SACRAL NEUROMODULATION
DESCRIPTION Sacral neuromodulation (SNM) is a 2nd-line treatment for lower urinary tract dysfunction, such as nonobstructive chronic urinary retention, urgency–frequency syndrome (overactive bladder), and urgency incontinence refractory to conservative and pharmacologic treatment. A continuous or cycling mode of electrical pulses are generated by an implanted device to activate or inhibit neural reflexes associated with lower urinary tract function via stimulation of the sacral nerves, which innervate the lower urinary tract and pelvic floor. The mechanism of action is unclear. 1 theory is that indirect stimulation of the pudendal nerve and direct inhibition of the preganglionic neurons suppresses detrusor over activity and therefore improves symptoms. An alternate theory is that stimulation may inhibit involuntary reflex voiding by altering the transmission of sensory input from the bladder to the pontine micturition center, inhibiting ascending afferent pathways but not the descending pathways. In the patient with nonobstructive urinary retention, SNM most likely causes an inhibition of the guarding reflex, with a reduction in sphincteric over activity that may reduce bladder outlet and urethral resistance.
Patients should have failed conservative management with medications and or behavioral therapies and should undergo extensive evaluation including UDS. The procedure of implantation occurs in usually 2 stages. Stage I consists of percutaneous placement of temporary wire leads into the S3 foramina. It can either be performed in the office or in the operating room. A 1–2-wk trial period occurs with the leads in place and voiding symptoms are reevaluated. If >50% improvement in symptoms occur, the patients moves on to Stage II which is always performed in the operating room. Permanent leads are placed as well as an implantable pulse generator. The most commonly used device is the InterStimTM (Medtronic, Minneapolis, Minnesota) (FDA-approved since 1997 for urge incontinence and since 1999 for urinary retention and significant symptoms of urgency–frequency) (Image 
).
REFERENCE
Hubsher CP, Jansen R, Riggs DR, et al. Sacral nerve stimulation for neuromodulation of the lower urinary tract. Can J Urol. 2012;19(5):6480–6484.
SANI SCORE
DESCRIPTION The SANI (Survival after Nephrectomy and Immunotherapy) score is a tool for predicting survival for patients with metastatic RCC in response to the multimodality treatment of aggressive surgical resection and systemic immunotherapy. The regional lymph node status, the presence or absence of constitutional symptoms, the location of metastases, the presence or absence of sarcomatoid pathologic features, and TSH levels are incorporated into the scoring algorithm. Patients are stratified based on predicted survival into low-risk, intermediate-risk and high-risk groups for appropriate treatment regimens and for prospective trials of new therapies.
REFERENCE
Leibovich BC, Han KR, Bui MH, et al. Scoring algorithm to predict survival after nephrectomy and immunotherapy in patients with metastatic renal cell carcinoma. Cancer. 2003;98:2566–2575.
SARCOMA, CLEAR CELL OF THE KIDNEY
DESCRIPTION Clear cell sarcoma of the kidney (CCSK) is a renal tumor that comprises ∼5% of all primary renal tumors in children. It is the 2nd most common pediatric renal tumor after Wilms tumor (WT). The mean age of presentation is 36 mo. It is unique from WT in its potential for bone and brain metastases. Clinical presenting symptoms of patients with CCSK are similar to those of patients with WT including abdominal distension or mass, abdominal pain, and gross hematuria. The genetics and cell of origin remain poorly understood. Several histologic subtypes are described, the classic pattern, which is present in over 90% of tumors, is characterized by round/oval cells with clear cytoplasm with uniform nuclei.
TREATMENT
• Radical nephrectomy followed by treatment with multi-agent chemotherapy and radiation
• In most recent NWTS-5 trial, vincristine, doxorubicin, and cyclophosphamide, alternating with cyclophosphamide and etoposide for 24 wk, and postoperative radiotherapy the 5-yr overall survival (OS) 89%. 5-yr and recurrence free survival (RFS) was 100% for stage I.
REFERENCE
Gooskens SL, Furtwängler R, Vujanic GM, et al. Clear cell sarcoma of the kidney: A review. Eur J Cancer. 2012;48:2219–226.
SAW PALMETTO
DESCRIPTION The extract of the dried ripe fruit from the American dwarf saw palmetto plant Serenoa repens (also known as Sabal serrulata) is the most widely used phytotherapeutic compound for the treatment of BPH. Berries from saw palmetto were 1st used by Native Americans in the early 1700s to treat testicular atrophy, erectile dysfunction (ED), and prostate swelling or inflammation. The mechanism of action is not completely understood, but may include alteration of cholesterol metabolism, anti-inflammatory, antiestrogenic, and anti-androgenic effects, and decrease in available sex hormone-binding globulin. In a systematic review of 32 randomized, controlled trials which included 5,666 men, Serenoa repens, at double and triple the usual dose compared to placebo provides no improvement for nocturia, peak urine flow, and symptom scores for men with BPH. (See also Section V: “Alternative and Complementary Urologic Therapies.”)
SYNONYM
Serenoa Repens, Sabal serrulata, Saw Palmetto Berry
REFERENCE
Tacklind J, Macdonald R, Rutks I, et al. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2012;12:CD001423.
SCABIES, UROLOGIC CONSIDERATIONS
DESCRIPTION An intensely pruritic parasitic infection that affects simultaneous areas of the body, including the genitalia, anus, legs, hands, umbilicus, and axillae. Diagnosis can be made by identifying the mite (Sarcoptes scabiei), expressed from the papular or linear burrow-like lesion. Transmission occurs from fomites or by direct contact with infected individuals, including sexual contact.
TREATMENT
• Lindane 1% cream, washed off after 8 hr. Do not use in pregnant or lactating women or in children <2 yr.
• Permethrin 5% cream, washed off after 8–14 hr.
• Crotamiton 10% cream for 2 consecutive nights; wash off 24 hr after the 2nd application.
• Treat sexual partners and close contacts.
REFERENCE
Peterson CM, Eichenfeld LF. Scabies. Pediatr Ann. 1996;(252):97–100.
SCARDINO-PRINCE PYELOPLASTY
DESCRIPTION Used to treat UPJ obstruction. An inverted J-configured incision is started on the anterior surface of the pelvis and brought down across the UPJ obstruction to a –2-cm point beyond the obstruction. The upper apex of the flap is then flipped down to the apex of the ureterotomy, where a 5-0 chromic stay suture is placed. The medial aspect of the flap is sutured to the lateral edge of the ureterotomy. The lateral edge of the flap is sutured to the lateral aspect of the ureterotomy, and the pelvis is closed.
REFERENCE
Kay R. Procedures for ureteropelvic junction obstruction. In: Novick AC, Streem SB, Pontes JE, eds. Stewart’s Operative Urology. Baltimore, MD: Williams & Wilkins; 1989:220–233.
SCHAEFER OBSTRUCTION GRADING SYSTEM
DESCRIPTION Schaefer’s obstruction grading system (also called Schaefer Nomogram) allows the use of urodynamic evaluation in patients with BPH to determine the effectiveness of a TURP of alleviating their symptoms. Using the urodynamic parameters of pressure (p) and flow rate (Q), a ratio is plotted and every data point reflects bladder contractility outflow conditions. Using a linear approximation to the p/Q data, an assessment can be made of outflow conditions. By comparing urodynamic data before and after surgery for patients with BPH, obstruction is defined as those outflow conditions that improve after surgery. They are graded (Grade 0–Grade VI) with grade 0/I outflow conditions not improving after TURP and Grade VI being severely obstructed and seeing the most improvement after TURP.
REFERENCE
Schaefer W. Analysis of bladder-outlet function with the linearized passive urethral resistance relation, linPURR, and a disease-specific approach for grade obstruction: From complex to simple. World J Uro.1995;13:47–58.
SCHILLER-DUVAL BODIES
DESCRIPTION Perivascular papillary structures seen in histologic specimens of yolk sac tumors, similar to the endodermal sinuses of Duval in the placenta of the rat (histo image).
REFERENCE
Moran CA, Suster S. Hepatoid yolk sac tumors of the mediastinum: A clinicopathologic and immunohistochemical study of four cases. Am J Surg Pathol. 1997;21(10):1210–1214.
SCHISTOSOMIASIS, UROLOGIC CONSIDERATIONS
DESCRIPTION A parasitic infection by the blood fluke Schistosoma haematobium. This condition has a broad spectrum of urologic manifestations due to the parasite’s life cycle: Infection across the skin, hematogenous migration to perivesical venous plexus, transmural migration into bladder, and shedding into urine. Typically, patients will exhibit polypoid urothelial mucosal lesions (active infection) or “sandy patch” flat, tan lesions (inactive infection). Significant upper urinary tract obstruction is possible with chronic disease. Classic symptoms are hematuria and terminal dysuria. Infection has been linked to bladder cancer, occurring earlier in life (40–50 yo); this is most commonly squamous cell carcinoma (SCC) (60–90%) and adenocarcinoma (5–15%). The presence of fluke eggs in urinary sediment is diagnostic of schistosomiasis. (See also Section I: “Bladder Cancer, Squamous Cell Carcinoma” and (Image ).)
TREATMENT
• Medical management: Metrifonate and praziquantel
• Surgical management: Infection refractory to medical management; ureteral or bladder outlet obstruction; persistent or refractory hematuria; or malignancy
REFERENCE
Michaud DS. Chronic inflammation and bladder cancer. Urol Oncol. 2007;(253):260–268. Review.
SCHWANNOMA, RENAL
DESCRIPTION Also called neurinoma or neurilemmoma, a tumor arising from Schwann cell neural elements of the kidney. Schwannomas of renal origin are very rare with only 20 reported cases in the literature. They present in middle-aged patients with a male-to-female ratio of 1:2. They typically appear as spherical, solid, and well-circumscribed encapsulated lesions. The vast majority are benign, and the malignant degeneration is very rare. Partial or radical nephrectomy (open or laparoscopic technique) is the treatment of choice as there are no reliable preoperative diagnostic methods.
REFERENCE
Sfoungaristos S, Kavouras A, Geronatsiou K, et al. Schwannoma of the kidney with magnetic resonance images of non-homogenous renal mass-a case presentation. Prague Med Rep. 2011;112(2):137–143.
SCLERODERMA, UROLOGIC CONSIDERATIONS
DESCRIPTION Scleroderma (systemic sclerosis) is a systemic, acquired disorder of connective tissue, including cutaneous sclerosis, visceral organ fibrosis, and vascular lesions. The condition commonly affects kidneys, with renal disease affecting 10–50% of patients. Lower urinary tract manifestations are also reported, including bladder fibrosis, microscopic hematuria, urodynamic abnormalities, such as poor compliance and obstructive uropathy. LUTS include urinary urgency, frequency, and incontinence.
REFERENCE
Lally EV, Kaplan SR, Susset JG, et al. Pathologic involvement of the urinary bladder in progressive systemic sclerosis. J Rheumatol. 1985;12:778–781.
