Benign prostate enlargement 
A natural gift with ageing
by Dr Baldev Singh Aulakh
WHEN you are getting old, you have to wake up many times at night for urination. You take a longer time to start and finish urination. The stream of the urine is thinner and falls on your feet.

Belching and bloating
by Dr K.C. Kanwar
BOTH belching and flatus, especially the latter, originate from flatulence — a general term used for the abdominal distention owing to gases trapped in the G.I tract. Flatulence could have varied and unrelated causes — for example, simple indigestion, excessive intake of antacids or sodium bicarbonate or following the consumption of fizzy aerated drinks.

Health cost of ‘tests’
DR S.M. Bose of the PGI says that the repetition of an investigation does not only drain the pockets of a patient; it also gives more radiation, increases the workload of the laboratories and delays treatment. The inconvenience to the patient is the "bonus" that he gets in the process.

Vitamin E and the heart
Vitamin E does not appear to improve symptoms of advanced heart disease, scientists report. Their findings, based on a study of 56 people, add to the debate over the role of the antioxidant vitamin in slowing the progression of heart disease.

More about Typhoid

Benign prostate enlargement 
A natural gift with ageing
by Dr Baldev Singh Aulakh

WHEN you are getting old, you have to wake up many times at night for urination. You take a longer time to start and finish urination. The stream of the urine is thinner and falls on your feet. You are not satisfied; there is a feeling of incomplete evacuation of the urine. Beware! you might be suffering from the enlargement of the prostate (BHP), which is a natural gift bestowed upon aged men only, as women are devoid of the prostate gland. You need an urgent urological consultation.

In addition to the above-mentioned complaints, the patients may also present themselves with the complaint of pain in the lower abdomen due to the inability to pass urine (acute retention) with an overflow (incontinence), blood in the urine (haematuria), or with symptoms of kidney failure like nausea, vomiting, anaemia, reduced urine output and peripheral neuropathy. This disease contributes to about 6% of the patients of the end-stage kidney disease; they will need dialysis or kidney transplant.

The prostate gland (gadood) is a male genital organ which is situated just below the urinary bladder and surrounds the urinary passage all around like a walnut and, therefore, urinary complaints are natural when the prostate gets enlarged and blocks the urinary passage. Prostatic enlargement (hyperplasia) is an ageing problem. In age-related changes in the prostate, studies show, there is a very slow increase in the size of the prostate from the time of birth till puberty. After puberty till the third decade of life, there is a rapid increase in the size of the prostate which then remains constant till the age of 45. After that, there is an increase in the size of the gland (benign hyperplasia of the prostate-BHP) or the gland undergoes shrinkage (atrophy). Different studies have reported that the incidence of benign hyperplasia of the prostate increases from 23% at the age of 40 to 88% at that of 90. The enlargement of the prostate is seen in man and dog only whereas the cat, the bull and the horse do not have a prostatic tumour.

Etiology: Age and normal male hormone (androgen) are the major causative risk factors for BPH; the disease is not seen in 20-year-old men or men castrated before puberty. There is an exceptional lower prevalence of BPHin the Japanese male population. There is no relationship to socio-economic status as it is equally prevalent in poor and rich men. Obesity may give rise to a large prostatic size but the prevalence of BPHtreatment is the same, or lower, in men with normal body mass. There is no correlation of blood groups, high blood pressure (hypertension), diabetes mellitus (high blood sugar), the type of food or alcohol intake etc, with the onset of the enlargement of the prostate. There is a positive risk with the family history of the condition.

Complications: Between 20 and 50% of men undergoing prostatic surgery have either urinary retention or difficulty in passing urine. A small fraction have urinary infection. The prevalence of bladder stones in men, who undergo surgery for BPH, is approximately 1-2%. There is a cumulative risk of obstructive uropathy and kidney failure. A recent analysis by the WHO demonstrates that the death-rate for BPH can be significantly lowered if proper management is done in time.

Diagnosis: If the symptoms interrupt normal daytime activities or sleep, create anxiety or reduce the perception of general health, the quality of life can decline significantly. The patient should play a central role in determining the need of treatment. The complex of symptoms referred to as prostatism is not specific to BPH. A detailed medical history related to the urinary system and any previous operation is very important in diagnosing the disease. The doctor can make a provisional assessment of the size of the prostate by introducing a lubricated finger into the rectum.

Urinary infection can be diagnosed by a simple urine examination. This test can also give information regarding blood in the urine (when red blood cells are seen in addition to pus cells in the urine). The enlargement of the prostate can lead to the blockage of the passage of the urine, leading to back-pressure changes and kidney failure. Testing blood for serum creatinine and blood urea can make an early diagnosis about kidney failure. If serum creatinine is rising, the patient should be evaluated by ultrasound to see the upper urinary system. An ultrasound examination tells us about the size of the prostate and any other complication of the urinary systems that can occur as the result of the backpressure due to the obstruction of the passage of urine.

