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OBJECTIVE: To assess the value of preoperative symptom score assessment and pressure-flow measurement in men undergoing transurethral prostatectomy (TURP). PATIENTS AND METHODS: In a prospective study, 95 men (mean age 74.3 years) scheduled for TURP because of their lower urinary tract symptoms, flow rates and urinary residual volumes were assessed using the self-administered International Prostate Symptom Score (IPSS) and urodynamic pressure-flow studies. At 3 months after TURP the patients were reassessed with a flow rate measurement and the IPSS. The baseline IPSS and urodynamic values were analysed with respect to the endpoints of the study, flow rate and IPSS after TURP, and the improvements thereof, respectively. RESULTS: There were significant improvements in mean IPSS (- 10.87 points) and peak flow rate (+ 7.06 mL/s) 3 months after TURP. Classifying the patients into subgroups with distinctly different initial values for IPSS, flow rate, residual urine volume and degree of obstruction (as expressed by Abrams-Griffiths number) showed that the flow rate and degree of obstruction influenced the improvement in flow rate but not in symptoms after TURP. Symptom improvement was only related to the initial level of symptoms. In a multivariate analysis, only age was an independent predictor of the outcome variables of flow rate and symptoms. CONCLUSIONS: Clinical decision-making remains a valid instrument for selecting patients for TURP. Both the IPSS and pressure-flow assessment are useful to exclude patients who are unlikely to benefit from TURP. Age is an important predictor of the improvement in symptoms and flow rates after TURP for the lower urinary tract symptom complex associated with benign prostatic enlargement.

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OBJECTIVE: To investigate the prevalence of erectile dysfunction (ED) in the South Australian community, and the influence of demographic and other risk factors. DESIGN: Survey by mailed questionnaire (based on the University of California, Los Angeles prostate cancer index) of a subset (men who agreed to participate) of a probability sample of the South Australian community who completed a multiuser interview survey. PARTICIPANTS AND SETTING: Men over the age of 40 in South Australia. MAIN OUTCOME MEASURES: Sexual desire, orgasm, ability to have an erection, adequacy (firmness) of erections for intercourse, frequency of erections when wanted, frequency of intercourse, nocturnal or morning erections, and history of prostate surgery; total sexual function score based on these. RESULTS: 612 men (86.7%) agreed to answer the sexual function survey; 427 (69.8%) returned questionnaires. ED was strongly correlated with age in all seven domains of sexual function. Erections inadequate for intercourse affected 3% of 40-49-year-olds, increasing to 64% of 70-79-year-olds. The frequency of intercourse considered normal for age by men 50-69 years was 1-6 times weekly; the disparity between this and reported frequency increased in men over 60 years, as did the difference between sexual desire and potency. A history of vigorous exercise was protective across all ages. High triglyceride levels, blood pressure medication and non-cancer surgery for prostate disease were independent predictors of poor sexual function at older ages. High cholesterol level was an independent predictor of impotence. CONCLUSIONS: We found similar or higher levels of ED than in comparable overseas studies. Disparity between potency and desire was greatest, and hence the age group in whom demand for treatment may be highest, in those 60 years and older. Cardiovascular risk factors were predictors of ED in these older men, suggesting that prevention may benefit sexual function. Non-cancer prostate surgery may be a greater contributor to ED than previously realised.

