1. Lavelle, M. T., Conlin, M. J. and Skoog, S. J.: Subureteralinjection of Deflux for correction of reflux: analysis of factorspredicting success. Urology, 65: 564, 2005

2. Stenberg, A., Larsson, E., Lindholm, A., Ronneus, B. and Lack-gren, G.: Injectable dextranomer-based implant: histopa-thology, volume changes and DNA-analysis. Scand J UrolNephrol, 33: 355, 1999

3. Stenberg, A., Larsson, E. and Lackgren, G.: Endoscopic treat-ment with dextranomer-hyaluronic acid for vesicoureteralreflux: histological findings. J Urol, 169: 1109, 2003

4. Putman, S., Wicher, C., Wayment, R., Harrell, B., Devries, C.,Snow, B. et al: Unilateral extravesical ureteral reimplanta-tion in children performed on an outpatient basis. J Urol,174: 1987, 2005

Re: The Impact of LatePresentation of Posterior UrethralValves on Bladder and Renal Function

O. Ziylan, T. Oktar, H. Ander, E. Korgali, H. Rodopluand T. Kocak

J Urol, 175: 1894–1897, 2006

To the Editor. The authors have reviewed the findings inpatients who present late with urethral obstruction, andlook for differences from the earlier presenting group. Acrossthe group they found that renal and bladder function wassimilar but they infer that there is a lesser degree of obstruc-tion in patients who present later. However, we would sug-gest that the variability of the condition is greater thansuggested in their article.

Our work, which was not referenced by the authors, hasshown 2 features of the variability of congenital obstructiveposterior urethral membrane (COPUM). The first feature, asHendren found,1 is a range in the appearance of the obstruc-tion endoscopically, which is a variable degree of the limita-tion of the posterior urethral lumen.2 The other variation wehave demonstrated is a variable degree of proximal radio-logical obstructive changes with similar changes on endo-scopic appearance of the COPUM.3 Thus, early and latepresenting patients can have a range of bladder and renalfunction outcomes.

We postulate that there may be different bladder reac-tions to the same limitation of the stream, a difference in thesecondary obstruction from distal prolapsing of the COPUMor perhaps different diseases that have a COPUM as acommon element. Study of the late presenting group in lightof the detailed endoscopic findings would be of interest, andwe thank the authors for their work.

Respectfully,Paddy Dewan

Urology UnitWomen’s and Children’s HospitalNorth Adelaide, South Australia

1. Hendren, W. H.: Posterior urethral valves in boys. A broadclinical spectrum. J Urol, 106: 298, 1971

2. Dewan, P. A. and Goh, D. G.: Variable expression of the con-genital membrane of the posterior urethra. Urology, 45: 507,1995

3. Dewan, P. A., Pillay, S. and Kaye, K.: Correlation of the endo-scopic and radiological anatomy of congenital obstruction ofthe posterior urethra and the external sphincter. Br J Urol,79: 790, 1997

Reply by Authors. We appreciate the commentary about ourarticle. However, there are several points to be clarified in thetext. In our series renal function was significantly impaired inthe late presenting group. Thus, what we tried to emphasize isthat it is not always true that late presentation is a morefavorable prognostic factor. Also, it may be misleading to de-scribe the obstruction as “lesser” in the late presenting group,because renal function was significantly affected in this group ofpatients. Bladder dysfunction was similar between the 2 groups.However, it was more pronounced in the late presenting patients.

We completely agree regarding the variability of ob-struction in patients with posterior urethral valves. How-ever, there are some difficulties in documenting the de-gree of obstruction. The interpretation of obstruction byendoscopic and radiological appearance is somehow a sub-jective analysis. The evaluation of voiding dynamics ob-tained by urodynamic studies may be a more reliableassessment. However, it also poses some technical chal-lenges.

Recently, in our clinic the endoscopic interventions of allpatients with posterior urethral valves have begun to berecorded routinely. The assessment of these findings couldlead to a better understanding of the pathophysiologicalprocess.

Re: A New Classificationis Needed for Pelvic PainSyndromes—Are ExistingTerminologies of SpuriousDiagnostic Authority Bad for Patients?

P. Abrams, A. Baranowski, R. E. Berger, M. Fall,P. Hanno and U. Wesselmann

J Urol, 175: 1989–1990, 2006

To the Editor. The 6 experts who authored this editorialare to be applauded for their forthright statement regardingthe deleterious effects of the use of conventional terminologyfor “diagnostic” authority in patients with chronic pelvicpain (CPP). The descriptive terms and symptoms used inthis editorial are in the “territory” of the pudendal nerve.Fall et al have made brief reference to pudendal neuropathyin the European Association of Urology guidelines onchronic pelvic pain.1 However, no such reference was madein this editorial.