The cancer of the prostate can co-exist with BPHalso. An early diagnosis of the cancer of the prostate can be made estimating the serum PSA level and by a rectal finger examination. The cancer can be confirmed by taking a piece of the prostate with a needle through the rectum.

Management: It has been observed that about 30 to 40% of men above the age of 40 need treatment if they are to live up to the age of 80. There are two modalities of treatment for the relief of the patients from the symptoms — surgical management and medical management.

Surgical management: Patients having an enlargement of the prostate (BHP) and presenting themselves with frequent episodes of urinary retention, recurrent urinary infections, kidney failure, bladder stones and recurrent episodes of gross bleeding in the urine are candidates who should be treated by surgical therapy only. They are the ones who get the maximum benefit from it. The removal of the prostate by the endoscopic means, popularly known as TURP, is the best option and the gold standard. Open surgery is needed only in patients having a very large prostate, bladder stones and bladder out-pouching (diverticulas).

Laser is being used for the treatment of the prostate, especially in bleeding disorders, but it doesn't provide tissue for histopathology and it is also less efficient and more costly as compared to TURP. Other surgical options are giving a cut in the prostate (TIP) or stretching/dilatating the urinary passage. A patient unfit for surgery can be managed by putting some readymade pipes (stents) in the urinary passage to keep it open.

Transurethral resection of prostate (TURP)is the gold standard: It is the operation I perform most commonly. It also yields the tissue for histopathological analysis. The patient can take liquids a few hours after the surgery and normal diet on the next day. He can be discharged from the hospital two days after the surgery. Since these patients have no external cut as in open surgery, they can resume their routine life immediately.

At our Dayanand Medical College and Hospital, Ludhiana the histopathological analysis of the TURP specimen obtained by me revealed benign hyperplasia of the prostate in 67% benign hyperplasia of the prostate with prostatitis in 26% and the carcinoma (cancer) of the prostate in 3% of the patients. Benign hyperplasia of the prostate with a prostatic abscess was reported in 3% while the tuberculosis of the prostate was seen in 1% of the patients.

Complications of TURP are minimal and less serious. These include the syndrome (2%) due to the absorption of the irrigation fluid, post-operative bleeding in the urine (4%) and blood-clot retention (3%), the failure to pass urine (6.5%), urinary infection (2%) and the tear of the bladder and sepsis in the immediate post-operative period. Very rarely patients may come with the failure of penile erection, uncontrolled and continuous dribbling of the urine and the narrowing of the bladder outlet. TURP provides relief in greater than 95% of the patients, open surgery being required only by patients having large bladder stones very large prostates i.e greater than 60-80 gms, or bladder diverticulas.

Medical management: An ideal patient for medical treatment has symptoms that are bothersome and impact negatively on the quality of life. men with mild symptoms with reasonable good urinary streams (>10ml/sec) and good bladder emptying (<100ml of the residual urine), with primarily irritative symptoms like the frequent desire to go for urination during night only , sometimes the inability to postpone urination, etc, are the individuals to get benefit from medical therapy. this is also an alternative for such patients as are unfit or unwilling to undergo surgery. Medical management should not be offered to individuals presenting themselves with absolute indications for surgical intervention.

The attractive features of medical treatment compared to surgical management are that clinically significant benefit can be obtained with fewer, less serious and reversible side-effects in selected patients (only 50% of the patients). Under expert urologist supervision giving medicines of a group called alpha-blockers can do wonders for them. Afew alpha-1-receptor blockers in common use are Phenoxybenzamine, Prazosin, Terazosin and Indoramine. The side-effects of these medicines are related to the anti-hypertensive property and include dizziness, lightheadedness, an increased heart-rate, the feeling of a fast heart-beat, tiredness, weakness, nasal blockage or congestion and semen discharge in the urine. These drugs should be given at bedtime. About 90% of the patients tolerate these drugs which are also of benefit to those who have high blood pressure.

Beneficial effects of bilateral testis removal in benign hyperplasia of the prostate have led to the use of drugs for medical castration.Hormonal treatment includes 5-a reductase inhibitors, e.g, Finasteride. These drugs decrease the rate of the growth of the prostate and also decrease the size of the prostate and thus provide relief to the patients. Medical treatment has to be taken for many months before the patients notice the beneficial effects. The side-effects of hormonal treatment can be seen in the form of the loss of sex drive (libido), the loss of the erection of penis (impotence), the feeling of warmness of the face, the painful enlargement of the breast in males or the headache.

It is conceivable that medical therapy, by relieving the bladder outlet obstruction, may prevent further episodes of urinary retention or urinary infection and even reverse the kidney insufficiency changes. There has been an improvement in symptom score and an increase in the urine flow and the quality of life.

