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Urinary candidiasis
LETTERS TO THE EDITOR
BLADDER
DIVERTICULA
To the Editor: The etiologic factors involved in the formation of bladder diverticula are important if one is to adequately treat those diverticula already present and also cope with possible formation of new diverticula. I was, therefore, hopeful that the article, “Bladder Diverticula in Infants and Children,” by Stewart B. Bauer, M.D., and Alan B. Retick, M.D., in the June issue (vol. 3, page 712) of UROLOGY, might differentiate between the problem of diverticula in children and in adults. I believe the authors have missed an opportunity to make such differentiation by not presenting the pathologic examination of the bladder diverticula; this may be because the surgical technique only involved removing the urothelial linings of the diverticulum. It has been my experience that bladder diverticulum in children usually contains muscle layers, and, therefore, presents as a true diverticulum; the acquired diverticula usually are of a “pseudo-diverticulum” type and involve only urothelium and a serosal covering. When one attempts to discuss the etiologic implications, I think it is most important to consider the pathologic differences. When one considers the early age, the relationship to the trigone, the lack of outlet obstruction, and the presence of muscle in the wall, the case for embryologic anomaly becomes greater in bladder diverticula in children and infants.
Alan H. Walther, M.D. 3737 Moraga Avenue San Diego, California 92116
URINARY
CANDIDIASIS
I enjoyed and commend Dr. Gilbert To the Editw: Wise and his associates for their interesting article, “Flucytosine in Urinary Candida Infections” in the June issue (vol. 3, page 768) of UROLOGY. I have had a special interest in managing urinary candidiasis for a number of years in conjunction with Dr. James Geyer, at the University of Oklahoma Health Sciences Center. Our regimen, after the diagnosis of candidiasis is made, consists of: 1. Removing all the factors conducive to growth of the Candida, namely, catheters, antibiotics, and others.
494
2. Alkalinization of urine to pH 8 by giving 8 to 12 Gm. of sodium bicarbonate orally in divided doses. The pH of urine is checked several times a day by Nitrazine paper. In vitro studies show optimum growth for Candida albicans to be pH 7.4. l Inhibition of growth was noted at pH range beyond 4.8 and 8.5. Since systemic acidification is less tolerated than alkalinization, we resort to the latter. Paine2 has shown that there was a significant decrease in growth of Candida in the pH range above 7.5. 3. In vesical candidiasis, irrigation of the bladder with sodium bicarbonate solution is undertaken. By alkalinizing the urine, we have been successful in managing urinary candid&is, and this has helped us avoid the use of amphotericin B. Although flucytosine (Ancoban) has recently been marketed for treatment of candid&is and is non-nephrotoxic, pancytopenia is a major complication.3 Caution is urged in its clinical use. 4 Johnny B. Roy, M.D. Department of Urology Kaiser Foundation Hospital Honolulu, Hawaii 96815 References TAOLA, P., SCHROEDOR, S. A., DALY, A. K., and FINLAND, M: Candida at Boston City Hospital, Arch.
Intern.
Med. 126: 983 (1970). The inhibitory actions of bacteria on Candida growth, Antibiot. Chemother. 8: 273 (1958). PAINE, T. F., JR.:
TASSEL, D., and MADOFF, M. A.: Treatment of Candida sepsis and Cryptococcus meningitis with 5fluorocytosine: a new antifungal agent, J.A.M.A. 206: 830 (1968). MEYER, R., and AXELROD, J. L.: Fatal aplastic anemia resulting kom flucytosine, ibid. 228: 1573 (1974).
