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Bilateral Traumatic Testicular Dislocation
606
LETTERS TO THE EDITOR
RE: MALACOPLAKIA OF THE BLADDER: EFFICACY OF BETHANECHOL CHLORIDE THERAPY D. H. Zornow, R. R. Landes, S. L. Morganstern and F. A. Fried
J. Urol., 122: 703-704, 1979
To the Editor. I read with interest this article by Zornow and associates on bethanechol chloride therapy. I have had 2 patients in my practice who presented originally with symptoms of lower urinary tract irritability and an endoscopically abnormal-appearing bladder, diagnosed histologically as malacoplakia. The gross appearance of the bladder has improved greatly on a regimen of simply maintaining urinary tract sterility. My original intent in following these patients so carefully was to see if the histological evidence of malacoplakia disappeared concomitant with the improved gross appearance of the bladder epithelium. The histologic evidence has not disappeared completely. I wonder if improvement similar to that reported by the aforementioned authors would have occurred with simply an infection-free environment for 6 months. My specific concern is whether we can attribute the improvement to bethanechol chloride alone. Insofar as its effect on the musculature of the lower urinary tract is concerned 10 mg. bethanechol chloride is almost a homeopathic dose. I wonder if there is any evidence that this oral dosage, indeed, corrects the enzymatic defect thought responsible for the development of the histological changes that we refer to as malacoplakia. In vitro demonstration of such an effect, unfortunately, cannot be equated necessarily with a similar in vivo effect of such a low oral dosage. Although the authors certainly are to be congratulated for their intriguing suggestion I would respectfully submit that either demonstration of the correction of the enzymatic defect or total exclusion of all other factors is necessary before the efficacy is attributed to oral bethanechol per se. Respectfully,
Alan J. Wein Division of Urology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania 19104
CONTACT SCROTAL THERMOGRAPHY
To the Editor. The temperature measuring device described by Lewis and Harrison is interesting.' Contact scrotal thermography seems to be a simple and safe diagnostic tool in the management of patients with varicocele. In our male infertility clinic we have been using for > 1 year the ordinary thermographic camera to evaluate patients with varicoceles. We have found scrotal thermography valuable in the detection of subclinical cases of this entity. However, although we continue to use the method routinely for all patients with infertility problems we do not always operate upon patients in whom the scrotal thermography studies indicate higher than normal temperatures but a clinically detectable varicocele is not found. We need more time to evaluate further the postoperative results in patients subjected to ligation of the internal spermatic vein for a subclinical form of varicocele. Scrotal thermography seems to be most helpful in the assessment of postoperative results, since the persistence of abnormal scrotal temperatures indicates an incomplete operation. However, we agree with the editorial comment by Dr. Lawrence Dubin that "The presence of varicocele alone is not an indication for a corrective operation". As Doctor Dubin indicated, "unless there is the usual stress semen pattern ... the varicocele is in no way detrimental", although there are some reports in the literature supporting that a long-standing varicocele may affect the testicular parenchyma by producing atrophic lesions. 2 Respectfully, N. Goulandris, M. Likourinas, D. Livanou
and C. Dimopoulos Department of Urology University of Athens Medical School King Paul's Hospital Goudi, Athens, Greece 1. Lewis, R. W. and Harrison, R. M.: Contact scrotal thermography: application to problems of infertility. J. Urol., 122: 40, 1979. 2. Lipshultz, L. I. and Corriere, J. N., Jr.: Progressive testicular atrophy in the varicocele patient. J. Urol., 117: 175, 1977.
BILATERAL TRAUMATIC TESTICULAR DISLOCATION
RE: A RE-APPRAISAL OF TREATMENT IN CHRONIC BACTERIAL PROSTATITIS
To the Editor. It was with interest that we read the article by Edson and Meek.' We had a similar case, which was thought to involve relatively unique circumstances. A 23-year-old member of a motorcycle club was involved in an accident. The patient was thrown over the handle bars, sustaining a laceration of the scrotum on the gas cap. We were consulted the following day. Pertinent history revealed that the patient had undergone right orchiopexy when he was a child. Physical examination revealed hypoactive bowel sounds, a firm abdomen and an empty scrotum with a sutured laceration. Both testes were at the level of the internal ring. With the use of intravenous diazepam both testes were brought into the scrotum but the right testis would not remain lower than the external ring. Several days later another attempt was made to lower the right testis with general anesthesia but unsuccessfully. Because of the patient's refusal to undergo an operation nothing further was done until 2½ months later, when the patient requested surgical repair. At that time he again stated that the right testis was definitely in the scrotum before the accident. A difficult right orchiopexy was done. The testis was in the superficial position just proximal and exterior to the external ring. The testis was fixed in position but finally it was mobilized. Although it is speculation it is possible that the orchiopexy was difficult because of an injury similar to the one described by Edson and Meek, that is a rupture of the tunica of the testis, which would account for the amount of fibrosis that was present.' We can only echo the feelings of these authors, that is an early operation (assuming the patient will allow it) would seem the most appropriate management.
