Over Active Bladder膀胱問題

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Oab  cases(1)

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Oab  diagnosis & evaluation

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Oab  medical management

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Prostate Problem前列腺問題

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THE ROADs NOT TAKEN

Brain-drain (or recently brain-gain) used to be an important part of life. When I

graduated as a doctor, there were not many opportunities for specialised training. I

considered going to:-

(1)Singapore – Upon graduation, half of my classmates from Sarawak did their

housemanship in Singapore. Many of our seniors had stayed on in Singapore to

get specialised training. A few succeeded but have to stay behind because their

spouses would not return to Malaysia. There is also a differential preference not to

train “foreigners” in Singapore. As a Yayasan Sarawak scholarship, I thought it was

my obligation to return to Sarawak.

(2) Australia – In 1988, I was offered a 1-2 years’ job in Perth as a urology registrar.

This was made possible because a Malaysian who had graduated as a urologist

by training in Malaysia had migrated to Perth. However, the Australian authorities

decided that I should only receive half of the pay of an Australian registrar. I would

also not be eligible to sit for the FRACS Urology exam.

Needless to say, I did not take up “compromised” offer.

(3) USA – At the same time, I considered training in the USA as they are supposed to

have the world’s most advanced medical centres. To do that, I passed the ECFMG

exam (Examination Conducted for Foreign Medical Graduates). The residency

programme in the US for surgery was 4 years and I was only able to get a visa for 3

years. There would be therefore the chance that I would not be able to complete my

training if I do not get a 1 year extension.

(4) United Kingdom – By a combination of factors (including somebody’s bad luck,

namely, a candidate was awarded a scholarship but committed suicide thereafter),

I was able to fight for a scholarship to do Urology in the United Kingdom. After

spending 2 years, namely, at the University of London and University of Edinburgh,

I returned to Malaysia. A few months after my return, the Professor GD Chisholm

of the University of Edinburgh offered me a job as a senior lecturer and honorary

consultant urologist at the Western General Hospital. When I was in the U.K,

Malaysia was undergoing an economical recession and I had a tough time making

ends meet and also in the cold dam weather. I also had a 2 year bond with the

Malaysian Government, just having utilised their scholarship. I therefore declined the

faxed letter of offer from the late Professor Chisholm who was my main mentor when

I was in Edinburgh.

However, in the current globalised world, it does not really matter where I stay and also

at this age.

Dr Clarence Lei Chang Moh

Date: 4th July 2011

MEN’S HEALTH: Hormonal Replacement Therapy更換荷爾蒙治療法(HRT)

Male menopause do occur although it manifests in a insidious manner and it is also not
as common as in females. Medical guidelines have been published, e.g. in European
Urology 2005 Volume 48, Page 1 – 4. There are other terminology used for this
condition, namely, Andropause, ADAM or Androgen Deficiency in Aging Male, PADAM,
Partial Androgen Deficiency in Aging Male, LOH or Late Onset Hypogonadism. The
latest description is that of TDS, Testosterone Deficiency Syndrome. The various
names illustrates that there is probably no sharp drop in the testosterone level but rather
a gradual decrease in level. In addition, there is often a variation in individual level as
well as a wide variation among the population of the level of male hormone. There is
probably also a normal natural decline of the male hormone with graceful aging. Other
hormonal replacements are still undergoing trials.

DEFINITION:

The definition of male menopause would be that of a “clinical and biochemical condition
associated with aging male”.

The clinical features would include decreased libido, erectile dysfunction (ED), sleep
disturbances, changes in mental status e.g. irritability, tiredness and poor memory.
There may also be bodily changes e.g. increase in visceral fat, decrease in lean body
mass and osteoporosis.

The scientific measurement is that of the blood total testosterone determination taken in
the morning between 7 – 11 am. The current lower limit of total testosterone is that of
<11 ng/L.

ASSOCIATED CO-MORBIDITY:

There are some conditions which are associated with an increased incidence of
TDS and these include diabetes, hypertension, obesity (waist circumference >90
cm for Asians), osteoporosis and dyslipidaemia. Some group these conditions as
the “metabolic syndrome”.

