UROFLOWMETRY - THE BEST SCREENING TEST IN UROLOGY

                  Uroflowmetry is a simple, noninvasive, reliable, repeatable and cost effective investigation to screen for and diagnose lower urinary tract abnormalities. Any person suffering from various urinary disturbances need this simple test to look for any abnormalities in voiding. In this test, one has to pass urine in a specialised funnel that is connected to a flow sensor.

• Elderly(>50 y) men undergoing non-urological surgeries may have underlying bladder outlet obstruction secondary to prostatomegaly. 
• Healthy men above 50 y also need this test as a part of general health checkup to identify obstruction at an early stage so that it complications like renal failure, retention, stones, bleeding and infections can be prevented.
• People with symptoms can be better assessed by this test and the treatment can be significantly guided by the findings on this test.

Uroflowmetry Machine

Normal pattern - to severely impaired flow patterns

Intermiitency

LASER PROSTATECTOMY FOR 17O GM PROSTATE IN A HIGH RISK PATIENT

 A 60 year old gentleman came to us with prostate enlargement and renal failure. He was on maintenance dialysis for the kidney ailment. His prostate was phenomenally large in size (170 gm).The patient was having severe urinary tract infection amenable only to a last line antibiotic -colistin (Multi Drug Resistant organism). He was kept on catheter by almost 4 months and considered to be a very high risk case by doctors outside. We did prostatectomy successfully using Thulium LASER technology. This remarkable feat was achieved in a single session and the patient was discharged within 48 hours of the surgery. He is now free of catheter and the infection.
Conventional method of doing prostatectomy (Trans Urethral Resection of Prostate – TURP) has limitations in such cases. As the size increases; the complications like bleeding and fluid overload also increase. Proceeding ahead with TURP in such cases would have been fraught with the risk of life threatening intra-operative and post- operative haemorrhage.
Currently Ramayya Pramila is the only centre with Thulium LASER facility in whole Andhra Pradesh. We are the pioneers in the field of LASER applications in urology. We were the first ones to use LASER technique for prostate removal way back in 2008.  This centre can boast of treating many such cases again testimony to the fact that the size of the prostate is of no consequence with this wonderful technology. This technology provides respite to high risk patients like patients on blood thinners, aged and frail patients with heart ailments who otherwise cannot be operated with routine methods.
Thulium LASER prostatectomy with morcellation provides significant reduction in bleeding, morbidity and hospital stay. We usually keep the catheter for 24-48 hours (a tube that drain the bladder) and discharge the patient within 48 hours. This is in total contrast to routine TURP where catheter and stay is prolonged (3-5 days) notwithstanding the complications like bleeding.

Slowly this technology is gaining widespread acceptance amongst urologist all over the world. We use smaller diameter endoscope for the surgery and therefore the incidence of post-operative stricture (narrowing because of damage to the urinary tract during the surgical procedure and hence recurrence of urinary problems) is low. It also safely preserves the continence and erectile function of the patients. 
We have done a total of 1250 cases till now using this LASER. Many of the cases were referred to us by cardiologists because of their cardiac problems. Some of patients were on drug eluting stents. In this group of the patients; blood thinners cannot be discontinued. Routine TURP in such patients would have been highly risky. A few were also referred by our fellow urologists; the reason being a large size of the gland. The complications like bleeding, blood transfusing was almost nil. We also did 2 patients in local anaesthesia (pudental block) as they were deemed unfit for any major anaesthesia.
We feel proud to declare that one of our urologists-Dr Naveenchandra Acharya-got first prize for paper on LASER prostatectomy on such high risk patients. He presented a data of 250 such procedures at European Urology Association Meeting held at Abudhabi. The paper was critically acclaimed at the summit. This will pave a way for acceptance of this technology amongst our colleague urologists.
We strongly feel that Thulium LASER is the new emerging platinum standard for prostate surgery and should be adopted by health care professionals for its versatile and superior technology. 

Health Camp Organised at Uppal

Ramayya Pramila in Media

World Diabetes day Hyderabad and Urologic complications of diabetes- BLUE CIRCLE it for treatment and prevention

World Diabetes Day (WDD) is celebrated every year on November 14. World Diabetes Day was created in 1991 by the International Diabetes Federation and the WHO.

