PROSTATE ENLARGEMENT

Prostate enlargement is a problem that men may face as they grow older. Surgical treatment of an enlarged prostate depends on the stage of the disease.

THE prostate is a fibro-musculo glandular organ present in men in the pelvis, below the urinary bladder and surrounds the upper part of the urethra. It is a part of the male reproductive system. In a normal man, in each of its three dimensions, it is about three to four centimetres big and is walnut shaped. It is quite small in children and grows till the time of sexual maturity.

It secretes the fluid that transports the sperms and makes up for the volume of the semen. It energises sperms and helps in their survival in the vaginal canal after ejaculation.

It starts enlarging after 50 years in about 70 per cent of men. This is called benign hyperplasia of the prostate (BHP). This is not cancer or infection. The exact cause of enlargement is not known, but is related to the levels of the circulating male hormone testosterone.

As the gland starts enlarging, it compresses the urethra traversing through it and causing difficulty in passing urine. It can result in retention of urine, necessitating emergency treatment.

Common symptoms will be:

# Frequency of urine due to bladder instability.

# Slow stream due to mechanical obstruction.

# Hesitancy or delay in starting the act of micturation.

# Precipitancy unable to control the urination.

# Incomplete emptying of the bladder.

# Haematuria due to rupture of blood vessels during straining to pass urine.

Other effects of straining to pass urine will be

# Passing flatus at the time of urination.

# Development of piles.

# Development of inguinal hernia.

The size of the prostate has no relationship to the symptoms it can produce. Sometimes a big gland can be totally symptom free and a small gland can produce agonising symptoms.

Enlargement of the prostate can be diagnosed by the symptoms and digital rectal examination. The most objective test is ultrasonography, which gives the size of the prostate, the amount of residual urine in the bladder (i.e. post void residue) and other complications of obstruction like stone formation and dilatation of the upper urinary tracts. Uroflowmetry is another test for objective assessment.

Cases not treated in time can produce complications like urinary tract infection, stone formation, large capacity and a weak urinary bladder, dilations of the upper urinary tracts and, ultimately, renal failure. But these can be prevented by timely treatment. Treatment of the enlarged prostate can be by medical or surgical means. Mild enlargements and, more importantly, those producing mild symptoms without many complications can be treated medically. The main drugs are blocking agents, which help to reduce the toxicity of the smooth muscle of the prostate and open up the urethral passage for better voiding.

Non-steroidal anti-androgen, which diminishes the effect of the male hormone on the prostate,helps to reduce the size of the prostate if given for a longer time.

Surgical treatment is indicated when the symptoms are severe and when the complications are manifested.

Surgical treatment is mostly the endoscopic method [TUR(P)] in which a special instrument with a telescope and a metal loop is passed through the urethra. Using electricity as its energy source and under vision, the prostate gland is resected and a channel is made to help a person pass urine better. There could be bleeding during this procedure which is controlled by electro-cautery and catheter drainage is likely during the immediate post-operative period. In laser prostatectomy, a laser is used as the energy source.

The other type of surgery is open prostatectomy where the enlargement is quite big and when there are associated complications like stone formation and diverticulum. This is also a major procedure necessitating blood transfusion and prolonged hospital stay.

Enlarged prostate — or BHP as it is commonly called — is not synonymous with cancer of the prostate, which is a different condition requiring different type of treatment. Cancer of the prostate develops mostly in people above 70 years. Often it is diagnosed by digital rectal examination (DRE), Trans-rectal ultrasound (TRUS) and blood PSA studies. The latter are quite specific for cancer of the prostate and the diagnosis should be made by a needle biopsy of the prostate.

Treatment options depend on the stage of the disease and it can be radical surgery, radiotherapy or chemotherapy.

Most cases of cancer of the prostate are very slow growing and these patients tend to live longer when compared to other malignancies.

Prostatitis is an inflammatory condition of the prostate, which can be bacterial or abacterial depending on the type of infection and is mostly prevalent during the sexually active age and in diabetics. It produces bizarre symptoms like bladder irritation, urethral or penile pain, perineal pain, lower abdominal pain and low-grade fevers.

It is best diagnosed by culture of the semen or prostatic secretions. If the organisms can be identified, the problem can be treated with antibiotics and periodic drainage of the prostatic secretions. In chronic cases the partner will also have to be examined for genital infections and treated simultaneously.

Many cases of prostatitis are difficult to treat successfully and take a long time to cure, as it requires good cooperation and perseverance on the part of patients.

Even though the prostate is a boon during the reproductive age, it may become a nuisance as one grows older.

SO YOU WANT TO FIT…

LET's face it: exercise can feel like drudgery if you don't spice up your routine with some variety after a while. And that's a big concession for a health nut like me to admit. So that is why I'm always on the prowl for hot new trends in exercise. We all could use a little motivational boost now and then. And by fat, the hottest and latest exercise trends are all in the mind/body genre.