Precautions before starting on testosterone replacement therapy include exclusion of
prostatic cancer. The growth of prostate cancer depends on testosterone. Therefore,
before the initiation of testosterone replacement therapy, one would need to do an
examination of the prostate, usually a digital rectal examination, DRE and also to
measure the blood level for prostatic specific antigen, PSA. However, prostatic cancer
is extremely common and testosterone replacement therapy is only contraindicated in
patients with a clinically active prostate cancer. Testosterone replacement therapy in
men with untreated subclinical prostate cancer is not associated with prostate cancer
progression in the short to middle term of a few years (Journal of Urology 2011; Vol.
185: 1256-1261).

WHICH HORMONAL PREPARATION TO USE?

There have been many preparations used over the years including tablets, creams and
injections. The aim is to have testosterone replacement therapy, not to give supra-
physiological levels. Orally absorbed testosterone will have to pass through the liver,

2

giving rise to liver toxicity. In addition, there is a question of compliance when the
patient has to take the capsules, usually twice a day. There are also some gels which
can be applied to the skin, in an attempt to mimic the diurnal rhythm of the normal
testosterone. In humid hot climate, gels may not be comfortable. Previously, there were
injections but these tend to give supra-physiological levels during the early days of the
injections. Moreover, many of these preparations were short acting, usually for about 3
weeks.

Obviously, injection therapy which can give a sustained replacement dose over a period
of months would be the most suitable formulation. One such formulation is that of
injection Nebido. This can be given every 3 monthly, although an earlier second dose
would be needed (usually at 6 weeks) to top up the testosterone level.

FOLLOW-UP:

Testosterone replacement therapy is an expensive medical treatment. Therefore,
patients should follow up with their doctor to review their progress including a prostatic
evaluation on an annual basis.



Dr Clarence Lei Chang Moh
Consultant Urologist


Enquries to : clarencelei@gmail.com
kuchingurology.com


Date: 15.6.2011

PAEDIATRIC RENAL TRANSPLANTATION馬來西亞腎臟移植

PAEDIATRIC RENAL TRANSPLANTATION IN MALAYSIA

CCM Lei, Koh ET, Murali S, Susan W, Yap YC, Lim YN

Institute of Urology & Nephrology, Hospital Kuala Lumpur

The first kidney transplant in Malaysia was done on 15^th December 1975 with a living related kidney from his younger brother.  The patient and kidney survived till 26.3.2006 when the patient died with a functioning kidney.  The first cadaveric kidney transplantation was done in Malaysia in 1979.  The cadaveric transplant programme was re-activated on 22.7.1992 when a brain dead American lady donated both her kidneys, one of them going to an 11 year old paediatric recipient.  Since then, the kidney transplant programme has remained stable, with an average of about 30 cases per year and more than one third of them from cadaveric sources.

With improved medical care by 10 paediatric nephrologists in Malaysia, there is an increasing number of paediatric kidney transplants. There are 25 children being worked up with a view to living related transplantation. Despite a good adult kidney transplantation programme, paediatric renal transplantation remains a formidable challenge, worldwide. All paediatric kidney transplantations in Malaysia are done at the Hospital Kuala Lumpur and the present review includes cases from 2000 to 2007.  There are a total of 58 recipients, with 23 from live donors.  The number of transplants are ( cadaveric in [ ] ): 2 [7] in 2000, 2 [2] in 2001; 3 [1] in 2002; 1 [3] in 2003; 1 [2] in 2004; 5 [2] in 2005; 3 [7] in 2006; 6 [11] in 2007). There were 3 mortality: 2 cadaveric (1 graft rupture and 1 non-functioning kidney) and 1 from a live donor who suffered severe pulmonary hypertension.  There were 3 nephrectomies: 2 cadaveric and 1 living related graft which at ruptured 3 weeks postoperative.  There were 3 significant surgical morbidity, namely, 2 perinephric haematomas which subsequently resolved and 1 aortoiliac renal artery false aneurysm which was repaired with the help of the vascular team.  One recipient required cystoplasty (for posterior urethral valve) before receiving a cadaveric kidney, which was unfortunately lost because of thrombosis 2 weeks post transplant. Many paediatric patients are on CAPD.  If there is primary function on table, the Tenchkoff is removed at the time of transplantation.  Ureteric reimplantation is via extravesical submusoacl tunnel over a ureteric stent..

