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Herpes Genitalis and Neurogenic Bladder and Bowel
0022-5347 /80/752-754;$02.00/0 Vol. 124, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
Letters to the Editor IDIOPATHIC RETROPERITONEAL FIBROSIS AND HLA-B27
To the Editor. The first case of idiopathic retroperitoneal fibrosis in a patient with the histocompatibility antigen HLA-B27 was reported in 1976. 1 The second and most recent case was reported in 1978. 2 It was suggested in both articles that possession of HLA-B27 might predispose to the development of idiopathic retroperitoneal fibrosis. The patients in both reports were American blacks. I have tested 2 of my patients with idiopathic retroperitoneal fibrosis and have not found HLA-B27 in either case. Both patients are American whites. Only limited conclusions can be drawn from these 4 cases. It is fair to say that HLA-B27 is not a requisite for the occurrence of idiopathic retroperitoneal fibrosis in American white patients. One could speculate that it might be so in American black patients. The prevalence of HLAB27 differs between American blacks and whites, being about 4 per cent for the former and at least twice as much for the latter. 3 A racial difference also appears to exist in the association between HLA-B27 and disease. Thus, among patients with ankylosing spondylitis and Reiter's disease 90 per cent of American white patients have HLA-B27 compared to only 50 per cent of American black patients. 3 On the other hand, to my knowledge, no case of an association between idiopathic retroperitoneal fibrosis and the diseases most closely related to HLAB27 has been reported. These diseases are ankylosing spondylitis, Reiter's disease, Yersinia and salmonella arthritides, and anterior uveitis.4 Also, epidemiologic studies of persons with HLA-B27 have to date failed to reveal idiopathic retroperitoneal fibrosis. However, this fact could be the result of the rarity of idiopathic retroperitoneal fibrosis since, even when the association is strongest, only about 20 per cent of persons with HLA-B27 have ankylosing spondylitis. 4 Furthermore, the prevalence of idiopathic retroperitoneal fibrosis in different races is unknown. Knowledge of the possible role of HLA-B27 in idiopathic retroperitoneal fibrosis awaits further studies but the evidence favoring such a role, especially in American white patients, is slim. Respectfully, Luis Fernandez-Herlihy Lahey Clnic Foundation Boston, Massachusetts 02215 1. Case records of the Massachusetts General Hospital (case 13-1976). New Engl. J. Med., 294: 712, 1976. 2. Willscher, M. K., Novicki, D. E. and Cwazka, W. F.: Association of HLA-B27 antigen with retroperitoneal fibrosis. J. Urol., 120: 631, 1978. 3. Calin, A.: HLA-B27: to type or not to type? Ann. Intern. Med., 92: 208, 1980. 4. McDevitt, H. 0. and Engleman, E. G.: Association between genes in the major histocompatibility complex and disease susceptibility. Arthritis Rheum., suppl., 20: F9, 1977.
glucose of 54 mg. per cent and a negative test for venereal disease. Cystoscopy was negative and a cystometrogram showed a hypotonic neurogenic bladder. The patient eventually did well, managed only with initial permanent bladder catheter drainage and stool softeners. He regained continence completely about a month after the onset of the vesicular eruption. This case is unusual because of the preservation of the bulbocavernous reflex and normal spinal fluid. Neurogenic dysfunction in herpes anogenitalis is believed to be secondary to sacral-meningomyeloradiculitis, 2 with spinal fluid examination showing pleocytosis even late in the course of the illness, 3 and increased protein. In our patient the dysfunction was caused by peripheral parasympathetic neuritis rather than meningomyeloradiculitis. Cases of anal or cervical herpetic inflammations with bladder or bowel neurogenic dysfunction are sometimes difficult to diagnose since multiple sclerosis, a spinal cord tumor or a psychogenic bladder may be considered. 4 It also can occur in patients undergoing immunosuppressive therapy, as reported by Jacobs and associates. Respectfully, Daniel E. Jacome and Gonzalo F. Yanez Palm Springs Medical Plaza Suite 306 1435 West 49th Place Hialeah, Florida 33012 1. Jacobs, S. C., Hebert, L. A., Piering, W. F. and Lawson, R. K.:
Acute motor paralytic bladder in renal transplant patients with anogenital herpes infection. J. Urol., 123: 426, 1980. 2. Oates, J. K. and Greenhouse, P.R.: Retention of urine in anogenital herpetic infection. Lancet, 1: 691, 1978. 3. Jellinek, E. H. and Tulloch, W. S.: Herpes zoster with dysfunction of bladder and anus. Lancet, 2: 1219, 1976. 4. Caplan, L. R., Kleeman, F. J. and Berg, S.: Urinary retention probably secondary to herpes genitalis. New Engl. J. Med., 297: 920, 1977.
