Urology


Neurogenic Bladder

What is a neurogenic bladder?
A neurogenic bladder is a loss of normal control of bladder function caused by damaged nerves. There are 2 kinds of neurogenic bladder problems: overactive and underactive.

If you have an overactive bladder, you are not able to control when or how much you urinate.

If you have an underactive bladder, it holds much more urine than normal. Because you cannot feel when the bladder is full, you leak small amounts of urine as bladder pressure builds.

How does it occur?
Nerves and the muscles of the urinary system work together to hold urine in the bladder and then release it when you go to the bathroom. Nerves tell the brain when the bladder is full. The nerves carry messages from the brain to the muscles of the bladder, telling the muscles either to tighten or to release. In a neurogenic bladder, the nerves that carry these messages do not work properly.

Neurogenic bladder may be caused by:

      • injuries or birth defects that affect the brain or spinal cord
      • diabetes
      • polio
      • Parkinson’s disease
      • multiple sclerosis
      • infection
      • strokes
      • heavy metal poisoning.

 

With an overactive or underactive bladder, you may not be able to empty your bladder completely. Urine that is held too long before being eliminated may lead to infections of the bladder or ureters. (The ureters are the tubes that go from each kidney to the bladder). Urine may back up into the kidneys and damage them.

What are the symptoms?
The symptoms of neurogenic bladder and the infections it can cause are similar to those of other medical problems. See your health care provider if you have symptoms such as:

      • leaking or dribbling urine
      • a frequent and urgent need to urinate
      • pain or burning when urinating
      • pain in the lower pelvis, stomach, lower back, or side
      • change in the amount you urinate, either more or less
      • chills
      • fever.

 

How is it diagnosed?
Your health care provider will ask about your symptoms and will examine you. A sample of your urine may be tested. Your provider may test your nervous system (including the brain) and your bladder. These tests may include:

      • x-rays of the skull and spine
      • x-rays of the bladder and ureters
      • EEG, a test that uses wires taped to your forehead to check for dysfunctions in the brain
      • CMG (cystometrogram), a test that involves filling the bladder to see how much it can hold and checking to see if the bladder empties completely.

 

How is it treated?
Treatment of a neurogenic bladder depends on:

      1. the type of bladder problems that you have
      2. the cause of the nerve damage
      3. your age, overall health, and medical history
      4. how severe your symptoms are.

 

Medicine may help control your symptoms. If you have an overactive bladder, your health care provider may prescribe drugs that relax the bladder, such as propantheline (Pro-Banthine) and oxybutynin (Ditropan). If you have an underactive bladder, you may be given a drug that stimulates a certain type of nerves. An example of such a drug is bethanechol (Urecholine). You may need to take antibiotics to prevent infections.

Long-term treatment for neurogenic bladder may include:

      1. Insertion of a catheter (thin tube) to empty the bladder. A small rubber catheter may be inserted 4 to 6 times a day to empty the bladder. This is called intermittent catheterization. A continuous catheter is another option. Continuous catheters are also called indwelling catheters. They empty the bladder continuously into a collection bag.
      2. Surgery to create an artificial sphincter. For this procedure, an artificial cuff is placed around the neck of the bladder. This cuff can be inflated to prevent urinary leakage and deflated when it is time to empty the bladder. You will still need intermittent catheterization to completely empty the bladder.
      3. Sacral nerve stimulation (SNS). For SNS, a small wire is inserted through the skin in the area around the tailbone. The wire stimulates the nerves to empty the bladder.
      4. Sling surgery. The surgeon creates a new support system, either from your own tissues or by using synthetic materials, to hold the neck of the bladder in the proper position and prevent leakage.

 

How long do the effects last?

You will need treatment for the rest of your life.

How can I take care of myself?

Follow your health care provider’s advice on how much fluid you should drink.

Carefully follow your instructions for self-catheterization. This will help to prevent infections.

Contact your health care provider right away if:

You have symptoms such as:

      1. sweating, headache, and dizziness that do not go away after you empty your bladder
      2. fever of 101°F or higher
      3. worsening pain for several hours in the back or bladder area


Urinary Incontinence

Urinary incontinence is the uncontrollable and uninhibitable leakage of urine through the urethra. Urinary incontinence could be secondary to many causes. Primarily it is related to, what is called overactive bladder, where the patient has frequency and urgency running to the toilet. It also could be related to stress urinary incontinence, where when the patient coughs or sneezes or exercise, he or she leaks urine. Overflow urinary incontinence is when the bladder is unable to empty and it, in fact, overflows. This is usually secondary to a bladder that will not contract or to urethral obstruction, such as stricture or prostate obstruction. Again the diagnosis of urinary incontinence requires a good thorough history and physical examination, especially in women understanding history of childbirth and pelvic surgeries. We then obtain a urinalysis along with a voiding diary, which is a day to day accounting of how much urethral leakages is associated with normal voiding and oral intake of fluids. Then based upon this data, we decide whether the patient could be controlled by noninvasive means, which may include fluid management and pelvic exercises, the so called Kegel exercises. The patient may need more aggressive evaluation including an urodynamic measurement, which in fact is a way to measure how the bladder and urethra works to identify the source of the incontinence and guide therapy. Therapy could include a range of pharmaceuticals and pelvic exercises, up to surgery.
What is urinary incontinence and what causes it?
When you are not able to hold your urine until you can get to a bathroom, you have what’s called urinary incontinence (also called loss of bladder control). In contrast, bladder control means you urinate only when you want to. Incontinence can often be temporary, and it always caused by an underlying medical condition.

More than 13 million Americans experience loss of bladder control. However, women suffer from incontinence twice as often as men do. Both women and men can have trouble with bladder control from neurological (nerve) injury, birth defects, strokes, multiple sclerosis (MS), and physical problems associated with aging.

Older women have more bladder control problems than younger women do. The loss of bladder control, however, is not something that has to happen as you grow older. It can be treated and often cured, whatever your age. Don’t let any embarrassment about incontinence prevent you from talking to your health care provider about your condition. Find out if you have a medical condition that needs treatment.

What does the bladder system look like and how does it work?
Bladder control means more than just telling yourself to wait to urinate until you get to the bathroom. It is not that simple. It takes teamwork from many organs, muscles, and nerves in your body.

Most of the bladder control system is inside your pelvis, the area of your abdomen between your hips and below the belly button. Your bladder is a muscle shaped like a balloon. When the bladder stores urine, the bladder muscle relaxes. When you urinate, the bladder muscle tightens to squeeze urine out of the bladder.

More muscles help with bladder control. Two sphincter muscles surround the tube that carries urine from your bladder down to an opening in the front of the vagina. The tube is called the urethra. Urine leaves your body through this tube. The sphincter muscles keep the urethra closed by squeezing like rubber bands.

Pelvic floor muscles support the uterus, or womb, and rectum and bladder. They also help keep the urethra closed.

When the bladder is full, nerves in your bladder signal the brain. That’s when you get the urge to urinate. Once you reach the toilet, your brain sends a message down to the sphincter muscles and the pelvic floor muscles. The brain tells them to relax. The brain also tells the bladder muscles to tighten up to squeeze urine out of the bladder.

Loss of bladder control in women most often happens because of problems with the muscles that help to hold or release urine: the bladder muscle, the sphincter muscles, and the pelvic floor muscles. Incontinence occurs if your bladder muscles suddenly contract (or squeeze) or if the muscles around the urethra suddenly relax.

 

Are there different types of urinary incontinence?

Yes, there are different types of incontinence. They include:

      • Stress incontinence – Leaking small amounts of urine during physical movement (coughing, sneezing, exercising). Stress incontinence is the most common form of incontinence in women. It is treatable.
      • Urge incontinence – Leaking large amounts of urine at unexpected times, including during sleep, after drinking a small amount of water, or when you touch water or hear it running (as when washing dishes).
      • Functional incontinence – Not being able to reach a toilet in time because of physical disability, obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet. For example, a person with Alzheimer’s disease may not think well enough to plan a trip to the bathroom in time to urinate or a person in a wheelchair may be blocked from getting to a toilet in time.
      • Overflow incontinence – Leaking small amounts of urine because the bladder is always full. With this condition, the bladder never empties completely. Overflow incontinence is rare in women.
      • Mixed incontinence – A combination of incontinence, most often when stress and urge incontinence occur together.
      • Transient incontinence – Leaking urine on a temporary basis due to a medical condition or infection that will go away once the condition or infection is treated. It can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation).

 

Does pregnancy, childbirth and menopause affect urinary incontinence?
Yes. During pregnancy, the added weight and pressure of the unborn baby can weaken pelvic floor muscles, which affects your ability to control your bladder. Sometimes the position of your bladder and urethra can change because of the position of the baby, which can cause problems. Vaginal delivery and an episiotomy (the cut in the muscle that makes it easier for the baby to come out) can weaken bladder control muscles. And, pregnancy and childbirth can cause damage to bladder control nerves.

After delivery, the problem of urinary incontinence often goes away by itself. But if you are still having problems 6 weeks after delivery, talk to your health care provider. Bladder control problems don’t always show up right after childbirth. Some women do not have problems with incontinence until they reach their 40′s.

Menopause (when your periods stop completely) can cause bladder control problems for some women. During menopause, the amount of the female hormone estrogen in your body starts decreasing. The lack of estrogen causes the bladder control muscles to weaken. Estrogen controls how your body matures, your monthly periods, and body changes during pregnancy and breastfeeding. Estrogen also helps keep the lining of the bladder and urethra plump and healthy.

Talk with your health care provider about whether taking estrogen to prevent further bladder control problems is best for you. Tell him or her if you or your family has a history of cancer. If you face a high risk of breast cancer or uterine cancer, your health care provider may not prescribe estrogen for you.

How is urinary incontinence diagnosed?
If you are having a problem with incontinence, the first step is to see your health care provider. She or he can refer you to a urologist, a doctor who specializes in treating the urinary tract. Some urologists further specialize in the female urinary tract. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth. A urogynecologist focuses on urological problems in women. Family practitioners and internists treat patients for all kinds of complaints. Any of these doctors may be able to help you.

To diagnose the problem, your health care provider will first ask you about your symptoms and for a complete medical history. Your provider should ask you about your overall health, any problems you are having, medications you are taking, surgeries you have had, pregnancy history, and past illnesses. You will also be asked about your bladder habits: how often you empty your bladder, how and when you leak urine, or when you have accidents.

Your provider will then do a physical exam to look for signs of any medical conditions that can cause incontinence, such as tumors that block the urinary tract, impacted stool, and poor reflexes that may be nerve-related.

A test may be done to figure out how much your bladder can hold and how well your bladder muscles function. For this test, you will be asked to drink plenty of fluids and urinate into a measuring pan, after which your provider will measure any urine that remains in the bladder. Your provider may also recommend other tests, including the :

 

      • Stress test - You relax, then cough hard as the provider watches for loss of urine.
      • Urinalysis - You give a urine sample that is then tested for signs of infection or other causes of incontinence.
      • Blood tests - You give a blood sample, which is sent to a laboratory to test for substances related to the causes of incontinence.
      • Ultrasound - Sound waves are used to take a picture of the kidneys, bladder, and urethra, so any problems in these areas that could cause incontinence can be seen.
      • Cystoscopy - A thin tube with a tiny camera is placed inside the urethra to view the inside of the urethra and bladder.
      • Urodynamics - Pressure in the bladder and the flow of urine are measured using special techniques.
      • You may be asked to keep a diary for a day or a week in order to record when you empty your bladder. This diary should include the times you urinate and the amounts of urine you produce. To measure your urine, you can use a special pan that fits over the toilet rim. These pans are available at drug stores or surgical supply stores.

 

How is urinary incontinence treated?
There are a number of ways to treat incontinence. Your health care provider will work with you to figure out which way(s) is best for you. Don’t give up or be embarrassed! Remember, many women have incontinence and all types of incontinence can be treated, no matter what your age.

