Caring for the urinary and sexual health
The burden of urological problems has increased tremendously over the last four decades. Increasing life expectancy in both men and women in India has exposed the elderly population to the diseases of the genito-urinary tract that was previously seen only in the West. The increase is also driven by greater public awareness of urinary problems and sexual health because of its impact on quality of life. Urologists are in the forefront of technological innovation such as endoscopic surgery, minimally invasive laparoscopy and indeed robotic surgery.
Common Urological Problems
Kidney Stones: The incidence of kidney stones is increasing in India and is possibly related to better diagnosis but is also due to increasing incidence of obesity. Kidney stones are also caused by dietary factors (especially decreased fluid intake) and genetic factors. CT KUB is the gold standard investigation for kidney stones. Although stones smaller than 4 mm pass spontaneously, delay in de-obstructing the kidney can lead to destruction of the kidney. Surgical intervention includesendoscopic treatment (LASER, ultrasonic lithotripsy), Percutaneous Nephrolithotomy (PCNL) and Extra-corporeal Shock Wave Lithotripsy (ESWL).
Kidney Infections: Acute pyelonephritis is not an uncommon presentation in patients who have had urinary tract infection. This condition is usually bilateral, with patients presenting with back pain and fever. Diagnosis is made by urine examination and upper tract imaging such as CT scan or Ultrasound scan. In diabetics, this condition needs to be aggressively treated as it can progress to Acute Emphysematous Pyelonephritis.
Haematuria: Haematuria is the presence of blood in the urine. It can be visible or non-visible haematuria (Dipstick or Microscopy). Any form of haematuria (RED FLAG SYMTPOM) needs to be thoroughlyinvestigated by the Urologist. The causes of haematuria are myriad but cancer affecting the genito-urinary system (kidney, ureter, bladder, prostate and urethra) needs to be ruled out. CT urogram and a cystoscopic assessment are mandatory in almost all cases.
Dysuria: Dysuria is a common urological problem affecting both men and women. In men, the most distressing symptom is the burning sensation at the tip of the penis. In women, the dysuria is throughout the urethra. Sexually transmitted diseases need to be ruled out. However, in many patients, despite investigating extensively, no cause can be found out. Investigations include STI screen (urethral discharge or urethral swab), urine for Culture and Microscopy, ultrasound of the kidneys and bladder, and recurrent cases need cystoscopic evaluation.
Common Urological Problems in Women
Recurrent Urinary Tract Infections
More than 50% of women will have an episode of UTI in their lifetime. In a significant number of patients, this may recur. More than 3 infections in a year are termed as recurrent UTI. Cystitis is characterised by dysuria, supra-pubic discomfort, increased frequency and urgency. Occasionally, this may be associated with haematuria or loin pain suggestive of pyelonephritis. Urine culture will reveal the offending organism and its sensitivities. The incidence of UTI has two peaks: Late teens, when the female becomes sexually active (honeymoon cystitis) and peri-menopausal (due to hormonal changes and its effect on the vaginal flora). Ultrasound scan with post-void residual is usually carried out in women with rec UTI. For uncomplicated UTI, a 7-day course of antibiotics suffices. Complicated UTI requires a much longer course. To prevent Rec UTI, general measures such as adequate fluid intake, time voiding, post-coital voiding and avoidance of constipation is recommended. Low dose antibiotic prophylaxis can be tried in those with recurrent UTI.
Stress urinary incontinence
Involuntary leakage of urine during physical straining such as coughing, sneezing, laughing etc. is stress urinary incontinence. It is a common problem amongst women, especially those who have had normal deliveries. The incidence of SUI is on the rise in India due to increasing awareness (previous under-reported). Clinical examination usually sufficesbut urodynamic evaluation may be needed in patients wherein history suggests "mixed incontinence". Treatment includes pelvic floor exercise and sling operations, which are minimally invasive.
