Articles

Author: Dr. Ali Thwaini

Dr Thwaini is a consultant urological surgeon with specialist interest in urological cancers, namely in renal cancers. He was the lead for renal cancers in the Belfast Health and Social Care Trust (Belfast City Hospital). His main skills are in advanced laparoscopy and renal cancer and renal reconstruction procedures.

Platelet-rich plasma cells with Low-Intensity Shock Wave for the Treatment of Male Erectile Dysfunction

Posted on by Dr. Ali Thwaini

Background

Male erectile disorder is becoming an endemic entity with more than 40% of men at the age of 40 being affected by this condition.

There are several aspects that led to this abundance. Mainly, the adoption of a sedentary lifestyle and associated medical conditions like diabetes and hypertension. This is obviously associated with bad social, habits such as smoking, and excessive drinking.

Thankfully, medical treatment has evolved in the past three decades to solve this problem, largely, however, many men feel stigmatized by their dependence on these tablets to maintain, and potentially improve their sexual function, and increasingly men are seeking natural and more durable solutions to cure the current problem and restore their manhood.

The human body is a dynamic entity with cells ever regenerating and replacing the dead ones. Different parts of the body regenerate at different rates, and the fuel for that process is normally the stem cells and other associated factors.

While these are mainly of embryonic origin. Recent evidence, however, showed the abundance of the cells and adults as well, mainly from the fat cells, and the bone marrow.

The utilization of cells in various aspects of the body is a novel field with very promising results.

One of the aspects of regenerative medicine is the utilization of platelet-rich plasma, cells to treat various clinical conditions.

Please let rich plasma contains mainly the liquid portion of the blood that contains various growth factors in addition to an important component of the blood cell. Platelets. For their clotting abilities, however, they contain a significant amount of growth factors that will help repair and regeneration. Of various injured organs.

To increase the concentration of the cells we tend to centrifuge the body at various speeds. This leads to the separation of the important components that can be utilized later for treating various conditions of which erectile dysfunction is one.

Since this is an oval technology, there has been a lot of skepticism us to the scientific application and the success of this procedure.

However, recent, emerging evidence, published and a midline journal, provided a good demonstration to the success of this procedure. Researchers did a prospective trial on 60 patients equally randomize between two groups.

 Those who received PRP showed significant improvement of their sexual function as opposed to the placebo group.

Low-Intensity Shock Wave Therapy (Li-ESWT)

This relatively new modality of treatment is gaining acceptance with encouraging intermediate-term results, as proven by their approval as part of the urology guidelines.

Shock waves appear to induce micro trauma to the tethered tissue hence, stimulating vascular flow and erectile function and one possible mechanism of action is through an endogenous stem cell-mediated regenerative effect. This microtrauma not only stimulates the local regenerative process, but the resultant signals act as a lighthouse for the ADCs to reach and synergistically enhance the local regenerative and repair process in the penile corpora.

Future studies are needed in the form of placebo-randomized trials to establish better the effects of platelet-rich plasma, cells combined with shock waves on ED.

References:

Platelet-Rich Plasma (PRP) Improves Erectile Function: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial

Evangelos Poulios et al. J Sex Med. 2021 May.

Nonsurgical Options for Penile Enlargement A Stretched Fact or a Myth?

Posted on by Dr. Ali Thwaini

Male cosmetic and functional enhancement remains to be an important yet seldom spoken about a topic among men. There have been several proposed treatment options for penile enlargement, most of which are surgical ranging from minimally invasive treatment to open surgery.

However, due to the inherent side effects of these procedures and the time needed to be off work other options have emerged recently was promising results. Below we will discuss one of the conservative options.

Penile Extender Device


This is basically an external device that can be simply applied by the person for a certain amount of time preferably on daily basis. The mechanism of action is stretching on the penis Leading to Mechano-transduction; A process whereby the mechanical stimulus of stretching the penis gets converted into a biochemical stimulation resulting in the progress of cellular proliferation and expansion of the extracellular matrix.

Interestingly, there have been several published small series about the utilization of a penile extender with various encouraging results. Some claim that the use of the penile extender for four hours on daily basis could potentially lead to an increase in the normal penile length of up to 2 cm in a flaccid penis to up to 1.8 cm in stretched penile length.

