A speech

Good Evening, Ladies & Gentlemen; 

may I have ur  attention please.

A special good evening to  Mr David Tolley, 

President of Royal College of Surgeons, & Mrs Tolley;  

Good evening also to Mr Sam McClinton, Past-President of the Scottish  Urological Society n Lead Examiner,  & Mrs McClinton,

This is not a formal dinner  but it is still good to say a few words at an important  gathering like this.

The Sarawak Club was founded in 1876 by Sir Charles Brooke, who was the second white Rajah of Sarawak.   

Sarawak was a separate state by itself: in fact  u may have noticed that one still need a passport to enter Sarawak! 

A surgeon,  Dr  MacDougall founded one of the earlier hospitals  in Kuching.  His wife founded a famous school very near to Pullman hotel, the St Mary’s school, where my wife, Ivy   Chin has been a senior teacher for > 20 years.  She is also responsible for this dinner!

I went Edinburgh to work under the late Professor Chisholm and Mr Tolley , to learn some urology!  It was in 1988  n 89. 

NOW EDINBURGH HAS COME TO KUCHING, HOPEFULLY ON A YEARLY BASIS !! Indeed there WAS ALREADY   a long tradition of  collaboration. While in Edinburgh I also had to report to the late Sir James Fraser who was the Post Graduate Dean of the College.  I discovered that he worked as a surgeon in Sarawak for many years, in his young days.

Malaysia, especially Sarawak is  peaceful with friendly people, wonderful patients. We are lucky  that the College with the help of Professor Khin Tun brought the MRCS exam here.  I understand that > 80 candidates applied and >half passed the recent exam  It is obvious that an Edinburgh  Royal College qualification  is  held in high regard in many parts of the world.

I want to welcome three special guests tonight: Dr John Chew, the Chairman of the Sarawak state Malaysian Medical Association & Dr Peter Wong , Secretary of the Malaysian College of Surgeons.  Thank you for the honour, Dr John Chew & Dr Peter Wong. We also have Dr Donald Liew, a young neurosurgeon at GH whom I hope can help us in the exam nest year!

Please enjoy the rest of the dinner and I hope we do meet again.

Dr Clarence Lei, clarencelei@gmail.com

MEN'S HEALTH - ED, Erectile Dysfunctio

HOW COMMON IS ED?


Men's health has been a neglected component of community health care.  There are many
programmes for the children and women; indeed many are sponsored by the State.
Erectile function is an important component of men's health and can be a strategy to
improve the provision of men's health.  Erectile dysfunction or ED is defined by the
National Institute of Health, U.S.A. as the persistent inability to initiate and/or maintain
an erection of the penis sufficient to permit satisfactory sexual intercourse. The term
"ED" is referable to "Impotence" because impotence implies a hopeless situation.
According to established epidemiology surveys, at least 10% of men have ED. However,
ED can be mild, moderate or severe. This figure rises to at least 50% in special risk
groups, e.g. patients with diabetes or moderate hypertension.

WHY BOTHERS WITH ED?
In the Asian community, ED is still a taboo subject, even with doctors.  It is well known
that ED impacts severely on the quality of life.  The ED patient typically suffers from the
following: guilt, depression, anxiety, frustration, low self esteem.  The partner may feel
rejected, thinking that the husband no longer desires her or is having an extra marital
affair.

WHAT CAUSES ED?
Although there is an inevitable psychological component with ED, most ED patients have
an underlying physical cause.  Patients should not seek treatment for ED in isolation.
The underlying causes should be treated:
• Arteriosclerosis or hardening of arteries.
• Hypertension.
• Diabetes.
• Heart disease.
• Neurological disorders.
• Neurological diseases.
• Diseases of the lower urogenital tract, e.g. cancer prostate, penile deformities.
• After pelvic surgery.
• Certain medications.