Overactive Bladder (OAB)
OAB is a symptom complex that is characterized by urinary frequency, urgency, with or without urgency-associated urinary incontinence. OAB is a very common urological problem amongst women. It is important to rule out UTI and neurological causes in such patients before a provisional diagnosis of OAB is made. Urodynamics is indicated wherein the picture is that of a mixed incontinence. Treatment includes behavioural and life style changes such as reducing or eliminating caffienated drinks. Bladder training and pelvic floor exercises also seem to be beneficial to these patients. Vaginal oestrogen cream in post-menopausal women can be tried on a short-term basis. Drug therapy includes anti-cholinergics and beta-3 agonist called mirabegron. Cases resistant to the above treatment usually end up with intra-vesical BOTOX injection.Neuromodulation such as PTENS and sacral neuro-modulation can be tried prior to surgical procedures such as augmentation cystoplasty.
Uro-genital prolapse is a common finding in a multiparous women with urinary or bowel symptoms. Vault prolapse is seen after hysterectomy. Clinical examination usually suffices but complex recurrent cases may require further investigations such as dynamic MRI scan. Most cases can be corrected surgically by the vaginal route. Vault prolapse can be treated by minimally invasive techniques such as Laparoscopy or indeed Robotic Sacro-Colpopexy.
Common Urological problems in Men
Lower Urinary Tract Symptoms (LUTS)
LUTS is usually caused by benign enlargement of the prostate (BEP) gland. It is common after the age of 40 years. Other can causing LUTS, BEP can also cause recurrent UTI, sexual dysfunction, stones and urinary retention. Examination includes palpating the prostate gland to rule out malignancy. PSA (Prostate Specific Antigen) blood test is strongly recommended. Ultrasound with post-void residual and a flow rate is sufficient to start the patient on medication. A combination of alpha blocker and 5-alpha reductase inhibitor is needed on a long term basis to treat the symptoms. Failure would need bladder outflow surgery such as TURP or LASER operation.
Raised PSA and Prostate Cancer
The incidence of prostate cancer is increasing in India with increased use of PSA blood test.Prostate cancer is diagnosed most often by prostate biopsy but also on histological examination of TURP samples. Patients with raised PSA can be offered mpDWI of the prostate prior to biopsy. Once the diagnosis is established, bone scan and MRI (or CT) is performed. Treatment depends upon the stage of the disease. Active Surveillance is popular for those with indolent cancer. Robotic Radical Prostatectomy has revolutionized the treatment of localized prostate cancer. Radiotherapy is also considered as an equally effective treatment option for localized prostate cancer. Treatment for metastatic disease includes hormonal therapy and possible chemotherapy.
Erectile Dysfunction and Premature ejaculation
Erectile dysfunction (ED) is a common problem encountered in day-to-day urological practice. On many occasions, the patient is hesitant to come out with this problem, especially among the elderly. Taking the patient into confidence is very important to get an accurate history. History of ED is very important in the ageing male as it indicates 'small vessel disease' and the patient needs to be evaluated for coronary heart disease. Investigations include clinical examination of the genitalia and DRE. Treatment includes PDE5 inhibitors (caution with nitrates) and for non-responders intracavernosal injection. Patients may opt for penile prosthesis as well if there is a failure with medications. Premature ejaculation (PE) is again a very common problem and is grossly under-reported. Treatment includes star-stop and squeeze techniques, anaesthetic sprays and condoms (to decrease sensitivity). Of late, SSRIs such as Dapoxitene has been shown to be promising.
Testicular Cancer is a not a common cancer but is often detected late because of the hesitancy by the male patient. Regular Testicular Self-examination needs to be performed any abnormality should raise suspicion of cancer. Clinical examination along with ultrasound clinches the diagnosis. CT scan and tumour markers form part of the investigation. Radical Orchiectomy is treatment of choice. Multidisciplinary approach is mandatory in managing such patients.
Urethral Stricture Disease
Sexually transmitted diseases, trauma, radiotherapy and instrumentation of the urinary tract are the most common causes of urethral stricture disease. Difficulty in voiding, double stream and straining during micturition are common symptoms. Flow rate, residual volume estimation and ascending urethrogram may be performed. Treatment for urethral stricture includes optical urethrotomy or indeed open urethroplasty.
Investigation for male infertility is under the remit of a urologist and andrologist. Thorough history and physical examination is essential. Blood tests and semen analysis will shed more light on the pathology involved. Ultrasound of the testes will provide us the size of the testis and any abnormalities such as a varicocoele. Close liaison with the gynaecologist is essential for obtaining the best results for the couple. Advancement in procedures (such as micro-TESE) ensures that sperms can be retrieved for successful IVF treatment.