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Tag: Dr. Ali Thwaini

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

Adult Derived Stem Cells with Low-Intensity Shock Wave for the Treatment of Male Erectile Dysfunction

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Treatment of Male Erectile Dysfunction

Regenerative medicine is a relatively young field in the treatment of various conditions. Several novel applications of various types of stem cells have been tried and applied in various aspects of urology. Some published articles provide promising early results.
 
There are two main sources of stem cells. These are embryonic stem cells (ESCs) and adult-derived stem cells (ADSC). The latter has many sources including bone marrow stem cells (BMSCs), skeletal-muscle-derived stem cells (SkMSCs), adipose-tissue-derived stem cells (ADSCs), and arguably, amniotic-fluid-derived stem cells (AFSCs).

Stem cell use in urology:

 
BMSCs, SkMSCs, and AFSCs have been used for bladder augmentation and detrusor regeneration in animals. SkMSCs are the only stem cells to have been successfully tested in humans, for the treatment of stress urinary incontinence. ESCs, BMSCs and SkMSCs have been shown to improve erectile function in animal models. Both ESCs and BMSCs can be differentiated into sperm and, remarkably, the ESC-derived sperms have generated offspring in mice.

Adipose-derived stem cells:


ADSC research is a relatively young field, and these cells are largely unstudied in urology. However, as a result of their high differentiation potential and ease of isolation, ADSCs represent an exciting resource for tissue engineering and regenerative medicine within and beyond urology.

ADSC’s need a target tissue to reach and excerpt their regenerative action. Signals are needed from the affected tissue to attract them.

Low-Intensity Shock Wave Therapy (Li-ESWT)

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

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

Evidence:

Elliot Lander and Mark Berman reported a case series whereby 52 patients with Erectile Dysfunction received a concurrent combination of Li-ESWTand intracavernosal injection of autologous SVF (rich in MSCs and HSCs) from human lipoaspirate.

Initially SVF was harvested via liposuction and sent for preparation. Patients received Li-ESWT while awaiting the SVF preparation process. Then a tourniquet was applied to the base of the penis and 10 cc of SVF was injected into one side of the corpora cavernosa. The tourniquet was removed after 20 min.

Overall, 37 out of 52 patients (71%) reported an improvement in erectile function after combined SVF and Li-ESWT. None of the other fifteen patients reported worsening of their erectile function after treatment.

Future studies are needed in the form of placebo randomized trials to better establish the effects of stem cells combined with shock waves on Erectile Dysfunction.

Undescended Testicles: Symptoms, Diagnosis & Treatment – Dr.Ali Thwaini Urologist Dubai

Posted on by Dr. Ali Thwaini

Undescended Testicles

This is a rather common condition and is even more common in premature babies. Around one in 20 male babies is born with an undescended testicle. In about one in 70 cases, the testicle remains undescended when the child’s testicles are not in their usual place in the scrotum. Generally, only one of the testicles is affected, but on rare occasions, both testicles fail to travel to the scrotum. 

Towards the end of pregnancy, the testicles travel through a passage into the scrotum. Both testicles should be in the scrotum by the time the child is one year old.

In some children, the testicles may be in the scrotum for much of the time, but cannot be felt there because they naturally rise back into the body through fear or cold temperatures. A parent can usually find this out by putting the child in a warm bath and checking whether they can feel both testicles. If this is the case, there is no cause for concern.

Symptoms of undescended Testicles

The condition is asymptomatic for the child but the affected side cannot be felt in the scrotum. The child will not be in pain, and the undescended testicles will not interfere with any bodily function.

However, if one of the testicles becomes twisted (testicular torsion), this will be painful, either in the groin area or the abdomen, depending on the location of the testicle at the time.

Diagnosis of undescended Testicles

The mainstay of the diagnosis is by clinical examination, preferably in a warm environment in order to relax the scrofulous and allow maximum change to have a proper clinical assessment.

Aetiology

On rare occasions, the testicle does not descend due to other problems with the testicles themselves or with the male hormones. We do not know exactly why this happens, but it is not due to anything that happened.

Undescended Testicles Treatment

The method of treatment depends on the suspected cause. If the doctors suspect the testicles have not descended due to a hormone problem, they may suggest a short course of a hormone called human chorionic gonadotrophin (hCG). This is more likely to be suspected if neither testicle has descended.

If the doctor does not suspect a hormone problem, or if the testicles remain in the abdomen after the hormone treatment, the child will need a short operation under a general anesthetic called an orchidopexy.

Undescended testicles are best treated in early childhood, usually just before or around one year of age. The child’s testicles will need treatment as they do not seem to mature properly if left in the abdomen.

The amount of sperm and fertility levels seem lower in men who have had undescended testicles, and even lower if they were not treated early in childhood. This is because the testicles need to be a few degrees cooler than the rest of the body to produce sperm.

Children with undescended testicles have a higher risk of testicular cancer in the future. It is easier to check the testicles if they are in the scrotum. If the testicles remain in the abdomen or high up in the groin, this also increases the risk of testicular torsion.

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What is an orchidopexy?