Treatments include:

      • Pelvic muscle exercises – Simple exercises to strengthen the muscles near the urethra, also called Kegel exercises. Taking a few minutes each day to do these exercises can help to reduce or cure stress leakage. A health care provider can teach you these exercises, most of which require no special equipment. One exercise, however, does use cones of different weights. You stand and hold a cone-shaped object inside your vagina. You then substitute cones of increasing weight to strength the muscles that keep the urethra closed.
      • Electrical Stimulation – Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Special devices called electrodes are temporarily placed inside the vagina or rectum to stimulate nearby muscles. This treatment can be used to reduce both stress incontinence and urge incontinence.
      • Biofeedback – Biofeedback used measuring devices to help you become aware of your body’s functioning. A therapist trained in biofeedback places an electrical patch over your bladder and urethral muscles. A wire connected to the patch is linked to a TV screen. You and your therapist watch the screen to track when these muscles contract, so you can learn to gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress incontinence and urge incontinence.
      • Timed Voiding or Bladder Training – Two techniques that help you to train your bladder to hold urine better. In timed voiding (urinating), you fill in a chart of when you urinate and when you leak urine. From the patterns that appear in your chart, you can plan to empty your bladder before you would otherwise leak. Bladder training—biofeedback and muscle conditioning—can change your bladder’s schedule for storing and emptying urine. These techniques are effective for urge incontinence and overflow incontinence.
      • Weight Loss – Extra weight can cause bladder control problems. If you are overweight, talk with your health care provider about a diet and exercise program to help you lose weight.
      • Dietary Changes – Certain foods and drinks can cause incontinence, such as caffeine (in coffee, soda, chocolate), tea, and alcohol. You can often reduce incontinence by restricting these liquids in your diet.
      • Medicines – Medications can reduce many types of leakage. They can also help tighten or strengthen pelvic floor muscles and muscles around the urethra. Some drugs can also calm overactive bladder muscles. Some drugs, especially hormones such as estrogen, are believe to cause muscles involved in urination to function normally.
      • Be aware that some drugs can produce harmful side effects if used for long periods of time. In particular, estrogen therapy can increase a person’s risk for cancers of the breast and endometrium (lining of the uterus). Talk to your provider about the risks and benefits of medications.
      • Implants – Substances are injected (through a needle) into tissues around the urethra. The implant adds bulk and helps the urethra to stay closed. This treatment reduces stress incontinence. Collagen (a natural fibrous tissue from cows) and fat from a person’s body have been used. This procedure takes about 30 minutes and can be done in a provider’s office using local anesthesia.
      • The success rate of implants varies. Injections must be repeated after a time because the body slowly gets rids of the substances. Before getting a collagen injection, you need to have a skin test to make sure you are not allergic to this substance.
      • Surgery – This treatment is primarily used only after other treatments have been tried. Different types of surgery can be done, depending on what kind of incontinence problem you have. Some surgeries raise, or lift, the bladder up to a more normal position. Other surgeries use implants to help the bladder function better.
      • Catheterization – A catheter is a small tube that you can learn to insert yourself through the urethra into the bladder to drain urine. Catheters can be used once in while or all the time. If used all the time, the tube connects to a bag that you can attach to your leg. If you use a long-term (or indwelling) catheter, you need to watch for signs of urinary tract infection.
      • Pessary – A pessary is a stiff ring that is inserted by a health care provider into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps to hold up the bladder and reduce stress leakage. If you use a pessary, watch for signs of vaginal and urinary tract infections. Visit your provider right away if you think you have an infection. Have your provider check the pessary on a regular basis.
      • Urethral Inserts – A urethral insert is a small device that you place inside the urethra, a technique that you can learn to do yourself. You remove the device when you go to the bathroom and then put it back into your urethra until you need to urinate again.
      • Urine Seals – Urine seals are small foam pads that you place over the urethra opening. The pad seals itself against your body, keeping you from leaking. You remove and throw it away after urinating. You then place a new seal over the urethra.
      • Dryness Aids – Absorbent pads or diapers help many women, but they do not cure bladder control problems. They can also cause low self-esteem (how you feel about yourself) and irritate the skin.


Male Infertility

Infertility is a common yet complex problem affecting approximately 15 percent of couples attempting to conceive a baby. In up to 50 percent of couples having difficulty getting pregnant, the problem is at least in part related to male reproductive issues. It is essential that men be assessed to pinpoint the treatable or untreatable causes of this heartbreaking health issue. Fortunately, with today’s high-tech procedures and powerful drugs, a diagnosis of infertility may simply mean the road to parenthood may be challenging but not impossible. So read below to learn more about the available treatment options so you are better prepared when talking with your urologist and/or fertility specialist.
What happens under normal conditions?
Male fertility depends on the production of normal sperm and the delivery of it to a female partner’s vagina. The process begins with spermatogenesis, or the development of sperm in the testicles. Fully developed sperm cells (spermatozoa) are produced by a complicated process of cell division that occurs over a period of several months.

Successful sperm development is controlled by the endocrine system and dependent on temperature and an appropriate genetic environment. Once formed, sperm leave the testicle and are stored in the epididymis where they fully develop. They are then pushed through the vas deferens and urethra during ejaculation

What is male infertility?
Male infertility is any condition in which the man adversely affects the chances of initiating a pregnancy with his female partner. Most commonly, those problems arise when the man is unable to produce or deliver fully-developed sperm.

What causes male infertility?
Your doctor will be interested in any factor, including possible structural and other defects in the reproductive system, hormonal deficiencies, illness or even trauma that might be impairing your fertility. Their investigation will center on many possible combinations of factors, the most common of which are:

Sperm disorders: Problems with the production and development of sperm are the most common problems of male infertility. Sperm may be underdeveloped, abnormally shaped or unable to move properly. Or, normal sperm may be produced in abnormally low numbers (oligospermia) or seemingly not at all (azoospermia).

Varicoceles: These dilated scrotal veins are present in 16 percent of all men but are more common in infertile men — 40 percent. They impair sperm development by preventing proper drainage of blood. Varicoceles are easily discovered on physical examination since the veins feel distinctively like a bag of worms. They may also be enlarged and twisted enough to be visible in the scrotum. This is the most common correctable cause of male infertility.

Retrograde ejaculation: Caused by the failure of nerves and muscles in the bladder neck or the opening into the urethra to close during orgasm, retrograde ejaculation occurs when semen pushes backwards into the bladder instead of out the penis. It is one of several difficulties couples may have delivering sperm to the vagina during intercourse. Retrograde ejaculation can be caused by previous surgery, medications or diseases affecting the nervous system. Signs of this condition may include cloudy urine after ejaculation and diminished or “dry” ejaculation with orgasm.

Immunologic infertility: Triggered by a man’s immunologic response to his own sperm, antibodies are usually the product of injury, surgery or infection. In attacking the sperm, they prevent normal movement and function of the sperm. Although researchers do not yet understand just exactly how antibodies damage fertility, they know that these antibodies can make it more difficult for sperm to swim to the uterus and penetrate eggs.

Obstruction: Blocking sperm from its normal passage, obstructions can be caused by a number of factors, including repeated infections prior surgery, inflammation or other development problems. Any portion of the male reproductive tract, such as the vas deferens or epididymis, can be obstructed, preventing normal transport of sperm from the testes to the urethra, where it leaves the body during ejaculation.

Hormones: Responsible for stimulating the testicles to make sperm, pituitary gland hormones play a pivotal role in fertility. Therefore, when levels are severely low, poor sperm development can result.

Genetics: Genetics plays a central role in fertility, particularly since sperm carry half of the DNA mix to your partner’s egg. Abnormalities in chromosomal numbers and structure as well as deletions on the important Y chromosome present in normal males can also impact fertility.

Medication: Certain medications can affect sperm production, function and ejaculation. Such medications are usually prescribed to treat conditions like arthritis, depression, digestive problems, infections, hypertension and even cancer.

How is male infertility diagnosed?
The process begins with a complete history and physical exam and is usually followed by blood work and semen analysis.

From a sample of semen routinely obtained through masturbation into a sterilized cup, the physician will be able to assess factors — volume, count, concentration, movement and even structure — that help or hinder conception.

Even if the semen analysis shows low levels, or even no sperm, it does not necessarily mean absolute infertility. Low numbers in any of the above categories may just indicate a problem with the development or delivery of sperm that simply requires further evaluation.

For instance, your physician may order a transrectal ultrasound, an imaging test that places a probe into the rectum to beam high-frequency sound waves to nearby ejaculatory ducts. This test can help your physician determine if these structures are either poorly developed or obstructed with cysts, calcifications or other blockages.

A testicular biopsy comes into play when a semen analysis is abnormal but your doctor has yet to determine the cause. This test is performed in an operating room under general or regional anesthesia through a small cut in the scrotum. It may also be done in a clinic using a needle inserted through skin over the testicle that has been anesthetized. In either case, a small piece of tissue is removed from each testicle for microscopic evaluation.

Besides a semen analysis, your doctor may order a hormonal profile to discover the sperm-producing ability of your testes and to rule out serious conditions. For instance, follicle-stimulating hormone (FSH) is the pituitary hormone responsible for stimulating testes to produce sperm. High levels may indicate that the pituitary is trying to stimulate the testes to make sperm though they are not responding.

How is male infertility treated?
The treatment for male infertility depends on the specific problem. In some severe cases, no treatment is available. However, many times there are a mix of medications, surgical approaches and assisted reproductive techniques (ART) available to overcome many of the underlying fertility problems. The options are:

Surgery: Minor outpatient surgery (varicocelectomy) is frequently used to repair dilated scrotal veins (varicoceles). Studies have shown that repairing these dilated veins results in improved sperm movement, concentration and structure. In some cases, obstruction causing infertility can also be surgically corrected.

Medication: While drugs are key in correcting retrograde ejaculation and immunologic infertility, hormone therapy with drugs such as clomiphene or gonadotropin can help in correcting endocrine imbalances.

If these techniques fail, fertility specialists have a variety of other high-tech assisted reproductive techniques that promote conception without intercourse. Depending on your problem your physician may look to:

Intrauterine insemination (IUI): By placing sperm directly into the uterus via a catheter, IUI bypasses cervical mucous that may be hostile to the sperm and puts them close to the fallopian tubes where fertilization occurs. IUI is often successful in overcoming sperm count and movement problems, retrograde ejaculation, immunologic infertility and other causes of infertility.

In vitro fertilization (IVF): Refers to fertilization taking place outside the body in a laboratory Petri dish. There, the egg of a female partner or donor is joined with sperm. With IVF, the ovaries must be overly stimulated, usually with fertility drugs that allow retrieval of multiple mature eggs. After 48 to 72 hours of incubation, the fertilized egg (embryo) is inserted in the uterus and normal pregnancy should result. While IVF is employed mostly for women with obstructed fallopian tubes, it is occasionally used for men with oligospermia.

Intracytoplasmic sperm injection (ICSI): A variation of in vitro fertilization, this procedure has revolutionized treatment of severe male infertility, permitting couples previously thought infertile to conceive. It involves injecting a single sperm directly into the egg with a microscopic needle and then, once it is fertilized, transferring it to the female partner’s uterus. Your doctor is likely to use ICSI if you have very poor semen quality or lack of sperm in the semen caused by an obstruction or testicular failure. In some cases, sperm may be surgically extracted from the testis or epididymis for this procedure.

Frequently asked questions:

Q. What diseases can cause male factor infertility?
A. A variety of diseases — from kidney disease to testicular cancer — can result in male infertility. For instance, systemic conditions and metabolic disorders, along with ordinary fevers and infections, can impair the development of sperm. In addition, sexually transmitted diseases can lead to obstruction and scarring of the reproductive tract while genetic conditions, such as cystic fibrosis, may result in lack of sperm or due to missing vas deferens or seminal vesicles. Since any number of illnesses can be a factor, it is essential that both you and your partner know and share your family and personal medical histories with your doctor.

Q. Can the use of steroids for body building cause infertility?
A. Yes. Steroids taken either by mouth or injection can shut down the production of hormones needed for sperm production.

Q. Do abnormal semen analyses or sperm lead to children with birth defects?
A. Not necessarily. For the majority of couples seeking fertility treatment, the risk of conceiving a child with a birth defect is the same as the general population. Though, some disorders (especially genetic disorders) that cause infertility may also cause an increased risk of conceiving a child with birth defects. It is for this reason that couples need thorough evaluation and counselling prior to proceeding with some forms of assisted reproductive techniques.

