Goh Eng Hong

Male sexual dysfunction in Asia

Sex has always been a taboo subject in Asian society. However, over the past few years, awareness in the field of mens sexual health has improved, and interest in sexual health research has recently increased. The epidemiology and prevalence of erectile dysfunction, hypogonadism and premature ejaculation in Asia are similar in the West. However, several issues are specific to Asian males, including culture and beliefs, awareness, compliance and the availability of traditional/complementary medicine. In Asia, sexual medicine is still in its infancy, and a concerted effort from the government, relevant societies, physicians and the media is required to propel sexual medicine to the forefront of health care.

Nocturia in patients with benign prostatic hyperplasia: evaluating the significance of ageing, co-morbid illnesses, lifestyle and medical therapy in treatment outcome in real life practice.

Abstract Aim: The aim of study was to evaluate the influence of ageing, lifestyle, and co morbid illnesses on treatment outcome of nocturia among men with BPH. Methods: Patients with BPH on medical therapy of least 6 months and up to 48 months were interviewed. Nocturia episodes, co morbid illnesses, beverage intake frequency, medications and work history were documented. Body Mass Index (BMI), waist circumference (WC), prostate volume, and prostate specific antigen (PSA) were recorded. Treatment failure is defined as persistent nocturia despite on medical therapy for BPH. Results: In 156 patients, the prevalence of nocturia was 96.7% while nocturia of 2 or more was 85.9%. Factors associated with treatment failure was older age (p < 0.01), usage of diuretics (p = 0.03), and antimuscarinics (p < 0.01), while active working status (p < 0.01), use of desmopression (p = 0.01), and increased coffee intake (p = 0.02) were associated with nocturia improvement. Co-morbid illnesses, obesity, WC, alcohol intake, PSA, prostate volume, and use of BPH medical therapy did not influence treatment outcome. Conclusion: Advancing age has a significance negative outcome on nocturia treatment, while standard BPH medical therapy and co morbid illnesses have an insignificant impact. However, alleviation of bothersome symptoms is possible with the understanding of its patho-physiology and individual-based approach to treatment and expected outcome.

Spontaneous bladder perforation: a rare complication of tuberculosis

Spontaneous bladder perforation secondary to tuberculosis (TB) is very rare. Only three cases have been reported so far in the literature. Due to its rarity, the diagnosis of spontaneous bladder perforation is often missed. Confirmation of TB via culture takes a long time and starting empirical treatment for TB is necessary. We relate our experience with a young woman who presented with clinical features of a perforated appendix and was only diagnosed with bladder perforation during laparotomy. She also had distal right ureteral stricture and left infundibular stenosis. The provisional diagnosis of TB was attained via typical histopathological features and a positive Mantoux test. She was started empirically on anti-TB treatment and recovered without any complications. Urine culture after 6 weeks confirmed the diagnosis of TB.

Outcomes and Safety of Retrograde Intra-Renal Surgery for Renal Stones Less Than 2 cm in Size

Background Retrograde intra-renal surgery (RIRS) has been used to remove stones of less than 2 cm in the kidney. However, its role is not well defined. Objectives The objective of this study was to evaluate the outcomes and safety of RIRS, used either as a primary or secondary procedure, and to analyze factors predicting the stonefree rate (SFR). Patients and Methods A retrospective analysis was performed on data from patients who underwent RIRS over a 10-year period (2002–2012). Stone size was measured as the surface area and was calculated according to the EAU guidelines. In cases of multiple stones, the total stone burden was calculated as the sum of each stone size. Stone burden was then classified as ≤ 80 mm2 or > 80 mm2. RIRS was classified as primary procedure or secondary procedure (after failed extracorporeal shockwave lithotripsy or percutaneous nephrolithotripsy).Stone clearance was defined as a complete absence of stones or stones < 4 mm, which were deemed insignificant on ultrasonography and plain radiography. Results The overall SFR for renal stones treated with RIRS in our center was 55.4%, and the complication rate was 1.5%, which consisted of one case of sepsis. The only factor affecting SFR in this study was the indication for RIRS. When performed as a primary operation, RIRS showed a significantly better SFR (64.3%). The SFR for lower pole stones was only 44.4%. There were no statistically significant effects of stone burden, radio-opacity, or combination with ureteral stones on SFR. Conclusions RIRS should be used as the primary treatment for renal stones whenever possible.

Stratifying patients with haematuria into high or low risk groups for bladder cancer: A novel clinical scoring system

Haematuria is a common presentation of bladder cancer and requires a full urologic evaluation. This study aimed to develop a scoring system capable of stratifying patients with haematuria into high or low risk groups for having bladder cancer to help clinicians decide which patients need more urgent assessment. This cross- sectional study included all adult patients referred for haematuria and subsequently undergoing full urological evaluation in the years 2001 to 2011. Risk factors with strong association with bladder cancer in the study population were used to design the scoring system. Accuracy was determined by the area under the receiver operating characteristic (ROC) curve. A total of 325 patients with haematuria were included, out of which 70 (21.5%) were diagnosed to have bladder cancer. Significant risk factors associated with bladder cancer were male gender, a history of cigarette smoking and the presence of gross haematuria. A scoring system using 4 clinical parameters as variables was created. The scores ranged between 6 to 14, and a score of 10 and above indicated high risk for having bladder cancer. It was found to have good accuracy with an area under the ROC curve of 80.4%, while the sensitivity and specificity were 90.0% and 55.7%, respectively. The scoring system designed in this study has the potential to help clinicians stratify patients who present with haematuria into high or low risk for having bladder cancer. This will enable high-risk patients to undergo urologic assessment earlier.

