Review | Sundayobserver.lk

Prostate although a commonly used medical term, was rarely discussed in public, in the good old days. However, nowadays, no eyebrows are raised, when you hear someone say, “I have an enlarged prostate”!

Now, the term “Prostatitis” (inflammation or enlargement) rings a bell alright among the men folk, but is rarely understood. Perhaps, due to misconceptions surrounding this medical disorder, one tends to rush to conclusions with his own diagnosis and some with grand motherly treatment.

To put things in its proper perspective, the Sunday Observer “health wise” presented the case to two eminent genito-urinary tract specialists in the country, Dr. Srinath Chandrasekera, Consultant Urological Surgeon and Senior Lecturer in Surgery of the Sri Jayawardenapura University and Dr. Suren de Zylva, Consultant Urological Surgeon, Colombo North Medical College Hospital, Ragama.

The walnut-sized prostate gland found in the genito-urinary tracts of males, surrounds the urethra just below the urinary bladder. The gland produces semen, the milky white fluid that nourishes and transports the sperms, through the prostatic urethral, during sexual excitement (orgasm).

Both specialists, while discussing the prostate and its maladies, allayed fears of men with this common and highly prevalent. disorder that could be treated with least inconvenience.

The male hormone, testosterone is very essential for a male to lead a normal, and healthy life. But, at the same time, the very same healthy testosterone which, from mid 30’s to 50’s is in ample production, tends to be an attributing factor in the enlargement of the prostate. This swelling compresses the urethra and partially blocks the urine flow.

(ii) Hesitancy in the onset; initiation; slowness in dribbles; longer periods to empty the bladder; process completed with a strain; and at the end, the feeling of incompleteness.

Due to one or more of these conditions, complications will set in due to retention of urine, which may necessitate the patient to be hospitalised, to facilitate the free flow of urine with the help of a catheter. Recurrence of this condition may lead to infection, which may result in bleeding.

The pressure developed in the urinary system, may lead to kidney ailments, which could be best avoided, if the symptoms are taken seriously.

The specialists were emphatic that sexual abstinence has no direct association with prostate related complaints.

While highlighting the minor consequences due to negligence to observe and take treatment the doctors also caution that ABSENCE of these symptoms does not mean that one does not have prostatic problems.

The message that urologists want to convey is that any normal healthy looking male who has the symptoms, to consult his physician who may refer the case to a specialist to be medically evaluated. After recording the history the patient will be subjected to a simple, painless procedure known as Digital Rectal Examination (DRE). And the cancer detection test-the Prostate Specified Antigens (PSA) will confirm whether the inflammation (Swelling) is benign (non-carcinogenic) or malignant (carcinogenic).

The initial treatment, barring major complications, in the opinion of the two urologists, is to opt for:

(i) Relax the prostate with alpha blockers which gives relief for 24 to 48 hours.

(ii) Shrink the prostate (in the case of larger ones) - relief for six-12 weeks.

If neither of the two procedures is not successful it will be decided to go for the common methods, through the natural orifice using the latest technique, the TURP. The Trans Urethral Resection of Prostate (TURP) is a time-tested, cost effective, and easily available surgery in all major hospitals (including State-run institutions).

Due to gross negligence on the part of the patient, if the prostate is allowed to grow slightly larger than usual, the specialists advocate the latest in medical technology - the laser method, which in their parlance is known as “Bloodless” procedure.

The most wonderful aspect is when the patient with a complaint of enlarged prostate gets rid of the prostrate is discharged on the same day and reports for duty at his workplace, the very next day!

A paper to be presented at Taipei Medical Congress

A paper on a recent study done in Sri Lanka on the baseline characteristic differences in Coronary Artery Bypass Grafting (CABG) surgery between the State and private sector hospitals is to be presented at the 17th annual sessions of the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS) to be held in Taipei Taiwan next month, March 5-8.

According to this study, it has been found that the patients undergoing CABG in the private sector are older and have a significantly higher BMI and poorer myocardial function, needing for more emergency operations and off pump CABG when needed.