Others have “extended” the use of penile extender into the treatment of Peyronie’s disease with an encouraging up to 40% improvement of the curvature after a few months of its use.
Of course, any treatment could come with inherent side effects. Penile extender use has the potential of bruising, swelling, and pain ranging between 30 and 40% most of which are simple and self-limiting.

References
Mohammadreza Nikoobakht et al. Effect of the penile-extender device in increasing penile size in men with a shortened penis: preliminary results. J Sex Med. 2011Mohammad Reza Nowroozi et al. Applying extender devices in patients with penile dysmorphophobia: assessment of tolerability, efficacy, and impact on erectile function. J Sex Med. 2015

The Shortest Distance Between two Points in a Straight Line

Posted on by Dr. Ali Thwaini

Peyronie’s disease is a rather common and potentially debilitating condition for sexually Active men.

What is Peyronie’s disease?

It must be quite unnerving in to wake up on a random morning to see one’s erect penis has “taken a turn”.

While the mainly this condition is idiopathic, some are attributed to various other clinical conditions such as Dupuytren’s contracture.

Painful erections with penile deviation to start with, however, with time, the pain settles leaving behind the penile deviation while erect, which sometimes interferes with sexual activity causing dissatisfaction for the patient and the partner

Treatment

There have been several attempts to treat this condition conservatively and most of these conservative treatments were, at best, equal to placebo.

These have ranged from a variety of supplements like vitamin E, Paraamino Benzoic Acid (Potaba) calcium channel blockers, and even local injection of steroids, with no beneficial effects

Surgical interventions on the other hand provide a definite alternative, however, they come with their inherent side effects.

These are generally divided into penile shortening and penile lengthening procedures;

While the former concentrates on shortening the healthy side of the penis to make it as short as this affected side, this inevitably results in losing some of the erect penis’s length, which all men find unsatisfactory..

Penile lengthening procedures, although seemingly appealing, they have the potential side effect of causing erectile dysfunction as it involves cutting the affected segment that’s responsible for the disease, thus causing the potentially venous leak, which will hinder the erectile process

Recently, there has been some treatment which was initially effective. Collagenase clostridium histolyticum (Xiapex) has been tried with initially promising results, however, due to its significantly high price and the potential side effects of corporal rupture, its use has faded, as with other treatments

Other physical treatments such as external shockwave treatment on Penile remodeling have been attempted with modest results

Regenerative medicine has become a viable alternative in a variety of clinical conditions, and Peyronie’s disease is no different.

Several researchers have attempted the injection of platelet-rich plasma cells (PRP) (with or without hyaluronic acid) into the area of the plaque, in addition to exposing the affected area to shockwave treatment and the results are thus far, promising

It takes one or more sessions depending on the severity of the condition and it is carried out as an outpatient procedure with minimal side effects

The immediate results are encouraging, however, we are still waiting for the intermediate long-term results

Watch the space!

References

Young Adults Male Infertility Causes & Treatment

Posted on by Dr. Ali Thwaini

Infertility is a common problem affecting young adults. At least one and six couples would be suffering from this condition. It is the inability to conceive after one year of unprotected intercourse. While traditionally fingers are always pointing towards the female partner, men are equally responsible for inFertility with 50% being caused by the male factor.

Of course, there are other factors causing infertility despite Both partners having normal parameters. When it comes to male factor infertility, there are several causes such as infections, trauma exposure to toxins, or congenital problems. Many of these factors are easily treatable, however, some might require an intervention to facilitate conception (Assisted fertilization). While this started fairly recently in the 80s with limited success, With the advancement of technology and medical sciences, success rates of dramatically increased.

Sperm harvest, though challenging, is becoming more feasible with the improvement in technology. This includes Microscopic testicular sperm extraction, Epididymal sperm aspiration, etc. The application of regenerative medicine in many aspects of healthcare is becoming more popular, however, when treating infertility, this remains to be experimental. Watch the space!

Dr. Ali Thwaini is one of the urologists and provides male infertility treatment in Dubai

Blood in the urine Have you ever noticed that the color of your urine is darker than normal?

Posted on by Dr. Ali Thwaini

Blood in the urine (hematuria) could manifest itself from a variety of conditions. This could be quite alarming finding when it happens. People would normally Google their symptoms and Dr. Google gives them the scare of their lives when going through the list of causes! First, red-colored urine doesn’t automatically mean that there’s blood in it.

