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.

Over Active Bladder膀胱問題

Bph case studies 10.7.11 dr lei

View more presentations from Wong Lei.

Oab  cases(1)

View more presentations from Wong Lei.

Oab  diagnosis & evaluation

View more presentations from Wong Lei.

Oab  medical management

View more presentations from Wong Lei.

Prostate Problem前列腺問題

Bph case studies 10.7.11 dr lei

View more presentations from Wong Lei.

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