Urologists
24 years of experience

Accepting new patients
Fox Chase - Burholme
Temple Urology Associates Jeanes Physician Office Building
7500 Central Ave
Ste 107
Philadelphia, PA 19111
215-707-3375
Locations and availability (3)

Education ?

Medical School Score Rankings
Pennsylvania State University (1986)
  • Currently 3 of 4 apples
Top 50%

Awards & Distinctions ?

Awards  
Castle Connolly's Top Doctors™ (2012 - 2013)
Patients' Choice Award (2011 - 2012)
Compassionate Doctor Recognition (2011 - 2013)
Top 10 Doctor - City (2014)
Philadelphia, PA
Urologist
Associations
American Board of Urology
American Urological Association

Affiliations ?

Dr. Pontari is affiliated with 4 hospitals.

Hospital Affilations

Score

Rankings

  • Jeanes Hospital
    7600 Central Ave, Philadelphia, PA 19111
    • Currently 3 of 4 crosses
    Top 50%
  • Temple University Children's Medical Center
    3509 N Broad St, Philadelphia, PA 19140
    • Currently 2 of 4 crosses
  • Temple University Hospital
    3401 N Broad St, Philadelphia, PA 19140
    • Currently 2 of 4 crosses
  • Temple University Hospital - Episcopal Campus
    100 E Lehigh Ave, Philadelphia, PA 19125
  • Publications & Research

    Dr. Pontari has contributed to 48 publications.
    Title Feasibility of a Femoral Nerve Motor Branch for Transfer to the Pudendal Nerve for Restoring Continence: a Cadaveric Study.
    Date December 2011
    Journal Journal of Neurosurgery. Spine
    Excerpt

    Nerve transfers are an effective means of restoring control to paralyzed somatic muscle groups and, recently, even denervated detrusor muscle. The authors performed a cadaveric pilot project to examine the feasibility of restoring control to the urethral and anal sphincters using a femoral motor nerve branch to reinnervate the pudendal nerve through a perineal approach.

    Title Pregabalin for the Treatment of Men with Chronic Prostatitis/chronic Pelvic Pain Syndrome: a Randomized Controlled Trial.
    Date October 2010
    Journal Archives of Internal Medicine
    Excerpt

    Evidence suggests that the urogenital pain of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) may be neuropathic.

    Title Central Nervous System Findings on Functional Magnetic Resonance Imaging in Patients Before and After Treatment with Anticholinergic Medication.
    Date May 2010
    Journal The Journal of Urology
    Excerpt

    Anticholinergic medications are commonly used to treat urinary urgency and frequency. Muscarinic receptors are located in areas beyond the detrusor muscle. In this study we measured changes in central nervous system activity in patients with lower urinary tract symptoms treated with tolterodine or a placebo.

    Title Evaluation of Chronic Pelvic Pain Syndrome in Men: is It Chronic Prostatitis?
    Date September 2009
    Journal Current Urology Reports
    Excerpt

    Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is not well understood. The mechanisms involved in its pathophysiology have yet to be fully elucidated. Men with CP/CPPS suffer from symptoms that may not necessarily be linked to concurrent prostate involvement. Recent literature embraces the notion that symptoms may result from complex interactions, and studies have looked at other disease syndromes in an attempt to reveal the etiology of the disease. The title of this article suggests an organ-centric etiology to explain symptoms of patients with this disorder, but this does not seem to be the case. In an attempt to answer the question, this article examines possible etiologies for CP/CPPS in which the prostate may be involved and discusses evaluation strategies for patients with CP/CPPS. It seems, however, that instead of limiting our focus to the prostate, a multisystem approach to discovery and symptom control would further improve patient care.

    Title Etiologic Theories of Chronic Prostatitis/chronic Pelvic Pain Syndrome.
    Date July 2008
    Journal Current Urology Reports
    Excerpt

    The etiology of chronic prostatitis/chronic pelvic pain syndrome is unknown. Whereas infection causes category I and II prostatitis, the evidence for an ongoing infection in category III patients is lacking. Immunologic, neurologic, and psychologic factors likely play a role in the development and maintenance of symptoms in these men. The traditional concept of pain as a simple response to a noxious stimulus has some merit, but modern research indicates that the response is much more complex, and we must look at a patient's physiology and psychology to be able to interpret each individual's pain response. It is some advance in the field to realize that we probably need to look beyond the prostate and address the entire biopsychosocial problem to be able to offer successful treatment to these men.

    Title Excessive Antibiotic Use in Men with Prostatitis.
    Date May 2008
    Journal The American Journal of Medicine
    Excerpt

    BACKGROUND: Prostatitis accounts for 2 million outpatient visits annually. The majority of prostatitis cases fit the definition of chronic pelvic pain syndrome, for which routine antibiotic use is not indicated. METHODS: Inpatient, outpatient, and pharmacy datasets from the Veterans Health Administration were used to quantify the magnitude of antibiotic use attributable to chronic pelvic pain syndrome. Specifically, men with a diagnosis of infectious/acute prostatitis or a urinary tract infection were excluded, and the remaining men with a diagnosis of prostatitis were defined as having chronic pelvic pain syndrome. RESULTS: The annual prevalence of chronic pelvic pain syndrome was 0.5%. Prescriptions for fluoroquinolone antibiotics were filled in 49% of men with a diagnosis of chronic pelvic pain syndrome compared with 5% in men without chronic pelvic pain syndrome. Men with chronic pelvic pain syndrome were more than 7 times more likely to receive a fluoroquinolone prescription independently of age, race/ethnicity, and comorbid conditions. Increased use of other antibiotics also was observed. High use was similar in men with either infectious/acute prostatitis or chronic pelvic pain syndrome. CONCLUSION: Despite evidence that antibiotics are not effective in the majority of men with chronic pelvic pain syndrome, they were prescribed in 69% of men with this diagnosis. Some increased use is probably due to uncontrolled confounding by comorbid conditions or inaccurate diagnostic coding. However, a 7-fold higher rate of fluoroquinolone usage suggests that strategies to reduce unnecessary antibiotic use in men with prostatitis are warranted.

    Title Mechanisms in Prostatitis/chronic Pelvic Pain Syndrome.
    Date May 2008
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We reviewed the current literature on mechanisms involved in the pathogenesis of prostatitis/chronic pelvic pain syndrome (CPPS). MATERIALS AND METHODS: A literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine. RESULTS: National Institutes of Health categories I and II prostatitis result from identifiable prostatic infections, whereas patients with category IV are asymptomatic. The majority of symptomatic cases are category III or chronic prostatitis (CP)/CPPS. The etiology of CP/CPPS is unknown. The traditional marker of inflammation, namely white blood cells in prostatic fluids, does not correlate with the predominant symptom of pelvic pain. An imbalance toward increased proinflammatory and decreased anti-inflammatory cytokines has been implicated and a few studies have shown some correlation of this with pelvic pain. The imbalance in some men may result from polymorphisms at the cytokine loci. An autoimmune process may be involved and experimental evidence indicates that this can be under hormonal influence. Recent findings include possible defects in the androgen receptor. The prostate may not even be the source of the symptoms. Pelvic pain also correlates with the neurotrophin nerve growth factor implicated in neurogenic inflammation and central sensitization. Finally, psychological stress may produce measurable biochemical changes and influence the other processes. The role of normal prostatic bacterial flora in inciting the inflammatory response has also been reconsidered. CONCLUSIONS: The symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.