The combined medical team to present the paper at the conference, which has also been responsible for this study is being led by Colombo Apollo’s Cardiothoracic Surgeon Dr. Sujeeth Suvarna and the others comprise Drs. Tolusha Harischandra, Thilan Walgamage and Saman Basnayake.

Dr. Suvarna in an interview with the Sunday Observer said: “In this study we retrospectively reviewed the case records of all consecutive patients who underwent isolated CABG in a single centre at Apollo Hospital, Sri Lanka from June to October, 2008 and we compared this data with the data published in 2008 of the clinical profile of CABG patients at the Colombo National Hospital Sri Lanka (NHSL) and we compared the data of 59 patients who underwent CABG at Apollo with 112 patients who underwent surgery at the NHSL.

A brief outline of the paper :

Background: A recent study of CABG in the Government sector of Sri Lanka established its baseline characteristics as being different from that of the current trend in developed countries. However, whether this is true in the private sector, which handles half the CABG work load of the country, is unknown. Therefore the objective of this study was to establish the present status of CABG in the private sector of Sri Lanka in comparison to that of the Government sector.

Methods: We retrospectively reviewed the case records of all consecutive patients who underwent isolated CABG in a single centre at Apollo Hospital, Sri Lanka from June to October, 2008. We compared this data with data published in 2008 of the clinical profile of CABG patients at the National Hospital of Sri Lanka (NHSL).

Results: The 59 patients who underwent CABG at Apollo were compared with the 112 patients at the NHSL.

Conclusion: Patients undergoing CABG in the private sector are older and have significantly higher BMI, hypertension, diabetes and hyperlipidaemia, smoking is significantly less. They have poorer myocardial function and undergo more emergency/urgent operations and off pump CABG when needed. These findings have implications for risk reduction strategies and training requirements.

Results: The 59 patients who underwent CABG at Apollo were compared with the 112 patients at the NHSL.

BMI (Body Mass Index), COPD (Chronic Obstructive Pulmonary Disease), PVD (Peripheral Vascular Disease), LMS (Left Main Stem), TVD (Triple Vessel Disease), EF (Ejection Fraction), PCI (Percutaneous Coronary Intervention)

Cardio - Pulmonary resuscitation (CPR)

Sudden cardiac arrest (SCA) is a leading cause of death in all the countries and is due to ventricular fibrillation (VF) ventricular tachycardia (VT) or due to cardiac asystole (CA). Results of resuscitation are very much better in patients with VF or VT as compared to patients with cardiac asystole.

The common causes of cardiac arrest are heart attacks, trauma, drug overdosage, electric shock and drowning and asphyxia in case of children.

Cardio -Pulmonary Resuscitation (CPR)

Three to five minutes of collapse can produce survival rate as high as 49% to 75%. As soon as you come across a collapsed person (with cardiac arrest) you must call for help and start immediate CPR.

Look for regular chest movement and if the collapsed person is breathing there is no immediate necessity to start mouth to mouth (or mouth to nose) respiration. If the victim is not breathing and if the pulse is not palpable start cardiac massage with rescue breathing without delay. The procedure of C. P. R. is given below;

Lift the chin with one hand, push down on the forehead with the other hand to lift the head back. Remove any foreign bodies in the mouth such as dentures and pull the tongue out if the tongue is interfering with respiration.

If the patient is not breathing, give the victim mouth-to-mouth (or mouth-to-nose respiration). Place your mouth over the patient’s mouth (or nose) so that no air can escape. Give two or three breaths into the mouth or nose. Majority of people who give C P R prefer mouth to nose respiration as far as I am aware.

Place your hand on the patient’s carotid artery (next to the Adam’s apple in the neck) and check for the carotid pulse. If there is no pulse begin cardiac massage immediately.

