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Evaluation of a Urinary Catheter With a Preconnected Closed Drainage Bag
URINARY TRACT DlFECTION
Editorial Cornment: Hete:ro§exual transmis§ion of human immunodeficiency virus occi.n·s :readily in Africa. The study by Simonsen and associates documents that genital ulcers and the presence of an intact foreskin independently increase the risk of human immunodeficiency virus infection. Genital ox- ano:rectal ulcers, which are cm.1.§ed most frequently by herpes simplex virus rnr syphilis, are logical cofactors to facilitate immunodeficiency virus transmission or acquisition. In addition to simply providing a portal of entry or exit for human immunodeficiency virus, the P immunological responses to herpes simplex virus and T palli.dum include activated macrophages and stimulated T lymphocytes. In vitro, such cells are more susceptible to human immunodeficiency virus infection than are unstimulated cells. Stamm and associates observed that historical or serological evidence of either of these diseases was associated with 3-fold to 8-fold increased risk of human immunodeficiency virus infection among 200 homosexual men. In an uncircumcised man balanitis, laceration of the glans penis or trauma of the prepuce during intercourse could facilitate invasion. In addition, the microenvironment under the foreskin could permit longer survival of human immumodeficiency virus on the epithelium and, thus, more time for viral penetration. The relationship of human immunodeficiency virus infection to the presence of a foreskin also suggests that the most frequent portal of ent:ry of human immunodeficiency virus in the male genital tract is the glans penis or penile shaft, rather than the urethra. Programs to control genital ulcers, particularly those caused by chancroid and syphilis, and circumcision could have an important salutary effect on human immunodeficiency virus transmission. Anthony J. Schaeffer, M.D.
Infection-Related Chronic Interstitial Nephropathy
T. H. HOSTETTER, K A. NATH AND M. K. HOSTETTER, Departments of Medicine and Pediatrics, School of Medicine, University of Minnesota, Minneapolis, Minnesota 8: 11-16, 1988 Kidney infection, when uncomplicated by anatomic abnormalities such as reflux or obstructing lesions, does not appear to lead to renal damage or hypertension. In children in whom predisposing anatomic causes (reflux) are particularly nent or in adults who have or develop these abnormalities, progressive renal injury with hypertension can occur with in fection. Infection appears to enhance the damaging effects of the underlying anatomic abnormalities. The mechanisms of progressive damage include the inflammatory effects of the infection itself, potentially "autoimmune" effects, and the inflammatory and infection-promoting effects of bacterial products, especially ammonia. After initial renal damage, the hemodynamic effects of systemic hypertension and of intrarenal hyperperfusion of residual nephrons may further promote progressive injury.
Editorial Comment: Urinary tract infections in the absence of anatomical abnormalities do not appear to lead to renal damage or hypertension. However, when infections are accompanied by reflux or obstructing lesions, particularly in children, significant progressive
227
K"enal fu_r;ctional can occur, Some of the mechanisms of progression that are reviewed include potentiation of autoimmune effects and inflammatory promoting effects of bacterial products, especially ammonia. Clearly; a careful urological evaluation is warranted for recurrent urinary tract infections, particularly i.n children with a high prevalence for predisposing anatomical abnormalities, such as reflux, or in adults who have obstruction. or reflux abnormalities, for example bladder outlet obstruction from benign prostatic hyperplasia, neurogenic bladder dysfunction caused by spinal cord injury or diabetes mellitus, and conduit urinary diversion.
High Prevalence of Cervical Dysplasia in Female Consorts of Men With Genital Warts T. HOCKENSTROM, F. JONASSEN, F. KNUTSSON, G.-B.