November 14 is the birthday of Frederick Banting who, along with Charles Best, first conceived the idea which led to the discovery of insulin in 1922.

Each year World Diabetes Day is centred on a theme related to diabetes. Diabetes Education and Prevention is the World Diabetes Day theme for the period 2009-2013.

The World Diabetes Day logo is the blue circle - the global symbol for diabetes which was developed as part of the Unite for Diabetes awareness campaign. The circle symbolizes life and health.

India is facing an epidemic of diabetes. At present, confirmed diabetes patients in India are 67 million, with another 30 million in prediabetes group. By 2030, India will have the largest number of patients in the world. Diabetes is not only a blood sugar problem, but brings along other complications as well.

Diabetes and urologic diseases are very common health problems that markedly increase in prevalence and incidence with advancing age

Diabetes is associated with an earlier onset and increased severity of urologic diseases. Apart from increased frequency and severity of urinary tract infections Diabetes is also associated with kidney stone formation, bladder dysfunction, sexual dysfunction and various other renal abnormalities.

Diabetic nephropathy

A complication that occurs in some people with diabetes. In this condition the filters of the kidneys, the glomeruli, become damaged. Because of this the kidneys 'leak' abnormal amounts of protein from the blood into the urine. This can lead to renal failure, cardiovascular diseases and high blood pressure.

Urinary tract infections

Diabetic individuals have a two- to threefold higher prevalence of asymptomatic bacteriuria and are at risk for developing more serious consequences. Emphysematous cystitis and pyelonephritis,relatively rare infections, occur almost exclusively in diabetic patients.

Other clinical manifestations that are unique or strongly associated with diabetes include abscess formation and renal papillary necrosis. 

Bacteremia secondary to UTI and pyelonephritis may also be more common in patients with diabetes.

Also of importance is the fact that many diabetic patients are infected with non–Eschereschia coli species in particular klebsiella and other gram negative rods, enterococci and other group B streptococci.

Additionally, urinary infections and asymptomatic bacteriuria with Candida Albicans occur commonly in diabetic women.

Diabetes and kidney stones

Individuals with type 2 diabetes are at an increased risk for developing kidney stones in general, and have a particular risk for uric acid stones. People with type 2 diabetes have highly acidic urine, and this metabolic feature helps to explain their greater risk for developing uric acid stones

Bladder dysfunction

Over 50% of men and women with diabetes have bladder dysfunction. Current understanding of bladder dysfunction reflects a progressive condition encompassing a broad spectrum of lower urinary tract symptoms including urinary urgency, frequency, nocturia, and incontinence. Symptoms due to BPH are more severe in diabetes patients. Previously, the dysfunction has been classically described as diminished bladder sensation, poor contractility, and increased postvoid residual urine, termed bladder cystopathy . However, bladder cystopathy most likely represents end-stage bladder failure with symptoms of infrequent voiding, difficulty initiating voiding, and postvoid fullness and is relatively uncommon.

Bladder instability or hypersensitivity is the most frequent finding, ranging from 39–61% of subjects. Diminished bladder contractility or sensation has been found less often and an acontractile bladder appears to be quite uncommon.

Male sexual dysfunction

Erectile dysfunction (ED) occurs in a substantial number of men with diabetes, with prevalence estimates ranging from 20 to 71%. In men with diabetes, the relative risk for ED increases with poor glycemic control, duration of diabetes, and the number of other nonurologic complications of diabetes (i.e., retinopathy, nephropathy, and limb loss).

Phosphodiesterase-5 inhibition leads to significant improvements in function in 50–70% of type 1 and type 2 diabetic patients with ED and controlled hyperglycemia. However, the efficacy is reduced compared with nondiabetic populations. Nonresponders to oral treatment benefit from intracavernosal injections of prostaglandin-E1 and related agents, as >80% of men with diabetes develop adequate penile rigidity.

Effective surgical interventions in such cases are limited to penile implants. The risk of periprosthetic infection after implantation in diabetic men ranges from 3.2–15%.