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OBJECTIVES: To identify predictors of poor symptomatic improvement after transurethral resection of the prostate (TURP), we investigated mucosal cell abnormalities in men about to undergo this procedure, and any association between these abnormalities and pre- and postoperative urinary tract symptoms. METHODS: Bladder lavages were obtained from patients undergoing TURP for outflow obstruction during 1995 to 1996 at the Repatriation General Hospital. Pressure flow studies were obtained preoperatively, and International Prostate Symptom Scores and flow rates were obtained preoperatively and 3 months and 2 years postoperatively. Cells from bladder washings were examined flow-cytometrically for Tn antigen expression and DNA cell cycle parameters. RESULTS: Of 192 patients recruited, 145 met the inclusion criteria. The frequency of Tn antigen expression, aneuploidy, and tetraploid aneuploidy in bladder mucosal cell washings in this group was comparable to a previous study. Weak, statistically significant associations were found between S-phase fraction and the initial International Prostate Symptom Score irrespective of whether total S-phase fraction cell numbers or categories were used. The trend of each of these associations was consistent (ie, patients with higher S-phase fraction values had more severe symptoms, poorer quality of life, and lower flow rates). The association was maintained at 3 months postoperatively but not at 2 years. Potential confounding factors did not explain the association. CONCLUSIONS: Bladder mucosal cell abnormalities can be found in men selected to undergo TURP to relieve obstruction and are associated with poor short-term symptomatic outcome. Further studies are needed to confirm these findings, in particular any association between higher mucosal cell proliferation rates and the presence of lower urinary tract symptoms.

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OBJECTIVE: To determine the natural course of patients with subjectively disappointing early results after transurethral prostatectomy (TURP), who experience prolonged discomfort and an initial deterioration in symptoms. PATIENTS AND METHODS: A consecutive series of 127 patients undergoing urodynamic studies and TURP were assessed 3 months after surgery using symptom scores and measurements of urinary flow rate; 107 patients reported improved symptom and quality-of-life scores, but 20 did not improve, with no change or a deterioration. These 20 patients were followed for several months using symptom scores, and measurements of flow rates and residual urine volumes. Baseline variables, including preoperative urodynamic studies, were compared between those who improved and those who did not. RESULTS: Over a mean (range) follow-up of 10.6 (6-15) months, all those initially not improving showed spontaneous improvement in all three variables with no further treatment and eventually achieved the same significant degree of improvement as those who improved soon after TURP. Preoperatively, those initially not improving had mean lower symptom scores, more bladder irritability and less obstruction than did those who improved. CONCLUSION: A significant proportion (approximately 15%) of patients with obstructive symptoms will experience considerable symptomatic discomfort for a prolonged period after an uncomplicated TURP and will not gain the full symptomatic benefit from the procedure until 6-9 months afterward.

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OBJECTIVE: To determine the prevalence and other characteristics of self-reported blood testing (prostate-specific antigen [PSA]) for prostate cancer in the community. DESIGN: Interview-based prevalence study. PARTICIPANTS AND SETTING: 695 men aged 40 years and over in the Spring 1996 South Australian Health Omnibus survey of a probability sample of 3011 households, weighted to reflect the age and sex distribution of the South Australian population. OUTCOME MEASURES: Number of men who had a PSA test in the preceding 12 months; number of first tests; the person initiating and performing the test; knowledge of the next step if test result abnormal; number of men visiting doctor for lower urinary tract symptoms in the preceding 12 months. RESULTS: 20.3% of participants reported having a PSA test in the preceding 12 months; 62.1% were first tests. Prevalence of testing was highest in the age group 70-79 years (35.8%). Most tests were initiated by the general practitioner (41.2%) and by patients (35.7%). Of those tested, 45.3% had inadequate knowledge of the next step. Visiting a doctor for urinary symptoms was significantly associated with PSA testing (P < 0.001): 47.7% of men who visited a doctor for urinary symptoms had been tested compared with only 17.4% of those who did not visit the doctor for this problem. Only age and visiting a doctor for urinary symptoms were significant independent predictors of having a PSA test. CONCLUSIONS: Investigation of lower urinary tract symptoms contributed substantially to PSA testing, and those tested did not adequately understand the consequences. Our findings suggest a need for a better framework for PSA testing in general practice, including all important elements of decision-making, such as evidence and patient preference, as well as the means to ensure adequate patient counselling before testing.

