British Journalof Urology (1991), 6 7 , 6 3 8 4 3 9 01991 British Journal of Urology
Urological Aspects of Behcet‘s Disease 2. KIRKALI, 0.YlGlTBASl and R. SASMAZ Department of Urology, Dokuz Eylul University School of Medicine, Izmir; Urology and Dermatology Clinics of SSK Ankara Hospital, Ankara, Turkey
Sumrnary-Behcet‘s disease, affecting mostly young males in the Mediterranean countries and Japan, is a rnulti-system disease with urological manifestations. In this prospective study of 100 consecutive patients with newly diagnosed Behcet’s disease, we found that 89%of the males had experienced scrotal ulceration and 6%had epididymitis. We also observed sterile urethritis in 3%. Other urological abnormalities appeared to be coincidental findings.
Behcet’s disease, first described by Turkish dermatologist Hulusi Behcet (1937), is more common in Mediterranean countries, the Middle East and Japan. Clinical manifestations include recurrent aphthous ulcers of the oral mucosa, skin lesions, genital ulceration, ocular inflammatory lesions, arthritis, epididymitis, intestinal ulcers, vascular lesions, neuropsychiatric symptoms and positive pathergy test (Nussenblatt and Palestine, 1989; International Study Group for Behcet’s disease, 1990). We have made a prospective study of 100patients with Behcet’s disease in order to detect urological abnormalities.
Patients and Methods Between May 1988 and May 1990,100 new patients with clinically diagnosed Behcet’s disease were seen. The diagnosis was based on the presence of oral ulceration and any 2 of the following: genital ulceration, typical eye lesions, skin lesions or positive pathergy test as described by the International Study Group for Behcet’s Disease (1990). Following diagnosis, the patients were interviewed by a urologist and asked if they had any urological complaints. A full physical examination, urine analysis and intravenous urography ( N U ) were performed in all cases. The series comprised 70 Accepted for publication 5 October 1990
males and 30 females, their ages ranging between 16 and 60 years (mean 30).
Results In 78% of the patients no urological complaints were registered. Sixteen patients complained of frequency and nocturia and 2 had passed stonesper urethrarn; 1 of these had had 2 previous operations for renal stones. Two patients had a urethral discharge and 2 others (aged 54 and 60) complained of minimal obstructive symptoms. Physical examination revealed active scrotal ulceration in 8 men and genital ulceration in 2 women. There were signs of scars from previous attacks of genital lesions in another 54 men and 24 women. In 4 men the epididymes were hard and nodular, suggesting previous episodes of epididymitis. A white male patient, aged 60, had absent testes and a scrotal incision scar; he stated that he had had a testicular abscess treated by bilateral orchiectomy 10 years previously. Another patient had bilateral flank incision scars following earlier stone removal. Two patients had a urethral discharge but direct microscopy was negative for micro-organisms and cultures were sterile. Urine analysis revealed pyuria in 3 patients and calcium oxalate crystals in 2. IVU was normal in 93% of the patients. Two had signs suggestive of urogenital tuberculosis; this was later confirmed by direct microscopy and urine culture and antituberculous treatment was initiated. A further 2 patients had pelviureteric junction
638
639
UROLOGICAL ASPECTS OF BEHCET’S DISEASE
(PUJ) obstruction which was corrected surgically. IVU revealed scarred kidneys with caliceal dilatation in 2 patients. Investigations for tuberculosis were negative and these were accepted as previous attacks of pyelonephritis. One patient had a ureteric stone which he passed spontaneously. Another patient with neurological signs of Behcet’s disease had an acontractile detrusor with normal sphincteric mechanisms but he managed well with suprapubic compression.
Discussion The aetiology of Behcet’s disease remains unknown. Patients may present with signs and symptoms in various systems of the body but initial presentation with urological symptoms is not uncommon. In a survey of 2031 patients in Japan, genital lesions were present in 76% of the men and 83.8% of the women (Mishima et al., 1979). In the male, genital lesions usually comprise painful skin ulcers in the scrotum or penis which may be deep and lead to scarring. Dressings, general hygiene and analgesics are the appropriate treatment. Epididymitis, probably caused by vasculitis, has also been observed and needs no specific treatment other than analgesics. We found that 89% of our
patients had experienced scrota1 ulceration and 6% had epididymitis. In 3% of the males we found sterile urethritis with discharge. Urinary tuberculosis and PUJ obstruction in 2% of the patients appeared to be coincidental findings.
References Behcet, H. (1937). Ueber rezidivierende, aphthose, durch ein Virus verursachte Geschwiir am Mund, am Auge und an der Genitalien. Dermatol. Wochenschr.,46,414419. International Study Group for Behcet’s Disease (1990). Criteria for diagnosis of Behcet’s disease. Lancet, 335, 1078-1080. Mishima, S., Masuda, K., Izawa, Y. et d (1979). Behcet’s disease in Japan: ophthalmologic aspects. Trans. Am. Ophthalmol. SOC.,16,225-229. Nussenblatt, R. B. and Palestine, A. G. (1989). Uveitis. In Fundamentals and Clinical Practice. Pp. 217-241. Chicago: Year Book Medical Publishers.
The Authors Z. Kirkali, MD, Associate Professor of Urology. 0. Yigitbasi, MD, Urologist. R. Sasmaz, MD, Dermatologist. Requests for reprints to: 2. Kirkali, Dokuz Eylul University School of Medicine, Department of Urology, Inciralti-Izmir 35340, Turkey.