Femalesexual dysfunction

Female sexual dysfunction is associated with biological, psychological, and social determinants. It includes disorders of desire/libido, arousal, inhibited orgasm, and sexual pain. Prevalence increases with age, cardiovascular disease, diabetes, cancer, hysterectomy, and neurological conditions.

Who is at risk for developing sexual and urologic problems of diabetes?

Risk factors are conditions that increase the chances of getting a particular disease. The more risk factors people have, the greater their chances of developing that disease or condition.

Diabetic neuropathy and related sexual and urologic problems appear to be more common in people who

• have poor blood glucose control 
• have high levels of blood cholesterol 
• have high blood pressure 
• are overweight 
• are older than 40 
• smoke 
• are physically inactive 

Can diabetes-related sexual and urologic problems be prevented?

People with diabetes can lower their risk of sexual and urologic problems by keeping their blood glucose, blood pressure, and cholesterol levels close to the target numbers their health care provider recommends.

Being physically active and maintaining a healthy weight can also help prevent the long-term complications of diabetes. 

For those who smoke, quitting will lower the risk of developing sexual and urologic problems due to nerve damage and also lower the risk for other health problems related to diabetes, including heart attack, stroke, and kidney disease.

Review of your medication,Certain medicines can affect the kidneys as a side-effect which can make diabetic kidney disease worse. For example, you should not take anti-inflammatory medicines unless advised to by a doctor. You may also need to adjust the dose of certain medicines that you may take if your kidney disease gets worse.

Urine leak in elderly men and women

Urine leak in elderly

Urine leak afflicts unto 30% of older people living at home. It is associated with embarrassment, stigmatization, isolation, depression, anxiety and risk of institutionalization. It predisposes to perineal rashes, ulcers, urinary tract infections, urosepsis falls and fracture. Also the cost of management of geriatric incontinence is high. Despite these considerations geriatric incontinence remains neglected by patients and physicians alike or dismiss it as a normal part of growing old. But it is abnormal at any age. More ever its increased prevalence relates more to age associated diseases and functional impairment than to age itself.

Regardless, incontinence is usually treatable and often curable at all ages even in frail elderly but the approach differs significantly from that used in younger patients.

Pathophysiology

At any age, continence depends on integrity of lower urinary tract and presence of adequate mentation, mobility, motivation and manual dexterity. lower urinary tract changes with age even in the absence of disease. Bladder controllability, sensation and ability to postpone voiding decline in both male and female. 

However there are more changes in female urethra w.r.t sphincter, pelvic muscles and length of urethra.

Involuntary bladder contraction increases in both sexes and elderly often excrete most of the fluid intake at night.

There may be associated prostate enlargement and obstruction of outflow due to prostate, renal disease, heart failure etc. The above changes predispose to urine leak.

In most of the cases the onset or exacerbation of urine leak is probably due to precipitants outside lower urinary tract that are amenable to medical treatment and treatment of these precipitants alone may be sufficient to restore incontinence.

Transient urine leak

Incontinence is transient in upto one third of elderly and more than half of hospitalized patients. Although termed incontinence it may persist if left untreated.

Urinary tract infections(UTI) are commonest cause of transient urine leak when urgency and burning sensation are so prominent that the older person is unable to reach the toilet before voiding. Incontinence is occasionally the only symptom of UTI and traetment of UTI resolves the incontinence.

Atrophic urethritis and vaginitis causes incontinence and urine leak in upto 80% of elderly women with incontinence. It is associated with urgency and occasionally sense of scalding that mimics a UTI and also exacerbates stress incontinence. Recognizing atrophic vaginitis is important as it may respond to low dose estrogen. This also prevents recurrent UTI's. 

Stool impaction (chronic constipation) may cause both fecal and urinary incontinence in 10% of older individuals. Disimpaction and healthy bowel habits restores continence.

In addition many drugs are associated with urinary incontinence. Excess urine production due to diuretics, caffinated beverages, diabetes and congestive heart failure may lead to incontinence , treatment of which corrects incontinence.

