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Changing the law on assisted dying may result in more preventable deaths. Chris Lavy and Nuha Yassin look at the arguments against AD.

Introduction Intracavernosal injections (ICI) are the second line treatment of erectile dysfunction (ED). To reduce the risk of complications, primarily priapism, the first administration has traditionally required face-to-face appointments. With a move to remote working, the safety and feasibility of an instructional video for the first self-administration of ICI was assessed. Methods Two centres recruited patients, with participants receiving a pack comprising a written instruction leaflet and a Viridal Duo prescription, followed by an email with our instructional video. Patients were given a specific time to self-administer their ICI (Alprostadil 2.5 micrograms), when our CNS was available for support. The same CNS would follow up two hours later via telephone to assess the experience using a Likert scale semi-structured interview. Results Thirty-nine patients were recruited between two centres, with 35 continuing to injection. The median age was 63 years (range 34–78). The most common ED aetiology was post-prostatectomy (18/35). Thirty-four (97%) recruits found the video instructions clear, with it being watched a mean 2 (range 1–8) times. Only 1 patient (3%) required telephone support. At the 2.5mcg dose, the mean erection hardness score was 2 (range 1–4) after an average of 5 minutes. No patients reported significant bruising at the injection site and there was no priapism. Thirty-three patients (94%) were very or extremely likely to recommend this method for starting ICI therapy. Conclusion Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity. Take-home message Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity.

Objective: To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons. Methods: Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups. Results: More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures. Conclusion: Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology. Level of evidence: Level IV

Introduction: The ISCP (Intercollegiate Surgical Curriculum Programme) was introduced in 2007. It heralded a shift in surgical training from the traditional apprenticeship model, to a system where competence is assessed regularly within the workplace. Central to ISCP is the recording of Workplace Based Assessments, such as PBA (procedure-based assessment) and DOPS (Direct Observation of Procedural Skills). These are assessments “for” learning rather than assessments “of” learning and central to their purpose is detailed feedback from trainer to trainee. The aim of this study was to assess the quality of the feedback recorded on ISCP. Methods: The anonymised ISCP portfolios for 170 core and specialty urology trainees working in 16 deaneries were analysed. Over a three month period 469 DOPS and 592 PBAs were recorded and the presence and quality of assessors' feedback were evaluated according to the presence of five criteria: • Encouragement through positive language, • Including strengths, • Raising appropriate development needs, • Suggestions for appropriate corrective action, • Providing explanations. Results: Feedback was recorded in 49% and 67% of PBAs and DOPS respectively. In those assessments where feedback was recorded, positive language was used in 83% in PBAs and 70% in DOPS. Strengths were recorded in 53% for both tools. Developmental needs, suggestions for development and detailed explanation were recorded in 25%, 26%, 29% for PBAs and 24%, 23%, 19% for DOPS respectively. Conclusion: This study highlights the lack of feedback being recorded on ISCP and the paucity of good quality feedback when it was given.

In 2009, recruitment into higher urological training changed dramatically to a process of national selection. This article describes the process used, presents feedback from the assessors and candidates involved, and discusses possible improvements for future rounds.

Vardenafil is a new phosphodiesterase type-5 inhibitor for the treatment of men with erectile dysfunction (ED). It was licensed in Europe in spring 2003 and in the USA in late 2003. It is a potent and selective inhibitor of the enzyme phosphodiesterase type 5, and in the presence of an erectile stimulus potentiates the intracellular actions of cyclic guanylate monophosphate. Several large, placebo-controlled trials have demonstrated efficacy both in the broad population of men with ED and in men with more difficult to treat ED. It is well tolerated with a side effect profile typical of this class of drugs. It has a rapid onset of action and has demonstrable efficacy for men using the medication for up to 2 years.

