Mens Health Page

Men's Health Week

Men's Health - 21 Frequently Asked Questions

1 What is Prostate Cancer?

Prostate Cancer is a condition of the prostate in which there is abnormal growth of prostate cells. The growth is uncontrolled (compared to growth of normal prostate tissue) and the cancer cells have a tendency to spread (known as "metastasise") outside the confines of the tissue to involve other parts of the body.

2 How do we detect prostate cancer?

Many of the men seen in the Urology Clinics have been referred because of one of three reasons

• For investigation of troublesome symptoms with urination
• As a result of an examination by the GP there appears to be an abnormal feel to the patient’s prostate
• As a result of tests which the GP has arranged there appears to be an abnormally high result to what is know as the PSA test

In there early stages of prostate cancer there are no particular symptoms which might signal the fact that cancer is present.

Prostate cancer sometimes produces a "nodularity" or "firmness" to the prostate that can make its presence known on a digital rectal examination (DRE) of the prostate. The problem is that other inflammations of the prostate that are not cancers can produce similar abnormalities and this can confuse the issue. Furthermore a number of prostate tumours occur within the front part of the prostate on the other side from the rectum. These tumours cannot be felt by DRE.

If the DRE is abnormal or suspicious, or the PSA is raised, then the urologist will normally recommend that a biopsy of the prostate gland be performed (see below).

3 What is PSA?

Prostate Specific Antigen (PSA) is a chemical produced normally by prostate cells. It is a type of chemical known as an enzyme, and it is believed to have a role in liquefying semen after ejaculation (which may help in sperm motility).

PSA is only produced by prostate cells (it is prostate specific), but is produced by both cancerous and non-cancerous prostate cells (it is not cancer specific). Although PSA is the best example we have of a marker for prostate cancer this non-specificity for cancer means that there are reservations about the interpretation of raised values

Essentially, one of the following scenarios may commonly occur

• A man with prostate cancer may not have a raised PSA test (this is known as a false-negative result)
• A man with a raised PSA may not have prostate cancer (this is known as false-positive result)
  

The recent introduction of age-specific ranges for normal PSA values was an attempt to make the PSA test a better one. Rather than use the absolute limit of more than 4 ng/ml most urologists now use the following values

As with DRE, the use of PSA by itself is not particularly accurate.

4 Should I have a PSA test and what will it mean?

Unless you have symptoms of difficulty passing urine, an abnormal-feeling prostate gland, or a strong family history of prostate cancer it is unlikely that your doctor will recommend that you have a PSA test performed. This is partly because of the uncertainties mentioned in the section above.

There has been a case put forward for the screening of asymptomatic (without symptoms) men – i.e. looking for possible cancer in men who have absolutely no symptoms at all.

The arguments for this view can be summarised as follows

• Advanced cancer which has spread beyond the prostate is not curable, so if there is any hope of curing a prostate cancer it must be detected whilst it remains confined to the prostate
• In a lot of men referred to the specialist and who are found to have prostate cancer it is already too late to offer a complete cure. Screening might detect the cancer at an earlier stage
  

Tumours detected by PSA testing are now thought to be significant tumours, which should be treated

Against this are the following points

• There is no conclusive proof that treatment of tumours discovered by screening makes any difference to the survival of the patient treated
• Lots of men discovered to have prostate cancer are elderly and suffer from other serious illnesses. Many of these men will die from other causes not related to the prostate cancer
  

If a PSA test is performed and is normal this is not cast-iron proof that you do not have prostate cancer, and your doctor may still wish to perform further tests (a biopsy, see below) if your prostate feels abnormal. Equally if your PSA is raised this does not necessarily mean that you do have prostate cancer, although there is good evidence that the higher the value of PSA test result the more likely it is that cancer is present.

If you choose to have a PSA test done you should be prepared to undergo a prostate biopsy if the PSA value is sufficiently raised to justify this course of action.

5 My PSA is raised and I need a biopsy - what happens now?

If either your prostate feels abnormal when the doctor feels it, or your PSA is raised (above the normal limit for your age) then your doctor might recommend taking a prostate biopsy.

This is performed on the ward as an outpatient procedure. It does not require an anaesthetic and you will be able to go home shortly after the procedure is completed.

Before the procedure begins the doctor will go through the procedure thoroughly with you and will explain again why it is being performed. He will then ask you to give your written consent to undergo the procedure. You will normally have been given antibiotics to prevent infection being caused by the biopsy (see complications, below).

