What is erectile dysfunction?

Erectile dysfunction is the inability of the male to attain or maintain erection of the penis sufficient for satisfactory sexual intercourse. It is well known that sexual function declines with old age and in our culture, erectile dysfunction is often gracefully accepted as part and parcel of growing old. However, even in our society, and irrespective of age, some men with this problem would admit to fear, uncertainty, loss of image and self- esteem and even depression because of it. Erectile dysfunction comprises a variety of physical aspects with important psychological and behavioral overtones. Many men with erectile dysfunction have normal desire for sex, orgasmic capability and ejaculatory capability and are only denied a normal sex life because of this disability. For social and cultural reasons, many troubled men with erectile dysfunction do not complain or come forth and seek medical help although a large proportion of them will admit to having the problem on direct questioning.

What cause erectile dysfunction?

Although erectile dysfunction is often regarded as to be tolerated as part and parcel of growing old, many elderly men will tell you that their erectile dysfunction only comes about only after a specific illness or following taking certain medicine. Many drugs can cause or exacerbate erectile dysfunction and the prescribing physicians should advise patients of such a possibility.
A normal level of male hormone is necessary to maintain sex drive. Erection of the penis is resulted initially from dilatation of the arteries to the erectile tissue of the penis. The erectile tissue is akin to a sponge, soaking up what blood that flows in and fills up the penis. The filling up of erectile tissue within the penis occludes the draining venous channels of the erectile bodies, helping to maintain the erection. This maintenance of erection is effected by a balance between total amount of blood flowing into the penis and that leaving the penis. If there is a problem in the mechanism of blood trapping within the erectile tissue, the erection may not be sustained. The whole cascade of event is mediated by the involuntary nervous system, which provides the stimulus for the dilatation of the arteries to the erectile tissue.         

This maintenance of erection is effected by a balance between total amount of blood flowing into the penis and that leaving the penis. If there is a problem in the mechanism of blood trapping within the erectile tissue, the erection may not be sustained. The whole cascade of event is mediated by the involuntary nervous system, which provides the stimulus for the dilatation of the arteries to the erectile tissue.         

Damage of the nerves to the erectile tissue will result in erectile dysfunction. While this often results from surgery to remove the rectum or bladder and prostate, pelvic radiotherapy can also lead to the same conclusion. Diseases that affect the involuntary nervous system may have a similar effect. Examples include stroke, multiple sclerosis and spinal cord injury. Impaired blood supply as a result of any arterial disease also lead to erectile dysfunction. Hardening and narrowing of the arteries associated hypertension or as a result of heavy smoking or excess blood cholesterol are examples.
Psychogenic causes of erectile dysfunction include psychological problems, performance anxiety, relationship problems, depression, and domestic and work pressures.
 
What test can be done?

A screening blood sugar level should be done if diabetes is suspected. A serum cholesterol assay is often included as part of the screening investigation, particularly if there is a family history of heart disease. If necessary, the urologist will do a screening assay of male hormone level. Routine X-ray of arteries is seldom carried out except in young patients who had developed erectile dysfunction following pelvic trauma. Measurement of penile expansion at night is reserved only for a small group of patients. Doppler ultrasound scan of the penile blood supply and pressure measurement of the erectile tissue are largely used for research.

What treatment is there?

Irrespective of culture and age, most men who are troubled by their erectile dysfunction can be helped. Most urologists offer a stepwise approach to the management of erectile dysfunction. Removal of any obvious causes such as certain drugs would be the first option. In patients deficient of male hormone, replacement would bring about a good response. Many cases of erectile dysfunction can be helped by a very simple vacuum constriction device but most patient find this clumsy. This device is placed over the penis before the air is drawn out of the cylinder, causing the penis to fill up with blood. A tight elastic band is then slipped over the root of the penis like a tourniquet to retain the blood. The use of these devices should be supervised by urologists and these devices can be obtained through practicing urologists.
 
