Featured Topics

Benign Prostatic Hyperplasia
Urinary Tract Infection
Blood In The Urine
Bed Wetting
Kidney Stone

Q. What is Benign Prostatic Hyperplasia?
The Prostate gland is an organ present in males only and it sits at the base of the urinary bladder, circumferentially surrounding the initial part of the urethra. Benign Prostatic Hyperplasia or BPH as it is commonly known is a benign (non calculus) condition in which the prostate gland progressively enlarges. As the gland enlarges it progressively compressive the urethra and also irritates the base of the urinary bladder resulting in obstruction to the flow of urine.

Q. How common is BPH?
BPH is a worldwide health issue in males and is also seen in men from the Indo-Pak sub-continent. It usually starts in men aged 50-55 years and by the time they reach 70 years of age more than 50% has some degree of enlarged prostate. The exact cause remains unknown, however, several factors may contribute most important is thought to be the changing balance of sex hormones which occurs with age.

Q. What are symptoms of BPH?
The symptoms of BPH are due to two main factors:
Compression of the urethra, resulting in obstruction to flow of urine.
Pressure on the base of the bladder resulting in irritation of the bladder.

1. Compression of the urethra produces hesitancy or delay in starting flow of urine when attempting to urinate.
2. Weak force of urinary strain.
3. Need to push or strain to start flow of urine.
4. Interruption in the flow of urine.
5. Feeling of incomplete emptying of the bladder
6. Dribbling after urination.

Pressure / irritation of the triagon produces

1. Increased frequency of micturation in both day & night.
2. Urgency or difficulty in delaying micturation.
3. In addition some patients may not appearance of blood in urine.

Q. How BPH is diagnosed?
BPH is generally not suspected in patients less than 50 years of age. However, above 50 years of age in patients with suspected BPH the basic evaluation would require:

• A careful and detailed Urological
• A complete physical examination which would include a digital rectal examination for the prostate gland.
• Appropriate laboratory.

All this is necessary to differentiate BPH from other conditions such as urinary tract infections, prostate infections, urethral stricture etc., which may also produce symptoms similar to BPH.

Q. What investigations are necessary?
Your Urologist would determine what tests to be done, this may include

• Blood Test
• Urinalysis & culture
• Ultrasound of the urinary bladder, prostate & kidney
• Possible urinamic testing this includes uroflowmetry and cystometrography
• Special such as PSA (Prostate Specific Antigen) which is an early indicator of the presence of cancer in the prostate gland.

Q. What options are available?
Depending upon the history, physical examination findings and laboratory reports. Patients are classified into 1 of 3 categories i.e., mild, moderate or severe. The mild form of Prostate enlargement only require watchful waiting. For the more advance forms of BPH either surgical intervention or drug treatment of the gland to improve symptoms is required.

Q. What is watchful waiting?
This is recommended in those patients who are only beginning to exhibit mild symptoms and signs of BPH. Since the process of enlargement of the Prostate gland is quite slow and takes several years such patients are simply told so and asked to come back after every 6 to 12 months intervals for reassessment. They are however, worn that ________ ______ of symptoms occur even in milder form of BPH with such intercurrent problems and urinary tract infections or stone formation.

Q. When does surgical intervention become necessary?
Urologists generally recommends a conservative approach and individual’s style is also taken into consideration. Surgery however, becomes necessary when certain complications develop such as recurrent urinary tract infections, urinary retention, recurrent blood in the urine, bladder stone formation or evidence of significant back pressure on the kidneys resulting in rise in the blood urea and creatinine.

Q. What surgical procedures are done?
The traditional method of operation is known as Open Prostectomy. This involves making a cut in the lower abdomen taking out the prostate and then closing up the abdomen with stitches. Another operation which is more commonly performed these days is known as TURP. This involves introducing a special instrument through the urethra and then removing the enlarged part of the prostate gland using electric current. This has the advantage of lesser complications, shorter hospital stay and faster recovery. Some other newer technologies have also come up such as laser and tuna, however, the Urologist has to decide which method will be best suitable for the individual problems.