You will then be asked to lie on the examination couch while the doctor re-examines your prostate to assess it. The doctor will then scan the prostate by inserting a small ultrasound probe into the rectum. You may be able to see the pictures of your prostate on the television screen. The doctor will then insert the biopsy needle up the inside of the ultrasound probe as it lies in the rectum adjacent to the prostate. The biopsy is then taken and as the needle is fired using a special device you may feel a momentary discomfort. It is usual practice to take 6 or more individual biopsies from various regions of the prostate and the procedure usually takes no more than 5-10 minutes to complete.

After the procedure is finished you will be able to get dressed and make your way to the sitting area. You will normally need to remain under observation on the ward for a while after the procedure to monitor for any complications. The most usual of these are:

• Bleeding from the back passage or in the urine
• Infection
• Difficulty passing urine

The bleeding usually settles spontaneously though you should drink plenty of fluids for the rest of the day to help flush out any blood clots which may form in the urine.

6 My biopsy was negative, what happens now?

This question is very difficult to answer accurately, but the important thing to note is that a negative biopsy result cannot exclude completely the possibility of cancer within the prostate. If the degree of cancer is very small it is difficult to hit it with the biopsy needle.

The usual practice of most urologists is to keep you under review by regular visits to the outpatient department and to repeat the PSA at intervals. If the PSA continues to climb steadily upwards this would be further evidence of possible cancer and it might be necessary to repeat the biopsies. This would not be done within three months because the act of taking a biopsy from the prostate artificially raises the PSA level and this would confuse the issue.

If the PSA remains stable it may be possible to monitor the situation. However the significance of a PSA which remains stable is unclear when it comes to excluding a cancer.

7 My biopsy was positive and I have been told I have prostate cancer. What happens now?

Further investigations will probably be required to determine whether the cancer is confined to the prostate. This has implications for the type of treatment that will be recommended to you.

A bone scan is a special scan using nuclear medicine techniques. Prostate Cancer that has spread has a tendency to settle in some of the bones of the skeleton and a bone scan will usually detect this. Detecting the presence of such metastases (as they are known) may affect the treatment your doctor would like to give you. However, recent studies have suggested that unless your PSA level is more than 20 ng/ml it is unlikely that a bone scan will be helpful and can probably be safely omitted. An exception to this is if there are bony pains that might suggest the presence of metastases.

8 What treatment will I be given for my prostate cancer?

Exactly which treatment is given depends to a large extent on your age and general fitness, the exact stage of the tumour, the level of the PSA test, and your wishes after you have been counselled by the doctor.

For tumours that are proven to be confined to the prostate the options for treatment include;

• Conservative treatment, also known as "watchful waiting"
• Surgery, in the form of a "radical prostatectomy"
• Radical radiotherapy
  

Conservative therapy is based on the fact that many men will die of other causes not related to the diagnosis of their prostate cancer. This form of treatment is obviously more appropriate in men older than 70 years whose life expectancy is generally less than 10 years from the time of diagnosis. This does not mean that men over 70 years old are automatically excluded from having surgical treatments. Conservative therapy does not mean no treatment; rather it means that you will undergo regular check ups with the consultant with a rectal examination and a PSA check.

Currently it is usual for Radical Prostatectomy to be restricted to men whose life expectancy is thought to be 10 years or more. This is because the benefits of such surgery probably only outweigh the risks for such men. Radical Prostatectomy is a major operation to remove the whole of the prostate gland. The operation is performed through an abdominal wound or through an incision in the perineum (the area of skin between the scrotum and the anus). The length of stay is variable but most men will expect to stay on the ward for about 7-10 days after the operation.

Radical Prostatectomy may be followed by a number of complications including:

• Impotence - following the operation there is a high risk of impotence (failure to get adequate erections). Recent studies suggest that over 56% of men will be completely impotent and a further 29% will have a reduced erection
• Incontinence - Over half of men will retain complete control of passing urine, but 23% of men will develop occasional loss of control and 3.5% will have complete loss of control
• Out of every 1000 men having the operation, 7 will die because of the treatment
  

The other option is Radical Radiotherapy, which uses a beam of x-rays directed at the prostate to kill the prostate cancer cells.

Out of every 1000 men having this treatment for prostate cancer up to 5 will die because of the treatment. Between 40% and 67% of men will have some degree of impotence and up to 3% will develop a degree of incontinence. Conformal radiotherapy is a relatively new technique that differs from conventional radiotherapy in that the x-ray beam is more focused to the tumour and hence there should be less damage to neighbouring normal tissues.

Brachytherapy is a variation of radiotherapy that uses internal radioactive seeds. These are implanted into the prostate under an anaesthetic and the radiotherapy treats the prostate from within.