Drugs that cause arteries to dilate can be used to treat erectile dysfunction. Sildenafil (Viagra®) is a drug that when taken by mouth, produces a localised dilatation of the arteries and erectile tissue of the penis. The tablet is taken approximately 1 hour prior to sexual intercourse and had been shown to be effective in 70-80% of erectile dysfunction sufferers, including Malaysian men. Because of its convenient administration, this drug is now the first line treatment in most erectile dysfunction sufferers. Men who are taking drugs containing nitrates MUST NOT take Viagra® as this may result in a severe and dangerous adverse reaction. Viagra® can be obtained through a doctor's prescription. The other commonly used drug treatment involves direct injection of prostaglandin E1 into the erectile body using a very small needle. In most patients, a good erection can be produced lasting a considerable period of time. Most patients inject themselves and urologists should be responsible for their training and supervision. When erection remains too long (priapism), it may have to be reversed to relieve the pain and preserve the normal characteristics of the erectile tissue. Finally, for those cases in which nothing works, a special device can be implanted into the penis to render it rigid. There are 2 main types of penile implants. Malleable devices are cheaper but render the penis rigid all the time. The penis has to be bent and tucked away at rest but concealability can be a problem

The most satisfactory implants are of the inflatable design using a pump placed in the scrotum and a fluid reservoir within the abdomen. Although complications are encountered with the implants, the inflatable devices currently give the best patients and partners satisfaction.

What are kidney stones?

Stones can form in the kidney from the crystals in the urine that build up and stick together. The function of the kidneys is to filter chemical waste products from the blood and remove them in the urine. The crystals in the urine tend to form stone when you do not drink enough water especially living in a hot climate country like Malaysia.

Pain from kidney stones

When the kidney stones block the flow of urine, it will cause severe pain. In some patients the stones are discovered incidentally, as they may not cause pain. The excruciating pain of kidney stones usually begins in your lower back and later, moves to your side or groin. You may feel nauseous, pass bloody urine or burning sensation on urination. The initial treatment would be painkiller and also antibiotics if you have fever.

What tests will your doctor perform?

Once your doctor suspects that you may have kidney stones, he will perform a series of tests to confirm the diagnosis:

• Microscopic analysis of your urine
• Urine culture for bacteria
• Intravenous urogram (IVU) – An injection of contrast will be given to you followed by a series of X-rays. Your doctor should be informed if you are an asthmatic and have a history of drug and food allergy.
• Ultrasound of your kidneys    

What treatment will be given for your kidney stones?

A number of treatment options are available to treat your kidney stones.

A. Expectant Therapy :

If you have "small" kidney stones, your doctor may suggest that you try to pass the stone naturally by drinking lots of water. Water helps to flush out the stone. You will be asked to strain all of your urine to catch the stone.

B. Medications:

If you have uric acid or cystine stones your doctor may prescribe you some medicine to dissolve the stone. Allopurinol ( zyloric) reduces uric acid. Polycitrate or bicarbonate helps dissolves uric acid and cystine stones.

C. Extracorporeal Shock Wave Lithotripsy (ESWL) :

If you fail to pass the kidney stone naturally, it can be crushed by ESWL. Shock wave is transmitted through your body and targeted at the kidney stone. The stone will crumble into sandlike particles which then pass easily through your urinary tract. The noninvasive procedure is performed on an outpatient basis with minimal pain.

D. Endoscopic lithotripsy:

ESWL may not be able to crush the kidney stones in some patients. Such patients may have to undergo endoscopic treatment to directly fragment and remove the stones. In this procedure the stone is crushed using probes introduced by endoscopic means while they are still inside the body. The probes are connected to a machine that produces the energy to crush the stone. The types of energy used include ultrasonic, ballistic and laser. ESWL may not be able to crush "hard" and "large" kidney stones. Stones in the ureter and bladder also need endoscopic treatment for fragmentation.   

How to prevent formation of future stones?

After the successful treatment of your kidney stones, the following advice must be followed to prevent formation of future stones. Once you have had kidney stones, you are at risk of having them again.
•    drink plenty of fluids, about a glass of water for every waking hour
•    follow your prescribed diet
•    take your medications
•    see your doctor regularly

PROSTATE CANCER

What is Prostate Cancer?

Prostate Cancer is one of the commonest cancers in men. The general statistics imply that this is predominantly a disease that affects the Western world and studies do show a wide difference in clinical incidence between that of the Western and Asian populations. With the expected doubling of the elderly population by the year 2020, it is likely that prostate cancer will be more evident in Malaysia in the coming years.

