Year: 2015

Highlights from #BAUS15

June 24, 2015/by Rebecca Tregunna

#BAUS15 started to gain momentum from as early as the 26^th June 2014 and by the time we entered the Manchester Central Convention Complex well over 100 tweets had been made. Of course it wasn’t just Twitter that started early with a group of keen urologists cycling 210 miles to conference in order to raise money for The Urology Foundation.

Monday 15^th June 2015

By the time the cyclists arrived conference was well under way with the andrology, FNUU and academic section meetings taking place on Monday morning:

The BJU International Prize for the Best Academic Paper was awarded to Richard Bryant from the University of Oxford for his work on epithelial-to-mesenchymal transition changes found within the extraprostatic extension component of locally invasive prostate cancers.
Donna Daly from the University of Sheffield received the BJUI John Blandy prize for her work on Botox, demonstrating reductions in afferent bladder signaling and urothelial ATP release.

Professor Reisman’s talk on ‘Porn, Paint and Piercing’ as expected drew in the crowds and due to a staggering 44% complication rate with genital piercings it is important for us to try to manage these without necessarily removing the offending article as this will only serve to prevent those in need from seeking medical attention.
With the worsening worldwide catastrophe of antibiotic resistance, the cycling of antibiotics for prevention of recurrent UTIs is no longer recommended. Instead, Tharani Nitkunan provided convincing evidence for the use of probiotics and D-Mannose.

The afternoon was dominated by the joint oncology and academic session with Professor Noel Clarke presenting the current data from the STAMPEDE trial. Zolendronic acid conferred no survival benefit over hormones alone and consequently has been removed from the trial (stampede 1). However, Docetaxal plus hormones has shown benefit, demonstrated significantly in M1 patients with disease-free survival of 65 months vs. 43 months on hormones alone (Hazard ratio 0.73) (stampede 2). This means that the control arm of M1 patients who are fit for chemotherapy will now need to be started on this treatment as the trial continues to recruit in enzalutamide, abiraterone and metformin arms.

The evening was rounded off with the annual BAUS football tournament won this year by team Manchester (obviously a rigged competition!), whilst some donned the

lycra and set out for a competition at the National Cycle Centre. For those of us not quite so energetic, it was fantastic to catch up with old friends at the welcome drinks reception.

Tuesday 16^th June 2015

Tuesday kicked off bright and early with Professor John Kelly presenting results from the BOXIT clinical trial, which has shown some benefit over standard treatment of non-muscle invasive bladder cancer, but with significant cardiovascular toxicity.

The new NICE bladder cancer guidelines were presented with concerns voiced by Professor Marek Babjuk over discharging low-risk bladder cancer at 12 months given a quoted 30-50% five-year recurrence risk. Accurate risk stratification, it would seem, is going to be key.

The President’s address followed along with the presentation of the St. Peter’s medal for notable contribution to the advancement of urology, which was presented to Pat Malone from Southampton General Hospital. Other medal winners included Adrian Joyce who received the BAUS Gold Medal, and the St. Paul’s medal went to Mark Soloway.

A plethora of other sessions ensued but with the help of the new ‘native’ BAUS app my programme was already conveniently arranged in advance:

‘Heartsink Conditions’ included pelvic and testicular pain and a fascinating talk by Dr Gareth Greenslade highlighted the importance of early and motivational referral to pain management services once no cause has been established and our treatments have been exhausted. The patient’s recovery will only start once we have said no to further tests: ‘Fix the thinking’

Poster sessions are now presented as ‘e-posters’, abolishing the need to fiddle with those little pieces of Velcro and allowing for an interactive review of the posters.

Pravisha Ravindra from Nottingham demonstrated that compliance with periodic imaging of patients with asymptomatic small renal calculi (n=147) in primary care is poor, and indeed, these patients may be better managed with symptomatic imaging and re-referral as no patients required intervention based on radiograph changes alone.

