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.

Pelvi-Ureteric Junction (PUJ) Obstruction

Posted on by Dr. Ali Thwaini

What is PUJ obstruction?

PUJ obstruction results from narrowing of the junction between the pelvis of the kidney and ureter, resulting in impedance to the flow of the urine from the kidney to the ureter.

The condition affects approximately one person in every 1000 adults and tends to occur more in men.

Most people have two kidneys, that filter the blood to remove waste products, which they excrete into the urine. Urine is carried from each kidney, through the ureter, to the bladder where it is stored.

As well as removing waste products, the kidney performs many vital functions, such as controlling fluid balance (how to dilute the blood is), regulating various salts or electrolytes in the bloodstream (eg: sodium, potassium, calcium, magnesium), maintaining the correct acidity of the blood, and regulating blood pressure.

Many different conditions can affect the kidney; one of which is PUJ obstruction that causes no symptoms or problems and is only discovered by chance when the patient is having a scan for another condition. Alternatively, it can cause:

• Recurrent episodes of loin pain which tends to worsen after drinking especially alcohol.

• Kidney infection (pyelonephritis).

• Kidney stones.

• Lump or swelling in the kidney area.

• Damage to the kidney as a result of either high pressure in the renal pelvis, kidney infection, or formation of kidney stones.

How is Diagnosis of PUJ Obstruction?

PUJ Obstruction

This includes blood tests, urine test,s and scans. CT scan is commonly used to assess the anatomy and the structure of the renal pelvis and a special nuclear medicine scan called MAG3 scan is used to confirm the obstruction and also to assess the function of the kidney.

If there is severe kidney infection as a result of the obstruction, then the kidney must be drained as a matter of urgency with insertion of a temporary ureteric stent or nephrostomy tube before any definitive treatment.

There are several treatment options for PUJ obstruction and these will be discussed with you; these include:

Active surveillance with careful observation with repeated scans.

Treatments for PUJ obstruction

The PUJ is the portion of the collecting system that connects the renal pelvis to the ureter. The standard treatment for pelvic ureteric junction obstruction is pyeloplasty.

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There are different ways to approach the kidney to perform the operation. These include via a flank incision, subcostal (under the rib) incision, transabdominal approach, or even sometimes through an incision in the back. 

Most commonly, however, this procedure is done using laparoscopy, or keyhole surgery.

Laparoscopy is a technique of performing a surgical operation using instruments inserted through narrow hollow tubes (‘ports’) rather than through a larger incision, as in traditional surgery. 

The result is shorter hospitalization and convalescence, often less bleeding and post-operative pain, and fewer wound complications.

Chronic prostatitis Symptoms

There’s a reason behind naming chronic prostatitis as chronic pelvic pain syndrome. This is usually due to the vague presentation and different manifestations in different men. This could be ranging in the form of penile tip pain or scrotal discomfort. Others could present with chronic low back pain and pain during ejaculation. This could be well associated with storage lower urinary tract symptoms.


Stem Cell Therapy in Male Factor Infertility: Research Proposal:

Posted on by Dr. Ali Thwaini

Background:

More than 10% of couples in the world experience fertility problems. Infertility, defined as failure to conceive a clinically detectable pregnancy after >12 months of unprotected intercourse, is a common condition, reported by 1 in 6 couples.

https://www.youtube.com/watch?v=0ZryWiMWyE8&feature=youtu.be

Stem cells exist as undifferentiated cells. They are present in the embryonic and adult stages of life and are considered as a source for differentiated cells that make up the building blocks of tissue and organs.

Due to their abundant source and high differentiation potential, stem cells are considered as potential new therapeutic agents for the treatment of infertility. Stem cells could be stimulated in vitro to multiply and then are utilized in vivo to “awaken’ the dormant spermatogonia” and are theoretically a potential source to develop various numbers of specialized cells including male and female gametes suggesting their potential use in reproductive medicine. During the past few years, considerable progress in the derivation of male germ cells from pluripotent stem cells has been made. In addition, stem cell-based strategies for ovarian regeneration and oocyte production have been proposed as future clinical therapies for treating infertility in women.

There are several sources for stem cells: Embryonic-derived stem cells (ESC), extra-embryonic derived SC, and mesenchymal derived SC. Each has their advantages and disadvantages. In this contest of male factor infertility, another source of stem cells could exit, albeit, a sparse source; this is derived from autologous Spermatogonial stem cells. Whilst harvesting them is a relatively simple procedure at an outpatient setting, and there are no ethical nor moral issues with harvesting them, they are relatively small numbers in the testis; hence, extracting them would be rather difficult and it is challenging to be maintained in culture. Moreover, there is a risk of immune rejection.

Challenges with stem cell therapy in male factor infertility:

Besides genetic factors, azoospermia also occurs due to injuries, exposure to toxicants, immune-suppressive and anticancer treatments. However, a large proportion of infertile males are diagnosed as idiopathic with unknown causes, reflecting poor understanding of the mechanisms regulating spermatogenesis and sperm function in humans.
While several sources exit to cultivate and improve stem cells for particular functions, generating pluripotent stem cells that have the potential to differentiate and undergo mitosis followed by meiosis into haploid cells remains challenging.
There have been few animal studies (particularly mice) where autologous mouse induced plutipotent cells have been produced (miPSC). Those actually were cultivated into mature spermatogonia and early spermatids. However, only a few studies made successful in producing spermatozoa in mice. This is yet to extrapolate and translate into human trials.

However, there are few human trials where a successful culture of hiPSC was achieved, resulting in spermatogonia and few spermatids.