Prostate Cancer is very rare before the age of 50 years and the risk of developing prostate cancer increases with age. The exact cause is unknown, but basically it begins when a group of cancerous cells (abnormal body cells that grow and spread uncontrollably) forms a tumour in the prostate.

What are the symptoms ?

In its early stages, prostate cancer may not cause any symptoms. But as the cancer progresses, the tumour grows, putting pressure on surrounding parts of the body.

The enlarged tumour may compress the urethra, blocking the flow of urine. When this happens, the patient may urinate more frequently than normal, get up too often at night and also have a reduced force of urination. Sometimes there may even be painful urination. Occasionally, there may be blood in the urine or semen or painful ejaculation.

In the later stages, prostate cancer may spread to nearby organs especially the surrounding lymph nodes and the bones. At this stage, many men may suffer from bony aches and pains as well as becoming increasingly unwell.

What are the stages of the disease ?

Prostate Cancer is best classified into its 4 stages. After the diagnosis of the cancer which is established by examining prostatic tissue under the microscope, staging must be done to see how extensively it has or has not spread. The best treatment of the individual case then depends on the stage the disease is at.

Stage 1

In stage 1, prostate cancer has no symptoms. It refers to relatively small foci of cancer which is located wholly within the prostate gland. It usually goes undetected and is often diagnosed "by surprise" after examining prostatic tissue following transurethral prostate surgery (done to improve urination). More recently, this can also be diagnosed by needle biopsy of the prostate gland if indications are present for such a biopsy. Stage 1 prostate cancer cannot be detected by digital rectal examination. There is also a very good chance that Stage 1 prostate cancer can be cured.

   
Stage 2. (T2NOMO or B)

Stage 2 prostate cancer refers to a more easily detected tumour although still within the prostate. There still may not be any symptoms. The tumour has however grown to the point where it can be detected by a rectal examination. This stage of prostate cancer also has a good chance of being cured.

Stage 3. (T3/T4NOMO or C)

By stage 3, prostate cancer has spread to the area just outside the prostate. Common symptoms at this stage include difficulties with urinating. Stage 3 prostate cancer has less chance of being completely cured, but treatment can effectively slow its spread, and can relieve most symptoms.

Stage 4. (T1-4 N1-3M1 or D)

Stage 4 prostate cancer is an advanced stage of cancer and refers to distant spread beyond the prostate. Commonly, the areas involved are the lymph nodes and the bones (figure 3) but other areas can also be involved. Symptoms at this stage can include difficulty in urinating, bone pain, weight loss and fatigue. At this stage of disease, treatment is targeted to relieve symptoms and hopefully to also slow the cancer’s growth.  

 
What treatment is available ?

Early Prostate Cancer.

When the tumour is limited to the prostate gland as in Stages A and B of the cancer, treatment given is to try to remove the tumour from the body and to prevent any possible spread. This can be done through surgery, or with the use of radiation.

1. Surgery.

The surgical removal of the prostate is called a prostatectomy. In this procedure, the entire prostate, and thus the tumor, is removed. Pelvic lymph nodes are also removed during this operation to ensure that they are not carrying any cancer. The side effects associated with prostatectomy may include impotence and incontinence, and as with any surgical procedure, there are some risks of other complications. A relatively young, otherwise healthy man is an ideal candidate for surgery.   

2. Radiation.

Radiation therapy uses high energy X-rays to kill and eliminate cancerous cells. There are different ways to administer this therapy, either externally or internally. Radiation therapy is a good option for patients who either wish to avoid an operation or may not be suitable for a major operation. Its side effects include fatigue, skin reactions, frequent and painful urination, stomach upsets, diarrhoea and rectal irritation or bleeding. Fortunately, most of these side effects disappear after the end of the treatment. A small percentage of patients may have more long term problems.

Radiation therapy has been used for many years to treat prostate cancer. Although some experts claim that the cure rate is as good as surgery, there are some major disagreements. However there is no doubt that radiation does cure some patients and have fewer risks than surgery. For this reason, it is commonly used in older patients and in patients with other medical problems. It certainly has its role in the treatment of prostate cancer.