Purpose: We determined whether voltage gated K+ (KV) channels are expressed and functional in human detrusor smooth muscleMaterials and Methods: Information on KV channels was obtained using electrophysiological patch clamp, immunofluorescence, Western blot and isometric tension recording techniquesResults: Patch clamp recordings from detrusor cells revealed a Ca2+ independent K+ current that was activated by depolarization in a voltage range near the resting potential of detrusor smooth muscle. The current was inhibited by 3,4-diaminopyridine, a blocker of KV channels. Antibodies targeted to KVα1 subunits revealed KV1.3 and KV1.6 expression in whole bladder tissue samples and specifically in detrusor smooth muscle cells. New specific blockers of KVα1 channel currents (correolide and recombinant agitoxin-2) had a myogenic effect, characterized by increased amplitude of spontaneous contractions without an effect on the frequency of contractions or on resting baseline tension.Conclusions: KVα1 subunits are ...

To establish methodology which rapidly and reliably assesses the effect of an alpha1-adrenoceptor antagonist on peak urine flow rates in men with benign prostatic hyperplasia (BPH). This methodology could then be applied to screening new drugs to treat BPH.Twenty-five patients with BPH enrolled in a double-blind, placebo-controlled, two-period crossover study. Patients were either withdrawn from their current alpha1-adrenoceptor antagonist therapy (n = 22) or were untreated prestudy (n = 3) and all met prespecified uroflowmetric criteria including: (1) a peak urine flow rate (Qmax)12 ml s-1 off therapy (or10 ml s-1 if untreated prestudy) and (2) a decrease in peak urine flow rate (Qmax) of2 ml s-1 after withdrawal from therapy. Study treatment consisted of tamsulosin 0.4 mg (or matching placebo) once daily for 8 days in a two-period crossover. Uroflowmetry was performed predose and once postdose (4.5-5.5 h postdose) on day 1, and once postdose (4.5-5.5 h postdose) on day 8 of each treatment period.After a single dose of tamsulosin, the least-square mean difference between tamsulosin and placebo in the change from baseline Qmax was 2.8 ml s-1 (P = 0.017 vs placebo). After 8 days dosing of tamsulosin, the least-square mean difference between tamsulosin and placebo in the change from baseline Qmax was also 2.8 ml s-1 (P = 0.044 vs placebo). Additionally, there was no significant difference observed between the single and multiple dose results (P0.200 for between group difference).Both single and multiple doses of tamsulosin 0.4 mg increased Qmax in men with BPH. A single dose produced a comparable response to multiple dose administration. The magnitude of the effect was greater than the effect generally seen in longer term clinical trials, but this difference may be explained by the patient population in this study which was preselected for 'responsiveness' to an alpha1-adrenoceptor antagonist. These results support the utility of single dose uroflowmetric measurements in rapidly providing preliminary data on new investigational agents, specifically agents which act to increase urine flow in men with BPH. However, clinical efficacy would still need to be confirmed with longer term clinical trials.

Corporal smooth muscle (CSM) tone is maintained by a finite balance between relaxant and contractile neurotransmitters. The aim of these experiments was to ascertain the degree to which cyclic GMP is involved in these interactions. We also sought to elucidate the pharmacological mechanism of action of MB in rabbit corpus cavernosum (RCC), an important tool in nitric oxide research. Using an organ chamber technique, strips of RCC were treated with the guanylate cyclase inhibitors Methylene Blue (MB) and LY83583; 100 μM MB led to increases in resting tension which were antagonized by indomethacin, nifedipine, phentolamine, but not superoxide dismutase (SOD). Contractile responses to noradrenaline (NA) were increased and relaxation to ACh was impaired by both MB and LY83583 and reversed with indomethacin, but not SOD. Pyrogallol had no effect on agonist-induced responses. The pharmacological action of MB in RCC does not depend on the generation of superoxide anions. Endothelium-dependant relaxation in RCC results in activation of soluble guanylate cyclase and release of a stable endothelium derived contracting factor(s), which is likely to be a constrictor prostanoid(s). Tonic production of cGMP in RCC inhibits the presynaptic release and contractile effects of NA and can be modulated by cyclo-oxygenase inhibition, demonstrating the important interaction and functional antagonism between cGMP and prostaglandins in the control of CSM tone.