    Title Evaluation and Management of Gunshot Wounds of the Penis: 20-year Experience at an Urban Trauma Center.
    Date April 2008
    Journal The Journal of Trauma
    Excerpt

    BACKGROUND: Although gunshot injuries to the penis occur relatively infrequently in patients with penetrating trauma, they often present dilemmas of subsequent evaluation and management. We review our extensive experience with gunshot wounds to the penis at a high volume urban trauma center. METHODS: The urologic trauma database was retrospectively reviewed to extract and compile information from the records of 63 patients treated for gunshot wounds to the penis. Data were accumulated for a 20-year period from 1985 to 2004 with regard to findings on physical examination, diagnostic evaluation, associated injuries, management, and outcome. We detail our technique of penile exploration and artificial erection in the management of these injuries. RESULTS: Penile gunshot wounds were associated with additional injuries in 53 of 63 (84%) patients. A total of 48 (76%) patients were taken to the operating room and 44 (70%) penile explorations were performed. Evaluation included retrograde urethrogram in 50 of 63 (79%) patients and was diagnostic for urethral injury in 11 of 12 (92%) cases. Primary urethral repair was performed in 8 of 12 (67%) patients with urethral injury versus 4 of 12 (33%) who underwent urinary diversion by means of suprapubic cystotomy. CONCLUSIONS: Evaluation and management of gunshot wounds to the penis may potentially be complex. Retrograde urethrogram should be performed in all cases except the most insignificant and superficial wounds. We describe our technique of penile exploration and artificial erection, noting excellent results in patients for whom follow-up is available. Additional studies are needed to prospectively evaluate techniques for management of gunshot urethral injuries.

    Title Chronic Prostatitis/chronic Pelvic Pain Syndrome.
    Date March 2008
    Journal The Urologic Clinics of North America
    Excerpt

    In the 20th century, the term "prostatitis" traditionally referred to inflammation in the prostate, often attributed to infection. Prostatitis in this century usually refers to a chronic pain syndrome for which the presence of inflammation and involvement of the prostate are not always certain. This article discusses chronic prostatitis/chronic pelvic pain syndrome and the various factors associated with diagnosis and treatment.

    Title Psychosocial Variables Affect the Quality of Life of Men Diagnosed with Chronic Prostatitis/chronic Pelvic Pain Syndrome.
    Date January 2008
    Journal Bju International
    Excerpt

    OBJECTIVE: To examine interactions between demographic, pain, urinary, psychological and environmental predictors of quality of life (QOL) in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). PATIENTS AND METHODS: In all, 253 men previously enrolled in the National Institutes of Health Chronic Prostatitis Cohort study in North American tertiary-care clinical centres (six in the USA and one in Canada) self-reported with validated instruments, including the QOL subscales of the Short Form-12 (physical, SF12-PCS; and mental, SF12-MCS), demographics, urinary symptoms, depression, current pain, pain coping, 'catastrophizing' (catastrophic thinking about pain), pain control, social support and solicitous responses from a partner. Data were collected through a one-time survey. Covariates determined to be significant were entered into a multivariable regression model predicting SF12-PCS and SF12-MCS. RESULTS: Adjusting for covariates, regression models showed that poorer SF12-PCS scores were predicted by worse urinary function (P < 0.001) and increased use of pain-contingent resting as a coping strategy (P = 0.026). Further, poorer SF12-MCS scores were predicted by greater pain catastrophizing (P = 0.002) and lower perceptions of social support (P< 0.001). In separate follow-up analyses, helplessness was the significant catastrophizing subscale (P < 0.001), while support from family and friends were the significant social support subscales (P = 0.002 and <0.001). CONCLUSIONS: These data suggest that specific coping and environmental factors (i.e. catastrophizing, pain-contingent resting, social support) are significant in understanding how patients with CP/CPPS adjust. These data can be used to develop specific cognitive-behavioural programmes for men with CP/CPPS who are refractory to standard medical therapy.

    Title Prostatitis.
    Date July 2007
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We quantified the burden of prostatitis in the United States by identifying trends in the use of health care resources and estimating the economic impact of the disease. MATERIALS AND METHODS: The analytical methods used to generate these results were described previously. RESULTS: The rate of national inpatient hospitalizations for a diagnosis of prostatitis decreased by 21% between 1994 and 2000. Hospitalization rates were 2 to 2.5 times higher for Medicare beneficiaries with a 42% decrease between 1992 and 2001. Combined physician outpatient and hospital outpatient visits revealed an age adjusted, annualized visit rate for prostatitis of 1,798/100,000 population. More than 6% of visits with a primary diagnosis of prostatitis had a concomitant diagnosis of benign prostatic hyperplasia. The most common medications associated with any visits for prostatitis were quinolones (annualized rate 319/100,000 population) and the rate remained about the same even after visits for infectious prostatitis were removed from the data. The cost of prostatitis was about $84 million annually, exclusive of pharmaceutical spending. Of 897 privately insured men with a medical claim for prostatitis in 2002, 14% missed some work because of the condition. CONCLUSIONS: Overall spending in the United States for the diagnosis and management of prostatitis, exclusive of pharmaceutical spending, totaled $84 million in 2000 and it appears to be increasing with time. Given the extensive gaps in our understanding of the diagnosis of and treatment for prostatitis, many of these expenditures may represent a waste of resources.

    Title Catastrophizing and Pain-contingent Rest Predict Patient Adjustment in Men with Chronic Prostatitis/chronic Pelvic Pain Syndrome.
    Date December 2006
    Journal The Journal of Pain : Official Journal of the American Pain Society
    Excerpt

    Cognitive/behavioral and environmental variables are significant predictors of patient adjustment in chronic pain. Using a biopsychosocial template and selecting several pain-relevant constructs from physical, cognitive/behavioral, and environmental predictors, outcomes of pain and disability in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) were explored. Men (n = 253) from a North American multi-institutional NIH-funded Chronic Prostatitis Cohort Study in 6 US and 1 Canadian centers participated in a survey examining pain and disability. Measures included demographics, urinary symptoms, depression, pain, disability, catastrophizing, control over pain, pain-contingent rest, social support, and solicitous responses from a significant other. Regressions showed that urinary symptoms (beta = .20), depression (beta = .24), and helplessness catastrophizing (beta = .29) predicted overall pain. Further, affective pain was predicted by depression (beta = .39) and helplessness catastrophizing (beta = .44), whereas sensory pain was predicted by urinary symptoms (beta = .25) and helplessness catastrophizing (beta = .37). With regard to disability, urinary symptoms (beta = .17), pain (beta = .21), and pain-contingent rest (beta = .33) were the predictors. These results suggest cognitive/behavioral variables (ie, catastrophizing, pain-contingent rest) may have significant impact on patient adjustment in CP/CPPS. Findings support the need for greater research of such pain-related variables in CP/CPPS. PERSPECTIVE: This article explores predictors of patient adjustment in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Cognitive/behavioral variables of catastrophizing and pain-contingent rest respectively predicted greater pain and disability. Catastrophic helplessness was a prominent pain predictor. These findings inform clinicians and researchers on several new variables in CP/CPPS outcomes and suggest future research.

    Title Chronic Prostatitis/chronic Pelvic Pain Syndrome and Interstitial Cystitis: Are They Related?
    Date September 2006
    Journal Current Urology Reports
    Excerpt

    Interstitial cystitis and chronic prostatitis/chronic pelvic pain syndrome are clinical syndromes characterized by pelvic pain with or without voiding symptoms such as urgency and frequency. There are many similarities in their epidemiology, adverse effect on quality of life, etiology/pathophysiology, natural history, and response to similar treatments. However, overlapping clinical definitions and similar entrance criteria for large-scale cohort studies make comparisons problematic. Newer efforts to classify pelvic pain syndromes should help in our recognition that interstitial cystitis and chronic prostatitis/chronic pelvic pain syndrome likely are not organ-specific syndromes but urogenital manifestations of regional or systemic abnormalities.