Q. What is the most important thing I should remember about male infertility?
A. Neither you nor your partner should be blamed for any problems you have with fertility. The American Society of Reproductive Medicine (ASRM) estimates that roughly one-third of infertility cases can be attributed to male factors, with another one-third due to women. In the remaining one-third of infertile couples, infertility is caused by either a combination of factors, or, in 20 percent of cases, is still unexplained. (In men, few or no sperm is the biggest problem; in women, the common problems are ovulation disorders and blocked tubes.) But today, physicians have the technology and surgical tools to address many of those problems.

BPH-Prostate Enlargement

Benign prostatic hyperplasia ( BPH) is one of the most common diseases to affect men beyond middle age. It becomes more likely as men get older. Since the number of men reaching a mature age is increasing, so are the number of cases of BPH. Today, only 20% of patients with BPH receive surgery to treat their problem. The remainder are often managed by “Watchful Waiting.” The majority of these “watchful waiting” patients will require medication in the future as their condition worsens.
BPH is rarely life-threatening. The symptoms of BPH are: frequency (the need to urinate often), urgency (the need to urinate immediately), nocturia (night-time urination), and incomplete bladder emptying. These can be very bothersome. These symptoms occur slowly and serious health risks are uncommon. These often impact a patient’s quality of life.

Growth and development of the prostate is affected by the male hormone testosterone. BPH is usually a slowly developing condition. This is not, however, always accompanied by a worsening of symptoms. As BPH progresses, the normal prostatic tissue is compressed more and more by the surrounding tissue. This then pinches the urethra. The prostatic urethra becomes less flexible, causing progressive obstruction of urine flow. Patients complain of hesitancy and a reduced stream. If bladder emptying becomes too difficult, the patient may develop urinary retention (urine cannot drain from the bladder). This intense stretching and strain on the bladder may make recovery of bladder function difficult, if not impossible.

History and Symptom Assessment
BPH is characterized by many obstructive and irritating symptoms, often referred to as lower urinary tract symptoms (LUTS). Symptoms include:

Obstructive symptoms

      • Hesitancy (stop-and-go stream)
      • Weak stream
      • Straining to pass urine
      • Prolonged urination
      • Feeling of incomplete bladder emptying
      • cute urinary retention (urine is trapped in the bladder)

Irritative symptoms

      • Urgency
      • Frequency
      • Nocturia
      • Urge incontinence

 

Symptoms can be assessed by means of the IPSS, (International Prostate Symptoms Score) or the AUA (American Urologic Association) symptoms score index. The physical examination is done by a digital rectal examination (DRE) on patients with BPH. DRE provides useful information about the size, consistency, and limits of the prostate. An analysis of the urine is done, either by dipstick or microscopic examination. A serum creatinine ( blood test) is used to assess kidney function. All patients below 75 years of age should also have their Prostatic Specific Antigen (PSA) levels checked. These tests are useful in helping to identify patients with prostate cancer.

Treatment Options
Watchful Waiting
Patients with low symptom scores and a normal PSA and DRE can be considered for watchful waiting. These patients are seen on a yearly basis. Symptom scores are checked over time. Patients with increasing symptom scores will progress to other treatments.

Medical Therapy
Medical treatment of BPH should be regarded as an option in its own right, rather than as merely an interim measure in patients waiting for surgery. Drugs such as Cardura, Hytrin, and Flomax have all been shown to increase urine flow rates and improve symptoms in about 60% of patients with BPH within 4 weeks of treatment. These drugs work by relaxing the smooth muscle in the prostate. This reduces obstruction to urine flow without affecting the bladder’s ability to contract. These drugs are given once a day. Most patients start with a small dose, and gradually increase the dose to improve their symptoms. Side effects from these drugs are tiredness, dizziness, and headache, which occur in about 10% of patients. Decreased blood pressure occurs in only 2-5% of patients and this can be minimized by lowering the drug dosage.

Other drugs like Proscar act by shrinking the prostate. Proscar reduces the volume of the prostate by 20-30% in two-thirds of patients. This results in improvements in both symptoms score and flow rates, and usually takes about 3-6 months.

Surgical Management of BPH
Surgical treatment is usually indicated for patients who have complications of BPH, those who have symptoms that are not adequately controlled by medical therapy or who elect to forego an attempt at medication for more definitive treatment. These standard surgical operations are available:

      1. Transurethral resection of the prostate (TURP)
      2. Transurethral incision of the prostate (TUIP)
      3. Open prostatectomy

 

In general, surgical treatments produce the best improvement in urinary symptoms and urine flow. If compared with medical therapy, there are more complications with this type of treatment. About 95% of prostatectomies are currently carried out by the TURP procedure. With this procedure, a scope with a surgical loop is introduced through the urethra and chips of prostate tissue are cut and removed through the scope’s sheath. The operation can be performed under spinal, epidural or light general anesthesia. A catheter is left in place for 36-48 hours after surgery. Symptoms and urine flow rates are improved in about 70-90% of patients. Complications include infection, bleeding, incontinence, retrograde ejaculation, and erectile dysfunction, although these are rare.

Even though BPH is almost never life-threatening, its symptoms can have a significant effect on the patient’s well-being. There are many ways to treat BPH and with successful treatment, an improvement in the patient’s quality of life can be achieved.


Varicocele

A varicocele is a like ‘varicose veins’ of the small veins next to one or both testes. It usually causes no symptoms. It may cause discomfort in a small number of cases. Having a varicocele is thought to increase the chance of being infertile. Treatment is not usually needed as most men do not have any symptoms or problems caused by the varicocele. If required, an operation can clear a varicocele. However, if you are infertile, treatment of a varicocele is unlikely to cure the infertility.
What is a varicocele?
A varicocele is a collection of enlarged (dilated) veins (blood vessels) in the scrotum. It occurs next to and above one or both of the testes (testicles).

The affected veins are those that travel in the spermatic cord. The spermatic cord is like a ‘tube’ that goes from each testis up towards the lower abdomen. You can feel the spermatic cord above each testis in the upper part of the scrotum. The spermatic cord contains the vas deferens (the tube that carries sperm from the testes to the penis), blood vessels, lymphatic vessels, and nerves.

Normally, you cannot see or feel the veins in the spermatic cord that carry the blood from the testes.

If you have a varicocele, the veins become bigger (they enlarge or dilate) and this makes them more prominent. It is similar to varicose veins of the legs. The size of a varicocele can vary. A large varicocele is sometimes said to look and feel like ‘a bag of worms’ in the scrotum.

Who gets a varicocele?
Varicoceles are common. About 1 in 7 men develop a varicocele – usually between the ages of 15 and 25. In about half of cases the varicocele is on the left hand side. In just under half of cases there is one on both sides. In a small number of cases it is on the right side. The reason why most occur on the left side is because of the different route the left veins takes out of the scrotum compared to the right.

What are the symptoms?
Varicoceles are usually painless and usually cause no symptoms. Some men may notice a ‘dragging’ feeling or slight discomfort from their varicocele. This may only occur at the end of a day, especially if you are on your feet all day. The size of a varicocele varies from case to case. Some cannot be seen, only felt. Some are large and can be easily seen. If you lie down, the blood from the veins drains away and the varicocele may seem to disappear. On standing, gravity will cause the blood to pool again and the varicocele reappears.

Are varicoceles serious?
Usually not. In themselves they are usually harmless. Causes of concern include the following:

Possible cause of infertility
Studies have shown that there is a higher rate of infertility in men with a varicocele compared to those who did not have a varicocele. It is thought that the pooled blood causes a slightly higher temperature in the scrotum than normal. This may reduce the number and quality of sperm made by the testis which can reduce fertility. Even if you have a varicocele only on one side, both testes can be warmed by the increased amount of blood pooled in the enlarged veins.

However, most men with varicoceles are not infertile. It is just that the chance of being infertile is increased if you have a varicocele.

 

Small testis

The testis on the side of the varicocele may become smaller, or not develop as much as the other side. This may contribute to infertility too.
Sudden onset of a varicocele in an older man
Rarely, a varicocele is a symptom of a blockage of a larger vein in the abdomen (see below).

 

What causes varicoceles?

 In most cases, the reason why the veins become larger is because the valves of the small veins in the scrotum do not function well. At intervals along the veins are one-way valves. The valves open to allow blood to flow towards the heart, but close when blood tends to flow backwards.

If these valves do not work well, blood can flow backwards (due to gravity) and will pool in the lowest part of the vein to form a varicocele. (This is very similar to how varicose veins form in legs.)

It is not clear why the valves do not work well.

Rarely, a varicocele may develop if there is a blockage of larger veins higher in the abdomen. This puts back-pressure on the smaller veins in the scrotum which then enlarge. This is more likely to occur in older men.

For example, if a varicocele suddenly develops in an older man, it may indicate a tumour of the kidney has developed which is pressing on veins.

But it must be stressed, most varicoceles develop in young men and are not due to a serious condition.

What is the treatment for varicoceles?
No treatment is needed in most cases. If a varicocele is causing no symptoms, then it is best left alone.

If there is just mild discomfort then supportive underpants (rather than boxer shorts) may help to ease or prevent discomfort.

Treatment may be an advised if you have persistent discomfort. Treatment involves tying off the veins that are enlarged. Another method of treatment is to use a special substance injected into the veins to block them. Both methods are usually successful. Your surgeon will advise on the pros and cons of the different surgical techniques.

However, after successful treatment, some men have a recurrence of a varicocele months or years later. This is because the veins left behind to do the job of taking the blood from the testes may themselves enlarge or dilate with the extra blood they will now have to carry. A recurrence can be treated in the same way as the first time.

Is treatment for varicocele a possible cure for male infertility?
Probably not. Until recently, it was thought that treating a varicocele in an infertile man would increase the chance of becoming fertile again. Studies have shown that after treatment, the sperm count and quality often improve. This was assumed to increase the chance of fertility. Some studies did indicate that fertility may be increased with treatment.

However, a recent large analysis (meta-analysis) of studies looking at this issue found that there was no good evidence to say that fertility is increased by treatment. If you are infertile, your specialist will be able to advise on current research related to this issue.


Erectile Dysfunction

Impotence, which is more commonly now called erectile dysfunction (ED), is a very common problem with significant medial and psychosocial implications. It is estimated that almost 1 in 2 men between 40 and 70 years of age suffer from some degree of ED. This extrapolates to some 30 million men in the U.S. alone and 100 million men worldwide who have this problem. When complete ED is looked at–that is, the absolute inability to achieve penetration–5% of men at 40 years of age and 25% of men at 75 years of age suffer this degree of ED.
Men with ED often suffer from a loss of self-esteem and self-confidence, and it may have a huge detrimental impact upon their relationships, both physical and emotional. What is not well appreciated is the link between ED and other medical conditions. ED may be the first sign of other significant medical conditions such as diabetes, lumbar disc disease, multiple sclerosis, abdominal aortic aneurysm and potentially coronary artery disease (heart attack).

How do erections occur?
Erection is a hydraulic event. Simply stated, it involves the inflow of blood into the erectile body (corpus cavernosum) followed by entrapment of this blood. Paired cylinders that run on the dorsum of the penis (the corpora cavernosa) contain the pressurized blood and form the rigid structure of the erect penis. Each cylinder is composed of a tough outer lining (tunica albuginea) which surrounds a centrally located spongy network of muscle (corporal sinusoids). Blood flows into these cylinders and causes rigidity when it is trapped and high pressure develops. After ejaculation/orgasm the blood drains out of the cylinders through veins present between the erectile tissue and the tunica.

The key event in the development of an erection is relaxation of the smooth muscle inside the erectile cylinder. This event is primarily mediated by the chemical (neurotransmitter) nitric oxide (NO). Blood flows in to fill the relaxing muscle, the muscle mass expands and pressure increases typically reaching 200 (mm of mercury). Loss of rigidity is dependent upon the contraction of the muscle in the erectile bodies. As this muscle contracts, the size of the spaces shrink, allowing the drainage veins to open, which results in loss of rigidity. This process is under adrenaline control.

What causes ED?
Atherosclerotic disease (hardening of the arteries) is the cause of approximately 40% of ED in men older than 50 years. The effect of cigarette smoking on the prevalence of ED has been evaluated in a survey of 4,462 male military veterans. After adjusting for age, race, marital status, vascular disease, psychiatric disease, hormonal factors and substance abuse, the risk of ED in a smoker is approximately 1.5 that of a non-smoker. Results of the Massachusetts Male Aging Study showed that the incidence of ED in men with treated heart disease was 21% for those who did not smoke versus 56% for smokers with treated heart disease. This indicates that cigarette smoking may cause ED through its serious threats on cardiovascular health rather than its immediate pharmacological effects.