Electromyography of the pelvic floor muscles may be used to assess their innervation using the technique of motor unit analysis. Prolongation of motor unit duration and an increase in motor unit amplitude reflects denervation and reinnervation of these muscles. This principle may be used to detect and investigate nerve damage in a variety of disorders which affect the musculature of the pelvic floor, including multiple system atrophy. It has also been used to investigate the effects of childbirth on the pelvic floor and to investigate the relationship between damage to the innervation of the pelvic floor and stress incontinence. Finally, urethral sphincter electromyography has detected abnormal electrical activity in some women with obstructed voiding, which may reflect abnormal relaxation of the striated urethral sphincter.

Summary The results of 12 years' experience in the surgical treatment of hypospadias fistula are presented. Overall, there was a success rate of approximately 50% for each attempt at surgical closure of a fistula. The chances of success were not significantly influenced by the number of previous surgical procedures. The best results were obtained with fistulae on the shaft of the penis which were closed with mucosal inversion and advancement of a skin flap over the fistula.

We report the clinical features, urodynamic results and neurophysiological findings in 6 patients with urinary symptoms related to tropical spastic paraplegia. The widespread nature of the pathological changes within the nervous system result in a complex variety of urodynamic and neurophysiological features.

Vardenafil has demonstrated efficacy for the pharmacological management of erectile dysfunction (ED). Accumulating evidence suggests that ED is frequently associated with underlying cardiovascular and metabolic conditions which are thought to be involved in the aetiology of ED. The present review aims to summarise and discuss the available evidence for the efficacy, safety and tolerability of vardenafil in patients with underlying conditions including diabetes, hypertension and dyslipidaemia.Relevant articles were identified through a PubMed search of clinical trials and postmarketing surveillance studies of vardenafil in patients with ED including those with diabetes, hypertension and dyslipidaemia.Across all trials, vardenafil showed good efficacy for the treatment of ED in patients with diabetes, hypertension and dyslipidaemia. Vardenafil also showed a favourable safety and tolerability profile. The concomitant use of medication to treat hypertension or dyslipidaemia was not associated with an increase in adverse events following vardenafil treatment.The prevalence of both diagnosed and undiagnosed underlying conditions is high among men with ED. The evidence presented in this review suggests that vardenafil is efficacious and well tolerated in patients with ED and diabetes, hypertension and/or dyslipidaemia and can be recommended as first-line treatment for ED in patients with these conditions.

To identify the relationship of erectile dysfunction, hypogonadism and the metabolic syndrome in the context of men's health.An Expert Panel Meeting was held in December 2006 in Vienna, Austria. In addition a comprehensive literature search was conducted.Men have a higher incidence of cardiovascular events than women of similar ages which has led to the belief that testosterone is a risk factor for cardiovascular disease in men. The latter hypothesis is no longer tenable. On the contrary, low testosterone levels are associated with (visceral) obesity, the metabolic syndrome, diabetes mellitus, cardiovascular disease and erectile dysfunction (ED). Testosterone therapy does not lead to an increased incidence of cardiovascular disease or events such as myocardial infarction, stroke or angina. Until recently (visceral) obesity, the metabolic syndrome, diabetes mellitus, cardiovascular disease and ED were viewed as more or less independent entities affecting the ageing male. It was not recognised that hypogonadism is a common denominator. With a more integrative approach to the health situation of middle-aged and elderly men, these conditions appear closely interrelated in their manifestations, hypothetically in their aetiology, diagnostic strategy and also their treatment.Improving sexual health is a portal to identify health hazards and improving men's health. Appropriate diagnosis and medical work up of men presenting with sexual symptoms may have the benefit of the diagnosing and treating other important conditions, such as obesity, diabetes, hypertension and hyperlipidaemia.

Erectile dysfunction (ED) is a common condition estimated to affect more than 150 million men worldwide. ED should be regarded as a shared sexual problem which has significant detrimental effects both on the men who experience this condition and on their partners.Evidence shows that the partner plays a key supportive role in the man's ED treatment and in successful long-term ED therapy. Including the partner in consultations may highlight discordant attitudes and communication problems between couple members which may indicate treatment acceptance or rejection, or realistic or unrealistic treatment expectations.Most patients with ED consult their physician in the absence of their partner. Therefore, involving the partner in therapy can be challenging. Two options which physicians should consider are: encouraging the patient to bring the partner into the office and, often more realistically, seeking information about, and providing information to, the partner, via the patient.The objective of these recommendations is to provide practical guidance on treating couples affected by ED, and suggest techniques that may be helpful in integrating the partner into the process of ED treatment.