RE: STUDIES OF FEMALE URETHRAL PRESSURE PROFILE. PART I. THE NORMAL URETHRAL PRESSURE PROFILE
P. Plante and J. Susset J. Urol., 123: 64-69, 1980 and RE: STUDIES OF FEMALE URETHRAL PRESSURE PROFILE. PART II. URETHRAL PRESSURE PROFILE IN FEMALE INCONTINENCE
J. Susset and P. Plante J. Urol., 123: 70-74, 1980 HERPES GENITALIS AND NEUROGENIC BLADDER AND BOWEL
To the Editor. We were interested to read these 2 articles and agree with the authors that the urethral profile can be influenced by the degree of patient relaxation. However, the authors were wrong in stating that "Glen and Rowan . . . have not found any significant modifications of the pressure profile according to the degree of bladder filling". We stated that "The normal urethral profile ... may remain unchanged in shape with increased intravesical volume or show an increase in one or both components of the profile .... A profile that deteriorates with increased bladder volume is abnormal and indicates a weakness in the closure mechanism". 1 We also emphasized that intravesical pressure should be recorded during the whole profile measurement, since uninhibited detrusor contractions can cause a deterioration in the profile. In part II the authors state that "The term sphincter incontinence was proposed by the International Continence Society... ". This is
To the Editor. We read with interest the article by Jacobs and associates on herpes infection and paralytic bladder. 1 Recently, we had a similar case, involving additional unique manifestations. A 43-year-old, sexually active man had acute urinary and fecal retention 1 week after he noticed typical herpetic (simplex) vesicles on the penis. Neurological examination revealed a mild, decreased rectal sphincter tone but bulbocavernous reflex was present. Laboratory investigations were unremarkable, including a protein electrophoresis of serum and immunoelectrophoresis of urine proteins. Skull and lumbosacral x-rays, and bone scans were normal. An excretory urogram showed bladder distension. A lumbar myelogram was normal and the spinal fluid showed no cells, protein of 40 mg. per cent, 752
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
Letters to the Editor IDIOPATHIC RETROPERITONEAL FIBROSIS AND HLA-B27
To the Editor. The first case of idiopathic retroperitoneal fibrosis in a patient with the histocompatibility antigen HLA-B27 was reported in 1976. 1 The second and most recent case was reported in 1978. 2 It was suggested in both articles that possession of HLA-B27 might predispose to the development of idiopathic retroperitoneal fibrosis. The patients in both reports were American blacks. I have tested 2 of my patients with idiopathic retroperitoneal fibrosis and have not found HLA-B27 in either case. Both patients are American whites. Only limited conclusions can be drawn from these 4 cases. It is fair to say that HLA-B27 is not a requisite for the occurrence of idiopathic retroperitoneal fibrosis in American white patients. One could speculate that it might be so in American black patients. The prevalence of HLAB27 differs between American blacks and whites, being about 4 per cent for the former and at least twice as much for the latter. 3 A racial difference also appears to exist in the association between HLA-B27 and disease. Thus, among patients with ankylosing spondylitis and Reiter's disease 90 per cent of American white patients have HLA-B27 compared to only 50 per cent of American black patients. 3 On the other hand, to my knowledge, no case of an association between idiopathic retroperitoneal fibrosis and the diseases most closely related to HLAB27 has been reported. These diseases are ankylosing spondylitis, Reiter's disease, Yersinia and salmonella arthritides, and anterior uveitis.4 Also, epidemiologic studies of persons with HLA-B27 have to date failed to reveal idiopathic retroperitoneal fibrosis. However, this fact could be the result of the rarity of idiopathic retroperitoneal fibrosis since, even when the association is strongest, only about 20 per cent of persons with HLA-B27 have ankylosing spondylitis. 4 Furthermore, the prevalence of idiopathic retroperitoneal fibrosis in different races is unknown. Knowledge of the possible role of HLA-B27 in idiopathic retroperitoneal fibrosis awaits further studies but the evidence favoring such a role, especially in American white patients, is slim. Respectfully, Luis Fernandez-Herlihy Lahey Clnic Foundation Boston, Massachusetts 02215 1. Case records of the Massachusetts General Hospital (case 13-1976). New Engl. J. Med., 294: 712, 1976. 2. Willscher, M. K., Novicki, D. E. and Cwazka, W. F.: Association of HLA-B27 antigen with retroperitoneal fibrosis. J. Urol., 120: 631, 1978. 3. Calin, A.: HLA-B27: to type or not to type? Ann. Intern. Med., 92: 208, 1980. 4. McDevitt, H. 0. and Engleman, E. G.: Association between genes in the major histocompatibility complex and disease susceptibility. Arthritis Rheum., suppl., 20: F9, 1977.