Previous articles in The Journal of Urology® demon-strate the neuropathic issues affecting CPP. Ricchiuti iden-tified abnormal neurophysiological testing in a cyclist withperineal pain.2 Amarenco and Kerdraon presented a schol-arly discussion of pudendal nerve neurophysiological test-ing.3 Relief of CPP can be achieved using pudendal nerveblocks of local anesthetic and triamcinolone.4 Indeed, in thesame issue as the editorial the pelvic symptoms that Cohen

LETTERS TO THE EDITOR2748

et al5 use for placement of a sacral nerve root stimulator areprecisely within the distribution of the pudendal nerve.

For more than 20 years widespread international experi-ence has demonstrated the role of pudendal neuropathy inscrotal pain, vulvodynia, stress urinary incontinence andfecal incontinence, and objective testing for pudendal neu-ropathy has been defined. Analysis of articles using thetechnique of “epidemiological evidence of causation” is anexcellent method for evaluating the putative role of puden-dal neuropathy in CPP. Pudendal neuropathy meets thetests of biological plausibility, strength of association, dose-response relationship, temporality, consistency of findings,analogy and reversibility. A recent article concerning failedsacral neuromodulation outlines the precise history, andphysical and neurophysiological testing that identifies pu-dendal neuropathy in women with the chronic pelvic painsyndrome.6

Responses to pudendal nerve perineural injections of bu-pivacaine and triamcinolone consistently define the proteansymptomatology of pudendal neuropathy in our populationwith CPP, which exceeds 1,500. All patients have objectiveneurophysiological measures of pudendal neuropathy thatinclude somatosensory and motor processes and autonomicdysfunction. This cohort would attest to the “bad” effect ofspurious diagnostic authority. They feel abused by a medicalprofession that focuses on taxonomy rather than etiology/pathogenesis. Patients would agree that it is “bad” to bemisdiagnosed by 12, 17, 24 or more urologists, or treatedusing pounds of antibiotics, varicocelectomy, orchiectomy orcystectomy for CPP.

Evidence based medicine suggests that the pudendalnerve has a role in the chronic pelvic pain syndrome. Ihumbly request that the authors of this editorial not over-look the importance of pudendal neuropathic pain and itsassociation with bladder, bowel and sexual dysfunction asthey progress to a new classification for the pelvic painsyndrome.

Respectfully,S. J. Antolak, Jr.

Center for Urological and Pelvic PainLake Elmo, Minnesota

1. Fall, M., Baranowski, A. P., Fowler, C. J., Lepinard, V., Malone-Lee, J. G., Messelink, E. J. et al: EAU guidelines on chronicpelvic pain. Eur Urol, 46: 681, 2004

2. Ricchiuti, V. S., Haas, C. A., Seftel, A. D., Chelimsky, T. andGoldstein, I.: Pudendal nerve injury associated with avidbicycling. J Urol, 162: 2099, 2000

3. Amarenco, G. and Kerdraon, J.: Pudendal nerve terminal sen-sitive latency: techniques and normal values. J Urol, 161:193, 1999

4. Antolak, S. J., Hough, D. M. and Pawlina, W.: The chronic pelvicpain syndrome after brachytherapy for carcinoma of theprostate. J Urol, 167: 2525, 2002

5. Cohen, B. L., Tunuguntla, H. S. and Gousse, A.: Predictors ofsuccess for first stage neuromodulation: motor versus sen-sory response. J Urol, 175: 2178, 2006

6. Antolak, S. J., Jr. and Antolak, C. M.: Failed sacral neuromodu-lation: simple tests demonstrate pudendal neuropathy. JPelvic Med Surg, 12: 35, 2006

RETRACTION

VOIDING DYSFUNCTION AFTER REMOVAL OF ERODED SLINGS

Volume 176, Number 3, Page 1040: The authors, Drs. Jonathan S. Starkman, Christopher E. Wolder, Alex Gomelsky,Harriette M. Scarpero and Roger R. Dmochowski, acknowledge making an erroneous statement in this articleregarding the recall of the ObTape™ (Mentor Corp., Santa Barbara, California) due to a high erosion rate. Thisstatement is incorrect. Rather marketing of ObTape™ was discontinued because of an introduction of a secondgeneration product, Aris™ by Mentor Corp., in March 2006. The authors apologize for this error and formally retractthe statement in this article suggesting recall of the ObTape™.

ERRATA

11C-CHOLINE POSITRON EMISSION/COMPUTERIZED TOMOGRAPHY

Volume 176, Number 3, Page 959: Acknowledgment: Robin M. T. Cooke provided writing assistance.

RELEASE OF SPINAL CORD TETHERING FOR NEUROGENIC BLADDER

Volume 176, Number 4, Page 1601: The 4th author’s name is Ferruh Simsek.

LETTERS TO THE EDITOR 2749