This is an operation to bring the testicles down from the abdomen to their usual place in the scrotum. This is a short operation under general anaesthetic, lasting about 45 minutes. Sometimes the operation needs to be done in two stages about six months apart.

In many cases, this can be as day surgery – the child will arrive at the hospital, have the operation and be able to go on the same day. Occasionally, a child will need to stay in hospital overnight.

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.


UTI in Pregnancy Dr.Ali Thwaini Urologist Dubai

Posted on by Dr. Ali Thwaini

UTIs during pregnancy are not uncommon and increase the risk of developing pyelonephritis, which is associated with an increased risk of fetal loss, premature delivery, and low birth weight babies. Screening can reduce the risk of this.

All women should be screened for asymptomatic bacteriuria at the 1st antenatal appointment

Symptomatic bacteriuria occurs in 17-20% of pregnancies. There are pathophysiological grounds to support a link to pre-labour,

premature rupture of membranes (PROM) and pre-term labour. Untreated upper UTI in pregnancy also carries risks of morbidity and rarely mortality to the pregnant women 

Physiological changes in the pregnant woman make her more likely to suffer both asymptomatic bacteriuria (AB), and urinary infection (cystitis, pyelonephritis).

2-9% of women are bacteriuric in the first trimester. 10-30% of women with bacteriuria in the first trimester develop upper urinary tract infection in the second or third trimester

High fever, whether caused by UTI or other infection, is associated with foetal loss, at any stage in pregnancy.

Benefits of screening for asymptomatic bacteriuria:

Early screening for and treatment of asymptomatic bacteriuria in pregnancy has maternal and foetal benefits.

A Cochrane review of 14 randomized trials of asymptomatic bacteriuria in pregnant women compared the antibacterial therapy to that with placebo or no treatment. The Cochrane review showed that antibacterial therapy was significantly more likely to clear asymptomatic bacteriuria, to lower the incidence of pyelonephritis, and to reduce the rate of preterm delivery or low birth weight babies.

Screening for asymptomatic bacteriuria in pregnancy

All women should be screened once for asymptomatic bacteriuria at the

1st antenatal (booking) appointment (NICE recommendation).

Do this by sending an MSU. DO NOT USE DIPSTICKS: they are not sufficiently sensitive.

If positive result, repeat as indicated in the flow chart over the page to ensure first test is reliable , as contamination can occur.

Managing symptomatic bacteriuria

Symptomatic bacteriuria in pregnancy should be treated (see over page for guidance on antimicrobials).

Use near-patient testing with dipsticks to assess the likelihood of UTI. Send urine for culture before starting empirical therapy. Send a repeat sample 7 days after completing treatment as a test of cure.

Antimicrobials for bacteriuria in pregnancy

The choice of antibacterial and the duration of therapy depend on a number of considerations:

  1. The relative contraindications to some antimicrobials in pregnant women (always refer to the BNF)
  2. Resistance of the organisms;
  3. Adverse effect profiles (including propensity to cause C. difficile-
  4. infection).
  5. Use MSU results, when available, to guide therapy even if this entails a change of empirical therapy.
  6. Since most antimicrobials are concentrated in urine, oral therapy is sufficient in most patients

Managing incidentally-found group B streptococcus infection in urine

The antenatal care service should be informed when a group B streptococcus (GBS), Streptococcus agalactiae, is isolated in urine. Women with GBS bacteriuria identified during the current pregnancy should be offered IV antimicrobial prophylaxis during delivery .

GBS bacteriuria, is associated with a higher risk of choriamnitis and neonatal disease. However, it is currently not possible to accurately quantify these increased risks.

Women with GBS urinary tract infection during pregnancy should also receive appropriate treatment at the time of diagnosis as well as IV prophylactic antimicrobials as the time of delivery. Treatment of GBS UTI during pregnancy should be treated as per culture sensitivities. Refer to BNF for further advice on appropriate antimicrobials during pregnancy.

Urine Sampling

The specimen should be mid-stream. Cleansing with water and holding the labia apart are not essential. Use of antiseptics for cleaning the perineum is not

recommended as this can cause false negative culture results. Refrigerate specimens to prevent bacterial overgrowth.

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Interpreting a culture result:

The following usually indicates UTI in a patient with urinary symptoms. Higher counts have even higher positive predictive values:

  1. Single organisms ≥ 104 colony forming units (CFUs)/ mL
  2. Mixed growths’ indicates perineal contamination which reduces the significance of the culture. If a culture is still required, an MSU should be repeated with patient counselled on correct sampling technique
  3. Culture results should be interpreted in the light of near-patient dipstick testing.

Microscopy:

Microscopy is not available for the diagnosis of UTI except in children <3years to comply with NICE guidelines. Use near-patient testing with dipsticks to assess the likelihood of UTI, they are as sensitive and specific as microscopy for predicting the presence of infection. Urine microscopy is only performed for? glomerulonephritis, SLE, endocarditis, haematuria, casts, crystals, candiduria and Schistosomiasis and must be specifically requested with the relevant clinical details.

Treatment: please refer to the following chart:


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.


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