SCLEROSING ADENOSIS OF THE PROSTATE
DESCRIPTION A rare benign lesion arising in the transition zone of the prostate. It is a part of the histologic differential diagnosis of prostate cancer. It is characterized by a cellular proliferation of variably sized glands and solid nests surrounded by basement membrane material in a cellular stroma. The contours of the lesion can be well circumscribed or infiltrative, raising concern for carcinoma. The specimen will be immunoreactive with S-100 and smooth muscle actin, indicating a myoepithelial differentiation. Other features differentiating this condition from cancer are that cells have bland nuclei and are sometimes surrounded by a hyaline-like sheath. (See also Section II: “Atypical Adenomatous Hyperplasia of the Prostate” and “Postatrophic Hyperplasia of the Prostate.”)
REFERENCE
Harik LR, O’Toole KM. Non-neoplastic lesions of the prostate and bladder. Arch Pathol Lab Med. 2012;136(7):721–734.
SCROTAL PAIN SYNDROME (CHRONIC SCROTAL PAIN SYNDROME [CSPS])
DESCRIPTION CSPS is not well documented in the literature and may have overlap with CPPS. CPPS is defined as pain and discomfort in the pelvic area, perineum, scrotum, penis, and pelvis. CSPS is described as chronic or recurrent pain located in the scrotum. There is little evidence for the widely held belief that CSPS is predominantly the result of a chronic bacterial infection.
REFERENCE
Strebel RT, Schmidt C, Beatrice J, et al. Chronic scrotal pain syndrome (CSPS): The widespread use of antibiotics is not justified. Andrology. 2013;1(1):155–159.
SCROTAL PEARLS (SCROTOLITHS)
DESCRIPTION Benign calcifications within the scrotum, usually free floating. Usually diagnosed by ultrasound, these are described as a hyperechoic density in the scrotal wall that demonstrates acoustic shadowing. Scrotal pearls can occur from infection or trauma and themselves are rarely symptomatic. They may also be noticed as artifacts after torsion of the appendix testis or epididymis.
REFERENCE
Chen P, John S. Ultrasound of the acute scrotum. Appl Radiol. 2006;353:8–17.
SCROTAL SKIN LESIONS
DESCRIPTION Scrotal skin lesions may be localized or a manifestation of more systemic diseases.
• Benign
– Amyloidosis (rare)
– Angiokeratoma of Fordyce: Small, 1–2-mm red, vascular papules seen predominantly in older men
– Atopic/neurodermatitis: Itch/scratch cycle with lichenification with or without excoriation. The posterior scrotum is a common site.
– Calcinosis, idiopathic scrotal
– Contact dermatitis: Allergic or irritant: Pruritis, burning, and stinging
– Crohn disease: “Metastatic.” Crohn disease may have associated scrotal ulcers and edema.
– Eczema frequently affects the genital region, particularly the scrotum. Patients present with lichenified erythematous plaques on the lateral scrotum. The eruption may develop into Lichen simplex chronicus (LSC) (also referred to as “Neurodermatitis”) characterized by extensive lichenification and hypertrophy of the affected skin due to excessive scratching and rubbing
– Epitheloid hemangioma, penis and scrotum
– Fixed drug eruption: Erythematous, well-demarcated “burn-like” area, may evolve from erythema to vesicles or blebs
– Folliculitis: Usually caused by Staphylococcus aureus
– Genital lentiginoses: Hyperpigmented macules that may be confused with melanoma
– Genital warts (condyloma): Uncommon on the scrotum
– Ichthyosis: excessive amounts of dry surface scales; inherited or acquired
– Insect bite
– Juvenile gangrenous vasculitis, scrotal (pyoderma gangrenosum)
– Langerhans cell histiocytosis
– Lichen simplex chronicus (LSC): Reaction to chronic scratching (See Eczema above)
– Lymphangioma
– Molluscum contagiosum: Pearly white papular, smooth-surfaced umbilicated papules
– Psoriasis: Well-demarcated papulosquamous plaques with silver scale; usually bleeds if scale removed
– Red Scrotum Syndrome (RSS): Persistent redness of the anterior 1/2 of the scrotum and may involve the base of the penis as well. Treated with oral doxycycline PO and tacrolimus 0.1% ointment twice daily. Gabapentin can be used as 2nd-line therapy
– Scabies: Red, linear, excoriated areas, often with papules, pustules, and burrows
– Sebaceous cysts/epidermal inclusion cyst
– Seborrhic dermatitis: Red scaling eruption (“inflammatory dandruff”)
– Secondary syphilis: Condyloma lata (moist, red, raised wheal-like lesions) or mucous patches (reddish ulcers with a violaceous border)
– Tinea cruris or jock itch: Involvement of the scrotum is uncommon
– Vitiligo may appear similar to lichen sclerosis: Hypopigmented or depigmented areas
• Malignant
– Basal cell carcinoma: Ulcerated lesion
– Kaposi sarcoma: A purple, papular, plaque-like, or ulcerated lesion
– Marjolin ulcer: Cancer arising from site of prior inflammation
– Melanoma (uncommon)
– Metastatic lesion: The scrotum is a rare site of cutaneous metastasis and associated with dermal and angiolymphatic invasion. The colon/rectum (34%), prostate (28%), and lung (14%) are the most frequent tumor origins.
– Paget disease: Primary extramammary from apocrine ducts or sweat gland carcinoma; secondary is intraepithelial spread from underlying malignancy
– Sarcoma: Leiomyosarcoma from the Dartos layer of the scrotum is most common, though still very rare
– Squamous Cell carcinoma (SCC): Papule or plaque that enlarges and ulcerates in older men
REFERENCES
Hoyt BS, Cohen PR. Cutaneous scrotal metastasis: origins and clinical characteristics of visceral malignancies that metastasize to the scrotum. Int J Dermatol. 2013;52(4):398–403.
Practitioners Handbook for the management of Sexually Transmitted diseases. http://depts.washington.edu/handbook/syndromesboth/ch10_lesions.html, Accessed April 6, 2014.
SCROTAL TONGUE
DESCRIPTION Scrotal tongue is not a urologic condition. It refers to a deeply fissured tongue. Sometimes called a geographic tongue.
REFERENCE
Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010;81(5):627–34. Review.
SCROTAL VARICES
DESCRIPTION Scrotal varices or varicocele is an abnormal dilation of the internal spermatic veins which drain the testis that can be palpated through the scrotal skin. Overall, they are present in 15% of the male population. Varicocele is the most common etiology of male factor infertility, being present in 35% of males with primary infertility and 81% with secondary infertility. They most commonly occur on the left secondary to drainage of the left internal spermatic vein into the left renal vein. Varicocele can impair testicular function with the likely mechanism being through thermal injury. Diagnosis is made through physical exam of the scrotum. Grade I varicocele is palpable with Valsalva only, grade II is palpable in the standing position, and grade III is visually apparent through the scrotal skin as a “bag of worms.” Scrotal ultrasound is not necessary unless the physical exam is unclear.
TREATMENT
• If a varicocele is not associated with infertility, decreased testicular volume or pain, it is considered subclinical and surgical correction is not indicated.
• Nonsurgical approach includes percutaneous radiographic occlusion and sclerotherapy.
• Surgical options include retroperitoneal, inguinal or subinguinal ligation, laparoscopic and microsurgical varicocelectomy.
REFERENCE
Hopps CV, et al. Varicocele: General considerations. In: Graham S, et al. Glenn’s Urologic Surgery. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
SCROTUM, ACCESSORY AND ECTOPIC
DESCRIPTION Accessory scrotum is a rare condition in which a small empty pouch of scrotal tissue is attached to the scrotum or the perineum. Ectopic scrotum is an anomalously positioned hemiscrotum usually found near the external inguinal ring. The testis generally accompanies the hemiscrotum to its abnormal position and may be normal or dysplastic. These lesions are often accompanied by other GU anomalies (upper tract). Surgical repair involves an attempt to bring down the scrotum and the testis. If the gonad is dysplastic and the ectopic scrotum is rudimentary, removal of 1 or both structures is reasonable.
REFERENCE
Kumar V, Marulaiah M, Chattopadhyay A, et al. Unilateral inguinal ectopic scrotum with covered exstrophy. Pediatr Surg Int. 2002;18(5–6):511–513.
SCROTUM, BIFID
DESCRIPTION A disorder characterized by separation of the labioscrotal folds, seen with mid scrotal or perineal hypospadias and intersex disorders. Embryologically, it is a failure of the genital swellings to fuse at the midline. The condition represents a spectrum of penoscrotal transposition abnormalities. Surgical realignment at the midline and hypospadias repair is recommended management. (See Section II: “Scrotum, Engulfment [Penoscrotal Transposition].” and (Image ))
REFERENCE
Sule JD, Skoog SJ, Tank ES, et al. Perineal lipoma and the accessory labioscrotal fold: An etiological relationship. J Urol. 1994;151(2):475–477.
SCROTUM, ENGULFMENT (PENOSCROTAL TRANSPOSITION)
DESCRIPTION The most extreme form of penoscrotal transposition, in which the scrotum is located in a cephalad position with respect to the penis. A milder form is bifid scrotum. Major renal anomalies include complete agenesis of the urinary system, unilateral or bilateral renal agenesis, polycystic or dysplastic kidneys, horseshoe kidney, ectopic pelvic kidney, and obstructive uropathy. Abnormalities of the external genitalia include a disproportionately long flaccid penis, complete urethral atresia, and hypospadias. Treated by hypospadias repair with scrotoplasty using an inverted omega skin incision around the scrotal skin and the base of the penis. This allows placement of the scrotal flaps beneath the penis.
REFERENCE
Parida SK, Hall BD, Barton L, et al. Penoscrotal transposition and associated anomalies: Report of five new cases and review of the literature. Am J Med Genet. 1995;59(1):68–75.
SCROTUM, EPIDERMAL INCLUSION CYST
DESCRIPTION Epidermal (epidermoid) inclusion cysts are benign tumors. They result from the implantation of epidermal tissue into the dermis or subcutis, from trauma or abnormal embryologic closure of the median raphe and urethral groove. These lesions appear solid on imaging and often contain a material that is a combination of keratin and cholesterol, often in a laminated configuration arising from a stratified squamous epithelial wall. They can be asymptomatic or more commonly rupture or become infected. Local excision is the treatment, since epidermoid inclusion cysts can mimic rare malignant tumors such as liposarcoma, fibrosarcoma, and even metastatic disease.
REFERENCE
Yang WT, Whitman GJ, Tse GM, et al. Extratesticular epidermal cyst of the scrotum. AJR Am J Roentgenol. 2004;183:1084.
SCROTUM, FAT NECROSIS
DESCRIPTION An uncommon lesion that is seen in prepubertal boys and can be a cause of acute scrotal pain. Typical presentation is an obese prepubertal child with recent exposure to cold, such as during swimming. Bilateral intrascrotal masses are present inferior to the testis. If the diagnosis is made with US and shows the classic presentation, conservative management can be employed.
REFERENCE
Donohue A, Utley WLF. Idiopathic fat necrosis in the scrotum. Br J Urology. 2008;47(3):331–333.
SCROTUM, GIANT NEUROLEMMOMA
DESCRIPTION Well-encapsulated tumors of neural elements (also called neurinoma or Schwannoma) within the scrotum. Most such tumors are benign, with malignant transformation as an extremely rare occurrence. Surgical removal of the lesion is the definitive treatment.
