- Email: [email protected]
FRII-02 PEARLS OF WISDOM: A HISTORY OF MALE GENITAL ORNAMENTATION
THE JOURNAL OF UROLOGYâ
e588
Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015
melanoma to Meckel’s diverticulum. Here we explore Dr. Greenblatt’s contribution to the field of Urology through the early development of the testosterone pellet. METHODS: Sources from medical journals and contributions from the Robert B. Greenblatt, M.D. Library at the Medical College of Georgia (MCG), including personal communications and unpublished material, were analyzed regarding the life and medical pursuits of Robert Greenblatt. RESULTS: Dr. Greenblatt was born on October 12, 1906 in Montreal, Canada. He earned his undergraduate and medical degrees at McGill University, finishing the latter in 1932. Dr. Greenblatt subsequently pursued further training in obstetrics and gynecology, eventually starting his practice at MCG in Augusta, GA in 1935. Following a period of time as a medical officer in the Navy, he returned to MCG in 1946 as Chair of the inaugural department of Endocrinology. Although primarily known for his work in women’s reproductive health, Dr. Greenblatt is less known for his development of the testosterone pellet, originally for the treatment of women with gynecologic disorders. He dedicated several studies to describing the absorption rates, benefits, and side effects of testosterone pellets. Furthermore, after observing a high proportion of patients expel pellets that were surgically implanted, he improved implantation techniques utilizing the Kearns instrument. Dr. Greenblatt’s other medical contributions included the development of clomiphene for treatment of infertility and using sulfanilamides to treat granuloma inguinale. Beyond medicine Dr. Greenblatt was a voracious reader and author, with a particular interest in spirituality. He authored several works regarding religion, including Search the Scriptures: Modern Medicine and Biblical Personages. CONCLUSIONS: Dr. Robert Benjamin Greenblatt eventually passed away from lung cancer on September 27, 1987. His contributions to medicine will not be easily forgotten; both the Endowed Chair of Endocrinology and the medical library at MCG carry his name. Ironically, Dr. Greenblatt’s contributions to hormone replacement therapy in women provided Urologists with the early groundwork for a common treatment modality for hypogonadism in men. Source of Funding: None
History of Urology Forum II Poster Sunday, May 17, 2015
1:00 PM-5:30 PM
FRII-01 BEHIND THE NAME: THE HISTORICAL PERSPECTIVE OF THE PATHOLOGIZING OF ATYPICAL SEXUAL DEVELOPMENT. Matthew Truesdale*, Hillary Copp, San Francisco, CA INTRODUCTION AND OBJECTIVES: As the political landscape changes with more widespread acceptance of variations of gender identity, a move away from the use of “disorders” in Disorders of Sex Development (DSD) to a less pathologizing “variations” in sexual development may be appropriate. We seek to provide a historical context of the current naming convention for DSD in the hope of expanding perception of sexual development. METHODS: We performed a literature search of all publications focused on the nomenclature used to describe the patient population currently known as DSD. RESULTS: The earliest description of variations in sexual development was by Theodor Albrecht Edwin Klebs in 1876. He categorized patients based on the nature of the gonads: 1) female pseudohermaphroditism 2) male pseudohermaphroditism and 3) true hermaphroditism. The categorization assumed that the gonads were an
indicator of the patient’s true sex and should dictate and inform treatment regardless of function or phenotype. Over time, clinicians began to appreciate that in addition to the gonads, genotype, phenotype, physiology and clinical diagnosis all contributed to the complex notion of the “true” gender. The term Intersex was introduced in 1923 to reflect this newfound understanding. In the 1990s, gender activists reclaimed the term Intersex. Political battles ensued pitting clinicians trying to treat patients born with atypical sexual anatomy with activists advocating acceptance of atypia and avoiding early intervention. The politics resulted in clinicians avoiding the term “intersex” given the contentious connotations. In 2006, a large consortium of clinicians, patients and families of children with anomalies of sexual development published a guideline for care of DSD patients and established the term “DSD” to describe any condition involving ambiguous genitalia, discordant internal and external genitalia, incomplete sex anatomy developments, sex chromosomal anomalies, and disorders of gonadal development. The term replaced the previously advocated umbrella term, “Intersex,” as a means of depoliticizing the clinical conditions. CONCLUSIONS: Although controversial, DSD allows clinicians a vocabulary for a patient population free of political connotation. Use of the word “disorders” inherently pathologizes this patient group and assumes a goal of making all patients into “normal boys and girls.” As our understanding of gender evolves, it may be time to accept atypia as normal variance and change the nomenclature to reflect this matured understanding. Source of Funding: none
