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When is a Varicocele Not a Varicocele?
281
LETTERS TO THE EDITOR
Reply by Authors. Since our report was published we have studied the clinical and urodynamic effects of flurbiprofen, a more potent prostaglandin synthetase inhibitor, in a double-blind crossover trial involving 30 women with detrusor instability.' The reductions in frequency, urgency and urge incontinence were statistically significant, as was the reduction in detrusor pressure increase during bladder filling and the increase in volume at which the first sensation of bladder filling occurred during cystometry. However, the increase in bladder capacity was not statistically significant. The side effects were significantly higher with flurbiprofen than with the placebo but they were less severe than the side effects produced by indomethacin. Obviously, prostaglandin synthetase inhibitors require further evaluation in the field.
effective to compensate for this and temperature increases! I would like to suggest that the mechanism of infertility in most varicoceles, failed varicocelectomy patients and about half of the idiopathic group is internal spermatic vein reflux, which manifests itself as 1) poor semen (often with the stress pattern), 2) elevated testis temperature and 3) varicocele as a frequent but not invariable manifestation. What this triad should be called is open to suggestions. Unless some cause for elevated temperature other than reflux or another etiologic mechanism comes to light I believe this explanation resolves the question for a significant segment of that large group of nonvaricocele patients with hitherto unexplained infertility, which can be diagnosed by measuring the intrascrotal temperature.
1. Cardozo, L. D., Stanton, S. L., Robinson, H. and Hole, D.: Evaluation offlurbiprofen in detrusor instability. Brit. Med. J., 280: 281, 1980.
Respectfully, A. W. Zorgniotti Department of Urology Cabrini Medical Center New York, New York 10003 1. Belker, A. M.: The varicocele and male infertility. Urol. Clin. N. Amer., 8: 42, 1981. 2. Zorgniotti, A. W.: Testis temperature, infertility, and the varicocele paradox. Urology, 16: 7, 1980. 3. Zorgniotti, A. W., Sealfon, A. and Toth, A.: Chronic scrotal hypothermia as a treatment for poor semen quality. Lancet, 1: 904, 1980.
BLADDER CARCINOMA Recently, I cared for a 63-year-old white male non-smoker with metastatic transitional cell carcinoma of the bladder. After repeated questioning regarding exposure to chemicals the patient recalled working with chemical inspection materials in a defense plant where he was employed for 2 years in the early 1940s. These inspection materials (Zyglo and Magnaglo) are comprised of iron oxides and a fluorescent material, which are applied to metal machine parts to detect cracks that would be missed by the naked eye. The earliest penetrant, Zyglo, contained emulsifying agents, petroleum distillates and a dyestuff called Fluorol 5GA, which has the chemical structure of a polycyclic hydrocarbon. Such chemicals are still in use today in steel mills and machine shops. The users invariably have skin contact with the agents. The increased incidence of bladder carcinoma among aniline dye workers is well established and may be a model for other environmentally influenced bladder neoplasms. There are no reports of this disease being related to chemical inspection material exposure. Therefore, it would be appropriate for physicians to ask persons with bladder carcinoma specifically whether they have been exposed to such chemicals. If such a history is elicited it would be of great interest to me to receive a brief report from the physician. In addition, it would be appropriate to relay the information to the Environmental Epidemiology Branch, National Cancer Institute, Bethesda, Maryland. Respectfully, Max Haid Division of Medical Oncology Evanston Hospital/Northwestern University Evanston, Illinois 60201 WHEN ·IS A VARICOCELE NOT A VARICOCELE?