Here's a round-up of what moves are keeping the very fit even fitter. Pilates is one of the most popular exercise systems going today. Developed in the 1930s by New York-based physical trainer Joseph Pilates, the system involves a series of stretching and strengthening types of exercises designed to keep ballet dancers limber and strong, with a non-bulky, elongated look. Migrating out of the ballet world to the fitness scene, Pilates is taught by certified instructors at clubs and spas that promise that latest, greatest ways to maintain sculpted perfection.

The emphasis is on posture, breathing and a confounding number of verbal cues to "rotate your pelvis", "move from your core", and "tuck your tailbone a centimetre more". Performed either on medieval-looking equipment, ominously given names like the "Reformer", or on cushy floor mats, Pilates may just tighten areas of your body that you thought had long ago lost the battle to gravity. Look for Pilates-trained instructors near you, or ask if they have learned any specialised forms of "core conditioning" work, a similar approach that aims to develop that sleek and toned look.

What else is capturing the attention of the fit crowd? Yoga maintains its first-place standing as the fastest growing exercise system in the U.S., parts of Europe and Asia. Depending on what lineage is followed, yoga is viewed as the superior method for restoring health and wellness, gaining fitness, and developing unity of mind, body and spirit. But the quality of instruction in most international cities varies widely. Most Westerners fasten onto the notions of control and discipline of the body without focussing on the inner-directed skills of unburdening the mind and directing the spirit.

Much of the clarity of mind and freedom from stress that is emphasised in various hatha yoga schools in India somehow gets lost in the translation by the time it reaches yoga studios in Los Angeles or Buenos Aires. Some classes, highly popularised in urban centres, lack the calming effects of yoga, while they feature the heated, strength-training aspects of Ashtanga or "power yoga", as it is called in Germany and the U.S. The celebrities Madonna and Sting swear by this approach, believing that it gives them the stamina necessary for their high-energy performances.

Then there are the hybrid trends that attempt to combine popular classes. For example, Pilates has just been combined with yoga to form Yogilates. Created in 1997 by Johnathan Urla, Yogilates is described as "an alternative path to optimal fitness and health" in his new book. Urla recommends you start with a beginner series at least three times a week, allowing your body time for recovery and "for the changes in your neurological pathways to be absorbed".

# You need enough floor space, a yoga mat to protect your back, a rolled towel to place under your head, and a firm pillow to sit on. Urla also recommends a yoga strap, two or three-pound dumb bells, and a foam yoga block. Wear loose clothing, remove dangling jewellery, shoes and socks. Start with a spine stretch and hip hinge by sitting up on the floor, and opening the legs slightly wider than your hips. Place your hands on the floor for support. Then hold your legs in parallel, flex your feet and allow your knees to bend slightly as you inhale and stretch your spine up straight.

Next, exhale and round your spine over, curling from the top of the head toward the ground. Use your core (abdominal and back) muscles to round your spine and feel the stretch in your spine. Inhale and roll your spine back up to sitting straight. Then exhale and hinge forward from the hips, keeping your back straight as you lean forward. Press your hands into the floor to brace your back and push yourself forward. You should feel the stretch in the back of your legs.

Inhale and bring your back up straight.

In the beginning, you may find that you are very inflexible in your hamstrings, the muscles in the back of your thigh. Be very careful with this exercise. Do not overstretch or try to grab your legs and pull beyond any strain, or you may risk an injury.

All exercises must be practised over and over to create any lasting change in your physique or performance. Start out very slowly with any routine you are learning, and perform the movement with control and ease. Never do any bouncing or jerky motions or you could strain or tear muscles, ligaments or tendons.

Developing the physical skills will certainly help you improve your health; however, developing the skills of awareness that accompany mind/body workouts may prove to be an even greater boost to your overall sense of well-being.

THEY ARE NOT HANDICAP

Though there are situations that can lead to the loss of an eye, such victims needn't despair. They can undergo rehabilitation for aesthetic, functional and psychological reasons.

IT is not infrequent to come across people who have sustained permanent damage to one of the paired structures of the body like the lungs, the kidneys and the eyes. Once we see them, it does set us thinking about what it is like to carry on leading a normal life. The fact is that the body's ability to cope with such situations is amazing.

As regards vision, while people who are monocular are able to perform almost everything that a binocular person does, there are a few functional and other limitations, some of which can be overcome. For example, even simple acts like threading a needle or pouring a drink into a cup can become a challenge. Likewise, getting used to limited peripheral vision especially in situations like when there is heavy traffic or the industrial work place with fast moving equipment can not only become unnerving but at times also hazardous.