Infarction is a well known problem of paediatric transplants mainly because of a mis- match in blood flow of large donor kidney and small vessels.  The larger vessels of external or common iliac are used for anastomosis.  The internal iliac may be  used to vascularise any accessory artery.  In 10 cadaveric paediatric transplants in 2006, 4 of them had ischaemia and 2 required a graft nephrectomy.  The other 6 kidneys have satisfactory renal function.  Most  paediatric recipients have a body weight >15 kg; 2 patients with body weight 10 to 15 kg were transplanted in deserving situations. Cadaveric donors less than 2 years old were extremely challenging and there were a total of 4 of them.  Two sets were transplanted enbloc and both did not do well: one had bleeding, possibly associated with heparin on the 8^th postoperative day and another kidney infarcted on the 10^th postoperative day.  The other set of small cadaveric kidneys were transplanted in 2 separate recipients and one patient died of unrelated chickenpox and the other kidney is functioning well.  One set of cadaveric donors were transplanted into 1 recipient, 1 in each iliac fossa and both kidneys are functioning well. 

All patients were closely followed by paediatric nephrologists throughout Malaysia. In addition to above vascular problems, 1 patient had exploration for wound haematoma, 1 lymphocele, 2 ATN requiring dialysis.  One patient re-started CIC for hypoactive bladder. One had angioembolisation  for bleeding after renal biopsy. Infection contributes to significant morbidity: UTIs in 9, CMV infection in 1, Herpes in 1, lung infection in 2. The patients were closely monitored with  immunosuppression and  for recurrent primary disease (2 cases of recurrent nephrotic, FSGS noted).  

PAEDIATRIC RENAL TRANSPLANTATION

image taken from 

Kidney stones (Renal calculi)腎結石

MEDICAL TREATMENT FOR RENAL CALCULI:

WHAT WORKS AND WHAT DON’T.

Dr Clarence Lei, FRCS Urol, Consultant Urologist, Stone Centre, NMSC

clarencelei@gmail.com

Urinary stones affects 5-15% of populations, with a 50% recurrence rate over 10 years. Ureteric colic is the most severe pain that men can ever experience and the standard treatment for most patients is that of Diclofenac. However, if this is given continuously for more than 48 hours, there is a nephrotoxic potential, especially in patients who are dehydrated.  For small stones (< 6 mm) in the lower ureter, removal can be facilitated by uroselective alpha-blockers (e.g. Tamsulosin, Alfuzosin). This is now known as MET medical expulsive therapy! Stones <5mm usually do not require intervention unless complicated by sepsis whereas untreated large stones eventually cause urosepsis.

The important medical treatment for urinary stones is that of water therapy such that the patient produces 2 litres of urine per day. The fluid intake of the patient depends on his environment.  Ideally, such fluid should be distributed throughout the day.  There is no good evidence of advantages of specific juices or herbals.

Uric acid stones can be effectively dissolved by medical therapy by urinary alkalinisation, keeping the urine pH at 7.0.  Uric acid stones comprise about 20% stones and are radiolucent on x-ray but readily seen on ultrasound and plain CT. Even staghorn uric acid calculi can be dissolved over 6 months.   However, the patient should have a good renal function to avoid accumulation of the medications used e.g. potassium, citrate, sodium (in Ural).

Potassium Citrate helps clear post ESWL lower pole fragments (“stone free = <5mm”). In a study when Potassium Citrate was given as Urocit-K tablets 60 meq/day, Urocit-K increased the stone-free rate to 45.5% from 12.5% in control group, over a 12 month period.  The citrate in the urine reduces crystallization of calcium and uric acid stones.  

Stones associated with infection are called struvite stones. Struvite stones are typically soft and faintly radiolucent. The stone and infection should be cleared by surgery and  vigorous antibiotic therapy (e.g. Amikacin) followed by prophylaxis e.g. Trimethoprim at night for 6 months, including in children. 

For patients who have underlying metabolic effects, the benefit of the specific medications may not justify the side effects and long term costs. The diet recommendations for patients with recurrent stone formation is that of less salt, and normal calcium. Patients with uric acid stones should take less uric acid in their diet e.g. red meat, nuts.