In patients with diabetes mellitus, irrespective of type, the prevalence of ED is approximately 50% (range 20-75%), the incidence depending on the patient’s age, duration of diabetes and severity of the disease. Chronic disease states associated with a high prevalence of ED include chronic renal (kidney) failure, hepatic (liver) failure, multiple sclerosis, Alzheimer’s disease, sleep apnea and chronic obstructive pulmonary disease (like emphysema). Endocrine disorders such as low testosterone levels, hyper-prolactinaemia, hypothyroidism and hyperthyroidism may also result in ED, but are the cause in only a small proportion of cases in the overall population. Pelvic trauma, pelvic surgery (radical prostatectomy, radical cystectomy or abdominoperineal resection), and radiation therapy to the pelvic area are associated with ED. This can result from nervous and/or vascular injury. Direct trauma to the perineum (bicycle straddle injury) can cause vascular inflow problems to the penis and may lead to ED that may be amenable to arterial revascularization. Many medications and drugs, including certain blood pressure medications, cold medications, hormones, antidepressants, tranquilizers, alcohol, tobacco, and other so-called recreational drugs, are associated with ED.

ED is commonly classified as psychological or organic (physical). Psychological erectile dysfunction, which is most prevalent in younger men (up to 70% of ED in men under 35 years of age) accounts for approximately 10% of ED in men older than 50 years of age. Psychogenic erection usually stems from anxiety and inappropriate release of adrenaline at the time of attempted intercourse. It is characterized by a sudden onset, intermittent problems and normal night-time and morning erections. It is the predominant type of dysfunction in younger males.

There is, however, a significant number of younger men with physically-based ED. Organic ED can result from abnormalities in blood flow, nerves, hormones or structural components of the penis. Vascular alterations involve diminished inflow or failure to halt outflow (venous leak). Nerve dysfunction can be secondary to disease of the peripheral nerves (diabetes), pharmacologic effects of drugs on the central nervous system (CNS), or surgical injury to nerves (radical prostatectomy, abdominoperineal resection or radiation therapy). Scarring of the smooth muscle itself (associated with diabetes mellitus, radiation and disuse) is under investigation as a potential factor of ED.

How is the patient with ED evaluated?
A careful patient interview and physical examination is important prior to commencing any form of ED therapy. Disease states, medications, trauma and prior surgeries should be noted.

Is there a history of any urologic problems? The patient’s development as a young man should be documented.

Was the onset of ED gradual or sudden?

Does the patient understand the important terms?

Does the patient have orgasmic dysfunction or premature ejaculation, versus ED?

Does he have nocturnal and morning erections?

Can he masturbate successfully?

Has he had painful or curved erections?

Is the patient in a stable relationship?

We commonly ask the patient to quantify his best erection in the last month (l00% rigid, 60% barely adequate for penetration, 40% engorged but too soft for penetration or 20% barely engorged).

A standardized questionnaire that is filled out by the patient prior to his appointment helps to gather this large amount of information. Patients with purely psychological ED should be identified and considered for counseling. Again, this diagnosis is made by the presence of normal nighttime and morning erections and normal masturbatory function. The absence of identifiable risk factors, however, does not exclude organic disease.

Precise definition of the cause of ED is possible with numerous vascular studies. These tests can identify patients with severe venous leak (who would be expected to fail drug therapy) or those with arterial blockages that can be bypassed. In the simplified approach to ED, this testing is reserved for young patients without risk factors, patients who fail to respond to therapy or patients with complicated histories or problems.

The most commonly used blood flow study is penile ultrasound. Another form of vascular test, known as DICC, is reserved for certain less common situations, especially in younger men and men with penile curvature. Other forms of vascular testing such as penile-brachial index (PBI) and plethysmography are now generally considered old-fashioned, are less accurate and have, therefore, fallen out of use.

Other forms of testing can be used to evaluate the psychological aspects of ED. The most commonly used one is called nocturnal penile tumescence testing (NPT). Done in the privacy of a patient’s own bedroom, it is a small computer box with rings attached to it that are placed around the penis. The device is used to measure nighttime erections (number, hardness and duration). Further tests can be used to assess the neurological nature of a man’s ED. In summary, the majority of men require little or no investigation. Certain groups of men with ED benefit from the aforementioned testing and therefore each patient is assessed individually and the decision regarding testing is made on a case-by-case basis.

Is it safe for a man with ED to resume sex?
The safety of continuing or resuming sexual activity is sometimes questioned in the older male, specifically those with heart disease. In the past, sex was often considered an event that could trigger a heart attack (known medically as a myocardial infarction or MI). Older patients and their physicians are often reluctant to discuss resumed or continued sexual activity because of its “dangers.”

A recent study looked at 1,774 patients (Muller) who had suffered a heart attack and were looked at carefully. The risk of suffering a heart attack in the 2 hours following sexual activity compared to other times of the day was 2.5 times for healthy individuals, 2.1 times for those with a history of prior chest pain and 2.9 times for those with prior heart attack, the study found. Regular exercise was shown to have some protective effect.

The hourly risk of suffering an MI in general is 1 in a million for a 50-year-old non-smoking, non-diabetic male (information derived from the Framingham Heart Study). Given one episode of sex per week, it has been concluded that the annual risk of MI would be expected to increase from 1% to only 1.0l%.

In another recent study (Drory), 88 patients with known coronary artery disease underwent exercise stress tests as well as home cardiac (Holter) monitoring during sex. One third of the men had decreased coronary artery blood flow during sexual activity. All of those patients who experienced coronary blood flow reduction during sex had previously had an abnormal cardiac stress test. No patient who had a prior normal stress test developed a decrease in coronary blood flow during sex.

In summary, sexual activity carries a low risk for patients with a normal cardiac stress test. Not all patients with ED require stress testing, however. Indeed, asking a patient if he can briskly climb two flights of stairs is a reasonable substitute for most men. All patients seen in our clinic are asked this question. If they answer yes, they are deemed to have enough exercise reserve to be able to pursue exertional activity such as sexual relations.


Reflux

What is reflux?

In the normal urinary system, two kidneys filter the blood and produce urine, the waste liquid. The urine produced by the kidneys then drains down tubes called ureters (you-re-ters) and into the bladder. At the bottom end of each ureter, a one-way valve normally allows urine to drain easily into the bladder, but prevents urine from moving back up the ureter toward the kidney.

If the one-way valve leaks, urine from the bladder can go backwards up the ureters to the kidney during urination. This is called reflux.

Why does reflux cause urine infections?
It is not uncommon for bacteria (germs which can cause urine infection) to move up through the urine channel to the bladder. Normally, this bacteria is rinsed completely out of the bladder the next time a child urinates. However, in children who have reflux, the bacteria can follow the urine from the bladder backwards up toward the kidneys.

About 1 out of 20 girls will develop a urine infection. Only about 1 in 200 boys will develop a urine infection. One-third of children with urine infections have reflux.

How will I know if my child has reflux?
Children with urine infections need an examination and some testing. These include an ultrasound of the kidneys and bladder as well as a bladder x-ray called a voiding cystourethrogram (VCUG). This important test is performed by putting a catheter through the urine channel into the bladder. Liquid dye is put into the catheter to fill the bladder. When the bladder is filled, x-rays are taken while the child urinates. This is the only test that can show whether reflux is present. This test also helps us to know how severe the reflux is, which is important in determining how it should be managed.

Is reflux dangerous?
If a child has many urine infections, damage to the kidney can occur. However, with proper treatment, this is extremely rare.

How is reflux treated?
The best treatment for reflux depends on how severe the reflux is. Fortunately, most cases of reflux are mild. Eighty-five percent of children with mild reflux will eventually outgrow it. In the meantime, we prevent kidney infections by using a low dose of a safe antibiotic taken once a day.

How long will my child need antibiotics?
In order to prevent damage to the kidney, your child will need antibiotics as long as he or she has reflux. For some children this means taking the antibiotics for a couple of years. Other children will need antibiotics for more than 5 years.

Is it safe for my child to take antibiotics for such a long time?
The antibiotics we use in this situation are very safe and rarely cause side effects. Your child is much safer on the preventive antibiotics than off of the antibiotics and having urine infections.

How will I know when the reflux goes away?
A yearly bladder test called a nuclear voiding cystourethrogram (NVCUG) will tell us when your child grows out of the reflux. Because the reflux doesn’t go away all at once, your child will still need to take the antibiotics and we will repeat the test six months after the first test shows no reflux. If two bladder tests in a row show no reflux, your child can stop taking the antibiotics.

If the reflux goes away, will my child have any more urine infections?
Even though the reflux is gone, sometimes children who have outgrown reflux will still get a bladder infection. For this reason it is important to watch your child for urine infection.

Is surgery ever needed to treat reflux?
Most children will outgrow their reflux and need no surgery. In four situations, surgery may be needed:

      • If a child’s kidneys can’t be protected from infection by using preventive antibiotics.
      • If a child reaches puberty (the time when reflux should have disappeared) and the reflux is still present.
      • If a child will not take the preventive antibiotics.
      • If kidney damage appears despite the preventive antibiotics.

 

For most children, a daily dose of antibiotic, periodic urine checks and a yearly exam is all that is needed


Hydrocele

Hydrocele is the medical name used to describe a collection of fluid around the testicle in the scrotum (the sac beneath the penis).
What causes a hydrocele?
During pregnancy, the testicles in boy babies actually grow inside the abdominal cavity, not in the scrotum. Four months before birth, a tunnel formed by the smooth lining of the intestinal cavity, pushes down into the scrotum. Between 1 and 2 months before birth, the testicle moves down through this tunnel to be anchored in the scrotum. The tunnel should close after the testicles move through it.

In some boys, the tunnel doesn’t completely close. This can cause swelling because the fluid which cushions the intestines can drain into the scrotum. Sometimes the swelling can increase and decrease as a child strains or cries. If the tunnel is large enough to allow the intestines to move down toward the scrotum, the boy has a hernia. Hydroceles are more common in boys who are born prematurely.

If the hydrocele is small it is usually safe to watch it. Many of them will go away as the boy grows. If the hydrocele is large or if it is still present as a boy gets older it needs to be fixed.

How is a hydrocele treated?
The best treatment for a hydrocele is a surgery to close the tunnel draining into the scrotum. Even when we don’t see a hydrocele on the opposite side, 60 out of 100 boys will have an open tunnel on both sides. For that reason we recommend checking both sides at the same time.

How is the surgery done?
An incision is made in the groin. The tunnel is found inside the abdomen and then tied off so that no more fluid can drain to the scrotum. The muscles are tightened to prevent a hernia. The incisions are closed with stitches that dissolve. No stitches have to be removed after surgery.

Is the surgery safe?
Yes! Almost all boys with a hydrocele can have their surgery as an outpatient. This means that the child comes in to the outpatient surgery center in the morning, has the surgery and is ready to go home by early afternoon. This surgery is performed under general anesthesia. Local anesthesia would be terrifying to a child and it also would make the surgery very difficult. Loyola has well-trained pediatric anesthesiologists who have had special training in the care of children. They use continuous oxygen, heart and blood pressure monitoring to make sure that the anesthesia is safe.

Are there any possible complications with the surgery?
As with any medical treatment there are some potential complications with hydrocelectomy. In most cases the standard surgery is 98% successful in closing the hydrocele and having the testicle stay in the proper position. Infection and significant bleeding are very rare. It is theoretically possible that the testicle or the tubes going to the testicle could be injured during the surgery. However, this is extremely unlikely.

Is there anything I should watch for?
If your child has a hernia it is possible that the intestines could become trapped and twisted in the tunnel. If this should happen your son would probably have swelling and discoloration in the groin and scrotum. It may turn blue or dark brown or red. He would probably be fussy and would not want to eat. He may vomit or have diarrhea and he may have a fever. This could be a strangled hernia, an emergency. If he has swelling in the groin with the color change and any of the other signs listed above call Dr. Hatch or Dr. Lindgren immediately through the hospital operator at 708/216-9000 or come to the emergency room.

