Of 103 patients who presented to a rural clinic in Africa with corneal ulceration, 62 (60.2%) had corneal ulcers which on clinical diagnosis were attributable to herpes simplex virus. There was a strong association between herpetic ulceration and a history of recent malaria; 37 of 62 (59.7%) herpetic ulcers occurred in the 3 month period from April to June which corresponds to the end of the peak season for malaria compared with 14 of 41 (34%) of the non-herpetic ulcers. Fifty per cent of herpetic ulcers had a geographic morphology, 27.4% were dendritic, and 22.6% presumed herpetic ulcers were stromal: 38.7% of herpetic ulcers occurred in children under 5 years of age. Bilateral herpetic ulcers occurred in 16.1% of patients but were more common in children under 2 years of age. Geographic and stromal ulcers tended to heal more slowly than dendritic ulcers (mean time to healing 12.6, 12.2, and 6.6 days respectively), and were more likely to result in severe corneal scarring (45%, 29%, and 0% respectively). Herpes simplex keratitis is a major cause of corneal scarring in Africa. It is often seen in children, may be bilateral, commonly is geographic in morphology, and has a strong association with malaria infection. Because it is not easily preventable, more effort must be made to ensure early diagnosis and prompt, effective treatment in order to prevent severe scarring and visual loss.
Solid urethral and peri-urethral lesions are rare and encompass benign and malignant aetiologies. A diagnosis without imaging is often challenging secondary to non-specific clinical symptoms and overlapping findings at the time of physical examination. Magnetic resonance (MR) imaging may be helpful in confirming a diagnosis while providing anatomical detail and delineating disease extent. This article reviews the normal MR anatomy of the male and female urethra, the MR appearance of solid primary and secondary urethral lesions, and the MR appearance of solid urethral lesion mimics.
• MRI is an important imaging technique in the evaluation of the spectrum of solid urethral lesions.
• With excellent soft tissue resolution, MR is accurate in staging primary urethral carcinoma.
• Disruption of the zonal anatomy of the female urethral wall indicates peri-urethral extension.
• Be aware of benign urethral lesions, particularly those that may mimic solid urethral masses.
Urethra; Carcinoma; Magnetic resonance; Solid lesions
Bovine herpetic mammillitis in Quebec
Bovine herpetic mammillitis is reported for the first time in Canada. It is a vesicular and ulcerative skin disease affecting the udder and teats of cows. It is caused by the bovine herpesvirus 2. The principal lesions consist of crusts that are found on the teats and may become complicated by secundary bacterial infection.Specimens collected from the lesions were used to differentiate the condition from pseudo-cowpox by serological tests, virus isolation and electron microscopy. Bovine herpetic mammillitis causes painful and therefore difficult milking which is followed by mastitis and an increased rate of culling.
Bovine; mammillitis; teat; bovine herpesvirus 2
In 126 patients with anogenital lesions, in which herpes simplex virus (HSV) infection was suspected or included in the differential diagnosis, the results of cytodiagnosis of herpetic infection (Tzanck smear) were compared with virus culture. Cervical lesions were excluded from this study. HSV infection was proved by culture in 78 patients and was absent or non-active in 41 patients. Excluded from this study were seven patients who did not yield the virus on culture but had positive Tzanck smear results from three investigators. The characteristic cytopathic effect of herpetic infection was found in 78 patients who yielded HSV on culture. Tzanck smear sensitivity for skin lesions was 79% and for mucous membrane lesions was 81% in men and 52% in women. Tzanck smear specificity for the 41 patients without herpetic infection proved by virus culture was 93%. Differences in sensitivity and specificity between the results found by three investigators (double blind screening) were not significant. The Tzanck smear is reliable, inexpensive, and easy and quick to perform; it is suitable for office diagnosis because it does not require a specialised laboratory.
The effect of a new antiherpetic compound of very low toxicity called acycloguanosine (Wellcome 248U) on herpetic ulcers in rabbit cornea was studied by the Corneal Epithelial Lesion Therapeutic Assay (CELTA). The therapeutic effect of 3% acycloguanosine ointment on dendritic ulcers was equal to that of 0.5% 5-iodo-2'-deoxyuridine (IDU) ointment. No toxic symptoms could be detected by slit-lamp on 4 days' treatment with this concentration of acycloguanosine. Because of its selective action on virus only, its extremely low toxicity in animals, and its availability for systemic administration, acycloguanosine seems to be an ideal antiviral compound for use in the treatment not only of herpetic keratitis but also of other herpetic diseases in man.