9 My Doctor says the cancer has spread beyond the boundary of the prostate but is not widespread yet - what does this mean?

A layer of fibrous tissue known as the prostate capsule surrounds the prostate. Your investigations have shown that the tumour is growing into this capsule (i.e. it is locally advanced) but your other investigations have not shown any evidence of widespread distant spread (known as metastasis)

Surgical treatment is usually inappropriate for this disease. The ultimate aim of surgery is to try and remove (and hopefully cure) the cancer. Cancer which has spread outside the prostate cannot be cured, but may be effectively controlled.

Possible treatments for this condition include radical radiotherapy or hormonal manipulations to control the prostate cancer

10 My doctor says my prostate cancer has spread to involve some of my bones – what treatment will I be given?

Both surgery and radiotherapy are inappropriate for this condition and most treatments use a variety of hormonal therapies to keep the prostate cancer under control

Prostate Cancer relies on the presence of the male hormone, Testosterone, for growth. In actual fact Testosterone is converted to a more active form known as Di-hydro-testosterone (DHT).

Hormonal therapies all work by reducing the level of Testosterone in the body to very low limits. There are three ways this can be achieved

• Tablets
• Injections
• An operation to remove the inner part of the testicles

The advantages and disadvantages are compared below. After reading this you may find it useful to discuss the options further with your doctor when you next visit the clinic.

11 I have a varicocele – what is it and how can it be treated?

A varicocele is an abnormal collection of dilated veins within the scrotum. The condition is said to occur in 1 in 10 normal men and is predominantly seen on the left side of the scrotum (in 15% of cases both sides of the scrotum are affected). The varicocele is usually much more prominent when you stand up.

A "dragging" feeling in the scrotum is common. Many men who turn out to have a varicocele are sometimes referred to a urologist because of difficulty conceiving a child with their partner. There is an association between having a varicocele and a reduced sperm count in some cases

Treatment is usually advised for men in two main circumstances

• Where there is evidence of significant discomfort which the patient wants alleviating
• Where a man is found to be sub fertile and a varicocele has been detected.
  

When fertility is not an issue and the pain is not very severe then the general advice would be that the varicocele is not serious and no treatment is required. This is always open to reassessment if the varicocele becomes more painful subsequently.

There has been a recent trend to offer treatment to younger men and teenage boys before any suspicion of subfertility becomes evident. This is because it is now believed that earlier intervention to treat a varicocele might reduce the chances of problems with fertility in the future.

Available treatments include;

• Varicocele ligation
• Embolisation of the varicocele
• Laparoscopic surgery
  

Varicocele ligation - This term refers to a surgical operation to ligate (tie off) the distended veins as they run through the groin into the scrotum (from the abdomen). A cut is made in the left groin approximately 5 to 10 cm long. The veins are identified and tied off and the wound closed with absorbable sutures.

The procedure is usually performed as a day case under a general anaesthetic, and takes approximately 45 minutes to perform. You will normally need two weeks or more away from work (depending on your job).

Complications of a varicocele ligation include;

• A collection of fluid (known as a hydrocele) may develop around the testicle in up to 15% of cases. If this is quite large it may need a subsequent operation to deal with it effectively
• There is a risk of damage to the testicular artery, which supplies the testicle.
  This artery runs along with the veins and can be very difficult to spot during surgery. It is likely that in the majority of cases it is tied off along with the veins. This usually does not matter because the testicle can get a good enough blood supply from the artery that runs with the vas deferens (which is left intact). In some cases this other artery is not large enough to supply the testicle. If this happens the testicle may become inflamed after the operation, and may subsequently shrink (atrophy). If you are an older man who has finished having a family this might have very few consequences for you, but if you are still considering having a family you should understand that this complication might lessen your chances of fathering a child. The exact rate of occurrence of testicular atrophy after this operation is not known but is thought to be less than 10%
• Recurrence of the varicocele occurs in anything between 0.6 and 45%

Embolisation of a varicocele - does not involve an operation. This procedure is performed in the x-ray department by a Radiologist under a local anaesthetic. A small cut is made over the groin on the right side. The Radiologist then passes a small wire up the large leg vein and then eventually guides it into the veins draining the left scrotum. Usually a small metal coil is placed into this vein to block it off. This has the same effect as the surgical procedure to tie off the veins.

This procedure is also done as a day case stay but occasionally patients need to stay overnight for observation.