The parasympathetic nervous system provides the primary pro-erectile innervation of the penis. Originating from the sacral nerve roots (S2–S4) the nerves provide vasodilating innervation to the cavernosal tissue. The parasympathetic nerves release a cocktail of pro-erectile neurotransmitters, of which the most important is nitric oxide (NO), which acts on the smooth muscle cell via a second messenger system involving cyclic GMP. The sympathetic innervation mediates detumescence and originates within the thoraco-lumbar cord (T11-L2) via release of noradrenaline. Our knowledge of the pharmacology of erection has recently provided us with a number of therapeutic approaches to the treatment of erectile dysfunction. The pudendal nerve represents the somatic innervation of the penis carrying both afferent impulses from the genitalia and motor fibres to the muscles of the pelvic floor.

Male sexual dysfunction after fracture of the pelvis is more common than previously supposed with rates as high as 30% reported when the complaint is specifically sought. With the increase in survival from major injuries, the long-term consequences of trauma are being seen with increasing frequency

In July 2010, the Joint Commitee on Surgical Training (JCST) launched a review of its quality assurance functions, which included the development of a new survey specific to surgical trainees. The survey was developed in conjunction with the Confederation of Postgraduate Schools of Surgery and aimed to provide detailed information on the quality of surgical training in the UK and to standardise the information from the different schools of surgery, thereby allowing some comparison between training schemes and units. A 20-question survey was developed for all surgical specialties, while a more detailed survey with questions relating to curriculum delivery was piloted in core surgical training and paediatric surgery.

Tadalafil is an inhibitor of phosphodiesterase type 5, and is currently undergoing regulatory review in the US and in Europe. Its chemical structure is significantly different from sildenafil, and in vitro studies confirm significant potency for PDE5 inhibition, with little activity against most of the other isoforms of the enzyme including PDE6, which is the isoform of the enzyme found within the retina. The half-life of tadalafil is 17.5 hours and clinical studies suggest significant activity 24 hours post-dosing. As with sildenafil, efficacy depends upon a normal sexual stimulus, and the drug can taken be as required. Tadalafil is effective in the treatment of men with erectile dysfunction, and it appears to have a relatively mild side-effect profile, with no visual side-effects noted.

We determined whether voltage gated K+ (KV) channels are expressed and functional in human detrusor smooth muscleInformation on KV channels was obtained using electrophysiological patch clamp, immunofluorescence, Western blot and isometric tension recording techniquesPatch clamp recordings from detrusor cells revealed a Ca2+ independent K+ current that was activated by depolarization in a voltage range near the resting potential of detrusor smooth muscle. The current was inhibited by 3,4-diaminopyridine, a blocker of KV channels. Antibodies targeted to KValpha1 subunits revealed KV1.3 and KV1.6 expression in whole bladder tissue samples and specifically in detrusor smooth muscle cells. New specific blockers of KValpha1 channel currents (correolide and recombinant agitoxin-2) had a myogenic effect, characterized by increased amplitude of spontaneous contractions without an effect on the frequency of contractions or on resting baseline tension.KValpha1 subunits are expressed and functionally important in human detrusor muscle.

To examine nitric-oxide (NO)-mediated relaxation in cavernosal smooth muscle in a rat model of diabetes, as previous experiments showed that HbA1c (an isoform of glycosylated haemoglobin and a marker of long-term diabetic control) impaired NO-mediated relaxation of normal corpus cavernosal tissue through the generation of superoxide anions.Eight weeks after the induction of diabetes, male Wistar rats were killed and cavernosal tissue obtained. Strips were contracted with 1 micromol/L noradrenaline before applying acetylcholine or electrical field stimulation (EFS) or sodium nitroprusside (SNP). Relaxation responses were repeated in the presence of L-arginine (100 micromol/L), indomethacin (10 micromol/L) or superoxide dismutase (SOD, 120 IU/mL). Young and age-matched control animals were examined in the same way.Eight weeks of uncontrolled diabetes caused a significant impairment in mean relaxation responses to acetylcholine (P0.05) and to EFS (P0.05), but not to SNP, compared with young and age-matched controls, respectively. L-arginine, indomethacin and SOD had no significant effect on this impairment. Ageing caused a lesser but significant impairment in EFS-mediated cavernosal smooth muscle relaxation (P0.05).Diabetes impairs endothelial and neuronal NO-mediated cavernosal smooth muscle relaxation in rats in vitro. This effect is not mediated by an alteration in the intracellular action of NO, the availability of NO, superoxide anion inactivation of NO or the generation of constrictor prostanoids. It is possible that cholesterol or advanced glycation end products are responsible for the effect of diabetes on penile smooth function.