Possible sources of stem cells:

These can be derived from either embryo of the placenta (the former might have ethical problems and both might be associated with future, though minor, risks of mutations). Other cells are derived from adult bone marrow and fat cells, which are rich in stem cells.
The function of stem cells in male factor infertility can be divided into three possible functions:

  1. Stem cells are self-homing, and when injected into the human body, they can differentiate into the cells types native to these organs and parts. In this scenario, spermatogonial stem cells (SSC), travel to their niches upon transplantation into sterile testes. The transplanted SSCs then attach to the Sertoli cells and closely connect the blood-testicular barrier (BTB) to migrate to their niche on the basement membrane
  2. The second type involves the activation of dormant and suppressing cells. The growth and development of the human body is accomplished through cell division. With age, some cells stop undergoing normal cell cycles after division and show a state of functional dormancy. Stem cells can activate dormant cells and suppressor cells and encourage them to re-enter the cell cycle, proliferating by division. This has been well demonstrated with chemotherapy-induced premature ovarian failure (POF).
  3. The third type involves the paracrine secretion of various enzymes, proteins, and cytokines to promote cell proliferation, inhibit apoptosis of functional cells, and differentiate existing tissue progenitor cells into tissue cells in order to repair damaged tissues and grow new tissues. Spermato-genesis is a process regulated by testosterone, endocrine, and paracrine secretion/autocrine factors, such as the IL-1 family.
  4. The fourth type involves the exertion of an immunosuppressive function through cell-cell contact and secretion of soluble factors, inhibiting the proliferation of natural killer cells.
  5. The fifth type involves the promotion of the recovery of intercellular signaling. The signal molecule of the cell interacts with the receptor protein on the cell membrane, causing a conformational change in the receptor and the subsequent production of a new signal substance inside the cell. This triggers a response, such as an ion permeability, cell shape change, or some other cellular function change.

There are several ways of retrieving SSC, simply shown I the figure below:

Flow chart showing different pathways of potential utilization of stem cells into spermatozoa. (Left) Somatic cells may be de-differentiated into induced pluripotent stem cells (iPSCs), and then re-programmed to differentiate through germ cell lineage via transplantation into the testis seminiferous tubules, xenografting or germline stem cells in culture. (Right) SSCs may be harvested from the testis and kept as a tissue biopsy or processed into a single cell suspension. The tissue biopsy may be treated as an organ culture, autologous graft or xenograft to proliferate and differentiate SSCs to spermatozoa. Cell suspensions may be grown in culture and xenografted, autotransplanted into the testis seminiferous tubules, or differentiated in culture to harvest spermatozoa. (m) TESE, (microdissection) testicular sperm extraction.

Procedure and protocol:

The process involves two phases: 

The first phase is stem cell harvest and preparation: this involves collecting adipose-derived stem cells from accessible parts of the patients. Traditionally, adipose cells are abundant in the abdominal fat and upper thigh. This would provide the MSC that are required for mechanisms 2-5. This would be mainly helpful for men with severe oligo-asthenospermia. They are able to produce sperms albeit in sub-fertile quality and quantity.
For men who are azospermic; in addition to the above, SSC harvest is aimed from testicular biopsy (attempted at the same time) with the aim of extracting SSC for culture.

After proper patient counseling and office preparation, under aseptic technique, diluted local anesthetic with adrenaline is infiltrated into the abdominal wall on both sides. Then we allow approximately 15 minutes for the local anesthetic to work. Afterward, we harvest the abdominal fat utilizing a special fat harvest micro needle, which is well tolerated by the patients. After achieving the desired amount of the abdominal fat, it is transferred to the Stem Cell laboratory for purification and culture purposes; a process that usually takes between two to three weeks.

For azospermic men, testicular biopsy is carried out simultaneously and SSC is sent to the lab as above.

Patients are normally well enough to go home on the same day. Patients is normally counseled for the possibility of minor discomfort and bruising in the abdominal wall (and thighs, if they were utilized for the fat harvest, in thin patients).

In the second phase, the injection of stem cells into the ovaries; after two weeks from the harvest, the patient is prepared for laparoscopic injection of the stem cells into the ovaries.

This procedure is normally carried out as a Day Case under general anaesthesia. It normally takes less than an hour. After revering from the anaesthetic, the patient is normally sent home with minimal analgesics.

Proposal:

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We aim to prospectively recruit male patients with primary infertility and have a primary testicular failure (severe oligospermia or azoospermia) and include them in the above trial.

We aim to recruit a minimum number of 30 patients.

After consent, men will enter the above trial, that includes the following:

  1. Clinic consultation.
  2. Fat harvest (usually from the abdominal wall) and testicular biopsy. These are performed under local anaesthesia in a properly equipped procedure room in the outpatient department.
  3. Samples will be taken to the official Stem Cell laboratory, located in building 64 at Dubai Healthcare City for culturing.
  4. Patients will be sent the home the same day on symptomatic treatment if needed.
  5. Patients will be invited again to the clinic after two-three weeks when mesynchymal stem cells (MSC-from fat) and spermatogonia stem cells (SSC) would have been adequately cultured and are injected back into the testes under local anaesthesia and ultrasound guidance.
  6. Patients will be sent home with analgesia and prophylactic antibiotics.
  7. Patients will be invited to the clinic two weeks later for follow up.
  8. Semen analysis will be tested in three months, with a possibility of obtaining testicular biopsy afterwards (depending the results of the semen analysis). This will be carried out in the persistence of azoospermia. The aim is to look for live spermatogonia or sperms at various stages of maturation. This will be happening in liaison with the fertility clinic for the potential of freezing if applicable.
  9. Results will be published upon written consent from the participants.