3. The No Treatment At All Dilemma. (Watchful Waiting)

Besides surgery and radiation therapy for early prostate cancer, there remains a third option of not treating at all. The rationale behind this is the fact that autopsy studies show a high incidence of prostate cancer and yet only a much lower number of men die or become ill from prostate cancer.

It is therefore not completely clear who will go on to develop serious problems and who will not ? Who shall we treat and who shall we not treat ? This is one of the most difficult questions facing both the physicians and the patients.

Advanced Prostate Cancer.

Both surgery and radiation can be used either alone or together to treat Stage C prostate cancer. However, most Stage C cancer treatment focuses not on achieving a cure, but on slowing the spread of prostate cancer and relieving its symptoms. Often times, the latter treatment would include some form of hormonal treatment.
Hormonal Treatment of Prostate Cancer.

Advanced prostate cancer, especially Stage D disease is generally not amenable to cure. Emphasis is therefore placed on control of the disease and this is most often done by either reducing the production of testosterone, the hormone that fuels the cancer, or blocking the hormones’ action. Depriving prostate cancer of the male hormone (testosterone) usually causes tumour regression (shrinking).
As a simple rule, hormonal therapy is reserved for men with stage D disease or men who have recurrent disease after radiation therapy or surgery. This can be achieved in one of several ways.

1. Orchidectomy.

This is the medical term for surgical removal of the testicles and is a small operation. Because 95% of the body’s testosterone is produced by the testicles, their surgical removal effectively limits the amount of testosterone available to fuel the cancer. The growth of the cancer is therefore slowed, and many of its symptoms alleviated. Side effects of this operation include impotence and hot flushes.

2. Oestrogens.

This was the traditional treatment for advanced prostate cancer and oestrogens are basically female hormones that worked by reducing testosterone levels. This treatment was however complicated by significant complications and now that safer therapy is available, oestrogen is very rarely used.

3. Anti - Androgens.

These drugs block the action of testosterone at the cell level. There are various drugs that act this way and are also used in combination with other therapies. Their side effects vary between the different groups of drugs.

4. LHRH analogues.

This group of drugs is usually given as an injection under the skin either monthly or 3 monthly depending on the depot preparation (figure 5). They act by shutting down testosterone production in the testicles. Its actions are therefore similar to that of orchidectomy. The side effect profile is also rather similar to that of surgical orchidectomy.

    
Conclusion

URINARY INCONTINENCE

What is urinary incontinence?

Urinary incontinence is the involuntary loss of control of urine which is socially and hygienically unacceptable. It is a very common condition and recent data has shown that up to 30% of women had experienced incontinence.

What are the causes?

A normal bladder can accommodate a significant volume of urine with no appreciable rise in pressure. Urine is prevented from leaving the bladder by the constant contraction of the sphincter which works like a tap. During urination, the bladder muscle contracts, raising the pressure inside the bladder and at the same time, the sphincter opens up to allow urine to leave the bladder. Incontinence can result from abnormal bladder contractions or a weak sphincter mechanism.

The most common cause is stress incontinence which occurs mainly in women. This usually occurs as a result of weakened pelvic floor muscles after childbirth. The other common cause is uncontrolled bladder contractions called detrusor instability or unstable bladder. The bladder muscle escapes volitional control and spontaneous contractions cause the urge to pass water when the bladder is not yet full. When this contraction produces a pressure which is too great to control urine leaks out and causes incontinence.

In men prostate enlargements are the most common reason for incontinence. Spinal cord injuries and strokes are the other causes that occur within our community.         

What are the symptoms?

In patients with stress incontinence, the urinary leak occurs due to physical stress. Depending on the degree of pelvic floor weakness leakage may occur in response to coughing or sneezing, jumping or jogging or lifting heavy objects. In severe cases the leak can occur with almost any daily activity. Patients with unstable bladders often have the urge to pass water despite the fact that their bladders are not yet full and thus they have to run to the toilet very often. If for some reason they are delayed in reaching the toilet a urinary leak may occur. Elderly men with prostate enlargements experience incontinence which is similar to the patients with unstable bladders. They also tend to have a slow urinary stream.

What tests are available?