REFERENCE
Fernandez MJ, Martino A, Khan H, et al. Giant neurilemmoma: Unusual scrotal mass. Urology. 1987;30(1):74–76.
SCROTUM, HEMANGIOMA
DESCRIPTION These lesions should be differentiated from angiokeratoma of Fordyce that appear in older men (see Section II: “Angiokeratoma of Fordyce [Penile and Scrotal Angiokeratomas]”). Hemangiomas represent 7% of all nonmalignant tumors and are the most common benign tumor of infancy; however, they involve the penis and scrotum only 1% of the time. Cutaneous hemangiomas also called (strawberry angiomas) may grow for up to 6–12 mo and then undergo involution. By age 7, complete regression will be seen in approximately 75–90% such that most do not need therapy. Subcutaneous hemangiomas are even more infrequent but tend to expand gradually and may clinically resemble a varicocele.
TREATMENT
• Large cutaneous lesions can be excised surgically or ablated with a laser.
• Subcutaneous lesions usually require surgical excision.
REFERENCE
Leavitt DA, Hottinger DG, Reed RC, et al. A case series of genital vascular anomalies in children and their management: Lessons learned. Urology. 2012;80(4):914–918.
SCROTUM, HYPOPLASIA
DESCRIPTION The unilateral or bilateral underdevelopment of the scrotum, which simulates labia majora, is most commonly associated with cryptorchid testes and ambiguous genitalia. Some syndromes associated include: Prader–Willi syndrome (PWS), Genitopatellar syndrome, many others. For a complete listing see: http://monarch.monarchinitiative.org/phenotype/HP:0000046, Accessed March 8, 2014.
TREATMENT
• A testicular prosthesis can improve the cosmetic appearance of the scrotum.
• Testosterone cream can also be applied for an improved cosmetic result on the affected side.
REFERENCE
Maat-Kievit A, Brunner HG, Maaswinkel-Mooij P. Two additional cases of the Ohdo-blepharophimosis syndrome. Am J Med Genet. 1993;47(6):901–906.
SCROTUM, IDIOPATHIC CALCINOSIS
DESCRIPTION Patients with this condition are typically young men who present with multiple hard nodules throughout the scrotal wall. Although the skin is usually intact, lesions may ulcerate. Thought to be caused by calcification of the scrotal dermal connective tissue (eccrine sweat glands) for unknown reasons. No therapy is necessary unless recurrent episodes of infection occur; then surgical excision may help.
REFERENCE
Tela UM, Ibrahim MB. Scrotal calcinosis: a case report and review of pathogenesis and surgical management. Case Rep Urol. 2012;2012:475246.
SEAPI INCONTINENCE CLASSIFICATION SYSTEM
DESCRIPTION SEAPI is an acronym for stress incontinence, emptying ability, anatomy, protection, and instability. Is useful as a reliable and uniform method of following the short- and long-term outcome of stress urinary incontinence (SUI) surgery. This system is similar to the TNM tumor staging classification system in that each component is graded with a score from 0 (no symptoms) to 3 (severe symptoms). After completion of the evaluation of the incontinent patient, a preoperative subjective and objective SEAPI score is determined. These scores are then compared with postoperative SEAPI scores to access treatment outcome. It has been found to have a high degree of reliability and internal consistency across a wife age range in both genders.
REFERENCE
Stothers L. Reliability, validity, gender differences in the quality of life index of the SEAPI-QMM incontinence classification system. Neurourol Urodyn. 2004;(233):223–228.
SEBORRHEIC DERMATITIS
DESCRIPTION Commonly referred to as dandruff, this condition can be seen on the penis, anus, or pubic hair. Pruritus is the rule, with the lesions in hair-bearing areas having a red base and waxy yellow crust. While the organism Pityrosporon orbiculare is suspected, the exact agent is unknown. Standard antidandruff shampoos are usually effective. Shampoo containing ketoconazole may be needed. Steroids should be used with caution, if at all, because this tends to be a lifelong problem. (See also Section II: “Pruritus, External Genitalia, Male.”)
REFERENCE
Margolis DJ. Cutaneous diseases of the male external genitalia. In: Walsh PC, Retik AB, Vaughan ED, et al., eds. Campbell’s Urology. 7th ed. Philadelphia, PA: Saunders; 1998.
SEMEN ANALYSIS, ABNORMAL FINDINGS AND TERMINOLOGY
DESCRIPTION A significant overlap exists between fertile, subfertile, and infertile populations, therefore, absolute parameters for infertility (except for aspermia or azoospermia) are difficult to measure precisely. In general, fertile populations demonstrate mean sperm densities of 70–80 million/mL. Assisted reproduction techniques (ART’s) are now able to overcome many of these abnormalities. (See also Section I: “Infertility”; Section II: “Semen Analysis, Technique, and Normal Values.” and “Semen Analysis, Abnormal Findings and Terminology.”)
• Aspermia: No semen ejaculated
• Asthenospermia: <50% of spermatozoa with forward progression of 3–4
• Asthenozoospermia: Poor motility and/or poor forward progression
• Azoospermia: No spermatozoa found in semen
• Globozoospermia: Round-headed sperm devoid of acrosome
• Hematospermia: Blood present in an ejaculate/semen
• Hyperspermia: Volume of ejaculate >6.5 mL
• Hypospermia: Volume of ejaculate <1.5 mL
• Leukocytospermia/pyospermia: Excess white cells >1 WBC × 106/mL) in semen
• Necrozoospermia: No live sperm in ejaculated semen
• Normozoospermia/normospermia: Refer to a normal semen analysis
• Oligoasthenoteratospermia: Very generalized abnormalities in sperm concentration, motility, and morphology; often associated with varicocele
• Oligoasthenoteratozoospermia: Signifies disturbance of all 3 variables (combinations of 2 prefixes may also be used)
• Oligozoospermia: Low concentration of sperm <20 × 106/mL
• Polyspermia: Abnormally high sperm density >250 × 106/mL
• Polyzoospermia: Excessive number of sperm in ejaculate sample
• Pyospermia/leukocytospermia: Excess white cells >1 WBC × 106/mL in semen
• Teratozoospermia: Reduced percentage of morphologically normal sperm, usually <50% spermatozoa with normal morphology
REFERENCES
Gilbert BR, Cooper GW, Goldstein M. Semen analysis in the evaluation of male factor subfertility. AUA Update Series. Vol. XI, Lesson 32; 1992.
Grimes DA. Oligozoospermia, azoospermia, and other semen-analysis terminology: The need for better science. Fertil Steril. 2007;(886):1491–149.
Rowe PJ, et al., eds. WHO manual for the standardized investigation, diagnosis and management of the infertile male. New York, NY: Cambridge University Press; 2000.
SEMEN ANALYSIS, TECHNIQUE, NORMAL VALUES
DESCRIPTION Normozoospermia/normospermia are terms sometimes used to refer to a normal semen analysis. After 48–72 hr of abstinence, a semen specimen is collected in a wide-mouth polypropylene container with a screw top through masturbation without the use of any lubricants that could contaminate the sample. Care must be taken to capture all of the ejaculate. The sample is kept as close to body temperature as possible and delivered to the lab within 1.5 hr. Analysis includes (may vary slightly by lab) total seminal volume, sperm concentration, sperm motility, sperm morphology, fructose content, coagulation time, liquefaction time, viscosity, and leukocyte count. Newer computer-assisted systems (CASA) can also evaluate curvilinear velocity, straight-line velocity, linearity, and amplitude of lateral head displacements. Antisperm antibodies may be considered a secondary test. Normal parameters are established by most labs. The following are general reference parameters and are typically determined on at least 2 specimens. (See also Section I: “Infertility”; and Section II: “Semen Analysis, Abnormal”; also see Section II for topics on specific semen abnormalities.)
REFERENCE
McLachlan RI, Baker HW, Clarke GN, et al. Semen analysis: Its place in modern reproductive medical practice. Pathology. 2003;(351):25–33.
SEMEN LEUKOCYTES
DESCRIPTION The leukocyte is the most common nonsperm cell seen in semen analysis, and it may be confused with immature spermatozoa on microscopy. Leukocytospermia and pyospermia are terms used to describe excess white cells in the semen sample >1 WBC × 106/mL. Elevations usually are associated with infection, but may be linked to reactive oxygen species and may be present when there is no finding of infection or immune response. Leukocytospermia is often found in patients with unexplained infertility. Semen cultures are prone to contamination, and the use of antibiotics to treat pyospermia is controversial. (See also Section I: “Infertility”; Section II: “Semen Analysis, Abnormal Findings and Terminology”; “Semen Analysis, Technique, Normal Values” and “Pyospermia.”)
REFERENCE
Agarwal A, Bragais FM, Sabanegh E. Assessing sperm function. Urol Clin N Am. 2008;35:157–171.
SEMINAL PLASMA HYPERSENSITIVITY (SEMINAL PLASMA ALLERGY) AND HYPERSENSITIVITY TO HUMAN SEMEN (HHS)
DESCRIPTION An allergic reaction to human semen that presents as a systemic reaction (ranging from mild to anaphylaxis) or a localized vaginal symptoms shortly after ejaculation into the vagina. 2 types described in the literature the more common reaction to human seminal plasma (allergic reactions to human seminal plasma [HSP] proteins) or a response to spermatozoa (hypersensitivity to human semen [HHS]). These conditions are likely underreported and may not be discussed or ascribed to dyspareunia or vulvovaginitis. These are seen exclusively in women (usually from 20–30 yr of age) and can be avoided through the use of condoms or less commonly through anti-allergy medications or allergen desensitization. Once established, it usually occurs with other male partners. In addition to the potential symptoms infertility is an issue.
REFERENCES
Carroll M, Horne G, Antrobus R, et al. Testing for hypersensitivity to seminal fluid-free spermatozoa. Hum Fertil (Camb). 2013;16(2):128–131.
Shah A, Panjabi C. Human seminal plasma allergy: A review of a rare phenomenon. Clin Exp Allergy. 2004;34:827.
SEMINAL VESICLE AGENESIS
DESCRIPTION Can be unilateral or bilateral (very rare). Unilateral agenesis results from an embryologic insult before separation of the ureteral bud from the mesonephric ducts. Unilateral agenesis is associated with ipsilateral agenesis of the ductus deferens and with renal agenesis in 79%, ipsilateral renal abnormalities in 12%, and only 9% had normal kidneys bilaterally. The contralateral seminal vesicle is often hypoplastic.
REFERENCE
Trigaux JP, Van Beers B, Delchambre F. Male genital tract malformations associated with ipsilateral renal agenesis: Sonographic findings. J Clin Ultrasound. 1991;19:3–10.
SEMINAL VESICLE, AMYLOIDOSIS
DESCRIPTION A benign localized condition characterized by subepithelial deposition of amyloid in the seminal vesicles. Amyloids are low–molecular-weight fibrils found in extracellular tissues; they consist of a variety of proteins. Its incidence increases with increased age and can often be misinterpreted as regional spread of bladder or prostate cancer. No treatment is necessary if asymptomatic.