W. R. Fair, D. B. Crane, N. Schiller and W. D. W. Heston
Respectfully,
David H. Kauder and John J. Bucchiere, Jr. Associates in Urology, North Shore, P.C. 496 Lynnfield Street Lynn, Massachusetts 01904 1. Edson, M. and Meek, J. M.: Bilateral testicular dislocation with
unilateral rupture. J. Urol., 122: 419, 1979.
J. Urol., 121: 437-441, 1979
To the Editor. The authors of this excellent study found that alkalinity of prostatic fluid increased to 8.32. In my series of 24 patients the pH of the prostatic fluid varied from 7.1 to 8.7, with a mean of 7.9. Elevated pH of prostatic fluid could explain the failure of long-term cotrimoxazole treatment because the previous pH gradient between the plasma and the prostatic fluid is abolished or may be reversed. In view of the findings of poor therapeutic response, a re-appraisal of treatment of chronic bacterial prostatitis was proposed by the authors. We found that direct perineal injections of various antibiotics into the prostatic lobes offers a good alternative in the treatment of chronic bacterial prostatitis. '· 2 In a study of 31 patients amikacin, cefazolin or gentamicin was injected in combination with cefazolin. 3• 4 After 1 injection 77 per cent of the patients were cured and repeated injections resulted in cure in up to 90 per cent of the cases. In a recent study 29 patients were treated with a 2 gm. injection of thiamphenicol glycinate, a chemical analogue of chloramphenicol. 5 Thiamphenicol levels in prostatic fluid varied between 1 and 4,000 µg./ml. and were unrelated to the time after intraprostatic administration. Serum levels decreased during the 24 hours of administration from 25 to 0.3 µg./ml. Definite cure was obtained in 66 per cent of the patients treated. The technique used in this study to collect urine and expressed prostatic secretion specimens and to localize urinary tract and prostatic infections has been described by Meares and Stamey. 6 In our investigation the second voided urine specimen (VB2), collected before the expressed prostatic secretion specimen, was replaced by a urine specimen obtained by suprapubic puncture. From each patient urine and prostatic fluid specimens were examined for infection 1 and 6 months after treatment. If the infection persists after 1 month the local treatment is repeated. Negative urine and prostatic fluid cultures 1 and 6 months after treatment, respectively, were taken as indications for cure of the bacterial prostatitis. In our opinion local antibiotic treatment by direct perineal injection
LETTERS TO THE EDITOR
RE: MALACOPLAKIA OF THE BLADDER: EFFICACY OF BETHANECHOL CHLORIDE THERAPY D. H. Zornow, R. R. Landes, S. L. Morganstern and F. A. Fried
J. Urol., 122: 703-704, 1979
To the Editor. I read with interest this article by Zornow and associates on bethanechol chloride therapy. I have had 2 patients in my practice who presented originally with symptoms of lower urinary tract irritability and an endoscopically abnormal-appearing bladder, diagnosed histologically as malacoplakia. The gross appearance of the bladder has improved greatly on a regimen of simply maintaining urinary tract sterility. My original intent in following these patients so carefully was to see if the histological evidence of malacoplakia disappeared concomitant with the improved gross appearance of the bladder epithelium. The histologic evidence has not disappeared completely. I wonder if improvement similar to that reported by the aforementioned authors would have occurred with simply an infection-free environment for 6 months. My specific concern is whether we can attribute the improvement to bethanechol chloride alone. Insofar as its effect on the musculature of the lower urinary tract is concerned 10 mg. bethanechol chloride is almost a homeopathic dose. I wonder if there is any evidence that this oral dosage, indeed, corrects the enzymatic defect thought responsible for the development of the histological changes that we refer to as malacoplakia. In vitro demonstration of such an effect, unfortunately, cannot be equated necessarily with a similar in vivo effect of such a low oral dosage. Although the authors certainly are to be congratulated for their intriguing suggestion I would respectfully submit that either demonstration of the correction of the enzymatic defect or total exclusion of all other factors is necessary before the efficacy is attributed to oral bethanechol per se. Respectfully,
Alan J. Wein Division of Urology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania 19104
CONTACT SCROTAL THERMOGRAPHY
To the Editor. The temperature measuring device described by Lewis and Harrison is interesting.' Contact scrotal thermography seems to be a simple and safe diagnostic tool in the management of patients with varicocele. In our male infertility clinic we have been using for > 1 year the ordinary thermographic camera to evaluate patients with varicoceles. We have found scrotal thermography valuable in the detection of subclinical cases of this entity. However, although we continue to use the method routinely for all patients with infertility problems we do not always operate upon patients in whom the scrotal thermography studies indicate higher than normal temperatures but a clinically detectable varicocele is not found. We need more time to evaluate further the postoperative results in patients subjected to ligation of the internal spermatic vein for a subclinical form of varicocele. Scrotal thermography seems to be most helpful in the assessment of postoperative results, since the persistence of abnormal scrotal temperatures indicates an incomplete operation. However, we agree with the editorial comment by Dr. Lawrence Dubin that "The presence of varicocele alone is not an indication for a corrective operation". As Doctor Dubin indicated, "unless there is the usual stress semen pattern ... the varicocele is in no way detrimental", although there are some reports in the literature supporting that a long-standing varicocele may affect the testicular parenchyma by producing atrophic lesions. 2 Respectfully, N. Goulandris, M. Likourinas, D. Livanou
and C. Dimopoulos Department of Urology University of Athens Medical School King Paul's Hospital Goudi, Athens, Greece 1. Lewis, R. W. and Harrison, R. M.: Contact scrotal thermography: application to problems of infertility. J. Urol., 122: 40, 1979. 2. Lipshultz, L. I. and Corriere, J. N., Jr.: Progressive testicular atrophy in the varicocele patient. J. Urol., 117: 175, 1977.