WHAT LIFESTYLE CHANGES CAN YOU MAKE TO DECREASE ED?
Obviously, a healthy lifestyle contributes to many of these diseases as well as to ED
itself.  This will include the following:
• Quit smoking.
• Reduce consumption of alcohol.2
• Exercise.
• Reduced obesity.
• Diet modification to reduce high cholesterol or triglycerides.
• Adequate relaxation and rest.
• Better communication with your partner.

HOW DO YOU ASSESS ED?
Depending on the severity of symptoms scored on the International Index of Erectile
Function (IIEF), ED can be classified as mild (score 12-21), moderate (score 8-11) or
severe (score 5-7).  The incidence of erectile dysfunction in Malaysia has been studied by
the National Family Planning and Development Board and is very similar to the
Massachusetts Male Aging study in U.S.  It is also age related. Briefly, 50% of men at 50
years of age have ED, 60% at 60 years and 70% at 70 years.


International Index of Erectile Function (IIEF)

Answer these questions if you are concerned about Erectile Dysfunction.

WHAT TESTS SHOULD BE DONE TO ASSESS ED?
In addition to a detailed medical history and physical examination (including DRE,
digital rectal examination of the prostate), certain tests can be done.  The urine
examination and blood sugar assessment is usually done.  If the patient also suffers from
a loss of libido (desire for sex), blood may be taken to check the hormonal profile
(namely, total testosterone and prolactin).  Depending on the underlying pre-existing
medical illnesses, blood for cholesterol, kidney function, liver function may also be
tested.  If the patient also has urinary symptoms, then other aspects of men's health (e.g.
urine flow rate and blood for PSA  or prostatic specific antigen) may be done.  In
exceptional cases, detailed evaluation may be done and this includes colour doppler study
of the blood flow to the penis and to test for nocturnal penile tumescence (NPT).
WHAT TREATMENT ARE AVAILABLE FOR ED PATIENTS?
Sildenafil (trade name, Viagra) was introduced in Malaysia in 1999 and that
revolutionised the treatment of ED.  Prior to that, the main treatment for ED was to inject
a drug into the penis to cause vasodilatation and erection.  If that fails, then the main
treatment was to surgically insert a penile implant.  In early 2004, the patients have a
choice of two new oral medications for ED, namely, Tadalafil (trade name, Cialis) and
Vardenafil (trade name, Levitra).  These drugs enhance the penile erection when a person
is sexually stimulated but the erection is not sufficient for sexual activity.  Penile erection
occurs when nerve stimulation causes the release of chemicals in the penis which in turn
causes dilatation of the vessels.  This group of oral medications block the breakdown of
these chemicals (called vasodilators) and therefore help to enhance the penile erection.
These drugs work only when the erection is insufficient for sexual activity and not if the
erection is normal.  If the erection is already normal, the vasodilator receptors are used up
and taking these oral medications will not enhance a normal erection.
WHAT DO PATIENTS EXPECT FROM THE ORAL MEDICATIONS?
The oral medications are remarkably effective and the effectiveness range from 80% to
about 50% in more severe cases.  Patients have to see their doctors to see the underlying
cause of their ED as well as to discuss treatment expectations.  For those patients whose
initial treatment with oral medication fails, further tests may be necessary.

WHAT ARE THE SIDE EFFECTS OF ORAL MEDICATIONS FOR ED?
As with all medications, there are some side effects.  These drugs cause increased blood
flow to the penis and to some other parts of the body as well and therefore, can cause a
drop in the blood pressure.  If patients are taking a class of drugs called nitrates for chest
pain, then it is an absolute contraindication to the taking of these 3 types of oral
medications.  In addition, these 3 medications cause side effects which are mostly related
to dilatation of blood vessels, namely:4
• Facial flushing.
• Indigestion.
• Backache.
• Headache.
• Nasal congestion.
• Dizziness.
The side effects are mild and transient.  If they persist, this usually means that the patient
has to decrease the dosage of the oral medication.  These 3 oral medications have been
proven with a high level of scientific evidence by doing double-blind placebo controlled
clinical trials to be effective.  This is unlike most of the traditional medications or fake
products which are touted in the market or Internet.  It is therefore important to get such
expensive medications from a quality assured outlet, e.g. Normah Medical Specialist
Centre.