Archana Fernando from Guy’s presented a prospective study demonstrating the value of CTPET in the diagnosis of malignancy in patients with retroperitoneal fibrosis (n=35), as well as demonstrating that those with positive PET are twice as likely to respond to steroids.

Wednesday 17^th June 2015

Another new addition to the programme this year was the Section of Endourology ‘as live surgery’ sessions. This was extremely well received and allowed delegates to benefit from observing operating sessions from experts in the field whilst removing the stressful environment and potential for risk to patient associated with live surgery. This also meant that the surgeon was present in the room to answer questions and talk through various steps of the operation allowing for a truly interactive session.
Wednesday saw multiple international speakers dominating the Exchange Auditorium:

The BJU International guest lecture was given by Professor Hendrik Van Poppel: a heartfelt presentation describing what he believes to be the superiority of surgery over radiotherapy for high-risk localised prostate cancer.
The Urology Foundation presented the Research Scholar Medal to Ashwin Sachdeva from Freeman Hospital, Newcastle for his work on the ‘Role of mitochondrial DNA mutations in prostate carcinogenesis’. This was followed by an inspiring guest lecture by Inderbir Gill on ‘Robotic Urologic Oncology: the best is yet to come’ with the tag line ‘the only thing that should be open in 2015 is our minds’
Robotic Surgery in UK Urology: Clinical & Commissioning Priorities was a real highlight in the programme with talks from Jim Adshead and Professor Jens-Uwe Stolzenburg focussing on the fact that only 40% of T1a tumours in the UK were treated with partial (as opposed to radical) nephrectomy, and that the robot really is the ‘game-changer’ for this procedure. Inderbir Gill again took to the stage to stress that all current randomised trials into open vs. robotic cystectomy have used extracorporeal reconstruction and so do not reflect the true benefits of the robotic procedure as the dominant driver of complications is in the open reconstruction.

These lectures were heard by James Palmer, Clinical Director of Specialised Commissioning for NHS England who then discussed difficulties in making decisions to provide new technologies, controlling roll out and removing them if they show no benefit. Clinical commissioning policies are currently being drafted for robotic surgery in kidney and bladder cancer. This led to a lively debate with Professor Alan McNeill having the last word as he pointed out that what urologists spend on the robot to potentially cure cancer is a drop in the ocean compared with what the oncologists spend to palliate!

Thursday 18^th June 2015

The BJU International session on evidence-based urology highlighted the need for high-quality evidence, especially in convincing commissioners to spend in a cash-strapped NHS. Professor Philipp Dahm presented a recent review in the Journal of Urology indicated that the quality of systematic reviews in four major urological journals was sub-standard. Assistant Professor Alessandro Volpe then reviewed the current evidence behind partial nephrectomy and different approaches to this procedure.

Another fantastic technology, which BAUS adopted this year, was the BOD-POD which allowed delegates to catch-up on sessions in the two main auditoria that they may have missed due to perhaps being in one of the 21 well designed teaching courses that were available this year. Many of these will soon be live on the BAUS website for members to view.

The IBUS and BAUS joint session included a lecture from Manoj Monga from The Cleveland Clinic, which led to the question being posed on Twitter: ‘Are you a duster or a basketer?’The audience was also advised to always stent a patient after using an access sheath unless the patient was pre-stented.

The updates session is always valuable especially for those studying for the FRCS (Urol) exam with far too many headlines to completely cover:

Endourology: The SUSPEND trial published earlier this year was a large multi-centre RCT that showed no difference in terms of rates of spontaneous passage of ureteric stone, time to stone passage or analgesic use between placebo, tamsulosin and nifedipine. There was a hot debate on this: should we be waiting for the meta-analysis or should a trial of this size and design be enough to change practice?
Oncology-Prostate: The Klotz et al., paper showed active surveillance can avoid over treatment, with 98% prostate cancer survival at 10 years.
Oncology-Kidney: Ellimah Mensah’s team from Imperial College London (presented at BAUS earlier in the week) demonstrated that over a 14-year period there were a higher number of cardiovascular-related admissions to hospital in patients who have had T1 renal tumours resected than the general population, but no difference between those who have had partial or radical nephrectomy.
Oncology-Bladder: Arends’s team presented at EAU in March on the favourable results of hyperthermic mitomycin C vs. BCG in the treatment of intermediate- and high-risk bladder cancer.
Female and BPH: The BESIDE study has demonstrated increased efficacy with combination solifenacin and mirabegron.
Andrology: Currently recruiting in the UK is the MASTER RCT to evaluate synthetic sling vs. artificial sphincter in men with post-prostatectomy urinary incontinence.