The concentrations of immunoglobulin A (IgA) and immunoglobulin G (IgG) were estimated in cervical mucus from 115 patients attending a clinic for sexually transmitted diseases. The patients were divided into two groups; those using combined estrogen/progestogen oral contraceptives, and those with presumed normal ovulatory cycles. Gonorrhea, trichomoniasis, candidosis, and herpes genitalis were diagnosed by conventional smear and culture techniques, and the two groups were subdivided according to these diagnoses. Gonorrhea, trichomoniasis, herpetic, and nonspecific cervicitis all caused marked increases in the mean concentrations when compared with a control group of uninfected patients with natural cycles (P = less than 0.01). Patients with candidosis and contacts of men with nonspecific urethritis showed a lesser rise. IgG/IgA ratios lower than that of serum suggested a considerable locally produced contribution of IgA. Oral contraception with the combined pill also caused a significant increase in mean IgA and IgG levels even in the absence of local infection (P = less than 0.01). an increase in the IgG/IgA ratio of this group may indicate that the hormonal effect was manifest through increased serum transudation. IgM was also detected more commonly in patients taking the pill. The marked effect of local disease on immunoglobulin levels in cervical mucus which occurs even in asymptomatic patients emphasizes the importance of screening for infection when studying these secretions.
To compare the structure and function of the urethral sphincter and the urethral support in nulliparous black and white women.
Eighteen black women (mean age 28.1 years) and 17 white women (mean age 31.3 years) completed this cross-sectional study. The following assessments were made: urethral function using multichannel cystometrics and urethral pressure profilometry, pelvic muscle strength using an instrumented speculum, urethral mobility using the cotton-swab test and perineal ultrasound, and pelvic muscle bulk using magnetic resonance imaging.
Black women demonstrated a 29% higher average urethral closure pressure during a maximum pelvic muscle contraction (154 cm H2O versus 119 cm H2O in the white subjects; P = .008). Although not statistically significant, black women had a 14% higher maximum urethral closure .23) and pressure at rest (108 cm H2O versus 95 cm H2O; P = a 21% larger urethral volume (4818 mm3 versus 3977 mm3; P = .06). In addition, there was a 36% greater vesical neck mobility measured with the cotton-swab test (blacks 49° versus whites 36°; P = .02) and a 42% difference in ultrasonically measured vesical neck mobility during a maximum Valsalva effort (blacks = −17 mm versus whites −12 mm; P = .08).
Functional and morphologic differences exist in the urethral sphincteric and support system of nulliparous black and white women.
A 31-year-old man was referred for further management of a urethral stricture. He was a victim of a traffic accident and his urethral injury was associated with a pelvic bone fracture. He had previously undergone a suprapubic cystostomy only owing to his unstable general condition at another hospital. After 3 months of urethral injury, direct urethral anastomosis was attempted, but the surgery failed. An additional 4 failed internal urethrotomies were performed before the patient visited Chungbuk National University Hospital. Preoperative images revealed complete posterior urethral disruption, and the defect length was 4 cm. We performed a buccal mucosa tubal graft without anastomosis of the proximal urethra for a long segment posterior urethral defect. The Foley catheter was removed 3 weeks after the operation and the patient was able to void successfully. After 8 months, he had normal voiding function without urinary incontinence.
Mouth mucosa; Transplants; Urethral stricture
A case is described of herpetic hepatitis in a pregnant woman with primary herpetic stomatitis. Intranuclear inclusion bodies and virus particles were found in hepatocytes, and herpes virus was isolated from a liver biopsy and from oral swabs but not from blood. From rising titres of neutralizing and complement-fixing antibody it is concluded that the oral infection was a primary one. Factors predisposing to the hepatitis are discussed.
