MAJOR ISSUES IN SEXUAL MEDICINE THESE DAYS IN INDIA

Female sexual dysfunction and unconsummated marriages:

Despite the land of Kama sutra; the Indian society is still largely conservative about sexual issues. There is lack of proper sex education in Indian High schools and adolescents. The sex word is supposed to be a taboo in both urban and rural society. Although the concept of swayamvara (girl choosing her own groom) existed in Indian Vedic Literature some 4000 years ago; the arranged marriages are still prevalent in the Indian subcontinent. The Institution of arranged   marriages in India has been proved to be immune to the social, economic and educational progress what India has achieved. In rural background many a times the arranged marriages are forced on girls on the basis of caste and financial reasons.

Only 1.1% of marriages in India result in a divorce compared with over 45.8% in the United States, though the Indian figure appears to be rising. The remarkably low rate of divorce can also be because of female partner silently suffering in the forced marriages without voicing any discontent about physical/verbal abuse. They are also less likely to complain about dissatisfaction about sexual life.

The main problem with arranged marriage many a times is that there is no proper communication between the couple especially on the issues of sexual needs and preferences. This lack of sexual communication in the immediate post marriage life can lead to marital malaise and unconsummated marriage. Lack of privacy, system of combined family; orthodox society, and lack of sexual education during adolescence leads to a lot of sexual problems in newlywed couples. In Indian society that premarital relationship is not accepted so most of the girls are virgins till the marriage. So there is lot of fear and anxiety amongst the females after the marriage regarding the coital act.

Unconsummated marriages are the most commonly seen problem in sexology clinic. This is prevalent among 5 to 10 per cent of the marriage population in India. In most cases, the female partner does not allow the male to have an intercourse due to fear of pain.Vaginismus is the commonest reason; anxiety being the common reason. The vaginal muscles contract because of panic reaction leading to severe pain during insertion. Proper sexual counseling and dilatation is the answer for this problem.

In India there are very few systematic sex surveys conducted; so proper information about sexual dysfunction is not available. Female sexual dysfunction is highly prevalent to the extent of around 2/3 rd of married woman suffering from it. Singh et al presented one interesting paper regarding this problem and have highlighted the high prevalence of sexual problems in Indian women.

Average Indian woman has a tendency to neglect the body predisposition after marriage. Multiple child births most often by Dayas (synonym: midwifery in rural Indian set up), sedentary life style, lack of  exercise leads to problems like putting on weight and loose vagina.The lack of self esteem and culture of silence further aggravates the sexual dysfunction in them. Frigidity is common and many a times they just indulge in coital act for fear of verbal/physical abuse upon refusing it.

Male sexual dysfunction:

Khurana et al have shown in their study shown that around 1/3 rd of Indian men have metabolic syndrome in the form of dyslipidemia, and diabetes. The pandemic of diabetes in India has also led to increase in incidence of sexual dysfunction. As metabolic syndrome and endothelial dysfunction (hence erectile dysfunction) go hand in hand; the erectile dysfunction may be higher in India than the other countries in the world. In urban India with the advent of software and BPO companies, night duties and long stressful working hours have contributed to increased incidence of sexual dysfunction. Of late there has been increased awareness about sexual problems in Indian men due to mass media, newspapers, late night programs in TV channels and various web marketing programs. The proportion of couples seeking an appointment with the sexologist is on the rise. One of the welcome changes that is happening now-a-days is the couple coming together and visiting the doctors. The female counterparts are also forthcoming in their complaints especially in urban India. The general myths like Dhat syndrome (losing semen and hence energy) and guilt/misconceptions about the masturbation still continues to haunt the adolescents in India. The age old misconception about losing one drop of semen is equal to 40 drops of semen is still surprisingly high in adults because of lack of sex education. In certain rural areas, there is a general misconception that the sex with the virgins gives relief from venereal diseases. This only underscores the urgent need of starting sex education right at the high school age on a warfooting.   

Various sexual practices and problems with sexual orientation in India:

Different sexual practices in India are influenced by the social and religious laws (sexual morality).Anything other than conventional sexual practices are not encouraged and viewed with disgust. In fact, oral sex is listed as 'illegal' under Section 377 of the Indian Penal Code, stated as being 'carnal intercourse against the order of nature', which does not carry the potential for procreation. But with the exposure to internet and pornographic literature more and more young adults and couples are engaging in alternative sexual practices. Common trends what we see in sexology clinic is more and more couples are engaging in foreplay, oral sex and other sexual positions other than the routine missionary position.

The prevalence of lesbian, gay, bisexual and transgender life styles (LGBT) is not known but logically it must be the same as in any other countries. There is general reluctance on the part of people to talk and express their views about it. The Delhi High Court struck down the provision of Section 377 of the Indian Penal Code which criminalized consensual sexual acts of adults in private, holding that it violated the fundamental right of life and liberty and the right to equality as guaranteed in the Constitution. But there has not been any positive response from the Government on this issue; it remains to be ambivalent about this problem.