Overall BAUS yet again put on a varied and enjoyable meeting. The atmosphere was fantastic and the organisers should be proud of the new additions in terms of allowing delegates to engage with new technologies, making for a memorable week. See you all in Liverpool!

Rebecca Tregunna, Urological Trainee, West Midlands Deanery @rebeccatregunna

Dominic Hodgson, Consultant Urologist, Portsmouth @hodgson_dominic

Guideline of guidelines: kidney stones

June 24, 2015/by admin Z.9

Abstract

Several professional organizations have developed evidence-based guidelines for the initial evaluation, diagnostic imaging selection, symptomatic management, surgical treatment, medical therapy, and prevention of recurrence for both ureteric and renal stones. The purpose of this article is to summarize these guidelines with reference to the strength of evidence. All guidelines endorse an initial evaluation to exclude concomitant infection, imaging with a non-contrast computed tomography scan, and consideration of medical expulsive therapy or surgical intervention depending on stone size and location. Recommends for metabolic evaluation vary by guideline, but all endorse increasing fluid intake to reduce the risk of recurrence.

Access the full article

Article of the Week: Quantifying ATP release from isolated bladder urothelial cells

June 24, 2015/by admin Z.9

Every Week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

ATP release from freshly isolated guinea-pig bladder urothelial cells: a quantification and study of the mechanisms involved

Linda M. McLatchie and Christopher H. Fry*

Department of Biochemistry and Physiology, FHMS, University of Surrey, Guildford, and *Department of Physiology and Pharmacology, University of Bristol, Bristol, UK

Read the full article

OBJECTIVES

To quantify the amount of ATP released from freshly isolated bladder urothelial cells, study its control by intracellular and extracellular calcium and identify the pathways responsible for its release.

MATERIALS AND METHODS

Urothelial cells were isolated from male guinea-pig urinary bladders and stimulated to release ATP by imposition of drag forces by repeated pipetting. ATP was measured using a luciferin-luciferase assay and the effects of modifying internal and external calcium concentration and blockers of potential release pathways studied.

RESULTS

Freshly isolated guinea-pig urothelial cells released ATP at a mean (sem) rate of 1.9 (0.1) pmoles/mm² cell membrane, corresponding to about 700 pmoles/g of tissue, and about half [49 (6)%, n = 9) of the available cell ATP. This release was reduced to a mean (sem) of 0.46 (0.08) pmoles/mm² (160 pmoles/g) with 1.8 mm external calcium, and was increased about two-fold by increasing intracellular calcium. The release from umbrella cells was not significantly different from a mixed intermediate and basal cell population, suggesting that all three groups of cells release a similar amount of ATP per unit area. ATP release was reduced by ≈50% by agents that block pannexin and connexin hemichannels. It is suggested that the remainder may involve vesicular release.

CONCLUSIONS

A significant fraction of cellular ATP is released from isolated urothelial cells by imposing drag forces that cause minimal loss of cell viability. This release involves multiple release pathways, including hemichannels and vesicular release.

Editorial: Mechanisms of ATP release – future therapeutic targets?

