‘Naked but not ashamed: Revealing the rare and the common for good outcomes in the management of genito-urinary disorders’

Introduction

Covering one’s nakedness is one of the early lessons we are given as children and uphold when old. Though some of the dressings of our ladies are getting shorter and shorter and the side slits are getting to the groin, and the men are dropping their underwear, there is still a deliberate attempt to keep the essential parts covered.

This upbringing with its cultural and religious reinforcement makes exposing the genito-urinary system a Herculean task even when there is a need to do so.

Positive outcomes in the man­agement of Genito-urinary disor­ders are hinged on revealing those parts of the body. – the genitalia. Indeed, exposure allows the diag­nosis of the disorder and situates it within the context of good urinary tract function and sexual pleasures as a desired outcome.

Exposure in this context not only applies to the anatomy of the genitourinary system but also to how it has been used and some­times who has been the recipient or denied the pleasures.

These areas are presented as follows:

i. Reveal for good outcomes – Covered can’t be cured, exposure offers a great chance of cure. The reality is that some of the presen­tations are rare. As one reveals, our management and its success or otherwise become the basis for write-ups and publications which when pooled help to improve out­comes as we are guided.

ii. Revisiting dogmas and embracing technology. For men, one of the reasons for exposing is in the management of Benign Prostate Hyperplasia.

Benign Prostate Hyperplasia is an enlargement of the prostate found at the base of the urinary bladder.

The patients present with dif­ficulty passing urine, straining to pass urine and poor stream. In ex­treme cases they are unable to uri­nate at all, referred to as retention of urine. We mainly performed an open surgery, though there were minimally invasive methods – trans­urethral resection of the prostate (TURP). The motivation to acquire equipment for minimally invasive methods was low. This was due to the prevailing perception that the Ghanaian and by extension the prostate of the African, was big. Our research revealed that 67 per cent of our prostates were smaller than 75g, which was the cut off for recommending and using this method.

Unfortunately, we deployed this method for only 20 per cent of the cases. With this finding, we pushed to adopt this method for more cas­es with its advantages. At the last review, we currently do more cases by TURP than Open surgery (55% vs 45 %) at the Korle Bu Teach­ing Hospital. Most of the other institutions across the country have also invested in and acquired this technology.

‘The next time you or a loved one needs surgery for an enlarged prostate it will not likely need a cut. We will just chip the mound of prostate away.”

Open prostatectomy

For the few that need open sur­gery, one bottleneck was the need to provide three units of blood at presentation due to the fear of bleeding and needing a blood transfusion.

We proved that group and save of blood is all that is needed for those with normal haemoglobin levels as they did not need any blood transfusion.

The operation must however, be done speedily.

iii. Making genito-urinary procedures pain-free

One question patients ask when they have to undergo procedures and surgeries around the genitals and the urinary system is, ‘Is it painful’?

Prostate biopsy is one of the common procedures we carry out. (taking pieces of the prostate to the lab/ histology to make sure there is no cancer )

The main concern has been pain associated with the procedure. To allay clients’fears, we conducted a study on patients going for pros­tate biopsy. The findings were that post procedure pain was minimal with scores averaging 1/10 to 2 / 10. We could therefore confident­ly assure them that there was no significant pain after the procedure. “Currently a course of paracetamol for a day or so is all that is needed. And many clients realized they don’t even need it. So, relax if you have to undergo the prostate biop­sy procedure.”

For major surgeries, pain relief is important, and we have improved pain management significantly. – The use of epidural analgesia, together with others, has proved effective taking into consideration cultural factors.

iv. Infection associated with genito-urinary disorders and com­plicating procedures has also been explored. Many who needed pros­tate biopsies and their attending physicians feared this complication. After reporting on these complica­tions, we found ways of prevent­ing it. We changed our antibiotic usage including using topical forms (iodine in the anal region), and oral medications, the dosages and dura­tion post procedure. The result is that the procedure is virtually free of this dreaded complication now.

v. Prostate cancer detection using PSA.

i. Flogging men to submis­sion with the prostate cancer big stick, is it justified?