    Title Functional Reinnervation of the Canine Bladder After Spinal Root Transection and Immediate End-on-end Repair.
    Date September 2006
    Journal Journal of Neurotrauma
    Excerpt

    The goal of this study was to transect and immediately repair ventral roots, selected by their ability to stimulate bladder contraction, to assess the feasibility of bladder reinnervation in a canine model. Brain-derived neurotrophic factor (BDNF) was delivered via an osmotic pump (0.5 or 5 mg/mL) to a cuff surrounding the reanastomosis site to the two root bundles on one side. Electrodes were implanted bilaterally immediately proximal to the site of surgical reanastomosis. Results were compared to four root-intact, control animals that also received bilateral electrode implantation. At 6-12 months post-surgery, five of eight nerve transected and repaired animals showed increased pressure and bladder emptying during electrical stimulation of the repaired ventral roots contralateral to the BDNF delivery side. Nerve tracing studies one year postoperatively determined the repaired roots to be S1 and S2 and showed regrowth of axons from the spinal cord to nerve sites proximal to the repair site and to the bladder, and the presence of neurofilament-labeled axons growing across the ventral root repair site. In conclusion, transected ventral and dorsal roots in the sacral spine can be repaired and are capable of functionally reinnervating the urinary bladder. This feasibility study paves the way for future studies utilizing other more proximal motor nerves to bypass the transection site for bladder reinnervation.

    Title How Does the Pre-massage and Post-massage 2-glass Test Compare to the Meares-stamey 4-glass Test in Men with Chronic Prostatitis/chronic Pelvic Pain Syndrome?
    Date July 2006
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The Meares-Stamey 4-glass test is the standard method of assessing inflammation and the presence of bacteria in the lower urinary tract in men presenting with the chronic prostatitis syndrome. However, most urologists do not use it in daily practice because of the time and difficulty in performing it, as well as the additional expense. We evaluated a simpler test, the 2-glass pre-massage and post-massage test, and compared it with the Meares-Stamey 4-glass test to detect inflammation and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome. MATERIALS AND METHODS: The study population included 353 men enrolled in the National Institutes of Health Chronic Prostatitis Cohort study with baseline leukocyte counts and 2-day bacterial cultures on specimens obtained from a standard 4-glass test (VB1, VB2, expressed prostatic secretions, VB3). The chi-square test was performed to assess associations of white blood cell counts in expressed prostatic secretions and VB3. A receiver operating characteristic curve was constructed to determine the optimal cut point of white blood cells in VB3 in predicting white blood cells in expressed prostatic secretions. Sensitivity and specificity of VB3 cultures predicting expressed prostatic secretions and positive Meares-Stamey results were calculated from 2 x 2 contingency tables. RESULTS: Analysis of binary leukocyte outcomes (no white blood cells vs any white blood cells) suggests that white blood cells tend to be present in expressed prostatic secretions when there are any white blood cells in VB3, p <0.0001, the optimal cut point being white blood cell counts of 3 in VB3 (best predictive ability with area under ROC 0.771) to predict 5+ in expressed prostatic secretions with a sensitivity of 76% and specificity of 70%. The optimal cut point of white blood cells in VB3 to predict 10 white blood cells in expressed prostatic secretions was 4 (62% sensitivity and 75% specificity). Uropathogens localizing to expressed prostatic secretions or VB3 confirms a positive 4-glass Meares-Stamey localization test. The sensitivity and specificity of a VB3 localizing culture only in predicting a positive Meares-Stamey 4-glass test result for any uropathogen were 44% to 54% (depending on definition) and 100%, respectively. The pre-massage and post-massage test predicted a correct diagnosis in more than 96% of subjects. CONCLUSIONS: The value of localizing leukocytes and uropathogens to prostate specific specimens remains controversial in chronic heavily pretreated patients, but these data may help direct therapy (anti-inflammatory or antimicrobial) when obtained at first presentation. The pre-massage and post-massage test has strong concordance with the 4-glass test and is a reasonable alternative when expressed prostatic secretions are not obtained.

    Title Implantable Fes System for Upright Mobility and Bladder and Bowel Function for Individuals with Spinal Cord Injury.
    Date January 2006
    Journal Spinal Cord : the Official Journal of the International Medical Society of Paraplegia
    Excerpt

    STUDY DESIGN: Postintervention. OBJECTIVES: To determine the effectiveness of the Praxis multifunctional implantable functional electrical stimulation (FES) system (Neopraxis Pty. Ltd, Lane Cove, NSW, Australia) to provide standing and stepping ability and bladder and bowel management for individuals with motor complete thoracic level spinal cord injuries (SCI). SETTING: Pediatric orthopedic hospital specializing in SCI.Subjects:Three males, ages 17 and 21 years, with motor-complete thoracic level SCI and intact lower motor neurons to the muscles targeted for stimulation. METHODS: Each subject was successfully implanted with the Praxis FES system. All three subjects received electrodes for upright mobility and the first two subjects received additional electrodes for stimulated bladder and bowel management. Following training, subjects were evaluated in their ability to use FES for nine mobility activities. Acute and chronic experiments of the effect of stimulation on bowel and bladder function were also performed. RESULTS: All three subjects could independently stand up from the wheelchair and could walk at least 6 m using a swing through gait pattern. Two subjects were able to independently perform swing through gait for 6 min and one subject was able to independently ascend and descend stairs. Suppression of reflex bladder contractions by neuromodulation (subject 1) and stimulated contractions of the rectum (subject 2) were observed in acute experiments. When stimulation was applied over the course of several weeks, a positive effect on bowel function was measured. Stimulated bladder contractions were not achieved. CONCLUSION: The feasibility of using the Praxis FES system for upright mobility and aiding aspects of bladder and bowel function was demonstrated with three subjects with thoracic level SCI.

    Title Combined Use of Alpha-adrenergic and Muscarinic Antagonists for the Treatment of Voiding Dysfunction.
    Date November 2005
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We provide an overview of the medical literature supporting the combined use of muscarinic and alpha-adrenergic antagonist therapy for the treatment of voiding dysfunction. MATERIALS AND METHODS: The MEDLINE database (1966 to 2004) of the United States National Library of Medicine was searched for pertinent studies. RESULTS: Although the mechanism of action of alpha-adrenergic antagonist therapy for voiding dysfunction has traditionally been assumed to be relaxation of the periurethral, prostatic and bladder neck smooth muscle, substantial evidence supports action at extraprostatic sites involved in micturition, including the bladder dome smooth muscle, peripheral ganglia, spinal cord and brain. Likewise the mechanism of action of anticholinergic therapy has been traditionally assumed to be inhibition of the M3 muscarinic receptor subtypes that mediate normal bladder contractions. However, M2 receptor mediates hypertrophied bladder contractions and there is evidence for an M2 component to the suprasacral control of voiding. CONCLUSIONS: Based on the physiology of alpha-adrenergic and muscarinic receptors the inhibition of each one would be expected to be more beneficial than that of either alone because they would work on 2 components of detrusor function. Patients who would likely benefit from this combination therapy are men with lower urinary tract symptoms, women with urgency/frequency syndrome (overactive bladder), patients with uninhibited bladder contractions due to neurogenic bladder, and patients with pelvic pain and voiding symptoms, ie interstitial cystitis and chronic prostatitis/chronic pelvic pain syndrome.