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PURPOSE: We determined the reliability of the International Prostate Symptom Score (I-PSS) in predicting the outcome of transurethral prostatectomy and, therefore, how useful it can be in patient selection for surgery. MATERIALS AND METHODS: A prospective trial was done of 105 consecutive patients undergoing transurethral prostatectomy at our institution. Patients were assessed with the I-PSS before and 3 months after surgery. Flow rates and preoperative residual volumes also were measured. RESULTS: There was significant postoperative improvement in all parameters of the symptom score and a change in symptom profile. Symptoms remaining with the greatest scores at 3 months postoperatively were frequency, urgency and nocturia. A significant correlation was found between I-PSS and quality of life before and after transurethral prostatectomy, and between postoperative improvement in flow rates and change in I-PSS. Patients with a greater preoperative I-PSS gained the most symptomatic benefit. The positive predictive value of a significant postoperative improvement of at least 7 I-PSS points depended on the preoperative I-PSS criteria applied. With a preoperative I-PSS of more than 17 the positive predictive value was 87% with a corresponding negative predictive value of 71%. CONCLUSIONS: The preoperative I-PSS predicted a symptomatic improvement of more than 7 points with high sensitivity. The predictive value depends on the definition of significant improvement (magnitude of I-PSS change) and the level of I-PSS symptoms defined as sufficient to warrant transurethral prostatectomy.

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OBJECTIVE: To determine the effectiveness of pelvic floor exercises and urethral milking as treatments for post-micturition dribble. PATIENTS AND METHODS: A method of measuring small amounts of urine loss during normal activity was developed; pads were worn for short periods (< 4 h) and then stored in two sealed plastic bags which were weighed within 72 h. Forty-nine men (age range 36-83 years) drawn from a hospital out-patient population, who had not undergone surgery on the bladder, urethra or prostate gland, entered the study. They were randomly assigned to one of three treatment groups; pelvic muscle exercise, urethral milking or counselling. Participants in each group followed the treatment specific to their group for 12 weeks. At 5, 9 and 13 weeks, urine loss was assessed using the method described. RESULTS: The groups were comparable for age, height, weight and pelvic muscle contraction strength and compliance of the men who completed the study was excellent. The outcome measure (improvement in pad weight gain) was strongly influenced by initial pad weight gain, or degree of urine loss at the start of the study and this was treated as a covariate in an analysis of variance model. After allowing for the effects of initial pad weight gain, the counselling group showed no improvement, the urethral milking group showed an adjusted mean improvement in urine loss of 2.9 g after 13 weeks, compared with 4.7 g in the exercise group. CONCLUSION: Both pelvic floor exercises and urethral milking are effective treatments for post-micturition dribble compared with counselling alone. Pelvic floor exercises were more effective in reducing urine loss than urethral milking in this study.

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OBJECTIVE: To study the effectiveness of combining DNA ploidy and the blood-group related membrane antigen Tn as bladder tumour markers which have been individually associated with high tumour grade and poor prognosis. In particular to (i) determine whether use of these two markers would improve tumour detection compared with either alone, particularly of high grade disease and (ii) determine whether intermediate rates of marker expression would occur in bladder cancer patients with no current tumour compared with those with a tumour and a control group with benign prostatic hypertrophy. PATIENTS AND METHODS: A total of 102 patients undergoing cystoscopic monitoring for either benign prostatic hyperplasia (BPH) or for transitional cell carcinoma (TCC) at the Repatriation Hospital and Flinders Medical Centre were included in the study. The patients comprised three study groups, those with BPH (n = 37), with TCC but no tumour present (n = 38) and those with TCC and a tumour present at cystoscopy (n = 27). Exfoliated cells obtained from bladder washings at cystoscopy were double-labelled using a monoclonal antibody to the Tn antigen and a DNA stain, propidium iodide and examined by flow cytometry. RESULTS: Rates of marker expression in 27 patients with tumours were 30% for Tn antigen, 30% for aneuploidy and 48% for either marker. Marker expression was strongly associated with tumour grade, with no expression at grade 1, 38% (3/8) tumours at grade 2 and 90% (9/10) at grade 3. In patients with a history of bladder tumours but no current tumour, rates were intermediate (30%) compared with patients with current transitional cell carcinoma (42%) and control patients (19%). CONCLUSION: The use of Tn antigen combined with DNA flow cytometry can increase tumour detection, particularly of high grade, aggressive disease. Gradation of expression of these markers across patient groups at increasing risk of a tumour, with intermediate expression in patients with no current tumour, suggests that marker expression may be detecting a preneoplastic stage of the disease, which is not possible with cytology. Given two parallel disease processes for superficial papillary and for high grade disease with invasive potential, the expression of high grade tumour markers in cells from cystoscopically normal bladders may represent a pre-clinical stage of aggressive disease. The identification of patients at risk of invasive disease using combinations of tumour markers may offer advantages in clinical management, particularly when no tumour is present and therefore no histopathological assessment is made.