Diseases of man caused by the virus of herpes simplex fall into two broad categories. The primary disease occurs only once in any individual's life and is caused by transmission of virus from an already infected human. Thereafter, the individual may be subject to recurrent herpetic disease, the manifestations of which are different from the primary disease. Recurrent disease varies in severity from trivial, to incapacitating and frankly lethal (as in diseases resulting from the virus's neurotropic and oncogenic properties). The source of the virus in recurrent herpetic disease has never been conclusively resolved, but is almost certainly endogenous to the patient. Theories, case reports and experiments exist to show that endogenous virus may, in periods of clinical quiescence, be latent (or persistent) at the site of the recurrent lesions itself, or more remotely in nerve tissues related to the site of recurrence.
At present, corneal transplantation is the only definitive means of controlling or terminating recurrent or chronic herpetic keratitis. Of 48 keratoplastic operations for various forms of corneal herpes, 16 in quiescent cases and 32 in cases of active keratitis, all but three brought about improvement.
Recurrence of keratitis in the graft is particularly likely if the visible lesion is not excised completely and a portion of the graft border lies in contact with diseased tissue.
The mode of action of corneal transplantation in improving herpetic keratitis is not clear but several possibilities have been suggested. At least in chronic stromal herpes the removal of diseased and necrotic tissue appears to be a very important factor.
The rabbit provides an excellent model for the study of ocular herpes because herpetic keratitis in the rabbit eye resembles human disease in its clinical features and in its propensity for spontaneous recurrence. This paper presents a method for the electrical induction of multiple episodes of in vivo reactivation of latent HSV-1 infection with peripheral shedding of virus. Physiological levels of current delivered via an electrode implanted over the trigeminal ganglion of latently infected animals has enabled us to modify and synchronize virus shedding in preocular tear film and to cause multiple episodes of reactivation in a single animal. For this reason, the model is well suited for antiviral efficacy testing and provides an excellent opportunity for investigation of virus-host cell interactions in latent and recurring herpetic disease.
The symptoms and diagnosis of the three most common female bladder-urethral dysfunctions (infection, stress incontinence, and irritable bladder syndrome) are examined so that the practitioner may better differentiate between these problems and some of their counterparts. Cystitis cystica, urethritis, and radiation cystitis are among the less common infections and are frequently missed. Other conditions can be mistaken for infections: urethral diverticulum, Hunner's ulcer, atrophic vaginitis, urethral stenosis. Stress urinary incontinence, arising from abnormal bladder-urethral unit physiology or from obesity, can benefit from Kegel's exercise to strengthen the external sphincter and pubococcygeus muscles. For irritable bladder syndrome, which is often misdiagnosed, a bladder drill with increasing voiding intervals is useful. Patient understanding of bladder function and the need for retraining is also important.
Urethral stricture description is not standardized. This makes surgical decision-making less reproducible and increases the difficulty of objectively analyzing urethroplasty literature. We developed a standardized system, the UREThRAL stricture score (USS), to quantify the characteristics of anterior urethral stricture disease based on preoperative imaging and intraoperative findings.
To develop the USS, we retrospectively analyzed 95 consecutive patients with urethral strictures who underwent open urethroplasty by a single surgeon (SBB) at Barnes-Jewish Hospital from 2009 to 2011. The USS is a numerical score based on five components of anterior urethral stricture disease that help dictate operative decision-making: (1) (UR)ethral stricture (E)tiology; (2) (T) otal number of strictures; (3) (R)etention (luminal obliteration); (4) (A)natomic location; and (5) (L)ength. Stricture management was categorized by increasing surgical complexity: excision/primary anastomosis (EPA), buccal mucosal graft urethroplasty (BMG), augmented anastomotic urethroplasty (AAU), flap urethroplasty, and a combination of flaps and/or grafts. Multinomial logistic regression analysis was used to compare USS to surgical complexity.
The mean USS for EPA, BMG, AAU, flap, and combination flaps/grafts was 5.78, 8.82, 9.23, 11.01, and 14.97, respectively. Increasing USS was significantly associated with surgical complexity (p < 0.0001).
The USS describes the essential factors in determining surgical treatment selection for urethral stricture disease. The USS is a concise, easily applicable system that delineates the clinically significant features of urethral strictures. Valuable comparison of anterior urethral stricture treatments in clinical practice and in the urological literature could be facilitated by using this novel UREThRAL stricture score.
