A Simple Operation for Postcoital Urethrotrigonitis in Women

Urinary tract infection is commoner in patients with spinal cord injuries because of incomplete bladder emptying and the use of catheters that can result in the introduction of bacteria into the bladder. 145 patients suffering from spinal cord injuries, admitted to the Institute for physical medicine and rehabilitation, Centre for paraplegia of the Clinical Centre of the University of Sarajevo, were included. The patients were divided in three groups according to the method of bladder drainage: Group A (n=61) consisted of patients on clean intermittent catheterization; Group B (n=54) consisted of patients with indwelling catheters; Group C (n=30) consisted of patients who had performed self-catheterization. From a total of 4539 urine samples, 3963 (87,3%) were positive and 576 (12,7%) were sterile. More than 90% of the infected patients were asymptomatic. The overall rate of urinary infection amounted to about 2,1 episodes, and bacteriuria to 8,1 episodes per patient. 77% of infections (113/145) were acquired within seven days from catheterization. Infection was usually polymicrobial; the greatest number of urine samples 1770/3943 (44,9%) included more than one bacterium. The vast majority of cases of urinary tract infection and bacteriuria are caused by Gram-negative bacilli and enterococci, commensal organisms of the bowel and perineum, representative of those from the hospital environment. Providencia stuarti (18,9%) being the most common, followed by Proteus mirabilis (16,3%), Escherichia coli (11,8%), Pseudomonas aeruginosa (10,2%), Klebsiella pneumoniae (8,1%), Morganella morgani (5,4%), Acinetobacter baumannii (4,6%), Providencia rettgeri (3,5%). 15,7% of isolates were Gram-positive with Enterococcus faecalis (8,6%) as the most common. 55,3% of isolates were multidrug-resistant, and the highest rates of resistance were found among Acinetobacter baumannii (87,8%), Providencia rettgeri (86,7%), Pseudomonas aeruginosa (85,4%), Providencia stuarti (84,3%) and Morganella morgani (81,0%). Lower rates of resistance were found in Group C, i.e. patients on intermittent self-catheterisation. Eradication of organisms was achieved in only 53 (10,05%) of patients; hence, antibiotic therapy had no or very low effect. Significant correlations were found between the method of catheterization and the frequency of bacteriuria and urinary tract infections. The analysis of Group C showed a rate of lower urinary tract infection and bacteriuria than the other two Groups of patients. The objective of this study is the update of etiology and antimicrobial susceptibility in urinary tract infections in this group of patients. In addition, possible correlations between UTI and the type of bladder management were examined.

Japanese guideline for clinical research of antimicrobial agents on urogenital infections: Second edition.

Introduction: Meatal stenosis is a recognized complication of circumcision done during nappy aged boys as a late presentation. The objective of this study was to describe the incidence of documented meatal stenosis in boys circumcised in infantile period. Method: Meatal stenosis was defined as change in appearance of the delicate lips of the urinary meatus, with loss of ellipticated shape to a circular shape because of scar and visually apparent narrowing. The study included 356 consecutive samples of boys aged 6 months to 6 years (mean 2.5 y.o), circumcised in first 2 months of life, who visited in my private office referred for reasons urinary or non urinary complaints. Results: The diagnosis was made in 32 of 365. Four of 32 stenotic cases were asymptomatic, common symptoms in other 28 boys were decreased urine caliber (11), crying before or during voiding (8), dysuria (5), penile deviation (3), bloody spotting (3). None cases had urinary tract infection, urinary tract sonography was within normal limit in all cases. Conclusion: Meatal stenosis is a complication of circumcision done during nappy aged boys as a late presentation. A careful meatal examination is indicated in any boys with history of circumcision during nappy age. We recommend to use lubricant or anti inflammatory ointments for prevention of meatal fibrosis and stenosis.