REFERENCE
Erbersdobler A. Seminal vesicle amyloidosis does not provide any protection from invasion by prostate cancer. BJU Int. 2009;103(3):324–326.
SEMINAL VESICLE CALCULI AND CALCIFICATIONS
DESCRIPTION Calcification of vas deferens seems to be specific to diabetes melitus and may be associated with calcification of the seminal vesicles. Other causes include: TB, schistosomiasis, gonorrhea, chlamydia, gonadal dysgenesis, and uremia with secondary hyperparathyroidism. Intraluminal seminal vesicle calcifications can be seen (Image ).
REFERENCE
Yadav R, Goel A, Sankhwar SN, et al. Incidentally detected bilaterally symmetrical seminal and vas calcification in young infertile male: A case report, literature review and algorithm for diagnosis. Can Urol Assoc J.2012;6(5):E206–E208.
SEMINAL VESICLE, CARCINOMA
DESCRIPTION Primary tumors of the seminal vesicles are extremely rare as there are no more than 60 histologically confirmed reported cases. The seminal vesicles are often secondarily involved by cancer of surrounding structures such as prostate, bladder, or rectal carcinoma. Lymphoma of the seminal vesicles has been reported. Primary adenocarcinoma of the seminal vesicle (the most common primary type) occurs in patients >50. Immunohistochemistry is helpful in diagnosis. They are PSA and PSAP negative. RP and/or cystoprostatectomy including pelvic lymph node dissection, offers curative treatment. Adjuvant or neoadjuvant chemotherapy is of unproven worth, but a combination of hormonal deprivation and radiotherapy seems to be more effective than any chemotherapy.
REFERENCE
Campobasso D, Fornia S, Ferretti S, et al. Primary bilateral seminal vesicle carcinoma: Description of a case and literature review. Int J Surg Pathol. 2012;20(6):633–635.
SEMINAL VESICLE, CYSTS
DESCRIPTION Cysts, of either congenital or acquired origin, located in the seminal vesicles. Many studies in the past have linked such cysts to other GU issues, including renal agenesis, infertility, hematospermia, GU infection, and adult polycystic kidney disease. Causes are congenital, ejaculatory duct obstruction (EDO), or a basement membrane defect, especially in cysts associated with adult polycystic kidney disease. (See also Section I: “Seminal Vesicle Masses and Cysts" and Image )
TREATMENT
• No treatment is necessary if asymptomatic.
• Aspiration, marsupialization, or excision, if symptomatic
REFERENCE
Labanaris AP, Zugor V, Meyer B, et al. A case of a large seminal vesicle cyst associated with ipsilateral renal agenesis. Sci World J. 2008;8:400–404.
SEMINAL VESICULITIS
DESCRIPTION Inflammation of the seminal vesicles that often occurs secondary to bacterial infection, causing prostatitis or epididymitis. Older literature referred to this condition as pyospermia. Symptoms are often vague and may include penile, scrotal, or perineal pain; painful ejaculation; hematospermia; lower abdominal or back pain; and LUTS. Diagnosis is often 1 of exclusion of other more common causes made with positive cultures from the ejaculate as well as imaging via transrectal US, CT, or MRI. Pyospermia/leukocytospermia is prominent on semen analysis. Abscess formation is a complication of seminal vesiculitis and can be an initial presentation of the disease. Treatment includes culture-sensitive antibiotics, transrectal aspiration, or excision (open or laparoscopic seminal vesiculectomy) for severe cases. Transurethral seminal vesiculoscopy with irrigation has been described. (See also Section II: “Pyospermia.”)
REFERENCES
Zeitlin SI, et al. Seminal vesiculitis. In: Nickel JC, ed. Textbook of Prostatitis. 1st ed. Informa HealthCare; 1999.
Liu B, Li J, Li P, et al. Transurethral seminal vesiculoscopy in the diagnosis and treatment of intractable seminal vesiculitis. J Int Med Res. 2014;42(1):236–242.
SEMINOMA WITH HIGH MITOTIC RATE (SEMINOMA, ANAPLASTIC)
DESCRIPTION Histologic subtype of seminoma, seen in up to 10% of all seminomas. Anaplastic seminoma is typically more aggressive and invasive compared to classic and spermatocytic seminoma, demonstrating increased mitotic activity and more β-hCG production than its counterparts. It is associated with increased local invasion and rate of metastatic growth as well. Patients usually present at a higher stage. Despite these findings, no survival difference after treatment has been reported when compared to classic seminoma, stage for stage. Treatment depends on tumor stage. Radical orchiectomy followed by either surveillance, radiation therapy, and/or chemotherapy are performed, depending on the extent of disease. (See also Section I: “Testis Cancer, Seminoma.”)
REFERENCE
Neill M, Warde P, Fleshner N. Management of low-stage testicular seminoma. Urol Clin N Am. 2007;34(2):127–136.
SEMINOMA, CLASSIC
DESCRIPTION The most common histologic subtype of seminomatous germ cell tumor (GCT), it accounts for ∼85% of cases. Typically presents in males in the 3rd–5th decades of life. Syncytiotrophoblastic elements are seen in 10% of lesions. These elements produce β-hCG, which can be used as a tumor marker to help assess resolution or recurrence of disease after treatment. Like all testicular tumors, treatment depends on tumor stage. Radical orchiectomy followed by either surveillance, radiation therapy, and/or chemotherapy are performed, depending on the extent of disease. (See also Section I: “Testis, Seminoma.”)
REFERENCE
Neill M, Warde P, Fleshner N. Management of low-stage testicular seminoma. Urol Clin N Am. 2007;34(2):127–136.
SEMINOMA, SPERMATOCYTIC
DESCRIPTION Accounts for ∼2% of all seminomatous germ cell tumor (GCT). Patients present later in life, usually in their 5th–6th decades. Unlike classic and anaplastic subtypes, spermatocytic seminoma rarely metastasizes. It is believed that this subtype arises from a different, more mature germ cell line, which likely contributes to its more favorable presentation. Due to its low metastatic potential, no further treatment is often recommended after radical orchiectomy. (See also Section I: “Testis cancer, Seminoma.”)
REFERENCE
Neill M, Warde P, Fleshner N. Management of low-stage testicular seminoma. Urol Clin N Am. 2007;34(2):127–136.
SEX REVERSAL SYNDROME (XX MALE)
DESCRIPTION These patients demonstrate small, firm testes; frequent gynecomastia; a small to normal penis; and azoospermia. Testicular biopsy may demonstrate seminiferous tubule sclerosis, causing elevated gonadotropins and decreased testosterone levels. Individuals are shorter than average height. There is no increase in the incidence of mental retardation, but there is an increase in hypospadias. Although karyotyping demonstrates 46, XX, molecular biologic mapping suggests that portions of the Y chromosome are present. It has been hypothesized that the portion of the Y chromosome containing the testes-determining factor has been translocated. Diagnosis is based on karyotype, molecular biologic mapping, and PCR using Y-specific probes. If necessary, phenotypic gender assignment is done very early, and appropriate surgical correction is performed. After puberty, management is more difficult because of andrologic problems such as hypogonadism, micropenis, undescended testes, lack of secondary sex characteristics, and impotence. Treatment plans must address these issues.
REFERENCE
Yamamoto M, Yokoi K, Katsuno S, et al. A case of sex reversal syndrome with sex-determining region. Nagoya J Med Sci. 1995;58(3–4):111–115.
SEX-HORMONE BINDING GLOBULIN (SHBG)
DEFINITION
Testosterone (T) circulates bound to either SHBG, albumin or corticosteroid binding globulin (CBG), or in an unbound form (free). SHBG-bound T is about 44% of the total T and is unavailable to cells. Albumin-bound T is about 50% of the total. Conditions that increase SHBG, include aging, hyperthyroidism, estrogens, HIV disease, anticonvulsants, hepatitis and hepatic cirrhosis. Conditions that decrease SHBG, include obesity, diabetes mellitus, hypothyroidism, androgenic steroids, nephrotic syndrome, acromegaly and glucocorticoids. The age-related SHBG increase means that older men may have a normal T levels even if they are hypogonadal, as they will have low levels of free or bioavailable T. Obesity, on the other hand, decreases SHBG and T, even when the available T may be normal.
REFERENCE
Paduch D, et al. The Laboratory Diagnosis of Testosterone Deficiency: AUA White Paper available at http://www.auanet.org/common/pdf/education/clinical-guidance/Testosterone-Deficiency-WhitePaper.pdf, Accessed March 27, 2014.
SEXSOMNIA
DESCRIPTION Sexsomnia, also known as somnambulistic sexual behavior or sleep sex is a particular form of parasomnia (disruptive sleep disorders) characterized by atypical sexual behavior during sleep. The repertoire of sexual behavior during sleep can vary from explicit vocalizations with sexual content, violent masturbation, and complex sexual activities including oral sex, and vaginal or anal intercourse.
The exact etiology is unknown, but precipitating factors are stress, sleep deprivation/fragmentation, alcohol or drug consumption, excessive fatigue and physical overactivity in the evening
TREATMENT
• Benzodiazepines are 1st-line therapy
• Sleep hygiene and safety precautions should be implemented
REFERENCE
Andersen, ML, Poyares D, Alves RS, et al. Sexsomnia: Abnormal sexual behavior during sleep. Brain Res Rev. 2007;56:271–282.
SEXUAL ANHEDONIA/EJACULATORY ANHEDONIA
DESCRIPTION Lack of appropriate pleasure from sexual activity. Patients typically elicit a failure of genital response. Men have difficulty initiating or sustaining an erection; pre-menopausal women have difficulty with lubrication. Ejaculatory anhedonia describes lack of pleasure during ejaculation. Although a psychogenic etiology is often present, the clinician must rule out hormonal influences. Medications such as selective serotonin reuptake inhibitors have been reported to cause this phenomenon as well.
REFERENCES
Hatzimouratidis K, Hatzichristou D. Sexual definitions: Classifications and definitions. J Sex Med. 2007;(41):241–250.
Ralph DJ, Wylie KR. Ejaculatory disorders and sexual function. BJU Int. 2005;(959):1181–1186.
SEXUAL FUNCTION SURVEY (SFS) (INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF)
DESCRIPTION The IIEF is a 15-item, self-administered questionnaire scale for the assessment of erectile function that has been linguistically validated in 10 languages. It addresses the relevant domains of male sexual function: Erectile function (EF), orgasmic function (OF), sexual desire (SD), intercourse satisfaction (IS), and overall satisfaction. EF is represented in items 1(5 and 15 of the questionnaire, with a score range of 0 or 1) to 5, a minimum score of 1, and a maximum score of 30. OF is represented in items 9 and 10, with a score range of 0–5, a minimum score of 0, and a maximum score of 10. SD is represented in items 11 and 12, with a score range of –5, a minimum score of 2, and a maximum score of 10. IS is covered in items 6, 7, and 8, with a score range of 0–5, a minimum score of 0, and a maximum score of 15. OS is covered in items 13 and 14, with a score range of 1–5, a minimum score of 2, and a maximum score of 10. In general, the lower the score, the worse the erectile function. (See Section VII: “Reference Tables: International Index of Erectile Function [IIEF] [Sexual Function Survey].”)