References:

  1. Vladislav Volarevic, Sanja Bojic, Jasmin Nurkovic, Ana Volarevic, Biljana Ljujic, Nebojsa Arsenijevic, Majlinda Lako, Miodrag Stojkovic. Stem Cells as New Agents for the Treatment of Infertility: Current and Future Perspectives and Challenges. Biomed Res Int. 2014; 2014: 507234.
  2. Fang Fang, Zili Li, Qian Zhao, Honggang Li, Chengliang Xiong. Human-induced pluripotent stem cells and male infertility: an overview of current progress and perspectives. Hum Reprod. 2018 Feb; 33(2): 188–195.
  3. Jing Wang, Chi Liu, Masayuki Fujino, Guoqing Tong, Qinxiu Zhang, Xiao-Kang Li, Hua Yan. Stem Cells as a Resource for Treatment of Infertility-related Diseases. Curr Mol Med. 2019 Sep; 19(8): 519–546.
  4. Connor M. Forbes, Ryan Flannigan, Peter N. Schlegel. Spermatogonial stem cell transplantation and male infertility: Current status and future directions. Arab J Urol. 2018 Mar; 16(1): 171–180.

Consultant Urologist in Dubai

Posted on by Dr. Ali Thwaini

After graduating from medical school, Baghdad University in 1994, Dr Thwaini relocated to Jordan where he started his career in Urology at the Royal Medical Services, which is a national tertiary referral center.

He acquired FRCS (Ireland) in 1999 and the Jordanian Board in Urology in 2000. He then moved to Abu Dhabi where he worked for three years as a specialist at SKMC. He acquired the Arab Board in Urology in 2001.

In 2004 he moved to the UK, where he finished his MD degree from Queen Mary University of London. His thesis was on prostate cancer.

In 2007 he entered the UK national higher training scheme in urology. This took place in Northern Ireland, where he worked in Belfast City Hospital, Altnagelvin Hospital and Craigavon Hospital, working with regional and national experts in the field. During his training, Dr Thwaini developed specialist interest in urological cancers. He completed his training in 2012 by acquiring the Intercollegiate Specialty Board Certificate in Urology (FRCS-Urology) and he acquired the CCT UK-wide accreditation. Work

Urologist in Dubai

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Dr Thwaini has been working as a consultant urological surgeon with specialist interest in urological cancers, namely in renal cancers. He became the lead for renal cancers in the Belfast Health and Social Care Trust (Belfast City Hospital). This is a tertiary regional referral centre for complex cancer and benign cases.

His main skills are in advanced laparoscopy and renal cancer and renal reconstruction procedures.

Dr Thwaini has travelled on charity trips to west Africa and East Asia along with other Urology colleagues, where they have carried out laparoscopic Urology workshops in those countries.

Recently, Dr Thwaini acquired the International Academy if Penoplasty fellowship from Milan, Italy and he’s certified for penile enhancement procedures. Dr Thwaini is has developed a vested interest in regenerative medicine with its applications in Urology.

Dr Thwaini is also an Honorary Clinical Lecturer at Queens University, Belfast. He is known for his academic contributions throughout his career with over 40 Medline publications in the field, in addition to his contributions in Urology book chapters.

Urinary Tract Infections (UTIs): Causes, Symptoms & Treatment

Posted on by Dr. Ali Thwaini

What is a urinary tract infection (UTI)?

Urinary tract infections(UTI) occur usually due to microbial inaction of the urinalysis tract ( that could be anywhere from kidneys, bladder, prostate- in men, and urethra) with the inflammatory response of the body.

The latter is usually manifested by various symptoms depending on the location of the infection and severity.

What are the symptoms of a urinary tract infection (UTI)?

For infections involving the urinary bladder, symptoms are:

  • painful urination and a burning sensation
  • needing to urinate frequently
  • sudden urges to empty your bladder, called urinary urgency
  • pain in your central lower abdomen, just above the pubic bone
  • blood in your urine

However, if infections affect the kidneys, the symptoms might be more pronounced, some of which are explained below:

  • pain in your sides or back that doesn’t change when you change position
  • fever and chills
  • nausea and vomiting

Certain symptoms in addition to those of a UTI could mean you have a prostate infection (prostatitis). These include:

  • fever
  • chills
  • fatigue
  • difficulty urinating or “dribbling”
  • pain in your pelvis or the area between your rectum and scrotum (perineum)

Causes of Urinary Tract Infections

Most UTIs are caused by the bacterium Escherichia coli (E. coli), which is naturally present in your body. The bacterium gets into the urinary tract through the urethra. The urethra is the tube that drains urine from your bladder.

UTIs are more common in women than in men because their urethra is shorter and the bacteria need to travel a shorter distance to reach their bladder.

At least a third of women will have one infection during their lifetime.these aren’t normally sexually transmitted , because the infection is typically from bacteria already present in the urinary tract.

UTIs in men are more common with older age, possible, because older men are more likely to develop enlargement of their prostate gland, called benign prostatic enlargement. The prostate wraps around the neck of the bladder, where the urethra connects to

the bladder. Enlargement of the prostate gland can choke off the bladder neck, making it harder for urine to flow freely. If the bladder doesn’t empty completely, bacteria that are normally flushed out with the urine might gain a foothold.

Other factors that can put you at greater risk for UTIs include the following:

  • being immobile for long periods
  • not drinking enough fluids
  • recent urinary tract surgery
  • diabetes
  • being uncircumcised
  • fecal incontinence
  • engaging in anal intercourse, which exposes the urethra to more bacteria

Diagnosis of Urinary Tract Infections

To diagnose a UTI, your doctor will examine you and ask about symptoms, including any past history of UTIs. You may be asked to provide a urine sample to check for pus and bacteria. The presence of pus strongly points to a UTI.

If your doctor suspects an enlarged prostate gland, they may do a digital rectal exam, using a gloved finger to feel your prostate gland through the wall of your rectum.

Treatment for UTIs

If you have a UTI, you will need to take antibiotic medications. Depending on the type of antibiotic your doctor prescribes, you will take the pills either once or twice a day for five to seven or more days.

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It’s also important to drink adequate fluids. You may be tempted to reduce your fluid intake if urinating is uncomfortable. Urination can help flush the bacteria from your system. Stay hydrated and urinate often while taking your antibiotics.