Recurrent urinary tract infection With persistent wolfhan duct masquerading as duplicated urethra

Ureteropelvic Junction Obstruction is a disease of newborns although it is manifested in later years of life in many cases. Various modalities for management of UPJ Obstruction are available today ranging from time tested open dismembered pyeloplasty to Robot assisted laparoscopic pyeloplasty. Various minimally invasive procedures in forms of endopyelotomy (both ante-grade and retro-grade), laparoscopic pyeloplasty, and robot assisted laparoscopic pyeloplasty are available for the urologist to choose from. In less advanced centers with little or no minimally invasive procedures availability, both in terms of lack of equipment and skilled surgeon open pyeloplasty remains the gold standard in management of ureteropelvic junction obstruction. Ever since its introduction by Anderson & Hynes dismembered pyeloplasty is preferred worldwide due to its universal application and excellent success rates. Non dismembered techniques of pyeloplasty are considered useful only is specific conditions. Increased vascularity of the anastomotic segment due to incomplete resection is very helpful for better outcome. This study aims to compare the outcome of dismembered pyeloplasty with non dismembered pyeloplasty (when not contraindicated). If the results obtained are comparable then it could be assumed that when not contraindicated non dismembered pyeloplasty can be considered in place of dismembered pyeloplasty to utilize the advantage of having better blood supply at the site of anastomosis. Obstruction of the urinary tract can occur during fetal development, childhood, or adulthood. The point of obstruction can be as proximal as the calyces and as distal as the urethral meatus. The cause of obstruction may be congenital or acquired and benign or malignant. The impact of the obstruction is influenced by the extent or degree of obstruction (partial or complete, unilateral or bilateral), its chronicity (acute or chronic), the baseline condition of the kidneys, the potential for recovery, and the presence of other mitigating factors such as urinary infection. These may ultimately lead to permanent renal damage, which may result in limiting the excretion of metabolic wastes and altering water and electrolyte balance.

Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment. A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach. Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores. Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.

BackgroundCongenital adrenal hyperplasia (CAH) is an autosomal recessive disorder that leads to the disruption of adrenal steroidogenesis. 21-hydroxylase deficiency is the most common form and is caused by the mutations in the 21-hydroxylase (CYP21A2) gene. Deficiency in the 21-hydroxylase enzyme can affect aldosterone and cortisol production and shift the pathway to increased androgen production. It is classified as classical and nonclassical depending on the severity of enzyme deficiency. The classical form can present as a life-threatening salt-wasting or a milder form of simple virilizing CAH. Female patients with classical 21-hydroxylase deficiency present with ambiguous genitalia secondary to increased androgen production. We present a case of salt-wasting classical CAH in a female patient with no signs of virilization that was diagnosed based on newborn screening.Case presentationA four-day-old full-term female was referred to our hospital for elevated 17 hydroxyprogesterone (17-OHP) on a newborn screen. She was born via normal vaginal delivery with an uncomplicated prenatal and postnatal course. Her newborn screen was drawn at day 1 of life resulted in 17-OHP of 128.20 nmol/L (normal cutoff of 85 nmol/L). Otherwise, she was active, feeding well with no other concerns. On admission, her vital signs were within normal, with an unremarkable physical examination. Specifically, the genitourinary exam demonstrated normal female external genitalia with no evidence of virilization, no clitoromegaly with a clitoris length of 12 mm and width 1-2 mm, no hyperpigmentation, and with normal-appearing vaginal orifice and urethral meatus. Confirmatory 17-OHP by mass spectrometry was sent along with the metabolic panel, and her initial electrolytes were within normal. Since there was a low suspicion for salt-wasting CAH given her normal labs and unremarkable physical exam, medication was not started, and the patient was admitted for monitoring. The potassium level trended up abnormally to 6.3 mmol/L, which prompted the initiation of empiric treatment with a physiologic dose of Hydrocortisone and Florinef on day of life 7, pending confirmatory 17-OHP level. Confirmatory17-OHP was 1242 ng/dL (normal <78) and following stimulation with Cosyntropin a markedly elevated 17-OHP 27,929.31 ng/dL (normal expected 7-106) and low cortisol level 2 mcg/dL, for which definitive treatment with hydrocortisone and Florinef were initiated. Subsequent genetic testing confirmed the diagnosis of 21-hydroxylase deficiency with mutations in the CYP21A2 gene for I172N, R356W, and c. *13G>A. Further genetic workup to explain the complete lack of virilization, including assessment of an androgen insensitivity panel and whole-exome sequencing, was unremarkable.ConclusionThis case illustrates the critical importance of heel-stick newborn screening for CAH to prevent a life-threatening salt-wasting crisis as female patients with classical CAH can present with a phenotypic complete lack of virilization that could be misleading and fatal if not recognized.Presentation: No date and time listed