T. RA.OBERG, Departments of Pathology, Obstetrics and Gynecology, and Dermatology, University of Gothenburg, Sahlgren's Hospital, Gothenburg, Sweden LOWHAGEN AND
Acta Derm. Venereol., 67: 511-516, 1987 Altogether 51 regular female consorts of men attending a venereal disease clinic for genital warts were examined using colposcopy, vaginal cytology and-when needed-surgical biopsy. Abnormal cytological smears were found in 18 out of 49 consorts (37%), which should be compared with 8 out of 124 (6%) matched female controls from a family planning clinic (p <0.001). Possibly premalignant lesions, i.e. atypical condylomata and/or frank dysplasia, were found in 14 (27%) out of 51 consorts. The prevalence of abnormal smears or biopsy-proven dysplasia was approximately the same in consorts with and without external warts. These findings call for close attention to the risk of development of cervical dysplasia in female consorts of men with genital warts. Editorial Comment: The authors support the concept that female consorts of men with genital warts have an approximately 25 pe:r cent incidence of p:remalignant cervical lesions. The prevalence of abnormal vaginal smears was 7 times higher in the studied women exposed to human. papillomavirus than in the control gnnirp. Urologists have an obligation to inform men with genital warts, whether external or intrau.rethiral, that their con.sorts have a significant risk of developing cervical dysplasia and, th.e:refm.·e, should seek gynecological evaluation. S1.ffveillance should include .repeated vaginal cytology and, if indicated, colposcopy. Anthony J. Schaeffer, M.D.
Evaluation of a Urinary Catheter With a Preconnected Closed Drainage Bag J. DEGROOT-KOSOLCHAROEN, R. GUSE AND J. M. JONES, Medical, Nursing and Research Services, William S. Middleton Memorial Veterans Administration Hospital; University of Wisconsin School of Nursing, and Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin Infect. Control. Hosp. Epidemiol., 9: 72- 76, 1988 The incidence of bacteriuria, significant urinary tract infection, and cost associated with the use of two urinary catheter drainage systems were evaluated in a population of hospitalized
228
URINARY TRACT INFECTION
adult males. A commercially available device comprised of a Foley catheter attached with a heat-shrunk plastic seal to the tubing of a closed drainage bag (preconnected system) was compared with a standard system that had the Foley catheter attached to the closed drainage bag after it had been inserted. Using a randomized prospective design, the performance of the preconnected system in 97 patients was compared with that of the standard system in 105 patients. Catheters were left in place a mean of 6.4 and 7.6 days in the respective groups. Bacteriuria occurred after catheter insertion in 11.3% of patients receiving the preconnected system and 13.3% of patients receiving the standard system (not statistically significant). When bacteriuria developed, it occurred within seven days of catheter insertion in 50% of instances, irrespective of drainage system employed, suggesting that manipulations related to catheter insertion were important in initiating bacteriuria. Significant urinary tract infections occurred in only 2% of all patients studied. The higher cost for purchasing the preconnected system was not warranted for the population of patients studied.
Editorial Comment: Catheter-associated bacteriuria remains the most common cause of nosocomial infections and a major cause of sepsis and death. The introduction of bacteria into the urinary tract via the catheter lumen before connection of the drainage system or subsequently by disconnection of the catheter drainage system is an important risk factor. Use of heat shrunk plastic to seal the junction between the catheter and tubing has been postulated as a safety device, and has been proposed to reduce inadvertent disconnection and the rate of acquired bacteriuria. The authors noted no difference in patients with the preconnected system compared to the standard drainage system. Therefore, the higher cost to purchase the preconnected and sealed system does not appear to be warranted. Taping the junction after insertion is less expensive and just as effective a deterrent for inadvertent disconnection of the catheter-drainage bag tubing junction. Anthony J. Schaeffer, M.D.