Many people drink cranberry juice during UTIs in hopes of clearing the infection. Lab experiments with mice showed that several substances in cranberry juice lowered bacteria count in the bladder. However, there is no strong evidence that drinking cranberry

juice during a UTI eliminates the infection or speeds recovery.

Recovering from UTIs

After starting antibiotics, you should feel better within two to three days. If your symptoms don’t clear up after taking antibiotics, see your doctor.

It’s important to finish all antibiotics prescribed, even if you’re feeling better. Stopping your antibiotics prematurely can encourage growth of bacteria resistant to common antibiotics. In effect, less than the full course of treatment kills off the

“weak” bacteria, leaving the stronger and more resistant strains.

Conclusion

Urinary tract infections(UTI) occur usually due to microbial inaction of the urinalysis tract ( that could be anywhere from kidneys, bladder, prostate- in men, and urethra) with inflammatory response of the body. Treatment for UTIs are antibiotic medications and drink adequate fluids.Dr Thwaini is a consultant urological surgeon in dubai 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).

Non-surgical methods for Penile Enhancement

Posted on by Dr. Ali Thwaini

Non surgical methods for penile enhancement There are several conservative measures that if used properly, might help in gaining some length and possibly strength during erection.

Penis stretching?

Penis stretching refers to using own hands or a device to increase the length or girth of the penis.
Although there’s evidence to suggest that stretching can increase penile size, the results are usually minimal. In some cases, they may even be temporary.

It’s important to remember that much of the evidence around penis stretching is anecdotal, as there are no randomized trials with its effects to draw a valuable conclusion.

Manual stretching exercises involve using own hand to massage the tissues along the length of the penis. This is intended to stretch the skin and create “micro-tears” in the tissue.
The tissues may appear engorged as they heal, making the penis look longer.
Some exercises also claim to increase girth. Girth exercises, such as jelqing, are also centered around tissue massage.
Consistency is key to maintaining either of these purported effects. However, excessive use of such exercises might lead to more tissue damage leading to harmful outcomes.


Penile Enhancement Exercises

Penile Enhancement Exercises


1. Stretching


This is carried out by grasping the penis just behind its head. Don’t hold it too firmly or too loose. The penis is then gently stretched initially downwards for 20-30 seconds followed by upwards stretch for another 20-30 seconds


2. Rotational stretch


This is achieved by grasping the penis just below its head and pulling it outwards firmly. It is normal to feel a stretch in the shaft but not any pain. Then the penis is moved in circular motion maintaining the stretch and grip. Each rotation should take around 30 seconds. For each direction, at least three rotations are to be performed.


3. Jelqing

Jelqing-penile enhancement


With the penis being partially erect and using a lubricant, the penis is held at the base with the thumb and index finger. Slow movement of the hand up the penis maintaining the pressure.This is one jelq and it should take you 2 to 3 seconds to do 1 jelq. This help in pushing the blood towards tip of the penis and will not cause any pain. Repeat this process.


4. Kegel


The key is to identify the Pubococcygeus muscle by stopping the flow of urine. Once recognized, the muscle is held in contraction for about five seconds and then released. This method is then repeated as many times as desired, ideally for about 30 minutes every day to see an improvement in erection.

5. Opposite stretch

After folding the tip and base of the Leno’s with each hand respectively, both hands are then pulled in opposite direction, without causing any pain. This position is held for about 30 seconds and then relax. This method is repeated as required and after enough number of stretches let your penis relax.


Research on penis stretching techniques is limited. None of the studies that have been done point to any one technique as an effective way to permanently lengthen the penis. However, a temporary increase in size may be possible.One 2010 review reported that men who used the Andropenis stretching device saw an increase in size with extended daily use. Participants used the device for six hours per day over the course of four months. They gained anywhere from 1.8 to 3.1 centimeters (cm) in length.
Stretching with a device

To use a penis pump:

  • Place your penis inside the air-filled chamber.
  • Use the pump mechanism to suck the air out of the chamber. This pulls blood into your penis, causing it to become erect.
  • Attach the included ring or clamp to your penis to keep it erect for up to 30 minutes. It’s safe to have sex or masturbate during this time.
  • Remove the ring.

To use a traction device:

  • Insert your penis into the base end of the device.
  • Secure the head of your penis within the two notches at the opposite end.
  • Fasten the silicone tube around the shaft of the penis.
  • Grip the ends of the silicone tube on the bottom of the device and slowly pull your penis outward. Stop pulling if it starts to feel painful or uncomfortable.
  • Leave the penis in the stretched position for 4 to 6 hours a day.

Potential risks and complications

Being too rough with your penis can cause large tears in the tissues or damage to the ligaments that connect your penis to your body. These injuries can potentially hinder your ability to get or maintain an erection. When wearing a traction device, follow your doctor’s instructions for how long to wear it. Wearing it any longer can cause injuries that affect the penis function. After using a pump, don’t let the blood stay in your penis for more than 30 minutes. Having an erection for more than a few hours can permanently damage your penis. Stretching exercises or devices may cause:

  • itching
  • minor bruising or discoloration
  • red spots along the penile shaft
  • numbness
  • vein rupture

See your doctor if your symptoms last for more than a couple of days or are severe. Your doctor can assess your symptoms and advise you on any next steps.

Your results will depend on the approach you take and how consistent you are with use. Traction devices, for example, must be used daily — often for months at a time — in order to achieve any noticeable effects. Anecdotal reports suggest that using a penis pump can produce much faster results, but there isn’t any research to support this.It’s also unclear how much time will pass before you see results from manual stretching exercises.

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The bottom line

If you have questions or concerns about your penis size, talk to your doctor. They can discuss your options for lengthening and explain how to do so safely.Learning how your penis responds to stretching and other forms of stimulation may help you feel more comfortable with your body. You may also notice changes in appearance or performance over time.Be sure to follow any product directions or guidelines provided by your doctor. If performed incorrectly, stretching can result in injury or erectile dysfunction.Seek immediate medical attention if you experience pain or discomfort while stretching, or if you notice any change in your erectile function.

