
rings were developed. The one herein illustrated is a spike-lined ring . These were fitted loosely over the relaxed penis at bed time . With the on-
UROLOGY
1
APRIL 1974 / VOLUME III, NUMBER 4
W!~~llIll11r>1111~ ~llll!!~~ I
IIiuuIllO IIullmulh ,
(From G . Tiemann & Company Catalog of 1876)
set of erection, the spikes would dig into the engorged, swelling penis, and the resultant pain was intended to waken the individual and stop the nocturnal emission or pollution . If needed, in addition a cold bath was also advised . JOHN R . HERMAN, M .D . References 1 . SCHwARZ, G . S . : Devices to prevent masturbation, Human Sexuality 7 : 141 (1973) . 2 . CROSS, S . W . : Practical Treatise on Impotence and Sterility, 2nd ed ., London, Henry Kimpton, 1883 .
529
A forty-six-year-old Caucasian loan was having lunch 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 scro . turn 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 pros fusely. Treatment is simple : cauterization of the bleeding angiokeratoma . Tara C . Sharma, MA), 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 .
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 clinically stable to allow delay in intervention for associated injuries . Furthermore, although misleading infomta • don may attend excretory urography, such events are uncommon, and this study has proved rapid and reliable, particularly when accompanied by high-dose or infusion volumes and tomography . Arteriogralhy 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 underestima tion of the kidney's reparative power, as well as hi diminishing indications for surgery . Applying experience to Dr. Marks' clinical examples, Case h might well have healed spontaneously, since the superior pole cap was adequately vascularized . Cliu" cal data favored conservatism with Case 2 WItl out arteriography, since uninfected extravasation within r Gerota's fascia is no longer a rigid indicator fordrm " , age and repair, particularly in the presence of sails . Case 3 m factory decompression down the ureter NUMRt at
528
UROLOGY
1
APRIL 1974 / VOLUME III .
indicatesth ure in the potential hazard extensive hemorrhage s uture (,, x panding hematoma), as well as the fact that parenchymal suture or drainage is seldom adequate in severe cases, or necessary in the nonsevere injuries ; a final lesson is the need for arteriography in the presence of severe, unrelenting, or delayed renal hemorrhage . Case 4 would probably have fooled afYone. pr. Marks and his associates are to be commended for their ambitious attempt to underscore the imporlance and reliability of arteriography in the evaluation
of the traumatized kidney ; our attempt to define its indications and encourage perspective in no way detracts from their good work . Norman E . Peterson, M .D ., Chief, Division of Urology, Denver General Hospital ; Derek P . Stables, FCP(SA), DMRD Associate Professor Radiology Colorado General Hospital 4200 East Ninth Avenue Denver, Colorado 80220
SPERMATORRHEA
RING
Nocturnal spermatorrhea or nocturnal emis-
sions was the term often used to circumvent the admission of male masturbation . In the 1800s and into the early 1900s masturbation in the male was considered very bad for the individual and was blamed on many things including politics . In 1827 a German, Heinrich Robbi, is quoted as having said,
"Masturbation comes from French influences and German nationalism was a likely antidote .", Masturbation's consequences were said to include insanity, paresis, impotence, epilepsy, death, and malformed children. Gross' stated, "I endeavored to show that confirmed mastur-
bation is just as sure to result in urethritis and the formation of a stricture as is gleet (gonorrhea). . . . ofone hundred and seventy-three (masturbators) in all, only twenty-two were free from stricture . . . . my notes show that thirteen out of every one hundred cases of stricture are due to onanism ." Victorianism contributed much to embellish the dangers of masturbation, and many and varied mechanical belts, corsets, girdles, and
rings were developed. The one herein illustrated is a spike-lined ring . These were fitted loosely over the relaxed penis at bed time . With the on-
UROLOGY
1
APRIL 1974 / VOLUME III, NUMBER 4
W!~~llIll11r>1111~ ~llll!!~~ I
IIiuuIllO IIullmulh ,
(From G . Tiemann & Company Catalog of 1876)
set of erection, the spikes would dig into the engorged, swelling penis, and the resultant pain was intended to waken the individual and stop the nocturnal emission or pollution . If needed, in addition a cold bath was also advised . JOHN R . HERMAN, M .D . References 1 . SCHwARZ, G . S . : Devices to prevent masturbation, Human Sexuality 7 : 141 (1973) . 2 . CROSS, S . W . : Practical Treatise on Impotence and Sterility, 2nd ed ., London, Henry Kimpton, 1883 .
529