A urine test is most commonly done but rarely provides very much information. The key test that will evaluate all urinary incontinence accurately as well as tailor the treatment to the particular disorder and patient is the urodynamics test. This is done by inserting two very tiny tubes into the bladder as well as a balloon catheter into the rectum and measuring bladder and rectal pressures during artificial filling of the bladder with saline. The patient will be asked to void during this test to measure voiding pressures as well. Ultrasound of the kidneys may be done in selected patients to exclude kidney damage.         

What treatment is available?

There are many varied types of treatments available and up to 80% of incontinence is curable. The cornerstone of good treatment is an accurate diagnosis from urodynamics. Patients with stress incontinence from a weakened pelvic floor can improve significantly by doing simple pelvic floor exercises or use devices like vaginal clones or biofeedback equipment. Electrical stimulation of the pelvic floor may be helpful for patients with mild degree of stress incontinence. For more severe stress incontinence surgery is the main recourse. Surgery ranges from minimally invasive procedures such as injections of substances into the urethra to increase resistance to open reconstrutive surgery. As for the unstable bladder, medications are the mainstay of treatment along with a self-administered plan of bladder training. Even patients with spinal cord injuries and paralysis can achieve continence by simple manoeuvres like clean intermittent self catheterisation. In this procedure the patient inserts a clean catheter into his/her urethra to empty the bladder and maintain continence. A variety of surgical procedures that are highly successful are also available including the use of an artificial urinary sphincter. The bottom line is that continence can be achieved in most situations if proper urological consultation is sought and urodynamics done.
       

What is urine infection?

Normal urine is sterile. When bacteria get into the urine, it can affect only the bladder when the term cystitis can be applied. Infection that goes up to the kidneys are more severe and can lead to kidney damage. Bacteria usually get into urine by going up the urethra (urine passage).
 
How do we know it is urine infection?

Urine infection is common and can affect children and adults alike. In children, urine infection presents with fever, irritability, vomiting, shivering and poor feeding. In adults, symptom ranges from frequency of urination, lower abdominal pain, burning sensation in the urine passage, cloudy and smelling urine to blood in the urine. When the infection affects the kidneys, the patient can be very ill with loin pain, shivering and even shock.
 
What predispose to infection?

Urine infection more likely to occur when there is an abnormality in the urinary tract (kidney, ureter, bladder, urethra). In a normal person, the female urethra is much shorter than that of the male and consequently, in the absence of any urinary tract abnormality, women get infection more readily than men. In women, sexual intercourse predisposes to urine infection. Typically, young girls get their first cystitis when they become sexually active. Such infections are not regarded as venereal diseases and do not transmit between partners. Diabetic patients are more likely to get urine infections due to the presence of sugar in the urine. After menopause, the state of the vagina and urethra becomes less healthy and more easily prone to infection. Infections are also more likely to occur when there is stagnant urine in the bladder because of incomplete voiding during micturition caused either by an obstruction of bladder outlet (urethral narrowing associated with menopause, prostate enlargement in men) or abnormal bladder function due to disease or injury affecting the nerves involved in the normal control of the bladder. Ultimately the types of bacteria that get into the bladder originate from the faeces and maintaining lower body hygiene is an important way to prevent urine infection.
 
How is it diagnosed?

Urine infection can be suspected based on a typical history of an acute onset of frequent urination, burning pain, lower abdominal pain, back pain and cloudy or bloody urine. The finding of red and white blood cells in your urine when examined under the microscope is highly suggestive of an infection. However, the diagnosis can only be confirmed by obtaining a clean catch specimen of mid stream for culture to isolate the offending bacteria and identify the effective antibiotics against it. Most laboratories can give results of urine culture within 48 hours. Occasionally, the same bacteria can be identified in the blood.
 
What other investigations would the doctor do?

A special X-ray of the urinary tract (intravenous urogram) is indicated when there is blood in the urine. This X-ray is also done in patients with recurrent infections or in patients who have kidneys stones associated with the infection. Ultrasound scan can also give useful information about the kidneys and bladder. Occasionally, a telescope inspection of the bladder (cystoscopy) is carried out to rule out associated bladder disease, particularly bladder tumours.
 
Recurrent Infections

Many women suffer from frequent UTI's. Nearly 20 percent of women who have a UTI will have another, and 30 percent of those will have yet another. Of the last group, 80 percent will have recurrences. It is well known that some women are more prone to get recurrent attacks than others. Research had shown that women with certain blood types are particularly prone to UTI's because the cells lining the vagina and urethra may allow bacteria to attach more easily. Further research will show whether this association is sound and proves useful in identifying women at high risk for UTI's.
 