Q. Is surgery always successful? Are there any complications?
Though surgery is quite effective and produces a significant improvement in the quality of life of most patients with severe BPH not everybody remains trouble free. About 15-20% patients experience short-term adverse effects such as persistent frequency of micturation and inappropriate leakage of urine. This however, usually resolves in most patients with appropriate treatment. 5% patients may also develop sexual dysfunction. Retrograde ejaculation is another possible problem. 2-3% patients may also fail to have any significant symptomatic improvement.

Q. Can BPH reoccur after surgical treatment?
Yes, since in both forms of surgical treatment of BPH not the entire gland is removed, there can be recurrence. However, since the prostate gland is very slow growing it takes more than 10-15 years to re-grow and that is in only very small percentage of people.

Q. Are there any medicines which can help in BPH?
Until a few years ago surgical treatment was the only option, however, now there are several drugs which can help alleviate symptoms of BPH. The three most tested drugs are Phinistrite (Proscar), Doxasine (Cardura) and Tryzocine (Hytrin). Other drugs such as Xatral, Apytrofan and Permixon have also undergone quite a few clinical trials. Selective use of one of these drugs show beneficial results in patients with moderate symptoms of BPH. The Urologist is best able to give further advise in this regard.

Q. Is there any risk of cancer?
Though, it is generally accepted that BPH is not a pre-cancerous condition but since both BPH and prostate cancer have similar hormone requirements and a specific increase is prevalence, it is possible that patients with enlarged prostate may have prostate cancer as well. In order to exclude cancer patients presenting with BPH symptoms should undergo a thorough physical examination including a digital rectal examination of the prostate, ultrasound of the prostate and other laboratory tests, particularly PSA. Based on these investigations the Urologist may require further investigations such as biopsy and CT Scan to make a diagnosis of prostate cancer.

Q. Is there a particular diet recommended for patients of BPH?
No, currently, no particular dietary factor has been identified that may help prevent development of BPH or halt the progress of BPH. However, since the BPH usually develops in patients above the age of 50 years, it is generally advisable to maintain a balance diet with low oil (Cholesterol Free) and adequate vitamin supplementation.

Q. Why is treatment is necessary?
As BPH progresses with time you can develop a number of bothersome and embarrassing symptoms. BPH can also cause more severe problems such as complete blockage to flow of urine, recurrent infection in the bladder, formation of bladder stones and back pressure in the kidneys leading to renal failure. In addition delayed treatment causes the bladder muscle to become weak and therefore, the functioning of the bladder can remain impaired even after surgery if treatment is delayed for too long.

Q. What is Urinary Tract Infection?
Normally the urinary tract from the kidneys down to the ureter the bladder and up-to the distal one third urethra is sterile i.e., bacteria free. However, there are certain bacterial organisms which are present in the perineum and the peri-anal area. Some times these organisms invade the urinary tract and this results in urinary tract infection.

Q. Are there any factors which predispose to urinary tract infection?
Yes, females due to their shorter and straighter urethra compare to the male urethra which is longer and has natural curves are more predispose to urinary tract infections. Also in females the urethra is in closer proximity to the vagina and the rectum both of which harbor certain organisms therefore, making them more prone to urinary tract infection. Men above the age of 50-60 years develop enlargement of the prostate gland which causes obstruction to the flow of urine. This obstruction to flow of urine is also a predisposing factor to urinary tract infection. Any instrumentation of the urethra such as catheter insertion can also lead to infection.

Q. What are the causative organisms of UTI?
There are several bacterial and non-bacterial organisms which cause UTI, however, Ecoli is a bacteria that causes UTI in 70-80% of cases.

Q. What are the symptoms of Urinary Tract Infection?
The typical symptoms of UTI include increased frequency of micturation, burning micturation, fever, foul smelling urine, appearance of blood in the urine. There can also be pain in the lower abdomen or in the loin area.