REFERENCE
Rosen RC, Riley A, Wagner G, et al. The International Index of Erectile Function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49:822–830.
SEXUAL HEALTH INVENTORY FOR MEN (SHIM) SCORE
DESCRIPTION The SHIM, sometimes called IIEF-5 (International Index of Erectile Function), is a validated questionnaire that assesses male sexual function and can be used as an adjunct for the assessment and treatment of ED. This is an abridged version of the original 15-question IIEF questionnaire. The SHIM questionnaire consists of 5 questions pertaining to the quality of the patient’s erections and sexual satisfaction over the last 6 mo. Each question is graded on a scale from 1–5. ED is then assessed based on the cumulative value of the SHIM score: 22–25, no ED; 17–21, mild ED; 12–16, mild to moderate ED; 8–11, moderate ED; 5–7, severe ED. (See Section VII for the SHIM Instrument.)
REFERENCE
Rosen RC, Cappelleri JC, Smith MD, et al. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;(116):319–326.
SHY DRAGER SYNDROME, UROLOGIC CONSIDERATIONS
DESCRIPTION Shy Drager syndrome, also known as multiple system atrophy, is a progressive neurodegenerative disease in which the etiology is unknown. Bladder dysfunction causing urinary incontinence and erectile dysfunction (ED) are early features. Urinary urgency, frequency, incomplete bladder emptying as well as urinary retention or any combination are seen as urologic manifestations of Shy Drager syndrome. In addition, weakness of the striated urethral sphincter contributes to incontinence. DO is seen on urodynamic evaluation.
REFERENCE
Fowler CJ, Dalton C, Panicker JN. Review of Neurologic Diseases for the Urologist. Urol Clin North Am. 2010;37(4):517–526.
SIGNET RING CARCINOMA, PROSTATE
DESCRIPTION A rare, high-grade neoplasm that carries a poor prognosis. A GI primary tumor should be considered with this pathology. Immunohistochemical exam demonstrates cytoplasmic immunoreactivity to PSA in signet-ring cancer cells, with intracytoplasmic vacuoles in the signet-ring cells staining positively for mucus with periodic acid-Schiff. This malignancy is more aggressive than other cell types; >50% of these patients die within a year of diagnosis.
REFERENCE
Matsuoka Y, Arai G, Ishimaru H, et al. Primary signet-ring cell carcinoma of the prostate. Can J Urol. 2007;14(6):3764–3766.
SILBER VASOEPIDIDYMOSTOMY
DESCRIPTION In 1978, Silber was the 1st to report the use of the microscope to perform a vasoepididymostomy. The distal epididymis is cut and, with aid of the microscope, the tubule exuding semen is identified. The freshly cut mucosal lumen of the vas deferens is anastomosed to this tubule, and the adventitia of the vas is then anchored to the epididymal tunic. The procedure is used in selected cases of obstructive infertility.
REFERENCE
Thomas AJ. Vasovasostomy. In: Novick AC, Streem SB, Pontes JE., eds. Stewart’s Operative Urology. Baltimore, MD: Williams & Wilkins; 1989:767–773.
SKENE (PARAURETHRAL) GLAND ADENOCARCINOMA
DESCRIPTION An extremely rare primary urethral carcinoma occurring in approximately 1.5 women per million and constituting <1% of all female malignancies. Presence of PSA in tissue and/or serum confirms a Skene gland origin, due to its homology to the male prostate. PSA levels normalize after treatment. Complete excision, using a technique similar to repair of urethral diverticulum, is curative. Decision for radiotherapy is based on tumor size and location, with smaller, distal lesions generally undergoing surgical excision and RT, and large or proximal lesions treated with radiation therapy (RT) in an effort to preserve organ function.
REFERENCE
Champ CE, Hegarty SE, Shen X, et al. Prognostic factors and outcomes after definitive treatment of female urethral cancer: A population-based analysis. Urology. 2012;80(2):374–381.
SKENE (PARAURETHRAL) GLAND, INFLAMMATION/ADENITIS
DESCRIPTION Skene glands are homologous to the male prostate gland and are located along the anterior vaginal wall, adjacent to the urethral meatus. These glands may become infected and present as a tender, fluctuant periurethral nodule. Infection or inflammation of the Skene glands can cause exquisite tenderness and may be associated with dyspareunia and vulvar vestibulitis. The most common pathogen is Neisseria gonorrhoeae. Treatment includes culture of infected area along with surgical incision and drainage if abscess formation is present. Appropriate antibiotic therapy is administered. Other causes of vestibulitis or vulvodynia should be assessed and evaluated.
REFERENCE
Metts JF. Vulvodynia and vulvar vestibulitis: Challenges in diagnosis and management. Am Fam Physician. 1999;(596):1547–1556.
SKIN TAGS, EXTERNAL GENITALIA (ACROCHORDON, PEDUNCULATED PAPILLOMA)
DESCRIPTION Benign, flesh-colored, soft pedunculated benign lesions that may occur anywhere on the body and generally are <5 mm, although larger lesions can be seen. They may be pinkish, skin-colored, or hyperpigmented and are more common on obese individuals. Usually asymptomatic, these lesions are often found in skin folds (neck, axillae, groin) and rarely involve the external genitalia. They may accompany hamartomatous skin lesions (fibrofolliculomas and trichodiscomas) associated with Birt–Hogg–Dubé syndrome. Irritation and possibly HPV types 6/11 are possible causes. No treatment is necessary, and they are usually considered clinically insignificant. If treatment is desired for cosmesis or irritation, then the tags may be treated by electrocautery, simple scissor excision, suture ligation of the base, or cryotherapy.
REFERENCE
Emir L, Ak H, Karabulut A, et al. A huge unusual mass on the penile skin: Acrochordon. Int Urol Nephrol. 2004;36(4):563–565.
SLEEP APNEA, UROLOGIC CONSIDERATIONS
DESCRIPTION Patients with obstructive sleep apnea may have their condition exacerbated by testosterone replacement therapy (TRT); their sleep apnea status should be monitored closely and treated if possible. Sleep apnea also may cause nocturnal hypoxia and may be a factor for erectile dysfunction (ED). Obstructive sleep apnea may also be involved with nocturia and daytime overactive bladder in women.
REFERENCES
Hanafy HM. Testosterone therapy and obstructive sleep apnea: Is there a real connection? J Sex Med. 2007;(45):1241–1246.
Lowenstein L, Kenton K, Brubaker L, et al. The relationship between obstructive sleep apnea, nocturia, and daytime overactive bladder syndrome in women. Am J Obstet Gynecol. 2008;198(5):598.e1–e5.
SLING MATERIALS
DESCRIPTION Slings, usually mid-urethral, are a common option for the treatment of intrinsic sphincteric deficiency. Sling materials are either autologous, allografts, xenografts, or synthetic. (See also Section I: “Incontinence, Female”; “Incontinence, Male”; Section II: “Urethral Sling.”)
• Autologous grafts (harvested at the time of surgery):
– Rectus fascia
– Fascia lata
– Vaginal wall
– Round ligament
– Dermis
• Allografts (processed by freeze-drying or solvent dehydration):
– Cadaveric fascia
– Cadaveric dermis
• Xenografts:
– Porcine dermis
– Porcine small intestinal submucosa
• Synthetic slings:
– Marlex
– Gore-Tex
– Silicone
– Transvaginal tape (polypropropylene mesh)
REFERENCE
Wilson TS, Lemack GE, Zimmern PE. Management of intrinsic sphincteric deficiency. J Urol. 2003;169(5):1662–1669.
SMEGMA
DESCRIPTION A substance composed of desquamated cells that originate from the epithelium of the glans penis and on the inner surface of the foreskin. Smegma is composed of 26% fat and 13% protein. It remains unclear whether smegma is only desquamated epithelial cells or whether secretions from preputial glands at the coronal sulcus contribute to smegma. The issue of smegma carcinogenicity is still controversial. Some believe that phimosis allows for retention of smegma, which is an irritant that produces malignant transformation of the epithelium by direct contact. 50% of men harbor Mycobacterium smegmatis in the preputial sac; this organism has been implicated in the conversion of sterols in smegma into carcinogenic compounds. Good puerperal hygiene is recommended if uncircumcised.
REFERENCE
Maden C, Sherman KJ, Beckmann AM, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst. 1993;85(1):19–24.
SMITH–LEMLI–OPITZ SYNDROME
DESCRIPTION An autosomal recessive multisystemic disease found in newborns that present with hypospadias and cryptorchidism. Anomalies in other systems include pernicious anemia, mental retardation, syndactyly, renal abnormalities, and microcephaly. These patients have an inborn error of cholesterol (biosynthesis defect of δ5,7-sterol, δ7-reductase), which results in deficiency of cholesterol and elevation of 7-dehydrocholesterol, a cholesterol precursor. Patients can take cholesterol with or without bile acids.
REFERENCE
Irons M, Elias ER, Abuelo D, et al. Treatment of Smith-Lemli-Opitz syndrome. Am J Med Genet. 1997;68(3):311–314.
SMOKING, UROLOGIC CONSIDERATIONS
DESCRIPTION Smoking is a modifiable behavioral risk factor with an array of impact on urologic disorders. The smoking population attributable risk of bladder cancer is 50% in men and 52% in women. The relative risk of developing both renal parenchymal cancer as well as upper tract carcinoma ranged in men from 27–37% and 10–24% in women. In addition, there is a dose-response relationship as the risk of developing RCC is increased in lifelong smokers who smoke >20 cigarettes a day compared those who smoke less. Smoking may cause irreversible damage to neuromuscular and vaso-endothelial mechanisms of erectile function as though only 20% of the population are smokers, 40% of men with ED are currently smokers. Smoking has also been associated with increased risk of acquiring HIV and HPV (both high and low-risk strains). The semen parameters in men who smoke have been found to be significantly decreased, especially sperm motility.
REFERENCE
Watson RA, Sadeghi-Nejad H. Tobacco abuse and the urologist: Time for a more proactive role. Urology. 2011;(786):1219–1223.
SNODGRASS HYPOSPADIAS REPAIR
DESCRIPTION Snodgrass hypospadias repair, also known as tubularized incised-plate urethroplasty, is the most commonly performed operation to repair distal hypospadias. The key step in the procedure is a midline incision of the urethral plate. The urethral plate is then tubularized beginning at the neomeatus, turning all epithelium into the neo-urethral lumen.
REFERENCE
Snodgrass WT. Snodgrass technique for hypospadias repair. BJU Int. 2005;95:683–689.
SOAP-BUBBLE NEPHROGRAM
DESCRIPTION The Soap-bubble nephrogram seen on IVP is caused by end-stage obstruction atrophy, this is a radiographic appearance of the dilated pyelocalyceal system in which overlapping curved, white densities several millimeters in thickness appear after IV or intra-arterial injection of contrast material. Dilated calyces are represented by bubbles, and remnants of Bertin columns appear as thin opacities between adjacent calyces.
REFERENCE
Ransley PG. Opacification of the renal parenchyma in obstruction and reflux. Pediatr Radiol. 1976;4:226.