An expandable titanium intraprostatic stent was inserted into 30 patients with infravesical obstruction due to benign prostatic hyperplasia (BPH). All of the men were considered unsuitable for transurethral resection of the prostate as a result of comorbid conditions. In 25 patients effective micturition was reestablished with this technique. In 21 of these men, who have been followed for longer than 1 year, the mean maximum flow rate at 1 year was 10.8 ml. per second and the mean residual urine was 56 ml. Although urinary tract infections occurred subsequent to stent insertion in 10 individuals, these resolved after appropriate antibiotic treatment and no stents have had to be removed for this reason. Followup cystoscopy or examination by electron microscopy of those stents that have been removed has shown partial epithelialization of the stent surface in a proportion of patients, and a minor degree of incrustation occurred in 1 case. We conclude that an expandable intraprostatic titanium stent is an acceptable alternative to transurethral resection of the prostate or long-term catheterization in this particular group of high risk patients.

The balance of penile smooth muscle tone is finely controlled, with contractile factors acting in opposition to relaxant factors. The principal agents in this process are undoubtedly noradrenaline and nitric oxide. Prostaglandins probably have a crucial role in the 'fine tuning' of corporal smooth muscle tone. Their effects on control mechanisms in the healthy penis are more likely to be modulatory rather than direct.

To examine the effect of HbA1c, an isoform of glycosylated haemoglobin (GHb, a product of non-enzymatic reactions between elevated blood glucose and haemoglobin), on nitric oxide-mediated corpus cavernosal smooth muscle relaxation, and to categorize the mechanisms involved.Corpus cavernosal tissue from Wistar rats (300-350 g body weight) was prepared for the measurement of isometric tension. After equilibration in Krebs solution gassed with 95% O2/5% CO2 at 37 degrees C for 90 min, optimal resting tension was applied. Tissue was precontracted with 1 micromol/L noradrenaline (NAd) and either relaxed with incremental doses of acetylcholine (ACh) or sodium nitroprusside (SNP). After washout, strips were again precontracted with NAd and then incubated with pyrogallol (100 micromol/L), 100 microL of haemoglobin or 100 microL of GHb in the presence of either L-arginine (100 micromol/L), indomethacin (10 micromol/L), allopurinol (100 micromol/L), deferoxamine (100 micromol/L), catalase (600 IU/mL), or superoxide dismutase (SOD) (120 IU/mL) before ACh- or SNP-induced relaxation responses were repeated.Haemoglobin and GHb significantly impaired the relaxation of rat corpus cavernosum to ACh in a dose-dependent manner. L-arginine reversed the impairment caused by Hb, but not GHb. A donor of superoxide anions, pyrogallol, mimicked this impairment to ACh when added to control strips. Catalase, deferoxamine, indomethacin and allopurinol had no significant effect on the impaired relaxation response to ACh, whilst L-arginine partially reversed it. SOD completely reversed the GHb-induced impaired relaxation; GHb did not alter the relaxation response to SNP.GHb significantly impairs endothelial NO-mediated corpus cavernosal relaxation in the rat, in vitro. This effect is caused partly by the generation of superoxide anions and the extracellular inactivation of NO.