Commonplace situations that can lead to a loss of an eye include intentional surgical removal of the eye for intraocular tumours, severe irreparable trauma to one eye which may pose a threat to the normal eye, infections when vision is irreversibly lost, and when a blind eye is disfigured or results in chronic irritation and pain. Such persons, once considered the end of the road cases as far as the ophthalmologist was concerned, can now undergo further rehabilitation for aesthetic, functional and psychological reasons.

The individual who is blinded in one eye undergoes an adaptational process to resume leading a normal life. This includes a relearning of spatial orientation, depth perception at near and far using various visual cues and greater movement of the working eye and head to cover a larger field, etc. From the medical point of view, given that there is only one eye, ophthalmologists recommend the following:

Wearing protective eye wear at all times, preferably made of polycarbonate lenses which are shatter proof, especially when outside the home environment, be it while driving, at school or at work. This is because, when exposed to injury, it is the "seeing eye" which is more likely to be injured.

That the only "seeing eye" be subject to periodic and complete ophthalmic evaluations to recognise early diseases.

Potential traumatic situations including contact sports and hazardous situations should be avoided, even if it means a review of the person's job description.

Physical rehabilitation of the patient includes various modalities. The most simplistic, and common, form is to place an artificial eye (prosthesis) in the eye socket. While this is frequently done by fitting a "stock eye" from a box, much like selecting a shirt from a clothing store which may or may not fit well, in the developed world and in a handful of centres in India, a "customised prosthesis" is tailored to suit the person's needs with much superior cosmesis.

When an eye is removed surgically, an implant is placed in the socket, usually at the same sitting, to act as a foundation on which the prosthesis rests and moves to a certain extent.

For any reason if a primary implant is not placed, secondary implants may be used. Choices of these implants are varied and the current generation of implants are designed to integrate with the orbit such that the overlying prosthesis may be coupled to the underlying implant for better movement. However, the latter is not without certain limitations and hence used in a limited way.

Finally, in the Indian environment we do come across patients who have had their eyes removed several years earlier before they finally seek attention. More often than not, due to the delay and lack of adequate care of the socket, a ready fitting of the artificial eye is impossible.

In such situations, major reconstructive surgery may be required either using synthetic materials or the patient's own tissues before fitting him with an acceptable prosthesis.

WHERE IS THE FAMILY PHYSICIAN ?

There is nothing inevitable about the decline in general practice's fortune but if this trend is to be halted and reversed, it can be only through consistent and constructive leadership. Before a series of tests, try and see the family physician first.

"Professions arise in response to the recognition of a social need, and their continued existence is dependent on their success in satisfying the expectations raised by the state of knowledge which they proffer."
-Sir Harold Himsworth

MR. S, 28, a worker in a pappad manufacturing unit, suddenly complained of chest pain, sweating and mild body ache, while working. The proprietor immediately fixed up an appointment with a cardiologist, Dr. X. In the evening, Dr. X saw him after an ECG evaluation and advised him to come the next day with the results of his blood tests, to rule out cardiac problems.

Mr. S developed high fever the same night. After completing the tests the next day, he again met Dr. X and brought to his notice the fever that he had had. Dr. X after going through the reports suggested that he consult another senior physician after adding that he had no cardiac problem to worry about. On contacting the senior physician, it was learned that he saw only a limited number of cases per day and that he could see Mr. S only after two weeks. On the third day Mr. S came to my clinic with his reports. On clinical evaluation after eliciting a good history, I did a simple blood test, which revealed malaria. He was given tablets for three days and he recovered.

I have narrated the case to explain that a primary care physician or family physician should be the physician a patient must see first. The message here is that similar physical complaints may be manifestations of different diseases like malaria, heart problems or lung diseases. In this case, the choice of specialist was made by a lay man. Hence, the patient had to suffer for three days before a diagnosis was made and suitable treatment was given, not taking into account the monetary loss incurred by the individual.

By tradition, the doctor first consulted in an illness is known as a GP. He is also called the family physician or the primary care physician. By practice, even today the doctor responds to a patient's call either by treatment at his office or by visiting the home. The family physician will be a doctor to all the members of a family and will look after them throughout his practicing years, being involved in many important events in their lives, including births, marriages and deaths. He acts as a friend, counsellor as well as a doctor, especially in rural areas, and is an honourable member of the family. After qualifying, a new doctor must immediately forget most of what he has been taught or has learned about medicine and start again. It is found that more than 50 per cent of them eventually go into family practice, but it is unfortunate that the medical curriculum, even now, tends to concentrate on the diagnosis and treatment of obscure illnesses which a family physician may rarely encounter in the course of a long career. The present day hospital and medical college environment is too refined and unrealistic to be of continuous use to the prospective family physician.