There are various conditions that might lead to darker color urine, sometimes red, but aren’t associated with bleeding; these could be simply dehydration, excessive beetroot intake, some medicine ( e.g. Rifampicin), or excess intake of certain vitamins. When you have altered color urine, the best thing is to get it checked with the laboratory.

Urine is normally tested using a special dipstick test that contains chemicals able to detect blood constituents. This is a very fast test, cheap, and fairly reliable. Urine microscopy is another alternative. Both are non invasive and easily performed. If these tests confirm the present of blood, further assessments are required. These are in the form of radiological imaging ( ultrasound scan, or sometimes CT scan).

The other test is a direct visual inspection of the urethra and urinary bladder. This is carried out in the clinic using a flexible cystoscope under local anesthesia. It’s a very common, easy, and efficient procedure to confirm, or better, rule out urinary bladder pathology. Whilst hematuria is an alarming finding, mostly it’s due to non-sinister causes; these could range from urinary tract stones, infections, benign enlargement of the prostate. However, occasionally, there could be a significant underlying pathology, such as urinary tract cancer. There are some predisposing factors though; with the main being smoking. And yes, Shisha smoking, though the thought of as a benign social hobby, is by no means less harmful than cigarette smoking (one shisha smoking equals 70 cigarettes!).

Therefore, if you develop such a symptom, it is always better to visit your urologist to have the necessary tests carried out. All these tests are available at the Mediclinic City Hospital.

What does it take to Become a Surgeon? -I Meant No Harm

Posted on by Dr. Ali Thwaini

There are many prerequisites to be a successful one. Those range from maintaining composure when the unexpected happens. Having the mental and physical endurance that matches the unpredictable nature of surgery. Communication and leadership skills. Above all, the humility of adopting an ongoing strive to learn in order to sharpen one’s skills, such as critical analysis and creativity. Achieving these goals appears challenging, but for them to be achieved in exceptional circumstances of escaping a war torn country, traveling between cities, working as a second-class citizen, and fighting to save patients’ and loved ones’ lives is captivating.

I Meant No Harm provides a distinct perception of many turbulent journeys through illness toward a cure. Those who succeed in their journey become the lighthouse that guides the surgeon through the dark times. Those who succumb to their illness while battling their disease leave their surgeons scarred for life.

Renal cancer The silent killer

Posted on by Dr. Ali Thwaini

Renal Cancer is one of the come in urological counters affecting people are different stages of their lives. There are about 75,000 renal cancer new cases diagnose every year the United States Constitution saying about 5% of all other cancers and women are equally affected. While there are no definite predisposing factors to the development of renal cancers, There is a weak link between obesity and hypertension and, of course, smoking, to the development of real Cancers.

Most are diagnosed Anecdotally, however, some Are hereditary. Such as VHL disease. Before the advancements in medicine and surgery, kidney cancers were diagnosed rather late and patients were beyond the stage of cure. Due to the rightfully low thresholds and imaging, most of these cancers tend to be diagnosed incidentally and in early stages, Hence the name “incidentalomas”.

The benefits of early diagnosis of kidney cancer Are multifactorial; With early diagnosis, Tumors tend to be at a very early stage And patients are being offered kidney Sparing operations. This type of treatment has the potential of preventing The development of chronic kidney disease. Also, when the tumors are diagnosed at an early stage, especially in people who are high-risk surgical candidates, there is the option of minimally invasive treatment, in the form of the use of high or low temperatures to remove the cancer cells; this is in the form of radiofrequency ablation, Microwave ablation, And cryoablation. These methods have safe, proving their efficacy and safety.

The third benefit of diagnosing early kidney cancer is having a chance to follow them up closely In order to understand the biology of the disease. Several studies have shown that small kidney cancers tend to grow at a very slow pace the elderly and there is an option of active surveillance in this particular cohort of patients. Having said all the above, nephron-sparing surgery remains the gold standard in early localized kidney cancers, especially when technically feasible and safe. Surgery, on par with Medicine, has significantly progressed, and we have moved from open surgery to laparoscopic and then robotic surgery. While all options have proven their Efficacy in curing kidney cancer, the latter two surgical options have proven their safety and efficacy in providing an early return to normal function with less perioperative complications.