The embolisation has advantages over the ligation procedure:

• A very small risk of developing a hydrocele (see above)
• Virtually no risk of damage to the testicular artery (see above) and therefore testicular atrophy

Complications of embolisation include:

• Migration of the coil out of the vein
• Allergic reactions to the x-ray contrast dye (the rate of severe allergic reactions with the dye currently used is approximately 0.02%)
• Bleeding from the right groin where the wire is inserted

The recurrence rate after this procedure is approximately 4-11%

Laparoscopic Techniques to treat varicoceles - This technique involves tying the distended veins inside the abdomen using a telescope. The procedure requires a general anaesthetic but can also be done as a day case.

The rate of recurrence and complications has not yet been determined. Potential complications include injury to the bowel, blood vessels or other organs. Laparoscopic varicocelectomy takes approximately one hour compared to an open surgical repair which usually takes anything between half and hour to 45 minutes (see above)

12 I have blood in my urine

The appearance of blood in the urine is frightening to most people; try not to be alarmed.

Whilst the presence of blood in the urine does not always signify a serious problem there are a number of important conditions that should be excluded, and it is therefore IMPORTANT that you visit your General Practitioner at the earliest opportunity and make the problem known to them.

What will my GP do? - After taking a full account of all the details your GP will probably decide to refer you for an opinion to one of the local Urologists (urinary specialists).

What will the Urologist do next? - Having confirmed the details the GP has elicited the Urologist will arrange for a number of investigations to pinpoint the cause of the bleeding. The most commonly performed tests are these:

• Urine examination: This is performed to look either for urine infection, or abnormal cells in the urine.
• Intravenous Urogram (also known as an "IVU" or an "IVP"): This is a special x-ray to examine the kidneys in close detail.

  In preparation for this test you may be sent (through the post) a sachet of medicine to help clear the bowels. This is so that when the Radiologist (X-ray doctor) takes the x-rays he or she will be able to see the kidneys in more detail.

  The test is performed after an injection into the veins of a special "contrast" dye. This contrast dye is excreted by the kidneys and shows them up on the x-ray pictures. Please be aware of the following two points;

  • Certain people are allergic to this contrast material. You will be asked if you have had a similar x-ray test before and, if so, whether you had any reactions to the injection.
  • Women of childbearing age will be asked for the date of the start of their last menstrual period. This x-ray cannot be done more than 10 days from this date unless you can confirm that you cannot be pregnant.




• Cystoscopy: This is the name given to a telescopic inspection of the urethra ("water-pipe"), and bladder lining.

This test is performed either under a local anaesthetic or a general anaesthetic. This decision will normally be made by the Consultant in charge of your case, for medical reasons, but if you have a strong preference for, or aversion against, either technique please talk to your Consultant.

In either event the examination takes approximately 15 minutes. If performed under a local anaesthetic you will be able to go home shortly afterwards although you will need an escort to take you home. Patients having a cystoscopy under a general anaesthetic may be able to go home later the same day. Please discuss your particular arrangements with your Consultant.

What happens next? - This depends on whether a cause for the bleeding is found either on the x-ray, or at cystoscopy. Some conditions may be dealt with immediately at the same time as cystoscopy although this might mean an overnight (or longer) stay in hospital. Your consultant will discuss the particulars of your case with you and will be happy to tell you about the alternatives for treatment.

13 I have a lump in my scrotum, what could it be?

There are a number of causes of this condition. Whilst most men are concerned about the possibility of a testicle tumour, the majority of causes of lumps in the scrotum are not cancers. However; if you discover a new lump in your scrotum you should go and see your General Practitioner for a check up to be certain that the lump is not due to a tumour, and for advice about how to manage the lump.

Your GP will examine your scrotum and will want to know how long the lump has been there and whether or not it is enlarging. An examination will usually be sufficient to provide an explanation for the swelling but if there is any doubt it is usual to arrange for an ultrasound scan of the scrotum to clarify the situation.

Your GP may arrange this him/her self, or may refer you to a Urologist for specialist advice.

If there is concern about the lump being due to a tumour then your GP will want you to see a specialist quickly, for advice about management. An Ultrasound scan will usually help confirm the diagnosis. The usual treatment is to have the testicle removed through a cut in the groin. This is performed under a general anaesthetic and you can expect to be in hospital for two to three days after the operation. Once the results of the tissue tests are known, and if the lump proves to be a cancer, then further follow up investigations will normally be required.

Scrotal lumps that are not cancers do not always need any treatment. Whether or not treatment is required will be determined by a number of factors including the level of discomfort or other problems that the lump causes you. This can be discussed with your GP or specialist.

14 I have / my son has – a tight foreskin. Does anything need to be done?

The majority of the boys referred for circumcision do not require the procedure to be performed. What then, are the indications for circumcision?