Incontinence due to lower urinary tract abnormality

Bladder(detrusor) over activity is the most common type of lower urinary tract dysfunction in a incontinent male or female elderly. It occurs due to increased spontaneous activity of bladder muscles. Over activity may be due to central nervous system abnormality or due to bladder abnormality. Anticholinergics, injection therapy helps in most of the cases.

Incontinence in the setting of outlet obstruction is second most common cause of incontinence in older men.

It may be due to urgency or overflow and treatment of enlarged prostate  relieves the symptoms.

In older women urethral stenosis due to fibrotic changes and atrophy may lead to incontinence. resolves by use of low dose estrogen cream and dilatation.

Stress incontinence is second most common cause of incontinence in women. Occurs due to birth and operative trauma and also due to age related atrophy. stress incontinence can be cured by sling surgery, pelvic exercises injection therapy etc.

Evaluation of urine leak involves identification of contributing factors lab testing for kidney functions. Urodynamics is strongly considered in certain group of patients with bladder weakness and over activity.

Successful treatment of urine leak in elderly is usually feasible.

Treatment of contributing factors such as medications and systemic problems can improve the incontinence.

Incontinence due to obstruction is treatable by removal of obstruction such as prostate surgery.

Multifactorial creative, persistent and optimistic approach increases chances of successful outcome.     

LARGE BLADDER CLOT EVACUATED ENDOSCOPICALLY BY MORCELLATOR

A 79 y gentleman underwent spine surgery and was put on LMW Heparin for DVT prophylaxis. On the post operative day 3, his PUC was removed and he went into retention. Foley's reattempted but failed leading to bleeding per urethra.
Urologist opinion was then sought.PUC was attempted only once by Urologist but could not succeed. Patient  was counselled for SPC and risk of hematuria due to concomitant use of LMW Heparin therapy. Trocar SPC was done under LA at bedside and around 1 litre urine drained. Later he developed repeated SPC blockage due to clots which were flushed at regular intervals by bladder wash syringe.
 Later it was decided to shift the patient to our center from outside facility,for cystoscopy and clot evacuation. On cystoscopy there was a false passage in bulbar urethra and obstructive prostate with  huge  clot in the bladder. As the bladder was already tense, any use of Elliks evacuator will increase the chances of  bladder rupture. Hence the massive clot was removed by Morcellator completely under anaesthesiologist cover.

PRONE POSITIONING OF A PATIENT WITH ANKYLOSING SPONDYLITIS FOR PCNL

Ankylosing spondylitis is a debilitating disease that causes fusion of vertebrae and sacroiliac joints with severe morbidity.

Performing surgery in such patients with restricted mobility and ventilatory difficulties is a challenging task.

One such patient underwent PCNL at our hospital for a partial staghorn kidney stone under spinal anaesthesia (which is sometimes very difficult due to fused vertebrae and ossification with loss of curvature). One may also observe the lack of side movement of the head due to fused cervical vertebrae.The procedure was uneventfully performed by our urology team and patient was discharged safely.

EMERGENCIES ALL SHOULD KNOW:ANAEMIA (SEVERE PALLOR)

SEVERE PALLOR

Pallor is a pale color of the skin which can be caused by illness, emotional shock or stress, stimulant use, or anaemia, and is the result of a reduced amount of oxy hemoglobin in skin or mucous membrane.Pallor is more evident on the face ,palms,conjunctiva,tongue etc.. It can develop suddenly or gradually, depending on the cause. It is not usually clinically significant unless it is accompanied by a general pallor pale lips,tongue,palms,mouth etc.

Common causes:

• anaemia, due to blood loss, poor nutrition, or underlying disease such as sickle cell anaemia 
• shock, a medical emergency caused by illness or injury 
• frost bite 
• underlying cancer 
• leukemia 
• peripheral vascular disease 
• emotional response, due to fear,embarassment ,grief etc. 
• lead poisoning 
• reaction to ethanol and/or other drugs such as cannabis, 
• malaria 
• hemolytic anemia 
• congenital heart disease 
• chronic renal disease 
• iron/folate/B12 deficiency 
• G6PD deficiency 
• GI Bleeding 
• worm infestations 
• malnutrition 

Paleness, also known as pale complexion or pallor, is an unusual lightness of skin color when compared with your normal hue. Skin color is determined by several factors, such as the amount of blood flowing to the skin, skin thickness, and the amount of melanin in the skin. Paleness is caused by reduced blood flow or a decreased number of red blood cells. Paleness can be generalized (all over) or local.