At Mediclinic and City Hospital, all the above modalities are available in treating kidney cancers and Patient’s are well managed by the multidisciplinary team to make their journey through illness and recovery as short and smooth as possible.

Fasten your Belt

Posted on by Dr. Ali Thwaini

Health is becoming more of a common topic with the vast majority of people being more involved and interested in promoting thief own health and well-being.

So many dietary regimes have been practiced and many have quickly risen and similarly faded away.

Few have remained, and lesser are now gaining popularity to almost becoming the lifestyle for many.

I’m going to talk about two types

Intermittent fasting

Intermittent fasting is one of the most popular programs being adopted by people all over the world.

There are several forms of intermittent fasting (IF). The principle is adopting fasting periods beyond the duration of an overnight fast and restricting feeding time windows, with or without caloric restriction.

A few examples are below:

Time-restricted feeding/eating (TRF), eating is limited to a certain number of hours each day.

Alternate-day fasting (ADF) as the name applies, consists of alternating days of feasting and fasting —feasting is compatible with liberal energy intake during 24 h and fasting implicates a restricted caloric intake ≤ 25% of daily needs ( less than 600 kcal during 24 h)

intermittent energy restriction (IER): It includes periods of energy restriction alternated with periods of habitual intake or minimally restricted dietary intake, allowing wider food choices. This approach helps “cheating” our metabolic rate to avoid going into starvation mode and keep burning calories.

continuous energy restriction (CER) for improving body composition. This has the potential of steering our metabolism to a slow energy-conserving mode. Thus, after an initial satisfactory weight loss, it becomes challenging to shed off more weight. Hence, this method is better avoided.

The ultimate goal of most IF regimens is to improve body composition. For this reason, they are suggested to maximize the loss of fat mass (FM), while attempting to preserve fat-free mass (FFM).

There is compelling evidence that IF elicits reductions in body weight and FM of ~3–8%, Improvements in blood lipid profile, blood pressure and insulin sensitivity.

Whist IF has recently emerged and increasingly gained popularity, its possible predecessor has been around for about 1400 years.

Ramadan fasting

During the 9th month (Ramadan) of the Islamic calendar (Hijra) many millions of adult Muslims all over the world fast during the daylight hours. Since Hijri calendar is 11 days shorter, Ramadan occurs at different times in the seasonal year over a 33-year cycle.

During Ramadan, Muslims abstain from ingesting food and liquids between sunrise and sunset throughout a month-long period. Thus, food and liquid intake become exclusively nocturnal.

Ramadan fasting (RF) can last ~12–18 h/day, depending on the geographic location and season of the year. Reductions in body weight, relative FM, and resting metabolic rate are common consequences of RF. It has also been shown that RF decreases total cholesterol, low-density lipoprotein (LDL), and fasting blood glucose levels. In parallel, RF seems to improve body composition, possibly through enhancements in the ability to mobilize saturated fatty acids for metabolic processes.

In the general population, weight loss subsequent to RF is largely caused by the unconscious restriction of food intake.

In addition, there is a metabolic shift toward the predominant use of fatty acids as fuel for adenosine triphosphate (ATP) synthesis during RF and this lowers body fat.

However, despite representing an important opportunity for some people to lose bodyweight and FM, the adaptations inherent to RF are typically transient and largely reversible within a small amount of time.

Thus, the prescription of maintenance strategies at the termination of Ramadan is of extreme value for the long-term preservation of healthy body composition.

Fluid intake during Ramadan

Water, which makes up around 70% of our bodies, is the most important fluid that replenishes our thirst and energy, especially during the month of Ramadan. Studies have shown that reduced intake of water affects our bodies on a cellular level and causes problems in their proper functioning because dehydration has many adverse side effects such as constipation, headaches, dizziness, tiredness, and dry skin.

During the daylight hours of RF, practicing Muslims are undoubtedly dehydrating, but it is not clear whether they are chronically hypohydrated during the month of Ramadan. No detrimental effects on health have as yet been directly attributed to negative water balance at the levels that may be produced during Ramadan.

Not only is water important for weight loss and maintenance, it also helps to get rid of harmful toxins and reduce the feeling of hunger. Due to these and various other reasons, it is imperative that we keep ourselves properly hydrated throughout the day.


Here are a few pointers to help you out:

Increase water intake
Drink at least eight glasses of water every day. If you are exercising or are outdoors in hot weather, you’ll sweat more and lose more fluids. So, ensure you increase your water intake to make up for this excessive loss.