The most common reason for referral for circumcision is for a "non retractile foreskin". The foreskin or prepuce is normally retractile after the age of two years, although adhesions may persist between the mucosa of the foreskin, and the glans penis, until adolescence. It is not essential for the foreskin to be retractile in young boys, provided that recurrent infections or balanitis do not occur, and there is no effect on passing urine. Ballooning of the foreskin is also the cause of some anxiety but is a sign of a tight foreskin rather than a true phimosis

Good examination technique will often resolve the issue. If the foreskin is gently but firmly retracted then in many cases it will be seen that the foreskin will retract. Where the foreskin will not retract it is often very valuable to grasp the preputial opening and pull the foreskin forwards. In many cases a good opening in the prepuce will become visible, and the glans will be visible. With these findings, and the absence of any symptoms, a circumcision is unlikely to be required

As the boy grows older a proportion of cases of tight foreskin will resolve spontaneously and further intervention will not be required. If puberty is imminent and the foreskin will not retract then circumcision may still be required to allow full sexual exploration and development to occur.

15 My Child has an undescended testicle – should I be worried?

Undescended testicles (UDT) are a common problem. The testes are usually present in the scrotum at birth although if the baby is born prematurely this may not be so. The degree of prematurity may need to be taken into account before deciding whether there is a problem or not.

Spontaneous descent of the testes is rare after the age of one year and a decision to operate is usually made around this time when the diagnosis has already been made.

The operation to bring the testicle down into the scrotum is called an orchidopexy, and is usually performed when the child is out of nappies (to reduce the risk of wound infection), mostly before the age of two years.

The operation is usually performed as a day case under a general anaesthetic. A cut is made in the lower part of the groin and the tissues which are "tethering" the testicle up in the groin are cleared away. The testis is then brought down to the scrotum and fixed to the scrotal skin with a dissolvable stitch.

Sometimes the problem is only discovered in later life. If the diagnosis is made before puberty then the testis would be brought down into the scrotum by an orchidopexy operation as described above. If the problem is discovered in adulthood then there is an argument to be made for removing the testicle (orchidectomy) completely. This is because such testicles never produce sperms and are at a slightly higher risk of developing cancers. Bringing the testicle down to the scrotum does not reduce the risk of the cancer developing, but it does make it easier to feel the scrotum and detect a cancer early if it occurs. Many Urologists would suggest removal of the testis to prevent any further problems occurring.

16 I want a vasectomy – can you tell me about it?

Vasectomy is becoming an increasingly popular form of contraceptive for many couples.

The operation is performed (usually) as a day case procedure under a local anaesthetic. If the surgeon feels that it would be difficult to perform under a local anaesthetic, or if you feel strongly that you could not tolerate a local anaesthetic procedure, then a General anaesthetic may be given.

Through either two small scrotal cuts, or one cut in the midline of the scrotum, the vas deferens (the tube that carries the sperms away from the testicle) on each side is cut and tied and the skin stitched up again, usually with dissolving sutures. You should plan to have at least 48 hours of complete rest at home after the procedure but, depending on the nature of your occupation, can return to work as soon after that as you are comfortable. Normal sexual relations can resume as soon as you are comfortable.

There are four extremely important points that you must remember when considering a vasectomy:

• Vasectomy is intended to be irreversible. Up to 10% of men will request a reversal of their vasectomy due to changes in their circumstances. Success of vasectomy reversal is inversely proportional to the length of time between vasectomy and attempted reversal. It should be stressed that vasectomy reversal cannot be guaranteed to be successful.
• You will not be sterile immediately after the vasectomy has been done. It is normal practice to perform semen analyses at 12 weeks and 14 weeks after vasectomy. At this stage the majority of men will have absence of sperms from both samples and will be confirmed sterile. The remainder will need to perform further semen samples as directed until two consecutive semen samples show no sperms to be present. In rare cases this may take up to a year or more to happen. You and your partner must be aware that until you receive written confirmation from the consultant that sterility has been achieved that you must continue to use a recommended form of contraception
• There is a risk of late failure of vasectomy and the quoted incidence is 1 in 2000. This means that vasectomy cannot be considered "100% foolproof" and is not a perfect technique. The timing of failure, if it occurs, cannot be predicted and testing for sperms is not possible because sperms may be intermittently present
• There is a risk of the development of scrotal aches following vasectomy. Some studies suggest that between 5-10% of men may develop persistent scrotal aches, for which no cause may be immediately obvious. Sperm granulomata may be the cause of pain following vasectomy, and in some cases removal of these lesions may bring about resolution of the pain.
  