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A questionnaire designed to measure the "milk mucus effect" was based on sensations and symptoms after drinking milk reported in interviews with 169 individuals, 70 of whom held the belief that milk produces mucus. This was used to measure responses in a randomized, double-blind trial of a flavoured UHT cow's milk drink, compared with a similarly flavoured and constituted UHT soy milk drink. The soy placebo was indistinguishable from cow's milk in a pretest of 185 individuals. Of 14 milk-mucus effect indicator variables, three showed significant increases after consumption of 300 ml of the test drink. These were "coating/lining over the mouth, throat or tongue" (39% increase), "need to swallow a lot" (31% increase) and "saliva thicker, harder to swallow than before" (42% increase). However, these increases occurred in both milk and placebo groups. It is concluded that the effect measured is not specific to cow's milk, but can be duplicated by a non-cow's milk drink with similar sensory characteristics.

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The belief that milk produces mucus is widespread in the community and is associated with a significant reduction in milk consumption. Sensations associated with milk drinking were reported by otherwise healthy believers and non-believers in the milk-mucus effect (N = 169) in an unstructured interview, with further responses prompted about the duration, type and amount of milk causing the effect. The site predominantly affected was the throat, with sensations related to difficulty in swallowing and perceived thickness of mucus and salivary secretions, rather than excessive mucus production. The effect required only a small amount of milk and was reported to be of short duration. The chronic respiratory symptom history and dairy product intake of 130 of these subjects were also assessed. Milk-mucus believers were different from non-believers, reporting more respiratory symptoms and consuming less milk and dairy products. Symptoms consistent with the known effects of food allergy or intolerance were not reported.

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OBJECTIVE: To review the evidence for teratogenic potential associated with the use of vitamin A and synthetic retinoids in Australia. DATA SOURCES: Relevant indexed journal articles and standard drug information reference texts were identified by Medicine and library search. Information was also obtained from the Australian National Perinatal Statistics Unit. DATA EXTRACTION: We summarised human and animal data relating to the teratogenicity of vitamin A derivatives and synthetic retinoids, including case reports documenting systemic effects from topically administered drugs, pertinent information relating to the clinical pharmacokinetics and adverse effects of these compounds, and the approved and potential indications for the use of these agents. DATA SYNTHESIS: Extensive experimental evidence points to the teratogenicity of natural and synthetic retinoids in animals. Data confirming an effect in humans are not as good. Nevertheless case series, case reports and some epidemiological data regarding isotretinoin suggest that synthetic retinoids are similarly teratogenic in humans. Although there are extensive guidelines and legislation dealing with the use of these compounds in the United States and Australia, the potential for teratogenicity induced by vitamin A still exists. This is because retinoids and vitamin A continue to be prescribed for women of child-bearing potential and documented evidence from the United States reveals that not all prescribers comply with recommendations that minimise the risk of malformations. Non-prescription forms of vitamin A are available without a pregnancy hazard warning, and potentially teratogenic amounts are available from dietary sources. CONCLUSIONS: There exists a potential for teratogenicity in association with the use of both synthetic and natural retinoids in Australia. Monitoring systems currently in place in this country may not detect these malformations should they occur.

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Recent studies have demonstrated that rhinovirus infections can be prevented in the family setting through use of intranasal interferon sprays which are commenced when another family member develops a cold. One hundred and twenty-seven children aged 4-9 years who had been hospitalized during their first year of life for severe infections caused by respiratory syncytial virus were studied virologically and epidemiologically during a seven-month period which included the winter months. The hypothesis was that a significant part of their respiratory morbidity would be preventable by a contact prophylaxis approach using intranasal interferon. However, the findings suggest that a preventive approach of this kind would not substantially reduce the burden of respiratory illness in these children because: the target children themselves more often introduced illness into the family than did other household members; rhinovirus infections preventable by interferon were associated with little lower respiratory morbidity; and rhinoviruses were minor contributors to the total respiratory illness burden in these respiratory illness-prone children.