Lower urinary tract infections (UTIs) are one of the most common clinical bacterial infections in women, accounting for almost 25% of all infections. UTIs are more common in women than in men, in a ratio of 8:1. Approximately 50-60% of women report at least one episode of a UTI in their lifetime, and by the age of 24, one in three will have symptoms of a UTI requiring antibiotic treatment. The most common inflammatory disease of the bladder in women is cystitis. During their lifetime, 20-25% of women suffer from acute cystitis, every third of them has a relapse of the disease within a year, and in 10% it becomes a chronic relapsing form. A form of recurrent cystitis is postcoital cystitis – cystitis that develops within 1-2 days after intercourse in women with a high opening of the external urethral orifice and its hypermobility, as well as in the presence of urethrohymenal adhesions.

A 12-year-old Somalian girl presented with chronic kidney disease and died as a result of female genital mutilation- A case report

Phalloplasty in Infants with Congenital Absence of the Penis

BackgroundThis case series describes the technical considerations and effectiveness of ‘endovascular embolic hemispherectomy’ for the treatment of medically intractable seizures in neonates and young infants with hemimegalencephaly (HME) and in...

An unusual presentation of pedunculated thrombus in the distal arch of the aorta after splenectomy for B-cell lymphoma

Management of Disastrous Complications of Penile Implant Surgery

Single incision open reduction and double plate fixation of complex tibial plateau fractures has been associated with high wound complication rates. Minimally invasive methods have been recommended to decrease the wound complication rates as compared with open techniques. Additionally, laterally applied fixed-angle devices appear to minimize late varus deformity without the need for additional medial stabilization. Accurate reduction of comminuted lateral and/or medial articular surfaces, however, often requires visualization through an open reduction. This study reports the complications, infection rate, and radiographic assessment of reduction associated with double plating complex AO/OTA 41-C3 tibial plateau fractures utilizing 2 incisions. Retrospective clinical review. Urban level 1 university trauma center. Over a 77-month period, 83 patients were treated for a complex bicondylar tibial plateau fracture at our institution utilizing a 2-incision technique. Dual plating using anterolateral and posteromedial incisions. Type and incidence of septic and non-septic complications and radiographic assessment of articular reduction and axial alignment. Eleven fractures were open (13.3%) and classified according to Gustilo as type II (1 patient), type III-A (7 patients), type III-B (2 patients), and type III-C (1 patient). Compartment syndrome was diagnosed and treated with fasciotomies in 12 patients (14.5%). The average time interval from injury to definitive surgical treatment was 9 days. Seven patients developed deep wound infections (8.4%). Three of these had an associated septic arthritis (3.6%). Clinical resolution of infection occurred after an average of 3.3 additional procedures. The presence of a dysvascular limb requiring vascular reconstruction was statistically associated with a deep wound infection (P = 0.006). Secondary procedures for complications included 13 patients who required removal of implants secondary to local discomfort, 5 patients who required a knee manipulation, 2 patients that were managed with excision of heterotopic ossification to improve knee motion, 1 patient that required an equinus contracture release, and 1 patient treated for a metadiaphyseal nonunion. Sixteen patients (19.3%) incurred deep venous thromboses. No patient was diagnosed with pulmonary embolism. Sixty-two percent of patients demonstrated satisfactory articular reductions, 91% demonstrated satisfactory coronal alignment, 72% demonstrated satisfactory sagittal alignment, and 98% demonstrated satisfactory condylar width. Comminuted bicondylar tibial plateau fractures can be successfully treated with open reduction and medial and lateral plate fixation using 2 incisions. Dysvascular limbs requiring vascular repair are at increased risk for deep sepsis. The use of 2 incisions, temporary spanning external fixation, and proper soft-tissue handling may contribute to a lower wound complication rate than previously reported.

An abdomino-perineal-vaginal pull-through for definitive treatment of hydrometrocolpos