To the Editor. Recent developments in our understanding of the role of elevated intrascrotal temperature on semen quality suggest the need for a reclassification of male infertility. Such an etiologic theory would bring together men with varicocele and that large group of men loosely classified as having idiopathic infertility because there is evidence that these share the same pathophysiologic mechanism. Other readily identifiable nonobstructive causes of poor semen would be classified as before. Students of the subject associate reflux within the internal spermatic vein with varicocele. A clinical picture resembling varicocele but without palpable or otherwise identifiable varicocele has been a cause for curiosity and disagreement among urologic surgeons. The concept that patients with varicocele-related poor semen have elevated testis temperature due to altered thermoregulation appears to be gaining adherents.' I have reported that 54 per cent of patients with poor semen but no varicocele have intrascrotal temperatures that are higher than a control group with excellent semen. 2 This elevated temperature corresponds to temperature levels obtained in a varicocele group with poor semen, suggesting that these 54 per cent have disturbed thermoregulation also owing to reflux. Recently, my collaborators and I have demonstrated that reversal of such elevated testis temperature by chronic scrotal hypothermia resulted in improvement in semen and/ or pregnancy in 5 of 6 hard core infertile couples, giving support to the theory of elevated temperature. 3 Elevated temperature appears to result from failure to pre-cool internal spermatic artery blood by countercurrent heat exchange within the pampiniform plexus with returning venous blood. Refluxing blood simply is traveling in the wrong direction to carry out its function. The scrotal convection heat loss mechanism by itself is not sufficiently
RE: COMPARISON OF 4 AND 10 DAYS OF DOXYCYCLINE TREATMENT FOR URINARY TRACT INFECTION
James E. Lockey, David N. Williams, Leopoldo Raij and Leon D. Sabath J. Urol., 124: 643-645, 1980 To the Editor. The authors state that flank pain and fever have been unreliable clinical indicators of renal involvement when the physician is trying to differentiate cystitis from pyelonephritis. A review of the study by Fairley and associates did, in fact, demonstrate conclusively that the presence of fever was a powerful discriminator to differentiate bacterial pyelonephritis from bacterial cystitis (reference 9 in the article). Failure of the patient to marshal! a febrile response was of no discriminatory value. Of 21 patients with confirmed symptomatic acute bacterial pyelonephritis 9 had fever. Of 22 patients with confirmed acute bacterial cystitis 1 had fever. When these numbers are subjected to statistical analysis the p value is <0.01. In essence, the presence of fever has proved to be an invaluable sign to differentiate acute bacterial cystitis from acute bacterial pyelonephritis. Respectfully, Richard A. Gleckman and Debra Hibert Division of Infectious Disease Saint Vincent Hospital Worcester, Massachusetts 01604
Reply by Authors. Doctor Gleckman and Ms. Hibert raise the important question of how to differentiate clinically between kidney and bladder infection. They cite the study by Fairley and associates and state that fever was associated statistically (p <0.01) with renal infection (reference 9 in the article). In that article there were 3 groups: 1) patients with bladder bacteriuria, 2) patients with renal bacteriuria and 3) patients with no or <10,000 organisms per ml. In their data a temperature (no indication of the degree of temperature elevation is given) was recorded in 4, 44 and 35 per cent of those groups, respectively. However, rigors (again no further information is given) was present in 15, 32 and 15 per cent of the groups, respectively. One would assume that patients with rigors had more dramatic temperature changes. In our study and in the study by Fang and associates (reference 4 in the article) patients with oral temperatures >lOOF were excluded and yet 23 to 30 per cent had a renal focus of infection as determined by the antibody-coated bacteria technique. These and other data would argue against the importance of fever alone as the discriminator of kidney versus bladder bacteriuria. Note by Editor. Doctor Gleckman and Ms. Debra Hibert were given an opportunity to review this material before it was published. They responded as follows: "It also is apparent to us that 2 problems still exist. 1) The authors of the article assume that the antibody-coated bacteria test is infallible and accurately differentiates between renal bacteriuria and bladder
LETTERS TO THE EDITOR
Reply by Authors. Since our report was published we have studied the clinical and urodynamic effects of flurbiprofen, a more potent prostaglandin synthetase inhibitor, in a double-blind crossover trial involving 30 women with detrusor instability.' The reductions in frequency, urgency and urge incontinence were statistically significant, as was the reduction in detrusor pressure increase during bladder filling and the increase in volume at which the first sensation of bladder filling occurred during cystometry. However, the increase in bladder capacity was not statistically significant. The side effects were significantly higher with flurbiprofen than with the placebo but they were less severe than the side effects produced by indomethacin. Obviously, prostaglandin synthetase inhibitors require further evaluation in the field.
effective to compensate for this and temperature increases! I would like to suggest that the mechanism of infertility in most varicoceles, failed varicocelectomy patients and about half of the idiopathic group is internal spermatic vein reflux, which manifests itself as 1) poor semen (often with the stress pattern), 2) elevated testis temperature and 3) varicocele as a frequent but not invariable manifestation. What this triad should be called is open to suggestions. Unless some cause for elevated temperature other than reflux or another etiologic mechanism comes to light I believe this explanation resolves the question for a significant segment of that large group of nonvaricocele patients with hitherto unexplained infertility, which can be diagnosed by measuring the intrascrotal temperature.
1. Cardozo, L. D., Stanton, S. L., Robinson, H. and Hole, D.: Evaluation offlurbiprofen in detrusor instability. Brit. Med. J., 280: 281, 1980.
Respectfully, A. W. Zorgniotti Department of Urology Cabrini Medical Center New York, New York 10003 1. Belker, A. M.: The varicocele and male infertility. Urol. Clin. N. Amer., 8: 42, 1981. 2. Zorgniotti, A. W.: Testis temperature, infertility, and the varicocele paradox. Urology, 16: 7, 1980. 3. Zorgniotti, A. W., Sealfon, A. and Toth, A.: Chronic scrotal hypothermia as a treatment for poor semen quality. Lancet, 1: 904, 1980.