Q. How is the Urinary Tract Infection diagnosed?
A urine analysis is often the first test which is done in patients who have the above symptoms. However, appearance of puss cells in urine D/R does not confirm UTI. There are other causes of puss cells in the urine. Confirmation of UTI requires a proper urine culture. Further investigations such ultrasounds and X-rays may be required to identify presence or absence of any underlying factors which may predispose to UTI.

Q. How is UTI treated?
Antibiotics are the main treatment strategy for UTI, however, the most appropriate antibiotics is usually decided after culture and sensitivity results. The appropriate antibiotics has to be taken in the right dose for the right number of days as prescribed by the physician to ensure complete eradication of infection. Incomplete treatment with antibiotic may result in temporary resolution of symptoms however, chances of recurrence of infection becomes much higher. In addition to antibiotics a high fluid intake is required to continuously flush out the urinary tract. In women appropriate perineal hygiene is necessary. Also sometimes if an underlying cause is identified surgical correction may become necessary.

Q. Can UTI occur in pregnancy?
Yes, pregnant woman produce certain hormones which result in dilatation of the urinary tract and also the enlarged uterus results in impaired flow of urine. Both of these factors predispose the pregnant woman to infection. Infection can occur in trimester of the pregnancy and appropriate treatment is necessary otherwise it can lead to complications such as pre-maturity, fetal loss and prelapsia. It is important that pregnant women inform their doctors that they are pregnant so that the doctor can select appropriate antibiotics which may not be harmful either to the fetus or to the pregnant women. It is also important to avoid X-rays during pregnancy.

Q. What precautions are necessary for UTI?
Adequate fluid intake to ensure the passage of urine at least 5-6 times a day and a light colored rather than yellow color urine is one of the most important precautions against UTI.
Recurrent infections in both males and females require further investigations since there may be an underlying cause which would require surgical correction to ensure complete eradication of UTI.
It is important for women to maintain perineal hygiene particularly during their menstrual periods to prevent migration of bacteria from the vagina and perineum to the urinary tract.
Voiding of urine after sexual intercourse is a useful prevention against UTI.

Appearance of blood in the urine is quite an alarming symptom. It indicates presence of some abnormality of some part of the urinary tract. Often this blood appear in the urine for a day or two and then it may disappear. To the patient this disappearance of blood is quite a relief particularly if he has taken some simple drugs or has visited the homeopath/hakeem. However, this disappearance of blood may not always indicate resolution of the primary problem. Particularly if the cause of the blood in the urine has not been completely investigated. Some of the common causes of blood in the urine are infection, stones, enlarged prostate and tumor.

In children and young women infection of the urinary tract is the commonest cause of blood in the urine. It is often a complain by symptoms of increased urinary frequency, pain and burning in the urine and fever. A urine culture is necessary to establish the diagnosis and also to determine the appropriate type of antibiotics. This is important to take the right dose of the antibiotics for the right period so as to completely eradicate the infection and prevent relapse.

In young adult males as well as in women and men of other age groups stone in the kidney, ureter or bladder is also a very common cause of blood in the urine. Patients often complain of pain in the flank region accompanies by occasional burning. The doctor may suggest a KUB X-ray followed by a special X-ray called IVP to confirm the diagnosis and also to plan the treatment. Stones less than 5mm in size often passed out spontaneously simply by drinking plenty of oral fluids. However, for larger stones some form of interventional treatment may be required. Currently at The Kidney Centre very few patients required open surgery. Most patients can obtain relief by non-invasive techniques such as lithotripsy or endoscopic technique which have the advantage of minimal pain and bleeding and early return to work.