SODIUM CYANIDE NITROPRUSSIDE TEST
DESCRIPTION A qualitative test for cystinuria. The assay involves the conversion by cyanide of cystine to cysteine. Nitroprusside binds cysteine resulting in a purple color in 2–10 min. The test detects cystine levels above 75 mg/g creatinine. If positive a quantitative 24-hr collections should be performed. (See also Section I: “Urolithiasis, Cystine and Cystinuria (Hypercystinuria)” and Section II: “Metabolic Stone Evaluation [24-hr Urine Studies].”)
REFERENCE
Eggermann T, Venghaus A, Zerres K. Cystinuria: An inborn cause of urolithiasis. Orphanet J Rare Dis. 2012;7:19–29.
SOLITARY FIBROUS TUMOR, RENAL
DESCRIPTION Solitary fibrous tumors (SFTs) are mesenchymal tumors arising at any site. When involving the kidney, they arise from the capsule, renal pelvis, or hilar fatty tissue. They present similar to patients with RCC. On gross appearance, the tumor is solid with a pseudocapsule. Microscopically, it shows a spindle cell proliferation. Controversy exists concerning the diagnosis of SFT and hemangiopericytoma because of overlapping immunohistochemical features. No cases of metastasis from renal SFTs has been described.
TREATMENT
Radical nephrectomy with complete resection including negative margins is needed for a favorable prognosis.
REFERENCE
Makris A, Tabaza R, Brehmer B, et al. Solitary fibrous tumor of the kidney: A case report. Can J Urol. 2009;(165):4854–4856.
SPERM GRANULOMA
DESCRIPTION Sperm granulomas form from the testicular end of the vas deferens after vasectomy. Because sperm is highly antigenic, the inflammatory reaction creates a granuloma, which is usually asymptomatic. Some studies have shown that men who undergo vasectomy reversal have higher success rates if they have a sperm granuloma at the vasectomy site. A mass in the scrotum, often tender postvasectomy, is diagnostic.
TREATMENT
• When chronic post-vasectomy pain is localized to the sperm granuloma, the lesion should be excised and occluded with electrocautery.
• Post-vasectomy congestive epididymitis may be relieved with open-ended vasectomy, which will produce a pressure-relieving sperm granuloma.
REFERENCE
Awsare NS, Krishnan J, Boustead GB, et al. Complications of vasectomy. Ann R Coll Surg Engl. 2005;87(6):406–410.
SPERM PENETRATION ASSAY (SPA, HAMSTER TEST)
DESCRIPTION Also called hamster oocyte penetration test and in some publications (Humster test), a test for infertility that assesses the ability of sperm to penetrate the ovum. The zona pellucida from hamster oocytes is removed, which allows capacitated human sperm to penetrate it. This assay requires the sperm to be able to undergo capacitation, the acrosome reaction, fusion with the oolemma, and incorporation into the ooplasm. If sperm penetration is 10–30%, the sample is considered normal, but this bioassay is not standardized. Some studies have shown that IVF success is correlated with a positive SPA, while others have not. These inconsistencies require that the physician become familiar with the lab performing this test. Although there are controversies surrounding SPA, it is a test that should be performed for unexplained infertility.
REFERENCE
Aitken RJ. Sperm function tests and fertility. Int J Androl. 2006;29(1):69–75.
SPERM VITALITY
DESCRIPTION Also referred to as sperm viability or sperm motility, this is 1 parameter in semen analysis during workup of male infertility. Determination of the percentage of viable and motile sperm in semen samples is helpful to determine if the sperm could be of therapeutic use for various fertilization techniques. (See also Section I: “Infertility”; Section II: “Semen Analysis, Technique, and Normal Values.”)
REFERENCE
Cooper TG, Hellenkemper B. Method-related estimates of sperm viability. J Androl. 2009;30(3):214–218.
SPERMATIC CORD, LIPOSARCOMA
DESCRIPTION A rare soft tissue malignancy derived from mesenchymal tissue. It is often mistaken for hydrocele, cord lipoma, or incarcerated hernia and preoperative diagnosis is rare. Most malignant paratesticular tumors are sarcomas, but 5–7% are liposarcomas. High-resolution ultrasound, CT, and MRI have become imaging of choice. Tumors in the literature have been reported to range from 0.4 cm to as large as 50 cm. The majority of tumors are low grade and well differentiated. Late recurrences and metastases may be seen, particularly with high-grade lesions. Radical orchiectomy with wide local excision and high ligation of the spermatic cord, is the treatment. Liposarcoma is radiosensitive and radiotherapy can be used to prevent local recurrence. (See also Section I: “Spermatic Cord Mass and Tumors.”)
REFERENCE
Li F, Tian R, Yin C, et al. Liposarcoma of the spermatic cord mimicking a left inguinal hernia: a case report and literature review. World J Surg Oncol. 2013;11:18.
SPINA BIFIDA/SPINA BIFIDA OCCULTA, UROLOGIC CONSIDERATIONS
DESCRIPTION Spina bifida is a birth defect that results in the incomplete closure of the embryologic neural tube, leading to incomplete development of the spinal cord and vertebrae. This usually involves the lumbar and sacral areas. As a result, many patients develop a neurogenic bladder dysfunction requiring long-term urologic care. Although 90% of patients born with spina bifida have normal upper urinary tracts, over 1/2 of these patients will show signs of renal deterioration if no urologic intervention is performed. Spina bifida occulta is the mildest form of spina bifida. The vertebrae may not fuse together, although the spinal cord and nerves are intact. Patients with spina bifida occulta may have no neurologic deficits at birth. Neurologic deficits that are present are usually mild compared to patients with spina bifida, and may develop later in life. Treatment involves aggressive urologic surveillance to preserve renal and bladder function. A neonatal renal US and voiding cystourethrography are obtained to assess for hydronephrosis and vesicoureteral reflux. Up to 20% of patients with spina bifida will have reflux. A urodynamic study (UDS) is also performed during this period to evaluate bladder compliance, detrusor pressures, capacity, leak pressures, contractions, and sphincter dyssynergia. Some institutions recommend prophylactic antibiotics and CIC until the neonate’s 1st UDS. Patients with poorly compliant bladders with elevated filling pressures (typically above 40 cm H2O) are in danger of upper tract deterioration and are typically started on clean intermittent catheterization (CIC) and anticholinergic therapy. If a patient fails conservative medical therapy, surgical procedures such as intravesical botulinum toxin injection, vesicostomy, augmentation cystoplasty, or urinary diversion (continent or incontinent) may be appropriate treatment options. It should be stressed to patients and their families to have strict routine follow-up visits to evaluate bladder or upper tract deterioration. (See also Section I: “Myelodysplasia Spinal Dysraphism, Urologic Considerations” and (Image ).)
REFERENCE
Joseph DB. Current approaches to the urologic care of children with spina bifida. Curr Urol Rep. 2008;(92):151–157.
SPINAL CORD COMPRESSION, UROLOGIC CONSIDERATIONS
DESCRIPTION Epidural spinal cord compression, if due to a urologic etiology, is most likely bone metastasis from prostate cancer. Other types of cancer (eg, breast, lung, kidney, GI) must also be kept in mind. Vertebral body metastases are present in the majority of patients dying from metastatic prostate cancer. Compression of the cord causes edema, venous congestion, and demyelination. Symptoms include back pain, progressive weakness, sensory loss, and paralysis. Bowel and bladder dysfunction are late findings. Neurologic impairment can progress overnight, so patients must be followed carefully. Survival of patients with spinal cord compression due to metastasis is relatively poor: 46% of patients survive <6 mo, and 20% <2 mo. Diagnosis is based on findings of CT and MRI. (See also Section I: “Spinal Cord Injury, Urologic Considerations.”)
TREATMENT
• Glucocorticoids, high-dose steroids 100 mg IV then 24 mg IV every 6 hr for 3 days, then taper
• Orchiectomy, high-dose ketoconazole (200–400 mg PO TID) or LHRH antagonist degarelix) to rapidly reduce serum testosterone if hormone naïve
• External radiation therapy with or without vertebrectomy note decompressive laminectomy has not been as successful as vertebrectomy with spinal stabilization, as most disease is located anterior to the spinal cord.
REFERENCES
Kuban DA, el-Mahdi AM, Sigfred SV, et al. Characteristics of spinal cord compression in adenocarcinoma of prostate. Urology. 1986;28(5):364–369.
Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: A randomised trial. Lancet. 2005;366(9486):643–648.
SPINAL SHOCK
DESCRIPTION After acute spinal cord injury (SCI), a period of areflexia and flaccid paralysis usually occurs below the level of injury. This period of spinal shock is variable; reflex detrusor activity usually returns after 2–12 wk, although it may take up to 1 yr. Urodynamic studies assessing bladder function are postponed until spinal shock resolves. Treatment is supportive during this period of detrusor areflexia. CIC is the recommended means of emptying the bladder, although an indwelling Foley catheter may be another alternative. (See also Section I: “Spinal Cord Injury, Urologic Considerations.”)
REFERENCE
Watanabe T, Rivas DA, Chancellor MB. Urodynamics of spinal cord injury. Urol Clin N Am. 1996;23(3):459–473.
SPINDLE CELL NEOPLASM, UROLOGIC CONSIDERATIONS
DESCRIPTION Mucinous tubular and spindle cell carcinoma (MTSCC) is a rare neoplasm of the kidney and is classified by the WHO as a variant of RCC. It is considered a low-grade carcinoma with a favorable prognosis. It typically presents in adult women in a 4:1 ratio. It is believed to be derived from the epithelial cells of the loop of Henle or possibly the collecting duct. There are also rare case reports of spindle cell neoplasm of the bladder and penis. The histologic features are characterized by elongated tubules and cord arrangements, which are separated by mucinous stroma. The parallel tubular arrays have a spindle cell configuration. There are also rare case reports of spindle cell neoplasm involving the bladder and penis.
TREATMENT
• Complete surgical excision appears to be adequate treatment
• Those with true sarcomatoid changes have increased risk of recurrence, regional adenopathy, or distant metastases
REFERENCE
Lima, MS, Barros-Silva GE, Pereira RA, et al. The imaging and pathological features of a mucinous tubular and spindle cell carcinoma of the kidney: a case report. World J Surg Oncol. 2013;11:34.
SPINNING TOP URETHRA
DESCRIPTION Spinning top urethra (STU) is a widened posterior urethra seen mainly in girls that is seen on videourodynamics. The most common mechanism for dilatation of the posterior urethra is unstable bladder contractions are resisted by a voluntary increase in the tension of the external urinary sphincter. The increased pressure results in a dilation of the posterior urethra. It is seen in patients with voiding dysfunction.
REFERENCE
Saxton HM, Borzyskowski M, Mundy AR, et al. Spinning top urethra: not a normal variant. Radiology. 1988;168(1):147–150.