BOOK REVIEW Endourology: New and Improved Techniques
u. JONAS,
N. F. DABHOIWALA AND F. M. J. DEBRUYNE, New York: Springer-Verlag, 162 pages, 1988 This book on endourology is the result of a urological teaching course in Amsterdam organized by the Universities of
Amsterdam, Leiden and Nijmegen, and the Institute of Urology in London. The course resulted in several manuscripts that were drawn from the participants. This short volume is comprised of 17 chapters that deal with various aspects of endoscopic management of urological disease. Several chapters describe the investigative work of the contributor and can serve to inform the practicing urologist of some ongoing studies with endoscopic instrumentation and procedures. Chapter 6 sp_ecifically deals with ultrasound endoscanning of the bladder and prostate, and it is an informative overview of newer techniques in ultrasonic imaging of the lower urinary tract. Chapters 3 and 11 provide excellent overviews of the subject of polytetrafluoroethylene (Teflon) injection for incontinence and vesicoureteral reflux, including a critical analysis of results and complications. These chapters are of special interest to those embarking on a program of endoscopic polytetrafluoroethylene injection. Chapter 16 describes the clinical experience with percutaneous coagulum nephrolithotripsy, and it is an interesting review of the investigation and current status of a procedure that may be helpful to clear difficult renal anatomy of small, scattered residual stone debris. The remainder of the chapters discuss the current clinical status of endoscopic treatment of various urological diseases, including internal urethrotomy for urethral strictures, bladder neck incision, resection of posterior urethral valves, transperineal 125 iodine seed implantation, superficial bladder tumors, electrohydraulic lithotripsy in the lower urinary tract, ureteroscopy and the percutaneous treatment of complex upper tract stones, such as staghorn calculi and stones within caliceal diverticula. While this textbook does not purport to be encyclopedic and it certainly is not an introductory or reference textbook in endourology, it does provide some insight into current status of endourological techniques by established investigators in this field. The textbook is well illustrated with helpful x-rays and photographs. The book stresses key concepts in endourology and adds current practice in more advanced endoscopic techniques while being brief and easy to read. Over-all, even though this textbook may not be sufficient for an introduction to the subject for urologists beginning endourology, it certainly is an excellent update for practitioners of endourology and those interested in clinical investigation of endourological techniques. It may be well used as a supplement to a more encyclopedic basic endourology textbook. Culley C. Carson, III, M.D. Division of Urologic Surgery Duke University Medical Center Durham, North Carolina
Editorial Cornment: Hete:ro§exual transmis§ion of human immunodeficiency virus occi.n·s :readily in Africa. The study by Simonsen and associates documents that genital ulcers and the presence of an intact foreskin independently increase the risk of human immunodeficiency virus infection. Genital ox- ano:rectal ulcers, which are cm.1.§ed most frequently by herpes simplex virus rnr syphilis, are logical cofactors to facilitate immunodeficiency virus transmission or acquisition. In addition to simply providing a portal of entry or exit for human immunodeficiency virus, the P immunological responses to herpes simplex virus and T palli.dum include activated macrophages and stimulated T lymphocytes. In vitro, such cells are more susceptible to human immunodeficiency virus infection than are unstimulated cells. Stamm and associates observed that historical or serological evidence of either of these diseases was associated with 3-fold to 8-fold increased risk of human immunodeficiency virus infection among 200 homosexual men. In an uncircumcised man balanitis, laceration of the glans penis or trauma of the prepuce during intercourse could facilitate invasion. In addition, the microenvironment under the foreskin could permit longer survival of human immumodeficiency virus on the epithelium and, thus, more time for viral penetration. The relationship of human immunodeficiency virus infection to the presence of a foreskin also suggests that the most frequent portal of ent:ry of human immunodeficiency virus in the male genital tract is the glans penis or penile shaft, rather than the urethra. Programs to control genital ulcers, particularly those caused by chancroid and syphilis, and circumcision could have an important salutary effect on human immunodeficiency virus transmission. Anthony J. Schaeffer, M.D.