BLADDER CARCINOMA Recently, I cared for a 63-year-old white male non-smoker with metastatic transitional cell carcinoma of the bladder. After repeated questioning regarding exposure to chemicals the patient recalled working with chemical inspection materials in a defense plant where he was employed for 2 years in the early 1940s. These inspection materials (Zyglo and Magnaglo) are comprised of iron oxides and a fluorescent material, which are applied to metal machine parts to detect cracks that would be missed by the naked eye. The earliest penetrant, Zyglo, contained emulsifying agents, petroleum distillates and a dyestuff called Fluorol 5GA, which has the chemical structure of a polycyclic hydrocarbon. Such chemicals are still in use today in steel mills and machine shops. The users invariably have skin contact with the agents. The increased incidence of bladder carcinoma among aniline dye workers is well established and may be a model for other environmentally influenced bladder neoplasms. There are no reports of this disease being related to chemical inspection material exposure. Therefore, it would be appropriate for physicians to ask persons with bladder carcinoma specifically whether they have been exposed to such chemicals. If such a history is elicited it would be of great interest to me to receive a brief report from the physician. In addition, it would be appropriate to relay the information to the Environmental Epidemiology Branch, National Cancer Institute, Bethesda, Maryland. Respectfully, Max Haid Division of Medical Oncology Evanston Hospital/Northwestern University Evanston, Illinois 60201 WHEN ·IS A VARICOCELE NOT A VARICOCELE?
To the Editor. Recent developments in our understanding of the role of elevated intrascrotal temperature on semen quality suggest the need for a reclassification of male infertility. Such an etiologic theory would bring together men with varicocele and that large group of men loosely classified as having idiopathic infertility because there is evidence that these share the same pathophysiologic mechanism. Other readily identifiable nonobstructive causes of poor semen would be classified as before. Students of the subject associate reflux within the internal spermatic vein with varicocele. A clinical picture resembling varicocele but without palpable or otherwise identifiable varicocele has been a cause for curiosity and disagreement among urologic surgeons. The concept that patients with varicocele-related poor semen have elevated testis temperature due to altered thermoregulation appears to be gaining adherents.' I have reported that 54 per cent of patients with poor semen but no varicocele have intrascrotal temperatures that are higher than a control group with excellent semen. 2 This elevated temperature corresponds to temperature levels obtained in a varicocele group with poor semen, suggesting that these 54 per cent have disturbed thermoregulation also owing to reflux. Recently, my collaborators and I have demonstrated that reversal of such elevated testis temperature by chronic scrotal hypothermia resulted in improvement in semen and/ or pregnancy in 5 of 6 hard core infertile couples, giving support to the theory of elevated temperature. 3 Elevated temperature appears to result from failure to pre-cool internal spermatic artery blood by countercurrent heat exchange within the pampiniform plexus with returning venous blood. Refluxing blood simply is traveling in the wrong direction to carry out its function. The scrotal convection heat loss mechanism by itself is not sufficiently
RE: COMPARISON OF 4 AND 10 DAYS OF DOXYCYCLINE TREATMENT FOR URINARY TRACT INFECTION
James E. Lockey, David N. Williams, Leopoldo Raij and Leon D. Sabath J. Urol., 124: 643-645, 1980 To the Editor. The authors state that flank pain and fever have been unreliable clinical indicators of renal involvement when the physician is trying to differentiate cystitis from pyelonephritis. A review of the study by Fairley and associates did, in fact, demonstrate conclusively that the presence of fever was a powerful discriminator to differentiate bacterial pyelonephritis from bacterial cystitis (reference 9 in the article). Failure of the patient to marshal! a febrile response was of no discriminatory value. Of 21 patients with confirmed symptomatic acute bacterial pyelonephritis 9 had fever. Of 22 patients with confirmed acute bacterial cystitis 1 had fever. When these numbers are subjected to statistical analysis the p value is <0.01. In essence, the presence of fever has proved to be an invaluable sign to differentiate acute bacterial cystitis from acute bacterial pyelonephritis. Respectfully, Richard A. Gleckman and Debra Hibert Division of Infectious Disease Saint Vincent Hospital Worcester, Massachusetts 01604
Reply by Authors. Doctor Gleckman and Ms. Hibert raise the important question of how to differentiate clinically between kidney and bladder infection. They cite the study by Fairley and associates and state that fever was associated statistically (p <0.01) with renal infection (reference 9 in the article). In that article there were 3 groups: 1) patients with bladder bacteriuria, 2) patients with renal bacteriuria and 3) patients with no or <10,000 organisms per ml. In their data a temperature (no indication of the degree of temperature elevation is given) was recorded in 4, 44 and 35 per cent of those groups, respectively. However, rigors (again no further information is given) was present in 15, 32 and 15 per cent of the groups, respectively. One would assume that patients with rigors had more dramatic temperature changes. In our study and in the study by Fang and associates (reference 4 in the article) patients with oral temperatures >lOOF were excluded and yet 23 to 30 per cent had a renal focus of infection as determined by the antibody-coated bacteria technique. These and other data would argue against the importance of fever alone as the discriminator of kidney versus bladder bacteriuria. Note by Editor. Doctor Gleckman and Ms. Debra Hibert were given an opportunity to review this material before it was published. They responded as follows: "It also is apparent to us that 2 problems still exist. 1) The authors of the article assume that the antibody-coated bacteria test is infallible and accurately differentiates between renal bacteriuria and bladder