June 24, 2015/by Karl-Erik Andersson

When Ferguson et al. [1] demonstrated ATP release from the rabbit bladder and concluded: ‘… ATP is released from the urothelium as a sensory mediator … ’, they opened a new field of research with focus on urothelial signaling mechanisms and afferent nerve functions in bladder control. Other investigators have shown, in several animal models, that ATP is released from urothelial cells during distention of the bladder and that the amount released is proportional to the extent of distention [2]. P2X3 purinergic receptors are present in the urothelium and specifically on suburothelial afferent nerve fibres. After release, ATP acts on these receptors to convey information to the CNS, where voiding can be initiated. P2X3 receptor knockout mice had marked urinary bladder hyporeflexia with reduced voiding frequency and increased voiding volume, suggesting that these receptors are involved in mechanosensory transduction underlying activation of afferent fibres that control voiding reflexes during bladder filling [3]. In the last decade the proposal of Ferguson et al. [1] has been well supported [4], making ATP release an essential step in the activation of the bladder.

Although release of ATP from bladder tissues has been studied extensively, there are still many unanswered questions. In a recent study, McLatchie and Fry [5] have used unique experimental approaches that allowed them to study some essential questions in a new way: i) from which urothelial cells is ATP released, ii) how is ATP stored, and iii) what release pathways are involved?

Previous studies have established that ATP comes from the urothelial cell layer, although they have not identified the actual cell type responsible. Using freshly isolated cells that could be separated into umbrella, intermediate and basal subtypes, McLatchie and Fry [5]showed that umbrella and basal/intermediate cells are equally effective in generating ATP release. The magnitude of ATP release from the urothelium was large compared with that from multicellular preparations.

ATP has for many years been known as a postjunctional contraction-producing transmitter stored in vesicles of cholinergic nerves [4], but whether the release from urothelial cells is vesicular or not has been unclear. Ferguson et al. [1] presented three types of argument against non-vesicular ATP release: i) rather than inhibiting ATP release, absence of calcium in the bathing medium actually potentiated the release, ii) tetrodotoxin in concentrations completely blocking field-stimulated smooth muscle contraction had no significant effect on electrically induced ATP, and iii) although the suburothelial sensory nerves are packed with secretory granules, there are no such granules to be seen within the urothelial cells. McLatchie and Fry [5] stimulated urothelial cells in suspension by imposing upon them a mild drag force stress and found that urothelial ATP release was reduced with 1.8 mm external calcium, and was increased approximately two-fold by increasing intracellular calcium. ATP release was reduced by agents blocking pannexin and connexin hemichannels. The calcium-dependence of ATP release and its influence by connexin/pannexin blockers suggested to the investigators that a major fraction (up to 50%) of release is through such channels. However, the conspicuous effect of N-ethylmaleimide, which has been proposed to reduce vesicular docking to the surface membrane of secretory cells, is consistent with a substantial fraction of release by vesicular exocytosis.

It is obvious that more than 15 years after the observation of urothelial ATP release, this remains a fruitful research field. As suggested by McLatchie and Fry [5], characterisation of the pathways involved may help to develop new therapeutics for disorders assumed to be characterised by increased ATP release, such as bladder pain and overactive bladder syndromes.

Read the full article

Karl-Erik Andersson

AIAS, Aarhus Institute of Advanced Studies, Aarhus University, Aarhus C, Denmark

References

1 Ferguson DR, Kennedy I , Burton TJ. ATP is released from rabbit urinary bladder epithelial cells by hydrostatic pressure changes – a possible sensory mechanism? J Physiol 1997; 505: 503–11

2 Vlaskovska M, Kasakov L, Rong W et al. P2X3 knock-out mice reveal a major sensory role for urothelially released ATP. J Neurosci 2001; 21: 5670–7

3 Cockayne DA, Hamilton SG, Zhu QM et al. Urinary bladder hyporeﬂexia and reduced pain-related behaviour in P2X3-deﬁcient mice. Nature 2000; 407: 1011–5

4 Mutafova-Yambolieva VN, Durnin L. The purinergic neurotransmitter revisited: a single substance or multiple players? Pharmacol Ther 2014; 144: 162–91

5 McLatchie LM, Fry CH. ATP release from freshly isolated guinea-pig bladder urothelial cells: a quantiﬁcation and study of the mechanisms involved. BJU Int 2014 [Epub ahead of print]. doi: 10.1111/bju.12954

The Social Media Revolution in Chinese Urology

June 23, 2015/5 Comments/by Wei Wang

It is well known that Twitter, Facebook and YouTube, the most popular social media platforms available in the West, are not easily accessible in China. It is also clear that urologists in the West have embraced these social media platforms (Twitter in particular), not just for personal interaction, but also for professional engagement, and journals such as BJUI have enthusiastically encouraged the use of social media for urologists through their use of Twitter, blogging, YouTube etc.