Penis Enlargement

Posted on by Dr. Ali Thwaini

Penoplasty (male enhancement)

The penile enlargement procedure is seldom discussed. Men in general are private about their privates at the best of times, and when it comes to such an intimate matter, they are even more introvert.

However, the amount of men going for penis enlargement procedures is up. 

A recent UK based study, a general questionnaire was sent to community men of various ages, They found that almost 50% would like a larger penis.

For the last five years, members of the International Society of Aesthetic Plastic Surgery carried out almost 50 000 enhancements worldwide.

There are several procedures that would increase the apparent length and the actual girth of the penis. These, however, are to be tailored to the anatomy of the patient, and also to patient expectations.

It is important to realise that there is no procedure that actually increases the real length of the penis. Penoplasty makes the penis appear longer by repositioning it in relation to the tissues around it.

Penoplasty (Penis Enlargement)

Although there are medical indications for penoplasty. However, these are rare indications, and surprisingly, the majority of men seeking penile enlargement have normal sized genital organs. The reasons for wanting a larger penis are often nothing to do with sexual performance. Most men seek this procedure mainly to enhance the appearances of their flaccid penis size, especially when going to the gym and using communal showers because.

There is a range of procedures. They can be generally split between those increase the length of flaccid penises, or more girth.

One thing you can do is use liposuction on the fat around the base of the penis — if you’ve got four inches of fat there, your penis will look four inches bigger when the fat is surgically sucked out.

The lengthening procedure, however, mainly involves making an incision at the base of the penis in an area that can be easily covered by the hairline, and dividing a ligament which is called the ‘suspensory ligament’ which connects the penis to the pubic bone.”

Once the ligament is cut, the penis will permanently come further out of the body.

Penis Enlargement Surgery

Cutting the ligament means the angle of erection will change so it’s not as upright, and there is a thing balance between cutting too much and too little of this ligament, and a skilled surgeon can keep this change to a minimum so you don’t end up with a downward-pointing erection.

Increasing the penile girth usually involves injecting material into the soft tissue underneath the skin on the penis. The most commonly used material is the patient’s own fat, usually from the abdominal area. There surgeons use a synthetic filler like hyaluronic acid, which is what women use to enhance the lips or fill gaps in cosmetic surgery. Each has its own pros and cons.

Post operatively, me are advised to refrain from having sex for at least about four weeks.

Although these procedures do not actually increase the surest penis length, as they significantly enhance the girth of the flaccid and erect penis, there will be an improvement in overall outcome, with more pleasurable for both partners.

Non-surgical methods for Penile Enhancement

penile enhancement

Non surgical methods for penile enhancement There are several conservative measures that if used properly, might help in gaining some length and possibly strength during erection.

Visit Dr. Ali Thwaini for Penis Enlargement Dubai, Complicated surgery often calls for expert surgeons

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Erectile Dysfunction

Posted on by Dr. Ali Thwaini

Erectile dysfunction (ED in men) impotence is defined as an inability to obtain or maintain an erection sufficient for penetration and for the satisfaction of both sexual partners.

ED in men can be caused by many factors and may have a gradual or sudden onset. It can be very upsetting and result in a lot of stress and worry. It can feel embarassing to discuss this with your doctor but it is important that you do, so that you can receive the appropriate help. Erectile dysfunction can also be a sign of other illnesses such as heart disease or diabetes, so it is important that you seek medical advice. 

  • ED in men becomes commoner with increasing age and is seen in 50 – 55% of men between 40 and 70 years old;
  • It is often associated with obesity, high blood pressure, high cholesterol & diabetes which are all significant risks to health;
  • Investigation is only indicated if both partners wish to pursue treatment;
  • Most treatable causes can be identified by a clinical history, physical examination and routine blood tests;
  • If there is no treatable cause, treatment with tablets is the first option for most men;
  • Other methods of treatment are only indicated if medication proves ineffective, causes side-effects or cannot be used because of specific medical conditions.

A psychological component, often called “performance anxiety”, is common in men with impotence. However, a purely psychological problem is seen in only 10%.

Of the 90% of men who have an underlying physical cause, the main abnormalities found are:

  • Cardiovascular disease in 40%;
  • Diabetes in 33%;
  • Hormone problems (e.g. high prolactin or low testosterone levels) & drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%;
  • Neurological disorders in 10%;
  • Pelvic surgery or trauma in 3-5%; and
  • Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie’s disease, inflammation, penile curvature).

TREATMENT:

Improvements in your lifestyle, such as a eating healthy diet, reducing alcohol intake, losing weight and increasing your exercise can dramatically improve erectile dysfunction. More specific treatment usually involves:

  • weight loss and increased exercise (this may reduced the risk of erectile dysfunction by up to 70%)
  • treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your the levels are normal);
  • lifestyle modification (e.g. reduce stress, stop smoking, reduce alcohol consumption & stop illicit drugs);
  • treatment of any anatomical abnormality if present (e.g. circumcision, frenuloplasty, penile straightening);
  • psychological support if necessary.

First line treatment will be medication with a phosphodiesterase inhibitor such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) or avanafil (Spedra). These drugs only work when used together with sexual stimulation and will have no effect on your sex drive. There is no evidence that these drugs are dangerous if you have underlying heart disease. However, they should not be used if you are taking nitrates (e.g. GTN, isosorbide) for angina

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ED in men


Phosphodiesterase inhibitors

  • The commonly used PDE-5 inhibitors are sildenafil (generic or ViagraTM), tadalafil (CialisTM), vardenafil (LevitraTM) and avanafil (SpedraTM)
  • They increase blood flow into the penis by blocking the naturally- occurring enzyme (PDE-5) which turns off an erection
  • You should only obtain PDE-5 inhibitors by prescription
  • Side-effects occur in approximately 1 in 9 patients (11%) but only3% stop treatment because of them
  • You should not use PDE-5 inhibitors of you are taking nitratemedications for angina or heart disease

These drugs boost the body’s natural mechanism for getting an erection. This allows erections to be achieved and maintained more easily but they do require sexual stimulation to be effective.