FRII-02 PEARLS OF WISDOM: A HISTORY OF MALE GENITAL ORNAMENTATION Justina Tam*, Wai Lee, Howard L. Adler, Stony Brook, NY INTRODUCTION AND OBJECTIVES: Evidence suggests that genital decoration has been in existence for 38,000 years. Genital pearling, in which small beads are permanently inserted beneath the skin of the genitals has been documented, though its origins are unknown. While relatively uncommon and predominantly performed in Asia, this phenomenon continues today. METHODS: A literature search was performed using Pub Med and Google. RESULTS: Artwork depicting decorative rituals of male genitalia has been found as early as the prehistoric period 38,000 to 11,000 years ago. Phallic artwork depicting plaques and holes which appear to represent skin scarification and piercing, has been found throughout Europe. Genital decoration, especially the practice of pearling, in which foreign objects are inserted beneath the skin of the penis, continues to this day. The most common motive for genital pearling is to enhance pleasure during sexual intercourse. This practice is mentioned in the Kama Sutra, and is also called “bolitas” in the Philippines, or “Tancho’s nodules” Southeast Asia. “Tancho” refers to a brand of Japanese hair pomade whose containers were thought to be made from a special non-reactive glass. The bottoms of these glass jars were melted or ground into beads for insertion. In the Japanese Yakuza crime syndicate, the implantation of each “Yakuza bead” is said to represent one year in prison. However, reports of prisoners implanting foreign objects indicate that the primary purpose of this act was to enhance sexual pleasure in their partners. Currently, body-piercing specialists can be found who perform genital nodule implantation, and internet forums such as BodyMod.org provide counsel about procedure and their results. Some users report performing the modification themselves with few complications. The most commonly reported complications include bruising and bead migration.
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015
Case reports of the implantation of penile nodules indicate that this uncommon phenomenon should be recognized despite having few reported complications. Although the diagnosis of an artificial penile nodule is straightforward, it must be differentiated from other conditions such as subcutaneous angiitis, cysts, or calcification of the penis. Often, there are no serious side effects but there are reports of infection and hematoma. Long-term complications may include scar tissue formation, pain, and erectile dysfunction. CONCLUSIONS: The practice of genital modification by genital pearling is an uncommon phenomenon generally practiced to produce enhanced sexual pleasure. Source of Funding: None
FRII-03 CASTRATION OF SEXUAL OFFENDERS IN THE UNITED STATES. Ariel Schulman*, Ruben Pinkhasov, Ciril Godec, David Silver, Brooklyn, NY INTRODUCTION AND OBJECTIVES: Urologists manipulate the male androgen axis with stimulation for hypogonadism and blockade for prostate cancer. Less common but more controversial is the castration of sex offenders, a practice that is currently legal in many states. We review the history and associated controversies of punitive castration in the United States. METHODS: Journals and news publications were examined for relevant historical information. RESULTS: Castration can be traced throughout human history and is documented as early as the 1700’s as punishment for sexual deviance in the United States. Surgical castration was used until the 1960’s when reversible forms of chemical castration were developed. Medroxyprogesterone (MPA,) a synthetic form of progesterone, is the drug of choice for long-acting, chemical castration. Formal legislation exists in nine states, including Louisiana, for castration of those convicted of a range of sexual crimes. There is variation among states regarding type of offense, method of castration and consequences of non-compliance. The goal is to reduce deviant sexual impulses to allow convicted sex offenders to return to the community. But the practice presents important ethical questions including the validity of informed consent given by a prisoner as a condition for release from incarceration and the justifiability of the detrimental consequences of iatrogenic hypogonadism. Further difficulties arise finding appropriately trained medical professionals to administer injections, perform surgery and monitor hormone levels. CONCLUSIONS: The practice of punitive castration in the United States is designed to reintegrate sexual offenders into the community while protecting the public from victimization. While seemingly well intentioned, critical issues including incentivized consent, the sequelae of iatrogenic hypogonadism and appropriate medical supervision remain unresolved. As Urologists, we may face the decision to participate in this procedure and should know its history. Source of Funding: “none”
FRII-04 SIR PERCIVALL POTT AND SOOT WART: THE EFFECTS OF SCROTAL CANCER ON CHILD LABOR LAWS IN THE BRITISH EMPIRE Drew Palmer*, Kari Bailey, Shiv Patel, Burlington, MA INTRODUCTION AND OBJECTIVES: In Britain during the 18th century, young boys were being used as chimney sweeps under brutal and appalling conditions. Sir Percivall Pott (1714-1788), a prominent English surgeon, was the first to describe the association between the contact with soot in these young chimney sweeps and scrotal cancer.