17 I can’t get an erection – what can be done about it?

This is a common problem, and probably more common than doctors in the hospital environment suspect, because many men may not seek treatment because of embarrassment. In addition a number of men assume that their declining sexual function is age-related and that "nothing can be done". In fact many men may continue to enjoy normal sexual function well into their eighties.

If your erections are poorer than usual your doctor may refer you to one of the local Urology specialists. Here you will be asked questions about the length of time the problem has been there and whether the lack of erections is total or partial.

Some men develop their difficulty during times of mental, financial, or work-related stress. If this is the case then counselling sessions, which your doctor will be able to arrange, may help the problem. For the remainder of men there may be a physical cause for the difficulty.

The specialist may send a blood sample to assess the level of male hormones in the blood although this is usually only required if there is a noticeable decline in your libido ("sex-drive").

Until recently there have been two main options for treatment - Intracavernosal injections of alprostadil (injections into the penile tissue), and the Vacuum device. This situation has recently changed with the launch of an intraurethral preparation of alprostadil (MUSE - Medicated Urethral System for Erection) and the tablet Sildenafil (Viagra).

The vacuum device consists of a plastic tube placed over the flaccid penis. The device has either a manual or electric mechanism for removing the air from the tube creating a vacuum inside it. This draws blood into the penis and the erection that develops is maintained by slipping a rubber band over the base of the penis. Success rates of up to 92% have been claimed in some studies. The device may cause some bruising but otherwise is free of major side effects. The device may be lent to you for a trial period by the specialist but will then need to be purchased.

Also very successful is the treatment called intracavernosal pharmacotherapy. The specialist will demonstrate this to you the first time to see whether the injection therapy works for you. The chemical (known as Alprostadil) is injected into the shaft of the penis towards the base and causes an erection by dilating the blood vessels and increasing the blood flow to the penis. In order to continue with this treatment you will have to undergo a short period of assessment, so that the Specialist can ensure that it is safe for you to inject yourself at home. There are some recognised side effects with this form of treatment. Bleeding and bruising may occur at the site of injection and with prolonged usage fibrous tissue may develop. If this happens please contact your Specialist.

The dosage is normally calculated to give you a good erection lasting about an hour. It is important that if the erection does not settle within four hours of the ejection, whether you gave yourself the injection or the Specialist injected you, that you seek urgent medical advice. This can be either from your General Practitioner, the Urology specialist or one of his on-duty team, or from the local Accident and Emergency department. Erections which last longer than this are called "priapism" and are quite rare with Alprostadil (0.4%). However, early treatment is very important to prevent any long-term damage to the penis and treatment is more successful if started early.

MUSE - Medicated Urethral System for Erection: is a new treatment which involves introducing a small pellet of the active ingredient (alprostadil) into the urethra (water-pipe). The pellet dissolves and the chemical is absorbed into the tissues.

Erections begin within about 5-10 minutes and last for about 30-60 minutes. The majority of men do not find the procedure uncomfortable. Side effects, although rare, include dizziness and a lowering of the blood pressure or a raising of the pule rate.

The partners of patients using this preparation sometimes complain of vaginal burning or itching.

It has been recommended that MUSE be not used in men whose partners are pregnant unless a condom form of barrier contraception is used.

Viagra - Sildenafil has been the subject of a lot of press coverage and is a very popular choice in patients with erectile difficulty. Sildenafil is available as a tablet taken orally and is usually effective in less than an hour. In some studies the effects of sildenafil last for two hours or more, although the effect gradually weakens.

Sildenafil works by preventing the breakdown of a naturally occurring chemical produced by the penis following sexual stimulation. It is therefore important to realise that Viagra (sildenafil) will only work in the presence of sexual stimulation. Men with a wide variety of conditions causing impotence appear to respond to sildenafil. However there are certain men in whom sildenafil should not be prescribed. ·

• Men taking medications called nitrates, for heart conditions, must NOT be given sildenafil, as there is good evidence that a serious fall in blood pressure can occur.
• Sildenafil should also be used with some caution in men with a history of moderate or severe heart problems.
• Men with certain penile conditions (such as Peyronie's disease) or who are prone to a condition known as Priapism should not be given sildenafil. · Sildenafil should NOT be used in combination with other treatments for impotence, because the effects of such combinations have not been studied. ·
• Sildenafil should not be given to men with known predisposition to bleeding conditions, or who have active peptic ulcer disease. · There is also a very rare eye condition called retinitis pigmentosa - sildenafil should be avoided in men with this condition.
  

Sildenafil is known to cause a number of side effects. Among these is; Headache (16%), Flushing (10%), Heartburn-like symptoms (7%), Nasal congestion (4%), Urinary Tract infection (3%), and a blue-tinge to the vision (3%). Diarrhoea, dizziness and skin rashes occur in 2-3% of men. Remember also that sildenafil is a drug in its infancy, and the full range of side effects may not be known for some time.