They may not work in severe ED in men or where the natural erectile mechanism has been irreversibly damaged. The drugs work by dilating (opening) the blood vessels supplying the penis; this causes a greater blood flow into the penis and improves your erection.

How should they be taken?

Depending on the medication you are prescribed, a tablet should be taken between 30 minutes and 1 hour before anticipated sexual intercourse. Some of the drugs are affected by eating a heavy or fatty meal before taking the drug. We normally advise you to take them on an empty stomach, or two to three hours after a meal.

You should read the manufacturer’s instruction leaflet carefully because this gives you full instructions. You are advised not to take more than one dose per day. Treatment is usually long-term.

Because of its long half-life, Tadafil (CialisTM) may be taken at a lower, daily dose so that the drug is always in your system to provide a background boost to erections. This can help with night-time and morning erections.

We normally advise you to try treatment for four to six weeks to see whether it works. Your urologist, GP or specialist will suggest a starting dose for you and you will be followed up to see if an increased dosage is needed.

When should they not be taken?

You must not use PDE-5 inhibitors if you take nitrate medications (GTN spray, isosorbide or amyl nitrate) for angina, heart disease or other reasons. If you are not sure whether you are taking these medications, please check with your doctor. PDE-5 inhibitors interact with nitrates and can cause a dangerous drop in blood pressure. This may result in cardiac arrest, or even death.

You should probably avoid taking these drugs with alcohol. If you are unsure as to whether PDE-5 inhibitors are safe for you, consult your GP, specialist or cardiologist who will be able to advise you.

PDE-5 inhibitors are not appropriate if you have been told that sexual activity is inadvisable (e.g. if you suffer from unstable angina or severe heart failure). They should not be used at the same time as other treatments for ED in men, unless you have been advised to do so by a specialist.

What are the side-effects?

The most common side-effects include headache (12%), flushing (10%) and indigestion (7%). Some patients develop altered (blue-tinged) vision and dizziness (3%). If dizziness does occur, you should not to drive or operate heavy machinery. It is important that you report any severe side-effect to your doctor, and consider stopping the drug until you discuss it with your doctor.
PENILE INJECTION THERAPY
Self-administered injections of prostaglandin E1 (Caverject® or Invicorp®) provide a simple means of obtaining a natural erection. You will be taught how to administer the injections (pictured) and told what to do in the event of problems such as an erection which will not go down.

Medicated Urethral System for Erection (MUSE):MUSE offers an alternative route for administration of prostaglandin using a small pellet inserted using an applicator into the tip of the urethra (water pipe opening). Once massaged the prostaglandin is released and helps the blood to flow into the penis to gain an erection. Some men experience a mild burning sensation afterwards in the water pipe but this is a good alternative option for men who do not like the idea of using injection therapy.

Vacuum Erection Assistent Devices (WEDs)
VEDs provide a simple way of obtaining an erection for 30-45 minutes by sucking blood into the penis and holding it in place with a constriction (pictured). Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects. Unfortunately, most patients have to purchase VEDs themselves.

PENILE PROSTHESIS
Insertion of a penile prosthesis (implant) (pictured) is an end stage solution when all other treatment options have failed. It involves a surgical procedure through a small incision in the junction between the penis and scrotum. Patients go home the following day if the procedure is uncomplicated, and the prosthesis can be used for sexual intercourse at 6 weeks following the operation. Complication rates are low in centres that conduct the surgery in large numbers. The risk of infection is <2% and over 85% of the devices are still functioning at 10 years. 

Prostate symptoms (bladder outlet obstruction)

Posted on by Dr. Ali Thwaini

The prostate gland lies just beneath the bladder and is normally about the size of a chestnut. The urethra (water pipe) runs through the middle of the prostate. The main function of the prostate is during your reproductive life. It produces fluid containing chemicals which nourish sperms to help with fertilisation.

If you have difficulty starting or stopping your urine flow, a weak stream, a feeling that you do not empty your bladder completely, increased frequency and urgency of urine passage by day or night and a tendency to dribble after you have finished, you should contact your GP for further advice.

Facts about prostate symptoms

  • By the age of 65 years, 50% of men will experience benign enlargement of the prostate. At the age of 90, 90% of men have prostatic enlargement;
  • An enlarged prostate alone does not always cause symptoms;
  • The severity of the symptoms is not related to the size of the prostate;
  • 1 in 3 men will suffer prostatic symptoms during their life;
  • 1 in 10 men will require surgical treatment for their symptoms;
  • Not all urinary symptoms in men are due to an enlarged prostate – incontinence, pain or blood in the urine may be due to other conditions;
  • The risk of prostate cancer is not increased by having benign enlargement of the prostate. You are no more likely to develop prostate cancer than a man without benign prostatic enlargement;
  • 30-40% of men with prostatic symptoms do not experience worsening of their condition with time and may not require any treatment;
  • If treatment is indicated, this usually involves with drugs which relax the muscle in and around the prostate and/or drugs which shrink the glandular component of the prostate;
  • If symptoms are severe, if there is no response to medical treatment or if there are complications of prostatic enlargement, surgical treatment may be indicated; and
  • The risk of acute, painful retention of urine is small (approximately 1 in 100) and it is not always preceded by prostatic symptoms. Acute retention usually requires surgical treatment.

What could have caused my prostate to enlarge?

