LETTERS TO THE EDITOR
DOPPLER
ULTRASONIC
EXAMINATION
To the Editor: We would like to underscore the note of caution voiced by A. J. Perri, et al. in the September issue (vol. 8, page 265) of UROLOGY .in regard to use of the Doppler ultrasonic flowmeter in the preoperative diagnostic evaluation of acute painful intrascrotal conditions. While evaluating this modality in our teaching hospitals, we explored all painful scrotal conditions in patients under thirty years of age who did not have obvious manifestations of genital or urinary infection. We therefore were able to correlate the accuracy of the Doppler diagnosis with the findings at surgery. Over a three-year period we personally have been involved with 4 cases of surgically remediable disease in which the Doppler findings showed a normal or increased flow on the affected side. One case was that of a thirteen-year-old boy whose testis had been torsed for well over fortyeight hours and probably represents a similar phenomenon to the case reported by Perri et al. The second case was a torsion of a large pedunculated appendix epididymis in a twenty-one-year-old. The remaining 2 cases (both in their late twenties) had identical histories of acute onset of pain at rest and physical findings consistent with acute torsion of the spermatic cord. Both patients demonstrated an increased Doppler signal over the testis and on surgical exploration were found to have hemorrhage into small testicular tumors: teratocarcinoma in 1 case and embryonal cell carcinoma in the other. It is particularly these two latter cases which I would like to bring to the attention of the readers; if exploration were delayed in these individuals on the basis of the Doppler findings alone, control of these malignant lesions may have been compromised. Mark D. Kiviat, M.D. Julian D. Ansell, M.D. University of Washington Seattle, Washington 98195
RECONSTRUCTION EXSTROPHY
OF BLADDER
Letter to the Editor: In the article, “Complete Reconstruction of Bladder Exstrophy: Experimental
UROLOGY
/ DECEMBER
1976 / VOLUME
VIII,
Program,” by Sanu Arap, M.D., Amilcar Martins Giron, M.D., and Gilbert0 Menezes de Goes, M.D., in the April issue (vol. 7, page 413) of UROLOGY, the authors suggested that following closure of bladder exstrophy, it should be possible to improve urinary control by assisting the reconstructed sphincters with electronic stimulation of the pelvic floor by means of intra-anal plug electrodes. The investigation of this possibility has been one of the objectives of a clinical study we had organized at the Squier Clinic to evaluate the effects of electronic stimulation of the pelvic floor in the management of persistent forms of urinary incontinence. In a preliminary report of this study published in UROLOGY in September, 1975 (vol. 6, page 312) with the title “Urinary Incontinence: Management with Electronic Stimulation of Muscles of Pelvic Floor,” we had mentioned that early results in the management of patients with incontinence after bladder exstrophy closure were very encouraging and that improvement had been noted. While a report of our observations and the results of our trial are now being prepared for publication, we would like to inform your readers that electronic stimulation can indeed improve urinary control after bladder exstrophy closure. In our series 27.2 per cent of patients postexstrophy closure have achieved continence. A. Sotiropoulos, M.D. Columbia University College of Physicians & Surgeons New York, New York 10032
SEX-HORMONE-BINDING GLOBULIN IN HUMAN PROSTATIC TISSUE PREPARATIONS To the Editor: In their article, “Inhibition by Estramustine Phosphate on Estradiol and AndrogenBinding in Benign and Malignant Prostate in Humans” (UROLOGY, vol. 8, page 118), I. Nilsson, Ph.D., L. Liskowski, Ph.D., and T. Nilsson, M.D., have failed to take into account the presence of sexhormone-binding globulin (SHBG) in human prostatic tissue preparations. The presence of this protein, which binds dihydrotestosterone with very high aifinity, has been well documented. l-3 Binding to these two components (androgen receptor and
NUMBER 6
643
SHBG) cannot be distinguished by the dextrancoated charcoal method, unless it is used with an androgen, or androgen competitor, which can differentiate between them.4*5 The concentration of SHBG present is increased in patients treated with estrogens. Other factors to be considered are the metabolism of dihydrotestosterone to .%-androstene&, 17/3diol during incubation6 and the instability of the androgen keceptor at the temperature used (20°C.). Such problems do not arise in the estrogen receptor assay; SHBG apparently does not bind estradiol with sufficiently high afBnity to interfere (at least in the breast carcinoma assay), estradiol is not metabolized, and the estrogen receptor is more stable. However, in a study such as this, it is advisable to include control “nontarget” tissues to check the validity of the method. B. G. Mobbs, Ph.D. Department of Surgery University of Toronto Toronto, Ontario M5S lA8 References WESTPHAL, U. : Steroid-Protein Interactions, Berlin, Springer-Verlag, 1971, p. 365. ROSEN, V., JUNG, I., BAULIEU, E-E., and ROBEL, P.: Androgen-binding proteins in human benign prostatic hypertrophy, J. Clin. Endocrinol. Metab. 41: 761 (1975). WAGNER, R. K., SCHULZE, K. H., and JUNGBLUT, Estrogen and androgen receptor in human P. w.: prostatic and prostatic tumor tissue, Acta Endocr. 78 (Suppl. 193): 52 (1975). MOBBS, B. G., JOHNSON,I. E., and CONNOLLY, J. G.: In vitro assay of androgen binding by human prostate, J. Steroid. Biochem. 6: 453 (1975).