Prostate cancer, if not diagnosed early and seen in an advanced stage, can be deadly. The use of prostate-specific antigen (PSA) and digital rectal examination is a good way of screening, so one can detect the cancer early. The discriminatory effect on prostate cancer risk and chances of cure has been explored.

What we have found is that if your PSA (normal 0-4ng/ml) is between 4ng/ml and 10ng/ml, the majority do not have prostate cancer (80-90%)

Do keep your cool if your PSA is in this range, get a referral, pick an appointment, and see your urol­ogist or genitourinary surgeon at a convenient time.

We must, however, caution that if you wait till your PSA is above 400ng/ml, we have found the can­cer had spread in all those above this figure, making cure impossible.

Operation for prostate cancer (radical prostatectomy) is very effective and offers a long-lasting cure. If you are young – less than 65 years and wish to live till 90 years or beyond then it may be worth considering surgery to take the prostate out if diagnosed with prostate cancer. Most patients (8/10) after the surgery make full recovery at one year. Most people are cured and with good return of urine control and erectile dysfunc­tion that allows a long productive and pleasurable life.

ii. While discussing screen­ing, an important cancer is kidney cancer. The 3rd commonest cancer we see at urology. The success at treatment is dependent on the size of the tumour or swelling.

In most parts of the world, it has been noted that with increased use of imaging like ultrasound, they are seen early with good chance of cure.

The unfortunate observation is that though the size of the tumours has decreased over time in the Country (16cm to 11cm) they are still rather big making chances of cure less. The main disappoint­ing findings occur when we find this in women after delivery with large tumours that are unlikely to respond to treatment.

Sadly, they have gone through antenatal clinics and had ultra­sound scans done which in normal circumstances could identify such tumours. However, the scans had only been focused on the pelvis and the baby while the kidneys next door are not scanned thus these tumours are missed.

We advocate that antenatal scans should include the kidneys as a policy to improve the outcomes in renal kidney disease. If done also at the time of prostate check by competent individuals, we stand a chance of improving the cu re for kidney cancers across all sexes.

vi. Rising incidence of uri­nary stones. Urinary stones directly destroy the kidneys whether in the kidneys, ureters, bladder, or urethra. It does that by blocking the urine flow especially if big and cause infection. Urinary stones a few decades ago thought to be un­common among us as a people, has become a common presentation. Assessing the type of stones that we see; it is obvious the cause has to do with dehydration.

The cause of this increase may be attributed to Global warming, dwindling quality water supply and resultant rising cost of quality wa­ter in the country. Possible fallout from the effects of galamsey.

Solving galamsey will directly save our kidneys.

Let us get back to old days when we drank directly from the taps.

vii. Be mindful of the hole! Choose right, hit right!

Finally,

The penis must be in the right orientation to allow for penetrative sex that is pleasurable and without pain. And for the un-initiated, they are concerned about how it looks. It can be in any direction- up, down or sideways.

This abnormality was said not to be common in the Africans.

If presented early – oral vitamins E causes return to normal. How­ever, surgery is required if presents after 1 year (late)

It is gratifying to note that sur­gery still offers a good outcome as a management option even at this stage.

Some have missed the hole and as a result fractured the penis.

Surgery corrects it and is best done as an emergency.

Some have well-fitting penis but choose the wrong holes

Usually at masturbation

Urology practice in Ghana

In 2005, there were only 11 urol­ogists in Ghana. With a concerted effort in training and mentoring, the country can boast of 66 urol­ogists working in various regions. The Ghana Urological Association has supported these endervours.

The writer is Consultant Urol­ogist, Korle Bu Teaching Hos­pital and Head of Department of Surgery of the University of Ghana Medical School.

BY PROFESSOR MATHEW YAMOAH KYEI