    Title A Case-control Study of Risk Factors in Men with Chronic Pelvic Pain Syndrome.
    Date September 2005
    Journal Bju International
    Excerpt

    OBJECTIVE: To compare the demographic, behavioural, clinical and medical history characteristics of men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and asymptomatic controls, to identify characteristics that might be associated with this syndrome. PATIENTS AND METHODS: Self-administered epidemiological questionnaires were completed by 463 men with CP/CPPS and 121 asymptomatic age-matched controls. We compared the prevalence of possible risk factors between men with CP/CPPS and controls, using generalized Mantel-Haenszel tests, and developed multivariate predictive models using logistic regression methods, adjusting for clustering by clinical centre within both methods. RESULTS: Compared to controls, men with CP/CPPS reported a significantly greater lifetime prevalence of nonspecific urethritis (12% vs 4%, P = 0.008), cardiovascular disease (11% vs 2%, P = 0.004), neurological disease (41% vs 14%, P < 0.001), psychiatric conditions (29% vs 11%, P < 0.001), and haematopoietic, lymphatic or infectious disease (41% vs 20%, P < 0.001). CONCLUSION: A wide range of self-reported medical conditions was associated with CP/CPPS. Further studies are necessary to determine whether they play a role in the pathogenesis of CP/CPPS.

    Title Ciprofloxacin or Tamsulosin in Men with Chronic Prostatitis/chronic Pelvic Pain Syndrome: a Randomized, Double-blind Trial.
    Date October 2004
    Journal Annals of Internal Medicine
    Excerpt

    BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is principally defined by pain in the pelvic region lasting more than 3 months. No cause of the disease has been established, and therapies are empirical and mostly untested. Antimicrobial agents and alpha-adrenergic receptor blockers are frequently used. OBJECTIVE: To determine whether 6-week therapy with ciprofloxacin or tamsulosin is more effective than placebo at improving symptoms in men with refractory, long-standing CP/CPPS. DESIGN: Randomized, double-blind trial with a 2 x 2 factorial design comparing 6 weeks of therapy with ciprofloxacin, tamsulosin, both drugs, or placebo. SETTING: Urology outpatient clinics at 10 tertiary care medical centers in North America. PATIENTS: Patients were identified from referral-based practices of urologists. One hundred ninety-six men with a National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score of at least 15 and a mean of 6.2 years of symptoms were enrolled. Patients had received substantial previous treatment. MEASUREMENTS: The authors evaluated NIH-CPSI total score and subscores, patient-reported global response assessment, a generic measure of quality of life, and adverse events. Interventions: Ciprofloxacin, 500 mg twice daily; tamsulosin, 0.4 mg once daily; a combination of the 2 drugs; or placebo. RESULTS: The NIH-CPSI total score decreased modestly in all treatment groups. No statistically significant difference in the primary outcome was seen for ciprofloxacin versus no ciprofloxacin (P = 0.15) or tamsulosin versus no tamsulosin (P > 0.2). Treatments also did not differ significantly for any of the secondary outcomes. LIMITATIONS: Treatment lasting longer than 6 weeks was not tested. Patients who had received less pretreatment may have responded differently. CONCLUSION: Ciprofloxacin and tamsulosin did not substantially reduce symptoms in men with long-standing CP/CPPS who had at least moderate symptoms.

    Title Mechanisms in Prostatitis/chronic Pelvic Pain Syndrome.
    Date September 2004
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We reviewed the current literature on mechanisms involved in the pathogenesis of prostatitis/chronic pelvic pain syndrome (CPPS). MATERIALS AND METHODS: A literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine. RESULTS: National Institutes of Health categories I and II prostatitis result from identifiable prostatic infections, whereas patients with category IV are asymptomatic. The majority of symptomatic cases are category III or chronic prostatitis (CP)/CPPS. The etiology of CP/CPPS is unknown. The traditional marker of inflammation, namely white blood cells in prostatic fluids, does not correlate with the predominant symptom of pelvic pain. An imbalance toward increased proinflammatory and decreased anti-inflammatory cytokines has been implicated and a few studies have shown some correlation of this with pelvic pain. The imbalance in some men may result from polymorphisms at the cytokine loci. An autoimmune process may be involved and experimental evidence indicates that this can be under hormonal influence. Recent findings include possible defects in the androgen receptor. The prostate may not even be the source of the symptoms. Pelvic pain also correlates with the neurotrophin nerve growth factor implicated in neurogenic inflammation and central sensitization. Finally, psychological stress may produce measurable biochemical changes and influence the other processes. The role of normal prostatic bacterial flora in inciting the inflammatory response has also been reconsidered. CONCLUSIONS: The symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.

    Title The Economic Impact of Chronic Prostatitis.
    Date July 2004
    Journal Archives of Internal Medicine
    Excerpt

    BACKGROUND: Little information exists on the economic impact of chronic prostatitis. The objective of this study was to determine the direct and indirect costs associated with chronic prostatitis. METHODS: Outcomes were assessed using a questionnaire designed to capture health care resource utilization. Resource estimates were converted into unit costs with direct medical cost estimates based on hospital cost-accounting data and indirect costs based on modified labor force, employment, and earnings data from the US Census Bureau. RESULTS: The total direct costs for the 3 months prior to entry into the cohort, excluding hospitalization, were $126 915 for the 167 study participants for an average of $954 per person among the 133 consumers. Of the men, 26% reported work loss valued at an average of $551. The average total costs (direct and indirect) for the 3 months was $1099 per person for those 137 men who had resource consumption with an expected annual total cost per person of $4397. For those study participants with any incurred costs, tests for association revealed that the National Institutes of Health Chronic Prostatitis Symptom Index (P<.001) and each of the 3 subcategories of pain (P =.003), urinary function (P =.03), and quality-of-life (P =.002) were significantly associated with resource use, although the quality-of-life subscale score from the National Institutes of Health Chronic Prostatitis Symptom Index was the only predictor of resource consumption. CONCLUSIONS: Chronic prostatitis is associated with substantial costs and lower quality-of-life scores, which predicted resource consumption. The economic impact of chronic prostatitis warrants increased medical attention and resources to identify and test effective treatment strategies.

    Title Chronic Prostatitis/chronic Pelvic Pain Syndrome in Elderly Men: Toward Better Understanding and Treatment.
    Date June 2004
    Journal Drugs & Aging
    Excerpt

    Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common of the prostatitis syndromes. It is characterised by pelvic pain, with or without voiding symptoms. CP/CPPS accounts for 2 million office visits in the US alone. Recent epidemiological studies have shown that CP/CPPS can affect men at any age, including those in their 80s. The aetiology is unknown but proposals include infectious, autoimmune, neurologic and psychiatric causes. Men with CP/CPPS are much more likely to have had a past medical history of cardiovascular, neurologic, psychiatric or infectious disease (particularly sinusitis) as compared with asymptomatic individuals. Although leucocytes are commonly found in the prostatic fluid of these men, they do not correlate with the symptoms.The clinical evaluation now includes a validated, self administered symptom score, the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), which was designed as an outcome measure for treatment trials. This can aid in diagnosis and follow-up of patients' response to therapy.Treatment for CP/CPPS is empiric and limited by a lack of randomised, placebo-controlled clinical trials. Antimicrobials are commonly used to treat the symptoms of CP/CPPS. However, the finding that asymptomatic men have equal or greater numbers of bacteria which localise to the prostatic fluid, compared with men with CP/CPPS, has raised doubts about the contribution of infection to the symptoms. Other commonly used drugs include alpha-adrenoceptor antagonists, anti-inflammatory drugs, tricyclic antidepressants and anticholinergic agents. The adverse effects of these medications are a concern in older men with CP/CPPS. Other therapies available include minimally invasive procedures such as microwave thermotherapy and transurethral needle ablation, and now neuromodulation devices.Although much progress has been made, particularly in the last 7 years, considerable work still remains to be done to determine the aetiology and pathogenesis of CP/CPPS, and to develop mechanism based therapy that is shown to be effective in controlled trials.