644
Methyltrienolone, a 5. BONNE, C., and RAYNAUD,J-P.: specific ligand for cellular androgen receptors, Steroids 26: 227 (1975). 6. VERHOEVEN, G., HEYNS, W., and DEMOOR, P.: Ammonium sulphate precipitation as a tool for the study of androgen receptor proteins in rat prostate and mouse kidney, Steroids 26: I49 (1975).
BACTERIAL PROSTATITIS BY LOCAL ANTIBIOTICS
TREATED
To the Editor: In the May issue (vol. 7, page 499) of UROLOGY, E. J. McGuire, M.D., and B. Lytton, M.D., discussed bacterial prostatitis and its treatment with trimethoprim-sulfamethoxazole for three months. In 60 per cent of the patients a recurrence of chronic bacterial prostatitis developed during a follow-up period of from one to two and one-half years after. Please allow me to draw your attention to our* excellent results obtained by local therapy: one injection of 4 gr. cefazoline and three of 80 mg. gentamitin or amikacin, under rectal control, into the peripheral prostate by perineal way cured 90 per cent of patients during a follow-up period of from one to three years. Luc Baert, M.D. Doomikse Wijk, 84 8566 Kortrijk (Belgium)
*Baert, L., Soep, H., and Pyck, J.: Chronic bacterial prostatitis, a new therapeutic approach: local antibiotics, Ann. Ural. 10:99 (1976).
UROLOGY /
DECEMBER 1976 /
VOLUME VIII, NUMBER 6
DOPPLER
ULTRASONIC
EXAMINATION
To the Editor: We would like to underscore the note of caution voiced by A. J. Perri, et al. in the September issue (vol. 8, page 265) of UROLOGY .in regard to use of the Doppler ultrasonic flowmeter in the preoperative diagnostic evaluation of acute painful intrascrotal conditions. While evaluating this modality in our teaching hospitals, we explored all painful scrotal conditions in patients under thirty years of age who did not have obvious manifestations of genital or urinary infection. We therefore were able to correlate the accuracy of the Doppler diagnosis with the findings at surgery. Over a three-year period we personally have been involved with 4 cases of surgically remediable disease in which the Doppler findings showed a normal or increased flow on the affected side. One case was that of a thirteen-year-old boy whose testis had been torsed for well over fortyeight hours and probably represents a similar phenomenon to the case reported by Perri et al. The second case was a torsion of a large pedunculated appendix epididymis in a twenty-one-year-old. The remaining 2 cases (both in their late twenties) had identical histories of acute onset of pain at rest and physical findings consistent with acute torsion of the spermatic cord. Both patients demonstrated an increased Doppler signal over the testis and on surgical exploration were found to have hemorrhage into small testicular tumors: teratocarcinoma in 1 case and embryonal cell carcinoma in the other. It is particularly these two latter cases which I would like to bring to the attention of the readers; if exploration were delayed in these individuals on the basis of the Doppler findings alone, control of these malignant lesions may have been compromised. Mark D. Kiviat, M.D. Julian D. Ansell, M.D. University of Washington Seattle, Washington 98195
RECONSTRUCTION EXSTROPHY
OF BLADDER
Letter to the Editor: In the article, “Complete Reconstruction of Bladder Exstrophy: Experimental
UROLOGY
/ DECEMBER
1976 / VOLUME
VIII,
Program,” by Sanu Arap, M.D., Amilcar Martins Giron, M.D., and Gilbert0 Menezes de Goes, M.D., in the April issue (vol. 7, page 413) of UROLOGY, the authors suggested that following closure of bladder exstrophy, it should be possible to improve urinary control by assisting the reconstructed sphincters with electronic stimulation of the pelvic floor by means of intra-anal plug electrodes. The investigation of this possibility has been one of the objectives of a clinical study we had organized at the Squier Clinic to evaluate the effects of electronic stimulation of the pelvic floor in the management of persistent forms of urinary incontinence. In a preliminary report of this study published in UROLOGY in September, 1975 (vol. 6, page 312) with the