Reference (more pdfs available on request):  Singh SK et al.  Medical therapy for calculus disease.  Brit J Urol Int. 2011, 107: 356-368.;

Pak CYC Medical Stone Management: 35 yrs of advances. J Urol 2008, 180; 813 – 819.

Image taken from nursing crib.com

http://nursingcrib.com/nursing-notes-reviewer/medical-surgical-nursing/renal-problems-%E2%80%93-renal-calculi/

CIRCUMCISION割包皮

CIRCUMCISION IN 2011

by Dr Clarence Lei Chang Moh, FRCS Urol

Consultant Urologist

INTRODUCTION:

I have been inspired to write on the above subject as it is “circumcision season during the current year-end school holidays”.  The following situations are common.

§         Neonatal circumcision:

I get this request occasionally, mainly from expatriates from the Middle East.  During the first week of life, the baby’s haematology is still protected by the mother and that would be the optimal time to do the circumcision. This can be done under a penile ring block with 1cc of 1% lignocaine solution injected with a 26G needle.  20% sucrose solution can be given to the child as a soothing agent during the circumcision

Jewish circumcision:

The Jewish circumcise within the first week of life. Jesus Christ was born as a Jew and his holy foreskin was said to be worshipped in at least 31 Western European churches!  However, the Jews have their own trained personnel to conduct the circumcision and also to do the follow-up visits. 

§         Ritual circumcision among the  Malaysian Muslims:

The Muslims in Malaysia usually circumcise at puberty, during the school holidays when they finish school after standard 6.  It is also a part of the culture of transition to manhood  and therefore, many of these circumcisions are done as ritual in a very cost effective manner.  They are usually done by trained medical personnel nowadays and most of the boys require only local anaesthetic.  However, as the living pattern of some of the modern Muslims do not follow “kampung culture”, some of the boys are better circumcised under a general anaesthetic.  In fact, I do see a number of “partially circumcised boys” who require a repeat circumcision as they were unable to cooperate with the procedure during the first circumcision!

§         Techniques of circumcision:

In 1992, a little boy had part of his penis sliced off by a hospital attendant in a government general hospital.  He subsequently required corrective surgery including meatoplasty.  There were also other similar incidences with medico-legal complications. The authorities recommended that the circumcision technique should therefore be that of a dorsal slit technique rather than a guillotine technique. I routinely use the dorsal slit technique with a pair of scissors and cut the inner and outer foreskin with a knife. The edges are then stitched with plain Catgut 4/0.   I use an ocular loop (usually 4 x) and low setting bipolar diathermy for all my circumcisions.

The media sometimes advertise the use of “laser  circumcision”.  In fact, laser would have been an extremely expensive technology and I do not know of anybody using laser for circumcision!  Various types of clamps have also been used for circumcision.  Again, if one can make a clean incision and put a few stitches, the clamp is really rather cumbersome.  If the skin edges are not sutured and if the clamp falls off prematurely, there will be a large gap and an ugly scar  formed by secondary healing. Moreover, in bigger boys, the vessels could still  bleed after the clamp drops off. If the patient requires a repeat circumcision, one would have to wait for more than a month to allow all the swelling and infection to settle down before the repeat circumcision.

§         Phimosis as an indication for circumcision:

In a small number of children, the prepuce opening might be very tight, causing obstruction to the urine flow. Typically, such a child would have ballooning of the prepuce at micturation and may be with some discomfort or crying.  The following indicates ballooning of penis from phimosis.

Such patients are probably better off with a surgical circumcision.  Circumcision is not covered by insurance policies, possibly because it is viewed as a cosmetic surgery or it is considered a congenital condition.

§          

§         Medical treatment of paediatric phimosis:

Some parents may be against a circumcision.  Moreover, the patient may not be fit for circumcision.  In such a milder case of phimosis, the foreskin can be softened with a daily application of a steroid cream (e.g. Dermovate) and retracting the foreskin gently at each bath. This may have to be done for a month or so and some of the phimosis will still recur. 

Late onset adult phimosis:

This can cause voiding difficulties and infection.  Up to 1/3 of these patients have underlying diabetes mellitus and therefore must be screened as such.  It can also happen in old folks’ homes where nobody cleans the penis.