SPLENIC INJURY DURING RADICAL NEPHRECTOMY
DESCRIPTION Of cases involving iatrogenic injury to the spleen, up to 12% have been reported to occur during nephrectomy. Splenic injuries usually tend to occur from excessive traction rather than direct injury or scalpel laceration; adequate exposure starting from an appropriate incision is essential. Capsular tears are the most common encountered event. The inferior portion of the spleen is typically involved, since the spleen has ligamentous associations (splenocolic, splenorenal, splenophrenic) with the kidney and other nearby organs and structures. The splenic artery can be found crossing the upper pole of the left kidney, dividing into segmental branches. Optimal treatment 1st involves recognizing splenic injury in a timely fashion intraoperatively. Depending on the extent of injury and condition of the patient, the decision is made to proceed with either salvage of the spleen or splenectomy. Splenic salvage techniques depend on severity of injury and includes the use of topical hemostatic agents, primary suture repair, partial segmental resection, or mesh repair. Complications associated with splenic injury repair or splenectomy include subphrenic abscess; injury to the stomach, colon, or tail of the pancreas; pancreatitis or pancreatic fistula formation; and pleural effusion.
REFERENCE
Merchant A, et al. Management of intraoperative splenic injury. Operative Techniques Gen Surg. 2008;(101):4–10.
SPLENOGONADAL FUSION
DESCRIPTION A rare congenital malformation in which an abnormal fusion exists between the spleen and the gonad or mesonephros derivatives. This fusion occurs in both sexes, but it is more common in males. Half of the cases are reported in children. The 2 types are continuous and discontinuous. In the continuous splenogonadal fusion, the main spleen is connected to the left gonad by a strand of tissue. This cord may be fibrous or splenic or contain beads of splenic tissue. The discontinuous type has no cord between the spleen and left gonad. 1/3 of all reported cases are associated with other congenital abnormalities, especially peromelia. The majority of cases present with scrotal mass or scrotal tenderness. Some are found incidentally during herniorrhaphy or orchidopexy. Although evaluation is usually done in the operating room, a technetium99 colloid liver spleen scan can easily identify splenic tissue in the scrotum if splenogonadal fusion is suspected preoperatively. Scrotal US does not help to diagnosis this entity.
TREATMENT
• Usually involves removing both the testis and adjoining mass.
• If the diagnosis of discontinuous splenogonadal fusion is made before surgery, the splenic nodule can simply be excised.
• For the continuous variety, exploratory laparotomy is necessary to identify the anatomy involved and deal with the continuous cord.
REFERENCE
Gouw AS, Elema JD, Bink-Boelkens MT, et al. The spectrum of splenogonadal fusion. Case report and review of 84 reported cases. Eur J Pediatr. 1985;144(4):316–323.
SPLENULE/SPLENOSIS, UROLOGIC CONSIDERATIONS
DESCRIPTION A benign condition associated with splenic rupture, typically during splenic surgery or trauma. Autotransplantation of splenic tissue occurs via seeding of splenic pulp in the abdominal or thoracic cavities. Hematogenous spread has also been reported. Patients are asymptomatic, and the discovery of splenosis is usually incidental on imaging studies. Splenosis in the abdominal cavity has been mistaken for primary malignancies, such as primary RCC. Similarly, thoracic splenosis can mimic metastatic urologic malignancies as well. The diagnostic modality of choice is nuclear scintigraphy. Once splenosis is confirmed and malignancy is ruled out, no treatment is necessary due to the benign nature of the condition.
REFERENCE
Fremont RD, Rice TW. Splenosis, a review. South Med J. 2007;(1006):589–593.
SPORTS HERNIA (ATHLETIC PUBALGIA, SPORTSMAN’S HERNIA)
DESCRIPTION A sports hernia is a painful, soft tissue injury that occurs in the groin area. It most often occurs during sports that require sudden changes of direction or intense twisting movements and is considered an “overuse” injury. It is a musculo-tendinous injury that involves the insertion of abdominal muscles on the pubis and the upper aponeurotic insertion of the adductor muscles. The pain develops during exercise, is generally unilateral but occasionally bilateral, and is typically located in the supra-inguinal portion of lower abdomen lateral to rectus abdominis, sometimes radiating to the testis. Although a sports hernia may lead to a traditional, abdominal wall hernia, it is a different injury. A sports hernia is a strain or tear of any soft tissue (muscle, tendon, ligament) in the lower abdomen or groin area. Because different tissues may be affected and a traditional hernia may not exist, the medical community prefers the term athletic pubalgia to refer to this type of injury. The existence, significance and diagnosis of sports hernia are all controversial. The condition needs to be differentiated from a direct, indirect, or femoral groin hernia, adductor longus origin “tendonitis,” or osteitis pubis based on history and physical exam. The symptoms are nonspecific and can include tenderness on palpation of the medial inguinal floor, tenderness on palpation over the pubic ramus, and exacerbated pain with resisted hip adduction. MRI may be useful in the differential. Rest, anti-inflammatory medications (NSAIDs) and physical therapy are beneficial. Rarely surgery may be necessary to repair the torn ligament or tendon.
REFERENCES
Litwin DE, Sneider EB, McEnaney PM, et al. Athletic pubalgia (sports hernia). Clin Sports Med. 2011;30(2):417–434.
Goel A, et al. Athletic Pubalgia http://radiopaedia.org/articles/athletic-pubalgia-1, Accessed April 6, 2014.
SQUAMOUS METAPLASIA, GENITOURINARY
DESCRIPTION The replacement of normal urothelium by mature squamous epithelium. Nonkeratinizing squamous metaplasia is thought to be a normal variant in premenopausal women, occurring under hormonal influence. This form is commonly found in the trigone; cystoscopically, it appears as a white patch. Keratinizing squamous metaplasia, also known as vesical leukoplakia, is a response to chronic irritation and infection. Some patients go on to develop squamous carcinoma. Keratinizing squamous metaplasia often occurs with long-term urinary catheters, a bladder stone, vesical schistosomiasis; long-term observation is warranted for the development of squamous carcinoma of the bladder.
SYNONYMS
• Pseudomembranous trigonitis
• Vesical leukoplakia
TREATMENT
Transurethral resection ablation and biopsy in cases of keratinizing squamous metaplasia
REFERENCE
Ahmad I, Barnetson RJ, Krishna NS. Keratinizing squamous metaplasia of the bladder: A review. Urol Int. 2008;(813):247–251.
STAMEY PROCEDURE (URETHROPEXY)
DESCRIPTION Stamey was the 1st to report the use of the cystoscope to aid in the performance of a transvaginal urethropexy. In addition, the nonabsorbable sutures that are placed with a needle carrier incorporate a Dacron pledget to buttress the suture at the level of the bladder neck. Used to treat stress incontinence in women; of the patients who have undergone this procedure, 82% of 192 were improved, and 65% of the 192 would be willing to undergo the procedure again. Another study showed that although the Stamey procedure has a high early success rate, the long-term results were poor. After 5 yr, only 18% of 28 women remained dry. Concomitant abdominal hysterectomy, respiratory disease, and obesity were likely to point to a lower long-term cure rate. Possible complications include long-term erosion of sutures into the urinary tract and long-term urinary retention if sutures are tied too tightly.
REFERENCE
O’Sullivan DC, Chilton CP, Munson KW. Should Stamey colposuspension be our primary surgery for stress incontinence? Br J Urol. 1995;(754):457–460.
STAMEY TEST (3-GLASS TEST, 4-GLASS TEST, MEARES–STAMEY TEST)
DESCRIPTION The 3-glass test described by Meares and Stamey is a method of collecting urine, which can provide information on the site of the urinary tract origin of RBCs or bacteria. Although this method is effective in localizing the cause of hematuria, it is more commonly used in diagnosing prostatitis. A specimen is collected from the urethra, midstream urine, and prostatic secretions. The 1st-voided 10 mL of urine is the urethral specimen (VB1). The midstream urine of 10 mL (VB2) is collected after the patient has voided about 200 mL. The patient is then instructed to stop voiding, at which time the physician massages the prostate and collects the prostatic fluid expressed prostatic secretions (EPS). Afterward, the patient voids again, and a 10-mL specimen (VB3) is collected. Cultures are sent on the 4 specimens hence the 3-glass or 4-glass test (nomenclature). When the bladder urine is sterile, urethral, and prostatic infection can be differentiated by comparing the bacterial colony counts of VB1 and prostatic EPS and VB3 counts. In urethral infections, the VB1 count is much higher than the EPS or VB3 count. The EPS and VB3 counts in prostatic infections significantly exceed the VB1 count. When interpreting bacterial colony counts, the clinician must take into account that the VB3 specimen is a 100× dilution of prostatic fluid. When the bladder urine is infected, the infection cannot be localized, because all specimens will show heavy growth of organisms. Note that this test is often replaced by the2-glass test, which collects a more convenient pre-/postprostatic massage urine sample. The premassage and postmassage 2-glass test has strong concordance with the 4-glass test and is a reasonable alternative when EPS are not obtained. The technique and diagnosis algorithm are discussed in Section I: “Prostatitis, General” and “Prostatitis, Chronic, Bacterial [NIH II].”
REFERENCES
Meares EM, Stamey TA. The diagnosis and management of bacterial prostatitis. Br J Urol. 1972;(442):175–179.
Nickel JC, Shoskes D, Wang Y, et al. How does the premassage and postmassage 2-glass test compare to the Meares-Stamey 4–glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol.2006;176(1):119–124.
STAUFFER SYNDROME
DESCRIPTION A syndrome associated with nonmetastatic hepatic dysfunction commonly seen in cases of RCC. Symptoms include fever, fatigue, and weight loss. The patient has unusual liver function tests, WBC loss, and areas of hepatic necrosis without hepatic metastasis. The presence of hepatic dysfunction should not be a contraindication to surgery. Hepatic function usually returns to normal after nephrectomy. If the syndrome persists, it is a sign of recurrent tumor. Diagnostic indicators are elevation of alkaline phosphatase and bilirubin, hypoalbuminemia, prolonged PTT, and hypergammaglobulinemia.
REFERENCE
Jacobi GH, Philipp T. Stauffer’s syndrome: Diagnostic help in hypernephroma. Clin Nephrol. 1975;(43):113–115.
STEINSTRASSE
DESCRIPTION A German expression for “street of stones,” referring to multiple stone fragments in the ureter after extracorporeal shock wave lithotripsy. Characteristically, stone fragments are found in a line within the ureter, which may or may not be obstructed. The condition occasionally presents with renal colic, nausea, or vomiting. Observation is sufficient if symptoms are tolerable or absent; with severe colic or obstruction, treatment is ureteral stent placement, percutaneous nephrostomy, or ureteroscopic lithotripsy (Image ).
REFERENCE
Weinerth JL, Flatt JA, Carson CC 3rd. Lessons learned in patients with large Steinstrasse. J Urol. 1989;142:1425.