Urological Aspects of Behcet‘s Disease 2. KIRKALI, 0.YlGlTBASl and R. SASMAZ Department of Urology, Dokuz Eylul University School of Medicine, Izmir; Urology and Dermatology Clinics of SSK Ankara Hospital, Ankara, Turkey
Sumrnary-Behcet‘s disease, affecting mostly young males in the Mediterranean countries and Japan, is a rnulti-system disease with urological manifestations. In this prospective study of 100 consecutive patients with newly diagnosed Behcet’s disease, we found that 89%of the males had experienced scrotal ulceration and 6%had epididymitis. We also observed sterile urethritis in 3%. Other urological abnormalities appeared to be coincidental findings.
Behcet’s disease, first described by Turkish dermatologist Hulusi Behcet (1937), is more common in Mediterranean countries, the Middle East and Japan. Clinical manifestations include recurrent aphthous ulcers of the oral mucosa, skin lesions, genital ulceration, ocular inflammatory lesions, arthritis, epididymitis, intestinal ulcers, vascular lesions, neuropsychiatric symptoms and positive pathergy test (Nussenblatt and Palestine, 1989; International Study Group for Behcet’s disease, 1990). We have made a prospective study of 100patients with Behcet’s disease in order to detect urological abnormalities.
Patients and Methods Between May 1988 and May 1990,100 new patients with clinically diagnosed Behcet’s disease were seen. The diagnosis was based on the presence of oral ulceration and any 2 of the following: genital ulceration, typical eye lesions, skin lesions or positive pathergy test as described by the International Study Group for Behcet’s Disease (1990). Following diagnosis, the patients were interviewed by a urologist and asked if they had any urological complaints. A full physical examination, urine analysis and intravenous urography ( N U ) were performed in all cases. The series comprised 70 Accepted for publication 5 October 1990
males and 30 females, their ages ranging between 16 and 60 years (mean 30).
Results In 78% of the patients no urological complaints were registered. Sixteen patients complained of frequency and nocturia and 2 had passed stonesper urethrarn; 1 of these had had 2 previous operations for renal stones. Two patients had a urethral discharge and 2 others (aged 54 and 60) complained of minimal obstructive symptoms. Physical examination revealed active scrotal ulceration in 8 men and genital ulceration in 2 women. There were signs of scars from previous attacks of genital lesions in another 54 men and 24 women. In 4 men the epididymes were hard and nodular, suggesting previous episodes of epididymitis. A white male patient, aged 60, had absent testes and a scrotal incision scar; he stated that he had had a testicular abscess treated by bilateral orchiectomy 10 years previously. Another patient had bilateral flank incision scars following earlier stone removal. Two patients had a urethral discharge but direct microscopy was negative for micro-organisms and cultures were sterile. Urine analysis revealed pyuria in 3 patients and calcium oxalate crystals in 2. IVU was normal in 93% of the patients. Two had signs suggestive of urogenital tuberculosis; this was later confirmed by direct microscopy and urine culture and antituberculous treatment was initiated. A further 2 patients had pelviureteric junction
638
639
UROLOGICAL ASPECTS OF BEHCET’S DISEASE
(PUJ) obstruction which was corrected surgically. IVU revealed scarred kidneys with caliceal dilatation in 2 patients. Investigations for tuberculosis were negative and these were accepted as previous attacks of pyelonephritis. One patient had a ureteric stone which he passed spontaneously. Another patient with neurological signs of Behcet’s disease had an acontractile detrusor with normal sphincteric mechanisms but he managed well with suprapubic compression.
Discussion The aetiology of Behcet’s disease remains unknown. Patients may present with signs and symptoms in various systems of the body but initial presentation with urological symptoms is not uncommon. In a survey of 2031 patients in Japan, genital lesions were present in 76% of the men and 83.8% of the women (Mishima et al., 1979). In the male, genital lesions usually comprise painful skin ulcers in the scrotum or penis which may be deep and lead to scarring. Dressings, general hygiene and analgesics are the appropriate treatment. Epididymitis, probably caused by vasculitis, has also been observed and needs no specific treatment other than analgesics. We found that 89% of our
patients had experienced scrota1 ulceration and 6% had epididymitis. In 3% of the males we found sterile urethritis with discharge. Urinary tuberculosis and PUJ obstruction in 2% of the patients appeared to be coincidental findings.
References Behcet, H. (1937). Ueber rezidivierende, aphthose, durch ein Virus verursachte Geschwiir am Mund, am Auge und an der Genitalien. Dermatol. Wochenschr.,46,414419. International Study Group for Behcet’s Disease (1990). Criteria for diagnosis of Behcet’s disease. Lancet, 335, 1078-1080. Mishima, S., Masuda, K., Izawa, Y. et d (1979). Behcet’s disease in Japan: ophthalmologic aspects. Trans. Am. Ophthalmol. SOC.,16,225-229. Nussenblatt, R. B. and Palestine, A. G. (1989). Uveitis. In Fundamentals and Clinical Practice. Pp. 217-241. Chicago: Year Book Medical Publishers.
The Authors Z. Kirkali, MD, Associate Professor of Urology. 0. Yigitbasi, MD, Urologist. R. Sasmaz, MD, Dermatologist. Requests for reprints to: 2. Kirkali, Dokuz Eylul University School of Medicine, Department of Urology, Inciralti-Izmir 35340, Turkey.