OBJECTIVE--To assess the presence of human papillomavirus (HPV) DNA in urethral and urine specimens from men with and without sexually transmitted diseases. DESIGN--Prospective study. SETTING--Two London departments of genitourinary medicine PATIENTS--100 men with urethral gonorrhoea, 31 men with penile warts and 37 men with genital dermatoses. METHODS--Urethral and urine specimens were taken, HPV DNA extracted and then amplified using the polymerase chain reaction. HPV types 6, 11, 16, 18, 31 and 33 were identified using Southern blotting followed by hybridisation. RESULTS--HPV DNA was detected in 18-31% of urethral swab specimens and in 0-14% of urine specimens. Men with penile warts had HPV detected in urethral swabs more often than did men in the other two clinical groups. "High risk" HPV types were found in 71-83% of swab specimens and in 73-80% of urine specimens containing HPV DNA. CONCLUSIONS--HPV is present in the urogenital tracts of men with gonorrhoea, penile warts and with genital dermatoses. In men with urethral gonorrhoea, detection of HPV in urethral specimens is not related to the number of sexual partners, condom usage, racial origin or past history of genital warts. HPV DNA in the urethral swab and urine specimens may represent different aspects of the epidemiology of HPV in the male genital tract. The preponderance of HPV types 16 and 18 in all three groups of men may be relevant to the concept of the "high risk male".
Urethral obstruction may be caused by prostatic hypertrophy, urethral stricture, or encrustation of a urethral-catheter lumen. Bacteriuria often complicates these obstructions. The sequelae include fever, acute pyelonephritis, chronic renal inflammation, and death. We hypothesized that even brief obstruction of the urinary tract containing a nonvirulent bacterium would result in these complications. Mice challenged transurethrally with Escherichia coli FN414, which is rapidly eliminated from normal mice without causing bacteriuria, bacteremia, or renal pathology, were subjected to reversible urethral obstruction by coating the urethral meatus with collodion for 1, 3, or 6 h. The majority of mice obstructed for 1 h demonstrated parenchymal renal inflammation 48 h later. At the end of 3 h of obstruction, 9 of 10 mice were bacteremic; some bacteremias were present at 48 h after removal of the obstruction. At that time, more severe renal inflammation was seen in these mice. As little as 6 h of obstruction resulted not only in the acute changes described above but also in chronic renal inflammation and fibrosis in the majority of animals sacrificed 3 and 6 weeks later. Additional studies demonstrated that urethral obstruction enhanced the uropathogenicity of another nonpathogenic E. coli strain (K-12 strain HB101) and caused more severe renal lesions in mice challenged with E. coli CFT073, isolated from a patient with symptoms of pyelonephritis. These findings demonstrate that brief urethral obstruction may (i) induce organisms which are cleared rapidly from the normal urinary tract to cause bacteriuria, bacteremia, and pyelonephritis and (ii) intensify the renal lesions caused by a uropathogen.
OBJECTIVE: To determine the number of Neisseria gonorrhoeae organisms in urine and semen in men with gonococcal urethritis, and to compare selected phenotypic characteristics of organisms harvested from the urethra and semen. DESIGN: Samples from two groups of subjects were examined. Patients with symptomatic urethritis receiving treatment at an STD clinic, as well as six subjects with experimental urethritis. Semen and urine specimens were obtained after the urethral exudate was sampled. RESULTS: Using quantitative cultures, we found an average of 6 x 10(6) gonococci in urine or semen of 17 men with symptomatic urethritis seeking treatment at an STD clinic, and 2 x 10(4) gonococci in secretions of six male subjects with early experimental infection. Gonococcal outer membrane opacity (Opa) proteins and lipo-oligosaccharide (LOS) recovered from urine and semen of these subjects were very similar. CONCLUSIONS: Men with symptomatic gonorrhoea excrete a large number of gonococci in semen which is not affected by the duration of symptoms. The similar phenotype of organisms in urine and semen suggests the bacteria come from the same compartment. These data help to explain the efficiency of gonococcal transmission from men to their partners, and identify an appropriate target for a preventative vaccine or immunotherapy designed to reduce the inoculum in infected patients.
Using magnetic resonance images we analyzed the relationship between urethral sphincter anatomy, urethral function and pelvic floor function.