HOW ARE THE MEDICATIONS TAKEN?
The 3 types of medications are taken on an as required basis.  The duration of action is ½
hour to 4 hours (Viagra and Levitra) although one of them can last up to 36 hours
(Cialis). Cialis and Levitra may be taken with or without food.
SUMMARY:
Assessment and treatment for ED is an important avenue for improving men's health.  For
many, treating ED is just as important as treating underlying medical illness and adopting
a healthy lifestyle.

Dr Clarence Lei Chang Moh, FRCS Urol, FEBU, FAMM
Consultant Urologist
Feb 2004

Sexual and overall quality of life

The role of Alpha Blockers in BPH, sexual and overall quality of life

Lower urinary tract symptoms, LUTS related to BPH not only impair the quality of life
but also affect sexual function.  The symptoms may be related to bladder outlet
obstruction or altered bladder muscle function.  There are two components of obstruction
viz static and dynamic.  Alpha adrenergic blocker therapy act on the dynamic component
by reducing the sympathetic tone of the prostatic urethra:

(1) irrespective of the size of the prostate gland
(2) improve the symptoms score viz IPSS by  8 points including nocturia and border
score
(3) improve the uroflow by 3 mls/s.
(4) works rapidly, within days
(5) can therefore be used before a trial off catheter in acute urinary retention.
(Alfuzosin XL 10 mg when  used for 3 days, 62% have successful trial off catheter.
Alfuzosin 10 mg daily achieves its maximum dose effect without the need of titration
and on a once daily basis, improving compliance.)
(6) The effect of alpha-blockers is sustained for many years; most clinical trials are up
to 48 months.  For uro-selective alpha-blockers, its systemic side effects are
minimal with 4.2% withdrawals from treatment due to side effects,  the main one of
Alfuzosin is that of dizziness, 3.1%.

There is a close relation between LUTS and sexual dysfunction.  This is possibly
related to the presence of PDE-5, nitride oxide, sympathetic tone of the prostate and penis
as well as similar innervation.  Accordingly, 70% of patients with severe LUTS have ED.
Treatment with Alfuzosin “improves the sexual drive, decreases ED by 26%, improve
painful ejaculation in 65%”.  There is a significant 30% abnormal ejaculation for patients
who are on Tamsulosin 0.8 mg versus a very low rate of 0.3% for patients on Alfuzosin.
Conversely, treatment with PDE-5 inhibitors either alone or in combination with alphablockers (which is safe) also improves LUTS.  Indeed, prolonged erection or priapism has
occasionally been reported as a complication of alpha-blocker therapy.

Improvement of LUTS and sexual function from alpha-blockers without significant
adverse events & positively impact on quality of life (BPH QoL20 score improved 45%
at 36 months).    This is more so when patients in this group have significant comorbidities.  In the AMORE, Asian Multi-national Prospective Observational Registry of
patients with BPH, there are significant associated hypertension (43%), diabetes mellitus
(14%), IHD (10%) and obesity (36%).  Treatment with Alfuzosin 10 mg daily has
marginal blood pressure changes in this group of patients, even >65 years of age and on
anti-hypertensive therapy.  Alpha-blocker therapy (e.g. Alfuzosin 10 mg daily) is
efficacious in the treatment of BPH, improves sexual function and quality of life.
 
e-References available on request from author.
Malaysian Urological Conference Lecture on 8.12.2007

by Dr Clarence Lei Chang Moh, FRCS Urol, FEBU,
Adjunct Professor, Universiti Malaysia Sarawak
e-mail: clarencelei@gmail.com