The last area of concern is HIV endemic in India. The National AIDS Control Program, with its focus on educating the general population about responsible sexual behavior, safer sex and condom use has had a significant impact. The reduction in the rate of HIV transmission in the country suggests success.

Left renal cell carcinoma with IVC thrombus

A 50 year old gentleman presented with mild to moderate  hematuria.On evaluation there was a  left renal mass with IVC thrombus.He was further evaluated with contrast enhanced CT scan which helped us in knowing the anatomical details of the mass and the extent of the thrombus in the IVC.The metastatic work up of the patient was normal.His performance index was also good.
Because of the large size and the vascular thrombus we decided to go ahead with angio-embolisation.Within 48 hours of the proedure we explored the patient with roof- top incision.
The vena cavotomy was done after taking control of the proximal and distal and bilateral renal veins with vascular slings and the thrombus was retrieved.The part of inferior vena cava which was appearing to be involved was also removed and the inferior venacavotomy incision was closed.This was subsequent followed by En Block Radical nephrectomy.

The patient recovered well  after the procedure and the post-operatively after 3 months he is doping well.

xtandi in advanced prostate cancer: A promising drug for chemorefractory disease

We had one patient -50 year old gentleman diagnosed with hormone refractory prostate cancer. His PSA was 100 ng/ml with multiple bony metastases and iliac and paracaval lymphadenopathy with left ureteric obstruction.

He had locally advanced prostate disease with hematuria.We treated with High Intensity Focussed Ultrasound(HIFU) to control the local disease and left ureteric stenting.We also started him on   docetaxel chemotherapy with prednisolone support.He did not show good response ; his PSA came down only to 90 ng/ml. We started him on Xtandi and were planning for samarium radio-isotope therapy for bony pains but he did show remarkable symptomatic as well as PSA improvement with Xtandi( after 1 1/2 months the PSA was 75 ng/ml).For now we have dropped our plans for samarium therapy.

 Enzalutamide is an androgen receptor inhibitor that acts on different steps in the androgen receptor signaling pathway. Enzalutamide has been shown to competitively inhibit androgen binding to androgen receptors and inhibit androgen receptor nuclear translocation and interaction with DNA. A major metabolite, N-desmethyl enzalutamide, exhibited similar in vitro activity to enzalutamide. Enzalutamide decreased proliferation and induced cell death of prostate cancer cells in vitro, and decreased tumor volume in a mouse prostate cancer xenograft model.

XTANDI is indicated for the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) who have previously received docetaxel. U.S. FDA Approves XTANDI(R) (enzalutamide) After Priority Review for Patients With Metastatic Castration-Resistant Prostate Cancer Previously Treated With Docetaxel.

 XTANDI is provided as liquid-filled soft gelatin capsules for oral administration. The recommended dose of XTANDI is 160 mg (four 40 mg capsules) administered orally once daily. XTANDI can be taken with or without food.

The most common adverse drug reactions (≥ 5%) reported in patients receiving XTANDI in the randomized clinical trial were asthenia/fatigue, back pain, diarrhea, arthralgia, hot flush, peripheral edema, musculoskeletal pain, headache, upper respiratory infection, muscular weakness, dizziness, insomnia, lower respiratory infection, spinal cord compression and cauda equina syndrome, hematuria, paresthesia, anxiety, and hypertension.Xtandi is specially contraindicated in epileptogenic patients.

The efficacy and safety of XTANDI in patients with metastatic castration-resistant prostate cancer who had received prior docetaxel-based therapy were assessed in a randomized, placebo-controlled, multicenter phase 3 clinical trial. The primary endpoint was overall survival. A total of 1199 patients were randomized 2:1 to receive either XTANDI orally at a dose of 160 mg once daily (N = 800) or placebo orally once daily (N = 399). All patients continued androgen deprivation therapy. Patients were allowed, but not required to continue or initiate glucocorticoids. The pre-specified interim analysis at the time of 520 events showed a statistically significant improvement in overall survival in patients on the XTANDI arm compared to patients on the placebo arm

RamayyaPramila Urology Hospital Launches Advanced Sexology and Fertility Clinic.

RamayyaPramila Urology Hospital a 42 year old HealthCare Institution launches a dedicated advanced sexology and Fertility clinic for both men and women.

The majority of people in India who suffer from sexual problems do so in silence and never take help of properly qualified medical personnel. The result is ruined relationships, divorce, loss of self confidence and self esteem and increased level of stress.The stressful life,competetive work environment,smoking,alcoholism and increased prevalence of diabetes and metabolic syndrome has led to increased incidence of erectile dysfunction.It is estimated that around 50 % people at the age of 50 years suffer from impotence.

The female sexual dysfunction is also rampant but because of shyness, cultural inhibition and lack of trained medical professional in this field; this problem has been largely ignored. Recent research has indicated that the prevalence of sexual dysfunction amongst females, ranges from 25% to 60%, the average being around 40%. However, with changing times, more and more women are becoming open to discuss their sexual problems with their physician and seek treatment for the same.

Male and female  infertility is on the rise in India. The reasons for this condition can include various things including hormonal imbalance, reduction of sperm count, testicular / ovarian diseases, obesity and bad lifestyle choices like abuse of drugs, excessive intake of alcohol and unhealthy eating habits.