title “Urinary Incontinence: Management with Electronic Stimulation of Muscles of Pelvic Floor,” we had mentioned that early results in the management of patients with incontinence after bladder exstrophy closure were very encouraging and that improvement had been noted. While a report of our observations and the results of our trial are now being prepared for publication, we would like to inform your readers that electronic stimulation can indeed improve urinary control after bladder exstrophy closure. In our series 27.2 per cent of patients postexstrophy closure have achieved continence. A. Sotiropoulos, M.D. Columbia University College of Physicians & Surgeons New York, New York 10032
SEX-HORMONE-BINDING GLOBULIN IN HUMAN PROSTATIC TISSUE PREPARATIONS To the Editor: In their article, “Inhibition by Estramustine Phosphate on Estradiol and AndrogenBinding in Benign and Malignant Prostate in Humans” (UROLOGY, vol. 8, page 118), I. Nilsson, Ph.D., L. Liskowski, Ph.D., and T. Nilsson, M.D., have failed to take into account the presence of sexhormone-binding globulin (SHBG) in human prostatic tissue preparations. The presence of this protein, which binds dihydrotestosterone with very high aifinity, has been well documented. l-3 Binding to these two components (androgen receptor and
NUMBER 6
643
SHBG) cannot be distinguished by the dextrancoated charcoal method, unless it is used with an androgen, or androgen competitor, which can differentiate between them.4*5 The concentration of SHBG present is increased in patients treated with estrogens. Other factors to be considered are the metabolism of dihydrotestosterone to .%-androstene&, 17/3diol during incubation6 and the instability of the androgen keceptor at the temperature used (20°C.). Such problems do not arise in the estrogen receptor assay; SHBG apparently does not bind estradiol with sufficiently high afBnity to interfere (at least in the breast carcinoma assay), estradiol is not metabolized, and the estrogen receptor is more stable. However, in a study such as this, it is advisable to include control “nontarget” tissues to check the validity of the method. B. G. Mobbs, Ph.D. Department of Surgery University of Toronto Toronto, Ontario M5S lA8 References WESTPHAL, U. : Steroid-Protein Interactions, Berlin, Springer-Verlag, 1971, p. 365. ROSEN, V., JUNG, I., BAULIEU, E-E., and ROBEL, P.: Androgen-binding proteins in human benign prostatic hypertrophy, J. Clin. Endocrinol. Metab. 41: 761 (1975). WAGNER, R. K., SCHULZE, K. H., and JUNGBLUT, Estrogen and androgen receptor in human P. w.: prostatic and prostatic tumor tissue, Acta Endocr. 78 (Suppl. 193): 52 (1975). MOBBS, B. G., JOHNSON,I. E., and CONNOLLY, J. G.: In vitro assay of androgen binding by human prostate, J. Steroid. Biochem. 6: 453 (1975).
644
Methyltrienolone, a 5. BONNE, C., and RAYNAUD,J-P.: specific ligand for cellular androgen receptors, Steroids 26: 227 (1975). 6. VERHOEVEN, G., HEYNS, W., and DEMOOR, P.: Ammonium sulphate precipitation as a tool for the study of androgen receptor proteins in rat prostate and mouse kidney, Steroids 26: I49 (1975).
BACTERIAL PROSTATITIS BY LOCAL ANTIBIOTICS
TREATED
To the Editor: In the May issue (vol. 7, page 499) of UROLOGY, E. J. McGuire, M.D., and B. Lytton, M.D., discussed bacterial prostatitis and its treatment with trimethoprim-sulfamethoxazole for three months. In 60 per cent of the patients a recurrence of chronic bacterial prostatitis developed during a follow-up period of from one to two and one-half years after. Please allow me to draw your attention to our* excellent results obtained by local therapy: one injection of 4 gr. cefazoline and three of 80 mg. gentamitin or amikacin, under rectal control, into the peripheral prostate by perineal way cured 90 per cent of patients during a follow-up period of from one to three years. Luc Baert, M.D. Doomikse Wijk, 84 8566 Kortrijk (Belgium)
*Baert, L., Soep, H., and Pyck, J.: Chronic bacterial prostatitis, a new therapeutic approach: local antibiotics, Ann. Ural. 10:99 (1976).
UROLOGY /
DECEMBER 1976 /
VOLUME VIII, NUMBER 6