Infection-Related Chronic Interstitial Nephropathy
T. H. HOSTETTER, K A. NATH AND M. K. HOSTETTER, Departments of Medicine and Pediatrics, School of Medicine, University of Minnesota, Minneapolis, Minnesota 8: 11-16, 1988 Kidney infection, when uncomplicated by anatomic abnormalities such as reflux or obstructing lesions, does not appear to lead to renal damage or hypertension. In children in whom predisposing anatomic causes (reflux) are particularly nent or in adults who have or develop these abnormalities, progressive renal injury with hypertension can occur with in fection. Infection appears to enhance the damaging effects of the underlying anatomic abnormalities. The mechanisms of progressive damage include the inflammatory effects of the infection itself, potentially "autoimmune" effects, and the inflammatory and infection-promoting effects of bacterial products, especially ammonia. After initial renal damage, the hemodynamic effects of systemic hypertension and of intrarenal hyperperfusion of residual nephrons may further promote progressive injury.
Editorial Comment: Urinary tract infections in the absence of anatomical abnormalities do not appear to lead to renal damage or hypertension. However, when infections are accompanied by reflux or obstructing lesions, particularly in children, significant progressive
227
K"enal fu_r;ctional can occur, Some of the mechanisms of progression that are reviewed include potentiation of autoimmune effects and inflammatory promoting effects of bacterial products, especially ammonia. Clearly; a careful urological evaluation is warranted for recurrent urinary tract infections, particularly i.n children with a high prevalence for predisposing anatomical abnormalities, such as reflux, or in adults who have obstruction. or reflux abnormalities, for example bladder outlet obstruction from benign prostatic hyperplasia, neurogenic bladder dysfunction caused by spinal cord injury or diabetes mellitus, and conduit urinary diversion.
High Prevalence of Cervical Dysplasia in Female Consorts of Men With Genital Warts T. HOCKENSTROM, F. JONASSEN, F. KNUTSSON, G.-B.
T. RA.OBERG, Departments of Pathology, Obstetrics and Gynecology, and Dermatology, University of Gothenburg, Sahlgren's Hospital, Gothenburg, Sweden LOWHAGEN AND
Acta Derm. Venereol., 67: 511-516, 1987 Altogether 51 regular female consorts of men attending a venereal disease clinic for genital warts were examined using colposcopy, vaginal cytology and-when needed-surgical biopsy. Abnormal cytological smears were found in 18 out of 49 consorts (37%), which should be compared with 8 out of 124 (6%) matched female controls from a family planning clinic (p <0.001). Possibly premalignant lesions, i.e. atypical condylomata and/or frank dysplasia, were found in 14 (27%) out of 51 consorts. The prevalence of abnormal smears or biopsy-proven dysplasia was approximately the same in consorts with and without external warts. These findings call for close attention to the risk of development of cervical dysplasia in female consorts of men with genital warts. Editorial Comment: The authors support the concept that female consorts of men with genital warts have an approximately 25 pe:r cent incidence of p:remalignant cervical lesions. The prevalence of abnormal vaginal smears was 7 times higher in the studied women exposed to human. papillomavirus than in the control gnnirp. Urologists have an obligation to inform men with genital warts, whether external or intrau.rethiral, that their con.sorts have a significant risk of developing cervical dysplasia and, th.e:refm.·e, should seek gynecological evaluation. S1.ffveillance should include .repeated vaginal cytology and, if indicated, colposcopy. Anthony J. Schaeffer, M.D.
Evaluation of a Urinary Catheter With a Preconnected Closed Drainage Bag J. DEGROOT-KOSOLCHAROEN, R. GUSE AND J. M. JONES, Medical, Nursing and Research Services, William S. Middleton Memorial Veterans Administration Hospital; University of Wisconsin School of Nursing, and Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin Infect. Control. Hosp. Epidemiol., 9: 72- 76, 1988 The incidence of bacteriuria, significant urinary tract infection, and cost associated with the use of two urinary catheter drainage systems were evaluated in a population of hospitalized
228
URINARY TRACT INFECTION
adult males. A commercially available device comprised of a Foley catheter attached with a heat-shrunk plastic seal to the tubing of a closed drainage bag (preconnected system) was compared with a standard system that had the Foley catheter attached to the closed drainage bag after it had been inserted. Using a randomized prospective design, the performance of the preconnected system in 97 patients was compared with that of the standard system in 105 patients. Catheters were left in place a mean of 6.4 and 7.6 days in the respective groups. Bacteriuria occurred after catheter insertion in 11.3% of patients receiving the preconnected system and 13.3% of patients receiving the standard system (not statistically significant). When bacteriuria developed, it occurred within seven days of catheter insertion in 50% of instances, irrespective of drainage system employed, suggesting that manipulations related to catheter insertion were important in initiating bacteriuria. Significant urinary tract infections occurred in only 2% of all patients studied. The higher cost for purchasing the preconnected system was not warranted for the population of patients studied.