§         Other common medical indications for circumcision:

If the prepuce is retracted and not replaced, it can strangulate the glans penis, giving rise to a condition called “Paraphimosis”.  It is not uncommon in young boys who “play with their prepuce” or in elderly men who have the prepuce retracted (e.g. by the nurse while cleaning the penis for urethral catheterisation) and the prepuce is not replaced. A little boy who was apparently turned away by the doctor who did not diagnose the paraphimois:

Another common indication for circumcision is that of infection of the glans penis and prepuce (a condition called Balanoposthitis). 

A common indication is that it is “a good hygiene” to have a circumcision.  Unfortunately, this gives the implication that men who are not circumcised do not clean their penis and foreskin! 

Is there any contraindication for circumcision?

The absolute contraindications for circumcision are:

(1)   Hypospadias, where the urethral opening is proximal. The foreskin is often used by the urologist to do surgical correction for the hypospadias. 

(2)   Any other underlying medical disorder  e.g. haemophilia.

What is the relationship between male circumcision and urinary tract infection, UTI?

For male children who have recurrent febrile UTI, circumcision has a beneficial effect.  For patients with high grade vesico-ureteric reflux, circumcised children have less kidney scars (10.2% compared to 5.2%, J. Urol 2010, 184: 1598-1603).  Such high grade reflux often also occurs in a condition affecting male infants, namely that of PUV, posterior urethral valve. These are some of the common medical indications for circumcision in children.

What are the community indications for circumcision?

(1)   It has been known for a long time that circumcision confers a beneficial effect in terms of cancer of the penis.  The Jews who are circumcised soon after birth do not develop cancer of the penis. The Muslims who are circumcised at puberty have a less incidence of cancer of penis.

(2)   It had been shown that the circumcised men in sub-Saharan Africa have less HIV/AIDS (BJUI 2008: 101, 394).  The WHO is leading a campaign for circumcision in these areas.

(3)   It had also been shown male circumcision confers a beneficial effect for penile HPV infection and also reduce cervical cancer in their female partners (NEJM 2002; 346: 1105-1112). 

§         The role of circumcision and penile size:

Many anxious mothers bring their obese boys to consider circumcision, thinking that the prepuce covers the penis.  Micropenis is indeed an extremely rare condition.  Most of the time, the penis is actually retracted and hidden underneath the pubic fat!  If the doctor does an aggressive circumcision, he may end up removing too much penile skin and the penis does not even come to the surface.  The size of the penis cans usually be shown to the mother by lying the patient down and putting pressure on the suprapubic fat to expose the penis! 

The following diagram illustrates the problem of childhood obesity and the “redundant foreskin”.

“Buried Penis”:

In rare cases, the penile skin is insufficient and prevents the penis from growing at puberty.  In such cases, the foreskin can be retracted and tacked down to penis by suture as below:

Postoperative care of circumcision:

The postoperative wound actually does not require any dressing except for wound inspection and reassurance of the parents. Topical ointment e.g. Chloramphenicol eye ointment may be applied on a daily basis to reduce adhesions to the garments. A lot of Muslim boys would just leave the penis “exposed” by wearing a loose sarung.  If there is any oozing, a circumferential light pressure dressing may help.  The wound can be inspected every few days and the child can probably have a bath after a week or so. I would recommend  avoiding long distant travel for about 2 weeks.  For men, bleeding can occur during an erection and therefore, I would recommend sexual abstinence for a month. 

§         How much foreskin to remove?

If one removes too much skin, there may be insufficient skin for free erection.  However, if not enough skin is removed, the sulcus and the glans penis are not exposed and the patient may require re-circumcision!

§         Uncircumcision:

There is a group of believers that the prepuce is an important part of the human anatomy and extremely rich in nerve endings.  Therefore, some communities do not wish to have circumcision and those who are circumcised at birth would have their circumcision revised by an uncircumcision operation. However, the prepuce probably plays a small part in overall sexual pleasure and a recent study showed no such difference (BJUI 2008; 101: 65-70). 

Dr Clarence Lei Chang Moh,

clarencelei@gmail.com