Materials and Methods
A total of 103 women with stress incontinence and 108 asymptomatic continent controls underwent urethral profilometry, urethral axis measurement with a cotton swab, vaginal closure force measurement with an instrumented speculum and magnetic resonance imaging. Striated urogenital sphincter length was determined and its thickness was measured in the proximal sphincter, where its circular shape enables estimation of striated urogenital sphincter area. A length-area index was calculated as a proxy for volume.
The striated urogenital sphincter in women with stress incontinence was 12.5% smaller than that in asymptomatic continent women (mean ± SD length-area index 766.4 ± 294.3 vs 876.2 ± 407.3 mm3, p = 0.04). The groups did not differ significantly in striated urogenital sphincter length (13.2 ± 3.4 vs 13.7 ±3.9 mm, p = 0.40), thickness (2.83 ± 0.8 vs 3.11± 1.4 mm, p = 0.09) or area (59.1 ± 18.4 vs 62.9 ± 24.7 mm2, p = 0.24). Striated urogenital sphincter length and area, and the length-area index were associated during voluntary pelvic muscle contraction with more urethral axis elevation and increased vaginal closure force augmentation.
A smaller striated urogenital sphincter is associated with stress incontinence and poorer pelvic floor muscle function.
urethra; urinary incontinence, stress; magnetic resonance imaging; female; muscle, striated
Pelvic fracture urethral distraction defect (PFUDD) may be associated with disabling complications, such as recurrent stricture, urinary incontinence, and erectile dysfunction. In this article we review the current concepts in the evaluation and surgical management of PFUDD, including redo urethroplasty.
Materials and Methods:
A PubMed™ search was performed using the keywords “pelvic fracture urethral distraction defect, anastomotic urethroplasty, pelvic fracture urethral stricture, pelvic fracture urethral injuries, and redo-urethroplasty.” The search was limited to papers published from 1980 to March 2010 with special focus on those published in the last 15 years. The relevant articles were reviewed with regard to etiology, role of imaging, and the techniques of urethroplasty.
Pelvic fracture due to accidents was the most common etiology of PFUDD that usually involved the membranous urethra. Modern cross-sectional imaging, such as sonourethrography and magnetic resonance imaging help assess stricture pathology better, but their precise role in PFUDD management remains undefined. Surgical treatment with perineal anastomotic urethroplasty yields a success rate of more than 90% in most studies. The most important complication of surgical reconstruction is restenosis, occurring in less than 10% cases, most of which can be corrected by a redo anastomotic urethroplasty. The most common complication associated with this condition is erectile dysfunction. Urinary incontinence is a much rarer complication of this surgery in the present day.
Anastomotic urethroplasty remains the cornerstone in the management of PFUDD, even in previously failed repairs. Newer innovations are needed to address the problem of erectile dysfunction associated with this condition.
Anastomotic urethroplasty; posterior urethral stricture; redo-urethroplasty; urethral injury
We investigate the
ability of physical exam to diagnose urethral
diverticula with or without magnetic resonance
imaging (MRI) and exclusive of invasive
modalities. A retrospective chart review of all
women undergoing urethral diverticulectomy at
our institution since 1999 was performed. We
identified 28 female patients with a mean age at
diagnosis of 42.6 years (range 18–66).
Common presenting symptoms included dyspareunia,
urgency, and frequency. Physical exam revealed a
suspected urethral diverticulum in 26
(92.9%) patients, which was confirmed
postoperatively in 17 of the 20 (85%) women
who underwent surgical resection. Noninvasive
imaging modalities (MRI or CT) were available
for review in 20 (71%) cases and made the
correct diagnosis of urethral diverticulum
(presence or absence) in 19 (95%) patients.
In those patients with symptoms of stress or
urge incontinence (11, 39%), voiding
cystourethrogram (VCUG) was performed. Urethral
diverticula are often easily diagnosed on physical
exam. MRI can be a useful adjunct for defining
diverticular extent in surgical planning,
especially for proximal and complex diverticula,
and should be the modality of choice if clinical
suspicion is high based on patient symptoms
and physical exam.