So what then of Chinese urology? Are we missing out on all this? Not at all! In fact, as a recent BMJ blog observed, China is among the most heavily connected populations on earth, and the smartphone revolution has seen this connectivity grow very rapidly in recent years, more than in many Western countries. The lack of access to Western websites has just meant that a host of home-grown websites have cropped up to allow the insatiable appetite for connectivity to be met. Therefore sites such as RenRen (like Facebook), Sina Weibo (like Twitter), and Youku (like YouTube). The BMJ have blogged about this and have highlighted the huge volume of activity on Chinese social media sites.

Figure from “Your quick guide to social media strategy in China”

At present, the most popular platform among Chinese urologists is WeChat. WeChat, (similar to WhatsApp), is connecting more than a half billion Chinese people now. Apart from free chat, video and voice call, group chat is perfect for professional online discussion. There are several major urological discussion groups. Each group has many hundreds of participants. It is estimated that more 3000 urologists (1/4) in China have been involved in one or more online discussion group. Earlier this month, Prof. Declan Murphy’s lecture slides were uploaded to our urology major discussion group after his presentation at the Asia Urology Prostate Cancer Forum in Shanghai.

More than 2000 Chinese urologists (1/6) watched his slides on smartphones that weekend and shared feedback using the app. Prof Murphy, one of the world’s foremost leaders in social media, even joined WeChat and engaged in dialogue with the discussion group.

At present, the top two most famous discussion groups are called scope art and Hippocrates group. A talented young urologist, Dr. QIan Zhang, set up scope art two years ago. More than 500 urologists from across the country were invited to join the group. New knowledge, case discussion and meeting information can be arranged in the group. Recently, the Top 10 WeChat urologists has been selected thorough WeChat vote platform system. More than 20,000 WeChat users voted for their favorite social medial stars. Several discussion groups were built based on the different specialties (stone disease, andrology etc.). Several leading uro-oncologists, urologists, pathologists, radiologists and related experts also built an MDT discussion group to discuss interesting uro-oncology cases to help select the best options for patients.

We are now also seeing these online discussions develop a physical presence. Recently, a WeChat integrated Hippocrates urological meeting was held in Jiaxing. When each speaker starts to talk, the slides were uploaded to the WeChat discussion group, allowing the entire membership of the discussion group to attach their comments and questions during the presentation. All the questions and comments are projected to the separate screen in the meeting hall. The speaker can discuss with all the members, wherever they are.

WeChat meeting in action in Jiaxing

As these examples demonstrate, social media significantly helps Chinese urologists communicate more effectively, especially in such a large country with a huge population. We are very keen to embrace these new communication platforms and to engage more with our colleagues in the West!

Dr. Wei Wang

Consultant Urologist, Beijing Tongren Hospital, Capital Medical University, China

WeChat ID: medtrip

Give the pill, or not give the pill. SUSPEND tries to end the debate

June 22, 2015/1 Comment/by Christopher Bayne

June 2015 #UROJC Summary

News of a landmark paper on medical expulsive therapy (MET) for ureteric colic swirled through the convention halls on the last day of the American Urological Association’s Annual Meeting in New Orleans, Louisiana. I watched the Twitter feeds evolve from my desk at home: the first tweets just mentioned the title, then the conclusion, followed by snippets about the abstract. As time passed and people had time to read the manuscript, discussion escalated. Without data to prove it, there seemed to be more Twitter chatter about the SUSPEND trial, even among conference attendees, than the actual AUA sessions.