    Title A Randomized Placebo-controlled Multicentre Study to Evaluate the Safety and Efficacy of Finasteride for Male Chronic Pelvic Pain Syndrome (category Iiia Chronic Nonbacterial Prostatitis).
    Date June 2004
    Journal Bju International
    Excerpt

    OBJECTIVE: To determine if finasteride can reduce symptoms in men with a clinical diagnosis of chronic nonbacterial prostatitis (National Institutes of Health, NIH, category IIIA chronic pelvic pain syndrome, CPPS) compared with placebo. PATIENTS AND METHODS: Men (76) with category IIIA CPPS enrolled in four North American prostatitis research centres were randomized after a 2-week placebo run-in to finasteride or placebo for 6 months. The primary efficacy variable was a subjective overall assessment (SOA); the secondary efficacy variables included the NIH chronic prostatitis symptom index (NIH-CPSI) and safety data. Patients were assessed at screening, baseline (after the 2-week placebo run-in), 3 and 6 months. RESULTS: Sixty-four patients had at least one assessment on medication (31 placebo, 33 finasteride); 75% of the finasteride and 54% of the placebo group had at least a mild improvement (defined as > 25% improvement in SOA), and 44% and 27%, respectively, a moderate or marked improvement (>50% improvement in SOA). The trend was similar in the NIH-CPSI scores. Five patients in the finasteride and seven in the placebo group reported medication-related adverse events. CONCLUSION: This randomized placebo-controlled pilot study suggests that finasteride was of benefit for some men with category IIIA CPPS, but the results do not justify recommending finasteride as monotherapy, except for men who also have benign prostatic hyperplasia. A larger, properly powered study, possibly evaluating combination with other therapies or specifically in men with prostatitis and benign prostatic hyperplasia, is required to confirm any clinical benefit.

    Title The M2 Muscarinic Receptor Mediates in Vitro Bladder Contractions from Patients with Neurogenic Bladder Dysfunction.
    Date May 2004
    Journal American Journal of Physiology. Regulatory, Integrative and Comparative Physiology
    Excerpt

    Bladder muscle specimens from seven patients with neurogenic bladder dysfunction were analyzed to determine whether the muscarinic receptor subtype mediating contraction shifts from M(3) to the M(2) subtype as found in the denervated, hypertrophied rat bladder. Seven bladder specimens were analyzed from six female and one male patients. Six of the patients had traumatic cervical spinal cord injuries (C(4)-C(7)), and the other patient had an L(1) congenital myelomeningocele. This was compared with results from bladder specimens obtained from eight organ transplant donors. The affinities of three subtype-selective muscarinic receptor antagonists for inhibition of carbachol-induced contractions were determined. The affinity of the M(3) selective antagonists darifenacin or p-fluoro-hexahydrosiladifenadol (p-F-HHSiD) was determined in six of the seven spinal injury patient specimens. The affinity was consistent with M(2)-mediated contractions in four of these six specimens, intermediate between M(2) and M(3) in one specimen, and within the M(3) range in one specimen. The other specimen, tested only with the M(2) selective antagonist methoctramine, showed an M(3) affinity. In the organ donors, the affinity of p-F-HHSiD was within the M(2) range for six of seven specimens, whereas the affinity of darifenacin was within the M(3) range for five of six and intermediate between M(2) and M(3) for the other specimen tested. The affinity of methoctramine in both organ donor specimens tested was within the M(3) range. Whereas normal detrusor contractions are mediated by the M(3) receptor subtype, in patients with neurogenic bladder dysfunction as well as certain organ transplant donors, contractions can be mediated by the M(2) muscarinic receptor subtype.

    Title Overview Summary Statement. Diagnosis and Management of Chronic Prostatitis/chronic Pelvic Pain Syndrome (cp/cpps).
    Date February 2003
    Journal Urology
    Excerpt

    Members of the Chronic Prostatitis Collaborative Research Network (CPCRN) met in a 1-day symposium to review recent findings and to debate unanswered issues in the diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The meeting was focused on producing an overview summary statement that would, as nearly as possible, represent the consensus views of the attendees. As discussed below, the participants agreed that a history, physical examination, and urinalysis/urine culture are mandatory for the evaluation of all patients presenting with CP/CPPS, with other assessments categorized as recommended or optional, depending on the history and physical findings. Observations and suggestions regarding first- and second-line therapies are also offered, with the recognition that randomized, placebo-controlled trials to guide selection of therapies for chronic nonbacterial prostatitis are currently lacking.

    Title Theories of Prostatitis Etiology.
    Date October 2002
    Journal Current Urology Reports
    Excerpt

    Prostatitis reflects a broad spectrum of prostatic infections, both acute and chronic. Chronic prostatitis, known as National Institutes of Health category III or chronic pelvic pain syndrome, broadly defines a disease that is still poorly understood, and as a consequence, difficult to treat. Typical symptoms include pelvic pain and voiding dysfunction. Infection is often cited as the cause of this condition, despite frequent negative cultures. A close look at the local prostatic microenvironment may yield clues. The role of inflammatory mediators and what stimulates them can point to potential sites of prevention. A genetic link or relationship to other diseases may prove to be part of the cause. Furthermore, a neurologic source, whether anatomic or psychologic, has been strongly debated. Ultimately, it may become clear that chronic prostatitis represents the final common result of a disease that originates from a cascade of multiple stimuli.

    Title Leukocyte and Bacterial Counts Do Not Correlate with Severity of Symptoms in Men with Chronic Prostatitis: the National Institutes of Health Chronic Prostatitis Cohort Study.
    Date September 2002
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We examine whether leukocytes and bacteria correlate with symptom severity in men with chronic prostatitis/chronic pelvic pain syndrome. MATERIALS AND METHODS: All 488 men screened into the National Institutes of Health Chronic Prostatitis Cohort Study before close of recruitment on August 22, 2001 were selected for analysis. The National Institutes of Health Chronic Prostatitis Symptom Index, including subscores, were used to measure symptoms. Urethral inflammation was defined as white blood cell (WBC) counts of 1 or more (1+) in the first voided urine. Participants were classified as category IIIa based on WBC counts of 5 or more, or 10 or more (5+, 10+) in the expressed prostatic secretion, or 1+ or 5+ either in the post-expressed prostatic secretion urine (voided urine 3) or semen. Uropathogens were classified as localizing if the designated bacterial species were absent in voided urine 1 and voided urine 2 but present in expressed prostatic secretion, voided urine 3 or semen, or present in expressed prostatic secretion, voided urine 3 or semen at 2 log concentrations higher than at voided urine 1 or 2. Associations between symptoms, and inflammation and infection were investigated using generalized Mantel-Haenszel methods. RESULTS: Of all participants 50% had urethral leukocytes and of 397 with expressed prostatic secretion samples 194 (49%) and 122 (31%) had 5+ or 10+ WBCs in expressed prostatic secretion, respectively. The prevalence of category IIIa ranged from 90% to 54%, depending on the composite set of cut points. None of the index measures were statistically different (p >0.10) for selected leukocytosis subgroups. Based on prostate and semen cultures, 37 of 488 men (8%) had at least 1 localizing uropathogen. None of the index measures were statistically different (p >0.10) for selected bacterial culture subgroups. CONCLUSIONS: Although men with chronic prostatitis routinely receive anti-inflammatory and antimicrobial therapy, we found that leukocytes and bacterial counts as we defined them do not correlate with severity of symptoms. These findings suggest that factors other than leukocytes and bacteria also contribute to symptoms associated with chronic pelvic pain syndrome.