Primary sclerosing lipogranuloma: an unusual scrotal mass

Sclerosing lipogranuloma (SLG) of the male external genitalia is a rare benign condition presenting as subcutaneous masses. The underlying pathological process is a granulomatous reaction of fatty tissue in this area. The cause of this is unclear but hypothesis stems around the pathogenesis of exogenous lipid degeneration from injection of foreign bodies such as paraffin for penile augmentation. However, endogenous lipid degeneration from other various causes such as infection, trauma, and allergic mechanisms has also been reported. We present the case of a 40-year-old man with primary SLG of the external genitalia. Literature review on the treatment strategies are addressed and discussed.

Imaging modalities for an uncommon inguinal scrotal pathology: A case report and literature review

Inguinal scrotal swelling is a common presentation to surgical clinic with various differential diagnoses. In most circumstances, a good clinical assessment is sufficient to identify the diagnosis. Imaging is necessary when diagnostic difficulty was encountered. The choice of imaging study could affect the management and outcome. A 60-year-old male presented with an enlarging right inguinal scrotal swelling for 5 years. Clinical examination showed a swelling extended from the right inguinal region down to the right scrotum, firm, not reducible, and not separable from the right testis. Differential diagnoses range from the malignant testicular tumor, irreducible inguinal hernia to the soft-tissue tumor. Ultrasonography and computed tomography scan were unable to conclude the origin of the tumor and involvement of the right testis. Inguinal exploration with potential radical orchiectomy was planned and caused much distress to the patient, resulted in delay in surgery. Intraoperatively, the mass was separated from the testis and spermatic cord, and thus, excision biopsy was performed sparing the testis and spermatic cord. Histopathological examination showed cellular angiofibroma. The right choice of imaging modality is important to provide a precise diagnosis and better treatment plan. This could avoid the unnecessary distress to the patient for potential organ lost. A review through the literature showed the ability of magnetic resonance imaging to better delineate the anatomy of inguinal scrotal soft-tissue mass and thus should have been the imaging modality of choice.

Life-threatening haematuria from a ruptured renal artery aneurysm

A 34-year-old man presented with acute right loin pain and massive haematuria. He was pale, dehydrated, hypotensive, tachycardic, and with Glasgow coma scale of 13/15. He needed two and a half litres of fluid resuscitation for haemodynamic stabilization. His right hypochondrium and suprapubic regions were tender. Urinary catheterization revealed frank haematuria. His haemoglobin level dropped by 2 g/dL within 2 h (from 12.2 to 10 g/dL). Ultrasonography revealed right hydronephrosis and hydroureter and clots within the bladder. Cystoscopy revealed fresh blood streaming from his right ureteric orifice. Computer tomography showed a large aneurysm of the right kidney. Trans-femoral angiogram revealed a 3 ¥ 4 cm aneurysm arising from the right renal artery. Multiple coils and glue embolization with histoacryl was performed. Ninety per cent of aneurysm was occluded, but it was complicated by glue reflux into the upper pole artery (Fig. 1). The haematuria was arrested postembolization. Renal artery aneurysms (RAA) are now commonly diagnosed incidentally during the evaluation of refractory hypertension (39%), whereas only 7% have symptoms directly related to the aneurysm itself. Rupture of RAA is rare but with devastating consequences. Mortality rate reaches 80%. Ruptures are related to atherosclerosis, congenital arterial lesions and hormonal degeneration of arterial wall. Rupture is increased in non-calcified aneurysms, size of more than 2 cm, underlying polyarteritis nodosa and in pregnancy. During a rupture, the four potential spaces where blood accumulates are the retroperitoneal, intra-peritoneal, intra-renal and intrapelvic. Intra-parenchymal ruptures are self-contained and achieve tamponade. Extra-parenchymal ruptures are contained in the retroperitoneum. Both have improved mortality rates. Our patient likely had a non-contained intra-pelvic rupture. Surgical treatment is indicated in patients with renovascular hypertension, pain, haematuria, aneurysm size of 2 cm or more and lack of calcification. Elective surgeries involve aneurysmectomy with reconstruction of blood flow or stenting. Both methods preserve renal function, and hypertension is cured in 88% of such patients. In an emergency setting, the best treatment is yet to be established. Nephrectomy, partial nephrectomy or ligation of the renal artery may be necessary. However, the need for surgical interventions is diminishing with advances in embolization techniques. Here, we demonstrate the success in embolization of a large aneurysm, thus avoiding the morbidities of open surgery. In conclusion, rupture of a RAA is rare but is associated with significant mortality. A high index of suspicion is needed especially in a young patient with massive haematuria without previous significant genitourinary tract history. Embolization, regardless of aneurysmal size, is a feasible first-line therapeutic option in an emergency setting.