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In the first of three studies investigating the widely held belief that "milk produces mucus," 60 volunteers were challenged with rhinovirus-2, and daily respiratory symptoms and milk and dairy product intake records were kept over a 10-day period. Nasal secretion weights were obtained by weighing tissues collected and sealed immediately after use. Information was obtained on 51 subjects, yielding 510 person-days of observation. Subjects consumed zero to 11 glasses of milk per day (mean, 2.7; SE, 0.08), and secretion weights ranged from zero to 30.4 g/day (mean, 1.1; SE, 0.1). In response to an initial questionnaire, 27.5% reported the practice of reducing intake of milk or dairy products with a cold or named milk or dairy products as bad for colds. Of the latter group, 80% stated the reason as "producing more mucus/phlegm." Milk and dairy product intake was not associated with an increase in upper or lower respiratory tract symptoms of congestion or nasal secretion weight. A trend was observed for cough, when present, to be loose with increasing milk and dairy product intake; however, this effect was not statistically significant at the 5% level. Those who believe "milk makes mucus" or reduce milk intake with colds reported significantly more cough and congestion symptoms, but they did not produce higher levels of nasal secretions. We conclude that no statistically significant overall association can be detected between milk and dairy product intake and symptoms of mucus production in healthy adults, either asymptomatic or symptomatic, with rhinovirus infection.

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In order to extend our earlier observation that children who experience frequent respiratory episodes may benefit from Vitamin A supplementation, 206 children aged 2-7 years who had been hospitalized for bronchiolitis during infancy were randomized into a controlled trial of Vitamin A supplementation. Of these, 149 met the criteria of protocol compliance after 12 months of follow-up. Mean plasma retinol at baseline was 39.2 micrograms/100 ml (s.e.m. = 1.0) and did not increase after 12 months (mean = 36.0 micrograms/100 ml, s.e.m. = 0.7) despite the older age of the cohort. The range observed (11.7-73.9 micrograms/100 ml) included some children at risk of marginal Vitamin A deficiency. Mean plasma retinol levels were 20% lower than those of children experiencing frequent respiratory episodes recorded earlier. Oral supplementation did not change plasma retinol levels, nor did it affect respiratory morbidity.

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Effervescent lozenges containing 10 mg of zinc acetate were evaluated as a treatment of upper respiratory tract infections in a double-blind randomized trial by using a placebo which was indistinguishable to most observers in taste and appearance from the active material. Of the 70 treatment courses used by 55 individuals in 34 families, 63 (33 zinc and 30 placebo) were considered evaluable, in that the volunteer used the medication at least four times daily for at least 3 days, the average utilization being 5.4 days at an average dose of six lozenges daily. Six users of zinc reported nausea (versus no placebo users), and eight reported an unpleasant taste or aftertaste (versus one placebo user). No benefit was observed among the users of zinc acetate. The mean duration of symptoms in users of the zinc was 12.1 days, compared with 7.7 days in those who used the placebo. Nor was any beneficial effect of zinc evident among the four zinc-treated versus the two placebo-treated individuals from whom rhinovirus was grown.

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The effect of Vitamin A supplementation on susceptibility to acute respiratory infections was investigated in a randomized controlled trial. One hundred and forty-seven preschool-age children with a history of frequent respiratory illness were randomized into Vitamin A supplemented (450 micrograms/day) and placebo groups. Respiratory symptoms were recorded on a daily basis over a period of 11 months. The children who received the supplement experienced 19% fewer episodes of respiratory symptomatology (P less than 0.05) than their placebo counterparts, despite the fact that their plasma retinol levels did not change. Children with a prior history of lower respiratory illness or of allergy benefited most from supplementation. The plausibility of a role for Vitamin A in the aetiology of respiratory proneness is reviewed.

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