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Urethral syndrome
LETTERS
URETHRAL
TO THE EDITOR
SYNDROME
I enjoyed the May 1986 Letter to the Editor: UROTECH supplement very much. The next time you run an issue of otherwise unpublishable material, I hope you will consider asking me to write about my approach to urethral syndrome. The bane of existence for almost all urologists, urethral syndrome, in my hands, is an eminently treatable disease. Greatly abbreviated, my approach is: (1) to determine, mainly by history, but also by examination, urinalysis with or without culture, and rarely x-ray films, that nothing else is likely to be causing the problem; (2) to make sure that women do not void less often than every four to five hours; (3) to reassure the patient that this is an extremely common problem; (4) to suggest exacerbating factors, some of which will surprise many urologists (cunnilingus, tampons, just before or after the menstrual period, vaginitis, especially low-grade monilial infections, new sexual partners resulting in changed “mutual anatomy,” coffee/tea/alcohol after bladder infections, and diaphragms or spermicides); (5) to define the distinction between UTIs (generally with severe burning throughout urination and possibly hematuria) and urethral syndrome (no burning or only at the end and no blood, with suprapubic pressure and urgency the major symptoms); (6) to explain about pelvic muscle contraction from stress or attempted compensation for bladder symptoms, often in a vicious cycle; and (7) to put them in control, usually with chlordiazepoxide hydrochloride-clidinium bromide (Librax) twice daily until symptoms subside in a week or two, and then as needed. In elderly women with atrophic vulvovaginitis, I generally use a combination of conjugated extrogens (Premarin) cream and oxybutynin chloride (Ditropan) one-half to 1 tablet two to three times daily. Most women want an explanation for the problem so that the discussion alone defuses their anxiety. I perform cystoscopy to rule out interstitial cystitis and bladder tumors in the small number of patients who fail to respond. I reserve urethral dilations for women who have had a good response in the past or those who cannot accommodate a 17-F cystoscope; even then I usually stop at 24-26E Phenazopyridine (Pyridium), while helpful for burning, rarely helps urgency and suprapubic pressure. I generally instruct patients to telephone two to three weeks after the first visit; most often it is the only visit needed until they get a bladder infection a year or two later.
UROLOGY
/
SEPTEMBER
1986
/
VOLUME XXVIII,
In this upper middle-class community with active, intelligent women who have nothing to gain from debilitating bladder problems, my approach to urethral syndrome has very quickly established my reputation as a urologist. I wish I had an equally effective approach to prostatitis. While I have no numbers of squiggles to prove my case, I think most urologists would be interested in a simple, effective, although initially time-consuming approach to this otherwise tedious problem. Muriel R. Friedman, Hilltop Professional 1855 San Miguel Walnut Creek. California
RETROPERITONEAL
M.D. Bldg. Drive 95496
GERMINOMA
To the Editor: We can all appreciate the thoughtful contribution of Brian Saltzman, W. Reid Pitts, and E. Darracott Vaughan, Jr., in “Extragonadal Retroperitoneal Germ Cell Tumors Without Apparent Testicular Involvement: A Search for the Source,” published in the June issue (vol. 27, pages 504--507, 1986) of UROLOGY. Their plea for thorough testicular evaluation in patients with extragonadal retroperitoneal germinal cell tumors is totally appropriate. In 1975, we wrote that “it is impossible to classify a patient with a retroperitoneal mass of germinal epithelium without completely assessing the testicles. We believe there is sufficient evidence to support the view that a patient with a retroperitoneal germinoma may have a microscopic testicular tumor with metastases.” We further stated that patients with primary mediastinal tumors and a negative retroperitoneum probably represented true primary extragonadal germinal neoplasms. * It should be noted that the 3 patients reported by Saltzman, Pitts, and Vaughan had primary retroperitoneal disease, strongly suggesting testicular origin. There still remain those few rare patients with primary germinal cell tumors in the chest, probably due to primitive rests of totipotential cells. James P Glenn, M.D. The Mount Sinai School of Medicine New York, New York 10029 ‘Wacksman J, Case G, and Glenn JF: Extragenital gonadal neoplasia and metastatic testicular tumors, Urology 5: 221 (1975).