SEXUAL DYSFUNCTION OF CHRONIC ILLNESS AND MANAGEMENT

Sexual dysfunction
Sexual dysfunction affects negatively quality of life.  An obvious component of sexual
dysfunction is that of erectile dysfunction, ED.  ED is defined as the persistent inability
to achieve and/or maintain an erection sufficient for satisfactory sexual activity. Age is
an important risk factor for ED. Sixteen per cent of Malaysian men aged 40 – 70 years
suffers from complete ED. Management  should  be aimed not only at treatment but also
at prevention of ED.  Despite having the first impotence clinic in GHKL in 1992, only
10% of Malaysian men with ED talked to the doctors and only 3.9% had received some
form of treatment.  Sildenafil (trade name Viagra) was found to be effective amongst
Malaysians in a double blind placebo controlled study published in 2000.  Even then,
Sarawakian men  sought advice regarding their ED after an average duration of 20
months.

Erection is a complex neurovascular event,  modified by psychological factors.  The comorbidities of ED are similar to those for ischaemic heart disease and strokes. ED should
be treated as part of total wellness of the patients by family doctor, taking into account
hypertension, ischaemic heart disease, dyslipidaemia, diabetes, psychological stresses,  
family factors, diet, exercise, smoking etc.

All such co-morbidities are common in chronic renal failure.  In addition, chronic renal
failure  is associated with hormonal imbalances involving testosterone and prolactin.
Studies of ED in chronic renal failure patients showed a prevalence of about 60% with
half of this suffering from severe ED.  Dialysis patients above the age of 50 have an
almost 70% chance of having ED.  In one study, it was found that the incidence of ED is
irrespective of social economic status and duration of haemodialysis.  In another  study,
63 out of 68 patients on peritoneal dialysis suffered from ED.

The treatment of ED has been revolutionised by the introduction of the phosphodiesterase
Type 5 inhibitor (PDE-5 I).  There are 3 main PDE-5 inhibitors currently being used,
namely,  Sildenafil, Vardenafil and Taladafil.   These medications can be taken ½ to 1
hour before sex; the effect of Sildenafil and Vardenafil last for 4 hours and that of
Taladafil for 36 hours.  They should not be taken on a full stomach.  Sexual and penile
stimulation is required as PDE-5 inhibitors enhance an erection but does not induce
an erection!   PDE-5 inhibitors are generally safe and the main contraindication is that
these medications should not be taken concurrently with any form of nitrates eg GTN,
Isordil, Imdur.  Taking PDE-5 I together with nitrates can result in hypotension. PDE-5 I
works in about 60% of ED patients, less if the patients have numerous untreated comorbidities.  The side effects of PDE-5 inhibitors include flushing, headache and nasal
congestion.  Another treatment is that of intra-penile injection of a vasodilator, e.g.
Caverject 20 mcg.  Over-dosage can result in prolonged erection viz priapism.   Any
erection more than 4 hours should be brought down, usually with penile aspiration or
injection of a dilute vasoconstrictor gradually e.g. Phenylephrine.   Other modalities
include penile rings to reduce venous leak and also vacuum pumps to increase blood flow
into the penis.  Finally, for patients with “end stage penile failure, ESPF”, a penile
prosthesis can be inserted by open surgery. Many traditional therapies are available but 2
these have not been tested with double blind placebo controlled trials.   Moreover, some
of these therapies (e.g. subcutaneous injections for penile lengthening) can have serious
side effects

The role of testosterone in erectile dysfunction has recently taken a more prominent role,
with the availability of long acting (3 months) injection testosterone.  There is some
association of  testosterone deficiency syndrome (TDS) with truncal obesity in men,
diabetes, hypertension, dyslipidaemia (metabolic syndrome).

The International Society for Sexual Medicine defines  premature ejaculation as
ejaculation which occurs within 1 minute of vaginal penetration and resulting in negative
personal consequences.  Premature ejaculation is probably more common than ED and
difficult to treat, especially if it is chronic. The treatment consists of physical methods
(e.g. squeeze technique) and the use of selective serotonin re-uptake inhibitors, SSRI, e.g.
Fluoxetine 20 mg 2 hours before sex.