Anemia, a condition in which the body doesn’t produce enough red blood cells, is one of the most common causes of paleness. Anaemia can be acute (sudden onset) or chronic (developing slowly).

Acute anemia is usually the result of rapid blood loss from trauma, surgery, bleeding stomach ulcers, or bleeding from the colon.Symptoms of acute onset anemia include:rapid heart rate, shortness of breath,high or low blood pressure,loss of consciousness,irregular or absent menstrual period (DUB) etc.

Chronic anemia is very common. It can be caused by not having enough iron, B12 or folate in your diet. There are also genetic causes of anemia such as sickle cell disease and thalassemia (a genetic disorder that destroys red blood cells). Anemia that develops more slowly can be caused by diseases such as chronic kidney failure or hypothyroidism (when the body does not produce enough thyroid hormone). Certain cancers that affect the bones or bone marrow can also cause anemia due to slow blood loss over a period of weeks to months.

Local paleness usually involves one limb. You should see your doctor if you have sudden onset of generalized paleness or paleness of a limb.Arterial blockage (poor or lack of blood circulation) can cause localized paleness, typically in arms or legs. The limb becomes painful and cold due to lack of circulation.Untreated arterial blockage of a limb can result in gangrene, which can result in the loss of a limb.

Paleness accompanied by signs of blood loss such as fainting, vomiting blood, bleeding from the rectum or abdominal pain is considered a medical emergency. Shortness of breath and sudden onset of paleness, pain and coldness of a limb are also serious symptoms that require immediate medical attention.Your doctor will also review your medical history and perform a physical examination to check your vital signs (heart rate and blood pressure). Pallor can often be diagnosed on sight, but can be hard to detect in people with dark complexions.

Investigations: 
CBC (complete blood count, evaluates if you have anemia),reticulocyte count (a blood test that shows if your bone marrow is replacing blood loss),stool test for the presence of blood,,thyroid function tests (low levels of thyroid hormone causes anemia),BUN and creatinine (kidney function tests),serum iron, B12, and folate levels (to see if nutritional deficiency is causing anemia)

Treatment

• Balanced diet, and iron (oral/parenteral), B12 or folate supplements,vitamin supplements 
• Erythropoietin to stimulate RBC production

• Blood Transfusion may be necessary in some cases 
• Anti-malarials,de-worming therapy, 
• surgery is an option for certain causes of acute blood loss, such as trauma. Surgery may also be required for treatment of arterial blockage. 

The long-term consequences for non-treatment of pallor depend upon the underlying cause. Untreated anemia due to blood loss can be fatal. Severe nutritional anemia can lead to other long-term health issues recurrent infections,cardiac failure,.

.


The development of pallor can be acute and associated with a life-threatening illness, or it can be chronic and subtle, occasionally first noted by someone who sees the child less often than the parents. The onset of pallor can provoke anxiety for parents who are familiar with the descriptions of the presentation of leukemia in childhood. In some instances, only reassurance may be needed, as in the case of a light complexioned or fair-skinned, non-anemic child.

Clinically, pallor caused by anemia usually can be appreciated when the hemoglobin concentration is below 8 to 9 g/d.The concentration of hemoglobin in the blood can be lowered by three basic mechanisms:

• Decreased erythrocyte production

• Increased erythrocyte destruction

• Blood loss

WHO's Hemoglobin thresholds used to define anemia(1 g/dL = 0.6206 mmol/L)

Age or gender group	Hb threshold (g/dl)	Hb threshold (mmol/l)
Children (0.5–5.0 yrs)	11.0	6.8
Children (5–12 yrs)	11.5	7.1
Teens (12–15 yrs)	12.0	7.4
Women, non-pregnant (>15yrs)	12.0	7.4
Women, pregnant	11.0	6.8
Men (>15yrs)	13.0	8.1

EMERGENCIES ALL SHOULD KNOW:ACUTE URINARY RETENTION

ACUTE URINARY RETENTION

 Acute retention causing complete anuria is a medical emergency, as the bladder is filled with urine and can stretch to enormous sizes and possibly tear if not dealt with in time. If the bladder distends more, it becomes painful. 