To determine, in a double-blind placebo-controlled crossover study, whether L-arginine improves the symptoms of interstitial cystitis (IC), a chronic condition in which nitric oxide (NO) may be important, as previous open pilot studies suggested that L-arginine reduced the pain and frequency associated with IC.Patients fulfilling the standard diagnostic criteria for IC were randomized to receive L-arginine (2.4 g/day) or placebo for one month. After a 2-week 'washout' period they received the other medication. Patients were assessed at each stage using a validated symptom index, a voiding diary, urine analysis and records of adverse events. Patients were asked about overall efficacy at the close of the study. The results were compared using a t-test, with significance indicated at P0.05.Sixteen (16) patients (mean age 51.3 years) were enrolled; the mean duration of IC was 5.4 years, the IC symptom index score 29.1, their nocturnal frequency 3.5 (voided volume 182 mL) and daytime frequency 12.7 (124 mL). Patients on placebo showed no differences in any recorded variable over the baseline values. L-arginine caused a statistically significant reduction in the overall symptom score of 2.2 over baseline, but there was no difference in voided volume, frequency or nocturia. As there was no significant difference for any variable between L-arginine and placebo, this reduction in score should be regarded with caution. Three patients withdrew because of side-effects (severe headaches, night sweats and flushing).Oral L-arginine produces a statistically significant improvement in the IC symptom index in patients with IC, but the effect is small. This effect may not be clinically significant as there were no improvements in the other variables assessed and no significant difference between the response to L-arginine and placebo. From these results the use of L-arginine cannot be recommended for treating IC.

To determine if the assay for free prostate specific antigen (fPSA) and the calculated ratio of fPSA to total PSA (f/tPSA) is stable in conditions likely to be met in routine clinical practice.Two blood samples were obtained from 27 patients attending a routine urology clinic. Sample 1 was centrifuged immediately, assayed for fPSA and tPSA, and the f/tPSA calculated. This sample was then stored at 4 degrees C for 24 h, 48 h and 1 week, or at -20 degrees C for 24 h, 1 week and 1 month before the assays for fPSA and tPSA were repeated. The second sample was left at room temperature for 24 h before assay and processing, as for sample 1.tPSA is a highly stable analyte; if whole blood samples are processed immediately, fPSA is stable for 24 h at 4 degrees C and 1 month at -20 degrees C. There was a significant reduction in the calculated f/tPSA in samples stored for/=24 h at 4 degrees C (P0.01); if the sample was stored at -20 degrees C the calculated f/tPSA was stable. After 24 h storage at room temperature, fPSA decreased by 6.3% and f/tPSA by 6.4%. Subsequent storage of serum at 4 degrees C for 1 week resulted in a 25% decrease from the baseline value. After 1 month at -20 degrees C the fPSA value was 13% lower than the baseline value.These results indicate that if there is to be confidence in the accuracy of the f/tPSA value, then blood samples must be handled and processed correctly. Total PSA is sufficiently stable to permit whole blood samples to remain at room temperature for 24 h before serum is separated. If fPSA is to be determined accurately then the whole blood sample must be centrifuged promptly. As the fPSA values in blood samples left at room temperature for 24 h are up to 25% lower than those on immediate assay, and the subsequent f/tPSA 29% lower, then for the optimum use of this test, these samples should also be handled appropriately.

To assess the role of extra-anatomic stents (EAS) as a means of urinary diversion in patients with ureteric obstruction secondary to malignancy.The technique for inserting EAS in patients with ureteric obstruction was described previously; to date, 13 patients (seven women and six men, mean age 45.3 years, range 22-78) have been treated. All patients had ultrasonographic evidence of hydronephrosis and/or significant biochemical evidence of renal impairment. Patients had advanced malignancy and one patient an abdominal aortic aneurysm.Urinary diversion was successful in all patients; two survived for more than 1 year, with stent changes at 6-monthly intervals. In three patients the stents were replaced by percutaneous nephrostomies because of problems with leakage or infection. The remaining patients died with functioning EAS in situ.In patients with ureteric obstruction secondary to malignancy or medical conditions excluding them from more invasive surgery, EAS provide a further therapeutic option instead of a permanent nephrostomy, which has associated inherent problems. This technique is not without potential problems and careful selection of patients remains vital in this difficult area.