Is there anything I can do to prepare my child for surgery?
Infants do very well with surgery. Children who are old enough to talk are sometimes anxious if they don’t know what will happen to them. You can ease this fear by talking about the upcoming surgery. Many local libraries have books or video tapes about going to the hospital or doctor’s office. We also have a video tape which can explain the Outpatient Surgery Center to children. Children are often fearful of an unfamiliar environment. It may help to bring a favorite toy or blanket on the day of surgery.

Like children, parents also are sometimes anxious about the unknown. Don’t hesitate to ask questions. We want you to have all of the information you need about your child’s care. It may help to write down questions as you think about them. Bring them with you to your child’s appointment and we will be happy to answer them.


Hypospadias

Hypospadias is the medical name used to describe a urine channel which ends under the tip of the penis. During pregnancy, the urine channel starts developing as a groove between two ridges. The ridges grow and fuse together on the under side of the penis to make a tube. This tube closes from behind the scrotum (the sac holding the testicles) out to the tip of the penis. As it forms, the tube leaves a little line on the skin which you can see on the scrotum and the penis. If the closing over of the tube stops before it reaches the end of the penis, hypospadias results.
What causes hypospadias?

No one knows exactly what causes hypospadias, but we do know that it is not caused by anything either parent did during or before the pregnancy. Hypospadias can occur in some family lines. However, in most cases, it is not inherited.

How is hypospadias treated?

If the urine channel almost reached the end of the penis, we can usually move the opening out to the tip without actually making the channel longer.

If there is more than 1/4 inch between the end of the urine channel and the tip of the penis, or if the penis is curved or bent downward (a condition called chordee) the urine channel will need to be lengthened. This can be done surgically by using some of the foreskin, some of the skin on the underside of the penis or skin from another area.

Are there any complications with this surgery?

There are potential complications with any medical treatment. In hypospadias surgery the most common complications are:Fistula and Stricture

Fistula is a leak point between the new urine channel and the skin of the penis. This would usually show up one to six weeks following surgery. The chance of a fistula depends on the type of surgery used. If a fistula develops a second, shorter surgery may be necessary. In the most severe case, a fistula could result in the opening up of the entire urine channel. Fortunately, this is very rare.

Stricture is a tight spot somewhere along the urine channel. This most often occurs at the tip of the penis or at the beginning of the new urine channel. The chance of a stricture developing depends on the type of surgery used. If a stricture develops a second, shorter surgery may be necessary.

Other less common complications could occur such as infection, bleeding, or skin rash.

Is the surgery safe?

Yes! Almost all boys with hypospadias can have their surgery as an outpatient. This means that the child comes in to the outpatient surgery center in the morning, has the surgery and is ready to go home by early afternoon. This surgery is performed under general anesthesia. Local anesthesia would be terrifying to a child and it also would make the surgery very difficult. Loyola has well-trained pediatric anesthesiologists who have had special training in the care of children. They use continuous oxygen, heart and blood pressure monitoring to make sure that the anesthesia is safe.

Is there anything I can do to prepare my child for surgery?

Infants do very well with surgery. Children who are old enough to talk are sometimes anxious if they don’t know what will happen to them. You can ease this fear by talking about the upcoming surgery. Many local libraries have books or video tapes about going to the hospital or doctor’s office. We also have a video tape which can explain the Outpatient Surgery Center to children. Children are often fearful of an unfamiliar environment. It may help to bring a favorite toy or blanket on the day of surgery.

Like children, parents also are sometimes anxious about the unknown. Don’t hesitate to ask questions. We want you to have all of the information you need about your child’s care. It may help to write down questions as you think about them. Bring them with you to your child’s appointment and we will be happy to answer them.


Circumcision

Circumcision is the medical term used to describe the surgical removal of the foreskin. In infants, circumcision can be done in the clinic with local anesthesia. However, after a child reaches age three months we prefer to do a circumcision in the operating room under general anesthesia. Using local anesthesia and performing the circumcision on infants older than three months can be frightening for the child.
How is the surgery done?
The foreskin has two sides, the inside skin and the outside skin. When a circumcision is done in the operation room it is performed by making a circular incision in the outside skin and a second one in the inside skin. The foreskin is then removed and the two skin edges are sewn together with stitches that dissolve. No stitches have to be removed after surgery. When a circumcision is done on a newborn it is usually done without using stitches.

Is the surgery safe?
Yes! Almost all boys can have their circumcision as an outpatient. This means that the child comes in to the outpatient surgery center, has the surgery and is ready to go home within about three hours. Emirates Hospital has well-trained pediatric anesthesiologists who have had special training in the care of children. They use continuous oxygen, heart and blood pressure monitoring to make sure that the anesthesia is safe.

Are there any possible complications with the surgery?
There are very few complications with a circumcision. The most common complication is bleeding, but this occurs in only one out of two hundred boys who have a circumcision. This bleeding might require some pressure on the site of bleeding or, rarely, a stitch. However, this is extremely unlikely. Infection or revision also are extremely rare.

Is there anything I can do to prepare my child for surgery?
Infants do very well with surgery. Children who are old enough to talk are sometimes anxious if they don’t know what will happen to them. You can ease this fear by talking about the upcoming surgery. Many local libraries have books or video tapes about going to the hospital or doctor’s office. We also have a video tape which can explain the Outpatient Surgery Center to children. Children are often fearful of an unfamiliar environment. It may help to bring a favorite toy or blanket on the day of surgery.

Like children, parents also are sometimes anxious about the unknown. Don’t hesitate to ask questions. We want you to have all of the information you need about your child’s care. It may help to write down questions as you think about them. Bring them with you to your child’s appointment and we will be happy to answer them.


Kidney Stones

What are they?

Kidney stones are crystals that form in the kidneys or small tubes that drain the urine from the kidney to the bladder. These tubes are called the ureters. The stones are often composed of salts and of calcium, but can be formed of other substances including uric acid and cystine.

Who gets them?
Kidney stones are more common in men than in women usually beginning in the 40′s or 50′s. They are also more common in Caucasians than in African Americans.

There are numerous reasons why people can form kidney stones. The most common reason is a failure to drink adequate amounts of fluids. Stones are more common in the warm weather months and in warm weather climates because people generally are more dehydrated due to excess fluid losses secondary to sweating. Other factors can contribute to stone formation including certain dietary excesses. As a general rule, it is fine for most people that form stones to drink milk and to eat other products that contain calcium. Patients who form kidney stones should not avoid calcium products unless specifically advised by their doctor.

Certain patients have metabolic disorders that lead to the formation of kidney stones. These disorders can usually be identified using a combination of blood and urine tests. In addition, certain stones are caused by infection with specific types of bacteria. Again, your doctor can identify if you are at risk for forming these types of stones.

What are the typical symptoms of kidney stones?
Pain. The pain is usually felt in the back on one side or the other. The pain will sometimes radiate around into the front of the abdomen down towards the groin region. Then the pain can sometimes be felt in the testicle or scrotum in men and in the vaginal area in women. Many patients with kidney stones will pass visible blood in their urine. Often times, however, the blood is only microscopic and thus it would require a laboratory test to show its presence. There are many other causes of blood in the urine besides kidney stones. We recommend that anyone with blood in the urine be evaluated by a physician.

Other symptoms. Symptoms of kidney stones can include nausea and vomiting. This is usually associated with the back or side pain. The pain typically comes and goes, meaning that it will start out relatively mild and become quite severe and then decrease in severity again. Sometimes in between attacks the pain will disappear completely. Other symptoms can include fever, particularly if the stone is blocking the flow of urine from the kidney and there is infection present. Frequency of urination or discomfort with urination can also be a symptom of kidney stones.

What are the treatment options?
Watchful waiting
Most stones that patients form will pass on their own. It is usually recommended that patients consume large amounts of fluids, at least two quarts per day. Water is recommended as the primary fluid. If patients are on any type of fluid restriction because of heart problems or high blood pressure, they certainly should consult with their physician before substantially increasing their fluid intake. With adequate fluid intake, more than 70% of stones will pass spontaneously. Oral pain medications usually are necessary. It is recommended that you contact your physician if you think that you may be experiencing a kidney stone. The most important criteria to determine if a stone will pass is the size of the stone. This can be determined most accurately by x-ray studies including an IVP, CT scan or ultrasound.

Extra corporeal Shock Wave Lithotripsy (ESWL)
ESWL is a noninvasive treatment for kidney stones. It involves using shock waves that travel through the skin and are focused on the kidney stone. The shock waves cause the stones to break up into small pieces that are then passed by the patient. The older ESWL machines involved placing the patient into a bathtub of water to aid in breaking up the stones. The newer machines, including the one here at Emirates Hospital, do not require placement of the patient into a tub of water. The primary advantage of ESWL is that it is noninvasive. It can usually be done with only intravenous sedation and does not always require general anesthesia. It is not always effective in large stones or stones in certain locations within the kidney. Also, some stones are simply too hard for ESWL and require a more invasive treatment.

Ureteroscopy
Ureteroscopy involves passing a small telescope into the bladder via the urethra and then up the ureter tube to the kidney. It is primarily used for stones that are lodged in the ureter tube, but with the development of flexible instruments can now be done any where in the ureter tube or in the kidney. Through the small telescopes the urologist is able to pass small instruments such as a laser to disintegrate the stone or basket-like devices to remove the stone. This procedure usually requires either general or spinal anesthesia. Although it is more invasive than ESWL, it can have higher success rates, particularly when treating stones in the ureter tube.

Percutaneous Kidney Surgery
Certain stones that are very large and exceed greater than one inch or those that fail to respond to the treatments listed above sometimes require a percutaneous treatment. This literally means through the skin, and involves passing a tube through the patient’s back and directly into the kidney. This then allows passage of instruments directly into the kidney. These instruments can be used to fragment the stone into smaller pieces and then remove the fragments. This treatment is one of the more invasive treatments for kidney stones and is performed relatively infrequently compared to the other treatments.

Open Surgery
On rare occasions open surgery is still recommended for kidney stones. This involves making an incision on the abdominal wall then freeing up either the kidney or the ureter tube, opening that area, and removing the stone. This is clearly the most invasive treatment for kidney stones and is seldom required with the advent of less invasive techniques.

If you have a kidney stone, or think that you might, you should see a urologist. He or she can then determine the proper evaluation and recommend the best treatment for your specific situation. Emirates Hospital offers the best Kidney Stone Treatment Dubai. Our specialists know exactly what to do, so you need not worry about anything. Your problem of Kidney Stone will be gone for good after getting the most top notch treatment for it from us.


Urodynamic Testing

Children with spina bifida or other neurologic abnormalities often have problems with the urinary system. Some patients have trouble controlling urination (incontinence). In some patients, the bladder is unable to empty when it is full. In other patients, the bladder can empty only partially. Besides causing urine leakage, bladder problems can also cause urine infections and potential kidney damage. In order to tell how well the urinary system works we use urodynamic testing.
Normally two kidneys filter the blood to produce urine. The urine drains down into the bladder where it is stored. The sphincter (control muscle) wraps around the urine channel and squeezes to hold the urine in the bladder. When the bladder is full, the sphincter relaxes to open the urine channel and the bladder muscle squeezes to empty the bladder.

In some patients these two muscles (the sphincter and the bladder emptying muscle) squeeze at the same time. This can cause dangerous pressure in the bladder. In some patients the bladder muscle cannot squeeze to empty the bladder. In order to tell how both of these muscles are working, we do three tests:

Uroflow – If a patient can urinate, we do this test to see how much urine comes out of the bladder and how fast the urine empties. The patient urinates into a special toilet to make the measurements. After the uroflow, a catheter is put into the urine channel to see if any urine is left in the bladder.

Urethral Pressure Profile – With the catheter in the urine channel we can measure how tightly the sphincter (the control muscle) can squeeze.

Cystometrogram (CMG) – A catheter with two openings is put into the bladder. Through one opening we can measure pressure. We can fill the bladder with sterile water through the other opening. A separate catheter is put into the rectum to help us measure pressure in the abdomen. While the catheter is in the bladder we measure how much the bladder holds and how hard the bladder muscle is squeezing. This helps us to know if the bladder fills easily and whether the bladder puts any strain on the kidneys.

Preparation for the Testing
Doing the urodynamic testing while a patient has a urine infection can be dangerous. If your child has cloudy or strong smelling urine or a fever, please call the nurses before the testing (04-349 6666) so that the urine can be checked and any infection can be treated before the urodynamics test.