The increase in bladder pressure can also prevent urine from entering the ureters or even cause urine to pass back up the ureters and get into the kidneys, causing hydronephrosis,sometimes kidney failure, and sepsis. A person should go straight to an emergency department  as soon as possible if unable to urinate for a long time and having a  painfully full bladder.

The causes are
Central causes

• Consumption of some drugs like amphetamine etc.,
• patients suffering from mental retardation,multiple sclerosis,stroke,diabetic autonomic neuropathy, 

In the bladder

• neurogenic bladder,spinal cord diseases,bladder neck contracture,etc.

In the prostate

• Prostate enlargement either benign or malignant

  urethra

• Congenital urethral valves
•  pinhole meatus
• Obstruction in the urethra, for example a stricture (usually caused either by injury or STD), 
• obstruction in urethra due to a stone

Urinary retention often occurs without warning. It is basically the inability to pass urine. In some people, the disorder starts gradually but in others it may appear suddenly. Acute urinary retention is a medical emergency and requires prompt treatment. The pain can be excruciating when urine is not able to flow out. Moreover one can develop severe sweating,chest pain,high blood pressure.

In the longer term, obstruction of the urinary tract may cause:

• Bladder stones
• weakness of detrusor muscle of bladder (atonic bladder is an extreme form)
• Hydronephrosis of one/both kidneys leading to renal dysfunction
• Diverticula (formation of pouches) in the bladder wall (which can lead to urine stasis ,stones and infection)

In acute urinary retention, catheterisation or suprapubic cystostomy (SPC) relieves the retention. These catheters are  inserted by preferrably urologist/trained health care professionals under proper antibiotic cover.

 If the procedure is not done in a sterile fashion, it can introduce infection into the bladder. This can result in an infection of the entire urinary tract. Therefore, sterile technique is a must when inserting a foley catheter. Careful washing of hands, meatus, and reusable catheters are also necessary with clean self catheterization techniques.

In the longer term, treatment depends on the cause.

 BPH may respond to Alpha blocker therapy/laser prostate.

 Some people with BPH are treated with medications like finasteride or dutasteride to decrease prostate enlargement. The drugs only work for mild cases of BPH but also have mild side effects. Some of the medications decrease libido and may cause giddiness,/ fatigue.. 

Older patients with ongoing problems may require continued intermittent self catheterisation in case of neurogenic bladder.

When you urinate, the brain signals the bladder muscle to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax. As these muscles relax, urine exits the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.In case of detrusor-sphincter-dyssynergia (DSD) is a condition where some brain/spinal cord diseases contribute to retention of urine.

Urinary retention is a common disorder in elderly males. The most common cause of urinary retention is BPH. This disorder starts around age 50 and symptoms may appear after 10–15 years. BPH is a progressive disorder and narrows the neck of the bladder leading to urinary retention. By the age of 70, almost 10 percent of males have some degree of BPH and 33% have it by the eighth decade of life. While BPH rarely causes sudden urinary retention, the condition can become acute in the presence of certain medications like anti-parkinsonism drugs,anti-psychotics, etc.

In young males, one of the the most common causes of urinary retention is acute infection of the prostate and  the infection is acquired during sexual intercourse.The other common cause is urethral stricture which will be treated succesfully by Optical urethrotomy where the urologist will  incise the stricture under anaesthesia cover.

A woman may experience urinary retention if her bladder sags or moves out of the normal position, a condition called cystocele.The abnormal position of the bladder may cause urine to remain trapped.Cystocele and rectocele are often the results of a dropping of the pelvic support floor for the bladder as seen in mulltiparae,elderly women etc.These are successfully treated by a dedicated urology team.