In general terms, we know very little about why the prostate gland enlarges with increasing age but hormone imbalance within the gland itself probably plays a part as well as certain genetic factors

There is some evidence that hormones and certain growth factors may work together to cause the prostate gland to enlarge. There also seems to be an inherited tendency in approximately 10% of men (1 in 10).

Medical treatment:

General measures (“watchful waiting”)

If you and your GP decide treatment is not necessary initially, some simple, self-help measures can improve your quality of life:

  • limit your fluid intake when you know you will be out of the house;
  • try emptying your bladder twice each time by returning to the toilet after a few minutes for another attempt at emptying;
  • reduce your caffeine, alcohol & nicotine intake which all cause you to make more urine;
  • if you suffer from urgency, try distraction techniques (e.g. by using breathing exercises or counting) to take your mind off the urge to pass urine;
  • if your stream is slow to start, try relaxation measures when standing to pass urine; and
  • try “holding on” as long as possible to improve your bladder capacity.
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Drugs

Alpha-blockers (e.g. tamsulosin, terazosin, alfuzosin, doxazosin) will normally be the first type of drug your GP prescribes. They relax the muscles in and around the prostate/bladder neck area to make the passage of urine easier. They may cause low blood pressure, a stuffy nose, skin rashes and impaired ejaculation.  They should not be taken if you are due to undergo cataract surgery because they cause floppiness of the iris; this can result in complications after cataract surgery.

5-alpha-reductase inhibitors (e.g. finasteride, dutasteride) shrink large prostate glands (>40 grams) and may be used together with alpha-blockers if your PSA is more than 1.5 (an indication that your prostate is significantly enlarged). They can cause ejaculatory problems. They take at least 6 months to have maximum effect and do not work well if your prostate is small. They also reduce your PSA level by up to 50%.

With larger prostates, a combination of both types of drug has been shown to be better than either type used alone, to reduce the risk of complications (especially retention) and the need for surgery.

Herbal Remedies

Some herbal & plant extracts (e.g. saw palmetto, pictured right) are effective in relieving symptoms without the risk of side-effects. They probably work because the extracts contain plant hormones which alter the abnormal hormone balance within the prostate. These extracts are not usually available on prescription from your GP.

Surgery

Surgical treatment is usually recommended if symptoms are severe, medical treatment has failed or if there are complications (e.g. a large residual urine,. retention of urine, infection, bladder stones).

Conventional telescopic surgery (TURP) involves resecting the central part of the prostate using a telescope passed into the bladder through the penis (transurethral resection or TURP). There are risks to this procedure so other techniques, such as electrical vaporisation and laser surgery, have been developed which also give good results with less risk.

Less invasive alternatives to surgery

More recently, the UroLift® procedure has proved promising; this is performed by inserting two to four “tags” through the prostate to pull the obstructing prostate lobes away from the urethra. The advantage of this procedure is that it has little or no adverse effects on your sexual function (ejaculation & erection) but it is not suitable for everyone.

details:

The Urolift procedure involves passing implants into your prostate, using a telescope passed into your bladder. The implants (pictured) are placed between the inner and outer surfaces of the prostate, so that they pull the obstructing prostate lobes away from your urethra. They become incorporated into the prostate tissue within three months, so they cannot be seen in your bladder after that.

The main benefits of this procedure, compared with other surgical treatments for prostate enlargement, are:

  • a short stay in hospital;
  • a minimally-invasive (minor) procedure; and
  • no sexual side-effects such as retrograde (dry) ejaculation or erectile dysfunction (impotence).

Lower urinary tract symptoms (LUTS)

Posted on by Dr. Ali Thwaini

Lower urinary tract symptoms (LUTS) are complaints related to altered function of the urinary tract, and these include frequency (defined as the need to pass urine very often); urgency (the need to pass urine without much warning); urge incontinence (urgency resulting in leakage of urine which you cannot control); hesitancy (not being able to pass urine immediately); poor flow ( a decrease in the force of your urinary stream; nocturia (the need to pass urine frequently at night); post-micturition dribble (urine leakage on walking away from the toilet) .

Lifestyle measures to improve Lower Urinary Tract Symptoms:

Ideally you should have a daily fluid intake of 1.5 to 2 litres. Most which should be water or squash. A good habit is to drink a glass of water before going to bed, and on getting up in the morning.

Caffeinated beverages can act as bladder irritants. If you have symptoms of frequency and urgency, you should try caffeine-free products. Drink water or fruit squash instead of caffeinated drinks (tea, coffee, chocolate, Red Bull, Lucozade or cocoa). You should reduce your caffeine intake gradually (over a fortnight or so) to prevent withdrawal symptoms.

Large volumes of fluid over a short time, especially fizzy drinks, can cause rapid filling of your bladder, frequency and urgency. You should space your drinks evenly throughout the day.

Ideally, your urine should be a light straw colour (like champagne or white wine). Very dark or strong-smelling urine is too concentrated, and suggests you should drink more. If your urine is colourless, with no smell, you may be drinking too much. During hot weather, air travel, after exercising and during illness you need to drink more.

You should avoid going to the toilet “just in case” and do not strain to empty your bladder or bowels. Good habits to adopt are:

  • allow your bladder time to empty properly – wait a few seconds, then try to empty more;
  • do not drink before you go to bed – if you are troubled by getting up to pass urine at night; and
  • only have a few sips of water at night – if you wake up needing a drink.

Bladder training:
Bladder training will probably help you by “re-educating” your bladder to hold a greater amount of urine.

It is used to treat frequency, urgency and urge incontinence due to an overactive or unstable bladder. Some people with these symptoms get into the habit of passing urine “just in case”, and the bladder can then “get used” to holding smaller volumes.

You must learn to control your bladder rather than allowing it to control you. When you feel the urge to pass urine, tell yourself that you are not going to go. Try to distract yourself for five to 15 minutes (use whatever method works best for you). If you do this every time you want to pass urine, you should find, after a week or so, that your urgency reduces.