NUMBER 3
259
URETHRAL
TO THE EDITOR
SYNDROME
I enjoyed the May 1986 Letter to the Editor: UROTECH supplement very much. The next time you run an issue of otherwise unpublishable material, I hope you will consider asking me to write about my approach to urethral syndrome. The bane of existence for almost all urologists, urethral syndrome, in my hands, is an eminently treatable disease. Greatly abbreviated, my approach is: (1) to determine, mainly by history, but also by examination, urinalysis with or without culture, and rarely x-ray films, that nothing else is likely to be causing the problem; (2) to make sure that women do not void less often than every four to five hours; (3) to reassure the patient that this is an extremely common problem; (4) to suggest exacerbating factors, some of which will surprise many urologists (cunnilingus, tampons, just before or after the menstrual period, vaginitis, especially low-grade monilial infections, new sexual partners resulting in changed “mutual anatomy,” coffee/tea/alcohol after bladder infections, and diaphragms or spermicides); (5) to define the distinction between UTIs (generally with severe burning throughout urination and possibly hematuria) and urethral syndrome (no burning or only at the end and no blood, with suprapubic pressure and urgency the major symptoms); (6) to explain about pelvic muscle contraction from stress or attempted compensation for bladder symptoms, often in a vicious cycle; and (7) to put them in control, usually with chlordiazepoxide hydrochloride-clidinium bromide (Librax) twice daily until symptoms subside in a week or two, and then as needed. In elderly women with atrophic vulvovaginitis, I generally use a combination of conjugated extrogens (Premarin) cream and oxybutynin chloride (Ditropan) one-half to 1 tablet two to three times daily. Most women want an explanation for the problem so that the discussion alone defuses their anxiety. I perform cystoscopy to rule out interstitial cystitis and bladder tumors in the small number of patients who fail to respond. I reserve urethral dilations for women who have had a good response in the past or those who cannot accommodate a 17-F cystoscope; even then I usually stop at 24-26E Phenazopyridine (Pyridium), while helpful for burning, rarely helps urgency and suprapubic pressure. I generally instruct patients to telephone two to three weeks after the first visit; most often it is the only visit needed until they get a bladder infection a year or two later.
UROLOGY
/
SEPTEMBER
1986
/
VOLUME XXVIII,
In this upper middle-class community with active, intelligent women who have nothing to gain from debilitating bladder problems, my approach to urethral syndrome has very quickly established my reputation as a urologist. I wish I had an equally effective approach to prostatitis. While I have no numbers of squiggles to prove my case, I think most urologists would be interested in a simple, effective, although initially time-consuming approach to this otherwise tedious problem. Muriel R. Friedman, Hilltop Professional 1855 San Miguel Walnut Creek. California
RETROPERITONEAL
M.D. Bldg. Drive 95496
GERMINOMA
To the Editor: We can all appreciate the thoughtful contribution of Brian Saltzman, W. Reid Pitts, and E. Darracott Vaughan, Jr., in “Extragonadal Retroperitoneal Germ Cell Tumors Without Apparent Testicular Involvement: A Search for the Source,” published in the June issue (vol. 27, pages 504--507, 1986) of UROLOGY. Their plea for thorough testicular evaluation in patients with extragonadal retroperitoneal germinal cell tumors is totally appropriate. In 1975, we wrote that “it is impossible to classify a patient with a retroperitoneal mass of germinal epithelium without completely assessing the testicles. We believe there is sufficient evidence to support the view that a patient with a retroperitoneal germinoma may have a microscopic testicular tumor with metastases.” We further stated that patients with primary mediastinal tumors and a negative retroperitoneum probably represented true primary extragonadal germinal neoplasms. * It should be noted that the 3 patients reported by Saltzman, Pitts, and Vaughan had primary retroperitoneal disease, strongly suggesting testicular origin. There still remain those few rare patients with primary germinal cell tumors in the chest, probably due to primitive rests of totipotential cells. James P Glenn, M.D. The Mount Sinai School of Medicine New York, New York 10029 ‘Wacksman J, Case G, and Glenn JF: Extragenital gonadal neoplasia and metastatic testicular tumors, Urology 5: 221 (1975).
NUMBER 3
259