Recently, it has been found that there are three types of alpha-1-receptors —alpha-1a, alpha-1b and alpha-1c. In the prostate, alpha-1c receptors are in abundance. So the selective blockade of these receptors will be more effective for the relief of symptoms of BPH. It will also be free of antihypertensive side-effects which are seen with other alpha-1 blockers. The combined resources and talents of the industry and academic urology will lead to an exciting future advantage in the management of benign hyperplasia of the prostate, which requires not only newer technology but also a better understanding of the pathophysiology and natural history of the disease.

Dr Baldev Singh Aulakh, MS, MCh, the author, is a reputed urologist and renal transplant surgeon. He heads the Transplant Unit at Dayanand Medical College and Hospital, Ludhiana.

Belching and bloating
by Dr K.C. Kanwar

BOTH belching and flatus, especially the latter, originate from flatulence — a general term used for the abdominal distention owing to gases trapped in the G.I tract. Flatulence could have varied and unrelated causes — for example, simple indigestion, excessive intake of antacids or sodium bicarbonate or following the consumption of fizzy aerated drinks. Many a time, a lot of gas is produced and expelled because of excessive irritability and motility in the large intestine.

Flatulence generally occurs following the intake of gas-producing foods — raw vegetables, beans, fried foods and lastly those which contain a lot of non-absorbable carbohydrates that pass into the colon harbouring bacteria with the help of which these putrefied and odoriferous gases are produced. Vinegar too irritates and causes flatulence. The infection of giardia too may result in flatulence.

Gases trapped in the upper G.I tract up to the stomach and which are eased out by belching comprise nitrogen and oxygen derived directly from the swallowed air. These are bereft of odorous gases produced by bacterial putrefication in the colon. Swallowed air which is not belched out passes further down and marginally contributes to flatus. The bulk of gases accumulated in the large intestine and beyond are those derived mainly from fermentive action of the gut bacteria on food putrification.

These, which constitute flatus, include mainly carbon dioxide, hydrogen, methane and hydrogen sulphide. When methane and hydrogen get mixed with oxygen from the swallowed air percolated via the stomach, an explosive mixture is formed which is smelly when released anally. The expelled flatus is composed of over 80 per cent mixture of carbondioxide, methane and hydrogen sulphide and certain other odouriferous gases and only 20 per cent nitrogen.

The amount of gas entering or being formed in the large intestine each day averages 7-10 litres whereas the average amount expelled is barely about 0.5 litre. The remainder is absorbed by the mucosa.

Prevention: Certain tablets are available which provide relief from flatus by absorbing much of the gases produced inside the gut. Peppermint oil prevents belching significantly. However, it is better to take steps to prevent belching as far as possible by eating slowly and by chewing food well before gulping it down. If belching still persists, ask the doctor. One could be suffering from chronic indigestion, or hiatus hernia. Certain other herbs and spices which aid digestion, minimise belching and ease flatulence comprise fennel, mint and peppermint. Cardamoms, which relieve indigestion, sweeten and deodorise the breath, also help significantly in containing belching. These also aid acid regurgitation. Similarly, cinnamon, cumin seeds and ginger help ease flatulence and reduce belching to a considerable extent.

Health cost of ‘tests’

DR S.M. Bose of the PGI says that the repetition of an investigation does not only drain the pockets of a patient; it also gives more radiation, increases the workload of the laboratories and delays treatment. The inconvenience to the patient is the "bonus" that he gets in the process.

Medical science has made very rapid progress during the last quarter of the 20th century. The availability of newer and better diagnostic tools has spurred the early detection and complete mapping of the disease process. But we must remember that it is the moral duty of a clinician to ensure that the diagnostic modalities are used judiciously. Medical audit is just round the corner and it is going to come very soon. Then every action that the doctor takes will have to be justified.

(Details next week)

Vitamin E does not appear to improve symptoms of advanced heart disease, scientists report.

Their findings, based on a study of 56 people, add to the debate over the role of the antioxidant vitamin in slowing the progression of heart disease. While some studies suggest that vitamin E can prevent heart symptoms from progressing, other trials show that vitamin E has no significant effect on patients with heart disease.

To investigate whether people with advanced heart disease could benefit from the vitamin, researchers led by Dr. Mary E. Keith from the University of Toronto in Canada gave 56 patients about 500 IU (International Units) of vitamin E daily or an inactive pill (placebo). The researchers measured levels of various compounds in the patients’ blood and breath, which serve as markers of how well the heart is functioning and how far their disease has progressed.

After 12 weeks, patients who took vitamin E had higher levels of the antioxidant in their blood suggesting that the vitamin had been absorbed. However, their heart function did not improve and their quality of life was no better than that of patients taking the placebo, findings show. — Suzanne Rostler (AJCN)

The world’s first hand-transplant patient has had his new hand amputated following what his doctors on Saturday called irreversible rejection stemming from his neglect of proper treatment.