Robert Pickard and Samuel McClinton’s group utilized a “real-world” study design to publish what many urologists consider to be the “best data” on MET. The study (SUSPEND) randomized 1167 participants with a single 1-10 mm calculi in the proximal, mid, or distal ureter across 24 UK hospitals to 1:1:1 MET with daily tamsulosin 0.4 mg, nifedipine 30 mg, or placebo. The study’s primary outcome was the need for intervention at 4 weeks after randomization. Secondary outcomes assessed via follow-up surveys were analgesic use, pain, and time to stone passage. Though the outcomes were evaluated at 4 weeks after randomization, patients were followed out to 12 weeks.

Some of the study design minutiae are worth specific mention before discussing the results and #urojc chat:

Treatment allotment was robustly blinded. Participants were handed 28 days of unmarked over-encapsulated medication by sources uninvolved in the remaining portions of the study
Medication compliance was not verified
The study protocol didn’t mandate additional imaging or tests at any point
Participants weren’t asked to strain their urine
Secondary outcomes assessed by follow-up surveys were incomplete: 62 and 49% of participants completed the 4- and 12-week questionnaires, respectively

The groups were well balanced, and the results were nullifying. A similar percentage of tamsulosin- , nifedipine-, and placebo-group patients did not require intervention (81%, 80%, and 80%, respectively). A similar percentage of tamsulosin-, nifedipine-, and placebo-group participants had interventions planned at 12 weeks (7%, 6%, and 8%). There were no differences in secondary outcomes, including stone passage. There was a trend toward significance for MET, specifically with tamsulosin, in women, calculi >5 mm, and calculi located in the lower ureter (see image taken from Figure 2).

The authors concluded their paper was iron-clad with results that don’t need replication.

“Our judgment is that the results of our trial provide conclusive evidence that the effect of both tamsulosin and nifedipine in increasing the likelihood of stone passage as measured by the need for intervention is close to zero. Our trial results suggest that these drugs, with a 30-day cost of about US$20 (£13; €18), should not be offered to patients with ureteric colic managed expectantly, giving providers of health care an opportunity to reallocate resources elsewhere. The precision of our result, ruling out any clinically meaningful benefit, suggests that further trials involving these agents for increasing spontaneous stone passage rates will be futile. Additionally, subgroup analyses did not suggest any patient or stone characteristics predictive of benefit from MET.”

Much of the early discussion focused on the trend toward benefit for MET in cases of calculi >5 mm in the distal ureter:

Journal Club participants raised eyebrows to the use of nifedipine and placebo medication in the trial:

A few hours in, discussion shifted toward the study design, particularly the primary endpoint of absence of intervention at 4 weeks rather than stone passage or radiographic endpoints. The overall consensus was that that this study was a microcosm of “real world” patient care with direct implications for emergency physicians, primary physicians, and urologists.

The $20 question (cost of 4 weeks of tamsulosin according to SUSPEND) is whether or not the trial will change urologists’ practice patterns. Perhaps not surprisingly, opinions differed between American and European urologists.

We owe SUSPEND authors Robert Pickard and Sam McClinton special thanks for their availability during the discussion. In the end, the #urojc banter for June 2015 was the largest and most-interactive monthly installment of International Urology Journal Club to date.

Christopher Bayne is a PGY-4 urology resident at The George Washington University Hospital in Washington, DC and tweets @chrbayne.

What’s the Diagnosis?

June 19, 2015/1 Comment/by admin Z.9

Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers.

This patient has undergone shockwave lithotripsy to an upper pole right renal stone.

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Article of the Week: Am I normal? A systematic review for penis length and circumference

June 17, 2015/1 Comment/by admin Z.9

If you only have time to read one article this week, it should be this one.

Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men

David Veale*†, Sarah Miles*, Sally Bramley‡, Gordon Muir§ and John Hodsoll*

*The Institute of Psychiatry, Psychology and Neuroscience, ‡King’s College London Medical School, King’s College London, †South London and Maudsley NHS Foundation Trust, §King’s College NHS Foundation Trust, London, UK

Read the full article

OBJECTIVE

To systematically review and create nomograms of flaccid and erect penile size measurements.

METHODS

Study key eligibility criteria: measurement of penis size by a health professional using a standard procedure; a minimum of 50 participants per sample. Exclusion criteria: samples with a congenital or acquired penile abnormality, previous surgery, complaint of small penis size or erectile dysfunction. Synthesis methods: calculation of a weighted mean and pooled standard deviation (sd) and simulation of 20 000 observations from the normal distribution to generate nomograms of penis size.

RESULTS

Nomograms for flaccid pendulous [n = 10 704, mean (sd) 9.16 (1.57) cm] and stretched length [n = 14 160, mean (sd) 13.24 (1.89) cm], erect length [n = 692, mean (sd) 13.12 (1.66) cm], flaccid circumference [n = 9407, mean (sd) 9.31 (0.90) cm], and erect circumference [n= 381, mean (sd) 11.66 (1.10) cm] were constructed. Consistent and strongest significant correlation was between flaccid stretched or erect length and height, which ranged from r = 0.2 to 0.6. Limitations: relatively few erect measurements were conducted in a clinical setting and the greatest variability between studies was seen with flaccid stretched length.

CONCLUSIONS

Penis size nomograms may be useful in clinical and therapeutic settings to counsel men and for academic research.

Editorial: When normal is not enough

June 17, 2015/by Paul Hegarty

This is a useful reference on penile size, flaccid, stretched and erect [1]. It is interesting to note that the stretch length is quite a useful surrogate for erect length. Measuring stretch lengths obviously has inter-observer bias. This paper describes the standard technique for measuring from the pubic bone along the dorsum of the phallus to the tip, which is usually the external urinary meatus. Some men could well take solace in knowing that their penile length is within the normal range; however, men who complain of having a short penis are usually more complex. In our assessment, it can be useful to measure flaccid stretch length and explain to the patient that his length is within range for his population, but being told ‘you are normal’ might not be enough. The feeling of inadequate length usually has emotional connotations that may not respond to reassurance. In my experience, these men have been told that they have a small penis in late childhood/early puberty, or else have witnessed an adult penis before their own growth. This misconception then goes uncorrected for several years until they finally present. Locker room comparison does not help, as there is a parallax error in viewing one’s own penis from above as compared with the full frontal view of one’s peers.

At the stage of presentation, a simple reassurance is unlikely to reverse years of conditioning. The patient could experience a dangerous sense of frustration should he feel dismissed as normal. So-called ‘penile lengthening’ by partial division of the suspensory ligaments only has a 27% satisfaction rate among patients with penile dysmorphobic disorder [2]. Provided a medical/anatomical cause is not to be treated, I recommend psychosexual assessment and counselling.

Read the full article

Paul K. Hegarty

Mater Misericordiae Univers ity Hospital & Mater Private, Cork & Dublin, Ireland

References

1 Veale D, Miles S, Bramley S, Muir G, Hodsoll J. Am I normal? A systematic review and construction of nomograms for ﬂaccid and erect penis length and circumference in up to 15,521 men. BJU Int 2014. [Epub ahead of print].

2. LiCY, Kayes O, Kell PD, Christopher N, Minhas S, Ralph DJ. Penile suspensory ligament division for penile augmentation: indications and results. Eur Urol 2006; 49: 729–33

What’s the Diagnosis?

June 12, 2015/by admin Z.9

Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers.

This image is from an 80 year old patient with a history of bladder TCC.

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Archive for year: 2015

Abstract

ATP release from freshly isolated guinea-pig bladder urothelial cells: a quantification and study of the mechanisms involved

OBJECTIVES

MATERIALS AND METHODS

RESULTS

CONCLUSIONS

June 2015 #UROJC Summary

Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men

OBJECTIVE

METHODS

RESULTS

CONCLUSIONS