STING PROCEDURE
DESCRIPTION This refers to subureteral transurethral injection (“STING”) of bulking agents to correct vesicoureteral reflux. The original coined term was subureteric Teflon injection (STING) using pyrolyzed Teflon (PTFE) particles suspended in glycerin. Due to concern over migration of the Teflon to the brain and lung it was abandoned in favor of other agents. Silicone was also used as a bulking agent (Macroplastique) and while effective was also abandoned due to safety concerns. Other materials such as glutahaldehyde crosss-linked bovine collagen [Contigen] and calcium hydroxyapatite (Coaptite) are also no longer used a bulking agents. Bulking agents such as Deflux (cross-linked dextranomer/hyaluronic acid copolymer) has been accepted and is currently in widespread use. The basic technique involves the periureteral injection at the 6 o’clock position of the ureteral orifice. A modification is the hydrodistention implantation technique (HIT) where the agent is injected inside the ureteral hiatus. Overall the success rate is inferior to that of open surgery. About 70% have reflux resolution after 1 procedure. With repeat STING procedures, the success rate increases to 90–95%. (See also Section I: “Vesicoureteral Reflux, Pediatric"; and Section II: “Bulking Agents, Injectable.”)
REFERENCES
Aubert D, Zoupanos G, Destuynder O, et al. Sting procedure in the treatment of secondary reflux in children. Eur Urol. 1990;(174):307–309.
Watters ST, Sung J, Skoog SJ. Endoscopic treatment for vesicoureteral reflux: how important is technique? J Pediatr Urol. 2013;9(6 Pt B):1192–1197.
STRANGURIA
DESCRIPTION Slow, painful, spasmodic expulsion of urine in a drop-wise fashion, usually occurring at the end of micturition due to spasm of the bladder and urethra. Associated with an irritative process in the GU system, it often refers pain to the urethral meatus. Historically, the pathophysiology has been attributed to a significant inflammatory component. The term is not commonly used in human medicine, but is firmly entrenched in veterinary medicine.
SYNONYMS
• Strangury
• Terminal dysuria
REFERENCE
Wright B, Husbands E. Strangury: the case of a symptom with ancient origins. BMJ Support Palliat Care. 2011;1:49–50.
STREAK GONAD
DESCRIPTION Streak gonads are hypoplastic and dysfunctioning gonads mainly consisting of fibrous tissue. Patients with streak gonad usually present with female phenotype, primary amenorrhea, infantile breast status, sparse pubic and axillary hair, infantile external genitalia and vagina, atrophic vaginal smear, immature uterus, high serum FSH, low urinary estrogen, and osteoporosis, as well as the streak gonad. Diagnosis is made by measuring FSH and urinary estrogen, and determining karyotype. (See Section II: “Gonadal Dysgenesis, Mixed and Pure.”)
TREATMENT
• Management includes laparotomy with excision of any intra-abdominal testis or streak gonads. These masses progress to malignancies, which may develop before puberty.
• Female sex assignment and reconstructive surgery are advised in cases with severely deficient virilization of the genitalia.
REFERENCE
Calabrese F, Valente M. Mixed gonadal dysgenesis: Histological and ultrastructural findings in two cases. Int J Gynecol Pathol. 1996:(153):270–275.
STRICKLER URETERAL ANASTOMOSIS
DESCRIPTION Through an extracolonic approach, a small linear incision is made in the taenia, and a small clamp is used to create a submucosal 3–4-cm tunnel exiting out of the colon laterally. The ureter is delivered through the tunnel, the spatulated end is anastomosed to the mucosa, and the taenia is closed while incorporating ureter adventitia.
REFERENCE
McDougal WS. Use of intestinal segments and urinary diversion. In: Walsh PC, Retik AB, Vaughan ED, et al., eds. Campbell’s Urology. 7th ed. Philadelphia, PA: Saunders; 1998:3137–3144.
STRUVITE
DESCRIPTION The mineral name for magnesium ammonium phosphate hexahydrate (NH4MgPO4·6H2O) stones. Struvite stones (also sometimes known as triple phosphate stones) are composed of calcium magnesium ammonium phosphate and form only in urine infected by urea-splitting bacteria, such as Proteus, Providencia, and sometimes Klebsiella, Pseudomonas, and enterococci. Because of their potential for rapid growth and substantial morbidity, early detection and eradication are essential (See also Section I: “Urolithiasis, Staghorn”) and (Image ).
REFERENCES
Healy KA, Ogan K. Pathophysiology and management of infectious staghorn calculi. Urol Clin N Am. 2007;343:363–374.
Xu H, Zisman AL, Coe FL, et al. Kidney stones: an update on current pharmacological management and future directions. Expert Opin Pharmacother. 2013;14(4):435–447.
STUDER POUCH
DESCRIPTION An orthotopic neobladder is made, based on 60 cm of marsupialized ileum, which is configured and sutured into a W to create a broad intestinal plate. In addition, a nontubularized segment of ileum extends from a limb of the W, simulating a chimney. The ureters are implanted into the chimney. The intestinal plate is anastomosed to the urethra and then closed into a sphere and connected to the urethra.
REFERENCE
Colombel M, Chopin DK, Studer UE. A procedure for bladder replacement using a low-pressure ileal reservoir. Ann Urol (Paris). 1993;(271):36–41.
SUPERFICIAL INGUINAL POUCH OF DENIS-BROWNE
DESCRIPTION A superficial inguinal pouch is defined as the space distal to the internal inguinal ring, but above the inguinal canal, between the external oblique fascia and Scarpa fascia. Studies suggest that a testis in the superficial inguinal pouch is, in reality, a cryptorchid testis.
REFERENCE
Herzog B, Steigert M, Hadziselimovic F. Is a testis located at the superficial inguinal pouch (Denis-Browne pouch) comparable to a true cryptorchid testis? J Urol. 1992;(1482 Pt 2):622–623.
SUPERNUMERARY KIDNEY
DESCRIPTION A supernumerary kidney is a rare condition in which a free accessory renal organ exists as a distinct entity, with its own blood supply, with presence of 2 normal kidneys. It is distinguished by its small size and/or abnormal position. The kidney is either a component of a bifid ureteral system or a completely duplicated system. When diagnosed, treatment for a supernumerary kidney should be based on pathologic processes affecting the kidney rather than its redundant appearance or abnormal position. Association of a normal kidney with a 2nd or 3rd ipsilateral smaller kidney is an extremely rare anomaly with only a total of 81 cases reported through 2013.
REFERENCE
Afrouzian M, Sonstein J, Dadfarnia T, et al. Four miniature kidneys: supernumerary kidney and multiple organ system anomalies. Hum Pathol. 2013. pii: S0046–8177(13)00522-4. doi: 10.1016/j.humpath.2013.11.015. [Epub ahead of print]
SUPINE STRESS TEST
DESCRIPTION Nonurodynamic method to test for intrinsic sphincteric deficiency, it is performed by placing the patient in lithotomy position and filling the empty bladder with 200 cc saline under gravity. The patient is then asked to cough and perform a Valsalva maneuver. A test is deemed positive if fluid is seen leaking from the meatus at time of cough or Valsalva. Studies have shown that it is a relatively quick and inexpensive test that has a sensitivity of 93.5% and specificity of 90.0%.
REFERENCE
Hsu TH, Rackley RR, Appell RA. The supine stress test: A simple method to detect intrinsic urethral sphincter dysfunction. J Urol. 1999;(1622):460–463.
SWYER SYNDROME (XY SEX REVERSAL)
DESCRIPTION A sex reversal disorder with a female phenotype and 46, XY genotype with pure gonadal dysgenesis. Patients have bilateral streak gonads and often present in adolescence as phenotypic females with delayed puberty. A 46, XY genotype may develop rapid breast or clitoral enlargement due to hormonally active gonadoblastomas within the streak gonads. The presence of the Y chromosome increases the risk of gonadal tumors and therefore a prophylactic bilateral salpino-gonadenectomy is often advised. (See also Section II: “Gonadal Dysgenesis [Mixed and Pure].”)
REFERENCES
Moreira-Filho CA, Toledo SP, Bagnolli VR, et al. H-Y antigen in Swyer syndrome and the genetics of XY gonadal dysgenesis. Hum Genet. 1979;53(1):51–56.
Zhu J, Liu X, Jin H, et al. Swyer Syndrome, 46, XY gonadal dysgenesis, a sex reversal disorder with dysgerminoma: A case report and literature review. Clinical & Experimental Obstetrics & Gynecology. 2011;38(4):414–418.
SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)
DESCRIPTION SIADH is the most frequent cause of hyponatremia. The condition usually results when plasma levels of antidiuretic hormone or arginine vasopressin are elevated when normal physiologic secretion of vasopressin from the posterior pituitary should be suppressed, causing a euvolemic hypo-osmolar hyponatremia. There are many causes of this syndrome of inappropriate diuresis, which include malignancies (such as small cell lung cancer, cancers of the GI tract, lymphoma), pulmonary diseases (pneumonia, TB, cystic fibrosis, asthma), disorders of the CNS (neurologic diseases as well as infection, bleeding, or trauma-related), and drugs. Intranasal desmopressin (DDAVP) to treat nocturnal enuresis can be associated with this condition. Acute management requires evaluation of the clinical status of the patient, assessment of the type of hyponatremia, and treatment based on the degree of hyponatremia. After the patient is stabilized, treatment can then be focused on determining the underlying cause of SIADH. If possible, removal or treatment of the underlying cause can result in full resolution. Long-term treatment consists of fluid restriction and possible use of pharmacologic agents such as demeclocycline (causes a nephrogenic DI) or vasopressin receptor antagonists.
REFERENCE
Ellison DH, Berl T. The syndrome of inappropriate antidiuresis. N Engl J Med. 2007;356(20):2064–2072.
SYSTEMIC LUPUS, UROLOGIC CONSIDERATIONS
DESCRIPTION The kidney (lupus nephritis) is the organ most commonly affected by systemic lupus erythematosus (SLE), a chronic, multisystem autoimmune disease with no known cause. A variety of diseases related to SLE can affect the kidney, with renal biopsy usually necessary to identify the specific type. The renal manifestations of SLE vary from patient to patient. Proteinuria with or without an elevated creatinine is the most common manifestation of renal disease in SLE. Urine sediment typically shows >5 red and white blood cells per high power field and/or ≥1 cellular cast in more severe forms of disease. Immune complexes result in injury to the glomerulus, and the specific lesion is determined by renal biopsy. International Society of Nephrology classification divides the SLE glomerular disorders into different classes: Classes I and II (minimal mesangial lupus nephritis and mesangial proliferative lupus nephritis) are the mildest forms; classes III and IV (focal proliferative lupus nephritis and diffuse proliferative lupus nephritis) more severe forms; and classes V and VI (membranous lupus nephritis and advanced sclerosing lupus nephritis) are the most severe forms. These more severe forms of lupus nephritis can cause impaired renal function, proteinuria, and the nephrotic syndrome. In addition to these glomerulopathies, SLE can also result in interstitial nephritis and renal vascular disease. Rarely, certain medications (eg, anti-TNFα therapy [infliximab and etanercept], chlorpromazine, diltiazem, hydralazine, interferon-α, isoniazid [INH], minocycline, penicillamine, quinidine, methyldopa, procainamide) can cause drug-induced SLE. Mild forms are not treated, but more severe forms are treated with cytotoxic agents (cyclophosphamide therapy) and prednisone. Renal replacement may be needed in the most severe forms.
REFERENCE
Waldman M, Appel GB. Update on the treatment of lupus nephritis. Kidney Int. 2006;70(8):1403–1412.