e589
METHODS: A comprehensive literature review was performed (JSTOR, PubMed) using the search terms Percivall Pott, soot wart, scrotal cancer, and the Chimney Sweeper’s Act of 1788. RESULTS: In 1765, Sir Percivall Pott was elected Master of the Company of Surgeons (the precursor to the Royal College of Surgeons). In his landmark paper Chirurgical Observations: Cancer Scroti, published in 1775, he identified the causation between “the lodgement of soot in the ruggae of the scrotum” in chimney sweeps and scrotal cancer (known as soot wart to those afflicted). The young boys often worked in the nude, leading to prolonged contact with the environmental carcinogen. By identifying this cause, Pott was the first to demonstrate an occupational link to cancer. During his research, he was moved by the plight of these young boys which he described as: “singularly hard. in their early infancy they are most frequently treated with great brutality and almost starved with cold and hunger. and when they get to puberty, become liable to a most noisome, painful, and fatal disease.” He described scrotal cancer as “a disease of the abdomen, most frequently indurating and spoiling the inguinal glands, when arrived within the abdomen, it affects the viscera and then becomes painfully destructive.” His work was opposed by master chimney sweeps and wealthy home owners but eventually it had influence on public opinion and helped lead to the reformation of child labor laws. The Chimney Sweeper’s Act of 1788 decreed that apprentices have a minimum age of eight years, parental consent, and acceptable living conditions. Unfortunately, these Acts were not enforced until 1875, when Parliament implemented an Act that required chimney sweeps to be licensed and that any violation of the previous Acts would result in loss of licensure. CONCLUSIONS: Sir Percival Pott was the first to identify the cause of the increased incidence of scrotal cancer in chimney sweeps, and his landmark work influenced public opinion which helped lead to a change in child labor laws in Britain. Source of Funding: none
FRII-05 THE OLDEST RETAINED URETERAL STENT: A HISTORY OF THE URETERAL STENT Rishi Modh*, James Mason, Akira Yamamoto, Thomas Stringer, Vincent Bird, Gainesville, FL INTRODUCTION AND OBJECTIVES: An 81 year old male presented for the evaluation of urinary tract infections. History and work up revealed that the patient had a ureteral stent placed about 35 years ago at the University of Florida by Dr. Birdwell Finlayson. We will review the origins of the ureteral stent as well as the outcome of our interesting case. METHODS: Literature review was performed to understand the history of ureteral stents. We searched pubmed as well as text books. We will also review the clinical course and treatment of our patient. RESULTS: For our case, first a nephrostomy tube was placed due to hydronephrosis, obstruction, and a positive urine culture. First the distal curl was removed and then remainder of the stent and stone burden was removed percutaneously. Urinary catheters and stents are documented as early as ancient Egypt. In the nineteenth century, Dr. Gustav Simon is credited as being the first person to “stent” a ureter. He described inserting a tube into a ureter during open bladder surgery. Dr. Joaquin Albarrano was the first to create a catheter for the ureter. In 1967 Paul Zimskind reported inserting a straight, open ended, silicone tube into a ureter to relieve obstruction. However this was a straight tube that easily became dislodged. The term “stent” was coined by Dr Montie is 1973.