Moreover the attributes which go to make a family physician do not appear in any text book. It is astonishing to note that for long, hospitals have failed to impress students with the fundamental attributes to enter family practice. The great qualities of a family physician are compassion, sympathy, understanding, faith, hope and affection.

GOING into a little bit of history of this speciality, the term GP came into use at about the beginning of the 19th Century in England. Prior to that, only three categories were present — physicians, surgeons and apothecaries. A hundred years ago a doctor was not a gentleman and was expected to enter through the back door, whereas his veterinary counterpart entered through the front door as he looked after the gentleman's horse. In 1827, the President of the Royal College of Physicians held that midwifery was an act foreign to the habit of a gentleman! In 1830, a Metropolitan Society of General Practitioners in medicine and surgery had been instituted. The GP at that time did everything. By the late 19th Century, teaching hospitals came up and were staffed by physicians, surgeons and obstetricians. But for the GP, hospital privileges were of little importance as he could do his surgery over the kitchen table or his obstetrics in the family bedroom much more safely than in the institution. As the hospital system developed, it was not really the possession of skills or a higher qualification that began to divide the profession but the question of whether or not the doctor had access to hospital beds. In 1948, the National Health Service of England formalised the separation of domiciliary and institutional services. Once the GP was excluded from the hospital, a marked deterioration in his status began. But later in March 1965, a Charter for the Family doctor services appeared and was produced by the British Medical Association. And now the real backbone of the NHS in England is the services of the general practitioner.

Meanwhile in the U.S. in 1962, the Association of American Medical Colleges noted that from 1900 to 1962, American medical graduates choosing general practice fell from 33 per cent to 18 per cent and projections for the following decade predicted the demise of the general practitioner. However, in a leading article, "End — or Beginning?" in The Lancet (July 24, 1965) it was stated that "there is nothing inevitable about the decline in its (general practice's) fortune; but if this trend is to be halted and reversed, it can be only through consistent and constructive leadership". During this period, a group of 10 general practitioners in the U.S. saw this rapid decline of general practice and were eager to keep up with the times yet preserve those precious attributes of the old generalist. They hastened to establish a movement to create the new specialty of family practice through an American Board of Family Practice (ABFP).

FAMILY practice is a horizontal specialty, much like paediatrics and internal medicine, and shares large areas of content with other clinical disciplines. It incorporates this shared knowledge and utilises it in a unique way to deliver primary medical care. It draws most heavily on internal medicine, paediatrics, obstetrics and gynaecology, surgery, psychiatry and preventive medicine. This establishes a cohesive unit, combining the behavioural sciences with the traditional biological and clinical sciences.


The ABFP defines the family physician to be one who serves the public as a physician of first contact and as means of entry into the health care system; assumes responsibility for his patients' comprehensive and continuing health care, acts as coordinator of his patients' health services; and accepts responsibility for his patients; total health care, including the use of consultants, within the context of their environment, including the community and the family or comparable social unit. The family physician performs two major functions which may be related entirely to individual patients but usually concern the family as a group. They are primary assessment and continuing care.

Primary assessment refers to the patient presenting to the doctor with previously undifferentiated, unknown illnesses or symptoms. The task of the family physician is to decide upon the severity of these symptoms, their prognosis and the way in which they affect the person's socio-economic conditions. This is one of the most difficult aspects of family practice. Assessment is made not only upon the information the patient presents to the family physician but is also related to the family physician's knowledge of the patients environment, his family, his work, his past medical history, his pattern of behaviour and the culture of the neighbourhood. Thus the roots the doctor develops in his community become important. After this assessment, the management of the problem is discussed with the patient and a mutually acceptable course of action is agreed upon. The term continuing care, is based on the knowledge of the social background of the patients over many years and for the chronic sick. It also means that the long term problems of people which may persist for months, years and sometimes for a whole lifetime can be managed.

Why do patients see a doctor? All patients consult doctors for some reason. Yet, it is very common to hear doctors speaking of unnecessary consultations, and patients who waste their time. Evident in all such phrases is the feeling that there was no reason for the patient's visit to the doctor. The truth lies either in the doctor's inability to discover that reason or because the patient has not learnt how to use the doctor. In most cases, the fault lies more often with the doctor than the patient. Thus a patient goes to a doctor for two reasons — to obtain recognition of his sickness, and to seek help in order to get better.

IN conclusion, the role and function of the family physician was described by Sir Theodore Fox, Editor of The Lancet in these terms: "his essential characteristic... is that he is looking after people as people and not as problems. He is what our grandfathers called `my medical attendant' or `my personal physician' and his function is to meet what is really the primary medical need a person in difficulties wants, in the first place, the help of another person on whom he can rely as a friend. Someone with knowledge of what is feasible but also with good judgment on what is desirable in a particular circumstance and an understanding of what the circumstances are".