CANDICIDIN FOR BENIGN PROSTATIC HYPERTROPHY To the Editor: I read with interest the article on “Efficacy of Candicidin in Benign Prostatic Hypertrophy,” by Lazarus A. Orkin, M.D., in the July issue (vol. 4, page 80) of UROLOGY. I had the opportunity to clinically evaluate this drug on a total of 21 patients during 1971 and 1972. Unfortunately, my observations do not parallel Dr. Orkin’s. In the group of patients I tested, using a protocol similar to that outlined by Dr. Orkin, objective improvement was less evident. Eight of the
UROLOGY
/
OCTOBER 1974
I VOLUME IV. NUMBER 4
BLADDER
DIVERTICULA
To the Editor: The etiologic factors involved in the formation of bladder diverticula are important if one is to adequately treat those diverticula already present and also cope with possible formation of new diverticula. I was, therefore, hopeful that the article, “Bladder Diverticula in Infants and Children,” by Stewart B. Bauer, M.D., and Alan B. Retick, M.D., in the June issue (vol. 3, page 712) of UROLOGY, might differentiate between the problem of diverticula in children and in adults. I believe the authors have missed an opportunity to make such differentiation by not presenting the pathologic examination of the bladder diverticula; this may be because the surgical technique only involved removing the urothelial linings of the diverticulum. It has been my experience that bladder diverticulum in children usually contains muscle layers, and, therefore, presents as a true diverticulum; the acquired diverticula usually are of a “pseudo-diverticulum” type and involve only urothelium and a serosal covering. When one attempts to discuss the etiologic implications, I think it is most important to consider the pathologic differences. When one considers the early age, the relationship to the trigone, the lack of outlet obstruction, and the presence of muscle in the wall, the case for embryologic anomaly becomes greater in bladder diverticula in children and infants.
Alan H. Walther, M.D. 3737 Moraga Avenue San Diego, California 92116
URINARY
CANDIDIASIS
I enjoyed and commend Dr. Gilbert To the Editw: Wise and his associates for their interesting article, “Flucytosine in Urinary Candida Infections” in the June issue (vol. 3, page 768) of UROLOGY. I have had a special interest in managing urinary candidiasis for a number of years in conjunction with Dr. James Geyer, at the University of Oklahoma Health Sciences Center. Our regimen, after the diagnosis of candidiasis is made, consists of: 1. Removing all the factors conducive to growth of the Candida, namely, catheters, antibiotics, and others.
494
2. Alkalinization of urine to pH 8 by giving 8 to 12 Gm. of sodium bicarbonate orally in divided doses. The pH of urine is checked several times a day by Nitrazine paper. In vitro studies show optimum growth for Candida albicans to be pH 7.4. l Inhibition of growth was noted at pH range beyond 4.8 and 8.5. Since systemic acidification is less tolerated than alkalinization, we resort to the latter. Paine2 has shown that there was a significant decrease in growth of Candida in the pH range above 7.5. 3. In vesical candidiasis, irrigation of the bladder with sodium bicarbonate solution is undertaken. By alkalinizing the urine, we have been successful in managing urinary candid&is, and this has helped us avoid the use of amphotericin B. Although flucytosine (Ancoban) has recently been marketed for treatment of candid&is and is non-nephrotoxic, pancytopenia is a major complication.3 Caution is urged in its clinical use. 4 Johnny B. Roy, M.D. Department of Urology Kaiser Foundation Hospital Honolulu, Hawaii 96815 References TAOLA, P., SCHROEDOR, S. A., DALY, A. K., and FINLAND, M: Candida at Boston City Hospital, Arch.
Intern.
Med. 126: 983 (1970). The inhibitory actions of bacteria on Candida growth, Antibiot. Chemother. 8: 273 (1958). PAINE, T. F., JR.:
TASSEL, D., and MADOFF, M. A.: Treatment of Candida sepsis and Cryptococcus meningitis with 5fluorocytosine: a new antifungal agent, J.A.M.A. 206: 830 (1968). MEYER, R., and AXELROD, J. L.: Fatal aplastic anemia resulting kom flucytosine, ibid. 228: 1573 (1974).
CANDICIDIN FOR BENIGN PROSTATIC HYPERTROPHY To the Editor: I read with interest the article on “Efficacy of Candicidin in Benign Prostatic Hypertrophy,” by Lazarus A. Orkin, M.D., in the July issue (vol. 4, page 80) of UROLOGY. I had the opportunity to clinically evaluate this drug on a total of 21 patients during 1971 and 1972. Unfortunately, my observations do not parallel Dr. Orkin’s. In the group of patients I tested, using a protocol similar to that outlined by Dr. Orkin, objective improvement was less evident. Eight of the
UROLOGY
/
OCTOBER 1974
I VOLUME IV. NUMBER 4