e588
Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015
melanoma to Meckel’s diverticulum. Here we explore Dr. Greenblatt’s contribution to the field of Urology through the early development of the testosterone pellet. METHODS: Sources from medical journals and contributions from the Robert B. Greenblatt, M.D. Library at the Medical College of Georgia (MCG), including personal communications and unpublished material, were analyzed regarding the life and medical pursuits of Robert Greenblatt. RESULTS: Dr. Greenblatt was born on October 12, 1906 in Montreal, Canada. He earned his undergraduate and medical degrees at McGill University, finishing the latter in 1932. Dr. Greenblatt subsequently pursued further training in obstetrics and gynecology, eventually starting his practice at MCG in Augusta, GA in 1935. Following a period of time as a medical officer in the Navy, he returned to MCG in 1946 as Chair of the inaugural department of Endocrinology. Although primarily known for his work in women’s reproductive health, Dr. Greenblatt is less known for his development of the testosterone pellet, originally for the treatment of women with gynecologic disorders. He dedicated several studies to describing the absorption rates, benefits, and side effects of testosterone pellets. Furthermore, after observing a high proportion of patients expel pellets that were surgically implanted, he improved implantation techniques utilizing the Kearns instrument. Dr. Greenblatt’s other medical contributions included the development of clomiphene for treatment of infertility and using sulfanilamides to treat granuloma inguinale. Beyond medicine Dr. Greenblatt was a voracious reader and author, with a particular interest in spirituality. He authored several works regarding religion, including Search the Scriptures: Modern Medicine and Biblical Personages. CONCLUSIONS: Dr. Robert Benjamin Greenblatt eventually passed away from lung cancer on September 27, 1987. His contributions to medicine will not be easily forgotten; both the Endowed Chair of Endocrinology and the medical library at MCG carry his name. Ironically, Dr. Greenblatt’s contributions to hormone replacement therapy in women provided Urologists with the early groundwork for a common treatment modality for hypogonadism in men. Source of Funding: None
History of Urology Forum II Poster Sunday, May 17, 2015
1:00 PM-5:30 PM
FRII-01 BEHIND THE NAME: THE HISTORICAL PERSPECTIVE OF THE PATHOLOGIZING OF ATYPICAL SEXUAL DEVELOPMENT. Matthew Truesdale*, Hillary Copp, San Francisco, CA INTRODUCTION AND OBJECTIVES: As the political landscape changes with more widespread acceptance of variations of gender identity, a move away from the use of “disorders” in Disorders of Sex Development (DSD) to a less pathologizing “variations” in sexual development may be appropriate. We seek to provide a historical context of the current naming convention for DSD in the hope of expanding perception of sexual development. METHODS: We performed a literature search of all publications focused on the nomenclature used to describe the patient population currently known as DSD. RESULTS: The earliest description of variations in sexual development was by Theodor Albrecht Edwin Klebs in 1876. He categorized patients based on the nature of the gonads: 1) female pseudohermaphroditism 2) male pseudohermaphroditism and 3) true hermaphroditism. The categorization assumed that the gonads were an
indicator of the patient’s true sex and should dictate and inform treatment regardless of function or phenotype. Over time, clinicians began to appreciate that in addition to the gonads, genotype, phenotype, physiology and clinical diagnosis all contributed to the complex notion of the “true” gender. The term Intersex was introduced in 1923 to reflect this newfound understanding. In the 1990s, gender activists reclaimed the term Intersex. Political battles ensued pitting clinicians trying to treat patients born with atypical sexual anatomy with activists advocating acceptance of atypia and avoiding early intervention. The politics resulted in clinicians avoiding the term “intersex” given the contentious connotations. In 2006, a large consortium of clinicians, patients and families of children with anomalies of sexual development published a guideline for care of DSD patients and established the term “DSD” to describe any condition involving ambiguous genitalia, discordant internal and external genitalia, incomplete sex anatomy developments, sex chromosomal anomalies, and disorders of gonadal development. The term replaced the previously advocated umbrella term, “Intersex,” as a means of depoliticizing the clinical conditions. CONCLUSIONS: Although controversial, DSD allows clinicians a vocabulary for a patient population free of political connotation. Use of the word “disorders” inherently pathologizes this patient group and assumes a goal of making all patients into “normal boys and girls.” As our understanding of gender evolves, it may be time to accept atypia as normal variance and change the nomenclature to reflect this matured understanding. Source of Funding: none