For most patients the dosage is 50milligrams taken about 30mins to 1 hour before planned sexual activity. The dose may be reduced to 25mg in some men, or increase up to 100mg in others. The maximum recommended use of the tablet is once per day.

Viagra is available on the NHS but is provided free of charge to patients in the following groups only:

• Patients who have had radical pelvic surgery
• Men who have had their prostate removed and / or been treated for prostate cancer (surgery and other treatment)
• Treatment for renal failure (transplants or dialysis)
• Spinal cord injury
• Severe pelvic injury
• Diabetes Mellitus
• Multiple Sclerosis
• Single Gene Neurological disease
• Poliomyelitis
• Spina Bifida
• Parkinson's disease

A General Practitioner can also prescribe Viagra to men NOT in the above categories, if those men were receiving treatment for impotence on 14 September 1998.

Men who fall into none of the above categories can also be prescribed Viagra by their General Practitioner using a private prescription.

These categories also affect men who would like treatment with Caverject, Erecnos, MUSE, or Viridal

(Information Source: Health Service Circular HSC 1999/115 Dated 7th May 1999. The NHS Executive)

For further information please ask your consultant Urologist, or talk to your GP.

18 I leak urine – why?

The problem of urine incontinence is a common reason for a referral to a Urology specialist. The exact number of patients with this problem is not known because many patients find the problem embarrassing and keep their symptoms hidden. Women are affected by this problem more often than men, possibly because of the after-effects of child bearing. Incontinence in men may happen after operations on the prostate.

There are several different types of incontinence although all of them result in urine leakage at inopportune times. The term "stress" incontinence refers to leakage of urine which results in response to any physical activity such as coughing, sneezing, bending down, or exercise. "Urge incontinence" describes the leakage of urine which is preceded by a urgent desire to pass urine. The continual leakage of urine is a third, although uncommon, type of incontinence.

What will the Doctor do? - The first thing the Specialist will decide, with your help, is whether any further investigation is necessary or desirable. The degree of leakage some patients experience is so mild that further investigation or treatment is unlikely to make the symptoms better. For those remaining patients with troublesome leakage some investigation is justifiable.

Sometimes the symptoms reported to the specialist may seem to represent either stress incontinence or urge incontinence. As the treatments for each are quite different it is important that the true cause of the problem be defined carefully. This is done by "Urodynamic assessment" of the bladder (this test is also known as a VCMG, or video-cysto-metrogram). This is an outpatient investigation which lasts approximately half an hour. After emptying the bladder the patient is asked to lie on a special couch. A small catheter is inserted into the urethra ("water-pipe") and a similar catheter is placed inside the entrance to the rectum ("back passage"). The bladder is filled with a special liquid, a mixture of saline and contrast medium which shows up on x-ray films. The pressure that develops inside the bladder is monitored and recorded on a computer screen. When the patient says the bladder is full the filling is stopped and the table is tipped slowly so that the patient is standing up. The patient is then asked to cough and strain to see whether any leakage occurs. Finally the patient passes urine until the bladder is empty. This test is will usually sort out which type of incontinence is present.

What treatments are available? - Patients with very mild symptoms may be helped enormously by wearing incontinence pads. Stress incontinence in men which occurs after prostate operations may be helped by injecting a synthetic material into the sphincter area (this is the ring of muscle around the upper part of the urethra or water-pipe which keeps you dry). In rare occasions it may be necessary to insert an artificial plastic sphincter device

Urge incontinence of anything more than a mild degree is usually managed initially by treatment with drugs such as oxybutynin, which prevent the bladder from contracting as strongly. Most of these drugs can cause side effects of a dry mouth, dizziness, blurred vision, or drowsiness. You should not drive a car or operate heavy machinery if you think you may have any of these side effects whilst taking these drugs. More severe symptoms, particularly symptoms which are unresponsive to drug therapy may require an operation known as a "clam ileocystoplasty" where the bladder is opened up like a clam shellfish and the defect closed with a small patch of intestine. This can be a very effective treatment for carefully selected patients.

19 I frequently have to get out of bed at night to pass urine

Known as nocturia, this can be quite a troublesome complaint for some people, particularly if sleep is affected.

Younger people tend to excrete more of their daily urine output during the daytime. By comparison it is common for elderly people, even in the absence of any other problems, to get up once or twice at night to pass urine. Before deciding to visit your doctor it would be reasonable to consider the answers to the following questions;

• Is this a new event; have things recently changed?
• Is the number of trips to the toilet at night excessive?
• Is your sleep disturbed?