glucose of 54 mg. per cent and a negative test for venereal disease. Cystoscopy was negative and a cystometrogram showed a hypotonic neurogenic bladder. The patient eventually did well, managed only with initial permanent bladder catheter drainage and stool softeners. He regained continence completely about a month after the onset of the vesicular eruption. This case is unusual because of the preservation of the bulbocavernous reflex and normal spinal fluid. Neurogenic dysfunction in herpes anogenitalis is believed to be secondary to sacral-meningomyeloradiculitis, 2 with spinal fluid examination showing pleocytosis even late in the course of the illness, 3 and increased protein. In our patient the dysfunction was caused by peripheral parasympathetic neuritis rather than meningomyeloradiculitis. Cases of anal or cervical herpetic inflammations with bladder or bowel neurogenic dysfunction are sometimes difficult to diagnose since multiple sclerosis, a spinal cord tumor or a psychogenic bladder may be considered. 4 It also can occur in patients undergoing immunosuppressive therapy, as reported by Jacobs and associates. Respectfully, Daniel E. Jacome and Gonzalo F. Yanez Palm Springs Medical Plaza Suite 306 1435 West 49th Place Hialeah, Florida 33012 1. Jacobs, S. C., Hebert, L. A., Piering, W. F. and Lawson, R. K.:
Acute motor paralytic bladder in renal transplant patients with anogenital herpes infection. J. Urol., 123: 426, 1980. 2. Oates, J. K. and Greenhouse, P.R.: Retention of urine in anogenital herpetic infection. Lancet, 1: 691, 1978. 3. Jellinek, E. H. and Tulloch, W. S.: Herpes zoster with dysfunction of bladder and anus. Lancet, 2: 1219, 1976. 4. Caplan, L. R., Kleeman, F. J. and Berg, S.: Urinary retention probably secondary to herpes genitalis. New Engl. J. Med., 297: 920, 1977.
RE: STUDIES OF FEMALE URETHRAL PRESSURE PROFILE. PART I. THE NORMAL URETHRAL PRESSURE PROFILE
P. Plante and J. Susset J. Urol., 123: 64-69, 1980 and RE: STUDIES OF FEMALE URETHRAL PRESSURE PROFILE. PART II. URETHRAL PRESSURE PROFILE IN FEMALE INCONTINENCE
J. Susset and P. Plante J. Urol., 123: 70-74, 1980 HERPES GENITALIS AND NEUROGENIC BLADDER AND BOWEL
To the Editor. We were interested to read these 2 articles and agree with the authors that the urethral profile can be influenced by the degree of patient relaxation. However, the authors were wrong in stating that "Glen and Rowan . . . have not found any significant modifications of the pressure profile according to the degree of bladder filling". We stated that "The normal urethral profile ... may remain unchanged in shape with increased intravesical volume or show an increase in one or both components of the profile .... A profile that deteriorates with increased bladder volume is abnormal and indicates a weakness in the closure mechanism". 1 We also emphasized that intravesical pressure should be recorded during the whole profile measurement, since uninhibited detrusor contractions can cause a deterioration in the profile. In part II the authors state that "The term sphincter incontinence was proposed by the International Continence Society... ". This is
To the Editor. We read with interest the article by Jacobs and associates on herpes infection and paralytic bladder. 1 Recently, we had a similar case, involving additional unique manifestations. A 43-year-old, sexually active man had acute urinary and fecal retention 1 week after he noticed typical herpetic (simplex) vesicles on the penis. Neurological examination revealed a mild, decreased rectal sphincter tone but bulbocavernous reflex was present. Laboratory investigations were unremarkable, including a protein electrophoresis of serum and immunoelectrophoresis of urine proteins. Skull and lumbosacral x-rays, and bone scans were normal. An excretory urogram showed bladder distension. A lumbar myelogram was normal and the spinal fluid showed no cells, protein of 40 mg. per cent, 752