The strain and anxiety that  infertility causes in a marriage can lead to problems not only in their relationship but can also lead to tension in the family in general. The person suffering from this condition can often feel humiliated and depressed, and the pressure he feels due to his family and friends can sometimes lead him to seek help from dubious sources like medical quacks etc and spend large amounts of money on treatment that is ineffective and in some cases be harmful to his health.

The mushrooming of sexology and fertility clinics all over our state has provided many patients a solace for their sexual and fertility problems.But a centre where male sexual dysfunction,female sexual dysfunction and fertility problems for both the partners  are taken care off is yet to come.Many times the problems of fertility and sexuality go hand in hand and the both partners can be victims of these problems.Many a times they have to run from pillar to post at different places for getting treatment for their problems.This is an attempt to start all these services under one roof.

Dr Ramayys hospital is known to do all complicated infertility and impotence surgeries like microdissection TESE,microsurgical varicocelectomy,microsurgical vaso-epididymostomy,penile implants,penile reconstructive and revascularisation surgeries.We have in our armamentarium  all the state of art equipments for fertility and impotence evaluation and treatement like microscope,NPTR,colour doppler ultarsound imaging,Vacuum erection devices,vibrator and electroejaculator etc.

The sexology and fertility services will be rendered by a team of doctors comprimsing of Dr naveenchandra Acharya(Andrologist and microsurgeon), Dr Runa Kamat( IVF specialist) and Dr Sharmila Majumdar(Sexologist dealing with male psychosexual dysfunction and female sexual dysfunction).Dr Naveenchandra Acharya has published many papers in the field of andrology and has also recieved best paper award in American Urological Association for his reasearch in seminology.He was the recipient of  the young investigator for his research in male infertility by Clical Biochemistry Association of  India in 2008.He is a member of the editorial board of the Asia Pacific  Society of the Sexual Medicine.His area of interest is male infertility genetics.

He has performed a number of latest penile implants for male impotence and also pioneered the procedure of seminal vesiculoscopy for the first time in India for obstructive azoospemria.

Dr Runa Kamat is infertologist and has been trained in the prestigious institute of PGIMER, Chandigarh.She many successful IVF and ICSI , Hysteroscopies and laparoscopic procedures to her credit.

Dr sharmila Majumdar has done M.S. in Sexuality, PhD: Behaviour Modification and Cognitive Restructuring.She has been trained under under eminent Psychiatrist and Sexologist at NJC, USA.As a Sexologist ; she has worked in the areas of Female sexual Dysfunctions & Male Sexual Dysfunctions. She has done reserach and presented papers in the areas of Female sexual dysfuntions, psycho-social aspects of male infertility, sexual attitudes of peri and post menopausal women, female orgasm, persistent female arousal syndrome, ED in Substance dependent patients, Psycho-sexual aspects of male aging, Psycho-dynamics of unnatural sex, Role of fantasy in sexual relationships etc.She is a consultant at the medical portals , guest editor and contributer in medical magazine and is faculty for many national conferences , CME on various aspects of sexuality in various cities of India.She is presently the only Female sexologist in India.

The  Hospital was established in 1970 by Dr.G.P.Ramayya as a first Specialized Uro-Surgical Hospital in the State of AP.   Dr GP Ramayya was the Professor of Surgery Osmania Hospital and Pricipal Gandhi Medical College.  He was also the personal surgeon to the Nizam of Hyderabad.

Dr Ramesh Ramayya , the present Chairman and Managing Director of the Ramayya Pramila  Urology Hospital has pioneered and was instrumental in introducing  many  Modern State of the Art Minimal Invasive, Non Invasive and Natural Orifice Urological procedures like PCNL, HIFU, LASER, RIRS, URS since his return from the UK in in 1986.

RamayyaPramila Urology Hospital has a strong four member highly qualified and experienced  team of Urologists. Apart from Dr Ramesh Ramayya,  Dr Naveen Acharya,  Dr Vamsi Krishna,  Dr Abdul Fathah offer a 24/7 Urology Service. 

In addition Dr Siva Prasad an experienced Anaesthetist trained at the prestigious Post Graduate Institute in Chandigarh is the full time Clinical Director to ensure standardized perioperative Care. The hospital audits patient care through an electronic platform Excelicare to ensure process driven, protocol based  Urology HealthCare Delivery to ensure excellent outcome.

Largest prostate gland removal in South India

The urologists at Dr RamayyasPramila Hospitals removed the second largest prostate gland in India and biggest gland in South India. The patient presented with inability to pass urine. The urologists said that the operation lasted for three hours adding that usually the prostate gland weighs around 20 grams but 465 gm prostate is quite rare and unique. The tumor measured around 10 cm x9.5 cm x 9.8 cm.Although the hospital is well equipped with State of the art Thulium LASER for removal of large prostate glands we undertook Open Freyers prostatectomy procedure as the size of the gland in pre-operative ultrasonography was phenomenally large.

The patient recovered well after the surgery and now passing urine freely .