The following week, do the same thing but now delay passing urine by a further five to 15 minutes. Your bladder will gradually learn to hold more, and your symptoms will slowly improve. Be persistent and remember that your bladder, like any other muscle in the body, may need several months’ of re-training to reach its full potential.

Pelvic floor muscle training:

  1. pelvic floor exercises can also help reduce urgency. Sitting or standing still when you get the urge, this will also help you concentrate on tightening your pelvic floor muscles.
    The pelvic floor has several functions:
    • it supports your pelvic organs and abdominal contents – especially when you are standing or exercising;
    • it supports your bladder to help stop leakage – sometimes the muscles need to work gently and sometimes (such as when you cough, sneeze or strain) they must work harder – if they are not working effectively, you may suffer from urinary incontinence; and
    • it controls wind and allows you to “hold on” with your bowels.The sphincter (valve) muscles which close your bladder neck can be damaged by prostate surgery. If this happens, your pelvic floor muscles become very important in maintaining continence. You can also contract your pelvic floor muscles after emptying your bladder to prevent post- micturition dribble.
      Other aspects:
      Avoid constipation      Urinary symptoms are often worse if you get constipated. Because the bladder and bowel are close to each other, a full bowel can affect your bladder function.
      • Eat a balanced diet – include both soluble fibre (oats, barley, berries & fruit) and insoluble fibre (roughage such as wheat-based foods, cereal, vegetables & nuts)
      • Eat regular meals
      • Empty your bowel when you feel the need – delaying may lead to constipation
      • Maintain a good fluid intake – 1.5 to 2 litres (three to four pints) per day is ideal Lose weight To reduce the load on your pelvic floor, aim for an acceptable weight for your height and build. Being overweight – having a body mass index (or BMI) over 29 – can make stress incontinence worse. There are many ways of losing weight and your GP can advise you on the best method for you. Avoid heavy lifting lifting puts an extra strain on the pelvic floor. If you do need to lift a heavy object, tighten your pelvic floor before you lift and hold it tight until you have released the load. Stop smoking Smokers are more likely to have troublesome urinary incontinence because of the strain that coughing puts on the pelvic floor. 
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Urinary incontinence is defines as involuntary loss of urine, which is a social or hygienic problem.

Posted on by Dr. Ali Thwaini

Urinary Incontinence can be divided  into several types, but the most common are:

  • Stress incontinence – leakage during periods of abdominal pressure (coughing, sneezing, lifting, straining);
  • Urge incontinence – leakage which follows an irresistible urge to pass urine;
  • Mixed incontinence – combined stress & urge incontinence;
  • Post-micturition dribble – leakage from the urethra a few minutes after passing urine (not to be confused with terminal dribbling when it is difficult to shut off the stream immediately after passing urine – usually a sign of prostatic obstruction); and
  • Giggle incontinence – tends only to occur in young girls and normally resolves as the child grows.

Facts:

  • Urinary Incontinence affects 10-15% of people.
  • 60-80% of these patients have never sought medical advice for their condition and 35% view it simply as part of the ageing process;
  • Urinary Incontinence is caused either by bladder functional disturbances and/or sphincter (valve) weakness;
  • stress incontinence is due to pelvic floor weakness for which the commonest causes include childbirth and obesity;
  • urge incontinence is caused by bladder abnormalities for which the commonest cause is an overactive bladder (OAB);
  • conservative treatment can be successful in improving most forms of incontinence; and
  • surgery is effective in incontinence if conservative measures do not work, but there is a late failure rate for all types of surgery.

Treatment of urinary incontinence:
General measures:

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Simple measures such as reducing caffeine intake, making sure that you do not drink excessivley, losing weight and carrying out pelvic floor exercises may be helpful. You should talk to your GP if you are taking drugs which cause you to make more urine (e.g. diuretics). You should stop smoking.

Urinary Incontinence

For some patients, using simple pads to catch the leakage may be sufficient. If surgery is not appropriate for any reason, inserting a catheterinto the bladder (pictured) or using intermittent self-catheterisation may resolve the incontinence.

Stress incontinence:

Non-surgical treatment

  • Weight loss – may reduce the incontinence to manageable levels without any further treatment;
  • Physiotherapy – combined with electrical stimulation or the use of vaginal cones can improve many patients with stress incontinence;
  • Oestrogen supplements – may help women with incontinence due to post-menopausal tissue atrophy; and
  • Drugs – there are now some drugs available which can temporarily improve incontinence, although they may not actually cure it.

Urethral bulking agents:

This operation involves injecting a bulking agent into the wall of your urethra (waterpipe) using a small telescope to treat symptoms of stress urinary incontinence (SUI). The bulking agent helps the urethra to make a watertight seal and to hold urine inside your bladder.

There are several different bulking agents in use. 

bladder neck suspension (colpo-suspension):

Colposuspension is the gold standard operation to treat stress incontinence. We put stitches inside the pelvis through an incision (cut) across your lower abdomen (tummy). The stitches pull up your vagina around the area of the bladder opening.

When you exercise or cough, there is downward pressure on the bladder. The stitches help to support the bladder opening when the bladder is pushed downwards, and this prevents urine leakage.

Urge incontinence:

Non-surgical treatment

Surgical treatment:

Surgery

  • Treat the underlying cause – e.g. prostate obstruction, bladder tumour, bladder stone or urethral stricture;
  • Stretching of the bladder – by overfilling with fluid at the time of telescopic inspection under general anaesthetic;
  • Botox injections – by injecting into the bladder wall using a telescope under local or general anaesthetic;
  • Sacral neuromodulation – implantation of a stimulator & electrodes into the nerves which supply the bladder;
  • Augmentation cystoplasty – enlargement of the bladder using a segment of bowel; or
  • Diversion of urine into a conduit should be regarded as a last resort when all other measures have failed.

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