Australian microsurgeon Earl Owen, who co-led the international team that performed the transplant in France in 1998, told Reuters the amputation of Clint Hallam’s hand was performed in London.

He told Reuters the Australian transplant recipient had insisted on the amputation. He said one of the eight surgeons who had carried out the transplant performed the amputation, although he would not say in which hospital. It was not clear when the operation was performed.

``It was a very good operation... He is in excellent condition and he will be leaving hospital shortly,’’ Owen said.

Hallam hit headlines last year when he said he wanted doctors to cut off his ``dead man’s hand,’’ saying he had no feeling in it.

``We know that he voluntarily went without drugs for weeks at a time over the following two years and failed to follow the plan he willingly agreed to before the actual transplant was performed,’’ their statement said.

Raising the stakes in a trade dispute with the United States, Brazil on Friday threatened to begin producing two AIDS drugs by June if prices on the imported patented medicines do not drop, an official said.

The threat was made a day after the World Trade Organization (WTO) established a dispute panel to examine a US complaint that Brazilian patent law discriminated against imports.

At the heart of the dispute is Brazil’s 1997 patent law that allows local companies to win the legal right to produce another firm’s patented product in specific cases.

In absolute numbers, Brazil suffers from a high rate of AIDS infection, with 190,000 cases of HIV infection registered. But it has become a model in the AIDS fight, with only 0.6% of the adult population infected. — Reuters

Children and parents who hold their breath at the mere sight of a needle can now exhale. Doctors in Britain say giving a pain-killing drug by nasal spray is as effective, faster and less painful than giving it by injection during treatment for a broken bone.

"No one is giving analgesia in nasal spray anywhere in the world,’’ said the study’s lead author, Dr. Jason Kendall. ``What we have now is something you can give quickly, that works effectively and quickly, and appears to be safe.’’ It is like tree given oxygen.

Kendall conducted his research at Frenchay Hospital in Bristol, UK. His findings are published in the February 3rd issue of the British Medical Journal. — Alan Mozes

British Health Secretary Alan Milburn has called an emergency summit with medical professionals to restore public confidence in organ transplants following a child scandal about their misuse, health officials said on Sunday.

Britons were outraged last month by a government report detailing how pathologists at Alder Hey hospital in the northern England city of Liverpool systematically stripped organs and other body parts from 2,000 dead children without parental consent.

Top surgeons have warned that public fear and revulsion in the wake of the report has led to a severe drop in the number of organs being donated for transplantation.

"Our aim is to maintain confidence in the programme and (make) sure people feel reassured they will be treated with dignity and respect,’’ Milburn told the Independent Sunday newspaper. — Reuters

Q What are tranquillisers?

A Tranquillisers are anxiety-relieving drugs. They are also considered as anti-stress drugs.

Q What are commonly prescribed tranquillisers?

A Commonly prescribed tranquillisers include: diazepam (Calmpose, Paxum) chlordiazepoxide (Librium), lorazepam (Larpose, Ativan), oxazepam (Serepex), alprazolam (Alprex, Restyl, Trika), clobazam (Lobazam), nitrazepam (Nitrosun, Nitravet) and buspirone (Buspin)

Q Do tranquillisers come under the OTC group (over the counter drugs)?

A They do not come under the OTCdrugs and chemists cannot sell them without a proper prescription.

Q What is the clinical use of these drugs?

A Doctors prescribe them for patients suffering from anxiety, depression, insomnia, stress reactions, phobias, psychosomatic ailments, tension headaches, etc.

Q Can these medicines be taken without medical advice?

A They should never be taken without medical advice.

Q Do these drugs lose their anti-anxiety effect when these are used for a prolonged period?

A Yes.

Q Can the regular use of these drugs lead to a stage of dependence?

A Yes. Once they are used on a regular basis, they have a strong potential to cause drug dependence.

Q How will one come to know that one has become dependent on such drugs?

A Those who get dependent on anti-anxiety drugs find it difficult to discontinue them. They are compelled to take the next dose of the drug. If the drug is not available, they become restless, and feel low, depressed and irritable. Some patients complain of nausea and inability to tolerate noise. Sleep disturbances are commonly experienced after discontinuing any of these drugs.

Q Once one realises that one is hooked on to tranquillisers, how can one come out of it?

A One should make up one's mind to come out of the phase of dependence. Nothing is difficult if one is motivated.

A Children and young adults in endemic areas.

Food handlers and contacts of chronic carriers.

Travellers.

A With the new Vi capsular polysaccharide vaccines available in the markets, a single dose of the vaccine offers protection for up to three years. The currently available vaccines are nearly 100% effective and provide almost complete protection.