    Title Demographic and Clinical Characteristics of Men with Chronic Prostatitis: the National Institutes of Health Chronic Prostatitis Cohort Study.
    Date August 2002
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We describe the study design of the National Institutes of Health Chronic Prostatitis Cohort (CPC) study characterizing men with chronic prostatitis/the chronic pelvic pain syndrome. MATERIALS AND METHODS: All 488 men screened into the CPC study before close of recruitment on August 22, 2001 were selected for analysis. The National Institutes of Health Chronic Prostatitis Symptom Index, including subscores, was used to measure symptoms. A comprehensive history, physical examination and demographic profile were obtained from each participant. Generalized Mantel-Haenszel procedures were used to investigate baseline associations between selected factors and symptoms. RESULTS: Chronic prostatitis/chronic pelvic pain syndrome is a chronic syndrome affecting men over a wide age range. The majority of CPC study participants are white, well educated and affluent. However, lower education, lower income and unemployment were associated with more severe symptoms. Patients most frequently reported pain in the perineum and tenderness in the prostate. The highest self-reported diseases were genitourinary (55%), allergies (53%), neurological (40%) and hematopoietic, lymphatic or infectious (40%). This disease has a significant negative impact on mental and physical domains of quality of life. Almost all patients (95%) reported antimicrobial drug use. Of these 488 participants 280 (57%) reported the previous or current use of 5 or more categories of prostatitis related treatments. CONCLUSIONS: Chronic prostatitis/chronic pelvic pain syndrome is a multifactorial problem affecting men of all ages and demographics. Patients with the chronic pelvic pain syndrome have dismal quality of life and many have benefited only minimally from empirical, goal directed therapy. Long-term followup of this cohort may answer important questions on the natural treated history of this syndrome.

    Title Quality of Life is Impaired in Men with Chronic Prostatitis: the Chronic Prostatitis Collaborative Research Network.
    Date December 2001
    Journal Journal of General Internal Medicine
    Excerpt

    OBJECTIVE: Health-related quality of life (HRQOL) impairment may be a central component of chronic prostatitis for men afflicted with this condition. Our objective was to examine HRQOL, and factors associated with HRQOL, using both general and condition-specific instruments. DESIGN: Chronic Prostatitis Cohort (CPC) study. SETTING: Six clinical research centers across the United States and Canada. PARTICIPANTS: Two hundred seventy-eight men with chronic prostatitis. MEASUREMENTS AND MAIN RESULTS: The Short Form 12 (SF-12) Mental Component Summary (MCS) and Physical Component Summary (PCS), and the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) were measures used. CPC subjects' MCS scores (44.0 +/- 9.8) were lower than those observed in the most severe subgroups of patients with congestive heart failure and diabetes mellitus, and PCS scores (46.4+/-9.5) were worse than those among the general U.S. male population. Decreasing scores were seen in both domains with worsening symptom severity (P < .01). History of psychiatric disease and younger age were strongly associated with worse MCS scores, whereas history of rheumatologic disease was associated with worse PCS scores. Predictors of more severe NIH-CPSI scores included lower educational level and lower income; history of rheumatic disease was associated with higher scores. CONCLUSIONS: Men with chronic prostatitis experience impairment in the mental and physical domains of general HRQOL, as well as condition-specific HRQOL. To optimize the care of men with this condition, clinicians should consider administering HRQOL instruments to their patients to better understand the impact of the condition on patients' lives.

    Title The Spanish National Institutes of Health-chronic Prostatitis Symptom Index: Translation and Linguistic Validation.
    Date October 2001
    Journal The Journal of Urology
    Excerpt

    PURPOSE: The prominence of health related quality of life end points in international clinical research underscores the importance of well validated and translated measures to enable cross-cultural comparison. The National Institutes of Health (NIH)-Chronic Prostatitis Symptom Index (CPSI) assesses symptoms and health related quality of life in men with chronic nonbacterial, NIH type III prostatitis. To expand its use to Spanish speaking patients we performed a translation and linguistic validation. MATERIALS AND METHODS: The 9-item NIH-CPSI was translated into Spanish according to a standard methodology of 2 forward translations, 1 reconciled version, back translation of the reconciled version and 3 independent reviews by bilingual experts. The purpose of this methodology was to create a single universal Spanish version that would be acceptable to native Spanish speakers inside and outside of the United States. After the translation process the Spanish version was pre-tested in Argentina, Mexico, Spain and the United States. Patient responses were analyzed to identify necessary modifications. The internal consistency of the CPSI was evaluated using Cronbach's alpha. Pearson's product moment correlations were used to evaluate construct validity. RESULTS: Data were collected from chronic prostatitis patients, including 15 in Argentina, 15 in Mexico, 4 in the United States and 3 in Spain. The translation had high reliability overall and in all subscales (Cronbach's coefficient alpha = 0.81 to 0.94), and the subscales correlated well with each other (r = 0.76 to 0.97). However, patients expressed difficulty in distinguishing the response categories "a menudo" ("often") from "normalmente" ("usually") in question 3. We revised "a menudo" to "muchas veces" ("much of the time") and "normalmente" to "casi siempre" ("almost always") to improve the distinctiveness of response categories. CONCLUSIONS: The Spanish NIH-CPSI has high reliability as well as face and construct validity in Spanish speaking men from various countries. The Spanish NIH-CPSI permits cross-cultural comparisons of men with chronic nonbacterial prostatitis.

    Title Comparison of Bladder Blood Flow in Patients with and Without Interstitial Cystitis.
    Date August 1999
    Journal The Journal of Urology
    Excerpt

    PURPOSE: We compared bladder blood flow during filling and emptying in patients with and without interstitial cystitis, and correlated blood flow with symptoms in those with interstitial cystitis. MATERIALS AND METHODS: Bladder perfusion was measured using a dual channel endoscopic laser Doppler flow probe. Measurements were obtained in superficial and deeper vascular beds from the bladder mucosa at the trigone and back wall at baseline, at the volume of awake capacity, during 80 cm. water hydrodistention and after bladder drainage. American Urological Association symptom score was obtained preoperatively in interstitial cystitis patients. RESULTS: In all areas bladder perfusion decreased with filling in interstitial cystitis patients and increased in those without interstitial cystitis. There were no significant differences in response to emptying the bladder, as perfusion tended to increase in both groups. There was no correlation between bladder perfusion at baseline, or in response to filling or emptying with overall symptom score. CONCLUSIONS: Bladder perfusion decreases with bladder filling in patients with but increases in those without interstitial cystitis. The inability of the interstitial cystitis bladder to increase bladder blood flow with filling may be a reflection of other pathological processes in the bladder mucosa. The lack of correlation between blood flow and symptoms suggests that bladder ischemia alone cannot account for the symptoms in interstitial cystitis.