BILATERAL TRAUMATIC TESTICULAR DISLOCATION
RE: A RE-APPRAISAL OF TREATMENT IN CHRONIC BACTERIAL PROSTATITIS
To the Editor. It was with interest that we read the article by Edson and Meek.' We had a similar case, which was thought to involve relatively unique circumstances. A 23-year-old member of a motorcycle club was involved in an accident. The patient was thrown over the handle bars, sustaining a laceration of the scrotum on the gas cap. We were consulted the following day. Pertinent history revealed that the patient had undergone right orchiopexy when he was a child. Physical examination revealed hypoactive bowel sounds, a firm abdomen and an empty scrotum with a sutured laceration. Both testes were at the level of the internal ring. With the use of intravenous diazepam both testes were brought into the scrotum but the right testis would not remain lower than the external ring. Several days later another attempt was made to lower the right testis with general anesthesia but unsuccessfully. Because of the patient's refusal to undergo an operation nothing further was done until 2½ months later, when the patient requested surgical repair. At that time he again stated that the right testis was definitely in the scrotum before the accident. A difficult right orchiopexy was done. The testis was in the superficial position just proximal and exterior to the external ring. The testis was fixed in position but finally it was mobilized. Although it is speculation it is possible that the orchiopexy was difficult because of an injury similar to the one described by Edson and Meek, that is a rupture of the tunica of the testis, which would account for the amount of fibrosis that was present.' We can only echo the feelings of these authors, that is an early operation (assuming the patient will allow it) would seem the most appropriate management.
W. R. Fair, D. B. Crane, N. Schiller and W. D. W. Heston
Respectfully,
David H. Kauder and John J. Bucchiere, Jr. Associates in Urology, North Shore, P.C. 496 Lynnfield Street Lynn, Massachusetts 01904 1. Edson, M. and Meek, J. M.: Bilateral testicular dislocation with
unilateral rupture. J. Urol., 122: 419, 1979.
J. Urol., 121: 437-441, 1979
To the Editor. The authors of this excellent study found that alkalinity of prostatic fluid increased to 8.32. In my series of 24 patients the pH of the prostatic fluid varied from 7.1 to 8.7, with a mean of 7.9. Elevated pH of prostatic fluid could explain the failure of long-term cotrimoxazole treatment because the previous pH gradient between the plasma and the prostatic fluid is abolished or may be reversed. In view of the findings of poor therapeutic response, a re-appraisal of treatment of chronic bacterial prostatitis was proposed by the authors. We found that direct perineal injections of various antibiotics into the prostatic lobes offers a good alternative in the treatment of chronic bacterial prostatitis. '· 2 In a study of 31 patients amikacin, cefazolin or gentamicin was injected in combination with cefazolin. 3• 4 After 1 injection 77 per cent of the patients were cured and repeated injections resulted in cure in up to 90 per cent of the cases. In a recent study 29 patients were treated with a 2 gm. injection of thiamphenicol glycinate, a chemical analogue of chloramphenicol. 5 Thiamphenicol levels in prostatic fluid varied between 1 and 4,000 µg./ml. and were unrelated to the time after intraprostatic administration. Serum levels decreased during the 24 hours of administration from 25 to 0.3 µg./ml. Definite cure was obtained in 66 per cent of the patients treated. The technique used in this study to collect urine and expressed prostatic secretion specimens and to localize urinary tract and prostatic infections has been described by Meares and Stamey. 6 In our investigation the second voided urine specimen (VB2), collected before the expressed prostatic secretion specimen, was replaced by a urine specimen obtained by suprapubic puncture. From each patient urine and prostatic fluid specimens were examined for infection 1 and 6 months after treatment. If the infection persists after 1 month the local treatment is repeated. Negative urine and prostatic fluid cultures 1 and 6 months after treatment, respectively, were taken as indications for cure of the bacterial prostatitis. In our opinion local antibiotic treatment by direct perineal injection