Cardiac Massage

Kneel beside the patients chest. Find the sternum, the breast - tone where both sides of the rib-cage meet and place your hands on the sternum. Bring your shoulders over the victim’s chest, keeping your arms straight. Press down on the sternum about one to two inches. Then relax the sternum and let the sternum rise back to the normal position. But do not remove your hands from the chest.

Give 15 - 20 such compressions for every two breaths you give. You must give about 100 compressions per minute.

In case of cardiac arrest (when the heart has stopped pumping blood) hypoxia (lack of oxygen) to brain begins to occur in about four to five minutes after the cardiac arrest. Brain death usually occurs after eight to ten minutes and CPR should be ideally started in the first five minutes of arrest as permanent brain cell damage or death of brain cells would have occurred in about ten minutes after arrest.

When you start CPR you must always call for help and arrange for an ambulance. After giving CPR for about 20 minutes most people get exhausted and you must get the help of another person, until the ambulance arrives.

With effective CPR the chest expands and the pulse can be felt. Continue with chest compression and rescue breathing in the rates of 30: 2 continue resuscitation (CPR) until qualified help arrives and takes over and until the victim breaths normally. If normal respiration does not start, get the help of another person if you are exhausted.

Risk to the rescuer

In Sri Lanka where pulmonary tuberculosis is still common there is the risk of the rescuer getting TB, HIV infection is a problem but it is very rare.

So it is advisable for the rescuer to use his or her handkerchief during mouth-to-mouth or mouth-to-nose respiration so that victims mouth or nose does not come into direct contact with the rescuer. In Sri Lanka, as far as I am aware many children do not receive CPR because of rescurer’s fear of causing harm to the victim. This fear is unfounded and CPR should always be done in case of children. Readers will agree with me that it is better to have a live child with a few rib fractures than to have a dead body without fractures. For lack of space. I am not discussing CPR in case of children in this article.

Immediate CPR and defibrillation (electric shock to the heart) within three to five minutes of collapse can produce survival rates as high as 78%.

As soon as you come across a person with cardiac arrest you must call for help and start immediate C P R until an ambulance arrives. Look for regular chest movements and if the collapsed person is breathing, there is no immediate indication for starting mouth-to-mouth or mouth-to-nose respiration.

As mentioned earlier if the victim is not breathing and if carotid pulse is not palpable, cardiac massage with rescue breathing should be started immediately.

With effective ventilation, chest will expand. Blow into the victim’s mouth or nose twice and then give about 20 chest compression. Continue with chest compression and rescue breathing in a ratio of 30:2. If the victim starts normal breathing continue with the chest compression. Continue C P R until qualified help arrives and takes over. If you are exhausted give over C P K to another person.

Common mistakes

I have come across hundreds of patients brought with history of cardiac arrest during the 23 years I served the Institute of Cardiology. National Hospital and majority of the victims were dead on admission as in almost all these unfortunate cases they had not been given mouth-to-mouth (or mouth-to-nose) respiration during the transport of the victim to Coronary Care Unit.

Only cardiac massage had been given. Some of the readers of the article may have observed in the TV that in case of almost all the victims brought by ambulances for admission to National Hospital, Colombo, during the period the victim is transferred from the ambulance to the I.C.U., the nursing staff who takes over the victim give cardiac massage but the staff rarely give mouth-to-mouth respiration.

As I mentioned earlier mouth-to-mouth (or mouth-to-nose) respiration is a must if the patient is not breathing.

Results of C P R

Results of resuscitation in case of patients warded in C C U are excellent especially, in case of primary ventricular fibrillation, thanks to the efficient nursing staff and doctors in the C C U, who work as a team.

I can remember 62 years old female patient who had been resuscitated successfully for cardiac arrest in 1974.

This fortunate lady who was a famous maths teacher, lived upto the ripe old age of 95 years after discharge from hospital and passed away two years ago. The above patient was brought to C C U in a collapsed state by a family physicians who had given both cardiac massage and mouth-to-mouth respiration; during transport of the patient in an ambulance.

No need to fear