On the day of the test it is helpful if your child drinks extra fluids about an hour before the test. This will help assure that the bladder is full for the first part of the test (the Uroflow).

Children are often nervous about medical tests. Sometimes they are nervous because they don’t know about the testing and how it is done. Sometimes they are afraid that a test will hurt. We will explain the testing ahead of time. Talking to your child about the test may help him/her to ask questions. Once the catheters are in place, the testing takes about 30 to 45 minutes. This can be boring for a child. It may help to bring some books, some music tapes or a videotape. Any activity which your child can to while sitting or lying would be fine.

During the Testing
You are welcome to stay with your child during the testing.

After the Testing
If your child can feel during urination, he/she will probably feel burning and stinging with urination for one to two days. Sometimes children’s pain medication (Tylenol, Motrin, etc.) can be helpful. You should use the dose recommended on the package no more often than every four hours. Sometimes sitting in warm water in the bathtub will help.

If your child has fever, pain in the abdomen, nausea, vomiting, cloudy or foul smelling urine, she/he may have a urine infection. Please call the your doctor if any of these symptoms occur.

Testing Results
Even though the testing is finished in an hour or two, analyzing the results will take a few days. You will be contacted by your physician with the results. Please ask questions about the testing and the results and be sure to make a follow-up appointment with your doctor for treatment that may be necessary depending on what the results show.


Undescended Testes

Cryptorchidism is the medical name used to describe a testicle that didn’t descend all the way into the scrotum (the sac beneath the penis).
During pregnancy, the testicles in boy babies actually grow inside the abdominal cavity, not in the scrotum. Four months before birth a tunnel formed by the smooth lining of the intestinal cavity pushes down into the scrotum. Between 1-2 months before birth the testicles move down through this tunnel to be anchored in the scrotum. The tunnel should close after the testicles move through. In some boys, the testicle doesn’t make the complete trip into the scrotum. It can stop in the abdomen or somewhere along the tunnel. When a testicle doesn’t make the complete trip three things result:

      • The tunnel doesn’t close, leaving a potential hernia.
      • The testicle has a higher chance of developing a tumor later in life.
      • The testicle is less likely to make sperm and male hormones normally.

 

Why don’t some testicles move all the way down?
No one knows exactly what causes an undescended testicle, but we do know that it is not caused by anything either parent did during or before the pregnancy. Cryptorchidism can occur in some family lines. However, in most cases, cryptorchidism is not inherited.

How is cryptorchidism treated?
The best treatment for cryptorchidism is a surgical procedure to bring the testicle into the scrotum. Some doctors have used hormone shots or hormone nasal sprays to try to bring the testicle into the scrotum. However, recent studies have shown that this is not successful in most patients.

How is the surgery done?
If the doctor can feel the testicle, an incision is made in the groin. The testicle is found inside the abdomen or in the tunnel and freed from the tissues which hold it out of the scrotum. A separate incision is then made in the scrotum. Anchoring stitches are placed to hold the testicle in the scrotum. Both incisions are closed with stitches that dissolve. No stitches have to be removed after surgery.

If your doctor cannot feel the testicle, he may decide to look into the abdomen with a telescope (laparoscopy) first to determine whether a testicle is actually present, and where it is located.

If your doctor cannot feel the testicle before surgery, there is a chance that there is no testicle on that side. This occurs in about 40 out of 100 boys when the testicle cannot be felt. If the doctor locates a testicle, he will then decide whether to make the incision in the groin or to bring the testicle down with laparoscopy surgery.

Is the surgery safe?
Yes! Almost all boys with an undescended testicle can have their surgery as an outpatient. This means that the child comes in to the outpatient surgery center in the morning, has the surgery and is ready to go home by early afternoon. This surgery is performed under general anesthesia. Local anesthesia would be terrifying to a child and it also would make the surgery very difficult. Loyola has well-trained pediatric anesthesiologists who have had special training in the care of children. They use continuous oxygen, heart and blood pressure monitoring to make sure that the anesthesia is safe.

Are there any possible complications with the surgery?
As with any medical treatment there are some potential complications with orchiopexy, the surgery to bring the testicle into the scrotum. In most cases the standard surgery is 98% successful in bringing the testicle down and having it stay healthy and in the proper position. However, in rare cases the testicle could move up as a child grows. Infection and significant bleeding are very rare. In unusual cases the testicle may not survive the trip into the scrotum.

Is there anything I can do to prepare my child for surgery?
Infants do very well with surgery. Children who are old enough to talk are sometimes anxious if they don’t know what will happen to them. You can ease this fear by talking about the upcoming surgery. Many local libraries have books or video tapes about going to the hospital or doctor’s office. We also have a video tape which can explain the Outpatient Surgery Center to children. Children are often fearful of an unfamiliar environment. It may help to bring a favorite toy or blanket on the day of surgery.

Like children, parents also are sometimes anxious about the unknown. Don’t hesitate to ask questions. We want you to have all of the information you need about your child’s care. It may help to write down questions as you think about them. Bring them with you to your child’s appointment and we will be happy to answer them.


Hydronephrosis

Hydronephrosis literally means water inside the kidney. It is usually used to describe a kidney with more than the usual amount of urine inside. In the normal urinary system, two kidneys filter the blood to produce urine which drains through a funnel system within the kidney called the pelvis. Urine then drains into the ureter (you-re-ter), the tube which connects the kidney to the bladder. A one-way valve at the bottom of the ureter allows urine to pass into the bladder, but blocks any urine from going backwards up the ureter to the kidney. The bladder stores urine until it is drained through the urethra, or urine channel, outside the body.
What causes hydronephrosis?
Sometimes the funnel system of a kidney is enlarged, but it functions normally. In this case, medications or surgical treatment may not be necessary.

Hydronephrosis can also be caused by a blockage in the urine system. The most common site of blockage which causes hydronephrosis is the connection between the pelvis, the funnel system of the kidney, and the ureter (the tube which drains down to the bladder). This is called a ureteropelvic junction obstruction or UPJ for short.

The second most common place for a blockage to occur is where the ureter meets the bladder (the ureterovesical junction or UVJ for short). The blockage is usually only partial and it allows urine to drain through an enlarged ureter called a megaureter. However, the urine doesn’t drain at a normal rate.

Children with either a ureteropelvic junction obstruction or a ureterovesical junction obstruction have a higher chance of having urine infections and kidney stones.

The third possible blockage occurs only in boys. Sometimes early in pregnancy, during development of the baby, small flaps of tissue can cause a narrowing of the urine channel just past the bladder. These flaps, called posterior urethral valves, make it difficult for the baby’s bladder to empty. Sometimes the bladder muscle becomes thicker as it works harder and harder to empty the urine from the bladder. Eventually, this can cause urine to back up to the kidneys and cause hydronephrosis in one or both kidneys.

Hydronephrosis can also result when a kidney doesn’t grow properly. Sometimes, very early in development, the ureter doesn’t form a channel for urine flow. This results in large cysts forming where the kidney should grow. This is called a multicystic kidney. These kidneys almost never make urine after a baby is born and they usually shrink and disappear.

We usually just watch multicystic kidneys by getting an occasional ultrasound exam. Multicystic kidneys rarely need surgery.

Hydronephrosis is not always caused by a blockage. If the one-way valves at the bottom of each ureter don’t work properly, urine can leak backwards from the bladder up to the kidneys when the bladder emptying muscle squeezes to drain the urine. This is called reflux.

What testing is necessary for children with hydronephrosis?
Many times, hydronephrosis is found in a developing baby when a woman has an ultrasound during her pregnancy. It’s important to remember that ultrasounds of babies performed before birth are only about 80% accurate. For that reason the ultrasound is usually repeated. In some cases, repeating the ultrasound during pregnancy is the only test necessary.

During pregnancy, the liquid which cushions the baby inside the uterus (called amniotic fluid) is actually urine which comes from the baby’s bladder. Very rarely, a serious blockage of urine drainage from the bladder occurs. This fluid is necessary for normal development of the baby’s lungs because it provides a cushion around the baby’s chest and it also helps to develop the lung tissue. If a baby’s urine cannot pass through the urine channel out into the space within the uterus, the lungs cannot develop normally. In very rare and severe cases, the problem can make it impossible for a baby to survive after birth. Fortunately, this is rare.

In all babies with hydronephrosis, we use the ultrasound exam to see how much amniotic fluid is present around the baby. Even if both kidneys are enlarged, if there is normal fluid around the baby, treatment is rarely necessary before birth.

What can I expect after my baby’s birth?
After your baby is born, we’ll repeat the ultrasound if hydronephrosis was found during pregnancy. In 1 baby out of 5, the ultrasound after birth is different from the ultrasound taken before birth. It may be necessary to repeat the ultrasound several days or weeks after the first one.

Two other tests may also be necessary. A voiding cystourethrogram (VCUG) is done by placing a catheter in the baby’s urine channel and filling the bladder with liquid dye while taking x-rays. This test is necessary in order to tell whether reflux is present and whether the urine channel is normal. This test will usually be performed before your baby leaves the hospital.

Sometimes a renal scan is needed. This test is done by injecting fluid into a vein. The fluid is filtered by the kidneys and its passage through the kidneys and bladder can be watched on a nuclear medicine camera. We usually wait until the baby reaches at least 4 weeks of age to perform this test because the baby’s kidneys are developing in important ways during this period of time. If the renal scan is obtained before four weeks of age, the results may not be accurate. The renal scan can tell us how well each kidney filters and drains.

Once the testing is completed, decisions and recommendations about treatment are made. Some children will need surgery to allow the kidneys to drain better and to relieve blockage or to stop reflux. In children who have very mild hydronephrosis, we usually recommend repeating an ultrasound every few months for the first 2 years. In other children with hydronephrosis, it may be difficult to tell whether the hydronephrosis is a result of blockage or simple enlargement. In this case, we may recommend repeated ultrasounds or renal scans. It’s important to remember that each child is unique and there is no one single plan for evaluation and treatment that is right for all children.

When parents hear about abnormalities seen on ultrasound either before or after the birth of their child, they can be anxious. Sometimes, it’s easy to feel nervous about a problem if you don’t understand it very well. Please ask questions. We are happy to give you the answers we have. You may think of questions at home before or after a clinic visit. Write those questions down so that you can ask them when you come to the clinic.


Meatal stenosis

Meatal stenosis (mee-ay-tal) is the medical term used to describe a narrowing at the end of the urine channel on the tip of the penis. No one knows for certain what causes meatal stenosis. Some urologists feel that irritation of the penis from urine in a baby’s diaper can cause inflammation, which makes the skin edges stick together, narrowing the urine channel. Meatotomy (mee-ay-taw-toe-mee) is the name of the surgery, which opens the urine channel.
Is meatal stenosis dangerous?
Most boys who have meatal stenosis have some narrowing of the urine stream. It may be hard to direct the stream or it may come out of the penis at an angle. Some boys with meatal stenosis have a small amount of blood at the end of the urine stream. This can appear on a diaper or underwear. Rarely, boys with meatal stenosis may have urine infections.

If it isn’t dangerous, why should my son have surgery?
Although most boys with meatal stenosis have relatively minor problems, as they grow, these boys usually notice more symptoms. A young boy with a narrowed urinary stream will have more difficulty urinating as he gets larger and produces more urine. It is best to take care of the problem before the symptoms get worse.

How is the surgery done?
The surgery is usually performed in the outpatient clinic with local anesthetic. A special cream is applied to the end of the penis and covered with a membrane dressing that looks something like Saran Wrap. About 20 minutes later the penis is numb. Occasionally the procedure is done in the operating room under a brief general anesthesia.

A small slit is made in the web of skin covering the urine channel. Sometimes we place three small stitches to keep the skin edges together. These stitches dissolve so they don’t need to be removed.

Are there any possible complications with the surgery?
There are very few complications with a meatotomy. The most common complication is a return of the narrowing at the tip of the urine channel. We try to avoid this by having parents separate the skin edges and put some antibiotic ointment into the urine channel twice a day for two weeks. This helps keep the urine channel open.

How is the surgery scheduled?
If the surgery is to be performed in the outpatient clinic, you can make the appointment directly with the clinic. Please mention to the assistant that you wish to schedule a clinic meatotomy (procedure).