In the older males enlarged prostate is the common cause of blood in the urine. Often there are associated symptoms of increased frequency, need to get up at night to pass urine, weak urinary stream, failure to completely evacuate the bladder etc. The urologist will examine the prostate may also need to investigate the ultrasound and other tests to decide the size of the prostate and the degree of obstruction to the urinary passage. The urologist would also need to determine the presence or absence of any other complication such as infection, bladder dysfunction, renal function impairment etc., to decide the kind of treatment required. Treatment with drugs is now available to provide relief for the mild to moderately enlarged prostate. For the more significantly enlarged prostate surgery by way of TURP may need to be done. TURP is an endoscopic procedure with the advantageous mentioned above. Other techniques like laser and tuna are coming up but TURP remains the gold standard.
Tumor of the urinary tract particularly of the bladder and the kidney is a very serious disease often there are no other symptoms except presence of blood in the urine. It is only after the urologist has thoroughly investigated by ultrasound, X-ray and some times even cystoscopy that the diagnosis is reached. Early diagnosis and early treatment can only improve the chances of survival. Some forms of surgery always required. For bladder tumor often Endoscopic surgery done in the early stages may be curative.

Thus it can be learned that appearance of blood in the urine should never be ignored and early appointment with the urologist should be sought so that proper investigations can be done to reach a conclusive diagnosis. There are a few other causes of blood in the urine and any of these problems if left untreated can become complicated and even life threatening.

What is Bedwetting ?
A good starting point for both the child and the parents is the realization that they are not on their own when it comes to bedwetting. This condition is remarkably common, affecting more than 50 million children worldwide. Bedwetting is a condition that physicians call nocturnal enuresis

How Bedwetting affects various age groups ?
At five years of age, more than 1 to 6 children still wet the bed. This means that in a classroom of thirty, there will be five who wet the bed regularly. Because children and their parents are too embarrassed to talk about the problem, it is unlikely that this condition will be known to each other. By the age of 10 years, 1 in 5 still wet the bed and even in adulthood, 1 in 100 still suffers from the problem.

Is Bedwetting anyone's fault ?
It is important to remember that it's not the child's fault for wetting the bed. Parents must also not blame themselves. Getting angry or punished the child will make the problem worse. Supporting and praising the bedwetter's efforts to stay dry will really help the child with this problem. Getting some help can speed things up and save a great deal of pain and anguish for the family.

Is there any reason to believe that Bedwetting is a symptom of a serious illness ?
No, not when bedwetting is the only symptom and the child is otherwise healthy! Most patients with involuntary bedwetting have a bladder that is normal in size but have poor control over emptying it; that is he/she does not feel the urge sufficiently well to wake up.

Children who start wetting the bed as well as themselves during the day after having been dry, may develop a urinary tract infection and should see a doctor.

Why does bedwetting happen ?
Although many factors have been associated with bedwetting, a major cause is the overproduction of nighttime urine.

Heredity
Bedwetting run in families. If both parents were bedwetters, there's a 75% chance that their children will also be bedwetters. Even if only be parent has a history of bedwetting, there's still a 40% chance of their children being bedwetters.

Over production of nighttime urine
During the night the body produces more of a substance called vasopressin leading to reduced urine production and more concentrated morning urine. Children who are bedwetters produce less than the normal amount of this substance which means that even during the night, they produce large quantities of urine. Their urine production exceeds the capacity of the bladder and so the child wets the bed.

The impact of Bedwetting goes beyond wet sheets
Bedwetting can undermine a child's normal development. It happens during the crucial years, when children are establishing with their siblings and friends. Bedwetting can affect their self-esteem and may subject them to testing and embarrassment. Many bedwetters, fearing detection by their friends, may being avoiding activities like sleepovers and camping trips.

Bedwetting also puts stress on the rest of the family
Many parents of bedwetters become distressed. They know how upsetting the condition can be for their child. And parents often feel frustrated because they don't know what they can do to help.

So speak to your doctor today
It is important that the problem is discussed with family doctor, health visitor or school nurse who will want to take a full history and do a few simple urine tests to eliminate any possible problem such as infection. Treatment is not usually started until the child is five years age. If encouragement doesn't help, then the doctor may decide to treat the child with Minirin Tablets, a medicine which works for most children by reducing the amount of urine produced overnight.

Remember

• Your child is one of million of children who wet their beds.
• It's neither your child's fault nor yours. Bedwetting can be caused by a number of factors beyond your child's control.
• Bedwetting can affect your child's entire outlook and lower his/her self-esteem.
• By being patient and positive, you can help keep bedwetting from being more of a problem than it has to be.
• There is simple effective treatment available today that may correct this problem.

