this side effect, following the initial injury, aw;d the later surgical correction of strictures once formed. The author employs the usual supportive measures and diagnostic radiography. For closed bulbar urethral injuries a suprapubic cystotomy, with or withot, t urethral catheter drainage, is usually performed. If the injury is severe or coupled with urethral disruption, a primary one-stage anastomosis is recommended. Strictures that develop after this type of injury are usually short and easily repaired in one stage. Injuries associated with pelvic fracture dislocation have been associated with more serious and extensive stricture formation. At present, the author recommends a retropubic exploration of patients with a large pelvic hematoma and insertion of a fenestrated no. 18 to 20 French Foley catheter through the urethra to the bladder to provide urethral alignment and positive drainage of apical hematoma. For maintaining the reduction, any traction required is applied to the apex of the prostate with a sling suture passed through the anterior commissure into the perineum. Balloon traction is specifically advised against since it may carry a risk of injury to the surviving bladder neck mechanism and interfere with later continence. The author uses a specially fenestrated catheter to provide effective drainage of urethral exudates and believes this is particularly important in traumatic urethral injury and repair. Holes are cut in the standard Foley catheter at the level of the urethral tear. The author prefers a direct suture of the spatulated ends of the mobilized urethra in the repair of short strictures to the pullthrough procedures advocated by others.
N E W E N G L A N D JOURNAL OF M E D I C I N E b y M. Berson, M.D.
Successful Treatment of Recurrent Nephrolithiasis (Calcium Stones) with Cellulose Phosphate, C. Y. C. Pak, C. S. Delea, and F. C. Bartter (290: 175, 1974)Sixteen patients with recurrent calcium nephrolithiasis and absorptive hypercalciuria were treated with a low calcium diet (400 mg. daily) and cellulose phosphate for a period ranging between 1.5 and 4.8 years. All patients demonstrated a decrease in twenty-fourhour urinary calcium levels toward normal, with the majority (10 of 16 patients) falling to less than 200 mg. per day. In addition the urinary state of saturation with respect to brushite (CaHPO4.2H20) decreased in 13 cases, often from supersaturation to undersaturation. New stone formation after initiation of therapy was almost completely eliminated. Serum calcium, serum parathormone levels, as measured by radioimmunoassay, and bone density, as measured by I ~2~photon absorption, remained normal during the treatment period. Serum phosphorus declined significantly in 7 of the 16 patients. There was no evidence of aortic, conjunctival, or soft tissue calcification, and fractures and metabolic bone disease could not be demonstrated. Supplemental magnesium was administered to prevent hypomagnesemia.
Dietary il,discretioll durin,~ the treatment period ira. paired a satisfactory respo,lse with regard to both total urinary co~ceutratinn of calcium and state, of brushite concentrati~m. Cases of "idiopathic" hypercalciuria may either he renal in origin, and thereby secondary to impaired renal hlbular reabsorption of calcium, or absorptive in origin and secondary to intestinal hyperabsurption of calcium. In the former, parathyroid function may be stimulated as a result of renal calcium loss, and both the hypercalciuria and hyperparathyroidism are best corrected with the use of thiazides. Absorptive hyperca]ciuria is best treated with a drug-inhibiting calcium absorption from the gut. Cellulose phosphate is a non. absorbable "exchange resin" with high affinity for calcium ions. The use of cellulose phosphate in normocalciuric nephrolithiasis may result in excessive reduction of calcium absorption with subsequent overstimu]ation of parathyroid function. Its use should, therefore, be restricted to cases of hypercalciuria due to intestinal hyperabsorption.
Asymptomatic Gonorrhea in Men, H. H. Handsfieht, T. O. Lipman, J. P. Harnisch, E. Tronca, and K. K. Holmes (290: 117, 1974)-Asymptomatic gonococcal urethral infection in the male has been well docomented previously. The present study attempts to elucidate the natural history, prevalence, and most accurate means of diagnosis of the asymptomatic male carrier of Neisseria gonorrhoeae. Asymptomatic men requesting evaluation for venereal disease, including asymptomatic contacts of women with proved symptomarie gonorrhea, were studied. Following careful history and physical examination, smear and culture of the distal 4 to 5 cm. of the anterior urethra was carried out using a calcium alginate-tipped wire urethrogenital swab. Smears were prepared for both gram and fluorescent antibody staining as well as for innoculation of Thayer-Martin agar and Kellogg'.~ medium. In addition prostatic secretions following digital massage were collected and studied in similar fashion. A total of 49 cases of culture proved asymptomatic gonococcal infection were detected. Of forty asympt~, marie male contacts of women with proved sympto~z~" tic gonorrhea, 16, or 40 per cent had positive anterior urethral cultures for N. gonorrhoeae. Twenty-four of the 49 patients (49 per cent) gave a positive history o! gonorrhea from one to sixty months previously, and all were treated with relief of symptoms at that time. A total of sixty-one anterior urethral specimens were studied by culture, gram, and fluorescent antibody" staining techniques. Of forty-three specimens positive by one or more methods, ten were positive by eul!n.~e alone, and sixteen were positive by culture wllI~c negative by fluorescent-antibody stain. Only three were positive by fluorescent-antibody stain and nega" tive by culture. Culture thus proved to be the naost sensitive of the techniques employed in deteetiolt asymptomatic urethral infection in men. ns of Nineteen of twenty-nine tested specime prostatic secretions were positive by one of the fore-
/ APRIL 1974 / VOLUME i l l NuMItI'JlIJ
.~ina three methods, ten by culture alone, and none antibody staining alone. Twenty-eight ssy~ptomatic men with positive cultures had both snterior urethral swab specimens and prostatic secretions exagnined. All 28 patients exhibited positive s~terior urethral cultures, while 26 of 28 had N. gonorrhoeae isolated from their prostatic secretions. uT~husprostatic secretions were positive only when ethral cultures were also positive, implying either gonococcal infection or contamination of ostatic fluid passing through the urethra. Treatment of 28 men with asymptomatic culturer0ved gonorrhea was withheld for a period between yen and one hundred sixty-tlve days. While symptoms subsequently developed in 5 patients and 5 exhibited spontaneous cure, 18 remained asymptomatic with persistently positive cultures on follow-up evaluations. Among ~,628 sexually active servicemen evaluated with urethral cultures, 59 or 2.2 per cent had N. g0norrhoeae recovered; 68 per cent of the infected men were asymptomatic.