FRII-02 PEARLS OF WISDOM: A HISTORY OF MALE GENITAL ORNAMENTATION Justina Tam*, Wai Lee, Howard L. Adler, Stony Brook, NY INTRODUCTION AND OBJECTIVES: Evidence suggests that genital decoration has been in existence for 38,000 years. Genital pearling, in which small beads are permanently inserted beneath the skin of the genitals has been documented, though its origins are unknown. While relatively uncommon and predominantly performed in Asia, this phenomenon continues today. METHODS: A literature search was performed using Pub Med and Google. RESULTS: Artwork depicting decorative rituals of male genitalia has been found as early as the prehistoric period 38,000 to 11,000 years ago. Phallic artwork depicting plaques and holes which appear to represent skin scarification and piercing, has been found throughout Europe. Genital decoration, especially the practice of pearling, in which foreign objects are inserted beneath the skin of the penis, continues to this day. The most common motive for genital pearling is to enhance pleasure during sexual intercourse. This practice is mentioned in the Kama Sutra, and is also called “bolitas” in the Philippines, or “Tancho’s nodules” Southeast Asia. “Tancho” refers to a brand of Japanese hair pomade whose containers were thought to be made from a special non-reactive glass. The bottoms of these glass jars were melted or ground into beads for insertion. In the Japanese Yakuza crime syndicate, the implantation of each “Yakuza bead” is said to represent one year in prison. However, reports of prisoners implanting foreign objects indicate that the primary purpose of this act was to enhance sexual pleasure in their partners. Currently, body-piercing specialists can be found who perform genital nodule implantation, and internet forums such as BodyMod.org provide counsel about procedure and their results. Some users report performing the modification themselves with few complications. The most commonly reported complications include bruising and bead migration.
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015
Case reports of the implantation of penile nodules indicate that this uncommon phenomenon should be recognized despite having few reported complications. Although the diagnosis of an artificial penile nodule is straightforward, it must be differentiated from other conditions such as subcutaneous angiitis, cysts, or calcification of the penis. Often, there are no serious side effects but there are reports of infection and hematoma. Long-term complications may include scar tissue formation, pain, and erectile dysfunction. CONCLUSIONS: The practice of genital modification by genital pearling is an uncommon phenomenon generally practiced to produce enhanced sexual pleasure. Source of Funding: None
FRII-03 CASTRATION OF SEXUAL OFFENDERS IN THE UNITED STATES. Ariel Schulman*, Ruben Pinkhasov, Ciril Godec, David Silver, Brooklyn, NY INTRODUCTION AND OBJECTIVES: Urologists manipulate the male androgen axis with stimulation for hypogonadism and blockade for prostate cancer. Less common but more controversial is the castration of sex offenders, a practice that is currently legal in many states. We review the history and associated controversies of punitive castration in the United States. METHODS: Journals and news publications were examined for relevant historical information. RESULTS: Castration can be traced throughout human history and is documented as early as the 1700’s as punishment for sexual deviance in the United States. Surgical castration was used until the 1960’s when reversible forms of chemical castration were developed. Medroxyprogesterone (MPA,) a synthetic form of progesterone, is the drug of choice for long-acting, chemical castration. Formal legislation exists in nine states, including Louisiana, for castration of those convicted of a range of sexual crimes. There is variation among states regarding type of offense, method of castration and consequences of non-compliance. The goal is to reduce deviant sexual impulses to allow convicted sex offenders to return to the community. But the practice presents important ethical questions including the validity of informed consent given by a prisoner as a condition for release from incarceration and the justifiability of the detrimental consequences of iatrogenic hypogonadism. Further difficulties arise finding appropriately trained medical professionals to administer injections, perform surgery and monitor hormone levels. CONCLUSIONS: The practice of punitive castration in the United States is designed to reintegrate sexual offenders into the community while protecting the public from victimization. While seemingly well intentioned, critical issues including incentivized consent, the sequelae of iatrogenic hypogonadism and appropriate medical supervision remain unresolved. As Urologists, we may face the decision to participate in this procedure and should know its history. Source of Funding: “none”
FRII-04 SIR PERCIVALL POTT AND SOOT WART: THE EFFECTS OF SCROTAL CANCER ON CHILD LABOR LAWS IN THE BRITISH EMPIRE Drew Palmer*, Kari Bailey, Shiv Patel, Burlington, MA INTRODUCTION AND OBJECTIVES: In Britain during the 18th century, young boys were being used as chimney sweeps under brutal and appalling conditions. Sir Percivall Pott (1714-1788), a prominent English surgeon, was the first to describe the association between the contact with soot in these young chimney sweeps and scrotal cancer.