If the answers to all these questions is NO, and particularly if things have not changed, there may not be a problem.

Causes of "nocturia" - passing too much urine at night - There are a number of different reasons why you might have to pass urine at night.

• Age - see above
• Taking drinks too close to bedtime - This is a simple cause to rectify. If you are in the habit of taking tea, coffee, or drinking chocolate/cocoa close to bedtime then try without them. You may find a substantial difference! Alcohol in particular, taken close to bedtime, will almost certainly mean more trips to the toilet!
• Medical Problems such as heart failure can cause a similar problem. If you have noticed any recent symptoms, or if you are known to have heart problems of any kind, then you should consult your regular doctor for a check up as soon as possible.
• Insomnia or other sleep related problems - Some people who find it difficult to sleep may notice that they pass urine more during the night. This may not be a urinary problems as such but more to do with the fact that whilst awake the desire to pass urine may be more evident.
• Urinary problems - Perhaps the most common of these is the onset of benign prostate disease in middle-aged and elderly men. Getting out of bed at night is a very common complaint suffered by many men. On its own it is unlikely to signal a serious problem. If you have any other urinary symptoms, or any concerns about your prostate, then please contact your General Practitioner in the first instance - a referral to the local Urologist can be made if necessary.
  

20 My child still wets the bed

The medical term for this is enuresis, by which we mean bed wetting after the age of 3 years. Although most children are dry at night by this stage it is important to remember that up to 5% of children still wet the bed at the age of 14 years. Most children who wet the bed will settle on their own by the age of 10.

Children with this problem will need to be seen by a specialist dealing with paediatric urology problems. The specialist will ask questions about the problem, for example how often it occurs, whether the child has any difficulties passing urine, and whether there is any wetting during the day. Wetting during the day usually (though by no means always) suggests a physical problem which needs diagnosis.

Providing a physical problem can be excluded there are a number of ways of dealing with this problem. General tips include not giving your child anything to drink after supper, and making sure that they empty the bladder at bedtime. Sometimes waking them up shortly before the usual time of bed-wetting can help.

For more difficult cases drug treatment may help. Imipramine is a drug which relaxes the muscle of the bladder. Desmopressin stops the kidneys from making urine at night and is usually given as a nasal spray at night time.

Some children find the use of alarms quite helpful. These work because the urine leak wets a pad which sets off an alarm – unfortunately by the time the alarm sounds the wetting may already have occurred.

It is important to remember that in almost all cases the child has no control over the situation and feels guilty and insecure about the wetting. These children need support rather than punishment if they are to overcome the problem.

21 I have a kidney stone? What will be done about it?

This will depend on the size of the stone and where it is situated. Small stones located in the kidney can be treated by "shock wave treatment" – The full name of this procedure is extracorporeal shock wave lithotripsy or ESWL.

You will be asked to lie on your side with the affected kidney over a water-filled cushion. The machine generates shock waves which are focussed onto the stone in the kidney. While the treatment is in progress you may feel some discomfort but painkillers can be given to you if you need them.

The treatment usually takes around 45 minutes to complete, and after a brief recovery period you can go home. Over the next few days you may notice small stone fragments passing in the urine. It is possible you may see some blood in the urine but this should settle quickly. Your Urologist will arrange a follow up after a few weeks and usually organise an x-ray to see whether the stone has gone.

If the stone is in the kidney but is considered too large for treatment with ESWL then it is possible that you will be offered an operation to remove the stone using a telescope placed directly into the kidney through the skin.

This is performed under a general anaesthetic and you will usually need to be in hospital for two to three days.

Sometimes a slightly larger operation to open the kidney through a cut in the side may be required if the stone is very large or if there are other problems.

Stones in the ureter (the tube running on each side from the kidney down to the bladder) can be treated by ESWL, but sometimes it may be possible to insert a telescope up the ureter via the bladder. This also takes place under a general anaesthetic. The stone can be broken up using special instruments or withdrawn from the ureter using a small wire basket.

Why did I get the stone? – In a lot of cases it is not clear why stones form. Some people have a family history of stone forming. Some professions are associated with a higher risk of forming stones, particularly those which involve working in hot environments or hot climates.

The single best thing that you can do to prevent recurrence of a stone is to drink plenty of fluids – water is best, and you need to drink at least 2 litres a day.

Your urology specialist will probably organise some blood and urine tests to determine whether there are any particular reasons for forming the stones in your case. Sometimes further treatment with drugs can be necessary.

© C Dawson 2002