within the Rochester City limits during a thirty-year period. One hundred and thirteen cases of hypospadias or 8.2 per thousand live male births were uncovered. In earlier studies from other centers, the rate per thousand live male births varied from 0.8 to 5.4. Analysis of the data suggests a multifactorial etiology for hypospadias, fitting a polygenic model. According to the authors, it appears that first-degree relatives of patients with hypospadias are five to ten times more likely than the general population to have hypospadias, and the more severe the hypospadias deformity, the higher the incidence of hypospadias in first-degree relatives.
JOURNAL O F P E D I A T R I C SURGERY by M. Berson, M.D.
The Management of a Cloaca, J. G. Raffensperger,
AMERICAN JOURNAL O F DISEASES OF C H I L D R E N by Y. Mohta, M.D.
Congenital Solitary Kidney, B. Emanuel, R. Nachman, N. Aronson, and H. Weiss (127: 17, 1974)-The absence of one kidney is an uncommon congenital anomaly, and the solitary kidney is a special challenge to clinicians when infection or stone formation is present, requiring long-term continuity of care. The authors reviewed 74 cases seen at the Children's Memorial Hospital in Chicago during the past seventeen years. The retrospective study, according to the authors, st~ggests that a solitary kidney is associated with multiple malformations, especially cardiac, gastrointestinal, and other musculoskeletal system. In this series moire than half the patients had a major urinary complication requiring intensive medical or surgical care. The authors, therefore, suggest that once the condition is diagnosed all possible effort should be made to conserve the functional and structural integrity of the renal tissue.
MAYO (~LINIC P R O C E E D I N G S
and M. L. Ramenofsky (8: 915, 1973)-Successful management of the cloaca in the neonatal period represents both an unusual challenge to the surgeon as well as relief from a potentially life-threatening congenital abnormality. The authors review their collective experience in the surgical treatment of the cloaca in 15 infants and children. The classification and embryology of cloacal deformity are briefly discussed and associated congenital anomalies noted. Intestinal and vaginal obstruction, urinary tract infection, declining renal function, and sepsis from retained vaginal secretions represent the main threats to the infant. Preoperative diagnostic procedures to elucidate the exact anatomic abnormalities are largely limited to perineal inspection with the aid of a nasal speculum and injection of contrast material into the uncovered tracts. Intravenous pyelography will reveal associated genitourinary defects as well as any progressive renal deterioration on serial studies. In many instances pelvic exploration will be necessary for final evaluation of urethral, rectal, and vaginal relationships. Therapeutically, the authors stress the need for immediate separation of the genital and urinary tracts in the neonatal period in addition to decompression of the colon. This may be accomplished with a vaginal pull-through procedure combined with either an abdominal-perineal rectal pull-through (one-stage repair) or a colostomy and rectal pullthrough at a later time. Alternatively, those infants with a short cloaca may be treated with a colostomy and dilitation of the vaginal opening.
by p. H~gedorn, M.D.
Study of the Incidence of Hypospadias in Rochester, Minnesota, 1940-1970, R. A. Sweet, H. G. Schrott, R. Kudand, and O. S. Culp (49: 52, 1973)-The authors reviewed the pediatric records of almost 14,000 live male infants born to mothers residing
UI~OLOGY / APRIL 1974 / V O L U M E
III,N U M B E R 4
Presaeral Teratomas in Children, S. Ghazali (8: 915, 1973)-Congenital teratomas, occurring most commonly in the area of the sacrococcyx, may present as either a perineal or presacral, intrapelvic mass. Urinary and rectal obstructive complaints are common because of displacement of the ureters and