e589
METHODS: A comprehensive literature review was performed (JSTOR, PubMed) using the search terms Percivall Pott, soot wart, scrotal cancer, and the Chimney Sweeper’s Act of 1788. RESULTS: In 1765, Sir Percivall Pott was elected Master of the Company of Surgeons (the precursor to the Royal College of Surgeons). In his landmark paper Chirurgical Observations: Cancer Scroti, published in 1775, he identified the causation between “the lodgement of soot in the ruggae of the scrotum” in chimney sweeps and scrotal cancer (known as soot wart to those afflicted). The young boys often worked in the nude, leading to prolonged contact with the environmental carcinogen. By identifying this cause, Pott was the first to demonstrate an occupational link to cancer. During his research, he was moved by the plight of these young boys which he described as: “singularly hard. in their early infancy they are most frequently treated with great brutality and almost starved with cold and hunger. and when they get to puberty, become liable to a most noisome, painful, and fatal disease.” He described scrotal cancer as “a disease of the abdomen, most frequently indurating and spoiling the inguinal glands, when arrived within the abdomen, it affects the viscera and then becomes painfully destructive.” His work was opposed by master chimney sweeps and wealthy home owners but eventually it had influence on public opinion and helped lead to the reformation of child labor laws. The Chimney Sweeper’s Act of 1788 decreed that apprentices have a minimum age of eight years, parental consent, and acceptable living conditions. Unfortunately, these Acts were not enforced until 1875, when Parliament implemented an Act that required chimney sweeps to be licensed and that any violation of the previous Acts would result in loss of licensure. CONCLUSIONS: Sir Percival Pott was the first to identify the cause of the increased incidence of scrotal cancer in chimney sweeps, and his landmark work influenced public opinion which helped lead to a change in child labor laws in Britain. Source of Funding: none
FRII-05 THE OLDEST RETAINED URETERAL STENT: A HISTORY OF THE URETERAL STENT Rishi Modh*, James Mason, Akira Yamamoto, Thomas Stringer, Vincent Bird, Gainesville, FL INTRODUCTION AND OBJECTIVES: An 81 year old male presented for the evaluation of urinary tract infections. History and work up revealed that the patient had a ureteral stent placed about 35 years ago at the University of Florida by Dr. Birdwell Finlayson. We will review the origins of the ureteral stent as well as the outcome of our interesting case. METHODS: Literature review was performed to understand the history of ureteral stents. We searched pubmed as well as text books. We will also review the clinical course and treatment of our patient. RESULTS: For our case, first a nephrostomy tube was placed due to hydronephrosis, obstruction, and a positive urine culture. First the distal curl was removed and then remainder of the stent and stone burden was removed percutaneously. Urinary catheters and stents are documented as early as ancient Egypt. In the nineteenth century, Dr. Gustav Simon is credited as being the first person to “stent” a ureter. He described inserting a tube into a ureter during open bladder surgery. Dr. Joaquin Albarrano was the first to create a catheter for the ureter. In 1967 Paul Zimskind reported inserting a straight, open ended, silicone tube into a ureter to relieve obstruction. However this was a straight tube that easily became dislodged. The term “stent” was coined by Dr Montie is 1973.