If it is decided that the surgery is to be performed in the outpatient surgery center you should receive a phone call from our secretary after your child is evaluated in the office. If you don’t hear from her, please call her at 04-349 6666.

Is there anything I can do to prepare my child for surgery?
Infants do very well with surgery. Children who are old enough to talk are sometimes anxious if they don’t know what will happen to them. You can ease this fear by talking about the upcoming surgery. Many local libraries have books or video tapes about going to the hospital or doctor’s office. We also have a video tape which can explain the Outpatient Surgery Center to children. Children are often fearful of an unfamiliar environment. It may help to bring a favorite toy or blanket on the day of surgery.

Like children, parents also are sometimes anxious about the unknown. Don’t hesitate to ask questions. We want you to have all of the information you need about your child’s care. It may help to write down questions as you think about them. Bring them with you to your child’s appointment and we will be happy to answer them.


Enuresis

What is Enuresis?

Enuresis (N-you-REE-sis) refers to the involuntary loss of urine beyond the age of expected toilet training. When it occurs during the daytime it is called diurnal (DYE-urn-al) enuresis; when it occurs during the night it is nocturnal (NOCK-turn-al) enuresis. Some children have only one or the other, while other children have both diurnal and nocturnal enuresis. Another word that is sometimes used to describe urinary leakage is incontinence.

Who gets enuresis?
Approximately 15% of children still experience wetting at the age of 5. Of those who wet, it will go away in about 15% each year even without treatment. This means that by age 15 there are still about 1-2% of children who experience wetting on a regular basis. Evaluation by a doctor is aimed at identifying any factors which are causing the wetting which could put a child at risk for further problems (like urinary tract infections or kidney injury) as well as shortening the time period until the wetting resolves on its own.

Nocturnal enuresis which occurs without any daytime urination symptoms [such as urinating frequently or the sudden need to get to the bathroom quickly (urgency)] is especially common if one or more family members (Mom, Dad, uncle, aunt, brother or sister) experienced nocturnal enuresis as a child.

Why does enuresis occur?
Enuresis occurs for a number of reasons. In some situations an exact cause can be found, such as when the ureter (the tube which carries the urine from the kidney to the bladder) attaches in the wrong place. This, however, is a rather infrequent cause of enuresis. Often times we do not know the exact reason that wetting occurs. There are many theories that have been proposed as causes for wetting, particularly in patients with nocturnal enuresis. Some possible causes relate to the amount of urine produced during the night, sleep patterns and their relationship to bladder filling and emptying, or the bladder being “too small” for the patient’s age.

When it starts rather suddenly in a child who previously has had no problems with wetting, enuresis can be the first sign of a urinary tract infection. This deserves prompt investigation by his or her primary doctor.

Children who have had numerous infections may have a bladder that is “small” for their age, or is more sensitive to filling, and thus experience urinary frequency and/ or urgency. This may cause them to not be able to get to the bathroom in time before they wet. Other children void so infrequently that their bladder gets over-filled (the “I’m too busy to go” syndrome!). Once they finally get the urge to go it may be too late to get to the bathroom in time. They also may not empty the bladder completely because it is too “stretched out” to squeeze efficiently. Constipation may also play a significant role in both enuresis and urinary tract infections.

Is enuresis harmful?
When enuresis occurs without any anatomical problems in the urinary tract and without any urinary tract infections, it is not necessarily “harmful.” As mentioned above, however, enuresis could be a signal of other problems with the urinary tract. Even if there is not a specific problem, however, one must also consider the effect that wetting may have on a child’s self esteem, his or her relationship with peers (is he or she being teased at school? unable to go to sleepovers?), and on the family dynamics.

Enuresis which occurs in conjunction with an anatomical problem or with urinary tract infections deserves a thorough investigation because, if left untreated, it could lead to further damage to the kidneys, bladder, or other organs.

What can I do to help my child stop wetting?
There are a number of steps to take to help your child. First, talk with your child honestly, and find out whether it is bothering him or her. (Until he or she admits that it’s a problem or a bother, it’s hard to get him or her to do what you suggest, not matter how good your intentions.)

Positive reinforcement and rewards are always a great first step. Try making a calendar or chart, then reward your child with a sticker or other prize when he or she has a dry night. Set realistic goals, then reward your child with a larger prize when he or she reaches that goal (such as a new toy for 5 dry nights in a row, etc.).

If the problem occurs only during the night, be sure you limit the amount of fluid your child gets for 1-2 hours before bedtime. Also, be sure he or she goes to the bathroom right before bed. If your child is still wetting the bed, the next step is probably to wake your child once during the night to go to the bathroom.

If your child only goes to the bathroom 2 or 3 times a day, that’s not enough. You can help by reminding your child to void every 2 – 3 hours, and also talk with his or her teacher so that your child is reminded to void on a regular schedule at school.

It’s also important to pay attention to your child’s bowel habits and be sure he or she is not constipated.

What if that doesn’t work?
If this isn’t working, it’s probably time to talk with his or her primary doctor about things, or see a pediatric urologist. This is especially important if your child has had a urinary tract infection. The doctor will then determine if any further tests are needed, such as ultrasound studies or X-rays of the bladder to look for things like hydronephrosis or reflux. Some patients will benefit from medications to improve bladder or bowel control.

Another possible treatment is biofeedback. This is specialized therapy to re-train your child about the muscles involved in holding and emptying the urine. Our doctor has experience with biofeedback for children with wetting problems, and has the biofeedback program in the UAE for children with wetting problems, recurrent urinary tract infections, or reflux. During the biofeedback sessions stickers are placed on the skin (We don’t use any catheters or other invasive measures!) and children, using a computer “game,” are instructed in how to identify the muscles that are important for urinary control.

Enuresis can be a tremendous problem for children and their families. While it may be considered only a bother, it may also be a sign of other problems with the urinary tract. If things don’t get better with what you can try at home, your child should be seen by someone specialized in the evaluation and treatment of such problems. The good news is that there is help! You don’t have to just wait for your child to “outgrow it!”.


Prostate Cancer

What is the prostate?

      • A male sex gland
      • The size of a walnut below the bladder and in front of the rectum
      • Produces the fluid that is part of semen

 

What Goes Wrong?

      • Three main types of problems — infection, enlargement, and cancer — can afflict the prostate.
      1. Prostate infections, called prostatitis, are fairly common in men from the teen years on. These infections can be brief or long-lasting, mild or severe, easy or difficult to treat with antibiotics. Symptoms of prostatitis can include frequent and/or painful urination, other urinary difficulties, or pain during sex
      2. Prostate enlargement, called benign prostatic hyperplasia, or BPH for short, is an unwanted but non-cancerous enlargement of the prostate. Although men in their twenties can suffer from BPH, it usually surfaces later in life. It’s estimated that half of all men have BPH by the age of 60, and 90% will suffer from it by age 85
      3. Prostate cancer: Cells normally divide when new cells are needed. But sometimes cells divide for no reason, creating a mass of tissue called a tumor. Prostate cancer is a malignant tumor that usually begins in the outer part of the prostate. In most men, the cancer grows very slowly.

 

Risk Factors for Prostate Cancer
Age – Found mainly in men over age 55. Average age of diagnosis is 70
Family History – Men’s risk is higher if father or brother is diagnosed before the age of 60
Race – Prostate cancer is found more often in African American men then White men. It is less common in Asian and American Indian men
Dietary factors – Evidence suggests that a diet high in fat may increase the risk of prostate cancer and diets high in fruits and vegetables decrease the risk

Recommendations for Screening

      • The prostate-specific antigen (PSA) blood test and the digital rectal exam (DRE) should begin at the age of 50
      • African Americans and men who have first degree relatives diagnosed before the age of 60 should start at 45 years old

 

      • Screening for Prostate Cancer
      •  Prostate-Specific Antigen Blood Test (PSA) – Measures substance made by the prostate gland
      • Digital Rectal Exam (DRE) – Physical exam of the Prostate Gland
      • Transrectal Ultrasound (TRUS) –Uses sound waves to make an image of the prostate on a video screen

 

Test Results

      • PSA levels under 4 ng/ml are considered normal, Just to be safe, if your level is 3 ng/ml or higher, or the level increases from one test to the other you should discuss the results with your physician.
      • After a DRE your doctor will discuss the test results with you. If they detect a suspicious lump or area during the exam, an ultrasound or biopsy may be recommended.
      • If any results come back abnormal, or you do not understand them contact your urologist for further information.

 

Symptoms of Prostate Cancer

      • Frequent urination
      • Inability to urinate
      • Trouble starting and stopping urination
      • Blood in the urine or semen
      • Painful ejaculation
      • Painful or burning urination

 

Diagnosis of Prostate Cancer

      • Confirmed only by an biopsy taken from part of the prostate
      • Pathologists then grade the biopsy to give likely hood of cancerous tissue
      • Then pathologists can tell what stage the cancer is in, 4 stages in all

 

Procedures for Prostate Cancer

      • Radical Prostatectomy – Removal of entire prostate gland and nerves
      • Radiation Therapy – High-energy rays to kill or shrink cancer cells
      • Expectant Therapy – Regularly scheduled screenings
      • Transurethral Resection of the Prostate – Partial removal of tissue from the prostate
      • Brachytherapy – confined dosage of radioactive seeds inserted directly into the prostate while minimizing healthy tissue damage
      • Cryosurgery – freezes abnormal cells of the prostate with a metal probe
      • Hormone Therapy – Decreases the androgen (testosterone) levels in the body
      • Chemotherapy – Anticancer drugs injected into a vein or taken by mouth

 

Side Effects of Treatments

      • Impotence – Could last for 3 months or longer
      • Incontinence – Loss of bladder control or dribbling
      • Bowel problems – Burning and rectal pain and/or diarrhea

 

Risk for Developing Prostate Cancer

Global Incidence

Global Mortality

What’s the Outlook
While the number of men diagnosed with prostate cancer remains high, survival rates are also improving. Almost 89% of men diagnosed with the disease will survive at least five years, while 63% will survive 10 years or longer. The increased number of treatment options make this possible


Urinary Tract Infection (UTI)

What causes a urine infection?

Urine infections occur when microorganisms, usually bacteria, enter the urinary tract and remain long enough to cause inflammation and other problems. It is thought that almost all urine infections are caused by bacteria entering the urine channel (the urethra [you-ree-thrah]) and moving up into the bladder. Sometimes urine infections can move up the tubes that drain the kidneys to the bladder (the ureters [you-ruh-ters]) to cause a kidney infection.

How common are urine infections?
Urine infections occur in about 1/20 school age girls, but less than 1/100 school age boys. Urine infections can occur in infants and they are more common in infant boys than in infant girls.

How would I know if my child has a urine infection?
The symptoms usually associated with a urine infection depend on the age of the child. Infants and very young children may have fever, fussiness, decreased activity, decreased appetite or just a general change in behavior. Of course, these same symptoms could be caused by an ear infection, a viral illness or other diseases. That’s why an infant with any of the above symptoms should be tested to see if a urine infection or any other type of infection is present. Older children may have pain with urination, loss of urine control (wetting), pain in the lower abdomen, fever or pain in the side of the back. Sometimes a urine infection will cause blood to appear in the urine. Sometimes children with urine infection pass urine that smells bad.

What should I do if I think my child has a urine infection?
You should call your child’s doctor to have your child examined and to have his/her urine tested.

How are urine infections treated?
Most urine infections can be treated at home with antibiotics taken by mouth. If your child’s doctor prescribes antibiotics it is very important that your child takes the antibiotics exactly as instructed. That is the best way to make sure the infection is completely treated. Occasionally, a child with a severe urine infection may need to be admitted to the hospital for antibiotics given through an intravenous line.

Are urine infections dangerous?
That depends on how severe the infection is an where it is located in the urinary tract. An single infection that is present only in the bladder may cause pain and difficulty controlling the urine, but it would rarely cause any long lasting damage. A severe kidney infection, however, may cause enough inflammation to cause part of the kidney to be scarred. Children who have suffered many kidney infections can suffer enough kidney damage to cause high blood pressure and even loss of kidney function. Fortunately, that rarely occurs.

Will the infection come back?
About 1/3 of children who have had a urine infection will develop another urine infection. That is why it is important to have your child evaluated by your doctor.