To determine the response of mechanosensitive pelvic nerve afferents, arising from the rat urinary bladder, to the purinergic agonist alpha,beta-methylene ATP and to the purinergic antagonist suramin.Using a newly developed in vitro bladder-pelvic nerve afferent model, multiunit recordings were taken from mechanosensitive pelvic nerve afferents arising from the rat urinary bladder, in response to bladder distension. Control experiments were performed by distending the bladder with saline at 0.04 mL/min, and recording the total afferent nerve activity and the bladder pressure response to the distension. Bladder distensions were then repeated using a solution of the stable purinergic agonist alpha,beta-methylene ATP (10 micromol/L), which is known to desensitize P2X-purinoceptors after prolonged exposure, and the total afferent activity and bladder pressure response were again measured. In a separate series of experiments the afferent nerve activity and bladder pressure response to bladder distension with saline was determined in the presence of the purinergic antagonist suramin (10 micromol/L) and repeated after washout of the drug. In both series of experiments, afferent nerve responses were compared with control using the paired t-test, whilst the bladder pressure responses were compared using one-way analysis of variance.Bladder distension with alpha,beta-methylene-ATP produced a statistically significant reduction in afferent nerve activity, by up to 75% compared with the control, whilst having no significant effect on the bladder pressure response. Bladder distension with saline in the presence of suramin (10 micromol/L) produced a significant reduction in the resultant afferent nerve activity, by 50%, which returned to normal after washout of the drug.These findings are consistent with the notion that ATP is released endogenously during bladder distension in the rat and is involved significantly in the activation of pelvic nerve afferents arising from the rat urinary bladder.

To report experience of a broad multimodality approach to the treatment of calculi in children using extracorporeal shock wave lithotripsy (ESWL), ureteroscopy/laser lithotripsy, lithoclast and percutaneous nephrolithotomy (PCNL).The treatment and outcome were reviewed in 43 children managed by a range of minimally invasive modalities, either singly or in combination, between 1990 and 1997. These patients represent a selected group deemed suitable for minimally invasive management during a period of developing experience with these techniques. Of this cohort, six children had previously undergone open stone surgery and contributory metabolic abnormalities were identified in seven. ESWL was the sole treatment modality in 24 children (56%). In five children (12%) ureteroscopy/laser lithotripsy was combined with ESWL, eight (18%) underwent ureteroscopy/laser lithotripsy alone, whilst three with bladder stones were treated with the lithoclast. Combined therapy including PCNL was required in three patients.Of the 43 children treated, 38 (88%) were rendered stone-free. Metabolic disorders accounted for three of the five cases of residual calculi. Complications requiring intervention occurred in two children (7%) and three subsequently underwent open pyelolithotomy or ureterolithotomy after unsuccessful minimally invasive treatment.Used selectively, the range of minimally invasive procedures available for adults, including ureteroscopy and PCNL, can be safely and effectively extended to the treatment of urinary tract calculi in children. The role of open surgery will diminish further with the availability of specialized instruments for paediatric PCNL.

Thirty-three impotent men underwent pharmacocavernometry and cavernography. Ten patients had a good clinical response to 60 mg papaverine, nine had a moderate clinical response and in 14, the response was judged to be a poor one. Twelve patients had evidence of abnormal venous leakage from the corpora. Subsequent investigation with isotope phallography showed six patients to have arterial insufficiency and in three of these patients this was amenable to reconstructive vascular surgery. We conclude that pharmacocavernometry provides a useful, cheap and reliable method for the investigation of impotent men which may be performed on an outpatient basis.

Objective To review the outcome of orchidopexy in boys with testicular ascent. Patients and methods The case notes of all the boys who underwent orchidopexy over an 18-year period, under the care of a single consultant, were collected. The reports of patients who at the initial assessment had normally descended testes and subsequently developed maldescent, were reviewed. Results At the time of the initial assessment, 69 boys (77 testes) had normally descended testes but subsequently developed maldescent. In the intervening period, 37 of these patients (38 testes) had undergone inguinal surgery for a hernia or a hydrocele (trapped testes). The remaining 34 patients had not undergone surgery and were designated as having an 'ascending testis'. The results of surgery were excellent in all but six cases. Of these, five testes failed to reach the bottom of the scrotum and one was excised. A hernial sac was found in 16 of 28 boys with a trapped testis in whom the data was recorded. Conclusion Testicular ascent is uncommon and can occur spontaneously or following ipsilateral groin surgery where scarring is a likely aetiological factor. The results of surgery are usually excellent.