    Title The National Institutes of Health Chronic Prostatitis Symptom Index: Development and Validation of a New Outcome Measure. Chronic Prostatitis Collaborative Research Network.
    Date August 1999
    Journal The Journal of Urology
    Excerpt

    PURPOSE: Chronic abacterial prostatitis is a syndrome characterized by pelvic pain and voiding symptoms, which is poorly defined, poorly understood, poorly treated and bothersome. Research and clinical efforts to help men with this syndrome have been hampered by the absence of a widely accepted, reliable and valid instrument to measure symptoms and quality of life impact. We developed a psychometrically valid index of symptoms and quality of life impact for men with chronic prostatitis. MATERIALS AND METHODS: We conducted a structured literature review of previous work to provide a foundation for the new instrument. We then conducted a series of focus groups comprising chronic prostatitis patients at 4 centers in North America, in which we identified the most important symptoms and effects of the condition. The results were used to create an initial draft of 55 questions that were used for formal cognitive testing on chronic prostatitis patients at the same centers. After expert panel review formal validation testing of a revised 21-item draft was performed in a diverse group of chronic prostatitis patients and 2 control groups of benign prostatic hyperplasia patients and healthy men. Based on this validation study, the index was finalized. RESULTS: Analysis yielded an index of 9 items that address 3 different aspects of the chronic prostatitis experience. The primary component was pain, which we captured in 4 items focused on location, severity and frequency. Urinary function, another important component of symptoms, was captured in 2 items (1 irritative and 1 obstructive). Quality of life impact was captured with 3 items about the effect of symptoms on daily activities. The 9 items had high test-retest reliability (r = 0.83 to 0.93) and internal consistency (alpha = 0.86 to 0.91). All but the urinary items discriminated well between men with and without chronic prostatitis. CONCLUSIONS: The National Institutes of Health chronic prostatitis symptom index provides a valid outcome measure for men with chronic prostatitis. The index is psychometrically robust, easily self-administered and highly discriminative. It was formally developed and psychometrically validated, and may be useful in clinical practice as well as research protocols.

    Title Sex Differences and Role of Nitric Oxide in Blood Flow of Canine Urinary Bladder.
    Date March 1999
    Journal The American Journal of Physiology
    Excerpt

    Continuous measurements were made of bladder blood flow by laser Doppler flowmetry in anesthetized dogs during bladder filling and emptying. In both mucosa and muscle, perfusion was inversely proportional to intravesical pressure. There was significantly greater perfusion in the bladder mucosa of males than females at baseline and up to 10 cm water filling pressure but not in the muscle. Intra-arterial infusion of the nitric oxide synthase inhibitor NG-nitro-L-arginine produced a significant decrease in resting bladder perfusion in the mucosa only, with no differences seen in the response to intravesical pressure. Intra-arterial infusion of L-arginine produced a significant increase in the level of perfusion in the mucosa seen immediately after the bladder was drained. No changes were observed in muscle perfusion after L-arginine. These results suggest that the perfusion of the bladder mucosa differs by gender and is regulated differently than the bladder muscle, possibly related to the different function of the two layers.

    Title Adverse Urologic Consequences of Spinal Cord Resection at the Time of Kyphectomy: Value of Preoperative Urodynamic Evaluation.
    Date January 1999
    Journal Journal of Pediatric Orthopedics
    Excerpt

    Four children with thoracic level paraplegia and severe myelokyphosis underwent distal spinal cord resection at the time of kyphectomy. All four children were continent before spinal cord resection and became incontinent immediately afterward. Two children in retrospect had preoperative urodynamics that showed intact innervation to the external sphincter, and two had no preoperative urodynamic studies. All four had evidence of lower urinary tract denervation on urodynamic studies performed after cord resection. The urologic and urodynamic consequences of spinal cord resection at the time of kyphectomy in children with myelodysplasia are reviewed. Resection of the distal spinal cord in thoracic level myelodysplasia may cause postoperative incontinence in some previously continent patients. Preoperative urodynamic evaluation and urologic consultation is recommended. If individual evaluation indicates that residual sacral function is beneficial to urologic management, kyphectomy without cord resection is preferable.

    Title Characterization of Muscarinic Cholinergic Receptor Subtypes in Rat Prostate.
    Date August 1998
    Journal Journal of Receptor and Signal Transduction Research
    Excerpt

    The purpose of this study was to characterize the muscarinic receptor subtypes in the individual lobes of the rat prostate. Immunoprecipitation was performed on homogenates of these 3 lobes using antibodies to the m1-m4 muscarinic receptor subtypes. Reverse transcriptase polymerase chain reaction assays (RT-PCR) were also performed using primers specific for each of the five muscarinic receptor subtypes (m1-m5). The susceptibility of the receptors to degradation by endogenous prostate proteases was assessed by mixing rat ventral prostate with rat heart (m2) and rat parotid (m3) prior to immunoprecipitation. In the ventral lobe, transcripts for the m1-m4 subtypes were amplified whereas in the dorsal and lateral lobes only the m2 and m3 sets of primers amplified PCR products of the predicted size. Immunoprecipitation of the ventral lobe resulted in predominantly m3 receptors, while the majority of receptors immunoprecipitated from lateral and dorsal lobes were the m2 subtype. The m3 muscarinic subtype was apparently susceptible to degradation by prostate proteases whereas the m2 subtype was not. These results demonstrate a regional distribution in the subtypes of muscarinic receptors in the rat prostate, and a greater susceptibility of the m3 receptor to degradation during immunoprecipitation than the m2 subtype.

    Title Logical and Systematic Approach to the Evaluation and Management of Patients Suspected of Having Interstitial Cystitis.
    Date June 1997
    Journal Urology
    Excerpt

    OBJECTIVES: To outline a systematic approach to the evaluation, diagnosis and treatment of interstitial cystitis (IC). METHODS: A review of the literature as well as of our experience. RESULTS: The exclusion criteria for the research definition of IC can be used as guides when obtaining the history, physical examination, laboratory workup, and finally urodynamics and cystoscopy/hydrodistension under anesthesia. Once the diagnosis is established, patients who are still symptomatic after hydrodistension are treated initially with oral medications. Those who do not respond to oral therapy are given intravesical therapy. Patients whose symptoms are refractory to both routes can be considered for a TENS unit, experimental oral therapies, chronic pain control with opioids, or, as a last resort, surgery to create a urinary diversion. CONCLUSION: As IC is a diagnosis of exclusion, the evaluation remains one of ruling out other disorders that produce similar symptoms in patients whose history suggests IC. Until the etiology and pathogenesis of IC are identified, specific therapy is not possible. However, symptomatic treatments are helpful in the majority of patients.

    Title Human Prostate Muscarinic Receptor Subtypes.
    Date September 1995
    Journal The Journal of Pharmacology and Experimental Therapeutics
    Excerpt

    The alpha adrenergic receptor subtypes of the human prostate have been intensively investigated, while the muscarinic receptor subtypes and their function have yet to be determined in this tissue. [3H]-QNB binding to muscarinic receptors was performed on membrane homogenates of adenoma from six prostatectomy specimens resulting in an average total receptor density of 46 fMol/mg protein. Pirenzepine, hexahydrosiladifenidol, and para-fluoro-hexahydrosiladifenidol, drugs with high affinity for the M1 subtype, were significantly more potent inhibitors of [3H]-QNB binding than the M2 selective drug methoctramine. Immunoprecipitation studies were done using antisera raised to individual M1-M5 receptor subtypes. Approximately 75% of the solubilized receptors in the adenoma specimens were immunoprecipitated with the anti-M1 antibody, in contrast to 5% or less with antibodies against M2, M3 or M4 subtypes. These immunoprecipitation studies confirm the preponderance of the M1 subtype in prostate adenoma suggested by the high affinity pirenzepine binding. M1 receptors, when incubated with agonist, coimmunoprecipitated with the alpha subunits of the guanine nucleotide binding regulatory proteins Gi alpha, Gq/11 alpha and G16 alpha. Immunohistochemical staining with the anti-M1 antibody demonstrates the M1 receptor to be localized to the glandular epithelium. The human prostate is the first peripheral tissue in which a preponderance of the M1 subtype of muscarinic receptors has been demonstrated.