What is Kidney Stone?
A kidney stone is a hard mass which occurs when certain salts and minerals present in urine bind together and form crystals. Such masses may grow to form stones ranging in size from a grain of sand to a golf ball. Smaller stones may pass out of the body through urine. However larger stones may block the flow of urine and cause pain obstruction or infection. If left untreated stones may lead to permanent kidney failure. Most of the stones are formed in the kidney and may travel to ureter or urinary bladder and grow there.

How common are Kidney Stones?
In Pakistan prevalence of kidney stones is more than other parts of the world. Kidney stones are formed in young and middle aged adults and are more common in males. Stones are a significant cause of hospitalization stay and loss of work hours. Since stones tend to recur even after they have been passed or removed, successful treatment depends on finding out the cause of stones.

How are kidney stones formed?
Reasons are not always clear as to why some people are more prove to form stones and others not. Normally urine contains chemicals that prevent crystal formation. The following factors may also contribute to stone formation in susceptible people.

• Drinking too little fluid.
• Chronic urinary tract infection.
• Misuse of certain medicines.
• Limited physical activity for several weeks.
• Blockage of urinary tract.
• Certain genetic and metabolic diseases.

Scientists do not generally believe that eating any specific food cause stones. However in susceptible people, certain foods may promote formation of stones. For, example a person may have a metabolic disorder (absorptive hypercalciuria) which causes too much calcium to be absorbed from the food he takes. This results in high level of calcium in the urine, which may cause calcium oxalate crystals to form.

What are the symptoms of Kidney Stones?
People having stones may have following symptoms:

• Severe Pain: usually starts suddenly in the kidneys or in the lower abdomen and may move to groin; pain may last for several minutes or hours followed by periods of relief.
• Nausea and Vomiting.
• Burning and frequent urge to urinate.
• Fever, chills and weakness – may indicate the presence of infection.
• Cloudy or foul smelling urine – also indicates infection.
• Blood in the urine.
• Blocked flow of urine.

Many of these symptoms may be associated with other kidney and urinary tract disorders.

How are stones diagnosed?
Normally X-Ray detect the presence of stones but when the stone is not radioopaque specialized X-ray techniques (using intra-venous contrast injections) or Ultrasound may also identify accurate size & location of stone and kidney function.
Blood and urine tests may be required to find out the cause of stone formation. Patients are asked about their diet, use of medication, life style and family back ground to learn about factors which contribute to their stone problem. These investigations help the doctor to plan the best possible treatment for the patient.

How stones are treated?
Treatment of stones usually depends upon their size and location. Stone should always be removed as it causes infection, obstruction and kidney damage. There are various methods of removing stones viz:

• Conventional open surgery

Used very infrequently now-a-days.

• Minimal invasive techniques:
• (For Kidney Stones) The kidney stone is removed by making a small hole through the skin. This procedure is known as Per Cutaneous Nephro Lithotomy (PCNL), by which a Telescope is introduced inside through that hole and the stone is broken down. Small fragments of the broken stone are removed; usually a single stitch is required to close the hole. This procedure can treat very large kidney stones.
• (For Ureter Stones) Stones present in the ureter below the size of 0.5 cm can pass out by taking excessive fluids. However those above the size of 0.5 cm are treated by Ureteroscopy (URS). This requires inserting a telescope through the natural urinary passage and breaking the stone inside the ureter, before removing the fragments.
• Non-Invasice techniques:

Lithotripsy: Extra corporeal Shockwave Lithotripsy (ESWL) is one of the safest non-surgical, daycare method of treating small and medium size kidney stone. In this method shock waves produced by a machine out side the body are transmitted in to the Kidney to break the stone. Fragments of the crushed stone are subsequently passed out through urine. Sometimes for larger stones a DJ Stent is placed with the help of Cystoscope, which allows safer and pain free ejection of stone fragments. Stent is removed when the patient is completely stone free.