A number of patients with medullary sponge kidney recurrently form and pass stones with the risk of developing an obstructive nephropathy. These patients may benefit from extracorporeal shock wave lithotripsy to the medullary collections, as this appears to reduce the frequency of symptomatic stone passage.

The ability of serum prostate specific antigen (PSA) to predict bone metastases at initial presentation was determined in 146 patients, and in 66 patients during a 3-year period; 14.7% of patients with bone metastases at presentation had a PSA value less than 20 ng/ml. All patients who subsequently developed bone metastases had a PSA greater than 20 ng/ml and the rise in PSA often antedated the detection of bone metastases. Bone scans are still necessary in the initial staging but following diagnosis and treatment can be replaced by serum PSA measurement in monitoring patients with prostatic cancer.

Summary— A total of 1209 undescended testes in 961 boys who had had no previous surgery for this problem have been reviewed with particular regard to the outcome of surgery in relation to the pre-operative and intra-operative assessment of the position of the testis. A third of impalpable testes were found at operation in the abdomen, a third in the inguinal canal and a quarter in the superficial inguinal pouch; 1% of all testes and 7% of impalpable testes were absent; 96% of all testes reached the scrotum at operation and this figure included 69% of abdominal and 94% of canalicular testes. In all 24 testes were excised—7 of which were abdominal, 8 canalicular and 9 were in the superficial inguinal pouch. The generalisation that the higher the undescended testis before operation the poorer the result, does not always hold true.

A group of 69 men with bladder outflow obstruction due to benign prostatic hyperplasia (BPH) were treated in a double-blind, placebo-controlled study with finasteride (Proscar, MK-906), a 5-alpha reductase inhibitor, 5 mg or 10 mg/day or placebo for 3 months; subsequently, 20 patients received finasteride 5 mg/day for a further 9 months in an open extension study. In treated patients dihydrotestosterone declined by over 60%, remaining unchanged with placebo. Symptom scores fell significantly in all 3 groups. Mean maximum flow rates fell slightly in placebo-treated patients but improved by 1.5 ml/s in the 10 mg group and by 3.3 ml/s in the 5 mg group. After 1 year's treatment, the reduction in symptom score and increase in flow rate were well maintained; the mean prostate volume was reduced by 14% and prostatic specific antigen declined by 28%. It was concluded that finasteride shows some efficacy in the treatment of BPH, with minimal toxicity, but 12 months of therapy or longer may be necessary to achieve maximal effect.

Urethrovesical dysfunction is common in patients with multiple sclerosis. We present the results of urodynamic and neurophysiological studies in a series of 24 patients with multiple sclerosis associated with urinary symptoms. Urethral sphincter electromyography showed only minor abnormalities but studies of central conduction demonstrated abnormal sensory conduction in 88% and abnormal motor conduction in 80% of the patients studied. These abnormalities of central conduction correlated well with the urodynamic findings.

Objectives Erectile dysfunction (ED) impacts greatly on men and their female partners. The Female Experience of Men's Attitudes to Life Events and Sexuality (FEMALES) study assessed levels of concordance or divergence among couple members’perceptions of the specific functional impairments characterising the male partner's ED, and their attitudes, beliefs and experiences relating to ED. Design and method Questionnaires were sent to partners of men with ED who participated in the Men's Attitudes to Life Events and Sexuality (MALES) 2004 study, and who consented to their partner's involvement. FEMALES questionnaire responses were analysed in relation to responses to equivalent questions provided by male study participants. Results Women's perceptions of the specific functional impairments characterising their partner's ED and the frequency of his erection difficulty were highly associated with assessments by the man. Significant associations were observed between couple members’responses regarding their attitudes, beliefs and experiences relating to ED. A number of sex-specific findings were highlighted, where couple members held divergent views on the effect of ED on the couples’everyday and sexual life. Conclusions A high degree of concordance in couple member's perceptions of the male partner's ED, and their attitudes and beliefs about ED was observed. However, a number of differences between males’and females’perceptions and attitudes were evident. Instances of discordance may be significant for the couple, and may contribute to treatment avoidance or conflict.