    Title Retained Sacral Function in Children with High Level Myelodysplasia.
    Date August 1995
    Journal The Journal of Urology
    Excerpt

    To assess the preservation of sacral function despite denervation higher on the spinal cord in children with myelodysplasia, we examined 151 myelomeningocele patients presenting for urodynamic evaluation from 1980 to 1992 with a lesion at L3 or above on neurological examination. Of the 151 patients 70 (46%) had denervation of the external sphincter on initial evaluation and 81 (54%) had sacral sparing, that is normal or near normal electrical potentials of the external urethral sphincter and/or retained reflexic bladder activity regardless of the presence or absence of sacral reflexes. Of the 81 patients with sacral sparing 57 (70%) had detrusor-sphincter dyssynergia and 21 had synergy or denervation of the sphincter in association with retained detrusor reflexia. Whereas only 18% of children age 1 year or younger with retained sacral function had upper urinary tract deterioration on initial radiological studies (manifested by reflux or hydronephrosis), 57% had deterioration when evaluated after age 1 year. None of the patients without retained sacral function had evidence of upper urinary tract damage at younger than 1 year but 28% of those studied beyond age 1 year had changes. Patients with flaccid lower extremities can retain sacral function, which puts the upper urinary tract at risk of deterioration. Our results show that this risk increases with time.

    Title Diagnosis and Treatment of Enterovesical Fistulae.
    Date June 1992
    Journal The American Surgeon
    Excerpt

    Presenting symptoms, diagnostic progression, etiology, therapy, and complications of 44 patients with enterovesical fistulae who came to three Yale teaching hospitals over a 9-year period were reviewed. Patients with diverticulitis as the cause of their fistula were older and came to the hospital with pneumaturia/fecaluria. Patients with pelvic cancer were more likely to have fecaluria, gastrointestinal symptoms, or hematuria. Patients with Crohn's disease were an average of 20 years younger than the patients with cancer or diverticulitis and they came to the hospital with pneumaturia, abdominal pain, abdominal mass, and tenderness. Computerized axial tomography scanning, cystoscopy, charcoaluria, and barium enema were useful in making the diagnosis; intravenous pyelography and colonoscopy were not. One-tenth of the patients were not candidates for operation, and one-quarter of the patients did not undergo complete operative resolution with restoration of enteric and urinary continuity. Nine patients underwent a two-stage repair consisting of resection/repair of the fistula with proximal fecal diversion and subsequent re-establishment of bowel continuity. These patients had a higher morbidity than the 19 patients who underwent one-stage repair. Enterovesical fistula is a challenging entity, the etiology of which may be suspected upon taking the patient's history or performing the physical assessment; however, the definitive diagnosis of enterovesical fistula can remain elusive. Single-stage repair can be achieved with low morbidity and mortality in many candidates.

    Title The Straight Radial-antecubital Ptfe Angio-access Graft in an Era of High-flux Dialysis.
    Date June 1991
    Journal American Journal of Surgery
    Excerpt

    Straight radial-antecubital polytetrafluoroethylene (PTFE) grafts were placed in 10 older (greater than 55 years) male patients with significant intercurrent diseases who were considered candidates for high-flux dialysis. Graft patency was 90% at 6 months, and suitable flow for high-flux dialysis (greater than 400 mL/minute) could be achieved with all grafts. Shorter dialysis times with no major cardiovascular, hemodynamic, or extremity complications were achieved with this mode of therapy. The principles and practicalities of high-flux dialysis are reviewed. This small series of patients demonstrates that the relatively low resting flow of the straight radial-antecubital PTFE graft should not be a major consideration in the choice of this vascular access procedure in patients being considered for high-flux dialysis. Straight radial-antecubital PTFE grafts preserved both the ulnar collateral to the hand and the brachial artery for later access, yet provided adequate flow in all patients in whom they remained patent.

    Title Seeking A Rational Approach to the Diagnosis and Treatment of Interstitial Cystitis.
    Date
    Journal
    Excerpt

    At least 90% of the half-million Americans with interstitial cystitis (IC) are women. But correctly diagnosing and treating the problem are not as clear as the statistics. The clinical hallmarks--bladder pain, urinary urgency and frequency, nocturia, and dysuria--are not confined to IC. A key feature of diagnosing the problem is to exclude the vast array of other possibilities, including carcinoma and detrusor hyperreflexia. To confirm the diagnosis, cystoscopic exam with hydrodistention is needed to visualize diffuse glomerulations or classic Hunner's ulcer. Treatment is empiric and can involve a variety of oral and intravesical therapies. Patients with a bladder capacity less than 250cc may benefit from surgery.

    Title Clinical Phenotyping in Chronic Prostatitis/chronic Pelvic Pain Syndrome and Interstitial Cystitis: a Management Strategy for Urologic Chronic Pelvic Pain Syndromes.
    Date
    Journal Prostate Cancer and Prostatic Diseases
    Excerpt

    The urologic chronic pain conditions such as chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis are syndromes whose evaluation and management are controversial. Part of the difficulty in diagnosis and therapy is the heterogeneity of etiologies and symptoms. We propose a six-domain phenotype, which can classify these patients clinically and can direct the selection of therapy in the most evidence based multimodal manner. The domains are urinary, psychosocial, organ specific, infection, neurologic and tenderness of skeletal muscles. This system is flexible and responsive to new biomarkers and therapies as their utility and efficacy are proven.Prostate Cancer and Prostatic Diseases advance online publication, 22 July 2008; doi:10.1038/pcan.2008.42.

    Title Category Iii Chronic Prostatitis/chronic Pelvic Pain Syndrome: Insights from the National Institutes of Health Chronic Prostatitis Collaborative Research Network Studies.
    Date
    Journal Current Urology Reports
    Excerpt

    Chronic prostatitis/chronic pelvic pain syndrome remains an enigmatic medical condition. Creation of the National Institutes of Health-funded Chronic Prostatitis Collaborative Research Network (CPCRN) has stimulated a renewed interest in research on and clinical aspects of chronic prostatitis/chronic pelvic pain syndrome. Landmark publications of the CPCRN document a decade of progress. Insights from these CPCRN studies have improved our management of chronic prostatitis/chronic pelvic pain syndrome and offer hope for continued progress.

    Title Gunshot Wounds to the Scrotum: a Large Single-institutional 20-year Experience.
    Date
    Journal Bju International
    Excerpt

    Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Penetrating trauma to the scrotum often requires operative intervention, with testicular salvage only possible when enough testicular tissue can be re-approximated in the traumatic setting. The present report represents the largest series of gunshot wound trauma to the scrotum in the literature. Further, it validates recommendations of the European Association of Urology guidelines on urological trauma that advocate operative intervention due to minimal rates of patient morbidity and the inherent limitations of scrotal ultrasonography in discerning testicular compromise.


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