Infections in Pregnancy

Pregnant women seem no more prone to UTI's than other women. However, when a UTI does occur, it is more likely to travel to the kidneys. About 2 to 4 percent of pregnant women develop a urinary infection. Scientists think that hormonal changes and shifts in the position of the urinary tract during pregnancy make it easier for bacteria to travel up the ureters to the kidneys. For this reason, many doctors recommend periodic testing of urine.
 
Treatment

The mainstay of UTI treatment is the use of an appropriate antibiotic. An uncomplicated UTI can be cured with 1 or 2 days of treatment. UTI's are treated with antibacterial drugs. The choice of drug and length of treatment depends on the patient's history and the urine tests that identify the offending bacteria. The sensitivity test is especially useful in helping the doctor select the most effective drug. The drugs most often used to treat routine, uncomplicated UTI's are trimethoprim, trimethoprim/sulfamethoxazole (Bactrim), amoxicillin (Amoxil), nitrofurantoin, ampicillin and newer antibiotics such as ciprofloxacin (Ciprobay), pefloxacin (Peflacin) and oflaxacin (Tarivid).
Often, a UTI can be cured with 1 or 2 days of treatment if the infection is not complicated by an obstruction or nervous system disorder. However, most doctors prefers to ask their patients to take antibiotics for 5 to 7 days to ensure that the infection has been cured. Single-dose treatment is not recommended for some groups of patients, for example, those who have delayed treatment or have signs of a kidney infection, patients with diabetes or structural abnormalities, or men who have prostate infections. Longer treatment is also needed by patients with infections that also affect the prostate or the testis. It is important to take the full course of treatment because symptoms may disappear before the infection is fully cleared. A pregnant woman who develops a UTI should be treated promptly. Only certain antibiotics are advisable during pregnancy and the doctor should be consulted.
Severely ill patients with kidney infections may be hospitalized until they can take fluids and needed drugs on their own. Kidney infections generally require several weeks of antibiotic treatment.
Various drugs are available to relieve the pain of a UTI. A heating pad or a warm bath may also help. Most doctors suggest that drinking plenty of water helps cleanse the urinary tract of bacteria. Occasionally, urine alkalinizing agents such as citrate and bicarbonate can significantly alleviate the irritative symptoms associated with UTI.
 
Recurrent Infections in WomenWomen who have frequent recurrences may benefit from preventive therapy. About 4 out of 5 women who have a UTI get another in 18 months. Many women have them even more often. A woman who has frequent recurrences (three or more a year) should ask her doctor about one of the following treatment options:

• Take low doses of an antibiotic daily for 6 months or longer. (If taken at bedtime, the drug remains in the bladder longer and may be more effective.) This therapy can be effective without causing serious side effects.
• Take a single dose of an antibiotic after sexual intercourse.
• Take a short course (1 or 2 days) of antibiotics when symptoms appear.
• Doctors suggest some additional steps that a woman can take on her own to avoid an infection:
• Drink plenty of water every day. Some doctors suggest drinking cranberry juice, which in large amounts inhibits the growth of some bacteria by acidifying the urine. Vitamin C (Ascorbic Acid) supplements have the same effect;
• Urinate when you feel the need; don't resist the urge to urinate;
• Wipe from front to back to prevent bacteria around the anus from entering the vagina or urethra;
• Take showers instead of tub baths;
• Cleanse the genital area before sexual intercourse
•  Avoid using feminine hygiene sprays and scented douches, which may irritate the urethra.
• Pass urine immediately after sexual intercourse
• Avoid excessive talcum powder over the genital area
• Cut down on the consumption of sugar and sweets whilst increasing dietary fibres.

 
Complicated Infections

When the infection proves difficult to treat, an underlying cause should be suspected. This can range from
a urinary obstruction, a nervous system disorder, a congenital anomaly of the urinary system, urinary stones or even tumours. UTI's are unusual in men. They usually stem from an obstruction, usually an enlarged prostate. All these cases should be referred to a specialist (a urologist) for further investigation.