Editorial Comment: Catheter-associated bacteriuria remains the most common cause of nosocomial infections and a major cause of sepsis and death. The introduction of bacteria into the urinary tract via the catheter lumen before connection of the drainage system or subsequently by disconnection of the catheter drainage system is an important risk factor. Use of heat shrunk plastic to seal the junction between the catheter and tubing has been postulated as a safety device, and has been proposed to reduce inadvertent disconnection and the rate of acquired bacteriuria. The authors noted no difference in patients with the preconnected system compared to the standard drainage system. Therefore, the higher cost to purchase the preconnected and sealed system does not appear to be warranted. Taping the junction after insertion is less expensive and just as effective a deterrent for inadvertent disconnection of the catheter-drainage bag tubing junction. Anthony J. Schaeffer, M.D.
BOOK REVIEW Endourology: New and Improved Techniques
u. JONAS,
N. F. DABHOIWALA AND F. M. J. DEBRUYNE, New York: Springer-Verlag, 162 pages, 1988 This book on endourology is the result of a urological teaching course in Amsterdam organized by the Universities of
Amsterdam, Leiden and Nijmegen, and the Institute of Urology in London. The course resulted in several manuscripts that were drawn from the participants. This short volume is comprised of 17 chapters that deal with various aspects of endoscopic management of urological disease. Several chapters describe the investigative work of the contributor and can serve to inform the practicing urologist of some ongoing studies with endoscopic instrumentation and procedures. Chapter 6 sp_ecifically deals with ultrasound endoscanning of the bladder and prostate, and it is an informative overview of newer techniques in ultrasonic imaging of the lower urinary tract. Chapters 3 and 11 provide excellent overviews of the subject of polytetrafluoroethylene (Teflon) injection for incontinence and vesicoureteral reflux, including a critical analysis of results and complications. These chapters are of special interest to those embarking on a program of endoscopic polytetrafluoroethylene injection. Chapter 16 describes the clinical experience with percutaneous coagulum nephrolithotripsy, and it is an interesting review of the investigation and current status of a procedure that may be helpful to clear difficult renal anatomy of small, scattered residual stone debris. The remainder of the chapters discuss the current clinical status of endoscopic treatment of various urological diseases, including internal urethrotomy for urethral strictures, bladder neck incision, resection of posterior urethral valves, transperineal 125 iodine seed implantation, superficial bladder tumors, electrohydraulic lithotripsy in the lower urinary tract, ureteroscopy and the percutaneous treatment of complex upper tract stones, such as staghorn calculi and stones within caliceal diverticula. While this textbook does not purport to be encyclopedic and it certainly is not an introductory or reference textbook in endourology, it does provide some insight into current status of endourological techniques by established investigators in this field. The textbook is well illustrated with helpful x-rays and photographs. The book stresses key concepts in endourology and adds current practice in more advanced endoscopic techniques while being brief and easy to read. Over-all, even though this textbook may not be sufficient for an introduction to the subject for urologists beginning endourology, it certainly is an excellent update for practitioners of endourology and those interested in clinical investigation of endourological techniques. It may be well used as a supplement to a more encyclopedic basic endourology textbook. Culley C. Carson, III, M.D. Division of Urologic Surgery Duke University Medical Center Durham, North Carolina