Avoid salty food
Reduce the amount of salt in your food, as foods containing high volumes of sodium trigger thirst throughout the fasting hours of the day.

Add fruits and vegetables to your meals
Eat fresh fruits and vegetables instead of salty foods because they are rich in water and fiber. They stay in the intestines for long, retaining water and hence suppressing your thirst.

Avoid drinking large quantities in one go
Refrain from drinking large quantities of water all at once or a lot during a meal. Instead, have small sips during the meal and drink water in between your meals between sehr and iftar.

Avoid juices and sugary fluids
Do not drink juices to break your fast as it contains high amounts of sugar leading to weight gain. Instead, try and stick with just water.

Add dates to your Iftar menu
Break the fast with dates. Not only is this a tradition because that’s how the Prophet Muhammad (PBUH) broke his fast; dates also help with hydration since they are a natural source of glucose, which encourages your cells to store fluid and fuel for energy.

Ramadan Mubarak!

References:

Frontiersin

Nature

islamicfinder

Invasive treatment of symptomatic prostatic enlargement. Many ways to skin a cat

Posted on by Dr. Ali Thwaini

All men have prostate. Half would develop a prostate enlargement in their fifties. Half of those will develop symptoms. Divide those by two, and the resultant number would represent those who need medical treatment. It goes on, with half of those in whom medical treatment fails, necessitating an intervention.

Treatment of Symptomatic Prostate Enlargement

Surgery has progressed in the past century, from open, to endoscopic, to laparoscopic and now the robotically performed operations.

To manage a benign prostate enlargement, and for the past few decades, transurethral resection (TURP) has always been the gold standard and the benchmark against which other modalities are compared to.

If you imagine a timeline for the evolution of benign prostate interventions, you’d see not infrequently, many have evolved across the decades, most of which disappeared for a variety of reasons; some from lack of producing similar ( let alone better!) results than the gold standard TURP, others failed due to inferior long term results. Others were simply non financially viable.

Some of the examples are the transurethral microwave thermotherapy (TUMT), transurethral needle ablation (TUNA), etc.

LASERs have entered this race, some as strong contenders, such as the Holmium laser (HOLEP, HOLERP), Greenlight laser ( stumbled initially but managed to pull through after enhancing its technology rendering better results). Thulium laser is another appealing technology.

Then came the vaporization (RESUM); it is a promising technology and it stands head and shoulder above the rest with its claims to preserve the ejaculatory function, being safe and bloodless. It can be carried out as a day case, which makes it very attractive in healthcare systems that struggle for hospital beds. The caveat is the severe storage symptoms that men suffer from in the first few days-weeks, during the shedding of the dead prostate tissues from the vaporization. Men would have to stay with a catheter for some time, which many, would find unacceptable.

However, for any problem, there is a potential solution. The EXIME short-term urethral stent would indeed sort out the severe storage symptoms ( in principle) by keeping the prostatic urethra patent during the sloughing period. However, while mechanically offering to keep the urethra patent, will it dampen the severe storage symptoms arising from the inflammatory response to the treatment? This needs to be prospectively assessed.

Last but indeed not least, is the UroLift. This one differs from all the other modalities (even including the gold standard) is the mere reliance on mechanically squeezing the prostatic lines thus creating a wider urethral channel for men to pass urine. No chipping, frying or freezing of any tissue, hence, one can assume that any inflammatory response ( if occurred after this procedure) should be trivial. It also preserves the ejaculatory function.

Now the challenges.. it is good for moderate-sized prostate and preferably with no median lobe. Other prostate sizes or shapes could impose a challenge.

It’s not cheap!

The learning curve is short, and its intermediate results are encouraging, awaiting long-term results. It per se does not preclude other modalities if it didn’t serve the purpose or if the symptoms recurred after some time.

Objective

In conclusion, there are several ways indeed “to skin the cat” none is perfect. One treatment can’t fit all conditions.

At the age of 51, and that’s my own personal opinion, if ( or should I say when!!) I need a prostate intervention, I’d probably go for the UroLift, knowing that it would, at least, buy me time until I’m less interested in preserving other functions, then I would go for other modalities ( possibly newer ones yet to be invented!).