Herpetic keratitis is caused by herpes simplex virus (HSV) and is a common cause of corneal blindness. Following a primary ocular herpetic infection, latency of the virus occurs, followed by subsequent recurrences of herpetic keratitis. Such recurrences may lead to structural damage of the cornea. Recurrent herpetic keratitis is a common indication for corneal transplantation. Recurrences of herpetic keratitis in the corneal graft may lead to corneal graft rejection. Several antiviral agents for HSV are available, including the thymidine analogs. Prolonged use of thymidine analogs may lead to toxicity of the ocular surface, including epithelial keratitis, corneal ulcers, follicular conjunctivitis, and punctal occlusions. Availability of topical antiviral agents that are safe and effective in the treatment and prophylaxis of herpetic keratitis is highly desirable. Ganciclovir is a potent inhibitor of members of the herpes virus family. The drug has been used systemically for the treatment of cytomegalovirus (CMV) retinitis. Its hematologic toxicity secondary to systemic administration led to its limited use in herpetic infections. On the other hand, topical ganciclovir has been shown to be as safe and effective as acyclovir in the treatment of herpetic epithelial keratitis. Furthermore, topical ganciclovir can reach therapeutic levels in the cornea and aqueous humor following topical application. Several clinical trials have shown that topical ganciclovir 0.15% ophthalmic gel is safe and effective in the treatment and prophylaxis of herpetic epithelial disease. Long-term use of ganciclovir ophthalmic gel in patients with penetrating keratoplasty following herpetic keratitis has prevented recurrences of the disease. Topical ganciclovir ophthalmic gel is well tolerated, does not cause toxic effects on the ocular surface, and does not cause hematologic abnormalities. Clinical studies have underscored the potential role of ganciclovir ophthalmic gel in the treatment and prophylaxis of herpetic epithelial keratitis. Future randomized, controlled, multicenter, prospective clinical trials are needed to assess the long-term safety and efficacy of topical ganciclovir in the treatment and prevention of herpetic keratitis and uveitis.
herpetic keratitis; cornea; herpes simplex; ganciclovir; acyclovir
Eleven patients who suffered persistent bladder dysfunction after pelvic surgery have been investigated by needle urethral sphincter electromyography (EMG) and bladder muscle biopsy, and the results compared with those obtained in a series of controls. Individual motor units recorded from the urethral sphincter in patients who had undergone pelvic surgery were strikingly abnormal, suggesting the presence of reinnervation, and the density of detrusor innervation was significantly reduced. However, since reduction in the density of detrusor innervation may occur in circumstances other than peripheral nerve injury, we conclude that urethral sphincter EMG provides the most effective means of assessing damage to vesico-urethral innervation as a result of previous pelvic surgery.
Sera from 19 patients with Chlamydia trachomatis culture positive non-gonococcal urethritis were studied for the presence of antibodies to chlamydial proteins by immunoblotting. Ten C trachomatis negative patients with non-gonococcal urethritis and 10 healthy controls were also studied. Acute phase sera from C trachomatis positive patients with non-gonococcal urethritis reacted only with the major outer membrane protein whereas all the convalescent phase serum samples reacted with the major outer membrane protein and with a 60,000 and a 62,000 molecular weight protein. Some sera also reacted with a 45,000 molecular weight protein. Five of 10 convalescent phase samples from patients with C trachomatis negative non-gonococcal urethritis showed a reaction pattern comparable with that observed in convalescent sera from C trachomatis from C trachomatis positive patients with non-gonococcal urethritis. Sera from healthy seronegative subjects were negative by blotting.
Most of the recent investigations of the lower urinary tract have been concentrated on the ureterovesical junction. Studies of 120 children examined by the method of voiding cinecystography and urethrography revealed that vesicoureteral reflux occurred in 22 cases without evidence of a lesion of the urethra, and in six children secondary to lesions of the urethra. Thirteen of the children studied had isolated lesions of the urethra. Urethral lesions encountered in this series of children included stenosis of the external meatus (14 cases), urethral valve (one case), urethral polyp (one case) and urethral stricture (two cases). The main advantages of cinefluorography and television control in this field lie in the fact that all phases of the voiding act can be observed and, when necessary, recorded on a movie film. Motion picture films provide visual evidence of the value of the method.
A 25 year old man developed mild urethritis and urethral colonisation with Streptococcus pneumoniae five days after a single orogenital sexual contact. The diagnosis was suspected because of the appearance of Gram positive diplococci in the urethral exudate. The incidence of urethral infection with S pneumoniae is not known. Pneumococci are unlikely to grow on the routine selective media used to identify Neisseria gonorrhoeae.