Why would a urine infection come back?
Several factors can make it easier for bacteria to enter the urinary tract and cause an infection. Irritation at or near the opening of the urine channel can interfere with the body’s natural defense system and allow bacteria to move into the bladder. If a child doesn’t empty his/her bladder completely at urination, infection is more likely to return. A child who empties his/her bladder infrequently may be at increased risk for a urine infection. Constipation can interfere with the normal function of the bladder. A partial blockage of the urine channel, the kidney or the ureters can also make infection more likely. Normally urine flows in one direction in the body: from the kidneys, down the ureters to the bladder and out of the bladder through the urine channel. About 1/3 of children who have urine infections are found to have backwards leakage of urine from the bladder up the ureter to the kidney. This is called reflux.

How can I protect my child from urine infections?
If your child has had a urine infection your doctor may recommend an evaluation to see if something can be done to decrease the risk of another infection. Your doctor may order an ultrasound exam of the kidneys and the bladder. This is done to detect any enlargement of the urine drainage system. Your doctor may also evaluate your child’s urination pattern (how frequently your child urinates and how much comes out each time). Your doctor may order a test to look for reflux (see above). This test is called a voiding cystourethrogram or VCUG and it is the only test that can detect reflux.

In general, making sure your child drinks plenty of fluids (there’s nothing better than water), has good personal cleanliness and urinates regularly are important ways to keep your child safe from urine infections. If your child has had urine infection, it is very important to follow your doctor’s plan for evaluating your child’s risk for getting another infection.


Uniary Tract Infection in Adults

Introduction

Urinary tract infections are a serious health problem affecting millions of people each year.

Infections of the urinary tract are common—only respiratory infections occur more often. In 1997, urinary tract infections (UTIs) accounted for about 8.3 million doctor visits.* Women are especially prone to UTIs for reasons that are poorly understood. One woman in five develops a UTI during her lifetime. UTIs in men are not so common, but they can be very serious when they do occur.

The urinary system consists of the kidneys, ureters, bladder, and urethra. The key elements in the system are the kidneys, a pair of purplish-brown organs located below the ribs toward the middle of the back. The kidneys remove excess liquid and wastes from the blood in the form of urine, keep a stable balance of salts and other substances in the blood, and produce a hormone that aids the formation of red blood cells. Narrow tubes called ureters carry urine from the kidneys to the bladder, a triangle-shaped chamber in the lower abdomen. Urine is stored in the bladder and emptied through the urethra.

The average adult passes about a quart and a half of urine each day. The amount of urine varies, depending on the fluids and foods a person consumes. The volume formed at night is about half that formed in the daytime.

What are the causes of UTI?
Normal urine is sterile. It contains fluids, salts, and waste products, but it is free of bacteria, viruses, and fungi. An infection occurs when microorganisms, usually bacteria from the digestive tract, cling to the opening of the urethra and begin to multiply. Most infections arise from one type of bacteria, Escherichia coli (E. coli), which normally lives in the colon.

In most cases, bacteria first begin growing in the urethra. An infection limited to the urethra is called urethritis. From there bacteria often move on to the bladder, causing a bladder infection (cystitis). If the infection is not treated promptly, bacteria may then go up the ureters to infect the kidneys (pyelonephritis).

Microorganisms called Chlamydia and Mycoplasma may also cause UTIs in both men and women, but these infections tend to remain limited to the urethra and reproductive system. Unlike E. coli, Chlamydia and Mycoplasma may be sexually transmitted, and infections require treatment of both partners.

The urinary system is structured in a way that helps ward off infection. The ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of urine from the bladder helps wash bacteria out of the body. In men, the prostate gland produces secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. But despite these safeguards, infections still occur.

Who is at risk?
Some people are more prone to getting a UTI than others. Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) sets the stage for an infection. An enlarged prostate gland also can slow the flow of urine, thus raising the risk of infection.

A common source of infection is catheters, or tubes, placed in the bladder. A person who cannot void or who is unconscious or critically ill often needs a catheter that stays in place for a long time. Some people, especially the elderly or those with nervous system disorders who lose bladder control, may need a catheter for life. Bacteria on the catheter can infect the bladder, so hospital staff take special care to keep the catheter sterile and remove it as soon as possible.

People with diabetes have a higher risk of a UTI because of changes in the immune system. Any disorder that suppresses the immune system raises the risk of a urinary infection.

UTIs may occur in infants who are born with abnormalities of the urinary tract, which sometimes need to be corrected with surgery. UTIs are rarely seen in boys and young men. In women, though, the rate of UTIs gradually increases with age. Scientists are not sure why women have more urinary infections than men. One factor may be that a woman’s urethra is short, allowing bacteria quick access to the bladder. Also, a woman’s urethral opening is near sources of bacteria from the anus and vagina. For many women, sexual intercourse seems to trigger an infection, although the reasons for this linkage are unclear.

According to several studies, women who use a diaphragm are more likely to develop a UTI than women who use other forms of birth control. Recently, researchers found that women whose partners use a condom with spermicidal foam also tend to have growth of E. coli bacteria in the vagina.

Recurrent Infections
Many women suffer from frequent UTIs. 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.

Usually, the latest infection stems from a strain or type of bacteria that is different from the infection before it, indicating a separate infection. (Even when several UTIs in a row are due to E. coli, slight differences in the bacteria indicate distinct infections.)

Research funded by the National Institutes of Health (NIH) suggests that one factor behind recurrent UTIs may be the ability of bacteria to attach to cells lining the urinary tract. A recent NIH-funded study found that bacteria formed a protective film on the inner lining of the bladder in mice. If a similar process can be demonstrated in humans, the discovery may lead to new treatments to prevent recurrent UTIs. Another line of research has indicated that women who are “non-secretors” of certain blood group antigens may be more prone to recurrent UTIs 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 UTIs.

Infections in Pregnancy
Pregnant women seem no more prone to UTIs than other women. However, when a UTI does occur, it is more likely to travel to the kidneys. According to some reports, 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.

What are the symptoms of UTI?
Not everyone with a UTI has symptoms, but most people get at least some. These may include a frequent urge to urinate and a painful, burning feeling in the area of the bladder or urethra during urination. It is not unusual to feel bad all over—tired, shaky, washed out—and to feel pain even when not urinating. Often women feel an uncomfortable pressure above the pubic bone, and some men experience a fullness in the rectum. It is common for a person with a urinary infection to complain that, despite the urge to urinate, only a small amount of urine is passed. The urine itself may look milky or cloudy, even reddish if blood is present. A fever may mean that the infection has reached the kidneys. Other symptoms of a kidney infection include pain in the back or side below the ribs, nausea, or vomiting.

In children, symptoms of a urinary infection may be overlooked or attributed to another disorder. A UTI should be considered when a child or infant seems irritable, is not eating normally, has an unexplained fever that does not go away, has incontinence or loose bowels, or is not thriving. The child should be seen by a doctor if there are any questions about these symptoms, especially a change in the child’s urinary pattern.

How is UTI diagnosed?
To find out whether you have a UTI, your doctor will test a sample of urine for pus and bacteria. You will be asked to give a “clean catch” urine sample by washing the genital area and collecting a “midstream” sample of urine in a sterile container. (This method of collecting urine helps prevent bacteria around the genital area from getting into the sample and confusing the test results.) Usually, the sample is sent to a laboratory, although some doctors’ offices are equipped to do the testing.

In the urinalysis test, the urine is examined for white and red blood cells and bacteria. Then the bacteria are grown in a culture and tested against different antibiotics to see which drug best destroys the bacteria. This last step is called a sensitivity test.

Some microbes, like Chlamydia and Mycoplasma, can be detected only with special bacterial cultures. A doctor suspects one of these infections when a person has symptoms of a UTI and pus in the urine, but a standard culture fails to grow any bacteria.

When an infection does not clear up with treatment and is traced to the same strain of bacteria, the doctor will order a test that makes images of the urinary tract. One of these tests is an intravenous pyelogram (IVP), which gives x-ray images of the bladder, kidneys, and ureters. An opaque dye visible on x-ray film is injected into a vein, and a series of x rays is taken. The film shows an outline of the urinary tract, revealing even small changes in the structure of the tract.

If you have recurrent infections, your doctor also may recommend an ultrasound exam, which gives pictures from the echo patterns of soundwaves bounced back from internal organs. Another useful test is cystoscopy. A cystoscope is an instrument made of a hollow tube with several lenses and a light source, which allows the doctor to see inside the bladder from the urethra.

How is UTI treated?
UTIs are treated with antibacterial drugs. The choice of drug and length of treatment depend 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 UTIs are trimethoprim (Trimpex), trimethoprim/sulfamethoxazole (Bactrim, Septra, Cotrim), amoxicillin (Amoxil, Trimox, Wymox), nitrofurantoin (Macrodantin, Furadantin), and ampicillin. A class of drugs called quinolones includes four drugs approved in recent years for treating UTI. These drugs include ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin (Cipro), and trovafloxin (Trovan).

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. Still, many doctors ask their patients to take antibiotics for a week or two 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 caused by Mycoplasma or Chlamydia, which are usually treated with tetracycline, trimethoprim/sulfamethoxazole (TMP/SMZ), or doxycycline. A followup urinalysis helps to confirm that the urinary tract is infection-free. It is important to take the full course of treatment because symptoms may disappear before the infection is fully cleared.

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. Researchers at the University of Washington found that 2-week therapy with TMP/SMZ was as effective as 6 weeks of treatment with the same drug in women with kidney infections that did not involve an obstruction or nervous system disorder. In such cases, kidney infections rarely lead to kidney damage or kidney failure unless they go untreated.

Various drugs are available to relieve the pain of a UTI. A heating pad may also help. Most doctors suggest that drinking plenty of water helps cleanse the urinary tract of bacteria. During treatment, it is best to avoid coffee, alcohol, and spicy foods. And one of the best things a smoker can do for his or her bladder is to quit smoking. Smoking is the major known cause of bladder cancer.

Recurrent Infections in Women
Women who have had three UTIs are likely to continue having them. Four out of five such women get another within 18 months of the last UTI. 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 such as TMP/SMZ or nitrofurantoin daily for 6 months or longer. (If taken at bedtime, the drug remains in the bladder longer and may be more effective.) NIH-supported research at the University of Washington has shown this therapy to 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.

 

Dipsticks that change color when an infection is present are now available without a prescription. The strips detect nitrite, which is formed when bacteria change nitrate in the urine to nitrite. The test can detect about 90 percent of UTIs when used with the first morning urine specimen and may be useful for women who have recurrent infections.

Doctors suggest some additional steps that a woman can take on her own to avoid an infection:

      1. Drink plenty of water every day.
      2. Urinate when you feel the need; don’t resist the urge to urinate.
      3. Wipe from front to back to prevent bacteria around the anus from entering the vagina or urethra.
      4. Take showers instead of tub baths.
      5. Cleanse the genital area before sexual intercourse.
      6. Avoid using feminine hygiene sprays and scented douches, which may irritate the urethra.
      7. Some doctors suggest drinking cranberry juice.

 

 

Infections in Pregnancy

A pregnant woman who develops a UTI should be treated promptly to avoid premature delivery of her baby and other risks such as high blood pressure. Some antibiotics are not safe to take during pregnancy. In selecting the best treatments, doctors consider various factors such as the drug’s effectiveness, the stage of pregnancy, the mother’s health, and potential effects on the fetus.

Complicated Infections
Curing infections that stem from a urinary obstruction or nervous system disorder depends on finding and correcting the underlying problem, sometimes with surgery. If the root cause goes untreated, this group of patients is at risk of kidney damage. Also, such infections tend to arise from a wider range of bacteria, and sometimes from more than one type of bacteria at a time.

Infections in Men
UTIs in men usually stem from an obstruction—for example, a urinary stone or enlarged prostate—or from a medical procedure involving a catheter. The first step is to identify the infecting organism and the drugs to which it is sensitive. Usually, doctors recommend lengthier therapy in men than in women, in part to prevent infections of the prostate gland.

Prostate infections (chronic bacterial prostatitis) are harder to cure because antibiotics are unable to penetrate infected prostate tissue effectively. For this reason, men with prostatitis often need long-term treatment with a carefully selected antibiotic. UTIs in older men are frequently associated with acute bacterial prostatitis, which can be fatal if not treated immediately.