Female sexual dysfunction (FSD) consists of impaired sexual interest (52%), orgasmic
dysfunction (19%), vaginismis (18%) and dyspareunia (4%).  Female sexual arousal 
disorder is  defined by WHO as the persistent inability to attend or maintain sexual 
excitement, express as a lack of genital lubrication or swelling response.  Chronic
illnesses including diabetes mellitus double the risk of FSD especially arousal difficulties,
pain during sex and infection.  Sildenafil does not treat FSD although it is postulated to
have some effect on clitoral erection and on the G-spot.

Fertility in patients with chronic illnesses is often decreased in part due to ED,
ejaculatory disorders and infection of the lower urinary & genital tract.  For patients with
ejaculatory problems, sperm can be harvested by post orgasm urine or electro-ejaculation.
Sperm can also be harvested nowadays from the testes and kept in sperm bank.  Modern
test tube baby techniques e.g. intracytoplasmic sperm injection (ISCI) can help many
subfertile couples.

SUMMARY:
ED is seen in about 60% of patients with chronic renal failure. Specific treatment with
PDE-5 I is effective in more than 60% of patients.  ED should be treated early together
with the co-morbidities viz hypertension, diabetes, ischaemic heart disease,
dyslipidaemia, mental health and testosterone deficiency syndrome.  Intra-penile
injection of vasodilators is useful in patients who do not respond to PDE-5 I.

NKF Annual Dialysis Meeting, Kuala Lumpur, 13th
December 2008

Damage only if op was done badly

SHRUNKEN-TESTICLES CASE , 
THE STRAITS TIMES: Sunday, August 26, 2000

SEVERE damage to both testicles could take place after surgery only if the operation
was done inappropriately or extremely badly, an expert witness from East Malaysia
said yesterday.
Dr Clarence Lei Chang Moh, 43, a consultant urologist who runs a specialist clinic in
Kuching, Sarawak, was testifying for the defence in the suit brought by American
cocoa trader Denis Matthew Harte, 36, against a Singapore consultant urologist and
Gleneagles Hospital.
Mr Harte is suing Dr Tan Hun Hoe, 46, and Gleneagles for medical negligence over
an alleged botched-up operation on April 28, 1997, which left him with shrunken
testicles.
Shortly after the operation, Mr Harte had a fall in the toilet and hit his head. The
next day, he complained of severe pain and a swollen scrotum. He saw Dr Tan again
only four days later, on May 2.
Dr Lei had said in his affidavit that varicocele ligation, the operation carried out, was
an accepted treatment to improve the general outcome for sub-fertility in men. He
felt that delay in diagnosing trauma to the testicles could cause them to shrink.
He added that it was his opinion that Dr Tan had done what a normal urologist would
have done in this region. He also found Dr Tan's standard of care to be adequate and
safe, he said.
He told the High Court yesterday that a man could experience swelling, significant
pain and collection of blood in the scrotum after such an operation.
Mr Edmund Kronenburg, one of the lawyers acting for Mr Harte, asked if a competent
surgeon should advise a patient of the risk of testicular atrophy. Dr Lei replied: "It is
exceedingly rare."
The lawyer suggested that it would be possible to get bilateral-testicular atrophy if
the surgery was inappropriately done. Dr Lei said: "It has to be a very, very
inappropriately-done surgery. You got to tie up all the arteries, all the veins. It has
to be a very, very bad surgery."
A Gleneagles staff nurse, Ms Looi Chai Hong, 57, and former nurse Tan Sang Eng,
45, who were on duty on the day of Mr Harte's operation, both testified they had not
found any injury on the site of Mr Harte's operation or any bruising to his scrotum
after his fall that day.
The hearing continues on Monday.