Reference:

Soum Lokeshwar, David Valancy, Thiago, Fernandes Negris Lima, Ranjith Ramasamy. A Systematic Review of Reported Ejaculatory Dysfunction in Clinical Trials Evaluating Minimally Invasive Treatment Modalities for BPH. Current Urology Reports

Diet for Stone Formers

Posted on by Dr. Ali Thwaini

Once a stone former. always a stone former!!

Urinary tract stones are the most common encounters in the field of urology. “Doctor, I’d rather give birth to 10 children than going through the pain of passing a stone!” Says many of my female stone patients.

Ureteric colic is an uninvited guest that barges in at any time. It is so severe at times that pilots, divers, and those operating heavy machinery, when suffering from a ureteric stone, aren’t allowed to resume their work until the stone has passed, for the fear of their lives and others.

Prevention is better than cure, and there are many, inexpensive and easily adaptable lifestyle modifications that wild help minimizing the chances of stone recurrence rate.

Below are some advice Preventing the Stone Formation

Water

60% of our bodies are made of it. It makes absolute sense to maintain a healthy water intake.

Drinking plenty of fluid is the most effective way of preventing the stone formation and reduces your risk of stone formation by almost one-third (30 to 40%). Not drinking enough can cause your urine to become concentrated, making stones more likely to form.

Try to drink two to three liters (four to six pints) of fluid (water or squash) each day. You should aim to keep your urine colourless throughout the day. This should give you a urine output of at least two liters (four pints)per day.

What about other fluids?

I, like many people, am addicted to caffeine. Whilst it has some benefits, it has its implications in stone formation, mainly increasing the Oxalate component of stones. Not to mention the fact that these fluids would actually deprive the body of water due to their diuretic effects.

Kidney Stone Diet Tips that may help:

  • Drink a large glass of water at specific times each day (e.g. when you get up, when you arrive at work, after using the toilet, etc);
  • Keep a bottle or jug of water by your side all day; you can flavour it with fruit squash;
  • Try to drink one glass of water every hour;
  • Add slices of lemon, lime or orange to cold water; this gives it a pleasant flavour and helps to make your urine less acidic;
  • Eat more fruit & vegetables because they contain a lot of water. Finally
  • Include moist/liquid foods in your diet (e.g. soup, stew & jelly).

Calcium:

Opposite to the traditional belief, reducing the amount of calcium in your diet can increase the risk of stone formation, by raising oxalate levels in your urine. A daily intake of up to 1000 mg per day is safe for calcium stone formers.

Most dietary calcium is found in dairy products (milk, yogurt, cream and cheese). A normal, varied diet will give you about 500 mg of calcium each day. The approximate calcium contents of dairy produce are:
• milk and yoghurt – 120 mg per 100 g
• soft cheese – 400 mg per 100 g
• hard cheeses – up to 1000 mg per 100 g

They were the numbers that will hopefully help you identify the right quantity of dairy products for daily consumption

If you have too much calcium excreted in your urine, the restriction might be of benefit here, but better consult your doctor

What about the other culprit? Oxalate

The majority of urinary tract stones are composed of calcium and oxalate. The latter is present and vast quantities of the following food items:

rhubarb, celery, spinach, beetroot and sesame seeds, all of which have large amounts of oxalate in them.

Black tea, chocolate, nuts (including peanut butter), cocoa and carob are all moderately high in oxalate.

Eating those items in moderation is the recommendation as most of them have lots of beneficial nutritional items.

Uric Acid Stones.

These are the second most common type of kidney stones. Historically they are related to large amounts of red meat consumption that could lead to gout, Hence the name Kings’ disease.

In addition to red meat the following items contain a large amount of uric acid and are butter taken in moderation by normal people and then matchless amounts by uric acid stone farmers:

• meat – all meats, including liver, heart, kidney, sweetbreads & meat extracts (e.g. Oxo)
• fish – especially anchovies, crab, fish roe, herring, mackerel, sardines, shrimps & whitebait
• others – yeast extracts (e.g. Bovril), beer, asparagus, cauliflower, mushrooms, peas, beans & spinach.

In summary

Urinary tract stones are one of the most common presentations and Urology and emergency. Stone attacks are very painful and cuddly to potentially serious illness and lots of work and activity.

Prevention is better than cure. Modification of lifestyle has amends beneficial results. For any further information and treatment visit your local urologist for further information and advice

Book an Appointment